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Home My WebLink About11-08-13 i ESTATE OF : IN THE COURT OF COMMON PLEAS ANNA MAE GROSS : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS' COURT DIVI�ION � . NO. '2 I _ I'3�- ��c � �o � � � ^' z c� �=-' c`n � � A r- --� C a A 2 1�`t � r� t-a� � (� �7 ..��r C.=s PETITION UNDER SECTION 3102 OF THE PROB�'T„ � c� {:� � � �t '�'r ESTATES AND FIDUCIARIES CODE FOR � ° `�7 � -- r SETTLEMENT OF SMALL ESTATE � �' �.� `�� `' b `f �-_ n�r n? G7 �.3 �Q '71 TO THE HONORABLE JUDGES OF SAID COURT: Doris L. Dunham and Randy Lee Gross, your Petitioners, file this Petition for Settlement of a Small Estate under the provisions of Section 3102 of the Probate, Estates and Fiduciaries Code and in support thereof avers that: (1) Your Petitioner, Doris L. Dunham is a competent adult residing at 934 W. Trindle Road, Mechanicsburg, Pennsylvania 17055, and is the daughter of the above decedent. (2) Your Petitioner, Randy L. Gross is a competent adult residing at 173 Vine Street, Apartment E, Shiremanstown, Pennsylvania 17011, and is the son of the above decedent. (3) Anna Mae Gross died on October 6, 2013 at the age of 82 years, but prior thereto lived and was domiciled at 1000 Claremont Drive, Pennsylvania, Cumberland County, Pennsylvania. A copy of decedent's Death Certificate is attached hereto as Exhibit"A." (4) Anna Mae Gross died without a Will. No Letters have been issued. (5) Anna Mae Gross had no probate estate when she died other than the following: Life Insurance Policy with Colonial Penn Life Insurance Company with a value of $7,554.00. The Beneficiary of the life insurance policy is The Estate of Anna Mae Gross. A copy of the death benefit is attached hereto as Exhibit `B." (6) The sole heirs and relationship to the decedent are as follows: Doris L. Dunham, Daughter Randy L. Gross, Son � � � i (7) Attorney Fees in the amount of$600.00 will be charged to the estate. (8) Your Petitioner avers that there are no outstanding debts of the Decedent. (9) Since the only asset is life insurance, no inheritance tax is due. WHEREFORE, your Petitioner respectfully requests that an Order be made authorizing Doris L. Dunham and Randy L. Gross to act as Fiduciaries for the Estate of Anna M. Gross and file a claim with Colonial Penn Life Insurance Company, with the proceeds made payable to the Estate of Anna Mae Gross pursuant to Section 3102 of the Probate, Estates and Fiduciaries Code. By Matthe A. McKnight, Esquire Supreme Court I.D. No. 93010 IRWIN& McKNIGHT, P.C. 60 West Pomfret Street Carlisle, PA 17013 (717) 249-2353 COMMONWEALTH OF PENNSYLVANIA : COUNTY OF CUMBERLAND : Doris L. Dunham and Randy Lee Gross being duly sworn according to law, deposes and says that the facts contained in the foregoing Petition are true and correct to the best of their knowledge, information and belief. ,�� Cii�G�l �- � ��/��.— (SEAL) Doris L. Dunham ._...._� ._ R:_',�;,�--�:��=� ._._=�'�-�:___--� (SEAL) �Ra�rdy L.`Gross Swo d subscribed before me this��ay of Novemb , ZO13. OMNIONWEALTH OF P�t�NSYLVANIA NotaMal Seal Karen S.Ns�el,Notary Public C�d�e Bo%Cumbe�land County My Comml��i�n Ex�n!rQ,L?gc,g,2015 Notary Public MEMBER,PENhlSYC�`�( J?'