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Home My WebLink About01-28-08PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of PETER MILLER File Number __ ~/ ~`•'~~(~ ~ ~~ ~ ~p also known as Deceased Social Security Number 183-14-4933 Petitioner(s), who is/are 18 yeazs 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 / aze the Personal Representative * named in the last Will of the Decedent dated August 27, 1999 and codicil(s) dated none * See Renunciation of Arlene M. Miller (spouse of decedent) named as Persona] Representative in Will and Renunciation of Luann Browder ~t~hter of_decedent)-named as one of the successor Personal Representatives in Will of Peter Miller. (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: ~~ ~ ~ ~ ', B. Grant of Letters of Administration =J~~, ~ __ (Ifapp/icable, enter.• c.t.a.; d.b.n.c.t.a.; pendentelite; duranteabsentia; durante~iit?&T atg N - . ~~ ~~ Petitioner(s) after a proper seazch has /have ascertained that Decedent left no Will and was survived by the following Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. a ase~~' ~) and heirs: ({f C~'~i=1 --'+.Sw _ ice = { ~` ~~ y ` ~.~ Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal residence at (List street address, town/city, township, county, state, zip code) Decedent, then 86 years of age, died on December 18, 2007 at 1700 Market Street, Camp Hill, PA 17011 Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ 9,000.00 (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania $ 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 appropriate form to the undersigned: Si nature T ed or rioted name and residence // _ „ Maraylyn Kelly 710 Sterling Court Enola, PA 17025 Form RW-02 rev. 10.13.06 Page 1 of 2 ~.-.,, _„ - _ _ , Oath of Personal Representative - - _ COMMONWEALTH OF PENNSYLVANIA ss ~ 8~8 J~~~ 2~ ~~Fi o~ I I COUNTY OF (,(,~'jL~t l~ . The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the fore oin Peti L~ / ~ g g ,~~T,e{a a~~aQnrect to the best of ~} ~lJ~ ~ I V -i1~S `d~~1 ~ . , the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decede~~~,~~ittoiief(s7 will wetP,'-and truly administer the estate according to law. Sworn to or affirmed and subscribed b re me the ~~ daycof r ~VVa ~~ ~ For the Register Signature of Personal Representative Signature of Personal Representative Signature of Personal Representative File Number: ~~ " °~~~" ~~ ~~ Estate of PETER MILLER Deceased Social Secu ~ty Number: 183-14-4933 Date of Death: December 18, 2007 AND NO W, ~ ~~ ~ , in consideration of the foregoing Petition, satisfactory proof having been presente before me, I S DECREED that Letters Testamentary are hereby granted to Maralyn Kellv in the above estate and that the instrument(s) dated December 18, 2007 described in the Petition be admitted to probate and filed of record as the las Will (a d Codicil(s)) of a dent. FEES /~'~ ~ ~~ . Register of W is ~ - Letters ............... $ Short Certificate(s) ........ $ • w Attorney Signature: Renunciation(s) .. o~ ..... $ ~~- ~ ~ Attorney Name: Susan H. Confair ~~U, f / ... $ /.S. • • • $ /U ~ Supreme Court LD. No.: 70241 Address: Reager & Adler, PC ... $ ... $ 2331 Market Street ... $ $ Camp Hill, PA 17011 ' ' ' $ Telephone: 717-763-1383 ... $ r Gib .g.gg~-~ TOTAL .............. $ Form RW-02 rev. 10.13.06 Page 2 of 2 105.805 REV (01/07) LOCAL REGISTRAR'S CERTIFICATION OF DEATH ~`~ ~~ WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 r P 13972146 Certification Number This is to certify that the information here given i correctly copied from an original Certificate of Deatl duly filed with me as Local Registrar. The origins certificate will be forwarded to the State Vita: Records Office for permanent filing. 