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HomeMy WebLinkAbout11-20-12 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 requests the grant of Letters in the appropriate form: Decedent's Information Name: Gerald J. Hartman File No: 21~ a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: 168-18-6753 Date of Death: 10/03/2012 Age at Death: 91 Decedent was domiciled at death in Cumberland County, PA (State) with his/her last principal residence at 5285 Dogwood Court Lower Allen Township Cumberland Street address, Post Office and Zip Code City, Township or Borough County Decedent died at 5285 Dogwood Court Lower Allen Township Cumberland PA 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 $ 450,000.00 If not domiciled in Pennsylvania Personal property in Pennsylvania $ If not domiciled in Pennsylvania Personal property in County $ Value of real estate in Pennsylvania........... $ TOTAL ESTIMATED VALUE$ 450,000.00 Real estate in Pennsylvania situated at (Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough County ❑X A. Petition for Probate and Grant of Letters Testamentary Petitioner(s) aver(s) that he/she/they is/are the Executor(s) named in the Last Will of the Decedent, dated 0 211 2/2 0 04 and Codicil(s) thereto dated (The Executrix named - Solita L. Hartman - passed away on November 9, 2012 and thereupon, Judith Hartman and Gary G. Hartman - became authorized to act. Judith Hartman as c osen to renounce. (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. Q NO EXCEPTIONS ❑ EXCEPTIONS ❑ B. Petition for Grant of Letters of Administration (If applicable) c..a.; ..n.; ..n.c..a.; pe en e I e; uran e absentia; uran a minor-Ma e 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 pending divorce proceeding wherein the grounds for divorce had been established as defined r in 23 Pa. C.S. § 3323 (g) and was neither the victim of a killing nor ever adjudicated an incapacitated person. C-) ❑X NO EXCEPTIONS F1 EXCEPTIONS ~.t < , Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and"fitirs-(aftach LT- additional sheets, if necessary): N 1-'-1 r r= Name Relationship Address CSC x~ - D 1 CIt Qn n c Form RW-02 rev. 10-11-2011 Copyright (c) 2011 form software only The Lackner Group, Inc. Page 1 of 2 Oath of Personal Representative Official Use Only COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF Cumberland } Petitioner(s) Printed Name Petitioner(s) Printed Address Gary G. Hartman P.O. Box 17119 r ° T L7 _ N Snowmass Village, CO 81615 rr O ri { `T1 .:.f3 C1 C:) 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, I~etitioner(s) will well and truly administer the estate accordin o law. Sworn to r affirmed and subscribed before J Date m ay of Date Date For the Register Date BOND Required? ❑ Yes ❑R No To the Register of Wills: FEES Please enter my appearance by my signature below: Letters $ 410.00 Attorney Signat ( 6 > Short Certificate(s).......... 24.00 ( 1 > Renunciation(s) 5.00 ( > Codicil(s) ( ) Affidavit(s) Printed Name: Richard E Connell Esq Bond Supreme Court Commission ID Number: 21542 Other Will .00 Firm Name: Ball, Murren & Connell Address: 2303 Market Street Camp Hill, PA 17011 Phone: 7171232-8731 Automation Fee 5. Fax: 717/232-2142 JCS Fee 0 . 0 TOTAL $ 482.50 E-mail: connell@bmc-law.net DECREE OF THE REGISTER Date of Death: 10103/2012 Social Security No: 168-18-6753 Estate of Gerald J. Hartman File No: 21-- a/k/a: AND NOW, 2 in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters Testamentary are hereby granted to Gary G. Hartman in the above estate and (if applicable) that the instrument(s) dated 02/12/2004 described in the Petition be admitted to probate and filed of record a ,t a last Will (and Codicil(s)) of Decedent. Ti ~ru ) ' toa td~l I Register of Wills T ' p- lwo'-~ ik\i, ti Form RW 02 rev. 10-11-2011 Copynght (c) 2011 form software only The Lackner Group, Inc. Page 2 of 4 UU LAST WILL AND TESTAMENT OF GERALD J. HARTMAN r , KNOW ALL MEN BY THESE PRESENTS, that I, GERALD J. , HARTMAN, presently residing at 133 Deerfield Road, Lower Allen Tiwnship, c.. Cumberland County, Pennsylvania, do hereby make, declare and publish this