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HomeMy WebLinkAbout01-31-13PETITION/FOR GRA~1T OF LETTERS REGISTER OF WILLS OF L1dj1~~~tr~j~Ggi~d~ COUNTY, PENNSYLVANIA Petitioner(s) named below, who isiare 18 years of age or older, apply{ies) for Letters as specified below. and in support thereof aver(s) the following and respectfully requests j the grant of Letters in the appropriate form: Decedent's Information T -~ Name: ~i^~ t! ~ ~ ~t D ~* ~, l / ai lc/a: a/k/a: a/k/a: Date of Death: ~/ - ;~~ - ~~/~ File No: ~ ~ ~ ~ ~ " ~ I ! c (Assigned by Register) Social Security No: f ~(o -,~,?~ - ,3C~~f f Age at death: ~S' Decedent was domiciled at death in C_ c~`~7~t`'~ ~LQ~t~f County, ~~ (Stare) with his/her last principal residence at / Q `F=t»~ L i,~G ri lr'~ '~,-~ Jim e ~~f•~.Gr,~~~y Street address, Post Of ue and Zip Code City, Township or Borough County Decedent died at ,~yf~ ~'t'i~i~sy~~~<>~~ ~i ~~' `lr~'s ~~- ~ ~E.~~,6,~~.1r~,~ ~~ Street address, Post office and Zip Code City, Township ar Borough County State Estimate of value of decedent's property at death: If domiciled in Pennsylvania ............................ All personal property $ 07, DG'S , ®U If not dotniciled in Pennsy!vania ........................ Personal property in Pennsylvania $ If trot domiciled in Pennsy[vania ........................ Personal property in County $ Value of real estate in Pennsylvania ......................................................... $ ~Q, D~?D , ~ TOTAL ESTIMATED VALUE.... $ ~-/~ , p©c~, c~ ~ Real estate in Pennsylvania situated at: / Z%~' ~c~f~i1_~y~t/~r-njC ~l/t' ~~-~,'1~,~ ~u~j~~.p~,;,~~~ cp (Attach ndditional sheets, i/'necessary.) 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) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated ..5 ' 3 ~ - ~oia and Codicil(s) thereto dated State relevant circumstances (e.g. renu,tciatior:, death ojexec,rtor, etc.) Except as follows: after the execution of the instrument(s) offered for probate Decedent did i~t many, 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 leave a child born or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. NO EXCEPTIONS ^ EXCEPTIONS ^ B. Petition for Grant of Letters of Administration (If applicable) c. t. u., d. b. n., d.b.t~.c.t.u., pende,zte life, clurunte absentia, durutzte minoritute 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 a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g) a~ld 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 Will and was survived by the follcf~ttn~ spouse (ifan.}rj and ht~ris (uxduch uclditionul sheets, i~~necessury): ~ 1 _ ` ~ •~ ___ . . ~ t_ .. r y ~...... .. c.,~.~.J Name Relationshi ~~~ '~ F--~ = y Ad3ress • ~,, .. _.. w,_. ~~ ~.__ .. ;, _,. _. , ~, ,~:.,. sT:~7 ., u'~i Fo,~n, tzw-nz ,~~v. Inilliznll Page 1 of 2 Oath of Personal Representative CO~t~{p~~,'v'E,~LTr{ CF Pc~~SYLV,~tit.-~ i, j ~. c7 _-_ , t ~ "~- ~° `' i ~- i _..::0~,_ _~~.CI_~~ i ' i ~./cse L, '' p. .:~ Tl~e Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are tnie aild correct to the best of the lu~owledge and belief of Petitioner(s) and that, as Personal Representative(s) of the D eden he Petitioi r s) will well aild truly administer the estate according to law. Sworn toJ~r affirmed and subscribed before -t s Dace /-~/- ~p/~ me thi .J Ada o ,s 7j Date By' ~--~ Date or the Register Date BOND Required: ~ YES ~ NO FEES: Letters ..................... . ( ~) Short Certificate(s)..... . (~ )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bo~td ........................ Commission ................. . Other ,,,,,,, .../.. Automation Fee .............. . JCS Fee . ................... . TOTAL ..................... S $ ,v~ D~ rf--4,~z -~ T- UC' ti $ -~ To the Register ojWills: Please enter my appearance by my signature below: Attorney Sig~lature: Printed Name: Supreme Court ID Number: Firm Name: Address: Phone: Fax: Etnail: DECREE GF THE REGISTER Estate of TIcTr~ `~ ~ /~~1E/ -~j ~ File Nc~: `~~ ~~ ~ Cl % u / a/k/a: AND NOW, .~ ' Zd' , in consideration of the foregoing Petition, satisfactory proof having been pre nted before me, IT IS DECREED that Letters ~~ct/I"Ic'/7 ,~Gr are hereby granted to _ ~`~ ~ fa~ ~ : ~,~~ r/~^ ir. the above estate and (if applicable) that the instrument(s) dated ~)/ _ _.~~ ,Z ii /,~ described in the Petition be admi ted to probate and filed of record as the last 1~Vil (and Codicil(s)) of Decedent. G~/~~~~J Register of Wills ~~ ~~ Fnrm R6V_/17 .,,,~ -nittnntr n n r.. a~, . ~ . -.~i `S)t i~11~ Cs,'iil~il'atC,- .1t't (t `-3 ~.y _, _ ~ ,. ~... ~~,~" ~ !!`: j.i ., 1~':C ;ilf( r ~ 1 r,~ t ~~ '7 ,'~1..~ -;~ ;~ 1 'r~1~\ iIEE.( 'af-,,1.t1K 11 ri~'i~f' lti't.'tl 1 r,~ ~.. .,. .i.~ - ~g~- ~ '~ i?_:i~~ L+i~ i!:.'.t (1(?~ ,+. i1 c)l'~crlli~ll ~-Cl-rlil<'~;1C' ll! 1!/C';.ll~l .~ . .at =. ~~- lli)l ., ,-~. .. Eti3t~it.' tl~~ ~.Oi,:;t~ f~tE?Iti~i-~li. }~~lt (iC(tTlll'1$ - - ~- i ~ ` E !'` .,~. '~. ~ r I • ;. t 1(yl \ iti-~itCj ~i? ~}ll' i`Y(:iiL i~ lt~l( s e;;. . l~j J ltV ..~~ ..t ~°E'~~~~~y -i ~.~~~~ .\ti~t[i I !~"tll4 i.~ I ! '~`.~l 1.24. (~:-~}~f ~llF li~~ LA ! F a ~ .z E . ~ ,,~~ P ~~~.66634 a . s~ ~ ~~ t l'l ilill'~)~]l)I?itia~lli;l~)~•l- - ~ i` is ~: ~ ~ ., ~.a .t l'a '~- t ! aa 1 _ sv;, St'y'? ..c+l- x`):11:_ f``~i1C'ia- lyue/Print In COMMONWEALTH Of DENNSYIVANIA • DEPARTMENT OF HEALTH • VITAI RECORDS Pe,Q1p0PO1 CERTIFICATE OF DEATH State File Number --1- 1 0 ,,~~7 c x{ 1. Decedent's Legal Name If first, Middle, last, Suffix) a. >ex a. auci.i a.su.,.s ,..,,,.... -. _--- -. ----~~ .~---. - -...... 2013 22 3091 anuar 22 , y - Harold A. Roughs Male 196- Sa . Age~lasr Birthday IYrsl Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (Mq/Day/Year) (Spee Month) 7a. Birthplace (City and State a Fonl{n Countryl Mcnths Days Hours Minuu f August 3, 1927 85 7b. Birthplace (County) 8a . Residence (State or Foreign Countryl Bb. Residence (Street and Number -Include Apt No.) 8c. Did Decedent Uve In a Township) l PA 140 Pennsylvania Ave. eton twp. es, decedent lived fn North Midd ad Residence (counlyl Cumber 1 a nd Se. Residence (tip Code) 1 7 ~ 1 ^ No, decedent Ilved wlthln limits of city/boro. 9. Ever in US Armed Forces? 10. MarRal Sutus at Time of Death ^ Married ,']{Widowed 11. Sunlving Spouse's Name (II wife, glue name prior to first marriage) Yes ^ No ^ Unknown ^ Divorced ^ Never Married ^ Unknown 11 . Earner's Name (first, Middle, Last, Suffix) Ben'amin F. Rou ht 13. Mother's Name Drlor to First Marriage (FIrs4 Middle, Las[) Mina A. Hinkle ' 4 t's Name lib. Relationship to Decedent f llc. Informant's Mallln{ Address (Street and Number, Clty, State, Zip Codel ] ] 0 2 Q 1 orman a. In Joseph E. Fink, Jr. Nephew 27 McNaughton Dr., Duncannon PA ' o u . s .......................................................