HomeMy WebLinkAbout01-29-13PETITI0~~1 FOR GRA~1T OF LETTERS
REGISTER OF WILLS OF ,~,~,~;;~~{,,~ COUNTY, PEiVNSYLVANIA
Petitioner(s) named below, who isiare 18 years of age or older, apply(ies) for Letters as specified below. and in
support thereof aver(s) the following and respectfully requests j the grant of Letters in the appropriate form:
Decedent's Information
Name: ~~,y~-- =_
a/k/a: '~
a/k/a:
a/k/a:
Date of Death: ~*_,_~~_ ~~},~ •
Decedent was domicile¢~at death in _ -,~~~s~ ~ ~~~,~ County
principal residence at .J,~r,.,~~~ %=,,,:, ~:~~ e`/In`7~ ~j, ~;,
Decedent died at
Street address, Post Office and Zip Code
File No: ~ ~ ! ~ ~ "` I r ,~,
(Assigned by Register)
Social Security No: ~~''~ ~~~ , f~`
Age at death• ~~'
(Srute) with higher last
City, Township or Borough
County
Street address, Post Office and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death:
_ c~
If domiciled in Pennsylvania ............................ All personal property $ ~'~ ~ ~~~+
If not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $
If trot domiciled in Pennsy[vania ........................ Personal property in County $
[value of real estate in Pennsylvania ......................................................... $ •~--
TOTAL ESTIivIATED VALUE.... $~ , ~i.~ - "
a
Real estate in Pennsylvania situated at: /~`~
(Attnclr ndditionnl sheets, i/'necessary.) Street addr~ss, 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 k'~.',~"
State relevant circumstances (e.g. renurrcintiorr, death of executor, etc.)
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not many, 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 ~'ti ~G~K..-~~ / ~cY.6{j i~.~ C''fAtrf ~~~~,~ ~ ~~ 1~~~~ .~ ~~i'ftPJ' 1.
~i~v/f'Ki+~
^ B. Petition for Grant of Letters of Administration (If applicable)
c.t.u., d. b. n., d.b.tr.c.t.u., pendente, duru-rte absetiti~t, duru;nt~':~i~inoritute
._~
If Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and;~~i~~lete list_of hei~•'~. ~-;;~.
r„~ ~ ~ ;.
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds fo~ivetce dyad bee~i•established a5 defined
in 23 Pa. C.S. § 3323(g) and was neither the victim of a killing nor ever adjudicated an incapacitated pei~5bn. ~ i._._ t17 ~ ' ` E
^ NO EXCEPTIONS ^ EXCEPTIONS ~ . ~ ~ ~ L ~~ ~ ,
Petitioner(s), after a proper search has/have ascertained that Decedent left no Vb'ill and was survivedb the foi1owin 5 Ouse •ffan and hei~ri; attach
Y , g. 1~ f..._.. Y) ,
uclditionul sheets, if necessury):
Name Relationshi Address ~ ._^a u:~ ~ `~"
a ~.___
>=o,•,~, nw n~ ,~w, lnilliz~ll Page 1 of 2
Oath of Personal Representative
co~,c~,co~~~,vE.aLT~I c~ P~~;~;s~; Lv,~~;l.~ }
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Tlie Petitioner(s) above-named swear(s) or affirm(s) the stat ments in the oregoing Petitio are aild correct to the best of the knowledge and belief
of Petitioner(s) and that, as Personal P.epresentative(s) ofthe eceden the Petttioi w~ and truly administer the estate according to law.
Sworn to affirmed a subscribed bzfore ~ Date % ~?~ ~~
me th's day of ~~~~ Date
By• ,2~ Date
or a Resister Date
BOND Required: ~ YES ~NO To the Register ojWills:
FEES: Please enter my appearance by my signature below:
Letters .................... .
( ~) Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Boiid ........................
Commission ................. .
Other
j .......
$ ~~ '~ (`
. (} (1
~ ~~
...~..
