HomeMy WebLinkAbout01-25-07
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF i.", pt jQE R L -A r--' P
Estate of 1:f A i! E L N, ~'~K J..I d L P r: R.
also known as
COUNTY, PENNSYL VANIA
File Number
~\
Ol ao~
, Deceased
Social Security Number /83 ,... 09 - 0 0 9 It,
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
XI A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is / are the
last Will of the Decedent datedJ>E C 1';2. :2.oa 0 and codicil(s) dated
I
E x.~ tL4 "0 K
named in the
(State relevant circumstances, e.g., renunciation, death of executor, etc.)
o B. Grant of Letters of Administration
~:~:~ ~-:-"l'
N
CJl
(lfapplicable, enter: c.t,a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante rrri1J.(Jri!ate) -0
Petitioner(s) after a proper search has I have ascertained that Decedent left no Will and was survived by the following spoJ:>r/if any) ~heirs:.
Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.), -! ..
J N
-""
(f{i,..J,
Name
-
Relationship
Residence
(COMPLETE IN ALL CASES:) Attach additiollal sheets ifllecessary. t' .
5 r) u Th HA MPf' 0 rv
Decedent was domiciled at qeath in County, Pennsylvania with his / her la principal resi at
J' C .
(List street address, tow/llcity, to)J!./l~.!}J.P, county, state, zip code)
Decedent, then 9 8
years of age, died on~tJ 23. Z4:>7at 8M ff'PElJsi3ueG. (Q bo~J
Decedent at death owned property with estimated values as follows:
(If domiciled in P A) All personal property
(If not domiciled in PA) Personal property in Pennsylvania
(If not domiciled in P A) Personal property in County
Value of real estate in Pennsylvania
$ IC:A o(')/')
",.
$
$
$
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:
7
Form RW-02 rev. 10.13.06
Page 1 of2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF
~~(~
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 ofPetitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly
administer the estate according to law.
Sworn to or affirmed and subscribed
l-
before me the d 5 day of
~~<=I
- - . ;~i,te,
Signature of Personal Representative
Signature of Personal Representative
File Number: ~ \
Estate of \.\o.:~...€__\ ~
() L OO8tf
&.....f~ ~~\ ckr
, Deceased
Social Security Number:
\ 'is 3 69 co91...o
Date of Death:
C\ o...r-- LN)....\"W ~3 D'l
'\ \ I
AND NOW, , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters \-e"::::'-\ ~C2..I"'~t
are hereby granted to P-.e>'csu-\- f". ~ ""'hd<kx- -
in the above estate
and that the instrument( s) dated ~ Q.,\"<"'\ \::Q...~ \ ~ .;t COO
described in the Petition be admitted to probate and filed of record as the last Will (a d Codicil(s)) of Decedent.
Short Certificate(s) . . . . . . . .
Renunciation(s) ..........
~\\\
jc~
~~
~~~.Db
3;;) . DO
Attomey Signature:
J:~r'~
:..:::.
FEES
TOTAL
$
$
$
$
$
$
$
$
$
$
$
$
$ 3;)~ .06
Letters
\$. (jJ
,D . ClJ
S~OO
Attorney Name:
N
rn
.~" .)
f'O ~':
Supreme Court J.D. No.:
.~-~: ~=r'-l
-u
\--',
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Address:
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,,_~"--i
~
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Telephone:
For/ll RW-02 rev. /0. /3.06
Page 2 of2
HIO).80) REV 1I1l)
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 State 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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P 12996757
No.
~2'(,~2
Date
,-.)
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H105.143 ReY. 01JtJ6
TYPE/PRINT IN
PERMANENT
BLACK INK
1 Name of Decedent (First, middle, last)
~ \ () 1 . GO ~
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH STATE FILE NUMSEfLi
-0
YIS
Hazel Naomi Burkholder
5 htJe (LaslbirthdaYl
98
7. Dale 01 Birth Month,da . ear
Bb. County of Dealh
..)
