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HomeMy WebLinkAbout12-06-10PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY COUNTY, PENNSYLVANIA - ----------------------- Estate of Shirley Bennett LOTZ File Number 21-10 ~- I ~~, t.~' also known as Shirley Anne Bennett-Lott Deceased Social Security Nurrtber 202-20-6116 Richard S Simpson II Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE `A' or `B' BELOW.) © A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the Executor named in the last Will of the Decedent, dated 05/26/2010 and codicil(s) dated State relevant circumstances, e.g., renunciation, 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: _-- ^ B. Grant of Letters of Administration appica e, en er: c..a.; .n.c..a.; pe en e i e; uran e a sen ia; uran a minor a e 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: (/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.) Name Relationship Residence , ~~ t~ -~ = ~ ~- t r t --; s ~ ~ ~ t7~ I ~_.. - ~' -.~ ~- ° -.ti.:. -- (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. `-..v - i t~ ~ ~_,~ Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal r`esid~ence at ~ ~ - Messiah Village, Mechanicsburg, Upper Allen, Cumberland County, PA 17050 (List street address, town/city, township. county, state, zip code) Decedent, then ~_ years of age, died on 11/21/2010 at Messiah Village, Mechanicsburg, Cumberland County, PA 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: 70,140.00 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 underslgned~ Signature Typed or printed name and residence J Richard S Simpson II 426 South Third Street ,/J Lemoyne, PA 17043 ~..~ "'VVV °R Form KW-U! Rev. 10-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc. Paae` 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } SS COUNTY OF Cumberland County } 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 L /~ bef me this day of ~~j ~ ~f ~ } For the Register Signature of Personal Representative Richard S Simpson II Signature of Personal Representative Signature of Personal Representative File Number: 21-10 - j ~ ~ ~ U Estate of Shirley Bennett LOTZ ,Deceased Social Security Number: 202-20-6116 Date of Death: 11 /21 /2010 AND NOW, ,fir ~' ~' i i '~ ~ 1 ~' r ~ ~~ ~~ ~ ~ in consideration of the foregoing Petition satisfacto roof , , ry p having been presented before me, IT IS DECREED that Letters Testamentary are hereby granted to Richar d S Simpson II ip„~t a above estate and that the instrument(s) dated 05/26/2010 ~` ~;_~, ~ described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. ~ ` `~~'-` -", ., ~ 1 / f /~ ~~ A FEES Letters ......................................... >' '' $ ~ r II ~ l ~ f-- ~) - .. - ; - =--r, ~. C -.. „ Short Certificate(s) ....................... i $ I~~) ~ ~-' 1 ~ Regis er of Wills - t~` _ ~ • ~~f~ C~{'c'hi ~ ~L ` ~~~~"I !t Renunciation(s) ............................ $ Attorne Si nature: Y 9 ?~Gt `~~~~~~~ c~ • '~l.' Attorney Name: J RY R. DUFFIE l ~~ r / Supreme Court I.D. No.: __09601 ~ ~ G C $ + ~ ` . $ ~ ~ JOHNSON, DUFFIE, STEWART & ' ~' ~ ` ~ - ~ ~' Address: 301 MARKE T ST. $ PO BOX 109 $ LEMOYNE, PA $ Tele hon p e: (717) 761-4540 TOTAL ................................... $ ~ L ~ ~ . jj ~~ Form RtN-02 Rev. 10-13-2006 Copyright (c) 2 006 form software only The Lackner Group, Inc. Page 2 of 2 M°'. i{ ~ I £ p° d t ~, s S t' r"e t %.n ~.eT ? f `,J A 0 ~1 !~ -» ` ~~ ~.,. ~ ~e~~~9{ ~ "~ {~~ ~~~6,"~~~~~~` a~Al .a ~,_ ' (" ~ ~C7~~0'~N~F~~i ^r(° ~Y~~;l~'"~ P 17.029066 ~. .y , t ) '11`~ ;,_ t ~i'~~°7illl~ti?t1I1 Elt~'I'l' t'i1CC? I~ ' ~1 i~} ? h n , .v °~'.'Y ~'~ ~ tr-t (' _ I'!.'1! '~ it ;rri1)~F~ ~.. ~.3il~ll ~iil.' t)= ~.~}r,"~i~~l ~K I ...