Automation Fee ............... .°~ " Gac.~
JCS Fee . .................... •.J ~_
TOTAL ..................... $-~.~.~-.5 G)
Attorney Sig~lature:
Printed Name:
Supreme Court
ID Number:
Firm Name:
Address:
Phone:
Fax:
Email:
DECREE OF THE REGISTER
Estate of ~/1~ ~f^ ~{/,JJG"/"~ I.L~Ct- ~/~~ /~ ~ ~< ' ~- ~~File No: ~`~ .~ / ~~3 .. / / ,.
w
aIk/a:
AND NO~V, ~ ~ ~ ~, in consideration of the fore oing Petition,
~V
satisfactory proof h~ ing been present d efore me, IT IS DE REED that Letter r5 ~~~/Y~E'//') t'
are hereby granted to - ~/'f' ~ ~~'~' r~
in the above estate and (if applicable) that
the instrument(s) dated fi~ !Z t°
described in the Petition be admitted to probate and filed of record as the last ~Vill (and Codicil(s)) of Decedent
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Type/Print In COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH • VITAL RECORDS
Permanent
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-~ - ~ ~ ~ State File Number:
1. Decedent's Legal Name (First, Middle, Last, Suffix) 2
S
.
ex 3. Social Security Number 4. Date of Death (Mo/Des Yr) (Spell Mo)
Jane E_ Kauffman Ft=_ma1 ovember 1,2012
Sa. Age-Last Birthday (Yrs) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (Mo/Day/Year) (Spell Month) 7a. Birthplace (City and State or Foreign Country)
91 Months Days Hours Minutes Myerstown , PA
May 2 9, 1 9 2 1 7b. Birthplace (county) Lebanon
Sa. Residence (State or Foreign Country) 8b. Residence (Street and Numb
I
l
d
A
er -
nc
u
e
pt No.) Sc. Did Decedent live in a Township?
P nn lvania -' O O O W ~ SOtl t. rl St. _ QYes, decedent lived in
Sd. Residence (County) twp.
Cumber 1 and Se. Residence (Zip Code) ~~lo, decedent lived within limits of Car 1 i s 1 e
city/boro.
9. Ever in US Armed Forces? 10. Marital Status at Time of Death Married [] Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage)
Q Yes ~ No Q Unknow
Q Di
n
vorced Q Never Married Q Unknown James E _ Kauffman
'
12. Father
s Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First
Middle
Lasi)
H
,
,
arry Kintner Sarah Kneast=_1
14a. Informant's Name 14b
R
l
ti
h
'
.
e
a
ons
ip to Decedent 14c. informant
s Mailing Address (Street and Number, City, State, Zip Code)
o
C Barr Slusst=_r Executor Blairs Mi11s, PA1 721 3/21 033Vanburt=_nR
+
z .....• ................•.................................. ..........................................:... lSa. P ace o Deat Check on y ones
If Death Occurred in a Hos ital: - •-•••• -•---•••--••----••-••---•••• ..............................
p Inpatient :If Death Occurred Somewhere Other Than a Hospital: ~] H
i
F
ili
'
° osp
ce
ac
ty Q Decedent
s Home
Q Emergency Room/Outpatient Dead on Arrival
Q ~ Nursing Home/Long-Term Care Facility Q Other (Specify)
•
z 15 b. Facility Name (If not institution, give street and number;
15 c. City or Town, State, and Zip Code iSd. County of Death
LL
m m 1 nd
16a. Method of Disposition Q Burial Cremation 16 b. Date of Disposition 16c. Place of Disposition (Name of cemetery
crematory
or other place)
v
w ,
,
Q Removal from State Q Donation '( '~ / 2 7/ 2 0 1 2 Ho 1 1 i n
Q Other (Specify) gt=_r Crematory
16d. Location of Disposition (City or Town, State, and Zip 17a. Signature of Funeral Service Licensee or Person in Charge of Interment 17 b
License Number
.
Mt _ Ho11y Springs ~ PA ~_ ~ , ~ 01 1 589E
E
17 c. Name and Complete Address of Funeral Facility
m Hollinger FH&Crematory501 N_ Baltimore Ave_Mt.Ho11y Springs,PA17065
'
° 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 wh
t
h
h
i- a
ig
est degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be
.
