HomeMy WebLinkAbout97-00522
IJETITION .'OR IIROIIATE Ilud (;RANT en' unTERS
[J VI'" /0. (i Ii ( No. 0>\ -q1-~~....
To;
Regi,tel of Will, lor Ihe
. /)1'("",1.\('(/. ('OlllIlY of ( :'Is\ 1(,,,Ir/.lv(j in the
8o/'i,,1 8I'('lIr;I.I' No, ,.( {'."I.. ':' I L: ~ t'..:! A'_, ('ollllllonweullh of Pennlylvunlll
Tl1l' p,'lliion of Ih,' IIll(krslgned 1"lpeelfllll.I' 1"I1I""Sl'llIs Ihal:
Yom !1l'tillolll'r(,\), who i<.;/al'l' IS ycm~ olugt' lor older an I Ill' l'XL'L'lll Y'
Inlhe lall 11'111 of Ihe aho\'~ dee,'delll. da,c'd r.t..(lI/. ",J C, ,
l~lde~c~(y dill)'~11~~,~P t' p .s J, Vo;.K liW (
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I>ee,'nden/wal dOlllid"'d al d,'ulh in" C~t)J"\J\.\)u-,,,..,:I- i"lrf! I) ('ollnly, Pennsylvania. wllh
h~r~ lall fumlly 01' priljdpal lelit!ell\:e al~, I.J &.'1 )[;)~' e('>t',,~.;..~~LE.~Lt' )
~..ff\..(;c0.JllW,.5 b(,,'Yu. ffl _../ /f"~. L__-)I()_..:-_IL1Ll'tlJ~~:..JY_.1~/1 '
(11\1 'lrl'l'l, tlllfllbn and tlllllldp;i1il.l'l
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III.. M (\ Nor LI'!:I't.: LJ'.!O('f)/NC. }[c'NI e LlI-ffJ_~-L:u~u~--,
F\l'\'pt \I'" follow..... dl'L'l'<iL'nl did 1101 IlHlITY, WU\ not <Jivol'rcd and did not have u child bOTn or adopted
IIftel' ",ec'ulioll of Ihe will offered 1'01' pl'obale; \l'as no,lhe vic/im of II killing and wal nevel adjudicated
in,'ollll',',elll: -....N"ly. "'-~__ .. _~ _ ..~_~.____~_._.
DCl'l'lldC'1l1 at death o\\'IlL'd properly with c~tilllalcd values us follows:
(If domiciled in I'a.) ^" I'elsonlllplol'erlY
(If nol domkiled in I'll.) Pel'sonal I'lopCrlY in PCllnlyll'allill
(II IWI dOlllkiled in Pa.) Pelsollal11l0l'erlY ill ('OUllly
Valtll' lll' t'L'all'slatl' ill Pl'IlIl,,\'!vilnia
:,i/llall'd lis follow,,, ~...~rv .L~'~c'.._~~m.. ..~_~.~_~ ..__~_~_.~__~.......
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WlII:KHURI'. pelilionel(sl lesl'ec,fully leqllell(l) Ibe I'lobal<' ~,f Ihe I~sl will and eodicil(s)
pI"selll,'d h"le\lilh IIl1d the gl'lInl of lellel'l~l'''~/~ JJU~_c /JLLIL"~ ~~____.~_~..
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OATH (W PERSONAL REPRESENTATIVE
(:()I\IMON\\'EALTlI OF l'Io:NNsnV ANIA } ~l>l
COlNI'\' 01" .,~ n '.. JUM_B~RLAND~~_ . ,
TiI,- pc',ilioner(11 ahovc'.nan""t Sll'"",,(s) or affirm(,) Il1allh" Ilalelllellls in Ihe foregoing pClition are
HUl' itlld \.'01'1'1.'\:1 10 till' Ill'\! ollhc ~no\\'h.'dgl' and hdid of J1l'lilionl'I'(.~) and that us personal TCr)reSen-
\Ull\'l'(';) (If till' i1ho\'l' dl'l'cdl'llI IWliti(lIIl'r(\) will \\,1..'11 and Inlly adlllinistl'l'lhc c~;falc according to law.
