HomeMy WebLinkAbout10-19-12PETITION FOR GR/ANT OF LETTERS
REGISTER OF WILLS OF ~~ ~ ~ r/ /}~.. ~ 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
a/k/a:
a/k/a:
Date of Death: _~~ / Z
Decedent was domiciled at death in ~l~h-, ~~~~~ ~ County,
principal residence at ~ ~ C1. !~d /Ly11 S7~
File No: ~ I- ~ ~ ` ~ ~ t~
(Assigned by Register)
Social Security No: ~~ - 32- ~~~Z
Age at death: / r; Z ter s
Sheet address, oat Office and Zip Code ~ 'City, Townshtp
Decedent died at ~/~uf ~ ~~~ ~-~-~~ ~-~ ~~~^~' ~ r C
Street address, Poat Office and Zip Code City, Township or Borough
(State) with his/her last
~ /3 os~c~'L C'~~ ,..J~
or Boroagh County
County S to
Estimate of value of decedent's property at death: .. ''
If domiciled in Pennsylvania ............................All personal property $ ~i ~rG • GC
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.... $ 2 . l'CC . GG
Real estate in Pennsylvania situated at: ~/GoC/L
(Attach additional sheets, ijnecessary.) Street address, Post Office and Zip Code City, Township or Borflagh Coanty
~A. Petition for Probate and Grant of Letters Testamentary ~ 99
Petitioner(s) aver(s) he/she/they is/aze the Executor(s) named in the last will of the Decedent, dated ~~J~7/~' l ~ and Codicil(s)
thereto dated tiles r,.
State relevant circamatances (e.g. renunciation; deatk ojexecutor, 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(8), and did not have a child born or
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
J~NO EXCEPTIONS ^ EXCEPTIONS
^ B. Petition for Grant of Letters of Administration (If applicable)
c.t.a., d.b.n., db.n.c.t.a., pendente lite, durante absentia, durance minoritate
If Administration, c.~a. or db.n.c.i: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(8) 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
rv
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Forn~RW-01 rev. loillizo~l Page 1 of 2
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Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COi;NTI~' OF ~~b~~~~nd
~~'#2 OCT (9 AM I i ~ 25
Peritioner(s) Printed Name Per,tionerls) Print
The Petitioner(s) above-named swear(s) or affirm(s) thl
of Petitioner(s) and that, as Personal Representative(s)
Sworn to or affir'ined and s b cribed bef r~
met ' ~ da of
By:
For the Regcgter
statements i f going Petition are d co to the best of the knowledge and belief
the D de a Petitioner(s) will w dminister the estate according to law.
Date ~~ ~ Z ~ ~ Z--
Date
Date
Date
BOND Required:~YES ~NO
FEES:
Letters ...................... S .
(5 )Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other
(~ ~ l L - ...... ~
Automation Fee .....:..::::::: ~~~~ ~~~~
ICS Fee . .......... . .
TOTAL ..................... $ R®
Estate of
a/k/a: .~
File No: - -
AND NOW,_~o~~ _, in consideration of the foregoing Petition,
satisfactory proof havtng been presented before me, IT IS DECREED that Letters
are hereby granted to ~ (~ 2. (-~ ~_/\,~/.p r~
to the above estate and (if annlicable) that
the instrument(s) dated _ __"j - ~ (') -- `~
described in the Petition be admitted to pro
Fo,~,~, Riv-nz ,•~,,. lniuiznti
To the Register of Wills:
Please enter my appearance by my
Attorney Signature:
Printed Name:
Supreme Cour
ID Number:
Firm Name
Address:
/~~, v '
e uetow:
%L'~~
~~~
~ / ~~1
~ l .
- 3/
Phone:
Fax:
Email:
DECREE OF THE REGISTER
and filed of record as the last Will (and Codicil(s)) of Decedent.
