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HomeMy WebLinkAbout02-15-12PETITION FOR GRIANT OF LETTERS REGISTER OF WILLS OF _ ~` L~~,~ I /~ ,,, _ COUNTY, PENNSYLVANIA Petitioner(sj 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 respecttitlly request(s) the grant of Letters in the appropriate form: D ecedent s Information Name: ~ P7S~',P -~ D Y` a/k/a. v a/k/a: a/k/a: Date of Death: - , ~ p ~ ~ Decedent was domiciled at death in (il l71'~2 principal residence at ~J a, ® 3 i Street address, Post Office nd Zip Decedent died at ~ ~.- r' ,~ j /y ~ /rt l~ ~h St t d File No: _~ ~ - (Assigned by Register) Social Set:urity No: ~ 7 3 ^ o? - ~ 7 Age at death: ~' t (state) with 's/her la t ~~~ City, To)vnship or Borough ~,,,,,,,~ tee a dress, Past Office and Zip Code ' ' ' V City, ownship or Borough County State Estimate of value of decedent's property at death: Ijdomiciled in Pennsylvania ............................ All personal property $ li o 0 D Ijnot domiciled in Pennsylvania ........................ Personal property in Pennsylvania $ If not domiciled in Pennsylvania...... , . , , . , , , , , . , , ,personal property in County $ Value of real estate in Pennsylvania ............. . ........ . TOTAL ESTIMATED VA.LUE.... $_ 0 0 0 0 Real estate in Pennsylvania situated at: (Attach additional sheets, ijnecessary.J Street addre s, Post Office and Zip Code City, Ta~wnship or Borough County A. Petition for Probate and Grant of Letters Testamenta Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in t e last Wili of the Decedent, dated 7 „ .Z , ) 9 thereto ted ~ ~ I~a~ ~ 9 g~ and Codicil(s) _ 7 •- ~•-•- • ~,~.a.•~ c~reumscances (eg. renunciation, death ajexecutor, etc.) Except as follows: after the execution ofthe instrument(s) offered forprobate Decedent didnotmany, was not divorced, was nota party to apendi»g divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(8), and did not have a child born or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. (~10 EXCEPTIONS ^ EXCEPTIONS ^ B. Petition for Grant of Letters of Administration (Ifapplicable) c•. t. a., d.b.t:., d.b.n.c.t.a., pender~te life, durance absentia, durance minoritctte If Administration, c.t.a. or d.b.n.c.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(8) and was neither the victim of a killing nor ever adjudicated an incapacitated person. ^NO EXCEPTIONS ~ EXCEPTIONS Fnrm RW-p1 rev. l0/! 1/101 Page I of 2 Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (ifany) and heirs (attach uclditionul sheets, i/necessary): r. -. Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } COUNTY OF ~, tJ ~ `~ ~ ~ } SS: O ~ 2 } Petitioner(s) Printed Name ~ ~ T '~ (.~ rYI+ A ~ ~{ X10 ~ r°,,. ,-r, r v~.a1~C ~ ~ , . -ti!J Official Use X14; ~"EB 15 ~~ 9~ ~+Z `" I The Petitioner(s) above-named swear(s) or affirm(s) the statements in the fore oing Petition aze true and correct to the best of the knowledge and belief of Petitioner(s) and that, as Personal Representative(s) of the Decedent etitione s) I wel and truly administer the estate according to law. Sworn to or affirmed and subscribed before me thi Its d f roar ~~ Date ~ , j D1 Z. BY~ ~ Date Fo the Register Date Date BOND Required: QyES O FEES: Letters .................... ( `~ )Short Certificate(s)...... $~_ ~~~ ( a )Renunciation(s)........: ( 2, )Codicil(s)........... . ( ~ )Affidavit(s)............ ...._.. Bond ................. ------ ....... Commission. ........... ~- ...... Other ~/t 1 ~ ........ ...... I ~ ~_ ~_ ........ Automation Fee ............... JCS Fee . .............. ~_ ...... TOTAL ..................... $ To the Register of Wills: Please enter my appearance by my sienaturP hpt.,..,. Attorney Signature: Printed Name: Supreme Court ID Number: Firm Name: Address: Phone: Fax: Email: DECREE OF THE REGISTER Estate of M , ~ -~ ~ ~- r f File No:1 -' ~ ~-1' a/k/a: '- t AND NOW,~~~~J~`t satisfactory proo tng been the instrument(s) dated described in the Petition be admitted to Form RW-01 rev. 10/11/2011 ~` ~ U ! ~ , in con ider tion of the foregoing Petition, before me, IT IS DECRE that Letters ~ ;by granted to ~~ in the above estate and (if applicable) that robate and filed'of record as the last Will (artd Codicil(s)) of Decedent. Register of i] ~k~ C-Piro. , Page 2 of 2 ~ ~•.,? .~.., ' OATH OF SUBSCRIBING WITNESS(ES) ~ ri ~-, ~ a, `.'' j GISTER OF WILLS '~~~ ~ u' __ ,, `~ ~, ~ ~~ ~a COUNTY, PENNSYLVANIA ~~ ~ .~ ' ~' ~~~ ~ . -~ ~ ~~ .y ~` r 4,'} f ~} ' ~ I' ~ s ~ ~ ~ '~ Estate of hQ. G. _ 1 ~ L L - ,Decea sed C~ Y~ Yl~`C r ~ ~ Q ~ I/~ . (each/ a subscribine witness to (Print Names) the D Wi11 T~Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that ~/ she /~/ they was were present and saw the above C;stator Testatrix sign the same and that she / ~ they signed the same and that she / e /they signed as a witness at the request of the Tes for estatrix in his presence and in the presence of each other. (Signature) ll1 0 ~ ~~ ~S I~) r~ (Str t Address) ~~~i~~t~l ~~ ~~~~ S (City, State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed before me this ~ ~ ~ day of t ~, ~~~ ~ c~-, Deputy for Register of/Willlls (:J (Signature) (Street Address) (City, State, ZrPI Executed out of Register's Office Sworn to or affirmed and subscribed before me this day of Notary Public My Commission Expires: (Signature and Seat of Notary or other official qualified 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 or copy of instrument(s) at time of notarization. Form RW-03 rev. 10.13.06 Forst RW-03 rev. /0.!3.06 OATH OF SUBSCRIBING WITNESS(ES) ~© ~. ~~ ~~ . -~ F..r ~ T"t ~. ~ ~ f C~ RE ISTER OF WILLS ~'` ~ -- ~ t~~a ~'~ L~ COUNTY, PENNSYLVANIA .~V~x ~ ~ Gl ! ~.; {~~; _~ ~ ~,,, _~` ^' __ f "~- • I ~r F ~+~ Q ^ l e ~' Estate of e G ~,~ Deceased u~ Q ~ ~ each a s _ / (PrintName/sJ ~ ( ) ubscnbmg w>tness to the Will ~" Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that she he they as /were present and saw the above estator t~Testatrix sign the same and that she / he they signed the same and that she / h~e /they signed as a. witness at the request of the Testator estatrix in er his presence and in the presence of each other. (Signature) (Signature) _ 3 ~ L~ ,~c ~- ~s ~ re (Street Address) JJ ~' J 5 eGfnGtI~CS ~Y ~~ ~~Jr (City, State, Zip) (Street Address) (City, State, ZipJ Executed in Register's Office Sworn to or affirmed and subscribed before me this ~ ~L day of ~' C .2-(., , ~/~.