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Home My WebLink About06-15-12PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY PEN NSYLVANIA 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) thl following and respectfully requests the grant of Letters in the appropriate form: Sandra J. Decedent's Information Name: Howard R Moore Jr a/k/a: a/k/a: a/k/a: Date of Death: _05/18/2012 File No: 21 - 12 '- ~- (Asstgned by Register) Social Security No: 199-34-9311 Age at Death: gg Decedent was domiciled at death in Cumberland principal residence at County, PA 427 N. 2nd Street, Wormle sbur 17043 (State) with his/her last Street address, Post Office and Zip Code Wormle sbur Cumberland Decedent died at Penn State Hershey Medical Center city, township or Borougn count v Street address, Post Office and Zip Code Hershe Dau hin pq City, Township or Borough Count y State Estimate of value of decedent's property at death: /f domiciled in Pennsylvania ........................ All personal property $ /f not domiciled in Pennsylvania ................. Personal property in Pennsylvania $ 10,000.00 /f not domiciled in Pennsylvania ................. Personal property in County $ Value of real estate in Pennsylvania........... Real estate in Pennsylvania situated at TOTAL ESTIMATED VALUE$ 10,000.00 (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 Testamenta Petitioner(s) aver(s) that he/she/they is/are the Executor(s) named in the Last Will of the Decedent, dated thereto dated and COdicil(S) Except as follows: after the execution of the instrument(es)aoffered for probate, Decedent d tl not marcut~as not divorced, was not a arty to a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. 3323 adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated persoryn. p § (g), and did not have a child born or QX NO EXCEPTIONS ^ EXCEPTIONS [X] B. Petition for Grant of Letters of Administration (If applicable) If Administration, c.t.a or d.b.n.c.t.a., enter date of Will in Section A above and com lete list ofthe ~s ente fte; urante a sentia; urante mtnontate 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. ~X NO EXCEPTIONS ^ EXCEPTIONS additional sheets, if necessary): Petitioner(s), after a proper search has/have ascertained that Deoedertt left no Will and was survived by the following spouse (if any) and heirs (attach Name Relationship Address Sandra J. Moore ... r~., Spouse 427 N. 2nd St , _ ~ ~ ~ -~ , Wormleysburg, PA 17043 ;~~ ~ ~ :• ~' I'' + ~ ,,,~, r. ~ ci . _ CJ1 . r ~-~ tt V r < . ""4 ~ f Form RW-O2 rev. 10-> 1-2011 Copyright (c) 2011 form software only The Lackner Group, Inc. N Pa ge 1 of 2 F`\,\ ~~/ Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } couNTY of Cumberland } ss: Petitioner(s) Printed Name } Sandra J. Moore Petitioner(s) Printed Address 427 N. 2nd Street Wormleysburg, Pq 17043 Official Use Only The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are true and correct to the belief of Petitioner(s) and that, as Personal Representative(s) of the ecedent, Petitioner(s) will well and truly administ Sworn to or a_ffi//trtmed and ubscribed before / best me th' `day of ~G~ fj~ . ~-='' E;-j-.~z7G~(,~,~ , ~/ !~ t~~~f~,~ er the By: Gam- / 1 r e Register BOND Required? ~ Yes ICI No FEES Letters ........................................... t 4 )Short Certificate(s).......... i )Renunciation(s) ............... I )Codicil(s) .................... ..... I )Affidavit(s) ....................... Bond .............................................. Commission ................................... Other $ ~- f~ ~:- /'/.. o To the Register of Wills: Please enter my aonc~ -- - ~~ ~r ~r~y signature below: ~. ..7 N ~~'.. l a6- ! ~' 7 F -~ r .:> knowledge•and . i r- `.e accordil ~ la w~n~ Date . ,y ~' ( ~ ~ ~ a Date Date Date r Attorney Signature: Printed Name; James J McCarthy Jr Supreme Court ID Number: PA 82266 Firm Name: McCarth Weisber Cummin s, PC Address: 2041 Herr Street Harrisburg, Pq Automation Fee.......... Phone: '"'"'~'~'~•~••••"•~ ~ ~ ~ 717/238-5707 JCS Fee ................. ........................ Fax: TOTAL .................. ' ~' ~ 717/233-8133 E-mail: jmccarth Y@mwcfirm.com DECREE OF THE REGISTER Estate of Howard R Moore Jr a/k/a: AND NOW, __.t ~- ~ ~- satisfactory proof naving been presented before me, IT IS DECREED that Letters are hereby granted to Sandra J. Moore Date of Death: 05/18/2012 Social Security No: 199-34-9311 __~ File No: 21 -12- in consideration of the foregoing Petition, of Administration in the above estate and (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of record as th I ill (and Codic' (s)) of Decedent. Register of Wills Copyright (c) 2011 form software only The Lackner Group, Inc. Page fll.~r_. ~~. ~ _fJ~ ~~_~~~., .~•,: 4a#,~ 3 CUME~Rf.ANp ~~~' Pq ___ ~ YP /Prin In Permane t COMMON WEALTH OF PENNSYLVANIA ~ pEPARTMENT OF HEALTH ~ VITAL RECORDS Black ink CERTIFICATE OF DEATH 1, pecedent's Legal Name (Firrt, Middle, Last, Suffix) Howard R_ Moor@, Ja z. Sex 3. Social 5ecurey Nu mber5tate File Number: Sa. Age-Lass Birthday (Vrs) 56. Under 1 Year Sc. Male 4. Date of Death (MO/pay/yr) (Spell M°) Months Under 1 Da 6. Date of Birth (MO/Da '199-34-937'1 May 18, 2012 (a8 Days Hourz Min utss V/Year) (Spell Month) ]a. Birthplace (City and State or Forei 8a. Residence (Slat<or Foral JUI 2'1 gn Country) gn Country) 8b. Residence (Street and Number- Y • '1943 ]b. Birthplace (County) PA Include APt Nb.) 8c. pfd pecedent Live In a Township? 8d. Residence (co~ntY) 427 N. 2nd St. pve:, decedent IIYed In Cumberland ea. Residence (Zip Code) ~7 9. Ever In US Armed Forces? 043 t~Yp. Yes 30. Marital Status at Time of peath i~N°, decedent Ilved within limits of p No pUnknown ~ Divorced ~Marrietl p Widowed WOrr^I Yab~p city/born. 12. Father's Name (First, Middle, Las[, Suffix) ~ Never Married p Unknow 11' ~Yi^B Spouse's Name (If wffe, give ham a n p'~a G e-7 G9 a prior o flrrt m rrlag<) I-iOWard R. Moore Sr. 13. Mother's Name prior o Firrt Marrla r ~J 14a. Informant's Name t ge (First, Middle, Last) O Sandra 16 b. Relationship to Decedent I f G Moore WIFE lac. n ormant s Ma ......................... ~ ilin Add eT and N mbe Citayr State, Zip Code If Death Occurred In a H°spital: •••~y """""••~••• 1Sa. Place of Deat C ec 427 u r, ) ~ IRI In Patient ......................... ~............ t. L@mo n y e PA 17043 Emergency Room/Out ilf Death •OC~- -• - "'• ••-•• °^..Y. one patient curretl Somewhere Other Than~a •HOS •ical Ne Zn W 15 b. Facllky Name (If not inrSitution, give strepet and nUmber~Yal .l SC. CI D e Nursing Home/Long-Term Ure Facility Hospice Facility •• •~~•••-' •'" ~ Hershey Medical Center b or town. State, and Zip Gpde Other (Specify) ~ D«event: Hom """ •: _ 16a. Method of Disposition ~ Burial Cerry Twp, Pq 1 7033 isd. county of Death e , ~ ~ Removal from State p ~ Gremaiion 166. Date of Disposition 16c. plac Dauphin Donation a of DFsposition (Name of cemetery, crematory, or other place) Other (Specify) Ma v 16tl, Location of Disposition (City or'TOwn, State, Y 22, 20'12 and Zip) va. si Enola Cemetery ~ Enola, P Hnature of Funeral Service Licensee or Person in Charge of Interment 176. License Number ~ A 17025 F 1]c. Name and Complete Address of Funeral Facility a Marlp A. Billow FD-•13845-L ~ 18. Decedent's Education - $U111Ven Funeral Home 51 N. Enola Dr. Enola, Pq 1702b t- highest de Gheck the box chat best describes the 19. Decedent of Hlspa nic Origin -Check the gree or level of school com Dieted at She time of death. box that bert describes whether the decedent p 8th grade or less 2D. Decedent's Race -Check ONE OR MORE races to Indicate what (] No diploma, 9th - 12th Is Spanish/His the decedent co ns{tlared himself or herself fo be. grade Pank/Latino. Check the "No" ~i Whke p High school graduate or GED com plated box if tlecetlent is not Spanish/Hispanic/Latino. ~ Korean p Some college credit, buT no degree ®No, no{ Spanish/Hispanic/Latino ~ Black or African American ~ Vietnamese ® Assoclaie degree ) p Yes, Mexican, Mexican American, Chicano p'american Indian or Alaska Natfve p Other Asian (] Bachelor's d (e g ~'• AS [] Ves, Puerto