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HomeMy WebLinkAbout03-26-13 f Reset PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF Cumberland COUNTY,PENNSYLVANIA C"> c M rn Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters as e0f ed bqlDw, a d l support thereof aver(s)the following and respectfully request(s)the grant of Letters in the appr l e hnn:� cry Decedents Information . _ Name: Kenneth W.Chase File No "� Q �} a/k/a: (Assigned b sr) &Wa: 1W 5t7847 Date of Death: February 26th,2013 Age at death: 42 rn Decedent was domiciled at death in Dauphin County, pa (state)with his/her last principal residence at 438 Water Street New Cumberland 17070 New Cumberland Cumberland County Street address,Post Office and Zip Code City,Township or Borough County Decedent died at Harrisburp,Hospital 17101 Harrisbura Dauphin Pa 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 $ 10,000.00 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. ... $ 10.000.00 Real estate in Pennsylvania situated at: none (Attach additional sheets,if necessary) Street address,Post Office and Zip Code City,Township or Borough County El 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 November 16,2005 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. 0 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,durante absentia,durante minoritate 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 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. 0 NO EXCEPTIONS a EXCEPTIONS I-)l ve r C J L. y_(d�-t r4 r-1 4 t L L.l,! s L( 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 Nancy B Stalker Mother 16 Warwick Circle Mechanicsbur2,Pa 17050 Beverly Beck Mother-in-law 9 Sunset Circle Mechanicsbur2.Pa 17050 Tracy Chase Sister 440 Youngchurch Road Shermansdale Pa Ashlee Chase niece 440 Youngschurch Road Shermansdale Pa 11•A N�. ( !-1 Ft Le N S t3,4 E R_ t N LP U-' h e ta. PP Form R W-02 rev. 10/11/2011 Page 1 of 2 Oath of Personal Representative Official Use Only COMMONWEALTH OF PENNSYLVANIA I SS: COUNTY OF Cumberland I C) Petitioner(s)Printed Name Petitioner(s)Pri2!2 .dress co : .- Nancy Barbara Stalker 16 Warwick Circle,Mechanicsburg Pa 17050 M r— rrf 2-1 The Petitioner(s)above-named swear(s)or affirm(s)the statements in the foregoing Petition are true and cor t to the best dfffie kif6,M e and belief of Petitioner(s)and that,as Personal Representative(s)of the Decedent,the Petitioner(s),will well and truly administer the 4t1te according to law. t Swom to or affi. ed an ubscribed before Date . h me 11s�da of Date By: Date )F e Register Date BOND Required: 0 YES 0 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). . . . . . . . . . . . . )Affidavit(s).. . . . . . . . . . . Bond.. . . . . . . . . . . . . . . . . . . . . . . Printed Name: Commission. . . . . .. . . . . . .. . . Supreme Court Other ID Number; Firm Name: Address: . . . . .. . Phone: Automation Fee. . . . . . . . . . .. . . Fax: JCS Fee. . . . . . . . . . . . . . . . .. . . . Email: TOTAL. . . . . . . . . .. . . . . . . ... . S DECREE OF THE REGISTER Estate of Kenneth W.Chase File No: 21- a/k/a: AND NOW, inconsideration of the foregoing Petition, satisfactory proof having been presented before me,IT IS'DECREED t1Jat Letters r fu LU are hereby granted to in the above estate and(if applicable)that the instrument(s)dated -z-C0 a described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s))of Decedent. Re V,1 ister of Wills C Form R W-02 rev. 1 0/1 112 01 1 Page 2 of 2 H105.805 REV(9/11) } - z 3 LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. RECORDED 