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HomeMy WebLinkAbout02-20-09PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND Estate of BEVERLY SAMPLE a/k/a BEVERLY F. SAMPLE also known as Deceased COUNTY, PENNSYLVANIA File Number Cs~•' ~ " !~ %' ~ ~ / to Social Security Number 229-20-5531 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 Executrix named in the last Will of the Decedent dated March 31, 2005 and codicil(s) dated January 2, 2008 (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: 0 B. Grant of Letters of Administration (If applicable, enter: c.t.a.; d.b.n.c.t.a.; pendentelite; duranteabsentia; duranteminorirate) 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 ofheits.) Name Relationshi Residence (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal residence at 12 Marshall Drive. Ant. #I-6, Came Hill, (East Pennsboro Townshiol PA 17011 (List street address, town/ciry, township, county, state, zip code) Decedent, then 83 years of age, died on February 9, 2009 at 12 Marshall Drive, Apt. #I-6, Camp Hill, PA 17011 Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ 60,000.00 (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: N/A TOTAL $ 60,000.00 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: Si ature T d or rinted name and residence %` Janie A. Jackson 6631 Conway Road, Harrisburg, PA 17111 717-564-1623 Form RW-01 rev. 10.13.06 ECORDI:D OFFICE OF REGISTER OF WILLS 2009 FEBRUARY 20 CLERK OF ORPH DNS' COURT %~ ~. CU;~IBEF:L=~I`'D CO., PA elof2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF ~-~ ~~~ 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) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me the a ° ~ day of r ~~ For a Register File Number: Estate of BEVERLY SAMPLE a/k/a BEVERLY F. SAMPLE ,Deceased Social Security Number: 229-20-5531 Date of Death: February 9, 2009 AND NOW, ~~ ~ ~ yt 1"C.Ia~UTAX U , , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IkS DECREED that Letters~'~rn are hereby granted to _ in the above estate and that the instrument(s) dated ~YGI'1 ~~I n ~~ described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s) of Decedent. FEES Letters ............... $ ' ~~ vy Register ojWills ,/~ ~ ~ ~ ~ Short Certificate(s) ........ $ Attorney Signature: ~~,tiCLY~%~X~-~~- Renunciation(s) .......... $ ... $ ... $ l~. ... $ ~~ Lt~ ... $ ... $ ... $ ... $ ... $ ... $ TOTAL .............. $ 02D "-~ FormRW-02 rev. /0./3.06 ojPersonal Signature of Personal Representative Signature of Personal Representative Attorney Name: Jean D. Seibert, Esquire Supreme Court I.D. No.: 41713 Address: 109 Locust Street Harrisburg, PA 17101 Telephone: 717-236-9301 RECORDED O'.FFICE OF REGISTER O:F WILLS 2009 FEBRi;'ARY 20 CLERK of / Page 2 of 2 ORPI~~NS' COURT p~ CUMBERLAND CO., PA .,Y - ~~ 1 ~ G/ 7~ LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, X6.00 P 15237083 Certification Number This is to certify that the information here given is correctly copied from au original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwardec: to the State Vital Records Office for permanent filing. G~ !