HomeMy WebLinkAbout03-09-12 (2)PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF COUNTY, PENNSYLVANIA
Petitioner(sj named below, who is; are 18 years of age or older, apply(ies) for Utters as specified below, and in
support thereof aver(s) the following and respecttitlly request(s) the grant of Letters in the appropriate form:
Decedent's Information
Name: ~~.,9rtc•Q c r' kAUT Z_
a/k/a:
a/k/a:
a/k/a:
Date of Death: 3~ 3~/ ~
Decedent was domiciled at death
principal residence at _~~c
County,
(State) with his t~re last
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at a 4-D l~J/a- I v»T" ~ -'~ rn ~A ~ rg2~~S ~.~-- ~rJyyr~~ 1/Jn lJ ~~
Street address, Past Office and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death:
Ijdomiciled in Pennsylvania ............................ All personal property $ lit ~~~ ` U 1
Ijnot domiciled in Pennsy!vania ........................ Personal property in Pem~sylvania $
Ijnot domiciled in Pe-tnsyh~ania ........................ Personal property in County $
Value ojreal estate in Pennsylvania .......................................................... $
TOTAL ESTIMATED VALLlE.... $ ~ ~ d y ' fi
Real estate in Pennsylvania situated at:
(Attach additional sheers, ijnecessary.) Street address, Poat Office and Zip Code City, Township or Borough County
~A. Petition for Probate and Grant of Letters Testamentary ~~
Petitioner(s) aver(s) helshe/they is/are the Executor(s) Warned in the last Will of the Decedent, dated _ ~ C -Z~~~J and Codicil(s)
thereto dated
State relevant circumstances (eg. renunciation, death of executor, etc.)
Except as follows: after the execution of the instrument(s) offered for probate Decede»t 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
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
~10 EXCEPTIONS ^ EXCEPTIONS
^ B. Petition for Grant of Letters of Administration (If applicable)
c.t.a., d.b.rt., d.b.n.c.t.a., pendente life, durance absentia, durante minoritute
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 A,
Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the following spo~ 'any) and }~ (atta~
additional sheets, i(necessutp): ~ .~: ='n C'a
Tam f. f ~ ~
_. -~
Name Relationshi Address ~
~ I
'
~~~
n
~^~
...../ C-
~~
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File No: ~~ I ~ ~ ~~
(Assigned by Register)
Social Security No: ~ - ~
Age at death:
f ~"s
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Forn+ RW-02 rev. IO/11/2011 Page 1 of 2
Oath of Personal Representative
CO'.~I~tONWEALTH OF PENNSYLVANIA }
} SS:
COliNTY OF CI YY~bE'r- I19 ~ ~ }
Official Use Only
P~ti tionerls) Printed Name Petitioner(sj Printed Address
~y~ B Q S n - c 7
me c: ti A ~,~sb~ r ~
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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 Personal Representative(s) of the Decedent the Petitioner(s) will well an~ truly administer the estate according to law.
~.._.-
Sworn to or affirmed an subscribed b~jfore Date ~~ ~ alt
me thi day o ~'!~ , G(y ~ ~ Date . 3~~D /Z
I3y. : ~ Date
For the Register Date
BOND Required:~YES ~VO
FEES: TT
Letters ...................... $_~/S~
( / )Short Certificate(s)...... y -
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commiss'on ................. .
Other ~ ........ /.S'
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:
Automation Fee ..............: ~~' ~ Fax:
JCS Fee . ................... ~ ,~~ Email:
TOTAL ..................... $ ~a
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DECREE OF THE REGISTER
Estate of ~~{'~~_! ~~i.t )T-~ .
a/k/a:
AND NOW, 1 D 4~ . in consideration of the foregoing Petition,
satisfactory proof a ing been presented before me, IT IS DECREED that Letters _
are hereby granted to t~PiU ~... i^ ti Srn-~ ~--
~, r. ~~ ~ J ~~,"-~ ,s- the abore estate and (if applicable) that
the instrument(s) dated _
described in the Petition be
Form R 64'-0? rev. ! 0/1 !!201
File No: ~~ ~ ~ ~ ~ a 9 3
to probate and filed of record as the st Will (and C icil(s)) of Decedent.
gister o~Jfp~' 11 ~ ~~
I~' Page 2 of 2
HIU5.Sp5 RED' i9/Ill
~ r 1 I TRAR'S CERTIFICATION OF DEATH
1~4f{fVM;IG:. t,,~ ~I legal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.~~ Z ~~~ - g ~~ ~ ~ ' ~ ~ This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
(,`~~~~( (~~ certificate will be forwarded to the State Vital
Q~P~'S ~u~j Records Office for permanent tiling.