Sworn '" <II affim,,'d and ""hS<Til1('",j)~t1U/,J7?1 ,,'t:}I{~-f.V_. '"
1,'.,ef',""II.'." 111,",."", 17TH, (;~).!'~I,J 01'_,_____ l'
15 - l~<' -1rt~; "~'I:::l,,;;,,' m-~==-:~== ~
No. ?,1 - 97 - 522
Estate of
.LlMV 0 VOSKUHL
_. lleceaslld
OECREF~ 01<' I)ROBATE ANn GRANT OF I,ETTERS
AND NOW ~__-~~--~~-~~...- .~tmLl9.,.~~~~~~ ,- 19~91~--, In considernllon of the petition on
the revcrse side hereof, snllsfnctory proof having heen presented hef<lIe me.
IT IS DECREED Ihnl Ihe instlumenl(s) dllled_3~W/l,RL26,~ t9.2lL~___..__~_-'---
described Ihereln be admitted to probate allll filed of record as Ihe Insl will of ....---~
AMV 0 VOSKUHL '
--~_..---- ~_...-,..~,.~_.._.__.,'_.._~_.~.-.~_....._..._' ~,_.,~-~-_._..~.__._--~-----'
and Letters _--...-..--.-~--II~TAM~I!..ll\l\L..---..-----~----- ..
arc hercby granted to __~~~_~__._O.QtQR1~Lt-L~IlK~!L_-~---
-----~.._------_.__.._.._~-~._--_.......------
------
"~;z;i,. fJn~ (l , ..
"( 0 ~ Regi"" 0 Will, ~
MARV CLEWIS
FEES
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Flied
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$ 6 nn
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$ 3.00
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TOT AL -- $ 1-99 ee
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PHONE
---
ATTORNEY (Sup, Cl. I.D, No.)
Probate, Letters, Etc. .."","
Short Cerllflcates(2 ) . . . , . . ' , . ,
Renunciation ...".,...,."..
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Mailed letters and order to Executrix on 6-20-97
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COMMONWeALTH Of I~ENN8VLVANIA' DEPARTMeNT OF tll!~lTH' VITAL ABOORDS
CERTIFICATE OF DEATH
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my estate, real, personal or mixed, wheresoever situate, unto my
niece, DOLORES M. BAKER.
ARTICLE IV
I direct that my Executrix shall not be required to enter
~ecurity in any jurisdiction in which she may,act.
ARTICLE V
I nominate, constitute and appoint my beloved husband,
THADDEUS J. VOSKUHL to be Executor of this, my Last Will and
Testament. In the event that he is unable or unwi.llin9 to serve
in that capacity. then I nominate, constitute and appoint my
niece, DOLORES M. BAKER as Alternate Executrix of this, my Last
Will and Testament.
~
... .
this
IN WITNESS WHEREOF, I.have
? 6 day of tr.........
hereunto set my hand and seal
, 1\.D. 1990.
Il,~g[t
INI! Sl-), /J-(L --<~/ / _(SEAL)
f
"AmY D. il'osltuh1
SIGNED, SEALED, PUBLISHED AND DECLARED by "AmY D. Vosltuhl,
the above named Testatrix, as and for her Last Will and Testament,
in the presence of us, who, at her request and in her presence and
in the presence of each other, all being present at the same time,
have subscribed our names as witnesses.
I{tJ lio/I~ (Qd'"''
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Address;
.. .
, .
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF LEBANON
55:
I, AMY D. VOSKUHL, WHOSE name is signed to the attached
or foregoing instrument, having been duly quall.fied according to
law, do hereby acknowledge that I signed the instrument as my Last
Willi that I signed it willingly, and that I signed it as my free
and voluntary act for the purposes therein expressed.
Sworn and
acknowledged before me ~~my D. Voskuhl, the
the ?-6 day of ~~ .' 1990.
Testatrix on this,
NOTARIAL SEAL
Rhoda J. Long
Notary Public, Palmv,a. Lnb, Co" PA
1.lt!:.'2.r!~.'!~lSion Expiro" ()"~::i. 1 9~.!
