Loading...
HomeMy WebLinkAbout03-06-13~ [`- !dJ ~ CV ~ ~ r--t F-- U ~ ~ 4 t.t... La.. E ' ® ® U C~ O L1._ U 4 ~ ~ ~ ~ z PETITION FOR GRA~1T OF LETTERS try <t ,~ k.... REGIS~I~O~VVILLS OF COUNTY, PENNSYLVANIA ~ ~ ~ v Q Q- `"' op Peti>don~s) l~Zmed bel~v,~~ho isiare 18 years of age or older, apply(ies) for Letters as specified belo~~. and in sup~t4~erea`~3ver(s) the Bowing and respectfully requests j the grant of Letters in the appropriate form: ~~ Decedent's Information Name: _ Y! Y! ~'L . ~~ // File No: 1 ~ - ~3 ~ ~ 7! a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: / y'~ - ~ O --~ /~ ~~ Date of Death: 02 oZ ~ o~ 4 / Age at death: ~~ Decedent was domiciled at death in _ ~u yt rpr/amount , /~ (Srare> with his/ e ast / 7 X70 principal residence at ~~ / ~' ,~ / ~ ~~r r /sic ~/ /j~ Street address, Post Offic and Zip Code City, Township or Borough County Decedent died at ~ c'S ~~~~ i ~ 't j~ ,~ /~,r~> 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 Pennsy!vania ............................ All personal property $ ~ O(!r oU U If not domiciled in Pennsy!vania ........................ Personal property in Pennsylvania $ If not domiciled in Pennsylvania ........................ Personal property in County $ Value of real estate in Pennsy!vania ............................. ........................... $ TOTAL ESTIMATED VALUE.... $ O d. U U G / Real estate in Pennsylvania situated at: /.S~G /~' /'t /~ ~,/ ~GK a~ ~ ~ y~~~u~ (Attach additional sheets, ijnecessary.) Street address, Post Office nd Zip Code City, wnship or Borough County Petition for Probate and Grant of Letters Testamentary '~~ ~ 7 °ZG~ Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated and odicil(s) thereto dated State relevant circumstances (eg. renunciatioie, death ojexecutor, 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 adopt ,and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. NO EXCEPTIONS ^ EXCEPTIONS c ^ 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 aba•entiu, durance 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 23 Pa. C.S. § 3323(8) 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 fallowing spouse (if any) and heirs (attach aclclitionul sheets, if necessury): Name elationshi Address ~'~ ' Sort ~ ~. t!~ r ~n ~ cam/ ~ k ~ a /t d ~- ~/ d n Form RW-t12 rev. !0/l1/1All `~/ Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF } } SS: } Official U~Only ~~ . ~ moo w m~ ~~ ~ ~~ ~ ~ ~ ~ ys t"` ~ ~ ~ " ~ ,,, ~ t . _ -~r„ Petitioner(s) Printed Name Petitioner(s) Printed r cV ~ K~ ~ ~ /a ~ ~ a `~ ~. O! 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 ,the Petitione (s ill well and truly administer the estate according to law. Sworn to or affirmed an subscribed before Date G oav me day of ~ Date y: - Date For the Register Date BOND Required: Q YES Q NO FEES: Lett r ..................... $ ~WQ ` ~ ~ ( ~~) Short Certificate(s)...... - Q6 ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . O h r ....... Cif !...... © a Automation Fee . .............. - O ~ JCS Fee . ................... . TOTAL ..................... $ -~--$-A9- To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature: Printed Name: Supreme Court ID Number: Firm Name: Address: ~~~ ~~ DECREE OF THE REGISTER Estate of // /~ ~ ~ File No: ~~ _ ~~ ~ ~ 7 / a/k/a: AND NOW, /~~ji''G fy ~p ~~~~ , in con, ' ation of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that L ters G5 rl7G'~ /'` are hereby granted to ~a(/~~ S G L L in the above estate and (if applicable) that the instrument(s) dated D ~ 04 described in the Petition be admitted to probate and filed of reco d the last