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HomeMy WebLinkAbout03-04-13r v PETITION FOR GRANT OF LETTER rn rn REGISTER OF WILLS OF CUMBERLAND COLRPENNL,V Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Leei~~a~Peci,,,~ed b~~ and in support thereof aver(s) the following and respectfully request(s) the grant of Let~sci~t t~ appropri,~;~rm: t ° ~ c~ --o `'~ ~ Decedent s Information ~ _ ~~ // Name: Dorothy J. Holtzman File No: ~ ~ ~ ~"' Z ~ "1-3' ~ ~o a/k/a: ~Ass~ned b,~Regi~elr . a/k/a: Date of Death: 01 /02/2013 Age at death: 79 Decedent was domiciled at death in Cumberland County, Pennsylvania (State) with his/her last principal residence at 644 N. Second Street 17043 Borough of Wormleysburg Cumberland Street address, Post Office and Zip Code City, Township or Borough County Decedent died at Street address, Post Office and Zip Code City, Township or Borough County State Estimate of value of decedent's property at death: Ifdomlclled in Pennsylvernier ................................A(I personal property $ 15.000.00 If not domiciled in Pennsy[vrcnia .............................Personal property in Pennsylvania $ If not donciciled in Pennsylvania ...... ....................Personal property in County $ Value of real estate in Pennsylvania .............................................................. $ 25, 000.00 TOTAL ESTIMATED VALUE.... $ 40.000.00 Real estate in Pennsylvania situated at: 644 N. Second Street 17043 Borough/Wormleysburg Cumberland (Attach additional sheets, ijnecessary.) 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/thcy is/aro the Executor(s) -named in the last Will of the Decedent, dated thereto dated State relevant circumstances (Gg. re~uinciation, death ojexecutar, eta) Except as follows: after the execution of the 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(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. ^ NO EXCEPTIONS ^ EXCEPTIONS ® B. Petition for Grant of Letters of Administration (if applicable) e.t.a., d.b.n., d.b.n.c.t.a., pendence life, durance absentia, durance minoritate If Administration, r~~~ or d.b.n.c.i~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 Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs (attach additional sheets, if necessary): Name Relationshi Address John A. Holtzman Son 644 N. Second Street Wormle sbur PA 17043 Keith E. Holtrman Son 8213 Simms Court Arvada CO 80005 Fornr RW-02 rev. !0/11/2011 _. .. and