HomeMy WebLinkAbout06-10-05
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of M Ii Be; L- D. R u. f' f'
also known as
No.
To:
1..1-D5 -OSLI
Register of Wills for the
County of r. fA f/l P; E;RL.lU'lJ in the
Commonwealth of Pennsylvania
Deceased.
Social Security No. L.. 0 I - /6 - :7 ""I <)0
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decendent was domiciled at death in CU t1l'5f!5RL-I1Nn County, Pennsylvania, with
h ~R last family or principal residence at 110(7 c./2../I.II!DoN' IN"'-Y,/VleCf-/l'tIJIC5$1AP.G.
(list street, number and municipality)
Decendent, then 7 'i?
at /toL7 <;PIRI\
years of age, died
Mo1PI Ill)
~AY
/Lj
,J820oS:
Decendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$ /,z) {)OO ~ 00
$
$
$
Petitioner_ after a proper search hL-- ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name
IAf'P
Relationship
~O
Residence
II
'/ICt.S(0/1/N
PI! 1703(;
THEREFORE, petitioner(s) respectfully request(s) the grant of letters
appropriate form to the undersigned.
c')
of admiD.iBlflltion
--,~~J;
C"
injjle
c;~:
.,'~.,
c:;
~
~
o
C
~
:g3
~~
'"~
c
",,0
c''::
(lj"';::
~~
",0-
~~
:;0
"
c
'"
u;
cDf24' I]\~ fJ r~
" :l.J,
o
G'"
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF (II V\'1 ~ l r11J D
} 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.
affirmed and
to
O~.(!1 4'~
~
subscribed J
day of
14
I
l
No.
II - 05 -51./
Estate of _1)f,.1~" fY\ fH3E.:.L- O. Rupp
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
ANDNOW'-r.",!::- 10 t.8'05. 'd' f h ..
'J W\J /'_' m consl eratlOn 0 t e petitIOn on
the reverse side hereof, satisfactory l'roof aving been presented before me,
IT IS DECREED that E::NNI uP
(jipare entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to bE::N/J 10 Ru-PP
in the estate of rYI A13E.L O. R II P P
~
~
"tr
...
"
"
c
..
<ii
)fu,,~~
FEES
Letters of Administration ..... $1nO. 00
Short Certificates( I ) . . . . . . . . .. $ 4. {)O
Renunciation ......li1lL $
o ~T~L - ~ ~~.~S
Filed .. ./P.-:I.. .. .. .. . .. .... A.D. 1If~
ATTORNEY (Sup. Ct. J.D. No.)
ADDRESS
PHONE
HI05.l\05 REV 1105
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.
Fee for this certificate. $6.00
p
U600083
No.
Hl(l!l143Rev,2J81
~~~,~ ~L~
Local Registrar
~1
J~ doos-
Date
C!
Q
0>
TYPEiPRINT
~
PERMANENT
BLACKIHK
CERTIFICATE OF DEATH
COMMONWEALTH OF PENNSYLVANIA. OEPARTMENTOF HEALTH. VITAL RECORDS
S"~I~ ~lL,"-NlJ..tIiOR
Mabel O. Rupp
NAME OF DECEOENT (First. Middle. la$l)
,
,o,GE (lnl Birthday)
SOCIAl SECURITY NUMBER
201- 16
5950
CATEOf DEATH {Monlh. DIlY. Year)
(Yl':"-Y ILl vl.l:..L.:-:-)
,
"
BIRTHPlACE (Oly and F
SlIlleOl"FOI"eignCoun1ry1 HO$PIT"'-
~Harrisburg, ,,,,,,,,,.,,, [;:J
1. la
FACIliTY NAME (II nGl il\stilulion. !IiVtlSlre<Il and number)
Sp,,',l HOC>I"I<.o1
AS DECEDENT EVER IN
U.S ARMED FORCES?
YesD NO~
"
"
~:.THER"S NAME (First Middle, lull Charles Kilgore %~THER'S N.6.ME (First, Middlu. Maidun s~abel Green
1;:a~MANT'S NAME (Type/Prinl) Dennis C. Rupp ~:~MAN1s1~~~~~RB;i~rn~fT~eli~w"ri. CPA 17036
METHOD OF DISPOSITION DATE Of OISPQSmON PLACE OF DISPOSITION- Name <>l'Cemalery. Crematory LOCATION - CilyfTown. Slate, Zip CoGe
. ~--.....O Bu,ial Oc.-amalion~'allfomSta",D 1-....1>..,.__) ",OIhe,PIIoca
~, -, May 17 2005 Hollinger Crematory
. 21a. OIlw'(~ecIIy) 211>' 21e.
Of FUNE SE C SEEORPERS ACTING AS SUCH LICENSE NUMBEtU_012662_l
221>.
ollie best 01 "'I'knowladll". dealh occurred al lha ~ma,date and place slatad
($tgnalure...-.dTlOel
23a.
