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HomeMy WebLinkAbout02-03-09PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF /~/,~,~i(~,~fizc/Ij COUNTY, PENNSYLVANIA Estate of „ /"~/~~ File Number ~' ~ ~ ~ _ ~ ~( /~ also known as ,Deceased Social Security Number u7~''.`~ Z' y~yy Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE 'A' or 'B' BELOW:) A. Probate and Grant of Letter T 5 mentar .and aver that Petitioner(s) is /~1ie the _ ~c~G l~ named in the last Will of the Decedent dated and codicil(s) dated-LY~'/iSl~~ (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 bom or adopte after execution of the instrument(s) offered for probate, was not the victim of a killing and was never adjudicated an incapacitated person: r o ..v ,_ ~ '~7 t - ^ B. Grant of Letters of Administration ~ rn ~ --~ , ? (ljappiicable, enter: c. t.a.,- d. b. n. c. t. a.; pendente lire; durante absentia; durair~t te) i t"~' i ;'~?-7 Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following s~&ai~ny) and~eirs: ~If', ~ -~ Adntitristration, c. t. a. ord.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) ~..' `~' -rt 3 ^} :: ; r_~ Name Relationshi Reside ---1 " '",7 (COMPLETE IN ALL CASES:) Attach addition/al~sheets if necessary. Decedent was domiciled at death in r~~~[~e=~l~/~ County, Pennsylvania with his /her last principa] residence at (List sb-eef addre.~'s, town/city, township, county, state, zip code) Decedent, then ~ years of age, died on 2.7' at / ^ ~~ / Decedent at death owned property with estimated values as follows: ~/ (If domiciled in PA) All personal property $ ~750~ ~_ (If not domiciled in PA) Personal property in Pennsylvania $ ~~- (Ifnot domiciled in PA) Personal property in County $ Value of renal es-ta/te~in/Pennsylvania/ , / $ ~Q„Qp© situated as follows: ~~/ /I~~.~ ~~ sue!-r/i' /%/,(~/ ~;Q/ ~l~ ~~ /'7i1/h Form R6V-02 re,-. 10.13.06 Page I of 2 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 CO~~I~~IONbVEALTH OF PENNSYLVANIA SS COI,~NTY OF ~~ "The Petitioner(s) above-named swear(s) or affirn~(s) that tl:e statements in the foregoing Petition are Uue and correct to the best of the knowledge and belief of Petitioner(s) and that, as persor:al representative(s) of dle L>ecedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me the ~ day of YI nl,.n ,. _ ~.,_,~ oJPerso~2a1 Representative Signature oJPersonal Representative F6r the R~gister Signature oJPersonal Representative "*'1 W _ zt =~t .. r--- ~ ira .~ f `" c_.^. -.3 '~L7 ,~,,, ,'_ , a File Number: ~L ~ l1~ ~ ~'' Estate of ~ ye I ~~ . !V `~~~ ,Deceased Social Security Number: ~ On~ " 5~. - ~~~ 7 Pate ofDeath: /~~ S ~~~~~ AND NOW, ~rd Q ~.~~, in consideration of the foregoing Petition, satisfactory proof having been presented before le, IS DECREED rat Letters ~ QS,f /Y1 J'l are hereby granted to ~ V~t'1 C • ~ p~Y~ _ in the above estate and that the instrument(s) dated ~ ~ I ~___,_________.___. ______ described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. FEES --~r~-~ Register oJWi!!s yL'v ^~,' n~n C Letters ............... $ ~ L`^ ~ . Short Certificate(s) ........ $~b, lJ(.' Attorney Signature: Renunciation(s) .......... $ ... $_ - ~~ ... $~ ... $ ... $ ... $ ... $ ... $ ... $ TOTAL .............. $~'?~ln(>. t~ Attonrey Name: Supreme Court I.D. No.: Address: Telephone: r-~~~n, RW-o? ,~w_ 10.13.or, Pabe 2 of 2 v~ i - G%9 - ~~ll ~ LOCAL REGISTRAR'S CERTIFICATION OF DEAT~I WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee fir thi< certificate. 56.(lU P 1~OU3125 Certil~ir<uion Number "Phis is to certifti that I'aL~ inirn~mati<t;~ here ~ri~~en is correctly copied film all lrri Sinai Certificate of Death duly filed with )~~e a~ i':.t'cal kc~~ist,<u-. The t~riginal certifirnte will he fortiva;-drd (o the State Vital Reeords OIfice lilt IICrn~aner)` filin~~. ~~ JAN/2 91IlOg Local Registrar ~ Date Issued sv c d _ ..o ~~ '~'i 107 ' ~ ~- - = •~ 5.../ ~ ("} bra ~ 0~ y i_T_1 W tEV 1lrzoos COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ANEMN CERTIFICATE OF DEATH ;K INK (See instructions and examples on reverse) STATE FILE NUMBER 1. Name of Decedent (First, middle, IasL suffix) 2. Sex 3. Social Security