HomeMy WebLinkAbout01-09-09 (2)PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF (~ ~'~~~~~ COUNTY, PEI~'NSYLVANIA
Estate of 4~? i. ~ /\'' : ,} )~~ '1''tt i~ ~ l d. 7 ,yam ~ l~ File Number o`' ~ ~ l.~ ~ VV Q~.
also known as - J
,Deceased Social Security 1`lumber I ~ ~ ` ~ E" ~~~~ ~ G
Petitioner(s), who isiare 13 years of age or older, apply(ies) for:
(CO~YIPLETE 'A' or 'B' BELOW:)
A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the t" X 1= ~ .:7Ytt ( named in the
last Will of the Decedent dated / ' ~' L%<~.?' , ;,~c:. ~ '~ and codicil(s) dated /y y da
(State re[evmrt circumstnnces, e.g., renunciation, death of executor, etc;) er.a
c~
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after executio~__f t~f e inshum~(s) of#'a~ed ~
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: "-=~ ~ -- ' ~'
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B. Grant of Letters of Administration ~,~; f\ .~
(Ijapplicable, enter: c.t.a.; d. b. n. c. r. a.; peadente lire; durmue absentia; durdiiieYi tp /ate) ~' --j
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Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spiitts~ if an ' r f
Adntinistra[ion, c. t. a. ord.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) ~--~( Y) a+~heus, ~(If
Name
Residence
(COtYIPLETE INALI CASES:J Atrach additional sheets if necessary.
Decedent was domiciled at death in ~ an, LJCO w l r¢.r ~ County, Pennsylvania with his /her last principal residence at
----- ~ ~~~j - r c K Z ~ L • _ is x3 t7~ L y7 •y
(List SL~ret address, [Owu/city, lorvnsh~~, count~~, stale, zip code) - '"` -- --
Decedent, then t~~~1 years of age, died on I ~~/~'L't+at _ /~ ~ i L h ~ ~%' ~ /Q1W ~-C S~~J7-~
u
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 Pennsylvania
(If not domiciled in PA) Personal property in County
Value of real estate in Pennsylvania
situated as Poll
$_ f7~ZC~~
S
$ I.3 0 .. Cti-v
Wherefore, Petitioner(s) respectfully request(s) the probate ofthe last Will and Codicil(s) presented with this Petition and :he gran[ of Letters in the appropriate form to
the undersigned:
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nted name and residence
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Form RGV-01 re~~. 10.13.66 Pabe I Of 2
Oath of Personal Representative
COIvI~tONtiVEALTH OF PENNSYLVANIA
SS
COUNTY OF _~~. (,~,~~ ~~ ~ ~~ .
'The Petitioner(s) above-named swear(s) or afftrnl(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 well and truly
administer the estate accorctiug to law.
Sworn to or affn-n-ied and subscribed
before me the ~~~ day of
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For th egister
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rture oJPersona! Representative
Si nature of Personal Representative ~
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Signature ojPersonalRepresentative ' ~ ~_
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File Number n/ ~ ' ~~ -~ ~Op2 3 n C~
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Estate of l ~ 1 ~n G~ ~ {~ ~ I v~ ~ (~ (,~G ~''` ,Deceased ~
I _ //~~ ~
Social Security Number: _ V ~,Q,~ ^ ~~~ p - ~ `J a2 V Date of Death: ~ ~ ~ ~ - (J~
AND NOW, _~~ (~ , c~f/~) , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DE ED that Letters ~~f~1 _j'y~ q~~ -T (•,1
are hereby granted to -e ~ 1 >,:, KI Shama
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_ `" in the above estate
and that the instrument(s) dated ~ (~ - I ?~ - ("} 7
described in the Petition be admitted to probate and filed of record as the~(last ~41i11 (and C'odicill~(~)) of Dec~ed/eynt.
