HomeMy WebLinkAbout08-18-15 PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF (I&h76,r,?Z#ALb 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
Name: Vvri3 6fJ. 40/1 File No: -2
a/k/a: od P Lo (Assigned by Register)
a/k/a: <S7. 1"
a/k/a: --'4rye Social Security No:
Date of Death: 4 UeJ4.5q, Zoe/tom' Age at death: 910Decedent was domiciled at death in (�u County, )1 (state)with his/her last
principal residence at 8 /V• M 1pre - /^/'sla
Street address,Post Office and Zip Code City, ownshi r Borough County
Decedent died at No1r.4Jk4(1%e!te
Street address,Post Office and Zip Code city,
ownshi Borough County State
Estimate of value of decedent's property at death:
domiciled in Pennsylvania............................ All personal property $ 07S
If OGiD`e v
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. ... $ .®0,• o a
Real estate in Pennsylvania situated at: A,/*
(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)avers)4WshcAhep-isi m the Executor(s)named in the last Will of the Decedent,dated /YDS: Ti D L3 and Cdiaii*
thereto dated
State relevant circumstances(cg.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 bom or
adopted;and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
t& NO EXCEPTIONS ❑ EXCEPTIONS
❑ B. Petition for Grant of Letters of Administration (If applicable)
ca.a.,d.b.n.,d.b.n.c.t.a.,pendente lite,durante absentia,durante minoritate
If Administration,c.t.& or db.n.c.ta.,enter date of Will in Section A above and complete li§t of heirs.
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds4'10 divorce hada*n eggblWrd as defined
in 23 Pa.C.S.§3323(g)and was neither the victim of a killing nor ever adjudicated an incapacitatedKgt . C�.
❑ NO EXCEPTIONS ❑ EXCEPTIONS
Petitioner(s),after a proper search has/have ascertained that Decedent left no Will and was survived by th'e1f Jloo��spdast(if-7 gird heirs(attach
additional sheets,if necessary): -�- t=
Name Relationship `--IAress –�
i� W r M
73
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Form Rw--02 rev.1011112011 Page 1 of 2
Oath of Personal Representative
Official Use Only
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF I'-it M 13MUM 1> }
Petitioner(s)Printed Name Petitioner(s)Printed Address
Vorlr)a, T. $r-ost'o us hnl o, ZtLne, M6 4ni Iry$! '
The Petitioner(s)above-named swear(s)or affirms)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 Representatives)of the Decedent,the Petitioner(s)will well and truly administer the estate according to law.
Sworn to or affirmed and stibscfibed before 1C' Dm17
me this "`day of t'�' ��� Date- r*�
By:ChA.LAXQ _ i M/Z�`/ U-j Dap cs
For the Register - m Z Da of� C/)
:L3
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BOND Required: ❑ YES WINO To the Register of Wills:
FEES: y pp Y l; ° rt -T1
Please enter m appearance b m si nalLre w: -rt
v C7
Letters. . . . .. ... . .. . . . . . . ... . $ _00 Attorney Signature:
W i m
t'
Short Certificate(s). . .. .. is „ Cr') Co
( )Renunciation(s).... . . .. .
( )Codicil(s). .. . ... . .. . ...
( )Affidavit(s).... . . . ..... r—
Bond.. .......... .. . .. . . .. .:. Printed Name:
Commission. . .... .. ...... . . . . Supreme Court
Other ... . . . . . ID Number: .!
. ... . . 1 'l Firm Name:
. . . .. . . (5.( Address: O l�
ib low 76 S3
... . . Phone: 717`744 -0Z0'?
Automation Fee. .. . . .. ... .. . . . Fax: 717- 7 ` i' 7,
JCS Fee. . ... .... . ... . .. . .. . . S.OD Email:
TOTAL. .... .. .. . .. . . .. .. . . . $ 7d•5�
DECREE OF THE REGISTER
Estate of Do! l w- Lo ri 1/000Wnrd Lv File No: 8
a/k/a: v rk5 , (o L
AND NOW, f6� ( A�—,inconsideration of the foregoing Petition,
satisfactory proof having been resented before me,IT IS DECREED that Letters Tesla m est ftt ry
are hereby granted to 12CMA T
in the above osmte 2nd(if applicable)that
the instrtmient(s)dated Alp 4 3 r
described in the Petition be admitted to probate and filed of record as the last W 11( ''j)of Decedent.
