HomeMy WebLinkAbout11-22-10PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF w'ILLS OF
~~
Estate of
also known as
Deceased
COLNTY, PE ~ ~SYLV aNIA
File Number ~ ~ ' ~ ~ ~ ~'~
Social Security Number
Petitioner(s), who is/are 13 years of age or older, apply(ies) for:
(COtiIPLETE 'A' or 'B' BELO{~':)
A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the
last Will ~ '~e ~d ,~4~ t _/b~ and codicil(s) dated
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,,,..._ relevant circumstances, e.g., renunciation, death of executor, etc.)
L.:cept as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the. instrument(s) oft ;~,
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for probate, was not the victim of a killing and was never adjudicated an incapacitated person: _ ~ ~ N x x
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^ B. Grant of Letters of Administration _ ^ x ~ 1 r
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(If applicable, ente~-• c. t. a.; d. b. n. c. t. a.; pendente life; durmtte absentia; durnnte nr`na"itate) _ ""' Z •_-
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Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spouse (if any) and hei ~ v ~ "
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Admit~istratioti, c. t. a. or d.b.ii.c.t.a., enter date of Will in Section A above and complete list of heirs.) "_ N ,., ,!„
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(COMPLETE IN ALL C.9SES:) Attach additional slheets nece ary.
D cedes t was do ~iciled at deaf in ~~ ~"~ J w ~`^ ~ punt Penns ania with his /her last rinci al residence at ~ ~~ U
~j Y~ Y p P
(List street address, town/city, township, cozmt)~, state, zip code) ~
Decedent, then years of age, died on at
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 follows:
1
For-ui RW-U? rev. to.l3.0~ Pale ~ Of ~~
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named in the
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
COiV1~10Nti~'E.~LTH OF PE~~iSYLVAi`1IA
SS
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I ire Peti~;,;.~~~s~ ~uuve-named swear(s) or affirm(s) that the statements in the foregoing Petition are tt~ue 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
/f ~?(~
before me the O'~ day of
S
~~
For the Register
Signnttu•e ojPe~icnl Rzpresentnt6/e
Signature oJPersonnl Representative
Signature oJPersonnl Representative
File Number: ~ ~ ~ ~ ~~ ~ ~ ~ ti~
Estate of ' ~ ~ ~ ~ ,Deceased
Social Security Number: ~ ~~ ~~ ~ ~ ~ ~~ Date of Death: ~~'` ~ ~ ~ _ 1 l:
AND NOW, /Y ~~~/y`~ ~C.`!~ %~~~~ ~(,~~~, in consideration of the foregoing Petition, satisfactory proof
having been presented be re me, IT IS DECREED that Letters l ~ `~~`'~ ~ ~'-/~ ~ ~ ~''Slf ---
are hereby granted to i~ ~. ~ + I ~ ~ ~ t'0"-
in the above estate
and that the instrument(s) dated ~/L1 1~~,~ (~'~ ~~:1~.~
described in the Petition be admitted to probate and filed of record ash last Will (and odicil(s)) of Dece ~~ M t.
FEES
Letters ............... $ ~~ ~"'~'' Register of Wills ~ - ~,;
Short Certificate(s) ...... $ ~ ~ ~ ) Attorney Signature:
Renunciation(s) .......... $
~' ~ ... $
~~ ...$ -~C~(~
... $
... $
... $
... $
...$
... $
TOTAL .............. $ ~ •~
Attorney Name:
Supreme Court I.D. No.:
Address:
Telephone:
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Fur„~ RW-v' rev. Iv.l3.vr Page 2 of 2
105.905 REV.(3/09)
This is to certify that this is a true copy of the record which s.s on file in the Pennsylvania Department of Health, in accordance with
the Vital Statistics Law of 153, as amended.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
H705.143 REV 1112006
TYPE /PRINT IN
PERMANENT
BLACK INK
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Linda A. Caniglia
State Registrar
CCU 2 a 201
Date
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse) CTATF FII F III Ir.,1000
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1. Name of Decedent (First, middle, last, suffix) 2. Sez 3. Social Secudty Number 4. of De h ( nth, day, year)
Jane Louise Kitzmiller Female 162 - 22 - 2720 ~/ Q
5. Age (Last Birthday) Under 1 ar Under 1 tla 6. Date of Birth Month, da , ear 7. Birt lace Ci and state or for ei n count 8a. Place of Death Check onl one
Months Days Hours Minutes Hospitel~ Other
86 Yrs. November 5 1923 DdU hln CO1111t PA Inpatient ^ ER /Outpatient ^ DOA ^ Nursing Home ^ Residence ^ Other -Specify:
8b. County of Oeath Bc. City, Boro, Twp. of Death Bd. Facility Name (If not instiNtion, give street and number) 9. Was Decedent of Hispanic Origin? ~ No ^ Yes 10. Race: American Indian, &ack, White, etc.