FEES ~~' .~ I~x Q ~ ~~~~ ' 1 ~' lhi.~
Letters ............. $ ~~D. ~~ Register of'Wills ,~0,. ~.~ (.~^~,,
Short Certificate(s) ........ $_ Attorney Signature: ~^'" ~`~"
Renunciation(s) .......... $
w ~ + ( .. $ ~ 5 ~ Attorney Name:
' $ ~~' ~ Supreme Court LD. No.:
$ Address:
-, ... $
... $
_ ... $
- ~ ~ ~ $ Telephone:
... $
TOTAL .............. $ '3, ~
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Porn aw-o. rev. to.i3.or Page 2 of 2
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LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~ Fee for Ibis certificate. ~6.OU
"'r'~~.ZN OF
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~9TMEfdT OF~~`P~~;
'I'hi,, is [f, certif~~ that the inlormatiun here ;*iven is
Lurrectl~ c(,hicd ti~um ,)n (~ri~~)nal Certit)cale f~•f~ Death
duly tiled with Ina as Lo; a! Registrar The t>r)~~Inal
ccltih~~ate will he: t~n~~i~;u~ded to tine StaL~ Vital
hceor~_(, Uf~fire fur pr~n)anent f71in~~.
P _2 5 0 i_~ 09_:3 4___
Ccrtif~ication Numher
IEV 1v2Das
'RINT IN
4NENT
KINK
1. Name of Decedent (Fim, middle, last, sufix)
S Age (Last Bidhtlay7
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See insiructlons and examples on reverse)
STATE FILE NUMBEI
2. Sex 3. Social Security Number q p
female 162 -36 - 9520
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ate of Death (MOmh tlay. year)
Dec. 12,2008
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Months Sys Ha,: Mi"mas Mar. 15 1948 Chambersbu e.~yVV'~.', ~.~„~~"'eam,~necxonlynna) -
6 0 Hospital. Other
Yrs ~ rg, PA A~,
ab can of Death ICylnpatrem ^ ER / ompanent ^ DoA ^ Nuraing Home ^ Resmenpa ^Other
ry &. City, Boro, 1w0. of Death fid. Fadliry Name (II riot insliNtion, give sheet and number) SPecrly'
9. Was Decedent of Hispanic Origin? Np ^ Yes 10. Race: American Indmn, BIaCN, White, etc.
Cumberland East Pennsboro Holy Spirit Hospital mYea,apedycuban. (S~rm
Mexican, Puerto Rican, etc.) W 1 t e
77. Decedent's Usual Lion Kind of work done tlunn most of workin life. Do rot stale retiretl 12. Was Decedent ever in the 13. Decedent's Education
KiM of Work Kirm of Business I Industry U.S. Armed Forces? (SDecdy only highest gratle completed) 14. Madlal Status: Married Never Marnetl, 15. Surviving Spouse (II wile, give maitlen name)
Elamle 2 ry /Secondary (0-12) Cdlege (1-4 or 5+) Widowed, Divorced (Speci!)7
billing clerk township ^Yea p divorced
16. Decedent's Mailing Address (Street city l town, state, rip cotle) Decedent's
Actual Residence 17a. State Did Decedent
1900 Beckley Dr. Pennsylvania ow~snP ,7~pYea,Deeedenuixedm Twp
New Cumberland, PA 17070 176. County CU.:ilo2r13nd ntlfgwp,Daoatlen,o~edw;,n;n
AcmalUmiu al nTaT:: l'nmharl a nrl ciryleore
s1 B. FaMer's Name (Firs[, mmdle. last, suffix) 19. Mother's Name (First, midtlle, maiden surname)
Glenn 'v1. Mellinger Frances Mellinger
20a. InformanYS Name (Type! PnnQ
K e l ]. i K i s h b a u g h 20b. Informant's Mailing Address (Street ctty /town, state, zip cads;
518 Sixteenth St.,Ne~w Cumberland, PA 17070
21 a. Method of Disposition ~~ ^ Cremation ^ DOnalpn 21 b. Dale of Disposition (Month, day, year) 21c. Place of Di
Burial Removal from Slate sposition (Name of cemetery, crematory or other place) 21 d. Location ICIry! sown, slate, zip code)
^ j Was Cremation or Donation Authorized Dec . 19 2 0 0 8 Spring H i 11 C e m e t e r
^ her - Spenly i by Medical Examiner /Coroner? ^ Yea ^ Np ~ Y S h i p p e n s b u r g, P A 17 2 5 7
22 orFUnerel rvme Lmensee (or person acting as srtch) 22b. License Number 22c. Name and Address of Facility
~ FD-013163-L Musselman FHSxCS,324 Hummel Ave.,Lemoyne,PA 17043
Complete ttems 23at oMy when cenitymg 23a. To the best of my knowledge, death occurred al the lime, date antl place staletl. (Signature arm title) 23b. License Number
phys'xaan is not availede al lime of death to 23c. Oats Signed (Month, tlay. year)
wrefy cause of tleeth.
