HomeMy WebLinkAbout02-22-13
01 ~a
t~ C:>
PETITION FOR GRANT OF LETTERS rn °7 4
REGISTER OF WILLS OF J COUNTY, PEWr t~GAND? -a c
a . ;7q o c-)
Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letter"g::s ~itieXEbelo-rta` d in
support thereof aver(s) the following and respectfully request(s) the grant of Letters in the oMpriate f*r 3: rn
9 r-
Decedent's nformation a c,~ to ~
Name: s ~.4 File No: "2--7 -7 ~
a/k/a: `(Assigned by Register)
a/k/a:
a/k/a: Social Security No: 2
Date of Death: Age at death: c?
Decedent was domiciled at death in County, 1-?4 (State) with his/her last
principal residence at
Street a dress, Post Office and Zip Code Cit , Township or Borough 0"' County
Decedent died at y -i 2 Ly rn / -y / r "C'/ r / f-':z / /
Street address, Post Office and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania All personal property $
If not domiciled in Pennsylvania Personal property in Pennsylvania S
If not domiciled in Pennsylvania Personal property in County S
Value of real estate in Pennsylvania S
TOTAL ESTIMATED VALUE.... S • /6:
Real estate in Pennsylvania situated at:/ L,' , / n
(Attach additional sheen, ijnecessary.) Street address, Post Office and Zip Code T-City, Towns ip 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 Cf tP% 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(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, durance absentia, durance minoritate
If Administration, ca.a. or d.b.nx.ta., 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(8) and was neither the victim of a killing nor ever adjudicated an incapacitated person.
DNO EXCEPTIONS ❑ EXCEPTIONS
Petitioner(s), after a proper search hasthave ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs (attach
additional sheets, ifnecessary):
Name Relationship Address
f
Form RW-02 rev. 10/111201 l Page 1 of 2
Oath of Personal Representative Official Use Only
COMMONWEALTH OF PENNSYLVANIA y
SS:
n 9 r%
` V cn :tr
►U b
Z V) ---,a z e,
. O
C Cs 'ra "rY
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are true and caq,l~l ct t the best of the kn edgr and belief
of Petitioner(s) and that, as Personal Representative(s) of the Decedent, the Petitio s) will ell and truladminister theWbte aor:orU4 to law.
Sworn to r ff rmed a Date
subscribed before ~ v
r~/J
met day fC /~4,% - Date
By: Date
For the Resister Date
BOND Required: Q YES 2<0 To the Register of Wills:
FEES: ~~7~ Please enter my appearance by my signature below:
Letters . $ 0, oo Attorney Signature: }
( ) Short Certificate(s)......
( ) Renunciations
( ) Codicil(s)..
( ) Affidavit(s)............ t -
Bond... Printed Name:
-1///, ~ ;,h 21
11
Commission Supreme Court
Other , , ID Number:
• • . Firm Name:
• • • • Address: LZ rte- c"
Phone:
Automation Fee Fax:
JCS Fee Email:
TOTAL $
DECREE OF THE REGISTER
Estate of i L'~Yr~ c ~1r f ~ i ~L,//✓L= File No: _ 00 /2 ~V 3
a/k/a:
AND NOW, r in con idera ion of the foregoi Petition,
satisfactory proof having been pre Vele' before me, IT ECREED that Letters
hereby granted to
---in the above estate and (if applicable) that
the instrument(s) dated
described in the Petition be admitted 1:4 probate at d filed of record as the last Will (at :d Codicil(s) of Decedea
Oegister o Wil f~yZ
Fnrm Rr91.,17 rnirrnnrr t
14IOs.8()S RI,% 19/1 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 ,a = This is to certify that the information here given is
REGISTER 4ILLS correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
*/7 ccrtificate will be forwarded to the State Vital
313 f~U ~s
I3"
f 2 7 a; Records Office for permanent filing.
19 . i ~J 1; CLERK OF
' SENT of ~~e s: ,-~lekxz c" FEA 1 1/2013
Local Registrar Date Issued
Certification Number PHANS" COURT
Type/Print In CUMBERLANID=€~A OF PENNSYLVANIA a 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 (MP/Day/Y,) (Spell Mo)
Asenath M_ Hartline F 179-12-5137 February 1 0,2013
Sa. Age-last Birthday (Vrs) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/Year) (Spell Month) 7a. Blrthp e~ (CI and Stale or Foreign Country)
At 9 8 Months DAYS Hours Minutes
January, 18,19 15 Carcase, PA
S a Reside 7b. Birthplace (County) Cum er an
. Residence (State or Foreign Country) 86. Residence (Street and Number -Include Apt No.) Sc. Did Decedent Live in a Township?
