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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
Name: KATHERINE COLLINS COX Flle NO: i~~ ~ " ~~~, _ /~
a/k/a: (Assigned by Register)
a/kla:
a/k/a: Social Security No: s7eao7oaa
Date of Death: December 1a, zolz Age at death: es
Decedent was domiciled at death in CUMBERLAND County, PA (State) with hislher last
principal residence at
Street address, Pnst Office and Zip Code City,'rowashlp or Borough County
Decedent died 8t HARRISBURG HOSPITAL, 111 SOUTH FRONT STREET. HARRISBURG, DAUPHIN COUNTY, PA 171D1
Street address, Post Office and Zip Code City, Township or Burough County State
Estimate of value of decedent's property at death:
Ijdomiciled in Pennsylvania ............................ All personal property $ 7(L ,~ ~ ~
If not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $
Ijnot domiciled in Pennsylvania ........................ Personal property in County $
Value of real estate in Pennsylvania ......................................................... $_
TOTAL ESTIMATED VALUE.... $ 7 E D (10.00
Real estate in Pennsylvania situated at
(Anach additional sheets, ifnecessoryJ Street address, Pnst OfBCe and Zip Code CiTy, Township or Boroogh Coanty
® A. Petition for Probate and Grant of Letters Testamentary
Petitioner(s) aver(s) he/she/they is/are [he Executor(s) named in the last Will of the Decedent, dated APRIL 14, 2009 and Codicil(s)
thereto dated
State relevant circumstances (eg. renunciadon, death ojezecataq etc.)
Exceptasfollows: after theexei;utionoftheinstrument(s)olleredforprobateDecedenldidnotmarry, was not divorced, wasno[apartytoapending
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 bom or
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
O NO EXCEP'P10NS O EXCEPTIONS ,
^ B. Petition for Grant of Letters of Administration (If applicable)
c. t. a., d. b. n., d. h. n. c. t. a., pendentelite, duranteabsentia, rluranteminoritate
If Administration, e.t.a or db.n.c.ta, 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 ofa killing nor ever adjudicated an incapacitated person.
O NO EXCEPTIONS Q EXCEPTIONS
r~~
Petitioner(s), after a proper search has/hava ascertained that Decedent left no Will and was survived by the followit~6pouse (ifany)~ heirs (att~
additiunal sheets, if~necessary): C "~' ~ M
~o ,~ rn~
Name Re-ationshi Addr ~~ ~ :~7
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Form RW-02 rev_ 1011112011
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Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SS:
Official Usc Only
Petitioner(s) Panted Name Petitioner(s) Printed Addrass
DAVID C COX 509 JOYCE ROAD, CAMP HILL, PA 17011
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 Ihat, as Personal Representative(s) oCthe Dee~cjent, the Petitiottci(s) y~11 tape!! and truly zdminister the estate according to law.
d ribed before ~~/ ta~ ~ ~ Date 1 L -.Zit - / .Z
Swont to or }{firmedaud subsc
~JK /~~ _- -_--
me this ~ y ~ ~ ; ' ; J -- Date _
By. ~. ~ _ - Date
~~r the Fegisler ~: ~ /~ ~ _ _ DaLC
BONU Required: e"YES Q NO
FEES:
Letters _ ....... ~ $ -
( ~; )ShortCertifictte(s)_ .... {_.
I 1 Renunciation(s)._ ..... .
1 )Codicil(s) ... . .. . . .... .
--_ --
_---
Bond ........................
Commission .................. -._
Other ........
Automation Fec . .... ... . . .. . ~~ ~~
...~.__.
JCS Fee . ..................
TOTAL ............ ........ b e ~ ' - ~ _~.t31~(F
_ ~~
Attorney Signature
Printed Name:
Supreme Court
ID Number:
rims Namc: _
Addree.r: _..
Phone
Fa ~ ~ _.----_ _. - -
[mail:
Tn 1he Register ~f Wills:
Please enter my appearance by my signature below:
~J ~~
DECRF,E OF THE REGISTER
Estate of KATHERINE COLLINS COX Filc No: ,, ~ - ~
alk/a:
AND NOW, , ~' '-: , in consideration of the foregoing Petition,
satisfactory proof having been presented before me. IT iS DECREED that 4etters ,' ''ir:r ~ ' y`
arc hereby granted to ~_ J
._.
