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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: Marie E. Deiter
a/k/a:
a/k/a:
a/k/a:
Date of Death: Anril 11.2012
File No• ~ ~ ~ ~ ' ~ ~ ~~,~
(Assigned by Register)
Social Security No: 204-18-0585
Age at death: 90
Decedent was domiciled at death in Cumberland County, Pennsylvania (State) with his/her last
principal residence at 3428 Bedford Drive, Camp Hill, PA 17011 Camp Hill Borough Cumberland
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at Holy Spirit Hospital, 503 N. 21st Street, Camp Hill, PA 17011 Camp Hill Borough 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 Pennsy[vania ............................ All personal property $ 40,000.00
If not domiciled in Pennsy!vania ........................ Personal property in Pennsylvania $
If not domiciled in Pennsy!vania ........................ Personal property in County $
Value of real estate in Pennsylvania ......................................................... $ 60,()()0.00
TOTAL ESTIMATED VALUE.... $ 100,000.00
Real estate in Pennsylvania situated at: 3428 Bedford Drive, Camp Hill, PA 17011 Camp Hill Borough Cumberland
(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 October 16, 2002 and Codicil(s)
thereto dated
State relevant circumstances (e.g. renunciation, death of executor, etc.)
Except as follows: after the execution ofthe 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
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, e.t.a. or d.b.n.c.t.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 (ifany) and heirs (attach
additional sheets, if necessary):
Name Relationshi Address
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Form RW-02 rev. 10/11/201 /
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Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF Cumberland
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Official Usc Only
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Petitioner(s) Printed Name Petitioner(s) Printed Address '~ ~ ~ c ~) -..~,
Rub D. Adams ^, r--
2939 Lincoln Street Cam Hill PA 17011
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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 administer the estate according to law.
Sworn to or affirmed and subscribed before ~, ~ ~ Date 2 ,M ~ ! L
me this~~ d~ 1 _, ~, ~ Date
By:
the
Date
Date
BOND Required: ®YES ~ NO
FEES:
Letters ..................... .
( 4) Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other Will ....... .
Supreme Court
15.00 ID Number: 77426
Firm Name: Saidis Sullivan & Rogers
Address: 635 N. 12th Street, Suite 400
T,emo~ne, PA 17043
...... Phone: (717)612-5800
Automation Fee ............... 5.00 Fax: (717) 612-5805
JCS Fee . .................... 23.50 Email: ~fPinhtelrn~ccr-attnrne3.c nnm
TOTAL ..................... ~ 269.50 ..
DECREE OF THE REGISTER
Estate of Marie E. Deiter File No: ~~'~ ~' ~ ~~~
a/k/a:
AND NOW, lit ~ , _~~JL_L_~, in consideration of the foregoing Petition,
satisfactory proof having een presented before me, IT IS DECREED that Letters Testamentary
are hereby granted to Rubv D. Adams
in the above estate and (if applicable) that
the instrument(s) dated October 16, 2002
described in the Petition be admitted to probate and filed of record as the lash Will (and Codicil(s)) of Decedent.
Form RW-02 rev. l0/11/201!
To the Register of Wills:
Please enter my appearance by my signature below:
$ 210.00 Attorney Si nature:
16.00
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Printed Name: John A. Feichtel
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CertifiL.(t~On v tlr ~_, _ ,.
J<-~1~/Print In COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH • VITAL RECORDS
Permanent CFRTIFICATF AF IIFATH
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1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number V 4. Date of Death (Mo/Day/Yr) (Spell Mo)
Marie E_ Dei.ter FI=_mal 204-18-0585 ril 11 2012
6a. Age-Last Birthday (Vrs) 56. Under 1 Vear Sc. Under 1 Da 6. Date of Birth (Mo/Day/Year) (Spell Month) 7a. Birthplace (City and State or Foreign Country)
Months Days Hours Minutes
90 May 15 ~ 1921 Zb. Birthplace (County)
Ba. Residence (State or Foreign Country) Hb. Residence (Street and Number -Include Apt No.) 8c. Did Decedent Live in a Township?
Pa t~Yes, decedent lived in NA T
TY3 ai-f twp
Hd. Residence (Cpgnty)
3428 Bedford DR t
.
Cumberland 8e. Residence (Zip Code) Q No, decedent lived within limits of city/boro.