Register of Wills
~d ~~~ ~G~
Page 2 2
_ .:~,,
~C~,~~~;~,~ TRAR'S CERTIFICATION OF DEATH
~i~~tt'' ~'~~I~~ gal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6~~ ~~~ ~ g ~~ ~ (; ~~ 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 v~ill be forwarded to the State Vital
~~~.5 ~i~il~~if Records Office for permanent filing.
P 18 8 8 2c~t~uvo co.r ~ ~.~~^~~,~;~. oc~ 1 ~/zot2
Certification Number Local Registrar Date Issued
;~
Type/Print In _ COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
Permanent ~ ~
_. P'CQTI Ct P'ATC AC ACATY
_ )
Y
~~
R
_~
1. Decedent's Legal Name (First, Middle, Lsst, SufRx) 2. Sex 3. 5 1 N ~ a ,Y4. Date of Death (MO/Day/Vr) (Spell Mo)
Dorothy Elizabeth Myers Fema1 `~~85-~~-g~.~2
pctober 8, 2012
Sa. Age-Last Birthday (Vrs) Sb. Under 1 Vear Sc. Under 1 Da 6. Dace of Birth (MO Day/Vear) (Spell Month) 7a. Birthplace (City and State or Foreign Country)
fit`
~l lOZ Months Days Hours Minutes ~~. 10 r 1910
7b. Birthplace (County) ~`~=-land
Sa. Residence (State or Foreign Country) Bb. Residence (Street and Number -Include Apt No.) Hc. Dld Decedent Uve in a Township?
PA 770 S. Hanover .Street j~Yes, decadent lived In twp.
ga. Reaid.npe (cot,nty)
~.'L]II~@rlaCld ge. Residence (Zip Code) No, decedent lived within limits of ~ar1 isle city/boro.
9. Ever In US Armed ForceaT 10. Marital Status a[ Time of Death Married Q Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage)
0 Yes ~ No ~ Unknown ~ Divorced Z] Never Married ~ Unknow
12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Mtddle, Lsst)
Holbert A. Myers Zora A_ Hutcnlel
14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Malling Addrezz (Street and Number, Clty, State, Zlp Code)
ffi Holbert G_ M era Nephew 1804 Walnut Bottom Rd, Newville, PA 17241
........................................................ ...Pa..................................r........1 a. ace.~....ea[... _ _ _
.. ec•.on y one .............................. ............................. ...... ............ .. ....... .....
If Death Oc
r
d i
H
it
l
~
•
"
`
s cu
re
n a
os
a
:
p
In Ylent ~
If Death Occurred Somewhere Other Than a Hospital: ~
( Hospice Facility ~]
Decedent's Home
~
Q Emer en Roam/Outpatient ~ Dead on Arrival
Nursln Hams/LOn -Term Gare Facility Other (Specify)
lSb. Facility Na (H not ins Itutlon, Iva street and n tuber;
Carlisle Reg~ona~ Medical Center 15c. City or ii~~yv sstate, a d Zip iSd. County of fi4ath
Car11s1e, PA 1015 Cumber and
I6a. Method of Disposition Burial ~ Cremation
o Rempyal from state p Dgnatipn 16b. Date of Olspositlon 16c. Place of Dlspositipn (Name of ttmetery ato 0 other place)
Oct 15
2012 C
ill
~ P
k C
Other (S eclfy) ,
enterv
e MemOria
ar
emetery
16d. LoeaYlon of Disposition (City or Town, State, and Zip)
NESwville, PA 17241 17a. Slgnat Funeral Servlc__ rson n Charge of Interment 17 b. Vicense Number
138504
17c. Name and Complete Address of Funeral Facility
H
ff
o
man-Roth Funeral Home a Cremato , 219 North Hanover Street, Carlisle, PA 17013
~ 16. Decedent's Education -Check the box that best describes the 19. Decedent of Hispsnlc Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to Indicate what
t- highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent consltlered himself or hersel/ to be.
