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HomeMy WebLinkAbout08-20-12PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF ~~ ~• ~~i t,i~l~~~~f~ ~~'~r`~° 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 Name: -i'~r~F ~ t~ ~ _ ~.I ; (~'~~ ~t~ ~~c~-%~ a/k/a: a/lc/a: a/k/a: Date of Ueath: _~,~; ~ Decedent was domiciled at death in _~.trt:t~l~c ,~~~,,~~ County, principal residence at (~~; (~~.-.~ ~;,~~.~~ ~, ~.y ~ ~ ~, ~ , ~~ ~ ,. Street address, Post Office and Zip Code Decedent died at !~ ~ ~ ~, ~ ~-~s: c Street address, Post Of ce and Zip Code FileNo: __ '~ ~ - ~ ~ " ~ ~ I (Assigned by Register) Social Security No: Age at death: cc, (Srare) with his/her last ,Township or Borough City, Township or Borough 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 Pennsyh~ania ........................ Personal property in County Value of real estate in Pennsylvania ........................................................ . TOTAL ESTINIATED VALUE... . Real estate in Pennsylvania situated at: (Attach additional sheets, if necessary.) County ~,~~1 ~~~ County State $ ~v~ $ i $ - $~~ ' C+r` , ~ t'~ Street address, Post Office and Zip Code City, Township or Borough County A. Petition for Probate and Grant of Letters Testamentar Petitioner(s) aver(s) h sh they is/are the ecuto s) named in the last Will of the Decedent, dated ~7 . , ~"" ~ f ~`'~ and Codicil(s) thereto dated •r State relevant circumstances (e.g, renunciation:, death ojexecte[or, etc.) Except as follows: after the execution ofthe 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. u., d. b. n., d.b.n.c.t.u., pendente lite, durunte absentia, durunte minoritctte 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(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 n~ ~b'ill and was survived by the following uclclitionul sheets, iJ~neeessury): ~a -~ (if any) ar~eirs (c111lt~~ t~ 1 _ Name Relationshi t ~_ .._. Address c~~ ~ ~V.I ~ .....: ..~ ~. y i • to t~ Form RW-02 rev. 1~/11/1011 1 .1. _yYj •~ f «.w } ~\ Page 1 of 2 ~+~v ~~ Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF Official Use Only Petitioner(s) Printed Name Petitioner(s) Printed Address ~ C:tiz e ~~ ~ ~P, :~ 3~ c~ 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) ofthe Decedent, the Petitioner(s) will well a-id truly administer the estate according to law. Sworn to or affirmed an subscribed before 1 ~ -~~- ~ ~' ~ Date~~ , ~~ me th~i~ ,~ day of ~ -- Date t By: BOND Required: ~ YES ~NO FEES: Date Date r, • _ ( ='~ )Short Certificate(s)...... ~ ~~ - ~,'~:' ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Ot~ier l~'~:1. ~~ ....... ~ ~~ : C ~ Automation Fee ............... ~ , % L 1CS Fee . ....................~~`. TOTAL ..................... $ I ~a ~~ ~ t-~~% For the Re,;ister To tl:e Register of Wills: Please enter my appearance by my signature below: Attorney Signature: Printed Name: C7 '-•-~""" Supreme Court _ O #`'' ~ ID Number: ~~ C ~ r,~ j f~ Firm Narne: r-- t ,. ~ , ; - N .~ , ~ ,-:,... ~ ; ., ~ , _ --, Address: ~---+ ~ C:~ , ..,,. ~ ..r.., ~~ ~ ~ ...p --, ?~ .. --- ~~ Phone: .,_. ~ ~, Fax: e Email: DECREE OF THE REGISTER ~ t ~~ 1(~. Estate of ~~Y ~ ~, ~ (~L, ~~~ , Ca ~ C~'~l.`~ (~ ~ File No: I -' a/k/a: AND NOW, ~ `~dt ~ ~.