HomeMy WebLinkAbout08-04-08PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF r?~MgERLA1~TD COUNTY, PENNSYLVANIA
F~tatenf Marci J. Hollenback
File Number G ~' ~ t ~ ~ ~~~
also known as
Deceased
Petitioner(s), who is/are IS years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BEL013!)
® A. Probate and Grant of Letters Testamentary az~d aver that Petitioner(s) is /are the
last Will of the Decedent dated and codicil(s) dated
Social Security Number 173-38-5938
named in the
(State relevant circumstances, e.g., reneurciatiat, death of execator, 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, vas not the victim of a killing and was never adjudicated an incapacitated person:
® 13. Grant of Letters of Administration
(If applicable, enter.• c.t.a.; d. b.n.c.t.a.; pendentelite; durnateabsentin; dmnnteminoritatr)
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: (!f
Administration, c. t. a. ord.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
Name Rehtionshi Residence
Frank P. Hollenback Spouse 21 Ray Rd., Middletown, PA 17057
Amy Seaman Daughter 250 Spring Knoll Dr., Hbg, PA 17111
Robert Seaman Son
(COMPLETE IN ALL CASES:) Attaclc additional sheets if necessary.
Decedent, was domiciled at death in Cumberland County, Pennsylvania with~t~§/her last principal residence at 12
Campbell Place. Camp Hill. PA 17011
(List street address, toivti/city, township, county, state, zip code)
Decedent,tl:en 52 years of age, died on January 9, 2002 •tc 12 Campbell Place, Camp Hill, PA 17011
Decedent at death owned property with estimated values as follows:
([f 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
situated as follows: 12 Campbell Place,_ Camp Hill, PA 17011
000
- -- ;=a
Total: $ 7~5-,~I
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicils} presented with this Petition and the grant
the undersigned:
Amy Seaman
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ate form to
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~--- I 6250 Spring Knoll Drive, Hbg, PA 17111
Form RW-01 rev, I0.I3.06 Page I of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF ~'t,~ ~.~I-~1~
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 wel l and truly
administer the estate according to law.
Sworn to ur affirmed and subscribed
before ;ne the _~ ~ day of
X11, ~~"
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For the Register
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S7gnarrn•e ofPers~rfil R`eJ?resetrlntive ~~,~v, ~
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Signature oJ'Personal Representative % y.;,
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Signature of Personal Representative _.{
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File Number: _ ~ ~ / ' ~(~~_ 1
Estate of Marci J. Hollenback
,Deceased
173-38-5938 January 9, 2002
Social Security Number: Date of Death:
AND NOW, ~~C11_~~sf ~ ~ ~~ ~ , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters of Administration _
are hereby granted to A~,y Seaman.
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 (ayd~~dicil(s)) o ceden±. , -~
FEES
Letters ......75~.~:~1.. $ ~i35
Short Certificate(s) ..?..... $ ~ CQ
Renunciation(s) ... ~...... $ ~
... $
... $
... $
... $
... $
... $
... $
... $
... $
TOTAL .............. $ a~°, roroo
,,
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.:
Address:
Telephone:
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. Lvo s
859
12 Walnut Street
Harrisburg, PA 17101
(717) 238-4777
Form RW-01 rev. 1.13.06 Page 2 of 2
1D5A05 REV.U,/uGl
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records in accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Calvin B. Johnson, M.D., M.P.H. Frank Yeropoli
Secretary of Health State Registrar
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H,05.144 Rav. ,/91 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
TYPENRINT CERTIFICATE OF DEATH f\ ~~
IN `~ , N A ~,,, (Coroner) ~ J t '~.~,J
PERMANENT
BLACK INN STgTE FILE NUMBER
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NAME OF DECEDENT (First, MMtlle, Lasil SE% SOCIAL SECURITY NUMBER DATE OF DERTH (MOMh, Gay Year)
+ Marci J Hollenback :
Fe
al J
8
2002
.