�'��OTARiES HI05.805 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, $6.00 ,,,,��""""'----- This is to certify that the information here given is �� N OF p ' ,1,��,,a��,P Fij%;�`__ correctly copied from an original Certificate of Death `a o r�; duly filed with me as Local Registrar. The original ��_ --- •=: z; certificate will be forwarded to the State Vital :�` � ' a, Recards Office for permanent filing. . : �' 19 � � � 5 51 `_o�,,q - ` �,��,,,��' js OCT 8 D13 �"'9TMENT OE��`° v J - Certification Number I� "��""'"�� ocal Registrar Date Issued � Type/Print In COMMONWEALTH OF PENNSVLVANIA•DEPARTMENT OF HEALTH�VITAL RECOR�S PefR1d"e"` CERTIFICATE OF DEATH Black Ink State File Number. 1.�ecedent's Legal Name(First,Middle,Last,Suffix) 2.Sez 3.Social Security Number 4.�ate of�eath(MO/Day/Vr)(Spell Mo) Anna Mae Gross emale 207-22-2191 October 6, 2013 Sa.Age-Lasi Birthday(Yrs) 56.Under 1 Year Sc.Under 1�a 6.Date of Birth(MO/�ay/Vear)(Spell Month) 7a.Birthplace(City and State or For�=ign Covntry) r 82 n.io�cns oav� �o��s M��i�� c 30, 1930 Mt. Ho11 S rin s PA 7b.Birthplace(COUnty) Sa.Residen<c(STate or Foreign Counxry) Sb.Resitlence(Street and Number-Inclutle Apc No.) 8c.oid oacedent Live in a Township7 � .�PA � � 1000 Claremont D�ive �Ves,decedent Ilved in Middlesax t�„P. � Sd.Residence(COUnty) . Cl1R1YJG'�L�Zc�I1C3 � Se.Residence(Zip Cotle) �No,decedenC Iived within Ilmits of city/boro. 9.Eve�in US Armed Forces? 10.Marital 5<atus at Time of Oeath � Married � W�dowetl 11.Surviving Spouse's Name(If wife,give name p�io�to fi�st marriage) �Ves �] No �Unknown W Divorced � Never Married 0 Vnknow 12.Father's Name(First,Middle,Last,SuKix) 13.Mother's Name Prior to First Marriage(First,Middle,Last) George Rictiwine Rosie n 14a.Informant's Name 14b. latio hip to�ecedent 14c. s M Iing Atl (5 antl be City,$tate,ZI Code) Doris Duntiam c�aug�itar ��' `�_ '�rin�`l�e �2�_, �'ec�ian�.csb�irg, PA 1705 � _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _15a.P ace o Deat C ec on�one _ _ _ _ _ _ _ _ __ _ _ _ If DeaCh OccU�r¢d I�n a HospiYal: �-Inpa[ient �if Deafh Occur�etl Somewhere Other Than a Hospital �Hospice Facitiiy �[] Decedent's Home ° O Eme�gency Room/OUCpatienc � Dead on Arrival � � Nursing Home/LOng-Term Care Facility O Other(Specify) 15b.Facilify Name(If not instit�tion,give street and number i5c.City or Tpwn State, d Zip C 15d. y of D th Claremant Nursing & Retiab_ G?tr_ Carl�.sle, PA 1°7�13 �`tnnberland 16a.Methotl of Disposition Burial � Cremation 166.Date f Oisposition 16c.Place of Disposition(Name of ceme[ery,crematory,or other place) � Removal from�5�afe � �onation �Ct l�i 2�13 Westminster CEIiIEteL�y � .g' O�Other(Specify) � 16d.locaiion of�isposition(CI[y or Town,State;antl Zip) 17a.Signa of Fun 5 ice Licensee or Person in Charge of Inferment 17b.License Nvmber Garlisle, PA 17013 138504 0 37c.Name a�d Complete Adtlress of Fiineral Facility Ho££man-Rbth Funeral Home & Crematory, 219 Nortti Hanover Street, Carlisle, PA 17013 18.