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HomeMy WebLinkAbout07-13-09PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of LILLIAN B. ROTZ ~ ~ ~(71 ~tl~ t File Number __ 11 -l also known as Deceased Social Security Number 199-07-5679 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 EXECUTORS last Wi11 of the Decedent dated SEPTEMBER 29, 1993 named in the and codicil(s) dated (State retevantcircumstances, 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: © B. Grant of Letters of Administration (lfappticable, enter: c.t.a.; d.b.n.c.t.a.; pendente tite,~ durance absentia; durance minoritate) 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: (If Administration, c. t. a. or d. b. n. c.t.a., enter date of Will in Section A above and complete list of heirs.) ra Name c~-a f="--~ " L~ YT "Y7 _.1 (COMPLETE lNALL CASES:) Attach additional sheets if necessary. ~ _~> ~- _~~ Decedent was domiciled at death in CUMBERLAND County, Pennsylvania with his /her last rinci al r ~~ 101 NORTH PRINCE STREET APT. 208 SHIPPENSBURG PA 17257 P P e~ence at_ t~_ ' - (Gist street address, town/city, township, county, state, zip code) ~ Decedent, then 86 years of age, died on JULY 1, 2009 at CHAMBERSBURG HOSPITAL, CHAMBERSBURG, Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ 5,000.00 (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania e situated as foI 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: or pnnted name and GLORIA J. CASSIDY, 10050 MCCREARY RD., SHIPPENSBURG, PA 17257 C\ t/ ~C `~ (/ I MERLE A. ROTZ, 1 LYNN AVE., NEWBURG, PA 17240 G. ROTZ, 2293 LINDSEY LOT RD., SHIPPENSBURG, PA 17257 Form RW-02 rev. !0. /3.06 Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND 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 lrnowledge 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 l.~.I G «~(,~ J For the Register Signature of Personal of Per.~al Representative ~ /~ /'~ Signature of Personal Representative `-> ~ ~~ ~ ~-[~ t.~ ~n ~ C, ~ r- ~. 1 File Number: ~' == ~ ca ~ y Estate of LILLIAN B. ROTZ ,Decease Y~ ~ ~ _ ` r Social Security Number: 199-07-5679 Date of Death: JULY 1, 2009 b ~ _ c.~ AND NOW, `(3~~ (:3T ~ ,~~, in consideration of the foregoing Petition, satisfactory proof having been presented before e, IT IS DEC ED that Letters TESTAMENTARY are hereby granted to GLORIA J. CASSIDY, MERLE A. ROTZ, AND RIDHARD G. ROTZ and that the instrument(s) dated SEPTEMBER 29, 1993 described in the Petition be admitted to probate and filed of FEES Letters .... J a d UU .... $ 3Li Short Certificate(s) ... ~ .... $ `~ Renunciation(s) .......... $ l~ ... $ % S ;~~_.~ ... $ S ... $ ... $ ... $ ... $ ... $ ... $ TOTAL .............. S (Q `~`~~ the last Will (and~odicil(s)) of Re of ills ~r Attorney Signature: ~'l'I~f:.Z,,/ in the above estate Attorney Name: SALLY J. WINDER Supreme Court LD. No.: 24705 Address: P.O. BoX 341 NEWVILLE, PA 17241 Telephone: 717 776.1245 Form RW-02 rev. 10.13.06 Page 2 of 2 OCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or phrtc~graph. Fre II,r thi~~ c~rtiil~ate, wti.OO ~,, 7hi~ ~, I:~ 1. j,~ vial tlt~ roll eau I ht~a =r. .t ;~I~~' p,AtH 1Jt p~ \ 1 I~ /;ICE, - y~;=V ccfrrc~t v ~~'4 t 1 S~rr~ln all Lori .n,l; ~'ut . cite ur I>L ~S-_ `~. f- _; x~ ~ ~G ~ lj Lll~" tilt (_i 1. ; 1 ii?t' I 1_c>.