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Home My WebLink About01-08-13 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: Kathryn N Smith Decedent's Information Name: Janet Shope File No: 21-13 - a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: 167-40-0126 Date of Death: 12/26/2012 Age at Death: 63 Decedent was domiciled at death in Cumberland County, PA (state) with his/her last principal residence at 555 S. Third Street, Lemoyne 17043 Lemoyne Cumberland Street address, Post Office and Zip Code City, Township or Borough County Decedent died at Harrisburg Hospital, Harrisburg, 17111 Harrisburg Dauphin Pennsylvania 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 $ 75,000.00 If not domiciled in Pennsylvania Personal property in Pennsylvania $ If not domiciled in Pennsylvania Personal property in County $ Value of real estate in Pennsylvania $ 150,000.00 TOTAL ESTIMATED VALUE $ 225,000.00 Real estate in Pennsylvania situated at 555 S. Third Street, Lemoyne 17043 Lemoyne Cumberland (Attach additional sheets, if necessary.) 517 Mountainview Road, Middletown 17057 Lower Swatara Dauphin 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) that 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. ❑ NO EXCEPTIONS ❑ EXCEPTIONS ❑X B. Petition for Grant of Letters of Administration (If applicable) c. t. a., d. b. n., d. b. n. c. t. a., pedente lite, durante absentia. durante minoritate If Administration, c.t.a ord.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 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. ❑X NO EXCEPTIONS ❑ EXCEPTIONS Decedent died unmarried with no issue. Her mother, Kathryn N. Smith, is sole intestate heir. Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if anyl~~.a~~Ynd heirs (attach additional sheets, if necessary): /v ' rn C> C- rn C? Name Relationship Address 221 = iq rT1 CO r C -D Form RW-02 rev. 10-11-2011 Copyright (c) 2011 form software only The Lackner Group, Inc. Page 1 of 2 i Oath of Personal Representative Official Use Only COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF Cumberland } Petitioner(s) Printed Name Petitioner(s) Printed Address Kathryn N Smith 509 McKinley Drive Elizabethtown, PA 17022 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, Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed an subscribed before Data r) Date me I day of Date By For the Register Date BOND Required? E] YES 0 NO To the Register of Wills: FEES: Please enter my appearance by my signature below: ~ Letters $ Attorney Signature: )Short Certificate(s)......... m r,-I ~ IT ( )Renunciation(s) ) ( )Codicil(s) \ rn ( )Affidavit(s) Printed Name: John S. Davidson Bond Cr7 , Supreme Court - Commission ID Number: 17139 Other x ~D• > _ Firm Name: Yost & Davidson X71 Address: 320 West Chocolate Avg P.O. Box 437 Hershey, PA 17033 Phone: 717 533-5101 Automation Fee Fax: 717 534-1293 JCS Fee C? TOTAL $ E-mail: jdavidson@yostdavidson.com DECREE OF THE REGISTER Date of Death: 12/26/2012 Social Security No: 167-40-0126 Estate of Janet Shope File No: 21-13- 6 0 - a/k/a: AND NOW \ 6Q , in consideration of the foregoing Petition, satisfactory proof having bee presented befor me, IT IS DECREED that Letters of Administration are hereby granted to Kathryn N Smith in the above estate and (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of record as th last Will (and Codicil(s)) of Dece~ t. = ~ CtIt ICYL Register of Wills ' Y 'Ty i, Copyright (c) 2011 form software only The Lackner Group, Inc. Pa of 2 l H I OS. ROS R F G t ~i l i) LOCAL REGISTRAR'S CERTIFICATION OF DEATH RMMRP~G,: ,440~"40 duplicate this copy by photostat or photograph. REG11.3 Ti Ei~ 0 Fee for this certificate. `.56.00 This is to certify that the information here given is , or- ykk, 0lA Of rI iecti J1 ~ coiy copied from an original Certificate of Death 1r' HNI 8 I _ o c ~~1=\ duly filed with me as Local Registrar. The original Y'p l~ K r a~ certificate will be forwarded to the State Vital CLER i GI Records Office for permanent filing. ORPHANS' CC:~. 13 3/Y1 i. S E R L A i ~ D t J L Certification Number Local egistrar Date Issued Type/Print In 12 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH VITAL RECORDS Permanent CERTIFICATE OF DEATH State File Number: Black Ink 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Data of Death (Mo/Day/Yr) (Spell Mo) JANET SH PE 167-40-012 So. Aga-Last Birthday (Yrs) 5b. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/Year) (Spell Month) 7a. Birthplace (City and State or Foreign Country) 63 M°^th, Dava Hgnr, Minutes AUGUST 30, 1949 7b. Birthplace (County) Ba. Residence (State or Foreign Country) 8b. Residence (Street and Number - Include Apt No.) 8c. Ditl Decedent Live in a Townshlp7 PENNSYLVANIA 555 S . THIRD ST- Oyes, decedent lived in tw'P. 8d. Residence (County) CUMBERLAND Be. Residence (Zip Code) No, decedent lived within limits of T.FMOVNF city/born. 9. Ever In US Armed Forces? 10. Marital Status at Time of Death 0 Married 0 WI owetl 11. Surviving Spouse's Name (If wife, give name prior to first marriage) 0 Yes M No 0 Unknown Q Divorced 0 Never Married r3 Unknow 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, middle, Last) CLARK SMITH KATHRYN HOOPER 141. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code) g CAROL STOFFEL SISTER 5350 ELIZABETHTOWN RD•, PALMYRA. PA 17075 15a. Place o Death eck only. ono 1..,..t . If Death Occurred In • Hospital: Q In Patle^t ~If Death Occurred Some-h- Other Th TM1an a Hospital: ~ Hospl a Facility Decedent's Mome 0 Emergency Room/Outpatient Dead on Arrival Nursing Home/Long-Term Care Facility Other (Specify) 35b. Facility Name (If not InsUtutlon, give street and number; ' 15c. City or Town, State, and Zip Cod7 15d. County of Death RRI BURG PA 17111 DAUPHIN 16a. Method of Disposition Burial 0 Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) 0 Removal from State 0 Donation 1 /2/13 RIVERV IEW CEMETERY Other (Specify) 16d. Location of Disposition (City or Town, State, and Zip) 17a,.51gnaC of funeral ervlce Licensee or Person in Charge of Interment 17b. License Number HUNTINGDON, PENNSYLVANIA 1665 iL 012165L 1?c. Name and Complete Address of Funeral Facility R. F E L HOME 260 E. MAIN ST. MIDDLETOWN, PA 17057 18. Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic Origin - Check the h Decedent's Race -Check ONE OR MORE races to 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. 0 Bth grade or less is Spanish/Hispanic/Latino. Check the "No" IE] White 0 Korean 0 No diploma, 9th - 12th grade box if decedent Is not Spanish/Hispanic/Latino. 0 Black or African American 0 Vietnamese ® High school graduate or GED completed No, not Spanish/Hispanic/Latino 0 American Indian or Alaska Native 0 Other Asian 0 Some college credit, but no degree 0 Yes, Mexican, Mexican American, Chicano 0 Asian Indian 0 Native Hawaiian 0 Associate degree (e.g. AA, AS) 0 Yes, Puerto Rican 0 Chinese 0 5 T aanlsn or Chamorro 0 Bachelor's degree (e.g. BA, AS, SS) 0 Yes, Cuban 0 Filipino 0 0 Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) 0 Yes, other Spanish/Hispanic/Latino 0 Japanese 0 Other Pacific Islander 0 Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) 0 Other (Specify) B JD . MD 2D5 DVM LL nd 21. Decedent's Single Race Self-Designation -Check ONLY ONE to Iicate what the decedent consltlered himself or herself to be. 22a. Decetlent'S Usual Occupation -Indicate type of work Japanese O [2CWhite E3 Samoan done during most of working life. DO NOT USE RETIRED. ack or African American O Korean O Other Pacific Islander ROUTING SPECIALIST O Bl 0 American Indian or Alaska Native 0 Vietnamese 0 Don't Know/Not Sure 0 Asian Indian 0 Other Asian 0 Refused 226. Kind of Business/Industry p Chinese 0 Native Hawaiian O Other (Specify) PHONE 0 Filipino O Guamanian or Chamorro ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced Dead (Mo/Day yr 23b. Signature of Person Pronouncing Death (Only when applicable? 23c. License Number BY PERSON WHO PRONOUNCES OR ER 26, 2012 CERTIFIES DEATH 23d. Date Signed (MO/Day/Yr) 24. Time of Death DECEMBER 27 2012 8 25. Was Medical Examiner or Coroner Contacted? p yes Np CAUSE OF DEATH Approximate 26. PaK 1. Enter the chain of events--diseases, in}ur{es, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest . Interval: Onset to Death respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Atltl additional lines if necessary ~Ay'Q.t;d tM0 1 'c-~~- f i S to I vt IMMEDIATE CAUSE a. (Final disease or condhlon ~ .a t as a consequence of): resulting in death) ~R-sltl-LLs~_ ~F3_~ CPtr- `7 Sd ~S b. ndCVY114,tCQ sequentially list conditions, Due to (or as a consequence of): It any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE Due to (or as a consequence of): (disease or Injury that initiated the events resulting d. Due to (or as a consequence of): In death) LAST. topsy perto No med? _ 26. Part 11. Enter other. I Ifl t d'ti f Ib tina to death but not resulting in the underlying cause given In Part I 27. Was an au Yes No O 126. Were autopsy findings avallable `i to complete the cause death? O Yea No m ~p 29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death E ~NOt pregnant within past year 0 Yes 0 Accide 0 Probably •~Accide l 0 Homicide s Pregnant at time of death 1K No 0 Unknown nt 0 Pending Investigation 0 Not pregnant, but pregnant within 42 days of death 0 Suicide 0 Could not be determined 0 Not pregnant, but pregnanC 43 days to 1 year before death 32. Dale of Injury (MO/Day/yr) (Spell Month) 0 Unknown If pregnant within the past year 33. Time of Injury 34. place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City, State, Zip Code) 36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred: 0 yes 0 Driver/Operator 0 Pedestrian 0 No 0 Passenger 0 Other (Specify) 39a. Certifier (Check only one): ---F" ~Certltying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated of Pronouncing 8. Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated 0 Medical Examiner/CO ner - On th s of ex ti and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated Signature of tertifler: a Title of certif.- • Po IfC1 A Sl t -1> License Number: OA 3 39b. Name, Address and 2Ip Code of Person Co ing Cause of Death (I[em 26) 39c. Date signed (MO/Day/yr) s. Pot~cyws►~: u~il 340< tv. wvt fie l- 6,arvish C~►} ~7~io iZ-2-7-ZO/Is jYr 40. Registrar's District Number 41. Registrar's Signature 42. Registrar File Date Mo Is ~ as aa~ Ia- a - la 43. Amendments REV 0 7/2011 Disposition Permit No. REV 07/20