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HomeMy WebLinkAbout11-08-12PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF Cumberland 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: Darrel E. Ge a/k/a: a/k/a: a/k/a: Date of Death: 11-5-12 File No: ~ ~ " 1.~ ' / /~~ (Assigned by Register) Social Security No: Decedent was domiciled at death in Camp Hill County, Cumberland (state) with his/her last principal residence at 39 South 36th Street, Camp Hill, PA 17011 C~~~~~ Ie~.~~t~,yr 1 C~~.~.1~~r~.l:~...~,-~ Street address, Post Office and Zip Code City, Township or Borough County Decedent died at Holv Spirit Hospital. Camp Hill, Cumberland County. Pennsvlvania 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 $ ~(~; G`L9Gt - v If not domiciled in Pennsylvania ........................Personal property in Pennsylvania $ If not domiciled in Pennsylvania ........................Personal property in County $ Value of real estate in Pennsylvania ......................................................... $ / ~,Z :$'° , tJ'C~ U TOTAL ESTIMATED VALUE.... $ % 5 ~ t Oc~c.~ 0.00 Real estate in Pennsylvania situated at: (Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough 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 thereto dated County and Codicil(s) State relevant circumstances (e.g. renunciation, death of ~recutor, 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 adopted; 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. a., d.b.n., d.b.n.c.t.a., pendente lite, dcirante absentia, durante minoritate 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 parry 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 Stephanie Ann George Daughter 28200 Charity Lane Hilliard FL 32046 Michael A. George Son ~ -~~~~ 8015 Page Wood Lane _ H ton TX 7 ~= ~=' ~`~ - -~~' . ~ _., ~ «i ~.~'_ _ . .`l . _ _ Form RW-02 rev. 10/Ili?OI1 `-1 t- -T7 V .._.'l_i _ ~. _:.. ~,,~,~ ~ r Page 1~ 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF Cumberland r } SS: 'r Official Use Only n -r ,~_ ___. .~-, r~~ -~-~ -; y .:° , T 7 _. _- ; :_ , Petitioner(s) Printed Name ~~ Petitioner(s) Printed Address-> ; = _ - ~ ' ' _,J ., ~ ti_~') ~~ , 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 Decedent, the Petitioner(s) will well and tru y administer the estate according to law. ~! ~-= h ,.- . ~ ~ ~ q,. ~ ~ ,4~, ;~` Date Sworn to Pr affirmed a ubscrib d before ~~ ~ - N ~ '~~ me thi ~h da~o ~ t~t.~ i~ ~~~ Date By: ~- ' ~ Date o e Register Date BOND Required: ~ YES ®NO FEES: Letters ...................... ~ ( )Short Certificate(s)..... . ( )Renunciation(s)........ . ( )Codicil(s) . ............ ( )Affidavit(s)............ ' Bond ........................ `~ Commission ................. . Other ........ To the Register of Wills: Please enter my appearance by my signature below: Attorney Sig printed Name: Joseph Ir Buc Supreme Court ID Number: 38444 Automation Fee . ............. . JCS Fee . ................... . TOTAL ..................... ~ 0.00 Firm Name: Law Offices of Joseph D. Buckley Address: 1237 Holly Pike Carlisle, PA 17013 Phone: Fax: Email: 717-249-2448 717-249-4103 7oeRT.aw(g~a~l_c~m DECREE OF THE REGISTER Estate of Darrel E. GeorPe File No: ~ / ~ ~ .~ . ~ ~ ~~ a/k/a: AND NOW, , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters are hereby granted to in the above estate and (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. Register of Wills Form RW-02 rev. 10/I1/?011 Page 2 Of 2 ~ ~ . l _ _, tj`. ~, - , r ~^ J ~ I.'wl( (4.f r f'L l~ r) ~1~%a~uQ~g.