HomeMy WebLinkAbout09-25-07
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND
COUNTY, PENNSYLVANIA
Estate of ROGER L. VAUGHN
also known as
File Number /~ 1- () 7 - () J77
, Deceased
Social Security Number 169-50-7730
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
o A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is I are the
last Will of the Decedent dated and codicil(s) dated
named in the
-_ ~J
(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 ofthe instOlment(s) offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
III B. Grant of Letters of Administration
(If applicable, enter: c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durWlte minoritaiii)
(.r1
Petitioner(s) after a proper search has I have ascertained that Decedent left no Will and was survived by the following spouse (if ali)) and heirs: (If
Administration, C.t. a. or d.b. n. c. t.a., enter date of Will in Section A above and complete /ist of heirs.)
I Name Relationship Residence I
DEBRA R. VAUGHN SPOUSE 2348 RITNER HIGHWAY, CARLISLE, PA 17015
NICOLE VAUGHN DAUGHTER 140 MONT ALTO ROAD, FAYETTEVILLE, P A
MIKE VAUGHN SON 863 CALWYN MANNOR, APT B 105, CARLISLE PA
(COMPLETE IN ALL CASES:) Attach additional sheets ifnecessary.
Decedent was domiciled at death in CUMBERLAND County, Pennsylvania with his / her last principal residence at
61 MOUNTAIN LANE. NEWBURG. HOPEWELL TOWNSHIP. CUMBERLAND COUNTY. PENNSYLVANIA 17240
(List street address. town!citv, township, county, state, zip code)
Decedent, then 53
years of age, died on JANUARY 21, 2007
at CHURCH OF GOD HOME, INC.
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
$
$
$
$
500.00
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 ed or rinted name and residence
DEBRA R. VAUGHN, 2348 RITNER HIGHWAY, CARLISLE, PA 17015
Form RW-o.2 rev. 10.13.0.6
Page 1 of2
Oath of Personal Representative
COMMONWEALTH OF PENNSYL VANIA
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 Decedent, Petitioner(s) will well and truly
administer the estate according to law.
Sworn to or affirmed and subscribed
ah.U
be ore me the U ~ day of
'I
' .r~ . ./ /,7/
X. ...... / ..y
/ //.: h/ i/ . ../// C;<'_~~/~
Signature of Personal RepresentatIve ,~-
(\ Signature of Personal Representative
Ut>ti~
\ 0 Signature of Personal Representative
File Number: c2/ol- O~ll
Estate of ROGER L. VAUGHN
, Deceased
Social Security Number: 169-50-7730 Date of Death: JANUARY 21, 2007
AND NOW, ~:5t_Qj{i,,-~'l..l.....-,--/ :J.S , Z nt'--( , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters OF ADMINISTRATION
are hereby granted to DEBRA R. VAUGHN
in the above estate
and that the instrument(s) dated
described in the Petition be admitted to probate and filed ofrecord as the last Will (and Codicil(s)) of Decedent.
FEES )d.Y'--t.ncto_~(.,v
Letters
$
20.00
4.00
Attorney Signature:
/lQJ .~
ROGV'~~ IN, ESQUIRE
Short Certificate(s) . , . . . . . . $
Renunciation(s) .......... $
JCP
AUTOMATION FEE
.. . $
.. . $
$
$
$
$
$
$
$
. . . . . . . . . . .. . . $
10.00
5.00
Attorney Name:
Address:
CARLISLE, PA 17013
Telephone:
(717) 249-2353
TOTAL
39.00
Form R W-02 rev. /0.13. 06
Page 2 of2
, I" I~. '0 ceruf\ that thc 11l1'Pll1ati<l\1 hell' ~i\ell i~ C()llt'((I~, l\'p',;d II"! I an ori;::inal ('erutlcate of death duly filed with me as
l( II I'~;gistrar. The ()rl,~illal 'lll!i'iLatl \\ill he lorwardL:d [I' Ilk 'y ui [~ec,mis Office for permanent filing,
WARNING: It is illegal to dupiicate this copy by photostat or photograph.
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H105-143 REV 1112006
TYPE I PRINT IN
PERMANENT
BLACK INK
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS'
CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
STATE FILE NUMBER
C ,'"1
f'..:.
~
\
1, Name 01 Decedent (First, middle, la51, suffix)
R r
5, Age (Last Birthday)
6. Dale of Birth (Monlh, day, year)
12/03/1953
53
y"
Newville,
PA
Bd. Facility Name (II not institution, give slree! and number)
Church of God Home
Inc:
12. Was Decedent ever in the
U.S. Armed Forces?