Lk
ter of Wills
Form RW--02 rev.1011112011 ge 2 of 2
H 105.805 REV(9/11)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
RECORDED OFFICE OF
(
"I S T r R O F WILLS This is to certify that the information here given is
Fee for this certificate, $ ....11, p"
,, - F - correctly copied from an original Certificate of Death
MIS AUG
17 PM 3 02 0°o l` duly filed with me as Local Registrar. The original
C=
certificate= z certificate will be forwarded to the State Vital
F j% (,r= ; y;' a Records Office for permanent filing.
P 2197 � P �,11 Sir cr <<T
19 !' '-:; r ` k
Certification Number """ """""'��fF Local Registrar Date Issued
Type/Print In COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS
a'..
PInk ICERTIFICATE OF DEATH
Black nk State File Number:
1.Decedent's Legal Name(First,Middle,Last,Suf,) 2.Sex 3.Social Security Number a.Date of Deem(Mo/DeY/Y')(Spell Mol
Doris W. Long F 201-18-9626 August 9, 2015
5a.Age-Last Birthday(Yrs) 5b.Under l Year Sc.Under I Da 6.Dale of Dinh IMo/Day/Year)(Spell Month) Ta.Birthplace(CRY and State pr Foreign Country)
90 Month, Days Hours Minutes November 5, 1924shura PA
]b.emhpbce(County)
eygeslQ¢nre(State or Foreign Country) Sb.Residence lSMeet and Number-Includ¢Apt No. St.Dld Decedent I.N.Ina Township]
Y''EEII 825 N. Hanover St. *es,decedent lNet,,North Middleton two. .
ad.Residence(County) --
Cumberland Be Residence(Zip Co, 17 13 ❑No,decedent Wad within limits of city/bom.
9.Ever In LI Armed Forces? 10.Marital Status at Time?f Death ❑Mauled '�Wlkowed 11.Surviving Spouse's Name(if wife,glue name prior to first marriage)
❑yes I$,No ❑Unkno ❑Divorced ❑Never Married ❑Unkno
12.Father's Name(Fiat,Middle,Last,Suffix) 111,Mother's Name Prior to First Marriage(First,Middle,Last)
Hughlett S. Woodward Mildred Mae Nonemaker
14a.Informant's Name 141 RelatlonsMp to 0ecetlent lac Informant's Mailing Atldress lStreet and Number,CRY,State,Zip Code,
0
Donna r si us Niece 47 Eml n Ln. Mechanicsburg, PA 17055
Cs _ ----- ___ _______ Lsa Pbap Daat (Check
_ I�Death Occurred In A HoiplUl Q'reabens Of Death Occurred Somewhere Other Than a Hospital__ _ ice y 13 HospFatllny -T]Decedent's Nome__
a�I o ❑Em¢rgency Aeom/OutWtient ❑Dead?n ArrivalNursing Home/Long Term Care Facility ❑Other(Specify)
Sn 15b.Facility Name(II not Institution,give street antl numb<rl 11Sc.Cltypr Tewn,State,and Zip Code15d.County of Death
Carlisle PA 17013 Cumberland
r 16a.Method of Disposition ❑Banal Cremation 166 Date oi0ispoution Ilk Place of Disposition(Name of cemetery,...matoN.orotherpiace)
E ❑Pemoval Nom Slate ❑Donation
❑on<r(So<cl , 8/11/2015 Hollinger Funeral Home & Crematory
v16d.Location of DlsPosltlpn(City or Town,State,antl Zle) 17a Signature oIF uneral Ielicenseepr Person InChargeofih-mr,,l1]b.License Number
Mt. Holly Springs, PA 17065 7yf,gyyyr FD-138812 -
Y
E vc.Nam¢andcgmpleteadare,sgfFun¢ralFacnbY Ho 1111inaeY' Funera Home & CCrr'eemma Dry, Inc. -
3 501 N. Baltimore Ave., Mt. Holl S Tin s, PA 17U6S
18.Decedenl's Education-Check the box that best describes the 19.Decedent of Hispanic Origin Check the 20.Decedent's Race Check ONE On MORE races to Indicate what
highest degree or Ieyel of school completed at the time of death box that best describes whether the decedent th<deced-considered himself or herself to be.
