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Home My WebLink About11-02-12PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF~u.Y-~n~s~.`C)..`a1 ~Q COUNTY, PENNSYLVANIA Petitioner(s) named below, who isiare 18 years of age or older, appl~~(ies) for Letters as specified below. and in support thereof aver(s) the following and respectfully requests j the grant of Letters in the appropriate form: Decedent's Inf tion .___. Name• ~ , r ~~ a/lc/a: a/lc/a: a/k/a: Date of Death: C~ c ~ ta, '~l~Q'~~ Decedent was domiciled at death in `. r,r~ ,~ C unty, principal residence at ~ `~ r`~ ,~ , Street address Post Office a d Z' C d ~r,-, File No: ~' ~ ~ ,~ ~' `~" (Assigned by Register) Social Security No: ~ ~p~p- a~-(~t~~S Age at d^ath: 1 V ~:v~ ~! • ~ Q- 1 > ip City, Township or Borough 1 i Decedent died at I Q~~Y~~ 5 ~.,,~ ~S ~ ~~ ~, ~, Street address, Post Office and Zip Co City, Township or Borough (State) with his/her last County ~.~ ~-1~,r'~ Pn my State Estimate of value of decedent's property at death: If don:idled in Pennsylvania ............................ All persopal p roperty y $ '~j ~ ~ ~` Lj If not don:ieiled in Pennsylvania ........................ Personal ro er m Penns lvania $ If not domiciled in Pennsylvania ........................ Personal property in County $ lialue of real estate in Pennsylvania ......................................................... $ TOTAL ESTIMATED VALUE.... $ ~ ~ Q(; c,~ Real estate in Pennsylvania situated at: (Attach additional sheets, irnecessary.) Street address, Post Office and Zip Code I~ City, Township or Borough County A. Petition for Probate and Grant of Letters Testamentary Ar Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated ~ - I VLt,I - ~ b t-~3 and Codicil(s) thereto dated State relevant circumstances (e.g. renu~:ciatior:, death ojexecutor, etc.) Except as follows: after the execution ofthe 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 adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. NO EXCEPTIONS ^ EXCEPTIONS Petition for Grant of Letters of Administration (If applicable) c.t.a., d. b. n., d.b.n.c.t.u., pendente life, durance absentia, durmite minoritute 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 i~123 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 udditionul sheets, if necessary): Name Relationshi Address t: 7 ~; , ~~ _% ~.~,, .. ^~ ~- `~: ~- ~} Form RW-02 rev. 1 0/1 112 0 1 1 S' ~-- --~ Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } SC; Ct~[, ~T`r~ ~"~F ~itic'rA] Usc Onlyr'''' ~ `: __,_, .~ _ r~~ < t`.? ~ . , E~ ~_;. ' ~.-•-; I ~-' t_ _ ...~-~ °~~.ioi;erls~ °~r,teL ~~a.~~e °~~:~;on~r~5; ~r:r.:e~.~c:~res~ -i i ~' Tl~e 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 Decedent, the Petitioner(s) will well and truly administer the estate according to law. Sworn to ~ axf~rmed a subscribed before Date a ~~o„ - ~O~Z lne t a O ~~i ~ ~' / ~~ Date By. r - l ~ Date rf he Re,;ister Date BOND Required: ~ YES ~ NO FEES: ~ Le rs ...................... $ ~~~Ol? ( )Short CertiEcate(s)...... /~- ~ G ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Qth r ' _~ ~~ ~Cf t(1 ........ ~~ - (~?C~ Automation Fee .............. . JCS Fee . ................... . TOTAL ..................... $ To tl:e Register ojWills: Please enter my appearance by my signature below: Attorney Signature: Printed Name: Supreme Court ID Number: Firm Name: Address: Phone: Fax: Email: DECREE OF THE REGISTER Estate of ~,r .~9f r~Z File No• ~~ ^~~ "~~ ~? a/k/a: AND NOW, L~ffL~/~~ ~-~~"'~ Z- ~L~/~ , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that tters ~"~' L'!) , (~,/'' are hereby granted to ~- !I /I ~ ~ ~ -s ~,~ in the above estate and (if applicable) that the instrument(s) dated l'1~L'irt ~~r ,~ ,~ L~Cr.