HomeMy WebLinkAbout09-22-08PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF
Estate of /e~O.iT01'ib/J ~f (~~y/~S
also known as
Deceased
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(CO,NIPLETE 'A' or 'B' BELOW:)
COUNTY, PENNSYLVANIA
File Number ~ ~ 0~ ~~ S
Social Security Number~J.s -a1-33a G
1//J A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the
last Will of the Decedent dated~Y ~~~U and codicil(s) dated
(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:
^ B. Grant of Letters of Administration
(If applicable, enter: c. t. a.; d. b. n. c. t. n.; peadentelite; duranteabsentia; durnntemirroritnte) tes
'7 ca
c~ .
Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spz~rs~jif any) and~eirs: (ff ~ _?
Administration, c. t. a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of'heirs.) `3 ~ ~-.~ ~
- _ t---
C Name Relationshi Residence's '_ CV
- _.: ~ _ ;.
_x, N -.
y ~
(COiVIPLETE IN ALL CASES:) Attach additional slteets if necessary.
Decedent was dgmic~iled at death in ~~u~A~/~e/ Cnimty, Pennsylvania with his /her last principal residence at
(List street address, town/cQity, torvnslrip, coung~, state, zip code)!
L>ecedent, then 7 S~ years of age, died ott~e'~T~~ at ~ as ~i`J
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property O Q
(If not domiciled in PA) Personal property in Pennsylvania ~`
(If not domiciled in PA) Personal property in County /P~
Value of real estate in Pennsylvania $
a.~
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 undersigned:
C Signature Ty ed or ri/red name and residence
%~ ~J~~~T /~ ~i~ i9 S
named in the
Form R6V-t7? rei< !0.13.06 Pabe I Of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
11-- II SS
COUNTY OF ~,( .t;~.f"Yl >r3~~ lC~/"1G'' ` _ .
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and coned to the best of
the k~rowledge 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. ~
Swot:: to or affirmed and subscribed
~ ~~~~
Signature ojPersonai Representative
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b fore me the _~,~lj,_~-(}d~aQy~f
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For the Register
Signature of Personal Representative
Signahu~e of Persona! Representative
File Number: ~ t ~ ~ U~ S
Estate of ~r~c-I m T~ aG~s // ~~ , D//eceased
Social Security Number: ~ 9S 6 7 .3300 Date of Death:~CJ~m DC~" ~~ ~~
AND NOW, , in con)sidera~tion of/,tlie foregoing Petition, satisfactory proof
having been presented before me, IT IS/DECREED that Letters / r°iS ~eh ~~
are hereby granted to l~v~er~ h'- ~C,~Cc.S
_ __ in the above estate
and that the instrument(s) dated ~ 2i./ ~ SOD ~ M.
described in the Petition be admitted to probate and filed of record as the last Will (aid Codicil(s)) o~ Decedent
FEES ~,iClt'p/')/!U _ /IbJ
Letters .. °~~ f Uv~... $ 3 ~ ~
Short Certificate(s) .. ~ . .. $ a ~ Attorney Signature:
Rer~iunciation(s) ........
~~ .. $
Attorney Name:
~ $ ) S
~ .
_ J .. $ 1 y Supreme Court I.D. No.:
n
$ Address:
. .. $
. .. $
. .. $
- • • • $ Telephone:
.
- .. $
TOTAL ............ oe
.. $ ~3(c,~{
Funs R6V-0' rev. lO.I3.0( Page 2 of 2
105.805 REV (OI/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 14544133
Certification Number
3EV 112006
PRINT IN
iANENT
;K INK
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.