8d. Residence (County) Oyes, decedent Iived in Iwp
44 Walnut Bottom Rd_
Cumber 1 and 8e. Residence (Zip Code) 1 7 O 1 3 decedent lived within limits of Carl i l city/ orn.
9. Ever in US Armed Forces? 10. Marital Status at Time of Death 0 Married Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage)
0 Yes No Unknown 0 Divorced 0 Never Married 0 Unknown
12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last)
Wi111s T_ M ers Elizabeth M_ Shambau(gh
14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street antl Nulmber, City, State, Zip Code)
m E3 On
150 Linn 3D Ca i
e
fn PA 17013
n........................... isa.. r.a~e.g.,oeat... c ec on y pne X.
s If Death Occurred in a Hospital: Inpatient ?If Death Occurred Somewhere Other Than a Hospital~1 V e.. ~`1-jospice Facility
-.--I o 0 Emergency Room/Outpatient 0 Dead on Arrival Nu Decedent s Home
,sing Home/Long-Term Care Facility 0 Other (Specify)
[1i 156. Facility Name (if not institution, give street and number' 15c. City or Town, State, and Zip Code ISd. County of Death
° Forest Park Health Carlisle PA 17013 Cumberland
16a. Method of Disposition J!O Burial 0 Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place)
L.f"1 0 Removal from State 0 Donation
O other (Specify) 2/ 1 5/ 2 0 1 3 Goodyear Cemetery
16d. Location of Disposition (City or Town, State, and Zip) 17a. Signature of Funeral Service Licensee or Person in Charge of Interment 176. License Number
ardners PA 17324 a(-
0 17c. Name and Complete Address of Funeral Facility 011589J.
T-TCD er FH&Cremator 501 N _ Baltimore Ave _Mt _ Holly Springs , PA
m 18. Decedent's Education - Check the box that best describes the 19. Decedent of Hispanic Origin - Check the 20. Oeced ent's Race -Check ONE OR MORE racees. to Indicate what
r- highest degree or level of school completed at the lime of death. box that best describes whether the decedent the decedent consitle red himself or herself to b
0 8th grade or less Is Spanish/Hispanic/Latino. Check the "NO" White 0 Korean
0 No diploma, 9th - 12th grade box if decedent is not Spanish/Hispanic/Latino. 0 Black or African American 0 Vietnamese
0 High hoot graduate or GED completed ~NO, not Spanish/Hispanic/Latino 0 American Indian or Alaska Native 0 Other Asian
0 Some college credit, but no degree E3 Yes, Mexican, Mexican American, Chicano 0 Asian Indian 0 Native Hawaiian
JW Associate degree (e.g. AA, AS) 0 Yes, Puerto Rican
0 Bachelor's degree (e.g. BA, AB, B5) r3 Yes. Cuban 0 Chinese 0 Guamanian or Chamorro
Filipino 0 Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) 0 Yes, other Spanish/Hispanic/Latino 0 lapanese 0 E-3 Samon
OtheraPacific Islander
0 Doctorate (e.g. PhD, EMd D) or Professional degree (Specify) 0 Other (Specify)
. MD, DDS, DV, LLB JD)
21. Decedent's Single Race Self-Designation - Check ONLY ONE to Indicate what the decedent considered himself or herself to be. 22 a. Deced
