HomeMy WebLinkAbout01-24-06
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
'~I-o~-071
Deceased.
Social Security No. ,/,7q. 1 ~ r.? /1
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 CUr'r7iJ'= RLltf,JD County, Pennsylvania, with
h last family or principal residence at Lr'f./;t CI:U?LjSLl~- pI k'€ l tJ Ttt"q .
r"JECHflt/I.:-Sl3uR'/PtJ. (list street, number and municipality)
J 70 ~-()
Decendent, then G, e-f years of age, died ;TiJ.t (II' u. 4 R Y ), . , ~ ~t:J (J " ,
at 'S1I...vlER SI'RIIV'G TwfJ. &'/-1), Cr~a.i..I.fE hKt:r i-t1Pt(j fIlJ:rCtMA1l1i1~r;',jJR- /7tJS-()
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:
L/c'Otl.OO
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$
$
$
$
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Petitioner_ after a proper search ha_ ascertained that decedent left no will and was survivedliy
the following spouse (if any) and heirs: .,
:..:\
Name c
It::. '. It L.=oaio I:!W1/I(L/:.;-
;:ft. n2 <tl
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
COMMONWEAL1;H OF PENNSYLVANIA
COUNTY OF CUM Bl2RLi11-JD
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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~ and SUb, scribed f ;&~V7~ , SJ J-~
before me. this 2::1 day of ,_/
t't~X1 (+{ft","~; . ,',
, ilYl/I >Regl er
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No. 11-0Lo-UV1L
Estate of va I+N J. :5 LA 2EV { cH- JIL
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW ~ kl'-.i \;LNR '-i 2..i .Y'f-OlP , in consideration of the petition on
the reverse side hereof, satisfactory proof havin& been presented before me,
IT IS DECREED that Eot-J N IE.J: H8t>RI LK-
~are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to \!30N N I S s. HeoR I c..K-.
in the estate of oJ'oitN S. f3/ Az..&v'ILtt 11L.
~~vm
FEES ''7{\
Letters of Administration ..... $ 'VJ.OO
Short Certificates( I ) . . . . . . . . .. $ 4 . 00
R ., $ SoQ
enuncIatiOn ................ .
,.JGP 0.- A F $ r.~. b () _
Filed . .01rN! :~~~~~. ~.~.~. O~
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
HIO).X05 REV' ]/11)
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.
No.
)-~'.~~. ~b.>-&.~~
Local Registrar -...
Fee for this certificate. $6.00
D
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12045649
JAN
5 2006
Date
( ."1
H10S,144 Rev. 01106
TYPEIPflINT IN
P::::t.N,w:! 1/30-153
, Name of Decedenl (First, middle, last) I'S" 3 Social Security Nurroer 14. 0"", 0,,," (Mo''", d.y, y"'1
John J Blazevich Male 179 - 32 - 8811 January 2, 2006
5 Age (Las1 birthday) 6. Underl ear Under 1 dav 7. DaleolBirth Mor1lh,da , ear , Binh lace C' andslaleOfIoJ ncount Sa. Place of Dealh Checkonlvone
64 I Monlhs Days Hours I Minules I June 15, 1941 I Clavsbura p" I~Si:~:lienl o DOA I ~h~~rSin Home lI:I: Residence
v" o ERIOulD< lien1 o Qlher.S(JI!(';fII:
~ Bb. CounlyofDealh Be. City, BorQ:2.Jf Death ad. Facility Name (llnolinslilu1ion, gi'les1reetandnuntler) 9. Was Decedenl of Hispanic Origin? 10. Race:.American Indian. Black,White,elc.
qiCNo o Yes (If yes, specify Cuban, (Sped,"
Cumberland Silver Spring 6412 Carlisle Pike, Lot 1/9 Mexican, Pueno Rican, etc.) White
.
11. Decedent's Usual Occ alion Kind of 'M)J"kdone durin rooslofworkin li/e'donolslaterelired 12, Was Decedent ever in Ihe US 13 Decedent's Edocalion '" on h'hest radeco ."" 14. Marital Slatus: Married, Never married, 15. Surviving Spouse {II wife, give maiden name\.
KindofWor1< I Kind of Businessltndustry Armed Forces? I ElemenlarylSecondary(Q-12) 1 College (1--4 or 5+) Wldowed,Divorced(Sp6cify)
Store Clerk Convenience StOl e o v" )!j No 11 vrs. ~ever Njarried
. 16. Decedenfs Mai~ng Address (Slreet, dtyr1own, slale. zip code) Decedenl's Pa. Did Decedent
6412 Carlisle Pike Lot Il9 k1ualResidence 17a. Slate liveina 17c.0{ Yes, Decedenl Lived in Si 1 "er ~T.'rin<J 'l'w[f'F
Townsh~?
. Mechanicsburg, Pa. 1705) 17b Co,"~ Cumberland 17d.O No, Decedenllived within
Actual Limilsof CityiBoro
18 Father's Name (First,middle,IaSI) 19 Molher's Name (Firsl, rr<<tdle, maiden surname)
John J. Blazevich II Genevieve Rhodes
203. Informant's Name (Typelprinl) 2Ob. lnformanl's Mailing Address (Slreel, CityAoWl1, stale, zip code)
Bonnie J. Hedrick 109 Souths ide .Dr. ~ewville, Pa. 17241
218. Method 01 Disposition 21b.DaleoIDisposrtion(Monlh,day,year) 210 PO,,,' O;,po,'.' (N,,,,, 0' """'e~, ,,,ma',,,,, oih" p""el , l'''. ""',., (Cily'"", ""', '" codel
- o Burial d{Cremalion o Removal from Srate o Donation
o OIher-SflI!dfv: Jan '4 2006 u~'H~~~~ FB/Crsmatorv Inc l\1t. Bollv Snas.Pa.1706c
~ 22.. E"l'~"I~L-;''''(''P''''''''.''',"'"1 I ;~<~'~ ~u~.~ 8 9 122'. N,,,,, '''' Add,,,, 01 ''''ily 5 0 1 N. Baltimore Ave.
