HomeMy WebLinkAbout04-07-08
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF Cumberland
COUNTY, PENNSYLVANIA
Estate of Donald H. Peterson
also known as
File Number
c!l I 0 8" 067 Lf
, Deceased
Social Security Number 472-16-5591
Petition(~r(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE ~' or 'B' BELOW:)
IZI A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is / are the Executrices
last Will of the Decedent dated March 27, 2006 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:
o B. 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 db.n.c.t.a., enter date afWill in Section A above and complete /ist of heirs.)
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County, Pennsylvania with his / her last P!inCitJal resideDCe at
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Name
Relationshi
(COMPLETE IN ALL CASES:) Attach additional sheets ifnecessary.
Dect:dent was domiciled at death in Cumberland
106 S. Frederick Street. Mechanicsburg. P A 17055
(List street address, town/city, township, county, state, zip code)
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Dec1edent, then 87 years of age, died on April I, 2008
106 S. Frederick Street, Mechanicsburg, P A 17055
at
Dect:dent at death owned property with estimated values as follows:
(If domiciled in PAl All personal property
(If not domiciled in PAl Personal property in Pennsylvania
(If not domiciled in P A) Personal property in County
Value of real estate in Pennsylvania
20,000.00
$
$
$
$
140,000.00
situated as follows: 106 S. Frederick Street, Mechanicsburg, P A 17055
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 d or rinted name and residence
Donna K. Peterson 106 S. Frederick Street, Mechanicsburg, PA 17055
Christine A. Konicki 1330 Valley Green Road, Etters, P A 17319
Form RW-02 rev. 10./3.06
Page 1 of2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
: 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
Sworn to or afftrmed and subscribed
before me the 7 _ day of
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. 19natur~ Personal Representatrve
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administer the estate according to law.
File Number:
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Signature of Personal Representative
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Estate of Donald H. Peterson
Social Security Number: 472-16-5991
AND NOW, /+p,/ I , 2fJ}'i)
having been presented b~e me, IT IS D GREED that Letters .
are hefl~by granted to . JJonnCi. /( it t:SO"\1
Date of Death: April I, 2008
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fthe foregoing Petition, satisfactory proof
in the above estate
and that the instrument(s) dated (Y/OJe-. h L 7 "7 cX.l/P
described in the Petition be admitted to probate and filed of record as the last W' I (and Codici
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FEES
Letters... .lctP,@.... $
Short Certificate(s) . . J . . . . $
Renuneiation(s) .......... $
Will .. . $
<.-JCf ... $
.auk> . .. $
... $
...$
... $
... $
...$
...$
TOTAL .............. $
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Attorney Signature:
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JOhn' Eakin
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Attorney Name:
Supreme Court LD. No.: 6351
Address:
Market Square Building
Mechanicsburg P A 17055
Telephone:
717-766-3172
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Form RW-02 rev. 10.13.06
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.
Fec for this certificate, '56.00
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,
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P 14328891
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Certification Number
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SHOULD READAS FOLLOWS:
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COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
REV 11/2006
I PRINT IN
'I1ANENT
.CK INK
"2 I 0 8"031
STATE FILE NUMBER
1, Name of Decedent (First, middle, las!, suffix)
Donald H. Peterson
5. Age {Last Birlhday)
4. Date of Death (Month, day, year)
5591 April 1. 2008
6. Date 01 Birth (Month, day, year)
Other-
o Nursing Home KJ Residence
9, Was Decedent of Hispanic Origin? !XI No 0 Yes
(If yes, specify Cuban,
Mexican, Puerto Rican, etc.)
March 6. 1921
Minneapolis. MN
87 y".
Bb. County of Death
OOth.r. Spe,,~,
10. Race:.American Iridian. Black, White, elc
(Specify) White
8<1. Facility Name (II nol instittJtion, give street and number)
Cumberland
Mechanicsburg
106 South Frederick Street
11. Decedenf's Usual Occ tion Kind of wori( done durin most of worki lile. 00 no! state retired)
Kind of Wori( Kind of Business I Industry
Computer Analyst U.S. Government
. 16. Decedent's Mailing Address (Street, city I town. slale, zip code)
106 South Frederick Street
Mechanicsburg. PA 17055
12. Was Decedent ever in !he
U.S. Armed Forces?
liJyes ONo
Decedenfs
Actual Residence 17a. Slate
13. Decedent's Education (Specify only highest grade completed)
Elementary I Secondary (0-12) COllege (1-4 or 5+)
12 2
14. Marital Status: Married, Never Married,
Widowed, Divorced (Specify)
Widowed
Did Decedent
Liveina
Township?
Pennsylvania
Cumberland
17c.D Yes, Decedent lived in
17d.1XI No, Decedent Lived Within
Actual Limits of
Twp
17b. County
Mechanicsbure:
Cily/Boro
18. Falher's Name (First. middll!. last, suffix)
Hans G. Pl~terson
20a. Informant's Name (Type / Print)
Ms. Donna K. Peterson
19, Mother's Name (First, middle, maiden surname)
Anna Thorsen
2Ob. Informant's Mailing Address (Street. city I town. state, zip code)
106 South Frederick Street, Mechanicsburg. PA
17055
21b. Dale of Disposition (Month, day, year) 21c. Place of Disposition (Name of cemetary, crematory or other place)
21d, location (City/town, stale, zip code)
Cremation Society of PA
Auer Memorial Home and
r
Harrisburg, PA
Cremation Services.
PA 1 10
23c. Date Signed (Month, day. year)
17109
Inc.
