HomeMy WebLinkAbout01-18-12PETITI FO-,R~ j-G~~RANT O LETTERS
REGISTER OF WILLS OF ~~1°~C ~~(.~'7~ COUNTY PENNSY
LVANIA
Petitioner(s) named below, who is; are 18 years of age or older, apply(ies) for Lc;tters 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 Infor ation
Name• (' ~1 ~~ 1
a/k/a: '
a/k/a:
a/k/a:
Date of Death•
Decedent was domiciled a death in ~~~!•' ~''~ County
principal residence at (o t ~ -~p~b~ ,~
File No: ~ ~ ~~~ j
~~
(Assigned by Register)
Social Security No: 1 ~ - °~' ~-~~- ~ Q
Age a~eath
with
Str et address, Post Office and Zi Code c
Decedent died at ~~ ~ (fit ~~.(~~ "~ .~...~ city, To nship~lr~B~rough
Street address, Post Office and Zip Code City, Township ar Borough County
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania ............................ All personal property $ ~ J~ ay ~
If not domiciled in Pennsy!vania ........................ Personal property in Pennsylvania $
If not domiciled in Pennsyh~ania ........................ Personal property in County $
Value of real estate in Pennsylvania ......................................................... $
/~ ~ TOTAL ESTIMATE VALUE.... $
ter tas
County
i
State
Real estate in Pennsylvania situated at: ~ `~~° ~--~s-l~ ~Gt 1~e7 ~ ~~'~'~e7~
(Attach additional sheets, ifnecessary.) Street address, Post Office and Zip Cod City, Township or Borough Count
Y
A. Petition for Probate and Grant of Letters Testamentary ~~~ /~ %,~
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated _~=--~--(=~... and Codicil(s)
thereto dated
State relevant circumstances (e.g. renunciation, death ojexecutor, etc.)
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not many, 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
do fed; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
O EXCEPTIONS ^ EXCEPTIONS
^ B. Petition for Grant of Letters of Administration (Ifapplicable)
c.t.u., d.b.n., d.b.n.c.t.u., pendente life, durunte absentia, durante minoritute
If Administration, c.t.a. or d.b.n.c.t.a., 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.
^NO EXCEPTIONS ^ EXCEPTIONS
Petitioner(s), after a proper search has/}tave ascertained that Decedent left no Will and was survived by the following spouse (ifany) and heirs (attach
additional sheets, i/'necessary):
Fnrm RW-t)1 ,~~~, lnillizntl Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
COUNTY OF ~~~~~C/[J`-~ t.~' 1 } SS:
Petitioner(s) Printed Name titionar(s) rintrd ~+alcires~~ ~ ' ~ ~ ~y=7>~.
Letters ...................... $-le~_
( !~ )Short Certificate(s)...... - l - _
~~_
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are true and correct to the best of the knowledge and belief
of Petiticner(s) and that, as Personal Representative(s) of the Decedent, the etitioger(s) w' ell and truly administer the estate according to law).
Sworn to or affirmed a d subscribed before r ~ / ~ Date ~ ~ ~/
the this ~ day Date
BY~
Date
For a Register Date
BOND Required: Q YES ~ ~IQO To the Register of Wi!!s:
FEES: rr Please enter my appearance bry my signature below:
( )Renunciation(s)..... ... .
( )Codicil(s) ......... ... .
( )Affidavit(s)........ ... .
Bond .................... ....
Commission .............. ... .
Other ~~,1\ .... ....
Automation Fee ............ .. .
7CS Fee . ................. ... _
TOTAL .................. ... $ •
in co side ation of the foregoing Petition,
nted before me, IT IS DECREED that etters `"-
are hereby granted to `S
in the above estate and (if applicable) that
i /S n r
DECREE OF THE REGISTER
Estate off'
a/k/a:
AND NOW
satisfactory proo avin eet
the instrument(s) dated _~
described in the Petition be ac
Form R W-02 rev. 10/1l/1011
a /~
File No• ~ ~ C~a~
to probate and filed
Attorney Signature:
Printed Name:
Supreme Court
ID Number:
Firm Name:
Address:
Phone:
Fax:
Email:
the last,Will (and
)) of
c
to 2 of 2
,LO.CAL R~~~ISTRAR'S CERTIFICATION OF DEATH
r WARNING .~ pis illegal to duplicate this copy by photostat or photograph.
.:_
~- ~- _ .
~~ ,t„ U„J ccu,j,caLC, ,~o.vv ' ) ,~ This is to certify that the information here given is
i
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
~.~~~~~ ~ certificate will be forwarded to the State Vital
rv ~: r.T
C ~ ° Records Office for permanent filing.
