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HomeMy WebLinkAbout09-11-09PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF W]:LLS OF COUNTY, PENNSYLVANIA Estate of ~,~ ~1~ /°L ~~~~~ ~~~ ]J~----~ File Number ~ ~ ~ - ~~~ ~ ~ ~y °~' also known as ~-~J ~,/ q Deceased Social Security Number ~`~7 ! ~~ / / ~ 7~ Petitioner(s), who is/are 13 years of age or older, apply(ies) for: (COiYIPLETE A' or 'B' BELOW:) Probate and Grant of L,ett~ers Testamentary and aver that Petitioner(s) is /are the ~_~~°G~a'~(- named in the ast Will of the Decedent dated ~~~/ / Q !~ and codicil(s) dated (State relevant circurnslances, e.g., renunciation, death of exeCtdor, 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 (Ijapplicable, enter.• c.t.a.; d.b.n.c.t.a.: pendente life; durante absentin; duratte ntirtoritnte) .r i7 -; ~ Is. - (CONIPLETE IN ALL CASES:) Attach additional sheets if necessary. ;~ ~._ ~ ` --;.- ~.3 = j De edent was domiciled at death in ounty, Pe nsylvania with hi / h 1• st principa}~esi~ence at (List street address, [ownp/city, township, count), state, zip code) Decedent, then J ~ years of ag,e, died on ~~ 3~v at 1. Q ~ ~_ ~~t ] ,~~ ~j„tg ~, ~~.~: r ~-~- (C{~/~ 5' ~ ~1.~ It f ~'U y ~} /f'J Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ ~ (~ UU , (~ V (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: 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 printed name and residence 7 `~~-7 ~{7~1> Forur R6V'-01 r~~~. to.13.06 Page 1 of 2 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: (lf Administration, c. t. a. ord.b.n.c.t.a., enter date of Will in Section A above and complete list o/'heirs.) Oath of Personal Representative CONINIONWEALTH OF PENNSYLVANIA COUNTY OF SS The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are tine and con-ect 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 affirms ed and subscribed before me the i ~ +~ day of ~~m~ ~ D~~ . _`~ For the Register Signature ojPersonal Representative Signature ojPersonal Representative Signature ojPersonal Representative T: l_J . ~' ~;iJ -a 'L' ~_ _, rn ;~ ? ;-,> ~-'-'C'^ f"r ~1 ~~~ W? ~ ~''~ .: ':~ t File Number. ~ ~ - Estate of ~ Or'O~"~u mC, LISQ r'Oyy`e- Q , Depceased Social Security Number: ~ 5 ~ - 24 -~ ~ ~ D Date of Death: C3 ~" , ~ ~ -1 AND NOW, ~~~./` . ~ i ~~, in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters ~~ST Ac~n2.t..~owyi are hereby granted to ~1hCL;rzS-rte L y~.\0.5t r in the above estate and that the instrument(s) dated U - ~ U - ~~ -14 described in the Petition be admitted to probate and filed of record as the last Will(~(and Codicilt(s)) of Decedent. FEES Letters ............... I i `i5 .W $ Short Certificate(s) ....... . $ ~ ~ -~~ Renunciation(s) ......... . $ a ~ e_3:_~ ~r~C t L~ .. . $ ~ `J JC.P .. . $ tl~ - OQ ~~~m~.-'t-~~~ .. . $ a . yy .. . $ .. . $ .. . $ .. . $ .. . $ .. . $ TOTAL ............. . $ ~ a- - c~l~ Attorney Signature: Attorney Name: Supreme Court I.D. No.: Address: Telephone: Register of Wills Fenn RVV-OZ rev. IOJ3A( Page 2 Of 2 RENUNCIATION REGISTER OF WILLS ~ tv n ~== o ~~ ,~ - -ti . ~~ ~ ~_. • ~~ -- ~=: ,- - ~ - .c . , a~ ,Deceased Estate of COUNTY, PENNSYLVAI~tIA I, (Print in my capacity/relationship as O~Y~ .. of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to 5~~ ,'~ I_ i n ,~ (Date Executed in Register's Office Sworn to or affirmed and subscribed before me this 1 ~}~'" day of ~~_~m~-.,. ~a:~q 0 - ~L- - ^I l~-A9 D uty or R ister of Wills Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation for the purposes stated within on this day of Notary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date; of expiration of Notary's Commission.) .P ~ ` ~ , .