HomeMy WebLinkAbout08-04-06Register of Wills of
Cumberland
County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of Toni A. Myers No. 21- aOCXP - ~~
also known as
,Deceased Social Security No. 170-52-2041
James A. Clouse
Petitioner(s), who is/are 1 B years of age or older, appl(ies) for.
(COMPLETE 'A' or'B' BELOW)
A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the Administrator named in the last Will of
the Decedent, dated and codicils dated
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:
QX B. Grant of Letters of Administration
(c.t.a; d.b.n.c.t.a; pedente life; 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:
ame e a ons Ip es ence
Jordyn L. Myers ~$ f'lar- 1920 Maplewood Drive
3~ ~t (4S ODU ~,.e ~ Carlisle, PA 17013 ~=.:>
Ryan E. Myers I z1z e Jq ~ Daughter 1920 Maplewood DriV _ ' `'y '
` Carlisle PA 17013 ~ _
Shea P. Myers I
812s ~
Son _
1920 Maplewood Drina;: ~ a~ '
Carlisle PA 17013 -~-
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland County, Pennsylvania with his/her family Y, = ~
.. i- ,
or principal residence at 230 Marion Avenue ~ North Middleton Twp. ._
Est street, num er, an mun c pad
Decedent, then 42 years of age, died 07/15/2006 at 210 Marion Ave., Carlisle, PA
(Location)
Decedent at death owned property with estimated values 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 of real estate in Pennsylvania $
5,000.00
situated as follows:
Wherefore, Pettioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented wkh this Petition and the grant
of letters in the appropriate form to the undersigned:
gna ur or pnnte name an res ence
/^~
vl - James A. Clouse 260 Union Hall Road
Carlisle, PA 17013
t/
Prepared by tha Peiawylvenia Bar Association
~opyripM (c) 2004 form sortware only The Lackner Group, Inc Form RW-1 (t9s~ )
Oath of Personal Representative
Commonwealth of Pennsylvania
county of Cumberland
The Petitoner(a) 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 representaWe(s) of
the Decedent, Petitioner(s) will well and truly administer the to according to law. /,/(~
Swom to or affirmed and subscribed v _ r
James A. Clouse
before me this ~ day of
Q~~~lr ,aoo~
Forfhe
No. ~ ~ 21- d (Q _ ~O~
Estate of Toni A. Myers ,Deceased
also known as
social S/e/c~'urity' No: 170-52-2041 Date of Death: 07/15/2006
AND NOW, WLIAii ~ ~O ,~_ , in consideration
of the Petition on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters ~ Testamentary ~ of Administration
(c.ta.; d.b.n.c.ta.; panderrie life; durance absentia; durance minodtate)
are hereby granted to James A. Clouse, Administrator
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.
FEES «~ ~ e /1 n
Lavers ..........................................a _~G .
ShoRCert~cate(s)......~.~.........; 40•oc~
Renundation ............................... $ ~ ~~ Attorney:
Affidavits ( ) ...........................5
Extra Pages ( ) ......................3
Codicil .......................................... $
O ,QD
JCP Fee .......................................3
Inventory ...................................... S
ocner .............................. S
a
5°
TOTAL ............................ $ ~'
of Wills
David J.
I.D. No: 29078
The Wiley Group, PC
Address: 130 W. Church Street
Dillsburg, PA 17019
Telephone2 717.432-9666
E-Mail:
Prepared by the Pennsylvania Bar Association Copyright (c) 2004 form software ony The Lackner Group, Inc. Form RW-1(1991)
Register of Wills of
Cumberland County, Pennsylvania
RENUNCIATION
Estate of
Toni A. Myers
No. 21-- ;2(j()~ ~ 0 tog '8"
also known as
, Deceased
The undersigned,
PATRICIA M. CLOUSE,
MOTHER
of
(Relationship) (Capacity)
the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters be issued to
JAMES A. CLOUSE
WITNESS my/our hand(s) this
day of
~ h Ll/~
(Signature) J~
Patricia M. Clouse
260 Union Call Rod
Carlisle, PA 17013
(Address)
(Signature)
j--
(Address)
_,I
(Signature)
Sworn to or affirmed and subscribed
~
of ~~ , cOoctJ
~~M\Lj(Jl~~L
My Commission EXPires% ~
(Signature and seal of Notary or other official
qualified to administer oaths. Show date of
expiration of Notary's commission.)
(Address)
before me this
day
NOTE: Renunciations executed outside the Office of Register of Wills
in some counties are required to be notarized.
