On March 20, 2024 a
Party Statement
was filed
involving a dispute between
Jean, Rachel A,
and
for Estates and Administration
in the District Court of Middlesex County.
Preview
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Commonwealth of wassathuset® 7
; “WOEUNTARY ADMINISTRATION Packet, The Trial Court
STATEMENT Probate and Family Court
PURSUANT TO G.L. c. 190B, § 3-1201 AMP Is3\
Estate of: Middlesex Division
Coctheeine— Aug. Ma soli
Date
of Death: —_/ 2 ~ G- D2
The Petitioner(s) (hereafter "Petitioner"), an interested person, makes the following statements:
1 Information about the Decedent
Name:
Also known as:
ecine
First Name AN Pesca Male. [Name
Name
conan Harggenel aw Shilo Ma, 0! d bY
2. information about the Petitioner.
Name: Ro ch ed, A Dean
Last Name
SY byes parched aca, =i leis Mg 61464
Mailing Address, if different:
Apt Unit, No. ef) CityrTown) Cate) Zip)
Primary Phone #: 9 7% - Yas Gol
The Petitioner's interest in the estate is as follows (e.g., Personal Representative named in a will, surviving spouse, heir,
devisee, etc. See G. Lc. 190B, §§ 31201, 1-201(24)): “zit Z wort tee A e LL
At least 30 days fave Glapsed’ since the déath of Decedent,
4. A death Certificate issued by a public officer is in the possession of the court or accompanies this statement.
5. The Petitioner is unaware of any unrevoked will relating to property in Massachusetts.
OR
CO The original will and codicil(s) are in the possession of the court or accompanies this statement. The Petitioner is
unaware of any instrument revoking the will and believes that the will filed with this court is the decedent's last will.
Copies of this statement and the death certificate have been sent by certified mail to the Division of Medical Assistance,
Estate Recovery Unit, P.O. Box 15205, Worcester, MA 01615-0205.
T. The probate estate consists entirely of personal property and the total value of all personal property owned by the
Decedent and subject to disposition by will or intestate succession at the time of the Decedent's death does not exceed
$25,000.00, exclusive of one motor vehicle.
FILE
MAR 2.0 2024
Docket No. - |.
DuPisal”
8. Aschedule of every asset of the probate estate and the estimated value of each is as follows:
Description of Property Estimated Value i
Motor vehicle make, model, VIN: va
GFA Savings account 9F31,53
|
Total:| P¥.3/, 53
owners of property. Also
9. The following are the names and addresses of all persons who, with the deceased, were joint
listed are the names and addresses of those who would take in the case of intestacy and the names and addresses of
those persons and/or charities who would take as devisees under the provisions of any will.
Name Address Interest
(feir
Kachel Sean 5Y Horse pond Re CO Devisee
Shicleg Wa olte6yY C Joint Owner
C Heir
LO Devisee
CO Joint Owner
CO Heir
(J Devisee
C2 Joint Owner
CO Heir
CI Devisee
oO Joint Owner
Oo Heir
(J Devisee
OD Joint Owner
are answerable
40. No petition is pending or has been granted in any jurisdiction. The undersigned understands that we
Representat ive of the estate or any other person having a
and accountable fo any subsequently appointed Personal
superior right to the estate.
and will
44. The undersigned will act as a Voluntary Personal Representative of the probate estate of the deceased
administer the same according to law, and apply assets of the probate estate to those persons entitled as creditors, heirs,
devisees under any will, and otherwise in accordance with G. L. c. 190B, § 3-1201.
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IL
7
oF Docket No. . »
of. ¢ atherine -Malegln akeisa\
SIGNED UNDER THE PENALTIES OF PERJURY
Gag
I certify under the penalties of perjury that'the foregoing its are true to the best of my knowledge and belief.
owe: 3/20/24 Signature of Petitioner (7
mM
Information on Attomey for Petitioner, if aw
Signature oF Attomey
Printnamey
Address) Apt Unit, No. etc)
eHTENT Sie) (ip)
Primary Phone #
B.B.O. #
Email:
J j (Do Not Write Below This Line-For Court Use Only) J |
CERTIFICATION
.