0110E OF Fee for this certificate, $6.00 REGISTER C F 1,y ! I � ---- This is to certify that the information here given is 7 correctly copied from an original Certificate of Death X13 N 26 1 eC ��`� lG; duly filed with me as Local Registrar. The original 1P X1.3 _ z certificate will be forwarded to the State Vital cz -- a Records Office for permanent filing. CLERK OF r F 19474711 ORPHANS* COURT x,99 i CUMBERLAND C C• P A Registrar Local Date Issued Certification Number rype/Print in COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS Bv.�nn CERTIFICATE OF DEATH steteFgeNumber 1.DerxndenNs Legal Name(Nutt,Middle,Last,SuffM) 2.Sea 3.Soda)Saarky Number 4.Date of Death(h%/DaV/Yr)(SW Mo) Kenneth W. Chase Male 161 - 58 - 7847 February 26,2013 ss Age last Birthday 1YrsJ 15b.Under 1 Year ISc.under 1 Da 6.Date d Brth(MO/Day/Year)lspeR Month) 7a.Welrthplaee( and stet PorAF«elgrd Country) Months Dap urs Ho Minutes 42 July 20, 1970 17b.shnhplea(county) Wasbington- So.Residence(State or Foreyn Cow") cob.Residence(Street and Number-Include Apt No.) ac DW Decedent live In a Township? 1 d 438 Water Street ❑vas Meeden pwe b Pap• ad.Reddsrce(Conty) ,ag�" Ise.Aleutian.(cep trade) 17070 C3NO,deaden lived within Emits d New Cumberland y/y,,,. 9.Ever in US Armed Forces? 10.Marital status at Time of Death Married 0WIdowed 11.Surviving Spouse's Name(if wife,give name prior to test mart) s ❑Yes I$NO ❑unknown ®Divorced 13 Never Married ❑unknown ) 3 12..Fathm's Nam W�F Chase tat,Suffix) 13.Mother's Name Prior to Hrst:;nege(First,Middle,Last) t Nancy B. Stalker 140.bformmt's Name 114b.-Rdation ship to Decedent 14c.Informant's Mashy Addres(Street and Number,City.State,ZIP Code) NaZICY B. Stalker Mother 16 Warwick circle Mechanicsburg, PA 17050 IlDitchOonrtr�d'MiiHospinl:•.•...•.. °""""""'»""""'r sa..Des ...° .once «...... .«.... ` 7 P IN Death Omrrted Somewhere Other Than a Hospial: Maspke FatlRty •»a"Dicedat's Home a ®Energeery tlent Dead on A !j h N Nome/Long-Term Care Facility Other(speft ISb.Fs1lib'Name pf rot Institution,bite street and number) 15c.City or?own,State.and Zip Code 15d.County of Death Harrisburg Hospital Harrisburg,PA 17101 Dauphin 16a.Method of UNpoekbn gf Cremation 16b.Date d Disposition 161.Play of Did; ❑Ranoval from State Q Donation Pin(Name of cemsery,aematary,or other place) other(sv«If1) March 4 2013 Hollinqer crematory 16d.Location of Disposition(City«Town,State.and ep) 17a. or nee«Person In Charge of Inem*nt 17b.License Number Mt. Hall i PA 17065 FD - 014889 17c Name and C«nPlete Address Funeral Fadaty Mal zzi F12nera Home 8 Market Plaza Way csburg, PA 17055 16.Decedent's Education-Check the box that best describes the 19.Decedent d Hispanic Orkin-Check the 20.Decedent's Race-Chad ONE opt MORE rant to Indicate what 12 hill"degree or level d school completed at tin tone of death. box that best desctibs whether the decedent the decedent considered himself or herself to be. ❑ate grade«less IsSpanhshQBspank/Lathro.Check the"No" N White Q Konen ❑No dpbms,9th-12th grads box If decadent Is not spansh/Hls pank-Astino. Q 012&or Arian American ❑Vietnamese M High school graduate or GED dompteted 10 No,not SPadshA*swnkAatlno ❑American Indian or Alaska Native ❑other Aden ❑Son*coWge cue t,but no degree ❑Yes,Medan,Mexican American,Chan ❑Asian Indian 13A-d-degree k4•AA.AS) ❑Yes,Puerto Rican ❑Chinese ❑Native Hawabn 138-haws degree(e.g.BA,A6,al ❑Yes.Cuban ❑NMpino ❑Guamanian«Chamorro ❑Samoan Q Masters degree 104•MA,MS,MEng,MEd.MSW,hBA) ❑Yes,other Spanhh/HispankA tMo ❑Japanese ❑other Pacific isi nder ❑Doctorate 1e4.PhD.Edo)or