HomeMy WebLinkAbout02-21-12PETIT~,O:~i FOR GRANT OF LETTERS
REGISTER OF WILLS OF ~ t ] ~ COUNTY, PENNSYLVANIA
Petitioner(sj named below, who is; are 18 years of age or older, apply(ies) for Letters as specified below, and in
support thereof aver(s) the following and respecttltlly request(s) the grant of Letters in the appropriate form:
Decedent's Inform tion~
Name: t
a/k/a:
a/k/a:
a/k/a:
Date of Death: ;_ Rti _
Decedent was domiciled at death
principal residence at 1 Z! e
Decedent died at
Office~nd Zip Code
address, Post Office and Zip
File No:Q~ ! Q' (~~~
(Assigned by Register)
Social Security No:~ '" ~~
Age a~ death•
or
City, Township or Borough ~ ~' County
Estimate of value of decedent's property at death: f`
If domiciled in Pennsy!vania ............................ Alt personal property $ v
If not domiciled in Pennsy!vania ........................ Personal property in Pennsylvania $
If not domiciled in Pennsy!vania ........................ Personal property in County $
Value of real estate in Pennsy!vania ......................................................... $
TOTAL ESTIMATED VALUE.... $
Real estate in Pemisylvania situated at:
(Attach additional sheen, ijnecessary.)
Street address, Post Offce and Zip Code City, Township or Borough County
A. Petition for Probate and Grant of Letters Testamentary ~'p~l
Petitioner(s) aver(s) helshe/they islare the Executor(s) named in the last Will of the Decedent, dated~~(~-LJa~ nd Codicil(s)
thereto dated
State relevant circumstances (e.g. rennnciatiott, death ojexectdor, etc.J
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not divorced, was not a party to a pending
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(8), and did not have a child born or
ado led; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
OEXCEPTIONS ^EXCEPTION5
^ B. Petition for Grant of Letters of Administration (If applicable)
C.C.G., d.b.tt., d.b.tt.c.t.a., pendente life, durunte ubs•entia, durante minoritate
If Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined
in 23 Pa- C.S. § 3323(8) and was neither the victim of a killing nor ever adjudicated an incapacitated person.
^NO EXCEPTIONS ^ EXCEPTIONS
Petitioner(s), after a proper search has/have ascertained that Decedent left no W ill and was survivedby the following spt~ (if any) and his (attach ~
p3 -Y, r~rt tC~
additional sheets, i(necessary): ~ fTi ~, ~
Name
Relationshi ~7 t- ~ r_
,
Address c.Q3_
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F~,-»~ tzw.nz rev. lnilliznll Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
L (~~ //~~j~,~~ } SS:
COUNTY OF t~[~C7'u-+l/"~ }
a~~~2 ~=c$ 21 ~t~ 9~ i2
Petitioner(s) Printed Name Petitioner(s) Printed ~ .
2 z ~ 1
1 ,l , r
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are true and correct to the best of the knowledge and belief
of Petitioner(s) and that, as Persona( Representative(s) of the Decedent, the Peti ' w' ell and truly administer the estate according to law.
Sworn to or affirmed an ubscribed before ~ Date? / O/ 1
me this d y of ~ , ~~Z, Date Z
BY~ Date
F r the Register Date
BOND Required: YES ~O
FEES:
Letters ..................... .
( /U )Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commiss'on .................
Other i /~ .,.,,..,
Automation Fee .............. .
JCS Fee . .................... -
To the Register of Wills:
Please enter my appearance by my signature below:
Attorney Signature:
Printed Name:
Supreme Court
ID Number:
Firm Name:
Address:
Phone:
Fax:
Email:
\ DECREE OF THE REGISTER ,n
Estate of r y) . File No• c~ ~ ~ I o~ as 3
a/k/a:
AND NOW ~ Q 1 c~ , in con ideration of the foregoing Petition,
satisfactory proo ing been pr se ted before me, IT I ECREE~that Legs ~
are hereby granted to 1 1~Cd ,~ to_
C
r in the .above estate and (if applicable) that
the instrument(s) dated ~1 aCX~ ~
described in the Petition be admitted to probate and filed of record as the last Will (anal Codicils of Decedent.
c~~. 6~
Register of Wi
Form RW-02 rev. lA/11/2011 ~~~ ~~
Page 2 of 2
H]OS.RO~ REV (OVOT
LOCALR ~; r 'S CERTIFICATION OF DEATH
WARNIN tsr~let(al, ! plicate this copy by photostat or photograph.
