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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF �J.M�r���{� COUNTY,P�NSYLV r�A �
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Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Lett��as speci�r�d b�o� and in
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support thereof aver(s)the following and respectfully request(s)the grant of Letters in g�rca�pnate�orm:�� :,,
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Decedent's Information ..�. �? � -
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Name: ��.I c y E I�z��-eT� (� e � ' � I J/
File No: " `� �� '/�c.l,l
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a/k/a: (Assigned_�y Regis�er) • :
alk/a: � _ �>
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a/k/a: Social Securit�To: a � �--x����:.a5 � 3 7
Date of Death: /d .�� 2t; r 3 Age at death: 6 � '
Decedent was domiciled at death in C`����c f'��,V d County, 1"� (srate)with his/her last
principal residence at 1 l 0�'-�i P�!�(d�+N S�- , l�ec ��►+c s 4��, C��.. �� (�,,��4
Street address,Post Office and Zip Code City, wnship or Borough County
Decedent died at `� ��( �"���� S�� + l�cc�r-N�c s���f"'y �..,�nl�z t-(A,�}� P/�
Street address,Post Offlce and Zip Code City,Towns6 p or Borough Coupty State
Estimate of value of decedent's property at death:
If domiciled in Pennsy/vania............................ All personal property $
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. ... $ �G`;;t;��tX�.pp
Real estate in Pennsylvania situated at: i�U� �r�d�^'�'� ST . � /" " <=h'O�"�t+c s b� r� �v r�b�i�r nf��
(Attach additional sheets,if necessary.) Street address,Post Qftice aod Zip Code City,Township or Borough County
�� Petition for Probate and Grant of Letters Testamentarv
Petitioner(s)aver(s�Fi�/she/the�ys�are the Executor(s)named in the last Will of the Decedent,dated -s C �— �"V� Z— and Codicil(s)
thereto dated
State relevsnt circumstances(�g.renunciation,death of e.recutor,etc.)
Except as follows: aRer 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.
�'NO EXCEPTIONS Q 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 db.n.c.�a.,enter date of Will in Section A above and complete list of heirs.
Except as fotlows: 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 kiliing nor ever adjudicated an incapacitated person.
Q NO EXCEPTIONS Q 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,ifnecessary):
Name Reletions6i Address
Form RW-02 rev.10/Il/201/ Page 1 of 2
Oath of Personal Representative � ot���ai us�iy '_� -,,
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COMMONWEALTH OF PENNSYLVANIA -�,- - t _' `-�'
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COUNTY OF } '' t.,�, �� , _
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Petitioner(s)Pri�fted Name Petitioner(s)Printed —=-�
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�,AFTJ'iCZ i . r'7��4-1 Z�)� l/v¢_sT' �'`��nt ]i �✓' �WSTG�Iv�ll �l � �7G f
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The Peritioner(s)above-named swear(s)or affirm(s)the statements in the foregoing Petition are true and correct to the best of the lrnowiedge and belief
of Pe6rioner(s)and that,as Personal Representative(s)of the Decedern,the Petitioner(s)will well and truly administer the estate according to law.
Swom to or affirmed an subscri ed before .� % .� -' ��—�., � Date �+ � i3_
me t ' +�a day o �� Date
By: � '� '�,� Date
For the Register Date
BOND Required: Q YES Q�'�O To the Register of Wills:
FEES: Please enter my appearance by my signature below:
Letters. . . . . . . . . . . . . . . . . . . . . . $ 1 �,�;ti•� Attorney Signature:
( '� )Short Certificate(s). . . . . . � � �
( )Renunciation(s).. . . . . . . .
( )Codicit(s). . . . . . . . . . . . .
( )Affidavit(s).. . . . . . . . . . .
Bond... . . . . . . . . . . . . . . . . . . . . . Printed Name:
Commission. . . . . . . . . . . . . . . . . . Supreme Court
Ot�er� :: :;:: ID Number:
�_��. . . . . . . . . C� Firm Name:
' ` '� ���L Address:
( . . .. . .
