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PE1'ITION FOR PROB,A TE AND GRANT OF I.JETTERS
REGISTER OF \VILLS OF C VI. IV' h '"1 it... "-'\ v)
COlJNTY, PEJ'..0JSYL V Ai', f.\
Estate of
i((f;~1 f
L
<'
...) / rY) /)/1 f' {' S
File Number
oJl- d()()8- ()C(j~~
also known as
, Deceased
Social Security Number /1? - ~ () - ty):::1 /
I r).) ');..1....-1 ( ,7
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Petltioncr(sJ, \\ Iii' ,ue 18 years of agc or older, apply(ies) for:
(COlly/PLETE './ 0" 'B' BELOW:)
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
'--=1Iamed in the- ;
"
~::.)
(Slate 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 oftheiI1st11tment(~ffered
for probate, v. as not the victim of a killing and was never adjudicated an incapacitated person:
:-:5
D' B. Grant of Letters of Administration
~ V- r v , Vl c} S ,/ C l.i..J -f __
(lfapplicable, enter: c.t.a.; d.b.n.c.t.a.; pendente lIte; durante absentia. durante lIlinoritate)
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
Adlllinistration, ct.a. or d.b.n.c.t.a.. enter date of Will in Section A above and complete list of heirs.)
I? .;"-S
Relationship
-5 l:::l() "\.. ,)"L.
1,;)0
P/l
(COiIIPLETE IN ALL CASES:) Attach additio/lal sheets if /lecessary.
County, Pennsylvania witJ(h~/ her last principal residence at
.' ..... Q/ T ..J ,-' C <..," ~n.f u~.
o5~
Decedent, then
{; ('
-, (
years of age, died on /;],-/) 2( ,-,'-7
at f Ice ~
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)
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r rei _~,
Decedent at death owned property with estimated values as follows:
(If domiciled in P A) All personal property
(If not domiciled in P A) Personal property in Pennsylvania
(I f not domiciled in P A) Personal property in County
Value of real estate in Pennsylvania
$ iff (}{){)".
$ ./
$
$
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situated as follows: hc;.Je c~ ( "'..< I" i,,;
;llel' ,'.-[ I C"_'>.\(:'f -~
1
\Vhererore. Petitioner(s) respectfully request(sl the probate oUhe last Wlil and Codicil(s) presented with this Petition and the grant of Letters In the appropriate form to
the undersigned:
Signature
Ty ed or printl:d name and residence
d..., \ ~ J,
~~,
/
{'I IN
/1 e cAe 1"\, {J. f,~'r ;/1
17!...):;~
Furm R IV-Oj IE\' I U J 3. i)6
Page 1 of2
Oath of Personal Representative
COI'vIMONWEAL TH OF PENNSYLVANIA
SS
COUNTY OF ('\ l-i 1"0'\ h~ /~ I G\ /) j
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and con'ect to)the best of
the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and;truly
,..;:J
administer the estate according to law.
Sworn to or affirm~d ~(d subscribed
g~
before me the ~ day of
_. U'L {It:- l J "v.>oS
t /1" ~ I . ~kL<;('A~IL
,r t I / " ') 1,,:;/ ~' ,
/ F the Register
Sig
Signillure of Persollal Representative
Sigllature of PerSOllal Represelltative
File K umber:
a2J- u)CC)6 - OOCJCr
Estate of A?o /~L( l- L- I S:/~~)'1 k' " ']
, Deceased
Social Security Number: i q '3 ,.30' () (: LI J Date of Death: J d. J'~ ,3--1 07
I
AND 010\\7, ,Jx::t3 , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT I ECREED that Letters ~i.m (()I~/-({Lf,(]l'
are hereby granted to .~ A .- ~ f1-,'J 'It _5, ~ ^'I~, (' "'-,
in the above estate
Short Certificate(s) . . . . . . . .
RenunclatlOn(s) ..........
{~o ...
and that the instrument(s) dated
deSCrIbed Il1 the PetltJon be admltted to probate and filed of record qS the last \Vill (an9 COdlCll(S)) ofrJledent. j ,
l · 1. I /
FEES 1'\ ..- ~ I : ,r, '~ ~I I /~O J7.).; '{,z
Letters ............... $ C~O (C~ RegisterofW IS~ ~ ~ ~(~UJt{ .J
$-H n C()
$
$ I C) . (D
$ ~::J" a.)
$
$
$
$
$
$
$
$ k)l. DC
Attomey Signature:
Attomey Name:
Supreme Court I.D. No.:
Address:
Telephone:
TOTAL .........
Fo I'll ! R~V-()2 I'ev ID,/3,Uo
Page 2 of2
o <is ... (ll-) ep
LOCAL RE(HSTRAR'S CERTIFICATION OF DEATH
VII ARNING: It is illegal to duplicate this copy by photostat or photograph.
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Thi" i" tu l'cnit\ thai thl.' intormatiol1 hl~rc gin'n )S
Llmccth \.'oplcd'lrom an uriginal Certlfic;ltc !)f Death
tluh fi]~d \\ ith nh:' ll" L1xal RI.~gistrar. The original
(ertlfic~lte will he iurwarJcd to the State Vital
RCL'(>rti:, Oflin' Jur p\.:IIli~I!1Cllt filing
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LUl',d Rcgi:-:,Iral
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Date I ,,'ued
COMMONWEALTH OF PENNSYLVANIA 0 DEPARTMENT OF HEALTH 0 VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See instructions and examples on reverse)
STATE FILE NUMBER
Hl05.144 REV 1112006
TYPE I PRINT IN
PERMANENT
BlACK INK (/31-165
I Name 01 Oealdenl (F.S!. middle. Iasl. suffIXI
Robert
L
Simmers
5 NJe (Last Bu1hdaYI
6 Dale oIllirth (Month, day, year)
7. Bi~hpIace (City and state or lor
69
21, 1938
Altoona, Pa.
8b County 01 Death
&1. Facility Name (II no! ",SlrtullOn, give street and number)
120 Kim Acres Drive
12. Was Dtteedenl ever in the
U.S. Armed Forces?
DYes ONo
198 - 30 -0041
ReSIdence OOthel' Specify:
10 Race' American Indan, Black, Whde, ete
( Spocif}?
White
13. Decedent's Educalioo (Specify ooIy highesl grodo compleled)
Elementary I Secondary (0-12) College (1-4 Of 5+)
12
DId Decedent
Live in a
Township?
17c. f)l Yes. Decedenl Lived In
17d 0 No, Decedent lived within
Aotual Limi1s 01
City I 80<0
. 16 Decedent's M.uhng Address (&reel, city I town, state, lip code)
120 Kim Acres Drive
Mechanicsburg, PA 17055
Decodonl's
Actual ReSidence 17a StaiB
PA
Cumberland
19 Mother's Name (First, middle, maiden surname)
Irene Lovell
17b. County
18 Father's Nama (First. mrldle. last. suffIX)
Lawerence Simmers
20a Inlormanfs Name [Type I Pnnl)
14. Marital S1atus: Malried, Never Married,
WKlOWed, Divorced (Specifyl
Married
Dorothy Stine
Upper Allen
Twp
Dorothy Simmers
20ll. Informanfs Mailing Address ISlreet, City Ilown, state, zip codel
120 Kim Acres Drive Mechanicsburg, PA 17055
21d locatlOO (cny IlOwn, Slale, lip CO<le)
21b Dal. of Dispositioo (Month, doy, year) 21e Plac. 01 Disposition (Name 01 cemele'Y, cremalO'Y or Olher place)
Conolite Crematory
SChaefferstown, Pa. 17088
22c. Name and Address 01 Fac."y
Myers Funeral Home, Inc. 37 East Main Street Mecnanlcsburg, PA 17055
23<: Date Signed (Month, day, year)
:lOa Was an Autq>sy JOb. Were Aulq>sy FIll(jngs 31 Manner 01 Death 32a Dale of Inju'Y (Month. day, year) 32b. Descnbe How 11lfU'Y Occurred 32e. Place ollntJ'Y Home, Farm, Slroel, F~ory,
PeI1orm8<l' :~:: ~~e:Ih~~leuon ~ N.'uf.1 0 Honucide ~~' tllc (Specty)
o Yes ~No 0 Yes 0 No 0 ~,:ciden~ ~i:e~:f:I:::~::: rd T'me of In~'Y I ~I::U.'Y a~0:?b~:.:,:~~nj~2=:.r o~00=132gLocOtloo~'~~r~, ~ I Wwn:'talel
33a Certifier (dleck only onel Db Signature and rtJt
~:~:~~~ia~n~~ ~rty::: ;~~:~~~::~~~::~~:r~ :;:.~_ ~a~ _~d ~~~~~ :e~ ~~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D ..
~~o=:~~~ ~ ::~J:.~'":~~~~':~ :~i:.~~~:':,~;:~~:rtZ~~~~:~:a;~~ manner 01 llated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 33d. ~: ~~~:~deY'26 . 2007
Medical ElIminef J COloner J8i
On I/lo basil oI81lmlnabon ond 'or InvI.bgalion, In my opinion, death occurred althe lime, date, Ind place, Ind due 10 I/lo CI.I8(I) and mlnner II llated.. 34. m ~":e1 01 'to:" 1f J~er Sc:uso ~~:'6"nJ7t Type I PM!
I lunt~Dist' ~ber P "" I "\ 1 .DaleFiledtMonlh,day,y rl, 6375 Basehore Roadl Suite III
., (~ I d\ 1.1 I J'\ I I ./-1 e e dl'J Mechanicsburg, PA 7050
DISpoSition Permit No 00 q'{ q a '1
Hems 24 26 mu::.t be ~eled by person
who prOflC'.lUllC65 Uedth ...
24 Time 01 Death Ap rx .
2:00 A. M
25. Date Pronounced Dead (Month. day. year)
December 22, 2007
CAUSE OF DEATH (S.. Instructionl and examplea)
Item 27. Pdrt I. Enter the ~ _. d1MlaSbs. InJunes. Of comiAicatlons - thai dltocUy caused the death DO NOT enler lermlnal e....ents such as cardiaC arrest
respu d.lary arrest. or ventncular fibrillatIon wllMul showing lhe ellok>gy. usl only one cause on each line
=t!:~~~~~ ~~~I dlse:;.
Probable Myocardial Infarction
Due 10 lor as a consequence of)
~~~~~~:e~'~ ~I~ a
Enl~ UNDERLYING CAUSE
(disease or Injury thai tntlialed the
events resullJilg '" daath) USl
Due to (Of as a consequence of)
Due 10 (or as a consequence of)
I
o
~
23b. License Number
26 Was Case Reterred to MedK:aJ Examiner I Coroner lor a Reasoo Other lhan Clemation or Donatxln?
~Yes 0 No
Approximdte IOterval Part II: Enter other siamficant conditions contributina to~, 28. Old Tobacco Use ConlriblAe 10 Death?
On""'lo Dealh but not resu~lng "' the underly"ll cause 1JV0fl "' PM lOVes 0 PrOOallfy
ONo OU-
29 if Female
o Not pregnant wlttun past year
o Pregnant alllme 01 death
o Nul pcegnanl, but pfegnan/ WIlhon 42 days
oIooath
o NoI pregnant, but pceg>anl 43 days 10 1 Yeal
betore ooalh
o lJntulOW1l j pregnanl WIlhon IIle past year
Coroner