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HomeMy WebLinkAbout06-26-09PETITION FOR PROBATE) AN,/D GRANT OF LETTERS REGISTER OF WILLS OF t~-'1 ~ ~ 1C~~G'`' COUNTY, PENNSYLVANIA r /2Jt / ~ " /"_ File Number ~ ~ ~ ~l C, ~ C~ / Estate of /~ ~' ~ (~ ~i - /~ /: /'7 C . ~ - also known as ,Deceased Social Security Number .fit: °/ - c'.~ - '/C-~ ~ J- Petitioner(s), who is/are 18 years of age or older, apply(ies) for. (COMPLETE 'A' or 'B' BELOW.•) h'~I A. Probate and Grant of betters Testamentary and aver that Petitioner(s) is /are the c.Ji ~f~,,.' r!/i /"i f i~C • V S named in the last Will of the Decedent dated~t~r~ ' >, h~i~ ~: r i and codicil(s) dated (State relevant circumstances, e.g., renunciation, death of exeerdor, 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: ^ B. Grant of Letters of Admiristration (If applicable, enter: e.t.a.; d.b.n.e.t.a.; pendente lice; durante absentia; Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spot Administration, c. t.a or d b.n. c. t. a, enter date of Will in Section A above and complete list of heirs.) =-~ Name (COMPLETEINALL CASES:) Attach additional sheets if necessary. r7 ..o ' :~t an3'It~irs: (~' CT _ , r-~ Decedent was domiciled at death in ~,.,' ~~ f~ . _.l ~ .. rL. County, Pennsylvania with his.Eder-last principal residence at / ~ '~iC J - - - -L~ (List street address, tawn/city, township, county, state, zip code) Decedent, then % r` Years of age, died on r7 ~ it c ,lt.~ % - at t-~ [ ~ / r~ ~ 6 '-~: f ~~ ` ~ ~ >l C' C 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 properly in County Value of real estate in Pennsylvania ~ /!~ ~ n ~U situated as follows: Wherefore, Petilioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of Letters in die appropriate form to the undersigned: t< ~ ~{/1it /-~dy5 cCc~. C~-l.,n~~-t-~ 7~ ~~ ~-©x Chase ,ion e ~'/~r~ ~~~~-~,~ ~~t ~ ~ Page 1 of 2 Form RW-02 rev. 10.13.06 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA ~. SS COi.INTY OF I ,1z.YYl~?~~ ~G~1~ The Petitioner(s) above-named swear(s) or affum(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 ._~ day of Gtnc' ;~~ l ~~ .sa Signature of Personal Representative ;, z7 ~ ~ 1~ m l ' - .., _ ~" %`• For the Register Signature of Personal Representative ~. __, -, C~ ~. ~ :.~ ~ ~ '~ n.~ ~? e 0~ c~S `> 7 File Number: /}~ ~/' Estate of ~ C~US ~- ~C~`h~ ~ ' `~~~"Y , Deceased Social Security Number: ~O 7 C~ ~~ ~C(1 ~r~( Date of Death: ~ U ~ C ~ ~ / /~ i~' inconsideration of the foregoing Petition, satisfactory proof AND NOW, 2 ~9 ~ f1 Rz ~ 0 C~t./7~_->~> having been presented before me, IT IS D REE that Le ers ~~ are hereby granted to " q in the above estate .i that the mctnrment(sl dated ~~ ~ / ~ ~~ described in the Petition be admitted to probate and filed of FEES Letters ....~LD`~,.QUU $ ~(~~ Short Certificate(s) ...~..... $ ~' ~ Renunciation(s) .......... $ G(.~, l ~ ... $ l S ~ ... $ ~°~ J E:~ ti ~ .. $ ... $ ... $ ... $ .$ ... $ .. $ p~,~'--ems-. TOTAL .............. $-~-- Form RW-02 rev. 10.13.06 the Attorney Signature: Attorney Name: Supreme Court LD. No.: Address: Telephone: Codicil(s)) of Register Page 2 of 2 IU5.ri05 NE~~~OI: (1T LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate. X6.00 This is to certitr that the inforu~ation here ~~ivef~ i~ con-ectly copie' fron) an original Cerdfir(te of Death duly filed with nee as Local Re~~i,trar. The ori~ainal certificate will he for«~ardcd trr the State Vital Records Office Yfa~ permanent filsn;~. ~ ~y ~''~ ~~~~ ~ _~. Certification Number ~,~~ O`' JU~2~09 _ Local Reg(strar ,. Date issued ns ~? .,n _ ~ ~ `3 ~-°- ~~~ Q• "-~rC7 ~.-• ~ , ~' } ~'7'7 :~~ 3 REV 11/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS / PRINT IN CERTIFICATE OF DEATH RMANENT _!