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HomeMy WebLinkAbout08-25-11r~' ON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN THE COURT OF COMM REGISTER OF WILLS PETITION FOR PROBATE AND GRANT OF LETTERS Rozella M. McLane ,Deceased ESTATE NO: 21- Estate of a/k/a: Rozella Ma McLane a/k/a: SS NO: 204-01-0303 a/k/a: of a e or older, apply(ies) for: COMPLETE SECTION `A' or `B' AND "C" as Petitioner(s) who is/are 18 yrs g lete Part C also) applicable: under to and Grant of Letters Testamentary or ^ AdministratioTest men aryn.c.t.a. comp [~ A. Proba and aver that Petitioner(s) is/are entitled to that fdorementi 9 24 1 egtters and codicil(s) dated -- the last Will of the above-named Decedent, d (State relevant circumstances, e.g. renunciation, death of executor, etc.) ' not m ,was not divorced, and did not have a child born caaac tat d persone nd was not a Except as follows, Decedent did ~'Y instruments offered for probate; was not the victim of f deaing, was never adjudicate an m p th wherein grounds for divorce had. been established as defined in party to a pending divorce proceeding at the ttme o 23 Pa. C.S.A. § 3323(8): N A $. Grant of Letters of Administration (If applicable, enter d.b.n., pendent lite, durante absentia, durante minoritate) ter a ro er search, has/have ascertained that Decedent left nodWilof Will in Section A and complete list of C. Petitioner(s), of p P to a pending divorce following spouse (if any) and heirs (If Ad never ad'udicated an incapacitated person; and was not a party exce t as follows: heirs); was not the victim of a killing; was J p ,. herein rounds for divorce had been established as provided in 23 Pa. C.S.A. § 3323(8 , ~ proceeding w g to pece t ~' Rela ;- Address _ ° - Name ,' ' ~:: ~ ~ ..J 1 r rn 3 __ „ .-~ ~ , ~. ,~., USE ADDTI'IUNAL SHEETS 1F NECESSARY Cf _ THIS SECTION MUST BE COMPLETED: penns lvania, with his/her last family or principal residence y Decedent was domiciled at death in Cumberland County, t Allen Drive Mechanicsbur U er Allen Townshi Cumberland Count PA 170 At Messiah Villa a 100 NIOUn Municipality: Township, Borough, City) (Street address with Post Office and Zip Code, Mechanicsburg Pennsylvania 92 ears of age, died 8/5/2011 at Decedent, then __ Y (Month, Day, Year of death) (City and State where death occurred) $ z ooo.oo Estimated value of decedent's property at death: All personal property ~ If domiciled in PA Personal property in Pennsylvania $ If not domiciled in PA Personal property in County $ If not domiciled in PA 2 000.00 Value of Real Estate in Pennsylvania Total Estimated Value $ Location of Real Estate in Pennsylvania: (Provide full address if possible.) N__ A__- Name(s) & Mailing Address(es) Signature(s) Sharon S. Umholtz, formerly Sharon Souder, 823 Boiling Sprm ~`/ ~ ~~ Road, Mechanicsburg PA 17055 ' Creedin L. Stoner 506 E. Marble St. Mechanicsburg PA 17055 ~ /~ ~, ~ ~~ Page 1 of Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court OATH OF PERSONAL REPRESENTATIVE ;: Commonwealth of Penns lvania ~ -~ `~" ' ` ' r ~A~~~- _. County of Cumberland ~ :~'"'-' r`~-' : - ~ ~ r, , c. . '.. C, ., ~,.