HomeMy WebLinkAbout04-17-09PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF C'v rn ~ e~'1 ~r ~ c~ COUNTY, PENNSYLVANIA
Fstateof P~t~ / ~ec~t~: r~ !7~/C!.S~C`1~
also known as
Deceased
File Number ~, ~ ~ LTV ~~
Social Security Number ~d ~ O` ~ / d~
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 ('I~, - ~ Xe~r ~J ~°~-`~ named in the
last Will of the Decedent dated /0~3 ~aOU ,f^ 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 aver execution of the instrument(s) offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
^ B. Grant of Letters of Administration ~
(If applicable, enter: c.t.a.; d.b.n.c.t.a.; penderaelite; duranteabsenta; dura6rTe~ r~ir ornate) *~ -. --
~„ ~~- ~.
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Petitioner(s) after a proper seazch has /have ascertained that Decedent left no Will and was survived by the following spotts~(~uty) a~jltetrs ~!~
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Administration, c. t. a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) - :~ ;-~-; ~;- : '.-.
D
Name Relationshi Residedce - c..
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C71
(COMPLETE W ALL CASES:) Attach addtional sheets if necessary.
Decedent was domiciled at death in Cum ~~ ~ jPa ~ County, Pennsylvania with his !her last principal residence at oZ ~ ~ U
/f~orj~ ~osCr~o.-cue-+ if/v~~ /Y/echvnlcs br^~ y e~ A-/ltn 7b+o /,." ~ (i,,,,b ~1 a~.a ~ .iO,4, /9c.~S~
(List street address, to n/ci[y, township, county, state, zip code)
Decedent, then 7 f years of age, died on ~ / ~ ~ ,L,~ tr ~! at I ~ ~~'~ s b 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 Pennsylvania
(If not domiciled in PA) Personal property in Caunty
Value of real estate in Pennsylvania
situated as follows:
$ a ~/ ao ~
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
name and residence
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Form KW-O2 rev. 10.13.06 Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
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 Imowledge and belief of Petitioner(s) and that, as personal represerrtative(s) of the Decedent, Petitioner(s) will well and truly
administer the estate acxording to law.
Sworn to or affirmed~ /and subscribed
before me the ~ 7 day of
r ~ ~-~~
or the Regime
sv
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aa.- rz-;: ~~
File Number: a ~ o~ o3t~~ ~ _ ~- ~ ~-~
~~ ~,
Estate of Pa.sv.\ '~,r_~,r~ N a~P ~ , Deceased
Social Security Number. Jl~ `~ ~~ ~ W~ Date of Death: Y"(.h d~,~ ,
v ,- -,
AND NOW, '~cl , in consideration of they foregoing Petition, satisfactc~proof ~ '
having been presented re me, T IS
are hereby grarrted,to
in the above estate
and that the instrument(s) dated U< .'~Ll~ ~( ~7 ~t U 1J !~
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
7~ FEES
Letters . °L. /:~~ .... $ lD~
Short t'.ertificate(s) . ~..... $ a O
Renunciation(s) .......... $
CJ ~ l~ .. $ IS
C ~ ... $ /U
... $ ~
$
...
$
...
$
...
$
...
... $
.. $
TOTAL .............. $ I10~` "°:°°r"'
Attorney Signature:
Attorney Name:
supreme court I.D. No.:
Address:
Telephone:
Form RW-o2 „~. ~o. 13.06 Page 2 of 2
xegister ojwitis
OCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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H106.1Y3 REV Il'2(IU6
TYPE ~ PRINT HJ
PERMANENT
BLACK INK
0
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH ^) + /~,~/^'I , ^
(See insVUd(ons and examples on reverse) STATE FILE NUMBER T \ V 1 ~~ ~L/~
1. Name d Decedent (first middle, Ms1, suffix) 2. Sex 3. Serial $ecwny Number 4. D/la,K j1ea~ ,Nana,. day,
D Y
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Paul R• Haverstock Male 204 - 28- 1006 D
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5. Aqe (tat &Mday) Under I e UrMer t der 6 Date d &M MmN, der , 7. a and clad «Nr e w«r 8a. P1xe d Death Check «Y oro
Monms Days Ixurs Mkwles ital:
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sp ONer.
71 Yr6 5 / 2 3 / 1 9 3 7 Camp H i 11, P A ~
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6dTnwuam ^ ER , a,tpatlent ^ DoA ^ Nursing Hans ^ ReSrdence ^ oa,er . spacYy
' 80. County of DeaN &. Gty, Bono, Twp. of DBaN ed. FaWiry Name Ill rat NsGtapn, give skeet end nunber) 9. Was Decadent d InSpank Orgn? ~ No ^ Ya5 10. Race: American (Man, Blxk, WNte Bk.
