HomeMy WebLinkAbout02-20-09PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF COUNTY, PENNSYLVANIA
Estate of I ~[ L't;~f Y i'~ c' ~`/~~ti~.L'I ~1 V1 File Number ~ ~ a C1 ~ 1~~~
also known as
,Deceased Social Security Number ~(~~~ -- ~;~-9.5~~'
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COiYIPLETE 'A' or 'B' BELOW:) _`
A. Probate and Grant of Letters esta en ary and aver that Petitioner( is re the ~-'XPC~LITC h named in the
last Will of the Decedent dated 5 ~ and codicil(s) dated
(State relevant circwnstances, e.g., renunciation, dealt 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 insttument(s) offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
^ B. Grant of Letters of Administration
(Ifapp[icable, enter: c. t. a.; d. b. n. c. t. n.; pendeiue life; durante absentia; durmuz ntinoritate)
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: (lf
Administration, c. t. a. ord. b. n. c. t. a., enter date of Will in Section A above and complete list of heirs.)
W aS
with his /her last principal
_'_~
(°r
(List street address, town/city, townsAip, count), state, zip code) / 11 ~ ~ '
-j CJI _
Decedent, then •~ years of age, died on z ~ l ~G at ~~~ /l; r~. lu~-~ L~TCf~~. ~ ;~Ct,1~~~~
Decedent at death owned property with estimated values as follows: /'~
(If domiciled in PA) All personal property $ ,~Ci , l.l~~~)
(If not domiciled in PA) Personal property in Pennsylvania $
(If not domiciled in PA) Personal property in County $
Value of real estate in Pennsylvania $~ C,~'i
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:
Signature ~/ Ty ed or tinted name and residence
Form RW-03 rev. !0.13.06 P1be I Of 2,
(CUIVlt'LL l C L!V ALL LAJLJ':J Attach addtttatal Sheets tf necessary. ' ~ -~
Oath of Personal Representative
COiviiVlONWEALTH OF PENNSYLVANIA
1 SS
COUNTY OF ~ 1~,~(Y\ `-~e ~ 1C~~'i G~
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are tt~e and con-ect to the best of
the knowledge and belief of Petitioner(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
before mP the ~._ day of
~~~~~
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For the Register
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Signature oJPersennl Representative
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Signature of Personal Representative
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File Number: ~ ~ U ~ b,~~7
Estate of ~1C~(C~'~~f e ` ~ ~`~0.t3~ ~~r~G~o~ ,Deceased
Social Security Number: 2~ ~ 3~ ~~~ ~ Date of Death: ~~ ~ ~ ~ ~ Z ~ ~-)~~
AND NOW, ~~~ ~ f ~ (}f ~ P Y1~~.~.t`l.~ .~.~~, in consideration of the foregoing Petitic n, satisfactory proof
having been presented before~r{Ie, IT IS ECRE/ED`[t(at((L~~etters
are hereby granted to ~ f~Q Y~Z P~ Cl 1~.~`tY`l`Cs
in the above estate
and that the instrument(s) dated ~ Da , ` l ~ ~G~~
described in the Petition be admitted to probate and filed of reco>;d as the last Will (end Codicil(s)),~of Decedent.
FEES ~ ~ ~ JX ~~~~ ~ ~L~ ~~!~t-5
~~
Letters ......qO,~~C $ ~)
-~-
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Short Certificate(s) ..~~..... $ 2 (J Attorney Signature:
Renunciation(s) .......... $
Attorney Name:
~~~~~1( ... $ I~
... $ ~,~; _ Supreme Court LD. No.:
~-- ~~ ... $ `J
$ Address:
... $
... $
... $
• • • $ Telephone:
... $
TOTAL .............. $
F~,~n~ Rw-oz ~~ev l0.l3.or Page 2 of 2
Register oJWills ` 9 t V _~
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for tt~iis certif~ea?e. X6.0(1
P ~.~1~73C3
Certifirttion Number
This is to certif~~ that the information here ~i~~en is
correctly copied from an original Certificate ul Death
duly filed with lne as Local Reg;sh-ar. The original
certificate will be forwarded to the State Vital
Records Office for permanent filing.