in the above estate and (if applica6lc) that
the instrument(s) dated s~'~
described in the Petition be admitted to probate and tiled of record as the ~kast Will (any Codicil(s)) of Decedent
~ J
k,
~' - / .~
Nc Ptutcr of Wilts i
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~~~,Ja ew-oz J~~,~. roiuiao~r Page 2 of 2
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P 19 0 6~~ 2 6 pREHANS' C{~: ~ T ~~ DEC ~ 8 2x12
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'I ~ _''' CUMBERLAND ~;n-t'~`L` -
Type/Print In COMMONWEALTH OF PENNSVLVgNIA pEPARTMENT OF HEALTH VITAL RECORDS
Perna°'°° C-F RTIFI('ATF AF f1FATN
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1. DGGedenY'S Legal Nam¢ (First, Mltltlle, Laat, Suffix) 2- 5¢z 3. Social Sacu rlN Number- '4. Date of D¢atM1 (MO/DaY(Y[) (SD¢II Mn)
Katherine Collins Cox 'Semale 578-30-7044 .December 14, 2012
a_ 4ga-Las[ Birthtlay (Yes) 56. Under 1 Vear Sc. Under 1 Da 6. Data u( girth IMO/Oay/Year) (Spell MontM1) ]a_ Rirt M1place (City and State ur Foreign CoVntry)
93 MOniM1Z Oays Houtz Minut(e5
September 19, 1919 >M1. RIrthPlage tGnpntY)
Hami
Ba. Residence (State or Foral Count R_ b. Residence (Street and Number -
8n [y) InCIUde Ap[ No.) 8c. Old D¢Ced GnY Llva In a Towns M1lp~
4905 Tr indle Rd- vas, detea¢n[nyea .n T7a t++D~n. Twn.
Bd. Rasltl¢nc¢ (COUmy)
Cumberland 8e. Resitlenc¢ (ZIp Code). QNO, decedent IIV¢tl wl[M1in Ilml[5 of clryfboro.
9. Evef In US firmed Forcesi ]O Marital Status at Tlme of Death Q MaYfl¢d ~L Witlowetl 11_ Sarrviving Spouse's Namc (I(wlfe, give name Helot to Flrt[ marrlag¢I
~Yas =]Cryo Unknown ODIVOfred QNevef Married ~Unknow
1J. Fatltar'z Name (First, Mlddla,.La St, Suffix) 13. MOtM1er's Nam@ Pflor t0 First Marriage (F IrSt. Middle, Lasc)
arold Wakelam Treasure Collins Am Olive Danlcs
14a. Informant's Name 14b. Relation5f11p to DeceJeni 14c Intorrna Ht's Ma111nH Atldfess (Street antl Number, City, State, ZIp Lodel
g David C. Cox Son 509 Soyce Rd. Camp Hi11, PA 17011
G ._ ............................__...................... ............._......_.,............... ........1sa.Pace o--Deat.._c ec on
y. one ......
...
¢ .
IY Death Occurred In a HOSpI[al: ~Inpa[lent .
...
....._. _ _ _
li Death Oc[urrecl SomewherC Othef TM1an a Hospital: Q-Husplce Facility --~- ~}-DGGeaent's Home ~~ ~-~~-~
° 0 Emergency Poom/OUtpatlent Q Dead on grflVal
- Nursing HOm¢/Long-Term Care Facility Other [Speclry)
15b. Fac11i[y Name (If not InStltution. Hlva sheet antl number, _
SSC. City or TCwn, State-and Zlp Code 15tl. County of DaatM1
Harrisburg Hospital Harrisburg, PA 17101 Dauphin
m 16a. MathOd of Dlaposl[lon 0 Burial ~Q CrcmatlOn
QR¢movel from State QDnnatlOn 16b. De[e f Dizpusltlon 16¢. Place Of DISp OSIt{on (Name or cemetery, crematory, or other place)
~D12
ESi D<M1er (sp¢clf) )ecem Br 1.( Evans Crematory
&
2 18d. location of Dlspositlun (City or Town, State, and ZIp) 1]a. Slgnatuf¢ of F vice LICenSCe Or Pnfson In CI[a rqe of Interment 1>b. License Number
$ Scllaef£erstown, PA 17088
3 O\2 1~
E 1]c. Name end Complete Atltlfess of Funeral Fecillty
g Parthremore Funeral Home & Cremation Services, -nc. 1303 Bridge. SC.NewCumberlandYA 17070
t8. Oac¢tlen['S Etlucatlon -Check <he box She[ best describes [M1e 19. Dnr.¢den[ of Hlsp9nic Origin -Chock the 20. Oecatlent's Ra[¢ - fM1eck ONE OR MORE races fo IndlcatC what
Yrlghesi dngrae or level Of scM1OOI cnmplatatl a[ the time of dratM1, box: [hat best dnscrlbaz wheth¢t Ch¢ decedent tYra dacetlrnt ronzltlered himself nr M1arself to be.