1 d Local Registrar Date Issued _'v tt/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS TINT IN "~NKT CERTIFICATE OF DEATH ($ae ifIStTMDt10{1a and examples en rwverswl r~> ~~ _ ~ - {~ ~~-, v ~ ~- l ~ ~ ~ ~ ., ~-, N - ~ o %: ,.h ~ ; Y~ . ~.~ r--~ . ., --• ,.. - - . i , ~-'~ ~~ ' ~ IXI t Yllt NUM6ER I. Name d D t (First, mie]le. last. suffix) 2. Sex 3. Sala) Security Number 4. Date of Deatn (Month, day, year) ~t~~ ~ der ill i 3 - ~y- 9~j A 5 e La t &nhd U d 1 c~ew.•1e•: ~ a ~ g . ( s ay) n er ear Under I tlay 6. Dated &M (Monet, da , yeaq 7. &Mplace (C' and state «brygn country) 6a. place W Death (Check only one) MUnNS Days NgaS MinNes n', [~[ /~ Hospital: Olhef. Yrs. /1'1a{I w / • ~ 9 Z~ J 9 k{91ll vT 6{k~ Q ~ r z ^ Inpatient ^ ER / Outpatient ^ DOp ~ Nursin 6b County of Death g ^ Resltlence Home ^Olner ~ Speciry: . tk. City Boro, Twp. of Deatn 6d. Fadkry Name (II not institution, give street a1M number) 9. Was Decetlent of Hispanic Origin? ®No ^Ves f 0 Race: Amencan Indian. Black WMIe etc (If yes, specity Cuban, ('LAtM ~asr zL,r, ~ ~ l}IVO ~ ~l~ja ,!{(Ah( ~C/V I ~($ Mexkan Puerto Rican t , , f5pec+M / , . e c.) 11 Decedent's Usual Oct lro Ki f d k ~ • . a n n o wor done dpi nws d wwkin lee. Do not stale retrc 12. Was Decedent ever ro the 13. Decedent's Etlumlion (Spaiy only highest grade completed) 14. Marital Status: Married. Never Married, 15. Surviwn9 Spase Ilf mfe give maiden name) Kind of Work U S Armed F T . . orces KUM d BJy~s`m~es~s / UidusUy Elementary /Secondary (0-12) College (1 d or 5.) Widowed, Divorced (Speci/y~ I G Yj (;yl1N /~N•Jtn..7rGr'. ~JYas ^NO (2 / I ' , A IK/ ' Y4 I // 16. Decedent's Masing Address (Street, city I town, state, zip code) Decedent's Did Decedent 1 /Y U G { P! N ~ / •//( C " rN Aiy9r./ ~ , • { / f Actual ResiderKa /7a. Slate Nl •f V a.N • /Y Live in a ^ Yes, Decedem Lived in Township? 17c. //// r (/n -^• ~ •' Twp. (/ / 1 y /J ~ d/M `J N(/ j ! ~ ~ 7 ~'{ Sl 17D. COUnIy_.. I^d ~4 A...M { d 17d. (~ No, Decedent Uved wil A l i mn p P~C~N+SLu/ ctua mitsd L 1B. Father's Name (First middle, last sufix) 19. Mama's Name ' I F rs l, myde, maiden surname) GI BOrc y ~ 1 / k ~ L { 20a. Informant's Nama (Type / Prinq 20b. Informant's Mailing Address (SUeeL city /town, state, zp code) : ~~ M;~I A I~ t . ~ r ~~2 r,•. Avg r31~~~-~~N~ ~~ i1 i~- 21a. Memel of Dispositron ^ Crematon ^ Dorlatron 21b. Date d Disposition (Monet, day, year) 21c. Place of Dispasron (Name d m~ea, crematory w other place) Baia) ^ Removy Irom Sate ! W ltd. laatron ICiry /town, slate, zip 4otle) a CnmMlon a Dorwtion Authorized ~~~ ( 7 ~/~~ M ^ Other - Spiny: ~ by Msdlcy Ezemlrwr / Coroner4 ^ Yea ^ No ~(~•""!~ 12 • T,OV f' ,/s{~n~ r w~ ~i7r ~C [ r,,~ ~ ` (L i/ b ~' o ~ ~ ~ ~ d'/T 22a. Sgnata Funeral Service Licensee (« person acting as slxm) 22h. License Number 22c. Name antl Address of Fac{iry - y/G K f' ~.s s ~'a- . ia I 1. 3 S / r .t - L' -oily~i)-~ oD~~~ •~ u.•,~~c~ji-N. y d Yr ~ ~ i7~-Yl'- ti,. Complete hem 23ac anty when candying 23a. To the best d my krpwle0pe, Beam occurred at the tma, tlab and place staled. (Signature and title) 23b License Nlxnber . physician a na avybble al lime d deem ro n d0. D /- (~~ ~ q y .. 5 7i~ cengy cause d deem. Q RA ~ 23c. Date Signed (Monet, day, Year) ~ , _ L' _ ^ q ~NPCI~ ~6F BF~O~ ~ ~ „ Items 2426 must be completed W person 24. Time of Deem 26. Dab Prorloumed Dead (Month, day, ye4ar)e 26. Was Casa Relened to Meticy Examiner / Coroner fa a Reason Olner than Cremation or Donation? who Dronounces Beam. /O; h .Q~/ ONh~ r ~ 7 , .,rver ^ r~+~ Yea CAUSE OF DEATH (Sep Ina4lsr;tlone and saampNS) t Approximate interval: Pan II: Enter ether s~ficant arMil s anlnblt Item 27. Pan I: Enter the fddD-LEY4D6 -diseases. njunes, a mrrplicaUass - that tirectly eased me deem. W NOT eda temwy evaus soh as mrtiac arrest to ee:t , 2g. Ikd Tooaao Use Contribute 1o Deam7 