As Register of Probate having the care and custody of the records pertaining to this court, | certify that the preceding document is
a true, exact, complete and unaltered copy of the Statement of Voluntary Administration filed with this court.
/ Date
Register of Probate
Preview
” : a ol ‘ ‘ - , Commonwealth of wassathuset® 7 ; “WOEUNTARY ADMINISTRATION Packet, The Trial Court STATEMENT Probate and Family Court PURSUANT TO G.L. c. 190B, § 3-1201 AMP Is3\ Estate of: Middlesex Division Coctheeine— Aug. Ma soli Date of Death: —_/ 2 ~ G- D2 The Petitioner(s) (hereafter "Petitioner"), an interested person, makes the following statements: 1 Information about the Decedent Name: Also known as: ecine First Name AN Pesca Male. [Name Name conan Harggenel aw Shilo Ma, 0! d bY 2. information about the Petitioner. Name: Ro ch ed, A Dean Last Name SY byes parched aca, =i leis Mg 61464 Mailing Address, if different: Apt Unit, No. ef) CityrTown) Cate) Zip) Primary Phone #: 9 7% - Yas Gol The Petitioner's interest in the estate is as follows (e.g., Personal Representative named in a will, surviving spouse, heir, devisee, etc. See G. Lc. 190B, §§ 31201, 1-201(24)): “zit Z wort tee A e LL At least 30 days fave Glapsed’ since the déath of Decedent, 4. A death Certificate issued by a public officer is in the possession of the court or accompanies this statement. 5. The Petitioner is unaware of any unrevoked will relating to property in Massachusetts. OR CO The original will and codicil(s) are in the possession of the court or accompanies this statement. The Petitioner is unaware of any instrument revoking the will and believes that the will filed with this court is the decedent's last will. Copies of this statement and the death certificate have been sent by certified mail to the Division of Medical Assistance, Estate Recovery Unit, P.O. Box 15205, Worcester, MA 01615-0205. T. The probate estate consists entirely of personal property and the total value of all personal property owned by the Decedent and subject to disposition by will or intestate succession at the time of the Decedent's death does not exceed $25,000.00, exclusive of one motor vehicle. FILE MAR 2.0 2024 Docket No. - |. DuPisal” 8. Aschedule of every asset of the probate estate and the estimated value of each is as follows: Description of Property Estimated Value i Motor vehicle make, model, VIN: va GFA Savings account 9F31,53 | Total:| P¥.3/, 53 owners of property. Also 9. The following are the names and addresses of all persons who, with the deceased, were joint listed are the names and addresses of those who would take in the case of intestacy and the names and addresses of those persons and/or charities who would take as devisees under the provisions of any will. Name Address Interest (feir Kachel Sean 5Y Horse pond Re CO Devisee Shicleg Wa olte6yY C Joint Owner C Heir LO Devisee CO Joint Owner CO Heir (J Devisee C2 Joint Owner CO Heir CI Devisee oO Joint Owner Oo Heir (J Devisee OD Joint Owner are answerable 40. No petition is pending or has been granted in any jurisdiction. The undersigned understands that we Representat ive of the estate or any other person having a and accountable fo any subsequently appointed Personal superior right to the estate. and will 44. The undersigned will act as a Voluntary Personal Representative of the probate estate of the deceased administer the same according to law, and apply assets of the probate estate to those persons entitled as creditors, heirs, devisees under any will, and otherwise in accordance with G. L. c. 190B, § 3-1201. “ et IL 7 oF Docket No. . » of. ¢ atherine -Malegln akeisa\ SIGNED UNDER THE PENALTIES OF PERJURY Gag I certify under the penalties of perjury that'the foregoing its are true to the best of my knowledge and belief. owe: 3/20/24 Signature of Petitioner (7 mM Information on Attomey for Petitioner, if aw Signature oF Attomey Printnamey Address) Apt Unit, No. etc) eHTENT Sie) (ip) Primary Phone # B.B.O. # Email: J j (Do Not Write Below This Line-For Court Use Only) J | CERTIFICATION . As Register of Probate having the care and custody of the records pertaining to this court, | certify that the preceding document is a true, exact, complete and unaltered copy of the Statement of Voluntary Administration filed with this court. / Date Register of Probate