HomeMy WebLinkAbout06-23-08PETITION FOR P OBATE AN(D~/GRANT OF LETTERS
REGISTER OF WILLS OF ~.{ ~e r l `'! COUNTY, PENNSYLVANIA
Estate of 1 ,111~~ l~/ ~~~ t ~ ~ ~ File Number CX~ y~ d~~~~
also known as
Deceased
Social Security Number 1 ~ ~ ~ f,~""_~~(~~
Petitioner(s), who is/aze 18 years of age or older, apply(ies) for:
(COMPLETE A' 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
(State relevant circumstances, e.g., renunciation, deat/i of executor, etc.)
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Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after executipt~of the insttut~ t(s) offered.
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: C° ~~ ~-- ~
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Jd.l B. Grant of Letters of Administration ; ~ y~
f ~ (Ifappticable, enter: c.l.n.; d.b.n.e.t.a.: pendente life; durante absentia; durayitelniopritate) ~
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Petitioner(s) after a proper search has !have ascertained that Decedent left no Will and was survived by the following:&pouse (if anyjand heirs: < (~:=
d d b t t date of Will in Section A above and complete list of heirs) _ i ~ -
(COMPLETE IN ALL CASES:) Attachdditiotta!sheets if necessary.
A nutustratton, c. t. a. or .n.c..a., en er
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N me Relationshi Residence ~
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Decedent was domiciled at ¢eatkt in i t a rr~ b ~ r- aim County, Pennsylvania wit~t his /her ITprinci
(List strelt htCdifsisjlowA(y~hq fotiJnFttt~, county, state, ztp coitFf " ' " r j d /~
Decedent, then ~_ years of age, died on y at / ~ ,~~ *'~ / "
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) ~-' All personal property
(If not domiciled in PA) Personal property in Pennsylvania
(If no omiciled in PA) Personal p~ in Co ~~
~..~ V of e e y v
the u
ie probate of the last Will and Codicil(s) presented with this Petition and the grant of
S~
named in the
or printed name and
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the appropriate form to
Form RVV-0? rev. lo. r3.o6 Page 1 of 2
Oath of Personal Representative
COMViONWEALTH OF PENNSYLVANIA
yy~ /~~ SS
COL~NTYOF ~~/// ~~~~ ~~/ ,
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 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 ~ ~~d~a~y jof
L .!-+~t.c.i
i
For the Register
Signature ojPersonnl Representative
File N tuber: ~ ~ ~~ ~~~~
Estate of 1~-~-her'~ e ~ ,Deceased
Social Security Number: / ~ ~ ~ ~ 0 '~ 7 (O L Date of Death;. ~~' / ~ ~ ~ ~. ~ O(~
AND NOW, . in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters
are hereby granted to
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 ..~.~~~: "~?.. $ ~D(~l
Shart Certificate(s) . ~..... $ 2.b
Renunciation(s) .. r...... $
... $ I D
_ ... $ S
... $
... $
... $
... $
... $
... $
... $
TOTAL .............. $
in the above estate
Register ojWills
Attorney Signature: r-a
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Attorney Name: _ _ ; ~ ~_ -
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Supreme Court LD. No.: _ = ~" ~~ ~ n,
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Address: -~ ~ ~~- c~ ~ --~~
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Telephone:
Form RW-(1 •' rev. 10.13.06 Page 2 of 2
105 SOS HLV (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 ~.4~52~084
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.
,,~~ , ~Zc~C~ ~ N UN 6 00
ocal Registrar ~ Date Issued
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TYPE /PRINT IN
PERMANENT
BLACK INK
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH ~ ~ L~ ~ 1 ~~~
(See instructions and examples on reverse) STATE FILE NUMBER l~ V1
1. Noma of Decadent (First, midtlle, Wst, suMs) 2. Sec 3. Social Secudy Number 4. Date of DeaM Month, tla year
Catherine A. Wertz Female 196 _ 18 _ 7184 June ~S, 2~0~
5. Age (Last 8irthdey) Undw 1 Under 1 day 6. Dale d &M (Monts, da , ear) 7. BirNplaca (Chy and state a kreign country) Ba. Place d Death (Check only one)
84 ~" ~' M`~" March 26, 1924 Vancouver, WA " 011w`
yrs. []tiripelienl ^ ER I Outpatient ^ DOA ^ Nursing Home ^ Residence ^Other - Speciry:
6h. Counry of DeaM &. CNy, 8oro, Twp. 01 DeaM ('d. Fadkty Name gf not bredlulion, gNe sked and number) 9. Was Decedent d Hispank Odgin? ^(No ^ Yes 10. Race: American Indian, BWCk, While, ek.