~!' (.Srr~rr! Addy e.rs) ity, Stale. Zip) Form RW-06 rev. 10.13.06 OATH OF NON-SUBSCRIBING REGISTER OF WILLS -~ O ~~n `VITNESS(F=~, .~-F' ~~~~ - "~ COUNTY, PENNSYLVANIA ~ ~~ Estate of r.~ "o cn r~ -a s.;'. •-: ~.- , --~ .a W t. r ? . ,.;=1 1•l Deceased F ~ and ~ 5 , ~r , (each) being duly qualified a ording to law, depose(s) and say(s) that she / he !they was /were well- acquainted with _~j'D J ~l y ~ r't. (,1,5G C' [a U~ and am/are familiar with the handwriting and signature of the decedent, and that the signature of ~ D f`U f~1(,, ~ I 't Gt~ ~tttJ ~. to the foregoing instrument purporting~to be the Last Will and Testament/Codicil of ~('QUe- x is in his/her own proper handwriting. l ~7 ~ ~d ~ ~^ r : ~u~ /~C~ (Street Address') (City, Stnte, Zip) Execa~ted in Register's Office Sworn to or affirmed and subscribed before me this 1 l+~ day puty r Re ster of Wills (Street Address) / G ~.~,P~~t~~ ~ ~' ~ (CC , Stnte, Zip) Form RW-OQ rev. 10.13.0( OCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It ia~ illegal to duplicate this copy by photostat or photograph. F'td for this cet~tificate, ~6.OQ P 15729470 Certification Number HIOS143 REV nngp6 TYPE / PRIM IN PERMANENT BLACK INN Ji 1 Thi,~ i> to certit~e. that the inti~rnu)tion here ~i~~en is rorrectl~ ro)~ied from an original Certifira(e of lleath duly tiled ~tiith me as Lo~.(I Rerristrar. The oril~inal certili~atr skill he I~~~nrardcd to the State Vital RerorLl< (lflier tier )~ern)anent Yilin~r. L~`ne ~'~ ~~eir~~ AUC/ 8 /2009 Lucal Kr11i~tru Bate Issued ~ tV Cf C~ 0 -.. O ~ } ~ _~ c ~ r"T' ~ _~ r ~ ; r -r~t =, _.. r-?~ J1. t_- _i ~ ~ ~ r .jy a _ "{ i + , COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) STATE FILE NIIMRER 1. Name d Decedent (Rrsl, mkMe, lest, suffix) 2. Sex 3. Sods) Security Number 4. Date of Death (MOnm, dey, year) Dorothy R. Musgrave female 159 _ 24 X178 Au list 7, 2009 5. Age Qact Birthayl Under t year Under 7 day e. Date of Birth (MOnm, dey, year) 7. Bintgkca (City sntl state a br elgn country) Be, Piece d Deam (Check Doty one) 85 """'" °"` "°"" N"or" October 27, 1923 Carlisle, PA liosplab other: Vrs. ^ Inpatiem ^ ER I Odpatiwnl ^ DOA ®Nursirg Hama ^ Residence ^Other ~ Specify: W. County of Death &. City, Boro, Twp. d Death Sd. Facility Name pf not Inslinrllon, give slreel eM number) 9. Was Deoetlenl of Hlspank: Origin? ®No ^Ves 10. Race: American Indian, Black, Whke, etc. Cumberland N . Middleton Ztap. Church of God Home Ill yes,spedryCuban' (~~ white Mexban, Puerb Rican, arts 71. Decedent'9 UWw Ikn Kkd d work tl orre Nr' moat d workin Ne. Do nd state retlred 12. Was Decetlent ever in me 13. Decedent's Etluaeon (Specify only hlgfresl gran tromp leted) 14. M lal Salus: Marred, Never Menletl, t B Surviving Spo use Qf wife, give maiden name) )(iM o1 WoM1~ KiM d Bus4tess I Indusby U.S. Armed Forces4 Elementary /Secondary (0-12) College (1-4 or 5+) W~Q Divorced (Specilyy Switc r ra Gov't ^Yea g]Np 12 