HomeMy WebLinkAbout04-22-10PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND
Estate of EVELYN M. WELKER
also known as EVELYN MARIE HERLD WELKER
COUNTY, PENNSYLVANIA
File Number ~~~~ ~ /S ~~
Deceased Social Security Number 180-OS-0712
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW.)
0 A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /
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(State relevant circumstances, e.g., renunciation, death of executor, etc.) ~-'~ ~"'? t- ~ .
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Exce t as follows, Decedent did not ma
P Try, was not divorced, and did not have a child born or adopted after execution of the:"ifis~nent(s) o~f red
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for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ~ ~~ • • ~ `Y~' '~`
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B. Grant of Letters of Administration
(If applicable, enter: c. t. a.; d.b.n.c.t.a.; pendente life; durante absentia; durance 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. ord.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
Name Relationshi Residence
LARRY L. WELKER SON 5395 RIVENDALE RD, MECHANICSBURG, PA
17050
(COMPLETE INALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in CUMBERLAND County, Pennsylvania with his /her last principal residence at
MANOR CARE HEALTH SERVICES 1700 MARKET ST. CAMP HILL BOROUGH PA 17011
(List street address, town city, township, county, state, zip code)
Decedent, then 93 years of age, died on FEBRUARY 28, 2010 at
MANOR CARE HEALTH SERVICES 1700 MARKET ST. CAMP HILL BOROUGH CUMBERLAND COUNTY PA 1701 I
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ 7,261.00
(If not domiciled in PA) Personal property in Pennsylvania $
(If not domiciled in PA) Personal property in County $
Value of real estate in Pennsylvania $
situated as follows: N/A
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:
Si ature T d or Tinted name and residence
LARRY L. WELKER, 5395 RIVENDALE RD., MECHANICSBURG, PA 17050
Form RW-O2 rev. 10.13.06 Page 1 of 2
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. _
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Sworn to or affirmed and subscribed ~
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before me the
~ day of Signatu of Personal Representative
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Signature of Personal Representative ' ` °r:~ t-~- ~
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For the Register Signature of Personal Representative ,;,Y~ <~> °'r-~
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File Number: oC 1- 1 V - ~ ~oZ (o
Estate of EVELYN M. WELKER ,Deceased
Social Security Number: 180-OS-0712 Date of Death: FEBRUARY 28, 2010
AND NOW ~ pL oL o~U 1 C~
in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters OF ADMINISTRATION
are hereby granted to LARRY L. WELKER
in the above estate
and that the instrument(s) dated N/A
described in the Petition be admitted to probate and filed of record as the last Will nd Codicil(s)) of Decedent.
FEES ,
$ u ~ /~(> Register of Wills
Letters ....... _J_aLtiL
Short Certificate(s) ........ $ ~'-~ • C~(~ Attorney Signature:
Renunciation(s) .......... $
S $a 3 ~~ Attorney Name: THOMAS E. FLOWER
~~~~'-~r" • • • $~~~ Supreme Court I.D. No.: 83993
... $
$ Address: SAIDIS, FLOWER & LINDSAY
• • • $ 2109 MARKET ST
... $
$ CAMP HILL, PA 17-11
$ Telephone: 717-737-3405
... $
TOTAL .............. $~`i~9~0
Form RW-02 rev. 10.13.06 Page 2 of 2
OCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~ Fee for this certificate, $6.00
This is to certify thax the informtation here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will be forwarded t:o the State Vital
Records Office for permanent filing.
P 15935986
Certification Number
d`' MA 0~ 01
Local Registrar ate Issued
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3 REV 11/2006
/ PRINT IN COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS U'7 '"% >r~;a
CK INKT CERTIFICATE OF DEATH ~ ~ -'~
(See instructions and examples on reverse)
1. Name of Decedent (First, middle, last, srdfix) STATE FILE NUMBER
2. Sex 3. Social Secu ' Number
MY
4. Date of Death (Month, day. year)
S. Age (Last &rthdaY) Under 1 veer Under 1 day a hero ~r wne nx.,.,rr, ae., ....,..~ -...:,._,_ ..... ... ~_ Fch 7 Q 7r1 t n
- - - - ., ,v ,nny onn) - -
Monms Days Fioun: Mkxxea Hospnel: Other:
93 Yrs. Jeri 15, 1917 Harrisbur
g ^ Inpatient ^ ER /Outpatient ^ DOA Nursing Hame ^ Residence ^ Other - Spedty:
fib. Cgunty of Death 8c. City, Boro, Twp. of Death 8d. Faritlty Name (I( rat ktstlhrtlat, sheet and
~ ) 9. Was Decedent of Hispanic Origin? ~ No [] Ves 10. Race: American Indian, Black, White, etc.
ClII[l}Jerland (It yes, specify Cuban, (Spedly)
Camp H111 Manor Care Health Services Mexicen, Puerto Rican, etc.) Wh1te
11. Decedent's Usual Lion Kind of work done du most of Ina. Do not state refired 12. Was Decedent ever m the 13. Decedent's Education
U.S. Armed Forces. (qty only hghest grade completed) 14. Marital Status: Married, Never Married, 15. Surviving Spouse (If wife, give maiden name)
Kind o} Work Kind d Business /Industry ~ Elementary /Secondary (0.12) College (1.4 or 5+) Widowed, Divorced l~+M
Labor Harrisbur Steel ^Y~xit~~ 12 widow
16. DecederMs Matting Address (Street, city /town, state, zip case) Welker C/O oecede"ea Did Decedent
Adual Residence 17a. State PA Live Ina 17c. ^ Yes, Decedent Lived in
Manor Care Health Services Townsfupp Twp.
