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HomeMy WebLinkAbout10-08-10PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND Estate of Mary Louise Polk also known as COUNTY, PENNSYLVANIA File Number 21 '-' ~~ _ ~(~/ ~~ ,Deceased Social Security Number 201-03-5882 Lauren E. Bogar Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE ;4' or `8' BELOW.) ^ A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the named in the last Will of the Decedent, dated and codicil(s) dated Thomas E. Polk. II. Son: Timothy H. Polk. son: and Rosemary Polk. daughter. have renounced their right to administer the Estate in favor of Lauren E. Bogar, Esquire State relevant circumstances, e.g., renunciahon, death of executor, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the instrument(s) offered for probate, was not the victim of a killing and was never adjudicated an incapacitated person: r.> c~ ® ~ ~ Q F~- B. Grant of Letters of Administration ~7 -b ,,,, C ) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following s ~ny) ~ heirs: _; ~/f Administration, c. t. a. or d. b. n. c. t. a., enter date of Will in Section A above and complete list of heirs.) `? ~ ~ I--t C7 F, , .-, r~ ~ s" -r 7 Name Relationship Residence ~--> `- `= =:,> Rosemary Polk Daughter 624 Greenway Terrace N ~ ~ ~ G Kansas City, MO 64113 c.~1 Thomas E. Polk II Son 160 Riverview Road Timothy H. Polk Son 1388 Englewood Drive (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal residence at 325 Bethany Drive, Apt. 3325, Mechanicsburg, Upper Allen Township, Cumberland County, Pennsylvania (List street address, town/city, township, county, state, zip code) 325 Bethany Drive, Apt. 3325, Mechanicsburg, Upper Allen Township, Decedent, then ~~ years of age, died on 10/03/2010 at Cumberland County, Pennsylvania Decedent at death owned property with estimated values as follows: (If domiciled in PA) (If not domiciled in PA) (If not domiciled in PA) Value of real estate in Pennsylvania situated as follows: None All personal property Personal property in Pennsylvania Personal property in County 299.000.00 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 ~~ ~ ~ a~ Lauren E. Bogar One West Main Street Shiremanstown, PA 17011 Form RW-02 Rev. ~o-~s-zoos Copyright (c) 2006 form software only The Lackner Group, Inc. Page 1 of 2 r \ Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF Cumberland } SS } 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 this ~~ day of Ir the Register ~~'r ~r Lauren E. Bogar Signature of Personal Representative C7 co ~ 0 gnature of Personal Representative r; ~ ~ m -~ '~' cri ~ C30 ,_i r^....... File Number: 21 ' ~ (~ - ~ ~22- ~ ~ Estate of Mary Louise Polk ,Deceased rn ~-- r -`?; ` ._ ~~~~ Social Security Number: 201-03-5882 Date of Death: 10/0312010 AND NOW, ~ ~C-~ v l ~ ~Q ~~ , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters of Administration are hereby granted to Lauren E. Bogar in the above estate 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 Letters .......................................... $ ~) ~ l1. L}}~~~1//.~~~~ Short Certificate(s) ....................... $ "~ (..~1.