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Home My WebLink About05-19-05 UNIFORM RENUNCIATION Register of wills of Cumberland County, Pennsylvlmia ;;1 25 RENUNCIA nON Estate of Betty Mae Addison also known as Betty M. Addison, Deceased No. 2/-05- OWi'i( The undcrsigned, William E. Addison, III and Cheryl Mengle Addison, childrcn ofthe above Decedent, hereby renounce the right to administer the estate and respectfully rcquest the Letters of Administration C.T.A. be issucd to Brian M. Addison. WITNESS thcir hands this ~ day of ~.......'I,2004. LJ",b--: <to Ai I William E. Addison, 11I 1li liO k. ~o.o\\a..~ Dv~~ CL.",,,,"\-e~'-- IL } . (Address) k:>\qzo ~CIAL llPLo .....0anIII NalllrNlc. ....11I... ... c...._: . .1lqllIw I/OfI2llOI almy Puhlic Ml' Commissiol1 Expires: [SIGNATURE ON FOLLOWING PAGEl . - . UNIFORM RENUNCIATION Sworn to or affirmed and subscribed before me this I I:".,' h,j,l'TFi"11L 1),'(,.I"lal"'....\I,~7- I LLlOih'ml rCIIIIIlCi,l1;,,".lqlc! Gt'UM.~ A c:\&scx> ~~ Cheryl A dlson Mengle ~. '7 & 51". Ill/tit [JrJI/e.- I Yr; fell un /rdjuQ I Ill- /705D (Address) g'Wl day of ~<;, (Jt ,2004 ,&LLLLC;Jn;;3~[u~ Not"')' Puhlic My COllllllissiou Expires: NOTARIAL SEAL GlENDA ANN BORDNER. NotaIy I'IJIIlc 8IIv8r SprIng Twp.. Cumbe!t8nd County Comm\!l.Sl!!"..J'xplres Aug. 12, ~. ,I PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Social Security No. 292-24-7039 No. 21- oS" OQSR To: Register of Wills for the County of Cumberland in the Commonwealth of Pennsylvania Estate of Betty Mae Addison also known as Betty M. Addison, Deceased The Petition of the undersigned respectfully represents that: Your Petitioner, who is 18 years of age or older, applies for letters of administration c.t.a. on the estate of the above decedent. Decedent was domiciled at death in Silver Spring Township, Cumberland County, Pennsylvania, with her last family or principal residence at 14 Ashburg Drive, Mechanicsburg, Pennsylvania. Decedent, then 75 years of age, died on May 16, 2004 at Select Specialty Hospital, East Pennsboro Township, Cumberland County, Pennsylvania. Decedent at death owned property with estimated valued as follows: (If domiciled in Pa.) All personal property $ (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value ofreal estate in Pennsylvania $ situated as follows: 14 Ashburg Drive, Mechanicsburg, P A 17050 1,000.00 115,000.00 i .;,.01 o Total $ 116,000.00 Petitioner after a proper search has ascertained that Decedent left no original will and was survived by the following spouse and heirs: Name Relationship Residence William E. Addison, Jf. husband William E. Addison, III Cheryl Addison Mengle Brian M. Addison son daughter son Forest Park Health Center, 700 Walnut Bottom Road Carlisle, P A 17013 1306 Woodlawn Drive, Charleston, IL 61920 76 Skyline Drive, Mechanicsburg, P A 17050 2769 Chestnut Run Road, York, PA 17402 THEREFORE, Petitioner respectfully requests the grant of letters of administration III the appropriate form to the undersigned. ~ Bri~ ---......... , OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS The Petitioners above named swears or affirms that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner and that as personal representative of the above Decedent Petitioner will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me this I Q+~ day of ,2005 k- ~~ ---- Register r'-;:'~ NO. ",(I-[J 5 () Li 58' Estate of Betty Mae Addison, alkJa Betty M. Addison, Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW, ,2005, in consideration of the Petition on the reverse side hereof, satisfacto proof having been presented before me, IT IS DECREED that Brian M. Addison is entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to Brian M. Addison in the estate of Betty Mae Addison, alkJa Betty M. Addison. FEES Letters of Administration.......