HomeMy WebLinkAbout03-10-06
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of hf'(oy Me GtyalAJ
also known as
No.
To:
~\-~~- ~~'\s
The petition of the undersigned respectfully represents that:
Register of Wills for the
County of ~ \)" "" ~ . in the
Commonwealth of PennsYlvania
Deceased.
Social Security No. -.:J2./1- r5 ~ -'01 ;lo
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
.Deeendent w"' domiciled al den'h in {} .Lh1bPfl~ County, Pennsylvania, wi'h
hiS la" family 0' p,incipal ,esidenee at .216 ie. 11 .J, (brhv, -# I?- '1 ~ _.
(list street, number and municipality)
years of age, died h6ruevu ~ 7 __, f1j~oo~,
J
Decendent at death Owned property with estimated values as follIows:
(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: .;;(/n !:;.rn ...A (-6diS/~ Pl"'t 17()1.~
= .
$ nf"l <"":",-hl'ljo+t'
$
:=
-=
Petitione,_ afte, a pmpe' smeh h"-- aseenained thaI deceden, left no will and was SU"'ived hy
the fOllOWing spouse (if any) and heirs:
N e Relationship
1~"/3
I~
~~ 1,3
A/c 2''1<1'1
THEREFORE, petitione,(s) ,espectfully 'cquest(s) the g'an, of lelle" of admini","'ion m the
appropriate form to the undersigned.
~
'"
Ii ~~1ji~/~/:
<=: -::; -
",.::; -
~'"
~c..
"''-
3 0
'ii:i
<=:
Ol)
Vi
~~~~-~~-
- . "
- ,J __ _. 'II :0
=- , C"' '/))~J!/1LUjO
-..'("'} >;H:~T.-!:J
~==
fJO ; I hid 0 I (]\ill 90uZ
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.
Sworn to or affirm<<od and subscribed J~~ #~ ~ ~
befo,e me this '-"0 *' d.y of ~
....
"""... "" 3"""-- ~ ~
::~~~::o~~'t I
No. ~~ _'J~_'Jl.\S
Estate of ~"'!J A#c braw ,Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW "" ",""" " '" .." '" '" 10 ~, in consid".tion of the petition on
the reverse side hereof, satisfactory pr~of having been presented before me,
IT IS DECREED that \;:N\'-'-~ ~~"<. ~,~ ~
is,"", entitled to Lette" of Administr.tion, .nd in .cco,d witb such finding, Lette" of Administ,"tion
are hereby granted to ~,\\..\..~v-..~,,< ':"\' <0 ~\::.~
in the estate of \.. <<. ~ ~'" ~ \. ~ ~ ~ ~
FEES
Letters of Administration $
Short Certificates( ).......... $
Renunciation ................ $
$--
TOTAL - $--
Filed ..................... A.D. 19_-
,~~ ~ "'I'J-<"V'__"~'~' ~~''''~
c""' ~efister of WiHs ~ \
~ ~. ~~':\) ~~'j ~-\
~ ~~ ~~",,\\~-
ATTORNEY (Sup. Ct. l.D. No.)
ADDRESS
PHONE
HIOS.KOS REV I/OS
c.)..\_~~ _ ~~\S
This is to certify that the information here given is correctly copied from an original cer~ificate 0 death du~'y' filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records OffIce for permanent hhng.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fce for this certificate, $6.00
No.
li>- ~. ~b.>..~~
Local Registrar
p
12270079
MAR
2 2006
Date
q.
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
r_'
c:::~)
C:::l
C.Jf'"\
C)
HIOS.143Aev,01,{16
TYPEIPRINT IN
PERMANENT
BLACK INK
1 NameofOecedenl (Firsl. middle, lasl)
o
,&-
STATE FILE NUMBER
3. Social Security Number
5 Age (Laslbirtnday)
68
247 58
cld7
YIS.
Bb. Counly01 Deatll
o ERtOlJI lien!
9.
Other"
D DOA 0 NUrsVl Home
Was Decedenl 01 Hispanic Origin?
IX.No 0 Yes (tlyes,speciIyCuban.
Mexbn, Puerto Rican,elc.j
o Residence 0 Other-
10. Race: Amerkan Indian, Black. WhHe. ele.
ISI"CiM
lack
hi hes! radeco leled
College (1"" 0/5+)
14. Marital Slatus: Married, Never married.
Widowed. Divorced (Sp6dM
15. SurvMng Spouse (If wife, give rreiden name)
210 Fern Ave.
Carlisle, PA
18. Falher'SName(Firsl,rOOdle,lasl)
17a.Slale
PA
Cumberland
Did DeclldSrll
livsina
Township?
