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Home My WebLink About01-27-14 (2) PETITION FOR GRA�1T OF LETTERS REGISTER OF WILLS OF � J,�i�Zt��-- 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 21 _ �, /. �Q� Name• � ' File No• �7 � a/k/a: � (Assigned by Register) a/k/a: a/k/a: Social Security No: �� ' ��{�-�f�d Date of Death: "��fT o 1 �, Age at death: �'„? Decedent was domici t death in County, �;U , (Srure)with his/her last principal residence at � Street address,Post OfGce and Zip Code �7�� City,Township or orough County Decedent died at� �� . Stree address,Post Office and Zip Cod City,Tow ship or Borough County State Estimate of value of decedent's property at death: t�/ If domiciled in Pennsylvania.......... .................. All personal properry �/j_� (,'-b'0 ,_(10 If�sot domici[ed in Pennsylvania. .................. ... .. Personal property in Pennsylvania $ - I�'not domiciled in Pennsylvania. .................. ..... Personal property in County ��,�,,,, . y.�-- va[ue of real estate in Pennsylvania.... .............................. .......... ............. $�� TOTAL ESTIMATED VALUE. ... $ i � nrn Real estate in Pennsylvania situated at: (A�tach udditional sheeu,i/'necessary.) Street add ,Post Office and Zip Code City,Township or Barough County � A. Petition for Probate and Grant of Letters Testamentarv c� Petitioner(s)aver(s)he/she/they is/are the ExecuCOr(s)named in the last Will of the Decedent,dat � !J and Codicil(s) tliereto dated [ � � / State rele nt circm tances(e.g.renunciation,dealh of execidor,etc.) � F.xcept as follows: after the execution of the instrument(s)offered for probate Decedent did not marry,was not divorced,was not a party to a pending divorce proceeding wl�erein the grounds for divorce had been established as defined in 23 Pa. C.S. §3323(g),and did not have a child born or adopted;and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. [�NO EXCEPTIONS ❑EXCEPTIONS n � � rn a c� � B. Petition for Grant of Letters of Administration (Ifapplicable) co � -"�x� � �' c.t.u.,d.6.n., d.b.n.c.t.a.,pendente�,�c�abse�iu,dtsC��minoritute n r" rv f;r� �,s If Administration,c.t.a. or d.b.n.at.a.,enter date of Will in Section A above and��ii�e�e list-�f hetr�s.r� Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds foCdiv�or,ce h d bee�r+estab�he�as defined in 23�a.C.S.§3323(g)and was neither the victim of a killing nor ever adjudicated an incapacitated per�pr��> =� � -�`� i v :� .: G� [C�NO�XCEPTIONS �EXCEPTIONS _ �.� F-' E" r� ' �_ Petitioner(s),after a proper search has/have ascertaiued that Decedent left no Will and was survived by the�llowing spou�,�f an}�i;A�irs(attuch udditio�sul sheets, if necessury): � Name Relationshi Address F��-��,Rw-oz ��v.�niuiznii Page 1 of 2 Oath of Personal Representative Official Usc Only COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF } Petitioner(s)Printed Name Petitioner(s)Printed Address � � !� I I l�`e�'.�4 �1 .�*. '-:�57 /�iC'��'-�c�GM r,�- /��a�3 Tl;e 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)azid that,as Personal Representative(s)of the�cedent,tlie Petitione s)w� well and truly administer the estate according to law. Sworn to o �f'firm�d and subscribed befor � : � � a Da '��7 L,� me i �fi`�da , i' D't By: Date For the Register Date BOND Required:�YES �NO To the Register of Wills: FEES: Please enter my appearance by my signature below: �� '-- G'� �=� � Letters . . . . . . . . . . . . . . . . . . . . . . $ . Attorney Signature: C, � n ( ) Sliort Certificate(s). . . . . . � � � � � � p3 � —.