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HomeMy WebLinkAbout07-30-10 his is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in act.ordance with the Viral Statistics Law of 1953, as amended. WARNING: It is illegal to duplicate this copy by photostat or photograph. Linda A. Caniglia State Registrar 5?00102 ~~ ~1H105-143 REV 112006 V/ TYPE /PRINT IN PERMANENT BLACK INK r ~ i w a ~\ (~\~ \J 0 w w 0 0 No. JAL 1 5 2010 Date COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) STATE FILE Nl1MRFR 1. Name of Decedent (First, middle, last, suffix) 2. Sex 3. Social Security Number 4. Dale of Death (Norm, day, year) Richard R. Cook M 263 _ 92 _ 5937 7/3/2010 5. Age (Last &Ahday) Under 1 ar Under 1 da 6. Dale of Binh Month, da , ear 7. Birth lace Ci and state or for ei n count 8a. Place of Death Check on one Monms Days Hours Mlnules Hospital: Other: 61 Yrs. 1/25/ 1 949 1am1 i FL ^ Inpatient ^ ER /Outpatient ^ DOA ^ Nwsing home Residence ^ Other - S i l~ y Bb. County of Death Bc. Ciy, Boro, Twp. of Death 6d. Facility Name (If not institution, give street and number) 9. Was Decedent of Hispanic Origin? [~ No ^Yes 10. Race: American Indian, Black, White, etc. i . (If yes, specity Cuban, (Specify) Franklin Gillford Twp. 85 Willowbrook Dr. ive Mexican, Puerto Rican, etc 1 tiVhite 11. Decedarrt's Usual Occu lion Kind d work done d unn most of workin life. Do not state retired 12. Was Decedent ever in the 13. Decedent's Educatbn (Specify only highest grade comp leted) 14. Marttel Status: Married, Never Married, 15. Surviving Spo use (If wife, give maiden name) Kind of Work Kind of Business/In~stry U.S. Armed Forces? Elements /Secondary (0-12) College (1-4 or 5+) ~ Widowed, Divorced (SfxnlyJ Truck Driver Tractor Traitors ®vea ^No 1 l Divorced - 16. Decedent's Mailing Address (Street, city /town, state, zip code) Decedent's l R iden e 17 Act St t PA Did Decedent Live in a Gillford 17c ®Y s De edent Liv d i Tw 85 Willowbrook Drive ua es c a. a e . , p. e c e n _ Tovmship? 17d ^ No Decedent Lived within Fr kli Chambersbur PA 17202 17b County , an n Actual Limits of City/Boro 16. Famals Name (Frst, middle, last, suthz) 19. Mother's Name (First, middle, maiden surname) Sidne - Cook Mary Olive Burns 20a. Informants Name (Type /Print) 20b. Informant's Mailing Address (Street, city /town, state, zip code) James Cook 464 Short Pine Circle, Orlando, FL 32807 21 a. Method of Dispositbn r [~ Cremation ^ Donation 21b. Date of Disposaion (Month, day, year) 21c. Place of Dispositbn (Name of cemetery, crematory or other place) 21d. Location (Ciy/ town, state, zip code) - ^ Burial ^ Removal from State i Wes Cremation or Donation Authorized 7 2010 y~' Services C ti PA Leola ^ ether- r byMedkalExaminer/Coroner? [Yes^ No / 7/ on rema uVans , 22a. Signature of Fune rvi Licensee (or person as suc 22b. License Number 22c. Name and Address of Facility - - FD 012633 L )~~n Brothers Funeral Home, Inc., Carlisle, PA 17013 Complete items 2 -c only when certig4ng 23a. o the best o y edge, des mad at the time, date and place stated (Signature and title) 23b. License Number 23c. Date ~ red (Momh, de ,year) physician is not available at time of death to ~/ // ~~~ S ~ ~ ] ~t / /) / ~~/ / Q~ (J a ceroty cause of death. ~~ c.,,, G' V . Items 24-26 must be completed by person 24. Time of De th ~ ~ 26. Date Pronounced cad (Month, day, year) ~_ 26. Was Case Referred to Medical Examiner i Coroner for a Reason Other than Cremation or Donator? - who pronounces death. ~ M. /• ~ ~ ~O / D ^Yes o CAUSE OF DEATH (See inetructlone and exa lea) ~ Approximate interval: Pan II: Enter other f death. 