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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
Name: Adams, Denita L.
a/k/a: Adams, Denita Lynne
a/k/a:
a/k/a:
Date of Death: February 20, 2012
File Noel ~ ~~ ~ 1~
(Ass:igned by Register)
Social Security No: 206-36-2036 _
Age at death• 55
Decedent was domiciled at death in Cumberland County, pennsylvania (Stare) with his/her last
principal residence at 149 N. Middlesex Road, Middlesex Township, Carlisle, Cumberland County
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at 149 N. Middlesex Road, Middlesex Township, Carlisle, Cumberland County., Pennsvlvania
Street address, Post Office and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania ............................ All personal property $ 5,000.00
If not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $
If not domiciled in Pennsylvania ........................Personal property in County $
Value of real estate in Pennsylvania ......................................................... $ 100,000.00
TOTAL ESTIMATED VALUE.... $ 105.000.00
Real estate in Pennsylvania situated at: 149 N. Middlesex Road, Middlesex Township, Carlisle, Cumberland County
(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
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated June 11, 2007 and Codicil(s)
thereto dated
State relevant circumstances (eg. renunciation, death of executor, etc.)
Except as follows: after the execution of the instrument(s) 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 bom 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 (If applicable)
c.t.a., d.b.n., d.b.n.c.t.a., pendenter life, durante absentia, durante minoritate
If Administration, c.t.a. or db.n.c.~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 fir 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/have ascertained that Decedent left no Will and was survived by the following spd~e (if any) and ors (atta~ ~,.
additional sheets, if necessary): ~,. (~, -_ , i-r~
Name Relationshi Address ~7 - ~
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yam. _ IU
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Form RW-02 rev. 10/11/101 / Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF Cumberland
}
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Petitioner(s) Printed Name Petitioner(s) Printed Address
Debra A. Adams 231 W. Rid a Street Carlisle Penns lvani 'C ' ~ ~
UMR~RI. ~,;~; C~, ~ . PA
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 Dece ey~i t, therPetitioner(s) ~rjl well~a~jd truly administer the estate according to law.
Sworn to or affirmed and subscribed before /-~1~~ ~(iG~:r~~ Date ~ ~__._.
me this day of , ~2 Date
By: Date
For e Register Date
BOND Required: ®YES Q NO To the Register of Wills:
FEES: Please enter my appearance by my signature below:
Letters ..................... .
( 5) Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other Will ....... .
$ 260.00
20.00
t 5 nn
Attorney Signature:
Offici~aJ,U~~nly
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e
{ ~r 1i41-~ CJ
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Printed Name: Robert C. Saidis, Esquire
Supreme Court
ID Number: 21458
Firm Name: Saidis, Sullivan & Rogers
Address: 26 W. High Street
Carlisle„-PA 17013
........
Automation Fee ............... 5.00
JCS Fee ..................... 23.50
TOTAL ..................... $ 323.50
Phone: (717)243-6222
Fax: (7171243-6486
Email: rcaidis ssr-attnrneya cnm
DECREE OF THE REGISTER
Estate of Adams. Denita L. File No: ~ I ~~
a/k/a:
AND NOW, ~ U ~t~, in consider tion of the fore oing Petition,
satisfactory proof hav g been presented before me, IT S DECREED t Lett rs _
are hereby granted to
in the above estate an (if applicable) that
the instrument(s) dated
described in the Petition be admitted to probate and filed of record as the last Will (and Codi ' s)) of D cedent.
Re ister of it ~~ -
Form RW-02 rev. 10/11/2011 ~ P e 2 of 2
H 105.305 REV 19/11)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: li'~~~~~'~t~"~~te this copy by photostat or photograph.
.. I ' 7 _.L.Ij
Fee for this certificate;, $6.00
P 18211041
;,`~
Certification Number
Type/Print In
Permanent
Black ink
'~~2!~,+~R 12 ~Fi
cI~R~ of
ORPHAN`S COUP -1
CUM(~ERl, ANf~ ~~ ~ ,~
This is to certify that the information here given is
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
Records Office for permanent filing.
a ~ , ;.
~ ~~ ,,~ /~ 3 2"12
Local Registratl Date Issued
COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS
CERTIFICATE ~F DEATH _..
