HomeMy WebLinkAbout07-06-05
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate o~o~\c."" Sea.\-\. E~ ) ~,..
also known as
No.
To:
~- O~) - (TIoe)1"
Deceased.
Social Security No. I q s- - ~y - u.l.f <..('f
Register of Wills for the
County of e~~..., \c...~~ 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 ,'~ 4j
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 C V""" \,~ r \ ~- J County, P~nnsylvania, with
h ,~ last family or principal residence at I q to. ~ -. s.~. J Co.. ""'" P \-\ ~ , \ .
(list street, number and municipality)
Decendent, then ~, years of age, died ~vW'\.~ d ~ , 19 2005',
at ""e.....Cv""'\......,\c...-.~ ,P~ \,0"'-' c.A S:~COL-
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: JJ/.q
loo.tJ~
.
$
$
$
$
Petitioner_ after a proper search h~ ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name
ov \c.. ~ SecA.\. (
" Relationship
~~";r
(1/\0 "'r
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF ~~O^ ~D...xI(,\
} 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
tep,.senMi~e(s) of the aho'e de~edent petitionet(s) Wiil~ 1-
truly admmIster the estate accordmg to law. / /
Sworn to or affirmed and subscribed f)( /f ./
be re me this lJl~ day of / b-
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No. ~I-OS- OLoOLP
Estate of ~(~ \.rcs ~
GRANT OF LETTERS OF ADMINISTRATION
3C!ot:t.- f~4.
Ii
, Deceased
AND NOW ('y,. 0 ';If; 7 ,Q (1) 5 \oG_. in considetation of the petition on
the reverse side~ tory proof havmg been presented before me,
lT IS DECREED that ~QS - ~ (l (~ P.b..-u !f.r"'" ~ .~
is/are entitled to Letters of Admin ration, and in accord with s~ch finding, Letters of Administration
are hereby granted to \)O~\c... s... --.S (I cttt;: r ~
in the estate of 1)1")\ "-C\ \0 <;,. ~ ~ ott-- <(' h-tt ~
,-);i~l\G\o..~l'\ GAl. .1~ I ~L _
R,gi"tt of WiU~ 't ~ ~
FEES
Letters of Administration $ 2CJ .Ou
Short Certificates( ).......... $ /.;?CO
Renunciation ................ $ 5. 0_0 _
o...v....TvyY'~ P $ 11) ~~')'o __
TOTAL _ $ 5;} J)U _
Filed .k. .'7. . .. . . .. A.D. "W-"""Q.(25
ATTORNEY (Sup. Ct. 1.D. No.)
ADDRESS
PHONE
II ]1)".:-\0") REV \/0")
This is to certify that the information here given is correctly copied froo: an original ce:~.ific~te of death d~lr filed with me as
Local Registr.ar. The original certificate will be forwarded to the State VItal Records OffIce for permanent fIlmg.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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--ttLU~ Ko.dlJlJ
Local Registrar
4'~
Fee for this certificate. $6.00
~A.I<luL d~0or)~
. Date
TYPE/PRINT
IN
PERMANENT
BLACK INK
1130-031
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
H105 144 Rev_ 1191
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Eby,
DATE OF BIRTH
(Momh,D."lY,'feaf)
DATE OF DERH (Monlh, Day. '1/eaf)
June 25, 2005
UNDER 1 DAY
Hours Minutee
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c
....
.....
Closed Head Trauma
DUE TO (OA AS A CONS[OUENC.E Of):
Motor Vehicle Crash
DUElO(0RASACONSEQU[NC~~- -
23b. 23c.
Wtt.S CASE REFERRED 10 ME~ EXAMlHEAICOAONER?
,.. JIll .., 0
a.
!~ PART.: ~~-=~C::=~~
! onaut and deaIh
i
I
230.
TIME Of DEATH P rx . DATE PRONOUNCED DEAD ~Monul. Day, Y&as)
2.. 5:30 A... 2.. June 25, 2005
27, MAl" I; Emllir 1M dlsa..... InJwln Of oomplical.lol\f wtUch c.aused lhe dealh. Do nolentef the mode 01 dying. such 8S catdiac or respulllof'y arrest, &hock 01 heaI1.laiIurII.
UlOI Ollly OJ"Ml cause on lJ&Ch line
NO~
No []
MANNER OF OERH
d.
WEAE AUTOPSY FlNotNGS
A\fAIlABlE PRIOR TO
COUPLHIQt4 OF CAUSE
OF DEATH?
Nalural
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Homk:id8
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DESCRtBE HON INJURY OCCURRED
Unbelted operator left
roadway, struck pole and
tree
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Au;-ialt'lI
P.Jlding Inllesligalion
ah. 21b.
CERTIFIER (Check only Uild)
-CERTIFYING PHYstClAN (l-'t,yl>lCli1rl ceotll'lfl{J Ci1USl;I ul ooat!l whvn dnultI&I physiciiil' hd:; prOlK~JI.ced tle.-Iltl and Gurllpleloo 1I0ll. 23)
To the bnt of my knowledge. death occw..-d du.1O the cauN(.} and manner _ alated. . -
SlIIciOe
2..
Could no! be dehumlllGd
o
Coroner
.PRONOUNCING AND CERTIFYING PHYSICIAN (f'hysa:.'ian boll! PfOl"lC..,,,w.cing lleath <and L'E.'rtity.nu lu cal!~ 01 dead I)
To the.... 01 lAY knowiedg.. ..th occurrltd al!he time, date, and P'**. arc! elf>> k) eN (:IIu.~.) _net manne,.. _ted.. . .
ORE SIGNED (MonIh, Day. 't1NI)
o 31<. 31d. June 27, 2005
NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE Of DEATH
(Item 27) Type or Prinl Michael L. Norris, Coroner
6375 Basehore Road, Suite #1
~ 32. Mechanicsburg, Pa. 17050
...
-MEDiCAL EXAMINER/CORONER
On lhe basi. o' examination and/or In"..lIgatlon, In my optnlon, death 'X,urred al the time, date, and place, and due to the c8uM(a) and
mann.,......ed............. _... . .................... -................................................................
;u..
REGIST
GNATURE AND NUMBER
J(~~1U..tij 1
~II.~/~I
Register of Wills of Cumberland County
RENUNCIA TION
Estate of ~~ \(. ~ ~<.o \i l:\,'1 , ~ r
Also known as .
No.....2.-1-0'2J - CoOIo
, deceased
To the Register of Wills of Cumberland County, Pennsylvania
The undersigned \.....or.' t\ ~ \\e",,-,- Ma~~,.
(Name) (Relationship) (Capacity)
of the above decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that
Letters e~ o..~ I/'A"'" '~\"-'~a -
be issued to ~ OVt\ (.'. ~ C:;c '0.\ \. E"'1
Witness my/our hand(s) this
day of
,20_,
~~.~
(Signature)
3H~ L\ (ne..I~Jn-,(d. 0euJ~0P\teR. bnol, PA
(Address) 17070
Commis~MW:e~L
LAURIi; A. BOYr:R. Notary Public
SW8tilra -1Wp., Dauphin County
. 3. 2007
(Signature)
Or
(Address)
Affirmed and subscribed before me this
_ day of
(Signature)
Register of Wills
Deputy
(Address)
(Signature and seal of Notary or other official
quaiiiieci 1O acirninisi.er OalnS. ;;iiOW Qiii.e 0;
expiration of Notary's commission)