~ described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent Fo~~,» Rcv-n~ ,~~,.. ~ni~~iznl~ c._. .. r...' J . x 1~__ i~J, iit. .. J 2 1)t~~~~~ ~z. ~,.~~^ le/Print In ~rmanent i I Wit.. ~ +,.= I r. ~~~? ~ C,;t~„ PA T- Ai i COMMONWEALTH Of PENNSYLVANIA • DEPARTMENT Of HEALTH • VI7Al RECORDS rcaTlclJrnTC nc ncnru ~sare r~ie rvumoer: 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Dat of Death (Mo/Day/Yr) (Spell Mo) Clifford E. Gra Male 166-20-6015 ~ f ~~~ sa. Age-last Birthday (Vrs) Sb. Under 1 Vear sc. Under 1 Da 6. Date of Birth (Mo/Day/Year) (Spell Month) 7a. Birthplace (City and State or Foreign Country) Months Days Hours Minutes F2enOV0 Penns 1Vania 86 May 2, 1926 76. Birthplace (County) Sa. Residence (State or Foreign Country) 86. Residence (street and Number -Include Apt No.) 8c. Did Decedent Live in a Township? Penns 1Vania 210 Bi S rin R d Yes decedent lived in I'~St Pe nnsbOrO Sd. Residence (County) g p g oa , _ - twp. Cumberland Be. Residence (Zip Code) 1 7241 ^ No, decedent lived within limits of city/boro. 93~ ~Fver in US Armed Forces) 10. Marital Status at Time of Death ^ Married ^ Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) L~Ves ^ No ^ Unknown ®Divorced ^ Never Married ^ Unknown 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior [o First Marriage (First, Middle Lazt) James Gray , Joanna Singiser 14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code) o Lynn G. Patterson Dau hter 3 Circle Drive, Ea leville PA 19403 G ........................................................ r... ................................... ~~ys ISa. Place o Deat C ec onlY one ;....................................................... ] P If Death Occurred In a Hos Ital: p Cpl In atlent .................................... ....................................~,. ••••••••••••••••••••••~•••••••••••••• :If Death Occurred Somewhere Other Than a Hospital: ~ Hospice Facility Decedent's Home ^ Emergency Room/Outpatient ^ Dead on Arrival • ^ Nursing Home/Long-Term Care Facility Other (Specify) s isb. fadllty Name (If not Institution, give street and number; 15c. City or Town, State, and Zip Code i5d. County of Death Harrisbur Hos ital Harrisbur PA Dau in •~ ~ 16a. Method of Disposition ^ Burial ~ Cremation ^ Removal from State ^ Donation 166. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) ^Other (Specify) 15, 2012 Cumberland Crematory, LLC Z v 16d. LowUpn of Disposition (City Or Town, State, and Zip) l 17a. Signa[ur o uneral Servic ensee or Person in Charge of Interment ~~ ~ '-- 176. License Number v Car isle, PA 17013 ~~ ~ FD-138630 E 17c. Name and Complete Address of Funeral Facility 3 Mal zzi ~.lneral Home Market 1 m r°- 18. Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to indicate what hi h st d l l f h l d g e egree or eve o sc oo complete at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be. ^ Bth grade or less is Spanish/Hispanic/Latino. Check the "No' ~ White ^ Korean ^ No diploma, 9th - 12th grade box i1 decedent is not Spanish/Hispanic/Latino. ^ Black or African American ^ Vietnamese ^ High school graduate or GED completed W 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, AS) Yes, Puerto Rican ^ ^ Chinese ^ Guamanian or Chamorro ^ Bachelor's degree (e.g. BA, A8, BS) ^ Yes, Cuban ^ Filipino ^ Samoan ^ Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) ^Ves, other Spanish/Hispanic/Latino ^ Japanese ^ 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-Designation -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 ^ American Indian or Alaska Native ~ Vietnamese ^ Don't Know/Not Sure Manager ^ Asian Indian ^ Other Asian ^ Refused 22b. Kind of Business/Industry ^ Chinese ^ Native Hawaiian ^ Other (specify) - P P d t aper ro uc s ^ Filipino ^ Guamanian or Chamorro ITEMS 23a • 23d MUST BE COMPLETED 23a. Date Pr Pounced Dead (Mo/Day/Vr) 236. Sig cure (person Pronoun ng Death (Only when applicable) 23c. License Number BV PERSON WHO PRONOUNCES OR / ~J 2~ CERTIFIES DEATH G• G !