HomeMy WebLinkAbout12-27-13 PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF_�(�1Y�'11J�d" � C,h 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 respectfiilly request(s)the grant of Letters in the appropriate form:
Decedent's Information � // '
Name• � G•\ e File No• �I � '�� I.�7��
a/k/a: L O�� �— (Assigned by Register)
a/k/a: n
a/k/a: Social Security No: � g y `� �� � � D ��
Date of Death• � � � — � O � 3 Age at death• Sg �
Decedent was domiciled at death in � Y County, (Su:re r with his/her last
principal residence at � , o �'U�-j!j�?d- �I��
Street addre s,Post Of6ce and Zip Code City,T wns �p or B ugh Count
1 ` � '
Decedent died at � � �' rU 1 C . 'I' ,
Street a ss,Pos Office and Zip Code Ci�y,Tovynshi�or Barough County S[ate
Estimate of value of decedenPs property at death: COif �l S �
If domiciled is Pennsylvania............................ All personal property $ �,�Q �, �
I/'nat domiciled in Pennsylvania. ....................... Personal property in Pemisylvania $
If�:ot domiciled in Pennsyh�ania. ....................... Personal property in County $
Vnlue af rea!estate in Pennsylvania......................................................... $
TOTAL ESTIMATED VALUE. ... $
Real es[ate in Pennsylvania situated at:
(Annch nddi�ionn!sheets,i�necessary.) Street address,Post Office and Zip Code City,Township or Borough County
n � � �J
❑ A. Petition for Probate and Grant of Letters Testamentarv � �-�l �
Petitioner(s)aver(s)he/she/they is/are the Executor(s)named in the last Will of die Decedent,dated %�'�" �;.�d Codt�„c�'il(e'�r
tl�erero dated rn � c� a�n :�-�
� ' r - ,_,..
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State relevant circwnstances(e.g.renuncinlion,�teatlt of executor,e1c.) �,,, � �,_ �7 ;�� C;:'w
-�,. U? ._.
-„ ,.: L;, t�:,�
Except as follows: after the execution of the instrument(s)offered for probate Decedent did not marry,was not divotced�as,-i�pt a p�to apmndin
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa.C.S.§3323(g),aitd�ria�hav hild barn.�3
adopted;ai�d Decedent was ueither the v;ctim of a killing nor ever adjudicated an incapacitated person. `�- �-�
_.�
. . N �__ ��i"i
❑NO EXCEPTIONS ❑EXCEPTIONS .-�"""'-'—' "�3 i�:i '�
----- - p� e^� C3
,.r � -ri
�, B. Petition for Grant of Letters of Administration (If applicable)
c.t.u.,d.b.,,.,d.b.,T.c.ta.,pendentelite,dz�runte ubsentiu,durunteminoritule
If Administration,c.t.a. or d.b.n.c.t.a.,enter date of Will in Section A above and complete list of heirs.
Except as follows: Decedent was not a parry to a pending divorce proceeding wherein the grounds for divorce had been established as defined
in 23 Pa.C.S.§3323(g)and was neither the victim of a killing nor ever adjudicated an incapacitated person.
�NO CXCEPTi��;�S �EXCEPTIONS
Pe[itioner(s),after a proper search has/have ascertained that Decedent left no Will and was survived by tlie following spouse(ifany)and heirs(uttach
udditionul sheets,i/'necessury):
Name Relationshi Address
� � Cr � �l eY S 0�15� 3 �' ��IeSTh'1 / S �� �T• l70/% S r�h s , l��
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3 C h c��� � , �. ��l s �i� ,�°y�7��-J-"
E
Form RW-O2 rev.l0/1 U201! P1ge 1 Of 2 � ��'`
���.
