HomeMy WebLinkAbout10-19-05
.
Register of Wills of Cumberland County
Estate of Jameel R. Johnson
also known as
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
No. ~ /'JOOS4~
To:
Social Security No. 166-70-3066
, Deceased.
Register of Wills for the
County of Cumberland 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 ies
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
(J
t'-,)
~~
"'J
Decedent was domiciled at death in Cumberland County, Pennsylvania, with hjL last family or priJllcipal ,____:
residenceat511 B Street. Carlisle, PA 17013
(list street, number and municipality)
$ 500.00
$
$
$
Decedent, then 18 years of age, died April 30 , 20 05 , at
2395 Ritner Highway (Route 11 ), Carlisle, Cumberland County, PA
Decedent at death owned property with estimated values as follows:
(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:
C)
(Y".
Petitioner~ after a proper search ha~ ascertained that decedent left no will and was survived by the
following spouse (if any) and heirs:
N R I l' h' It 'd
ame e a Ions Ip esl ence
Celeste F. Johnson mother 511 B Street, Carlisle, PA 17013
Freddie Johnson, Jr. father
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form
to the undersigned.
Residence(s) ofPetitioner(s)
511 B Street, Carlisle, PA 17013
c/
OJ /-;JOe) )-1~~
.
Register of Wills of Cumberland County
OA TH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
}
SS:
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 petitiooe<(s) will well w>d buly administe, the estate acc7~('to IaW'~1 / /, :) ~~
Sworn to or a,ffirmed and.subscnbed {Ltibii Jj=tJ,,/Jt~ '; '. .
Before me thIS ~ day of _~ _ ;
?~ ReW e 20M JL ~ '~,;
'-flU V fl No. ;) ( - J- 6 () 5'- q ;L ~
C:;)
Ci-'i
tate of Jameel R. Johnson
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW 0 c./J.{;eA (i 20~ in consideration of the petition on the reverse
side hereof, satisfactory proof having een presented before me,
IT IS DECREED that Celeste Fay Johnson
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to Celeste Fay Johnson
in the estate of Jameel R. Johnson
FEES II] t
Probate, Letters, Etc, ... t.; klf!.iN $
WiJl-... '" '''''' ". '" ". ",... """ $
Renunciation" . .. " . ... ".." " .... $
Short Certificates (j ) ." .. .. .. .. . $
lCP.,....,...,..,....",.,.",."",. $
Automation Fee". "f J.~p" , $
Bond. .. , " ". ". " . " .. " , " ". ...." $
Total Ltl-t.l/)', $
Filed ck f i ~. 20 0.::
d () . olJ
Craig D. Charles (55080)
Attorney (Sup. Ct I.D, No,)
3 Spend A Buck Drive \/
Dillsburg, PA 17019
Address
S.ot
4. (n)
(~'(il)
4 4. at;
717-432-5159
Phone
,tn'
'to
1>>.
~
~,
E
H10'5.00'; RE\lJ01/04)
d hlIJOS*..t/;;'. Co
This is to certifY that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
In accordance
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~ (j,J.. )/J,A
No.
Charles Hardester
State Registrar
Calvin B. Johnson, M.D., M.P.H.
Secretary of Health
'J II
J"f
8"7 '^, 70
L I.'
JUN 0 7 Z005
Date
t. r)
I.'
UPRINT
IN
'ANENT
CKINK
I
'-,
~29-487
>NAME OF DECEDEN1 (First, Middl~, Last)
t. Jameel
UNDEA1Y'EAR
Months q&ys
'-
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
046497
H10S.144 A:e:Y:-,: ll91
UNDER 1 DAY
Hours Minutes
Johnson
DATE OF BIRTH
(Month, Day, Year)
SEX
2. Male
Sli'JE FILE NUMBER
SOCIAL SECURITY NUMBER
R
.. 166-70-3066
D.8J'E OF DE.8J'H (Mooth, Day, Year)
.. April 30, 2005
CITY, BOA
PLACE OF DE.8J'H (Check only one see instructions on other side)
HOSPITAL:
Inpatient 0
...
FACILITY NAME (II no! instiMion, give street and number)
BIRTHPLACE (City and
State or Foreign Country)
Qthe, M
(SpeOty)P
Ie.
RACE - American Indian, Black, White, etc.
(SpecIfy)
Black
1..
DECEDENT'S USUAL OCCUPATION
(~t-:o~~~d~eu~r~~r~f
. 110. Student 110. College
DECEoeporr'S MAILING ADDRESS (Street. CityfTown, State, Zip Code) DECEDENT'S
511 13 Street ~~~';NCE
Carlisle, PA 17013 ~~':.:;'ns
11.
FPJliER'S NAME (First. Middle. Last)
10. Freddie Johnson Jr.
INFORMANT'S NAME (T ypelPrint)
.... Celeste Fay
METHOD OF DISPOSITION
Burial rn Cremation 0 Removal from StateKJ
Other (Specify!
MARITAL STATUS. Married
Newt' Married. Widowed,
0Iv0r08d (Specify)
1~ever Married
SURVIVtNG SPOUSE
(tllNife. give maiden name)
Cumberland
Did
-.,.
