HomeMy WebLinkAbout09-24-10PETITION FOR PROBATE AND GR4~TT OF FETTERS
REGISTER OF W ILLS OF ~~'--~9~~`~-~--~~~: ~ COUNTY, PEN~ISYLVA~TIA
Estate of ~~ j ~'' ~ ~ ~~~„~~~~~
also known as
Deceased
File Number !~~ ~ ~ ~ ~ ~ ~ I ~~~
Social Security Number lax ~~" ~~
Petitioner(s), who is/are 1 S years of age or older, apply(ies) for:
(CO~~IPLETE 'A' or 'B' BELOW":)
c~.a
^ A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the c~rtamed in tkt~.,
last Will of the Decedent dated and codicil(s) dated ~~._ `~ ~" * + ,~-7
~> ~ ~- --.
(State releva~tt circumstances, e.g., renunciation, death of executor, etc.) `- {'r't ~ ~__ ~ "~
z~,, ~ ~ ~... -1
CI.~ ~
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after executioner ~ i~~tiume~t s) offered '~,. _~'
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: Y•~ -
~+.~„ .. .7.__i
e%' . y., _
B. Grant of Letters of Administration cam{
(If applicable, enter: c. t.a.,, d. b. n. c. t. a.; pendetue lire; durance absentia; durance ntino,-itate)
(COMPLETE IN ALL CASES:) Attach additiol:al sheets if necessary. ~~
Decedent was domiciled at death in ~~~~~{'~'~.. Cqunty, Pet~ns•ylvania wdth,his /.her last principal residence at ,~~~ _.2.~
(List sheet address, toiwt/city, township, counl)~, state, zip code) ~ ~ '
r-_ c- ~ c
Decedent, then ` ~ `~J years of age, died on ~J ~ at
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property
(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:
~ ~ ~ ~
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
fhr nnrtrrcionPrl•
~-~
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
Adtrtirtistration, c. t. a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
Forst RW-0? ,•~~,. 10.13.06 Pale 1 of 2
Oath of Personal Representative
COIv1iv10NWEALTH OF PEN~•SYLVANIA
SS
COUNTY OF ~~,~.; I. ~ IaE~~~'~ ~CCZ11
'The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and con•ect to the best of
the knowledge and belief of Petitioners} 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
Si~nauu•e of Persa~al Representative
Signature of Perso~:al Representative
r•..a
For the Re 1SteC S~gnalure of Persacal Representative Cam) ~ ~~ ~~-`-; -
r~t ~ -.~
~~ ' ;
~~~
File Number: ,--,~ 4 - ~ l ~ ~ ~ ~ ~ -` ~~-yy~^^*
Estate of ~ ~ '~ `~ ~ '1 \~ c~~ , De~"eased c.:r~ '_ • ' '_-'
GT'~
- ~-~l Lf L ~ Date of Death: C1 - t ~ -~ ~ ~ ~ L
Social Security Number:F ; l I ` ~i*)
~_.i ~ //
AND NOW, ,]~~ ~ ~ ~ ~~` ~ ,-~ ~ ~~' ll.i , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED thhat Lettersr ~ ~~~~.~ ~~1 L~ ~t-~~ ~ „'~~
are hereby granted to ~ (~~ ~ ~~,- ~ ~ 7 i ~~ I
~~ ~~
in the above Pstate
and that the instrument(s) dated _
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
~, .,
FEES (-• ~ C I l .,:~.~'i ,~~~'~.~ / ~ ~ 4 ~ ~ ~C~ )~-~~C ~~ 1
Lett ... .......... $ l_' `' ~j Regtsler of Wills•-~,~ ~ f~~ ~~,~ _ ~~>
ers .. -_~j r ~;
Short Certificate(s) ........ $ ~~ ~.j Attorney Signature: ____
Renunciation(s) .......... $
Attorney Name:
- ~ ~ l ~I ~ • • • $ ~ f~• ~% ~~' __ Supreme Court LD. No.:
... $
$ Address:
... $
... $
... $
• • • $ Telephone:
... $
TOTAL .............. $ l ~ • ~i C!.
Page 2 of 2
I-•o~•,n Rw-r~? rev. ra.~3.or
t)-CAh REtaISTRAR'S t;ERTI~ICATIaN tai DEATI~I
UU,~f~NiNG: et i<, illegal to duplicate tF~i~ copy b~ phofios~tat or phot~grap~t~.