-. A ~ ~~ ~~ _~ Deputy for Register of ills Executed out of Register's Office Sworn to or affirmed and subscribed before me this day of Notary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date ofexpiration of Notary's Commission.) NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at dine of notarization. Fonrt RW-03 rev. i0. /3.06 OATH OF SUBSCRIBING WITNESS(ES) ~ .~. ~~ ~; , ~, ,, REGISTER OF WILLS ~ ~ ~ ~ ~ i COUNTY, PENNSYLVANIA ~~~ ~~ - ,~ `` '~ ~~ Estate of ~~~~ ~" / eceased 15', /~ I ('i/'/ U, /' LL /`~ ~ l j / Lel -~~ / / ~~ ~/U Ll /i;~(each) a subscribing witness to (Print Name/sJ the ^ Will ~icil(s) presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that she he /they C~ /were present and saw the above Testator /~1`estatrix sign the same and that she / he ~ they signed the same and that she ~ they signed as a witness at the request of the Testator / estatrix in he /his presence and in the presence of each other. (Signature) '`~' (Street Address) /`Ur (l"fi/ D/ (City, Slate, ZipJ Executed in Register's Office Sworn to or affirmed and subscribed before me this of Deputy for Register of Wills day (SignalureJ (Street Address) (City, Slate, ZipJ Executed out of'Register's Office Sworn to or affirmed and subscribed before me this _ / `1 day of ~ r~a~~, Ola ~~ Notary Publi My Commission Expires: as v~ a?, ao1Y (Signature and Seal of Notary or other official qualified 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 or copy of instrument(s) at time of notarization. Fonn RW-03 rev. J0.13.06 ~TM ~ V~~ Notarial Seal Betsy A. Barnhart, Notary Publk PenbroOk Boro, Dauphin County My CAmm~slon Exgres Jan. 27, 2014 Member, Pennsylvania Association of Notaries OATH OF NON-SUBSCRIBING WITNESS(ES) REGISTER OF WILLS C~ ~_ COUNTY, PENNSYLVANIA Estate of ~dl~r Deceased e..v~ ~L ~ 1.~ G ~C~ and /~~ ~~j lti ~ ~ / / ~' Y , (each) being duly qualified acclording to law epose )and ay )that she he they was were well- acquainted with ~Q 'n~ t_, l ~ •C.~ and a are amiliar nil' with the handwriting and signature of the decedent, and that the signature of ~t» c,` ~. 1~~-u h t/ to the11foregoing`ilnstrument purporting to be the Last Will and Testamentl~odicil f ~C-1G~ ~ C~0 ~C.~~ C{ is in his er own proper handwritin€;. (.L~ (Signature) n I f .3~ L ~7C~( ~l J h1~ r-f ~i11 (Street Addr ss) ~ (City, Sate, Zip) Executed in Register's Office Sworn to or affirmiied and subscribed before me this I ~ day r of t ~~a. Deputy for Register Wills ~~ (Signature) (Street Address) `s~ ~ / ass City, S te, Zip) >~,. c-^¢ r. ~' ~:=~ .C CJ~ ~ ~ V 1 ~^`F~ ~~ `--- ~~~' ~ ~' c ~.. ~ r~: Forst RW-04 rev. l0.I3.Oh OATH OF NON-SUBSCRIBING WITNESS(ES) ~,,~, GISTER OF WILLS ~7.~'_,..~., OUNTY, PENNSYL`JANIA Estate of ~ ~ ~ a, I -~ ~ ~ ~~S''!'.~J -~ Deceased r a` ~ Fv• ~ W y'l~ and ~ Y~ r) ~ ~ c~ • ~ Y (each) being duly qualified according to law, depose(s)/and say(s) that s:he / he /they was /were well- acquainted with _ ~~ Gi ~, f~OS•f ~, and am/are familiar with the handwriting and signature of the decedent, and that the signature of L~ .~ 10[ ~ d~~~~~~ to the foregoing instrumen purpo ing to be the Last Will and Testament/C;odicil of 1 ~ • ~ .