HomeMy WebLinkAbout11-21-08PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF
Estate of
Elmer E. Clouse
also known as
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
File Number '~ ~ ~~ ~ ~ ~~~
Deceased Social Security Number ZC ~ ~a '~ ~3 9~'~'
A. Probate and Grant of Lette s Tes amentary and aver that Petitioner(s) is /are the
last Will of the Decedent dated ~ 2 ~- 2a o a and codicil(s) dated
Executor (s) 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 bom or adopted after execution of the instrument(s) offered
n/a
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
a B. Grant of Letters of Administration c~-_'3
(If applicable, enter: c.t.a.; d.b.n.c.t.a.; pendente life; durance absentia; durpttte minoritate)~
Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the followingc~ (rf any) heirs:` -(If
Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) tT `- 7 _
- .~ y r~ N
Name Relationshi Reside~6,~'~ ~ ~~ ~_ ~ ,',
':-'~ ~=~i-t ~ ~t
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(COMPLETE IN ALL CASES:) Attach additional sheets ijnecessary.
Decedent was do ct ed at de th in, Cumber 1 a n d Coun Pennsylvania with his / her lasj principal residence at
~"c~~ nnu~7 ~ ewv~i'lle, Pennsylvania 17241
(List street address, lown/city, township, county, state, zip code)
Decedent, then $ l ears of age, died on NOV . 3 ~ 2 ~~ 8 at
Car is e ~egional Me ica en er
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
situated as fo
$ ~Z.oo. va
y
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:
Si nature ^T ed or rioted name and residence
I` Lu..., yG l~t~ l~ v err, ~. l1 ~o t-f J ~
CUMBERLAND COUNTY, PENNSYLVANIA
Form RW-02 rev. ]0.!3.06 Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA .
SS
COUNTY OF C ~.l tii~ t~7 C ~'L ~ ~'~
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 of Petitioner(s) and that, as personal representative(s) of the Decedent,l?etitioner(s) will well and truly
administer the estate according to law.
Swom to or affirmed and subscribed
C1 ~'~ ignatu e ojPe sonal Repr entative
be ore me the ~_ d~a/y~ of ~
~~ ~ ~ ,.` ~'lJ~ Signature ojPersonal Representative ? ~
7 "~ fr>
~ ,~_ A ~~
~!;)
J ~ ~or~ he R egister Signature ojPersonal Representative r ~~ ~""
7 ~ ~ C
~_.~ ~7 ~~
~ / 7 ~ `:'
File Number: ~
Estate of ~ ~^~ t ~ ~• C ~° r~I C. ,Deceased
/ ~ ~ ~ ~ 9 ~Z Date of Death: / 1' ~ V • 3 z ~ ~
Social Security Number: 2 °
AND NOW, :~ J bt ~ ~~~~~$-' in consideration of the foregoing Petition, satisfactory proof
having been presented before me, I IS DECREED that Letters~4'V1G rR ~'' Q
are hereby granted to
in thz above estate
and that the instrument(s) dated ~'
described in the Petition be admitted to
and filed of
FEES
~~~~
Letters ............... $
Short Certificate(s) ........ $ I i~, ~~ _
Renunciation(s) .......... $
'~ ... $ f ~ ~ ~~
~~7 6~ ~ ... $ S,C~
... $
... $
... $
... $
... $
... $
~~-
TOTAL .............. $ ~(~ .
the last Will (and Codicil(s)) of
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.:
Address:
Telephone:
Register ojWills
Form RW-02 rev. 10.13.06 Page 2 of 2
,- .._
LOCAL REGISTRAR'S CERTIFICATION C)F DE1~T~
V~JARNING: It is illegal to' duplicate this copy by photostat or photogra;~h,
Fce fur this certificate. $6.0O
P x.499961.4
Certification Number
H11Yr143 REY 112006
TYPE/ PRM1T IN
PEHMANEN7
BIACN INK
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'T'his is to ccrtif~ that t17c information here given is
corrertl ~ copied (rtfm an original Certificate o1~ Death
duly filed with 11~Y1 as Lo: al Registrar. The original
certificate will hr for~:varded to the State Vital
Recurds~ Office for Cermanent filin_~.
