HomeMy WebLinkAbout11-30-12
PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF LLBIo 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' Information .
Name: C' l~G l- ~K 11 F1 File No:
a/k/a: (Assigned by Register)
a/k/a:
n ~
a/k/a: Social Security No: G'~J "
Date of Death: 1) ~ ~ / Age at death:
Decedent was domiciled at death in C y/i U U Cou . ty, ` (State) ith hid/her last
principal residence at 7J I' 3 I Hj,t,.y'
Street address, Post Office and Zip Code City, Township or Borough Con
Decedent died at i 70 is Gy~,( V e ~[i,,y(~~Pa't!d G(~.lt A ,
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 $ c o,
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.... $ / JJ
Real estate in Pennsylvania situated at: I
(Attach additional sheets, (fnecessary) 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/are the Executor(s) named in the last Will of the Decedent, dated /°``-and Codicil(s)
thereto dated "
State relevant circumstances (e.g. renunciation, 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.
-gNO 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, durante 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 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. r
❑NO EXCEPTIONS ❑ EXCEPTIONS M .
Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by thT911174Ding spous anyfmd its (attach
additional sheets, if necessary): M ED -V C7 C-1 G r:;y
Name Relationship ~d O-S s~ O "
C7 =3 ct
GO
Form n w-02 rev. 101112011 Page 1 of 2
Oath of Personal Representative Official Usc Only
COMMONWEALTH OF PENNSYLVANIA }
SS:
COUNTY OF
etinoner(s)?Tinted Name Pen:iunerls Printed :Address
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregom '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 Petiti ne (s L11 the estate according to law. 1
Sworn to or affirmed a bscri ed b ore L Date { W~ l
met 's flay f Date
-AIA
By: i M7 '?M/1714 Date
F e Register Date
BOND Required: ❑YES To the Register of Wills:
FEES: Please enter my appearance by my signature below:
Letters Attorney Signature: C1 :L9
( Short Certificate(s)...... p r~ m
( ) Renunciation(s).........
t
( ) Codicil(s) C')
Y,.
( ) Affidavit(s)............ CD
Bond Printed Name: _ cr)
Commission Supreme Court S'. ^rt s'
Other ID Number:
• • • • Firm Name:
Address: r--
Phone:
Automation Fee Fax:
JCS Fee . S Email:
TOTAL $
DECREE OF THE REGISTER
Estate of k~,r(?~ V File No: I-~ -
a/Wa:
AND NOW, ~V~~~~~/ in consideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Lette
are hereby granted to Lf LC j S A'V - D 1 e> -~,n a
in the above estate and (if applicable) that
the instrument(s) dated 1'C - ~ l 19 C /
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
Register of Wills M/1
Form Rw-n2 rev, tni1112nt1 Page 2 of 2
W01X1)i HI A' "I I,
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
RECORDED OFFICE OF
Fee for this certificate, $6.00 REGtSTIfER OF `,PLLS is t( u'uil~ that the information here gig°eit is
corrc tl~ copc(_l t)om an original Certificate of Death
' d dLIk tJli_cl with nic is Local Registrar. The original
z01? i OsUt 30 Fn `i 16 ~ O
cc tacate ill he lorwatded to the State Vital
kccortk Office tin- permanent filing.
CLERIC OF
P 18 8 8 8 3 3 6RPHANS- COURT NO
5/20 2
Certification Number CUMBERLAND C:0., PA MrfVTr~~?~''i
[,Deal Re(_,)strar Date issued
y~
Type/Print In COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS
Permanent
Black Ink CERTIFICATE OF DEATH State File Number:
1. Decedent's Legal Name (First, Middle, Last, Suffix) Z. Sex . Social Security Number 4. Date of Death (MO/Day/Yr) (Spell M.)
Petra E. Die££enbach FemalJ3
209-60-7715 November 3, 2012
S.- Age-Last Birthday (Yrs) Sb. Untler 1 year 5c. Under 1 Da 6. Date of Birth (MO/Day/Year) (Spell Month) 7a 'rth lace,(City anQ State or Foreign Country)
52 M,ntns Davs H,prs Min tes Au 11, 1960 N13anglelm, rmany
g 7b. Birthplace (County)
Sa. Residence (State or Foreign Country) 86. Residence (Street and Number - Include Apt No.) Be. Did Decedent Live in a Township?
PA 133 "S" Street Yes, decedent lived in
8d. Residence (County) twP.
Cumberland 8e. Residence (Zip code) 17013 0No, decedent lived within limits of Carlisle city/boro.
