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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 r'
Name: Carolyn J Arrigo File No: 3C0 b
a/k/a: (Assigned by Register)
a/1,/a:
a/k/a: Social Security No: 167-38-2765
Date of Death: 02/16/2013 Age at death: 58
Decedent was domiciled at death in Cumberland County, Pennsylvania (state)with his/her last
principal residence at 238 West North Street Carlisle Cumberland
Street address,Post Office and Zip Code City,Township or Borough County
Decedent died at 238 West North Street Carlisle 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 $ 30,000.00
If not domiciled in Pennsy lvania. ....................... Personal property in Pennsylvania $
If not domiciled in Pennsy lvania. ....................... Personal property in County $
Value of real estate in Pennsylvania......................................................... $
TOTAL ESTIMATED VALUE. ... $ 30,000.00
Real estate in Pennsylvania situated at:
(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
Petitioner(s)aver(s)he/she/they is/are the Executor(s)named in the last Will of the Decedent,dated 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 apending
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,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.
Q NO EXCEPTIONS O 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): Cl) w
ZD
Name Relationship tmdgUess —0
Lori Lee Jakubs Daughter 818 14th Street,Apt I
Vir inia Beach VA 23454" ' m ►��
Phillip Arrigo Son 21640 Liberty Street, 180 (n
LeKinaton Park,MD 20 -0
o �
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¢ C7 r._,. rT7
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Form RW-O2 rev.10/11/2011 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
Lori Lee Jakubs 818 14th Street Apt.I
Virginia Beach,VA 23451
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 denti. rie(s)will wel d truly administer the estate according to law.
Sworn to or affirmed an subscribed before Date °
me day of l <� Date
By Data--,
For the Register Date- 'r
W
BOND Required: ® YES Q NO To the Register of Wills: ;:0 A r- 1'^ r,
FEES: Please enter my appearance by�s a ire below:
E
00 c s n -rt -
Letters . . . . . . . . .. . . . . . . . . .. . . $ Attorney Signature: -rt
O ) Short Certificate(s).. .. . . C t �, C)
( )Renunciation(s).. . . . . . . . = o r--
( ) Codicil(s). . . . . . .. . . . . . V - C/) Q
( )Affidavit(s).. . . . .. . .. . . N
Bond.. . . . . . . . . . . . . . . . .. . . . . . Printed Name: Mark A.Mateya
Commission. . . . . . . . . . . .. . . . . . Supreme Court
0 er ID Number: 78931
lv X . . . .. . . 1 C;.(
. . . . . . . . Firm Name: Mateya Law Firm
. . . . . . . . Address: 55 W.Church Avenue
. . .. . . Carlisle,PA 17013
. . .. . . Phone: 717-241-6500
Automation Fee. . . . . . . . . . . . . . . Fax: 717-241-3099
JCS Fee. . . . . . . . . . . . . . .. . . . . . Email: mam atPyalaw_rnm
TOTAL. . . . . . . . . . . . . . .. . . . . . $ '0 00
DECREE OF THE REGISTER
Estate of Carolyn J Arri¢o 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.10/11/2011 Page 2 of 2
14105.805 REV(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 R E C O R D E D 0 F F!C E 0 F This is to certify that the information here given is
REGISTER 0 F WILLS Lrttio�t�P�jN OF pFN'ytr correctly copied from an original Certificate of Death
ttttt oy` L` duly filed with me as Local Registrar. The original
13 APR 1 �� 1Q ? �t� certificate will be forwarded to the State Vital
U
J:,
a Records Office for permanent filing.
aW
P 19434446 CLERK0 °��q91 - -f�a~?�ttt fa . � '� ' FE 25/1013
HAMS COURT ---.MENTOE
Certification Number " '"„II Local Registrar Date Issued
CUMBERLAND CO., PA _ _
Type/Print In COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH•VITAL RECORDS
Permanent #2013-02-092
Black Ink CERTIFICATE OF DEATH State.Fig.N,.mber:
1-Detadem's Legal Name(First.M1dc11e,Last,SIMI) 2.Sax 3.-.1 Security Numbar q.pate of Da.M(MO/Dey/Y,)(Spell Mo)
Carolyn J Arrigo Female 167-38-2765 February 16,2013
5e,,Age-Last Blrthday(Yr.} j5b.Under 1 Year IS..Under 1 O.V
6.Data of Birth(Mb Day/Year)(Spell Month) 7s.Birthplace(City and States or Fpreis.Country)
i Months Days Houn Minutes
1 58 February 14, 1955 17b.Birthplace(County)
Ba.Residence(Stets or Foreign Country) Eb.Residence(Street and Number-Include Apt No.) Sc.Di Decedent L1,,In a Township?