~ Renunciation(s) ............................ $ ~)C~S $ ~~.~L /~ttYl_C~~ 13y1 $ ~ ~ C'~ $ $ $ $ $ $ ~~ TOTAL ................................... $ ~ ~. ~L Attorney Name: Lauren E. BOgar Supreme Court I.D. No Bogar 8 Hipp Law Offices Address: One West Main Street Shiremanstown, PA 17011 Telephone: 717-737-8761 Form RW-02 Rev. 10-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc. Page 2 of 2 Attorney Signature: ~~ ~ '~j~°~~ IU~.,tinS K8~ .01/rt71 ~ ~ ~ --. ~~~ LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 P 16805009 Certification Number This is [o certify that the information here given correctly copied from an original Certificate of Deg duly filed with me as Local Registrar. The origi) certificate will he forwarded to the State Vi Records Office for rmanent filing. ~~~,. ~ ~ r a s zoo ~ i Local Registrar ~ Rte' ttrzaos COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH .VITAL RECORDS E /PRINT IN ~LACKNINK CERTIFICATE OF DEATH (See Instructions and examples on reverse) Date Issued C'7 rv ~ C _ c , ='` c'7 ~~ 1 ~ ~ 7 1. ~ `-": C~ ~ wj ~~ ~ ~ i -~ ~ ~ - _ *` 'l t. Narre of Decedent (First, madde, WeI, sumz) 2. Sax 3. Sorel Security Number m 4. Data a Deam (Momh, day. Year) Louise Polk - ,- October 3 2010 6. Age (feel RirlMay) Under 1 r Under 1 6. Date of Binh Monm a 7. Si ce G and stale a to ' !M. Wece of Deam Check on one s DaW Hour B8 Hospital: mer: O f g 98 Yr6. Jul 30 1912 Franklin CA • PA ^ Inpatient ^ ER /Outpatient ^ DOA iq Nursing Hans ^ Residence ^ Omer Specify 8b. County of Deem &. City, Born. Twp. of Deam 6d. Fadkry Name (II not iraeMkn, Aive street and number) 9. Wes Decedent of Fespank Ongin? No ^ Yes 1g. Race'. American Indian, BWCk, White, etc. n, 7~.,~1 ,..,7 7 ,..' •l t7 (If yes, specify Cuban, ' lAitWCL ltillll LIJwP_r Hilen BQ yll a Mexkan, Pueno Rkan, ek.) r~1 (ralllte t t. Decedarll's Usual lion Kntl of work done du ~ moat of Me. Da not state relit 12. Wm Decedent ever n dw 13. Decedent's Education (Spedty onty hghast grade conroleledl 14. Marital Status: Merced, Never Merced, 15. Surviving Spouse QI wife, give maiden name) KiM of WoM Knd of Buexwssl laWetry U.S. Armed Forces? Elenlenmry / Secazlary ((}12) College (td or Sr) Wzbwed, Divorced (Spea'yJ ^ Yes No 16. Deceden's Meitmg Address (Street, clry /town, slate, zip code) Decedent's Did Decedent Iff:~'';; P A l A • rs 7 ~ L ctua Readence ,7a. state Tiv ei sh ' 17c. ~Yas, Decedent Livetl in 325 Wesley Dr. • nil iwp o t lp . E 7~~~ t rved wltMn MechaniCSbur PA 17055 17b. County WaLL7CJ.la11d t7d. t DlLm M Ac ue its 18. Famer's Name (First, midde, last sash) 19. Mother's Noma (Fret, mtlde, maiden sumeme) William Ke erreis City/Born g Blanch Johnston 20e. InlcrmanYS Name (type f Pnnt) Rosemary Polk 20h. InlamanYs Meiling Address (Street, dly /town, slate, zip cede) 624 Greenwa Terr. Kansas Cit MO 64113 21a. Memad of Dleposikon r ~~ ^ Daretion ^ 6aal ^ RamovalfrdnStar ~ 21b. Daro of Gspositkn (Monet, deY. Year) 21c. Place of Disposition (Name d cemetery, aernetory or oma stete,~ 2 ~ a waacremelbn«DOnatlonANlwNaadwVea^ ~ ^ Omer ~ ' M Medcd Ezammarl AA October 6, 2010 flinger GYemation Service y ~ 110 f Mt HOll ri s PA _,D ~ 22a. Funeral 22b. Lkrerge NaMer v,,..