HomeMy WebLinkAbout07-18-07
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF
CUMBERLAND
COUNTY, PENNSYLVANIA
Estate of Jacqueline M. Hoffman
also known as
File Number
2006-01029
. Deceased
Social Security Number 192-30-0608
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(State relevant circumstances, e.g., renunciation, death of executor, etc.) (") c::. N
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Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of-:$;rnstrumen~offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
o A~ Probate and Grant of Letters Testamentary and aver that Petitioner(s) is / are the
last Will of the Decedent dated and codicil(s) dated
N/A
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Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE ~ / or 'B' BELOW:)
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o B. Grant of Letters of Administration
d. b. n.
(Ifapplicable, enter: c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate)
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: (If
Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
I Name Relationship Residence I
Benjamin F. Hoffman Spouse Deceased March 19, 2007
Patricia Hoffman Daughter Renunciation attached
Sonya M. Montgomery Granddaughter 1622 Holtz Rd., Enola, P A 17025
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland County, Pennsylvania with his / her last principal residence at
1622 Holtz Road. Enola, East Pennsboro Township. Cumberland County, Pennsylvania
(List street address, town/city, township, county, state, zip code)
Decedent, then 67
years of age, died on September 22, 2005
at Halifax, Pennsylvania
Decedent at death owned property with estimated values as follows:
(If domiciled in P A) All personal property
(If not domiciled in PA) Personal property in Pennsylvania
(If not domiciled in P A) Personal property in County
Value of real estate in Pennsylvania
12,500.00
$
$
$
$
situated as fo Hows:
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 ed or rinted name and residence
Sonya M. Montgomery, 1622 Holtz Road, Bnola, P A 17025
Form RW-02 rev. 10.13.06
Page 1 of2
Oath of Personal Representative
COMMONWEALTH 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 beliefofPetitioner(s) and that, as personalrepresentative(s) of the Decedent, Petitioner(s) will well and truly
administer the estate according to law.
Sworn to or affirmed and subscribed
befo me the . / jIl day of
Signature of Personal Representative
Signature of Personal Representative
File Number:
rY/-~ - "/0:11
Estate of Jacqueline M. Hoffman
. Deceased
Social Security Number: 192-30-0608
Date of Death: September 22,2005
AND NOW,
having been presente
are hereby granted to
c..!LJa 7 , in consideration of the foregoing Petition, satisfactory proof
efor e, IT IS DECREED that Letters of Administration, d. b. n.
Sonya M. Montgomery
in the above estate
Letters ............... $
Short Certificate(s) . .~. . . . $
Renunciation(s) .......... $
. .. $
. .. $
... $
. .. $
.. . $
.. . $
.. . $
. .. $
...$fi
TOTAL .............. $ 00 0.00
Attorney Signature:
Attorney Name:
Michael Cherewka
Supreme Court J.D. No.: 35073
Address:
624 North Front Street
Wormleysburg, PA 17043
Telephone:
(717) 232-4701
Form RW-02 rev. 10.13.06
Page 2 of2
1GOl JUL \ 8 PM \2: 43
CLERV, Of
ORPHAN'S COURT
REGISTER OF WILLS CUM?rp':.t1' CO.. PA
CUMBERLAND COUNTY, PENNSYLVANIA
RENUNCIATION
Estate of JACQUELINE M. HOFFMAN
, Deceased
I, PATRICIA HOFFMAN
(Print Name)
, in my capacity/relationship as
of the above Decedent, hereby renounce the right to
Daughter
administer the Estate of the Decedent and respectfully request that Letters be issued to
SONYA M. MONTGOMERY
1/'7/07
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(Signature)
(Date)
1622 Holtz Road
(Street Address)
Enola, P A 17025
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
Executed out oj Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purposes stated within on this r' '1+L day
~~~ ,~~ory
Cr ~ OJ'L
N ary Public
My Commission Expires:
Deputy for Register of Wills
Form RW-06 rev. 10.13.06
(Signature and Seal of Notary or other official qualified to
adminis "
NO SEAL
LESLIE G LEACH
Notary PubIc
~IDOD\~
My Commillloft Exf*eI Jul2I. 2001
'ssion.)
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Thi s 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.
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Local Registrar
Fee for this certificate, $6.00
p
13352408
MAR Z 2 2007
Date
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COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
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:t PRINT IN
WANEMT
JD< IN!(
74 YIlI.
- 811. County 01 0elIIIl
Cumberland
. 11. 0eaIdIrtI UIuII
Kild aI Wortc
Decedenl'1
Actual FIeIIdence 178. SIale
PA
17C.l9 Yea.OecedenlLl'llldin East Pennsboro
17d. 0 No, Decedent Uved wlIhil
ActIlallinllll 01
Twp.
