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HomeMy WebLinkAbout11-07-07 PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WillS OF Estate of Thelma S. Grove also known as CUMBERLAND COUNTY, PENNSYLVANIA File Number 21- (Jl- lO I L , Deceased Social Security Number 203-10-2624 R. Gary Sipe Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE 'A' or 'B' BELOW) [!] A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the Executor last Will of the Decedent, dated 12/21/2005 and codicil(s) dated named in the 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 instrument(s) offered for probate, was not the victim of a killing and was never adjudicated an incapacitated person: o B. Grant of Letters of Administration (It applicable, enter. c.t.a.; d.b.n.c.t.a.; pedente lite; durante absentia; durante mmontate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) anHtleirs: (If AdministratIon, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)'.) ~:..:; I Name Relationship Residence .' .'. ) I ..--.; '.,- -~ Ii --', S,,) ~..:'") ....- (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania with his I her last principal residence at 474 Bethany Drive, Mechanicsburg, Cumberland, PA 17055 (List street address, town/city, township, county, state, zip code) Decedent, then 91 years of age, died on 10/30/2007 at Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property (If not domiciled in PAl Personal property in Pennsylvania (If not domiciled in PAl Personal property in County Value of real estate in Pennsylvania situated as follows: 750,000.00 $ $ $ $ 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 appropriate form to the undersigned: -{ R. Gary Slpe Typed or printed name and residence 1216 Kings Circle Mechanlcsburg, PA 17050 Form Rev. 10-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc. Page 1 of2 ~. Oath of Personal Representative } SS } 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. before me this '7~ iZ -I: YL ~~, s;g_m of "-,, Re~ R. ary Slpe Sworn to or affirmed and subscribed day of f00~~.',-D106( t0~L-y~O-Qj~ ~ . 1.. ~o; the_Rilgister --, - 0 Signature of Personal Representative Signature of Personal Representative File Number: 21-- Ot - /()I;). Estate of Thelma S. Grove , Deceased Social Security Number: 203-10-2624 Date of Death: 10/30/2007 AND NOW, ~\~~ \UA. l , ~f~Sl , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters Testamentary are hereby granted to R. Gary Sipe in the above estate and that the instrument(s) dated 12/21/2005 described in the Petition be admitted to probate and filled of record as the last Will (and Codicil(s)) of Decedent. FEES Letters..................... ....... ................ $ ..,E5 tD () I C'J:) 071../-.00 ~ct~ V-~YL4 ~J:~~LiJf:1W .' Register of Wills 0.... r iJ:~ Attorney Signature: ., Short Certificate(s)........................ $ Renunciation(s). ................ ............ $ JMcA.1.L ~<!.2 O....,...,_:T\...~~~ 15,c~ lo.(::() $ 5cD $ $ Attorney Name: James D. Bogar Supreme Court I.D. No.: 19475 Bogar & Hipp Law Offices Address: One West Main Street $ $ $ $ $ $ TOTAL..................,............... $ 1.9) I-f . cD Shiremanstown, PA 17011 Telephone: 717-737-8761 Form RW-02 Rev. 10-13-2006 Copyright (c) 2006 form software only The Lackner Group. Inc. Page 2 of 2 LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee tor this certificate, $6.00 P 13823560 Certification Number Hl05143REV 1112006 TWE I PRINT IN PERMANENT BL.'.CI(INK This is to certify that the information here given is 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 Office for permanent filing. --t~~~~ 11/ I /ff7 '&cal Registrar . 