Loading...
HomeMy WebLinkAbout01-08-09PETITION FOR PROBATEf nA'nN~D GRANT OF LETTERS REGISTER OF WILLS OF ~~~~:~,~It~LI lh1 COUNTY, PENNSYLVANIA Estate of Betty Jean Hostetter also known as Deceased File Number ~" ~ - ~ ~ _ ~~ Social Security Nurr~ber 191-24-1301 Petitioner(s), who is/are 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 Executor last Will of the Decedent dated May 2,2000 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: none ® B. Grant of Letters of Administration (If applicable, enter: c.t.a.; d. b.n.c.t.a.; pendentelite; durante absentia; duranteminoritate) 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. or d. b. n. c.t.a., enter date of Will in Section A above and complete list ofheirs.j Decedent, then 77 years of age, died on 12-12-2008 at home 42 Center Drive Camp Hill, PA 17011 Decedent at death owned property with estimated values as follows: ••~~ (If domiciled in PA) All personal property $ Cam. ~XJ ([f 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 named in the Form RW-02 rev. 10.13.06 Page 1 of 2 ~ ~ i~t ~`'`'~,t (COMPLETE INALL CASES:) Attach additionalsheets if necessary. ~ Z Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principa~sic#ence at N V ~" ~` 42 Center Drive Camp Hill, PA 17011 ~ "" , (List street address, town/ciry, township, county, state, zip code) 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: Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF Cumberland SS 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) ofthe Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me the ~~ 'day` of _ - °~L- (.~ For the gister r. ~ / ~: --- ~' Signature off~ersonal Representative Signature of Personal Representative Signature of Personal Representative File Number: ~ ~ ` (~`"J `" (~(~ / Social Security Number: 191-24-1301 AND NOW, ~~~ , ~~, in having been presented befor e, IT IS DECR D that Letters / ~,~ are hereby granted to Estate of Betty Jean Hostetter foregoing Petition, satisfactory proof N Q ~ ~ - _ ~ t~7 _ a ~ "~ ~ rr., ~ rte- z . r ,~=~: g e (~ ~. O _ " ~ ~ .- c Deceased ~ ~ ~; ~. in the above estate and that the instrument(s) dated ,~ - ~ ~~(~ described in the Petition be admitted to probate and filed ofrecor~l~s the last Will (and Codicil(s)) of Decedent. FEES Letters ............... $ r ©, Short Certificate(s) ........ $ _, R,e{nunciaion(s) .......... $ ~~ 'V ... $ ... $ (C~~ 62~ ... $ ... $ ... $ ... $ ... $ ... $ ~ ~s TOTAL .............. $ of Wllls Attorney Signature: Attorney Name: Supreme Court LD. No.: Address: Telephone: Date of Death: 12-12-2008 Form RW-02 rev. !0.!3.06 Page 2 of 2 Last Will and Testament N '~ w '17 _ . ~~~ ~ x , t _> BETTYJ. HOSTETTER ~ ~ ,.~ <<: o _ ~` -~~ I, BETTY J. HOSTETTER, of 42 Center Drive, Camp Hill, Cumberland Cy, N ~--, "` ~`n r Pennsylvania, declare this to be my will, hereby revoking all prior wills and codicils. „o ~~ Distribution of Personal Property FIRST: All my personal effects, clothing, furniture, furnishings, jewelry, automobiles, other tangible personal property of every kind, and insurance thereon, I give to my husband, MELVIN E. HOSTETTER, if he survives me for a period of thirty (30) days. If he shall not so survive me, then I give the same in equal shares to such of my children who survive me for a period of thirty (30) days and not to the issue of any child who shall not so survive me, to be divided among them as they may agree or, if they are unable to agree, as my executor may decide. The share of any minor child shall be selected and held by my executor for delivery to such child at termination of minority or, at the discretion of my executor, may be delivered either to the minor or to another to hold for the minor during minority, and the receipt of the minor or such other person shall be a complete discharge of my executor. Any items not so disposed of shall be sold by my executor and the proceeds added to my residuary estate. Marital Trust SECOND: If my husband, MELVIN E. HOSTETTER, survives me, I give to my trustee hereinafter named, without deduction for estate or inheritance taxes, a fraction of the property of which (a) the numerator is the smallest amount that, if allowed as a federal estate tax marital deduction, would result in the least possible federal estate tax being payable by reason of my death, and (b) the