HomeMy WebLinkAbout02-13-08
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND
COUNTY, PENNSYL VANIA
Estate of JOSEPHINE M. CLOUSER
also known as
File Number :JJ - ()'g' - () ) &I
, Deceased
Social Security Number 091-28-1721
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
IZI A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is / are the EXECUTOR
last Will of the Decedent dated OCTOBER 7, 1994 and codicil(s) dated
RENUNCIATIONS FOR DA VlD C. CLOUSER AND KAREN L. SHEAFFER ARE ATTACHED HERETO.
named in the
(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 instrument(s) offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
o B. Grant of Letters of Administration
;'<~
(If applicable, enter: c.t.a.: d,b.n.c.t.a.: pendente lite; durante absentia; duran'k~~ritate) ;:;:~
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Petitioner(s) after a proper search has / have ascertained that Decedent left no Will and was survived by the following spou~e~If-aJ,1Y) ~~eirs:
Administration, c.t.a. or d.b.n.c.t.a., enter date a/Will in Section A above and complete list a/heirs) ! ;c: h~ =
~;rnm~C~ ~~ ~
(If
Name
Relationship
(COMPLETE IN ALL CASES:) Attach additional sheets ifnecessary.
Decedent was domiciled at death in CUMBERLAND County, Pennsylvania with his / her last principal residence at
7073 CARLISLE PIKE. CARLISLE BOROUGH. CUMBERLAND COUNTY. PENNSYLVANIA 17013
(List street address, town/city, township, county, state, zip code)
Decedent, then 77
years of age, died on JANUARY 16,2008
at CARLISLE HOSPITAL
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property
(If not domiciled in P A) Personal property in Pennsylvania
(If no! domiciled in PA) Personal property in County
Value of real estate in Pennsylvania
66,000.00
$
$
$
$
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:
T ed or rinted name and residence
MICHAEL K. CLOUSER, 317 EAST PORTLAND ST., MECHANICSBURG, PA 17055
..L--
Form RW-02 rev. 10.13.06
Page 1 of2
Oath of Personal Representative
COMMONWEALTH OF PENNSYL VANIA
SS
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 ofPetitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly
administer the estate according to law.
f fVl~ k. ~~
Signature of Personal Representative
day of
Signature of Personal Representative
(,.-
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~ Signature of Personal Representative
File Number: r2 / -/) :? - {)J f5Lj
Estate of JOSEPHINE M. CLOUSER
, Deceased
Social Security Number: 091.28-1721
Date of Death: JANUARY 16,2008
AND NOW, ( .3 ,,;: Go5i , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT DECREED that Letters TESTAMENTARY
are hereby granted to MICHAEL K. CLOUSER
in the above estate
and that the instrument(s) dated OCTOBER 7,1994
described in the Petition be admitted to probate and filed of record ~s the last Will (e~OdiCil(S)) of Decedent.
FEES ~-l :J '0. /...-~ cZJ 1 / 'J
Letters .."............ $ 135.00 Register of Wi! s l.-p",., 7tJ." "-::L6L
Short COOifi",!",) . . .. . . . . $ 4.00 Attorn"" Sign'lure' .1 ~g.3 ~ "
Renunciation(s) .......... $ 10.00 ROGER B. IR ,', ESQUIRE
JCP . . . $ 10.00 Attorney Name:
AUTOMATION FEE . . . $ 5.00 Supreme Court J.D. No.: 6282
WILL . . . $ 15.00
. .. $
.. . $
... $
... $
.. . $
.. . $
TOTAL. . . . . . . . . . . . .. $
Address:
60 WEST POMFRET STREET
CARLISLE, PA 17013
Telephone:
(717) 249-2353
179.00
Form RW-02 rev. /0./3.06
Page 2 of2
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee tor this certificate, $6.00
P 14120365
Certification Number
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. JAN 1 8 Z008
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REV 1112006
I PRINT IN
\AANENT
.CK INK
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
STATE FILE NUMBER
1. Name 01
6. Dale of Birth (Month, day, year)
Yrs
11/2/30
NY
Schenectady,
8b. Countyot Death
ad. Facility Name (If not institution, give street and number)
Carlisle Hospital
Cumberland
11, Decedent's Usual Occ lion Kind of worll done durin mo51 01 workin liIe. Do not slale retired
Kind 01 Work Kind of Business IlnduslTy
Waitress Restaurant
. 16. Decedenl's Mailing Address (Street. city Ilown, stale, zip code)
7073 Carlisle Pike
Carlisle, PA 17013
12. Was Decedent ever in the
U,S, Armed Forces?
Dves GiNo
Decedent's
Actual Residence 17a. Slate
Pennsvlvania
Cumberland
13. Decedent's Education (Specify only highest grade completed)
Elementary I Secondary (0-12) College (1-4 Of 5+)
U NK
17b. County
18, Father's Name (First, middle, last, sufti.)
