HomeMy WebLinkAbout03-05-14 REGISTER OF WILLS
CUMBERLAND COUNTY PENNSYLVANIA
SMALL ESTATES AFFIDAVIT
For Insurance Proceeds
NOT to be used for S ttlement of mall Estates under 26 Piff.G&A 53-10-2
(Original Death Certificate Must Accompany this Form)
Deceased Docket No.
also known as
Social Security No
Before the Register of Wills of said County personally came Me'ty, 1 tL7fJ,i14? who resides
at /[�S�/hfk Ar/�/.a 6ee being duty sworn,
M- 1 ............. .........
depose d that age -t
a resident of
in said County,departed this life,at
on the -14 day of
A.D.20 /9 o'clock . P M,,possessed of personal
- -
property estimated to be of the value of$ and possessed of real estate,the estimated value
and the location of which is as follows:
Except as follows,Decedent did not marry,was not divorced,and did not have a child born or adopted after execution(me
testamentary writings whether or not offered for probate;was not the victim of a killing, was never adjudicated an me# led :ta-
I M
person,and was not a party to a pending divorce proceeding at the time of death"herein grounds for divorce bad been ighed as
defined in 23 PA CS.section tLn -Z)C)
3323(8): Ay 0
The total amount of insurance proceeds payable by(geZ��/ does not exceed$11,000 and 60 daythyLvielairsed
since the death of the insured.The undersigned agrees payment cannot be made under this Affidavit if a written claim ftD ' e has bee
made by a Personal Representative of the estate and no other heir(s)having preference exist or have released their benefits. ithe CJ p;;
undersigned.
That said decedent left a spouse—whose name and residence is
�O MeChoALc5hz-,kq PA 170-5o ..........4.
...... ....................I'll,.......... --------- ........ ------ -----_ ........
and the following as next of kin: (use additional sheet i re aired
NAMES RELATIONSHIP RESIDENCE
11 l,t""c a 150A 0-40,2 bl,�eplrle rral2clscn C,4 ?fQu
&wl 4 y 0 7t2S
That the above owned we 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 KNOWN PROBATABLE ASSETS that would require an estate proceeding.
Therefore,NO ESTATE WILL BE RAISED,AND LETTERS ARE NOT NEC A RY
Signed
By:
Sworn and subscribed to before me this
��ho ly
day of . Register of Wills:
Kindly enter appearance in the above case this
day of -,20 --------
C I.D.No.
Attorney
BE IT REMEMBERED,that as of the day of A.D.20
There has been NO ESTATE PROCEEDING RAISED FOR THIS DECEDENT AND NO LETTERS HAVE
BEEN ISSUED BY THIS COURT.
Lisa M. Grayson, Esq.
Register of Wills&Clerk of Orphans'Court
My Commission Expires First Monday,January,2018