HomeMy WebLinkAbout02-02-10PETITION FOR PR BATE AND RANT OF LETTERS
REGISTER OF WILLS OF COUNTY, PENNSYLVANIA
Estate of~/''.P!/L J ~Y ~ ~~~~ File Number `~ ~_,~~~U~~
also known as
Deceased Social Security Number>~®~ ~3 ~. -~j 7 ~
Petitioner(s), who is/are 13 years of age or older, apply(ies) for:
(C01>'IPLElE 'A' or 'B' BELOW:)
~A. Probate and Grant of Letters T tamentary and aver that Petitioner(s) is /are theme^~~C~~~~ named in the
last Will of the Decedent dated ~~ " Z "zvd and codicil(s) dated
(Slafe relevant circumstances, e. g., renunciation, death ojexeculor, e1c.)
::
.....
Exce t as follows Decedent did not marr was not divorced and did not have a child born or ado ted after exec f the ins ®ent s o~f~ -~~y
p Y~ P m (^~~
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ~` .--; --`
^ )3. Grant of Letters of Administration ~---` t,~..~
(Ijappficable, enter: c.t.a.; d. b. n. c. t. a.: pendente lire; durance absentia; 'na•itn .- ~~!
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Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the followin use (if ar~and h~i~~: ~'
Adrninistralivn, c. t. a. or d.b.n.c.1.a., enter dale ojWill in Section A above and complete list of heirs.) Q '-
irQ
Name Relationshi Residence
(CONIPLETE IN ALL CASES:) Altaclr additio,tal s/ieets if necessary.
~e~ en was ~iciled at death irl~c:~/J9~~~Li7~/f d County, Pews ]vania with his ! der last principal residence ate ~ ~
(List street address, tofu„/city, township, count), stale, zip code)
Decedent, then ~~• years of age, died on r'Z~y~glUat ~~ r ~ ~
yd ~ Boa
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) Ail personal property , ,~ ~^
(lf 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:? ~~~~~r~~-~''e G~/UI~C~/~G,r~D C.s~.~G/.S~', ~~ /7~~~
Wherefore, Petitiuner(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:
Signature Typed or printed name and residence ~
y
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F~,-,,, Rrv-oz rc~~. ~a~3.o6 Page 1 of 2
Oath of Personal Representative
COMiv10NbVEALTH OF PENNSYLVANIA
SS
COUNTY OF ~ I~-erl a. ~ d
"The Petitioner(s) above-named swear(s) or affirni(s) that the statements in the foregoing Petition are true 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.
Si~na1 ,re of Persona! Representative
Signature of Persona! Representntive
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For Register .., Signature of Persona! Representative ~~-r~ ~,,,,~-~'"" ~`
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File Number: ~ ~ ! (/ ~l ~/tY
Estate of L ,Deceased
Social Security Number:~~~~~ - (~~75 Date of Death: I / ~~ ' ~~~~ /
AND NOW, ~ , ~__, inconsideration of the foregoing Petition, satisfactory proof
having been presented b, ore me, T DECREE hat Letters (~~fiQ,~'Y1 ~.~ ~rL-{
are hereby granted to _
and that the instrument(s) dated
described iii the Petition be admitted t robate and filed of recor as the last Will (and CCodicil(s)) of Decedent.
FEES ~~!/.d~'L/Y(~~1~' .~~L
Letters ............... $~o.~
Short Certificate(s) ........ $ . t3v
Renunciation(s) .......... $
... $
S ... $~.,~.. ~
... $
... $
... $
... $
... $
... $
TOTAL .............. $ Z ~U
Register- of Wills
Attorney Signature:
Attoi7~ey Name:
Supreme Court I.D. No.:
Address:
Telephone:
in the above estate
r-~,~,n Rrv-u~ rev. lu.l3.ur Page 2 of 2
Sworn to or affirmed and,~ubscribed
before me the ~~`-'/'~ day of
Z ~- lv -l~l Dt~
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
' t t 1 r r , , , r , , „, , , ,, , , ..
Fee for this certificate, $6.00 This is to certify that the information here given is
1~tt,~~p~ZH OF pF,jyf r correctly copied from an original Certificate of Death
~~,,~`'~o~ _ _ ~ ` duly filed with me as Local Registrar. The original
9 ; certificate will be forwarded to the State Vital
_-
c°~ ~:~ a
Records Office for permanent filing.