17b.Counly Cumberland
City 1 Boro
18. F..... ,... (Fill. middIlI. IaII. .....)
Harry Hoffman
2Oa. InIormant'I Name (Type 1 PIlnl)
Sonya M. Montgomery
218. Melhod 01 0IIp0&III0n 0 CrImatian 0 0aNli0n
IX! IUiIl 0 AemovaIIrom Slale I WtIa ClwlI8lIan or DanaIIon AlIlhorIzId
o Oller. Specify. by IIedcII EDINMr I ear-? 0 Yes 0 No Ma r ch
~ 22a. SIpUe of FwIa Ser\IicI UcenIet (Of pnan ICting . SUCh)
~ ~
~ ..... 23a< 0Illy when cdytng
phyIicllIl ill not MIIaIIlI at lime of dIldh to
c:erIfy _ 01 dIldh.
2111. Dale oIlli1po8l1tcn (MalIIl, day, y88Il
19, MoIh8l't Name (FhI. middIlI, maiden surname)
Rubie Carpenter
2011. IrIorrnanI'I MaIling ~ (SlrIIl, cIy 1 lawn, Ilala. ~ code)
1622 Holtz Rd. Enola, PA 17025
21c. PIac8 of DiIpoIltIOn (Name of cemel8Iy, CIlIIII8Iory or olher place)
21d. ~Iion (City 11own, ltate, ~ code)
Stone Church Cemetery
22c. Name ond ~ 01 FacIIly
Richardson Funeral Home Inc. 29 S. Enola Dr. Enola, PA 17025
23b. l.IcllnBe Number 231:. Dale Signed (MonItl. day, year)
Silver Spring Twp. PA 17025
..... 24-26 mual be ~ by pelIOIl
.~d88IlI.
26. Wu Cue ReIwrred 10 MedIcal Ellamlner 1 Coron8r lor a Aea80n 0Iher than Cramation or 00nalI0n?
o Yea ~
ApprmdrnIIt InI8MI:
0naeI1o 0eaIh
Part n: Enter olher ......... ........... alI1Irbdind ID _
but not IlIUlIng II I1e lI1dertyIng cue giyIn in Part I.
26. [*l Tobecco UtI ConlrIMe to Death?
o Yes 0 Probably
D No D Unknown
29. n Female:
o No! pregnant wtIhln pISI 'fG8I
o Pregnant at time 01 death
o No! ~ but pIegIlIll1l wilhin 42 days
of deolh
o No! pregnant. but pIegIlIlnl 43 days 10 1 year
before death
o UnImown W prIlJ18I1t WIIhin the past year
32c. PIac8 of IrVY: Home, Farm, Slreet factory,
0IItce 1luiIdng, etc. (Specify)
a.
./re:;, ....
~ef4
~""J
=Ial aJdIons. W any,
m _1alIICI0lI......
EnIIr lINIIEIlLYWG CAUSE
. =:-~I1~
b.
Due to (or as 8 COI1I8qUGI1C8 01):
e::; -. co X~ . c:: /.... ~. "'... ....
Due to (or as 8 COI1I8qUGI1C8 01):
C e; ~~' <=c e:; --....~,/ :r
Due 10 (or 811 . oonsaquence 01);
/"0 >,c;...r....~.. / ;":.... h..-e"s;,.....
;) ~ 4"'~J
321. If TIlIIIIPOIIaIlon Injury (Spsd/y)
o Oriwr I Operator D "-9lr 0 PedaIlrtan
Ollw . Spsd/y;
33a. CaI1Iller (dleclt rrif one) 3311. Slgnatute and T1tle of Cer1IfIer
. =:::"~~==:'~IIle"':...c~~':~~_~~~~~_________________ f1 ~
. "'-IIIClnt and ~ phyalc\In (PhyIIcian both pIIll'QIlClng death and C8ItIylng \0 CllIl88 01 death) 33c, Ucenee NlInbef
To'" _ 01 my IIMwledge, doIIlh occumd at ... lImI, daII, and plICe, and due 10'" C8U81(1) and --- 8lI11a!l1d.. - - - - - - - - - - - - - - - - - 0 ..A t:7 preP .r ,? & L
. IIIdIcII Examnr I CorllIIIr
On ... .... 01 uamInalIon and 1 or InveIligalIon, in my oplnlon, doIIlh occumd at ... time, -, and plICe, and due 10 lIIe cauae(l) and ~ 8111a!l1d.. D 34. Name and AdchSs of Perscn Who CompIaIed Cause 01 DeaIl1 (Ilem 27J Type I Print
.7../. A..r.... ,('I.-{ ;"814
/e1.e'~' A--. ,.;;.~.,. &/A-..,,;
DYes oNo
o NaIInI 0 Homicide
o Accidenl 0 PendIng m-tlga1lcl1
o Suicide D Could Not be Det8flllined
.2 ~ 4. __"
..2 Ii' A..-?
d.
