HomeMy WebLinkAbout02-08-13PETITION FOR GRANT OF LETTERS
REGISTER OF WII.,LS 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: _R__odney N. Tolbert ___ File No: ~ ~ - ~~-~
a/k/a: (Assigned by Register)
a/k/a:
a/k/a: Social Security No:
Date of Death: 1 /26/2013 Age at death: 80 _
Decedent was domiciled at death in Cumberland County, Pennsylvania _ (State) with his/her last
principal residence at 106_Hammond Road 17257 South Newton Township. Cumberland County
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at Manor Care ___ _ 17201 Borough of Chambersburg_ Franklin PA
Street address, Post Office and lip Code CSty, Township or Borough County State
Estimate of value of decedent's property at death:
Ifdomiciled in Pennsylvania ................................A(1 personal property $ 500,000.00
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 VALUE.... $ 500.000.00
Real estate in Pennsylvania situated at: none _
(Attach additional sheets, if 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 1 /22/2013 and Codicil(s)
thereto dated none _ _
none
State relevant ri_rc..±~atances (eg. 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, 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(8), and did not have 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.a., d.b.n., db.n.c.t,a., pendente life, durante absentia, durante minoritate
If Administration, ~~a or db.n.c.a! 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(8) and 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 th~'ollowing spouse(if an~eirs (attach
additional sheets, if necessary): C ~ ~^' ~ ~
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FormRW-02 rev. io~~liaoll Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF CUMBERLAND }
__ ~
Petitioner(s) Printer
106 Hammond Road
Shi~pensburg__ __ ~~_~- ,'h7 __
150 Stony Point Avenue ~- y s
Official Use Only
ORPHANS'GGURT
CUMBERLAND GG., PA
The Petitioner(s) above-named swear(s) or affum(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 Petitioner(s) will well and truly administer the estate according to law.
Swcrn to ~r aff>,mled an~ s bscribed before Date ~ ~
me . -~-- d.ay of ~ C ~ ~_ _ _ Date ~ ~-`'f ~
rr a ri ~
BY~ 1~~-~_ - __ Date
or the Register Date __ __ ____
BOND Required: ^ YES ®NO
FEES:
Letters ....................... $ 410.00
(~ ~~} )Short Certificates(s) ...... ~(~J U2~39°99'
( )Renunciation(s) .......... _
( )Codicil(s) ............. .
( )Affidavit(s) ............ .
Bond .........................
Commission ....................
Other Will _ .. , , ..... 15.00
Inheritance Return ......... _ .___1.5.00
Inventory _.. _ ........ , 15.00
Automation Fee ............... 5.00
7CS Fee ....................... 23.50
To the Register of flrlls:
Please enter my appearance by my signature below:
Attorney Signature:
Printed Name:
Supreme Court
ID Number:
Firm Name:
Address:
Phone:
Fax:
Email:
TOTAL ......................$ - ~-5~4~:~.70
DECREE OF THE REGISTER
Estate of Rodney N. Tolbert File No• ~~ ~ ~
a/k/a:
AND NOW, - ~ c~__~,~~ , in consideration of the foregoing Petition,
satisfactory proof having been prese d before me, IT IS DECREED that Letters Testamentary
hereby granted to Joan W. Tolbert. a/k/a_Joann W. Talbert. and Douglas R.
Tolbert _ _ _ __ in the above estate and (if applicable) that
the instrument(s) dated January 22, 2013 _ _ _ _ _
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)} of Decedent.
Form RW-02 rev. 10/11/2011
Register of Wills ~ ( ~pCc ~,~7 ~~~
Page 2 of 2
H IOS.ti05 RF.A' ~0/I li
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
VIIARNING: It is illegal to duplicate this copy by photostat or photograph.
RECORDER OFFICE OF
Fee for this certificate, $6.00 REGISTER OF l~ItaLS ~a,hi~ i~ to ccrtif~ that the information here gi~~en is
1Qi3 FEB 8 Ail 11 12
CLERK aF
19 3 3 6 ~ 4~ OoRPHANS• caURT
Certification Number ~UI~CBERl.AND Co., PA
c(~rrectly copied from ,gin original Certificate of Death
duly) filed ~~ith ^)e as Local Regisri•ar. The original
certificate ~4~ill hr for~~arded to the State Vital
R(~cor~ Office I~l.)r p • anent filing.
o i l~ ~ lzd~~
_f ca Reeistrar Dj:tte Issued
TYPa/PNnt In COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS
Pertnanant
Black Ink CERTIFICATE OF DEATH 5
1. Decdent's Legal Name (First, Middle. Last. Suffix) 2. Sax 3. Social Security Number 4. Date Of Duth (MO/Oay/Yr) (Spell Mo)
Rodney N. Tolbert Male '168-26-5476 January 28, 2013
Sa. Age-Lear Birthday (Yrs) Sb. Undv 1 Year Sc Under 1 Da 6. Oat! of Bir[h (MO/Day/Ypr) (Spell Month) 7a. BlKhplau (City and State or Foreign Country)
Months Days Hours Mln.,ces
Chamberabu PA
Februa 21, 7932
80 ry 7b. BlrehPllu (County) Franklin
Bi. Residence (Stara or FOrcign Country) Sb. Residence (Street and Number -Include Apt No.) 8C. Did Decedent Lhr! In !Township)
PA 706 Hammond Rd. ryes. decadent cued In South Newton
se. Reshtenc! (e^<,nty) ewP.
Cumberland g!. Msidlnce (Zip Code) 17257 Q No, deceaeni Il..ed wehm Rmlta ^f city/born.
9. Ever In US Armed Forces? 10. MaNtal Status si Time of Death Ma Mid Widowed 11. Surviving Spousds Name (If wife, gWe name prior to first marriag!)
Q Yss ~ No Q Unknown Q DNOrosd Q N!v!r Married Q Unknow Joan Wagner
12. Father's Nam! (First, Middle, Last, Sufflz) 13. Mother's Name Prior [o First Marroge (First, Middle, List)
Robert E. Tolbert Eva Nuckels
14a. Informant's Namv 14b. Reotlonshlp to Decedent 14c Informant's Malling Address (Street and Number, City, State, Zip Code)
~~ Joan W. Tolbert wHa 706 Hammond Rd. Shfppensburg PA 77257
i5 .. w ............................ .................................... ...................................
If Death Occurred In a Mospltal~ Inpatient tf Death Occurred Soma here Other Than a Hofpltal: ~ Hospice Facility ~ Deceden['s HOmf
J Ema en Room/Ou Lilo[ Dlad on ArrNal Nursin Homa/LOn Tlrm Gr! Fitlll Other 5 1
CSS 15b. Facility Nam! (If not Institution, give street and numbvrj 15c City or Town, SUte, end Zip Cod! 15d. County of Death
~ Manor Cara ~ Chambersburg, PA 77207 Franklin
~, 16a. Method of Dlapositlon Burial Q Cremation 16b. Date of DispoaitlOn 16c. Place Of Oisposltlon (Namv of cemetery, crematory, or other place)
Q Removal from Stcte Q Donation
other( )
January 30, 2073 Rollin Green Cemete
9 ry
16d. Loudon of Disposition (Glty or Town, State, and Zip) 17s. Slgnatur! of Funeral Servlc Ucensee or Parson in Chan! o} Interment 17b. Uunsa Number
Camp HIII, PA 17077 FD-072884-L
17c. Namv and Compote Address of Funeral Flclllty
Dugan Funeral Homa and Crematory Inc. 57 Asper Drives, Shippensburg, PA 77257
~ 18. Deodlnt'a Eduction -Check th! bex Chat best dascNbls the 19. D!cldent of Hispanic ONgin -Check The 20. Daeadent's Rac! -Check ONE OR MORE races to Indica[e what
f- highest dlgr!! or 1!v!I of school completed at the time Of death. box that bast describes whether the decdlnt th! decdvnt considered himself or herself to be.
Q Bth grade or lass is Spanlah/Hlapinic/Latino. Chuck the "NO° )~( White Q Korean
Q No diploma, 9th - 12th grade box If decedent is not Spanish/Hispanic/Latino. Q Black or Afrlun American Q VlKnameae
Q High school graduate Or GED completed No, not Spanish/Hispanir/LatinO Q AmeNCan Indian or Alaska Native Q Other Asian
Q Som! Collage credit. buT no degree Q Vas, Mexlcn, Maxlun American, Chluno Q Allan Indian Q Native HawaHan
Q Aasoclaty degree (e.g. AA, AS) Q Yls, Puerto Rican Q Chinas! Q Guamanian or Chamorro
Q Bachelor's dlgrN (a.g. BA, AB, BS) Q Yas, Cuban Q Rllplno Q Samoan
Q Master's degre! (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Yes, other Spanish/Hispanic/Latino Q Japanese Q Other Pacific (sander
Doctorit! (a.e• PhD, Edo) or Professional degree (Specify) Q O[har S
( pacify)
. MD DOS DVM LLB JD
21. Decedent's Single Races Self-Designation -Check ONLY ON! to indicts what the decedent <onsidered himseH or herself to ba. 22a. Decedent's Usual Occupation - Indleata typo of work
~[ White Q Japanese Q Samoan done during mOit of working Rfl. DO NOT USE RETIRED.
Q Black or AfNCSn AmaNCan Q Korean Q Other Pacific Islander professor
Q Amvriun Indian or Aaska Ns[ivv Q Votnamefe Q Don't Know/Not Sure
Q Aalan Indian Q Other Asian Q Refused 22b. Kind of Business/Industry
Q Chinese Q Native Hawaiian Q Other (Spa ify)
Q FII{pln0 Q Guamanian or Chamorro @dUCatlOn
fTlMg 1 a - MU BE P O 3a. Dire Pronounced Dlad Mo Day 23b. Signature o Person Pronouncing Deat On y when applica 23c. Ucensa Number
BY PERSON WHO PRONOUNCES OR
CFRTIFI DEATH
23d. Dit! Signed (MO/Day/yr) 24. Time of Death
2: 7 O AM 35. Was Madiul Examiner or GOroner ContacYadi Q Yas {•a( No
CAUSE OF DEATH
Approximate
26. PaK 1. Enter the £hain of evenb-disassas, injuries, or compllutionz-the[ directly caused the death. DO NOT enter terminal evertts such as cirdisc acres[ I Interval:
respiratory arrest, Or vantNCUlar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cola on a Ilna. Add additional lines if necessary [ Onset to Daa[h
IMMEDIATE CAUSE - - > a Metastatic osseous diseaaa i
(Float d/lease o ondltion D..e [o (o as a mnsagaance of): t
resulting in deaml Metastatic Prostate cancer I
b.
sequlnuslly list conditions, D.,. t^ (or as a consequence ofi:
If any, leading to the u<.aa i
listed on lino a. EMlr the Atrial fibrillation
UNDlRLYINe GUSE Duo to (or as a consvqu nce of): )
,~ (disaas! or inj ry that
-
In¢lated tae axenss real,ltmg d. Anemia
~ In death) LAST. Due to (or as a consaquenu of): l
26. PsR 11. Enter other silniflcnt conditions contribu[Ine to death but not resulting in the underlying cause given In Part I 27. Wes an autopsy performed?
S Yes No
28. Were autopsy flndlnBS available
~' to complete the cause of death?
Y!s (~ No
a 29. If Female: 9D. Did Tobacco Use Contribute to Death? 31. Mannar o/ Dea[h
E
s Q NoY pregnant within past year Q Yas Q Probably )]$( Natural Q Momicld!
a
a~' Q Pregnant at time of death
Q No[ pregnant, but pregnant within 42 days of dear[ ]~ No Q Unknown Q Actlden[ Q Pending Inwstlgatlon
)= SWCide Q Could not be determined
~ Q Not pregnant, but pregnant 43 days to 1 year before death 32. Data of Injury (MO/Day/Yr) (Spell Month)
Q Unknown If Prlgnem within the past Ypr
33. Time of Injury
34. Places of Injury (e.g. home; constrvRfon situ; farm; uhool) 35. Location of Injury (Strvvt and Number, City, States, Zlp Cod!)
36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred:
Q Yas Q Driver/Operator Q PadastNSn
Q No Q Passenger Q Other (Specify)
39a- Certifier (Chuck only one):
~ Certifying physician - To the best of my knowodga, dlith occurred due to the cola(s) and manner stated
Q Pronouncing $ Certifying physician - To the bast of my knowledge, death e<CUrred at the time, data, end place, and due to the cause(s) and manner stated
Q Medical Euminar/(bronvr - On the basis of examination. and/or Invaztfgation, in my opinion, death occurred at the time. date, and poca, end due [o the cause(s) and m nn r s[atvd
c
Signature Of rzKlfler: ~~. S .~ .L~<!6 J~,$,~S ntle of ca rtlflar: M~B-B-S- ucanaa Nnmber MD05930.9L
39b. Name, Address and Zip Code of Parson Completing Gauss of Death (Item 26) 39c. Data Signed (MO/Day/Yr)
Yogindra S. Balhara, M.B. B.S. 767 Sth Ave, SUIIB B, beBburg, PA 17201 January 28, 2013
40. egiserar s DlstNet Numb
er ql. Reg z 5 Lure 42. glstrar Fi a Date (MO Dey/Yr
7
/ ~~ /~
43. Amandmants
H 105-143
Disposition Permit No. 0802760 0.EV 0]/2013
JRZ - 5.1 tolbert.l January 22, 2013
LAST WILL AND TESTAMENT
I, Rodney N. Tolbert, of 106 Hammond Road, Shippensburg,
Cumberland County, Pennsylvania, being of sound and disposing mind,
memory and understanding, do hereby declare this to be my will,
hereby revoking any and all former wills and codicils thereto by me
heretofore made.
I.
I direct that all my just debts and funeral expenses,
including all expenses of my last illness, sha ll be paid from my
estate as soon as practicable after my decease as a part :~f the
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expense of the administration of my estate.
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I give, devise and bequeath the residue of my e;State o
v'ev'~'r~
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nature and wherever situate to my children, namely Cynthia R.
Tolbert, Jeffrey W. Tolbert, and Douglas R. Tolbert, in equal
shares, provided that the share of any child who predeceases me or
dies on or before the thirtieth day following my death shall be
distributed to said beneficiary's issue, per stirpes, living on the
thirty-first day following my death, and in default of any such
then-living issue, such share shall be added to the share or shares
of my other then-living children.
III.
In the event all of my children and their issue predecease me,
or die on or before the thirtieth day following my death, I give
and dev ise the residue of my estate of every nature and wherever
situate as follows:
A. Thirty percent thereof to Middle Spring Presbyterian
Church, Shippensburg, Pennsylvania;
B. Ten percent thereof to the American Heart Association,
Dallas, Texas;
C. Fifteen percent thereof to the American Cancer Society,
Atlanta, Georgia;
~~. D. Ten percent thereof to the Alzheimer's Disease & Related
' Disorders Association, Chicago, Illinois;
~ E. Ten percent thereof to the Chambersburg Hospital, Cancer
\,~ Division, Chambersburg, Pennsylvania;
V
F.
Ten percent thereof to the Leukemia Society of America,
New York, New York;
G. Fifteen percent thereof to the Shippensburg Public
Library, Shippensburg, Pennsylvania.
IV.
In the event any grandchild of mine is to receive a share of
Page 2
my estate, his or her share shall be held IN FURTHER SEPARATE TRUST
by my trustees herein, Cynthia R. Tolbert, Jeffrey W. Tolbert and
Douglas R. Tolbert, for the following uses and purposes:
A. If my grandchild is under the age of eighteen years, to
expend and apply so much of the net income (any income
not expended or applied to be accumulated and added to
principal) and so much of the principal of his or her
trust as trustees shall consider advisable for the
support and education (including college education, both
graduate and undergraduate) of that child until he or she
attains the age of twenty-three years;
B. After my grandchild attains the age of twenty-three
years, thereafter to pay such child the net income
together with so much of the principal thereof as trustee
ti
shall consider advisable for the support and education
{including college education, both graduate and
undergraduate) of such grandchild after taking into
-~ consideration his or her other readily available assets
and sources of income;
C. Up to one-half of the then-remaining principal and
accumulated income at age twenty-five on the request of
the grandchild shall be distributed to the grandchild.
At or after age thirty, up to the entire balance of the
principal and accumulated income then remaining on the
request of the grandchild. Distributions at or after
these stated ages shall be made only in the event the
Page 3
grandchild requests such distribution by a writing
intended to take effect during 1 i f e by that child upon or
after attaining the stated ages and delivered to the
trustee.
D. If any such grandchild shall die before receiving final
distribution of his or her entire share, the
undistributed balance shall be distributed to my other
grandchildren living at the time of said grandchild's
death.
V.
Any fiduciary under this will shall have the following powers
in addition to those vested in them by law and by other provisions
of my will applicable to all property whether principal or income,
\~
\~ including property held for minors, exercisable without Court
approval,. and effective until actual distribution of all property:
A. To retain any and all of the assets of my estate, real or
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personal, without regard to any principle of
diversification of risk.
B. To invest in all forms of property including stock,
common trust funds and mortgage investment funds without
restriction to investments authorized for Pennsylvania
fiduciaries as they deem proper, without regard to any
principle of diversification of risk.
C. To sell at public or private sale, to exchange or to
Page 4
lease for any period of time any real or personal
property and to give options for sales, exchanges or
leases, for such prices and upon such terms or conditions
as they deem proper.
D. To allocate receipts and expenses to principal or income
or partly to each as they from time to time think proper.
E. To compromise any claim or controversy.
F. To distribute in cash or in kind or partly in each.
G. To hold property in their names without designation of
any fiduciary capacity or in the name of a nominee or
unregistered.
v2.
I direct that all taxes that may be assessed in consequence of
my death of whatever nature and by whatever jurisdiction imposed,
shall be paid from my residuary estate as a part of the expense of
the administration of my estate.
V22.
The interest of the beneficiaries hereunder shall not be
subject to anticipation or to voluntary or involuntary alienation;
and the principal and income shall be paid by the trustee or
guardian directly to or for the use of the beneficiary entitled
thereto, without regard to any assignment, order, attachment or
Page 5
claim whatever.
VIII.
I appoint my wife, Joan W. Tolbert, also known as Joann W.
Tolbert, and my son, Douglas R. Tolbert, as co-executors of this my
will.
IX.
No bond shall be required of any fiduciary hereunder in any
jurisdiction.
IN WITNESS WHEREOF, I hereunto set my hand and seal to this my
last will and testament, consisting of seven typewritten pages, the
first five of which bear my signature in the margin for the purpose
of identification this ~--~ y of 2~~.
(sE~)
Signed, sealed, published and declared by the above-named
testator as and for his last will and testament in our presence,
who in his presence, at his request and in the presence of each
other have hereunto set our hands as attesting witnesses.
~~~ ~ ~ ~ ~ ;sae ~lu~~~rs l~~
Page 6
We, Rodney N. Tolbert, ~~/,~~//, ,.~, and
~ -.~-~ ul'~(~It,~ the testator and the witnesses respectively,
whose names are signed to the attached or foregoing instrument,
being first duly sworn, do hereby declare to the undersigned
authority that the testator signed and executed the instrument as
his last will and testament and that he executed it as his free and
voluntary act for the purposes therein expressed and that each of
the witnesses, in the presence and hearing of the said testator
signed t:he will as witnesses and to the best of their knowledge
said signer was at that time eighteen years of age or older, of
sound mind and under no constraint or undue influence.
Subscribed, sworn to and acknowledged
before me by the above-named signer and
subscribed and sworn to before me by the
above-named witnesses this L~.day of
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N ary Public
COMMONWEALTii OF PENNSYLVANIA
Notarial Seal
varin L. Walter, Notary Public
Chambersburg Boro, Franklin County
„__~ My Gommlasion Expires May 13, 2013
Page 7
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