HomeMy WebLinkAbout12-05-05
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of KENNETH E. GOTTSHALL. SR.
also known as
Social Security No.
, deceased.
No. 21-05- '\ ~ 5 L\
To: Register of Wills for the
County of Cumberland
Commonwealth of Pennsylvania
171-28-2560
The Petition of the undersigned respectfully represents that:
Your Petitioner, who is 18 years of age or older applies for letters of administration on the estate of the
above decedent.
Renunciations for Charlotte G. Williams and Denise E. Gottshall are attached hereto.
Decedent was domiciled at death in Cumberland County, Pennsylvania, with his last family or principal
residence at 420 N. Walnut Street. Mt. Hollv Sorinqs. Pennsvlvania
Decedent, then ~ years of age, died
Services. Carlisle. Pennsvlvania .
November 21 , 2005, at
Manor Care Health
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property
Value of real estate in Pennsylvania, situated as follows:
420 N. Walnut Street. Mt. Hollv Sorinqs. Pennsvlvania
$100.000.00
$15.000.00
Petitioner, Kenneth E. Gottshall, Jr., after a proper search, has ascertained that decedent left no will and
was survived by the following spouse (if any) and heirs:
Name:
Relationship:
Residence:
Kenneth E. Gottshall, Jr.
Charlotte G. Williams
Denise E. Gottshall
Son
Daughter
Daughter
203 E. Pine Street, Mt. Holly Springs, PA 17065
6 Winder Crescent, Newport News, VA 23606
7 Pine Road, Mt. Holly Springs, PA 17065
WHEREFORE, Petitioner respectfully requests the grant of letters of administration in the appropriate
form to the undersigned.
-77
''j. ~ C~ /~fL ~.
'Kenneth E. Gottshall, Jr. r
203 E. Pine Street
Mt. Holly Springs, PA 17065
I
u1
OATH OF PERSONAL REPRESENTATIVE
(,)
o
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ss
Sworn to or affirmed and subscribed
before me this S ~\.. day of
December, 2005.
~~. ~ ~~.~, :-~~..~~~~
-;-, v ~.. Register '
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The Petitioner above named swears or affirms that the statements in the foregoing petition are true and
correct to the best of the knowledge and belief of Petitioner and that as personal representative of the above
decedent, petitioner will well and truly administer the estate according to law.
'j- ~.dJ ~-~ 4~ q _
Kenneth E. Gottshall, Jr. .r
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RENUNCIA TION
In regard to the Estate of Kenneth E. Gottshall
, deceased.
To the Register of Wills of Cumberland
County, Pennsylvania.
The undersigned
Charlotte G. Williams and Denise E. Gottshall
of the above decedent hereby renounce(s) the right to administer the estate and respectfully
ask(s) that Letters
of Administration
be issued to Kenneth E. Gottshall, Jr.
WITNESS our hands this
23rd
day of
November
,2005.
/. 11'
'fl/ . . '
( ~~M I . ;()zt7JtIh<LJ
CHARLOTTE G. WILLIAMS
l_.L_
C:"
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(.')
6 Winder Crescent
ADDRESS
L:_
Newport, News, VA 23606
~;Z1;c ~~LL
DENISE E. GOTTSHALL
U")
I
L~'
7 Pine Road, Apt. 203
ADDRESS
Mt. Holly Springs, P A 17065
SWORN AND SUBSCRIBED BEFORE ME
COMMONWEALTH OF PENNS VANIA
Notarial Seal
'. K~f(:n S, Noel, Notarv Public
Larhsle I?o~o, Cumberland County
My COnUTIlSSlOn Expires Dec, 8, 2007
H IO'.X()' REV I/O' ).. \ - '\:) 'S. _ \ ~I :~ fu,
This is to certify that the information here given is correctly copied from an original certificate of death duly filec wilh me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permancnt filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate. $6.00
~~.~~~~.~,
Local Registrar
p
12045010
NOV 2 5 2005
No.
Date
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H105.143 Rev. 2187
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
TYPE/PRINT
IN
PERMANENT
SLACK INK
STATE FILE NUMBER
....
Z
W
"
W
()
W
"
LL
o
~
z
SEX
Male
3.
TH Ch ck
DATE OF DEATH {Month, Day, Year)
4. Nov 21, 2005
NAME OF DECEDENT (First, Middle, last)
,.
AGE (Last Birthday)
KENNETH E.
GOTTSHALL,
SR.
2.