• . . . . . . . Phone:
Automation Fee. . . . . . . . . . . . . . . �`)� ' Fax:
JCS Fee. . . . . . . .. . . .. . . . . . . . . ��� 5� Email:
TOTAL. . .. . . . . .. . . . . . . . . . . . $ LF��7 ��Z-8:6'0-
DECREE OF THE REGISTER
Estate of � � �2QC� l(�,l File No: �����'�J�s,.��
a/k/a:
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AND NOW, �p�1 ( ?�( ��1��U'�,�,� , c��J � ,in consi era 'on of the oregoing Petition,
satisfactory proof having been presented before me,IT IyS.�ECRE D that Le s `'�(
are hereby granted to l .�� C'
in the a ove estate and(if applicable)that
the instrument(s)dated I ,
described in the Petition be ad tted to probate and filed of record as the last Will(and Codicil(s))of Decedent.
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Register of Wills . _��� � ���.���i� �� � �
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Form RW-O2 rev.10/Il/2011 ( P e 2 of 2
H105.805 R8V(9/11
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3 �� LOCAL REGISTRAR'S CERTIFICATION OF DEATH
l / WARNING: It is illegal to duplicate this copy by photostat or photograph.
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Fee for this certificate, $6.00 '�Y �� � = vi� '_;;, �""`TH�OFp��` This is to certify that the information here given is
n�''��,P Ey f_ correctly copied from an original Certificate of Death
;i�� ����� fi �;� � � ? ����o y G` duly filed with me as Locai Registrar. The original
L � `: y; certificate will be forwarded to the State Vital
.�, � _ '°` � a� Records Office for permanent filing.
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�s� �;,� � --.,MENT,OF,,,���''
Certification Number ���-��`�� E-., , /'� Local Registrar Date Issued
Type/Print In COMMONWEAITN OF PENNSYLVANIA•DEPARTMENT OF HEA�TH•VITAI RECORDS
°ef'"a"�"` CERTIFICATE OF �EATH
Black Ink State File Number:
� 1.Decedent's Le�al Name(First,Middle,Last,Suffix) 2.Sex 3.Social Security Number 4.Date of Death(MO/Day/Vr)(Spell Mo)
Nan E_ Ke11e 2'17-54-5837 October 24, 20'13
Sa.Age-Last Birthday(Yrs) Sb.Under 1 Vear Sc.Under 1 Da 6.Date of BiKh(MO/�ay/Vear)(Spell Month) �a.Birthplace(fity and State or Foreign Country)
� 65 Mo�Tns o�v� Ho��� ^'��^��e5 February 29, "1948 Harrisbur PA
� �b.9irthplace(CO�nty)
8a.Residence(State or Foreign Co�ntry) Sb.Recidence(Street and N�mber-Include Apt No.) 8c.Did Decedent Live in a Township?
Pennsy2vania '1'I 09 Baldwin Street o ves,de�eae„�r�ea�., .vp.
Sd.Resid�ence:{COUnty)
�.'LZITltJG,Z'Zc�7jC3 8e.ftesidence(Zip Code) �NO,tlecedent livetl wiihin limits of Meehaniesburg city/boro.
3.Ever in US A�metl Fo�r_e57 10.Ma�ital St�atus at Time of Death � Married � Widowed 11.Surviving Spo�se's Name(If wife,give name prior to firsT marr age)
�Ves [�NO 0 Vnknown �Divorced � Never Married 0 Unknow
12.Father's Name(First,Mitldle,Last,Suffix) 13.Mother's Name Prior to First Ma�riage(First,Middle,last)
Jac7c Kir7c
lAa.Informant's Name 146.Relationship to pecedent 19c.Informant's Mailing Address(Street antl Number,City,State,2ip Code)
Mr_ Brian C. Ke11ey Son 1"109 Baldwin Street Mectiani
C°, . isa_c�ace of oeaxn(cneck o.,iv o.,e � � -���}i�rriTm
_ If Oeath Occ�rred In a Hospital �1 Inpatient �If Death Occurred Somewhere Other Than a Hospital �Hospice Facility �Dec e
� Emergency Room/Outpatient � Dead on Arrlval � � Nursin HomC/Long-Term Care FaCility 0 Othe�(Specify)
156.Fac11i[y Name(1(not�in titution,give s reet and number) 15c.City or Town,Sta[e,antl Zip Code 15d.Coianty of DeatF�
'I'i 09 Ba1dw'n 5
16a.Meihod oF Disposition O B��rial ^y Cramation 16b.Date of Oi ion 1 c.Place of DisCOSition(Name of cemeiery,crematory,or orher place)
O Removal from State O Donaeio5i '
- � o o��,���sPe�;,,,� "i O/ / Ol[3 Svy Hill Cremato �
� 16d.LocaYfoh of Dispos(tion(City or Town,5[ate,and Zip) 1>a.Si� at of�ral Service Licensee or Person in Charge of Interment 1J6.Lice�s6 Number
Pi-iiladelphia, PA 'I 9'I 50 O'1 272"I L
E l�c.Name and Complete Address of F�neral Facility
Chadwicic & McKinne E'un
18.Decedent's Education-Check the box that best describes the 19.Oe edent of Hispanic Origin-Che<k the 20.Decedeni's -Check ONE OR MOftE races to indicate what
�- highesc degree or level of school comple<ed at tM1e time of death. box that best describes whether the decedent the decedent conidered himself o�herself to be.
