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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF 0'I'n14r4A, J COUNTY, PENNSYLVANIA
Petitioner(f) 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: E ke P M y e oe S File No: 12 I
a/k/a: (Assigned by Register)
a/k/a:
a/k/a: Social Security No: o? ()r
Date of Death: S n j 2J-- , ago Age at death: N046
Decedent was domiciled at death in Cu Kk~Cllecp County, A (state) with 10/her last
principal residence at u."Al Kv ~a 2-0 /4 sh /3 s4 C444 vt r
Street addre s, Post Office and Zip Code ity, Township or Borough County
£`/,kaf ro ~l + d 4 r j"' q r
Decedent died at /.t w>:►(r.v'f8o~,+.t 5dt,~, A G / am'kk
Street address, Post Office and Zip Code Ci y, Township or B rough County state
Estimate of value of decedent's property at death:
Ifdomiciled in Pennsylvania.. All personal property $ yC 0 c Gl~
If not domiciled in Pennsylvania Personal property in Pennsylvania $
$ -
If not domiciled in Pennsylvania Personal property in County
Value of real estate in Pennsylvania $ "-U
TOTAL ESTIMATED VALUE.... $ a . 0000
Real estate in Pennsylvania situated at: N b N F
(Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough County
[ ( A. Petition for Probate and Grant of Letters Testamentary / 204,(1,
Petitioner() avers) he/she/tbaimis/wit the Executor(s) named in the last Will of the Decedent, dated 07 r'-- era 6 it, and Codicil(s)
thereto dated IVF /1.
le 9 v U J r ✓K si r- A s
State relevant circumstances (e.g. renunciation, death 4executor, 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.
K`N'O 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 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 #loOng spouse,(+tf any I s (attach
additional sheets, ifnecessary): W
M "TS C'? C~3 fi)
Name Relationship
ltd ss'Tl
C7 C> ar
c) mi
Fora, aw-02 rev. 10111/2011 Page I of 2
Oath of Personal Representative Official Use Only
COMMONWEALTH OF PENNSYLVANIA }
II } SS:
C01 N T Y OF C tf"e rLAP4
Penzioner(s) Printed Name Pertioncrf s Printed Address
~Rv~D L• M ,~J~S 214fq t>,r•r ~v NEw~~~~P e~ / ? z'4
The Petitioner(ts) above-named swear(s) os.a€kFw(s) the statements in the foregoing Petition are true and correct to the best of the knowledge and belief
of Petitioner( and that, as Personal Representative(* of the De ede t, the Pet' i ner wi well and truly administer the estate according to law.
Sworn to r affirmed and subscribed before Date -4 2t1/?-
ht"' Date
me day o C~
_pT f,
B 1 L'I " 2 Date
For the Register Date
BOND Required: Q YES NO To the Register of Wilts:
FEES: Please enter my appearance by my signature below:
Letters S ,/1 cc, Attorney Signature:
( ) Short Certificate(s)...... Q r~ M C7
( ) Renunciation(s)......... W r
( ) Codicil(s) M = C-) C/)
( ) Affidavit(s)............ T t r''t
M
Bond Printed Name: ' Cn '0_
Commission. . Supreme Court rte
Other ID Number: c5 ca ^t
Firm Name:
Address: O~
Phone:
Automation Fee ICIC Fax:
JCS Fee. R Email:
TOTAL S -
DECREE OF THE REGISTER
Estate of File No
a/k/a:
AND NOW, inconsideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DEC ED that Letters
are hereby granted to W f r S
in the above estate and (if applicable) that
the instrument(s) dated / ~2 - - t✓%q
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
&'1171-in I a ~ s~jb? a411,
Register of Wills( ~cr r~7
Fors, RPV-n2 rev. 10/1112011 Page 2 of 2
tili~<. w> I: f.A
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate. $0.00 t l),s iw t(: that thr- information i)t(e "ken is
ctl}' copied from an orjt inal Certificate of Death
RECQR E F duk filed v'ith me as Local Re jstrar. The orioinal
fL
REGISTER r 9
OF Vi! i,_S i. ~ cej,ihf ate will be forwarded to the State Vital
t IZ«++jc'~ Office fov permarlent filing.
012 DEC 4 Pn 1
P 18882556
I ,c S 2 a/20tz
fame-
CLERK C
Certification Number l/~.tt/~}[~yT L(~cal Re~_)stra: Date Issued
Type/Print In rrlIyi
T~ 0 R " P H A ' N a:JQA IfAl. OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH - VITAL RECORDS
ERTIFICATE OF DEATH
Black Ink State File Number:
1. Decedent's Legal Name (First, Middle, Last, Su ~x) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Yr) (Spell Mal
h F. 01-1 - Sept_ 22, 2012
Sa. Age-Last Birthday (Ys) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/Year) (Spell Month) 7a. Birthpla ( ity and State or Foreign Country)
Months Y. Hours MlnuYes Harrs~burg PA
l 86 yrs _ May 22 , 1926
8a. Residence (State or Foreign Cou n[ry) 86. Residence Stre t and Number - Include Apt No.) Sc. Did Decedent Live in a Township?
