HomeMy WebLinkAbout06-12-15 REGISTER OF WILLS
CUMBERLAND COUNTY PENNSYLVANIA
SMALL ESTATES AFFIDAVIT
For Insurance Proceeds
NOT to be used for Settlement of Small Estates under 20 Pa.C.S.A. 63102
(Original Death Certificate Must Accompany this Form)
Deceased ...... ( ......_._ ._.".........W_. 1. _ s- -e- Docket No. 15 '�p os
also known as Social Security No. ( " .
_.........................._......._........_........_............_.._...--....__.._........._...---._...._.........__.-......._. _..........
Before the Register of Wills of said County personally came p` A. (Jrt: _ who resides
at �� C _ Yl D 71 bein dul sworn_.._ _...._ ►- - Y.._..._._ - .._.__..........4--- )-7- ---...-._......... -....._.. -...__. Y
de oses and says that n rr /-
, g
P Y _......._ ._l _.....'......_.......(V .....
�-2 .............
_. age .._........_.._ ,a resident of
.. ...... .... 4Y.e_rna>nS tv -� .._...... o��
-�-,
1 I C� � �
in said County,departed this life,at _� 3a _......_.._._....__.._...._.. on the _.._._...._.__t�n ....._.... day of
W.`�........... ... _........._. A.D.20 _. J`f..�.._30- o'clock M. possessed of personal
- . t . ,
property estimated be of the value of$ 3 ��e 3 and possessed of real estate,the estimated value
i........................._.........__._......_._.
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 of any
testamentary writings whether or not offered for probate;was not the victim of a killing, was never adjudicated an incapacitated
person,and was not a party to a pending divorce proceeding at the time of death wherein grounds for divorce had been established as
defined in 23 PA C.S.section
3323(8):
The total amount of insurance proceeds payable by does not exceed$11,000 and 60 days have elapsed
since the death of the insured.The undersigned agrees payment cannot be made under this Affidavit if a written claim for same has been
made by a Personal Representative of the estate and no other heir(s)having preference exist or have released their benefits to the
undersigned.
That said decedent left aspouse—whose name and residence is (� - ✓.3
and the following as next of kin: (use additional sheet if required)
NAMES RELATIONSHIP RESIDENCE
af� �� -!•s �.-� `� I�t � . C-,rte-� �-sh�Y.err,�s-b��-�°�
i-7c,tr
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 LETTER,5,ARE NOT NECESSARY.
Signed t
By: d1
Sworn and subscribed to before me this
day of .3Q1-�, 920 Register of Wills:
Kindly enter appearance in the above case this
c___......_. day of _........._....._........_.._.......... 20
Publi
wi c�a
' ....._......_. .... .........__.._..._....__... _._.......... ........................ .........- --......_.__..........- ........._.._.............._......_........................................_.._....._..................._............_......
� �
U- t� �� c� , Attorney
BE IT REMFrBE#Dth"a�t as of the day of ,A.D.20
LU TheB leas betl�NO-ES�AtI'_E PROCEEDING RAISED FOR THIS DECEDENT AND NO LETTERS HAVE
BERN ISSUE BY H3S ftOURT.
L o
CI ,
Lisa M. Grayson, Esq.
Register of Wills&Clerk of Orphans'Court
My Commission Expires First Monday,January,2018