O 9th grade or Iess is Spanish/Hispanic/Latino. Check the"NO" White � Korean
� No tliploma,9ih-12th arade box if deceden(is not Spanish/Hispanic/latino. � Black or African American O Vie<namese
� High school grad�ate or GED completed [}�No,not Spanish/Hispanic/Lailno O %merican Indian or Alaska Native Q Other Asian
O Some college credtt,buC no deg�ee (�Ves,Mexican,Mexican American,Chicano 0 Asian Indian � O Native Hawatian
� Associate degree(e.g.AA,AS) �Ves,P�erto Rican �Chin � Guamanian o�Chamo��o
�] Bachelcr's degree(e.g.BA,AB,95) �Yes,Cuban O Filip no O Samoan
�� Master's degree(e.g.MA,M5,MEng,MEd,MSW,MBA) O Yes,other Spanish/Hispanic/latino �lapanese � Other Pacific Is�ander
� Doctorate(e.g.PhD,FdD)or Pro£esslonat degree � (Specify) � Othe�(Specif
Y1
.MfJ,DDS,DVM,LLB,JD
21.Oe edPnt's Single Race Self-Oesignation-Gheck ONIY ONE eo indicate wha[the decetlent considered himself or herself to be. 22a.Decedent's Usual Occupation-Indicaie iype of work
�Wh{te � lapane<e � Samoan done during most of working life. DO NOT USE RETIREO.
Black or African American � Korean � Othe.�Pacific Islander 211SL1Z�C�1I1Ce Undewriter
O %merf<an Indian or Alaska Native �Vietnamese � Dc.n't Know/NOt Sure
W 0 Asian Indian O OtM1�r Asian [� ftef�setl 22b.Kind f Business/Industry
� O Chinese O Native Hawalian 0 Other(Specify) � _1 S.V��Ne C
Q Q Filipino O Guamanlan o�CM1amor�o ��
. ITEMS Z3a-�23d MUST BE GOMPlETFO 23 Date Pr tl De)a)ct(MO/Day/Vr) 236/./Signat�re oT Pers nProno�ncin/g yOe�ath(Only wh�en ap/p�licable) 23c.license N�mber
BV PERSON WHU PRONOUNCES OR ���Z`f Z-O� j'� //�m /I /�//A���. // �( J R�,�S�9Q�
� GERTIFIES DEATH
23d.Date 51 ned(Mo/�ay/Yr 24_Time Death � ' 1 L-� �1��{(..1:(��/�i- i�-:�-�-
2 �-(7 25.Was Medical Examiner or Coroner Contacted? Ve5 � No
CAUSE OF DEATH App�oximate
26.Part t. Enter[he chain of e --diseases,injuries,o mplications--that directly cavsed the tleath. DO NOT enter terminal events such as cardiac arrest, Interval:
respiratorY arrest,or ventrlc�lar flbrlllaFion wltho�t showing the etlology. DO NOT ABBREVIATE. Enter only one cause on a line. Atltl atldiilonal Iines if necessary. � Onset to Deaih
�-- �cvn`e�- � 1 �'r�o«r
IMMEOIATE CAUSE ---------------> a. �n!-
(Final diseasc o ondition Due[o(o as a conseq�ence of):
resulting in death)
b' t
SequentiallY��s�CondiYiOns, Due to(o�as a consequente of):
if any,leading io the cause
Iisted on line a. [nter the
UNUERLYING CAUSE Oue fo(o�as a conseqt�ence of):
(disease o�inj�ry that
- n�c�aced c�,e e �<s�eswc�.,g a.
