HomeMy WebLinkAbout06-27-11IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
REGISTER OF WILLS
:PETITION FOR PROBATE AND GRANT OF LETTERS
Estate of Lisa ]. Goss ,Deceased ESTATE NO: 21- :; ~ ~ ~ ~ ~ ~
a/k/a:
a/k/a:
a/k/a: SS NO:
187-40-7873
Petitioner(s) who is/are 18 yrs of age or older, apply(ies) for: COMPLETE SECTION `A' or `B' AND "C" as
applicable:
^ A. Probate and Grant of Letters Testamentary or []Administration c.t.a., or d.b.n.c.t.a. (c~smplete Fart C also)
and aver that Petitioner(s) is/are entitled to the aforementioned Letters _ under
the last Will of the above-named Decedent, dated 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 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:
Decedent was the victim of a killing
Name Address Relationshi to Decedent
Rebecca E. Aikey 1457 Ryland Drive, Mechanicsburg, PA 17050 Daughter
Matthew I. Aikey 1457 Ryland Drive, Mechanicsburg, PA 17050 Son*
* Son is 17 years old CO
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THIS SECTION MUST B ECOMPLETED: --~=~ ~ rn r
Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or gel resi~nce
At 740 Sterling Court, Enola, PA 17025 (East Pennsboro Township) ~-~ <~"~~-] __,-,
`} , _,
(Street address with Post Office and Zip Code, Municipality: Township, Borough, City) =~~` "r't r_.»:
Decedent, then 46 years of age, died 6/5/2011 at Enola, Cumberland Count ~ ~ nsylvar~
(Month, Day, Year of death) (City and State where death occu t',_:
Estimated value of decedent's property at death: ~..'
If domiciled in PA All personal property $ _ 50,000.00
_If not domiciled in PA Personal property in Pennsylvania $ _ _
_If not domiciled in PA Personal property in County $ _
-Value of Real Estate in Pennsylvania $ _ 200,500.00
Total Estimated Value $ 250,500.00
Location of Real Estate in Pennsylvania: (Provide full address if possible.) 740 Sterling Court, Enola, Pennsylvania 17025
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Signatu e(s) 1~1ame(s) & Mailing Address(es)
Rebecca E. Aikey
`.
1457 Ryland Drive, Mechanicsburg, PA 17050
tntenm rorm ttw-uz revisea rz.~b. to by Cumberland County pendtng action by the Court Page 1 of t
OATH OF PERSONAL REPRESENTATIVE
Commonwealth of Pennsylvania ~ SS
County of Cumberland
The 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 representatiue{s) of the
Decedent, Petitioner(s) will well and truly administer the estate according to law.
Sworn to or aff rmed and subscribed ~y
be ore me this ~ ~ da of
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For the Register ~ ~1 `~ '~ _ ~ ~"~
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DECREE OF PROBATE AND GRANT OF LETTERS ~ -~ ~ `_~
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Estate Of LISA J. GOSS ,Deceased File Number: 21- : ~?i~ ! E -_~ ~~
AND NOW, this ~ day of ' 1 ' ' ~ ' , in consideration of lthe Petition on
the reverse side hereon, satisfactory proof havi g been presented before me, IT IS DECREEL> that Letters
Testamentary x of Administration are hereby granted to:
(If applicable, enter c.t.a., d.b.n., d.b.n.c.t.a., etc.)
in
'~ ~ ~ Y~ -
the above estate and that instruments(s) ated described in the petition be
admitted to probate and filed of record as the last Will and Codicil(s) of Decedent.
~^
Glenda Farner Strasbaugh, ~ f
Register of Wills ~-~ _ ~"~='~~-'~ + ~'
FEES:
n ~
Letters .................... $
Will .......................
Codicil(s) .............. .
(~) Short Certificates ~~ - ~~
( )Renunciations.......
Bond ............................
Other ............................