Prepared by the Pennsylvania Bar Association
Copyrtgh\ (c) 2004 form software only The Lackner Group. Inc.
Form#RW-4 (1991)
Thi" i:-. to certifv that the information here given is conectly copied from an original certificate of death duly filed with me as
Loc,t1 Registrar~ The original certificate will be forwarded to the State Vital Records Office for permanent filin~)(p ~ &9'ir
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No,
~~'o~~~
Fee for this certificate. $6.00
p
12726327
JUL 1 8 2006
Date
.......:
-1105.144 REV. 02/20C6
TYPE I PRINT IN
PERMANENT
BlACK INK 1/30-284
1. NinE! of Decedent (Fim, rriddle, lasl suffb:)
Toni
5. Age (LaslBinhday}
42
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH . VITAL RECORDS
CERTIFICATE OF DEATH (CORONER)
A
Myers
6. OateolBirth Month,da,
7.BIrttl
a trldslaleor
- 52 - 2041
STATE FilE NUMBER
4. Date of Dealh (Monlh. day, year)
July IS, 2006
v~
Oct. 24, 1963
Carlisle, PA
Reo"""" D"""', s""i~
10. Race:America"llr1diirl,Black,While,elc.
(Spec;~1
White
Bb. County 01 Death
\. Cumberland
11. Oecedenrs Usual ion Kind 01 work done most of woOli Ife. Do oat state retired.
Kind of Work KWld of Busness {Industry
Admin. Assist. Holy Spirit Hospi
. 16. Decedenl's Mailng Address (SITeeI. city I town. stale. zip code)
230 Marion Avenue
Carlisle, PA 17013
18. Father'sNlWTIe(Fil'Jl,middle,las(,slifix)
James A. Clouse
208. InloonanrsNne (Type/Prin!)
ad. FaciIlyNane(llnotinslilulion,giveslreelandlM.lflber}
210 Marion Avenue
12. WasOecedenleverir1lhe
U.S. Anned Forces?
al Dv" E1No
Decedenl's
ActuaIResidence 17a.Slale
13. Decedent'! Education (Spedly only highest grade completed)
ElementiW)' I Secondary (0-12) College (1.... or 5+)
1
17b. Counly
PA
Cumberland
Did Decedent
Livella
Township?
170 1m V",,,,,,",,,,'Uwd. North Middlp.t:on
17d. 0 No, Decedenl Lived wilhi'l
Acluallnnil9of
Twp.
City/Boro
~
~
A. Clouse
19. Molher's Name (First middle. maiden sumame)
Patricia M. Kell
2Ob. InformCllt's MaUing Address (Slreet, city I town, stale, zip code)
260 Union Hall Rd., Carlisle, PA 17013
21c. P1aceofDi9po$ilion(Nameolcemel~.Cfemaloryorolherplac:el 21d. Localion(Cily/klwn,state.zipcode)
Evans Crs:nation Services
Leola, PA
. ~
Complete Items 23<H: only when certtfying
physici8f1isnotaYaiableallimeofdealtllo
certify cause of death
Items 24-26musl beoompleled by person
who pronounces dealh
Brothers Funeral Hane, Inc., Carlisle, PA 17013
23b. license Number 23c. Dale Signed (Monlh, day, yearl
24. TimeolDeath
Aprx. 8:00
25. Dale Pronounced Dead (Month, day, year)
P.. July IS, 2006
26. Was Case Referred 10 Medical EXarrlner I Coroner lor a Reason Other than CrematKln or Donation?
ll!1v" DNo
CAUSE OF DEATH (See Instructions and uamples)
lIem 27. PART I. Enter lhe dlOOJimnll.- diseases, If'lJU/ies, or complications - that di'ecby caused !he death. 00 NOT enter terminal e'o'eflls such as car(\iac arrest,
resplraloly arrest. or 'o'eflb'icl.Wflbrllalion wiltloulshowi1g the eliology.lislonly one cause on each Ins
: Approximaleinlerval
Oosel 10 Dealt1
P<r1 II Enlerolhersianili::anl c.ondimsmnlribulina Iodelllh 2B. Did Tobacco Use Contribute 10 Deatt1?
but not resulting in !he underlying cause given in Part lOVes 0 Probably
~No DUm".."
29. If Female
o Notpregnantwilt1inpastyellf
o Pregnantallimeofdeath
o Nolpregnant.bulpregnanlwithin42days
ofdealh
o Not pregnlJfll,but pregnant 43 days 10 1 year
otdealh
Ii!' Unknown if pregnant wilhin the pasl year
32c. Place of InjUlj': Home, Farm, SlfeeL Fildofy.