0 f Date Issued -...l ~ ~-.) "--', ,.-, '-_.J .j:"" COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH (See Instructions and examples on reverse) STATE FILE NUMaER II. Pt.ct cI D.d\ Chect - iii,,,...... OERt_ OOOA O........H_ 0- o""".Sf>oaIr '~7,,~=-<>;;n, IilNo Oy" 10r::.,,-............_* -'P_-."") White 13 -.E-ISpodfy""''''''"lI'''''_1 " M_S.....,_....._. E""""'-YISecondwy(O.I2) "-(1~"S+1 _.0;...../_ 12 Widowed 1 NIff\e 01 o.c.dMI (First, middle, Iut, sufb;l Thelma Grove $. ... (laIlWf>da,) s, 0.. of 8dl Monlh. 91 September 7,1916 Mechanlcsburg, y" .. """""010." Cumberland ad. FIIQIity N......(trnolins&ilulion, s;v. ItrMtlndnumblr) East Pennsboro Holy Spirit Hospital 11 o.c:.o.nr.UI&lIlOa:u IIion KindrJworkcble KindclWutl Bank Teller 12. W...Oecedent....inlht U,S. Anntd ForteI1 oy" 1l!I.. ~r. AdtllllUsidenot 17.. Sill. PA Cumberland 18. MaCher', Name (hst, ~ nuiden NTIMleJ Matilda Fowhl 474 Wesley Drive Mechanlcsburg, PA 17055 16 FMh<<"', NlllU (Frst, middle, lut. "'fib:) 17b Counly Albert Slpe o w ~ " ~ 20. kl!onnlflt'INarne (Typt/Prinl) 3 Socill s.c.n, Numb<< 203 - 10 4.0Ilecto.lIh(Monft,GlJ,""1 October 30, 2007 [);d_ Uv.in. T_' T... Lower Allen 17c. iii Yes.o.c.dtnlUvtdin 17d 0 :U=~wtdv.1thin City/Bora 2(1), Inbm"'''1 MtiingAdrtUl (s..... cily/1oMl,...., lipcodt) 1216 Kings Circle Mechanicsburg, PA 17050 21c. Pa.:. of 0i1pOSition IN..... of CIIlMtrt, aemttory or oIhIr plactj 21d. l.oc:ttion (Citr I lawn, ..., zip Cllldt) Barren's Salem Union Cemetery Dillsburg, PA 17019 22c. Namt Ind Adlt... of FtciitJ' Myers Funeral Home, Inc. 37 East Main Street Mechanlcsburg, PA 17055 100I124-26 mu" bt almpItted b~ ~5Oll . IIIIhopronoun08lo.alti 11:30 AM M 25, D." Pronounc:.d Dud (MontI. day, ~..) October 30, 2007 CAUS& OF DEA TN C8M Instructions .nII ...mpt..) Item 27 PART I Em. ....~-di..AiU. ~I. 01 c:ompicationt-lh-'dirllCCl'fcauHdIMdltIh DO NOT ....l<<lwmin..ItY....1I sudl UCll"dillCll"J.&t, ~spir.Jarr", OIw..ia.d.librillation~lhoutshOYoingrtl..tiology, U5ton!rOf\4lcau..on.1Ch in. 23b. l.ic.nu Numbtr 23c Om. Signed (MclnII. da~, ~..) 2& WuC... IWMtd IoMrldical Ellamlnlr/Ccrontf b.Rauon 0.. INn ~ 0I00n11ti0n? o y" iii No App-o:cim.-.jnqnoal' PIftIl:EnllroltwsicnficantCClnlilionlcon.ibdinaliodulll 21 OkfTcbaocoUuCcnibutekloOull? OnNl 10 o.aIh bulnolrllulinginlMundlrlJingcau.."YMinP..1 0 V.. OProblbly 0'" 0........ 32f. It Transportllicwl lnjury (SptcifyJ ocn,.'Opwstu op",- oPode..... M 0""". ""''"'' 311 Cwtifi...{c:n.ct~ONII J3b. :tr"IndTitltofCwtiNr ~:::::::::~:::d:::::::'u~:th~;:~~t~::::~;-:I~~~~~~~~~_2~1_ _ _ __ __ :"':_ __ __ _ _ __ _ n ... 'AA~ ~ ~:a:=~:: ==~=:::::u::=~::~~:U~II:~~:'~:):d manner IS ltalN.. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.D 3k liotnH NurrW.- 3Jd. OM Sipd (fklnlh, da~.,..-) ~.alb~amiot:~f~~-;;and'Orln'l.IUllation,lnm"Plnlon.ct.athoceurrWaltheUm"d'l..andplllC..anddu.loth.caul"llandmann.alltatad.__D f\,\ 0 4- a'1 ~J Ii , D 1- D(t""t~.t~ibm~K~tttt~~~ 5l.. 'f~NOU: PH'U- 17011 =:,=:'<J:~."'~ . P.>1V'l1~ PNlC.AJmONIA Du'lolor...conuqu.nc:.ol) SequM1IaIJ hI condIlIDnJ. if any. INdng to QUM hl<<i on MI. a En..- ill UNOERl VIHG CAUSE (ci..~OIinjurylh..iniUtlld.,. . .~ltfftll;kinllir,dINlhlLAST. Dallo (or al. c:onl.qu.f1C1 of): Dulli.llDl' 1t.'Dfluqu.nc:'ol}' JOa Wu..Aulop$, P<<fOlmed? JCh W..AiIIDpI~ Findings 31. Man.....ofOeIth ~\I~=~:1I1;omple1ion iii Natural 0 HCImictdtl 0,.. iii.. OAc:cideri1 DP'ndlnglnv.SliglIliOll o Suicide OCoold NOl be Delllfmined .l2d. TiIM of Injury 0,,, iii.. ~ l!l i5 ! NONS1 <2t.f'v'f\11 0 N fYllOoJ"t(UJ II"\"L II\k~l11 28.IfFMlIIa' o NO! P9anl _in pat J.. Pr9n.lifMoIdtlCh o Not p..,.m. but pr~ v4lin 42 da~. 