HomeMy WebLinkAbout08-23-11PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND _ - COUNTY, PENNSYLVANIA
nthon Klitsch Jr. Fite Number 21 - (` - ~~~~
Estate of Edward A y
also known as Edward A. Klitsch Jr. Social Security Number 178-01-0254
Deceased
Anne Carolyn Klitsch
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE `A' or `8' BELOW.)
Executrix named in the
~X A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the
last Will of the Decedent dated 06/15/2009 and codicil(s) dated
(State relevant circumstances, e.g., renunciation, death of executor, etc.) pp
After the execution of the documents offered for probate: Decedent did not mar was not did not have a hild bortn o~adoptedn was not thpeovictim o~
wherein grounds for divorce had been established as provided in 23 Pa. C.S.A. §3323 (g);
a killing; and was never adjudicated an incapacitated person, except as follows:
NIA
B. Grant of Letters of Administration
app ica e, en er c..a.; .n.c..a.; pe en e i e; uran e a sen ia; uran a moron a e
Petitioner(s), after a proper search, hn~lr date of X111 on Section A above and com~lplete 1st of heirs);dwastnot the vict9m of a kil~ingnwasnnever s (if
Administration, c. t. a. or d. b. n. c. t. a. , e
adjudicated an incapacitated person; and was not a party to a pending divorce proceeding wherein grounds for divorce had been establishe as
provided in 23 Pa. C.S.A. § 3323 (g), except as follows:
Decedent at death owned property with estimated values as follows:
(If domiciled in PA)
(If not domiciled in PA)
All personal property
Personal property in Pennsylvania
120,000.00
(If not domiciled in PA) Personal property m County $
$ 177,700.00
Value of real estate in Pennsylvania
situated as follows: 233 Bailey Street, New Cumberland, Cumberland County, PA 17070
Wherefore, Petitioner(s) respectf quest(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:
ignature Typed or printed name and residence
Anne Carolyn Klitsch 350 Juniper Drive
,~ Etters, PA 17319
Form Rev. 12-26-2010 (interim form, pending action by the Court) Copyright (c) 2010 form software only The Lackner Group, Inc. Page 1 of 2
(COMPLETE IN ALL CASES:) Attach additional sheets Ir necessary. .u ,r-.~_ -- - ~
Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal residence at .~_
233 Bailey Street, New Cumberland Borough, Cumberland County, PA 17070
(List street address, town/city, township, county, state, zip code)
LifeCare of Mechanicsburg, Upper Allen Township, Cumberland County,
Decedent, then 92 years of age, died on 08/06/2011 at PA
HIOi.t{US REV i01J0?1
LOCAL REGISTRAR'S CERTIFICATION Q-F DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
P 17728482
Certification Number
'This is to certify that the information here given is
correctlw copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will tie forwarded to the State Vital
Record~~ Office nor permanent filing.
AUG162011
_.. ;
Local Registrar ~ '~° I}~ ;rued
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3 REV 11/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
1 PRINT IN CERTIFICATE OF DEATH
SMANENT
ACK INK (See Instructions and examples on reverse STATE FILE NUMBER
2, Sez 3. Social Security Number 4. Date of De (Month, y, Year)
,.tom ~~ ~ ,Iasl,sufPor) ~(~~t% 178 - 01,-- 0254 ~
Under 1 r Under 1 6. Date of Birth Moat da 7. BI ace and riate or fore' coon 8a. Place of Deatit Check on one
_ 5. Age (Last Birtltday) Hospital: Other:
_ 9 2 Shenandoah, PA Inpatient ^ ER I Orrtpetient ^ DoA ^ Nursing Home ^ Residence ^ otner - sl~edly:
• Yrs. 9. Was Decedent of Hispen~ ORgM? ^ Yes 10. Race: Amedcan Indian, Black, White, etc.
Bb. Courdy of Death Bd. Foci Name (H not IrtstltiNon, gNe street and ntmber)
8c. City, Boro, Twp. of DeaM titY (If yes, specny Cuban, (Specyly) wy~ it ,n
~ ~m1n .~,~~~y ~ UPPer Allen TF1p • L (.~ r~ ~ (~ 1 v t~~~ ~JYJIJI ` Mexk~rt, Puerto Rk;en, etc.) r \ T C'~
. 11 Decederd's Ueud "` Kind of work one d~ moat d world Nte. Do not state reti 12. Wu Decedent ever M the 13. Decedent's Edtz:etbn (Spedly only highest g tared) 14. Marital Status: Monied, Never Married, 15 Survhnng Spouse (If wife, gNe maiden name)
wkiowett, Divorced (sPaclNl
of Wog u.s. Armed Forces? Elemerna (secondary (0-12) couege (1-4 or 5+> Widowed
Senio r~ Kind of Business I Industry 12
V.P. & Treasurer Ban in ®Yee ^ No
Decedent's Did Decedent T,~
• 16. Decedents Malting Address (SV~~ city I town, state, zip code) Pennsylvania Live in a 17c. ^ Yes, Decedent Lived in
Actual Residence 17a. State Township?
233 Bailey Street Cumberland 17d.I~No,DecedentLivedwitttln New Cumberland c;y,~,o
17b. County Actual Limits of
• New Cumberland, PA 17070
19. Mother's Name (First, middle, maiden sumeme)
16. Father's Name (Frst middle, last, suffix) Mar Betz
Edward A. Klitsch Sr.
