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HomeMy WebLinkAbout04-27-11IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA REGISTER OF WILLS PETITION FOR PROBATE AND GRANT OF LETTERS ,~ Estate of ~~ , ~a ~ ~, ~' 1~ c"~ ~, ,Deceased ESTATE NO: 21- ~_" t,f ~ ~ L~ a/k/a: a/k/a: a/k/a: SS NO: I Cy `1- ~ z - C,~<~ ~ y Petitioner(s) who is/are 18 yrs of age or older, apply(ies) for: COMPLETE SECTION `A' or `B'~' AND "C" as applicable: CAA. Probate and Grant of Letters Testamentary or ^ Administration c.t.a., or d.b.n.c.t.a. (com~~lete Part C also) and aver that Petitioner(s) is/are entitled to the aforementioned Letters --(' < ~-~~ ~.~. -~~ _ under the last Will of the above-named Decedent, dated t -~ y _ ~~ ~ ~ ____ _ 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 instruments offered for probate; was not the victim of a killing, was never adjudicated an incapacitated person, and was not a party to a pending divorce proceeding at the time of death wherein grounds for divorce had been established as defined in 23 Pa. C.S.A. § 3323(g): ^ 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 tlhe 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 anti 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:- ''-- (~ c yX:J ~ y ,tr <.. ~`r`~ ~~ T; ~~'~ ~ ~; .~ r, , ._~- .r. ,, USE ADDITIONAL SHEETS IF NECESSARY _~ - -. -- ~:T~i _._~. - .-_ THIS SECTION MUST BE COMPLETED: -r? `;~ •::r~ ~ Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or principa~.restdence ~ ~ At 1~ v` ~d s ~.~ ~ ~~~ ~S (Street address with Post Office and Zip Code, Municipality: Towns ip, Borough, City) - Decedent, then ~_ years of age, died `i - 3 -- ,~~: ~ ~ at ~~ ~ G,~~, ~ ~~.~ r-~ ~°,~ (Month, Day, Year of death) (City and State where death ccurred) Estimated value of decedent's property at death: _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 $ -- Total Estimated Value $ ~~t ©.c~- Location ofReal Estate in Pennsylvania: (Provide full address if possible.) Signature(s) Name(s) & Mailing Address(es) >, 3 tr ~- r~;,ti ~- S ~ i_«..-:..,. c,.-._ nisi n~ _ _~ ,~ ~~ Name Address tionshi to Decedent ~~~«~~~~~ 1 ~~~~~ ~~-~~ ~cviscu ~~.~o. iv oy ~umoenana ~ounry penoing action by the Court Page 1 oft OATH OF PERSONAL REPRF,SEI~ITATIVE Commonwealth of Pennsylvania ~ SS County of Cumberland T'he Petitioner(s) herein named swear or affirm 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 . -~ .r - bef~rr~ me tr:~IS __ .~ ~ h day of ~~ ? ,ry ~; ~ ~_ `~ r.t:: C`~ ~ Per' 'he Register i -, --" i n ~_ _~:.~ _, ~h- DECREE OF PROBATE AND GRANT OF LETTERS ` ~~~., ~ ~ ~~~ 1 .~J -__..