HomeMy WebLinkAbout11-28-05
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of m()~.Qll) A-. K fJC1CH2..--
also known as
No. c-21- 05 -- )03'-1
To:
Deceased.
Social Security No. l q.4 -. ~;) - Of S"2
Register of Wills for the
County of 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
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
. Decendent w"' domiciled at death in LU."':,~ fr.nty, J:,nn\ylvania, with
h Ie:. last family or principal residence at I 0., n' m(Jli:1tt s;( / !( f'r"? .t-} \ \ I / 70 / J .
(list street, number and municipality)
~cen&ent, th.en Ag
at \L, OI'Yle
e::~1{lb.QT) ~g
, -l-9 :20 Cl.. (',
years of age, died
Decendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property $ Iq 61rV
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled in Pa.) Personal property in County $
Value o. f real estate in ~nnsylvania .~ . d $ ~
sit~d as follows: "' I eo ^ &-to ,/ \ ~ 0' '"U f"Y\(J ~ Sf~ 4-1 .
~ ~'l"\\ \-\ It(. ( '~~('Ar-,rJ ('f)tJ-----;::r{~
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 of administration in the
appropriate form to the undersigned.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF HUJVTJNG'DDN
} 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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No. d 1- 05- 10,=)4
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Estate of fYlo::t\;)"o,,, h 12 0311 , Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW \;\llJve.VY\lQJA ~q
the reverse side hereof, saRsfa~tQry proof havin
IT IS DECREED that ~
is/are entitled to Letters of Administration, and in a . rd with such finding, Letters of Administration
'1t>c,)CDS;-in consideration of the petition on
been presented before me,
:et::'::a:~a:;ed~~b> ~ ~g~
FEES
Letters of Administration ..... $45 CO
Short Certificates( ).......... $ J c ,CO
~~~ ~-toD;<)...""b'\"-r $ 5. GO
,,=)~p $IO.cD
. TOTAL _ $ eo.=O
Filed ) ~:??~ :.C?~-:-.. .. .... A.D. 19_
ATTORNEY (Sup. Ct. J.D. No.)
ADDRESS
PHONE
H IWi)~f)"i RFV 1((\:"
This is to certify that the information here given is correctly copied from an original certificate of death duly file9 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..,
".. .
Fee for this certificate. $6.00
F
p
,
12140138
No.
11- d- -I)S
Date
-".'
(:--~-)
r,y
c.:..;.
H10514~ Rev. 1191
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
TYPElPRlHT
It
PEAMAHEHT
IUCI( INK
30-108
NAME Of OECEOENT (First. MicXte.lul)
. M.a t thew
UNOEA 1 YEAR
- Doyo
UNDER 1 DAY
...... -
lIWEfU...-.
SEX socw.. SECURITY NUt.mEA
Regan .. Male ..194-52-()452
ORE OF BIRTH EMRTHPt..ACE (Cay and PlACE OF DERH t'O-=* lWv an6 .. ilW'liCIIMI on~ ail>>)
(MoIc\. o.y. .....) &ate or Foreign CounI'y) HOSPITAL.: OTHER:
Oct.21,1957 Greenwich.conn _0 ::::00
~ ~ k
OF D€RH FACIUTr NAME (II nof~. QMlIlr....-ld number)
o
III
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A
0IlIEOf..~ _ Coy. \1o?i\
.. OctoDer 28, 2005
DId
-
.....
aJMBERLAND _1 17o.Ga ::;,.,-==.::
llOTHE...._lF....__Suname)
..~line M. Moore
lNfOllMANT'.llAII.IIIO ADIlAESS (SO.... Wbon. -. z., Codal
35 Farm Lane, James Creek" PA 16657
PlACE Of IlISPOSIl1ON ._.. "'- l.OCRIOll.~_ZIp
or 0hII P*- .
Harnsburg, PA 17109
Camp Hill
...
KIND OF 8U&NESSIINOUSTAY
~ DECEDENT EVER IN
U.$. ARMED FORCES?
...0 Nol!!!
Goverrunent
llECEllEHT'S
ACTUAL
AESIllENCE
(Sea-
on~1ide)
t7..Rbda
PA
17It.