1 r~e~' tilt tili~ ;.eriiti~:ite. ~;(~ =)!j
P _-_16 8 5__4.3..0_ ~ _ __
n I
~,t;rl1l-1:1~-1 ill .~ ~.!)lill,,"'
t'~•J
>~
C Q r,~ _ '
~ /~ t_ -
~ r,
-V
F
~ ..,
C.:
~J N rte,
.. Z. -;
V # ~"~
0
w
0
U
D
LL
0
w
Z
H105.144 REV 11P2008
TYPE/PRINT IN
PERMANENT
BLACK INK
;;,;1,
;;;a~ I ,-~ )~ tf~ , ~ t )~~~, t,,;; J)e irrl(/rlnarl~ln here t~i~en is
~~~,t"~~,,' ~'~/ ~~ t 1.I-i`t it' t..~flrt~R.i a+ id II tii'-~`Illi:l (erg-Il.ale OI Dl'ath
t~ J~
off- ~,, ,! 11~, 1 s . ,i . jl ll .,~ ~~, I >,3~.,(1 K~`~-~trar. I I;e t.Y) -~~-nall
~~ ,
~. ,~
;`~ ,~.~_ ~.'( ~. r~)f~j~.-E~~ ~o~ll •~, ill,,,jr~c~l t(t thL~~ ~S1atc Vital
~, y ~y ~ ~~ -~t~,~-r ~ ~ 1116 !~ ~~ ~, ~gla-l~~)u f~iiir~~~
lt" . ~u,'y, . ' --~
~q
4 ~,
/~+
r Y ~
,,,._~ ,.
1 =~l.~l( ~5~.':''ti1h~13 I~aR I`SSUc~j
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See Instructions and examples on reverse) areTC ni c r.u u~or=o
1. Name of Decedent (First, midde, last, suffix) 2. Sex 3. Social Security Number 4. Date of Death (Month, day, year)
Robert P Motter 210- 44 - 6743 Se tember 10 201
5. Age (Last Birthday) Under 1 year Under 1 day 8. Dale of Binh (Month, de ,year) 7. Birthplace (City and state or f carat) 1 3a. Place of Deam (Check only one)
Abnaa Days Hours Minutes
Carlisle, PA Hospital: Other:
5 6 Yrs. a tember 2 5 19 5 3 ^ Inpatient ER /Outpatient ^ DOA ^ Nureing Home ^ Residence ^ Omer • Specity:
- fib. County of Death 8c. Ciry, Boro Twp of Death 8d. FacNity Name (I1 not ktstttution, give street and number) 9. Was Decedent of Hispanic Origin? [~ No ^ Yes 10. Race: American Indian, Black, Whtte, etc.
~
Cumberland
South Middleton
Carlisle Regional Medical Center (If yes, spedry Cuban,
Mexican, PuertoRkan,etc.) (Specify)
P~hite
11. Decedent's Usual lion Kind of work d one du nest of IHe. Do nd state refired 12. Was Decedent ever M the 13. Decedent's Edtxxtbn (Spenaty only highest grade comp leted) 14. Marital Status: Married
Never Mamed
15
Surviving Spo use (If wife
give maiden name)
Kkd of Work KaW of Business /Industry U.S. Armed Forces? Elementary /Secondary (0-12) College (1-0 or 5+) ,
,
Widowed, Divorced (Specify) .
,
Food Service Giant Foods ^Yea~No 12 ~ ied Constance Warner
- 16. Decedents Meiling Ad~ess (street dry /town, stela, zip oode)
851 North Hanover Street Decedent's Did Decedent N . Middleton
Adual Residence ,7a. Bate pA Live in a , 7c, ~ Ves
Decedent Lived in Tw
- Carlisle, PA 17013 ,
p.
Township? 17d. ^ No, Decedent Lived within
17b.County~
,
~P~
~a~~ AaualLimttsof
City / Born
18. Father's Neme (First, middle, IasL suffix)
' Marlin H. Motter, Sr. 19. Mother's Name (First, middle, maiden surname)
Margaret E. Gips
20a. Informant's Name (Type /Print)
Constance Motter 20b. Informant's Mailing Address (Street, city /town, state, zip code)
28 S. Alydar Blvd., Dillsburg, PA 17019
21 a. Method of Diapcedion ^ Cremation ^ Donation
-
n 21 b. Date of Disposition (Month, da ear
y, y ) 21 c. Place of Di
sposition (Name of cemetery, aemalory or shat place)
21d. Locetion (Ciry /town, state, zip code)
~.~ Burial ^ RemovelfromBate I WasCrartlrNbnorportstlonAuthorized
g
^ Sept. 16, 2010 Cumberland Valley Memorial Carlisle, PA 17013
Other -Specify: by Madlcal Examinsr / CoronarT ^ Yes ^ No
_
22a. Signahxe of Funeral reon acting u such) 22b. License Number 22c. Name ant Address of Facility Hof fman-Roth Funeral Home & Crematory
- - 138425
Compete ttems 23ac Doty when certifying 23e. To the t d my knowledge, death occurred at the rime, date and place stated. (Signature and title) 23b. License Number 23c
Date Signed (Month
day
year)
physician is not available al time of death to .
