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Home My WebLink About08-31-11 (2)IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA REGISTER OF WILLS ~ -~~ PETITION FOR PROBATE AND GRANT OF LETTERS ~o =~~~ -~~ ;~~ ,M ~ ?.',~, r `~ .. Estate of ANDREW SVEN OLSON ,Deceased ESTATE N -JY' ~~ ~ ~ ; ~` T, 1 r ~-. a/k/a: SS NO: 087-= ' ~ 9864 -` ~ _ 'D R' f % ~.f3 ~ Petitioner(s) who is/are 18 yrs of age or older, apply(ies) for: COMPLETE SECTION `A' or `B' AND "~" as --~-, applicable: D A. Probate and Grant of Letters Testamentary or ^Administration c.t.a., or d.b.n.c.t.a. (complete Part C also) and aver that Petitioner(s) is/are entitled to the aforementioned Letters 08/10/2000 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): N/A ^ B. Grant of Letters of Administration to appucable, 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: N/A THIS SECTION MUST BE COMPLETED: Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or principal residence At 770 S. HANOVER STREET CARLISLE CUMBERLAND COUNTY PENNSYLVANIA 17013 (Street address with Post Office and Zip Code, Municipality: Township, Borough, City) Decedent, then 100 years of age, died 8/20/2011 at (Month, Dav. Year of deathl Estimated value of decedent's property at death: If domiciled in PA If not domiciled in PA _If not domiciled in PA _Value of Real Estate in Pennsylvania Location of Real Estate in Pennsylvania: (Provide full address if possible.) Signature(s) Total Estimated Value $ __ 50,000.00 $ 50,000.00 Name(s) & Mailing Address(es) DAVID NELSON, 8165 ROUTE 220, HUGHESVILLE PA 17737 ANN McMAHAN, 103 CHIPPEWA ROAD, PENNSDALE, PA 17756 CARLISLE, PENNSYLVANIA (City and State where death occurred) All personal property Personal property in Pennsylvania Personal property in County Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court Page 1 of 2 tnaunc RcV ,nrrn-,, _ - - - - - - - - - - ~,1-11-C~~~3d LOCAL REGISTRAR'S CERTIFICATION C)F DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 P 177277~J5 Certification Number This is to certify that the information here given is correctl~/ copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. -, ~~ A 2 2011 Local Reegistrar Date Issued --- --- --- _ __ ~.--__ _ __.__ C7 r-- __ __ __ ..,. ~ e*' G7 r _. ~ .r r J ~.~ -_~ ~ - ~ ~ ~ ~ ti r ~ ) i ~ ~ / ~~j ~~ \ •~• yr H105.113 REY 112oW TYPE /PRINT IN COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS u CERTIFICATE OF DEATH (See instructions and examples on reverse) 1. Name of Decadent (First, mMde, last, suffix) STATE FILE NUMBER 2. Sex 3. Social Secudty Number a n.r. ,a rL•x, n.....x, a... 0 i 0 U 0 4 2 -__.. ,...,..,..~~ ..or, rear raw S. O son Male 087 -03 -- 9864 Auclust 20, 2011 5. Age 1~ &rNtdaY) Under 1 r Under 1 da 6. Date of Birth Monts, da ,. 7. Bi Ci end state or I ' n coun 8a. PWce of Death Check on one 100 "'°""" Day '~'"' kk"xB~ June 11, 1911 BrOOklyn ~ ~ Hospital: Other: Yrs. ^ Inpatient ^ ER /Outpatient i^ DOA Nursing Home ^ Residence ^ ONx3r - Sperity: ~• Cotxrty of Deem !k. City, Boro, Twp. of Death !!d. Faality Name (If not insNtutlon, give street and number) 9. Wea Decedent of Ftl enk 0 ' m~ l Cumberland Carlisle Cha 1 Pointe at Carlisle w yea, apedty cubanP ~ ^ Yea 10. Race: American Indian, Black, white, etc. Mexican, Puerto Rican, etc.) ~ (~~ White • 11. Decedents lJsual lien Kind of work done du ' neat d kfe. DO rat slate 12. Was Decedent ever let the 13. Decedent's Education (Spedfy only highest grade contpieted) 14. MerMel Status: Married, Never Married, 15. Surviving Spouse Qf wile, give maiden name) KkW of Work Kind of Btektess/IrMustry U.S. Armed Forcea7 Elementary /Secondary (a12) College (1.4 or 5+) W ~~' ~~ (~tyl Ptlrchasi Mena er ®Yes ^ Na 1 Widowed 16. Decedents Meii Address (Street, city / lawn, state, zqr code) Decedents Did Decedent 770 SOU~h Hanover Street Aaw~ Residerxg 17a. State PA TL~ens~ ' 17c. I^Y~77~ Yes, Decedent Lived in T,sp Carlisle, PA 17013 ,m•~„nty Cumberland p 17d.t.