HomeMy WebLinkAbout04-21-09PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA
Estate of Janet M. Ferguson File Number 21-- ~ - Q3~;1~,
also known as
,Deceased Social Security Number 169-38-5455
Cheryl L. Zygmunt
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or `8' BELOW.)
A. Probate and Grant of Letters Testamentaryand aver that Petitioner(s) is/are the named in the
last Will of the Decedent, dated and codicil(s) dated
State relevant circumstances, e. g., renunciation, deafh 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:
~X B. Grant of Letters of Administration
app Ica e, en er c..a.; ..n.c..a.; pe en e I e; uran e a sen la; uran a moron a e
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
Administratlon, c. t. a. or d. b. n. c. t. a., enter date of Will in Section A above and complete list of heirs.)
Suppress heirs for Section "B" (Grant/
Name Relationship Residence
Cheryl L. Zygmunt Daughter 1104 Heather Drive n
Chambersburg, PA 1J ~°
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(COMPLETE IN ALL CASES:) Attach additional sheets if necessary. ~ ==
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Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal re~irJer~ice at = ,
Shippensburg Health Care Center, 121 Walnut Bottom Road, Shippensburg, Shippensburg Towns~p
(List street address, town/city, township, counfy, state, zip code)
Decedent, then 87 years of age, died on 03/02/2009
Shippensburg Health Care Center, 121 Walnut Bottom Road,
at Shippensburg, Shippensburg Townshp, Cumberland County, PA
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 follows:
0.00
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:
Signature Typed or printed name and residence
Cheryl L. Zygmunt 1104 Heather Drive
~C ~ ~~ ~ ,~ .~ _~ Chambersburg, PA 17202
Form
ISCV. IV-IJ-LVVO
Copyright (c) 2006 form software only The Lackner Group, Inc.
Page 1 of 2
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Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA } SS
COUNTY OF Cumberland }
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 ~ ~,i~~G ~ il!i'~L-~~
S~ Signature ofPerso Representative ryl L. Zygmunt
before me this °~ ~ day of ~~
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~Ct'"G Signature of Personal Representative " _~_
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For the Register Signature of Personal Representative _ ,`j ~_~' -p -
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File Number: 21-- C~ _ ~~
Estate of Janet M. Ferguson ,Deceased
Social Security Number: 169-38-5455 G~Date of Death: 03/02/2009
AND NOW, ~~ , o?vc~ / , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters of Administration
are hereby granted to Cheryl L. Zygmunt
in the above estate
and that the instrument(s) dated
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
FEES 19.7 (J r
Letters ...................................... .... $ 2C~ , r.>Z:
\~/~, ~ t
Short Certificate(s) .................... .... $ L-~ , ~~~
!
Renunciation(s) ........................ ..... $ Attorney Signature: J
~~ $ ~~ , (~ Attorney Name:
~~'ti MA~'t s~C~ $ J : ~~
Supreme Court I.D. No.:
$
$ Address:
$
$
$ Telephone:
$
$
TOTAL ............................... ... $ '~ l ~ CS~
a, r~i~
A. Weiale Esauire
01624 ~/
Weigle 8~ Associates, P.C.
126 East King Street
Shippensburg, PA 17257
717/532-7388
Form RW-02 Rev. 10-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc. Page 2 of 2
OCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~ Fec lul thi•~ ~crtiticate, tiff.OO
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(~~~rtif~a(tion Numhcl~~
' This i, to certify that the information here given i,s
cl)rrectly ropicd from an original Certificate of Death
duly filed with me as Loral Registrar. The original
certificate will he Forwarded to the State Vital
Kecords C)Ifice 1cn~ permanent filing.
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Lot egisU-ar nor Dale Issued
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS `~ -'-~ .. '
CERTIFICATE OF DEATH ~' W
(See instructions end examples on reverse) STATE FILE NUMBER CT
t. Name of Decetlem (First, mitltlle, last, su6ix) 2. Sex 3. Social Seauay Number /. Dale of Death (Hoorn, da , ear
~
3
Janet M. Ferguson female 169 - 38 - March 2, ~~0
5. Age (Lest &nhdey) Under 1 year Under 1 day 6. Date of Bidn (Month, day, year) 7. &dhplace (City and rook or law n country) 6e. Place of Dewh (Check awy me)
Mmau Usya !burs MMea Hospael: Other:
87 Yra. 01-29-1922 Yellow Creek, PA. ^Irrpatrem ^ER/Oulpeliem ^DOA urskg Home ^Residence ^Olher~Spedly:
6b. Canty of Death &. Cdy, Boro, Twp. w Daeth /b. Faakty Name (II not klwawa,, gNe Mlew arM number) 9. Was Decetlenl of Hispanic Orin? [~ No ^ Yes 10. Race: American Intlien, 81ecte, WTae, etc.