Professional degree opec„y) ❑Other(specify) e.L MD m 21.Decedent's Style Rene Set'-DMp*tbn-Chad ONLY ONE to bdi me what the decadent considered himself,or herself to be.22s.Decedent':usual Occupation-bdlate two of work is White ❑Ppsnese ❑Samoan dare during most d working Eft.DO NOT USE RETIRED. ❑Black orAhkonAmerican ❑Koreea ❑Other Pacific blinder ❑AmeNan Indian or Alaska Native ❑Vietnamese ❑Don't Know/Not Sure Construction Wacker Q Aden Indian ❑Other Asian ❑Refused 22b.Kbd of Busk*spndustry, ❑Chinese ❑Native HawaEan Q other(specify) ❑"Apino Q Guamanpn or tlemorre Construction ITEMS 23e-Vid MUST BE COMPLETED 23a.Date Pronounced Dead 1 V r7213b.ignature of Person Pronourcry Death(Only when app)kable 231 llceme Number a conic PRONOUNCESoR February 26,2013 23d.Date signed[hW9V/Yr) 24. of ,/N-06:59 PM as Medial Examiner or Coroner contacted? ®Yes ❑ No ` CAUSE OF DEATH 26.Pact L Enter the I ADOroxi.coo -diseases,Injuries,or directly caused the death.DO NOT a for terminal events such as anBac arrest• i Interval: respiratory arrest,or veeMcular fibrillation without she the etiology.tilt'.00 NOT ABBREVIATE.Enter only one cause on a Ike.Add additional Imes N necessary� Onset to Death IMMEDIATE CAUSE , a.Probable Myocardial Infarction (Final disease or condition Due to(or as a consequence of): - i resulting In death) b. Sequentially an conditions. Due to or as a con i 3 N ant',lading to the Cause ( seguarKe 7 Rated on Ins,a.Enter the Dice S utimtvm CAUSE Due to(or as a consequence of): ' (disease or Injury that i Initiated the events resulting d. In death)LAST. Duerr(or = ( consequence d 26 Part E.Enter other LMAIMb but not resulting in the underlying cause given in Part 1 27.Was ee topq performed? Hypercholesterolemia,Cigarette Smoker 2>L Were❑eauopsYlkd19 No to complete the cause of death? Yes 13 No 29.if Femalr. 30.Did Tobacco Use CorraWrme to Death? 31.Manner of Death ❑Not pregnant uvMuio pest year ❑Yes M Probably ®Natural ❑NamRide Q Pngrta t at time of death ❑No ❑unknown ❑Accident ❑Pending Investigation ❑Not pregean,but program within 42 days of datt 13 Suicide ❑could not be determined n°- Q Not PnBnan.but Pngnan 43 days to I"or before daft 32.Date d Injury(Mo/Day/Yr)(Spell Month) ❑Unknown if pregnant within the post Year 33.Time of Injury E 34.Piece of Injury(e4,home;construction sin:farm;schod) 3S.Location of Injury($treat and Number.City,State,Zip Code) 3 36.ktjury at Work 37.R Transportation Injury,Specify: 38.Describe How Injuy Occurred: Q Yes ❑Driver/operator Q Pedestrian a Q No ❑Passenger Q Other(SP*dfYJ 39a.Certifier(Chad only ore): Q CertlMry physidan-To the best d occurred due to the couse(s)and mama stated ❑pronouncing a PhYdden knowledge,death occurred at the time,date,and prate,and due to the ousels)and mama state i M Medical ExamMer/Cer«er-On f and/or WNuft8tbn,in my opinion.death occurred at the time,date,and piece,and due to the com(s)and mama stated Sigeatun d axtlfler: TWO d certifier:Coroner License Number. 39b.Name,Adores and Zip Coded pletkg Cause of Death(Rem 26) 39c Dote Signed(Mo/Day/Yr) Graham S.Hetrick,1271 South 28th Street,Harrisburg,PA 17111 February 27,2013 40. s District Nu dw 41.Rqk s 42.Registrar Fie Date oey r) ai..J►la � 43.Ama dmw 0819599 HMS-143 Disposition Permit No REV 07/2011 2i-13-3�z cQ w M <*> M rn C-> IN t RENUNCIATION ' 71 CO71 M :.1 C> REGISTER OF WILLS (D `: F—, C k�mlan� COUNTY,PENNSYLVA c= C � U-1 Estate of I)-P v'-\n H Ck u n C C V\Q S e ,Deceased in my capacity/relationship as (Print Nam .i n - ` of the above Decedent,hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to (Date) (Signature) a Sin e� Cly-C1� (StreetAddress) e� a�iCs b u IiCDSn (City,State,Zip) Executed in Register's Office Executed out of Register's Office Sworn to or affirmed and subscribed Before the undersigned personally appeared the before me this day party executing this renunciation and certified of that he or she executed the renunciation for the purposes stated within on this V\A day of �.c c th , Deputy for Register of Wills Notary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) COMMONWEALTH OF PENNSYLVANIA Notarial seal Kathleen Susan May,Notary Public Farm RW-06 rev.10.13.06 Hampden TwP•,Cumberland County MY Gomm10011 Expires Oct.7,2014 MEMBER PENNSYLVANIA ASSMAT!(N(?F Mt1TAR1Fe Form RW 06-rev. 10-13-06-Renunciation- 3855 http://www.ccpa.net/DocumentCenter/Vew/3855 C__ Co rn RENUNCIATIONx �r Cf, , REGISTER OF WILLS ` `:" il M�WQUD COUNTY,PENNSYLVANIA w cn Cr) C) Estate of V_U\ar� Deceased 17 A, 4en2l in my capacity/relationship as (Print.Nramej S1 S4tr of the above Decedent,hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to h[OA S-�aQ -✓ (Date) (Signature) qqO �e� 6� s (cvv.Stata,zip) Executed in Register's Office f tce Executed out of Register's O,f, we Sworn to or affirmed and subscribed Before the undersigned personally appeared the before me this day party executing this renunciation and certified of that he or she executed the renunciation for the purposes stated within on this 15 day of M.ccX-c�%, � 'cl, 01 'zz-_ I -i lAurtTj Deputy for Register of Wills Notary Public My Commission Expires: (Signature and Seat of Notary or other official qualified to administer mssn)b U �O �SYT Notarial Seat Toni L.Schaertei,Notary Public Fairview Up.,York County MY Commission Expires Aug.30,2016 Form R TIC 06 rev.10.13.06 MEMBER,PENNSYLVANIA ASSOCIATION OF NOTARIES 1 of 1 3/5/2013 11:32 AM X 4 `"' M rn ca 7.0 � C->-a -. c:� cn -r C,> Va RENUNCIATION °�' �r AZ22 REGISTER OF WILLS �"" w w..� ;� &.rZ&o1 COUNTY,PENNSYLVAI'IA ;;;; � cr-1 Estate of &AlVeA �1 C C ,Deceased I, /1(nP_ �/J 4�i°�'J , 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 gvhle (Date) (Signature) �dr / kc (Street Address) '2 >, e A (City,State,Zip) Executed in Register's Office Executed out of Register's Office Sworn to or affirmed and subscribed Before the undersigned personally appeared the before me this day party executing this renunciation and certified of that he or she executed the renunciation for the purposes stated within on this day of �,cnLs C4- , 92.01 � J a, (F AAatt�- Deputy for Register of Wills Notary Public My Commission Expires: - /-JO/6 (Signature and Seat of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) -COLOVIONVVEALTH OF PENNSYLVANIA NOTARIAL SEAL Form RW-06 rev. 10.13.06 ALBERTA E.BRISCOE,Notary Public Upper Darby Twp.,Delaware County My Commission Expires May 21,2016 Form RW 06-rev. 10-13-06-Renunciation- 3855 http://www.ccpa.net/DocumentCenter/View/3855 rn Tn tea - RENUNCIATION .�-�+ �_�� �►„� � � r-- r,) Ys� 4.J� ►o"r.w REGISTER OF WILLS C.D rn���LAN COUNTY,PENNS,YLV NEJ �� _„ a e c-n 01 Estate of VNenr\t-4\ W 1 - Cl—w e, Deceased I, Agkjce, -O-WC in m y capacity/relationship (Print:'4Tame) as 1'1 t C-C P, of the above Decedent,hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to i i's (Date) (Signature) - `40 ` ov�� Chorch�i Qd (Street Address) (City,State,Ap) Executed in Register's Office Executed out of Register's O,f, we Sworn to or affirmed and subscribed Before the undersigned personally appeared the before me this day party executing this renunciation and certified of that he or she executed the renunciation for the purposes stated within on this day jfX,-t1 dam. Q.