~~eac~c `D~~~ NU 5 2008
Local Re~Tisu<<r Date I~~~ued
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse) STATE FILE NUMBER
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1. Name al Decedent (Frcsl, mode, lest. SuRUO 2. Sax 3. Sodal Security Number 4. Dale of Deam (Mmm, day, year)
Elmer E. Clouse Male 201 _18 _3982 ovember 3, 2008
5. Aqe (last SirdWey) Under 1 yeas Under s day 8. Date of &nh (MPMh, tley, year) 7. Bidtplara (Cky and state aloe ' country) Ba. Place of Deem (Check only orw~)
Hwmml. rnner.
82 "'°'"" °'" "°"' ""'°` March 4, 1926 Newville PA
xx
Yrs. y>a Inpatient ^ ER / Outpatient ^ DOA ^ Nursing Home ^ Residence ^Odrer - Spec4y:
Bb. County of Deam fie. City, Boro, T d Death
~ ( r)
~~~~~~ Medical
~~~ 9. Was Decedent of Hlapank Origin? No Yes
~ 10. Raw: Ameroan Indian, Bradt, Whim, etc.
Cumberland Midleton
South -
C
t (n yea,spedtycaban, M
YY 111 t e
en
er Meown, Puerto Rkan, etc.1
11. DawdenYa llsrml Ion Kntl d work d one du ~ most d ~ IHe. Do rwl smm reread 12. Was Decedent ever in the 13. Decedem's Educatbn (SVeaiy only higlmsl grade wmp mled) 14. Madml Status: Martied, Never Monied 15. Surviving Spo uw (II Mle, give maiden name)
K'xN d Wok Kind d Buskress /Industry
Mill Owner Feed Mill U.S. Armed Forces?
~vee ^Na Emmemary / SePOadary (012)
1LG Collage l1-0 or 5.) Witlowed, Divoroetl (Specify)
Widowed
tfi. Decetlanl's Mailing Address (Sheet MY /lawn. smm, zip code)
844 Doubling Gap Road Dewdent's ppi Did Decedent
AcmmResidenw ne.smte Liveina na.KlYea,Deaermnniredm Lower Mifflin Twp
Newville PA 17241 nb. cm,nty Cumberland T°w~lp? t?d.^NO, Oecetlent Lroed wimo
AcNel umim d Cky /Boo
1fi. Fathers Name (First, mitlde, m51, suffix) 19. Mdher'S (Fi middle, maiden eras)
ssler
.~ ~'
B
Charles R. Clouse re
erea
20a. Inlormard's Name (Type /Print) 20b. InbrmanYS Meiling Adtlress (Street, city / mwn, smm, zq cads)
Jerry A. Clouse 118 A South Railroad St. Hummelstown PA 17036
21 a. Method d D'aposilon ^ Cremafren ^ Donation 21 b. Date of DisposPoon (Month, day, Year) 21c. Place of Dopwilion (Name d cemetery, aemelory «omer plow) 21tl. Lawtbn ja /lawn, state )
p~cotl17241
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N
g] Burial ^ RemovalhomSYate !vruCnmetbn«DOn•tlonAutho,Iratl 11/7/2008 Newville Cemetery ewvl
e
^ OtMr ~ SpedN: ~ M Medkal Examin« / C«aneR ^ vas ^ No
22a. Signa~FUreral («person acing as aucn) FD ~l~~
95 L ~1~"J~i°°r°P°LIrPF~"ral Home Inc 15 Big Spring Ave
- ~• ~ t7 Newville PA 17241
Cwplele rams 23es any when wrt8yop afire best d my knarktlge. death accunetl al dre time, dam and pmce crated. (Signature eM rtlel 23b. Liwrue Nunber 23c. Data Sigwtl (Month, day, year)
plryei~n H not available d core d deem m
rten6y caw. a deem.