denominator is the value as finally determined for federal estate tax purposes of the property which became, or the proceeds of sale, investment or reinvestment of which became, part of my federal gross estate. The size of this trust shall be determined as though my executors elected to qualify it for the marital deduction in accordance with Section 2056(b)(7) of the Internal Revenue Code or similar provision in effect at my death, regardless of whether my executors in fact so elect. I recognize that, depending upon the amount of other bequests, the amount of my nontestamentary dispositions, the amount of state death taxes, and other factors, the marital trust may be nonexistent, or may amount to the entire balance of my testamentary estate so that my residuary trust is nonexistent. Property not qualified for the marital deduction shall not be allocated to this marital trust. During the lifetime of my husband, trustee shall hold and distribute the marital trust as follows: Trustee shall pay and distribute to him the entire net income from the principal of the marital trust, which payments shall be made to him periodically but not less frequently than quarterly. In addition, trustee shall from time to time pay to my husband, or shall apply directly for his benefit, as much of the principal of the marital trust as the disinterested tnzstee, in its absolute discretion, may consider desirable for his health, maintenance and support, after considering all resources available to him. If any property that is part of the marital trust shall be or become unproductive of income consistent with its value, my husband may require my trustee to make it productive or convert it within a reasonable time to property that is clearly productive of income consistent with its value. Qualified Terminable Interest Property Election THIRD: My executor shall, in its absolute discretion, determine whether to elect under Section 2056(b)(7) of the Internal Revenue Code of 1986, or corresponding provision in effect at my death, to qualify any portion of the marital trust for the federal estate t ax marital deduction. Generally, I anticipate that my executor will elect to minimize the estate tax payable by my estate. However, I would expect that some consideration be given to the estate tax that would be payable by my husband's estate upon his death, especially if he should die prior to the time the election is made. The determination of my the executor with respect to the exercise of the election shall be conclusive on all affected persons. Taxes, Costs and Final Disposition of Marital Trust FOURTH: On the death of my husband, trustee shall deduct and pay to his personal representative, from the marital trust, an amount equal to any additional administration expenses and estate and inheritance taxes assessed against his estate by reason of the inclusion therein for tax purposes of the then remaining principal of the marital trust. Such amount shall be determined by my trustee, whose determination shall be conclusive. Any then remaining balance of principal shall be added to and thereafter shall form a part of the principal of the residuary trust, hereinafter created, to be held and distributed as though originally a part thereof. If the residuary trust shall 2 not have been created for any reason or shall have been exhausted, the remaining principal shall be held in trust l.rpon the same terms and conditions hereinafter specified for 'the residuary trust. Effect of Disclaimer of Marital Trust FIFTH: If my husband, his guardian or the personal representative of his estate should disclaim his interest in any portion or all of the marital trust, the portion of the marital trust in which he disclaims his interest shall be added to the residuary trust to be held and distributed as though originally a part of it. If the residuary trust shall not have been created for any reason or shall have been exhausted, such portion of the marital trust shall be held and distributed on the same terms and conditions hereinafter provided for the residuary trust. All of the provisions of the residuary trust in favor of my husband shall apply to the disclaimed property despite the disclaimer, except to the extent he explicitly disclaims the benefit of such provisions, in their application to the disclaimed