BIRTHPLACE (City and PLA E F
Stale or Foreign Country) HOSPITAl;:
7. Carlisle, Pa ~:'."'."D
FACILITY NAME (If not institutloo, give street and number)
RlIllcIe<1ce 0 :~fy) 0
RACE - Amelil;an lnd\an, Black, White. el
(Specify)
69
Yrs.
5.
COUNTY OF DEATH
~\
Cumberland
8c.
10.
Whi te
SURVIVING SPOUSE
(llwil.,l1iv.maidloor'lam.)
8b.
DECEDENT'S USUAL OCCUPATION
(~v:o~~:t~ ~e~ri~~r:')11
. 11.. Production Worker lib. Paper Mill
DECEDENT'S MAILING ADDRESS (Street. CltyfTown. Stele, Zip Code)
17e. 0 Yes. decedent lived in
twp.
Old
decedenl
17b. CountvCUmberland ~~~~p? 17d.[iJ ~~h~~~~~~i~:::of Mt. Holl V SpringS
MOTHER'S NAME (First. Middle. Maiden Surname)
I.. Elmerta Cam bell
INFORMANT'S MAILING ADDRESS (Slreet. CltyfTown, Stale. Zip Code)
20b. 203 E. pine Street Mt. Hall S rin s Pa 17065
PLACE OF DISPOSITION- Name of Cemetery. Crematory LOCATION - CltyfTown. State, Zip Gode
or Other Place
citylboro.
2005
Holly Springs Caretery 21d.Mt. Holly Springs, Pa 17065
NAME AND ADDRESS OF FACILITY
22c. Ronan Funeral Hare 255 York Rd.
LICENSE NUMBER
23b. R1II5;0 qq 8L
2Ic.Mt.
.2.1 JC05
23 0
WAS CASE REFERRED TO A MEDICAL EXAMINER ICORONE~
26. Yes 0 No ~
: Approximate PART II: Other significant conditions contributing to death. but
. interval between not resulting In the underlying cause given in PART 1.
: onset and dealt1 ~
\. '-.."C\na~
DUE TO (OR AS A CONSEQUENCE OF):
tl
"
Sequentially Ilsl conditions b
if any. leading to immediate { c."
. cause. Enter UNDERLYING
CAUSE (Disease or injury
. thai initiated events
resulting on death) LAST d.
WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH
PERFORMED? AVAILABLE PRIOR TO
COMPLETION OF CAUSE Natural
OF DEATH?
DUE TO (OR AS A CONSEOUENCE OF):
DUE TO (OR AS A CONSEQUENCE OF)
DATE OF INJURY
(Monlil, DilY, Ye'f)
TIME OF INJURY
INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED.
D
D -D~D
30a. 30b. M. 30e. 30d.
Could nol be determined 0 PLACE OF INJURY. At home. farm. street. factory. offtce LOCATION (Street. CltyfTown, State)
lJulldlng,ete.(Speeily)
28b. 29. 30e. 3ot.
CERTIFIER (Check only on.) SIGNA RE AND TITLE 0 RTIFIER
.CERTIFYING PHYSICIAN (Physician certifying cause of death when anolt1er physician has pronounced death and oompleted item 23) D f "--
To the best of my knowl.oge. death occurred due to the causests) and manner as stat.d.................................. ............................... 31b.' I .. "
LICENSE NUMBER DATE &,!GNED (M::mth. Day. Year)
.PfoO:~~.~I~fG~~~~:I:J1~~:.~th~~~~:: ~~~:i~~e~:~~~~~~~.d:~~h d~: t~~Z~~ut~e~{~i:~~ ~~~er a. stated.............. ........ 0 31 e. ~\) C) t \.l '2 L( ( 10 31 d. \'\() Q'J "'2 2. oJ ~ b
NAME AND ADDRESS OF PERSON ~ COMPLETED CAUSE OF DEATH
(lIem 27) Type 0' Print t? c~ r ~ l) "" <...I.:l""" ~.... r"I'
D <:'I;o::,f)~ .n ~ 0_ '
32. '" l..A::l GL-.t"Iv.T .~~! 0.... ....i) ,...C.rl..l~""
:TE FtLED (Month, DaNa,) ~
Accldent
~
D
Homicide
Pending Investigation
v..D
NoD
Suldde
-MEDICAL EXAMINER/CORONER
On the b.sl. of examination and/or Investigation. in my opinion, death occurred at the lime. date, and place. and due to the eauses(s) and
mann.r as stated...........,.. ................... ......... ... ........... ....... ... .............n
31a.
REGISTRAR'S SIGNATURE AND NUMBER ~ ~
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