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HomeMy WebLinkAbout06-14-12: IN THE COURT OF COMMON PLEAS ESTATE OF KALTENBAUGH :CUMBERLAND COUNTY, PENNSYLVANIA CARSON W. n : ORPHANS' COURT DIVISION~o - ~ ~ a NO. 021~~~rQ~'~J ~,~ c ~ ~~ <:; ~ O ' BATE, D._..., NDER SECTION 3102 OF THE PRO ~ - t R PETITION U TATES AND FIDUCIARIES CODE FO r- w ~ ES SETTLEMENT OF SMALL ESTATE TO THE HONORABLE JUDGES OF SAID COURT: Jackie A. Kaltenbaugh, your Petitioner, files this Petition for Settlement of a Small Estate under the provisions of Section 3102 of the Probate, Estates and Fiduciaries Code and in support thereof avers that: (1) Your Petitioner, Jackie A. Kaltenbaugh is a competent adult residing at 24 E. Main Street, Newville, Pennsylvania 17241, and is the brother of the above decedent. 2012 at the age of 69 years, but prior (2) Carson W. Kaltenbaugh, died on May 9, A t. 1 Newville, thereto was last domiciled at 9 E. Big Spring Avenue, p , Pennsylvania, Cumberland County, Pennsylvania. A copy of Decedent's Death Certificate is attached hereto as Exhibit "A." (3) Carson W. Kaltenbaugh died with a Will. No Letters have been issued. A copy of Decedent's Last Will and Testament are attached hereto as Exhibit "B." (4) Carson W. Kaltenbaugh had no probate estate when he died other than the following: Life Insurance rom 1tAARP L fe Insurance Program is atta ~d asas Correspondence f Exhibit "C." (5) The sole heirs and relationship to the Decedent are as follows: Jackie A. Kaltenbaugh, Brother Roxie G. Bittinger, Sister (6) Your Petitioner avers that there are no creditors of the Decedent and there are no claims unpaid known to Petitioner. WHEREFORE, your Petitioner respectfully requests that an Order be made authorizing Jackie A. Kaltenbaugh to act as Fiduciary and claim the proceeds with HARP Life Insurance Program and distribute according to Decedent's Last Will and Testament, pursuant to Section 3102 of the Probate, Estates and Fiduciaries Code. By ~ iarcuslA~vicKnight, III, Esquire preme Court I.D. No. 25476 IRWIN & McKNIGHT, P.C. 60 West Pomfret Street Carlisle, PA 17013 (717) 249-2353 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND Jackie A. Kaltenbaugh, being duly sworn according to law, deposes and says that the facts contained in the foregoing Petition are true and correct to the best of her knowledge, information and belief. ~ (SEAL) ackie A. Kaltenba h Sworn`~d subscribed before me this ~' stay of June, ~~. aot~r~o~w~~TM of ~nsnva~rN seas Karen 5. Noel, trotary Publk Came eoro, ~ HI05.805 REV (9/II) LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 P 1848756 Certification Number Type/Prim In Permanent 7 _. 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 Records Office for permanent filing. Z~:t~.~~t~fi~~l~~~• ~~ 1 o/Za~2 Local Registrar Date Issued COMMONWEALTH OF PENNSYLVANIA • DEPA0.TMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH _r k Ink 1 2. Sex 3. Social Security Number - - 4. Date of Death (MO/Day/Yr) (Spell Mo) . Decedents Legal Name (First, Middle, Last, Suffix) 2012 9 176 34 9172 Ma l y , e Carson W. Kaltenbaugh Ma S Age-Last Birthday (YR) 56. Under 1 Year Sc. Vnder 1 Da 6. Date of Birth (MO/Day/Yesr) (Spell Monih) 7e. Birthplace (CtI yand State or Foreign Country) a R West V1r 1I11a ;~ . .i Months Dayz Hours Minutes 69 Jan_ 24, 1943 7b.Birthpiace(000nry) Har S Residence (State or Foreign Country) 8 .Residence (Street and Number -Include Apt N .) B<. Dld Decedent Live In a Township? a . PA 1 DYas, decedent lived In twp. B d. Residence (cpunty) 9 E _ Bi S rin Av 1 7 4 0, decedent Ilved within limits of NEwville city/boro. CLanberland 8a. Residence (Zip Gode) Marital Status at Tlme of Death Q Marrlld ~ Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) d Forces? 