J' "
/., (~ I) I
_ (/ .IHl' -.) r.:)'/ <U././ ,/
Amy ,1). VI" uh
Lr f'l'dtti' ~ 1t:1
Notary pub ic ' ,I
My COIlUl\ission Exp.: 1.;/;.3/;1
------~---------------------~-------------------------------------
COMMONWEALTH OF PENNSYLVANIA
ss:
COUNTY OF LEBANON
We, William M. Brandt and Charlene R. Hurst, the
witnesses whose names are signed to the attached instrument, being
duly qualified according to law, do depose and say that we were
present and saw Amy D. Voskuhl sign and execute the instrument as
her Last Willi that she signed it as her free and voluntary act
for the purposes therein expressed; that each of us in the hearing
and sight of the Testatrix signed the Will as witnesses and that
to the best of our knowledge, the Testatrix was at that time 18 or
more years of age, of sound mind and under no constraint or undue
influence.
Sworn and
Charlene R. Hurst,
1990.
subscribed before me. by William..M '-Brandt and
wi tnesses, this ~;~ day of '" ,
/1l(J1(1r-'l/~Y
1:7 witness
(11/ () '{ /,l ,,' l~', j/tt' If
Witness
~2i /td (L ,~ .J~f~11
Notary Pllblic I / ,~
My Comm. ExP.: /.".; ,.3/11
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nllodiJ J, l.ong
Notary Public, Pa'Il1Vra, L..b, Co., PA
M Commleslon E. I... D.c. 3, 1991
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1. ROIl e"a.. (Seh.dulo ,1,) ( 1 )
2. SIOC~' and land. (Sd1odvlo I) I 2 )
3. Clo..'y Hold S,ocillPa_,hlp Intoro., ISehodulo CJ ( 3 I
4. Mortgag.. and Nal.. Rtcol.ablo (Sehodvlo D) ( 4 I
5, Ca.h, lan~ Dop..'" & MllCollanoov. P.,,,,nal Praporty I 5 I
(Sehodvlo E)
6, Jolnlly Ownod P,apony ISehodulo F)
7. Trontfort (Scllodulo GJ (Sehodulo LI
8. TOIal Gra.. 1.'''1' (10101 L1n.. 1.7)
9, Funeral bP4N''''' Ad"'lnl.troU.... COI", MIKIllanHilI
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10. Dob... Mongago L1ablllll.., L1.n, (Sehodvlo II
11. T OInl Dodudlon. 110101 L1n.. 9 & 10)
12. Nil Volvo of E"alo (L1n. 8 mlnv, Uno III
13, Chorllablo and Go..,nmonlal Ioquo"l 15eh,dulo JI
14. Nil. Vol.. SublOCllo T..(L1no 12 ,"'nu. Llno 13) __
15, 5"""",1 Trontfon (for do", 01 doo,h alto< 6-30-94)
SM Intlructlan, for Appllco~lo PorconlOgo on Rovor.. (15)
Sldo. (Inclv~o .01.... 110m Sehodvlo K a. Sehodulo M.)
, 16. A...unt 01 L1no 14 ",.ablo al 6'"' rOlo
(Iocludo .alu.. fro," Schodulo K or Sehodvlo M.)
17. A...vnl of L1no 14 la.ablo a' 15'"' '01,
(Inelvdo .01.., f.o," Schodvlo K 0. Sehodulo M.)
18. Prlnelp.lta. dvo 'Add 10. fro," Un.. 15, 16 and 17.1
19. Crodl', SpavlOl.Jt.orty Crodl' Prior ~ymon" DllCovn, ~ ()
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20. If L1no 1911 groo'orlflon L1no 18, on'" Iho dlHo.onco on Uno 20, ThI,I, Iho OV"I'AYMINT.
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A. Ent.r ,h. in'"est on ,h. balance due un Un. 21 A.
8. en... Iho 10101 of llno 21 ond 21,1, on Uno 211. Thi. I. Iho BALANC' DU',
Mob Ch.c~ I'.y.ltlo I., ..,I,to. ., Will,. 110'0.'