~-~ ~ :' ~ ~ ~ , in consideration of the fore oin Petition, _ g g satisfactory proof having bee ~resented~' fore me, IT IS DECREED that Let rs ' ~' ~ ~% f L are here y granted to ~ l' ',' '~. y~~ ~(. '~ ~(" in the abo, a estate u7d (if applicable) ghat the instrument(s) dated _ ~ -- ,~ I ~~ J (~ described in the Petition be adm>tted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. ;._. ~~ ~ , Register of Wills ~~ ~~' ~ ~! ~"~L!'~'~~'I~~-- ~'`(' ~ -~~`~~ i ~ ~ J Fame RW-02 rev. IO/! 1/201 ! Page 2 of 2 ~" ~ ~~ ~' ~ •,r r r ~j~ ~~ + .. ) ~, - ^ barr~~ ,~~ia. t1~Jt .~t't~tis~zttc'. `~~~.+,(~ ~ ~~ 1~ ~~ 4 ~~'~ ~~~ J ~~ E ~ ~ .. ~~ c~~~B~~~J~v~ co./ PA i ~...,. Type/Print In COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS VV~~ Permanent (^GQT~C~f"ATC flC r'1C ATLJ 0 v D O_ Q Z 1. Decedent's legal Name (First, Middle, Lasi, Suffix) .~cace rrre rv 2. Sex 3- Social Security Number umoer: 4. Date of Death (Mo/Day/Yr) (Spell Mo) Orth Middleton 8d. Residence (County) 65 Greystone Rd_ , t.,.p. , CL~rlaSld 8e. Residence (Zip Code) 1 701 3 ONo, decedent lived within limits of city/boro. 9. Ever in US Armed Forces? 10. Marital Status at Time of Death ~ Married [~ Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) Q Yes ~ No ~ Unknown ~ Divorced ~ Never Married ~ Unknown _ 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last) Ro M_ Westhafer Beulah M_ Holler 14a. Informant's Name 14b_ Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code) o Che 1 Calamalz Daughter 65 Greystone Rd_ Carlisle, PA 17013 ..................."............................................ .......... ..._ iSa. Place o Deat C eck only one ° P If Death Occurred in a Hospital: In atient ~ :If Death Occurred Somewhere Other Than a Hospital: Q Hospice Facility ~ Decedent's Home Emer enc Room Out atient 0 g Y / P ~ Dead on Arrival ~ Nursing Home/Long-Term Care Facility ~ Other (Specify) 15 b. Facility Name (If not institution, give street and number; 15c. City or Town, State, and Zip Code 15d. County of Death z LL 65 Graystone Rd_ Carlisle, PA 17013 Ctm~berland 16a. Method of Disposition [] Burial ~ Cremation 166. Date of Disposition 16c. Place of Disposition (Name of cemetery crematory or other place) v ~ Removal from State ~ Donation , , p O[her(Specify) 8 20 201 2 brans Cre<nati.on Services 16d. Location of Disposition (City or Town, State, and Zip) 17a. Signature of Funeral Service Licensee o n in rge of Interment 17b. License Number _ Leo1a, PA ~ ~ FD 012633 L E 17c. Name and Complete Address of Funeral Facility 1~~in Brothers Funeral Home, Inc_ 630 S_ Hanover St_, Carlisle, PA 17013 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 F - 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" kite ~ Korean ~ No diploma, 9th - 12th grade box if decedent is not Spanish/Hispanic/Latino. ~ Black or African American ~ Vietnamese ~gh school graduate or GED completed biro, not Spanish/Hispanic/Latino 0 American Indian or Alaska Native ~ Other Asian ~ Some college credit, but no degree ~ Yes, Mexican, Mexican American, Chicano 0 Asian Indian ~ Native Hawaiian Associate degree (e.g. AA, AS) ' ~ Yes, Puerto Rican 0 Chinese ~ Guamanian or Chamorro Bachelor s de ree e- BA, AB, BS 0 g ( 6- ) ' ~ Yes, Cuban ~ Filipino ~ Samoan ~ Master s degree (e.g. MA, MS, MEng, MEd, MSW, MBA) ~ Ves, other Spanish/Hispanic/Latino ~ Japanese Q Other Pacific Islander Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) ~ Other (Specify) e. MD, DDS, DVM, LLB, JD) 