Automation FEE......... 5.00
JCS FEE .................. _ 23.50
<~ 7~F
TOTAL ................ $ ~~8 :-s0
Signature of Counsel Required to Enter appearance
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Atty's Signature .,~l~G~~~~~ ~" ~'~' r----`_~"
PRINTED Name: f~7lLI-h~~~ C ~~=-f~t,~~X~~
Supreme Court ID No.: 35073 ___
Address: 624 North Front Street
Wormleysburg, PA 1.7043
Phone: 717-232-4701
F'~{: 717-232-4774
Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court Page 2 of 2
OCAL REGISTRAR'S CERTIFICATION GF DEAT'H
VW'AI~NING: It is illegal to duplicate this copy by photostat ol~ phoitograpt~.
Fee i~OI- 6.his certil~i(_a[e. Sh.O~ )
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H105.144 REV 11/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
PERMANENTN CORONER'S CERTIFICATE OF DEATH
BLACK INK See instructions and exam les on reverse
Jt•7'~ !t'] 4 ( p ~ STATE F=ILE NUMBER
1. Name of Decedent (First, middle, last, sunix) 2. Sex 3. Social Security Number 4. Date of Death (Month, day, year)
Lisa J Goss Female 18Z 4Q. 7873 June 5 2011
5. Age (Last Birthday) Under 1 year Under 1 day 6. Date of Binh (Monet, day, year) 7. Birthplace (City and state a for eign country) 6a. Place of Death (Check Doty one)
Marms oars "a"5 M""r~ Lewistown, Pa "ospilal: aher:
46 Yrs. Februar 2 , 1965 ^ Inpatient ^ ER /Outpatient ^ DOA ^ Nursing Fbme Residence ^Omer • Specfy:
6b. Counry of Death 8c. City, Bor Death 6d. Facility Name (n not institution, give street and number) 9. Was Decedent of Hispanic Origin? ®No ^Yes 10. Race: American Indian, Black, White, etc.
pf yes, specify Cuban, (Specify)
Whlt@
Cumberland East Pennsboro 740 Sterlin Court
Mexican, Puerto Rican, etc.)
11. Decedent's Usual Occu lion Kind of work d one drrin rtast of Nfe. Do not state retired 12. Was Decedent ever in the 13. Decedent's Education (Specify Doty highest grade comp leted) 14. Mahal Status: Married, Never Married, 15. Surviving Spouse (If wife, give maiden name)
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`~~ U.S. Armed Forces? Elementary /Secondary (0-12) College (1-4 r 5+)
'~ W'do'"~' Divorced (Spealy)
Divorced
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rnstra ira
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ee ^Yes ^i~b
16. Decedent's Mailing Address (Street, dty /town, state, zip code) oecadant5 pA Did Decedent r~nY ast eons ono
Tw
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740 Sterling Ct. p.
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Actual Residence 17a. State Township? 1
PA 17025
Enola County Cumberland ,7d. ^ No, Decedent Lived wnnn
17b
, .
Actual Limns of City I Boro
18. Fames's Name (First, mule, last, sumx) Clifford E. DOSS 19. Mother's Name (First, middle, maiden surname) ,tenor Hummel
20a. Informant's Name (Type / Prinq
Rebecca Aikey 20b. Informant's Marling Address (Street, c' ! t tale zip
1~5T~1~ylan~)Dr. Mechanicsburg, PA 17050
21 a. McUad of Disposition ^ matkxr ^ Donation 21 b. Date d Disposition (Month, day, year) 21c. Place of Disposition (Name of cemetery, crematory or other place) 27d. Locaton (City I town, state, zip code)
^ Burial ^ Rertaval from State i Was Cremation or Donation Authorized June 8, 2011 Hoffman Crematory
^ Other - Specify: ~ by Medical Examiner /Coroner? ^Yes ^ No
22a. Sktnatae of Funeral Service Licensee (or person acting as such) 22b. License Number
FD-13845-L 22c. Name and Address of Fadlity
Sullivan Funeral Home 51 N. Enola Dr. Enola, PA 17025
Complete Hems 23ac anty when certifying 23a. To the best of my knowledge, death orxurted at the time, date and place stated. (Signature and title) 23b. t.icense Number 23c. Date Sgned (Month, day, year)
physidenrs rat available at time of death to
cernly cause of death.