White ent's Usual Occupation -Indicate type of work
0 Japanese 0 Samoan done during most of working life. DO NOT USE RETIRED.
0 Black or African American 0 Korean 0 Other Pacific Islander
° DAmerican India, orAlaska Nall— 0 Vietnamese 0 Don't Know/NOtsure Secretary
0 Asian Indian 0 Other Asian ED Refused 22b. Kind of Busin¢
Chinese ~s/Industry
O p Native Hawaiian pother (specify) US Naval BasO
0 Filipino 0 Guamanian or Chamorro
ITEMS 23. - 23d MUST BE COMPLETED 23a. Date Pronounced Dead (MO/Day/Vr) 23b. Signature of Person Pronou nctng Death (Only when applicable) 123 c't. License Number
BY PERSON WHO PRONOUNCES OR Q IQ zd
CERTIFIES DEATH
23d. Date Signed (Mo/Day/Yr) 24. Time of De at ,500
2 25. Was Medical Examiner or Coro er Contacted- 0 Yes N No
CAUSE OF DEATH
26. Part 1. Enter the chain of events--diseases, injuries, or complications--that tlirectl Approximate
y caused the death. DO NOT enter terminal vents such as cardiac arrest Interval:
respiratory arrest, or ventricular fibrillation without showing the etiology. D NOT ABBREVIATE. Enter only one cause o a Iirte. Add additional lines If necessary j Onset to Death
n✓,Aty~~'~_-T_
IMMEDIATE CAUSE a.
(Final disease or condition to (or as a con qq 1:
resulting in death) ~i 5e♦,~ ~
Seque..[ially list conditions, b ~(/A ~ ~-f-==-
as 4 n<e of): L~
i an
isted y, leading to the cause to (or
l on line e a. Enter the At
UNDERLYING CAUSE Due to (or aswconsequence of).
(disease o injury that
initiated the events resulting d.
in death) LAST. Due to (or as a consequence of):
26. Part If. Enter other significant con d'Tions t 'b I t d th but not resulting in the underlying cause given in Part I 27. Was an autopsy pertormetl?
D Yes No
28. Were autopsy findings available
m to cnmplete the ca of death?
1 ° 29. If Female: 0 Yes 0 No
3o. Did Tobacco Use Contribute to Death? 3. Manner of Dea
0 th
E Ig Not pregnant within past year 0 Yes r Probably 1Natural 0 Homicicl
de
S Pregnant at time of death 0 0 Unknown Accident
m 0 Not pregnant, but pregnant within 42 days of death l 0 0 Pending Investigation
1C t- 0 Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Da /Yr 0 Suicide 0 Could not be determined
0 Unknown if pregnant within the past year Y ) (Spell Month)
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 fnjury, Specify: 38. Describe How Injury Occurred:
O Yes 0 Driver/Operator 0 Pedestrian
0 No 0 Passenger 0 Other (Specify)
39a. Certifier (Check only one):
Certifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated
0 Pronouncing & Certifying physician - T the best of my knowledge, death Occurred at the time, date, and place, and due to the cause(s) and manner stated
0 Medical Examiner/Coro~n on the b f examination, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the Cause(s) and manner stated
Signature of certifier: Title of certifier: License Number:
-z ' M17 M 035a~
39b. Name, Address and Zip Code f Person Completing Cause ofd 5h 11tem 26) 39c. Date Sign I'd (M Day/Vr)
r /`+9 3 /mDTE Av-e- 1.y* l S r P#i i~ob a 1r ao 3
40. Registrar's District Number 41. Registrar's 51 n Lure 42. Registrar e Dat (MO/Day Y0
° 43. Amendments
0
0
Disposition Permit No. O Upt~
REV 077/20/201
11
rnM
Mt u'CC:7
=r y=. r rv ny 01
OATH OF S[;BSCMBItiG WIT~ESS(ZS~
C) w
REGISTER OF WILLS I- M
~ gym.
COUNTY, PENNSYWANL~,a
Estate of Deceased
(each) a subscribing witness to
(Print Names)
theAf Will ❑ Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and
say(s) that sh h they was / were present and saw the above Testator estatrix sign the same
and that she /(he/ they signed the same and that she /a they signed as a witness at the request of
the Testato / Testatrix in her his presence and in the presence of each other.
r
(Signature) (Signature)~
(Street Address) (Street Address)
'75 Z-L
(City, State, Zip) (City, Slate, Zip)
Executed in Register's Office Executed out of Register's Office
Sworn to or affirmed and subscribed Sworn to or affirmed and subscribed
befur me this day before me this day
of ( q All ! G of
r
Deputy for Register Mi is 'rotary Public
My Cori- ission Expires:
(Signature and Seal of Notary or other officia' cuai .e to
administer oaths. Shou date of expiration of Notary's Commission,.)
NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time or notarization.
