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HomeMy WebLinkAbout04-26-12 Reset PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF LJ(/P~ ~~~~N ~ 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: LI S T I N ~ ~ ~l.~c1C.:1~-~-i2?'~~ File No: ~ ~ - ~ <~ - L%~{ ~-~~ a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: __~ Q2- / ~{ - ~S?~ Date of Death: ~ P ~ r ~ q ~ ,2-y f z. Age at death: Decedent was domiciled at death in C~li'itgc~--~2L,q<,,t/r~ County, VVSYLt/ t! (stare) with his/her last principal residence at ,~ 18 (g~Q-I l-~y Sr'~ _/VL~ CcJy~1 ig~Yt~-„gyp , ~- /~Q7v ~,t/1-tf~~~t Street address, Post Office and Zip Code City, Township or Borough County Decedent died at x-18' 'Vl~(~'y ~f /1/~ Cc1n ~j~~-~/rj ~~(,~J~~,~n P~ Street address, Post Office and Zip Code City, Township or Borough County State Estimate of value of decedent's property at death: Ifdotni'ci[ed in Pennsylvania ........................... All personal property $ I a~~ , (~ If not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $ If not domiciled in Pennsylvania ........................ Personal property in County $ Value of real estate in Pennsylvania ......................................................... $ TOTAL ESTIMATED VALUE.... $-~pp 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 ..riQ1U, ., ~ ~-y~~ and Codicil(s) thereto dated State relevant circumstances (eg. renuxciabon, deatk of exccator, 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. ~10 EXCEPTIONS ©EXCEPTIONS ^ 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, Gt.a. or db.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. O NO EXCEPTIONS O 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 G7 '»_ e-..y ~ 7s m ~~zc~ ~; - _,~C N '. t C!a ~ ~ Form RW-02 rev. 10/11/2011 T _i ~' Rage 1 r Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF Petitioner(s) Printed Name Petitioner(s) Printed Address r L(.=1'V1z~ ~ . ~l'l/G(~YLi" Fl l~L S 1 ~!J ~i.Jf't/Scs'"-'~~O~tl~'~ ~~S~~`~ V,' , 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 Decedettt, the Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before ~ wt ~ f -~../ ~ '. ~ ~ z- Date '~ - ~ ~ ~' ~ me this ~~day of , ~~Z Date BY~ ~J Date the Register _ Date BOND Required: Q YES ~ NO To the Register of Wills: FEES: Please enter my appearance by my signature below: Letters ...................... $ ( ~,) Short Certificate(s)...... ~ ~ C5 ~ ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other ........ (.2 i 1 ~ I ........ ~" ~Z~ Automation Fee ............... `- - ! ICS Fee . .................... J TOTAL ..................... $ Attorney Signature: ~ r/ Printed Name: C,PS~12'(~ ~ ~J Supreme Coart 70~ ID Number: Firm Name: ~-J,)k?2 ~~ ~'~~(~ Address: ~ ~UU tf'll~lZfLty'T S'~12.~b"f" 1 ~ " a Phone: ~ ~ 7; 3 f q- v7/ 3 Fax: ?17 ~!2- 77 (~7 Email: /-f~4~1JAfL,r1J~D~/~IP~k'Qf lUti'l DECREE OF THE REGISTER Estate of .