HomeMy WebLinkAbout03-30-12PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF - ~~~~k~/V h COLTNT'Y, PENNSYLVANIA
Petitic:~~;•Iaa named beios~. who isare t~ years of ale or older. apply(iesl for Letters as specified belo•~,v, and in
suppor~ thzr~of aver(sj the ~oiiowin~ aad res ectf~;; ,; A
p 1_ r„quest~,~ the _Trant of Letters .n the aonronri;,r~ fnrm•
Decedent's Information
Name: ~~y /~u Gt~E~Tlrl/
a/k,'a.
a/k/a:
a/lu"a:
Date of Death: 20i~Z
Decedent was domiciled at death in
principal residence at g~ /,~lv.,l~~
County,
(ware) with his/her last
Street address, Post Office and Zip Code w ~ ~~~~ _~wy
City, Township or Borough County
Decedent died at L ' ~~ ~ 50tt'tH ~ l~D/ SLE uri~~~~rs~D ~'
Street address, Post Office and Zip Code City, Township or Borough Count
Estimate of value of decedent's property at death: Y State
If domiciled in Pennsylvania ............................ All personal property $
If not domici/ed in Pennsylvania ........................ Personal roe '~ ~~~ ` D~
If not domiciled in Pennsylvania ........................ Personal propel to Counsylvania $
Value of real estate in Pennsylvania ............... p p ~ ty $
TOTAL ESTIMATED VALL~E.... $ 7t~QD ~ 4/)
Real estate in Pennsylvania situated at:
(Attach additional sheets, il'necessary.) Street address, Post Office and Zip Code City, Township or Borough Count
Y
~, A. Petition for Probate and Grant of Letters Testamenta
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated _3 ~.~}%
thereto dated and Codicil(s)
State relevant circumstances (eg. renunciation, death ojexecutor, 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 Administration, c.t.a. or d.b.n.c.t.a., enter
(If applicable)
c. t. a., d.b.n., d.b.n.c.t.a., pendentelite, cftrranteabsentia, duranteminoritate
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for dive
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 bythe
additional sheets, if~necessarv):
Fm•mRW-02 rev. l0////Zpl1
~~ I ~ I
File tio• ~_ ~ ~ - 3
(.~!csigned by Register)
Social Security No: ,~_ 7~f -Zy-Q9~
Age at death: 8.
of hett3.
,- :.7C7
i estab~ied as~t4
~ ~„ _i
~J -r ~
s r ~ 1-?'`i
ifany)~d heirs.(tittucti?
Page 1 of 2
Oath of Personal Representative
COM1~tONWEALTH OF PENNSYLVANL4 }
ss:
Cni_'vTY OF ~~~~
~~ i~~
°2 ~~
Fri 3~ 35
The Petitioner(s) above-named swear(s) or affirm(s) the statements in foregoin ,tit' are tnle and correct to the best of the knowledge and belief
of Petitioner(s) and that, as Personal Representative(s) of the Dec ilt, the eti ' 'er will well and truly administer the estate acco ding to law.
Sworn to or affirmed a subscribed beforg - 3~~ ~~~
met ' day of ' r(~~1 ~ Date
$y; Date
the Register Date
Date
BOND Required: Q YES - VO To the Register of Wills:
FEES: Please enter my appearance by my signature below:
Letters .............. ...... $ - J L~
~
(
)Short Certificate(s).. .... ~~
( )Renunciation(s)...... __
.. .
( )Codicil(s) .......... .. .
( ) Affidavit(s)......... .. .
BOlld ..................... ...
Commissi n ...
...........
...
Other i
Automation Fee ............
JCS Fee . ................. .. .
...
TOTAL .................. ... $~f fY - SZ
I Attorney Signature:
Printed Name:
Supreme Court
ID Number:
Firm Name:
Address:
Phone:
Fax:
Email:
DECREE OF THE REGISTER
Estate of ~ r
a/k/a:
AND NOW
satisfactory prof
File No:~ ~I ~ o~ ~ ~-j
y
been presented before me, IT
are hereby granted to
the instrument(s) dated ~ ~ a~ i ~
described in the Petition a admitted to probate and filed
Form R6V-02 rev. !0/!1/20/!
~~~
DECREED that I
Yv `
' ~~
ord as the lest
..Q' ter of Will -
in co side ation of the foregoing Petition,
hers ~~
~~c/~Q in
in the above estate and (if applicable) that
(^,an~d Cod c- s)) of
/- W~ j `~
~~
~- ~-~;
Page 2 2
T _ _ _
ulna snc vr.~• ,..,,. ~ - - - _. _ _ _ _ __ -. - -
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNIN 't~~-cate this copy by photostat I~r photo ra h.