❑ath grade or less Is Spanish/Hispanic/Latino.Check the'Ne" White ❑Korean
❑Nodiploma,9th 12thgrade box if decedentis not5panlsh/Hispanic/Latino. ❑Black or African American ❑Vietnamese
Hlgh schoglgraduate or GEDcompleteJ No,not Spanlsh/Hispanic/Latino ❑American Indian or Alaska Native ❑Other Asian
❑Some college credit,but no degree Yes,Mexican,McaIc.n Amark.,,Chicano ❑Aslan Indian ❑Nebee Hawaiian
❑Associate degree(e.g.AA,AS) ❑Yes,Puerto Rican ❑Chinese ❑Gua la rr
or Chamoo
E3Bacheloes degree(e.g.BA,A%85) C3 Yes'Cuban ❑FRIPino ❑Samoan
❑Master's degree(e.g.MA,MS,MEng,MEd,MSW,Ni ❑Yes,other Spanlsh/Hitpamt/Latino ❑Japanese ❑Other Pacific Island,,
❑Doctorate(e.g.PhD,EdD)or Professional degree (Specify) ❑Other(Sveclfy)
..MO DDS DVM LLB 1D
21.Decedent's Single Race Self-Oesignatlon Check ONLY ONE to Indicate what decedent considered himself herself to be. 22a.Oecedent'i Usual Occupation-Indicate type of work
White ❑Japanese ❑Samoan done during most of working life.00 NOT USE RETIRED.
❑Black or African American ❑Keraan CI Other Pacific Islander
p ❑AmericanIndia,orAlaskaNatWe ❑Vietnamese [I Don't Know/Not Sure Customer Service
❑Aslan Indian ❑Other Aslan ❑Refused 22b.Kind of Business/Industry
❑Chinese ❑Native Hawaiian ❑Other(Specify) Insurance
❑Filipino ❑Guamanian or Chamorro
ITEMS 23,.25 MUST HE COMPIL ED 23a Date P o aced Deatl(Mo/Oay/Yrl 23b.Signature of Person Pronouncing Death(Onl,when applicirl, 23c Ucens, umber
BY PERSON WHO PRONOUNCES OR /'�'
CERTIFIES DEATH .JC
.. 23tl.D e g etl /Oay/Yr Z4.Time f Dea /J {J -
30/� /O. SA"I 25.We,Medical ExaminerorCoroner Contactetl7 ❑ Yes No
CAUSE OF DEATH i approximate
'26.Part1.Enter thechainofevents--diseases,inlurles,orcompllcations-that d,realycaused thedeath.OO NOT enter terminal eventseuch as cardiac arrest, Interval:
respiratory arrest,or ventricular fibrillati-Mthout showing the eHologiv DO NOT ABBREVIATE.Enteronlyenecauseona line.Addadditionalllnes if necessary. 1 Onset to Death
IMMEDIATE CAUSE L/r 9L01 C'Fu Ce/
(Final disease or cendtion Due to(or as A consequence pfl:
resulting in death)
Sequentially Its,cbndill-, b Due to(oras a consequence of): i -
If any,leading to the cause
-- IHtetlonlinea.Enter Lhe c1
UNDERLYING CAUSE Due to(or as a consequence of). -
(dlsease or Injury mat
F Initiated the events resulting d.
in death)LAST. Due to for as a consequence of):
S 26.Pan 11.Enter gthersi¢nlllcanlconditlonscontributing to death but net resultlnRin theundeHV,gcause given mean 1. 27.Was anautopsy dert?ffinfned]
❑Yes CTNo
E ]8.Were autopsy Ilndings available
to complete the cause of death?