Will nd Codicil(s)) of Decedent. Register of Wills ~j Form RW-02 rev. 10/11/2011 " Page 2 of 2 H 105.8 REV (9/,1 J,~ M ~ ~ p LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. RECaR0E0 0~`F~C~ 0~` Fee for this certificate, $6. This is to certify that the information here given is ~G1ST>~R 0~' ; L~.S correctly copied from an original Certificate of Death ~~~~ ~~~ ,~ ~ duly filed with me as Local Registrar. The original b ~~ ~ ~~' certificate will be forwarded to the State Vital (/~{ Records Office for p rmanent filing. F~ 193987 s• c ~~ A o~ ~3 QiJ~T Certification Nu~~~1~BFRLl4RD ~~., ~~ Local Registrar Date Issued Type/Print In COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS Permanent CERTIFICATE OF DEATH _____ _.._ _._____.___ ^_ ~ u Z 1. Decedent's legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Yr) (Spell Mo) Ann M. Be11 Female ~ 9 Z - 3 U - ~ Q'¢ Z Fabruar 28 2013 Sa. Age-Last Birthday (Yrs) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (Mo/O ay/Year) (Spell Month) 7a. Birthplace (City and State or Foreign Country) Months Days Hours Minutes Freeland PA O Au ust 29 1922 7b. Birthplace (County) Luzarne 8a. Residence (State or Foreign Country) 8b. Residence (Street and Number -Include Apt No.) Sc. Did Decedent Live in a Township? Pen va is D Yes, decedent IiVed in twp. 8d. Residence (County) 1501 Sim son Farr Road Cumberland 8e. Residence (Zip Code) ($ No, decedent IIVed within limits of NeW Cumberland ctty/boro. 9. Ever in US Armed ForcesT 10. Marital Status at Time of Death ~ Married ~[ Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) Q Ves ~ No Q Unknown Q Divorced ~ Never Married Q Unknown 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last) in east Mello Catherine O'Donnell 14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code) o David J. Bell Son 430 Allendale Wa Cam Hi11, PA 17011 C _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 15a_P ace o_ Deat C ec_ on done _ _ _ _ _ _ oc _ _ _ If Death Occurred Ina Hospital: d Inpatient 1 if Death Occurred Somewhere Other Than a Hospital: d Hospice Facility ~[] Decedent's Home ° Q Emergency Room/Outpatient Q Dead on Arrlvat 1 ursing~Home/Long-Term Care Facility O Other (Specify) 15 b. Facility Name (If no institution, five street and number) 15c. City or Town, State, and Zip Code SSd. County of Death Z M : c i6a. Method of Disposition Burial Cremation 16b. Date of Disposition 16c. Place of Disp ton (Name of cemetery, crematory, or other place) p Removal from State O Donation - Q Other (Specify) March 4 2013 Gate of Heaven Cemeter Z 16d. Location of Disposition (City or Town, State, and Zip) 17a. Signature u al Service Licensee or Person In Charge of Interment 17b. License Number ~ U er Allen TW PA 17055 FS 012 849 L E 17c. Name and Complete Address of Funeral Facility . 8 Parthemore FH&CS. Inc. PO Box 431 New berland PA 17070-0431 r~ 18. 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 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. (~ 8th grade or less is Spanish/Hispanic/Latino. Check the "No" ~ White Q Korean Q No diploma, 9th - 12th grade box If decedent is not Spanish/Hispanic/Latino. Q Black or African American Q Vietnamese Q High school graduate or GED completed ~ No, not Spanish/Hispanic/Latino Q American Indian or Alaska Native Q Other Asian Q Some college credit, but no degree Q Ves, Mexican, Mexican American, Chicano Q Asian Indian Q Native Hawaiian ~ Associate degree (e.g. AA, AS) Q Yes, Puerto Rican ~ Chinese Q Guamanian or Chamorro Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban p Filipino O