HomeMy WebLinkAbout09-16-05
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Register of Wills of Cumberland County
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
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Social Security No. /9 /-IJ,'J,e:..er!f!J qD
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Register of Wills for the
County of Cumberland in the
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
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Your petitioner(s), who is/are 18 years of age or older, appl
for letters of administration
on the estate of
. a, with h_last family or principal
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Decedent, then
years of age, died AU1
? -I-h 20 D 5
,
, at
Decedent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(Ifnot domiciled in Pa.) Personal property in Pennsylvania
(Ifnot domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$
$
$
$
LlI).e5f~ rrlOkd
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Petitioner_ after a proper search ha_ ascertained that decedent left no will and was survived by the
following spouse (if any) and heirs:
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THEREFORE, petitioner( s) respectfully request( s) the grant of letters of administration in the appropriate form
to the undersigned.
/70/9
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Register of Wills of Cumberland County
OA TH OF PERSONAL REPRESENT A TIVE
COMMONWEALTH OF PENNSYL VANIA
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COUNTY OF CUMBERLAND
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 ofpetitioner(s) and that as personal representative(s) of the above
decedent petitioner(s) will well and truly administer the estate according to law.
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Reglster
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Sworn to or affirmed atld subscribed {
Before me this \ ~ ~~ day of
~~'-"V"\~~ ~""-'( , 20 ~ S. .
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I) / -0)-6? 3D
No. 0\
Estate of :h~fh 5tfiti e. /]; r ,Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW ) b M clo...J Snl, M ~ 20..as:in consideration of the petition on the reverse
side hereof, satisfactory proof Itaving bet';resented before me,
IT IS DECREED that
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to
in the estate of
fJ!1~ L ~~
Register of Wills ~ (L-
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Attorney (Sup. Ct. LD. No.)
FEES
Probate, Letters, Etc. ............. $
Will ................................. $
Renunciation......... ......... ..... $
Short Certificates ( ). . .. . .. . . . . . $
JCP.................................. $
Automation Fee................... $
Bond................................. $
Total $
Address
Filed
20_
Phone
Thi, is to certify that the information here given is correctly copied from an original certificate of death d~ly filed with me as
L,HtI Rcgistrar~ 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.
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Local Registrar '
Fee for this certificate. $6,00
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BLACK INK
1/30-065
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
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Schaeffer
SEX
2 Male
STATE FilE NUMBER
SOCIAL SECURITY NUMBER
UNDER 1 DAY
--t.i(;U~MIOUI;S
DATE OF BIRTH
(Month, Day, Yttar)
,. 191-42-9390
ORE OF DEATH (Month, Day, 'fear)
. Augus t 8. 2005
BIRTHPLACE (Clly ami
Slate Dr FOle'gn COUnlIY)
PLACE OF DEATH (Check onf~ one see InSlIUChons on ulhef 5/de)
HOSPITAL
InalientO
~='I~lD
AD
Carlisle
...
WAS DECEDENT EVER IN
U.S ARMED FORCES?
VOS D No [J
PA
Did
Decedent
ttveina
township?
15.
17c.O Yes, deca08nt lived in_ .:~~~'..-::~~i;;-.:..., ~.r...'L.. '~r
MARITAL STATUS. Married
NaWlr Married, Widowed,
Divorced (Specify)
14. Divorced
top
17b, Coun
Cumberland
:h:CllCt"::~~e:of carlisle Barou h
cityJboro
21c.
s PA
PA
2"'.
TIME OF DEATH DATE PRONOUNCED DEAD (Monltl, Day, Veal)
24. 11:00 25. August '16, 2005
27. PART I; Elller the diseases, injuf1as or complicBl1ons which ceuS6d the dealh, Do no( enter Ihe mode of dying, such as cardiac or respiralOfY a1f861, shock or heart lailura.
llsl only one cau~e on each line
Occlusive Coronary Artery Disease
DUE TO (OR AS A CONSEQUENCE Of)
...
IApptoKimale
I Interval between
! onset and death
._-~_.-------t-
!
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----- ---~---+----"'-------
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NoD
signtficant conditions contributing 10 death, bul
not reauling in the underlying cause g;ven in PART I
b.~__.
DUE TO (CIA AS A CONSEQUENCE OF)
c_____._._____~______~_.______~_._____.____~_.___
DUE TO (On AS A CONSEQUENCE Of):
d
WERE .-.UTOPSY FINDINGS
.....-.JLABlE PRIOR TO
COMPLETION OF CAUSE
OF DEATH?
Nalural
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[]
DATE OF INJURY
(Month, Ddy, Yedf)
TIME OF INJURY
Coroner
MANNER OF DEATH
Homicide
[]
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[] ~1~:d~;9~:r~N(I~~:AlhOme,l~rm. s1re8l,"iaClOfy, office
'00.
NOJ2'l-.
Yes 0
No []
^<:cioont
Plltoding Invesllgation
2.. 21b.
catTWIER (Ch&Ck only one)
.CERTIFVING PHYSICIAN (PII>'~lClo;ll1l.bllll~lflg<':o;llJ~8 01 n<.)o;lH. wl'''11 .mulh.,r JJ/lyMCldlO has prOlluunCt..4:l dealh ;JIIU cOlllplell;ld Ul~" 231
To the but or my knowledge. death occurred due 10 lhe cauae(s)and manner.. slllted. .
SuiCIde
2..
Couid nol be OEitermined
.UEDICAL EXAMINER/CORCHER
On t.... Miala ole.amlnaUon andJorlnve.t1gatlon,ln my opinion, death occurred allhe time, date, end place. and due to Ihe cauae(a) and
menner.. .t.led..
31a.
REGISTR
'S S'GNATUAE AND NU"BE~ J}( I> /
LICENSE 'NiTMBEA --~---roATE OONEOlMonth, Day, 'real)
LJ "c. _,~ August 16, 2005
NAUE AND-ADDRESS OF PERSON WHO COMPLETED CAUSE Of DEATH
(lIem271Typeo,P,'n. Michael L. Norris. Coroner
6375 Basehore Road, Suite #1
~ " Mechanicsburg. Pa. 17050
.PRONOUNCING ANDCERTIFYIHG PHYSICIAH (f'tl>'"~.,.,,, oulh p1UlllKjl\':"'y d.,,,lh dllll l.UflLlyu'9 tu ';d"~>l! "I dlJ<JUll
To the bu. of my knowledQa, death occurred althe Uma, da", and p1aea, eod due 10 lhe cauM(a) and manner aa a..ted..
34.
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