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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: Roy Charles Atkinson File No:
a/k/a: _Roy C.Atkinson (Assigned by Register)
&Wa:
tea: Social Security No: 382-14-8104
Date of Death: September 21,2012 Age at death: 90
Decedent was domiciled at death in Cumberland County, Pennsylvania (State)with his/her last
principal residence at 18 Blue Mountain Vista,Unit 31,Mechanicsburg,Silver Spring Township Cumberland
Street address,Post Office and Zip Code City,Township or Borough County
Decedent died at Bridges At Bent Creek,Mechanicsburg,Silver Spring Township,Pennsylvania Cumberland 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 $ 40,000.00
If not domiciled in Pennsylvania. ....................... Personal property in Pennsylvania $ 000
If not domiciled in Pennsylvania. ....................... Personal property in County $ 0.00
Value of real estate in Pennsylvania......................................................... $ p_pp
TOTAL ESTIMATED VALUE. ... $ 40.000.00
Real estate in Pennsylvania situated at: n/a
(Attach additional sheets,if necessary.) Street address,Post Office and Zip Code City,Township or Borough County
21 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 August 14,2009 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.
Q NO EXCEPTIONS Q EXCEPTIONS
El B. Petition for Grant of Letters of Administration (If applicable) C^i m
c.t.a.,d.b.n.,d.b.n.c.t.a.,pendente Kil dDranteabsee ia, r�gminoritate
If Administration,ca.a. or db.n.c.t.a.,enter date of Will in Section A above and5nblptle lisFdf!h1&S
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds fa gv-e had be�jestabJishoPas defined
in 23 Pa.C.S.§3323(g)and was neither the victim of a killing nor ever adjudicated an incapacitated pe.)4A 7) C's c>
0 NO EXCEPTIONS O EXCEPTIONS i e; ZZ3 o'l
Petitioner(s),after a proper search has/have ascertained that Decedent left no Will and was survived by the fet. spouses(fjany)ind irs(attach
additional sheets,if necessary): r°
"Y7 CD
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
Patricia George Atkinson 18 Blue Mountain Vista Unti 3I Mechanicsburg,PA 17050
The Petitioner(s)above-named swear(s)or affirm(s)the statements in e-foregoing Petition are tfue and correct to the best of the knowledge and belief
of Petitioner(s)and that,as Personal Representative(s)of the Dece t,the Petitioner(s)will ell a rttl a minister the estate accordi to la .
r I
Sworn to rrmedn subscribed before } .
met is dj ' f c>7611_3 Date
By: Date
For the R ster Date
BOND Required: Q YES Q NO To the Register of Wills:
FEES: Please enter my appearance by my si uature below:
Lett rs.. . ... ..... .. . ........ S �V•t/V_ Attorney Sign re:
( )Short Certificate(s). .. . . .
( )Renunciation(s).. . . . . . . .
{ )Codicil(s). . .. . . .. . . . ..
{ )Affidavit(s).... . .. .. .. .
Bond..... ... .... .... . .. . . Pri ed ame: Taylor P.Andrews,Esq
Commission. . ....... . .. . ..... Sup me Court
Other , . . . . . ID Number: 15641
i 1( == . . . . . . i 510
c . . . ... . . 2- Firm
3.
Name: Andrews&Johnson
Address: 78 West Pomfret Street
Carlisle,PA 17013
. . . . Phone: 717-243-0123
Automation Fet. .. . . . .. .. . .. .. Fax: 717-243-0061
rt,e P _ Email: jpandrewc ,na net
TOTAL. ...... .... .. . ....... $ 0"Q(1
DECREE OF THE REGISTER / p
Estate of Roy Charles Atkinson File No: ! j 3" p
a/k/a:
AND NOW, 2((f�l } ,inconsideration of the foregoing Petition,
satisfactory proof having been presented before me,IT IS DECREED that Letters Testamentary
are hereby granted to Patricia George Atkinson
in the above estate and(if applicable)that
the instrument(s)dated
described in the Petition be aq9tted to probate and filed of record as the last Will(and Codicil(s))of Decedent. %
Register of Wi sUt/� —
Form Rw oz rev.10/11/2011 ngge 2
C10
�_; = m
ter
WILL
I, ROY CHARLES ATKINSON, of 18 Blue Mountain Vista, Unit 31, Mechanicsburg, _ 0) �
Cumberland County, Pennsylvania, 17050, declare this to be my last will and revoke anyvill
previously made by me.
Item One: I direct that all my debts and funeral expenses, including my gravemarker shall be
paid from my residuary estate as soon as practicable after my decease as a part of the expense of
the administration of my estate.