pie y person • ' 26. Dale Prorwunced Dead (Month, day, year)
Iwems 2426 must oe corn tad b 24. Time of Deam 26. Was Case Relenetl to Metlrcal Examiner I Coroner for a Reason Omer Ivan Cremation or Donation?
tro proraunces death. n : O a,~ ~ M
/~ I ^ Yes ^ No
CAUSE OF DEATH (See Instructions and examples)
Item 27. Pan t. Enter the chain of events -diseases, mjuries, a complications -that directty caused the death. DO NOT enter terminal events such as cardiac crest, r Approxhnale interval: Pan II: Enter other si°nfcant ,;ondil'ons ron~pin ~o t death pg. qd Tobacco Use Contribute to Death?
respiratory anent. or venlncular fibrillation without showing the etidogy. Lill Doty one cause on each line. Onset le Death but not resulting in the untledying cause g en in Pan L ^ Ye ^ Pro6abty
IMMEDIATE CAUSE (Final tlisease or ^ No e-ynlmown
cmdition resuRirg in death) -~ ~, 1 , /~~ I O (1,... _,.(~ ~l ~ 1
'I" Y r rn-1l~--. ~'~.p,S (~!/1/~/~iAn~.~ 29. If Female:
a Due to (or as a ronsequence ot). t
Sequentiapy IRI rormttions, H any, r C~r'W r Dregnant within past year
leading to the cause fisted pit line a. b~ r ^ Pre nant al lime o(death
Enter the UNDERLYING CAUBE Due to (or as a ronsequence of)' ~ g
(dsease or injury mat initiatetl the t ^ Nol pregnant, but pregnant within 42 tlays
evenh resumng m deem) LAST. of death
Due to (or as a ronsepuence off:
d. ^ NoI pregnant, but pregnant 43 days l0 1 year
~ 6ebre tleeth
30a. Was an Arnopsy 30b. Were Auropry Frmings 31. Manner~l Deelh ^ Unknown it pregnam within the past year
Pedrrmed? Availade Prior to CAmpletion - / 32a. Date of Injury (Month, tlay, year) 32b. Describe Hex Injury Occurred 32c. Place of Ina Home, Farm, Street, Fact
of Cause of Death? ^ Homicide
aNral OMice Builtling, etc. (Speciy) ~~
Yes ^ Ne [~-Gs ^ No ^ Accme^t ^ Pending Investigalron 32tl. Time of Injury 32e. Injury al Work? 32f. If Transportation Injury (SpedryJ ;12g. Location of Injury (Street, coy I town. state;
^ Suicitle ^ Could Nol be Determinetl ^ Driver I Operator Passan
M ^ Yes ^ No ^ 9er ^ Pedestrian
^ONer - Speciy~
33a. Cenifer (deck cMy one)
CertHying physican (Physician cemying cause of tleeth when another physmian has pronounced death and completed Item 23) 336. Signature antl Title i r
• To the best of my knowledge, death occurred due to the cause(s) and manner as sfated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ ~ ~~
• Pronoundng and certifying physician (Physcian both pronouncing death antl cenitying to cause of death)
To the best of my knowledge, tleeth occurred al the timr., sate, and place, and due ro the cause(s) and manner as sletetl_ _ _ _ _ _ 33c. License Num 33d. Dale Signed lMOnm. day. year)
• Medical Examiner/Coroner ^ VV D^~ ~~_
On the basis of examination and! or investigation, in my opinion, death occurced at the time, tlate, and place, and due to the cause(s) and manner es stetatl_ ^
34. Nam/e'a(n~tl A)tld~ass of/Person Who Completes Causleol Death (Item 27) Type t Print
35. Registrar's Sig a arm Disl ct N 1 36. Date Filetl onth, d y, year) t ' N"~~J~i ~ (A ~j` ~ t/x.. ~ 1' _