PA 20-5 14i~1 Street QYes, decedent lived in twp.
Rd. Residence (County) t 1'.13, n
r.liil n Be. Residence (Zip Code) No, decedent lived within limits of Mt- H 1 1 G~2.r i T] Q 2,ty/born.
9. Ever in US Armed Forces? SO. Marital Status at Time of DL Married Widowed 11. Surviving Spouse's Name (If wife, givename prior to first marriage)
Q Yes No Unknown Q Divorced Q Never Meath 0 Unknown
12. Father's Name (First, Midtlle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last)
Jose h Pom o nn h n]c
14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City. State, Zip Code]
n~'Nr J '9 T. In 2144 Pine Road Newville PA 17241
0
_ 15a. P ace o Deat C
_ 1f Oe Lh Occurred {n a Hospital- L_I Inpat)e nt ; If Death Occurred Somewhere Other Than a Hospital: t_] Hospice Facility d Decedent's Home
Q Emergency Room/Outpatient Q Dead on Arrival ff Nursing Home/Long-Term Care Facility 0 Other (Specify)
c ISb. Facility Name (If not institution, give street and number; 15c. City or Town, state, and Zip Code 15d. County of Death
a Cumberland czT, -I 16a. Method of Disposition BIYIa [X Cremation 16b. Data o Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place)
p Removaler m State popnanpn 9/25/2012 Ho113.n er FH/Cremator
other (specify) c3 Y : =nc
Z. 16d. Location of Disposition (City or Town, State, and Zip) 17a. Signature of Funeral Service Licenseeorr Pej~ n in Charge of Interment 17b. License Number
Mt_ Holly Springs, PA 1 7065 717 s p F13-1 3881 2-1-
E 17 c. Name and Complete Address of Funeral Facility a amore e _
n
18. Decedent's Education - Check the box that best describes t e 19. Decedent of Hispanic Origin - Check the 20. Decedent's Race -Check ONE OR MORE roa es to indicate what
t- 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 t be.
WSth grade or less is Spanish/Hispanic/Latino. Check the "No" White p Korean
E] No diploma, 9th - 12th grade box if decedent is not Spanish/Hispanic/Latino. Q Black or African American Q Vietnamese
High school graduate or GED completed NI, not Spanish/Hispanic/Latino Q American Indian or Alaska Native Other ..,an
E3 Some college credit, but no degree s, Mexican, Mexican American, Chicano E] Asian Indian 0 Native Hawaiian
E3 Associate degree (e.g. AA, AS) p Yes, Puerto Rican E3 Chinese E] Guamanian or Chamorro
Bachelor's degree (e.g. BA, AS, BS) ~ Yes, Cuban E] Filipino Samoan
E3 Master's degree (e.g. MA, Ms. MEng, MEd, MsW, MBA) E3 Yes, other SpanlshJHispa nic/Latino E3 Japanese E] Other Pacifc Islander
Doctorate (e.g. PhD, Ed D) or Professional degree (specify) Other (Specify)
. MD, DDS DVM, LLB JD
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 E3 Japanese E] Samoan done during most of working life. DO NOT USE RETIRED.
Black or African American t] Korean Q Other Pacific Islander
p 0 American Indian or Alaska Native C3 Vietnamese O Don't Know/Not Sure a Ore
_ E3 Asian Indian [J Other Asian M Refused 22b. Kind of Business/industry
0 Chinese E3 Native Hawaiian Q Other (Specify)
p Filipino O Guamanian orchamorro Knouse Foods , Sr1c
ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced Dead (Mo/Day r) 23b. Signature of Person Pronouncing Death (Only when applicable; 23c. License Number
BY PERSON WHO PRONOUNCES OR q ova o?O~ Z
CERTIFIES DEATH
23d. Date Signed (MO/DayJYr) 24. Time of Death
25. Was Medical Examiner or Coroner Contacted? Q Yes 0 No
CAUSE OF DEATH Approximate
26. Part I. Enter the chain pf events--diseases, injuries, o mplications--that directly caused the death. DO NOT enter terminal events such a cardiac arrest. Interval:
respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only o ne c n a 1 Add additional lines if necessary a Onset to Death
aus o L
IMMEDIATE CAUSE 62_~/fil/ Q ( `7 I~✓IGC.Ci
a consequence nf):
(Final disease or ceath) ondition Due to 49
resulting in d
b.
sequentially list conditions, Due to (or as a consequence of): _
if any, leading to the cause
listed on line a. Enter the
UNDERLYING CAUSE Due Yo (or as a consequence of): -
(disease or Injury that
initiated the events resulting d.
in death) LAST. Due to (or as a consequence If):
26. Part It. Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part 1 27. Was an autopsy p rfo med?
o Ves No
28. Were autopsy findings available
io
comPlete the cause of death?
