HomeMy WebLinkAbout10-07-09PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF ~`,t,~~(~~-i~D COUNTY, PENNSYLVANIA
Estate of (~~, ~ ~~~~S~L-~
also known as
Deceased
File Number ~ ~ ~ ~ C~ - U
Social Security Number ' ~~' 34 ~ ~~~ 1
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 ~X e l'f~(. I art K named in the
last Will of the Decedent dated Z~ ~ ~ - 2~~~ 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:
B. Grant of Letters of Administration
(/'applicable, enter: c. t. a.: d. b. n. c. t. a.; pendentelite: duranteabsentia: durantentinoritate)
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. cr. ord. b. n. c. t. a., enter date of Will in Section A above and complete list of heirs.) t'*~
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Name Relationshi Residenc ?7 ~.~
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(COMPLETE IN ALL CASES:) Anach additional sheets if necessary. ; ~ ~
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Dec•ee~~dent w s~omiciled death in ~ ~ County, Penns ]vania with his /her last principal r~'idence at W ~ ~ ~
(List street address, town/city, township, county, state, zip code
Decedent, then ~ years of age, died on ~G1' 1 • ~ ; ~11C1~ at 1 ~ ~J~ ~tM .
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ ~~(~. Vt~
(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:
Form RW-02 rev. 10.13.06 Page 1 Of 2
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:
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
/} p SS
COUNTY OF I t) ~V~~ ~ ~ n(,~
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
`~ 'S h
before me the t day of
r~ r ~ / ~'
Signature of Personal Representative
r FCr the Regy';t r Signature of Personal Representative _
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File Number: 2 ~ - ~ ~ - U ~ ~~~ ~ ~ -~
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Estate of , Dp~ga~ed ._
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Social Security Number:
AND NOW,
Date of Death: rn
in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters
are hereby granted to
and that the instrument(s) dated
in the above estate
described in the Petition be admitted to probate and filed of record as the last Will (and Codici
FEES
Letters $ ~-t~ , Cid
Short Certificate(s) ........ $ ~ c~ ~ (~~%
Renunciation(s) .......... $
LUG l1 ... $ f5~ ~~
... $
... $
... $
... $
... $
... $
1
TOTAL .............. $ ~S -6:96--
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.:
Address:
Telephone:
Form RW-02 rev. 10.13.Oh Page 2 Of' 2
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LOCAL REGISTRAR'S CERTIFICATION OF DEA1'•H
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee t~or this certificate, $6.O0
P 15716428
Certification Number
'hhis is to cerlil~ tha_ ;Le 'int~n~lnatiOn h,~rc Bluth is
a)rrectly cty~~icd fr~xn an of~r;nai Certiiir_atc of Death
duly Filed ~~~ith Inc a. Lt)cll Registrar. "T'he ori~~inal
certificate ~~ill he i~t)n~~ardcd [o the Stale Vital
RecTn~ds Of~ficc fix- ~~rr;nal~enl filim~.
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Local cgistrar Dale Issued
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS I.. ~ )
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PERMa~F_"NT CERTIFICATE OF DEATH
BLACK uih lSee instructions and examples on reverse) nr~.~ ~n ~ ~ ~~ n.n~n
1. Name of Decedent (`~rsl, n.iddle. last. suf!nj 2. Sax 3. Social Security Numbor d. Dole o! Death IMOnIh. tlay, year)
Carol J. Ebersole S 161 - 34 - 1841 2
5. Age (Last Binnday) Under t year L'nder 1 da 6. Date of E!nh IfAOnm, da ear) 7. B,nh loco Cif end state or total n count r 8a. Place of Dear (check onl • onef
M.,u.,~ .~.~vs Hous r.~~n~t~s Hospital. Other:
66 vs 1/6/43 Philadel hie ^mpaeem ^ER'Outpatient ^DOA pt,NaraingRpn,a ^Residenae ^ana;~speeity:
Bo. Coun!y o= Death Bc. C'y, Bare, Tvrp. of Death Bd. Factl,ly Name (If not inslnubon, give street and number, 9. 'h'as Decedent el Fiispame Ong~.n? ~] No ^ yes 10. Race'. American Indwn, Black, White, em.