as my Last Will and Testament, hereby revoking all former Wills and Codicils heretofore made by me at any time. I. Payment of Expenses. I direct that my Executrix, hereinafter named shall have the power, but not the duty, to pay all my just debts, expenses of my last illness, and funeral expenses from my estate as soon after my death as shall be found convenient. GIFTS II. Personal and Household Effects. (a) I bequeath my automobiles, household and personal effects, including such household goods, if any, as may be my individual property and not the property of my wife, SOLITA L. HARTMAN, or owned jointly by me with her, and other tangible personalty of like nature (not including cash or securities), together with any existing insurance thereon, to my wife, SOLITA L. HARTMAN, if she survives me by thirty (30) days. (b) Should my wife, SOLITA L. HARTMAN, predecease me or not be living on the thirty-first day after my death, I bequeath such tangible personalty and insurance thereon to my issue, per stirpes, living on the thirty-first day after my death, to be divided among them by my Co-Executors with due regard for their personal preferences in as nearly equal shares as practical, provided, however, in the absence of agreement or if any of them is a minor, then as my Co-Executors deem appropriate; provided that articles not so divided shall thereafter be disposed of by my Co-Executors by public sale or in such manner as my Co-Executors shall select and all proceeds therefrom shall form a part of the residue of my estate hereinafter disposed of. I direct that the expense of packing, shipping, insuring, and delivering any such property to a beneficiary entitled th reto shall be paid by the Co-Executors as an administrative expense of my estate.p r:> o rn c7 T -4 e C_ D Cn -1- cc I intend to leave a memorandum setting forth suggestions as to the distribution of certain items, and while the memorandum is not to be legally binding, I hope that suggestions in it will be carried out. III. Rest, Residue and Remainder: A. Gift to Spouse. I give, devise and bequeath the rest, residue and remainder of my estate, whether real, personal or mixed and of any nature whatsoever and wherever situated, to my beloved wife, SOLITA L. HARTMAN, if she survives me by thirty (30) days. B. Specific Bequests. If my wife should predecease me or not be living on the thirty-first (31S) day after my death, I give the following gifts to the individuals named provided however that for any individual then below the age .)f thirty (30) years, the share shall be held, IN SEPARATE TRUST, by my Trustee, herein named, as provided below: KEITH NEIJSTROM (my grandson) - Five Thousand ($5,000) Dollars; and Ten Thousand ($10,000) Dollars each to the following: KATRINA NEIJSTROM GIARDINO (my granddaughter); KEVIN NEIJSTROM (my grandson); KENNY NEIJSTROM (my grandson); KERRY NEIJSTROM (my granddaughter); KAREN NEIJSTROM (my granddaughter); JEFFREY HARTMAN (my grandson); BRIAN HARTMAN (my grandson); KIMBERLY HARTMAN (my granddaughter); The amount for my grandson, Keith, is intentional and not an oversight. The $5,000 bequest above-mentioned shall be the only gift to him. 1. For any trust created for any beneficiary above listed below the age of thirty (30) years, the income of the trust shall be accumulated. The principal and income of such Trust may be distributed by the Trustee at his sole discretion from time to time for the beneficiary's support, maintenance or education without regard to his or her ability to pay. The Trustee shall have no further responsibility for any funds so paid or applied. -2- 2. The beneficiary of a separate trust shall have the right to withdraw the entire balance (principal and accumulated income) thereof at any time after reaching thirty (30) years of age. 3. If any of the beneficiaries for whom a Trust has been established above shall predecease me or die before distribution of any share to which they would have been entitled had they survived, the respective share shall be paid: 1) To his/her then living descendants, per stirpes; or in default of such descendants, 2) To my then living