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Home My WebLink About04-23-09PETITION FOR PROBATE AND GRAFT OF LETTERS REGISTER OF WILLS OF ~u,~~.~,~~ COLT~tTY, PEi~,~iSYL~'ANIA Estate of ~~~ \) ~(f ~ ,~ ~~~ also known as' Petiitioner(s), who is/are 18 years of age or older, apply(ies) for: (CO;YIPLETE A' or 'B' BELOW':) Deceased File Number ~ ~ \ 0~"1~ Social Security Number ~ ' ~~ P~fi~,.~ A. Probate and Grant of Letters Testamentar and aver that Petitioner(s) is /are the L~ V I ~ named in the last. Will of the Decedent dated "~ and codicil(s) dated (State relevant circumstances, e.g., renunciation, death ojesecutor, etc.) Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after executio~-e~f the inshum~s) offered for probate, was not the victim of a killing and was never adjudicated an incapacitated person:~= C7 ``~ _r~_l7 _{~ ^ B. Grant of Letters of Administration (Ijapplicable, eiuen• e.t.a.,,d.b.n.c.t.a.; pendentelite; durance absentia; Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the Administration, c. r. a. or d.b.n.c.r.a., enter date of Will in Section A above and complete list of heirs.) nte'rir/rtAritare) i r' - J ~',i ~ ;j~'`trse (tf any~Ctd heirs: (!f ~~ . -~-t ~ . (COiYIPLETE IN ALL CASES:) Attac~/h^ additJtional sheets if necessary. ~/ Decedent was domiciled t death itt,j,,'yit~'Ic-_~(~f-~ Count ,Pennsylvania with his /her last principal re idence at Q c (ListsU•eet address, town/city, township, county, state, zip code) ``,, n,/1 I~~ ~ Decedent, then years of age, died on - ~ at ~! ~ ~ 1'7~ y ~~/° J~ '~~ !Z'~~5~~ Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ . ~~ ('~pC~ (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania ~^~ e..~ $~~~ situated as follows: l~Ue.t~t,~iv13~_f'~~ ~ ~~'~ 1 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: 7 ~~ l 7~,~ ~ar~n,eyv-o? re~< 10.13.06 Page 1 of 2 Oath of Personal Representative C0~IMONWEALTH OF PENNSYLVANIA SS COUNTY OF ~,~~ ~~ The Petitioner{s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are trtie and con~ect to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) ofthe Decedent, Petitioner(s) will well and truly administer the estate according to Iaw. ~` Sworn to or affirmed and subscribed before me the ~_~dQa~y~yof For the Register File Number: Si anu•eojPersonnlRepresentativ r-.a n `~ :- r-~ n ; ; Signature ojPersonal Representative ~' ' ' -~ C_' ~7 -' ;T7 tV - Signature ojPersonal Representative - `~~ -~~` - -.. - ~ _y p - d 1 0 ~t tl3q ~ ~s ~ Esiate of de? ~ ~ ~~Q ~,` ~-1 ,Deceased Social Sec ity Number: ~ ~ 1 ~.Q ~~~~ Date of Death: ~s.Y~~ y ~W~ AND NOW, ~ ~`l , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters 1 r~C ~ ~'l.t are hereby granted to ~ ~C ~ ~~2_~~ ~s ~ Y' _ __ __ _ in the above estate and that the instrument(s) dated Y~c _ ~J~r ~<%_-R-~ a ~ ) ~C described in the Petition be admitted to probate and filed of recorder the lasj Will FEES c~,1~L/ C/,~t ~ Letters ..... ~ a ~ U ~ $ ~~ Short Certificate(s) ..`.~ ... . $ ~ (p Attorney Signature: Renunc ation(s) ......... i I I .. . $ _ $ ;~ Attorney Name: ~ (. ~ • • • $ l y Supreme Court LD. No _ ~~ .. . $ s $ Address: .. . $ .. . $ . .. $ - • • • $ Telephone: . .. $ TOTAL ............ .. $ I x ~ cil(s)} I'unn RW-0_' rev. 10.1.0( PdgS ~ Of 2 IOS 50~ RI~.~ rn1/n?l LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, S(i.O0 P 150~i87~ Certification Number This is to certify that the information here given is correctly copied fro!n an original Certificate of Death duly filed with me a~~ Local Registrar- The original certificate will he t<Trvvarded to the State l'ital Records Of-flee for permanelat filing. JA~III 0 8 09 ~'ZIZI2e~ii~rar~~~' ~^~-~. Date Issued ( C7 /~• `-~'" ~~ ~ ^° ~ - i -O ~" "S3 _i_ ~ r- ~ ' -, ( ,.. ,..