/y /J ~/ ~ r~~ ~] ACK INK (See instructions and examples on reverse) STATE FILE NUMBER iJ' ~ G~ ! ~' ~~ 'J t. Name of Decedent (First, middle, last. suNlx) 2. Sex 3. Social Secudry Number 4. Dylhl of Death (Month, day, yearl m advs H. Miller female 204 - 03 - 9632 L1 ~~ ~ 5. Age (Last Birthday) Under 1 ear Under 1 da 6. Oale of Birth Month, da , ear 7. Birth lace Ci and state or lorei n count aa. mace or ueam ~~ Hospital: Other: Months Days Mours Minutes July 26, 1912 Morris Run, PA ®Inpatlent ^ER/Outpatient ^DOA ^Nursin g Home ^Residence ^other Speciry. 96 YrS. h D Fatiliry Name (II not Instit ed ution, give street and number) n' 9. Was Decedent of Hispanic Origi + ®No ^Yes 10. Race: American Indian, Black, White, etc. 8b. Counry of Death eat &. C Bom, Tw f M~ P~ ° . (If yes, specify Cuban, (SpacrM Harrisburg Harrisburg Hospital Mexican,PuertbRicaPem.( white Dauphin M d i in S o 15 S ive maiden name) use Qf wile Do not state retired kl INe f Was Decedent ever in the 12 13. Decedent's Education (Spedly only hghesl grade oompleted) S ro'r )r 14. W d d~Di arrie , , g urv v g p . 11. Decedenrs Usual Oau aeon Hind of work done B . wor n urin most o . U.S. Armed Forces? econdary (0-12) Elementar College (1d or 5+) ( P ry vome iUOwe Kind of Work Kind el Business/Industry y ~ Widowed Reli ion ^ vea ®"° J, Secretor Did Deced em U r Allen 16. Decedent's Mailing Address (Street, ciryltown, wale, zip code) Decedents Penns lvania PPe Twp y Live in a 77c ®Yes, Decedent Lrvetl m Actual Residence 17a. Slate Township? 221 Messiah Circle Cumberland nd ^Np, Decedenumed wenm PA 17055 17b. GOUnry Actual Limas of _Crtyl Boro Mechanicsburg, 18. Earners Name (First, middle, last, suKx) 19. Mother's Name (First, middle, maiden surname) Edward Haglund Hilma Fransholm 20b. Informant's Mailing Address (Street, city I town, state, zip code) 20a. Intamant's Name (Type I Print) Jud A. Ha s 7994 Foxchase Lane, Glen Burnie, MD 210 1 Ih taco) 27tl L°gli0n (Gtyltown stale np codel tion n ^ D i t ^ 21 b. Dale of Disposition (Month, day, Yaar) 21 c Place of Disposawn (Name of cemetery, crematory or o er p o a on Cremation 21 a. Method of Disposit rtwval from State Wea Cremation or Donation Authorized l ^ R ® June 24, 2009 Rolling Green Cemetery Lower Allen Twp. ,PA 17011 e Buria i ' by Medical Exeminerl Coroner? ^ Yes^ No S ^ ec Other 22a. Signet of F eral Se Licens or non acting as sucn( 22b. License Number 22c. Name and Address el Facility Inc., P.O. Box 431, New Cumberland, PA 17070 themore FH & CS P , ar ~ FD 013 340 L 23b. License Number when certirying 2 To the best of my knowledge, death occurred al the tlme, date and place stated. (Signature and title) c onl i 23 23c. Date Signed (Month, day, year) y tems a- Complete physician is not available at time of death to certiry cause of death. to orwunced Dead (Monty, day, year) 26. Was Case Referred Im Medical Exami 25 ner I Coroner for a Reason Other than Cremation or Donation? . 24. Time of Death Items 24-26 must be completed by person / , ~ f~ M ) ~ // // ~ ^Ves ®Na T ,' c/ ~,/ ronounces death ho tn4 D . D w r Approximate Interval: Pad IC Enter other,~odfi r ndif s conMb Y l ea to d ath 28. Dld Tobacco Use Confrihute to es) CAUSE OF DEATH (See Instructlan and examp ^ Prbbabl Onset to Death but not resulting In the underlying cause given in Pad I. ^Ves y nts such as cardiac arrest i l , eve na Emer Ina rhain of events -diseases, injuries, or complications -mat directly caused ath. DO NOT enter term Pan I Item 27 , ^ No ^ Unknown . . respiratory arest, or venMalar fibrillation without showiry tie etiology. List Doty one ca se on eacn line. MMEDIATE CAUSE (Final disease or ~ /~ ~ ~ ~f '~ I' ~ytT" ~~ ~ 29. II Female: ith t ^ t ~ I t VD '~, de rontlaion resuting in ath) w in pas year Not pregnan _~ a r ^ Pregnant at time of deem Due to (or as a consequence op: , ^ Nat pregnant. nut pregnant within 42 days $Bpuentiallyy list ronditlons, if any, b. n leading t0 the f2ese 1151ed °n line a. Due to (or a a co segyence opp' r t l '„-, }~~~~ ~ ~}~ ~~7 ~>~ r Enter the UNDENLVING CAUSE ~ f; ~ ~ p1 dealn nant 43 days m t year re re nant but ^ N t ; ,t . +~ r (disease a Injury that initlated the c ~ s(, P ''v `~'U/t , p g g o p events resulting In death) LAST. Due to (or as a consequence o1). 