HomeMy WebLinkAbout09-08-05
Register of Wills of __~~~mbe~land____ County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of Janet Irene Gillam
also known as
No. 21-05- 802
, Deceased
Social Security No. 193-30-0383
Nancy D. Lemmons
Petitioner(s), who is/are 18 years of age or older, appl(ies) for:
(COMPLETE 'A' or 'B' BELOW)
D A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the Administratrix
the Decedent, dated and codicils dated
named in the last Will of
State relevant circumstances, e.g., renunciation, death of executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents
offered for probate; was not the victim of a killing and was never adjudicated incompetent:
~ B. Grant of Letters of Administration
(c.t.a; d.b.n.c.t.a; pedente lite; durante absentia; durante minoritate)
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:
Name
Relationship
Daughter
Residence
Apt. 101,2514 Tunlavr.Road NW ~.~
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Washington, DC 20007c Q c,n
35 West Maple Avenue .-)
Shiremanstown PA 17011:-
Joyce M. Gillam
Nancy D. Lemmons
Daughter
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland County, Pennsylvania with his/her family
or principal residence at 403 Allegheny Drive, Upper Allen Twp.
(list street, number, and municipality)
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Decedent, then
97
years of age, died
08/25/2005
at Messiah Village, Upper Allen Township, Cumberland County, PA
(Location)
Decedent at death owned property with estimated values as follows:
(If domiciled in PAl All personal property
(If not domiciled in PAl Personal property in Pennsylvania
(If not domiciled in PAl Personal property in County
Value of real estate in Pennsylvania
$
$
$
$
7,000.00
situated as follows:
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant
of letters in the appropriate form to the undersigned:
ignature
yped or printed name and residence
Nancy D. Lemmons 35 West Maple Avenue
Shiremanstown, PA 17011
Prepared by the Pennsylvania Bar Association
Copyright (c) 2004 form software only The Lackner Group, Inc.
Form RW-1 (1991)
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumberland
The Petitioner(s) above-named swear(s) or affirm(s) that 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 representative(s) of
the Decedent, Petitioner(s) will well and truly administer the estate according to law.
S~m to o,"ffi..,d ," ,eb,,'bed )\ ~.$ ,(Q, cJ2 n1.='A-JAAl L
Nan y D. mmons
otk>
before me this C) - day of
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No.
~
21-05- ~
~O~
Estate of
Janet Irene Gillam
, Deceased
also known as
Social Security No:
193-30-0383
Date of Death:
08/25/2005
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AND NOW,
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, in consider~tiOljl
of the Petition on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters D Testamentary 00 of Administration
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(c.I.a.; d,b,n.c.t.a,; pendente lite; durante a~sentia; durante minoritat~5
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are hereby granted to
Nancy D. Lemmons, Administratrix
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in the above estate and that the instrument(s) dated
described in the Petition be admitted to probate and filled of record as the last Will of Decedent.
\~ndo.., Si?.Ar1~1 1-1hl1.()b"*~
Register of Wills it
FEES
Letters........................................$ 45. co
4.(.::>0
Short Certificate(s).... ........... ...... $
Renunciation..... ............ .............$
5.00
Attorney:
Gary L. James, Esq.
Affidavits ( )...........................$
I.D. No:
27752
James, Smith, Dietterick & Connelly, LLP
134 Sipe Avenue
Hummelstown, PA 17036
Extra Pages ( ),...................$
Address:
Codicil............ ... ... ...... ...... ..........$
JCP Fee.....................................$ ~LJ .CiJ
Telephone1 717/533-3280
E-Mail: glj@jsdc.com
Inventory.................................... $
Othe~~~....$ 5 0.:')
TOTAL............................$ _I oq . DO
Prepared by the Pennsylvania Bar Association Copyright (cl 2004 form software only The Lackner Group, Inc,
Form RW-1(1991)
SEP-06-2005 11:38
Register of Wills of
Estate of
Janet Irene Gillam
also known as
The undersigned,
Joyce M. Gillam ,
Cumberland
County, Pennsylvania
RENUNCIATION
No.
2H5- ~ 8CbJ
Daughter of Decedent of
(Relationship) (Capacity)
the above Decedenl, hereby renounce(s) the right to administer the estate and respedfully request(s) lhat Lelters be issued to
Nancy O. Lemmons
WITNESS my/our hand(s) thio
Swom to or affirmed and subscribed
before me this
6th
day
o,~
NotaryPublicKurt Berlin
My Commission Expires; 6/30 /200 9
(Signature and seal of Notary or olller offieial
qualified to ~lI;lminlsler oaths. Sho.... date of
expiration of Notary's C(lI'I'Imission,l
Prepared b)' tM Pennsylvania Bar AlOlOocIallon
COPl/righl (el 2004 form ""ltwilre only Tho ,"-W GrouP. Inc.
. Deceased
6th day of September, 2005
(Slsnat~~ ~
Apt. 101, 2514 Tunlaw Road NW
~ashington. DC 20007
rass)
(Sign~ture)
(Address)
c)
C)
(Signature)
(Address)
KURT BERLIN
Notary Public, District of Columbia
My CommIssion Expires: (:) b - ..3 0 - 01
NOTE: RenunCistions executed outside the Office of Register of Wills
in some counties are required to be notarized.
