HomeMy WebLinkAbout12-09-08PETITION FOR PRROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF (,_L(~'Y-~Y-~N~ COL~`~TY, PEN`~1SYLVANI~
Estate of ~~ ~Q,Q/1~ ~ L(~~ File Number ~~ ~ ~ ~!~ ~ ~~~~
also known as
,Deceased Social Security Number ..
Petitioner(s), who is/are 13 years of age or older, apply(ies) for:
(CO:LIPLETE A' ar 'B' BELOGY:)
A. Probate and Crant of Letters T stamGen~t} ry and aver that Petitioter(s) is /are the ~~1 NJVE / l ~t named in the
last Will of the Decedent dated Q ~ y0 OI and codicil(s) dated
A.)
rJ
(State relevant circumstances, e.g., renunciation, depth ojezecutor, elc;l q -r , ` yr
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution o~tli~s~t~tment~ffere`d';__. ' j
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forprobate, was not the victim of a killing and was never adjudicated an incapacitated person: , ~,;~t"'-i--, f ~ ~t
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^ B. Grant of Letters of Administration ;~~-rt ~ r
(ljnpplicabie, enter: c. t. n.; d. b. n. c. t. a.; pendente lire; durnnte absentia; durm+t¢.u;'i~tnte) ~ f'i
Petitioner(s) after a proper search has !have ascertained that Decedent left no Will and was survived by the following spou,8~t (if any) and'ii2lrs: (Ij r
Ad+trinisd~ation, c. t. a. ord.b.n.c.ca., enter date of Will in Section A above and complete list of heirs.) ...
~_ _ Name Relationship Residence ~
(COrYIPLETE LV ALL CASES:) Atlach additiatal sheaf is if ne7ce~ssary.
f Decedent was domi~led a~ heath in~ r/ ~/VJ County, Pennsylvania1vith his he last principal re,~idence at
(List street address, tower/(city, township, county, state, zrp code] ~ ~ 1 - O ~ / - / ! ` ~
Decedent, then 25 ~ years of age, died on ~ ~ U 1S at /L.Q Y' r~~{~'(.~_ t~ (~~#[ ~"0/V
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 Pennsy]vania
(If not domiciled in PA) Personal property in County
Value of real estate in Pennsylvania
situated as Ybllows:
7~,DOd
Wherefore, Petitioner(s) respecttiilly 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:
nature
or printed name and residence
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Form Ri-Y-O? rc+~. 10.13.06 Page 1 of 2
Oath of Personal Representative
CO~iiV10NWE_~LTH OF PENNSYLVANIA
n SS
COUNTY OF
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The Petitioner(s) above-named swear(s) or affirn~(s) that the statements in the foregoing Petition are true and con~ect 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 aff~rm~e-d~}and subscribed
before me the ~' ` day of
~~~ ~ 1 ~- ,c~O~~S
Fcr tl Register
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Signature ojPersona Representative
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Signn[ureoj PersonalRepresentntive `,,,Q ~
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Signaau~e oJPerso~tn! Representative ~ =~ ( ~-~
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File'~Number: ;,% ~ l/
Estate of 1.1 I , ~~ry f `' ~.~ ~ ~ ~~~~ ,Deceased
Social Security Number: I ~~~ ~f7`~ GI ~-~(.~ Date ofDeath:~~~
AND NOW, I~t~ 1 I~I,' ~,~ ~~~i- ~C~~~ ,~' U , in consideration of the fi~regoing Petition, satisfactory proof
having been presented before ni , IT IS DECREED that Letters l{i F ~ ~- -._
are hereby granted to ls~C` Y1 ~ ~ ~ ~ ~L~ ~ h.~'.'i ~ --
ir, fire above estate
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 .~ ` -t--
Ll~ ~ Register of Wills l~~x ~~ T~-~ ;~
Letters ............... $ ff
Short Certificate(s) ........ $ ~ ~.(~ ~ ~ Attorney Signature:
Renunciation(s) .......... $
$ Attorney Name:
'~ ... $ Supreme Court LD. No.:
L.$ ',
$ Address:
... $
... $
... $
• • • $ Telephone:
...