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e 3. _ _ anuary
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AGE (Lase Binhtlayl UNDER 1 YEAR UNDER t DAV DATE OF BIRTH
(M
nth
D
Y BIRTHPLACE (City antl
S
l
F
C PLACE OF DEATH (Che ck only one -see Instruarons on other side)
Months Days Fours Minutes .
o
ay,
eari te
ae
prergn
ountry) HOSPITAL'
OTHER:
52 vra
Aug
14
1949 e NY
~ Inpatient
^ EFUDpeparlem0 DDA^ Nurs'n9 Omer
H
^
~
^
5. .
,
e. 7. M. nma
Reaiderrce
(specayl
COUNTY OF DEATH CI BOR POF DEATH FACILITY NAME pl not inslitulion. give street antl number) WAS OEGEDENTOF HISPANIC ORIGIN? RACE American Indian, Bieck, White, etc.
No ~I Yes ^ If yes, specify L'undn, lSpenly7
Cumberland Wormleysburg 12 Campbell Place M
i
P
rt
Rl
t
L
ex
can,
ue
o
can. etc.
.
,
eb. Be. 84. 9. tO.rM i1~
DECEDENT'S USUAL OCCUPATION KIND OF BUSINESS/INDUSTRY WAS DECEDENT EVER IN DECEDENT'S EDUCATION MARITAL STgiUS-Married SURVIVING SPOUSE
(Give kintl of work dome during moss ~.~y,~,,~~ U.S. ARMED FORCER? S it onl h hest rade com eted Never Married. Widowed, (Il wife, give maiden name)
H
fvrorking rile; dv rwluserenred)
arr
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sb
LU
q .xyyNy Ves^ No® ElementarylSecpMary College Divorced (Specify)
I
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tta. '~'^~~"~/~~-~ 116. .VU.7l.L1~ ,2. 13. +5 10,1"GL11~ 15.
DECEDENT'S MAILING ADDRESS!SVeel. Gtyrrown. Stale, Zip Codei DECEDENT'S 1VaTll
T
~
a
12(+",J~'TT P~~Q
"`'•~!~"`i .
AC
UAL 1la.Stale
Y Dia 1]c.^Yes,tlecedenilivedin twp_
Ca:p Hill. PA. 1'11 RESIDENCE eecudeN
(seemelruplipna li,-dine
i8 on omen side) ~ township? No, decedem lived
. 1]D. COUnI 1]tl~ wrthrn actual limits of city/6oro.
FATHER'S NAME tFirsl. Mitldte, Last) MOTNER'S NAME (Frcsl. Mrddle. Maben Surname)
,e. RF~2rt ,e. ~~ ~
INFORMANT'S NAME (TyperPrin[7 INFORMANTS MAIL WG ADDRESS (SIreE. Crt/gown, Stale, Zip Codel
pa. FRANK P. Hollenback ~, 12 Campbell Pl. Camp Hill, PA. 17011
METHOD OF DISPOSI710
N DATE OF DISPOSITION PLACE OF DISPOSITION-Name of Cemetery, Crematory LO
A
TION~CVy/TOwn, Stale, Zip Code
G
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LL
Burial yL Cremation^ Removal )rpm Stale^ ^
.
^ (Month. pay. Year) or other Place O
.
.
Boro of Paxtan
~Hb
°onation
°ine"5°~p"'
01/11/2002
Heth-El Cemeter g,
g.
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' zlb. zm. Y x,d. PA.
SIGNATVREO UNE LS VIC LIC EE OR 5 ACTING AS SU M LICENSE NUMBER NgME AND ADDRESS Of FgGUTY
"
~ Reese FH- 911 N
2nd
St
Hb
PA
17102
==a 336. 1 157-L .
.
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,
Compote it ms2 <onlyw nceniryin iol my wleage, deem occurretl a[the lime, date and place stated. LICENSE NVMBER
e GATE SIGNED
physician is Nabla at ti of de o
ceeiN ca°x of death. ISlgn
.and Tkle) (Month, Oay, Year1
z3.. z36. zx
Hems 26-26 must be complNea 6y
TIME OF DEATH A rX
P .
DATE PRONOUNCED DEAD (Month, DayV r7 WAS CASE REFERRED TO MEDICAL E%AMINERICORONER?
person who promurrces aaam . Yes N
^
8
J
2002
Z.. :00 A M. p
26
anuary
,
zs.
