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PETITI4N FOR GRANT U�'LETTERS
REGISTER OF WII.LS OF CV KC`�t 'c;,, lr�p»t'J� COUNTY,PENNSYLVANIA
Petitioner(s) narned below, who is/are 18 years of age or older, apply(ies) far Letters as specified below, and in
support thereof aver(s}the foilawing and respectfu]ly request(s}the grant of Letters in the appropriate farm:
Decedent's Infarmation
�� ✓� - n
Name: �`J E T"[`�. C.. ��2t��.$ Fiie No: � ��'�f�
a1k/a: (Assigned by Register}
aJk1a:
a/k/a: Social Security No: ,Q►7.. -"1,�,,--rjl!�3
Date of Death:��►r}�.t`r+b�t"' r"..�" i�.'�13 Age at death: �U
Decedent was domiciled at death in �.V 1� Count , )
y - '�V`�'ay�v"�'S11Z,► (State with his/her last
principal residence at 3 �G • �. 1 �W � �����
Street address,Post Oftice and Zip Code City,Township or Barough County
Decedent died at � t CSL �'1 �1.+� . , �-� �7 �l�
Street address,Past Office and Zip Code City,Township or Borough County State
Estimate af value of decedent's property at death:
If domiciled in Pennsylvania............................ All personal praperty $ �, �,(3,.."'�
If not domiciled in Pennsylvania. ....................... Personal properky in Pennsylvania $�—�
If not domicited in Fennsylvania. ....................... Personal praperty in County $
Value af real estate in Pennsy[vania......................................................... $
TfITAL ESTIMATED VALIIE. ... ��-C'Z CX".B.Q4
Real estate in Pennsylvania situated at: 'r►Or'�,�
(Anach additional sheets,if necessary.) Street address,Post Office and Zig Code City,Township or Boroagh County
� A. Petition for Probate and Grant of Letters Testamentary �C���
Patitioner{s}aver heJsheithey islare the Executar{s}named in the last Will of the Decedent,dated �CC.�'ri�C' and Codicil{s}
thereto dated ��C��C'c3 W • �l.Ck-�9.f' �� i�2.C.P_f"1�ti.lr�st' L�{ . a-CX']�
State relevant circumstances{e.g.renunciation,death af executor,ete.)
Except as follows:after the execution afthe instrument(s}offered for probate Decedent did not masry,was not divorced,was nat a party to a pending
divorce proceeding wherein the grounds far divarce had been established as defined in 23 Pa.C.S.§3323(g},and did nat have a chitd barn or
adopted;and Decedent was neithcr the victim of a killing nor evar adjudicated an incapacitated person.
�No�XCE�r�o�vs ��xc�PTta�vS
� B. Petition for Graut of Letters of Administration {Ifappticabie)
c.t.a.,d.b.n.,d.b.n.c.t.a.,pendente lite,durante absentia,durante minoritate
If Administration,c.t.a.or dh,rt.c.xa.,enter date of Will in Section A above and�m,�plete list�of h��rs;.''
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds fo�ive�e had been estabjished,as definefl
in 23 Pa.C.S.§3323(g}and was neither the victirn of a killing nor ever adjudicated an incapacitated pe}'9@n� �,, �
�J �. �'" '
�NO EXCEPTIONS �EXCEPTIUNS r— �; , � ;;
Petitioner{s},after a groper search haslhave ascertained that Decedent lett na W il l and was survived by the�ia�tg�spause(i�any}and heirs(attach
additional sheets,if necessary): '��° �:'=
;��� t � __..,_,
�„ ._...
Name Relationshi e�dd�ess r�-'
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Fa�n�v-�z r�.roir�i.zolr Page 1 af 2
Oath af Persanal Representative at�f����v�e on�y
CQMMONWEALTH OF PENNSYLVANIA } � `
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} SS: � _...
COUNTY tJF } �,��° �
�.' ...
Peritioner{s}Printed Name Petitianer{s}Printed t�ddi'�ss.-,,. ?�- '
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The Petitioner(s)abave-named swear(s)or affirm(s)the statements in the foregoing Petition are true and conect to the best of the knowledge and belief
of Petitianer(s}and that,as Personai Representative(s)af the De t„the Petit' er(s)wi well and truly administer the estaze according a law.
Sworn to or affirmed and subscr' ed before ����-- �° �f ���.—.--�.,�,Y , . Date � / f�
TTle t �S � {�c� t} �� � Date
By: Date
` For rhe Regisrer DatC
$OND Reyuire . Q NO To the Register of Wilts:
FEES: Please enter my appearance by my signature below:
Letters. ... ... . ..... . . . . ... . . $ �.� Attorney Signature:
( 'a� ) Short Certificate(s)... . . . ����"�
{ }Renunciatian(s}........ . �,,,.���-�—�� �.« ��ry ,��,, Q,,�
( )Codicil(s). . . . . . . . . . .. . � ed1,.� . \�►1J��.
