HomeMy WebLinkAbout04-04-05
Estate of ANNA A. BROON
also known as
CUMBERLAND
Register of Wills of ~ County, Pennsylvania
PETITION FOR GRANT OF LETTER
No. Zl-05-0323
, Deceased
Social Security No. 185-01-0536
Date of Birth
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE "A" or "B" BELOW:) .
o A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut_ named in the Last
Will ofthe Decedent, dated and codicils(s) date
Slale relevant circumstances, e.g., renunciation, death of executor, etc.
Except as follows: Decedent did not marry, was not divorced, and did not have a child born' or adopted after exec'ution of
the documents offered for probate; was not the victim of a killing and was never adjudicated incapacitated:
6a B. Grant of Letters of Administration
(d.b.n.c.La; pendete lite; durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and Was survived by the foHowing
('f ) d h .
spouse 1 any an elrs:
I Name Relationship Residence I
PATRICIA B. HALLOCK DAUGHTER 3763 PRES'IDN LANE
CENTER VALLEY, PA 18034
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(COMPLETEIN ALL CASES:) Attach addItIonal sheets tfnecessary.
CUMBERLAND
Decedent was domiciled at death in ~ County, Pennsylvania,
residence at
4905 EAST TRINDLE ROAD, MECHANICSBURG, PA 17055
(list street. number and municipality)
Decedent, then ~ years of age, died December 3, 20q'ht CAMP HILL, PA
(Location) .
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with his/her last J~ily ~.~ pririciMl
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Decedent at death owned property with estimated values as follows:
(If domiciled in P A) All personal property
(If not domiciled in P A) Personal property in Pennsylvania
(If not domiciled in P A) Personal property in County
Value of real estate in Pennsylvania
(,.)
..;:-
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$
$
$
$
175,000.00
situated as follows: YORK ROAD, MONAGHAN 'IU'VNSHIP ID: 380-000-0D-0092-Ao-OOOOOO
Wherefore, Petitioner(s) respectfully request(s) the probate of the Last Will and Codicil(s) presented with this
Petition and the ant of letters in the a ro nate form to the undersigned:
T ed or rioted name and residence
3763 PRES'lDN LANE, CENTER VALLEY, PA 18034
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Lehigh '
The Petitioner(s) above-named swear(s) or affirm(s) that the statement in the foregoing Petition are true
and correct to the best of the knowledge and belief ofPetitioner(s) and that, as Personal Representative(s) of the
Decedent, Petitioner(s) will well an trul administer the estate according to law.
S.S.#
Sworn to or affirmed and subscribed
before me this ~k day of
-'iYt{~ , 20 or
S.S.#
~4vr.~
For the Register
Tel. #
. S.S.#
Tel. #
No. 2/-05-03L5
Estate of At-J f\f A A. J3Ro WtJ
Social Security No.: 1~5-01- 053l.P
AND NOW, '1/rr / 05. , 20_. in consideration of the P~tif,id6 on~ite re~
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side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letter~ 0 Te~eri~.;
C.Jl
A Of Administration (d.b.n.c.i.a.; pendente Hie, durante absentia, dunantic minoritate)
are hereby granted to \fJ1I rffi e I /f- 8. i/r;li(}~
in the above' estate and that the instrument(s) dated
described in the Petition be admitted t~ probate and filed of record as the Last Will of the Decedent.
Date of Death:
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Fees
Lellers ........... .... .........$ & ~O. zg
Short Certificate(s).....$ O.
Renunciation ..............$
Affidavits ( )...........$
Extra Pages ( ) ........$
Codicil..... ...................$
JCP Fee ......................$
Inventory ....................$ 'fJ. D D
Tax Rett)f1} .......r......$
Other ..H:.u.w.......:.....$ ~:B 0
TOTAL :...........:$ ~q . 0
Attorney:
J.D. No.:
Address:
Telephone:
Fax:
Thomas J. Turczyn, Esquire
10383
1711 Hamilton Street
Allentown, PA 18104
610-432-7600
610-432-7390
Date Filed 4/ 1/0!j
HI05_805 REV 91X6
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph. 2..1 -05 -0325
No.