~~•~~~~'' is in his/her own ro er handwritin~~. r r ,~ (Sigttu ure (Street Address) ~~ .~~ ,~~ (City, State, Zip) ~ 7D~,~" Executed in Register's Office Sworn to or affirm fed'' and subscribed before me this ~t ~~ day Deputy for Register of ills Form RW-04 rev. 10.I3.Oh (Sig lure) (Street Address) ~' r ~~ ~ ~ '1~ C ~ D,S,~ (City, State, Zip) ~ P~Jr ~'~~ _ ~y ~ ti) - ~l i ~! -- rr ~ t"I'I ~:' . c~ ~ c7 cx~ . ~:~ r- „~, V1 * ? ~=~1 X '~ __ ~_.. ~CJ ~ ~ : -~ ; T t~~ ~ ....i tin ~. ~' rn ~~ ~` ~,/~r^• OY'~`} ~ 71'v ~Y R~"' Y.e s i` p~ ~Y1(J ~ 1~ ~~7 G~~'a ~I~ IrV, l~ ~'1 a ~ ~~ ;n ~-h~ U, s. u~~1 ate ~~ra_ n ~ j'Y1 a ~ CGS, , oZ o 1 ~, e _~ ~, ~~C: ~:n~ ~ ~Ji:' { 7 C7 r _ . >J" ©~ ~ '. -fir. '~ '~v R: RENUNCIATION REGISTER OF WILLS C ~ . ~~,- a„ i COUNTY, PENNSYLVANIA Estate of ~e s ~ ,~~ ~~ c-a ~~~ ~~ ~~~ ~, ^' z., ; 6' X11 L ~ ,... r-: }.i •~ a_ J ~ f „- _7 ~ ~ ~ ~~ `d ~ -' ...~ ='l "= ~ r; "j ~'~ f'r ~. ~j Deceased in my capacity/relationship as ,,/ (Print Name) G..`ct ~~`~ ~~' of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to (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 rev. 10.13.06 (Signatur ) S IBS Ems r --/ZiND~ 2.~ (Street Address) G-~ EC(t A N lCSB cA.FZ~ ~/`~- 1 '~ a ~ J (Ctry, State, Zrp) Executed out c f Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation for the purposes stated. within on this ! ~ day of 1=elo.,.~~,,....t , _ac~i z ~~ ,-, Notary Pub 'c My Commission Expires: ~P ~ - all aZ ®~ `~ (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) COMMONWEALTH OF pEryN51(L,VANIA Notarial Seal Belly A. eamhart, Notary Publk penbrook Boro, Dauphin cour-ty My Ccmmtmk,,sion Expires Tan. 27, 2014 Member, Pennsylvania Assodation of Notaries RENUNCIATION ~' - .~ -~ REGISTER OF WILLS ?~~ ~. ~ = ' C , ts.~,~~,.~`_ COUNTY, PENNSYLVANIA j~~ cn "z ; ~~- Q Q ~ . x t_ s . ~++yy n ~--, ~ ~J'~ ~', .c-- ~'~ ~, Estate of __ ~ ~ ~ a / ~ 1, ~ Ci S •~ e •7~ ~e ~- ,Deceased I, ~~' ` e ~ ~r ~- e~~ ~ ~ s d- ~ , in my capacity/relationship as (Print Name) ~ ~ • ~ ~i`1~e ~` of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to ~~~ ~ (Date) Executed in Register's Office Sworn to or affirmPrl and subscribed before me this day of ~ua~ U ! a (Signature) (Street Address) (City, Stare, ZipJ ~ Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation for the purposes stated within on this /~! day of f....~ b~~-car .a ~ U 1 Z _? n ..~ Deputy for Register of Wills Form RW-06 rev. 10.13.06 Notary Public ~'~- My Commission Expires: ~otn • 021, aD ~~ (Signature and Seal o1'Notary or other official qualified to administer oaths. Shaw date ofexpiration of Notary's Commission.) croMr~oHw~un~ of wwv- i Notarial seal &~tsy A. Bamhatt, Notary Publk Penbrook 8oro, Dauphin County My Cbmmission Expires ]an. 27, 2014 ~tamber; Pennsylvania Association of Notaries xim-nog Ri::v ton n LOCAL RE h ~' AR'S CERTIFICATICIN OF DEATH WARNING: It ~~I~'~~br~ii C~ this copy by photoslrat or photograph. - ..L.IJ Fee for this certificate, $6.00 P 18266948 Certification Number Type/Print in Permanent Black Ink ~_ i ~~ .