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HomeMy WebLinkAbout01-10-13Reset PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF 1~171'ltl ~irE') h-ti;~~ COUNTY, PENNSYLVANIA Petitioner(s) named below, who islare ] 8 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: pV~~S~- ali- trS~-iL~:.- aJkla: C.ui ~ ~ - - a/k/a: Date of Death• ) ' ~ `- i Decedent was domiciled at death in principal residence at (iC`7 1~thd~'~ Street address; Post Oftice and Zi~j Code I~ccedent died at l l v ( ~-itna ~S_C-~t~u.:v~ L_1 v, Street address, !'ostbffice and Zip Code Estimate of value of decedenPs property al death File No: ~ ~ ~~ ~ " ~-t~~~ ~~ (Assigned by Register) Social Security No: _c~bo~ -o~d -~~~~ Ag(e) at death: ~'~ 'Y ~ (Srare~ with his/her last City, Township or ;h Comrty ~~ ~,~ P~- County State City, Township or /f domiciled in Perursvh~anin ............................ All personal property /f rrot domiciled in Pennsylvania .. . ..................... Personal property in Pennsylvania If not donric•iled in Penrtsylvnuia ........................ Personal properly in County Vahre of real estate irr Peurrsrlvnnirr ........................................................ . TOTAL ESTIMATED VALUF,... . Real estate in Pennsylvania sihiated at: (~1 narh oddiriounl sheeta~, i)~necessnr>>.) $- ~i Ut70.00 Street address, Post Oftice and 'Gip Code City, Township or Borough Cnnntv © A. Petition for Probate and Grant of I etters Testamentary Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated e~ ~~: and~dic~ll(s) thereto dated ~ w __ 1'R State relevant circumstances (e.g. reuunciatian, death ofexecrrtor, etc) iWr'1 ~ ~ -~" (~S :37:;7 ' C7 Gxceptasfollows: aRerthcexecutionofthcinstniment(s)offeredforprobateDecedentdidnotmarry,wasnotdi~~re~up~not~[rtyt~pcriiling divorce proceeding wherein [he grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g},~gn~id;~ot have a chi hp7rn or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. ~..t ~-•~ .,t 'Z'7 -rry "'~1 -, C.~ =rt =I -.t Q NO EXCEPTIONS Q EXCEPTIONS _, ~ y~'? „k:7 1't'1 B. Petition for Grant of Letters of Administration (If applicable) ~'"a _.i F.. rn e.t.a., d.b.a., d.b.n.c.t.a., pendente lire, durance absentia, 1!!u•ante mGaaritate If Administration, e.t.a. or [l b.n.c.[.u., enter date of Will in Section A above and complete list of heirs. Except as follows: llecedent 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. ~1V0 EXCEPTIONS o EXCEPTIONS Petitioner(s), aftera proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (ifany) and heirs (attach rulditionrrl.rheets, ijnece.rsat7~): Name Relationshi Address ~ Fm~m R{1'-01 r~e~t 111'l l.'?Ol l PagC I Of 2 ~~..ij~- Oath of Personal Representative COMMONWEAL"fH OF PENNSYLVANIA } /~~ ~ } SS: COUNTY OF ~uV11t~-/l.A'~-'~ } Petitioner(s) Printed Name Petitioner(s) Printed Address .~cki`I~ ~ ~ 1,1~4.~t~ 1 t ~, 4nrtit11 c~ . ~' J l ~ .,s ~ ~ I /frsi ~' ' 1 CLcF;~C ~r ORPN~`hS' C`~~' ri' t ~ iJ . , The Petitioner(s) above-named swear(s) or atlirm(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 Dece n[, the Petitioner(s) wit well and truly • mtst r the estate according to law. Sworn t or ffirmed a subscribed be ' re Date me t~~~ay o " "~ ~ Dare Bv: ~/// n I(` ~ Date Letters ..................... . f ~' )Short Certificate(s)..... . ( ~ )Renunciation(s)........ . ( ~ )Codicil(s) . ........... . ( ) Afrdavit(s)........... . Bond ........................ Commission......... . . Other ~~~Ci' y}U(ll I $ ~~ ~C: ~_ IJ.~- ~~ ~,U ... Automation Fee ............... ~ ~' JCS Fee ..................... ~-~%-~~_ TOTAL ..................... $~h~~.5t' -0'0(]' Attorney Signature: 1n/~ ~.. ~/ 1 t' l ~°"' , Printed Name: K~~-, ~ ' S 1-~'-~' 1'~'1`~"Y~ Supreme Court - -T ID Number: ~~l ~ 7cj Firm Name: Address: Lvt /~t}- v c, fc~31S «, v~`~ L ~. ~ t l 11 Z -v 3 is Phone: 71 `7 St(p" SS ~(( Fax: _i i ~ (o l I -c~ l00( Email: ~-wtSS i~S p~'~, UQ /1 2yr~ ~ n b~ T DECREE OF THE REGISTER Estate of L(~'(i 1 ~~ .. t;-`I :~~, t-t~;r ~ ti~.~ File No: ~~ / ~ - G(; ~/L afk/a: l .. ~=,G.,~r _ (~s ~ L% ~~ Cr C_-~ t. ~r5~ ~- AND NOW, J~dllf,tQ rtr' ~ "~ ~ _, in eonstde'ation o the foregoing Petition, satisfactory proof having been pre ~ ted before me, IT IS DECRtF~ED that Lette s~~P.~ are hereby granted to GIC,~~(h ,~, D~111.t 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 tie last Will (~n~ Codicil(s)) of Decedent ills Fnrm R R'-D? rein. 1O~I L301 / Page 2 Of 2 BOND Required: Q YES (~ NO To the Register of Wills: FEES: Please enter my appearance by my signature below: .I. .,... f~f i u ,~ °d ~ ~ ._. iii3 ~G11 1.Q x P~ r4 - :2. '• , P 1.9~6~>~~ cLE~~ c~ ~ ~ . a~~wa~sf cc~~x, '` ~~~~ ~ `. / ~ /~ ' , I I CUhi6ERLAR~~ :; Ilr, ~}~ ~C I% Type/Print In COMMONWEALTH OF PENNSYLVANIA _ DEPARTMENT OF HEALTH . VITgl 0.ECORO3 Pe; ~k;~k` CERTIFICATE OF pEATH 6ta[a F ~( - S 1. D¢cedent's Legal Nama (First Mltltlle, Last, Suffl%) 3. 5<x 3. SOCIaI Security Number 4. pat<ef Oeafh IMe Oay/Vr) (Spell Mo) Louise Gale Horstlck ~Sl<a1e 202-20-0689 Jan 5 2 1 Sa. Ag<-Last Blrthtlay (Vra) 56. Under 1 Yepr Sc. Under 1 Da 6. Oele ^f Birth (MV/Day/YIaN (Spell Montll) Ja. B M1 la a GI {ntl StiTC.pr Foreign CvuntrV) 8.7 MontM1S pays Moura Minu[<s )Vlarl~]'1 1 1925 K. l'ti ~ Jb. BlrtM1plac< (GOUnty) 8a. Rasltlence (5[at<Or Foreign Gauntry) gb. RGSldance (Street and Number- Inclutl<Ap[ NO.) gc. Dltl D<udent LIVe In a TownshlpT Pennsylvania 1 l 07 Apple Dr _ Ov<a, a.4ed¢ne By<d i^ twv~ Bd. RealL1] I }Zt1a. ld r'IE?C)•18I11CSY3112'g T I T Ha. Resltlenc< (21p Gatle) NO, tl<cetlant Iivsd wltM1ln limits of _ city/bero_ 9_ Evar In US Armatl Forces 10. Marlfal Status at Tlm< of Dpatft ~ Married Q WldOwetl 11. Surviving Sptfuzs's Nams (It Wlfe, give name prior to RrSt mxrlage) Q Yea $) Ne Q Unknown ~ DIVO ed ~ Ne r Married Q Unkn ow 12. Fa[M1er'z Name (First Mltltlle, list, 5uffla) 13. Mother's Name Prl^r [o First Marriage (First, Midtlla, Lis[) Edwin E_ Horstick 14a. InfOYmant's Nams 14b. R<IitlensM1lp [o D<Gatlen[ 14c. In p ant's Malling Atldress (Street and Number, Clty, State, Zip Code) m S Jack A_ Horsticls Hrottaer 513 Nimitz Rd_ Dover DE 1 7 G w gr ...............Q.n....................P .............. ........ .............................. If Dsatlt Occurred In a Hespl<al: ~ Inpa[I<nt S ........... :...aca.9.... fat... on ___ __ _ ... ec ......Y on............................... ........ ... ..".... ....... .... lf Death Occurred Somewhere Other TM1an a Hospital: Hosplc<Faclllt ~~~ ~~~ [~~~~--- y[~"Deceden['a Heme J Em<r Rpom/Out atlenf Dead On Arrival - Nural Hom</Long-T<Cm Care Faclllt OtFler (Spec) 15b. facility Nam< (If not Instl[utlon, give street and number; 13c. CI[y or Town, State, antl Zlp Cotle 13tl. Cpunty of Oewth Hos its esi 16a- MethOtl o} DISpO3ltlon ~] Burial [~ Cremation 16b. Oat< of D{spos tfon 16c. Place of Izpoal[IOn (Nams of cemetery, cremetery, or other place) Q R<mOyel from State Q Donation other lees=Iry) l/l0/2013 S s Ce[mt I6 .Location Of Dlspoal[lon (City or Town, Stat¢, end Zlp 1?a. Slt^a[ur< pt Funeral 5¢rvic¢ Llcan3ea r P<rsOn In CM1arg< of Interco<nl 1J6. license Number Harri sburga PA FD-'138866-L 1JC Name and Cempl<S<Atldr<ss of FUnaral Facility Hetrick-Bitner Funeral Hartle 1 1n ~ 1H. Decedent's Education -Check the box [hat beat tlescrlbe3 the 19. p<c<tlen[ of Hlapanlc Orlgln -Check [It! 20. D<catl<nt'3 Rece - Gh<Ck ONE OR MORE races eo Indleat< What hlHh<s< dagref or I¢Vel of school completetl at the time of daa[M1. pe%that bast describes whether the decedent [he decedent consltleretl himself or M1erzalf to be. H<h grads or Isss Iz SPanlvh/Hlapanlc/Latino. GI+<ck the "NO" Whl[e Q Korean No diploma, 9th - 12[M1 grade box If dec<tlant Is no[ Spanlah/HlspaniULatlnO. Q Black or African American ~ Vlatnam<se ® Hlgh school gratluat! Or GEO comp)<t<d No, not SpanlaM1/Hispanic/Latino p gmeYlcan Ine{an or Alaska NatlVe Q Other ASlan p some cou<gs credit but no degree Q Yas, Mexican, M<xlcpn American, CM1lcano Q 4slan Intllan Q NatlVe Hawaiian Q Associate tlagree (¢.{. M, 45) Q Y<s, PuaRo Rican Q Chln LSe ~ Guamanian er Chamorro ~ Bachelor's degree (e.g. BA, AB, 06) Q Yes. Cuban (J Flliplno ~ Samoan Q Maztei s tl<gree (e.g. MA, M5, MEng, MEO, MSW, MBA) Q Yes, other Spanish/HlSpanl4Latlno Q Japanese O Other PacHlc Islander 0 oocterate (e.g. PM1O, Edp) or Professlpnal tlegrre (Specify) Q O[h<r (S PeUM e. MO DDS DVM LLB JD 31. Decedent's 3ingla Rice Self-D<slgnation - Ghack ONLY ONE to Indicate wtla[ [he decedent consld<red himself Or M1erself to be. 22a. Decedent's Usual Oceu Peelan - In Icata type Of work ~] WM1lte Q lapanssa [~ Samoan Bona tluHng meat of working life. 00 NOT U6E RETIRED. Q Black or African American O Koran Q O[M1<r PacIRC Islander Q American Indian or Alaska Na[IVe Q Vietnamese [] Don't Know/NOT Surs Clerk Q Aalan Intllan ~ O[M1ar Aalen [] R<fua<d 22b. Kind of Business/Industry Q CM1inese Q NatiV<HaWSllan [] O[M1er (SP¢clfy) ~ Flliplno Q Guamanian or Chamgrro PZ'liC1C+I1t1al Life =n8_ COa ITEMS ZBa -33 T gE COMPLETED 23a- aC< Pronounced Dea Mo pay 23b. 51gneturc o P<rzon PrOnouncing <ath Only when appllcs 23c. License Num er BY PERSON WHO PRONOUNCES OR CIRTIFIgi DEATH 23d. Da<C 5{gn<d (MO/payfYr) 14. Tlmw o1 D<a[h 1 15. Waa Medical Examiner or GOCOner GontactetlT Q Vez No CAUSE OF DEATH Appro%Ima[< 26. Part I. En[ar the S:M1a n of events--dls<aaa[, Injurle3, or compllcatlons--that dlr<cYly caused the death. DO NOT enter terminal <V<nt3 aucM1 as cartllac srr¢st i Inbrval: f¢Spira[Ory arrest- or VantflcUlar flbrlllatlon wi[houL showini the e[IOIpgY. DO NOT ABBREVIATE. Enter only on<cause