. I' sun TO AHSW'. AU QUUTlONS OMIlIYnst SID' AND TO IlICHIClC MATH .. '~ _
Und.. p,nolllll of porlury, I doclor. Iha, I ha.o o.a,"lnod Ihl. rolurn, including accomponylng ICh,dvl.. and "alo,".n'., and 10 I~O b", 01 my ~nowl.dgo and bollof
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ba..d on olllnfor,"otlon of whleh prop.ror ho, ony .nowl,dgo. ,
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RESIDENT DECEDENT i ~
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COMMONW\ALlH 0' PlNNIY...NIA
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
6
*'
lURE AU OF INDIVIDUAL TAXES
INHERITANCE: "IX DIVISION
DtP1. "0001
HAMR1SIURO, PA lI1Za-060'
NOTICE OF INHERITANCE TAX
APPRAlSEHENT. AllDWANCE DR DISAll.OWANCE
OF DEDUCTIONS AND ASSF.SSHENT OF TAX
U1,\\4"."",,,,1I
WlL LI AM BRANDT
46 E MAIN ST
PALMYRA
ESQ
DATE
ESTATE OF
DATE OF DEATH
F JL E NUMBER
COUNTY
ACN
11-03-91
VOSKUHL
06-03-97
21 91-0522
CUMBERLAND
101
AMY
E--------- ~
-.:~_~~~~~U"I R:Mltt=-.-J
MAKE CHECK PAYABLE AND REMIT PAYMENT TOI
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ..
iiiv: iS4i-EX -AFP--r09: 97Y -iloTicE" 'aF - "fNHEiiii' ANCi - 'fAx -APjiiIAiiEHENr; - ALi."aWAlici" oR" -" - - -.. - -.." - -" - --
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
AMY D FILE NO. 21 97..0522 ACN 101
PA 17078
ESTATE OF VOSKUHL
DATE
11-03-97
TAX RETURH WAS I C X) ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE XNTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASI!D ON: ORIGINAL RETURN
I, R..I E,t.t. CSo~dulo Al
2. Slooko and londo ISoh.dul. II
5. Cla,.1v Held stock/Partnership Int.r.lt (Sch.dule C)
4. Kortgll.,/Not.. RacIlyabla (Schedule DJ
I. C'lh/lank Depolita/Hilc. Parlonal Property CSchMdule [)
., Jointly OWnod Prop.rty ISo~dul. fl
7. Transfers (Sohedule Q)
e. Tot.1 Auoto
I CHANOED
NOTEI To inlura proper
credit to your account_
subMU the upper porUon
of this for_ with your
bx pay...nt.
.00
,00
,00
,00
67.401.91
.00
.00
leI
III
121
(5)
C41
151
1'1
171
67,401.91
APPROVED DEDUCTIONS AND EXEMPTIONS:
.. Funeral Expen.../Ad., Co.tI/H1.c. Expen... CSchedule H)
10. D.bto/Hortg... ll.blllll.o/LI.no (Soh.dul. II
II, Tot.1 D.duotlano
12. H.t V.lue of T.x R.lurn
15. Charitable/Goyernaental Beque.t.) Non-elected 9115 Trust.
14. Hot V.lue of Elt.lo Subj.ot to T..
2.255.31
.00
Ill)
1121
CUI
1141
191
(10)
,.,Jili :\1
65,146.60
.00
65.146.60
will
ISoh.dul. JI
If .n ........nt w.. 1..u.d pr.v1ou.1Y, l1n.. 14, 15 .nd/or 16, 17 .nd 1.
r.fl.ct f1gur.. th.t 1nclud. the total of ~ r.~urn' .......d to dat..
ASSESSMENT OF TAXI
IS. AMount of lln' 14 .t Spauo.1 r.to 1151_
I'. AMOUnt of lln' 14 t...bl. .t lln..I/CI." A r.l. 1161
17. Aoount of lln. 14 t..obl. .t Call.lor.I/CI.ol I r.t. 1171
Ie. Prlnclp.1 To. Duo
TAX CREDITS I
PAYHENT
DATE
07-29-97
NOTE I
.00 X .00.
.00 X .06._
65.146,60 X .15.
ClI)
.00
,00
9,771.99
9.111,99
RECEIPT
HUHIU
AA211587
DISCOUNT C + I
INTEREST/PEH PAID C.)
488.60
f;283.39
AHOUNT PAID
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
9,711.99
.00
.00
,00
. IF PAID AFTER DATE INDICATED. SEE REVERSE
fOR CALCULATIOH DF ADDITIONAL INTEREST.
