HomeMy WebLinkAbout04-18-12PETITION 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, arn~ in support thereof aver(s) the
following and respectfully requests the grant of Letters in the appropriate form:
John Connelly
Decedent's Information
Name: James Daniel Neilson
a/kla:
a/k/a:
a/k/a:
Date of Death: 03N 7/2012
File No: 21 (~ ~~
(Assigned by Register)
Social Security No:
Age at Death: 59
Decedent was domiciled at death in Cumberland County, pA (State) with his/her last
principal residence at 5257 Terrace Road, Mechanicsburg 17050 Hampden Cumberland
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at Harrisburg Hospital Harrisburg Dauphin 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 $ 50,000.00
If not domiciled in Pennsylvania ................ Personal property in Pennsylvania $
Ifnot domiciled in Pennsylvania ................ Personal property in County $
Value of real estate in Pennsy/vania ................................................................... $
TOTAL ESTIMATED VALUE $ 50,000.00
Real estate in Pennsylvania situated at
(Attach adddional sheets, if necessary.)
Street address, Post Office end Zip Code City, Township or Borou4ih County
® A. ?etition for Probate and Grant of Lette Tes -ment
Petitioner(s) aver(s) that he/she/they is/are the Executor(s) named in the Last Will of the Decedent, dated 11/28/1993 and Codicil(s)
thereto dated
State relevant circumstances (e.g., renunciation, death of executor, etc.)
Except as follows: after the execution of the instrument(s) offered for probate, Decedent did not mar 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. §73323(8), 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
^ B. Petition for Grant of Letters of Admini~}ration (If applicable)
c.t.a., d.b.n., d.b.n.c.t.a., pedente lite, durante absentia. durente minoritate
If Administration, c.t.a or d.b.n.c.t.a., enter date of Will in G?~±ion A abov and complete list of heirs.
Except as follows: Decedent was not a party to 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):
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Name Relationship Address ~''~ Y== =
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Form RW-02 rev. 10.11-2011 Copyright (c) 2011 form software only The Lackner Group, Inc.
Page 1 of 2
Oath of Personal Representative r ,~ ,
~F~~~~
COMMONWEALTH OF PENNSYLVANIA } ~~ `-,~`
} SS:
COUNTY OF Cumberland } -i~-•-• ~ ,~ Official Use Only
.~_~ ~ ~~I..E aF
,? 1 ~'
Petitioner(s) Printed Name Petitioner(s) Printed Addr• ~ '
John Connelly ~~~~ ~a ` ~^
~'Y~ 134 Sipe Avenue
Hershey, PA 17033 CLERK QF
CUMR~~?! A~J~! ~;Cl . PA
-~~.~~ c.vv~c-nauicu avvcaita/ u~ anu~n(s) UIC SLd[emef11.5 In me iOregoln Ye[I[IO a and correct to the best of the knowledge and
belief of Petitioner(s) and that, as Personal Representative(s) the ent, P i ' er w I e I an ruly administer the estate accord' g to I w.
Sworn to or affirmed a subscribed before Date ~ 51 ~ 2
me thi ay f ~ ~ G) ~
Date
By:
Dale
r e Register ~ Date
i
BOND Required? ~ YES
FEES: '
Letters ..........................................
( 1 )Short Certificate(s).........
( )Renunciation(s) ..............
( )Codicil(s) ........................
( )Affidavit(s) ......................
Bond .............................................
Commission .................................
Other ~~ ~~
J NO
$ ~') .
,~ ~
~~
To the Register of Wills:
below:
Automation Fee ............................
JCS Fee .......................................
TOTAL .........................................
riease enter
Attorney Signature:
. ----
Printed Na e: Gary .James Esq.
Supreme Co
ID Number: 27752 _
Firm Name: James, Smith, Dietterick 8 Connell LLP
Address: 134 Sipe Avenue
Hummelstown„ PA 17036
Phone: 717!533-3280
Fax: 7171533-2795
E-mail: glj(ailjsdc.com
DECREE OF THE REGISTER
Date of Geath: 03h 7/2012
Social Security No: 217-54-6661
Estate of James Daniel Neilson File No: 21 ~'p, '-'.f5~~
a/k/a:
.~.
