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HomeMy WebLinkAbout12-07-12PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF ~~~~~ ~~ ~ 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 rr Name: ~ ,; ; .. t_ L, Gu ~ .•, ~ o L L 0.f! S~ File No: v~ 1 `~ ~ - ~ ~~ _ a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: !) S- ~!o - 939 7 Date of Death: l~vZ /d E( /Z Age at death: (~ Decedent was domiciled at death in C" u ~n ~ . County, ~~G . (state) with his/her last principal residence at Street s: ~ Decedent died at -~- Street address, Poat Office and Zip Code Estimate of value of decedent's property at death: If domiciled in Pennsylvania ............................ All personal property $ 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.... $ ~~ D ~ // !!// A' /, Real estate in Pennsylvania situated at: ,J S ~ ~ xe C C >e ~ X. !'7 ~ ~1 ~n.~ ~ S U~,r" ~' ~~ • / >tl f S C~tm (Attach additional sheets, ijnecessaty.) Street address, Poat Office and Zip Code City, Town ~p 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 C ~ il(s) thereto dated ^--' ~ .~.. ..., Csa ___ sir O rn c ~ ~ «- ~,~,p State relevant circumstances (eg. renunciation, death ojexecutor, etc.) ~ _ ~ t~7 ~ ~ Except as follows: after the execution of the instrument(s) offered for probate Decedent did not many, was no~ive~vas not a party al~pbnding divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3320 did noi'11t~ve a e"~+ Id$brn or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. 7e D Q ^ NO EXCEPTIONS ^ EXCEPTIONS n O ~ ~ ~ "~rY C7 ~J 'B. Petition for Grant of Letters of Administration (If applicable) ~ -~~ W ~ ~ c.t.a., d.b.n., d.b.n.c.t.a., pendente litejaietrante absent~lura ritate 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. ~NO EXCEPTIONS ^ 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, i/'necessary): Name Relationshi Address G zra r~ ~ l 1~c:rr ~it.« SOS ~ d ~ ortc~ l~~ fd f1.Z- Form nw nz rev. initianu Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF } Official Use Only RECORD D 4FF1CE OF RE6lST ~ 0~ ~`~1LLS 7~I2 DEC `' Petitioner(s) Printed Name Petitione ) d Tess ~e~c~~~ 1 , ~i.n~i~«G.H 1 IS S£Cond /(o~O/ RLAND C 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 knowledge 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 subscr'bed before ~ L-----~~ Date 1Z ~ / Z met ' day of ~, ~~ Date By: ~ Date For the Register Date BOND Required: YES ~~10 FEES: Letters ...................... $ ~ U. V V ( ~ )Short Certificate(s)...... ~1 • U~~ ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other ........ Automation Fee ............... JCS Fee . .................... ~ •fj~ TOTAL ..................... $ //~,~ SO To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature: Printed Name: Supreme Court ID Number: Firm Name: Address: Phone: Fax: Email: DECREE OF THE REGISTER Estate of C7 P C(~ L . Mrs n~j~ )111.0) •r~fi • File No: ~~` _ ~ a ~- ~ ~- a/k/a: AND NOW, ~(„Q ~~Qr "~ ~ 2Cl~Z , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters ~( ` are hereby granted to _ ~'~QaC~h ~~ ('1 Yl ~' ( , in the above estate and (if applicable) that the instrument(s) dated described in the Petition be Form RW-02 rev. 10/! 1/10/ l to probate and filed of record as the last Will (and Codicil(s)) of Decedent. • / egister of Wills P 2 of 2 LOCAL REGISTRAR'S CERTiFICATIOiV OF ~EATF~ WARNING: ft is illegal to duplicate this copy tay photostat ol~ photograp±~. .. - ~\( RECORQEfl OP~1CE OF ;,., ~)( (iJ()ni,ati(~), t'(~J~~ ~i~en }'t'L' ~OI [h1S CBTilhla~e, ~(1.U~) Ilp rig f : ~)5 i(! 1 r Xll', Il RE~~S~ER ©~ ~~~.E.S ~;~~p,~Zii ~F a~C~ ~. Ol)~( 1~ '_~,j tcii ~lii# . ,•n (~)t~in~~i Certif)~ (te ~;f Death ~~f? 1 ptf~~;" ~' ~ ~(lf I Il.