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HomeMy WebLinkAbout02-20-13PETITION FOR GRANT OF LETTERS re.. REGISTER OF WILLS OF ~ « ~((~ COUNTY~ENNSYL~, ~NIA~ rn a n ~ '~ Petitioner(s) named below. -who isiare 18 years of age or older, apply(ies) for L~,et~as sped~d b~',o~ and in support thereof aver(s) the following Ind respectfully requests j the grant of Letters in~ ~n~nat~ortn:•~~ 7~, r~ ~'~ Decedent's Information ~ ~~ Z~ -13 ~ ~ ~ ° ~ Name: 1.,, ~~,r-File No: '~ ~ ~ -r -ten ~ ' ~3'©~~ a/k/a: (Assigued~ egi r) ~, a/k/a: ~ ~ --~ N ~,.~ a/k/a: Social Security,~Jo:~ ~ I~~~j ~~~ Date of Death: 1) 2c~ 13 Age at death: ~S a Decedent was .domiciled at death in (,e~m hr.r' ]~n•~ ~~ County, ~~ns I v ,` (Stare) with his/her last J principal residence at ~i1.1 ~ t„~P_c~ IiUo~, ,S~-rrr.~-- ~ l"Gv~ /t 1~ C 1 .t Yl/l~V ~/aVt~ Street address, Post Office and Zip Code ~ City, Township or Borough County Decedent died at W `~ 3 ~ ~ }- )~, r ~~-1•-rt,.~,~-- (~-1 i,~j o ~ Vrn},~rtu~-~ al~- Street address, Post Office and Zip Code City, Township or Borough County State Estimate of value of decedent's property at death: If don:iciled in Pennsylvania ............................ All personal property $ a0 If not domiciled in Pennsy!vania ........................ Personal property in Pennsylvania $ If not domiciled in Pennsy!vania ........................ Personal property in County $ >value ojreal estate in Pennsylvania ......................................................... $ OO ~ ~ ~ I TOTAL ESTIMATE/D VALUE.... $ . ~Q Real estate in Pennsylvania situated at: ~ ~ ~ (~,~GS-1-- (~ 8r~1n 5-~- , l~Cr-)+i~1,~~ Ct~~,~~~rt~. (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 thereto dated and Codicil(s) State relevant circumstances (eg. renunciation, death ojexecutor, etc.) Except as follows: after the execution of the instrument(s) offered for probate Decedent did not 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 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.u., d.b.n., d.b.n.c.t.a., pendente life, durante abaentiu, durante minoritute 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 parry to a pending divorce proceeding wherein the grounds for divorce had been established as defined in 3 Pa. C.S. § 3323(g) 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 W ill and was survived by the following spouse (if any) and heirs (attach uclclitionul sheets, if necessary): Name Relationshi Address ~.~~~ iu~~ -a Fo--,~~ Rw nZ rev. JO/l1/1011 Page 1 of 2 ~; -~~' Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF _~t~r' },LJr`,~~.Y~D~ } Official Use Only 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 Decedent, the a 'tioner(s) will well nd truly administer the estate according to law. Sworn to or af~,rmed a bscribed before Date ~. me th' day of ~ /'GIQ/' , ~D®~ Date By: Date the Register Date BOND Required: ~ YES ~ NO To the Register of Wills: .FEES: Please enter my appearance by my signature below: Letters ..................... . ( ~) Short Certificate(s)..... . ( f )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other ....... ~ ~~ ~~ .. Automation Fee .............. . JCS Fee . ................... . TOTAL ..................... Estate of a/kJa: $ ~~~~ 00 d~0 /r: !1d ~oa ~J -00 ~~ d $ 6-6~- ~20~`~~ Attorney Signature: ~. c~ ~`' m ~ Printed Name: +~ Supreme Court ~~~, r ~ ID Number: f~i C'~ cn C9 i,. r rv ~ rn ~ C:J ~ ~ Firm Name: p' ~ Address: r.., ~., _ -~ --r~ ""r"! ~ -,~-, ~ . - ,~ ~ _ [~ ,.~.-Z'~ ~" ~ ~ ~- ~ Phone: ~ ~"'`~ "'n Fax: Email: DECREE OF THE REGISTER File No: ~ ~~ ~J ' v Z ~~ AND NOW, Ci /" ~b 4l 4/~ , in conside ation of the foregoing Peti ion, satisfacto roof havin been re ented before me, IT IS ECREED that Letters / S' rD ~ D/1- rY P g P are hereby granted to u t° in the above estate and (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of re Form RW-02 rev. !0/11/2011 as the last Will (and Codicil(s))„of Decedent. Register of Wills ~~ Page 2 f 2 H)05.8 REV (9/1)) r LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is i~e~~l~t~o~duplicate this copy by photostat or photograph. ~>G OFFIGE Of RE FPP fnr rh;c certificate ~~ (1(1 ~IST~'~ Of ~ ~ „__ This is to certify that the information here given is ~QI3 fE~ ~Q ~ ~.