~~ Ar,y 1 ~, 5 p
Fee for this certificate, $6.00
P 18211480_
Certification Number
~~ TYPe/Print In
Permanent
G
yg
_Y
IPA""' This is to certif that the information here ive^ i.
~ ~'~ ~: 4 j1'' p~SH OF pE ~- Y g <
~~`; j Z i'~~R 3d tttttii~~~~, tiy~~ correctly copied from an original Certificate of Death
~~~ rte, duly filed with me as Local Registrar. The original
C~R~ ~~ ~ ,,,; z~ certificate will be forwarded to the State Vital
.o
~,~ C~U L' ~ ,a; Records Office for permanent filing.
~~ a
_ ~,,,
a,n,~~R~_av~ co.. °~~ ~~ ~
''9lMENT OF Ill"i O1Z
9 ~``PII .Q1~~1~~`nl~r~~r'MAi~ 1 2/Z
,,,,,,.,.,,,1)J~
Local Registrar Date Issued
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH ~ VITAL RECORDS
CERTIFICATE OF DEATH
Ist, Suffix) 2. Sex 3. Social Security Mumber5tate Flle Number:
MARY L . WELTON 4. Date of Death (Mo/Day/Yr) (Spell Mo)
sa. Age-Last Birthday (Yrs> sb. underl rear sc. underl Da Female. 274-24-0983 March 71, 2072
1 6. Date of Birth (MO/Day/Year) (Spell Month) 7a. BJit~pi~ (CJty and State or Foreign Country)
84 Months Days Hours Minutes 11'':: PA
fie. Residence (state or Forei count April 4 , 1 9 2 7
gn ry) 8b. Residence (Street and Number -Include Apt No.) gc. Dld Decedent Livebinfia 7'owlnsh p7 unry) Er 1 E!
Pennsylvania 85 Winchester Gardena
gd. Residence (co°ncy> ea, decedent eyed In _ North Mi dd 1 e ton
Cumber 1 and ge. Residence (ZIp Code c'^'p•
9. Ever In V 5 Armed Forcesi ) 1 7 0 1 3 Q No, decedent Ilyed wlthln limits of
Yes yr No 1 Marital Status at Tme of Death ~ Married }~ Widowed 11. Survlyln 5 city/boro.
-Lr ~ Vnknown 0 Divorced - ~ Never Married 0 Vnknown B Pouse•:: Name (If wife, giya name prior to first marriage)
12. Father's Name ((First, Middle, Last, S°Hix)
John L . SnydE'r 13. Mother's Name Prlo to First Marriage (First, Middle, Last)
14a. Informant's Name L i 11 iajn McChesney
Debra Mi 11 er 146. Relationship to Decadent lat. Informants Melling gddress (StreeQ)~.L/lrtnber, City, State, ZIp Code)
Grand Dau hter
................................................. ... . 1 146 P
............... ....r.....
ariz.sle
If Death Occurred in a Hospital: ~- ~• "••""'•"""""' a. ace o eat ec on ). pn~ 8 B an t
7013
I~ Inpatient ..........................~ ...-............. :C 1Ve.
Emergenry Room/Out ; If Death Occurred Somewhere Other Than a Hospital: ••~ ~•~~• "•""""" '•• •• _ _ ___
Patient Oead on Arrival ~ ••••••••••••-•••
Hospice Facility ~ ~• •'"•"
ursin Home/Long-Term Cara Facility Other S ~ Decedent's Home •
156. Facility Name (If not Institution, glue street and number; 15c: City or Town, State, and ZIp Code ( Pacify)
Sarah A. Todd Memorial Home 15d. County of Death-
16a.MethodofDlsposltlon Carlisle, PA 17013 Cumberland
Q Removal from State 0 Burial }~ Cremation 16b. Date of Disposition 16c. Place of DIs
Other (Specify) ~ Donation p°siHOn (Name of cemetery, crematory, or other place)
March 13~,"~ 2012.- Ronan Ftmeral Hom= CC~Y'P.[Dgt )
16d. Location of Disposition (City or Town, Sate, and ZI CI13r
Carlisle, PA 1 7013 p) 17a. Signs f Funeral Se Licen r Person in Chai
'ge of Interment 1'lb. License Number
iTC. Name and Ctomplete Address of Funeral Feclllty ~ Fes'-012909 j.,
D.`-...- x_ __
b~~J y~irt icoaa L%
e. Decedent's Education -Check th 8r 1181E PA 17013
e
Ighest de p Px that best describes The
gree or level 07 school tom laced
t
h 19. Decaden[ of Hispanic Orlgln -Check the
a
t
e time of death.
~ Hth grade or less box that best describes whether the decedent
~ No diploma, 9th - 12th grade is Spanish/Hlspa nit/Latino. Check the "No"
~ High school graduate or GED completed
~ Soma colle
d box if decedent is not Spanish/Hispanic/Latino.
