Loading...
HomeMy WebLinkAbout03-30-10PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of Arthur W. Beraeron. Jr. File Number _ ~~ r~~~ t ~ °z~ also known as ,Deceased Social Security Number 4377021134 Carol B. Beraeron Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE 'A' OR 'B' BELOW.) <~~ c-, ~.-~. C7 A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the `~' ~ amed in the last Will of the Decedent dated 5/15/1996 and codicil(s) dated -' ~ --' ~ r-- renunciation of Kathleen Levin stop decedent's onl child is attached ~ ° -~ o ~ 1 ^~ JRl (State relevant circumstances, e.g., renunciation, death of executor, etc.) •~ ~ = r ~> Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of~ instrument offered ~ `=~' for probate, was not the victim of a killing and was never adjudicated an incapacitated person: 'r B. Grant of Letters of Administration C.t.a. (If applicable, enter.• c.t.a.; d.b.n.c.t.a.; pendente life; durante absentia; durante minoritate) 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 Administration, c. t. a. or d. b. n. c. t. a., enter date of Will in Section A above and complete list of heirs.) Decedent was domiciled at death in Cumberland County, Pennsylvania, with his /her last principal residence at 410 Freedom Drive Shiooensbura PA 17257 Southampton Twp Cumberland Cnty (List street address, town/c:ty, township, county, state, zip code) Decedent, then 63 years of age, died on 2/8/2010 at Carlisle Regional Medical Center Carlisle PA 17013 Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ 1 500.00 (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania $ none 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: Signature Typed or printed name and residence /~ 7 ~ ~ ~ Carol B. Bergeron ~~~~- ~~i~L~~ z z? d1n Grccrlnm rlrivo Ch4.,...,.,..L.,~~.. .~. .__-- Form RW-02 rev. 10.13.06 Page 1 Of 2 (COMPLETE INALL CASES:) Anach additional sheets ijnecessary. Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition 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. Sworn to or affirmed and subscribed before me the ~ ~ day of ~~ Signature of Personal Representative Carol B. ergeron S J C7 `` ~.~ ' Signature of Personal Representative -~ :;$; -.~~ ':' For e Register Signature of Personal Representative : ; ~ _X j ~ ' "Y~ ~' ~ - _ -::- _J '`-- ,~ ~ File Number: c.~+ Estate of Arthur W. Beroeron Jr ,Deceased Social Security Number: 4377021134 Date of Death: 2/8/2010 AND NOW, March ,~~ , 2010 , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters of Administration c.t.a. are hereby granted to Carol B. Bergeron in the above estate and that the instrument(s) dated May 15. 1996 described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) f D d FEES Letters ............. Short Certificate(s) Renunciation(s) JCS fee Automation fee Will ....... $ 20.00 ••••••• $ 16.00 •••••~~ $ 5.00 .... $ 23.50 .... $ 5.00 .... $ 15.00 .... $ .... $ TOTAL $ 84.50 o ece ent. Register of Attorney Signature: Attorney Name: Supreme Court I.D. No.: 17516 Address: 14 North Main Street Suite 200 Chambersburg PA 17201 Telephone: (7171264-6029 .