Hems 21-28 must Oe uvIXl~ml~ M persw 24. Time of Death 25. Date Prarouwed Dead (Mtxdh, day, year) 26. Was Case Referted ro Medkal Examiner I Cor«rer for a Reason Other than Crematbn «D«lalon?
who prorpuNes deem. ~ 5 5 F, M. ~ ~ _ 3 - 0 8 ^ Yea L~}+~
CAUSE OF DEATH (See Instruetlone entl examples) r Approximam interval: Pen II'. Enmr alher;~jf nt cantlitbns cmtributhw m tleam. 28. atl Tobarxro flee Conlribum to Deam?
Item 27. Pen I: Enter th drew of events -dseasns, iryuries, or mnpliceraw -Nat directly wusetl the tlealh. DO NOT solar terminal avems such as wNiac artest r Orreet to Deam but not resdtirg N the untledging woes given in Pad L Y
^ Probably
es
^
rasPhaorY ertesl, a venhiMar fibdlmtion wtlhad stuwog the otology. UG only ow wwa on each fiw. ~ r
~
~
Lld~rv ^ Unknown
IMMEpATE CAUSE IFrW dkease «
wrMiron realrrg m oral ~~ M V L 7 r y l2 ~~ A N r n r L (J rC ~
a.
29. K Fenmle:
^
Due to (« as a wnsequence oFt:
nray kM wrrdaats, a eery, p_ ~
w
mSe
g6
o Nd Pregnant Mlhin pall year
^ Pregnam at eras d tleath
a
r
ro
r
WAFALYpHi CAUSE a Otte m (« as a cansegwrrw o9: r
Enmr Bte
^ Nd Dregranl, but pregnant wilhm 42 days
(tlisessa «'e1'uy mat Xvd&e0 me a 1
ewnm rasutlkg n Deem) LAST. r d loam
Duero (« a9 a consequence oQ: I ^ Nd pegnam, bN pretgrenl43 tlays m 1 year
d. wlae deem
^ Unknown 6 pregnant wahM me pest year
30A Wes an Autopsy 30b. Were Aubpsy Fedmps 37. Manner d Deem 32a. Dale d Injury (M«m, tley Year) 32b. Describe How Injury Oaurted 32c. %aw d Injury: Home, Fenn, Sheet, Factory,
Perlorrtred7 Avaiade Pd« m Currpmf ,~,/
~tural ^ Mo
i
ld
~ Olfiw Buikirg, ek. (Seedy)
d Cane of Deem? m
c
o
L
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^ Yea Q"No ^ Yes ^ tJO ^ Aatiwnl ^ Peridng Imastigetkn 32d. Tinre d Inpry 32e. Inlury al Wark? 321. H Trewpodeeon Injury (Specvyy) 32g. txcatbn of Injury (Street, MY /form, crate)
^ Suklde ^ Could Not bo Detarmoetl ^ Yes ^ No ^ Driver / Operat« ^ Passenger ^Pedestrian
M ^Dltler ~ SpedN:
33e. Carefree (Greek ady one) 330 Signs d 11tle of Cenlfi«
'
• Certltylnp physlden (Physican wrtlryiny cause d deem when amttrer physidan has pronounced deem aM conpleled Item 23) ~I
~ ~- / /v /~'
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To the bestdmy knowmdge,tm•Ih xcurred duo to Hm rauee(s)eM manner nsMted_________________________________ ^ V
-
• ProtNNAlalrg AIM wrldyllg phyeiclen (Physician Odh prppuncing deem and cenitying to wtlse of Beam) .License Number 33d. Dale Signed (MOnm. day, year)
To the best d my krmMeage, deem «curred at the time, dale, end place, entl due to the wuee(a) eM manner es ataled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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Al .D o 3 g e$ o L ~ r- 3- v
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ororor
On the bests d examination and / «Investlgetun, in my opinion, deem «curred at the lime, date, and pmts, end due to tM cauaele) and manner ea smted_ ^ 34 Name acrd Atltlress d Parson Who Ccmpmlea Cauca of Deam (Tram 271 Type /Print
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35. Registrar's ' rxt Die6id rNrer"1
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Elmer E. Clouse ~-' ~^~~ ~-~
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I, Elmer E. Clouse, of 844 Doubling Gap Road, being of lawful age, sq~n~ mind 'aid
memory, and under no restraint, do publish this, my Last Will, revoking a l others previously rude
by me.
