HomeMy WebLinkAbout12-13-05
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of L {J ~€rce, 'fa 11'(1 VI"
also known as p, ~ K-Y 1 a 1"(1 rI) I
Deceased.
Social Security No. IlN-1-f:2. - .J/j')t.f
~ 1-05-1010
No.
To:
Register of Wills for the nd
County of Clt>'JhPrla 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 was domiciled at death in
hi') last family or principal residence at
Dec~der~ 5~ r ~ars of ~~' died
at n If r osp, al)
f/;ff~~~b~) \wp. 'r'#ia :JM:):
cJl rn-o J L
$~
$
$
$
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:
Petitioner_ after a proper search hL-- ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name ,.-:-
.JI-'/I/ FA-
-(
t~-:--.:)
THEREFORE, petitioner(s) respectfully request(s) the grant of letters
appropriate form-to the undersigned.
,-) c..>1
of admiiiis~tion i~e
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF C l-lm 13 ~ lflrN /)
} 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.
Sworn to or affirme<;l., and
b fore me this , :;
~
subscribed
day of
5
f JJ;-,1.A!~~ i
I ~
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Estate of
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW .--D E:CC--'1V\ B ~~ /3 )6 05 , in consideration of the petition on
the reverse side hereof, satisfactoryyroof having b"'in l!!:.esented before me,
IT IS DECREED that _l:>oRI ~ DAY\f50bJ. J A-Lllh.J I
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
areherebygrantedto DORIS DltVV5DrJ TAI.-IPrN I
in the estate of 1....kvV R r2I\1Cf= Tit Ll PrN \
d~
Register of Wills
~
Letters of AdminfJ.'s ~~~~ ..... S Jqf~g
Short Certificates ... . ~ . . .. s Q 1FT)
RSRH..",,:g.l:aR J ...~.r..... $ ~'-
S
TOTAL _ SQ!J .rr7J
Filed ..................... A.D. 19_
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
HI05.R05 REV 1/05
This is to certify that the information here given is correctly copied from an original certificate of death duly 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.
Fee for this certificate, $6.00
p
11933725
No.
143 R..... 21B7
~~~~~
DEe 0 6 2005
Date
~~
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COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
STATE FlLENUIolBER
0_
deced'ilnt
liwina
17b,Co\lntv r.llmhprl;:ann townsl1ip? 17d.Ga ~~=of
MOTHER'S NAME (First, Middle, M.1den SUmlllll8)
1'. Helen Fedorka
INFORMANrs MAILING ADDRESS (SlreaI, ClIyfTown, State. ZIp CocIe)
2Gb.
PlACE OF DISPOSITION. Name of cematlll)', Cr8fT18fory
orOlherPlace'
21c.Con-Q-Lite Crematory 2~.chaefferstown, PA
NAMEA."lDADDRESSOFFACILlTYPart emOTe FH&CS, Inc.
NAME OF DECEDENT (First, Middle, Last)
1.
AGE (Laat tlirthday) N
Moo..
BIRTHPLACE (CIty alld
State f1/foreign Country"J
New KensingtonP
7.
54 YI'$.
..
COUNTY OF DEATH
.
Cumberland
East Pennsboro
50.
".
D:CECENrS USUAL OC".cuPATION
ld~~'=.":'~
.. 11.. Asst. Director 11b. State Gov't.
DECEOENrs MAILING ACDRESS (Sueet. CltyfTown. State. Zip Code) DECEDENT'S
541 Rupley Road ~~NCE
Camp Hill, PA 170ll ~~~:r-
...
FATHER'S NAME (Flrsl, Middle, Last)
18. Anthony August Taliani
INFORMANT'S NAME (TypalPrlnt)
....
METHOD OF DISPQSmQN
. Donation 0 Bc.IrilIl Dcr-llon~alhlmsIaIeD
. 21.. Othar(Spedfy) D 21b. December 7,2005
. SIGNATURE OF '" se e LICENSEE OR PERSON ACTING AS SUCH LICENSE NUMBER
22b.
