HomeMy WebLinkAbout02-0721Register of Wills of Dauphin County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of c:e,~. ~~ /'} . .St ~~~ _ No
also known as
21-Q2-721
Deceased Social Security No. J/.3"y~-OIJ.j~
I'etitione, tsl, who is/a,e 18 years of age nr older, apply lien) tor.
(COMPLETE "A" OR "B" BELOW:)
l~ A. Probate and Grant of Letters and aver that Petitioner(s- is/are the execut named in the Last Will of the
``~~ Decedent, dated and codicil(s) dated
State relevant circumstances, e.g., renunciation, death nl 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 documents offered
for probate; was not the victim of a killing and was never adjudicated incompetent:
B. Grant of Letters of Administration
le.t.a., a-bnc.r.a -. pendeme tire: dmame amen ra; de,m-,re ..,,r,o,narel
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse
(if anv} and heirs:
Name Relationship Residence
_ o°~/l/NE" /y1. /'/-l~~c if = 1FE, /5"N 1.0 ~ ~r C-1rn H/~L
/ ~D ~/
Decedent was domiciled at death in (~ 1%f ~~~~~ _ County, Pennsylvania, with his/her last family or principal
residence at ~5 ~~• Zp~1 -ST f}ryi~/L~~~
~~ [[ (list street, number and muri~cipality) L~ ~./ ,o
Decedent, then 7~ years of age, died ~ /i! ~~ ~_, 20 OL at ~~~K-Sys / ~ ~~. C ~~71~~c /~
0.ocauonl
Decedent at death owned property with estimated values as follows:
Uf domiciled in PAI All personal property .............................. S ~ ~~ ~ ~TJ _
Ilf not domiciled in PA) Personal property in Pennsylvania ................... . .. S
(If not domiciled ir1 PA) Personal property in County .......................... S
Value of real estate in Pennsylvania ............................................... S _
Total........ ....................................... S f~P .
Real Estate situated as follows: /t%~~
Wherefore, Petitioner(s) respectfully requestfs) 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
l ~ ~Nn/~ ~ - ~yir.~ %~~ S
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Oath of Personal Representative
Commonwealth of Pennsylvania
County of Dauphin
The Petitioner(s) above-named swear{s1 and 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 tc~...~aw. ~A
Sworn to and affirmed and subscribed
before me this 12th day of
Estate of JEFFREY A SHAW Deceased
also known as
Social Security No
No. 21-02-721 _
193-48-0039 Date of Death: JUNE 27 2002
AND NOW, AUGUST 12 20 ~_, in consideration of the Petition
on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters ^ Testamentary ®of Administration
are hereby granted to
(c. it I~.n ~: 1 f~ei~~en~i lit~~; ~uian~e xt~+ei~ti~, Juianiu ~~~ii~eiii~.~i ~:1
ANNE MPHILLIPS-SHAW AKA ANNE M, SHAW
in the above estate and that the instrument(s), if any, dated
described in the Petition be admitted to probate and filed of record as the last Will of Decedent.
FEES
Letters ........................... S 25.00 ~
Register of Wills
Short Certificate(s).......... S 9.00
Renunciation .................. S
Affidavit ( )....••••••••••••• $
Extra Pages ( )......... •. • $
Codicil .......................... $
JCP Fee ........................ S 5.00 Attorney:
Inventory & Tax Forms... S I.D. No:
Other ............................ S Address:
TOTAL ................ $ 39.00 Telephone:
DATE FILED:
Ed'W-7a
DECREE OF REGISTER
~_ .-
ihis is to Gerrity that tide information here given is correctly copied tram <))~ original ccrtiflcate of death duly tiled with me as
Lucal Regisnar. The ori«inal certific.ite will he forwardL~d ~o the Starr `~'ir~l Rc~c~rds Office for permanent filing.
VNARNING: It is illegal to duplicate this copy by photostat or photograph.