AND NOW, ~ t ~ ~r<~Z ,tin consideration of the foregoing Petition,
satisfactory proof hav g been presented before me, IT IS DECREED that Letters Testamentary
are hereby granted to John Connelly
.r. uie aoove estate ana pr applicable) that the instrument(s) dated 11/28/1993
described in the Petition be admitted to probate and filed of record as a last WiII (anc~C dicil(s)) of
Copyright (c) 2011 form softwarla~nl} The Lackner Group, Inc. V II ~ ~\ 1 /i~~U~ , • /` ~ of 2
LOCAL ~f~~~ ,CERTIFICATION C)F DEATH
WARNING: ~~~ ~~ai: to,l,~yt~licate this copy by photostat or photograph.
Fee for this certificate, $6.00 ~ ~t I ~ ~~R ~ 8 ~~ $ ~ `~ 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 oJginal
certificate will he forwarded to the State Vital
~R~~~ S C~U~~ Records Office for permanent filing.
c~m~~=~~ ~N~ ~~
P 18331867 _
Certification Number
Type/Print In
Permanent
Black Ink
3
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~ ~~~~U 3 ~~ ~Gl
Local R_ istrar Date issued
COMMONWEALTH OF PENNSYLVANIA . DEPARTMENT OF HEALTH ~ VITAL RECORDS
C'FRTIFI['ATF AC 1'1FAT1-1
1. Decedent's Legal Name (First, Middle. Lsrt, Sufflz) 2. Sex 3. Social Security Number~~ e , 4~„as to of Death Mo/Dry r) (Spell Mo)
James Daniel Neilson Male 217-54-6661
O ~
Sa. Age-Lase Blrthtlay (Yrs) 3b. Vnd•r 1 Yeer Se. Untl•r 1 D• e. Date oT Blr[h (MO Ory/Yeer) (Spell Menth) 7a. Blrthplau (City and stele or Ferelsj Cou try)
Menthe Dayt Hours Minutes Fros tbUYg, i"IIJ
59 Se tember 4 1952 7b. Birthplace (County) Alle an
ga. Realdenu (StaN or Foreign Country) Bb. Residence (Street and Number -Include Apt No.) He. Did Oeud•nt Llye In a Township?
P v a ®Yea, d.c•dene uy.d m _ HamPdan
twp.
ed. Residence (County) 5257 Terrace Road
Cumberland Ba. Resldenu (Zip Code) 17 O QNO, tleudent Ilyed wlthln Ilml[s of city/boro.
9. Ever In US Armed Forces] 10. Marital Status at Tim• oT Death Marrlsd Q Widowed 11. Surviving Spouse's Name (If wife, give name prior to firs[ marNage)
Q Yes ®No QUnknown Q Divorced Q Never Marrlsd QUnknow BetBy Harris Crewe
12. Father's Name (Pint, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last)
Jamca Gordon Neilson Mar aret Idabelle Ewin
14a. Informant's Name ]4b. Relationship to Decadent 14c. Informant's Melling Address (Street and Number, City, State, Zip Code)
Mra. Bata C. Neilson Wife
R
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o erac
5 cs o
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ace
ny
.......................................... n ............_....................... .......... °:...............a~t... _
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....... ......... ... ......... ..... ....... ....... .....
...... ...~u,. . ..
If ~Ge~ch Occurred In a Hotpltel: pedant ~If Death Occurred Somewhere Other Than a Hoa Ital:
p Hosplca Faclliry ~~ LJ ~Deutlent'a Home
$ Eme ency Room/OUtpetlent Dead on Arrival ( Nursing Heme/LOn -Term Grc Facility Other (Specify)
1Sb. Facility Name (If not Institution, gNe street end number; 15c. City or Town, Stets, end 21p Cede lSd
County of Death
~ Harri)sbur -HOS ital .
Harriabur PA 17101
D u n
~ 16e. Method of Disposition Burial Cremation lBb. Date of Dlsposltlon 16<. Place of Dlsposltlon (Name of <emebry, crcmato
ry, Or other place)
pp
16 Q Removal from State Q Donation
ocher (sp.clHl March 20, 2012 Cremation Society of PA
16d. Loudon of Dbpotitlon (City or Town, State, and 21p) 17a. aturc o/ Funer 1 Servlc tae or Person In Chane Of Inbrrnent
~n 17b. LI<anse Number
Harrisburg, PA 17109 `.L h FD-138753
i7c. Name and Complete Address of Funeral Facility
Auer Cremation Services of Penn lean a Inc 4
~' 18. Decedent's Education -Check the box that beat describes the 19. Decedent of Hispanic ONgin -Check the 20. Decedent's Rece -Check ONE OR MORE races t0 Indicate what
~ highest degree or level of school completed at the time of death. box that best describes whether the decedent the decadent considered hlmsell or herself to be.