Number 4 Data of Death (Month, day, year) Evelyn C. Moore female 202 - 52 •+-1297 January 25, 2009 5. Age (Last Birthday) Under 1 year Under t day 6. Date of Birth (Month, day, year) 7. Birthplace (City and state or for ego country) Ba. Place of Death (Check Doty one) Mmtns Oays Hars Mlnures Hospital: Other ~ ~ gg May 16, 1919 Hudson, WI Yrs ~] Inpatient ^ ER / ONpalienl ^ DOA I ^ Nursing Home ^ Residence ^Other ~ Specity. Sb. County of Death 6c. Clty. Boro, Twp. of Death Bd. Facility Name QI not institution, give street aM number) 9. Was Decedent of Hispanic Origin? ®No ^Ves 10 Race. Amerkan Intllan, Black, WhAe. etc. Cumberland E. Pennsboro 'flap. Holy Spirit Hospital (II yes. Specity Cuban, M i P rt Rm a (Specity) hit ~ ex pan. ue p an. c) w e I 11. Decedent's Usual Occu lion (Kind of work d one tl urin moss of workin life. Do not stale retired 12. Was Decedent ever in the 13. Decedent's Education (Speciy only highest grade comp leted) 14. Marital Status: Marred, Never Married, 15. Surviving Spo use (II wile, give maiden name) j Klnd of Work Klntl of Business! IMustry U. S. Armed Forces? Elementary /Secondary (0-12) College (1d or 6i) Widowed, Divorced (Specify) Homemaker Domestic ^Yes ®Np 10 Widowed 76. Decedent's Maitirg Address (SYreet, city! town, state, zip code) Decedent's Did Decndenl '. Pennsylvania 117 Fourth Street AauaiResidence 17a.slate ? 17o^Ves,DecetlentDVeem rwp 'I Townsn¢ New Cumberland, PA 17070 r ,7b Cognry Cumberland ntl $] no'uD~m~s olwetl within New Cumberland city/Boro 1 B. Famei s Name (First, rmitlde, last. suXix) 19. Mother's Name (First, middle, maiden surname) Oscar Olson Clara Mattson 20a. Informant's Name (Type /Print) 20b. Inlortnani's Mailing Address (SlreeL city / lawn, slate, zip code) Joann C. Worle 403 Seventh Street, New Cumberland, PA 17070 21 a. Method a Disposition ^ Cremation ^ Donation 21 b. Dale of Disposition (Month, day, year) 27 c. Place of Disposition (Name of cemetery, crematory or other place) 21 d Location (City! town, slate, zip code) ® Burial ^ Removal from Stale ~i Was Cremation or Donation Authorized ^ Other-Specity i byMeditalExaminerlCOroner? ^ves^Np January 29, 2009 Rolling Green Cemetery Lower Allen Twp. , PA 17011 22a. SgnaNre rvice ensee (or person acting as such) 22h. License Number 22c. Name and Atltlress of Facility FS 012 849 L Parthemore FH & CS, Inc., P.O. Box 431, New Cumberland, PA. 17070 Complae Items 2 only ceniying 23a. To the best of my knowledge, death occurred at the lime, dale and place staled. (Sgnature and title) 23b. License Number 23c. Date Signed (Month, day, year) physican Is not availab 1 of death Io ceNty cause a deem. Items 24-26 must be completed by person 24. lime of Deam n 25. Date Pmnouncetl Dead (Month, day, year) 26. Was Case Refened to Medal Examiner /Coroner for a Reason Other Than Cremation or Donation? wip pronounces death. n ~ x ~ F r M. ~~ S C ^Ves ~ No CAUSE OF DEATH (Sce inatrudlona and examples) r Approximate interval: Pan IC Enter abet SigniM1cant condNOns contributing to death, 2B. DW Tobacco Use Contribute to Death? Item 27. Pan I: Enter the chain of events -diseases. injuries, pr complicatiom -that directly caused ttte deem. W NOT Baer lertninal events such as cardiac artesl, r Onset to Deam but not resulting in the untladying cause given in Part I. ^ Yes ^ Probably respiratory aresl, or ventricular fibrillation without showing the etiaogy. List only one cause on each line. r r ^ No ~nknown I r -yI IMNEDUTE CAUSE ((Final disease or ,max, _ I T ~ cpnditbn resultin m deaMl ~ ~yU /~ L 29. lf Fem ale: g -~ a. y ~ r V xvV` ! I~ ~ Zt : ` r' r ~-~ ~ Due to (or as a consequexe oB: r L•7 Nol pregnant within past year Sequeaialty list gondi0ms, 5 arty, b ~ l d d li t d li ^ Pregnant at time of death ea ug M re cause s e on ne a. Due to (or as a consequence oq: ~ Enter Flre IMDERLYING CAUSE ^ Nol Dregnanl, but pregnant within 42 days (dsease or injury that initiated the c events resulting m death) LAST. of death Due to (or as a consequence oQ: ^ Not pregnant. but pregnant 0.3 days to 1 year d i bemre seam ', ^ Unknown if pregnam within the past year 30a. Was an Autopsy 30b. Were