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HomeMy WebLinkAbout07-09-15 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. X3102 L l (Original Death Certificate Must Accompany this Form) Deceased 'f 0�/ � ( 4u� J Docket No. ��- 15 - � S .._�.. _... -._......._.........._.........._ _ .._ ... ._. _-.._....._.__........._...._.._._ _............_`i��` '_..__.........._.. also known as Social Security No. (Q�] l `t©� �{ ..............._........._............._.............._......_..............__._.._..__....._...._.............._............_._........_.._.......-- --- ...............__......._.........-- ... Before the Register of Wills of said County personally camep� who resides ' i Ra Yl ) 70 ,being duly sworn, at ............�_v_�....__... _.. __l'1... -._...1,�".'........ _�... ............... - . �`' ....__..__._..........._._.... -............_......__._................. deposes and says that A-� (-� (i � � ��.� age � a resident of _............. ..... _... - g ................ ._.... 1 0. 0 Yarn �S w A— } 4 in said Count departed this life,at 3U on the h da of p Y� P sS�^2- __ ...._....__.._......__. Y X(�._............ __.... A.D.20, - ......_.. __��__i.....J�D............_ o'clock _._.... -M.,possessed of personal property estimated be of the value of$ 3 8' 3 1 ,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(g): 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 (�. _ and the followingas next of kin: (use additional sheet if required) NAMES RELATIONSHIP RESIDENCE I7eif 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 ARE NOT NECESSARY. Signed By: G� Sworn and subscribed to before me this day ofv._r _.._.._........ ,20 Register of Wills: Kindly enter appearance in the above case this __.. .__ .l -._.... 20 ..............__._..........._....... -._....__� LU ._._, . --............_.....L� _ ........__�_............_..................... .....'...._......._.. ..... ..............__._.....-_.. __............ ---.......__._...... ..... ._............._......-......__. J _............_..............__......._......._._..__.....0__- ,.: Li— rF�pFres I.D.NO.o ;C7 rn Lis_ c Attorney rn c , C7 L: ,.. BE IT R' TMRWE I Zthlat as of the day of � � .20- � p Thekg leas ben- NQESTAfI'_E PROCEEDING RAISED FOR THIS DECEDENT AND NO La HAVE rri rn BEIM ISSUg BY iHLS�OURT. = rn SCD � � p 2i � � � C) -n111 tern �r1 -n Lisa M. Graysny;Esq. © `� o Register of Wills&Clerk oll�Orphans'CcU t My Commission Expires First Monday,January,2018 ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF In Re: Estate of Albert N. Wrightstone,Jr. CUMBERLAND COUNTY PENNSYLVANIA NO.21-15-0665 CERTIFICATE OF SERVICE OF ORDER ORDER DATE: July 9,2015 JUDGE'S INITIALS: LMG TIME STAMP DATE: 07-09-2015 IN RE: Small Estates Affidavit ..,...,,,.,;..................................................................................:............................. SERVICE TO: Kathy Wrightstone 131 E. Green St Shiremanstown,PA 17011 METHOD OF MAILING: ENVELOPES PROVIDED BY: ®USPS ❑ PETITIONER ❑ RRR ❑JUDGE ❑ HAND DELIVERED ❑ CLERK OF ORPHANS COURT ❑ OTHER MAILED: ...................................................................................... SERVICE TO: METHOD OF MAILING: ENVELOPES PROVIDED BY: ❑USPS ❑PETITIONER ❑RRR ❑JUDGE ❑HAND DELIVERED ❑CLERK OF ORPHANS COURT ❑ OTHER MAILED: l�J Deputy Clerk of Orphans' Court