(If yes, spedN Cuban, (Spedly)
Cumberland Shippensburg Twp. Shippensburg Health Care Center Hexican,PUenoRican,eta) white
11. DxetlenPS Usual Oau Lion Kind p wofx d one tl unn most of waNi kle. Do nw state rwiretl 12. Waz Decetlenr ever n the 13. Decetlem's Etlucakan (SpeciN aN nighesl gratle canp leredJ 14. Martial SlBlus: Martred, Never MameQ 15. Surviving Spo use (If wife, gNe maiden name)
Kmd w Work KiM w &uiness /Industry U.S. Armed Fomes? Elementary /Secondary (0-12) CWlege (1-0 a 5.j Wed' Divorced (SOeCiyl'I
Mena er Clothin Manuf. ^rea C~Nn 12 Widowed
16. Decedent's Meiling Adtlress (Street, oily /tam, Slate, zip code) Decedent's DM oewdea
PA U'e m a 17
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121 Walnut Bottom Road ~
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DeradamL;,edwmrin
Cumberland T°t"~b~D? 17e ^ Ne
Shi ensbur PA 17257 ,
17b'D°a'ry Aaaaltinltsa cdy/Bom
13. Father's Nanre (Fear, mitldk, lazt, sWlix) 19. MoNer's Name (First, mitltlle, maitlen sumeme)
Abraham Hoover Eva Hale
20a. IMOrmanr's Name (Type ! Pdnl) 20b. IMartunl's ktwlvg Adtlress (Straw, ary / bwn, stale, zp code)
Cher 1 Z munt
21 a. Method of Disposaia ~ I -Lrremation ^ Doration 21 b, Date d D'spositlon (HaiM, daY, Year) 21c. Place a gspcsilan (Name a cemetery, cremalay a other place) 21 d. Locarbn (Ctly /corm, state, zip cotle)
^ .u~C/O RemaallranSata !Dae~Ca3L,~„E:r~iD°ic°"«o~°i~°""d~vaa^Ntr 3/3/2009 Thomas L. Geisel Crematorium Chambersbur PA 17202
Iu f nice Liceruee (a person acting az auto) 22b. License Number 22c. Nacre antl Address w Faciltly
FD-013391-L Thomas L. Geisel Funeral Home, Falling Spring Rd., Chambersburg,PA
omplwe Items 23ac asy wM diNing 23a. To the best knowledge, deaM oceurretl w the line, m and place sorted. (Sgnelure antl tick) 23b. license Number Signed (Month, dsy, year)
23c
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skdan N trot avaikde at tine a tleath to n
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Items 24-26 must a mmpkletl by person 24. Time of Dewh 25. Dare Pronanced Dead (Month, day, r) 26. Wes Case Rekrretl to Medical Examiner /Crooner 1w a Reason Other than Creme' nor Donation?
w1ro pmrpunces death. O M. ^ Yes
CAUSE OF DEATH (See Instructions an0 examples) r Approximate interval: Pan IL Enter aher 5iallxaw coMaions conhiakne b tlealA, 26. Dq Tobacco l/se Gontdbwe to Death?
hem 27. Pan I: Emer the cha n a events - tlaeases, njurlea, or complications -deal directly ceusetl the dawn. DO N07 emer Iemunal evems such as cerdkc enesl, r prow to Death at rro1 resulting in IM uakrying reuse given in Pad L ^ Yes ^ PrcbaNy
respiratory arrest, a venlriwlar fibrdlalron wlthan stwwing the wbbgy. Lkt onN aN CalRe on each lute. ~
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^ No ^ Unknown
IMMEDIATE CAUSE IFinal diseahe or //~~
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crodawn resulting m death) _~ a, ~ ~~ N Lo ~, S '~~ ~/` ! ! `' / 1 ~ ~ ~~~/ JC.(,{/Tf/ 29. N Female:
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Due to (or as a consequen
ce tol):
~ Not pregnant w4Nn past year
^ Pregrant al time of death
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SequenliaW list contlAions, a any, b. ~~.~~ ~ / Ir p~y K~
leadengg to thhe cause IisIN a Ilne a. Due (or as a taus uence of r r
EnrerIM UNDERLYING CAUSE q )' r ^ Na pregrenl, WI pregrrenr wkNn 42 tlays
(dsease a injury that iwlieted the c. ~ 'S ~ ~ r
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evenu resultin
in tleaN) LAST ddeath
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Due to or az e cwuequenCE oq: - Na rant, bM Pr nr 4
^ Dm9 agna 3 days Io 1 year
d •~ I belroe death
^ Unknown k pregnam wahin the pall year
30a. Was an ANOpsy 30b. Were Autopsy Findings 31. Manner M Death 32a. Date a Irqury (Month, tlay, year) 32b. Describe How Iryury Occurted 32c. Place of Injury: Horne, Farm, SIree6 Factory,
Pedomred? Avaiade Prbr to Completion
atural ^ Haniatle Oaice Building, etc. (Specityl
a Cause w Deelh?
^ Yes ~ ^ Yes ^ No ^ Aa:reenl ^ PerMing Imewigarbn 32d. Time al Injury 32e. Injury at WwN+ 321. II Trenspenaf Injury (Specxy) 32g. Location of Irryury (Sheer, city! town, stale)
^ Suidde ^ Cold Na be Determined ^ Yes ^ No ^ DMer! Operate ^ Passenger ^Pedestnan
M ^Other ~ Specity:
33e. Cenilia (check only ore) 33b. Sigrulure and Tale w GenMkr /
• CMHying phystclen (Physician cenilying Cause of death when anaher pltysiaan nos pronarxetl death and cornpleled Item 23) ~~g
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To the beat w my knowledge, 0eeth occurretl tlue to the cause(s) antl manner as ataled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~
• Pronouncing antl certxying phyaklan (Physician both pronounckg death as cenilying to cause of death)
To the best w my knoMetlge, dewh ottunetl a1 the Ilme, date, and place, antl tlue to the cause(s) end manner as staletl_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. Lbeaze NurMer 33d. Dale Signetl (MOrr41, tlay, year)
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Metliral Examiner/Coroner
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On the beefs of ez ion S / or investigation, ire my opinion, death occurred et the time, dale, and place, end due to the rausge) end manner as slwetl_ ^
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34. Name antl Addr^eslIsol Person Wlro Canpleeled Causp.~1 D~ejat
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