- `~' Form RW-02 rev. 10.13.06 Page 2 of 2 OCAL REGISTRAR'S CERTIFICATION OF DEATH WARRIING: It is illegal to duplicate this copy by photostat or photagr~~1h, ,ttr'~~1,SH Df ~F~ ~ ~~ fi i~ rt ,tr~; ,. t,ltt u1 I~ .~; i I ~~I , for ~~cal~ ~ ,~, c-` ' t ), ~f;, t,(_nt.l t LI ail .,I. r1 r ,I.L ~~'~ ys - ~~ o; ~" ~ c(ul tiled Aril .~ sr~ (r,~:;l Rk ~~~~ ~ ~ ,~ :: ) 11~ III°~n~ II ~ z,l ~.111lIC~1~~ ,~ ~~, f 1~1) ~ ui;c~c3 Il~~ ,ri)tr t :c --- , ~~c~rtitl~rlhiln ~~ , ~jti1fNT 04~~~`'~; / .~,l~~b~1 ~, _ _ ---- ~------- 6~--~6~_1Gd r Re~i.rr,lf ;7;.1;~ ,.u~'t~ r,~ C? ~' C O c:~ ~ ~ r --^j~rn- H105~143 REV 11/2D06 -~-; (~ -t'i T _ rvPE /PRINT IN COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS -' ~ - > PERMANENT ~ - aLACK l"" CERTIFICATE OF DEATH _~ --i - - ' ' (See instructions and examples on reverse) ~~~~ ~~ i ;'- 1. Name of Decedent (First, mitltlle, last, suhp) STATE FILE NUMBER ~1 Arthur W . Bergeron J r . z. se* 3. social securay Number 4 Dale m Deem (Momh, ear) M3l-e 437 _ 70 _ 1134 Febrtaazy 8, 2010 5. Age (Last Birthday) Untler 7 ear Untler 1 tla 6. Date of Binh Month, tla , ear 7. Binh ace (Ci antl stale or forei n chant Momhs Days Hours Minutes 6a. Place of Death (Check on orre 63 Yrs. 12-5-1946 ~eS~ia ~ Hpp(o(sv~.pnal: other. 6b. County of Deem Bc. Chy, Boro, Twp. of Death 6d. FaciHy Name (II not institmion. give street and number) u~npaeem ^ ER /Outpatient ^ DOA ^ Nursing Home ^ Residence ^ Other -Specify. 9. Was Decedem of Hispank Origin? ®No ^ Ves 10. Race: American Intl~an, Black, While, etc. I Gl~xland SouthmicYileton 4Wp. Carlisle Regional Medical Center gf yes, speciry Cuban, (sr+~ihl ) l 71. Decedent's Usual Occ alion Kintl of work done tlurin most of workin tile. Do rwl state retired 12. Was Decedent ever in the 13. Decedent's Education S Mexican, Puerto Rican, etc.) ~~ / Hi.StArlapind of WOrk Kirtd of Business/Intlusfry U. S. Armed Forces? Elements /Seconds (~ iy only highest gratle completed) 14. Wdowetl~aD vorcetl ied Never Married, 75. Surviving Spouse Qf wile, give maiden name) U. S. ATiDSr War College ry ry ( ) College (1-4 or 6+) ISPa~'rN1 Yes ^ No 12 {.g Maxxied Carol B.FldShQ]1713Lg • 16. Decetlenl's Mailing Atltlress (Sheet, city/ town, state, zip cotle) Decedent's 410 FYeedcm Drive, Shipper3sbk~g, PA 17257 Actual Residence na. Stale pA lDiveDn sedan? Ctsr>berlapd Township? 17c ®Yes, Decedent Lived in S013thaNptA71 Tw 176. County 17tl. ^ No, Decedent Lrvetl within p 1B. Father's Name (First, middle, last, suffix) Actual Limits of City/Born Arttns W. BeT'gP,r~l ~ . 19. Mother's Name (First, middle, maiden surname) Elsie Stewart 20a. Informant's Name (Type /Print) CaZ'Ol $, ~ert771 20b. Informant's Mailing Adtlress (Street, cdy /town, state, z'ry code) 410 FYeedom Drive, Shippery~;)~urq, PA 17257 21 a. Method of Disposition ®Cremation ^ Donatron 27b. Date of Disposition (Month, day, year) 27 c. Place of Dis sitbn Name of cemele cremato ^ Burial ^ Removal Irom Slate r Wes Cremation or Donation Amhorizetl~'I p0 ( ry~ ry or other place) 21d. Lowtbn (City/town, state, zip cotle) ^ Other-S r by Metlicel