HomeMy WebLinkAbout08-03-11 r _ ~ I r
Register of Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS ~~ ~~-
Estate of Dolores Farrell Peterson Estate No. ~ ~
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Also known as Dolores Peterson, Deceased ~' ~-; ~ ~~
Social Security No. 296-14-4009 ~~~
Joellen Peterson Placewav b --~
Name of Petitioner who is 18 years of age or older, applies for: ~
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X (COMPLETE A OR B BELOW :)
A. Probate and Grant of Letters and avers that Petitioner is the executrix named in the
Last Will of the Decedent, dated June 3, 2009, and codicil(s) dated N/A
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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 ~
documents ffere for probate; was not the vic im of a killing an was never adjudicated incapacitated. 1 ;~~, (,~,~ ~~, ~~"" - P
-ksa.. ~ ~ rg ~t ~o ~cQ. p r~~ i a.~ t~~-t,v.Q,a ~~~`~~ h~ra-; ~ ro,~,~, ,.
B. Grant of Letters of Administration ~~ g "_I~I `~ ~ ~~ `~Q~`~' ~"~''~"~ ~S~~C~s
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(c.t.a., d.b.n.c.t.a., d.b.n.) ~' C-'S-;Q . ~ ~3 ~.3
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Petitioner(s) after a ro er search has/have ascertained the Decedent left no Will and was survived b the following spouse (if any) and heirs:
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COMPLETE IN ALL CASES:
Decedent was domiciled at death in Lancaster County, Pennsylvania, with his/her last family or principle residence at:
1 Alliance Drive, Apt. 104, Carlisle, Carlisle Borough, Cumberland Countv. PA
(Address) (City) (Township or Borough)
Decedent, then 87 years of age, died June 23, 2011, at Carolyn Croxton Slane Hospice
(Date of Death)
Residence, Susquehanna Twp., Dauphin County, PA
(Location)
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ 24,000.00
Value of real estate in PA $ 0.00
Total $ 24,000.00
Real estate situated as follows: N/A
Wherefore, Petitioner respectfully requests the probate of the last Will presented with this Petition and the Grant of
Letters in the appropriate form to the undersigned:
~i nature T ed or rinted Name and Address
~ f- Joellen Peterson Placewav.
~~ 127 Foxbury Drive
Elizabethtown, PA 17022
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumberland
The Petitioner above-named swears or affirms that the statements in the foregoing Petition are
true and correct to the best of the knowledge and belief of Petitioner, and that, as personal
representative of the Decedent, Petitioner will well and truly administer the estate according to
law. ~
Sworn to or affirmed and subscribed ~..
before me this ~ ~ day of oellen Peterson Placeway
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DECREE OF REGISTER ~°
Estate of Dolores Farrell Peterson Deceased Estate No. - f -U~~
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also known as Dolores Peterson
Social Security No. 296-14-4009 Date of death June 23, 2011
AND NOW, ~~ ~~-~ ~, a2~ ~ ~ , in consideration of the Petition above,
satisfactory proof ha~ing been presented before me,
IT IS DECREED that Letters (X) Testamentary () of Administration (c.t.a., d.b.n.c.t.a., d.b.n.)
are hereby granted to Joellen Peterson Placeway
in the above estate, and that the instrument(s), if any, dated June 3, 20092 and codicil(s) dated
N/A, described in the Petition be admitted to probate and filed of record as the last Will of
Decedent.
FEES
Letters
Short Certificate(s)
Renunciation ll ~ j ~1
~t~'~~CSTt
Citation
I.T.R.
JCP Fee
Inventory
Other ~~~~
TOTAL
$ (~0.
$_ o(~' `"
~~-sue
Attorney
I.D. #
Address
Telephone
Date Filed
53702
1255 South .Market Street, Suite 102
Elizabethtown, PA 17022
717-361-8524
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LOCAL REGISTRAR S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.010
P 17451698
Certification Number
This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly Filed with )Y~e as Local Registrar. The original
certif~_cate will he forwarded to the State Vital
Records Office for permanent filing.
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~~ye. "~~.,~era~r~D~.t-~ JUE~ 2 7 D11
Local Registrar Date Issued
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H105-143 REV 11/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
TYPE /PRINT IN
Pl3uc~ CERTIFICATE OF DEATH
(See instructions and examples on reverse)
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1. Name of Decedent (Bret, middle, last, su(tix) 2. Sex 3. Soael Security Number V m 4. Date of DeaM (Monts, day, Year)
Dolores Peterson Female 296 -14 -4009 June 23, 2011
_ 5. Age (Last BirMdey) lJrder 1 r Urder 1 8. Date of Bits Month, de , r 7. BI C and state w coon Ba. Place of DeaM Check un one
87
- Dam "°'"' ""'~"a Feb. 28, 1924 Toledo, OH Hospital: Other:
Yrs.
- ^ Inpatlent ^ ER /Outpatient ^ DOA [~ Nuesirg Home ^ Residence ^ Other - Spealy.
Bb. County of Deets
• Dauphin Bc. City, Bwo, Twp. of DeaM
Susquehanna Twp. Bd. FacNny Name (d not Iredtudon, ghre street and number)
Carolyn Croxton Slane Hospice 9. Was Decedent o1 Hlspank; Orgin? ~ No ^ Yes
("~'c~n~ 10. Race: American Indan, Black. White, etc.
