HomeMy WebLinkAbout02-16-05
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate o[ Joanne Mae Campbell
also known as
No. c2/-() 'J - o/s-t1
To:
Deceased.
Register of Wills for the
County of Cumberland in the
Commonwealth of Pennsylvania
Social Security No. 199-34-8737
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, applies
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decendent was domiciled at death in Cumberland County, Pennsylvania, with
her lastfamilyorprincipalresidenceat 222 Sprinq Ln., East pennsboro T,,!p.
(list street, number and municipality)
Decendent, then 59
at
years of age, died January 11
,2t~0 5
Oecendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$ 500
$
$
$0
Petitioner_ after a proper search hlL- ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name
Annette Sheel
Relationship
Daughter
Hill
Thomas Paul Heckert Son
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF Q.UXY\ '001\ \ n .,cI
} ss
The petitioner(s) above-named swear(s) or affirm(s) that 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 above decedent petitioner(s) will well and
truly administer the estate according to law. ~,
Sworn to or affir~t. and subscribed I ~)l0}>>L5l~)1-/
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No. ~1-O~-OI:l9
Estate of ~Xl ~ '-1\\n.>> ~ (j 1YI,oh.. 21 , Deceased
GRANT OF LETTERS OF ADMINISTRATION
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AND NOW
the reverse side hereof,
IT IS DECREED that
is/are entitled to Letters of Administration, and in accord wi
MI_, in consideration of the petition on
pres ted before me,
such finding, Letters of Administration
,)i,Ciln Ql0
..,
(~ ,,,1,'40
I
are hereby granted to ~ AI iti 0 D
in the estate Of%-::O " n' '---mo. 0
Gw *~~ __1J;J;:ES 5"". el\)
Letters or Aamfursttatron ..... ~ ,{Xl
Short Certificates( )...,...... $J;? (JI)
Renunciation ................ $ .OD
)QP $~1.(~
TOTAL _ $ 0.0
Filed ct:.\.El-. .Q. 5:........ A.D. ~_
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
RENUNCIATION
,;) J - D~- () /5'1
Joanne Mae Campbell
In Re Estate of
deceased.
To the Register of Wills of Cumber land
County, Pennsylvania.
The undersigned Thomas Paul Heckert
of
the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters
b. ed t Annette Sheely
e,ssu 0 (.l ~;). 7
WITNESS{b.' 0/ ~
hand this / V: -14. day oifbv'0 ,8005".
~ faJ. IJuW
(Signature)
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'is 21 Er hnJ Qd.
(Address)
G.,",,? It ll. Ilo II
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(Signature)
(Add",,)
(Signature)
(Address)
~j hi-- i~ to cerlifv that the information here given is correctly copied from an original certificate of death duly filed with me as
LW,JI Rcgistra/ The original certificate \\-'ill be t"or\\'arded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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Local Registrar
Fee for this cel1ificate. $2.00
P 10899636
JAN 1 3 Z005
Date
,-.',
i-<e.,2/67
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
o
NAME OF OECEDENT (First, Middle, Lilst) SEX ~ I :OCIAL SECURITY NUMBER DATE OF DEATH (Mo~lh. Day. Year)
L Joanne M. Campbell 2. Female 3.199 - 34- 8737 . 1/11/05
AGE (LasIBirthday) NO R1 " UN 1 AY DATE OF BIRTH BIRTHPLACE (City and P ACEOFD ATH hckonl " int Uo~ thri
Monlhs I DilYs Hours Minutes It (Month,Day, Yeilr) Stale or Foreig~ Countf}') HOSPITAl IOTHE"
59 Y~ 2/2/45 Pittsburgh,Pa Inp.~.nl !XI E"IOYlpah.nlD DOAD NY...m~ 0 RaoidancaD ~~:~fy) 0
, e. ,. e, -.
COUNTY OF DEATH CITY. BORO, TWPOF DEATH [ACllITY NAME (if nOllnslilulio~. give slreel ami number) I~:S DECEDENT OF HISPANIC ORIGiN? I~CE - Amarican I~dian. Blade, While, et
Dauphin Derry Twp. 6d. M.S. Hershey Medical Center Nol[] Yes Q II yes. specify Cuban. (Spedly),
Ob Mexlclln.Pue Ric8n.elc_ Whlte
eo. ".
DECEDENT'S USUAL OCCUPATION KINO OF BUSINESS /INDUSTRY AS DECEDENT EVER IN (S~~~~~~~'Y~~I~~,.t.1~~~e~dl MARITAL STATUS. Uilrried, SURVIVING SPOUSE
(1~t":o":.~oIi~:" ~ ~r~~,';:t US. ARMED FORCES? Never Married. Wldowe-d. (Kwil',gi....mal<lannarna)
YltSD No[li EI.manLo'Yisocondo'YJpk Collego OIVQfced(Specify)
Secretarial u. (0_121 U k (l-4o<S+) Widow
1b. 11b. 12. ". ".