-. _~_, >>~.. W _,I ~ 1, .., t ~'~, ~ ~.-~ . r . . ~- ~ ~;r y t ~ ~ ~...f ` V T - _~ ~ + y ~ REV 11/2006 COMMONWEALTH OF PENNSYLYANlA • DEPARTMENT OF HEALTH • VITAL RECORDS ' PRIM IN •rANENT CERTIFICATE OF DEATH CK INK (See Instructions and examples on reverse] ~^1 1 ~ STATE FILE NUMBER ~l ` ~ r~ ~ .. ^i~/1 - t 1. Name of Decedent (First midtlle, IasL suffix) 2. Sex 3. Sceial Sacunry Number 4. Date of Deam (Month, day, year) Bett S~lell J y . y - _ January 4,2009 5. Age (Last Binnday) Under t year Under 1 say 6. Date of Binh (Momh, day, year) 7. &nhplace (City and state or foreign country) Ba. Place of Deam (Check onry one) Matins Days Hours Alinules Hospital: Omer 82 8/8/1926 Harrisburg Vrs. ~ Inpatient ^ ER / Oufpeuent ^ DOA ^ Nursing Home ^ Residence ^Other ~ Speciry-. eb. County of Deam &. City, Boro, Twp. of Death Bd. Facility Name (If rrol irlslnulion, gNe street antl number} 9. Was Decedent of Hispanic Ongtn7 ~] No ^Ves 1 D. Racer American Indian, Black, White, etc. Cumberland Ca Hill mP Hol S iris Hos ital (If Yes, speciry Cuban, i y p p M P n Ri ISPaciM ex can, ue can, etc.) o W t I l t2 it. Decedent's Usuet Lion Kind of work done tlu ~ most N nrorkin life. Do rot state retlred 12. Was Decedent ever in Me 13. Decedent's Education (Specify onty highest grade completed) 14. Mental Status: Marred, Never Married, 15. Surirving Spouse (II wife, give maiden name) Kerb of Work Kind of Business I IMustry U.S. Armed Forces? Elementary / Secrondary (0.12) Collage (1-4 or 5+) Wbowetl. av~ (~r~ Meter Maid Cit of Harrisbu ^Yes pNO 12 Widowed 16. Decedents Mailing Atldmss (Street, cal' /town, stale, zip code) Cn Decedent's PA Did Decedent 17050 Actual Residence t7a. Slate Live in a 17c. ^Yes, Decedent Lived in Twp. • 51 Lon ood Drive Mechanicsbur PA y g y ,7b.c°unry Cumberland r°w"a"'p? 17d.[~NO,DecedenlLivedwithin Mechanicsbur g Actual Umns of Clry /Born 18. Father % Name (FrsL middle, last, suffix) 19. Momer's Name (Rrsi midde, maiden surname) Walter Balsbau h Rosa ntz 20a. Inlamant's Name (Type / Print) 20b. InfarmanYS Melling Address (Street, city /town, spte, zip code) Bruce W. Shell Jr. 51 Lon wood Drive Mechanicsbur PA 17050 21 a. Method of Disposition j ^ Crematon ^ Donation 21b. Date of Disposition (Month, day, year) 21c. Place of Disposition (Name of cemetery, crematory a other pace) 21 d. Location (City I town. state, ip cotlel [~ Bunai ^ Removal from Slate j Wae Gelnatbn or DOnadon Autnonnd 1/10/2009 Woodlawn Memorial Gardens Harrisbur PA ^Ye ~ ^ gher - S ~ e by Med(eaf Examiner /Coroner? g, re Funerel (or person eaing such) 226. License Nwnber 22c. Name and Address of Fagliry - - FD013945L Neum er Funeral Home Inc. 1334 N. 2nd St. Harrisbur PA 17102 Complete Items 23a-c ody when rtifyn'ng 23a. To ~ my krrowkdge, tleath rncurred at the INrle, date and place sealed. ]Signature and tore) 23b. License Number 23c. Date Signed (Month, day, year) physkian N not available al time of deem to rurtdy cause d deem. Hems 2a-26 must be corrpleten Dy Parson 24. Time of Death / ~ 25. Date Pronunced Deatl (Honor, day, year) 26. Was Case Referred ro Medical Examiner I Cararar for a Reason Other ehan Cremation or Donation? who pronounces deem. ` ' ,~ M. ^Yes ^ No CAUSE OF DEATH (Sae InaWetions and examples) r Approximate interval: Pan II: Enter Diner 51®~dlCem card'mons centnbetirw to deem, 20. Did Tobacco Use Conmbute to Deam> Nem 27. Pan I: Enter the gpgyl of eveMS -diseases, irquries, or Cmtplkalbrls -that diredN caused the deem. DO NOT enter terminal events such as cardiac artes4 r Onset to Deam but not resunug b the undertying cause gNen in Part I. ^Yes ^ Probably respmtory anesL or venlnalar fibngation wntaul stewing the etidogy. List Doty one cause on each line. ~ i ^ ~ ,-, , / L~JJ~~r~m IMMEDIATE CAUSE /Final disease a condition resullbg In deem) ~~ a. S ` ~ 3 i S r r 29. n~.F,ema/Ie' ' Due to for as a consequence ot): r Not pregnant within past year Sequentially list carbAiom, n arty, b. n`„\ rvx...~, e'1~ ~,, (~ j r i h i i r ^ Pregnant at tlme of death e cause l sted on l lead rg to t ne a. Due to or as a cron ue Enter the UNDERLYMG CAUSE ( ~ ~Ce °~~ r ^ N°I pregnam, ba pregnant within 42 Days (dsease a "vgury /hat initiated the °. ~~,,/ n~ F'Ar~. vCC i events resunrng in deem) LAST - of death Due to (or es a cronsaquence or•: ^ Nol pregnant Dut pregnant 43 days l0 7 year d. 1 balsa tlaath ^ Unknown it pregnant wihin me past year 30a. Was an Autopsy 30D. Were ANOpsy Findings 31. Man of Deam 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occurted 32c. Place of Injury: Home, Fann, Slree6 Factory, Performed? Available Prior to Completion NaNral ^ Hanicbe Office Bdlding, etc (Sp,sayJ of Cause d Death? ^ Ves No ^Yes ^'~ ^ Acodenl ^ Pondng Imestigetbn 32d. Time d Injury 32e. Injury at Work? 321. If Transponation InjuN (Spe°iNl 32g. Location of Injury (Bereee, oily /town, state) ^ Suicide ^ Cab Not be Dmemtined ^Yes ^ No ^ Diner I Operate ^ Passenger ^P M gher ~ Specify: 33a. Canilier (check Dory era) 336. Signature and TAIe of Ce r • CerlHyfrg physcian (Physician tarehying cause of death when another physician has pronounced death and completed Hem 231 ~A}~~ - (' G To tM beat of my krrowkdge, deem acurred due to the cause(s) end manner m stated_ _ ,. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ /ru 2 w- • Pronouncirg orb cenitying physklnn (Physican boor pronouncing deem and certifying M cause of deem) l h d d ^ 33c. License Number 330. Dale Sigrred (Manor. tlay, year) i. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ace, orb due to t e cause(s) an manner as sute To the beat of my anowkdge, death occurred at the time, date, and p `<~ f a 3 y ~ lJ J / ~ /OL, • Med(ul Exemimr lCarorror On the Deals of examinetbn and I a inveaUgatlon, in my opinion, death occurred a1 the time, dale, erb place, end due to the cause(s) end manner as aleted_ ^ 34 Norma and Adtlmss of Person Woo Completed Cause of Deam (Item 27) Type I Print A ~~ E ' ' tfikl.a..r 72 v I . Cyco• ~ s Sigrtaki aM D tna N ~ /~ ~ 36. Regislrer nLt~ c' - ~~ I ~ I I I I 36. Dort Filed~yroo~h, Y, l~~~j' /~ / 4 ,~ `i ~ !'L NL Cr{u2 i { 2e A7 ' - - ,:: ~- o ~n i~tll p + f7ur1 _. __.,_____..,_ 0308944 ~~~~ ~i11 ttn~ C~1P of BETTY JANE SHELLY r~~ <-~ c-"~ - "-t "t 7 ; } ~ ~.;~ ~~~mPn~ F ~..~ w.: G~ _-~ ~; ~A. __.. _; ` _r , --- f _~ r> <C"' G'i3 I, BETTY JANE SHELLY, of Hampden Township, Cumberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. ITEM I: I devise and bequeath all of my estate of every nature and wherever situate to my husband, Bruce W. Shelly, providing he shall survive me by thirty days. ITEM II: Should my husband, Bruce W. Shelly, predecease me or die on or before the thirtieth day following my death, I devise and bequeath all of my estate of every nature and wherever situate to my son, Bruce