Q 8th grade or less is Spanish/Hispanic/Latino. Check the "NO" ~ White Q Korean
d
Q No
iploma, 9ih - 12th grade box if decedent is not Spanish/Hispanic/Latino. Q Black or African American ~ Vietnamese
~' High school
raduate or GED
l
t
d
g
comp
e
e
~ No, not Spanish/Hispanic/Latino 0 American Indian or Alaska Native Q Other Asian
Q Some coll
dit
b
d
ege cre
,
ut no
egree Q Yes, Mexican, Mexican American, Chicano Q Asian Indian Q Native Hawaiian
i
t
Q A
d
ssoc
a
e
egree (e.g. AA, AS) Q Yes, Puerto Rican Q Chinese Q Guamanian or Chamorro
Q Bachelor's degree (e.g. BA
AB
BS) Q Y
C
b
,
,
es,
u
an Q Filipino Q Samoan
Q Master's degree (e.g. MA, M5, MEng, MEd, MSW, MBA) ~ Yes, other Spanish/Hispanic/Latino Q Ja
an
p
ese Q Other Pacific Islander
~ Doctorate (e.g. PhO, EdD) or Professional degree
(Specify) Q Other (Specify)
e. MO, DDS, DVM, LLB, JD
21. Decede ni's Single Race Self-Designation -Check ONLY ONE to indicate what the decedent considered himself or herself to be
22a
Decedent'
U
l O
.
.
s
sua
ccupation -Indicate type of work
White Q Japanese Q Samoan d
d
i
one
ur
ng most of working life. DO NOT USE RETIRED.
~ Black or African American ~ Korean Q Other Pacific Islander
Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure C 1 e r}t
Q Asian Indian ~ Other Asian ~ Refused 22b. Kind of Business/Industry
Q Chinese
~ Native Hawaiian Q Other (Specify) Army Despot
Q Filipino Q Guamanian or Chamorro
ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced Dead (MO/Day/Yr) 23b. Signature of Person Pronouncing Death (Only when applicable) 23c. license Number
BY PERSON WHO PRONOUNCES OR
CERTIFIES DEATH ~~7'~
\ ~
_
Z_ {~
23d. Da
~i ned (MO
/
Day/Yr) 24. Time of Dea \~~
~
\C~~ `
\
~ ,
`w~
r
1
- ~ ~"
'
~
\
~O
Cam
w
---
+ 25. Was Medical Examiner or Coroner Co ntacted7 es Q No
CAUSE OF DEATH
Approximate
26. Par[ 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:
.
respiratory arrest, or ventricular fibrillation w
i
thout
show
i
ng the etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add additional fines if necessary Onset to Death
y
~
r
r
~
IMMEDIATE CAUSE - ----> a. t ~1 ~ \~ y/ ' ~ ^ 1~~~
t
(Final disease or condition Due to (or as a consequence of):
resulting in death)
b.
Sequentially list conditions, Due to (or as a consequence of):
if any, leading to the cause
listed on line a. Enter the c.
UNDERLYING CAUSE
Due to (or as a consequence of):
(disease or injury that
initiated the events resulting d_
~
u in death) LAST.
Due to (or as a consequence of):
_
S
i5
26. Part I1. Enter other s~nifica nt conditions contributive to death but not resulting in the underlying cause given in Part I 27
Was an auto
s
erfor
d?
~ .
p
y p
me
Q Yes No
ZS. Were autopsy findings available
to complete the cause of death?
~
v
E Q Yes Q No
29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death
(~ N
t
t
i
hi
~ o
pregnan
w
t
n past year [~ Yes Q Probably `Q~ Natural Q Homicide
P
m ~
regnant at time of death ~ No ~ Unknown ~ Accident 0 Pending Investigation
Not
t
b
° pregnan
,
ut pregnant within 42 days of death
Q
Q Suicide Q Could not be determined
~ N
t
b
~
- o
pregnant,
ut
pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Yr) (Spell 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, Zip Code)
36. Injury at Work 37. If Transportation Injury, Specify: 3S. Describe How Injury Occurred:
Q Yes Q Driver/Operator Q Pedestrian
Q No ~ Passenger Q 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
~ Pronouncing ffi Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated
Q Medical Examiner/COrOn r O basis of examination, and/or investigation, in my opinion, death occurred at the time, date. and place, and due to the cause(s) and manner stated
~
Signature of certifier: i
~L h-`.. Title of certifier: ~[~ O ~ 6 Zt..(~ G
v License Number:
39b_ Name, Address and Zip Code of Person Completing Cause of Death (Item 26) 39c. Dat Sign d (Mo/Day/Vr)
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40. Registrar's District Number 41. Registrar's S' re 42. Registrar File Date (Mo Day/Yr
~ )
~
_ ~
~
tJ oil .a'~- ~d La-
43. Amendments
t ~ H105-143
Disposition Perm(t No. C) 1. ~l. ~ ~ REV 07/2011
~ i - i~ - iii.
