HomeMy WebLinkAbout06-19-12~f_lailt''i~ ":'.! C'F~I eset
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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND COUNTY, PI~PJT~~i.~~~lI7P~~i 3~ Z I
Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters as s~gifie~i _below, and in
support thereof aver(s) the; following and respectfully request(s) the grant of Letters in the ap~~'~r~~J;=tr
Decedent's Information a1MBERL~D CG., PA
Name: Sara A. Stewart, aka Sara Adeline Stewart File No: ,~ C~ ~ f ~'~ ~\ ~ /
a/k/a: (Assigned by Register)
a/k/a:
a/k/a:
Date of Death:
Social Security No:
Age at death• 77
Decedent was domiciled at death in Cumberland County, penns~vania (State) with his/her last
principal residence at 928 Baltimore Road Shippensburc PA 17257 Southampton Townshi p Cumberland County
Street address, Post Office and Zip Code City, Township or Bor ough County
Decedent died at Chambersburg Hospital Chambersbure PA 17201 Chambersbur Bg orough Franklin County Pennsylvania
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 $ 10,000.00
If not domiciled in Pennsy[vania ...................... .. Personal property in Pennsylvania $
If not domiciled in Pennsy[vania ...................... .. Personal property in County $
{'alue of real estate in Pennsylvania .................... .................................... . $
TOTAL ESTIMATED VALUE... . $ 10,000.00
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 June 9, 2010 and Codicil(s)
thereto dated
Glenn R. Stewart died ,4nril 7 hl ~ Timnth~T Rnrgnyn~, alternate, rennnncea (e .. attached r .mmciatinn)_
State relevant circumstances (eg. renunciation, death of executor, 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(8), 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) dbncta
c. t. a., d. b. n., d.b.n.c.t.a., 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 not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined
in 23 Pa. C.S. § 3323(8) 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 (if any) and heirs (attach
additional sheets, if necessary):
Name Relationshi Address
Timothy J. Burgoyne Son 3837 Alto Avenue, Carrollton, TX 75007
Judy A. George Daughter 47 George Street, Massena, NY 13662
Diana M. Gabri Daughter 8 Plum Street, Massena, NY 13662
Michele A. Bronchetti Daughter 1188 Imperial Drive, Webster, NY 14580
see attached continuation list
_~~?c~- z -t,~
FormRW-02 rev. 10/ll/20/l
Page 1 of 2 ~ ~
~~
Sara A. Stewart, aka Sara Adeline Stewart
Petition for Grant of Letters
List of Heirs continued.. .
File No. 2011-00861
PA File No. 21-11-0861
DOD: 6/28/2011
SSN: 204-26-8237
William A. Stewart Stepson 3668 Coals Ridge Road, Fayetteville, PA 17222
Glenda L. Stewart Stepdaughter 322 Greendale Road, York, PA 17403-3517
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
} ss:
COUNTY OF CUMBERLAND
Petitioner(s) Printed Name Petitioner(s) Printed Addr '" ~'`'
Michele A. Bronchetti 1188 Im erial Drive Webster NY 14580 ~~~ER~ 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 Decedent, the Petitioner(s) will well and truly administer the estate according to law.
Sworn too affirnled and subscribed before
me this ~ day of ~' ; ~ ' ~ ~-
B _\ t <
Y~ ~~~11 c 1 1~~
For the Register
'tYL~C1"itL~e ; ~~ ~G'y1L' ~ Lit ~ Date
Date
Date
Date
lv//~~/oZ
BOND Required: ®YES ~ NO To the Register of Wills:
FEES' Please enter my appearance by my signature below:
Letters ..................... .
( ,~ )Short Certificate(s)..... .
( ~ )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
~1t.(ter ...... .
Automation Fee .............. .
JCS Fee .....................
