HomeMy WebLinkAbout09-03-13 REGISTER OF WILLS
CUMBERLAND COUNTY PENNSYLVANIA
SMALL ESTATES AFFIDAVIT
ForInsurance Proceeds
NOT to be used for Settlement of Small Estates under 20 Pa.C.S.A. 53102
(Original Death Certificate Must Accompany this Form)
Deceased 3'ER.N.........A..._....Cy.Pl�T�IIZ.�...................................................................................... Docket No. .........._-L-_r..... _1....�_�......1�....[...��(.�?.._....
also known as Social Security No. ��'� - ��-�. �
Before the Register of Wills of said County personally came �-�c��c� ,i�. _CypH�'RS� ................................ who resides
_......
at — _�being duly sworn,
�.._�..........�r.�_�..r�rc�}......:�r.......,�....�..u_...o....t a..,.............{�...lk......
deposes and says that ........_�'E.�4'N........I�t...-....�Y.P_�1'�25................................................................................................................................... �age �.�......... �a resident of
...... _..
C-�G1Ae� '�..v..'��......:......_N_�=`�'..�...:�._�................._��rx�.�............................................................................................................................................................................................................._`.:�.��................................�cr
�-.....
in said County,departe�his life,at S on the � f� d . o�
�.............:o�..$........................... �
���;� A.D.20 0"�' C�S o'clock � M� essed ers3t�
........... . ... .._�'........................................................ \3............ �`.j............................................................ � � �,-�' A, -7
P P Y GC� 1�......... P '��� � �:.
_... r=�
ro ert estimated to be of the value of$ c� ,c�1 , aa,and ossessed of real estate rth tamated value;
� ��.
and the location of which is as follows:
� �'? �� c:,> <:���
Except as follows,Decedent did not marry,was not divorced,and did not have a child born or adopted afte�e eCAti�n pf a►t� ' -,��'�"'
_°
testamentary writings whether or not offered for probate;was not the victim of a killing, was never adjudic�'Oed4u�►'ttwltapac�ed � ^'"_}
person,and was not a party to a pending divorce proceeding at the time of death wherein grounds for divor��een estab3�hed as ��g
defined in 23 PA C.S.section ° --{ �
Ci) s.':a
3323(g): h� � � � � ��
The total amount of insurance proceeds payable by �1 G L does not exceed$11,000 and 60 days hav elapsed
since the death of the insured.The undersigned agrees payment cannot be made under this Affidavit if a written claim for same has been
made by a Personal Representative of the estate and no other heir(s)having preference exist or have released their benefits to the
undersigned.
That said decedent left a spouse—whose name and residence is _N`.A..................................................................................................................................................................
and the followin as next of kin: (use additional sheet if re uired)
NAMES RELATIONSHIP RESIDENCE
crci;� - R LyP1��'�' Snw3 \6.�erma,n"� 'D+r. Fu��� PA. 1'1�aS
That the above named are the spouse&and all the known next of kin of said decedent,to the best of my knowledge and
belief.
Your Petitioner avers there are NO I{NOWN PROBATABLE ASSETS that would require an estate proceeding.
Therefore,NO ESTATE WILL BE RAISED,AND LETTERS ARE NOT NECESSARY.
Signed n
gy: '�
Sw rn and subscribed to before me this
,�� ay of ��n�j��� ,20 �� Register of Wills:
T.....
Kindly enter appearance in the above case this
��.�...t�(�.,��-..... . ..... . ��-���v..... day of �20 ...
_..............................................................................................................................���....
�, r....t • .�� I.D.No.
� '`' `'' ��` Attorney
�_..
;X..i CJ.
BE IT RE�IEMBE�D,tt�atc�s�the day of ,A.D.20
There hasbeen NQ�STA��'��I�.QCEEDING RAISED FOR THIS DECEDENT AND NO LETTERS HAVE
BEEN ISSUED BY THI�;�Q�J�'I'.