respiratory aney, a venldcdar fibrillation w9MN shown tlw e ~ Onset ro beam Mn rwl reselling In die underryirg cause given n Part I. ^Ves Prohabry 9 eolo9Y. List ady one pose an eaGl line. IMMEDIATE CASE IFna;dsease w nw i candaan res le Beam ~ '~ A No ^ Unkrrown _i a. ~ // G i ~~/y~fo,ysy ~J „K `~ °• ~ 29. II Female: Due to la as a consequerxxs o I f I/ / ~ ~ ~ - ^ NUl pregnam wimm past year i SequeMUW sst cmM1lians. Aarry, / / leadingg ro the carrse Nsletl m ire a. U' ' I r ^ Pregnant al Ume of deem Emer dla UNDEgIYWG CAUSE Due to (a es a aaxsequence pry: (disease a injury mat initialBtltl the I evenle resunir m tleatnl IAST c' I ^ Na pregnant out pregnant wimin 42 days d d th g Due b (a as a consequence oq: ~ s ea ^ Not pregnant but pregnan143 days to 1 year d s bef«e death ^ Unknowm q pregnant wanin dre pall year 30a. Was an Aulapsy 30b. Were ANOpsy Rntirgs 31. of Deem 32a. Dyad Perrormed? AvyWble Prior b Completion '.,/ injury (Madh, day, Year) 320. Describe How Inryry Occurred 32c. Place d Injury: Nome, Farm, greet Factory, d Cause d DeamT L~J Nabry ^ Hancide Omce Buikfing. etc. lSpeciM ^ Yes [a'!!o ^Ves ~ ^ ~~nl ^ Panting Imesdgyian 32d. Time d Iryury 32e. Injury al WoM1? 32f. tl 7ransporbUon Injury (SpeciN) 32g. Laation of Inlu7lStreet. city! lawn. state) ^ Yes ^ No ^ Driver / Operala ^ Passenger ^Pedesman ^ Suicide ^ Coukf Not pe Debmkrad M Olher~ Specity 33a. Cdnilier (deck onty one) 33b. Signature and Ttle d NII • Cedhying phyakbn (Pnysipan ceNrying muse d Beam when andher physician has pronouaed dean ant anpleled hem 23) To the hest of my knowNdga, path occurred dw b Ilb muagq and mambr ae abbd_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ''' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Pronouncing and cerhtybg physcian (PhysKan ham pronouncing Beam pry ceNryk b muse d tl m ~ ~ ~~ g ea l Ta ma beat of my krrowledge, death atoned at IM Gme, date, and ace, and due to Na pl uuse(s)aM manner as abted________________ _ ^ 33c. License Number 33d. D e Signetl IMOnm, day, year) • Medical Examimr /Coroner On the buia d eumination and / a inwatlgaaon, In my opinion, death occurred y ea Uma, dab, and place, and due to tM muse(s) and manner as anted ^ ~~ ~ ? sJ a{ l /~ J~ ~ _ ~ Name and Address of Person Who Com erect Cauu of DeaN dee m 27 T ) YDe / Pnn1 35. Registr; ' t and Diyrkl Number .Date FNad (Monet day year) ./ 1 ~~~~ j /~ • G~ 7 /1+/J , , 7 ,,, Disposition Permit No. { ~' V ~ V LAST WILL & TESTAMENT ~, ~,~ (Pour-over Will) `--' r' .~ o ~;, _ y ~~ ~' ~,~^ PETER MILLER r~ ~ -_-= _ ~'~ ~ ~' 1, PETER MILLER, a resident of Columbia County, State of "-~syl~ania -- revoke any prior Wills and Codicils and make this my Last Will & Tesf~r~ent. ~"' - _ , =--; ca J '• ARTICLE ONE -- -Payment of Expenses £~ Taxes - I instruct my Personal Representative to make payments from my estate viz: 1. Except to the extent paid by United States obligations accepted by the United States Treasury Department at par in payment of federal estate taxes that are assets ofthe- MILLER FAMILY TRUST Dated: ~t/S ~ o~ 7 ,1999, and that are required to be applied by the Trustee of said Trust in payment of federal estate taxes that become due because of my death, my Personal Representative shall pay said federal estate taxes by first applying to such payment any such United States obligations that are assets of my estate. 2. My Personal Representative shall pay from the residue of my estate or shall direct the Trustee of said Trust to pay, or both, as determined in the sole discretion of my Personal Representative, the expenses of my last illness and funeral, valid debts, expenses of administering my estate, including non-probate assets, and any estate or other death taxes which become due because of my death, including any interest and penalties. 