�ecetlent's Education-Check the box tha(best describes the 19.Decedent of Hispanic Origin-Check the 20.Decedeni's Race-Check ONE OR MORE ra s to intlicate what t- highest degree or level of s<hool completed at ihe tlme of tleath. box iiiat best descNbes whether the decedent the decedent considered Fimself or he�self to be. '�Hth grade or less s Spanish/Hispanic/Latino. Check the"NO" �White � Korean O No diploma,9th-12th grade box if decetlen[is nof Spanish/Hispanic/Latino. � Black or Afrlcan American � VieTnamese � Fiigh school graduate or GED completed No,no<Spanlsh/Hispanic/Latino � American Intlian or Alaska Native � Other Asian O Some colleg¢credit,but�o degree O Ves,Mexican,Mexican American,Cliicano �Asian Intlian � Native Hawaiian � Associate degree(e.g.AA,AS) O Yes,Puerto Rican �Chinese O G�amanian or Chamorro O Bachelor's deg�ee(e.g.BA,AB,BS) � Ves,Cuban O Filipino 0 Samoan � Maste�'S tleg�ee(e.g.MA,M5,MEng,MEtl,MSW,M6A) O Yes,othe�SpanisFi/Hispanic/La<ino O lapanese O Other Pacific Isiantle� � Doctorate(e.g.PhD,EdD)or Professional degree (Specify) � O[her(Specify) (e. .MD 005,DVM,LLO,JD 21.Decedent's Single Race Self-�esignation-Check ONLV ONE to indicate whai tM1e decetlent consitlered himself or herself to be. 22a.Decedent's Usual Occupation-Indicate type of work $] White �Japanese � Samoan done during most of working life. DO NOT USE RETREO. � 61ack or African American 0 Korean � Other Pacific Islander � American indian or Alaska Native �Vietnamese � Don't Know/NOt Sure Laborer ? � Asian Indian � Other Aslan O Refused 22b.Kind of B�siness/Ind�stry � o cn�.,ese O Nailve Hawalian � Other(Specify) Rubber Manu£acturing � O Filipino O G�amanian or Chamorro ITEM5�23a-23d MUSF BE COMPLETE� 23a.Oate Pronounced Dead(MOJDay/Vr) 23b.Signature of Person Pronouncing�eath(OnIY when applicable) 23c.License Number CERTIF ES P ATH PRONOUNCES OR . � � �U/� 23d.Date Signed(MO/Day/Yr) 1.4.Time of Oeath T� ��-L [��.. (y �U � �7(�� 25.Was Medical Examiner o�Goroner Co tactetlT 0 Yes � No � � CAUSE OF UEATH � � Approximate 26.Part 1. Enter the chain of events--diseases,injuries,or compiications--that directly<ausetl the death. DO NOT en�er terminal<vents such as<a�tllac arrest, � Interval: ,respiratory arrest,or ventricular fibri�lation without sFiowing the e[iology. �O NOT ABBREVIATE. Enter only one ca�se on a line. Add atlditlonal Ilnes If necessary. I Onset to Oeath P..,s�,.,..0..,4 ' IMMEDIATE CAUSE ---------------> a. � (Final tlisease o ndition � Due io(o as a conseq�ence of): � res�ISing in death) b. � Seq�entially�IiSt CotitliLionS, Due to(Or as a conscquence of): � If any,leading So the cause 1 Iistetl on lir�e a. Enier the . UNDERLYiNG CAUSE D�e fo(o�as a conseq�ence ofj: � (disease or injury that � - initlated ihe events resul<ing d_ � �n deatM1)LAST. D�e to(or as a conseq�ence ofJ: 1 °v 26,Oert Ii. Enter other sienifcant cond'f'o ontribut'n2 fo deaCh b�t not resuliing in tMe underlying cause given in Part I. 27.Was an autopsy perfo�med? - � . O Yes O�No � 28.Were autopsy fintlings a ailable to complete ihe causey f death? m � Yes B No 29.If Female: 30.