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HomeMy WebLinkAbout01-11-12Reset PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF ~Gl,/-'J B~~„f f~-~/D COUNTY, PENNSYLVANIA Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters as specified below, and in support thereof aver(s) the following and respectfully request(s) the grant of Letters in the appropriate form: Decedent's Information Name: ~ L~ ~ File No: ~ ~ ~ ~ - a~~ a/k/a: (Assigned by Register) a/k/a: ~. y "3gf.2 a/k/a: Social Security No: ~~~ Date of Death: (~ / - ~6 - Old Age at death: ¢~ ~ Decedent was domiciled at death in ~~UM~~[~v~ County, 1'h- (state) with his/her last principal residence at . f 9 ~~ C ML-:_ST7G~UT . C~9M P/~/~L . , l~?tYf Cty`-~18EeCCA.(/.Z~ [,/~/ G/ ~~~~r Street address, Poat Office an~d/Zip Code C ,Township or Sorosgh County Decedent deed at O~p%T,~4'L, ~Q3 /~6271a ~ ~ ~ ~~ AMP /~- CLL~Il~~i~}it/,D. Street address, Post O[fice and lip Code City, Township or Borough County at Estimate of value of decedent's property at death: q If domiciled in Pennsylvania ............................ All personal property $ C/~, ~ er[~''/ If not donrieiled in Pennsylvania ........................ Personal property in Pennsylvania $ If not donviciled in Pen»sylvania ........................ Personal property in Cou~y $ Valve of real estate in Pennsylvania ......................................................... $ ( ~ Q7 ~y TOTAL ESTIMATED VALUE.... $ Real estate in Pennsylvania situated at; ~ l~~ ~./~F~T~LIT STi~~T C/d~--A ~~~`~ /~/~ ~U./~'1~ ~~ (Attach additional sheets, ifnecessary.) Street address, Post Ofru:e and lip Code City, Tow~hip or Borough County ~A. Petition for Probate and Grant of Letters Testamentary _ Petitioner(s) aver(s) he/shelthey is/are the Executor(s) named in the last W ill of the Decedent, dated ~ -- ~ 9 ~?-orl and Codicil(s) thereto dated State rdevaot dreumstauces (ug. rewranatiow, deeNk of execrtor, eta) Except as follows: after the execution of the instruments) offered for probate Decedent did not marry, was not divorced, was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g}, and did not have a child born or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. NO EXCEPTIONS ©EXCEPTIONS ^ B. Petition for Grant of Letters of Administration (lfapplicable) c.t.a., d.b.n., d.b.n.c.t.a., pendente Cite, durance absentia, durance minoritate if Administration, Gta. or db.n.~ta., enter date of Will in Section A above and complete list of heirs. Except as follows; Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g) and was neither the victim of a killing nor ever adjudicated an incapacitated person. O NO EXCEPTIONS ©EXCEPTIONS Petitioner{s), after a proper search has/have ascertained that Decedent left no W Ill and was survived by the following spouse (if any) and heirs (attach additional sheets, if necessary): Nance Retatioashi Address C J r...;~ _ :. ~ _~ _ - ;-~ ` ~ ~' m _._ ..ter .. - --1 ~ .:~~ ~. i~~-i CT ``~' ~ -~ Form RW-02 rev. IGVII/2011 Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA ', ~j~ ~~ /~ ; SS. COUNTY O F ~_~.~~~~~G.~~7/'N1~ Official Use Only - -- ~.. ,, Petitioner(s) Printed Name Petitioner(s) Printed Address J i 1, ~ ~~.-! ~~ ~ - 7 ,/ C '~~ ~ ~ ~l°1 ~ L~ l11 i __ ~ G'1,R The Petitioner(s) above-named swear(s) or affirm{s) the statements in the foregoing Petition true and correct to the best. of the knowledge and belief of Petitioner(s) and that, as Personal Representative{s) of the Decedent, the Pet' ioner{s) 1 w 11 and truly administer the estate according to w. Sworn to or affirmed and subscribed before Date m ~ //' 2 ~/?r me this ~ Y tray of ~ l.~`~_~' ,~~~ /~ Date By: r ~ ~ (,~j 7 Date For the Register Date BOND Required: Q YES ~ NO FEES: "' 1 Letters ............... . . . .... $ ~ ~ , ,-. {~~(~~ )Short Certificate{s)...... ~ ,~(':; . C~L° ( ) Renunciatian(s)_....... . ( )Codicil{s) . ........... . ( )Affidavit{s)...... _ .... . Bond..