HomeMy WebLinkAbout04-11-2005
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of J C;\,n ~ ,--4", "
also known as
No.
To:
J I -OS -03~3
Register of Wiils for the
County of ~"'^~ (\~V'\ d in the
Commonwealth of Pennsylvania
Deceased.
Social Security No. i ~ 7 - ..z..~ - ~ G:, I ~
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, app~ /,1""}
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
h \ ~
Decen$ent, then (0 &>
at \ 0 f(~ l P PI
years of age, died ), t ~ '"'I ["2-6 cr c(
, 19
Decendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property $ a
(If not domiciled in Pa.) Personal property in Pennsylvania $ 0
(If not domiciled in Pa.) Personal property in County $ 0
Value of real estate in Pennsylvania $ 0
situated as follows:
petitionerh ~5 after a proper search ha-L ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name Relationship Residence
A t 700'7
;'-."_,~t
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of admlni~tr~tion in~he
appropriate form to the undersigned.
-
""
'"
.,
u
::::
<1)
~";;'
"'~
<1)....
p::~
-g.g
(t$"';::
3~
<1) '-
50
...
::::
0lJ
U3
~""~ J't~ ~:"
:::-:"?
...- i
r .j
-Z.
r-~-
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CvWl be.y-Iand
} 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.
rc
J h.~ A-~ &i>v~.
I
L
,.....,
'"
'tr
....
::3
....
ell
\::l
01)
en
Estate of
No. c9./-oC;--03;<3
:h h I) W,"{;ctWJ Cv~4~
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
/fh ~ L -
AND NOW 0 . /J,., I ~~tD~, in consideration of the petition on
the reverse side hereof, sat" ac ory pr f having b~ pr ted before me,
lT IS DECREED that ~ ~ $ (J ( I .
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to
in the estate of
joh f)
UJ if L cHh r; r ,fI;~
FEES
Letters of Administration $
Short Certificates( ).......... $
Renunciation ................ $
$
TOTAL _ $
Filed ..................... A.D. 19_
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
....."..............
TJ-,i, ;,; tn (',=~+;fy ',~:,. '1~'C: ;~r0~'""2';0,--: ';('~C ;:;VCr: :, C,w~r>('tIY lMp'__ _ :e of death duly filed with me as
1 I R t'1I 1" cr2i.'al c~rtiLcaL will he ccrw;n .,j 10 the Sute Vital Recbrds"Umcc lor permanent filing.
~l)ca egis. ;. "Le _
WMilNING: It is illegal to duplicate this copy by photostat or photograph.
~\ ,~... .JI!
r ',., J
[~ C ...., 1'"' r\:;
."" I'...~i
>-.,.; \.J'
J:.,'I~I~(W'Orpl;;---___
,I'..\.'- ~1Jt -
i~/.. '.. ~-;."':.
~'~_. . U-;.
~~!., \"P..
~C)I' c' '-..,.": . I:~~
~e-) _.1;'~r I.:a:::..~
~ \. 'j;j ~ " ~
l.,_ ""
\.~"- . .: /.~l
""'- -9'..o~ ~\.~II'
...-----~rMEN1 \\~ ~ """'
',........."'N/NNIJlJll",1
~ t\. ~b.~~~
Local Registrar
FtC ,'J! Ihi, cer~ificate. $2.00
!"'"...,,)
No.
"")
!-tAft 1 znO~
Date
..~
.......\.")
( .1
(:.:.:J
....r:'''''.
H10S, U3 Rev. 2/87
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
BIRTHPLA.CE (City find
State or Foreign Country)
STATE FILENUM8ER
PRINT
..
~NENT
KINK
III
H'
1.
AGE {Last Birthday)
h k0!11 on .se
5.
COUNTY OF DEATH
fittsburgh,PA
SEX
J1ale
P OF D TH
HOSPITAl
I"palient [ig
8,.
DATE OF DEATH (Month. Day, Year)
.. Feb. 27, 2004 .
68 v"
ERIOu\ca\,&M 0
~e..o.r.eeO ~::~fyJ 0
RACE. American Indian. Black, White, et
\5p",,"') White
10.
FACILITY NAME (If not institution. give street and number)
80.
York
York Hospital
8d.
AS DECEDENT EVER IN
U.S, ARMED FORCES?
Yes 0 NOCf
12.
MARITAL STATVS. Married,
Ne~ef Married, Widowed.
Divorced (Specify)
1.. married
SURVIVING SPOUSE
(lfwif..gi....maoderofl.rnej
17b, County
PA
Cumberland
Dm
decedent
live in a
township?