9. Ever in US Armed Forces? 10. Marital Status at Time of Death IN Married E3 Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage)
Yes No Q Unknown 0 Divorced E:1 Never Married Cl Unknown L2w1s Dle££enbach
12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (Firs[, Middle, Last)
unknown Helga CUnknown)
14a. Informant's Name 14b. Relationship to Decedent 14c.1Informant's Mailing Address (Street and Number, City, State, Zip Code)
Lewis Die££enbactL Husband 33 "B" Street, Carlisle, PA 17013
0
b ..........................................................y
1sa. pace of
. neat <c. ec, on.y one
t++**rr
If Death Occurred in a Hos Ikal: tJ In - -Spice F--
p pat _If Death Occurred Somewhere Other Than a Hospital: t.l H -Oacilit.y Decedent's Home
Q Emergency Room/O U[patlen[ Q De Dead on Arrival Q Nursing Home/Long-Term Care Facility Q Other (Specify)
15 b. Facility Name (if not institution, give street and number; .lsc. City ,r Town, State, and Zip Code lstl. County of Death
133 B" Street Carlisle, PA 17013 Cumbe lan
16a. Method of Disposition Q Burial Cremation 16b. Date of Disposition 16c. Place of Dispos -c- (Name of cemetery, crematory, or other place)
O Removal fr,m state p D,nati,n Nov 10, 2012 Ho££man-Roth Funeral Home Crematory
cc p other(Specify)
16d. Location of Disposition (City or Town, State, and Zip) 17a. Sign
atu of Funeral Serv' is o Interment 176. License Number
Carlisle, PA 17013 138504
0 It. Name and Complete Address of Funeral Facility
Ho££man-R
m 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
.2 highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be.
E] 8th grade or less is Spa nlsh/Hispanic/Latino. Check the "No" White Q Korean
No diploma, 9th - 12th grade box if decedent is not Spanish/Hispanic/Latino. C3 Black or African American Vietnamese
W High school graduate or GED completed EX No, not Spanish/Hispanic/Latino 0 American India, or Alaska Native 0 Other Asian
Some college credit, but no degree Q Yes, Mexican, Mexican American, Chicano Q Asian Indian Native Hawaiian
Associate degree (e.g. AA, AS) E3 Yes, Puerto Rican
Bachelor's degree (e. g. BA, AB, RS) Q Yes, Cuban Chinese Q Guamanian or Chamorro
Filipino 0 Samoan
Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) ID Yes, other Spanish/Hispanic/Latin, Japanese Q Other Pacific Islander
Doctorate (e.g. PhD, EdD) or Professional degree (Specify) 0 Other (Specify)
MO, ODS, DIM LLB, j0
21. Decedent's Single Race Serf-Designs[ton - Check ONLY ONE to indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation - Indicate type of work
IM White C:] Japanese C3 Samoan done during most of working life. DO NOT VSE RETIRED.
0 Black or African American E3 Korean 0 Other Pacific Islander Packer
0 American Indian or Alaska Native Vietnamese Lj Don't Know/Not Sure
0 Asian Indian 0 Other Asian E3 Refused 22b. Kind of Business/Industry
E3 Chinese E:3 Native Hawaiian [:3 Other (Specify)
p Filipino O Guamanian or Chamorr, Pet Food Mfg'
ITEMS 23a -;WHO M PRONOV NOES VST BE COMPLETED 23 Cate Pronounced
By PERSO Dead (MO/Day Vr) 23 Signature of Person Pronouncing Death (Only when applies blel 23c. License Number
N ORf ~
CERTIFIES DEATH J - - C~ /f - ~CF//-
3 ate Signed Mo/Da)({jYr) 24. Time of Death ; ^O~~ ,~r/ ti /,t[/
Oc/ 25. Was Medical Examiner or Coroner Contacted? Q Yes Q~}y6
CAUSE OF DEATH
26. Part 1. Enter the chain of events
--diseases, injuries, or complications--that directly ,used the death. DO NOT enter terminal App
arrest Interoxirvmate
events such as cardiac
al:
respiratory arrest, or ventricular fibrillation withhopoutt~ showing the etiology. DO NOT qgg REV1ATE. Enter only one cause on a line. Add additional lines If necessary Onset to Death
IMMEDIATE CAUSE a. ~Q2 _/V__.a!-•~/`/ Ar/~i>• _i
(Final disease or c.En---------------
ndition (or as a cons ~'~-S
resulting In death) w quence
b.
Sequentla liy list conditions, Due to (or as a consequence of):
If any, leading to the cause
listed on line a. Enter the
UNDERLYING CAUSE Due to (or as a consequence of):
(disease injury that
F Initiated the events resulting d.
in death) LAST. Due to (or as a consequence of):
26. Part 11. Enter other significant co dItions contrib ti v death but not resulting in the underlying cause given in Part 1 27. Was a autopsy performed?
M Yes 13P-4.
128. Were autopsy findings available
m to com Piet. the cause of death?
