HomeMy WebLinkAbout08-21-09PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND
Estate of
also known as
Randv W. Mowe
COUNTY, PENNSYLVANIA
File Number 21-09- (~~ (p
,Deceased Social Security Number 160-48-8181
Daisy C MOWERY
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 named in the
last Will of the Decedent, dated 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 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
appica e, enter: c. t. a.; .n.c.t.a.; pe ente de; urantea senna; urantemmontate
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.)
Suppress heirs for Section "B" (Grant)
Name Relationship Residence
PETERS, Carol A Sister 549 E Liberty St
Chambersburg, PA 17201
MOWERY, Darryl L Brother 399 Running Pump Rd
Shi ensbur PA 17257
MOWERY, Daisy C Mother 118 S Fayette St
Shi ensbur PA 17257
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal residence at
118 S Fayette St, Shippensburg, Shippensburg Borough, Cumberland, PA 17257
(List street address, town/city, township, county, state, zip code)
Decedent, then 5$ years of age, died on 07/20/2009
at 118 S Fayette St, Shippensburg, Pennsylvania
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:
40.000.00
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
Daisy C MOWERY 118 S Fayette St
,q; i Shippensburg, PA 17257
Randall W MOWERY
Form RW-02 Rev. 10-13-2006
Copyright (c) 2006 form software only The Lackner Group, Inc.
Page 1 of 2
l '`\
1
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
before me this ~ ~ ~ day of
/~ -
~' // Fot; e ~ egister
Daisy
Signature of Personal Representative
Signature of Personal Representative
File Number: 21-09- ~ (g~O
Estate of Randall W MOWERY
Deceased
Social Slecurity Nl~umber~: r_ 160-48-818L1 Date of Death: 07/20/2009
AND NOW, 2•I5~ ~ 6-U l/'( ~(~1.~ ~ I (~~ , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters of Administration
are hereby granted to DalSy C MOWERY
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
Letters ............................................ $ "lo• ob
Short Certificate(s) ........................ $ ~ 2, ~D
Renunciation(s) ............................. $
l~~C,t~ $ 10. (~O
~~ YY1~~'tflV~, $ ~ • ~'D
$
$
$
$
$
$
TOTAL .................................... $ I I ~.
Attorney Name: Forest N Myers
Supreme Court I.D. No.: 18064
Law Office Forest N Myers
Address: 137 Park Place West
Shippensburg, PA 17257-9212
Telephone: 717/532-9046
Form RW-O? Rev. 10-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc. Page 2 of 2
Attorney Signature: -~°
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See instructions and examples on reverse) STATE FILE NuMeER
1. Name of Decedent (First, mitldle, last, suHrx) 2. Sex 3. Social Security Number 4. Date of Death (Month, day, year)
Randall W Mowery Male 160 - 48 - 8181 July 20, 2009
5. Age (Last Blnhday) Under 1 year Untler 7 day 6. Dale of Sinn (Month, tlay, year) 7. Birthplace (City aM stale or foreign country) fie. Place of Death (Check only one)
53 MmtM . oars HWr~ MmNas Hospital: other.
Sep. 18, 1955 Chambersburg, PA
Vrs. ^ Inpatient ^ ER I Outpatient ^ DOA
^ Nursing Home esdertce ^Other -Specify.
eb. County of Death 6c. , Bo wp. of Death 6d. Facility Name (II nd in6lilulion, give street antl number) 9. Was Decetlent of Hispanic Origin? ~ No ^ Yes 10. Pace. American Intlan, Black, White, etc.
Cumberland
Shippensburg
118 S. Fayette Street (If yes, speciy Cuban,
Mexlcan,PUenoRican,elc) (Specit~
white
11. Decedem's Usual Occu tWn Kind of work d one Bunn most of world IHe. Do rrot scale retired 12. Was Decedent ever in fhe 73. Decedents EducaHOn (Specfy only hghesl grade comlN eletl) 14. Martial Status: Marrred, Never Manned, 15. Surviving Spo use (II wre, give maiden name)
Klyd of Work Kintl o1 Business /Industry U.S. Armed Forces? Elementary / Secontlary (P72) College (1 d or 5.) WitloweQ Divometl (Sped/y)
Divorced
Forklift 0 erator Government ^ves {3rlo 4
76. Decedent's Mailing Atldress (Street, pry I town, state, zip cotle) Decedent's Penns lvania Did Decedent
y
Actual Resitlence 17a. State
Live Ina 17c. ^ Ves, Decetlenl Lrcetl m Twp.
