HomeMy WebLinkAbout09-06-06
Register of Wills of Cumberland County
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of. J{U:;Jjin,Lb- 11. fO$ti7pt..
also known as
No. J\ Olo O-~
To:
Register of Wills for the
County of Cumberland in the
Commonwealth of Pennsylvania
, Deceased.
Social Security No. Z{ J4 - r2- - J? '-;J YJ
The petition of the undersigned respectfully represents that:
Your petitioner~, who is!~ 18 years of age or older, appll e-i.
j, t? I) ,
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decedent was domiciled at death in ;;;'#YJ.t.lt~tounty? Pennsylvania, with.lti!:....last family or principal
residenceat 11r;-r LdtJ;7< 01,7.4 ))1'2((/': /Jltkl {;A/~f;/'21dj"-lbl /1/1 /7c7C>
(list street, number and municipality) /
for letters of administration
on the estate of
years of age, died
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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:
$ ~2.J&6cVI)
$
$
$ O..bO
Petitioner_ after a proper search ha~ ascertained that decedent left no will and was survived by the
following spouse (if any) and heirs:
Name
THEREFORE, petitioner(s) respectfully request(s) the grant ofletters of administration in the appropriate form
to the undersigned.
Residence( s) of Petitioner( s)
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Signature( s) of Petitioner( s)
ry6L ~oj ~
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Register of Wills of Cumberland Count;y
OATH OF PERSONAL REPRESENTATIVE
COMMONWEAL TH OF PENNSYLVANIA
}
SS:
COUNTY OF CUMrnERLAND
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.
~~,> ~/
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Sworn to or affIrmed and su scribed
Before me is
{
day of
200U
~~ljt~~LJ
Registpv~'- (. '1
No. d\ Ow C>1<61
Estate of Rc& LJ (3 ,"\1\ dwJ~ /t~ Deceased
GRANT OF LETTERS OF ADMINISTRATION
en
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20 J2!.a in consideration of the petition on the reverse
in the estate of
m,c1V/p ) J1/Ul..5,W{)C'.,..
~ :i~JM/lJJY()j 117 ,~ckr
Register of Wills ~ r- L
8 I l ':'?- ;/J / :l /
r~ ,i1~/paJ/ / fb-{/.fl<' ) IJ I Lj 2-
Att~rney (Sup. Ct. J.D. No.)
~o .06
FEES
Probate, Letters, Etc. ............. $
Will................................. $
Renunciation.... ... ................ $
Short Certificates (5) ............ $
JCP.................................. $
AutomationFee................... $
Bond....,............................ $
~otal_ $
Filed q -f l€' 20(j.p
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Address
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Phone
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W,ARNlNG' It is illegal to duplicate this copy by photostat or photographl,
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COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH . VITAL RECORDS
CERTIFICATE OF DEATH (CORONER)
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6 Da1eofBinh Monih,d
7, Birthplace Ci
Dale of Dealh (Month. day, year)
August 24, 2006
1, Name of Decedent (First. middle, last. suffiX)
Michelle
3. Sodal Security Number
Roswog
M
209 52 -
5. Age (Last Birthday)
12 Was Decedent evef in the
US, Armed Forces?
Dyes 181 No
Decedent's
Actual Residence 17a. State
Pennsylvania
Cumberland
17c, ijO Yes, Jecedent lived in
17d. 0 No, Decedent lived within
Actual Limits 01
July 15,1973
E. Pennsboro
33
D Inpalienl D ER I Qulp'benl D OOA D Nursing Home
9. Was Decedent 01 Hispanic Origin? [j] No 0 Yes
(II yes, specify Cuban,
MeXican, Puerto Rican, etc,)
Yrs
Bb, County of Death
ad, Facility Name (If not inslilution, give street and number)
Cumberland
1763 Creek Vista Drive
13. Decedent's Education (Specify only highest grade completed)
Elementary I Secondary (0-12) College (1-4 or 5+)
12 4
14. Marital Status: Married, Never Married
Widowed, Divorce-j (Specify)
Never Harried
11 Decedent's Usual Occupation Kind of war1\. dor1e durin most of workin ijfe.Oo nol state retired
Kind of Work Kind of Business f Industry
Benefits Coordinator Healthcare
16. Decedent's Mailing Address (Street. city / town, slate, zip code)
1763 Creek Vista Drive
New Cumberland, PA 17070
18. Father's Name (First, mK:ld~, last, suffix)
Francis E. Roswog
2Oa, Informant's Name (Type! Print)
Frank E. Roswo
17b.County
19 Mother's Name (First. middle, maiden surname)
Barbara Ann Lanko
2Gb Informant's Mailing Address (Street, city !town, slate, zip code)
7 Gale Road, Camp Hill, PA 17011
21b Date of Disposition (Month, day, year) 21c Place of Disposition (Name of cemelery, cremalory or other ~ace) 21d Location (City !town, slate, lip code)
r-..)
