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HomeMy WebLinkAbout08-19-11PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND Estate of Grace J Tipton - also known as COUNTY, PENNSYLVANQI File Number 21 ' " ~(1 ,Deceased Social) Security Number 201-18-6093 Randall F. B ra and Judith M. B ra Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE `A' or `8' BELOW.) ® A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the Executors named in the last Will of the Decedent, dated 06/17/2004 and codicil(s) dated State relevant circumstances, e.g., renunciation, death of executor, etc. After the execution of the documents offered for probate: Decedent did not marry; was not divorced; 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); did not have a child born or adopted; was not the victim of a killing; and was never adjudicated an incapacitated person, except as follows: No Exceptions (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. '' Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal residence at Claremont Nursing & Rehabilitation Center, Carlisle, Middlesex Township, Cumberland County, PA 17013 (List street address, town/city, township, county, state, zip code) Claremont Nursing & Rehabilitation Center, Carlisle, Middlesex Decedent, then ~4 years of age, died on 07/24/2011 at Township, Cumberland County, PA 17013 Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ 3,500.00 (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania $ situated as follows: None Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to the undersigned: Signature Typed or printed name and residence Randall F. Byra 15 Scarsdale Drive Camp Hill, PA 17011 (717) 761-3303 ~. Judith M. Byra 15 Scarsdale Drive Y~ Camp Hill, PA 17011 (717) 761-3303 Form RW-O2 Rev. 12-26-2006 (interim form, pending action by the Court) Copyright (c) 2010 form software only The Lackner Group. Inc. Page 1 of 2 B. Grant of Letters of Administration (Ifapplicable, enter: c.t.a.; d.b.n.c.t.a.; pedente 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) and heirs (if Administration, c.t.a. or d.b.n.c.t.a., enter date of Will on Section A above 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: ~ - . ~-. 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, Petitioner(s) will well and truly administer the estate according to law. ~ // G ~ ~ '~ f' i~-% Sworn to or affirmed and subscribed t~ bef a me this day of // . .., ~ ~ ~' For the gister Signature of Personal ~~ Signature of P oval Represenfafive Randall F. Byra Judith M. Byra Signature of Personal Representative ;~ ~;~-- rn ~~~~ ~7 ,--, _.... G" File Number: - ~7 ~~ Estate of Grace J. Tipton ,Deceased °~- ~~ ~~;~? 4~~1 1 .: `~ ~ _.~ Social Security Number: 201-18-6093 Date of Death: 07/24/2011 ~G__ , in consideration of the foregoing Petition, satisfactory proof AND NOW, having been presented before me, IT IS DECREED that Letters Testamentary are hereby granted to in the above estate and that the instrument(s) dated 06/17/2004 described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. FEES ~ J'~. ~ p Letters ................................~.. $ :- Short Certificate(s) ....................... $ I ~° ~ y Renunciation(s) ............................ $ $ ~ 4 $ ~ O $ $ $ $ $ $ TOTAL ................................... $ ~'~ Supreme Court I.D. No.: '~~~~~ Bogar & Hipp Law Offices Address: One West Main Street .~ Camp Hill, PA Telephone: (717) 737-8761 Co ri ht c 2006 form software only The Lackner GrouF~, Inc. Page 2 of 2 Form RI/1~ OZ Rev. 10-13-2006 PY 9 C ) Attorney Signature: ~ ~ ~ Attorney Name: .James D BOQar OATH OF SUBSCRIBING WITNESS(ES) REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA ~.. ;.