.n
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O_~ZH O~ ~L~3~~RIB~~G ~~D~~E~~(~,~~~ ~~~
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REGISTER OF ~~'ILLS ~ ~ _ -~~'
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~,(,;i /r ~ C-`~`" d ~-l~(":'~ COt~~1TY, PE~ 1 'SYLVA~IL~ - ~ ~ r
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Estate of
,Deceased
1, ! /,.,
_ ~~~ ~~ ~ ~~ ~~~'~ 1 ~,''~-S ~~ ~~ , (each) a subscribing witness to
(Print Name./s)
the lid' Will ^ Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and
YO - ..
sa s that ~~ ,
sh~~'/ he /they `was /,were present and saw the above Testator / Testatrix,,.-' sign the same
._...
~--~-
and that ='she.:Z~ he /they signed the same and that ~ she / he /they signed as a witness at the request of
- :.
the Testato~;t` /Testatrix in her %' his presence and in the presence of each other.
(Signature)
(St,•eet Address)
(City, State, Zip)
Execccted in Register's Office
Sworn to or affirmed and subscribed
before me this
day
of
~pu~~~
a fo:- Regser of ~,~ils
'~._
(Signature)
SD/ ~. ~~Yiu~v~2 s7:
(City, State, Zip)
(Street Address)
Execccted occt of Register's Office
Sworn to or affirmed and subscribed
before me this ~~ day
o f O/c3 .
'_~ 0:~_ ~~ P'a<~ic
'~1}~ ~;om~rissior: Exp:es: Q~.D/~ ~~ ~D/~
~Si2nature and Sea'. ofvotary or o.`;er e:t ,. ~ _ ~aiu~e;: to
adm;niste: oaths. Sho« date o`expiration e`i~iotar}'s Commission.)
NOTE: To be taken by officer authorized to administer oaths. Please have present t original or copy ~~t~3~l~time of notarizati
DENISE WHITZEL
Notary Public
For»c RW-03 rev. /0. /3.06 CARLISLE BOROUGH, CUMBERLAND COUNTY
My Commission Expires Apr 6, 2015
;~ l ~ l3 - l/i2
~...~... ..,. .,,, a.
~~ ~ ,
~ ~ :., a .. n,~
,. a _
REGISTER OF ti~'ILLS ~ '~~'' '~ ~~ ~~ ~'~
(,~ ~'~"1 ~~~~' ~ ~c~~Otl~"TY, PE~,:~'SYLVANL~ ~? ~: °:5 ~:T~ ~ , 4
Estate of ~ _~~'~ /"~~' ~ ..'~ ~ ~~(~ ~ C•.r'~ ,Deceased
`~s
(each) a subscribing witness to
-- // (Print Name/s)
the C1~Will ^ Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and
say(s) that she /. he ~ they '"was /were present and saw the above Testator /Testatrix. sign the same
~~
_ _.~;
~__. . ..
and that she / he %.th.~:.y~ signed the same and that she l'he)/ they signed as a witness at the request of
the Testator /Testatrix .. in ; 'her /`his presence and in the presence of each other.
(Signature)
(Street Address)
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this
of
(S nature)
~D~Of1./~.7f S~,
(Street Address)
C.Q~/~sl~ ~~, ~7a~~3
(City, State, Zip)
Execcted occt of Register's Office
Sworn to or affirmed and subscribed
day before me this ~~ day
of D/
?~1~~ ^Ca~~~:issior. Expires: ~ ~P ~~~~
(Signature and Sea: of?votary or ot:~,er o:~f~~~ ;:~ai;~e~ to
administer oaths. Shoe date of expiration cf:votar;'s Commission-)
NOTA~.IAL SEAL
NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy f instrument(s) a~?~I`~~So~ ~i~~n.