1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/V r) (Spell Mo)
Denita L ne Adams Female 206 36 :>_036 February 20, 2012
Sa. Age-Las[ Birthday (Vrs) Sb. Vnder l Year Sc. Under 1 Da 6. Date of Birth (Mq/D ay/Near) (Spell Month) ]a. Birthplace (City and State or Foreign Country)
Months Days Hours Minutes MarCl'1 25 , 1956
55 ]b. Birthplace (County)
Sa. Residence (State or Foreign Country) 8b. Residence (Stre t and Number -Include Apt No.) Sc. Did Decedent Llve in a Township?
Penns lvania =. 149 N. Middlesex Road Yes, decedent lived in _ MiddleseX Twp.
Bd. Residence (County)
Cumberland 8e. Residence (Zip Code) Q NO, decedent lived within limits of city/born.
9. Ever in VS Armed Forces? 10. Marital Status at Time of Death Q Married Q Widowed 11. Sun•iving Spouse's Name (If wife, give name prior to first marriage)
Q Yes ®No Q Vnknown Q Divorced ® Nev r Married Q Vnknown
12. Father's Name (First, Middle, Last, affix) 13. Mother's Name Prior to First Marriage (First, Middle, Last)
Veda J_Ci
14b. Relationship to Decedent
nt's
N a(n
e
14a
l ~pr ~a 14c. Info cgtant'[SJM aillp¢.ry¢d rpss (St G9et ;nd lLLU mber~CitK StatwZip GokJ+13
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b isa. P ace o eat on y one .....
........... ............. ......... ....... ....... ............
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... ...... .. ... ..
.......................................................... .................................... ..r
If Death Occurred in a Hospital: ~ Inpatient ; .
..............................
...
.
..
.
If peach Occurred Somewhere Other Than a Hospltai: ~ Hospice FaclilTy Decedent's Home
_
° Q Emergency Room/Outpatient [~ Dead on Arrival
• Q Nursing Home/Long-Term Care Faclilty Other (Specify)
oaC 156. Faclilty Name (If not Instil uiion, glue street and number; SSc. City or Town, States, a d Zip Code iSd. County of Death
149 N_ Middlesex Road Carlisle"PA 17013
16a. Method of Disposition Q Burial ~ Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place)
m p RemoYal from state o D°nati°" Ho££mari-ROtYl 1?uneral Home and Crematory
.it' Other (Specify)
16d. Location of Disposition (City or Town, State, a^^' xip)..7013 1]a igna re °f Funeral Service r Person in Chxirge °f Interment 1]b. License Number
~ 219 N_ Hanover St_ Carlisle _--~-' 013144E
0 1]c. Name and Complete Address o7 Funeral Facili
Ho££man-Roth Funera~ Home and ematoryf 219 N. Hanover St., Carlisle PA 17013
18. Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to indicate what
t- highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be.
Q 8th grade or less is Spanish/Hispanic/Latino. Check the "NO" ® White Q Korean
~ No diploma, 9Th - 12th grade box If decedent is not Spanish/H(spanic/Latino. Q Black or African American Q Vietnamese
High school graduate or GED completed Q No, no[ Spanish/Hispanic/Latino Q American Indian Or Alaska Native Q Other Asian
Some college credit, but no degree Q Yes, Mexican, Mexican American, Chicano Q Asian Indian Q Native Hawaiian
Q Associate degree (e.g. AA, AS) Q Ves, Puerto Rican Q Chinese Q Gua manlan or Chamorro
Q Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban Q Filipino Q Samoan
Q Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Yes, other Spanish/Hispanic/Latino Q Japanese Q Other Pacific Islander
Q DocTOrate (e.g. PhD, EtlD) or Professional degree (Specify) Q Other (Specify)
. MD, DDS DVM LLB JD
21. Decedent's Single Race Self-Designation -Check ONLY ONE to Indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation - Indicate type Of work
White Q Japanese Q Samoan done during most of working Ilfe. DO NOT USE RETIRED.