3. It is the purpose and intent of this Paragraph (and Sub-Paragraphs) that, so far as is practical, any estate taxes paid shall be paid out of my entire estate whether passing by this Will or otherwise concerning property over which I possessed a general power of appointment, before distribution to any beneficiary: 3.1. If estate (or income) tax or any part thereof is paid by, or collected out of, that part of my estate passing to or in the possession of any person other than my Personal Representative, in its capacity as Personal Representative, such person shall be entitled to reimbursement out of any part of my estate, or otherwise, still undistributed. Such reimbursements may be by a just and equitable contribution by the persons whose interest in my estate would have been reduced if the tax had been paid before distribution or whose interest is subject to equal or prior liability for the payment of taxes, debts, or other charges against my estate. 3.2. If any part of my gross estate on which estate tax has been paid consists of the value of property included in my gross estate under IRC Section 2041, my Personal Representative shall be entitled to recover from the person (or persons, 1 prorata if more than one recipient) receiving such property by reason of the exercise, nonexercise, or release of a power of appointment, such portion of the total tax paid as the value of such property bears to the taxable estate. 3.3. In the case of any such property received by my spouse for which a deduction is allowed under IRC Section 2056 (relating to the marital deduction), this Paragraph (and Sub-Paragraphs) shall not apply to such property except as to the value thereof reduced by an amount equal to the excess of the aggregate amount of the marital deductions allowed under Section 2056. 3.4. If any part of my gross estate consists of property which is includible in my gross estate by reason of IRC Section 2044, relating to certain property for which a marital deduction was previously allowed, my estate shall be entitled to recover from the person receiving the property the amount by which the total tax which has been paid exceeds the total tax which would have been payable if the value of such property had not been included in my gross estate. 3.5. My Personal Representative may (i) exercise all of the foregoing elections and any others available under any tax law, to obtain, to the extent practicable, both the optimum reduction in my estate taxes and in the income taxes estimated to be payable by my estate or the beneficiaries thereof, any business interests in my estate and the optimum deferral of all of those taxes, (ii) make adjustments between income and principal amounts and to allocate the benefits from any election among the various beneficiaries of my estate, and (iii) compensate for the consequences of any election that it believes has had the effect of preferring one beneficiary or a group of beneficiaries of my estate over others. 3.6. All such foregoing elections and adjustments shall not, however, diminish any portion that would create an adverse taxable event to my estate or beneficiaries thereof. ARTICLE TWO - Specific Allocations - I give and bequeath the following: 1. I give all of my tangible personal property (unless such has been transferred to, and otherwise designated in, said Trust) to my wife if she survives me, or if she does not survive me, to the Trustee of the - MILLER FAMILY TRUST Dated: ^~/4u8~ a?7 ,1999, 2. I give all interests in real property used by me or my wife for residential purposes, and all real estate contiguous to or used in conjunction with such property, to my wife if she survives me (unless such property has been transferred to, and otherwise designated in, said Trust). (end of Article) ARTICLE