~7?~
Local R~
Fee for this certificate, $2.00
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10689003
DEe 0 6 2004
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H105143 Rev. 2/87
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
STATE fiLE NUMBER
liNT
. 221.
en. 23a-c only when certifying
phy'$idan ia not available at time of death to
certify tause of death.
SEX
SOCIAL SECURITV NUMBER
3. 185 01 0536
Q!\TE OF PEATH (Month, Day, Ve",)
.. r.~.. (' r' /f, IJl-'A) -! , I) ~t) ~'
,ENT
,NK
1.
AGE (Last_y)
BIRTHPLACE (Clly and
State or Foreign Counlry)
5. 91 Vrs
COUNTV OF PEA TH
Rossville Pa
Residence 0 ~~:r'dY) 0
RACE - Amelitan Indian. Black, v\tllle, el
(Speedy)
10. Whi te
SURVIVING SPOUSE
(II Wife, IJive "'.Ideo name)
n. Cumber land
DECEDENT'S USUAL OCCUPATION
(of=~~~~~
11.. Salesperson l1b~owmans Dept Sto
DECEDENT'S MAILING ADDRESS (SIreel. CitylTown. Slale. Zip Code) DECEDENT'S
ACTUAL
RESIDENCE
(See instllJCtions
on other skie)
IWp
17b. County
Cumberland
cllylbDro
lICEt)"H~~r_ L
22b.
To the best 01 my knowledge, dMtt\ occurred at the time. date and place stated
(SIgna'ure and Tille)
231.
'TIME OF DEATH DAT~;;~~O~NCEDDEtD~M";'th. D~~. ve":>,, ,~,'
24. ' (J{J AM 25. ,.,.,,.-'Ir)D(/,,, _) "~,I,ll
27. PART I: En..r"" dis......lnjurie. orGOmpIicaUon. which caused Ibe dedi. Do POt enter 11M mocM ofdyinll. such u cardiac or re.ph"atofy ......sl, shock or heartfailuct.
Lisl only one ceuM on eac:flline.
a,
23b. 23<.
WAS CASE REFERRED TO A MEDICAL EXAMINER ICORONER?
28. Yes 0 No
: Approltimate PART 11: Other significant condluons contributing 10 deatn, bul
. interval betw not resulting in the undenying cause given in PART I
: on.e' and death L
SequenbaJIy lisl condilions b
it any, teading 10 immediate
. cause, EnI.. UNDERLYING
CAUSE (oesease or injury I c
. that initiated events
resulting on death) LAST d.
WAS AN AUTOPSV V'lERE AUTOPSV FINDINGS
PERFORMED? AVAILABLE PRIOR TO .
COMPLETION OF CAUSE
OF DEATH?
OLE TO (OR
MANNER OF DEATH
ve.O
NoD
Suidde
~
o
DATE OF INJURV
(MOOIh, Day, Year)
TIME OF INJURV
INJURV AT WORK? DESCRIBE HOW INJURV OCCURRED
PElOding Investigation
D
o
D
30a. 30b. M
P~CE OF INJURY - AI home, farm, street. factoI)'. office
bUilcing.elc. (Speedy)
30e.
Ve.O NO~
28a. 28b.
CERTIFIER (Check only one)
.~~':t.~f::?or~~~;~~e~ls~~:~c=:t~~~~S: I~ :e~I:=(:r~~3';.r~~~r~s h~~r:~~~.~~~.I~~~~ .~~~_I~.I~~~ ?~~..
Natural
Acddenl
Homicide
I;I/I~ I,ll
Ve. 0 No 0
3Oc.
Could not be delermined
29.
.PRONOUNCING AND CERTIFYING PHYSICIAN (Physician both pronouncing death and certifying 10 cause of death)
To the beat of my knowtedge, death occurred at the time, d.te, Ind pllce, Ind due to the caus'l(s) and manner.. s.tatetl...
'MEDlCAL EXAMINER/CORONER
On the b.sta of e"min.twn aAdlor In,,u'tgIUon, 'n my op'nion. death occurred at the lime, dlte. and place. and due to the uusea(s) and
mlnner.satated. .................. ..................
311.
REG'STRAR'S SIGNATURE AND NUMBER
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