~ ~ r' , , ~~: ~ ;~ . ,.. ~ ~~~~ ~' -~-' ~ ~, Estate of GRACE J. TIPTON ,Deceased James D. Bogar and Beth B. Lengel , (each) a subscribing witness to (Print Name/s) the ~ Will ~ Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that she / he /they was /were present and saw the above Testator /Testatrix sign the same and that she / he /they signed the same and that she / he /they signed as a witness at the request of the Testator /Testatrix in her /his presence and in the presence of each other. - ~ ~ ' (Signatu ) Jades D. ar (Signature) Beth B. LeIIgel One West Main Stree (Street Address) Shiremanstown, PA 17011 (City, State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills One West Main Street (Street Address) Shiremanstown, PA 17011 (City, State, Zip) Executed out of Register's Office Sworn to or affirmed and subscribed before me this //'`L day of ~ l~" o%~ ~~ ,~ i~%~~ Notary Public My Commission Expires: Q -3 - ~O - 3 (Signature and Seal of Notary or other 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) at time of notarization. Form RW-03 rev. 10.13.06 DIANE MONTGOMERX NOTARY PUBLIC SNIREMANSTOWN BORO, CUMBERLAND MY COMMISSION EXPIRES AUGUST 3, 2013 IT_~Ih 12EV' rUl/u_t ;~~' ~- ~ r- d ~~ LOCAL REGISTRAR'S CERTIFICATION C)F DEATH WARNING: It is illegal to duplicate this copy by photostat or photogr Kph. Fee for this certificate, $6.00 P 17644475 Certification Number This is to certify that the information here given is correctly copied 1 i-om an original Certificate of Death duly filed with n~le as Local Registrar. The original certificate will '~~e forwarded to the State Vital Records Office fi rr permanent filing. r hJ' ~ ~ , ~_ ? ~~ Il Local Registrar Date Issued f.~, "~7 = "~"' '~ ~ U ~ r «~ rn ~~ ~ , ~ . "-"} ( Wis... "F"t -.. HtOS143 REV 118006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS TYPE r PRINT IN CERTIFICATE OF DEATH PERMANENT BLACK INK (See instructions and examples on reverse) STATE FILE NUMBER 2. Sax C 3. Sodel Securty Pkmber QQ 4. Dale d oeari ( ~]da ,year) 1. Name d Decedent (Fist, middle, last. stMix) [ O' - 1 ~S - ~ ©~ ~ ` ~ ~Q'' 1 5. Age (Last BiAtday) Urdu 1 lktdsr t da 6. Date a Birttt Month, 7. Bi C' and state a coon 6a. Piece a Death Check one MoNha Days Hours MnNes ` ( Hospital: Other ~~ Yrs. ' `~ (~ ~~ ~QhZ 1 ~ ~ ~~ ^ Inpatient ^ ER / Ou~atiel» ^ DOA Nursing Home ^ Residence ^ Other Specify: 9. Was Deoedent a 'ileparwc Odginl '~ No ^ Yes 10. Race: American Indian. Blecit, While etc. 8b. County a Death 1k. City, Boo, Twp. a Death 8d. Fadiry Name (H not vtstduiort, gyre street and rxxnber) (n yea. speriy Cutan, (sP•pM • 4 Mexican. Pwrm Rican. ek.) ~• ~nbwr o-X~ V`'1 ~ ddl~ w -~ ~ 11. Deaderx's Usual Kxxf d wode done moat a We. Do na state 12. Wes Decedent ever n the 13. Decadence (seedy o^N' higfbst 9~ ~^tW~) 14. Marital Scotus: Marred, Nwer Married, 15. Surviving Sparse (i wife, give maiden rerre) U.S. Amted Forces? / Widwred, Divorced (Speaty~ KinddWark IGddewktesa/lrtdrstry Emrttenmry Setatdary (0.12) Camge (1d a 5+) ti J __ , ^ Yes '~ No I town. state, zip code) tr ~e 17a Spate ~ ~ ~ r^ 17c. pl Yes, Decedent lived in `^' `^~~-y' All+w'~1 Twp. • 16. Decedent's MaAng Address (Street, dry (~ 5 Ls ~f-$ ~tZ p Y . ~ To"~p ~ 17d. ^ No, Decedent lived within s ; 17b. County ~ Actwl Limits a City /Born • 18. Fariefs Name (F C ntidttie, last. ) 19. Momefs Name (First, midde, maiden sumente) ~- Int. Jc~ 20a. Informants Name (Type /Print) 20b. Infamencs Mating Address ( , dy / t ,stem, zip code) ~ I /A~ 21 b. Dam a Dispoeiiort (Monty, day, year) 21c. Plecs a DiaposRbn (Name of cemetery, aemetory a ollmr plate) 21 d. l.ocatgn ICdy I town, smm, zip code) 21a. Method a ~ Craretion ^ Datation o ^ Burid ^ Renwval trom S'trte 1 was Cr«trnort a Donation Artlariaed ^ ~ ~ ~ ~'1 O I 5 .