{ }Affidavit{s}.. . .. ..... ..
Bond... . . ... .. . . .. .. . ... . ... Printed Name: �{1'C1 � ���.�
Cornmissian. . . . . . . . .. . . ... .. . Supreme Caurt
O be ..... . ID Number: ��'1�D� �
I ` p 5-�J
� !�-�.. �{ Firm Name: k.. �
r . .. ... .. i�•. TrJ Address: . l'� . �,..ti �'1
... . . . � -d "+� �
.. .. . . Phone: �1—�.3 �
Automation Fee. . ... . . . . . . .. .. Fax: � �1 �-��Q��
JCS Fee. . . . .. . . . .. . .. . . .. . . . . ��`aZ Bmail: h ` ('Y�►
To�ra�.. .... .. .. .. ... . ...... � 1 ' .
DECI2EE OF T�IE REGISTER
Estateaf � t�� � a���fl�_����.�, �/_�f� FileNa. ��LI' j��1����
a/k/a:
AND NOW � � �
, ��� C� ,� , ���'I� ,in cansider tion of the foregoing Petitian,
satisfactory proof having been prese LLted before me,IT IS D CREED that Letters �,���11�1�.�'t�(!��./
are hereby granted to�� i{ �,� �� �j(,�,i'�(1��,, 1�r
in the abovTtate and(if applicable)that
the instniment{s}dated ��'.�`Yl V :�� , l
described in the Petition be admitted to probat and filed of recard as the last Will(and Cadicil(s)�of Decedent.
t�
� � r �,- s � �
Register af Wills , - �'" ; ����
�o�xw o2 r�V.rair�rzorl Page 2 of 2
H705.805 REV(9/l l) _
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It:is illegal to duplicate this copy by photostat or.photograph.
r,n,._, � �
Fee for this certificate $6 Ob ,,11�n��°"""' y This is to certify that.the information here given is
�^���„aLjK QF PFiy correctly copied from an original Certificate of Death
• as��c,� _- `�G, : duly filed with me as. -Local Registrar. T'he original
. ` � �, l � z�� `�� =: ya certificate wili be .forwarded to tfie State Vital
; _.. � . i _�. �� - i�- � a; Recards Office for rmanent filing.
.
=O :,: ��`` "
P 19� 5 $4 5��.�� �: �. _�`',,q9jMENT OF,�``P~ , ' p
�.
- r � � G-�'.�i�{
Certification N m. er "'������""' Local egistrar Date Issued
�tl�48ERLAF�� f��., �'Aa
Typw/PNnt In COMMONWEALTH OF PENNSVLVANIA�DEPARTMENT OF HEALTH•VITAL RECOROS
Pefnian�^t CERTIFICATE OF DEATH
61ack Ink State Flle Number:
1.Daeed�ni's Lasal Nama(Flrsi,Mlddle,Last,SuHix) � 2.Sex 3.Soclal Security Number 4.Dafa of Oa�th(MO/Day/Vr)(Spsll Mo)
Betty C_ Barnes le '182-22-5103 September 5� 20'13
Sa.A`o-Last Birthday(Yrs) Sb.Untlar 1 Yqr 5c Under 1 Da 6.Date of BIKh(MO/Day/Y�ar)(Spell Monih) 7 BlRhpl City antl SU Forelsn Gountry)
9O . Manths �:�l3tYS No��: Mi��ce: �..-�O� 1 923 �Tarr�s� � �� �,.. .
�b.Birthplaca(COUnty) ll Il
6�.ResiNnc�'Siau or FoY�I/n o��[ry) � Hb.Residenee(St��af and NumDer-In<IUE�ApC No.) 8e.Oid Dec�d�ni Llve In a Townahip7 �� � � . �� �
Peruls lvania 3609 Kohlex' P1� y�4 , Q9 r.s.a�caaer+e uwe ir, �� twa.
.. Stl.Re.Iaenc�Icauncyl. ... . . .
G1�iil17�r1arld.��� � a..rte:m.o�.(ziP coe•) ��� O No,.aaceaenc nved w�tn�n umies ot �� c�ev/boro.
