HomeMy WebLinkAbout12-21-09PETITIQN FOR PROBATE AND GRANT 4F FETTERS
REGISTER OF WILLS OF Cumberland COUNTY, PENNSYLVANIA
Estate of Dorothy R. Moucrs J ~r
Zile Number / `~"' Q - (~~ '~
also laio~vn as
a G~ '~ L '- `~~"4a,j
,Deceased Social Security Number X863
Petitioner(s), ~vlto islare 18 years of age or alder, apply(ies} for:
(COMPLETE A' or 'B' BELOW.} ~ ~"'
C (~ ; : +;~
~ -~U-
A. Probate and Gractt of Letters Testameatary and aver that Petitioners} is /are the ~ crn-1 ` ' 7 -±~
last Will of the Decedent dated ~ ~~" narntact ~:t'~~
. ,__ and codicil(s) dated '-. ~='`'~"t~'TC3'
rY~~~ ~ ~ F~. '~~~~
--,-
(SJute relera-rt circulllstances, e.~, Te-!u!lClaJlaq, death ojexecutar, e-r.J :" ~ --.. _ ~==~~
.,. J. t
Except as follows, Decedent did not marry, was not divorced, and did not have n child born or adapted after executio ~ _~ ~ r q
~,~ ~
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: n of the insinirrt@i~(s) aff'erec~=~r ~~
Q B. Grant of Letters of Administration Pendente Lite
(Ijapplicable, e-rter.• c t.a.; cfb.n.c.J.a.; pe-lderlJe life; durance abselltiu; dura-rte »rino-•itoteJ
Petitioner(s) alter a proper search has !have ascertained that Decedent left na Will and was survived by the fallowing spouse (if any} and heirs: (Ij
tldr-:iriistraliwr, c.l.n. yr db.n.c.t.a., e-rler dale of Tlfr~l i-r Sectian~I above artd complete list of/Iei-s.}
Name Refutioltshi
Cindy Schaeffer Residence
Daughter I30 Lebo Road, Carlisle, Pennsylvania 17013
Rita Shelrnan Daughter
830 Meadow Brook Road, Carlisle, Pennsylvania 17013
Decedent at death owned property with estimated values as follows:
(COMPLETE WALL CASES.) Attach additional sheers if necessary.
Decedent was domiciled a~E deatJi in Cumberland County, Pennsylvania with his !her Iasi principal residence at
Church of God Home Inc. SO1 N. I~lanover Street Carlisle, Penns ivania 17013
(List street address, totir-r/riq ; Jon~nsllip, corrnry, state, ^ip code)
Decedent, then g4 years of age, died on Jane 29, 2008
At
situated os follows:
Wherefore, Petitioners) respectfully request(s) the probate of the last W it! and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to
thc^ rsigned:
(Ifdomiciled in PA} All personal property -- ~~? -
(lfnot domiciled in AA
} Personal property in Pennsylvania $
(Ifnot domiciled in PA} Personal property in County ~
Value of real estate in Pennsylvania
$ -- c~ -'
Form R1V-02 rev. !0.]3.06
7~ 7
Page 1 of 2
Oath of Personal Representative
COMMQNWEALTH OF PENNSYLVANIA :
SS
COUNTY OF CUMBERLAND
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Fetition 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. /"~
Signatrtre~6f Pyfsatta! Representative
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V ~ ~N
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Sigrrat rite of Persona! Representative -~-
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Far the Re ester tV ' ~ {
~' 5ignature of Persona! Representatn~r . Ca i f,.~ "'- _ : ; -,
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File Number. „~ --~,
Sworn to or affirmed and subscribed
before me the o2., ~ day of
~2
Estate of Darathy R. Mouers Deceased
Social Security Number: 209-12-9853 Date of Death: June 29, 2008
AND NOW, ~ 4 ~~ ~~. ~ ~ ~~ in consideration of the foregoing .Petition, satisfacto roof
having been presented before me, IT IS D.ECItEED that Letters Pendente Litc rY p
are hereby granted to Jonathan Crest, Esquire
in the above estate
and that the instruments} dated
described in the Petition be admitted to probate and filed of record as the last 1~i11(and Codicil(s)) of Decedent.
