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HomeMy WebLinkAbout10-21-11PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of Martha E Black File Number 21 ~ - ~ -- ~ ~ ~C_,( also known as ,Deceased Social Security Number 202-20-4148 Thomas A. Capper Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE A' or `t3' BELOW:) ^ A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the named in the last Will of the Decedent dated 08102/2000 and codicil(s) dated (State relevant circumstances, e. g., enunciation, 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 and was never adjudicated an incapacitated person: ^X B. Grant of Letters of Administration C.t.a. app rra e, en ec c .a.; n.c..a.; pe en e i e; uran e a sen ra; uran a moron a e Petitioner(s) after a proper search has !have ascertained that Decedent left no Will and was survived ¢y thg following spo~1use (if any) and heirs: (If Administration, c. t.aA~or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) n W,t S n 0-~/-1 ~ _pa ~ + -I'b G.- P~n~~n Gr:vof•tG ~/`dC~P~~~~ a-t ff< "{jh~ o~F ~l~-K1 a.ktre,n Gr'dJl~Ors '~aTT~ ~; ~v~c.~ l~.•~ Name Relationship Residence bo.en Psficlot•'s ~P~iIAQa ~~ 3 P~cS~~ See attached schedule n ~:~ 'z' (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. ~ =~ ~ - ; .:~ .~l Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal residence-,~ ~'~- _ 111 ~~,;;` 210 Big Spring Road, Newville, PA 17241 ~= ~_ ~ f; ~~ Decedent, then $5 years of age, died on 0 8/2 812 0 1 0 Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ (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: ~ -- `'f' C ~~ i^- 8,530.00 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 Thomas A. Capper 2303 Market Street '~ ~ ~ Camp Hill, PA 17011 Form Rev. 10-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc. ~.1 _~ ; _ at Carlisle Regional Medical Center, S. Middleton Tom.. Cumberland Gotnta=, Page 1 of 2 yJ ',3J 3 l9~ PETITION FOR PROBATE AND GRANT OF LETTERS (Continued) REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of Martha E Black also known as Deceased Name Sherry D. Wiest Delores J. Garman George M. Black, Jr. Richard A. Black, Sr. File Number 21 Social Security Number 202-20-4148 Relationship Residence Daughter 319 Highland Court Berkeley Springs, WV 25411 Daughter 4585 Mont Alto Road Waynesboro, PA 17268 Son 82 Lonnie Burke Road Portal, GA 30450 Son 698 Mountain Road Newville, PA 17241 '~` . __ ~~ -.:? - > ~_ _ ~ ~ .'~ r-r-i ,.~ ., _ . `~; _`-,_- ,.~~i=,- - -. `7 -- ~~ ~ 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. Sworn to or affirmed and subscribed before me this _ o~! day of -Call 1 41 Signature of Persona! Representative ~ .~ r`--'- ...~, ~ h.? -%' C.lj ~ _.... Signature of Personal ReQresentative ; "y C i~ For the Register ~ - - ~ , -.=-, `7~ -- ;-.~ ~i A _~., ~~~ n File Number: 21 - + 1 '" ~ ~, Estate of Martha E Black ,Deceased Soci~a-`S-ecurity Number: Z02-20-4148 Date of Death: 08128!2010 AND NOW, „r\ }(~?P~~'~ ~ Q ~ , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters of Administration c.t.a. are hereby granted to Thomas A Capper in the above estate -- and that the instrument(s) dated 08/02/2000 described in the Petition be admitted to probate and filed of record as the last Wilt (and Codicil(s)) of Decedent. ~ ~ ~~ FEES Letters ............................................ $ .~ Ir -~ ~ n~ f W WflIS i Short Certficate(s) ........................ $ ~ ~ ~7 glS ~ ,., t a B /W/~4'~` Renunciation(s) ............................. $ ~ ~a Attorney Signature: ~.L~' ` ~ ~ $ ~ ~. ~~ Attorney Name: Thomas A Capper C ~-~ cry Y~ ~$ ~ ~ -~mc . . . , ~ r'1 --~ ~ ~ $ ~~' ~ Supreme Court I.D. No.: 75020 -- ~=: ~ Bait, Murren ~ Connell $ address: 2303 Market Street $ $ Camp Hiil, PA 17011 $ Telephone: 7171232-8731 $ $ TOTAL .................................... $ ! ~ t J Form f~tN-02 Rev. 10-f3-20o6 Copyright (c) 2006 form software only The Lackner Group, Inc. Page 2 of 2 nal Representative Thomas A. LOCAL REGISTRAR'S CERTIFICATION OF DEATIHI WARNING: It is illegal to duplicate this copy by photostat or photograph. 1-:c f<)( this I,rirtifirate. `~fi.(11) ,~r%;• Thl~ i> t11 ,rrii(~ tl ,u Ih~ .nf~nmation here. I~i~en is ~~,~ZHOFpE~~- II'' ~, N rlntLCtll~ L ly~>i~d 111/ 1 ~:r, tlnt~inal C~rtifi~ate of Death /~~ ~ - ~ duly filed ~tiith n)~ ~, L,(Iwi Renlstrar. 1~he on ,)nal `.!L ~i~ ~ s,( cr t(iicntc skill ,t ,~yr,aardc•d to the titatu ~%Ital I~ v; ai f~ ~~1rci.s t), ~ I~1( III) ryt in~a 0 :, ,,~~! 7~4~~ ~°9yl ,~~,,,,r _. . _ _ ~~ - - =-- - - -----~ - 11~- Certif(catif~n Numher xx~,f= y ~t"+1c:~ c, ( !1..!r ~~ _F._ D'ite ~~ued T rJ C.. _ -i ,:1 3> f" -' i ;i ?~, ~` j~ -,I }C~-i.I ~ --i H705~143 REV 11Y2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~ -_ ~-'~ C~ TYPE 1 PRINT IN ~_. "T..( PERMANENT CERTIFICATE OF DEATH BwcK INK (See Instructions and examples on reverse) ~r,r< <„ ~ ,,,,,,ono 0 1. Name of Decetlenl (First, mitltlle, 1851, suffix) 2. Sex 3. Salel Security Numher 4. Dale of Death (MOnln, day, year) Martha E. Black Female 202 -20 - 4148 August 28, 2010 5. Age (Last Birthtlay) Under 1 er Untler 1 tla 6. Date of &nh Monts, tla , ear 7. &nh lace (Cg antl stale or le er n coum Ba. Place o1 Death Check oN one MANS Days Hours Minutes Hospital. Other: 85 yrs 11-10-24 McConnellsburg, PA ®Irpallenl ^ ER /Outpatient ^ DOA ^ Nursing Home ^ Residence ^ ONer ~ Specity: Bb. Camry of Death Bc. Cay, Boro, Twp. of Death Btl. Facil4y Name (h not Y161i(Ullen, give alreet antl number) 9. Was Decedem of Hispanic Origin? No ^Ves 10. Race' American tndlen, Black, White, etc. Cumberland S. Middleton Tw p. Carlisle Re gional Medical Center (uye5,5peeAyCuban, Maxkan, Puerto Rican, etc.) (s/»`im White t t. Decedent's Usual Oa lion Kntl of woe done B urin most of work' IAe. Do not state reliratl 12. Was Decedem ever in dre 13. Decetlenl's Educetbn (Sperity only highest gratle comp leted) 14. Marhal Status: Marrietl, Never Marrietl, 15. Surviving Spo use (h wife, givx maitlen name( Kled of WaN Nintl of Business/ Intlust ry U.S. Armetl Forces? Ele nlary ! Secontlary (0-12) n Cdlege (1.4 or 5+) WitloweQ Drrorcetl (Specify) homemaker ^ vas L~9 No 2 years t 2 years widowed 16. DecedeM's MaiNrg Atltlress (Street, cAy I town, slate, zip code) 210 Sig Spring Road Decedent's DId Decedent Ac1ualResiderlce neslate PA Liveina nc ~1ves,DeoeeernLivetli, West pennsboro Twp. Twr, NeWVllle, PA 17241 Cumberland T0W°sNp? 17d.^No, Decedent Livetl within 17b. County ACWel Limits of Cgy/Born 18. Fathers Neme (First, midde, lest, suKix) 19. Mothers Name (First, midtlle, maitlen surname) Ralph Hohman Hazel McQuade 20a. Infamanl'S Name (Type / Pdnt) 20b. Intamanl's Mailing Address (Street, city !town, state, zip code) Richard A. Black 698 Mountain Road, Newville, PA 17241 21 a. Method of Disposaion ^ Cremation ^ Donagon • 210. Date of Dispcedion (Month, day, year) 21c. Place of Disposilron (Name d cemetery, cremato a aher ry pace) 21tl. locelbn (City Mown, state, zip axle) ® Burial ^ Removal Iran State i Wee Cremation or Donellon AuMorhetl _ ^ Otner- 'byMergulExamineryCOrarrer? ^vas^NO 