Item Two: I give, devise, and bequeath my entire estate to my wife Patricia George Atkinson
if she survives me by 60 days. In the event that my wife Patricia George Atkinson predeceases
me or is not then living on the 61st day after my death, then 1 give, devise, and bequeath my
entire estate to my son Jeffrey Hughes Atkinson, per stirpes.
Item Three: I appoint my wife Patricia George Atkinson, Executrix of this my last will.
Should my wife Patricia George Atkinson fail to qualify or cease to act as Executrix, I appoint
my son Jeffrey Hughes Atkinson to act as Executor with the same rights, powers, and duties.
Item Four: I appoint the wife of my son Jeffrey Hughes Atkinson, Rebecca Rosenlund
Atkinson, Guardian/Trustee of any property which passes to any person under the age of 21
years and with respect to which I am authorized to appoint a Guardian/Trustee and have not
otherwise specifically done so. Guardian/Trustee shall establish separate guardianship accounts
and shall have the power to use income from time to time for the beneficiary's education,
including technical and vocational training and graduate school, travel, support, and welfare
without regard to his or her parents' ability to provide for such education, travel, support, and
welfare, or to make payment for these purposes, without further responsibility, to the beneficiary
or to the beneficiary's parents or to any person taking care of the beneficiary. Guardian shall
administer the account until the beneficiary becomes 18 years of age, at which time the Guardian
shall transfer the principal and income remaining in the separate guardianship account to my
Trustee, being the same person as my designated Guardian, who shall then administer a trust
account, of both principal and income and any other funds transferred to the accounts designated,
for the beneficiary's education, including technical and vocational training and graduate school,
travel, support, health, and welfare. When the single guardianship or trust account is less than
$10,000.00 or the beneficiary of the separate trust becomes 21 years of age, the share of the
beneficiary remaining in the account shall be paid to the beneficiary in full and the guardianship
or trust terminated. In the event of the death of any beneficiary after my decease and prior to
reaching the age of 21 years, his or her share shall be distributed equally, share and share alike,
among his or her children, otherwise to my surviving children or child, per stirpes, equally, share
and share alike, to be administered in accordance with the guardianship and/or trust provisions.
Guardian and Trustee shall not be required to file accountings with any court. In the event that
any provision of this will shall be interpreted to violate the Rule Against Perpetuities, then the
remaining provisions of this will shall not be invalid. Trustee shall administer the trust and
dispose of assets so as not to violate the rule, making distribution as required to a life or lives in
being plus 21 years.
Item Five: All estate, inheritance, succession, and other taxes, imposed or payable by reason
of my death, and interest and penalties thereon, with respect to all property comprising my gross
estate for tax purposes, whether or not such property passes under this will, shall be paid out of
the principal of my residuary estate, without apportionment or right of reimbursement.
Item Six: I direct that my personal representative or guardian shall not be required to give
bond for the faithful performance of their duties in any jurisdiction.
Item Seven: In addition to the rights and powers given to the fiduciaries by law or elsewhere in
this will, I give to my Executor during the full time necessary for the administration of my estate
the following rights and powers to be exercised in his or her sole discretion.
A. To retain any real or personal property which may at any time form a part of my estate so
long as he or she deems it advisable.
B. To invest in any real or personal property without restrictions as to legal investments.
C. To repair, alter, improve or lease for any period of time any real or personal property and
to give options for leases.
D. To sell at public or private sale, for cash or credit, with or without security, to exchange
or to partition, to mortgage or pledge real or personal property, and to give options for
leases.
E. To make distribution in kind.
F. To compromise claims.
IN WITNESS WHEREOF, I have hereunto set my hand this day of August, 2009.
Signed --CLJ--)
ROY CHARLES ATKINSON
The preceding instrument, consisting of this and two other typewritten pages each identified by the
signature of the Testator was on the day and date thereof signed, published and declared by the
Testator therein named as and for his last will, in the presence of us,who at his request, in his
presence and in the presence of each other have subscribed o
;7s.
Va 5L4 U-4
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
We, John H. Broujos and t C a r� .�t c se ,witnesses whose names are signed to the
attached or foregoing instrument being duly qualified according to law, do depose and say that we
were present and saw the Testator sign and execute the instrument as his last will; that he signed
willingly and executed it as his free and voluntary act for the purposes therein expressed;that each
of us in the hearing and sight of the Testator signed the will as witnesses; and that to the best of our
knowledge, the Testator was at the time 18 or more years ge, sound and under no
constraint or undue influence. t
Sworn and subscribed to before
me this /�e day of August, 2009.
