HomeMy WebLinkAbout977390STATE OF PENNSYLVANIA
ssm
COUNTY OF WESTMORELAND
977390 7/1 0/20 14 9:48 AM
LINCOLN COUNTY FEES: $30.00 PAGE 1 OF 7
BOOK: 836 PAGE: 37 AFFIDAVIT
JEANNE WAGNER LINCOLN COUNTY CLERK
111111111111! 1111 1 1 111111111111111111111111E111II till' 1111111111111111111111
AFFIDAVIT OF SURVIVORSHIP
I, GREGORY C. MOORE, Personal Representative for the Estate of Clair E.
Miller, being first duly sworn upon my oath, depose and state as follows:
1. I am the Affiant herein and am of adult age.
2. This Affidavit is made pursuant to W.S. 2 -9 -102.
3. On July 29, 2010, SUSAN MARY MILLER passed away on July 29, 2010,
in Sandy, Clearfield County, State of Pennsylvania, as is evidenced by the Certificate of
Death attached hereto as Exhibit "A" and incorporated herein by this reference.
4. Decedent left Clair E. Miller as her surviving spouse; and Kathleen Dawn
Shugars, Matthew Scott Miller, and Melissa Ann Johnston as surviving children.
5. At the time of Susan Mary Miller's death, she and her spouse, Clair E.
Miller, owned as tenants by the entireties, real property located at 245 Cottonwood Lane,
Smoot, County of Lincoln, State of Wyoming, and more particularly described as
follows:
The home and property located at 245 Cottonwood Lane, in Smoot, Lincoln
County, Wyoming, approximately .75 acres, to -wit:
T31N R118 Lot 24
6. At the time of Susan M. Miller's death, said home and real property passed
to her surviving spouse, Clair E. Miller.
7. On July 1, 2013, Mr. Clair E. Miller passed away in Afton, Lincoln County,
Wyoming, as is evidenced by the Certificate of Death attached hereto as "Exhibit B" and
incorporated herein by this reference.
8. Decedent left Kathleen Dawn Shugars, Matthew Scott Miller, and Melissa
Ann Johnston as surviving children.
In the Estate of Clair E. Miller, Probate No. PR- 2013 -53 -DC
Affidavit of Survivorship re: Home (Gregory C. Moore)
1 of 4
9. Decedent died testate, and left real and personal property to his surviving
children, to be divided in equal shares, minus administrative fees and expenses.
10. On October 23, 2013, I was appointed to serve as the Personal
Representative of the Estate of Clair E. Miller. A true and correct copy of the Order
Admitting Will to Probate and Appointing Personal Representative is attached hereto as
"Exhibit C
11. As Personal Representative, I am charged with the task of marshalling the
assets of Mr. Miller's Estate. With the passing of Susan Miller, the house became the
sole property of Clair E. Miller.
12. The distributees have agreed that Kathleen and Nick Shugars shall receive
the Wyoming home belonging to Susan M. Miller and Clair E. Miller, as evidenced by
the Certificates signed below.
13. I, GREGORY C. MOORE, have personal knowledge of the above facts.
DATED this 12th day of June 2014.
RE"? 4(4 .(1 ?>;'133_,,00RE
SUBSCRIBED AND SWORN to and acknowledged before me, a Notarial
Officer, this 12th day of June 2014, by GREGORY C. MOORE.
WITNESS my hand and official seal.
My Commission Expires:
July 1, 2016
In the Estate of Clair E. Miller, Probate No. PR- 2013 -53 -DC
Affidavit of Survivorship re: Home (Gregory C. Moore)
2 of 4
NOTARIAL SEAL
BEVERLY J PRICE
GREENSBURG CITY, WESTMORELAND CNTY
My Commission. Expires Jul 1, 20.16.
CERTIFICATE OF APPROVAL
The undersigned, MATTHEW SCOTT MILLER, son of Susan Mary Miller and
Clair E. Miller, hereby approves the release of the Wyoming home to Kathleen and Nick
Shugars from said estate.
DATED this 15 day of I, v►�
STATE OF \)1A u c
�OF
ss,. ,„apilun ►►il °4®
1§ +�G °off! vi:0
The foregoing was acknowledgedgoef¢ m8 a m aril Officer, by MATTHEW
SCOTT MILLER, who personally appealed fore me s 3 day of
'iLin'e— 2014.
m'
°i� �7 °mmooa7�1,,, A
'Witness my hand and official seal.
My Commission Expires: 3 O
2014.
MATTHEW SCOTT MILLER
c2 P
TARY PUBLIC
In the Estate of Clair E. Miller, Probate No. PR- 2013 -53 -DC
Affidavit of Survivorship re: Home (Gregory C. Moore)
3 of 4
"7 0(oet$Li I
CERTIFICATE OF APPROVAL
The undersigned, MELISSA ANN JOHNSTON daughter of Susan Mary Miller
and Clair E. Miller, hereby approves the release of the Wyoming home to Kathleen and
Nick Shugars from said estate.
DATED this day of 2014.
STATE OF �P -Vl��� I V& (6.-
ss.
COUNTY OF cll.` I'L eAr
M ISSA ANN JOHNSTO
The foregoing was acknowledged before me, a Notarial Officer, by MELISSA
ANN JOHNSTON, who personally appeared before me this f Y day of
2014.
Witness my hand and official seal.
My Commission Expires:
NOT Y PUBLIC
In the Estate of Clair E. Miller, Probate No. PR- 2013 -53 -DC
Affidavit of Survivorship re: Home (Gregory C. Moore)
4 of 4
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Susan M. Rothbauer, Notary Public
Cranberry Twp., Butler County
My Commission Expires Aug. 6, 2017
1. flute dDecedent(Raimiddle, tsdTa)
Su SC1n rYlark '')lif t
2. Sex
r1rYlalt
3,SadatSeariryNumber d.
ed NIMoAN, day, year)
a aoho
C S.Age(lasl8lliday)
11 �T�'i)
6 y..
Under al
Under 1day
6. Dale ol Bath (MAnAday ,year)
7, &Mplace (City and staled Ionian mwLy)
8e, Place dlDeath (Check ontyorre)
web
Days
lids
awes
Feb
eb
n(� i/�
i"1 em
dn� sbu Mss
IIIr'1 'PA
s
Hospilat
❑Inatient, ER /OU aneol ❑DOA
p y
Mir,
Nu skg Ha Residence f
I ❑Other.spedy:
Z Bb.CaunyelDeath
l
le�R l tic'
Sc. C9y;Bor wp.dDeath
S� nd
6d. FeatlyNemo (II rat Miaa,oho dred and aarbe6
1',
IoL19 7 �ee5ure goad
9. Was Decedent ol Wapan1cOdgln �No ❑Yes
(If Yes.acedhCuban.
Markan, Polo Ran, etc.)
IO. Rai AmeaicanInden. Black, WlNe,etc.
(Peak
white
a 11, Decedent's Usual d„ ..Ian r of hYdrk done dud most of Be. cal brie
12. Wes Daredo l ever In the
U.S.Armed Forms?
❑Y� �N2
13. Doodads Education (Sped) only Nghest grade completed)
14. Manta Status: Maded, Never Married,
taloned, Merced (Seedy)
married.
15, Boning Spouse (II wtlo, ptre maiden name)
Clair E. miller
03 IOM of Wak
W T rJi rs Ride
d&chess /*dusty
�r uca ton
Elementary ndal(0.12)
ISa
College(I -or5s)
W I6. O emd OO anlb HaaggAdd n res s(9rm L 1 dy /loam, lale, 7ipcode)
w lQ6w "Treasure i. t✓
•Du6ots PR isgol
Dodoes PA Old Doe ant /1., 111 ��f
4(041 17cgYes,DecedentUvedIn S µ1l d V
Twp
T+ h 4
n1nar
Iro.Couny ateAelCl. 17d No. Decedent Uved 4, I
Actual
Ul as of py e
19 Falhere Name (Fast middle, last MP)
Ch arles R. Greene,
19. Mothers Name Fat, middle, maiden sumamo)
mare,. A 'Cassidy
288, Informant's Neme (Type IPrW)
atr E. rnl lllgr
I
20b.Informenl's MaiilAkcets (9�eel city Nate, code)
log�rtreQsure La1s Du6ots PA i58o!
2 21a Me ted os poskan
p f Di
E Burial RamnavelhanSala
in 1 Specify:
Cranadal D n
Wei CaemelknorponellonANhodced
byMedlul Examiner I Coroner? ❑Yes ❑No
21b. Dale d Wpmeim (Month day, year)
a Q
AU J aolo
21e. Place d Dts posNonU7amedmmotory ,oandory aalhayam)
///yyy
Si-. Paul ��i���
2ldlom0m(Olyllam stale, abcode)
i_a obe Ph.