.~ , !L'
~C OL
-,
TOTAL ..................... $ ~ ~ ~)~~,
Attorney Signature:
.~ ~!_ ~
' YI3 e Gaily
?GfI2 JUN 19 PI'i 3~ 2 a
~I C_'1.~.k 4 < ~ ~ U~~
l
Printed'Name: Jared S. Childers
Supreme Court
ID Number: 307404
Firm Name: R. Thomas Murphy & Associates
Address: 2005 Fast Main Street
~yneshnro, PA 1726R
Phone: 717-762-1032
Fax: 717-762-1832
Email: ~arerlonrthnmasmnmh~ cnm
DECREE OF THE REGISTER
Estate of Sara A. Stewart, aka Sara Adeline Stewart File No: - ~ - \ ~;;
a/k/a:
AND NOW, ~L~ ~ ~ ~ ~~ ~~ 1 , ~~, in consideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters of Administration dbncta
are hereby granted to Michele A. Bronchetti
in the above estate and (if applicable) that
the instrument(s) dated June 9 2010
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
i
~~~~ ;~ ~ ~ ~ ~~~ iL. 1 _
Register of Wil s y~
1- ~ `i ~~. f" ~X I ~, ~ ~ ~~4 1 l l 1 ~" ~ ~~~~
Form RW-02 rev. 10/11/2011 I J
Page~2 of 2
i Flaw i `.~~~; i . t'~.LJ
2J2 JUN 19 P~ 3~ 2 f RENUNCIATION
oRPw;N~s ca~~~
CUMBERLAf ~tP~I.AN>J
COUNTY, PENNSYLVANIA
Estate of Sara A. Stewart ,Deceased
I, Timothy J. Burgoyne , in my capacity/relationship as
(Pant Name)
alternate or successor co-Executor of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
Michele A. Bronchetti
~ o•~~
(Date)
,,~~,~'
(Signature)
3837 Alto Avenue
(Street Address)
Carrollton, TX 75007
(City, State, Zip)
~Xe~Efi"eC~ lI2 RE'gLSter'S Office
Sworn to or affirmed and subscribed
before me this
of
day
Execrste~l oast of Register's Offiee
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciatio for the
purposes stated within on this ~ ~~ day
of ~ y ~
J ~~ ~-,
Deputy for Register of Wills
Form RW-06 rev. 10.13.06
REGISTER OF WILLS
Not Public
My ommission Expires: ) ~_ j -,~~~
(Signature and Seal of Notary or other official qualified to
administer ~&i1~& ssion.)
`=6 .., ••
~'s°pY',''°"' JESSIGA FOSTER
'~? Ncla.ry public, State of Texas
'•,;?.i;~•;y' ~` ~ My Commission Exp, 12-01.2012
Loc,~~~~~~~~s c,~~~~~i~~~r~~n~ ~~~~r-
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WAI~MIN~~~i~tFFl~~at'~~ uplicate ths~ c~a~Y ~~~~ ~t~catost~~t ~xt~ ~~~a ~Fzl~.t,~°-~,~:~fi~+
Fee for this certificate, $b f lO "
~~3~~~,3~~ ~_ _
Certification (~`umt~lEr
TYPe/Print In
Permanent
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COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VrfAL RECORDS
cs/"ATC At' a'1CAT{J
lack In k
5uHlx) 2. Sex 3. Social Security Number 4, Date of Death (MO/Day/Yr) (spell Mo)
Last
Middle
al Name (First
t'
d
L
,
,
,
en
s
eg
1. Dece
Male 204-26-7934 April 29, 2012
Glenn Rex Stewart
(Yrs) Sb. Under 1 Year Sc. Under 1 Da 6. Dafe pf BIKh (MO/DSy/Year7 (spell Month) ]a. Birthplace (City and State or Foreign Country)
e-Last Birthda
A
S
y
a.
g
MpntMa Days Hours Minutes AmbefsOn, PA
78 September 30, '1933 7b. Birthplace (county) Franklin
Residence (State or Foreign Country)
8a 86. Residence (Street and Number -Include Apt No.) Hc. Did Decedent Llye In !Township?
.
PA 928 Baltimore Road J$res, decedent hoed In Southampton iwp.
Btl. Residence (County)
Cumberland
8e. Residence (Zip Code) 17287 Q No, decatlent Ilyed within limits of city/born.
