HomeMy WebLinkAbout08-12-11PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA
Estate of SARA E. BLACK File Number /~~~' 1(" ~0 ~U
also known as
,Deceased Social Security Nttmber 180-01-9759
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' OR 'B' BELOW.)
0 A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the EXECUTOR named in the
last Will of the Decedent dated 11/19/1991 and codicil(s). EXECUTOR
WALTER D. COFFEY RENOUNCES HIS RIGHT TO BE HIV
(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 instrument(s) offered
for probate, was not the victim of a killing, was never adjudicated incapacitated, and was not a party to a pending divorce proceeding at the time
of death wherein grounds for divorce had been established as provided in 23 PA C.S. section 3323 (g):
NONE
B. Grant of Letters of Administration
(If applicable, enter: c. t. a.; d.b.n.c.t.a.; pendente liter durante absentia; durante minoritate)
Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spouse (if any) ~,nd heirs: (If
Administration, c. t. a. or d. b. n. c. t. a., enter date of Will in Section A above and complete list of heirs.) C? `~_ .~-~
Decedent was domiciled at death in CUMBERLAND County, Pennsylvania, with his /her last principal residence at 604
WALNUT BOTTOM ROAD SHIPPENSBURG PA 17257 SOUTHAMPTON TOWNSHIP
(List street address, town/city, township, county, state, zip code)
Decedent, then 94 years of age, died on 7/18/2011 at SHIPPENSBURG. CUMBERLAND COUNTY
PENNYSLVANIA
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ 200.00
(If not domiciled in PA) Personal property in Pennsylvania $
(If not domiciled in PA) Personal property in County $
Value of real estate in Pennsylvania $ 50.000.00
604 WALNUT BOTTOM ROAD, SHIPPENSBURG, PA 17257
situated as follows:
Wherefore, Petitioner(s) respectfully request(s) the
the undersigned: „
the last Will and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to
~~ Signature f'~~ ~ ~ ~ Typed or printed name and residence
ISAAC W. BLACK JR.
142 KLINE ROAD
Page 1 of 2
Form RW-0? rev. 10.13.06
(COMPLETE INALL CASES:) Attach additional sheets if necessary. ~''`
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
The Petitioner(s) above-named swear(s) or 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, ' itioner(s) will and truly
administer the estate according to law. ~] ~ /~ ~ ,~ i~~/~~
Sworn to or affirmed and subscribed
befog me the ~~~ day of
For the Register
Signature of Personal Repre
Signature of Personal Representative ~ `'- ~ ~ ~ ;-~
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Signature of Personal Representative
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Social Security Number: 180-01-9759 Date of Death: 7/18/2011
AND NOW, AUGUST , 2011 , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters TESTAMENTARY
are hereby granted to ISAAC W. BLACK. JR.
in the above estate
and that the instrument(s) dated NOVEMBER 19. 1991
described in the Petition be admitted to probate and filed of record a~the last Will ~jand Codicil(s)) of Dygcedent. n ~
FEES
6~
Letters ................... .. $
Short Certificates .. ~ ... 6a
() •. $
..
R n ci ion(s) ............. $ 6 6
.... $ ~~~
.... $
.... $ _ ~
.... $
.... $
.... $
.... $
.... $
.... $
TOTAL $
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.: 25502
Address: 49 WEST ORANGE STREET SUITE 3
SHIPPENSBURG
Telephone
PA 17257
7175323270
Form RW-02 rev. 10.13.06 Page 2 of 2
Estate of SARA E. BLACK ,Deceased
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LOCAL REGISTRAR'S CERTIFICATION OF DEA~j~'~H
WARNING: It is illegal to duplicate this copy by photostat oi• photograph.
P 17~gd~~~
_ _ ___ ,_._,..__ ttt P`r~//~~ _ This is to certify the! t})e inforr~iatiorl here given is
~~~~ttto~~~ iy~~~ ~ correctly copied from an original Ce~rtific~ate of Death
lam` duly fined with me a~ Loc~a Re`i~crar. The original
~o _ - z certificate will be I`c>rwardc~d tc the State Vital
~ -y~~ a~ Records _Office for permanent filing.
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~ -~~ s./3
CERTIFICATE OF DEATH ~,~-•
(See instructions and examples on reverse) RTATF FII F Nllf„IAFR
H105.143 REV 118006
TYPE /PRINT IN
PERMANENT
BLACK INK
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1. Name of Decedent (First, middle, teal, suffix) 2. Sex 3. Social Security Number 4. Date of Death (Month, day, year)
Sara E. Black Female 180 - 01 - 9759 7-18-2011
5. Age (Last Birthday) Under 1 ar Under 1 da 6. Date of Birth Month, da , er 7. Bi ce and ante or fe et cormt 8e. Place of Death Check on one
Morrtlu Days Hours Minutes Hospilai: Other.
9 4 Yrs. 9 - 2 5 -1916 Shi e s n b u r P A ^ Inpatient ^ ER / OtdFatieM ^ DOA ®Nursing Home ^ Residence ^ Other -specify:
6b. County of Death 6c. City, Boro, Twp. 01 Death 6d. Faalily Name (If not institution, give street end nrmreer) 9. Was Deceden of Hispanic Origin? ^X No ^ Yes 10. Race: American Indian, Black, While, etc.
(M yes, specify Caen, (Spear
Cumberland Shippensburg Twp. Shippensbur Health Care Center Mexican,PuenoRican,etc.) White
11. Decedent's Usual lion Kind of work done d u ' most of 9fe. Do not state yeti 12. Was Decedent ever in the 13. Decedent's Education (Sprrcity only highest Bade comp leted) 14. Marital Status: Martied, Never Married, 15. Survivkrg Spo use (If wife, give maiden name)
Kird of Work
Kind of Brxsirress/Industry U.S. Armed Forces?