~ ._ , Estate of ~~ [ /rj (,]~? ~ /~ , C ~ ~l /~ ~'. ,Deceased File Number: 21- ~~ C ~ = j~~ _ _~ ~, AND NOW, this day of L~~ , in consideration of t:he Petition on the reverse side hereon, satisfactory proo h ving been presented before me, IT IS DECREED that Letters ;-Testamentary of Administration are hereby granted Ito: id . ~ / / / r' (If applicable, enter c.t.a., d.b.n., d.b.n.c.t.a., etc.) the abate estate and that instruments(s) dated /~ d admitted to probate and filed of record as the last ill icil(s) of T~"l '~ ~ `~~ ~ r _. a -~ , ., '` t :1, ,~ Glenda Farner Stras Register of Wills /~'~ FEES: Letters ....................$ ~ ~. ",C' Will ....................... cl Codicil(s) ............... __ (~~ Short Certificates ( )Renunciations....... Bond ............................ Other ............................. ................................. Automation FEE......... 5.00 JCS FEE .................. ~ 23.50 .~j~ TOTAL ................ $ //2-~! Signature of Counsel Required to Enter Appearance Atty's Signature PRINTED Name: _ Supreme Court ID No.: Address: Phone: Fax: _ described in the l,Etition be cedent. n Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court Page 2 of 2 lfl: i;at~ Rt=v nn ins Fee k~~~r this rertii~i~a~~c. ~'~~;.O~~ LC)~'AL REGISTRAR'S ~CERTI~I~AI~IGN (~F DEA-~T•I-~ '~iARNING: It is illegal to duplicate this rcag~yr by ~hotos~tat or ~hotogra~l~. ~~IrrrU'i'nirir' rfll'~ i~~ ;O ~t'f-~;~~ °f<€! ';1C' J(l)l)Plll3tlyJ11 ~~eCe r'IVel1 IS , ~ ~~~Qf~ ~~,,'~ A,--- f ~; ~,- t.+.,I-re~.t1~~ ~~uhie~~ '~' ~za ,(~ ~~tri;rinal ('e~~~titicate ~~f Death ,~`~~~ ~``~~,~~ t Elie fil~~~i tititf~ ±~~L:~ <r. I.{~;~al IZe~~i~trar. "~~he ~>ri~~inal r .. ,~ , ~~ ~ ~ '', , ~ttitl~,l~t.~ ~~~ r„ ,;1fi ti~~u-~1cd to Cf~~e State Vital v~: ,` ~ A,•~ ~';e~f)I~ts; ~)j;!-~' f.~? ~'"t~llillt_'I1S 1~11111~. * ~ _ ~ y~• < ~4R•' ; 4 r; .~ \ ' 4 ~ T ~ ,,,,,,,,r9r .: _ --~-- - ~ !ti~~:li KL_r~(r,tr.ir 1_~at~~ 1~~5ued ~. C) :~-~ - :z~ ~:.:# - t --~ --~ ~c~x ; , _; ~; ;T C7 m ~~J ...j ~ --_3 _.. -_} __ - _ _ . _._ ' '~ t. _ P _~74~6~~_~ (_'ertlf~icatif>17 tiunlr~e~~ :~~ ~ ~ ,L 1)x.1 ~ i i ~ , ~~' / , ~., ~~ ~rldS-N.1 AEA +t 2W0 TYPE 'HINT IN PERMANENT BIACK iNK !. Name d Dscederr (First, nli0de. Wst. suCix( William R. Clark i. Age (Last Butnday) Under t year 61 Wnthx Days Yrs. COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS -~--~ r' ~" ' CERTIFICATE OF DEATH ?~''' ~ •- `'`~ ~~ ' •. 'Ti (See instructions and examples on reverse) STATE FILE NUMBER ~~' 2 Sex 3. Socal Security Number ~ Date d Daatn talonm day year) Male 164 - 42 - 4084 ri.l 3, 2011 lhttler t aay 6. Date of Birm IMOnm. day. year) 7 Brdpuce lCiry arW sale a tore country) Ba Puce of Deam (Check only one) Hours M:rwres Hwp~lal. Other. May 31, 1949 Rutland, VT ^ InpaDent ^ ER Outpawnt ^ DOA ^ Nurs,ng Home ~ F'esidence ^Oma - SpeWy: dD. Counnty,.d.,LOe~atn.,, Bc Gry, Boro, Twp. of Death ed. FaaLry Name (If not nstnubon, give sweet and nurMerl 9. Was Decedent d Hrspan,c Ong,n ~ ~ No ^ Ye. t J Race: Artbncan Indian, B1agt, VJtik, at. ~ l.uitu.JCi