Codicil(s) Page 1 of 2 t'~ Oath of Personal Representative off4aial vse only COMMONWEALTH OF PENNSYLVANIA } ~,~, ~ w :U COiJNTY OF CUMBERLAND } SS: ~ ~ ~ ~ ~ Petitioner(s) Printed Name Petitioner(s) Printed Ad s ~"' ~ m hn A. H I man 644 N. 2nd Street ~ to ~ ~ Wormle sbur c3 ~ ~ 1 ~ ~ ~ ~ ~ ~ c~ ~ sv ~ ~ The Petitioners}above-named swear(s) or affirm(s) the statements in of Petitioner(s) and that, as Personal Representative(s) of the Deceden Sworn to o~ ~~rmed an s 'b bef~~ A ~ me thi ay.of ~2 lay: or a Register ing Petitio are true and correct to the best of the knowledge and belief i ner wi well and truly administer thc estate according to law. Date Date Date Date BOND Required: 0 YES ®NO FEES: Letters ....................... $ 90.00 (3 )Short Certificates(s) ...... 15.00 (1 ) Renunciations} .......... 5.00 ( )Codicil(s) ............. . ( )Affidavit(s) ......:.... ........... . Bond ......................... Commission ................... . Other ......... Inheritance Tax Rtrn . , , . , , . , . 30.00 Automation Fee ................. 5.00 JCS Fee ....................... 23.50 TOTAL ......................$ 168.50 To the Register of 1W~lls: Please enter my appearance by my signature below: Attorney Signature: Printed Name: Supreme Court ID Number: Firm Name: Address: Phone; Fax: Email: DECREE OF THE REGISTER Estate of Dorothy J. Holtzman Fite No: ~~~'~ ~" d ~~! a/'k/a: AND NOW, .! ~I ~ry~`~1 V " / consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters are hereby granted to ' th b t t d 'f 1' abl th t the instrument(s) dated described in the Petition be admitted to probate and filed of record in e a ove es a e an (~ app is e} a last Will {ancj Codicil{s)) of Register of Wills G~~Z,~~,~G Form RW-02 rev. 10/11/2011 Page 2 of .. ~~~'~:~~),~1 .. A ~ ~ cTnT~ nG GI nQinn ~'.: A.` ~ .'.. ~. A `r r~lC~~-~~'wv~ .a - a _ . r, ~ ~ ` ~ ~.-~o ~ OFFICE Of VI~'AL STATISTICS 4 ~~; I,~I III ~ I I~ II'I ~ ~,~ i III III i .I I 'rl'~' ~ ~ ~I I I ~ ~~ ,v~'l il~.'J:. - ~ ~~ ~ 'lu~~~ ~I~i~ll~q!I, ~ Ili - ~ -= I I III~IIIII ~ ~, ~~ ~ERTIFI }ATIt~N OF .DEATH STATE F,il.~ NUMBER: 2013000120 DATE IS$UED: January ~, 201 DE~~~I'ENT INFQR I; ~Ii, ~~if~N 5TA ~I~li BILE ~~1'1'E: ~'a~~ll~2~ry 3, 20'!.3 ,,~~~II''ll'i~llll~l~;l NAM DOROTHY ~ ~~ ~~I~~ ~ ~ ~LTZMAN ~,~, LI i~, ~'` ~ -- ~ ip~ i~'~I ; ~,~il~'I E 11~~~ iii ~ ~ Ill ~ it ~~,1~ I _ ~lil~~i, ~ I DATE OF DEATF~. ~I nua 2 2013 ~ SEX: FE~ ~~~ ~~~~L€~- ~ AGE: 079 YEARS. ~ Ii~ ,~-~ ry ~ I~ ; DATE OF BIRTH: Jutt+~ 28, 1933 _~ ~ ~ BIRTHPLACE: LEES CFtf7SSROADS, PENNSYLVANIA '> '~ ( ~ PLACE HIERE DEATH ©C~URR~~b EMERGENCI~ ~~ i I~ M~OUTPATIENT ~' ~q ~~'~'~~I~II'I ~~I~ ~, FA, ~~, ~I~T''~ I~IAME OR STREE T~DORESS: PEACE.. ~,~ ~ ~i~~~~Gl©NAL MEDICAL CENTER _ lil , , ' ~ ,I ~C~N OF DEATH: PORT CHARLOTTE CH ~ ' ~I'E COUNTY ~ ; ;~i ~~ II I IVY l'' I ~,~~~ - ' ~ IIIIIIlul~~ SV~~'~li/IVING SPOVSE DECE~ENT'Sll' ~SIDENC~ AND HISTORY INFt~~EI~111AT10N ~ / .MARITAL STATUS: WIDOWED SPOUSE: NONE RESIiI~ENCE: S44 N 2ND ST, WORMLEYSBURG,; PENNSYLVANI~- 17043 \ ~IuC' ~~ #INTY: CUMBERLA DI ~ ~ ~il~ll'~,' t ,~ I,~ _ ~ ~ ~ ~ ,I;, , I p ~~~~~~~ .~. C U t N INS ALES PERSO ~ T ~ ~~ ~ I~~ ~ ~ II~ PA I . EAL ES ATE C TO S N R I ~ r I I I ' I I~ ~ ~ ~ '~f r ... RACE: ~C V~fhi~ , ~~I~~II~i~ ~~!I~~~~I Black or African Arr~erican ,_„_Asian Ind~a~~~r~f~,~~~~ Chinese ,,,~,_1~~ilipino Nabve ~i ~I~~~ I~~ ~,~ ' ~~ I,~ ~~ American Indian ~~Il~klaskan Native--Tribe: ~ -„-Japanese -Korean ~,,,„VietnarTl ~ ,_Guamian or Chamnrro ~- _~amoan ^Other Pacific Isl: sian: -„-Other: 1 ,-„-,Unknown _Qtfier A ._~ HISPf~~~l~,'~R HAITIANORIGIN~N±D,N~fT OE HISPA~~~II~~~~tA1TIAN ORtG~tPl~ '~ ~~iI~~~1g11!Ii~l ~~~ E 4~, ~ ' I iC'I~'C"?'~N: HIGH S~HOOtw (~RADUA~TE OR G ~ I,~ I ~, i ~, ~,~ `I i~ ~'~ AVER IN W~.~.~, ARMED FOR~E~ '~ ~ ,~~Iili~i I ~~~~ ,~, ~~ I c~- I I,ll~ ~ ~ I, ~ ~~~~ ~P~,I~I~'~tS ~ AN D 1N~OIl~MANT INF'~B ~ ~ ~ON I,~,l q~~ ~ I~~ ~ ~Il~lo~ ~~ w ~rn ~ ~~~ ~I~ ~I~ ~ ~~I III FATHER: BENJAMIN F JOHNSON _ ~ C+ ~ ...,. a^y ~ MUTHER: RACHEL. A COMMERER ~ -~u`~ ~ ~~ ~ ~ INFORMANT: JOHN A HOLTZMAN r ~ ~ ~ RELATIONSHIP TO DECE~h~ENT: SON ~~ y,, ~ , ~~~ -~ ,~ ° ,,, Illlp ~, 1NFURMAIVT'S ADDRE,~~~ ~~1~6;~4 N 2nd St, Wt,>r,~Ml~1(SBUR~, PENNSY ~ N~~~IA 17043 ~ ' ~ ~~ o o ,Iq~~~~~~~1~~ ~ ~I~~~I ~~~'~PLACE OF DIS i ,'d~`~'`~1ON AND F~1'N'L~'tAL f:ACILI~'1~IIli'~~~~ ORMATIO ~ I ~II~ ~i,~`~ I lui ~~~I. 'PLACE OF DISP~ ' ~ ail ~L CREMATION SC3C~~'~`Y INC ~ rv r~ i~~ 'ION: INTERNATIONA HARBOUR HEIGHTS, FLORIDA ,, ~ -~ ~ ~ ~ ~ ~, `~ `METHOD.OF DISPOSITION: CREMATION ~ ~ ~ 3~` ~ "''~ FUNEF~ ~ I IRECTC?RILiCENSE NUMBER: BETTY~A I ~~ ~ ROUSE, 'F019596 ~ ~~,,llilli,~r~,l iI~~A F j ~ ~i ~AC`ILITY: ICS C~~EM4TION SOCIETY,,,,I ~ +~~~ X65 ' ~i~,'~,I'll~ lil,i ll~ IV 2620 HIUH'LANDS Rte sU~~~ ,~ RBOUR HEIG~fTS, ~ELORIDA 983 i °j~I ~ I~I, I ~ ~ ib~ lid' ~ ~ ~~„ ~ ~ , I I I ~ i ~l il~ ~I Iill~ll i i I CIi~ ~_ ` iil i~j I ~I ~ it i CE~'"IFIER INFf.'