0 8th gfadG or lass l5 Spanish/Hizpanlc/La[In0_ Check tM1e "NO' Whl<a ~ Korean
Q Nn diploma, 9th 12tM1 grade box If d¢cetlGn[ Is noT Spanls M1/Hl9panlr/La[Ino. Q Black m African American ~ Vietnam GSe
~ Mlgh school graduate or GEO Gompletatd ~ No, no<SpanlsM1/Nlspa nlc/Latino Q gmer{can Intlian or Alaska Na[IVe Q Other Asian
Q Suma collage cretll[, but nu Jagree ~ VGS, Mezlcan, McXlcan American, CM1ica no Q Asian Indian ~ Na[IVr Hawaiian
0 AsaoclatG degree (e.q. qA, qSJ Q yes, Puerto Rican ~ Chmes¢ Q Gua manlen Or fFamorr0
® Bi¢M1elor's tlagren (¢_g. BA, qg, BSJ ~ Ves, Cuban Q Filipino ~ Samoan
Q Master's degree (a.g. MA, M5, MEng, MEtl. MSW, MBA) ~ V¢s, other Gpanlsh/Hizpanlc/Lotion Q Ja pan¢ss Q O[I[er paclllr Islander
O Do¢[pra[e (G.g. PM1D, FdD) or Professional d¢grae (Sp BClfy) _ Q Ocher (SpGrify)
. MD OOS DVM LLB ID
21. Dacndent's SInHI¢ Race Sal(-Dgzlgnatlon -Gh GGk ONLY ONE to 1naIGaC¢ wl[et tha decedent cOnslaerad M1lrnself or herself to 6P 22a. DecetlCnt's Usual Occupation -Indicate type o1 work
WM1lte Q la pan¢se Q Samoan pone Burin
H mOSt Of Wofking 11(e. DO NOT UiC RETIRED.
Rlack or q/rlcan AT¢rlran ~ Korean O Other Paclflc Islander
~Amarican luJian or Alaska Natlvc QVI¢tnamas¢ QDOIyt KnowJNOt Sure Physical E'dl1C8CiOnTe3CF1 E'r
~ Asian Intlian Q O[h¢r Asian ~ Refused ?26. Kind of Business/Industry
p chmese p Naeve Hawaaan p Dmer (spetlrY)- public Educ at Son
-
p Fluplno p Dnamamm~ or chamorrn
ITEMS 33a - 2 MUST BE COMPL ~ EO 23a. pace pronounce eatl (MO Day/Vr) 236. Signature of Prrsou pronounGing D¢a[ (Only wM1en applicab el 23<. UCCnse Nunrb¢r
BY PERSON WHO PRONOUNCES OR
CERTIFIES DEATH Y
~ Z f / ~ 2 q ~ Z,
` .~ ~ (J ~ ~ C
~
~-~ a,/
• t O (..i ~~ 6 S a c
23tl_ Dale Slgngd (Mo/Day/Yr)
24. Time u/ Oath 1
~
~lV Cl~-G_~\_J~ ,
( ]~ ) ~ Z4\Z, /' 3 N 25. Was Madl¢al Examiner or Coroner COntactedl
Q Y¢s
QrNo
CAUSE OF DEATH
Approximate
26. Part 1, En r tM1e h f --dl5ease5. InJud¢s, O mpllcatlOns--that directly Gausea the death- DO NOT enter terminal a nts 5 cM1 a ar Jiac a es[ InTCrval;
t
resplYetory err asC, or ventncVlar flbrillatron without showing tM1a ¢TlologY. 00 NOT 4BeREV1gTE. Enter n I na cause on a ec¢szarv s
n Y r~ a lie e Adtl addl[lonal linrs
lr n On ¢t to Death
~1 1 r
IMMEDIATE C4USE --- -a a.-__-~Cs.> ~P T~~.C:M~ ~~1
\\~1~ c
.
- ~~
(Final tllsaas¢ Or COndltlnn pus [o (O( a5 a GOns¢quenc6 of):
r¢sul[In81n JaatM1f
~
~ ( I
l .`~L
b.
l ~~ ~ z~
(- `
S
'
5¢quentlally Ils[ condl[IOns,
Due [
n
(of as a consequence of - T"~-
).
II env, leading tO tM1e c
e
listed on Ilne a. Enter LM1e
c.
UNDERLYING CAU6E Uue to (nr as a consCau Cn[e of):
(dlzaase Or Injury [hat
F {nlt{ated Tha ¢ Gnts rGSUlflntl d. _
In deetM1) LAST- Due t0 lOr az a consepucnc¢ of):
,y
a] 26. PatC 11. Enter otfiCrS ¢nlficam ontlltlp t Ib 1 [ dea(M1 but not razulting In Lhf underlying ca US¢ given In Part I 2J. Was an autopsy p¢rformetl)
~ Oyes
2a_Werea topsY findings aVallable
m in mple a tM1¢ c of death?