9. Ever (n US Armed Forces? 10. Marital Status at Time of Death Q Married [~
Widowed 11. Su rvlving Spouse's Name (If wife, give name prior to first marriage)
N
Q Yes [~Np Q Unknown Q Divorced Q Never Married Q Unkno
12. Father's Name (First, Middle, Lasf, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last)
ohn chu
14a. Informant s Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code)
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C .......................................................... ........................................ ........15a: P ace of Deat-.. Chet on one
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_ If Death Occurred in a Hos ital: LSr In
p patient : -
--...........................-.-----
If Death Occurred Somewhere Other Than a Hospital: ~ Hospice Facility `L"J Decedent's Home
° Q Emergency Room/Outpatient Q Dead on Arrival
. Q Nursing Home/Long-Term Care Facility Q Other (Specify)
16b- Facility Name (If not institution, give street and number; 16c. City or Town, State, and Zip Code 16d. County of Death
Hol S i.rit Hos ital
m 16a. Method of Disposition ~ Burial Q Cremation i6b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place)
Q Rempyal frgm sta
Q Dgnatipn
g)
Q Other (Sped April 16 ~ 2012 St John's Cemetery
~ 16d. Location of Dis poslilon (C(ty or Town, State, and Zip) Ignatu re Funeral Service Licensee or rson In Charge of Interment 1?b. License Number
Mechanicsbur Pa 16 4-
E 17c. Name and Complete Address of Funeral Facility
M ers-Harper Funeral Home Inc 1903 Market tre t
m 18. Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race - Gheck ONE Oft MORE ra s to indicate what
f- highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be.
Q 8th grade or less is Spanish/Hispanic/Latino. Check the "NO" White Q Korean
No diploma, 9th - 12th grade box if decedent is not Spanish/Hispanic/Latino. ~ Black or African American Q Vietnamese
High school grad uafe or GED completed Q No, not Spanish/Hispanic/Latino Q American Indian or Alaska Native Q Other Asian
Q Some college cred K, but no degree Q Ves, Mexican, Mexican American, Chicano Q Asian Indian Q Native Hawaiian
Q Associate degree (e.g. AA, AS) Q Yes, Puerto Rican Q Chinese Q Guamanian or Cha mono
Q Bachelor's degree (e.g. BA, AB, BS) Q Ves, Cuban 0 Filipino Q Samoan
Q Master's degree (e.g. MA, M5, MEng, MEd, M6W, MBA) Q Yes, other Spanish/Nispanic/Latino Q Japanese Q Other Pacitic Islander
Q Doctorate (e.g. PhD, EdD) or Professional degree (Specify) Q Other (S
pecify)
. MD, DDS DVM, LLB JD
21. Decedent's Single Race Self-Designation -Check ONLY ONE to indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual occupation -Indicate type of work
[~ White Q Japanese Q Samoan done during most of working life. DO NOT USE RETIRED.
Q Black or African American Q Korean Q Other Pacific Islander
Cl
k
Q American Indian or Alaska Native ~ Vietnamese Q Don't Know/Not Sure er
Q Asian Indian Q Other ASian Q Refused 22 b. Kind of Business/Industry
0 Chinese Q Native Hawaiian Q Other (Specify)
Q Filipino Q Gua manlan or Chamorro
ITEMS 23a - 23d MUST BE COMPLETED
BY PERSON WHO PRONOUNCES OR 23a- Date Pronounced Dead (MO/Day/Yr) 236. Signature f Person Pro nounci Death (Only wh ap Iicable7 23c. Ucense Numbe
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CERTIFIES DEATH l/L /~ ~~/~ A_ j~~o ~~
23d. Date Signed (MO/Day/Yr) _ 24. Ime of Death
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~~ ~~ 25. Was Medical Examiner or Coroner Contacted? Q Yes .~_ No
CAUSE OF DEATH - Approximate
26. Pert 1. Enter the chain of events--diseases, injuries, o mplications--that directly caused the death. DO NOT enter terminal a ents such a ardiac arrest Interval:
respiratory arrest, or ventricular fibrillation without sh
Owing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary Onset to Death
G
IMMEDIATE CAUSE > 5 ~~ S' S -
(Flnal disease o ndition pue to (o as a copse of):
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resulting in death) ,y~ A
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b. / / y U C t Y ~~.. 2
Sequentially list conditions, Due fo (or as a conseq ue a of): -
if any, leading to the cause
listed on line a. Enter the
UNDERLYING CAUSE Due to (or as a consequence of):
(di:ease or iniury that
F initiated the e., ncs resul<ine d.
e
In death) LAST-
Due to (or as a consequence of):
ij 26. Part 11. Enter other significant conditions contrib utine to tleath but not resulting In the underlying cause given in Part I 27. Was an autopsy performed?