~~~ a l ~ I / o-~ Loco] 1 gistrar Date Issued __ _ _ _ _ _ __. _._ RECORDED OFFICE OF _ _. REGISTER OF WILLS 2009 FEBRUARY 20 w, CLERK OF ~\ ORPIL~NS' COURT CU~IBERL AND CO., PA H105-1/7 REV 11!NO6 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VRAL RECORDS P R/MANENTN CERTIFICATE OF DEATH BLACKINK (See Instructions and examples on reverse) STATE FILE NUMBER 0 0 z 1. Name d D9CCdenl IFxsl, mitlde, last, waial Qvpfl f Scan tt... 2. Sea 3. Sabi Beauty Number 4. Dale d Deam (Month, day, year) Malt, zzq -LU -231 ~tbfktss n 5. Age (Last Butraayl U 1 year Urxler t day 6. Dale of &M (Monlq day, Year) 7 &nhpace (Qry aM slab a f caaury) W. Place of Death (Check oay one) ? ktdww oars taws Mawus _ g J Yrs O C ~(7s7c ~ .2~ I -1.1~' 1 ' Hospital: Other. r~! ~/ s•f 1 (~ 1 C7.. ^ IryalleM ^ ER I OulPatient ^ DOA ^ Mnairlg Hans L'l nasiEertca ^qMr • Spedh: W. Canty d Deam & Ciry, eao, 7wp. of Deam M. Fatuity Name (II rat nsbtdan, give slr6el antl numbed 9. Was DeaKlea a Miapaac Qpn? ~•No ^Ves 10. Rata: Amaecan utdian, Black, WdN, eN. C1wNybtC l an cl eitm p L-{ 1 t l ~ ~. h~arw,h w.l ~r", " Z- b (AkatcarlWerto ~ . aaa (spedM ~k;c.-vim ~cr: 11. Deceded's llsua Oa Ian Kmd d work G one drru most d waA lee. lb not stale retired 12. Was Decetlenl ever in the 13. Daceaea's Education (Spedly ally higlasl grave comp leted) 14. Martial $laluc: MarMd, Never Married, 15. Slrrvivug Spo ~ w (It wife, give maiden name) K,W d Wak 14M ss /Industry U.S. Armed Forces? Elementary /Secondary (412) Cdlege (1 i or 5~) M WPM' ~~ {SOear w.-~ G d ~ -~-1 of De ~~: v ra4ea ^Na ~ ,; n . , 16. Decedent's Mauklg Address (Street coy /town, stare, zw code) I~. Ma~yhn~ ~;JL O• .1--~ Decetlenl's Adual Residence t7a State Did Decedent t~~n S..)IJliAa R.. Live ins 17c.^Yes, Decades Livedm Twp. y~ c ~{; l ~ Y ti 1~ ~ C' 170. Coudy C U.M-lo, l rtC!-sn r 4.. Township? 17d. LJ No. oettMM LMd wahh ~~,t, ~-C.; t C P 1 y .1 ctatiL-~ coy R Boro Aaue Lines d 19. FddMr 5 Narre IFirsl, rtlidtlle, Iasi, sueia) 19. wmei s Narre (First middle, makkn surnartta) 211x. InbrmaM's Name (Type / Prn11 20b. InlamanYS Mailing AddreR (Street city / bwn, stale, pip mM) ~0.1'~;t -dC~GitS~An (old3k COpwa~ ~sQ. (t{arr.S~...f ~Q, 1711( 21a. Mel nod of Disposilan ~ ^ Cretnauon ^ DonaUOn 21b. Date of Disposuion IMailh. day, Year) 21c. Place of Dispovlion (N me d ce tery , aemelay a othx Platt) a 21d. laadon (CNy /town, slaty zp soda) r y ~1 Baial ^ Remaal han Slate i Was Cnrwlion a Dolutbn AumaWe ~' Ar ckr c~ y C y 1 s ' ' r , l•M ~ C~C{ ~• : l1 ~ a11~ '~W laJtls n ~ ~ ~ya~ j-~•L c ^ amar ~ . M wow Enw1Aw / coralM ^ tea ^ No , , r ~ . t 22a. kua tl icensae ( g as sucml ~~ 22b. License Number 22c. Nenre aM Adaess d Factory ,p E l•} l - - 6 / ~ 17 - ~•- µfr • s ew ~S3Z l~L...~ S l Q- ~ ~ o Conpkte Nerns 2 < when cerlaying 23a To tM oast d my knowledge, tleam a <un ee at IM Bm e, tl ele arq place sMtetl. ISgnalae antl aM) ~ 2J0. L N umbw le S igned (~aan, d 23c Da ay, year'r plrysiwn ra rid al tine d deem to / - ~ ~~ /f ~ ~ ) ~ / ~ /C~ / ~ ' L r ~ '7 /~ ~ S /~ T ~ (L - / ~ j ~ /~ % CO a1rkM puss d de9m. ,~<- .~ 1 ~ (~-• C.C~ ir L, ~l. J • .r1 , sL Mms 24-28 rapt W CoTpleled M person 2 one of Deam ^ 25. to Prataaaed Dead IMmin, OeY, year) ^ C 25. Wag Cage NBIMreyo Medical Evatrlkter / Corawr br a Reason Oma Nan Cremation a Dortelion7 wM naaatcea Deam. ~ :O~ ~f - M. .~G~,~ (.. .;1GU ^ Yea ~No CAUSE OF DEATH (Sea InstruoUOrla and eaamplas) r Approanale inwua: Pail N: Eraer Dinar ~ ~ ~ ~ ~ 28. Did Tobacco Use CaNibule b Deam? Item 27. Pan L Enter tltechain devents -diseases, ipu , a rarrlpkcaoors -mat erectly caused Ow deem. W NDT emer lerminat evens u cardiac amesL r Onsd b Deam bd not resW611gi n M wdalyitng caw given in Part I. ^ Yas ^ PrWaay respaatay arrest. a venlricWar IibriY M eliobgy. LM ally use on eadl kne. w ~ ^ ~ ryn KK~1 WIIEgATE CAUSE IFirtal daease a de arvklun resaag n am) ~ a / 1 ~ © Ll.YY1 r ~ 29. 