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HomeMy WebLinkAbout03-04-13 PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF YLiQ)COUNTY, PENNSYLVANIA Petitioner(s) named below. who is/are 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 Information Name: / -Ale ~.l (J/~~1 G/ ,/L /2 File No: a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: Date of Death: o~3 ~C>/ Age at death: 93 Decedent was domiciled at death -County, (state) with his/her last principal residence at S ~3~ GZ/ ~~G~) IGG rr .7 =Ci~v//~S /3u/' ~.9 i7 Street address, Post Office and Zip Code City, Township or Borough County~~/lw~- . Decedent died at at Sf1L: Z %~~i dlgL tll//Z L-- /-/L- /yf by Street addres , Post Office and Zip Code City, Township or Borough County State Estimate of value of decedent's property at death: If dotniciled 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 $ TOTAL ESTIMATED VALUE.... $ Real estate in Pennsylvania situated at: (Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough County 0fl A. Petition for Probate and Grant of Letters Testamentary MM / Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated and Codicil(s) thereto dated 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 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. ['t!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 durante absiR1, du~tel'"-t noritate du n If Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above an ;Mete list heiR c) z, cr) 'O Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds f4WivfiM=9d been establ%QT defined in 23 Pa. C.S. § 3323(8) and was neither the victim of a killing nor ever adjudicated an incapacitated p6§0= M ❑NO EXCEPTIONS ❑ EXCEPTIONS c-'> Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by th6lbA4ing'spouse{t any):and hens (attach ti-_ additional sheets, if necessary): f~, l Name Relationship ~ Address c cy, Fora, RW-02 rev. 1011112011 Page 1 of 2 Oath of Personal Representative Official Use Only COMMONWEALTH OF PENNSYLVANIA I ,,Mb/ 11MQ( ) SS: COUNTY OF 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 Petition (s) will well and truly administer the estate according to law. Sworn to r affirmed a d subscribed before Date me i' day of Date "ay B Date or the Register / Date BOND Required: Q YES NO To the Register of Wills: FEES: Please enter my appearance by my signature below: Letters $ 0, ©O Attorney Signature: ) Short Certificate(s)..... . 00 ( ) Renunciation(s)........ . ( ) Codicil(s) Bond Printed Name: C c~ rri Commission Supreme Court C, Other ID Number: C `zu Firm Name: :r -r- {r 11 f t-,r Address: ~ V y.,,:. ryj Phone: _U C7 C* CA Automation Fee. . . . . SyM Fax: Crl JCS Fee ` 2 Email: TOTAL $ 1 3." DECREE OF THE REGISTER Estate of ce J File No: ~2l - 13--DaC00 a/k/a: AND NOW, in consideration of the foregoing Petition, satisfactory proof having bdUn presented before me, IT IS DECREED that Letters are hereby granted to T Ce hL -Do in the o ve estate land (if applicable) that the instrument(s) dated described in the Petition be admitt d to probate and filed of record as the last Will (and Codicil(s)) of Decedent. &tp i1 Ij b"a Register of Will 0 y~{~ Farm RW-02 rev. 10/111201 J Page 2 of 2 [110> XO~ RIA Itbl I1 LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: Itj it dff licato this ropy by photostat or photograph. l RECORD: A REGISTER OF ,'B'ILLS Fee for this certificate, x+6.00 This is tO certify that the information here eLken is l0 ~t P correctly copied from an orig 'Gi3 { t[li) L~ Pal mat Certificate of Death duly fuel with me as Local Registrar. The on inal \x 4 .C1t,l(catc will be forwarded to the State Vital CLERK ' Rccor(OlTice IOr permanent filing. ORPHANS' COURT P 19180073 CUMBERLAND CO PAS der4~`t% Certification Number Local Registrar Date Issued /Print In COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS s .,k Ink CERTIFICATE OF DEATH State File Number: 1. Decedent's Legal Name (First, Middle, Last, Suff.) 2, Sex 3. Social Security Number 4. Date of Death (MO/Day/Y,) (Spell Me) Lawrence J. Dougherty, Sr. Male 162 - 22 - 5726 Feb 23 2013 5a. Age-Last Birthday (Yrs) 5b. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/year) (Spell Month) ]a rt p ce City gDrl State or Foreign Country) Months Days Hours Minutes YA 83 October 12, 1929 7b.81dhpla a(County) SEFU-y-Mll 8a. Residence (Slate or Foreign Country) Bb. Residence (Street and Number - Include Apt No.) 8c. Did Decedent Live in a Township? Pennsylvania 532 West E1rtB,n0od Avenue Yes, decedent Ned in Upper Allen h P. Be. Residence (County) Cumberland 8e.Resid-e(2ipcode) 17055 ❑No,deced,ntIIVdw8hh lim0s,f city/bor.. 9. Ever In US Armed Forces) 30. Marital Std atus at Time of Death &g Married Widowetl 11. Surviving SpousMe's Name Iif wife, give name prior [o first mardagel ❑vea $]N, ❑unknown ❑Diy,me ❑NeyerMarnetl ❑unk❑ now Frances . Filippelli 12. Fathei s Name Illicit, Middle, Last, 5uHix) 13. Mothe, I Name Prior to First Marriage (First, Middle, Last) John Dougherty Anna Brennan 14, Informant's Name 14b. Relationship 10 Decedent 14c. Informant's Mailing Address IS,reet and Number, City, State, Zip Codel o Frances M. Dougherty Wife 532 W. ElMicod AMM gq 17055 G ,1 a. Pace, Death Chec 95. o ~e...............................~.. a Il Death Occurred ina Hospital: Inpatient It Death Occurred Somewhere Other Than a Hospital: Hospice facility LJ •acetlent's Home O ❑ Emergency RoomOutpatient ❑ Dead on Arrival Nuning Home/Long-term Care Facility Other (SpecRy) Si i5b. Facility Name 111 not institution, give street and number' 15c. Ciry,r Town, State, and Zip Code 15d. County of Death M.S. Hershey Medical Center Hershey Pa. 17033 Dauphin a 16a. Method of Disposition C] Burial ~ Cremation 16b. Date of Disposition 16c. Place of pisposiHer, (Name of cemetery, crematory, or other place) ❑ Removal Irom State Donation Y ❑ omer(s,_FY Fdxuar1 Y 25 2013 Hollinger Crematory Z led. Location of Disposition (City or Town, State, and Zipl I)a. S f f ffb -see or Person in Charge of Interment 17b. License Number Mt. Holly Springs, PA 17065 FD - 014889 e I]c. Name antl COmpkte Atldress of Funeral Facility Mal zzi Funeral Home Market a W "icsbura. PA 1705-9 18. Decedent's Education -Check the boa that best describes the 19. Decedent of Hispanic OHgI Check the 20. Decedent's Race Check ONE OR MORE races to indicate her highest degree or level of school completed at the time of death. box that best describes whether the decedenl the decedent considered himself or herself to be. ❑ 811, grade or less Is SPanlsh/HI1Panic/Latin'. Check the 'No" White Korean ❑ No diploma, 9th 12th grade boxif decedent Is not Spanish/Hispanic/Latino ❑ Black or Afdcan Ame - Vietnamese High school graduate or GED completed ®No, not Spanish/H,p-c/L,Hn, ❑ American Indian,, Alaska Native 0Other Asian Some college credit, but no degree j] yes, Mexican, N icar American, Chicano ❑ Asian Indian [I Native Hawaiian Associate degree fe IT AA, AS) O Yes, Puerto Rican Chinese 0 Guamanian or Chamorro Bachelor's degree (e.g. BA, AB, BSI ❑ Yes, Cuban Filipino C] Samoan Master's degree (e.g. MA, M5, MEng, MEd, MSW, MBA) Yes, other Spanish/Hispanic/Latin, O Japanese ❑ Other Pacific Islander ❑ Doctorate(e.g. PhD, EdD) orprofessional degree 0-IFvl ❑ Other(Spi,00 e.. MD