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PETITION 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: John Michael Hailev File No: ~I - f c~ - ~ ~3
a/k/a: (Assigned by Register)
a/k/a:
a/k/a: Social Security No: 226-66-3805
Date of Death: 11/21/2012 Age at death: 64
Decedent was domiciled at death in Cumberland County, P~ySylvania (stare) with his/her last
principal residence at 1017 Harriet St.. North Middleton Twn Cazlisle Cumberland
Street address, Post Office sod Zip Code City, Township or Borough County
Decedent died at 1017 Harriet St. North Middleton Carlisle Cumberland PA
Street address, Post Office snd Zip Code City, Township or Borough County Stste
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania ............................ All personal property $ 93,000.00
If not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $
If not domiciled in Pennsylvania ........................ Personal property in County $
Value of real estate in Pennsylvania ......................................................... $ 1 n7,nnn_nn
TOTAL ESTIMATED VALUE.... $ 200.000.00
Real estate in Pennsylvania situated at: 1017 Harriet St., North Middleton Carlisle Cumberland
(Attach additional sheets, ijnecessary.) 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/aze the Executor(s) named in the last Will of the Decedent, dated and Codicil(s)
thereto dated
Stste relevant circnmatancea (eg. renanciatton, 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
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
Q NO EXCEPTIONS Q 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.r+a or db.n.c.~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.
Q NO EXCEPTIONS Q EXCEPTIONS
Petitioner(s), after a proper search has/have ascertained that Decedent left no W ill and was survived by the following spouse (if any) and heirs (attach
additional sheets, if necessary):
Name Relatlonshl Address C
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Form Rw-Ol rev. 10/11/2011 Page 1 of 2
~~~
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
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t" ~} ~ ~Jse Only
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Petitioner(s) Printed Name Petitioner(s) Printed Address
Adessa R. Miller
Michael Haile 209 St. Johns Church Roa Cam Hill PA 170 U~ ~~ ~1, ;; ;~
17 W Pomfret St. A t. 12, Carlisle, PA 17013 ~ ~ ~ ~' ' ('~ • pA
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 lrnowledge 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 or affirmed and subscri ed before Date 11'~Ol ~Z`
met ' day of Z Date ) (moo - )Z
>3y: Date
the Register Date
BOND Required: Q YES ~ NO
FEES:
Letters ..................... .
( ~ )Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other ........
~~l`(I ........
$ Z .(JCS
•UU
To the Register of Wills:
Please enter my appearance by my signature below:
Attorney Signature:
1 `^^~`~`
Printed Name: Mark A. Mateya
Supreme Court
ID Number: 78931
Firm Name: Mateya Law Firm
Address: 55 W Ch„rrh Avenue
~`~*t+ , PA 1701 ~
Automation Fee ............... -
JCS Fee .....................
TOTAL ..................... $c'~,r• c`~U 8.00
717-241-6500
717-241-3099
,nainQp mate~+alaw nm
Phone:
Fax:
Email:
DECREE OF THE REGISTER
Estate of John Michael Hailev
a/k/a:
AND NOW, l~"~U D ia~1 ~~ ~7 ~ 1 ~ , in consideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters P
are hereby granted to I'~L'(.,Q~ Ct ~ ~ A !1l ~' ~- y
~. A l (.~'1Gt~.,~_ _ ~~,(! / ~ O G in the above estate and (if applicable) that
the instrument(s) dated l 11 ~ I ~ ~D l 2
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of De edent.
egister of Wills ~ t ~~ ~ P
(~
File No: ~ ~ - ~ ~ - I ~~.~
Form RW-02 rev. 10/11/2011 Page 2 0 2
~_ m~ cns r; c~: , _,
LOCAL ~~-~i,~~~~5 CERTIFICATION OF DEATH
WARNING~'~t~` Sila~,cf~t ta~!c~u~licate this copy by photostat or photograph.
Fee for this certificate, $6.00
P 18883773
Certification Number
TVPe/Print In
VJ. Permanent
Black Ink
9
Dlspositlon Permit No. Ut' ~ ~ -~~ L-}'
.~•
~J
Ci,lf) ~f . I ,~ ~,r
~, Il ~'~
Ci)i~'~,~~1 ''~~,D ~J., PA
~.~ ~ ,:
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.