$ ~(oO.(x) Short Certificates Cd ............$ R .0) Renunciation .........................$ \o.CO ~X0~-''O._j''-\...2..~--' $ e s. (.>0 j,(\ n Ie. ()u TOTAL $~53oJ Filed 5.:.I~..:.\?5.......... A.D. 2005 Register of Wills ~ LC2cpv-b-"J Sean M. Shultz, squire Attorney J.D. No. 90946 II Roadway Drive, Suite B Carlisle, PA 17013 (717) 249-5373 AFFIDA VIT William E. Addison was admitted to Forest Park Health Center on May 24, 1996 with a diagnosis of331.0, Alzheimer's Disease and is in my care. Due to his physical and mental condition, Mr. Addison is unable to make or carry out financial decisions on his own behalf, or as an executor or administrator of an estate. Mr. Addison will not recover from the disease. 41/. Date: L\ 112J 06 COMMONWEALTH OF PENNSYLVANIA ) ): ss. COUNTY OF CUMBERLAND ) A tl:il~ On this, the !2;1h day of , 2005, before me, the undersigned officer, personally appeared, Jeff Harris, MD., known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. ~ ~~ ct1fM~ (SEAL) :\i:Jli:'..~2.!S0a' , I DoII\: ~ '1 ~-' '" ..,..co' ,',IC-'c-.,,' p. 'hHC J I~ . .. ,'~.\..<;:>c..:,.'I L;;., 1 .. ........ , t_~3~:~.~~~~~,~to:~I'::"'~' '~:~l;~:'~ :~,(,:;"):~'~' f'.:,r.c ~?2,:';~:!:~J '; 1/:..,': CJ AFFIDA VIT William E. Addison was admitted to Forest Park Health Center on May 24, 1996 with a diagnosis of 331.0, Alzheimer's Disease and is in my care. Due to his physical and mental condition, Mr. Addison is unable to make or carry out financial decisions on his own behalf, or as an executor or administrator of an estate. Mr. Addison will not recover from the disease. Date: 1/ + 85 ~ ,Lflv Joseph Pi n D.O. COMMONWEALTH OF PENNSYL V ANLA. ) ): S8. COUNTY OF CUMBERLAND ) April On this, the LL day of 1'vJMd1, 2005, before me, the undersigned officer, personally appeared, Joseph Pion, D.O., known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. IN WlTNESS WHEREOF, I hereunto set my hand and official seal. (SEAL) i----- -0""081 Seal I Dolly M. Housel, Notary P!.:t'ic \ Sou~h r,/;iddl~O!l Twp., .Cum~_,,::r:,.;C'~: t:?::~;.:J L"~.Y. r'mmISSIO'1 Ev~,es.'''''c.;-''..:-'''-,..:>, ~ " .., ../_,,"" . _....n .~.:.:.i-'.... "',.' .-. ',.~ r-f~-;:'~,~~r, P8n:-;s~.t~7_~;::;;:-- - -. ~-:.-" C:J Thi... i~ 10 certify that the information here given is correctly copied from an original certificale of death duly filed with me as LDl,,1 Rcgistr"r~ The original certificate will be forwarded to the Stale Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. /,'I('~t",oTpl,t...-.__ l~/ ~4'~,- l""~""-\~' s~' ~'. \-p'%, ~c:::I::"", 'I~~ ::'~'".d ,,~~ '*'~' "'""",,,"!'*I ~a ". .', ~l \.~./.'~",,\, , "1-9" /!I-~Y" -"--- ''''INTIi, ~ ,...... ""'''''''#'#1111'11111' ~_o~c~"~r F<:e for this certificalc-, S2.00 P 1 0 3 :2 S ,[;.1 '/ t1A'LJ 9 7004 ",,) Date l,lJFlev2/67 .c2 HJ 5- 0 Lj fJ't" COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS :J: <=) (~7~~~~d~,.u~"::i:~1t! 1,.. Computer Clerk 11b, PHEAA DECEDENT'S MAILING ADDRESS (Slrelll. CilylTown. Slale. Zip Code) DECEDENT'S 1111. Stale a 14 Ashburg Drive ~~~~6ELNCE ~~Ildelll 16. Mechanicsburg,Pa 17050 ~~':I~~I~)S l1b. Coul11v Cumberland \:~~h~P? l1d.O ~~hi~~l~\i~if~ot FATH~'S N,,!