descendants, per stirpes (any portion thus accruing to a child for whom principal is then held in trust hereunder to be added to and thereafter treated as part of such principal). C. Residue. If my wife, SOLITA L. HARTMAN, predeceases me, or is not living on the thirty-first (31S) day after my death, I give, devise and bequeath all the rest, residue and remainder of my estate after the specific bequests above-made in III. B., whether real, personal or mixed, as follows: 1. If the rest, residue and remainder of my net estate after specific bequests above-provided plus taxes, debts and expenses and allowable deductions exceeds Five Hundred Thousand ($500,000) Dollars I give the sum of Five Thousand ($5,000) Dollars each to the following charitable entities or their successors: SALVATION ARMY, 1122 Green Street, Harrisburg, PA 17102; AMERICAN RED CROSS (local chapter), 1804 N. 6th Street, Harrisburg, PA; CATHOLIC RELIEF SERVICES, P.O. Box 17090, Baltimore, MD 21203-7090; CFCA (CHRISTIAN FOUNDATION for CHILDREN and AGING), One Elmwood Drive, Kansas City, KS 66103; HELPING HANDS for HONDURAS, 3700 Big Ben Road, Virginia Beach, VA 23542. Should any of the named charities not be in existence at the time of my death and have no successor entity whether by merger or acquisition, their share shall be distributed proportionately among the other charitable beneficiaries -3- identified in this paragraph. 2. If my net estate as above described in III. C. 1 does not exceed Five Hundred Thousand ($500,000) Dollars, the charitable gifts are not payable. The determination of the value of the net estate is at the sole discretion of the Co- Executors, and their calculation shall be deemed final. If any charity named challenges the determination of the net value of the estate, the gift to it shall be cancelled. Should the Attorney General challenge the determination of the net value of the estate, all charitable gifts provided for above are cancelled. 3. The rest, residue and remainder of my estate after the gifts set forth in III. B. and payment, if any, of the possible gifts in III. C. 1 and 2, shall be divided in the following proportions: 16 2/3 % to my son, GARY HARTMAN; 33 1/3 % payable to my Trustee, IN TRUST, for the benefit of my daughter, JUDITH; and 50% to my Trustee, IN TRUST, for my daughter JOAN, under the terms and circumstances provided herein. a) The income from the trust for the benefit of JUDITH is to accumulated and invested as part of the trust corpus. If JUDITH leaves the religious order of which she is now a member (or any successor religious order of the Sisters of Christian Charity), the trustee shall pay to her the principal and accumulated income from the trust and the trust shall end. If my daughter, JUDITH, remains a member of the religious congregation until her death, then, upon her death, the trust corpus, including principal and accumulated income, shall be paid to the Sisters of Christian Charity, Mallinckrodt Convent, Mendham, New Jersey (or the successors to that religious congregation). b) The trust created under this paragraph for my daughter, JOAN, shall be used for the following purposes: 1) the income from the trust shall be payable to her on a quarter-annual or such other convenient basis as the trustee determines; 2) the principal shall, on an annual basis, on the anniversary of my death, be payable to her in fractional shares beginning at 1/15 for the first year, 1/14 for the second year, 1/13 for the third year, and so on, until, on the fifteen anniversary of my death, the entire balance of the trust, including principal and accumulated interest, shall be payable outright to JOAN and the trust shall then terminate. c) If my son, Gary, predeceases me, his share shall be paid as -4- follows: 1) To his then living descendants, per stirpes, or in default of such descendants, 2) To my living descendants, per stirpes. d) If my daughter, Joan, predeceases me or dies before her trust has been fully paid, her share or the remainder of her trust shall be paid as follows: 1) To her living descendants, per stirpes, or in default of such descendants, 2) To my living