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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: Catherine G. Lange File No: ~ ~ - ~ <~ - (, ~ ~~
a/k/a: (Assigned by Register)
a/k/a:
a/k/a: Social Security No:
Date of Death: March 23, 2012 Age at death: 88
Decedent was domiciled at death in Cumberland County, pennsylvania (stare) with his/her last
principal residence at 17 South West Avenue Shiremanstown 17011 Shiremanstown Cumberland
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at 17 South West Avenue Shiremanstown 17011 Shiremanstown Cumberland PA
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 $ 403,000.00
If not domici~d in Pennsy[vania ........................ Personal property in Pennsylvania $ ~ BB
If not domiciled in Pennsy!vania ........................ Personal property in County $ ~ 00
Value of real estate in Pennsylvania ......................................................... $_ ~ Op
TOTAL ESTIMATED VALUE.... $ 403 000.00
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
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 January 20, 2011
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 born or
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
NO EXCEPTIONS ~ EXCEPTIONS
Q B. Petition for Grant of Letters of Administration (If applicable)
c. t. a., d. b. n., d.b.n.c.t.a., pendente lite, durante absentia, durante minoritate
If Administration, c.t.a. or tLb.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.
NO EXCEPTIONS ~ 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
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Form RW-02 rev. !0////20]1 Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF CUMBERLAND
.ter . ,_,,~.
~O fCia'i3st<Onlq ' ~_,~J-
,t . - !GI
f
~.. ._ (;nisi ~~ ~i`"I ~~ .^7
Petitioner(s) Printed Name Petitioner(s) Printed Address ;,,
Jack E. Lane v_
17 South West Avenue Shiremanstown PA 17011 C~)~Q`;J!.1"<,{~i } (;Q , 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 Perscnal Representative(s) of the Dece ent, the Petitioner(s) will well and truly administer the estate according to law.
Sworn to cr affirmed and subscri'aed before ~~ Date ~ -Z 4' - / ~,
1 t
me this. ~ ,day of ~ ~ C C ~ 't ~, ~_ Date -~
By '~ ,t~~1. C'tl
Date
For the Register ~ Date
BOND Required: ~ YES A NO To the Register of Wills:
FEES: Please enter my appearance by my signature below:
Letters ..................... .
( 10) Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other
........
Will Fee
~ 410.00
40.00
15.00
Automation Fee ............... 5.00
JCS Fee . .................... 23.50
TOTAL ..................... $ 493.50
Attorney Signature:
Printed Name: John E. Slike
Supreme Court
ID Number: 6262
Firm Name: Saidis, Sullivan & Rogers
Address: 63_S North 12th Street Suite 400
Lemoyne PA 17043
Phone
Fax:
Email:
717-737-3405
DECREE OF THE REGISTER
Estate of Catherine G. Lanee File No: ,~ ~ - q ~ - C'; ~j
a/k/a:
AND NOW, ~T~s ~~ (' `E L-J C~ ~''~ I ~ , in consideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters Testamentary
are hereby granted to Jack E. Lange
in the above estate and (if applicable) that
the instrument(s) dated January 20, 2011
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
Form RW-02 rev. 10/!1/2011
~~a ~ nr ~C~ . ~~ l tit( i -~~ r~) het i l'1~~',
Register of Wills
Page 2 of 2
N l n9-kps RHV poi i I i
~~~QG~!-l~F~ISTRAR'S CERTIFICATION OF DEATI•i
~~;`1fil7~RNIN~~!`L~,'~ys illegal to duplicate this copy by photostat or photograph.
Fee for this certificate~~i~~~~ ~g ~~ ~' 3~ 'f his is to I.~ertify th<(° t}re information 1(e -e ri~(~^ i5
correctly copied trOrn an original Certifica c of Death
CiLE~~ Q~ duly filed with nc~ ~J; ! Deal Regrstrar. Tie c)rrgir7al
QRP~'S v~Vi-1~ Certificate will be forwarded to the ';tale ;%ita!
~,~1~~~~1 ~~~~') ('t~ , pA Records Office fbr f)r~rm~anent tiling.
P 1861558 MA 2 s 12
--- --- a~
- --1~' ~------ --- g_ __~__ _
Certification NwnbeJ Local Registrar fate !sued
Type/Print In COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS
Permanent
reef-~•, ~, n .
--- - • • • ~_-.. ~ v r - • ,"", Slate File Number:
1. Decedent's Legal Name (First, Middle, Last, Suffix)
2. Sex 3. lal Sacurl~r Number 4. Data of Death (MO/Oay/Vr) (Spell Mo)
Catherine G. Lan a F
~`j8-l
-3
y
emale
33 ~ March 23, 2012
Sa. Age-Last Birthday (Yrs) 6b. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Da
/N
l
y
ear) (Spe
l Month) 7a. Birthplace (City and State or Forei
gn Country)
Months Days Hours Minutes
PA
gg Scranton,
July 29 , 1923 7b. Birthplace (County) Lackawanna
ga. Residence (State or Foreign Country) 86
Residence (St
d
.
reet an
Number -Include Apt No.) Bc. Did Decedent Llye in a Township?