20b. Informants MaNing Address (Street, city I town, state, zip code)
zoa.IMomtant'sName(Type/PRnt) 350 Juni er Drive, Etters, PA 17319
Anne C . Kl i t S C h 21 d. Locetbn (City I town, state, zip code)
21 a. Method of Disposition ~ ®Crematon ^ Donation 21 b. Date of Dispoatiion (Month, day, year) 21 c. Place of Dispositon (Name of cemetery, crematory or otMrr place)
^ Burial ^ RemovelhomState ~ wucramatiatwDor>ttwnaulnorizsd ^ August 15, 2011 Evans Crematory Schaefferstown, PA 17088
^ Other • ~ by Madkri EzaminerlCoroner4 Yes No
• 22b. Lkeruse Number 22c. Name end Address of Fedllty
22a. Sgna of F L' (or ng as such)
_ ~ FD 013 340 L Parthemore FH & CS, Inc.~P~ONmBox 431, New Cumbeslda~dd, PAr)17070
Complete Hems 23ac Dory when cartflyirg 23a. To the best of my krtowNdge, deatn occurred at the n nd place stet (sigaemre and tine) ~ ~ ~ ~~
physician is not avaeable at tiros of death to
ceRny cause of death. ~
25. Date Provo Dead onth, day, Year) 28. Was Case Referred to Medical Examiner /Coroner for a Rea n Other the Cremation ar Donatlon
• lterrts 24.26 muri be completed by person 24. Tim/e~ot Dee /~ Q r ,, ^ Yes ~No
• who prorwunces death. d r 3 ~ T1 M• ~v 26. Did Tobearo Use Contribute to Death?
r Approximate interval: PaR II: Enter other '
CAUSE OF DEATH (Sea Instructions end szamplas r Onset to Death tart not resulting in the underlying cause givmn in PeR I. ^ yes ^ Probably
Item 27. PaR I: Enter the drain of events -diseases, injuRes, or complications • Ihat directly caused the death• ~ NO•f enter terminal events such es cardec arrest, r ^ No ^ Unknown
respiratory arrest, or ventricular fkxillrifon without showing the etiology. Ust Dory one cause at each one. r
r ~~^ 29. n Female:
r ,J
MEDIATE CAUSE (Ernst disease or n ~ ~~~ lJl 0 r~ r ^ Not pregnant within past year
canddion resulting kt ath) _~ a r
r /Y~ ~ t~1 ^ Pregrtent at time d death
Due to (or as a consequence oQ: r `I~ i•~'
t ^ Not pregnant, but pregnant within 42 days
Deity list , n ant, b. _ .
~ng to the t~rree fisted on one a' Due to (or as a consequence oQ:
Enter ttte UNDERLYING CAUSE
(disease or injury that initiated the c.
events resulting m death) LAST.
Due to (or as a consequence op:
d.
30a. Wes an Autopsy 30b. Were Autopsy Findings 31. Manner of Death
Perfortrted? Available Prior to Completion ~ turel ^ Homidde
r
32a. Date of Injury (Month, day, year) 32b. DescRbe How Injury Occuned
of death
^ Not pregnant but pregnant 43 days to 1 year
before death
^ Unknown if pregnant within me pest year
32c. Place of Injury: Horne, Farm, Street, Fadory,
Office Building, etc. (Seedy)
of Cause of Deets? 32e. I u at Work? 32f. It Trenaportenon Inury (SDecNI') 32g. Location of Injury (Street, city /town, state)
^ Acddent ^ Pending Investfgetbn 32d. Time of Injury ^I ry
^ y~ [.~,.~ ^ Ves ^ No ^ Yes ^ ~ ^ DRverlOperetor ^ Passenger ^ Podestdan
^ Suktide ^ Could Not be Determined M. ^ Other • Sperdly
33b. Sign lure rtifier
33a. Certlfler (dteck Doty one) ,
C•rt~a9 PhY•kl•^ (physician ceRtiYi^9 cause of death when another physkan hu pronounced death end completed Item 23) ^
• To the beat of my k~•d9a, duth oxuned dos to the uuss(a) and manner es stated - - - - - - - - - - - - - - - - - - - - - - - - - - - -' - - - - mac. Lk;enee Number 33d. Date k3rted ( th, day, year)
• Prorroundng and rxrtNying physichn (Physidan both pronoundng death and ceRflyGtg to cause of death) , ,t ^~ /e~ ~~ ~ CO
To the beet of my ImoaMdge, death occurred ri the time, dab, and place, and dw to tfN csuss(s) and manner u risbd - - - - - - - - - - - - - - - - - - ^ V ~ ` lJ
• frladeel i'cxsminerlCoronar
On the basis of ettaminatlon and 1 or In,readgeNon, In my opinion, derih occurred ri the time, deb, and place, end dw to the cause(s) and manner as atrisd_ ^ 34. Na~ /tQa~esa~o~v-~(~.1'W~ttif Death (Hem 27) Type / Rnt
35. Registrar's and. District ~ I~ I ` I ~ / I I ~~~re ~" y y~~ ~(CL//- ~~
~ -- / - ! ! /
Disposition Permit No. OCn I D 0 ~ -