.!)~.~ ~ ~ ,~t,,yz~~_FEB 8 20 9
Local Registrar Date [slued
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3EV 11/2006
PRIM IN
ANENT
.K INK
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS t.~7 ; 7
CERTIFICATE OF DEATH \ W
(See instructions and examples on reverse) STATE FILE NUMBER ~ O C ` ~ \~~
1. Name of Decedent (Frst middle, lass. suffix) 2. Sex 3. Social Security Number 4. Date of Death (Month, tlay. year)
fame ~ -95 7 F b. 15 2009
5. Age (Last Birthday) Under 1 year Under 1 day 6. Date of Binh (Month, day, year) 7. &nhplace (City and state or forego country) be. Place of Death (Check only one)
k1an1M Deys Novrs Minutes Hospital Other.
Apr . 2 3 , 19 2 8 L y k e n s , P A ^ I
$ 0
i
t ^ ER /O
t
i
^ DOA ^ N
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R
id
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pat
ent
urs
ng
ence
mer ~
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npat
ome
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6b. County of Death &. City, Roro, Twp. of Death 6d. Facility Name (tt not Insktution, give street aM number) 9. Was Decedent of Hispanic Origin? No ^ Yes 10. Race: Amencen Intlian, Black, While, etc.
Cumberland Lemoyne 802 Market St. (N yes, speary Cuban,
Mexican
Puerto Rican
etc
) (Speclyt
whit e
,
,
.
11. Decedent's Usual Oct tan Kind of work d one Burin rtrosl of workln IAe. Do not stale retired 12. Was Decedent ever in the 13. Decedent's Education (Specify only hghest grede compl eted) 14. Marital Status: Maned, Never Marred, 15. Surviving Spo use (II wife, give maaen name)
Kira of Work Nind of Busirass / IMustry U.S. Armed Forces? Elementary /Secondary (0-t2) College (1-4 or 5+) Widowetl, Divorced (Specify,
school teacher education ^Yea~INO 12 4 divorced
16. Decedent's Mailing Adtlress (Street, city /town, state, zip code) Decedents Did Decedent
1 C7 a h 1 a Live in a 17c
^ Yes
Decedent Uved in Tw
Slate P P rl n R
t
l Residence 17a
A
8 0 2 Mark ° t S f . y
.
,
p.
.
c
ua
Township? a~
Lemoyne, PA 17043 I7b~enty Cumberland 17d.y>INA1uaDicUedento'ivetlwithinLemoyne city/mm
i 6. Father3 Name (First, mkkle, last, sufrix) 19. Mother's Name (First, midfle, maitlen surname)
Daniel Underkoffler Minnie Erhart
20a. ImortnanYs Name (Type / Print) 20b. Informant's Mailing Address (Street, tiry /town, state. zip cotle)
Haden Kauffman 6200 Wilson Blvd.,#614, Falls Church, VA 22044
21a. Metlwd of Disposition j ^ Cremation ^ Donatan 21 b. Date of Disposition (Month, day, year) 21c. Place of Disposition (Name of cemetery, crematory or other dace) 21 d. Location (City I town, state, zip code)
Buda) ^ Re al from Slate ' waa Crematk,n pr Iyonatbn Audtorized 2 0 0 9
19
Feb Rolling Green Cemetery amp H i 11 , P A 17 01 1
r . Spacty; hY Medical Examltter I Lororter? ^ Yes No ,
.