TIME OF DEATH DATE PRONOUNCED DEAD (Monlh, Day, Yea')
2... 3:48"~, M 25, f1Io. I'--Il-h ,.)OU5
78 Y's
,
COUNTY OF OEATH
".
Cumberland
East Pennsboro
0<.
DECEDENT'S USUAL OCCUPATION
tGiYol<i"".r......_..~......
oI"....<>G')l;t$"grYibTm'
KIND Of BUSINESS IINOUSTRY
Manufacturing
1t. 111>.
DECEDENT'S MAILING AOORESS (511",. ClIyfTo..-n, Stale. Zip Code)
1100 Granddon Way
Mechanicsburg, Pa. 17055
DECEDENT'S
ACTUAL
RESIDEf<tCE
(Sae;nslnlclions
onolhersida)
l7a.Slate
17b.CU\lt\lv
Cumberland
o
.
.
,
~
<
I
"'"
00_'
~"" in a
township?
ERIOU"'......O
~o
11.,"'.0<000 ::.:'coI)oJD
RACE - Ame'lcafllndian, Black. While, eI
(SpotiIy)
".
White
MARlTAlSTATUS-Marriad,
Na'(H~d.Wido\llad,
DiW1dg;~
Hc. f!] YIIS,.:lar:edenllivadin amp
SURVIVING SPOUSE
(....r..iI<.."'.""'n~J
...,
I7d.O~~~\:";":<>l'
cilylbOfo
'"
Mt. Holly Springs, PA 17065
WWE AND ADDRESS OF FACILITY
220. Myers Funeral Home. Inc
UCENSE NUMBER
37 East Main Slreel Mechanicsburg, Pa
CATESlGNED
(Monlh,Dav.Yea')
17055
<7-
p;
n. PAAT I: r...'...al.......lnjo.no....c_Mc......,._cao.o_Ihod..lII. Ponol."twlho.._"'''JIna,._..C.rdl.C...ro.pl.....'VOffHt.................fojl'''..
lJ..ool'..................chlln. ~
23b 23<:.
WAS CASE REFERRED TO A MEDiCAl EXAMINER /CORONER?
26. Ye,S6l.ro.-'fIt- NoD
'Appro><imal8 PART II, au- oignificanl condition. contribuUrI!Ilo daalh, b.JI
:inlerv~bel....... nGl.asullinyinlheu_rtving causegi'.tan in PART I
: onset and de'""
.'
~l!:_
c1
[:
DUl;TI>(ORot.S~Clm5EQUEIiCEOF)
EN OF)
s.quenlialyJislcondilions
ifeny,laadinglolnmadlale
.....se.Ente.UNDERLYING
CAUSEtDisease",in;.l<y
" that inilialedevenls
.uulingondulhjLAST
W"S AN AUTOPSY WERE AUTOPSY FINDINGS
PERFORMED? "VAIlABlE PRIOR TO
COMPlETION OF CAUSE
OFotATH1
DATE OF INJURY
{M.,..., Oaj,voorl
MANNER OF DEATH
Nalural R1
AGddant t[J
o
Humi<;itle
o
o
o :'~CE OF INJURY
......ng..,c{Soocifjl
30..
JOb. M 30e.
Alhoma, llllm, $IN;leI,factory,oIli<;e
YesO NaO
Piln<lV\u Inv~~...auoo
Ye.O NOG;t
'?r
"
Yes 0
Coukln<>llledele,mj"ea
Suiclae
"
Z
w
o
w
U
.
o
~
21.0. Ub
CERTifiER (C_onl)' one)
1:':..r:f=IGJ'~~~'~a.=,~.i~': ~a::~a~:~:r~3~~=~~':~ta.~~~~.~~~~~..~~.~~~~,~~1~,d.il~~~.~~}.
.PRONOUNCIKG AND CERTIfYING PHYSICIAN (ph~'1CIlN'l boll> pron<lUC'.dnij dean, and 'e'UI~"'!Ilo.> cause of d....rto)
Tothoobe.lolm~knowl...I..d..lllO<:cu.....dallll.U.......dala.andplac:a.andOu.tglll....."..a(.jandman",na..IaIIHl...
b.III:tlml
TIME Of INJURY
INJURY AT WORK7 DESCRIBE HOW INJURY OCCURRED
~,.
lOCATJON (SUee1,CilylTowo. SlaIa)
,.
SIGN1\TURE AND TITLE OF CERTifiER ~
31b.~ ~.
liCENSE NUMBER DATE SIGNED 1M"'''/>. D..y. Y""'J
o ". M Ot>/Z08Zc- ,,,. - - ~ 5
NAME "NO AOOflESS OF PERSON WHO COMPlETED CAUSE QF DEATII
(llem2T) Tyl"l OtPMI TJ.:.dc;=u-rr/fVs...... "",,"C.
o t:!9~ //al'fa- d...... ,If.d.
u c- 'c, t'" "11
CATE FILED (Monlh, Oay. Yur)
"
.
IS. .;(c,N5'