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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND 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 ~ _ I~ ,~a
Name: Richard A. Walton File No: ~~
a/k/a: (Assigned by Register)
a/k/a:
a/k/a: Social Security No: 193-24-0765
Date of Death: February 15 2012 Age at death: 79
Decedent was domiciled at death in Cumberland County, Panncvlyani~ (state) with his/her last
principal residence at 216 S Enola Drive Enola 17025 East Pennsboro Township Cumberland
Street address, Post Office and Zip Code City, Townshrp or Borough County
Decedent died at Hol S irit Hos ital 503 N. 21st Street Cam Hill 17011 Cam Hill Cumberland PA
Street address, Post Office and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death: 1,000.00
!f domiciled in Pennsylvania ............................ All personal property $
If not domiciled in Pennsylvania ........................Personal property in Pennsylvania $
If pat domiciled in Pennsylvania ........................ Personal property in County $
Value of real estate in Pennsylvania ......................................................... $
TOTAL ESTIMATED VALUE.... $ 1.000.00
Real estate in Pennsylvania situated at:
(Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough County
^ A. Petition for Probate and Grant of Letters Testamentary ~`•'
Petitioners avers he/she/the is/are the Executors named in the last Will of the Decedent, dated ~ artodicil(s) ~~
() () Y () ~, ^.~ ~,
thereto dated ~ ~ f v i , ,.~
State relevant circumstances (e.g. renunciation, death of executor, etc.) 'la >> r` _.
_r:- ~ N : -
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not divorced; sv~ti e~ party to a pending; "~,
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g), and ~l~tCwe a ~iid born`or-`~;
. -r
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. ,: ~_ ~ :Y
®NO EXCEPTIONS O EXCEPTIONS ~`' -i ~ 'c9 Q
CX3
^ B. Petition for Grant of Letters of Administration (If applicable)
c.t.a., d. b. n., d.b.n.c.t.a., pendente life, durante absentia, durante minoritate
If Administration, c.t.a. or d.b.n.c.i: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.
O NO EXCEPTIONS Q EXCEPTIONS
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 (attach
additional sheets, if~necessary):
Name Relationshi Address
Kathleen M. Havran daughter 4115 Mountain View Road, Mechanicsburg, PA 17050
Carol M. Oliveira daughter 55 Ridgeview Road, Hummelstown, PA 17036
Form aw-nZ rev. toilvzntl Page 1 of 2
v-
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
}
} SS:
}
To the Register of Wills:
Please enter my appearance by my signature below:
Petitioner(s) Printed Name Petitioner(s) Pri r
Kathleen M. Havran 4115 Mountain View Road, Mechanic ~ T
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 Petitioner(s) and that, as Personal Representative(s) of the )~ e~ nt, the Petitioner(s) will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed before m' Date ~ ~ a"
me i~~sday of C ,
By• i1 D ~c 1 (mil
For the Register
Date
Date
Date
BOND Required: ~ YES ~ NO
FEES:
Letters ..................... .
( )Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other ~~•••~••
S . cstl
Automation Fee ............... ~ 6
JCS Fee .....................
'TOTAL ..................... $ ~ .00
Attorney Sign e:
' ted Name: Lisa Marie Coyne, Esq.
Supreme Court
ID Number: 53788
Firm Name:
Address:
Official Use Only
~~,_~. t.[.~_,' ' ~'t~~
~..
~
~ ~,~~
,
.i __!J
~~ i ~~ ~.
Coyne & Coyne,P.C.
ZQtll A"tarlrot Street
r;aml~jlL PA 17(]11
717-737-0464
717-737-5161
licaC~rn~nPanrlrnyna rnm
Phone:
Fax:
Email:
DECREE OF THE REGISTER
Estate of Richard A. Walton
a/k/a:
AND NOW, ~~~7 Cl,~ ~~~ , ~_, in consideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters of Administration
are hereby granted to Kathleen M. Havran
in the above estate and (if applicable) 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.
C
gister of Wills G ~ C
'~ ( ~-~Q.~I,PJ~~~ b'
Form RW-02 rev. 10/ll/2011 Page 2 of 2
File No• ,-~ ~ - 1 a - .,2
RENUNCIATION
,, ~' ~~ 0~
~- ~r~~, ~ ~ ~~~w
~t~12 FEB 22 ~tr~ $~ 28
C~~~ ~~
~P pj~~ ~i ~C ~~PA,
REGISTER OF WILLS ~
~ ,
CUMBERLAND COUNTY, PENNSYLVANIA
Estate of RICHARD A. WALTON
I, CAROL M. OLIVEIRA
(Print Name)
DAUGHTER
Deceased
in my capacity/relationship as
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
KATHLEEN M. HAVRAN
~1 /~
(Date)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of _ ,
Deputy for Register of Wills
Form R W-06 rev. 10.13.06
~~~ (~
(Signature)
55 RIDGEVIEW ROAD
(Street Atl~fress)
HUMMELSTOWN, PA 17036
(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 renunciation for the
purposes ted within on this °~7_ ( ~ ~ day
f ~,La 2e~ ~ '~
~~
of Public
My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
i~QN~'~At~A1.fM.Of ~~NNSyIY_. to
NOTa1t~kAG SEAL "
~i~a M1Mrie Boyne, Notary,Publi~
}i~rty~,owr~SbD. Guts~betlsttd County
~' ~~.,~~
LC~I~'Ai1L~=~Et~_ RAR'S CERTIFICATION OF DEATH
''' at to du licate this co b hotostat or hoto ra h.