~ _ 7 ~ ~, ..,}! ix ,t,, .. X14 - r , . ~ ~~ 1 ~~ .. ~, , . r rU n ~ _ _ 4 ' ~~ j -~ . I J (,. -.. .J ~~ ~ ~ r H105-143 REV 11!2006 TYPE /PRINT IN PERMANENT BLACK INK COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) CTATF FII F NI IA.IFFR 1. Name of Decedent (Frst middle, last, sulfiz) 2. Sez 3. Social Security Number 4. Date of Death (Month, day, year) Shirle Anne Bennett-Lotz Female 202 - 20 - 6116 11/21/2010 5. Age (Last Birthday) lklder 1 ar Under 1 da 6. Date of Birth Month, da , ar ). BiM ace C' and state or for ei Doan 6a. Place of Death Check on one Monlns Days Hours Minutes Hospital: Other: 83 Yrs. 6/13/1927 Butler, PA ^Inpatient ^ERlOutpatient ^DOA ^Nursi Home ^Residence rg ~ Other - Specify: ~. County of Death 6c. City, 8oro, Twp. of Death 6d. Facikry Name (If n« institufion, give street and number) 9. Wu Decedent d Hispanic Origin? ~ No ^Ves 10. Race: American Indian, Black, White, etc. (if yes, specify Cuban, (Specil» Cumberland U Allen Messiah Village Mexican, Puerto Ripn, etc.) White 11. Decedent's Usual tiort Kind of work done B urin most of workin He. Do not state retired t2. Was Decedent ever in the 13. Decedents Education (Specify only highest grade canp leted) 14. Marital Status: Married, Never Mamed, 15. Surviving Spo use pf wife, give maden name) Kind of Work Kind of Business/Industry U.S. Artred F«cas7 Elementary /Secondary (0-12) College (1-4 or 5f) Widowed, Divorced (Specify) Executive Secretary Medical Hos ital ^Yes~No 2 Widowed 16. Decedent's Mailing Address (Street, city /town, state, zip code) Decedent's Did Decedent 11PP''11 Actual Residence t7a State Pennsylvania Live ina t7c Decedent Lived in Alper Allen T YLJ Yes 340 Messiah Circle ,~ . , . Cumberland township? 77d. ^ No Decedent Lived within M i shut PA 17055 , t7b. County Actual Limits of City/Boro 16. Fathers Name (First, middle, last suffix) 19. Mothefs Name (First, middle, maiden surname) Robin E. Bennett D.O. Genevieve M. Rice 20a. InlormanYS Name (Type /Print) ZOb. Informants Mailing Address (Sheet dry /town, state, zip code) Att Dane V. Smith 24 Ridgewood Dr. Redding CT 06896 21 a. Method of Disposition r ^ Donafion Cremation 27b. Date of a Month, da , ar spos4ion ( Y Ye ) xsposdion Name of tamale ruemat 21c. Place of D~ ( ry, Dry or other place) ltd. Location (City) town, state, zip code) I Burial ^ Removal from State Was Crematlon « Donation AutMrized ^ Other-S r by ~ /Coroner? ^Ves^ N~ 11/26/2010 Coles Cemetery Derry, PA 15627 22a. SignaW of unerel Lice 22b. License Number 22c. Name and Address of FaciGry Nei 11 Funeral Home , Inc - FD 013239 L 3401 Market St. Cam Hill PA 17011 to ite only when certifying ' 23a. To ihe~d my knowledge, death olxurred at the time, date and place stated. (Signature and title) 23b. License Number 23c. Date Signed (Month, day, year) physician of available at tirtle of death to certiy use of death. ~ /~ L ~ \~~-~ Q,' l I~~ ~.~-~ ~~ ~l/ ~ti / ~~~ ~/~~`Z/ 77~% ~ _ L /( I 'cifV 2'rh~''--{^ ~ ~i ~ V 24.26 must he completed by person 24. Time of Death ' / ' 25. Date Pronounced Dead (Month, day, year) 26. Was Case Referrr[~ed~tp Medical Examiner / Corater f« a Reason Other than Cremator « Donation? who pronounces death. ~ ~ M. N ~ ~ ~ ') ~ ~ ~ ^Ves t,1y~IJo CAUSE OF DEATH (See inatructbns and examples) 1 Appmzimate interval: Part II: Enter other tijgnificant condi[iorts contributing to deaM~, 28. Dd Tobacco Use Contribute to Death? kern 27. Part I: Emer the Clain of events -diseases, iryuries, a conlpfications -Nat directly caused the death. DO NOT enter temlklal events such as cardiac arrest, r Onset to Death but not resulting in the underlying cause given in Part I. [~ yu ^ pr~bry respiratory anent, «ventricular fibrillation without showing the etbbgy. List Dory one cause on each line. r 1 - 1~ y -iJ. No ^ Unknown IMMEDIATE CAUSE (Final disease or ~_.. ~ r cordition resukklg in Bath) 29 M F ~ r a. C ~ a ~ o - N Due to (r as a nuance of): k. t - ot pregnant wthin past year ^ Pre n nt t e W d h sequentially list conditions. if any, b. 7 ~ r, ,:> c~-. ~ ~Ci Gc..