~RMA?ION ~I ~,;, lih .:TYPE OF CERTIFl~R: MEDICAL EXAMINER MEDICAL EXAMINER CASE NUMBER; 132208002 TIME ~F QEATM (24`hr}; 0649 l ~ERYIFIEf~'S NAME:f RI,~UL H IMAMI ~ I ~ ~ I,'' R: ~ ~ ~ % - ,Ili l; VIII; ~,I . CERTIFIER S LICENSE N~~SE ME23662~ ~ i ~ ~~''~I ;ail l ~ h ~~ ~ „ NAME OF ATTENDI ~I~; ~ ' SICIAN (if other fi~a~,n Certifier): NOT ENT,~~~~R ~ ~ ~ ~~,~ ~~ ~ I,IIi ,I ,~~ ~ ~ ~, ~~, ~ ~; Ii~l, ~~ ~~li III I,' ~' ~ J I~dlrl I i ~ I I ~~ I I I ~' - I~~I ! !1111 ~ ~,' ~~iliu! I ,! ~!, i \ ,~ I~~~~~ Illll Q~ ~ ~ II~ ~, A~~G.1V~ SIGiVATURE C~RTiF1ES TS !S A TRI~E ,I'~ ~~~E QFFICIAi. RECORD Oh# FILE IN TWIIS FICE~. RE~~~ ~~i~~~l~'~~ 3408388 -~- ~ ~ ~~~ THIS DQCUM~iWT f~~'RRINTED QR PHOTbcdP I I URrrY PARER WITH WATEq,~,~~I~F~S O~ THE G~IEA'~ ~ ~~ ll;~, ~~lli ~' rARNING: Olr 71E STATE OF OWIDA. DO. NOT' E WITHOUT VERIFY(N(i THE R~,REs~EIVC~ ~OF THE W14TER- ,; ~ ~ ~ I N.I I~II~II, MARKS. THE ~~~OCUMENT~ACf= CONTAI I ~' ~ I'~OLORED BACKGi UND, GC7~LC~ ~MBOSSEt~ SEAL, ANQ ~,pl~ '~ ~~ I _ ._ T p~ ~~ ~ THERMf)CHROMlC FL. THE BACK CONTAIN; ~ CIAL LINES WITH TEXfE DOCUMSNI' WILLNO PRO UC ~I RCOLOR CORY. 1 ~k DH ;FdRM 1946 (04.10) ~ ~ * 2 9 3 5~ 1` 4 6 H105.805 REV (01/07) LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this -:copy by photostat or photograph. ~~c~~;~~ ~~~~C~ of ~ ~ ~' ~ ~ ~~ ~ ~ F ~ This is to certif that the information here iven is Fee for this certificate, $6.00 ~~ j ~, ~ ,,~~~~~""""'--.. y g ,rr_.?u nc „_-._ `'~~~~ ~~t) ~ ~~ f P 17530490 Certification Number ,G ~~~~~s. ~a~~~:_~ ~~~~ERiA~a co.~ pQ 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 Offi for permanent filing. ~~~ ~ ~ ZQ Local Registrar Date Issued ~Nt06.t44 Rev tt12006 ~ COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS TY~ERI~PIR~~ ~~ CORONER'S. CERTIFlCATE OF DEATH (See Instructions and e)camples on reverse) STATE FILE rA,MeEa 1. Name of DeaMsA (Fiat; nrdde, w6 wAbc) 2. Ssx 3. Saclel SeanAy tfumWr 4. Date aT Daalh(Mentl4 dat4 yer) JOHN IDWARD :HOLTZMAN - - i Aye ~ Drtletey) tlyder t lkwx t & Date d Brh f 7. and ataos a ea Pha of Dash Chsdc a~ lever a,. lam, -usr, Hwpda~: over: 77 Yom. Oct . 30 1933 Hummels town PA ^ ~va~ O ~+! oetpaNent ^ DoA ^ NrasYrp fbme Resldwros Oanar • . 