3Oa. Was an AuIop8y
PerIomlad?
311I. Were AuIop8y Flndnga
AvaiaIlIe Prior ID ~
of Cause of Death?
31. toIannor 01 DaaIh
DYes ~
32d. line of Injury
32g. ~Ion 01 ,,*,ry (Sl...., cIy 11own, slale)
M.
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33d. Dale Signed (Month. day. year)
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36. Registral'1
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HI05.905 REV.(6f06)
This is to cenify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records in accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
WARNING: It Is illegal to duplicate this copy by photostat or photograph.
~
No.
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Frank Yeropoli
State Registrar
Calvin B. Johnson, M.D., M.P.H.
Secretary of Health
3965992
NOV 0 6 200G
Date
TYPEIPRIMT
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PERIIANENT
BLACK INK
CERTIFICA'FE:9F-DEA TH
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H105.143 Rev. 2187
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
NAME OF DECEDENT (Fhl. MIele-.. ....)
1. Jacque! ine M. Hoffman
AGE (LMl1llrthdey)
5. 6 7 Vr..
COUNTY OF DEATH
sex
, z.Female
SOCIAl SECURITY NUMBER
1. ) 92" ''30
HD8PlTAl:
...-.- at) ~ 0 DOl< 0
-0 ~)O
RACE - "'-ic8n IndiIIn, BI8dc, V't'hIIe.
(SpecIfy)
1.. White
SUR\IMNG SPOUSE
(1-......__1
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17b. Counlv
MARlTALSTATUS-~.
"'-- u.ntecI. WIdlMM.
Dlworced (SpecIfy)
14. Married
DId 17c. g v... decedenlllved In E a s t
decIcIInl
Cumberland ::.:.:.." 17d.O :;"~=of
WOTHER'S NAME (first, ....... ....... S\Jmwne)
1.. Martha Neuman
:'~~ri:~(~ crr::-"PT-'~m
PLACEOf' DISPOSlTION- NllmeofCemeleoy. ~ LOCATION - ClyfTown,SIaIie. ZIp Code
or 0IhIr Plece
Z1c.Stone Church Cemetery 21d. Silver Spring Twp. PA
NAME AND ADORESS OF FACILITY
22c. Richardson F.H. Inc. 29 S. ProIa Dr. EooIa PA 17025
LICENSE NUN8ER DATE SIGNED
(Month. Dey. V_)
23b. 23c.
WAS CASE REFERRED TO "MEDtCAl. EXIIMINER /CORONER?
Y.. 0 No iiJ
PART .: 0IhIr sIgn/IIc8nt concIiIIona c:anlrI>uting 10 de8lh. but
not......un; In \he ~ _ given In PART I.
F. Hoffman
twp.
c:Iy.tlGro.
OF\:
Y.. 0 No 9' Y.. 0 No 0
a.. 2Ib.
CERTIFIER (Check ody ....)
1:r=="'~~1~r:"c.=c=..=-;.~.~~.~.~.~!.~~................ 31...
"PRONOUNCING AND CERTIF'I'ING PlMllCIAN (PhyU:i8n boIh prllIlClUIldng dNlh Md C8fllfylng 10 C8UM of death) LICENSE ~/ ~f'.l- _ _
To.....oImyk-*lge.....oooumodill...tIme.....-'~.-'cIue..._I.)__...._-.d...................... 0 31c. .} 'E 31d. S,g. if;( ~ l.t.JoJ
"IIEDlCALElCAIIItERlCOROMER ~~~~ /C(=~: c~~~~j'TH
On ......... of UMIIMIIon lIItdIor 1nvestlplIon, In my opinion, d.... occurnd "'''Ilme, d.... _ pIac8, _..10.. C8lIM8(.1 _ do ,,) ,f..,u4 oJ' /f w
31L- - _led............................................................................................................................................................ 0 32. 1/",. (( A f i ,_ 1/
REGlSTRAR'SSlGNAlUREANDHUMBER ~ I ~TEFILE
IVJ I,p, I, I 34.
Natural
Ac:ddenl
SuIckIe
;g
o
Homidde
Pendlng InweIIgeIIon
DATE OF IllJURY
(UonIb, Da<t. Yowl
o
o ~ONoO
~ ~ M.~
o PlACE OF INJURV - "thome. f8nn. IIrMl, fKIory. oIIIcot
........ - (\Ipodfy)
He.
TIME OF INJURV
INJURY "T WORK? DESCRtBE HOW INJURY OCCURRED.
Could not be detMnlned
29.