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Home My WebLink About06-06-06 Register of Wills of_~~______~~_~be_rla~_ County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of Anna V. Burkholder No. 21-- n ~- O~4) also known as , Deceased Social Security No. 174-20-6382 Connie L. Kohr Petitioner(s), who is/are 18 years of age or older, appl(ies) for: (COMPLETE 'A' or 'B' BELOW) [!] A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the Executrix the Decedent, dated 05/02/2002 and codicils dated named in the last Will of State relevant circumstances, e.g., renunciation, death of executor, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: o B. Grant of Letters of Administration (c.t.a; ~.b.n.c.t.a; pedente hte; durante absentia; durante mlnontate) 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: I Name Relationship Residence I (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania with his/her family or principal residence at 2436 Lambs Gap Road, Hampden Twp. (list street, number, and municipality) Decedent, then 78 years of age, died 05/18/2006 at Select Specialty Hospital, East Pennsboro Twp. (Location) Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property (If not domiciled in PA) Personal prop~rty in Pennsylvania (If not domiciled in PA) Personal property in County Value of real estate in Pennsylvania 150,000.00 $ $ $ $ situated as follows: Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of letters in the appropnate form to the underSigned: ignature Typed or printed name and residence onnie L. Kohr 99 Mountain Lane Enoia, PA17025 L:~ 2- L-:-t .) / Prepared by the Pennsylvania Bar Association Copyright (c) 2004 form software only The Lackner Group, Inc. U..J:,~<\j'p~RW-1 (1991) Oath of Personal Representative Commonwealth of Pennsylvania County of Cumberland The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed ,,~) /----= . L--c..~ c:L- %~ Connie L. Kohr before me this G bh day of ~ ,d()OL &~q:lUfiLVU Q;uJ _.J v For the RegistfUt ~d<....-..< \~ r....:> ,-:::;) '__- :::J (.J~ c_ J1 --,e:l ;~--) CO) -~..: "'J ,-0 ___J ,:') I G') No. 21-- Ole - D i1 Cl , -'J ---) - _ _ce_-, -,'--, Estate of Anna V. Burkholder :'<> I Decea~ed' N \.D also known as Social Security No: 174-20-6382 Date of Death: 05/18/2006 AND NOW, ~l n ~ · / . , /)()l\ ( p , in consideration of the Petition on' e reverse side hereon, satisfactbry proof having been presented before me, IT IS DECREED that Letters [!] Testamentary D of Administration (c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate) are hereby granted to Connie L. Kohr, Executrix in the above estate and that the instrument(s) dated 5/2/2002 Short Certificate(s)..................... $ described in the Petition be admitted to probate and filled of record as the last Will of Decedent. ~JfL ~~11 (Jba~~JP\ Register of Will~ " rt-~rt; James G. Morgan, Jr. 260.00 FEES Letters.. .............................. ........$ \1r1t;66 Ren u nciation.............................. $ Attorney: Affidavits (1 )........................... $ ~oo I.D. No: 06897 Tucker Arensberg, P.C. 111 North Front St. Extra Pages ( ).................... $ Address: Codicil............................. ...........$ JCP Fee.....................................$ 10.00 Harrisburg, PA 17108-0889 Telephone: (717) 234-4121 Inventory.............................. u.... $ E-Mail: Other.......... ................................$ 20.00 3o\J>O TOTAL............................ $ Prepared by the Pennsylvania Bar Association Copyright (c) 2004 form software only The Lackner Group, Inc. Form RW-1(1991) i]' i" :0 certify that the infornlation here given is correctly copied from an original certificate of death duly filed with me as , I( I: :gistrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fce for this certificate. $6.00 P 12412457 ,\lo. ITEM j Oll<$- SHOULD READ AS FOLLOWS: ~ -d.~#(J' ~ /'1(1 ~a~a..~ (/ I, 0212006 ~N ~~T //30-244 1. Name 01 Decedent (First, middle, last. suffix) Anna 5 Age (Lasl Birthday) 78 ~~~ 'CS ~~:. "-:-J ;"1 "'J -', ~.._) '.' ) :. ~l ,~ MAY 2 62006 I 0.... Date~ -v r...) 1"0 \.0 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICA ~E OF DEATH (CORONER) 1-74 STATE FILE NUMBER 4. Dale 01 Death (Month, day, yea-) May 18, 2006 19. Mother's Name (First, middle, maiden surname) Anna M. U/K 2Ob. Informant's Mailing Address (Street, city Ilown, slate, zip code) 6375 Basehore Road Suite I ~chanicsbur 2lc. Place of Disposition (Name 01 cemetery, crematory ()( other place) v Burkholder 7. Bi ace Ci 31,1927 U/K Yrs Bb. County 01 Death Bd. Facifity Name (If nol institution,igive street and number) Select Specialty Hospital 16. Decedent's Mliting Address (Street, city llown, stale, zip code) 2436 Lambs Gap Road Enola, PA 17025 12. Was Decedent ever in the U.S. Armed F()(ceS? Dyes []No Decedent's Actual Residence 17 a. Slate PA i 3. Decedenl's Education (Specify only highest grade comple1ed) Elementary I Secondary (0-121 College (1-4 or 5+) 10 17b.County Cumberland 18. Father's Name (First, middle, last, suffix) George A. Burkholder lOa. Informant's Name (Type I Pmt) 21 b. Date of Disposition I(Month, day, yea') - 20 - 6382 8a. Place of Death Checl< on one Hospital: Other: fifllnpatienl D ER I Outpatient D OOA D Nursing Home 9. Was Decedent of Hispanic Origin? rn No Dyes (If yes, specify Cuban, Mexican, Puerto Rican, etc.) D Residence D Other . Specify: 10. Race: American Indian, Black, White, ele (Specify) Wh i te 14, Marital Status: Married, Never Married, Widowed, Divorced (Specify) Never Married 17c. ~ Yes,DecedenlLivedin Hampden 17d. D ~iu~;~U'l8d will1i1 Twp. Cily I Bora .. lbllinger Crematory i22c. Name and Address of Facifity Richardson Funerallbne Inc. 29 S. Enola Dr. Enola, PA 17025 23b. License Number 23c. Dale Signed (Month, day, year) 17065 Complete Items 23a< only when certifying physician is not available at time of death to certify cause 01 death Items 24-26 must be compIeled by person who pronounces death. 24 Time of Death 25 Dale Pronounced Dead (Month, day, I year) 3:40 P. M. May 18, 2006 CAUSE OF DEATH (58elnstructlons and examples) Item 27. PART I: Enler the!;,~ - diseases, Injuries, or C()(Oplications -thai direclly caused the death. DO NOT enler terminal evenls such as cardiac arrest, respiratory arrest, ()( wnbicular fibrillation without showing the etiology. List only one cause on each line. : Approximate interval: : Onselto Death :'~~~~u9tn~~ J:~~\ dlse~ Pneumonia Due to (or as a consequence of) Sequenlially list conditions, if any. ~~"C ~~~~~N~ ~Zi,~ (disease ()( injury thai initialed the events resulting In death) LAST. COPD Due to (or as a consequence of) Due to (Of as a consequence ot) 26. Was Case Ref to Medical Exammer I ~ner for a Reason Other than Cremation or DonalJon? 