21. De ent's Single Race Self-Designation -Check ONLY ONE to indicate what the decedent considered himself or herself to be. Wh 22a. Decedent's Usual Occupation -Indicate type of work ite ~ Japanese 0 Samoan done during most of working life. DO NOT USE RETIRED. ~ Black or African American ~ Korean ~ Other Pacific Islander ~ American Indian or Alaska Native ~ Vietnamese / Don't Know Not Sure Homemaker Q Asian Indian ~ Other Asian ~ Refused 22b. Kind of Business/Industry Q Chinese ~ Native Hawaiian Q Filipino ~ Other (Specify) ~ Guamanian or Chamorro Her- OWl'1 home ITEMS 23a - 23d MUST BE COMPLETED BY PERSON WHO PRONOUNCES OR 23a. Date Pronounced Dead (MO/Day/V r) ..~ 23b. Signature of Person Pronouncing Death (Only when ap 'cable) 23c. license Number CERTIFIES DEATH Q _ { .Date Signed ( o/Day/Yr) 24. Tim Death ~_ 1 ~/JV_y1 eL 5 ~ 25. Was Medical Examiner or Coroner Contacted? ~ Ves No CAUSE OF DEATH Approximate 26. Part 1. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest Interval: respiratory arrest, or ventricular fibrillation without showing the etiology. D O N OT ABBREV I AT E Enter only one cause on a line. Add additional lines If necessary Onset to Death / ' ~ -/ / ` /~ ~ IMMEDIATE CAUSE --- --> a. ~X- y-~! Lv ~,~ r~~-~~ (Final disease or condition Due to (or as a consequence Of): i~-/L~'^^ ~~ resulting in death) / ~ ~ b ~ • ' ~~ L~~ ~- I~ L ~ l. Jam`/ Sequentially list conditions, Due to (or as a consequence of): ,,o ~ ~ if any, leading to the cause ~ ~`M~~ Q Y~'~ ~ "/~~C~~ listed on line a. Enter the c. (~ UNDERLYING CAUSE Due to (or s a consequence of): w (disease or injury that initiated the events resulting d. ~ v in death LAST. Due to (or as a consequence of): _ v 26. Part 11. Enter other siQnifica nt conditions con[ributin¢ to death but not resulting in the underlying cause given in Part 1 27. Was an autopsy perfor d? Q Yes No a 28. Were autopsy findings available CO v to complete the cause of death? ~ Yes ~ No _, a E: 29. If Fe e: of pregnant within past year 30. Did Tobacco Use Contribute to Death? 0 Yes P b bl 31. Ma er of Death v ~ Pregnant at time of death ~ a y ~ No Unknown Natural 0 Homicide id 0 Ac t P di I °' o Not re Want, but ~ p g pregnant within 42 days of deatF c en ~ en ng nvestigation ~ Suicide ~ Could not be determined r- ~ Not pregnant, but pregnant 43 days to 1 year before deatF 32. Date of Injury (MO/Day/Yr) (Spell Month) ~ 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: ~ Yes Q Driver/Operator ~ Pedestrian 0 No ~ Passenger 0 Other (Specify) 39a. Certifier (Check only one). ~ Certifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated ~ Pronouncing ffi Certifying physician - To th est of my knowledge ath occurred at the time, date, and place, and due to the cause(s) and manner stated ~ Medical Examiner/Coroner - On the ball o xaminati nd/o i estigati n my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated Signature of certifier: ~' Title of certifier- ~~' -~ License Number- ~7~~~ /~ ~~ 9b Name, Address and Zip Code of on Completing pause of De (Item 26J y _ 39c. Date Signed (Mo/Day/Yr) ru. M -f-O~~ ~ ~¢.G1-t' ~ b ~o - i ct N umber 4 .Registrar's Dist~r 41. Registrar's S'~~^dtu r e -'Z O (~ .+~~ ~ 1 2. Registrar File Date (Mo/Day/Yr) ]T~ y t- r a. V ~ ~ ~' ~ -~ r_._...