HomeMy WebLinkAbout03-18-08
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND
COUNTY. PENNSYLVANIA
Estate of MAE K POLK
File Number
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) I--C~", (t)C'~L_
~1f;;r,) {fllO""'<< a~
. Deceased
Social Security Number 178-16-616-5
Petitioner(s), who is/are 18 year'< of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
IZ1 A. Probate and Grant of Letters Testamentary and aver that Petitioner{s) is / are the Executor
last Will of the Decedent dated October 15, 2004 and codicil(s) dated NONE
named in the
(State relevant circumstcmces. e.g., re11"t.lnciatlon. death if executor. etc.)
Excepla:s 101l0w5, Decedenl did nol marry, was nol divorced, and did nol have a child born or ltdopled aller execulion of lhe inslrumenl(s) o1l'ered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: NONE __
o B. Grant or Letrers or Administration
_..:~~
(If applicable. enter: c,t.a.; d,hn.c.t.a.: pendente lite: durante absentia: durante mint>ritlitt3)
Petitionel( s) after a proper search has / have ascertained that Decedent left no Will and was survived by the following spouse (if any) and:.lBlirs: (1f
AdminislroJiun, c./. a. or d b.n. C./. a., erller dale of Will in Secliun A above and comp/ele list of heirs.)
Name
Relationship
Residence
~=:J
--
(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 ___
160 Gardller Drive. Shipoollsbw~. ShipootlSbure; Township. Cwuberlattd County. Pennsylvania 17257
(Lisl slreel address. Juwnkity. township. cuunty. siule. zip "'ode)
Decedent. then 86
years of age, died on March 9, 2008
at Shippensburg, CWIlberland Counly PennsylvlIIlia
Decedenl at death OWIK:d properly with eslimated values lIS 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
$
$
$
$
18,000.00
situated as follows: NONE
Wh"",fun:, Peliliun"".) rtlllpt>eUully n:qU<:llI(.) the: probah: of the: wi Will and Codicil(.) p.....enh:d with lhi. Pelition and the: grant of L<:11c:rs in [he: appropriale: form 10
the undersignw:
T ed or rinted name and residence
==:J
James K.Polk, 160 Gardner Drive, Shippensburg, Pennsylvania 17257
\/
Fonn RW-02 rev. 10.13.06
Page 1 of2
COMMONWEAL TH OF PENNSYL VANIA
Oath of Personal Representative
SS
COUNTY OF CUMBERLAND
The "'lHw""'1') abov"""",,," '-' j o...mnn(,) "'1 ... ..._, m the foregom. "'nnon "'" true and '''''''''10 ... """ of
... know I""," and ""Hef of Petin""",<,) and lI>ot, " """""'" ..........Hve(,j of the Dee,,"enl, PetiLio""'1') will well and lru1y
administer the eslale according lo law.
Sworn to or aftinned and subscribed
bt:fon~ me the i R 1'1'1 day of
!~2fX) /
'~ '. i~/)l/
Register
--
/
/''gnature of Personal Representative
/
V
--
Signature of Persono/ Representative
--
File Nwnber:
cO / '\ Y r"i -1 /'Q
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--
Estate of MAE K POLK
Date of Death: March 9, 3008
,Deceased
AND NOW,
having been presented betore me, i I
are hereby granted to Jallles K. Polk
~
and that the instrwnent(s) dated October 15, 2004
described in the Petition be admitted to probate and tiled of r
FEES f
, /)It/{ , in considemtion of the toregoing Petition, satisfactory proof
ECREED that Letters Testal!lenlaty
:=
Letters .
............. .
$
Short Certificate( s) . . . . . . . . $
Renuncirtion(S) ...... . . . . $
~s
'."-;0 \ (.fm;;). ." :-
'" $
...$
...$
'. $
...$
. .. $
$=
I C:), 00
'.g;~}t
Lf6~
TOTAL. . . .. .
FormRW.02 rev. 10.13.06
--
= in the abo;:;:;;
d as the last Will (and Codicil(s)) of Decedent.
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lreg,.,,,~. ills '_.....~~:.A '7 1.){~/1~
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Attorney Signature:
Attorney Name:
H Anthony Adams
Supreme Court 1.D. No.: 25502
Address:
49 West Orange Street
Suite 3
Shippen~bw-g, PA 17257
Telephone:
717-532-3270
Page 2 of2
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LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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Dille' ls,mcd
H105.143 REV 11/2006
TYPE I PAINT IN
PERMANENT
BLACK INK
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
STATE FILE NUMBER
\(
Bb. County 01 Death
. OJnilerland
Bd.FacilityName(lfnotinstrtulion,givestreetandnumber)
178 - 16
6165
4. Date 01 Death (Month, day, year)
M9rch 9, 2008
1. Name of Decedenl (Firs!, middle. last, suflix)
Mae
E.