~ Hth grade or less Is Spanish/Hispsnlc/Latino. Check the "NO" White ~ Korean
~ No diploma
9th - 12th grade b x If d
d
t I
S
i
h
~
,
ece
en
s not
pan
s
/Hlspanic/Latino.
Black or African American Q Vietnamese
~ High school graduate or GED completed ®No not Spenlsh/Hispanic/Latinp Q American Indian or Alaska Native 0 Other Asian
~ Some college credit, but no degree Q Ves, Mexican, Mexican American, Chicano ~ Asian Indian Q Natiye Hawaiian
0 Associate degree (e.g. AA, AS) O Yes, Puerto Rican Q Chinese 0 Guamanian or Chamorro
'
Q Bachelor
s degree (e.g. BA, AB, BS) 0 Yes, Cuban ~ Filipino 0 Samoan
'
~] Master
s degree (e.g. MA, M5, MEng, MEd, MSW, MBA) ~ Ves, other Spanish/Hispanic/Latinp 0 Japanese ~ Other pacific Islander
Q Doctorate (e.g. PhO, Ed D) or Professional degree (Specify) Q Other (S
ecif
)
p
y
. MO ODS 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
Whl[e 0 Japanese ~ Samoan done during most of working Ilfe. DO NOT USE RETIRED
.
0 Black or African American ~ Korean 0 Other Peclfic Islander
Q American Indian or Alaska Natiye ~ Vietnamese Q Don't Know/Not Sure Teacher
Q Asian Indian ~ Other Asian ~ Refused 22 b. Kind of Business/Indust
ry
Q Chinese 0 Natiye Hawaiian Q Other (Specify) Public Sch
l
oo
Q Filipino ~ Guamanian or Chamorro
ITEMS 2 a - 29d MUST BE COMPLETED 23a. Date Pronounces Dead Mo Day r) 23 Signature o Person Pronouncing Deat On y when app Ica a 23c
License Num e
r
.
CERTIFIES DEATH PRONOUNCES OR `O pp
''
/ Zvi
~ I,
`
~~~:~Q-atCC\ _/\J q\{'~° Mfl -l ~t ~~"2~
23d. Date Signed (MO/Oay/Yr) 24. Time of Deathv
ANA 25. Was Medical Examiner or Coroner Conta[tedT Q Yes ~ No
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 cardi
t (
ac arres
Interval:
respiratory arrest, or ventricular fibrlllatlon without showing the etiology. 00 NOT ABBREVIATE
Enter onl
o
I
.
y
ne cause on a
lne. Add additional lines if necessary ~ Onset to Death
IMMEDIATE CAUSE --------------> a. ~~ V LT \ O lZ A 1J ~ A \ L V \"2 G.. ~
(Final disease or condition Due to (or as a consequence of):
resulting in death)
b. /~ D\J A N G C7 n F [~\ A
Sequentially list conditions, Due To (or es a consequence of):
if any, leading to the cause
listed on line a. Enter the
V NDERLVING CAUSE Due to (or as a consequence
ofl.
(dlse r injury that
initiated the events resulting d.
