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HomeMy WebLinkAbout02-01-13PETITION 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 requests the grant of Letters in the appropriate form: Decedent's Information Name: Lois W. D. Wallace a/k/a: Lois Wallace. a/k/a Lois Willoughby Davidson Wallace a/k/a: a/k/a: Date of Death: 01/21!2013 File No: 21 -13 -~ ~) (Assigned by Register) Social Security No: Age at Death: 94 Decedent was domiciled at death in Cumberland County, pA (State) with his/her last principal residence at Messiah Lifeways, 100 Mt. Allen Dr., Mechanicsburg 17055 Upper Allen Twp. Cumberland Street address, Post Office and Zip Code City, Township or Borough County Decedent died at Messiah Lifeways, 100 Mt. Allen Dr., Mechanicsburg 17055 Upper Allen Twp. Cumberland PA 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 $ If not domiciled in Pennsylvania ................. Personal property in Pennsylvania $ If not domiciled in Pennsylvania ................. Personal property in County $ Value of real estate in Pennsylvania........... $ Real estate in Pennsylvania situated at NONE (Attach additional sheets, if necessary.) 150,000.00 0.00 TOTAL ESTIMATED VALUE$ 150,000.00 Street address, Post Office and Zip Code City, Township or Borough Q 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 thereto dated 11/23/2010 County 09/11/2009 and Codicil(s) (State relevant circumstances, e.g., renunciation, death of executor, etc.J Except as follows: after the execution of the instrument(s) offered for probate, Decedent did not mar ,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. ^X NO EXCEPTIONS ^ EXCEPTIONS ^ B. Petition for Grant of Letters of Administration (if applicable) c. t. a.; d. .n.; d. .n. c.t.a.; pedente cite; urante absentia; durante mmoritate 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 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 Petitioner(s), after a proper search has/have ascertained that Deo~lent left no Will and was survived by the following spouse (if any) and heirs (attach additional sheets, if necessary): ~,. n ~ -~ ~ ~ ~ .-. rY11 .-.. Name Relationship Address ~ :-~, --- .~; .~~, ~~ r n- ~~~~ r°r~y ~~~ M ~~ ~ ~~ -~ ~ ~~ ~~ ;~ c~ r~ ~ ~ ~ ~ -r~ A `~ Form RW-02 rev. ~0-1 ~-2oT ~ Copyright (c) 2011 form software only The Lackner Group, Inc. -Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } SS: couNTY of Cumberland } Official Use Only Petitioner(s) Printed Name Petitioner(s) Printed Address Gerald J. Brinser 6 E. Main Street P.O. Box 323 Palmyra, PA 17078 r-~; c `.~' rn rn ~ rn ~? ~ s ~~~ ~ ~~~ ~ ~-~ The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are true and corre~todbe st ost.eknov~i}e and belief of Petitioner(s) and that, as Personal Representative(s) of the D cedent, Petitioner(s) will well and truly til~pte~e e ac~a'd' to law. Sworn to 9~ffirmed and ubscribed before ~ ' -~`~ •z S-` ~ CJ Date~""~ / / 3 me this. r day of ~ t , ~ ~~ ~ Date{j~ ~ gy. i(,,Q, o `~ Date Fort egister Date BOND Required? ~ Yes ~ No FEES Letters ............................................ $ ~~lL~ ' ~ ~ ( ~ )Short Certificate(s).......... ~ y". t:~ ( )Renunciation(s) ............... ( ~) Codicil(s) ......................... ~~--4, ~, ( )Affidavit(s) ....................... Bond .............................................. Commission ................................... Other ~- Automation Fee ............................. ,_ JCS Fee ......................................... TOTAL ........................................... $ .~ f Printed Name:r/ Keith D Wagner DECREE OF THE REGISTER Estate of Lois W. D. Wallace a/k/a: Lois Wallace, a/k/a Lois Willoughby Davidson Wallace AND NOW, /"!0 /' satisfactory proof having been resented before me, IT IS DECREED that Letters are hereby granted to Gerald J. Brinser Date of Death: Social Security No: File No: 01/21/2013 196-22-5011 21 - 13 " (~ ~_~~ ZL~/..~ , in consideration of the foregoing Petition. Testamentary in the above estate and (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of record To the Register of Wills: Please enter my appe~ance by my signature below: Attorney Sig Supreme Court ID Number: 43891 Firm Name: Brinser, Wagner 8< Zimmerman Address: 6 E. Main Street P.O. Box 323 Palmyra, PA 17078 Phone: 717/838-6348 Fax: 717/838-6912 E-mail: keith@bwzlaw.com 09/11/2009 11 /23/2010 st Will (anodicil(s)) of Dece nt. Register of Wills ,~J/~ ~} ~.y~j .~' Form RW-02 rev. 10-1 ~-20~ ~ f~/, Copyright (c) 2011 form software only The Lackner Group, Inc. of 2 ZI-I~.t3~3~- RECORDED OPI"ICE OF' . . REGISTER OF' ~¢~I~.LS 1013 FE8 1 ~~ 3 SQ - CLERK 01= - P ~. ~ ORPHANS' COURT 0 ~ 002- CUMBERLAND CO., PA . Type/Print In COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS Permanent CERTIFICATE ~F DEATH _ _-. _. C ~ J W O_ 1. Decedent's Legal Name (First, Middle, Last, Su ix) - L... `S C.c.s 2. S~ 3. Social Security Number /' / 9 - 4. ate of D°'~th (Mo/Day/Yr) (Spell Mo) t~ ~ \ 'a-©~.''~ Sa. Age-Last Birthday (Yrs) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (Mo/D ay/Yea r) (Spell Month) 7a. Birthplace (city and S tate or Foreign Country) Q - Months Days Hours Minutes / //~~ ~ i.T'~ G ~/yL b ~ 3 ( 7b. Birthplace (County) /!) 8a. R ence (State or Foreign Country) 8b. Residence (Street and Number -Include Apt No.) c. Did Decedent Live in a Tow/ p7 es, decedent lived in V!~'C .~. /'T~/G~ ~/ twp. 8d. Residence (Count ) y ~L. ti1 ly,l .~ 8e. Residence (Zip Code) ` D No, decedent IWed within limits of city/boro. 9. Ever in US Ar ed Forces? 10. Marital Status at Time of Death ~ Married Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) ~ Yes No ~ Unknown ~ Divorced ~ Never Married ~ Unknown +-- 12. Father's Name (First, Middle, st, Suffix) 13. Mother's Name Prior to First,Marriage (First, Middle, Last) :s .> r ~5 o rJ v w rid 14a. n ormant's Name 14b. Relationship to Decedent ~ 14 Infor ant's Mailin A_ ddress (Street and umber, Clty, State, C de) A C .~~. ~ o ~ nJ L . ~ e ~2 ~ ~ ~ o ~ n ~ .e _ ~.a~ ~ 65$ ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 15a. Place o_ Deat C ec on done oc _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ If Death Occurred in a Hospital: [] Inpatient Ilf Death Occurred Somewhere Other Than a Hospital: [7 Hospice Facility ~ Decedent's Home ° ~ Emergency Room/Outpatient ~ Dead on Arrival 1 „j~~Flursin Home/LOn Term Care Facilit g g- y O Other (Specify) 1 Factlity Name (If of Ins itutios t,k~ive street and number) 15c. City or own, State, and Zi Code iSd. County f Death LL ` \ !- ~ W ~ S ~ ~ ~ V 4- ~ ~.1 C J sv` C\° -• 16a. Method of Disposition O Burial re mation 16b. Date of Disposition 16c. Place of D' osition (Name of cemetery, crematory, or other place) °O ~ Removal from State D Donation .~ / . ~E ~ Other (Specify) J ~~ 3'- / / / ,fir '- L. ! ~. ~' ~-~ ~~~IC 16d. Location of Dispositi n Gity or Town, fate, and Zip) 17a. ig ature o uneral Servi Licensee or P rson in Charge of Interment 17b. License Number ~ ~ ~ ~ ~~~iL S~OwN o GIB f ~ 17c. Nam d om etc Address of Fu al Fa ill __~ // ~G/J~J / iJ/e l`Y' J ~~~ °a$ 18. Decedent's Education -Check the box that b t describes the 19. Decedent of Hispanic Origin -Check the 20. 