Oath of Personal Representative OFficial Use Only
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF }
Petitioner(s)Printed Name Petitioner(s)Printed Address
r e5 u z�� c� S ' S ��
The Petitioner(s)above-named swear(s)or affirm(s)the statements in the foregoing Petition are true and correct to the best of the knowledge and belief
of Petitioner(s)and that,as Personal Representative(s)of the Decedent,the Petitioner(s)will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed before ��Q�(,� �,��(J�-C/� Date �02 � � �-!�j
me t 's�day oi �1 J.3 Date
By: ' Date
For the Register Date
BOND Required:�YES �NO To the Register of Wil[s: n �; :� �
FEES: Please enter my appearance by my si�af31-e belonc:� G�j �
C�
, � � -., '��
ti. �---,� ,{„l7 >,
�.° t�
Letters . . . . . . . . . . . . . . . . . . . . . . i. Attorney Signature: {
( /..� ) Sliort Certificate(s). . . . . . 2G`� '� �"� �'" � � ' ' �'�
G�' i_.. ��, ,.�; —.3 ., -_.
( ) Renunciation(s).. . . . . . . . '"; �n �? G,, c'.�
� )Codicil(s). . . . . . . . . . . . . ... —:. �;-rt _��
Affidavit s .. . . . . . . . . . . .. � 1 :.:�.� .�. _'
Bond..). . . . . . . . (.). ,_� .: t_>
. . . . . . . . . . . Printed Name:
_. ..�
„ "° � '.�_ �
Commission. . . . . . . . . . . . . . . . . . Supreme Court --+ a �
Other . . . . . . . . ID Number: � � L� �� k`t
�} . . . . . . . . �S-�� "
Q.'C . . . . . . . c5.�iti Firm Name:
_
. �
�� i rtil� . . . . . . . . �•L�L Address:
. . . . . . . . Phone:
Automation Fee. . . . . . . . . . . . . . . `Z. ��� Fax:
JCS Fee. . . . . . . . . . . . . . . . . . . . . �, '' Email:
TOTAL. . . . . . . . . . . . . . . . . . . . . $ �
DECREE OF THE REGISTER
Estateof ����(� �,���� �°�1�- ��(��V ��CY CaV�����FileNo: � � —� � "�a�j��
a/lc/a: ��
AND NOW, ��� ��m� �, ��'�.� , in consideration of the foregoin Petition,
satisfactory proof having been presented before me,IT IS DECREED_t at� ett���1 Y I �Y�
are hereby granted to ���`1�1'l
in the above estate and(if applicable) that
the instrument(s) dated
described in the Petition be admitted to probate and filed of record as the last Will (and Co ici!(s))of Decedent.
���.� � �, �' � ' . �
� ��� �
Register of Wills� � ������ /� ��y�
' 6 �L
Fo,��„n�voz ,��v. rnittiznit Page 2
H105805 REV(9/1I)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
REG���� �a" �`�� uF
Fee far this certificate, $6.00 ,, �,,,�����"' y�- This is to certify that the information here given is
R��i�� �,� �` ` ,'.-� ���" p�SN OF pE'
�'� �, �%`-_ correctly copied from an original Certificate of Death
;+o`ti` _ _ L` duly filed with me as Local Registrar. The original
't=j3 ��� 2 7 r i'[� c . Z� certificate will be forwarded to the State Vital
� a� Records Office for permanent filing.
;* *�.
� 139 � 7 � 0 � c�.��� i =��,� �_ -: ��,,,,
Q R P N A�S' C.��� � �9rMENT�E�'�`�',, �Z.�°``^`1q.'�.'.°"fi�'�"��-°,vr D E,� 10/Z 013
Certification Number ""����"""" Local Registrar Date Issued
g GUMBE#�L.�'�P�� Cr;�., PP� �
� Typa/Print In COMMONWEAI.TH OF PENN3YLVANIA•
Pertnenent DEPARTTAENT OF HEALTH•VITAL RECORD3
Bleck�r+k Case Number: J-2o-13-72-0548 CERTIFICATE OF UEATH
. aga r� ay r ce
cia���� eT f81.Richard Heiler nnaie � �H =`��= �� o December 7,20'13 �
a. p es� rl ay �e . ee� c n ay . a�e o rt ay e pall o rt p aeB en �ete or ro O� oiantry
�l� 58 M��ws� oavs �o���ar M����ae Hanover, PA�
Octobar 4. "I 955 �n.einnpe�o<co.,m» YOZ'
-h 8a.Reatdenca(S�etO Or Fo�610�Country) Hb.ROe�Cance(Slraet enO Ntimba�-tnclWa Ap1 No.) 8e.Did�eeeGerH Liva In e Townehlp'I .