�4 Deputy for Register of Wills Notary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to adkninister oaths. Show date of expiration of Notary's Commission.) .QNWMTH OF PENNSYLVANIA Notarial Seal Toni L.Schaertel,Notary publk Falmlew Twp.,York County Form R l�'06 rev.10.13.06 My Commission Expires Aug.30,2016 MEMBER,PENNSYLVANIA ASSOCIATION OF NOTARIES 1 of 1 3/5/2013 11:30 AM low H105.805 REV(01/07) Zl-0- 342- LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. t: Fee for this certificate, $6.00 oV, This is to certify that the information here given is OF pF�; correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital a. Records Office for permanent filing. P 16461278 �P�11� .IMENT ? Certification Number ocal Registra Date Issued C= G"> `Q CA v r' ry rn M r z rr, cn ' Cf) c d C-> �✓.� +F M 3> '4 i 3 1 H105-143 REV 110M COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS TYPE PAW IN PERMANENT INK BIACI( CERTIFICATE OF DEATH (See instructions and examples on reverse) STATE FILE NUMBER a 18b Name a Decedent(First middle,test sulfa) 2 Sax 3.Soda)Security Nrxrber 4.Dam a Death(Mond1,day.year) ,cI)H N �Eck John F. Beck 144-22 - 3961 - 5 (O Age(Last Birthday) Urlder 1 Under 1 der 6.Date a Birth Monet, 7. and state« 6a.Place a Death One p tel: Other. I 0 Yrs. � �r'Ll�r I 3 1 .4. Wi1C�"Dd, NJ 1131kowt ❑ER/Di pebent ❑DOA ❑Nusing Home ❑Residence ❑Other-spar .County a Dam 11c.qty.Sao,Twp.a Death Sol.Facility Nacre(It not instina im give street and reinter) 9.Was Decedent a Hspenc Otgin' to Rece:American khdrn,Bhdc whim,Coe p,.a No El Cuffberland East Pennsboro Hot Spirit Hats ital l""°" " e�.) (White .D9dedrM'c Usual OW a work done ' most of cite Do not state 12.Was Decadent warn the 13.Decedent's Education($pacify only highest grade ocmphte� 1 Never Maned is.Surviving Space(q Wit.ghw maiden none) IGM of work Otis a ltraaises/khdetry U.S.Anted Faces? Widowad,Divaoad(Syredyj Elementary/SecaWary(0-12) Colop(1-4 or 5+) Warehouseman Computers El Yes C@ No 12 Married verly A. Johnston .DecedenPS Meting Addnesa(Street daty/town,state,zp Dods) Decedents Did Decoders r� [7'r,,.,,�Actual Residence 17a.state Pennsylvania Uve n a 17c.[%Yes,Decoders Lived in men T 9 Sunset Circle Tom, WP7d.❑No.Decades Lived witlwn Mechanics PA 17050 t7D c°'°"1' CL3n►berland AcualLknasa city/Sam .Formers Name(Prat node,last sul6x) 19.Mowers Name(Feat node,maden surname) k Frank J. Beck Rose St. John E i 20a rnlonrerwa Nerve RYPe/P" 20b.tnormanrs Maft Address(Street,city I own,slate.ZIP Code) Beverly A 9 Sunset Circle Mechanicsb PA 17050 21a.WOW of Dtapoption Cremation ❑ 21b.Dam a Disposition isposbon(Month,day.year) 21 c.Place a (N neacenaeloy.xelllatery afltflaPlecN 21d Location(Cfy/own.slate,zip cods) w ❑ Bair ❑ Pmnwat from Stem $Was Closet.a txretwn Aan,arta.d June 6 2010 Dugan DmW j C4 ❑ Omer- 'by Mescal Exiarrw/caan.r► Ya❑No r g Crematory Shippensburg, PA 22L stg oho a F SWAM LDcereee« acting as ooh) 22b Lioeea Nunher ?2a Name and Address at Facity 8 Market Plaza way I - I. FD-138630 Mal zzi Funeral Dome Mechanics b PA 17055 Contphw 23aa any whn 23a.To the beat a my ,death occurred at the time•dam and ptece atamd.