� . ' :. ._ _� .,� _
� �z _i
� a
� �-�- ti.�
6'' � m
��:� r .° , �' Q � Glenda Farner Strasbau
'`'� ��� U Register of Wills&Clerk of Orphans'Court
My Commission Expires First Monday,January,2014
_ -. . _
w,..�..� �,f,��.�..�.A�,�..w_�, �.u,,�.�.,«�.,.�.,�.: .
Ht05.805 REV C9I1O
LCJCAL REGISTRAR'S CERTIFICATION G1F DEATH
VifARN1NG. It is iilegai ta duplicate this aopy by photostat ar photograph.
RECO�I��'� G�;'IC� �F
�'"Ef.fOP t�"!IS-GeI`t1�lCilt�y .��•�. t1�{�'�t�` ',• 5 �""• �prurau�irr... `j'}�I$ 1S tt7 C�Ttl�y tll"dt t�IC 1T1fOITTl2t1{}Il t1�fP� g1V�Tl 1$
' � : �-1� ��' `�-�� ` �,,,�'''�,p��+�o�PFyy= carrectly copied from an original Certificate of Death
�'���' - 'ri��_ duly filed with me as Local Registrar. The original
��ii� ��� � �� � �� z��� `=: ��; certificate will be farwarded to the State Vital
;° - a� Records Office for permanent filing.
.
�.� �* - *r
P 19 8 4 0 415 oR��a�s�co��r �o���'f'T ��P~���r �.d..��. p-��u�. �/��.I��
MENS��,,
Certificatian Number �;(,�����{�A��j ��},� �f� '"'-"""""" +', Locai Registrar Date Issued
Typa/print in COMMONWEAITH 6F PENN5VlVANiA�ClEPARTMENT Of NEALTM�V�TAL RECORRS `
�ei�ki;;ki CERTlFICATE OF £]�EATti
Sfat�Ftle Numbar:
3.O¢eetlent's Logal NarYle(Fl�s[,Mlddla,Last,Suffix) 2.Sex 3.Sqcial 5<cu�iiy Number 4.date of Death(MO/bsy/V)(5{}�pll M
� � S'�7 - ��- 89 1 `$ '^�.$ '1;�' �He s
Sa.Age-last Birthday(Yrs) Sb.Undet 1 Yaar Sc.Under 3 6a 6.�ate of BiKh{MO(OayjYaar}{SpeIF�MOntfi} '7a.B�rt�bce(Qty a��n tat4���s3jcn Countty} � �
�y M�cmths �.�Oays Npun Minutes � {)� � T,� d� � . �
.��CI� � �!�"l +�'7 �� `j� 7b.BlrthPlate(GOUrvky) ..
8a.Re9 enee($t/te�Or Far4ign CduntryJ. ' Sq.R�sid�mnce(S(tr�ay�at and Number-4rrClude A]pk No.)�� .8c.Did DeeGedent Uve In a Township7 � � �� . .
Sd. ICcnc�( unty}: . . '��() {"' t�.��n+.�T��}i'y�a`, � �Yes,daCedcntliv4din � � twP.
Se.Rezide�rx(2iP CQd � ( �� � � �No,der.eQc�t lived withF�ilmits of t v !V�w dSylboro.
9.Evar in US Armed Forcesi 10.�Marltal StatuS a[Time of Death 0 Marrlqd Widowetl 11.Surviving Spo�+se's Name(If wife,glve namc prlar to first marHage) -
0 Yes �/40 �Unknown 0 Divorced �Nrbver Marr�sd Q UnknoWn
12.F �Rr's (Ftrsi,Midtlia,(ast,Sufflx} 1 MO;har's Nam�P�io�SO Fi MarAag�S First� lddia,lastj
q.��".¢r- �e+�!Y"►.fzr �,,,c+�r t^t g,, ��.c[5.+2}�
14a.InfolmanYS Nsme 14b.Relatlonship to De[ed�enC 14c.Info�manYS Malling Address xreec and Numtier,CISy,Siat¢.� Ip Cod�y � ���
� r � lr��¢.�'3 S o r., � 6 r.e c N eY.a� �f"y rt n���Q J"'"'.a f"'�p"
G ••••.._......•-••.. .. ...::.. .•••:. .. �-••� � -•....-•••••............_,........?. 4.... n � .. on�on .. .-•-•.:__ .�. . ..�. : .