FEES
Letters .. , .. , • , , , , , , , , $ ~Q .(S~ Register ajlt'ilJs
Short Certificate(s) .... , . , • $ $ • ~ Attorney Signature•
Renunciation(s) .......... $
$ Attorney Name:
' ' ' $ Supreme Court I.D. No.:
... $
.. $ Address:
... $
... $
... $
' S Telephone:
... ~
TOTAL .............. $
Farnr !t!Y-0? rev_ 10.13.06
Pale 2 of 2
his is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with
the Vital Statistics Law of 1953, as amended.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
58.7588
No.
H10S143 REV 11/2006
TYPE /PRINT IN
PERMANENT
BLACK ~
tiA
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G
1. Name d Decedent (First, nddde, teal, wNx)
Dorothy R. Mouers
5. Age (Last BfrHMaY)
84
Yrs.
Bb. Corsdy of Deem
Cumberland
~" ( Deya I Houa I ktinaes
12. Was Decedent ever in the 13. Decedent's Education (Spr
U: OAmred F~ Ek3mentary / Secland2ery (0.1t
°ecedenea PA
April Residence 17a. staN
17b.Corarty Cumberland
April 2, 1924 Newville PA ~
&. City, Baro, Two. of Death Bd. FadWy Name (M not instikrlion, give street and mardrer)
S. Middleton Carlisle Regional Medical Center
Seamstress I`NidoF/1nOi~0'''
Shoe Factory
18. Decedent's Me~irrg Address (SrreeL city /town, stMe, zip code)
801 N. Hanover St.
Carlisle PA 17013
16. Famx's f4errre (First, middle, last, atdfbr)
Cloyd McCalister_
20e. Intortnerd's Name (type /Print)
Rita Shelman
21a. Mailed of Dsposition ! . ®Cremelbrr ^ Daration
^ ^ Muriel ^ Removal horn Slate Crerastfort a oorrdon Aulhc
Linda A. Caniglia
State Registrar
DEC 1 ~ 2009
v. Deter:
etient ^ ER / OrrtpatieM ^ DOA ^ Nursing Hone ^ Residence ^Other • Specify;
9. Was Decedent of Hispanic Origin? ®No ^ Yes 10. Baca: American Indian, Blade, While, etc.
(M Yes, specify Conan, Spspq;
Mepcan,PuertoRipn,etc.) ( White
srrpbted) 14. Marital Status: Married, Never Married. 1s. surviving Spouse (If wife, give maiden name)
or 5+) Widowed. Divorpd (Spedly)
Widowed
Tavrshfapo 17c.®Yes,DecederdLivedn N. Middleton T
~v.
17d. ^ No, Decederd Lived witldn
Actual Limits d ~ / Boro
1g. Moth's Name (Fxst.gdd~e maiden surname)
aOml a 'son
20b. InfonnaM's Making Address ( dy / b,m zp
830 Meadow~irook 1: ,~arlisle PA 17015
21b. Date d Disposteor, (Monet, ,lay, Year) 21c. Dispohitlbn Name cry, place) 21d. Location (city /town, state, zip Does)
Jul 1 2008 Ho~~man-l~ot~iunera ~` &
°tl~r~ Yea^-~ y rematoryome Carlisle PA 17013
~°~~ a~
- E1~') 22b.LiaerweNtalrber
138504 2x.N~eandAadressaFaany Ho man- of unera one
219 N. Hanover St., Carlisle PA 17013 rematory
Meets 23e•c oNy when 23a. To the beet or my krawbdge, death or~sred at time,
place anted
(Si
nat
rse and titl
DMA k not evatleble at time of b
certlyrprreeddeeth .
g
e)
8 ~ ~s ~. ->.., c a9 ~~ e~~
23b. License Number 23c. Date
'
.
24 ~ ,~. a o ~a qoS -~ ~a ~~o
~
pane 24.26 mrat be oornpleled by person
who Dronouaes deem. . rwne of Dealh~ Q
VlI Oar) 25. Date Pranunced (Month. da
n ~f /~iYQ~~)
~
~ 26. Was Case Referred to Medical Exemater / Corare r for a Reason OMrar than Gemation
D
M.
OC 7 ! -
j
r~,,~
^ Yes L~T'ro or
onatbn?
