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Home My WebLink About06-18-12~C~~'G~~i ~F'~;~ t~ PETITION FOR GRavT OF LETTERS R OF WILLS OF ~ ~2r3~Lf}~,~ COUNTY, PE~~iSYLV~~1t_-~ ~D12 .~~~ -$ P~E~ u ~ ~ ~ ;~ bz c,v. ~t o :~ -~ i~3 ars of a~J~ ~ o:4c ^' ins! r `esters as ne r:zd heio•,~. ar.d it t~;.t:~:~.l..t ~~ ...: l~~fF~~TR~fT~~-t~iiV J V~~1'1,~) :ii. iCt,(~~~b_Il'? _~II~ r25~'~C[:L11`. I'~Ct::,~.,, tY`~ '3~alli Of LZL~C~ :n tl1Z di~jJC~~~r„l~Z :Jr:Ti: ~"'f)~C~~3 ~o ri~ation rame• C1E~T`AL+.t01±' ~- I D!/$ File No• -~ ~ - ~oZ - ~ ~ 11 ~ ~"1 a,~k/a: (Assigned by Register) a/k/a. a/k/a: Social Security No: ~ ~ 7- 3 Z- c! ~~ ~ ilatr of Tleath~ .4AR_t~. 2•pl:L Age at death: ~~ Decedent was domiciled at death in Lilwlkl~~,~-~~D County, principal residence at ~ A~T~RS RPAt1J ~~~-15LL~ p~'1 Street address, Post Office and Zip Code City, Decedent died at E-YRiv'l a (State) or Borougph `~ ter last ~Q~xI~ county Street address, Post Office and Zip Cade City, Township or Borough County State Estimate of value of decedent's property at death: If domiciled in Pennsylvania ............................ All personal property $ z`~..~ 0~ If not domiciled in Pennsylvania ........................Personal property in Pennsylvania $ If not domiciled in Pennsylvania ........................Personal property in County $ Value ofrealestatein Pennsylvania .............:........................................... $ TOTAL ESTIMATED VALUE.... $ Real estate in Pennsylvania situated at: (Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough ~ A. Petition for Probate and Grant of Letters Testamentary Petitioner(s) aver(s) he/she/they is/are the Executor(s) named to the last Wtll of the Decedent, dated thereto dated County and Codicil(s) State relevant circumstances (e.g. rentmciation, death ofexecutar, 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. 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.t.a., enter date of Will in Section A above and complete list of heirs. Except as follows: Decedent was vot 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 W ill and was survived by the following spouse (if any) and heirs (attach udclitionul sheets, if necessary): Name Relationshi Address T M~ ~ ~ ~s -~~~Z,~ 7. L- o~J3 ~5 use ~~' S ~ ~/{~sc~ ~~- 17o/.Y S'o~l ~3 j ~Rl.! l/,~' e`er [1S~'~ I Cy -~A~o~/ ~ . t~4~/~ Art 2 ~Od t~'®tt)~T ,l los t ~~ Far-,» Rw-nz ~-w. lniuizntt Page 1 of 2 Oath of Personal Representative CObi:~(ONWE.~LTH OF PENNSYLVANIA } ~ Ss: CnL'~TY OF ~MB,~L~}~~ ~±r~ `~~{'ie9a113sE a?t~Y ~{7..r- [[ r . ,~ 2Df2 JUN -8 P~! 3; 13 r•,~. I t~ S ~ ~ G,r O~g ~ ~LT~ ~ L The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are tnte and correct to the best of the knowledge and belief of P:•titioner(s) and that, as Personal Representative(s) of the D cedent, the Petitioner s) w' well and truly administer the estate according to law. S~,vort: to r affirmed and subscribed before Date ~ ~~ the tl~' day of ~,) c ~ ti~ _~ ~c~ Date /~ C Date '3y'r /~l Date For :he Register BONll Required:QYES ~NO FEES: 7C Letters ..................... . ( -7,. )Short Certificate(s)..... . ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other •••••••• $ ~ ~~ `~~ __1__2ys[1G-- ........ Automation Fee ............... JCS Fee. ~C) ~ ~? TOTAL ..................... $~ t~ To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature: ~~J - Printed Name: Q- ~ 'r~ Supreme Court ,y ~ ~~ ID Number: ~ 1~- ~ 1 Firm Name: re-' ~~ t Address: ~ ~ O '~ Sr'. (' S '7~/ Phone: 1~ T- Z~ 3 r ~~l 3 Fax: I ~ 3 ' ~ ~ ~ Email: e G.,.< < + ~ . Gary DECREE OF THE REGISTER Estate of ~?~'~TR,l~I J~ 'L yd~S a/k/a: ~' AND NOW, ~% ~d M/~'s L- ~- y0/~.~ , , in consid ration of the oreg iilg Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters ~1i~rn t +1 ,1 c~~Ll~ (~ ~ are hereby granted to 1 fYl CL (~ • ' in the abov estate and (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. ~ Register of~Wil ~ ~ ;.