Polk
y"
4, 1921
M:!:bnnellshlrg Pa.
Other:
o Nursing Home QQ Residence DOttier. Specify'
9. Was Decedenl of Hispanic Origin? I&l No 0 Yes 10, Race American Indian, Black, White, ate
(II yes, specify Cuban, (Sp9l;ify)
Mexican, Puerlo Rican, etc.) Write
5. Age (Last Birthday)
86
160 Gardner Drive ShiwensJ=:g Pa. '17257
Wi<'bwed
11. Decedent's Usual Occu lion KlOd..el work done durin mosl of worki life. Do not stale retired'
Kind of Work Kind 01 Business J Industry
Seamstress L' aiglon Clothing
. 16. Decedent's Mailing Address (Street, cily /Iown, sIale, zip code)
12, Was Decedent ever in the
U,S. Armed Forces?
Dy., IKlNo
Decedent's
Adual Residence 17a.SIate
13. Decedent's Education (Specify only highest grade completed)
Elementary I Secondary (0-12) College (1-4 or 5+)
6th
14. Marilal Stalus: Married,NeverMarried,
Widowed, Divorced (Spec;fy)
160 Gardner Dr. ShiwensJ=:g Pa. 17257
17b, Covnty
PA
OJnilerland
Did Decedent
Liveina
Township?
17e. [;. Yes, Decedenl Uved in Shia::ensburo Two.
17d. 0 No, Decedent lrved wilhin
Actuaflimilsof
Twp
CityfBoro
18J~~~aD.(First~laSI.SUflIX)
19, Mother's Name First middle, maiden surname)
lwf E.
20a. Informant's Name (Type I Print)
James K. F\:Jlk
2Ob. lmormanl's Mailing Address (Street, city J town, stale, zip code)
160 Gardner Dr. ShiwensJ=:g Pa. 17257
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21c. Place of Disposibon (Name of cemetery, crematory or other place)
21d. Location (City/towll,stale,zipcode)
Mickl1e Spring Canetery
ShiwensJ:lurg Pa. 17257
22c, Name and Address of Facihty
Fogelsanger-Bricker Funeral H:me Inc. 112 West King st. Shiwe1Sb.Jrg Pa. 17257
23b.license Number
Q}J
RN 5518 '1lc
23c. Dale Signed (Month, day, year)
J I q lOB
lIems 24-26 musl be compleled by person 25, Date Pronounced Dead (Month, day, year)
who pronounces death. A.r~ (C X\p'\ (\! e \q :!J I q I 06
CAUSE OF DEATH (See instructions and examples)
Ilem 27. Part I: Enler the ~ - diseases, injuries, or complications -lhat directly caused the death. DO NOT enter tenninal events such as cardiac arrasl,
respiratory arrest, or ventricular Ilbrillation without showing the etiology lisl only one cause 011 each tine
26, Was Case Referred to Medical Examiner / Cororrer lor a Reascn Other than Cremation or Donalioo?
Dy" ij\No
Approximate interval
Onselto Dealh
Part II: Enler o1her sianillCanl condilions contributino to deatt', 28. Did Tobacco Use Con!rtlUle 10 Dealh?
but not resultmg in the underlying cause given in Parl I. DYes 0 PlObably
D No ~t "'k""'"
29. II Female
~NcJ!pregnanlwithinpastyear
D Pregnanlallimeoldeath
D NOlpregnanl,bulpreqnanlwilhin-42days
otdealh
o Ne,lpregnanl. bUlpregnanl-43daysto 1 year
beloredeath
o Unknown it pregnant within lhe past year
32c. Place ollnlury: Home, Farm, Street, Factory,
Ofllce 8U1ldmg, E'lc, ($prof}')
HlO('I~~
32g. location 01 InjUry (Slreel, city flown, statl~)
Sequenlialf~islCOfldlliOnS,i1any,
~~I~~~o JNDc:~t~II~~~~ME a
(disease or injury that irlitialed Ihe
events resulting m death} LAST.
QOl2.tl~""iZ.'(~"2-'\~'I2-i b', S? AS'L
Duelo(ora~'{consequence 01): ..
!:!'"\f'i-1;2. T'YK:SIDI'l-
Due 10 (or as a co~sequence 01)'
10 ,\H'~5
20 ~n<.a.S
~~d~~tr~~~~~ J~~) dise:;
Due to (or as a consequence 01)
;2
c0
DYe~ No
[]y" [I No
31. Manner oi Dealh
I$- Nalulal 0 Homicide
DA,<x:idenl DPendinglnvestigalion
o Suicide 0 Could Nol De Detmmined
32d, Tlmeo! Injury
o
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30<1. Was an Autopsy
Performed?
3Ob. Were Autopsy Finding~
Available Prior to COI11p1elion
of Cause or Death?