LGwn, ~ ~ SEP 1~ 8 200
Local Registrar Q Date Issued
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH ~j /~ A c
(See instructions and eicamples on reverse) STATE FILE NUMBER ~ 1 O 0 l/ ` J 3
1. Name of Decetlenl IFirsl, middle. last, sutlix) 2. Sex 3. Social Security Number 4. of D ath (MOOIh, day, year) p
female 195 -07 '` 3300 ~~QD
5. Age (last Birthday) der 1 year Under 1 tlay 6. Date of Birth (Monts, tlay, year) 7. Birthplace (City antl state or forego country) Ba. Place of Deem (Check ony one)
kromtw paya Ham wnnas Hospital: Other
Aug . 11 , 1913 A 1 t o o n a , P A
9 5
atient ^ DOA ^ Nursin
Home ^ Resdence ^Other - S
eciy
atienl ^ ER I Out
m
g
p
fay
p
p
Yrs
Bb. Count' of Death &. Ciry, Bom, Twp. of Deam 8d. Facility Name Qf ial institution, give street and number) 9. Was Decedent of Hispanic Origin? No ^ Yes 10. Race'. American Intlian. Black, White, etc.
(If yes. specity Cuban, (Specify
Dauphin Co. Harrisburg Harrisburg Hospital Mexican,PUertoRican,etc.) white
It. Decedent's Uwal Oct Ibn Klntl of work d one tlun most ¢I wore Itle. Do not state retiretl 12. Was Decedent ever in the 13. DecedenYS Etlucation (Speciy only highest grade compl eted) 14. Marttal Status: Marred Nev@r Married, 15, Surviving Spo use (II wife, give maiden name)
Kits of Work
KirM of Business / Industry 115. Armed Forces?
Elementary /Secondary (0-12)
College (1-4 or 5+) Widowed, Divorced (Specify
su 2rvisor vital r ^Ye6 ( "° widow d
16. Decedent's Mailing Address (Street, coy I town, state, zip code) Decedent's Did Decedent
Decedent Lived in r, Cl W? Y A 1 1 2 n Twp
te P e n n a v 1 V'l n t a Live in a
17c
~ Yes
l R
id
17
Sl
A
5 2 2 5 Wilson Lan 2 '
.
,
.
ence
a.
a
ctua
es
T°w"anip. , 7d ^ N¢, oep@dam LI~@d wilmn
17b
Coun
Cumberland
Mechanicsbur PA 17055 .
ty
Actual Limits of Ciry / Boro
10. Famer's Name (First, mk1~e~., last, sufilx) 19. Momer's Name (First. mitldle, maitlen surname)
Herbert S. Mark Sarah bane Lupton
20a. Informant's Name (Type 7 Print) 20b. Inlortnanl's Mailing Address (Street city /town. sUte, zp code)
Robert M. Haas 36 Golfview Rd., Camp Hill, PA 17011
21 a. Method of Disposition ~ ^ Cremator ^ Donation 21b. Date of Disposition (Momh, day, year) 21 c. Place of Dispositon (Name of cemetery, crematory or Omer place) 21 d. Location (Ciry /town, stale, zip code)
Burial ^ Removal from Slate j Was Cremation or Donation AuMOrized Sept . 2 0, 2 0 0 8 R o 11 i n g Green C e m e t e r y amp H i 11 , P A 17 011
Cher - Speciy: by Matlical Exemin@r I Coroner? ^ Yes ^ No
lure of Funeral rvk:e Licensee (or person acting as such) 22E. License Number 22c. Name aM Address of Facility
_,e. FD-013163-L Musselman FH&CS 324 Hummel Ave. Lemo n2 PA 17043
ate Items 23a<onty when cedityirg 23e. Tome East of my knowledge, de unetl at the time, date antl place statetl. (Sgnelure a~ title) 23b. License Number 23c. Date Signetl (Month, day, year)
physkdan is rot available at time of death to
cenity cause of death.
Time of Death
24 25. Date P anted (Monet, ay, year) 26. Was Case Referred to Medical Examiner /Coroner for a Reason Other than Cremation or Donation?
ttems 24-26 must be cornpletetl by person . 4~g ^Ves ^ No
who pionourices death. M. ~
CAUSE OF DEATH (See instrttetlone end a am lee) r Approximate interval: Pad II: Enlar other sianificent conditions contriddinq 1o death, 28. Did ToEacm Use Contribute to Death?