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-0
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en
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M Residence 0 Other - Specify
10 Race: American Indian, Black, White, etc
(Specify)
white
Lower Allen
Twp
City/Boro
Gate of Heaven Cemetery
lic Name and Address 01 Facility
Upper Allen Twp., PA 1705
23b License Number
arthemore FH & CS, Inc., P.O. Box 431, New Cumberland, PA 17070
23c, Dale Signed (Month, day year)
~
Complete Items 23a-c only when certifying
physician is r.ot available at time of death to
certify cause ofdealh
lIems 24-25 must be completed by person
who pronounces death
CAUSE OF DEATH (See instructions and examples)
Item 27 PART I: Enter the ~9~vents. diseases, InJunes, or complications" that directly caused the death. DO NOT enter terminal events such as cardiac arrest
respiratory arrest, or ventricular fibrillation withoul showing the etiology Usl only one cause on each line
Approximateinlef'lal
: OnsetloDealh
26 Was Case Referred to Medical Examiner I Coroner lor a Reason Olt1er than Cremation or Donation?
~Yes ON!)
Part II: Enter other ~ihonsconb'ibutino to death
but not resulting in the underlying cause given in Part I
24 Time of Death Aprx. 25, Date Pronounced Dead (Month, day, year)
9:00 A. M August 24, 2006
~~~d71~~A~~5t~~~~ J:~i~~ dise~
Lacerations to Neck
Due to {or as a consequence of)
Seq':'8ntiallylist~nditions,.ilany,
~~:~~o 0ND~~t~N<r ~~t;E
(disease or injury that iniliated the
events resulting In death) LAST,
Due \0 lor as a consequence of)
Due to (or as a consequence of)
3Oa. Was an Autopsy
PerfQl1Tled?
30b, Were Autopsy Findings
Available Prior to Completion
of Cause 01 Death?
31 Manner of Death
Describe How InWi Occurred
JUyes 0 No
g. Yes 0 No
o Natural 0 Homicide
o Accidenl 0 Pending Investigation
S. Suicide 0 Could Not be Determined
neck, self-inflicted
321, if Transportation Injury (Specify) 329 Location of Injury (Street. city I town, slate)
o Driver I Operator 0 Passenger
o Other - Specify
33b, Signa reand e rti
28 Did T abacca Use Contribute to Death?
o Yes OProbably
o No 0 Ul1known
29 If Female
o Nolpregnant within past year
o Pregnantaltlmeofdeath
o Notoregnanl,but pregnanl within 42 days
of death
o Not pregnant. but pregnant 43 days to 1 year
of death
o Unknown If pregnant within (he past year
32c Place of Injury: Home, Farm, Street. Factory,
OffICe Building, etc (Specify)
Home
33a, Certifier (check only one)
Certifying phYSician (PhYSician certityil1g cause of death when another physician has pronounced death and completed Item 23)
To the best of my knowledge, death occurred due to the cause(a) and manner IS state9_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - - - - - - - --
~:Ot~:u:~~~,a~~ ~~:~~~~:~~~a~~:~:r~~ ~~ht~~~~~~~i,n;n~e::~:;da~~rtiZ:9t~0 t~~u~:uo~e~~~t:~d manner as stat!d_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D
Medical Examiner I Coroner
On the basis 01 examination and I or investigation. in my opinion, death occurred althe time, date, and place. and due to the cause(s) and manner as stat!1. _
33c License Number
10<1 / I ~ / I / 1
August
34 '1"1"f. ~1fjlj'~sl" 'trs:>n "&8'f'IjIl"Hr',"se t~f8WJ7t Type I Pnol
6375 Basehore Roadr Suite #1
Mechanicsburg, PA 7050
(See instructions and examples on reverse)
Cumberland,PA
Coroner
33d Dale Signed (Month. day, year)
25, 2006