HomeMy WebLinkAbout08-16-11I N TH E COURT OF COM M ON PLEAS OF CUM BERLAND COUNTY, PENNSYLVANI A
REGISTER OF WI LLS
PETITION FOR PROBATE AND GRANT OF LETTERS
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V M ers , ~e~sBd ESTATE IVO.21-
Estateof Jacqueline y
a/k/a:
tea: SS NO; 1 77'-24-5805
a/k/
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.~ont>ralefle Part C also)
and aver that Petitioner(s) is/are entitled to the aforementioned Letters Testamentary N A under
the last Will of the above-named Decedent, datedF~bruary 5 , 1 9 91 and codici.l(s) dated
(State relevant circumstances, e.g. renunciation, death of executor, f;tc.)
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 wasnot a
party to a pending divorce proceeding at thetimeof death wherein groundsfor divorce had been es#ablished asdef fined in
23 Pa. C.S~A. §33230: N A
D B. Grant of Lettersof Administration
(If applicable; enter d.b.n., pendent lite, duranteabeentia, durarrteminoritate)
C. Petitioner(s), after a proper search, has/have ascertained that Decedent left no Will and wa:~ 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 ir.~ 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
prooeedingwherein groundsfor divoroehad been established asprovided in 23 Pa. C.S.A. § 3323(g};~except as fo~ows:
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U5E ADDITIONAL 51-I tt i 5 i r Nt~ta~rs t
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THI S SECTI ON M UST BE COMPLETED:
Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or principal residence
At
(Street address with Post Office and Zip Code, Municipality: Township, Borough, City)
Decedent, then 81 years of age, died August .9,, 201 1 at Carlisle, Pennsylvania
(Month, 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 ~ 1 2 5 , 0 0 0 . 0 0
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 Esti mated V al ue $ ~ o
Location of Real Estate in Pennsylvania: (Provide full address if possible.)
Sianaturelsl Name(s~ & MailingAddress(e~
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Michele Rae Clppinger
209 Forge Road
Boiling Springs, PA 17007
interim corm tcw-u~ rev~sea i~.~n.lu w ~,umvenana ~.uun~y pcnuinn acuvu uy uic ~~~~~~
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LOCAL REGISTRAR'S CERTIFICATION OAF DEATF~
\NARNING: It is illegal to duplicate this copy by photostat or ~~hotograph.
Fee for this certificate, $6.00
P 17~275~~83
This is to certify that tr~e inft)rnation here given is
correctly copied from an o ~iginal Certificate of lleath
duly filed with me as Lo(~al Zegistrar. The original
certificate will be; forwarded to the State Vital
Records Office for permanent tiling.
Local Registrar Date Issued
Certification Number
C7 ~°
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H1p5-t43 REV 112008 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
TYPE ~ PRINT IN CERTIFICATE OF DEATH
PERMANENT
BUCK INK (See instructions and examples on reverse) STATE FILE NUMBER _
2. Sex 3. Social Security Number 4. Date of Deatlt (Month. del', Y•a)
,. Name a Deceda<d (Fast midde• iBeL suNx) Female 1 7 7 _ 2 '4 _ 5 8 0 5 August 9 , 2 01 1
Jacqueline V. Myers
5. Age (Lest BiNsdey) IlrMer 1 r lhlder 1 da 8. Date of BIM , de , r 7. BI lace end state a I 8e. Place of Death Check onl ~ one ._
Mates ~ Han kanutea Hospital: Other:
g 1 Y~ 8 / 6 / 1 9 3 0 Car 1 i s 1 e P A ^ tnpaient ^ ER I Outprdient ^ DOA ~I' Nursing Hans ^ Residrnce ^ Other - Spedfy:
