HomeMy WebLinkAbout07-24-14 (2) O.C. Form 1
Petition for Settlement of Small Estate
(Rev. 10/04)
In the Court of Common Pleas of Cumberland County, Pennsylvania
Orphans' Court Division
Estate of Stephen L. Miller �
Late of Middlesex Township � � I _ '� . U�C� Z
Cumberland County, Pennsylvania, deceased : No.
Petition for Settlement of Small Estate
Pursuant to section 3102 of the Probate, Estates and Fiduciaries Code, the
undersigned petitioner respectfully represents that:
,..,
1. The name and address of the petitioner are: c7 '�"'. _,��
C O -1-" -z-� ;-�-z
30 Maizefield Drive �� c__ r-, ;c�
Shippensburg, PA 17257 ��:�' r-��- t '��
�
�n�r�_ �.., � �
2. The relationship of the petitioner to the decedent is: ��
son c�}C;;� ' �;' t � �-;
�'�; �aa �,_:� ;„
3. The decedent died on: �* rv `"�;
October 17, 2011 �"'
4. The decedent was domiciled at time of death in Cumberland County,
Pennsylvania, with a last family or principal residence at:
The Claremont Nursing & Rehabilitation Center, but prior thereto lived
and was domiciled at 167 Amy Drive, Carlisle, PA 17013
5. The decedent's social security number is: 165-38-0358
6. The death certificate is attached hereto.
7. The decedent died:
� (a) intestate
❑ (b) testate
If the decedent died testate:
❑ (i) thz will has been probated, and a copy is attached
hereto. Letters have been issued to:
1
�
, . .
❑ (ii) the will has not been probated and the original will
is attached hereto. �If not attached, explain.J The
personal representative(s) named therein is (are):
8. The name(s), relationship(s), and interest(s) of all parties beneficially
interested in the estate are:
Name Relationship Interest Sui Juris
Estate of Theresa P. Miller spouse (now deceased) 100% Yes
[Petitioner is the sole heir of the Estate of Theresa P. Miller]
9. A spouse's elective share:
� (a) has not been claimed (Spouse died on 02/22/14)
❑ (b) has been claimed. [Give details.]
10. If the decedent died testate, the decedent:
❑ (a) was not married or divorced after the date of execution of
the will
� (b) was married or divorced after the date of execution of the
will. [Give details.J
11. If the decedent died testate, the decedent:
� (a) did not have a child or children born or adopted after the
date of execution of the will
� (b) had a child or children born or adopted after the date of the
execution of the will. [Give the name and date of birth or
adoption of each such child.J
12. The decedent died owning property (exclusive of real property and property
payable under section 3101 of the Probate, Estates and Fiduciaries Code) of a gross value not
exceeding $50,000, which is itemized below. (Include account numbers and registration
numbers, etc. If a bequest is adeemed, explain.J
2
. • .
Item Amount
Wells Fargo Bank Checking Account#1 O l 0187826390 $10,115.99
Wells Fargo Bank Savings Account#1010187826400 247.22
Total $10,363.21
13. An itemized statement of all claims against the estate is set forth below:
(a) The following person(s) claim(s) the family exemption under
section 3121 of the Probate, Estates and Fiduciaries Code by virtue
of being a member of the same household as the decedent:
Name Relationship Amount or Items Claimed
NONE
(b) The following persons claim reimbursement for debts, expenses,
and other claims (including inheritance tax, if applicable) they
have paid with their own funds:
Nature of
Person Claiming Date of Debt or
Reimbursement Payment Pa�ee Expense Amount
NONE
(c) The following claims remain unpaid:
Claimant Nature of Claim Amount
NONE
14. � (a) All claims are undisputed.
� (b) The following claims are disputed:
[Give detailsJ
15. The petitioner has paid or will cause to be paid all Pennsylvania inheritance
tax due on all property to be awarded under this petition.