01...., ONolP".ant,bI.ilp~lnd.l'llot,.. 01- OUnknovinilP'.-mwitlinhlpul.~. J2c. ~oflniwr: ticrnI, FImI, St.. FIdOIy, OlbBoMlOnt''''(~ 32" locatlDnolIl1urrISt..citr/tow.n,''*1 ,~ ""'\ ~ d .....\ LAST WILL AND TESTAMENT OF THELMA S. GROVE I, THELMA S. GROVE, of Mechanicsburg, Cumberland County, Pennsylvania, make, publish and declare thisa?~ and~for my Last will and Testament, hereby revoking all other WiTls C'fnd ..-~....J Codicils heretofore made by me. FIRST: I give and bequeath the sum of Five ThousanCland No/100 ($5,000.00) Dollars to the FRANKLIN LUTHERAN CHURCH, ~~e ~.. church of my late husband, GLENN B. GROVE, of Franklin Church Road, Dillsburg, Pennsylvania, to be used for general church purposes as deemed appropriate by the FRANKLIN LUTHERAN CHURCH. SECOND: I give and bequeath to my niece, LUCILLE SIPE WILT, of 410 Third Street, New Cumberland, Pennsylvania, the hutch located in the second bedroom provided, however, that should she predecease me, I direct that the bequest specifically set forth under this Clause be and become a part of my residuary estate to be distributed as set forth in Clause SEVENTEENTH hereinbelow. THIRD: I give and bequeath to BETTY GROVE McCAUSLIN, of 181 Dug Hill Road, Biglerville, Pennsylvania, the Corner Cupboard (including all dishes and knickknacks normally located therein and thereon), the davenport and love seat, glider rocker, bedroom suit and chest of drawers (including anything located therein except, however, any jewelry, which is not included in this bequest), provided, however, that should she predecease me, then to my niece, KATHY J. McCAUSLIN, of 124 Robson Road, Di1lsburg, Pennsylvania. FOURTH: I give and bequeath to ERIC G. GROVE, of 7 Maple Place, Andover, New Jersey, the nephew of my deceased j \ ~ ~ ~ ~ ~ ~ husband, GLENN B. GROVE, the American Flag and case that was placed on my deceased husband's casket, provided, however, that should he predecease me, then to DALE R. GROVE, brother of my deceased husband, GLENN B. GROVE, of 237 Hickory Road, Littlestown, Pennsylvania. FIFTH: I give and bequeath to my niece, CINDY K. SOWERS, of 1366 White Oak Tree Road, Gardners, Pennsylvania, the small black stand and mirror, provided, however, that should she predecease me, I direct that the bequest specifically set forth under this Clause be and become a part of my residuary estate to be distributed as set forth in Clause SEVENTEENTH hereinbelow. SIXTH: I give and bequeath to my great-niece, SUZANNE WILT SCHMITT, of 105 S. Madison Street, Harrisburg, Pennsylvania, my white crochet afghan with pink roses, provided, however, that should she predecease me, I direct that the bequest specifically set forth under this Clause be and become a part of my residuary estate to be distributed as set forth in Clause SEVENTEENTH hereinbelow. SEVENTH: I give and bequeath to my great-niece, JoANN WILT LOWER, of 1365 Old Quaker Road, Etters, Pennsylvania, my crochet log cabin afghan, provided, however, that should she predecease me, I direct that the bequest specifically set forth under this Clause be and become a part of my residuary estate to be distributed as set forth in Clause SEVENTEENTH hereinbelow. EIGHTH: I give and bequeath to my nephew, DANIEL EDWARD GROVE, of 401 North 5th Street, Lemoyne, Pennsylvania, the Grove Farm picture, provided, however, that should he predecease me, I direct that the bequest specifically set forth under this Clause be and become a part of my residuary estate to be distrib- uted as set forth in Clause SEVENTEENTH hereinbelow. 