28. Did Tobacco Use ConMbute to Deathl Item 27. Pan I: Enter the chain of events -diseases, injures, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, i Onset to Death but not resulting in the underlying cause given in Part I. ^Yes ^ Probaby respiratory arrest, or ventricular tibrill ion without showing the etiology. List only one cause on each line. , ^ No ^ Unknown IMMEDIATE CAUSE (Final disease w ~ conddion resulting in ath) -~ I7 a ~ f~ ,,~ i / 1 /d /"' WIC-v ~ 29. If Female: ^ Nol re nam within ear ast Due to (or consequence o : Sequentially list conditions, if any. b L ~ , i ~~~j~py/7J/ L' 4 '=~ ~ p p g y ^ Pregnant at time of death ^ leading to the cause listed on line a. Enter the UNDERLYING CAUSE Due or es a conseque"~/~f): ~ - r Not pregnant, but pregnant within 42 days (disease or injury that nitrated the ~j~// sr L~~ ~~~~ ~-ze ~ ~r ~ ~ c' ( !Ct ! -' L~ ~-~i ~ d th LAST lk ~ ~(i!'1 /~ ~~p~y 1 G f M1~+ ~ of death ^ N t b t t 43 d t 1 - . events resu rg n ea ) . Gue to (or as a consequence ol): . r -~+-K , ot pregnan , u pregnan ays o year before death • d. ~ Unknown if pregnant within the past year 30a. Was an Au[opsy 30h. Were Autopsy Findings 31. Manner of Death 32a. Date of Injury (Month, day, year) 32b, Describe How Injury Occurred 32c. Place of Injury' Home, Farm, Street, Factory, Penormed? Available Pror to Completion of Cause of DeaM? Natural ^ Homicide O'fice Building, etc. (SpecilyJ ^ Ves ~ No ^Yes ^ No ^ Accident ^ Pending Investigation 32d. Time of Injury 32e. Injury at Work? 32f. If Transportation Injury (Specify) ^ ^ ^ 32g. Location of injury (Street, city I town, state) ^ Suicide ^ Could Not be Determined ^Yes ^ No Driver/O rator Passenger Pedestrian pa M. ^ Other -Specify: 33a. Certifier (check only one) 33b. Signet a and Tide of Certifi • Certdying physician (Physician certitying cause of death when another physician has pronounced death end completed Item 231 death occurred due to the cause(s) and manner ea stated To the best of my knowledge ~ ~ O ~~ , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Pronouncing end cartltying physician (Physician both pronouncing death and certiying to cause o1 death) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 33c. icanse Number 33d. Date Signed IMOnth, day, year) To the beet of my knowledge, death occurred et the time, date, and place, antl due to the cause(s) and manner as ateted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ YN 'Y ~ `3 ~ Z G ~ , f • Medical Exsminsr/Coroner ~ ~ ' f 1 d~ ~l On the basla of examination and / or invettlgatlon, In my opinion, death occurred at lM time, date, and place, and due to the cause(s) end manner es atetsd_ ^ 34. Name and A~ ass of Perso Who ggompleted Cause of Death (Item 27j Type I P' t l~ G- I~r ~, ~t ~ f~ R i t ' 35 ' N r-` Fil . z;v 7 c Q czrc eg s rar . s a and Dist mba 36. to ed (Momh, day, year) Disposition Permit No. ~ ~la 1 `1~ ~~'--a ~_) c~ ,..I ~- --; ~ --0 ~ C..... - : (--- - ~ I?t C.a ; ~, . , ) - - ~ ~ _ ~;-;~ _ - _ :, , ,_- _. . __. --=-{ .. - r 1' l t+ + ~~ `, ~J .. ~ 1 ~ ,~• LAST WILL AND TESTAMENT c a ~ - ~. ri ~...-~. :. ~ ~_ 7 ~ ~... w OF c~ t-- _ ~...3 ~, _ : _:-~ C~ RICHARD R. COOK _ ~; .~. . , ..~~, .,~.~ I, RICHARD R. COOK, of , 8 Peiper Court, Carlisle, Cumberland County, Pennsyl~naa, make this my will. I revoke any other wills or codicils to wills made by me. ARTICLE I. DISTRIBUTION OF MY PERSONAL PROPERTY ESTATE I give all my tangible personal property to my child Anthony Preston Cook, presently residing in Chambersburg, Pa and my child Miranda Kaye Cook, presently residing in Wauseon, Ohio, share and share alike. Tangible personal property includf;s stamp or coin collections but does not include other money or stock certificates or other evidences of intangible rights or interests. Tangible personal property does not include any property that is held primarily for investment purposes or used in connection with any business in which I may be engaged or in which I may have any interest at the time of my death. ARTICLE II. DISTRIBUTION OF THE RESIDUAL ESTATE TESTAMENTARY TRUST A. I give the residue of my estate to my Trustee, IN TRUST for the benefit: of my child Anthony Preston Cook, and my child Miranda Kaye Cook, (hereinafter "Trust Beneficiaries") to share, as described more fully below. Interpretation of and application of the distribution scheme described in Article II herein is ito be carried out by and is at the sole discretion of my Trustee. B. My Trustee may accept funds from inside my estate or from outside of my estate, including but not limited to, insurance proceeds payable at the incident of my death. C. PROVISION FOR INTEREST VESTING IN BENEFICIARIES UNDER AGE TWENTY-FIVE -- Notwithstanding the foregoing provisions, whenever any interest in my estate, including this