Mve in a
township? 17d.~ :~i=of
MOTHER'S NAME (First. Middle, Maiden Surname)
11. Celeste Cunrnin s
INFORMANT'S MAIUNG ADDRESS (Street, CityfTown, State. Zip COOe)
. 511 B Street, Carlisle, PA 17103
PLACE OF DISPOSITION. Name of Cemetery, CrematOfy LOCMlON . CltyfTown, State, Zip Code
'" Qthe, Ploce
17c.D Yes, decedent lived Mt
two
17., State
17b. Cou
Carlisle
d1y-'
22b. FD-014404-L
To the best 01 my knowledge, death occuned at the time, date and place stated.
(Signature and Title)
21C.St.
1'17109
EA
E OR PERSON ACTING AS SUCH
LICENSE NUMBER
2...
TIME OF DEATH [).Q"E PRONOUNCED DEAD (Month, Day. Year)
2.. 11: 10 M 25. April 30', 2005
21. MRT I: Enter the diseases. injuries or complications which caused the death. Do no1 enter the mode of dying, such as cardiac or respiratory arrest, shock or heart falture
list ontyone cause on each line. '
b.
Head Injuries
DUE 10 (OR AS A CONSEQUENCE OF):
Motor Vehicle Crash
DUE 10 {OR AS A CONSEQUENCE OF):
...
IApproximate
: interval between
! onset and_
DUE 10 (OR />S A CONSEQUENCE OF):
d
WERE AUTOPSY FINDINGS
A\l\ILABLE PRIOR TO
COMPLETtQN OF CAUSE
OF OE.8J'H?
MANNER OF DEATH
DATE OF INJURY
(Month. Day, _)
TIME 'X~l1:Y.
Yes 0 NO~
INJURY I(f WORK?
Natural
o
)t
o
Homicide
Pendlng Investigation
g .:.pril 30,2005 aJ): 10 P'M.
O PLACE OF INJURY -AI home, farm, street, factory,office
~,",no,"'(Specify) Highway
Carlisle, PA
Yes 0
No 0
Accident
2811. 28b,
CERTIFIER (Check only one)
-CERTIFYING PHYSlQAN (physician certifying cause of death when another physician has pronounced death and completed llem 23)
To ttM beet 01 my knowtedge, death occurred due to the cauae(a) u1d ITlIInner.. atm.d. .. ...........,.,.
Suicfde
29.
Could flOC be determined
D
Coroner
'IIEDlCAL EXAIIINEAlCORONEA
On the .... of examination end/or Inveetlgetlon, In my opinion, death occurred ~ the time, date, end piKe, and due to the I*IM(.) end
menner.atmed,..,.......,........... ..,.......,.,.,....,.... . ,.,... ,...,..................".....,.. ...,
31..
REGISTRAR'S SIGN.8J'URE AND NUMBER
I.? I..?I~;) I
DATE stONED (Month, Day. 'I9ar)
D 31c. 31.. May 2, 2005
NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH
(lIem27)TypeorPnnt Michael L. Norris, Coroner
~ 6375 Basehore Road, Suite #1
~~. Mechanicsburg, Pa. 17050
DiQ"E FILED (Month. Day, Year)
-PRONOUNCING AND CERTIFYING PtfYSICIAN (PhysICian both pronouncing death and certifying to cause 01 death)
To 1M bn1 of mv knowtedge, deeth occunwd at the Dme, __, and pleoe, and due to the ceuee(a) end lnIInner.. atated.. .
H.
...
OCT- 5-05 WED 16:40 PHICO INS CO
7045284067
P.02
.
Register of Wills of Cumberland County
RE~UNCIATION
Estate of J'AmGe-~ 3h!lU-fb#
Also known as
No.~;? I:JOOrqcJfe7
. deceolsed
To the Register of Wills of Cumberland County, Pennsylvania
The undersigned rR€DDJ~ .:JOJ.I~II} FllrliEf(. 8E)lEA~J"'Il"
(Name) (Relationship) (Capacity)
of the above decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that
Letters Or A~mIHlrrMT'{)'"
be issued 10 ('EtES"ie F. ::13~
Witness my/our hand(s) this
day of
,20_"
Affinned and subscnbe<.lLbefore me this
~day of tJ di'(\~~::";'I"1 .
,I r .,~\ " t. t' , d/,/<
\I ~ ~".' ""~ ;-,(,.~ ',.t~.-"." ,"/..
/il j. /,-::: ~'~;'''''';''''''~:",'':<,'<,:.,
'~-!-~~. ;4, .fti/lfC;A!ivr< "'>:'::',,';;
Notary Pu he ~'::' >::'.J t,.~,_\"~""> ~~,';; .;-.t' ~:IY~, ,:>).;:,
;~ c.J~' \, C::.":J ' ',," " ;'
My Commission ;xpilps: hi ''" ' , /,
OJ "? J () C4 '0. ~.\,' ci U "-') .l ~:.:~:
(1 _ j 5 t .~~'~~::,~~f~'J,.~.' ,,~~e~:~:~'~~.:,~
(( "4 r:.r~"llI".,e~':I!:.~' .('. "~.) ':",
""1'" (;'U'~'T" \;,'Y-,/'"
("1 ;J 1, . ~""'~.'.,"
Or . flll'I:IIIII'" .
dk~~ ~~~~,
(Si~)
jJ. !J/~t33 r:-;, &i;n~5 0u, J q~~1
. (Address)
(Si&n8rure)
(Address)
Affirmed and subscribed before me this
_ day of
(Signature)
Register of Wills
(Address)
Deputy
J
(Signature and seal of Notary or other official
qualified to administer oaths. Show date of
expiration of Notary's commission)
so.;} I;' ~j
.v ,.,~j b ...'......