2 ~ ~ d 1..) NINTH: I give and bequeath to BETHANY VILLAGE, of 325 Wesley Drive, Mechanicsburg, Pennsylvania, my sewing machine, with specific direction that it be used in the Craft Program. TENTH: I give and bequeath to DALE R. GROVE, my de- ceased husband's brother, of 237 Hickory Road, Littlestown, Pennsylvania, the end table and light, silverware, black antique chair, glass candle holders, small clock on shelf and wooden set of buildings (located on the corner cupboard), provided, however, that should he predecease me, I direct that the bequest specifi- cally set forth under this Clause be and become a part of my residuary estate to be distributed as set forth in Clause SEVENTEENTH hereinbelow. ELEVENTH: I give and bequeath to my niece, JOYCE SOWERS IRVIN, of 86 White Oak Tree Road, York Springs, Pennsylvania, my jewelry, diamond watch, diamond ring, wedding ring (all being located in the dresser in my bedroom) and the cedar chest (lo- cated in the second bedroom), provided, however, that should she predecease me, then to my niece, PENNY SOWERS DAVIS, of 228 N. Main Street, York Springs, Pennsylvania. TWELFTH: I give and bequeath to RYAN T. SIPE and TYLER R. SIPE, the children of KIMBERLY J. ANSERSON SIPE and R. GARY SIPE, or the survivor thereof, of 1216 Kings Circle, Mechanicsburg, Pennsylvania, the curio, the Hummel Collection and all other pieces which accompany that collection. THIRTEENTH: I give and bequeath to my niece, PENNY SOWERS DAVIS, of 228 N. Main Street, York Springs, Pennsylvania, the dining room table and four (4) chairs, provided, however, that should she predecease me, I direct that the bequest specifi- cally set forth under this Clause be and become a part of my residuary estate to be distributed as set forth in Clause SEVENTEENTH hereinbelow. 3 i ~ ~' '1 '> ~ ) "0 ,. FOURTEENTH: Any and all personal property, furniture, contents and the like owned by me at the time of my death and not specifically set forth in this, my Last Will and Testament, shall be and become a part of my residuary estate to be distributed as set forth in Clause SEVENTEENTH hereinbelow. FIFTEENTH: I give and bequeath the sum of Five Thou- sand and No/100 ($5,000.00) Dollars to my friend, JOETTE GIBSON, of 503 Katrina Court, Mechanicsburg, Pennsylvania, provided, however, that should she predecease me, I direct that the bequest specifically set forth under this Clause be and become a part of my residuary estate to be distributed as set forth in Clause SEVENTEENTH hereinbelow. SIXTEENTH: I give and bequeath the sum of Five Thou- sand and No/100 ($5,000.00) Dollars to my niece, MARLENE SIPE DAUGHERTY, of 910 Sterling Court, Enola, Pennsylvania, provided, however, that should she predecease me, I direct that the bequest specifically set forth under this Clause be and become a part of my residuary estate to be distributed as set forth in Clause SEVENTEENTH hereinbelow. SEVENTEENTH: I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, as follows: (A) Thirty (30%) percent thereof to my nephew, R. GARY SIPE, provided, however, that should he predecease me, then to his wife, KIMBERLY J. ANDERSON SIPE. In the further event that both R. GARY SIPE and KIMBERLY J. ANDERSON SIPE predecease me, I give and bequeath said share, in equal shares, to RYAN T. SIPE and TYLER R. SIPE, the children of R. GARY SIPE and KIMBERLY J. ANDERSON SIPE. 4 ~ ,~ ~ d ~ (B) Thirty (30%) percent thereto to KIMBERLY J. ANDERSON SIPE, provided, however, that should she predecease me, then to R. GARY SIPE. In the further event that both KIMBERLY J. ANDERSON SIPE and R. GARY SIPE predecease me, I give and bequeath said share, in equal shares, to RYAN T. SIPE and TYLER R. SIPE, the children of KIMBERLY J. ANDERSON SIPE and R. GARY SIPE. (C) Ten (10%) percent to LUCILLE SIPE WILT, provided, however, that should she predecease me, then to her issue per stirpes, by representation. (D) Fifteen (15%) percent to DALE R. GROVE, provided, however, that should he predecease me, then to his issue per stirpes, by representation. (E) Fifteen (15%) percent to BETTY GROVE McCAUSLIN, provided, however, that should she predecease me, then to her issue per stirpes, by representation. EIGHTEENTH: Should either RYAN T. SIPE or TYLER R. SIPE, not have attained the age of twenty-five (25) years at the time for distribution to them, I give, devise and bequeath their share to my hereinafter named Trustee or Trustees, IN SEPARATE TRUSTS, to hold, manage, invest and reinvest the shares so received, and to use and apply from time to time such portion of income and principal for their post-high school education (in- cluding college, trade school or other similar training or education), as my Trustee or Trustees, in their sole discretion, deem advisable. The Trustee or Trustees, in exercising their discretionary authority with respect to the paYment of income or principal of the within Trust to either RYAN T. SIPE or TYLER R. SIPE, shall take into consideration any income or other resources available to them from sources outside this Trust. Any income or principal not so applied shall be dis- tributed to either RYAN T. SIPE or TYLER R. SIPE when they attain the age of twenty-five (25) years. In the event either RYAN T. 5 J '\, , ~ J J :J- '\:..1 , . SIPE or TYLER R. SIPE die prior to the termination of the Trust established herein for their benefit, the interest of either RYAN T. SIPE or TYLER R. SIPE in said Trust shall cease with any income and principal passing to the survivor as between the two of them or the separate trust established hereunder for that survivor's benefit. NINETEENTH: In addition to all powers granted to them by law and by other provisions of this Will, I give the fiducia- ries acting hereunder the following powers, applicable to all property, exercisable without court approval and effective until actual distribution of all property: (A) To sell at public or private sale, or to lease, for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms (including credit, with or without security) or conditions as are deemed proper. This includes the power to give legally sufficient instruments for transfer of the property and to receive the proceeds of any disposition of it. (B) To partition, subdivide, or improve real estate and to enter into agreements concerning the partition, subdivi- sion, improvement, zoning or management of real estate and to impose or extinguish restrictions on real estate. (e) To compromise any claim or controversy and to abandon any property which is of little or no value. (D) To invest in all forms of property, including stocks, common trust funds and mortgage investment funds, without restriction to investments authorized for Pennsylvania fiduci- aries, as are deemed proper, without regard to any principle of diversification, risk or productivity. (E) To exercise any option, right or privilege granted in insurance policies or in other investments. 