, aJ Hev uB7
Fie for thiti certiticam, w_'.00
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21-02-721
- ,,,,r:
Local Registrar
I d ~ ~7 2~UL
Late
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
NAME Of DECEDENT Ifvv. M10dIe.:av1 ~ SEK SGCUL SECURITY NUMBER DALE UEA7H:MCmn. Day. 'yeti ~I
'~ Jeffr . A. Shaw - 48 - 0039 .. ~h
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AGE ILav Bamaayl UNOER,YEAR UNDERIDAA' 'GATE OF BIRTH BIRTHPLACE-1:ay aria
MonIM r Days Hours T Mastro Month IJev rear ilule or Icreyrr I.Wnlryl ~
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PLACE OF DE ATH ~1'nav.•r.ny ore .Iav:s nn ane~suNi
HOSPITAL ~-- -_---- --- ----- OTHER: _--
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COUNTY OF DEATH CRY, BORO. TWP OF DEATH FACILITY NAME PI nut ,nvluucn. y~ve sheet antl nunoer~ MMS
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DE E 'S USUK OCCUPRION KINDOF BUSINESYINDUSTRY WAS DECEDENT EVERIN DECEDENT'S EDUCATION MARI7ALSWUS~MarrNd SURVIVING SPOUSE
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DECEDENT'S MAILING ADDRESS ISIreal. Cey/Town, SIa4.Zq COdel DECEDENT'S
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UAL 17s. Slats
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RESIDENCE tlecea«a ~
Pa 17011
Can Hill
p ~^ ~^ ~e~ Cumberland Ownfnrp7 ~{~ No. wcw«w av.a ~~~ ~~~~
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FQNER'S NAME IFUV. Mbda. Lass) MOTHER'S NAME IFuv. Middle. Masan Swnamnl
Howard Shaw Patricia Campbell
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INFORMANT'S NAME (TYparPraMl INFORMANT'S MAILINOADORESS :eee1.C /Town, Salle Zp(:owl
Anne Shaw 15 North 2bth ~treet Camp HIll, Pa 17011
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METHOD OF DISPOSITION
' DATE OF DISPOSITION PLACE OF DISPOSRKN7 ~ Name d CmNtsry, Crematory I OCATION ~ Ctty/TOwn, Sala. Zq Cow
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BW1M ^ CrMnaltlnAJ f,elrgyal nom Slalf ^ (I.Aaan' DaK MNr) or DIMI PMCe
Der,.Iden^ OIMr,SPacAyl ^ . July 1, 2002 East Harrisbur
Cremato Pa
Harrisbur
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URE OFfUN L E PERSON ACTWG AS SUCH LICENSE NUMBER ` NAME AND ADDRESS OF FACILITY Mar et tee
:x4.. 011654-L =_~ Fss-F[arner Funeral Home Inc Hill, Pa 170
ms xaa<o Irrg 7o uN by a my anowlatlgs, warn occurrea ad Ina hrne. date antl yIa<e sated Ia:ENSE NUMBER DATE SIGNED
Pnyfrcr.n a avaaa4q al Irma of warn b ISglratwe aria tulel (Moran. DaY. year)
c.nay cause a warn.
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4ama x.-26 muetMcompMled Dy TIME OF DEATH DATE PRO UNCED DEAD 1Marm. Day. Year) MAS CASE REFERRED 70 MEDICAL XAMINERICORONER7
• person wfto Prorotarcas wain.
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27. PART 1: EnNr IM dlseaus. nlurles or CAnrpllcalrora wMCn Causes the wain Do not aMM IM mow al Ing, sr<n as caral.c or respualory anew. slwck or nfan lalure A
i pro.Imats PART II: Omar sign~fkam mrWiYOns ConpiDlAmq to warn. WI
LIV only one cause on eatJr MN. ~ eYerval MNrean not rosu4trg m Nre wrderlyurg carne GNen n PART I.
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NNS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER Of DEATH DATE OF INJURY TIME OF INJURr INJURY AT KORK7 DESCRIBE MOH! INJURY OCCURRED.
PEF,FOf1MED7 AWIIABLE PRIOR 10 IMOnm. OaY. Pearl
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PLACE OF INJURY ~ AI Igms, farm, Creel. IaaaY• 7mta LOCATION (Shaer Caylkvrn, $lal6)
Dulldrrrg, ac. ISpecavl
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CERfIF1ER ICnaca arvy onel SIGMA! ERTIFTER
'CERTIFY WG PHYSICIAN IPnys¢an CrvMyrtrg Cause d rleahr when andner pMSC~an Has {xrxia.rcN :deem arvd ctanyivlea Hero 251
Te TIN Mal of my 4rwwNtlAe, weN oeeuryed dal b Me cau••lal and manrNr ae fUled ..