CAUSE OF DEATH (See Instructions snd examples)
r Approximate kderval
Nam 27. Pad I: Enter the ddin d evaMa -cheeses, iryuriea, a carpicaMorm -flat directly posed the deem. DO NOT enter terminal events such as prcac arrest
i : part II : Eller odrer ,
..
28. Dld Tobacco flee Corrhibute b De
m?
, r
resp
ralpy arrest. ar verdriddar tibritiation wiMaW showing the etiobgy. List only one pose on each ins. r Onset b Deem
riNED1ATE CAUSE Fine) dispse ar r but rat resrrtlktp in the underyirrg pose given in Pert I. e
^ Yea ^ Probably
G~~
/~ ~ -
~/.c p ~ 'v-av
^ No ^ Unknown
29. If Ferrrgle:
Nil pregnant wMNn peal ypr
^ Pregnant at Bete d deem
^ NrM pregrrenl, but Pregnant witirin 42 days
of dead,
^ Na pregnerd, but pregrrerd 43 days b 1 year
bebre death
^ Unknown tl pregnant wltldn Mrs past year
32c. Place d :Hans, Farm, Sreet, Facbry,
ORp 8u'g, ek. (svecihl
^ es ^ Yes errdxg Nwestgatan xrre of Inwry 32e. Inlury at WorkT32f. II T '
^ Sredde ^ Could Not be Detennned .. ^ Yes ^ No L^ motor ^ Passenger ^p ~ Location of Injury (Sheet, cMy / btm,
catction reaNNq n ~) _~ a PN4- LI YY! (7 ~YL- /r~ i
Due b,(or as of). /~ ;
~Ie~ carrddrorrs, d any, b. / ~ ~ L~1~7 / C.. ~~ l'~~ r ,•
b aeaee Meted On ins a. r
(ErNer UNDERLYING C~AUdSE Due b (or as a prrsequerae of): r
°~ 9'~ ) LAST c. r
Due to or as a ~
( consequence of):
r
d. r
30a. Was an r
' 30D. Were ~ 31. Mara, Deem 32a. Date w Iryary (Monet, say, year) 32b. Describe I~ow Injrxy occwrea
Perlonned? Availabb Prig to ~/
d cause of Deem? Naturel ^ Homicide
Y ~ ^ AcrrdeM ^ P 32d T
a' 33a. Certllier (dredc any one) "'"°r • Peary-
/1 ~MYM9 PhY (~Y 3~. S' Nre and Idle of CeANier
I(..ee 7o the beat of k prime pose of deem when anWhar physician has praaunced deem and prrpleted Mem 23) ~~
my nowkdge, deem ocetrrred due to the pose(s) snd manner as atabr!_ - - - - - _ - - _ _ ^ - !
• Prorounckp and cMlfying physlcyn (Physician bon proraunang deem and ceditying to pane of deem) _ - _ - _ - -' - - - - - - - - - - - - - - ~ 33c. License Number
To the beat of my krrowbdge, deem occurred at the time, dsle, end pYce, and due to the cause(s) and manner ae shted_ _ _ _ _ _ _ _ _ _ _ 33x1. Date Sigrtad (Monet, day, ye )
• Mewl Examiner /coroner - - - - - - - Mr7 0 702 90 3- [.._ G /2 9 / mod'
Orr the frosts of ezsmbstlon and / or invesOgetton, In my ophYon, d~lh occurred ra the time, date, acrd
o place, end due to the cause(s) and manner as stated_ ^ ~ Nartre and Address of Person Who C ed of Death (I~y 27) T !Pmt
w ~. tore arW~~ttriot r n .Dale Filed (Month, day, year) ~~ ~ ,6 oS .N7ti ~ Ct11/
~ - H. ~t13..1:~ ~ I f I~ I ~ I ~ I 36 ~ .e~.c~.f-,+.c-~- gpn..•..~~ 2.t
C+1-1E,.c.idz.~ ~ Pal- /7a/.f'-
Disposition Pemrit No. _ ~ ~~ ~~
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
Date
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068708
STATE FILE NUMBER
ZFemale 3.L0 12 _ 9863 4~ Data of Deatn ("bMt,' da''' r)
. ~~_ ~.,.~ ...__... _ June 29 , ~08