~ No, not Spanish/Hi
ge cre
it, but no de
0 Associate de gr"
gree (e.g. Aq, q5) spanic/Latino
O Yes, Mexican, Mexican American
Chicano
Q Bachelor's degree (e.g. BA, AB, BS) ,
0 Ves, Puerto Rican
~ Master's tlegree (e.g. MA, MS, MEng
MEd
MSW
MB ~ yes, Cuban
,
,
,
A)
~ Doctorate (e.g. PhD, Ed D) or Professi
l d Q Yes, other 5
Panlsh/Hlspanlc/Latlno
ona
egree
. MD DDS DVM LLB JD (Specify)
L. Decedent's Single Race Self-Designation -Check ONLY ONE to In
1~}LWhlte dicate whet the dec
d
~ Japanese
~ Black or African America e
ent considered himself or
~ Samoan
n Kor
Q American Indian or Alaska Native Q Vietnames
~ Other Pacific Islander
e
Q Asian Indian ~ Other Asian ~ Don't Know/Not Sure
Chinese ~ Native Hawaiian
Q Filipino ~ Refused
~ Other (Specify)
Q Guamanian or Cha m
o
EM529a- M B CO PLETED
' PERSON WHO pRONOVNCES OR 23a. Date Prono Dea
Mo Day r Sl
23
'.RTIFIES DEATH M
///~~ ~~-
~A~_~ `
gnature o Person Pn
^
eck ONE OR MORE races to indicate what
the decadent considered himself or herself to be.
® White Q Korean
Q Black or African American Q Vietnamese
Q Amerlca~n Indian or Alaska Native ~ Other Asian
Asian Intllan ~ NaTiVe Hawaiian
Q Chinese ~ Guamanian or Chamorro
Q Filipino Q Samoan
Q Japanese Q ether Pacific Islander
~ Other (Specify)
self to be. 22a. Decedent's Vsual Occupation -Indicate type of wore
done during most of working Ilfe. DO NOT USE RETIRED.
22b. Kti~n~d of~ ~Bu~s~in~ess/Industry
HO~DIi91C171g
~.n ~ ~ iaXi%rcz!-e o?330 ~cc'~ 4`- 7"-~,c~z_.~:~_ ,e,~ ~ R^~ ~"a 34?~L
25. Was Medical Examiner or Coroner Cont ct tl7
CAUSE OF DEATH ` ~ N
26. Part 1. Enter the chain f ..
resplrato ~~~-diseases, Injuries, or complications--[hat directly caused the tlesth. DO NOT enter terminal events such as cardiac arrest 'O'PPro~imate
ry arrest, or vent Icular fibrillation without showln She etlolo Inte al:
H gy. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Ilnes If necessary
IMMEDIATE CAUSE j/~//~-N L.Ty ~j~ Dnset tq Death
------------> a. ;
(Final disease or condition ' k/{~~
resulting In death) Due to (or as a consequence of):
b. 1-I-L P FKa~-r~.tt~f~
sequentially Ilst conditions, Due to (or ~ w4-~-`
If any, leading to the cause as a consequence of):
listed on Tine e. Enter the
UNDERLYING CAUSE
(disease or Injury Shat Due to (or as a consequence of):
Initiated the events resulting d,
In death) LAST. Due to (or as a con
sequence of):
26. Part 11. Enter other si nifl tl ri t h but not resulting in the underlying cause given In Part 1
~ C otLn iV A-.~..t gr.YC..t-E~-t{ 8 t SE^ ~ z~. wa: an aut°p:Y pertormedz
ym CO'IVL~EpI ft/~- {-4'IE.MC.T f=f1d Lt,l rc.C-_ Yes
>•t 2B. Were autopsy findings avalleble
se 29. If Female: to complete the cause of death?
€ [}Slot pregnant wlthln past year 30. Did Tobacco Use Contribute to Death? 3'L. Manner of Death Yes ~ No
Pregnant at time of tleath 0 Yes ~ Probably Q~Natural
Q Not pregnant, but pregnant within 42 days of death ~_ ~ Unknown ~ Homicide
~ ~ Not pregnant, but pregnant 43 days to 1 year before death 32. Date of In u Q Sulc de t 0 Cou dl not be degterimined
Q Unknown if pregnant within the past year 1 ry (Mo/Day/Vr) (Spell Month) 0
34. Place of Inju 3-1. Time of Injury
ry (e.g. home; construction site; farm; school) 35. Location of In
\ Jury (Street and Number, CI[y, State, Zip Code)
Qs
36. Injury at Work 37. If Transportation InJarry, Specify:
Q Yes ~ / Aerator 0 Pedestrian 3fi. Describe How Injury Occurred:
Driver O
N° O Passenger ~ Other (Specify)
39a. Certifier (Check only one):
Q'Lcrti Ving physician - To the best of my knowledge, death occurred tlue to the causes
P n ing g. Certifying physician - To the best of my knowl d a, death o ) antl manner staafted
Q Medical Examiner Cor e fi ccurred at the Lime, date, d 1 c stated
/ Q,ner -~he sis of examination, and/or Investigation, In my opinion, death occuprra ` and due to the <:ause(s) and manner anne
Signature of certifier: l/ 1 ed at the time, date, antl place, and tlue to the cause(s) and m r stated
39b. Name, gddress and 2i Title of certifier: f/H'rJ License Number: 4t1.d _O 44B~ -C.