,
,
certify cause d death.
ttems 24-26 must be corttpleted by parson 24. Time of Death 25. Date Pronounced Dead (Month, day, year) 26. Was Cese Refened to Medical Examiner /Coroner for a Reason Other than Cremation or Donatbn?
_
"'"°p'°r'"""°'~m~ 7:06 P. M. Se tember 10, 2010 Yea ^"°
CAUSE OF DEATH (See Inatructlona end examples) r Approximate interval:
ttem 27. Pad I: Enter the d]ak1 of evems -diseases, inwdes, or oomplkatbns -that directly caused the death. DO NOT amen terminal events such as cardiac arrest, r Onset to Death Part II: Enter otlter;pgttificent conditions contributira to death,
but not resulting in the urdedying cause given in Part L 28. Did Tobaa~ Use Contribute to Death?
^ Yes ^ Probably
raspiretory areal, or ventricular fbdBatlon wfmart showing the etiology. List Doty one cause on each M1ne. r
r
IMMEDIATE CAUSE (Final disease or r
^ No ^ Unknown
tbnditianresultingin th) Probable M
a
di
~
l I
f
i 29. IfFemele:
yoc
r
a
-~' a.
n
arct
on
Due to (or as a consequence oft: ~ ^ Not pregnant within past year
segt,antlallyllMaxtdilions,tta b. Hypertensive Cardiovascular Disease r
tc the cause listed on k e a. r ~ ^ Pregnantattimeofdeam
Enter a UNDERLYING CAUSE Due to (or as a consequence of): r ^ Not pregnant, bW pregnant wtthin 42 days
(dseese or injury that iMtialed the c. i
events resulting in death) LAST. r of deem
Due to (a as a consequence oft: r Not pregnant, but
^ pregnant 43 days to 1 year
• d, ~ before death
^ Unknown if pregnant within the past year
30a. Was en Autopsy
Pedomted? 30b. Were Autopsy Endings
AvaiaWe Prior to Completion 31. Manner of Death
"~,( 32e. Date of Injury (Month, day, year) 32b. Describe Fbw Injury Occurred 32c. Place d Injury: E tome, Fenn, Sheet, Factory,
of Cause of Deam?
IN Natural ^ Homicide
` Office BuAding, etc. (Spedty)
~-,s
^ Yes t~U No ^ Yes ^ No ^ 'ant ^ Pending Investigation 32d. Time of Injury 32e. Injury at Work? 32f. It Transportation Inlury (SP~YI 32g. Location of Injury (Brest, city /town, state)
~ \ ^ Sukdde ^ Could Not be Determined ^ Yes ^ No ^ Driver I Operator ^ Passenger ^ Pedestria
M. ^~' ~dY: 3
33e. Certifier (check only one) 33b. Signature and Title of Ceniber
• CMIry4ng plryskfen (Physician certflying cause of death when another physician has proraunced death end completed Item 23)
T
th
o
e best of my knowbdge, death occurred due ro the cease(s) end manner as ahted_ _ _ _ _ _ _ _ _ _ _ _ ^
• Pronoun
i
d
g
i
- - - - - - - - - - - - - - - - - - - - - - ~l ' C ~ ~ L. OIle r
c
ng an
csn
y
ng physician (Physk;iaan both Ixorwundng deem and Certitying ro cause of deem)
To the best o} my knowkdge, death occurred at the time, data, and place, and due to the cause(s) end mutnsr as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. License Number 33d. Date Signed (Month, day yeart
Medleel Exeminer /coroner
On the basis o1 examinstion and I a lnvesti
stl
i
i
i September 14 , 2 010
g
on,
n my op
n
on, death oecumd at the Nma, date, and plsn, end dw to the cause(s) and manner as atated_ ~ 34 Nana A ss led se of De Ite
1°d
~'~ ~:`
'9
~
~d m 27 T /Print
~~r
35. Registrar' 'are ant Diatric' ~Wenbe^ to Filed (Month, day, year) o
c
ceiro
e,
roi
6 3 7 5 B as a ho r e Rd . , Suite 4~ 1
Mechanicsbur , Pa. 17050
Disposition Pertntt No. `~ ' ~ V J^ I h ~ 1.1`"1
'T