~.~~ Hqw 2 s/2a~2
Local Registrar Date Issued
COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH .VITAL RECORDS
/"Ca~Tacal'~ w T
1. Decedent's Le ~ ~ State Flle Number:
gal Name (First, Middle, Last, Suffix)
2. Sex 3. Social Security Number 4. Date of Deaih (MO/Day/Vr) (Spell Mo)
John Michael Halley M
l
a
e 226 O N
Sa
Age-last Birthda
(V
) Sb
.
y
rs
. Under 1 Vear Sc. Under 1 Da 6. Date of BiKh (MO/Day/Year) (Spell Month) ]a. Birthplace (City and State or Forei
n Count
/[,
~1 g
ry)
Months Days Hours Minutes MaS51eE3 Mill v1r 1n1a
64
'
. Novanbar ~ ,
I 948 ]b
Birth
l
.
p
ace (cpunty) Nelson
8a. Residence (State or Foreign Country) Hb. Residence (Street and Number -Include Apt No.) 8c. pid Decedent Uye in a Township?
PA
r~S'es, decedent IlYed In North Middleton cw
Bd. Residence (County) 1 O 1 7 Harriet St
P
.
CLUN~erland 8e. Residence (Zip Code) ~ 7Q ~ 3 Q No, decedent Ilyetl within limits of
city/born.
9. Ever ih US Armed Forces] 30. Marital status at Tlme of Death Married Q Widowed 11. Surviving Spouse's Name (If wife, give name prior to flrsi marria
Q Ves ~ ryo Q Unknown Q Di
)
ge
vorced Q Never Married Q Unknown TaISLiTy Gross
'
12. Father
s Name (First, Middle, last, Suffix) 13. Mother's Neme Prior to First Marriage (First, Middle, Las[)
John L
Haifa
.
Am Hu hes
14a. Informant's Name 14b. Relationship to Decedent 14c. IMormant's Mailing Address (Street and Number, City, State, Zip Coda)
Adessa R
Miller D
ht
o _
aug
er 209 St_ Johns Church Rd_ Camp Hillr PA
a If Death Occurred In a Hos Ital: ec.-on y one ............................ •._ ... _.. .........
P t~ Inpatient pif Death Occurred Somewhere Other Than a Hos ital: ~ f[+w~[ ""'""' -
P IJ Hos
ice Fa
ilit
~~~~ """~~ -
~~~~-
J
4 c
y
P
D d
ece is Home
Q Emergency Room/Outpatient Dead on Arrival Q Nursing Home/Long-Term Care Facility Other (Specify)
15D
d . Facility Name (If not Institution, give street and number; 15c. CI[y or Town, State, and 21p Code
15d. County o1 Death
X017 Harriet St_ Carlisle, PA '1703 C
b
tmf
eriand
16s. Method of Disposition Q Burial Q Cremation 16b. Date of Disposition 16c. Place of Dlspositlon (Name of cemetery, crematory, or other place)
p Removal from state Q Donation
Other(sPe~ify) '1'1/24/2012 E<rans Crsnation Services
z i6d. Location of Dlspositlon (City or Town, State, and 21p) 1]a. Signature of Funeral Service Llcensf<ery~Charge of Interment 1]b. License Number
L
//
1
PA
~/
~ eo
a
//~`
JJ~a~CSS--
FD 0'12633 L
1]c. Name and Com lets Address of Funeral Facill~J(
.
§ F7win ~rothers Funeral Hcme
2nc
630 S
H
S
~ ,
_
_
anover
t., Car1i ter PA "I7013
38. Decedent's Education -Check th
b
h
b
,- e
ox t
at
ast describes the 19. Decedent of Hlspa nic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to indicate wh
highest degree or level of school completed at the tim
t
f d
h
a
e o
eat
. box that bezi describes whether the decedent t
h
e d
ecedent considered himself or herself to be
Q 8th grade or less
~
y
~"
.