~IL ik-t - ~2fiT-r~R1~~ 43. Amendments L Disposition Permit No. \ ) ~~"~ D ~ - 1~ (J H105-143 REV 07/2011 r°,~ ~~ ~ ~.~ ~ ~~~ `>~'~ LAST WILL AND TESTAMENT ~ `~ ~" " ~.-..- s... ;- na ~ ~ c:~ T-, ~, ; ~--, ~.~~; Q - c ~ BE IT REMEMBERED THAT c~ ~ „~- ~ ~r~ ~.~ ~ I, BERNEICE M. GERHARDT, a resident of Cumberland County,~'~' Pennsylvania, being of sound mind, memory and understanding, do make, publish and declare this to be my LAST WILL AND TESTAMENT, hereby revoking any and all Wills and Codicils previously made by me. I I declare that I have two daughters, DIANE M. HARPER and CHERYL D. CALAMAN. II I direct that all my just debts and funeral expenses shall be paid from my residuary estate as soon as practicable after my decease. III I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. IV I give and bequeath to CUMBERLAND COUNTY HISTORICAL SOCIETY my baby carriage, miners lamp, coffee grinder, wooden horse and other items I have that set forth in a list which I have prepared and maintain with this Will. V I give and devise my one-fifth (1 / 5) share in the Laurel Lake Cabin to be divided equally among the other four owners, per stirpes. VI I give and devise my real property situate at 65 Greystone Road, Carlisle, Pennsylvania, to my daughter, CHERYL D. CALAMAN, per stirpes. VII I give and devise my real property situate at 306 S. Market Street, Mechanicsburg, Pennsylvania to my granddaughter, DAWN M. CHEUGH, per stirpes. VIII I give, devise and bequeath all the rest, residue and remainder of my property, whether real or personal, wherever situate, including any property over which I may have a power of appointment to my granddaughter, DAWN M. CHEUGH, or if she fails to survive me to my grandson, STEVEN L. HARPER, per stirpes. IX I nominate, constitute and appoint my granddaughter, DAWN M. CHEUGH, as Executrix of this LAST WILL, to serve without bond. If my granddaughter, DAWN M. CHEUGH, is unable or unwilling to act in that capacity, then I nominate, constitute and appoint my grandson, STEVEN L. HARPER, as Executor of this LAST WILL, to serve without bond. IN WITNESS WHEREOF, I, BERNEICE M. GERHARDT, have set my hand to this LAST WILL this 27~ day of September, 2010. ~~ f~ ,;;, ~ ~ y-1 !r BERNEICE M. GERHARDT Signed, sealed, published and declared by the above-named BERNEICE M. GERHARDT, as and for her Last Will and Testament, in the presence of us, who, at her request and in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses. AF. ,~ ~i `il_..n..-- ./~~~-...--..F ,~`^ ~ ~ ) ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. I, BERNEICE M. GERHARDT, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my LAST WILL; that I signed it as my free and voluntary act for the purposes therein expressed. ,. i ~ ~/~ ~. J. ~i'~' ? i~c'"_„~, ! ~ ~ '~ c ~ c..=- `lam' / BERNEICE M. GERHARDT Sworn or affirmed to and acknowledged before me by BERNEICE M. GERHARDT, Testatrix, this 27~ day of September, 2010. a Notary Public ~~~~ ~ ~ ,.n~~~s~~ .aa+.. a..,.. _` ~ ~ 8 L i` ftir a AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ss. COUNTY OF CUMBERLAND We, /~~L~,~~l~ ~~ ~`~ ~-~~" `'~ ~ ~~c .~ ~~~ and ~~ ,; ~;~ ~~; ;l j~. ~ u ~ ~ '~..: t !. !, •J the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her LAST WILL, that BERNEICE M. GERHARDT signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to. the best of our knowledge, the Testatrix was at the time 18 years of age or more, of sound mind and under no constraint or undue influe ce. ,> ~, f ,;;;~-'~ ~~ ~, ~~--_ .