3, Social Securily NUrTDer
4.- .c;te 01 Death (Monlfi.., year)
183 - 09 - 0096 > January 2~007
Sa, Place of Dealt! Check on one
Hospital:
01 tienl 0 E
Other:
isnt 0 OQA ~ Nursln Home
9. Was Decedent of Hispanic Origin?
5( No 0 Ves,(lfyes,specify.Cuban,
MeXICan, Puerto RICan, etc.)
o Residence 0 Other-
10. Race: American Indian, Bleck, While, e1c.
1-
White
13. Decedem's Education S c
ElementarylSecondary (()'12)
8th
pointe at Shippensburg
h. 11m rade co le1ed
Coaege (H or 5+)
'd-\
Cumberland
Shippensburg TWP
11. Decedenl's Usual Occ tion Kind of work clone durin most of work' life; do not slate re1ired 12.
seamst~~:;k Sewi~gO~a~r~~~
_ 16. Decedent's Mai~ng Address (Streel, dyAown, stale, zip code)
Pa.
129 Walnut Bottom Road Shippensburg
17b. CountyCumberland
19. Mother's Name (Firsl, middle, maio'en surname)
18. Father's Name (Fitst, middle,last)
1.. Marital Stilus: Married, Never rrflrriecl, 15. Surviving Spouse (If wife, give rreiden name)
Widowed, Divorced (SpecdJ1
widowed
~~D~edent 17c. II ves,Oecedenllivecl~.i;hip'pensburq
Township?
Twp.
17d. 0 No, Decedenllived wlthin
Actual lirrils 01
C~l&ro
Mathias Ryston
2Oa. Inlorrrent's Name (Typelprinl)
Flohr
Ida J. Baer
2Ob. Informant's Ma~ing Address (Slreet, cityAown, stale, zip code)
749 Boundary Blvd. Rotonda West Fla.33947
Robert F.
BurkhOlder
21c. Place of Dispos~ion (Name 01 cemetery, cremalory or other place)
Spring Hill Cemetery
22c. Name and Address 01 Facmty
ogelsanger-Bricker Funeral
o
ill
U>
=>
U>
<(
:ii'
CAUSE OF DEATH (See InstrueUons and examples)
~em 27. Part I: Enter the ~ - diseases. injuries, or cofT1)lications - that directly caused Ihe dealh. DO NOT en\lr lerminal events such as cardiac arresl,
respiratory arrest, or ventri;:ular ftdlation without showing the eliology. DO NOT abbreviale. Enter only one cause on a line.
IMMEOIATE CAUSE IF""'diseaseor ~::t~ ~ ...1-. ..J-I. ,(,~
condl\lOnresuRlIlgllldealh) -? a. __ /W ~
Due to (or as a consequence
Sequentially list cond~ions, K any, b.
leadil'lQ to the cause listed on line a
- Enter the UNDERL YlNG CAUSE
. (disease or injury tl'lat initialed lhe
events resullllg in death) LAST.
Due to (or as a consequence of):
Due to (or as a consequence of):
308. Was an Aulopsy
Performed?
d.
3Ob. Were Autopsy Findings
AvaitablePriorloCorrplelion
of Cause 01 Dealh?
o Ves 0 No
32d. Time 01 Injury
32e.lnjuryatWork?
o Ves 0 No
32a. Dale of Injury (Month, day, yea!)
31. Minoer of Death
CI. NaMal 0 Homicide
o Accklent 0 Pendllg Investigation
o Suicide 0 Could Nol Be Determined
o Ves XJ No
M.
f-
Z
ill
o
ill
C>
ill
o
U.
o
UJ
::i
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z
33a. Certifier (check only one)
Certifying physician (Physician cer1ifying cause 01 death when aoolhel physician has prooourv::ed death and co~leted Item 23)
To the best of my knowledge, death occurred due to the cause(s) and manner as staled .~,.......................~~._......_...~....-.. .~_..__.._........ . .
Pronouncing and certifying physk:lan (Physician both pronouncing death and certifying to cause of death)
To the best of my knowledge, dealh occurred at the time, date, and place, and due to lhecause(s) and manner as staled
Medical examlnerlcoroner
On the basis of examina
21d. Locaoon (CityIloWll, stale, zip code)
Shippensburg,PA
Approximale mlelVal.
onse1lodealh
o Yes :b(No
Par1lt: Enlerolnersioniflcanlcondilions conlrbulino10 de.ath,
but not resuling in lhe underlying cause given in Par11
28. Did Tobacco Use Conlooute 10 Dealh?
~ g:k=
29. If Female
not pregnant within past yeal
o Pregnantetlimeoldealh
o Not pregnant, but pregnant within .2 days
oldealh
o Not pregnant, but pregnant.3 days 10 1 yeal
beloredeath
o Unknown K pregnant within the past yea!