in death)LAST.e �ue to(O as a consequence of):
� s 26.Part 1�, Enxer other sienif'cant conditions contributine to death but not resulting in ihe underlying cause given in Part 1. 27.Was an autopsy pertormed7
� O ves No
, `� . 2R.Were autopsy fin n�s available
. to complete The cause of death?
m � Yes No
29.If Female: 30.Did Tobacco Use Contribute to Death: 31.Manner of Death
o � Not pregnant wifhin past year � Yes yQ Probably �(Natural � Homicide
VO Pregnant a[Lime of deaih O No � Unknown 0 Accident O Pending�nvestigatlon
� m � Not pregnant,but pregnant wi<hin 42 daYS of aeath p S�icide � Could not be determined
� ti � NoY p�egnant,but p�egnan[43 tlays to 1 yea�befo�e death 32.Date of Injury(MO/Oay/Vr)(Spell Month)
� Unknown if pregnant within the past year 33.Time of Injury
� 34.Place of Inj�ry(e.g.home;construct�on s�te;fa�m;school) 35.Locaflon of Injury(Street and Number,Gity,County,Siate,Zip Code)
36.Injury at Work 3].If Transportation Injury,Specify: 38.Describe How InjurY Occ�rred:
[] Yes � Driver/operator � Pedestrian
0 No � Passenger � Ofher(Specify) �
� 39a.Certifier-physician,certified n e practitloner,metlical examiner/coro er(Check only one):
� Certifying only-To the best of'my knowletlge,tleath occ�rred due to thP.c �e(s)antl m ted.
O PronouncinR�Certifying-To the best of my knowledge,death occurred at the Sime,date,�antl place,and due[o the cause(s)and m ted.
O Medical Examiner/COroner-On the basis of examination and/or investigation,in my opinion,de�ath{c��,c�c�rred at the time,date,antl placerand tlue to the cause(s)and manner s[ated.
Signature of certitier: Title of certifier.�v`� License N�..,ee�:A1 P/�4 f3��
�� 39b.Name,Atldress and Zip Code of Person Com leting Cause of�eath(Item J6) 39c.Date Signed(MO/Day/Vr)
ku6:* ��u 3 »-T'r:� (�e rZoe.d Ca 1-F;�l !a , ! 0�1 l. z avi3
40.Registrar's O�stric[NuYnber. � � 41.R rar s Signaiure 42.Registrar.File Dete{MO/Day/V�). .
�✓�"� O � � t �_5� o/
43.Amendments � '
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� Disposi[lon Permit No. � % Y����� REV O�/2012
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LAST WILL AND TESTAMENT:., _„ ;=� �
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OF _ � . , ��
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NANCY ELIZABETH KELLEY �� r,.� __L � . �
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I, NANCY ELIZABETH KELLEY, currently resident at 1109 Baldwin Street,
Mechanicsburg, Pennsylvania, being over the age of eighteen(18) years and of sound mind and
disposing memory, do hereby make and publish this, my Last Will and Testament, to-wit:
ITEM ONE
I do hereby revoke all Wills and Codicils and testamentary instruments heretofore made
by me.
ITEM TWO
I hereby direct that no other action shall be had in the County Court or any other court in
relation to the settlement of or administration upon my estate than the probating and recording of
this Will and the return of an inventory, appraise�nent and list of claims.
ITEM THREE
I hereby appoint PATRICK T. BEATY, sole Independent Executor under this Will and
of my estate and direct that no bond shall be required of him. In the event of the death or
inability of PATRICK T. BEATY,then I appoint, LINDA C. BEATY, Independent Executrix,
under this Will and of my estate and direct that no bond shall be required of her.
ITEM FOUR
I direct that all my just debts and funeral expenses and any taxes that have been or may
be assessed in consequence of my death, of whatsoever nature and by whatsoever jurisdiction
imposed, shall be paid from my residuary estate at the time of my death.
