HomeMy WebLinkAbout05-31-06
Register of Wills of
PETITION FOR GRANT OF LETTERS
E. ~vY\~+h) Yr. No. d 1- OLD - 4,0
County, Pennsylvania
Lj t\VL
also known as
Estate of
, Deceased
Social Security No. / (p 2. - 3(p- 9/ YO
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' OR 'B' BELOW:)
r-.)
Q A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the executor_ na:med in the lail Will
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ofthe Decedent, dated and codicil(s) dated: ~ --
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c.)
State relevant circumstances, e.g., renunciation, death of executor, etc.
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Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after exeeutiorD:l:t the
documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: . 1
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11 B. Grant of Letters of Administration
(d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate)
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Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse
(if any) and heirs:
Name
. il/e} fA
I 7~'f/
Residence
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(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in f!(1IrJ her Ia.n rl County, Pennsylvania, with his/her last family
or principal residence at :25 I1"i.sh CrO{J ROM. III ew v/J Ie. P A- / 7:Z '1-/
(list street, number and mu~icipality) , ~
Decedent, then years of age, died,~, at ..p:PYU a/"7 1"/, 2X>(p af IYkr.J7I1~u::J ( W V
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ ~ tJ ( 0 DO
(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:
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codici/(s) presented with this Petition and the
rant of letters in the a ro riate form to the undersi ned:
Form #RW-1 Page 1 of 2
(J6' - Y7<D
Oath of Personal Representative
Commonwealth of Pennsylvania
County of eumJ:;erlancL.
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
Decedent, Petitioner(s) will well and truly administer the estate according to law.
X 6lt~ -/z, ~ ,/If ,~~ I
Sworn to or affirmed and subscribed
before me this .saP day of
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No. 21- Olr D4l0
Estate of L )'rlY\ E. Sm ith , J Y"'.
Social Security No.: /ft,J.., - 3t:,- 11{10 Date of Death:
AND NOW, \
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Deceased
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, 'be Qoolo ,in consideration
ide hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters Testamentary of Administration 1f> ~ rA f\l\fN\t\<:..~
d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate
are hereby granted to C. ry s+aJ /'It . S yY'\ i +h.
in the above estate and that the instrument(s) dated
described in the Petition be admitted to probate and filed of record as the last Will of Decedent.
FEES
Letters ........................ $ 135. co
Short Certificate(s) ..... $ dO' 00
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Register of Wills U V ~
Attorney: [1:'511 /Y1. GI2.I::A5cw"; z.5t:9
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Pt), &).::
CarlL 56
7/1 ,2'11
I.D. No:
51'-' ilL? Co
Ly I1n f Situ '.fA
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Renunciation .............. $
Affidavits ( ) ............... $
Extra Pages ( ) .......... $
Codicil....................... $
JCP Fee ..................... $ 10.0'0
Inventory .................... $
Other ......................... $ 5- CO
Total................... $ 110.. dU
Address:
Telephone:
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WEST VIRGINIA DEPARTMENT OF HEALTH & HUMAN RESOURCES
BUREAU FOR PUBLIC HEALTH. VITAL REGISTRATION
PHYSICIANS I MEDICAL EXAlIIN TI~.TE!!8F
ROOM 165, 350 CAPITOL STREET, Es10N,i;WW I
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MARRIED CRYSTAL rwntESANO
138. ~....sTATE
PA
13b. COUNTy
CUMBERLAND
13t tNSIDE CITY lat. lIP COOE
UMITS?
("-HOIlOI 17241
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25 ~TE PRONOUNCED peAD (Month, Oay, ...... J
4:05
PM FEBRUARY 14
2006
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-'-orcOdliQn ~ SPINAL CORD INJURY W!~aIEXTENS~:~ ~~jj.\:'::':I:.rtv
teIul1Ing..dN1f>I DUE TO lOA AS A CONSEOUENCE OFI' PRESSURE ULCER
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thI,iilitialed _to
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DUE TO lOA AS A CONStOUENCE OFI'
DUE TO lOA AS A CONStOUENCE OFl
to death bul no! resulting in the undlItIyii'ogcause ... in Part l.
29 MANNER OF OEATH
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o HonlocicIe
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On \I1e _ d e___ and/or InIoeSllgalO>. "' my the .. dale. and lllaCe and !lUll 10 itle c~lln and."""",,, .... SlItell
31b SlGNATIJRE ANa TITlf OF CERTFIER
"JIAMMING XIE, MD
FI WHO COMPLETED CAl.ISI! OF DEATH (
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Form VS-002 (Rev. 6/92)
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