17e, ~ Yes. decedent lived in
15. Francis A. Kaczor
SOuth Middleton
lWp.
".
FATHER'S NAME (First, ~ddle,.lVtj,.
11. Matthew GrlIIln
INFORMANTS NAME (lype/Print)
200. Gr ory W. Griffin
METHOD OF OISPOSITION
OonaUon 0 aurial []:Cremation ~emoval from Stale 0
_ 21.. OtheqSpecify)
. S\GI~A FUNE RVICE
. 22..
CcmpIe\e tams 23.-c only when certifying
physician i& not availa.ble at time 01 death to
~f caU18 of death,
i1d. 0 ~~h~e~~t~~7~j~: of
dtylboro.
MOTHER'S NAME (First. Middle, Maiden Sumame~
1.. Bridgett Clancey
INFQRMANrs MAILING ADDRESS (Street. CilyfTown, Slale, lip Code)
200.201 East Crawford Ave. Altoona, PA 16602
PLACE OF QISPOSITION. Name 01 Cemetery, Crematory LOCATION - CitylTown, Stale, Zip Code
or Olher PlcJce
2~t. Zion Cemetery
2004
Sequl!lntilllty rial conditiot\1l b
jf any. feeding co immedMtle
~. Enter UNDERLYING
CAUSE (Dina" or inlury { c
that inlU,led eventl
rlllUftirlg on death) LAST d.
WAS AN AUTOPSY WERE AUTOPSY Flt.mINGS
PERFORMED? AVAILABLE PRIOR TO
COMPLETION OF CAUSE
OF DEATH?
o ,S'SA5.f.
DATE SIGNED
l""'JJl1c D>><. Ve..) /j ....,7'~
230. 230rt:L'>R.AV~,...'1 '" ,
WAS CASE REFERRED TO A MEDICAL EXAMINER ICORONE!2,/
26. Yes 0 No\.L:::1
: Awroximc;..te PART II: ()Iher s)gnl1lcant conditions contributing 10 death. but
I interval between not resulting in the underlying cause given in PART I.
: onset snd death
DESCRIBE HOW INJURY OCCURRED
27. PART I: Ene- tfl. dl....... III/url.. or colftpllc.tloro. WhiCh "ll..d tI\. d..tI\, 00"01. enwttha mild. 01 d~lng, .uch.. ,.rdl.c or r..pfflletry .rr..I, .hock or h...rt IllIur..
UI' Ollly one CIll.. 0" ..ch llrl.
DUe TO (OR AS A CONSEQUENCE OFj
DUE TO {OR AS A CONseQuENCE OF}'
Voso
::::~ROF;iTH
Accident If]
o
DATE OF INJURY
(Monll'l. o.~. Yel')
tiME OF INJURY
o
o
Could not be delermined 0 ~~CE OF INJURY
buttdi~. etc. (SpeeWy)
21.. 2'b, 29. 30e.
CERTIFIER (Ched< only one. SIGN REI.D
.CERTlFYlNG PHYS,CIAH (Physician certiMng cause of deeth wh4Jn another physk:1an has p,ronounced death and compleled item 23) ~
To u.. bHt of my knowlaCtg.. d.ath oceurnd due to the cau...(.) .nd mann.r.. .Ia .d.......,.........,............"......."..."......."..".."'k' 3ib.
L1CEN E NUMBER DATE SlG)lE~J.Month, Oay, Year)
.P:c:':~:~I:rm~Hk~;;I~~.~~~I~~~~~~:~ITl:~~.~~~c;~:~,d:~~hd~n:,~e~Z~2ul~.~~)~~~~:~~.ra. .t.t.d......., .,........... 0 31, . 06 16q~ l... 31d,03/fJ02.4I"'I
NAME ANO ADDRESS qr PERSON "'1...00 COMPLETE.D CAUSE OF DEATH
'MEI)ICAL EXAMINER/CORONER I"em 21) Type 0' Pnn' ,P-'tI^\J "" ~ .It/'l tf\<:>
:l:.:rb::::tf.~~~~n.t\on andJor InvestigatIon, In my opinion, d..,h occurred at the tlm_. datf. and plac.. and due to the eauses{5) and 0 1 ,., ~\ pit "f.'" 'C. c;, I"'I"'Iti S
31a, 32. 11..,.
REGISTRAR'S SIGNATURE AND NUMBE P DATE FILED (Montl1, Day Year)
t\.\~~~~
Homieide
Pending Investigation
30b.
NoD
Suicide
,..