s. married Robert S. Musgrave 16. DeatlalCS Mailing Atltlress (Slreel, ciryltown, state, zip code) Decedent's Penns lvanla °rveo eetlenl N. Middleton y 801 North Hanover Street Carlisle, ^~~Reaidente t7a. 5Wle vc ®ves, oeceeent Livetl in rwp. PA 17013 Cumberland Tpwnanip. nd. ^ Np, D«etlam LNetl witnb "b cpunry Adaal Isnfla d city r Baro 18. Fatfrer's Name (First, mitltlle, last, saga) 79. Molfrer's Neme (First, mode, maiden wmame) George Rhoades Cora Albright 20a. InlonnanYS Name (Type / Print) 20b. Informenl's Meeing pMress (Slreel, city /town, slats, rip aMa) Sharon Potteiger 478 Wolfes Bridge Rd. Carlisle, PA 17013 21 a. Method d DispaNian ~ Cremation ^ Daretiat 21b. Dale o1 DLSposllion (MOnlh, ay, year/ 21 c. Plate al Dl posekm (Nana Of cemetery, cremelory or Omer place) 21d, localkM (City / town, stale, xip Cade) ^ Burial ^ RemovalfromSlate j NhsCrrKtwbnor0orreNOnAWhodze0 August 10, 2009 offman-Roth Funeral Hone and C li l PA 17013 ^ Omer-Spedty~ bYMetlkelExaminer/COronx7 ®Yea^Np ar s e, 22a~ ref Se ace (or persm ) 22b. Ucense Number 22c. Name sntl Atltlrass al Facility r 1$ e , _ H ff 138425 o man-Roth Funeral Home and Crematory Inc. 2i9 N. Hanover St. Carnpkle hems 23ec Dory when ceniryirg physidan w nd availade at time of deem to 23a. 7o the best olmy ge, tleam ocanetl at the time date erg pl a staled. (Signature an le) ~ ~ v 236. License 1JUmbar (} /~ , 23c. to Signed (Month, dey, year) y ~ ^ awry ease d tleatR ~.C.- i , lL~ ~ ..~~>~~0 ~~ /~V 1 ~ ~)/~(} l' ~~ / /~ ~C.iv / Items 2426 must De tandele0 by person 2 e of Death m 25, to ronouncad Dead (Month, dey, year) 28. Was Cese Ralerrad to Madicel Exemirrer I Coroner bra son Other than CremeUOn or Donatbn7 who Dronourrces deem. / D ~ ~. M. .t ~ ^ Yes No CAUSE OF DEA7M (See Inatructlons an amplea) r Appmzimete interval. Pert IL Enter char siynifmanl aMd~ons conln6uam to tleam 28. Did To6aca Use CanlnbMe b Deem? Item 27. Pan l: Enter the drain d events - tliseases, mjunes, or complications - Ihat tliredly caused ttre deem. W NOT emer terminal events such as wrtliac anesL Onset to Death Mrt nd resuding In Ure uMerryirg ease peen in Pan I. ^ Yes ^ Pmbabty respiretory arrest, a ventncdar fibnealion wimWl showing the elbbgy. LIST ody one alas on each rms. IMNEgATE CAUSE IR l di /~ ~ /'• / ~ / / ~ No ^ Unknown na sease or arrddbn resuaarg in m) ( ~ ~ ( ~G •.a l c.it~ , % ~~/1 29 II FemelB: _~ a ,- . w l © Due to r.As uence Ott: i Nol pregnant withb past Yaer r SeglknlisMy liar cm6lions, it anY, 6, ( ~ to the ease Farad on ens a ^ Pregnant al lime d Beam . Dua to Enter UNDERLYING CAUSE (or as a C0115eg1191MR oQ: I ~ Nol pragnanl, bur Dregnent within 12 days (tl189ase a bFe1' fhal irritletetl me ev 6 resumrg in tleath) LAST. t of oath Dua Ip (or es a cons uence o eq t): ^ Not pregnant, bur pregnant 43 tlays to 1 year d before tleam ^ Unkrrown if pregnant wkMn me pest year 30e. Wag an AMOpsy 30b. Were ANOpsy Endings 31. Manner d Deam 32a. Date of Injury (Month, tley, year) 326. Descnba How Injury Occurtetl 32c. Place of Injury: Home, Ferm, Slreel, Feclory, Performed? Aveilade Prior to Cpmpletion ~ Natural ^ Ybmzda OAice Buibing, etc. (Slxxiyt d Cause o1 Deam? ^ Ves [.