HomeMy WebLinkAbout01-18-06
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of~\o...~-~~<:~~ ~
also known as \..V, \\,G\,M..... ~
~ I-O~ -052
No.
To:
Register of Wills for the c..c...,v'\'\. ~ \;.....~
County of .~C>--'c-~'^- in the
Commonwealth of Pennsylvania
Deceased.
Social Security No. ~ c..:::> S --'-\'-\ - '18"-\ ~
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 ~~, ~ \o....",} County, Pennsylvania, with
h last family or principal residence at ..-, lJ...)~ ~ S<Ir "'i:-'0.;,,-,,,, ". A. \IOd5
(list street, number and municipality)
Oo<:y{
,~
Decendent, then S C)
at
years of age, died
~~
\.LQ
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 ha_ ascertained that decedent left no will and was survived!by
the following spouse (if any) and heirs: I,-..,:~I
Name Relationship
v 0-$' \.s1:.. '-'v. \,\...c
t~
<:~
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~VI tl ~ fl 110~
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration III the
appropriate form to the undersigned.
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This is to ce.iiiy ';"d the;
Local RCi"istrdf The onglli
.,::11]!( die ciC~llh clul:, fikd \\ lih tnl' 11'
IU,_ ()tfice tOI P','li llanelli filing.
W I\RNING: It is illE,:gal to
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photostat or photograph,
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10885541
1\',
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l)a!<'
H105144 Aev. 1191
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
c.
TYPEiPfUNT
IN
PERMANENT
BLACK INK
BlRTI-lPLACE (C.ry ana
SiateorForetgnCounl')')
DATE OF DeATH (Nonltl. Oa~ 'Mar)
October 16, 2004
~)o
MARrTAL.. $TMUS . Married
--.-
-(Spec",)
". Never Married ,.
RACE. Amedc:u Inc;tian, Bt&ck, WMc
",,*,,>,
to. Whi te
StJRVJ\I1NG SPOlJse
{n Me. g,.... maooen I1MleI
Ilb.
Cumberland
Enola
o
llJ
::>
:1
:J
-<
10 22/2004
L~...2' PERSON ACTING AS SUCH LiceNSE NUMBER
~ _,014404-L
10 !tie best or my knowledge, dNIh oo:urred at th8 bmI, dale and pW:e satlld.
(SV\alure and Title)
-
TIME OF DEATH ORE PRONOuNCEO DEAD ~MOilIh. Ooty, '-tl
..,4:41 PM II. 21, October 16, 2004
27. MAT I: Entef the....... irIfutiM Of c:ompIicetionallri\ich c:auMd thedMlh. 00 not ~ me moQlI of ~ tl.ICh U CUdi.ac at rMpi<"&%of'J &IrMI, Mol;:K Of hurl.......
UIt ~ one '*""ton -.h line.
2rc.
Lakeside Cemeter
NAIoIE MID AOOAess OF F-'CIUTY
.... Hetrick Funeral
UCENSE 'WilBER
Head Trauma
DUe 10 (OR AS A CONSEQUENCE OF):
23b. Z3c.
WM CASE REFERRED 10 MEDICAL EXAMlNERJeoA0HEA1
20, ,..IXI ~ HoD
'~imMI PAATu; Othertligniftcanc~~>>dNdl.bul:
: interval ~ not re&uIIng Irl the UftOettyIng C&UM gMn In fAAT I.
iDnMt and duch
b.
Due 10 tOR AS A CONSEQUENCE OF);
DOE 10 (OR AS A CONSEOUENCE Of);
d
WERE AUlOPSY FtNOINGS
~PAIORlO
COMPI.ETJON OF CAUSE
OFllERH?
MANNER OF DEATH
OATE OF INJURY
(MOlUh. Day, 'l'eat)
Oct 16, 2004
TIME OF JtlJURY
Approximately:
10:00 AM
INJURY Xl WORK?
"IOEDICAL I!XAIlINEIlICOIloNER
On.... baq of ~ and/or InMMIstadon. In my 0 . deet:tI 0CGUmId
..........8Iated........ .... ..... .....................
31L
REGISTRAR's SlGNA7URE AND NU"""R
~
w BJoomfiled
N_.. 0 _ 0
-- flU ,,-,_ 0
... 0 No [l!J ........ 0 0 PlACEOf' INJURY, AI....... _. _. ..""'Y......
- - ... """"001..__ ~-''''(S~)ConslruCtion site
~ccn-"""_ SIaN AN
-CER1lFV1NG PHYSICWt (PhV8ician ~ Cluaeof de.Ih tWhen anoNr ~hu Pl'onounc.d dMG'l ind oom~ kern 23)
1G...-.of..r..............Ih~..IOIhe~.J..........._-.a.d....................................... .
'"K)HQUHaNQANQ CEIlITIfrYtNG PtfYSICIAN (Ptl)'lleiwllXltl ~ dlMlh and~ 1Ocau.. of <*fI1
T........oI"'l'~ dMthOOCUfNd........ ctate. Md.... Md dull.. ....---<.)........................... ....
~9.n-:J
...
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUtYlI3~~D
} 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 ~r affirm"f and. mbscribed f ~~~ -
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01)
Vi
No. ~ - O(r -05 2
Estate of Q.LA1~K WILLI A1Yl BRon~f1~ ~, Deceased
GRANT OF LETTERS OF ADMINISTRATION
. . o~
AND NOW ~ JkJo.J jiB )11_, in consideration of the petition on
the reverse side hereof, satisw~tory proof having been presented before me,
IT IS DECREED that L:.t-A1:ZI<" W, LL I A-rn BI<OTlt Ef?:') 11L
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to (tj LM \{ WilL ( A1Y\ J3 fZ.O Tft eR.S ID:..
in the estate of (! LIVf<.I<- \tV j LL.-111-11l J3K.DTIf~~C; Sf'.
FEES ~
Letters of Administration ..... $ .
Short Certificates({ ) . . P((' . .. $ . .
Rt;l1Ull"~alitJH ~ . ~. . . . . . .. $ 1.').0
$ -
. . TQ~L _ $\J1. 00
Filed 0"kN.:.I.g .l.V. . .. .. A.D. 19_
Register~l V n !
ATTORNEY (Sup. Ct. LD. No.)
ADDRESS
PHONE