9. Was Decedent of Hlepenic Origin? "o ^ Y~ 10. Race: Americert Iridert, Black, White, etc.
Bb. County of Death ec. City, Boro, Two. d Death Bd. Fedliry Name (II not instltution, ghro street end number) (I1 yes, specBY ,^,l>ben,
~t ~ ~ Cumberland N . Middleton Church Of God Ttome Mexican, Puerto Rican, etc.) (~ite
~ It wife glue maiden name)
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11. Deceder's Usual Kktd d work done du mast d IHe. Do not stale 12. Was Decedem ever In the 13. Decedent's Eduastion (Spedly qtly ltiglseat grade tomPleted) 14• Widowed ~ (SPecf7') Msnied, 15. Survwmg Sparse ( ,
Kind of Wok KkM Buelrteeallndltsgy U.S. Amted Forces? Elementary I Secondary (0.12) Cogege (1.4 a 5+)
Laborer Manut~acturing ^ Yes ~ ~ 1 2 hridowed
Decedents Did Decedent
18. Decedents Maikrlg Address (Street, city I trnm, state, zip aide) Actual Residence 17a. State P P n n G ~ ~ V a n l a Live in a 17c. ~ Yes, Decedent Lived in ~L~ M i ~ [~ 1 P ~" n n Twp.
8 01 N . Hanover S t . Township? 17d ^ No t>acederd thred within
Carlisle, PA 17013 17b.courA>Cumberland ,~,,~,,,,~~~ cnyieom
18. Fatlters Name (Fast, middle, least, stdfix) 19. Mothers Name (Fue4 middle, maiden aumeme)
Harry J:. Fishel Ruby Franklin -
2~. IMormants Name (Type ~ Print) 20b. Inlomsartts Melling Address (street sty ~ town, stare, zip code)
Michelle R. Clippinger 209 Forge Rd. Roiling Springs, PA17007
rV 21b. Dare of Disposition IMF, daY~ Year) 21c. Place of Diepcefiiort (Nanre of cemetery, cremetay ur other place) 21 a. Location (city /town, stare, zip code)
21a. Metlsod d Disposition r LOCromeOon ^ Donatlorl
^ Burial ^ Removal fromstaro ; ~ A~ Y~^ ~ 8 / 1 2 / 201 1 Hol t finger Crematory
^ Other .
22e. Sdgnehae of Furlerel Licensee (a person acting as such) 22D. Ucertse Number 22c. Name and Address of Facility
~ 011589E HollingerFH&CrematoryMt.Holly Springs,. PA 17065
' 23b. Literate Number 23c. Date Signed (Month, day, year)
Complete items 23a-c any when ' ' 23e. To the best d Imowledga, death oo tied et Ure time, date end place stet (SigneNre and tide) (! r~ ( /~''''1 Q ~j} _
physician is not avaNable at time of deatlt ro ~/ ~ Q ~ ~ ~ ~ ~ 1V ~ ( / ~ `-' ~ V ~ ~ ~ I
t>srtily rx+uwe of death.
24. Time of DeaM 25. Date Proractrlced Dead (Manlh, day, year) 26. Was Case Refe~~(,to Medical Examiner I Coranur fa a Reason Other then Cremation a Danatiat7
Items 24-28 must be cortplerod DY person ~± t y rq ,~ ^ 1'es LQ No
who Pronoura•s death. tp r I S ~ r M• ZS ~ ~'
CAUSE OF DEATH (See instructbns end exsmplea) ,Approximate interval: Part II: Enter otMu °.111Ik'a^--°-^' cortdl8are axtL~m"" ro dear - 28. Did Tobacco Use Contdbute to Death?