�id Tobacco Use Con[ribute to DeathT 31.Manner of Oeath o �NOt pregnant within past year � Ves � Probably 0'Naturaf � Homicide O Pregnant at time of tleath �No � Unknown O Accident Q Pending Investigation � Not pregnant,but pregnant with�n 42 days of deatti � Suicide � Could not be determined � O Not pregnant,but pregnant 43 tlays to 1 year betore death 32.Date of Injury(MO/Day/Y�)(Spell Month) � 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 Nvmber,City,Co�nty,State,Zip Code) f 36.Inj�ry ai Work 37.If Transportation Inj�ry,Specify: 38.Describe How Injury Occurred: � � Ves � Driver/Operator O Pedestrian 0 No O Passenger � Ofher(Specify) � 39a.� rtitier-physician,certified nurse practitioner,medical examiner/<oroner(Check only one): IQ Certifying only-To fhe best of my knowledge,death occurred due to the cause(s)and manner stated. � � Pronouncing Sa CeKifying-To the best of my knowledge,death occurred at the time,date,and place,and due to the cause(s)and manner statetl. � Metlical Examiner/COroner-On the basis of mtnati ntl invr_stigation,in my opinion,death oIc,curred at the time,date,and place,and tl�e to the c se(s)and m r stated. � Signature of certiHer: TIHe of certifier. r��s��'�"�� Llcense N�mber:��O'O�ILGa9�/-t � 39b.Name,AdCr¢ss and Zip Cotle of Person Completing f Death(Ixem 26) 39c.Date 516�ed(MO/Day/Yr) �tza��sr �s. �./os�F' rso 5 i83v Gboo fi4�' .tn. �.�°�-+ �.� i7esS /o • Z- '3 � 40.ft@qistrar's Oistric[Number 41.Regis s Si�nat�re 42.Registrar File Date(MO/Day/Vr � io � _ � ac� 43.Amentlmeiits O � /[ n H105-143 Disposition Permit No. C l��dC D I D REV 07/2012 : � . � Colonial Penn Life Insurance Company Galonial Penn Plaza 19th c` v[arket Sts.;Philadelphia, Pennsvlvania 191�i Insiu-ecl: ANNA Nt GROSS Certificate Number: TL�I0291�7�B Issue Age: 61 Owner: ANNA M GROSS Certificate Date: VI.�RCH 0�4, 1992 46 E PENN ST Premitun: ��1.70 �IONTHLY CARLISLL- PA 17013 Nonforfeiture Interest Rate: 7.00�`0 PLAN This is Qroup modified benefit whole life insw�ance. The insurance is lia�ited dw�ing the first two certificate years for non-accidental death. We will pay the a�plicable clelth benefit if you die while the eertificate is in force, subject to the terms of this certificate. Premiums are payaUle to age ]00. A. NON-ACCIDENTAL DEATH BENEFIT LIMITED BENEFIT ANIOUNT IST CERTIFICATE YE�1R �1133 LIMITED BENEFIT ANIOUNT 2ND CERTIFICATE YEAR $2266 FULL FACE ANt�U[VT 3RD CERTIFICATE YEAR AND AFTER $75�4 DEATH BENEFIT AMOUNTS B. ACCIDENTAL DEATH BENEFIT ATT?�INED AGE 44 AND UNDER �I510� ATTAINED AGE 45 AND OVER �%�S=F YE4R ATTAINED CASH PAID-UP EXTENDEO TERM YEAfl ATTaINE� CASH PAIU-UP EXTENDEO TERM A6E VALUE INSURANLE INSURANCE AGE VALUE INSURANCE INSUBANCE 1 62 $00 $00 0 YRS 0 DAYS I 1 ?2 $1,72� $3660 6 YRS 209 DAYS 2 63 $114 $35�4 0 YRS 3�9 DAYS 12 73 $1,932 $3942 6 YRS 2�7 DAYS 3 64 $276 $S 16 2 YRS �6 DAYS 13 7=� $2,142 $�4206 6 YRS 27� DAYS � 65 $444 51254 3 YRS b� DAYS 14 7� $2,346 ��44=�ti 6 YRS 275 DAYS 5 66 �606 $1638 4 YRS 7 DAYS 1� 76 $2,��0 ��466S 6 YRS ?6� DAYS 6 67 $780 $2022 4 YRS 290 DAYS 16 77 $2.75=F $�1573 6 YRS 2�g DAYS 7 68 $954 $2376 � YRS 139 DAYS l7 73 "�2,9�2 $5058 6 YRS 194 DAYS 3 69 $1,134 $2712 5 YRS 299 DAYS 18 79 �3.156 $524�4 6 YRS 147 DAYS 9 70 $1,332 $3060 6 YRS 67 DAYS 19 80 $3,360 $�418 6 YRS 90 DAYS 10 71 $1,530 $3372 6 YRS 1» DAYS 20 81 $3,552 $��62 6 YRS l4 DAYS Beneficiary: ESTATE, UNLESS SUBSEQUENTLY CHANGED. 579-SCHIREV!