~ ~ ~ a leafing to tlta cause Nsted on line a g a a rne eat ^ . Enter Ble UNDERLYING CAUSE Due to (or as a consequence off: 1 1 - Not pregrtanl twt pregnant withn 42 days (disease « injury that ktitiated the r r events resulting in death) LAST. c _ of death ~ Due to (or as a consequence of): r r _ Not pregnant but pregnant 43 days to 1 year bet«e death d. r r - - ^ Unknown if pregnant within the past year 3qa. Was an Autopsy 30b. Were Autopsy Endings 31. Manner of Death 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occurred 32c. Place of Injury: Home, Farm, Sheet, Factory, Performed? Available Pri« to Completion l ^ H i f id Office Buildi etc. ~. (~fY1 of Cause of Death? ata om e c ^ Yes No ^ Yes ^ No ^ Accident ^ Pending Investigation 32d. Tme d Injury 32e. Injury at Wod? 32f. If Transportation Injury (SpecryJ 32g. Location of injury (Street, ary /town, state) ^ Suicide ^ Cot4d Not be Det rmin d ^Ves ^ No ^ Driver/Operator ^ Passenger ^ Pedestrian e e M ^ Other - Spea~/y: 33e. Certifier (check Dory one) 33b. signature and T pf Cerf_' r • Certifying physkien (Physician certifying cause of death when another physician has pronounced death and completed Item 23) - ~' ~/~ ~ f-, my ledge, death occurred due to the nu To the best of know sal:)sndmannerustated--------------------------------- ~ ~ < - • Proraundn9 artd ~fY1n9 phyaictan P ~ both ( hysiclan pronourldng death and certifying to cause of death) 33c. se Number 33d. Date Signetl (Month, day, Year) To the best IN my knowedge, death occurred at the time, date, end lace, and due to then p use(s)andmannerushted------------------ • Yedlcal Examiner/Coroner ~ ~ ~ S ~ ,, Z _ ~ . ~ (-- ~ Z ~ :., On the bash of examinatbn and / or investigation, in my opinion, death occurred at the time, date, and plan, and due to the ruse(s) and manner as stated_ ^ 34_ and Address IN person yJho C«roleted Cause of Death (Item 27) Type I Print 35. R is s$x~~palure a~ Din ' r 36. ate Fled (Month. day. year) '-~ "~ I "~ ~, ~ i t N c~C~ '~v~ Disposition Permit No. ~ '~1 ~ I ~ V ' L .` ~ _# :~.1 _} ~.~' ~" r___. ; , ~J~ ~~~=: OF SH/RLEY BENNETT LOTZ I, SHIRLEY BENNETT LOTZ, of Upper Allen Township, Cumberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. I. I direct that all my legal debts and funeral expenses including my gravemarker and ali expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my decease as a part of the expense of the administration of my estate. I direct my Executor to pay all inheritance, transfer, estate, income and similar taxes (including interest and penalties) assessed or payable by reason of my death on any property or interest in propert~+ which is included in my estate for the purpose of computing taxes. My Executor shall not require any beneficiary to reimburse my estate for taxes paid on property passing under the terms of this Will or otherwise. III. ~ i bequeath my automobile, household goods, jewelry, including, but not limited to, my yellow geld diamond ring and my platinum diamond ring, and other tangible personal property of a like nature (not including cash or securities), together with any insurance thereon, to my daughter, DYANE VALERIE SMITH. Should my daughter, DYANE VALERIE SMITH, predecease me, then I direct that my Executor shall liquidate said items of personalty and the net proceeds therefrom shall be added to my residuary estate. IV. I bec.fueatn the sum of One Thousand ($1,000.00) Dollars to my friend, MARY LOUISE SHETT~ER, pro~~ided she shall survive me. V. I bequeath the sum of One Thousand ($1,000.00) Dollars to my friend, LISA STARNER, provided she s-~ali survive me. VI. I bequeath the sum of One Thousand ($1,000.00) Dollars to my friend, SUSAN FULGINITI, provided she shall survive me. VII. devise and bequeath the residue of my estate of every nature and wherever situate as Follows: . A The lesser of five (5%) percent of my residuary estate or the sum of Ten Thousand ($10,000.00) Dollars to GRANT FOUNDATION, P.O. Box 81048, Pittsburgh, Pennsylvania 15217, for the benefit of Hospital Albert Schweitzer Haiti. I further direct that this residuary bequest shall be paid by GRANT FOUNDATION to the governing body of Hospital Albert Schweitzer Haiti and to be used as part of the general operating fund. B. The lesser of five (5%) percent of my residuary estate or the sum of Ten Thousand ($10,000.00) Dollars to PRESBYTERY OF CARLISLE, PRESBYTERIAN CHURCH, (U.S.A.) to be given to the Presbyterian Church of which I am an active member at the time of my death. Further, I direct that the bequest be given to the Presbyterian Church of which I am an active member at the time