descendants, per stirpes. IV. Power of Appointment. No provisions of this Will shall exercise any power of appointment I may have. V. Adopted Persons. For the purposes of this Will, adopted persons shall be considered children of their adoptive parents, and they and their descendants shall be considered descendants of their adoptive parents, regardless of the date of adoption. FIDUCIARIES VI. Executrix: I hereby nominate, constitute and appoint my wife, SOLITA L. HARTMAN, as Executrix of this, my last Will and Testament. In the event that my said wife shall predecease me, or be unwilling or unable to act as Executrix, then I nominate, constitute and appoint my son, GARY G. HARTMAN, and my daughter, JUDITH HARTMAN (a.k.a. SISTER SHARON OF THE SISTERS OF CHARITY), as Co- Executors of this my Last Will and Testament. VII. Trustee. I hereby nominate, constitute and appoint my son, GARY G. HARTMAN, as Trustee of the Trust or Trusts created by this Will. If Gary is unable or unwilling to serve, I name DONALD A. HARTMAN, my brother as Trustee of the Trusts. VIII. Bond. I direct that my Executrix or her successors, any Trustee appointed hereunder or successor and any guardian appointed hereunder shall not be required to give bond or other security for the faithful performance of their duties in any jurisdiction. IX. Resignation. Any individual Executrix (Executor) may resign at any time without court approval. -5- X. Compensation. No compensation shall be paid from the estate to my Executrix (Executor). However, expenses incurred in the performance of their duties are reimbursable. XI. Protective Provisions. To the extent permitted by law, the interest of beneficiaries in principal or income shall not be subject to the claims of their creditors and others, nor to legal process, and shall not be voluntarily or involuntarily alienated or encumbered, except that nothing in this article shall preclude the assignment of all or any part of a beneficiary's interest to his descendants. Further, exceptions may be made if my Trustee approves. XII. Early Ending of Trusts: The Trustee, at his discretion, may exhaust all of the principal and income in carrying out the purposes of the Trusts herein created and should the amount held in trust be or become so small as to make it impractical or economically unfeasible to continue holding any amount in trust, the Trustee may pay the total amount of said Trust directly to the beneficiary of such Trust. XIII. Management Provisions: My Executrix and Trustee shall have, in addition to the powers and authority conferred upon them by law, the following additional powers and authority: A. Sell/Lease: To sell at public or private sale, exchange, lease, mortgage or pledge any property, real or personal, at any time, and upon such terms and conditions as they shall deem wise. B. Retain/Invest: To retain and to invest in all forms of real and personal property, including common trust funds, mutual funds and money market deposit accounts regardless of any limitations imposed by law on investments by executors or trustees, or any principle of law concerning investment diversification. C. Title to Property: To cause any security or other property which may constitute a portion of a Trust to be issued, held or registered in their own name, or in the name of a nominee, or in such form that title will pass by delivery. D. Capital Changes: To consent to the reorganization, consolidation, readjustment of the financial structure, or sale of the assets of any corporation or other organization, the securities of which constitute a portion of a Trust or of my estate, and to take any action with reference to such securities which, in the opinion of the Trustee of Executrix is necessary to obtain the benefit of any such reorganization, consolidation, readjustment or sale; to exercise any conversion privilege or subscription right given to -6- them as the owner of any securities constituting a portion of a Trust or of my Estate; to accept and hold as a portion of a Trust or of my Estate securities resulting from any reorganization, consolidation, readjustment, sale, conversion