testamentary trust, vests absolutely in a Trust; Beneficiary under age twenty-five, my Trustee shall retain the interest upon a separate trust or together in one trust with the other Trust Beneficiary, as my Trustee decades at. his or her discretion, keeping in mind the interests of the Trust Beneficiaries arf; best-served by minimizing estate and trust expenses whenever possible, and to pay to each Trust Beneficiary as much of the net income or principal according to the follo~~vang: 1. My Trustee address the health, education, maintenance and welfare needs of my Trust Beneficiaries. Page 1 of 5 2. My Trustee shall make every effort to utilize the Trust funds to assist the Trust Beneficiaries with their post secondary education expenses. 3. My trustee may distribute to and among the Trust Beneficiaries, or any of them from time to time, all or any portion of the net income and such portions of the principal as my Trustee, in his absolute discretion, may deem advisable. 4. Such distribution of income and principal may be made in such proportions among the Trust Beneficiaries as my Trustee, in his absolute di>cretion, may deem advisable, without regard to equality, and the pattern of any distribution of income or principal need not be followed at the time of any other such distribution. Any of the net income not distributed by my Trustee in accordance with the foregoing provisions in any calendar year shall be accumulated and added to the principal of this trust. 5. If a Trust Beneficiary dies before reaching the age of twenty-five years, his or her interest shall constitute a part of the beneficiary's estate. 6. This trust shall terminate upon the earlier to occur of the following events: (1) At such time as all of the Trust Beneficiaries shall have attained the age of twenty-five years; or (2) At such time as there is no Trust Beneficiaries of mine then living. 7. Upon termination of this Trust in accordance with the provisions of subparagraph C hereof, or if either of the events specified in Article II, Subparagraph C 6 above has theretofore occurred, the balance of the principal then remaining shall be distributed to the Trust Beneficiaries, per stirpes. ARTICLE III. PAYMENT OF EXPENSES AND OTHER CHARGES I desire a modest Christian burial. I direct my Executor to pay my funeral and burial expenses (including the cost of a monument or marker over my grave). The estate, inheritance and similar taxes assessable on my death (including taxes on assets not passing under this will) shall also be paid as a cost of administering my estate and my Executor shall not request any beneficiary to pay any part of such tax. ARTICLE IV. MISCELLANEOUS PROVISIONS A. Spendthrift Trust. To the extent permitted by law, neither the principal nor income of any trust shall be liable for the debts of any beneficiary or, except t:o the extent otherwise specifically provided, to alienation or anticipation by a beneficiary. B. Matters of Interpretation. For simplicity, I have expressed pronouns and other terms in one number and gender, but where appropriate to the context these terms Page 2 of 5 shall be deemed to include the other number and genders. The bold headings are for convenience and shall not affect interpretation. ARTICLE V. APPOINTMENT OF FIDUCIARIES AND POWERS A. I name James Ronald Cook, presently residing in Orlando, Florida, to be my Executor (hereinafter "Executor"). B. I name "Farmers and Merchants Trust Company of Chambersburg" to be my Trustee (hereinafter "Trustee"). If administration of my estate or trust should be necessary in any jurisdiction where my Executor or my Trustee is unable to qualify, or if my Executor or my Trustee deems it necessary for any other reason, I give to my Executor and my Trustee the power to designate any individual or corporation with trust powers to serve with my Executor or my Trustee or in my Executor's or my Trustee's stead. I request that no security be required of any Executor or Trustee, including an Executor or Trustee named pursuant to the preceding sentence. Reference in my Will to my "Executor" and my "Trustee" are to the one or ones acting at the time, except where otherwise specifically provided. C. Any