~ (II yes, specity Cuban, (Specfy»
Dauphin Harrisburg Harrisbur Hos ital Mexican, Puerto Rican, etc.) White
11. Decedent's Usual Occ anon Kind of work d one dudn most of workin life. Oo not slate retired 12. Was Decedent ever in the 13. Decedents Educatbn (Speciy only highest grade comp leted) 14. Marital Status: Marred, Never Marded, 15. Surviving Spo use (If wife, give maiden name)
Kind of Work Kind of Business/Industry U.S. Armed Forces? Elementary / Secrondary (0-12) College (1-4 or 5-) Widowed, Divorced (SpeciryJ
Clerk Warehouse ^ Yes ~ No ~ 2
16. Decedent's Maiing Address (Street, city /sown, stale, zip code) Decedent's Uid Decedent
Peruzsylvania Live in a
t
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id
17
^
300 East Main Street
Mechanicsbur PA 17055 c
ua
es
ence
a. State
i7c.
Yes, Decedent Lived in
Township? Twp'
rib. county Cumberland rid. ~] No, Decedent Lived within Mechanicsbur
q
gI ActualUmits of
City/Boro
18. Father's Name (First, middle, last, suffix) 19. Mother's Name (First, middle, maiden surname)
Unknown Verna Unknown
20e. Informant's Name (Type / Pdnt) 20b. Informant's Mailing Address (Street, city /town, state, zip code)
L. Kitzmiller
21a. Method of Disposition r ^ Cremation ^ Donation
• 21b. Date of Dispostion (Month, day, year) 21c. Place of Disposition (Name or cemetery, crematory or other place) 21d. Location (Cgy!fovm, state, zip code)
,
t~l Burial ^ Removal from State + Waa Cromatlon or Donation Authorized
^ od,er - s ' by Medial Examiner/Coroner? ^ Yea^ No
~
October 20 2.010
Mechanicsbur Garret
Mechanicsbur PA
22a. S'
er etvi Lf rises (or person acting as such) 22b. License Number 22c. Name and Address of Facility g Market Plaza Way
- - FD - 014889 Mal zzi Funeral Home Mechanicsbur PA 17055
Co ate it ~ only when c ing
physician is twt available at time of death to 23a. To the best of my knowledge, death ocarred at the Ome, date and place stated. (Signature and 8tle) 23b. License Number 23c. Date Signed (Month, day, year)
certity cause of death.
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Items 24-26 must l>a completed by person 24. Time of Death 26. Date Pr Dead onth a ear
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~ 26. Was Case Referred to Medical Examiner !Coroner for a Reason Other than Crematon or Donation?
~ who pronounces death. M. ~ G~ f
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+ ^ Yes ~ No
CAUSE OF DEATH (See Instructions and examples) + Approximate interval: Part II: Enter other;fjgnificant conditions contributing to deatFy 28. Did Tobacco Use Contribute to Death?
