HomeMy WebLinkAbout03-28-06
Register of Wills of Cumberland County
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of -:;:;.... L IV ,. S~ "" j I 'W No. :2-DD Ie)"" 0 2. (P g-
a/so known as To:
Register of Wills for the
County of Cwnberland in the
Commonwealth of Pennsylvania
. Deceased.
Social Security No. I tf~- I V - I'll 'Z.-
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl r
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
for letters of administration
on the estate of
Decedent was domiciled at death in ~{...l:ounty, Pennsylvania, with h.k last family or principa}
residence at I \{ t) (AI ~ c. \ &.. ~ ; ve.. , U-f ..JALAA, I . C 5- ~v:s ( ~ PH /~ :. 7Wr' ' "
(list street, number and mufucipality) f
C"I
Decedept, then %- S years of age, died ,c--t b zr . 200 , . at
/~/r ~j;",T P.J}~L'4
Decedent at death owned property with estimated values as follows:
(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: /qo W"J/." ~., ~~'t:.J.h''/\n I"JA
./ /
SO. ()OO.-
I
I 0 Of tTOO.. -
Petitioner-S:- after a proper search ha~ ascertained that decedent left no will and was survived by the
following spouse (if any) and heirs:
Name
,~ t?"'"
· ,""Cc "7'"
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form
to the undersigned.
Signature( s) of Petitioner( s)
<:BQ~~~
~~;t~
Residence( s) of Petitioner( s )
l\.~ e: E\m~QQ~ ~\le, I M~~.~~
llJ.olJe~)e\l J)" Mechtlnl"csbu ~ .Q1
/ I /
Register of Wills of Cumberland County
OATH OF PERSONAL REPRESENTATIVE
The petitioner( s) above-named swear( s) or affinn( s) that the statements in the foregoing petition are true and
correct to the best of the knowledge and belief ofpetitioner(s) and that as personal representative(s) of the above
decedent petitioner( s) will well and truly administer the estate according to law.
~~~~
COMMONWEAL TH OF PENNSYL VANIA
}
COUNTYOFCUMffiERLAND
Sworn to or affrrmed and subscribed
Before me this 2f?-lh
Mf1.YCn
day of
, 20 010
SS:
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en
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p--e^ ~cUpuh.pgister (J.
No. Ob - 0 L(oY
Estate of Jean LDUlStMrJJI'r', Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW '-1iVlaJt c.h.. :2-9+h 200&, in consideration of the petition on the reverse
side hereof, satisfactory proof having been presented before me, .
IT IS DECREED that !<..atQlj1l L. muler cznd- Ba..r.ha.r(J. O. ml lieV'
is@ntitled to Letters of Administration, and in accord with such fmding, Letters of Administration
areherebygrantedto {{OtOOle~. Mill!#' and MrbtJ./d (J. IYllller
v
in the estate of J ( tVJ L!Jc,.{ i S~ /YJ I i If r
FEES
Probate, Letters, Etc. ............. $
Will ................................. $
Renunciation...... ..... ....... ..... $
Short Certificates (5) ............ $
JCP................ ...... ..... .... ... $
Automation Fee................... $
Bond............................. .... $
Total $
Filed '-1YltlJvCA ~ 20 {){p
1-00.00
;Lb. 00
IO.OD
5',00
2 q5 00
~d a 7'aAluA -M1cu1~
. Re ister Of,WillS f&> ~ .. -~
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M~le Cu-,N6
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Addre~ ')J,.' II ,<?.A-
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Phone
H10" '<(1" RE" 1'(1"
This is to certify that the information here given is correctly copied from an original ce~ificate of death dulr 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.
~I'?~
Local Registrar
Fee for this certificate, $6.00
p
12226561
MAR 0 2 2006
Date
'.}
t (-,j
(I
c>~
3 Rev. 01106
'PRINT IN
AANENT
CKINK
1. Name of Decedenl (First. middle. IaSI)
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH STATE FILE NUMBER
Miller
7. Dale 01 Birth Monlh, da , ear
Feb.26,1923
8. Birth lace C' and stale or fore'
East Pennsboro
Other:
o ERIOu alient 0 DOA 0 Nursi't Home 0 Residence
9. ~s Decedent of Hispank: Origin?
No 0 Yes (It yes, specify Cuban,
Mexican, Puerto Rican, etc.)
14. Marilal Status: Married, Never married. 15. Surviving Spouse (11 wife, give maiden name)
Widowed, Divorced (Specify)
widowed
140 Wesley Dr.
Mechanicsburg,
17a. Slate
Pennsylvania
Cumberland
~~e ~:aedent 17C.)!i.. Yes, Decedent Lived in Lower A 11 en
Townsh~?