10 S A 9 . rme . Ever in U ® Yes ~ No ~ Unknown () Divorced 1® Never Married ~ Unknown - Middle, Last, Suffix) 13. Mother's Name Prior to First MarNage (First, Middle, Last) Father's Name (First 12 , . Jack Wa e Kaltenbau h Wanda E. Henry 14b. Relationship to Decedent 14c. Informant's Malting Address (Street and Number, City, State, Zip Code) ' s Name 14a. In}ormant Jackie E. Kaltenbau Brother 24 E_ Main St_, Newviller PA 17241 ~ _ ~ ......................................................... ...Pa..................................~ Igf In t1eM : l ec_.or, one .. ...... ... ... ... ...... ............a: P, ace...°.....eat... 4..... ..Y. ...... .... .. ........ ... ..... If Death Occurred Somewhere Other Than a Hospital: CY~HOSplce Facility t~ Deeedent'S Home _ I : f Death Occurred In a Hospita Room/Outpatient Dead on Arrlvai j Nursing Home/long-Term Care Facility Other (Specify) Emargen 156. Facility Name (If not Institution, give street and number' lSC. City or Town, State, d Z{p Cod! lSd. County of Death aciberland Cl Carlisle Regional Medical Center . Carlisle. PA Method o1 DlSposltion [~ Burial Creme[ion 16a 16b. Date of Dlspositlon 16c. Piece of DlsposlHOn (Name of cemetery, crematory, or other places) . p Remgyal frgm st.te O D°^atl°^ 5/1 5/201 2 G1.miberland Valley MaTlorial Gardens Other (Specify) 16d. Location of Disposition (City or Town, Sta[a, and ZIp) in f Interment 17b. License Number 17s. Signature of Fune Service Licensee or eO FD 012633 L Carlisle PA - C 17e. Name and Complete Address of Funeral Facility PA 1 701 3 E)win Brothers Funeral Hcme, =nc_, 630 S. Hanover St., Carlisle, ~ cedent's Education -Check the box [hat best describes She 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to indicate what 16 D ~ . e highest degree or level of school completed st the time of death. box that best describes whether the decedent the decedent considered himself or herself to be. K orean ^Bth grade or lass Is Spenlsh/Hispanic/Latln°. Check the "NO" ~Whlte ~ box If decedent is not Spanish/Hlspanlc/Latino. Q Black or African American ~ Vietnamese ~ No diploma, 9th - 12th grade Q High school graduate or GED completed gFo, not Spanish/Hispanic/Latino ~ American Indian or Alaska NafNe ~ Other Asian i H ll ve awa sn ~ Some college credit, but no degree ~ Ves, Mexican, Mexican Amencan, Chicano Q Asian Indian Q Nat ~ Chinese ~ Guamanian or Chamorro Ri can ~ Associate degrees (e.g. AA, AS) Q Yes, Puerto Guban Q FIIIPino 0 Samoan ~ Q Ves , Q Bachelor's degree (e.g. BA, AB, BS) MEng, MEd, MSW, MBA) O Yes, other Spanish/Hlspanlc/Latino ~ Japanese O Other Pacific Islander MS MA ree (e g r's de Q M t , , . . g as e ~ Oddorate (e.g. PhD, fd D) or Professional degree (Specify) ~ Other (Specfy) e. . MD DDS DVM LLB JD cedent's Single Race Self-Designation -Check ONLY ONE to Indica[e what [he decedent considered himself or herself to be- 22a. Decedent's Usual Occupation - Indleat! type of work 21 D . e Samoan done during most of working Ilfe. DO NOT USE RETIRED. s! Q Other Pacific Islander McCharllC Q BlBlack or Atrican American Q Korean ' t Know/Not Sure Q American Indian or Alaska Native Q Vietnamese Q Don ~ Refused 22b. Kind of Business/Industry i an 0 Asian Indian ~ Other As if y) Q Chinese Q Na[IVe Hawallsn ~ Other (Spec Ku-lnay Shoe Corp. Ch emorrq ~ Filipino ~ Guamanfan or MS MUST BE COM ETED 23a. Date Pronounce Dea Mo Day r 23 .Signature of arson Pronouncing Death Only w en app Ica le 23c. Ucenae Num er BY PERSON WNO PRONOUNCES OR ~ / ry~ ~l CERTIFIES DEATN M 23d. Date Signe (MO/Day/Yr) 24. Time of Death i ; m 