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HomeMy WebLinkAbout09-13-10PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF ti's"ILLS OF c.- ujn ~~''' 1~• "~ COU~,'TY, PENNSYLVANIA f / Estate of ~~ ~ ~ /t ~ ~ ~~ ~ ~~~ File Number ~ •^ ~ c~ ` ~') `-~ also lazown Deceased Social Security Number G~ Q ~ .1 ~ Q ~ G ~~ Petitioner(s), who is/are 18 years of age or older, appty(ies) for: (COiLIPLETE 'A' or 'B' BELOW":) A. Probate and Grant of Letters Tes mentary and aver that Petitioner(s) is /are the ~,TC'f Ct, t X named in the last Will of the Decedent dated ~o//a~~~~ and codicil(s) dated (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: (COtY1PLETE IN ALL CASES:) Attach additional sheets if necessary. _. , Decedent w do idled at death in ~ ~! '~~ County, Pennsylvania with his /her last principal residue at_ ~ ~ d ~ ~i,~~.r• ~ ~-~t-- !tee , ,t,,,- ~ .. (` v~.~. Lz ,/~ /~ (List street address, lo,wrlcity, township, count)r, slat ,zip code) r i 7~" ~j Decedent, then ~~ years of age, died on 7 ~x:~ at ~~ Decedent at death owned pr-oper-ty 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 follows: Form R6V-0? re+~. 10.!3.06 Page 1 of 2 rv C'> ° ^ B. Grant of Letters of Administration ~ ~»... :~ , (!f npplicn6le, eruer: c. t. n.; d. b. n. c. t. n.; pendente lire; rlurarue absentia; cfur ioritnteJ ~ "" .? ~") L, `-`-Z ~ ~ "•p ~ Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following ~} any) ~d_ heirs:`-~1~` r ? Adntinistratian, c. t. a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) ~% rn ~ ~ _~ ~ " - 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: Oath of Personal Representative COy1iv10NtiVEALTH OF PENNSYLVANIA SS COUNTY OF (: c;/«.~e~yc~., d 'The Petitioner(s) above-named swear(s) or af6rn~(s) that the statements in the foregoing Petition are true and con-ect to the best of the knowledge and belief of Petitioners} and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. :;worn to or affirmed and subscribed before me tl;e _ ~ ~ day of 4. ~., . ~ "~,, ~ ~ t ~ ~, Signature of Persona! Representative ~'~~ t/7 ~' 'ZT t'~"i c~ . ; ~ _. =Ty rte ~ -- For the Reg stet Signature of Persona! Representative `~' C;,:i ~ W ~ ~ ' - • ~.::~ <:--~ t~ - - - --~ t~. . ~~ rn __ ri~~~ File Number: "° -- Estate of ICES--P/~~i/ K -~ ~ ~..~'" ~ ~ ~~ ~ ,Deceased °._.-T Social Security Number: ~ ~ ~ /U' ~ $-% S Date of Death: ~ `- ~j~l "~"" 2 ~1 U AND NOW, •~-:. i1`-~'Y,_,j~-~ ~ j =~? .-`-,~=; ~ ~, in con//sideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters "T-f'S tTL.sw~ l .,____ are hereby granted to ~~~=--~-r° P ~E ~~ ~ ___________ iii file above estate and that the instrument(s) dated ~ D 3 described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. FEES ti Letters ............... $ ,.~ ~~ l.~ (.,' Short Certificate(s) ........ $ i r~ L! Renunciation(s) .......... $ ~ ~ 1 ~~ ~ ~~ ~,~ ~ t~ ... $ ~~ ~~~' ~" ~. } . . . $ .;rte ~ 1. j ©l.~r ~ __ ... $ ...$ ...$ ...$ ...$ ... $ TOTAL .............. $ . _~ ~ ` ~~. ,. ~ , _~ . ~ , Register of ~r'ii! ~' ~~ ~ (-~~ ~~,~ ~ r ~ ~ C~ ~~~ Attorney Signature: '~..- v-- '~ Attorney Name: L~S~ ~~~~~~ C~.~~,~,L Supreme Court I.D. No.: ~ 3 ~~~ Address: ~ ~~1 ~iCc~.'~~1:~-~ ~~' Telephone: ~C 7" ~~ ~'-~ y6 c~ Page 2 of 2 rur,n Rw-U? rev. rU.13.Ur, -ALM RE~ISTRAIR'S EI~'II"I A~`I I ~ ,~ 3~1 °~!