��� Penns lvania 3'I 9 CYiesnut St_ re,,aa�eae„�n,.ea�„
�a.
�� ea.Re,�d«,�,�co...,ry Ho 11 S r i n s
Cumbe r 1 and 8e.Realtlanca(Zip Cotle) No,a�aer,�n�aa wm,�n nrona w Mt- Y p �3 �m,�ro
9.Eve�in U9 Armad Forcae't 10.Ma�itel Stalua el Tme ot DeatM1 Mer+latl Witlowetl 1 t.3urvlvinq Spo�ane'a Name(H wNe,piva neme prior to flrst martie0e)
� �v., 1� �o � u.,w,�,,, p oi�o.�ee Q NeverMartleA p u.,k.,w," CYler1 D2tt2r
12.Fetl�eYp Name(Fl�st,Mldtlle.La>y S�/flx) 13.MotlieYS Name P�ior b Fi�a[Martiapa(Fira[.MItlWO.Lanl)
Kermit Heller Blanche Swope
14a.IMOrtnan�'a Neme 14b.RalatloneMip lo�ecetlent 14c.InfOrtnenl'e Mall�np Atltlresa(St�eOl e�tl Number,CNy,9tata.Zip COtl9)
� Cheri He11er wife 399 Chestnut St_ Mt_E3p11ySpringsPA
�j '15a.Plxe oT Dea�h Chack on pne� �
t�i IT Oea1h OcCUned in a Hoapttel: � Q IhplMen[ � 1/DeetM1 Occurtetl Somawhar9 Other Than e Hoepita�: HOSp�cO e ty • enl's O
p O Emerpency Room/O�npatient � Daetl on Arrlvel � Nurslnp Homart.onpp_Term CBre Faciilty � Ottier(9peely) . Te
� 15b.Fecility NwrtN cIf not inititutlon, � sVe9t anE numbar) Sc.City or Town,gtat0,s� 21p Cotle 15tl.CwnH�Death
Rid e Rd 1�Mile Ea t�o�Centerville Rd Carlisle PA �70�5 Cumberland
� 1Be.Ma�Mtl of Olaponition � Burlel Q Cremetlon 18b.Da�e ot Diapoattion lBC.Place W Diaposnlon(Neme o/eemefery,eremetory,or other place7
�, []Removal hom State � Oonatlon
� ome�s n 0 2/"I 1 /201 3ca cM�orHolnly Spri ngs, PA 1 7065
aCa�a+ apoaition ty or ow, tate,an p pnature ��
Mt. Ho11 S arge0
� y prings�PA �' . � i O'1�'1589L
a � i7n Na�„e a.w comdeie naaress o�Funeroi F ci i �
� Ho111ngerFH&Crematory, 50'1 N.Baltimore Ave.Mt.HO1lySprings, PA '17065
� l8.�ecetlent'e ECUCallon-Che k the bwc tM1at best tleeMbea the t9.Decetlent M HlspaMe Oripin-CMeck the box 20.�acedent'a Race-Check ONE OR MORE rneea to intlicate wliet
hlOhaDl tlap�ee o�leval of�chool eomplated at tM1e Iime ot tleatli. V�at bBSt tlaeMbea wheV� 1�0 tlecetlBnt Iw M1e tlecetlanl crnsitleretl M1kneelf or M1erseH lo bG.