6b. CouMy d Deah 6c. Cky, Born, Twp. of Dim b. FadMy Name (tl na tetAuuar, yNe street and raniber) 8. was DeadsM aYtihperAe onprr? No ^ Ya 10. Rea: Arrrdeur ~. Bhde, whb. ele. (tl yes. ~p•dM ~+, 1~)1 Sn dex Shamokin Dam 3388 N. Old Trail "''~ °i~''°) e1e.) White 11. Deadut's uwel d vrork d ale most d Me. tb not ame /2: Wa DeaderA ever In the 73. Deadenl'e Eduoarion (Speay ~Y f ~ ~v l•bdl 44. Medal Shcuc AA6nMd, Never blerrfe4 ts. StMvirrp Sha m p wNe, NIw malderr name) IoM a tYak tGd a Badness / tndratry US. Amad Forees7 elerrrntary / Secardary (atz) College (1.4 a 5+) yyldowet4 Dherad (SpdM V' ~ ~« ^-~ Doroth J. Johnso 18. DsadaAY MaNnNAddrees lit ~r ! tarn, abde, ~fp cads) Deaderrl's Did Decedent 3388 N . Old Trail "`~' ' na. slae pA T 17e. ^ Yee, D.aaent urw b , T1vp. ,~e Snyder t'a ~ a ' ~*"^ Sha ~aad ki D kin Dam PA 17876 . , r mo n am ~,,, 8oio 18. FMher's fora (FM, mldrle, bM. suaq 19. Mdfrers Name (Piet, mldde, nrdden surrwa) Arth z n 20a Nlanrrtl's fNme (type / ~ 2tN>. tdamrN's Msllrq Address (Street, dry! tarn. slats, zlp mde) . Doroth J. Holtzman 3388 N. Old Trail Shamok• D PA 2ta. Mehat d DlepoMbrr ~,, ^ p 21b. Date d Dispalfal (Math, dry, veer) 21e. Plea of Dbpostlon preme d amagry, ,smeary «athar Agee) 214localbn (t3ly /tan- etYe, bP arde) ^ oar Fi«norrt~s~ MEsuMnar ""'°'~'d~Y«^-~ June 18 2011 Pomfret Manor Cremato Sunbu P 22a. d Ucuaee ( 220. Lloense Number 22a Name and Address of FaeRly - 601 N. HihS . Coepleb tt.me 23at 6nly rNnn osrtlfyYrp 23e. Tb>M beet a my tarorrledpe, ash ooaered ai h• urns, am and Ppe• smba (slgmee. aro tltle) 23b. tJarw Number 23a Deb Signed QAarNtt dry, y..r) phyekien is nd avabbb at Ilse ol4uh b arlly arm of deaNt kerns 24.26 mrN D• canpNld br perem 24. ltra of Deah 24. Dab Prenorerced Dead lMaa-4 dry, year) 26. Was Case Rebrred b Medlal erarriner! Corarar for a Reason ONrer han Crematlon a Donetbn7 w''°p°^01e1C°~d~ 11:55 A. M. June 17 2011 ~ Yee 0"° CAUSE OF DEATH (See lnstructfone and examples) a ApprainWe YNervM: Put tl: EnUr aha 26. DId Tabacoo the CabbM b Dah? bm 27. Part k E~ the f~,9tlYfdt- dbeew, >~a, a conpla6ona -6W dMedry earned the deah. DO N0T enter temiitel event suds ae ,Mac u,w1, r orwt b Deah but not rewAtlnp to lM uMsdyYrp earn given fn Pad L ^ Yut ^ fhebably neplydory arrsel, a varddaAar IbrNatlan rdhout ahowkg tlu etlolopy. Lkt aNy one aim an each Ins. i r ~ No [~ lhYerown NAME h FYrI dMase a r ~1 ~ .. C~mshot Wound to Head r 28. N FerneN: ^ r Dw b (a u a caeequena of): r r . Na prepnrA wlNn pal gar ^ Pre rwrt at 1NIr d deah N bt andtlaK. N mY b. r .. y ~ b Balm bled on kle a. pw b (a m e t Eder IMbERIYNq CAUSE ~•~s• ef): ^ ~ P-grrk OU prprwil MIAin 42 days d°'°le.hb~" °. ~ .... , ,,ear, Otra