25. Was Medical Examiner or Coroner Contacted? Q Ves ~ No S CAUSE OF DEATH Approximate 26. Part 1. Enter the chain of events--diseases, Injuries, or complications-that directly Caused the death. DO NOT enter terminal events such as cardiac arrest. ~ Interval: i Onset to Death a l li If dd ddl l ry ona nes necess a t respiratory arrest, or ventricular flbrlllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne- A IMMEDIATE CAUSE ------------> a. A TnL E '1 E~"P \i2 A~O~~ ~A\L\1['1 } (Final disease or condition Due to (or as a consequence of): i resulting in death) e F=tIC Ice wit A 'P[ ° ` ~P\ RAT \[7 t.) b, R Sequentially list condlHOns, Due t° (or as a consequence of): if any, leading to the cause } listed on Tine a. Enter the < Due to (or as a <°nse qua^<! °fl= S UNDERLYING GUSE air (disease or Injury that F eG Initiated the events resulting d• Du! to (or as a Coosa in death) LAST. quenee of): °- l t Ib tl to death but not resulting in the underlying cause given In Part I 27. Was an autopsy performed? di t 26. Part 11. Enter ocher 1 Ifl a t \ ~ V C+`C1~Z 1 GV~G'R. 'RC~P[DC17IC Yes No + ~ ~' C ' . . !~ ~ \b `r ~~G\~ O W~tT \A1 ~ 26. Were autopsy findings available . • TR hGT t U p GGT• V !J to complete the cause of death? V fiTi V ~ . [i \ , Yes No 30. Dld Tobacco Usa Contribute to Death? 31. Manner of Death 29. If Female: Not pregnant within past year Q Yes O Probably .~ Natural Q Homicide ident ~ Pending investigation A ' ~ Pregnant at time v7 death nt within 42 days of death b .g N° O Unk^own cc ~ 0 Sulclde Q Could not b! determined ~ ut pregna ~ Not pregnant, but pregnant 43 days Lo 1 year before death ~ Not pregnant 32. Date of Injury (MO/Day/Yr) (Spell Monih) ~ , 0 Unknown if pregnant within the past year 33. Time of Injury 34. Plac! of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, Clty, State, 21p Code) 36- Injury at Work 37- If Transporta[lon Injury, Specify: 38. Describe How Injury Occurred: Q Ves ~ Driver/Operator O Pedestrian ~ No ~ Passenger ~ Other (Specify) 39a. Certifier (Check only one): Certifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated ® nner stated d h . e cause(s) an ma ~ Pronouncing 8: Certifying physician -TO the best of my knowledge, death occurred at the time, date, and place, and due to t andplace, and due to the cause(s) and manner stated date th occurred at the time i i d , , n on, ea Q Medical Examiner/Coroner - On the basis of examination, and/or investigation, In my op Title of certifier: ~~ ~ License Number: r'~ \7 A'rt O ~ 24 Signature of certifier: Address and 21p Code of Person Completing Cause of Death (Item 26) 39c. Date Signed (MO/Day/Yr) Name 396 , . VA0.T~ Qs~):t L\,\-E t1~0\c.41 Rc--~vt..c L GEwl t'E S / / l~ ~ 41. Registrars ature 42. Registrar 1 e Date Mo Day r 40. Registrar a (strict Num er to ota at-a.c0 43. Amendments - Dlspositlon Permit No. O ~~O~c~ ~ REV 07/2011 LAST WILL AND TESTAMENT I, CARSON W. KALTENBAUGH, of the Borough of Carlisle, Cumberland County, Pennsylvania, being of sound mind, disposing memory and full legal age, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils heretofore made by me. ONE: I direct my Executor to pay all of my debts, funeral and administrative expenses as soon as c nient after my decease. Furthermore, I direct that all state, inheritance, succession and other death taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property composing of my gross estate for death tax purposes, whether or not such property passes under this Will, shall be paid by the Executor from my estate, and that none of the aforesaid taxes shall be prorated among those persons named herein or otherwise beneficiaries hereunder. TWO: My Executor may, at his discretion, compromise claims, borrow money, retain property for such length of time as he may deem proper; lease and sell property for such prices, on such terms, at public or private sales, as he may deem proper; and invest estate property and income without restriction to legal investments unless otherwise provided hereunder. THREE: I authorize and empower my Executor to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could do if living. My Executor is authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said Executor. FOUR: I give, devise and bequeath all of my estate of every nature and wherever situate my sister, ROXIE G. BITTINGER, and to my brother, JACKIE A. KALTENBAUGH, share and share alike, per stirpes. FIVE: I nominate and appoint JACKIE A. KALTENBAUGH to be the Executor of this my Last Will and Testament. SIX: No person(s) shall benefit hereunder unless such beneficiary shall survive me by sixty (60) days. SEVEN: No Executor acting hereunder shall be required to post bond or enter security in this or any other jurisdiction. 2 EIGHT: No beneficiary may assign, anticipate or pledge his or her interest in any income or principal held or distributable hereunder, and no beneficiary's creditors may levy, attach or otherwise reach any such interest. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 12`" day of April 2012. ~; { !~ t ~~ ~ ` S (SEAL) CARSON W. KALTENBAUGH Signed, sealed, published and declared by the above-named Testator, as and for his Last Will and Testament, in our presence, who, at his request, in his presence and in the presence of each other have hereunto set our names as subscribing witnesses. 3 ACKNOWLEDGMENT AND AFFIDAVIT WE, CARSON W. KALTENBAUGH, KAREN S. NOEL and SHARON L. SCHWALM, the Testator and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and that he had signed willingly, and that he executed it as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as a witness and that to the best of their knowledge the Testator was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. "Vt/ `~ r Il a~ t , ~~c~~~t ILL (~ c C~#RSON W. L ENBAUGH REN S. NOEL ~~ 1~~/~'~~~Q SHARON L. SCHWALM COMMONWEALTH OF PENNSYLVANIA . SS: COUNTY OF CUMBERLAND . Subscribed, sworn to and acknowledged before me by CARSON W. KALTENBAUGH, the Testator herein, and subscribed and sworn to before me by KAREN S. NOEL and SHARON L. SCHWALM, witnesses, this 12th day of Apri12012. ~ l Notary r~NwEALTH OF PENNSriVAl1 Notarial Seal Marcus A. MdCnight III, Notary Public Carlisle Boro, Cumberland County My Commission 6rplres Oct, 10, 2013 4 .._... , ®I Life Insurance Program rrom May 22, 2012 Jackie Kaltenbaugh 9 E. Big Spring Ave Apt 1 Newville PA 17241 Insured: Emmett D. Kaltenbaugh Contract #: A2335956 Deaz Mr. Kaltenbaugh: New York Llfe Insurance Company HARP Operations Claims Service P.O. Box 30713 Tampa, FL 33630-3713 1-800-695-5165 Please accept our condolences on your recent loss. We understand this is a difficult time for you and your family. As you may know, the beneficiary of this Contract is Carson Kaltenbau the beneficiary is deceased, the benefit is now payable to Carson Kaltenbau h's estate. Therefore, please have the enclosed claim form completed by the executor of the estate and return it along with a copy of the executorship papers and a certified death certificate for the insured and the beneficiary. Once these requirements have been received in my office, this claim will have my immediate attention. If an estate will not be established, please have the enclosed Survivorshi Affidavit completed and returned with a separate claim form from the applicab e