DECEDENT'S MAILING ADDRESS (Street. CilyfTown. Slale. ZiP Code) DECEDENT'S 17a. Slale Pennsvlvaniaoid ~ Yes,decedent~vedi~ East pennsboro
ACTUAL 1k <wp
RESIDENCE decedent
222 Spring Lane (Seeinslructions courll"cumberland livelna l1d.D No. decedenl lived
16. -, n. 1.,n')c 00 oIher side) 17b. township? wilhinactuillllmilsof cilylbofo
FATHER'S NAME~Firsl. Middill. Last) Robert Campbell MOTHER'S NAME (First, Middle, Uaiden Surname)
16. 16 Mary Murdock
INFOfIMANT'S NAME (Type/Print) Sheely ~:~~R~OS M~L~NG ~D8r~ (s~er' ~itY~nfple, if f11 ,
20.,. Annette Pa
METHOD OF DiSPOSITiON ] I DATE OF DISPOSITION PLACE OF DISPOSITION- Name of Cemetef}', Crematory DJ:OCATION - CityfTown, Slata, Zip Code
OooationD Burial DCremillion ~emovillfromStille 0 (Monlh Do~ v..,) or other Piece
2101. Olllar(Specily) o 21b Jan 13 2005 21c. Evans Eagle Crematio 21d. Leola, Pa
SIGNATURE Of m~ SER'9CE Llf~~Eltt PERSON ACTING AS SUCH LICENSE NUMBER I ~AME AND ADDRESS OF FACILITY
n, C II 11""- 22b, F.D 011897-L 22<:. Sullivan FH 51 N. Enola Dr Enola Pa
Complele items :~tOnIY wtlan certifying TolheoostofmylmoW'iedge,dllalhoa;urred atlhetime, date and place stated LICENSE NUMBER I~ATESIGNED
physicianisnotava bJealtimeofdeathlo (Signature and Titie) (Monlh, OilY, Year)
cl!rlllycausaofdealh 23a. 23b. 23...
Items 24-26 must ba cOlTlpleted by TIME OF DEATH I I DATE PRONOUNCED DEAD (Monlh. Day, Year) WAS CASE ""E""EO '~L EXAM,"E" 'CO"O':Z(
person who pronouncesdeaUl. 1'2.')-'b ~M. 25. -~""'"V \I. }.COo;"" 26. Yes No
24.
27. PART I: Enho'lh.di......, InJu,I.."'compllc'~on. which <auo.dlh. d.alh. Do nol~Ia'u.. modo 01 d~ln~. ."ch.. cortli.c 0' 'aopl'alo'1."a.~ .hoo~ or hurt lollu,.. : Appro~imale PART~:
ar signi\icillll wIldltions contribuling 10 death, bul
U.lonlyoftac."..onaochlin.. ,intervalbetwae~ notresultinginlheunde.-1yl~gcausegivenlnPARTI.
IMMEDIATE CAUSE (Finel (\,,,J : onset and dealh
JiseaseOf coodition . Q,-..a';' ,v\"""',"^" : iyl.",,~ iI,,~-I D~ tI,(~tJ.;.IMJ,Z.
'e"ulli~gindealh)_ ~:;~ASA>JC;~UENCEOF)
Sequenlially li&l conditions L w,,\O '7)J 1
"any.leadi~gtoimm&diale DIJETO(';""ASA&\ENC~Of'~
cause. Enler UNDERLYING Awl<. "". 1\01>'"
CAUSE(DiseaseOfinjury
lhaliniliilledevenls ~ TO (O~",S A :(tSEOOENCE OF) :
'eslJlli~g ondealh) LAST .~ ",.}-'\))I.
WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED
PERFORMED? AVAILABLE PRIOR TO ,0' l~onlh,Day.Ve"1
COMPLETION OF CAUSE Natural Homicida 0
OF DEATH? Yes 0 NoO
Accide~l 0 Pe~d;ng Investigation 0
Yes..e::l NoD Y",,0 NoO 0 0 30a. 30b. M 3" 30d.
Suicide Could~olbedetermi~ed PLACE OF INJURY I LOCATION (Street. CilyfTown, State)
building,.IO, (Specify) Att'onl<l, farm,sl,eel.laclof}'. office
2h. 26b. ". ", 30f.
CERTIFIER {Check only one) SIGNAl? x:~ OF CERTIFIER
'l~~~F~~I~r~~t:I~~~.lf~l.s.f.::rh~~~~i::'~a~u:: I~ rhe:~..';'i~:~(:r~~tJ~X~i;~il~. h:I~!:~.\~~~.~~.~ .~~~~~. ~~.~ .:~.~~.~~~.~ .i:~.r.~ ,~~~ ...............1'" 31b. vCA.---
/ LICENSE NUMI~~~: I DATE S'17E~ r,onlh. Day. Year)
.PRONOUNCING AND CERTIFYING PHYSICIAN (Physician bOlh pronO<Jnc;ng dealh a~d cenitylng to cause 0' daath) ...................0 ", .."f"1 iZ-l. 31d. , I oS-
To Ih. b..l 01 my knowledg., d...lho....u....d III Ih.. tim.., dat.. and plac.. ,ilnddu.loth...au...(.)andmann.ra....ilt.d.
'MEDICAL EXAMINER/CORONER NAME AND ADDRESS 01; PERSOl1 WHO COMPLETED CAUSE OF DEATH
On the baai. 01 examination and/or InV..Uglltlon, In my opinion. death o....urr.d iltlh.. lima, daM, and pill.... and due 10 the c.......(., and (Itl!m27)TypeorPn~1 /1hJ UiJIl-v~
milnnaralltat.d.. 0 }1.S. Hershey Medical Center Hershey, PA 17033
". 3.
REtfI'~S SIGNA,EAN2),!!!1'8ER IA Jo?/I/I ~/1ED (Month. Day. Year)
'" ~l-- ~~~r- 3 ~ / '" 4 A ~ ..--
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CERTIFICATE OF DEATH
STATE FllENUMBE"
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