~ ~NING: It i=~ illegal to d~~+l~~~te ~!hls ~~~3~:~~r ~ ~cltc~~t~~ ,~~i~ h~.r'~~:~i ~,; ~ , . ,:. •C't' ti}1 ti`19'~ i~t'!-lljil~'~l1'.'. (,(}:1 r ,~,;- ~ ~ ) f!l'~ ;t- 1,-' r Itlltl~lioE~k 911j'C'3~t.'it t:s j,,l _; h ,Ir 1~t~ ~~ a~ 1 `` 6 d~r~ ~(,~ --- ~~ ili't 1 t ~ 1 t l +', ` ti ~' li r.t~ L) cli 3l .ilC° t F ~ ~e`~_i~~l L~ , ,rf ., r~~~C~ i^ - ,~(I;~~ l), "_ r ,t ~~+:' `~l);_(4 ~ ~t,L' ~I s. iil~ll f r _ 4, f e tt `~ .~ wt" `~ at -. ~ 1! sj jtl t~Yi' .5i~.ti, ~'u iX,a)~ ~ y-~ ' `~~„`JI. j.~'y ~ 1 3~~;C ?~,(-"l.";, dit,.. (. t )~U I~. ) tail-1! )E~ f). 1!@i"", `_ 'A ''~ -(lifer''' ""~ >F. ; • ~ ~ R. '~ si ,1:. ~~ _ ~ ~1 - ., ~y tV © ; ,1 l_. ~ -- 1 _~. ,_~ f.~.,l s , • ~ ~~~ :~ 1 REV tt,2oo6 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~~1 ~'7 ~ - ••~~ i ~ PRINT IN C~ C. - :._ ,.~ K ,~ CERTIFICATE OF DEATH = z~ ap ~~~= ~r~ (See instructions and exampled on reveres) -U • • CTaTC LII C NI IaICLO h 1 NarM d Decedent 1Flrst, mrOdk, hsL sldfis) 2. Sex 3. Sol;lat Security NumDw 1. OW d (MOnN, dry. yw) _~' -".') Jose hive T. Goetze Female 203 - 10 - 8515 July 30, 2010 "'~ S. Age (Last BrfWay) lArOer t ar Undw 1 da 8 l)ob d BkN Monty, da , 7 Ci and SfW a for Ba. Plea d DeaN ChncFt on OM 95 Mmes oars ~ MnWp Hospllal: Otller: Yrs. May 5 , 1915 Harrisburg , PA ^ Inpa,wu ^ ER I OutpaWnt ^ DOA ®Nurseg Fiats ^ Reciaerta ^ Ofnr - Seedy: BD Colnry of OeaN 6c. Cary Bono. Twp. d Death 6d. Faclkty Name to not utsotution, give street and number) 9. Was Decedent a Hlapanc Orgm? ®pp ^ Yes 10 Rau: Amercart kttian, Black WhY, etc. Cumberland Mechanicsbur g Brid es at Bent Creek Assisted Livi g ("yee,specdyclaDan, $Aexlcarl Puerb Ricart etc ) (so.~ , , . Whit e t Decedents usual Kid d worn d one most d We. Dona wM refr t2. was Deaden wet n n,e t3. Decedents Edtratbn (Speay only IkgMp grade comp leted) t4 MariW Steals: Marred, Never tdarned, 15. Sunning Spo rty pt w/e, gne maiden name) KuW d Wok Knd d Busewaa/Industry U.S. Armor Forces? Elertterttary / SecorWary (D-12) Cdlege (11 « 5+) Widowed, Dnorced (SPec+l1'I V.P. Secretor Trea urer Weldin ^r.eC~Nd 12 Widowed ts. Decedents Melling Alfdress ISaeeL atY /town, state. zip coos) Decedents PA Did Deuderlt 210 0 Bent Creek Boulevard Actual Rastdertu t 7a. state Liva in a , 7c, ^ yes, pecedertt LtvW in Twp. M h i PA 17050 b „D ca„h, Cumberland Tdwnshlp~ 17d ~N°~D°`°deMLnsOwnf""MechanicsburR ec an cs urg, Actualtmllsa Gy/Bao t8. Fame! s Name tFirsl rtedtlle, last, wrcu) 19. tdodtsls Name (FesL rtkddls, maldan surname) Charles Ellsworth McComse Mar Ethel Tennant 20a. Intatttartrs Name (Type !Pmt) 20b. klfanurM's Mallrg Address ISDeaL ury /town, wu; zp code) K. Lee Goetze 114 Franklin Square, Mechanicsburg, PA :17050 21 a. Medlod d Dlsposrtion 1 ^ Cremauort ^ Donation 21D. Date d Disposrpon (Monty, ear. year) 21c. PWU d Dleplxeiort (Name d cernebry, crerrtatay «dfwr place) 21d. London (City! town. sh4. tp acts) K~B«,ar ^ R.rnovalkomstate. ~ w.ecremelionort3atarfonA1R110ftaed ^ 1 ^ Au ust 5 2010 g East Harrisbur Cemeter g y Harrisbur PA g M MMdical Ves No ^ ONef . - •ly. , , ?2a slQnatwe ~ S.nln ,« as zzD. License NurtlDer zz~. Name and Address dl Fac~ay i~ul-e rman-Auer Fun ra 1 Home Inc . ~ ~ - i FD013801-L lUU Jonestown Roa , Harrisburg, PA 17109 Compete d c any urNyeg 23a To d,e Dest d my krawkdge, deaN oawred ar Ne time, WM and place stated. (SignaNre