HomeMy WebLinkAbout11-20-09PETITION FOR POBATE AND GR.r~NT OF LETTERS
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REGISTER OF ~tiILLS OF "Y-'+-t':~ 1 COUNTY, PEN~,~SYLVA~I~
Estate of ~r ~~ J~a -,.~ 5 =,,.~ ~~ ~.~ File Number ~ ~ f-C~-. I ' ~~'
also Known as
,Deceased Social Security Number 3 ~' ~ _~~ G 3 5 / S
Petitioner(si, who is/are 13 years of age or older, apply(ies) for:
(COtbIPLETE 'A' or 'B' BELOGV:)
A. Probate and Grant of Letters Tes amentary and aver that Petitioner(s) is /are the ~ x L t. ~ ~ - named in the
last \~'ill of the Decedent dated 7 i Zou " _ 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) of`ered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person
^ B. Grant of Letters of Administration
Petitioner(s) after a proper search has /have ascertained that Decedent ]eft no Will and was survived by the following spo~.rse (if any) and heirs: (/f
Administration, c. t. a. ord. b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
_ ~ ~ ~ ~~-~ 6`~ - ,
(COflLPLETE LV ALL CASES:) Attach additional sheets if necessarv. - 'i7
=:::
Decedent was domiciled at de~th in C .~~, ~z T I:~ ~~~ County, Pennsylvania with his / he last principal resr~ce at ~~
(List street address, town/city, township, courtly, state, zip code) ~ 7.r- ~
G / /' ((~~ I ' / / p ) J
Decedent, then ~._ years of age, died on (C ( 3~ 'L.v "`~ at lr r a~ s )t ~ .( V j(~, / `t~:,,,~ v, l I ~
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ _ 1 ~- t~ t~ t~ t'
(lf not domiciled in PA) Personal property in Pennsylvania $ __
(If not domiciled in PA) Personal property in County $
Value of real estate in Pennsylvania $ ~ ~~ i~ p r.~ ~>
ri
situated as follows: ~ (y N ~' ~~._.~ ~ ~'` ^~-~ L ~ ~l ~, n „` ~ b ,,,„ ~ ~ `f / 7 Z )_~
v
Wherefore, Petitioner(s) respectfully request(;) the probate of the last Will ar.d Codicii(s) presented with this Petition and the grant of Letters in the appropriate form to
the undersigned:
(ifapplicnble, enter: c. t. a.; d. b. n.c.l.a.; pendente life; duraate absentia; durcnte mutoritn!ej
~_ Signature Tvped or printed name and residence
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Forst Rsv-m_ r~~~ to.13.06 Page 1 of 2
Oath of Personal Representative
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COUNTY 0 F i,l.G''~'~~-~.~L~.~sryt ~U
CONI~IONbVEALTH OF PENNSYLVANIA
SS
The Petitioner(s) above-named swear(s) or affii:n(s) that the statements in the foregoing Petition are true and correct to the best of
the kno~.vledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly
administer d,e estate according to law.
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Signature of Personal Represen
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Sionatur2 of Personal Representative
For the Register Signnttue ojPersonal Representative ~~~ e-.a
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File N umber:
Estate of / t?ece"aced `~'; P:-
Social Security Number: .
Ja~J~ "~ ~~ -~~ 15 Date of Death: = t; - r
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AND NOW, .10~
(~_~ _i ~ ~
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"~ ' '~ ~ Ll`_~ ~ , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, I IS ECREED that Letters~~F'l~.~c. hn~~.'Lti~
Sworn to or affirmed an,~~d,,sr:bscribed
before me the ~'~~ day of
a~~~~?
are hereby granted
and that the instrument(s) dated
described in the Petition be admitted to
and filed of record as the last Will (and Codicil(s)) of Decedent.
FEES
~~L
~~ L)
Letters .............. $
Short Certificate(s) ........ $ Ci o~`~
Ret~ru~ciation(s) .......... $ _----
ir, the above estate
... $
.. $
.. $
..~
..~
... $
..~
... $
TOTAL .............. $
Fnnn RvV-0' rev. 10.13.0(7
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.:
Address:
Telephone:
Register of Wills
Pale 2 of 2
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~a~A~= HE(aISTR,AH' CEHTiFICAT1aN OF DEATH
~~~~~±~<~: It is illegal to tiuplicata this copy by photostat or photograph.