IF TOTAL DUE IS lESS THAN .1. HO PAYHEHT IS REQUIRED,
If TOTAL DUE IS REFLECTED AS A "CREDIT" (CR I, YDU HAV IE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.1
.,~...---,......-
o
I~.
t(i
r
ME.R~ATJDNI flt.te. of d.c.dllnh dylftl Dn or "fol'. DIC..b.r 12, 1912 ~~ If tnV' future Intt"..t In the ..t.,. 11 trtn,f.rl'ed
In pO....llon or enjoy..nt to eleu . tcolh"r.l) 'o.nef101.rl.. of tht dec.den' tft.r the .llplreUon of any ..t.te for
Ilf. or for'y..r., the C~nwt.ltn h.r.by tMPr...lv r...rv.. the right to ~ppr.l.. and ...... tr,",f.r Inh.rlt.no. f.IC"
.t t~ l.wfyl CI... . (oallet'tal) rete on eny 'uch future tnter..t.
_Of
HOTlCEI fo fulfill the r,qulr'Hnh of S.cHon 2140 of the IntI.rHlnOe and E.t.t. TIll ,,~~, Act U of 1..5. (72 P.S,
S.oHon'140),
PAYMENT I
D.ttClh thl tOJl portion of thlt Notto. Ind .Ubllit wHh YO\lr ".y.ent to thl A'I).
--..... ohtictl; or "nty orrier p.ytble tOI REGISTER OF NU.LI, AGENT
af WlIlt prlnUd on the r.v.". .Ide.
REfUND (CA)1 A r.fund of . tlM crldlt, lIIhloh w., not r.qullt.d on thl rill: Return, IIlIY b. r.ctIJ.lt.d by colltPl.tI". '" "Appllo.Uon
for R.fund of P.nn'Ylvenl. Inherltano. and Eltlt. T.IC" tREY-IJIJ). "ppli~~tlo~t art tv.llebl. .t the Off10.
of the R..ht.r of WUlI, eny of the ZJ A.v.nu. Dlstriot Offlo.., or bv e.lI irlq the .p.cl.l 2~-hour
.,....rlng ..rvle. nuIlbe" for for., ordllrlnl' In Pennlylvanl. I-IOO-S6Z-ZGSO, outside Pennnlv."l. and
..!thin 100.1 H.rr hbur. .r.. (117) 717-'0'4, TOO' (711) 772-2252 (Hlllr Inl IIlP.lrsd Only),
a.ACTlONSl tiny pertV' In Int"..t not ..tI,fled ..Ith thl .pp~~Is.'.nt. .1I0"lnOI or dlsl': 'I"IRO. of deduotlon., or ......lMnt
of t(tIC tinclucHn. dhcotA"lt or Int.r..U II .ho~n on thh Hotlc. IUlt obj.ct within .hty(60) d.y. of r.c.lpt of
thh Motlc. bYI
--.rltt.n prot..t to thl PA n.pert..nt .,f R.v.nue, !Iolrd 0' "JlPIIIs. O.pt. ZII021, H"r.!.lburg, PA 1712141OZI, OR
u.l.ctlon to hlv, the ..U" a.t.r.ln.d .t tlUdlt of the Hcount of the plrson.1 r'p"..nt.tlvl, Oil
--app..1 to the Orphan,' Court.
ADMIN
IS1RAlIl/t
CORRECTIONS I
Feotu.1 .rror. dl,covlr.d on thl, ........nt .h~~ld b. .ddr....d In ~rltln. tal P".O.p.rt..nt of R.VInUe,
lur"" of Indlvldu.l TlM'I, ATTN. Po.t A.......M AIV'I.. Unit. Dept, 110601, Herrllburl, PI. 1712140'01
PhoM 0'17) 717-6105. S.. PI" ft of the bookl.t .'In.tructlon. for Inht>ritltnc, hM A.turn for. Rllldent
Dtc.-.nt" (REV-IID1) for '" 'M~IItn.tlon 0' Idlini,tr.ttv'IY corr.etlbl. .rror..
DISCOUNT I
If tny t.IC due I. p'ld wlthtn thr.. IS) o.l.nd'r ~nth, .ft.r thl d.c~t'. d..th, . ftv. p'rc~t ('~) dl,count of
the t.IC p.ld II .110Med.
