HomeMy WebLinkAbout06-24-05
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of f-IeAfher flJAn-e +RUsf-
also known as 4e AJJ.-.e-:- !Yl, (-CtUS+
Noc2l -():;- - 05LY/
To:
Deceased.
Social Security No. ~ -Lj~, (,,~'7"3
Register of Wills for the
County of in the
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl i -eS
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 CL./ft\ber/f,r.JD County, Pennsylvania, with . .
h f'f' last family or principal residence at c;>):) ~AI+~ C'rde ) CA.il",Q) PA l7o/~ /Vr'Jr..fAfhJt;NJIP"k/v 0>-wr41P
(list street, number ana municipality) ,
.3 3 years of age, died 4 Dr /; / e , ~ d.od; ,
HO"t 'tk I ) I-I~r{' ).) hUr:J I D~ih }"j u.,,-,,,,i')I ) ~
Decendent, then
at !-IArr:'sbiJcJ
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:
$ LJ5,ooo
,
$
$
$
Petitioner_ after a proper search h~ ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name Relationship Residence
AI' r p~ 09'-18
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administr~~ion in the
appropriate form to the undersigned.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF Cu 'N\bOA DC! A"=~
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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.
,
affirme~ and subscribed J-'< ~ r (f d-<
;:Ll ~ day of
" 00 ~ W_
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No. ~-()5 -()~,
Estate of ~~~ R (" 0<\C\..i\..JJ.. r--~-t ~~ ~():tHr , Deceased
'N\. Fcl0.A.S\
GRANT OF LETTERS OF ADMINISTRATION
AND NOW ~ I ~d.DOS: in consideration of the petition on
the reverse side here f, sa 'sfactory proof having been presented before me,
lT IS DECREED that . . - 'C'" \" .
is/are entitled to Letters of Administration, and in ac d with such finding, Letters of Administration
are hereby granted to~~O-- \"' C n~~
in the estate of Wo...~)>... '0f\o. ~1.9 ~(~~
O-,'K.o. ~~ "- VV\ \-c... ,,y-
FEES
Letters of Administration ..... $ ~ a. ()()
Short Certificates( ).......... $ ().[) . C)b
R@R1:uldati9ll G...v..-ro~~ $ 5. w_
...J~ $' D .Du,_
TOTAL _ $lrlS.U)
Filed ~'\JL. ~.\. . . . . .. A.D. ~~S-
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^ L~ R~ d, fvA.U1 7~ :1sq
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ATTORNEY (Sup. Ct. I.D. No.)
II fVorth CP~ r r:: +. '" Y1 ~ Sell ()ms v/l1e U1.a" ,
ADDRESS ) /"/0/
5'')()-6JI~ 34~;
PHONE
Thi', i~ to certify that the information here given is correctly copied fro~ an original ce:t.ific~te of death dul.t filed with me as
Im,t1 Registrar. The original certificate will be forwarded to the State Vital Records Offtce for permanent tIlmg.
WARNtNG: It is illegal to duplicate this copy by photostat or photograph.
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Fee for this certificate. $6.00
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,/ Date
..<"->dd-.J-
'~,.,.:.'
..; '1 ~7 II 0 q .', to
i / "1" ~ ~) ,1.. ..,'
No.
Hl05 1...... Rev. 1/91
c21- 05 - O<Qlol .,'
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS'
CERTIFICATE OF DEATH
(Coroner)
TY~T
IN
PER1IN4EHT
BLACK lHK
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SlATEF1LEN~
SOCIAL se:CURfTY NUMBER
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TIME Of OER"H ~ PRONOUNCeo DEAD (Mcw1th. Dav. .r)
... 9:23 PM .. ... Aprit 18, 2005
21. ""'" I: Emer lMI~, infUrieIOI ~nlwhich ~the ........00 nll(en\M1M~Q(~. tueh UcaflMc Of ~~, 8hock0ln..n taillA
UIt oNy one cauM on 'Md\.....
'''wrox~
:int.efvaI between
10l'lMC arld dMctI
NRTU:
OtMl'~condilionIiconcributingto~but
not~lnthe~,**gNenInPARTl
Cardiac D srh hmia
OUF 10 (OR AS A CONSEOUENCE OF);
DUE 10 tOR /4:3 A CONSEQUENCE OF):
DUE 10 (CIA AS A CONSEOUENCE OF):
d
WERE AUTOPSY FINDINGS
1UlJl.A8l..E Pf\K)f\ 10
COMPLETION Of c.wse:
Of' (leATH?
N.""..
-
P.nding l"",",iglltion
Ir.4ANNER OF DENH
ONE OF INJURY
(MOI'IIh.Dly. ....rl
DESCRl8E HON INJURY OCCURRED
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CouIcInoc~det..-mined
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CERT1FIEII (Ch<<:k only one)
'CERT1FY1HG PttYStCUJt(Phyfician~ cau..oIoe.lh when~ ph~,*pr~ dNth.nd completed Item 23)
Tv.... bMI of '"J~.'" oc:c:urNd due ~ 11M C8UM(.J.... JMMW" lUted. . . . . . . . . . . .
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.~ ~Oc:ER1lFY1HG pt4YSK:MH (Ph~ both ptO"lOUncinQ dulhando.tif')<ing lQ~oI de8fflJ
To........,...,.know6edp.....~.CCh. u.n., ..... "",-0., Mddueto Che'*'-<.J..-.4 ,...........etated.. .
-0IEDtCAL EXAlIlNER/COROHER
On the bMIe of .;umlnMkN'l .ndlor mv..t~6on., tn my optn.Ion, dMtt\ occ:urred....... tn., o.te, .Ad plltCl, and due to the c.uM(.) and
~..~h....... .. .................... ..............
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~TRAR'S $GNRURE AHONVM6ER ~
.~ d- '-Y dL/fI71?1
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