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HomeMy WebLinkAbout02-15-13 PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF Cy olio e.2 ,Z4,tc~ 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 n to A- 12- Name: dC _ a it11 A a l*7 File No: a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: G ~Z c, Date of Death: ;I- - (6 - i 3 Age at death: Decedent was domiciled at death in C u b-Ae kr1 )tvl County, IPA (State) with hiso last principal residence at `l0 1 S 5 P , , ✓zv>*:rI r 67Z nE 5 C~ 72-1s )e (fuwt)*iZL a. c1 Street address, Post Office and Zi Cade City, Township or Borough County Decedent died a>4e~2. ele z~ o s p t-7-,4 L- C.a'8~ is )-e cum 4&-, ,wd d0A Street address, Post Office and Zi Code City, Township or Borough County State Estimate of value of decedent's property at death: Ifdomiciled in Pennsylvania All personal property $ 00 U If not domiciled in Pennsylvania Personal property in Pennsylvania $ IJnot domiciled in Pennsylvania Personal property in County $ [value ojreal estate in Pennsylvania $ TOTAL ESTIMATED VALUE.... $ 6ZS, 00 Real estate in Pennsylvania situated at: c t fowl W g o 1 S S ty CAt A -J-,1 &7- oT &S (Attach additional sheets, ifnecessary) Street address, Post Office and Zip Code Township or Borough G4~c LAS County E3 A• Petition for Probate and Grant of Letters Testamentary ~~7 q Petitioner(s) aver(s(/she/they is/are the Executor(s) named in the last Will of the Decedent, dated / - ! - J g and Codicil(s) thereto dated State relevant circumstances (e.g. renunciation, death ojexecstor, 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(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. ~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, durunte 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 fgr*ivorce had bet4 i<stabl* defined in 23 Pa. C.S. § 3323(8) and was neither the victim of a killing nor ever adjudicated an incapacitated p6sovc) M C7 ❑ NO EXCEPTIONS ❑ EXCEPTIONS n , Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by tha`~ ilg*an~5bous*{&ny) P 1~ (attach additional sheets, if'necessary): D s TTR~r1t C1lf t 7 c~(n QCS Name Relationship © C= c", CD r' m Form Rw 02 rev. 10/11/2011 Page I of 2 Oath of Personal Representative Official Use Only COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF C j 016ekkW 4 } Petitioner(s) Printed Name Petitioner(s) Printed Address (Lt)4M A P-7 CAek-SA i PA /76/-S- 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 Deced nt, t Petitioner9(s) w well and truly administer the estate according to law. Sworn to or affirmed and subscribed before Date mot of Date B A Date For the Register Date BOND Required: Q ----Q" NO To the Register of Wills: FEES: Please enter my appearance by my signature below: Letters $ ( 1 1 \ Attorney Signature: ( ~j ) Short Certificate(s)...... L" ( ) Renunciation(s)........ . ( ) Codicil(s) ( ) Affidavit(s)........... . Bond Printed Name: Commission Supreme Court C w 'v M Other ID Number: X 4 -rt e? - - r ^ rn Cl> ao cn ~'j..~;, Firm Name: 7U r,, f" ~irT1-1+~- i f-e ' KM Ll.}'I ~.Cc Address: r~. M <1l ~ C7 C7 Q -vj -n C rf Phone: o r` m Automation Fee Fax: r- 01) O JCS Fee. Email: TOTAL $ 1 y~. SC? 060 DECREE OF THE REGISTER Estate of An) ~26) o 1 File No: a/k/a: AND NOW, rj~~ - i j , in consideration of the foregoing Petition, satisfactory proof having been presented before in T IS DECREED that Lette are hereby granted to (Y~ N - C t fYl in the above estate and (if applicable) that 'T 1 the instrument(s) dated g )j i ~ Y l~ described in the Petition be ad ~ to probate and filed of record as the last Will (and Codicil(s)) of Decedent. L' Register of Wihs- fY~ Form R6R02 rev. 10/Il/20i1 Page 2 of 2 1-11(15.x05 REA' ON I LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 RECORDED OFFICE OF This is to certify that the information here given is REGISTER OF WILLS ~p~(H 6F pfy correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original 1013 FEB 15 M 10 LI Ze certificate will be forwarded to the State Vital Records Office for permanent filing. CLERK OF r. F RPHANS' COURT °9- P~~I; IMNT OF?``` ~ir~ Qews~n'rcac FED ? /2013 Certification Number CUMBERLAND CO., PA Local Registrar Date Issued Type/Print In COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH - VITAL RECORDS Permanent Blacklnk 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 Mo) Anna M_ Rohm emal 180-26-5197 Februar -6,-2013 5a. Age-Last Birthday (Y-) 5b. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/Year) (Spell Mth) 78. Bl rthpla (City d State or Fo I Country) I 8 4 Months Days Hours Minutes December 5, 192W Lari I E; urg , 76. Birthplace (county) Perr Count Sa. Residence (State or Foreign Country) 8b. Resltl ence (Street and Number - Include Apt N Sc. DId Decedent Live In a T hl p PA 85 Spring Garden Estat es, decedentllvedIn S~ou~tl Middleton twp. V 8d. Residence (County) Cumber 1 and Be. Residence (Zip code) 1 7 0 1 5 0 No, decedent lived within limits of city/bor.. 9. Ever in US Armed Forces? 30. Marital Status at Time of Death 0 Married Widowed il. Surviving Spouse's Name (If wife, give name prior t° first marriage) Ves No Unknown Divorced Never Married 0 Unknow 124 Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marrlage (First, Middle, Last) Oscar Dewey Baughman Ste11a Mae We11e17 14a. Informant's Name 14b. Relatlonshlp to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code) William A_ Rohm Son 2977 Eno1a Rd_, Carlisle,PA 17015 W _ _ _ _ _ _ _ _ 152_P ace c Drat Check on Yon _ _ a_ If Death Occurred in a Hospital Inpatient If DeatM1 Occurred Somewhere Other Than a Hospital F-7 ❑ Hospice Facility b Decedent's Home ° 0 Emergency Room/Outpatient 0 Dead on Arrival I 0 Nursing Home/Long-Term Care Faclltty Other (Specify) 15b. Facility Name (If not institution, give street and number) 15- City or Town, State, and Zip Code 15d. County of Death arlisle Re Tonal Mec3 Center Carlisle PA 1 701 5 Cumberland 16a. Method Disposition O Burial Cremation 16b. Date of Disposition 161. Place of Disposition (Name of cemetery, crematory, or other place) E3 Removal l from State m ~ DonaL(on D Other(Specify) 2/8/2013 Hollinger Funeral Home & Crematory Z 16d. Location of Disposition (City or Town, State, and Zip) 17a. Signature of Funeral Service Uc n r Person In Charge of Interment 17b. License Number t _ Ho11y Springs , PA 17065 FD - 1 3881 2 17c. Name and Complete Address of Funeral Facility Hol t finger Funeral Home & Crematory , Inc 1 in PA 17065 18. Decedent's Education - Check the box that best describes the 19. Decedent of Hispanic origin - Check the 20. Drcetlent's Race -Check ONE OR MORE races to Indicate what f- 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. 0 8th grade or less Is Spanish/Hispanic/Latino. Check the "No" ba White 0 No diploma, 9th - 12th grade box If decedent is not S h His Korean v~ High school graduate or GED completed pe nis/ panic/Latino. 0 Bmerlack or African American Vietnamese No, not Spanish/Hispanic/Latino O Aican Indlan or Alaska Native E3 Other Asian 0 Some college credit, but no degree 0 Yes, Mexican, Mexican American, Chicano 0 Asian Indian 0 Native Hawaiian 0 Associate degree (e g. AA, AS) 0 Yes, Puerto Rican C-1 E3 0 Bachelor's degree (e. g. BA, AB, BS) 0 Yes, Cuban Chinese Guamanian or Chamorro Filipino 0 Samoan 0 Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) 0 Yes, other Spanish/Hispanic/Latino 0 Japanese 0 Other Pacific Islander 0 Doctorate (r. g. PhD, EdD) or Professional degree (Specify) 0 Other (Specify) . MD, --SID VM, LLB, JD 21. Decedent's Single Race Self-Des(gnatlon - Check ONLY ONE to Indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation - Indicate type of work White 0 Japanese 0 Samoan done during most of working life D0 NOT USE RETIRED. Black or African American 0 Korea 0 Other Pacific Islander 0 AmerlcanIndia, orAlaska Native 0 Vietnamese 0 Don't Know/NOtSure Telephone Operator 0 Asian Indlan 0 Other Asian 0 Refused 22b. Kind of Business/Industry 'a 0 Chl nese 0 Native Hawaiian 0 Other (Specify) M Filipino 0 Guamanian or Chamorro Manufacturing ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced Dead (Mo/Day/Vr) 23b. Signature of Person Pronouncing Death (Only when appllca ble) 23c. License BY PERSON WHO PRONOUNCES Number OR b,(w0. CERTIFIES DEATH I Z9 j3 _ 2 d. Date Slgnid (Mo/Day/Yr) 24. Time of Death _-,t 2 U) of O rj ' ` 25. Was Medical Examiner or Coroner Contacted? 0 Ves No CAUSE OF DEATH I 26. Part 1. Enter the chain of events--diseases, Injuries , or compllcatlons--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, I Interval: respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Ilnes if necessary. 