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HomeMy WebLinkAbout01-15-13 Reset 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 request(s) the grant of Letters in the appropriate form: Decedent's Information Name: Thomas B. Donmoyer File No: I y I V 0, co c a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: 186-30-5614 Date of Death: May 1, 2005 Age at death: 65 Decedent was domiciled at death in Cumberland County, Pennsylvania (State) with his/her last principal residence at 7043 Carlisle Pike, Lot 333, Carlisle, 17013 Middlesex Township Cumberland Street address, Post Office and Zip Code City, Township or Borough County Decedent died at 1700 South Lincoln Avenue, Lebanon 17042 South Lebanon Township Lebanon PA Street address, Post Office and Zip Code City, Township or Borough County State Estimate of value of decedent°s property at death: !"000 If domiciled in Pennsylvania All personal property $5 69(3 6~ uvJD 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.... Real estate in Pennsylvania situated at: (Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough County C> w Q A. Petition for Probate and Grant of Letters Testamentary c C> I'~ c Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated = C~ an`tF odiasp thereto dated fr1 C? . r t 73 ]a. r- t---A n i C:< 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; tv"-b- oMparty4Aa pending,-1 divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g), andlj d jttit have a cfiild born OE adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. o rV a't"t 0 NO EXCEPTIONS 0 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, e.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 0 EXCEPTIONS Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs (attach additional sheets, if necessary): Name Relationship Address Deborah McDowell (see attached renunciation) Child 1555 Sky Valley Drive, Apt. A203, Reno, Nevada, 89523 Dale Donmoyer (see attached renunciation) Child 513 Doubletree Court, Inman, S.C. 29349 Thomas Donmoyer, Jr. Child 741 East 4th Street, Kennewick, WA 99336 Form RW-02 rev. 1011112011 Page 1 of e Oath of Personal Representative Official Use Only COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF CUMBERLAND } Petitioner(s) Printed Name Petitioner(s) Printed Address Elizabeth B. Place 17 South Second Street Floor 6 Harrisburg, PA 17101 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 Petition r(s) will well and truly administer the estate according to law. Sworn to or affirmed subscribed before Date / f me ~}h day of 1 , Date By: Q { ? Date For the Register Date BOND Required: Q YES Q NO To the Register of Wills: FEES: Please enter my appearance by my2gnature be6r: rr1 C C_ 4-,, Lett s $ 1r Attorney Signature: - - W C") rtI ( ) Short Certificate(s)...... ( ) Renunciation(s)......... C1-1 rri ( ) Codicil(s) A~:l t ( ) Affidavit(s)............ t -vi -I Bond Printe ame: Elizabeth B. Places-'' I-11 Commission Supreme Court rte) y s ~1 Other ID Number: 44682 rej C> Firm Name: SkarlatosZonarich LLC Address: 17 South Second Street Floor 6 Harrisburg, PA 17101 Phone: (717)233-1000 Automation Fee Fax: (717) 233-6740 JCS Fee . Email: ehn tl7d ~karlatnsznnarich_com TOTAL $ 0-66- DECREE OF THE REGISTER Estate of Thomas B. Donmover File No:11 ' I •J~~~~~ a/k/a: AND NOW, in consideration of the foregoing Petition, satisfactory proof having bee resented b re me, IT IS DECREED that Letters of Administration are hereby granted to Elizabeth B. Place in the above estate and (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of cord as the last Will (and 1I11 C,,((odici (s)) of Decedent. Register of Will Y~' 1 J Form RW-02 rev. 10/1 11201 i ` { Page 2 of 2 H105.905 REV.(8/11) This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with the Vital Statistics Law of 1953, as amended. WARNING: It is illegal to duplicate this copy by photostat or photograph. U_ w•t ca LID Rs t _ N -tunun, - 1✓rL e 1 00 - ~1 p,%TH OF pE - v CE: ' Marina O'Reilly Matthew • L r3 U-) C-_ CO - i State Registrar L~.J L,.1= ...