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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF (-jn,,,,.~.~!',,Q~~,~ 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.~i a~ < ~`
a/k/a:
a/k/a:
a/k/a:
Date of Death: Q / 1 y / 1 /
Decedent was domiciled at death in C ,~„~„ bL~ 1/a.~~ County,
principal residence at 40o Ki~wt a.. ea.4 . _ C~~ ld~. L/
Street address, Post O[fice and Zip
Decedent died at I1srick.~y A'k~~ t •~( ~
Street address, Po ffice and Zip Code
Estimate of value of decedent's property at death:
File No• ~ r< - ~~
(Assigned by Register)
Social Security No: AFL ~ L2.' g~~
Age atn/death: Q/ i y/ r l
'>r`'.ewR r r.~u~ r c (stare) with his/her last
City, Township or Borough
City, Township or
If domiciled in Pennsylvania ............................All personal property
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... .
Real estate in Pennsylvania situated at:
(Attach a itional sheets, ifnecessary.)
$ t. eo
County
tti
State ~~
$ 1 , 6a o.00
Street address, Post Office and Zip Code City, Towuship 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 6 / 10(O ranad Codicil(s)
thereto dated
c~
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 dive
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g),
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
~O EXCEPTIONS ®EXCEPTIONS
C -"I
imt a pari'y.0o a
of have a'~iild
t~---. ,`
a -;
3 _._ -r~
_-r .- :.~
B. Petition for Grant of Letters of Administration (If applicable) ~ Si2,
c.t.a., d.b.n., d.b.n.c.t.a., pendente lite, durance absentia, dura minoritate
If Administration, c.~a. or db.n.Gi: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
Form RW-02 rev. 10/I!/2011 Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
}
} SS:
}
Official Use Only
Petitioner(s) Printed Name Petitioner(s) Printed Address
~~l r k .ll !70//'
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 den the Petiti er(s) we d truly administer the estate according to aw.
Sworn to or affirmed anted subscribed before F~~~~~ Data l~/~~1~/Z
me `lay of
By:
For the Register
BOND Required: ®YES NO
FEES:
Letters ...................... $
(~ )Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other ......
LU ~ ...... 1 ~ . oa
To the Register of Wills:
Please enter my appearance by my
Attorney S
Date
F~ ...:
~_-, ~ ...A.i
-
~1..._.
a®elow:
~
Z t >
-.j..y.
~--
~ ~
CQ
Printed Name: ~,p.~y:Cf Jst,ceL. ( apA~ct,~
Supreme Court
ID Number: Lo4Slq
Firm Name: ~Ll.r..~ ~ ~q A•atl~ QL.
Address:
(~air'•'S~u~ . .~ l? lol
•••..... Phone:
Automation Fee ............... ~ (~ Fax:
JCS Fee . .................... S Email:
TOTAL ..................... $
Estate of
a/k/a:
File No: ~ ! ' ~ ~-~~~ 113~_
AND NOW, a~`~' (~( ~~' ~ in co er tion of the foregoing Petition,
satisfactory proof having been presented before me, IT DECREED that Letter ~ Q,(')'~ ~~
are hereby granted to ~, C
e above fate and (if applicable) that
the instrument(s) dated ~
described in the Petition be
Form RW-01 rev. 10/11/1011
DECREE OF THE REGISTER
G..ers
and tiled of record as the last Will (and Codicil(s)) of Decedent.
egister of Wills ~jy~ r
Page 2 of 2
xtossos aev totro~>
LOCAL REGI~~R'S CERTIFICATION OF DEATH
WARS®~ uplicate this copy by photostat or photograph.
f~GIS; c~ Cry `~~w!-~
Fee for this certificate, $6.00
z~~Z ocT ~+~ aM 9~ so
~~~i' ..;
Q~~~S ~ .
P 17729306
Certification Number
This is to certify that the information .here given' is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will be forwarded to -the State Vital
Records Office for permanent filing.