TOTAL .............. $..
Form R6V-(1 _' rev. 10.13.0(> Pace 2 Of 2
I05_KI15 REV' IUI/fl"r ~ f ~ x
LOCAL REGISTRAR'S CERTIFICATION OF DE~~Tt~
WARNING: It is illegal to duplicate this copy by photostat or photogra~rh.
Fee for this certificate, X6.00
~~ 14a~o~c~
Certification Number
"This is to certiiv that tie i ifr~rmation here given is
correctly copied~fron ar oriL~inal Certificate of Death
duly filed with nx as Locrl Re~zistrar- The original
certificate will he forwarded to the State Vital
Kecoru~,yoyff~ice G!r p~rr~an.'nt filin,r..
~~~»~rt.~ ~~ "l ~~`"~e,° DEC ~1~8
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Local F:e~istrar Gate Issued
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I IEV 112006
RINT IN
ANENT
KINK
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse) STATE FILE NUMBER
1. Name of Decedent (First, middle. last, su6x) 2. Sex 3. Social Security Number 4. Date of Death (Month, tlay, year)
Val Jean E. Grubb Female 186 - 22 0112 12/6/2008
5. Aga slant BirtMay) Under 1 year Under 1 day 6. Date of Birth (Month, day, year) 7. RiMplace (City antl stale a for eign country) 6a. Place of Death (Check only one)
Mmlhs Days Hours Minuses Hospital: Other:
g1 Vra Jan 5 1 9.27 Natrona Pa ^Inpalient ^ERl Outpalienl []DOA ['Nursing Home ^Residence ^Other Specify.
Bb. County of Death 6c. City, Boro. Trop. of Death i3d. Facility Name (Ii not inslllNion, give street and number) 9. Was Decedent of Hispanic Origin? [~NO ^Ves 10. Race: American Indian, Black. White, etc.
(If yes, sPecity Cuban, (Specs
Cumberland Hampden Twp Loyalton of Creekview Mexiran,PUadpRaan.stn) W~ite
t1. Decedem's Usual Occu tan Kind of work done tlunn most of works life. Do rat stale retir 12. Was Decedent aver in the 13. Decedent's Education (Specify only highest grade compleletl) 14. Marital Status. Married Never Married 15. Surviving Spouse (II wife. give maitlen name)
Kind of Work Kira of Business I Intluslry U.S. Armed Forces? Elementary / Secontlary (0-12) College (1-4 or 5.) Widowed Divorced (SpeclM
h 1 Dist ^Y°a ~"° Widow
16. Decetlenl's Mailing Address (Street. city !town, state, zip code) Decedent's Dltl Decetlenl
Pennsylvania Live in a f 7c ®Ves
Decedent Lwed in Hampden Twp
f 7
Sl
R
1100 Crandon Way ,
Actual
esitlence
a.
ate
, Township?
CumberlanrJ ,7d^~
°i~musoiiyedwnnm
f7b
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Mechanicsburg, Pa p°nty
.
city,/B°m
e
16. FaMer's Name (First. middle, last, susix) 19. Mother's Name (First, mitltlle, maiden surname)
Roy W. McMeans Elizabeth Cole
20a. Inl°rmant's Nama (typo! Print)
h
B 20b. Informant's MeilingPQQre~s (slrLainewn, alalMe chi Pa 1 7 0 5 5
142 Hill
,
er
eec
Dianne M. ,
21 a. Method of Disposition ^ Cremation ^ Donation 21 b. Dale of Disposition (Month, day, year) 27c. Place of Disposition (Name of cemetery, crematory or Omer place) 21 tl. Location (City :town, slate, zip code)
Burial ^ Removal from State ~ Was Crematbn or Donation Authorized
12/10/08
Green Memorial Park
Rollin
Pa
Camp Hill
^Odrer-Specify: byMedkalEzaminro/Crooner? ^Ves^Nq g ,
22a. ~ of F Brat Service see (or person acing as such) 22b. License Number 22c. Name and Address of Facility S u 11 i va n F u n e r a ;1 H o m e
- r~ FD 011897-L 51 N. Enola Dr. Eno.La,Pa 17025
Complete ems 23ac onty when ~tying
sidan a rat evadable al time of deaN to
pn 23a. To th t of my krawkdge, death occurred at the dine, dale and pl ce staled. (Signature aM tide)
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/v ~ 23h/L~icense Number
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~ I 7 ~ 23c. Oate Signetl (MOntn. tlay, year)
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certny cause of death. x
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Items 2a-26 must be completed by parson 24. 7me of Death r
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? 25. Date Pronouncetl Dead Month, day, year)
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f~'I ~ 26. Was Case Referred to Medical Examiner I Coroner for a Reason Other than Cremation or Donation? I
who praaunces death. U r c
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J L~k~x / "'k 0" ^Yas t~JO
CAUSE OF DEATH (See Instructions and examples) r Approximate irnarval: Pan II: Enter other SjgpjQ{;nt corail ons conlnWfne to death, 26. Did Tobacco Use Contribute to Death?
