Loading...
HomeMy WebLinkAbout01-17-12PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of Gary L Smith File Number 21-12 (~ ~"( p.~j also known as ,Deceased Social Security Number 194-40-4562 Adam Smith Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE A' or B' 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 and codicil(s) dated ~~? ' f" _.. ...~; -~ 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 tljvorce. proceeding g § (g); did not have a child born or ado t y e m of a kelinin and wasfne Broad ud cated anentca liacitated person, exce3t as fol ows: 3323 p ed; was not th victi , - _ 9, 1 P P P _;~:~ B. Grant of Letters of Administration (1/applicable, enter c.t.a.; d. b. n. c. t. a.; pedente life; durante absentia; durance 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: Name Relationship Residence Adam Smith Child 107 E Springville Road Boiling Springs, PA 17007 Jason Kirk Smith Child 3 Terri Drive C it 1 Tyrone Dee Smith Child 684 N. Middle Road wvi PA 7241 (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 684 N Middle Road Newville Cumberland PA (List street address, town/city, township, county, state, zip code) Decedent, then ~~ years of age, died on 01/01/2012 at Hershey PA Decedent at death owned property with estimated values as follows: (If domiciled in PA) (If not domiciled in PA) (If not domiciled in PA) Value of real estate in Pennsylvania All personal property Personal property in Pennsylvania Personal property in County situated as follows: 684 N Middle Road, Newville, PA $ 363,000.00 g 137,000.00 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: :~- Form RW-~2 Rev. 12-26-2010 (interim form, gentling action by the Court) Copyright (c) 2006 form software only The Lackner Group, Inc. Page 1 of 2 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. / ~ ,-7 ~/~ ~~ Sworn to or affirmed and subscribed Representative Adam Smith before me this ~'? day of ~~~ ~') ~ ~ j~ Signature of Personal Representative ~y Signature of Personal Representative ;, -. For the~ftegister _., __.. File Number: 21-12 - (S(j (p- ~j } _ , ~., ~ ; Estate of Gary L Smith ,Deceased --, 4 Social Seccurity Number: 194-40-4562 ~,~ ~ Date of Death: 01/01/2012 AND NOW, JC~-~ ~ ~ -~ 1 r' _~_V__L s , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters of Administration are hereby granted to Adam Smi h in the above estate and that the instrument(s) dated described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. FEES Letters ...................................._.... $ ~,~~ . /~~lJ Short Certificate(s)......... L,f......... $ ~ ~ • V V r Renunciation(s)......~ .................. $ ~~J. (~_ ~t~CS $ 3 ~~ $ $ $ $ $ TOTAL ................................... $ (.~~ ~ , ~~ ~~ ~r- Supreme Court I.D. No.: 78931 Address: 55 W. Church Avenue Carlisle, PA Telephone: 717-241-6500 Form f~W U2 Rev. 10-13-2006 Copyright (c) 2006 form software only The Lackner Group. Inc. Page 2 of 2 Attorney Signature: Attorney Name: Mark A. Mateyo H705.805 REV 19/I l l Fee for this certificate, $b.©© ~ ! , ~ ~ _ This is to certify tFu)l tl~ie information here given is correctly copied fmm a(7 original Cerk.ificate of Death ~~ _, ,,~ duly filed with me a, Local Registrar. The original ~~ ( , ;~.T c<.rtificate will he 'onvarded _ to the State Vital ~'t~" Records Office for f, ~alnent filing. (,~ , , i P 1~1~C1E7~__ a ~ ~3~1_a- ert~fication Number Local Registrar Uate Issued Type/Print In COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS Permanent f"FQTg Cgf"ATC AC gICATY ZZ 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number>~ N4. Date of Death (MO/Day/Yr) (Spell Mo) Gar L. Smith Male 194-40-4562 Januar 1 2 12 Ss. Age-Cart Birthday (Yrs) Sb. Under 1 Yaar Sc. Vnder 1 Da 6. Data of Birth (MO Day/Year) (Spell Month 7a. Birthplace (city and Stab or Foreign Country) Months Days Hours Minutes j-tC ur h PA June 6 1949 7b. BlKhplau (County) ga. Rssidanu (Stab or Foreign Country) Bb. Residanu (StrasL and Number -Include Apt No.) ec. Did Deesdsnt Live In a Township? Penns lvania 703 L y ouis Ln . ®v.t, decedent Ily.d In Hamvden ty~p sd. Realdence (co~nLy) Cumberland Be. Residence (21p Cods) )ENO, decadent INed within limits of city/boro. 9. Ever In US Armed Forus7 10. Marital SLatua at Time of Daeth ~ Married ~ WI owed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) Q Yss ® No Q Unknown Q DNOrced ~ Never Married Q Vnkno w 12. FatheYS Name (First, Middle, Last, Suffix) 13. MotheYS Name Prior to Firsi MarNage (First, Middle, Last) K-rk E Sm- 14a. Informant's Nama 14b. Relatlonshlp to Deesdsnt 14c. IMormant's Malling Address (S<raet and Number, Clty, State, Zip Code) 170^-y Adam C S i h _ m t Son 107 E_ S tin villa Rd.Boilin S tin s yY.'