(4 1i ~I f)' 3 ?.Oi ti ~_L'ltih'al' IEIE' OCl4?lflal ~~~~ ~~(~ ~ ~~ J ~~~ ~ ~'~ rrt)J(i tl' ~ .~, f ~ )r•t tr(iec~ [(~ Ih.. titate ~~ital t~ a; ~~Ji q~,~= 2s ~~ E~t'~i) t, t },1 ~.'_ ~I 'Ii f'1J.iNr'J7( k1~7nt~ CLERK OF '~ ~~,~,\ `'"~" ~~,' P 19 0 6 4 5 8 8 ~ COURT '~=)'~r ~~Pi~'~ __DF~C 05/2011 -----pRPHANS ~aE~iY ~>F lll~. ~ COChfICa[iptl '!Vlllllh:'C PA ~~ """"'-~"-'-'" G~µ$ERLAND C4., - _ `- [_.iLa~ ~z~~~)<<-,,.~~ t-.~~(t~~ i<~)ea Type/Print In COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECD ROS Permanent CERTIFICATE OF DEATH Black Ink State File Number: >~~ O 1. De<edent's Legai Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Yr) (Spell Mo) Male 175-40-9397 n~~~Y• 4 2012 Sa. Age-Last Birthday (Yrs) Sb. Under 1 Vear Sc. Under 1 Da 6. Date of Birth (Mo/Day/Year) (Spell Month) 7a. Birthplace (City and State Foreign Country) Months Days Hours Minutes Y $t.OW17 ~~ 63 Fe 5 1949 7b. Birthplace (County) r Fo rei gn Country) 8a. Residence (5[at e o 8b. Residence (St ~t and Num b er -Include Apt No.) Sc. Did Decedent Live in a Township? re _ ~ s _ 1V8LYA V _ ~ + 35 W. Keller $t. QYes, decedent lived in twp. 8d. Residence (County) b M~ i ]8Ll c$ llrfL city/born. 8e. Residence (Zip Code) o, decedent lived within limits of 9. Ever In US Armed Forces? 10. Marital Status at Time of Death ~ Married ~ Widowed 11. Su rviVing Spouse's Name (If wife, glue name prior to first marriage) ~ Yes ~[NO ~ Unknown ~Dlvorced ~ Never Married Q Unknow 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last) Rai H. Ment>lolLsn Ru A. Kirbsugh 14a. Informant's Name 146. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number. City, State~,,Z~ip Code) g Gerald L. Ment>tolL9iCil Jr. Son 1315 2nd St _ Altoona, PA 16171J1 s _ .......... .--~---~-------------- ............__..._..._....------------~ If Death Occurred In a Hospital: ~-Inpatient 5 a _.. ewe " eat ... e.=... ~^.r. ...... .................................... --••-------- ---~-------.......... one ............_................. ............................... 1f Death Occurred Somewhere Other Than a Hospital: Hospice Facility Decedent's Home o ~ Emarglncy Room/OU[patient Q Dead On Arrival • Q Nursing Home/Long-Term Care Facility Other (Specify) a2 15b. Facility Name (If not institution, give s[reet and number', 15c. City or Town, State, and Zip Coda 15 d. County of Death M_5. Hershe Medical Center Hershe Pa. 17033 Dauphin 16a. Method of Disposition Burial ~ Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) ~ o Donation o Remo r o 1206 2012 Green Memorial Park Rolli Othe r (Spaclfy) / ng Z 16d. Location of Disposition (City or Town, State, and Zip) 17a. nature of Funer Servi ice or Pers n C rge of Interment 17 b. license Nvm ber ~ Hill PA 17011 014819 E s 17c. Name and Complete Address of Funeral Facility ers-~+~'•rlw~- Fti)Jneral Some Inc. 1903 Market St. Camp Hill, PA 17011 ~ 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 [o Indicate what ~- 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. Q Sth grade or less Is Spanish/Hispanic/Latino. Check the "N O" kite Q Korean 0 No diploma, 9th - 12th grade box if decedent Is not Spanish/Hispanic/Latino. Black or African American 0 Vietnamese 0 Hlgh school graduate or GED completed not Spanish/Hispa nlc/Latino Q American Indian or Alaska Native Q Other Asian Q Some college credit, but no degree s, Mexlca n, Mexican American, Chlca no ~ Asian Indian ~ Native Hawaiian Associate degree (e.g. AA, AS) 0 Ves, Puerto Rican ~ Chinese 0 Guamanian or Ghamorro Q Bachelor's degree (e.g. BA, A6, BS) Q Yes, Cuban ~ Filipino ~ Samoan 0 Master's degree (e. g. MA, MS, MEng, MEd, MSW, MBA) QYes, other Spanish/Hispanic/Latino ~ Japanese ~ Other Pacific Islander ~ Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) ~ Other (Specify) e. MD DDS DVM LLB JD 21. Decedent's Single Race Self-De5lgnation -Check ONLY ONE to Indicate what the decedent c0 nsidered himself Or herself to be. 22a. Decedent's Usual Occu patlon -Indicate type of work ~(Nhlte ~ Japanese 0 Samoan done during mast of working life. DO NOT USE RETIRED. ~ Black or African American 0 Korean 0 Other Pacific Islander ' Q American Indian Or Alaska Native ~ Vietnamese ~ Don't Know/Not Sure tier Tech• ~ Asian Indian Q Other Asian 0 Refused 226. Kind of Business/Industry Q Chinese ~ Native Hawaiian Q Other (Specify) ~ Filipino ~ Guamanian or Chamorro In$Uraz>,ce ~. ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced D¢ad (MO Oay Vr) 23b. Signature of Person Pronouncing Death (Only when applica e) 23c. License Number BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH Zo I Z I 23d. Date Signed (MO/Day/Yr) 24. Time of Death /t IZ r, 2C-P >4 25. Was Medical Examiner or Coroner COntactedT ~ Yes No CAUSE OF DEATH Approximate 26. Part 1. Enter the chain of a cots--diseases, injuries, o mpllcatlons--that directly caused the death. DO NOT enter terminal a ants such a ardiac arrest Interval: respiratory arrest, or ventricular flbrl llatlon without show ing t he etiology. DO N OT AB B R E V I ATE. Enter only on e c a u s e o n a Ilne. Add additional Tines if necessary Onset to Death \ ~ ~ ~ ~ h p / ~ M ~ - ' I ' ^ IMMEDIATE CAUSE > ~ CJi ~/[ C_A T~~T'l/C (A 1< \ ~bI-UL-X` (Final disease or condition (or as a conseque c er resul[ing In death) b. Sequentially Ilst conditions, Due to (or as a consequence of): if any, leading to the cause listed on Ilne a. Enter the UNDERLYING CAUSE Due to (or as a consequence of): ~y (disease or in)ury that F initiated the events resulting d. ~ In death) LAST. Due to (or as a consequence of): 26. Part 11. Enter other sianlflcant conditions contrlbutln¢ to death but not resulting In the underlying cause given in Part I 27. Was an autopsy perF rmed? //'~, / / .~r/ ^vf, t y~ ~ ~ /~ . ] ` ^ D vas a No ~ ~ - ~ _ . L/~ t ~/S.~M~G ~,., • -v~..J 28. Were autopsy findings available v to complete the caus of deathT D Yes No 29. If Femal¢: 30. Dld Tobacco Vse Contribute to Death? 31. Manner of Death € Q Not pregnant within past y¢ar 0 Yes Q Probably "'Natural ~ Homicide c7 Q Pregnant at time of death 0 No ~ Unknown 0 Accident 0 Pending InVestlgation ~ ~ Not pregnant, but pregnant within 42 days of death 0 Suicide ~ Could not be determined ~ Q Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (Mo/Day/Yr) (Spell Month) ~ Unknown if pregnant within the past year 33. Time of Injury 34. Place of Injury (e. g. home; construe[ion site; farm; school) 35. Location of Injury (Street and Number, Clty, State, Zip Code) 36. Injury at Work 37. If Tra nsportatbn Injury, Specify: 38. Describe How Injury Occurred: ~ Ves Q Driver/Operator 0 Pedestrian No ~ Passenger 0 Other (Spe<Ny) 39a. Certifier (Check only one): Certifying physician - To the best of my knowledge, death o red due to the c e(s) and m tatetl ®."Pronou ncing g. Certifyln (clan - To the best of my knowledge, death o red at the time, date Sand place, and due to the c e(s) and m stated r Q Medical Examin r - On ba urination, and/or Investigations in my opl nlon, death o red at the time, date, and place, and due to the ca use(s) and m stated y~ 'f r~ Signature of certifier: Title of certifier: ~ .C J '. License Number: _S- J~ ~. ~~V~ 39b. Nama, Address and Zlp Cotle of Person Completing °~erte..''fi"sr,ixy Medical Center, Hershey, Pa.17033 39c. Date Signed (MO/Day/Yr) 40. Registrar s District um er 41. Reg stye Signature 42. Registrar File Da/[a Mo Day r) /tea /~ ~~ /~/ s~ d ~ Z_ 43. Amendments DISp051[IOn Permit NO. 0756990 Rev o~i2o 1