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Form #RW"'(1~')
HIO:'i.SO') REV I/O::;
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the Stat.? Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate. $6.00
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COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
Rev. 2/87
CERTIFICATE OF DEATH
1.
AGE (Last Birthday)
BIRTHPLACE (City and
State or Foreign Country)
3. 193 - 30 - 0383
PLACE F DEATH Check onl one. ee insl lions on
HOSPITAL
InpatienlO
7. Oliver Twp PA Ba.
FACILITY NAME (If not institution, give street and number)
DDA 0
NAME OF DECEDENT (First, Middle. Last)
Janet
SEX
2. Female
97 Vrs.
5.
COUNTY OF DEATH
Bb. Cumberland
DECEDENTS USUAL OCCUPATION
Upper Allen
KIND OF BUSINESS IINDUSTRV
/J? p,J"u4"1}
AS DECEDENT EVER IN
U.S. ARMED FORCES?
Ves 0 No Ii]
12.
Bc.
(~~v:o~~~~its~~o~teu~nr~?lr~)sl
11a. Homemaker 11b. Home
DECEDENT'S MAILING ADDRESS (Street. CitylTown. State. Zip Code)
403 Allegheny Drive
1rechanicsburg, PA 17055
FATHER'S NAME (First. Middle. Last)
1B. John Murfin
INFORMANTS NAME (TypeIPrint)
20a. Nanc Lemmons
METHOD OF DISPOSITION
Burial 0 Cremation ~emoval from State 0
Other (Specify)
F FUNERAL S)'RVICE LI
DECEDENTS
ACTUAL
RESIDENCE
(See instructions
on other side)
17a. State
PA
Did
decedent
Jive in a
township?
17b. County Cumberland
MOTHER'S NAME (First. Middle, Maiden Surname)
19. Lola G. Rhoads
PA 17011
lIems 24-26 must be completed by
person who pronounces death
24.
27. PART I: Enler the dl.ea.... InJurle. or compllcallon. which cau.ed the death. Do not enter the mode of dying, .uch a. cardiac or r..plratory arrest. .hock or he.rt failure.
Lilt only on. cau.e on each Une.
IMMEDIATE CAUSE (Final
disease or condition
resulting in death)~
Sequentially list conditions
if any, leading to immediate
cause, Enter UNDERLYING
CAUSE (Disease or injury
that initiated events
resulting on death) LAST
E
DUE TO (OR AS A CONSEQUENCE OF}:
WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH
PERFORMED? AVAILABLE PRIOR TO ~ 0
COMPLETION OF CAUSE Natural Homicide
OF DEATH? 0 0
Accident Pending Investigation
Ves 0 NoB VesO No 0' Suicide 0 Could not be determined 0
DATE OF INJURY
(Month. Day. YElar)
STATE ~lLE NUMBER
SOCIAL SECURITY NUMBER
ERlOutpatlentO
Residsnce 0 ~t~:~fy) 0
RACE. American Indian. Black. White. el
(Specify)
White
10.
MARITAL STATUS. Married.
Never Married, Widowed,
Divorced (Specify)
14.Widowed
SURVIVING SPOUSE
llfiNife. give maiden name)
He. IKl Yes, decedenllived in
UDDer Allen
twp.
17d. 0 ~~h~e~I~~?~i~I~~ of
citylboro.
23b. 23c.
WAS CASE REFERRED TO A M~~AL EXAMINER ICOIRONER?
26. Ves g) '~7 No 0
; Approximate PART II: Other significant conditiCl1S contributing to death. but
: ~~:~a~~:::~ not resulting in the undeftying cause given in PART I.
fell j, ,.-
hs
'. (.......
TIME OF INJURY
INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED.
29.
30a. 30b, M.
PLACE OF INJURY. At home, farm. street, faclory, office
building, etc. (Specify)
30e.
Yes 0 No 0
30e.
2B.. 2Bb.
CERTIFIER (Check only one)
.~~~~:F~~tGor~~~;~~e~hJ.S~~:rhc~'~~~;~~~~uJ": t~ ~ti:~a~~:~(:r~~3r~~~~i~a~s h:t~fe~~~~~~~.~. ~~~~~. ~~~ .~~.~~~:~~.~ .i:~~ .~~.)............
'MEDICAL EXAMINER/CORONER
On the basis of examlnatlon and/or Investigation, In my opinion, death occurred at the time, date, and place, and due to the causes(s) and
manner as stated.,.... .. ......................... ...................................... ...,.... ....,...... .......................".........,...
31a. ~
REGI
33.
J2J.dio<i II ;t
.0
30d.
LOCATION (Street. Cityrrown, State)
301.
SIGNA TU~E A~D TITL~ 0; CERTIF.IER . .' / i'j
31ti- -:5 UO-U 7//,)~L,(~.)-?L.- I" J. LL-
L1CEN~E~UM~ER r-- ,,:_ DATE SIG~EO ~ont': Dr. Year)_
31c/J1...fof;:?J t.f 7'J 31d. [/<6.- Ci.'S ',)(/i"
NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH
(Item 27) Type or Print SAltA.'-I /';ODf.'...[. A j(~\ fci 1,,1 D
100 ,Yll I.int'.' L>r 1<<2-
32. (lJeCf7CiIJiC,,';:;b/'C' ') l-C~G'
DATE FILED (Month. Day. Vear)
34.