Pen I: Enter Ure fl131G d events -diseases, kryunes, or compNratbns -mat drectty caused me tleath. W NOT enter temunal events such as cardiac erred, r Onset to Death
Item 27 Mn rat resulting in me untlerlyirg cause given in Pan I. ^ Yes ^ Probably
.
respiratory arrest, a ventricular fibmladon wilhoN showing the etidogy list Doty one ease an each line. ~
r ®, No ^ Unknown
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IMMEDIATE CAUSE IFinel Ns[~asa or ~ G K ~7 E S j (V ~ N t ~ pp ~ F ~"1 f L ~ R C I C~ G
condttion resulting in deem)
~ a R ~ ~ ay e i u ~T.t s
'p1 c+ b¢ tcs t
29. II Femal
t
i
hi
P
~
Due t° (or as a consequence of): ~ ~ ~e , rs
CoRo e~rA R y A RTC(ty p I S t~ s 2:
Seq°andaNy lit ¢pndnldl6, X any. b M •
2y'T 21 v1 L. t" I /2i(Z 1 ILfF iZ O t~ pragnan
w
t
n past year
o
^ Pregnant al Time of death
.
leadmp to Ete cause listed on In1e a.
i ^ Not pregnant twt Dregnant within 42 days
Due to (or as a consequence op:
Enter the UNDERLYING CAUSE of Beam
(disease or injury mat aiEated the o ~
events resuttirg in deem) LAST.
r ^ Not pregnant but Dregnant 43 tlays to 1 year
Due to (or as a consequence o0: before tleath
t
d ^ Unknown 0 pregnant wilhm the pest year
,
30a. Was an Autopsy 30b. Ware Autopsy Flndings 31. Manner of Death 32a. Date of Injury (Month, tlay, year) 32b. Describe How Inryry Occuned 32c. Piece of Injury Home, FeM, Street Factory,
Office Building, etc. (SpecifYl
PenoMed? Aveilade Prior to Compk4ion
of Cause of Deam? ~~/
Iym~aNral ^ Homicide
~,~ ^ Academ ^ Pending Investigation 32d. Time of Injury 32e. Injury al Work? 32f. If Transponatbn Injury (Specify) 32g. Laation of Inryry (Street dry I town, stale)
^ Yes Id•N0 ^Ves ~.~AOo
^Ves ^ No ^ Orirer/ Op@retor ^ Passeiger ^Pedesman
^ Suicide ^ Caltl Not ce Determaetl M Omer - Spea'fy:
33a. Cemher (check oMy one) 33b. Signature and Title of Cagier
• CMNying phyakian (Physician ceniM"9 ce'~ of death when arather physician has pronouraed tleam aM completed Item 23)
death OCCUned due f0 the C@U80(B) end mats@r a6 lilBtBd_ _ _ _ _ _ _ .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 12~
TO the beet rN my Krwwledge ' ~ /~L,~v OL ,4ea • /~~/ ~ n
,
• Pronouncing and ceNitying physician (Physcian both p!onounang tlea!h and cenitying Ie cause of death)
^
d manner as stated
th
d
t 33c. License Number 33tl. Date Signeo lMonlh, tlay. year) ~
f G 2
'
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
o
e cause(s) an
ue
To me best of my knowledge. death occurred at the time, date, and place, ono ~ ~
~t ZI ~1 ~ O p ~
G. ~ ~ ra-~+ ~ Y
S
• Medical Examined Coroner
On the bests of examination antl / or investigation, in my opinion, death occurretl at the time, dot@, and place, and due to me cause(s) antl manner as stat¢tl_ ^ .