9-1'10 Lurgan Cemetery Lurgan, PA 17232 22a. Signature of F rsee or person aamg as such) 72b. Licerwe Nrxrrber 22c. Name end Atldress o(Faciliry ~ ~ r FD-012984-L Fo elsan er-Bricker Funeral Home Inc., Shi ensbur PA 17257 Canplete 0ems 23a-c mly when ced'Ayirg 23a. To the best of my knowletlge, deaN occurred el the time, dale antl place stated. (Signature aM M1lle) 23b. License Number 23c. Dale Signetl (Month, tlay, year) pryskian S not available al lime of death to certdy cause of tle9th. Items 24-26 must he completed by person 24. Time of Death 25. Date Prawunced Deed (MaMh, ay, year) 26. Was Case Refe r re d to Medical Examiner I Coroner for a Reason Other then Cremation a Donalion~ who pronounces death. "~ / 5 ~ M l ~ ~ Z ~ 2 0 ( U a - n ^ Yes c L7 No CAUSE OF DEATH (See Inetructlone antl exemplea) ~ Ayproximate inlenal: Pan II: Enlar other 5ion91cam mndt ons cony bWrp to death 26. Old Tobacco Ilse Conlnbme to Death? Item 27. Pert I: Emer the chain of events - dseases, ir{urles, or complicelicns ~ that direaty reused the death. DO NOT enter terminal events such as cardiac anest, Onset b Death but na resutling in the untlerlying cause g,ven m Pad I. ^ yes ^ Probably respiratory arrest, or ventricular fibrillation without showing the eliobgy. Lal only ale cause on each line. ^ No ^ Unknown IMMEDIATE CAUSE Final tlisease a I C ~ ~ 'K/.-. ,[ condition resuamg m death) 2g. Il Female: ; -~ a ~A1 '~N l t i ni Due to (or as a c~o qua` a of $¢puenlialry Y51 conditions, 9 any, b_ ~ l ~~ ~? ~ (~\ -~~ ~\,~/ leadin to the Luse lislatl m line a o pregnan w l n past year ^ Pregnant al time DI death ^ gg Due W C Enter the UNDERLYING CAUSE (ore onsequence of ~ ~ ~ pr g pregnan ys Nol a nenl, but t whhin 42 tla f tl lh n (disease or injury that inilieletl the ~ W~ ~ l ~v~ ~ ~ ~ 11 ~~ A ~ ,1 i~ events resulting in death( LAST. 111 -~ c o ea ^ ~ Due to (or as a wnsequence olj: Not pregnant, but pregnan143 days l0 1 year before death tl. ^ Unknown g pregnant within the past year 308. Was an ANOpsy 306. Were Autopsy Firstlings 31, Manner M Death 32a. Date of Injury (Month, day, year) 32b. Describe How Injury I)ccared :32c. Place of Injury: Home, Farm, Blreel, Factory, Pedormetl? available Prior to Complefan ^ OHice Buil6rg, etc. (Specfy) of Cause of Death? Natural Hanlcide rre~ff ^ Yes I~NO ^Ves ^ Ne ^ Acadenl ^ Pemdng Imesligmion 32d. Time of Injury 328. Iryury et Work? 321 II Transportelion Injury (Spenly) 32g. Location of injury (Street, city /town, state) ^ Suickfe ^ Coultl Not be Determined ^ Yes ^ No ^ Driw:r/Operator ^ Passenger ^ Pedestrian M Other -Specify: 33a. Cenilier (check ony are) • CMH l lel Ph h i i rtM i f 33b. Sgnelure a Tdlav`~f CerlAwr ~ ~~ ~'~ y rrp p ys ys sn ( c an ce y ng cause o death when another physkaen has praxwnced death end completed Item 23) To the best of my knowledge, r1Mh occumtl rice lathe cease(s) sntl manner as 6Wed _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S~(F ~ ~ VVV • Pronounclnp srM avtMyMg phyaklan (Physidan both pronouncing death end certifying to cause of aeemj To the beat of my knowledge, death occurred at me Ume, data end place, and due to the uwe(a) end manner es etated_ _ _ _ _ _ _ _ _ _ _ ^ 33c Lice${ \Number M \' J L~ 2~ y 7 33tl. Dale Sign~}(M`~n7th, d}ay~..Y~ LJ 2 U ~ ~ ~ Q / G ~ Metlkal Examiner/Comrwr • % -- . / On the bests of exsminMfon end / or Irneatlgation, In my oplnton, death mad el the lime, dale, snd place, end due to the cause(s) and manner ea Neted_ ^ 34. N erM.Adtlress of Person Who Canpl ed Cause of Death (Item 27(Type I Pnnl n ~ \~ C 35. Registrars Signature a put' Z ~ z / ate Filed (Month, day, year) 1 ~ \~ ~ ~ ( -~ ~~ ,~ ' C ' ~ 3/ z>~i ~M c~ ~ ~ ~o / C -~ L ~ Disposition Permit No. Q 51 ~ n ~I ~i . -~ ,',i !) `f 7 E~ ~~iacP~ ~ ~. ~ ,~ ~, _ _.~_, ,, - .. iJ _,.... - _ ~:' % _~_ I, MARTHA E. BLACK, of 9443 Upper Strasburg Road, Upper Strasburg, Franklin V County, Pennsylvania; being of sound mind and memory declare this to be my Last Will and Testament and revoke any will or codicil previously made by me. ITEM I: I direct that all my just debts and funeral expenses, including my gravemarker and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my decease as a part of the administration of my estate. ITEM II: I give, devise and bequeath all of my estate of every nature and wheresoever situate to my husband, GEORGE M. BLACK, providing he shall survive me by thirty (30) days. ITEM III: Should my husband, GEORGE M. BLACK predecease me or die on or ~ ~i~ ~ c~.lry~°rY ro>~~~ ~~ ~ ~~~ ~7l7J 53P-.Afp'6' before the thirtieth day following my death, I give, devise and bequeath all of my estate of every nature and wheresoever situate to my issue per stirpes in shares of equal value, share and share alike. ITEM IV: I appoint my husband, GEORGE M. BLACK executor of this, my Last Will and Testament. Should he fail to qualify or cease to act as executor, I appoint my son, i '' j; ~I . ,~~~ ,'_. ~ i i~ RICHARD ALLEN BLACK and my daughter, DECOKES JEAN GARMAN, co executors of this, my Last Will and Testament. ITEM V: I direct that my executor or his successor shall not be required to give bond for `the faithful performance of their duties in any jurisdiction. (i ! ~ IN WITNESS WHEREOF, I hereunto set my hand and seal to this my Last Will and A~S~ Testament, written on two (02) sheets of paper, dated this Z~ day of , 2000. (SEAL) ARTHA E. BLACK The preceding instrument, consisting of this and one (O1) other typewritten page, each identified by the signature of the testatrix, MARTHA E. BLACK, was on the day and date thereof signed, published and declared by MARTHA E. BLACK, the testatrix herein named, as and for her Last Will, in the presence of us, who, at her request, in her presence, and in the presence of each other, have subscribed our names as witnesses hereto. i. ~ residing at ! i! ~1(~ n~1C_- residing at t 2 . ,~j ~, ._, il' ' COMMONWEALTH OF PENNSYLVANIA SS ~ COUNTY OF CUMBERLAND L j i We, MARTHA E. BLACK, the testatrix in, and the undersigned witnesses to, the will, l the attached or foregoing instrument, who have signed the instrument, having been qualified ~ ~ according to law do depose and say: I ~ (a) that I, the testatrix, do hereby acknowledge that I signed the instrument as my will, that I signed it willingly and as my free and voluntary act for the purposes ., therein expressed; and (b) that we, the witnesses, were present and saw the testatrix sign and execute the instrument as her will, that she signed it willingly and executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testatrix signed the will as a witness and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. RTHA E. BLACK ;~ Q i ; Witness Witness -~ ~ ~ Subscribed to and subscribed or ~ ~ affirmed and acknowledged before me i by MARTHA E. BLACK, the testatrix 1 and the witnesses whose names are signed above this Z~, ,day of , 2000. ~; S ~- Notary P{lblic ~ Notarial Seal Sally J. Winder, Notary PuWto Shlppensburg Twp., 4umbsrland County My Cnmmissi~n Ex res Feb. 13, 2003 _ ~...__ .