F-3 Yes Q No
29. If Female: 30. Did Tobacco Use Contribute to Death? 31✓r~M'anner of Death
o Not pregnant within past year 0 Yes Probably p.jVatural 0 Homicide
C1 Pregnant at time of death ~ No ~nkn own Accident Pending Investigation
C3 Not pregnant, but pregnant within 42 days of deatY C3 Suicide E3 Could not be determined
t-. 0 Not pregnant, but pregnant 43 days to 1 year before deatF 32. Date of Injury (M./Day/Y,) (Spell Month)
0 Unknown if pregnant within the past year 33. Time of Injury
34. Place of Injury (e.g. home; Instruction site; farm; school) S. Location of Injury (Street and Number, City, State, Zip Code)
36. Injury at Work 137- If Transportation Injury , Specify: 38. Describe How injury Occurred:
E3 Yes Driver/Operator 0 Pedestrian
E] No E3 Passenger C] other (Specify)
39a. -iffier (Check only one):
~$Certifying physician - To the best of my knowledge, death occurred due to the c use(s) and manner stated
Pronouncl l ng R, Certifying Physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the c se(s) and m stated
Medical Examine r/Corone n the is of examination, and/or investigations In my opinion, death occurred at the time, date, and place, and time to the cause(s) andm stated
Signature of certifier Title of certifier: t`^T1 License Number: r-1D IL.S S p p -7~~F
39b. Name, Address and Zip Code of Person Completing cause of Death (item 26) 39c. Date Sig d (MO/ y/Yr)
M+C` A-D iJ e ~}vt-. M1- Hvl1 r ( ) >atS QTY' 2r
40. Registra s District Number 41. Registrar's yam- 42. Reg File Date (Mo/Day
43. Amendm nts
Y
H10S-143
Disposition Permit No. 0 REV 07/2011
WILL OF
ETHEL P. MYERS C> a~
c ca r" M C->
I, Ethel P. Myers, of Mt. Holly Springs, Cumber TCoun;
Pennsylvania, declare this to be my last Will and hereof oke all
prior Wills and Codicils. n
1. I direct that all my just debts, funeral expls
gravemarker and administrative expenses $i-all be'paid
from my residuary estate as soon as praiicable of my"
death.
2. 1 direct that all inheritance, estate, transfer, succession
and death taxes of any kind whatsoever which may be
payable by reason of my death shall be paid out of my
residuary estate.
3. 1 direct that my entire estate be distributed as follows:
A. I leave everything to my husband, Lloyd M. Myers.
Should he predecease me, I leave my estate to be
distributed in equal shares to my children, Ruth
Ann Myers, David L. Myers and Dorothy J. Myers.
B. Should Ruth Ann Myers, David L. Myers or
Dorothy J. Myers, predecease me, their share
shall lapse and go to the surviving children.
4. 1 appoint David L. Myers as Executor of this my last Will.
If he should predecease me or cease to act in such
capacity, 1 appoint Dorothy J. Myers as alternate.
5. The Executor of this Will shall have the power to
distribute my estate in kind or in cash, or partly in either.
6. 1 direct that no Executor acting under this Will shall be
required to enter bond in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand this--~'f_ day
of--tQ ^I , i " 'C'- , 2004.
LAW OFFICES OF (~i' 6,a 1
STEPHEN J. HOGG Ethel P. Myers 9~(
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
The preceding instrument consisting of this and one other page
was on the day and date hereof signed, published and declared by
Ethel P. Myers, as and for her last Will in the presence of us, who at
her request, in her presence and in the presence of each other have
subscribed our names as witnesses hereto.
ITIESS WITNESS
r~
LAW OFFICES OF
STEPHEN J. HOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
ACKNOWLEDGMENT
State of Pennsylvania
ss
County of Cumberland
I, Ethel P. Myers, the testatrix, 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 therein expressed.
Ethel P. Myer
Sworn to or affirmed and ackno ledged bef me by Ethel P.
Myers, the testatrix, this day of , 2004. 77 NOTARIAL SEAR.
r
STEPHEN J. HOGG, NOTARY PUEL;C
CARLISLE BORO, CUMBERLAND co., PA Notary Pu bGclAttp
MY COMMISSION EXPIRES SEPTEMBER 9, 20(1
AFFIDAVIT
State of Pennsylvania
ss
County of Cumberland j
We, E~t jCu~ C)u, and 1-iStl , r ,`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 testatrix sign and execute the
instrument as her last Will; that the testatrix signed willingly and
executed it as her free and voluntary act for the purposes therein
expressed; that each subscribing witness in the hearing and sight of
the testatrix signed the Will as a witness; and that to the best of our
knowledge the testatrix was at that time 18 or more years of age, of
sound mind and under no constrain or undue influence.
f;.
Sworn to or affir ed ands scribed ' before me by witnesses,
this day of ,ZL , 2004.
LAW OFFICES OF ~ ~NOTARIAL SEAL aryPublic Attorney
STEPHEN J. HOGG STEPHEN J. HOGG, NOTARY PUBLIC
19 S. HANOVER STREET MYCARLISLE BORO, CUMBERLAND CO., PA
COMMISSION EXPIRES SEPTEMBER 3,2005
SUITE 101
CARLISLE, PA 17013