Q Bth grade or less is Spanish/Hispanic/La[Ino. Cheek the "NO" ®White Q Korean
Q No tliplOma, 9th - 12th grade box If decadent is not Spanish/H{spal`c/Latino. Q Black or African American Q Vietnamese
Q High school graduate Or GED completetl ®No, not Spanish/Hispanic/Latino Q American Indian or Alaska NsHVe Q Other Asian
Q Some college credit, but no degree Q Ves, Mexican, Mexican American, Icano Q Asian Indian Q Native Hawallan
Q Associate degree (e.g. AA, AS) Q Yes, Puerto Rlun Q Chinese Q Guamanian 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/L o Q la
panese Q Other Paclflc Islander
® Doc[orata (e.g. PhD, Ed D) or Professional degree S I
( pee ty) O Other (Specify)
. MD DDS DVM LLB JD
21. Dacadant's Single Raea Self-Designation -Check ONLY ONE to Indicate what the decedent co dared himself or herself to be. 22a. Decedent's Usual Occupation -Indicate type of work
® White Q Japanese Q Samoan done during most of working INe. DO NOT USE RETIRED.
Q Black or African American Q Korean Q Other Pacific Islander
Q American Indian or Alaska Native Q Vietnamese Q Don'S Know/Not Sure AttOrne
Q Asian Indian Q Other Asian Q Refused 226. Kind of Buslness/Industry
Q Chinese Q Nature Hawallan Q Other (Specify)
Q Filipino Q Guamanian or Chamorro
Law
MU BE MPLlT[ 2 e. ate ronounea Dea Mo Day r . 5 gneture o coon Pronouncing set n y w an app lu 3c. Uunse Num e
BY P[RgON WHO PRONOUNCES OR r
cgRnPlgS DgATH March 17 2012
23d. Date Signed (MO Day/Yr) 24. TI ~f I;ea
25. Was Medical Examiner or Coroner Contac[etl7 Q Yes
CAUSE OF DEATH
Appreximet~
26. Pert 1. Enter the chain of wants--tlls•afes, Injuries, or complications--that directly caused the death. DO NOT enbr terminal events such as cardiac arrest I Interval:
resDlratory arrest, or ventrl<ular flbrillatlon without showing t
h
e etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilnel. Add additional Tines If necessary Onset to Death
(^
~
IMMEDIATE CAUSE -------------> a. ~ ~ i--O ~,~
(Final disease or condition Due to (Or as a consequence of): {
resuking In death)
b. ~ti •) av~ U ~
Sequentially Ilst conditions, Due to (or as a consequence of):
If any, leading to tM cause ~-" tom
,,
listed on line a. Enter the ~ ~~ 1~ ~ ~~I ~ @ X~-~--[L-_
UNDERLYING CAUSE Due t0 Or as a wnsequenca Ot):
W (disease or Injury that
Initiated the events resulting d.
In death) LAST. Due to (or ss a consequence of):
26. Part 11. Enter other but not resulting in the underlying cause given In Part I 27. Was an autopsy performed?
y~+ Vet
28. Were autoPry findings available
to compleN the cause of death?
ppp Ves No
29. If Female: 30. Dld Tobacco Use Contribute to Dgth7 31. Manner of Death
Q Not pragnanT within past year
Q Pregnant at time of tleeth Q Yes Q ~PP babN
N
k
~ I~IQatural Q Homl<Ide
~
Q Not pregnant, but pregnant within 42 days of death Q
o Q
lJn
nown [] Accident Q Pending InvattigatlOn
[] Sulclde Q Could not be determined
~ Not pregnant, but pregnant 43 drys to 1 year before tleeth 32. Oats of Injury (MO/Day/Vr) (Spell Month)
Q Unknown If pregnanS wlthln the past year 33. Time oT Injury
34. Place of Injury (e.g. home; construction site; farm; school) 35. La<ation of In)ury (Street and Number, Cley, State, 21p Code)
36. Injury at Work 37. It Transportation Injury, SpeeNy: 38. Describe Haw Injury Occurred:
0 Ves Q Orive r/Operator Q P•desRian
Q No Q Passenger Q Other (Specify)
39~a. CeJ~~ifler (Check only one):
[QrCertif
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hy
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o
e
est o
my
now
edge, death Occurred due to the uusa(s) and manner stated
Q Proneuncing a Certifying physician - To the best of my knowledge, death occurred at the time, data, and place, and due to the cause(s) and manner stated
Q Medical Examiner/Coroner - On the basis minetlon, •ntl/or InvestlgKlon, In my opinion, death occurred at the time, det•
plava, and due to th
Q.