(II yes, speci!y Cuban, (Specil)7
Golden Livin enter Me"i`on' Pnad° Rman, etc.f
CPCetlent's Usual Occupal or 'K r of wo sdone s!ot wo kin life. Do not state rel~redl
no
t' t2..has Decedent ever n the 73. Decedent's Education (Specity only highest grade completed) 14. Marital Status: Ma,~etl N er Ma rri_d, 75. Surv ving Spouse (II wle. gve maiden name)
_
K,ntl of eusinessllndustry
I;:rd of Work U.S. Armed Forces? Elementary /Secondary (0-12) College (1 ~4 or Et) Ndowetl Dvorced l..pecyy}
^ Yes ~ No
16. Decedent's Ma'ang Address jStreet, aty l;own, slate, np cadet Decedent's Did Decedent
Live lna 17
Penna
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Pennsboro TWp. Two
46 Erford Road .
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Actual Residence '7a. Stale
Township?
a°Lamastoi~edwi
Cumberland nd ^ n° tnin
Camp Hill, Pa. „b c°un,y
I oiy,!~°rn
t8. Father's Name rFrst. rn~.dcle, last, s~.ifl.x) 19. Mother's Narne IFirsl, middle, maiden surname)
20a. Inlormam's Name (Type ~ Droll 20b- Inlormant's Mailing Address (Street city I town, state. zip code)
n J. Ebersole
Allis
o 236 Walnut St., Highspire, Pa.
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2.a Me;hetl of Dispos,;ion L4 Crematon ^ Donation 21b. Date of Disposition (M1lonln, day, year) 21o Place of Disposition (Name o! ce^retery, crematory or other plane) 27d_ LocaSon ICilyl town, state, zip code)
^ ee~rial ^ Removal trcn: State r Was Cremation or Donation Authorized
^ ana, - soech: r by Medical ExaminerlCoroner? f~ Yaa^ Np
9 21 09
BFH CREMATORY
Grantville Pa.
22a. Signature • Fcreral Service Licensee br person acting es such) 22b. License Number ^2c Name and Address of Facihly
/LWr,/ ) f ~ ~,i
Ccmple~e ne s 23a~c cvy when cen,:yino 23a. T Lde nest of my Knowledge, dealt occurred al Ina time, doe and place staled. (Signature and Idle) 23b. License Number 23c Date Signed (Month, day, year)
phy;~~ian ia.,o, a~n~i,hia at „ma °I dealt ~n f-- ~ U i
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t 24-2C rated .~+ parser 2J. T r•,e of Death /~
' 25. Dale Pronounced Doad th1 rnth day, year / 26. Was e Reler-end ~ro Me/than Ex in r /Coroner fur a Reas n Other loan Cremation or Donal on?
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C Yes LINO `Z `~Rk'~"
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o Dmnou ces
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CAUSE OF DEATH (See instructions and examples) r Approximate interval. Pert It. Enter other ~gDf~~j~g7]p,llons cenrnbutin a to death, 2B. Did Tobacco Use Contribute to Death?
I r7. P~ ., ~ lh ch of g ~ d a - I m : t s ~ that d- ly used the death. DO NOT attar term'nal events such as cardiac arrest, Onset to Death but o; resulting In the underlyrg cause given it non I. ^ Yes ^ Pronably
re : story e rest o van c~ ar I'b Ilet env-hour show ng the etiology L sl only >ne cause or each I'no ^ 'JO ^ Unknow
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IMMEDIATE CAUSE (Final disease or 1 ~ 29- If Female.
