HomeMy WebLinkAbout05-19-10PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of PHYLLIS A. SHELLENBERGER No.
also known as To:
Register of Wills for the
Deceased. County of CUMBERLAND in the
Social Security No. Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl LIES for letters of administration
on the estate of
(d.b.n.; pendente liter durante absentia; durante minoritate)
the above decedent.
CUMBERLAND _ County, Pennsylvania, with
Decedent was domiciled at death in
h Eg.__ last family or principal residence at 940 ~"IALNIlT BOTTOM1~~RD SO NTH MIDDLB~TON CARLISLE Pte.
Decedent, then 72 years of age, died 6/612009
at MANOR CARE 940 WALNUT BOTTOM ROAD CARLISLE PA 17013
Decedent at death owned property with estimated values as follows:
All ersonal roe 9.067.50
(If domiciled in Pa.) p p p m'
(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:
NONE
0.00
Petitioner after a proper search ha S ascertained that decedent left no will and was survived by
*hF, fr.nnw;n~ spouse (if anv) and heirs: n
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D NNIS R. S ELLENB RGER
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P.O. BOX 394
LC ""'BERRY PA 17339
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THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA l ss
COUNTY OF cuMBE L D J
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 above decedent petitioner(s) will well and
truly administer the estate according to ]aw.
Swurn to or affi end 'nd subscribed
b re me this day of
}
,' -
gister
DENNIS R. SHELLENBERG R
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L-,."1 C~ ~_,
No. '.~-~ `~ /GTR- -
EState Of PHYLLIS A SHELLENBERGER ~ DeCeaSeC~
GRANT OF LETTERS OF ADMINISTRATION
n?
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~y
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'~'I'1 ~j~ ~~~(_,(, ~ ~~~ ~' , in consideration of the petition on
AND NOW
the reverse side hereof, satisfactory proof ving been presented before me,
IT IS DECREED that DENNIS R. SHELLENBERGER
is,~are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to
DENNIS R. SHELLENBERGER
in the estate of PHYLLIS A. SHELLENBERGER ~
FEES ~;~j
Letters of Administration . $ ~~-
Short Certificates ( ) . • _ $ ~ ~~~
TOTAL $ ,-~ r7 ,~,
Filed . . . . . . . . . . . . . A.D. ~:1-~~
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vv't.J'
717-607-4650
PHONE
54 E. MAIN STREET
MECHANICSBURG PA 17055
ADDRESS
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~.OCAL REGISTRAR'S CERT'~F~CATIOt~ O~ E'T
WARNIFdG; It is illegal to duplicate this cope` ~y photo~ta~ or phs~):o~r~~~ +.
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IA • DEPARTMENT OF HEALTH • VITAL RECORDS
COMMONWEALTH OF PENNSYLVAN
iREV,frzws CERTIFICATE OF DEATH
!PRINT IN
les on reverse) BTATE FILE NUMBER
MANENT (See instructions and examp
1CK INN 4. Date of Death (Month, day, year)
Sex 3. Social Security Number t
2
laat,aunix)
mbdle
denl(Fxal
D .
female 186 - 28 - 6491 June 6, 2009
,
,
age
' Name Of
Shellenberger
Phyllis Amy
ath (Check only one)
f D
Date of Birth (Month, tlay, year) 7. Birthplace (City and slate or foreign country)
6 e
ea. Place o Other
Under
5. Age (Last Blrthtlay)
Months t Under t day
year
Days Hwrs Min~ies .
A Hospital:
atient ^DOA
l
^ER IO
g
®Nursm
^ ^Oihe[~ $pacif '.
Home Residence Y
January 16, 1937 Milton, P ^Inpatie u
p
m
i
Ori
i
f Hi n? ®No ^Ves 10 Race: American Indian. Black, While, etc.
7 2 Vrs Fadll Neme II not institution, give street and number)
8tl
ry ( g
span
c
9. Was Decedent o
specify Guhen,
(It yes (Specify)
Bb. County of Death .
Bc. City, Boro, Twp. of Death
Manor Care ,
Mexican, Puerto Rican, etc.) whit e
Cumberland S. Middleton Zbrp.
com
let
d)
Marital Status'. Marrietl, Never Mzr
14
ried.
15 Surviving Spouse (If wife, give maiden name
r
do
f
n the
ne dud most of woddn life. Do not stale relimtl i2. W S D
1
~2N
(
s
e a
)
p
only highest 9a le
Golle e t 4 or 5+
.
Widowed, Drvorcad (SpecilyJ
x
wo
11. DecedenYS Usual Occu clan KiM o mad Fames?
f 8usinessllydustry
Kl
d (0-
Sec ndary
entary I
El Never Married
Klntl of Work ®
n
o
Communications ^vea "° 12 t
d
Operator r
d en
DidDege
Ltyeina ne ®Yes Decedent'_r,eq n
i S Middleton Two
en
Dege
a
a Pennsylvan
16. Decedent's Mailing Address (Street. city' town, state, zip cotle) Actual Residence 17a. Slate Township?
Decedent Lrveo v+~
^ No
77d
th~n
,
.
rland Acf'~alumilsnl
t Bottom Road
b
l
C Cny ~ Borc
e
nu
um
940 Wa
nb.cpamv
Car 1 i s le , PA 17 01.3 is Mothers Name (First. middle, maiden surname)
oat. aadtxi Evelyn Pinina Swank
midde
me (Picot
N
r
.
.
a
s
,a Fmhe
Robert Russell Shellenberger
stale, zip cotla)
gity ngwn
Address (street
r
,
.
ng
200 m.grmanrs Mai
Box 394
O
P Lewisberry, PA 17339
,
.
