HomeMy WebLinkAbout06-25-12PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF
,______ COUNTY PENNSYLV
Petitioner(s) named below, who is/are 18 years of age or older, a 1 ies for Letters ANIA
as specified below, and in
support thereof aver(s) the following and respectfully request(s) the granpof Letters in the appropriate form:
Decedent's Information
Name: 5
a/k/a:
a/k/a:
a/k/a:
Date of Death: [~ ~ m ~
Decedent was domiciled at death in
principal residence at ~,.~ (.~ i l ~h 1,
(~ yirne[ aaaress, Post Office and Zip~Code
Decedent died at CIA CI IAA ~ht.~ll I t„~ti ~.In` .n
File No: ~~ - ~~ . ~ ~~
(Ass-gned by Register)
Social Security No: '~~-~'~
Age at death:
(Stare) wi his er 1 t
City, Tow ip or Borough
---•
Street address, Post Office and Z v
Code ~ w~
Estimate of value of decedent's property at death: City, Township or Borough
If domiciled in Pennsylvania .....
.......... .
If not domiciled in Pennsylvania..
' ' '
' • • All personal property
......... ,
If not domiciled in Pennsylvania. • • ' ' ' ' ' ' '
" • • • Personal property in Pennsylvania
" " '•••••••••••••
alue of real estate in Pennsylvania ................... ... Personal ro e
P P rt3' in County
......
Real estate in Pennsylvania situated t• .. • . ,
TOTAL ESTIMATED VALUE... .
a.
(Attach additional sheets, ijnecessary.)
County State
Street address, Post Office and Zip Code
City, Township or Borough
A. Petition for Probate and Grant of Letters Testamentar county
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated
thereto dated
and Codicil(s)
State relevant circumstances (eg. renunciation, deatk of executor, etc.)
Except as follows: after the execution ofthe instrument(s) offered for probate Decedent did not ma
divorce roceedin wherein the rounds for divorce had been established as defined in 23 Pa. C.S. 3323
P g g try, was not divorced, was not a party to a pending
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
§ (g), and did not have a child born or
~NO EXCEPTIONS []EXCEPTIONS
^ 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 Atabove andlcom rleteabsenria, durante minoritate
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce hadlbeen esablished 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 r~~,
~~'
Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the following i(ifan aq~i ~.
uclditionalsheets•, ifnecessury): ~'. --~-
Name T.f Y) xeirs(~ ,/
C.'^ :a`
Relationsht ~ fV
-~ .,
l:-
~ ~7
Form RW-02 rev. /D/[//201/
Page 1 of 2
Oath of Personal Representative
COi~I~10NWEALTH OF PENNSYLVANI }
} SS:
COUNTY OF ~ ~~ ~~ }
Official Use Only
Petitioner(s) Printed Name Petitioner(s) Printed Address
i ~ - ~3; -~br~ r t
~
I
I r '~ 1 v ~u~JCJLZ~~, l U~
To the Register of Wi!!s:
Please enter my appearance by my signature below:
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 De de= ,the Petit'oner ) will well and truly administer the estate according to law.
Sworn to or affirmed subscribed before Date ~ ~ o
me t i ~ ay of ~ ! ~ ~ -
By Date ~~~ ~-/~ , ~,
Date
For the Register Date
BOND Required: YES ~ NO
FEES:
Letters ..................... .
(5 )Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
$ a. ~~
C
Other ........
........
Automation Fee ............... - :~~~--
JCS Fee . .................... ~//. ~
TOTAL ..................... $ LL I
?,~
Attorney Signature: ~"--=
N
c.._
C
2
r"-~rt ~.
~.,~ ~ ~ -
~ _~ _:~~
f_ tV i 9 -.