~~tl 1ti '_'!~l `t. ~11C I)CI'~ ~;~'~Z:~ s La'1'lIl1L ~1't I 11C j"11 .\.11'ill. 1 iv, ;c `>I.IC.' ~ I U 1 .a ~~ I~CI(`I k{'• {. )i~t. .nl~ l~_l 1, i~ ll ,ill =_ o ~`/~ _ ------ P ---15 6 6 3 9.11_._.__ ~ F~~A~_ ~~'`'~ - - ----Q~1_a~ .:,, T,~F N~ C,E . ~''' - CertificatiLyn ~lumbcl- A _.! . - L/ac~ e ~I:Ir ~ ~ Il,ite 1~tit~L~L': C ~ _.r, 4 . `` ~ tp hj -~ ` :; , •~ y -~ C') r-, ..~; 1105143 REV 11200fi COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~ "-'1 " .`.~ } TYPE/PRINT IN ~+ - ~ " F ''~( BLACNNNKT CERTIFICATE OF DEATH (,,,,~ - (See instructions and examples on reverse) STATE FILE NUMBER ~` 1. Name of Decetlem (Fleet, mklGe, last, suffix) 2. Sex 3. $ocia15ecuray Number 4. Date of Death (Month, day, year) Ld.P.~i.an B. Ro~z P - - 5679 Ju,~ 1 2009 5. Age (Les181rthday) Untler 1 year Under 1 day 6. Dale of Binh (Momh, day, year) 7. Birthplace (City aM state a foreign country) Ba. Place of Death (Check only one) Yfvlena bun PA Haspdal: Omer: 86 ~~` ~ ~'"` "~'~ Sep~embeh. 9, 1922 Shd " g '" , Yrs. r r f ~Snpatlenl ^ ER / ONpatienl ^ DOA ^ Nursing Homo ^ Resitlence ^Other - Specity. Bb. County of Death Bc. Ciry, Boro, Twp. d Death 8d. FadA1y Name (If not institution, give sheet and number) 9. Was Decedent of Hispanic Origin? ®No ^ Yes 10. Race: American IrMian, Black, Whee, etc. Pnanh,P,i,n Co. Chambensbwcg (K Yes, spedty Cuban, (S yy~ Chambe~cabung Habpitak Mexican,PUenoRiwn,ec.) Ullu~e 11. Deceden's Usual Occu tron KI11d of wale doce duri most d world life. Do rtol aWte retired 12. Was Decedent ever in the 13. Decetlenl's Educetion (Speciry only highest grade completed) 14. Marital Status' Mame4 Never MarneQ 15, Surviving Spouse (d wde, give maiden name) Kintl of Work Ki of Business / IMustry ~ U.S. Armed Forces? Elementary /Secondary (0-12) College (t d a 5+) Wgowed Dlvaced ISpeciryq manager C.~ot u.ng Fac~ony ^Yes ®NO Soh Gl,i.dawed 16. Decedent's Mailing Address Islreel, coy /tam, slate, zq code) Decedent's Did Decedent Pa Li 101 Non~h Pni.nee S.t. Shi,ppen.a bung, PA ve~mlapo „c, I^I~~ Yes, Decedem Lived m T..rp_ `~"~' `~'~"~ 17e. Stale Cumbeh Y a d . . n 17d. tdl NO, Decetlenl Lived whin Shi.ppen,a bung Bonoug~ 17b. County 17 2 5 7 nasal Limks a 4y l Borrt 18. Fa9rer's Name (First, mitltlle, lest, suffix) Anthun ~ li k 19. Mother's Name (First, mitltlle, maiden wmame) . m e Peane. F. Ke,ECey 20a. IMormanl's Name (Type /Pant) 20b. Inlament's Mailing Address (Sreel. city /toms, slate, zip code) G2on,i.a J. Casa~,d 10050 McCneany Road, Sh,i.ppevusbun PA 17257 21a. Method of Disposition i ^ Cremation ^ Donelun 21b. Date of Disposition (Momh, tlay, year) 21c. Pace of Dkposition (Name o1 cemMery, crematory a other place) 21d. Localbn (City /lam, stale, zq catle) ® Banal ^ RenmvelhanSale ~waaDrem.liano<I>a,.IronAathan~ad ^ Other - Specity: I DY Medical Ezsminer /Coroner? ^Ves ^ No Ju,e. 6 2009 y f Mongu~C Cemetery ~ou~~Amp~on Twp. ran n oust 22a. 5 r Funeral ( n ~ g as 71D. License Number 22c. Name eM Address of FaciMy 112 W ea t K~ n S~ieeet - FD 014351-L . . g Pogek~angen-Ba,i.ckeh FcYne~ca.C Hame Inc. Shi. evu,bun PA 17257 e Items 23ac ady when ce ' 23a. To the o knowledge^tleam e0 irte, date place staled. (Signatae end title) J~n 23b. License Number 23c. Date Signed (Month, day, year) physiaan is rot available at time a death to cenity cause a death ~ // ,..J~ /j / 1~ ~-C~' L -"llJ/''-- L~ `~~-i~~' /l.