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 edent considered himself or herself to be. O 8th grade or less is Spanish/Hispanic/Latino. Check the "No" White ~ Korean ~ No diploma, 9th - 12th grade box " ecedent is not Spanish/Hispanic/Latino. ~ Black or African American ~ Vietnamese ~ High school graduate or GED completed No, not Spanish/Hispanic/Latino ~ American Indian or Alaska Native ~ Other Asian ome college credit, but no degree ~ Ves, Mexican, Mexican American, Chicano Q Asian Indian p Native Hawaiian Associate degree (e.g. AA, AS) ~ Yes, Puerto Rican Q Chinese Ian or Ghamorro ~ Bachelor's degree (e.g. BA, AB, BS) ~ Yes, Cuban ~ Filipino ~ Samoan ~ Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) ~ Yes, other Spanish/Hispanic/Latino ~ Japanese Q Other Pacific Islander ~ Doctorate (e.g. PhD, EdD) or Professional degree (Specify) ~ Other (Specify) e. MD DDS DVM LLB JD 21. Dec nt's Single Race Self-Designation -Check ONLY ONE to indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation -Indicate type of work White ~ Japanese ~ Samoan done during most of working life. O NOT USE RETIRED. Q Black or African American ~ Korean ~ Other Pacific Islander y~ Q American Indian or Alaska Native ~ Vietnamese ~ Don't Know/Not Sure /~ t _. ~~ 1 ((S ~ Asian Indian ~ Other Asian ~ Refused 2b. Kind of Business/Industry Q Chinese ~ Native Hawaiian Q Other (Specify) / ~ Filipino ~ Guamanian or Ghamorro ~~ ~~E~.` u~.~m.~_~/~ ITEMS 23a - 23d MUST BE COMPLETED 23a. Dat Prono need Dead (MO/Day/Yr) 23 b. Signature of Person Pro uncing Death (Only when applicable) 23c. License Number CERTIFIES DEATH PRONOUNCES OR O \ 1 ^ ~ -3 ~ (l~J ` ? ~ ~ ~ ~ ~ 23d. Date igned ( /Day/Yr) 24. Time of Death - F h v ~, 25. Was Medical Exami or Coroner Conte cted7 ~ Ves No CAUSE OF DEATH 1 Approximate 26. Part 1. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, 1 Interval: respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. I Onset to Death I ~1 y /l A ~/ Q .r( /1 IMMEDIATE CAUSE ---------------> a. // ~~~ ~ ~ c~~ ~ L ~s -7~• 1 ~` ~ 1 (Final disc asc or condition ~ Due to (or as a consequence of): ` \J `' resulting In death) I 1~ , ) b. _~ 1 Sequentially list conditions, Due to (or as a consequence of): 1 if any, leading to the cause 1 listed on line a. Enter the c. I UNDERLYING CAUSE Due to (or as a consequence of): 1 ... (disease or injury that I ~ initiated the events resulting d. I u_ in death) LAST. Due to (or as a consequence of): ~ 26. Part 11. Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part I. 27. Was an autopsy perf d? 0 ~ Ves No ~ 28. Were autopsy findings av table m to complete the taus death? °w D Ves No -+ E 29. If Female: 30. Did Tobacco Use Contribute to Death? 31. nner of Death - ~ S ~ Not pregnant within past year Q Pregnant at time of death O Ves O Probably p No 'Unknown atural 0 Homicide Q Accident O Pending Investigation m p Not pregnant, but pregnant within 42 days of death p Suicide p Could not be determined ~ O Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Yr) (Spell Month) p 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, County, State, Zip Code) 36. Injury at Wark 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred: ~ es ~ Driver/Operator O Pedestrian ~o O Passenger O Other (Specify) 39a. Certifier -physician, certified nurse practitioner, medical examiner/coroner (Check only one): Certifying only - To the best of my knowledge, death occurred due to the cause(s) and manner stated. Pronouncing ffi Ce I in - To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated. O Medical n r/Gor er - .~. b nation and/or Investigation, in my opinion, deg occurred at the time, date, and place, and due to the cause(s) an d man ne r stated. - { ' l ~ Sig of certifier. Title of ce rtifier:~ license Numb~~~ T ~v and Zip od on Completing Cause of ea (I)em 26) 9c. Date Sig d (MO/ y/Y r) p egistrar District Number 41. Registr ignatur 42. Registr r File Date (Mo/Day/Yr) 43. Amendments S /~ /~`~ ~~ H105-143 Disposition Permit No. ` ( REV 07/2012 ~. r' ~ ~ m ~ CD ~ ~ ~ C j'~ .~n",J d ~•7 ~ ~' ~ ..~ ti:,7 ~"~"~ i 9""{ LAST WILL AND TESTAMENT ~. ~ ~ ~' ~"a~ '=' OF ~ " ~ ~ ~~ LOI S W . D . WALLACE ~ ~ ~ .~ ~,` ~ ~ ~x ~.,.~ r r~~ I, LOIS W. D. WALLACE, -~ ~ ~ of Messiah ~Tillag n ~._ Cumberland County, Pennsylvania, declare t his to be my Last Will and Testa- ment, hereby revoking any will and codicils previous ly made by n-~e . I - I direct the payment of all my just debts and funeral expenses out of my estate as soon as may be practical after death. II - I bequeath certain items of my tangible persona property, not including cash and securities, in accordance with written list made by me during my lifetime. In the absence o designation on such a list, said items shall be sold and added t the residue of my estate. III - I devise and bequeath all of my estate of whatevez nature and wherever situate unto my husband, Robert W. Wallace, providing he survives me. IV - Should my husband predecease me; teen T ~?.irPryt t'~a} rr SAII~IS, FIAWER ~ LINDSAY ATPDRNEYS•AT IAW 2109 Market Street Camp Hill, PA executor hereinafter named divide my estate into two separate a equal shares to be distributed as follows: A. One share shall be divided equally among Karen F. Barber, now of Box 26, Rachel, West Virginia, and Linda F. Kuchenbrod, now of 549 Surf Avenue, Beachwood, New Jersey. Should either Karen F. Barber or Linda F. Kuchenbrod be deceased at the time of my death, their respective shares shall 1 .J` distributed to their issue per stirpes. B. The other said share shall be distributed a~ SAIDIS, FLOWER Sz LINDSAY ATTORNEYS•AT•LAW 2109 Market Street Camp Hill, PA follows: 1. 25% of said share shall be paid to St. George's United Methodist Church, 235 N. 4th Street, Philadelphia, Pennsylvania. 2. 25% of said share shall be paid to Hendersor. Settlement, P.O. Box 205, Frakes, Kentucky. If no longer ir. existence said share shall be divided between St. George's Church, Philadelphia, Pennsylvania, and United Methodist Church, Bedford, Pennsylvania. 3. 500 of said share shall be paid unto the United Methodist Church, Bedford, Pennsylvania, to be known a~ the Willoughby-Davidson Fund, to be invested and reinvested by them and the income therefrom to be used for the maintenance of the cemetery at the rear of the church, for church missions and for such other current expenses as the governing body shall fron time to time determine. 4. If any of the organizations mentioned in subparagrap'rls 1, 2, and 3 are no longer in existence at the time of my death, its share shall be divided proportionately among those named organizations still surviving at the time of my death. V - I appoint my husband, Robert W. Wallace, Executor of this, my Last Will and Testament. Should my said husband fail to qualify or cease to act as such, then I appoint PNC Bank, 2 ~/~ ~'G' to act in this capacity. Neither of my personal representative shall be required to post bond in this or any jurisdiction. VI - My spouse and I have executed complementary Wills this date and entered into an Agreement which prohibits certai changes to the Wills without the written consent of the person's spouse. IN WITNESS WHEREOF, I have hereunto set my hand arld seal or. this, the ~ day of September, 2009. ~~%~~ ~~G~ (SEAL) Lois W. D. Wallace SAIDIS, FIAWER ~ LINDSAY ATi~DRNEYS•AT•LAW 2109 Market Street Camp Hill, PA Signed, sealed, published and declared by LOIS W. D. WALLACE, Testatrix, therein named, on this and three (3) other sheets of paper as and for her Last Will and Testament, in our presence, who, in his presence, at her request, and in the presence of each other, have hereunto subscribed our names as attesting witnesses. ~/ ~~~/ ~ J ~` Name ~f,; . Name Addres Addre s s~~ 3 COMMONWEALTH OF PENNSYLVANIA) SS. COUNTY OF CUMBERLAND) WE, the undersigned, the testatrix and the witnesses, respectively, whose names are signed to the foregoing instru- ment, being first duly sworn, do hereby declare to the under- signed authority that the testatrix signed and executed the instrument as her Last Will and Testament and that she signed willingly (or willingly directed another to sign for her), and that she executed it as her free will and voluntary act for the purposes therein expressed, and that each of the witnesses, in ~~.r~e prese~lce and hearirig of the testatrix, signed the will as witnesses and that to the best of their knowledge the testatrix was at that time eighteen years of age or older, of sound mind, and undez• no constraint or undue influence. ~ , ~~ ~ ~ ~; -~~~'~' Testatrix ~, ~~ ., ~. Witness ,~ SAII~IS, FIAWER ~ LINDSAY ATIDRNEYS•AT•LAW 2109 Market Street Camp Hill, PA Witness Subscribed, sworn to and acknowledged before me by the testatrix, and subscribed and sworn to before me by both witnesses, this f~` day of September, 2009. CflMIVION~/VEALTH OF PENNSYLVANIA Notary Pub 1 i c Notarial Seal Yvonne Sersch, Notary Public Camp Hill Boro, Cumberland County My Commission Expires Feb. 1, 2~i2 Member, Pennsylvania rlssc~rl~tlon of Notaries 4 CODICIL I, LOIS W.D. WALLACE, of Upper Allen Township, Cumberland County, Pennsylvania, declare this to be the sole Codicil to my Last Will dated September 11, 2009. I. I hereby revoke Paragraph V of said Will, and in lieu thereof provide as follows: "V. I appoint Gerald J. Brinser, Executor of this my Will. In the event he fails to qualify or ceases to act as Executor, I appoint Keith D. Wagner, Executor of this my Will." II. In all other respects, I hereby ratify, confirm and republish my Last Will dated September 11, 2009, together with this sole Codicil as and for my Last Will. IN WITNE ~ ' ~~~ SS WHEREOF, I have hereunto set my hand this. da of ~~,~~~, Y 2010. , r o~~~~"~ ~~`C,~~,~.~ (SEAL) LOIS W.D. WALLACE Signed, published and declared on the date thereof by the above named LOIS W.D. WALLACE, as and for the sole Codicil to her Last Will dated September 1 1, 2010 in the presence of us, who, at her request, in hoer presence, and in the resence of each other, have subscribed our names hereto this ~~ day of ~~ ~~~ ~ 2010. ,, 'R~ ~ '~ ~° ..~~~-~~.- Residing at -,~.y~-~ ~-~.-~ 1 .~~~ ~. ~; Residing at_~~~ ~1~.~~ ti~~~~~ , ~ ~-~ ,~~-- ., ~, ~4 ~.: .~, `~' r~ r~n ~~ ~ -~ ~ n ~~ ~ c~ ~~~ ~ b. r m ~ -~ ~ ~ ~ ~ ~c ~t ; C..J ~~-- y-- ~ `..~ _ 1 _ -~? t`.... CO "3'1 COMMONWEALTH OF PENNSYLVANIA COUNTY OF LEBANON WE, LOIS W.D. WALLACE, GERALD J. BRINSER and '_~ ~~ ~.- ~~~~Y~~~~~~-~i`~ the testatrix and the witnesses, respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last Will and that she signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the Will as witnesses and that to the best of the witnesses' knowledge the testatrix was at that time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. ~~ 1 t ~ ~ LOIS W.D. WALLACE ~~ f -~ ;'~~ _-~ ~~.-~ TNES S f E t .. ~~ 1 Subscribed, sworn or affi~?ed a d acknowledged before me by GERALD J. BRINSER, witness, this v~~~ "`tray of ~j ~!QN~t, 2010. COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL WENDY L. CRAWF~RD, Natary Public Palmyra Bora.. Lebanon County ommission Ex fires Se tember 10 2013 ~~~~~ ~ ~~(SEAL) otary Public On this, the da of ~e ~'e~ , 2010, before me, a Notar Public the undersi ned Y Y ~ g officer, personally appeared GERALD J. BRINSER, Attorney I.D. No. 09655, known to me or satisfactorily proven to be a member of the Bar of the Supreme Court of Pennsylvania, and certified that he was personally present when the forgoing instrument, including acknowledgement and affidavit was signed by testatrix, LOIS W.D. WALLACE, and l~~ ~. -~°-t~.:~v`~:~.~,,~;._~ witness. 1~ IN WITNESS WHEREOF, I hereunto set my hand and official seal. COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL WENDY" L. CRAWFORD, Natary Public Palmyra Boro., Lebanon County My.Commi~.i~n 're b r 1 ~., ~ ~,~ SEAL ) Notary Public _..- -2-