~----, ,/ _ ~~ ~ ; ~~'~ ~ ~ J .~i E .'%/r._...~ k_ ,. .i ~ /' iii Sworn or affirmed to and acknowledged before me this 27~ day of September, 2010. '> j. Notary Public '~ ~~~{tic A,i 'vi,•~isl~ ~1c7`t.~~' ~i_~~fG c ~.... a9%'ES`d.SBRa?KBtQALY. ~.GhIH i3Y~Y'+'"u. £•Mi~Ri~YMf +:h£%l'"=95Y• PETITION 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 Name: BERNEICE M. GERHARDT a/k/a: a/k/a: a/k/a: Date of Death: 811512012 File No : 21-12- ~ ~~ ~~ (Assigned by Register) Social Security No: 204015869 Age at death: 94 Decedent was domiciled at death in CUMBERLAND County, PENNSYLVANIA (State) with his/her last principal residence at 65 GREYSTONE ROAD, CARLISLE 17013 NORTH MIDDLETON TOWNSHIP CUMBERLAND Street address, Post Office and Zip Code City, Township or Borough County Decedent died at 65 GREYSTONE ROAD CARLISLE17013 NORTH MIDDLETON TOWNSHIP 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 $ 33,000.00 If not domiciled in Pennsylvania .............................Personal property in Pennsylvania $ If not domiciled in Pennsylvania .............................Personal property in County $ Value of real estate in Pennsylvania .............................................................. $ 0.00 TOTAL ESTIMATED VALUE.... $ 33,000.00 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 12/8/2010 and Codicil(s) thereto dated NONE State relevant circumstances (e.g. renunciation, death of e_recutor, 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) c. t. a., d. b. n., d. b. n. c. t. a., pendente lite, durante absentia, durante minoritate If Administration, c.t.a. or d.b.n.c.za., 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 h~i~ (attach additional sheets, if necessary): ~~ `~ ~ Name Relationship Address ~ ~ ~- `--' ~_' ~? ~=_ ` tom.) r-° ~ _.. :"_ ~ = _. ..~= R7 Formxwo? rev. ~oi~rizorr Page 1 of 2 Oath of Personal Representative Official Use Only COMMONWEALTH OF PENNSYLVANIA n ~i ~`-'~ ~ `Y rn ~~ ..' ~ COUNTY OF CUMBERLAND } =~ `- ~ ~`;;- ~ r ~ ~~ -~ - ..,~ ~ -, - Petitioner(s) Printed Name Petitioner(s) Printed Address p .--, - - CHERYL D. CALAMAN ~~ ~' = ~; 65 GREYSTONE ROAD CARLISLE --x' PA eK7013` . ~ ; `r ~,. N ~'~ 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 armed an bscribe before ~ f ~ ;~ ^ ' l ~~i, J1 ~` r Date me tht -.u~day of ~ ~ Date By: Date ~'orthe Register Date BOND Required: ^ YES ® NO FEES: Letters ....................... $ ( )Short Certificates(s) ..... . ( )Renunciation(s) ......... . ( )Codicil(s) ............. . ( )Affidavit(s) ............ . Bond ......................... Commission ................... . Other ......... Automation Fee ................ . JCS Fee ....................... TOTAL ......................$ To the Register of Wills: Please enter my appearance byf ray signature below: Attorney Signatur ~~ ;°` I j' ~~ ~ ~ l.._ " l Printed Name: MURREL R. WALTERS, III Supreme Court ID Number: 24849 Firm Name: MURREL R. WALTERS, III Address: ATTORNEY AT LAW 54 E. MAIN STREET MECHANICSBURG PA 17055 Phone: Fax: Email: 717-697-4650 717-697-9395 DECREE OF THE REGISTER Estate of BERNEICE M. GERHARDT File No: 21-12- a~'~~:. a/k/a: 0 AND NOW, , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters TESTAMENTARY are hereby granted to CHERYL D. CALAMAN in the above estate and (if applicable) that the instrument(s) dated 121812010 described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. Register of Wills Fo~~n~ xw oz rev. ~oi~lizorl Page 2 of 2 .