is Spanish/Hispanic/Latino. Check the "NO" t_-t .. hate Q Korean
No diploma, 9th - 12th grade
box if decedent Is no[ Spanish/Hlspanlc/Latino. 0 Black or African American Q Vietnamese
$ H
ig
h school graduate or GED completed g1Vo
no[ Spanish/Hls
anl
/L
ti
o
r
,
p
c
a
no ~ American Indian or Alaska Native 0 Other Asian
Q 5 e college credit, but no degree Q Yes, Mexlca n
Mexican Ameri
Chi
,
can,
cano Q A:Jan Indian Q Native Hawaiian
Q Associate degree (e.g. AA, AS) Q Yes
Puerto Rican
,
Chinese
Q Bachelor's degree (e.g. BA, AB, BS) Q Yes
Ian or Chamorro
Q
Cuban Q
,
Fill
O Pino Q
Samoan
Q Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Ves, other Spanish/Hispanic/Latino Q Ja
an
p
ese Q Other Pacific Islander
Q Doctorate (e.g. PhD, Ed D) or Professional degree
S
if
(
pec
y) ~ Other (5 1
.MD DDS DVM LLB JD Pac fy)
21. Decedent's Single Race Self-Designation -Check ONLY ONE fo indicate what the decedent considered himsell or herself to be
22a
Decede
~xOVhRe
t'
V
l
.
.
n
s
sua
Occupation -Indicate type of work
Q Japanese Samoan
done Burin
Q Black or African American Q Korean Q Other Pacific Islander 8 most of working life. DO NOT USE RETIRED.
Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure Self-~TI~jlOyEd
i
I
Q A
di
s
an
n
an Q Of her Asian Q Refused
Q Chinese Q Native Hawaiian ~ Other (Specify) 22b. Kind of Business/Industry
Q FIIlpino Q Guamanian or Chamorro
Mechanic
ITEMS 2 • - 2 d MU BE OMPLETED 23a. Dale Pronounce Oead Mo Day 236. Signature of Peron Pronouncing Deat Only when a
BY PERSON WHO PRONOUNCES OR
plicabl
23
p
e
c. License Num e
CERTIFIES DEATH ~d Y, ~ ~ ~ ~ V,/r r
23d. Date Signed (MO/Day/Vr) 24. Time of Death
25. Waz Medical Examiner or Coroner Contacted?
Q Yes $~ No
CAUSE OF DEATH
Approximate
26. PCS 1. Enter the chat f t --diseases, Injuries, or complications--that directly caused the death. DO NOT enter ter
i
l
m
na
events such as cardiac arrest t Interval:
r piratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter onl
one cau
I
y
se on a
lne. Add additional lines if necessary S Onset to Death
I
MMEDIATE CAUSE ---------------> a. may` ~~` `~~ i
(Final disease or condition Due to (or as a se
con
uence
f
q
o
):
resulting In death)
b. 7
Sequentially Ilst cond)HOns, Due t
o (or sequence of):
if any, leading to the cause as a con
listed on Ilne a. Enter [he
UNDERLYING CAUSE Due to (or as a consequence of):
(disease or Injury that
F
fF initiated the events resulting d.
In death) LAST.
Due to (or as a consequence of):
S 26. PaK 11. Enter other sianlflcant dill t "b ti d h but not resulting in the underlying cause given in Part 1
•
~ 27. Was an auto
psy pertormedT
'~ Yes B~j
2B. Were autopsy findings available
to compote the cause of death?
~ 29. If Female: 30. Dld Tobacco Use Contribute to Dea[h7 31. Manner of Death Q Ves Q No
Q Not pregnant within past year
Q Yes
'
~' Q Pregnant at time of death
Q Probably .Q'Ratural Q Homicide
Q NO ~fJnknown
N
ot pregnant, but pregnant within 42 days of death
Q
Q Accident Pendin Invests
0
l
f- Q No[ pregnant, but pregnant 43 days to 1 year before death 32. Date of In Q Suicide
Could not be deter
mined
Jury (MO/Day/V r) (Spell Month)
Q U
k
f
n
nown I
pregnant within the pas[ year
33. Time of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City, Sate, Zip Code)
36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred:
Q Yes Q Drive r/Operator ~ Pedestrian
O No Q Passenger Q 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
Q Pron
i
ounc
ng 8. Certifying physician - To th best of y kn lodge, death occurred at the time, date, and place, and due to the cause(s) and m
Q Medical Examiner/Corone
O
r -
r stated
n~ basis of exawrd/or Inyestigatlon, In my opinion, death occurred ai the time, date, and place, and due to the cause(s) and m
~~
y[ _ /tom cafe
Signature of certifier: ~-~ f ~x~ - Title of certifier: , v[~ ~
3 g
3 License Number: I1L ~ ~l ~~~ ~
L-
9b. Na~e Address and ip Cod f Perso Completing Cause of Death (Item 26) 39c. Date SI
ed (M
/D
B
r-
4 o
Sy/Yr)
r
- V rf ~t. ~ ~ J) ~ _
0
Re
istr
'
Di
3
.
