HomeMy WebLinkAbout11-07-08PETITION; FOR PROB ATE ~~TD GR-~NT OF LETTERS
REGISTER OF WILLS OF
Essate of /~~ c) ~ C ~ ~- ~~, ~~ ~ .
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also known as ~ -+
. Deceased
Pe~:itioner{s), who is/are 13 years of age or older, apply(ies) for:
(CO;LLPLETE A' or 'B' BELOW:)
®` A. Probate and Grant of Lette
last Will of the Decedent dated <! ~
COUNTY, PE~,~iS~'LVAM:~
File Number ~ ~ ~ ~ V ~ d~
Secial Security Number ! `[ "' ~ ( ~ ~ ? ~ -
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tary and aver that Petitiot:er(s) is /are the
and codicil(s) dated
(State relevmu circums[nnces, e.g., renuncintien, dendr of erecuta-, etc.)
Except as follows, Decedent did sat marry, was not divorced, and did not have a child born or adopted after execution of the inshument(sl offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
(CO.tiLPLETE LV ALL CASES:) Attach additional sh ets ifnecessary.
Decedent was domicile at, eath in ~f'l G'+C G`am' r County, Pen syly ~a wit ~!~ her last princ pel
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(Lut street address, town/city, toYVnslup, coturq~, state, ztp code/ ® ._`
Decedent, then _ years of age, died on // _'i i ~r at ~~''~~~~ ~ ~4i~ Cr. ~ ~~' ~ ~-~~
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) Al] 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:
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named in the
Forst RFV-0? reic !0.13.06 Pdbz I Of 2.
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^ B. Grant of Letters of Administration ~
(Ijapplicabfe, erue~: c. t.n.,~ d. b.n.c.t.n., pendente lire; durante absentia; cfur_ i~noritnte) ! ~
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Petitioner(s) after a proper search has 1 have ascertained that Decedent left no Will and was survived by the following sp$t~e~any) a:~d heirs (~~' ,~
Acfminstratiai, c. t. a. or d.b.tt.c.t.a., enter date of Will in Section A above and complete list of heirs.) --'i J _ _.
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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 for to
the undersivne~t
Oath of Personal Representative
CONI~iONWEALTH OF PENNSYLVANIA
COUNT' OF
SS
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and conect to the best of
the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitio er(s) will well and truly
administer the ;,stzte according to law. 'Is
Sworn io or affirmed and subscribed ~ [ ~
be~fo\re me the _~__d/ay of
r
Signanue ofYersonal Representntive
Signature of Persona! Representntive
Signahu-e of Persata! Representative
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File Number: ~ `~ r \_~.~
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Estate of ~CJt~1 U~'\ ~ ~loC,~C,:r ~ 5 ~1(~• ,Deceased
Social Spec~ur~~ity Number: ~ ~ ~ ~ .~ ~ Date of Death: I L ~ ~ ~ C)
AND NOW, ~~,Xi~ ~~~Q•C~1 ~~_, , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters ~~`~'~ ~L.t"~~(~~p~'L~
are hereby granted to ~ O~LYA~ ~ ~~ OC lac s ~ ~ ~
in the above estate
and that the instrument(s) dated
described in the Petition be admitted to probate
FEES
Letters .....:~~-~.~ a, L` $ ~G
Short Certificate(s) ...~... . $ ~'
Renunciation(s) ......... . $
L~~1~ .. . $ 1~~
~~ ~ .. . $ t(?
rry
.. . $
.. . $
.. . $
.. . $
.. . $
.. . $
TOTAL ............. . $ `~`~
filed of record as the last Wit (and Codicil(s) of Decedent.
,~ R.~.L ~''~ ~ ~
Register of Wills ~ ~ ' ~~~
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.:
Address:
Telephone:
P<,~~,~, Rw-oa rev. ro.l3.or Page 2 of 2
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H105-143 REV 11/2006
TYPE /PRINT IN
PERMANENT
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(see instructions and examples on reverse) ~_,_~ , ,~.\ ll~ ~,~ ~L~
1. Name of Decedent (Flrsl. middle, last. suKx) 2. Sex 3. Social Security Number 4. Date of Death (Month, day, year) ` •
Adolph J. Mockaitis, Jr. Male 191 - 14 - 7735 November 3, 2008
5. Age (Lass einhtlayj UMer 1 year Under 1 tlay 6. Dale of Binh (Monts, tlay, ear) 7. Birthplace (City antl stale or foreign country) 3a. Plow of Death (CDeclc any one)
87 ""~"° °aya ""'~ '""""~ June 14, 1921 Brandonville, PA "°~p"ah omer
Yrs. ^ Npatiant ^ EA / Outpallent ^ DOA Nursing Home ^ Residence ^Other - Speciry~.
eb. Ccunry W Doath 8c. City, Boro, Twp. of Deam 6d. Facility Name (If Ipt dsliluaon, ghre street and number) 9. Was Decedent of Hispanic Orgin? ~ No ^ Yes 10. Race: American Indian, Black, White, etc.
