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HomeMy WebLinkAbout01-23-13PETITION 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: Russell E. Mentzer, Sr. a/k/a: a/k/a: a/k/a: Date of Death: 12.04.2012 Decedent was domiciled at death in Cumberland principal residence at 37 Kenwood Avenue Street address, Post Oftlce and Zip Code Decedent died at 361 Alexander Spring Road Street address, Post Office and Zip Code Estimate of value of decedent's property at death: File No: r~l - ~ ~ - QCs v (Assigned by Register) Social Security No: Age at death: 84 County, South Middleton TwQ. (State) with his/her last South Middleton Twp. Cumberland City, Township or Borough South Middleton Twp. Curnberiand City, Township or Borough County PA _ County State If domiciled in Pennsylvania ........... . ................All personal property $ 5000.00 If not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $ If not domiciled in Pennsylvania ........................Personal property in County $ Value of real estate in Pennsylvania .................... . TOTAL ESTIMATED VALU$a .. $ ~ ~ Real estate in Pennsylvania situated at: ® ~ c_ (Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Towns~- mnBorough=:;== ra^~~ ,`°~;7 County %T7 ~.. i_" rV ~t t o °.d ® A. Petition for Probate and Grant of Letters Testamentary ~ ~ ~ ~~ c.a Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated ~' ~ :~'~ 'C' ~i~d Codicil(s) thereto dated _ , ,. r State relevant circumstances (e.g. renunciation, death of executor, etc.) -'Y"b ~ ~-' d" +^d Except as follows: after the execution ofthe instrument(s) offered for probate Decedent did not marry, was not divorced, ~ not a par 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. Q NO 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, durance 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 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 Q EXCEPTIONS Form RW-02 rev. 10/11,'201: Page 1 of`2~ 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): Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND } } SS: } Official Usc r c ~ ~ ~, ~i. ~.~ T a Petitioner(s) Printed Name Petitippp (s) Printed Address Betty E. Mentzer 37 Kenwood Ave., Carlisle, PA 1'/~ 3 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 teat, as Personal Representative(s) of the Deced t, the Petitioner(s) will well and truly administer the estate according to law. v Date .~ ~ Sworn to ~r affirmed and subscribed before me t ~ day of ~ ~` Date 13 , ~ Date y• For the Redf,ster Date BOND Required: Q YES ~O FEES: /~/t Letters ...................... $ G. ( )Short Certificate(s)...... ~ (~) Renunciation(s)......... ~ ~ ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other •••••••• Automation Fee . .............. ~~ JCS Fee . .................... .~ry ` ~c~ TOTAL ..................... $l~ ~ SU To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature: Printed Name: W~lltam P. Douglas Supreme Court ,7926 ID Number: Douglas Law Office Firm Name: Address: 43 West South Street Carlisle, PA 17013 717-243-1790 Phone: Fax: 717-243- 955 Email: douglaslaw@earthlink.net DECREE OF THE REGISTER Estate of Russell E. Mentzer, Sr. File No: c~ ~ - ~ ~ " ~ ` ~ - a/k/a: AND NOW, ~ ~ ~ , in consideration of the foregoing Petition, satisfactory proof having been p nted before me, IT