--•----• .............. Commission ................. . Other Automation Fee ............... !~ ~ ;~~ JCS Fee . .................... -~~. =7 TOTAL---•-----•----...---- $ ~ ~ ~ To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature: Printed Name: Supreme Court ID Number: Firm Name: Address: Phone: Fax: Email: DECREE OF THE REGISTER Estate of !'~~G~-t~'~ 1~7~7~?~~~ ~~~ / /F 7 a/k/a: File No• _~ ~ ~ ~ ~, ~-~ ~ ~ ~"~ AND NOW,.. ~~ .~'' }, ' ~ ~ ~~ , ~~1 ~ , in consideration of the foregoing Petition, satisfactory proof having been present d before me, 1T IS DECREED that Letters ~~-~ ~ }C~yy~;~ ~`1 ~C~,'~'Ll are hereby granted to L,t ,! , ~ t <<.t ~~ti i ~~~ l~~~ ~1~~~ . in the above estate and (if applicable) that the instrument(s) dated i described in the Petition be Form RW-ll2 rev. IO,~IIh011 -,-~-~ to probate and filed ofrecord as the last Will (and Codicil(s)} of Decedent. l' r Register of Wills ~ ~ ~ ~~ r ~~ ~ ~~~~~~~ ~ ~ ~ (~' . ~ Page 2 of 2 ~- _ c orb' n -~ LOCAL I~'IS'~'R~ CERTIFICATION OF DEATH WARNING: ~_-iS~illegal to`, i~~~licate this copy by photostat or photograph. Fee for this certificate, $6.00 P 17928140 Certification Number i ~ t ~ ~ ~ This is to certify that the information here given is correctly copied from an original Certificate of Death ~~ ~~~ ~i; duly filed with me as Local Registrar. The original r rl ~ -' ,, certificate will be forwarded to the State Vital ~~'~~~~~ ~ `'"`'~~~ Records Office for ermanent film /~~2~ ~ ~ ~ A ~ ~ ~ ~~2 _ _ _ .Local Registrar Date Issued COMMONWEALTH OF PENNSYLVANIA • DEPA0.TM ENT OF HEALTH VITAL RECORDS f"C ~T~C~f ATC f1G ~ Type/Print In Permanent ~_ - - - -- - - - State File Number: 1.,Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Yr) (Spell Mo) v~LL Robert H. Petry Male 168 - 24 - 3912 January 6, 2012 __ Sa_Age-Last Blrthd~(Yrs 6b. n Ye Under 1 Da 6. Date of Birth (MO/Day/Year) (Spell Month) 7a. Birthplace (City and State or Foreign Country) Months Days Hours Minutes Warren, PA 86 August 1, 1925 7b. Birthplace (County) [„Tgi-ren 8a. Residence (State or Foreign Country) Pen a lvania Bb. Residence (Street and Number -Include Apt No.) Hc. Did Decedent Llye In a Township? --3956 Chestnut Street Oyes, decedent lived in LyyP Sd. Resl County) n Cumberland 8e. Residence (Zip Code) 17 01 1 ~ No decedent Iiyed within limits of Camp Hi11 , City/bore 9. Ever In US Armed Forces? 30. Marital Status at Time of Death 0 Married ® Widowed 11 Su rv(ying Spouse's Name (If wif i . e, g ve name prior to first marriage) (~ Yes Q No ~ Unknown ~ Divorced Q Never Married ~ Unknow 12. Father's Name (First, Middle, Last, SufFlx) 13. Mother's Name Prior to First Marriage (First, Middle Last) , Howard Kistler Petry, MD Marion Hughes 14a. Infprmant's Name 14b Relationshi t D d ' . p o ece ent Willi S 14c. Informant s Malling Address (Street and Number, City, State, Zip Code) o G am _ Petry Son 4 Stephen Terrace, Camp H311, PA 17011 -.-----... ........................................ .....-...................-----........,.... - a ate p eat et qn y qne _ _ If Death Occurred in a Hos ital~ In ••••~•~~~~--•-••••- --•-••--------•• .................... .- P - patient wt•+rr If D h • ~ -, -- ---,--- ---,• ; eat Occurred Somewhere Other Than a Hos ital~ - "' P u Hospice Fatlllty ~' Decedent's Home m.r E en R O t _ g cy oom/ u patient ~ Dead on Arrlyal Nursing Home/Long-Term Care Facility Other (Specify) 15b F ili f • . ac ty Name (I not institution, gWe street and number) 15c. City or Town, State, and Zlp Code lSd. County of Death Hol S irit Hoa ital E. Pennsboro Twp PA 17011 Cumberland I6a. Method of Disposition Burlsl 0 Cremation 16b. Dste of Disposition 16c. Place of Disposition (Name of cemete c mat ry, ory, or other place) O Remoyai from State p Donation Januar 13, Rolling Green Cemetery Other (S if pec y) 2 O 1 16d. Location of Disposition (City or Town, State, and Zip) 17a. Signature of Fu al Servic see