Q Black or African American Q Korean Q Other Pacific Islander Clerical
Q American Indian or Alaska Native Q Vietnamese Q Don't Know/NOi Sure
Q Asian Indian Q Other Asian Q Refused 226. Kind of Business/Industry
Q Chinese Q Native Hawaiian Q Other (Specify)
Q Filipino Q Guamanian or Chamorro Federal GOV ' t
ITEMS 23a - 23d MUST BE COMPLETE 23a. Dace Pronounced Dead (Mq/Day Vr) 23 .Signature Of Person Pronouncing Death (Only when app icablej 23c. License Number
BY PERSON WHO PRONOV NOES OR
CERTIFIES DEATH ~.r--._iL~ ~, /a_`.
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I~ B _
23d. Date Signed (MO/Day/V r) 24. Time of Death (~/~,
z0 'a0 ~¢_- 25. Was Medical Examiner or Coroner Contacted? Q Ves ~ N°
CAUSE OF DEATH Approximate
26. Pert 1. Enter the chain of events--diseases, injuries, o mplicatlons--that directly caused the death. DO NOT enter terminal a ants such as cardiac arrest Interval:
°w^ng the etiolog~NOT ABBREVIATE._Erit ly on< C~s~ n a Ilne. Add additional lines if necessary Onset [O Deat~
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O
respiratory arrest, or ventr'ICUIar flbrlll ~ ~~ s
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IMMEDIATE CAUSE ---------------> a. ~ r1 """-'--~ 1 CT r ~ aT
(Final disease o ondition Due to (qr as a consegU ante of):
resulting in death)
b.
Sequentially list conditions, Due to (or as a consequence of):
if any, leading to the cause
listed on Ilne a. Enter the
UNDERLYING CAUSE Due to (or as a consequence of):
(disease or injury that
i fed the events resulting d.
'
c death) LAST. Due to (or as a consequence of):
in
s 26. Part 11. Enter other sianlficant conditions contributing [o death but not resulting in the underlying cause glYen in Part I 2]. Was a autopsy pe mad?
_ Q Ves N°
~ 28. Were autopsy findings avaliable
La complete the cause of death?
Q Yes Q No
29. If Female: 30. Did Tobacco Vse Contribute t0 Death? Manner of Death
3
1
o ~NOt pregnant within past year .Ves Q Probably ~~
rr
-tlF Natural Q Homicide
Q Pregna time of death Q N° Q Unknown 0 Accident Q Pending Investigation
~' Q Not pregnant, but pregna ni within 42 days of deatf Q Suicide Q Could not be determined
~ Q Not pregnant, but pregnant 43 days t° 1 year before death 32. Dale of Injury (MO/Day/Vr) (Spelt Month)
Q Unknown if pregnant within the past yeal 33. Time of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Num be •, CI[y, State, Zip Code)
36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred:
Q Yes Q Driver/Operator Q Pedestrian
~ No Q Passenger Q Other (Specify)
Certifier (Check only one):
Certifying physician - To the. besT of my knowledge, death o tarred due to the cause(s) and manner stated
Pronouncing 8a Certifying physlci n - To the best of my knowledge, death occurred a[ the [Ime, date, and place, and due to the cause(s) and manner stated
Q Medical Examiner/COr n he basis f examination, and/or Investigation, In my opt nlon, de th o
u rred at the time, date, and place, and due t°
t
he
c~a use ) d d
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Signature of certifier: Title of certifier:
L License Number:r 1/ ~~
396. Name, Address and Zip Code of Person Compl In Cause of Deaf (Item 2
t
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~ ~ 3 c. D to Sign (MO/Day/Vr)
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ZS 2 , -~ ~~c i ~-e 2! L
40. Registrar's District Number 41. R stray's Signature 42. Registrar File Dale M° Day r)
43. Amendments '
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l _1 ~Z 30 ~{ a 3 H105-143
Disposition Permit No. REV 0]/2011
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CIE~'~K CF
+~Rph~~~~'S ~+tJ~=~T
LAST WILL AND TESTAIV~~1~R`-~`T~~r' ~'~" ~~
OF
DENITA L. ADAMS
I, DENITA L. ADAMS, of 149 North Middlesex Road, Carlisle, Cumberland County,
Pennsylvania, declare this instrument to be my Last Will and Testament, in manner and form
following:
F RST: I hereby expressly revoke all Wills and Codicils heretofore made by me.
