HomeMy WebLinkAbout01-14-08PETITION FOR PROBATE AND GRANT Off' LETTERS
REGISTER OF WILLS OF ~~(~~1'Yl ~~!" ~ CL/1 ~~ COUNTY, PEIv'NSYLVANI?
Estate of ~~, ~) ~ NV ~ ~-S ~ / ~~, J ~• File Number ~~~0 ~Jw ~ /
also known as
Petitioner(s), ti~ ho is!are I3 years of age or older, apply(ies) for:
(COMPLETE '.-t ' or `B' BELOW:)
^ 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
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(State relevant circunutaaces, e.g., renunctauon, death of executor, etc.) -~~, e ~
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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 tI}€ t`r~rstrumetll{s) offered
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for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ~=
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B. Grant of Letters of Administration T'
(If applicable, enter: c.t.n.; d. b. n. c. [. a.: pendente liter durance absentia; durance nilnoritate)
Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spouse (if any) Sal heirs: (If
Adtnirtistration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
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Decedei t was domict d at deat to u County, Pennsylvania with his /her last principal residence at /
1~ ~ ~ i,SSI`t 'C~f~t1i~ /~./ A- J 7(~ 2.5 f1'1~~4 IIJ~ ~~ lam ~~ Gl
(List street address, torvidcity, township, connt)~, state, ?ip code) ' / 9/ .
Decedent, then ~_ years of age, died on at ~ L, ~ 7 sS /9 m ~~ J~L~ J'~ ~-
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ L~1 ~00 • U~
(IF not domiciled in PA) Personal property in Pennsylvania $
([f not domiciled in PA) Personal property in County $
Value of real estate in Pennsylvania $
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 widersigned:
Signature Ty ed or rioted name and residence
~~ ~~~ ~OnQ1~ l~. t~aS~~~-Icy J~. J~11~~' Pi~n~e~yn oc~ .1~as
n~i ~ 1. r~lvy
t~ an t ~ ~~~~~~
named in the
3 lle~lh/ov~/ ~Dr. t~-~l~ p~ J~c?zs
1~,~ JGs C~~i~nn L!- ~v~c~ Df~ ~ ~y2~
Fa~ni R6V-03 rev. !0.13.06 - Page I Of
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Oath of Personal Representative
COivIMONWEALTH OF PENNSYLVANIA
/ ~ ` / / SS
COUNTY OF .U/(-~~4.G~1~~~I1 """~`/~/~/~ ` t( ,J., ,~
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petitio~n;3r<e,'tiiie and cbn-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
administer the estate according to law.
Sworn to or affirmed and subscribed
before me the ~_ day of
or the Register
File Number: n/ / ~~~~~ ~y ~ /
Estate of ~FJ~Y1G.![.X Vy, f~(~~JL~~~ ~~- ,Deceased
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Social Security Date of Death: ~ °~~~
AND NOW, 7 °~GG ~ , in conside do of the oregoing Petition, satisfactory proof
having been presen before me, I DECRE D t t f tt~ers i7,GS ~~~'
are hereby granted ~ ~. ~~~11`-l ~ i~~ ~~1
/`~M ; ~~ ~~ ~ ~ , , c ~'/ in the above estate
and that the instrument(s) dated
described in the Petition be admitted to probate and filed of
FEES
Letters ......y ~ ~~ $ 3U
Short Certificate(s) .. ?.... $ ~~
Renwlciation(s) .......... $
JC...P ... $ r o
~~ ... $ 5
... $
... $
... $
... $
... $
... $
... __~~~
TOTAL .............. $
the last Will
Attorney Signature:
Attorney Name:
Supreme Court LD. No.:
Address:
Telephone:
Codicil(s)~,j$f~ecedent.
F~,„~ aw-o. ,~~ io.r3.o~ Page 2 of 2
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LO5.8O5 REV (01/07)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
P 13991926
Certification Number
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.
L~~ ci e istrar Date Issued
jEV 11/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
IANENT
PRINT IN CORONER'S CERTIFICATE OF DEATH
.K INK See Instructions and exam les on reverse
1. Name a Decedent (Rrsl, mitlde, Iasi. suffix) 2. Sex 3. Social Seariy Number 1. Date7Qae198Qib1B5r~C •
Donald W Hostetler Sr. Male 206 - 34 - 7950 January 6, 2008
5. Age (Last Birthday) Under 1 year Under 1 day 6. Date of Blnh (Manor, day, year) 7. BiMpece (City aM dale ar foreign country) 6a. Place a Deem (Check only one)
63 c'" """' Dec. 13, 1944 Lemoyne PA "°~~' °thef
Yrs. pa ^ ER!
^ In bent Oulpetient ^ DOA ^ Nureirg Hans Residence ^Other -Specify:
eb. Couay a Deam &. Clry, Twp. f Dam Bd. Facility Name (N nd mstttution, give street and mmbar) 9. Wea Decedent a Hispanic Origin? ®No ^ Yes 10. Race: American Indan, Black, While, ek.
Cumberland East Pennsboro 843 Melissa Court (If yea, apeaiy caber,
~
Mexican, Porno RMan, etc.)
e
1 t. Decedal's Uauel am Kind a work Bone dWn most a Itle. Do rat state re 12. Was Decedent ever In me 13. DecetlenYS Education (Spedy any highest grade competed) 14. Markel Sptus: Marred, Never Marred, 15. SurvNing Sparse (It wife, give maiden name)
Kind a Work xM Bust /
CPA Sel~ ~m
r~o U.S. Armed Forcaa7 Elementary /Secondary (012) College (1-4 a 5+) Wkbwed, DNOmetl (Spedyyl
p
y ^Yea~NO 12 4 Divorced
16. DecedenYS Mating Address (Brea, city /town, smte, zip cede) DecetlenYS PA Did Decedent v
843 Melissa Court yr
AcIUalResidence na.state Liveina ncE,!}Ya,Decedatlivedin Fast Pennchoro
Twp.