16. All parties beneficially interested in the estate, other than the petitioner,
including all holders of claims that are denied, or, in the case of an insolvent estate, all holders of
claims who will not be paid in full, have: N/A
3
� � r
ti • .
� (a) signed the joinder in this petition which is hereto attached;
or
� (b) been mailed at least ten (10) days written notice of the date,
time, and place of the Orphans' Court audit session at
which the petition will be ruled upon by the Court, a copy
of which notice is attached hereto.
17. Your petitioner proposes:
(a) that the family exemption, if any, be paid or satisfied as follows:
N/A
(b) that the following claims be paid: [Refer to section 3392 of the
Proaate, Estc�tes and�'ic�ueia;°ies Cod2 t� establi�h prioriry among
claims, if necessary.J
Claimant Nature of Claim Amount
NONE
(c) the balance, if any, be distributed as follows:
Item Amount
NONE
18. Attached Exhibits are as follows:
A. Death Certificate of Stephen L. Miller
B. Death Certificate of Theresa P. Miller
C. Letter from Department of Public Welfare indicating no Medical
Assis�ance reirribursement�iue �o tlie State �f Pciin�yl�ailia
ure o etitioner
Typed Name: Keith R. Miller
�' y �---
Signature of Attor ey for Petitioner
Typed Name: Michael J. Connor, Esquire
Supreme Court I.D. No.: 75927
Office Address: 247 Lincoln Way East
Chambersburg, PA 17201
Telephone Number: 717-262-2185
4
Verification
The undersigned petitioner hereby verifies, subject to the penalties of 18 Pa.
C.S.A. §4904 (relating to unsworn falsification to authorities), that the facts set forth in the
foregoing petition which are within his (her) knowledge are true, and, as to the facts based on
information received, after diligent inquiry, he (she) believes them to be true.
Date:
' nature of Petitioner: Keith R. Miller
Joinder
I (we), the undersigned, being parties other than the petitioner beneficially
interested in the estate of the foregoing decedent, do hereby certify that I (we) have read the
foregoing petition and join in the prayer thereof.
None
5
t � . .
� �QCAL REGlSTf�AF�'S CERTIFfCAT10N OF DEATH
WARNING: It is iflegat to duplicate this copy by photostat or photograph.
�ee for this certificate, �6.00 '���If/��������������.�� Tl:is is t� c�rtify that the inioi:mation here aiven is
�'' p��N QF pE corLectl �o d from an oriQir.al Certificate of Death
�,o F, N,y-._ y - p:e
�,��`o���^��G� duly filed v�iih i,1e as Local Re6istrar. The oriainal
!:g�a � � • \,�?1 certitic3te ��ill �e forwarded to the State Vital
� . z'i
��°; �; jn�� Records Oriic� for permanent filinQ.
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"9�EN1 CF,� .�'e�.c.�C�� �-X' � 8I
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Certification Number """""""� Local R�Qi�trar Date Issued
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H105-143 REV 11f2006 COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS
TYPE I PflINT M . .
r�w�rr CERTIFICATE OF DEATH
aucic wic (See instructions and examples on reverse) �rA�Fl�NuMeeA
1.Neme o�oeceden�(Funt m�aae,las4 wlfu) 2 sex a.social seauiry rJ�mCer 4.oem d oeam(Mmm,my,v�)
Ste hen L. Miller Male 165 - 38 -0358 10/17/2011
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Wnm. dn nwc �.bxnn Haspital: Other. �
62 v,�. 5/2/1949 Carlisle, PA p,,p„��, ❑ERlOulpatleM Oooa �NunipHOme ❑A�m� ❑an��-sx�r
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� (II yas,�pedy Cuban. . (S7�N
� � Glmiberland Middlesex Ztap. C aremnt Nursing & Rehab. Center M�.����� White
. n.oecee��rs uus�ww � mwan�mre ' mosi d wo �ra.oo��s�e�am iz was o.reaem.ve�n me �a oeceaMrs�uon�SaedN�r�va���ea1 u.wmd sue:Ma�4 ww�n+.�we, is.s�a spo�..ln+Yaa,a�+mww,re�l
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c da
Service Technician Motorola Co. ❑r:� �r+o 1 Married Theresa P. Natcher
- ie.oae�enrs Meaq nmress Isiree�.cnr r rown.sra�e.na�e) oeceaa�rs oitl��m • Noxth Middleton r
nrn�l Resitlenre na Su1e PA uve in a t7a�]Yes.Decedent tived in "m-
167 Amy Drive ��c�H C,lmiberland T0N�f8""" na.❑��i„ms�w�1VBtlW� �i
1 PA ���o
1&Fatlre�s Neme(Fe��e,hsL surtu) 19.Motlrrs Name(Fut4 Mtlme,maEen wmemel
Sterrett - Miller Florence - Brocker
20e.InMmenCS Name(TyPe I Prml) ' 2(Ib.INwnunYS MWny ALNsu(S�aN.dq'�bwM tlate,zy mOe) .