Lu
a
v Q Yes
Q No
29. If Female:
No[ pregnant within past year 3D. DId Tobacco Use Contribute to Death}
Q Ves Q Probably 31_ Manner Of Death
~--N-.rtur al Q Ilnmirid¢
~ Pregnant at time Of tleath No known
O ~n
(] Acclde nt Q Pentling Inveztiga[lon
m Q Not pregnant, but piegnan[ wlthln 42 days O( death Q Suicide p Cnulrl not b¢ dC[erminrd
Q Nnt pregnant, but piegnan[ 43 tlays to 1 Vear hnfore Beach
If 32. pate of InJu
rY lMO/Oay/Yr) (Spell MonfM1)
~ Unknown
Pregnant wlthln the past year 33. Time oT Injury
34. Place of Injury (e,g. Home: cOnsffucflnn site: fain: SCM1OOI) 35- Locdtion Ot Inlury (Street and Number, City, STa[e, ZIp Code)
i5. Inlury at Work 3'J. If Transportation Injury, Spaclfy: 3q. Describe Now Inlury Occurred.-
Ves Q D[IV¢r/Operator [~ P¢tlasirlan
0 No Q PassanRGr Q O<har (Specify)
39a_ Certifier (CM1eck Only una):
~ CS
rtlfying physlGian To tM1¢ bust of my knawl¢tlg¢, death occu tied tlue To [Me c use(s) and manner stated
O
1x)'9 oV ncing 6 Cnrtify'rng phYSltlan -TO the bas[ of my kn wladge, Jaa[h occurred at [M1e lima, d a, antl place, and due [o [he cause(s) antl manner s[atrd
~ p[Mical Examiner/Coroner - On [M1¢ basis Of examinatiOr~ and(or }nves<Igatlnn, In my oplnlo fp.~a F ccu ~.dJ a[ the limn., data,/j d place, and due to fF
sels) anJ man er Stated
u
~
V
~~(~/
>IBnatura Of rattlRar:_ 2 ~~ Title O(cartlfier I •
U t10 / `
y~cGnre NUmb_r' a _[
(
Q O
39b. Np m¢, Address antl Zlp Code of Persun Comple[Ing Cause p( D¢a[h (Item 26)
Wali
1
1 39c. Data Si tl (MO/Day/Vr)
n
Hanna 2-ID /
1
5• Front St. Harrisburg, PA 17101 ~
2/14/12
40. R¢HlStraY s Dlstrlct Numbef
~ 41. R¢gis[rar's Slgna ~ 42. ¢glstrar Flle Dale (MO/Oay r)
a2/ - ul ~ ~i~/~ ~~ ~~' ~ L
43. gm¢ndm¢n[s
ITEM ~ ~~` %Ti~}/IOL/~ G~~NKEG¢/!7 /2~%~sl>~Z~- ~'cLCi//S ~~
SHOULD RL'AD
Dlspo[Ition permit NO. O() 1 S~FZZ M105-143
REV O]/JO11
LAST WILL AND TESTAMENT
OF
~-.e
KATHERINE C. COX ~ :~; ~o ~
-° ~ r~~
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F_, ;_
I, KATHERINE C. COX, now domiciled in Cumberland County, Pennsylvahi~, decl~X~
~.,, vy _~
__, '-~~
this to be my Last Will and Testament. I revoke all other wills and codicils that I may have
previously made.
Article I
My just debts and expenses of my last illness, funeral, and administration of my estate
shall be paid by my Executor from the principal of my residuary estate as soon as practicable
after my death.
Article II
All inheritance, estate, and succession taxes (including interest and penalties thereon, but
not including any generation skipping tax) payable by reason of my death shall he paid out of
and be charged generally against the principal of my residuary estate without reimbursement
from any person. This provision is not a waiver of any right which my Executor has to claim
reimbursement for any such taxes which become payable as the result of any property over
which I have the power of appointment.
Article III
i give, devise and bequeath my tangible personal property to my husband, J.
FREDERIC COX, II. In the event J. FREDERIC COX, II predeceases me or fails to survive
me by thirty (30) days, then I give, devise and bequeath my tangible personal property in
accordance with any memorandum I have handwritten or signed, located with my will or with
my valuable papers and found within 30 days of the probate of my will. Gifts may only be to
persons wlio survive me or to organizations which exist at my death, and if there is a conflict, the
memorandum having the latest date shall govern. To the extent no such memorandum is found,
or all of my tangible personal property is not disposed of pursuant thereto, my tangible personal
property shall be added to my residuary estate and pass under Article IV hereof.