P 1 ~ 16 0 8 6 8 ~~~..~~~ ro . ~a ~~~ ~
a,~t
Certification Number
TYPe/Print In
p ant
~~C
`~
~-#.
Local Registrar Date Issued
COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS
lack Ink `
fi 2. Sex 3. Social 5¢curity Number~~a'6 4. Dat¢ of Death (MO/Day/Yr) (Spell Mo)
1 . Decedent's Legal Name (First, Middle, Last, Suf
x) Pma ]
19 6 - 14 -- 3 5 2 3 ar e h 3 , 2 O 1 2
-
Frances Irene Kautz
eign Country)
or
or F
t
f Birth (MO/Day/Vear) (Spell Monts) 7a.9a gyp=
(
D
l
6
C11Y
S A
P
;
~
a
e o
.
U rg
a. Age-Las[ Birthday (Yrs) Sb. Under 1 Year Sc. Under 1 Da
s
H [7
Months Davs Hours Mlnr,tes Apr i 1 2 7, 1 9 2 3
8 8 7b. Birthplace (County) U 1
8 idence (State or Foreign Country) Bb. Residence (Street and Number -Include Apt No.) 8c. Dld Decedent Llve In a Township?
R
9 '1 '' [wP.
es
a.
Penns lvania 40 Walnut Bottom Rd. s, decedent used ln;3 tI', Mj-ra r
B d. Residence (COUnry) [~[J O, decedent lived within limits of city/born.
Cumberland Be. Residence (Zip COda)
Surviving Spouse s Name (if wife, glue name prior to Rrst marriage)
wed 11
WI
9 .
o
. Ever in US Armed Forces? 10. Marital Status at Time of Death Q Married
d Q Unknown
Q Ves ®No Q Unknown Q Divorced Q Never Marrie
Mother's Name Prior to First IVlarriage (First, Middle, Lasi)
13
1 .
2. Father's Name (First, Middle, Last, Suffix)
Mary Peters
Oscar Lambert
146. Relatlonshlp to Decedent 14c. Informant's Melling Address (Street and Number, City, State, 21p Code) 1 7 0 1j
14a. Informant's Name
ter 20 Ba berr Drive Mechanicsburg PA
t
D
'
i
au
Treva L. Bryson
"...
~
G ..................................r
...
...••••••...•••••...•• .._._a:•.,aee.o_,__eat.__ '• ec on•y one _
....... ..... .............................. µs
re Other Than a Hospital: ~ Hospice Facility tJ Decedent's Hom¢
h
d S
O
'a`~ I P~
..-.••••••...•••••....••••...-•••••
I
f Death Occurred in a Hospital: ~ In tient omew
e
ccurre
lf Death
Care Facility O'[her (Specify)
T
Q Emergency Room/Outpatient Deed on Arrival
• erm
rain Home/LOn
u g g S6d. County of Death
d
s~ 15 b. Facility Nsme (If not lnstltullon, give street and number) e
i6c. City or Town, State, and Zip Co
PA 17015 Cumberland
lisle
C
= Manor Care Health Services ,
ar
Place of Dlsposltion (Name of cemetery, crematory, or other place)
16c
ltl
16a. Method of Dlsposltlon ][][Burial Q Cremation .
on
16b. Date of Dlspos
p Removal from State O Opnallgn 20 2 Woodlawn [flemorial Gardens
March 8
Other (Specify)
16d. Location of Dlsposltion (City or Town, State, and Zip) ,
17a. Sign tux F ef3L~ervice LI or Person In Charge of Interment 17b. License Number
l
~
Y„J Harrisburg, PA 17109 FD 138182
d
17c. Name and Complete Address of Funeral Facility -
1 34 N.2nd S rest Harrisbur PA 17102
l Home =nc
F
.
unera
eum er
cadent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to Indicate what
19
D
h
°rd .
e
e
18. Decedent's Education -Check the box that best describes t
ecedent ronsidered himself or herself to be.
he
d
st describes whether the decedent t
th
t b
b
~. a
e
ox
~
/
"
highest degree or level of school completed at the lime of death.