Theresa P. Miller 167 Amy Drive, Carlisle, PA 17013
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o ❑ e� ❑ w��swe �w..c�w�«��.u�nw��a 10/18/2011 Ebans Cr�natiOn Services Leola, PA
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.' m sigiawrc d wne� (a Pa z2h.ucmme Numhar 72c.Mame aiw�wa�ess a Feotny . .
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_ � FD 012633 L Fkvin Brothers Ftiuleral Home, Inc., Carlisle, PA 17013
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c.re�y m�.a a.em.
� Nems 2426 mua he mnpleted hy W� 24.ime ol DeaN 25.Dale DeeO(MOnlh,daY,YeM 28.Wa5 Case Rel m Medcel Exartdnet/COraner la e flee9on Otliv tllHn Gemallon of OanaAO�7
- ,���� �,'15 A M. ct-aber I �- 2 0 I l ❑Y�
� � CAUSE OF DEATH(Sea Instructlons and�xamplu) � pppo�ela nlenaC Per1 II:FsW dMr gjq,���m������deam. xB.UE Tabccm Uee Comfiu�e m DeaN7
Xem 77.Pa21:EMer Cie chain d even�s-6wa�n�hguri%s.a mmpOCaliau•tlrct d�tlY aueed tlw dmN.DO N0T xHar bmiYul avenh wch as rart9ac erteat, � Onset lo Death bui not rtwltNB n tlw uMeM�M cauee T'��PM l ❑Ya ❑P�ol�aElY
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n auee 6he m 9�ro e. Due b(or as e areeq�Ce dl: � d asm
�EALYWC CAUSE ���
j . �aa�,.ar Mury mn�meiee me � � ❑Na p.�wu,aa c�e�nem e�mye m i year
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� 'LQCAL REGt�T�i�R'S C�F�T[�I��TIO� O� DEATH
W'�fiR�3�Ni�: tt is i(lag�3 �o �:�pl;�a#� t�-�i� ���Y bY phc�t�s#a} cr pho`o�,ap�.
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�� ���"- �l �_ �il..d �IiI, �.��. � L�:.�,1 P���istrar. The on�ina'
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;,�; �,: �-:tii.�ur= tiw.il be t�r�4arde� to the S.ate Vita
=� s ��3y ��j F:��Jii.;� Uilii,� i0i ���CiT'.'.'.:1�°C'it�il'_i3�
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Ceriiiicatio� iv�rrnber . ,,; r �c�.. ReJtstr�i � �Da�e Iss�:ed
TYP��p������ COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAI RECORDS
P«ma^•^= CERTIFICATE OF DEATH 5<ateFileNUmb�r.
