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HomeMy WebLinkAbout01-17-08 Estate of also known as PETITION FOR PROBATE AND GRANT OF LETTERS C lI\ f\I\. \:, (ud PI rJ ~ ~ E{e.I~rJ S-T~~ REGISTER OF WILLS OF COUNTY, PENNSYL V AI\IA File Number ~\ \)~ ()~l~ I) 3~ , Deceased Social Security Number I g l? '.. 07 Petitioner(s"j, \\ho is/an,; 18 years of age or older, apply(ies) for: (COI11PLETE 'A' or 'B' BELOW:) o A. Prob:lte 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 (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: .6~. Grant of Letters of Administration (If applicable, 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) (COJ'dPLETE IN ALL CASES:) AttacfT'tdditiO/lCets if /lecessary. D,Rlf dent was domiciled ~I(death . L U/wL fAil! Cg.J.l~y, Pennsylvania with hiP C ' N~ ~~~~ (List street address, townleity, towns /zip, coullty, state, zip code) / Decedent, then '1 0 years of age, died on I b 1:26 ipal rrJ21nce ~ I b I '?> Decedent at death owned property with estimated values as follows: (If domiciled in P A) All personal property (If not domiciled in PAl Personal property in Pennsylvania (lfno! domiciled in PAl Personal property in County Value of real estate in Pennsylvania situated as follows: I V C k K~ P /0 $,~ -~ I $.:tc $ .: ,.. , -<-]-', ~'~ 6~ L :z:.. -,... .." ~..'-~~ -.J 'r-' " -- '-- - , Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant ofLett~~in the appmiate formio,: :::: the undersigned: .. I -'''~l ~ Ty ed or rinted name and residence w c::- lASSie e.~ G D J ~.f\l~.~ ~VA I ., 0 ~ ~'-'" For>llRW.02 rev./O.IJ06 Page I of2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF C Ll ('<')~'f 'nrc:l SS The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and conect 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 administer the estate according to law. (JJ0oJJ ~ before me the -D- day of Signature of Personal Represelllative ''---) C;C) -lJ . , i"-":> ~-':"l c::.::) CC1 Sworn to or affirmed and subscribed L :!;::B- -=:1t<> Signature of Personal Representative -...l ..." Signature of Personal Representative --.:.1.0.. :_~I W N .r:- File Number: 'd.. \ t)'6 \)\:) ~~ Estate of C- [..f e.\~ -r-. s.-\-~wo...rt , Deceased Social Security Number: Date of Death: AND NOW, having been presented before me, IT IS DECREED that Letters are: hereby granted to , in consideration of the foregoing Petition, satisfactOlY proof in the above estate and that the instrument(s) dated described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. FEES Letters ..... ~ \ qp. . . . Short Certificate(s) . . 3. . . Renunciation(s) .......... ct2> ~ ~b Register of Wills ~ \~ TOTAL $ $ $ $ $ $ $ $ $ $ $ $ $ "'Lt\""" Attomey Signature: \t) 6" Attomey Name: Supreme Court LD. No.: Address: Telephone: FO/"l" RW-02 rev. 10.13.06 Page 2 of2 H I05.K05 REV I/O) This 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. Fee for this certificate. $6.00 No. ~!??~ 7~<~ Local Registrar ,/,l p 12840616 OCT 3 0 2006 Date Cj G 1"-.) c::t t.:;'~..) 0:> ,- :E:: ,..;i::..- -1 -0 0) .. t 1~': rv .f7 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH 90 6b Coun~ 01 De8Ih v~. 3-31-1916 Lock Raven. PA ad. FaciltyN....llfnot_\iOl1,~ve_llrldl\\ll11berl 80. Pia<:e of IJeaIh Check ore Hosp\tlll: 01h0r: OlnpiJienl OERIOu/paIisnl ODOA i]NurolngH<lme 9. Was_ofHOparicOrigil1? No OVes Iff yes, specify Cuban, Claremont Nursing Home MexIcan,PuertoR1con,otc.) Il W.._.....1he 13. 0eced1lll!.E4JcaIIon(Sl>edfyooyhlghesl9rOOecomp\eled) 14. MarilalS1aluo:Marrfed,NeverMarried, U.S. Armed ForteS? Elemen1ay I Secondary 11>12) College 11-4 or 5+) WIdowed, Di'IoIted (Specify) OVes Ii1No 12 Widow 7. lrld_or 188 - 07 STATE FlLENUMBER ~ \ t>CO QbloB. 