HomeMy WebLinkAbout12-15-05
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate af A;:. ~ H,
also known as
/
CUi l-tt Sto
No. -.dJ - 05 ~ I oro
To:
Deceased.
Social Security No. I q J-/-. ~'O- (0 gc;~
Register of ":ills fOVhe lonc1.
County of t.I J (),1 EY III the
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), whc(0are 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.i 1 m D..ef laf'd County, P,e~lllsylvania," with . _
h(,l last family or principal residence at .]()({? C!CPJrtOoe.. "'fl. U!2cJ-. ,Jp ':705-;;0
(list street, nurltber and mun1cipality)
7 - 4- ,~) Ot/-
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:
$ [:AOC). (~
$
$
$
Petitioner_ after a proper search haS..- ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
,Name
FA /1,0-5:::7
'I
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration irGhe
appropriate form to the undersigned.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF ~~\~
} 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. f . /J ( / .
Sworn to or affirmt<d and subscribed f~udi.~
be~me this I O~ day of
~ i/I.d=S-
ill . '
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No. ~I-OS - lO'(l)
Estate of (4 (\P '-1Yl "lli \ l.l' l~ i 0
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW ~Q.Q }(y\hDJ... l5 W~, in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
LT IS DECREED that .
is/are entitled to Letters of Administration, and in a ord with such finding, Letters of Administration
are hereby granted to Qr"" ~ ~ ~ \ \. ~"'cg> r-
in the estate of Q...x~ ~ \::)o.\u.\ ",~\Q
~10~!JCW10A1~~~
Register of Wills ",
FEES
Letters of Administration ..... $ (~D . (X)
Short Certificates( ).......... $ l.\. .00
~Cfrr<.~.. $?, I....'O_S.OD
.:sJ5~~ $ \0. (..JU
TOTAL _ $ "3=t.C0
Filed . \'-?-.~. \. "?"".-. ~.q~,?:,. . .. A.D. ~---
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
~
II
RI\ 'l'~(\
This is to certify that the information here given is correctly copied from an original ce~'~ific~te of death dult filed with
Local Rcgi,strar. The original certificate will be forwarded to the State Vital Records OffIce tor penn anent fIlmg.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
me as
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Fee for this certificate, $2.00
Local Registrar
/1
JUL - 8 20,)4
No.
Date
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H105 143 Rev 2187
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
STATE FILE NUM8ER
TYPElPRINT
IN
PERMANENT
BLACK INK
...
z
w
o
w
u
w
o
..
o
w
:!i
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AGE (last 8IrtMay)
SOCIAL SECURITY NUMBER
3, 194 10
.,
COUNTY OF DEATH
88 Vrs
Ib,
Cumberland
White
DECEDENT'S USUAL OCCUPA nON
1~7~'IiI'7:Od.:t'~J,:dil
SURVIVING SPOUSE
(II wife, give maiden "111M)
lWp
Mechanicsburg, PA
Cllylboro
Holy Saviour Cemeter Bethlehem, PA 18017
NAME AND ADDRESS OF FACIliTY
22., Connell Funeral Home, PA
liCENSE NUMBER
.t,.hockortM.ftfal"'re.
21,
: Approximale
, interval between
: onset and dealh
PART II:
Other signiflcar11 conditions contri uting to death, but
not resulting in the underlying cause given in PART I
r
r:'c,(u('
Sequenllarty list condItionS
11 any. leading 10 immediate
. cause Enter UNDERLYING
CAUSE (OIsene or i'1ury
Ihat initiated evenls
resolllng on death) LAST
WAS AN AUTOPSV IJI.f:.RE AUTOPSY FINDINGS
PERFORMED" AVAILABLE PRIOR TO
COMPLETION OF CAUSE
OF DEATH?
r
DUE TO (0 AS A CONSEQUENC Of)
'T
vo'O
MANNEP. OF DEATH
NalUfal ~ Homicide 0
Accident Pending Investigation 0
Suicide D Could not be determined D
DATE OF INJURY
(Month, OIly. Year)
TIME OF INJURY
INJURY AT IhQRK? DESCRIBE HOW INJURY OCCURRED
28.. 28b.
CERTIFIER (Check only one)
.~~~~F:=.Gor~~~~::~J.s~r::a. ~~~~~:.r:: g.e:~.:=:r~}t'r ~~~rar. h~~r.i.~.~.~~~~~.~,~~~~.i~~~.~~~
2',
30., 3Gb. M.
PLACE OF INJURY. At home, farm, street. factory, omce
buildlng..le.(Spedfy}
3",
NoD
I 48-439 I
I I I I
July8,
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