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IICE NSE NUMBER DATE 51 DtMo- m. Uav Pearl
'PRONOUNCING AND CERTIFYING PHYSICIANIITysrCUn rxan J:on~wr. nrT deem aiulialayeul lo:.a~~x ~d:denn:l _
Toth pest of my knowledge, tleatnoccurred al VNNrrre, date and pitta and due to lM tautllf)aMmannaraf Elated... .. ....... .... ~.~ ~] 7 )
Jl< _-h L~_i., i_..}Z}~__.. ______._~Id__ ~.j.~.--~T-_C~e~`
NAME AND AOD ESS OF PERSON WMO COMPLETED CAU E OF DEATH
• 'MEDICAL EXAMINER/CORONER (item 111 Type w Pnnl ~ ~I
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On Ifte basis of easminNion and/w inresHga,don, in my opmlon, tleNn occurted al the lime, dale, and lace, and tlue to the cause a and
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REGISTRAR' 1 NATURE AND q~~j' r
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~1~~~`_ ADD a.-
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CERTIFICATION OF NOTICE UNDER RULE 5.6(al
Name of Decedent:
Date of Death: ~ ~ ~ 7 ~ D
Will No. ~ ~~ ~ ~ ~ V ~ ~ J Admin. No. ~~' U ~- ~ U ~ ~ ~''"~
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on
Name l Address
L~~' i~ l
A'l~JI~I ~ ~N I ~-f. ~1 ~S .. ~l~/-~Zl ~ ~ ~ l` ~ . ~ ~1~ T ~~~ ~ ! L L I ~~' l J
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date: ~ ~ ~ ~ ~ ' ~ ,,Z t~' I/~~- ~~ .
Signature
Name _ ,~y/~~ 6~ . ~~a ~ L ~ l ~'S -~~,~
Address j ~~ /y~ ~1 ~'~ ~'%
Telephone (~ 1~) 7~ ~ ~ ~ ~ --r
Capacity: ~ Personal Representative
Counsel for personal representative
JRD/June 30, 1992/17858 ~ ~ ~
,¢O~ ,~ 4 2004
In Re: Estate of Jeffrey A. Shaw : ORPHANS' COURT DIVISION
Late of Camp Hill Borough : COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY
Estate No.: 2002-721 : PENNSYLVANIA
:
: NO. 21-JeffreyA. Shaw
NOTICE OF FAILURE TO FILE STATUS REPORT AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 6.12, SUPREME COURT ORPHANS' COURT RULE
Personal Representative: Anne M. Phillips-Shaw
Counsel for Personal Representative:
Date of Decedent's Death: 06/27/02
Date of Delinquency Notice: 07/14/04
The undersigned, Glenda Famer-Strasbaugh, Clerk of Orphans' Court, in accordance
with Rule 6.12, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court
Division, Court of Common Pleas of Cumberland County, that neither the above named personal
representative nor the above named counsel for the personal representative have filed with the
Register of Wills or Clerk of the Orphans' Court his, her or its Status Report required by Rule
6.12, Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12,
Supreme Court Orphans' Court Rules, was given by the Clerk of the Orphans' Court on April 30,
2004, and that the ten (10) day notice to file the Status Report has expired. Accordingly, in
accordance with Rule 6.12 the Court is hereby notified of such delinquency and the undersigned
requests that a Court conduct a hearing to determine whether sanctions should be imposed upon
the delinquent personal representative or counsel for the delinquent personal representative.
Date: 07/14/04
/ Glenda Famer Strasbaugh'
Clerk of the Orphans' Court
Distribution: ~ersonal Representative
~-e~n?l Cnr Personal R
~stme File
A heahng is scheduled for at in Cou~room No. 3. If the Stares Repo~ is filed prior to
the he~ng date, the hearing will automatically be c~celled.
STATUS REPORT UNDER RULE 6.12
Name of Decedent: J~----~.le_~ /~[,
Date of Death:
Will No.: Admin. No.: 200' 2 ' 72
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the
following with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes 1~ No [~
2. If the answer is No, state when the personal representative reasonably believes
that the administration will be complete:
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final account ~wi, J~ k~the Court?
Yes No
b. The separate Orphans' Court No. (if any) for the perT~Onal rel~sentat!ve s
account is:
c.Did the personal representative state an account inft~rnally..: toT~e parties
in interest? Yes [--] No [--]
c. Copies of receipts, releases, joinders and approval of formal or
informal accounts may be filed with the Clerk of the Orphans' Court
and may be attached to this repo,rt.
Signature
Name
Capacity: [--] Personal Representative
[-] Counsel for personal representative