HomeMy WebLinkAbout04-05-12PETITION FOR GRANT OF TTERS
REGISTER OF WILLS OF ~~ ~.~
COIINT'Y, PENNSYLVANIA
Petitioner~;~ named below. who is:are l~ years of a~~~ or older. zppl~~(ies) for Letters as speciTied bzlo"~u, and in
suppor~ thzreof aver(sj the following anu respectfuih, requestO the Jrant of Letters !.n the appropriate form:
Decedent's Information
Name:~~;i'~ic9i.I ~ na~sot
a/k/a.
a/k/a:
a/k/a:
Date of Death: ~ - /S" - / .~
Decedent was domiciled at death in v ~ C
principal residence at / V 1.
e•
.~1 Street address, Post Office and Zip Code
Decedent died at J ~ t~0~ Ca r ~ 1 ~d0 /'1~t~~c,~-
Street address Post Off d '
File No: ~~ ! - ~ a _ ~ ~ ~-~'
(Assigned by Register)
Social Security No:
Age at death: 7 ~
~~ (ware) with/~is/her last J
~~T~ fi. (s~yr
City, Township ~ r Borough County
tce sn Ztp Code City, Township br Borough Count
Estimate of value of decedent's property at death: y
If domiciled in Pennsylvania ............................ All personal property $ '`y ~(}
If not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $
If not domiciled in Pennsylvania ........................ Personal property in County $
Value of real estate in Pennsylvania ........................... .
............................. $ f~
TOTAL ESTIMATED VALLIE.... $ ~.
Real estate in Pennsylvania situated at:
v,~
State
(Attach additional sheets, i(necessary.) Street address, Post Office and Zip Code City, Township or Borough Count
Y
A. Petition for Probate and Grant of Letters Testamentar c7~~
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated ~~ ` ~~ ' /~(
thereto dated _ wand Codicil(s)
State relevant circumstances (eg. renunciation, death of executor, ertc.)
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(8), and did not have a child born or
ddpted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
[~j'NO EXCEPTIONS ^ EXCEPTIONS
^ B. Petition for Grant of Letters of Administration (If applicable)
c.t.a., d.b.n., d.b.n.c.t.u., pendente life, durante absentia, durante minoritate
If Administration, c.t.a. or d.b.n.c.Ga., enter date of Will in Section A above and complete list of heirs.
Except as follows: Decedent was not a parry 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
Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived bythe:
additional sheets, if'necessury):
Name ~ Relationsh
~__,,
r:.
followiri~~se (ifany~d heirs~-}t
''1 ~ ~ p
~~
Addresi~ ` ` "70 tJ'1
z GL' ~
c
`~ -- - .~
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Fonn RW-02 rev. !t)/!1/1011
Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
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} SS:
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Officiaj TJ,Se
R~~~ JF ~~'~ ",;~-f-I ,
"~~~c
~sM~~„,,
~~~ 3J
Petitioners) Printed Name Petitioner(s) Printed Address
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 Decedent, the,Petitioner(s) will well and truly admi ister the estate according to law.
Sworn to or a trmed an subscribed before C~ ~ ~' ~ ~ Date ~-J~ ` /oZ
me this day o ~.~- ~ Date
Date
the gister Date
BOND Required: AYES ~NO
FEES:
Letters ...................... $
(~ )Short Certificate(s)...... ~
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other ~" ~! ........ /~
Automation Fee .............. .
JCS Fee ..................... -
TOTAL ..................... $
To the Register of Wills:
Please enter my appearance by my signature below:
Attorney Signature:
Printed Name:
Supreme Court
ID Number:
Firm Name:
Address:
Phone:
Fax:
Email:
n _ DECREE OF THE REGISTER
Esta e of ~~„ -
a/k/a
~~
AND NOW
satisfactory pro in
File No~l ~ ~ "-" ~I
_ ~ ~ ~, in consid ration of the foregoing Petition,
been presented before me, IT IS DECREED that Lette s~
are hereby granted to „ ~ ~ "
in the above fate and (if applicable) that
the instrttment(s) dated _ j
described in the Petition be
to probate and filed o~,~e~ord as the fast Will (arl{.if~odici~l(s)) of
Form RW-0? rev. !0/l1/2011 ~ /~ `! ~~II ~~~f ~~ l~~ ~ Of 2
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
n . Ito dupiicatte this copy by photostat or photograph.
` "" `~' ""° `'`'"„"'°`~• '°"•"v This is to certify that the information here given is
~(~ ~ 2 A~~ -~ ~~ ~ ~ ; ~ J 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
C~~~~ ~r Records Office for permanent filing.