e
ca
a(s) and manner stated
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-SlgnNUra of cerYlfl•r: Tltla of cartlfler: -. Cr
q Lic•ns• Number: f-V ] ~ ~1 ~ 7Z )
39 me, Addr and 21p Cod• of Person Completln of Dee 3 to Sig d (MO D Y/Y 1
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40. Registrar s District Num er 41. eglstrar s Slgna
ag rtrv F a Dab Day
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43. Amendments
Dlsposltlon Permit No. 07257$7
H105-143
REV 07/2011
OATH OF SUBSCRIBfNG WITNESS(ES)
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA
Estate of James Daniel Neilson
Joan Y. Murphy
Deceased
(each) a subscribing witness to
(Pont Namds)
the ~W 11 ^ Codicil(s) presented herewith, (each) being duly qualified according to~ law, depose(s) and
says} tha# he he /they was were present and saw the above Testator Testatrix sign the same
and that ,she he /they signed the same and that she he /they signed as a witness at the request of
the Testator Testatrix in his her presence and in the presence of each other.
c7 _
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(Signat ) JO Y. Murphy (Signature) .lN] ~ m ~ C.' ; 1'<J
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5255 Terrace Road :~ O ~ x~
(Sheet Address) (Street Ado'ress) ~~ - -' T'1
-b -1 ~ ~.-._ r'T"i
Mechanicsburg, PA 17055 ~' rv ~•~ Q
(City, State, Zip) (City, State, Zip)
Executed in Register`s O;~ce Executed out of Register's Office
Sworn to or affirmed and subscribed Sworn to or affirm~ed~and~subscribed
before me this day before me this--~--~ day
of of ~ L- a n l ~
>_
Deputy for Register of Wills Notary Public
My Commission Expires: ~~ll ~ 1'n(3G.~' c'17 i ~ i
(Slgnatwe end seal of Notary «olher official qualified to
edmiraster oaths. Show date of expiration of Notarys commisaton.)
aoMMONwF~-i.Tfi of a NsnvarrA
iroarw seat
Suety M. ladr, I!lofat~- PubMc
or , ~~pan oxx~f
2014
NOTE: To be taken by Officer authorized to administer oaths. Please have present the or;ginal ,~r copy of lnsfrurrent(s) at time of notarization.
Form RW-O3 Rav. 10.13-2006 Copyright (c) 2008 form software oNy The Leckn« .;tuuq, loc.
OATH OF SUBSCRIBING WITNESS{ES)
REGISTER OF WILLS OF CUMBERLAND
Estate of James Daniel Neilson
Tyson E. Murphy
Deceased
(each) a subscribing witness to
(Print Names)
the Will ^ Codicil(s) presented herewith, (each) being duly qualified according tt, law, depose(s) and
say(s) that she he they
and that she he they
the Testator Testatrix
was were present and saw the above Testator Testatrix sign the same
signed the same and that she he they signed as a witness at the request of
in his her presence and in the presence of each other.
~-
(signora Tyson E. rphy
5255 Terrace Road
(Street Address)
n
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(Signature) `
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(Street Address) ~" ~ L 7 ~-y
3~
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Mechanicsburg, PA 17055
(City, State, Zip} (Gty, Stara, lip)
Executed in Register's Office Executed out of Register's Office
Sworn to or affirmed and subscribed Sworn to or affirmed and subscribed
before me this day ~ ~ ~--~r
before me this.-~s~-"--day
of of~ ~ i'- ~ n 1
Deputy for Register of Wills V
Notary Public
a~ ~
My Commission Expires: ~Q~ ~ m1~ ~~
t
(Signature and seal or Notary or other olflt9al que6fied to
edmmistar oaths. Show data of expketicn cr ryotarye commission.)
CAM lr OF P LVANIA
~~
te
St
~
~r DMt d~Y
X034
NOTE: To be taken by Officer authorized to administer oaths . Please have present the origtna: or ~i:opy of instrumentFS) at :me of notarization.
COUNTY, PENNSYLVANIA
Form RW+O3 Rev. f0.13-2006 Copyright (c3 21)06 torm software only The Lackner Group, !rK.
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