19, Mother's Name (Firs!, middle, maiden surname)
20a. Informant's Name (Type I Print)
John R. Diehsner
Michael K. Clouser
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3. Social Security Number
091- 28 -1721
2008
16
Other
D Nursing Home 0 Residence DOther. Specify
g. Was Decedent of Hispanic Origin? s:3 No 0 Yes 10 Race: American Indian, Black, White, elc
~:'~~~~~~~:;'lCl (Specify) Whi te
14. Marital Status: Married, Never Married,
Widowed, Di'tlorced (Specif>,1
Widowed
Twp
Did Decedent
Live in a
Township?
17c, 0 Yes, Decedent lived in
17d.f] No, Dec~~nl Lived within
Actual Umllsof
Carlisle
City/Boro
Josephine A. Ruzieski
21a. Method 01 Disposition
21b. Date 01 Disposition (Mooth, day, yea~
2Ob. Inlormanl's Mailing Address (Street, city I town, stale, zip code)
317 East Portland st.
PA 17055
21 c. Place of Dispos;tion (Name 01 cemetery, crematory or other place)
23b. License Number
21d, Location (City I town, slate. zip code)
Leola, PA
Home
PA 17025
230. Date}i i6'iv;e;
. ~
Evans Cremation Service
Su ivan Funera
51 N. Enola Dr. Enola
.,.t-ID
CAUSE OF DEATH (See instructions and examples)
Item 27. Part I: Enter the ~ - diseases, inJunes, or complications -that directly caused the dealt!. 00 NOT enter terminal events such as cardiac arrest,
respiratory arrest, or venlr1culaf fibrillation without showing !he etiology. list ooly one cause on each line.
HP tl r"lqt7! - L.
26. Was Case Referred to);\edical E.aminer ! Coroner lor a Reason Olher than Cremation or Donation?
o Ves IY<6
Appro.imate interval Part 11: Enter other slonificanl conditions conlribulina to death, 28, Did Tobacco Use Contribute to Death?
Onset to Death but nol resulting in Ihe underlying cause glv9n in Pari L 0 Yes 0 Probably
o No 0 Unknown
~=J:s&:n~~; ~~~~ dl1e~
Sequentially lisl conditions, if any,
~~t~~~ 8:D~~II:a~ru~g a.
(disease or iryjul'{ thai initialed the
events resufllOg In death) LAST.
~bl..s
Due 10 (~Nn~ce on.
b f'/'
DuetO(O~ceof)'
Due to (or as a consequence on:
a.
d.
308. Was an Autopsy
P_,
Dves s:
3Ob. Were Autopsy Findings
Available Prior to Completion
of Cause of Death?
31,Uan~Death
~tural 0 Homicide
o Accident 0 Pending Investfgalion
o Suicide 0 Could Not be Determined
M.
Dves ON<>
32d. Time 01 Injury
333. Certifier (check only one)
Certifying physician (Physician certilying cause of death when another physician has pronounced death and completed 1Iem 23)
To the be.t 01 my knowledge, death occurred due to the cauae(8) and mannef a6 statecL.. _.......... _................................................
~~=:~:ta~~ =:::,hJ:a~~a~::~:a; :hti:::~r:~e;::c:~~rt~:~ol~=~~~~~ manner as stated-.. .......... _.. _ _.. _ ...... .. _ 0
~~c:~:~m~~~~;= and I or Investigation, In my opinIon, death occurred at lhe time, date, and place, and due to the cause(s) and manner as stated- D
CVF
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4- -pf b
/}H
29. If Female
o Not pregnant within paSI year
o Pregnant al lime of death
o NoI pregnanl,but pregnant wilhin 42 days
of death
o Not pregnant, but pregnant 43 days to 1 year
before death
o Unkl'lOWll iI pregnant within the past year
32c. Place oll,njury: Home, Farm, Street, Factory,
OffICe BUilding, ale. (Specify)
32g. location of Injury (Street, city Ilown, state)
,uD
33d. D", S~j 7i't'ld f'
34.NamaaM7:ess~k~~W~a~~/~rin~o
~6/ ~'l<X"'" d4;e. S,c~ t;' ~~-K:.
~tz.'t' ,,~/.Z p+ 1"701.j
:R,gislr"'SSignal"~~ ~
I J..1 I, AI II II
6OC13'73Q
Disposition Permi! No
LAST WILL AND TESTAMENT
I, JOSEPHINE M. CLOUSER, of Silver Spring Township, Cumberland County,
Pennsylvania, declare this to be my Last Will and Testament, hereby expressly revoking all Wills
and Codicils heretofore made by me.
1. I direct my executors to pay all of my debts, funeral and administrative expenses as
soon as may be done conveniently after my decease.
2. I authorize and empower my executors to sell any realty owned by me at my death
and not specifically devised herein, at either public or private sale, and to give good and sufficient
deeds therefor, in fee simple, as I could do ifliving.