land ~p ~ IIf yes. specAy Cuban. ~ Spy Monroe 1501 Williams Grove Rd. Mexican. Pueno Roan, ea ( _ White t t DecedanYS Usual Oa Don lKua or wont ,lone dun most d wonu Ins. Do not sate raved t Z. Was Decedent ever in the 13 Decedent's Educatan ISpecrry Doty rognest grade compkledl t s Mental Sutus: Hamad, Never Horned, t 5. Sun~v~ng Spo,.se ~f wrfe. grve nwden rams( Krrd d WarK Kind of Busxkss. Industry US. Armed Forces' Elemenury ;Secondary (0-121 Cduaga ~ t ~3 or 5.l W'ddwe0• Divorced ISpealyt Tailor Self-ert~iployed ^Ya: ~7N0 12 2 Never Married t6 DeceaanYS Maang Address (9reM. city town. sate. xrp code) Decedent's Da Decadent 1501 Williams GrOVe Rd. ActwlRes+dBrtce na Stale ~t?nnG~lvania Uveina t7c.~ Yes,DeceaerttLwedm MOnroe Twp Mechanicsburg, PA 17055 176. County C1alilberland Township' t7d. ^ No, Dxrdem L:gad wrtnn Araual Lmrs d GY , 8aro t8. FaCkr's Name (First mrdde, Wsl SuCixl t9 MoCkr's Name ~FrsL mrddk maiden strnamel -~ John Clark Jo ce Potter 20a. Inldrmants Name (Type ; Pmt) 200 Inlormant's M>,bnq Address ISUeat, ary • town iUte. tp coda( -- Guy Clark 1115 Sunnyside Rd. York, PA 17408 _ • 2t a Medal d Dcsposrrpon Cremalan Donatan 2t D. Date d Di Y y sposttan I Wme of c tremor o {~, ^ sposrDOn ,Monet. b , earl 2tc. Puce d D~ emetay. Dry or otfkr puce) 210 Locatan ,C,ry town. ;;dk. zql code( ^ Banal ^ Renaval from Sate ;Was Cremation a Odrktion AuMorized ~ ^ Diner - SGecr/y: ! by ftNdiwl Exarrurkr I Coroner? ~ Yes ^ No 4 7 2011 er .t".i sburQ . PA ~ ~ a 22a. Srgnauus d Funeral Stwae Ucensee for person acwg as sucnl 22b License Nurtaer 22c Name and Address of facd~ry ~ _ ~ .___- ,~ Hetrick Cremation Services FD-013592-L Cartpkk Ilan!s 2]ac orsy when csr6ryur9 phyLtwt 6 red aviaiDN al faM d death Io 23a. To the best d my urowledge, deem occu at the Dms oats and place sated. ISrgnature era DWI 23D. License Number 23c. Cale Sgred :Monet, Day, year) ~ cau:.,>, daa~ ~ -,.~~-- ~ i~.J ~ a 3 ~~ S 5 - L / 3~ao ~ Hems 21.26 must be _ COrtpkted Dy person ""'° pdridrr,aa beet 24. Time of Death '1: 5 5 h M 25 Dak Proraunced Dead (Monet, aay, year) / 26 'Nos Case Relerrad to McOiCdi Examiner 'Coroner br a Reason Cmer roan Cremator ar Donauon~ ~o r i y 3 ^ Yes ®No CAUSE OF DEATH (See Instructions and eaamptes) ~ Approxunate :rnerval 1lerrt 27 Part I: Enkr the tbain d events - diseases, ryurks, or cdnwDCatans -Cal Mrecdy caused the Death. Dp NOT enter temunat events such az carWac an t Part n Enkr other ~pnrtaant condr v,n< rortr ~ u19 to seam, 28 Da ToOacco Use CbrarlOute a Dsam7 es . r Onset to Death respratory artest, a ventncuyr Iibrala00n wMout sfawmg dk otology. List ony Ork cause on earn une. r twt rat resin m the ~ ~ ur~nY n9 ease wen .n Pan I c 9 Yes ^ Pr ^ o0a0ly i IYYEDIATE CAUSE '1Final disease a i condition rasultrg a dsaCt( , A ^ No ^ Urwwwrt ( _~ a. r 29..1 Femme: Dw