/ ~ ~ I ~ ~-'~' ry, ~/~~ ~ 23d. D e Sig ed (MO/ y/Yr) 24. T' a of Dea[F}a / L-~ ' °' Z 1 / ' 25. W edical Examiner r r rContacted? ^ Yes No CAUSE OF DEATH t Approximate 26. Part I. Enter the chain of events--diseases, injuries, or complications--that directly caused [he death. DO NOT enter terminal events such as cardiac arrest Interval: respiratory arrest, or ventricular Rbrillatio without srowing the etiology 0 NOT ABBREVIATE. Enter only one Cause on a line. Add additional lines If necessary ; 0 set to Death ~ /l ~y~7 /~ J J I IMMEDIATE CAUSE -.-_---_-._-_-x y, /y Il /~ r-1...' / ~~ ~ L' i~('~7~ G ~2'~Irl/ ~L/ ~~L~L~'C j'''-'~ i ~!'~YGt~T (Final disease or condition ~~ Due to (or as eq ence ff: resulting in death) ~~^~ ~ ~ ~ j / ~~~ ~ ~ ~-. G~v~C s b. ~ i~s~t Sequentially list conditions, Due to (or at a consequence of): /// If ~ any, leading to the cause / _ ~/ ~ ~ a ~r~} l ~ ` ~~ ~ ~] ,L~ listed on line a. Enter the c. G/y, /t ~f-.. ~ zr c/Y/~ -L JA,I /7iY'L~ '~~~ ' 7/i •~'lr(~ UNDERLYING CAUSE ~~ Due to ( as a consequence w - (disease or injury that //jj~~ss // ~~- /y ~ Initiated the events resulting d. _ /l/~ ~',Jr~LZ ~~~ ~ ~ Z ~(• <j~ L L2'~^/ y 27~~ C1~~~., ! l , _ ~r1 'n~ ~ V in death) LAST. Due to (or a a consequence off: S 0 26. Part 11. Enter other significant conditionsconditions contributin~to deathdeath but not resulting In the underlying cause given in Part I 27. Was an autopsy perfor ^ Yes No ~ 28. Were autopsy find ngs available °u to complete the cause ,death? ^ Yes No - 29. I( Female: 30. Did Tobacco Use Contribute to Death? 31. M 'r of Death e ^ Not pregnant within past year ^ Yes ^ Probably Natural ^ Homicide ~ ^ Pregnant at time of death ^ No ^ Unknown ^ Accident ^ Pending Investigation ^ Not pregnant, but pregnant within 42 days of death ^ Suicide ^ Could not be determined t°- ^ Not pregnant, but pregnant 43 days [0 1 year before death 32. Date of Injury (MO/Day/Vr) (Spell Month) ^ Unknown if pregnant within the past year 33. Time of Injury 34. Place of Injury (e,g. home; construction site; farm; school) 35. Location of Injury (street and Number, City, State, Zip Code) 36. Injury at Work 37. If 7ransportatlon Injury, specify: 38. Describe How Injury Occurred ^ Ves ^ Driver/Operator ^ Pedestrian ^ No ^ Passenger ^ Other (Specify) 39a. CertfR eck only one) ^ Eying physician -TO the best of my knowledge, Eath curved due to the cause(s) and manner stated Pronouncing & Certify g physi n ~ To [he best of y k ledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated ^ Medical Examiner/CO oner - the oasis of exa nano nd/or investigation, in my opinion, d~ h «urred at the time, date, and place, and due to th use(s and manner stated i1 ~" Signature of certifies. Title of certifier. I ~Y~ License Number: 39b. me, Address n p C Pers C m I tin ause of DeatF~(iLarn 26) ~ 39c. [e SI ned o/Oay/Yr) 40. Registrar's Dis t Number '" 41. Regl rar's ignat ure 42. Registra r f il e Date Mo/Day/Yrl ~ L 1 ~ ~ .h ~r ~~ I) ; ~ t~ yJ ~j ~ v .1 ! ~.~ 43. Amendments 0819413 H105-143 Dispositon Permit No. REV 07/2011 C7 - --,•, .~ ~ ,, _, .; ~:.~ .