~,; . ,,
P 1822~3$2~ ' ~
Certification Dumber
Type/Prim In
Permanent
~_ss
2
_ ~ a1.Z
Local Re istrar Date Issued
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VffAL RECORDS
" -- - - - - - - - ' ' State File Number:
1. DlcedenCS 4gal Name (Flat, Meddle, 4a4 Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Yr) (Spell Mo)
Lsroy P. Boysr Mals '162-22-62'10 Jon ~2, 2012
Sa. Age-4st Birthday (Yn) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Binh (MO/Day/Year) (Spell Month) 7a. Blnhpbca (Oty arld Sm
» Forllgn
G4untry)
Months Days Hours Minut
n
r
63
es Ssptsmbsr 18. '1026 3Y r~dil~ Pi
7b. Blnhplace (County) {)I
Ba. Residence (Stat,J_prAFOroign Country) Bb. Resldenu (Street and Number -Include Apt No.) 8c. Ok1 Oeudent Uw In a Township?
PP
7 a B ~~~ vas, deaden[ Ryed In E~.t P~nn~bOr'O
~p
Sd. ResWenee (County)
Cumberland
Be. Residence (Zap Ced!) O No, decadent Ilwtl wlthln IImILt o/ city/born.
9. Ever In US Armed Forces? 30. MlN41 Status at Tlme of Death Marrlld WI ow! 11. Sullying Spouse4 Name (If wth, giw name prior to flat marriage)
~] Vas Q No Q Unknown ~ OWOrud ~ Nwar Marrlad Q Unknown
12. Father's Name (First, Meddle, 43t, Su x) 13. Mother's Nama Prior to Flnt Marriage (First
Meddle
4st)
,
,
Nelson Boysr Unknown
14a. informant's Name 14b. Relationship to Decadent 14c. Inlormant's Mllling Address (Street and Number, Clty, State, Zlp Code]
Mlchelts Bischof DAUGHTER
~ 037 Woodrldpe Dr. Enola, PA X7026
~+
E ......................................................... .................................................... ~:...aft.°....~•.t............on•y one .............................. ... ... ..- ......... ... ... .... .
li Death Occurred In a Nos Ral: curved So "' "' '-••••-• •••• ••• ••• •• ••••••-•••
P Inpatient 11i Daeth Oc mewhere Other Than • Hospital: ~ Noaplca Faclllty •~ Decedent's Home
Eme en Room/OUt client Dead on Arrival ] Nunin Home/Len -Term Gro FacilRy Other (S el )
1Sb. Facility Name (H net Inseltution, gWe street and number) 1St. City or ?Own, State, and 21p Gede lSd. County M Death
Clarsmortt Nur
i
i R
h
bilM
s
ng
a
a
atlon Canbr c.rllakt, PA '17013 Curnbarlana
lfia. Method of Disposition Burlsl Cremation lfib. Date o1 Dispofltlon ific. Place e/ Dispositlen (Name of crmetery, Crematory
or other platy)
~ Removal from State ~ Donation
Other (S ecify) ,
Jan '17r ZO72
RbiurErCUOn Cemetery
16d. Loudon of DlsposRlon (City or Town, State, antl 21p) 7a. Signature of Funer 1 Smrvl U«ensee or Person In CMr`e of Interment 17b. License Number
HaMsburg, PA 17112 ~ I
]
-~
'
~ j
,y
~b ~ ~ FD-
13046-L
17c. Name and Complete Address of Funeral Facility
Sullivan Funeral Hants 61 N. Enola Dr. En W., PA '17026
.g 1B. Decedent's Eduutlon -Check the box that best deacnbea the 19. Decadent Of Hlapanle Origin -Check the 20. Decadent's Rau - Ghlck ONE OR MORE taus to Indleate what
hlgMst degree or Iwel of school completed at the time of death. box that beat deserlbes whether the decadent tM deutlent considered himself or heraeH to M.
~] 8th grade or less
la Spanlah/Hlspanle/4tino. CMck the ^NO" White Koroan
0 No diploma, 9th - 12th grade box If decedent Is not Spanish/HlspeMe/4tlno
0 Black or Afr{c:sn Am
i
.
er
can 0 Vletnames!