17b. County Cl~riberland 17Q„n No, Decedent Lived within
XX..7XC Adual Urrdts of ~~ Hl 1 1 Ciry / Boro
18. Father's Name (Fast, midde, lest, suffix) 19. Mother's Name (First midrib, maiden aumame)
James E. Lebo Irene M. Herld
20e. Infantanrs Name (Type /Print) 20b. InfomranYs Mailing Address (Street, city /town, state, zip code)
Larry L. Welker (son) 5395 Riverdale Blvd Mechanicsburg PA 17050
21a. Hefted of Disposition ;
, }~ Cremation ^ Donation 2tb. Dale of Dispositon (Month, day, year) 21c. Place of D
^ Burial ^ Removal from State ~ Wag Crematlon a Donation Authorized bpos~n (Name of cemetery, crematory or other place) 21tl. Location (City /town, state, zip code)
^ onter-spepy: (byMedfcdExaminer/~- .~^No Mar 2, 2010 Con-O-Lite Vault Company Schaefferstown PA
~• s ' actlng ~ ~) 22b. License Nrsnber 22c. Name ant Address d Fadlity Neimryer FLlnera 1 Home
~ FD 013945E
Compete Hama 23a-c only when codifying 23a. To the best knowledge, deem occurred at ttre rime, date and place stated. (signature and rifle)
physician b not evailabb at thne of death to 23h. l.idense Number 23c. Date Signed (Month, day, year)
cenlty cause of deaM.
nervy 24-26 must ba completed b1, parson
who pronounces death. 24. Time of Death ~ ~ ~
A M 25. Date Pronounced Dead (Month, day, year) 26. Wes Case Referred to Medical Examiner /Coroner
` for a Reason Other than Cremation or Donation?
. ^ Yes ~'Itl
CAUSE OF DEATH (See Instructions and examples)
Item 27. Pad I: Enter the chain of events -diseases, injuries, a compliranons -that directly caused the death, DO NOT enter temdnal events such as cardiac enest r Approximate knerval: Pad II : Enter other '
28. Did Tobacco Use Contribute to Death?
,
respretory arrest, a ventricular fibritlation winaut showkr the et'
g iology. Ust only ane cause on each line. ,
Onset to Death
r but not resulting in the underlying cause given in Pan I. ^ Yes (~ Probabry
IMMEDIATE CAUSE (Final disease or .
wrMNion resuning in atlr) _~ a r
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^ No .e•1~nknown
Due to hoe op: r
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Not pre
nant withi
Sequennelly nst condnons, it any, b .
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n past year
lea
to the cause hated an line a.
Enter a UNDERLYgrD CAUSE Due to (or as ~nsequence of): ,
, ^ Pregnant at time of death
edi~~ a orb 9ry t~m'ia~S the c (` AL \
-~~li/ ; ^ Not pregnant, but pregnant within a2 days
Due to consequence of).
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^ Not pregnant
but
re
nant 43 da
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ys
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year
before death
30a. Was an Aut
opsy
Pedamed?
30b. Were Autopsy Endings
Available Prar to Competan
31. Manner of Death
32a. Date of Injury (Month, day, year
)
j ry
32b. Describe How In u Occurred ^ Unknown it pregnant within the past year
of Cause of Death?
~Nalurel ^ Homicide 32c. Place of Injury: Home, Farm, Street, Factory,
Office Building, etc. (SpecityJ
^ Yes No Yes o
^ ~ ^ Accident ^ Pending Investigation 32d. Time of Injury 32e. Injury al Work1 321. If Transportation In'u
I ry (SP~dY)
32 . Location of In'
g wry (Street, city /town, state)
^ Suicide ^ Couk1 Not be Determined rl va. (~ ti„ ^ Driver /Operator n Passenger I-lPedaetrian
33a. Certifier (check only one) ~ ,,,.,o, .,,.o,.,,,.
• Certlfylrtg physician (Physidan certitying cause of deaM when another physican has pronounced death and completed Item 23) 33b. Sgnatwe a Ue of Certifier
To the best of my knowledge, death occurred due to the cause(s) and manner as sbterL _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _
• Pronouncing and certifying physician (Physician Moth prorauncing death and certifying to cause N deaM) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
To the bast of my knowbdge, death occurred at the Ume, date, and pace, and due to the cause(s) and manner as atafed_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
• Medlpl Examiner /Coroner
On the basis of examination
d /
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H ^ 33c. L~be~nse/~Number~ ~.
Mwly 4 (~ ~~ ••• ~ 3 . D e Signed th, day, ear )
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an
or
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gatlon, in my opinion, death occurred M the Nme, date, and place, and due to the cause(s) and manner as steted_ ^
34
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35. Registrar's Signor and District N /
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36. D~te FlJed
th, dyy, year) .
ame an
Address of Person Who i
,ompbted Cause of Death
~ ~ ~ ~ - , A 1 (A (Item 27) Type /Print
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