Printed Name: ~U-.~' C~
Supreme Court C~` ~,. -, ; -~ ;
ID Number: C~C..;~ ~=
~_ -
J ~ ~
,
Firm Name: _ D ~ `-`~
Address: r"
Phone:
Fax:
Etnail:
DECREE OF THE REGISTER
Estate of ~~ f ~ _ 1~~fP,n fl K-A ~C111 I ~n ~~ ~~1~'ile No: ~ ~ ` I t~ - `~a
a/k/a:
AND NOW, ~ ~~ -~1 ~ ~~ ~ , in consider tion of the foregoing Petition,
satisfactory proof having been ese ed before me, IT IS DECREED th t Letters Q.
are hereby granted to I I E j~ ,/(1~~
in the above estate and (if applicable) that
the instrument(s) dated
described in the Petition be admitted to
Fa,,~, nw-nz rw. roii~izni~
and filed of record as the last Will (and Codicil(s)) of Decedent.
Register of ill ~ ; ~"~, p ~~~ ~ ~ -~
l~G
Page 2 of 2
HIOS.Zt05 (tFiV Iv(I i'l
.~-~ " ~ ~ ~ L 7U~-~
LOCAL REGISTRAR'S CERTIFICATION OF dEATIi
WARNING: It is illegal to duplicate this copy by photostat or photagraph,
Fee for this certificate. $6.00
P X9536993
Certification Nmnber
S IyPe/Y rnt In
Permanent
Black Ink
F
This is to ec°rt71 that ((c i(tfotr:a,uj^ here ~il~en i
correctly coi>ieu `t-(iltt au ~ril,?iual Certjli(ate of l.eatl
duly tJled wit9a rle CIS Loct,l Rc:ri~t).~r. The origins
certificate c.°il; i.~t' forwarded t~~ the Suite Vita
Records fJf('ic~~ tl)r p-' ~ ianent ti~in~'.
t
-~--~~~~-1~
_o Re`ristr~ts L)at(' Issued
LVMMUNWtALIH VF YGN N~YLVANIA ~ UtYARI MtN1 Vh HEALIH ~ VIIAL Rtt_UNU~
CERTIFICATE OF DEnTW
Betty Amelia Divans 2. sex 3. social secu
3a. Age-Last Blrthtlay (Yrs) 3b. Untler 1 Year
Sc
Vntl
r 1 D Female ~ g;
.
e
a 6. Dale of Birth (MO/Day/Yeer) (Spell Month) 7
Months Da
a
yE Hours Mlnutea
82
8a. Residence (State or Forel July 25, '1929 7b
gn Country) gb. Residence (Str
t
ee
and Number - Intlutle Apt No.) 8c. Ditl Decedent Live
gd. Residence (countyA 129 Walnut Bottom Road 1$vea, decedent uYed
Cumberland ga. Resiaence fzlp epde) ~ 7225 QNO, decedent Ilyetl I
9. Ever In VS Armed Forces?
10. Marital Status at Tim of Death
Q Married Wltlowetl 11
Q ~" {~ No Q Unknown Q Dl
Su
i
i
.
rv
v
yorcetl
ng spo
Q Never MarHetl Q V nknow
F
12
h
'
.
at
er
s Name (First, Mitldle, L•EY. Suffix)
M ei-llOn Cline 13. Mother's Nsme Prior to 1
14s. Informenrs Name Ada Crouse
Bernard Givens 14b. Relationship tv Decedent 14 c. Informant's Mailing Adb
Son 428 South Second SM
......................•__........__
..._................. ace o Deat Chec o
S If Death OccarreC In • H°sPital: +s~y I^ .........................
._..._............ ?..a:_._.....__.__...... one
Yst~~ patient
.