~lNo,Decadentthredwtthin Carlisle Actual Limits of Ciry I Born 18. Father's Name (Frst, midde, last, suffix) 19. Mother's Name (Flret, middle, maiden surname) Gustave T. Olson Lydia Sandvik 20a. InbnnanYs Name (Type /Print) 20b. Infomtanl's MaNing Address (Street, city /town, state, zip care) Dorothy Hostetter 5 Alliance Drive, Apt. 304, Carlisle, PA 17013 • r y, year) 21 c. Place of DI 21a. Method of Disposition r ~ Crematbn ^ Donation 21b. Date of DisposNfon (Month, de spoeklon (Name or cemetery, crematory or oNter pLx~e) 21 d. Location (Ciry /town, state, z~r code) • ^ O~su~l ^ Removal hamstere ~ ~.:ramiE t~~ A~Yea^ Na August 22, 2011 Hoffman-Roth Funeral Home & Carlisle, PA 17013 22a. a Funeral ~ ectirg as wch) 22b. Lk:ertsa Ntxr~er 22c. Name and Address of Fadliry Hof fman-Roth Funeral Hone & Crematory " - 138504 iterts when certilykrg 23a. To Na best of my death ocarred at the ' date ce stated. (Signature and title) 23b. Lk:ense Numbe~ 23c. Date Signed (Month, day, year) physician ie rat at Ilene of death to certlry cause a death. (LL(~1 1 ~ l il.( ~->ll~ . 111 V ~ I~ ~ (.j f~ g C(L R1v~ x.:51' cQC:v "' c~ G i ~ . • Moms 24-26 must be urongleled by person 24. Tine of Death 25. Date ronouraed Deed (Month, day, year) • ~ P ~~ O o : ~. ~ ~ M Q 1~ L1 26. Wea Case Referred to Medaal Examiner I Coroner (or a Reason Other than Cremetbn or Donation? ~l r 1 U lJS I. ~ C7 ~ C~.l G i ~ ^ Yea No CAUSE OF DEATH (See Instructions and examples) r Approximate interval: Pert 11: Enter other al~lll4'8[d conditions centrlbuNne a dean, 26. Did Tobacco Use Contdbute to Death? Item 27. Pert I: Enter the ahakt of events -diseases, kry'uries, or complicatlons - Ihat directly caused the death. DO NOT enter terminal events such as certfac emest. r Onset W Death but not resulN m the ands respiratory arrest, ar ventrkxAar ILdtiation wNfwut shaving the etblogy. list any one cause on each line. r ng • dying cause given in Part I. ^ Yes ^ Probeby W~MED~IA ~CMAUSM (e~ dsease or n t ; ^ No ~ Unknown ng de ) -~- a. 1 v W Q i V ~ ~~ 29. N Female: Due to (or as a consequerxa oQ: r ^ Not pregnant wtlhin past year lest oorMNions, d any, ' ^ P rant at time of tleaM to cause Hied on line a. b' r re9 Enter UNDERLYING CAUSE Due to (or as a consequence of): i ^ Not pregnant, but pregnant within 42 da - lareeege or injury that inaeted Nte c, r of death ~ events resulting m deaM) LAST. r Due to (or as a consequence of): r ^ Na pregnant, but pregnant 43 days to 1 year • d. r r before death r ^ Unknown if pregrumt within me past year 30a. Was an Autopsy 30b. Were AutWsY Fxxfngs 31. Manner of Death 32e. Dare of Injury (Monty, day, year) 32b. Descnbe How Injury Occurred 32c. Place of Injury: Home, Fann, Street, Factory, Pedomad? Available Pdor to Completion of ~~ of D~~q I~NaNrel ^ Homicide Office Bulldirg, ek:. (SpecityJ ^ Yes ~ ^ Yes ^ Na ^ Accident ^ Pending Invesfigetbn 32d. Time of Injury 32e. Injury at WorkT 32f. N Transportation Ir~ury (Seedy) 32g. Location o1 inryry (Street, dty /town, state) ^ Suicide ^ Could Not be Determined M ^ Yes ^ No ^ Driver/Operetor ^ Passenger ^ Pedestrian Other - Seedy: 33s. Certifrer (tirade only one) 33b. Signet d title of CertiNer • Cenlfying physlelan (Physldan cenilying cause of death when another physician has pronounced death end cortplated Item 23) ^ To the best of my knowledge, dnM oecunad due to the causs(a) and manner a stated _ _ _ _ _ _ _ _ _ ~ - ~. f+ ~.) rev., V- • Pronouncing and tartllyMg phyakian (Physidan both pronourxing death and certifying to cause of desM) -' - - -' - -' - - - - - - - - - - - - - - - 33c. License Number 33d. bete Signed (Month, day, year) To tM best of my knowledge, daMh ax:umd st tM time, data, and place, and due to the cause(s) and manner as stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ ly` 1~ b 1 1 Z y (C ~ U y V ~' a I ~ i V • bledbal Examhrar/Coroner V l V On the bsa4 0l axaminatlon and / or inveatigetfon, In my opinion, death occurred at the Nma, date, end place, and due to the cause(s) and manner as atated_ ^ 34. Na(m'e~end Address of Person Who Completed Cause of Death (Item 27) Type /Print s~ 35. Registrar re and ' ' Date Fged (Month, deY. Year) ~••' ~ ° r y ~' p • 3r 2 n g ~'^> ~" J ^ r~.fl - ~ ~-i I [ I ~i f- I ~ a0 '1 'l 1~Vt>nr. 'l, ~~~~ C,ZrLIJ/.c,. Pp l~ol$ Disposition Permit No.~ ~ ~o J I