Item 27. Part 1: Enter the chain of events -diseases, injuries, or complications - that drectly caused the death, DO NOT enter terminal events such as cardiac arrest, r Onset to Death but not resulting in the underlying cause given in Part I. [] yes ^ Probabty
respiratory arrest, or ventricular fibrillation without showing the etiology. List Doty one cause on each line. '
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^ No ^ Unknown
IMMEDIATE CAUSE (Final disease or
c ~
condiAOn resuldrg in death) _~ a. ~, ~ ~ ~ ~ S'~'-l ~" e ~-~- /~~ f~ '\ ~
L + ~`~---~
+
29. If Female:
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Due (or as a c nsequence of) +
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pregnant w
o
n past year
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Sequentially List conditions, IF any, b `,.b ~() yt Ci T'U / l!~ K,!` ~ ~ (S~~ ~~ ` ~
leadin
to the cause listed on line a Pregnant at lime of death
^
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. Due to lm as a copse uen of '
Enter the UNDERLYING CAUSE q ) ' - Not pregnant, but pregnant within 42 days
(disease or injury that initlated the c r
events resuking in death) LAST. ~ of death
[]
Oue to (or as a consequence oft - Not pregnant, but pregnant 43 days to 1 year
r
~ d' ~ before death
^ Unknown it pregnant within the past year
30a. Was an Autopsy 30b. Were Autopsy Findings 31. Manner of Death 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occuned 32c. Place of Injury' Home, Farm, Street, Factory,
Performed? Available Prior to Completion fp7
N
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t
i
id Office Building, etc. (Specify)
of Cause of Death? ura
om
a
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^ Yes ~. No
^ Yes ^ No ^ Accident ^ Pending Investigation 32d. Time of Injury 32e. Injury al Work? 32f. If Transportation Injury (Specify) 32g. Location of injury (Street, city /town, state)
^ Suicide ^ Could Not be Determined ^ Yes ^ No ^ Driver/Operator ^ Passenger ^ Pedestrian ,~ q
M ^ Other - Specify:
33a. CertiY~er (check only one) 33b. Signatureand Title of Ce 1
tier
• Certifying physician (Physician certifying cause of death when another physician has pronounced death antl completed Item 23) ~ 1
__
~ ~ ~
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To the beat of my knowedge, death occurred duo to the oase(s) and manner to stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ,
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.
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• Pronouncing and aRifying physician (Physician both pronouncing death and certifying to cause of death) 33c. License Number 33 a Si ed ( onih, day, year)
~
_
To the best of my knowledge, tleath occurred at the time, date, end place, and duo to the ause(a) and manner as stated_ _ _ _ _ _ _ _ ^
MedlealEzaminer/Coroner ~
• ~~ ,.s ~ /_(( ~ ti ~ ~ L / ~'Gr~~
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On the beefs of examination and! or investigation, in my opinion, death occurred at the time, date, and place, and due to the auae(s) and manner ea atsterL ^ 34 Name and Address~f Persory~}IO Cause of Dea
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is r' ature Dis i Num
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Disposition Permit No.
LAST WILL AND TESTAMENT
OF
. f
KITZMILLER
JANE L ;-
x x
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I, JANE L. KITZMILLER, of the Borough of Mechanicsburg, County of ~ =% N ~ x
~,
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Cumberland and State of 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 same can be conveniently done.
2.
I give, devise and bequeath all the rest, residue and remainder of my estate, real,
personal and mixed, whatsoever and wheresoever situate, to my three(3) children,
share and share alike, per stirpes.
LASTLY, I nominate, constitute and appoint my daughter, CAROL A M
FASTING,and my son, GARY L. KITZMILLER, Co-Executors of this my Last Will
-1-
and Testament.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this '~ ~ day
of June, A. D., 2002.
ter... I <'.,,~~ -~ ~ (SEAL)
Jane L. Kitzmiller
Signed, sealed, published and declared by the above named, JANE L.
KITZMILLER, as and for her Last Will and Testament, in the presence of us, who have
subscribed our names hereto as witnesses, at the request of said Testatrix, in her presence
and the presence of each oth°r
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COMMONWEALTH OF PENNSYLVANIA )
: SS
COUNTY OF CUMBERLAND )
I, JANE L. KITZMILLER, 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 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.
Sworn and subscribed to before me
this ~ ~ day of June, 2002.
Notary Public
`~ ~`~ ~.~ (SEAL)
Jane L. Kitzmiller
Narrtd Seat
K. vainer. tvagryPtt~c
Mecf~#,~ e~ao~, Afsnt~etisx! County
~rCarmis~etonE~MrstMar. 27, X006
ru.meer. Ae~.rtMr+r Ateocifltoi+0a'No1~bs
-3-
COMMONWEALTH OF PENNSYLVANIA )
SS
COUNTY OF CUMBERLAND )
We, the undersigned, J. ROBERT STAUFFER and JOHN M. EAKIN, the
witnesses whose names are signed to the attached or foregoing instrument, being duly
qualified according to law, depose and say that we were present and saw the within
testatrix, JANE L. KITZMILLER, sign and execute the instrument as her Last Will and
Testament; that the said testatrix, JANE L. KITZMILLER, executed it as her 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
Sworn and subscribed to before me
this ~ day of June, 2002.
1=
I.~~ .
~'~ Notary Pu lic
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tar~a~rd Ses1
~ M1etr~ 8~4 C~ur~A ~-~
I ~ ioe9xrissitxt ~~"~ Mar. 27, 2Q06
1u~e~'+wber. ~tmanA~rania Associatlor- Of NCB
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