0 Yes Q ~o
29. If Fema}~: 30. Did Tobacco Use Contribute to Death? Meath
o ® t pregnant within pas[ year 31. anner of Death
E3 Yes Probably [~~ural Homicide
Pregnant at time of death No known 0 Accident Pending Invest)
m Q Not pregnant, but pregnant within 42 days of death Hatton
i- 0 Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury Suicide 0 Could not be determined
E3 Unknown if pregnant within the past year ry (Mo/Day/Vr) (Spell Month)
33. Time of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 3S. Location of Injury (Street and Number, City, State, Zip Code)
36. Injury at Work 137- If Transportation Injury, Specify: 38. Describe How Injury Occurred:
0 Yes Ej Driv.r/Operator IF_-] Pedestrian
No Lj] Passenger Q Other (Specify)
39a. C;e1f i (Check only one):
C rtifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated
0 Pronouncing & Certifying hys ician - To t t of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated
E3 Medical Examiner/C,ron - On of examination, and/or investigation, in my opinion, death o ed at the time, date, and place, and due to (s) and manner stated
Signature of certifier: Title of certifier: K License Numbef:-- ,c~9
39b. Nam dr s ~ip C,tl of Person Completing Caus f D th Ite~ 6) T Q 39c, pate Signed (fvlo/pay/Vr)
40. Regis ar-s District Number t.~li~,7~` 41. R gistra is S ture '~a, 42. Regist r Filteat-e (ay/Yr)
43. Amendments
SaO_
Y
-143
Disposition Permit No. \ ) 1 \ ~J L~l R E HV 300 77/20/20
11
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LAST WILL AND TESTAMENT ' M
OF
- r.
PETRA E.DIEFFENBACH - 3
I, Petra E. Dieffenbach, 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 Lewis M. Dieffenbach and all references in this Will to "my spouse" are references
to Lewis M.. Dieffenbach.
The name of my child is Denise M. Braun. All references in this Will to "my children" are
references to the above-named child.
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
DISPOSITION OF PROPERTY
A. Specific Bequests. I direct that the following specific bequests be made from my estate.
However, such bequests (other than bequests, if any, to my spouse or my children) shall be made
only if my spouse, Lewis M.. Dieffenbach, and my children do not survive me.
My remaining tangible personal property shall be distributed to Lewis M.. Dieffenbach. If this
beneficiary does not survive me, this bequest shall be distributed to Denise M. Braun. If this
beneficiary does not survive me, this bequest shall be distributed with my residuary estate.
B. Residu Estate. I direct that my residuary estate be distributed to my spouse, Lewis M.
Dieffenbach. If my spouse does not survive me, my residuary estate shall 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 my spouse's
heirs-at-law, their identities and respective shares to be determined under the laws of the State of
Pennsylvania, then in effect, as if my spouse had died intestate at the time fixed for distribution
under this provision.
ARTICLE IV
NOMINATION OF EXECUTOR
I nominate Lewis M.. Dieffenbach, of Carlisle,Pa., as the Executor, without bond or security.
ARTICLE V
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 VI
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. Thirty Day Survival Requirement. For the purposes of determining the appropriate distributions
under this Will, no person shall be deemed to have survived me unless such person is also surviving
on the thirtieth day after the date of my death.
C. Common Disaster. If my spouse and I die under circumstances such that there is no clear or
convincing evidence as to the order of our deaths, or if it is difficult or impractical to determine
which person survived the death of the other person, it shall, for the purpose of distribution of my
life insurance, property passing under any Trust or other contracts, if any, and property passing
under this Will, be conclusively presumed that I predeceased my spouse, and notwithstanding any
other provision of this Will, my spouse (or my spouse's estate as the case may be) shall receive the
distribution to which my spouse would otherwise be entitled to receive without regard to a
survivorship requirement, if any.
D. 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.
IN WITNESS WHEREOF, I have subscribed my name below, this 3 day of
®Cy-vj~; ' 2c I .
Testator Signature:
Petra E. i=fenbach
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 Petra E. Dieffenbach (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:
Name: Kim Smith
City: Landisburg
State: Pennsylvania
Witness Signature:
Name: Phil Smith
City: Landisburg
State: Pennsylvania
Witness Signature:
Name: Diane Gray
City: Carlisle
State: Pennsylvania
PENNSYLVANIA
Self-Proving Clause
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
I, Petra E. Dieffenbach, 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 instrument 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 Petra E. Dieffenbach, the Testator, this
,31 dayof OC- o6e-C- , 2e}/L
Testator Signature
Petra E.Dieffenbach
Signa of officer
"4uvym/ t ?k'~ L' C'
Official capacity of officer
(Seal)
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
ROLAND L. DOYLE JR., Notary Pubbc
Mechanicsburg Boro., Cumberland Co
My Commission Expires December 31, 2012
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
We, Kim Smith and Phil Smith and Diane Gray 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 time 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 Kim Smith and Phil Smith and Diane Gray
the witnesses, this 3 i day of C to- ~ ~ z
Witness Signature: _ 4/4
Name: Kim Smith
City: Landisburg
State: Pennsylvania
Witness Signature: ? ?il `
Name: Phil Smith
City: Landisburg
State: Pennsylvania
f!
Witness Signature:
Name: Diane Gray
City: Carlisle
State: Pennsylvania
l
Signature
A10,1 b•% 5k~ C-
Seal and official capacity of officer
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
ROLAND L. DOYL JR., Notary Public
Mechanicsburg Soro., Cumberland Courtly
My Commission Expires December 31, 2012