Is Spanish/Hispanic/Latino. Check the "NO" LK white Q Korean
Q 8th grade or less
box If decedent Is not Spanish/Hlspa nic/Latino. Q Black or African American Q Vietnamese
Q No diploma, 9th - 12th grade
d ~FJ O, not Spanish/Hispanic/Latino Q American Indian or Alaska Nature Q Other Asian
l
t
e
e
Q Hlgh school graduate or GED comp
Q Ves, Mexico n, Mexiean American, Chicano Q Asian Indian Q Native Hawaiian
college credit, but no degree
Puerto Rlca n. Q Chinese Q Guamanian or Chamorro
Q Yes
s
~
,
4.s oclaie degree (e. AA, AS)
B. Samoan
,
ban Q FIIIDino
C
V
es,
u
Q Bachelor's degree (e. g. BA, AB, BS) Q
other Spanish/Hispanic/La[Ino Q Japanese Q Other PaclFlC Islander
MBA) Q Yes
MSW
,
,
Q Master's degree (e.g. MA, M5, MEng, MEd,
if
)
S
Q O
h
y
er (
pec
t
Q Doctorate (e.g. PhD, Ed D) or Professional degree (Specify)
. MD DDS DVM LLB JD
ck ONLY ONE to indicate what the decedent considered himself or herself to be. 22a. Decedent's Vsual Occupation -Indicate type of wor
i
Ch
a
on -
e
nt's Single Race Self-DeslgnaT
21. Dec)~
~6Jhite Q Japanese Q Samoan done during most of working life. DO NOT USE RETIRED.
B
Q Black or African American QKOrean QDther PacHic Islander Department Of Revenue
'
t Know/Not Sure
Q American Indian or Alaska Native Q Vietnamese Q Don
22b. Kind of Business/Industry
Q Asian Indian Q Other Asian Q Refused
Q Chinese Q Native Hawaiian Q Other (Specify)
State WorKer
Q Filipino Q GuamanlanorChsmorro
b
er
23d MUST OE CO PL ED 23a. Date Prono need Dead (MO Day r) 23 .Signature of Person Pronoune Deat (Only when app Ica a 23c. License Num
ITEMS 23a -
BY PERSON WMO PRONOUNCES OR ~ ~ I ~ ` ~~~i G~
CERTIFIES DEATH ~'~f c7 LJ tJ
23d. Date Signed ( o/Day/Vr) 24. Time of Death
_ .Was cal Examiner or Coroner ~n[acted7 Q Yes No
CADS OF DE H Approximate
26. Part I. Enter the h-1 fevents-diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, Interval:
Add addi[lonal lines If necessary Onset to Death
n a Ilne
l
.
y one cause o
EVIATE
B
R
.-Enter on
respiratory arrest, or ventricular fibrlllstlon without showing the etiology. DO NOT AB
[
.
.
L
IMMEDIATE CAVSE ------------> a.
~ Due to (or as a consequence of):
(Final disease o ndition
resulting in death)
b.
Sequentially Iis[ conditions, Due to (or as a consequence of):
if any, leading to the cause
listed on Ilne s. Enter the
Due to (or as a consequence of):
V NDERLYING CAUSE
aWC u ry
that
(disease or InJ
s r
e
e
initiated the ve is r sultinB d' Due to (or as a consequence of):
i
~ In death) LAST.
in the underlYing cause given In Part 1 27. Was autopsy peAor ~dT
lti
ng
26. Par[ 11. Enter other i ifl t dlti t ib ti t d th but not resu
p Yes [C3'N
28. Were a topsy Rntlings available
~ to complete [he cause o ath7
'i
Ves
30. Did Tobacco Use Contribute to Death? 31. M r of Death
- 29. If Fe Ff:
nant within past year
re
~f 0 Ves Q P~IY atural Q Homlcid¢
ation
v
sti
di
I
p
g
th
f d Q No QTj known g
ng
n
e
Q Accident Q Pen
i
d
°
' ea
Q Pregnant at [Imo o
s of tleath
ithin 42 da ne
Q Suicide Q Could no[ be determ
m y
~ Not pregnant, but pregnant w
ear before death
to 1
43 d 32. Date of Injury (MO/Day/V r) (Spell Month)
~- y
ays
Q Not pregnant, but pregnant
Q Unknown If pregnant within the past year 33. Time of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, Clty, State, Zlp Code)
36. Injury at Work 37. If Tra nsportatlon Injury, Specify: 3B. Describe How Injury Occurred:
Q Ves Q Driver/Operator Q Pedestrian
` 0 No Q Passenger Q Other (Specfy)
39a. C er (Check only one):
ertifying physician - To the best of my knowledge, death o currad due to the cause(s) and manner stabd
c se(a) and m stated
au annex
t
th
d d
^
e
an
ue
Q Pronouncing 8. Certifying physician -TO the best of my knowledge, death occurred at the time, date, end place,
ntl manner stated
u
and due to [he cs se(a) a
and place
date
d at the time
h
d
r
I ,
,
,
re
eat
Q Medical Examiner/Coroner - On t sis of examination, and/or Investigation, In my opinion,
3
mber:000 ~ / ~3- - `'
N
i
cu
~ ~
cense
u
L
Signature of certifier: Title of certifier
39b. Name, Address and Zlp Code of Completing Cause of Death (Item 26) 39c. Dat¢ Signed (MO/Day/Vr)
% Pas-- ~- o f 3 f s t f Z-
~
s~ ~~ s ~ r
r . ,
D
ay
r Ff a Date Mo
41. Ragislrar nature 42. Registry
Reglst ar s District Number
40
//
.