or Person in Charge of Interment 17D. License Number Lower Allen Twp. PA 17011 n FD 013 340 L 17c. Name and Complete Address of Funeral Facility ' ° Parthemore FH Sr CS, Inc., P.O. Box 431, New Cumberland, PA 17070 m 18. Decedent's Education -Check the box that best describes the 19. Decadent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR M I- ORE races to Indicate what highest degree or level of school completed at the time of death. box that best describes whether the decedent thejj~tecedent considered himself or herself to be. Q 8th grade or less I S i h " " ' s pan a /Hispa nlc/La[Ino. Check the NO ~ W hlte ~ Korean 0 No diploma, 9th - 12th grade .b~o~xCJf decedenS Is not Spanish/Hispanic/Latino. 0 Black or African American ~ Vlefnam¢se Q Hi h sch l d t g oo gra ua e or GED completed pg ~JO, not Spanish/Hispanl</Latino 0 American Indian pr Alaska Native 0 Other Asian ~ Some college credit, but no degree 0 Ves, Mexican, Mexican American, Chicano Q Asian Indian ~ Native H ii awa an Associate degree (e.g. AA, AS) Q Ves, Puerto Rican Q Chinese 0 G i ' uaman an or Cha morro Bachelor s degree (e.g. BA, AB, BS) Q Ves, Cuban ~ Filipino ~ S ' amoan Q Master s degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Ves, other Spanish/Hispanic/Latino ~ Japanese ~ Oth P ifi l er ac c Is ander Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) ~ Other (S if pec y) . MD DDS DVM LLB JD 21. Dess tlent's Single Race Self-Oeslgnation -Check ONLY ONE to Indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation -Indi t t f ' ca e ype o work White 0 Japanese 0 Samoan done dur{n t f k g mos o wor ing Ilfe. DO NOT USE RETIRED. ~ Black or African AmeHCan ~ Kprean O Other PaciFlc Islander D American lndlan or Alaska Native O Vietnamese O Don'[Know/Not Sure Ow11er/Operator ~ Asian Indian ~ Other Asian ~ Refused 22 b Kt d f . n o Business/Industry ~ Chinese 0 Native Hawaiian Q Other (Specify) _ p Flllplnp O Guamanian or cnamprrp Retail Auto Parts ITEMS 23s - 23tl MVST BE COMPLETED 23a. Date Pronounced Dead (MO Day r) 23 b. Signature of Person Pronouncing Deat Only when applicable 23c BV PERSON WHO PRONOUNCE Lic n N b . e se um er S OR / ' , ^ t ~ O / ~~ ~, ~j/ r f, /,~ f ~7 f•~ 23d TDaEe Sgn d ( M O/Day/Yr) 24. Times of Dea th •_ ~ ' \ ' ~r ~~ / ~~ J ( ,, p O t `~ ' ~ ' VN' 25 W M d l . { as e ica Examiner or Coroner Contacted? Q Yes No CAUSE OF DEATH Approximate 26. Part 1. Enter the chain of events--diseases, InJurles, or compllcatlons--that directly caused the death DO NOT ent t i l . er erm na events such as cardiac arrest Interval: respiratory arrest, or yentr(cular fibrillation w i thout sho Ing he etl I gy. DO OT ABBREVIAT Enter only one cause on a Ilne. Add additional Ilnes If necessary Onset to Death ~ ~ ~j ~ ~ y IMMEDIATE CAUSE --------------> _ ~j ,LQ/ ~ ~ ~a ~"~p i.. (Final disease pr condiHO^ Due to (o quen of): res Ulting In death) b. Sequentially list condltlpns, Due to (or as a consequence of): If any, leading io the cause listed on line a. Enter the UNDERLYING CAVSE Due to (o as a consequence of): (disease or InJury that initiated the events resulting d. In death) LAST. Due to (or as a consequence of): 26. Part 11. Enter other sia Ifl t ditto ntrib tl i d h but not resulting in the Underlying cause given In Part I 1` 27. Was an autopsy Perfo~rjL~d7 D Ves ~Np 28. Were autopsy Flndings available ~ plete the cause of deaths 29. If Female: to coo Yes ~o S 30. Did Tyb a co Use Contribute to Death? 