<r . _ ~ , ,. ~~,.~ ~- .. f ~ ~ ''. - . ... .._ _t,., - ~ . .._ , :._~.t J ~~~'~` fs)i' tlii~. (__'iiil~+~<)(._'. Vii?.!'.)+; 1•., ~~ E.~ . ,~ P ~~;'Cil~,::t)1:3Ui1 'vliili~`,t1- Type/Print In ~~~.!!l~~~ Permanent Black Ink W Q a v O_ 4 Z ~~ ~ ~~~ 28 ~ 8~ 2 ~ C~~iBE~~~JC Cd. I P ' A ~~ ~ y ~ ~~'~ef.~.c-~C~. AUK 1 6 :~ 2012 -- COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE [7F I7F~TH 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number) ~o 4, Date of Death (MO/Day/Yr) (Spell Mo) Berneice M_ Gerhardt F 204 01 5869 Au 15, 2012 Sa. Age-Last Birthday (Yrs) 56. Under 1 Year Sc. Under 1 Da 6. Date of Birth (Mo/Day/Year) (Spell Month) 7a. Birthplace (City and State or Foreign Country) ~- ~ Months Days Hours Minutes ChLlrChtoW1Z, PA =~ 94 Nov_ 9 ~ l 9l 7 7b. Birthplace (county) C~nberland 8a. Residence (State or Foreign Country) 86. Residence (Street and Number -Include Apt No.) 8c. Did Decedent Live in a Township? Pe ~'es, decedent lived in NOr-th Middleton t Sd. Res nce (County) 65 -GreystOne Rd_ wp. CLUnberland Se. Residence (Zip Code) 1 701 3 Q No, decedent lived within limits of city/boro. 9. Ever in US Armed Forces? 10. Marital Status at Time of Death Q Married ~ 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 Unknown _ 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last) Ro M_ Westhafer Beulah M_ Hoslar 14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code) o Che 1 Calarrl~-ii~ Daughter 65 Greystone Rd_ Carlisle, PA 17013 ~-+ ........................................... .... ..... ............. ......... ..... ...... ......_.__. _.... lSa. Place o Deat Check oni one ......_.......................--•--.......... Y s o P If Death Occurred in a Hos ital: ~ p In atie nt ; ....... ............ _ ..........................y-..~..................................... .. ..................................... =1f Death Occurred Somewhere Other Than a Hospital: LJ Hospice Facility ~ Decedent's Home Emer enc Room Out atient Q B Y / P Q Dead on Arrival • Q Nursing Home/Long-Term Care Facility Q Other (Specify) ~ lSb. Facilit Name If not institution, Y ( give street and number; 16c. City or Town, State, and Zip Code lSd. County of Death Z 65 Greystone Rd_ Carlisle, PA 17013 G~snberland -- 16a. Method of Disposition Q Burial ~ Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) m v Q Removal from State Q Donation c Q Other (Specify) 8 20 201 2 >~rans Cremation Services Z 16d. Location of Disposition (City or Town, State, and Zip) 17a. Signature of Funeral Service Licensee o n in rge of Interment ~ 17b. License Number Leo1a, PA FD 012633 L ~ 17c. Name and Complete Address of Funeral Facility 3 °' Etsin Brothers Funeral Homo, Inc_ 630 S_ Hanover St_, Carlisle, PA 17013 ° 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 I - 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" hite 0 Korean Q No diploma, 9th - 12th grade b o x if• decedent is no[ Spanish/Hispanic/Latino. Q Black or African American ~ Vietnamese ~gh school graduate or GED completed ,~ ,~ L~'v o, not Spanish/Hispanic/Latino Q American Indian or Alaska Native Q Other Asian Q Some college credit, but no degree Q Ves, Mexican, Mexican American, Chicano Q Asian Indian Q Native Hawaiian Q Associate degree (e.g. AA, AS) ~] Yes, Puerto Rican [~ Chinese ~ Guamanian or Ghamorro Q Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban [~ Filipino Q Samoan Q Master's degree (e.g. MA, M5, MEng, MEd, MSW, MBA) Q Yes, other Spanish/Hispanic/Latino Q Japanese Q Other Pacific Islander Q Doctorate (e.g. PhD, EdD) or Professional degree (Specify) ~ Other (Specify) e. MD, DDS, DVM, LLB, JD 21. De ant's Single Race Self-Designation -Check ONLY ONE to indicate what the decedent considered himself or herself to be. Whit 22a. Decedent's Usual Occupation - tndicate type of work e Q Japanese Q Samoan Q Black or African American ~ Korean Q Other Pacific Islander done during most of working life. DO NOT USE RETIRED. Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure HOmema]cer Q Asian Indian Q Other Asian Q Refused 226. Kind of Business/Industry Q Chinese Q Native Hawaiian Q Other (Specify) Q Filipino Q Guamanian or Ghamorro Her' OWIl home ITEMS 23a - 23d MUST BE COMPLETED BV PERSON WHO PRONOUNCES OR 23a. Date Pronounced Dead (Mo/Day/V r) ...-~ 236. Signature of Person Pronouncing Death (Only when ap cable) 23c. License Number CERTIFIES DEATH ~ . Date Signed ( o/Day/Yr) 24. Tim Death _ ~ W ~~ S ~ 25. Was Medical Examiner or Coroner Contacted? Q Yes No CAUSE OF DEATH Approxima[e 26. Part 1. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest Interval: respiratory arrest, or ventric lar fibrillation without showing the etiology. DO NOT A B B R EV IATE.s Enter only one cause o n a l ine. Add additional lines if necessary Onset to Death > _ ~ ~J '(/ / s / ^~ ~ IMMEDIATE CAUSE ----- - - a _ ~~ Y ~-~I, G~ ~ ~~~ (Final disease or condition Due to (or as a consequence of): ~~ resulting in death) ^ . _ L~ ~ ~ ~y \/~ ~~ C ~' ~~. Sequentially list conditions, Due to (or as a consequence of): ~ if any, leading to the cause ~~ /'~ /'~ /~ ~yp ~ / P ~j ~ /~ listed on line a. Enter the c. _ ~ ~(J V L.l~~ C/t. r ' vY ~ ~ L ~C~si ~Y~ UNDERLYING CAUSE DueDUe t~a consequence of): W (disease or injury that initiated the events resulting d. w in death) LAST. Due to (or as a consequence of): u_ 0 26. Part 11. Enter other significant conditions contributive to death but not resulting in the underlying cause given in Part I 27. Was an autopsy perfor d? ~ Q Yes No ~- 28. Were autopsy findings available to complete the cause of death? v Q Yes Q No _, E 29. If Fe e: of pregnant within past year 30. Did Tobacco Use Contribute to Death? Q Yes Q P b bl 31. Ma er of Death l v Q Pregnant at time of death a y No Unknown Q Natura Q Homicide Q Accident Q P di I ti ti m Not re Want, but Q p g pregnant within 42 days of deatF en ng nves ga on Q Suicide Q Could not be determined i°- Q Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Yr) (Spell Month) 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 Ves Q Driver/Operator ~ Pedestrian No Q Passenger Q Other (Specify) 39a. Certifier (Check only one): Q Certifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated ~ Pronouncing ga Certifying physician - To th est of my knowledge ath occurred at the time, date, and place, and due to the cause(s) and manner stated Q Medical Examiner/Coroner - On the basi o xaminati nd/o i estigati n my opinion, death occurred at the time, date, and place, and due to the cause(s) and m anner stated G ~ Signature of certifier: Title of ce rtifier• ~N~' -0 License Number: L~~~3 /~ ~~~ 9b Name, Address and Zip Code of on Completing pause of De (Item 26) O - 39c. Date Signed (Mo/Day/Vr) .-•a. ~ ~~. ~ ~.~t- ~ b ~ - 4 .Registrar's District umber 41. Registrar's Si venture t'Z O ,.~~-' ` Jg (~ 2. Registrar File Date (MO/Day/Yr) jT~ - ~_ - - }~ 43. Amendments L Disposition Permit No. \ ) ~~ "4~ ~ ~ (, lJ H105-143 REV 07/2011 LAST WILL AND TESTAMENT BE IT REMEMBERED THAT I, BERNEICE M. GERHARDT, a resident of Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do make, publish and declare this to be my LAST WILL AND TESTAMENT, hereby revoking any and all Wills and Codicils previously made by me. I I declare that I have two daughters, DIANE M. HARPER and CHERYL D. CALAMAN. II I direct that all my just debts and funeral expenses shall be paid from my residuary estate as soon as practicable after my decease. III I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. IV I give, devise and bequeath all the of my property, whether real or personal, wherever situate, including any property over which I may have a power of appointment to my daughter, CHERYL D. CALAMAN and my grandson, MICHAEL S. D. WOGAN, in equal shares, per capita. ~ _' A.. ~~ „~ ~tJ ~t^1 ~ J ' ' [ F ,~ .r..1... ~, ~~ .~.~, m. , C ~ ~ Y~ N~ i'_,y . 1. ., '~'^i `' `. ..~. ~-t .':. ~ ,.. ---~ ;.".~.? ..0 L.+'7 N 't'i v I nominate, constitute and appoint my daughter, CHERYL D. CALAMAN, as Executrix of this LAST WILL, to serve without bond. If my daughter, CHERYL D. CALAMAN, is unable or unwilling to act in that capacity, then I nominate, constitute and appoint my grandson, MICHAEL S. D. WOGAN, as Executor of this LAST WILL, to serve without bond. IN WITNESS WHEREOF, I, BERNEICE M. GERHARDT, have set my hand ~~~ to this LAST WILL this ~ day of ~ ~ ~, s~ ~ Y-~ ~~} `~-- , 2010. ,, _ K ~ ... BERNEICE M. GERHARDT Signed, sealed, published and declared by the above-named BERNEICE M. GERHARDT, as and for her Last Will and Testament, in the presence of us, who, at her request and in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses. fey/' j f/~ < J / .J off l7 /"_ ~, ~ o` %: ~ ~ f V .~ ~~ - ~ ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. I, BERNEICE M. GERHARDT, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my LAST WILL; that I signed it as my free and voluntary act for the purposes therein expressed. t : , :~ BERNEICE M. GERHARDT Sworn or affirmed to and acknowledged before me by BERNEICE M . GERHARDT, Testatrix, this , day of 1~~rc ~~, ~~~. ~ , 2010. f_.,~ ~, ~ ~ / Notary Public ~. .t _ . y. }. ~ . j } j~ 5. ...., '..J S . ~ _ L. : '4 . , ~,: AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ss. COUNTY OF CUMBERLAND ~~ We, ~c~i~`~ x ~~- ~ ~-u /1 G ~ G ~~ 1 and f l L -5~- ;~7:~~ J, the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her LAST WILL, that BERNEICE M. GERHARDT signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge, the Testatrix was at the time 18 years of age or more, of sound mind and under no constraint or undue influ ce~~i j. t ~, ~e ' r /f C ~ -~ -~o ~ ,;~ . ,. -__. Sworn or affirmed to and acknowledged before me this ~'~ day of ,,.C ~-~ , 2010. ,~ ~~~ Notary Public F,.j ; ~.~~ ~ ~.n ;_ , i. F "' ' dd ~r .~'t" ... i."