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Home My WebLink About04-25-11IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA REGISTER OF WILLS PETITION FOR PROBATE AND GRANT OF LETTERS Estate of ~~~~ ~~5~" a , -- f /~ ~S c;~-/ ,Deceased ESTATE NO: 21- ,~ (, ~ ~ - `~ a/k/a: ~ a/k/a: SS NO: Petitioner(s) who is/are 18 yrs of age or older, apply(ies) for: COMPLETE SECTION `A' or `B' AND "C" as applicable: Qom: Probate and Grant of Letters Testamentary or ^Administration c.t.a., or d.b.n.c.t.a. (complete Part Calso) and aver that Petitioner(s) is/are entitled to the aforementioned Letters under the last Will of the above-named Decedent, dated _~~~~y __ and codicil(s) dated C? ~' {...., ~`°' ':~ 7~ rte-- "a' r 17 (State relevant circumstances, e.g. renunciation, death of executor, etc.) ._~.--== rn ~.~ ~' Except as follows, Decedent did not m ~ ~ ~" -~. arty, was not divorced, and did not have a child born or adopted af#et~.~.x'e~i,ttion o~''the - instruments offered for probate; was not the victim of a killing, was never adjudicated an incapacitated p~'~d w~•not a _: party to a pending divorce proceeding at the time of death wherein grounds for divorce had been e~~ished as~d`efinecl,~n r _: 23 Pa. C.S.A. § 3323(g): _~ .~` `_ ..~ ~. ~ C~ c. J "~-~ ^ B. Grant of Letters of Administration (if applicable, enter d.b.n., pendent lite, durante absentia, durante minoritate) C. 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 Administration c.t.a. or d.b.n.c.t.a., enter date of Will in Section A and complete list of heirs); was not the victim of a killing; was never adjudicated an incapacitated person; and was not a party to a pending divorce proceeding wherein grounds for divorce had been established as provided in 23 Pa. C.S.A. § 3323(g), except as follows: ~a Add _ ~ ~~' in/ ~'~i ~~ ^ ~~~ (~ ~ ~C ~'.^ r~ ~ -, /~a~ % t'.c rt,c'~ ~,.~ ~~ ~i U°' neianonsm to ueced~ i~,~ G~ ~/Try ttCF. annrT~nN~t cu~~-rc .~ "'ECESS ARY ant THIS SECTION MUST BE COMPLETED: Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or principal residence At _r ~ C~'~'s i1~'~r--,' r-?.~~-,~,r /Uc~cc~ f3u~°l-r , (Street address with Post Office and Zip Code, Municipality: Township, Borough, City) Decedent, then ~~ ct~ ears of a e died f~/; i~ ~ ,1~~' (1~4onth, Day, Year of death) (City and State where death occurred) Estimated value of decedent's property at death: If domiciled in PA ` `' - All personal property $ _~~ L~~; "" _If not domiciled in PA Personal property in Pennsylvania $ _If not domiciled in PA Personal property in County S _Value of Real Estate in Pennsylvania S Total Estimated Value S ~~ ~ LAG " Location of Real Estate in Pennsylvania: (Provide full address if possible.) Signatures ~, Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court Page 1 of 2 OATH OF PERSONAL REPRESENTATIVE Commonwealth of Pennsylvania ~ SS ~ County of Cumberland ~. ~ ~~ ,~~, ~. (~, :"T~ ~ . - ~ .,-~ Z C7 q . ~ , ; ~-;, The Petitioner(s) herein named swear or affirm that the statements in the foregoing Petition arm and~r~~ correct to the best of the knowledge and belief of Petitioner(s) and that, as personal represent~~~~~j~) oftt~e ' Decedent, Petitioner(s) will well and truly administer the estate according to law. -~_~, ~~y __ . _.. _ :~ Sworn to or affirmed and sunscribed ~ ' ., .~~ .~.~ before me this _ .