The 11~ t.IC 8InI.ty non.,.rtlclpatlon ptn.lty II coeput.d on t~ tot_t of thl t.IC and I"t.r..t ......td, ~ not
p.ld blfor. JtnYlrY 1', 1"'. thl flret d.y.fter thl .nd of thl tlIC ......ty period. This non-p.rtlclpatlon
Plnllt" It tpp..ltbl. In the .... """'Ir end !n the the 'H' tI.. P.rlod .. YOU would ",p..1 thl teIC If1d Inter..t
th.t h.. bien ......ed " Indlc.ted on thl. not lei.
PINAL TV 1
IN1EIlt!IT.
Inter.., II Chtr"d blllnnin. with flr.t d.y of dellnqu.ncy, or nlnl (.) 1I0nU,. Md one (I) d." fro. the dlt. of
de.th, to tM dltl of P'VlMf\t. hIC.. ...,Ich b.c... delinquent b.fore JlRUery I, 1912 blar lnter..t .t thl rlta 0'
.1Jt ('10 percent Plr IM'oIIl o.lculatld .t . d.lly ret. of .00016it. 1011 t.M.. which bee... dtllnquoent on and .ft.,
JlJ'Ulrv 1, 1'12 ..Ill bier Int.r..t .t . ret. 'fhlch will VIrV frOll e.l.nder VI., to c:..l.ndar yl., with that nt.
ennouncad bV thl PA DIp.rt,,"t 0' _.venut. The Ippllclbt. Int.r..t r.t.. 'or 191Z through 1"7 .r.,
t!!.t Inter..t fltto Oalh Inter..t F.ctor I!!! Inter..t Rlt. bib Int.r..t Feotor
It" taX .OOOMI 1917 .X .00021t7
1.11 ax .000"11 1"141"1 11;( .ODOJOl
It~ m .00OJOI 1"2 .X .00U"7
I.n IIX .Ions, 1"]-Jl~'4 IX .0ODltz
I." lOX .00027~ 199'-1997 .X .000141
ulnt.r..t I. c.lcul.t.d .. fallCMf"
INTEREIT . BALAHCE OF TAX UNPAID X HUHIER OF DAYI DELINqUENT X UAlLY I"TEREIT FACTOR
44M>>' NottCI ,..utd .ft" thl; ta)( bIcIDH' delinquant ..Ill relllet In lnt.,..t clloulltlon to flft.." (ll) d.y,
beyond the dlt. of thl ......-.nt. If p.y.."t h a" .ft" the Int"..t coeput.Uon d.ta .hown on thl
Notlc., Iddltlonal lnter..t ..,.t be ctlcul.ttd.
STATUS REPORT UNDER RULE 6.12
Name of Decedent: ,j..,.,. '.,I- ._;~ i h ,) (C~ ,.., (
Date of Death: 6 (' ~ (q'-;
Will No. 11(47 - W-.J'? ~ Admin, No.
Pursuant to Rule 6,12 of the Supreme Court Orphans'
Court Rules, I ~eport the following with respect to completion of
the administration of the above-captioned estate:
Statt)fhether administration of the estate is complete I
Yes+- No__
2. If the answer is No, state when the personal
representative reasona~ly believes that the amninistration will be
completel____ ~~\
1.
). If the answer to No, 1 is Yes, state the following I
a. DiJ the personal re~esentative file a final
account with the Court? Yes NO_~,
b. The separate Orphans' Court ". (i f any) for.
the personal representative's acccunt is: /l/{;?\
c. Did the personal representative st~ an
account informally to the parties in interest? YeB~ No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerlt of th, e Orphans' Court and may b,e at;...tac~ d to this raprt,:
I J /l(, :J
Date: , ('i,,(q7 / ( /. '~/
, 's \Ire '.
. (( ;1\jM. G \1" "~1k~r
Name (Please type or pr~t)
'f 6 (? l'..t~;,J ?7 r
Address -t1d(WIl -{'Co.
I ) r'? r.. ~ '?if I (
Tel. No,
C"
1"1
n:
r-.-_,
P,
j_L? .5
()Q
Capacity: _____Personal Representative
ircounsel for personal
~representative
(HAH :rmfl AM))