� if o�aitf occUrraa in a�:HOx t i .. . " ' •••••••••• ••••• "'"'•••• •••••••• ''"••:, ••••• �•••:••••_••
P1 �in tt t zif i?oath O Currcd Sa htr Citlt �Thatt a H�ospltai: � �HosR�ce FaG[iity � '�CSeGadont's H4ma
� EmtrB�n Rpam(t7uLPaC(aryt �.� Daad on Arrlvai NurvJin .tt ��a/4aetQ-Term Care F,wGiiiry . Otirer SSpecl ) �. .� .
15b,faclilty Name-(If��o[lnstltutiqn,�iva strq.rs;antl.n�lmbar; •15c.Clty or ToWn,Siatq!, 2ip Co.d�e 15tl:Caunty f Clbath
G o�c�¢..a L�v��v .>r ss�..> o rr+�e C.Fa w^Y .�� �'7 O/l C m�'Y�a.s-�4�n��
�, 16a.Methotl of Dixpositbn 8urlal� Q rematbn 36b.pate o4 b sponitbn 16c.Piac�of Dlsposltbn{Name of cem�tery,cfemEi�.�4khar piaca}
� �ft�mo„s�f����a�z�} o�.,g�,a., 'g .3t -t 3 t�`"'-�o,�-� YY'}vrr' „�ty� r
�' ach+er s � �� . . ..
� 16t7.Lf.YCAtioll of¢ISPOSIt1an(City pY Town,State,and 2{p) . � � 17m.SI � . o F�neral Servite ansea Or P�rson in Charga Interment 17b:Licanse Numbar
� �`'�'r�' �"'.�.-�� N�j o-�-1�t bs ` � . -c��d..��/-�
c.Ne rW Com Address F n�rai ekiity
� �S�,cr. �a�r,� r��ce 4s j� o� "�ve ask: o u 11�'� n^>�s 4
u� 18.DwGedanYS Education-Chack Lhe box th>t bet�describes Che 39. imcedwn!4 HlspaniG Qrigin-Check th 20.bec�dant'a Race-Gheck ONE MORE reces to InCica[e what
h�ghest degree a�level 09 school completad at Lhe nmw of Eea[h. box that besc dascrlbes whether xhe tlecadwn� ths tlacadeM considerwd himself or herself to be.
�8th gratle or le�ss Is SpanlshfHispanicf Wifno. Check tha"No" �$.Whit2 Q Korean
0 NO Gipbma,9th-12th grad< box if dscadcnt iS not Spat�IShjHispinicjLaHnd. 0 Btack ot RtTican Am4��can � Vtciriamts�
���Nigh scfiooi graduata or GEO complated �j No,r�ot SpaMafi/HlspanicJLaHtio Q Amarlcan tndta�4r Alaska Nativa � bthar AsfAT
Q Som collage rcdlC,but no de$ra� Q Y4�s,Maxican,Mexican Americen,Chlcano �Aslan Indlan � NaHVa NQwallan
� A9sociate dsgree(e.g.AA,AS) �Ves.PueKO Kican �Chinese � Guamania�or Chamorro
0 B.athelor's dagroe(e.g.BA,A6�BS) �Vas,Cuban 0 FIIlpino 0 Samoan
� MaSt�r's degrea{e.g.MA,MS,MEng,MEtl,MSW�MBA) �Vws,othar SpanishfHispa�{c(WLino �)apan�sa d Other PaCiHC isiander
Q OoctoraUe(�a.6.PhQ,EtlD3 or Prufasstonai da6��e jSpccify3 �dth�r(SPeci£y5
.MD DDS PVM Ll6 JP
21.DecedenYs 5ingla Racd Self-Designatlon-Ch�ck ON4Y ONE Co intlicaic what the dec¢dent Considermd himselT ar harself+to be. 22a.OacedenYs Usual Occup#llon-Indtcece iype of wo�k
�White . �lapan�se Q Samoan done da�ing most of working IIfB. 00 NYJT USE RETIRED.