~ ~ ~~,~ Fo,,~~ Rw-nz rev. In~(1~2n1I Page 2 of 2 File No: r'X ~ - ~ ~ " L~ ~ G if;l;i Tlii 'jt' ~,_ LOCA~ REGISTRAR'S CERT°II=ICATION OF CHEAT VUAR ~~% i~~~~uplicate this capy by photostat or phatoc~r~:p~, ~~~t 1 I t." E..~~ `~~l~S Fee for This certificate. ~ti+/.00 ~~~~ .~~~ _8 Q~ ~~ ~ ~ Ilil,"' ` _ ih15 i~ tti L+n' t ~ r)i( . ' ~,y~ ri Of ~ "~ I,~t(, ~~'% \ colrc ctl~~ tnpl ~(~ ~ t, r~ ,,tom; ~r~ ~, Vi.l.i i;~t ~- Imo; A Z ~ ~~l'htlcaCc ~~ ( ~~ i. ' _ ... QRPF~AN S ~vURT , - , C~uIBERIAND CO.f P!~ ``= o~.~, ',~. ~~~, --, P 18 3 2 9 511 \~9lritENt Q~°~~`1'`', ~~ _-- . __---- --_ 10?20~2 t~ertificati~Jn N=)niher I,o~ '~ Type/Print In Permanent k S~ ~~ ~~ V COMMONWEALTH OF PEN NSVLVANIA DEPARTMENT OF HEALTH • VITAL RECORDS !`CRTIFIIC'ATF AF 1']FOTH _. _.._ _......___. lack In 1 2. Sex 3. Social Security Number 4. Date of Death (Mp/Day/Yr) (Spell Mo) . Decedent's Legal Nama (First, Middle, Last, Suffix) Gertrude L ons F 2"17 32 946"1 April 9, 20"12 6 a. Ag¢-Last Birthday (Vrs) Sb. Under 1 Year Sc. Under 1 Da 6. Dat¢ of Birth (MO/Day/Vear) (Spell Month) 7a. Birthplace (City and State or Foreign Country) A Vi t i ~ enna, us r a Months Oays Hours Minutes F ~ 927 brua ~ 3 r \ , e y 7b. Birthplace (County) 85 S Residence (State or Foreign Country) Bb. 0.esid¢nce (Street and Number -Include Apt No.) 8c. Did Decedent Live in a Township? a . pA [Yes, decedent IiV¢d in West Pennsboro t,,,,p. 8 Alters Road 8d. Residence (county) Cumberland Se. Residence (tip Code) - ENO, decedent Ilved within limits of city/boro. 9. Ever in VS Armed Forc¢s7 10. Marital Status at Time of Death Married O Widow¢d 11. Surviving Spouse's Name (If wife, gWe na m¢ prior to first man(age) Ves ~ No DUnknown ~ Divorced Q Never Married ~ Vnknow 'I'h~^lg L. L 0115 12. Father's Name (First, Middle, Last, Suffix) 33. Moth¢r's Name Prior to First Marriage (First, Middle, last) Franz Gruber Hedwi Staedler 14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, Ci State Zip Code P~ 'I'~O'I5- 969 li l C Thcacias L_ Lyons Husband e, ar s 8 Alters Road, ~ G .................................... ... isa:p_ace.o. neat... c ¢~ on one .. ... .... ....... ... ... ......... ... ....... ....... ..... . ... .. . ... ....... ... ........ ... .. .. ... ... ..... ..............Y..... ... ' ~ . I z ......................................................... ..... . f Death Occurred in a Hospital: [~ Inpatient : ] Decedent s Home If Death Occurred Somewhere Other Than a Hospital: ~ Hospic¢ Facility [ y Q Emergency 0.oom/Outpatient ~ Dead on Arrival _ $1 Nursing Home/Long-Term Care Facility Other (SpecHy) ' 2 i5b. Facility Name (If noY institution, give street and number; 16 c. City or Town, State, and Zip Code i5d. County of Death C ~llberland ' ' Nlar3orCare Health Services t 170 13 Carlisle, PA 16a. Method of Disposition Burial ~ Cremation 166. Date of Dlsposlfion i6c. Place of Disposition (Name of cemetery, crematory, or other place) .~' ~ Removal from State ~ Donation Other (Specify) 4 1 3 20'1 2 St _ Patrick's New Catholic C~nete 16d. Location of Disposition (City or Town, State, and Zip) 17a. Signature of Fu ral 6¢rvice Licens Pers Charge of Interment 17 b. License Number Z ~ Carlisle, PA '17013 _ FD 0'12633 L E 8 17c. Name and Complete Address of Funeral Facility F~win Brothers Funeral Hc(me Snc. 630 S_ Hanover St_ Carlisle PA '170'13 °rb' Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to indicate what 18 `- . ecedent considered himself or herself to b¢. e d highest degree or level of school completed at [he time of death. box that best describes whether the decedent th ~ w ' 0 8th grade or less Is Spanish/H(spa ntc/Latino. Check the "NO' ~ vvhite Q Korean Q No diploma, 9th - 12th grade box if decedent Is not Spanish/Hispanic/Latino. ~ Black or African American Q Vietnamese ~ High school graduate or GED completed j~Np, not Spanish/Hispanic/Latino ~ American Indian or Alaska NatiV¢ Q Other Asian g