or subscription. E. Expense of Trust or Estate: To pay all costs, taxes, charges and expenses in connection with the administration of a Trust or of my Estate. F. Allocate: To determine what is "income" and what is "principal" hereunder, and their decision thereon shall be final; and to purchase securities at a premium or discount, and to apply or charge said premium or discount against income or principal as the Trustee or Executrix may determine. G. Borrow: To borrow money from any person, firm or corporation, for the purpose of protecting and preserving or improving my Trust or Estate hereunder; to execute promissory notes or other obligations for amounts so borrowed. TAX PROVISIONS XIV. Marital Deduction. No property ineligible for the marital deduction shall be used to satisfy that deduction. Property distributed in kind in satisfaction of the marital deduction shall be distributed at the lower of (i) its value at the time of distribution and (ii) its adjusted Federal Income Tax basis. Subject to the foregoing, my Executrix shall have absolute discretion in selecting the property to be allocated to the Marital Deduction. In calculating the amount of the marital deduction, (i) all other property which qualifies for the marital deduction and (ii) all other deductions and credits which are allowed in the calculation of the federal estate tax in my estate shall be considered first. However, credits will be used only to the extent that their use will not increase the death taxes on my estate. XV. Death Taxes. I direct that all transfer and inheritance taxes, state or Federal assessed because of my death, whether the funds, property or insurance proceeds to which such taxes are attributable pass under this Will or not, shall be paid out of my residuary estate; that my Executrix pay, or provide for payment of all such taxes at such time or times, and in such manner as my Executrix deems best. XVI. Tax Options. I authorize my Executrix: A. Death Taxes. To exercise any options available in determining and paying death taxes in my estate; B. Income Taxes. To join with my wife in filing a joint income tax -7- return; and C. Gift Taxes. To consent to any gifts made by my wife being treated as having been made one-half by me for the purpose of laws relating to gift tax. IN WITNESS WHEREOF, I, GERALD J. HARTMAN, the Testator of this, my Last Will and Testament, typewritten on nine (9) sheets of paper which I have identified at the bottom of each page by my signature, hereunto set my hand and seal the day of 52004. (SEAL) GERA J. HARTMAN -8- The preceding instrument consisting of this and eight (8) other typewritten pages each identified by the signature of the Testator, GERALD I HARTMAN, was on this day and date thereof signed, published and declared by GERALD I HARTMAN, the Testator therein named, as and for his Last Will, in the presence of us who, at his request, in his presence, and in the presence of each other have subscribed our names as witnesses. -9- COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF CUMBERLAND I, GERALD J. HARTMAN, 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 that I signed it as my free and voluntary act for the purposes therein expressed. GERALD J. JIAR-TMAN Sworn or affirmed to and acknowledged before me, by GERALD J. HARTMAN, the Testator, this day of , 2004. Notary Public NOTARK MA CAA J CSR I-A 6i, tufty Pic Camp K CLyo, C~~ , ~ Cwr, COMMONWEALTH OF PENNSYLVANIA . SS: COUNTY OF CUMBERLAND We, and 1114aly and oMas fl ap~0 re the witnesses whose names are signed to the attached or foregoin Xtfunt, being duly qualified according to law, do depose and say that we were present and saw GERALD J. HARTMAN, 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 that time eighteen or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by /aura 4, aw'n/an , and Thomas ,4. afre.11 , witnesses this t-A day of - e k/'[u a 52004. *Notad Publ NOTARIAL. SEAT. COPPERSMITH, NoW L En, CudxftW J 2,x 7 H105.805 REV (9/11) &4 97 LOCALEA 1STgi t'S CERTIFICATION OF DEATH WARN( ik- ij,111, 4.,,1,1 uplicate this copy by photostat or photograph. Fee for this