> !I7 ( )Renunciation(s).. . . . . . . . � ` .—; � � ) Codicil(s). . . . . . . . . . . . . �7 � r'" N r�? �:3 ( )Affidavit(s).. . . . . . . . . . . � �' i� :� C, '� Bond.. . . . . . . . . . . . . . . . . . . . . . . Printed Name: :+.. - � -� -w� -ei Commission. . . . . . . . . . . . . . . . . . Supreme Court 'm, `= . ' � �?"�. --� f-.� C..� ..�_� __ .�? .._. ,. Other . . . . . . . . ID Number: �{ � ��rb . . . . . . � __; � c� . . . . . . . . . Firm Name: "'� °� � �� r � . . . . . . . . ^• Address: � . . . . . . . . Phone: Automation Fee. . . . . . . . . . . . . . . Fax: JrS Fee. . . . . . . . . . . . . . . . . . . . . • Email: TOTAL. . . . . . . . . . . . . . . . . . . . . $ DECREE OF THE REGISTER Estate of �I I ZG�U�� K. 1 1 �'e � � � File No: Q�� — �y' �� a/k/a: AND NOW, � ,o��' in considera ion of the foregoing Petition, satisfactory proof having been presented before me,IT DECREED that Letters are hereby granted to � in the abo e e�tate,and(if applicablel that the instruinent(s)dated ll�l(—l.� Q� g described in the Petition be admitted to pi ate and filed of record�s the last Will (and Codicil(s))of Decedent. egister of Will Fo,,,�aw-oa ,��v. ioiiriznti Page 2 of 2 H105.805 REV(9/11) LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. �ECa�r�� o��cc� oF Fee for this certificate, $6.00 ��l�� f �'?►�S ,,,��""""'�---- This is to certify that the information here given is �� ,1H OF p"' �_ � ,,��'��,a Fiy�y-_ correctly copied�rom an original Certificate of Death �_+�y �� 2� �Jm � y �,�� __ `fl; duly filed with me as Local Registrar. The original � < <3 ?o =� -:� z; certificate will be forwarded to the State Vital �L��K �� ;* y�� a� Records Office for permanent filing. , . , *; i ' P 2 019 4 � �A��Ha�t s� c o u�; O��'�9TMENT OF,��`P°? \' c'.� � % � � a� ��o, _17�1 rn+ `!� rt '� Certification Number L��i�� G�•. �/� "'��""" Local R gis ar Date Issued �. , \ , Type/Print In COMMONWEALTH OF PENNSVLVANIA�OEPARTMENT OF HEAITH�VITAL RECOROS Pef'"a"e"` CERTIFICATE OF �EATH Black Ink State Flle Number: 1.�ecedenc's Legal Name(First,Middl¢,Last,Suffix) 2.5¢x 3.Social Security Number 4.�ate of Deaih(MO/�ay/Yr)(Spell Mo) �.Q.�za.b�th R. W-i.rce�a.nd �ema,2.e 7 81-74-0900 Nove.mben 26 201 3 Sa.Age-LasC BiKhday(Vrs) Sb.Untler 3 Vear Sc.Under 1 Oa 6.Daie of Birth(MO/�ay/V¢ar)(Speil Month) 7a.Birthplace(City antl Stat¢or Forei��COUntry) _�, Months Days Hours Minutes iZoa.�c.i.n s �4C.YL 92 Ma.y 13, 1927 7b.Birthplace�co�,.cY> gQQ.�h. Sa.Residence(Sta2e or ForelQn Country) 8b.Resitlence(Street and Number-Inclutle Apc No.) 8c.Did Decedent Live in a TownshipT Pen.ree .Q.VQYLf.Q �Ves,decedeni Ilvetl in twp. sa.Resiae��e tco�„iv� 7 700 Ma.hFze� SX'h.e.¢x Cumbele.2a.nd 8e.Resitlence(Zip Code) No,decetlen[lived within limits of Camp H'L'e.� city/boro. 9.Ever in US Armed Forces? SO.Marital Status ai Time of�eath O Married !Jd W�tlowed 11.SurvWing Spouse's Name(If wife,give name prio�<o first ma�riage) �Yes ,�] No �Unknown � Olvorcetl � Never Marrled �Unknow 12.Fafher's Name(Firsx,Mitltlle,Last S�ffix) 13.Moiher's Name Prior to Firsi Marriagg(First,Middle,Last) A.es�ced Huclean O#tcc i{..eba.�g�-rz 14a.Informant's Name 14b.Relationship�o�ecetlent 14c.Informant's Malling Atltlress(Street and Number,Clty,State.2Ip Code) Ja.n.iee �_ Ma Da.cc lite�e 21 3 �he.e.dom S�aeex �a.d� Fice.e_dom PA J 6637 C, _ _ _ _ _ _ _ _ _ _ _ _isa.a ace o oeax c ac on Yone _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ If�eath Occurred in a Hospifal: �� Inpailent �If O¢ath Occ��red Somewher¢Other Than a Hospital d Hospice Faclli[y Z7 Decedenc's Home ° � Em¢rgency Room/OUtpaiient 0 Dead on Arrival � [g(Nursing Home/LOng-Term Care FacillYy �Other(Specify) og ISb.Facilify Name(If not institu[lon,give street and number) SSc.City or Town,State,a d Zip Code - SSd.County of O¢ath Ma.na�cCa.he - Cam H-i,-P� Cam H.i_.e.e �PA 17011 Cumbe.h.Zand 36a.Meihod of Disposition Burial � Cr¢matlon 16b.