0 Ferrele: ^ N a itl l Due to (a a 1 ~ i a pragrw w wt pal year ^ Prague el Ume d deem o kyapyeaqq Oue to (o s coruequerKe ol): UkIDER~YaMA E a. u l E ~ ^ Nd preplarK, bIA prrxytara wdNn 42 days n r, u (duesee p utNrty mat ekWlBtl me a. evenb rewain n Beam) LAST r ~ a seam g . Due to (a as a cansepurke dl: , tip preywa 43 says u 1 year ^ d. r ~ ^ lAUnow'n a prequra wimp tlu pe9t year 3Da Was an Adopsy ago. Were Adapsy FinOrgs 31. Marna d Deam 32a. Dale d Irqury (Mann, pay, year) 32b. Describe How Injury Ocawred 32c. Place a ptjury: Hone. Farm. Sbeet Faday, Perbnndd? Avatlade Prior M Caripelion d caw d Deam? Natural ^ Homicide Otltca 8+19, ~~ (SPec'rY) ^ Ves ~NO ^ Yes ^ No ^ A.a~dem ^ Penarg Invesogaiat 32d. Time of Injury 32e. injury a Work? 321. II Trarwpatalbn Mjury (SpecrtyJ 32g. lacaaan d kyury (Sven, dry I loin, slate) ^ Suicide ^ Carld Nd M Delemwud ^Ves ^ No ^ Driver / OpBmla ^ P r olan M ^OIMr' Spedy: 33a. Gaudier (aredi Day anal ~ 33b. Sgnalae and ruled f • C•rabm9 pAysklan (Physican wmlyulg caw d deem wtun anolMr physician Ms pronounced Beam one canpelee Mrn 23) - To mu oplamy knowedge, rNath occurred tlwto me cauea(a)aM manner as Maletl________________ _________________ ^ • Prortounehg rid cendying pnywalan (Pnysidan bdn pronaraug death aM certifying u cause d deem) To ttN Wal d my kltowkdpe, loth accred at dN time, dare, end plan, and due to tM tauae(a) and manner as sYted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. l tvMer r /y 33d. Data Si/~ (w m . f r / ~ / • • kMdkal EaantYlarlCaotrr On tlu Web a eumhlnlort and I a Imeadgatlon, W my oplnbn, tlealh occurred a1 LM Nme, dale, end plan, and due b LM cauaa(a) and maruur d amled_ ^ J (/ 1 27) Type I Pdu /~ 34. Name a ss Par s a npleNO ~ onyWM CG C~ / 1 Registrar's - a e aM a91 Nu ~ \ ~ (~ 36. D Filed Keay, year) ~ ~ / ~ / l ' Y F y a • `~~ • ~ ^ 7 J .J y /11 I I I rTl , r ' ' Dsposmon Permit No. ~ ~ l `~ K ~~ r ' I / V WILL OF BEVERLY SAMPLE I, Beverly Sample of Cumberland County, Camp Hill Pennsylvania, declare this to be my last Will and hereby revoke all prior Wills and Codicils. direct that all my just debts, funeral expenses, gravemarker and administrative expenses shall be paid from my residuary estate as soon as practicable after my death. 2. I direct that all inheritance, estate, transfer, succession and death taxes of any kind whatsoever which may be payable by reason of my death shall be paid out of my residuary estate. 3. I direct that my entire estate be distributed as follows: A. I direct that my entire estate be distributed equally between my grandson, Benjamin Jackson III, my niece, Diane Napier, my niece, Bernice Childer, my niece, Lucy Mae Jones and my sister-in-law, Janie A. Jackson. B. Should any of the above mentioned predecease me, their share shall lapse and be divided equally among survivors. 3. I appoint Janie A. Jackson as Executrix of this my last Will. If she should predecease me or cease to act in such capacity, I appoint Carmen Clark as alternate. LAW OFFICES OF STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 4. The Executrix of this Will shall have the power to distribute my estate in kind or in cash, or partly in either. 5. I direct that no Executrix acting under this Will shall be required to enter bond in any jurisdiction. IN WITNESS WHERE , I ha hereunto set my hand this ~_ day of , 2005. ~ ~ ro o~ o n ^^ BB~ ~~ ~4~0 Beverly Sam le ~' 7 ~ ~ ~ O~O~OO ~r~~ ''d N C-" y O C/~ Q `t7 The preceding instrument consisting of this and one other page was on the day and date hereof signed, published and declared by Beverly Sample as and for his last Will in the presence of us, who at his request, in his presence and in the presence of each other have subscribed our names as witnesses hereto. LAW OFFICES OF STEPHEN J. HOGG I9 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 