OMh tb lTc Q R"WYLVANIA
Notarial Seal
Wanda K.Hunter,Notary Public
Carlisle Boro,Cumberland County
MY Commission Expires May 1o,2o13
Member,Pennsylvania Association of Notaries
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
I, ROY CHARLES ATKINSON, whose name is signed to the attached document, having been duly
qualified according to law, do hereby acknowledge that I signed and executed the instrument as my
last will;that I signed it as my free and voluntary act for the purposes therein expressed.
ROY-CHARLES ATKINSON, Testator
Sworn and affirmed to and acknowledged
before me this day of August, 2009.
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Wanda K.Hunter,Notary Public
Carlisle Boro,Cumberland County
My Commission Expires May 10,2013
k-4Qmher.Pennsylvania Association of Notaries
H105.805 RGV(9/11)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00 I,,,ur "" -- This is to certify that the information here given is
QF pF�, correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
Z;w certificate will be forwarded to the State Vital
tic
°
v' Records Office for permanent filing.
a'
P 18 8 8 2 4 81 ,,wt- SO 21120��
Certification Number """"""""" Local Registrar Date Issued
t°Type/Print In COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS
Permanent CERTIFICATE OF DEATH Black Ink Stara File Number:
1.Decedent's Legal Name(First,Middle,Last,Suffix) 2,Sox 3.Social Security Number 4.pate of Death(Ma/Day/Yr}(Spelt Mo)
Ro C_ At7ci_nson M 382 14 8104 tember 21 2 12
5a.Age-Last Blrthday(Yrs) Sb.Under 1 Year 5c,Under 1 ba 6.Date of Birth(MO/Day/year)(Spell Month) 71.Birthplace(City and State or Foreign Country}
r Months Days Hours Minutes BG"3 C1'(= M1(:'Y11 a.17
1{ 90 Ma, 17 r 1922 17b.Birthplace(County)
8a.Residence(State ar Foreign Country) Bb.R.sidonca(Street and Number-Include Apt No.) at.Did Decedent Live 1,a Township?
PA CYYes,decedent lived in Silver cuT�rlP1cr twp.
Bd.Residence(County) 1 8 Blue Mountain Vista
CLnnberland 18e.Residence(Zip Code) 17050 ONO,decedent lived within limits of city/born.
9.Ever In US Armed Farces? ltl.Marital Status at Time of Death TO Married E3 Widowed 11.Surviving Spouse's Name{if wife,give name prior to first marriage)
Sa Yes 0 No 0 Unknown (�Divorced [3 Never Married E3 UnknownPatricia Gar
12.Father's Name(First,Middle,Last,Suffix) 1.3,Mother's Name Friar tO First Marriage(Fine,Middle,Last)
Clarence W. AtkirJ.scan Zoa Belle Hu 11e!s
14a.Informant's Name 14b.Relationship to 0e11dent I 14c.Informant's Malting Address(Street and Number,City,State,Zip Code)
Jeffrey H. Atkinson Son 314 78 Banf1� Court Ever e CO
......................................................... ....................................................15a.P ace
Or Dearn... ..ec on.Y one .. ..... .. ........ ...__. .._ ...._____
...... ..... ... ...... .__ _ ... ._....._ ...._...,..._.. ..__.
_ If Dsath Occurred in a Hospital: 'tom` inpatient - if Death Occurred Somewhere Other Than a Hospital; Hospice FacfHty Decedent's Homes
Emergency Room/Outpatient 0 Dead on Arrival Nursing Home/Long-Tar-Care Facility Other(Specify)
15b.Facility Name(if not institution,give street and nu-be,; •i5c.City or Town,State,and Zip Cod. 1Sd.County of 111,h
Bridges At Bent Creels Mechanicsburg, PA 17050 Ctunbarland
i 16a.Methqd of Disposition E] Burial [$Cremation 16b.Date of Disposition 1 161.Place of Disposition(Name of cemetery,Crematory,or other piece)
`a E3 Removal from State E3 Donation
Other(Specify) 9/22/2012 E za s Cremation Services
26d.Location of Disposition(City or Town,State,and Zip) 17s.SignaLUre of Fun.ra7 Service Ucensea in of Interment 174.License Number
Lee la, PA � . E D 01 2633 L
E 17c.Names and Complete Address of F ra
unei Facility
t3 Ekvin Brothers E'urxeral Home Sac. 630 S_ Hax°]_over St. r i le, PA
18.Oecede Vs 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
ti 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.