Q Bfh preEa vr leaa Cacatlen�s�nol S e[�no.Cheek tM1e"NO"boa�H
Q No WPloma.9lM1-12Lh 9�tle .. PanlaM1MisPanitYLetino. Whifa O
.� Hipfi acM1OOI praCUate w OED crompletetl No,not S Bleck or AMCan AmMean Koraen
Q Som�coRepe erotlit.but no tla � Pen�ahMiapanlclLatino Q qmerfeen Indlan or Aleaka NatNe � ��nameee
OBe Q Vea.Mexitan.M�ICan Ameeicen.Cliicano Anlun Indien 0 OMer Aelen
Q Aasoclate Os9ree(a.fl�/a�As) � Nativs Hawailan
� BeU'fB10Ye Ga Q, ��as.Puarto Rieen CMnase .
O �uamanlan or CM1emortv
prae(e. BA,AB,BS) Q Vea.Cuban Fflipino 3emoan
� MaatBra tlepree e.p.MA.MS,MEnp,MEtl,MSW.MBA) Q Yea,OtM1ar 3penlaM1MispeMGLatlno Jepaneaa Q ONer PacMC IalHntlar
Q Doetorete(a p.PM1D.EtlD) r Profeeelonel tleBree
(e.p.MO,oos,DVM,LL6.JO) (SpecHy) p�rys��gp���
21.Deeedarx'e Sinyla Reca Self-Oealpnatlon-Check ONLY ONE �o Intlicat0 wl�al tM10 tlxeO>nt con9iGa�eU M1lmeeM o�hanBlt lo ba. � 228.�eeeCOM'a Ueual OccupOtlOn-InGICR(ety pe of work
Q��f° O Jepenme O 3emOan tlorx tliarfnp most ofworhinp IHe.DO NOT VSE RETIRED.
BlackwAMCanAmerleHn p Ko,ea„ p o��a�Pa�re�„�a„ee, Maintenance Director
Pij O Amerlean IrWlan or Alaeka Nellva O Vie�nameae O Don't KnowMOt S�re
� Q Aalen Intlian Q Othar Aala� � Refilaetl 22b.Kind of Buainass/InOUStry
� Q CM1ineaa Q Netive Hawailan Q OtM1er(3peeHy) Nur s i n Home
Q F���P��� . . Q OuamBn�an o�CM1amortO �
� a' 230.Oe�e Pronotance0�asd(MO/�ayKh 2'b.S�qnat�e Ot Pa�San P�ono�ncin0 DealM1 Onl wf�en applicebla)
BY PER80N WFIO PRONOUNC63 OR < Y c. cense iam r
CERTFI 3 E �7N � �
23tl.Date 6i9�eG( o/DOyKh 24.Tima of OeetN � .
� � Approx."1'I 00 A_M. zs.wes rneai�i�s.��.,ar or coro�.co.x�ee� rea rio
CAUSE OF DEATH qpproximete
2B. Part 1. Enter zna�„o.s„�«-d�saase..�.,��„ss,o««„w��a<�o.,.-�ne�a��a� �.,ee..,a�:
reapiratory artaet.or venlrlc�la�flbr�llallon witM1O�al eM1Owin tt�e atiolo �'��aetl IM tleath.OO NOT en�l�tertninei evenlf s�ch ee eartllae arraat. Onn![lo DeMM1
g BY-OO NOT ABBREVIATE.Entar oMy orw uuae on a Ilne.AOtl aOtlltlanal lin<a H necesaery
IMMEDIATE CAU3E e Atherosclerotic Cardiovascular Dfseasa
Ce,eiM1)a�s��aa w contlltlon roaulttn0�� �ae t aa a mnsequanca
b.
3puentially Iist eorWitlone,H Due to 0
on Ilr�ie�a�Enter ths�a�ee Itptetl as a eonaeQ�ence o :
UND6RLYINO CAV3E c.
