HomeMy WebLinkAbout09-27-12PETITION FOR GR-~~IT OF LETTERS
REGISTER OF WILLS OF ~ ~,~ ~~~ V ~~~~~~~l~~t~~~ COIJtiTY. PE~1~1S~~LV aNI~
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Decedent's Information
Name: n11C~ ( l
a~'k,'a:
dilv'a:
a/k/a:
Date of Death:
Decedent was domiciled at death in ~U/K C
principal residence at ~ ~C Q 1JQ
Street address, Office and Zi//p Code
Decedent died at ~1 ~,tle_t'4 d~~~ L~lktUe ~
File No: !'~~ ~ - , '~ ~ft' ~ ~.
(Assigned by Register)
Social Security No: " ~ ` 0~.3~
Age at death:
(State) with
,Township/or Bora/ugh ' County
~1I c.5l,~u~t ~nI be~vd, /°~
Street address, Pos~tOffice and Zip Code City, Township or Borough
Estimate of value of decedent's property at death:
If don:ieiled in Pennsylvania ................... .
/f not domiciled in Pennsylvania ............... .
If not domiciled in Pennsylvania ............... .
Value ojreal estate in Pennsylvania.....C. -. ,.,.,... .
Real estate in Pennsylvania situated at: (~(~ f 1
...... All personal property
...... Personal property in Pennsylvania
:::::: Personal property in County
TOTAL ESTIM/~ATED VALUE
PtJ ~.g1tK' ~t'yIQNCCSIDv tS
County ~ State
$ ~a~a
S
~ ems- • D oa0 ~
$ ~' too "
~ ~7QSCJT ~r~m fG~r/
(Attach additional sheets, i~necessary.) Street address, Phut 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 __~' ~ ' a(~('j ,~, and Codicil(s)
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
ad ted; 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., pendertte lite, durunte absentia, durunte minor•itute
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
additional sheets, if necessary):
ra.a ___ ~.-??
(ifany) it~~heirs ~ti7W~~
.'c.
Name Relationshi Addres~~- - <
U` ~ __- -
.~ `.~ ,
For-n, aw-n~ ,-~~. lnittiznll Page 1 of 2
Oath of Personal Representative
CO~I~[O~SVE.~LTH OF PE~'NSY"LV,~VL~ }
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orfc~~l ~~~ only
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The Petitioner(s) above-named swear(s) or affirm(s) the statements in the fore oing Petition are tn:e and correct to the best of the knowledge and belief
of Petitioner(s) and that, as Personal Representative(s) of th e edent, he titione ) well ai d ruly administer the estate according to law.
Sworn tQ ~r ff;rmed ay~d subscribed be ore Date ~a -~~o~
me tlai rr'd~Y of ; ; : ~ ,.
~ ~ Date
Bx ~ --~ l , ~ _ ~ ~~"f Date
Fa• the Resister ~- ~ Date
BOND Required:^YES
FEES:
Letters ......................
( ~j ) Sltort Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Boiid ........................
I..L'.
Commission ................. .
Other
x'11 ~ 1 ....... 1 ~ 1
Cl(-~
Automation Fee .............. .
JCS Fee . ................... .
TOTAL .....................
r. (^L-
To the Register of Wills:
Please enter my appearance by my signature below:
Attorney Signature:
~
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Printed Name: ~~ r'*7
Supreme Court ~~b
ID Number: ~~ ~" ~ '
-
Firm Name: ` S° '~ .
Address: ~~ - -=: ~-
-p .. r- .
Phone:
Fax:
Email:
DECREE OF THE REGISTER
Estate of
a/k/a:
File No: ~' ~ ~ ~~ - o` ~ ~ ,~ ' ,
~r~ ' ~
AND NOW, ~~~,~ ~ `' °~;~-~, -f ~ ~ / ~~~ ~ ,~ y~ , -_, in consideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters ~ S ~ ~ ' r'~r~j j
are hereby granted to UR V i C1 J~ /~i1~C~-~ 1 ~C ( ( J
in the above estate and (if applicable) that
the instrument(s) dated j t ~- / ~ -~~[''(',~<
described in the Petition be admitted to probate and filed of record as the last Will (and Codi~,~il(s~) of Decedent.
l !