Perna lvania
17 South West Avenue OYes, d«eeent used In
gd. Residence (County)
_ twp
Cumberland
8e. Residence (Zip Code) 17011 ENO, decedent Ilved within limits of Shiremanstown
9
Ever In US A
d
.
rme
tiny/boro.
Forces? 10. Marital Status at Tlme of Death ®Married Q Widowed 11. Surviving Spouse's Name (If wife
~ yes ~ No ~ Unknown ~ Di
given a
i
fi
,
pr
or to
rst marriage)
vorced ~ Never Married ~ Unknown Jack E
Lan
12
F
h
'
.
.
at
ge
er
s Name (First, Middle, Las[, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last)
Thomas Gallagher
Elizabeth Chamoni
14a. Informant's Name
g 14b. Relationship to Decedent 14c. Informant's Mallin Address (Street and Number, Ci
Jack E
Lan a
°
_
Husband 17 S. West Avenue, Shiremanstown,
pA 17011
s -. iSa. P ace o Deat
If Death Occurred in Hos Ital- rw ------•--.---•---------~-•~--~ ..................... ec on y one
P 1_I Inpatient
If D
th O
++
--~------•------"--'----"
- ~
;
ea
fr
ccurred Somewh
~w ..............
ere Other Than a Hos ital- wr
----~--'---'--"'--
P - U Hos Pice Facility -----'-----'•------"
Q Emergency Room/OU[patlent (] Dead on Arrival
cal Decedent's Home
(] Nursing Home/Long-Term Care Facility Other (Specify)
15b. Facility Name (If not instlTUtion
glue street antl n
b
•
~ ,
um
er;
15c. City or Town, State, and Zip Code lSd. County of Death
17 South West Avenue
StLiremanE:town, PA 17011 Cumberland
16a. Method of Dlsposltion B
i
l -
~ ur
a
0 Cremation 16b. Date of Disposition 16c. Place of Dlsposltion (Name of cemetery, crematory, or other place)
O Removal from States (] Donation March 27
,
otnar(sP«Ify) 2012 Rolling Green Cemetery
16d. Location of Dlsposltion (City or Town, State, and 21p) 1Za. Signet of ral 5 rvice Li
~ censee or Person in Charge of Interment IZb. License Number
Camp Hi11, pA 17011
§ FS 012 849 L
11c. Name and Complete Address of Funeral Facility
P
h
I
~ art
emore FH & CS, Inc., p.0. gox 431, New Cumberland
PA 17070
'
,
16. Decedent
s Education -Check the box that best describes the 19. Decadent of Hispanic Orlgln -Check the
'
20. Decedent
s Race -Check ONE OR MORE races to Indicate what
highest degree or level of school completed at the time of death. box that bast describes whether th
d
e
ecadent the decedent considered himself or herself to be.
Q 8th grade or less Is Spanish/Hls
l
/L
"
"
pan
c
atino. Check the
NO
Np di 1 f~ White
~
pma, 9th -
Q Korean
2th grade b x if d
d
C
a
ece
ent is not Spanish/Hispanic/Latino. 0 Black or African American Q VieTnamese
Q H
g
h
ool
rad
u too
E
D com
lated N
o
m
e
o
C
^
°
e
o, opt Spanish/Hlspanlc/Latino ~ Amer can Indian or Alaska Native ~ Other Asian
5 e c Ileg cr dit, but degre ~ Ves
Me
i
M
i
l
,
x
can,
ex
can American, Chicano ~ Aslan
(] Associate degrees (e.g. AA, AS)
lndian ~ Native Hawallan
(] Ves
Puerto Rica
,
n ~ Chinese
Q Bachelor's degree (e.g. BA, AB, BS)
Cuban ~ Guamanian or Cham orro
Yes
,
Q Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Filipino 0 Samoan
~ Yes
other S
anish/Hi
i
,
p
span
c/Latino ~ Japanese Q Other Pacific Islander
Dottorate (e.g. PhD, EdD
or Professional degree
(Specify) (] Ocher (5
. MD DDS DVM LLB JD pacify)
21. Decedent's Single Race Self-Designation -Check ONLY ONE to indicate what the deced
t
en
considered himself or herself to be. 22a. Decedent's Usual Occupation -indicate
White 0 Japanese 0 Samoan
tYPe of work
done Burin
(] Black or African American ~ Korean - 0 Other Pacific Islander g most of working life. DO NOT VSE RETIRED.