(
Residence '~~°"' Puerro Rk;en' ero•) White
• 11. Decedents Usual Bon Kind of wak d ew most of Nla. Do rat state re 12. Was Detxirderd ever In the 13. Decedent's Education (Speak any hlglleat grade com leted) 14
Medtal Stat
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Kind d Work Kindel 8uairwcs/Industry
Teacher Public School
U.S. Amwd ForrxreT Ek+menfary I Secondary (0.12)
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CoNege (1.4 w 5+)
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Wes' DNarced (~~/
Widowed 5. Surviving Spouse (H wits, give maiden name)
16. Decedents Maidng Address (Street, sly /town, stela, zp code) Decedents Did Decedent
PA
1 Alliance Drive ~ Apt . 104 Aca,ai Residence na. stale
Live in a 170. ^ Yea, Decedent Lived in 7wp,
Carlisle, PA 17013 Cumberland T~"sNp? 17d. ®No, Decedent Lived vritMn Carl lets
,7b.cwmtY
Actualumitaat ciy/~
1 B. Father's Name (First, rtdddle, last, suKx) 19. Mothers Name (Flret, middle, maklan sumeme)
Dominick Jose Farrell
20a. Infomrants Name (Type /Print) 20b. Informant's Mailkg Address (Street, city / taro, state, zip code)
Joellen Placewa 127 Foxbu Drives Elizabethtown, PA 17022
• 21 a. Medad of Disposition r ®Cremetlon ^ ~~ 21b. Date of Dispoaltbn (Monts, day, year) 21c. Place of DiaposNlon (Name of cemetery, txxnetory or other place) 21 d. Location (City I town, state, zip code)
^ Burial ^ Removal Tram stale ~
2011 Hof fman-Roth Funeral Home &
cr«~e June 26
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r ~ Yea^ No Carlisle, PA 17013
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22a. lore d
I uch) z2b. Licarwe Nurrrber 22c. Name and Address a FacilNy - era Ome tame Ory
- - 138504 219 North Hanover Street, Carlisle, PA 17013
cer6yirq
physlcien re not or deaM ro 23a To the best al my krawledge, deaM aaxared et time, date and place slated. (SigwWre end Ede)
~ 23b. Lkenee Number 23c. Date S' MmM, da
r9red 1 Y. read
certtly r~ d deeM ~3 5861D ~ ~ 3 oZ D L
Ibnw 2h28 must be cempbted by person
~°°~~ 24. Time of DeaM
~ 25. rorarxrced Dead (Monts, day, ~ 28. a (:sae Referred tgJ.kdlcel Examiner / Corarwr fa Odwr dwn Cremetbn or Donetbn?
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7- a. ao~ ~ ~~ No
CAUSE OF DEATH (See Instructions exempts) r Approximate Interval:
Irom 27. PaA I: Enter dw ~ - dfaeeces, inf arias, w canp6cedorw - Met dkectly caused dw des . DO NOT enter tennlnel events such ae cardiac arrest, r Onset ro DeaM
rea
ireta
arrest
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f Part II: Enter odwr
but not resWdng in dw underlying cause given In PeA I. 28. Did Tobecm Use Contrbule to DeaM?
^ Yes
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, w ven
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on w
aut a
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ng Me e6obgy. List only site cause on each Ikw. ,
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MIMEDIATE CAUSE Fhd dbeese w Q No
^ Unknown
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ardition resulting in r~M)
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29. I
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~W.sAra
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Duero (w ea a ccnsequence oq: i
Net conditlorrs, H ant, b ~
~ Not
t wiMin
pregnan pest year
^ Pegant at Nme of deaM
ro cause Nsted an Nrw a.
^
6rbr UNDERLYg4G CAUSE Due to (w as a oonsequance oq: r Not pregnant, but
p+e9nent wiMln 42 days
(disease w injury. that kridated the i
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events resunkrg n deaM) LAST.
i of deaM
^
Due to (w as a consequence of): Not Pregnant, but pregnant 43 days 101 year
• d ~
r bekxe deaM
^ Unknown n fxegnern wiMin aw pest year
30a. Was an Aubpsy
PeAomwd? 30b. Were Auropay Frrdkge
AveNabt Prior ro Cortrpletron 31. Manner of DsaM 32a. Date of In'
fury (Monts, day, Year)
32b. Deecrlbe How Injury Qa:urred
32c. Place of I ' Home, Fann, Street, Fact
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of Cause of DeaM? ~ NaNrel ^ HoMdda Odirw Bui
, ero. /SpealyJ
^ Yes ~ ^ Yes ^ No
^ Accident ^ Pending Investigation
~ Tme of Injury
32e. Infury al Wank? 32f. n Treneportatlon Injury (Spec4y)
32g. Locetron d injury (Street, city I town, state)
^ Sulfide ^ CotNd Not be Detennkwd M ^ Yes ^ No ^ Driver/Opereror ^ Passenger ^ Pedestrian
Olhar - SpecHy:
33e. Ceruder (dwac oMy one) 33b. Signs rid Title of Certlller
• Certifying phyelcian (Physician ceAityiry souse a deaM when anodwr pirysiden has pronounced deaM and completed Item 23)
'
7otMbestofmllknowiad9e,daMOCCUrredduetotfwause(e)andmannaeseteted---------------------------------1°- (W~r~,N,` 11`
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• PronOUrwirrg end txrtlfying physklert (Physkian bWh Mwauncktg deeM and ceAilying ro cause of deaM) 33c. License Number 33d. Date Sigrwd (Monts, day, year)
7o the beat of my knowbdge, dssth oceurred et the tlme, date, end place, end due to the ease(s) and manner ea etated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^
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exeminetlon end I w Investlgstion, In my oplnlon, loth oaurred at the Bme, date, and plea, and due to the cause(s) end msnner as sated_ ^ 34. Name end Address of Person VVho Completed Cause of DeaM (item 27) Type / Pdnt
35. liegistrer re and
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~ 36 Date Bled (Monet, day, read
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Disposition Pennn No. O ~4~ 1 ~ Q ~`~