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HomeMy WebLinkAbout11-05-09PETITION FOR PROBATE AND. GRANT OF LETTERS REGISTER OF ~V'ILLS OF Cy.v~ ~.c~ ~..v-~t COUNTY, PENi~ISYLVANIA Estate of _ ~~" "[~ L .. D f,~'t-(~vt. ~~"- File Number ~' ~ ~ ~~ ~ I ~ l ~ ~~ also known as Deceased Social Security Number ~~2'~Z-' ~ 3 ~f Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COt>'IPLETE 'A' or 'B' BELOW.) A. Probate and Grant of Letters Testamentary a d aver that Petitioner(s) is ,t~nr~'the LX ~' ~ ~~ ~'k named in the last Will of the Decedent dated ~~'/~'!'~~^- .~c ~~G~n~d~ ills) dated ~~i~ (State relevant circumstances, e.g., renunciation, death of exeartor, etc.) Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the insttument(s) offered for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ^ B. Grant of Letters of Administration (If applicable, enter: c. t. a.; d.b.n.c.t.a.; pendente life; durance absentia; durance minoritnte) 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 Adrrrirtistratiort, c. t. a. or d.b.,t.c.t.a., eater date of Will in Section A above and complete list of heirs.) Name Relationshi Residence (COMPLETE IN ALL CASES:) Attach additiot:al sheets if necessary. Decedent was domiciled at death in ,y ~ -~/L ~ .a .~ County, Pennsylvania with 1°ris /her last principal residence at 7C.~tIG (List street address, torvrr/city, township, county, state, zip code) Decedent, then ~ 3 years of age, died on ~~ 2S /~ at /~lj`J~'~ ~pUL 19L-7 Gc--T~3~'S ~ ~~ G ~~''~ Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ /lj, ®cv / (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania $ ~,3~lpesu © w situated as follows: `/t'>L-~ ~L~ (oC-~~`~STj~ ~ /~1 ~-/~~'°~' /1-~ / y~ ~ .r: .+ i ~s ; Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with dais Petition and the grant of I~ the appra~te forti~,td ' C the undersigned: ii''##''~~ .+C iw;, .: t,,.,_, :i...t Si nature T ed or rinted name and residence ~ -~-~ ~--~ +Q ~~, ~ ~ ~_ `_ _ ~, "'+.~ .~•~~ C~,~ h~ 1 ~.„ a PA t ~v~~v Form R 6V-D? rep-. l 0.13.06 Page l o f t Oath of Personal Representative COM1~10NWEALTH OF PENNSYLVANIA SS COUNTY OF ~`,^n ~~~- ~-"`'~" 'The Petitioner(s) above-named swear(s) or affirni{s) that the statements in the foregoing Petition are tine 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 an~d~truly administer the estate according to law. ~ } ;` s. _ ,. X11 ~' . A Af . ~ ~ ~` '* `~~ Sworn to or affirmed and subscribed ~' ~ ••C ~ -~ Y` ~'° L_ ~-- b~fore me the day of y ~~.~, 2001 ~ ~ , '~`~ For the Register Signature of PCYSOna~ Representative ° :~ ~ ;~~ tw~'~ Ct~ ~..., ~..,~ ...~ __ ~c _ .~•, Signature of Personal Representative ~ _ ~' _ ~~'~j ~ -~-~- ~~ ~,~ ~-~ r °Y? SignatLU•e of Persona! Representative File Number: ~ ~ ~~ Estate of ~ ~~~ } L '!~ ~ 6Y` ~"~ ,Deceased / .- 2 / _ Social Security Number: l ~~" ~Z ~ s ~ 3 ~~ Date of Death: l ~ ` Z'~ ^ ~'~'`~~ AND NOW, ~, ~, in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT CREED that Letters r~>ii+ir~i~'~ are hereby granted to CL As? h' L • Jl rL~ ~ in the above estate and that the instrument(s) dated ~7~-'7~n"3'''~~1v2 1 G ~~ described in the Petition be admitted to probate and filed of recor as the last Will (and Codicil(s)) of Dece nt. (~ FEES ~G?~ J_ Letters ............... $ ~~ V• ~~ Register ojWills Short Certificate{s) ........ $ ~~ Rene ~n tion(s) .......... $ G ... $ i, o,~u -,.