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HomeMy WebLinkAbout08-18-11PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of JEAN E. BLOSSER File Number 21 "' ~ ~ ' ~(,'~ also known as ,Deceased Social Security Number 174-20-0563 Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE 'A' OR 'B' BELOW.) Q A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the Executor named in the last Will of the Decedent dated 7/22/97 and codicil(s) dated none Jeffrey B Blosser aka Jeffory B. Blosser has renounced his right to serve as Executor (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, was never adjudicated incapacitated, and was not a party to a pending divorce proceeding at the time of death wherein grounds for divorce had been established as provided in 23 PA C.S. section 3323 (g): Not applicable B. Grant of Letters of Administration (If applicable, enter: c. t. a.; d. b. n. c. t. a.; pendente liter durante absentia; durante minoritate) 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 drlvriiaeiotvntin~n i. t ~ ~.. ~ l~ H i. t .. ..Ht...,. rl..t....f id7:11 :.,. C....s;~.,.. A .,r.........,,..1 ....,..,....l,.s,. l:..s ..!'1 ,.:,.,. 1 Decedent was domiciled at death in Cumberalnd County, Pennsylvania, with his /her last principal residence at 442 Walnut Bottom Road Carlisle PA 17013 Carlisle Borough (List street address, town/city, township, county, state, zip code) Decedent, then 84 years of age, died on 7/31/11 at Thornwald Home 442 Walnut Bottom Road Carlisle PA 17013 Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ 3,000.00 (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: 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 Typed or printed name and residence rL.- Bonnie L. Gutshall 320 Enola Road Carlisle PA 17013 Form RW-02 rev. 10.13.06 Page 1 of 2 (COMPLETE INALL CASES:) Attach additional sheets if necessary. F``` Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND 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 affirmed and subscribed \~` ~~ Y Signature of Personal Representative before~me the c~a., of onme L. ~utsnaii Signature of Personal Representative For the Register Signature of Personal Representative ["~ ;:. ~~ -`.J File Number: 21=~~~' ® '~ ~ ~ ~._ _,.~ t_.. ~i ~.. ---i Estate of JEAN E. BLOSSER ,Dec ased f,., r~_. ,_ A ~~ ~~, ~.~. ; ~*-~ Social S urity Number: 17/4-20-0563 Date of Death: 7/31/11 AND NOW, ~ -S~ / ~ , 2011 , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters Testamentary are hereby granted to Bonnie L. Gutshall in the above estate and that the instrument(s) dated 7/22/ 1997 described in the Petition be admitted to probate and filed of record,as the last Will (anc~Codicil(s)) of Dec~ci~nt~ n FEES a ~' v •~/ " ' • QU eg'ster 6Y`ills Letters ....................~.... $ ` Short Certificate(s) ~ $ Attorney Signature: R n nciation s • D O $ , ~~ Attorney Name: No V. Otto III r • • • • $ • ~ ~ Supreme Court LD. No.: 27763 .... $ .~- ••.. $ Address: 10 E High St "" $ Carlisle .... $ ,... $ PA 17013 .... $ $ Telephone: 717-243-3341 TOTAL ............................. $ Form RW-02 rev. 10.13.06 Page 2 of 2 C7 -r~::. ~~. ,--- . ~. _ RENUNCIATION _~ £-,~-~ -~ ~- REGISTER OF WILLS ~ ~~ ~-~ ~, -' r~ CUMBERLAND COUNTY, PENNSYLVANIA ~ Estate of JEAN E. BLOSSER ,Deceased I, JEFFREY B. BLOSSER , in my capacity/relationship as (Print Name) CO-EXECUTOR of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to BONNIE L. GUTSHALL , ~ -~~ -ii (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of (Signature) 105 Susan Lane (Street Address) Carlisle PA 17013 (City, State, Zip) Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciat~for the purpose tated w'thin on this %~ day of ~~~~ Deputy for Register of Wills Form RW-06 rev. 10.13.06 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.) C4Nflvi(~N'V~~_1'H OF.1 ~~'VA1~1Ip- NOiTARIAL ~~ Victoria L. Oita, Not> ~ Cow Carlisle Boro, G~im~ M commission ex ices Dxembcr 24, 2014 u,nC tin[ .