✓
ITEM FIVE
I will, give, bequeath and devise to my son, BRIAN KELLEY, in absolute fee simple,
all my property of every nature and description, real, personal or mixed, wherever situated.
ITEM SIX
In addition to the authority conferred on fiduciaries by law, I authorize my Executor: (1)
to retain any real or personal property pending distribution hereunder without liability for loss or
depreciation resulting from such retention; (2)to distribute any real or personal property in kind;
(3) to dispose of real or personal property by public or private sale, or exchange, or otherwise,
and receive or administer the proceeds as a part of my estate; (4) to sell, lease or exchange
property and to receive or administer the proceeds as a part of my estate; (5) to pay, as he or she
deems best (unless state law requires a specific method for payment), all my debts and ta�ces, that
may by reason of my death, be assessed against my estate or any portion of it; (6)to vote stock,
to exercise any option or privilege to convert bonds, notes, stocks or other securities belonging to
my estate into other bonds, notes, stocks or other securities, and to exercise all other rights and
privileges of a person owning similar property in his/her own right; (7)to abandon, adjust,
arbitrate, compromise, sue or defend and otherwise deal with and settle claims in favor of or
against my estate; (8)to do all other acts in his or her judgment that may be necessary or
appropriate for the proper and advantageous management, investment and distribution of my
estate. The foregoing powers may be exercised as often as is deemed necessary or advisable
without a placation to or approval by any court in any jurisdiction.
-2-
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ITEM SEVEN
I direct my Executor to apply as much of the proceeds of my estate as may be necessary
to the payment and full satisfaction of the mortgage on my property at 1109 Baldwin Street,
Mechanicsburg, Pennsylvania.
IN TESTIMONY WHEREOF, I have hereunto subscribed and signed these presents at
Mechanicsburg, Pennsylvania, in the presence of the witnesses whose names are affixed hereto
and whom I have requested to sign their names hereto as witnesses, and in the presence of said
witnesses I have declared and published the foregoing as my Last Will and Testament on the S?��
day of , 2012.
� ���� �� �-(��/�G��.�
NANCY ELI BETH LLEY �
Testator
The foregoing Will was on the day and date above set out signed by the Testator,
NANCY ELIZABETH KELLEY, in our presence and in the presence of each of us, and at the
time she signed this Will, he declared that it was her Last Will and Testament, and at her request
and in her presence and in the presence of each other, we hereunto sign our names as attesting
witnesses.
NAME ADDRESS
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OATH OF SUBSCRIBING WITNESS(�� � ���
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REGISTER OF WILLS `� _��` •
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��M�e✓'I.°,'�c� COUNTY, PENNSYLVAI'�P�'A rv f��. °�
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Estate of ,v1�Lv1 �� �z,���k-tC� KE�� F� , Deceased
_S�"�A+�l 1j �'`+`►�'� �—� ,"���+ �� ���; y , (each)a subscribing witness to
� (Print Name/s)
the�Will �Codicil(s)presented herewith, (each)being duly qualified according to law, depose(s) and
say(s)that she/he/�e was wer present and saw the above Testato /Testatri sign the same
and that she/he/they signed the same and that she/he they signed as a witness at the request of
the Testat /Testatri in her/his presence and in the presence of each other.
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r��✓���/y� ���Q 1�� `i'l��� `�'��� � ��,�,�_�; y� � �_��,� ,
(Street Address) (Street Address)
. 1�r�irrra���;��,r�� �� i i���/ �-�-��,�-���---��� �� . ;�� �l r �
(City.State.Zip) (C+ty,Smte,ZiP)
Executed in Register's Office Executed out of Register's Office
Sworn to or affirmed and subscribed Sworn to or affirmed and subscribed
before me this day before me this 5�'j1 day
of , of �D UGrI�,�.� , o�0�3
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.)
N01'E: To be taken by Officer authorized to administer oaths. Please have present the original or copy of in 0 M�NWEALTH O�S�'LVANIA
Nota�ia!Seal
Form RW-03 rev.10.13.06 Lori A.B.ZerUe,Notary Pubtit
Gty of karri�Curc,t,Dauphfn County
My Commission Expires Jan.7,2014
Member,PennstNanfa Association of Notaries