g
ar
s
strict N er
41. Registrar s SI ^ 42. Re Istrar FA1 a O
ate Mo Oay
10 `
4 3. Amendments
~ , a~
~T . ~, ao ~
H 105-143
REV 0]/2011
LAST WILL AND TESTAMENT
OF
JOHN M HAILEY
I, John M Hailey, of Carlisle, Pennsylvania, revoke my former Wills and Codicils and declare this
to be my Last Will and Testament.
ARTICLE I
IDENTIFICATION OF FAMILY
I am married to Tammy Hailey and the failure of this Will to provide for any distribution to Tammy
Haney is intentional.
The names of my children are Adessa Miller and Michael Hailey. All references in this Will to "my
children" are references to the above-named children.
ARTICLE II
PAYMENT OF DEBTS AND EXPENSES
I direct that my just debts, funeral expenses and expenses of last illness be first paid from my
estate.
~
,-- ~'
ARTICLE III ° ~ °~'
_. _:~, ~~
PET CARE DIRECTIVES
=~=~~~ _
`''
'-~: {=~'
Notwithstanding any other provision of this Will, I further direct that:
`~ N
,.
~,
~., t.
~ .
_ .
_-
- _-~
I give my following pet(s): ~ - ~ `::' ~-= ~--
crt ~~~ Q
+v -„
cat, Simba
and any other animals which I may own at the time of my death, to Judy Hailey, presently residing
at 209 Louise Court, Enola, Pennsylvania 17025, with the request that (s)he treat them as
companion animals. If (s)he is unable or unwilling to accept my animals, I give such animals to
Michael Hailey, presently residing at 17 West Pomfret Street apt12, Carlisle, Pennsylvania 17013,
with the request that (s)he treat them as companion animals. If (s)he is unable or unwilling to
accept my animals, my Executor shall select an appropriate person to accept the animals and treat
them as companion animals, and I give my animals to such person.
ARTICLE IV
DISPOSITION OF PROPERTY
Residuary Estate. I direct that my residuary estate be distributed to my children in equal shares. If
a child of mine does not survive me, such deceased child's share shall be distributed in equal shares
to the children of such deceased child who survive me, by right of representation. If a child of mine
does not survive me and has no children who survive me, such deceased child's share shall be
distributed in equal shares to my other children, if any, or to their respective children by right of
representation. If no child of mine survives me, and if none of my deceased children are survived
by children, my residuary estate shall be distributed to Judy Hailey, Enola, Pennsylvania. If such
beneficiary does not survive me, my residuary estate shall be distributed to my heirs-at-law, their
identities and respective shares to be determined under the laws of the State of Pennsylvania, then
in effect, as if I had died intestate at the time fixed for distribution under this provision.
ARTICLE V
NOMINATION OF EXECUTOR
I nominate Adessa Miller, of Camp Hill, Pennsylvania, and Michael Hailey, of Carlisle,
Pennsylvania, as Co-Executors (the "Executor"), without bond or security. If one of the above
nominees does not serve for any reason, the remaining nominee shall serve as sole Executor
without bond or security.
ARTICLE VI
EXECUTOR POWERS
My Executor, in addition to other powers and authority granted by law or necessary or
appropriate for proper administration, shall have the right and power to lease, sell, mortgage, or
otherwise encumber any real or personal property that may be included in my estate, without
order of court and without notice to anyone.
My Executor shall have the right to administer my estate using "informal", "unsupervised", or
"independent" probate or equivalent legislation designed to operate without unnecessary
intervention by the probate court.