I DECREED that Letters ~ ~ ~ ~~fi~(~~"1~~(~-~ are hereby granted to . - ~ ~- 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 the last Will (and todicil(s)) of Decedent. ,~,~,nr~r~ ~GU~~.r,'l ~~-`~ r~~C,t-ti% G `~J Register of Wills ~~ t ~ ~~'` (,Lt ~.t;~. j~~~i l_. J~'t~~ j-'~ l ~~ Form RW-02 rev. 10/1 //2011 ~I~age 2 ~f 2 H105.805 REV (y/I1) - LOCAL REGISTRAR'S CERTIFICATION OF DEATH 1NAI~NING: It is illegal to duplicate this copy by photostat or photograph. ~ ~" ~ ~ '~ °' yl i" ~ t ~ :~ . Fee for this certificate ~~ ~ ., ~ ~ t ~ U ~° ~ phis is to certif~~ that th~~ information here given is ~ ~, " currently copied ii-om an (>riginal Certificate of Death ~~~, I~~l ,~ ~,,i /..,, ~ i~ ) 23 ~I`i C 7 duly tiled with me as Local Registrar. The original JIII> •• i~ G certificate ~Iti~ill he Forwarded to the State Vital l~:~curds Ottine tier permanent filing. a p Q ' C~ ~ ~ .., v l e ~ , ~ tv~ ~ c.K~~ D 6 2012 ~ / Certification ~,,~r --- - -- ~ ~~„ „~.; ', ~U~ff~~LA(~~ _~ ,~_., ~~ E_,JCaI Re~~istrar Date Issued Type/Print In Permanent COMMONWEALTH OF PENNSYLVANIA _ DEPARTMENT OF HEALTH _ VITAL RECORDS Black ink CERTIFICATE OF DE 1. Decedent's Legal Nam< (First, Middle, Last, Suffix) Russell E _ Mentzer Sr ATH State Flle Number: 2. Sex 3. Social Security Number 4 Dace of D h Sa. Age-Last Birthday (Yrs) , . sb. Under 1 Vear Sc. Under 1 Da 6 Male 183- . eat Mo/Da /Yr) (S 12-4709 ( Y Pell Mo) December 4 r 2012 I 84 Months Days Hours Minutes . Date of Birth (MO/Day/Year) (Spell Month) F b 1 7a. Birthplace (CI ty and State or Foroign Country) e 5, 1928 Carlisle PA Sa. RgsiAdence (state or Fore kY'' f gn Cou Wiry) Bb. Residenc@ (Street and Number -Include Apt No.) 37 Sc. Did Decedent Li 7b, Birthplace (county) C land ve In a Townshi ? 8d. Residence (County) Kenwood Ave _ p Ves, de~ldent uYed In land 9. Ever In US Armed F rtes? 10 M 8e. Residence (21p Code) twp ~ No, decedent lived within limits of I . arital Status at Time of Death Ves ~ Married Widowed city/boro. ~ F Q NO Q Unknown Q Divorced Q Never Married Q Unka 11. SuBrveitt Spo Ee's Name (If wife, give name prior to first marriage) j 23 d. Da Signe Mo/Day/Yr) 24. /TI f Deaj~i ~ ~y/ ~2 ~~ {I 7 ` ~ 25. Was Medical Exa or Coroner er ' Contacted? Q Ves 26 P 1 CAlJSE OF DEATH No . art . Enter the Chain of events--diseases, injuries, or compli respirato arre t cations--that directly caused the death DO NOT Approximate ry s , or ventricular fibre elation without showing . enter term the etiology. DO NOT ABBREVIATE Ent I inal events such as cardiac arrest - Interval: IMMEDIATE CAUSE --- ----_.___> ~ ~ XJO~-~ ~ . er o n y one c se o /1 -~ I .~ ' / a Ilne. Add additional IineS if n sary Onset to Death aces (Final disease or condition reswting In dea[ro b. ~ ~ ~~ D t ~ , ~~ /_~~L~ / ~ df~ ~~ equence of). /AriAf n f ~ ' ~i / "--2 / € s n equentla ley list c nditions' If any, leading to the cause . /~~~ylwr Q n s z~ D [ ( q A of). /J ~ i'YS/Js~d~ ivB~>(~. IIS[ed on line a. Enter the UNDERLYING CAUSE (disease or injury that eta (or s a of F Initiated the events resulting d. f 1 - ~ n death)LAST. i D _ a4J u¢ (or as a consequence of): 26. PaK IL Enter other slgnit'ica nt condlti Crib •t d th but not resulting in the under) I n aus y g c e given In Part 1 27. Was an autopsy performed? O Yes No w 28. Were autopsy findings available S 