Mar
med Forces? 10
I
VS A ital status at Time of Death Q Married Witlowed 11. Surveying Spouse's Name (If wife, giye name prior to first marriage)
.
r
n
9. Ever
Yes Q No [] Unknown Q Dl vorFed ~ Neysr Marrietl Q Unknown
12. Father's Nsme (First, Midtlle, Lass, Suffix) 13. Mo[he YS Namc Prior to First Marriage (Firs[, Middle, Last)
Raymond A. Stewart Hulda June Piper
Informant's Nam! 14b. RelaYlonship to D<cetlent 14c. Informant's Mailing Address (Street and Number, Clty, State, Zlp Gode)
14a
.
rt .son 3668 Cores Ridge Road Fayetteville PA '17222
Stew
W
lli
A
~ a
i
am
-
e~th
ace O
.. ec only one .. ......... ....... ...... .... ........ -_. .......- ...... .....
wi ....... -.. ... .. ... --
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........................................................... ...Pa -...,. ....,... ............
J
Decd enf's Home
r.v
If Death Occurred Somewhere Other Than a Hospital: [J Hospice Facility }
If Des[h Occurted In a Hospital: t_f In LIenY ;
r
h
_ _
ome
5
Q Emergen Room/Outpatlen< Dead on ArrlYai Nursing Home/Long-Term Care Facility Other (Specify) SOrI
z SSb. Facility Name (If not institution, giye stce t d 15c. City or Town, stele, sntl Zlp Code lSd. County of Death
jg ~ LnOi s~ Guilford Townshl Franklin
(son's home) ' P
Method of Dlsposltlon ~ Burial 0 Cremation
S6a 16b. Date of Dlsposltlon 16c. Place of Disposition (Name of cemetery, crematory, or other place)
~ .
Q Remoy.l from state O Donaeion 4
20'12 Parklawns Memorial Gardens
ocher (sveglfy) ,
May
Z 16d. Location of Disposition (City or Town, State, and 21p) 1]s. Signature of ~ 5a Ice Lice~n a or Person (n Charge of in[ermen<
/
J
/
(J 17b. License Number
Chemberaburg, PA 1720'1
/
t-/r
1 ~P
~
FD-0'12984-L
1]c. Nam! •nd Complete Address of Funeral Facl lily
'
17257
Fogelsanger-Briekar Funeral Home 712 W King St. PO Box 336, Shippensburg, PA
~ Decedent's Education -Check the box Yhat bas[ describes the 19. Deceden[ of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races Co Indicate whet
18
.
highest degree or level of school c:ompietetl a2 [he Ylm! of death. box that beat tlescrlbes whether [he deCetlent the decedent consideretl himself or herself to be.
~ 6th grade or Isss is Spanish/Hispsnlc/Latino. Check the "No^ ~[ White ~] Korean
Q No diploma, 9th - 12th grade box If decedent Is not Spanish/Hispanlc/Latlno. Q Black or African American Q Vietnamese
l
an
Q High school graduate or GED compieietl ~ No, not Spanish/Hlapanic/Latlno Q American Indian or Alaska Na[Iye Q Other Ay
N
ur
ii
e Hawa
an
at
Q Some college credit, but no degree Q Yes, Mexican, Mexican American, Chicano ~ Asian Indian Q
o
i
Ch
an or
a mon
[] AssodaCe degree (e.g- AA, AS) Q Yei, Puerto Rican [] Chinese Q Guaman
S
amoan
~' Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban Q Filipino ~
lfl
I
l
de
Q O
h
P
er
s
an
r
t
ac
c
Q Master's degree (e.g- MA, Ms, MEng. MEd, MS W, MBA) Q Yea, other 5panlsh/Hispanic/LlYlno Q Jepeneae
Q DoROrate (e.g. PhD, Edo) or Professional degree (Specify) Q Other (Specify)
. MD DDS OVM LLB JD
le Race self-Designatlpn -Check ONLY ONE to Indicate what the decedent considered himself or herself <o b<. 22a- Decedent's Usual Occupation - Indicate type of work
nt's Sin
c
21
D
d
g
.
e
e
e
White Q Japanese Q Samoan done during most of working Ilfe. DO NOT USE RETIREp.