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condNOn resulting m ceatn'. _~ ~~ ~ (~ '~'nt I n.~N'Y/~/I t'x / '1 "~
a nanl within pa5l
ear
^ Not
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Due to for as a consequ~ b D
g
y
^ Pregran' at Cme of death
S II/ I t C o.. fay. p ~/ a
fY^e%Nx1 iN~) r
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e tl ~ I h a I 'I d I e Du o io~ as as consequenc
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E ( t UNDERLYING CAUSE a h n d7 days
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et Ceaeh hoot but Dregna^
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ear
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er,s esu: ng dea dl LAST. r g y y
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Due to (or as a consequence ot,.
d belore death
^ Unknown it pregnant within the past yea'
30a_ W'as an Au!opsy 3^.~. Were AWnpsy Endings 31. Manner of Death 32a. Date of Injury (Month, day, year) 325. Describe How Injury Occurred 32c. Place of Inlury: Home. Farm, Streal, Factory.
Pe'lormed? Availab'.e Pria• to Completion rr~- -!~~~ OI ice B lding, etc. (Speciyf
ise of Dea"
of Ca~
v LlrJatuml ^ Homicide
.
.
~ Investi
ation
ident ^ Pendin
^ A 32d. Tine of Injury 32e. Injury a1 Work? 321 II Transponalion Inj~y (Speci(yJ 32g. Loeatien of Inj ury IStreei, city/ town, slate)
^ `!es ~o ^ Yes g
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cc ^ N
^ V ^ Dnver10perator ^ Passenger ^ Pedeslnen
^ Suicide ^ Could Nat ba Determined
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Othor- Specrly:
33a_ Cenitier (check only one', 33b. Signalu•a and T~ o`f ,C!e ' r ~y/!
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• Cenitying physician !Physician cenirying cause of death when another physician has pronounced death and completed Item 23) `\
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To the best of my knowledge, death occurred duetothe cause(s)and manneras slated_________________________________~ //
License Number
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33d. Dale Signe
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• Pronouncing and cedirying physician (Physician MIh pronouncing Death and ceni!ying Io cause of death)
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e cause(s)an
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Tothe Dest of my knowledge, death occurred al the time,date, an (~,
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• Medical ExaminerlCoroner
On the basis of examination and 1 or investigation, in my opinion, death occurred at the time, dale, and place, and due to the cause(s) and manner as staled_ ^
34. Name and Address of Pe; \ n Who Completed Cause of Death (!
!err. 27) Type I Print
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3E. Rags 5 na,area Dis,:~nerC 1~
~ 38. poly F^ed (MOmh, d`y. yea RICHARDM MAGILL MD PC
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I, CAROL J. EBERSOLE, of Dauphin County, Pennsylvania, declare this `~
to be my Last Will and Testament hereby revoking all prior Wills and Codicils.
ITEM I. I direct that the expenses of my last illness and funeral be paid
from my estate as soon as practicable after my death.
ITEM II. I hereby reserve unto myself the right to make a list disposing
of items of personal property. If I make such a list, from time to time, it will be
signed and dated, will describe the items to be devised and the individual
devisees thereof. If no such written statement or list is found and properly
identified by my Executor within thirty (30) days after the issuance of Letters
Testamentary or Letters of Administration, it shall be presumed that there is no
such statement or list and any subsequently discovered statement or list shall be
ignored. Any reasonable distribution expenses incurred with respect to tangible
personal property, including but not limited to packing, shipping, storage and
insurance expenses, shall be paid by my Executor as an administrative expense
PAGE I OF IV
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of my estate. These items are of negligible value and are being distributed as a
remembrance of my life.
ITEM III. I give, devise and bequeath all of the rest, residue and
remainder of my estate of whatsoever kind and wheresoever situate as follows:
A. 40% to my daughter, ALLISON J. EBERSOLE, per stirpes;
B. 40% to my son, DAVID L. EBERSOLE, per stirpes; and
C. 20% in equal shares to my grandchildren born prior to or within nine
months of the date of my death, per stirpes.
ITEM IV. If a beneficiary under this Will has not attained the age of
twenty-five (25), the share of that beneficiary shall be placed in separate Trust, for
the benefit of that beneficiary.
ITEM V. In the event that a Trust is created by or as a result of any part
of this Will, the duties of the Trustee shall be to administer the terms and
conditions of the Trust as follows:
A. To expend and apply so much of the net income and so much of the
principal of the trust as Trustee shall consider advisable for the
support, care and education of the child until the child attains the age
of eighteen (18) years.