DOS, OVM, LLB, 1D 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 W White 0 )apanese ❑ Samwn done during mast of working life. 00 NOT USE 0.ETIRED. Black or Alrican American f] Korean ❑ Omer Pacific Islander Sales Consultant American Indian or Alaska Native ❑ Vietnamese ❑ Don't Know/Not Sure ❑ Asian Indian ❑ Other Asian ❑ Refused 22b. Kind of Business/IMUS,ry ❑ Chinese ❑ Naflve Hawailan ❑ Other (Specify) ❑ Fl4pin, ❑ Guamanian or Chamorro Window Products ITEMS 23a- 23d MU5T BE COMPLETED 23a. Date P tic d Dead (MO Day/vrl 236. Signature of Person Pronouncing Death (Only when appBCable) 23c. License Number BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH 3 3 23d. Date Signed lMo/Dey/Y,) 24. Timeof Death 9 3 Z5 Was Medical Examiner or Coroner Contacted? ❑ Yes N No CAUSE OF DEATH Approximate 26. Part 1. Enter the chain ofevents-diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest Interval: respiratory arrest, or ventricular fib,illationn with,,, showing the etiology. DO NOT ABBREVIATE. Enter only one cause on line. Add additional lines if necessary Onset to Death IMMEDIATE CAUSE a. l_.Krdic nUl Wsoll4 rk•, /-T Wr[\•}- IFinaldiseu condition Due to (or as a -equence,n. resulting In death) RRi~kk b. ` yV10C.t4 Sequentially listroMilons, S Due to for asaconsequence off. if any, leading to the cause listed on line a. Enter he UNDERLYING CAUSE Due to (or as a consequence of): _ (disease orin),ry that y initiated the events ,,,Ming d. Ht4r 1 ~4k~W~C In death) LAST. Due to (or as a consequence of). g 26.Partll. Enter othersgri Fcantcond't on t'b[ d [h but net res,lting In the underlying cause given in Partl 27. Wasan autapsyp rformed] F ❑ Ves Nq 28. Were autopsy findings aY.Hable to complete the cause of death? ❑ Yes NO 29. If Female: 30. Did Tobacco use Contribute [ Dth] 31. Manner of Death o ea Not pregnant within past year ❑ Yes ❑ Probably r[J Natural 0 Homicide Pregnant at time o! death ❑ No Dnknown Accident ❑ Pending Investigation Not pregnant, butpregnantwithin 42 daysofdeath Suicide Could not be determined ❑ Not pregnant, but pregnant 43 days to lyear before death 32. Date of Injury (Mo/DaY/Yr) (Spell Month) ❑ 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 F37n, p,rtatloInjury, Sp ecify38. Describe How Injury Occurred. Yes perator Peestrian No er ❑ Other (Specify) 391. Certifler (Check only one): ❑ Certifying physician To the best of my knowledge, death occurred due to the cause(s) and manner stated Pronouncing g Certifying physician - To the best,( my knowledge, death occurred at the time, date, and place, and due to the case(s) and manner statetl ❑ Medical Examiner/COrgaer-On [he/ba}`'{~ (j/era in tbn, antl/or investigation, in m,,p,,,,n, death occurred at the time, date, and place, and due to the cause(s) and manner stated Signature of certifier. (VX' /Lll_ LTC Title of temper: OlD License N,mbe,; O j o(y a - Y 39b. Name, Address and Zip CI' e of Person Completing Ca D h Ite 261 39c. Date Si d IM O. r) eleven Ch fek1Jen Y~I`~•~le~rs~iey Medical Center, Hershey, Pa.17033 aa3 dO. Registrar 'sDc'N=mbar l~ 41. Re, gisyar's 5lyna 42.gistra~Fllel ale (MO3aynr) D)7 I(VAvf/ ir•'P~"'IA`7•.