~.-~~ ,.~, ,.,_, --- _ _ _ _ _ _ _ _. __ __ _ _ _. _ "/ - LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat oar photograph. Fee for this certificate, $6.00 ?* _, P X7727458 =` :.: °o -~; :r~-: ~~~ ~7;) ~..! ~~A~jH~OF ~~~" This is to certify that the information here given is Pfy~~~ - correctly copied from nn original Certificate of Death r duly filed with me as Local Registrar. The original ~,~ zo certificate will be forwarded to the State Vital ti ~' a Records Office. for permanent filing. * ,. ~ ~~` - -~ . MENT 0 rltll' `czx~X'• ~ 4 2011 Local Registrar Date Issued H105-143 REV 11/2006 -'1"~ (,`F, TYPE/PRINT IN COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~ ""~ PERMANENT BLACK INK CERTIFICATE OF DEATH r~ ~~} (See Instructions and examples on reverse) ,~ STATE FILE NUMBER t. Noma of Decedent (Post, middle, last, suffix) 2. Sex 3. Social Security Number 4. Date of Death (Month, day, year) Jean Blosser Female 174 _ 20 _ 0563 5. Age (Last Birthday) Under 1 year Under 1 day 6. Date of Birth (Month, day, year) 7. Bidhplace (City and state or forego country) 8a. Piece of Death (Check Doty one) rxcran D ~-~ v.r Y. _ . `i y....~ ~• ~rl >r.~ ~ -'r a aye ~ ~~~ April 21, 1927 Hospital: Other. Yrs. Elliottsburg~ PA ^Inpatient ^ER/Out bent 6b. of Death Pa ^ DOA Nursing Home ^ Residence ^ Other - Speciry: Caunry Bc. City, B,.Q,gyr Twp. of Death &l. Facility Name (II rat institution, glue street end number) ' i I 9. Was Decedent of His nic 0 in? • pa rg No ^ Yes 10. Race: American Indian, Black, White, etc. Cumberland Carlisle Thornwald Home (tfyea,specirycuban 11. DecedanPS Usual lion Kind of wale done most of IHe. Da nd stele talked 12. Was Decedent ever In the , (~yM Mexican, Puerto Rican, etc.) white 13. Decedent's Educetbn (Spedty only highest grade completed) 14 Marital Stat s M l d N Kind of Wok Kind of Buskresa / IMuWy U.S. Armed Forces? Sales R tail Cl thi . u : ar e , ever Married, 15. Survrvi Elementary /Secondary (0.12) College (1-4 or 5+) Widowed, Divorced (Specify) ng Spouse (If wits, gore maiden name) e o n ^Yea ®No ' g Divorced • , 6. Decedent s MaiNng Address (street, dry /town, stela, zip code) Decedent's Walnut Bottom Road Actual Residence t7a. State Did Decedent PA Live in a 17c ^ y D • Carl isle , PA 17013 17b. County es, ecedent Lived in Township? Twp. CLUt>berland 17d ®No, Decedent Lived wNdn 18. father's Name (First, midde, last, soft&) AdualLimhsor_ Carlisle cm/~ Newton Stambaugh 19. Mother's Name (Rrst, middle, maiden surname) Rase Collins 20a. IMartnant's Name (Type / Print) Bonnie Gutshall 206. Informant's Meiling Address (Street, city /town, state, zip code) 320 Enola Road, Carlisle, PA 17013 • ° ~ 21 a. Method of Disposition j Y Y ) sposltian Name of camel crenreto a otf+er ~ Cremation ^ Donation 21b. Date of Di Month, da , ear 21c. Place of Di ( ery, ry place) 21d. Location C' /town, state, zi code ^ Burial ^ Removal tram gate ~ wa. cromarton w Dorretbn Authorlxd Aug . ~~Oll Hof fman-Roth Funeral Home & (~ p ) ^ Otfter • SPeuf ~ ~ Al dk ` • a e Y al l~raminer / Caorteff Yes ^ No ~ ~ Carlisle , PA 17013 ' I 9 ~ such) 22b. License Number - 138504 22c. Name and Ad~ess of Fadllty Hoffman- oth Funeral Home & Crematory e h 23a. Tome beat of m 1 PA 17013 ~Ya9 y kravAedgs, deelh occurred M the Ume, date and place stated. (Signature and title) 23b Licence Number PhY~n IS tar al time of death to ,~y~` ~ry of death. +~ ~ /~~ ~ ~ Get~C44-~ d Q~l/ . 