N 228,+ red Foetal (pr
IA D fill
s f1
Map es sot) 1
../i2� Ot) tL
224.UcenseNumber
FboI4G01
27c. Name cud Address elFecaty o
Coble roma cur l Home ail S. main Sf.DuBois PA I5801
i Complete hems 23atmy
ph is not argade el tine d death ID
oeAB
obit) torso
23a.To4a heel of my edge, deadsammedalte time, dale and plamshted .(Sgnatureend ale)
234.Umns
2 DateSgned(Month,day,year)
pr r�
Ci1q do /6
z Rams 24.26 must De condoled b /parses
ce whopronouam dada
24. Tune dDeath 1 25.
y. oo P M
P
Dead ,yasrl
r 7 0
26, Was C498Ralermd48Med�calF�adnarlCannrPo
�{'es 0 N
Reason Other 4 CremelbnorOasa6on7
CAUSE OF DEATH (Seto Inds ellen
1008127. Pen It Enter Ohl app pffi1- dsemes, Ignites, acaopdadnns- that droctly caused to
rk1Oalay afresh orvemdcdar fbnib6a OM showing the e0ot% list drip co cause co
1641803910 CAU5E1Fhelbseased
ndewe
DO NO
each Fee.
es)
er wmonelevena such as cardiac a nest,
Appvdmalehtervdl:
OmwelaDdaa
Par 8: Elder dhet •nlcmdelnn5wnN'hsea,elo4,80,
but not nsuakghthe adaAykhgmusa photo Peru
28. Did Tobacco Use Cott* 9Death?
❑Yes ❑Probably
No Ei Wows
mn7ilan osukhg In death) a. Q, m o p'( 5 Is
0 Pr)
29. U Female:
Due t eseconsemyuance r7
Seguenti islm0bas, II any, b La C%n °m( C'1 1 fcl La n O
X k948814 eaee9T610dmDne.
Ct.�U
Not pregnantwltldnpastyear
❑048'0dBt6meddesN
Enter UN0ERLYIND CAUSE Due to (or es a consequence 0: (fame orinlIu Mt hl[stad the
evmots restetig11dna)LAST, c'
l
O�IZ�1oc yo 1y
Ndlp'eprant but pnpmhmlw6hkh42days
ofdaaO
Due lo(oresa consequence o:
d
I
Not ppd. hut pepwe43 days to1year
beta/death
Ultimo d gonad orifih die paslrat
308. Was on Autopsy
Perten ed?
Yes ®No
30b. Were Autopsy Reims
AvadahloPriartoCanpalkn
olCauseofDeam?
❑Yes hb
31. Manner el Death
®Naturd ❑FlaNdde
AmHenl Pegg lnventgaI
Sddde Codd Not be Delem1ed
328. Date of Injury (Menl, day, year)
32b. Describe lbw lm(ury Domed
Street Fad
320. 78888 11411
a28
32d inn n of 0*ay
M.
32e. Injury of Work/
yes Ns
321. II Trenspoial Injury (3pody)
Merl Operator Passenger ❑Pedestden
❑OM
329. too* of laity (Steer cny/ lm'a 1100)
33a.CemCw(choked/ono)
CedUying ph M a n oarying cause d death wtaan man physklan has armored death Mmmplded tam 23
To the best of my bole* demh occurred duo lo the made) end member a sated.
Pronouncing ndceniryingphyeldan(Phystdan both p or :dogdeathaNmAiyinglocauseor death)
To the best of my knowledge, death mowed al the Me, dole, and pace, and due to the ceuee(e) end mom m dated_
Nettled EnMner /Coroner hd
On the basis de7kMutlonend orlmeslgaUan ,hmyopUldn, death ammcde UuUme,dan,ud Oho. and duo lo04 euee(d) !Ad rmnne mOHO_ W
37b. Im Tila //1I
h ,v�
l r s1
33c,Uonse Note
Data S'
(MdnN,degyea
7 60/0
34 ame andAddmss nth �°Co pMedcauseci Imm
am
'M �h4 }E'P� J n1d��
Ili IluU gets QOC�c +on ci ►6B5L
Type IP
a S
Sign adeand t I
1. 14 131313 10 11 1
36. Dale Red(Month,day,yea)
'1- I -1►
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with
the Vital Statistics Law of 1953, as amended.