Dauphin
Harrisburg
Harrisburg Hospital (N yes, specify Cuban,
Maxran.PaenoRkan,akj ISpecy)
White
t 1 Decedents Usual Occu alron KNd d work done d arn most of wa Ida. Do not stile retired 12. Was Decedem ever N the 13. D adept's Education (Spe«ly onN Dighest grader cangl eted) 14. MarNd Status: Mauiad, Never Married. I5. Sunivkg Spa ce Id wrh, give magen name)
KiM of Wurk KiMd eusuressY lnarstry U.S. Armed Faces? Elementary /Secondary (D12) Cokege (1-4 a St) Witloaed, Divorced (Specrtyl
Prin in ^ Yes 9 Widowed
t6 Decedent's Maiknq Address (Skeet. city /town, slate, zip calel Decedent's Did DaCadanl
P@nn8VlVelli~ LMYanA
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2620 N. ROS arden Blvd
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ACtudMNdanc• Y7a 51au
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rsaD...an,Lwwln
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gland Towrlsflp7 t7a ^No
Deceaenl Liven mNln
ME:ChaR1CSbUr PA ,
Y7b. caamr -
Acweltmisd Y,aylBao
t8 FaNeis Name (First midme last sump I9 Molnar s Name (Post, middle, rudtlen sumemel
William Haverstock
20a. InfwmanYS Name (Type ! Prmry 20h. Inlormanfs Mdnng Atl(kess (Skad, cdy / rown, state, zp cadet
Linda Haverstock 124 Robson Rd. Dillsb PA 17019
21a Method of Disposition ^ Cremaudn ^ Donation Zlb Date oY Dispostan (Momh, Osy, year) 2)c. Place d Dispositon (Name d cemetery, crematory a other place) ltd. Lacalron (CIry r rown, stale, zp code)
^ Bund ^ Remdvanr«nslate ~wasaemationaDanaka,AaN«Ina ^
^ 4
0 lli ~+~rv,~, Hill PA 17011
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Yes
Other ~ ~i Ellt Yadkd ExamtnarlCoronarT 1
9 n Green i P rk
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~ 22a. Signaure F al s such) 22D. license Number 22c. Nana era Adaess d Fadkry Nei 11 tllneral Hone, Inc
- ~ Fp L 3401 Market St. Cam Hill PA 17071
Compla,e uem ~ c onty wlcen r'xtrldyirg 23a. Tome Dest of my knowledge, death occunetl al the acre, dais and placer stated (Signature arltl title) 23b. License Number 2x. Dale Syr>td ,MdnN day, year)
physician is avaiWble al lone d deaN to
cenily c of desN.
bans 2426 must ce cumpleletl by person 24. Tvne of Dea r
a 25 DaI/A anted Dead ,day, ear)
r D 26. Was Case Releired to d Examiner I Cororrer I« a Reason ONenNen Cremaum « Duelwr,?
^
who Prawwxes deaUr Y ~
A(. I Ya5
CAUSE OF DEATH (Sea Insfructbna erYd eaempleq t Approxpnale (mend: Pan II: Enter Oder siwy(ram corlalion•.LglylpWj¢gag,Ay7, 28. Dra TCbdC<o Use CamrbuM b Deam7
IWm 2] Pert I: Enter are sGdNS'1dYGdi a>ea5es. rnAares, ompkaliMS ~ Nat dkeclly caused tea deaN. DO NOT enter terminal evanls such as caraac arrest, Onset ro Death
r but rrq resuning m Ne untledymg CauSa given N Pan 1 ^ Yes ^ Pirbady
Showirlg Ne etiol
ogy Lisl ady one rouse on each line.
re5pualory anesl, or venku:ular 116rdleaon wnho I ^ fwr ^ Unkrrown
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IMMEDIATE LAUSE (Final asea5a err \ ~ PS l 29. II Femal6'.
J
WMIiM re5~dang n aNl _~ / )
e ^ NW
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Oue ro (or as a consequence op.
Se9uentialiYY Im casdn~als, n any,
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ey
^ wegnam err time of seam
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kadk a Ina se Acted tin line a
Enter p, UNDEALYW6 CAUSE Due to (a as a catsequerKe dl_ fk,l pregnant Dut Pregnant wvltwr 4L rArys
tit dean
laseax or ayury WI mewed Ne
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avenls rewllmg in demnl LAST.