¢ (alaeaee or i J�ry tl�e� � ve to(or as a conaequancp ofl: �
y,� initiatltl tl�p eva/rts reaukinp
� in Geaw) LqgT.
a.
w o
Z6.PeR 11.En1e�otM19r�HIanM t tlltl Mb N t tl th bW not�Ba�ltlng in tM1e unOerlylnq cau B^givm��in Part 1 27.Wae aOn e�nopey pa�adNo
� Remota Myocardial Infarction vo.
ze.were eueooay n.,aio �neme
�, . � como�ece u,e ce�se o9eeaxnv
�. zs.ir Fe..,e�e: ao.o�a rocacco vae conwnvie io oea�n7 0 � vea [g' rio
Q Not preB�ent wXt�in pent yaar Yea 31.Marmer W Dealh
� Q NOropnant e�tima ol tleatM1 Q No � Unkob1wn Q Attitlan[ O PenE np InveDtl Uon
Q pregnani,but prapnenf wltMn 42 tlayn of death � pe
� Q Not preqne�t.but pragnant 43 tlaya to�year beTOro tlea�M1 � Q SWCiCe Q Cwltl not be tlatemilrwtl
32.Date ot Inj�ry(MO/DeyKh(3paN MontM1)
Q Unknown H p�epnant wi✓�In tl�e pant yeer 33.Tme of Injury
34.Place of Injury(e.0�h�e:consvuct�on nite;fartn;ac�ool) 35.Locavon of Injury(Street antl Number,City,Co�nry.Stata.Zip Code)
36.Injury at Work 3>.1/Trenaponetlon Injury,Spacity: 38.Deecribe How InJury Occurr0tl:
O Yee Drivar/Operato� 1p-�-1 PedaaMan
Q No Paseenper LI Other($pacHy)
39e.CsnHier(Check only one):
- Cart In
� Q Hy p ptryalcian-To tha beet of my knowletlpe.tleatv�oe vned tlue fo the ceuee(a)entl mannar ntatetl
_ � Pronounelnp 6 Certlrylnp phyelelan-TO the best of my knowiatlpe, urtaE at Ihe time.tlate.entl pleca.mtl d�e�o the ce�ae(a7 anA mennar ateteG
C Q MBtllcai EwefnineNCOroner-On iMe beala aI examina enC/ ,In my oplMOn.tlea�h oeeurratl at the tlma,Cate.antl place.�C Eue to tha ce�ae(s7 antl mannar atntetl
� ��
� aio�ee�.eorron�nec rmeof�enme.:-Chlef Deoutv Coroner LlcenseNUmber.
¢
_ 39b.Neme,Atltlreu enU�LIO Cotle oT Paraon Complalin0 Cauae of OaatM1(11am 26) 39c.Dete SlpneC(Mp/Day/Yr)
� Matthaw S4onar,Chief Deputy Coronar 6375 Beshora Roatl Suita#�,Machaniceburg,PA�7050 oe�ar„ber y o,2oy s
U 42.R9piaha�f�11B Data(MO/Day/Yh �
40.Repietrafa OlslriM Number 4l.ReglalraYa Slpnature �
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aa.nmanama.,�a
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/�Q�( /�� I H IOSt43
Dlspoaltlon Pertnit NO. `. \ �_�3`b REV 07/2012
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RENU101CIATION � � �:�ry �`; , � ��;
. C.i 3 :.�.:i �
.. » -S� �-� �.:�,.`.Y
`''a C'� . �11 Y� i�
�.`.
REGISTER OF WILLS —� '
' �
N i 4'�
UYY� �Cl COUNTY, PENNSYLV�N�A "`'
� r�a �;,, <.�
� __;.�
Estate of � ���l l�( �i cinard ��Q 1 �Pi/� , Deceased
I� �' d����� � �1e l��_ , in my capacity/relationship as
(Print Name)
_ G�G l)ta Y��.C- of the above Decedent,hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
C'.�r1Q�'1 1-�21 l�
�Z� t�J 2oi �,�.�
(Date)
( nature)
�L� G�-�e.St�n�� S-�
(Street Address)
m+ i-���1u s�p��s� �� �-�c�c��
(Ciry,State,Zip)
Executed in Register's Office Executed out of Register's Office
Sworn to or affirme and subscribed Before the undersigned personally appeared the
bef e me this � I7 t� day party executing this renunciation and certified
of ;�?I! ,c��, that he or she executed the renunciation for the
purposes stated within on this day
of
,
�
� � '
eputy for Register of Wills Notary Public
My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration ofNotary's Commission.)
Form RW-06 rev. 10.13.06