on a Ilne- Atltl atltlltlOnal Ilnes If n<caisary ( Onss<to Death I ~ / //~ p 3 IMMEDIATE CAUSE - > e. ( ~~LIJ_xCl: ~~I hJr/ ~ /T ~/'7Y].'1~-yy'rt ~~%(,.. ~ Mti(/pl_ f (Final dlseas¢ or cpntlltlon GG Due [o for az a consequence ofl: r¢sulting in deathf b. Sequentially Ils[ conditlana, Pue [p (er ea • consequence of): 11 any, laatling to [M1e cause _ Ilaf<d o^ Ilna a. En[<r [he __ UNDERLYING OUSE Dus to (or as a conseq Uence on: ~ (mzuse o. mjurv [hat c mRlated [M1e e.,enta reawu^g a. ~ to de.[h) )AST. Pee LP (or u a conxgwnpe of): 26. PFK 11. En«r otM1¢r I n but not ..auRins In Me undarlYlnB caU3e given In Part I 3J. Was an autepsY PsrfOrmetlT Q Ves ® Np m 2H. Were autopsy ndinga ivallebl< to complete [he cause pf deatM1T Q Yez ® NO 39. If Famels: 30. Ditl Tobacco Ua< Centrlbuta t0 O<a[M1T 31. Manner Of Death P~ ~9 pregnant wl[M1ln past year pregnant a[ time Of death Q Y<s Q Propably Q Ne abnknown .~WCUraI Q Homicide ('~ A ltl t Q P tli I [I l $' Q Not pregnant but Pr<Snant witM1ln 42 tlays Of tleetM1 ~ cc ¢n en nyea gat on ng Q Sulcltle Q Could net be determined ~ NO[ pregnant but prainant 43 tlays to 1 year b<for! death 32. Da[< pf Injury (MO/Day r) (Spell Montlt) Q Unknown If pregnant wltM1ln the pas<year 33. Time of Injury 34. Place of Injury (e.8. M1ems; cons[rucUOn site; farm; zchoel) 35. Location of Injury (Street and Number, Clty, Stets, zip code) 36. In)ury a[ Work 3J. IT Tranzportatien Injury, SpeclN: 3H. Describe Now Injury Otturretl: Q V<s Q Orlver/Operator Q P<deairlan f].~R6 Q Paszen8er Q O[M1er (SP<clty) 39f! ~Cert~fifier (CM1eck only ane): Ifying physicla^ - To the bast of my knOwletlge tlestH occurretl tlue [e tM1e cause(s) antl manner s[i[¢tl , """l O Pronouncini H. Gar[Ifying physician - To the best of. y know)<dgs. death occurretl a[ the [Ims, date, and place, and due to tM1< cause(s) antl manner stated [] Matllcal Ewaminer/COronsr - On the bills Of eze ,antl/or InVestlgpLlon, in my opinion, tleath occurred at the tlml. tla[¢, and plate, and du<ttf th<c ause(a) antl ma n ner Stated ! ` , Signature of certifier: TI[le Of certifier; f License Number: ~J '~~7 f YLU 39 Nams, Addr<s3 antl 21p Cetle o1 Person Co~ ng Cauza of paa[h (Item 2 1 39c_ Date gn¢tl (MefOSy(Yr) 40. Reglatrar'• strict Numba• 41, s 51 nature a3. Rsi atrar FKe pate (MO Oay r - - ~ 43. Am<ntlmenfs Dlsposltlon Parml<Np. LL8_~ ~l ~ /O qEV OJ/2011 I ~ • ~~-~ i ~_. RENUNCIATL~i ~~~ ~~°~" ~~ REGISTER OF V'~FL~L~ ` ``~` ~'~ ~~` `` `'~ CUMBERLAND COUNTYE[~~S~V,I~'RII~ i~ ORPHA~15' C~~ Estate of LOUISE GALE HORSTICK ~~~~~~~~rl` `~~~' ~rA I~ JACK A. HORSTICK in my capacity/relationship as beneficiary/brother of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to JUDITH GALE WHITE j- ~c--13 (Date) Executed in Register's Office Sworn to or affirmed an subscribed be re e this ~ day o ~~ ~ 2013. ~/ /~-~ putt' for Re ste s c ~ -~ (Sign ure) (St(r~e~et Address)( ~-- (City, State, ip) Executed out of Register's Office Before the undersigned personally appeared the Party executing this renunciation and certified that he or she executed the renunciation for the purposes stated within on this day of .2013. 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.)