Q Black or African American Q Korean Q Other Pacific lalsnder Operations Research Analyst
Q Amadcan Indian or Alsske Natlye Q Vietnamese Q Don't Know/Not Sure
d
ua[ry
Q Asian Indian - O Other Asian Q Refusetl 22 b. Kind of Business/In
p enlnlse O Native Hawauan O other (Specfy) Lettarkenny Army Depot
Q Filipino Q Guamanian or Chamorro
ITEMS 23a - 23 MVST BE COMPLETED 23a~ Date Pronounced Deatl (MO/Day/Vr) 23b. Signature of Person Pronouncing Death (Only when apple ca bee) 23c. License Number
9Y PERSON WHO PRONOUNCES OR April 29, 20'12
CERTIFIES DEATH
23d. De<e Signed (MO/OSy/Vr) 24. Time of Death
8:20 PM 25. Wes Medical Examiner or Coroner Comactetl? Q Ves ~( No
CAUSE OF DEATH Approximate
Part i. Enter the chain of eyynts--diseases, injuries, or compllcaflons--Ghat directly causetl the tl<afh, DO NOT enter Germinal events such as cardiac arrest, interval:
26
.
respiratory arrest, or ventricular flbrllla[lon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Atld additional lines If necessary Onset fo Death
IMMEDIATE CAVSE ---------> s (diopeth is Interstitial flbrOS}s
(Final disease or condlCion Due to (or as a consequence ofj:
resu lung In death)
b. 3
Se ntlally Its[ contli[IOn s, Due to (o as • conaeq vent! qf): -
If ~ y, leading to Che cause
listed on Ilne !. Enter the
-.VNDERLYING CAVSE Due to (or as a consequence of):
(disease or InJury that
F initlaied Lhe !vents resulting d.
as a con
in death) LA5T. Du! to (or sequence of):
- 26~ Pert 11. Enter other sl¢niflca < di I [ Ib ti Cp dia<h but not resu !ling In the vn deriving cause given In Part I 27. Was an eYtopry performed?
Y<s No
28. Were autopsy findings available
tp complete [he cause of death?
Yes D No
29. if Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death
E Q Not pregnant within past near Q V!s ~ Probably ~$[ Natural p Homicide
is Q Pregnant at Ylme of death j$[ No Q Unknown [] Accident Q Pending Investigation
m Q No[ prcgnan<, but pregnant within 42 days of deal[ [] 5ulcltle ~ Could not be tle[ermined
but pregnant 43 data tp 1 year before dear
Q Nat pregnant 32. Date pf InJury (Mq/DeY/Yr) (6pell Month)
~ ,
(~ Unknown if pregnant within [he Past year 33. Time of In}ury
34. Plat! of Injury (e.g. home; construction setae farm; school) 35. Location of InJury (Street end Number, Clty, State, ZIP Code)
36. InJury at Work 37. 1f TransportaUOn InJury, Specify: 38. Describe Mow InJury Occurred:
Q Yes Q Driver/Operator Q Pedestrian
Q Nq Q Passenger 0 O[h!r (Specify)
39a. CerHfler (Check only one):
$( Certifying physician - To the best of my knowledge, death occurred due to the cause(s) end manner statetl
Q Pronouncing 8. Certifying physician - To the best of my knowledge, death occurred at the time, date, and plat!, and due to [he cause(s) and manner seated
Q Medlcel Examiner/Coroner - On the balls of ezaminetton, antl/or InyesHge<IOn, In my opinion, death occurred at fhe time, dale, and place, end due tp the cause(s) and manner stated
signs<ure of certlfler:- ~T~nm.ff~ .~aac.F~. ~71..Z~ flue qT Cer[Iner: M~D~ ucensl Number: MDO24325E
39b. Nsme, Address and Zip Code oT Person Comple<Ing Cause o1 Death (Item 26) 39c. Date Signed (Mp/Day/Yrj
Samuel O. Brlcke r, M.D. '144 S 8th St, Ghambersbur9. PA '172Ot April 30, 20'12
40. Reglafra is Dlsfric[ Number 61. RiglsY 42. Registrar Fil¢ Date (MO/Day/Yr)
r / O' ~ / ~-
B
43. Amend mints
H105-143
Dlsposltlon Permit No. 0676880 REV 0]/2011