23c. Date Signed (MOmh, day, Year) . 24 Time of Death Hams 24 26 b ~ $ 5 07 L 'J .3/ ab / . . must e cartpleted by person 25. Date Praxxxaed Dead (Month, day, year) 26. Was Case Referred to Medical Examiner /Coroner for a Reason Otfter than Cremation or Donation? who pronorxtces death. M. 7 I coil ^Yea ~No CAUSE OF DEATH (See Instructbna and examples) hem 27. Pert I: Enter the rAain of eveM.a - dseases, in(rales, a cafplications - that drectly caused the death. DO NOT enter terminal eve r Approxirttele Mtervel: Pad II: Enter other siarificant axMhirm ~pn rkudirui to a,, ~,. 28. Did Tobacco Use Contribute to Death? nts such as cardiac artest , r showing thee' respiratory artest, a ventricular fibrillation without tab91'. Ust only one cause on each lens. r Onset ro Death but not resuhing in the urrdedying reuse given ~ Part I. Yes ^ Probably ~ IMMEDIATE CAUSE ((Fmel disease a ~` mrxlition resWlirg in death) W ~ ~ r No ^ Unknown r ~, a. r V~ 29. If Female: Due to (or as a consequence o . IIyy hsl rxxWhions, h any, b n ~ ^ Not pregnant within st ear Pa Y IeaIhs cause Neled on Gne a. Enter thMe UNDERLYING CAUSE Due to (or as a carsequerrce of): r r ^ Pregnant at time of death r e ~sn~ s ~LA ~ c r ^ Nor pregnant, but pregnant within 42 days +re re ultkrg SL • r of deem ~ • Due to (a as a consequence of): d r ~ ^ Not pregnant, but pregnan143 days to 1 year ~ r belare death 30e. Was an Autopsy 30b. Were Autopsy Fndirgs 31. Manner of Death ^ Unkrawn h pregnant wihin the past year 32a. Date of In)ury (Month, day, year) 32b. Describe How Inprry Occurred Pedarmed? Available Prior to Completion ' of Cause d Deem? ~ Natural ^ Horttidde Wry, 32c. Place d In Home, Farm, Street, Factory, Ohice Building, etc. (Speci/yJ .r1 ` ` ^ Yes ~NO Yes No ^ ~~ ^ Pandin9lnvestigetlon 32d. Tirtre of Inlury ^ ^ 32e. Injury at Work? 32f. If Tran rtadon 1 'u 9 fury (Street, dty /town, state) sP° rq ry (~1H1 32 . Location of In ^ Slmdde ^ Could Not be Determined ^ Yes ^ No ^ Odver /Operator ~ Passenger ^Pedestrian M 33a. CerBfier (check only one) ' Other • Spea'ly: • Certifying physlcfan (Physkyan certitying cause d death when another physiclen has To the best of m praaunced death ant completed Item 23) y knowledge, death occurred due to the cause(s) and manner as stated_ _ _ 33b. Signs and Title of Certhler - ~ A n ~` ~ ` (~^ M D VVV 1' y _ _ _ _ _ • Pronouncing and certilyfrtg physkian (Physidan b081 prrxaundng death and ceNtying to cause of death) - - - - - - - - ~ ~ v - - - - - - - - - - - - - - - - - Tothe best of m know y ledge, death occurred at the time, date, end place, arM due to the cause(s) and manner as stated ^ 33c. License Number 33d. Date Signed (Month, day, year) o w _ Medical 6csminer /Coroner On the basis of exrmrinetbn and / I i - _ _ _ _ _ _ _ _ _ _ ,~~ ~ ~ ~ ~ ~ ~ C ~ V ~ v,~ 0 - - - - - - ° , or nveat getion, In my oplMon, death occurred et the time, date, erM place, and due to the cause(s) and manner as stated_ ^ 34 N LLD 35. Registrar' lure and District~laril6Sn - ~ . ame and Address of Person Who Canpleled Cause of Death (Item 27) Type / Print r~-~ 38. Date Filed (Month, day, year) ~6 ~ ~ y ~ ~ g ~ L"~ S( J`j /1~ J ~ s • 7J ~ . Fa~.c- +~e~ Lo2 I t I ~f I b I , _ tve~~, t`~vt C.tr r..~~H. Pe ~~ o t Disposition Permit No.