31. Mau er of Death ~ Not pregnant within past year Vas c Q Probabl ry ~ y ® atu rat Homicide ~ Pregnant at time of death 0 No ~ Unknown ~ id O A t- cc ent ~ Pending Imestlgation ~ Not pregnant, but pregnant within 42 days of death )~ Not pregnant, but pregnant 43 days to 1 year before death 32. Date of In O Suicide ~ Could not be determined jury (MO/Day/Yr) (S ell Month) p Q Unknown If pregnant within She past year 33. Time of Injury 34. Place of InJury (e.g. home; cons<ruttion site; farm; school) 35. Location of Injury (Street and Number, City, State, Zip Code) 36. Injury a[ Work 37. If Transportation Injury, Specify: 3B. Describe How Injury Occurred: Q Ves ~ Drlyer/Operator ~ Pedestrian Q No Q Passenger Q Other (Specify) 39a. C er (Check only one): Certifying physician - To the bes of my knowledge, Bath occurred due to the cause(s) and m tested ~ Pronouncing $ Certifying p an - To th my knowledge, death occurred at the time, d ce sand place, and due to the cause(s) and m -stated O Medical Examiner/(:Or n h r O - t e tlon, a /or Inyesttgatlon, in my opinion, death oc ( red at the time, date, and place, and due cy5 [o th ( ) d ~ate d // ~ ~~ // ~/ ~~~ ) Signature of certifier: Title of certifler~ ~jCJ' Ucense N b ~ LJ ~ ~O um er: . ((/ 39 e, Addr sand c~f Person Com Ieting Cause of Death (Item 26) ~ 39c. D 51 ~d ( /~at,/yr) ~ - /~ ~ Y r 7 -`" ~t s t ' 40. Registrar s District Number 41. Registrar's Signature 42. Registrar file Date (MO Day r) ~i a ~ ~ o--- ~/mod/~o~1. 43. Amendments ,., ,_ Disposit(on Permit No. CP /[ J f ~ Z H105-143 REV 07/2011 ~~~~ ~n~~ ~,~na~ ~~~~,~n~nn~ OF ROBERT H.PETRY r~ _~ -~ T.'.7 _.. L.. `-..1 -:r- ~_,._ `l.'~~ ~'t _ _i.) ~,-7 t' I, ROBERT H. PETRY, of the Borough of Camp Hill, Cumberland County, Pennsylvania, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time made. ITEM I: I direct that all inheritance and estate taxes becoming due by reason of my death, whether payable by my estate or by any recipient of any property, shall be paid by the Executor out of the residue of my estate, as an expense and cost of administration of my estate. The Executor shall have no duty or obligation to obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other property not passing under this Will. ITEM II: I direct the Executor to pay the expenses of my last illness and funeral expenses from the residue of my estate as an expense and cost of administration of my estate. ITEM III: I give to my children living at the time of my death all of my household furniture and furnishings, books, pictures, jewelry, silverware, automobiles, wearing apparel and all other articles of household or personal use or adornment and all policies of insurance thereon, to be divided among them as they shall agree. Should there be no agreement, the Executor shall divide this property among them in as nearly equal portions as the Executor, in the sole discretion of the Executor, deems appropriate, having due regard to the personal preferences of my children. ,.,.wa ~:~. ~ ~:~~ f-7 Page 1 ' ITEM IV: I give, devise and bequeath all the rest, residue and remainder of my estate, not disposed of in the preceding portions of this Will, to my children, in equal shares. If any of my children is not living at my death, the share of such deceased child shall be paid to his or her issue, per stirpes. ITEM V: In addition to powers given by law, the Executor shall have the following discretionary powers: (a) To retain any property received by the Executor; (b) To sell real estate, publicly or privately, for prices and on terms as the Executor deems proper, without liability to the purchasers to see to application of the purchase moneys; (c) To compromise controversies; (d) To distribute income or principal in cash or in kind, or partly in each, at fair market value at the time of each distribution; (e) to hold investments in the name of a nominee; (f) To borrow money from any person, including the Executor, to pay indebtedness of mine, or of my estate, expenses of administration or inheritance, legacy, estate and other taxes, and to assign and pledge assets of my estate; and (g) To undertake all other acts in the Executor's judgment deemed necessary for the administration and settlement of my estate. c~ Page 2 ~~ ITEM VI: Any person who has died within thirty (30) days of my death, or under such circumstances that the order of our