~~~ 220. Nerve arM Address of Fadihy erS~[anL lKi ~ 014819 1903 Market St. Hill PA 17011 Conpl•u items 23ec arty when cerdlykg physician is not avatiebb at tithe of death re 23e. 7o me best d my , deem eau at the fi~ staled. (SigneNre a tldal 23b. Number i 23c. Date Signetl IMonm. daY, Year) cantiy Hausa of deem. ~'..51.'7J O~~ ~-~c.~er 3. 2CyiC~ barns 21-26 must be corlgleted by person who pralaxices deem 24. Time of Deam~.a ~ 26. Date Danc1ed Dead ( ,day, year) ~ t 26. Was Case Relened Io Medical Examiner /Coroner la a Reason Omer man Crematkn a Donation? . / . ~~ M. 7 !,r ~ ,~ U / O L ^ Yes ~No CAUSE OF DEATH (Sea Inetru«lona end examples) r Approzknete interval: hem 27. Pan I: Emer the chakl d events - diseases, njunes, a cornpfiCetions ~ the! dzectly caused the deem. DO NOT enter lennkrel events such as cerdiec arrest i Onset to Deam ras i l t l i d fiM9h im k h i m Pan II: Enter omar ' ~ but not resuking n me undertying cause given in Part I. 26. Did Tobacco Use Contdhute to Deam? [~' Ves ^ Pmbabty ory arres p re . a van r d ar n w t an s ow ng a ekobgy. List only tine cause an each Ikte. t IMMEDIATE CAUSE Fnal disease or u ^ No ^ Unkriovm ,' pp _ ; mndlion resultlrg n r~m) ~ µ~ ON 1 C ~ p ~i~ i ~.~.C~. i ()/ [ r (,t L-Y~tIO l.i /?t ~. y ~i ~i (_' A'i l' r ~ li't. [i C41-S 29. N Female _~ a t ~7 Due to a as a c ( onsequence oq: Nel r pa ye U4 p egnant wbhin sl ar SepamialN Isl Coaalians. it airy, b. leading to 9k reuse Asled an Ina a ^ Pregnant at time of tleath Enter the UNDERLYWG CAUSE Due to (a as a conseWence ol)'. ~ ^ Not pregnant, but pregnant within 42 tlays (disease a injury met iretiated the i of death c eveMS resulting in deem) LAST. i ^ Duo t0 (0r as a CbmegaerlCe ~: i Not pregnant, but pregnant 43 tlays t0 1 year d_ t before Beam ^ Unkrrown it pregnant within the past year 30a. Wu an Aunpay Penamietl? 30b. Were Aulapsy Fndngs Avefieble Prior to Compktkn 31. Manner of Deam tt 32a. Dale of In'u Monet, da , ry ( y year) 32b. Describe How Injury Occurred 32c. Waco of In u Home, Farm, Street, Factory, M ry of Cause of Deam? rra~ wk Natural ^ Homicide Odke Bui etc n9, - /Spa'YyJ ^ Yes ®No ^ Yes ^ No ^ Accitlenl ^ PeMkg Investlgation 32d. Tkne of Injury 32e. Injury at Work? 32f. N 7renslwrtadon Injury /Specify) 32g. Location of injury (Street tlry /sown, state) ^ Suitltle ^ CoaM Na he Oaemknetl ^ Yes ^ No ^ Driver/ Oparata ^ Passenger ^ Pedestnen M ^ Omer ~ Spezyy: 33a. Cartlfier (dtedr arty one) 39b. SigteNre end Tme of CeNfier • CertgYln9 phyekien 11'hnkian OemAing cease of deem when aramar physician has prorpunced deem aM mnpleted Item 23) ~ca To the Mat of my knowledge, death tlCCllrrad dIM ro Me eeltae(a) and 11181111« as stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1.19 ~ ~L/rLy+v/It.6ZY ~~~'~ 1Y1 O Pr«rounclnp and rxYtNying phyakhn (Physician bom prorawrirg deem end certAykg b ceuee of deem) • 33c. Lkense Number 33d. Data Signed (Monet, tley, year) To 1!w beet d my knowledge, deem aeumd at the time, data, and plea, and due to d1e uuee(s) end mennar as statetl_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ • Medleal EzamnerlCOroner +y1f~ ~Irl Sy, ~ j O ~ r~ l 1 C On the bah d azaminetbn and I «InvesdgMbn, In my opinbn, death aeurred at the tnM, date, and place, and due to d1e uuaa(e) and manner as stats~ ^ 34. Name and Address d Person Who Competetl Cause of Deam (Item 27) Type / Pnnt 36. Regnuays Dlshict N ~2i / i ~~ / i I i - ~~~~ ~e 36 Dale F' ( , tley year) ~ ~~ +'vY ~`~ ~ rr2~( ~ >' ~I.,s~. ;>;•,~~I~ ~-~" ... n ~ ono _ . , ~ ~, . Disposition Perms r~. 0542137 ~ rv o C Q ~~ o O ; `r ` ~ '- nj~n -t ` i ~ i-~~ _ RENUNCIATION t C? f ~n ~ -; C'~ ~C _ ~ _~ -~ -= •-? REGISTER OF WILLS ~ ~ ~ n T CUMBERLAND COUNTY, PENNSYLVANIA °' , Estate of Mary Louise Polk ,Deceased I~ Timothy H. Polk , in my capacity/relationship as (Print Name) son of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Lauren E. Bogar ( te) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills Form RW-06 rev. 10.13.06 (Street Address) St. Paul, MN 55104 (City, State, Zip) Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation for the purpo es sLLtated within on this ~r~ day of ~ft'/11~1~s•' o~UIC~ ~~ Notary Public My Commission Expires: ~ ~ -mod/.3 (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) ~_ DIANE MONTGOMERX NOTARY PUBLIC SHR2EMANSTOYIHI BORO, CUMBERUND CO MY COMMISSION EXPIRES AUGUST 3, 2013 h.3 A ~ ~` ,.. d ~ :~ =12~~ ""t ~~: _:7 r- ~ m 1 ~~ Cif ~ ~ _"-i _J~ ~~ J , RENUNCIATION "~' ° ~~`~ "' `~ T' REGISTER OF WILLS rn CUMBERLAND COUNTY, PENNSYLVANIA a~ - ~o - l~aa Estate of Mary Louise Polk ,Deceased I Rosemary Polk , 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 Lauren E. Boar (Date Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills Form RW-06 rev. 10.13.06 (Signature) 624 Greenway Terrace (Street Address) Kansas City, MO 64113 (City, State, Zip) Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation for the purpos stOted within on this ~~ day of ~~ ~~Lr ~b/O Notary Public G~~ i~~ My Commission Expires: ~-~-o~C?~ (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) DIANE MONTGOMERY, NOTARY PUBLIC SHIREMANSTOWN BORO, CUMBERLAND COU MY COMMISSION EXPIRES AUGUST 3, 2013 n rv - - G © ~ ~ -- o O ; _, ., , ~ -. C71 ~ ~ Ct ~ ~ =, RENUNCIATION ~~; r' ~' °D ` -~ ` ^, ~_ ~' REGISTER OF WILLS ~ ~ °° CUMBERLAND COUNTY, PENNSYLVANIA ~ "~ ~,l -~~- ~D~a Estate of Mary Louise Polk ,Deceased I Thomas E. Polk, II , in my capacity/relationship as (Print Name) son of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Lauren E. Bogar ~~~6~~ (Date)~~ (Si ure) 160 Riverview Road (Street Address) Executed in Register's Office Sworn to or affirmed and subscribed before me this of day Deputy for Register of Wills Form RW-06 rev. 10.13.06 Athens, GA 30606 (City, State, Zip) Executed out of Register's Office Before the undersigned personally appeared the parry executing this renunciation and certified that he or she executed the renunciation for the purposes stated within on this !~~'~` day of OC fvb ~ r- ~L~IC> Notary Public G~%~~~ My Commission Expires: ~-~ ~~.~ (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) DIANE MONTGOMERY, NOTARY PU SHMY COMM SSION EXPI ESMAUG ST13, 20113