survivor(s) and the death certificate. If you have any questions, please contact us at 1-800-695-5165, between the hours of Sam to Spm Eastern Standard Time Monday through Friday. Sincerely, C'.eadm~ Se~w,ice New York Life/AARp Life Insurance Program ~Ic~~u~ ~~ux% FM: CL-FNCOVER ® Life Insurance ~p~m {~,,, Mail to: 1 PO Box 30713 Tompa FL 33630-3713 Claim Form Please type or print legibly Insurance Contract Number(s): ~ Z ~~~ 1 •. ~ •~ ~ ~ Name of nf{,-~ Deceased ~ i p ~ l Nickname or d l.M ~ l .. ,1 l.. Mai en Name Birthdate of ~ ~ ~ ~ Deceased: I I ~ ~~ Deceased's Date of Death: ,-- ~ ~ ~) ~ I Manner of Death: ya'1 Natural j'°"' ^ Unknown ^ Acadent' ^ Suiade' ^ Homiade' ^ Other ' Please attat~ ies of lice and coroner's r rt and a relevant news articles. ~ ~ Beneficiary ~~ Name: I h,~ 1.~~~ /, (~ ~ V ~;l,Jl.~ 5 ~ ,V/ ~1 ~~,.~ . < 1 \lJ~ ~ ~ Relationship to fhe Deceased: ^ Spouse ^ Child ^ Grandchild _ ^ Parent Other Birthdate of Benefiaary: ---'-"'-_"__ Home ~ ~ ^ ~ f j n ^ ~~ Phone / i l.(/ 1.// i G E-Mail Address of Benefiaary: Alternate Phone Mailing Address of Benefiaary: U. ~] p~/ / <`. ~ - ~ ~lM t (~ l.r ~C:%~ l ~i.~t ^ Individual Beneficiary: If you request benefits to be paid to the funeral home, a copy of the'assignment is required. ~ ~ ~ n. ^ Minors: tf a legal guardian of the child's estate/property has been appointed by the court, he or she must sign on behalf of the minor child and submit a copy of the guardianship papers. If signing under the UTMA/UGMA, please sign your name and indicate your relationship (father, mother, etc) to the minor child as "Custodian of (name of child) under the (name of resident state) UTMA/UGMA. Corporation: Claim Form must be signed by Corporate Officer(s) and must indicate the title by which you are authorized to act on behalf of the company. Estate: Be sure to submit a copy of the certified appointment papers and provide Estate Tax ID below. Claim Form must be signed by an Estate Representative. Trust: A copy of the Title, Signature and Notary pages of the Trust are required, including the pages showing the Trustee and Successor Trustee. Provide Trust Tax ID below. Claim Form must be signed by a named Trustee. ^ Collateral Assignee: A copy of the assignee's statement of interest must be provided. Claim Form must be signed by the assignee or their authorized representative. at • Enter your Socal Security ~! Social Enter Taxpayer Identification ~' Taxpayer ... ~% / ~ /~ I Number if you are an Security - j Number if claimi benefits as an Identification ~ ~~ - , individual beneficiary Number ! Estate, Trust or Corporation Number °~"4' ~.~' 4 °!'~@ ~~,~*, e~i "'7aa ,+~vk"y,,f~" ,3!' ,~^a. "~ ~cc~~s~' ~~..,n r ~ yan °;` ~ ~.,. ~ .,: .,~ -:~a,.1,dxk'vl~~_i~~:y~a~•~s~~:z,?;~dl`7uatne~.3raiesd~sar~=' ~'~ '~ §ll.r...ri~..n'SI~F •~~~..n_ .~.~..rio'"t,L+.~t:Y+R`~~~5s~tt:a'S~~'i'd'u~.e"'?i,~.c~.;ia.~x:surstia.7 Check o~ if statement below applies. ^ I have been notified by the Internal Revenue Service that I am subject to back-up withholding as a result of failure to report all interest or dividends. I have read and understand the Fraud Statement that is a liable to the state in which I reside. New York Residents: An PP y person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. • I certify, under penalty of perjury, that the Social Security or Taxpayer Identification Number and Back-up Withholding status information in Section 3 are correct. l also certify that I am a U.S. person, including a U.S. resident alien (non-US person must complete form W&BEN). • The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid back-up withholding. Signature 6-s ~/a Date (NDCF2012v03a)