property, as well. Residuary Trust SIXTH: I give the balance of my residuary estate, including any part of my estate not distributed under the foregoing provisions hereof, to my trustee, to hold and distribute as follows: During the lifetime of my husband, MELVIN E. HOSTETTER, trustee shall pay and distribute to him or for his benefit the entire net income therefrom, which payments, if requested, shall be made to him periodically but not less frequently than quarterly. In addition, should the principal of the marital trust be completely withdrawn or exhausted, trustee shall from time to time pay to my husband, or shall apply directly for his benefit, as much of the principal of this residuary trust as the disinterested trustee may consider desirable for his health, maintenance and support, after considering all resources available to him. Upon the death of my husband, the trustee shall divide the then-remaining principal of my residuary estate into equal shares, one share for each child of mine then surviving and one share for each deceased child of mine with issue then surviving, and distribute said shares to such living children, and in equal portions per stirpes to the then-surviving issue of a deceased child of mine. If the inter-spousal exemption from Pennsylvania death taxes was applied at the time of my death to this trust, trustees shall pay from the principal of such trust the Pennsylvania death taxes plus any interest and penalties thereon due on the trust property at my husband's death. 3 Adopted (and After-born) Persons SEVENTH: In the construction of any devise or bequest herein to any person or persons described by relationship to me or to another, any person adopted under the age of eighteen (18) years whether adopted before or after my death, shall be considered the "child" and "issue" of his or her adopting parent or parents. Income Undistributed at Death of Beneficiary EIGHTH: Except in the case of income from trust the marital trust, all income that is undistributed and accrued at a beneficiary's death shall be treated as if accrued thereafter. Minors and Incapacitated Persons NINTH: If any income or principal shall be payable to any person who shall be a minor or who shall be incapacitated for any reason, trustee shall hold such income and principal during minority or incapacity and shall be entitled to apply such income and principal to the health, maintenance, support and education of such person during minority or incapacity without the appointment of any guardian or committee or any authority of court. Trustee shall be entitled to make direct application hereunder or to make application by payment of income and principal to the parent or other person in charge of such minor or incapacitated person, or to his or her guardian or to a custodian under the Uniform Transfers to Minors Act. Any remaining income and principal to which such person shall be entitled shall be paid and distributed to such person upon the termination of minority or incapacity. Irrespective of the foregoing, all net income from the marital trust shall be paid to or applied for the benefit of my husband at least annually. Appointment of Guardian of Estates of Minors TENTH: I appoint my executor as guardian of the estates of minors with power to hold all property payable by law to a guardian appointed by my will and to use the same for the minor's health, maintenance, support and education, either directly or by payment to any person selected by my trustee to disburse it whose receipt shall be a complete acquittance. Guardian may, in discharge of all of the guardian's duties hereunder, pay any minor's share deemed impractical of administration to the parent or other person in charge of the minor or to his or her guardian or to a custodian for the minor under the Uniform Transfers to Minors Act. My executor as guardian 4 shall have the same powers as my trustee. Protection of Beneficiaries (Spendthrift Provisions) ELEVENTH: No interest in income or principal shall be assignable by a beneficiary or available to anyone having a claim against a beneficiary before actual payment to the beneficiary. Powers of Executor and Trustee TWELFTH: My executor and trustee and their successors shall have the following powers in addition to those given by law to be exercised by them in their