"1: 410 A.J',
L..
33a Certiher (check only one)
CertifYing physician (f>t1ysiclun certifying r.<luse of death wilen another physician has pronounced death and completed Item 23)
To the best 01 my knowledge, dealh occurred due 10 the cause(s) and manner as staled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pronouncing and certifying physician (PhysiCian both plOnounclng death and certifying 10 cause 01 deatrl)
To the best 01 my knowledge, dealh occurred 81 the time, dale, and place, and due 10 the cause(s) and manner as fitated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
Medical Examiner I Coroner
On the basis of examlnatlon and / or I urred at lhe lime, date, and place, and due 10 the cause(s) and manner as stated_ [}
12 1/ I~ IIISI
l-J/\.?-\....c.p-\ Doc~O-Z
33d.D,lleSigncrl(Mon:h,day,yem)
M~\2c~ I!...L2DO'i$
34, Name and Address oj Person Wllo Completed Gause 01 Ueatli (Item 27:T~l(>! Prill! I I
C-J>.Q..\05 S....."'Oo\l4>.\- t.-\ 1\ So.,~V\ :t;A'iLIT~ S-I,'ff"\'
S"h\'f~r-:SBl)~,", ,Vf>.. (t '2.51
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35. Heglslrar's Slgnalurc'andtJistri
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Disposition Permit No. (J 0 761 9 ).
LAST WILL AND TESTAMENT
KNOW ALL MEN BY THESE PRESENTS, that I, MAE K. POLK, of
Shippensburg, Franklin County, Pennsylvania, being of sound and disposing
mind, memory and understanding, do make, publish and declare this my Last
Will and Testament, hereby revoking all prior wills and codicils by me at any time
heretofore made.
FIRST: I direct the payment of all my legal debts, funeral expenses
including my grave marker and all expenses of my last illness, state, federal
estate and inheritance taxes and administration costs shall be paid as soon as
may be conveniently done following my decease leaving all specific bequests free
of tax to the legatee. I further direct that the burial of my son, James K. Polk,
be in my cemetery lot at the Middle Spring Presbyterian Church cemetery.
SECOND: I give, devise and bequeath all my property be it real, personal
and mixed to my son, James K. Polk. If James K. Polk should predecease me or
if we should die in a common disaster, I give and bequeath all of my property be
it real, mixed or personal to my son, Joseph W. Polk.
THIRD: I direct that all taxes that may be assessed in consequence of my
death, of whatever nature and by whatever jurisdiction imposed, shall be paid
from my residuary estate as part of the expenses of the administration of my
estate
FOURTH: I nominate and appoint, James K. Polk, as Executor of this my
Last Will and Testament. If he should fail to serve or be unable to serve, then in
either of those said events, I nominate and appoint, Joseph W. Polk, as Executor
of this my Last Will and Testament.
IN WITNESS WHEREOF, I, MAE K. POLK, to this my Last Will and
Testament set my hand and official seal, this I j day of (~~r 2004.
'/:) -
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MAE K. POLK
/f~j (~1---l11 (SEAL)
Sworn to and subscribed, declared and
Published by MAE K. POLK, as
Her Last Will and Testament, and so
Done in the presence of we the
Witnesses, who sign at her request,
And in her presence, and in the presence
Of each other.
,
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COMMONWEALTH OF PENNSYLVANIA:
:SS
COUNTY OF CUMBERLAND
I, MAE K. POLK, whose name is signed to the foregoing instrument,
having been duly qualified according to law, do hereby acknowledge that I
signed it willingly; and that I signed it as my free and voluntary act for the
purpose therein expressed.
" -) '-71
1/- _
, (a_-+-?
MAE K. POLK
A/,"/" '-) " ,;
LJ -~~q?
Sworn to and acknowledged, before me,
By MAE K. POLK, the_Iestagi~,
This ~ day of //;---C~ 2004.
(
Notary Public
>~~);;lf::d ~<Jl
H
COMMONWEALTH OF PENNSYLVANIA:
:SS
COUNTY OF CUMBERLAND
WE, Darlene M. Bigler and Sharon Coleman Adams, the witnesses whose
names are signed to the foregoing instrument, being duly qualified according to
law, do depose and say that we saw the Testatrix sign and execute the
instrument as her Last Will and Testament; that she signed willingly and that she
executed it as her free and voluntary act for the purposes therein expressed;
that each of us in the hearing and sight of the Testatrix signed the Will as
witnesses, and that to the best of our knowledge and belief the Testatrix was at
the time at least eighteen (18) or more years of age and of sound mind and
under no constraint or undue influence.
r
DCuJ~JC-'~ '~/J ?
r
Sworn to and subscribed before me by,
Darlene M. Bigler and Sharon COle~~
The witnesses, this I S'l-y day or~" 2004.
c-~ ~)
Notary PLJoifc:
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