E ❑Yes ❑No
A 29.If�V/p.�AI,: 30.Did Tobacco Use Contribute to Death] 31.M))net'of Death
E lY Not pregnant within past year ❑Yes ❑ robably [$'Natural ❑Homiclde
Q Pregnant at time of death ❑No (g Unknown ❑Accident ❑Pending Invesligatmn
( an ❑Not pregnant.but pregnant within 42 tlays of death ❑SuIC10e ❑Could not be determined
❑Not pregnant,but pregnant 43 days to 1 year before death 32.Date?f Injury IMo/OayMl(50¢11 Monthl
❑Unknown Ire
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 Number,City,County,State,Zip Code)
36.Injury at Work31.I1 TA nspgrtatl?n Injury,Specify. 38.Describe How Injury Oct ad:
❑yes ❑Dnver/Operator ❑Pedestrian
❑No ❑Passenger ❑Other(Spenfy)
39a nIfer physician,certified nurse pracilloner,medical examiner/coroner(Check only one).
Certifying only-To the best of my knowledge,death occurred due to the cause(,)and mann,-Had,
❑Pronouncing&Certifying-To the best of my knowledge,death occurred at the time,data and place,and due to the cause(sl and manner stated.
❑Medical Examiner/COn the basis o�ftion and/j� tigatlon,In mY opinlon,tleath occurred at the time,date,and place,and due to theaus
A, s) d an etl.
J sianamre?Iceronen�(iil(�1*�9�LCfId�u2lryGCC�N deerpenlner: uanseNumber/ `�Pd373F-P
' J 39b.Name,A dress an Lp Code of p Completing Cause of Death(Item 26) C 39c.Date 51 tl(M/Day/Yr)
40.Registrar's District Number 41.Reglstra 51 ature� 42.Pegist,ar'FIle Date IMo Oay rl
it !I t>
Z.Amendments
C
se
se
H105 143
REV
0]7/201/201
Dlsoositlon Permit No. ! '6 ,Y
1 2
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LAST WILL AND TESTAMENT OF DORIS W. LONG U, o
w -n
I, DORIS W. LONG, unremarried widow, currently of Hampden Township, Cumberland
County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make,
publish and declare this my Last Will and Testament, hereby revoking and making void any and
all prior Wills and Codicils by me at any time heretofore made.
1.
I direct the payment of all my just debts and funeral expenses as soon after my decease as
the same can conveniently be done.
2.
I direct my Executor to sell my residential real estate, the household furnishings therein,
and any motor vehicles I own at the time of my death at public or private sale, the net proceeds
thereof are to be added to the residue of my Estate and divided and distributed as per my
instructions hereinbelow.
3.
I give, devise and bequeath the following specific bequests as follows, to wit:
A. $5,000 to CAMP HILL CHURCH OF GOD, currently located at 123 North 21St
Street, Camp Hill, PA, outright and absolutely.
B. $5,000 to DOUBLING GAP CENTER, INC., CAMP YOLIJWA, currently
located at 1550 Doubling Gap Road,Newville, PA, outright and absolutely.
C. $10,000 to my nephew, R. DOUGLAS SHEAFFER, outright and absolutely. In
the event he predeceases me,then to his issue,per stirpes.
FOR PURPOSES OF CLARIFICATION: I am aware that it is usual and customary
that specific devises and bequests be given priority status in estate distributions and that death
taxes, commissions, fees and expenses associated with the value thereof be paid from the residue
of my Estate and not be assessed against the individual recipients. This is in accord with my
wishes.
4.
All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever
and wheresoever situate, I give, devise, and bequeath to be divided as follow, to wit:
A. One-third(1/3) to my sister, ALTA W. SHEAFFER,per stirpes.
B. One-third(1/3) to my nephew, R. DOUGLAS SHEAFFER,per stirpes.
Page 1 (��„
C. One-third (1/3)to my niece, DONNA J. BROSIOUS,per stirpes.
5.
