HomeMy WebLinkAbout06-08-10PETITION FOIZ P1~0]BATE AN]D ~R.ANT ®F ]LETTERS
REGISTER OF WILLS OF C k ril C3E72L~-~ COUNTY, PENNSYLVANIA
Estate of R; chard ~'• l.i~Ot~[,S6r' File Number •~"/D ~"' ~~cf
also known as 1QiC~Id.!'t~ ~/IIP.I" C~DGIe~/''
Deceased Social Security Number ~77- •?~^ 6 6os
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW.)
® A. Probate and Grant of Letters Testamentary and aver that Petitioner(s~ is /tee the ~~'-~'~'' X
last Will of the Decedent dated .?~.v1 ~ ~. ~, d.~7
(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
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
^ B. Grant of Letters of Administration
(If applicable, enter: e.t.a.; d. b.n.c.t.a.; pettdente life; durante absentia; durante mi,toritate)
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
Adtrtittistr•atiott, e.t.a. or d.b.,t.c.t.a., enter date of Will in Section A above and complete list of heirs.) ~ t~
(List street address, town/city, township, couril)~, state, zip code)
Decedent, then 77 years of age, died on ~ ~' 2o1D at ~~ ~s (ilJ • C~ne~P,~l e~1 • . ~-I~I CS~KI'`9', ~"I,' l ~'D$s
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
$ ~ o, o00
$ - - __
$ .?S.O~a
situated as follows: ~ o`Z b ~• ~,~,YI c~1':, rYleeh[~,vl ~C.s6urr, , Pty ~ loss'
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
~~,~j '- JC~7H Hums i~v~ cue
XTt,~`.f~/ttii~ ~~~ 3D/ N. ~~LriGk st: _ /Ylec±hau~ic~sbKr4~_ P~+ 1?OSf'
named in the
Fo,~m kw oz rev. 10.13.06 Page 1 of 2
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(COMPLETE IN ALL CASES:) Attach additional sheets if necessary. ~!j ~ ~ ,~,'~ ~'•~
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Decedent was domiciled at death in C tt..m het- a~ County, Pennsylvania with his,~e~- last principal ~`idence at ~ .:1
Green fit- . 8ornw,ln Me~n~in~ ...,,o, ('~~_~,.~~,..../ r ..~r. ao..M~ __ ~z
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF C l.t, M (3E7L[.~4/ll~
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, Petitioner(s) will well and truly
administer the estate according to law.
Sworn to or affirn}zd and subscribed
h
before me the fi day of
~c~Y~ 0 f 0
For the R ist
Signature ojPersonal Representative
Signature of
k /4•T~
Signature ojPersonal Representative ~ e+.'
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~'~.~-ry
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File Number: ~~ -~ ~ _ ,~ ~> n ao
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Estate of ~~~teth~LG'. (~eUStr ~l~ ~~ ~/XQ/'' G n4SCY
Decd ~ -`' r
, ~
Social Security Number: ~ ~- b G b 5' Date of Death: / r1 Q.~ aZ $, ~l 0 y,.,t
AND NOW, , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters T~SC/7/R.~'4
are hereby granted to ~ li.~i i'y h f ff uh s i n 9er
in the above estate
and that the instrument(s) dated •~k1'1G ~.~, ~.dO7 _
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of D edent.
FEES ~~.J~.C ~~~~ ~~~'~~ Q-'-7 ~~' ~~~r~~~- . ~~
$ O • ~ Register ojWills r Lty/y"j ~„~.~ a,~
Letters ............... ~-~`
Short Certificate(s) ........ $ ~Q • ~ Attorney Signature:
Renunciation(s) ......
1~,~1 f
s~~S
... $ ~~ ~
... $ 5-G~
Attorney Name
Supreme Court I.D. No.:
Address:
3s~i3
C~ CI o usQr Gad.