First: All expenses, fees, costs, and taxes related to this estate shall be paid from the probate
estate assets, and all gifts and bequests shall be paid from the net distributable estate.
Second: I give, devise, and bequeath my entire estate, real, personal, or mixed, of every kind
and nature, and wherever situated, which I may own, or hereafter acquire, or have a right to dispose
of at my death, to my wife, Bessie V. Clouse.
Third: In the event that my wife does not survive me, then I give, devise, and bequeath my
entire estate, real and personal, to my children, share and share alike, per stirpes. It is my desire that
all my children share equally in my estate. The deed to my and Bessie's property at 844 Doubling
Gap Road has been transferred to my son, Jerry A. Clouse, with my desire that he maintain the
property in good repair. I direct that upon the death of the second to dies of myself or my spouse,
Bessie, that Jerry share this gift of property with his brother and sisters, and give them each, within
three years of the death of the second of my spouse or myself to die, the sum of Fifteen Thousand
($15,000.00) Dollars each. In the event that my son, Jerry, wishes to~ sell the property at 844
Doubling Gap Road, I direct that he grant each sibling, in order of birth from the oldest to the
youngest, a first right of refusal to purchase the property. Should one of m;y children other than Jerry
become the owner of the property, I direct that the child owning the property gift the sum of fifteen
thousand dollars to each of his or her siblings. in the even± ±hat ±he property is sold to someone other
than my children, I direct that the proceeds of the sale be distributed equally between my children,
their heirs and assigns. I further direct that all expenses incurred by any of my children in
maintaining the property be reimbursed to them upon the occurrence of any of the above.
Fourth: I nominate and appoint my son, Jerry A. Clouse, to be the Executor of my Last
Will, granting to him authority to sell and convey any or all of my estate, real and personal, or mixed,
upon such terms and prices as he shall deem proper, without obtaining any prior order of the court
therefor. I also grant him full power and authority in the settlement of my estate, to compromise,
adjust, and settle any and all debts and liabilities due to or from my estate,, for such sums, and upon
such terms and conditions as he shall deem best. In the event that he shall for any reason decline to
serve, or fail to qualify for any reason, or having qualified and been appointed, fail to complete the
administration of my estate, then I nominate my son, Randy E. Clouse to be the Alternate or
Successor Executor. I direct that no bond or surety shall be required of any administrator or
fiduciary named herein.
IN WITNESS WHEREOF, I have hereunto subscribed my name, and acknowledge and
publish this instrument as my Last Will and Testament in the presence of the undersigned witnesses,
on / - ~ ~? ~ .~C ctc~ , -
Elmer E. Clouse
Signed, sealed, published and declared by Elmer E. Clouse, Testator, as and for his Will, in the
presence of us, who at his request, in his presence, and in the presence of each other, have hereunto
subscribed our names as witnesses hereto.
,~1~ ~c~~- ~ ~~~'ij residing at ~- C~1 ~ ~G~ ~~
'1~ ~ ~ ~. `--14~ residing at -1-~zrZ~ s h ~~r ~ ~°"
COMMONWEALTH OF PENNSYLVANIA
COUNTY C)F DAUPHIN
ss
We, Elmer E. Clouse, ~~ ~1}~~i_ ~~ I~,~a and ,..7 ~. '~ `_ ~ ,the Testator and the
witnesses whose names are subscribed to the attached Will, being duly ualified according to law,
do depose and say that we were present and saw the Testator sign and execute the instrument as his
Last Will; that he signed it willingly and that he executed it as his free and voluntary act for the
purposes therein expressed; that each of us in the hearing and sight of Elmer E. Clouse signed the
Will as witnesses; and that to the best of our knowledge he was at that time 18 or more years of age,
of sound mind and under no constraint or undue influence.
Testator: ~~^~ cry- _~._~e,-~.,-..x.
Sworn and subscribed to before me, thi~;~
..,
Witnesses: _,
r~~
r'
~ ~
day o~ .~ , I!;~ , E
Notarial Seal ~
pc,t~1 ar R. Luhn III, Notary ~ ubilc
H~rr;SbUrg, Dauphin County
ti+y ~'omrnision Expires April 24, 2000