`> ~1 7 1 ~Z'C, l C (-~~-1 File No: ~ ~-1 ~ -L ~~-(~ ~-~ a/k/a: AND NOW, ~~ ~~ ~ ~ ~ '~ (~ 't~ ;~L1 ~ ~ , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that etters .P, l 1 ! ~ are hereby granted to in t e above esta a and (if applicable) that the instrument(s) dated []_- ~ C~~y described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent Register of Wills ~ Form RW-02 rev. 10/II/2011 ~~ ~ '~~ ~ ~ ~~~ ~~~~t~~ ~ ~ ~ ~~ Page 2 of 2 t)Inc v c vnti ml' LO 1~~,~j~~~fiAR'S CERTIFICATION OF DEATH W ~I~N~. It is i`~~ytal to duplicate this copy by photostat or photograph. Fee far this certificate, $6.00",; l~ ~~~ ~~ ~~~.; (~; ~ ~ ']'his is to certify that the information here given is correctly copied from an original Certificate of Death ~ duly filed v~'ith me as Local Registrar. The original ~~ERK (~}r ce^rtificate Mill be t~>rwarded to the State Vital ~R~~~J~ UGU~r Records Office t)r ~erm;anent filing. Ct1MI~~R{ Ah~l (;i i PA _ P 18388504 __ ~~y1,,Ly~ a~~t~ot~ Certification Number Loci] Registrar Dace Issued Types/Print In COMMONWEALTH OF PENNSYLVANIA . DEPARTMENT OF HEALTH ~ VITAL RECORDS Permanent 1. Decedent's Legal Name (First, Middle, lest, Suffix) v, v ~ a ^ Statc File Number: 2. Sex 3. Social Security Number 4. Oates of Death (MO/Day/Yr) (Spell Mo) AuE;tin C_ Dougherty Male 192 - 14 - 5570 A ri1 9, 2012 6a. Age-Last Birthday (Yrs) 56. Under 1 Vear Sc. Under 1 Da 6. Date of Birth (MO/Da /Yea ) (S l y r pe l Month) ]a. Birthplace (City and Stale or Forefgn Country) Months Days Hpur, Minute, McAdoo PA 87 I / October 24, 1924 ]b. Birthplace (county) Schu 1ki11 Ba. Residence (State or Foreign Country) 8b R id . es ence (Street and Number -Include Apt No.) Bc. Did Decedent Live In a Township? Penns lvania QYes, decedent lived in 8d. Residence (County) 218 BHilE:y Street tw, _ p_ Cumberland Be. Residence (Zip Coda) ].7070 No, decedent lived within limits of NeW Cumberland city/boro. 9. Ever in US Armed Forcers] 30. Marital Status at Tlme of Death (~ Married Q Widowed 11. Surviving Spouse's Name (If wife Yes Q No Q Unknown Q Di give name rior t fi d , vorce o rst marriage) Q Never Married Q Unknown P 12. Father's Name (First, Middle, Las[, Suffix) Arlene M. Bennin h0££ 13. Mother's Name Prior to First Marriage (First, Middle, Last) John J. Dou pert Anna Brennan 14a. Informant's Name 14b. Relationship fo Decedent 14c. Informant's Mailin Add S g ress ( treet and Number, City, State, Zip Coda) Arlene B. Dou hert Wife 218 Baile Street New Cum ......................................................... d PA 1 7 O aces o e t a ~ ...................................................... a : If Death Occurred In a Hospital: ~~ In bent .......................... ec on y one ............................. ............... Pa ;If Death Occurred Som h th """" ew ere O er Than a Hos ital~ "'••--- P ~ ~ Hospice Facility Decedent's Home Q Emergency Room/OUtpatlent 0 peed on Arrival Q Nursing Nome/Long-Term Car F Il ' a a< lty Other (Specify) 15 b. Facility Name (If not instituflon, give street and number; SSc City or Town St t ~ . , a es, and 21p Code 35d. Coun 218 Bai1e Street tv pf Daatn m New Cumberland PA 17070 Cumberland 16a. Method of DisposltiOn Burial Q Cremation b ~' 16 . Date of Dlsposi[lon 16c. Place of Disposition (Name of cemete Q Removal from State Q ponation ry, crematory, or other place) Other (S ecif ) A il 1 p y pr 2, 2012 Rolling Green Cemetery 16d Location of Dis iti C Z . pos on ( ity or Town, State, and Ztp) 1]a. Signet of F ral Servic Licensee or Person In Charge pf Interment 1]b . Licenses Number Camp Hill, PA 17011 E 1]c. Name and Complete Address of Funeral Facility FS 012 849 L 3 Parthemore FH & CS Inc_ P.O. Box 43 New Cumberland PA 17070 18 Dec d t' ~ . e en s Education -Check the box that bas[ describes She 19. Decadent of Hlspanlc Origin -Check the 20 D hi h d t d ' . g