~~~,~7~~ } Certification Number ~f ~ - Type/Print In ~ .-- Permanent I ~I -its 3 ~_ GL~~ ~RPNQNS.= ~~~lBE'RZAND correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. ~sanv~ ~~@~.c~,c,~.x . F 4 2 013 ~ ~ ~ Local Registrar Date Issued COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS CERTIFICATE ~F DEATH _ 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number _ 4. Date of Death (Mo/Oay/Yr) (Spell Mo) Wendy Lynne Fullerton Female January 30, 2013 Sa. Age-Last Birthday (Yrs) Sb. Under 1 Year Sc. Under 1 Oa 6. Date of Birth (MO/Day/Year) (Spell Month) 7a. Birthplace (Ci and State or Foreign Country) f rj2 Months Days Hours Minutes NOV 16i 1960 Buffa~0 NY 1 7b. Birthplace (County) Erie Sa. Residence (State or Foreign Country) 8b. Residence (Street and Number -Include Apt No.) Sc. Did Decedent Live in a Township? 443 WE3t NortYl Street ~Ves, decedent lived in twP. 8d. Residence (County) Cumberland 8e. Residence (2Tp Code) Q~No, decedent lived within limits of Carlisle city/boro. 9. Ever in US Armed Forces? 10. Marital Status at Time of Death ~ Married 0 Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) 0 Yes ®No ~ Unknown Divorced Q Never Married ~ Unknown 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Mtddle, Last) Robert Merle Fullerton Marilyn Arlene Elsaesser 14a. Informant's Name 14b. Relationship to Decedent 14e. Informant's Mailing Address (Street and Number, CI Stale, Zip Code ~ ; ~ Adam Fullerton son 443 west North Street, Car isler Pl , 17013 G W _~ ......................................................... .................:......_............. 1 a. ace o eat ... ec., on_y one .- r+Y ... 1 ...................................... ............................ .................................... •.................................• If Death Occurred in a Hospital: ~ Inpatient ,If Death Occurred Somewhere Other Than a Hospital: LJ ~HOSpice Facility ~ Decedent's Home ° ~ Emergency Room/Outpatient Q Dead on Arrival _ ~ Nursing Home/Long-Term Care Facility Other (Specify) a~ 15b. Facility Name (!f not institution, give street and number; 15c. City or Town, State, and Zip Code 15d. County of Death ~ 443 West North Street Carlisle, PA 17013 Cumberland ~, 16a. Method of Disposition Q Burial ~ Cremation 16b. Date of Disposition 16e. Place of Disposition (Name of cemetery, crematory, or other place) Q Removal from State p Donation Feb 4 .2013 Hoffman-ROtY'1 Funeral HOSiie & Crematory Other (Specify) ~ Z ~ 16d. Location of Disposition (City or Town, State, and Zip) 17a. gna re of Funeral Servile Lice se r Person in Charge of Interment 17b. License Number Carlisle PA 17013 / ] ( C i. 013144E 1 c. a and Co pl t Ad ess of Fun al till t~3ot~~man-~o~iz ~unera~ ~ori~e & Cremato , 219 North Hanover Street, Carlisle, PA 17013 ~' ° 1B. 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. ~ Bth grade or less is Spanish/Hispanie/Latino. Cheek the "No" ~ White ~ Korean ~ No diploma 9th - 12th rade b if d d t I S i h i c , g ox ece en s not pan s /H spani /Latino. Black or African American ~ Vietnamese ~ High school graduate or GED completed ~ No, not Spanish/Hispanic/Latino )] American Indian or Alaska Native Q Other Asian ~ Some college credit, but no degree ~ Ves, Mexican, Mexlean American, Chicano ~ Asian Indian ~ Native Hawaiian 0 Associate degree (e.g. AA, AS) Q Yes, Puerto Rican ~ Chinese ~ Guamanian or Chamorro ' ~ Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban ~ Filipino 0 Samoan Q Master's degree (e.g. MA, M5, MEng, MEd, MSW, MBA) ~ Yes, other Spanish/Hispanic/Wtino ~ Japanese ~ Other Pacific Islander ~ Doctorate (e.g. PhD, EdD) or Professional degree (Specify) ~ Other (Specify) e. . 