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Home My WebLink About07-11-06 Estate of Register of Wills of Dauphin County, Pennsylvania PETITION FOR GRANT OF LETTERS 1,1 ,. O~-O{, t( No. ~~t:t,'rla ~8 r"-,...1~~ ~ also known as , Deceased Social Security No. '''1\ ..:;) ~ - Sc:2'1b Pctllionel(S}. who is/ole 18 year. of aoe Of aide" applvUe3) tOI (COMPLETE" A" OR "B" BELOW:) Q A. Probate and Grant of Letters and aver that Petitioner(sl is/are the execut Decedent, dated and codicil(sl dated named in the Last Will of the State lelevant circumst80(~es. e.g., ,enunciation. deat.h of executor. ete Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: ~ B. Grant of Letters of Administration (c,t.a., d.b.n.c.t.8," pendente lite; dtll80te ftbsentia; dUllltlfc minofitsle) 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 Relationship Residence -PoVG> G Ri ",^C S-. A N:C~ l (..> 'v S 0 ~ (C (list street, nul'nhel slId rnunfcivah,v) Decedent, then a years of age, died J. J ~ 20 05- c 4,q" L ISL~ RtGt..fJ/t-LMr"DIC'4 t , _, at '-' H.ocatlonj C E.,.N~''<-. ~l. Decedent at death owned property with estimated values as follows: (if domiciled in PAl All personal property .............................. $ (If not domiciled in PAl Personal property in Pennsylvania. . . . . . . . . . . . . . . . . . . . . . $ (If not domiciled in PAl Personal property in County. . . . . . . . . . . . . . . . . . . . . . . . . . $ Value of real estate in Pennsylvania ............................................... $ Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Real Estate situated as follows: 3s;'C:D~ 0 ~ ..-' <~,~ 00 ,UU Wherefore, Petitioner(sl respectfully request(s) the probate of the last Will and Codicil(s} presented with this Petition and the grant of letters in the appropriate form to the undersigned: Typed or printed name and resIdence RW-7 Oath of Personal Representative Commonwealth of Pennsylvania County of Dauphin The Petitioner(sl above-named swear(sl and affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(sl and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. I )(-d~k;:g~ Sworn to and affirmed and subscribed before me this I / f\- ~ 2c& - JJf.Urrk (fM f1U~ JUr ~Wut( Pp day of DECREE OF REGISTER Estate of fi&t tho WI. allhu- Deceased No. ;71-- /J1tr () b Lf also known as Social Security No: /71 - ~ t - S;L 7 (P Date of Death: -it /~ ro /2- [) q""- AND NOW, ~. ( ( , 20 0l.P , in consideration of the Petition on the reverse side hereon, satisfactory proof havi~ been presented before me, IT IS DECREED that Letters 0 Testamentary ~ Administration are hereby granted to Wil!IC<-.eA-t o. /3 ; r)] e.,/ Ie.' i1 < (Iii 1\ (: t . IWflfiente Ille, /luriill!r.' absentl.l, (JUfante rtll'I(Jlllill,') in the above estate and that the instrument(s), if any, dated described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Short Certificate(s).......... $ Renunciation.................. $ Affidavit ( )................. $ Extra Pages ( )............ $ Codicil.......................... $ JCP Fee........ ..:..~.t1).. $ Inventory & Tax Forms... $ Other............................ $ y(fl) ~t4-- Jiu/Uc ~s')~'L Registe' of Wills ~ ~.~+ Letters........................... $ 00.00 lS--V() Attorney: 1.0. No: Address: TOTAL................ $ 4Ci.60 Telephone: DATE FILED: RW-7a Hlll:,,;-';O." RE\ ji(l-" 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. ~'- ~:O~~~~ Fee for this certificate. $6.00 C' !~ 12045120 NOV 2 8 2005 Date TYPE/PRINT IN PERMANENT BLACK INK 1130-128 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH (Coroner) ,;l ,~p 10 /6~:;( ( H105.144 Rev. 1/91 ... ~ w @ o ... o w ::; '" z SEX 2. Female STATE FILE NUMBER SOCIAL SECURITY NUMBER DATE Qli.QEATH (Month, Day, Year.r' 4. ~ember 26, 2005 BIRTHPLACE {Ci,ty and PLACE OF DEATH (Check only one - see instruclions on other side) Slale Of Foreign Counlry) HOSPITAL' Inpatient 0 ... FACILITY NAME (II nol institution, give slreet and number) g~:;lylD RACE. American Indian. Black., White, etc. (Spedly) 10. White SURVIVING SPOUSE (U wife, give maiden name) Bitner 17b. Coun Did _nt Ilveina Cumber land township? 17d.D :;'::'-=~:I= ot MOTHER'S NAME (First, Middle. Maiden Surname) 19. Evel L . Ca.larnan INFORM1Ir8(rt:r.GMiddi;t~~Rd:.~Z;P~'i'lisle, PA 17013 PLACE OF DISPOSITION. Name of Cemetery, Crematory LOCATION - Cityrrown, State. Zip Code or Other Place twp. citylboro. 30/2005 LICENSE NUMBER 2Q.:rrnberland Valley Mem. Grds ld. Carlisle, PA 17013 NAME AND ADDRESS OF FACILITY ~ing Brothers Funeral Hone, Inc., Car lisle, LICENSE NUMBER DATE SIGNED (Monlh. Day, Year) 23b. 23c. WAS CASE REFERRED TO ME~L EXAMINERlCORONER? Yes~ NoD 28. ' I Approximate PART II: Other significant conditions contributing to death, but : InteNal between no1 resulting in the undertying cause given in PART l. ! onset and death j PA 238. TIME OF DEATH D,l(TE PRONOUNCED DEAD (Monlh. Day, Year) 24. 5: 40 A. M. 25. November' 26 J 2005 XT, PART I: Enter the diseaYs, injuries or complications which caused the death. Do not enter the mode of dying, such as cardiac or respiratory arrest, shock or heart fadure. Lisl CNlly one cause on each line Chronic Obstructive Pulmonar Disease DUE TO (OR AS A CONSEOUENCE OF): DUE TO lOR AS A CONSEQUENCE OF)' DUE TO (OR AS A CONSEQUENCE OF); NO~ Yes D No D Accident Pendjng Investigation D D D D Coroner d WERE AUIDPSY FINDINGS AVAILABLE PRK>R m COMPLETlON OF CAUSE OF DE.(I'H? MANNER OF DE,<>;rH D,<>;rE OF INJURY (Month, Day, Year) Natural ;& D D Homicide 288. 28b, CERTIFIER (Check only one) .CERTIFYING PHYSICIAN (Physician cerhfying cause of death when another physician has pronounced dealh and compleled Item 23) To the best of my knowledge, death occurred due to the C8USe(S) and manner as stated. , , . . . . . Suicide 29. Could not b8 determined -PRONOUNCING AND CERTIFYING PHYSICIAN (Physician both pronouncing death and certifying 10 cause of death) To the bat 01 my knowtedge, deeth occurred at the time, date, and p1ace,.nd due to the cause(s) and manner as stated. D,GJ"E SIGNED (Monlh, Day, Year) D 31c. 31d. November 26, 2005 NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE QF DEATH (Item 2?) Type or Prinl Michael L. Norris, Coroner ~ 6375 Basehore Road, Suite #1 ~ 32. Mechanicsburg, Pa. 17050 DATE FILED (Month. Day, Yea .MEDICAL EXAMINER/CORONER On the basis of examination and/or Investigation, In my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner as stated.. . . . . . . . . . . , . . . . . , . . , , . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318. REGISTRAR'S SIGN,<>;rURE AND NUMBE""" _., 4'\.. C'~,... "...1..1- \..... L' ~ H ~'-_CJt\.~..- ~ II H..I \ ID I 34. o os-