W. Shelly, Jr., if he is living on the thirty-first day following my death; and should my husband, Bruce W. Shelly, not be living on the thirtieth day following my death and should my son, Bruce W. Shelly, Jr., not be living on the thirty- first day following my death, I devise and bequeath all of my estate of every nature and wherever situate as follows: A. Twenty-five percent thereof to my daughter-in-law, Gwendolyn J. Shelly, if she is living on the thirty-first day following my death; and if she is not living on the thirty-first day following my death, her share shall be added to the shares for the other named persons in this ITEM II. B. Twenty-five percent thereof to my granddaughter, Cheri A. Shelly, if she is living on the thirty-first day following my death; and if she is not living on the thirty-first day following my death, her share shall be added to the shares for the other named persons in this ITEM II. C. Twenty-five percent thereof to my grandson, Brian S. Shelly, if he is living on the thirty-first day following my death; and if he is not living on the thirty-first day following my death, his share shall be added to the shares for the other named persons in this ITEM TI. D. Twenty-five percent thereof to my grandson, Todd E. Shelly, if he is living on the thirty-first day following my death; and if he is not hiving on the thirty-first day following my death, his share shall be added to the shares for the other named persons in this TTEM II. ITEM III: I direct that aI1 taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. ITEM IV: I appoint my husband, Bruce W. Shelly, executor of this my last will. Should my husband, Bruce W. Shelly, fail to qualify or cease to act as executor, I appoint my son, Bruce W. Shelly, Jr., executor of this my last will. Should both my husband, Bruce W. Shelly, and my son, Bruce W. Shelly, Jr., fail to qualify or cease to act as executor, I then appoint my daughter- in-law, Gwendolyn J. Shelly, executrix of this my last will. ITEM V: I direct that my executor or his successors, shall not be required to give bond for the faithful performance of their duties in any jurisdiction. ..----~~ IN WITNESS WHEREOF, I have hereunto set my hand this p~ ~ ___, day of '~'`~r / 1989. ~,~ ' n ~ e y e y The preceding instrument, consisting of this and one other typewritten page identified by the signature of the testatrix, $etty Jane Shelly, was on the day and date thereof signed, published and declared by Betty Jane Shelly, the testatrix therein named, as and for her Iast will, in the presence of us, who, at her request, in her presence, and in the presence of each other, have subscribed our names as witnesses hereto. • ~" E:S 2, r OATH OF NON-SUBSCRIBING WITNESS(ES) RE STER OF WILLS COUNTY, PENNSYLVANIA Estate of oil ~3°•a Deceased ~' !„~ , ~~ ~ ~~-~ ~ and ~ ~ /~' ,~~ ~- , (each) being duly qualified according to law, dep/o~se(s)`a/nd say(s) that she / he /they was /were well- acquainted with ~~~ ~~ ~ ` _ ~T~~// ~ and am/are familiar with the handwriting and signature of the decedent, and that the signature of to the foregoing instrument purporting to be the Last Will and Testament/Codicil of is in his/her own proper handwriting. (City, State, Zip) ~ Executed in Register's Office Sworn to or affirmed and subscribed before me this a~ day of rt ,~. ~, nature) (Street Address) ~3uiCS/.~G~G /~ ~ 7asZ1 ~j~~~ ~ City. State, Zip) r~_ (("'''~~ ~za iJ - ~, ~~ ~~_ ~; -„ .. ~t.J ~~ ., :i Y~ ~~, _~. \C.J x~ rv ~~ ~~Y. Form RW-04 rev. 10.13.Oh