[�Biack or African American 0 Korean 0 Other PaGR<tsiandar � �"R...t_��.+
p O American MA�an ar Aiaska NaHve 0 Virtnam4sa Q Don't Know/NOt 54re ti��
� �Astan Intli�bn n Other AsiYn Q A�fusaed 22b.Kind of Businebi/Industry
� 0 Ghinesa O NaHVe Hnwalian [� Other(Specify) ` `�� /�y -}-�
�Fillpino []GuamanlenorChBMOrro �qV`'< <.++/�� `"- ��"�'` dr�
/TEMS $�- MV9T�6£CO EOt 23a.Rata Pronou�te Ocad(MO 6ay 2 b. gnature'qf Parson ron nci�g OeaL {Only wNen apptiCabl6� 26t:lic�ngt.Numbe�
BY PER'SOM 1NN0 PRONt}LIVCES OR - G��,.^� Q,,,_�� � . � . . � . � .
tERTI 1ES�OEA'k'H. �1?�V . . . .. �� .
23d.DiCe SI�Md{Mo/Dby/Yrj .'t4.Ylme of :�h4� �� � �� �
-� �25.�WOS�MedlcalE%emina�orCOronerCOntected? �.�0� V<s �,� No
, CRUSE OF.[7EATH�. � � � � apProximac�
26.P#rt�t. EMar rti�e cFy�n of�v�nts-disea%bs,injuries,or mmpiications--that d{nRCtiy tausad the d�9th. DO NOT etiter tarminai lv�nis suGN as ca�diac arce5t tnterval:
Ysspiratory arrest,ar ventricular fibr111atlon without ahowing ch�etlology. DK1�NOT ABB0.EVIATE..Enter enly one caua�on a Ilne.Add addltlonal Ilnes H necassary Onaetlo Oeath
IMMEOIATE CAUSE -"--"""'--> a. ��L/ � ��` � "'�'��
(Fine�dlsza�a o�candlCion Ou� ( conasqu� cs f}: �
�tsuitln8 in death) � /� � /� �'�{' . . . .
b. YG''s"`C� �"-"�'� .C�7�s . . . . .
Sequqntially Ilst cond�%lons.�� . � . . Due io(o�as a<onsequ4 c6 afa� . . � � .. . .
if anY,leadling to Yha cs4uxe� .. � . . � � � � � . . .
Iistad ori line N�.�Enierthe�� � . . � .
UNDERtYiNt$CAUSE � �� � . Oua to(ar as a cans6CUZrwee+of}: . � � �
�� (disnett o In3urY that � " . � . . .:. ... . . ..
IniNaCetl ehe 9vonts r uking �tl�.
in deach)LA6T. Due to(or as a conseque a ot):
- �. �, 26.Pimt��. Ee�tar aLhar' ( H4 t EIN t 164et[ Ya d th but not ras�iting in Lh�a uhtl�riying eause g3ven in Part i . . �27 W s»et autapsy pa rmedT
Yas No
�:2$Werq��autoPSy tinaings avalleb�e
'� . . . . . . . .. . fo mmpYes th�a cause Nf�death?