THREE - Estate Residue Disposition- I give the rest, residue and remainder of my estate, that may not have been transferred to said Trust during my lifetime, consisting of all the property I can dispose of by my Will and not effectively disposed of by the preceding Articles of this Will, to the Trustee of said Trust, as amended and existing at my death, in order to be added to and disposed of as a part of the assets of such Trust. ARTICLE FOUR - Personal Representative Appointment - I hereby nominate and appoint my wife, ARLENE M. MILLER, to serve as the Personal Representative of my Will. 1. My wife shall have the power to nominate any additional or Successor Personal Representative. 2. If my wife is unable or unwilling to serve, then I hereby nominate LUANN BROWDER & MARALYN KELLY to serve together; or, one shall serve alone if the other is unable to serve. ARTICLE FIVE -Fiduciary Provisions - The following shall apply to my Fiduciary /Personal Representative: 1. Administrative Powers: My Personal Representative, in addition to all other powers conferred by law that are not inconsistent with those contained herein, shall have the power, exercisable without authorization of any court to (i) sell at private or public sale, to retain, to lease, and to mortgage or pledge for the purpose of borrowing money, any or all of the real or personal property of my probate estate (if any), (ii) make partial distributions from my probate estate (if any) from time to time and to distribute the residue in cash or in kind or partly in each, and for that purpose to determine the value of property distributed in kind, and (iii) sell to, buy from, lend to, and borrow from the Trustee of said Trust even though such Trustee may be the same as my Personal Representative. 2. Administrative Provisions: 2.1. I direct unsupervised administration of my estate and that my probate estate (if any) be administered in as informal a manner as my Personal Representative deems advisable and as applicable law permits. No bond or other indemnity shall be required of any Personal Representative. Iexpressly waive any requirement that any Trust created by me be submitted to the jurisdiction of any court, or that the Trustee of such Trust(s) be appointed or confirmed, or that their accounts be heard by any court. This waiver shall not prevent any Trustee or beneficiary from requesting any of these procedures. 3 2.2. To effect the nomination of my Personal Representative, the person possessing the nomination shall file with the court, having jurisdiction over my estate, at any time after the date of my death. If a 30-day period lapses during which no Personal Representative is acting hereunder and no nomination is filed with the court, a statement that a designated person or entity is nominated as an additional or Successor Personal Representative shall be filed, by the heirs (beneficiaries) of my estate, to effectively appoint a Successor Personal Representative on my behalf. ARTICLE SIX - Postmortem Directives - I have no specific directives concerning the disposal of my body or a memorial service other than those arrangements I have made, either verbally or expressly, with my Personal Representative or family member(s) or other entity. ARTICLE SEVEN - Contents of Will, Testimonial and Attestation Provisions - This Last Will & Testament consists of seven (7) Articles (this Article inclusive) and four (4) pages. Following this (final) Article Seven is an unnumbered page containing aself-proving affidavit. IN WITNESS WHEREOF, I HAVE HEREUNTO SET MY HAND AND SEAL THIS a~ 7 DAY OF A~,Nf~is T ,1999. x ~~ ,s ~ ~~i~ PETER MILLER Signed, sealed, published and declared by the above named Testator as (and for) his Last Will & Testament in our presence who, at his