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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND COUNTY,PENNSYLVANIA
Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters as specified below, and in
support thereof aver(s)the following and respectfully request(s)the grant of Letters in the appropriate form:
Decedent's Information
Name: Edward A.Siemon,III File No: 1- 1 91
a/k/a: (Assigned by Register)
a/k/a:
a/k/a: Social Security No:
Date of Death:Aumw 15,2015 Age at death:68
Decedent was domiciled at death in Cumberland County,Pennsylvania (Beate)with his/her last
principal residence at 540 Brentwater Rd.Camp Hill,PA 17011 East Pennsboro Township Cumberland
Street address,Port Omee and Zip Code City.Township or Borough County
Decedent died at
Street address,Post Office and Zip Code City,Township or Borough County State
Estimate of value of decedents property at death:
If domic6d in PextUbank...........................All personal property E 1,000.00
Ijnot domic"in Pennsy6unie. .......................Personal property in Pennsylvania S
Ijnot domidkd in Pennsylvania. .......................Personal property in County S
value ofreal estate in Pennsylvania......................................................... $ 0.00
TOTAL EST111"TED VALUE.... S 1.000.00
Real estate in Pennsylvania situated at:
(Attach addidonal sheet&ifnecemary.) Street address,Post Office and Zip Code city,Township or Borough County
❑ A. Petition for Probate and Grant of Letters Testamentary
Petitioner(s)ave(s)be/shehhey is/am the Executor(s)named in the last Will of the Decedent,dated and Codicil(s)
thereto dated
State relevant circumstances(e g.renuachaim dealk afemermr.etc.)
Exceptasfollows:afterthe execution ofthe instrument(s)offered for probate Decedent did not marry,was not divorced,was not a party to apending
divorce proceeding wherein the grounds for divorce bad been established as defined in 23 Pa.C.S.§3323(g),and did not have a child bom or
adopted;and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated persons.
Q NO EXCEPTIONS Q EXCEPTIONS
® B. Petition for Grant of Letters of Administration (if applicable)
ata,db.n.,db.aata.,pendente lite,dwonte absentia,dtuante mbtoritate
If Administration,Gla or d b tt,ata,enter date of Will in Section A above and complete list of heirs
Except as follows: Decedent was not a parry to a pending divorce proceeding wherein the grounds for divorce h9M,8 establishbd k dei rn
in 23 Pa C.S.§3323(g)and was neither the victim of a killing nor ever adjudicated an incapacitated person. n
(D NO EXCEPTIONS 0 EXCEPTIONS G� -r) o
Petitioner(s),aftapWaseatehbasihaveasmumadibatDecedentleRnoWMandwasswvivedbytbefollowmgs flmy)an psratm 7
addfdonalAwt%ifnecessary):
QDi
Name Relationship Address ::3
Diane Butgraff sister 37 Whittakers Mill Rd ==
Williams—bum s A23185 ►--�
- C'n
ry co
Foran RW-02 rev.1011112011 Page 1 of 2
Oath of Personal Representative °fcia un only
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF Cumberland }
P a Printed Name Ped iona(a)Printed Address
0
Dianellurgraff 37 Whittakers Mill Rd.,Williams VA 23185 '"' 70
.rn
M v'
The Peudoner(s)above-named swears)or affam(s)the stmements in the feregoiag Petition are true and cemed m the Det of�o owl r and 1
of Pcd6oner(s)and that,as Personal Rq wseatative(s)of the Deft&A the s)will and Indy adrddster&Willi m ""
Sworn to or affirmed and subscribed before Date rn
me dayof 1 r-t C
Date c
By:
For deRexbter Dame
BOND Required:0 YES 0 NO To She Reamer of WWs:
FEES: Please eater my appearance by my signature below:
Letters...................... S 'Q0 Attorney Signatnn:
( � )Short certificate(s) .....
( )Renunciation(s).........
( )Codicil(s). ............
( )Affidavit(s)............
Bond........................ Printedfer:
e: RO
Commission ................. Sopremrt
Other ...... ID Nom 76057
jn\JCE�
C ...... l S Firm Name: Central PA Estate dt Elder Law PC
...... Address: 1853 William Perm Wav
...... PC)Box l 11574 J
...... Lancaster.PA 17605-0574
...... Phone. 717-8244838
Automation Fee. .............. Fax: 717-8244759
,o
JCS Fee. .................... Email•
TOTAL..................... S .
DECREE OF THE REGISTER �]
Estate of Edward A.Siemon.nI File No:
a/k/a: `,,
AND NOW, 1"kJ�M 9--" J-7t L,in consideration of the foregoing Petition,
satisfactory proof havinown presented before me,IT IS DECREED that Letters . Ad j n(,5--frjA)M
are hereby granted to�i Ct f< D �CJ`f U f G1�
in the above estate and(dapplicable)that
the instrument(s)dated A--
described in the Petition be admitted to probate and filed of record as the last Will(and Codicil(s))of Decedent.
. m
Register of Wills �^ Q
Form RW-0I ,ac 1011112011 Page 2 of 2