corporate Executor or Trustee shall receive for its services the compensation for which it willing to undertake similar services for others at the time such services are rendered, as evidenced by its published fee schedule in effect from time to time, unless it is willing to agree upon a fee that is less than its customary fee, Any individual who serves as Executor or Trustee shall be entitled to receive reasonable compensation for his or her services and, whether or not such individual receives compensation, shall be entitled to be reimbursed for expenses incurred for such services. D. I grant my Executor and my Trustee the powers set forth in 20 Pa. C.S. §3311-3332 and 20 Pa.C.S. §7771-7780 respectively. In addition, my Trustee may merge any trust under this Will with any trust having the same trustee and substanti,~.lly the same dispositive provisions. If at any time after my death the size of any tri:~st under this Will is so small that, in the opinion of my Trustee, the trust is uneconomical to administer, my Trustee may terminate the trust and distribute the assets to the person or persons authorized to receive the trust income in such shares as my Trustee may deem appropriate. No Trustee who is also an income beneficiary of the trust at issue shall exercise any discretion granted in the preceding sentence. My Exe~:,utor and my Trustee may distribute tangible personal property passing to a minor to any adult person with whom the minor resides, and that person's receipt shall bc; a sufficient voucher in the accounts of my Executor and my Trustee. E. It is my desire that my Executor, herein above named, and my Trustee consult with Mateya Law Firm in the handling of my estate and testamentary trustt, they being familiar with my affairs. Page 3 of 5 ARTICLE VI. DEFINITIONS The following definitions shall be applicable to all of the provisions of my Will except where otherwise specifically stated: 1. The use of the masculine shall include the feminine or neuter and the use of the singular shall include the plural, and vice versa. 2. The term "estate," where appropriate, shall include any trust hereunder. 3. The term "minor" shall mean an individual who has not attained the a~;e of twenty- one (21) years. ,~ Executed this ~ ~ ~ day of J , 2010. i+' , ,r Richard R. Cook Signed, sealed, published and declared for his Last Will and Testament by the testator in our presence, we all being present at the same time; and we, in his presence and at his request and in the presence of each other, have subscribed our names as witnesses whereof, all on the date last above-written. 14 W:.i ~7 Page 4 of 5 COMMONWEALTH OF PENNSYLVANIA CUMBERLAND COUNTY Before me, the undersigned authority, on this date personally appeared RICHARD R. COOK, Mark A. Mateya, and' 1~~~-~~~,~"~~,.~. ,known to me to be the testator and witnesses, respectively, whose names are signed to the foregoing in:>trument and, all of these persons being by me first duly sworn RICHARD R. COOK, the testator, declared. to me and to the witnesses in my presence that said instrument is his Last Will and Testament and that he had willingly signed and executed it in the presence of said witnesses as his free and voluntary act for the purposes therein expressed, that said witnesses stated beforE; me that the foregoing Will was executed and acknowledged by the Testator as his last Will and Testament in the presence of said witnesses who in his presence and at his request and in the presence of each other did subscribe their names thereto as attesting witnesses on the day of the datE; of said Will and that the testator, at the time of the execution of said Will was over the age of eighteen years and of sound and disposing mind and memory. Sworn and acknowledge before me by RICHARD R. COOK, the testator, Mark A. Mateya, witness, and ~ ~ ~-? l A ~C,~. ,witness, this •" /V G~.,._ day of , 2010. ~,c~~~~~~2L RICHARD R. COOK Witness ~) ~_ Witness G~ . ; My commission expires: Notary Public .;v~~M1UNWEALTH OF PENNSYLVANIA Notarlat Seal arances A. Aumiller, Notary Public -;Huth Mitldleton Twp., Cumberland County Page 5 Of 5 y.. ~`~y Commission Expires March 16, 2014 ^e~!ber. Pennsytvania ~ssociatlon of Notarie"s