request, in his presence and in the presence of each other, have hereunto subscribed our names as witnesses. x ~, / ~ ~~~ i ss dress fitness Address Subscribed, sworn to and acknowledged before me this - day of ~y~~-sr ,1999. NOTARY SEAL: o ry P is Notaris~l Seal Richard A. Marsh, Notary Public Stroud Twp., Monroe County My Commission Expires Feb. 3, 2003 4 Member, Pennsylvania association of Notaries - AFFIDAVIT OF TESTATOR STATE OF PENNSYLVANIA COUNTY OF COLUMBIA I, PETER MILLER, the Testator of the within, hereby certify that I executed my signature on said Will on - ~~ day of S'GCS~ ,1999. I further certify that I requested signatures as witnesses to my Last Will & Testament from the following individuals: ~• -~. ~~~~~~~ (and) C'/a>R J_' g~> ~/eR Witness Name Witness Name PETER MILLER AFFIDAVIT OF WITNESSES - We, ~ , ~t~rl~9~~K- & ~/ ~~o7i~ ~J ~ ~~P_~ (the witnesses), being first duly sworn, do depose and say to the undersigned authority that we witnessed the Testator's execution of his Last Will & Testament and that he signed it willingly and that each of us, in the presence and hearing of the Testator, hereby sign herein as witness to the Testator's signing, and that to the best of our knowledge the Testator is eighteen years of age or older, of sound mind, under no constraint or undue influence and competent to make testamentary disposition of real and personal property. x Wi ne fitness Address _ J Address Subscribed, sworn to and acknowledged before me this - day of NOTARY SEAL: Notari.u Seal Richard A. Marsh, Notary Public Stroud Twp., Monroe County My Commission Expires Feb. 3, 2003 Member, Pennsylvania Association of Notaries ~~'~~ RENUNCIATION ~~ c~ G~~ ~~- o REGISTER OF WILLS ~ ~ c ; ~ CUMBERLAND COUNTY PENNSYLVANIA ~ ~ ~ ~ __ ~' ._ f Jam' ~ _ ~~ ,iJ a W LP; Estate of PETER MILLER ,Deceased 1, Luann Browder , in my capacity/relationship as (Print Name) daughter of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Maralyn Kelly January ~ I , 2008 ~c.c..cz.~~ ~~~ (Date) (Signature) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills Form RW-06 rev. 10.!3.06 (Street Address) (City, State, ip) ~/!~ Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunc'a i for the purpo es stated within on this day of ~(~1~-t~tt~-y Z°° ~ry Public Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of No Commission.) COMMONWEs4LTH OF PENNSYLVANIA Notarial Seal t L B~arnterrran, Notary Public ~~ t3orr. CtmntraAand County l~Mmder, Pennsylvania Association of tdatarN~ ~~ `I~ ~~ ~~ c~ RENUNCIATION ~° °' ~,~ __ f.. t--- ..;~ REGISTER OF WILLS r~ ~ ~' ~1 CUMBERLAND COUNTY, PENNSYLVANIA ~ ~;- ~, --,:, 7J ~ , ~ t...) Lt~ Estate of PETER MILLER Deceased I, Arlene M Miller, by Agents, Luann Browder & Maralyn Kelly , in my capacity/relationship as (Print Name) spouse of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to MARALYN KELLY January , 2008 (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills Form RW-06 rev. l0. /3.06 (Signature) ~~~' ~ ~ (Street Address) r~.Nys ~ytt/ts rev (City, State, Zip) a'11 Executed out of Register's Office ~UGrn ~~.~~~` Before the undersigned personally appeared~he party executing this renunciation and certified that he or she executed the renunciation for the purposes stated within on this ~ ~f ~ day of ~c~~-~-~ ~S Ci/G~t~ !~ otary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) COMMONWEALTH OF PENNSYLVANIA Notarial Seal Susanne K. Sather, Notary Public Camp Hill Boro, Cumberland County My Commission Expires Aup. 25, 2009 Member, Pennsylvania Assoclatian of Notarla~ NOTICE -This Power of Attorney authorizes the person named below as my Attorney-in-Fact to do one or more of the following: to sell, lease, grant, egcumber, release or otherwise convey any interest in my real property and _~ _ ivexecut~leeds and all other instruments on my behalf unless this power attorney is otherwise limited herein to specific real property. L_ ,_ _ , ~., ~ ' ~ ~ DURABLE POWER OF ATTORNEY ji){(~/.