to for as a consequence d) ' Segusrt6riy bet cori0iso,ts. /any, I D ^ Not oreyrwa weM Pest 1'~t ~aprg k Ills cause ftikd On Irk a ~ EnW 6 Due to ar as UIO t ~ ^ Pregrwu al Drtk d death ( k a consequerce ofd: r ERLYING CAUSE Idseasa a vtF,ry Ctal i,raWed me i ^ Nd pregnaril Oia o<egnar* wCtn 4? days events restilprtg n deaml LAST c ' of deem Due to (or as a consequence of(~ ' ~ d. i ^ Nd pra4nara, Ot! pregnare U nays b t yeaY b f - ~ e ore bath ^ JOa. Was an Awapsy Pertarrtt d7 31Jb. Were Autopsy Frtdrys 31. Manner d Deam 32a. Oak d I u Monet, da M ry l y. year) 320 Describe How infury Occurred Dnxrgwn .f W wiM Ck ~~ f~ Year s Avylapk Prar to Carnpleoon d Cause d DeamY rf~~-''~ ~avawrW ^ Momcda 32c ~ ~'B 'Mary" Hark. Farm. Street, FaUOry, uudrg, etc. iSpecryJ ~~''] ^ Yes c7C No ~ti ^ Yes ^ No rr~~ LJ want ^ Pendrtq Investyatan 320. 7~me d ItMury 32e Inryry at Worx7 32f. if Transponanon IMuN lSPecrN/ 32g. Loca;:on ,~ ~ryury lSlrttat. rry town, staler ^ juk~b ^ CauW Not De Daterm~ned M ^ Ves ^ No ^ Omer . Operaar ^ Passenger [~ Pecestran 33a G2Nfkr icrkrJc only Orkl Other ~ .ipecr/y: _- ' Certilprp physician tPhysaran camtyvg cause or naam when another pnysaan has prpaunced Deem era compiwed Item 231 Ta dk Wet d my krawlsdgs, death xcurrW dw to 1M towage) and manna as atate4 _ _ _ _ _ _ _ ^ P _ _ _ -' - _ - -' - - -' - - - - - - - ' :3b ~,gndWre end Tltla : t Cemaer ~/ ~ /~7/~-i ~~z !/ ~ ~/~/ ~, ti/ s/ `~ • ' ~~ ~~~ . ronouneirip and ceni/ytnq physician tPnysaan Dom prdnourKUtg deem ono cenityug to cause of deaml - - - io tM bat d m y knowledge, dikdt occurred at tM thee, data, and piece, and dw to tfk uuselsf and manna a• sated_ _ _ _ _ _ _ _ _ _ ~ • Ilsdicsl Etanrrta / Corerkr - ' ' ' ' ' - ' i3c :_,cense trumber /~~ ~ .-- ]3d Date ~i ed i rennet a ~ y Karl ~ ~ On dk beus d eaarrwuhon and I or inv ion, ilallget ion, deeN occurred al rile lima, da4, and place, and dw Io tfk cause(s) and r1laMla as anttlil_ ^ ~ ! ~ ~ ' ~~ 35 Regisuar : at a ono 31 Name and a/sAS of P/e~rs'on NM te0~ausa~~,I Geam •item 27i type Pima ~ ~ % ~~ , t \ ~ • ~. ~ ale F: ihbnm. day. years ._ '7 'v"" -' I ~ • ~j O A {cwt /e/S%"_] ~ /- O V l~~/fGl;~^„~ / / ~~ ! ! U O ~ ~ Q D~spoatan Pamrt No ( J .J i ~ /`~ y ~,a7 Y WILL O F ; ~ - ___ _ - _.~~ ~=- CLARKE _, ~ ~ MICHAEL R -- `~'`' `-' . ,, . ~, ,.. I, Michael R. Clarke of Cumberland County, Mechanicsburg, Pennsylvania, declare this to be my last V~ill and hereby revoke all prior Wills and Codicils. 1. I direct that all my just debts, funeral expenses, gravemarker and administrative expenses shall bye oaid from my residuary estate as soon as practicable after my death. 2. I direct that ali inheritance estate, transfer, succession and death taxes of ar ~ kind whatsoever which may be payable by reason of my death shall be paid out of my residuary estate. 