Samoan Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) ~ Yes, other Spanish/Hispanic/Latino ~ Japanese D Other Pacific Islander D Doctorate (e,g. PhD, EdD) or Professional degree (Specify) D Other (Specify) e. MD DDS DVM LLB JD 21. Decedent's Single Race Self-Designation -Cheek ONLY ONE to Indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation -Indicate type of work QJ White Q Japanese D Samoan done during most of working life. DO NOT USE RtTIREO. Q Black or African American Q Korean D Other Pacific Islander Q AmerlcanlndianorAlaskaNatiVe ~ Vietnamese O Don't Know/NOtSUre Ra isterad Nurse ~ Asian Indian Q Other Asian Q Refused 22b. Kind of Business/Industry p Chinese O Native Hawaiian ~ Other (Specify) p Fiilplno ~ Guamanian or Chamorro Health =assurance ITEMS 3a - 23d MUST BE COMPLETED BV PERSON WHO PRONOUNCES OR 23a. Date Pronounced Dead (MO/Day/Vr) ~ 1 S J 23 .Signature of Person Pronouncing Death (Only when applicable) 23c. License Num er CERTIFIES DEATH ol ~~3 p `t ~ Q~~ ' 2 Date Signed (Mo. (Qay/Vr) 24. Time of Death ~ lV F `rn 25. Was Medical E finer or Coroner Contacted? Q Yes No CAUSE OF DEATH ~ Approximate 26. Part 1. Enter the Shain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, , Interval: respiratory arrest, or Ventricular fibrillation without showing the etiology- DO NOT ABBREVI ATE. Enter only one ca use on a line. Add additional lines if necessary. 1 Onset to Death / , -----> a. ~~'t12~ ~ l~lA L y L2.$ICft, t /t 1L° 1~L' G' i'Or E'I+- ~i~ ~ IMMEDIATE CAUSE -------- (Final disease or condition Due to (or as a consequence of): I resulting in death) i I b. t Sequentially list conditions, Due to (or as a consequence of): , if any, leading to the cause I listed on line a. Enter the c. ~-_--- I ~ I UNDERLYING CAUSE Due to (or as a consequence of): ~ c (disease or injury that I ~ initiated the events resulting d. I In death) LAST. Due to (or as a consequence of): ~ 26. Part 11. Enter other slanificant conditions contributing to death but not resulting In the underlying cause given in Part 1. 27. Was an autopsy performed? e5 ~ ~x~~ D Yes ~ No ~ ~ ~ r~' 28. Were autopsy findings available m - ~ to complete the cause of death? ~, Q Yes ~ No .91 29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death (~, Not pregnant within past year O Yes Q Probably jd] Natural O Homicide p Pregnant at time of death O No ~ Unknown O Accident p Pending Investigation r~ 0 Not pregnant, but pregnant within 42 days of death p Suicide p Could not be determined ~ Q Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Vr) (Spell Month) ~ Unknown if pregnant within the past year 33. Time of Injury 34. Place of Injury (e.g. fiome; construction site; farm; school) 3S. Location of Injury (Street and Number, City, County, State, Ztp Code) 36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred: Q Yes p Driver/Operator Q Pedestrian L~`No Q Passenger O Other (Specify) 39a. Certifier -physician, certified nurse practitioner, medical examiner/coroner (Check only one): Certifying only - To the best of my knowledge, death occurred due to the cause(s) and manner stated. . D Pronouncing 8a Certifying - To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated. occurred at the time, date, and place, and due to the ca USe(s) and manner stated. tion and/or investigation, in my opinion, deat h Q Medical Examiner/Cor er - On the ba sis of e xa m i na o n n ~ / ~ /~ ~ ~~ A ~ ` ~ ~ Signature of certifier: Y VI~LI~[i~ ~WY^r--- Title of certifier: KJ t ~ • license Number: Cho ~ ~~L 39b. Name, Address and Zlp Code of Person Completing Cause of Death (Item 26) 39c. Date Signed (Mo/Day/Vr) jrNlC411~9L