~ NOV 0 7 2011 O Type/Print In Permanent Black Ink ~~ w d ( ~ '~ ._. _„~ t L COMMONWEALTH OF PENNSV LVANIA DEPARTMENT OF HEALTH VITAL RECORDS ['FRTIFICATF C>tF DEATH _____ _.._ _. ______ 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (Mo/Oay/Yr) (Spell Mo) Darryl E_ Ge:merge ale 165-36-4213 ~~v_5,2012 S a. Age-Last Birthday (Vrs) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/D ay/Year) (Spel l Month) 7a. BI place (1~ity an S ~ `YY' tate or Fo eig n Country) rP Months Days Hours Minutes t 4 1 9 4 7 ian i s s urg , H ec 6 5 Oc _ ~ 7b. Birthplace (County) um er an Sa. Residence (State or Foreign Country) 8b. Residence (Street and Number -Include Apt No.) 8c. Did Decedent Live in a Township? Penna _ 3 9 S _ 3 6th Street QVes, decedent lived in iwp. Sd. Residence (County) ~ Ca p H i 1 1 Cumber 1 and 8e. Residence (Zip Code) m [~'N o, decedent lived within limits o city/boro. 9. Ev US Armed Forces? 30. Marital Status at Time of Death ~ Married 0 Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) es Q No Q Unknown ~~vorced Q Never Married Q Unknown 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last) Arthur George Joyce King 14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, Stale, Zip Code) Stephanie George daughter 8200 Charity Lane, Hilliard FL32046 ~ . ...................................... . lSa. Place of Death Check onl one - __.__ _-__ __-_------- _____ _______ ____•_- -----, ...... ... ...... ......... .. ... .. .. ... ..................---...-......-..........Y........-...-.................--•--•- s~-- . I ......................................................... . . f Death Occurred in a Hospital: Inpatient = . 1f Death Occurred Somewhere Other Than a Hospital: LJ Hospice Facility ~ Decedent's Home ~ ~ Emergency Room/Outpatient ~ Dead on Arrival • Q Nursing Home/Long-Term Care Facility 0 Other (Specify) 156. Facility Name (If not institution, give street and number; 15 c. City or Town, State, and Zip Code 15d. County of Death Holy Spirit Hospital Cara Hi11 PA 17011 umberland 16a. Method of Disposition ~ Burial remation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) r~ 0 Removal from Slate Q Donation 0 Other (Specify) OV _ 7 , 2 ~ 1 2 Ho11 ingzr Crematory c ~ 16d. Location of Disposition (City or Town, State, and Zip) 17 ignat `re of Funeral ervice Licensee or Person in Charge of Interment 17b. License Number a 1~3t _ Holly Springs , PA i 7 ; 65 ~~ ~, a-O i 31 63L 17 c. Name and Complete Address of Funeral Facility Muss:~la.-(._z.z :~~~&~ :, 324 Hummel Ave_ ,i,emc~ ne PA1 7x43 Q1 18. Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. Decede is Race -Check ONE OR MORE races to indicate what ~°- highest degree or level of school completed at the time of death. box that best describes whether the decedent the d ent considered himself or herself to be. Q 8th grade or less is Spanish/Hispanic/Latino. Check the "No" hire Q Korean Q No diploma, 9th - 12th grade box if decedent is not Spanish/Hispanic/Latino. Q Black or African American Q Vietnamese ~gh school graduate or GED completed Q No, not Spanish/Hispanic/Latino Q American Indian or Alaska Native Q Other Asian ~ Some college credit, but no degree Q Yes, Mexican, Mexican American, Chicano Q Asian Indian Q Native Hawaiian Associate degree (e.g. AA, AS) Q Ves, Puerto Rican Q Chinese Q Guamanian or Chamorro 0 Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban Q Filipino Q Samoan Q Master's degree (e.g. MA, M5, MEng, MEd, MSW, MBA) Q Ves, other Spanish/Hispanic/Latino Q Japanese ~ Other Pacific Islander Q Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) Q Other (Specify) e. MD, DDS, OVM, LLB, JD 21. Dece 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 bite ~ Japanese ~ Samoan done during most of working life. DO NOT USE RETIRED. Q Black or African American Q Korean Q Other Pacific Islander Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure i cii7 e c tin i