It is my intention that beneficiaries named before or after the date of this Will on my
life insurance, annuities, individual retirement accounts (IRAs), in Trust for or joint bank
accounts and any other assets for which I may designate beneficiaries will receive such
investments and that my Will provisions shall not control such investments.
6.
I nominate, constitute and appoint my niece, DONNA J. BROSIOUS, to be the
Executrix of this my Last Will and Testament. In the event that she is unable or unwilling to
act as Executrix, I appoint my sister, ALTA W. SHEAFFER,to be Executrix in her place
and stead. In the event that she is unable or unwilling to act as Executrix, I appoint my
niece's husband, CRAIG D. BROSIOUS, to be Executor in her place and stead. I further
direct that they shall not be required to file bond or other security in the Office of the Register
of Wills for the purpose of administering my Estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this day
of oU"Wlalal , A.D. 2013.
d�Lb (SEAL)
DORIS W. LONG
Signed, sealed, published and declared by the above-named DORIS W. LONG, as
and for her Last Will and Testament, in the presence of us, who at her request and in her
presence, and in the presence of each other, have hereunto subscribed our names as witnesses.
Page2
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OATH OF SUBSCRIBING WITNES
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REGISTER OF WILLS
CUt",9C-Z1,+AVCOUNT17,PENNSYLVANIA
Estate of Ppl'� 4
141- Deceased
0
V
F , (tach subscribing witness to
(Print Narnels)
the,K Will-B-eadicit(t)presented herewith,<(�ljfieing duly qualified according to law, deposes) and
4D
says)that the-fte /4hejt wase present and saw the above Test/Testatrix sign the same
and that -sl�-1'he k+m-y- signed the same and that 414o4 he-Libr-y- signed as a witness at the request of
the �est�tst/Testatrix in her 414if3--- presence and in the presence of each other.
X MA&
(Signature) (Signature)
&
(StreerAddress) (Street Address)
(City,State,Zip) (city,State,Zip)
Executed in,Register's-Office Executed out of Reg i.Fter's Office -
-Sworn to or affirmed and,,sub8cribcd Sworn to or affknied and subscribed
before me this day before me this day
of of
Deputy for Register 0 Tills 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.)
NOTE: To betaken by Officer authorized to administer oaths. Please have present the original or copy ofinstrument(s)at time ofnotarization.
Forin R JV-03 rev. 10.13.06
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OATH OF SUBSCRIBING WITNESS:(�..�)ry �
W.w u) C)
REGISTER OF WILLS
C14 M dfkd'etXDCOUNTY,PENNSYLVANIA ,
Estate of �d�'✓S 41 ze ���� �/O/'�tS �iQQf�k1,�lY�` 1p/Z�, �c. ,Deceased
l";Ghetto' J, le ,.(�:ar, .a subscribing witness to
(Print Namels)
thdXWill presented herewith,_( being duly qualified according m-law, depose(s) and
say(s)that she ley was ere- present and saw the above ,Testator-d Testatrix sign the same
and that _ she 1}3 -1- y- signed the same and that she44ay signed as a witness at the request of
the . @e t /Testatrix in her�• presence and in the presence of each other.
(Signature) (Signature) Jrur,,l'tk
6 C/nuser GPd
(Street Address) (Street Address)
Mechem;esba21, P# /ps*s'
(City,State,Zip) (City,State,Zip)
u
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Executed in Register's Office Executed out of Registers Office �. ��ry Q
ESco
Swom to or affirmed and subscribed Sworn to or affirmed and subscribed Do
IL V1
before me this day before me this �' day o v = X N
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ofofGO
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W
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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.)
�a� � 1bbe��liQ�t1�1�1t�1�e7 aUtNTl2C610 administer oaths. Please have present the original or copy of instrument(s)at time of notarization.
Form R6F-03 rev. M13.06