L~ is ;~i~~ p~ pY Y p p g p
~~pp ~--~ zz a~~ s: z~
Fee for this certificate, $6.Ol~~l~ ~+- This is to certify that ',he information here given is
P
correctly copied ti~om can original Certificate of Death
C~E~ G~F duly filed with me as Loca] Registrar. The original
~~~J~ ~OURj certificate will he tixwarded to the State Vital
~~~~~~ ~~ t.~„ pA Records Ott-ice for permanent tiling.
182281.5 ~ ~ a~ ~,
Certification Number
Type/Print In
Permanent
Black Ink
w~
.~~
~_
Local Reg strar ~ L>ate Issued
COMMONWEALTH OR PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS
CERTfFICATE OF DEATH
1. Decedent's Legil Nama (Flat, Middle, Last, SuMx) 2. Sex 3. Soc1a15ecurity Number 4. Date o} Death (MO/Day/Yr) (Spell Mo)
Sa, Aga-Last Birthday (Yrs) $b. Under 1 Year Sc. Under 1 Oa 6. DaL of Birth (Mo/D ay/Year) (Spell Month) 7a. Blrthplau (City and State or Foreign Country)
Months Days Hours Mlnu[ea
7H Juns 6, '1932 7b. Birthplace (county)
ea. Residence (state or Foreign Country) 8b. Residence (SCreet and Number - Intlutle Apt No.) Bc. Dld Deddent LWe in a Townshlp7
216 3
E
l ~7vea, dedaent rayed m East Rsnrasboro twp.
Bd. Residence (County)
-
no
s Dr.
8e. Resfdenu (Ztp Cod!) Q No, decedent IWed within limits of cfty/born.
9. Ever in US Armed Forces? SO. Marital Status at Time of Death Married Widowed li. Surviving Spouse's Nama (H wife, give name prior to first marriage]
Yes {~ No [] Unknown Q Divorced Q Never Mewled Q Un wn
12. Father's Nama (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last)
14a. Informant's Nama 14b. Relationship to Decadent 14c. informant's Melling Address (STreet and Number, Gty, State, Zip Code)
gg-~~~+~+
L!
c
3 ......................................................... ..-.........-.........................,
If [>•ath Octurratl in a Hospital: '~~ Inpatllnt ; ........... ~:...~c~. ~....~at... sc on- . one .... .-... .. ....... .,. ,.. ... ......... ... ....... ....... .....
If Death Occurred Somewhere Ott~ar Than a Hospital: ~ [~ Hospiu Facility ~t Decedent's Home
a Emer enry Room/Out alien[ Dead on Arrival
, Nursln Home/LOn -Term Ore Facility Other (Specify)
SSb. Facility Nama (N not Insdtu[len, give stteN and nom W r; 15c. City or Town, State, and 21p Code lSd. County o[ Death
16a. Method of Dlspositbn Burial
Q Cremation 16b. Data of DlsposHlon lbc. Pled o1 Dlaposltlon (Nama of cemetery, crematory, or otMr place)
a
Q Removal from State Q Don tl
other (sp•tlfY>
F@b 19 20'12
vans Cremation
16d. Location of OlaposlHOn (City or Town, State, and Zlp) . SI t r of Funeral $arylen Charge of Interment 17b. License Number
~
Lgrols, PA 17640 G
FD-1386-L
17 c. Name and Complete Address of Funeral Facility
~ 18. Decedent's Edudtlon -Check the box that best describes th! 19. Decedent of Hispanic Origin -Chick the 20. Decetlent's Race -Check ONE OR MORE races to Indicate what
highest degree or Iwel of school completed at the lime of death. bon that best describes whether the dscetlent the decadent considered hlmseH or herself to be.
~ 8th grade or less Is $panlsh/Hlspanic/Latino. Chstk the "NO" White )~ Korean
Q No diploma, 9th - 12Th grade box If deddent la not Spanish/Hlspani4La[Ino. Black or African Amarfcin Q Vietnamese
High school graduaN or GED completed )~ No, not Spansh/Hispanlc/Latino )'~ American Indian or Alaska Native (] Other Asian
Some College crediT, but no degree (] Yaa, Mexican, Mexican American, Chicano 0 Aslsn Indian Q Native Hawaiian
0 Associate degree (e.g. AA, AS) )~ Yaa, Puerto Rican Q Chinese (] Guamanian Or Chamorro
Q Bachelor's degree (e.g, BA, AB, BS) ~ Yes, Cuban [] Filipino Q Samoan
Q Masters degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Yea, other Spanish/N(spanic/UUno Q Japanese ~ Other Pacific Islander
Q Doctorate (a.g. Ph O, Ed D) or Professional degree (Specify) (] Other (Specify)
. MD DOS DVM LLB JD
Zl. Decedent's Single Race Self-Oasignatlon -Chick ONLY ONE to Indidta what the decadent considered himseM or herseN to be. 22a. bacetlent's Usual Occupation - Intlicate type of work
White [] Japanese Q Samoan done during most of working life. DO NOT USE RETIRED.