(~NO ^Ves ^ No ^ Acddenl ^ Panding Investigation 32d. Time of Injury 32e. Injury et Work? 321. If Transponelion Injury (Sped/yJ 32g. Location of Injury (SlreeL hry /town, stale) ^ Suidde ^ Could Nd ba Determined ^ Vas ^ No ^ Dover I Operator ^ Passenger ^Pedashian M ^Omer ~ Speciry: 33e. Cenif~ (aleck mly one) • Cenlrydng phyrddan (Physican ceNrying cause of tleam when arwlher physitlan has prorwurxxd tleam end canpleted Item 23) 33b. Signature 7me pf CerMier •Y ~ ~ /r ~ ~ 1 ~ /~ 'r /) ~ 6y To the bell of my knowlatlga, aelh occurred due le the ceuse(st sod marmer es amtel,________________________________~ r ' A k L /`~:.~"' ` ~ • Pronouneing and cerlltying physician (Physician both prpwundrg deem end arglying to cause of tleam) To the beat of m knowled e dmM occurred et IM Ilme d t tl l d d t th ^ 33c. License Number 33d Dete Sgned (Month, tley, year) y g , , a e, sn p ace, as ue p e cause(s) end manner as abted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Medial E mi C ~ tSn~l f ~ ~ xa ner~ otoner On she basis of ex mlaDOn and / or Investl albn I m l l d th d l th ^ till) ~.3 E 5 ~ E • ` • i ~ / g , n y op n an, ea oaurre a e Ilme, tlale, end place, sntl dire la the ausNs) sntl manor as staled_ ~ Neme and Adtlrass d Person Who Completetl Cause d Deetn (Item 27) Type / Pnm Re isVar's a d Di t i t N B YfLMj~ ~~ A'te` l1 g re n r c er~ s ygp ~ I I a i 5 i ~ .Dale Rletl Month. tley, year) \ ~~ , r i ~3 N ,~,-~t,TY.~>.-~ AMY ~~,+ t~U I.1, , ~ , ,~~p~ Disposition Permit Nn. ~ ~ l4l 0 ~ O {. ~ _ ~ r 7 <f Ci -l ~ L ~ ~ .. rn r- cx: _ - ~ ~ c. - L ~ ~ ` ` I _ -~-~~ ,~ , ~ / Q _; . /~ _ _ N : sassau~irL ~ui~.sa~.~.u s~ sautuu .zno pagz.zasgns o~.unaaau a~uu aau~.o uaua ~o aauasaad auk ui puu `~.sanba.z .zau ~~ ` aauasa.zd .zau ui ` ouM ` aauasaad .zno ut `.zadud ~o _Gaaus auo uo ua~.~.i.zM • su ` ~uau~u~.sa~ puu jjzM ~.suj .zau .zoo puu `pauzuu a~oqu xi.z~.u~.sa~. `a~u.z~sn~ •~ ~CU~o.zoQ ~g pa.zujaep puu pausijgnd `pajuas `pau~iS . ~' ~, 'tiL6T `~.sn~n~ ~o Cup ~ szu~ juas puu puuu ~Ctu ~.as o~una.zau anuu I `dOd2IdHM SS;3N,LIM NI • ar ` a~u.z~sny~ • S ~aago~ `uos ~Cuz puu aa~ia~~.od • Z uo.zuuS `.za~.u~nup ~~u .zo~.naaxa pa~.n~.i~.sgns su ~.uioddu I `a~.u~.sa Buz ~o uOT~L'.I~.SIUiUIpL' aLj~. ~uianp cans su ~.au off. asuaa .zo ~:Izjunb off. jiu~ jjuus au uosuaa ~Cuu ao~ ~? puu `a~uz~sny~ •S ~.zagog `puugsnu ~~ `~.uauzu~.sa~. pine jjiM ~.suj ~:uc siu~. ~o .zo~.naaxa su ~.uioddu I - 11I •uoi~.aipsianC ~.ua~.adu~oa ~o ~..znoa ~ ~o .zap.zo uo .zo `saua~C gj ~o a~u auk suiu~.~.u ~.zuiai~auag auk ji~.un ~unoaau s~uinus pa,ansui ~Cjju.zapa~ u ui .zouitu pzus ~o au~uu auk ui plan ag jjuus ~C.zuiai~auag .zouiu~ u o~ ajqu~.nq -i.z~.sip auzoaag jjuus gaigM a~.u~.sa ~~u ~o aauus Cud - III • ajduzts aa~ uz puu ~Cja~.njosgu `sadzi~.s ,zad anssi ~uininans .zau .zo siu off. pasuaaap ~z pine `~utnzj 3:z `•ar `a~u.z~sn~ •S ~.aagog pine .za~za~.~.od •Z uoauuS `ua.zpjtua oM~. Buz o~.un sa.zuus junba ui a~u~.sa aai~.ua btu u~.uanbaq puu asi~ap `a~i~ I `au~ a~i~.zns ~.ou jjuus puugsnu Cut ~I - II • ajdu~is aa~ ui puu ~Cja~.nj -osgu `anu.z~sny~ • S ~..~agog `puugsnu ~~ off. a~.un~.is .za~aaauM ` juuosaad puu jua.z ` a~.u~sa a.zi~.ua dtu u~.uanbaq puu asi~ap ` ani~ I - I • apuuz ~Cjsnoinaad anuu I uaiuM sjjzM jju axona.z puu jjzM ~.suj Cut aq off. siu~. a.zujaap `uiuunj~(suuad `~~.uno~ puuj -.zaguin~ ` ajstjau~ ~o u~noaog auk ~o `Q11d2I~Sf1I~ '2I ~CH,I,02IOQ ` I ~~caut~fisar~ ~u~ ~~} X~~~~