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H105~143 REV 1112006
TYPE /PRINT IN
PERMANENT
BLACK INK
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS -~ ~~
CERTIFICATE OF DEATH `'_' -'`
(See instructions and examples on reverse) CTATF FII F NIIMRFFT ~ -
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fTkulh ( Ih, tlay, yeatl=, "
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2. Sex 3. Social Security Number 4. Dat
1. Name M Decedent (First, middle, last, suKix) y
p
Male 383 _ 10 _ 3515 D(il" e~ 3D 00~
George R. Rae -"~
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e (Last Birthday) Under 1 year UMer 1 tlay 6. Date of Birth (Month, day, year) 7. Birthplace (City end state or for
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eign country) 6a. Place of DeaN (Check only one) ----
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. MWxhx- Days Hours MnMea HOaplldl: /
e
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ef: -)> x„J I ,
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Yrs. 4/15/18 Port Huron, MI ^Inpatient ^ER/oalpatiem ^DOA ,
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CJ Nursing Home ^Residence Speciy:
Bb. County o/ Death &. Ciry, Boro, Twp. of Death Btl. Fecdhy Name (II rat In5ldulian, gNe street antl number) 9. Wes Decedent of Hispanic Origin? ~ No ^ Ves 10. Race: American Indian, Black, White, etc.
(tlyes.apecilyDuban, (S°ep~
green Rio! e Villa +Ihite
Puerto Rican
etc.)
Mexican
e
Cumberland W.Pennsboro TWp. ,
,
11. Decedent's U::ual Oct lion KiM of work done du most of world tile. Do not state reliretl 12. Was Decedent ever in the 13. Decedent's Education (Spepty Doty highest grade completed) 14. Madlel Status: Married, Never Marrietl, 15. Surviving Spouse (h wife, give maiden name)
Widowe4 Divorced (Specdy~
Kind of Work IGntl of Business / IMUSIrK U.S. Armed Faces? Elementary /Seconds eg )
ry (012) Coll a (1 d or 5t
12 5+ Widowed
Geoc~aphy Professor 5hippeTdsbLTrg Univ. ®Yes ^No
16. Decedent's Naidng Address (SreeL city /town, state, zip code) Decedent's
Pennsy Did Decedent
lvania Uve ins 17c
Decetlenl Lived In Twp.
^Yes
114 N. Prince St. .
,
Actual Resitlence 17e. Sate
TownsMp?
Cumberland nd.CC1 No,Decadenlwedwdhm Shippensburg
Shippensburg, PA 17257 17b.Caunty Actual limos of Ciry I Boro
Father's Nama (First, middle, last, sWfix)
18 19. MoMer's Name (Frst, midde, maiden surname)
.
George Rae Charlotte Ramsay
ZOa. IMormant's Name (Type / Pdnt) 20b. Intomant's Metling Atldress (Sreet ceY I lawn, slate, rip catle)
Shippensburg, PA 17257
114 N. Prince St.
Thomas S. Rae ,
21 a. Methotl of Dispositron i ®Cemation ^ Donation 21b. Date of Disposition (Month, day, Year) 21c. Place of Dsposihon (Name of ceme9ery, crematory or other place) 210. locatron (Ciry /town, slate, zip mtle)
^ Burial ^ Removal from Sate ;Was Cremation orDOnatlonAUthorittdlIn~a 11/1/09
^ Smithsburg Crematory Smithsburg, MD 21783
No
^ Other - Spt'dly j try Medic Ezaminer / Cttoner? !:J Yes
nC
.
r IFunerai nacwl such) 22b. Ucense Number 22c. Name and Address of FadlAy Oge ranger- r1C er Liners Ome,
l
~ 22
u
a.
FD-011776-L
~ P.O. Box 336, Shippensburg, PA 17257
• ~
,
Complete hems 23a< oNy when ce 'ng
physician's nal Ilvailable al time of tlealh 10 23a. To the best of my knowledge, tleeN attuned at Vie time, tlate and place aWled// (,S,ignature antl Lille)
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~ ~1 7~ ~L~C
knl 23b. ~ic~l /~e_ Number
~ ~ (/J D 7 9 S S 2//3~}c. Date Signed (Month, tlay, year)
D~C~o b2r ~ v, ~DO 9
cedily pose d creath. ~;
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e of Death
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24 25. Date Prawuncetl Dead (Month, day, year) 26. Was Case Retertetl t etliral Examicer /Coroner for a Reason Other Than Cremation or Donation?