axe of Funeral Se ' 'tenses (or person acting as such) 22b. License Number 22c. Name and Address of Facility
t~
d 013163-L
FD 324 Hummel Ave.,Lemoyne,PA 17043
Musselman FH~CS
( ~~,y.a
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• Compels Items 23a~c only wheq ceniryag 23a. To me best of knowledge, deaU oa ad at dre tlme, date and place staled. (Signature aM IMe) 23b. License Number 23c. Date Signed (Month, day, year)
physidan k not available al time of death to
ceniry cause of tleath. ~~ ~1 ~
~ ~[rLCv^-•'`~ ~~
~ N a ~9~' ~ 7 ~ ~ _
.~,6r=~~ ~" ~ s ~2~
Items 24.26 must be completed by person 24. Time of Death ye
a
r)
25. Date Praneuncetl Dead (Month, day, 26. Wes Case Referred t Medical Examiner I Coroner for a Reason Other an Crematan or Do tion'+
wtp pronounces Beam. ; ~ M. ~
-
^
L! G:v" 1 ~l (~ ~ ^ Yes o
CAUSE OF DEATH (See InstruMions end examples) ~ Approximate interval: Pan II: Enter other sig0ificanl conditions centritwsne to tleeth, 26. Oa Tobatto Use Contribute to Death4
Item 27. Pan 1: Enter the than of evenu - tliseases, inrynes, or complicetbns -that tiredly caused the death. DO NOT solar terminal events such as cardiac arrest, ; Onset to Deam but not resulting In the underlying cause given in Pan I. ^ Yes ^ Probably
respiratory aresl, or ventraWar fibnllalion withoN showing the etioagy. list only one reuse on each line. r ^ No known
IMMEDIATE CAUSE (Final tlisease or ~ i
cantlifion resorting in death) ~ a ( 29 If F ale:
N
t
Duet as a nseque e o ~ r
~ r ~
ol pregnant witha past ar
Ye
Pregnant al lime of death
Sequendalry list cerditbns, if any, b, ~/ r
leadngg to the cause Flied on line a. Due to or a sequerxa oQ:
UNDERLYNFG CAUSE (
E
m t
~ t ^ Not pregnant but pregnant within 42 days
nter
e
(disease or injury that initiated the c
~OJ`• r
r of tleafh
events resuMng in death) LASS
Due to (or as a consequence op: r ^ Not pregnant Mn pregnant 43 days to 1 year
d
t before death
^ Unknown if pregnant within the past year
.
30a. Was an Amopsy 30h. Ware Autopsy Flndmgs 31. Mamler of Death 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occurtetl 32c. Place of Injury: Home, Farm, Street Factory,
Penortned? Available Prior to Completion
of Cause of Death?
^ Natural ^ Homicide Oflke Building, etc. (Spedty)
^ Accident ^ Pending Investigation 32d. Time of Injury 32e. Injury at Work? 321. tt Trensponation Inlury (Speatyl 32g. Location of Injury (Street, city I Town, state)
^ Vas ^ No ^ Yes ^ No
^ Yes ^ No
^ Driver I Operator ^ Passenger ^Pedestnan
^ Suaide ^ Could Nol be Determined M ^ other -spec/ty.
33a. Certifier (check only one) 33b. gnature and 1 enitier
• CedNytng physician (Physician cenitying cause of death when another physidan has prorwunced deem and completed Item 23)
tleeth oceumetl due to the cause(s) and manner as staled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
To the hest of my knowledge M
,
• Pronouncing and cerlltylnq physician (Physican troth pronoundng tleath and certifying to cause of Beam)
^ 33c. License 33tl. Date Sig (MOnM, day, yearj
^
To the best of my knowledge, tleath occurred at the Brae, dale, and place, and due to the cause(s) antl manner as smtetl_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1
0 \ ~~ \
G/
• Metlioal Ezaminer I Coroner
On Me basis of ezamination and I or invesllgatbn, In my opinion, death occurted at the time, date, end place, end tlue to the causes) aM manner as staled_ ^ 34. Name aM Awe ~P WheDOp o Canple1ad Caus~ ath gtem 27) Type / P nt (~/
^
` `
~rsc
is
Q V 1 ~-
Q lA
' ea
Date F' etl (Month
36 I
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~
Cr
re and Distnc
35. Registrar's S
O`er I~ ~I~ I / I~ I y, y
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Will of Margaret Eve Kauffman
Part 1. Personal Information
1, Margaret Eve Kauffman, a resident of the State of Pennsylvania, Cumberland,
declare that this is my will. My Social Security number is 206-38-9505.
~~S yr~~:,K,
Part 2. Revocation of Previous Wills
I revoke all wills and codicils that I have previously made.
Part 3. Children
I have the following children now living: Hadan E. Kauffman, Janice L Enders
and Kathleen M Adams.