* `,`
P 16053779 ~°4~~99 -~ ~~~?~~'~ ~ - , ,,~ JAN Z 1 010
•--aMENt OFD trt~ ~..~~ ~ ~~-C,~
Certification Number ~""""""""'''~~r Local Registrar Date Issued
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~los-143 REV tlrztxls
TlPE /PRINT IN COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
PERA4ANENT
BucK INK ~ CERTIFICATE OF DEATH
(See instructions and examples on reverse)
STATE FILE NUMBER
0
. ~
0
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0
0
1. Name d Decederd (Full, middle, last, sul9x) _ -
CAROLYN E
BLAIN 2. Sex 3. Social Security Nranber 4. Dale of Daelh (Month, day, Year-
. Female 206 - 32 - 0975 Januar 26 2010
5. Aqa (last fiirihday) Undr 1 year Urldar 1 day & Dale d Birth (Month. day, ar) 7.11iAtplece (q and slate ar tbtatlry) 8a. Pace d Death (Check one)
MaaM Days Mows arkssas Froapilal: Other.
7 2 vrs. $ e t 1 1 19 7 Car 1 i s 1 e , P a ^ Inwlienl ^ ER / Outpatient ^ DOA ^ Nwskq Home Residence ^OMer • Specify.
• flb. CaunN d Death 8c. Cqy, Boo, Twp, d Death 6d. Fardlily Name (N not in ,give street and rnaNler) 9. Was Decedent d HispaNc Origin? ®No ^ Yss 10. Race: American 4Wkn, Sledc, White, ek.
' Cumber 1 and Penn Tw
P •
6 3 5 M t . Rock Road (11 yes, spaciry Cuban,
Mexican, Puerto Rion, etc.) (Spy
Whit e
11. Decedent's Usual Goo (Kind d wont d one d ur' most d Ge. Oo nil stele re9red) 12. Was Decedent ever in Ste 13. Decedent's Eduction (Specify only highest grade comp leted) 14
Madlal SIaWa: Married
Never Married 15
Survivir
S fl wil
i
id
Kind d Work
Homemak
Kind d Busilas / kldttsky
U.S. Amled Forces?
Elementary / Seeandary (0.12)
Cdlege (t-4 or 5+) .
,
.
Widowed, Divorced (Spariry~ .
q
pouse (
e, g
ve ma
en name)
er Homemakin ^Yes ~No _______g_____ _____________ -
16. Decedent's Maiine Address (SIreN, city !town. stale, zip code)
74 McAllister Church Road Decedent's Did Decadent
AUuaI Residence na. sale P e nn s v l v a n i a are in a ,?e. ~] Yas. DeadeM Lives in Wept P e nn s b o r o T,ra
Carlisle Pa 17015 TO1N"~? 77d.^ No.Deced.nlLtwdwklAn
Im.co~nn Cumberland AcIUaIL~nitscf c~yleorD
I& FaMu's Name (First, midda. lass, wlfu) 19. Ma1Mr's Name (Pant, midde, maiden wrname)
Nelson Viering Carol n Unkn w
20a. IniormaM's Name (Type /Print)
Li 20b. kdamlard's Mailklp Address (Street, cNy ! lewn, state, zip cods)
sa Wilson 635 Mt. R Carlisle, Pa 17015
21a. Method d Disposition i ®Cremation ^ Donation 216. Dale of Disposition (Month, day, year) 21c Place d D'
Ispai4on (Narne d cemetery, crerrrotory a other place) 21d. Location (City I rown, state, zip code)
^ Burial ^ Removal Iran Slate ~ W
C
• as
remation a Donation Authorized Jan 2 8
^ Othar • Specify, t by Medical Examiner /Coroner? }~] Yea ^ No s 2 0 1 0 Hollinger Ftmeral Home & Cre[Dato Inc . Mt . Holt S rl s Pa 1706
22a. Signaure I Benito ee acting as such) 22b. License Number 22e. Name and Address d Facik7y
- FD-012909-L Ronan Fluieral Hone 255 York Road Car '
Camplele I 23a-c only when cenityklg
physidan rwl available al time d death ro 23a. To Ule best of my knowledge, deaM occurred at Its Woe, dale and pea staled. (Signature and INM)
n n 1
f
~ 23b. Lk;ense Number 230. Dale Signed (Month, day, Year)
• ceNty ease d death. ~. ~
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it
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Items 24.25 muss Ix canpleted by parson 24. Tune d De th 25. Date Pronounced Oead (Month, day, year) 26. Was Case Referred to Medal Examiner /Coroner for a Reason Other ernalbn or Donetbn?
