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HomeMy WebLinkAbout10-16-12Reset PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF ~`' 1^''i ~~~=~ ~'~`~'~ 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: .~~. C ~ ~ ~y ~ --~ ~"v ~.~ a/k/a: a/k/a: Date of Death: ~ . ~ 2 - / ~ File No: ~Q~ ~ ~ ~ p~° I ~ ~~~ (Assigned by Register) Social Security No: .~ 1 ~ z,G~ ~ ~~~ Age at death: Decedent was domiciled at death in C ~= -'1~++~~'~ ~ ~ ^'~ County, ~~ ~ (state) with his/~~last principal residence at 2 ~ , ~, t .~'T ~-~~~ Cv~ C~1 ~-/J C v~~vr~e,Q ~ t~,,~~ Street address, Post Office and Zip Code City, Township o orou County ,~ s.~ _ . '~ ...Decedent died at .~ !~ ,~ ~/. 2 ~ S i ~ c~ ~'tt© ~~~ !' ~~// C'y,~i~tZ/G.~-~t~ 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 $ ~-s ~ ~~~ ` ~~ 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... r. $ ICJ 0.00 Real estate in Pennsylvania situated at: 1 ~. ~ ~ ` ~ ~ ~` ~~ ~'~ ~y C ~~ °~ B~'t~ ~a~r /> - Cis /Lt t~f~ ~C~ ~~ (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 ~~~' / ~ ~ `' ~ Z"and Codicil(s) thereto dated !'~ State relevant circumstances (eg. 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 ado ted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. NO EXCEPTIONS o 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 a~b.n.c.i:a., enter date of Will in Section A above and complete list of heirs. ~ f;Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined " m 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 spo~~e~if any) and rs (attach -..t.~ additional sheets, if necessary): ~ -~ ~ rn ~_'~ '~ -- --, Name Relationshi ~r~ ~~_; - --i ~~ :~: Address ~-- ~__, ;- ~_,, Cn C~ ~-. ; . . _~ J _' • • t"` ~~ Form RW-02 rev. 10/11/2011 R ~. j' .'/~, "'t+"~ Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } COUNTY OF ~~ tit 4~ e~2 ~~ ~ /~ } t~ ~~~J (att~,Only r..~ ~~ ~~~; ~_ ~~ t {~,- ~~_. ~ C:7 ; ._., - -~ ~i Petitioner(s) Printed Name Petitioner(s) Printed Address ~ = -, ;. ~- n ~,.- ,~: S ~~ ,~ T .~ ~l 3 ~ ~,Q s~ L ~ N /. t~: f~s~ ~~ y -s ~~n / The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petit' n 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 'll well and truly administer the estate according to law. Sworn to or affirmed and subscribed before Date LEA `~ 1~l Z me is da of ~ ~~~ ~ ~ ~~ Date B Date Far the Register Date BOND Required: Q YES ~NO ~ FEES: ~r~ . L~f~ Letters ...................... $ ( ~) Short Certificate(s)...... G~ • ~ `~ ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Oth r ....... ~' Automation Fee ............... ~ " `'`' JCS Fee . ................... . TOTAL ..................... $ --~:~@6' To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature: ,~ Printed Name: Supreme Court ID Number: Firm Name: Address: Phone: Fax: Email: ~~~ o DECREE OF THE REGISTER Estate of ~ ~ ~ ~ /~ ~ ~ File No: ~ ~ ~ 1 ~~ ! ~ ~J a/k/a: /I /~ Q / r', v ~ ~ l~~l /~ AND NOW, ~ J D ~ ~'./' /lam , ~~ ~ ~, in consideration of the f regoing Petition, satisfactory proof having been presented before me, IT IS EC ED that Let ers ,l~,51~C1I"7`)~ ~~/~~ are hereby granted to y1 t ~n , ~ • Gl /' ,, in the abave es~ate and (if applicable) that the instrument(s) dated ~ ~ ~~ described in the Petition be admitted to probate and filed of record ~s the last Will`(and Codicil(sl) of I~'~cedent. ~ Register of Wills Form RW-02 rev. 10/11/2011 f ~ `JPage 2 f~ .~~ ,.,.~. 1 ~T.r., ~`; f =r= -, ,_- ~~ ~::'; ,_ i '` ~c~rvt .,....~ i ~rl ~ ~ .r, . i._ Vii- / ~.