~~`} day of ~ _ ~~;. ~ ~ ~ ~ ? . ,~'' ~C ~'''~ For the Register DECREE OF PROBATE AND GRANT OF LETTERS Estate of ~U~ ~( j ~; ~~ ~~~ (~~~°~ J~ ,Deceased File Number: 21- - AND NOW, this `~Z~_ day of }~~~ (1 ~ ~.~~ j ` , 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: (If applicable, enter c.t.a., d.b.n., d.b.n.c.t.a., etc.) ~i~~~~ n r~ 1 c 4' ~ , , ~f~) ~C f'a __ in the above estate and that ><nstruments(s) dated r_P ~ ~ ~ C~ _ ~ ct ~ ~ described in the petition be admitted to probate and filed of record as the last Will and Codicil(s) of Decedent. FEES: Letters ....................$ ' ~ ~ _ Will ........................~-~ .~1_ Codicil(s) ............... _ (~) Short Certificates ,~ . G~~ (~) Renunciations....... i (; . z''~; Bond ............................ Other ............................. ................................. Automation FEE......... 5.00 JCS FEE .................. 23.50 TOTAL ................ $ Atty's Signature PRINTED Name: Supreme Court ID No.: Address: Phone: Fax: Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court Glenda Farner Strasbau h Register of Wills Signature of Counsel Required to Enter Appearance Page 2 of 2 ~aL• REC~STRA-RSS t;ERTF ~"~ ~; ~"„`: - ~~h'il~~~91~l~d ~x ~=w ill~c~ai tea ~lu~~dca~;1;~ t~~~ ~ Iti:~tw,l:~~r~ ~~~° ~~rl~k;~~al :_~~ ~-~I`_ ~ ,> ~~~,~ It)' tl~i'•. E~c~rtilii~st~~. ti(`~.1~1) P 17246640 (_~i')'li1i~`~:i:t1t) „ti1111)"~C~ .w- H105-143 REV 1112008 TYPE /PRINT IN PERMANENT BLACK INK 0 ~_ 0 U 0 Z 'f tiit~t i t Y } f! r t ~~ iy ~ n ~~~ ~x f~ 4 j ~ .1~~.~\'. ,J A S'r'i ~yJ 1 i.a R t ~ y ~. ~~ ~~, ~c -.: ~ ~ a r'r R ~- .~ __ _ ._ _ _. '`, C ~ r-.., =~ Q ~ ~ ~~ 'T.1 ~...t ! ~ ~ ~ -~ ./lJ 4' 34 ~ 7 ~r 1.1 ~~.. ~ m re.~ - ~. ate- Rcr~~ .. j vt -- -- ,; ~ r - -- ~ n ~" ~ , - ) C~ _.k . - -~-; ~.J ~ ,' - - = .3 ` ; - ( ~.. "rl COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) ~r.T~ <„ ~ ,,, ,,,o~„ 1. Name of Decedent (Post, midde, last, suffix) 2. Sex 3. Social Secudy Number 4. Date of Death (Month, day, year) Mary Rose Simpson female 313 - 12- 2491 Feb. 11, 2011 5. Age (last Birttday) Under 1 ear Under 1 da 8. Date of Birth Month, de , r 7. Birth a Ci and state a fa ' taunt 8a. Place of DeaNr Ctrede one • 89 Yrs Mortis Days Hours Mkxxes Jan. 23, 1922 Terre Haute, IN Hospital: ®,npatient ^ER/outpatient ^I>DA Other: ^ NursingHome ^ Residence ^Dther-specify: Bb. county of Death &. City, Boro, Twp. of Death Bd. Fadlity Name (II rat insGlution, give sheet and number) 9. Was Decedam of Hispanic Origin? ®~ ^ Yes 10. Race: American Indian, Black, White, etc. • Dau hln De T M.S. Hershe Medical Center (11 yes, spedly Cuter. Mexicen, Puerto Rican, etc.) (Spec/y) white 11. Decedent's Usual Occu tion Kind of work d one Burin most d IHe. Do rat slate refired 12. Was Decedent ever k the 13. Decedent's Education (Specify Doty higftest grade comp leted) 14. Marital Status: Married Never Married 15 Surviving Spo use (1f wife ive maklen name) Kind of Work Kind of Business /Industry Ar U.S med Forces? Elemenla / Serxxtda 0-12 ry "( ) Coll ~ (1-4 or 5+) , , Wes' Dkrorced (~/ryJ . , g manufacturin ~ L zxYes ^ No 12 divorced 16. Decedent's Mailing Address (Street, city /town, state, zip code) Decedent's Did Decedent PA PO Box 15 Actual Residence 17a. State Live in a 17c. ®Yes, Decedent lived in Hop ewe 11 T,,,p Newbur PA 17240 Tovmafrip? 17b.County Cumberland 17d.