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HomeMy WebLinkAbout08-03-12PETITION 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 i Name: Rosanna V Donnelly File No: ~ / a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: Date of Death: 7/5/2012 Age at death: Decedent was domiciled at death in Cumberland County, PA (State) with his/her last principal residence at 1100 Crandon Way Rm 218 Hampden Cumberland Street address, Post Office and Zip Code City, Township or Borough County Decedent died at Holy Spirit Hospital Camp Hill 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 Pennsylvania ................................All personal property If not domiciled in Pennsylvania .............................Personal property in Pennsylvania If not domiciled in Pennsylvania .............................Personal property in County Value of real estate in Pennsylvania ............................................................. . Real estate in Pennsylvania situated at: (Attach additional sheets, if necessary.) $ 1, 500.00 0.00 TOTAL ESTIMATED VALUE.... $ 1, 500.00 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 in the last Will of the Decedent, dated thereto dated County and Codicil(s) State relevant circumstances (e.g. 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(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, c.~a. or d.b.n.c.~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 (if any) and heirs (attach additional sheets, if necessary): ~~ --*-i Name Relationship /t 3 Address ~ ~ ~°" t~;~ ~::~ ~- c 3 `~.: 56 Sherwood CI-~ c~.~ ~-~ ~ - ~- Robert TSin le son ` - Enola PA 17025 ~.~. ` ~ f~~--~--~` C7 C- ~ <~ cw ` ~.. ,, ,.~. ~ ~ ~..,..~ ~n -- ~ ~ -~ - - Form RW-02 rev. 10/11/2011 ~, F; ~.:, t`~ ``~ Page 1 of 2 ~.,._ Oath of Personal Representative ~cial Use ~~ O ~! ~ 'CJ C ~" ~ ? COMMONWEALTH OF PENNSYLVANIA } ~ ~ ,`- - ~ c-; ~ } SS: ~ t 1 ... r. ~ ~ COUNTY OF Cumberland ~'~ - -~ Petitioner(s) Printed Name /~ Petitioner(s) Printed Address -=~ _ {p f- ,-~"1 56 Sherwood~Et' c,~~-~1-= ~- w `' --~, Robert T. Sin le Enola P`/~ 17025 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 an bscribed bef9~e me this ~ day o ~~ `~ ~'~%~-- By. ~~. c„~,e~ or.-the Register Date ~' Date Date Date BOND Required: ^ YES ^ NO FEES: Let ....................... $ ~~ ~ BLS ( ) Short Certificates(s) ...... • ~ n ( )Renunciation(s) ......... . ( )Codicil(s) ............. . ( )Affidavit(s) ............ . Bond ......................... Commission ................... . Other ......... Automation Fee ................ . JCS Fee ....................... TOTAL ......................$ ...~ J , l~Lt t .a~ To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature:. ~ ~,,.,~ ~,.., ~~~ Printed Name: James H Turner Supreme Court ID Number: 29928 Firm Name: Turner & O'Connell Address: 4701 N Front St Harrisburg PA 17110 Phone: Fax: Email: DECREE OF THE REGISTER Estate of Rosanna V Donnel a/k/a: AND NOW, ~ satisfactory proof having been '~~~~ ~ in consi erati n of the forego' g Peti ion, anted before me, IT IS DE RE D thyt Letters i o/~ are hereby granted to ~ ~ ~ /' CI T __ - in the abov estate and (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of as,~he last Will (and Codicil(s)) of Register of Wills Form RW-01 rev. 10/11/2011 File No: ~C-~' ~- ~y 2of2 -' .- . , ~3 ,} ~'tt (()I- l~ll'; ::~'1'i)1lC~iiti. `~{.11(t N ,^ r~ Q D O C'ertific~ltic~n ~'ul?~i~~c'i' Type/Print In Permanent Black Ink ~~'i~~ BUG -3 ~~~ 8~ 3~ C~~?R~~v`;~ ~vuR r ~~ CUMB~RtAN~ CO.r PA~ -~ ~ , „,r/~ , / f l r "~ COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH _____ _.._ _. _~__ 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Vr) (Spell Mo) Sa. Age-last Birthday (Vrs) Sb. Under 1 Year Sc. Under 1 a 6. Date of Birth (MO/D ay/Year) (Spell Month) 7a Birthplace (City and State or Foreign ou ry 87 Months Days Hours Minutes June 14 1925 7b. Birthplace (County) ' 8a. Residence (State or Foreign Country) 8b. Residence (Street and Number -Include Apt No.) Sc. Did Decedent Live in a Township? ~ Ves, decedent lived in __E"OT'O twp. 8d. Residence (County) 213 Spring Lane Summ@rdalie Apt 8e. Residence (Zip Code) QNO, decedent Ifved within limits of city/born. 9. Ever in US Armed Forces? 10. Marital Status at Time of Death Q Married 4 Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) Q Yes No Q Unknown Q Divorced Q Never Married Q UnkRDwn 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last) ec 14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street an Num er, ity, State, Zfp Code) ~ 1 a. ace o Deat C ec on y one .. ......... ........ ...... ... ......... ..- -~--... ....... ...... . . ... . ... ... ..... . ... ........ ... ... ~ If Death Occurred In a Hospital: ~~ Inpatient e . ..... . lf Death Occurred Somewhero Other Than a Hospital: LJ Hospice Facility Decedent's Home ~ Q Emergency Room/Outpatient Q Dead on Arrival _ Q Nursing Home/Long-Term Care Facility Other (Specify) o~ z 156. Facility Name (If not institution, give street and number; 15c. City or Town, State, and Zip Code lSd. County of Death ~, 16a. Method of Disposition Q Burial 4 Cremation 16b. Date of Disposition 6c. Place of Disposition (Name of cemetery, crematory, or other p ace) C° Q Removal from State Q Donation Other (Specify) U 1 16d. Location of Disposition (City or Town, State, and Zfp) 17 Signat re of Funeral Service Licensee or Person in Charge of Interment 17b. License Number v °1 Leola, PA '17540 - - ° E 0 u 17c. Name and Complete Address of Funeral Facility m 18. 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 ~°- 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 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 ~] No, not Spanish/Hispanic/Latino A i Chi M i M i [ ` V Q American Indian or Alaska Native Q Other Asian Q Asian Indian Q Native Hawaiian Q Some college credit, but no degree Q Associate degree (e.g. AA, AS) mer can, cano es, ex can, ex can J Q Yes, Puerto Rican Q Chinese Q Guamanian or Cha morro Q Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban Q Filipino Q Samoan Q Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Ves, other Spanish/Hispanic/Latino Q Japanese Q Other Pacific Islander Q Doctorate (e.g. PhD, EdD) or Professional degree (Specify) Q Other (Specify) e. 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. g Black or African American Q Korean ~ Other Pacific Islander Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure Q Asian Indian Q Other Asian Q Refused 22b. Kind of Business/Industry Q Chinese Q Native Hawaiian Q Other (Specify) Q Filipino Q Guamanian or Chamorro ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced Dead (Mo/Day/Vr) 23b. Signature of Person Pronouncing Death (Only when applicable) 23c. License Number BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH ~ ~ ~ ~ ' 2 `.~ ( ~~ ~ ~ G ~ Q/~ 3S 3~j ~Gp (~- _ 23d. Date Signed (MO/Day/yr) 24. Time of Death ~~~~ ~ ~ 9 - w~ S Z~ 1 Z l Z' . l S Q/l^ 25. Was Medical Examiner or Coroner Contacted? Q Yes No CAUSE OF DEATH Approximate 26. Part I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, Interval: er only one cause on a line. Add additional lines if necessary Onset to Death 1 pT nt N OT A B REV E. E owing the etiology. D O respiratory arrest, or ventricular fibrillati rthout ss h /J ~. g7 C ~ ~ F / N ~ IMMEDIATE CAUSE ---------------> a. ~~`~I a ~^~ ~ .C~~~~/~ / t- J / ~ 7 (Final disease or condition a to (or as a consequencee o~:~ resulting in death) b. Sequentially list conditions, Due to (or as a consequence of): if any, leading [o the cause listed on Ilne a. Enter the c. UNDERLYING CAUSE Due to (or as a consequence of): (disease or Injury that initiated the events resulting d. z v in death) LAST. Due to (or as a consequence of): S 26. Part 11. Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part I 27. Was an autopsy performed? p Q Yes ~ ~. 28. Were autopsy fin ings available to complete the cause of death? v Q Yes No -+ a 29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death l Q Homicide t E v of pregnant within past year Q Pregnant at time of death Q,~, ~Yes Q Probably QTR" Q Unknown ura a Q Accident Q Pending Investigation m Q Not pregnant, but pregnant within 42 days of death Q Suicide Q Could not be de[ermined ~ nant 43 days to 1 year before death but pre Q Not re nant 32. Date of Injury (Mo/Day/Yr) (Spell Month) g p g , Q 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, City, State, Zip Code) 36. InJury at Work 37. if Transportation Injury, Specify: 38. Describe How InJury Occurred: Q Yes Q Driver/Operator Q Pedestrian Q No Q Passenger Q Other (Specify) 39a. Ce er (Check only one): ertifyfng physician - To the best of wledge, death occurred due to the cause(s) and manner stated Q Pronouncing 8a Certifying physicia a best of my knowledge, death occurred at the time, date,~and place, and due to the cause(s) and manner stated na /pne'r(stat~ed /C/ Q Medical Examiner/Coroner - O s of examination, and/or investigation, in my opinion, occurred at the time, date, and place, and due to the ca uses an~d T ~ / / ~ / 1 /~.7 J/ Signature of certifier: Title of certifier: L ~ License Number: 39b. me, dress and Zip Co r Com pleti -se of D th (Item ;~yG) / 39c. Date Sig /D~y/Yr) _ r (lT1~L ( - ~ l er 4 R i is Distri Num b 41. Re ar's Signature e Date (Mo/Day Yr ) ar Fil 42. Reg is ~ ) C7C ~~ ~~ ~ r ~ 7 e ~ -7 / C~ IC~G.~ 43. Amendments Disposition Permit No. ~ REV 07/2011 O"7 ta.2 S3 ~11~-1y3