-,E (Fit, tol\deJp, last) MOTHER'S NAME (Firs1, Middl" faiden Surname) 18. M1Cnae uroan 19. Laura Wl son INFORIJANTS NAtE fl)'pelPri~) INFORMAt:JT"S MNLlNQ ADDRESS (Strut, CitylTowl1. Stale, ZlP Code) ,... Ulery Mengle "M.. /6 Sl< line Drive Mechamcsbur Pa 17055 METHOD OF DISPOSI!!2r'l PLACE OF DISPOStTION. Name ot Cemetery, Crematory . Oona(,onO Bunal ~rema1ion~emovalfromStateO(Monlh.MO.Y.Y...)20 2004 orOlherPlllCll . 21., Other (SpeCIfy) 21b. ay, 21c. Rolling Green Cemetery Hill Pa SIGNA ERAL SERVIC LlC EO PERSON ACTING AS SUCH LICENSE NU~B..F!3 65 NAME AND ADDRESS OF FACILITY 22.. 22b. VII 4-L 22e.M ers-Harner Funeral Home Inc Carp Hill, Pa 17011 Com it 23a--conl llIl co 9 liCENSE NUMBER DATE SIGNED phys'Clal1'sl1otllvallallleat~meordeathto f'/TD 06 ?qo(.. (Mol1th, Oay, Year} (ot. celllfycauseoldeath 23b. I.j f 23c. ~ It: 1 Items 24.26 must be completed by WAS CASE REFERRED TO A MEDICAL EXAMINER ICORONER? person who prol1OOOCes dealh 24. 26, Yes 0 N 21. PART I: EnI<Ir'" di.._., ..;u.... oroompliclllion. whloll uu..d lII.dulh, Do not...t..... """'" oldylng, ...11.. urdirlo or ...pl..tory .....t. o""".or 1I..1t 1.,,,,... 'Approximate PART II: Other sigl1dicant COl1dWons contributil1g to de(lth. but Lit.lonl~ 0IllI cau.. on..."" II.... : inlerval betwee nOI resultll1g Il1thll ul1dllnYlng cause given 111 PART I : ol1setal1ddealh CERTIFICATE OF DEATH .. AGE (LastBlnhday) SEX , Female STATEfllENUIolBER SOCIAL SECURITY NUMBER , 292 24 - 7039 DATE OF DEATH (MO(llh. Day, Year) .. May 16,2004 n, BIRTHPLACE (Cltyal1d StatllorForelgl1Cool1try) HOSPITAl C 1 b I"p.~.nl ag 1. 0 urn US, Ohio 8.. FACiLITY NAME (1Il1ot insti\ulion, give stretlt ilr1d number) , . . COUNTY OF DEATH 75 fRlOulp.benlO '~D R..._o.O ::~'~I 0 14. l1C.~YIlS,deCedemllvedil1 MARiTAL STATUS - Married, Nev~f~r~('s~?;jed, Married RACE -Amencal1lf1<ljan, Black, Wille, eI (Spetify) lo,Whi te SURVIVING SPOUSE 111,."!e,g"em,'''''nna,,..) " Cumberland IIe.East Pennsboro KINO OF BUSINESS/INDUSTRY DECEDENT'S USUAL OCCUPATION ".William E. Silver Spring Addison ~p c'tylboro IMMEDIATE CAUSE (FIlial dlseaseorCOlldihol1 resulhogil1dealh)_ SeqU&rl~a~y lisl collditlons ,I allY. 1Iladl11lil10 immediate cause El1terUNDERLYING CAUSE (Disease or Il1jury that ,M>aled evel1ts resuihl1\l 011 death) LAST I: F-1~Il.-Ute.Jr" RIl.-I.JR~ OUETO(ORASACONSEQUENCEOFj WAS AN AUTOPSY Vl'ERE AUTOPSY FiNDINGS MANNER OF DEATH Pl:RFORMED? AVAILABLE PRtOR TO --[ COMPLETION OF CAUSE Nalural Homicide 0 OF DEATH? 0 ACCident Pel1dingln.estigatlon iesD N~ 1'8$0 ".::..0 SuiCide 0 COUld 1101 bedetermiJled 0 DATE OF INJURY (Monlh.o..v.Y""1 TIME OF INJURY INJURY AT WORK? DESCRiBE HOW INJURY OCCURRED 26a. 28b. CERTtFIER(Checkooiyooe) '1~~J:f:~~tGJ~~~~~eg'ghl.sd~rh~~~~i~a~U.,s: t: 11e:~ha~::~(:)~~3~r~~~~a~.h:M~~~~~~,~.~.~a.I~..~~.~.m.~~,ta.d.l.t~~ ?~.)... ". 30a. PLACE OF INJURY l>uil<linQ,.tc, (Sp.cify) 30e. '" M YesD NOD ,,,. 30d. LOCATION (Slreel. Cityrrowl1. Stale) -Athome.farin,slrellt,lactory,olfico n REGISTRAR'SjlipNATURE AND NUMBER J ___ /J """,_.~ . " .,.. . ," -' ,. ...'........("-- billt>ll/.r I ....0 31b. LICENSE NUMBER 0,,,. 1'-1 D 064':/ <f'j"t- ",. NAME AND ADDRESS OF PERSON w-l0 COMPLETED CAUSE OF DEAHl (llem21)TypeorPrinl f I<~ rV"tii~~1 o ". tt"C T HaSp rri}-t- c 1'9w1" 1-1 "..~ DATE FILED (Mol1th, Day, Yea,) .PRONOUNCING AND CERTIFYING PHYSICIAN (PhyslClal1 both prOflO<.lllClfl(! dealh alld cart>tylng to cause or deathl Tothe beal of my I<l1owledge, death occurred atthe lime, dale, and place, all dduetotheca"sel(I).l1dmal1neraaetated... 'MEDICAL EXAMINER/CORONER 0" Ihe baala 01 aumlnallon and/or Inveallgatlon, In my oplnton, duth oc~urred at tile time, date, and place, al1d due 10 11I1I caulee(aland maol1e.nat.ted 3101. P4 " v