___0
=-"0
IW:E._-.__...
-
I~ite
_SPOUSE
11-_-......
"""""-SlllfUS._
---
--
~.ever Married
11..0 ___......
..."
CaIrp Hill
v 3, 2005 ,
UCENSE NU~
C//tJ/'Q/-L
11UE Of llERH
ORE PRONOuNCED DEAO_. Day. ....,
October'31, 2005
-
VIO\SCASE
NoD
.. 6:00 II.
%7. MIlT I: E:-O:::= =':.~which~"'''-Ih. OOAGI.....lhemodtol~ ~ .ClrCllcor~"""'lIhac*orhewt 1IiiILq. !==-.
:GnMI..-ddeMt'l
I
H
ertensive Cardiovascular Disease
DUE 10 lOR ASACONSEOUENClO OF):
DUE 10 (OR AS ACONSEau€NCE OF),
DUE 10 (OR AS A CONSEOUENClO OF):
.
MAE AUfOI'St FINOIN08
~PAIllR1O
COUPlETlON OF CAUSE
OF Dl!RH7
lIANHEII OF DEA7H
I'MT'" 00..__-....._...
..._....~....._.."""L
Seizure Disorder
TIME OF OWRY
-
ORE OF INJUAV
-Day.....,
o
o ~
O PlACE OF INJURY. AI. home. r:.nn,...... **-Y. of&>>
-....--
-
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-
--
--
~
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... 0 No~ ...0 No 0
- _.
caR'fIIIER (Ch<<:a ontv one)
-CUlTWYING PHVSICIAH (PttyIiciIln ~~ 01 ~ when anoGler ph.,.... hM pr~ deelh Wldc:ornplNd n.m 23)
.....bMtDfmyknowNdga.......OOCIIntld.........C8Uee(.)and__...,.,.........................................,.......... .
-
zo.
CouAd not bit dIittlm1nId
-1tRONCMJNQrtQ AND CBlTWYINQ ItKYSICIAH (Ph~ boIh pronouncing ~ and <*1lfying to CauM 01 dMIh)
TolfM"'oI"r~.4eftIb____""''''''''''andprlac:lt........Io'''''''.''''''''''''''''''''''"""""""""""" .
'1WlICAl.~
OnIll4_ol.__..-..u.n.In""opIn.....__..Ill4_......_~.__I.__.I_
ftWNW..M8ted............................................. ................................................_
31..
REGiSTRAR'S SIONArURE AND NuMBER
_AND
o .... Coroner
LICENSE """__0.,.....,
o ... 1 NoveDlber 2, 2005
"""" AND AOORE$S OF PE!'SQN WHq COWl.E1EDCAUSf OF DUJ:H
(.....27)Typo........ Micllae~ L. Norr1s, !;oroner
6375 Basehore Road, Suite #1
~~ Mechanicsburg, Pa. 17050
DArE FIlED I"""'. Coy. .....,
...
-,)-cJoo~
HIO\.905MS REV.(Ol/03)
This is to certifY that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records In accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
~/I~
Charles Hardester
State Registrar
0434718
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FEB 02-2004
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Date
C)
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-..J
Ht05.14J Rev, 2187
COMMONWEALTH OF PENNSYLVANIA. OEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
121282
T"tPE!PAINl
IN
PERMANENT
BLACK INK
81
UNDER 1 YEAR
- Days
SEX
.. Male
STATE FILE NUMBER
SOCIAL SECUF=ltTY NUMBER
NAME OF DECEDENT (FlrSI Middle, :..as)
t. VINCENT F. REGAN
,. 048 - 18
v"
UNDER 1 DItt
"""" 1 M""..
BIRTHPLACE Ie"" and Pt.4CE OF O€ATH {C~1t Ofll,. one '>ee ,n!!1UCliOfl!; 0" ort>e! SIde)
State Of Fcre.gn Countlvl HOSPITAL
Inpat..nt ~ fRlOotpat~ 0
7 Ia.
FACIlJ'T'Y "'AME (II nol ~S1'11JIlon. give SlIeel and numberl
AOE {La~ Birttlday)
..