certificate, $6.00 '012 OCT -9 PM 12:I8 This is to certify that the information here given is NTH OF yo~~c,P _ correctly copied from an original Certificate of Death k``yt~~~ _ duly filed with me as Local Registrar. The original r'>,(r,.' I certificate will be forwarded to the State Vital ORPH COURT - 11& a Records Office for permanent filing. LAND CO., PA P 18861145 °~'qqr~ 5 MENT 14 Certification Number Local Registrar Date Issued /Print In COMMONWEALTH OF PENNSYLVANIA -DEPARTMENT OF HEALTH • VITAL RECORDS nkInk` CERTIFICATE OF DEATH State File Number- 1. Decedent's Legal Name (Pint, Middle, Last, SuHlx) Z. Sex 3. Social Security Number d. Date of Death (MO/Oay/Yr) (Spell Vol Gerald Hartman Male 168-18-6753 October 3, 2012 So. Age-Ust Birthday (Yrs) St. Under Near Sc. Under 1 Da 6. Data of Birth (MO/Day/Year) (Spell Month) ?a. Birthplace (City and State F' Foreign Country) Months Days Hours Minutes All=; PA 91 March 15, 1921 m. Birthplace (County) Lenign So, Residence (State or Foreign Country) 8b. Residence (Street and Number Include Apt Np.) 8c. Did Decedent live in a To hi 7 Pennsylvania 5285 Dogwood Court Yet, decedent lined inoeNer Allen 1 v Bd. ReslderNe(county) Cumberland Be. Residence (Zip Code) 17055 []No, decedem Imed within umlts of y/Mrp 9. Ever In US Armed Forces? 10. Marital Status at Time of Death a Marned ❑ Widowed 11. Surviving Spouse's Name (I/wife, give name prior [q firs[ marnagel E Yes []No ❑Unknown []Divorced []Never M.med ❑Unknown solita L. COOK 12. Father's Name (First, Middle, Last, Sums) 13. Mother's Name prior to First MaMage (First, Middle, Last) Jonas Hartman Marie Schmidt 14a. Informant's Name 141. Relationship to Decedent 14c.In-nni,t's Malling Address IStreet and Number, Ch, Stale, Zip Code) g Hartman Son Po Box 17119 Snwm)ass Villa a 81615 (•i 15a. aced Deat c eq on one _ If DeaM Occurred In a Hosplnl: Inpatient :I! Death Occurred Somewhere OtMr Than a Hosplbl: Hospice Facility Oecetlent's Home ❑ Emergen y Room/Outpatient Dead on Arrwal Nursing Home/Lang-Term Care Facility Other (Specify) 4n 15b. FacNlry Name (I( not Institutbn, give street and number; IS,. City or Town, State, d Zip Code I5d. County of Death 5285 Dogwood Court Mechanicsburg, PA 17055 Cumberland 16a. Method of Disposition Burial Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) m ❑ Removal Irom State ❑ Donatbn ober(spegir) Eut 10/8/2012 of Heaven Cemete Z 16d. Location of Dlspositon (CJry or Town, State, and Zip) 17a. Sig aNre o ee or Person In Charge of Interment 171. License Number Mechanicsburg, PA 17055 FD 013239 L 17c. NP cad Complete dress of Funeral Facility 3 Nei~el FUnera~ Home, Inc. 3401 Market St. Camp Hill, PA 17011 10.Decedent's Eduntign- Check the box that best describes the 19. Decedent of Hispanic Origin-Chack the 20.Decedent's Race- Check ONE OR MOREnres to indicate what highest degree or kval of school completed at the time of death. box that best describes whether the decedent the decedent considered hlmsel(or herself to be. ❑ 8thgndeor less Is Spanish/Hlspanic/Utlno. Check the"No- JM White Korean ❑ No diploma, 9th 12th Brad. so, if decedent 1, not Spau,h/Hispanic/latino. []Black,r Afric-Annim1mn Vietnamese ❑Highschool graduate or GED completed No, not Spanish/Hltp1mc/latina American Indian or Alaska Native ❑0herAslan Some college credit, but no degree Yes, Mexican, Mexican American, Chicano Asian Intlian Native Hawaiian ❑ Associate degree (e.g. AA, AS) ❑ yes, Puerto Rican Chinese Guamanian or Chamorra ❑ 8achebh degree (e.g. BA, AB, RS) ❑ Yes, Cuban Filipino ❑ Samoan ❑ Mastee, degree (e.g. MA, MS, MEng, MEd, MSW, MBA) ❑ Yes, other 5p,m,h/HISWnk/Ulino ❑ Japanese Other Pacific 1,1,,der ❑ Doctonte (e.g. PhD, EdO) or Professional degree (Specify) ❑ Other (SWclty) e..,1 DD DVM LLB iD Zl. Decedent's SingleSRace Self-Designation -Check ONLY ONE [o Indicate what the tlecetlent considered hlmseH or herself to be . 