32c. Place of Injury: Home, Farm, Slreet, Factory, OffICe
Building, etc. (Specify)
&
(~~
32tl. Describe how Inju1)' Occurred:
321. lfTransponalion Injury (Specify)
o DriverlOperalor 0 Passenger
o Pedeslrian 0 Other - Specify:
331>. Signature and Title ol CerMeT
32g. localion (Street, City/l.OWII, slale)
OJ 0 C>1 7 q I -L 33d D;'r2.~("'~' ~ yea')
34. Name and Address 01 PelSOfl Who ~leled ~'!Ie 01 D~lh (ne2:J?t)ypeJPrinl
VYltu'qC"')1)l 6C~~ (
UX>? 4-& wltlnD r1c~}U J t'\Jtre-Nk>lL(51'-4
(See instruction and examples on reverse)
Permit # 0175367
t occurred al the time, date, and place, and due to the cause(s) and manner as staled.. .....0
35
Zrl I~II 151
.....0
H)()~S{)~ RFV ),'11';;
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 State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
Fee for this certificate. $6.00
p
12667963
05 SEP 2006
Date
1'-.)
(::;:":':)
C:.l
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C-
:<.:;~"
80
V<s.
d \ <Yl ()O~
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
N
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10 Rev. 01.Q6
""'""""
::RMAHEKT
ILACKINK
1. Noll'!'l! 01 Decedenl (Frst ~, Iasl)
STATE FILE NUMBER
Paul S.
Burkholder
3. SociII Securty Nurrber
174 20
5. 1qe (Last birthday)
7. Dale 0' Birth Month. da ,
11. Decedent's Usual li:ln mofWOft:donedur' tl'I')Slofwortc lfe'oonolStllerelired
Principa'r' Educ~'f.~lIStry
16. JloGe<IO,r.jo\flroQ Idct.- <Str.... ""...... .la'e. ~-I
1. /::> WlnODrlar Lane
Gettysburg, Pa. 17325
12.
rrA~
ode
5 + CoIoge ('-< or 5+)
.104. Ma SIIu: Matritd. Ne\W qrrild.,
"'!tnttorr ~~
o Rnmnc. a Other.
10. Race: hMti::In .....'" BlIck, ~e, *-
(SfMd'n
white
1$. s.rnm.~(I"'giA-""",)
Mary Lou Meyers
eb. County or Oelth
Cumberland Co.
Camp Hi 11 Boro
17b. County
Pennsylvania
Adams
Old 0..:"",
lrte in I 17c. Ja: V-.o.:<<Ienllrtedin
Townsh4>?
ClIrnnprl and Two.
171. Slate
17d. a No.~UrtwdwtNn
......,..-aI
ClyI9oro
la. Fllher'sName(Fntmicldle,lasl)
19. Mother's N.me (Fisl, mkkAe, rraiien surname)
Hazel Flohr
Samuel Burkholder
Mary Lou Burkholder, wife
2a>. ~fom'o,,'. Malog __ (Slr....""-.. """ ~ cod.)
175 Windbriar .Lane Gettysburg, pennsylvania 17325
201. Inlormanl's Name (TyptJpmt)
~ kms 231< only when oertitying
phyIban is not ,VlliIdlIe at"" of dMlh 10
~C1l.1MofdNfh.
. 1lems2'.26m.rslbe~byptf$On
. wtw)pronclU"CUdeath.
231.. best of rrtf~, death OCC\KI'ecI.t thin. date and P'ace staled. (SignltUf' Ind lille)
21c. PlaceofDisposh::ln(Na1Mof~,C1tm1tofyordherptle'l
Evergreen. Cemetery
210. l.Dcotiot1 (Cay-.. ...... '~-I
Gettysburg, Pa. 17325
211. Me{hod of OGposi""
'D ani a Otmltion 0 Aem:wal from Slal. 0 DoNllion
o Olhe<.S
. 22a. S~tuTe of Funeral S<<W::t Li::enset (or person acti1g IS such)
~ .~....j'''-
22b. license Nurrber
08555-L
22t. Name Ind.tddr-.s of FICiky
Monahan FH 125 Carlisle St. Gettysburg, Pa. 17325
23b. Li:onooHurrbor 230:.OoIoSlgnod(lolornh.ctoy."'"