Form RW-03 rev. !0./3.06
-ti
w rn
rn S n Co -a
OATH OF SLBSCMBENG W1T`ESS(B*-'-jt rn r\)
N
K Q Ca
REGISTER OF WILLS -C
i
COUNTY, PENNSYL.,VANLk M N - rn
Co o
Estate ofZ Deceased
1,2 /7//,
(each) a subscribing witness to
(Print Name/sJ
the Pill O Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and
say(s) that she he / they ~ were present and saw the above Testato / Testatr'x sign the same
and that she he / they signed the same and that rshe he / they signed as a witness at the request of
the Testator / estatri in er his presence and in the presence of each other.
l
(Signature)
natur J r r f Z)'q l~
(Street Address)
(Street Address)
(City, State, Zip) (City, State, Zip) 14
Executed in Register's Office Executed out of Register's Office
Sworn to or affirmed and subscribed Sworn to or affirmed and subscribed
befoye me thisc day before me this day
Of
f t , _ r13 of ,
Deputy for Register Of', li, s Not--r\' Pubiic
My Coni mission Expires:
(Signature and Sea! of Notary or other efri; ; unit. es to
administer oaths. Show date of expiration o: Notary's Commission.)
NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of notarization.
Form RW-03 rev. 10.
n w M
M C>
fA ^O r^ ~ C3
rn C7 G"1
W Sy. T - tU rrl P9
ax ~i11
~7 N f,- M
I, ASENATH M. HARTLINE, of the Borough t~F MoungHo~l 740n
Springs, Cumberland County, Pennsylvania, declare this to be
my last will, hereby revoking all prior wills and codicils made
by me.
DISTRIBUTION OF PROPERTY
I: I direct my executor to sell all of my property,
real and personal, at either public or private sale as he may
deem best.
II: I bequeath the sum of Ten Thousand ($10,000.00)
Dollars each to my grandchildren living at the time of my death,
if they shall attain the age of twenty-one years, with interest
therefrom in the meantime to be used by their guardian for their
health, maintenance, support and education; provided that such
legacy shall not vest in them unless and until they shall attain
the age of twenty-one years. If any of my grandchildren shall
predecease me or shall fail to attain the age of twenty-one years,
I declare that their legacy shall lapse and be distributed as a
part of my residuary estate. This bequest specifically includes,
but is not limited to, my presently living grandchildren, who
are Heather Ann Hartline and Jason Benjamin Hartline.
III: I bequeath the sum of Five Thousand ($5,000.00)
Dollars to my brother, Gilbert N. Myers, provided that not less Asenath M. Hartline
than Two Thousand ($2,000.00) Dollars of this legacy shall be
irrevocably dedicated and used to help defray the expense of
his funeral and burial. Should my brother predecease me, this
gift shall lapse and be distributed as a part of my residuary
estate.
DISTRIBUTION OF RESIDUE
IV: I direct that all taxes that may be assessed in
consequence of my death, together with interest and penalties
thereon, of whatever nature and by whatever jurisdiction imposed,
shall be paid from my residuary estate without apportionment as
a part of the expense of the administration of my estate.
V: I give the rest of my estate to my son, James W.
Hartline, if he survives me by thirty days. If he shall not so
survive me, I give the rest of my estate, per stirpes, to my
issue who survive me for a period of thirty days.
APPOINTMENT OF GUARDIAN OF ESTATES OF MINORS
VI: I appoint my executor as guardian of the estates
of minors with power to hold all property payable by law to a
guardian appointed by my will, and to use it for the minor's
health, maintenance, support and education, either directly or
by payment to any person selected by my executor to disburse
whose receipt shall be a complete acquittance. Guardian may,
in discharge of all the guardian's duties, pay any minors share
deemed impractical of administration to the parent or other person
in charge of the minor or to his or her guardian or to a custodian
c.~~► l ALI_
Asenath M. Hartline
for the minor under the Uniform Gifts to Minors Act. My executor
as guardian shall have the same powers as my executor, and shall
serve without bond.
APPOINTMENT OF EXECUTOR
VII: I appoint my son, James W. Hartline, executor of
my will. If he is unable or unwilling to qualify as executor,
or having qualified is unable or unwilling to act, I then appoint
my daughter-in-law, Kathryn A. Hartline as executrix hereof.
I direct that my executor or his successor shall not be required
to give bond of furnish security for the faithful performance
of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand this
~7Z day of z 1989.
-1 1/)A A
- C
N!,
Asenath M. Hartline
The preceding instrument, consisting of this and two
other typewritten pages identified by the signature of the tes-
tatrix, Asenath M. Hartline, was on the day and date thereof
signed, published and declared by Asenath M. Hartline, the tes-
tatrix 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 hereto.
ILI