ece ent es s 0.ace -Check ONE OR MORE races [o Indicate what egree or level of school completed a[ the time of death. box that best describes whether the decadent th d Q 8th d e ece ent considered himself or herself [o be. grade or less is Spanish/Hispanic/Latlno. Check She "NO" White Q Korean Q No dl ploma, 9th - 12th grade box if decedent Is not Spa Wish/Hlspanlc/Latino ~ Black or Af Q Hi h s h i l d . g r c oo gra can American Q Viertnamase uate or GED completed ~" No, not Spanish/Hispa nlc/Latino Q gmarican Indian or Alaska Native Q Other Asian Q Some collage credit, but no degree Q Yes, Mexican Mexican America Chi , n, cano Q Asian indlan Q ~ Associate degree (e. g. AA, q5) Q Ves, Puerto Rican Native Hawaiian Chinese Bachelor's degree (e.g. BA, AB, BS) Q Ves, Cuban Q FIII ~ Guamanian or Chamorro M ' aster Q Samoan s degree (e.g. MA, MS, MEng, MEd, MS W, MBA) Q Yes, other Spanish/Hlspanlc/Latlnp Q J apanese ~ Doctorate (e.g. PhD, Ed D) or Professional degree Q Other Pacific Islander (SPecify) . MD DDS DVM LLB lD Q Other (Specify) 21. Decedent's Single Race Self-Designation -Check ONLY ONE to Indicate what the decedent considered himself or h lf erse to be. 22a. Decerden['s Usual Occupation -Indicate Q Whites Q Japanese Q Samoan type of work done duri Q Black or African American ~ Korean Q Other Pacific Islander nH most of working lifer. DO NOT VSE RETIRED. QAmerican indlan or Alaska Native 0 Vietnamese Q Don't Know/NOL SUre Administrat Q Asian Indian or Q Other Asian Q Refused Q Chinese Q Native Hawaiian Q Other (Specify) 22b. Kind of Business/Industry Q FIIIPI^° Q Guamanian or Chamorro ITEMS 23a - 23 VST BE COMPLETED 23a ate Pronounce Dead Mo State Government BY PERSON WHO PRONOUNCES OR aY ~ 3b. Signature of Person Pronouncing peath (Only when applicable 23c. LI<ense Number CERTI / FIES DEATH / ~ ~ /~ 2 .Date Sigp d (M Day/Y 24 T pf D ath ~~ ~~ ~ 3O . ~ I /'~ ~ ~~ ~ '--'"Y! • 25. W s Medical Examiner or Coroner Contacted? Q Yes No CAUSE OF DEATH 26. Pas 1. Enter the chain of event --diseases, Injuries, or complications--the[ directly caused the death Approximate 00 NOT . enter terminal events such as cardiac arrest re plra[ory arrest, or ventricular flbrillaf without showing the etiology. DO~ Ag6$EVIATE. Enter onl ~ Interval: ~~\/ y cause on line. Add additional lines if necessary Onset t° Death IMMEDIATE CAUSE ---------- ----~ a. ~ ~ ~ _ /~ T~ ~j` ~ ..S J (Final disease or conditlpn Du o (or quen C resulting in death) ,y r ~ ~~ i}'f as a c~~~ y( '4r ~LJ I ~~~ / , b. j Sequenilall Il t d y s con itions, ~f Due t~ (1r as a p~ Ape of) _/ " if any, leading to the cause / / ~ .y-Q ~ .n// /,tv(~ l/(y~/~` /p~ _~~~~ 1 ~f j_/`- ~ ` ~ listed on Ilne a. Enter the c (VA/Tll- ` ( ~ ( / r ~ ~ ~ ~ UNDERLYING CAVSE C ,Qj - Due to o sequence (disease or Injury the[ ( r as a con of): initiated the erv ss l ~ en resu ting d. In death) LAST. Due t0 o as a con ( r sequence of): _ S 26. Part 11. Enter other sl¢nlflc S dlti L Ib tl t d th but not resulting in the underlyin cause i " ~ ~ g g ven in Part I 27. Was an autopsy perform D ' /'( ~//^-- l ~ ~ < ~ ~ o yes p ` ~ ~ / t !~%/ ~~ ~~ ~ /~ d ~.