(S gekn and title) 23b.License Number 23c.Dam Sigurd(Month.day,year) not ova" dMirla awe a loth Items 24.26 rust be compb6ed by person 24.Tams a Death /L,./� 21.Dam Pronounced Dead(Math,dry.year) 26.was Case Refereed to Medical Ecanhisr/Coroner for a Reason Other then Cranstian«Drxetiah? • who Praaanraoes seam ���/+a r) M. I,tJN 2-C)a'(� Yes ❑No CAUSE OF DEATH(See Instructions and examples) ,Approxnste intervat Pat k Enter o0er' 28.Did Tabs=Use Cordnbute to Dam? Ism 27.Part I:Endo the{gyp,of events-diseases,i iuriss,or aomplicaO«n-that directly caused the death.DO NOT enter terminal events such as cardiac arrest. Onset to Death but not mkd&V in the udolying cause given in Pan I. [--]yes ❑ i respiratory anes,or ventricular fibrillation withers S40MV due etiology.Let only Cob ease on each line �Proh�se�•v ^� El No L�l UNaawn = nn(Fiml)daese« 1ii�L i ' {' 29.1 Feanele: death } ' 1 a. Due to(or as a Dry: i ❑Na Mrsant within pat year �� ' ❑Pregnant at time a can rat Conhddtiae.r arty, b. a Enter 1M4DERL a' Due to(or as a mnagcsnce of): ❑Nor Wegrent but progntrt whuir,42 Jaya a dead, • events rewlbaq dam)LAST. Die o(«as a Consequence op: ❑Not Wagnnt but Wegant 43 days to I yea n before mod, x CL i ❑Udmown i pregnant W"sae peat year 30L Was an Autopsy Palamedt 3tld.Avadebb Prior Completion 31.Maurer a Death 32a.Date a Injury(Math,day,yeah 32b.Describe How Iryury Occurred 32c.�a I*ry.home.Farm,Stall•Factory. a cause a Dam? l' Newrat ❑fantod. erg.etc.(S°'°rt1 ❑Yes 1pl No C1 Yes ❑No / ❑ ❑Ps d'wg Invesbganan 32d.Tme a nNry 32e.Injuy Y WaK1 321.M Transportation hujury tSpedy) 32g.Location a injury(Street,city/town,slam) / ❑suicide ❑codd Na be Determined M ❑Yes ❑No ❑Odver/Opssor❑Paesager❑pedestrian Other.spasm Centibx(chock ah ) 33b.sigaaaa and rue of Cartier • CwWft physician(Phhymian cw*pw cam of dam when another physcan has Pronounced(loam and oanptemd Ism 23) To do bet of mylawrledpe,&MaxrssdduetotheawMs)a ndnennsras smmd---------------------------------❑ �� Mq ad corillift 0"Ichn(ftylocisir both pronouhdrg death and ar17y&q to cruse of death) 33R License Ncmber 33d Date Silted(Month.day.yeo) T0#0 bad ofmyhroohdye,doghocaawdatdo a.dit and pla m and due b the aws(s)and mannaas stud------------------ �+, MKkg ExaNrmNCamner ��4 Z(s S�S� Q E V�=2.t`)/© l On ft bash of exan"M and/or Irtwaplgatlon In my opbft%Beth ocetwed at the dme,dam,and place,and dw to de cores(,)and marre r a stdmL ❑ 34.Name and Address of Penaoq Who Compered Cayse a Damp/Pont 35. a SOali a and District 36.Date Wed Norm.day.yeah �+46 r l02 1 1 I o�l I I o J a �� ' n+ Jl; eA -Nit a DoosiWnPenmihNo. Qd7Cl712 Form RW-06-rev. 10-13-06-Renunciation-3122 http://www.ccpa.net/DocumentCenter/HomeNiew/3122 RENUNCIATION > ©, C� CIATION rn M = a-) Co M n cnrn REGISTER OF WILLS � r- r\) rtl r— rn COUNTY. PEN,, NSYLVANI co �k C) CD C W Ca 1 Estate of en 1)6 V\ Wa haw, Deceased L In r&�-5�,Ciii Illy capacity/relationship as �j e t,,vl of the above Decedelit, hereby renounce the right to administer the Estate of the Decedent and respectfidly request that Letters be issued to #Datel !Signature) 10,IQ I Ock 1 n.W-' iStreet Addressi Uw(�-LAnf-- n.6 43 001Y,Slate,Zid E.vecuted in Register's Office E.vectiled out of Register's Office Sworn to or affirined and subscribed Before the undersigned personally appeared the before iiie this day party executing this renunciation and certified of that he or she executed the renunciation for the purposes stated within on this 1 day of rn&AS—,'\A Deputy for Register of Wills Notary Public My Conumssion Expires: (Signature and Seal of Notary or other official qualified to NOTARIAL SEAL DON TRAUBE Notary Public LEMOYNE BOROUGH,CUMBERLAND COUNTY Form R117-06 rev. 10.13.0o My Commission Expires Jun 3,2013 1 1 of 2 3/8/2013 2:35 PM MMMOMMMMOW t"r''1 C-> 03 � ` M C-> -+ .y r- r tai r" RENUNCIATION � :3 . .