Item 27. Pen I: Enter the rhekt at events -diseases, injuries, a oomplicatsxls 'that directly caused the deatll. DO HOT ewer tenninel events such as cardec arrest, i Onset to Death but rat resulting in the underrying ceu9e given in Pan I. ^, Y~' ^ Probably
respiretay enest, a ventdctdar flbrilleDon wklaut showing the e8dogy. list Doty one cause on each line. r L°1 No ^ Unknown
,
I ~pIAlE CAUSE (Final disease a I v. ` ~ ,~i i 29. ~H'7Fe~m~ale:
cortd'tion resufiirtg a death) ~. a. r~ ~ in l ~~ ~G1 ~ I ~ ~ ~' -~-~ ~ t , b N01 pregnant within pest yser
Due to (a a axtseq off: ~ ^ Pregnant at time a death
,e C~ F 1i1.'~ f ' l~ `~ 1 ~ r - ^ Na pregnant, but pregnaa within 42 days
Ust conditions, 4 any, b, f vi - r
ro cause gsted on Brie a. r of death
Due to (or as a consequence of):
Saw UNDERLYMG CAUSE r
(disease a injury Brat initiated the c r - ^ Not pregnant but pregnant 43 days to 1 year
evems resutlkg m deem) LAST. Duero (a as a consequence of): r ^ hUetn pregrrent wtlhin the past year
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32a. Date of Injury (Ninth, day. year) 32b, Descri6a How Injury Occuned 32c. Place of IrNttry: biome, Fann, Street Factory,
30e. Was an Autopsy 30b. Were Autopsy Fndxgs 31. IA~nner of Deetll Olfica BWldng, ea. (Sperrhl
Performed? Avatleble Prior to Completion ,N-J{ Naturel ^ Hanicide
of Cause of Death? 32g. Location of injury (Street, ary I rovm, state)
,~,/ ^ Accident ^ Pertdkg Investigation ~d• Time of Injury 32e. IMury at Work? 321. fi Trenaponation Injury (Speciy)
^ vas 6.X No ^ Yea ^ Ho ^ Y~ ^ t,,o ^ lMverfOperata ^ Passenger ^ Pedestrian
^ Sukide ^ Could Na be Delennined M. Otller - Specify:
33a. Certifier (dtedc only one) 33b. Signature and Title a e r ~ t }J~
• CaAXying physkian (Phydaan cenilying cause d death wAtert anotlter physician has praatxsced death and campbted Item 23) ~ ~ ~~ ~ V '
To iM best of my knowledge, loth oxumd dw to the oase(s) end msnrrer u stated-' - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 33c. license Number 33d. Date S/ig~ned (ManM, day. year)
• Pronouncksq tip csrtllying physklan (Physiden Doh proracxtchtg deatlt and cert8ying ro cause a death) ~( D ~2 ~ ~ Q d ~- l.~ ~ ~ i
To the bast of my knowledge. death occurred N the time, date, end pleat, end dw to the ease(s) and manner as stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ D ` ~ -' Z
• filadfal Examkrer/Coroner
On the bob of axaminetion end I or investigation, In my opinion, death oecurrod at the tkne, dale, and place, end dw to the cause(s) end manner es stetad_ 34. Name end Address of Persat Who Complet~cl Cause of Death (Hem 27) Type I Print
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35. Registry Nre and 36 Date Filed (MorM, day, Year) l I ~. ~ ~ q I •-I ~ ~ H
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~~"~R-- Dispasitlon PermO No-. ~~
OATH OF NON-SUBSCRIBING WITNESS(ES)
REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
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Estate of Jacqueline V. Myers ,Deceased
Michele Rae Clippinger and
each) being duly qualified according to law, depose(s) and say(s) that she /~~ was / ~ well-
acquainted with Jacque 1 i ne V . Myers a:nd am/~~ familiar
with the handwriting and signature of the decedent, and that the signature of Jacqueline V. Myers
to the fore oing instrument purporting to be the Last Will and Testament/Codicil of Jacqueline V .
g
Myers
is in ~i~/her own proper handwriting.
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(Sign ure)
(Street Ad ress)/~
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(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before e this ~~t~. _-.~ day
of - ~ ~`~•
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y
e ty for Register of Wi11c
(Signature)
(Street Address)
City, Stale, Zip)
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Form RW-04 rev. !0.13.06
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OATH OF SUBSCRIBING WITNESS(ES~
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REGISTER OF WILLS cx~
CUMBERLAND COUNTY, PENNSYLVANIA
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Jacqueline V. Myers ,Deceased
Estate of
Anthony L. DeLuca, Esquire , (each) a subscribing witness to
(Print Names)
the (~~Will ~ Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and
say(s) that ~s~/ he / was / ~a~ present and saw the above x'~st~a~ / 'Testatrix sign the same
and that ~~/ he /~ signed the same and that ~~~/ he /~1 signed as a witness at the request of
the T~t~t~r /Testatrix in her /~ presence and in the presence of each other.
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( ignature)
(Signature)
113 Front Street
(Street Address)
Boiling Springs, PA 17007
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed_ acid ;subscribed
befor this ~ ~ h day
of ~0l
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for Regi,ter of Wills
(Street Address)
(City, State, Zip)
Executed out of Register's Office
Sworn to or affirmed anal subscribed
before me this day
of _,
Notary Public
My Commission Expirf;s:
(Signature and Seal of Notary or o~:her 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) ait time of notarization.
Form RW-03 rev. 10.13.06