-46 J : c~ v a c- 1 J Q * * 7 V4 o~~g9lMENT OF~o`PMAY 0 2 201Z No. V Date H105.143 Rev. 2/87 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS 047468 TYPEIPRINT CERTIFICATE OF DEATH STATE FILE NUMBER IN NAME OF DECEDENT (First, Middle, Last) SEX SOCIAL SECURITY NUMBER TD.ATTE OF DEATH (Month, Day, Year) PERMANENT y. BLACKINK 1 Thomas B. Donmoyer 2, Male , 186 - 30 - 5614 May 1, 2005 AGE (Last Birthday) UNDER 1 YEAR UNDER 1 DAY DATE OF BIRTH BIRTHPLACE (City and PLACE OF DEATH Check only one- see instructions on other side Months Days Hours Minutes .(uo.~th, D~y~ Stale or Foreign Country) HDSPnAL: OTHER: Hospice 65 Yrs . J 1~ Lebanon, PA 11 ~u~ehent ❑ DOA ❑ Nursing El Oher COUNTY OF DEATH CITY, BORO, TNP OF DEATH FACWTY NAME (If not institution, give street and number) WAS DECEDENT OF HISPANIC ORIGRACE -Amencan Indian, Black, White, et . NoE3 Yes If yes, specify Cuban, (Specify) eb. Lebanon So. Lebanon Twp. ad VA Medical Center OMexican,Pue oRican,etc. 10 White 1,,.Carlisle, 6, . 7, y 6a. e 11 Residence (Specify) DECEDENTS USUAL OCCUPATION KIND OF BUSINESS I INDUSTRY AS DECEDENT EVER IN DECEDENT'S EDUCATION MARITAL STATUS - Married, SURVIVING SPOUSE (Give kindofwwkdonedunngmost U.S.ARMEDFORCES? (SpeciyonyhighestgradecompletedNever Maried, VJdowedtwifegivemaidenname) IV 0 iwwlong rite; do not use reared) Yes® NoElementary/secondary Conege Dlvoad(Specify) r-4 r, 0 0) Truck Driver Truckingp (14or6t) 11a. 11h. b ,2. u,4. Divrced 16. N/A In H (Y 00 ) " Ln U I DECEDENTS MAILING ADDRESS (Street, City/Town, State, Zip Code) DECEDENT17a. Slate ennsy vania ad " ACTUAL 17c. Yes, decedent lived in ® Ml(j(~1 PSPX twp. M N 00 7043 Carlisle Pike, Lot 333 RESIDENCE decedent r- r-i See instructions live in a CO 00 PA 17013 on other side) 17b. County Cumberland township? 17d No, within actual ual li dece limits ts N N CO 00 of cilylboro. FATHER'S NAME (First, Middle, Last) MOTHER'S NAME (First, Middle, Maiden Surname) 18. Norman B. Donmoyer 16. Myra Stroh W A INFORMANTS NAME (Type/Print) INFORMANT'S MAILING ADDRESS (Street, Cityyrown, State, Zip Code) U3 u 20a. David B. Donmoyer lob. 810 South Humer Street Enola PA 17025 METHOD OF DISPOSITION is DATE OF DISPOSITION PLACE OF DISPOSITION- Name of Cemetery, Crematory LOCATION - City/Town, State, Zip Code p Burial 13 Cremation Removal from State ❑ (Month, Day, Yew) or Other Place N Doeadon❑ Other (Specify) ❑ • 21bMay 5, 2005 2,c.Indiantown Gap Nat'l Cem 2>lUast Hanover PA 17001 Q SIGNA F ERALSER E S 0 SON ACTING ASSUCH LICENSE NUMBER NAME AND ADDRESSOFFACIUTYlrefZ & Bowser Funeral Home Inc .22 22b. FD-013674E 22c. plet ' s 23a-c only whefi certifying a best of my knowledge, death occurred at the time, dale and place stated. LICENSE NUMBER DATE STGNED` P1012 IS not available at time of death to (Signature and Title) - (Month, Day, Year) certiy, cause of death. 23a. 13b. 123c. _ Items 24-26 must be completed by TIME OF DEATH DATE PRONOUNCED DEAD (Month, Day, Year) WAS CASE REFERRED TO A MEDICAL EXAMINER /CORONER? person who pronounces death. W 24. 11:37 p. M. 26. 26. Yes No Z 27.PARTIt Enter the disease:, injuries or compacations which caused the death. Donmedvrthemodeordymg, sumscamucor rezpimory a,res4 ahxkor heart taiiure. Approximate PART II; Other significant conditions contributing to death, but H List only one ease on each line. r interval between rat resulting in the underlying cause given in PART I. a IMMEDIATE CAUSE (Find onset and death disease or condition Lung cancer - resulting indeath)-► a. DUE TO (OR AS A CONSEQUENCE OF): Sequentially list conditions b. ' if any, leading to immediate DUE TO (OR AS A CONSEQUENCE OF); 0 cause. Enter UNDERLYING x CAUSE (Disease or irqury c that initiated events DUE TO (OR AS A CONSEQUENCE OF): resulting on death ) LAST d. W WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED. PERFORMED? AVAILABLE PRIOR TO (Month, Day, Year) COMPLETION OF CAUSE Natural Homicide ❑ OF DEATH? ❑ Accident E] Pending Investigation Yes ❑ No ❑ . `Yes E] No © Yes E] No SUldde ❑ Could not he determined 3oa. farm M. 30c. 30d. ❑ PLACE OF INJURY -At home, farm, street, factory, office LOCATION (Street, City!