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HomeMy WebLinkAbout10-05-12Reset PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF Cumberland COUNTY, PENNSYLVANIA Petitioner(s) 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 respectfully request(s) the grant of Letters in the appropriate form: Decedent's Information 2 ~' ~ 2 ~~ U Name: Katherine Lee Clarkson File No: a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: 270-44-8587 Date of Death: 9/24/12 Age at death: 24 Decedent was domiciled at death in Cumberland Cotmty, pp (ware) with his/her last principal residence at 601 Yorkshire Drive Carlisle 17013 Boroueh of Carlisle Cumberland Street address, Post Office and Zip Code City, Township or Borough County Decedent died at Carlisle Resional Medical Center Borou¢h of Carlisle Cumberland PA Street address, Post Office and Zip Code City, Township or Borough County State Estimate of value of decedent's property at death: If domiciled in Pennsylvania ............................ All personal property $ 70,000.00 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 Pennsylvania ......................................................... $ 225,000.00 TOTAL ESTIMATED VALUE.... $ 295 000.00 Real estate in Pennsylvania situated at: 601 Yorkshire Drive Carlisle 17013 Borough of Carlisle Cumberland (Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough County A. Petition for Probate and Grant of Letters Testamentary Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated and Codicil(s) thereto dated __ State relevant circumstances (e.g. renunciation, death of executor, etc.) Except as follows: after the execution ofthe 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(g), and did not have a child born or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. NO EXCEPTIONS ~ EXCEPTIONS B. Petition for Grant of Letters of Administration (If applicable) dbn c. t. a., d.b.n., d. b. n. c. t. a., pendente life, durance absentia, durance minoritate If Administration, c.t.a. or d.b.n.c.~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(g) and was neither the victim of a killing nor ever adjudicated an incapacitated person. 0 NO EXCEPTIONS ~ EXCEPTIONS Petitioner(s), after a proper search has/have ascertained that Decedent left no W it l and was survived by the following spouse (if any) and heirs (attach additional sheets, if'necessary): Name Relationshi Address William H Clarkson Brother 3341 US Highway 36 East `~ New Castle IN 47362 "~ . ~ ~ . ,. ,~ ~ . ~ cr% ~ `.- C. j..;.. L -' - > ?~ rr~ .} ~ "Ti ~.n Form RW-02 reg. to~l~izoll Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF Cumberland } } SS: } RFGO~~~~u~~~~ '' • E DF ~Tr r' (``' t 212 OCT -S' AM 9= 15 Petitioner(s) Printed Name Petitioner(s) Printed Address -, William H. Clarkson r i.'... 3341 US Hi hwa 36 East New Castle IN 47362~f'~V (.,~~ ~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 Petitioner(s) and that, as Personal Representative(s) of ~, Dpce~{'t~the Peti i e wel nd truly administer the Sworn to or firmed a snb cribed before J~y~-~~/ me thi , day of s~~ knowledge and belief e actor ing t law. BOND Required: Q YES Q NO FEES: Letters ...................... $ (~ )Short Certificate(s)..... . ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other ......•. To the Register of Wills: Please enter my appearance by my signature below: Attorney Signat Printed Named John C Oszustowicz Supreme Court ', ID Number: 37076 Firm Name: Law Office of John C Oszust~wicz Address: 104 S Hanover St. Carlisle, PA 17013 ........ _ Phone: Automation Fee ............... ~- Fax: JCS Fee . .................... • ~ Email: TOTAL ..................... $ .AA'' 717-243-7347 DECREE OF THE REGISTER Estate of Katherine Lee Clarkson File No: a/k/a: AND NOW, ~~ ( ~ ~ f7-~-, in consideration of tl~e foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters are hereby granted to in the above estate a d (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. egister of Wills •~ ~ FormRW-01 rev. 10/!1/20/l ~ Page 2 oft "~ f -- LOCgR~r,~i$~p-R'S CERTIFICATION OF DEATH WARI~~~>~C~i~~e4~ll~ duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 ~~~2 ~~~ -5 AM 9~ ~ J ,L.t:f':'~ ; OFiPH~N"S COURT (~1MBERlAND CO., PA P 18882527 Certification Number Type/Print In Per ant it ~_ This is to certify that the information here given is cojrectly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital 5 Records Office for permanent filing. L~ve ~~ n SE,~' 2 5/2012 Lc~)cal Registrar Date Issued COMMONWEALTH OF PENNSYLVANIA _ DEPARTMENT OF HEALTH ~ VITAL RECORDS l~C QT~Cgf"ATC AG s1CATu - - - - -- - - - - State F Ie Number: 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Yr) (Spell Mo) Katherine Lee Clarkson emale 270-44-8587 Sapteznber 24, 2012 Sa. Age-Last Birthday (Yrs) 6b. Under 1 Vear Sc. Under 1 Ds 6. Date of Birth (MO/Day/Year) (Spell Month) 7a. Birthplace (City and State or Foreign Cou ntryj 64 Mpncna oaya Hpura Mlnutea S@pt 25 , 1947 Ann ArbO MS 7b. Birthplace (cqun > Was anew Ha. Residence (State or Foreign Country) Bb. Residence (Street and Number -Include Apt No.) Bc. Did Decedent Uye in a Township? P 601 Yorkshire Dr . OYes decedent lived in , Bd. Residence (County) twp. Ctamberland He. Residence (Zip Code) 1 l~NO, decedent IlYad within limits of Carlisle city/boro. 9. Ever In US Armed Forces? 10. Marital Sbtus at Tlme of Death 0 Married Q Widowed 11. Surviving Spouse's Name (If wife glue name rior t fi , p o rst marriage) ~ Ves [~ No Q Unknown ~ Divorced ~ Never Married ~ Unknow 12. Father's Name (First, Middle, Last, Suffix) 13 Mot(~er's Namepranteo F t Morris (First, Middle, last) Henry H_ Clarkson mar ra al ~aver~ 14a. Informant's Name 14b. Relationship to Decedent 14 Nf a t' M II g Address (S Numb CI Stat 1 Code William H Clarkson brother ~ ~~ U A ~l~ `~g`a~ ew t~ ~ G _ 3 }N 47362 S ghway . N as~ ef 1 ... ec - ~ ... If Oeath Occurred In a Hospital: ~~ In dent Pa ~ , , ec.. on.y one .............................. curved Som ere Ocher Than a Hos Ital- ~~~~~~ ~'~~~~~~~~~"""'""'""""' - --"'^""-'-'-^•^• ;H Death Oc ewh p ~( Hosplc! Facility ~~ O l ' H Emergency Room/Outpatient Q Dead on Arrlyal iSb l ecer ent s ome Nursing Home/Long-Term Care Facility Other (Specify) • ~ . Faci it?. Name (If not Institution, give street and number) Carlisle Regional Medical Center lSC. City or Town, State d 21 de 15d. pun f D th Carlisle, f~A lp'/~015 ~um~erYand ~, 16a. Method of Disposition ~ Burial Cremation O Remp„al,rpmstate p Dgnaclon 36b. Dale of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other lace) S t 26 ocn (speciryl ep , 201 Hoffman-Roth Ellneral Home & Crematory 16d. [ 7 f Ispo itl (CI State, and 21p) ~r~~s~e f ;3A ~c~a~~~ 17a. Signatur of Funeral Service Licens tfEharge of Interment 17b. License Number ~ 138504 17c. Name and Complete Address of Funeral Facility a .~ e & Cremato 219 North Hanover Street, Carlisle, PA 17013 1H D d ' ~ . ece ent s Education -Check the box that best describes the 19. Decedent of Hispanic Origin - Gheck the 20. Decedent's Race -Check ONE OR MORE races to Indicate what highest degree or level of school com leted t th ti f d p a e me o eath. box that bert describes whether the decedent the decedent considered himself or herself to be. ~ Hth grade or less Is Spanish/Hlspanic/Latino. Check the "No" ~ Whlfe ~ Korean Q No diploma, 9th - 12th grade box If decedent is not 5 panish/Hispanic/Latino. ~ Black or African American ~ Vietnamese Q H g sc o l rad uate or GED completed ~ No not Spanish/His anic/Lati o m o e e e , p no 0 American Indian or Alaska Native ~ Other Asian ~ 5 a c II g r dlt, but no degree ~ Ves, Mexican, Mexican American Chicano Q Asian Indi , an Q Native Hawaiian Q Associate degree (a.g. AA, AS) ~ Yes, Puerto Rican Q Chinese ' QS Bachelor ~ Guamanian or Chamorro s degree (e.g. BA, AB, BS) Q yes, Cuban ' l ~ Master s degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Yes, other Spanish/Hispanic/Latino 0 la panese ~ O h a t er Paciflc Islander ~ Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) ~ Other (Specify) . MD ODS OVM LLB JD 21. D cedent's Single Race Self-Designation -Check ONLY ONE to indicate what the decedent considered hlmseH or herself to be. 22a. Decedent's Usual Occupatlo -Indicate type of work [White ~ J p ese Q Samoan ^ o ge done during most of workln Iife DO NOT USE RETIRED. [?Black or African American ~ K ~ Other Pacific Islander g Q American Indian or Alaska Native ~ Vietnamese Q Don't Know/Not Sure F..XeCI]t1Ve Director Asian Indian ~ Other Asian ~ Refused 22b. Kind of Business/Industry ~ Chinese ~ Nativ H ii e awa an Q Other (Specify) Q Filipino O GuemanlanorChamorro Non-Profit Organization ITEM 2Sa - 2 MV9T OE CO PLETE 2 a. Date Pr Mo Day r) 2 51 ature o Person Pronouncing Death On y w e BY PERSON WNO PRONOUNCES OR ©^ .y uji e ~ n appiica 23c. LICMSe Num e r CERTIFIES DEATN t~ C.7 a ~~ ~ ~ 23d. Date 51 ed (My/Day/Vr) 24. Time pf Oeath f/ ~~C ~ / / 25. Was Medical Examiner or Coro er Contacted? ~ Yes No n r FAUSE OF DEATH Approximate 26. Part 1. Enter the chain of events--diseases, injuries, or complications--that dlrecTly caused the death. DO NOT enter terminal events such as cardi ac arrest Interval: respiratory arras[, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lin ) If es necessary Onset to Death /tom __ IMMEDIATE CAUSE ~~ ~~ " / / G ~ ~. ___ ________> a. / -- / ~ ; (Final disease or condition a ~ (~/QT Due to (or as a consequence of): resulting in death) i ~-n j ~ " Se tl ll li b ~ sC / ~ / ` C ^r ~~ quen s y st conditions, Due r as a conseq enu ce of): fO ~- If any, leading to the cause j listed on Ilne a. Enter the V NOERLYING GUSE Due to (o as a consequence oi): (disease or Inj ry that F Initiated the events resulting d. i d P4 n eath) LAST. Oue to (or as a consequence ot): 26. P K 11. Ent Lthey s~ n 1 C t h but not resultln In the underl~ Q c ~n In par)) _ I ' 27, Was an autopsy ps~rf9cmedT ~GL T~' /t'. v l CV7 °'+° . rte.. '/Y' 3C/^7C7~ Y ° ~ ate,' C es L f No ~-C G~ "~E ~~ ~= ~i1-«-Ge iC ~. ~ ~~.I~~ zH. were a~:opa fimm~ s ll bl Y g ava aa e 29. If Fe le: to complete the cause a th7 ~ V es No ~ 30. Id Tobacco Uae Contribute to DeathT [q Not pregnant within past year 31. er o Death ~ Yes Q Probabl ~ y Natural 0 Homicide ~ Pregnant at time of death Cf No ~~Unknown . I- Q Not pregnant, but pregnant within 42 days of death Q Accident 0 Pending Inyastigatlon ~ No[ pregnant, but pregnant 43 days to 1 year before death 32. Oate of Injury (MO/Oa /Vr 5 Q Suicide ~ Could not be determined Y ) ( Pell Month) 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, City, State, Zlp Code) 36. Injury at Work 37. If Transportation Injury, Specify: 3B. Describe How Injury Occurred: 0 Ves 0 Driver/Operator 0 Pedestrian ~ No Q Passenger ~ Other (Specify) 39a. Certifier (Check only one): Q living physician - To the best of my knowledge, death occurred due to the cause(s) end manner stated Q Pr i 8 onounc ng . Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the c se(s) and manner stated Medical Examiner/Coroner - On the b i f as s o examination, and/or investlgatlon, in my opinion, deat h c d at the time, date, and place, and due to the cause(s) a d mann r stated c / J~f /mo Signature of certlfler~ - Title of certifier: ~ % /' / J License Number: ~~~L ~~~~p 396. Name, Address and Zip Code of Person Completing Cause of Death (Item 26) / L B9c. Date Signed (MO/Day/Vr) ~~ ~~ /T l C ~ 40. Registrta/ ~rG~j1s Dis[rlet um er 41. Reglstra ture ! 2. Re Istrar FI a Date (MO Day r - ` 43. Amendme\ts ~ ~~ ~~ (,~ Disposition Perm It NO. C )-I.q~Q~~ H105-143 REV 07/2011