~ ~ ~~~ ~ ,.~ by ttladlcal Examiner/Coroner? ^ Yes No t71 y • ^ Omar . a F ( Par~^ 22b. License Number 22c. Name antiAddress of Faciity /^` ., ~.'~ ~~ y n{ {}•~ ~ /f) Cam.. ~ ]~ Q 1 ^/ * ~L Q = - es ~~rg 8s a ) ^ ~ ~ .l/J r ' , ~M4 a a17I•~S~ } c/~ V • .' V~~' ill i {/•r..1 ~ { • Y J ~ / best a my k^ar'ledg•, death orxxxred at me time, demand place scored. (signature, and ) 23b. License Number 23c. Dam Signed (Mash, day, freer) CantpMm 23ac any what certifyiq Q ~ ~ ~ 1 physidan is nor avaiable rt time d sari m % ~ ~`~ ~ ~~ ~ ~ ~ 1 ~ J X11 d t adiy rouse a deem. 24. Time a Dam 26. Dam Prorgtxtced Dead (Month, day, year) 28. Was Casa Refened to Medical Examktar I Coster for a Reason man Crentatbn a Donation? Items 24-26 must be conpbted by P~o^ i ~1 ^ Vas No - who pratounces deem. a U ~ `~ M. J J 1 a t"; ~ri~i ~ ~ . r Approximam interval: Part II: Enmr amar 28. Did Tobacco Use CaNdbWe m Deam? CAUSE OF DEATH (See Inatruetioru and examples) r Onset W Deem but not reselling in the urtdadyirtg cause given kt PeA I. ^ Yes ^ Probably tlem 27. PaA I: Enmr me ffi81p. - disaa5es, injuries, a canpicalions -mat dkedy caused the death. DO NOT enmr terminal events such as cardac arrest, ~ No ^ Unknown r respkatory anesl. a ventriaAer fibriiation wimad showing me etiobgy. list only one cause an each fine. r ~ 29. d Female: ~ DIATE CAUSE ((Fatal dissse es r ~~ rl S' ~ !~. s:; E [> 8^'~~-ti: +~~- cartdtion resulting in rleari) __~ avt Y1 ~ ~ c l~ 9 r S ; ®Na pregrurd vadtat pall year ^ Pregnant at Ume a dean Due to (a as a co^sequena of): r kst catditbns, d a^y, b. r ^ Nor pregnant, but pregnant wimkt 42 days b ease iabd an ins a. ~ a deem Erser IMiDERLYING CAUSE Due to (a as a consequence ~: r (6sase a i"N"Y met ititieted rie c t ^ Nor pregnant. but pregnant 43 days b t year everxs reaWtirg n deem) LAST. ~ before deem Due to (es as a co^segwna of): t ^ Unknown it pregnant wimwt rie past year 1 • d. r i 308. Was an Autopsy 30b. Were Auopsy Fndktgs 31. Maurer of Deem 32a. Dam of Injury (Monet. day, year) 32b. Describe How Injury Otx:uned 32c Olice B ~dr g ems. FgA~Y1SVeet. Facrory. Performed? Available Prior to Cartpletion ~ Natural ^ Homidde d Cause a Deem? t~ 32d. Time of Injury 32e. Inµxy at Work? 321. d Transportation Inryry (SpecAy) 32g. Lacaticn a injury (Street, dry /town. smm) ^ Yes ~ No ^ Yes ^ No ^ Accident ^ Pending Investigation ^ Driver/Operates ^ Passenger ^ Pedestrian ^ Suicide ^ Could Not a Detennkted M. ^ Yes ^ No Oder - ~~ f 33b. signature and Title of Certifier /`-~ 33a. Certil'tar (cttedc only one) / r CeANyktg physicmn (Physicen artiyktg cause a deem when another physician has pronotxxsd deem and rxxrtpkdad Imm 23) -- To the beq a my bto•dadge, deem occunsd due to the caus(e) srd manner a strted - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ~. License Number 33d. Date signed (Monet, day, year) • Pronouncirg and txertHy4ng physkiut lPhy~^ bori Pd^9 deem end certifying m cause a seam) rL To tM hart d mY knowladgs, deatlt occurred rt the time, dam, end place. end due to the auaa(s) end manner a statad- - - - - - - - - - - - - - - - - - ^ My/ li % 2 !o i z/ , L ~ ~ • ~ ~ ' ~~ c ttlsdicalExamfrtar/Coroner ~ On the hail a exarnlrtatbn and / a imreadgatbn, In my opinion, dam oeeurnd rt the time, dam, and Plan. and due to the awe(s) end rnanrter as stand... 3a. Name and Address a Person WFto Completed Cause a Deam (Imm 27) Type / Pdnt 36. Day Filed Monet, year ~} ~ 7 ~ 36. and ~y IA '"h:~:../~. /" L't is G 7 a z Q Disposition Permit No. Q~ I ~ ~~•~