Cumberland
St. Middleton Twp
Carlisle Regional Medical Center nl yea, opacity Cuban,
Medan, PUeno Riran, eic.l (specd» White
11. DeradeM's Usual Occ Lion Kutl of wok d one dai mast of world tile. Do not slate reliretl 12. Was Decedent ever in the 13. Deceden's Education (Spedty only highest grade comp leted) 14. Marital Status: Married, Never Married, 15. Surviving Spo use (II wife, eve maiden name)
Nind of Wok Kind d Busirwss J Intluatry U.S. Amred Forces? Elementary /Secondary (0-12) CoNege (1-0 or 5+) Widowed, Divorced ISpedf»
W
Housekeeping Hospital ^vea ®Nn 8 Married William
ertz
tfi.Decoded'sMarlingAdaess{SlreeLdly/lown,slate,zipcode)
7073 Carlisle Pike Lot 25 Decedent's ~ DitlDecedent Silver Spring T
Aduel Resider¢e na. Sore PA Lwema t7c.(~Yes, DeCerlenl Lived in wp.
Carlisle PA 17013 nb. camry Cumberland T°w"~I'~? 17d.^No, Decedent Uvetl wNhk
Aduel Lanus d Ciry / Boro
i6. father's Name IFirs4 mitldle, last. suNU)
Arthur Q. May 19. Mdher's Name (Fist, misae, maiden surname)
Cassia Morton
20a. InlomunYS Name (Type / Rind
Kenneth A. Lupp ZOh. Indamant's Ma4ing Address (S1reeL cNY I town stale, z axle)
1765 Chase Pointe Girdle, # 1137, Vi?- in' ach,
2ta. Matltod d Disposition ^ Cremation ^ DonaNOn 2ih. Date or Disposition (Monts, day, year) 21c. Place d Dispcaitkn IName of cemetery, crematory a oMer place) 21tl. Lacatlon (Ciry I town, state, zip code)
• [~B~del ^ Removaliromslate ~w.acrematbnart3anaUanArdhalud June 9
2008 Westminster Cemetery Carlisle, PA 17013
^ Other -Specify: t by Aladkal Examktar f CrxorwR ^Ves ^ Nq ,
~ 22a. S" are d Funerd service Ucen (or rson acting as ouch) 22b. Ucense Numbar
131
4E 22c. Noma and Address d Fackiry H f f ma -R >rh Fun a11 gg e & Cr emat or y , Inc .
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219 N. Hanover
t.,
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170
Complet Items 23aC ody when cenay6lg 23e. To the bell d my knowledge, deaW occared al Me Wne, date aM place stated. {Sgnature and lea) 23b. Lkense Number 23c. Dale Signed (Mats, day, year)
physican is nd avdlahla at Ume d death to
ceraly cause d dBelh.
Hems 2426 muss tre completed by person 24. 7me of DeaM 25. Date Praraxtced Dead (Mon day, ea
r),
/ 26. Was Case Rdened b M/cO'kai Exartkner / Caarer Nx a Reason OUwr Man Cremation or Doreadon?
who pnxrouoces deeM. .(':O) ~- At. C
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Qd ^Ves [1}IIb
CAUSE OF DEATH (Sea Inatructbrut antl examples) , Appoximate Interval: Pan II: Enter char ilgnNmant condNaw contnhuf g to death 26. Did Tobacco Use Conidhute to Death?