IYIC~-~'l~tn,ic S bH.r~, ~A- 1 ~m~S'
... $
... $
... $
... $
... $
... $
TOTAL .............. $
Telephone: ~ ~ 7 ~" ?~ ~ "' 0 ~ 9
Form R6V-0? re~~. ID.l3.0G Page 2 of 2
OCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~ Fee for this certificate, `~6.0(~
P ~G~1_5~__-
Certification N~)I1~her
H1 OS-113 REV 11/L006
TYPE /PRINT IN
PERMANENT
BLACK INK
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This is to certify plat the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate w~iil he irorwarded to the State Vital
Records Office for permanent filing.
r ~ ~~ ~~
.ocal Registrar Date Issued
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse) ,._.__ _.. _ .....
' "a'nad°a~dan`(Frs<'""da°''"`su~„' Richard Elmer Clouser 2 ~" Male 3 Sa'ffi~"°bar 24 6605 a.DffiedoaamtMOnm.d~28, 2010
s. age (Last errnaay) under 1 year under 1 day s. Date d BirMr (Hoorn. day, year) 7. Birmpbrn (City and state «
for
eign Gantry)
8e. Place d Deam (Check ony orTe)
77 "°'"" °"' """` '"'""" September 27, 1932 Mechanicsburg, Pa. "~kffi omer
Yrs. ^ Irpffiient ^ ER ! Oulpadenr ^ DOA ^ Nurskg Home ~,(Lesslerae ^Omer -Specify:
8b. Couray d Deem
Cumberland 8c. Ciy, Boro, Twp. d oeam
Mechanicsburg 8d. Faddy Name (H not irntllution street and rexnber)
12b'~West Green Street 9. Was Decedent d Hispanic Origin? ~ No ^ Yes
If
rif
C
b 10. Race: Amarican Indian, BFaL*, While. eoc.
(
yes,ape
y
u
an. (~°~ White
IAenan, Puera Rican, etc.)
11. Decedents Usual d wodc done oast d kb. Do rat state 12. Wu Decedent ever n the 1 3. Dece0enl's Eduatbn (Specify ony trgheffi grads wmp lered) 14
M
SIffi
s
H
d
N
d
M
i
d 1
S
Burl'SII9W'~chnician
Ke1d d ~~i~
U.S. Armed Forces?
Elementary / Seooaaery (0.12)
f~ LL
Cogege (1-4 «s«) .
~
u
:
er
es
~, e
~ewr~
on
e
.
I
~Wea 5.
urviving Spouse (n wife, give maitlen name)
^ Yes Q{„_
J
~
`
" ~rcv
~yg ~dra~ ( jow s$0
~
L
~
16.D W@$L lafe`~Lrne'eLe'nP`~) >
~
°ea0ent
M
e
chanicsburg
PA 17055 ARe
pdxae
,
7a
.
slate L
nain
,7c.^ Ye,RDecedsMLivadin Tom,
um a an TAP?
ec anlcs ur
, ~
17b. County t 7d. No, Decoder Lived wihin g
Adud limila d City I Boro
16. Femer's Name (Feat, middle, bsL suffix) Elmer Alonzo Clouser 'g' Homers "~'"° (~ n°d°°• nrffiaen surname) Nellie
20a.lnformant'aName(Type/Print) Kath n J. Hunsin er
ry 9
~' ~f~nnrsa°~Ad°`°''~:/~"''i~~e~RL'~)Street Mechanicsburg, PA 17055
2ta. Method d Dispaition i ^ Cremation ^ Oorntbn
~~ ^ Remwalfr«nStap 21b. Dale d DieposiCm (Modh, day. year)
J 21c. Place d Dispaitlon (Noma d certrel«y, sanatory «omar place) 21 d. Laation (Cdy /town, state, ail code)
WasGematlonwDaptionAtrtltorized
^ oap
dl
- r U
^ une 2, 2010 Mechanicsburg Cemetery Mechanicsburg, Pa. 17055
r
s
cN E:amNrr /
Yea ^ No
22a d Fuwal acting as such) 22b.
12662-L 22c. Name arW Address d
y rs Funeral Home, Inc. 37 East Main Street Mechanicsburg, PA 17055
Camplffia Mann when arWyiriq
phyairian i not available ffi tins d deem b . To the hest d krowbdge, deem oaxared at the tirtw, dace and place slated. (Sigrnture and title) 23b. License Number 23c. Date
Signed (Hoorn, day, year)
certify caws a seam.
hems 24-26 mwt be canpleled by person
who pronaarss deem. 24. Tme d Deem
Z
' L' 8 A 25. Dab Pronaaaed Dead (Mmm, day, year)
~ Z Q
Z 2fi. Was Case Referred to Me~gd£xaminer /Crooner for a Reason Other man Cremffiion w Donation?