~~ ~_sa 2 ~~~~ ~~s ~ ~ ~ 'T'his is to certify that the information here give correctly copied from an original Certificate of D duly filed with me as Local Registrar. The ori~ ~~~ K certificate will be forwarded to the State f~ R:ecords Office for permanent filing. CUMRFRI-A~ff '1 , ~ o~ ~e1G Local R gi, rar Date Issued COM MONWEAI(H OF PENNSYLVANIA. DEPARTM ENT OF HEALTH VITAL RECORD ['FRT~F~!'JsTC AC rICATY ~..e.e me ,...moor: 1. Decedent's Legal Name (Firs[, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (Mo%Day/Yr)(Spell Mo) LELA M. HOSTETLER EP•7AT.F 073- 26 - 3737 I 02/08/2012 Sa. Age-last Birthday (Yrs) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/VCar) (Spell Month) Ta. Birthplace (City and Slate or Foreign Count ) -~~ 88 Months Days Hpurs MIn„t!5 03/24/1923 Duntroon Ont. Cana~a ____ - - - - Tb. Birthplace (County) Sa. Residence (Siat¢ or Foreign Country) 8b. Residence (Street and Number -Include Ap[ No.) gc. Dld Decedent live In a Township? - ~ '~' - Q9ve5, de~ed¢nl Ryed in Unper Allen lwp. 320 Messiah Circle Sd R . esLgL~~cgrr~y~nd 8e. Residence (Zip Coda) ONO, d¢cedent Ilv~ed within limits of city/born 9. Ever In US Armed Force ST 30. Marital Status at Tlme of Death [~ Married Q Widowed 11. Surviving :ipouse's Name (If wife, giv¢ na m! prior to first marriage) Q Ves ~ No Q Unknown Q Dlvo reed Q Never Married Q Unknown HOSTF'T'- .~'rz 12. Father's Name (First, Middle, Las[, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last) E.J. SWALM 'TECKLEY) 14a. Informant's Name 14b. Rll ' " atlonship to Decedent 14c. Informant's Malling ,gddress (Street and Number, City, State, Zip Code) 17OSS o PAUL HOST EZ LER ' 1 M bent bur A o _ If Death Occurred In a Hospital: `~ Inpatient p eO ............°-----° .............. .............°----------°-...... ur e lf Death Occ red Som where Other Than a Hospital: (~ Hospice Facility ~ Decedent's Home y Emergency Room/OUlpatlent Dead on Arrival Nursing Home/Long-Term Car! Facility Other (Specify) 3 15 b. Facility Name (H not InstltUtlon, glvG street and number; 15c. City or Town, State, and 21p Code 15d. County of Death ---- 320 Messiah Circle Mechanicsbur PA 170SS Cumberland ~, 16a. Method of Dlspositlon [~ Burial Q Cremation _ _ 16b. Date of Disposltlon 16c. Place of Disposition (Name of cemetery, crematory, or other place) p Remgyalfrpmslate p Donation O[h¢r (Spiel ) 02/11/2012 Grantham Memorial Park 2 16tl. Location of Dlspositlon (City or Town, State, and Zip] STa. ature of is Licensee or Person in Charge of Interment 1Tb. License Number -- Mechanicsburg PA 170SS 012461 - L lye. Name and Complete Address of Funeral Facility - - - S . GFR~T .n ~ 18. Decedent's Education -Check Th¢ boz that best describes the 39. Decedent of Hispanic rigin -Check She 20. DecedenT's Race -Check ONE OR MORE races to Indicate what - ~- highest degree or level of school com plated at the time of death. box that best describes wh¢thcr the decedent th¢ decedent considered himself or herself [o be. Q Bth grad! or less Is Spanish/Hlspanic/La[Ino. Check the "NO" ® White Q Korean Q No diploma, 9th - 12th grade. box If decadent Is not Spanish/Hispanic/Latino. ~ Black or African American 0 VI¢tnamese 0 Hlgh school graduate or GED completed ®paNo, not Spanish/Hispanic/Latino 0 American Indian or Alaska Native Q Other Asian Q Some coll¢ge credit but no tle ree , g u Yes, Mexican, Mexican American, Chicano ~ Asian Indian (] Native Hawaiian A i d ® ssoc ate egre! (e.g. AA, AS) ~ Y¢s, Puerto Rican 0 Chinese Q Guamanian or Chamorro ' ~ Bachelor s degree (e.g. BA, AB, BS) 0 Yes, Cuban ~ Filipino 0 Samoan ' ~ Master s dlgre¢ (e.g. MA, M5, MEng, MEd, MSW, MBA) ~ Yes, other Spanish/Hispanic/Lalinq Q Japanese 0 Other Pacific Islander ~ Doctorate (e.g. PhD, EdD) or Professional degree (Specify) ~ Other (Specify) . MD DDS DVM L B 1D 21. Decedent's Singl¢ Rac! Self-D¢signatlon -Check ONLY ONE to intlicaT¢ what [he decedent considered himself or herself to be. 22a. Decedent's Usual Occupation - Indicate type of work ~] White (] Japanese (] Samoan done during most of working Iifl. DO NOT USE RETIRED. ~ Black or African American ~ Korean 0 Other Pacl(ic Islander Q American Indian or Alaska Native (] VI¢tnamese ~ Don't Know/Not Sur¢ Librarian As s is t_an t _ ~ Asian Indian ~ Other Asian Q Refused 22b. Kind of Business/Industry Q Chinese 0 Native Hawaiian Q Other (Specify) Q FIIIPIno p Guamanian qr chamgrrq Library ITEMS 23a - 23 MVST BE CO PLITEO 23a. Dale Pronounced Daad Mo Dey r 23 Slgnat re o Person Prpnounr_ing Death (Only when app~ble] 23c Licens¢ Number _ - . CERTIFI S DEATH PRONOUNCES OR ~ ~~, 23d. Oat! Signed (MO/DaY/Yr) 24. Tim! of Death '~- ~ ^~~~~Y t '~/ - R~ ~'3 ~ a5.5-~ L C> ~ ~ 25. Was Medical Examin¢r or Coroner Contact¢dT 0 Yes ~ No CAUSE OF DEATH Approximate 26. Part 1. Enter She chain of events- diseases, injuries, or complications--that directly caused the death. DO NOT ent¢r terminal events such as ca rdlac a rest Interval: r . respiratory arrest, or ventricular fibrlllatlon wi thout showing the etiology. DO NO T ABBREVIATE. Enter only one cause on a Ilne. Add additional Rn¢s if ne<essa ry Onset to Death ` ' w IMMEDIATE CAUSE > Q Y C~r/~LQIL ~a-rJ ` ~~ ~~~' (Final disease or condition Due to (or as a consequence ofj: resulting in death) b. 5lquenttally Its[ conditions, Due to (or as a consequence of): if any, leading to the cause listed on line a. Enter The UNDERLYING CAUSE Due to (or as a consequence of): (disease or injury that F Initiat¢tl the events resulting d. ~ in death) LAST. Due to (or as a consequence of): S 26. Part 11. Enter other 1 nificani dition butln th but not resulting in The untlerlying cause giv¢n in Part I 27. Was an autopsy performed? Yes No 2g. Were autopsy fihdings available to complete She cause of d¢athT E O Y¢s Q No 29. If Femal¢: 30. Did Tobacco Use Contribute to Death? 31. ner of Death -- - Q Not pregnant within past year Y ~ es 0 Probably 1 0 Natural Q Homicid! gna nt at time of death Q ~ N ` ~No Q Unknown Q Accident Q Pentling Investigation 0 pregnant but re nant within 42 d f d h r , p g ays o eat Q Suicide 0 Could no[ be tletermined Q Not re nant b t d - p g , u pregnant 43 ays to 1 year before death 32. Date of Injury (MO/Day/Yr) (Spell Month) ~ Unknown if pregnant within the past year - - 33. Tim! of Injury 34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City, State, Zlp Code) - 36. Injury at Work 37. If Transportation Injury, Specify: 38. D¢scribe How Injury Occurred: - 0 Ves ~ Driver/Op¢rator (] Petlestrian 17 No 0 Passenger (] O[har (Specify) 9a. Certifier (Check only one): - - -- ertifying physician - To the best of my knowledge, death occurred du! to the cause(s) and manner stated Pr i 1L C onounc ng ertifying physician - To the best of my knowledge, death occurred at the time, data, and place, and clue to the cause(s) and manner staled Q Medical Examiner/COTOner urination, and/or investigation, In my opinion, death occu rrld at the time, date, and place, antl due to th¢ cause(s) and manner stated M ^ Signature o TI[le of certifier: V rV_ Licent¢ Numblew S~G~~ ~S~ 39b. amc, dre and Zi~ of Person mpleting Ca f Dea h (Item 26 / ~ ~ c. Date Signed/p~~' Z n s C/~F~_.~ /vcl~-i ~ /?~-1 ~-t~-+ ~ sG Clc uritsc i C ~ S . . 4 V O. Registrar's Istric[ Number 41. Re Srar s Signature 42. Registrar Fil! Da[! Mo Day r O~-~' O~ Io 301 h 43. Amendments Disposltlon Permit No. ~~ I 7 / 'y y H105-143 REV OT/2031 THIS IS THE LAST WILL AND TESTAMENT of me, LELA MARGARET HOSTETLER, presently residing at 105 Budea Crescent, Scarborough, Ontario, in the Township of Scarborough, in the County of York, and Province of Ontario, made this 2nd day of DECEMBER, 1966. 1• I HEREBY REVOKE all former Wills or other testamentary dis positions heretofore made by me and declares this to be my last Will and Testament. 2. resid rio, I~NOMINATE, CONST E AND APPOINT'/LEWIS HE Ares ly at R.R. #1, ionville, Ont io, in the aid Pr ince of to be t Executor of t s my Will. ~ N_,a_ ~8f S'~-e ~ -E-tQ c ~ ~d ~ od i c r ~ , ~~ ~ - ~o-d~t~-~, -~-7-~ 3• I WILL AND DIRECT that all my just debts, funeral and testamentary expenses be paid and satisfied by my Executor as soon gas conveniently may be after my decease. 4• I GIVE, DEVISE BEQUEATH AND APpOIrdT all my real and per- sonal estate which I am seized or possessed of or entitled to, or over which I may have any power of appointment, unto my husband, PAUL EUGENE HOSTETLER, absolutely. 5• IN THE EVENT that my husband, PAUL EUGENE HOSTETLER, shall predecease me, or should we both die simultaneously, I THEN GIVE, DEVISE BEQUEATH AND APOINT all of my said estate unto any children of mine then surviving me, in equal shares pesr stirpes. 6• IN THE EVENT that my husband, PAUL EUGENE HOSTETLER, shall predecease me, or should we both die simultaneously, I APPOINT KILDRED GLADYS HAWES and ROBERT HAWES, preser.~tly residing at 3110 Richmond Crescent, in the City of Niagara Falls, in ~e Prot~;nce ~f Ontarrio, to be the Guardians and Trustees of my s:~'i. hi ~re ' `~~' ~~~ ~ ~~ ~~ ;F °ts .~- - 2 - to maintain, clothe, feed and educate them, and to pay any residue of my estate, to which they are entitled, ~to them when they attain the age o.f twenty-one years. ~• IF ANY PERSON should become entitled to any share in my estate before attaining the age of twenty-one years, the share of such person shall be held and kept invested by my Trustees and the income and capital or so much thereof as my Trustees in their absol- ute discretion consider necessary or advisable shall be used for the benefit of such person until he or she attains the age of twenty- one years. IN TESTIMONY WHEREOF I have to this my last Will and Test- ament, written upon this and the. preceding page o= paper, subscribed Imy name the day and year first above written. SIGNED, PUBLISHED AND DECLARED ) by the said Testatrix, LELA ) MARGARET HOSTETLER, as and for ) her last Will and Testament, in ) the presence of us, both present ) ~at the same time, who at her re- ) quest, in her presence, and in ) the presence o~ each other, have ) hereunto subscribed our names as ) witnesses. ) ) ( Address ) a' ,. ) ( Occupati~' . ) . /~ ~ j .