4. Dale 01 Death 1M""", day, yoer) October 26, 2006 1735 5. Age ILaol Brlhday) Evel Stewart B.llafeolBlr1hMlJ1l/1, , Cumberland Middlesex Twp. 11. Decedenr. Uoual ~ 01_ done """ 01 lie. Do 00t _ retiJed. ~oIWort' i<jnddllu$i1eSS/I_ Clerk State of PA , 16. _.MaiirGAddnlooIS_clylklWn,_,rlpcocle) 1000 Claremont Road Carlisle, PA 17013 Oeoedenf. Aduel Reelder<:e 17a. S1ala Pennsylvania I);dDeeeclent Uvelnill TownthIp? 17b.CotI1ty Cumberland 17C.1iI v",_lNedirHiddlesex 17d.O :U=dUved- Twp. CityIBoro D ,,: 19. _Name(Fil1l.m~dle,meIden""''''') Helen Elizabeth Toot 201>. _1Il111Melllrq_I_cly/klWn,_,zlpaldel 8 Ed ewood Drive, Hechanicsbur 21c. PlacedDlopooition(Named~,CIIIll'*"Yor_p\8:8) 18. FaJhe(.N....IFOsI,midd.,IasI.suffi><) Charles Hen Keller 2Oa. .formanl'll NiIl'o (Type I PIlnQ 006 2.. 00 6 : Approximmei1feMlt : 0n0el1D DeaI1 28. I);dToboccoUeeConlJibulllIoDealh? D Yes Oprobably o No 0 Unknown 29.1_ o No! JlI09!18Ilf wihIn paot year o Pregnllll.. lime of death o Not pregnent, bol pregn... wllhln 42 dayo of_ D NotP<O!lnent,but_l43dayllD1_ 01 daeth Un~ ~pregnlO1t....it!he paot_ 320. Place of 1Ijtay: Home, Form, _ facloly, ab!lullfl1g,8lc.(Spod/y) =iolcord1tlono,~lWIY' . tlC8U98li1tl!ldoona. Enter UNDERL Y1NG CAUSE (_"'~1helinilatodthe 1MlIl~ ,..~ting. death) LAST. Ct~~}Vt'UIIAi..r kCLUQ~ Dueto(or...~nce~ ..J::1.. t M~ 1M Due to (or as a conuquenee ct'r Due ID (or as ill. ~uence 01')' d. 32g.lDc:a<Ionoflnjuyl_,cilyl_,_l o V", 3Ob. W...Au1DpayFi1dlogo 31. MII7"ofDoalh ~=~a:u.~ m- D- 0- D PeodIng!nvellllgBtlon 32<1. r...dkjtry o SuIcIde 0 CoukINolbeOe\lorm\necl OVes ONo 308. Was M /4JkJr-y Pertonned? M. 338. Cortlltlf (chect< on~ one) . ~PJ"::=:='':::-::"'':::~:~~~~_~~)__________________.D . PronoUflCing Ind cartIfyklg phyolcIJo (phyolcilll both proI1llIIlClng _lrld cartifying 10 cau.. of daelh) To the baatolmy Imowladge, deatIt_otthe_, -,lIldplace,and dualDtheClllJO(J)andl1llll""lIalatI<L _ _____ _ ____ _ _ _ ___ . ~.: =- ~eo.:::.IIlflJ 0' 'llYOIttlIatlon, 10 my opinion, _ oecurred at the lioIl, dat>, and place, and dua to till ClUaa(S) and menoar II atalt<I. _ .D ~ Durable Power of Attorney for Health Ca,~;'< (Pennsylvania Statutes Annotated title 20, ~~ 5601 to 5607) ~ C::::) ;---~.... (:c ,---- -J -0 -"~ -'- I, [U~ 1'4/v ST~f+-rn- Print your full name am of sound mind and [ voluntarily make this Durable Power of Attorney for Health Care. There are two parts to this document: Part I sets forth my health-care instructions; Part 2 appoints a person to make health-care decisions for me on matters not covered in my instructions. This document shall take effect upon my incapacity. c, \--1 w (1) N c- PART 1-Health-Care Instructions (2) I am one of Jehovah's Witnesses. On the basis of my firmly held religious convictions, see Acts 15:28,29, and on the basis of my desire to avoid the numerous hazards and complications of blood, I absolutely, unequivocally and reso- lutely refuse homologous blood (another person's blood) and stored autologous blood (my own stored blood) under any and all circumstances, no matter what my medical condition. This means no whole blood, no red cells, no white __.~. . latelets and no blood plasma no matter what the consequences. Even if health-care providers (doctors, nurses,-etc.) believe ifiafonTY-blooolTansnlsion- rapy.wlpreserv~ life-Ufh_lth,-I.do not -want+t----Fllmi4'+:f-ela- tives or friends may disagree with my religious beliefs and with my wishes as expressed herein. However, their disa- greement is legally and ethically irrelevant because it is my subjective choice that controls. Any such disagreement should in no way be construed as creating ambiguity or doubt about the strength or substance of my wishes. Also, because many health-care providers view Jehovah's Witnesses' refusal of blood with disapproval and even hostility, I am concerned that someone may claim that I orally consented to a blood transfusion. Thus, I hereby state that it is my conscious decision that my absolute refusal of blood transfusion shall not be revocable by me orally. If anyone claims that I have orally consented to a blood transfusion, I demand that such claim be ignored unless confmned in writing signed by me and subscribed by at least two disinterested witnesses. (3) With respect to minor blood fractions. or products containing minor blood fractions, according to my conscience I Af initial one of the three choices below] J<!.-:'~ I - ^ 'A J II./;)J(a) N NE. ALL. l (c) SOME. That is, I ACCEPT: [initial choice(s) below] Products that may have been processed with or contain small amounts of albumin (e.g:, streptokinase, and some recombinant products [such as erythropoietin (EPO) and synthesized clotting factors), and some radionuclide scan preparations may contain albumin). Immunoglobulins (e.g., Rh immune globulin, gammaglobulin, horse serum, snake bite antivenins). Clotting factors (e.g., fibrinogen, Factors VII, VIII, IX, XII). Other: (4) I accept and request alternative nonblood medical management to build up or conserve my own blood, to avoid or minimize blood loss, to replace lost circulatory volume, or to stop bleeding. For example, volume expanders such as dextran, saline or Ringer's solution, or hetastarch would be acceptable to me. With respect to non-stored autologous blood. (my own non-stored blood), according to my conscience I ACCEPT: ice(s) below] 'f ~ J: Sea) D AL YSIS OR HEART-LUNG EQU~PM~NT (div~rsion of my blood within ~n extracorpor~al circuit tha~ does not Involve storage or more than brtef mterruptlOn of blood flow and that IS constantly linked to my clTculatory system, provided any equipment used is not primed with stored blood). l EMOOILUTION (dilution of my blood within an extracorporeal circuit that does not involve storage or more than brief interruption of blood flow and that is constantly linked to my circulatory system, provided any equipment used is not primed with stored blood). (c) INTRAOPERATIVE OR POSTOPERATIVE BLOOD SALVAGE (contemporaneous recovery and reinfusion of blood lost during or after surgery that does nol involve storage or more than brief interruption of blood flow, pro- vided any equipment used is not primed with stored blood). (d) NONE. ,J r~p- \\ r \ (6) With respect to providing, withholding, or withdrawing life-sustaining treatment at the end of life, and consistent with vania Statutes Annotated title 20, 9 5404, my declaration, which in no way alters my absolute refusal of blood -as directed ve, is: [initial one of the three choices below] N To PROLONG LIFE: That is, if to a reasonable degree of medical certainty my condition is hopeless (for ample, if to a reasonable degree of medical certainty I have an incurable and irreversible condition that will result in my death within a relatively short time, or if I am unconscious and to a reasonable degree of medical certainty will not regain consciousness, or if I have brain damage or a brain disease that makes me unable to recognize people or communicate and to a reasonable degree of medical certainty my condition will not improve), I do not want my life to be prolonged. Thus, in such situations, I do not want mechanical respiration (ventilation), cardiopulmonary resuscitation (CPR), tube feeding (artificial nutrition or hydra- tion), etc. However, I do want palliative care-treatment for comfort. (b) To PROLONG LIFE. That is, I want my life to be prolonged as long as possible within the limits of generally accepted health-care standards, although I realize this means that I might be kept alive on machines for years in a hopeless condition. (c) OTHER. [If you do not completely agree with either (a) or (b) above, you can initial here and write your own end-of-life instructions in the space provided.