Notary Public
CARLISLE B
OROUGH, CUMBERLAND COUNTY
Fornc RW-03 rev. IOJ3.06
My Commission Expires Apr 6, 2015
M
LAST WILL AND TESTAMENT
Jane E. Slusser, being of sound mind and disposing mind,
memory and understanding declare this as my Last Will and
Testament and making void all former wills by me at any time
heretofore made.
First I order and direct that all my just debts and funeral expenses be
paid by my Executor as soon as may be done after my death.
Second I bequeath my diamond ring to my granddaughter, namely Taylor
Nichol Slusser.
Third I give and bequeath my dry sink unto my grandson, namely
Norman Barry Slusser, II.
Fourth I order and direct and bequeath all the rest and remainder of my
estate unto my grandson, Norman Barry Slusser, II.
Fifth I order and direct that the sum of five thousand dollars ($5,000.00)
be paid by my Executor to my niece, Patricia Ann Zeager.
Sixth If my grandson Norman Barry Slusser, II should predecease me,
then in that event, the rest of my estate is equal shares to my
grandchildren, namely Cody Jared Slusser and Taylor Nichol
Slusser share and share alike but subject to protective trust
provisions herein after the age of twenty-three (23) at the time of
my death.
Lastly, I nominate and appoint my grandson, Norman Barry
Slusser, II to be the Executor of this my Last Wiii and
Testament.
If my grandson fails to carry out my wishes or cease so to serve
them, in that event, I nominate my niece Patricia Ann Zeager to be
the Executor.
7 . F'....
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Page 1 of 2
r
SELF-PROVING AFFIDAVIT
Commonwealth of Pennsylvania
County of (,~~,n~~p~lun~_
We, <J~ ~~ u 51 Esser
h r ~ s ~~~ = rz f~'P.~ ,and
Krvp n s ~e~ Goo n r o.~ ,the testator
and the witnesses respectively, whose names are signed to the attached instrument in those
capacities, personally appearing before the undersigned authority and first being duly sworn, do
hereby declare to the undersigned authority under penalty of perjury that the testator declared,
signed, anCi Executcu the inStriiiil~r3t a::, l;i ~,~h~r last vi'il~; h°/chc signed it ~~illingly or willingly
directed another to sign for him/her; he/she executed it as his/her free and voluntary act for the
purposes therein expressed; and each of the witnesses, at the request of the testator, in his or
her hearing and presence, and in the presence of each other, signed the will as witness and that
to the best of his or her knowledge the testator was at that time eighteen (~8) years of age or
older, of sound mind and under no constraint or undue influence.
_,
~.-.:~ ~. -~~--~ - [Signature of Testator]
arse [Printed or typed name of Testator]
~'c~ / ~,% ~-/u„~ „~ ~- ~ ~F~-~ . ~~ ~ _ 5I ~ [Address of Testator, Line 1 ]
C'« r i r s l~ ~~ t ~ o ~ ~ [Address of Testator, Line 2]
~h~ i h ecz [Signature of Witness #1 ]
[Printed or typed name of Witness #1 ]
y ~~~, ter- ;;~ ~ ,,~, ` . ' - [Address of Witness #1, Line 1 ]
[Address of Witness #1, Line 2]
[Signature of Witness #2]
~~,.~ m, [Printed or typed name of Witness #2]
~~ ~ ~ f~L o ~~ ~= u :2r [Address of Witness #2, Line 1 ] .
/Y~Ec~.~-F-~ ~,1~G~13~~,~~--~ ~-~ ~ ~701~~~ [Address of Witness #2, Line 2]
and acknowledged before me,
a notary public, by
the testator, and by
and
~,~ r Pn S'~p h ~n s ~.~ ,the. witnesses, this
j ~ day of c+~, ~ ~-' , 20~_.
[NOTARIAL SEAL]
~ ~ ~~ ~~
Notary Pub ic's Sign re
My Commission Expires: ~~/~~~'~
NOL1RtAl SEl1t
KELLY J Nt1GMES
N01ary Pt~b11C
NOR'INMR~OIE'pN ~ry
NAt CannMis~loin ExpMru hb 11, 200a
Page 2 of 2