If Death Occurretl somewhere Other Than s~HOSpltai:~
Q Emar ency Room/Outpatient Q Deatl on Arrly 1 N
ursing Home/LOn -Term bra Facility
i 15 b. facility Name (If not instltutlon, give street and number)
1sc. City or Town, state, sntl 21p Code
Chambersburo Hospital
Chambersbu
m 16a. Method of Disposltlon Bu real
, ~' PA '1720'1
Cremation
Q Removal from state Q OonatiOn 16b. Date of Disposition 16c. Place of Disposltlon (I
other spec) ) J
une 18, 20'12 Knobsville Cemetery
16d. LoceUOn Of Dsposltlon (C%
T
ry Or
own, State, and 2i
Knobsvllle. PA ~ 7233 p) 17a. signatu of Funeral service ace ate or Person In
~' ~
ITC. Nsme sntl Complete Atltlresz Oi Funeral Facility
3 Kelso-Cornelius Funeral Home Ltd 725 N
l
or
and Avenue, Chambersburg, PA '1720'1
rs' i6. Decedent's Etlutatlon -Check the box th
t b
a
est describes the 19. Dacetlent of Hispanic Origin _ Check the
- highest degree or level of athool completed at the time of tleath. box Shat b
Q 8th gr•Oe or leas I
est describes whether the decedent the del
s
s
panish/Hispanic/Latino. Check the "NO"
]$[ N° d~plOm a, 9th - 12th gratle boz H d
~ Wh
ecedent Is net 5
Q High school grad ua[e or GED completed No
no[ 5 Panish/Hispanic/Latino. Q gla,
~
,
P•nish/Flispanic/Latino Q Am
Q Some college creClt, but no tlegree '
Q Yes
Mexican
Q g
l
M
,
,
sso e
ate tlegree (e.g, qq, ,es)
exican American, Chicano Q AEU
Q Yes
Puerto Ri
l
Q B
h
'
,
ac
e
or
s degree (e.g. BA, AB, gs)
can Q Chli
Q Yes
Cuban
Q M
'
,
aster
s degree (e. g. MA, M5, MEng, MEd, MSW, MBA
Q Filit
) Q Yes', other Spenlah/Hi
Q D
spanic/Latino Q JaPI
octorate (e.g. Ph O; Etl D) or-Professional degree
(e. MD DOS DVM LLB JO (s°ecifY) Q Oth
21. Decedent': single Race S¢If-Designation _ Check ONLY ONE to indicate what the detetlent
]$
l White
,
considered himself or herself [0 1
Q Japanese Q s•moen
Q Black Or Afri
can American Korea Q Other Pacific Izlantler
Q American ndlan or Alasl:e Native Q Vietname
se Q Don'i Know/Net Sure
Q 4sian Indian Q Other Asian "
Q Chinese - Q NathrF Hawallan ~ Refused
Q Oth
Q F
i
l
er (Specify)
~pine Q Guamanian or Chamomo
ITEMS 23a - 23d MUST BE COMPLETED 23a
Date P
.
ronounced Deatl (MO/Des
BY PERSON WHO PRONOLNCES OR Y r) 23 b. Signature of Person P
ronouncing 1
CERTIFIE3 DEATH June 13, 20'12
23d. Cates 5(gnetl (MO/Day/Yr) 24. Time of Death
3:26 PM 25. Was Medical Examiner or Coroner t
z6. pare L Enter [he than pf ey n CAUSE OF DEATH
_~
--diseases
In)arl
r
"~
,
es, or eompllcations-[hat direttly reused the death. DO NOT enter term
espiratpry arrest. Icular fibrlliaflon without showin
th
ti
l
g
e e
o
ogy. DO NOT ABBREVIATE. Enter only one cause of
IMMEDIATE CAUSE -----___~ a cardiac arrest- unknownn etiolo
s
gy,
uspect PE
(Final tliseaae or con dltlon Due to (o
resulting In death) r as a consequence of):
t. dementia
-seq~enuanv net condmonE. ~ ~
Due tp (o
f any, leading to the cause r as a consequence Of):
listed on line a. Enter Me c chronic renal failure
VNDER LYING CAUSE
Due to (or
(~Seese Or Ineae That
• - es a tonaegaente of):
¢
iniil ated the v is r salting d. oiebetes mellitus
.n death) LAST. ~ ---
Due to (or as a con
sequence Of);
*
26. Part il. Enter other sl¢nificant o dl i
rib [i [ d
but not resul<ing In the untlerlying cause given in Part i
29. if Female:
Q Nqt pregnant within past year 30. Did Tobacco Use Contribute to peath?