Dun b (or es a consequerx:e oll. d preplaM, ow p+egram aJ days to 1 year
bekre tleaN
tl ^ Urdrewn n gayreM wNrb era pant
ear
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30a. Was an Autopsy 30b Were Awopsy FiMngs 3t Manner of Deem 32a. Data d Injury IMauh, day, year( 32b. DeurNe Fbw Irqury Occurred 32c. Pbce a kyury Mare Farm Skeet. Factory,
Penormed? gvailable Pna to Completion
d Cause of Deetn7 ~
~Naladl ^ Honnnde Ollx:e Bwldwg, etc (SY'sary)
~ ^ Acridam ^ Pandin
Inveatguuwl 32tl. Time d kyury 32e. Irytay at W«k1 321 q Trdrs{roMtion hywy ($perily) 329. La:dion of irywy (Skeet, wtY I broil, slalal .
^ Yes
JO ^ Yus ^ No y
^ No
^ V ^ Drwarl Operator ^ Passenger ^ Petleshwn
^ SuKnde ^ CauW Nd be Onmrmured M es ONer - Sreaty'
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33a CeNfrer (cYreck my ere) 3~5. Signalwe and Tine of Conifer ~
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• Cenlrying physldan lPnys'ican cenAyutg causedaaaN when anuNer DDYsken has pranwrxeU deuN aW Caryanle0 uam'231
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To Nor best of mY Wwkdgo, daaN acumd
• PronourKlnq aM cenlryMg phYalclen (PDYSinan b«n Drawwlrmg death arW ceniryky ro cause of deaN) ~ Liu ~ Nwroer
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~ 330. D Sipwd (Monty. day. Year)
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• Medical Examirw/Corona
On Ve baa4 0l uamination and I or inveatigalion, in my opinion, deaN occurred al tea tlme, data, and place, and dw Yo YM uwe(al eM manrlar as anted_ ^ 34. Yfa ~1 Addr /± led erase ap~aN (tan~~~~ qla ~ ~
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TH
V Disposition Permit No. D~~ O 7~z
LAST WILL AND TESTAMENT ~,
~:
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I, PAUL RICHARD HAVERSTOCK, of the Township of Upper ~kbi~, City -~::
~1l-.
_~ __
of Cumberland and Commonwealth of Pennsylvania, being of sounc~~nd disp~ing''
mind, memory and understanding, do make, publish and declare this as and for my
Last Will and Testament, hereby revoking and making void all former Wills and
Codici{s by me at any time heretofore made.
FIRST. I order and direct that all my just debts and funeral expenses be
~~;
paid by my Co-Executors, hereinafter named, as soon as conveniently may be
done after my decease.
SECOND. I give and bequeath any motor vehicle in my possession at the
time of my death, together with any existing insurance thereon, unto my daughter-
in-law, SUSAN HAVERSTOCK, absolutely, if she survives me.
THIRD. I order and direct that all the rest, residue and remainder of my
estate, real, personal and mixed, whatsoever and wheresoever situate, be divided
into four (4) equal shares. I give, devise and bequeath one (1) such equal share
unto each of my children, nar•!ely: SHIRLEY LOUISc 1~1ARTiN, LINDA SUE
HAVERSTOCK and DAVID SCOTT HAVERSTOCK, absolutely and in fee simple;
and I order and direct that the fourth (4th) such equal share shall be paid over and
distributed in equal shares unto my grandchildren who are living at the time of
~A~- ~>F~~~ts II distribution of my estate, per capita and not per stirpes, share and share alike,
MARLIN R. McCALEB
absolutely and in fee simple; provided, however, that if any such grandchild has
not attained the age of twenty-one (21) years at the time of distribution of my
estate, then I order and direct that the share provided herein for such grandchild
shall be paid over unto his or her parent or parents, as the case may be, as
Custodian or Custodians for said grandchild under the Pennsylvania Uniform
Transfer to Minors Act.
LASTLY. I nominate, constitute and appoint my children, namely, SHIRLEY
LOUiSE iViARTIN, LINDA SUE HAVERSTOCK and DAVID SCOTT HAVERS T OCK,
Co-Executors, of this, my Last Will and Testament, all to serve without bond in this
or any other jurisdiction.
IN WITNESS WHEREOF, I, PAUL RICHARD HAVERSTOCK, have hereunto
set my hand and seal, to this, my Last Will and Testament, which consists of three
(3) typewritten pages to each of which I have affixed my signature this ~_ day
of ~~. .~ , A.D., Two Thousand Eight (2008).
~`°{~~~ ~,~,,.-:~..%,.w:~ _t.c'.~.--zt.Y-'"~~>~ (SEAL)
The preceding instrument, consisting of this and two (2) other typewritten
pages, each identified by the signature of the Testator, was on the date thereof
signed, sealed, published and declared by PAUL RICHARD HAVERSTOCK, the
Testator therein named, as and for 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
AW ~~FF~~~_5
MARLIN R. McCALEB
-2-
subscribed our names as witnesses hereto.
~° ~'-G
...,
LAW OFFICES
MARLIN R. McCALFft
-3-