0 American Indian pr Alaska Native Q Vietnamese ~ Don't Know/Not Sure
Homemaker
Q Asian Indian 0 Other ASlan ~ Refused
Q Chinese 0 Natlva Hawallan ~ Ocher (Specify) 22b. Kind of Business/Industry -
0 FIIIPIno ~ GuamanianorChamorro
Domestic
ITEMS 2Sa - 23d MUST BE COMPLETED 23a. D~ ro~ tine ~ed ly)o pa r) 23b. Sig elute of Person Pronouncing Death Only when applicab j 23c. Ucanse Number
By PERSON WHO PRONOUNCES OR 3 U a-
CERTIFIES DEATH - ,-s (
~~~ ~O~
2 e Sighed ( o/D ~ 24. Tim th _ - vl/MY~(~`/'
0
r o
25. a Medical Examiner o or Her Contstted 0 Yes No
CAUSE OF DEATH
26. Part 1. Enter the chain of events--diseases, Injuries, or complications--that directly ce used [he death
APProximate
DO NOT
.
enter terminal a ants such a
rasps ratory arrest, or ventACUlar fibrillation without howin t v s cartllac arrest Interval:
s g he etiology. DO NOT ABBREVIAT
E
E
n
te
r
onl
.-
y one cause on a line. Add additional Ilnes if necessary ( Onset to Death
~
y
--
-
-
IMMEDIATE CAUSE ---------
L C` ~- ~~~G
------> a.
_ ~ ~, K
(Final disease or condltlon Due to ( r nee If)
resulting in death) / (S (/ , t ~
b. _C 1 F >^ hB-4 -~' a ~ ~
°
~ ~/' a iti ~
-,
Y~
Sequentially Ilst conditions, Du
3
t
`
e
o ( r eq uance of):
If any, leading ip the cause as a
listed on Ilne a. Enter the
UNDERLYING CAUSE
Due t° o sequence o
(disease or Injury that ( r as a con f): -
F tnltlated the events resulting d.
~ in death) LAST. Due to (or as a consequence of):
26. Part II- Enter char I Ifl d ath but not resulting in the underlying cause given in Part I 27
Was an
t
~~ C ~~
~
~
~ .
au
ops
l./L
_ ~ Yes Y Perfo Nmoed?
~L
I
~ 28. Were autopsy findings available
to
l
3
!
E co p
ate the cause o eath?
(] Ves No
29. If Fe le: 30. Did Tobacco Use Contribut
t
D
Na
ag
°~ e
o
eath?
~
ot pregnant within past year 31. Ma~^ of Death
Q Pregnant at Time of death ~ ~ Probably •~Natu ral 0 Homicide
NO ~ Unknown
N
Q
ot pregnanT, but pregnant within 42 days of death
(] Accident 0 Pending Investigation
~ ~ Not pregnant, but pregnant 43 days So 1 year before death 32
Date of In Suicide
~ Q Could not be determined
(M
Ju
.
ry
o/Day/Vr) (Spell Month)
~ Unknown if pregnant within the past year
33. Tlma of Injury
34. Place of Injury (e.g. homes; construction site; farm; school) 35
Lo
ti
.
ca
on of Injury (Street and Number; CI
ty, State, Zip Code)
36. Injury at Work 37. If Transportation Injury, Specify:
3g. Describe How Injury Occurred:
Q Yes 0 Driver/Operator ~ Pedestrian
~ No ~ Passenger ~ Other (Specify)
39a. Certifier (Check only one):
~L'@rti/ying physician - To the bast of mV knowledge, death occurred due to the cause(s) and
m Hoer stated
(] Pronouncing 8. Certifying physician - To the best of my knowledge, death o red at the ti
d
c
me,
ata, and place, and due to the cause(s) antl m
Q Medical Examiner/ - n the basis of or inv i
r I
n
n my opinion, deat~urred a[ the time, data, and place, and due to the cause
Signature of certifier
Title of certifier: Cleanse Numbe ~~L-,./L
39b.
! /~Q
Addre
s
and
i
C
,
•-
}y-
~
p
o a yf P ~n Completing Cause of ea
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th (It m 26) c~•
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l i•G~Y
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Registrar's Distri
J
t N
.
c
um 41. Registra Ig lure
42. gistrar fie Date (Mo Day
~ / _ a /'
4 3. Amendments
-~~°~ G ~~o / Z
DlsposlTion Permit No. D ~ • O l 52. H105-143
REV 07/2011
LAST WILL AND TESTAMENT
OF
CATHERINE G. LANGE
G.~
L~
,-,y I, CATHERINE G. LANGE, of Shiremanstown, Cumberland County, Pennsylvania,
,~
~~ ha~s~ revoke my prior wills and declare this to be my will:
. ~.