~ . -~~~~ -,~ The Petitioner(s) herein named swear or affirm that the statements in the foregoing Petittere true a><ad ~ :=~ correct to the best of the knowledge and belief of Petitioner(s) and that, as personal repre~n~ative(s) ©f the=;,~ ~, Decedent, Petitioner(s) will well and truly administer the estate according to law. c ~~`~ Sworn to or af€irmed and subscribed rr~~ ~~ re me this ,/1~ __ day of ~_._. ~,> or the Register Estate of Rozella M. McLane ,Deceased File Number: 21- 1 ~ -___Q ~~~ AND NOW, this ~~!sz day of the reverse side hereon, satisfactory proof x Tectamentarv of Administration (If applicable, enter c.t.s., d.b.n., d4b.n.c.t.a., etc.) Creedin L. Stoner and Sharon S. Umholtz ~ m the above estate and that instruments(s) dated 9/24/1999 described in the petitiar- he admitted to probate and filed of record as the last Wili and Codicil(s) of Decedent. Glenda Farner Strasbaugh, /~ ~' ~ Register of Wills FEES: .$ ~ . b8 Letters .................. . Will ....................... • ~l3 Codicil(s) .............. . (5) Short Certificates ' ( )Renunciations....... Bond ............................ Other ............................ ~mation FEE........ 5.00 ~'EE .................. .50 .~' _.~rl3~ ;L ................$ 44 West Main Street Mechanicsburg PA 17055 717-697-8528 717-697-7681 /~Q~" ~ ~ ~ , in consideration of the Petition on been presented before me, IT IS DECREED that Letters are hereby granted to: Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court Signature of Counsel Required to Enter Appearance Atty's Signature PRINTED Name: Keith O. Brenneman Supreme Court ID No.: 47077 Address: Phone: Fax: Page 2 of 2 DECREE OF PROBATE AND GRANT OF LETTERS )S.t;05 RLV ((11/()71 TIFICATION 0~= DEATH AL REGISTRAR S CER hotostat or photograph. LOC licate this copy by P WARNING: It is illegal to dap ~ee for this certificate, ~b.00 P 17644681 - Certification Number 'This is to certify thatlth(rln~i,la~ Ce t fic~te ~f De th correctly copied from an ~ duly filed with me as Local Rf'g~~t h~; ~State~Vital certificate will be forwards d t Records Office for permanent filing. ~ V~ ~ ~ ~ -_ ~- ~1~ ~~r --- - Datt~ Issued Local Registrar _ ~_ ,:- _• __ . -- _. _ -- ,--- ---- ; ri ~, ~._._ .. . '.~ r-- '~ ='rj~ _ ~3 ~.: - -~„ .__, COMMONWEALTH OF PENNSYLVANIA • DEPART DEATH HEALTH • VITAL RECORDS .,.... tit~~ ,, HEV „~, CERTIFICATE OF TYPE I PRINT IN (See instructions and examples on reverse) STATE FILE NUMBER PERMANENT 4 Dale of Death ontt day. year) BLACK INK 2. Sex 3. Stxaal SecuntY Number (a~ d _ ~~ _~_ 1. Name d Detredenl (First, middle, fast. sulfa) /~ O ~~' Q. ~/1 ~ ~ C ~ (~ Ba. Plaat of Death (Check aYY one) K , / 1 7 Bintglace (Gty and state a b co~M ether. 6. Oare d Bill (Harm, day, Year) HosptaL [] Residence ^Gf1Bf ~'~' lJrdar t Year Under 1 day n bent ^ DDA ~rsing Home 5. Age ILasf BirtldaY) IAOrsns ~ Flours M+rAa ~\A _ _i - ,, ~= l ~ T ^ InPafienl ^ ER I OutPa v No ^ Yes 10. Raze: American bdian. Black. Wnne, etc. - 2 11UC,.4;Y~N+, 9. Was Decedent of Hispanic On9~ {SGec~Yl A ~J FacaitY Name lif abf ~• eve sheet and number) (If yes. speaN Cuban, w ~~I ~ / ~ Yrs .• Mexican. Puerto Rican. att.) gb. Coratty of Death 8c. Ctry, Boro. Tvrp. d Death ~ ~ ~ ~ / ~ ~ ~ ` I r ,Q ~~ N wile, give maiden name( Lv , ri 9~ ~~e1~ 74. Mental Status: Married. Never Mattied, t5. Survivirq Spouse ( ~ 12. Was Decedent ever kt the 13. Decedents Eduatrm (Speary onN fkr3tte Ik>ge (i-4 or 5+) Widowed, Divorced (Speahl ~` ` ""~' d waki kle. Oo na sate r U.S. Armed Forces? Eiementary~ ary (0.12) i .. - t t Decedenfs,JStJBf tion Kind d wak done Kmd d'K°dt Itintl d &rsiness I Industry ^ Yes ~ Did Decedent .~-,/ ~ Twp Dazedents ©^ Liva m a 17c. {?Sl Ye& ~e~ V~ I bwn, state. zp code) 17a. State ~ 11 TownsNp? t 7d. ^ tJO. pecedent Lived whin City ~ Bao Actual Residence n ~ , ~ ~ O N 11,1A ~~ Acluai (ink)s d 16. pecedtrtl's Mailing Address aft l~lJ~.- ~~ 1 ~ f2 ~x~ ~ 17b. Cautry ~ ~J p~J'~j 19. Mott>ar's Name (First, nwddM, maiden surreme) ~~ ta. Earner's Name (Fast mddla• fast, sulhx) ,~ .Q Address (Sheet, cdY 1 bvm, stale, zip code) ~~ 2pb.