who pronounces death. ~_ (' .,~ A M. 1G...v\ ~' ~ ~ N Ark I ~
r~ ^Yes ~ No
CAUSE OF DEATH (See instructions and examples)
r Apprarimale Interval:
hem 27. Pan I: Ener the dwin of events -diseases, kyluies, or cornpkations -that drecay caused Iha death. DO NOT solar temilnal events such as cardiac arrest, 1 Onset l0 Deaal
u
l
t
i
l
fi Part II: Enter other sienificant conditions comnbuline to deaM
but nil resulting h Ma underlyirq cause given in Part I. 26. Ikd Tob Use ComribWe to Death?
[o^ Prohabty
rasp
a
ory arres
. or ventr
cu
ar
bri9ation wilhad shoviurg the elidogy. l.hl only one cause on oath line. ~
IMMEDIATE CAUSE lFkal dsaase or ^ , ~
r
„n i /
s,
,s ~ ^ No ^ Unknown
~~~
- - _~~
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candliorr resuhing in deaM)
- xG.i ..JJ--++•~s•.. ~ j j! (
~.,
~
IV'~/J'
~i(/L (
(/[ ~
~ 29
11 Female:
-
_' a _
~
•,
.
j
, .
r
~
/
Dtw ro (or a consequence d): pregnant within past year
L
1
J~
Sequentiasy 651 conditiens. il any, b. r
le ro the cet,se Nsted on line a. t ^ Pregnant at tirlw d death
Enter UNDERLYING CAUSE Duero (or as a consequence r
~•
Nol pregnant, but pregnant within 42 days
(disezse a' Thal irolial the
events resdu~g n deaM) LAST. c' ~ of deaM
DUQ ro (or as a Consequence d): r ^ Nol pregmM. bw pragnan143 days a 1 ar
Ya
• d. t ^ 6Uenlorkrlovm d pregnant wittlkl the past year
30a. Was an AWapsy
Performed? 30b. Were Autopsy Fxxkngs
Available Prior b Canplelian 31. Manner ant 32a. Dale of Injury (Monts, day, year) 32b. Describe How Injury Occuned 32c. Place d kpury: Home, Farm, Street, Fadory,
Natural Homicide
^ ~~ BUildalg. ~. ()
of
ause d DeaM
^ ~
Yes No ~
C
Yes ^ AccMarlt ^ Pendng Investigation 32d. Tana d Iryury 32e. kqury a! Work? 321. II Traluporlelion Irqury /Specify) 32g. Location of Injury (Street. MY /town, stale)
^ Suicide ^ Could Nol be Determined ^ Yss ^ No ^ Drhrer / Operator ^ Passenger ^Pedestrian
M OMer • Specify.•
33a. Cedifier (dleck Drily one)
• Certifying physician (Physican certifying Cause d death when another physician has prarourlced deaM and conplaled Item 23) 33b. Signature e d Ceni9ar
~~
To the bast of my knowledge, deaM occurred due to the cwse(s) and manner as sMhd_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
~ - ~
g y g phytrcran (Physrnan bosh prorwwrung deaM and certifying to cause of death)
• To thehest of and knowled e, deaM occurred al the time. dale, and lace, end dw to the pus sand manner as atsled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^
Y 9 P H)
• Medial ExaminerrCorona ~ ~~ N a ^ 33d. Dale Signed (Month, day, year)
!7 ~/ ^ry~
~~D~//~~_ ~^r~/~V
On the basis of exammatlon and / or Investrgabon, in my opinion, death occurred a! the lime, date, end pace, end due to the cause(s) and manner as slated_ ^ 34. Name nil ess d Person ed Gauss of DeaM (Item e
3 . R i 's Sign'alwe and Dis ' Nu ~ ~~ ~ ' ~I / I ~ I
r 3e. ~ f9ed (MaWI, daY,'/ear) ~
U ~ ~ ` ~ ~. ~ ) ~ ~ ~` ~/L/ ~~~ /
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Disposition Permit No.