Items 24-26 must be canpieted by person
who Pronounces tleatn. n
.
a ~, a 5 A M. t o bar .3D ao 0 9 ^ Yes o
CAUSE OF DEATH (See Inatrucllona and examples)
di , Approximate interval:
l Patl IC Enter other siondicant corltldiols contdbutirw to death,
cause
iven In Pad I
di
i
the untled
in
b
t
t 26. Did Tobacce Use Conldbule to Death?
^ Yes ^ Probabty
ac artes
, Onset to Death
Item 27. Pad I: Enter the chain of events -diseases, mjudes, or complications -that diredty rausetl the death. W NOT enter terminal evems such as car g
.
ng
n
y
g
u
no
resu
respiratory arrest, or ventricular tibdllation wdhoul sMlwing the etiobgy. Lill only one cause on each line. ~ ^ No ^ lMkrrown
IMMEDIATE CAUSE Final disease or '-^ _ _ C ~ Q-
condixxl resuding in ~ath) ~ (T~--~ Q
~ ~ ~ Q- / ~ ~ ~J J.
\ ~ y ~ 29. II Female:
nt within
ast
ear
^ N
n
l
.
~
_~ (,
a p
y
o
preg
a
Due to (or as a nsequence op: '
t
^ Pregnant el time of tlealh
it an
ditions
il
li
t
y, b,
,
s
con
SequeMia
y
leading to the ceiuse listed on Ilne a. Due to (or as a consequence oQ:
Enter the UNDERLYING CAUSE
that initiated the
tlisease or injur i
r
~ ^ Not pregnant, but pregnant wihin 42 tlays
of tlealh
t,
y
(
events resuding m tlealh) LASL I ^ Not pregnant, but pregnan143 days to 1 year
Due to (or as a consequence on:
r belore death
^ Unknown tl pregnant within the pall year
d
30a. Was an Autopsy 30b. Ware Auopsy Fkxkngs 31. Manny of Death 32a. Date of Injury (Month, tlay, year) 3ffi. Describe How Injury Occurted 32c. Place of Injury: Horne, Farm, Street Factory,
Odice Budding, mc. /Specity)
Performed" Available Pdor to Complelbn
? {-~/
Natural ^ Homidde
of Cause of Death ^ Acddent ^ peMirlg Imesligalion 32d. Time of Irryury 32e. Injury at WoM? 321. II Tmnsporlation Injury (Speaty) 329. Location of Injury (Sreel, city /town, sate)
^ Yes [Y7 No ^ Yes ^ No
^ Yes
^ No ^ Driver /Operator ^ Passenger ^Pedestdan
) ^ Suicide ^ Couid Nol be Detemkrled M ^Other ~ Spenly
33a. Cedifier (cneck Doty one) 33b. Signatue end firer
Q
• Certflying physician (Phys'wian certihying cause of death when another physician has prorwur d tlealh and completed Item 23)
_
ner as staled
th
d
_ _ _ _ _ _ _ ,
' a
~
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
man
e cause(s) an
To tMr best of my knowledge, death occured due to
• Prommncing and certifying physician (Physician both prowurlMng death antl certilying to cause of tlealh)
d
^ 33c. License N r 33d. Date Slglred (MOnlh, day, year)
/
'
[
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zr
_ _ _ _ _ _ _ _ _ _ _
To the best of my knowledge, death occurted el the lime, tlate, and place, end due to the cause(s) antl manrrer es smte _ _ _ _ _ _ _ ~6 (O ~~ S ~ ~p
~
~
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• Medilal Examitrerl Coroner
On the basis of examination end I or investigation, in opinion alb occurred el the time, date, and place, and due to the cause(s) antl manrrer as stated- ^
34 Name end Adtlress of Person Who Completed Cause of Oeath (Item 27) type I Print
Dr. Darryl Guistwite
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Registrar's Signature and Distr IN Filetl (Monn~~~ r)
36 522 ,S• Pltt St. , Carlisle, PA 17013
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// D'ISposition Permd Na. l./ (y~ (~~
RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse S uare
Carlisle, PA 1713
RAE GEORGE R
Estate File No.: 2009-01079
Paicl By Remarks: 1RwCHARD LEWIS BUSHMAN
Receipt Distribution
Receipt Date: 11/19/2009
Receipt Time: 15:28:41
Receipt No. 1059017
Fee/Tax Description Payment Amount Payee Name
PET LTRS ADM OTHER 20.00 CUMBERLAND COUNTY GENERAL FUN
JCP FEE 10.00 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN
----------------
Cash $35.00
Total Received......... $35.00