Fee for this certificate, $6.00
P 17928058
Certification Number
?~~2 ~'~$ ~ ~ ~~ t~; ~~ This is to certify that the information here given is
correctly copied from an original Certificate of Death
e+~~ 0~ duly filed with me as Local Registrar. The original
certificate will be forwarded to the State Vital
QR/~ ~J{~T Records Office for permanent filing.
~x~~~~.~r r„~ . pA G~ n. l~ °~'~ J,9M 05/2012
Local Registrar Date Issued
COMMONWEALTH OF PEN NSVLVANIA • DEPARTMENT OF HEALTH VITAL RECORDS
CERTIFICATE OF DEATi-1
Types/Print In
Permanent
Black Ink
~I
saO
Y
2, sex 3. So<I>I Security Number 4. Date of Death (MO/Day/Vr) (Spell Mo)
Henry J. G r o t h e I I Male - 194-44-9050 Jal-ltlary 3, 20 1 2
Untler 3 Da 6. Date of Birth (MO/Day/Near) (Spell Month) 7a. Birthplace City and State or F reign Country)
~
Months Days Hours Minutes Bet-L1E'_3
a, 1"]a latJC~
November 14, 1957 7b. Birthplace (County) goalery
Sa. Residence (State or Foreign Country) 8b. Residence (Street and Number -Include Apt No.) Sc. Did Decedent Llve In a Tgwnship7
Pe 1 QYes
decedent Ilved In
tw
Bd. Residence (County)
C~Jbrldge Dr1Ve ,
__
p
CL>mberlacxl He. Residence (Zip-Code) I(1 No, decedent Ilved within limits of ME!C1ZanlCEibllrg city/born.
9. Ever in US Armed Forces? SO. Marital Status at Tlme of Death Q Married Q Widowed 11. Su rvlVing Spouse s Name (If wife, give name prior to first marriage)
Ves Q No Q Unknown Q Divorced ~. Never Married QUnknown
12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Iarriage (First, Middle, Last)
Henry J. Grothe Helen M. Carter
14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code)
0
'II-leodore J. Grothe Brother
2001 Cris Lane Ei~ola, PA 17025
_ ...
............................. ......................
......,............................ ..-.....15a. ace o Deat
...................... e~ qn.r. pne .
.....
.
,.+l
If Death Occurred in a Hospital: u Inpatient l _________ _ _
~
......
......................
lf Death Oc urretl Somewhere Other Than a Hospital: LJ Hospice Facility ~ Decedent's Home
Emargenry Room/Outpatient Q Desd on Arrival
• ~ Nursing Hpme/Long-Term Care Facility Ol:her (specify)
e~ 15 b. Facility Name (If not Institution, give street and number, ISc. City or Town, State, and Zip Coda SSd. County of Death
MlanorCare o£ Carlisle 940 Walnut Bottom Road Carlisle, ]?A 17015 QJmberland
16a. Method of Disposition Q Burial $] Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place)
Q Removal from State Q Donation
other(speafy)
Jat,,,ary 5, 2012
CLJmberland Crematory LLC
16d. Location of Dlsposltlon (City or Town, State, and Zip) 1]a. Signstu re of Funer>I Ice Licensee or Person In Charge of interment 1]b. Licenses Number
Carlisle, PA 17013 _y~~ ~- F'D 012774-L
E 1]c. Norma and Complete Address of Funeral Facility
3 Richardson Etimeral Home Inc. 29 Soalth Elzola Drive Enola PA 17025
art 18. Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to indicate what
,- highest degree or level of school completed at the time of death. box Mat best describes whether the decedent She decedent considered himself or herself to be.