6 ~ , <',<~I " d '\-:-:0 . . I' (F) To exercise any election or privilege given by the Federal and other tax laws, including, but not necessarily being limited to, personal income, gift and estate or inheritance tax laws. (G) To make distributions to my herein named benefici- aries in cash or in kind or partly in each. (H) To borrow money from themselves or others in order to pay debts, taxes, or estate or trust administration expenses, to protect or improve any property held under my will, and for investment purposes. (I) To select a mode of payment under any qualified retirement plan (pension plan, profit sharing plan, employee stock ownership plan, or any other type of qualified plan) to the extent the plan or the law permits them to do so, and to exercise any other rights which they may have under the plan, in whatever manner they consider advisable. TWENTIETH: I nominate and appoint JEFFREY J. ANDERSON, of 6111 Glatfelters Station Road, Seven Valleys, Pennsylvania, as Trustee of the hereinabove described trusts. In the event of the death, resignation or inability to serve for any reason whatso- ever of the said JEFFREY J. ANDERSON, I nominate and appoint, TIMOTHY C. BARRETT, of 253 Noah Drive, Franklin, Tennessee, as Trustee of the hereinabove described trusts. I direct that my Trustee or Trustees shall serve without bond and shall receive fair and reasonable compensation. TWENTY-FIRST: I direct that all inheritance, estate, transfer, succession and death taxes, of any kind whatsoever, which may be payable by reason of my death, whether or not with respect to property passing under this Will, shall be paid out of the principal of my residuary estate. 7 , . . , TWENTY-SECOND: All interests hereunder, whether principal or income, which are undistributed and in the posses- sion of the fiduciaries acting hereunder, even though vested or distributable, shall not be subject to attachment, execution or sequestration for any debt, contract, obligation or liability of any beneficiary, and furthermore, shall not be subject to pledge, assignment, conveyance or anticipation. TWENTY-THIRD: I nominate and appoint R. GARY SIPE, Executor of this, my Last Will and Testament. In the event of the death, resignation or inability to serve for any reason whatsoever of the said R. GARY SIPE, I nominate and appoint KIMBERLY J. ANDERSON SIPE, Executrix of this, my Last Will and Testament. I direct that my Executor or Executrix, my Trustee or Trustees, and their successors, shall not be required to post security or a bond for the performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, this ,,2 I At day of 'j}.Jl \\iL~ ' 2005. j~Q, /4 ~. (SEAL) THELMA S. GROVE 8 . . Signed, sealed, published and declared by the above- named Testatrix as and for her Last Will and Testament in our presence, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as attesting witnesses. Address Address 9 OATH OF SUBSCRIBING WITNESS(ES) REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA ,;< 1- 0-,- 1012.. .') Estate of Thelma S. Grove C"-' I -__1 -('1 , ~ , Deteased CJ ~ James D. Bogar, Esquire and Beth B. Lengel , (each) a subscribing witness to (Print Namels) the t!2IWill C1 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 / they signed the same and that she / he / they signed as a witness at the request of the Testator / Testatrix III her / his presence and in the presence of each other. (S~~ V3, cfl#lfJ 1 West Main Stree 1 West Main Street Public My ommission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) (Street Address) (Street Address) Shiremanstown, P A 17011 (City. State, Zip) Shiremanstown, P A 17011 (City. State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed Executed out of Register's Office Sworn to or affirmed and subscribed before me this .to -+ V\ day of \JrJ\I 1- ~.\x r , ~OO=t- . before me this day of Deputy for Register of Wills NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of notarization. Form RW.03 rev. 10.13.06 r \~ 1'0 , '....y \LJ.iis ,",. e::: ot; !';;~";':-~ . '. ,,'Ei.i- ,....J~..I f" tn \":,~- \";~.I.I .-roo) ;,. 1St; l~<! ,'"