Some college credit, but no degree Q Ves, Mexican, Mexican American, Chicano Q Asian Indian O NaHye Hawaiian 0 Associate degree (e.g. AA, AS) Q Ves, Puerto Rican 0 Chinese Q Guamanian or Chamorro ~ Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban Q Filipino Q Samoan ~ Maste YS degree (e.g. MA, MS, MEng, MEd, MS W, MBA) Q Yes, other Spanish/Hispanic/Latino ~ Japanese O Other Pacific Islander ~ Doctorate (e.g. PhO, Ed D) or Professional degree (Specify) ~ Other (6p¢cify) . MD DOS DVM LLB JD dent'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 21 D¢c~ . r B'W hite - 0 Japanese 0 Samoan done during most of working life. DO NOT USE RETIRED. Q Black or African American ~ Korean ~ Other Pacific Islander Hcxnanalcer ' t Know/NO[ Sure 0 American Indian or Alaska Native ~ Vietnamese Q Don ~ Asian Indian ~ Other Asian Q Refused 22b. Kind of Business/Industry ~ Chines¢ Q Native Hawaiian ~ Other (Specify) Filipino ~ Guamanian or Chamorro Her CAN31 hO1Tle ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced Dead (MO Day r) 23b. Signature of Person Pronouncing Death (Only when applicable) 23c. Licens¢ Number BV PERSON WHO PRONOUNCES OR t 1 _ q - , n ~`\ [ ~ ~p (~\~\ ~N ~ 2315'-t CERTIFIES DEATH ~I L ~yjiL V Lie `t~~ 23d. Date Signed (MO/Day/Yr) 24. Tim¢ of Death I`-'tl _, 'Z `~ ~ 25. Was Medical Examiner or Coroner ContacTed7 V¢s 0 No CAUSE OF DEATH Approximate 26. Part 1. Enter She chain of events--diseases, Injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest. Interval: O NOT ABBREVIATE. Enter only on¢ cause on a Iin¢. Add additional Ilnes if necessary Onset [o Death D g the etiology. respiratory arrest, or ventricular fibrillation without showin ` ~ ^ ~[ IMMEDIATE CAUSE ---------------> (Final dis¢ase o ondition Due to (or as a consequence of): resulting in death) b. 6aq u¢ntially list conditions, Due to (or as a consequence of): if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE Due to (or as a consequence of): W Lha isease or In Ju ( e ¢ ryi ^ i itlated the Ve is r suiting d. iz on in death) LAST. Due to (or as a c sequence of): S Enter other i ifl t d(t t Ib tl t d th but not resulting In the underlying cause gWen in Pan 1 27. Was an autopsy performed? Part 11 26 - . . Q Yes ~ No g- 2g. Were autopsy findings available to complete the c of death? ease Q Yes No 29. If Female: 30. Dld Tobacco Use Cgntribute fo Death? 31. Mann¢r of Death E ~ Not pregnant within past year ~ Yes O Probably ~ Natural ~ Homicide a~ ~ Pr¢gnant at time of death ~ ~ Unknown ~ Accident ~ Pending Investigation ~' but pregnant within 42 tlays of death nant Not re ~ Suicide 0 Could not be d¢termined , p g 0 s to 1 year before d¢a[h na n[ 43 da t b L 32. Date of Injury (MO/Day/Vr) (Spell Month) ~ y , u preg ~ Not pregnan ~ Unknown if pregnant within the past year 33. Time of Injury 34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, Gity, State, Zip Cod¢) 36. Injury at Wqrk 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred: 0 Yes ~ Driver/Operator ~ Pedestrian 0 No ~ Passenger Q Other (Specify) 39a. Certifier (Check only one): ~ Certifying physician - To the best of my knowledge, death occurred du¢ to the cause(s) and manner stated ~ Pronouncing 8< Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to [he c se(s) and manner stated cu red at the time, date, and place, and due to the cause(s) and manner stat¢d h Q M¢dlcal Examiner/Coroner - the basis of examination, and/or Investigation, In my opinion, deat c /^ ~ - ~_ Licens¢ Number: b O (~ ~' /.S - L Signature of certifier- Title of certifier: !J 39b. Name, Address and 2Ip Co Person Completing Caus¢ of Death (Item 26) iJ e~. f ) ~~S T4~ f ,~.C • ~ I C 39c. Date Signed (MO/Day/Vr) . Y s ~ ,a 5 (,, rf- - <<,.~ ~ ~ S csz ~ P -9 (~ f r ' ~~ a < < z. 40. Registrar's District Number 41. Registrar's ~~~ 42. R¢gistrar File Dace Mo Day r) _ C 0 a 43. Amendments 2 B Disposition Permit No. Ot 13 O `J" ~ REV 07/2011