1 Onset to Death 1 IMMEDIATE CAUSE a. SL~Ir'Q~Y-'N A fY0 (Final disease or condition Du (o as a cons quanta f): resulting in death) / 1 I e ~ b. l Y~ G1 0 4F~ ~j O (mil r t~ -4!A ,(((w w I Sequentially list conditions, to a c n If any, leading to the cause Due (or o eq uence o listed on Ilne - Enter the 1 UNDERLYING CAUSE Due to (or as a consequence of): (dis injurythat M F initiated the events resulting d. In death) LAST. Due to (or as a consequence of): 1 8 26. Part 11. Enter other si,nif'cant conditions c.ntributinix t death but nut resulting in the underlying cause given In Part I. 27. Was an autopsy performed? ~9 0 Yes No 28. Were autopsy findings available w to complete the cansaf death? 0 Yes ~O No w 29.1 f Fel: ale: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death o /•s-~~ Not pregnant within past year 0 Yes 0 Probably D Pregnant at time of death 0 Natural O Homicide 0 Not pregnant, but prgnant -'thin 42 days of death '~O 0 Unknown 0 Accident O Pending Investigation I- 0 Not pregnant, but preegna nC 43 days to 1 year before death 32. Date of Injury (MO/Da /Vr 5 0 Suicide 0 Could not be determined 0 Unknown if pregnant -[thin the past year y ) ( pell Month) 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 Work 137, If Transportation injury, Specify: 38. Describe How Injury Occurred: 0 Yes 0 Driver/Operator 0 Pedestrian 0 No 0 Passenger 0 Other (Specify) 398. Certifier- physician, certified nurse practitioner, medical examiner/coroner (Check only one): 0 ertitying only - To the best of my knowledge, death occurred due to the cause(s) and manner stated. ,0 Pronouncing & Certifying - To the best of my knowledge, death occurred at the time, data, and place, and due to the cause(s) and manner stated. 0 Medical Examiner/Coroner - On the basis of examination and/or Investigation, In my opinion, death occurred at the time, date, and Place, and due to the c u e(s) and man... stated. Signature of certifier: Title of certifier: License Number: rn D Llr- i+ L I ♦♦TS 39b. Name, Agfires a d ZIq Code of Person Com plrting Ca us f Death (Item 26) 39c. Date Signed (MO/Day/Yr) Sat~~ /ilx~cl ~.dar 3c.1 Alc>wt(> ~ 5~~; s 9-11 C~tc1:It, Y{A I~-O i5 ~cbruq Cp aol3 40. Registrar's District Number 141. Registrar's 51 n ure 42. Registrar Ile Date (MO Day/Vr) 43. Amendments O Z Disposition Permit No. REV V O S~ I.~ l 077/20 012 /20 , ry CJ ;a rn c o rn w rn ;0 rVI ca c ca N~ MxCl) ca r-- ~ M M LAST WILL AND TESTAMENT > OF P", Cs ANNA M. ROHM I, ANNA M. ROHM, of South Middleton Townsh,-p rrnn Cumberland County, Pennsylvania, make this Will, revokifig alk-m~ o former wills and codicils. cn ITEM I: I direct that all my just debts, funeral expenses, and administration expenses, including my -rave marker, shall be paid from the assets of my estate as soon as practicable after my decease. ITEM II: It is my direction that my body be cremated, there be no memorial service, viewing or flowers. ITEM III: I devise and bequeath all of the residue of my estate, of every nature and wherever situate, in equal shares, to my three sons, namely WILLIAM A. ROHM, STEVEN W. ROHM and TED M. ROHM, or their issue, per stirpes. ITEM IV: I direct that all taxes which 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. ITEM V: I appoint my son, WILLIAM A. ROHM, Executor of this, my Last Will. Should my son, WILLIAM A. ROHM, fail to qualify or cease to act as Executor, I appoint STEVEN W. ROHM and TED M. ROHM, or the survivor thereof, Executors of this, my Last Will. IN WITS HEREOF, I have hereunto set my hand this C(~day olE 'J ~ 1993. _(SEAL) Anna M. Rohm The preceding instrument, consisting of this typewritten page, identified by the signature of the Testatrix, Anna M. Rohm, was, on the day and date thereof, signed, published, and declared by Anna M. Rohm, the Testatrix therein named, as and 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 thereto. ~ZI4441-- 'd COMMONWEALTH OF PENNSYLVANIA ) COUNTY OF CUMBERLAND ) We, Anna M. Rohm, Robert R. Black, and 64zrlA12 i L the Testatrix 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 Testatrix signed and executed the instrument as her Last Will, and that she had signed willingly (or willingly directed another to sign for her), 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 witness, and that to the best of their knowledge the Testatrix was at the time eighteen years of age or older, of sound mind and under no constraint or undue influence. 14 Testatrix Anna M. Rohm Witness Robert R. Black Witness Subscribed, sworn to and acknowledged before me by Anna M. Rohm, Testatrix, and subscribed and sworn to before me by Robert R. Black and ~7-cusr 1 ~e tfr'~E'f ' witnesses, this ~ day of ,A y 1993. Notary Public Notarial Seal Anita L. Lkjhtner, Notary Public Carlisle 6oro, Cumberland County My Commission Expires Sept. 9, 1996