23b. License Number
26. Was Case Referred to Medical Examiner I Coroner for a Reason Other than Cremation Of Donation?
DYes ~NO
'7- cO r;
Approximate interval:
Onset to Death
Part 11: Enter olher sianificanl condilions contribufina to death,
but not resulting in the underlying cause given in Pari I.
28. Did Tobacco Use Contribute to Death?
DYes 0 Probably
~No DUnkrlOWn
29. If Female
o Not pregnant within pasl year
o Pregnanl at time of death
o Not pregnant. but pregnant within 42 days
of death
o Not pregnant. but pregnant 43 days to 1 year
before death
o Unknown if pregnant within the past year
32c. Place of I.njury: Home, Farm, Street. Factory,
Offa BuIlding, etc. (Spec!fy)
=I:~n~~~d:~~) dise:~
~ntialfy ~st~ions. ~ any,
~~:~~o ~~~~~I~~rumr a
(disease or iryjury lhat initiated lt1e
BVef1ts resultlOQ In death) LAST.
b,
d.
308. Was an Autopsy
Performed?
n. Were Autopsy Findings
.A,vailable Prior to Complefion
cf Cause of Death?
31. Manner of Death
EV'Natural 0 Homicide
o Accideot 0 Pending Investigation
o Suicide 0 Could Not be Determined
32d. Time of InjtJry
32f.IfTranspoflalion Injury (Specify)
o Driver I Operator 0 Passenger DPedestrtan
OOther. Spec'~'
:b' Signature and Title of eartHier 1)..
32g. location of Injury (Street, city flown, state)
OY.s Cl(No
DYes ONo
M.
33a. Certifier (check only one)
Certifying physician (Physician cerlifying cause ot death when another physician has pronounced death and completed Item 23)
To the besl of my knc,wleOge, death occurred due to the cause(s)snd manner as stated.. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
~::~~~t: ::r~hJ:a~~a~~~::~~ ~tti:~~~in~~~~a:~~n~ol~~:~~)~~ manner as stated.. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
:::~::~sm~~~~;'= and} or Investigation, in my opinion. death occurred at the time, date, and place, and due 10 the cause(s) and manner as stated_ 0
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0195874
Disposition Permit No
LAST WILL AND TESTAMENT
OF
DONALD H. PETERSON
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I, DONALD H. PETERSON, of the Borough of Mechanics burg, Countt~-i-' :x
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Cumberland and State of Pennsylvania, being of sound and disposing mind, mefiiory and ~
understanding, do make, publish and declare this my Last Will and Testament, hereby
revoking and making void any and all former Wills by me at any time heretofore made.
1.
I direct the payment of all my just debts and funeral expenses as soon after my
decease as the same can be conveniently done.
2.
I give and bequeath all the rest, residue and remainder of my estate, of whatsoever
nature and wheresoever the same may be situate, to my wife, MARY K. PETERSON,
absolutely and unconditionally.
3.
In the event that my wife, MARY K. PETERSON, should predecease me, or should
she: die within thirty (30) days from the date of my death, then in such event, I give, devise
and bequeath my entire estate, real, personal and mixed, whatsoever and wheresoever the
same may be situate, to my children, share and share alike, per stirpes.
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F or the purpose of facilitating the settlement and distribution of my estate, I
authorize, empower and direct my Executrices hereinafter named, or any substitute personal
representative, to sell any and all real estate which I may own at the time of my decease, as
well as my personal property, at either public or private sale or sales.
LASTL Y, I nominate, constitute and appoint my wife, MARY K. PETERSON,
Executrix of this my Last Will and Testament and in the event that my said wife should
predecease me, or should she be unable or unwilling to serve in such capacity, then in such
event, I nominate, constitute and appoint my daughters, DONNA K. PETERSON and
CHRISTINE A. KONICKI, Co-Executrices of this my Last Will and Testament in her
place and stead, and in all instances, I direct that my said personal representative be excused
from posting bond or other security for the faithful performance of their duties, in any
jurisdiction.
Tn
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 2- 7~y of
March, A. D. 2006.
/1-------
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Donald H. Peterson
(SEAL)
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COMMONWEALTH OF PENNSYL VANIA )
: SS
COUNTY OF CUMBERLAND )
I, DONALD H. PETERSON, the testator, whose name is signed to the attached or
f4)regoing instrument, having been duly qualified according to law, do hereby acknowledge
that I signed and executed the same instrument as my Last Will and Testament; that I signed
it willingly, and that I signed it as my free and voluntary act and deed, for the purposes
therein expressed.
f}~
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Donald H. Peterson
Sworn and subscribed to before
me this i)1/11 day of March, 2006.
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Notary Public
NOTARIAL SEAl.
HEIDI M. NElSON, Notary Public
Medlanicsburg Bora, Cumberland Co.
My Commlsslon expires June 27, 2007
COMMONWEALTH OF PENNSYLVANIA)
: SS
COUNTY OF CUMBERLAND )
We, the undersigned, J. ROBERT STAUFFER and JOHN M. EAKIN, the
witnesses whose names are signed to the attached or foregoing instrument, being duly
qualified according to law, depose and say that we were present and saw the testator,
DONALD H. PETERSON, sign and execute the instrument as his Last Will and
Testament; that the said testator executed it as his free and voluntary act for the purposes
therein expressed; that each of us, in the hearing and sight of the testator, signed the Will as
witnesses; and that, to the best of our kn~edge, the testator, was, at the time, eighteen (18)
or more years of age, of sound min'Y"'dm~ CO~~dures~due influence.
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Sworn and subscribed to before
me this ;rrh day of March, 2006.
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Notary Public
I NOTARIAl SEAl
HEIDI M. NELSON, ~ Public
Mechanicsburg Bora, Cumberland Co.
'. My Commission expires June 27, 2007
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