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 White ~ Japanese ~ Samoan done during most of working life. DO NOT USE RETIRED. ~ Black or African American ~ Korean ~ Other Pacific Islander ~ American Indian or Alaska Native ~ Vietnamese ~ Don't Know/Not Sure ~ Asian Indian Q Other Asian ~ Refused 22b. K1nd of Business/Industry ~ Chinese ~ Native Hawaiian ~ Other (Specify) Q FIIiplno 0 Guamanian or Chamorco ITEMS 23s - 23d MUST BE COMPLETED 23a. ~jYe Pronounced Dead (Mo Day r) 23 b. Stgna re o Person JAR\~r q~}~ncing D~ea~th /O/r~yJ~when app icable) 23c. L e nse NuCm er A BY PERSON WHO PRONOUNCES OR ~C j~ y ` . ` '_~ ~ [~ ~ ~ !1 CERTIFIES DEATH ~l Ul/`l WP/~- a~U .7 _ ~~ ~ ~~ ~~ V ~l! f~V W '" ! 1 - J ` 23 ^ [e Signed (Mo/D y/Yr) 24. Time of Death ~ ~ D ~~ U~- _ _ 25. Was.Medieal Examla~eR or Coroner Contacted? [~~ Yes- No CAUSE OF DEATHS 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, Interval: respiratory arcest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary ) Onset to Death IMMEDIATE CAUSE -----> a_ ~T Q~~ ~ ~ CCif"' C. /~ O ~t ~ `~ _Q V'tL C (Final disease or condition Due to (or as a consequence of): _ resulting In death) i b. Sequentially list conditions, Due to (or as a consequence of): if any, leading to the cause ~ S listed on line a. Enter the e. ~ i UNDERLYING CAUSE Due to (or as a consequence of): ~ (disease or injury that _ z initiated the events resulting d_ ~ _ ~ in death) LAST. Due to (or as a consequence of): s 0 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 perfo ed7 Q ~ ~' Ves No 2B. Were autopsy findings available ~ , to complete the cause death? Yes No E 29. If Fe le: rNaot pregnant within past year 30. Did Tobacco Use Contribute to Death? ~ Y s ~ P ob bl 31. M er of Death N l i S ~ Pregnant at time of death r y a ~o ~ Unknown atura ~ Homic de ~ Accident 0 Pendin Investi ation a~' ~ Not pregnant, but pregnant within 42 days of dealt g g ~ Suicide ~ Could not be determined ~ Q Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Yr) (Spell Month) Q 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, State, Zip Code) 36. Injury at Work 37. if Transportation Injury, Specify: 38. Describe How Injury Occurred: D Y s ~ ~ Driver/Operator ~ Pedestrian P O h if ) o ~ assenger ~ t er (Spec y) 39a. C ifler (Check only one): Certifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated ~ Pronouncing ~ Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated Q Medical Examiner/Coroner - On the is of examination, and/or investtgatfon, In my opinion, dea t h o ccurred at the time, date, and place, and due to the ca use(s) and manner stated / ~ , r n _ Signature of certf r. ~/`~~ Title of certifier. , v, ~ License Number 'v\~ y.~ Q .T~. .3 39b. Name, Address nd Zip Code of Pers n Completing Cause of Death (Item 26) ~ ' 39c. Date Signed (Mo/Day/Yr) 1<a~l. .. e ro i.,.-1-~~ iV~- ~ S~ Z Tr :.~.~i ~ c ~ _ L a. ,nti ~-, ~ ( ~ ~ I o ~) 1 - 3 O -~ 02 O f 40. Registrar's District Number 41. Registrar's ure ~ 42. Registrar File Date (Mo Day r) ' at-at6 ~ - ~ ~ ~ ~b ~ 43. Amendments Disposition Permit No. O T~ oS J 1 l~ REV 07/2011 ~>- / ~ - ~ ~,o~ Estate of c^' :w~.. ~ ~ m REl~iIJ~CIATI~~ m ~ m ~ o ~,~~ m ~~ ~~ ~v ~, r iv © ~.,,~ i~ REGISTER OF WILLS ~ ~ ~ ~ ,~ PE~tNSYLVAI~A~ c~ COtJNTY ~ym bcr ! cn~r~ ~ `~ ~'"~ , ~ ~~~ r„~ ` r~ ~ rv rte ~ . GD Deceased I, ~~~ ~(,~ ~~~ ~N2~~ 65~. ___, in my capacity/relationship as (Print Name) ~_~~ of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to ~' 1 Z~ ~~ (Date) (Street Address) ~~f/lY t~h~J ~ >~~ Z 1Q~g (City, State, Zrp) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of , Deputy for Register of Wills Form RW-06 rev. 10.13.06 Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunc' t~c~n for the purposes stated within on this day bf~'E'~`~Ul Ac~Z~ 2~ of Public y Co mission Expires: ~ `3 ~,~ ~J (Signature and Seal of Notary or other off cial qualified to administer oaths. Show date of expiration of Notary's Commission.) OOtNMONWEALTH OF PENNSYLVANIA Notarial Seal Susan K. Mackey, Notary Pubik . Dickinson Twp., Cumberland County My Commission Expires Sept 3, 2013 Member. Petu-ranta Association of Notaries, ,