HomeMy WebLinkAbout04-11-06
Register of Wills of Cumberland County
PETITION FOR GRANT OF LETTERS OF AD~INIS~TION
Estate of. ~bi' e S~Cd \; S h:)[1C No. 'cl \'-0 193 7.-U
also known as D--l)\~)~ C::> hct:-.c To:
Register of Wills for the
County of Cumberland in the
Commonwealth of Pennsylvania
, Deceased.
Social Security No. Ii C (.;, Lf - c-.('l ~3
The petition of the undersigned respectfully represents that:
Yourpetitioner(s), who is/are 18 years of age or older, appl Y1l7)
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
for letters of administration
on the estate of
c\
Decedent was domiciled at death in LLAri\.h.e c ic.. ((;ounty, Pennsylvania, with h_ last family or principal
residence at J-'-\ ~ K1L.-6- u..Je:xs<::L L \\.) <.:? (' \' \ ~ <;, \ ~ .? ~ I/C) \ 3
(list street, number and municipality) .
Dece~ent, th~n ~ () years ofage~ died f}\Jr; \:;: ,20 () lo , at Lt'L/O
CC~1. \ '- '::J l "- .~ ~C\ \ a '0(I......\. \f\*, <\ \. iC'rC, \ C' 'ff, \<2 \"
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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:
J. D Ot:>
,
$
$
$
$
Petitioner_ after a proper search ha_ ascertained that decedent left no will and was survived by the
following spouse (if any) and heirs:
Name
. \' \, \\~ 'S \,0 v.' _ 'd--I..\
THEREFORE, petitioner(s) respectfully request(s) the grant ofletters of administration in the appropriate form
to the undersigned.
Signature( s) of Petitioner( s)
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Residence( s) of Petitioner( s)
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Register of Wills of Cumberland County
OATH OF PERSONAL REPRESENTATIVE
COMM:ONWEAL TH OF PENNSYL VANIA
COUNTY OF CUMBERLAND
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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 lmowledge 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.
{
R VA P LJJdL 9 XJ~16
Sworn to or affIrmed and subscribed
Before me this / I ......--L day of
/1/~n/ , 200 It:?
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No. 2 (-- () ~-
Estate of S h 0 (~ \~ ~~~\ e.:~ . Deceased
I
GRANT OF LETTERS OF ADMINISTRA nON
AND NOW ( 20tfb: in consideration of the petition on the reverse
side hereof, satisfactory r9Qf~avi' g beep. presented b~ore my,
IT IS DECREED that LL:( v I /l fA c... J J fw t/-
Ware entitled to Letters of Adp;1inistration, aiid in accord with 'such fmding, Letters of Administration
are hereby granted to C7( v (I /i -I (j ,C; k r)H
t<ohtr,\~
IS~ fvfc ". f .J ), ~ __
c/<fJ~. /a..iff~ .Y6z; J' ~~ (
- r9l ~ ~ ~ /7L/J&/V7/C~;/ /
Register of Wills /
in the estate of
FEES ;l 0
Probate, Letters, Etc. ............. $
Will................................. $
Renunciation.... .. . .. . .. .. .. .. .. . .. $
Short Certificates 0) ............ $ /2--
JCP. . .. . .. . . . . . .. .. . . . ... . ... .. .... .. $
Automation Fee................... $ ( u
Bond................................. $ '5
Total; - . $ 0 7
Filed 1( {t I W 20 (rf ../
1 iW {
Attorney (Sup. Ct. LD. No.)
Address
Phone
11:" :-'11; R\\ 1\-';
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.
Fcc for this certificate. $6.00
11.~~. ~eu..~~~
Local Registrar
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APR
3 2006
No.
Date
;2F()&~JJ-e)
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H105.l43 Rev. 01JU6
TYPEi1"R1NT IN
PERMANENT
BLACK INK
1 Name 01 D<<edeffi (Fwsl, middle, last)
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15
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COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH STATE ALE NUMBER
5 ,...(""tbirthdaYI
40
Top
3. Social Security Nurrber 4. Oa1e of Death (MontIl,aay, yearl
Robbie S. Shoff
170 - 64
April 2, 2006
Yrs.
Other:
tient C DOA 0 Nursin Home 0 Residence 0 Other.
9. rr'~fC~~:=~t~uban, 10, (~Ameranlndian.8laCk,Whle,e\c.
Mexican, Putt10 Rican, etc.) .
wtute
14 Marital stalus: Married, Never married, 15. Survivi'lg Spouse (II wile, give maiden name)
WJdoW~, OiYorcod (Spocif)j
Bb. County or Death
\ .
Cumberland
Carlisle
11. Decedenrs usual Otc alion lnd 01 wof1l: done durin onslofworkin .Ie' do not slale relill30
Molde~indOIW<l<k Carl sle Trr"~Bu'&'~~l Co
16 Decedent's Mailing hkIress (Street, cllyflown, stale, zip CXlde)
Did Decedeol
Liveina
Townstl,,?
