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Home My WebLink About06-21-07 PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF Cumberland COUNTY, PENNSYL VANIA Estate of Antoinette S. Gough also known as File Number CA \ OS d1lo~ . Deceased Social Security Number 204-28-1346 January 14.2005 Petitioner(s), who islare 18 years ofage or older, apply(ies) for: (COMPLETE ~' or 'B' BELOW:) IZI A. Probate and Grant of Letten Testamentary and aver that Petitioner(s) is / are the Ann Marie Gough Broscius, Executor named in the last Will of the Decedent dated April 21, 1988 and codicil(s) dated (State relevant circumstances, e.g., renunciation, death of executor, etc.) Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the instrument(s) offered for probate, was not the victim of a killing and was never adjudicated an incapacitated person: o B. Grant of Letten of Administration (lfapplicable, enter: c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate) ~ -xi Petitioner(s) after a proper search has / have ascertained that Decedent left no Will and was survived by the following spouse (i~) andb.eiist-,(lf Administration, c.t.a. or db.n.c.t.a., enter date ofWil/ in Section A above and complete list of heirs.) 20 ~ \'J?:7~i\ Name Relationshi \~.0, Decedent was domiciled at death in Cumberland Manor Care. CamD Hill (List street address, towwcity, township, county, state, zip code) '1"'\ O~ . ~ -0 "7 County, Pennsylvania with his / her last principal residence at (COMPLETE IN ALL CASES:) Atttlch addition. sheets if llecessllty. t'> - Decedent, then 106 years of age, died on January 14, 2005 at Manor Care, Camp Hill Decedent at death owned property with estimated values as follows: (If domiciled in P A) All personal property (lfnot domiciled in PA) Personal property in Pennsylvania (If not domiciled in PA) Personal property in County Value ofrea1 estate in Pennsylvania 0.00 $ $ $ $ situated as follows: Wherefore, Petitioner( s) 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: T or rioted name and residence FormRW-02 rev. 10.13.06 Page 1 of2 Oath of Personal Representative COMMONWEALTH OF PENNSYL VANIA : SS COUNTY OF Cumberland The Petitioner(s) above-named swear(s) or atImn(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 Decedent, Petitioner(s) will well and truly administer the estate according to law. JlI ~~@'/Md~Y1r~ gnohlTe of Personal Representative Sworn to or affirmed and subscribed before me the day of SignohlTe of Personal Representative File Number: ~\ 05 bqlo~ ~o .:-:0 ~10 ':0 r- r- rT1 '> - ::IJ ~,,'" (/) 7' Ono .~1' :~ Date of Death: January 14. 2005 ~ !"'-:t c:;:::) c:::> -..J <- c:: :-% N SignahlTe of Personal Representative Estate of Antoinette S. GOuWt ~ '-F! N ..,., (h ~I~~,-) f.;/~ g~J . S-~.~ --n ;=:, t':':"rl ....j <..~) Social Security Number: 204-28-1346 AND NOW, ~ 611 having been presented befo . , IT IS DECREED th are hereby granted to - FEES in the above estate and that the instrument(s) dated Ap-,I cJ / described in the Petition be admitted to probate and filed of recor Letters ............... $ Short Certificate(s) . . . . . . .. $ Renunciation(s) .......... $ ~\\\ ... $ \'< ...J l ~~ . .. $ \0 ~ ^"" -=> ... $ <:; ... $ ... $ ... $ ... $ ... $ .., $ TOTAL ...... . . . . . . ., $ ,.:;,+00 ~ d.(),(P '-t. 00 Attorney Signature: Attorney Name: Supreme Court lD. No.: Address: Telephone: Form RW-02 rev. 10.13.06 Page 2 of2 HI05.805 REV 9/86 This is to certify that the information here given is correctly copied fro~ an original ce~ificate of death dul~. 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. Fee for this certificate, $2.00 ~I?~ Local Registrar ,....;) c::.:>> JAN8.d 2005 :; i::D c- ~~ ""!> ~ :D - zw:;:<;;: CJoo CJQ" 0-- : ::D :u~ ~ p 10899753 No. 05.143 Rev. 2/87 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH' VITAL RECORDS CERTIFICATE OF DEATH ;po. :Jt 'f? N r- f~~.; :~='-j (. ):::.) {:?~ ~~~"!, r:;:~ r-~ :.D CJ C~ -'01 -~1 CJ r"lr".\ '"0'"/' NAME OF DECEDENT (Firsl. Middle. Lasl) 1. AGE (Lasl Birthday) STATE FilE NUMBER ~ \ 0 S aq <OS'W- RHilHncII 0 =1)1) 0 RACE. American Indian, Black, White. at (Specify) 5. 106 Vrs. COUNTY OF DEATH SEX SOCIAL SECURITY NUMBER 2. Female 3.204 28 - 1346 BIRTHPLACE (Cily and PLACE OF D A TH h State or Foreign Country) HOSPITAL: 7Harrisburg, PA ~:::-ti.nlO ERIOu.....ion'O OOAO FACILITY NAME (If not institution, give street and number) 8b. Cumberland 8e. Camp Hill DECEDENrs USUAL OCCUPATION KIND OF BUSINESS I INDUSTRY (C:-~~~~u~r:3>'t 110. Housewife llb. Domestic DECEDENrs MAILING ADDRESS (Street. CilyfTown. Slate, Zip Code) DECEDENrs 1700 Market Street ~~~PD~NCE Camp Hill, PA 17011 (Soeinslruclions on other side) 17b. County Cumberland 10. MARITAL STATUS - Ma_. Never Monied. Widowed, D1vorcad (Specify) Widow 14. 17c. 0 Yes, decedent lived in Did decedent live in a township? 17d.1Xl ~~h~~~~~ of Camp Hill Frank Sariano Ann M. Broscius a. J s cA.-.... c,.,.,4.....,., DUE TO (OR AS A CONSEQUENCE OF): 28. : Approximate , interval between : onsel and death 14 2005 White SURVIVING SPOUSE (tfwife. give maiden name) lwp. city/boro. on II J. ~......1. G.,.r,.,.1 V.....J.... ~ JJ. Sequentialy list conditions I b. if any, teading to immediale cause. Enter UNOERL YING CAUSE (Disease or injury c. . that initiated events resulting on death) LAST d. WAS AN AUTDPSV WERE AUTOPSY FINDINGS PERFORMED? AVAILABLE PRIOR TO COMPLETION OF CAUSE OF DEATH? cue TO (OR AS A CONSEQUENCE OF): DUE TO lOR AS A CONSEQUENCE OF): MANNER OF DEATH Natural gJ Homicide 0 Accident 0 Pending Investigation 0 Suicide 0 Could nol be determined 0 DATE OF INJURY (Monlh. Day. Year) TIME OF INJURY INJURV AT WORK? DESCRIBE HOW INJURV OCCURRED. Ve. 0 No 0 3Oe. 3Oa. 3Ob. M. PLACE OF INJURV - At horne. farm, slree', faclory. off.... building. etc_ (Specify) 30.. Yes 0 No IiZI VesO NOIXJ 280. 28b. CERTIFIER (Check only one) .~:~:F~:tGJ::'~~~~~~7l~~ C:~~~J8du= tr:: ~::.::~(:r~~j~~~a~.h:t~r:~~~~~~.~.~.~~~~.~~~.~~~~~~.i.t~.~~.)............ ...... fKJ 29. -~ .p~O~~:~I:,o,.,~N~~:I:r~~.~~~~~: ~~~:~~.~~r:~~~~i.'::: dc:,~ ~~~~~ut~.~~):~~ ~:~~er as .laled. ............. ........ 0 'MEDICAL EXAMtNERlCORONER ~~::rb::~::.~~~.~I.~~~I~. ~~.~~~.I~~~~~~~.~~~~.~:.~ .~~ .~~.~~~.~: .~~~.~ .~~~~~~~. ~.t. ~~~. ~l.~~.'. ~~~~:. ~.~~ .~~~.~~'. ~~.~ .~.~~..t~ .t.~~. .~~~~.~~.(.~! .~~~.. 0 31a. REGISTRAR'S SIGNATUR p", 1"(,"1 ~.';M:E/?? 1;;<.1/.?-,(.,7Z~ I~ /1 coli /1/ I 34. oJdfj ~ \ OS (Jqlo~ BE IT KNOWN HEREBY, that I, ANTOINETTE SARIANO GOUGH, of the City of Harrisburg, Dauphin County, Pennsylvania, being of sound and disposing mind and memory, do hereby make, publish and de- clare this to be my Last Will and Testament, hereby revoking and making null and void any and all last wills and testaments and codicils thereto by me at any time heretofore made. I hereby nominate, constitute and appoint my daughter, ANN MARIE GOUGH BROSCIUS, to be the EXECUTOR of this my last Will and Testament. I give, devise and bequeath my entire estate, real personal and mixed, and wheresoever the same may be situate, to my daughter ANN MARIE GOUGH BROSCIUS. IN WITNESS THEREOF, I have hereunto set my hand and seaf'~6 ~ .~ p> f.A.:r day of ~ I r g r ~lh ~ [U~.~~ f!2 hi :z: v) :tJ ;t> ,-..... 1'.)-, 0 ..,..~O)~ _ c;ll"'7-, o -,"'JO 00 C) ("")0" ~ "', ~ Signature cz..A~J~ ~ ATTESTATION: This instrument was by the said ANTOINETTE SARIANO GOUGH, on the date thereof signed, published and declared by ANTOINETTE SARIANO GOUGH, to be her LAST WILL AND TESTAMENT, in our presence and in the presence of each other have hereunto sub- scribed our names as witnesses: J~ ~' 1L/ ' .tL~~ d-. \ D~8\O~ OATH OF NON-SUBSCRIBING WITNESS(ES) Cumberland REGISTER OF WILLS COUNTY, PENNSYL VANIA Estate of Antoinette S. GouJdl , Deceased ?kJJ!adh~:&/V~ (each) being duly qualified according to law, depose acquainted with with the handwriting and signature of the decedent, and that the signature of to the foregoing instrument purporting to be the Last Will and TestamentJCodicil of is ini'iS/her own proper handwriting. and ogWf 7t( ~ . ,she l..u I they was / were well- ~lI1~ k~'/Jr#~ ~ 'gnDJUTe) , r ;( Q~7n~ (Signature) ~ Executed in Register's Office Sworn to or affirmed and subscribed d ( day ~. (") Co ~::o co 1:1 ~.'B~P r-zm 4 -:0 ,,_CJ);:<::. ',::J go CJ -n oc: ; ::0 ::o-i '):> r--J <:::::> = ..... <- c:: :z: N ~ :x '!! N Form RW-04 rev. 10.13.06