Office BU"f{~lcdmnce
32g. l.ocatiooorlnjlJ'y (SlJeel.dtyfloWn. state)
Marion Ave., Carlisle, PA
:m~~~~~~J:~dise~
Gunshot to Head
Due to (orasa coosequenceof)
!z
I
o
~
3Oa. WWSMAlJlop9y JOb. WereAulopsyFlr'ldings
Performed? A~ailable Prior 10 CompletDn Pvf
01 Cause 01 Oealh? DNarural ~Homicide
o Acddent OPendinglnvesbQation 32d. TiApofi~. 32e InjuryatWrn.? J2f tlTransportatioolnjury(SpecifyJ
o Suicide 0 Could No! be Determi1ed 0 V ~ N 0 Driver 10000alor . 0 Passenger 0 Pedeslrian
8:00 P. """" 0 DQ1he"S_
J3a. Certlfler(ched<.onlyone) 33b. Signature C
~:~~I~:~lak~:=~:.=r: ~u~et~~=u~~~7~:=;~s.=:~~~~ ~~ ~~~_I~ 2~1_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ -D ...
P,onouncing 1M c.rtlfytng pnysicl.n {Physician bolh pronouncing death if\d certifying 10 cause 01 death) n J3c. license Num 33d. Date Signed (Monlh. day, year)
To the bnt of my knowItdge, dtlth occurred aI the time, d8te, and pllce,lnd dutto IhecIL*(I)andmlnntrllltaltd... -- - - -- - - - - - - - - - - _...L.J J 1 17 2006
Medical EJ[arnlntr I Corontr IV'I U Y ,
On thl blllI of tlllmlnation and I or Investigltion, in my 09inlon, duth occurNd M thttm., dati, Ind place, anet dutto the cauI~I)lnd IIIInntrllltat!lt _ -R. 34. ~~~fP~ ~~~~~~b~~1-Type/Prif11
JS 'Sl"'."~o;, ,t\~ \ 36. Dale ""' 1"""0.,,>,,,,"1 6375 Basehore Road Suite 1/1
~ "", ~C'JC"\.Uu1\.'6 18. II Id-.I \ 10 I f a..OO~ Mechanicsburg, PA 17050
31. Manner of Death
Coroner
Due to (or as a conMql.lence of)
. events resulting in death ) LAST.
Ooe to (or a& a c:onlSequence of)
Jives ONo
~ves DNa
examples on reverse)
jan M. Wiley
David j. Lenox
Timothy j. Colgan
Christopher j. Marzzacco
David E. Hershey
Bradley A. Winnick
Thomas M. Clark
Ari D. Weitzman
THE WILEY GROUP
Attorneys at La"W"
Wiley, Lenox, Colgan & Marzzacco, r.c.
August 4, 2006
~ --~,
Glenda Famer-Strasbaugh, Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, P A 17013
~,'~
In Re: Toni A. Myers, Deceased
Dear Ms. Famer-Strasbaugh:
--J
This letter accompanies the Petition for Letters of Administration of James A. Clouse. Mr.
Clouse is the father of the decedent, and steps forward to act as the administrator on behalf of the
decedent's three minor children as shown on the probate petition.
The decedent had recently, January 25,2006, received a final divorce decree from her husband,
Jeffrey Myers, who is the natural guardian of the three children. At the time of her death, Jeffrey
Myers was in arrears to the decedent in child support payments.
The estate is essentially a bankrupt estate from the information we have at this time, the probate
assets being three automobiles, the newest of which is a 1998 Ford Windstar, and a checking
account of approximately $1,000.00. Other non-probate assets include qualified retirement
benefits and a life insurance policy wherein the named beneficiary is the decedent's father. Debts
of the decedent including funeral costs, final medical bills, etc., will probably exceed $10,000.00,
the largest of which being a VISA bill for more than $5,000.00. Thus, the estate is expected to
be a bankrupt estate, and Petition wishes the Letters of Administration to be in his name so that
he may take care of bills and deal with the landlord regarding issues surrounding decedent's
rented residence.
Thank you for your prompt attention to the enclosed petition.
Sinc:crely,
130 W. Church Street, Suite 100 · Dillsburg, PA 17019 · Phone: (717) 432-9666 · (800) 682-4250 · Fax: (717) 432-0426
Offices in Harrisburg · York · Carbondale
www.wileygrouplaw.com