S>'4f'hf.' >, 7~.U. 7 DO i+Nl-4- t4~~lE'~ t'lyt~/v~ lM1sc6. -es b~++eti '~ 61e(~.t 88' 2e / S 40. Registrar s District Number / 41. Registra nature y y ~ 42. Registrar Flle Date Mo Day r) ) ~~ tJf ~ / / / G OJ7~ ~~ 43. Amendments Disposition Permit No. O L7 155(0 ( H305-143 REV 07/2012 s c °--~ ~ `,~' ~ ~~~ rn ~ ~ ~ m cy Q ~ _ ~vy .r ~r~ a2~ U ' cT, ~~ ~ . ~ ~ o~ ~~~ LAST WILL AND TESTAMENT ~ ~ -~ =~ ~;, ,: --3 ~ , ~..,.. O F ~ ~ ~ -r~ ANN M. BELL I, ANN M. BELL of 1501 Simpson Ferry Road, New Cumberland, Pennsylvania 17070, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking all other Wills and Codicils previously made by me. ITEM I: I direct that payment of all my just debts, expenses of my last illness, funeral expenses, and the costs of administering my estate from my estate as soon after my death as conveniently may be done. ITEM II: I give, devise and bequeath all of the rest, residue and remainder of my estate, of every nature and wherever situate, together with all insurance policies thereon, to go in six equal shares as follows: One share to each David J. Bell, Mary C. Bell, Jean M. Bell, Margaret M. Woodward and Robert Bell, who are my children and in the event any of them are not then living then his or her share to go then to my surviving said children. The sixth and last share to be divided equally among my following named grandchildren then living to wit: Christopher Bell, Doreen Sgrinia, Eric Thomas, Michelle Ripple, Gregory Thomas, Nathan Bell and Robbie (Robert Bertram) Bell. ITEM III: I hereby appoint said David J. Bell as sole a ~(~ executor and in the event he refuses or unable to act for any reason then said Mary C. Bell to be sole executor. ITEM IV: All shares of principal and income hereby given shall be free from anticipation, assignment, pledge or obligation of the beneficiaries of any of them and shall not be subject to any execution or attachment, levy or sequestration or other claims of the creditors of said beneficiaries or any of them. ITEM V: No anatomical gifts (organ donations), no autopsy, and no cremation. IN WITNESS WHEREOF, I, Ann M. Bell, have, to this my Last Will and Testament, set my hand this ~~day of ~~O.d.,~ Y` 2 0 ( SEAL ) Ann M. Bell Signed, sealed, published and declared by Ann M. Bell, the above named Testatrix on the day of 20 as for her Last Will and Testament, in the presence of us, who, in her presence, and in the presence of each other, have, at her request, subscribed our names as witnesses hereto. C residing at ~~ ~ ~i'I Name _Q.~L.~, re s idin at ~ ~,~-2-• Name COMMONWEALTH OF PENNSYLVANIA :SS COUNTY OF CUMBERLAND WE, the undersigned, the Testatrix and the witnesses, respectively, whose names are signed to the foregoing instrument, being first duly sworn and qualified according to law, do hereby declare to the undersigned authority that we were present and saw the Testatrix sign and execute the instrument as her Will, and that she had signed willingly 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 witnesses and that to the best of their knowledge, the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence, and I, the said Testatrix, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament, that I signed it willingly, and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn to and subscribed before me this a2 day of c7'QB~~- , 2 0 0 ~" Not ry Public My Commission Expires : ~F~-~ls ~9,~-ao °~ { - ,, _ ,'. ; ,~ ;s l:..~~~;:;;~_-,..; ' _~~;1~rENI~ISYLVANIA"~ itiU(~;iAL SQL Robert E. Myers, h~;ury Public Fairview Twp. York County Comrr~ssion Expires Jan. 19, 2009 ~~ TP~tatri x^