HomeMy WebLinkAbout11-10-05
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PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of 126s)\-\ \-e
also known as
(2 LL, ~oTT
No. ;</ - D5 - () '7 ~'-/
To:
Register of Wills for the
County of in the
Commonwealth of Pennsylvania
Deceased.
Social Security No. (07:>- ~ d -0 flU
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl
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~~c~ County, Pennsylvania, with
h <.e,{' last family or principal residence at "~ C. C(!. c..-r f7 Qn n\cc~ 'C n I..C~ b0.f5 I~
(list street, number and municipality)
Decendent, then G:"( , years of age, died
at~A J \}21 ru-r :t::!QSpd:CU
)
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:
me . , t k
,~~,
.':q "II OC.XJ' 0 Q k
$~~~:~
$
$
$
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
\call'l<0b."<5 Pt
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in ltlie
L:.,
appropriate form to the undersigned. t..n
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CCLn1kl J!Ct;7C(
} 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.
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IX
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No. ,..Q 1- C5' 01 ~4
Estate of~~<\n ,L~ V [}1-t'ort
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW I~O~l{I1IJJ;A Jp -W_, in consideration of the petition on
the reverse side hereo~i~factory ~~of h,aving been presented before me,
IT IS DECREED that ObRA+ t r 1 ~ ctt
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted td i~LBG-12- T P f' 21'--.t -e t:-
in the estate of ~o '")Q L ll. V 7 --f J! ~ e)B:-
~~~ ~ QA.1tVL/\
Register of Will~ 1-
FEES .
Letters of Administration $ L\5 U\.)
Short Certificates( ).,........ $ 'j\ .Gu
R@_l1"i<4io~-T."~""J9'.,:-. .. $ S' v'\)
. '~Ij> $ 11\ /1)
TQ.TAL _ $ to~-dD
Filed \.\,,,": J.Q ;'. .Q.<:'.. . . ., .. A.D. 19_
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
f1
Thi s is to certify that the information here given is correctly copied from an original certificate of death d~ly filed with me as
Local Registrar. 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. 7J
Fee for this certificate. $6.00
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H105.143 Rev, 2/87
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
TYPE/PRINT
IN
PERMANENT
BLACK INK
CERTIFICATE OF DEATH
STATE FILE NUMBl::R
SOCIAL SECURITY NUMBER
31 6 3 <...:.: ,3 2 -
"
AGE (last Birthday)
BIRTHPLACE (City and
Slate Of Foreign Country)
he
instruction
5. 6 7 Yrs
COUNTY OF DEATH
8b,
Cumberland
DE(:EDENTS USUAL OCCUPATION
(~i":~rl~~~iie~~od~~teu~n,r~/~t
Homemaker
Ellio t
Iwp
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I .j
\..;
~,~
'"1
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z
LLJ
0
LLJ
U
LLJ
0
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LLJ
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Z
16.
FATHER'S NAME (Fir9t. Middle, last)
18, W ill i a m 5 t u d t
INFORMANTS NAME (T Vpe/PIinI)
20.
METHOD OF DISPOSITION
Burial Q Cremation ~tlIno...al from Sldte 0
Odun city)
l1d. 0 ~ih~e~~~rli~:: of
MOTHER'S NAME (First, Middle, Maiden Surname)
19. Cora Barkh mer
INFORMANTS MAILING ADDRESS (Streel, Cityrrown, Slale, Zip Code)
20b. 6319 Basehore Road Mechanicsb
PLACE OF DISPOSITION- Name of Cemetery, Crematory
or Olher Place
clty/b"",o
PA 17050
5
lIems 24-26 must be completed by
person who pronounces death
23a.
TIME OF DEATH
24.1.:,5"0
/~\i.\<<s+",h c. Po.,cn>o
DUE TO (OR AS A CONSEQUENCE OF)
(\e,- y,C C"r
26,
: ApproKimale
: ~~:~~~::':~
27. PART I: EnYr th. d'......, mlun., or compllutlon. whh:n e.u..d the de.th. Do nol.nt.r Ut. mod. of dyt..g, .uch " c.rdlac or r..plralory .n.at, .hoell or Mart tallur.
UalonlyoMcau..on.ach IIn..
I L r
E
DUE TO tOR AS A CONSEQUENCC OF)
DUE TO lOR AS A. CONSEQUENCE OF)
WERE AUTOPSY FINDINGS MANNER OF DEATH
AVAILABLE PRIOR TO & D
COMPLETION OF CAUSE Natural Homicide
OF OEATH? D D
Accidenl Ptmding In'leliligalion
Ye,D NOf;?1 Ye,D NoD SUIcide D Could not be dl;;lermilll.ld D
DATE OF INJURY
(Monlh.Day, Yllaf)
TIME OF INJURY
INJURY AT WORK? DESCRIBE HCJIN INJURY OCCURRED
Ye, D No D
30a. 30b. M JOe,
PLACE OF INJURY - At home, farm, street, factory, office
b."Win\,l.f>1c (Sr""lfyl
28. 28b. 29. ~e.
CERTIFIER (Check onty one)
.~~~~:F~~tGor~~f~~~~~::,s~~:~hC~~~~i;'ia~u~ t~ g;:~.~~:~t:)~~3~K~J~~"~s h:t~C:~~l~.~~~:~.~ ,~~~~l. ~~~ .:~"~~~~~~.~ .i~:.r~ .~~.~..,
.PRONOUNCING AND CERTIFYING PHYSICIAN (Physician both pfOllouncinl.J death alld certifying to cause of Jeath)
To the he.t or my knowledge, duth occurred at the time, date, and plaea, and due to the c.ause.(a) and manner.s staled...
34.
DC
.WEDICAl EXAMINER/CORONER
~~~~:rb::I:t::.~.~ln.t10n and/or In\lullliilil'lon, In my opinIon, death occurred at the time, ~a~e:, ~~~,~~~,~~.', ~nd due to the eausu(a) and 0
31.
~GISTR~, ~~ SIGNATURE AN~ NUMBE~.
33. - , leN {1r.J.l I 1.21