- REGISTER OF WILLS COUNTY,PENNSYLVAk cn �n PIP cry Estate of ' ��7� Deceased I, in my capacity/relationship as (Print Name) of T 6i� WCZ-L— of the above Decedent,hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issue o 0 1 06A3 . (Date) (Signature) 7$19 -k"*Ut1CZoz& K0*0 (&reet Address) (City,State,Zip) Executed in Register's Office Executed out of Register's Office Sworn to or affirmed and subscribed .Before the undersigned personally appeared the before me this day, party executing this renunciation and certified of that he or she executed the renunciation for the purposes stated within on this ' day of l'h,,.-ek ao}3 . Deputy for Register of Wills Notary Public My Commission Expires: C fitlko ls' (signature and seal of Notary or other official qualified to administer oaths. show date of expiration of Notary`s Commission.) PEL Pq Michael Price NOTARY PUBLIC N°TARV Anne Arundel County Farm RW-06 rev.10.13.06 � 2 ` � State of Maryland My 6���l jonExpires i LAST WILL AND TESTAMENT rt r OF KENNETH W. CHASE r RJ cy w a- I, C I TH W. CHASE, of Etters, York County, Pennsylvania, being of sound CIZ c ardispon 'mind, memory and understanding, do hereby make, publish and declare C-I.N this as and for my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me. FIRST I direct the payment of my just debts and expenses of my last illness and funeral z from my estate as soon after my death as conveniently may be done. I direct my personal representative to provide for my funeral and the disposition of my remains in v accordance with my wishes I have made known to her, and I authorize her to expend funds from my estate, in such amount as she shall consider necessary and desirable for the purpose. SECOND I give, devise and bequeath all the rest, residue and remainder of my estate to my beloved wife, MARGARET R. CHASE, absolutely and in fee simple if she survives me by thirty (30) days. THIRD SAIDIS SNUFF, FLOWER In the event that my wife fails to survive me by thirty (30) days, then: & LINDSAY ATTORNEYS•AT•LAW A. I bequeath all my household goods, furniture, furnishings, vehicles and 2109 Market Street Camp Hill, PA personal effects according to a handwritten list made by me during my lifetime. In the absence of a list or designation on the list, then I bequeath such items in kind to my residuary beneficiaries named at paragraph C. of this item THIRD, • . f J and any such items not distributed in kind to my said beneficiaries may be sold by my personal representative and the proceeds added to the residue of my estate; B. I give the following pre-residuary legacies to the following persons, per capita: 1. To Joseph A. Beck, $5,000, in lieu of an executor's commission; and 2. To Ashlee Chase, Thomas Whalen, Timothy Whalen, Diana Whalen, Sean Whalen, Daniel Whalen, and Taylor Atkins, $5,000, each. C. All the rest, residue and remainder of my estate I give, devise and bequeath, in the following proportions, to the following persons who survive me. Provided, that the share of any beneficiary hereunder which would otherwise lapse as a result of the beneficiary having predeceased me shall be divided z among the surviving beneficiaries in the same proportions, one to another, as hereinafter set forth: 1. 25% to my mother, NANCY B. STALKER, of Mechanicsburg, PA; 2. 25% to my wife's parents, JOHN and BEVERLY BECK, of Mechanicsburg, PA, or the survivor or them; 3. 20% to JOSEPH A. BECK, of Cleveland, OH; SAIDIS SNUFF, FLOWER 4. 20% to TRACY CHASE; and & LINDSAY ATTORNEYS•AT•LAW 5. 10% to DIANE WHALEN. 