PA 238 West North Street QYes,decedem ltv,d in
8tl.Residence(County)
ge.Residence(Zip Code) NO,decedent lived within limits of - Car11s1e nty/boro.
9.Ever in US Armed Forces? 10.Marital Seafus at Time of Oeatfi Q Married E3 Widow,d 11,Surviving Spouse's Nam,(it wife,give name prior to flrst marriage)
Q Yes Q No W3 Unknown QQ DFvorced Q Never Married Q Unknow
12.Father's Nam,(First,Mlddla,Last,Suffix) 13.Mother's Name Prigr to First Marriage(Frst,Middle,last)
Robert Diehl Lath WaicTamari
14a.Informant's Names 14 b.Relatlenship to Decedent 34c.Informant's Mailing Address(Street and Number,City,Siesta,21p Code)
Lori Lee Ja3cubs dau hter 818 14
-............... ..........._..... .:._.._......._......._.................. ,__-...se;.._a d..-.....-.Ot Other tt .............................stswa..._....._........._.._._........ .__............................... 51
_ If Death OcNrted loa Hospital: y Inpatlem Flf Death Occurted Somewhere Other Than a Hospital: Maw Facility �Decedent's Home
Emergency Room/OUtP;ulI nt. Q.Dead on Arrival i Nursing Home/Long-Term Care Facility Other(Sp7717M-
SSb_Facility Name(If not InsUtution.glue screet and number; 15c.City or Town,state,and Zip Code of Death
238 West North Street Carlisle PA 17013 rl nd
0
16-Method of Olspo.Rion Q Burial Cremation 16b.Data of-{-position 36c.Place of Oispesition(Name of camatery,cremes<ory,or pthcr plat,)
Q Remey.l from state o Dpnanpn - 25, 2013 Ho£fmari-Roth Funeral Home &
other(spaclry) Crematory
16d.Location of Disposition(City or Town,State,and Zip) 17 a. ignatu of Funeral Sarvica Li r Parson in Charyte of Interment 121b_License Number
Carlisle, PA 17013 ) 013144E
17c.Names and Complete Address of Funeral Facility -
u 18.Decedents Education-Check the box that best describes the 19.Dec,de of Hispan c Or gin-C the 2 . ecede ,-ChA M cat w at
highest degree or level of school completed at the time of death. box that best describes whether the decadent the decedent considered himself or herself to be.
Q 81h grade or less Is Spanish/Hispanlc/Latino-Check the'No. X1 White Q Korean
(3 No diploma,9th-12th grade box if decedent is not Spanish/Hispank/Latino. Q Black or African American E3 Vietnamese
1�) High school graduate or GEO completed No,not SPanlsh/Hispanic/taHno Q American Indian or Alaska Native Q Other Asian
Q Some college credit.but no degree Yes,Mexican,Mexican American,Chicano Q Asian Indian )3 Native Hawa6an
Q Associate dagra.(e.g.AA,AS) Q Yes,Puerto Rican [:3 Chinese )3 Guamanian or Chamoro
r
Q Bachelor's degree(e.g.BA,AB,BS) Q Yea,Cuban Q Filipino Q Samoan
Q Master's degree,(e.g.MA,MS,MEIN,MEd,MSW,MBA) E3 Yes,other Spanish/HispanicAL .no )3 Japanese E3 Other Patin.Islander
Q Doctorate(e.g.PhD,Edo)or Professional degree (Specify) Q Other(Seeclfy)
MO DOS DVM,LLB lD
21.Decedent's 5ingle Race Sel(-Designatf°n-Check ONLY ONE to Indicate What the decedent considered himself or herself W be. 22a.Decedent's Usual Oe Petlon-Indicate type of work
$j White Q Japanese Q Samoan done during most f working life. DO NOT USE RETIRED.