(F(l a~ ...............°---.-...................-----°........• ........°-°---...............-•------.. ...........~_.. 'c•.9.....:SE... one _ _ H Death Occurred In a HatPital: IRI In ... Vic.. on.Y ..................................... ................................... ................................... patient ~If Death Occurred Somewhere Other Than a Hospital: ~i Hospice Facility ~ Decedent's H 25 ome Emer enry Room/Out anent peed on Arrival Nursin Homa/LOn -Tenn Carc Facility Other (Specify) lSb. Facility Name (N not institution, give rtrest and number; lSC. City or Town, State, and 21p Code SSd. County of Death ~ M.S. Harshe Medical Center Hershe Pa. 17033 Dau hin 16a. MaMOd of Dlsposltlon Burial Cremation 16 b. Date of Dlsposltlon 16c. Platt of Dlsposltlon (Nama of cemebry, crematory, or other place) Removal hom Sbta ~ Donation Other (Specify) 1/3/2012 Bitner Crematory, LLC 16d. Lorstlon of Dlsposltlon (City or Town, State, and 21p) 17a. Slgnatura of Funs 1 e Vesnsse or Person in Charge of Interment 17b. License Number Harrisbur PA 17110 g, FD-014404-L 17c. Name and Complete Address of Funeral Facility Hetrick Cremation Services ~' 1g. Deudsnt'a Education -Check the box Chat bast describes the 19. Decedent o} Hispanic Drlgin -Cheek iM 20. Decedent's Race -Check ONE OR MORE races to indicate what highest degree or level of school complebd at the time of death. box that best describes whether the decadent Me deudsnt considered himself or herseM to ba . ~ 8th grade or leu Ia Spanlah/Hlapanl4Latlno. Check the "NO" a] Whi<e Q Korean Q No diploma, 9th - 12th grads box If decedent Is no[ Spanish/Hispanic/Latino. 0 Black or Afrlun American Q Vietnamese 0 High school gradueb or GED completed )gJ No, not Spanish/Hlspanl4Latlno Q Amsrlun Indian or Alaska Native ~ Other Asian ~ Some college credit, but no degree ~ Yes, Mexican, Mezlean Amerieari, Chicano Q Asian Indian Q Natlva Hawaiian ~ Associate degree (e.g. AA, AS) ~ Yes, Puerto Rican hl s O e ~ Guamanian or Chamorro ' F 'n o Q Bachelor s degree (s.g. BA, AB, BS) Q yea, Cuban ' O a Mas<sr s degree (s.g. MA, MS, MEng, MEd, MSW, MBA) ~ Vet, other Spanish/Hlspanic/Latinp Ja fy~ Q P nose ~ Other Peciflc Islander LJ D OCCOr1Le (e.g. Ph O, Ed D) or Professional degree (Specify) Q Other (Specify) . MD DDS OVM LLB JD 21. Deudent'a Single Rate Salf-Designation -Check ONLY ONE to Indicate what the decedent considered himself or hanalf to be. 22a. Decedent's Usual Occupation'- Indicate type of Work Whlb Q la Panese Q Samoan done during most of working life. DO NOT USE RETIRED. Black or Afrlun American ~ Korean Q Other P lfl I l d ac c s an er 0 Amsrlun Indian or Alaska Native ~ V{stnamese Q Don't Know/Not Surs 0 Allan Indian Q Other Allan Q Refused 22b. Kind of Business/Industry Q Chinese ~ Natlva Hawaiian ~ Other (Specify) Q FIIIPino O GuamanianorChemorro Federal Dept of Defense ITEMS 28a - MV T BE C MPLETED 23a. Data Pronounced Daatl Mo Day r 2 . Slgnatura O Person Pronouncing Death (Only when appilca Is 23c. Lfcense Number BY PERSON WHO PRONOVNCES OR 0, ) O ~ / ~~ CERTIf1E5 DEATH 23d. Dets Signed (MO/Dey/Yr) 24. Tima~f DsaL^ ~ t~ L• 3 25. Was Medlin Examiner or Coroner Conbctsd7 ~ Yes No CAlJSE OF DEATH Approxima[e 26. Part 1. Enter the chain of events--diseases, Injuries, or complications-that dlrerSly caufed the death. DO NOT enter brminal events such as cardiac arrest In[erval: . respiratory arrest, or ventricular flbrlllatlon with~out s bowing She etiology. DO NOT ABBREVIATE. Enbr only one cause on a line. Add additional Tines if necessary ? Onset to Death ~ / IMMEDIATE CAUSE ----___> ~~+C~p,~~ '~~i ~ ~ ~~C , (Final dlseaM or condltlon Due to (or ea • consequence f): resulting In death) b L wrv G ~) Grer'L, Sequsn<lelly Iitt conditions, Due to (o as a consequence of): if any, leading to the cause listed on Ilne a. Enter the UNDERLYING UUSE Due to (or as a cones quanta ofl: ~ (disease or Injury that F Initiated the events resulting d. In death) LAST . Due to (o as a consequence of): 26. Part 11. Enter other slsniflcant conditl t ib i t d h but not resulting in the underlying cause given In PaK I 27. Wsa an autopsypsrformedl m P ~ • /~ . ~ . .