~ In death) LAST. Due to (o as a consequence of):
26. Part 11. Enter other si 171 t ditl [ Ib ti t d h but not resulting in the underlying cause gWen In Part 1 27. Was an autopsy pertormedT
~ H~~E[iNAT (Z~t-{ \ A Yes No
~ 2B. Were autopsy fin Ings available
\~'n\~~ G ~~ ~¢Fc\~~~\ G QG\ ~V~L7
mplete the cause of deathT
to co Yes No
~a 29. If Female: 30. Dld Tobacco Use Contribute To Death? 31. Manner of Death
N
E
s Q
ot pregnant within past year 0 Yes ~ Probably 'ffi Natural 0 Homicide
P
f
~' Q
regnant at time o
death
Not •~' No ~ Unknown ~ Accident ~ Pending Investlgatlon
re
nant
b
t
t
h
~ p
g
,
u
pregnan
wit
in 42 days of death
p swcide ~ Gould not be determined
N
f- Q
ot pregnant, but pregnant 43 days to 1 year before death 32. Date of In Mo/Da
Jury ( y/Vr) (Spell Month)
Q Unknown If pregnant within the past year
33. Time of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 33. Location of Injury (Street and Number, City, State, Zip Gode)
36. Injury at Work 37. if Transportation Injury, Specify: 38. Describe How Injury Occurred:
~ Yes ~ Driver/Operator 0 Pedestrian
~ No ~ Passenger 0 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
P
i
ffi C
f
ronounc
ng
e Ki
ying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the c se(s) and manner stated
~ Medical Examiner/Coroner - On the basis of examination, and/or Investlgatlon, In my opinion, death occurr
e
d
af the time, date, and place, and due to the cause(s) and mann r stated
cc
--
e~
Signature of certifier: Title of certifier: 1~ L L
License Number: j" ~ ~ ~ ~ Zf" (
39b. Name, Address and Zip Code of Person CompletlnB Cause of Death them 26)
45 S
i
i 39c. Date Signed (MO/Day/Vr)
pr
nt Dr
ve, Carlisle, PA 17015
' (o / LL
40. Registrar
s DlstrlR Number . -~
41. Registrar sSigrrrJJJ/~~~`^~
~~ 42. Registrar Fi a Oate Mo Day
--
f~ ~~
43. Amendments
Disposition Perm It No. 6 - 1 '1.~01~~ H105-143
REV 07/2031
~~z~t ~iI1 rz~ (~P~tr~m.Pnt
.~
I, DOROTHY E, lrl=~L~tS, of the. Borough of Carlisle, Cumberland
County, Pennsylvania, declare this to be my last will and revoke
all wills and codicils which I have previously made. ~ -`~
c-
r° -+ ~
I. I direct my executrix hereinafter named to p '-1.1 0~ my
~ •:. s> ~
just debts, funeral and administrative expenses and a~~estate,
-i ~
transfer, inheritance and succession taxes whether
• payable b~
4'
reason of property ~~~si.ng under t~•is will of otherwise, as soon
after my decease a~ Tria~~-bercanven`~rrt.
II. I give and•'bequeath the s:um~+of Five Thousand and no/100
• •. ~,
($5,000.00) Dollars to the Dickinson Presbyterian Church of
Cumminstown, Penns:Irlvar~~~,,.-(12 •Church Road, Carlisle,
Pennsylvania I701~~ tb be used as the Board of Trustees may
;.
~~• ..
determine. ,,•~ ,; .~a a,.. ,.
__ .,.,
III. I give a~rd°b~queath to my niece, .MARY LEE BURY, the sum
~~.
of Five Thousand and no/100 ($5,000.00) Dollars; to my n;~-ce, E.
~... .. i
JEAN BIXLER, the sum of Five Thousand and_r}o/100 (55~#100.Ot~,) .~-'• ~
w --
Dollars; to my nepih°e ~ J01~N K: BILLER, JR:°, the sum of Fi~v~ ,
Thousand and no/100 ($5,000.00) Dollars; to my nephew, HOLBERT G.
MYERS, the sum of Five Thousand and no/100 ($5,000.00) Dollars;
and to such person or persons as in the judgement of my personal
n
~~~
a~:~._
,~r ..-
r-`'--~-
-` T-
T1
tT'~t
~~
~ ~_~
~~
representative shall have taken care of me during the final
portion of my life, and if there be more than one such person, to
T
be divided between or among them in such proportion as my
executor may deem appropriate, the sum of Five Thousand and
no/100 ($5,000.00) Dollars, and if there be no such person, then
to lapse.
IV. I give and bequeath to my sister, OLIVE L. MYERS, such
articles of tangible personal property having sentimental, family
or heirloom significance.