34. Name antl Adtlress o1 Parson Who Completed Cause of Death plem 27) Type r Print
~C
Y
I"~/1 )~~
F
nature and ~
istrars Si
Re
35 36. Date Fil (Mon h, day. year) y
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Disposition Permit No. ,_3 _„~
LAST WILL AND TESTAMENT
OF
DOROTHY M. HAAS
I, DOROTHY M. HAAS, of New Cumberland, Cumberland County, Pennsylvania, being of
sound mind, memory and understanding, do hereby make, publish and declare this as and for my
Last Will and Testament hereby revoking and making void any and all other wills by me at any time
heretofore made.
I . FV
C;.J
`"' ~ ~'j
I direct that my Executor hereinafter named shall pay all my just debts and fune`r~ `e~pen~s
T-_ -- ~
:~,,
as soon as conveniently may be done after my decease. ~, ~ rv
~ ,. ~~.
All the rest, residue and remainder of my estate, whether real, personal or mixed, and .- ~ ~~
wheresoever situate, I hereby give, devise and bequeath as follows:
A. One-half ('/2) unto my son, ROBERT M. HAAS, per stirpes.
B. One-half (''/z) unto my daughter, DONNA LEWIS, per stirpes.
If either child does not survive me, but leaves descendants who so survive me, such
descendants shall receive, per stirpes, the share such child would have received had he or she so
survived me.
III.
I hereby nominate, constitute and appoint my son, ROBERT M. HAAS, as Executor of this,
my Last Will and Testament. If the said Robert M. Haas should predecease me, fail to qualify or
cease to act as such, then I nominate, constitute and appoint my daughter, DONNA LEWIS, as
Executrix.
IV.
No fiduciary acting under this Will shall be required to post bond in this jurisdiction or in
any jurisdiction in which he may act.
IN WITNESS WHEREOF, I, DOROTHY M. HAAS, the Testatrix, have unto this, my Last
~JVill and Testament, consisting of two (2) type-written pages, set my hand and seal this
,~ ~~-
,'( -~" day of
~~
A.D., 2000.
(SEAL)
Testatrix
SIGNED, SEALED, PUBLISHED and DECLARED by DOROTHY M. HAAS, the above-
reamed Testatrix, as and for her Last Will and Testament, in the presence of us who have hereunto
subscribed our names as witness at her request, in the presence of the said Testatrix, and of each
other, and we certify that at the time of the execution thereof, the said Testatrix was of sound mind
and disposing mind and memory.
,1~~~ ~ Residing at: Sd~ ~i4~i'y~ S
Residing at: 5"d a h~i4.e,Q%~/~ S`T
~~ G~l~,deCr,/1-L~ I~ ~ 7O~C~
2
COMMONWEALTH OF PENNSYLVANIA
SS..
COUNTY OF CUMBERLAND
We, DOROTHY M. HAAS, the Testatrix, and ,and
_ /1~~~ ~~~ ,the witnesses, respectively, whose names are signed to the foregoing
instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix
signed and executed the instrument as her Last Will and that she had signed willingly, and that she
executed it as her free and voluntary act for the purposes therein expressed, and that each of the
witnesses, in the presence and hearing of the Testatrix, signed the Will as witness and that to the
best of his/her knowledge the Testatrix was at that time eighteen years of age or older, of sound
mind and under no constraint or undue influence.
,1
Lt- v'"'
[TEST RIX]
~~~~~
Witness
Witness
Subscribed, sworn to and acknowledged before me by the Testatrix, DOROTHY HAAS, and
subscribed and sworn to before me by ~ ~~ ~. (aT, ~-, ~ and ~,~- ~~ ~ 1. ~~ . ~) ~ t ~,~~~ ,
witnesses, this '~"~~ day of ~~1~,~~ , 2000.
~~
1/'lw ~ ~!~ 2~
'No ry Public
(~ AL)
Notarial Seal
Leann M. Bensch, Notary Public
Harrisburg, Dauphin County
My Commission Expires Oct. 24, 2002
3