!
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-
M. .,~
(/~ G7 ^ Yea L'
'T^o
CAUSE OF DFJITH (Sae InaUuctlala and examples) r Approximab interval:
Ibm 27. Part I: Erxsr me l~jpy(, - , kTjuriea, « campMca6ms - mffi drectly awed dre death
DO NOT emsr Terminal events such as ardiac arrest Part 11: Eraer otlnr ' 2& Did Tabecm Use CantrbWe b Deem?
.
, r Onset to Deem
respkelay arrest, «vemiadar flbdlaticn wkhad shorwrg me etiology. List anty one cause an eerh ins. r but not resulting b me underyirg cave given in Part I. Yes P
^ ^ raboby
r
gM1EWATE CAUSE (FeW disease « r
j r
' ^ No ^ Unknown
-./
carrdrl
on resrdkrg in deem) _~ a
C
i G /~i G i / ! ~ ~ ~
~ i 29. II Fertnb:
.
.
~
D
ue to (w as a consequence ot):
tit carrdsi«n, tl arry, b. i
Nd pregnant wrimin Past Year
^ Pre
nant ffi tim
d d
m
~
~ a' D
i g
e
ee
Lys C
ue a (a as a cansequerae af): pragrwu, but pregnenl within 42 days
^
ed
(~~re&wrlid g MI d~eaMLAST~ c. ~
D
a
' ~
ue
(« as a consequence ot): ^ p but Pregnant A3 days to 1 year
d. 1 ^ Unwawn d pregnant wihin me pest year
30a. Was an Autopsy
Perlonned? 30b Aukpey Frrdxx3s
AvaileDle Prior a Completieon 31. Hamer m 32a. Dab d Nyrrry (Monet, day, year) 32b. Desaibe How Injuy Ocarred 32c. Plan d kgraY: Ibme, Fann, Sbeffi, Factory.
d Cause d Deam?
ab~ ^ Homici0e Office Buildng, etc. (Speclty)
^ Yes No ^ Yes ^ No ^ AcCderN ^ Pending Investigation 32d. Time d blmY 32e. ml«N ffi Work? 32t. If Trensportafion Injury (Sped(Y) 32g. Location d Iryury (Street, dty I fawn, state)
^ Suicide ^ Couk1 Not be Detemrkntl ^ Yes ^ No ^ Driver I Operel« ^ Passenger ^Pedestdarr
M Omer - Speciy:
33a. Certifier (dredr any one) 33b. Sigrwt«e and T
• ~Mn9 I~1'+bbn IPMmdarr ceAifying ease d deem when anodrer physician has rxonpxrad deem and cartpffied Item 23)
To the best d my bTOwladpa. deem oceumd dw p the ease(s) and marTrnr as statad_ _ _ _ _ _ _ _ _ _ _
• PreratsTek
and a
Ul
i
h
~
- - -
p
r
y
rq P
( bon Pmnoua+n9 deem and artilykrg a ease d deem)
1n
To ffp best of my knowpdgs, deem occumd ffi the tlme, dap, and place, and due to tM
caws(t) and manner as stased_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. Licenne Number 33d. Date Sk,Med (Month, day, year)
• Msdkffi ExarrTkrer / Carawr
O
th
b
k d `
~ ~ J ~ ~ V ~.
~ J ~ '
n
e
as
axamkretlon and / « Mvastlgatbn, in my opinion, dsalh occurred ffi the tlme, dap, and place, and due W Me tau
sa(e) end manner as sated_ ^ ~. Name and ass d Person Who
Completed Cause d Death (Ite
m 27) Type / Print
35. R s Signature and District N«rVtEr ,,
~- s .. n
36. Deb Filed (Month. day, Year)
-s
~ Dispositim Permd No. t~ ~ " ~ % L i~ V `U ~ ~lil Gy •- ~ ~
_ / i A /-' / 7.. r....