Examiner/Coroner? L+J y¢s^ No 2-9-2010 SDLlt)1S17liZTj C:Y'~at.OY112D ~}hc~ m 22a. Sgnature of F ne.al servk icon ~ r per nin as a°ph) z26. Licens¢ Number """"'~7 , MD 21783 22c. Name antl Address of Facility ~ ~ a FD014351-L >!bgelsanger-Bricker Ftmeral Ike lr1c, 112 West King yy..,,,,„„..., PA 17257 Complete ikms 23a-c only when cenitying 23e. To the bell of my knowledge, tleath occurretl al the Time, dale and place sutetl. (Signature and title) ~ ~ ~1~N"`7 physkian is cwt available at time of death l0 236. License Number certity Wuse of tlealh. 23c. Date Signed (MOnlh, tlay, year) Items 24-26 mull be completed by person 24. Time o1 De3~ 25. Date Pronounce ad (Month, tl year who prorwunces death ~ ? ~ ~ M G 2~^ ~ ~ ~ ~ U 26. Was Case Referred to Medical Examiner /Coroner for a Reason Other Ihan Cremation or Donation? J C l.i ^Yes ©No Item 27. Pan I. Enter the chain of evem~ - ,CAUSE OF DEATH (See inatructlons end examples) r Approximate interval: Pan II'. Enter other son 1 t r dd tribulino to ath 28. D'tl Tobacco Use Contribute to Dealh~ tliseases, injuries, or complications -that tlirectly causetl the tleath. DO NOT enter terminal evens such as cardiac arrest, respiratory erred, or v¢nlricular fibrillation without showing me etiology. List only one cause on each line. Onset to Death but not resuding in the untlenying cause given in Pan I. ^Yes ^ Probe IMMEDIATE CAUSE Final tlisease or \_ ((`~~I ^ No r-a own conOdion resudirg in ~eath) ~ ~r ,Gy~ \ ~~.~x1/1~~ t;} ~` \C L7U -~ a CJ \ 'l ~~,./ S 29. II Female: Due to nse~quen~j nf): L Sequenl4nlly list conddions, II any, b ~Y~'•/-~C / ~ i ~ /' / ^ Nol pregnant wilhln pall year leading to the cause listed °n line a. \ V \ ~~~1~^pq `F(~r ^ Pregnant al time of deallt Enter the UNDERLYING CAUSE Due to (or as a consequence ol). IdiSease or injury that imlialed the ^ Not pregnant, but pre t Thin a2 tla gnan wi ys events restating in tleath) LAST. °- of death Due to (or as a consequence ol): ^ Nol pregnam, but pregnant 43 tlays to 1 d. r year _ ____.. r _ _ ~ before death . em tipsy ^ Unknown d pregnant wdli t the past year P¢normetl'+ A Nabk Pria to Completion ~ ~ er ~ sc How IMUry Occurred 32c. Place of Injury. m Farm Street Factory, of C s of Death? Nawml ^ Homiatle Olllce Building, etc. (Spxr/yJ ^ Vos ~ Ne ^Yes ^ No ^ Accident ^ Pending Investigation 32d. Time of Injury 32e, Injury at Work? 327 II Transp°nation Injury (SF>ealy) 32g. Location of infury (Sheet, chy /sown, stele) ^ Suicide ^ Caltl Not be Determinetl M ^Yes ^ N° ^ Driver/Operator ^ Passenger ^ Pedestrian ^ Other Specify' 33a. Cenifier (check only tine) • Certifying physician (Physician cenitying cause of tleath when aiwiher 33b. Signature and TTTdie el Ceni ier , physician has pronounced tlealh and completetl Item 23) , ~ \ R ~ ~, To the best of my knowledge, death occurred tlue to the cause(s) antl manner as statetl _ _ _ _ _ _ _ ^ C 4' Y~r \ \ . __________________ ____ \ W~~~ Pronouncing antl certifying physician (Physician both pronouncing death and cenitying 1° cause of tlealh) 7o the best of my kn¢wletlge, death occuretl