...,.
LAST WILL AND TESTAMENT ~
co
OF rr~ e~v
~~
CAROLYN E. BLAIN ~,
~ .,
I, CAROLYN E. BLAIN, of West Pennsboro Township, Cumberland Coin,
Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make,
publish and declare this as and for my Last Will and Testament, hereby revoking all other wills and
codicils heretofore made by me.
FIRST: I direct that all my just debts and funeral expenses, including my grave
marker, shall be paid from the assets of my estate as soon as practicable after my decease.
SECOND: I give, devise and bequeath the residue of my estate, of every nature
and wherever situate, to five of my children, equally, namely ROGER R. BLAIN, MICHAEL D.
BLAIN, RANDY N. BLAIN, STEVEN L. BLAIN, and LISA MAY WILSON. Should any of
my five children named herein predecease me then and in that event their share shall be distributed to
their issue per stripes living at the time of my death and in default of such then living issue such
share shall be added to the share or shares for my other five children named herein and/or their issue.
THIRD: I have specifically not made any provision in this my Last Will and
Testament for my daughters, CAROLYN S. LINE and CONNIE R. LUCAS for reasons which
~~(' they are aware of.
FOURTH: I direct that all taxes that may be assessed in consequence of my death,
of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a
part of the expense of the administration of my estate.
FIFTH: I nominate, constitute and appoint, my son, ROGER R. BLAIN,
Executor of this my Last Will and Testament. Should my son, ROGER R. BLAIN, fail to qualify or
cease to act as Executor, I appoint my son, STEVEN L. BLAIN, Executor of this my Last Will and
Testament.
SIXTH: I direct my Executor and his successor to retain the services of Ronald E.
Johnson, Esquire to act as attorney for the estate.
~~
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SEVENTH: I direct my Executor and his successors shall not be required to give bond for
the faithful performance of their duties in this or any other jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and
Testament, consisting of two (2) typewritten pages, each identified by my signature, this ~
day of August 2009.
T
(SEAL)
Carolyn E. Blai
Signed, sealed, published and declared by the above-named Testatrix, CAROLYN E. BLAIN,
as and for her Last Will and Testament, in the presence of us, who, at her request, in her sight and
presence, and in the sight and presence of each other, have hereunto subscribed our names as
COMMONWEALTH OF PENNSYLVANIA )
SS.
COUNTY OF CUMBERLAND
I, CAROLYN E. BLAIN, 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 Testament; that I signed it willingly; and that I signed it
as my free and voluntary act for the purposes therein expressed.
!!S////~~w'~orn or affirmed to and acknowledged before me by CAROLYN E. BLAIN, the Testatrix,
this oc y day of August 2009.
COMMONIiVEAL.T`H OF PENNSYLVANIA C
NOTARIAL SEAL
SHELLY SEXTON Notary pub
Carlisle Boro, Cumberland Counfiy
Commission Ex 'res 'I 26, 2011
No
T.
~' ~/~ ~sEai.>
is
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA )
SS.
COUNTY OF CUMBERLAND
We, RONALD E. JOHNSON and ~ or T, ~~Yt,~r..s ,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 Testatrix sign and execute the instrument as her
Last Will and Testament; that Carolyn E. Blain, signed willingly and that she executed it as her free
and voluntary act for the purpose therein expressed; that each of us in the hearing and sight of the
Testatrix signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at that
time 18 or more years of age, of sound mind and under no constraint or undue influence.
~wo of armed to and subscribed to before me by RONALD E. JOHNSON
and ~ ~r ~{ • H!s , witnesse ,this 2 L da o Au st 2009.
~ _y ~ ~
~ (SEAL)
COMMONWEALTH OF PENNSYLVANIA onald E. J i
NOTARIAL SEAL
SHELLY SEXTON, Nary Public (SEAL)
Carlisle Boro, Cumb+e~land County. , Witn ss
C~o~mmiseion 'res. 26, 2011 ~ lI D .
Notary Public