gna nt at time of tleath Q Yes Q Probably
Q
No<
Q pregnant, but pregnant within 42 tlays of tleath ~ N° Q Unknown
Q Not pregnant, but pregnant 43 days to 1 year before death
32. Date of In)ury (Mo/Da
Q Unknown if pregnant withi
/Yr)
th
S
y
n
(
e past year
pell Month)
3d. Place of Injury (e.g. h° e, construction site; farm; school)
, 3s. Location of Injury (Street and Numbe
36. Injury e[ Work 37. If Transporta<lon Injury, Specify:
Q Y Q Dreyer/Operator 3g. pescrlbe How Injury Occurred:
Q Pedestrian
Q N° Q Passenger
O Other (Speelfy)
39e. Ce rtifler (Check only one):
Q Certifying physician - To the best of my knowled e, death o
Pr
he
r~~ se(s) and manner se^tetl
onvu ncing ffi Cer~lfying physician _ To the best of my knowledgeadeeth °
ccu d
Q Medlcel Ex
at th
i
r
am
e time, date, d place sntl due t° 1
ner/Coroner - On the basis of examinekion, sntl/or Inyesfl
getlon
in m
i
,
y op
nion, tleath occurred ei the time, d
signature of certifier: /~ ,/ (~
'r~ ~ ~
~
Title of certifier: D.O.
39 b. Name. Address and Zlp Cotle of Person Com plating Cause Of Death (It
em 26)
R. Lucas Shelly, D.O. 'I 12 N 7th St, Chambersburg
PA '1720'
,
1
40. Feg:strar's District Number 41. Regis nature
~
/
d3_ Amen.: ~-._ / ~s
v
Disposltlon Permit NO. 0739409
:-22-6675 i ~ June 13,'20'12
Shippensburg
twP.
rithln limits of
let Chembaraburg Pq~~7pp~
Franklin
-~ t FD-0'12050-L
etlent considered himself or herself to be_ o In Olcate what
to Q Korean
k or African American Q Vietnamese
rncan Indian pr Alaska Native Q ether Asian
n alendian Q Native Hawaiian
Irmo Q Guamanian or Chamorr0
n Q Othe rPaciflc Islantler
Ir (Specify)
. 22a. Decedent's Usual Occupation - Intlieate type of wort
e done dating most Of working Ilfe. DO NOT USE RETIRED.
Homemaker
22 b. Kintl of Business/Industry
Domestic
eath (Only when applicable) 23c. License Number
P.. >
~"W..a
onteeted7 Yea ryo -~~~
nal events such ac arrests. //~~~°-•• ~te
a Ilne. Ada ad ir~es if n ces•ary
ath
- ~ ~.'-`. ...l.J
t ~ ',"~ fy7'-Ji
to complete Me cause of tleath?
31. Manner of Death Q Ye Q N
j$[ Natural Q Homlcltle
Q Aecltlenf Q Pending InyestigatlOn
Q sulelde Q Could not be determined
ease(s) andam stated
Ke~and plate, ntl tluert0 the cause(s) and m n r stated
License Number: OSO'IOggSLe
39c. Date Signed (MO/D•y/Yr)
June 17, 20'12
H105-143
REV 07/2011
WILL
OF
BETTY A. DIVENS
I, BETTY A. DIVENS, of Antrim Township, Franklin County, Pennsylvania,
being of sound and disposing mind, memory and understanding, revoke any prior
wills and codicils and declare this to be my will.
My husband Harold L. Divens has predeceased me. As of the time of
execution of this will my lineal issue consist of my five children, eight
grandchildren and one great-grandchild. My son Bernard H. Divens has two
children, Shelly and Chad, and one grandchild, Kendra. My son John M. Divens
has three children, Krista, Cory and Jennifer. My daughter Vickie K. Hickman
has no children. My son Samuel M. Divens has two children, Heather and
Samuel, Jr. My daughter Dolly J. Buckley has one child, Alisha.
ITEM I. E%PENSES AND TA%ES. I direct that as soon as may be con-
venient after my decease there be paid from my estate all of my just debts,
expenses incident to my illness, my funeral expenses and, from the principal
of the residue of my estate, all of my state and federal inheritance and
estate taxes.