1lK ~, f`~,l iti ~ { i.NLX-•• before death ^ Unknown If pregnant within the past year d. v i d Describe How Injury Occurred 32b 32c. Place of Injury Home, Farm Street, Factory. Was an ANOpsy 30 Were Autopsy Findings 30h 31. Manner of Death a ear 32a. Dale of In Monts, Jury ( Y. Y ) . OHlce Building, etc. (Spealy) a. Pedormed7 . Available Prior to Completion l ^ Homicide ®'N of Cause of Death? atura est' anon I tli ^ P ^ 32d. Tmte of Injury 32e. Injury at Work? 321 If Transportation Injury (SpecMyJ 32 . Location of 9 In u Street, ci /town, state) I ry ( N (~ ^ Ves Lry No ^ Ves ^ No nv an n Accident 9 N ^ Yes ^ No ^ Drwer/Operator ^ Passenger ^ Pedestrian ^ Suicide ^ Could Not be Determined M. ^ Other -Specify 33b. Sgnalure arts Title of Certifier f^ 1 r.~ f~.~ 33a. CenHler (check only one) • Certdying physician (Physician certifying cause of death when another physcian has pronanced death and completed (tam 23) ~ `-" - ^ - 7 To the best of my knowledge, death occumtldue to thecause(s)antl manner es atated-------------------------------- 33c.1' rise Number ~ end certNying physician (Physician both pronouncing death and certifying to cause of death) /` onouncin • P ^ to Signed (Month, day, year) {{ ~/ / / J(/) ~^} ' 7 ' g r and place, end due to the cause(s) and manner as stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ date th occurred et the tlme d (, ( / , , ea To the hest of my knowledge, • Medical Examiner/Coroner On the baste of examination and / or Investigation, in my opinion, death occurred at the tlme, date, and place, and due to the cause(s) and manner as state4 ^ 34rynNa/~m1e and Add of Who CgmWe1etl CA¢sa °t Oeat ~ ~ ~ 4'},Atr/ /y Vf x/h h Iltem 2 ype I y, /~ ~ /~ r 6'~ /~jc,r, G f / ~ •-" Y ~,....~ 36. Date iletl Moplh, day, year) ./r " 35. Registrar's Slgna a rid District Nu (// I I / I ~ I / I / / ~~ ~ /~`)~ ~ /,~/ ~ Tff /~~~ L~ /' ~ ~ ~ ~ ~ ~~ Disposition Permit No. 1,~r/.~ J~ '1 ~, L i ,a1 ~Jy i ~1i ~~tl4k ~1C~ii~1 ~tlt ~f `lt~ lt (~~ ~~ ' k ctl k '~ ~'~ . ~~ ~ :~_~ ~ : r ~, f~ _ - `r i \ 77 ± f ~ ~L....J~ _ ~ \_.- __ ~ J ~, ~_ ~_ rr. ~laclys Joarzne Miller ~ ~' 4,...~ ~~ ~_. t, Gl,ADYS J0r1NN[: 1l11LL1?R, of the town of Mechanicsburg, County of Cumberland, and Commonwealth of Pcm~sylvania, being of sound mind and memory, do make, publish and declare this t<~ be my Last Will and 'I'estan~ent in manner and form following, hereby revoking any Will or Wi11s heretolare made by me. W t ~~ ~ 1t5 1 [ direct that all my just debts, the expenses of my last illness and my tu~7eral expenses shall be paid ii-om the assets of my estate as soon as practicable after my decease. And I direct that all taxes that -nay be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, including interest and penalties thereon, if any, shall be paid from my residuary estate as apart of the expense of the administration of my estate. SL.COND I direct that certain of my tangible personal property be distributed in accordance with a written statement signed by me or in my handwriting which I may leave at my death. 