~~,m.. ~ ~ SF~P 1 ~ Z011
Local Registrar Date Issued
5,µi peyiyepay CObtMONYYEALTH OF AENNBYLVANU •. DEPARTMENT OF NEALTN • VITAL
"'E CORONER'S CERTIFlCATE OF DEATH
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LAST WILL AND TESTAMENT c'~ ~~ ~
OF ~~~' ~- tv
r r ~ ' ~;
U'% C.'_ <~.+
LOTS M. DOUGHERTY ~`~ ~
~;
7t> aid ~="
of Lower Allen Township
DOUGHERTY
LOIS M
I Cumberla nd ~''ounty
,
,
.
, ,
Ferinsvlvania, declare this to be my last will and revoke any will previ-
ously made by me.
ITEM I: I devise and bequeath all of my estate of every nature and
wherever sy.tuate to my spouse, PAUL E. DOUGHERTY, if he survives me.
ITEM II: Should:+.11y spouse, PAUL E. DOUGHERTY, fail to survive me,
I hereby devise and bequeath all of my estate, cf every na~~ure and
wherever situate, to my son, C.~ARLES E. DOUGHERTY.
ITEM III: I appoint my spouse, PAUL E. DOUGHER'I'Y, Executor of this
my last will. Should my spouse, PAUL E. DOUGHERTY, fail to qualify or
cease to act as Executor, I appoint my son, CHARLES E. DOUGHERTY, Execu-
for of this my last will.
ITEM IV: No fiduciary acting hereunder shall be required to post
bond or enter security for the faithful performance of his or her duties
in any j~_irisdictior~.
IN WITNESS WHEREOF, I, LGI(S M. DOtJGHERTY, ha~,re hereunto set my hand
ar:d seal this. ~~~ day of ` ~'`~ X010.
LOTS M. DOUGHERTY
Page i of 3
SIGNED, SEALED, PUBLISHED and DECLARED by LOIS M. DOUGHERTY, the
Testatrix above named, as and for her Last Will and Testament, and in
the presence of us, who at her request, in her presence and in the
presence of each other, have subscribed our names as witnesses.
Witness
COMMONWEALTH OF PENNSYLVANIA:
. SS.
COUNTY OF CUMBERLAND
414 Bridge St., New Cumberland, PA
Address
414 Bridge St., New Cumberland, PA
Address
I, LOIS r~1. DOUGHERTY, the Testatrix whose name is signed to the at-
tacked cr foregoing instrument, having been duly qualified according to
law do hereby acknowledge that I signed and executed this instrument as
my Last will; that I signed it willingly and that I signed it as my free
and voluntary act for the purposes therein contained.
~~~
LOIS M. DOUGHERT
Sworn to or affirmed to and acknowledged before me by LOIS M.
DOUGHER.TY the Testatrix, this Irk _ day of :,`\l~Q 2G1G.
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
KELLY A. BIRDSALL, Notary Public
New Cumberland Boro.,Cumberland Co.
My Commission Expires .June 18, 2013
Notary Public
Page 2 of 3
COMMONWEALTH OF PENNSYLVANIA
. SS
COUNTY OF CUMBERLAND
1 S
~y ~. ~`1r`t
W-~, ~
~n~ ~
~ ~
~- ~~~ ~\
- -
tree witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, depose and say that
we were present and saw Testatrix sign. and execute the i~?str~.zmPnt as her
last will; that Testatrix 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; that to the .best of our knowledge, the Testatrix was at that
time eighteen o.r more years of age, of sound mind and under no
constraint or undue influence.
Sworn to or affirmed to and ackno dged before me by
~V ~~~ ~~~ and ~`~~. ~~~ ~~-~~~
witnesses, this ,C~r day of JU~~ 2010..
COMMONWEALtH OF PENNSYLVANIA
NOTARIAL SEAL
KELLY A. BIRDSALL, Notary Public
New Cumberland Boro.,Cumberland Co.
My Commission Expires June 18, 2013
~V .~4~, O.~ci~.(AAG.A../
Notary Public
Page 3 of 3