Black Ink
1_Oec�tl�ne's LeQal Nami(Firrt,Mitltlle,Lasi,Suffix� 2.Sax 3.Social Sew�iry Numb�r 4.DaC�of Dsa[h(MO/Day/Y�)(Spell Mo)
Thereaa P.Miller . Femaie 'I86-28-6486 � February 22,2074
Sa.P.atrGast 6irthtlay(Vrs) Sb.Under 1 Year Sc.Under 1 Da 6.Date of BiKh(Mo/Day/Year)(Spell Monch) 7s.BirthPlau(CiSy and SUta or For�ign CounVy)
Monihs Oays Hours Minutes CBfliSlO,PA
79 July 5,'1934 7b.BiKhplacs(COUnty) Cumberland
Sa.Rnsttlence(Swie or ForeiQn Gountry) Sh.Rasitlencw(Streec antl Number-Inciude Apt Na.) 8G Oid Decodent Live in a Towruhip?
P°` 30 MaizeTioltl �IYes,tlecedsn!Itved in Southampton Twp. t,,,,P_
Sd.Risitlenu(Counq) .
Ffenklltl Se.R�siA�nc�(7Jp Coda) "1'7257 0 No,tlecedenc lived wtthin Ilmits of clry/boro_
9.Ev�r in US Armsd Forcef7 10_Ma�ital StaNS ai Tim�of Daath 0 Married �[W�tlowstl il.SurviNnQ Spouse's Name(IT wifa,Qivw name prior tn first ma�riags)
0 Vss �[No �Unknown �Divorced �Nevsr Marrtad 0 Unknown �
12.FathsYs Name(First,Mitltlle,last,SufFlx) 13.Moth�r's Nams Prlor ta First MarriaQe(Fin[,Mitldle,LasY)
Glenn E.Natcher Viola P.Porter
14a.InformanYS Nam• 14b.Relailonship So Dseedent 14c IntortnanYa MailinQ Addrwss(SYrset and Numbsr,City,5[ac�.Zlp Code)
� Keith R.Miller Son 75�ead E Qd Lane ShipPens6urg PA'17257„".... ... ....... ....... .....
G ...""'-_' """"" '�_�c"iac.o.-"e_acn _scto27 ....._ .... " """- ""' .
,� .......""'_"....""' """"""........ ..."""'_'..." "'_""' ....
, °.. ...._..' "' ' ._. ........
�f U�ath Occurretl In a Hospital: �Inpai(anC �It Deafh Occurt�C Sam�wh�r�OCt+er Than a Hospital: �Hospic�Faclliry � �J Decsdent's Hom�
y EmarpancY Raum/OUtpatisnt O Dead oti A�riwl �• Nursin Home/LOn -T�rm Care Fac(Itty OH�er(Spetify)
�S 35b.Fa4lity Nam�(If nuY InntituHOn,sW�str�et antl numbsrJ 15�City or Tawn,State,anG Zip Cotl� 15d.Counry af Oeath
(J� z Chambecsburg Hospitai Chambersburg,PA�720� Franklin
�� X � 16a.M�[had of Dispositlon Q Burial C�smation i6b.Oau of Oisposi�ion 16�Plau af Dispastiian(Name of cemwtary,cswma2ory,o�aihe�plau)
�� p nemo�al from s:ne p oon.non Fabruary 28,20'14 Hollinger Crematorium
�' Ocher(SP sUfi')
�
� 16tl.LocaLOn M Oispo ition(Ciry o�Town,Siate,and 2ip) 17a.SiQnafu�e of Fu e Licsnsse or Person In CharQe of Interm�nt 17b.Licsnse Number
� Mt.Holly Springa,PA�7065 FD-O'12984L
� 17c Nams an Complets Addrssa W Fun�ral Faeili[y ' �
Foqelsanger-Bricker Funeral Home'I'f 2 W King St.PO Box 336,Shippensburg,PA'17257
� 18.p�csA�nY's Etluwtlon-Ch�ck eh�box that G�st descrtb�s ths 19.�sc�dsrtt ot Hlspanic OriQin-Ctieck the 20.Oecedeni's Racr-Clieck ONE OH MORE races to indiote what
hlghesC tleQre�o��evs�ot school completed at the time o7 death. box thrt best tl�scrfbss whecher th�decedant ths deceAent constdared himself or hendf io ba.