-� 24.fP f-+maia� � ���. 30.O{tl Totiacco Us Contriput<io D<ath? 91.Msnner af Oealth �-
�.Nat pe'agnent withFn part y�ar Q Yes �mbabty ��NafuYSi [] HOmtCltl�
p PregnBnt a[Um�a of deatM Q No ��, :Oknawn Q Aceitl4M � P�nding iav<ntigation
'�' � Not Dr4gnant,but prognant wlthin 42 days of deaM . p 5ulcltle. p Could'+ot be tlwtermined
Q Not prognanS,but pr�gnant A3 days to 1 yaar before d�Dath 32.Dake of Injury(MO/Oay/Yr)(Spael)Month)
� Unkeiow»If pragnant within the pask yesr 93.Time af InJury
34.Pface ofi i�jury(a.g.Nom�;<onstruction Eiie;farm;sCfiaot} 35-l4calion of in)ury(Strcat ant!Numb�r,City,State�2ip Code)
36.Mjury at Work 37.If Transportatbn InJury,Sp+9Cify: 38.bescrib�Mow InJ�ry Occurred:
�Yes �Qriv�rlaP�rator � Padast�ian
(_j No [�Passenga�� Q OttieY{Specityj
39a.GeRlfier(Check only One):
�CeKlfying physician-To Che b4st of my knowledgm,death 4cwrred due io the causa(s)and manner s(ated
�pronauncirtg 8�tartNying Ph sician-To tha best of my knowiedge,tleatfi occurred at tf�e tfine,drke,and ptaca,and dua to fh�e<ause(s}antl manner stated u
[3 Medicai Exam7ncrjGar Or�tha Is aminatian,�nGjor InYaStigation,in my opin{on,death acCUl'rad at ihe�imc,dat4,a*�d pi0tq antl dUe ta tha ca sa{s)snd manner atatad
'Title of Certlfler: T ��Yf'��"t�+ _ ti e.,:e Nume�f.r7�'7' OZ�'S��"'�f
5lgnature of G¢rtlfier: - .
39b.N me,Addres9�.i�nd 2ip Code of PorsOn�GompleCing Cause 4P Daath(Item 26) 39c.Date Signbd(MO/O ,r)
�t��a.�wf m� z9Zdi�t.n S�' t""' s`�'l� +`�1�r r-�r mv 8""'oZ-ry"" '/ ' .
4�.RegfsKaY'a DlStrict Nwmber � 41.Ret r's Signetu�e 42�-RvRgFStrar F<Oste(MO aYIY�
� �,�---�:��`�, v�
a3.nmer�dments �
� #4 Should R�ad: August 28, 20'13 ��
� #8 o Should 27eadz Camp fiill
#23A S1-tould be Blank 8/3p/1 3
t}���j'.�.� Kios-xas
pispositioYf Pcrmit Na. y�� REV 67j2012
: ORPHANS'COURT DIVISION
. COURT OF COMMON PLEAS(JF
In Re: Jean A.Cyphers . CUMBERLAND CQUNTY
. PENNSYLVANIA
. N0.21-13-0936
CERTIFICATE C1F SERVICE(JF ORDER
ORDER DA"I'E: 9/5113
NDGE'S INITIALS: GFS
TIME STAMP DATE: 9/5/13
IN RE: SMALL ESTATE AFFIDAVIT
.............�...........,......,......,..,......,....,.................,,......,,........,..,.�...�...�......�........,....
SERVICE TO: CRAIG CYPHERS 31 GREENMONT DRIVE ENOLA PA 17025
METHOD OF MAILING: ENVELOPES PROVIDED BY:
�USPS �PETITIC}NER
❑RRR ❑JUDGE
❑HAND DELIVERED ❑CLERK C3F ORPI-�ANS CQURT
❑ OTHER
MAILED:9/5/13
.�.........�,...,,«��..�,...�.....�..................................«<.....,�.....,�,....,,.,.,..,...�.,.....,......,...,
SERVICE TO:
METHC}D UF MAILING: ENVELQPES PRC}VIDED BY;
❑USPS ❑PETITIONER
❑RRR ❑JUDGE
❑HAND DELIVERED ❑CLERK OF ORPHANS COURT
❑OTHER
MAILED:
�.
Cy' r `
Deputy
Clerk of drphans' Court