V. I give and bequeath the residue of my estate as follows:
1. 33 1/3~ to my sister, OLIVE L. MYERS;
2. 33 1/3$ to my sister, ELVA M. BIXLER, and if she
shall predecease me, then in equal shares to her two children,
JOHN K. BIXLER, JR. and E. JEAN BIXLER;
3. 33 1/3$ to my nephew, HOLBERT G. MYERS, if living,
and if deceased, in equal shares to his two children, A. KYLE
MYERS and ALLISON E. MYERS.
If the beneficiary or beneficiaries of any of the foregoing
share or shares shall have predeceased me, said legacy shall
lapse and be added to the share or shares of the beneficiaries
living at the time of my death.
VI. I appoint my sister, OLIVE L. MYERS, as Executrix of
this will, and if for any reason she shall fail to qualify or
cease to act as such during the administration of my estate, I
appoint my nephew, HOLBERT G. MYERS, as substituted Executor of
this my last will. Should both my sister, OLIVE L. MYERS, and my
`~
\~
~~
` ~.
nephew, HOLBERT G. MYERS, fail to qualify or cease to act as
executors, I appoint WILLIAM S. DANIELS as Executor of this my
last will.
VII. I direct that neither my executrix nor her successors
shall be required to give bond for the faithful performance of
their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand this /~ ~`
day of '~~ 1~~cc ~ ,~ C - 1991 .
,;~ ,
`t
DOROTHY MYERS
The preceding instrument, consisting of this and two other
typewritten pages identified by the signature of the testatrix,
DOROTHY E. MYERS, was on the day and date thereof signed,
published and declared by DOROTHY E. MYERS, the testatrix therein
named, as and for her last will, in the presence of us, who at
her request, in her presence, and in the presence of each other
have subscribed o ames as witnesses hereto.
//
~ _ ~f
~~ - ;-
OATH OF NON-SUBSCRIBING WITNESS(ES)
REGISTER OF WILLS
C~~'~~ /~ COUNTY, PENNSYLVANIA
~1- t~-- l ~ ~~ ~
Estate of _s"L ~/~ ~~ ~~ ~ `1,~~'''~ Deceased
and ,
(each) being duly qualified according to law, depose(s) and say(s) that she / he /they was /were well-
acquainted with ~!~~Yh~ ,~'' /7"'~1~f and am/are familiar
with the handwriting and signature of the decedent, and that the signature o~-~~~- ~li'~
to the foregoing instrument purporting to be the Last Will and Testament~~dizi~~f
.~~ ~~ ~ ~ ~ ~- is in his/her own proper handwriting.
(Signature)
(Street Address)
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of r d 1
~`~ V
eputy for Register of Wills
Signs ure) / J y f
(~'treet Address)
(City, State, Zip)
c'
rn n ''
i"7 ~
~, _ ~} , 7
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Fonu RW-04 rev. !0)3.06
~~~~~r'.r[' ~~=~i~E C
?0110CT 19 Aid I i ~ 25
~~~ ~ ~ - TOATH OF SUBSCRIBING WITNESS(ES)
QC~PHAf~1'S uUUR t
CUMEiERIAND CO., PA
/ REGISTER OF WILLS
~l~~i-, /~i.-~/~y ~ COUNTY, PENNSYLVANIA
~.~- (,~- ~~J~ C
Estate of ~e~o- ~~ 1 / ~ • l~
presence and in the presence of each othe .
_ ~~^ .
(Signature~j~/ ~ ~ ~ S, ~. /~/ ~~: Lp
(Street Address)
Deceased
(each) a subscribing witness to
(Print Names)
the Will ^ Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and
say(s) that she / he /they was /were present and saw the above Testator /Testatrix sign the same
and that she / he /they signed the same and that she / he /they signed as a witness at the request of
the Testator /Testatrix in her /his
(Signature)
(Street Address)
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
eputy for Register of Wills
t!/I' X24 .P ~ ~/°9" / ~~
(City, State, Zip)
Executed out of Register's Office
Sworn to or affirmed and subscribed
before me this day
of ,
Notary Public
My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of notarization.
Form RW-03 rev. !0.13.06