Dy" IXINo
13. Decedent's Education (Specify only highest grade completed)
Elementary I Secondary (0-12) College (1-4 or 5+)
10
11. Decederll's Usual 0wJ ation Kmd 01 work donediJrin most 01 workin life, Do not slate retired
KindofWori< Kind of Business flnduslry
Laborer Shoe Factory
. 16 Decedent's Mailing Address (Street, city flown, stale, zip code)
61 Mountain Lane
. Newburg, PA 17240
=;~iOence 17a.Stale Pennsylvania
17b,Co""~ Cumberland
- 50 -7730
4. Date of Death (Monlh, day, year)
January 21, 2007
Other:
~ Nursing Home 0 Residence OOlher "Specify
9. Was Decedent of Hispanic Origin? ~ No 0 Yes 10. Race: American Indian, Black, White. ate
(If yes. specify Cuban, (Specify) W hit e
Mexican, Puel10 Rican, elc.l
14. Marital Status: Married, Never Married,
Widowed, Divorced (Specify)
Married
Did Decedent
Liveina
Township?
17c.lKl Yes, Decedent Lived in Hop ewe 11
17d. 0 No, Decedent Lived within
AclualUmilsof
TwO
City/Boro
19. Mother's Name (First, middle, maiden surname)
Irene R. Mixell
18, Father's Name (First, middle, last, suffix)
Howard G. Vaughn
20a. Informant's Name (Type I Print)
NLcole Vaughn
21a. Method 01 Dispostlion
2Ob. Informant's Mading Address (Street, city / town, stale, zip code) P A
266 Philadelphia Ave. Apt. 4 Chambersburg 17201
21d. Loca1ion(Crty/town, state,zipcode)
Smithsburg, MD
21783
"
w
w
=>
'"
..
'"
21c, Place 01 Disposition (Name 01 cemetery, crematory or other place)
Smithsburg Crematorium
. ~
'~~'->J~ \-- "-.)
RN
lIems 24.26 must be completed by person
who pronounces death
24. Time of Death
25, ?~e Pronounced Dead (Month, day, year)
c
?y \1 pM -\\),.1\00..,
CAUSE OF DEATH (See Instructions and examples)
lIem 27. Part 1: Enter the~ diseases, injuries, or complications -thaI directly caused the dealh. DO NOT erlter terminal events such aSCBldiac arrest,
resPiratOryarrest,orVerltriculalflbrillatiOnwit.Z,s 'ngtheetiology. List only one cause or each line
IMMEDIATE CAUSE (Final disease or
condilion resulting In death) ~ a. __ ,~' ( ;Vt-t U"'"V
Due to (or as a con~quenc 01):
Seq~entiall~ list coodilioos, if any,
~~t~~~~o JJO't~t~I~~~A~~~ a
(disease or inJury that mitiated the
evenlsresuthng In dealh) LAST.
I Approximateinlerval
: Onset 10 Dealh
,
:1 ~vr
: /
,
,
,
,
,
,
,
,
Due 10 (or as a consequence 01)
'(\'
o
~
Due 10 (or as a consequence of)
3Oa. Was an Autopsy
Performed?
JOb. Were Aulopsy Findings
Available Prior to Complmioo
01 Cause 01 Death?
31. Manner of Death
~ Natural 0 Homicide
DAccident o Pending Investigation
32d. Time ol InJury
Funeral Home
Inc. Shippensburg, PA
23b. License Number
&1 I '';'\.,,-.'1
28, Did Tobacco Use Cootribule to Death?
DYes~probably
o No 0 Unkrlown
29. If Femalll
O'Notpregrlantwithinpaslyear
o Pregnantatlimeoldeath
o Not pregnant, but pregnant within 42 days
01 death
o Not pregnant, bul pregnant 43 days to 1 year
before death
o UnknOWl1 if pregnant within the past year
32c PlaceolfnJury: Home, Farm, Stree!, Factory,
Office Building, etc. (Specify)
DSuicide
M
32t.IITransportatiOllll1lury (SpeCify)
o Driver I Operator DPassenger DPedeslriar;
D01her. Specily:
33b.Sigf\atureasi~1je'r / ,,' .
~ j.-L~f' t:Z~pJ-0
"
~ )
o
ci.-
DYes~o
D Could Not be Delermined
Dyes DNo
33a. Certiher (chcck only Orle)
Certifying physician (Physiclarl certifying cause 01 death when al\Cllher physician has pronounced death and completed Jlem 23)
10 the besl of my knowledge, dealh occurred due to the cause(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pronouncing and certifying physician (Physician both pronouncing death and ceT1ilying to cause 01 death)
To the best 01 my knowledge, death occurred atlhe time, date, and place, and due to the cause(s) and manner as slated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
Medical Elaminer {Coroner
On the basis 01 examination and I or investlgalion, in my oplni
3:', Registrilr's Signature and District
~ '
I '2.., I, :t-I I' .Ii1I
DIspOSition Permit No
32g. location 01 Injury (S1reet,city/lown,slate)
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