b (a as a tronsegwrra oft: t ^ ~ p~L ~ fegwr ~ ~ b t Y•a d. ~ Debw dash ^ ttdafoern N preprssrl adtlih 1M past year 30a. ~n~ 90b. A ~ 31. Merner d Dealh 32a Dab d Moray (Mantl4 deg year) 32b. Daabe Fbw Yr~ay ooarrsd ~ 32c. ~ W Y~atr. N Streel, Facbry. ^ fbk l ^ ~~ J Blidig, d Cum al Deah1 aa . ^ Ya ~ No ^ Ya ~No ^ Aaiderk ^ P•^dnI f 32a Tyne d ~Y 32e. May at Ylarlf! 321. tl Trurspaletlar In(uy (Seedy) 32¢ loeatlon d ~ (~ dy /ban, aHls) ~Suldde ^ CaMI Not ba Dstemdned [] Yes ^ No ^ ~! ^ ^PedeNrlsn M. ~• 33a CadNw (dfedt ally ar) 330. Sf~pAes 1'kN CutYMr r /C • CertNybq pbyaldan (Physkln aMNyltg awe d dadr wfnn eno6rr plryskian has prarorened deah and odrpleted bra 23) TolhabegotarybawMdpe,daalhaeeunWduetolMoaws(s)and'mwwrast+as4,._____~_~_____~_~__~_____________ ^ - • P-awuneYw ~ ~rbq (~~ ban ponwrcaq deatlr and arttlyYq b awe d dealt, TblMbatamylaawYdpe,asaMoeourredattMtlme,aqe,andpMa,anddwbtlrauee(a)andmannra.slabd..----------------- ^ 33R Lberre Number 33a Date slprd dry, yu) • Madlal Earabler/ Caorrr ~.,( On tir bulls d eounlbtatlon and! ar b my opbdon, deadr oeerewd tt the Nme, dab, and pMa, and dw b lira ,use(s) and aeanwr a sdbd.. ~J 34. Names urd Addreet d Parson Wlq ComplsMd Celtn d Durk Ib+127) TYDe I PrIR jHig1i0w' a"d I ~ 6'~ ~-~ y ~ 31 flid("1on°'~d"''"°" William D. Pheasant 316 W. Market St., . ~ OS~~'~~ Z. neaverzown, rA tiut.s DNpakbn PenNt Na 2 ~=i3= D~ _ .. _. RENUNCIATIaN ----;~ _ _ _ - - rte.,: - ~ - ~ m- ~~ ~~ ~ ~_~ ~' `~~ ~. ~~~ -~ ~~ ~ ~ ~ ~~ °~~ ~ ~t ~ c~ ._._ ~ --~ ~, ~> i'"' v~ Q3 REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA Estate of DOROTHY J. HOLTZMAN ,Deceased I, Keith E. Holtzmal'~ , in my capacity/relationship as (Print Name) son of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to John A. Holtzman (Dore) Executed in Register's Office Sworn to or affirmed and subscribed before me this ,~ ~" , day of - Deputy for Register of Wills Form RYY-06 retie. 10.13.06 Q? 1 2 Cimmc ('rntrt ~~sreer Aaaress/ Arvada, CO 80005 (City, State, Zip) Executed out. of Register's Dffice Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation for the purposes stated within on this i ~-~' ~` day Notary Public My Commission Expires: t a -l~ ~- 2-~ ~ ~ (Signature and Seal ofNotary or other official qualified to administer oaths. Shaw date of expiration of Notary's Commission.) KATHLEEN A SISSON NOTARY PUBLIC STATE CF COLORADO NornRV io ~s~mzoto MY COMMISSION E7~IRES OCTpBER 10. T018