Q High school graduate or GEO completed No, not Spanish/Hiapanlc/4tlno 0 American Indlen or Alaska Native ~ Other Allan
~ Some colleg! credit, but no degree 0 Ves, Mexican, Mexlun American, Chicano 0 Allan Indlen ~ Native Hiwalian
Q AsseclaN degree (e.g. AA, AS) 0 Yes, Pueno Rican 0 Chlnefe 0 Guamanian Or Chamorre
'
Q Bachrlor
s degre! (e.g. BA, AB, BS) ~ Ves, Guban Q Flllplno 0 Samoan
'
Q Master
s degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Ves, other Spanbh/Hlspanit/4tlno ~ lapenefe J(] Other Paelflc Islander
~ Oeeterob (e.g. PhD, EOD) or Prohasional dgroe (Spaelfy) ~
Other (Specif/)
. MD DDS DVM LLB JD
21. Decedent's Single Raee Self-DaslgnKlon -Check ONLY ONE to Indicate what the deutlent considered himself or heneN to be. 22a. Decedent's Usual Oc<upatlon -Indicate type of work
~'] White
Q lapaneae ~ Samoan done during most oT working Ilfe. DO NOT VSE RETIRED.
Bl
k
ac
0
or Afrlean American ~ Korean ~ Other Paelfic Islander ~arlt ~~Or
0 Amarlcan Indlen or Alaska Native ~ Vietnamese ~ Don't Know/Not Sure
Q Asian Indlen ~ Other Allan ~ RNuaed 22b. I(Ind of Businea Industry
Q Chinese ~ NatWa Hewallen ~ Other (Specify)
Q Flllplno Q Guamanan Or Chamorro Loal QOVeRSnNrst
MV B COM D 3a. Date Pronounu Mo ay r 5 gnaturs o Person Pron un<In at On y w en app G • .Uunse Num
BY PERSON WNO PRONOUNCES OR o ~ - i a - a o ~ /~ P
CERTIFIES DEATH ~ ~ ) /1 J ~t ~ ,1 ~ A /'\ ~ N ~z O iL'7 /_
24. Time of Deith n ~ ,t ~./ C/l/V \- JV \ iV 7 TGJ
23d. Gate Signed (MO/Day/Vr) a
• 3o A
~
tv i 25. Was Metllul Examiner or Coroner Contaete<IT ~ Yas o
CAUSE OP DEATH
Approximate
2fi. Pan 1. Enter the chain O/ vents-diseases, InJuAes, or eomplleatlOns--that directly caused the death. DO NOT enter brminal wenu such ea urdlac arrost 4 Interval:
respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enbr only one cause en a Ilne. Add itldltlonal Ilnes if necessary Onset to Death
i
/
t
,. ,
J
r~- p i
IMMEDIATE CAVSE -------------> a. 1' 1 W E~/ \ \ L> ~+`
•
(Final disease or condition Due So (or as a consequence ot):
rosulling in tleeth)
b.
sequennaliy cast tondelon:, Due to (or as a to segwnt. on:
n
if any, leading to th! cause
Ilsbd on Ilne a. EnHr the j
c
VNDERLYtNa GVSE
Due to (or as • ton»quenee en:
fi (disease or Injury that
G Inltlated she events resulting d.
In death) LAST. Due to (or as a consequence ot): )
1
26. Pan 11. Enter other sleniflunt tendltions tontrlbutln! to d th but not rosulling in th! underlying cwse given In Part I 27. Waa an autopsy perfe edT
Ves No
~. 2B. Were autopsy findings avallabl!
to complete the cause o1 death?
Yef NO
29. H Female: 30. Oltl Tobacco Use Contribub to Death? 31. Manner of Death
Q Not pregnant within past year ~ Yes ~ Probably .Natural ~ Homicide
~ Pregnant at time of death
.~' ~ No Unknown Accident ~ Pending Invesilgatlon
0 Not pregnant, but prognant within 42 days of death
Q Suicide ~ Coultl not W determined
~ Not pregnant, but Pregnant 43 days to 1 year before death 92. Date of Injury (MO Day r) (Spell Month)
~ Unknown 1/ pregnant wlthln the past year
33. TLme o1 Injury
34. Place of Injury (e.g. home; construction sate; farm; school) 35. Location of Injury (StreK and Number, City, !:Late, Zip Code)
36. Injury at Work 37. If TransportatlOn Injury, Specfy: 38. DescAbe How Injury Occurred:
Q Yes ~ OrWer/Operator 0 Pedestrian
~ No ~ Passenger Q Other (Specify)
39a. Gnifler ([hack only one):
Q Certifying physician - To Me best o1 my knowledge, death occurred due to th! cause(s) antl manner stated
Pron
i
a C
if
ounc
ng
ert
ying physician - To the best of my knowledge, death occurrod at tM time, date, and place, and dw to tM caui:e(s) and manner statetl
O Medlin Examiner/Coroner - pn th
e basl
a o1 e
xaml atlon
and/or Inv
tl
atl
I
i
,
g
on,
n my op
nlen, dlle~KM
reccurrod it the Hme, date, end place, and dw to the cau (s) d manner s tl
a
t
(
~
`
`
[[~~ (~
--
~
~
!