B. To pay, after the beneficiary attains the age of eighteen (18), the net
income together with so much of the principal thereof as Trustee
shall consider advisable for the beneficiary's support and education
PAGE II OF IV
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after taking into consideration all other readily available assets,
sources of income and other resources.
C. To distribute to the beneficiary the entire balance of principal and
accumulated income then remaining, upon the beneficiary's request
at or after the beneficiary reaches age twenty-five (25). Distribution
at or after age twenty-five (25) shall be made only in the event the
beneficiary requests such distribution by a writing intended to take
effect during the beneficiary's lifetime, executed by the beneficiary
upon or after attaining age and delivered to Trustee.
D. If a beneficiary shall die before receiving final distribution of his or
her entire share, the undistributed balance shall be distributed
outright to his or her surviving issue, per stirpes, and in default of
any such issue then to my residuary beneficiaries, per stirpes. The
share of any child whose original share is then being held intrust to
be added to and treated as part of that trust.
ITEM VI. I nominate and appoint my daughter, ALLISON J.
EBERSOLE, to serve as Trustee for any Trust established in or created by this
Will. If my daughter, ALLISON J. EBERSOLE, is unable to serve or continue
serving as Trustee, I nominate and appoint my son, DAVID L. EBERSOLE, to so
serve.
PAGE III OF IV
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ITEM VII. I nominate and appoint my daughter, ALLISON J.
EBERSOLE, Executrix of this my Last Will. If my daughter, ALLISON J.
EBERSOLE, is unable to serve or continue serving as Executrix, I nominate and
appoint my son, DAVID L. EBERSOLE, to serve as Executor.
ITEM VIII. I direct that my Executrix, Trustee or their successors shall not
be required to give bond for the faithful performance of the appointed duties in
any jurisdiction.
ITEM IX. I direct that all taxes due at my death or as a consequence of my
death shall be paid from my residuary estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
day of ~ o_ , 2006.
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CAROL J. ERSOLE
WITNE S
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WI SS
NOIRA F. BLAIR
ATTORNEY
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF DAUPHIN
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We, ~/~ .~ ~ ~,~~~ ir! m~~ ~ C ~t~`w,.~--N~ ~~yvr-~~usr ~-; and Nora F.
Blair, Esquire, the witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, do depose and say that we were
present and saw CAROL J. EBERSOLE, the testatrix, sign and execute the
instrument as her Last Will; that the testatrix signed willingly and executed it as
her free and voluntary act for the purposes therein expressed; that each
subscribing witness in the hearing and sight of the testatrix signed the Will as a
witness; and that to the best of our knowledge the testatrix was at the time
eighteen (18) or more years of age, of sound mind and under no constraint or
undue influence.
Sworn to or affirmed and subscribed to before me by the above-named
witnesses, this l;`~= day of /_ ~.,~,~,,,, _, 2006.
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N@RA F. FAIR
5440 Jonestown Road
Post Office Box 6216
Harrisburg, PA 17112-0216
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WITNE S
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Notary Public
OMM AL OF PENNSYLVANI
NOTARIAL SEAL
LOWER PA~ON TWP.,~ DA!)PH N COUNTY
MY COMMISSION EXPIRES SEPT. 30 2007
ACKNOWLEDGMENT
COMMOriWEALTH OF PENNSYLVANIA
SS
COUNTY OF DAUPHIN
I, CAROL J. EBERSOLE, the testatrix whose name is signed to the
attached or foregoing instrument, having been duly qualified according to law, do
hereby acknowledge that I signed and executed the instrument as my Last Will
and that I signed it willingly and as my free and voluntary act for the purposes
therein expressed.
Sworn to or affirmed and acknowledged before me by CAROL J.
EBERSOLE, the testatrix, this f 1 ~ day of ~ J~„L„G,,_ 2006.
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CAROL J. ERSOLE
A ~'. ~ ;.
Notary Public
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OT RIAL SEAL
LOWER P~Op Tyyp ' QgUPH N COU TY
MY OMMISSION EXPIRES SEPT 0 2007
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