-- ... $ v~~ ... $ ... $ ... $ ... $ ... $ ... $ TOTAL .............. $=~~--/1 Attorney Signature: Attoney Name: Supreme Court I.D. No.: Address: Telephone: r-~,•„f Rw-o~ rev. ia.~3.vr Page 2 of 2 z~-zoos-~~3~ OATH OF SUBSCRIBING WITNESS(ES) REGISTER OF WILLS ~ ~ . r t~LY~1'~~~1~„~., ~. COUNTY, PENNSYLVANIA ``" ~~~" ~ " Estate of ~'~ tii ~ ~ _ ~~~ ~-- - I~, e „~ .. ~ ,'' ~ ~; ~o ~n C"" ' c'~ ~ I r eas~~ ;~,~ ~.. .:~ (each) a subscribing witness to (Prin Name/s) the C~ Will ^ Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that sh / he /they a /were present and saw the above Testator / estatr' sign the same and that / he / th signed the same and that ~sl~ / he /they signed as a witness at the request of the Testator / stat ' in e /his presence and in the presence of each other. (Signature) (Signature) ~foo ~ H d~ ~ ~,a~,-~~ v (Street Address) (City, State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed oefore me this '~~ day 7 -~~ Deputy f r Register of Wills (Street Address) (City, State, Zip) Executed out of Register's Office Sworn to or affirmed and subscribed before me 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.) NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of notarization. For~rt R W-03 rev. ! 0. ! 3.06 OATH OF SUBSCRIBING WITNESSES} ~J REGISTER OF WILLS (~-~~ ~ l~ COUNTY, PENNSYLVANIA Estate of ~ ~~ S ~ - ~~ Z ~ ~- ,Deceased IIA~ ~2 ~w G ' Z~ `'~ , (each) a subscribing witness to (Print Name/s) the Will ^ Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that sh / he /they wa /were present and saw the above Testator / estatri sign the same and that sh / he /they signed the same and that / he /they signed as a witness at the request of the Testator / estatri in /his presence and in the presence of each other. L (Signature) (Street Address) ~e~ (~a ~ /1 oS~ (City, State, Zip} tw _.. : (Signature) ~ _ -- ~~ ~' "` -, (Street Address) ~j ~ -~} ~F" ^ /Y~ ~' ~ .. Y .~ (City, State, Zip) ~ .,,,,. '~ ` -~, Executed in Register's Office Sworn to or affirmed and subscribed before me this ~~h day of /~/e v e j-s--, ~ ~ r ~ ~2 Q ~, 9 Deputy for Register o ills Executed oict of Register's Office Sworn to or affirmed and subscribed before me this ~~ti day of !Y ~ t' P ~~--~ ~~ r ~ D O Notary blic , My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) NOTE: To be taken by Officer authorized to administer oaths. Please have present the orsginal M~,Tc~ ~t~~+~d~~C1VFA :.~u ~ ~ .. ,.,,~. ''may pUI3iIC Form RW-03 rev. 10.13.06 t ruttt~ ~~R' ~+~ ,.s '~ a~rad County ivly ~:ork'er~-a~~ :~.~, . :. April 22, 2011 f'~arrtb~r, prxrtnaylv~xoi~ r~;;~,aotiiation of Notaries 105.805 REV (01/07) ~ ] a~~Ca" / /1 ~{f _ LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 P 15691585 Certification Number REV flntx>s COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS 'RINT IN 4NENT CORONER'S CERTIFICATE OF DEATH K INK See instructions and examr~les on reverse ~E'27_ 1 Zn ~ P ~ CTATC GII G .II I\~oCo This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. p~`' OCT 2 7 2009 Local Registrar Date Issued fV w~ti~ :5.1 ,.~ 'r ~...i . `.') 