�ate of�ISposltion 16c.Place of Dispositlon(Nam¢of cemetery,crematory,or other place) O Removal from Siate � Oonation :� o Other(Specify) 7 2/02/207 3 Ghe.e_n.eawn Cem�t2hy � 16d.Locailon of Disposition(Ciiy or Town,Sfac¢,and Zip) 17a.Signature of Funeral Service lice�se¢ n In Charge of Iniermeni S7b.Licens¢Number $ Roecic.�n S �e.i.vt AA 16673 f FS O15334 � 1JC �aTodd�Ty�eT T�i.am�aarcra�u.neaa.Z Hame Zvec., 734 New SZ�cee�, Rowc-i n S �r..�n. PA 1 6673 18.Deced¢nt's Educaiion-Check the box�hai best tlescribes the 19.�ecedent of Hlspanic Origin-Cl�eck tl�e 20.Decedent's Race-Check ONE OR MORE ra s to indicate what '- highest deg�ee or level of school completed at the time of tleath. box that best describes whether the tleceden� he decetlent considered himself o�herself to be. 0 Sth gratle or less is Spanish/Hispanic/Latino. Check the"NO" �WhiSe 0 Korean 0 No diploma,9th-12th grade box if decedent is not Spanish/Hispanic/La[ino. � Black or African American � Vietnamese � High school gratluate or GED completed f�'No,not Spanish/Hispanlc/Latino �American Intlian or Alaska Naiive O Other Aslan 0 Some college credli,but no tlegree �Ves,Mexican,Mexican Amerlcan,Chicano O Asian Indian O Native Hawallan [� AssociaSe degree(e.g.AA,AS) �Ves,Puerio Rican O Chinese O Guamaniari or Chamorro 0 Bachelor's degree(e.g.BA,AB,BS) � Ves,Cuban O Filipino O Samoan � Master's degr¢e(e.g.MA,M5,MEng,MEd,MSW,MBA) � Yes,oiher Spanish/Hispanic/Latino O lapanese O Other Pacific Islantler O Dociorate(e.g.PhO,EdD)or Professionai d¢gree (Specify) O Other(Specify) .MD DDS,DVM LLB JD 21.Decedent's Single ftace Self-Designailon-Check ONLY ONE to intlicate what the tlecedent considered himself or herself to be. 22a.�ecetlent's Usual Occupation-Indicate type of work ,�Wlilte �Japanese � Samoan done tlu�ing most of w`o`�king life. �O NOT USE RETIREO. � Black or African American O Korean � OSher Pacific Islander $O�rGr<ee Q�L � American Indian o�Alaska Native 0 Vleinamese O �on't Know/NOt Sure p � 0 Aslan Intlian O�ther Aslan p Refused 22b.Kind of Business/Indusiry � O Chinese O Native Hawailan O OtFier(Specify) � Filipino � Guamanian or Chamorro `+Q� a ITEMS 23a-23d MUST BE COMPIETED 23a.Oai Pronoun etl Dead(MO Day/Vr) 23b SignaCUre of Person Pron In eath(Only wh¢n applicable 23c.License Number BV PERSON WHO PRONOUNCES OR /� 2 ^ � ^ �� CERTIFIES DEATH L� �'� �✓ � J ��1�� c T - �� K 3� zsa.o x s�sne (mo/oay/vr) za.ri.,,e of oeaxn !�r �� Z�j �2 �\'� � �_?j� 25.Was Medi<dl Examiner or Coroner Contacfed7 � Ves No CAUSE OF UEATH Approximate 26.Part 1. Enter tlie chain of e ents--tliseases,injurles,or complicatlons--that directly caused ihe d¢ath. DO NOT enter terminal evenis sucl�as cardlac arrest, Inierval: respiratory arrest,or ventricular fibrillation with�howing the etio�ogy. DO NOT ABBREVIATE. Enter only one cause on a Ifne. Add addiilonal Ilnes if necessary. 1 Onset to Death � � IMMEOIATE CAUSE ---------------> a. N�.1/KOALO�.,�� (Final disease o ontlltbn Due to(o as a consequence of): � resulting in death) b. � Sequ ntlally Ilsf c nd�tlons, �ue to(or as a consaq�ence of): if any,leatling�o She cause listed on line a. Enter the UNDERLYING CAUSE Oue to(or as a consequence of): , (disease or InJury that � LL 'nifiaietl ihe evenis resulting tl. 1 � V In tleath)LAST. �ue to(or as a consequ¢nce of): 5 � � s 26.Part 11. Enter other si¢nif'can[contlitions coniribuiin¢[o death buf not resulting In the under�ying cau e given in Part 1. 