Item 27. Pan C Enter me chain of events - dseases, Injuries, or complications - that dlredly cans tleam. DO NOT enter tannin, veins s as caNiac artesl, r Onset to Death Ma not resuaing in rte untlertying cause given in Pan I. ^ Yes ^ Probably
respiratory anent, or veMncular fbnllatbn without s g the etiology. Ust ably a cad on each line.
i
^ No ^ Unknown
IMMEDIATE CAUSE (Final tlisease or r 29. II Female:
roMiacn restating in death) _~ a r
^
ue to (or as a nsequence oil'. ~ Not pregnant within past year
^ Pregnant a1 time of death
Sequentlelty list condaans. H any, b i
loading to me cause ksted on tiro a. Due to (or as a consequence of): r ^ N01 pregnant bill pregnant within 42 days
Enter iha UNDERLYING CAUSE
(tlisease or injury mat inilHtetl the c
h
LAST
d
of death
events resuaing in
eat
)
.
Due to (or as a consequence of): ^ Not pregnant, but pregnan143 days l0 1 year
d. before tleath
^ Unknown if pregnant within the past year
30a. Was an Autopsy 30b. Were ANOpsy Firaings 3t. M of Death 32a. Date W Injury (Monty, day, year) 32b. Describe How Injury Occurred 32c Place of Injury: Home Farm, Street Factory.
PedomaN? Available Prior to Completion
of Cause d Deaih?
Natural ^ Homidde Ogice Builtllnq, etc. (Specity)
^ Ves o ^Ves ~' ^ Acrdtlent ^ Pendirg Investigation 32d. Time of Injury 32e. In'ryry at Work? 321. II Trensportalion Injury (Specs 32g. Location of Injury (Street, city I town. sMte)
^ Suicide ^ Could Not be Determines ^ Yes ^ No ^ Driver /Operator ^ Pas rig edestnan
M ^Olher~ Specity:
33a. Cenifer Idreclr Doty oriel 33b. Signatur Cen er
• CMitying physician (Physaran certifying cause of deem wnen another physician has pronourrced tleam antl completed Item 23) -
T° the best of my knowledge, tleath occurte0 due to the cause(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
• Pronouncing end certifying physician (Physaian Doth pronouncing dean aM certiying to cause of death)
To the best of my knowledge, death occurred el the time, date. and place, and tlue to tyro cause(s) and manner as slated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^
• Medical Examinerl Coroner n umber
'
~~ ~`.... 3a. D to Signed onth, day. yeaq •
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On the basis of examination and I or investigation, In my opinion, death acurretl at the lime, date, and place, and due to the cause(s) and manner as stated- ^ 34 Napre and Address of Person Who Completetl Ca
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se of Death (I
re^J~2') Type I Pnnl
Regi ai ! e antl r
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~ 36. Date dad ( ih, tlay, year) /
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Disposition Permit Nc. L~ , ~U / ~~
LAST. WILL OF VAL JEAN E. GRUBB
I, VAL JEAN E. GRUBS, of the Township of Hampden, County of Cumberland,
State of Pennsylvania, being in good bodily health and of sound and disposing
mind and memory and not acting under duress, menace, fraud, or undue influence
of any person whomsoever, merely calling to mind the frailty of human life,
and being desirous of disposing of my worldly goods while I have the strength
and capacity so to do, I do make, publish and declare this my Last Will and
Testament. I hereby revoke, cancel and annul all ~T former Wills and Testa-
ments, including codicils thereto, by me at any timE~ made, and declare this
alone to be my Last Will and Testament.