0': 36 ,4.M
26. Was Cast ~ed 10. MedIcal wrriMf~
o v" .~
2-t. Tme ofDMth
CAUse OF DEATH (See InIttVCtlons and 4:
Item 27. Part 1: Enlef \ha ~ - diselses, ~ies. 01' CO~OOns -hi directly caused lht 681th. DO NOT enter terrrinal events such as cardilc Irrest,
r....lory IlTesl. Of ventn:ullt billion ~ shOwi'lg the .liob;1. 00 NOT .bbr.....l.. Enler onfy OM ca... on . Int. .
"1IED1AT'ECAUSE(FN'-"or "'...~~ ~ ~ -s.-~~~\",""", :
,,"'!M"'''....''l.-I-'7 .. ---~.
Du'''louu__ooQ: 'll.. \. . '.\ r'\. :
SequenI~"'isl"",",,,,,,.h"Y, b. ~~~....~J..\.a...~...... .., .""Co..~~ ~')C..r..~'
... ~~:;::~c~~.. Due 10 (Of as I conNqU<<lC' of):- :
. (d"lSeaSeorl\jlnythalinlia1<<S1he
t!'Ienls resoling in dNth) lAST.
: Awroximll.rnertil:
: onHtlodellth
Part It Enl., other sicnificlnl t::OfI.iilicns txlnlrIlumo kl dIlllth
but not fuuling in the UndefttlnQClI.M given it Part!.
2a. Oil T_IJM CootrbM" 0."'1
~i: g =
29.1_
o HaI"..........put,..
o "'-...oI....aI_
o HaI_",,,,,,,,""""2"""
aI_
O'HaI",.....",,,,_,,,,,,,,,, ,_
_.-
o UniolowTlV",,"""'flepal)'OOt
321:. P'ocoalIr1july:Homo.F"",_F~.OlIco
IlAdilg. ole. (SfMd'n
Out to (Of IS I connquence 01):
o Yes ~No
d.
3(I).W*"e~FMInOS
Availlh'ePriorlo~lion
of Cause 01 Death?
o Yes 0 No
3211. D.le of Injury (Month, day. year)
32b. Desabe how' lnjufy OcculTed:
3Oil. Was an Au10psy
Ptt'btmed?
31. Man~olDealh
liI"'N.lVtll 0 Honicde
o Accident 0 Plnd~ lnwsf'lgIlion
o Sole'" 0 Could Hal Be 00lemit10d
32d. Time of Injury
34 ~""(Slr""",,-'-I
M.
330. Cel1ifie< (ched< ""'" """I
Cef1lfylng phyIltbn (Physician certifyino cause of dellh when .nother physiciIn has pronoun:ed deefh and corrcJIeted nem 23)
To the best of '"' knowtedte. duth occlHTed due to the caUH(s) and manner as stated
Prtlnoundnglnd certifying physltbn (PhysIcian bolh prOnovnc:ing death Ind certi1'fin9 tl uus.e 01 dMth)
To the best of '"' knowWdee, death occ~ at the time, d.~.- and place, and .we 10 the caWH(s) and manner IS slated.._._._._.______.M_........_...
Medal eltlrNnerlto""*,
On lhe bub crl'ltIminaUon andJor lnvatipUon. In my opinion, death occurred ,t the Un'll!, date. anet plaee,and due to the caUM(S)lnet manner IS llated ._._._0
35. 36. C.le Fled (Month, day, YNr)
III IOIOI~ I
JRZ - 5.1 burkholder.2 November 30, 2000
LAST WILL AND TESTAMENT
I, Hazel N. Burkholder, of Southampton Township, Franklin
County, Pennsylvania, being of sound and disposing mind, memory and
understanding, do hereby declare this to be my will, hereby
revoking any and all former wills and codicils thereto by me
heretofore made.