4 ~ i '~ ~ ~ ~~--~++~~,,„,, ~Y 1 ue " f..i ~ - ~ ...s ~~;~ w~ N ;.,:.. C.,~7 ~. "' ' u 1. Name of Decedent (Fret, ndddle, last, suffix) 2. Sex 3. Social Secudry Number 4. Date of Death (Month, day, year) Doris L Palmer Female - 22 ~ 55 October 25, 2009 5. Age (fast Birthday) Under 1 year Under 1 de 6. Date of Birth (Month, day, ear) 7. Birthplace (City and state or is ' country) Ba. Place of Death (Check oMy one) 8 3 Yrs rAOnths Deys Hour Minutes January 13, 192b Lemoyne, P~ Hospital: ^ ^ Omer . lr>padent ERIOut bent pe ^ DOA ^ Nursing Home Residence ^Other Spedy: 8b. County o1 Death Bc. City, Bor bf Death 9d. Fedliry Narrre (II rat instHtAion, give street and number) 9. Was Decedent of Hispanic Origin? o ^ Yes 10. Race: American Indian, Black, White, etc. Cumberland Lower Allen 4006 Gettysburg Road (tf yes, speciy Cuban, g~rjy) ~ Mexican, Puerto Rican, etc.) w lte 11. Decedent's Usual Occ tion Kind of work rl orte dart most of work INe. Do rat state retired 12. Wes Decedent ever in the 13. Decedents Educatkn (Specify only highest grade comp leted) 14. Marital Status: Marled Never Married 15 Survivin S o use (It wile ive aid Kind d Work Kind of Business 1lndustry U.S. Armed F ? Elementary /Secondary (0.12) College (1-4 or 5+) , , W~'~• Divorced (Specify) . g p , g m en name) housewife own home ^Yea No 12 widowed 1 B. Decedent's Mailkxj Address (Street, city /town, state, zip code) Decedent's Did Decedent ~,/ Actual Residence 17a. Stale P e n n s y l v a n i a Live in a 17c ~t~}i'es Decedent Liv¢d in r• n >:J ? Y ~ ~ ~? •1 4 0 0 6 G e t t y s b u r g R d. . , T,~,p, , m. county Cumberl a n d T°w"a~"p? 17d. 4L~J No, Decedent Lived within Cam ' H i t P A 17 O l t Actual amts a city r Born 19. Father's Name (First, middle, lest, suffix) 19. Mother's Name (First, middle, maiden surname) ` C?~~~t~r H. D2ci,maz M. Grace 0rn2r 20e. Informant's Name (Type /Print) ~ 20b. Informant's Mailing Address (Street, city /town, state, zip code) 1 7U5 {~thr .1 G. L~ii~ , 4517 F1or~nce ~ ~~-. , ~nt.'?,M'Chdt].iC.:;~?u.r~ ;oA 21a.MethoddDi sPoeitron ~ ^ Crtrmanon ^ Donatbn 21 b. Date of Disposition (Month, day, year) 21 c. Place of DisposlNon (Name of cemetery, crematory a other pace) 21 d. Locatbn (City /town, state, zip code) nal ^ Removal from State (Was Cremetlon tx DonaNon Authorized ^ No r • Speciy: j by Medical Examiner /Coroner? ^ Yes ~ ~ t . ~ (~ '~ ~ 0 (~ ~ ° ;~ O 11 1 I'1;J G .r '~ ? fl C ~ ill ~ t n r Y C 3 m ~ H 111 p .~ 1.7 01 1 , tare d F Servkxt Ucertsae (a person string as such) 22b. License Number 22c. Name and Address of Fedfiry ,ts.~ FD-013173 ]• .. a^,s~l~na~ FH&CSS, 32~ Humm~t ~v~. ,La:noyna, P?1 17043 e Hems 23ac ony when certifying 23a. To the beat of my knowledge, death occurred at the tlme, date and place stated. (Signature end title) 23b. Lkense Number 23c. Date Signed (Month day year) physician Lt not available at time W death to , , corny cause a deem. Hems 24.28 must be competed by person 24. Time of Daath PrX . 25. Date Pronamced Dead (Month, day, year) 26. Was Case Refered to Medkal Examiner f Coroner for a Reason Other than Cremation or Donation? who pronounces death. $ ; Q Q A , f,4. October 2 5 , 2 0 0 9 Yes ^ No CAUSE OF DEATH (See instructions end examples) r Approximate interval: Hem 27. Part I: Enter the tdlein of events -diseases, injuries, or compketlons -that dledry caused the death. DO NOT enter terminal ¢vtxlts such as cardiac arrest, r Onset to Death l ' Part II: Eller other slanificant rb inns _.