absolute discretion, which powers shall be applicable to all property held by them, effective without the order of any court and until the actual distribution of all such property: A. To retain any investments at discretion including stock of any corporate fiduciary hereunder or of a holding company controlling it; B. To invest and reinvest at discretion without the obligation to diversify and without restriction to so-called "legal investments", with the specific right to invest in stocks, bonds and real estate, including non-income producing residential real estate for the occupancy of any present income beneficiary or beneficiaries, and in such common trust, diversified, money market and mutual funds as my executor and trustee deem appropriate, including any such funds of any corporate fiduciary hereunder or any successor or affiliated corporation or a holding company controlling it; C. To sell, to grant options for the sale of, or otherwise convert any real or personal property or interest therein, at public or private sale, for such prices, at such time, in such manner and upon such terms as they may think proper, and to execute and deliver good anti sufficient conveyances, assignments and transfers thereof without liability of any purchaser to see to the application of the purchase money; D. To borrow money and to secure the repayment thereof by mortgage of real or personal property, pledge of investments or otherwise, without liability on the part of the lenders to see to the application thereof, E. To compromise claims by or against my estate or any trust created hereunder; F. To allocate and distribute different kinds or disproportionate shares of property or undivided interests in property among beneficiaries or trusts, in cash or in kind, or partly in each; G. To register investments in the name of a nominee or to hold the same unregistered in such form that they will pass by delivery; H. To join in any recapitalization, merger, reorganization or voting trust plan affecting investments; to deposit securities under agreement; to subscribe for stock and bond privileges; and generally to exercise all rights of security holders; I. To manage, operate, repair, alter or improve real estate or other property, and to lease real estate and other property upon such terms and for such period as my executor and trustee deem advisable even for more than five (5) years and beyond the duration of any trust; J. To deduct administration expenses upon either the federal estate tax return or fiduciary income tax return with or without adjustment as between principal and income, as my executor shall determine; K. To join with my husband and file any income tax or gift tax returns that may be due on my behalf and to pay so much of such taxes as my executor may deem appropriate and to consent to any gifts made by my husband being treated as having been made one-half ('/2) by me; L. To combine, without prior court approval, any trust herein with any other trust with substantially similar provisions, although such other trust may have been created by separate instruments and by different persons, and, if necessary to protect different future interests, to value the assets at the time of such combination and to record the proportionate interest of each separate trust in the combined fund provided however, that no such combination shall be permitted if the effect of such combination would be (1) to violate the applicable rule against perpetuities; (2) to disqualify any interest in one or more of such trusts for a deduction for federal estate tax purposes which would otherwise be allowable; or (3) to cause the loss of the exempt status of one or more of such trusts from the imposition of the generation-skipping tax; M. To exercise any stock options which they may receive; to borrow such funds from any source as my executor or trustee may deem necessary for the exercise of such options; and to pledge assets as my executor or trustee deems appropriate for this purpose; N. No fiduciary shall be required to qualify before, be appointed by, or, irr the absence of a breach of trust, account to any court (and failure to account alone shall not be considered such a breach); nor shall a fiduciary be required to obtain the order or approval of any court in the exercise of any power or