° Q Yes No
~ 28. Were autopsy findings a aila ble
to mple the c of death?
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Q No
29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death
o Q Not pregnant within past year Q Ves Q Probably Q Natural Q Hom tide
Q Pregnant at time of death Q No 0 Unknown Q Accident 0 Pending Investigation
m Q Not pregnant, but pregnant within 42 days of death Q Suicide Q Could not be determined
t- Q Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/V r) (Spell Month)
Q Unknown IF pregnant within the pas[ year 33. Time of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City, State, Zip Code)
36. Injury a[ Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred:
Q Ves Q Driver/Operator Q Pedestrian
Q No Q Passenger Q Other (Specify)
39a. Certifier (Check only one):
Q Certifying physician -TO the best of my knowledge, death occurred due to the cause(s) and m stated
Q Pronou ncing lL Certifying physician - To the best of my knowledge, death o red at the t e, date, and place, and due to the cause(s) and m r stated
Q Medical Examiner/COro p
et -
On the basis of examination, and/or investigatio nr in my opinion, death o red at the time, date, and place, and due <o the c e(s)
and m toted
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Signature of certifier: F
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Title of certifle r:
Ucense Number:
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39 b. Name, Address and Zip Code of Person Completing Cause of Depth (Item 26) 39c. Date Signed (MO/Day/V r)
~r . l,~~Lhe-ems ~ e3 N ` z l ~T C - Ifi t 1~ I t ~-I - ~ z - ~
40. Reglstra is District Number 41. Registrar s Sig 42. Registrar File Dat (MO/Day/Vr)
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43. Amendments
Disposition Permit No- V ~~ `~~ ~/ ~ H1p5-143
REV 07/2011
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LAST WILL AND TESTAMENT ~ ~~<.~ ` ?~~~
OF -n - cn
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MARIE E. DEITER
I, Marie E. Defter of the Borough of Camp Hill, Cumberland County, Pennsylvania,
declare this to be my Last Will and Testament, hereby revoking any will previously made by
me.
I- I direct the payment of all my just debts and funeral expenses out of my estate
as soon as maybe practical after my death.
II. I devise and bequeath all the rest, residue and remainder of my estate of
whatever nature and wherever situate unto my daughter, RUBY D. ADAMS or if she is
deceased, to her issue per stirpes.
III. I nominate, constitute and appoint my daughter, RUBY D. ADAMS as
Executrix this, my Last Will and Testament. In the event she is unable to serve as such, then I
appoint her daughter, ANN MERMELSTEIN as Executrix. Neither of my Executrices shall
be required to post bond in this or any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal on this, the
SAIDIS
SHUFF, FLOWER
& LINDSAY
n rroavevs•~ r•~~w
2109 Market Street
Camp Hill, PA
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. y,~~` ~u,c'. ,~ ~,~~~ ~- (SEAL)
Marie E. Deiter
Signed, sealed, published and declared by Marie E. Defter herein named, on this and one (1)
other sheet of paper as and for her Last Will and Testament, in our presence, who, in her
1
presence, at her request, and in the presence of each other, have hereunto subscribed our
names as attesting witnesses.
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Name
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
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Address
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 constrain or undue influence.
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Ma~~e E. Deiter, Testatrix
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Witness
'Witness
SAIDIS
SHUFF, FLOWER
& LINDSAY
2109 Markel Street
Camp Hill, PA
Subscribed, sworn to and acknowledged before me by the Testatrix, and subscribed
and sworn to before me by both witnesses, this '!-~ ~~ day of ~~~; ~ f t;,~>~ j'"~' ,
2002.
,-_., _ ,
Notarial Seal r'
Sallie Allshouse, Notary Public
Carlisle Boro, Cumberland Counttyy ~,,
My Commission Expires Mar. 29, 21704
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