~C ~~C V G-: J~ C 26. Were autopsy findings avalla ble t l ~ ., C ~- 29. If Female: o co p ats the cause of des [h] 3D. Did Tobacco Use Contribute tp Death? Q Not pregnant within 31 Ma ast e f D Q Yas p ar V Q Pre nant f ti Q Q Pry . r o eath r ~ ~ g o me of death 0 Not r b No Q known ral Q Homicide p egnant, ut pregnant within 42 days of death Q Accident Q pending Investigation ~ Q Not pregnant, but pregnant 43 days to 1 year before death 32. Date of In Jury (MO/D /V Q Suicide Q Could not be d¢[ermined ay r) (Spell Month) Q Vnknown If pregnant within the past year 33. Time of In)ury -) 3a. Places of injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, CI ty, State, Zip Code) 36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How In Q Ves Driver/O Jury Occurred: Q Aerator Q Pedestrian Q Passen No Q gar ~ Other (Specify) 39a. r (Check only one): Certio ing physician - T° the best of my knowledge, death occurred due to the cause(s) and manner stated iO Pron uncing 8< Certifying ph sician T th b y - o e est of my knowledge, death occ red at the time, date, and place, and due to the cause(s) and manne Q Medical Examiner/COr er - the basis of t n r s aled axes inatlon, and/or Investigatio in my opinion, death occur at the time, date and place and d h ~-- 3 ~ , , ue to S e cause Signature of cer[iFler: ,A_~`J (s) and manner stated Title of certlFler: License Numb 9b q N er . e, Ad ss a p Code of P r on m leting Cau Dea[~ m 26) ,t ~ 4 /~~ ~,' Al ~n 39c. O to Signed (Mp ~) r~iJ -~jL~J _ ~J~H~C 6 _ 0. Regisira is District Numbe / C f'1 ` r 41. Registrar's 42. Registrar FI a Data Mo Oay r ~ ,~i O 4 _ / r/f 3. Amendments // ( ~d i ~/ ~o~ /~ Q'/L _ Disposition Permit No.~( n~~n (] H105-143 _. _... _ _ REV 0]/2011 :? :;~ = ~7 LAST WILL AND TESTAMENT ~=c~ :~ ;. , -~- - -; ~~ c _ . AUSTIN C. DOUGHERTY . _,:: ~" L `~ ''~ ~' : `~ ~ .~ ~ .~ ~ T7 I, AUSTIN C. DOUGHERTY, of New Cumberland, Cumberland County, Pennsylvania, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time made. ITEM I: I direct that all inheritance and estate taxes becoming due by reason of my death, whether such taxes may be payable by my estate or by any recipient of any property, shall be paid by the Executrix out of the property passing under ITEM III of this Will, as an expense and cost of administration of my estate. The Executrix shall have no duty or obligation to obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other property not passing under this Will. ITEM II: I direct the Executrix to pay my just debts and the expenses of my last illness and funeral expenses from the property passing under this Will as an expense and cost of administration of my estate. ~~ ITEM III: I devise and bequeath all the rest, residue and remainder of my estate to my wife, ARLENE B. DOUGHERTY. In the event my wife predeceases me or, in the event she does not survive me by thirty (30) days, I devise and bequeath my estate as follows: (a) One-third (1/3) to my son, BRYAN R. DOUGHERTY. In the event my son predeceases me, this share shall be paid to his issue, per stirpes; (b) One-third (1/3) to my son, KEVIN R. DOUGHERTY. In the event my son predeceases me, this share shall be paid to his issue, per stirpes; and (c) One-third (1/3 to my son, DAVID DOUGHERTY. In the event my son predeceases me, this share shall be paid to his issue, per stirpes. In the event any of my sons should predecease me leaving no issue surviving him, his share shall be paid to the other named beneficiaries. ITEM IV: In the settlement of my estate, my Executrix shall possess, among others, the following powers: (a) To retain