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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF C•�,�.��.,�- ,o,�d COUNTY,PENNSYLVANIA
Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters as specified below, and in
� support thereof aver(s)the following and respectfully request(s)the grant of Letters in the appropriate form:
Decedent's Information �
Name: l.._c�r� ,,� File No: ��' �3���� �
a/k/a: (Assigned by Register)
a1k/a:
a/k/a: Social Security No:
Date of Death: 8 � S � �3 Age at death: 3�
Decedent was domiciled at death in C-�w•�.Y�ahd County, �T�-��s 1���:G (srare)with his/her last
� principal residence at '� ��f �M S�, Y���,a�:1\e. � �p �'��}1 , •M be..r 1 o�v� C�•
Street addre�,Poat Office aad Zip Code City,Townahip or Borou���1 Connty
Decedent died at Z.�^'�'R rg�+e.-�'a �� o`� w„� y►,��k.� ��}, 3 Sr,,�,,.�1, 1M:c ���aw h "T'w� �,�,,,�w,.��
Street addre::,Po�t Office and Zip Code City,Townahip or Boroug6 County State V A
Estimate of value of decedent's property at death:
If do�ntc�ltd�n P��nsylvania............................ All personal property $
If not domiciled�n Pennsylvan�a. ....................... Personal property in Pennsylvania $ �
If not donetc�led�n Pe»nsylvan�a. ....................... Personal property in County $ ,
Value of real estate fn Pennsylvan�a...... ........................ ....................... $
' TOTAL ESTIMATED VALUE. ... $ �GO 0. 6�9�-
Real estate in Pennsylvania situated at: ,
(Attach additionat sheets,if necessary.) Street address,Poat OftIce and Zip Code City,Township or Boroug6 County
� A. Petition for Probate and Grant of Letters Testamentary
Petitioner(s)aver(s)he/she/they is/are the Executor(s)named in the last Will of the Decedent,dated and Codicil(s)
thereto dated �
State relevant circumatancea(ag.renu�clation,destb ojarecator,etG) r.,,;, �
� �
. 'w,.", �p �
_ Except as follows: aRer the execurion of the instrument(s)offered for probate Decedent did not marry,was not divo��Ed�9ras not a P�y to�n 8
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa.C.S. §3323(g),�ppd not hav�child"•t�o�or ,
adopted;and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. �'t1 �n C � �r
�NQ EXCEPTIONS �EXCEPTIONS r"` � �Tt � fi r''�
� � � .
� B. Petition for Grant of Letters of Administration (If applicable) � � � � �
c.t.a.,d.b.n.,d.b.n.c.t.a.,pendente lite,dur�J'e�s�ia, nte�o�ate • .
If Administration,�c.t.a. or r�b.n.c.�a.,enter date of Will in Section A above and comp�t�ist of hbRs. �„�'"'�,,,.tr�
• Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorC�had been esta�hed�dp�ned
in 23 Pa.C.S.§3323(g)and was neither the victim of a killing nor ever adjudicated an incapacitated person. ,
�NO EXCEPTIONS �EXCEPTIONS , ;
Petitioner(s),after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse(if any)and heirs(attach
additional sheets,if necessary):
Name Relationshi Address � •
Sb 0.�h �- �h Sl►�.,�1� �e�. a�3 P0.�sA,� S� , o �e�sb ,1J� �3�b9 ..
.
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Fo�Rw oz .�.ro�»noll Page�1 of 2
y
� Oath of Personal Representative o�e���use on�y
COMMONWEALTH OF PENNSYLVANIA } �
} SS: �
COUNTY OF c�..w•�ltr la� }
Petitioner(s)Printed Name Petitioner(s)Printed Address � '
�ti1e O Cto� E. SytBn k � Sr• � BQx 3�'� 'n[W ��oOv�-'*�t��
� , Pa c-�o�
`^Qr►'�0� �JQ..YLIt(L'�' PO ��f �D � ��YY.S"T�YI t 1r� I 3�D�G�
The Petidoner(s)above-named swcar(s)or affirm(s)the statements in the forego' g Perition are true an ect the best of the knowledge and belief
of Petitioner(s)and that,as Personal Representative(s)of the Dec e Pe oner( 11 w 11 an the estate accord' to t .
Sworn to ��rmed d ubscribed b for Date �
y m e t ' d�y o f /� ' Date �
,
• By' Date
F r e Register Date '
BOND Requlred: � YES � NO To the Reg�ster ojWills:
FEES: Please enter my appearance by my signature below:
Lett rs. . . . . . . . .. . . .. . .. . . . . . $ ��'�a Attorne Si nature: .
Y 8
, ( )ShortCerti�cate(s).. .. . . Q-ao
( )Renunciation(s)... . . . . . .
( )Codicil(s). .. . . .. ... . . .
( )Affidavit(s).. . . . . . . . .. . '
Bond... ... .. .. .. . . . ^s •
• •• • • •• • • PrintedName: c� �p
Commission. . .. .. . .. .. . . . .. .. Supreme Court 1� 0 'w' �„�
Other � � � � �
• �• • � • • ID Number•
• .,..
. . . .. . . � � � � �
, . . ... . 0•�� Firm Name: � ys► 1' }—► '""� �
� t�►i
,
• • • • • • • Address: �. �p
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. . . . .. . � � ' � �•�, .
.. . . .. . Phone: • � � � rn
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Automation Fee. .. . . . . . . . ' p
Fax: �,,, ..r�
JCS Fee. . .. .. . . . . . . . . .. .. .. . � Email: �
TOTAL. . ..... .. .. . . . .. . . .. $ ��
�J�� v`� .
DECREE OF THE REG T
.
I� ER
Estate of /' File No: �I "������_
a/k/a: �
AND NOW, , ,in consid� 'on e foregoin Petition,
satisfactory proof having been presented before me,IT IS D CRE D that tter p�
are hereby granted to e , . .
— ��� �� in the above estate and(if applicable)that �
.
the instrumer�t(s)da.ted �
described in the Petition be admitted to probate and filed of recor he last Will( d Codicil(s)}of cedent.
Register of Wills
Form RW-02 rev.10/ll/2011 - P1ge Z f
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