Article IV
All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever
situate, I give, devise and bequeath to my husband, J. FREDERIC COX, II, of Cumberland
County, Pennsylvania. In the event J. FREDERIC COX, II predeceases me or fails to survive
me by thirty (30) days, then I give, devise and bequeath all the rest, residue and remainder of my
estate, of whatsoever nature and wheresoever situate to my son, DAVID C. COX, of
Cumberland County, Pennsylvania, per stirpes.
Article V
1 nominate, constitute and appoint my husband, J. FREDERIC COX, II, as Executor of
my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any
reason whatsoever of my Executor, I nominate, constitute and appoint my son, DAVID C. COX,
as successor Executor of my Last Will and Testament. I direct that my Executor or successor
Executor be permitted to serve without bond. In addition to those powers granted by law, I grant
them power to distribute in cash or in kind, in like or in unlike shares, and to file any qualified
disclaimer I could have filed if living. My Executor or successor Executor shall receive
reasonable compensation for services rendered to my estate.
2
Article VI
In addition to the powers conferred by law, I authorize my Executor or successor
Executor, in his absolute discretion:
(a) to retain in the form received and to sell either at public or private sale, any real
estate or personal property except that which I specifically bequeath herein,
(b) to manage real estate,
(c) to invest and reinvest in all forms of property without being confined to legal
investments, and without regard to the principal of diversification,
(d) to exercise any option or right arising from the ownership of investments,
(e) to compromise claims without court approval and without consent of any
beneficiary,
(f) to file any federal income tax return for any year for which I have not filed such
return prior to my death,
(g) to make distributions in cash or in kind, or in both, and to determine the value of
any such property,
(h) to employ any attorney, investment advisor, or other agent deemed necessary by
my Executor or successor Executor; and to pay from my estate reasonable compensation for all
their services,
(i) to conduct alone or with others, any business in which I am engaged in, or have
an interest in at time of my death, and
3
(j) to receive reasonable compensation in accordance with their standard schedule of
fees in effect while their services are performed.
IN WITNESS WHEREOF, I, KATHERINE C. COX, hereby set my hand to this my
Last Will and Testament, on ~: ,r ti , 2009, at Harrisburg, Pennsylvania.
KATHERINE C. COX r
In our presence, the above-named KATHERINE C. COX signed this and declared this
to be her Last Will and Testament and now at her request, in her presence, and in the presence of
each other, we sign as witnesses.
Name
i.. ~'
~'1 'P
Address
2000 Lin~lestown Rd., Suite 202 Harrisburg PA 17110
2000 Linglestown Rd. Suite 202 Harrisburg~PA 17110
I, KATHERINE C. COX, Testatrix, who signed the foregoing instrument, having been
duly qualified according to law, acknowledge that I signed and executed this instrument as my
Will, and that I signed it willingly as my free and voluntary act for the purposes therein
expressed.
Sworn to or affirmed and
Acknowledged before me by
KATHERINE C. COX, the Testatrix
on ~QR ~ ~ , 2009.
~~~~' ~ ~2~<<-~~
Notary Public
rrr~F"" _
I
~U yf icrr ~~,i: ~. JI
., ,.,, =~Ldt=~WA
F.-r;Pii;n ^aunry
~ir~~~; auG. 11, 2(710
KATHERINE C. COX
4
We, the undersigned witnesses who signed the foregoing instrument, being duly qualified
according to law, depose and say that we were present and saw the Testatrix sign and execute
this instrument as her Will; that she signed and executed it willingly as her free and voluntary act
for the purposes therein expressed; that each of us in her sight and hearing signed the Will as
witnesses, and that to the best of our knowledge, that she was at that time eighteen (18) years or
more of age, of sound mind, and under no constraint or undue influence.
Sworn to or affirmed and ,
Subscribed to before me ~ ~ n _
by b~~~~,,,~l~k° ~~~ ~f~~-, 1 '' c~ ~`,~
and - C ~n~n. ~ itn s
witnesse , on ,~',' f ~ , 2009.
~"~~c~i',Zl~ ~~1.~ ~~.
Notary Public
Witn s
COMM~N~lJEAC.TH Oi P[i•diV~Yl_VHNIA
~_Notan~i .al
C! I ~ is ~ ~ `a•~tn , r'37~fic
S isq~eh mc~ ~ sm~ i au~?h~n County
r~ny C ~nnnrsio i r spin s qua, 11, X010
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