11 Yes~ No Part II: Enter other sianificant conditions mnbibutino In death but not resulling in the undenying cause given in Part I. 28. Did Tobacco Use Contribule 10 Death? DYes D Probably D /10 D Unknown 29. If Female D Not pregnant within past year D Pregnant altime of death D Not pregnant, but pregnant within 42 days of death o Not pregnant, but pregnant 43 days to 1 year of death o Unknown if pregnant within the pasl year 32c. Place of Injury: Home, Farm, Street, Factory, Office Building, etc. (Specify) DYes .aNO DYes D No 31. Manner of Death Jd Natural 0 Homicide o Accident 0 Pending Investigation 32d. Time of Injury D Suicide D Could Not be Determined 3Oa. Was an Autopsy Perl()(med? 3Ob. Were Autopsy Findings Available Prior to Complehon of Cause of Death? 32b. Describe How InJUry Occurred 1.4, 33a. Certifier (check only one) . ;:~W::tor~~~~~:=~:::~;:c~~: :u~t:~~ua,::~:~~:~e~~:=~~ ~~~ ~~ ~:~~_I~ ~)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _lJ .. Cor one r . ~::u:~a~ ~:~:~~~:~::: ~:tl::~i,n;:=:c~da:rti~~9t~0 ~~:uo~:f~~d manner a, 'tatid_ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _lJ 33d. Date Signed (Month, day, year) . Medica' examiner I Coroner : VI Ma y 2 5, 2006 ~ On the basis of examination and I or Inve'tlgatlon, in my opinion, death occurred at the time, date, and place, and due to the ~u,,(,) and manner a'slatt{ _ -A 34. Name and Address of Person Who C()(Opleted Cause of Death (Item 27) Type I Print 35. Regis s ignalureand~Num~ __ 36 DateRied th day) Michael L. Norris, Coroner .. //~ ~." loti / le(I / 1/ I '.3- q't ~ h A~~~a~!~~g~~~, R~idI7B~bte //1 (See instructions and examples on reverse) ~ /-0&-0'1'1) (2:fNtt t ::UHi r r NIt 0 'Qf.'~frl(lttt..~ltt OF ANNA V. BURKHOLDER I, ANNA V. BURKHOLDER, of Camp Hill, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all Wills by me at any time heretofove made.. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. 2. I direct that there shall be paid out of my residuary estate all estate, inheritance and like taxes together with any interest ~r penalty thereon imposed by the Government of the United States, or any state or territory thereof, or by any foreign government or political subdivision thereof, in respect to all property required to be included in my gross estate for estate, inheritance or like tax purposes by any of such governments, whether the property passes under this will or otherwise. 3. I give and bequeath the sum of$I,Ooo.OO to my friend, HARRY E. WOLFE, if he survives me, otherwise the gift sh~lllapse. 4. I"~ ,r, I give and bequeath the sum of $1,000.00 to my friend, GORDONJKQ~,lt~e , . /,U~j \..J survives me, otherwise the gift shall lapse. '- ~v! , . t~_ l. 1 or, t''t c,~ \ \~~ '] 6..., . ~ ,\ d" 1"..1 - I":" p juUv ~ .0 nr .) 'Oil ... 1 ... , ~ ,- ~ . " " ,:':' r' :'" ,.- I . r-.. "\-'. ~ -l .JU jjbju UJljeV\..l:i(j d-n 1- D ~ - 0 Lf tj ( 5. I give and bequeath the sum of$I,OOO.OO to my friend, CONNIE KOHR, ifshe survives me, otherwise the gift shall. lapse. 6. All the rest, residue and remainder my estate, real, personal and mixed, I give, devise and bequeath in equal shares to my friends, HARRY E. WOLFE, GORDON KOHR, and CONNIE KOHR. In the event a legatee predeceases me, the gift shall lapse. 7. Lastly, I nominate, constitute and appoint my friend, CONNIE KOHR, to be Executrix of this my Last Will and Testament. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~J.. day of May, 2002. r' ~ ~,V,. Anna v. ur 0 er (SEAL) Signed, sealed, published and declared by the above named ANNA V. BURKHOLDER as and for her Last Will and Testament, in the presence of us who have subscribed our names hereto as witnesses, at her request, in her presence and in the presence of each other. ~ m.c:k . -2-