~~ Yes No ice/ ~ l~J~~+~ 28. Wars autoPay flndln iladle gs ava $$$ to wmplate the cause of deathT 29. If Femels: ~ Yes ~ No 30. Did Tobacco Us Contribute to Death? 31. Manner of Death Q Not ^~^ nant wthin past year Q Yss `~ Jdrob bl ' . a Y m Natural 0 Homicide ~ Preg t aL time of death Q Unknown ~ No ~ Accident ~ ~ Pending InvesHgatlon Q Not prcgnanL, but Pregnant within 42 days of death ~ ~ Not pregnant, but pregnant 43 days to 1 year before death 32. Data of In u Mo Da /Yr 5 ~ Suicide Q Could not ba determined J ry ( / Y ) ( Pell Month) Q Unknown if pregnant within the past year 33. Time of Injury 34. Place of Injury (e.g. home; construction alb; farm; school) 35. Coca<lon of Injury (Street and Number, City, State, Zip Code) 36. Injury a< Work 37. if TranaDOrtation Injury, Specify: 3g. Describe How Injury Occurred: Q Yes 0 Driver/Operator Q Pedestrian O No ~ Passenger 0 Other (Spe<Hy) 39a. CeKMer (Check only one): ~ Certifying physician - To the bast of my knowledge, death occurred due to the ca as(s) and manner stated m Pronouncing Sr Certl/ying physic To LM beat of my knowledge, death occurred at the time, data, and place, and due to the cause(s) and manner stated O M di i E i a ca zam ner/Coroner - t eels of examinaHOn, and/or InvesHgatlon, in my opinion, d e ath o ccurratl at tM time, data, and place, antl due to th e cause(s) and manner stated B A g ~ _ ` Signature of ceKHler: ~ Title of ceK111er:~ ` t__) LI<ense N b O_ \ ~ 1 9 S ~I o um er: ~ 39b. NamO ~~ress aSnd 21p Code of Pe2on Completing Gus. oT ~~'f(~i~'~ Medical Cente 17033 39c. Data Signed (MO/Day/yr) ershe Pa , y, . O 1 o Z/ 1 "z 40. Registrar s District Num 41 R at r s 5 -a -a= a ,~-- . 42. Registrar FI a Dab Mo Day r 43. Amsndm nts i- ,LOCAL ~i~?GISTRAR'S CERTIFICATION OF DEATH - WARNING: ~ is illegal to duplicate this copy by photostat or photograph. O 7 ~/ /~~ H 305-143 Dlsposltlon Psrmlt No. J REV 07/2011 RENUNCIATION REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of Gary LSmith -~ ,Deceased :;-~ - : ~~ I . _._ ::-, _. , 1, Tyrone Dee Smith in my capacity/relationship as nn e Child of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Adam Smith (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills Form RW-06 Rey ~o-~3-zoos i Tyrone Dee Smith 684 N. Middle Road (Street Address) Newville, PA 17241 (City, State, Zip) Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the ren iation for the purposes stated within on this~day o ~0/a-. l~t~/ (~ . V~U:v~t.L~.E.~ Notary Public My Commission Expires: (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) CQ~'iMONWEALTH OF PENNSYLVANIA Notarial Seal ~ranaG, A. Aumiller, Notary PubUc South "7 .g/ti^ton "i~,vp., Cumberland County MY ~:al"~.o~ ?-sion i=xpires March 16, 2014 Copyright (c) 2006 form software on~~l"-&ek+~l'Gi. ice, ltld ~.~~cxa'ation of Notaries RENUNCIATION REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of Gary L Smith ,.~ ,Deceased __~ .-~ - ..a ~~ Jason Kirk Smith in my capacity/relationship as ,. , nn ame , Child of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Adam Smith ~~ (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills Form RW-06 Rey ~o-as-zoos (Signs e) Jas Kirk Smi 3 Terri Drive (Street Address) Carlisle 17015 (Gty, State, Zip) Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the ren,~aciation for the purposes stated within on this ~ day o~ ,2t~1~ Q- Notary Public My Commission Expires: (Signature and seal of Notary or other offiGal qualified to administer oaths. Show date of expiration of Notary's commission.) COMNlONWE4ETH OF PE(d~ISYLVANIA r-._ ___ Nntarlal Seal F r3r, s•~ A, ,~stm?Pier, Notan/ Public South v;ad~e*er +Mp.: Cumberland County ~y ~~orr;n~tssir:,. ?.?c~iirPS March 16, 2014 Copyright (c) 2006 form software only T9h ~ LacknereG croup Inc ~~ ~~'~' ?c'iatfCO Cf NCtarle5