arq alts) 230. Lewnse Number 23c. Cate S1gr~O lMOnN, day. Year! pnyseaan .s na av urns d death to csMy cause d dWN. ~ ~ / _ ~ ~ tip' L~`lG~ ~/ ~ (~/ ~ ~/ r~ ~ ~ D ~ ~j0 items 20-26 must oe cartglete0 DY per.orl 2a Tens of DeaN 25 Date Pranolrxed Dead (Monty, day, year! 26. Was Case Refe Medical Exarmer I Caater t« a Reason Ofw Nan Crelrlafort a Catalan? wrq prortartces deaN. ~ / O M. ~ ~ D ~ 1%~ ~ ~ ^ Yes No CAUSE OF DEATH (Sty InstrtxYlone uM ea I•e) 1 Appro><unate ~nerval: Pan il: Enter odwr 28. Did Tobacco Use Conribtlle b Oeaft? :tern 27 Part 1 Enter the !Notre of averus - diseases. ayunes. « compwcauons -Nat deectly caused tM deaN. DO NOT enter termnal events such as cardac arrest, 1 Onset :o DeaN out not resulting kt the underryetg cause gush tit Pan I. ^ yq, Probably respuatary arrest, « wntncuWr ntx~.Naedn «Mwt showeg dte ettobgy. list any aw cause m each Nne. r 1 1 ^ No UriWtoem WMEOUTE CAUSE,Fr~ dsease « / ~ 1 c«t6aon reWrWlg .n deoae) c ~G E ~'/~~ h'am` 7~~~ 1 29. d FemeN: ~ a Ir~r r s ~~ ~ Due to to as a ~ o/p' ~ p ~}.~-~ / /~, t SequanoaYY hst oon6uau. A arty. 0. (.Q~Q-iEk1~~l ~ / T~ lY,r/~ ~ ~«+'~A// !7~ 1 Nadup to tFw ca se lisud an irte a r a•9rtarf ~ ~ Yw ^ Pregara Y erne d daft -y C u Enur Bw UNDERLYING CAUSE Dus to ,« as a consepuerwe ofJ: ~ J Nd pregnant tM pragyrM w~tn ~2 days Idiseasa a ryury dtal eMwNO dte i evens resulMg .n OeaN) LAST. c d daeN ^ ~ Duero (a as a consepuenca of): Nd pregrwe, bU pre¢wf U days b 1 yar r 0. ~ before dsaN ^ theutowut .t prerywtt wtlM fr pap year 30a Was an Autopsy 30b Were Autopsy FutOUlgs 3t Manner d DeaN 32a. Date d Iryury (Monty, day, year! 32D DesuiW How Iryury Occurred 32c. Plan d Irytey Home, Farm, $trNL Factory, Pert«med~ Avaiabk Prat to Completion N t l ^ Fi d Olfiu BlxlOetg, ek. (Seedy) d Cause of OeaN? ura a orrucl e ^ les No ^ Yes ^ N ^ Accdent ^ Pertdutg Irneskgalgn 32d. Tune d Injury 32e. Iryury at Work? 321 II Transponatlon Inryry ($pe[ryJ 32g. Loutan d utpuy IS0se1, cry ! btvn. state) o ld Nd u D ^ S ~O ^ C t 0 ^ Yes ^ No ^ Drrwr, Oparala ^ Passenger ^ Pedeslnan u e ou e ermule M. OdNr~ Specdy: J3a Carutler tcneca orgy Dior) 330 Sgnature arW Tnb of Cenl • CMifying phyaicien,Physclan cenilyvrg cause W JeaN «Mn argeier physlGart has prorwlxrce0 deaN and canpleled hem 23) - To tM Deel d my knowledge, OeaN occurred dw ro tM cwee(e) and martrter ee shNd _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ICJ • Pronouncug and artfyutg phyeinen iPnysloan Dom pronouncrlg aeaN and clTmlyelg to cause d deaNl / ` 33c. License NI1nIWr 330. Data Signet! IMonN, Day !earl To tM Dee 01 my knowledge, death occurred p the Dme, tLre, and plea, end Mr. ro tM uuse(e) and manner as sated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ • Medical Eaartww/Coroner Pj~} ~ ~ 3 ~ SS'y~ ~f .~ ? O ,~ f is ~ D ! J f~~ On tM Wei eaamirWgn arty / or inwetiget~ m pinion, death occurred p tM time, deb, and plan, and dw to tM cause(s) and It1iMIM u etatad_ ^ 3a Name and Address of Person Who C tW Cause d DaaN lttern 27) type ~ Pnm o H l ' . y ~ v ~ M L~Z ~~ rar egt5 s a and 36 Da=FiIW IMmN, Day, y ~~/z1~~/ /yi ,.., ~.., /~~ _ , ~L f • v(i /+r~war~ y (7+'t!~~ rte' ~ / ~ p / U5:iZ5U1 Olspositan Perms No. r~.