Q Bth grade or less is Spanish/Hispanic/Latino. Check the "NO" [XWhite Q Korean
No diploma, 9th - 12th grade box If decedent is not Spanish/Hispanic/Latino. Q Black or African AmeNCan Q Vietna mesa
High school graduate or GED completed ~( No, noY Spanish/Hispanic/Latlnq Q American Indian or Alaska Native Q Other Asian
Q so college redit, but no degree Q Yes, Mexican, Mexican American, Chlca no ~ Asian Indian Q Native Hawaiian
Q Associate degree (e.g. AA, AS) Q Yes, Puerto Rican Q Chinese Q Guamanian or Chamorro
Q Bachelor's degree (e.g. BA, AB, BS) Q Ves, Cuban Q Filipino Q Samoan
Q Master's tlegree (e.g. MA, Ms, MEng, MEd, MSW, MBA) Q Vas, other Spanish/Hlspa nic/Latino Q lapane:se Q Other Pacific Islander
Q Doctorate (e.g, PhD, Ed D) or Professional degree (Specify) Q Other (Spec)
fV) _
. MD DDS DVM LLB JD
21. Decedent's single Race Self-Designation -Check ONLY ONE to intllcate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation - Intlica[e type of work
~] White Q Japanese Q Samoan done during most of working Ilfe. DO NOT USE RETIRED.
Q Blaek or African Amerleen Q Korean Q Other Peclflc Islander yam.,.,
Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not sure Sel£ EYxJplDyed
Q Asian Indian Q Other Aslsn Q Refused 226. Kind of Business/Industry
Q Chinese Q Native Hawaiian Q Other (Specify)
Q Filipino Q Guamanian or Chamorro HOIIIL B111 ].der
ITEMS 2B> - 2 MU BE C MPLETED 23 ate Pronounce Dead Mo nDay Vr 23 ig atu re o Pars nouncing Death (Only en applicable) 23c. Cleanse Number
BY PERSON WHO PRONOUNCES OR ~"
O~
~''~
pC
CERTIF
1E5 DEATH
~,-
pvsao 998
a
,
L
to Signed (MO/D r) 24. of Death
2 dlcal r Coroner Contacted? Q Yes Q No
a
CAUSE O
TH Approximate
26. Part 1. Enter the chain of events--diseases, Injuries, or complications--that tlirectly caused the death. DO NOT enter Lerminsll events such as cardiac arrest Interval:
respiratory arrest, or ventricular fibrlllaflon without showing
t
he etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary Onset to Death
`
_
IMMEDIATE CAVSE ---------------> a. ~ ~ / J `c- IJ 5--.~f
(Final disease or condition Due to (or as a consequences of):
resulting In death)
b.
Sequentlally list conditions, Due to (o as a consequence of):
u env, leading to Me Cause
listed on Ilne a. Enter the
UNDERLYING GUSE Due to (or as a consequence of):
~ _
(disease or injury that
- Initiated the events resulting d.
~ in death) LAST. Due [o (or as a consequence pf):
s~ 26. PaR 11. Enter other sl¢niflcant conditions contributing to death but not resulting In the underlying cause given in Part I 27. Was an autopsy perfo tl]
D
Q Ves No
~ 26. Were autopsy findings available
to complete the cause of death?
B+
~ Q Yes No
g
i 29. If Female: 30. Dld Tobacco Use Contribute to Death? 31. Manner of Death
E Q Not pregnant within past year Q Ves Q Probably ~~NStural Q Homicide
ss 0 Pregnant at Lime of death ,.nJrl6 Q Unknown Q Accident Q Pending Investigation
si; Q Not pregnant, but pregnant within 42 days of tleath Q Suicide Q Could not be determined
Q Not pregnant, but pregnant 43 days [0 3 year before death 32. Date of Injury (MO/Day/Yr) (Spell Month)
Q Unknown if pregnant within the past year 33. Tme of Injury
34. Place of Injury (e.g. home; consLru<tion site; farm; school) 35. Location of Injury (Street and Number, Clty, State, Zip Code)
36. Injury at Work 37. If Tra nsportatlon Injury, specify: 3B. Describe How Injury Occurred:
Q Yes Q Driver/Operator Q Pedestrian
Q No Q Passenger Q Other (Specify) _
39a. Ca (Check only one):
ertltying physician - To the best of my knowledge, death oc< red due to the cause(s) antl m r stafetl
Q Pronouncing Hr Certifying physician the bast of my knowledge, death o red at the time, date, and place, and due to the cause(s) and m stated
r
Q Medical Examiner/Coroner - On a ba atlon, and/or Investigations in my opinion, death
~ red ai the time, data, and place, and due
to the cause(s) and manner stated
5
ur
/
J
Signature of certifier: Title of certifler~ Y
G License Number: OO I O ~ C „$~~ L
39b. Name, Address and ZI Code o n Cgmpleting Cause of Death (Item 26] 39c. Date Signed (MO/Day/Vr)
r e. S 6 f}s ~ ~_ ~cvl . stSL-I~/~ I ~-Qt~- ) 1 3( r z
40. Registrars Distr ct Num er~j ~1 41. Registrar's Signature ~ 42. Re isfrar Ff a Date Mo
Day r
vc ~ ~~C ~ ~ / ~]
..~~ m'Y U ~ Z~
43. Amendments
2/
Dlsposltlon Permit Np. _Q .~ .~V//G° 6 H305-143
REV OJ/2011
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LAST WILL AND TESTAMENT r~ -~ ~ ~'' ~ ~ ~'~~
BE IT REMEMBERED THAT ~~~~
~° ~: _; <~;=
_
I
HENRY J
GROTHE
II
a resident of Cumberland Count
P
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f
and ~_ f" ~"?