- LAST WILL AND TESTAMENT ~ -~ 1 . ~ ~ - ~ ~~' ~~ _.I_~ I, Clifford E. Gray, presently residing at 133 West Locust Street, Apartment C-15, Mechanicsburg, Cumberland County, Pennsylvania 17055, being of sound mind, memory and disposition, do hereby make, publish and declare this my Last Will and Testament, hereby revoking and making void all wills by me at any time heretofore made. FIRST. I direct that upon my death I be cremated and that my Executrix make all necessary arrangements as soon as possible to accomplish this directive. SECOND. I order and direct the payment of all my legally enforceable debts and funeral expenses as soon as may be convenient after my decease. THIRD. I give, devise and bequeath all my estate, real, personal and mixed, whatsoever and wheresoever situate, in equal shares, to my children as follows: A. ONE (1) SHARE to my daughter, CATHERINE GRAY, on a per stirpes distribution basis; B. ONE (1) SHARE to my son, ALAN S. GRAY, on a per stirpes distribution basis; C. ONE (1) SHARE to my daughter, LYNN A. GRAY, on a per stirpes distribution basis; and D. ONE (1) SHARE, to my daughter, SANDRA B. LUTZ, on a per stirpes distribution basis. FOURTH. I nominate, constitute and appoint my daughter, LYNN A. GRAY, to be the Executrix of this my Last Will and Testament; if she be unable to fulfill the duties of Execu±rix, I then nominate, constitute and appoint my son, ALAN S. GRAY, to be the Executor of this my Last Will and Testament; and if he be unable to fulfill the duties of Executor, i then nominate, constitute and appoint my daughters, CATHERINE GRAY and SANDRA B. LUTZ, of the survivor thereof, to be the Co-Executrices of this my Last Will and Testament. FIFTH. I direct that my personal representative(s) shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I, Clifford E. Gray, have hereunto set my hand and seal to this my Last Will and Testament, written on one (1) page, this ~~~'` day of NOV C.M.43~,R. , 2003. ~~'~~ (SEAL) WEIGLE & ASSOCIATES, P. C. -ATTORNEYS AT LAW - 1Z6 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 This instrument was by the Testator, on the date hereof, signed, published and declared by him to be his Last Will and Testament, in our presence, who at his request and in the presence of each other, we believing him to be of sound and disposing mind and memory, have hereunto subscribed our names as witnesses. ' .~~ -__~._ COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS I, Clifford E. Gray, the person whose name is signed to the 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 that I signed it as my free and voluntary act for the purposes therein expressed. fit`=~~~ Sworn or affirmed to and acknowledged before me by Clifford E. Gray, the Testator, this ~~ day of N ov~.w,,b e r' , 2003. Tit~r~~ L. ~ri~t>it, l~+~tary ~'~blic Shipp~-~~b~r~ ~., ~;~~~iy a# Cumi~~and gay C.r~rnmission ~xpir~s A:cv. 5, ~4 WEIGLE & ASSOCIATES, P.C. -ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND and ~ =~ ~, ~ ~ .~ .e ,the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Clifford E. Gray, the Testator, sign and execute the instrument as his Last Will; that he signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator, signed the will as witnesses; and that to the best of our knowledge the Testator was at the time eighteen (18) or more years of age and of sound mind and under no constraint or undue influence. ~ , ,r= -~ ;~ ~ _ Sworn or affirmed to and subscribed before me and L, ~ Iv ~ /~ ~ ~-' ~.? ~ 1~c ~ ~~ witnesses, this ~o~ day of ~lpvevh,~i~~ , 2003. ~- II NOTARIAL SEAL Thomas L. Brigh¢, ~V~Yary Public Shippensburg Tvup,, ~;ounty of Cumberland My Commissian empires l~lc~v. 5, 2UO4 WEIGLE & ASSOCIATES, P.C. -ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397