~ x~ ,1'y, r,, /V 4rJ ~ y~ ~ ~ (O ' ~ --7-' I 1 V lJ l / 2. G7l'~ y Items 2426 muss be cemDleled by person wla ronatnces tleath 24. T Death ~y p ~ U ~ `' 25. Dale Pronounced Deed (Month, tlay, ye~ar7) ~ ~ ~ 26. Was Case Relerred to Medical Examiner /Coroner for a Reason 01 r than Cremation or Donation? p . L ~ /~i- M. ~U ~ Gov ^Ves „~No CAUSE OF DEATH (See Instructions antl examp s) r Approximate inienral: Pan II: Enter other •jgD4icanl tY~tons cenlri6uN~ q to alh, 26. Did Tobacco Use Canlnbule to Death? ffem 27. Pan I: Ema the ~ of everrt - tlkseases, ryunes, or Canpkcaliore - that tlireclFY caused the death. DO N0T enter temtkial evems wch es cardiac arrest, t Onset to Death bd rwl resulting in lire underrying cause given in Pan I. ^Ves ^ Probably respiratory artesl, or venlricwer finripation wkliaa showing the etpbgy List atly one reuse on each kne. r ~ ~ No ^ Unknown IMMEDIATE CAUSE IFin l di as o se r a e caMlGOn resukl n death ~1 ~ T ~' , ~ G ^d ( Q s\1 '~ ~ ` G~ nq~ ) ^ µ~ 29. tl Femak: . v -)• e. ` I N - rnrn Due to (or as a wreequence otl: II SequemieXy lest contitias, d any, b. __ _.,1 ~ ~ `~` l°. a S~' ~ \S~Ga C ~~~ \ ~ \~ 4~' ] ~ U~ leaden99 to the cause ksled on tine a W Na pregnant within past year ^ Pregnant et time of death . Enter tce UNDERLYWG CAUSE buy to (or a consequence ol): 1\ 1,., I- ' (disease or iryury tlNl intlialed the c. \ ~~~C QS~~C-tJ.~ l \Q.L/'~'l~~ Y lqC ~._ ~ `per events restating m tleath) LASS t ^ of tlealn~nl, but pregmnt wi1Nn 42 days Due to (or as a con sequence op: r ^ Not pregnant, but prepnan143 days to 1 year d ~ belore tleath ^ Unkrawn it pregnant within the past year 30a. Was an Amopsy 30b. Were ANOpsy Fmdirgs 31. Man alh 32a. Dale of Injury (Momh, tlay, year) 32b. DewrAe How Injury Oceurtetl ~ 32c. Place of Injury: Home, Farm, Slreel, Faawy, Penormetl? Available Prior to CaKrglelron Nature) ^ Haniade OKice Buadng, etc. (Specity) of Cause d Death? ^ Yes o ^Ves ^ No ^ ax'eem ^ Pen6nq Invemigatian 32tl. Time a Injury 32e. Injury at WakT 321.11 Trensponalbn Inury (Specrty) 32g. Lowtbn of Injury (Street, dly I bwn, stele) ^ Suside ^ CouM Nol be Determined ^ Yes ^ No ^ DrNer / Operate ^ Pesserger ^Pedestnan M ^Other ~ Spealy: 33a. CenNier (check Dory one) ~ sician (Ph • Cenltyin h siden cenff in cause a death when slather h sician h d d th d l t d h 23 336. Signature artl T4ce~~dier g p y y y g p y as pronounce ea an comp e e em ) - To the best of my krwwledge, death occwretl due to the cause(s) end manner es stNed_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~~~// • Pronouncing antl cengying physician (Physkian both proraurcing death and cenffying to cause of death) death occurretl of me ti To the best of m knowled e e dat d l d d t th d d ^ 33c. License