SECOND: I hereby direct my Executor to pay all my just debts, funeral and
administrative expenses out of my estate, as soon as practicable after my death.
T IRD: I direct that all taxes which may be assessed in consequence of my
death of whatever nature and by whatever jurisdiction imposed shall be paid out of my estate
as a part of the administration of my estate.
FOURTH: I give and bequeath such of my personal property as may be listed on
SAIDIS,
FLOWER Sz
LINDSAY
.+r~otwevs.,vuw
26 West High Street
Carlisle, PA
an unsigned memorandum kept with my Will to persons named thereon, provided they survive
my death. Should such a memorandum not be found with my Will, it shall be conclusively
presumed that none was prepared, and all of my personal property shall be considered a part
of the remainder of my estate.
FyFTH: I hereby give to JEREMY J. SHUGHART, of Carlisle, Pennsylvania,
MATTHEW W. SHUGHART, of Carlisle, Pennsylvania, and JOHN E. SHUGHART, of
Shermans Dale, Pennsylvania, my home at 149 North Middlesex Road, Carlisle, Cumberland
County, Pennsylvania, should I own it at the time of my death.
S XTH: All the rest, residue and remainder of my estate, be it personal or real,
of whatsoever nature and wheresoever situate, I hereby give, devise and bequeath to
STANLEY K. ADAMS, of Carlisle, Pennsylvania, and DEBRA A. ADAMS, of Carlisle,
Pennsylvania, in equal shares, or their issue, per stirpes,
EIGHTH: I hereby nominate, constitute and appoint DEBRA A. ADAMS, of
Carlisle, Pennsylvania, to be the Executrix of this my Last Will and Testament. No personal
representative shall be required to file bond in this or any other jurisdiction.
IN WITNESS WHEREOF, I hereunto set my hand and seal this ~ ~ ~~' day of
SAIDIS,
FIAWER &z
LINDSAY
nrtotweYS•xruw
26 West High Street
Carlisle, PA
.~ ' .t ~ l,Z. , 2007.
.~~~L.AI - C,CLYGirnJ
Denita L. Adams
SIGNED, SEALED, PUBLISHED and
DECLARED in the presence of:
_-w~~~ _ ~
2
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF CUMBERLAND
I, DENITA L. ADAMS, whose name is signed to the attached or foregoing instrument,
having been duly qualified according to law, do hereby acknowledge that I signed and
executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free
and voluntary act for the purposes therein expressed.
Swom or affirmed to and acknowledged before me, by Testatrix, this ~L~' day of
2007.
.CX t~~G~ 9 1
Testatrix
Not~rv Public
NOTARI tA~8EAL
M4ERtENE J. MARHEVKA, lNOT1111Y PUSL~
M COMMISSIONREXFIRES,1201®
SAIDIS,
FIAWER ~
LINDSAY
~.~W
26 West High Street
Carlisle, PA
3
COMMONWEALTH OF PENNSYLVANIA ,
ss.
COUNTY OF CUMBERLAND ,
We, ~1. h~r~ ~ . ~f ' e ~ and / C~ Q ~--- L1JQf _ ,the
witnesses whose names are signed to the attachegoing instrument, being duly
qualified according to law, do depose and say that we were present and saw Testatrix sign and
execute the instrument as her Last Will; that she signed willingly and that she executed it as
her free and voluntary act for the purposes therein expressed; that each of us in the hearing
and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge
the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint
or undue influence.
Sworn or affirmed to and subscribed to before me by t ~ ~ ! and
/C~~~ vcz L . ~ )(~..r~, witnesses this r 1 da of , 2007.
-~
~' ~
~.._
Witness
SAIDIS,
FLOWER ~
LIl~IDSAY
n~'iowvexs~,u~uw
26 West High Street
Carlisle, PA
~~
Witne s
Notary Public
NkERt.ENE J.
CARLISLE,
fv1Y CUMMIS
._..__~~
IItEhLENE J. MN1EI
CARLISLEE~ ql
{ MY COMAM881L
1EN1(A, NOTARY PI!R~.
3ERLAND Ct?UA~-~ ~'
EXPIRES JUh~lt: ;~
a