decision granted hereunder; O. To disclaim any interest in property without court approval; and P. To do all other acts and things necessary or appropriate in the management, administration and distribution of my estate or trust. Payment of Death Taxes THIRTEENTH: My executor and trustee shall pay all estate, inheritance, and other death taxes, together with interest and penalties, that shall be payable with respect to property or interests therein subject to taxation by reason of my death and whether passing under my will or any codicil thereto, or otherwise, including jointly held and other nontestamentary property. My executor and trustee shall pay the same out of the principal of the residuary trust, and under no circumstances shall any such tax be paid out of or charged against the principal of the marital trust. Trustee may advance to my executor from the principal of the residuary trust such amount as may be required by my executor for the payment of such taxes. Loans and Advances to Executors of Testatrix and her Husband FOURTEENTH: Trustee is further authorized in its discretion, to make such loans, advances or expenditures out of the principal of the residuary trust as trustee may consider desirable in order to facilitate the settlement of my estate. In exercising such authority, trustee may pay in whole or in part the expenses of my last illness and burial, debts, income taxes, estate or inheritance taxes and penalties and interest thereon owing by me or by reason of my death, which payments may be made directly by trustee or to my executor, and neither my executor nor any beneficiary shall be required to reimburse the trustee for any funds so loaned, advanced or expended. Likewise, on the death of my husband, trustee may make similar loans, advances or expenditures as trustee, in its discretion, may consider desirable in order to facilitate the settlement of his estate, which shall be made out of the principal of the marital trust to the extent that the same has not been appointed by him and is sufficient for such purposes; otherwise such loans, advances or expenditures may be made from the principal of the residuary trust. Termination of Small or lmpractical Trusts FIFTEENTH: Whenever the disinterested trustee, in its absolute discretion, determines that the size of any share held in any trust hereunder does not warrant continuing the same in trust, or its administration would be impractical for any reason, trustee, without further responsibility: A. May pay such share to the person entitled at the time to the income from it; or B. If such person is a minor or, in the opinion of my disinterested trustee, is disabled by advanced 7 age, illness or other condition, my trustee may pay such share to the parent or other person in charge of such minor or incapacitated person, or to his or her guardian, or to a custodian under the Uniform Transfers to Minors Act; provided, however, that any property held under the marital trust may be paid only to my husband or to his guardian. Appointment of Executor and Trustee SIXTEENTH: I appoint my husband, MELVIN E. HOSTETTER, as executor and trustee. If he is unable or unwilling to qualify as executor or trustee or, having qualified, is unable or unwilling to continue to act, I appoint my daughter, CYNTHIA L. HOSTETTER, in his place. Any action, decision or exercise of discretion, herein anticipated and required of the "disinterested trustee", shall be made and exercised by CYNTHIA L. HOSTETTER, who is hereby appointed as disinterested trustee. Waiver of Bond SEVENTEENTH: I direct that no fiduciary hereunder shall be required to furnish bond in any jurisdiction, and if any bond is necessary, no surety shall be required. Interchangeableness of Language EIGHTEENTH: Words used in the singular may be read to include the plural or the plural may be read as the singular. Similarly, the masculine form may be read to include the feminine and neuter; the feminine maybe read to include the masculine and neuter; and the neuter may be read to include the masculine and feminine. Headings NINETEENTH: The headings used on the various paragraphs of this will are included for convenience only and have no legal significance. I have signe this will this ~ day of ~ ~q ~ , 2000. ~- BE J HOSTETTER COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF YORK We, BETTY J. HOSTETTER, JAN M. WILEY, ESQUIRE and PATRICIA A. BELLUSCIO, the Testatrix and the witnesses respectively, whose names are signed to the attached or 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 Testament and that she had signed willingly (or willingly directed another to sign for her), 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 this Last Will and Testament as witness and that to the best of their knowledge the Testatrix was at the time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. Sworn to and subscribed before me this ~n~day of 2000. C2c.