Q Black or African American Q Korean Q Other Pacific Islander He memake-r
Q American Indian or Alaska Native Q Vietnamese Q Don't Knew/Not Sure
Q Asian Indian Q Other Asian [:]Refused 22b.Kind of Busln,ss/Industry
Q Chinese Q Native Hawailan Q Other(SpeclfV)
Q FIIIPino Q Guamanian or Chamorro
Own Home
TfiMS SO-23tl MUST BE COMPLETE 23a.Date Pronounced Dead(MO ay r) 23 Signature o Person Pronouncing Death(Only when applicable) 23c Ucwnse Numb,r
BY PERSON WHO PRONOUNCES OR
CERTIFIES DEATH
23d.Data Signed(MO/Oay/Yr) 24.Time of Death
A rOlt. 1:00 A.M. 125.Was Medical Eaammer or Coroner Contacted? )oa Yes No
CAUSE OF DEATH i Approximate
26.Part,1. Enter the chain of events--diseases;injuries,or complications--that directly caused the death. DO NOT enter terminal events...h as cardiac arrest Interval:
respin tory arrest,I, ventricular fibriilatlon without showing the etiology. DO NOT ABBREVIATE.Enter only one cause on a line.Add add;tlo,al lines if necessary t Onset to Death
F
IMMEDIATE CAUSE ------------> a. Pending Investigation )
(Final disease or condition Due to(or as a consequences oil: [
resaltlng in death) €
Is.
Sequen Wly list contlRlens, Doe to(or as a ronsequ,nce of): €
If•ny,leading to the cause
Bstaci on line a. Enter the
UNDERLYfNG CAUSE Due to for as a consequence of): I
(disaase or Injury that
Initiated the events resulting d.
c In death)..�. ) Due to(or as a consequence on:
26.Part 11_Enter other f Hint t onditi n h but not resulting in the underlying cause given In Part I 27.Was an sutopsy performed?
S
Yea No
_ 26.Wareautopsy s able
to<Vmp/eM he cause d,I dearth?
Yes m No
29.If Female: 30.Oitl Tobatto Use Contributes to Death? 31.Manner of Death
e r3 Not pregnant wthin past year Q Yes )7 Probably 0 Natural
Q Pregnant at time of death Q No O�Unknown Q H ending I
Not Pregnant,but Within 42 days of death Q Accident )� pending InvesUgaHen
Q gnan Q Suicide Q Could not be detarmined
Q Not pregnant,but pregnant 43 days to 1 Year before dealt 32.Date of Injury(Mo/Day r)(Spell Month)
G3 Unknown if pregnant within the past year J...Time of Injury
34.Place of Injury Wa.home;...structfon site;farm;school) 35.Location of Injury(Street and Number,Cfty,State,Zip Code)
36.Injury at Work 137'11 Transpertatlon Injury,Specify: 38.Describe How Injury Occurred:
1:3 Yes Q Driver/Operat- 0 Pedestrian
13 No Q Passenger Q Other(SPellfy)
398.CeniRer(Check only one):
Q Carttfying physician-To the best of my knowledge,death ecc red due to the causaW and manner stated
Q Pronouncing.6 Certiying physician-TO the best of my knowledge,death occurred at the time,date,and place,and due to the cause(.)and manner stated
EM Medical Exami...) Invertigatton,in my opinion,death otturred at the time,date,and place,and due tp the ca'use(sj and manner stated
Signature of certiflc/L Title of_In_Coroner
License Number.
39b"Name,Address and Zip Code of Person Completing Cause of Death(Item 26) 39c Date Signed(MO/Day/Yr)
Charles E.Hall Coroner 6375 Basehom Road,SUite 1,Mechanicsburg,PA 17050 February 19,2013 °
40.Registrar's District Number 41.Registrar's SIr ,Me ,_� 42.Registrar Ie Date ay
43.Amendments
� ' Hi05-143
Dispositbn Permit No" �( J ti REV 07/2011
RECORDED RED OFFICE OF
IECC1STL OF WILLS
RENUNCIATION 'b i3 APR 1 619 Q 92
REGISTER OF WILLS CLE G1
CUMBERLAND . COUNTY, PENNS ANS' COURT
YIO
LAND CO., PA
Estate of Carolyn I Arrigo , Deceased
I, Phillip Arrigo , in my capacity/relationship as
(Print Name)
son of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
Lori Lee Jakubs
326//3
(Date) ignatur
(Street Address)
(city,Sl ,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
X/ A a
Deputy for Register of Wills Notar34Public
My Commission Expires:Seq+ewbe4—\, t3
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
ANGELA D.HOLLAND
Form RW-06 rev.10.13.06 NOTARY PUBLIC STATE OF MARYLAND
My Commission Expires September 1,2013