~In7brtnants MaiNng c / Prat() ~) ~ - pid. tan (Oft I tovxt, sate, z'P code) 20a. b,drmarN's Name (TYPe ^ rpon (Name al a+metery. cremalorY a ether place) ~ D Y 21b. Date of Dispostua+ (Haan' daY' Year) 21c. Place of 0ispo+ yin _C~~ I ~`~ ~,R 1 [] Gertrofion ^ ponation u1 \~~~ ~ ~ ~ ~d 2ta Method d OisPosffron i 1 D ( Y^/ I~~.VlL0..Y~1 • ~, ^ Rerttoval from State j Exam«krr~l ~ ~ ~ and Address d Faa7aY i uWi ^ t ~ such) ~. Ltcertise N~ / I }-~ Dale SgMd {Morin. day, Yea ~ • ~ (a Demon 1 ! ~ ~ 23D~~Lic//~ns~ Ntarte~e-r/ - d knowledge. death tttuned at the/tjim~. dare and Place . lstgnaaYe and ) , Il_I~J j g i` 2 f 5 ~ °~°s / . o nM' ~~ ~ "' - -_" ~ I finer I Caster for a Reason Otnar dtan Crematbn a Donalbn? Cmrplafe berm 23at onM ~"" Ce~g p /J~,, . G. ;;~~~~// 26. Was Case Referred w Medal F_xam phyppart s na avaiable ri time d death ~ prypy cause d deem. 25. Date Pronamcefdy (MaCSh. daft YBBf) ^ Yes ~° 24. T Deaff Q D ~ •J ~' Approximate intaroal: PaA 11: Erder aher '"'-- M^tlibrafro b deat0. 28. Did Td>azco Use CatbidAe w Death? Irons 24-26 must ba oonproted by Person / ~7 ` ~~ M' m Part I. ^ Yes ~ProbadY ~ who P ~~, a but rot resulGrg in Me undaMfe9 ~ ~" ^ ~ ,bin instructions and ettarnW~) i Onset to Death l CAUSE OP DEATH l~ eased ~ ~. ~ f10T enter larrrkrtal events such ss cardiac arrest, t daeases, ~~• a .~,bns _ ~ direatY r ~ , /~ % 29. d Fenrole: the ebotogY. Ust sty one cause on each tine. ',, ~ ,(/~ ~ t `( ~ f ~ ~, a~M vriNn Pas< Y~ Item 27. Pan I: Eller me T~-~ - ,M,fqu Sturwktg ~~Lf~ %~ `V ` " r raspiretaY anesL a ventricular ^ ~ _~-- ~ ~ ^ pregnant at time d deem ~tdrpor' ui~rest;Aa,g~n deaNl a a. "`~ `~-S ~ ~/~G~l ~~- ' ~~ ^ Na pregnam. txn wemam within e2 eats r -1 Due or as a conseQuence °D~ ' ~LI ~ / d derih V r ~ Nd DragnanL Dut Dregnaa 43 days fo 1 Year lly fist mrtdtions, a arty. d. uer~e of): ' treiae death b me cause kskd m kre a. pus to (a as a wrsseQ r withn the past Year El°~ "~te U-gEpLYMIG CAUSE r ^ Unkrawn A pregnant resuNng ~fn~)~ c Due to (or as a cortseQuence otl: r 32c. Race d Injury: Fiane. Fenn. Street. Factory. pl{rce 13uikYng. etc. (Specify) d. 32b. DsscriFe How Injury Oaarad ~ 32a. Date d Injury (Morin, day, yeah 32g. Locelion of tnIWY (Street, city 1 town. state ~ Were AMY Fsds~e 37. Manner d Death J ~' ~~"';°P~ Avaaade Prbr b Congletion ~-Nataal ^ fiorrticide Sze. Injury at Work? 32f. n Transportatlen kMuY (Spetffyl d Cause d Deem? ^ Ar~ident ^ Pertdrg Imestigalion 32d. Tune d Injury Dinar I qua ^ passertgar ^ Pedestrian ~`~,~ ^ Yes ^ Wo ^ L!J ~] Yes ~ No ^ Yes ^ No ^ Stridde ^ Could Na be petennned M. 01~` 1 ale Certifier 'V ~ ' ~ / ~ 33d. Uare (Mortlh, daY. Yeart 33a. Certifier (crock oay °'1Bl deem and completed k8m 23) - - - - - - - - - - - ease d death when artotlter physician has Pro^ar"c~ _ -' _ _ e Ntrnber _ ~fi/ / [ • ToCa ~N~P~ m• ~ ~ctrrrse due to the cause(s) ~ and certiyeg to cause d deaN) - _ - - - - - - - - -' - - - - /t S(~ (J`~ ~ T "~ (,/ 0 prptouncing end certilY-"g P ~ t~ ~, ~te~, and Placa• and due to tlx causNa) e~ manner ss stated- - - - - ' - - - L/ th Ptem 27) Typa 1 Prue To the bast d my knovrrod9e• and due to the taua!(a) and manner Y atated_ ^ 34. Nome Address d Per Wlw a t L~ d ~ ~ bash d exarrtinriion and 1 rx ktvariigribn• in my opinion. death occurred ri the time, dare. end plea. /I /" ''~ `~ ~ ~~ u 36. Date Feed (Month. say, yeaA j U O /Y9~ // ~ I;t I) ~ ~ ~ ,1 ~ ~i ~ ~c~„ ~ 8 ;fie C ~ ~:-~...~,~ < < ~:, ~ ~ s gnature a(n~d.District Nu Z pisposilan Perrtat No.