of my death to be invested and reir,~,~este~ by the Ch~:rch's governing body in a separate fund and the principal ar~d ...come in. said fund to be used by the Senior Pastor in service at said Church in said Pastor's discretion to assist women and families in financial difficulty because of domestic abuse or abandonment. C. The balance thereof to my daughter, DYANE VALERIE SMITH. Should my daughter, DYANE VALERIE SMITH, predecease me, I devise and bequeath a residuary to my grandson, TAYLOR LELAND SMITH, subject to the provisions of Paragraph ~JIII. 2 V111. Should any of my issue, including my grandson, TAYLOR LELAND SMITH, entitled to a share of my estate not attain the age of twenty-five (25) at the time of distribution to him or her, I devise and be~~ueath the share of each such issue to MID PENN BANK, Camp Hill, Pennsylvania, 1N SEPARATE TRUST, to held, manage, invest and reinvest the shares so received, and the accumulation of income thereon, and to use and apply the income and principal, or so much thereof as, in Trustee's sole and absolute discretion, may be necessary or appropriate for such issue's support and education (including trade school and college education, both graduate and undergraduate) after taking into consideration his or her parent's ability to provide for such support r~r ed~~caticn, cr .o make payments for these purposes, without further responsibility, to such issue or to such issue's parent or to any person taking care of such issue. Any principal or income not so applied shall be distributed to such issue absolutely when he or she attains the age of twenty-five (25). If he or she dies before attaining the age of twenty-five (25) the Separate Trust shall terminate and such share shall be distributed to his or her personal representative. IX. i he interest of the beneficiaries hereunder shall not be subject to anticipation or to voluntary or involuntary alienation. X. I nominate, constitute and appoint, RICHARD S. SIMPSON II, Executor, of this, my last Wili.. Should RICHARD S. SiMPSON 11 fail to qualify or cease to act as Executor, I appoint MID PENN BANK, of Camp Hill, Pennsylvania, Executor, of this, my last Will. Xi. I direct that my Executor, and his successor, shall not be required to post bond in any jurisdiction for the faithful performance of his or her duties. XII. Mly corporate fiduciary shall be entitled to compensation based on its regular schedule of ~ fees for such services in effect from time to time during the period over which the services are performed. 3 ~~ ~~ IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ "' da of Y . 2010. ~,._L,r,. gle e'~'~l.o~'i (SEAL) SHIRLEY B NNETT LOTZ Signed, sealed, published and declared by the above-named Testator, as and for his Last Will and Testament, in the presence of us, who, at her request, in his presence and in the presence of each other have hereunto subscribed our names as witnesses. ACKNOV COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND . ss: I, SHIRLEY BENNETT LOTZ, Testatrix, whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. oyln~ ~ l - L. v ~'s. SHIRLEY ENNETT LOTZ Sworn or affirmed to and acknowledged before me, by SHIRLEY BENNETT LOTZ, the Testatrix, this ~ ~~ day of , 2010. Not ry Public COMMONWEALTH OF PENNSIrL.VANIA NOTARIAL SEAL Gail J. Mahoney, Notary Public Lemoyne Borough, Cumberland County 4 M commission expires Feb 19, 2014 ~. ,, AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA . ss. COUNTY OF CUMBERLAND We, ~t°r~~-1 I~ • j~tt~7~~ ~ and Q ~' re'F" ~ ~ I`~-~t-~-'~ ,the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the foregoing i instrument as her Last Will and Testament; that she signed willingly and that she executed it as her I'rree and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge, the Testatrix was that time at least 18 years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by '~'r~~ ~ ~ ~l.l~i '~--- and ~ ~ . ~ k~ ,witnesses, this o~~9~1~-day of 201 Q. No ary pubc :399609 COMIVIONWF.ALTH OF PENNSIiLVANIA NOTARIAL SEAL Gail J. Mahoney, Notary public Lemoyne Borough, Cumberland County ~ e F 19, 2014 5