Pt-~AI'~'S VOIJRT
P 181612 ~ ~~R~ ~,~!~ rn Pa ~~m.l j~ MA 1 8 12
Certification Number Loca] Re (strar
g~ Date Issued
Type/Print In COMMONWEALTH OF PEN NSVLVANIA DEPARTMENT OF HEALTH VITAL RECORDS
Permanent
~~•~ •• •~.~ • a. v vCM ~ n State Flle Number:
1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Vr) (Spell Mo)
Shirley J. Dodson fem 210-26-9854
6a. Aga-Last Birthday (Vrs) 56. Under 1 Year sue. under 1 Da Mar _ 1 5 2 O 1 2
6. Date of Birth (MO/Day/Vear) (Spell Month) 7 Blrthpla (G tyu ~5gtategrAForeign Country)
77 Mpnchs Dava Hpt,r~ Mlnptes Dec.9,1934 ~Iar:r1SD Y
8a. Residence (State or Forei 7b. Birthplace (County) ~ aup 1 n
gn Country) 8b. Residence (Street and Number -Include Apt No.) Sc. Did Decedent Live in a Towns hipT
Penna_ OSA Front St_ Ves, decedent lived in
Bd. Residence (County) twp
Be. Residence (Zip Code) NO, decedent lived within limits of Wormleysburg
9. Ever In US Armed Forces? 1 arital Status at Time Of Death Q Married 0 Widowed 11. Su rvivin 5 city/born.
Q Yes ~NO Q Unknown Divorced Q Never Marrletl Q Unknown B Pouse's Name (If wife, give name prior to first marriage)
12. Father's N e (First, Middle, Last, Suffix) 13. Mother's Name Prior t° First Marriage (First, Middle, Last)
Harold Delmar Bertha Naomi 7?ressler
14a. Informant's Name 146
Relati
hi
,~ .
ons
p t° Decedent 14c. Informant's Mailing Address (Street and Number, CI
Linda J_ Barrs dau hte
a
G
'
` r
4 Scarsdale Dr.,Camn Hil
l
PA1 701 1
1
~
- a. e ° ec on one
If Death Occurred In a Hos Ital: .....................
P ~ Inpatient .................eat... ..............Y.... .........
.. _
if D
th O
- --- ~- -
P
__
g
ea
fw ................°----°--.w
ccurred Somewhere Other Than a Hos itai:
.......
'gyp---
Emergency Room/Outpatient 0 Desd on Arrival
L.~ Hos ice Facility LI -Decedent's H
ome
Nursing Home/Long-Term Care Facility Other 5
15b. Facility Name (If not instil utlon, glue street and number; ( Pacify)
•i6
c. City or Town, State, and Zip Code iSd. County of D th
Manor Care Ca
i
m m H
ll PA 17011
16a. Method of Disposition Q Burial Cremation
Cumberland
16b. Date of Disposition 16c. Place of Dis
Q Removal from Slate Q Donation Position (Name of cemetery, crematory, or other place)
o[h
Mar
s
1 7
201
er(
p«ify)
.
,
Hollinger Crematory
16d
L
ti
f
i
$ .
oca
on O
Disposition (City Or Town, State, and Zip) 17 Igrtaf ure of F n Ice Licens or Person in Char
ee
Mt_Holiy Springs, PA 17065
~ ~ %~ ae of Interment 176. LICenseN b
r
~ ~
~- F D - 0 1 3 1 6
3 - L
17c Jyau e
~La qqrrrr~t ~J~.P{y~~~ F~~~$
`lit''
ral
M
Se
lla Il dd
~ s
~
lI
t'~ri LF C.:.~l
, nc_,324 Hummel Ave_,Lemoyne
PA 170143
1B
D
d
'
~ ,
.
ece
ent
s Education -Check the box that best describes the i9. Decedent of Hispa nlc Origin -Check the 20
highest degroe or lev
Dec
d
'
l
f
h
.
e
ent
e
o
sc
s Race -Check ONE OR MORE races to indicate what
ool completed at the time of death. box that best describes whether the decedent the decedent: consid
8th gratle or less
d h
ere
imself or herself to be.