LAST WILL AND TESTAMENT
OF RICHARD E. CLOUSER a.k.a. RICHARD ELMER CLOUSER
I, RICHARD E. CLOUSER, a.k.a. RICHARD ELMER CLOUSER, currently of 126 West
Green Street, Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind,
memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking
and making void any and all prior Wills by me at any time heretofore made.
1.
I direct the payment of all my just debts and funeral expenses as soon after my decease as the saw
can convenientl be done. _ o ~?'-
y ~ a c~
_~ ~ ~. ~ ... _3
:,
1'7'1 ! _{ ,
I direct that my real estate, consisting of my residence and an additional lot be sold a~~~~ or ~"° ~.
private sale. My Executrix, m her sole and absolute discretion, may select the manner of sale,~ke° deem .. ~-,~- "~`
~.~
best. ~,
3.
All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and
wheresoever situate, is to be divided and distributed in four (4) equal shares amongst my herein named
children, to wit: DEBORAH A. DOZIER, KATHRYN J. HUNSINGER, WILLIAM T. CLOUSER
and TIMOTHY CLOUSER. In the event that any of my said children fails to survive me, his or her
share, as the case may be, shall be proportionally divided amongst those named above who do survive
me, per capita.
FOR PURPOSES OF CLARIFICATION: my son, RICHARD E. CLOUSER, has been left
out by design and not by accident.
4.
I nominate, constitute and appoint my daughter, KATHRYN J. HUNSINGER, to be the
Executrix of this my Last Will and Testament. In the event that she is unable or unwilling to act as
Executrix, I appoint my daughter, DEBORAH A. DOZIER to be Executrix in her place and stead. In
the event that she is unable or unwilling to act as Executrix, I appoint my son, WILLIAM T.
CLOUSER, to be Executor in her place and stead. I further direct that they shall not be required to file
bond or other security in the Office of the Register of Wills for the purpose of administering my Estate.
WITNESS WHEREOF, I have hereunto set my hand and seal this v~~ day of
A.D. 2007
EAL)
_HARn F_ ('T.OTT4FR
Signed, sealed, published and declared by the above-named RICHARD E. CLOUSER, a.k.a.
RICHARD ELMER CLOUSER, as and for his Last Will and Testament, in the presence of us, who at
his request and in his presence, and in the presence of each other, have hereunto subscribed our names as
witnesses.
~d~I/ ~}n~~b~f
~~
2
OAT]FI OF SUBSCI~BING WITNESS(IiJS)
REGISTER OF Vi~ILLS
~~~Efir'-~~•~ COUNTY, PENNSYLVANIA
~I-tU- ~~S~I
Estate of _~l CHAyeO F CLbKSE7Z ~ ~ 12~GSoi~ ~-Z,r!?~~ (,~,m~~~ ,Deceased
f etc-~}~a subscribing witness to
(Print Name/s)
the J~1 Will ' f s~} presented herewith, (~~~eing duly qualified according to law, depose(s) and
say(s) that s~e~/ he /~e~ was /~er~ present and saw the above Testator ~`~'~-~-+-=-• -ign the same
and that s~ he / signed the same and that "b3t~"f`he /-~e~-. signed as a witness at the request of
the Testator?-n,-stz~iri;t in 1 his presence and in the presence of each other.
(SfgnattueJ C hQ ~ ~ ~ i „ /C~$
~ ~/out ,~?d.
(Street.4ddressJ
(City, State, Zrp)
E~:ecaated in Registel's Office
Sworn to or affirmed and subscribed
before me this ~t Cl day
of ~/~ p , ~~L~.
r
eputy for Register of V~/ills
(Scgnatw•e) ~ ~ -- •~
;;~•~ C... ~.,~~ .i
(Street Address) ,~ ~-;~ =~
(City, State, Zip) - ~„;~ ;"``,
.~" ~. , ~~
L~ l
Execaated oast of Register's Office
Sworn1 to or affirmed and subscribed
before me this
day
of
Notary Public
M}~ Conunission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
NOTE: To be taken by Officer authorized to administer oaths, Please have present the original or copy of instrument(s) at time of notarization.
Form /21.1'-03 re~~. 10. /3.t7G