~ t~ ~ ~ ~- ~_: OF rn ~Tr ~„ ~, r c,a _ , ~~- JOSEPHINE T . GOE T ZE ,;~`~ 4~•J ,- _ ry -`~~; -~: I, JOSEPHINE T. GOETZE, of Silver Spring Township, Cumberland'. County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby 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 same can conveniently be done. 2. I direct that there shall be paid out of my residuary estate all estate, inheritance and like taxes together with any interest or penalty thereon imposed by the Government of the United States, or any state or territory thereof, or by any foreign government or political subdivision thereof, in respect to all property required to be included in my gross estate for estate, inheritance or like tax purposes by any of such. governments, whether the property passes under this will or otherwise. 3. I give and bequeath $1,500.00 to the United Church of Christ, Green and Verbeke Streets, Harrisburg, Pennsylvania. 4. All the rest, residue and remainder of my estate, of whatsoever nature anal wheresoever situate, I give, devise and bequeath to my daughter, K. LEE GOE',TZE, -1- absolutely and in fee simple. 5. Lastly, I nominate, constitute and appoint my daughter, K. LEE GOET;ZE, to be Executrix of this my Last Will and Testament and I further direct that no bond gar other security be required of my personal representative to guarantee faithful perforrr.~ance of his duties. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~~,~~lay of October, 2003. Y~. .~ . c,L~.. ; . j v~z (SEAL) ~~ ~ Jos p me T. oetze v Signed, sealed, published and declared by the above named JOSEPHINE T. GOETZE as and for her Last Will and Testament, in the presence of us who have subscribed our names hereto as witnesses, at her request, in her presence and in the presence of each other. ~. ~~~ -2- COMMONWEALTH OF PENNSYLVANIA ) SS COUNTY OF CUMBERLAND ) I, JOSEPHINE T. GOETZE, the testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the same instrument as my Last Will and Testament; that I signed it willingly, and that I signed it as my free and voluntary act and deed, for the purposes therein expressed. ~ - ~ -_ ~ ?~ i~ ~ ~ ~ /~C ~ . _;~ ~_. SEAL sep me . Goetze ~,' Sworn and subscribed to before ~. me this ~~~ ~~ day of October, 2003 .J% 11 COMMON-yyEALTN OF PEPJNS VANIA y ~ L~~ ' / ' , ~ r ~r1 I s~, otary Pu is ~, M' Neon. ~ro aoro, cumberl~ county My Car-rnission E~ires Jurwe 27, 2007 COMMONWEALTH OF PENNSYLVANIA) SS ~P~'~~~iOf No6e~ies COUNTY OF CUMBERLAND ) We, the undersigned, i ~n a i M ~.~A ~~~,, t:,, and ~~~ ~-~ ~% ~ ~ L:.. ~ n~~ '~ , the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified accordingg to law, depose and say that we were present and saw the testatrix, JOSEPHINE T. GOETZE, sign and execute the instrument as her Last Will and Testament; that the said testatrix executed it as her free and voluntary act for the purposes therein expressed; that each of us, in the hearing and sight of the testatrix, signed the Will as witnesses; and that, to the best of our knowledge, the testatrix was, at the time, eighteen (18) or more years of age, of sound mind, and under no constraint, duress or undue influence. z-~. Sworn and subscribed to before me this r' c ~~ day of October, 2003. ~r F Y ~ R f ~ S. otary Pu is COMMONWEALTH OF PENNSt,VANIA Notarial Seal Reid M. Nelson, Notary Public Medtaniwburg Boro, Cumberland Couni~+ My Cdnrnission E~goir~es June 27.2007 Member. Perx~sylvania Association Or Not~ies -3-