�Sth{rade x i�ss is Spanish/Hispanic/LStino.Check th�'NO" ]�Whit� � Koraan
� No diploma,9ch-12th arad� box H d�utlwnt is no[Spa^bh/Hispanic/Latlno. O B�+ck o�AfMr�n Am�rican ��K+++m��
�[Hiph school traduau or GED complst�d $[No,no[Spanish/Hispanic/latino 0��atican Indian o�Alaska Native �Othe�Asisn
�Some collegs credli,but no deQree O Yes,Mexican,Mexton Art�arican.Chicano 0�����^d��� �Gu manla oir�Chamorro
�Assodau d��ree(t.Q-AA.AS) 0 Yes.Pu�rto Rlon Q Chines� �ymoan
Q Bachelo�'s d���e(s.Q.BA,AB,BS) �Yes,Cuban O���Pino 0
0 Mast�Ys d�ar��(e.Q.MA,M5.MEna,MEd,MSW,MBA) 0 Yes,o[h�r Spanish/Hispanic/LStino Q laPanese O aher PacMc Islander
0 �oceorav(e.Q.PhD,Ed0)or Profeaional dsar�e (Spsdfy) 0 Ocher(Spsdfy)
.MO.DDS,OVM.LLB,lD
21.D�eedenYS Sinals Rac�Salf-0ssi¢nation-Ch�ck ONLY ONE io Intlicais wha2 the tl�cedsnc consitlereG himsalf or hersalf to b�. 2b.Decetlinc's Usual Occupation-Indicste typi of work
�yyh� - Q Japanese 0 Samoan dans Gurinp most of workinQ Iifs.DO NOT USE RETIRED.
Q Black or African Art�eriqn �Korean �Othsr Paciflc Islantler Telaphona Operator
0 qrt�erican Indian or Alaska Na�iv� �Vl�tn m�se �Oon't Know/NOC Sure
y� Q Asian Indlan 0 Oth�r Asian 0 RNused 22b.Ki�A of Businass/InAUSW
� 0��;,.�� 0 NaCiv�Hawaifan O osn.r(spea�y) Teiephona Company
� �Fllipino �Guamanian o�ChamoRo
ITEM523s-23A MUST BE COMPLETEO 23a.Oa[e P�onounutl D�atl(MO/Oay/Y�) 23b.Siana�ur�of Ps�son P�onouncinQ�eath(Only when appiicabls7 23c.Lic�nsa Numbar
BY PERSON WHO PRONOUNCES OR �
CER'TiF1E5 DEATM
23tl.Date SianeG(MO/Oay/Yr) 24.T1ma of Death
� Pronouncad'12:49 PM 25.Was Medipl Fiaminer or Coroner Contacted7 � v�s � No
CAUSE OF DEATH App�oxlmaie
26.Part 1. EMer the chain of evenu-dis�uas,inJuries,or eompliotlons-that dir�cNy ous�d tha death.�O NOT�nt�r terminal rvenu such as eartliac arrest. �^�arv��=
respiratory arcest,o�vsnvicular flbrlllation wiihout showfnQ tha etloloQy. OO NOT AB6REVIATE. Enicr only on�aus�on a Iin�.Atld addiYional�in�s If necessary Ons�c to Death
IMME�IATE GUSE --�> Probable acute cardiac event
(Final dlzease or mndition Oua to(or as s consequence o�: _
rasuiLnQ In deach)
b.