~ ,~ .Q,~ NOTARY PUBLIC MY COMMISSION EXPIRES: Notarial Seal S. Dawn uladfelter, Notary Public Dillsbur~ Boro, York County My Commission Expires May 17, 2001 em sf, PBMSylvania Association of Notaries 9 i~ - ~' i~ _ ~~~ ~' -~' LOCAL REGISTRAR'S CERTIFICATION OF DE,~~1~?• WARNING: It is illegal to duplicate this copy by photostat or photogr~(l~h. i=ce for the: ~ertificatc. S(T.(lU P 15000475 Certificatil~L) tiumher ;~'~ ~~ ft 9 ~' a o ~ ~ ~ ,~ F~ ~ ~ ~ It,; \~\-~j~'1fNT ~F'~,~'''''i This is tf~ rcrtily teat tll- is~forln_(tion i-sere ~~i~~en iti ~urrectl~~ cl~pied~f fn) ,Ir ~ri~_irrLl l,er(ificate of Death L1uly lil~:tl v.ith nc .IS l.l,;I Rcglstr,u. The orieinal rerUiicilte r.~~lll 1x t~3rk-. Irc~eel lu the State Vital Rerl~rd~; t)f~lice lift ix„-nrlneni ~iling. ~~--.~_ ~'2 ~ urn 1 6108 __ !_cy~tl k:e__*istr:u~ ~~~~ Date lssaed C7 inn ° c , ~ `~ _ i c t` _ # ~~ ` ~ , I"?_ 3 j !y '., t. ' .1 1. i f'1 irY7 ~~ 'T1 `~ r 4 ~_ I v 11f2W6 71NT IN KENT .INK COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See Instructions and examples on reverse) STATE FILE NUMBER 1. Name of Decedent (Rrsl, middle, last, suKx) 2. Sex 3. Social Securiry Number 4. Dale of Death (Month, day. year) Betty J. Hostetter female 191 - 24 r 1301 December 12, 2008 5. Age (Last BiMMay) Under t year UrMer t day 6. Dale of Binh (Month, day, year) 7. BiMlplace (City antl stale or fo reign country) Be. Place of Daem (Check only one) Maas oars Hours km~res Hospital: Olner: 7 Yra. Mar e h 2 9 , 19 31 A11nV l lie , PA ^ Inpatient ^ ER / Outpatient ^ DOA ^ Nursing Home ®Resitlence ^Other ~ Specify: Counry of Death B6 &. City, Boro,'wp. of Death Bd. Facility Name (II not inslhulion, give alr9el antl number) 9. Was Decedent of Hispanic Origin? ®No ^ Yes 10. Race: American Indian, Blad. While, etc. . (II yes, specity Cohan, (Specify) Cumberland Lower Allen Twp. 42 Center Drive Mexican,PUedoRican,etc.) white 11. Decedent's Usual Occu Von (Kind of work d one Burin most of workin tile. Do not stale retired 12. Was Decedent ever in the 13. Decedent's Education (Specify only highest grade completed) td. Marital Slags: Marrietl, Never Marrietl, 16. Surviving Spouse (II wife, give maiden name) Divorced ISpecil t Widowed Kind o1 WoM Kind of Business /Industry U.S. Armed Forces? EI¢mentary! Secondary (0-12) College (1 ~d or 5+) y , Supervi>or Health Insurance ^Ves ®NO 12 4 Max•ried Melvin E. Hostetter 16. Decedent's Mailing Address (Slreel, city /town. stale. zip code! Decedent's Did Decedent Lower A11en Pennsylvania LiYeme nn DecetlemLweda Twp. ®Yea 42 Center Drive , . Ac1ualResidence 17a.Slale Townsnlp? 17d Decedent Lived within ^ No Camp Hill, PA 17011 . . rib. cppmy Cumberland Actual Limds Ol Cityl Boro 16. Father's Name (First, mitlde, last, sulnxl 19. Mother's Name (Frcsl, midtlle, maiden surname) Harve Zei ter Susan Wen er 20a. Inlomranl's Name (Type ! PrinQ 206. mlamant's Matang Atltlress (Slreel, city! lmm, state, zip crone) Melvin E. Hostetter 42 Center Drive, Camp Hill, PA 17011 21a. MetlnO of Disposition ~ [~ Cremation ^ Donadon 21 b. Date of Disposllhn (Month, day, year) 21c. Pace of Disposition (Name of cemelay, crematory a other place) 21 d. Location (City I town, stale, zip code! ^ Baal ^ RemrnallromSlate WasCrematlonorDOnallonAUthodzed December 15 2008 F.vans Crematory Schaefferstown, PA 17088 ^ Other - Specify I by Medical Examiner I Coroner? ~ Yes ^ Na , 22a. SgnaNre eivk nsee la person acting as srxdr( 22b. license Number 22c. Name antl Address of Faallty - FD 012 848 L -- New Cumberland PA 17070 Box 431 Inc P O Parthemore FH & CS ~ ~;~-- - , , ., . . , Complete nems~c Dory when cenityeg 1 ti f Beam l0 a bl 23a. To the best of my knowledge, death occurred at the erne, dale and place staletl. (Signature and title) f1 . 