9.Ever In VS Armad Forees7 SO.Ma�lial Status at Tima of Death Marricd Widowed 11.Survivin/Spouse's Name(If wife,pive nama prlor to first marrlase)
� 0 Yas �No �UnknOWn 0 Divorced O Never Marri�tl �Unknown
12.Fsih�r's Name(F�rst,Middl�,laa�,SuHlx) 13.MoCh�r's Nama Prior to Firai Marrlai�(First,M�dCla,Last)
p,n�s ���- Lottie McC.ausliIl
14a.InformanYS Nama 14h.Relatlonship So DaNdent 14c.InformanYS Mallina Addrszs(Street snd Number,City,SbCa,Zip Code)
g Willlaxt� E. T�+"^as Jr_ Son 3609 Kohler Pl. #4� Hi11� PA 170"1'1
� -. � .. _ _ � � �� - - -- - - - - a. �c�o ea� r. ao�on• . � � - - - - -- -�- -- -�
If DpH�Oceurrad����1-�nspltal•� �❑Inpatlent � �It Deafh Otel�rro <SOmlwAtM�OtherTh�n a HOSphal: I�HOaplu Faclllly' �L���OSCede�!'s Home�'
$ 0 Emer �rfcy Room/quCp�q�ni � �O� D�ad�on Arrlval � � Nurlln �HOine/LOn�-T�rm Care Faclll O aher(Sp�cl/y) �� �
� i5b.Faeii�r Nama li not Insqcucion,Rlvn stre�c>na number) 15c Glty or Tow�� Stata,antl Co . � 15 Go�n f De�th
Hospice 22esidenoe Susqtae�annc-a 7ew�_• PA �t �nt
� 16a.M�t1�od of Dlspofiflon � Burlal 0 Cr�maHOn 16b.Dat�01 DlsposlHOn 16c.Plau e7 Dlsposlilo (Name of cwm���ry,<r�mROry,o�o[h�r p��c�)
� O T+� :rt sc t o oo�.iio., g��1/2013 =nd3aritawri C•ap Nat30rlal Cex[�tery_
p otn <sw.1b)
16d Lo HO.o(DI p Iflo (City Town,Stale,�ntl Zlp) �17a.51{n�tur�of Fun�ral5� UCt on in Chirse o1lnTprment 17b.llG�na�Number
17C.NaT1 inQ Compl�t��dEress of Funeral FaclliCy . .
� i -Bi Funeral HoR►e 3125 Walnut St TaaTM-isb PA '17'109
� 18.DecedanYf Etlucalion-Cheek[he box that besC d�scrlbas the 39.Deeetlent of HlspaniC Orlsin-Ch�ck th� 20.�wcedlnYS Race-Chack ONE OR MORE races to Indleate what
r hi`hert dasrte or level Of uhool compl�ted�t She fim�of death. bOx that best d�scNWf wh�th�r ihe dated�nt the deudenc conslCercd himself or herself to be.
O 9th arada or less Is Spanlsh/Hispanic/LaHno. Check tM"NO" �White O Korean
� NO Ciploma,9th-12th srodf bo�c H decedent Is nOt Spanlsh/Hispanl</Latino. � Blatk or Afrlcan Am�rlCa� 0 VlaSnam�se
� HI`h school{raduate or GED eomplatad QNO,nof Spanish/Nlspanic/laHno �Am�rlun InCian or Alaska Native 0 Oth�r Asian
0 Som�toll�`a crsdit,but no tlear�e 0 Ves,Maxlun,Mexi4n AmeMUn,Chlwna �Aab�Indirn O NaHVe Hawalian
p nssociate desrae(a.{.AA,AS) 0 Yes,Puerto Rlcan �Chinese � Gwmanian or Chamorro
ja Bach�lor's desro�(�.Q.BA,AB,BS) ��'es,Cuban � F���P��a O Samoan
O M�si�r's des�e�(�.5.MA,M5,MEnt,MEd,MSW,MBA) � Vas,oth�r Spanish/Mlzpanic/Latino 0 Japan�se � Othar Paeifie Isl�nde�
O DocCOraq(a.s.VhD,EdD)or Professlonal Ce`res (Spadly) �OCher(Sp�cHy)
.MD DDS DVM LLB JD
21.D�udenC's Slnsle Ract Self-Daslgna[IOn-Ctieck ONLY ONE to Intllute wh�t th!Eeudmt conaldared himself or herselT to be. 22a.Decedwnt's Usual Occupatlon-Indlcat!typa of work
�White �JaPi�ese � Samoan d durinQ � �a( f�orkins Ilf��O�O�N�OT USE REfIRED.