Register of Will ~' ~ j ~^:
Fni~m R 6V-OZ r ~ i ~~ ~
w. tni~r.znii Page 2 0 2
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COMMONWEALTH OF PENNSYLVANIA • pEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
I. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sev 3. Social Security Number 4. Date of Death jMo/Day/vrl (Spell Mol
Angelo A. Antonicelli Male 717-12-2387 September 22, 2012
Sa. Age~Last Birthday jVrsl 56. Under l Year Sc. Under 1 Da 6. Dale of Birth jMo/D ay/Year) jSpell Month) )a. Birthplace )City and State or forei Country)
§
Months Days Hpp.a Minutes 1
t
b
22
20 ezu3sylvanla
West Fairview, >
92 Sep
em
er
,
9 ]b. Birthplace lcWntvl C12mber aRd
Ba. Residence j5tate or Foreign Coun[ryl Bb. Residence j6treet and Number - Inclutle Apt No.) 8c. Did Decedent Live in a Township?
Pennsylvania 5 ~~~~ Lane fret, ae[eeent Iiyee Ir. Silver . inq twp
Bd. Residence jCOUnty)
Clmlberland Be Residence j21p Code) 17QSQ ^Nn, decedent Itvetl within limits of ____ city/boro.
9. Ever In US Armed Forces? 10. Marital Status at lime of DeaM ^ Married ~ Widowed 11. Surviving Spouse's Name if wife, give name prior to Rrit m gel
~] Vez ^ No ^ Unknown ^ Dworcetl ^ Never Married ^ Unknown
12. Father s Name (First, Middle, last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, LasU
Orazio Antonicelli Annie Girardi
14a. Informant's Name 1db. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number city, State, 21p Code 1 7QSQ
David A. Antonicelli Son 5805 Ste hens Crossin Mechanicsbur PA
lsa. v ace o peat check Holy one
...... ........_.....
VP..
If Death Occurred in a Hospital'. ll Inpatient If Death Occurred Somewhere Other Than a Hospital: Hospice Facility Decedent's Home
^ Emergency Room/Outpatient ^ Dead on Arrival
~ ^ Nursing Nome/LOng~Term Care facility ^ Other jSpeclfyl
156. Facility Name III no[ institution, give street and number; lsc. CI[y or Town, State, and Zip Cotle SSd. County of peach
5 Evergreen Lane Mechanicsbur , PA 17050 (12mberlarul
16a. Method of pisppsition Burial ^ Cremation 16b. Date of Dlzpositton 16c. Place or Oliposi[ion (Name of cemetery, crematory, or other place)
^Rempyal npm state ^Dpnanpn pt. 28, 201 Gate of Heaven Cemetery
^ omer fsvecirvl
164. Loco ion of Disposition (City or Town, Stale, antl Zlpl I?a. Signa[u u era) Servic L' or Person In Charge of Interment
p 1?b. License Number
Mechanicsburg, PA 17055 ~~
~ FD-138630
12c. Name and Complete Address o(Fun<ral Facility
Mal zzi Funeral Home 8 Market laza Wa icsbur PA 17055
10. Decetlent's Educa[ion-Check the box tha[best describes [h< 19, Decedent of Hispanic Origin-Check the 20. Detttlent's Race-Check ONE OR MORE races to indicate what
highest degree pr level of school completetl at [he time of deaM. box that best tlescribes whether the decedent he decedent consideretl hlmselt or herself to be.
8th grade or less Is Spanish/Hispanic/Latino. Check [he'NO' (g White ^ Korean
No tllploma, 9th ~ 12th grade box if decedent Is not Spanish/Hlspa jc/Latino. ^ Black or African American ^ Vietnamese
High school graduate or GED completed No, not Spanish/Hispanlc/Latlno ^ American Indian or Alaska Na[Ne ^ Other Asian
~ Some college credit, but no degree ^ Yes, Mexican, Mexican American, Chicano ^ Asian Indian ~ Na[IVe Hawallan
Associate degree je.g. AA, AS) ^ Yes, Puerto Rican ^ Chinese ^ Guamanian or Chamor•o
Bachelor's degree je.g. BA, AB, BS) ^ Ves, Cuban ^ fllipino ^ Samoan
Master's degree je.g. MA, M5, MEng, MEd, MSW, MBA( ^ Yes, other Spanish/Hispanic/Latino ^ lapanese ^ Other Pacific Islander
^ Doctorate je.g. Ph D, EtlDl or Professional degree (Specify) __ ^ Other jSpeclly)
.. MD, DDS DVM, LLB, )D
21. Decedent's Single Race Self-Designatipn -Check ONIY ONE [o Indicate what the tleceden[ considered hlmselt or herself [p be. 22a. Decetlent's Usual Occupation ~ Indicate type o/work
g] White ^ Japanese ^ Samoan done during most pf working life. p0 NOT USE RETIRED.
