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Home My WebLink About01-23-08 PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of BETH ANN BURKHOLDER also known as File Number 21 08 - oOR~ , Deceased Social Security Number 177-42-0390 Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE 'A' OR 'B' BELOW:) o A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is / are the last Will of the Decedent dated and codicil(s) dated named in the ~-, (j ~ ~;j ~o ...~..;~ ~2 :'~ (State relevant circumstances, e.g., renunciation, death of executor, etc.) . c:.~ ~; ~ . . Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution ofthe-iq$fiiIment(s) offer~d ';"-:.','--) -r for probate, was not the victim of a killing and was never adjudicated an incapacitated person: - j -, 1 -i: .., , (ZJ B. Grant of Letters of Administration _ ::'::j ) <"0 (If applicable, enter: c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate) \D 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: (If Administration, c.t.a. or d.b.n.c.t.a., enter date o/Will in Section A above and complete list o/heirs.) Name Relationshi Residence 37 Summerfield Drive Carlisle 37 Summerfield Drive Carlisle PA 17015 Richard M. Burkholder Father Nanc J. Burkholder Mother PA 17015 (COMPLETE IN ALL CASES:) Attach additional sheets ifnecessary. Decedent was domiciled at death in Cumberland County, Pennsylvania, with his / her last principal residence at 304 South Filbert Street Mechanicsburg P A 17055 Mechanicsburg Boro (List street address, town/city, township, county, state, zip code) Decedent, then 46 Carlisle years of age, died on 1/4/2008 at Carlisle Regional Medical Center Cumberland County P A 17015 Decedent at death owned property with estimated values as follows: (If domiciled in P A) All personal property (If not domiciled in P A) Personal property in Pennsylvania (If not domiciled in P A) Personal property in County Value of real estate in Pennsylvania $ $ $ $ 1.000.00 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: Typed or printed name and residence Richard M. Burkholder 37 Summerfield Drive Carlisle Nancy J. Burkholder SummErfield Drive 717-245-2656 PA 17015 717-245-2656 Carl isle PA 17015 Page 1 of2 Form RW-02 rev. 10.13.06 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA SS COUNTYOFCUMBERLAND The Petitioner(s) above-named swear(s) or affmn(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 anu.ubSCribed before me the ~:!Jf'i day of UJ7rl ;J~ Signature of Personal Representative Richard M. Burkholder Signature of Personal Representative . Burkholder co ~ ~ c_ '.) Signature of Personal Representative File Number: 21 - O~ - DD<j;;'" ~2:T:"': Estate of BETH ANN BURKHOLDER :;':':j ~. -f , De~eased c...J .- \JJ Date of Death: 1/4/2008 AND NOW, I , Qff) ex , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS ECREED that Letters of Administration are hereby granted to Richard M. Burkholder and Nancy J. Burkholder in the above estate and that the instrument(s) dated described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of De edent. Letters ............................. Short Certificate(s) ............ Renunciation(s) ................ ~.... Attorney Name: FEES $ --d1f1XL $~ $ $ _119.m $ S,C)[) $ $ $ $ $ $ $ $ 51.00 Attorney Signature: Supreme Court J.D. No.: 29943 Address: 10 East High Street Carlisle PA 17013 Telephone: 717-243-3341 TOTAL ............................. Form RW-02 rev. 10.13.06 Page 2 of2 1l105.X1J5 REV (01/0;1 LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 P 14124936 Certification Number This is to certify that the information here given is correctly copied from an OIiginal Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. (~"l Reg;'tr'" d'S' C) :::-':0 . .,..., C:i) I ~ ~'. " ...:::1 ,---'"", co (-- ~~~ N (...) '; r"~, <") "11 v --=- ~l) --1 c....) H1CI5-1-1J REV 112lW TYPE PRINT IN PER~.lANENT Bl ACt', INK COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) STATE f'llE NUM8ER 1 N3me01 DeceuenlIFlfsLmlOdle l..Ist. sultt),1 Beth Ann Burkholder 5 Age (last Biflhday) 6 Dale 01 Birth (Month. day, year) 46 y>> May 17, 1961 80 Counl~' ct Deiilh 1\ DllLHlenl ~ US;Jal Dce'J all()n rllfld Gf v,ork done oorm masl ut Wu/KlIl liIe Do not slale retired Kind c.l Work Kin,j of Business I Induslry Owner Operator Consulting o y" tillN, Oecedenl's Actual Residence 17a Stale PA Cumberland 19. Mother's Name (First, middle, maiden sumame) Nancy J. Sample . 