HomeMy WebLinkAbout09-12-06
Register of Wills of Cumberland County
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estateof Q.()().vL~ '( Ci1-ovf' SfL, No. a \ vlo OlQs--
also known as To:
Register of Wills for the
County of Cumberland in the
Commonwealth of Pennsylvania
, Deceased.
Social Security No. / & '5 - 70 -Cc 'if 71
The petition of the undersigned respectfully represents that:
Your petitioner( s), who is/are 18 years of age or older, appl
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante rninoritate)
the above decedent.
I\vD
Decedent was domiciled at death in C (J M Ot/LL I County, Pennsylvania, with h_ last family or principal
residence at
(list street, number and municipality)
Decedent, then
G,q
years of age, died
5\Pt, 1:
, 20 0 Cp
, at
Upplvt
i=(LA""'jC.. rO(L 0
.~
\"7~\' " -
'TowN'j H 'f
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:
$ 3$-,000
$
$
$
Petitioner_ after a proper search ha_ ascertained that decedent left no will and was survived by the
following spouse (if any) and heirs:
Name
L (,v ~' s -1/.1 r.
f"',"~
.f~~".~
C~ (/*)
-1- ....."c~
THERE~ORE, petitioner(s) respectfully request(s) the grant ofletters of administration in the'~lpp~opri~form_
to the underSIgned..:
Signature(s) ofPetitioner(s)
@~~tu;-~
Register of Wills of Cumberland County
OATH OF PERSONAL REPRESENTATIVE
COMMONWEAL TH OF PENNSYLVANIA
}
SS:
COUNTY OF CUMBERLAND
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 ofpetitioner(s) and that as personal representative(s) of the above
decedent petitioocr(,) will well and trn1y admini,'cr the e'late ="'~law. A
Sworn to or affIrmed and subscribed {~ ~~ _ L~ il
Before me this I ~ day of '
Sf1e-t'Yl ~ , 20 lip
~ ~J\ 1I.17^-_~~da ,
~~ ~ R-;i;;;;P;:;;:~
(Zl
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e
....
A
~
No. :J \ 0 \.Q Ol~';'
Estate of R.e,~ G~(1)eceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW \ ~ SO~"f'\'ov-- 2<&, in consideration of the petition on the reverse
side hereof, satisfactory proofb~een presente<!-l3efore me, c
IT IS DECREED that V\e~ C. ~(D~ '::::''f
is/are entitled to Letters of Administration, and ~ accord with such fmding, Letters of Administration
are hereby granted to ~:...) c: b<t:X-~ ...).(
in the estate of ~ f Gro~ ~'('"""
\
~J~&~~~~~
Register of Wills ~ ~
~,oD
FEES
Probate, Letters, Etc. ............. $
Will................................. $
Renunciation... . . . . . . . . . . . . . . . . " . . $
Short Certificates ( ). .. . . . . . . . .. $
JCP.................................. $
Automation Fee... ......... ....... $
Bond. . . . . . . . .. . . . . . . . .. . . . . . . . . . . .... $
Total $
Filed--'i.\ l ~ - 2()C::U
Attorney (Sup. Ct. J.D. No.)
1-. cD
lO.eX:)
S.oO
Address
IOCI-od
Phone
H RL\ ".;;
This is to certii'v that the information here given is correctly copied from an original certificate of death dlll) riled wiil] 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.
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Lo,'al Rl':'istrar '.,
h:e t'or thi, certificate. S6.00
P 12727298
SEP 1 1 2006
'\io,
Dale
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)Hl05,143REV.02!2006
TYPE/PRINT IN
PERMANENT
BlACK INK
1. Name of OeceOent (Fir<;l, middle,lasl, suffix)
d\
D~ OI'1S-
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
69
4/10/1937
Newville, PA
N
STATE FILE NUMBER ~
4. Dale of Deaftl (Monftl, day. yeM)
Sept. 8, 2006
.>
Rodne
6. DateQfBirth Month,d
7. Birth
8a. Place of Oeat~ ChecI<. onl one
Hospital
Dln,_' DERIOu~_ DOOA DN""ngH"'''
9. Was~lofHispanicOrigin?.KJ No DYes
(If yes. specify Cuban.
Mexican, Puerto Rican. etc.)