' Cumberland Carlisle Forest Park Health Center Of yes, specity Cuban, (SP~iM
Mexican, Puerto Rican, etc.) Wl7lte
11. Decedents Usual Occu tbn Nmd of wok tlCra duri nrost of rookie Ida. Do nm state reared 12. Was Decedent ever in the 13. Decedents Education (Specfy only highest grade complel,ed) 14. Marital Status: Marriaq Never Mertieq 15. Surviving SpWSe (If wife. give maiden name)
Kits M Wok Kind of Business /Industry U.S. Amled Farces? Elementary / Secondary (612) College (1-0 or 5+) Widowed, Divorced (Specify)
Machinist Government (BYea ^na 12 widowed
56. Dec¢denl's Mailing Atltlress (Street, city /town, state, zip mde) Decedent's Did Decedent
101 Winchester Gardens y~y
ACWaIReaderice ,7a stale PA Liveina 1,c.y~Yea
DecetlemLNedm North Middleton
Carlisle, PA 17013 ,
T
Township? _ ~
17b. County Cumberland 17d: ^ No, Decedent LNed within
Actualumila o,
CM /Bore
1B. Father's Name (First. middle, last, surtix) 19. MomerS Name (Rrsi, midde, maiden sumemej
Adolph J. Mockaitis, Sr. Anqela Matusik
2Da. Iniclmam's Name (Type /Print) 20b. InfortnenYS Mailing Address (Stem, cdy /town, state, zip Nda)
Ronald Mockaitis 2430 S rin Rd., Carlisle, PA 17013
21 a. Method of Disposition i 11 Cremation ^ Dariadon
7~'
• 21b. Date of DisposAbn (Momh, tlay, yeerj 21c. Place of Disposition (Nanre M camel
M'~ c~torY o' aNer plmej
21tl. Lxalion (Clly /town, sbte
zip code)
^ Burial ^ Removal hum Slate ~
^
'Wen0rema1~orpone1~'A""'a~ed Nov. 5, 2008 Hoffman-Roth Funeral Home & ,
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omer-spety:
~ W Metlkal Examirrer / coronae
(~1Yaa^aw ar
s
e, PA 17013
;.Sgna~l
rviceLk arpe ~ a5s11Cn) 22b.LicBrneNUmber 22c.NameeMAtlINa55otFBCtiliry Hoffman-Roth Funeral Home & Crematory, Inc.
- 1 8425
ComplMe hems 23ac only when cerlityilg 23a. To Ina best of my lawwledge, Beam occurted at the time, date and place stated. (Signature and title) 23h. License Number 23c. Dale Signed (Month
day
year)
physioan i5 not avaAable at lime of death to
wnlry caaae pl death.
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pems 24.26 must be completed by cerson
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ouncas deem 24. Time of Death 25. Date P\ro/r~wunced Dead (Month, day, year) 26. Was Case Refe
n
edlo Medical Examiner 1 Coroner for a Reason Other than Cremation or Donation?
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- ~ _ j Ci ~ M. / 1 ~'V E' M (1Z 1 ~ c~ Q ~ ~ l
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^ Yes i-.d,^'
CAUSE OF DEATH (See Inamuctiona antl examples) r Approximate'mterval:
Item 27. Pan I: Enter the chain of evens - tl'eeases,'mjunes, or complications - Nat tlirtvdly caused the death. DO NOT enter lertninal events such az tartlet artesl, Onset to Death
respiratory artesl, or ventrkular flbillalbn wilhcul showing me elidogy. List only one cause on each line. Pan II: Enter other Sion hranl cond'fions conMhut' o t death
but clot resuping in ma undenying rouse given in Pan I. 2R. Did Tobaaro Use ConNhule to Death?
^ Yes ^ Pmbab
fry
IMMEDIATE CAUSE Final d5ease or
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caddbn resuping in
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Due to {or as a cons of): Not pregnant wahin pall year
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Sequentialty list condltials, it any, D.
Ieadirg t0 the Cause fated on line a. ~~ ~ Q Q~ ~ A ^ PregnaM at tlme o1 death
Due to a as a c
Enter the UNDERLYWG CAUSE ( o~~a0~~ ^ pregnant, bN pregnant wphln 42 days
o
(disease or injury that initiated me
c death
of
events rasulang m death) LAST.
Due to (w as a consequence ot): ^ Not pregnant, but pregnant 43 days to 1 year
tl. ~ ~
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^
d pregnant within the past Year
70a. Was an Autopsy
Penomwd? 30b. Were Autopsy FiMugs
AvailaNe Prior to Completion 31 Manrer d Deam 32a. Date of Injury (Month, day, year) 32h. Describe How Injury Occuned 32c. Place of Injury: Home, farm, Street, Factory,
al Cause of Dealfi?