2109 Market Street Camp Hill, PA 2 t FOURTH I direct that any and all inheritance, estate, and transfer taxes imposed upon my estate passing under this Will or otherwise shall be paid out of the principal of my residuary estate. FIFTH In addition to the powers conferred by law, I authorize any personal representative acting under this instrument, in her absolute discretion: A. To retain in the form received, or to sell either at public or private sale any real or personal property; B. To exercise any options to subscribe for stocks, bonds, or other investments; C. To join in any plan of lease, mortgage, consolidation, exchange, reorganization or foreclosure of any corporation in which my estate or any trust may hold stocks, bonds or other securities; D. To sell, transfer, convey, mortgage, pledge, lease or exchange any property, real or personal, which at any time may form part of my estate, for the payment of debts or taxes, or for any purpose of administration or distribution, for such prices and upon such terms as my personal representative, in her sole discretion, may deem wise, and to execute and deliver deeds of conveyance or SAIDIS SHUFF, FLOWER transfer thereof; & LINDSAY ATTORNEYS•AT.LAW E. To make settlements and compromises on such terms as my personal 2109 Market Street Camp Hill, PA representative in her sole discretion may deem wise without the necessity of obtaining any court approval thereof; 3 e F. To make distribution hereunder either in cash or kind, as my personal representative in her discretion may deem wise. SIXTH I do hereby nominate, constitute and appoint my wife, MARGARET R. CHASE, to act as Executrix of this my Last Will and Testament. Provided, however, that if she is unwilling or unable to act as Executrix, I direct the duties of Executor be performed by my brother-in-law, Joseph A. Beck. SEVENTH I direct that no personal representative, guardian, trustee or other fiduciary appointed under this instrument shall be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I, KENNETH W. CHASE, have hereunto set my hand and seal to this my Last Will and Testament, consisting of four (4) typewritten pages, the first three (3) of which bear my signature in the margin for identification, this day of /(V f , 2005. a&kC&6q W1 L" KENNETH W. CHASE Signed, sealed, published and declared by the above-named KENNETH W. CHASE, Testator, as and for his Last Will and Testament in the presence of us, who SAIDIS have hereunto subscribed our names at his request as witnesses thereto, in the SHUFF, FLOWER & LINDSAY presence of said Testator and of each other. ATTORNEYS•AT•LA W 21 Market Street ADDRESS tp Camp Hill, PA ADDRESS 1�1�d1� 4 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND We, KENNETH W. CHASE, 1"6"-2ffowx— and U, the Testator and witnesses, respectively whose names are signed to the foregoing or attached instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and Testament and that he signed willingly and that executed 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 witnesses and that to the best of their knowledge the Testator was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. K NETH W. CHASE Witness Witness Subscribed, sworn to and acknowledged before me by KENNETH W. CHASE, the Testator and subscribed town ,sworn or affirmed to beforp by dyes me and �J/j jAank— witnesses, this jjz�!�Aay of 2005. COMMONWEALTH OF PENNSYLVANIA Notarial Seal Sara J.Ensinger,Notary Ptbic otaryy 06-blfc Carlisle Boro,Cumberland county My Cwnis-�, Expires Oct.17,2009 Member,Pennsylvania Association of Notaries SAIDIS SHUFF, FLOWER & LINDSAY ATTORNEYSoAToLAW 2109 Market Street Camp Hill,PA 5