HomeMy WebLinkAbout06-17-05
PETITION FOR GRANT OF LETTERS OF DMINISTRATION
~il1s for the lo.vJ .
~~\ III the
ealth of Pennsylvania
Estate of Wu..\-rk'.(W\\\l.o.w-. To..l\t~("No.
also known as To:
Deceased.
Social Security No. \"\ "" - ~'-+ - 1.o~01
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, app IZ...
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante rninoritate)
the above decedent.
Decendent was domiciled at death in
h \ <; last family or principal residence at
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:
Petitioner_ after a proper search ha2- ascertained that decede t left no will and was survived by
the following spouse (if any) and heirs:
Name Relationship Residence
$ ~.poO
$
$
$ ,",0, Q_OCl. 00
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c.\r....L ~t-.e. 'f"~ ~A \ iDCo \
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THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
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This is to certify that the information here given is correctly copied from an origin I certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Recor s Office for permanent filing.
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WARNING: It is illegal to duplicate this copy by photo tat or photograph.
Fee for this certificate, $6.00
Local Registrar
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Date
2005-0507
COMMONWEALTH OF PENNSYIYANIA . DEMRTMENT OF HEALTH
CERnFICATE OF DEATH
(Coroner)
H105.144Rev.1191
BIRTHPI.ACE (CiIy and
S&ateorForeignCountry)
Phila., PA
MARITAL STATUS. u.Md
Never Merried, Wldl:lMd.
--
Married
SURVIVING SPOUSE
(fI wife. ~ maiden name)
Patti [unknown]
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17d.~ ~':::OI
Maiden Surname)
dis
SS _. Cilyfbwn. S1aIe. Zip Code)
5577 Old Busthead Broad Run VA 20137
ag~'c,- lOCR1QN-clly/1l>wn.......ZIpCode
ervices, Inc. .,.. Media, PA 19063
ESS OF FACIUTY
agh Family Funeral
LICENSE NUMBER
ShippensburR
_.
Home, Norwood,PA 19074
DATE StGNED
(Month. Day. ....)
24. M. 25.
'D. PART I: Enter the dIseaseS. Injuries or cornpIlcations which caused the de8Ih. Do not entef the mod&of dying, suc" as cardlec 01 respiratory arrest. shock or heart tal
UI5l only one c:.- on eedllin8.
....
TIME OF DEATH
10:20 PM
DATE PRONOUNCED DEAD (Month. Day, Veer)
May 20, 2005
.... -
~CASE ~ERREDlO ~EXAMINER/CORONER?
20. '-ne!... -U NoD
,Appro_imate MRT U: Other significant condiI'IonS contributing to death. buI
: interval betWMfl not resulting in the underlying C8UM giYen in PART I.
i onset and de8lh
~gJ.aHu\\OOld klthelrad
DUE 10 (OR AS A CONSEQUENCE OF):
b.
OUETO(OA AS A CONSEOUENCE OF):
DUE 10 (OR AS A CONSEQUENCE Of):
2Ie. 28b.
CERTIFtEA (Check only one)
.CEATlFYING PHYSICIAN (Physician cerli1ying cause 01 dealh -.t1en another physic18n has pronounced death and completed l!em 23)
Tothl bMloflrtyknoWledge. "'OCCUI"NIddueloU.~J .............,...............................,.,....................
SUicide
...
Could not be determined
J},~~1'1
...
Natural
D
D
~
Homicide
Pending Investigation
DAlE OF INJURY
(Month. Day. Veer)
5/20/05
OESCRIBE ~f'~'1f~~Wle
d.
WERE AUlOPSY FlNDINGS
""'"-ABLE PRIOR 10
COMPlETION OF CAUSE
OF DEATH?
MANNER OF DEJmi
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.PRONOUHQNG AND CERTIFYING PHYStCIAN (Physician bolh pronouncing ooalh and cerlifying 10 cause 01 dealh)
To tMbnt of my know*Ige.....oc:c&M'ed.1 the lime, .... ..pIKe. and-.to the cauM(.Jtlnd manner.. stilled.. .... ................... .
.MEDlCAL EXAMlNERICORONER
On the ~ of .......Ination and/or InvHtiglllton. in my opinion, dHlh occurred lit the time, deI...net ptIlce, end due to the CMlM(e)....
~_8tMed.................................... ..... ..... ..... ....... ............. ..........................
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REGISTRAR'