~., ' Jinn to *th, but rat resulting in the underlying cause given in Part I. 28. Did Tobacco Use Contribute to Death? ^ Yes ^ Probably resp rotory anent, or ventricular fibdlleHon without shrnving the etfoklgy. List Doty one cause on each I tne. r r IMMEDIATE CAUSE IFlnal disease a ' ^ No ^ Unknown condllbn resultng in death) r ~- a. Occlusive Coronary Artery Disease r 29. if Female; Dire to (or as a tonsequence of): ~ ^ Not pregnant within past year list conditions, it any, b. ~ to cause NMed on one a. ^ Pregnant at Gme of death Enter the UN~RLYMq CAUSE Due to (or as a consequence oft: i Not hnanf, but pregnant within 42 days ^ Idleease a injuy tltat ktinated the c t Ls resulting m death) LAST. r of dean Due to (or as a consequence of): r ^ Not pregnant, but pregnant 43 days to 1 year d, r t before death ^ Unkrawn it pregnant within the past year 30a. Was an Autopsy PeAormed? 3i1b. Were ANopey Findxtgs AvaAade Prior to Competion 31. Manner of Death 32a. Date of Irtjuury (Month, day, year) 32b. Describe How Injury Otxurred 32c. Place of Injury: Fbme, Farm, Street, Factory, of Cause of Death? Natural ^ Fbmicide Office Building, etc. (Specify) ^ Yes '~, No ^ Yes ^ No ^ Accident ^ Pending Invesnganon 32d. Time of Injury 32e. Injury at Work? 32f. If Transportation Injury (Sptrcity) 32g. Location of Injury (Street, dty /town, state) ^ Suicide [] Coukl Not be Determined ^ Yes ^ No ^ Driver /Operator ^ Passenger ^Pedestdan M. Other • ~ry~ 33e. Certifier (check only one) 33b. Signature end C • phyaklan (Physiciert ceniying cause of deeM when arather ptysician has pronounced death and completed Item 23) Coroner TotMbesttNmyknowNdge,deethaetxroddwtothecauaa(a)andmanrlerasahtad___--^.,----"---"--"-"----"-"""""- ^ - • Pronourlclrtg end certfying physklul (Physidan btklt pronouncing death and certifying to cause of death) To tM hest tN my knorrMdge, death occuned M the time, dots, end Place, and duo to the rouse(s) and manner a stated_ - _ _ _ _ _ _ _ _ _ _ ^ """""" 33c. License Number 33d. Date Signed (Month, day, Year) • MetikslExamkter/Ctxorter lM the bale tN examinegon tutd I tx tnvastlgaNOn, In my opMbn, death occurred at the tMie, date, end plats, and due to the cause(s) and manner a stated" ~ October 26, 2009 ~ N~ Papon ~;~ ~~~ ~ Typo J Print 3s.RegiatreraSignatu otetdctN .~ - ~ l ~ E f I ~ ~ I ~~ I 3s. Data (Mont y,yar) d 6375 BaseLhore Road, Suite #1 M h ic b PA 170 0 f aL; ~~ ec an urg, s 5 Disposition Permit No. O .J tp ~ ~ ~ S 21- Zoo~_ /v3~ Last Will and Testament of -~ .~ 1 _.~ Doris L. Palmer ~" `~ ~' Q~J ~r"-r- ~ t, I, Doris L. Palmer, of Lower Allen Township, Camp Hill, PA do ~ `~ ptl~lish`~~s declare this to be my Last Will and Testament, hereby revoking all wi eret~by fit i any time heretofore made. ~, `~" ~ ~~ 1.) I give, devise and bequeath my entire estate to my daughters, Karen Louise Kelly and Kathryn Grace Leib. 2.) I appoint my daughter Karen L. Kelly as the Executrix of this last will and Testament. 3.) My Executrix is to serve without bond and to be compensated at 5% of the Estate. 4.) My Executrix can hire professionals to help with the preparation of tax returns, sales of real estate, mutual funds and retirement accounts, life insurance policies etc. IN WITNESS WHEREOF, I, Doris L. Palmer, the Testator, have hereunto set my hand and seal this I CQ ~~ day of ~ ~,~,~,2009. Doris L. Palmer Signed, sealed and declared by the above named, Doris L. Palmer, as and for her Last Will and Testament in the presence of us, the subscribing witnesses, who at her instance and request, and in her presence, and in the presence of each other, have hereunto set our hands and seals this (.~ `~ day of ~ ~~2009. Karen L. Kelly, Witness Kathryn G. Leib, Witness