ARTICLE VII
SPECIAL DIRECTIVES
I, hereby state, that in addition to the directives and bequests as set forth in this Will, it is my desire
and wish to include the following special directives and last wishes:
ARTICLE VIII
MISCELLANEOUS PROVISIONS
A. Paragraph Titles and Gender. The titles given to the paragraphs of this Will are inserted for
reference purposes only and are not to be considered as forming a part of this Will in interpreting
its provisions. All words used in this Will in any gender shall extend to and include all genders, and
any singular words shall include the plural expression, and vice versa, specifically including "child"
and "children", when the context or facts so require, and any pronouns shall be taken to refer to
the person or persons intended regardless of gender or number.
B. Liability of Fiduciary. No fiduciary who is a natural person shall, in the absence of fraudulent
conduct or bad faith, be liable individually to any beneficiary of my estate, and my estate shall
indemnify such natural person from any and all claims or expenses in connection with or arising out
of that fiduciary's good faith actions or nonactions of the fiduciary, except for such actions or
nonactions which constitute fraudulent conduct or bad faith. No successor trustee shall be obliged
to inquire into or be in any way accountable for the previous administration of the trust property.
C. Intentional Exclusion. The failure of this Will to provide for any distribution to the following
person(s) or organization(s) is intentional: Tammy Hailey (wife)
D. Beneficiary Disputes. If any bequest requires that the bequest be distributed between or among
two or more beneficiaries, the specific items of property comprising the respective shares shall be
determined by such beneficiaries if they can agree, and if not, by my Executor.
IN WITNESS WAEREOF, I have subscribed my name below, this / `~ day of
~.r1-fh°i-" ~~ O ~ L.
Testator Signature: ~ '
Jo Hailey
We, the undersigned, hereby certify that the above instrument, which consists of ~] pages,
including the page(s) which contain the witness signatures, was signed in our sight and presence by
John M Hailey (the "Testator"), who declared this instrument to be his/her Last Will and Testament
and we, at the Testator's request and in the Testator's sight and presence, and in the sight and
presence of each other, do hereby subscribe our names as witnesses on the date shown above.
Witness Signature: "`~ ~~XJ~~-
Name: William Roberts
City: Carlisle
State: Pennsylvania
Witness Signature:
Name:
City:
State:
Joe Byers
Mechanicsburg
Pennsylvania
Witness Signature:
Name: dy Haile
City: nola
State: Pennsylvania
PENNSYLVANIA
Self-Proving Clause
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
I, John M Hailey, the Testator, whose name is signed to the attached or foregoing instrument,
having been duly qualified according to law, do hereby acknowledge that I signed and executed
the instn~ment as my Last Will; that I signed it willingly and as my free and voluntary act for the
purposes expressed in the instrument.
Sworn to or affirmed and acknowledged before me by John M Hailey, the Testator, this ~~
day of ~~ }-P,,..~ ~~ Z ° i
Testator Signature
John M H ley
~ __
Co MoNyyEq~TH pp pENNSYlVgN~q Signa a of officer
Fora M. Vopf, Np ~ public
No-d~CwP . CumoNynd County
Member. Pennsylvan~~ ~Y 21.2013
AssodaNon o/~aries
Official capaci of officer
(Seal)
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
We, William Roberts and Joe Byers and Judy Hailey the witnesses whose names are signed to the
attached or foregoing instrument, being duly qualified according to law, do depose and say that we
were present and saw the Testator sign and execute the instrument as the Testator's Last Will; that
the Testator signed willingly and executed it as the Testator's free and voluntary act for the
purposes expressed in it; that each of us in the hearing and sight of the Testator signed the Will as a
witness; and that to the best of our knowledge the Testator was at that tune 18 or more years of
age, of sound mind and under no constraint or undue influence.
Sworn to or affirmed and subscribed to before me by William Roberts and Je~Byers and Judy
Hailey, witnesses, this ~ day of -~L~,~~ o~ , ~ c~~ ~7
Witness Signature:
Name: William Roberts
City: Carlisle
State: Pennsylvania
Witness Signature:
Name: Joe Byers
City: Mechanicsburg
State: Pennsylvania
Witness Signature:
Name: Judy Hail
City: Enola
State: Pennsylvania
CO MONWEALTH OF PENNSYLVANIA
Notarial Sed
Fora M. Vogt, Notary Publte
North MiddNAar Twp., Curnbarlfr-d County
My ComrMssbn F.xpiros May 21, T01S
gembe*, Pennsylvania Assodation of Notaries
rn
Signature
~ .~ ~~~c
Seal and officia capacity of officer