U/iL-t-t f~yyl p Code of Persoh Completing Cause of Death (Item 26) -
s- )C/~({(>r )lir(fyytJ LNgn (Q21 gP(LfAJ(~ ~p~y~ G~¢~t S.L~ n 39c. Date 51 netl (MO/OaY/Vr)
40. Registrar's District Num a 41. Registrars acute r ~ r 7 U ] ~t S ~t i 1 'LO 1 Z_
'br - ~~~ 42. Registrar FI a Date Mo Day
.~ 43. Amendments
Disposition Permit No.__ (~f7 Z fti ~I~cll; H305-143
-- - -. _ REV 07/2011
LAST WILL AND TESTAMENT OF
MARY LOU WELTON
I, MARY LOU WELTON, of Cumberland County, Pennsylvania, declare this to
be my Last Will and Testament and hereby revoke all prior Wills acid Codicils.
1. I direct that all my just debts, funeral expenses, and administrative
expenses shall be paid from my estate as soon as practicable after my death. It is my
wish that upon my death my body shall be cremated, and my ashes shall be given to my
granddaughter, Debra D. Miller, to do with what she wishes.
.J
r
2. I direct that all of my personal property that I own at the time of my death
shall be divided equally between my daughter, Gay D. Freeman, and my granddaughter,
~J Debra D. Miller, per capita.
~.,.
3. I direct that all cash that I have at the time of my death shall be divided
~ equally among my children Gay D. Freeman, Fredrick C. Welton, ar~d John E. Welton,
per capita.
-~_.. _~
~ 4. I appoint my son-in-law Larry L. Freeman as Executor of this my Last
~ Will and Testament. In the event that my son-in-law is deceased, unable or unwilling to
serve or shall cease to serve for any reason whatsoever, then I nominate, constitute and
appoint my granddaughter, Debra D. Miller, as alternate Executrix of"this my Last Will
~` and Testament.
5. I direct that no Executor or Executrix acting under this Will shall be
required to enter bond in any jurisdiction.
6. I recommend that my Personal Representative retain the law firm of Allied
Attorneys of Central Pennsylvania, L.L.C., to probate my estate.
~ ..::
.>
_x.,
IN WITNESS WHEREOF, I have hereunto set my hand this
u/~(,~
of /~/(
2012 _ s~ ~'n ~; ' ' `-
,
. ,
. ~ r-
w ~- _,
-
- ~ ~
c~ _
MARY L` U WELTON _~z, ~, ~"-~-
'
-y. G'• ~
tG'
Page 1 of 4
The preceding instrument consisting of this and three other pages was on the day and date
hereof signed, published and declared by MARY LOU WELTON, as and for her Last
Will in the presence of us, who at her request, in her presence and in the presence of each
other have subscribed our names as witnesses hereto.
Witness
fitness
Page 2 of 4
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA :
SS
COUNTY OF CUMBERLAND
J
r
~,
J
J
j r.
I, MARY LOU WELTON, the TESTATRIX, 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 and Testament; that
I signed it willingly, and that I signed it as my free and voluntary act fir the purposes therein
expressed.
MARY U VVELTON
Sworn or affi ~ and acknowledged before me by MARY LOU WELTON, the
TESTATRIX, this ~ day of ~( 2012.
~,c~
tary Public orney
NOTARIAL SEAL
STEPHANIE E CFIERTOK, Notary Public
Cari'~sle 13aro, Cumberland County
My Commission Expires March 24, 2015
Page 3 of 4
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
~~.~ ~~ r^^ ~ ~~ ~~' and w-~ ~ e~('
~ the witnesses whose names are attached to the foregoing document, 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 subscribing
~~~~ witness in the hearing and sight of the testatrix signed the Last Will ,and Testament as
witnesses and that to the best of our knowledge the testatrix was at t11e time 18 or more
v
'~ years of age, of sound mind and under no constraint or undue influence.
~?,~~
Sworn or affirmed and subscribed before me by
~~ ~ ~/U~ and
~ ~ this
fi
~_ day of , 2012.
of ub ic/ .ttorney
NOTARWL $~A~L ~•
l~k1ANIE E ~HERTOK, Notary Public
CarBsie Boro, Cumberland County
My Commission l:~ires March 24, 2015
Page 4 of 4