deaths cannot be established by proof, shall be deemed to have predeceased me. Any person (other than myself? who has died at the same time as any then beneficiary under this Will or in a common disaster with that beneficiary, or under such circumstances that the order of deaths cannot be established by proof; shall be deemed to have predeceased that beneficiary. ITEM VII: I appoint my son, WILLIAM S. PETRY, to be the Executor. In the event of his death, inability or refusal to serve, I appoint my daughter, PATRICIA ANN PETRY, to be the Executrix, referred to in this Will as "Executor". In the event of her death, inability or refusal to serve, I appoint my son, DAVID H. PETRY, to be the Executor. The Executor is specifically relieved from the obligation of filing bond or entering security. IN WITNESS WHEREOF, I have set my hand and seal to this, my Last Will and Testament, consisting of this and the preceding two (2) pages, at the end of each page of which I have also set my initial for greater security and better identification this .,~. day of , 2011. (SEAL) Page 3 n ~~ We, the undersigned, hereby certify that the foregoing Will was signed, sealed, published and declared by the above-named Testator as and for his Last Will and Testament, in the presence of us, who, at his request and in his presence and in the presence of each other, have hereunto set our hands and seals the day and year first above written, and we certify that at the time of the execution thereof, the said Testator was of sound and disposing mind and memory. /~zU ( ~~ , t ' J. AL) .- Residing at ~~ ~ S ~ ~~ Residing at 1crf ~-~' 4- . ~' (SEAL) Residing at sue-. ~-~.E.e- ~~- Page 4 539684v1 c~ -~., OATH OF SUBSCRIBING WITNESS(ES) }~-° _ C ~ _.._ ~- - __ ..., f-r-~ ..., ._ REGISTER OF WILLS = _ -- " ?~ CUMBERLAND COUNTY, PENNSYLVANIA .. .. `( . Estate of ROBERT H. PETRY ,Deceased Howell C. Mette (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 ) (Signature) 205 North 26~' Street (Street Address) (Street Address) Cam, Hill, PA 17011 (City, State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of , (City, State, Zip) Executed out of Register's Office Sworn to or affirmed and subscribed before me this ~ ~ day of ~~ N.r.~~~,,~. , 2012 in Dauphin County, Pennsylvania. C';)f`~~MC~N'ilir~=A1.?''i t?a= PEhE4SXLVA!`3~A ~ -/ ~ ` ~~' ~y-~------ Deputy for Register f Will~~~., ~ ~rocnn~s, ~otaryPUblic No Public ~`, S ~a;.er lr n n r, t2 .~ ~n r;orsnty r L rn,~ ~~ ~ ~ F .~ iz, zo~4 My Commission Expires: o~ _j a- ! y r ~ ri ~„rao ,~,oc~a o , o~ iVotrtries (Signature and Seal of Notary or other official quai~fied 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 copy of instrument(s) at time of notarization. 549979v1 Form RW-03 rev. 10.13.06 OATH OF SUBSCRIBING WITNESS(ES) ~ ~ .' ...~ ~: <~ _ ; ~~~ ~n _. REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA ~ ~~' `~ _, , ._ ~~, ~~; ~~., Estate of ROBERT H. PETRY ,Deceased Robert Moore (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 / 6e /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. (Signature) 414 Carol Street (Street Address) New Cumberland, PA 17070 (City, State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of _ (Signature) (Street Address) (City, State, Zip) Executed out of Register's Office Sworn to or affirmed and subscribed before me this ~ ~ day of /a~-t~--a-,,~ , 2012 in Dauphin County, Pennsylvania. Deputy for Register of Willg~t~~ ~r~r -~~~ _, € `'~~ ~'~~'"'~xL`~~r~lza ~~~~J ~Z . ~~"~0~- s,^t;,r : ~~~ ~ Not Public lob;, ~ r ,nth ,rs tary Public My Commission Expires: ~ -~~ -~ ~ 5~"'~ ~`'"''r~r' ~I'' ~~~' rn;"~ :'n~nty (Signature and Seal of Notary or other official qualified to t,~y t ~~rn,, ~ ~ 4r E~:7! Ys Feu. 12, 2014 j,y~ , , i;•,r~n J ran~~ ssociation o.' lVOtaries 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 copy of instrument(s) at time of notazization. 549980v1 Form RW-03 rev. 10.13.06