Part 4. Grandchildren
I have the following grandchildren now living: Avery L Adams, Haley L Adams,
Kevin A Kauffman, Mark F Enders, Michael A Enders, Robert K Adams, Ron E
Kauffman and Ross C Adams.
Part 5. Failure to Leave Property
If I do not leave property in this will to one or more of my children or
grandchildren named above, my failure to do so is intentional.
Part 6. Disposition of Property
All beneficiaries must survive me for 45 days to receive property under this will.
Page 1 of 6 Initials: _,~~~ ` _~ Date: l.S~''D:~'
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Will of Margaret Eve Kauffman
As used in this will, the phrase "survive me" means to be alive or in existence as
an organization on the 45th day after my death.
All personal and real property that 1 leave in this will shall pass subject to any
encumbrances or liens placed on the property as security for the repayment of a
loan or debt.
If I leave property to be shared by two or more beneficiaries, it shall be shared
equally by them unless this will provides otherwise.
ff I leave property to be shared by two or more beneficiaries, and any of them
does not survive me, I leave his or her share to the others equally unless this will
provides otherwise for that share.
"Entire estate" means all property I own at my death that is subject to this will.
I leave my entire estate to my children Hadan E. Kauffman, Janice L Enders and
Kathleen M Adams in equal shares.
Part 7. Executor
I name Hadan E. Kauffman to serve as my executor. If Hadan E. Kauffman is
unwilling or unable to serve as executor, I name Janice L Enders to serve
instead.
No executor shall be required to post bond.
Page 2 of 6 Initials: ~, Y 1-r' ~`L~ lc., ~' ate: S l)~
Will of Margaret Eve Kauffman
Part 8. Executor's Powers
I direct my executor to take all actions legal{y permissible to have the probate of
my will done as simply and as free of court supervision as possible under the
laws of the state having jurisdiction over this will, including filing a petition in the
appropriate court for the independent administration of my estate.
I grant to my executor the following powers, to be exercised as he or she deems
to be in the best interests of my estate:
1) To retain property without liability for loss or depreciation.
2) To dispose of properly by public or private sale, or exchange, or otherwise,
and receive and administer the proceeds as a part of my estate.
3) To vote stock, to exercise any option or privilege to convert bonds, notes,
stocks or other securities belonging to my estate into other bonds, notes,
stocks or other securities, and to exercise all other rights and privileges of a
person owning similar property.
4) To lease any real properly in my estate.
5) To abandon, adjust, arbitrate, compromise, sue on or defend and otherwise
deal with and settle claims in favor of or against my estate.
6) To continue or participate in any business which is a part of my estate, and
Page 3 of 6 Initials: !~ 1~ ~ ~-~-Date: _ `~~
Will of Margaret Eve Kauffman
Part 12. Severability
If any provision of this will is held invalid, that shall not affect other provisions
that can be given effect without the invalid provision.
Signature
I, Margaret Eve Kauffman, the testator, sign my name to this instrument, this
!S day of Y~ ~:\ ~'~ , at
.,~~~ r~tq . I declare that I sign and
execute this instrument as my last will, that I sign it willingly, and that I execute it
as my free and voluntary act. I declare that I am of the age of majority or
otherwise legally empowered to make a will, and under no constraint or undue
influence.
Signature: ~..Li.1a.~u.3a.~ ~`- ~~zr.~~n~-~-
L
Wltn@8S@S
We, the witnesses, sign our names to this instrument, and declare that the
testator willingly signed and executed this instrument as the testator's last will.
In the presence of the testator, and in the presence of each other, we sign this
will as witnesses to the testator's signing.
~C~' r ~'
Page 5 of 6 Initials: l:~C ;~~/".~ Date: 4 ~ I5 I D 6
Will of Margaret Eve Kauffman
To the best of our knowledge, the testator is of the age of majority or otherwise
legally empowered to make a will, is mentally competent and under no constraint
or undue influence.