any investments I may have at my death, as long as the Executrix may deem it advisable to my estate to do so; (b) To sell either at private or public sale and upon such terms and conditions as the Executrix may deem advantageous to the estate, any or all real or personal property or interest therein owned by the estate; ~ 1~l'/l• (c) To pay all costs, taxes, expenses and charges in connection with the administration of my estate; (d) To compromise controversies; and (e) To do all other acts in the Executrix's judgment deemed necessary or desirable for the proper and advantageous management, investment and distribution of the estate. ITEM V: Any person who shall have died at the same time as I shall have, or in a common disaster with me, or under circumstance that the order of deaths cannot be established by proof, or within thirty (30) days of my death, shall be deemed to have predeceased me. ITEM VI: I appoint my wife, ARLENE B. DOUGHERTY, to be Executrix ofmy Estate. In the event my wife cannot act or refuses to act as Executrix, I nominate and appoint my sons, BRYAN R. DOUGHERTY, KEVIN R. DOUGHERTY, and DAVID DOUGHERTY, to be Co-Executors of my Estate. In the event any ofmy sons cannot actor refuses to act as Executor for any reason, the remaining named Co-Executors shall act alone 3 ~ , as Co-Executors. The Executors are specifically relieved from the duty or obligation of filing any bond or other security. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, consisting of this and the preceding three (3) pages, at the end of each page of which I have also set my initials for greater security and better identification this day of January, 2004. (SEAL) AUSTIN C. DOU We, the undersigned, hereby certify that the foregoing Will was signed, sealed, published and declared by the above-named Testator as and for his Last Will and Testament, in the presence of each other, have hereunto set our hands and seals the day and year first above written, and we certify that at the time of the execution thereof, the said Testator was of sound mind and memory. Laura J. H hes oyle ~ ~ ~ ~L~~_ Amanda L. Baker Residing at: 549 Bridge Street, Apt. 2 New Cumberland, PA 17070 Residing at: 699 Kohler Mill Road New Oxford, PA 17350 ~ y~/J ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. I, AUSTIN C. DOUGHERTY, Testator, 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 for the purposes therein expressed. Sworn to and subscribed before me 's ~ day of J ~ 4. NO ARY PUBLIC My Commission Expires: (SEAL) Not~aw. sou e~tv~ai- SUMPLE-suwv~w Notary Public WEVMCUftABERIAPID 80R000H CUMOERlANO C ~ 5, 2007 CommMtion (SEAL) A STIN C. DOUG AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. We, Amanda L. Baker and Laura J. Hughes-Doyle, 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 Testator, AUSTIN C. DOUGHERTY, sign and execute the instrument as his Last Will and Testament; that Testator signed willingly and he executed said Will as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the Will as witnesses; and that to the best of our knowledge the Testator was at that time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. ~ ~ - ~~~~~ ~~ '~G ~ Amanda L. Baker Laura J. ug -Doyle Sworn to and subscribed before is ~ day ofJ/~~~ NOTARY PUBLIC My Commission Expires: (SEAL) Nowsu s~ e~ae~w- sum-suwv~w coin Commww~ Nov 1 S, zoo?