29. If Female: Q Nof pr egna nt within past year 30. Did Tobacco Vse Contribute to Death? to c plate the c of death? oO Ves aQ No 31. Manner of Death m a Q Pregn nt at time of death Not Q Ves Q Prob a bWy 0 NO ~ Na[u ral 0 Homicide i- 0 pregnant, but pregnant within 42 days of death ~ Not pregnant, but pregnant 43 da s to 1 r 0 Vnk o n Q gccide nt Q Pending Investigation S i y year b¢fore death Q Unknown if pregnant within the pas[ year 32. Date of In Jury (MO/Day/V r) (Spell Month) u ~ cide Q Could not b@ determined 34. Place of Injury (e.g. home; construction site; farm; school) 33. Time of Injury Cher s Nam¢ (First, Middle, Las[, Suffix) John Mentzer Y _ Swartz 13. Mother's Names P for to First Marriage (First, Middle, Last) Anna W ~ g 14a. Informant's Nam¢ 14b. Relationship So Decedent Rieke Mentzer on 1 son 34c. Informant's Mailing Address (Street and Number, CI tv, state zip cpde) c ~ 15a ace D , 39 West Oa kwOOd r-. r 1s e, PA o ... ........ If Death Occurred In a Hospital: InpeHen[""""••---•• ~ .... . o_ eat _ ec on y one r .................... _ ... )if Death Oc •~ tut ed 5 ~~~ ~~ •~~~• f Q Emergency Room/Out pat ant Q Dead on Arrlyal i5b F lll ........-°-••°-•--.... _ _ __ t omewhe re Other Than a Hospital Hospice It • Facie y ""••"- p .•••..• CJ ~~e~eder;i~:~iio~;;~.. Q Nursing Home/Lon -Term C F • . ac ty~Name (If not fns Lotion, lye street and nom ber'~ Carlisle Reg~onal Medical Center g are acility Other (specify) 15 City o To State, d ZI Code 1sd.cquntynfD CarllsY ch P 1 16a. Method of Disposition Burial Q Cremation Removal from State 0 Donation ea e, A 7013 16 b. Date of Dls Lion 16c. Place of Disposition (Name of cemete C11[ilbarland pOSe ry, crematory, or Other place) D 10 Other (spe~ify)_ 16d L i ec , 2012 Westminster Memorial Gardens Z $ . ocat on of Dlsposltion (City or Town, State, and Zipl C l 17a. Slgnatu f Funeral Servlc ten;tee or I Ch ,J ar isle r PA 17013 n arge of Interment 17b. License Number 17c. N and Complete Address of Funeral Facility 13850 ~ Ho££man-Roth Funeral Home & Cra 16. Oeced ant's Education -Check th b mato r 219 North Hanover Street t- e ox that best describes the highest degree or level of school completed t th i 19. Decedent of Hispanic Origin -Check the Car]-1.910 r PA 17013 20. Decade Wt' R a e t me of death. Q Bth grade or less box [hat best describes whether the decedent i S s o race -Check ONE OR MORE races to Indicate what the decedent a sidered himself h (~ No diploma, 9th - 12th grade HI h school r B d t s panish/His panic/Latino. Check the "N O" box If decedent Is no[ Spanish/Hispanic/Latino or erself to be. White Q Korean g a ua e or GED completed Some college credit, but no de gree . ®No, not Spanish/Hispanic/Latino B Q lack or African American ~ Vietnamese Q American India l ~ Asso<late de gree (e.g. AA, AS) Q Yes, Mexican, Mexican American, Chicano n or A aska Native ~ Asian Indian Other Asian e Q Bachelor's d gree (e.g. gq, qg, g5) ' Q Yes, Puerto Rican Q Ves, Cuban Q Natlye Hawallan ~ Chinese Q Guamanian or Cha m Q Master s degree (e.g, MA, M5, MEng, MEd, MSW, MBA ) D ~ Yes, other Spanish/Hispanic/Latino otto Q Filipino 0 Samoan octorate (e.g. PhD, Ed D) or Professional degree (S if Q Japanese Q Other Pacific Islander . MD DOS OVM LLB JD pec y) ~ Other (Specify) ' 21. Decedent's Single Race SeIF-Designation -Check ONLY ONE to Indicate what The decedent considered himself or her ® White Q Japanese self to be. 22a Decedent's V l O ~~ Q Black or African American Q Korean Q Ameri I d Q Samoan Q Other Pa Uflc Islander . sua ccupatlan -Indicate f work type o done during most of working Ilfe. DO NOT VSE RETIRED can n ian or Alaska Native Q Vietnamese ~ Asian Indian ~ Other Asian ~ Don't Know/Not Sure . Truck Dr1 Vat Q Chinese Q Native Hawallan Q Fili i Q Refused Q Other (Specify) 22b. Kind of Business/Industry p no ~ Guamanian or Chamo rro ITEMS 23a - 23d MUST BE COMPLETED By PERSON WHO PRONOUNCES OR CERTIFIES DEATH rrrppp y ) 23/~ Dat@ P, noun d Dea Mo Da Vr 2 ! Trucking Com 23 b. Signature of P r tin D¢at g (Only when applicable) pany 23 Litens¢ Num er --~ -~ ~- r • •__• e~~o rvumoer, Clty, State, Zip Code) 36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How In ~ Yes Q Driver/Operator Q Pedestrian Jury Occurred: 0 No ~ Passenger ~] Other (Specify) - 39a. Certifier (Check only one): ~ C~.cHfYing physician - Tu the be aof my k wledga, d h tutted due to th t e cause(s) and manner stated ~P ncing 8, Certifying phys~ i n - To a b<s y wledga, death occurred at th e time, d te, a d place, and due to the cause Medical Examiner/Coroner - On the b iz o ~ Ina n, and/or Invests anon In (s) and manner stated B m i , y op nion, th ~{ red at the time, date, and place, and due [o th (s and m Slgnatu a of certifier: ~ r 3 ( J Title of ce rtifler: ~/ b. am<, Address and Zip Cade of P Co License Number PI g Cau of N t (It 26) 39c. Date ed /D e 4 o ay/Yr) 0. Registrar's District Number Z 2 ~ ~ 41. Registra ylr~t..ro ~ ~ 42. Registrar F e Date Mo Day r) a\11 _ _ - ~ /j O 4 - ~t ` _ a 3. Amendments t `~ ~~ ~` r O~ Dlsposltion Permit No. 1 ( ~ ~~ p ~ H1O5-143 REV 07/2011 ~~C~° 'n .°s- ~3 ~ ~ '~ i RENUNCIATION _3 v::~,j L~ f:: r- ;~ ~~ REGISTER OF WILLS ~ L ~. ~~ << ,~ Cumberland COUNTY, PENNSYLVIT~Q ~ ~ ° : ;; , ( Estate of Russell E. Mentzer Deceased Son I Ron C. Mentzer (Print Name) in my capacity/relationship as of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Betty E. Mentzer January 23, 2013 (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills Form RW-06 rev. 10.13.06 c -~ -~-~ (Signature) 446 Cloudview Lane (Street Address) Stevensville, MT 59870 ((,'ity, State, Zrp) 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 pure ~s stated within on this day of ~ ~~~~ Notary Public v My Commission Expires: (Signature and Seal of Notary or other official qualified to a ~i fission.) FINM»r A. Pni1Ne N sao~ply t~M~NM Cow E~tp1rM l4/.'1~13 a r. ~. r- m - ,., RENUNCIATI(~ ~~ = ~ u = '_ REGISTER OF WILLS Cumberland COUNTY, PENI`~'~-~LV~~NIA ©n'~i~tiS` ` ~y Estate of Russell E. Mentzer Deceased Son I Ricky J. Mentzer (Print Name) in my capacity/relationship as of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Betty E. Mentzer January 23, 2013 (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills Form RW-06 rev. 10.13.06 (Signature 95 West Oakwood Drive (Street Address) Carlisle, PA 17015 (City, State, Zip) 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~or the purpos s stated within on this ~3/ day of ~ ~lJ/3 ~ ~ ~~~~ 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.) ~~ ~~ HNtl~ A. Bsrbo~r, Notary public Ca~IkN A. CuaM~oMand County ~- Comadpbn Eltpbro 11i11M=0"l3