27.Was an autopsy performedi � - � Ves .B� No � 28.Were autopsy findings available � m to complete the cause of tleath7 � � O Ves .� No 29.If Female: 30.�id Tobacco Use Contribute to�eaihT 31.M�an�¢ of Death So �ot pregnani within past year � Ves O Probabiy .�NaTUral 0 Homicitle � 0 Pregnant at[ime of death � � No �nknown � Accident O Pentling Investigation �' �� Noi pregnant,but pregnant within 42 days of death 0 Suicide � Could not be determined r � Not pregnant,but pregnant 43 days to 1 year before dea[h 32.�a(e of Injury(MO/�ay/Vr)(Spell MonSh) `-�1 `� 0 Unknown if pregnant within the pasf year 33.Time of Inj�ry W 34.Place of Injury(e.g.home;construction site;farm;school) 35.Location of Injury(STreet and Numbe�,City,County,State,Zip Code) ^ 36.Inj�ry a[Work 3'l.If Transportaiion Injury,Specify: 38.�escribe How Injury Occurred: '�� Ves O Driver/Ope�aior 0 Petlest�ian � O No O Passenger 0 Other(Specify) 39a. rtifi¢r-physician rttfied nurse practiiloner,medical ezaminer/coroner(Ch¢ck only one): ,_� Certifying only-To th¢best of my knowletlge,death occurred due to the cause(s)and mann r statetl. � Pronouncing 8a Certifying-To the besx of my knowletlge,death occurred at the Sime,date,antl place,and due So ihe cause(s)and manner staYetl. � O Medical Examiner/COroner-On e basis of examinatlon antl/or Investigafion,in my opinion,d¢ath oc�c�uIr��/�{J af ihe time,date,antl place,and due co the cta/u,s�e(s)a d'cnn^�scated. z Signature of certifier�� Title of certifier: • �/ License Number: ^i/��/LO �x��'L t � 39b.Nam¢,Atltlress antl Zip Cotle of P¢rson Completing Cause of�eaih(ISem 26) 39c.Oate Signetl(MO/Day/Yr) � �r:� �- 8: d�r- .�90 o Iwr- c�.u.�� .! L.c..-� l�-;1I /`7 �i /� 2 / 40.Fegistrar's District Number 41.R istrar's SlgnaTVre 42.Regis�rar File Daie Mo Day r) �t a �-0$7 �_- �.� ._ 1� \'�7 \ a�13 � 43.Amendments � O 9 6 4$O 8 `+ios-ias Disposition Permi�No. REV O]/2012 ' , . . � � � rn � � � � o � _ - , - � _ - rn � � � ..�.{ c�-� � .�. �� - r ��'°r--� 9'� �a�_.1��-- �� _� � � � '� � `� _ - _- - F—- � F = by the above-named Testatrix in the presence of us, who in her presence and at her request and in the presence of each other, have subscribed our names as witnesses thereto. �U`• � ��°,� ' � 1��.;- OATH OF NON-SUBSCRIBING WITNESS(ES) REGISTER OF WILLS .t.��n�'a�--�- COUNTY, PENNSYLVANIA � �/� � /� Estate of 2��-�+�- ��.�1 �� , Deceased �=- � � r - �� and CM.c., � , , t—c. , �sdch) being duly qu�ified acco ding to law, depose(s) and say(s) that she/he/they was/were well- acquainted with � - ��z�,`��, and am/are familiar with the handwriting an signature of the decedent, and that the signature of �� l(/�� J - to the foregoing instrument purporting to be the Last Will and Testament/Codicil of � is in his/her own proper handwriting. ;`�G � , �,r {S/g�iature) (Sign ture) `'� �-��C� �� + 3 1�,�.��-, �� b ress) �;I� (Street Address) �`�l .3 �� u ar- Q � � (C�ty, tate,Z�p) (City,S�ate,Zip) Executed in Register's Office � _ � �3 rn Sworn to or affirmed a�d subscribed � � � � � before me this oC��1 day r�n � r� `' �' � � z,, r tv r.r� r°7 �[ r � rx', � � � of ��1� ��L� m u, �� LJ �= ��: G, c�� -� -.� ��., • � c� �-� � ca r,� ._z, - c:� �:�: +.�.: r:> � ;i7 t—` �°., i��'1 eputy f �p�gi v �i -,� `�`% c� ��,,,q�"�� G..� � FormRW-04 rev. l0.13.0(