~ . :' c -~c~z~ va~~~ . . ) . ( Name ) ) ( Address ) ~~~~ ) • ~-~. . ) ( Occupation. ) ) ~~_ ~, ~~„ n n rn rl a W W U w A A W H A ~e w qH Z a a H ~v- H ~I ~c ~1c ~c ~c ~a c~ a~ .,a iJ p •~-1 ~{-) •ri IJ ~ RS w`n~ ~ o i~ `~ o O id ~ U tT W • ~ll O cn a~ ~+ A to 3 ~-~ a~s~+~a a sa~oa Id ~ H co d' 3 Codicil to LAST WILL AND TESTAMENT, Lela Margaret Hostetler tThis is the second codicil, dated December 4, 1992.) (The first codicil is dated April 10, 1998.) (The will is dated December 2, 1966.) All the provisions of the above mentioned will shall stand except Item 2, which is replaced with the first codicil. All other provisions of the will shall stand except Item 5, which is herewith replaced with the following: In the event that my husband, PAUL EUGENE HOSTETLER, shall predecease ~, or should we both die simultaneously, I then give, devise, bequeath, and appoint all of my said estate to Messiah Village, Mechanicsburg Pennsylvania, noting the following: (1) We have invested X21,000 with Messiah Village because of the generous allowance the Village made to us in the aquisition of our cottage at 518 Cherry Circle. The interest from this investment will be given to us in regular payments until both of us are deceased. Upon our deceasse the total investment of $21,000 will become the property of Messiah Village. <2> We have invested $6094.00 in a burial trust with the Jacob Engle Foundation. This will be held in trust, with the interest accumulating, until the decease of the first spouse. After funeral expenses have been paid, the balance will remain in trust until the decease of the second spouse. After the funeral expenses have been paid for the second spouse, the balance will be placed in the estate. If there is a shortfall toward funeral expenses, that amount shall be paid from the estate. <Two lots have been purchased in the Grantham Memorial Park. Arrangements have been made with Gerald Weaver, Funeral Director, for our respective funerals.) Lela M. Hostetler "'' .~ rel ~ ~~ rn er Witnesses of the above signature ~ "'~ ~' -=% !- ~ ~ ~~~ ------ ------------ Tj "-! Lb 1.~ s'7i Kenneth D. Mark 2~ ~' c~ - r ~~- - ---------- ---- Daniel E. Deyhle BRETHREN IN CHRIST CHURCH Office of the Convention Director Paul Hostetler, Grantham, PA 17027 • (717) 766-2621 4 ~¢/ W Z~ f~\ °~ :~ ., y Codicil to LAST WILL AND TESTAMENT, Lela Margaret Hostetler Dated December 2nd, 1966 Date of codicil - April 10, 1978 All provisions of the above mentioned will shall stand except Item 2. which is herewith replaced with the following: I NOMINATE, CONSTITUTE AND APPOINT Beth L. (Hostetler) Mark, Karen F. (Hostetler) Dehyle, and Helen K. (Hostetler Gruenewald to be Executors of this my will. ~~ ?~~~ ~~ Lela M. Hos a er Witnesses of the above signature Kenneth D. Mark Ric and A. Gruenewald rv ~.; ~ ~ ~~ -.mot ~ C ~ t -:~ ~'..y ~ ~ }-- ' ~`1 ,~ ~ L/.)