~ Res""ne' 0 OIhe" Specly
10. Race: American 100M, 81~, While, etc.
(Specify)
White
, j. Decedenfs Usual Occ:upaliOl1 Kind of wcO. done durin most of worki life. Do 1'\01 stale mijred
Kind of Work Kind of BU$iness I Industry
Rubber Production lisle Syntec
. 16. Decedents Mai~ng Address {Street. city Ilown, slate, zip code)
7 Countryview Estates
Newville, PA 17241
12. Was Deceden1 eYtY in the
U.S. Anned FOfCeS?
Dyes :f]No
\3. Decedent's Education (Specify only highest grade compleled)
Elementr I Secondary (0-12) College (1-4 or 5+1
14. Marital Status: Married, Never Married,
Widowed, Divorced (Specify)
WidcM
8b. County of Death
Bd. Facility NOO'le {If 001 institution, give street and number)
~I
Cumberland
Twp 7 Countryview Estates
Decedent's
AcltJatReSidence 17a.Slale
17b.Coonty
PA
Cumberland
Did Decaden!
Live in a
Township?
,,,~ Yes._'U""'i, Upper Frankford
17d. 0 ~iu=~riyed wilM
T.p
City/Boro
18. Fathe(s Name (First, middle, las1, suffi~)
19. MolheIs Name (FiTsl, middle, maiden sumame)
Hazel Mae Hi hlands
2{)b. Informant's Mailing Address (Street, city f lOwn, stale, zip codel
7 Countryview Estates, Newville, PA 17241
21d. Loca\iof1 (City ItoYoTl, state, zip code)
James E. Grou
2Oa. Inlormanl'sName (TypeIPmt)
Rodne E. Group,
o
w
"
~
;/
s CrEmation Services
Leola, PA
Hane, Inc., Carlisle, PA 17013
CA.USE OF DEA.TH (See instructions and. mples)
Item 27. PART l: Enler the c!liinJ.lt~- diseases, irljUf'ies, or complications -that direclly caused !he death NOT enter terminal events such as cardiac anest.
respiratory attest, or venlricular fibrillalion wiltloutshowing lheetiology_Lislonlyonecauseoneach line
2Jb. Licen Number
b77Q{o'f L
: Approxirnaleifltefval
; OnsetloOealh
Part II: Enterolhersianfficantcondilionsoonbibulina to death
bufnofresullir9in ItIe tIfJde(lying cause given itl Pari I
28. OidTobaccoUseConlributetoDeatl1?
Dyes 0"""".,
o No ~known
29. II" Female
o N01pregnanlwilhinpastyear
o Presnanl at time or death
o Not pregnant, but pregnantwitl1in 42 days
o(deafh
o Not pregnant, but pregnant 43 days to 1 yeat
oIdea/h
o Unknown if pregnan1 within the pao;l yeM
3e:. Place oI1nJlJry: Home. Farm. Street. Factory
Office Building, etc_ (Specify)
::O:~CItiA~~; d::~ dise~
f<-l.\~ 't~ l~
Due to jor al5 s COIlsequeflCeof)
c.G.N.\~~
: 't 0....0 \,
Sequentially liSt condiIions~ ff any,
~~~ U:OER~~G ~~uSe
(disease or injul'(lhal initiated the
evenis resultiflg rn demh f LAST.
Due 10 (orasa consequence of)
Due to (oral5 a con5f!'Clueoce o(J
Dy"
DYes DNo
31Mann~ath
EfN~"'" 0-"'"
o Accidenl DPendinglnvesligation
o Suicide 0 Could Not be Determined
32d. Timeofll'ljury
319. Localion of Injury (Street, cily I tClwfl. state)
JOa. Was an Au10psy
Performed?
30b WereAulopsyFindings
Available Prior 10 Completion
oi Cause of Oealh?
~
~
o
I
33a. C'rtifier(Checkonlyooe)
Certifying physician {Physician certifyiog cause of death when another physicicJl has pronounced death and completed Item 23)
To Ins bHtof myknowltdge, de.lh occurred due to ttIe cau.tlI) and manner as .tatest_ _.... _.. _ _ _ _ _ _.. _ _ _.... _.. _ _ _ _ _.. _ _ _ _ _ __
~t~~=~~a~ ~=~=~.~:~:: ~:t~~,n;n~=::a:rtir:t~O ~~::~:~d mlnn&t II .tltt<!_ _ _ _ _.... _ _ _.. _.. _ _.. _ _.IJ
~~:I~~m::~~o:':, and I or Invesli9atlon, In my opinion, dHttl occuned It tn. time, date,.nd place, and dU'lo the caus.(s).nd man,"" llltattd_ _ .IJ
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