7v 23D. License Number k I r r " 1~ r` 23c. Dale Signetl (Month, tlay, year( I ' ~7 ~ ~ me o e a pnyskian is not ava a .. ~ I I~ r l W (~ ~ ` ~ ~ . JV j ~ 1 ~: , ~ , ~ ~. I J cerliy cause d tleatn. ) -'•M/~ L~t~~ I ~ . 2d Time of Death 26. Date Pronounced Dead (Month, day, year) to Medical Examiner /Coroner for a Reason Dlher Than Cremation or Donation? 26. Was Case Refe r r e d Items 2d-25 must be completed by person who Pmraunces tlealh. . ~ , rr• ( p tI I ~ ~~1 %M. I ~ I ~ C, ~, ~~ -- ,, ,, "" ~~ ^ Yes ~o CAUSE OF EATH (See Instructions and examples) r Approximate interval: Pan II: Enter omen s'pnilicant condil'ons contnbulirw to death, 28. Did Tobacco Use Contribute to Deathp Item 27. Pan I: Enter the chain devents -diseases, Injuries, or canplications - Iha1 tliremy causetl the death. W NOT anon terminal events such as cardiac arrest Onset la Deam but not resulting in the undertying cause given in Pan I. ^Ves ^ Probably respiratory artest, or ventricular f~bdllalim without snowing the etiology List Doty one cause on earn Ilse. ^ No ^ Unknown IMMEDIATE CAUSE (Final tlisease or ~ condition resulting m death) a 29.11 Female: t within ast ear ^ N l . ~ Due to (or as a ~quence oU~ p y o pregnan ^ Pregnam al time of deem yO ~ r ~ it any $equenlialty till conQlrons b _ ~ , . to Ina f2115E Fsled on line a l din ^ Nol pregnant, but pregnant within d2 days gg ea . pue 1¢ (or as a ronaegnenCe OI~' ~ UNDERLYING CAUSE th t E of dealn er n e (Q~seaae or Injlpy Thal initiated the ~ c events resulting In death] LAST ^ Nol pregnant. bN pregnant d3 tlays to 1 year Due to (or as a ronsequence o11: d before death ^ Unknown it pregnam within the past year 30a. Was an Autopsy 30b. Were Autopsy Rndrtgs 31. Manner of Death 32a. Dale of Inlury (Month, day, year) 32b. Describe How Injury Occurred 32c. Place of Injury. Home, Farm. Slreel, Fatlory. 0%ice Building, et<. (Specify! Pedonned? Available Prior to Completion f Deamp f C ^ Natural ^ Homicide o ause o ^ Accitlenl ^ Pending Invesligalion 32d. Time of Injury 32e. Injury al Work? 321. II Transponalion Injury (Specilyl 32g. Location of Inryry (Slreel. oily I town, stale) ^ Yes ^ NO ^Ves ^ No ^ Yes ^ No ^ Omer I Operator ^ Passenger ^ Petleslnan ^ Suicide ^ Could Nol be Determined M ^Other ~ Specify: 33a. Ceni9er Icneck only one) 33b. Signature and idle of loan • Cenifying physician (Physician cenilying cause of tlealh when another physician has pronouncetl death and completed Item 23) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ to the cause(s) antl manner as staled d d tl lh , ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ occurre ue ea To Ina best of my knowledge. • Pronouncing and cenilying phystcian (Physidan bolo pronouncing deem and ceniying to cause of deaml ^ 33c. License umber 33d. Dale Signed tMonlh. day, year) To the best of my knowletlge, death occurred at the lime, date, and place, and due to the causNs) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~,I D ~ .L ~7 ~ /I I ~_ ( - / .J ~ (,L/ ~ ,(~ tJ • Medical Examiner! Coroner On the basis of examination and f or investigadan, is my opinion, tlealh oecurretl al the time, dale, and place, and due to the causels) and manner as stated_ ^ 34. Nenre end Atldress of Person Who Completed Cause of Death (Item 21) Type / Pnnl r t 3~ - ' t ~ X 1~ 35. Registrar's Signature a islncl Number ~I /I~ l ~ I / I O`'' I 36. Dale Rletl (Month, tlay, year) ('' ` r CI ~~ 1 I I i I V C, ~C: il'~ X521 Cec~icLt- Li~P~'7" pelt!, PEE I'IC~iI F ~ / G , (/ Disposition Permit No. ~ ~~lr~ ~~ lV t ' RENUNCIATION R GIS ER OF WILLS OUNTY, PENNSYLVANIA ~~~ ©~ 0 .d x. m -~ G.J O -' :- - ~; C~ ~ r - . <:._~ r~x r i Estate of ~5~~~/~ ~- / ~ ~v ~ ~~s~~~-~`~/ ,Deceased I, /' ~~~~~1/%i~ ~ l'~, ~~`~~`~~lc.. / _, in my capacity/relationship as (Print Name) ~LiS~ of the above Decedent, hereby renounce the right to administerth~e Estate of the Decedent and respectfully request that Letters be issued to (Date) (Signature) Executed in Register's Office Sworn to or affirme and subscribed bef re me this `~ day N ~. Deputy for Register of W lls (,Sn~eet Address) (City, State. Zip) Executed out ofXegister'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 day of , Notary Public My Commission l~xpires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) Fonn RW=06 rev. 10.13.06