0 Blaek or Afrlwn Am�rican � Korean O Osh��Padfic Island�r �erSOI7�1 .�"e�"""'s t0
� �Amarlcan InClan or Alaska Nativw �Vi�lnam�s� 0 Oon't Know/NOt Sure s Wife -
�Asl�n indlan O Other Aslan 0 Rafused 22b.Kind of Business/Intlustry
� O Chlnese O Na�lve H�w�ilan 0 Other(Sp�cify)
0 Fllipino 0 Guam�nlan or Chamorro �QZIilOrlW�alt.tl Of PA
1 S���Ha-.29 MUBT eE COMPLETBO ���23a.Data Pronounce Daad(MO Day r.) 2 .SI`nature o Prrion Pronoun<ina Death Only w en app.a la � 3c.Lleense NumbaY
OV PERSON�.YVHO CRONOLNCES OR � � � . � . � . � �
CERTIFIES�EATN � � � � .
23d.OaSw�5lsn�ti(MO/OaY� r) � 24.�.T •of D ath .. .
� �� � �� � 35.Was Medic�l Exe.minsr or Corona�ConSaRetl7 � � Yes � No �
� � . . . CAUSE OF.DEATH�� . � � . ��� �nwarox�mate
26.PaR 1. Enier the chaln of w�nu--dis�ases,InJuNSa,or eamplloHOns--that directly pus�d�M death. DO NOT enter terminal events such as�cardiae arrost, � IMerval:
r�spiratory srrasc,or ventrlcular fiGrillation wlthOUt showinQ the ttloloQy. DO NOT ABBREVIATE. Ente�only one cause on a Ilne. Add addltional Ilnes if netessary. 1 Onset W Death
M C�4 3 �-a-�--. c C o t o n Cc. �
IMMEDIATE CAUSE --------------> a. " � 4 r � rS
(Fin�l tlis��sa or eonGttlon D�e fo(or as a conseq��n<e on: �
rosultlnQ In daath) �
b.
Sf9wnClally ilst eorMltlons. �. Dw tn(or s�.eonce9u�nca efl: �. �. ��. �: ��. � .
If anv.I�adini�to tMf uusa.. . . .. . � . 1. � -
IISt�O on Ilrtr a. EntsQ�tha �� . . � .
UNDERLYINO GUSE��� � �� � � Du!to(or as a cof�saquen<!ofl: � � � . �. � .
� (dis�aa�or inlury that � . . � � �� ��
InHbtsd[he,tv�nts r�aulring� `.�d. � �� � . � �.
� in tleath)LAST. Dw t0(or�s a co�seqwnca of): �
.� �Z6.P�R Ii.��Ent��.othe� 1 Ifl t tlIH � ontritiuHna So tlaath bu[not�esultin`.fn tha underlylnQ cause Qlven In Part 1.� � � 27.Was a�n auiopsy m�tli
� a . . .. . � . �. . ���Y�s No
� � . . � � �. . � � � � .. � �. 28.W�rc�UtoPSYfl ssawilabl�
� � � .�. �. �� � . n�r �..to co��++W�t�the ce e f Ee�Sh?
� Yas No
29�;:1}p ale:�� 30.PId Tobatto Us�ContrlbuC�Co D�KIiT 31 M�n of�paeh �
ot prosnant wlthln past year � Yes O P�obably �Naturol O Memicide
S Pr�inant at Hm�of tlaath �No 0 Unknown � Accid�nt 0 G�nAinQ InvestlLaflon
�' p Not pr�aMnt,but pr�i�+�t wl[hln a2 Caya of d�ath p Sulcide p Could no[b�tlatermined
p Not pre`nant,but presnane 43 days to i ysar baforw Ceath 32.Daie of InJury(MO/Day/Vr)(Spell Month)
� Unknown if preQnant within the past yair
33.Time o�InJury
34.Place ot ln)ury(e.`.homa;ConStructlon slta;farm;school) 35.Locatlon of InJury(Str�ei and Number,Clty,Couniy,State,2ip Cotl�)
36.InJury�t Work 37.MTranspoK�tlon Injury,Sp�N1y: 38.Dascrlbe How Infury Occurred:
0 Ves 0 DAVer/Operator O Pedes[rlan
� �NO O vasse�ser p Ot��r(Speciry)
3 Rlfl�r-physlcian,CartlfleE nurse pfattltloner,medlcal�xaminer/coronar(Chetk only one):
C�rtiH��e only-To the best of my knowledsa,d�ath oeeurred dw to Sh�c�use(a)�nd mann�r stac�tl.
Pronouncins&Gertifylni-To the bas[of my knowledge,deat�occurred at the tim�,Oat�,�nd placa,and tlu�to tM uu:�(s)and manner staied.