~~~
L~r jL-•
~ v, ~ GIFTS
~~~! I. Personal and Household Effects: I give all my articles of personal or household use,
1
!.~ ..J
including automobiles, together with all insurance relating thereto, to my husband, JACK E.
LANGE, if he survives me by sixty days. If he does not survive me, then I give all such property
and insurance in accordance with a written list made by me during my lifetime. In the absence of
a list or designation on a list, then I give all such property and insurance thereon to my children as
so survive me, to be divided among them as they may agree or, in the absence of agreement, as
my Executor may think appropriate.
In making the division of my personal property, consideration shall be given to giving
certain items, which are appropriate, to the children of our deceased daughter, Patrice.
My Executor may make whatever arrangements my Executor deems appropriate for
storing and delivering articles of personal or household use to the beneficiaries, and may pay the
cost thereof and any related expenses including insurance from my residuary estate.
II. Residuary Estate: I give the residue of my estate, real and personal:
A. To my husband, JACK E. LANGE, if he survives me;
B. If my husband does not survive me, the residue shall be divided into three equal
shares and;
1
C ~~
(1) one share shall be paid to my son, Paul R. Lange, or if he is deceased, to his
issue per stirpes;
(2) one share shall be paid to my daughter, Rosemary Hill, or if she is deceased, to
her issue per stirpes; and
(3) one share shall be divided among the children of our deceased daughter,
Patrice, or their issue per stirpes.
III. Disclaimer: In addition to any disclaimer rights conferred by law, I authorize my
spouse, within nine months of my death, to disclaim in whole or in part any interest, benefit,
right, privilege or powers granted under my Will or otherwise conferred on my spouse through
joint ownership or designation. The disclaimer shall be in writing executed by the beneficiary or
his or her guardian, committee, executor, administrator or other representative delivered to my
Executor and filed in the court having jurisdiction over my estate or as otherwise provided by
law. Any interest, benefit, right, privilege or power disclaimed under this provision including the
principal supporting any disclaimed income interest shall pass or be distributed as though my
spouse has predeceased me.
IV. Powers of Appointment: No provision of this will shall exercise any power of
appointment I may have.
V. Adopted Persons: Persons adopted during minority shall be considered as
children of their adoptive parents, and they and their descendants shall be considered as
descendants of their adoptive parents.
FIDUCIARIES
VI. Guardian: My daughter, Rosemary Hill, shall be guardian of any shares of my
2 C-~
estate which are payable to the children of our daughter Patrice, until they respectively attain the
age of 21. As guardian, my daughter, in her sole discretion, may pay income as well as principal
to or for the support and education of her children and may pay said sums to their stepfather, Dan
Kyle, or to any person who is caring for our daughter's children without further responsibility. As
each child attains the age of 21, the guardianship shall terminate and that beneficiary's share shall
be distributed to him or her.
VII. Executors: I appoint my husband, JACK E. LANGE Executor under this Will.
Should he fail to qualify or cease to act as such, then I appoint my daughter, ROSEMARY HILL,
as Executor in his place. My Executor shall not be required to post bond in this or any
jurisdiction.
VIII. Survivorship: My husband shall be deemed to have survived me if the order of
our deaths is not clear. Any persons other than my husband shall be deemed to have predeceased
me if the order of our deaths is not clear.
IN WITNESS WHEREOF, I have hereunto set my hand and seal on this, the ~4'~
day of ~-p-
.~ ~' ~~^
i ~~ ~,_~(SEAL)
CATHERINE G. LANGE ~~
In our presence the above-named Testatrix signed this and declared it to be her will, and now at
her request, in her presence, and in the presence of each other, we sign as witnesses:
~ Name Addr ss
.>
Name
Address 1 ~ ~~~
3
COMMONWEALTH OF PENNSYLVANIA)
COUNTY OF CUMBERLAND)
SS
WE, the undersigned, the Testatrix and the witnesses, respectively, whose names are
signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned
authority that the Testatrix signed and executed the instrument as her Last Will and Testament
and that she signed willingly (or willingly directed another to sign for her), and that she executed
it as her free will and voluntary act for the purposes therein expressed, and that each of the
witnesses, in the presence and hearing of the testatrix signed the will as witnesses and that to the
best of their knowledge the Testatrix was at that time eighteen years of age or older, of sound
mind, and under no constraint or undue influence.
Subscribed, sworn to and acknowledged before me the Testatrix, and subscribed and sworn to
before me by both witnesses, this o20~-r`. day of
I ~o~t
l f~
otary Public
COMMONWEALTH OF PENNSYLVr1NIA
NOTARIAL SEAL
CYNTHIA J. RULE, ^dotary Public
Lemoyne Boro., Cu^~berland County
My Commission Expires Februar,~ 3, 2012
4
~'~
Testatrix