/
s 43. Amendments
B
7~
v o/ v o i REV 07/2011
Dlsposltlon Permit No.
r-.;
^-
n
LAST WILL AND TESTAMENT ~'
,r~~ !
. GC!]~ ~
OF ~c-~;rj ,,,,„
~~ ~~
FRANCES I. KAUTZ ~
~'-~ ..
~~
I, FRANCES I. KAUTZ, of Hampden Township, Cumberland
County, Pennsylvania (Camp Hill, PA 17011) being of sound and
disposing mind, memory and understanding, do hereby make, publish
and declare this to be my Last Will and Testament, hereby
revoking any and all wills and codicils at any time heretofore
made by me.
ITEM I - I hereby direct my hereinafter named personal
representative to pay all of my just debts, funeral expenses, and
estate and inheritance taxes as soon as after my death as may be
found convenient.
ITEM II - I direct that I be buried next to my husband in a
lot that I own in Woodlawn Memorial Gardens, Harrisburg,
Pennsylvania.
ITEM III - All the rest, residue and remainder of my
estate, whether real, personal or mixed, of whatsoever nature and
kind and wheresoever located, I give, devise and bequeath to my
children, Landis D. Kautz, Jr. and Treva L. Bryson, in equal
shares.
~~
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Cr"s
--rt
Page 1 of 4
If either my son or daughter should predecease me, then his
or her share shall be distributed to his or her issue, by
representation. If my deceased son or daughter shall have died
without issue surviving him or her, then the share of such
deceased child shall be distributed to my other child but if he
or she should also have predeceased me, then to his or her issue,
by representation.
ITEM IV - I appoint Landis D. Kautz, Jr. as co-executor and
Treva L. Bryson as co-executrix of this my last will and
testament.
ITEM V - I direct that my personal representatives shall not
be required to give bond for the faithful performance of his or
her duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal this ~ q'~ day of 2005.
Frances I. Kautz
Page 2 of 4
s
Signed, sealed, published and declared by the above
testatrix, Frances I. Kautz, as and for her Last Will and
Testament, in our presence, who, at her request, in her presence
and in the presence of each other, we, believing her to be of
sound mind and memory, have hereunto subscribed our names as
witnesses.
~~ l/>' of
0 of
~ ~(/L~-P
~ ,~ i ~ ~o
So 5 ,~Qnl~w c ~ ~i /e.
Page 3 of 4
i
CONII~lONWEALTH OF PENNSYLVANIA
COUNTY OF DAUPHIN
y,1e~ Frances I. Kautz
: ss
testatrix, Kent H Patterson
and Christina V. Fields ,
witnesses, respectively, whose names are signed to the attached
or foregoing instrument, being first duly sworn, do hereby
declare to the undersigne3 authority that the testatrix signed
and executed the instrument as her Last Will and Testament; that
she signed it willingly and executed it as her free and voluntary
act for the purposes therein expressed; that each of the
witnesses, in the presence and hearing of the testatrix, signed
the will as witnesses; and that, to the best of their knowledge,
the testatrix was at that time eighteen (18) years of age or
older, of sound mind and under no constraint or undue influence.
Frances I. Kautz
,~G~'
Subscribed, sworn to and acknowledged before me by Frances
I . Kautz, the testatrix, and subscri Ch as d na V ~ Fielbds ore me by
Kent H. Patterson and •
witnesses, this 14th day of January 200 .
My Commission Expires: Notary P lic
~: rr~M N F P V
NOTARIAL SEAL
MELISSA J. HARPLE, Notary Public
City of Harrisburg, Dauphin County
My Cortwnissbn ExpNes May 10, 2005
Page 4 of 4