Rican ~ Asian Intlian egreee(e.g. gA, qg gS) p Chinese ~ Native Hawal(an Master's degree ( ,g. MA, MS, MEng, MEd, MSW p Yes, Cuban p Guamanian or Chamorro p Doctorate 'MBA') p Yes, other Spanish/Hispa nic/Latino ~ Filipino ~ Samoan (e.g. PhD, EdD) or Professional degree p Japanese . MD OpS DVM LLB JD (Specify) ~ Other S p Ocher Pacific Islander 21. pecedent's Sin le Race Self- ( pacify) ® While p Japanese B Designation -Check ONLY ONE to indicate what the decedent consideretl himself or herself To be. 22a. pecedent's Usual Occu ~ Black or African American ~ Korean ~ Samoan Patle n -Indicate tYPe of work p American Intlian or Alaska Native ~ Vietnamese ~ Other Pacific Islander done during most of working Iff DO NOT USE RETIRED. s CI Asian Indian p ocher Asian O ~ used ow/Not Sure Lab Technician Chinese ~ Native Hawaiian 22 b. Kind of Business/Industry c ~ Filipino p Guamanian or Chamorro ~ Other (Specify) ITEMS 23a - 23d MUST BE COM PLETEp 23a. Date Pronouncetl Dead (Mo/Day/Vr) 23b. SI State Government CERTIF ES DEATH PRONOUNCES OR May 1 g, 2p12 gnature of Person Prpnquncin Death Only when a g ( ppllcabie) 23c. License Number 23d. Date SlRned (MO/Day/yr) 24. Time of Death 12:19 PM 25. Was Medical Examiner or Coroner Contacted? 26. Part L Enter the chain of CAUSE OF DEATH ® ve: p Np respirator ~~`-diseases, injuries, or com Dlicatfons--that directly caused the death. DO NOT enter terminal events such as vrtliac arrert y arrert, or ventricular fibrillation wlihout showing the eilo to Approximate gy. DO NOT ABBREVIATE. Enter only one cause on a line. Adtl additional lines it necessary - Interval: IMMEDIATE CAUSE -----____ a, TraUmatlC Brain in-U I Onset to Death (Final disease or condiHOn ~ resulting In tleath) Due to (or as a consequence of): seq..en:lally l;st conditions, b. Pedestrian Vs. Bus if any, leading io the cause Due to (or sequence ot): listed on line a. Enter the as a con UNDERLYING CAUSE w (disease or injury that c Due io (or as a sequence of): initiated the events re~„Inng d won In death) LAST. u Due io (or as a co sequence ot): ag 26. Part ll. Enter ocher sianifi ~ d i ^ ' S ib i bvS not resulting in the under) in E Y B cause given In Part I 27. Was an autops - ~ (] Ves Y D ® Noed? 28. Were autopsy findings available ~' 29. If Female: to complete the cause of death? S (] Not pregnant within past year 30. Did Tobacco Use Contribute to peath? p Yes No O Pregnant at time °f death ~ Yes p probably 31. Manner pf peath o ~ p Not pregnant, but pregnant wlih in 42 days of death ~ No 1'~ Unknown ~ Natural (] Homicide Not pregnant, but pregnant 43 days To 1 year before death ® Accident g Inverts O Unknown If pregnant within the past 32. Date of Injury (MO Da ~ Sulc{de ~ Pentlin Hatton year / Y/Yr) (Spell Month) p Could noT be tlefermined 34. Place of Inlu May 1 s, 2012 33. Time of Injury rv fe.g. home; ponrtruenon srce; farm; scnoop Apx 07:43 A Roadway 35. Location of Injury (Street antl Number, Ctty, SSat<, Zip Code) 36. Injury at Work 37. If Transportation In)u N. 7th Street & Boas Street Harrisburg, PA 17104 Ves ry• SPecify: ® No ~ Driver/Operator ® Pedertrian 38. pescribe How Injury Occurred: O passenger pothers Pedestrian Vs. Bus ( pacify) 39a. Certifier (Check only one): p Certifying physician - To the best of m p Pronouncing ffi Certifying physician -lf a ge• am o«urred die totem<r a~sa (s) and m r rtatea ® Metlical Examiner/Coroner - On t st V knowledge, death ccu red t the time, tlate, and place, and due to the cause ml tlon, and/or Investigation, In my opinion, tlea{h occurretl at the Time, date, and place, and due toitha ause Signature of certitler: (s) and manner rtafetl 39b. Name, Adtlress and Zip Code of person Completing Cause of Death (Item 26) Title of c<rt'tier: Coroner Graham S. Hetrick, 1271 South 28th Street, Harrisburg, pA '17111 L1Ce^se Number: 40. Registrar's District Number 39c. Date Signed (Mo/Day/Yr) al. Registrars s May 21 . 2012 _ gnat~ra a3. Amendments 42. Registrar Flle Data (MO/Day/yr) _~ DlsppsiSion Permli NO. ~7(i„)~ 1 S 5' H305-143 REV 0]/2011