c i an Q Asian Indian Q Other Asian Q Refused 226. Kind of Business/Industry Q Chinese Q Native Hawaiian Q Other (Specify) h0 s p i t a 1 Q Filipino Q Guamanian or Cha morro ITEMS 23a - 23d MUST BE COMPLETED BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH 23a. Date Pronounced Dead (Mo/Day/V r) ~ + " O ~ _ ~ ©, Z 23b. Signature of Person Pro ouncing Death (Only when applicable) 23c. License Number ~- ~ /~, ! ~'Y i T ~ b C~ 23d. Date Signed (Mo/Day/V r) 24. Time of Death f ~ ~p 25. Was Medical Examiner or Coroner Contacted? Ves Q No CAUSE OF DEATH Approximate 26. Part i. 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 fibrlllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary Onset to Death /~~ 7.~,F IMMEDIATE CAUSE ---------------> a. L ~~i~ r'n l~ / ~~ ' (Final disease or condition Due to (or as a consequence of): resulting in death) ~ ~ h /~'f / - ~ ~ ,r c~ ~ 1 c ~ t>,.~ ~ o-i-n 'ar rn c.tvt n cam. ~ nit .~ . b. Sequentially list conditions, to (or as a co nseq ue a of): if any, leading to the cause listed on Tine a. Enter the c. UNDERLYING CAUSE Due to (or as a consequence of): ~ (disease or injury that - initiated the events resulting d. ~ U Due to or as a copse uence of in death) LAST. ( q ) 26. PaK I1. Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part 1 27. Was an autopsy perfor o Q Ves o g ~~ 28. Were autopsy findings available G ! _ _ _ .s ~^ JJ_ n • v to tom pleie the cause of death? m , 29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death °- ~ Q Not pregnant within past year Yes Probabl Q Q Y Natural ~ Homicide v 0 Pregnant at time of death ~ No Q Unknown Q Accident Q Pending Investigation m ~ Not pregnant, but pregnant within 42 days of death 0 Suicide 0 Could not be determined ° but pregnant 43 days to 1 year before death 0 Not pregnant 32. Date of Injury (MO/Day/Yr) (Spell Month) I , 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 Transportation Injury, Specify: 38. Describe How Injury Occurred: ~ Yes ~ Driver/Operator ~ Pedestrian ~ No ~ Passenger ~ Other (Specify) 39a. Certifier (Check only one): Q Certifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated Pronouncing & Certifying physician - To the best of my knowledge, death occurred at the time, dale, and place, and due to the cause(s) and manner stated n d manner stated se(s) a red at the time, date, and place, and due to the tau u r o cc Medical Examiner/Coroner - On the basis of exa anon, and investigation, in my opinion, death ^ / ~ y ` /~ n Mf' 1{-'c~ N b i •"" ~~ ~ ~ er: cense um l L Title of certifier: i ~ Signature of certifier: 39b. Name, Address and Zip Code of Person Completing Cause of Death (Item 26) 39c. Oate Signed (Mo/Day/Yr) ~ ~ ~' M ~ C' 2. Zt ~ ~ ~ O 1 1 - ~'- / 2~ 40. Regist ar's Oistric Number 41. Registrar's Si ure 42. Registrar File Date (MO/Day/Yr) / I i 43. Amendments Disposition Permit No. C.~ ` ~ (~"~ 9 / ~ H1o5-143 REV 07/2011 RENTUNCIATION REGISTER OF WILLS Cumberland COUNTY, PENNSYLVANIA ~'., ~• ~~, :~A ~ i .. y~~ _ -- __ ~~~ : _:_. ~<_-: .~ --~ zi-.z IiFL -.~~.F y~ -~, rti:~ ~.J _, 5 '-~ --__ ~ _~ _ ;_.,~.~ ~,~~ r~ Estate of Darrel E. George ,Deceased I, Michael A. George , in my capacity/relationship as (Print Name) son of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Stephanie Ann George November 8, 2012 (Date) Executed in Register's Office Sworn to or affirm ~~nd subscribed befor e this day of G' `:Cep ; f r p~~y for Register of Wills _..-- n P /~~, ~` ~ ~ ~~` (Signature) 28200 Charity Lane (Street Address) Hilliard, FL 32046 (City, State, Zip) Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation for the purposes stated within on 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.) Form RW-06 rev. 10.13.06