118 S. Fayette Street Tpwnshrp? va.®Np.Decetlenumetlwhnm Shi ensbur
pp g
170 ~n'y Cumberland
1 257 AGIIIaIIxrNlspf
coy/Bprp
16. FaMer's Name (First, mdUe, last, suffix) 79. Mother's Name (First middle, maiden surname)
Jack S. Mowery Daisy Hancock
20a. Informant's Name (Type I Print) 20b. Informant's Mailing Atldress (Street city I town, state, zip code)
Daisy Mowery 118 S. Fayette Street, Shippensburg, PA. 17257
21 a. Metfatl of Dispositbn ®Cremation ^ Donalron 21 b. Date o/ Dispostlan (MOnm, tlay, year) 21c. Place of Dispositbn (Name of cemetery, crematory or other pWcel 21 d. Location (City I town, slate. zip cotle)
^ Burial ^ Rertwvalfrom5tate WesCremationorponationAWhorizetl 7-23-2009 Thomas L. Geisel Crematorium Chambersburg
PA. 17202
^ Other - Speciyy: by Metlical Exe r /Coroner. ^ Yes ^ No ,
22a. Signatu a ervice - or pe n acti ass 226. License Number 22c. Name antl Atldress of FedlHy
~ FD-014781-L Thomas L. Geisel Funeral Home, Falling Spring Rd., Chambersburg, PA
Cam I s 23ec only when cenRy 23a. To the best of my knowledge, death occurred at the time, date and glare sieletl. (Slgralure aM IHk) 23b. License Number 23c. Dale Signed (Month. day, year)
ph can Is not available at Hme of death to
cenity cause o1 tleath.
Items 24-26 must oe compleletl by person 24. Time of Death Ap TX . 25. Date Pronounced Dead (Month, day, year) 26. Was Case Refertetl to Metlwal Examiner I Coroner for a Reason Other roan Cremation or Donalron?
who pronounces death. 11 ' OO P . M. Jelly 21 , 2009 ~ves ^ No
CAUSE OF DEATH (See Inetruetlons antl examples) r Approximate interval; Pan II: Emer other smnifwant cord rhos coninbul rtq to death, 29. Ditl Tobaaro Use Gonlrbute to Death?
Item 27. Pan I: Enter the chain of events - tllseases, injures, or complications -that tlirecdy wusetl Hte death. DO NOT enter terminal events such es cardiac artest, r Onset to Death but not resuaing in the untledying cause given In Pan I ^ Yes ^ Probably
respiretory arrest, or ventricular fibrillation without showing the eliobgy Lisl omy one cause an each line. ~ ^ No ^ Unknown
IMMEDIATE CAUSE IFinal tlisease or
contl4ron resulting In deatnl _~ a Probable Myocardial Infarction
2s.nFamaie.
Due to (or as a consequence oq: ^ Nol pregnant wbhin past year
Sequemially list contlHions, d any. ° ~ ^ Pregnant at time of death
leatling to the cause Nsled on line a. Due to or as a copse ante of r
Enter the UNDERLYING CAUSE ( qu )~ Not
^ pregnant but pregnant within 42 tlays
(tlieease or injury Ihel inrialetl the a
events resuHlnq m death) LAST of dealC
.
Due to (or es a consequence oQ:
^ Not pregnant, but pregnant 43 tlays l0 1 year
d Defore tleath
^ Unknown II pregnant wthin the peat year
30a. Wes an ANOpsy 30b. Were Autopsy Fintlings 31. Manner of Death 32a. Dale of Injury (Month, tlay, year) 32b. Describe How Injury Occurtetl 32c. Place of Injury: Home, Farm, Street Factory,
Pertormed? Available Prior to Completion Natural
^ Ibmxade Office Builtling. etc. (Spedty)
of Cause of Death?
^ Yes No ^ Yes ^ No
^ Accident ^ Pentling Inveslgatan
32tl. Time of Injury
32e. Inlury et Work?
321. II Transponalan Injury (Specily)
32g. Location of Injury (Street ctly /town, slate)
^ Suicide ^ Could Not be Determined ^ Yes ^ No ^ Dover I Operator ^ Passenger ^Petlestnan
M ^Other ~ Specify:
33a. Cendrer (check only onej 33b. Slgnalure and 7
r
• CenMying pnysklen (Phys'xien ceniying cause of tleath when another pfrysidan has pranourced death antl completed Item 23) ,
C O T ORE: r
To the best of my knowledge, death occurred tlue to the cauee(5) antl manner u sbted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^
• Pronouncing antl cenitying physlclan (Physician both pronouncing tleath antl certifying to cause of tleath)
t t
ti
d
t
^
l .License Number 33d. Dale Signetl (Month, tlay, year]
he
me,
ace, and due to the cause(s) end manner es smted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
7o the bell of my krmwledge, tleaM occurretl e
a
e, antl p J ll ly 21 , 2 00 9
• Medical Examiner/Coroner
On the bests M examinetion and I or In getlo n my oplnlon, death occurred et the time, dale, antl place, end due to the teasels) antl manner es etetetl_ ~
34 of parson y~~ Cp~ppie~pd Cause o~.p~y~ ~It p7 T / Prinf
1'111: Cla~~ L. 1VO L'L 1S I,OIO~e~ ype
36. Registrar's Si Dlstn m r
/ '
C 36. Date Filetl (Month, day, year) 6375 Basehore Road Suite 411
l ~I / I zl
I
I ~ ,~•~ ZB~ Mechanicsburg, PA 7050
` ~ _ Dispos4ion Permit No, ~~~/ Q / YJ O