Nalu[al ^ Homicide OfIKa Building, etc. (SpecityJ
^ Yes ~ Jo ^ Yes ^ No ^ Aaident ^ Pentlirlg Investigatgn 32a. Tme of Injury 32e. Injury at Wok? 32f. a Tansponalion Injury (Specify) 32g. Loca{bn of ItryUly (Street, city 1 town, state)
^ Suicide ^ Could Not be Oelertnined ^ Yes ^ No ^ Dever I Operator ^ Passenger ^Pedestnan
M ^Other - 5pep(y:
33a. Certifier (check ony orzl 33b. Signal I f
• CeniTying Dhyskian (Physician tMirying rouse of deem When another physirAan has pronounced death antl completed Item 23j
To tM best of mY Imawledge, death oxvrrred due to the cause(s) arts manner es slated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
• Pronouncing and certitying physlclan (Physician troth pronoundrg deem antl certpyirg to cause of death)
Ta the best of my knowled
e
death occurred al the time
dale
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tl du
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^ 33c. Li um 33d. Date S' 4MOnth, day, year)
g
,
,
,
p
ace, an
e
o
e cause(s) eM manrwr as slated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
• Medical Examhrer I Cororrer nl~ ~ /''
/ •r R/CJp 17 L ~"
~ ~ 3 O
On the basis of examination arts / or Investigation, in my opinion, death oaumed at the Lime, date, and place, antl due to me cause(s) and manner as stated- ^
34 Ha
a ~
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b Address al Person Who Completed Cause of Death (Ite m 27) Type / Pam
35. Registrar's 5 t aptl Dlst C Date Filed (Month, day, yearl `
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VeY'T NC//
Disposition Permll No. L7~~~ `.' I `JI
LAST WILL AND TESTAMENT N
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ADOLPH J
MOCKAITIS ~
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I, Adolph J. Mockaitis, of North Middleton Township, Cumberland County, Pennsyly nia,
declare this to be my Last Will and Testament and revoke all y~Iills and Codicils previously made
by me.
I direct that all my legally enforceable debts and funeral expenses, including all expenses of
my last illness, shall be paid from my residuary estate as soon as practicable after my death as a part
of the expense of the administration of my estate.
2
I devise and bequeath the residue of my estate of every nature and wherever situate, including
any property over which I shall have any power of appointment, to my son, Ronald Mockaitis, of
Carlisle, Pennsylvania.
All federal, sta±c and other death taxes payable because of my death, with respect to the
property forming my gross estate for tax purposes, whether passing under this Will or otherwise,
including any interest or penalty imposed in cotmection with such taxes, shall be considered a part
of the expense of the administration of my estate and shall be paid out of the principal of my
residuary estate without apportionment or right of reimbursement.
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LAST WILL AND TESTAMENT OF ADOLPH J. MOCKAITIS
4
I appoint my said son, Ronald Mockaitis, Executor of this my last Will.
I direct that all fiduciaries acting under this Will, whether or not named herein, shall not be
required to give bond for the faithful performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal, this 3~ Sfi day of
I~uC~st- , 2001.
_- ~ ;;
olph . Mo artis
The preceding instrument, consisting of this and one (1) typewritten page, each identified
by the signature of the Testator, was on the date thereof, signed, published and declared by
ADOLPH J. MOCKAITIS, the Testator therein named, as and for his last Will, in the presence of
us, who, at his request, in his presence and in thy. prese~~cf, of each other, have subscribed our names
as witnesses hereto.
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2
LAST WILL AND TESTAMENT OF ADOLPH J. MOCKAITIS
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND
I, ADOLPH J. MOCKAITIS, the Testator whose name is signed to the attached or
foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I
signed and executed the instrument as my Last Will and Testament; that I signed it willingly, and
that I signed it as my free and voluntary act for the purposes therein expressed.
,. __
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Adolp ' J. Mockaitis
Sworn or affirmed and acknowledged before me by ADOLPH J. MOCKAITIS, the
Testator ,this ~t ~~ day of f~uSu ~~ , 2001.
Notzr'sat Seat
MIC.FtaP,I ~. F?l`;'~i°, {~;Jid('y` ~UC:IC
Car~i:.c; La,~, Cum.~e;'an~ t,cai~niv
M.y ~piYti711SSIQf1 i_tip~i~S iV°C. sl;, ~~UL
3
LAST WILL AND TESTAMENT OF ADOLPH J. MOCKAITIS
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND
WE, Gt.-~i l~ ~ ~.. G~_ ~~c~~ ~~~- and 1~ ~'~ ~y ~~~ , f ~ i" i { ~~ ,the
witnesses whose names are attached to the foregoing document, being duly qualified according to
law, do depose and say that we were present and saw ADOLPH J. MOCKAITIS sign and execute
the instrument as his Last Will and Testament; that he signed willingly and that he executed it as his
free and voluntary act for the purposes therein expressed; that each subscribing witness in the
hearing and sight of the Testator signed the Last Will and Testament as witnesses and that to the best
of our knowledge the Testator was at the time 18 or more years of age, of sound mind and under no
constraint or undue influence.
Sworn or affirmed and subscribed before me by
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I')~I Y ~~i, ~,`i'c t this ~` day of ~~ ~;,C , 2001.
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