Autopsy Findings 31. Man i of Death 32a. Dale of Injury (Month, day, year) 32b. Describe How Injury Occurted 32c. Place of Injury: Home, Farm, Slreel, Factory, Penormetl? Availaae Prior to Gompletron ~ 111 ddd NaWtel ^ Homicide Office Building, etc. (Specity of Cause of Death? ^ Yes ~ ^ Yes ~NO ^ Acatlenl ^ Pending Investigation 32d. Time of Injury 32e. Injury al Wod7 32f. II Transportatlon Injury (Speciyl 32g. Laalion of Injury (Street, city I town, state) ^ Suicide ^ Could Nol be Determined ^Ves ^ No ^ Dover !Operator ^ Passenger ^ Pedestrian M ^Omer -Specity: 33a. Certifier great Dory one) 33b. Signature and Title of Ce • Certltying physician (Physcian cenirying reuse of death when another physician has Donounced death and completed Item 23) // '. To the beat of my krwwkdge, death occurred due to the cause(s) end manner as stated., _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ ~ / • Pronouncing and cenNying physician (Physician both pronoundng death and certifying to cause of deahl To the beef of my knowledge. deem occurred al the time, date, and place, and due to the cause(s) and manner as saated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. Cleanse Nu bar 33d. Date ignetl tMonth, day, year) - x _ ~ ' r • Medical ExaminerlCaroner ) / ~V ~ G~l ~/~ ~ 1 l • /d On me basis of examinetlon and I or Investigation, in my opinion, death occurred at the time, dale, and place, and due to the cause(s) and manner as statad_ ^ 34 Name an ompleted Ca se of D9alh (Item 27 d A/dd`r~ss of P~rson Who C )^Type I Prior L 36. Registrar' azure and Dis m ~ ''~ ~ ' 38 Dale Filed ( Ih, day, year) ' _ ~l ! ~M r / j ' ~I / G'~{~ ! /,I. 'G`G~/!Z ~ ~ I.~I I I f I s/~,~~cn> ~ ~ 1~ ,~ ~ r IV (/ Disposition Permit NO. ').1~ ~Z,~~ .' G a ~~~t t11 ~n.~ C~I~~~~m~en~ ~~_~ OF EVELYN C. MOORS e- i c;a w -n ~~ w _~ __,_, _~ -. ~~ ~t., -P' I (~;} r._Y' Z'i ti_ti~ I, EVELYN C. MOORS, of the Borough of New Cumberland, Cumber- land County, Pennsylvania, declare this to be my Last Will and Testament, hereby revoking and making void any and all wills pre- viously made by me. I. I direct that all my just debts and funeral expenses, includinc my gravemarker and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my decease as a part of the expense of the administration of my estate. II. I devise and bequeath all the rest, residue and remainder of my estate of every nature and wherever situate to my husband, MICHAEL J. MOORS, provided he survives me by thirty (30) days. III. Should my husband, MICHAEL J. MOORS, predecease me or die on or before the thirtieth (30th) day following my death, I devise and bequeath all the rest, residue and remainder of my estate to my issue per stirpes living on the thirty-first (31st) day following my death. IV. I nominate, constitute and appoint my husband, MICHAEL J. MOORS, Executor of this, my Last Will and Testament. Should my husband, MICHAEL J. MOORS, fail to qualify or cease to act as such, I appoint my daughter, JOANN C. WORLEY, Executrix of this, my Last Will and Testament. IN WITNESS WHEREOF, I have hereunto set my hand and seal jh. thi s day o f ~- Lc ~ i~ ~> ~ , 19 7 6 . -.-~~-~~-t/ C ~-~-a~2-e._ (SEAL) elyn C. Moore ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUMBERLAND ) I, EVELYN C. MOORE, Testatrix, whose name is signed to the 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. C1"; y~~--~-~---- E"elyn C. Moore Sworn or affirmed to and acknowledged before me, by EVELYN C . MOORE , the Testatrix , thi s ~ ~~ day o f /~~ir y~~s,~` , 19 7 6 . /~ , /: ,~, ~ f~ Notary ublic /~; My Commission Expires: AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) S5. COUNTY OF CUMBERLAND ) j . -- b/,r° ~ rtl L_ _ '~ j~ z'~i-rJ , and ,~ ~° f~ ~'/~ the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the foregoing instrument as her Last Will and Testament; that she signed willingly and that she executed it as her free and voluntary act for the pur- poses therein expressed; that each of us in the 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~~J ~q,~~.~ and a /~ .~ ' witnesses, this l~~f day of us T , 1976. 7 '~ ~. ~ Notary Public My Commission Expires: ~~