. L Hollinqer FB/Crem.lnc.Njt. Bolly Spgs. Pa. 17065
Co~lelel!erns23a-col'llywhencertifyino 23a. Tolhebesl01/'lly' knowledge, dealh occurred a1 Ihe lime, dale and place staled. (S ignalureandlitle) 23b. license Number 23c.DaleSigned(Month.dsy,year)
physx:ien is not available al time 01 deelh 10
certilycauseofdeath.
. nems 24.2tJ mJsl be COlTllleted by person 24 Time of Death Aprx. I~ Dale Pronoun.:ed Dead (Monlh,day, year) 26. Was Case Relerred to a Medical ExaminellCoroner?
~ who prooouncesdealh. 7:00 A. M. January 2, 2006 t,\-~Y" o No
CAUSE OF DEATH (See KlstnJctlons and examples) ,Approximalein1erval: ParlII: EnlerolhersionificantcondrlionsconlributinolodeaIn, 2B Did Tobacco Use Conlrmle 10 Death?
ftem27. Part!: Enterlhe~-diseases, in~ries,orco~licalions-thatdifectlycausedlhedeath. 00 NOT enter lerminal events such as cardiac arrest. onsel10 dealh but notresuftingin1he underlying cause given in Part 1 DYes o Probably
respiralory arrest. or ventricular fibrillation wrthou1 showilg lhe eliology. 00 NOT abbreviale. Enler only one cause on a line o No o Unknown
IMMEDIATE CAUSE (Final disease or Probable Myocardial Infarction 29. II Female:
condijionresullingindealh) -? .. o Not pregnant within past year
Sequentiallylislcoodilions.i1any, DUOI~(~i~~i~;ce~~ronary Artery Disease o Pregnanlallimeoldealh
b. o Nolpregnanl,butpregnanlwithin42days
- leadIng 10 the cause Iisled on Linea. Duelo(orasaconsequenceo~: o/death
Enler lhe UNDEAl Y1NG CAUSE
. (diseaseorifljurylhatinijiatedlhe ,. a NoI pregnanl,but pregnanl 43 days 10 , year
events resufting in dealh) LAST. Due 10 (or as a consequence 00: beloredealh
d. o Unknown if pregnanl within the past year
308. Was an Autopsy 301:1. Were Autopsy Findings 31. Manner 01 Dealh 32a. Date of Injury (Monln, day, yearj 32b. Describe how Injury Occurred: 32c. Place of Injury: Home, Farm, Slreet, Faclory, Office
Performed? Available Prior 10 CofTlllelion )l Natural o Horricide Building,elc.(Specifyl
of Cause of Death?
o V" )(.No o V" o No o Accident o Pendinglnvesligalion 132','niu~"W"k? 321. ItTransportalionlnjury(SpeciM 32g. Localion (Street, cityl1own, slale)
32d. Time of Injury
o Suicide o Coukl Nol Be Determined DYes 0 No o DriverlOpefalor o Passenger
M o Pedeslr,i;l!\ 0 Other - Spedfy:
333. CertJfler (check only one) 33b.~''''y..~..,
Certifying phySician (Physician certifying cause of death when another physCian has pronounced death and cofTl)leled Ilem 23) ~ . Coroner
To the best of mr knoWledge, death occurred due to tlM! cause(5) and manner as stated __._......._._........." .............. .....~. ....., .............. ..........".............,..............0
Pronouncing and certifying physiciln (Physician both pronouncing death and certifying to cause 01 dealh) 33c. LicenseNurrber 33d.DaleSigned(Month.day,year)
To the best of my knowledge, death occurrad at lhe time, date, and place, and due to the cause(s) and manner as stated.."....... ................ ..- ....................."...,.......0 January 3, 2006
Uedlcalex.amlnerlcoroner NMi~t~e1. of ~~n lrorrt1~ c:use~r~~l~(~~~ Type/PrinI
On Ihe basts of examination and/or investigation, In my opinion, death occurred at the lime, date, and place, and doo to the cause(s) and manner as stated ,..,....ll.. 34.
35. A...~'tt!~"..~oC\'~~~~\..... . M, l~'::;;'"~;O~ 6375 Basehore Road, Suite #1
1 d,.1 \ I~I \ 101 Mechanicsburg, PA 17050
....
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH (CORONER) STATE FilE NUMBER
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(See instructions and examples on reverse)
Register of Wills of Cumberland County
RENUNCIATION
Estate of 0011(\ 3. 8/ Q le v/ elt 1il
Also known as -10 h /I{ :f 8 J CL 7...f!. rJ I c. h
, deceased
No. J2j - O{p.- Cl) fJ 1
To the Register of Wills of Cumberland County, Pennsylvania
The unde,,;gned ler /!/;; . L. 1!1/{) u u ({ A D / ()~ ( r'
(N e) (Relationship) (Capacity)
of the above decedent, hereby renounce( s) the right to administer the estate and respectfully request( s) that
Letters
be issued to
Witness my/our hand(s) this M!!?aay of
1~~~;~:bif~
My Commissi OTARlAL SEAL
Beverly L. Kelley, Notary Public
City of A ltnnl1a, Blair County
. ,.\y commission expires June 20, 2009
Or
Affirmed and subscribed before me this
_ day of
Register of Wills
Deputy
(Signature and seal of Notary or other official
qualified to administer oaths. Show date of
expiration of Notary's commission)
r;-
J gr./zIJOfC/
l
2006
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(Signature)
(Address)
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