ITEM 1. I direct that my executors hereinaftE~r named pay and discharge
all of my just debts and funeral and testamentary e~:penses.
ITEM 2. I order and direct that I be buried in a lot which I own situate
at the Blue Ridge Memorial Cemetery, located in Hari°isburg, Pennsylvania.
ITEM 3 All the rest, residue and remainder of ~y entire estate,
wheresoever situate and whatsoever it may consist of', I give, devise and
bequeath, absolutely and in fee to my dearly beloved Husband, CHARLES M. GRUBB.
In the event my Husband dies with me in a simultaneous disaster or fails to
survive my death by thirty (30) days, then I give, devise and bequeath my
entire estate, absolutely and in fee to my dearly beloved children, share and
share alike, per stirpes.
ITEM I hereby nominate and appoint CHARLEti; M. GRUBS Executor, of
cv
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this my Last Will. Should the Executor herein named. fail to gualify or cease
to act as Executor, then I appoint DIANNE M. BEECHES. as Executrix in his
stead .
L_ ~ ~
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~ ,~,' VAL JE GRUBS
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ITEM I direct that my personal representatives, as well as their
successors, shall not be required to give bond for the faithful performance
of their duties in any jurisdiction.
L JEAN E. GRUBB
COMMONWEALTH OF PENNSYLVANIA
ss
CODNTiTY OF CIINIDERLAND
I, VAL JEAN E. GRUBB, Testatrix, whose name is signed to the attached or
foregoing instrument, having been duly qualified according to law, do hereby
ac~.owledge that I signed and executed the instrument as my Last Will; that I
signed it willingly; and that I signed it as my free and voluntary act for the
purpose therein expressed.
Sworn or affirmed to and acl~owledged before me, by VAL JEAN E. GRUBB,
~~ _l,~,/~~1
the Testatrix, this ~_ day of ~,~f t-~ fit. ~ 1982,
,%
Notary Public ~`,~
My Commission Expires:
BARBARA L. SHELLEY, Notary Public
Cumberland County, Pe
My commission Expires August 19, ~'.#, "~~
The preceding instrument consisting of this anal one (1~ other typewrite
page, identified by the signature of the Testatrix, was on the date thereof
signed, published and declared by VAL JEAN E. GRITBB, the Testatrix therein
named, as and for her Last Will and Testament, in our presence of each other,
have hereunto subscribed our names as witness.
Lsiding at 107 St. John's Church Road
Suite #2
" Camp Hill, Penna. 17011
~ .
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Residing at 306 Glendale Drive
Shiremanstown, Penna. 17011
- 2 -
A F F I D A V I T
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND ~ ss
We, James M. Bach, Esquire
and _,_ Albert D' ostino
the witnesses whose names are signed to the attached or foregoing instrument,
being duly qualified according to law, do depose ani3. say that we were present
and saw Testatrix sign and execute the instrument a:~ her Last Will; that she
signed willingly and that she executed it as her frE~e and voluntary act for
the purpose therein expressed; that each of us in tr~.e hearing and sight of
the Testatrix signed the will as witnesses; and that to the best of our
knowledge the Testatrix was at that time 18 or more years of age, of sound
mind and under no constraint or undue influence.
Sworn or affirmed to and subscribed to /before me by;~
r ~ and ~~' ~ z~` ~~/~~, /~ ,(~~
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w~esses, this ~ -- da f ' r;~ t°~ C, , 1982.
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No i;ary Public
My Commission Expires:
BAt~6A~A t.. SHELLEY, rotary Public
Cumberland County, PA
My Commission Expires August 19, I~'~'~~~
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