HomeMy WebLinkAbout03-11-13
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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS 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: Patricia Ann Miller File No: 1-2 7 7
a/k/a: (Assigned by Register)
a/k/a:
a/k/a: Social Security No: 204-26-9861
Date of Death: June 25, 2011 Age at death: 76
Decedent was domiciled at death in Cumberland County, Pennsylvania (State) with his/her last
principal residence at 1000 Claremont Road Middlesex Township Carlisle PA 17013 Cumberland
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at 1000 Claremont Road Middlesex Township Carlisle PA 17013 Cumberland Pennsylvania
Street address, Post Office and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death: 20,000.00
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 $
TOTAL ESTIMATED VALUE.... $ 20.000.00
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 ~ d 7
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, date tL~ Q rrt i-`~ and Codicil(s)
thereto dated
State relevant circumstances (e.g. renunciation, death of execuloi',.) f ! ` t r I
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marvpw6 nbi divoxgd, wammmv party to a pending
an did- t, ve a child born or
, -Kb
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C:S. § X345 g.t
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated pR _ = r
0 NO EXCEPTIONS 0 EXCEPTIONS
C n
B. Petition for Grant of Letters of Administration (If applicable) d.b.n.
c.t.a., d.b.n., d.b.n.c.t.a., pendente lite, durante absentia, durante minoritate
If Administration, ca.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 for divorce had been established as defined
in 23 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 Will and was survived by the following spouse (if any) and heirs (attach
additional sheets, if necessary):
Name Relationship Address
Form RW-02 rev. 1011112011 Page 1 of 2
Oath of Personal Representative Official Use Only
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF Cumberland }
Petitioner(s) Printed Name Petitioner(s) Printed Address
Barbara A. House 462 Champlain Street Toms River NJ 08757
i i I
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petitio a true and correct to the best of the knowledge and belief
of Petitioner(s) and that, as Personal Representative(s) of the/Dece nt the Petitioner( 11 well and truly administer the estate according to law.
Sworn to or affirmed and subscribed before Date l
ni 's tl day o Date
B Date
For the Register Date
BOND Required: Q YES Q NO To the Register of Wills:
FEES: Please enter my appearance by my signature below:
Letters $ Attorney Signature:
( ) Short Certificate(s)..... .
( ) Renunciation(s).........
( ) Codicil(s) ~L--
( ) Affidavit(s)........... .
Bond Printed Name: Keith O. Brenneman
Commission Supreme Court
Other ID Number: 47077
Firm Name: Snelbaker & Br eman, P.
Address: 44 West Main 7~1 C->
a
CY
Phone: 717-697-8528 r''- :=r 4;:;>
Automation Fee Fax: 717-697-7681 t
JCS Fee. Email: = =
Fr
TOTAL $ 0.00 t
IU:l -ri
DECREE OF THE REGISTER
Estate of Patricia Ann Miller File No:
a/k/a:
AND NOW, , in consideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters
are hereby granted to
in the above estate and (if applicable) that
the instrument(s) dated
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
Register of Wills
Form RW-02 rev. 1011112011 Page 2 of 2
14 105 805 RE%' (9/I I 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 R E C 0 R - . + "This is to certify that the information here given is
REG; y correctly copied from an original Certificate of Death
S ER Bt vii,, '
$ duly filed with me as Local Registrar. The original
10. c( rtiiicate will he forwarded to the State Vital
ppp
1 V
Records Office fur perrrranent filing.
ll
n ' J CLERK FO 1 V2013
~l~1fN1 Q`~~III~
Certification Number ORI HANS COURT Local Registrar Date ISSUed
Type/Print In CUMBERLA V LT[-~ PENNSYLVANIA . OE PARTM ENT OF HEALTH ~ VITAL RECORDS
Permanent V f C
Black Ink
1. Decedent's Legal Name (First, Middle, Last, Suffix) ERTIFICATE 2. Sex OF 3. So DEATH cial Security Number State File Nu4.mber:
Date of Death (MO/Day/yr) (Spell Mo)
James W. Miller Male 174-20-1918 February 6, 2013
Sa. Age-Last Birthday (Yrs) 56. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/Year) (Spell Month) 7a. Birthplace (Clfy d State or Foreign Country)
o~t 84 Mpncna Days Hours Minutes March 11, 1928 RossV Ily PA
7b. Birthplace (County) York
Sa. Residence (State or Foreign Country) 86. Residence (Street and Number - Include Apt No.) 8c. Dld Decedent Llve in a Township?
PA 2 Trinity Dr. West Apt 11 3(es, decedent uved in
8d. Residence (County) twp
York Be. Residence (Zip Code) 1701 C~ No, decedent Itved within limits of
9. Ever to US Armed Forces? 10. Marital Status at Time of Death 0 Married Widowed 11. Survtvin 5 city/boro.
Yes ~ No E3 Unknown 0 Divorced Q Never Married E3 Unknow g Spouse's Name (If wife, glue name prior to first marriage)
12. Father's Narr)e (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Mitldle, Last)
Paul Miller Maude McClellen
74. . Informant's Name 146. Relationship to Decedent
0 14c. Informant 's Mailing Address (Street and Number, City, State
Barbara House , 2Ip Code)
G dau hter Ch a
462
n
a..... am 1 i
V
1sa. P ace p Deat ec ne St . T
er Na 8757
s If Death Occurred In Hos Ital t~va~iy ..........g ..................on Y. O
P Ld Inpatient _ If Dea[ Occurred -m-;%
Than a Hospital: --I.,J •Hospl«cen`4 cjR1
Emergency Room/OUtpatlent re Othr
D
E3 Dead on Arrival --hi g Care Facility Other S Decedent's Hom
;cif e
15b. Facility Name (If not Institutgive street and number; 15 c. City ( Peclfy)
L iPe Care Hospital or Town, State, and Zip Code
1stl. county of Death
Mechanicsburg, PA 17050 Cumberland
16a. Method of Olsposltlon 0 Burial Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of m Ej Removal from State EJ Donation Feb 9 , 2013 cemetery, cremator,, or other place)
p Other (Specify) Hoffman-Roth Funeral Home & Crematory
v 16d. Location of Disposition (Illy or Town, State, and ZIp) 17 Ign of Funeral Service a or Person In Charge of Interment 17b. License Number
Carlisle, PA 17013
013144L
E 1W. Name and Complete Address of Funeral Facility
Hoffman-Roth Funeral Home & Cremato 219 Nor H -
18. Decedent's Education -Check the box that best describes the 19. Decedent of Hlspa nic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to indicate what
,2 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.
