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Home My WebLink About08-30-12Reset ~--_.~ ~_~ PETITION FOR GRANT OF LETTERS C?` ~~~ -~--, ~~ ~' r=~' REGISTER OF WILLS OF CUMBERLAND COUNTY, PE ~YLVA r~' `-~ ~' Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letter~~ specifies beloiu~ `:aiid in support thereof aver(s) the following and respectfully request(s) the grant of Letters in the a .dpriate fin: _-~=;; ~~ .. - ,='- Decedent s Information ~' _~~ ...~ --~ ~j~` • • ,~,~ ~ Name: Tyler D Hockenberry File No: D `~ _/J c.~ --~-~ a/k/a: (Assigned by Register) a/k/a: a/k/a: Date of Death: Julv 25, 2012 Social Security No: 184-64-~p ~`j ~., Age at death: 39 Decedent was domiciled at death in Cumberland County, P~~ytvania (state) with his/her last principal residence at 8 Cleversburc Road Shippensburc PA 17257 Southampton Twp Cumberland Street address, Post Office and Zip Code City, Township or Borough County Decedent died at 8 Cleversbur~ Road Shippensbur~ Southampton 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 $ 45,000.00 If not domiciled in Pennsylvania ........................Personal property in Pennsylvania $ If not domiciled in Pennsylvania ........................ Personal property in County $ Value of real estate in Pennsylvania ......................................................... $ TOTAL ESTIMATED VALUE.... $ 45000.00 Real estate in Pennsylvania situated at: NONE (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 thereto dated 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. Q 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.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 no Will and was survived by the following spouse (if any) and heirs (attach additional sheets, if necessary): Name Relationshi Address Larry D. Hockenberry Father 8 Cleversburg Road, Shippensburg, PA 17257 Stacy J Pattillo Sister 235 Whitley Drive, Chambersburg, PA 172012 ~~ .sc~ fu c~ ~ t and Codicil(s) Form RW-02 rev. 10/1 //2011 Page 1 of\ ~~ Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF Cumberland } } SS: } Official Use Only ~.,. , c~ -mz ..-_ :.._ ~; ~r~ ~~ ,; ~3 ~ ~? ~ ~`.. -r..7 ~J ~ ~ ~. ~ L. ., ~ _ ~! :: ~--. _. Petitioner(s) Printed Name _,. Petitioner(s) Printed Address~,-~`= ,~:' ~~ Stac J. Pattillo 'A..;t ~ ~~~~ t'T"f 235 Whitle Drive Chambersbur PA 17201 '• 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)'v~ill well and truly administer the estate according to law. Sworn to affirmed nd s bscribed be ore -~ r ~ . ~, '. ~4 ~~ ~ (~- ~ ~'~'~ Date ~, ~ ~~ / ~-- ~ 1 t me th~s ~hday o " ~ " ~ ~ G' Date By. ~ ? ~l_ Date F the Register Date BOND Required: Q YES Q NO FEES: Letter ...................... $ ') , ~ ~~ ( )Short Certificate(s)...... 1 ~ 1~ ( I) Renunciation(s)......... . L~~' ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other ....... Automation Fee .............. . JCS Fee . .................... ~~~ TOTAL ..................... $ ~$AA To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature: Printed Name: H. Anthony Adams Supreme Court ID Number: 25502 Firm Name: H. Anthony Adams Address: 49 West Orange Street Suite ~ Shippensbur~, PA 17257 7175323270 7175326673 h d m~law(a~P.mhar~mail_c~m /.~ 9~ ~ DECREE OF THE REGISTER Estate of Tyler D. Hockenberrv a/k/a: File No: rC. ~ ~ /l. ' ~ ~`7!,v~ AND NOW, -~ satisfactory proof having %~~,~ ~~~ ~~~ , in consideration of the foregoing Petition, presented before me, IT IS DECREED that Letters of Administration _ are hereby granted to Stacv J. Pattillo in the above estate and (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of record Register of Wills Form RW-02 rev. 10//1/2011 r. „ .,. t. ' ~ ~ ~f ~ U~ 3Q I ~ Ctl1~R8~F~~j~Jn"~~~~~ ~. C~., Pq ~~ rL 0 u 0 O Q P x.8587864 Type/P rlnt In Permanent RI ck Ink ~~--~ ,-.,,, COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS ["FRTiFIr~TF nF I7F4T1-1 _. _.. -. a 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4, Date of Death (Mo/Day/Yr) (Spell Mo) --,~ -~ . ~-~, oL Wit., b.t,-~ ~ ~ :~, - ~. `~ - ~--~ S ~ ~ - s o Sa. Age-Last irthday (Yes) Sb. Under 1 Vear Sc. Unde 1 Da 6. Date of Birth (MO/D ay/Year) (Spel l Month) 7a. Birthplace (City and S tate or For gy-noun ry) / Months Days Hours Minuses ~ ~ 3 ~ a ~ r ~ ` t 2 »~?j 7b. Birthplace (County) Sa. Residency,(State or Foreign Country) 8b. Residence (Street and Number -Include Apt No.) 8c. Did Decedent Live in a Township? p Y'rr~ p `, Yes, decedent Ifved in ~Jc-.~ ~-~"A'r~~~~T.` r-> twp. Sd. Residence (County) a "~GV['1S PV~' y~ Yf~ i ~ 8e. Residence (Zip Code) ~~ ~~j ~- Q No, decedent lived within limits of city/boro. 9. Ever in US Armed Forces? 10. Marital Status at Tlme of Death ~ Married Q Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) Q Yes '® No [] Unknown Q Divorced ~j Never Married Q Unknown 12. Father's Name (First, Middle, last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last) L~ r 7 . 1 ~ ~L, ~-~ r ~c 1C'Y, c7..i a zJ 14a. Informant's Name ~ 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code) G ................ ........ ............... ...........; . . 15a. Place of Death Check onl one ... ,,, ,,, ,,,,,,,,,_ ,,, ,,,,,,, ,,,,,,, ,,,,,, ....... ..._........_......_........(..............x......1............................... ... ... ............................................... If Death Occurred in a Hospital: ~] Inpatient : If Death Occurred Somewhere Other Than a Hospital: ~ Hospice Facility ~ Decedent's Home ° Q Emergency Room/Outpatient Q Dead on Arrival _ Q Nursing Home/Long-Term Care Facility ~ Other (Specify) 15b. Facility Name (If not institution, give street and number; 15c. City or Town, State, and Zip Code 15 d. County of Death - ~ c~ ~.•« - ~ Q ~ cam:: a-.v ~ ~.~ ~ P~ ~ ~ -z ~ S 16a. Method of Disposition ~^BUrial Q Cremation 16b. Date of Disp s Ion 16c. Pla of Disposition (Name of cemetery, crematory, or other place) , C° Q Removal from State Q Donation -mot ` /' ~ • Q Other (SPecify) 'T 30 i~ ~'r'~~~fl' c~d G~, ~ \ `1~r c (City or Town, State, and Zip) 16d. Location of Disposition 17a. Signature of Funeral Service Licensee or Person In Charge of Inter ant 17b. License Number ~ . cs~ • P i~ pi ~- ~`y - ~iZ ~~~\ - L a 17c. Name and Complet ddress of Funeral Facility V _ m 18. Deced~ 's Education -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race - Che k NE OR MOR aces 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 "N O" ® White Q Korean Q No diploma, 9th - 12th grade box if decedent is not Spanish/Hispanic/Latino ~. Q Black or African American Q Vietnamese Q High school graduate or GED completed ® No, not Spanish/Hispanic/Latino Q American Indian or Alaska Native [~ Other Asian ~ Some college credit, but no degree Q Yes, Mexican, Mexican American, Chicano Q Asian Indian Q Native Hawaiian Q Associate degree (e.g. AA, AS) Q Yes, Puerto Rican Q Chinese Q Guamanian or Chamorro Q Bachelor's degree (e.g. 8A, AB, BS) Q Yes, Cuban Q Filipino Q Samoan Q Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Yes, other Spanish/Hispanic/Latino Q Japanese ~ ~ Other Pacific Islander Q Doctorate (e.g. PhD, Edo) 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 Vsual Occupation -Indicate type of work ® White Q Japanese Q Samoan done during most of working life. DO NOT USE RETIRED. Q Black or African American Q Korean Q Other Pacific Islander Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure : KSS'10t~CJG .t ~ Asian Indian - [] Other Asian Q Refused 22b. Kind of Business/Industry Q Chinese ~ Native Hawaiian Q Other (Specify) ~t ~ 2!•/ t L~ SYL G7JS{Yy [] Filipino ~ Q Guamanian or Chamorro ITEMS 23a - 23d MVST E COMPLETED 23a ate P onounced Dead (MO/Day/Yr) 23b. Signature of Person Pronouncing Death (Only when appilca bie) 23 c. License Number BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH O 23d. Date Signed (MO/Day/Yr) Ime o eath r 25. Was Medical Examiner or Coroner Contacted? Q Yes Q 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: EVIATE. Enter only one cause on a Tine. Add additional Ilnes if necessary Onset to Death ng the etiology. DO NO T ABB R respiratory arrest, or ventricular fibrillation without show{ // ~ ) t~ ^ ~{ IMMEDIATE CAVSE ---------> a. ~ ~O ~ f T .J Ly, ~!~ / l /7'' Ty' Y ~9 (Final disease or condition Due to (or as a consequence of): resulting in death) b. Sequentially Ilst conditions, Due to (or as a consequence qf): if any, leading to the cause listed on line a. Enter the c. UNDERLYING CAUSE Due to (or as a consequence of): W (disease or Injury that Initiated the events res atHng d. s v In death) LAST. . Due to (or as a consequence of): Enter other siRnifica nt conditions contributing to death but not resulting in the and erlying cause given in Part 1 Part II 26 27. Was an autopsy performed? o . . Q Yes Q No ~ S_ - 28. Were autopsy findings available to complete the cause of death? m Q Ves ~ No 29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death 22 E~ Q Not pregnant within past year Q Yes Q Probably Q Natural Q Homicide S Q Pregnant at Lime of death Q No Q Unknown Q Accident Q Pending Investigation °J Q Not pregnant, but pregnant within 42 days of death Q Suicide Q Could not be determined but pregnant 43 days to 1 year before death Q Not pregnant 32. Date of Injury (MO/Day/Yr) (Spell Month) , Q Unknown if pregnant within the past year 33. Time of In)ury 34, Place of Injury (e.g. home; construction site;.farm; school) 35. Location of Injury (Street and Number, Cliy, State, Zip Code) 36. Injury at Work 37. If Tra nsportatlon Injury, Specify: 38. Describe How Injury Occurred: Q Yes Q Driver/Operator Q Pedestrian Q 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 , Q Pronouncing 8. Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated th occurred at the time, date, and place, and due to the cause(s) and manner stated a Q Medical Examiner/Coroner - On the basis of exam ion, a /or investigation, {n my opinion, de / ~ Signature of ce rtlfie r: Tltie of certifier: / /(1 License Numbe r:~~ a-~ oTcs~ ~~_~ °b. N e, Address and Zip Co a of Person Completing Cau of D ath (Item 26) 39c. D to Sign d (MO/Day/Yr) b ~~ 1 ~ - w 'P qoy a I 40. Registrar's District Number 41. Regist s Sig ature / ate (MO/Day/Yr) 4 Registr File D ._ _ ~ ~ y - ..L- ~r^ 43. Amendments ~J~ '2, H105-143 Disposition t' ~~--~ ~ ~ ` y /.`"' __._ _.. _.._ REV [17/2011 ~n ~~ ^•.~ -z-1 ~ _ _.h.r~ 3. ~`' ~J _. .. '.._ 1 I RENUNCIATION J .. S/ 4~; ~ ~ ~:~ K_.- C. J C7 ~ ~ --~ ~~~ ..~ ISTER OF WILLS - ` _., ~° _r~ ° ~~ c~ COUNTY, PENNSYLVANIA ~ ?' ~'°~ N c.~ Estate of I, Deceased ~'~~ , in my capacity/relationship as Print Naihe) _ ' r '~ of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to '3G~ ~r~ t' ~_... (Date) _, (Signat e) ~' ~, ~,-,mss ,~ ~ r~ ~ /~ (Street Address) ~' ;J L~ ~ c (City, State, Zip Executed in Register's Office Executed out of Register's Office Sworn to or affirmed and subscribed Before the undersigned personally appeared the before me this day party executing this renunciation and certified of that he or she executed the renunciation, for the ~~ Deputy for Register of Wills ~ ^ ~~ ~t~~ purposes stated within on this ~~ ~- day of Q Z..~ ~ ~ ~' t ~ .. _ _ - -~.. _ _.._ Notary Public OMMONW~~~~ a~ p~NNSYLVA ommission Expires: ~ Notadai Seal Notary Public (Signa re and Seal of Notary or other official qualified to H, Anthony Adams, ensburg BOro, Cumbe~a 31 2~i~~ni ter oaths. Show date of expiration of Notary's Commission.) Shipp Tres MaY My Commission Exp' Member PennsY4~~nia Ass'-x-ation of Notaries Form RW-06 rev. 10.13.06