.
z0a. Imprmaprs Nama lTrpe Pnm1 811 East Street, '
Dennis R. Shellenberger
Place of Disposition (Name of cemetery, crematory or other place)
21 c
.
21 d. Lnoellon (City f town. stale, z p ^otla
^ Cremation ^ Donation .
21 h. Dale of Dlsposinon (Month, tlay, year) S 11 V e r S D T In g T W p . , P A 17 ~ 5
z, a. Memgd of Diapgaingn
n Authorized
ti
~~~ Stone Church Cemetery
2 009
Jllne 1 ~
o
'~, Was Cremation or Dona
Burial ^ Removal from Slate
^ Vas ^ No
Medical Examiner I Coroner?
'
b ,
,
y
22c Name antl Atltlress of Facility
^ Other -Speciry'
z2b. Clcense"umber p,p, Box 431,
f F orals Lkensee ragn a°nng as apghj
more FH & CS , Inc . ,
th
New Cumberland. PA 17070
zza. sign re p
e
FD 013 340 Par
~ 23c. Dale gned (MOn!n, tlay. year)
23b-Llgenae Number
-
' 23a. To the hest of my knowledge, each occurred al the urre, tlale antl place slate . (Sig lure and tittel
~, / I 1 [~~ `-~ /
/
/
ms 23a-c only when cam ing
N GJ .J
°
It
_ /
U~ C
(/,,
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/
1
e
Complete
l..
physician is not availame at tine of tleath to
Was Cese Relerretl m Metlical Examiner r COrope
26
r fora asap Other then Crematon or Donation?
cartlty cause of death.
e of Death
Ti
4 .
25. Dale P pounced atl Month, tlay, yeai) ~ ye5 ^ No
m
.
2
Items 2a~26 must be completed by person M-
who pronounces death I ~ DD
Approximata'mterval'. Pap II: Enter other gri (cant cond'1 o s co t but no to death, 28. Oltl Tobacco Use Cnniridule io Dealnn
L
Yes ^ P•obably
r
but not resullin to the undehying cause
CAUSE OF DEATH See instruction d examples)
DO NOT anger lertninal events such as cardiac arrest, Onset to Death 9
d the th
' ^
given in Pan I.
NO ~' UnknOWn
.
wations - that directry cause
Item 27. Pan I. Enter the rh 'n of evens -diseases, injuries, or compl
ithout showing the etiology- Lisl onty one cause on each line. i
hll
tl
i l
on w
b
a
respiratory west, or ventricular l
~ e
29. II Fema
~ ~
s
~ f n ~
r
i
'
^ Not pragnam wnn~r oast yFar
~
y t
sease o
Final d
IMMEDIATE CAUSE
'9'-~-- YJ ~
condlllon resulting In death) _~ 1 ;
a ^ Pregnant at ome et deatn
Due Iq (or as a cons gUenCepns 01
1
^ Nm pregnant. out pregnant within 42 days
Sequentially Ilsl conditions, ~' any, h. ~ of tleath
leading to the cause listetl online a. Due to Iqr as a consequence o(1'. 1
DERLYING CAUSE
^ Not pregnant- but oregnam 43 tlavs m t year
1
Enter the UN
(dsease or injury That Initialed the
events resulting to tleath) LAST. Due to for as a consequence oi)'.
r before tleatn
^ Unknown tt pregnant wuhn trio oast year
d 32c. Place t l j ry Home. ° 'm Street. Facmry.
Date of Injury (Month, day. year) 32b- Descr be How Injury Occurred
32a Orrice B Id rig. etc. ISp cJV)
.
Was an Autopsy 30b. W e Autopsy FrW'ngs 31. Manner of Oeath
30a
.
Pedormetl? Aval bl P' to Completion ^ Natural ^ Homicide
k?
If Transportation Injury (Speciryy)
32f
32g. Location ,.
i injury (Street, c ry town, stag '
of Cause of Death?
^ Accitlent ^ Pentling Investigation 32d. Time of Injury 32e. Injury a1 Wor .
^ Driver I Operator ^ P n er ^Petleslrian
^ yes ^ No ^Ves ^ No ^ Yes ^ No
^ Suicide ^ Could Not be Detarmined M. ^Other ~ Specity~
~
33b. Signature a Ifler `
_
~
~
_ ~
33e. Cenilier Ieheck only one) ,
• CertiTying physician (Physkian cenitying cause of death when another physician has pronouncnU death and compleletl Item 23) - - - -- - - - - - - - - - - ^
- - - - - - - - - - -
es stated ~ i
33d. Date Stgnetl (MOnlh. day. years
- - - - - -
33c. Licari umher /
To the best of my knowledge, death occurred due to the cause(s) and manner
ician (Physician both pronouncing demh and cenitying to cause of death)
_ _ _ _ _ _ _ - ^ ~ ~ d
h
d
t S L
/ / ~(~ Cy
- - - _
ys
- _ _ _ _ _
• Pronouncing end certttying p
T
death occurred at Iha time, date, and place, end due to the cause(s) and manner as state
e
l
d
,
e
g
To the best of my know
i Print
• Medical Examiner /Coroner date, and 1 oe, and due to the cause(s) and manner as stated- ^ 34 Name arM Atltlress of Person Wht Compleletl C f Death Illem 271 Type
I Guy g.).wht .~ app
tbn and 1 or Investigation, in my opinion, death occurred at the lime, P a ~
i
1 r
na
On the basis of exam ~
36 Date Flletl (Month. day, year) GQY l.-W1-
~r
~
~~~ 1 I S,et r ~ ~ ~O l 3
35. Registrar' Ignalure and DI rict Nu ~ l ~ ~ I ~ I v~l ~~ J ~ J % J22 c~ •
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