1?,xcept as t may have provided in such statement, I decline to make any other specific bequests or devises iu this u:~w~izn-rit<,~a~~n.is c~.u;r~~rs ni~u~~-~,~~,~~,i ~~~~n n~~c my Last Will and direct instead that the balance of nay 'Cestaulentary )/state be distributed under the remai~~ing provisions herein. 'Cl IIRD I wil ,devise and Ifequeath, all the rest and residue of nay estate, real, personat ar miYeii, wherever situate, to my daughter, .tUU1' ANN IIAI'S, provided she survives me by thirty (30) day's. ~, t DOUR"I' I t En the event that my said daughter prt:deceases ~-pie or rails to survi~~ ii7e b;~ thirty (3~} d~~y of inti~ death, then 1 will, devise and beq~-cath all the rest of my estate, real, personal or mixed, wherever situate. to my grands~~~n, 'I'OUI) U~)[1GL.~S 1!r?,Y5, provided he survives me by thirty (~0) days. ~ ~ ~~ d~~ FII~'hlI 1 appoint my daughter, JUDY ANN IiAti'S, d~,xeculrix of this my Last Will. Should my said daughter fail to qualily or cease to act in that capacity, I appoint my son-in-law, ~YILL{ri.D1 ,I. iiA`1'S, to serve i2t that office. Should iaiy said second cl~;;:~i;_e i~~il t;~ yu~!hlj~ or cease to act in that f office, I appoint my grandson, ~1'C)I)t) ht)UG~~,AS HAYS, to serve in that ollice with respect to i tl;;~ my Last Will and ~f'c:>famcnt. S I X'1'1-( I dir~:ct teat my L;hecutrix or her successors shall not he required to give bond for the Faithful perfurmance of her duties in any jurisdiction. D:AYi)ItU-I'i~+i•tl~iLf S1'I [F.Iv''rti~\[~IIrrC;d;,l\i \CilLlxlt' IN ~VI'1'NLSS ~VIILRI~.O1~, 1 have hereunto set my hand this ~ day i~f~ --~- 2001. -------- - -- ---- -------------- CL ~' JUANI~LM[L~.+'.it ~)it~il illy ~C~a:~f-CI iFI Ili li i,;.;-~iil i~i( L?j' the tVove naitied fC.Jt:~l[t;\~ Cc ~.i.`~7~~.'_S aD d./t-Y:;tl :`V i~ NIII,I.C(t, as and tc~r her Last Will and "hestament in the presence of us, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as witnesses hereto. ('~ . ~ ' v residing; at _~~1~.. _ . .~.~. - -- --- I/ ~.r ----------- ~------~=-k---_ ____ ---- - --- ~,~-, residing at -,~ ~ !~' L~'~`=~- _ ~~-~ - ll:',AvORl)-PILO,A~'11.1,S~CLII~:i`:'rS\lillcr-(~<iJ\! Vi,'iIIJ1~1t' ACKNOWLI?DG~IIi.N"T AND Ahh'IDAVI'T OF WITNESSES COMMONWEALTH OF PGNNSI'L.VANIA } ~ ~ ~ ~~' ~~~ ~ ss: couNTY Or ~ ~` `~ `~ ~ 1, Gladys Joanne l1'liller, the 'Testatrix whose name is signed to the foregoing instrument, having been duly qualified accor(ling to law, do hereby acknowledge that I signed and executed the instrument as m_y last Will; and that I signed it willingly and as my tree .and voluntary act tur the purposes therein expressed. Sworn to or Ca~'irnled and acknowl dged bei-ore me by Gladys Jo:tune Miller, the t estatrrx, this ~ (lay cif ~<.~/'' -_____ _ CONIIVION~YEAL,'1'II Ola I'1?NNSYl,Vr1NIA COUNTY OF ~~ U lei ~E~~~N~ Glad s J anue 1\'Iiller ,~ i Nota ublic a ~I~arza~.ggVlehman, ~lotarv='.~?I,reai f~t~chc,ntamfB~lo~ ~~,Cumf~ec(a,;r!:'~.;~pt~ Public ,,~,,~x...,~....~,~',~;.i,: ~.. UGE!'-~~. end ~~untY SS: ,.,.r. _t . .xr„ ~~.n i na ('v (l'H- uMa~r r. (r~uld ~lQ' n Cu/~~ YI~L_ .<'1_> the witnesses whose names arc signed to the foregoing instrument, being u y qua 1 to accor ing o aw, and say that we were present and saw the "I'estaU-ix sign and execute the instrument as her Last ~~'ill; that the "Testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in lliC hCaflilg alld sight Ot the hCSlatrlX signed the Wlll as a ~Vtt1CSS; and that t0 t11L' Hest Ot Olti' kliGtviedge, till' I eStatrlX was at that "tithe at least 18 or more years oC age, of sound mind and under no constraint or wldue influence. _. ~ ~- n Nota'fvlPublic I):AvUKll-PRl)~,11'ILI,S~CLn~.N'1'ti~hlillerC~~G.1\1 \4ill.l)OC ~otarlal Ssa! ~ Fleuina ,~,'~iehmarr, rJotary- i•'ubUc ~ectrantc,btrr~ 6oro, Cumberland Count ' ~9p Gonirnl~aia i_...,.._ .............,'~ t:xpi+.es t5pri{ ~8, 2003 °°---~--...n,.