H105.144 REV 112006
TYPE/ PANT IN
PERMANENT
BLACK UBS
1i
WARNING: It is illegal to duplicate this copy by photostat or photograph.
7825367
No.
COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
Disposkion Perot No. D 1 (pia a 1
Marina O'Reilly Matthew
State Registrar
February 11, 2014
Date
065140
therSignificant,
ondittons:
i
ecedent:
Marne: Clair'E. Miller:-
Gender: Mate
t of`. Birth: April' 8, 1937/
Date and Place of Deaths
Date Death: July 01 2013
':City -of Death: Aftoh
Location: Star'Valley;Medical Center 110 HospitalLane
<Additionai Decedent Information:
Norvelt,
Smoot Wyoming
Widowed
Yes
William F Miller
Edna Hughes
Kathleen Shugars
Place'of, Birth
;Residence
arital Status:
Armed; Forces:
:Nrne of Father:
Name; ofMother:
Informant:
x Disposition
Methocr of Disposition: Burial
f
Place of Disposition: St. Paui,Cemetery, Latrobe PA.
F uneral.Home'or Facility:
.Facility: Schwab, Mortuary, Afton, Wyoming
Catise<`ofrDeath
4The iminediate cause 'is listeb`on:the,frrst line followed by any underlying causes.
Acute Myocardial Infarction
Natural Death.
Physician
Michael Pieper, D.O.
110 Hospital l.an'e; "PO'Box:579., Afton,
August 06; 2613''
7691
7' This is a true certification of the document on file in the office of Vital
Statistics, Services, .Cheyenne, Wyoming.
DATE ISSUED. Thursday, 'July Oa, 2014
This.copy is not valid unless prepared on paper with an engraved border.
se
.c i;riiiii:,_y!�" C rrj i vii `Y'� +Y +7:1:: �:��i�.i\, s R Ff; .4y
��v3 °,!r L .�.b �..���•�lff�r=;��';�q ".r �r'�G: ��?3� �''ti
FATION AL RECORD I
State File Number:
Social :Secunty Ntainber
Age of the Time of Death:
James Mcariide
Deputy State 12egistrar
2013- 002367.
fJ� %5,1.7 i4 �wiS�LJ ;ism
iil
i r- �v
IN THE DISTRICT COURT FOR THE THIRD JUDICIAL DIS WCf3 201
IN AND FOR TJIE COUNTY OF LINCOLN, STATE OF WYOMING
KENNETH O. ROBERTS
CLERK OF DISTRICT COURT
IN THE MATTER OF THE ESTATE LINCOLN COUNTY STDISTRICT YOMING
OF Probate No. PR- 2013 -53 -DC
CLAIR E. MILLER,
Deceased.
BBL
BY
ORDER ADMITTING WILL TO PROBATE -AND
APPOINTING PERSONAL REPRESENTATIVE
The Petition of Gregory C. Moore being filed in the above- entitledmatter, praying
for admission to Probate of a certain document filed herein, purporting to be the Last Will
and Testament of Clair E. Miller., Deceased, and for appointment of a Personal
Representative thereof, and that Letters Testamentary be granted, this day regularly
coming on to be heard; and after examining said Petition and proofs of evidence in
support of said Will, from which it appears that said document is the Last Will and
Testament of Clair E. Miller, Deceased, executed in all particulars as required by law,
and that said Testator died on the 1 day of July, 2013; the Testator was a resident of the
County of Lincoln in the State of Wyoming at the time of death; that the value of said
estate is estimated at approximately $8,250,000.00.
IT IS ORDERED that said document heretofore filed, purporting to be the Last
Will and Testament of Clair E. Miller, Deceased, be admitted to probate as the Last Will
and Testament of said Clair E. Miller; and that Letters Testamentary thereon issue to said
GREGORY C. MOORE, upon taking oath required by law, bond having been waived by
the beneficiaries.
2
DATED this day of
LOU p 1 "'w
OT.J4tt
ry ierk of the Third
Estate of Clair E. Miller t ''s;,. l� R4 "s f c; °s within and fo s id
Order Admitting Will to Probate and Appointing Personal l epres.",enta ee the state, of for do
Page 1 oft e rel! .a ,;;i; l ify the foregoing to be a full,
nos co"Ipiete copy.