^No,DecedenlLivedwithin g, Actual Limitsol city/Boro 18. Father's Name (First, middle, last, suffix) Elmer Miller 19. Mother's Name (First, middle, maiden surname) Clara Hays Stewart 20a. Informant's Name (type /Print) 20b. Informant's Mailing Address (Street, city /town, state, zip code) John M. Simpson 200 West Main St., PO Box 15, Newburg, PA 17240 21a. Method of Disposition r ~} Cremator ^ Donation • 21b. Date of Disposition (Month, day, year) 21c. Place of Dispositon (Name of cemetery, crematory or other place) 21d. Location (City/town, state, zip code) ^ Bwial ^ Removal from State r Wa Cremadon ro Donallan Autfariaed • ^ Other- MedkalExaminer/Crooner? vea^ No Feb 12, 2011 Hoover FH & Cremator Inc Harrisbur PA 11112 22a. Signature F rat Service Licensee (or acting as such) 22b. l kense Number 22c. Name and Address of Facility - FD 013902-L Hoover FH & Crematory, Inc. PO Box475, Hershey, PA 17033 Contplele items y when ng 23a. To Nre best of my knowledge, death attuned at the fime, date and place stated. (Signature and tttb) 23b. Licerxe Number 23c. Date Signed (Month day year physician is nd available at tune of deaN to , , cerMY muse of death. • Items 24-28 must he completed fry person 24. Time of Death 25. Date Pr orau nced Dead (Month, day, year) 28. Was Case Relened to Medical Examiner I Coroner for a Reason Other than Cremation or Donation? role pronamces death. ': o ~ ~. M. F / / e{j YV H - I , Zo l l ^ Yes ~ Na CAUSE OF DEATH (See Instructions and examples r Approxknate interval: Hem 27. Pad I: Eller the Hof events -diseases, injuries, a complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, r Onset to Death Part 11: Enter otlrer 1ilfiNfltaml oorditions contributigq to death but not resuNing in ifs underlying cause given in Part I. 2B. Did Tobacco Use ConbibNe to f)eath? ^ Yes ^ Probabty r respiratory arrest, o ventricular fibrillation without slowing the etiobgy. List only one cause an each kne. r IMMEDIATE CAUSE Fi i r I~c~ Idl No ^ Unknown ( nal d sease or corxfition resulting in death) ~ i 29. M Female: -~ a. ~ l1.2,U N1 A111 ~A r ®N i Due to (or as a consequence of): r r baNy kst candilions, d any, b. r b the cause ksted on line a. d pregnant w thin past year ^ Pregnam at time of death ^ p~ to w as a Enter UNDERLYING CAUSE 1 consequence of): ~ Nol re ant, but r P 9n p egnant within 42 days (dsease a injury that in4iated the r events resulMg M death) LAST. c' ~ of death ^ Due to (or as a consequence oQ: Not pregnant, but pregnant 43 days to 1 year • d ~ r before death ^ Unkrrowm if pregnant within the past year 30a. Was an Autopsy 30b. Were AWOpsy Findings 31. Manrrer of Death 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occuned 32c. Place of Injury: Home, Farm, Street, Factory, Performed? Available Prior to Completbn ®Nat r l ^ Fi kid ~ Office Building, etc. (Specify) of Cause of Death? u a on e ^ Yes ^ No ^ Yes ^ No ^ Accident ^ Pending Investgetion 32d. Txne of Injury 32e. Injury at Work? 32f. If Transportatbn Injury (Specify) 32g. Lacatkn of injury (Street, city /town, state) ^ Suicide ^ Could Not be Delermkned ^ Yes ^ No ^ DriverlOperata ^ Passenger ^ Pedestrian M' ^ Other - Specify: 33e. Certifier (check any one) 33b. Signature and Title of Certifier • Certgying physidan (Physiaen certifying cause of death when aratfx:r physician has pronounced death and completed Item 23) /~/~ ~ ` To the beat of my