Rf 8th grade or less Is Span lsh/Hlspanlc/Latino. Check the "NO" [X White Q Korean
No diploma, 9th - 12th grade box If decedent is not Spanish/Hlspanlc/Latino. 0 Black or African American 0 Vlet namese
E3 High school graduate oGED completed No, not Spanish/Hlspalc/Latin. M American Indian or Alaska Native Ej Other Asian
Ej Some college credit, but no degree yes, Mexican, Mexican American, Chicano [3 Asian Indian
Q Associate degree (e.g. AA, AS) Q Yes, Puerto Rican Native Hawa Ilan
Bachelor's degree (e.g. BA, AB, BS) Yes, Cuban Chinese Guamanian or Chamorro
0 Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA
) C3 [ Filipino Samoan
Yes, other Spanish/Hlspanlc/Latino Q Other Paclflc Islander
0 Doctorate (e.g. PhD, Ed D) or Professional degree Japanese
(Specify) Q Other (Specify)
. MD, DDS OVM, 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 - Indlca[e
White Q Japanese Ej Samoan done during type of work
0 Black or African American Korean Other Pacific Islander g most of working life. DO NOT USE RETIRED.
E3 American Indian or Alaska Native 0 Vietnamese C3 Don't Know/Not Sure Truck Driver
Ej Asian Indian Other Asian 0 Refused
Q Chln ase 22b. Kind of Business/Industry
c [j Filipino O Native Hawa Ilan Other (Specify) rucking
Guamanian or Chamorro T
ITEMS 23- - 23d MUST BE COMPLETED 23a. Da a Pronounced Dead (MO/Day/Yr) 23b. Signature of Pers
BY PERSON WHO PRONOUNCES OR ll ing Death (Only when appllcable) 23c. License Number
CERTIFIES DEATH 1- LQ ` ^ /
23tl. DaIgne (MDayYr 24. Time of Death FV1 `-t
t 8~~ 25. Was Medical Examiner or Coroner Contacted? 0 Yes No
CAUSE OF DEATH
26. Part I. Enter the chain of events--diseases, Injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest. '0'P Proximate
respiratory arrest, or ventricular fibrillation without showln [he etlolo Interval:
g gy. DO NOT ABBREVIATE. Enter onlyone cause on a line. Add additional lines If necessary ? Onset to Death
IMMEDIATE CAUSE \ 1 C`},-) - i
(Final disease or condition Due to (pr as a consequence of):
resulting In death)
b.
Sequentially list condltions, Due to (Or as a consequence of):
I any, leadin1, toEthe cause
IIf tetl on line nter the
UNDERLYING CAUSE Due to (or as conse quence of):
(disease or injury that a
F Initiated the events resulting d.
In death) LAST. Due to (or as a consequence of):
S 26. Part I. Enter other s-nlficanr conditions contributing t death but not resulting In the underlying cause glven In Part I 27. Was an auto
psy pertormed?
O Ves Q-tap
28. Were autopsy findings available
to complete the cause of death?
a 29. If Female:
E pTJot pregnant within past year 30. Did Tobacco Use Contribute to Death? Yes c2-N.
31. Manner of Death
's 0 Pregnant at time of death M Yes E3 Probably Natural 1-3 Homicide
C3 Not pregnant, but pregnant within 42 days of death No E3 Unknown Ej Accident 0 Pending Investigation
i- No[ pregnant, bu[ pregnant 43 days to 1 year before death 32. Date of In'u Suicide
O Unknown if pregnant within the / ry (MO/Day/Yr) (Spell Month) Could not be determined
past year
33. Time of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of injury (Street and Number, CI
ty, State, Ztp Code)
4 36. Injury at Work 37. If Transportatipn Injury, Specify: 38. Describe How Injury Occurred:
E3 Yes Driver/Operator C3 Pedestrian
E::] No Passenger E3 Other (Specify)
39a. Cgytifler (Check only one):
Certifying physl clan - To the best of my knowledge, death curved due to the c se(s) and manner stated
Pronou ncing Sa Certifying physI ahn, - the bes[ of my wledge, death occurred at the time, data, and place, and due to the c se(s) and manner stated
D~ Medical Examiner/Coroner - On th as1 f exam fn n
E3 War Investigation, in my opinion, death occurred at the time, date, and Place, and due to the s
e(s) and manner stated
Signature of certifier: a n a Title of certifier: x J License Number: V „~N ZcKl V Z---
3 9b. Name, Address d Zlp Code of son Completing Cause o eath (Item 26) 39c. Date Slgn (M /Day/V )
~lC~ S\JJ eN~ Q L $ L c~ l ~a k r e e~ L c-.nno P ~F? 8 zo (
40. Reglstra is District Number 41. Reglstra is Slpnstu re - 1 42R rar Ile Date (Mo/Day r)
43. Amendments
o_
Disposition Permit No. 0&xa. \vZ`O H305-143
REV 07/2011