is Spanish/Hispanic/Latino. Check the "NO" White
Q No diploma
9th - 12th
ratle
,
g
box If~decedent Is not Spanish/Hispanic/Latino. ~ Black or P.frican American 0 Korean
Q High school graduate or GED completed
Q Vi
t
e
namese
Q No, not Spanish/Hispanic/Latino
Q Some college credit, but n° degree - Q American Indian or Alaska Native Q Other Asian
Q Yes
M
i
Q
,
ex
can, Mexican American, Chicano ~ Asian Indian Q Native Hawaiian
Associate degree (e.g. AA, AS) Q Ves
Puerto Ri
,
can
Q Bachelor's degree (e.g. BA, AB, BS) Q Yes
Cuban ~ Chinese Q Guamanian or Chamorro
,
~ Master's degree (e.g. MA, M5, MEng, MEd, MSW, MBA) ~ Ves, other 5 ~ Filipino ~ Samoan
Panish/Hispanic/L
ti
a
Doctorate (e.g. PhD, EdD) or Professional de
no (] Japanese 0 Other Pacific Islander
gree
(Specify) _ O Other
. MD DDS DVM, LLB JD (Specify)
21. cedent's Single Race Self-Designation -Check ONLY ONE to Indicate what the decedent considered himself
h
Whit
lf
or
erse
So be. 2Za. Decedent's Vsual Occupation -indicate
e Q Japanese Q Samoan type of work
i
~ B
eck or African American Q Korean done during most of working life. DO NOT USE RETIRED.
~ Other Paclflc Islander
Q Ameri
i
dl
can
n
an or Alaska Native Q Vietnamese
Q ASIan Indian Q Don't Know/Not Sure claims processor
~ Other Asian Q Refused
b In
ese - (] Native Hawaiian Q Other (Specify) 2%: b. Kind Of Business/Industry
Q F
i
i
Q PnO Q Guamanian orCham insurance
ITEMS 23a - 23 MVST BE COMPLETED 23a. Date Prorrriwwo Dead MO Day Vr) 23 . SiBna[ure of Person Pronouncing Death Only when applicable) 23c. License Number
BY PERSON WHO PRONOUNCES OR h ? / ~ ~~ /
CERTIFIES DEATH V J/
~
23d. DJatte251 d (/y~I o/Day/Vr) 24. Time of Death
~jf~y~i '~`~ RNIo Z 3 93 ~
V 3~ S
C
S~
' ~
~,
~"~ 25. Was Medical Examiner or Coroner Contacted?
tf I~ Yes No
CAUSE OF DEATH
26
. Pert 1. Enter the ch 1
y a _s_.._d iseaus, InJu rtes, °r mplicatlons--that tlirectly caused the death
Approximate
DO NOT e
re
irat
t
Ve
.
p
n
er terminal events such as cardiac arrest
ory arrest, or tri ular fibri at w hout s o g the a logy. DO NO BREVIATE
n n
Ent r o 1 - Interval:
.
y one cause on a Iin~e. Add additional lines if necessary Onset to Death
IMMEDIATE CAUSE ---------------~ a. ~ )
(Final disease or condition
Due t° (or a sequence of):
resulting In death) °^
b.
Sequentially I15[ conditions,
Due to (or sequence of):
it env, iead]ng co the cause as a con
listen on une a. Enter the
UNDERLYING CJtUSE
Due to 0
(dise r InJury that ( r as a consequence of):
G In lHated the events resulting d.
in death) LAST.
C1 ( r
Due to o as a consequence of):
c 26. Psrt 11. Enter other signiflca t dill t Ib tl t d th but not resulting In the underlying cause given In P
rt 1 -
~ a
27. Was an autopsy performed?
O Yes ~ No
28. Were autopsy findings available
E to complete the cause of death?
29. If Fe 30. Did To se Contribut
~ Yes Q ryo
t
N
[
D
's e
o
o
eath?
pregnant within past year 31. Ma Death
- ~ Pregnant at time of death Q Probably
/e Natural Q Homicide
Q Nos
~ Q Unknown
j] No[ pregnant, but pregnant within 42 days of death
[] Accident (] Pendin
g
lnvestiga[ion
t- t
o
Q Not pregnant, but pregnant 43 days t° 1 year before death 32. Dale of In [] Suicide Q Gould t be determined
(M
Ju
/D
ry
O
ay/Vr) (Spell Month)
Q Unknown if pregnant within the past year
33. Time of tn)ury
34. Place of Injury (e.g. home; construction site; farm; school) 35
L
.
ocation of Injury (Street and Number, Cit•/, State, Zip Code)
36. Injury at Work 37. If Transportation Injury, Specify:
36. Describe How In
Yes Jury Occurred:
O Q Driver/Operator ~ Pedesirlan
' Q No Q Passenger Q Other (Specify)
3 9a. C er (Check only one):
Certifying physician - To the beat of my knowledge, death occurred due tp the cause(s) and manner stat
Q Pr
d
e
onouncing Sa Certifying p sician -Tot Of my knowledge, death occurretl at the time, date, and place
~ Medical Examiner/(,OrOn
and due to th
,
e cause
asis of examin etiOn, and/or inves[IgatlOn, in my opi nlon, d th (s) and manner stated
ed at the time
tlate
and place
a
d d
3 ,
,
,
n
ue to the caVSa{s) artd martrter stn
signetr.ro of r: [YY/UUfII/LJ(/J)'~///J L)/`Y ~J
N~ dre and Zlp a o~+e on Co 1 e Title of certifier: License Number:
of Death (Item 26)
39 at Signed o/Day/Vr)
4 0. Registrar's District Number 1. Registrars atu re
4Z' R~l ~a~ ~ D
~~+
ate (M° pay r
~ ' - d 'l
4 i
/
3. Amendments
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Disposition Permit NO._S/ ~ ( / ( ~ ~ H106-143
REV 07/2011
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SHIRLH? J . DODSOIQ
n..~
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I, SHIRLEY J. DODSON, of the Borough of Worml.eysburg, .,~~~
_~rl~d
~ l...J
r
-_-~.~~
County, Pennsylvania, declare this to be my last will and _
y
revoke ``
a~jy rte;
w~r~.