of the time, date, antl place, and due fo the cause(s) antl menrrer es statetl_ _ _ _ _ _ _ _ _ _ _ _ _ _ j~ 33 L' se N tuber ~ 33d Date Signed (Month, tla • Medical Examiner/Coroner ~ _ / C, o On the basis of examination antl / or investigation, in my opinio ,death occuretl et the time, date, antl place, end due to the cease(s) antl manner as statetl_ ^ 34. am tl Address of Pers Whc Goi ?elect Ca se of Deelh gle.m' )Type / Print ° 35, Regishar's Signature. antl Disir r er ~ ¢ ~ ~ ~Jv ~. \~~~(R~ ~~-;" $ ~ I zj r I ~ ~ I ~ 36. ate Filed (MOnlh, day, year) ` J \) Disposition Permit No. ~ ~~ /' •~ C~ t LAST WILL AND TESTAMENT I, ~ r ~--~~~ `,~.~ ; '*~ ,~ r, ~ ~ ~-~ ~ ,,'Sr ,being of sound mind and body, do hereby bequeath all my worldly possessions, including all retirement and insurance monies, fi~rnrture and household goods, vehicles, bank accounts and any money or property due from my divorce settlement to my fiancee, C t~ ,.-~ upon my death. This Will supercedes any and all previous W4ills ~ a ~ ~ Signed, _ __c~e'~"- ~. ~ f ~ date 5 =i s'- ~ iJ r; ~ f~~ ~ - o ~ ~ ~~ :,?r ? ~, ., , _ . ~~ ,__ - J o '- c ;; , ~ ~`~ ~~ w - :;~ > c~ OATH OF NON-SUBSCRIBING WITNESS(ES) REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA Estate of Arthur W. Bergeron, Jr. ,Deceased Terry R. Powers and Lauren N. Huiett (each) being duly qualified according to law, depose(s) and says(s) that she / he /they was /were well- acquainted with Arthur W. Beroeron. Jr and am/are familiar with the handwriting and signature of the decedent, and that the signature of Arthur W. Bergeron Jr to the foregoing instrument purporting to be the Last Will and TestamentlCodicil of Arthur W. Bergeron. Jr is in his/her own proper handwriting. ~'? ;, ;' ~~ ~ ~..~ ?-fit /~~ ~ 1 Signature) ~._ (Sign e 410 Freeedom Drive (Street Address) Shiooensbura PA 17257 (C:ry, State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed before me this ~~~~~~~ day ~ '~ , Deputy for Register Wills 410 Freedom Drive (Street Address) Shiooensbura PA 17257 (C:ry, State, Zrp) :^? - r~ ~=' ,- ~ ` C= "~ ~ 7 ^ T ~, y ` J ~J -- _ ~; r . rn t.3 . (-J _ AMY -~-„ ~ -- ~~ ' Form RW-04 rev. 10.13.06 RENUNCIATION ~ o -.: c-, v - -w ~, v - am REGISTER OF WILLS - `"- s~ a CUMBERLAND COU N TY, PENNSYLVANIA :~ _=. c ~ ~•,,~ =,~-;t, -~ ~ ' ~~ Estate of Arthur W. Bergeron, Jr. Deceased I, Kathleen Levingston , in my capacity/relationship as (Print Name) daughter of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Carol Bergeron , 3 5 i ~J (Date) Execu~2t~ in ~egi~tcr's Jffcs Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills Form RW-06 rev. 10.13.06 (Signatur ) 1208 Althea Court (Street Address) Chesapeake VA 23322 (City, State, Zip) ~~'Exscute~ ~~zt ~,f F.egister's n,~,~acp 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 ~ ~ , ~r Notar Public 1 My Commission Expires: '-1 13~~ 13 ,,,~~e+~~e~~r~si~di (Signature and Seal of Notary or8it~er o~qu~lified t'Ai~ administer oaths. Show date ofQk u~t1 ~Wotary' ;Comrt~ssion.) • p ~ ~~ G~~~~ \~ ~ ~ s ~ .~ Q \~~ ~° ~' O, •s• '` ~O '~.; ~Mor~r~vE~ m.~`` '0j~eo~N~-~•