Number ~ 33d, Dale Signed (Month, day, year) y g , , m e, en P att, en ue o e cause(s) en manner es stale _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Metllcel Examiner I Cororrer ~ ~' ~ 2 O ~-. ~ J ~ ~C15 ~ ~ ' ~-- I ~ 1 On the basis minatfon antl / or Inves' 'on, i my opfmon, death occurred el the time, date, antl place, end due to the cause(s) and manner es sleled_ ^ 34 Name arM Address of Person W~Compleletl Cause of Death (I m 27) Type /Print _ , r ~ y 35. Registrar' ignatur nd lelrbl mbe 36. Dale Filetl (Momh, day, year) ~ tom-, n i~ ~ ` ~ \ C V\ ~•~~ Fl l~ `_~ ' 7 i ~ ' Z Zoo . j"}-Zn C V~aw~ ~` `~ V Disposition Permit No. O /~ ~ / U'V LAST WILL AND TESTAMENT I, LILLIAN B. ROTZ, being of sound mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking all prior wills and codicils made at any time before by me. FIRST: I direct that all my funeral expenses and just debts be paid as soon as practical after my death. SECOND: I give, devise and bequeath all my property, be it real, mixed or personal, to my children, Merle A. Rotz, Richard G. Rotz and Gloria J. Cassidy, in equal shares, share and share alike, per stirpes. THIRD: I nominate, constitute and appoint, Merle A. Rotz, Richard G. Rotz and Gloria J. Cassidy, to be the Executors of this, my Last Will and Testament. IN WITNESS WHEREOF, I, LILLIAN B. ROTZ, to this my Last Will and Testament, set my hand and seal, this ~ day of September, 1993. ~ ~ . ( SEAL} Lil ian B. Rotz Sworn to and subscribed, declared and published by LILLIAN B. ROTZ, as her Last Will and Testament, and so done in the presence of we the witnesses, who sign at her request, c~ o and in her presence , and in the = ` ~, ~~ ~~ ~a ,, // y~L ~ presence of each other . ,~ G~.~~~,1 ~~~~~i „~ ~, c-,, ~' ~ '~' Y i 1 G ~ iii "i7 ~ .: J p ~ - -- ~~ ~ 1 f v r COMMONWEALTH OF PENNSYLVANIA: :SS COUNTY OF CUMBERLAND I, LILLIAN B. ROTZ, whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; and that I signed it willingly; and that I signed it as my free and voluntary act for the purpose therein expressed. x~~~ ~ ~ a~ L'i"14.1an B. Rotz ~ Sworn to and acknowledged, before me, by LILLIAN B. ROTZ, the Testatrix, this °~~ day of September, 1993. I'~OYARIAL SEAL Notary Public DAWN tvi;~NiE SNOOP. Notary Public Shippersb~arg, Cumberland County, PA ~y C,®mmiss!on Expires Feb. 5, 1996 COMMONWEALTH OF PENNSYLVANIA: :SS COUNTY OF CUMBERLAND We, H. Anthony Adams and Sharon Coleman Adams, the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we saw the Testatrix sign and execute the instrument as her Last Will and Testament; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses, and that to the best of our knowledge and the Testatrix was at the time at least eighteen (18) or more years of age and of sound mind and under o straint or and influence. -~~. _ - H. Anthony Adams ~~ ~~; -~ ~ /Sharon Coleman Adams Sworn to and subscribed before me by, H. Anthony Adams and Sh on Coleman Adams, tr.e witnesses, this jZ day of September, 1993. Notary Public ~~O-~ARiAL SEAL Df1b'VN tvifi~R1E SNOOP, Notary Public ;;;hppensburg, Cun?berland County, PA tirV Co~nmis5ion Expiras Feb. 5, 1996