(own, State) ambling, etc. (Spedry) 26a. 26b. 29. 30e, 30L z CERTIFIER (Check only one) SIGNATUR NDZTLEOFCERTI ER w J//~ 'CERTIFYING PHYSICIAN (Physician certifying cause of death when another physician has pronounced death and completed item 23) 31b, V / J 0 'To the best of my knowie ge, death occurred due to the causes(s) and manner as Ste et d ❑ w LICENSE NUMBER DATE SIGNED (Month, Day, Year) o 'PRONOUNCING AND CERTIFYING PHYSICIAN (Physician both pronouncing death and certifying to cause of death) MD-425532 May 1, 2005 0 To the best of my knowledge, death occurred at the time, date, and place, and due to the causes(s) and manner as stated ®31c, 31d. y 0 NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH w 'MEDICAL EXAMINER/CORONER (Item 27j Type or Print Q On the basis of examination andlor investigation, In my opinion, death occurred at the time, date, and place, and due to the causes(s) and ichael A. Veliuona, M. D. Z manner as stated 31a. 32. VA Medical Center, Lebanon, PA 17042 REGI T SIGNATURE AND NUMBER DATE FILED (Month, Day, Year) - - - 1 b4t tStt t = T1! ILE WEVIIIIIIIIIII i- - -i , RECORID'-D r TE-E i'~ l= Q13 a 5 RENUNCIATION CLERK C REGISTER OF WILLS ORPHANS' CUMBERLAND COUNTY, PENNSYLVANIA CUMBERLAND F Estate of Thomas B. Donmoyer Deceased I, Thomas Donmoyer, Jr. in my capacity/relationship as (Print Name) Child of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Elizabeth B. Place, Esq. /3 1.2 (Date) (Sigr a ryV 741 East 4th Street (Street Address) Kennewick, WA 99336 (City. State, Zip) Executed in Register's uf°dce Executed out of'Register's Office Sworn to or a ed and su scribed Before the undersigned personally appeared the before et i da party executing this renunciation and certified of that he or she executed the renunci t' on for the purp stated wi~hin on this day o Deputy for Register of Wills,. Not Public My mission Exp s: Signature and Seal of Notary or other official qualified to • • administer oaths. Show date ofexpiration of Notary's Commission.) Z 00 Fonn RW-06 rev. 10.13.06 RECCRCw' 0''17-'11C REGIS C= fmx~S '03 Jr5 F;" 2 5l RENUNCIATION CLEg v r, F CUPdBERL~llrt CaO. REGISTER OF WILLS [ABERLAND COUNTY, PENNSYLVANIA Estate of Thomas B. Donmoyer Deceased I, Dale Donmoyer in my capacity/relationship as (Print Name) Child of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Elizabeth B. Place, Esq. (Date) (Signa »v;J4 513 Doubletree Cou (Street Address) Inman, S.C. 29349 (City, Stale. 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 day party executing this renunciation and certified of that he or she executed the renuncia~ on for the of purposes stated within on this Z 1 day Deputy for Register of Wills Notary Pr Iic su,,,-k v l Y1 ~J My Commission Expires: LP _ 5 '7 (Signature and Seal of Notary or other official quaidied to administer oaths. Show date of expiration of Notary's Commission.) Forst RW-06 rev. 10. 13.06 r%ECO111E 0 ~F 9 - OF R E 0 i S 0 mS RENUNCIATION '613 U li 115 ? at51 e CLD K r - REGISTER OF WILLS 0 R H A v' $ERLAND COUNTY, PENNSYLVANIA CUMBERLAND "'0., ?A Estate of Thomas B. Donmoyer , Deceased I, Deborah McDowell in my capacity/relationship as (Print Name) Child of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Elizabeth B. Place, Esq. (Date Ignature) 1555 Sky Valley Drive, Apartment A203 (Street Address) Reno, Nevada, 89523 (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 day party executing this renunciation and certified of that he or she executed the renunciation for the purposes stated within on this / 7-'-" day of Deputy for Register of Wills otary Public My Commission Expires: (Signature and Seal ofNotary or other official qualified to administer oaths. Show date of expiration of Notary's Commission) . nr, JANET L. MOORS Notary Public -State of Nevada Form RW-06 rev. 10. 13.06 ~ 4 q~p~t pecorded in Washoe Count}r No: 04-83~12 - E~ires December 2, 2018