-NOTE: Unless your agent knows your wishes about artificial I1utrrtTOri--ariifhydritiorr;youragerrtmay fiot be able f<nnake-decisioifs abo-iITffiese ma.tters.] (7) Other health-care instructio problems, etc.): No nation, current medication, allergies, other medical (8) I am primarily concerned that my refusal of blood and choice of alternative nonblood management be respected regardless of my medical condition. My rights under the federal and state constitutions and state common law require health-care providers to respect and comply with my treatment decisions. My rights are not dependent on, and do not vary with, my medical condition. Thus, my decision to refuse blood and choose nonblood management must be re- spected even if my life or health is deemed to be threatened by my refusal. Stamford Hasp. v. Vega, 674 A.2d 821 (Conn. 1996) (Witness patient's refusal of blood protected by state common law right of bodily self-determination); In re Dubreuil, 629 So. 2d 819 (Fla. 1993) (Witness patient's refusal of blood protected by state constitutional rights of personal privacy and religious freedom); Norwood Hosp. v. Munoz, 564 N.E.2d 1017 (Mass. 1991) (Witness patient's refusal of blood protected by state common law right of bodily self-determination and federal constitutional right of personal privacy); Fosmire v. Nicaleau, 551 N.E.2d 77 (N.Y. 1990) (Witness patient's refusal of blood protected by state common law right of bodily self-determination); In re E.G., 549 N.E.2d 322 (Ill. 1989) (Witness patient's refusal of blood protected by state common law right of bodily self-determination); Public Health Trust v. Wons, 541 So. 2d 96 (Fla. 1989) (Witness patient's refusal of blood protected by state constitutional rights of personal privacy and religious freedom); In re Milton, 505 N.E.2d 255 (Ohio 1987) (non-Witness patient's religion-based refusal of treatment pro- tected by 1st Amendment guarantee of free exercise of religion); In re Brown, 478 So. 2d 1033 (Miss. 1985) (Witness patient's refusal of blood protected by state constitutional rights of personal privacy and religious freedom); In re Os- borne, 294 A.2d 372 (D.C. 1972) (Witness patient's refusal of blood protected by 1st Amendment guarantee of free exercise of religion); In re Estate of Brooks, 205 N.E.2d 435 (Ill. 1965) (Witness patient's refusal of blood protected by I st Amendment guarantee of free exercise of religion). . [This footnote applies only to pregnant women.) If I am pregnant and there is a reasonable chance my fetus could survive, I want my life to be prolonged for the sake of my fetus, notwithstanding my instructions in Paragraph (6)(a). However, in no way does this change my wishes about nonblood treatment for both myself and my fetus. After any efforts to save my fetus, my instructions in Paragraph (6)(a) shall again control. I- I L The United States Supreme Court has said that "[i]t is settled now... that the Constitution places limits on a State's right to interfere with a person's most basic decisions about ... bodily integrity." Planned Parenthood v. Casey, 505 U.S. 833, 849 (1992). In Cruzan v. Missouri Department of Health, 497 U.S. 261 (1990), the Supreme Court stated: "It cannot be disputed that the Due Process Clause [of the Fourteenth Amendment to the United States Constitution) pro- tects an interest in life as well as an interest in refusing life-sustaining medical treatment." Id. at 281. The Court also said: "The principle that a competent person has a constitutionally protected liberty interest in refusing unwanted medi- cal treatment may be inferred from our prior decisions." Id. at 278. In addition, in Washington v. Harper, 494 U.S. 210 (1990), the Supreme Court said that prison inmates suffering from mental disorders possess "a significant liberty. inter- est in avoiding the unwanted administration of antipsychotic drugs under the Due Process Clause of the Fourteenth Amendment." Id. at 221-22. The Court also observed that "[t]he forcible injection of medication into a nonconsenting person's body represents a substantial interference with that person's liberty." Id. at 229. There is no indication in these Supreme Court cases that a person must be in a tenninal, irreversible, incurable or untreatable condition, or in a permanently unconscious or vegetative state in order to exercise his fundamental Four- teenth Amendment right to refuse treatment or otherwise control what is done to his body. Indeed, Nancy Cruzan her- self was not terminally ill. See 497 U.S. at 266, n.l. Moreover, implicit throughout the majority opinion in Cruzan and expressly stated in Justice O'Connor's concurrence and all the dissents (except Justice Scalia's) is the acceptance of advance written directives as clear and convincing evidence of a formerly competent patient's wishes. Therefore, be- ucauseJ haveprepar_ed this advance directive while competent, if I become incompetent, my wishes as expressed herein must be respected as if I were competent. (9) [This paragraph applies only to pregnant women,] In Planned Parenthood v. Casey, 505 U.S. 833, 860 (1992), the Su- preme Court confirmed that "viability marks the earliest point at which the State's interest in fetal life is constitutionally adequate to justify a legislative ban on therapeutic abortions." Thus, since I have the right to abort my pregnancy before viability I necessarily have the lesser right to refuse blood transfusions before viability. In addition, even if my fetus is viable, the Supreme Court has said that mothers cannot be exposed to increased medical risks for the sake of their fe- tuses and that the state's interest in the potential life of the fetus is insufficient to override the mother's interest in pre- serving her own health. Thornburgh v. American College of Obstetricians & Gynecologists, 476 U.S. 747, 768-71 (1986); see Planned Parenthood v. Casey, 505 U.S. 833, 846 (1992). Also, in the cases of In re A.C., 573 A.2d 1235 (D.C. 1990), and In re Doe, 632 N.E.2d 326 (Ill. App. Ct.), cert. denied, 114 S. Ct. 1198 (1994), refusals of treatment by women with viable fetuses were upheld. Although both of these cases involved Caesarean sections, as a matter of principle and logic they show that it is the pregnant woman who should decide what is to be done to herself and her fetus. Therefore, I demand that my refusal of blood and choice of alternative nonblood management be followed and that my doctors manage my care and the care of my fetus without transfused blood. (10) In sum, based on federal and state constitutional law and state common law, I demand that the instructions set forth in this document be followed regardless of my medical condition. Any attempt to administer blood to me contrary to my instructions will be a violation of my Fourteenth Amendment liberty interest in bodily self-determination, my First Amendment right of religious free exercise, my state constitutional rights of personal liberty or privacy and religious freedom, and my state common law rights of bodily self-determination and personal autonomy. PART 2-Appointment of Health-Care Agent (11 ) I hereby appoint the following person as my health-care agent: [Notice: You may choose any adult to be your agent, but it is recommended that you not choose your doctor, any of your doctor's employees, or any employee of a hospital or nursing home where you might be a patient, unless the individual is related to you by blood, marriage, or adoption.] 'D A0 I a\ C G lA S 5 Ie. ~ 6~ 5 €- ~ ~ M..ed ~ ~ PI} !7()~ Work Telephone: (_) ~ A-M.. e... Home Telephone: (111) 7 ~ Co t..(.....{,) 1- Other: (_) Agent's full name: Agent's address: (12) If the agent appointed above is unavailable, unable, or unwilling to serve or continue to serve, then I appoint the following alternate agent to serve with the same powers: [See "Notice" in Paragraph 11 above.] Alternate agent's full name: L-e. 17 Il t2-0~ I ,,,'.;.').;..-t it. ~( {Jft rJ~- ~ Alternate agent's address: Work Telephone: ( _ ) Home Telephone: ( _ ) Other: (_ ) D~J'Y4 1. r..f;1 I~ I . ;' I 1 (13) I I ) To the extent this document sets forth my health-care instructions, there is no need or reason to look to my agent for a decision. However, I grant my agent full power and authority to ensure that the wishes expressed in this document are followed by health-care providers. Further, I grant my agent full power and authority to make health-care decisions for me on matters not covered by this document. My agent's authority is effective as long as I am incapable of making my own health-care decisions. In hannony with the limitations in the preceding paragraph, my agent's authority shall include but not be limited to the following: (a) To consent to, refuse, or withdraw consent to any or all types of medical care treatment, surgical procedures, diag- nostic procedures, medication, and the use of other mechanical or other procedures related to health care. This authorization includes the power to consent to pain-relieving medication for relief of severe and intractable pain. (b) To request, review, and receive any infonnation, oral or written, regarding my physical or mental health, including, but not limited to, medical and hospital records, and to consent to the disclosure of this infonnation. (c) To employ or discharge my health-care providers; to authorize my admission to or discharge from any hospital, nursing home, mental health or other medical care facility; and to take any lawful actions that may be necessary to carry out my wishes, including the granting of releases from liability to health-care providers. (I5) A copy of this document shall be as valid as the originaL I ask that a copy of this document be made part of my penna- nent medical record. I have provided copies of this document to my health-care agent and alternate agent. It is my intention that this document be honored in any jurisdiction in which it is presented and that it be construed liberally to give my agent the fullest discretion in making health-care decisions in my behalf consistent with my instructions. (16) Ifmy health-care providers cannot respect my wishes as expressed in this document or as otherwise known to my agent and a transfer of care is necessary to effectuate my wishes, I direct my health-care providers to cooperate with and assist my agent in promptly transferring me to. another health-care provider that will respect my wishes. In such circum- stances, I direct my health-care providerslo transfer promptly all my medical records, including a copy of this docu- ment, to the other health-care provider. (17) This document revokes any prior health-care power of attorney or health-care proxy executed by me. (18) The provisions of this entire document are separable, so that the invalidity of one or more provisions shall not affect any others. (14) (19) I understand the full import of this document and I am emotionally and mentally competent to execute it. (.:.. 13 y -'I 1- '-I ^1 S r e:- i-/ /} I? ,- 8- ;:;1 / {/' (20) SIGNED: ?our Sign~re \~" I..t. L. 1 N 1'1 .s T t: lv A 11 Date 0/ j I / > ~ :37S' ~~ ~(J1l- /7D/~ Address (21) STATEMENT BY WITNESSES: I declare that the person who signed this document (the principal) or the person who signed on behalf of and at the direction of the principal knowingly and voluntarily signed this writing by signature or mark in my presence. Also, I am not the person appointed as agent or alternate agent by this document. ) ~~ Signature of witness I DAu,'CG~SS/~ PoA Print name ~f~~ Address - ~ (f? '1 a~ tUMd 6s.w Signature of witness 2 aui<J tlJM t( S kJ '1-,)1- 'if Avis Wo.-'VtA I Print name 375 Address Cl o..VU\lLCV\. 1- b Vl v~ ~tM"I(S~1 fA 170/3 Page 4 of 4