~ Black or African American ^ Korean ^ Other Pacific Islander
In
h
t
/W
se
^American lndlanpr Alaska Native ^Vietnamese ^DOn'I Know/NOt SUre spec
or
are
ou
man
Asian Indian ^ Other Asian ^ Relused 22b. Kind of Business/Industry
^ chmeae ^ Natve Hawallan ^ ome. jspeCiryl Naval Depot
^filipino ^Guamanian or Chamorro
REM523a - 33d MUST BE COMPLETED 23a. Date pronounced Dead jMo Day/Yrl 236. Signature of Person Pronouncing Death jOnIY when applicable) 23c. License Number
BY PERSON WNO PRONOUNCES OR
CERTIFIES DEATH S tP106er 22 2Q12
p y
23tl pate Signed jMo/Day/Yr) 24. Time 0/Death
11 ; 58 AM 25 Was Medical Examiner pr Coroner Contacted? ^ Yes $) No
CAUSE OF DEATH Approximate
26. Part I. Enter the chain of events-diseases, injuries, or complications-that directly caused the tleath. DO NOi enter terminal events such as cardiac arrest Intervar
respiratory arrest, o ventrkular fibrillation without showing the etiology. DO NOT ABBREVIATE Enter only one cause on a line. Add addlnonal lines if necessary Onset to Death
r
/~
IMMEDIATE CAUSE --- ~Ci /•-~)~Cl-C ~'~C r /~• J'T(t ~-~ ~ __._._
.-......> a '
IFi al dise ondltlon due to (or as a consequen oil
s
resultrn8 in
death)
h
. _ ________ ____
Sequentially list [ondltlpns, Due to jpr as a [onsepuence oft.
it any, leading to the cause
listed on line a Enter the c. __ _ ~ _ _ __ _ _
UNOERLVING CAUSE Due to jar as a consepuence oft
lei:ease pr inp,rv that
ted the eyena resulting e _ __
~n aeaal tasT. Die to for as a mn:egoenae ofF
26. Part 11. Enter others 0.nifca onditi tribal rig to death but not resulting in the underlying cause given in Part I 2). Was an autopsy pert rmedi
^ Yes ~No
28. Were autopsy findings available
[o omplete the cause of death?
c
^ Yes No
29. If Female: 30. Did Toba[[p Use Contribute [D Death? 33. Manner of Death
Not pregnant within past year ^ Yes ^ probably ~Na[ural ~ Homicide
~ Pregnant t time of death ^ No f7 Unknown Accident ^ Pending Investigation
~ Not pregnant, but pregnant within 42 tlaYS of death 71 ~ Suicide ~ Could not be determined
Not pregnant, but pregnant 43 tlays to 1 year before death 32. Date of Inlury IMp/Day/Vr) jSpell Month)
Unknown'rf pregnan[wi[hin the past year 33. lime of Injury
34. Place of Inlury je.g. home; construttion site; farm; school) 35. Location of Inlury (Street antl Number, City, State, Zlp Codel
36. Inlury at Worts 37. 11 Transportation Injury, Specify: 38. Describe How Inlury Occurred:
re ^ Drwer/opaaror ^ Pedeslaan
~ No ^ Passenger ^ Other j5peciNl
39a. Certifier (Check only oriel.
^ Certifying physician - fa [he best of my knowledge, death occurretl due to the causejsl and manner stated
^ Pronouncing & Certifying physician - To the best of my knowledge, tleath occurretl at the time, date, and place, and due to the causejsl and manner stated
man a states
r
d
n
^ Medical Examiner/Coroner ~ s Df and/or investigation, In my opinion, death occurred at [he [Ime, date, antl place, and due to the causelsl an
(-
f
te
c
~Jv100^ a U
~ ~~
Ucense Number.