0 Medlcal Examiner/COroner-On t basls of examination and/or InvesH{atlon,In my opinion,d�ath ocwrred at ihe cima,d�ta,and place,and dW to the<aus�(a)anG manner stated.
signaturs ot c ' i ` '' Tieie ot�enres�: M1 UCen1a Number: M� O 3 O S 7.j �
39b.Mam�,Addr�sa sn�y�Zip Code f �rfon CompNilns Gus�of O�ath(Itfm 26) . 39c�Oat�Sitn�d(MO/Oay/Yr)�
� 7�'a.tL.r Ye-rau-�1cQ M�j .P9�2 Ti�:.,d /c iQ.d. �cz�r. .C//// .4� i7ui/ 9 =f- da i3'
40.R�QIWS�D� u�r � 43.RaQIsK 51`natur� 2.Ras�rtrar tl� ��Y�( ay r
� 43.Amandmenis .. � �� . . � .. . . . .. .. . .
�
DlsposiLlon Parmlt No. ��C!/O l��.F�Q REV 07/012
. . r �. `
LAST WILL AND TESTAMENT
OF
BETTY C. BARNES
I, BETTY C. BARNES, of 4531 Sequoia Drive, Apartment B-246,
Harrisburg, Lower Paxton Township, Dauphin County, Pennsylvania,
being of sound mind, memory and understanding, do hereby make,
publish and declare this to be my Last Will and Testament, hereby
revoking any and all former Wills and Codicils by me at any time
heretofore made.
ITEM I : I direct that all my funeral expenses and estate or
inheritance taxes be paid by my hereinafter named Executor as soon
after my death as may be found convenient .
ITEM II : I give, devise and bequeath all the rest, residue
� and remainder of my estate, both real and personal, wherever
� situate, to my son, WILLIAM E. BARNES, JR. , if he survives me . If
my son does not survive me, I give, devise and bequeath all the
rest, residue and remainder of my estate, both real and personal,
wherever situate, to his wife, LYNN A. BARNES .
ITEM III : I appoint RICHARD W. CLECKNER, ESQUIRE, Executor of
this, my Last Will and Testament . If he is unable or unwilling to
qualify as Executor, or, having qualified, is unable or unwilling
to continue to act, I then appoint WILLIAM E. BARNES, JR. , Executor
of my Will .
� .. �
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;,-� C=S �,�. ...... ...
�.:.+ �i�..:.: �_.., .�..
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ITEM IV: I direct that no personal representative hereunder
shall be required to provide security, surety or bond in any
jurisdiction for the faithful performance of any duty under this
Will . This clause is applicable only to such guardians, personal
representatives and trustees as are specifically named in this
Will, or an attorney in the law firm of Cleckner and Fearen.
IN WITNESS WHEREOF, I, BETTY C. BARNES, have set my hand and
seal to this, my Last Will and Testament, this ��n� day of
�'t/�G'F_',.,.,,,la c�/ , 19 9 7 .
��Lf� l,• �Ql�li,�v (SEAL)
BETTY . BARNES
* * * * * *
Signed, sealed, published and declared by BETTY C. BARNES, the
Testatrix, as and for her Will, in the presence of us, who, at her
request, in her presence and in the presence of each other, we
believing her to be of sound mind, memory and understanding, have
hereunto subscribed our names as witnesses .
,-
,�
�n,�.F OF r G�.� l�7DS
� �'%��Z��` � OF /F������2�C�,ti ./9 / i i 0
� . � ,
. _
COMMONWEALTH OF PENNSYLVANIA .
. SS .
COUNTY OF DAUPHIN .
We, BETTY C. BARNES, Testatrix, �(�r�n/� G. � ���,�/D ,
and �G��p/ � ��� �OS�� , witnesses, respectively, whose
names are signed to the attached or foregoing instrument, being
first duly sworn, do hereby declare to the undersigned authority
that the Testatrix signed and executed the instrument as her Last
Will and Testament 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 (18) years of age or older, of sound mind and under no
constraint or undue influence.
�
B T C. BARNES - Testatrix
J ,
�� ����
(��.�,�.� _. �� ��
;
Subscribed, sworn to and acknowledged before me by BETTY C.
BARNES, Testatrix, and subscribed and sworn to before me by
�dr�.��� �. /L��� and ��rG�� � /�.,'r;��s�'�
, �
th i s �sr c�C day o f ,���%e�.-, ��r--- , 19 9 7 .
`b��,.� � / �C'��°�
NOTARY P BLIC
My Commission Expires :
Notarial Seal
Jenny A.Tobias,Notary Public
Harrisburg,Dauphin County
My Commission Expires Feb. 15,2001
Memh�r,Pann�Ylvania A�Sa�i�iiqn 9f N�i�fl��