knowledge, death occurred due to the eaute(s) and manner ust~ted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ ~ "'"~'~ I ' • Pronouneing and certltying physiclen (Physician both proraurxting death and certitying to cause of death) 33c. License Number 33d. Date Signed (Month, day, year) To the beat or my knowMdge, death aceurred at the time, date, and place, end due to the cause(s) and manner sa atated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ® • Medkal Examiner/Coroner ~ ~ ~g~ 2 / j ~~ ~ ~~ ~ ~ On Nre basis of axeminatlon end / or investlgaNon, In my oplnlon, death oeewnd at Nst time, date, end plsee, and due to the cause(s) end manner ea stated_ ^ 34. Name end Address of Person Who Completed Cause of Death (Item 27) Type I Print 35. Regisbar's and D r t 36 D t Fil d M h d / ~ ~I ~ I ~I ~ I - . o e ( ont , ay, year) ia- ~ N ~ ~ ~ ~~ M. S. Hershey Medical Ctr. ~S v~ ~ ~ U h vsy ~o~ Disposition Permit No. ~ LAST WILL AND TESTAMENT ,~ ~~ f7 ~ --- ~~~"' ~ z Fn ~~~ ._ . - - MARY M. SIMPSON ~i ;~ a -~ ~ -,~ _ ~ ~ '~~- ~ J ~ ~ I MARY M. SIMPSON, a resident of Sullivan County, te St~a of Indiana, being of sound and disposing mind and memory, do hereby make and declare this to be my Last Will and Testament, hereby revoking any former wills heretofore by me made. ITEM ONE It is my will that the Personal Representative who administers my estate, hereinafter named, shall first pay all of my just debts, expense of last illness, fur..eral expenses, taxes and costs of administration. ITEM TWO After the payment and discharge of Item One herein,, I give, devise and bequeath all of my property, real or personal,, including jointly held property with any of my three children, to my daughter, Tomi Kay Higginbotham, as Trustee, to hold the same in i.rust for the use and benefit of my father, Elmer Thomas Miller, for the remainder of his life. In the event that my f ather does not survive me or upon his death should he survive me, i1t is my will that this trust shall terminate and the Trustee shall divide the property remaining at such termination among my three children, namely; John Michael Simpson, James Reid Simpson and Tomi Kay Higginbotham, in equal shares, share and share alike. ITEM THREE I nominate and appoint Tomi Kay Higginbotham as E:x~ecutrix herein. IN WITNESS WHEREOF, the said Mary M. Simpson has hereunto set her hand and seal to this, her Last Will and Testament, this 29th day of June,- 1984. Mary M, mpson The foregoing instrument was on this 29th day of June, 1984 , signed by the Testatrix and declared by her to be her Last Will and Testament, in our presence, and was signed by us as witnesses, in her presence, and in the presence of each other at her request. ~~ J sse H, edwe Tracey a OATH OF NON-SUBSCRIBING REGISTER OF WILLS ~) WITNESS(ES) .,.L) L7 ~ ' ST C . ~ ~ _,~,_ a:~ , 'r-. - ,~ C17 :%~ COUNTY, PENNSYLVANIA ~ ` ~~ ~ ~ ~;.1 7 u' _7 1 `~y =~ ;_{•_~ ~_} ; _. ...~ ~ ~::. --' Estate of ~ ~S~ ~i~d~ .S C t''/ _ ,Deceased ~~dt n/ ~'~ ~- ~.! ~~ ~S c~~-~" and ~l6ti C~/°~ ~ . ,~~-~:r,~ ,S~''~ (each) being duly qualified according to law, depose(s) and say(s) that she / he /they was /were well- acquainted with i~~iPf /l ~ v.S/s ~~ ~`~~_S ^ --~'` and ~arr>/are familiar with the handwriting and signature of the decedent, and that the signature of ~~ ,~c~,~si- cY ~ to the foregoing instrument purporting to be the Last Will and Testament/Codicil of l?~~i~ ~ ~.~ `S~/~g~ ~,, is in his/her own proper handwriting. ~/'~/ G (,8~¢iiature) (Street Address) (City, State, Zip) / ~~ =_ (Signature) ~/~ (Street Address) (City, State, Zip) Execccted in Register's Office Sworn to or affirmed and subscribed before me this ~~~ ~ day ~~ tt y~ ~ /; v ~1 ~, _ . ~~~ I ice` ~~ ~ ~ -~~C(., (~ ~ ~t-('~`~c ~•- Deputy for Register of Wills Form RW-04 rev. l0. I3.0< OATH OF SUBSCRIBING WITNESS(ES) Estate of r~.? ; ~t _- ~-~. I~ceased= ::_.~ ~ ,~_, ~: --r, C4 mil/ r ~ , (each) a subscribing witness to (Print Name/s) the Will ®Codicil(s} presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that she~Y he /they wa /were present and saw the above Testator /Testatrix sign the same and that s e /they signed the same and that sl~i / he /they signed as a witness at the request of the Testator /Testatrix in her /his (Signature) presence and in the presence of each other. /" ~%' / t - ~,~ (Signatur l (Street Address) (City. State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of , Deputy for Register of Wi11s (Street Address} (City, State, Zip) Executed out of Register's Office Sworn to or affirmed and subscribed before me this ~' S~ ~~ ,day of ' ~~ , ~~ ~ ~ _ ~- N ry Public J ~/~~ ~'~~~'- y Commission Expires: iG~ l.~`f ~~~~,~ (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of noti-riz~~tion. REGISTER OF WILLS ~-;- COUNTY, PENNSYLVANIA z; :J -~ ~.- ~~ ~~~~1 _ - ~, --, .~ , ' :_>> ~._J "rte Form RW-03 rev. 10. t 3.06 REl~i IT101 CIATIUN ~-- ~~: ` A ca ': ,~ ~ ` T ~" ~ t ~ RGISTER OF WILLS ~ f ~~ ~~~ ~ `~ ~ s ' `~-~~ ~- CUMBERLAND COUNTY, PENNSYLVANIA _ , ;~=? t-=~ -~~ ~ ~ - _ L~~~7 ~_..-r ~.._ _.,.~ _., _ ;-.__ - ; ,-t E~_ Estate of Mary Rose Simpson - ,Deceased I, Tomi Higginbotham , in my capacity/relationship as (Print Name) Executor of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to John Michael Simpson 03/28/11 (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills (Signatzrre) 7651 Robertson Road (Street Address) Terre Haute, IN 47802 (City, State, Zip) Executed out of Register's Ofj~ice Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation; nor the purposes stated within on this _=8th day of „ March 2011 Nota;~ Public My Commission Expires: June 22 , 2.017 (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of 1`fotary's Commission.) Form RW-06 rev. 10.13.Oh RENUNCIATION " ~= - ~~ ~^~ <~ _...~ -r., ~ . r..:i ~_ REGISTER OF WILLS -r-~ m ~~,~~ ~ ~ ( r~ ~ (~i i _ -. COUNTY, PENNSYLVANIA J ~ -- ;~ J, Y, ~ ~ i 3 -~ ~ =~ ,-ter G..~/ cf~. _ . a _ • T ~ , ~ ~...~ . ~~' :~ Estate of I ~ r ,Deceased I, C ~ , in my capacity/relationship as (Print Name) StJ l~ of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to ~Q~ ~ ~ f+ ~ h«~ l S~ rr~~ sa~I (Dat ) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of , Deputy for Register of Wills --__ C"~ (Si re) .3`~ ~ J ~e " 1 C o n~ ~' 2 ~~~ (Street Address) ~o Rw o ~ 111 C .~. ~ 1.~ ~ (City, State, Zip) Executed out of Register's Offic°e Before the undersigned personalty appeared the party executing this renunciation and certified that he or she executed the renunciation for the purpo stated within on this _~~-~ day otary Public ~ ~i~`'~' ~~~~ My Commission Expires: !~~ ~~~'- ~'~ %~ (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) Form RW-06 rev. 10.1 _i.06