HomeMy WebLinkAbout08-21-05
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of .-b~:JS; 'c:>d.Lo-=-<:':"~~
also known as
No. 021 - O~ - ()7..pq g-
To:
Deceased.
~377
Register of Wills for the (. I
County of C lAA~ 4...\ ~ in the
Commonwealth of Pennsylvania
Social Security No. .;?I5S G'i'
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, app~
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decondent was domiciled at death in ~.....,o t Conntx, Penn,..vania, wiJ1l
h i-''S last family or principal residence at '7.. ~pre)S I t&-rr /~l ~ I~
(list street, number and municipality)
:J ~ I'?
Decendent, then
at
bld
years of age, died
,~/-
for letters of administration
on the estate of
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: ,/\I' .4
[
$
$
$
$
C:;S-b~
Petitioner - after a proper search ha~ ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name Relationship Residence
THEREFORE, petitioner(s) respectfully request(s) the grant of letters
appropriate form to the undersigned.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF f!"u/P?6
} 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.
aff1~d and J .-..
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Estate of
No.;<1-1J5" tThqcg
~ :r S.sd IU-WJ(c.. c
/
GRANT OF LETTERS OF ADMINISTRATION
, Deceased
are hereby granted t; \l,oh-'11'\ \::. ~. S:c:x-\.\c'H_JSKt
in the estate of 0 rJ. ^ '1'('- 1" St ~clJ Ol.A..::...sk I
(
Register of Wills ~ ~ I
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ADDRESS
?I? . ;;'3 i - ?~t'1
FEES
Letters of Administration ..... $ &:> .00
Short Certificates( ).......... $ J,4 .00
R .. $5c.D
enunclatlO.l1 ....... .~. . '1" .
o....../".-rtJ'r;'\A..~}) "T<<~ $ ,Jf. o~ ....
TOTAL _ $74.00
Filed '~'" 1{. . . . . , . ,. A.D. 19AiliLS-
PHONE
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Register ofWiHs of Cumberland County
RENUNCIATION
Estate of ~ ;;-~.. ..L/.,..,...,s 'c.. .'
Also known as .
No.oIl- oS -D18~
, deceased
To the Register of Wills of Cumberland County, Pennsylvania
The undersigned An ~(_C:'.. bUt( 'C-t' 'A
ame) (Relationship) (Capacity)
of the above decedent, hereby renounce( s) the right to administer the estate and respectfully request( s) that
Letters f:1b:. ( ~ < ~ f..---+-.
be issued to V'flJ ~GoJL r s: ~ -L (~......... '> '-..' ,
Witness my/our hand(s) this }/ S- day of
;r~4-7
,20_.
t<. (2,~P~ '~a~to-O'
(Slgnature
/ ~C) 'I- ~ n aaftV 'it-I.
J~u.:d:XJ).)A~). W O.s reef
. My Commission Expires:
c::i-I/-~ r
.
(Signature)
Or
(Address)
Affirmed and subscribed before me this
_ day of
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(Signature)
Register of Wills
Deputy
(Address)
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(Signature and seal of Notary or other official
quaiiiieci to aciminisi.er oams. 3ilOW ciai.t; of
expiration of Notary's commission)
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Thi" is to certify that the information here given is correctly copied from an original ce~~ificate of death dult filed with me as
Lon! Registrar. 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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Local Registrar (/
Fee for this certificate. $6.00
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ITEM # 2...
SHOULD READ ASFObLDWS,
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COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
"'05.1<<_.1/91
NT
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SEX
2. 20
BIRTHPLACE (Cjly on<! PLACE OF
Slete Of FOfeign Country) HOSPITAl..:
n...andl Ar' ,_tienl IXl
7 \AI er lzona..
FACILITY NAME (If not institution. give lh'eeI and nllTlberl
STATE F\\.E KUMeER
socw. SECURITY NUMBER
..205 - 68-
ORE OFDEAni(MonIll. Dey. _l
June 18. 2005
~D
OECEDENrS
ACTUI\I.
RESIDENCE
(See il'llllructionS
on oIher aide)
"'P
17b.Co
Cumberland
-.,
ORE OF DISPOSITION
(Monlh, Day, ""1
D 21b. June 2 I, 2005
SEE OR PERSON ACTING AS 8 elf LICENSE NUMBER
Fd 012774 L
~Hollinger Crematory
NAME AND ADORESS OF fi\CIUTY
gichardson F. H.
UCENSE NUMBER
21d Mt. Holy Springs, FA 1706
29 S. Enola Dr. Enola, FA 17025
ORE 6IGHEIl
(MMh. Doy. ~
23b. uo.
WAS CASE REFERRED 10 MEDICAL EXAMINERICORONER?
.....~/n~ NoD
....
nME OF 0EAJli OIQ'E PRONOUNCED DEAD !M_. Day, ~
24. 7:40 AM M. H. June 18, 2005
27.1'1UIT I: enlOr"'"_.InI_ "'~.._ c:auudlhodealh. Do note""'''''' modll ofdylrtg.lUdluc:ardiaoor_atorv__ 0' ...art......
UltonlyOM _011-.....
M
.-
ltntelvll bItWMn
:onMI and death
I
i
HIlT": OIhor.-_..........ng.._bul
not_InIlloUllClerlylng_gMnInPllRTI.
DUe: TO tOR AS A CONSEQUENCE Of):
[JUE 10 (OA AS ACONSEOUENCE Of):
d
WEllE AU'roPSY FlNDlMG
_lABIE PRIOR 10
OOMPI.ETlON OF CAUSE
OFDERH?
-- _.
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.C8IT1I'YIHO PHYSICIAN (Ptlyoiclan _ C8lJOO "'_ when""""""............... pronounced death and completed '10m 23)
To"__aC""knowtecIglt.IIeIlII"I~"'1O"~.)and....nner..~..................................",,""""""" .
.......
...
Homlcldll
P-.ding In......igatlon
Could not be determiMd
DATE OF INJURY
(Man.... Oe~ ....r)
Jun 16, 2005
nMEOFINJURY
INJURY AT WORK?
DESCIIIBE HOW INJURY OCCURRED.
Passenger- auto vs tractor trailer
MANNER OF DERH
.....0
No 00
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10:30 PM
..... D NoIXl
._UNClHQI\NOcER11l'Y___"""p'~_andcen;y;ngIoC8U88"'-"')
To'" __ of my 1cnowIedglI, dNIh OOCurrM......... cIaIe, and"", iliad due to'" cauM(.) and ftNII1ner........ . . . . . . . . . . . . . . . .. . . . . . . .
"IIElllCAL EXAMINEfI/COIlONEA
Oft the..... of ......nlltkNl Mdlor anv-t..tIon. In my opinion. cleeth occulTed at..... time. dale, and pi..,., and due to the C8UM(.) and
--_..................................................................................................
31..
REGJSTRAR.SSIG~NDNU
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