~.....P.................................., ital: In anent : Hos d i h O lSa. D ace o eat « an one .......................................................... .............................. ..... ....... ..... 11 Death Occurred Somewhere Other Than a Hospital: ~ Hospice Facility ~Oecedent't Home If ° ccurre n a p Deat ^ Emergency Room/Outpatiem ^ Dead on Arrival ~ Nursin{ Home/LOn{-Term Care Facillry Other (Spaclfyl f D h z 1 56. Facility Name (II nos institution, give street and number; Avenue i l eat lSC. City or Town, State, and Zip Code lSd. County o PA 17013 Cumberland Carlisle r 1 van a 140 Pennsy 6a. Method of Disposition ~^(Burial ^ Cremation , 16b. Dau of DlsPosi[ion 16c. Place of Disposition (Name of cemetery, crematory or other lace) Paul's Lutheran C~lurc~3 Cemeter 13 St f ^Remiryaurirmstare pDgnangn Other lSpecdY) . 1/28/ 1 6d Loca iron of Disposition (City or Town, Stare, and Zlp) 17025 i7a. Signature or Funerals Ice License ar Person In Charge of Inurment /1-ur 17b. License Number 011825-L Enola, PA ~ a'J~ 4 E 1 7c. Name and Complete Address of Funeral F><ility 206 Maple Aven s FH l h Marysv'lle, PA ue 17053 l , oni a S Decedent's Education ~ Check the box that Dest describes the 19 e , . Decedent of Hispank Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to indicate what ° h . ighest degree or level of school completed at [he time of death. b ox that best describes whether the decadent ' • the decedent considend hlmsell or herself to bt. ^ Korean Whi ^ ern grade or I¢ss It b NO Spanish/NisDanic/Latino. Check the ox it decedent is not $panish/Hispanic/Utino. le ^ Black or Alrlcan American ^ Vietnamese ^ No diploma, 9th ~ 12th grade RJ Migh school graduate or GED completed ~ No, not Spanlsh/Hispanic/Latina ^ American IrWian or Alaska Native ^ Other Asian Natve Hawaiian ^ Some college credit, but no degree ^ Yes, Mexican, Mexican American, Chicano ^ Arlan Indian ^ se ^ Guamanian or Chamorro Chi ^ Assonate degree le.g. AA, ASI ^ Yes, Puerto Rican C b ne ^ ^ FIIIDIno ^ Samoan ^ Bachelor's degree le.g. BA, AB, B5) ^ ^ Master's degree (e.g. MA, M5, MEng, MEd, MSW, MBAI ^ u an Yes, Yes, other Spanish/Hispanic/Latino ^ laDanese ^ Other PuiRc Islander ^ Do<torau le.g. PnD, Edo) or Drolessional degree (Specify) ^ Other (Specify( ¢.. MD, DDS, DVM, Lla, 10 lf w her id d hi Decedent's Usual Occupation -Indicate type of work 2Za sel(to be Z . . mse ere 1. Decedent's Single Race SeII~Designation ~ Check ONIY OHE to indicate what the decedent cons (White ^ Japanese ^ Samoan done during most of workln{ k(e. DO NOT USE RETIRED. ^Other Pacific Islander Factory Worker ^Black or African American ^Kq!!an ^ Amen<an Indian or Alaslu Native ^ Vietnamese ^ Don't Know/Not Sure Kind 01 Buslnest/Industry 22b . ^ Asian Indian ^ Other Asian ^ Refused ^Other(Specify) Crystal MFG. CO ii an ^Chinese ^NativeHawa ^ Filipino ^ Guamanian or Chamorro . sting Death Only w en ap Icablel 23c. License Number ITEMS 23a - 23d MUST BF COMPlETEO 23a. Dau Pronounced Dead IMO/Day rf 23b. Signature of Person Pronou / BY PERSON WHO PRONOUNCES OR J ~ ~ _ ,S rJ`~~ (~ V y` rl F<t,(J alb/~J.~(- CERTIFIES DEATH - I / ' 23d. Date Signe (MO/Da /Vr) 24. Tim I Deathv~ Z ~ G /h 25. W as Medical aminer or Coroner Contacted? ^ Yes No CAUSE Of DEATH I Approximau Inunal: 16 Pan I. Enter the 4hain vl events-tliseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest. nly one cause on a line. Add addltlonal IlneS If necessary Onset to Death DO NO7 ABBREV TE. Enur o in Ue etiology h i h . ow respiratory arrest, or venlrlcular fibrillation w ~/lout s ~/t} l IMMEDIATE CAUSE ~-~~~~-~~~> a. ~J / ® - b /~ `~ ! ifinai disease or condition Due to (or a consequence ol): resulting in d¢athl b. Sequentially Ilse conditions, Due to (or ai i consequence 01): II any, leading to the cause - listed on tine a Enter the UNDERLYING CAUSE Due to (or as a consequence of): (disease or injury that miuated the events resulting d. in deals) UST. Due to (or ai a consequence oft: ~ Z6. Part 11. Enter other s a (ice t conditons contributing to death but not resulting In the underlying cause given in Part I 27. Was an autopsy performed? ^ ytf No 0 E Ze. Were autopsy lindi available to complete the cause of death) Yef No d 30. Did Tobacco Use Contribute to Death? nnar of Death M a 31 . 19. II Female ear thin ast t ^ Yes ^ Probably a ~, ,i ' y~ natural ^ Homicide c y wi ^ Not pregnan D th f d i ^ No ^ Unknown ^ Accident ^ Pending Investigation ea me o ^ Pregnant at l nant within 42 days of death t b t re ^ Suicide ^ Could not be determined g , u ^ Nor pregnan p ^ Not pregnant, but pregnant /3 days [0 1 year before dean 32. Date of Injury (Mo/Day/Yr) (Spell Month) 33. Time 011n)ury ^ Unknown it pregnant wlthln the past Year ;4 Place of Inlury le.g. home, construction site; term; uhooll 35. Location of Injury (Suet{ and Number, City, Stale, Zip Cgde) 36. Inlury at Wort ^ ves 37. If iransVOrta lion Inlury, Specify'. ^ Driver/OVerai or ^ Pedestrian 39. Describe Mow Injury Occurred: ^ No ^ Passenger ^ Other lSpecily) 39a. ertitier (Check only one): e to the wuselsl and manner stated d d h occurre u Certilymg phytuian ~ To the best of my knowledge, deat death ac rnd at the time, date, and place, and due to the cause(s) and manner soled knowled e f g , my Dronaunung & Certifying physician ~ To the best o ^ Medical Examiner/Coroner ~ On a basis o xam' n, and/or Investl n, In my opinion, death ccurred at the [line, date, and place. and due to the~use(~ ndr~anns~rrrita[eo ~,~~,~y,~~J Ucense Number: /T/ /n LC^' ~~, S~gnarure of certlfie Title of certifier: 39c. Date Signed (Mo/Day/Yr) 396. ame, Addr and Zip Code of Per n Completing Cause of Death (Item 261 I C U _ J ~ /1 R ar's Signaru 12. Registrar Flle Date (MO Day r) 40. Registrar's District Number ~~ ~ ~~ So a 5 ~ 43 Amendm¢nlt Disposition Permit No. ~ ~^ ~~/ ^1 acv 07/2011 4 LAST WILL AND TESTAMENT OF HAROLD A. ROUGHT . ~.~. ,__. ;; ~~ I, HAROLD A. ROUGHT, of Cumberland County, Pennsylvania, declare this to be my Last Will and Testament and hereby revoke all prior Wills and Codicils. 1. I direct that all my just debts, funeral expenses, and administrative expenses shall be paid from my estate as soon as practicable after my death. It is my wish that upon my death, my body shall be buried beside my beloved wife, at our plot in St. Paul's Evangelical Lutheran Church Cemetery, Enola, Pennsylvania. 2. I give, devise, and bequeath all of my real property and personal property that I own at the time of my death to my daughter, Elesa D. Kreiger. 3. Should my daughter, Elesa D. Kreiger, predecease me, then I give, devise, and bequeath all of my real property and personal property that I own at the time of my death to my son-in-law, Robert Kreiger. 4. I appoint my nephew, Joseph E. Fink, Jr., as Executor of this my Last Will and Testament. In the event that Joseph E. Fink, Jr. is deceased, unable or unwilling to serve or shall cease to serve for any reason whatsoever, then I nominate, constitute and appoint my nephew, William Fink, as alternate Executor of this my Last Will and Testament. 5. The Executor of this Will shall have the power to distribute my estate in cash or in kind, or partly in either. 6. I direct that no Executor acting under this Will shall be required to enter bond in any jurisdiction. 7. I recommend that my Personal Representative retain the law firm of Allied Attorneys of Central Pennsylvania, L.L.C., to probate my estate. -, ~~. IN WITNESS WHEREOF, I have hereunto set my hand this ',7 day of ~/~..~~,~ , 2012. t~ ,< , ; ,... ~ '~ d. HAROLD A. ROUGHT ~~ _~ ___ :. -.: , _ , e .~...~ ~ ~.~ ~ .' ~~ t~.,..yy ... '- bs rrwr' ~ r. ~ ~ f d.. .. L~.A C.~ .- :~ Page 1 of 4 The preceding instrument consisting of this and three other pages was on the day and date hereof signed, published and declared by HAROLD A. ROUGHT, as and for his Last Will and Testament in the presence of us, who at his request, in his presence and in the presence of each other have subscribed our names as witnesses hereto. Y ^V,.. J +._s u ..~ (-..~ J "'L... (±~b .~} Witness ~UV ness ~u_ ~ r i :,~' Page 2 of 4 ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS I, HAROLD A. ROUGHT, the TESTATOR, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly, and that I signed it as my free and voluntary act for the purposes therein expressed. HAROLD A. ROUGH COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND S.S. .-~ ~ r On this ~ I day of ~ ~ , 2012, before me personally appeared HAROLD A. ROUGHT, kno to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and he acknowledged that he was the declarant who executed the same for the purposes therein contained. IN WITNESS WHEREOF I hereto set my hand and official seal. ~~ ~ -:~'~~ _ _ ~ .~ ~ ~~ ~_ -f ~ Notary P ~ic u Y @yd ~~= x '.1_a `~~~°_~~~~ ~ ~~~ A~~f~~~~PyubyliG ~ J 5 11 ... i d.~,9f ~ ~d tks€ ;iii. ~1 9~ Y, e~-nrarru _s:ss.. ~ _ . xn ...--.+ - .: ..S i a `II '`~ Page 3 of 4 AFFTIIAVTT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS ,r. ; --- ;. ~. ,. " ., WE, ~"~ , , , ~ ~ ~ : ,, ; . -and ~ ~C. ~ ~. ~ C `_ ~ ~ ,., ~ }~~ the witnesses whose names are attached to the foregoing document, being duly qualified". according to law, do depose and say that we were present and saw testator sign and execute the instrument as his Last Will; that he signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the testator signed the Last Will and Testament as witnesses and that to the best of our knowledge the testator was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. ~~~ ~,>~ f,;, ~ _ ____ _ Sworn or affirmed and subscribed before me by .~ '-.i ~;~._~~ -., _. ~,.~ t ~ ~- ~'- ~ ~ ~ ~ ,,. ~ ~ ~,_{ r ; r' ~~c~. i ~ and ~~~~~ ~ ~t~.~. /v~ . ~ ~. ~a this _ _~r.--" ~ I ~' day of ~~.~~ , 2012. l~ otary Pub is orney ~-,. ~"tA ~ , ~ .; 3 . f ...,. <...<. w~. r ~ `<~ / ~~ ~, "1 Y ~ .Y C /~ Page 4 of 4