0 8th grade or less is Spanish/Hispanic/Latino. Check the"No" rMhIt. E3 Korean
E3 No diploma,9th-12th grade box if decedent Is not Spanish/Hispanic/Latino. O Black or African American E3 Vietnamese
E] High school graduate or GED completed 4,,3 TNo,Oat Spanish/hispanic/Latino 0 American Indian or Alaska Native 0 Other Asian
0 $o-a college credit,but na degree (- Yes,Mexican,Mexican American,Chicano E3 Asian Indian E3 Native Hawaiian
E3 Associate degree(e.g.AA,AS) 0 Yes,Puerto Rican 0 Chinese E3 Guamanian or Chamorra
J;3�1!11achelor's degree(e.g.BA,AS,BS) 13 Vas,Cuban 0 Filipino 0 Samoan
0 Masters degree(e.g.MA,MS,MEng,MEd,MSW,MBA) C'7 Yes,other Spanish/Hispanic/Latina 0 Japanese 0 Other Pacific islander
0 Doctorat.(e.g.PhD,Ed D)or Professional degree (Sp.cify) 0 Other(Specify)
005,OYM,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-Indicate type of work
g^OVhita 0 Japanese 0 Samoan done during most of working life. 00 NOT USE RETIRED.
E3 Black or African American 0 Korean 0 Other Pacific Islander
p Cl American Indian or Alaska Native 0 Vietnamese 0 Don't Know/Not Sur. (7eLTxtaL±n
= E3 Asian tndh- 0 Other Asian [�R.tus.d 22b Kind of Busyness/Indust y
E3 Chinese 0 Native Hawaiian 0 Other(Specify) C:)
0 Filipino 0 Guamanian or Ch.m.rro US N M C->
ITEMS 2Be-23d MUST BE COMPLETED 23a.pate Pronounced Dead(MO Day 123b.Signature of P.rson Pronouncing beat (On r,when gi/,all 23c. .N CD
BY PERSON WHO PRONOUNCES OR .7M•
CERTIFIES DEATH +1*-
23 bate ign.d(MO/0 y/Yr) 24.Ti of Death �•+�
! 25.Was Medical Examiner or Coroner GOntacted7 -Jz No
CAUSE OF DEATH xT t ryw�,at.
26.Part 1. Enter the chaln of events--diseases,injuries,or complications--that directly caused the death. 00 NOT enter terminal events such aC'.-M afr'e5t r-r) I • to 1:
respiratory arrest,ar vontn..I.r fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additIpmal lipe sp3ecessary . Onset,,B.,peath
IMMEDIATE CAUSE pr Z71.T.4-r g e-eg2ry e-4,-xz.. CVJ�+ ) p L+l.•0
______________..> a.
(Final disease ar condition Due to(ar as a conseq vence of): (y
resulting In death) e'-'"• �,:
Sequentiafly list conditions, Du.to(o as a consequence of): «�
If any,leading to the taus. "'^"- �} r,... M
UNDERLYING on line a. Enter the 1. z
UNDERLYING CAUSE Due to(o as a consequence af): -0
(disease or injury that y r 4!'
Initiated the events resulting d. r--'
In death)LAST. Due to(o as a consequence of):
�j 26.Part II. Enter other sianificanc cooAltigOs an I, tine to death but not resulting in the underlying cause given in Part I 27.Was autopsy p dorm ad?
a n Yes Ea2c
'a 28.Were autopsy findings.-liable
A to complete the taus.of death?
C3 Yes 0 No
� 29.if Female: 30.Did Tobacco Use Contribute to Death? 31.Mann er of bath
E3 Not pregnant within past year 0 Yes E3 Probably M Natural E3 Homicide
E3 Pregnant at time of death No E3 Unknown E3 Accident 0 Pending investigation
0 Nat pregnant,but pregnant within 42 days of death [] Suicide E3 Could not be determined
rS i- E3 Not pregnant,but pregnant 43 days to 1 year before death 132.Date of Injury(Ma/Day/Yr)(Spell Month)
M 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)
."i 36.Injury at Work 137.If Transportation Injury,Specify: 38.Describe How Injury Occurred:
0 Yes 0 Oriver/Operator E3 Pedestrian
v+V E3 No E3 Passenger E3 Other(Specify)
39a.CertIna,(Check Only one):
ertifying Rhysic'.O-Ta the best of my knowledge,death otcurrad due to the causes)and mann.r stated
0 Pro noun cing 'Certifying physician-To 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/COron.r-On the asis of.xa inatton,antl/Or Investigation,in my opinion,death occurred at the time,date,and place,and du.to the lease(5 Q^d7mdnnor stated
5lghatu re of Certifier. Title of certiFler: V"(� License Number��7 • /
396.Na ddress and Z p Code of Person Co-pi.ting C f Oath(item 25) 381.D to Signed(Mo/Day/Yr)
C �� T �'
40.ft.gtstrar's District Number 41.R.gistrar s.j t�'re 42.Registrar File Date{MO/Day r)
43.Amendments