COUNTY OF DERH
"
oeCEDEfIIT'S MAILING ADORESS (Street. CltyfTown. State. lip Code)
MARITAL STATUS. Man14td
N.......Marri&d.WidC)wed.
DNorcecl (Speedy)
14. Married
RACE. Amencan Indian. Black. WhlI:e. Me
lS~)
,..White
SUAVMNG SPOuSE
(If .....1.. >JIve milId8n namel
!y'~
Dauphin
...
DECEDENT'S USUAL U ION
((~r:"~~~~::~,:f
Hospital
...
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35 Farm Lane
l~James Creek, PA 16657
FRHER'S NAME (First. Middle, last)
...Martin J. Regan
INFQAMANT'$ NAME (! ~Print)
~s. Arline M. Regan
METHOD OF DISPOSITION
O Burial 0 Cr..,.liOn!Xl Removal fro", Slat. 0
DoN1ion Other (Specify\
. 21.,
. SIGN.vuAE OF F
DECEDENT'S
ACTUAL
RESIDENCE
tSeetnstrUClIOO8
OI'Iolt1efslde)
17.. Stale P A
17b.Coo
0"
-
liW....
_,,7 17..[ij :...""::'..':::'.. James Creek
MOTHER'S NAME (Frst. MIdCle. M/JIden Sv.rname)
11. Elizabeth Anderson
If,fF'()RMANrs MAIUHG ADDRESS jsateet. CIfy!Town, sa.e, Zip Code,I
35 Farm Lane, James Creek, PA 16657
PlACE OF DISPOSITION. Name otc.mewy. Cremarot)/ LOCATION. CilylTown. Sttile. z:a.>CodII
..""*"*"
17c.D .....~Ilwdit\
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21J:ast
PA 17109
003
23b. 23c.
Vt6'S CASE FtEFERAED 10 MEDICAL EXAMINERlCOAONER?
VA.. \tl
NoD
...
I Apptollimlll.
linteNat~
: OnMt and Mdt
I
i
PARTH:
O<<fter~~~lOdNth.bul
not rMuIting in the Uf\deIty\ngca.- Qiven in PAAT I.
Pc c."
"..,..IL~ .
t:
C o!\'r~ /t/",S c.", (...,,-
..~T
WERE AUTOPSY FINDINGS
"""'lABLE PRIOA 10
COMPlETfOH OF CAUSE
Of' DEIlTH.
MANNER Of DEATH
DATE OF INJURY
(Monlh. Day. '!'ear)
TIME OF INJURY
INJURY If1 'NOfU(1
DESCRIBE HOW INJURY OCCURRED.
N......
GO
o
o
HomiCide
PendinV ,"vntigatiOtl
o
o
o ~E OF INJURV. Al hOme. farm, 1tl'Ht.lactOf'1. office W.
buildlng, etc. [Spec"")
....
,.. 0 NoD
_0
NoD
A(cidenC
"""ido
Coukl nee bit determined
o
.28a. 2R.
CERTIFIER lCheck only one}
-CERTIFYING PHYStCfAH (Ptlys1Cl$n certdyirlO catJseofdurh whfJ(! anoltlBf t:lt1I'SlC>anhas plonounced dealf'l af'O comP1eled Item 23)
Tohbntotmyknowtedge, deMh OCC""" due to the CIIUM(a) and manneo,.. atMecI. ........ ................
'".
-PRONOUNCING AND CE"TIFYING PHYSICIAN IF't1I''ilCoan both plOfIOU!'1Clnl;j O@ath al'lCl certltylnoto cause 01 death'
To 1hlt.... c,t my knowledge, death occumtd.t me 11l1\li. doIle. and piau. and d.... to the eauH(s) and mann.'.. Nt... . . .
-MEDICAL EXAMINER/CORONER
On the baale o' .1Iamlntltlon and/or lnv..tlgation. In my opinion, d..th occurr.d
manner.. st..ed.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . , . . . . .
31a.
REGISTRAA'S SIGNATURE AND NUMBER
...