ITEM II. RESIDUARY GIFTS. I direct that my entire residuary estate be
converted into cash and that my residuary estate be divided into equal shares
with one share going to each child of mine who survives me, and one share
divided equally among the children who survive me of any child of mine who
predeceases me.
/~ ~ ;~=
Betty A. Divens rr~i~ ~ ~' =-
~;
N C. i t~
C;r ,-~
"
C7 C;
Q ~ :
~' ,
-~ ; ;-,~
?'i
~ __ - '
`~
~
ITEM III. FINANCIAL GUARDIAN. In the event that any person who is a
beneficiary under this will or who is a beneficiary of insurance proceeds or
who is a beneficiary of other property with respect to which I have power to
appoint a guardian is under a legal disability due to minority at the time of
distribution, I appoint my herein named Financial Guardian as guardian of the
estate of said minor beneficiary and I authorize my said guardian to use such
amount or amounts of income or principal as shall be necessary, in the sole
discretion of my said guardian, for the maintenance, support, medical expenses
and education of said minor during the period of his legal disability due to
minority.
ITEM IV. APPOINTMENT OF FIDUCIARIES. I appoint as Financial Guardian of
any financial guardianship hereunder the surviving parent of the minor
beneficiary, provided that surviving parent was married to a child of mine at
the time of the death of my child, and provided that no such surviving parent
shal 1 serve or continue to serve as a financial guardian for a minor grand-
child of mine if the minor's surviving parent has remarried after his or her
marriage to my child. I appoint First National Bank of Greencastle, Penna.,
as Alternate or Successor Financial Guardian to serve in all financial
guardian situations not above provided for.
I appoint Bernard H. Divens and Vickie K. Hickman or the survivor of them
as Co-Personal Representatives of my estate. If both of them fail to qualify
or cease to act, then I appoint as my Alternate or Successor Personal Repre-
sentative the oldest child of mine willing and able to act as such. If all of
.~.' ,l d / s„<,-ems
betty A. Divens
- 2 -
my children fail to qualify or cease to act, then I appoint First National
Bank of Greencastle, Penna., as my Personal Representative.
ITEM V. NO BOND. I direct that no fiduciary appointed hereunder shal 1
be required to post bond in this or any other jurisdiction.
1988, this my will, typewritten upon three (3) sheets of paper.
f
(SEAL)
tty A. Divens
In our presence BETTY A. DIVENS signed this and declared it to be her
will and now at her request, in her presence and in the presence of each
other, we sign as witnesses.
IN WITNESS WHEREOF, I, BETTY A. DIVENS, the Testatrix, hereby execute on
- 3 -
/ OATH OF SUBSCRIBING WITNESS(ES)
V~
~~ / I ~y ,~ ~ REGISTER OF WILLS
V ~ (.(~-~` L COUNTY, rENNSYLVANIA
Estate of
~,i ~~,- ~~7~~1
f trl,,t _
,,,1
ia..~J
<~t~~2 JUA- 25 ~F; 9~ ~
~.,
Deceased
each) a subscribing witness to
the~Will ~ Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and
say(s) that she / he / hey was / ere present and saw the above Testator /Testatrix sign the same
and that she he /they signed the same and that she / he / ey signed as a witness at the request of
the Testator /Testatrix in her his presence and in the presence of each other.
~ .S/~~i4ck.k.~e C( r
(Signature)
(Street Address)
/c~A ytu~s~~, t i4 l 7L (oF
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of ~1.1 V1Q , ~~
Deputy for Register of Wills
(S ature%
~~~ ~ ~QQe~4ZC1~%R~i~ L~r,
(Street Address)
~s~~ ~A /7z~8'
(City, State, Z p
Executed out of Register's Office
Sworn to or affirmed and subscribed
before me this _ ~~ day
of ~v1 Ir1.P~_, o~d 6 ~
~.~Ir ~ ~~
Notary Public
My Commission Expires: ~u ~ ~( Z 6 Z Q! ~
(Signature and Seal of Notary or other ofticial qualified to
administer oaths. Show date of expiration of Votary's Commission.)
NOTE: To be taken by Ofticer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of notarization.
Form RW-03 rnr. 10.!3.06
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