Dispassion Permit No. __-(~~ ~~_ y~ L_ _
~~?~ __~_ ~ C 2 2008
Lucal RL~~~isU~ar Date: Isstfcd
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LAST WILL & TESTAMENT , ~~~`' ~' ~`~ ~, ~~~
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I, GLENDA M. MELLINGER, OF 1900 Beckley Drive, New Cumberland, Cumberland ~,
County, Pennsylvania, revoke my prior Wills and declare this to be my Last Will and Testament.
FIRST: Debts and Funeral Ex enses: My debts and the expenses of my last
illness, funeral and burial shall be paid out of my estate.
SECOND: Personal and Household Effects: I give all my automobiles and all other
articles of personal and household use, together will all insurance related thereto, to my daughter,
KELLI E. KISHBAUGH.
THIRD: Protective Provisions: No interest in income or principal shall be
assignable by, or available to anyone having a claim against a beneficiary before actual payment
to the beneficiary.
FOURTH: Death Taxes: All federal, state and other death ta:Kes payable because of
my death on the property forming my gross estate for tax purposes, whel:her or not it passes
under this Will, shall be paid out of the principal of my probated estate just as if there were my
debts and none of those taxes shall be charged against any beneficiary. Any death taxes on
future interests may be paid whenever my executor may think best.
FIFTH: Residuary Estate: I give the residue of my estate, real and personal, to my
daughter, KF?LLI E. KISHBAUGH.
Seventh: Executors: I appoint my daughter, KELLI E. KISHBAUGH, Executrix of
this Will to serve without bond, but for any reason she fails to qualify or ceases to act, I appoint
my sister, Peggy A. Houseal, Executrix in her place.
Executed this 13 day of O c`.t'a1~, ~ 2007.
GLENDA M. MELL,
In our presence, the above-named Testatrix signed this and declared it to be her Will, and
now at her request, in her presence and the presence of each other, we sign as witnesses:
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Residence ~ ~, s ~rP ~p,~
Residence ~" ~ 2
COMMONWEALTH OF PENNSYLVANIA
' ss.
COUNTY OF `~C! ~tl~ _
We, Glenda M. Mellinger Barbara J Leonhard and Janet L Becker, the Testatrix and
witnesses, respectively, whose names are signed to the attached or foregoing instrument, being
first duly affirmed, do hereby declare to the undersigned authority that the Testatrix signed and
executed the instrument as her Last Will and Testament and that she haci signed the instrument
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 oi'the Testatrix, signed the
Will as witnesses and that to the best of our knowledge, the Testatrix was at the time eighteen
(18) years of age or older, of sound mind, and under no constraint or undue influence.
Glenda M. Mew lli ge ~'
--z
Barbara J. Leonhar
an t L. Becker
Subscribed, affirmed to and
acknowledged before me, this ~~?th day of
~GfC~~iv , 2007.
. Notari;~Seal
Doris Marie Dahlharnmer, Notary Public
Conewago Twig., York County
My Commission Expires June 26, 2009
Member, Pennsylvania Association of Notaries
commission expires: (~/~ oel~i~~~