Black or African American Q Korean Q Other Pacific Islander
Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure @e@tt@r
Q Asian Indian Q Other Asian D Refused 22b. Kind of Business/Industry
0 Chinese [] Nature Hawaiian Q Other (SPecNy)
)~ FIIlpino Q Guamanian or Chamorro
1 M 27a - 2S MU BE COMPLETE 3~. eta Pronounce Dea Mo Day r 23b. Sign Lure o Person Pronouncing Deet On y when app Ica e 2 License ber
BY PERSON WNO PRONOUNClS OR r N ~ it3~
CERTLiJES DGTi ~ -O ~
Cif ~• ~ /l J J
// ''--
Da C;.,.--- ~/ ~ / ~~ , (f' L G,~~~t `j~f
23d. DaM Signed (MO/DaV/Yr) 24. Time o
f
r
~
' ~~ ~-f) E ~ 25. was Medical Examiner or Coroner Contaned7 Q Vas No
CAUSE OF DEATH Approxlm.te
26. Part 1. Enter the chain of events--diseases, Injurbs, or mmplleations--that directly Caused the death. DO NOT enter terminal events such as drdlac arresT. Interval:
respiratory arrest, or yintrlcular flbrtllatlon wHh t showing the etiology. DO N07 ABBREVIATE. Enter only one cause on a Ilne. Add additional lines If necessary a Onset to Death
ou
M 1 ~ i
IMMEDIATE CAUSE ---------------> a.
/ S L[.. f ~I ~ /a3~! I'a'\ OM !1-A
~•.~.I~~
_
i
_
(Final disease Or condition Due to (or as sequenu o():
rasulting in death) I
b.
$equentlally Ilst condi[ions, Du• to (or as a Consequence of):
if any, leading to the cause
listed on Ilne a. Enter th4 c
UNDERLYING GUSE Du! (or as a co p n
ta
(disease or Injury that
f
/ ~
~
/1 n
Initiated the events resulting tl.
~SGWI Wr
~Q,JL ~/s'G /~.~
C lk_3CKS3~t_
In death) LAST. Dua to (or as • eonsagwnce of):
26. Pare 11. Enter other sl¢nifleant conditions contrlbu[Ina to death but not rasulting in the underlying cause given in Part t 27. Was an autopsy peAo dT
vas No
28
yall
p
l
e
ffi' <o eompietr
the
wus W
]
th
a
Yes
29. If Female:
Q Not pregnant within past year 30. Did Tobacco Us Co~~ Ibute to Death)
Q Vas jj~Probibly 31. M r of Death
Natural )~ Homicide
(] Pregnant at time of death 0 No Q Unknown Q Accident (] Parading investigation
°~ Q NoT pregnant, but pregnant within 42 days of death Q Suicide Q Could not be determined
)~ Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Vr) (Spell Month)
Q Unknown if pregnant within the past year 33. Time Of Injury
34. Plau of Injury (e.g, home; construction site; farm; school) 35. Location of Injury (Stroll and Number, City, State, Zip Code)
36. Injury at Work 37.1 Transportation Injury, Specify: 3B. Describe Mow Injury Occurred:
)~ Yes 0 Dreyer/Operator Q Pedestrlen
Q No 0 Passenger Q Other (Specify)
39a. Ifler (Check only one):
Certi/ying physician - To the bast of my knowledge, death occurretl tlue to the c sa(e) and m r stated
Q Pronouncing 6 Ctrtifying ysic4n - To the eat of my knowledge, death occurred at the time, date, and place, antl tlu• to the cause(s) and manner stated
(] Medial Examiner/COr - On t ml it n and/or Investigation, In my opinion, deat
h occurred at the tfine, date, and place, end due to the
nd manner atatatl
cause(s
)
a
,
u
y
~
s
~
~
~
D
~O/
~ ~
Signature of certifier:
Title of certifier: /
I
~[.(f
Licens! Number: /S
39b. e, Atldre sand ed of~rson Compl ~ng Caut! Of Death Item
i 39c. D• SI na
~ Day/Yr)
~ / ~O /
G
s /
40. Rag stray s atr et
t a
eglat
ra
l i
s g at ra _ egistnr to o oar
~~
43. Amendments
DispOSitlon Permit No. Q~ ~~7 p~ H305-143
REV 07/2031