HomeMy WebLinkAbout03-05-14 (2) REGISTER OF WILLS
CUMBERLAND COUNTY PENNSYLVANIA
SMALL ESTATES AFFIDAVIT
For Insurance Proceeds
NOT to be used for Settlement of Small Estates under 20 Pa CSA 53102
/ � '��' //(Original Death Certificate Must Accompany this Form) // l/
Deceased V Dl� t ..'...... 1"C.GG h l ...__ .... Docket No. S _7r� 7`Q
also known as .h, _ f��/,C,(l'(/ ,,,1..,,.h �j�, Social Security No c`Q - /{7,,sr7
Before the Register of Wills of said County personally campeQr'lQ�y lG7tf JC/q,( rL!!r,, who resides
at j7251 S7�. ..... being duly sworn,
deposes nd says that / ,._.,f] t age a� ,a resident of
/Q � . I�L.<?eAe�yniiCSbur� f']1 L_7066 .. ...__. ..... .. ......... ,
in said County,departed this life,at /,vl� s�/F_,`f NasPif'CZ / on the 6 fh day of
A.D.20 /p . .7,'_y _..,.__,_ o'clock P_ M.,possessed of personal
property estimated to be of the value of$ gyp, tf ,and possessed of real estate,the estimated value
and the location of which is as follows:
u
Except as follows,Decedent did not marry,was not divorced,and did not have a child born or adopted after execution cMQ Z r
testamentary writings whether or not offered for probate;was not the victim of a killing, was never adjudicated an inc>, led
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person,and was not a party to a pending divorce proceeding at the time of death wherein grounds for divorce had been �fished as
defined in 23 PA C.S.se cfo �s 1 r-n
(g): /V
3323 9 Z V' .
p� ».�L-S
The total amount of insurance proceeds payable by6elh-o hf/r //hQn[,12 / does not exceed$11,000 and 60 day vetelapsed �' _
since the death of the insured.The undersigned agrees payment cannot be made under this Affidavit if a written claim f03�am7e has beet -:"CC� •
made by a Personal Representative of the estate and no other heir(s)having preference exist or have released their ben� .uytsthe O F r'n
undersigned. /� �// E',>Q
That said decedent left a spouse-whose name and residence is / 1 a(rll PV r.tc1...Q Kcu h_t-
>o [6ES4(/JCK Prire� 1 chatiicshura PA /Z2M /
and the following as next of kin: (use additional sheet if required)
NAMES RELATIONSHIP RESIDENCE
j Pcu SO/2 232 CA ?SK4?3
flrc �' dau fifer ar G r -10y
That the.above named are 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 ARY.
Signed
By. (J��
Sworn and subscribed to before me this�j
day of Mr
C_h -NO qr
JlJ Register of Wills:
eKindly enter appearance in the above case this
U day of ,20
. . Nelacy-Plic
I.D.No.
Attorney
ty try
AT RFA1EMBERE that as of the Jam ' day of WW1 a ti�— A.D.20/yt
rere ha;*een N(tRSTATE PROCEEDING RAISED FOR THIS DECEDENT AND NO LETTERS HAVE
' &ESN If ED B @S COURT.
E , )G
Z
`c�` Lisa M. Grayson, Es .
0-- Lr7 Register of Wills&Clerk of Orphans'
,�.,� My Commission Expires First Monday,January,2018