51qwnNally ilrt wndltions, Due to(or as a mnsequ�nce o�:
if anY.I�adinp to th�ous� '
Iise�d o��in�a. Enter the e ou•so(or as a eo.,asy�.nc.ofl:
UNOERLYIN6 CAl.ISE _
� (dls�as�or inlury shat __'__"'
ini4at�d tht w�ntc r�zulHnp d. Du�to(o�as a cons�qusnu ofl: �
� In d�ath)LAST. . �
� 26_PaR 11. Enier oth�r ' ifi t dit'o ontributin¢to deaih but noi resultinQ In the undsrlyinQ cause piven In Part 1 27.Was an aucopry p�rformedl
y Yes No
� 28.W�r�autoPSYftndinas avaflable
to compleea N�aus�uf d�aYh7
}�' � 0 Yas 'No
� 29.If F�mals: 30.Did Tobacca Us Contribut�to Oaach7 31.Manner of Death
-�NOt preanant wlthln part year �No QO Probably �$Natural �Momidds
� Pr�anant at tim�of dsath Unknown �AccldenL� 0 P�ndinQ Im�sSlQation
�' 0 Not preQnanc,but pManant wlthin 42 tlays of dasth 0 Sulclda �Could nnt be tleterminad
Q Not preQnant,but pr�Qnani 43 days to 1 year betor�deaih 32.Dat�ot Injury(MO/Oay/Yrj(Spail Month)
Q Unknown It P��anant withln!h�Pat[Ysar - . 33.Time of Injury
34.Plac�ot Injury(�-L.heme;conrtruction slte;farm;sGfiool) 35.Loution of Injury(SVeet and Number,Ciry,County,Snts,Z(p Cotle) _
3fi.In)ury at Work 37.�f Transpartailon Injury,SOecify: � � 38.Describe Now Injury Oceurred: �
�Y�s Q Oriv�r/OP�ram� Q P�GesVlan�
O No 0 PasssnQer 0 Ochsr(SP�ctfy)
39a_Grtlfl�r-physlGan,urtlflsd nurse pfattitlonsf�msEiul�xaminar/wroner(Ch�ck only on�): �
�Csrtifyinp only-Toth�6est W my knowl�Ap,d�ath occurred t1u�to th�ous�(s)and mann�r stated.
�Pronouncina&GrLfyinQ-TO th�b�st of my knowlsdae,death occurr�d at t1�e tlme,date,and plau,and du�to ths cauze(s)and m>nn�r stated.
$M�dical Examinsr/COron�r-On N�buis of sYaminaHOn�nd/or Inv�rtlQatlon,In my opinlon,d�ath ocwrr�d at the tim�,d�te,�nd plaee,and du�to th�ous�(s)and mannar statsd.
s�Qn.c.,r.ot urt�na:� �-=�L A �// 9 nu.m«rare.r: Deputy Coroner �IC�nse Numbef:
39b.Nama,Addrsss and Zip CoAe ot Psrson ComplecinQ Causs of Wath(lum 26) �., 39c.Oat�SiQn�d(MO/DSy/Yr)
Mr.Kenneth L Pefffer Jr_ �497 Loudon Road,Chambersbury,PA�7202. , _ Fabruary 25,20�4
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�'� pennsylvania
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DEPARTMENT OF PUBLIC WELFARE
July 16, 2014
WALKER CONNOR &SPANG LLC
JULIA M METZ ESTATE PARALEGAL
247 LINCOLN WAY E
CHAMBERSBURG PA 17201
Re: Stephen Miller
SSN: ###-##-0358
Dear Ms. Metz:
Pursuant to your letter dated July 07, 2014, the Department's, Estate Recovery
Program, has reviewed the information you provided regarding the above-referenced
individual.
It has been determined that this individual did not receive any type of assistance
during the questioned period.
Therefore, according to the information you provided, the Department's Estate
Recovery Program will not seek any recovery from this estate. If your client applied for
Medical Assistance and had an application and/or hearing pending at the time of death,
please advise us and provide any additional information that may affect a recovery by our
Department. ;�;
Thank you for your cooperation in this matter. If you have any questions, please ` �°
contact me. =
Sincerely
�� Y�
Vince A. Porter �
Recovery Section Manager
(717)772-6604
Bureau of Program Integrity � Division of Third Party Liability � Recovery Section
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
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