Twp
PA 17055
17b. Counly
17d. 0 No, Decedent Lived within
ktual Umils of
Cilylt3oro
18. Father's Name (Firs!. middle, Iasl)
Casper Thomas Effinger
19. Mother's Name (Rrst. middle, maiden surname)
Ruth Naomi Harris
20a. Informanl's Name (Type/print)
Raegene L. Miller
21b. Dale of Disposition (Monlh, day, year)
lOb. Informanfs Ma~ing Mdress (Slreet, cityAown, slale, zip code)
140 Wesley Dr.
Mechanicsburg, PA 17055
21c. Place 01 Disposition (Name of cemetery, crematory or other place) 21d. Location (CilyAown, state. zip code)
o Removal from Stale
o Donalion
2006
Rolling Green Cemetery
22c. Name and MOrass of Facility
Camp Hill,PA17011
17043
Musselman FH&CS,324 Hummel Ave.,Lemoyne,PA
23c. Dale Signed (Month, day, year)
23b. License Nurrber
22b. license NulTber
n,>lete Rems 23a-{; only when certilying
physician is nol available at lime of death 10
certify cause of death.
lIems 24.26 musl be COfT1)leted by person
. who pronounces death.
24.
Jl.pproximale interval:
onset 10 dealh
26. Was Case Referred to a Medical Examiner/Coroner?
o Yes ,., No
Parlll: Enter olher sianilicant cond~ions contributinn to death, 28. Did Tobacco Use Contribute to Death?
but not resuhing in the underlying cause given in Parl '- ~ ~~s g ~~C:~:
CAUSE OF DEATH (See instructions and examples)
Rem 27. Part I: Enter the ~ - diseases, injuries, or COfT1)lications - that directly caused the death. DO NOT enter terminal evenls sue as cardiac arrest,
respiratory arrest. or ventricular fibrillation w~hout showing the etiology. 00 NOT abbreviale. Enter only one cause on a fine.
IMMEDIATE CAUSE (Final disease or C \t A
cond~ion resutting in death) -7 a
b. Due 10 (or asst~
Due 10 (or as a consequence oQ:
DYes r1..NO
d.
3Ob. Were Autopsy Findings
Available Prior 10 CofT1)letion
of Cause of Death?
o Yes 0 No
31. Manner of Death
)( Natural 0 Homicide
o kcidenl 0 Pending Investigation
o Suicide 0 Could Nol Be De\e<<nmed
32a. Date of Injury (Month, day, year)
32b. Describe how Injut)' Occurred:
29 If Female:
~ot pregnant w~hin past year
~ nant allime of death
ot pregnant, but pregnant within 42 days
~ ~.' eath
~l pregnant. but pregnant 43 days 10 1 year
before dealh
o Unknown if pregnant within the pasl year
32c. Place of Injury: Home, Farm, Street. Factory, Office
Building, etc. (Specifyl
~
Sequentially lisl cond~ions, it any,
leading to the cause listed on Line a
Enter lhe UNDERLYING CAUSE
. (disease or injury that in~ialed the
evenls resuhing in death) LAST.
Due to (or as a consequence oQ:
JOa. Was an Autopsy
Perrormad?
32d. Time 01 Injury
33d. Date Signed ( th. day, year)
2>3bA3cL ~1) O~
34. Name a~~ ~r~~ CorrllJeled Cause of Dealh (lIem 27) TypelPrint
h 0 I. \4 b,^S'" ~'t;.. C~<> ~ \ \ \..,
32e. Injury at Work?
o Yes 0 No
321.
32g. Location (Streel, cityllown, slate)
M.
33a. Certlfler (check only one)
. Certifying physician (Physician certifying cause of dealh when anolher physician has pronounced death and COfT1)leted hem 23)
To the best of my knowledge, dealh occurred due to the cause(s) and manner as slated ..........._.........___......_..........._.....__.__...__.___.._.......0
Pronouncing and certifying physician (Physician both pronouncing death and certifying 10 cause of dealh)
To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and mannef as slaled......__.__._____..._O
. Medical examlnerlcoroner
On the basIs of examination and/or Investlgallon, In my opinion, dealh occurred at the time, date, and place, and due to the cause(s) and manner as slated_O
~5. f\egislm's S~ and O\sII~1 M-m w
~/Y/t:: 1;1..1/1~1/1/1
(See instructions and examples on reverse)