Elementary I Secondary (0-12)
College (1d or 5+) Widowed, Divorced (Spealy)
Laborer Knouse Foods ^ Yea ®No 8 Widowed
16. Decedents Maikng Address (street, city I town, state, zip Dods) Decedent's Penns 1 V a n 1 a Did Decedent
Actual Residence 17a. State Y Live in a 17c. ®Yes, Decedent lived in Southampton Ttyp,
6 0 4 Walnut Bottom Road Cumberland Townah~? 17d. ^ No, Decedent Lived within
nb
county
'
Shippensbur P A 17 2 5 7 .
Actual L
unds o1 ciry/Boro
1 B. Father's Name (First, middle, last, suffix) 19. Mother s Name (First, middle, maiden surname)
David Spangler Laura Helm
20a. IntortnaM's Name (Type I Print) 20b. Inbrmant's Mailing Address (Street, r9ty I town, stare, zip Dods)
Ike W. Black, Jr. 142 Kline Road Shi ensbur PA 17257
21 a Method d Disposition r ^ Cremation ^ Donation 21 b. Date of Disposgion (Month, day, year) 21c. Place of Dispruition (Name of cemetery, crematory cr other place) 21d. Locetion (City /town, stale, zip code)
r
X^ Burial ^ fiemoval from Stale r Was Cromatron or Donation Authorized
^ Other • r by Medical Examiner /Coroner? ^ Yes ^ No
7 - 21- 2 01 1
Westminster C e m e t e r
Carlisle P A 17 1
22a. Spneturo r L' rson ailing as such) 22b. License Number 22c. Name and Address of Facility
- - 014831-L Fo elsan er-Bricker F.H. Inc. 112 W. Kin St. Shi ensbur PA 17 7
Comple 23a-c onty whence ' 23a. Ta the best of my knowledge, ilea ~ occurred at the time, date end p
tated.
Signature and title)
ace
s 23b. Licertse Number y,year)
23c. Date Sir,~ed (Month, da
ptysician is rqt avertable of Ikne o1 death to (
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cen9y cause of deMh. 1`-/' `~
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Items 24-26 must be certrpleled by person 24. Time o Death 25. Date Pronounced Dead (Month, day, year) d/tp Medical Examiner /Coroner for a Reason r than Cremation or Donation?
26. Was Case Refen
e
wta pronounces death. (S M, I $ a 1 I ~
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^ Yes L~ No
CAUSE OF DEATH (See Instructions end exempt r Approximate interval: Pan II: Enter other sianflicant conditions contrbrdine to death. 26. Did Tobacco Use Contribute to Death?
Item 27. Pan I: Enter dre drain of events -diseases, injuries, a corrrp9catans - that directly caused the death. DO NOT enter terminal events such es cardiac arrest, r Onset to Death but not resulting in the undenying cause given in Pan I. ^ Yes ^ Pty
respkalory artest, or ventricular fibrillatbn without showing the etiobgy. List only orre cause on each line. ~
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^ No Unknown
IMMEDIATE CAUSE (Final disease or /1 r
cordition resuairg in death) _~ a (r~ 111.yd1'11 i ~ ~ 29. If F~~ie:
ear
LYl Not
re
nant within
ast
Due b (or as a consequence of): r p
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p
y
^ Pregnant at time of death
Serp~entially list conditions, 9 any, b. i ^
leading ro the cause listed on tine a. r
Enter the UNDERLYING CAUSE Due to (or as a consequence ot); r Nol pregnant, but pregnant within 42 days
o1 death
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(disease or inprry that initiated the
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events resulting m death) LAST.
Due b (or as a consequence o1): r year
o
pregnan
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pregnan
ays
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before death
d
~ ^ Unknown ri pregnant within the pest year
.
30a. Was an Autopsy 30b. Were Autopsy Findkxrs 31. Mannpyol Death 32a. Dale of Injury (Month, day, year) 32b. Describe Fbw Injury Ocwrred 32c. Place of Injury: Home, Farm, Street, Factory,
Periormed? Available Prior to Congletion
of Cause of Death? ,L~1/
Natural ^ Homicide 09ice Building, etc. (Specify)
^ ^ Accident ^ Pending Investigation 32d. Time of Injury 32e. Injury at Work? 321. II Trensponetion Iryury (Speciy) 32g. Location o1 injury (Street, city /town, stale)
^ Yes No Yes No
^ Suiade ^ CouW Not be Determined
^ Yes ^ No
^ DriverlOperator ^ Passenger ^ Pedestrian
M. ^ Other -Specify:
33a. Certifier (check only one) 33b. Signature end Title of Cedrlie - ~ ~,,.-
C' /
• Cerltlyirg phyafcian (Physician ceniryirg reuse of death when another physician I>es pronounced death and completed Item 23)
death occumd due to the cause(s) and manner as staled
e
To the best of m
knowled : °'~~ G' ~ '
,
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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• Pronoundng end tertgyfn9 PhY~~ I~Ys~n both prorwrxrdrg death end cenitying b cause of death)
To the beat of my knowedge, death oxurred at the time, date, and place, and due to the cause(s) and manner as Meted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^
33c. License umber
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33d. Dale Signed nth, day, year)
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• Medcal Examiner/Coroner _
On the baste of examination and / or imesl' lion, In m o infon, deMh occurred at the time, date, and lace, and due to the ceu sand manner as stated_ ^
~ Y P P ce1 I Name and ddress o rson Vyho us ea 27 T I Print
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