Tothe beat of my knowlec:lge. dealh OCCllrredalthellme. dale an:l place slated.
(Signature.,dTlIIe)
"'-
TIME OF DEATH
DATE PRONOUNCED DEAD (Monlt1. ~y. V..r)
2S.TI .<
..
.
TT. PART I: _lMcI...._, ltl........ orCOlllpll...UO..._..._u.....dI. Donot._tt>oo ..ocI....<lylng, .""h..c...I....,,_p
UlUon/yOM._.on..clll.....
..".~.n_o'_rt'-ll......
C;:;/ (.,;j
,
ft-/ efH (','T. L
DUETO/ORASACOHSEQUENCEOF):
(' ~",H l r .,/
SaquentlalyllstCGfldlllons b.
lfany,le8dlngtolmmedlate
caute. Enter UNDERLYING {
CAUSE (Disaua or injuly _ c.
lhaI WllllBted events
~gondealt1}LA8T d.
WAS AN AUTOPSY WERE AUTOPSY FINDINGS
PERFORMED? AVAILABLE PRIOR TO
COMPLETION OF CAUSE
OF DEATH?
DUE TO lOR AS A CONSEQUEIvCE OF):
DOE OORASACONSEOUENCEOl'):
MANNER OF DEATH
"",," iii ""..""'" 0
......, 0 Pendinlllnves!illation 0
s_ O Could nol be determtned 0
DATE OF INJURY
It.4onlh.D~.~..,)
DATE OF DEATH (Monlh, Day, Year)
..
ER.QutpallMlD
00,0
R..__ 0 :e~) D
RACE - American Indian. Black, While.
(Spodlyl
10 White
SURVIVING SPOUSE
(d_.gr...rNl~"'''''')
1 ('--4",,5+)
MARlTALSTA1US .ManietO,
Never Married,WICIowoKl,
DiYorced{Spaclry)
14. Married
15.Doris Dawson
17c. 0 Yes, dKedenllivad in
...
""""""
LOCATlON.ClIyfTown,State,ZipCodepo Box 158
17088
,,,
, ,
(Month, D.y, Y811r)
23b. 23c.
WAS CASE REFERRED TO A MEDICAL EXAMINER /CORONER?
26. YesD. by FD np No 0
;Approllirnale PARTn: OtherslgnJftcanlconditlonscontribuUnglodefllh,but
. interval belween not resulllng In theunderfying cause given in PART l.
: onset and lleelh
L1CENS NUMBER
y
TIME OF INJURY
INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED
VesO NoD
30c.
..,.
PlACE OF If>lJURY
buIIdlllCl......(SpecIIy)
....
30b. to!
Athome,lann.lllnlet.faclDiy.otIIce
",.
LOCATION (SIreeI, CilyfTown, State)
....
81GNATIJRE AND TITlE OF CERTIFIER
/I.V,
YesD Nolll
YelD
"0
2". 21b.
CERTIFIER (Check only one)
'~~~Gof~=.g'~~~dUJ:i:3:'~~=<:r=',r~~~~~.~~.~~.~.I~.~.~~.).
".
.p~~~~~":i':G:k~;;==:O~::~1tPhJ:~m".~r=,~:'d-:~~U~j.~~~IISStaMd,.......
*MEDICAL EXAMINER/CORONER
On the bul' or.ll8ftIlnltLon anciIOI" InvllSt11l1ltlon, In my opinion, death occurred slIM time, date, and pl.ca, and due to the caus.als' and
manner..statMl...................................... ............................ ......................... .................................
318.
REGISTRAR'S SIGNATURE AND NUMBER
7~
1.1)1 l/.i / 1/ 1
.........0 31b.
LICENSE NUMBER . _ f __ _ DATE SIGNED Moo\"" OIly ~ar)
....0.31c. rtb (! /Lt 7). L 31d (/1 ''11$
NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH
(ltem27}TypeorPnnt 1., rl, ." C'\.;, t1P
J~: j)~I-, .ril~d. L-eMv,!rlf"', pl+iliJ'-I'j
o
".
DATE FILED (Month. Day, Vear)
,.])