previously made by me.
c.~
ITEM I. I direct that all my just debts and funeral expenses,
including my gravemarker and all expenses of my last illness, and any and
all taxes and assessments imposed by any governmental body as a result of
my death, whether on property passing under this will or otherwise, shall
i~
a
oii
be paid from my residuary estate as soon as practicable after my decease
as a part of the expense of the administration of my estate.
ITEM II. I give and bequeath all of my household goods,
automobiles, jewelry, and all other articles of household and personal
use, equipment and ornament, together with all insurance thereon and
relating thereto, to such of my issue, per stirpes, as survive my death
by thirty (30) days.
ITEM III. I give, devise, and bequeath all tlhe rest, residue, and
remainder of my possessions and estate of every nature and wherever
situate to those of my issue, per stirpes, as survive my death by thirty
30) days.
ITEM IV. I appoint my daughter, LINDA J. WOO1)RING, executrix of
this my last will.
ITEM D. In addition to the other powers and authorities granted to
my personal representatives by Pennsylvania law anti by the other terms
and provisions of this will, I hereby give to my personal representatives
the following powers and authorities effective without court approval and
1
._ ~ •
until actual distribution of all property: to compromise any claim or
controversy; to make distribution in cash or in kj.nd, or partly in cash
and partly in kind, and in such manner as my perscnal representatives may
determine and at valuations finally to be fixed by them; to invest in all
forms of property, including any stock or other securities in any
corporate fiduciary or its successor without restriction to investments
authorized for Pennsylvania fiduciaries, as my personal representatives
deem proper, without regard to any principle of risk or diversification;
to retain any or all assets of my estate, real or personal, without
regard to any principle of risk or diversification.; to sell at public or
private sale, to exchange, or to lease for any period of time, any real
or personal property and to give options for sales, exchanges, or leases,
for such prices and upon such terms or conditions as my personal
representatives deem proper; and to allocate receipts and expenses to
principal or income or partly to each as my personal representatives deem
proper in their sole discretion.
IT8I~1 VI. I direct that my personal representatives and fiduciaries
shall not be required to give bond for the faithful performance of their
duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand this ~ 8 day
of ~~' 1995.
SHIRLE J ~°DODSON
2
._
.- , ,
The preceding instrument, consisting of this and two other
typewritten pages, each identified by the signature of the testatrix was
on the date thereof signed, published, and declaresd by SHIRLEY J. DODS~N,
the testatrix therein named, as and for her last gill, in the presence of
us, Who at her request, in her presence, and in tY;ie presence of each
other, have subscribed our names as witnesses hereto.
Q
\I
~I
Samuel L. Andes
~ ,z.r-- _...
. B rt DeLone
3
r
COMMONWEALTH OF PENNSYLVANIA )
( SS..
COUNTY OF CUMBERLAND )
The undersigned, being the testatrix whose :name is signed to the
attached or foregoing instrument, having been duly qualified according to
law, does hereby acknowledge that I signed and executed the foregoing
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.
J `/ DODSON
Sworn or affirmed to and acknowledged
before me by the tes at.~ iAx'- nwamed above
this ~gt~'1 day of ~C~ 1995.
e ~~~ h '~'~`-
t MrN11 nD ~t'r PuBi.~c
Notary Public ~~~~-cu~~~rlnco•.p"
IN CaMMN1iI0M E>iflRES APR1~ 7,199E
COMMONWEALTH OF PENNSYLVANIA )
C ss..
COUNTY OF CUMBERLAND )
WE, SAMUEL L. ANDES and J. BART DeLONE, the witnesses whose names
are signed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw the
testatrix sign and execute the instrument as her last will; that she
signed it willingly and that she executed it as rler free and voluntary
act for the purposes therein expressed; that eacYl 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
acknowledged be ore me this
~~.~'1 day of ~, C~.~~ , 1995.
Sam L. Andes
--~id `W u
J . Bart De~Lone