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and disposing mind, memory and understanding do make, publish and declare this to be my LAST
WILL and TESTAMENT, hereby revoking any and all Wills and Codicils previouslymade byme.
I
I declare that I am not married and that Ihave no children.
II
I direct that all my just debts and funeral expenses shall be paid from my residuary estate as
soon as practicable a$er my decease.
III
I direct that all taxes that maybe assessed in consequence of my death, of whatever nature
and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the
expense ofthe administration ofmy estate.
IV
I hereby direct that all my tangible personal belongings located at 121 Cambridge Drive,
Mechanicsburg, Cumberland County, Pennsylvania, be given to my niece, ALEXANDRA E.
GROTHE, provided she survives me for a period of thirty (30) days. In the event that she either
predeceases me or fails to survive me for a period of thirty (30) days, there these tangible personal
items are to be given to my brother, THEODORE J. GROTHE, provided he survives me for a
period of thirty (30) days. In the event that he predeceases me or fails to survive me for a period of
thirty (30) days, then these items are to pass pursuant to the residuary clause: ofmy Will.
V
All the rest, residue, and remainder of my estate, whether real or personal, wherever situate,
I hereby give, devise and bequeath to my brother, THEODORE J. CiROTHE, my nephews,
THEODORE J. GROTHE, III, and RYAN P. GROTHE, and my rviece, ALEXANDRA E.
GROTHE, in equal shames, per capita.
VI
I nominate, constitute and appoint my brother, THEODORE J. CJROTHE and my niece,
ALEXANDRA E. GROTHE, as Co-Executors of LAST WILL and TESTAMENT, to serve
without bond. If either of them is unable or unwilling to so act, then the other may so act alone also
without bond.
IN WITNESS WHEREOF, I, HENRY J. GROTHE, II, have set my hand to this LAST
WILL this a~ dayof, 2009.
H NR ROTHE,II
Signed, sealed, published and declared by the abo~ve~amed HENRY.' J. GROTHE, II, 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 w'tnesses.
~_
ACKNOWLEDGEMENT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ss
I, HENRY J. GROTHE, II, Testator, whose name is signed to I:he attached or foregoing
instrument, having been duly qualified accon~iing to law, do hereby acknowledge that I signed and
executed the instrument as my LAST WILL; that I signed it as my free <ind voluntary act for the
purposes therein expressed.
HE . GROTHE, II
Sworn or afFinned to and acknowled~d before me by HENRY :f. GROTHE, II, Testator,
this ~~iayof;~,, 2009.
COMM NWEA NNSYL!/ANIA
Notarial Seal
Joette L. Mc(iowen, Notary Public
Mechanicsburg 80%. dxrtberlend County
My Commission Expires July 6, 201:`
~~~
ary Public
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ss
We, R. Mark Thomas and ~17 ! /// ~ VL J~~-7-Z ,the witnesses
whose names are signed to the attached or foregoing instrument being duly qualified according to
law, do depose and say that we were present and saw Testator sign and execute the instrument as
his LAST WILL; that HENRY J. GROTHE, II signed willingly and that he executed it as his free
and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the
Testator signed the Will as witnesses; and that to the best of our knowledge:, the Testator was at the
time 18 years of age or more, of sound mind and underno constraint or undue influence.
. Sbvo or affirmed to and acknowledged before me by R. Mark Thomas and
~b~ ~ ~C,~~,r z this ~~iayOf~, 2009.
C
tary Public
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal ~
Joette L. Mc(iowen, Notary Public
Mechanicsburg l9oro., Cumberland County`
Bey Commission Expires Jury 6, 2010