17c,]I: Ves, OecllOent U,ed" Middlesex
PA
Cumberland
17a. Stale
243 Redwood Lane
Carlisle, PA 17013
18. Farhat's Nan (FII'SI. rrD:De,IaSI)
17d. 0 No, Decedenl !.Ned within
Aclual limits of
clty,tloro
17b. Counly
19, Mothefs NamB (FIrst, middle, maidetl surname)
John W. Shoff
201. I~brm,"fs Name (Typ&'ptinl)
Barbara A. Watkins
200. Infomanfs Maiting Address (Street, cilyltoWfl, stale, zip code)
Ger linda J. Shoff
243 Redwood Lane, Carlisle, PA 17013
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28. 0., T ob8aXt UN Conl1iMe 10 Oea#l?
o Vos 0 I'!ObabIy
DNo(;}-l!n"-
29. II Ferrele:
o Not pregnam witltir plSl )'8lIl
o Pregnant at lime of death
o NoIp__nl,bulp,_nt_42days
01 death
C Not pregnant, but pregnanl 43 aays 10 1 year
betoredealh
o Unknown if preonant wiltUn the pasl year
32c. Place of Injury: Horne, Farm. street, Facroty, 0ftic6
Building,etc.(Sp!lCiffj
21b. Osle 01 Disposilion {Month, day, year)
21c. Place of Disposition (Name of camelary, crematory or other place)
21d. Location (Cityllown, state, zip code)
Carlisle, PA
eorrpe{e lems Z3a-c only when certityng
pllysnn is not availebtl al tine oldaath 10
certify causa of duth
. Items 24.26 nust be COfJ1lleled by person
who pronounces daaltl.
EWing Brothers Funeral Hane, Inc., Carlisle, PA 17013
12JO I ~S 1\.1 R~Si~2>2Lo-L fuiiuitoni'7"'i:OOCD
26. Was Case Referred 10 II. Medk:al ExalOOerK:ooloef?
0(0 t:l Vos cv6"
25. Date onounced Dead (Monlh, day, year
. Ju.L
CAUSE Of DEATH (See instructions and examples)
lI.em27. Part t Enter the ~ - d$eases, il~ies, Of corfllli:alions - that direcUy caused \he dealtl. 00 NOT enter lennlnal evenls sl.dlas cardiac arwt
respiratory arrest, or venlrk:uIar fmrilalion Mhout showIIg lhe eliOOvY. 00 NOT abbrevtate. Enter only one C8\J$41 on 8 &ne.
=~~US;r..7.:d"'~ . I'rf/lll-?- th/l-JJJv 1lBt'IM'f/~ F/J1 vJlVt- ,
O~Io{"'a'a~op; _ / /J ,I ~ 'IJ J. /Aa.:.
b. tf.IJ[ ''', t7'! "UtJ!J1:H,.vr 1tt"tJ-'/ : 11 frflfflt- riJ 'l-"I-v :
b "'..lo,," consequenc. oQ: /l... - I ' /. .~:
1Ylt--rk(.fA-riJ tndt1?,c-1111"-' M- ~ ~ptr> V)Jt :
DU{ 10 (di- 3S a consequence of): :
Part II: Enter olher 8lnnificanl condiOOn... cnnllhdinD kI dealh,
but no! resuling in the underlying cause jjYen in Part'
: Approxirreleinlerval'
: onsello deal.tl
Sequentially IsICl)f1dkions, if any,
1eedJn.Q101heC8UHistedonline 11..
- Ent8l' Ihe UNDERL \1NG CAUSE
. (diseaseorinjurylhallUtaledlhe
events rQ&U1ilQ i1 death) LAST.
308. Was an Amopsy
Perbmed?
g-(es 0 No
d
n. Were Autopsy Firw:lings
Available Prior 10 ~etK,"
of Cause 01 Dealh?
o Ves 0 No
32g. localion (SIr..!. dYAown, slate)
32b. Descrl:le how Injury OccUlTed:
31. Manner 01 Dealh
~Iural CHorric'de
o ~ent 0 Pending Invesligation
o SuicidE! 0 Could Nol Be Delermined
M.
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330. Certi1Iel' (check ""~ 0011
Certttylng physk::lan (Physician certifying cause 01 death when anottw!r physician has pronouoced d1931h and co~leted Item 231
V ;'o~u~~:':;:~:;;~~~~~~;;~:~;:~;:~~~;:::~~~i:::'::'::;:;e.;:..:~:....."':';.
Uedical examlnerlcl)ron8(
On the basis of examlnaUon and/or InvestlgaUon, in my Opinion, death occurred at the time, date, and place, and due to tne causei,s) and manner IS stated. ......0
33d. Date Signed
Ih,day, year)
'Wli
34. Name and Address of Parson Who Cool>Ialed Cause of Dealh {Item 27}TypelF'rinl
Df\.lI11-'4t-;Q tfu/Y)!?2- f ~ .
I ~ I \ I () I 87.-0 ;-lJtt.HV' &v 111"'1 /h:J.' C11J'V11SYf- ,fe--IfWJ
(See instructions and examples on reverse)
as
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