We declare under penal of perjury that the foregoing is true and correct, this
(5~h day of r ~ ~ ~ ~~ , at
:~%Y~tr
Witness #1: ,~~ ~ ~'~~~~
Residing at: 1 ~O ~ ~ ,'c.i`-er {[~r. ~(o ~- K ~~ ~-e/l V'°~ . ~ ~7 3 ? 0
Witness #2:
Residing at: ?3~~~~.~L.t-lr;~~1"r ~f ~~.r ~ ~r ~~x~~ ~~ ~~ l ~~~~
Page 6 of 6 Initials: ~ ~ ~ ~<. ~'~~ ~~ ~ ~ ~ Date: -~;~ ,_,-t"=
Affidavit
ACKNOWLEDGMENT
Commonwealth of Pennsylvania
County of: ~;t.vv~~r t A.Yt~-
I, Vic`' ` _"1 „~ _, the testator whose name is signed to
the a a ed or foreg n instrument, having been duly qualified according to
law, do hereby acknowledge that I signed and executed the instrument as my
Last Will; and that 1 signed it willingly and as my free and voluntary act for the
purposes therein expressed.
Testatc
Officer:
COMMONWEALTH lVF PENNSYLVANIA
Notarial Seal
Cathy L. Youngblood, Notary Pubiic
Lemoyne Boro, Cumberland County
My Commission Expires June 22, 2010
Member. Pennsylvania Association of Notaries
Affidavit -Page 1 of 3
Affidavit
AFFIDAVIT
Commonwealth of Pennsylvania
County of: C.;~~n~~-~o.~
We, ~~~v s ~ ~ ! ~ c~.C~ ~~ S and
~~ t~k~-~h c.~l~~ ,the witnesses whose names are signed to
the attached or foregoing instrument, having been duly qualified according to
law, do depose and say that we were present and saw the testator sign and
execute the instrument as his/her Last Will; that the testator signed willingly and
executed it as his/her free and voluntary act for the purposes therein expressed;
that each subscribing witness in the hearing and sight of the testator signed the
will as a witness; and that to the best of our knowledge the testator was at that
time 18 or more years of age, of sound mind and under no constraint or undue
influence.
Swom to or fFrmed and subscribed to before me by
~u5~ C ~c~cP ~tip~S and ~-~.`~~ `~ 1C~-cc~.~ s ,< <-' ,
witnesses, this ~ S day of ~~~ ~c~~~ .
Witness: ~~. ~~ ~~~-'-°-
Witness:.~1~
Affidavit -Page 2 of 3
Affidavit
Officer:
COMMONbVEALTH OF PENNSYLVANIA
Notarial Seal
Cathy L. Youngblood, Notary Public
Lemoyne eoro, Cumberland County
My Commission Expires June 22, 2010
Member, Pennsylvania 4ssociation of Notaries
Affidavit -Page 3 of 3
a \ C %c1. O l-I
OATH OF SUBSCRIBING WITNESS(ES) n
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REGISTER OF WILLS .
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G i9~'18~L /~~~ COUNTY PENNSYLVANIA ~ -'~ %
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Estate of / V/// ~C~ ~~~~ / ~~ l~~ ~~ ~~~~1~/~/ ,Deceased
G L/ Z~ ~~'~l l~ ~~'1~~~ ~/ i~~'S = C ,4 ~A~ ~ , (each) a subscribing witness to
~ ~~ (Print Name/s)
the O'Will ^ Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and
say(s) that she / he /~f~ was / wer present and saw the above Testator /Testatrix sign the same
and that she / he /they signed the same and that s}~~~/ they signed as a witness at the request of
the Testator /Testatrix in her /his presence and in the presence of each other.
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Sigiia k) ~ gn¢taire)
,_7_~~~ ~/~t,~r,.-~ l ~ ~~-~% l~r
(Street Address) T (Street Address)
(Ci[y, State, Zip)
~/vrf~ f ~a~-~ , ~~ ~ .~ ~ 7~
' (City, State, Zip) ~
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
Deputy for Register of Wills
Executed out of Register's Office
Sworn to or affirmed and subscribed
before me this / 9~L'. day(1
of ti~ c~-~~ .
~_
Notary Public
My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
COMMONWEALTH OF PENNSYLVANIA
NOTE: To be taken by Ofticer authorized to administer oaths. Please have present the original r copy of ins t notanzauon.
UNDA E HERMAN, Notary Publb
Form RW-03 rev. l0.13.06 ~~
Commiss~res Aug.28,2012