16 Dececk-nl ~ M.:IlllngAoJ'€:$S (Streel city' 101'011. stale. liP ewe) 304 South Filberty Street Mechanicsburg, PA 17055 17b. County 18 Fa:~,ersNilm" (F,lst, Il"dd,e last SUtlLX) Richard M. Burkholder 2ua IntOIlT1i:infs Ni>me IType ,Prir.l) \..D 3 SOCial Security Number 177 - 42 of Dale of Dealr, (Month, day. year) January 4, 2008 Other 10 AaceAmeucantndlan,8lacK Whi16,elc (Spe~,fy) White 14 Marital $latus: Mdmed Never Married Widowed Di~orced {SpOCltn Never Married DtdDecedllnl llveina Township? 17c. 0 Yes, Decedentliv{.>d In 17d_.P4, ~1~~=~IJivecI within Twp Mechanicsburg Cllyi80ro 21b. Dala 01 OIsposihOfl (Month. day, yeae) 20b tnlormanl's Ma~ing Addless (Street, city I town, stale, zip code) 37 Summerfield Drive Carlisle, PA 17015 21d localiontCily/lOWn, slate, Zlpcodel Richard M. Burkholder 21e Pliice of Disposition {Name 01 cemele~, cremalofy or other place) AtoIlL;)....1 hcmSI'-Ile Hollinger Creamatory Mount Holly Springs, PA 17065 22c. Name and Address 01 facility . " Myers Funeral Home, Inc. 37 East Main Street Mechanicsburg, PA 17055 23b. license Numbel ne~ 24.26 must be completed b~ person who prooounces death 24 Time of Death O<}$"I I CAUSE OF DEATH (See Instructions and examples) Item 27 Part I. Enler ltIe 1d.Ili!!12l..e.illlki - dl:>eaStls, InfLmes, or oompIicallofls ~ Ulal difec\l~ caused the dealh. 00 NOT enter terminal e~ents such as ca/wc arrest reSpllatory arfest, Of ~entllclJla/ hbnllation ~iltlOUt showing Itle ellology lisl ullly one cause on each ~ne I ApproKlmale inlerval : Onset 10 Dealh ~ 1 J.ka l-1 :~.. . . , . , , , ::=~~~~~ ~~~l) dlse.:; Si!quelllli.lHy lislconQllions, d any, =:~H~R~:'~~~t a (ciJsease J( InJUry lhal inillaled !he events rtsulllflg lfl dealh) lAST. JOb Were Autopsy Findir\Qs Ava~able POO/IO Compkltlon ofCau~eofDealtl? 31 ManoerotDealh ~illUlill OHonllClde o AtUO(:fll [J Penwf"I!lln'lestlgatlOO o SUICllll! [] Could Not be Dehwnined M 30a Was an Autopsy ,"lertulmed? Ole~ gNo 0"; oNo 32d. TllrIE!01 10flJfY 33a Cenllier (chec~ ooly one) Certifying physician (ptI~:;.Il;ran cenrfYlllg cause ut Otlalll ~hclI ariUUltlt flhysj(~lalllras protlounced Lleath and eumP't'led Item 2Jl loth. be51 01 my ILnowkldge, death occurred due 10 the cause(lj and manoeras 11a1eeL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 ~~~:u:s~t~ =~hJ:~~~~(:::r:~I:~ 1~~i:I,~~nin~e~~~~~~~;l~~~~~~~~(~~~ manner as staled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 ~~:~~:~m~":~~;f~:t: and I or investigation, in my opinioJn. death occurred althe time, date, and place, and due to the caUIWl(S) and mannef as slated_ [] i '0 ~ IJ 111."). I \ Id. I OI~1l0~I!lon f'ell1ll1 No /) 6 Cf ~ 9 s I~ . I os. OO7/r~ L. 26 ~fElrled 10 Medical baminar I CorOflEl( lor a Reason Othe/than Cl\mation or Oooabon? g:)s 0 No Part II: Entef olhef ~~~..IILd:!:.i1I:J 28 Did Tobacco Use Coolubule 10 Death? bul not resulting in the underlying cause given in Parll 0 Yes 0 Probably o No 0 UIl~nown 29 It Female o NoI pr"\lflanl wrthin paSI ~eal o Pregnanlalllmeotl:lealh o NoIPfegnant,butpfegnanlwllt~n42d..ys olooalh o Not pl'egnant, bUI pregnanl 43 dayS 10 1 year beloredealh o Unknown 11 pregnar,t wllhll'lthe pas! year 32c Place 01 IfltUry: Hume, Farm, Sl:reet, Factory OfIiceBiJlldrllg, ale (SjJec:rly; 329 location ollnlUfY (Slreet clly!lown, sllila)