]]. PAAT I; Enter Ina eiseases, injuries or complications which caused Intl Beam. DO rro(enter the mode of dying, such as cardiac or respiratory arrest, snook or heart failure. iAPproximale PART N: Other eignibcani condilbns caniribNingto eealh
but
List Ony one cause on each line. interval between ,
not resulting In me uneerlying cause given in PART I.
nsei acrd death
IMMEDIATE CAVSE (Final
a~a~e"`pntlkipn Acute Necrotizin Lobar Pneumonia _
wngmeeam)-. a. R
Hepatic Cirrhosis
DUE TO (OR AS A CONSEQUENCE OF).
5egueMiaeyr condnlpns 6. Acute Pancreatitis
it any, leading to immediate DVE TO (OR ASA CONSEOVENCE O~-.
se. Enter UNDERLYING
CAUSE (Disease M iniury c
mat milNted events OVE TO (OR AS A CONSEQUENCE OF)-.
esulhng in aaam) LAST
a.
VAS AN AUTOPSY
PERFORMED? WERE AUTOPSY FINOWGS
AVAlLA81E PRIOR TO MANNER OF DEATH DATE OFINJURY TIME OFINJURY INJVRV AT WORK? DESCRIBE HOW INJURY OCCURRED.
COMPLETION OF CAUSE
I~o~ (Month, Oay. Year}
OF DEATN? ^
Natural ILY Homicide
/
, Yes ^ No^
~
^ ~r
^ Accident
^
Pendmglnvestigatwn ^ 3pa. 306. M. 30c. 30d.
Yes
No Yes ~1 No
Suietde ^ C
t
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d
^ PLACE OF INJURY- AI home, )arm, sueei, factory, o%ice LOCATION (Street. Gty/Town. Stale)
za..
zab. ou
hoe
eterminee
x
2a. builMrg, am. (speciryi
3p,-
~.
CERTIFIER Check oMy one)
'CERTIFYING PHYSICIAN (Physician certifying cause of deem when another physician has pr°nwrrced Beam and competed Item 23) SIGNATURE AND TIT FI R
To the tlesl of mY krwwbdga, Ham occurred due to the cauaHsl arM manner as a,ated ........................... ......... .......... ....... ^ 7/D. COT OnE',r
-
N
N
E
P
Y
n
)
l LICENSE NUMBER DATE SIGNEDIMonih OayY r}
best f
To dle
ykrww
tleam occurred at
edge.
tM tlms, daleParrd plead arW due
to Vre eauae(a)aM man
na
rasetated ............. .......... ... ^ ~1~. ,,,. March 7, 2002
NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH
'MEDICAL EXAMINER/CORONEA - °'emz')TypaprprimMichael L. Norris Coroner
,
On i6e beats of eaamination end/or investigation, in my opinion, death uccurted atthe time, dater and place, and due to the csuae(s)antl
t 6375 Basehore Road
Suite $1
manna,.da
a,ed .................................................................................................. /'~
],a. ,
3:. Mechanicsburg, Pa. 17050
REGISTRAR'S SIGNATURE AND NUMBER a1a
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DATE FILED(MOnih. Day Year
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RENUNCIATION
REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
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Estate of Marci .T Hollenback ,Deceased
I, Robert Seaman
Son
(Print Nanre)
in my capacity/relationship as
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
Amy Seaman
~ ~ 18 ~f3
(Date)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of ,
Deputy for Register of Wills
Form RW-06 rev. IO.I3.06
`~ -
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rgnatureJ _1
(Street Address)
~.~1'cvr'I,.SG~C1~G ~~~ / ~//~
(City, State, Zip~~
Executed nut of Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purposes stated within on this 18th day
of January 2008
cal(~,11'Yl~~I~.I~-C~~C~,~,(,!~21.('
N~t~ry Publ~
My Commission Expires: '(Ylp~ 3, aC~~O
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
NOt11RIAl tEAI
JENI~IfER ~ I(I1lOMCK
CITY OF MARRISlURG, DiAIII~INri COIMIY
MY Comm~ion ExpNrt Moir ~, X010