Item 27. Pan I: Enter the chain devents- Mseases, injuries, or mmplicalom -Met deedy caused the deaM. DO NOT enter terrtkreal eveMS such ae rsrtaan arrest, i Onset to DeaM but not resuNMg In the underrylp cause given in Pen I. ^ Yes ^ Probably
mspirakry arrest a ventricular hbdlalion wkMm sMwkig Ure eaobgy. Lill a,ry ore cause an each line. , ^ No ^ Unknown
IIIMEDIA7E CAUSE /Flnd disease a L y r
corldXion resWlltg in deaNl) ~ a. ~4'lAS S i• YC 1 YLY r0. C-{fW'~ l tl` ` ~L {'Krtt~r lr `Pq ~ r ~dd.~S
'
~~ 29. II Female
^
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Due m (or as a consaquarrs oQ: i-'- Not pregnant wiMk pall year
^ PregnarN at tine d deaM
SequeNlagy lest conMlons, it any, h, - ~
~ayt~ to lha cazae listed on fine a. Dua to a es a consequence op: r
Enter the UNDERLYING CAUSE ( r ^ Nd Ixegnent, but pregnant within 42 tlays
(disease a kYay Mal initiated the c r
k
ltln
LAST
~ of deeM
even
resu
g n
. Due to (a as a consequence oQ: i
) ^ Not Pregnant, but pregnant 43 days to i year
~~ deekh
tl. i ^ llMuwvm it pegnam within Nte past year
30a Was an Autopsy 30b. Were Aulepsy Rndim35 31. Manrrer of M 32a. Dale of Injury (Monts, day, year) 326. Describe Haw Injury Occuned 32c. Fgace d Injury: Rome, Farm, Street FactaK
PMOrmed? Avaiiabb Piwr b Compleam OMce Building, ek. (Specity)
d Cause d DeeM7 ~ ^
^ Yes [ Jo ^ Yes No ^ ~~ ^ PenMng Investigalbn 32tl. Tune d Injuy 32e. Injury at Work9 321. N Transpalation Injury (Speciry) 329. Locedon d Injury (Street, cAy /town, stale)
^ Suicide ^ Could Nd be Dekrmined ^ Yes ^ No ^ OMrer! Opereta ^ Passenger ^Pedealiar
M OMer -Specify:
33a CenNier (cned~ mry one) 336. Slgna and Title of Ce
• Cen(fytng pfryaicien (Physkian certdyrng cause d deaM when aralMr physician has pronounced deaM and completetl Nem 23)
Toth Gast of mY knowledge, death ocourtad dtubiM Cause(al entl manner as atalelL________________________________ ^
• Pronouncing and cartayMg physklen {Physician 6dh promumng death antl cenityktg to cause of death) .License Number 33d. Dale Sgn (M M, day, year)
To its Gast of my knowledge, death ouurced et Ne Ilme, dale, uM plau, and tlue to Me cause(s) and manner as ataNrL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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• Med
cal Ekaminer I
oroner
On the hole d eaaMnafkn and f or (mresligadon, M mY opidon, death aepxred ar the tMw, sate, sntl place, antl tlue to the cauae{s) and manner u atelerL ^ ,
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~ Name A
dd
ress d Person Who Cunpleled Cause of DeaMa,(Item 27) Type I Prins
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naWre and Dishic
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Regi 's
ii Dat filed (MmM
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Disposition Permit No.
June 20th, 2008
To Whom It May Concern:
Mr. William Wertz is currently a resident at Forest Park Health
Center. He was admitted to the facility on June 6th, 2008. His
spouse/primary caregiver, Catherine Wertz, passed away and;
therefore, he requires placement in a long term care facility,
because of his inability to care for himself in the community.
Mr. Wertz is not capable of understanding his rights and
responsibilities related to having the diagnosis of dementia and;
therefore, is not capable of assisting with any Probate proceedings.
Thank you for your assistance in this matter.
Sincerely,
~~
r. Joseph Pion ._ --~,
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Graham Medical Group .~ ~
100 South High Street ~'~
Newville, PA 17241
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(717) 776-3114 Q ~
Phone (717) 960-7700 • Fe. (717) 243-8519
700 Walnut Bottom Road Carlisle, PA 17013-3699