22a. Dettdent's Usual Occupation -Indicate type o(work ®White []Japanese []Samoan done during most of working life. DO NOT USE RETIRED. ❑ Black or AMcan American ❑Korean Other Pxiflc lsiaroer ASSistant Vice President American Intlian or Alaska NatNe ❑ Vietnamese ❑ Don't Kn-/Not Sure 1 Affairs ❑ Asian Intlian ❑ Other MIan ❑ Refused 22b. Kind of Business/Industry ❑ Chinese ❑ NatNe Hawaiian Other (Specify) Filipino Guamanian or Chamorro Corru nications HEMS 23a-23d MUST BE COMPLETED 23a. Date Pronounced Dead (MO/Day/Vr) 23b. Signature of Person Pronouncing Death (Only when applinblel 23c. Unm, Number BY PE SON WHO CERTIF ES DEATH PRONOUNCES OR 10 03 12 23d. Date Signed (MO/Day/Yr) 24. Time of Death ApproX 9:22 PM 25. Was Medical Examiner or Coroner Contacted? C1 Yes ❑ No CAUSE OF DEATH i Approximate 26. Part 1. Enter the chain ofevents--diseases, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest Interval: respiratory angst,or-ocular fibrillatioIhh,ut showing the//AAAeti~ologTy/DO NOT/fABBREVIATE Enng/'ronly one cause on a line. Add addlli,,al lines l( necessary On"l to Death IMMEDIATE CAUSE [2(Q~'i 2ls~G! (Final disease or condition Due to for as a conse9uence ofi. reaulung In death) b S..uenflally list conditions, Due 1(11 asaconte9uence of). i( any, leading to the cause IIs[ed on linen. Enterthe UNDERLYING CAUSE Due to (or as a consequence of): (disease or Injury tMt a initiated Me events resulting d. in death) LAST. Due to (or as a consequence on: 5 26 Part II.Ena, other significant conditHm, contributing to deal but notresulting In the underlying cause gwenin PonI 2?. Was an autopsy pe~rfyor~m~ed? .1 Yes I1.IY0 f ~ 128. Were autopsy findings available to complete the cause of death? Yes ❑ No Y 29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death o Not pregnant within Past year Yes Probably 'Natural Homicide Pregnantat HmeofcInth '5f No ❑ Unknown ❑ Accident Pending investigation Not pregnant, bbn pregnant within 42 days of death ❑ Suicide Could not be determined Not pregnant, but pregnant 43 days to 1 year before death 32. Do. of Injury (MO/Day/Y,) (Spell Month) Unknownif pregnant within the past year 33. Time of Injury 34. Place of Injury (e.g. home; construction site; (arm; school) 35. Location of Injury (Street and Number, City, State, ZIP Code) 36.Inh,, at Work 31. R Transportation Injury, Specify: 38. Describe H-injury Occurred: ❑ Yes ❑ Driver/OWrator ❑ Pedestrl, m ❑ No Passenger ❑ Other(Specify) 39a. Certifier (Check only one): If Certirying physician- To the best of my knowledge, each occurred due to the cause(s) and manner stated ❑ Pronouncing BCertlfying physician-tithe bes my knowledge, death occurred A the lime,date, and place, and due to the cause(s) and manner stated ❑ Medical Examiner/Coroner - e b IS of aminatlon, and/or Investigation, In my opinion, death occurred a[ [he time, date, and place, and due m the nose(s) and manner stated Signature of certifier: 29 Title of certifier: MO License Number M121z 42-T/;~ 39b. Name, Address and Zip Code of Person Completing Cause of Death (Item 26) 39c. Date Signed (Me/DaY/Yr) lf',,lga-k f3. L offer +17 v- u ft0,'fr n /7a lr 0"" Ic>/7 40. Registry/s District Number 41. R~egisy, nInu 42. Regl tror Fll1 Date (MO/Day r) otik 1 Ala W a oa r 3.crJ~, 43.Amendmemt H105-143 Disposition Permit NO. REV 07/2011 RENUNCIATION REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of Gerald J. Hartman c-- c- Dec sed r-r1 T T ~=L7 O ETl I. Judith Hartman (aka Sister Sharon) in my capacity/relationship as (Print Name) Co-Executor of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Gary G. Hartman i . 11120/2012 l r" (+k,4 (Date) (Signature) ' Judith Hartman (aka Sister Sharon) 2160 Warrensville Road (Street Address) Montoursville, PA 17754 (City, State, Zip) Executed in Register's Office Executed out of Register's Office Sworn to or affirmed and subscribed Before the undersigned personally appeared the before me this da party executing this renunciation and certified day that he or she executed the renunciation for the of purposes stated within on this day(( of PIN-M , a Deputy for Register of Wills 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.) COMMONWEALTH OF PENNSYLVANIA Notarial Seal Kristen M. Gasbarre, Notary Public Carlisle Boro, Cumberland County My Commission Expires Feb. 11, 2013 Form RW 06 Rev. 10-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc.