HomeMy WebLinkAbout02-14-13
PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF ~LCiy? ~,1 COUNTY, PENNSYLVANIA
Petitioner(s) named below, who Ware 1S 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 Informs ion
Name: /
~ '~1 Ef" /yJ~+h rP1f_ File No: 1<j~~/
a/k/a: (Assigned by Register)
a/Wa:
a/k/a: Social Security No: 0,
Date of Death: 2 a P7 O Age at death: ILI
Decedent was domiciled at death in &M z6-1,A~Ir r Count , (state) with is/her I pt
principal residence at r ot'' -1 / ~ k Q~
Street address, Post Office and Zip Code City, Township or Borou Count
Decedent died at~
Street address, Post Office and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death: ~q
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 $
ESTIMATED VALUE.... $ h c~ D
Real estate in Pennsylvania situated at: TOTAL
(Attach additional sheets, ifnecessary) Street address, Post Office and Zip Code City, Township or Borough County
-dA. Petition for Probate and Grant of Letters Testamentary C
Petitioner(s) aver(s) he/ /they is/are the Executor(s) named in the last Will of the Decedent, dated oZ' r~P/I / I - and Codicil(s)
thereto dated 11711A
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, was not aparty to apending
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.
14NO EXCEPTIONS ❑ EXCEPTIONS
B. Petition for Grant of Letters of Administration (If applicable)
c.t.a., d.b.n., d.b.n.c.ta., pendente lite, durante 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 theirs.
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds fc#3Jivgze had bee$tkabliWrdRdefined
in 23 Pa. C.S. § 3323(g) and was neither the victim of a killing nor ever adjudicated an incapacitated pMrr~p C)
NO EXCEPTIONS ❑ EXCEPTIONS M n U~ p
.AJ D ham h Petitioner(s), after a proper search has/have ascertained that Decedent left no W ill and was survived by thePoo IcadniTousc4br y) a hamh (attach
additional sheets, i/necessary): ;z bf ; C7
"T7 '7 t -n
Name Relationship
a3 r- M
a
F-►
Forn, aw-02 rev, 101112011 Page 1 of 2
Oath of Personal Representative Official Use Only
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF 6~(- ~
Petitioner(s) Printed Name Petitioner(s) Printed Address
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 D edent, th titioner(s) iill~well and true administer the estate according to law. l
Sworn to or affirmed an subscribed before) Date, 5 ~7
me s jl -day of Date
B C, J C/O, Date
For the Register Date
BOND Required: Q YES ( O To the Register of Wills:
FEES: Please enter my appearance by my signature below:
Letters S 5~.. Attorney Signature:
1( ) Short Certificate(s)......
( ) Renunciation(s)........ .
( ) Codicil(s)
( ) Affidavit(s)........... .
Bond Printed Name:
Commission Supreme Court c
OJ,her ID Number: n :U
Iher i .K~n... 5. Cin fit C11)
Y ti L' Firm Name: _V Mn rC
i Address:, t-- t -6-
ri
c-> -rt
Phone: C7 C", -ry e.t
CZ
Automation Fee. Fax: rn
JCS Fee Email: "t7 C?
TOTAL S
DECREE OF THE REGISTER /
Estate of File No:
a/lc/a:
AND NOW, ' 7 +1' -(j in consideration of the foregoing Petition,
satisfactory proof having been presented before me, S DECREED that L tter ' e T t /'I
are hereby granted to 1 1 c
in the above estate and (if applicable) that
the instrument(s) dated _ C~4 1 0(o (E
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
Register of Wil~ C L
FormRW-02 rev. 1011112011 Page of2
IIIO N0 REV (91]1 1
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
I ~t "IV~ :duplicate this copy by photostat or photograph.
REGISTER OF WILLS
Fee for this certificate, $6.00 This is to certifv that the information here viven is
t ~p ~~'`pLSH OF pF\
1013 FEB 1 F t 1 01 correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
CLERK OF certificate will be forwarded to the State Vital
ORPHANS' COURT , * Records Office for permanent tiling.
_L L 1 jJMBERLAND CO., PA
P
Certification Number1fNT
Local Registrar Date Issued
Type/Print In COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH _ VITAL RECORDS
Permanent
Black Ink CERTIFICATE OF DEATH State File Number:
1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Yr) (Spell MI)
Esther W_ Humphrey £emal 063-42-9834 7anua 29, 2013
Sa. Age-Last Birthday (Yrs) 5b. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/Year) (Spell Month) ]a. Birthplace (City and State or Foreign Country)
92 yrs . Months Days Hours Minutes . une- 12 , 1920
?b. Birthplace (County) Ontario
11 . Residence (State or Foreign Country) 8b. Residence (Street and Number - Include Apt No.) 8c. Did Decedent Live in a Township?
Pennsylvania 1208 Redwood Hill Circle Yes, decedent lived in mj aegl aAx cwp.
8d. Residence (County)
Cumberland 18e. Residence (Zip Code) 1 701 c; El No, decedent lived within limits of city/bor..
9. Ever in US Armed Forces? 10. Marital Status at Time of Death )El Married Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage)
O Yes M No E3 Unknown El Divorced Never Married E3 Unkn.w
12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to Firs[ Marriage (First, Middle, Last)
James Walsh Margaret Wilson
14a. Informant's Name 14b. Relationship to Decedent 14c. InformRant's Mailing AddHresis SltreeCt aind Number, City, State, 27 Code)
a Jean Nichols Daug
E 11hter 1208 edwood ~rcle CarlisPA 17015
C -ath - - - _ _ _ _ _ _ _ _ is- Place o Death jCtieikjnly e _ _ _
If De Occurred In a HOSpital M Inpatient - .17 Death Occurred Somewhere the, han a Hospital: In Hospice Facility Decedent's Home
° 0 Emergency Room/Outpatient E3 Dead on Arrival I 0 Nursing Home/Long-Term Care Facility Ej Other (Specify)
vd 15b. Facility Name (If not institution, give street and number) 15c. City or Town, State, a d Zip Code 15d. County of Death
1208 Redwood Hill Circle Carlisle, PA 17015 Cumberland
161. Method of Disposition O Burial 0 Cremation 16b. Date of Disposition 16c. Place of Ois pos ltlon (Name Of cemetery, crematory, or other place)
o Removal from State R9 Donation January 30, Humanity Gifts Registry
O Other (Specify)
16d. Location of Disposition (City or Town, State, and Zip) 1]a. SI r of nera Service Ltc or Person in Charge of Interment 1]b. License Number
Philadelphia, PA 19105 138504
E 17c. Name and Complete Address of Fun1 eral Facility
s H - H e c 19 N_ Han ov S Carlisle PA 17013
18. Decedent's Education - Check the box that best describes the 19. Decedent of Hispanic Origin - Check the 20. Decedent's Race -Check ONE OR MORE races to indicate what
I- highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be.
C3 8th grade or less is Spanish/Hispanic/Latino. Check the "NO" Iff White Korean
E] No diploma, 9th - 12th grade box if decedent is not Span)sh/His
High school graduate Or GED completed No, not 5 Wish/His panic/Latino. Blackor African American Vietnamese
Some college cretlit, but no degree pa panic/Latino El American Indian or Alaska Native 0 Other Asian
O E3 Yes, Mexican, Mexican American, Chican. E3 Asian Indian 0 Native Hawaiian
Associate de
gree (e.g. AA, AS) C3 Yes, Puerto Rican
E3 Bachelor's degree (e.g. BA, AB, BS) O Yes, Cuban O Chinese 0 Guamanian or r C ha mono
Filipino O Samoan
O Master's degree (e.g. MA, M5, MEng, MEd, MSW, MBA) Q Yes, other Spanish/Hispanic/Latino D Japanese EJ Other Pacific Islander
Doctorate (e. g. PhD, EdD) or Professional degree (Specify) 0 Other (Specify)
. MD DDS DVM, LLB JD
21. Decedent'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
5d White O Japanese El Samoan done during most =kip g life. DO NOT U SE RETIRED.
E3 Black OrAfricanAmerica, E3 Korean 0 Other Pacific Islander 2nterloL' igner
j )3 American Indian Or Alaska Native O Vietnamese E3 Don't Know/Not Sure
O Asian Indian 0 Other Asian Q Refused 22b. Kind of Business/Industry
Q Chinese El Native Hawaiian ED Other (Specify)
CI Filipino O Guamanian or Chamorro Sel£ Employed
ITEMS 23a - 23 MUST BE COMPLETED
y ) 23b. Signature of Person Pronouncing Death (Only when app ica le 23c.icense Num
BY PERSON WHO 2 .Date ro pounced Dead (M30;
PRONOUNCES OR Q' ~~//t{~' ~j~ /Y V //fit A/
CERTIFIES
CERTIFIES DEATH 7 / • ('J_y,/.CZ~~ l.. CW~ )4
23 Date Signed (MO/Day,[Yr~ / 4. Time of Death kae'J ~ r ~r 1 25. Was Medical Examiner or Coroner Contacted? O Yes ~1Vo
U0
CAUSE OF DEATH I
26. Part 1. Enter the chain of events--diseases, Injuries, or complications--that directly caused the death. Approximate
DO NOT enter terminal events such as cardiac arrest, I In[e rval:
respl rStory arrest, Or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines If necessary. I Onset to Death
IMMEDIATE CAUSE > C t^ 4I t
l W 1,
(Final disease or condition Due to (or as a nseq ue nee of): I
resulting in death) ~
b.
Sequentially list conditions, Due to (or as a consequence of):
if any, leading to the c
I fisted on line a. Enter thee
UNDERLYING CAUSE Due to (or as a cons '
(disease injurythat ,,sequence of):
F in Mated the a nts resulting
d.
in death) LAST- e Due to (,,a . a consequence of): I
1
.j 26. Part 11. Enter other si,nlficant conditions cont,ibutin¢ [ death but not resulting in the underlying cause given In Part I. 27 . Was an autopsy performed?
S 114 C, O Yes ffi No
128. Were autopsy findings available
m fJy to complete the eau a of death?
Yes of
29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death
E J~ Not pregnant within past year M Yes 0 Probabl
Pregnant at time of death 1' El Natural O de
Not pregnant, but pregnant within 42 days of death ~'~O Unknown 0 Accident Ej Pending Investigation
.2 )l Not pregnant, but pregnant 43 days to 1 year before death 32. Date of In Q Suicide Could not be determined
~~E3 Unknown If pregnant within the past Jury (MO/Day/Yr) (Spell Month)
v 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)
1 36. Injurya[ Work T
.
If Transportation Injury, Specify: 38. Describe How In
Yes Driver O Jury Occurred:
/ perator M Pedtrin
M No Passenger O Other (Specify)
39a. Certifier - physician, certified nurse practitioner, medicccu'amineroner (Check only onnj'er
CIE. Certifying only - To the best of my knowledge, death o red due to the cause(s) and m O .r F1 Pronouncing & Certifying - To the best of my knowledge, death occurred at the time, date, and place, and due to the c se(S) and manner stated.
0 Medical Examiner/Coron on t
er- basis of examination and/or Investigation, in my opinion, death occurred at the time, date, and place, and due to the ca (s) and manner stated.
signature of certifier: 1=C' i Title of certifier: License Number: ~S~ O f 6z~ f
r 39b. Name, Address and Zip Code of Person Completing Cause of Death (Item 26) 39c. Date Signetl (MO/Day/Yr)
G-~G o.,~ 6' . ci5l w r. J -T -7 luc~..nf.. Way C_;;-_ r c-SMc, C A t-7 ,zt5 J .moo , ~-4 f3
i 40. Registrar's District Number 41. Registrar's Lure 42. Registrar File Date (MO Oay/Yr)
so
3
° 43. Amendments ~C>
0
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0
- REV D7/701
Disposition Permit No.
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10 LD rn p
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ryl 7"1
LAST WILL AND
OF ;.5
ESTHER W. E[OMBREY
C/) C'
C-
I, Esther W. Humphrey, a resident of 2211 Circle Road,'
Carlisle, Cumberland County, Pennsylvania, being of sound mind and
disposing intent, do hereby make, publish and declare this to be my
Last Will and Testament, hereby revoking all prior Wills and
Codicils.
Article I
I order and direct my Executrix, hereinafter named, to pay all
of my debts, funeral expenses and expenses connected with the
administration of my estate as soon after my death as is reasonable
possible, from my residuary estate. However, my Executrix need not
accelerate or pay those unmatured obligations which, in her
opinion, might be proper and more advantageous to retain or renew
and pay as they become due and payable. Should any real property
pass under my Will, it shall pass subject to any mortgage lien
thereon.
Article II
I give, devise and bequeath all of my estate, whether real or
personal, of every nature and wherever situated, and whether
acquired before or after the execution of this Will, to my
daughter, Ella Jean Nichols.
AZI, L4), 4u,-" v"&~[
sther W. Humphrey
Article III
In the event that my daughter, Ella Jean Nichols, does not
survive me, I then give, devise and bequeath all of my estate,
whether real or personal, of every nature and where ever situated,
and whether acquired before or after the execution of this Will, in
equal shares to my granddaughters, Jennifer Nichols Silverman and
Lisa Nichols Hathcox.
Article IV
I hereby nominate and appoint my daughter, Ella Jean Nichols,
as Executrix of this, my Last Will and Testament. I hereby further
direct that my personal representative shall not be required to
give bond for the faithful performance of her duties in any
jurisdiction.
IN WITNESS THEREOF, I have hereunto set my hand and affixed my
seal 7" 2;z- day of 1996.
W ' Jr'r-w✓~
Esther W. Humphrey
The proceeding instrument, consisting of this and two
other type written pages, each identified by the signature of the
Testator, was on the date thereof signed, published and declared by
Esther W. Humphrey, the Testator, therein named, as an for her Last
Will in the presence of us, who, at her request, in her presence,
and in the presence of each other, have subscribed our names as
witnesses hereto.
&nar/ .
Mona K. Yin n
Debbie C. Contreras
STATE OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
We, Esther W. Humphrey, Mona K. Yingling, and Debbie C.
Contreras, the Testator and the witnesses, respectfully, whose
names are signed to the foregoing instrument, being first dully
sworn, do thereby declare to the undersigned authority that the
Testator 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 expresses, and that each of
the witnesses, in the presence and hearing of the Testator, signed
and Will as witnesses and that to the best of each witness'
knowledge and belief, the Testator was at the time eighteen years
of age or older, of sound mind and under no undue constraint or
influence.
A-11. Q A,
Testator
Wi ness all,
1
IL
fitness
Subscribed, sworn to and acknowledged before me by Esther W.
Humphrey, the Testator and subscribed and sworn to before me by
and Q r, (-ally Ire- 4 S ,
witnesses, this 7 Z day of 1996.
ry Public
Notarial Seal
John L, Perry, Notary Public
Carlisle Boro, C.sn terland gount
tiny Cornmis for