a
~
,
[~
J
Signaturo of tenlfl.r:
l ~~
~~,
~~~.C~ ~ - `~
QJ1.A LA A >I f7~"1 TKIa o4 cenlfler. V~ V _ //
Uunse Number: VY
DV~ -1 /1
~
39b Name, .ttd ss nd 21 Code o1 Person Completing Luse of De th (ITlm 2fi) 39c. Gate Slgne (MO/Day/Yr)
40. RKistra s D strict 41. glstror s uro - 4 eglstror et Mo aY r
a
13 -~?c, i ~
- ~--
43. Amendments
Dispostion Permit No.
v ~" ~ !1 $ REV 07/2011
LAST W/LL AND TESTAMENT
OF
LEROY P BOYER
I, LEROY P. BOYER, widow man, of East Pennsboro Township, Cumberland
County, Pennsylvania, being of sound and disposing mind, memory and
understanding, do hereby make, publish and declare this to be my Last Will and
Testament, hereby revoking any and all Wills and Codicils previously made by me at
any time heretofore.
FIRST: I hereby direct that my personal representative(s), hereinafter
named, to pay all of my just debts, not barred by any statute of limitations, as well as
my funeral and testamentary expenses, including Pennsylvania Inheritance Taxes, as
soon after my demise as may be practicable.
S E O N D: I hereby give, devise and bequeath alt the rest, residue and
remainder of my estate to my two daughters:
-~
` ~~ ~'.
Michelle Bischof (50%) and,
~. ~ ;
Patricia Erb (50%). --
THIRD: A. Should my daughter Michelle pre decease me, I ~ret;t that ~~ -
her one half share shall pass to her three children, Brandon Bischof, Stephen Bischof
and Benjamin Bischof, equally and per capita.
B. In the event that Stephen and Benjamin have not yet attained the age of 18,
their fractional shares shall be held in trust for them by their father, Stephen Bischof,
until each reaches the age of 18.
C. Should my daughter Patricia predecease me, I direct that her one half share pass to
her sister, Michelle.
FOURTH: I hereby nominate, constitute and appoint my daughter,
Michelle, as Executrix of this, my Last Will and Testament. In the event that Michelle
predeceases me, fails to qualify, ceases to act, or for some reason is incapable of
pertorming such task, I then nominate, constitute and appoint my daughter Patricia as
my executrix.
FIFTH: The above named persons shalt not be required to post bond
or surety in this or any other jurisdiction for faithful compliance of the duties as
executrix of my estate or as trustee over funds passing to Stephen and /or Benjamin.
IN WITNESS WHEREOF, I hereby set my hand and seal and
declare this to be my LAST WILL AND TESTAMENT, consisting of this, and one
other typewritten page, identified by my signature, dated on this,
the ~ day of ~ ,1 ggg
'~
LEROY . BOYER ~~
(Testator)
BE IT KNOWN, that at the request of the testator, we have witnessed the signing
of i document, in his resence, and in the presence of each other.
~"` ' i ~ ~` (Address)
` (/(~ (Address
COMMONWEALTH OF PENNSYLVANIA )
COUNTY OF CUMBERLAND )
LEROY P BOYE ~~~ ~~,C~ c.~_ ~~ ~~
and ~ ~ ,the Testator, and the witnesses, respectively,
whose na s are signed to the attached and foregoing instrument, being first duly
sworn, do hereby declare to the undersigned authority that the Testator signed and
executed the instrument as his Last Will and Testament. Furthermore, he signed and
executed it willingly, as a free and voluntary act, for the purposes therein expressed.
Each of us, as witnesses, in the presence and hearing of the Testator and each other,
signed the Will as witnesses, and that to the best of our knowledge and sight, the
Testator, was at the time eighteen (18) or more years of age, of sound and disposing
mind, memory and understanding an nder no nstra~ t, duress or undue influence.
_ J
LEROY BOYER
Testator)
WITNESS
WIT SS
Subscribed, sworn to and acknowledged before me by:
LEROY P. BOYER, the Testator, and by
,and ~ ~
the witnesses, all of whom personally appeared before me, the undersigned officer.
on this, the ~ day of
My Commission Expires:
- , 1998.
_ - B. _ _
TARY PUBLIC
Notarial Seal
Donald B. Owen, Notary Public
East Pennsboro Twp., Cumberland County
My Commission Expires Nov. 24, 2000
MemAer P?nnsylvani,~ . ssnciation of Notaries