3. I direct that my entire estate be distributed as follows: A. I direct that my entire estate go to Guy Clarke, Carl D. Stewart and Roy B. Clarke in equal shares. B. Should Guy Clarke, Car! D. Stewart or Roy B. Clarke predecease me their share shall la~,se and be divided into equal shares between the survivors. 4. I appoint Betty Neshteruk Executrix of this my last: UVill. If Betty Neshteruk should predecease me or cease tc act in such capacity, I appoint Guy Clarke as alternate. 5. The Executrix of this Will shall have the power to distribute my estate in kind or in cash, or partly in either. 6. I direct that no Executrix acting under this Will shall be required to enter bond in any jurisdiction. LAW OFFICES OF STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 IN WITNESS WHE OF, I have hereunto set my hand this ._~..., day of ~-- .~~'~'~~ '201 i . ~,, ~~.i ~ ~ ~ ~ ~ `~~ ~ ~. ~~- _ M c ael .Clarke NJ`~ (K~- ..- e LAW OFFICES OF STEPHEN J. NOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA ] 7013 The preceding instrument consisting of this and one other page was on the day and date hereof signed, published and declared by Michael R. Clarke as and for his last Will in the presence of us, who at his request, in his presence and in the presence of each other have subscribed our names as witnesses hereto. r ~ r "' ~ !- ~~. ~ ' WITNESS I NES ' 1 f r , ~ ACKNOWLEDGMENT State of Pennsylvania LAW OFFICES OF STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 County of Cumberland ss I, Michael R. Clarke, the Testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my last Will; that I signed it willingly and as my free and voluntary act for the purposes therein expressed. . ~- ~~ ,R k~... .., jjy .~ ~ `fit n Michael R. Clar e Sworn to or affirmed an cknowled .. fore me y Nlichael R. Clarke the Testator, this ~- ~da of ~L~' r.~'r ._~.~n.,...,m,_..... Y ~ ~ ~ ,.... ~ 1. ..~..,~.Fa. ..~~.._~..~ _.. r_, ~- :~~ae ,~., otary Public/Attorn y AFFIDAVIT State of Pennsylvania ss County of Cumberland We, ~ ~; ~ ~-1~~:S1 ~ ~~ and .,-, - ~ ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the Testator sign and execute the instrument as his last 1/Or'ill; that the Testator signed willingly and executed it as his free and volunta!-;J act for the p.~rposes therein expressed; that each subscribing witness in the hearing and sight of the Testator signed the Will as a witness; and that to the best oi` our kno ledge the Testator was at that ti - 18 or more years of age, of so nd mind end under no constraint o undu 'nflu nce. :~ y ~ ~ ~ ~ ~. ~ ~. ~~, rn to or affi d and subscribed to befo a me by witnesses, this day of 1 ~- z.. , 2 11. ,. ~m~a...w._~ ~~~,~~, ~L_~ ~f~o~ary~Public%Attorney YJ, ~~i~ "._""4J ~.bd~li~~~ ~~ ~".r~Sf+rc•,~~+ '~.'°4,,5~~ ~ ..,.~Tit9~C~"~!91,Y,y'ap!.~ Q A 'p•{h ~4 ~7a~ i 4 ~: