HomeMy WebLinkAbout09-20-12O.C. Form 1
Petition for Settlement of Small Estate
(Rev. 10/04)
Cumberland
In the Court of Common Pleas of ~~ County, Pennsylvania
Orphans' Court Division
Estate of Anthony L. Perry ;
also known as No. r
,deceased
Petition for Settlement of Small Estate
Pursuant to section 3102 of the Probate, Estates and Fiduciaries Code, the
undersigned petitioner respectfully represents that:
1. The name and address of the petitioner are:
Mary L. Perry
1219 Cross Creek Drive
Mechanicsburg, PA 17050
2. The relationship of the petitioner to the decedent is: Wife/Executrix
3. The decedent died on: June 9, 2012
Cumberland
4. The decedent was domiciled at time of death in ~ County,
Pennsylvania, with a last family or principal residence at: 1219 Cross Creek Drive,
Mechanicsburg, PA 17050
5. The decedent's social security number is: 019-30-3851
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6. The death certificate is attached hereto. ~~ ~:..~ -x-~ ,.~-Y`~
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7. The decedent died: ~ -~- ~= '~ : ~ r
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^ (a) intestate ,.~.
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If the decedent died testate: .c-- ~"
1
^ (i) the will has been probated, and a copy is attached
hereto. Letters have been issued to:
^Q (ii) the will has not been probated and the original will
is attached hereto. ~If not attached, explain.) The
personal representative(s) named therein is (are):
Mary L. Perry
8. The name(s), relationship(s), and interest(s) of all parties beneficially
interested in the estate are:
Sui Juris
Name Relationship Interest es or no
Mary L. Perry Wife 100% y
9. A spouse's elective share:
^Q (a) has not been claimed
^ (b) has been claimed. [Give details.)
10. If the decedent died testate, the decedent:
x^ (a) was not married or divorced after the date of execution of
the will
^ (b) was married or divorced after the date of execution of the
will. [Give details.)
11. If the decedent died testate, the decedent:
® (a) did not have a child or children born or adopted after the
date of execution of the will
2
^ (b) had a child or children born or adopted after the date of the
execution of the will. [Give the name and date of birth or
adoption of each such child.)
Name
Date of Birth or Adoption
12. The decedent died owning property (exclusive of real property and
property payable under section 3101 of the Probate, Estates and Fiduciaries Code) of a gross
value not exceeding $25,000, which is itemized below. Include account numbers and
registration numbers, etc. If a bequest is adeemed, explain.)
Item Amount
Checking account with Citizens Bank $1,455.87
Savings account with Fulton Bank 148.79
Total $1, 604.66
13. An itemized statement of all claims against the estate is set forth below:
(a) The following person(s) claim(s) the family exemption under
section 3121 of the Probate, Estates and Fiduciaries Code by virtue
of being a member of the same household as the decedent:
Amount or
Name Relationship Items Claimed
Mary L. Perry Wife $3,500.00
Total $3, 500.00
3
(b) The following persons claim reimbursement for debts, expenses,
and other claims (including inheritance tax, if applicable] they
have paid with their own funds:
Nature of
Person Claiming Date of Debt or
Reimbursement Payment Payee Expense Amount
Mary L. Perry 6/13/12 Malpezzi Funeral Home Funeral 5,694.92
Total ~,by4•yL
(c) The following claims remain unpaid:
Donald B. Swope, Esquire
Member's 1st FCU
Fulton Bank
Ko h I's
AT&T
Nature of Claim Amount
Attorney's fees & costs 958.50
(class 1)
auto loan (class 6) 6,946.61
credit card (class 6) 1,140.68
credit card (class 6) 21.78
cell phone (class 6) 37.66
Total 9,105.23
14. ^x (a) All claims are undisputed.
^ (b) The following claims are disputed:
[Give details)
15. The petitioner has paid or will cause to be paid all Pennsylvania
inheritance tax due on all property to be awarded under this petition.
16. All parties beneficially interested in the estate, other than the petitioner,
including all holders of claims that are denied, or, in the case of an insolvent estate, all holders of
claims who will not be paid in full, have:
^ (a) signed the joinder in this petition which is hereto attached;
or
(b) been mailed at least ten (10) days written notice of the date,
time, and place of the Orphans' Court audit session at
which the petition will be ruled upon by the Court, a copy
of which notice is attached hereto.
4
17. Your petitioner proposes:
(a) that the family exemption, if any, be paid or satisfied as follows:
Mary L. Perry - $~~.u .1
(b) that the following claims be paid: [Refer to section 3392 of the
Probate, Estates and Fiduciaries Code to establish priority among
claims, if necessary.)
Claimant Nature of Claim Amount
Donald 8. Svrope, Esquire Attorney's fees and costs 958.50
(class 1)
Total $1,604.66
(c) the balance, if any, be distributed as follows:
Item
Amount
Total ~ 1, 604.66
Signature of Petiti er
Typed Name: ry L. Perry
____
~„o.- ~..~,_.~ _ _y
Sign orney for Petitioner
Typed Name: Donald B. Swope, Esquire
Supreme Court I.D. No.: 01625
Office Address: 50 East Market Street
Hellam, PA 17406
Telephone Number: 717-840-0110
5
VPrificatinn
The undersigned petitioner hereby verifies, subject to the penalties of 18 Pa.
C.S.A. §4904 (relating to unsworn falsification to authorities), that the facts set forth in the
foregoing petition which are within his (her) knowledge are true, and, as to the facts based on
information received, after diligent inquiry, he (she) believes them to be true.
Date: ~/(~~~
Signature ofition~ Mary L. Pe
Joinder
I (we), the undersigned, being parties other than the petitioner beneficially
interested in the estate of the foregoing decedent, do hereby certify that I (we) have read the
foregoing petition and join in the prayer thereof.
6
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
fFRTIFIfATF fl[ IIFATLJ
1. Decedent's Legal Name (First, Middle, Last, Suffix) 2 . Sex 3. Social Security Number) V ~ 4' Date of Death (MO/Day/Yrl (Spell Mo) i
Anthon L Perr Male 019 - 30 - 3851 June 9 2012
Sa. Age-Last Birthday (Vrs) 56. Under 1 Vear Sc. Under 1 Da 6. Date of Birth (MO/Da y/year) (Spell Month) 7a Birthplace (City and Sl ate or Foreign Country)
Months Days Hours Minutes SomerVl le MA
72 June 8, 1940 76. Birthplace (County)
Sa Residence (State er Foreign Country) 8b. Residence (Street and Number -Include Apt No.) 8
c Oid Decedent live in a Township?
Pennsylvania 1219 C
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1-lalflpden tw
L'M"es, decedent lived m
8d. Residence (County
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OSS Cree
Drive _
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Cumberlan 8e Residence (Zip Codel 17050 ^No, decedent lived within limits of city/boro.
9 Ever in US Armed Forces? 10. Marital Status at lime of Death ®Married ^ Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marnage~
Ves ^ No ^Unknown ^ Divorced ^ Never Married ^Unknown Mary j~e
12. Father's Name (First, Middle, Last, Suffix) 1 3. Mother's Name Prior to First Marriage (First, Middle, Last)
Unknown Unkn
14a. Informant's Name 14b. Relationship to Decedent 1 4c. Informant's Mailing Address (Street and Number, City, State, Zlp Code
o Mar L. Perr Wife 1219 Cross Creek Drive Milani PA 17050
ri ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
...........
................................... lSa. Place of Death Check only one
.............................
....
..
o v
If Death Occurred in a Hospital: In a[lent .
.
............................................................................................ ..
:
:If Death Occurred Somewhere Other Than a Hospital. ^ Hospice Facility ~ Decedent's Home
~~T
^ Emergency Room/Outpatient ^ Dead on Arrival Z
CC
^ Nursing Home/Long~Term Care Facility ^ Other ~Speci(y)
~
156. Facility Name (If not institution, give street and number; lSc. City or Town, State, and Zip Code lSd. County of Death
LL 1219 Cross Creek Road Mechanicsbur PA 17050 Cumberland
~
v 16a. Method of Disposition ~ Burial ^ Cremation
^ Removal from Slate ^ Donation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place)
K Other (Specify) June 13 2012 Indiantown Ga National Cemeter
Z 16d. location of Disposition (City or Town, State, and Zip) 17a. Si of Fun€ra ervi a Licensee or Person in Charge of Interment 17b. License Number
v Annville
PA 17003
, FD - 014
E 17c. Name and Complete Address of Funeral Faculty
Mal zzi Funeral Home 8 Marke
t az
m 18. Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 0. 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.
^ 8th grade or less is Spanish/Hispanic/Latino. Check the "NO" ~ White ^ Korean
^ No diploma, 9th - 12th grade box tf decedent is not Spanish/Hispanic/Latino. ^ Black or African American ^ Vietnamese
^ High school graduate or GED completed No, not Spanish/Hispanic/Latino ^ American Indian or Alaska Native ^ Other Asian
Some college credit, but no degree Yes, Mexican, Mexican American, Chicano ^ Asian Indian ^ Native Hawaiian
^ Associate degree (e.g. AA, ASI ^ Yes, Puerto Rican ^ Chinese ^ Guamanian or Chamorro
^ Bachelor's degree (e.g. BA, A8, 85) ^ yes, Cuban ^ Filipino ^ Samoan
^ Master's degree (e.g. MA, MS, MEng, MEd, M6W, MBA) ^ Yes, other Spanish/Hispanic/Latino ^ lapanese ^ Other Pacific Islander
^ Doctorate (e.g. PhD, EdD) or Professional degree (Specify) ^ Other (Specify)
e.. MD, DDS, DVM, LLB, 1D
21. Decedent's Single Race Self-0eslgna[ion -Check ONLY ONE to indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation -Indicate type of work
White ^ Japanese ^ Samoan done during most of working life. DO NOT USE RETIRED.
^ Black or African American ^ Korean ^ Other Pacific Islander SF~
^ American Indian or Alaska Native ^ Vietnamese ^ Don't Know/Not Sure
^ Asian Indian ^ Other Asian ^ Refused 22b. Kind of Business/Industry
^ Chinese ^ Native Hawaiian ^ Other (Specify)
^ Flllplnp ^ Guamanian or Chamorro U.S Army
ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced Dead (Mo/Day/Yr) 23b. Signature of Person Pronouncing Death (Only when applicable) 23c. License Number
BY PERSON WHO PRONOUNCES OR
CERTIFIES DEATH
June 9, 2012
23d. Date Signed (MO/Day/Vr) 24. Time of Death
A rox. 5:00 A.M. 26 Was Medical Examiner or Coroner Con[acted? Ves ^ No
CAUSE OF DEATH Approximate
26. Part I. Enter [he chain of events-diseases, injuries, or complications--that directly caused the death 00 NOT enter terminal events such as cardiac arrest Interval.
respiratory arrest, or ventricular fibrillation without showing the etiology DO NOT ABBREVIATE. Enter only one cause on a line Add additional lines if necessary Onset to Death
IMMEDIATE CAUSE > a. HypertenS lV2 Cardiovascular Disease ____ __
IFinal disease or condition Due to (or as a consequence of)
resulting in death)
b. __
Sequentially list conditions, Due to (or as a consequence of):
i(any, leading to the cause
listed on line a. Enter the c.
UNDERLYING CAUSE Due to (or as a consequence of):
v, (disease or Injury that
initiated the events resulting d.
~
u in death) LAST. Due to (or as a consequence of).
~ 26. Part II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in Pan I 27. Was an autopsy pertormed7
0
^Ves No
~ Hyper 1 ip idemia 28. Were autopsy findings available
[o complete the cause of death?
^ Yes ^ No
u 29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death
E ^ Not pregnant within past year ^Ves ^ Probably ~ Natural ^ Homicide
u° ^ Pregnant at time of death ^ No ^Unknown Accident ^ Pending Investigation
^ Not pregnant, but pregnant within 42 days of death ^ Suicide ^ Could not be determined
^ No[ pregnant, but pregnant 43 days to 1 year before death 32. Dale 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; schools 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:
^ Ves ^ Driver/Operator ^ Pedestrian
^ No ^ Passenger ^ 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 & Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the causes) and manner stated
Medical Examiner/Coroner - asis exam tlon, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated
Signature of Certifier'. Title o(certifler: ACtinQ Coroner License Number.
39b. Name, Address and Zip Code of Person Completing Cause of Death (Item 26) 6375 Basehore Road, Suite 1 39c. Date Signed IMO/Day/Yr)
Matthew S. Stoner, Acting Coroner Mechanicsbur PA 17050 June 12 2012
40. Registrar's Dist
rict Number 41. Re
gi
st
r)r's I nature 42
.
Registrar File
Date (MO Day/Vr)
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43. Amendments
0693682 Hlos-143
Disposition Permit No. REV 07/201]
LAST WILL AND TESTAMENT
OF
ANTHONY L. PERRY
I, ANTHONY L. PERRY, of 1219 Cross Creek Drive, Mechanicsburg, Cumberland County,
Pennsylvania 17050, being of sound and disposing mind, memory and understanding, do hereby
make, publish and declare the following as and for my Last Will and Testament, hereby revoking
and making void any and all Wills and Codicils by me at any time heretofore made.
FIRST: I direct that all my just debts and funeral expenses be fully paid as soon after my
demise as maybe found convenient.
SECOND: I give, devise and bequeath all of the rest, residue and remainder of my estate,
whether real, personal or mixed, of whatsoever nature or kind and wheresoever situate, to my
beloved wife, MARY L. PERRY, absolutely and in fee simple.
THIRD: Should my wife, MARY L. PERRY, predecease me, fail to survive me for a period
of thirty (30) days, or should we die simultaneously, Ihereby specifically give, devise and bequeath
the contents of my home and my wife's jewelry to my stepdaughter, VONDA L. RUPPERT.
FOURTH: Should my wife, MARY L. PERRY predecease me, fail to survive me for a
period of thirty (30) days, or should we die simultaneously, Ihereby give, devise and bequeath all
of the rest, residue and remainder of my estate, whether real, personal or mixed, of whatsoever nature
or kind and wheresoever situate, to my stepchildren, DINO R. RUPPERT, VONDA L. RUPPERT
and DEBRA L. ADLER, to be divided among them, in equal shares, per stirpes.
,~
Page 1 of 3 Pages
FIFTH: It is my specific intention to exclude my son, LEE C. PERRY, from any bequest or
share to which he may otherwise be entitled from my estate for reasons of which he is aware.
SIXTH: I herebynominate, constitute and appoint my wife, MARY L. PERRY, as Executrix
of this, my Last Will and Testament. In the event that my wife, MARY L. PERRY, should
predecease me or for any reason does not act or ceases to act as such Executrix, I hereby nominate,
constitute and appoint MICHAEL B. SWOPE as alternate Executor of this, my Last Will and
Testament. My said Executrix/Executor shall have full power to do any and all things necessary for
the complete administration of my Estate, including the power to sell, at public or private sale and
without order of Court, and without the necessity of filing a bond, any real or personal property
(except as otherwise provided herein) belonging tome, and to compound, compromise or otherwise
to settle and adjust any and all claims against or in favor of my estate, as fully as I could do if living.
My Executrix/Executor shall have the right, but not the obligation, to distribute property in kind at
then current values and on a non-pro rata basis.
SEVENTH: I hereby direct my Executrix/Executor to appoint Donald B. Swope, Esquire,
as attorney for my estate in the event his services are available.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and
Testament, this'~p`'' day of Ns~e~n.~r 2006.
r
~ SEAL
NTHONY L. ~, RRY f
This instrument, with each page bearing the signature of the above-named Testator, was by
him on the date hereof signed, sealed, published and declared by him to be his Last Will and
Testament, at his request and in his presence and in the presence of each other, have hereunto
subscribed our names as witnesses.
residing at 425 Bank Hill Road, Wrightsville, PA 17368
..~...~_ ~- residing at 330 Popps Ford Road, York Haven, PA 17370
Page 2 of 3 Pages
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF YORK
. SS:
We, ANTHONY L. PERRY, Donald B. Swope and Michele M. Duncan, the Testator and
the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being
first duly affirmed, do hereby declare to the undersigned authority that the Testator signed and
executed the instrument as his Last Will and Testament and that he had signed the instrument
willingly, and that he executed it as his free and voluntary act for the purposes therein expressed, and
that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witnesses
and that to the best of our knowledge, the Testator was at the time eighteen (18) years of age or older,
of sound mind, and under no constraint or undue influence.
~.-y
A THO L. P Y, Testator
Witness
~~ ~ ~„`
.~ ~1~ ~~
Witness
Subscribed, affirmed to and
acknowledged before me by
the aforesaid Testator and
witnesses respectively, the
~0`'' day of ~r~ 2006.
~'~- 2~
Notary Public
COMMONWEALTH OF PENNSYLVANIA
My Commission Expires: No ~~~-,~~IA? SEAL
SHARON L. SWOPS. NC7TARY PUBLIC
HALLAM BOROUGH, YORK COUNTY
MY COMMISSION EXPIRES Q~CEMBER 19, 2010
Page 3 of 3 Pages
#~ pennsylvan~a
DEPARTMENT OF PUBLIC WELFARE
September 4, 2012
SWOPS AND SIPS
DONALD B SWOPS ESQUIRE
50 MARKET ST
HELLAM PA 17406
Re: Anthony Perry
SSN: ###-##-3851
Dear Attorney Swope:
Pursuant to your letter dated August 28, 2012, the Department's, Estate Recovery
Program, has reviewed the information you provided regarding the above-referenced
individual.
It has been determined that this individual did not receive any type of assistance
during the questioned period.
Therefore, according to the information you provided, the Department's Estate
Recovery Program will not seek any recovery from this estate. If your client applied for
Medical Assistance and had an application and/or hearing pending at the time of death,
please advise us and provide any additional information that may affect a recovery by our
Department.
Thank you for your cooperation in this matter. If you have any questions, please
contact me.
Sincerely
~~ ~ ~~
Vince A. Porter
Recovery Section Manager
(717)772-6604
Bureau of Program Integrity ~ Division of Third Party Liability (Recovery Section
PO Box 8486 (Harrisburg, Pennsylvania 17105-8486
IMPORTANT NOTICE
NOTICE OF ESTATE ADMINISTRATION
THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE
ANY MONEY OR PROPERTY FROM THIS ESTATE OF OTHERWISE
BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND, PENNSYLVANIA
In Re: Anthony L. Perry, deceased
No.
To: Fulton Bank
Cardmember Service
P.O. BOX 6335
Fargo, ND 58125-6335
Please take notice of the death of decedent and to the proposed actions described below:
The decedent, Anthony L. Perry, died on the 9th day of June, 2012, at Mechanicsburg,
Pennsylvania.
The decedent died testate (with Will).
The persons seeking an order from the court are:
Mary L. Perry; 1219 Cross Creek Drive, Mechanicsburg, PA 1.7050
A petition for the settlement of small estate was filed on or about September 18, 2012, and will
be audited on November 27, 2012, in the Court of Common Pleas, Orphans' Court Division,
Cumberland County Court House, One Courthouse Square, Courtroom 1, Carlisle, Pennsylvania
at 9:30 a.m.
If you have any objections to the relief requested you should file them in writing with the
Register of Wills before the hearing or you may appear in person to voice any objections.
-___
Date: n/J~~~~
Donald B. Swope, Esquire
50 E. Market St., Hellam, PA 17406
717-840-0110
Counsel Representative
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT' DIVISION
IN RE: No.
ESTATE OF
ANTHONY L. PERRY
CERTIFICATE OF SERVICE
I, Donald B. Swope, Esquire, attorney for the Estate of Anthony L. Perry do hereby
certify that on this date I served the Notice of Estate Administration to the following by
depositing same in the United States mail, postage prepaid, addressed to:
AT&T Mobility
P.O. Box 537104
Atlanta, GA 3 03 5 3 - 7104
Fulton Bank
Cardmember Service
P.O. Box 6335
Fargo, ND 58125-6335
DATED: /~
Kohl's
P.O. Box 3043
Milwaukee, WI 53201-3043
Members 1st Federal Credit Union
5000 Louise Drive
P.O. Box 40
Mechanicsburg, PA 17055
--- -~-,_
,- =!-= -
onald B. Swope, Esquire - -
Attorney for the Estate of Anthony L. Perry
Supreme Court I. D. 01625
50 East Market Street
Hellam, PA 17406
(717) 840-0110