~~t,re i'a 43. Amendme,is 2 Disposition Permit He. 0887602 RH1o5-143 EV 07/2011 RECO2FLDN F FIC OF REClr 0 S Z 13 MIR ti F 2 05 LAST WILL AND TESTAMENT OF LAWRENCE J. DOUGHERTY, SR. CLE A'C 0RPHANS' C01JR T, CUMBERLAND CC., PA I, LAWRENCE J. DOUGHERTY, SR. of 532 W. Elmwood Avenue, Mechanicsburg, Cumberland County, PA., being of sound and disposing mind and of full age, do make, publish and declare this as and for my Last Will and Testament, hereby revoking any and all prior Wills or Codicils. ITEM I. I direct that all my just debts and funeral expenses be paid by my Executrix or successor as soon after my decease as may be conveniently done. ITEM II. (a) I leave my entire Estate, of whatever nature, real, personal or mixed of whatever kind and wherever situate which I now own or may hereafter acquire, to my wife, FRANCES M. DOUGHERTY. (b) In the event my wife shall predecease me, or not survive me by thirty (30) days, I leave my entire Estate to my children, ELAINE MARIE HERALD, JOHN CHARLES DOUGHERTY, RICHARD MICHAEL DOUGHERTY, NANCY LOUISE HARVEN, MICHAEL JOHN DOUGHERTY, LAWRENCE JOHN DOUGHERTY, JR. and ROBERT AUSTIN DOUGHERTY, in equal shares, per stirpes. ITEM III. I expressly direct that all principal and income of any Estate or Trust created hereunder shall be free and clear of the debts, contracts and engagements of those beneficially interested therein, and from anticipation, assignment, alienation, attachments, executions or sequestrations, by any process, legal or equitable, and shall be paid over directly to the persons entitled thereto hereunder upon their own proper receipt in writing only. ITEM IV. (a) I nominate, constitute and appoint my wife, FRANCES M. DOUGHERTY, to be the Executrix of this, my Last Will and Testament. If she is unable or unwilling to serve as Executor, I nominate, constitute and appoint my daughter ELAINE MARIE HERALD to serve in her stead. (b) Any successor fiduciary shall have the same powers, rights, duties, discretion and immunities which I have conferred upon the original fiduciary. (c) No fiduciary hereunder shall be required to enter security in any jurisdiction. ITEM V. In addition to the powers elsewhere granted herein, or by law, my Executrix and her successor, at their sole discretion and without leave of Court may: 2 (a) Compromise any claims by or against my Estate, without consent of any beneficiary; (b) Make distributions hereunder either in cash or in kind at valuations to be determined by my Executrix or her successors; and (c) Sell property for such prices on such terms, and at public or private sale as she may deem proper and grant options for the purchase of property. IN WITNESS WHEREOF, I have hereunto set my hand and seal this day of 2 0 . LA E C DO HE Y, R. SIGNED, SEALED, PUBLISHED and DECLARED by the above-named Testator, JEFFREY HOFFMAN, as and for his Last Will and Testament, in the presence of us, who at his request, in his presence and in the presence of each other, have hereunto subscribed our names as witnesses. 1,41) 'jV'07_ Address t I Iv- Q~ Address 3 ACKNOWLEDGEMENT AND AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA: SS COUNTY OF bjVj k WE, LAWRENCE J. DOUGHERTY, SR., the Testator, and witness, whose nam s are signed to the attached instrument dated the day of ~ Y'10 L4 - , 2006, being duly sworn, do declare to the undersig ed authority that the Testator executed the instrument as his Last Will and Testament and that he signed willingly, and as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witness, and that to the best of his or her knowledge, the Testator was at that time eighteen years of age or older, of sound mind and under no constrain or undue influence. i E J. OUG O L fitness k - Z,22~-' - Witness Subscribed, sworn to and acknowledged before me by LAWRENCE J. DOUGHERTY, SR., the Testator, and subs Vibed and sworn to before me by the above, his witnesses, this day of M4!4 2006. aLM:UAI) -7Q~L~X Notary Public 4 C~ISxIBFv;fil OF PE"d d V Notarial Seal Aimee L. Paukovits, Notary Public City of Harrisburg, Dauphin Comity Iv1 Commission FK.)fies Apr. 17, < '7