17e. IX: Yes,DecBdentlivlllfill
W' M'
North Middleton
Twp.
17013
17b. County
17d. 0 No, DecBdenllived within
kluallIr1itsor
c;"'''''''''
Not Ascertainable
2Oa. Inlotmanl's Name (Type/Prinl)
19. Molh8l"s Name (First. middle, maiden surna )
Harriet Me Graw
Willarnae Me Graw
2Ob. Inlonnanrs Mailing Address (Slresl. eity~wn, slate, zip code)
o
w
<J)
:;:)
<J)
<C
::J
<C
o RelTXlvallromSlale
21C. Place of Disposlion (Name of cemelery, Cfemaloty or other place)
210 Fern Ave., Carlisle, PA 17013
21d. locatDn (CilyJlown, slale. zip code)
Annville PA
......
24
Brothers Funeral Harre, Inc., Carlisle PA 17013
23b. License Nurrtl!H' 23c. Dale Signed (Month, day, year)
(
CAUSE OF DEATH (See instructions and examples)
lIem27, Pari f: Enler lhe~ - diseases. jn~ries, o. COmplicalions -Ihat directly causedlhe death. 00 NOT elllet lerminal events such ascan:fiac arrest.
.espialory aITes!, or Yentri':uIar fibriUalion wnhout showing lhe eliology. DO NOT abblevlale. Enler only one cause on a line.
=~~~;,~~~~J:~:d~f a. T r~ ~ r~~ '_r~._ t"'. ~ o. \
Due 10 (or as a consequence o~:
II,'
26. Was Case RefelTed to a Medical Examiner/Coroner?
DYes VNO
ParllJ: Enter other sianificanlconditionst;ontributino tOdealh,
bul noIresulting in the undertying cause givBl1 in Pari J.
28 Did Tobacco Use Conlri>ute 10 Death?
DYes 0 Probably
o No 0 Unknown
Sequentiatylislcoodkions,ilany,
leaditlg 10 lhecause JislBd on line a.
- Enlerthe UNDERLYING CAUSE
. (disaaseorinjutylhatin~ieled Ihe
evenlsresulting indeathj LAST
I-:. C'<-'>_""
o Yes r:(NO
d.
3Qb, Were Aulopsy Findings
AvailabIePrio'loCo~'etion
01 Cause 01 Death?
DYes 0 No
131 MannerofDealh
lIS Nalural 0 Homicide
o Accident 0 Pending Invesligetbn
o Suicide 0 Couk:f No! Be Deterlrined
32a. Dale Dlln~ (Monlh, day, year)
32b. Descrile how Injury Occurred:
29. II Female:
o Not pregnanl wlhin pasl yeaf
o PregnaJll allime of death
o Not pregnant, but pregnant within 42 days
aldealh
o Not pregnant but pregnanl43 days 10 1 yeat
belDredeeth
o Unknown if pregnant within Ihe past year
32c. Place of Injwy: Home. Fann. Skeel Factory, Offics
Building, sic. (SpedM
Dueto(Ofasaconsequenceo~'
Due 10 (or as a consequence 01):
35.
':~W(:\.D~~ ~~~~
IB.I II~' \ 10 I
(See instructions and examples on reverse)
'S2.!
-.
""
';1 S;' - (-lG
308. Was an Aulopsy
Performed?
32d. TItflB 01 Injury
32e. Injury al Work?
o Yes 0 No
321. If Transporlaoon Injury (SpeciM
o DtiverlOperator 0 Passenger
o Pedeslrian DOIher-Specify:
33b. Signaturea~ICer1ilier
S/ y '-<~r<-.-~
33c. License NutOOer
320. location {Slteet cityAown, SIale)
f-
Z
w
o
w
u
w
o
"-
o
~
z
33&. Certifier (check onlyonel
Certifying physician (Physician Clrlifying cause of death when another physician has ptllt1()Unced dealh and completed lIernlJ)
To Ihe best of my knowtedge, death occurred due Ie lheCOIUSe(s)and manner as Sblted----.-__.._._.___.._______._D
Pronounclng.and certifying physlclirn (f't1ysician boIh PronotJncing death and certifying 10 cause of death)
To the best 01 my knowledge, duth occurred at the time, date, and place, and due to the cause(S) and manner as sblled
Medical lxamlnerfcoroner
On the basis of examination and/or investigation, In my opinion. death occamed at the lime, date, and place, and due 10 the CilUH(S).iInd manner.as sa.ted_O
u.
----'I'
3Jd. Date Signed (Monlh. day, year)