ITNESS WITNESS ACKNOWLEDGMENT State of Pennsylvania County of Cumberland ss I, Beverly Sample, 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; that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Beverly S ple Sworn to or affirmed a d acknowle/dg~~,i before a by Beverly Sample the testator, this day of fit' , NoTARU-L sEAI --- Gj STEPHEN J. NOGG, NOTARY PU®LiG CARLISLE BORO, CUMBERLAND CO.: i~A INY COMMIS810N EXPIRES SEPTEMBER 3, zoos Notary Public/, State of Pennsylvania AFFIDAVIT ss County of Cu berlan II ~ . We and h1 Sc~ ~ ~) ~ rZ.,the witnesses ose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the testator sign and execute the instrument as his last Will; that the testator signed willingly and 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 Will as a witness; and that to the best of our knowledge the testator was at that time 18 or more years of age, of sound mind and under no constraint r due influence. ~~ 5~ ~ /S~LI~S~~ S ~~ ~~ Sw rn to or affir ed and su this day of bed to before me by witnesses, ~ i _ 2005. LAW OFFICES OF v STEPHEN J. HOGG STEPHEN ~ ~ Y~B~ to Public/ 19 S. HANOVER STREET CARLISLE BORO, CUMBERLAND CO.. PA SUITE 101 MY COMMISSION EXPIRES SEPTEMBER 3, 2005 CARLISLE, PA 17013 CODICIL OF BEVERLY SAMPLE I, BEVERLY SAMPLE, of Camp Hill, Cumberland County, Pennsylvania, declare this to a Codicil to my Last Will and Testament dated March 31, 2005. FIRST: I revoke Paragraph 3 of my Last Will and Testament aforesaid, and in lieu thereof, substitute the following Paragraph 3: " 3. I direct that my entire estate be distributed as follows: A. I give and bequeath any automobile that I own at the time of my death to my sister-in-law, JANIE A. JACKSON, if she survives me. I direct that all of the rest, residue and remainder of my estate be distributed equally among my grandson, BENJAMIN JACKSON III, my niece, DIANE NAPIER, my niece, BERNICE CHILDER, my niece, LUCY MAE JONES, and my sister-in-law, JANIE A. JACKSON. B. Should any of the above-mentioned predecease me, their share shall lapse and be divided equally among survivors." SECOND: In all other respects, I ratify and confirm my Last Will and Testament dated March 31, 2005. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~~day Beverly Sample of _ , 2008. `! ~ J/~(,~'/~`'~~~j~,-J~y)~ .~ /' '~ 1 R C (Seal) Signed, sealed, published and declared by the above-named Beverly Sample, as and for a Codicil to his Last Will and Testament, in the presence of us, who, at his request, in his presence, and in the presence of each other, have hereunto subscribed our names as witnesses. ~~ Address ~~ Address ~ n 0 ~~ ~°0~0 ~~r~~~ 7~~~7yCJ bOO~00 n o~ ,.C~, ~ 0~0 Commonwealth of Pennsylvania County of Dauphin Wei Beverly Sample and Debbi Sue Middaugh Jean D. Seibert, the Testator 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 Testator signed and executed the instrument as a Codicil to his Last Will and Testament and that he ha.d signed willingly (or willingly directed another to sign for him), and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Codicil to the Will as witness and that to the best of his or her knowledge the Testator was at that time eighteen (18) years of~ age or older, of sound mind and under no constraint or undue influence. SS X Testator Subscribed, sworn to and acknowled~ before me by Beverly sample , the Testator, and subscribed and sworn to before me by Jean D. Seibert and Debbi Sue Middaugh , W1trieSSeS, this end- day of , 2008. Notary Public ~,QPv1CvfQFv`tiVEl+LTP~i7t ~~!`•~Fa~,.'°,_d°~,€",;;s+ ti___~. H-__ .k E ,, C: +'ri?;;~'"I. p, CiGJ~ n1f1 ~OUilfjl