Hems 24.26 must be completed by person 24. Time of Death 25. Date Proraunced Dead (Month, day, year) 26. Was Case Referred to Medical Examiner / Cororar for a Reason Other than Cremation or Donation?
who pronounces death. A rX . .12:45 P . M. June 5 2011 ~ Yes ^ No
CAUSE OF DEATH (See instructions and examples) , Approximate interval: Pan IL Enter other siariificant tarWilions conttibWina to death, 26. Did Tobacco Use CoMritwte to Death?
Item 27. Pan I: Enter the drain of events -diseases, injuries, or conplicetans -that dreclty caused me death. DO NOT enter terminal events such as cardiac ertesL n Onset to Death but not resuning in the underlying cause given n Pan L ^Yes ^ Probabty
respiraary arrest, or ventricular fibriNation without showing its etiobgy. List Doty are cause on each kite. ~ ^ ~ ^ ~~,xm
Itr1A~DUITE CAUSE (Final disease or n
axidtion resulting in ath) ~ a. Gunshot t O Head ~ 29. If Female:
^ N
it
i
Due to (or as a consequence oq: r ot pregnant w
h
n past year
^ Pregnant at time of deem
Sequen6aAy Nst conditions, if any, b, ~
Ieadr~ to me cause listed on line a. Due to (or as a consequence of): n
Enter the UNDERLYING CAUSE ~ ^ Not pregnant, but pregnant within 42 days
(dsaase a irqury that initiated the c '
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am
LAST
i 01 deem
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s resu
ng
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)
Due to (or as a consequence of): ~ ^ Not pregnant, but pregnant 43 days to 1 year
d. n before deem
Unknown if pregnant within the past year
30a. Wes an Autopsy 30b. Were Autopsy Findings 31 Manner of Death 32a. Dale of Injury (Month, day, year) 32b. Describe How Injury Occurted ~ 32c. Place o(Injury: Fbme, Farts, Street, Factory,
Performed? AvaNaWe Prbr to Completion
of Caused Death?
^"°1efal ~Hen'~
June 5 2011
Shot b known Assailant -Hand un Office Building, eta (Specify)
Home
^ Yes ~ No
^Yes ^ No [] Accident ^ Pendng Investigatbn 32d. 7xne of Injury 32e. Injury al Work? 321. If Trensportation Injury (Spedty) 32g. Location of Injury (Street, city /town, state)
^ Suicide ^ Coukl Not be Determkred Aprx . j~
^Yes K'l' Na ^ Driver /Operates ^ Passenger ^Pedestrian
12:45 P.M Other-sP~r Ster Court Enola PA
33a. CenNier (check Doty are) 33b. Signature and Tit
• Certifying physician (Physician rxirtrfyirg cause of death when arxxher physician has pravwnced death and cortrpleted Item 23) ' ~1
Droner
~
To the bestolm know
Y ledge, death occurred due to the cause(s- and manner as slsted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ (J
• Pronouncing and certifying physcian (Physician both praxxmcing death and cenirying to cause of death)
t
^
d
d 33c. License Number 33d. Date Signed (Monet, day, year)
manner as ata
e
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
To the best of my knowbdge, death occurred a< the time, date, and place, and due to the cause(s) an June 6 2 011
• Medical Examiner /Coroner
and place
and due to the cause(s) and manner as stated
date
tM the bests of examination and ! or investigation
in m
o
inion
death occured at the time
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, 34. Name and A~aress of Person Wry Completed C use of Death (Item 27) Type /Print
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35. Registrar's t and D' t N s ~ i
m, des ,yea
36. to An enroc
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o
oroner
.
6375 Basehore Rd.
Suite ~~1
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/ Disposition Permit No. O ~y ~^'~~