Enola, PA ]7025 Township?
,~, ~„ny 17tl.^Na, Decedent LNed waNn
Actual Umim d Ciy I Boro
16. Famet's Name (Post middle, last, wNu) 19. Homer's Name (First middle, maiden surname)
-Earl F. Hostetler Alberta Bodenheimer
20a. InfonnanYS Name (Type I Pra) 2W. InlorrrenYs Maltlng Address (Slraet dry I torn, stale, zip coda)
Donald W. Hostetler Jr. 1408 Princeton Rd. tfechanicsburg PA 17050
21 e. Method a Disposition i ®Cremetion ^ Donetlon 216. Dore a Disposition (Month, day, year) 21c. Place of Disposaion (Name of certbtery, craatay a other pace) 21e. Location (city /town, else, zip cede)
^ Burial ^ Remove boor Sate I Wan Cremation a Datatlan Autltodad1n
^omer•spedy: ~byMemulExrrt6tar/Caroner7 tJYes^NO U~ . / 0 ..
8
Hollinger Crematory
t. Holly Springs, PA 17065
22a. Signature o(F ~ : " (a person ectkg ss such) 22b. Lkense Number 22c. Name aM Address of Fadliry
~ ~-, ~ FD 012774-L Richardson Funeral Home Inc. 29 S. Enola Dr. Enola, PA 17025
Carrplae tterrs 23aa any when cerlgying 23a. To me my kmMetlge, darn occuned at me time, date end pace slated. (Signature aM tore) 23b. Lkensa Number 23c. Date Signed (MOnlh, day, year)
physidan re not availade a Nme a Beam to
cenily cause d darn.
hems 2d-26 must be conpleted try person 24. Time 3CDF'~W C 25. Ooh Pronaxaed Deed (Honor, day, year) 26. Was Case Refened to Medical Examiner / Coroner la a Reason Other man Cremation or Donation?
who prmaxaes death. 10:45 A. M. January 6, 2008 (~rea ^Na
CAUSE OF OEATN (See Inatructiona and examples) r Approximate interval: Pan II: EMa other sianifirant condhions cenhihulino a deem, 2B. Dltl Tobacco Use ContnbNe to Deam?
ttem 27. Pan L Enter ate TA2i6ffi events - eiseases, injures, a complicetiam -that directly caused the deem. DO NOT enter terminal events such as caMiac anes4 r Onset ro Death but rat resuhin n Nte uncle
g i n'Pn9 cause given in Pen I.
^ Yes ^ Pro6ahly
respiratory arrest, or ventncdar fiDAllatbn wMaa showing me etiobgy. tie a,y ore cause on each Rre. ~
IMMEDIATE CAUSE (Fi
l di
r ^ No ^ Unknown
na
sease or
cartdfition resulting m deem) _' ~
a. Occlusive Coronary Artery Disease r 29. II Female:
Due to (or as a consequence of): r ^ Nor pregnant whhm past year
SequeaieW list conddions, if arty, D. ~
lad ro tfie cause listed an Ire a ^ Pregnant al time a deem
. Due to or as a con
Eraer. me UN~RLYNIG CAUSE ( seQuerae a): ~
^ Nor pregnant bN pregnant wimin 42 days
ev~~ resWhr g m deam~LtfMT e c i of deem
Due to (a es a consequence of): r ^ Nor pregnem, but pegnant 43 days to 1 year
r
d.
before daM
^ Unknown tt pregnant wNNn me pall year
3Da. Wac an Autopsy 30b. Were Autopsy FiMkps 31. Mender a Deem 32a. Date a Injury (MOmh, day, year) 32b. Descd6e How In)ury Occuned 32c. Place a Inprry Home, Farm, Street, Feclory,
Perlomied7 Available Pda to Competion
NeNrel ^ Hesdcide ONae Build'mg, etc. (SpealyJ
a Cause of Deem?
~~.ax
^ Yes ~NO
^ Yes ^ No ^ Acdtlmt ^ PeMing Irnestigagon 32e. Tore of Injuy 32e. Injury at Work? 32f. If Transportation Injury (Speedy) 32g. Laratlon a Injury (Street Uty /town, state)
^ Suicide ^ CouM Nd be Daermmed
^ Ves ^ No ^ Driver /Operates ^ Passenger ^Paestren
M Olhar ~ Spedy:
33e. Certlfier (deck Doty one) 33b. Sigrehxe and T
• CrtrtllyNtg physialan (Phyaidan cendying cause of deem wtgn anaher physiden has praauncetl death aM aarmleled Hem 23) Co rove r
To the bast of my lmowledpe,dam orxuned due to tM nuea(a)and mannerasteled_-------------------------------- ^
• RonouncMg sod aroMn9 phyaklen (Physkian boor portamdng deem end cenNying ro cause d deem)
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Signed (Honor, day. year)
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_ _ _ _ _ _ _ _ _ _ _ _
. E„,a,,.,/cesoror January 8
2008
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On the bale d axaminstbn and / or Invatigetloh m mY opnbn, deem accumd a tlr Nma, aM, and peas, end due to the oases) arM mamtx a slalsd_ ,
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~,Ngrge _
~~ P~ ~~ ~ 3e dJ~em (ttern 27) Type / Pnnl
Mic or
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3s.Registrer mreand ~ L~l ~ I'~I ~ 1' I
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3t~te
( 'mY'~r e orr s OI
Oner
6375 Basehore Road, Suite I~1
- ~ Mechanicsbur PA 17050
OaPosiUOn Parmh No. f1 ~~~ Iu_~~_. _.. _..