- %!1~~~ i ~ ,~ _.L.. 7 l~:' 1(ii ~ial~ eij~i~ll:itd~, ~>4) (}(: Type/Print In Permanent Black Ink 1. Decedent's Legal Name (First, Mid Jacquelyn Stuart Sa. Age-Last Birthday (Yrs) Sb. Undo Month 88 8a. Residence (State or Foreign Coun Pennsvlvania ~'~'Z ~c;T f 6 P~ L~ a~ Viii ~f°1{ ~) ..,;.,t~. ~', ~ 1 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH VITAL RECORDS CERTIFICATE OF DEATH State File Number: Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Yr) (Spell Mo) Female ne 28 2 12 L Year Sc. Under 1 Da 6. Date of Birth (MO/Day/Vear) (Spell Month) 7a. Birthplace (City and State or Foreign Country) Days Hours Minutes Bushne 11 I11 ino s September 24, 1923 7b. Birthplace (county) Sb. Residence (Street and Number -Include Apt No.) 8c. Did Decedent Live in a Township? 129 East 16th Street OYes, decedent lived in t`^ip. 8e. Residence (Zip Code) 7 Q ®No, decedent lived within limits of N c- C` h l A city/boro. 9. Ever in US Armed Forces? 1D. Marital Status at Time of Death ~ Married ~ Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) ~ Yes ® No ~ Unknown ® Divorced ~ Never Married ~ Unknown ~ 12. Father's Name (First, Middle, Last, Suffix) Justin P. Stuart 14a. Informant's Name 14b. Relationship to Decedent Anthon Stuart Son 13. Mother's Name Prior to First Marriage (First, Middle, Last) Ma C v 14c. Informant's Mailing Address (S[reet and Number, City, State, Zip Code) G . ................ ......................................... ........................................... t~+. atient e I i l ..................................... .. 15a : P ace o Death C ec on one .............................. ...----.............-----....---~ ....... ..................................-..Y....... lf Death Occurred Somewhere Other Than a Hospital: ~ Hospice Facility [~ Decedent's Home oc ° np ta : IJ If Death Occurred in a Hosp Q Emergency Room/Outpatient ~ Dead on Arrival • ~ Nursing Home/Long-Term Care Facility Other (Specify) 15 b. Facility Name (If not Institution, give stroet and number; 15c. City or Town, Stata, and Zip Code SSd. County of Death LL Select S e Cam Hill PA 17011 Cumberland i~ 16a. Method of Disposition ~ Burial ~ Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) v Q RemovalfromState Q Donation 7/3/2012 Cremation Society of Pennsylvania c ~ Other (Specify) 16d. Location of Disposition (City or Town, State, and Zip) 17a. Signa a of~neral Serv' icen a or_Person in Charge of Interment 17 b. License Num er a Harrisburg, Pennsylvania, 17109 ~- 1 ~ 17c. Name and Complete Address of Funeral Facility v Auer Cremation Servi es P in - check the 20. Decedent's Race -Check ONE OR MORE races to indicate what anic Ori f His d t m g o p en 18. Decedent's Education -Check the box that best describes the 19. Dece ibes whether the decedent the decedent considered himself or herself to be. d h b ~ escr est at highest degree or level of school completed at the time of death. box t k the "No" ~ White ~ Korean i Ch L no. ec at Q 8th grade or less is Spanish/Hispanic/ Q Black or African American ~ Vietnamese ic/Latino h/Hi i . span s ~ No diploma, 9th - 12th grade box if decedent is not Span anic/Latino 0 American Indian or Alaska Native 0 Other Asian h/Hi i S sp pan s ~ High school graduate or GED completed ~ No, not Chicano Q Asian Indian Q Native Hawaiian Mexican American i M , can, ex Some college credit, but no degree ~ Yes, tan or Chamorro rto Rican ~ Chinese O P O Y ue es, 0 Associate degree (e.g. AA, AS) Samoan ban Q Filipino ~ C Y u es, Q Bachelor's degree (e.g. BA, AB, BS) Q anish/Hispanic/Latino Q Japanese ~ Other Pacific Islander other S ~ Ves p , ~ Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Doctorate (e.g. PhD, EdD) or Professional degree (Specify) ~ Other (Specify) (e. MD DDS, DVM, LLB, JD LY ONE to indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation -Indicate type of wor k O N 21. Decedent's Single Race Self-Designation -Chec done during most of working life. DO NOT USE RETIRED. White ~ Japanese Q Samoan fi I l d er s an c Q Black or African American ~ Korean ~ Other Paci S Stems Anal St ' p t Know/Not Sure ~ American Indian or Alaska Native Q Vietnamese ~ Don 22b. Kind of Business/Industry ~ Asian Indian ~ Other Asian ~ Refused 0 Chinese ~ Native Hawaiian ~ Other (Specify) Federal Government ~ Filipino Q Guamanian or Chamorro Licens licable) 23c n a h l h O . pp y w e n ( ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronou ced Dead (MO/Day/Yr) 2 .Sig lure of Person pronouncing Deat ~~ jyrJ BY PERSON WNO PRONOUNCES OR ~~~~~~~ /I ~ 1()// ~ CERTIFIES DEATH e/ 'l, ~~d Date Signed (MO/Day/Yr) 24. Time of De th r- O N w F v m' E v° °~ 0 ~~~~ 7 ~ as Medical Exa finer or Coroner Co tatted? Ves o 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`/e~tio~logy. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary Onset to Death IMMEDIATE CAUSE ---------------> a. ~~"~ f~- ~`~ ~" ~ Ri ~~~~ i (Final disease or condition Due to (or as a consequence of): resulting in death) b. Sequentially list conditions, Due to (or as a consequence of): if any, leading to Che cause listed on line a. Enter the c. UNDERLYING CAUSE - Due to (or as a consequence of): (disease or injury that initiated the events resulting d. in death) LAST. Due to (or as a consequence of): 26. Part 11. Enter other significa nt conditions contrlbutina to death but not resulting in the underlying cause given in Part I 27. Was an autopsy performed? Yes No 26. Were autopsy findings available io complete the cause of death? I--1 vet ~ No If Female: Not pregnant within past year Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death ~ Not pregnant, but pregnant 43 days to 1 year before death ~ Unknown if pregnant within the past year Place of Injury (e.g. home; construction site; farm; school) 30. Did Tobacco Use Contribute to Deatn ~ Ves Q Probably Q No Unknown 32. Date of Injury (Mo/Day/Yr) (Spell Mo of Injury (Street and Num .l. Manner or ueacn ..Natural ~ Homicide ~ Accident Q Pending Investigation ~ Suicide Q Could not be determined P i. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How In)ury Occurreq: ~ Yes ~ Driver/Operator Q Pedestrian 0 No ~ Passenger ~ Other (Specify) ia. Certifier (Check only one): 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 Q Medical Examiner/coroner <Qryt~pasi ination, and/or investigation, in my opinion, death occur/re~d at the time, date, and place, and due to the cause(s) and manner stated ~~VV ~~ Q. Title of certifier: :~ /J License Number:'~>n L'7 -3 S ~ y ~? -~- Signature of certifier: d Ib. Name, Address and Zip Code of Person Completing Cause of Death (Item 26) 39c. Date Signed (MO(Day/Yr) - o~.~.;.~.a- ?r 3 ~ . 7>r-, - -~ ~. ~ ~ i7~r ~ G -z~--tom ). Registrar's District Number 41. Registrar's Signature 42. Registrar File Date (Mo Day Yr) `~~ H105-143 Disposition Permit No. O L , REV 07/2011 LAST WILL AND TESTIMENT FOR JACQUELYN STUART, BORN ON 09/24/ 1923 IN BUSHNELL ILLINOIS, USA. LAST RESIDING AT 129 EAST 16TH STREET NEW CUMBERLAND , PA . 