Signature of certlller. - Title of certifier.
39b Name, Adtlress and Zlp Code of Person Compl In I D ath jltem 26) 39c. Dale Signed jMo/Day/Yr)
Seffrey Matzoni 6 Market Plaza Way, Mechanicsburg, PA 17055 September 25, 2012
4o. Registrar's Distrkt Number 41. gl ignM
r 4Z Regl tray File Date jMo/Day r)
a I .. ~ I~ ~ t,
~ .~' e,ryh'c.t' ~yb" avJl~
43 Amendments
Dlspasltion Permit NO 069378_
H 105-143
REV OI/ZOl l
WILL OF
ANGELO A. ANTONICELLI
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I, Angelo A. Antonicelli, of Cumberland County,
M hanicsburg, Pennsylvania, declare this to be my last Will and
~~by revoke all prior wills and codicils.
_Jo
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n r~ 1. I direct that all my just debts and funeral expenses,
,. ~ve marker and administrative expenses shall be paid from my
~iduary estate as soon as practicable after my death.
~~
2. I direct that all inheritance, estate, transfer,
succession and death taxes of any kind whatsoever which may be
payable by reason of my death shall be paid out of my residuary estate.
3. I direct that my estate be distributed as follows:
A. I leave everything to Helen L. Antonicelli.
Should she predecease me, I direct my entire
estate be divided in equal shares and
distributed to my children David A. Antonicelli,
Stephen M. Antonicelli, Debra A. Hershey, ! a.; ~.v-;.
Brian A. Antonicelli, and Matthew E. Antonicelli.
Should any predecease me, their share shall
lapse and be given to the estate of the
deceased child.
4. I appoint Helen L. Antonicelli as Executrix. If she
should predecease me or cease to act in such capacity, I appoint David
A. Antonicelli as alternate.
5. The Executrix of this Will shall have the power to
distribute my estate in kind or in cash, or partly in either.
6. I direct that no Executor acting under this Will shall
be required to enter bond in any jurisdiction.
IN WITNESS WHEREOF, I, Angelo P~. Antonicelli, have
hereunto set my hand this day of ,
2002.
LAW OFFICES OF
STEPHEN J. HOGG ~O~-G4 - .~. ~ ~~. t r,~~-z~~~s ~ ~ t .
19 S. HANOVER STREET AN O A. ANTONICELLI
SUITE 101
CARLISLE. PA 17013
The preceding instrument consisting of this and one other page was
on the day and date hereof signed, published and declared by Angelo A.
Antonicelli as and for his last Will in the presence of us, who at his request,
in his presence and in the presence of each other have subscribed our
names as witnesses hereto.
LAW OFFICES OF
STEPHEN J. HOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
~`~ :~ l~L
Witness
~-
Wit es Ji
ACKNOWLEDGEMENT
LAW OFFICES OF
STEPHEN J. HOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
Commonwealth of Pennsylvania
County of Cumberland
ss
I, Angelo A. Antonicelli, the testator, 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 willingly and as my free and voluntary act for the purposes therein
expressed.
~~~ ~ ~~ ~. ~~~ ~: z«E L -~c
AN LO A. ANTONICELLI
Sworn to or affir , d and ackno~rledged before me by Angelo A. Antonicelli
the testator, this <~S day of ~ T ; ~ ' ,,. , 2002.
,~`
°.. ~~ ~ sue`'
`Notary Public/A
AFFIDAVIT
Commonwealth of Pennsylvania
County of Cumberland
ss
We,~_ISi~. ~, ~ 1~~~=~ and ~~`~~a~"`~ I~ . G~L~Qr"~>~/, 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 the
testator sign and execute the instrument as his last Will; that the testator signed
willingly and executed it as his free and voluntary act for the purposes therein
expressed; that each subscribing witness in the hearing and sight of the testator
signed the Will as a witness; and that to the best of our knowledge the testator
was at the time 18 or more years of age, of sound mind and under no constraint
or undue influence. (/rl
~ i .
Sworn to or aff ed and subscribed to before me by witnesses, this ! }~
day of ~' ~ , 2002. ,,,.! ~,
`~
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Notary Public/A r