3. I give, devise and bequeath all of my estate of every nature and wherever situate to
my three children, Karen L. Sheaffer, Michael K. Clouser and David C. Clouser, share and share
alike, the child or children of any deceased child taking the share their parent would have taken if
living.
4. I nominate and appoint Karen L. Sheaffer, Michael K. Clouser and David C.
Clouser, to be the executors of this my Last Will and Testament; they are to serve as such without
bond.
f) o-
S. I hereby suggest that my personal representatives retain the servic~sr:of I~
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McKnight & Hughes, as attorneys in the settlement of my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 7il
October, 1993.
day of
~~ ~~id#2/ (SEAL)
.' JOSEPHINE M. LOUSER
Signed, sealed, published and declared by JOSEPHINE M. CLOUSER, the testatrix
above named, as and for her Last Will and Testament, in the presence of us, who at her request, in
her presence and in the presence of each other have subscribed our names as witnesses hereto.
2
ACKNOWLEDGMENT AND AFFIDA VIT
WE, JOSEPHINE M. CLOUSER, BETZI A. MORRISON and CHERYL L.
CLELAND, the testatrix and witnesses respectively, whose names are signed to the foregoing
instrument, being first duly sworn, do hereby declare to the undersigned authority that the
testatrix signed and executed the instrument as her Last Will and that she had signed willingly, and
that she executed it as her free and voluntary act for the purpose herein expressed, and that each
of the witnesses, in the presence and hearing of the testatrix, signed the Will as a witness and that
to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of
sound mind and under no constraint or undue influence.
~~~~
\ ,""l) . / IJ , ./ / U.,LtJ..-f .../
v SEPHINE M. C USER
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by JOSEPHINE M. CLOUSER, the
testatrix herein and subscribed and sworn to before me by BETZI A. MORRISON and
CHERYL L. CLELAND, witnesses this'" day of October, 1994.
()/~ 1 ~
(_ Notary Public
~B~aISeal
. D"":' Irwin, Notary Ptblk:
My e ~\-" CulTlberlaTx1 ~
.... Comrl'llSSion Expires Q:t. 3, 1996
""'I>mber, Pennc,,"~';;' t.~= I
. ''"J''VCU J/a, ~lIOn of Notaries
RENUNCIATION
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REGISTER OF WILLS
CUMBERLAND COUNTY PENNSYL VANIA
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Estate of JOSEPHINE M. CLOUSER
, Deceased
I, KAREN L. SHEAFFER
(Print Name)
, in my capacity/relationship as
of the above Decedent, hereby renounce the right to
EXECUTRIX
administer the Estate of the Decedent and respectfully request that Letters be issued to
MICHAEL K. CLOUSER
(Date)
1- ~q-O?S
~
(Signatu e)
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1382 ARMSTRONG VALLEY ROAD
(Street Address)
,/
/
Deputy f~ Register of Wills
/
HALIFAX P A 17032
~d~~~
Executed out of Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciatiowr the
pu oses stated within on this &9 day
, 02..>>-0 Pi
?:: - (.&vt,,<-~/---
Notary Public rJ _ 1- ~
My Commission Expires: Of/A. ~ 3>0, ou-o
Executed in Register's
Sworn to or affinned
before me this
of
//
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
Form RW-06 rev. 10.13.06
E S>4LVIi\NIA
''''OMMONWEALTH OF P .
'v NOTARIAL SE~;tary Pub~c
1 LAURA A. TARASEWIC~~uPhin County
\ SU~Queh8nn.a TwP:. Aug 30, 2008 ,
, Mil (ommissl(ln Expires :----
RENUNCIATION
';.~:....)
G.:
REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYL VANIA
1"-)
f'-.,)
Estate of JOSEPHINE M. CLOUSER
, Deceased
I, DAVID C. CLOUSER
(Print Name)
, in my capacity/relationship as
of the above Decedent, hereby renounce the right to
EXECUTOR
administer the Estate of the Decedent and respectfully request that Letters be issued to
MICHAEL K. CLOUSER
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t- ~ \) f' V r, ~ '--( 6') ~ OG ~
(Date)
([-~ CC~
(Signature)
17922 25TH AVENUE EAST
(Street Address)
TACOMA W A 98445
(City, State, Zip)
Executed in Register's Office
Sworn to or affIrmed and subscribed
before me this day
of
Executed out of Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
pu oses stated within on this Of /) K day
of ~ , Zo>;g'
NZ;Ublic ~ -, .. '.':'o~~O~:~Pire'
My Commission Expires: lto? r, "'ashington
. f t, i'} I.~.':";C
(Signature a.r.d Seal of Not'aIJ.qr other official qualified to
administer 'OJlt4~>l;how dllte of ~xt~tion of Notary's Commission.)
Deputy for Register of Wills
Form RW-06 rev. 10.13.06
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