1707t~ BEING OF SOUND MIND AND D~'ING BODY I HEREBY BEQUEATH ALL MY WORLDLY ASSETS, BOTH SOLELEY AND JOINTLY O~-~NED TO MY ONLY NEXT OF KIN, MY ONLY CHILD , ANTHONY A STUART BORN ON 10/03/1959 , SSN 17854301 1, RESIDING CUR:RENTLTY AT 293 DORSEY LANE DILLSBURG, PA , 17019 IN ADDITION, I RE -CONFIRM PO~'JER OF ATTORNEY PAPERS TRAY I SIGNED A FEW DAYS AGO. LAS TLY I REQUE S T MY SON CREMATE ME AND TAKE ME TO ILLINOIS TO BE INTERNED NEXT TO MY PARENTS WITH A SIMILAR l~'IAR:KER. ~-~-- ~~ ``~ Q MY SON HAS AGREED TO D O THIS . o ~., o.., ,__- `~ ~' o `.-~~ GOD REST MY SOUL. t_...._ ~ "~.: - -~ CJ ''- - _. - } --- _...y __ -- ~~' `-~' ~ \ ~~' ~ SIGNED -JACQUELYN STUART ,; ~~;~_: ~i . b--•-- u...t c: ~ : ~° c,.,~ -- ~~:~~- +°.F ~„ WITNESS ~ NOTARY ~ r ~z 1 C~ ;~~~ ~~ ~ ~~^e ~~rnq~n ~~~ ~ ~ NAME-------------------------------------- ,~ c~,~~~~ ~~r ~~ ~U~ ~7 ~ C~!~v~i~l~~~l~vEA~.l"H aF PENNSYLVANIA ------------------------------~---- Notarial Seal SIGNANTURE------------- I Wiliiart? C~ Wierman, Notary Public NQ~nr Cumterlanti Boro, Cumberland County j ~ ~riy Commission Expires Sept. 15, 2012 SEAL CORNER> ~aNembe? l~'ennsylvanfa Association of Notaries ~~ ~_ ~ ~~ _T`# 7 `. ~. ~- '" ~~.`,_ ~~_:, OATH OF SUBSCRIBI~;G `VITNTESS(ES) off; ~ -..., REGISTER OF WILLS ~,,,,~M~c~C~-N~ COUNTY, PENNSYLVANIA ~~-1~-1//~~ ~-- _, -:a r~ ~'b -~..°! CT"+ '~ L~ Lr _.,__~ :_J,~ ~~ ~ ..ti 'T' ti::?-.; f ~~ .~ T-1 ~~ ~ ~ _..~ Estate of ~ _~,~ L ~ v->/ ~ ~/r~.~ .~~1 y ~i2 ~ _, Deceased "y ~ ~ ~ , (each) a subscribing witness to (Print Na,ne/s) the Will ^ Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that she /~ /they 'a /were present and saw the above Testator / estatri sign the same and that/ he /they signed the same and that she /~ they signed as a witness at the request of ___, the Testator::/ Testatr~ in -~he;~ his presence and in the presence of each other. L.. (Signature) (Street Address) (City, State, Zip) Execccted in Register's Office Sworn to or affirmed and subscribed before me this of day Deputy for Register of Wills (Signature) ~~1~ ~~ ~~, ~~~~ (Street Address) G\ lyl ~ ~~ (City, State, Zip) Execicted oict of Register's Office ~ ~ n, ' Sworn to or affirmed and subscribed ~_ c~ s7 ~ ~ >- ~, ~: r., day before me this ~ ~ ~ ...~ of ~L~. ~~ ~~~, ~ ~. ~ ~ u ~ ~u~ t i ~ , ~. :.~ c:a I ~ _ ~ ~;'~ ~ ~ v ' - ~ ..~ . C,i ~ a , i ; ~j ~ Cs. ~; j : ~ ~ , :~ ~ ~` ~ ~~' ~ ~s iii Notary Public -~ ~~ 3 ... ~ ~~' ~ ~=~ ~ My Commission Expires: °~ `"`~ ~:t ~, ~.:: ~, (Signature and Seal of Notary or other official qualified to ~} .~' ~'~~ administer oaths. Show date of expiration of Notary's Com missi on. NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of notarization. Fonrz RW-03 rev. 10.13.06 OATH Off' NON-SUBSCRIBI~,TG `VITNESS(ES) REGISTER OF WILLS COUNTY, PENNSYLVANIA r-- ~, Estate of ~..~ ~ l~ .y ~ ~~v ~ ~ ,Deceased ~`~/ ~~ ti ~~ti - r c,~C~c.-tom ~ and , R (each) being duly qualified according to law, depose(s) and say(s) that she he /they was were well- .__--- acquainted with ~C ~ ~C ~-r` ~~CEGi~~ and am/are familiar with the handwriting and signature of the decedent, and that the signature of ~GLCC~ ~~2-r ~~ ~ (uG~-l' to the foregoing instrument purporting to be the Last Will=and Testament/Codicil of ~~'~-~ ~~~,~ ~~~~ ~ is in his he own proper handwriting. (Signature) Street ddress) 1 ~S ~lJ~~' ~ --~ ~~0 C (City, State, Zip) Execccted in Register's Office Sworn to or affirmed and subscribed befo ; me this ~ day of ~~ ,~ -~ P ~. ! eputy for Register of Wills (Signature) (Street Address) (City, State, Zip) f.... T~ ~ r~ _ ~~ +- ~ F-} (~ [ ~ f ~. s,~ ~..:T ~^ ,c.._ C ~ r ~`_ ~ J ~__ ~J` C ~ .. . ' ~.~ .. i r.•_ t i ~ ~ ~ • ~ -- Gf1 ri Form RW-04 rev. lOJ3.06