I.
L,_:~)
--'
1')
Ui
I direct that all my just debts and funeral~-e)Xpe1;\se8,
" 'I J -
including all expenses of my last illness, shall be ~a~d fr~ my
("\0
estate as soon as practicable after my decease as a part ~ the
expense of the administration of my estate.
II.
I give, devise and bequeath the residue of my estate of every
nature and wherever situate in four equal shares to be distributed
as follows:
A. One equal share to my son, Paul S. Burkholder;
B. One equal share to my son, Robert F. Burkholder;
C. One equal share to the children of my deceased son, Roy
L. Burkholder, namely Steven R. Burkholder and Scott A.
Burkholder, equally.
-1
D. One equal share to the children of my deceased daughter,
Lois B. Jones, namely Carole Jones Crusey, Greg Jones and
Linda Jones Keen, equally.
E. Should any of the above-named beneficiaries predecease me
or die on or before the thirtieth day following my death,
their share shall be distributed to their issue, per
stirpes, living on the thirty-first day following my
death, and in default of any such then-living issue,
their share shall be distributed equally among the
remaining shares with beneficiaries surviving.
III.
Any fiduciary under this will shall have the following powers
in addition to those vested in them by law and by other provisions
of my will applicable to all property whether principal or income,
including property held for minors, exercisable without Court
approval, and effective until actual distribution of all property:
A. To retain any and all of the assets of my estate, real or
personal, without regard to any principle of
diversification of risk.
B. To invest in all forms of property including stock,
common trust funds and mortgage investment funds without
restriction to investments authorized for Pennsylvania
fiduciaries as they deem proper, without regard to any
principle of diversification of risk.
Page 2
~
~
C. To sell at public or private sale, to exchange or to
lease for any period of time any real or personal
property and to give options for sales, exchanges or
leases, for such prices and upon such terms or conditions
as they deem proper.
D. To allocate receipts and expenses to principal or income
or partly to each as they from time to time think proper.
E. To compromise any claim or controversy.
F. To distribute in cash or in kind or partly in each.
G. To hold property in their names without designation of
any fiduciary capacity or in the name of a nominee or
unregistered.
IV.
I direct that all taxes that may be assessed in consequence of
my death of whatever nature and by whatever jurisdiction imposed,
shall be paid from my residuary estate as a part of the expense of
the administration of my estate.
V.
I appoint my sons,
Paul S. Burkholder and Robert F.
Burkholder, as co-executors of this my will.
Page 3
VI.
No bond shall be required of any fiduciary hereunder In any
jurisdiction.
IN WITNESS WHEREOF, I hereunto set my hand and seal to this my
last will and testament, consisting of five typewritten pages, the
first three of which bear my signature in the margin for the
purpose
of
identification
this
_td~
day
of
o ef'~ -
, 2..1J..QQ .
IfwJ~ Al,BwzhIu)~
(SEAL)
Signed, sealed, published and declared by the above-named
testatrix as and for her last will and testament In our presence,
who in her presence, at her request and in the presence of each
other have hereunto set our hands as attesting witnesses.
I'i'Ll 0~ &/J~ tA4'c/l.
~YIJ.1TauKh-wSt.~ef~ffA
We, Hazel N. Burkholder,
Ck/ f p~~,
0e/ /'2/#/r and
the
testatrix
and
the
witnesses
respectively, whose names are signed to the attached or foregoing
instrument, being first duly sworn, do hereby declare to the
Page 4
undersigned authority that the testatrix signed and executed the
instrument as her last will and testament and that she executed it
as her free and voluntary act for the purposes therein expressed
and that each of the witnesses, in the presence and hearing of the
said testatrix, signed the will as witnesses and to the best of
their knowledge, said signer was at that time eighteen years of age
or older, of sound mind and under no constraint or undue influence.
~RaIl~-k1~
Subscribed, sworn to and acknowledged
before me by the above-named signer and
subscribed and sworn to before me by the
above-na~es this ,~ day of
. ,2~
~.;;(~--
Not~y Public
Notarial Seal
Carin L Wllter, Notary Public
Chamb.raburg Boro, Franklin County
My Commission expires May 13, 2Cj1
Page 5