~~,(`)'r . .~..., ~...~ ~ ~ 1. ~_ jai' ~~- ~ ~ OVER ASSETS -~-~ ~_.L --- c~ -~-.- ~~ I, ARLENE M. MILLER, the undersigned, have appointed PETER MILLER, my husband, as my lawful Attorney-in-Fact, and if he is unwilling or unable to serve then I appoint LUANN BROWDER & MARALYN KELLY to perform together (or one shall serve alone if the other is unable to serve) for me and in my name all acts which I might and could do if present and capable, including, but not limited to, the following duties: 1. To sell and convey real or personal property and to enter into sales or exchanges and to make and execute any and all conveyances or encumbrances of such property; to execute, endorse, collect, deposit and receive checks against or in my bank accounts, including checks drawn on the Treasurer of the United States; to draw upon any bank deposits and time certificates in whatever form therein; to buy, sell or exchange securities and to execute stock and bond powers, assignments and bills of sale; to enter any safe deposit box rented by me or jointly with others, to remove any of the contents thereof and to terminate the lease. 2. To assign, transfer, convey and deliver to the Trustee of that certain Declaration of Trust referred to as the - MILLER FAMILY TRUST Dated: d3-~ e?7 ,1999, any and all of my property such as cash, stocks, bonds, securities, annuities and any other property of any kind whether real or personal; to endorse and deliver to said trustee(s) any checks, drafts, certificates of deposit, notes receivable or other instruments for which I have an interest in as monies payable or belonging to me; to designate the Trustee, of said Trust, as the beneficiary any life insurance policies, employee benefit or pension plans or individual retirement accounts owned by me or in which I have an interest, and, in general, to do all things which I, as a grantor of a living trust, might do if present and capable. This Power of Attorney shall "spring into effect" immediately upon the execution of an opinion letter or medical certification of my attending physician (to be attached hereto) certifying my incompetence/incapacity to .carry on my normal affairs because of a mental or physical impairment and shall continue therein until a -. certification from a licensed physician declares that the impairment is no longer effective. 1 I understand the full import of this Durable Power Of Attorney Over Assets ~' document consisting of two (2) pages, of which this is the second (2nd) page, and I have emotional and mental capacity to execute such document. ARLENE M. MILLER The Declarant/Principal has been known to me (an undersigned, as a signature witness) and I believe the Declarant to be of sound mind. I am not related to the Declarant by blood or marriage, nor would I be entitled to any portion of the Declarant's estate upon her death. I am neither the Declarant's attending physician nor a person financially responsible for her medical care. ~~~/ S' Address - ACKNOWLEDGEMENT - STATE OF PENNSYLVANIA COUNTY OF COLUMBIA On this ~_ day of ~ s~~ 1999, before me, the undersigned, appeared ARLENE M. MILL R, who acknowledged before me to be the person executing this instrument by her signature as her free act and deed and- who witnessed the Declarant's signature to this instrument and that to the best of their knowledge the Declarant was at the time 18 or moi' / ars ~e, of sound mind and under no constraint or undue influence. /l NOTARY SEAL: Notary Notarial Seal Richard A. Marsh, Notary Public Stroud Tvrp., Monroe County My Commission Expires Feb. 3, 2003 Member, Pennsylvania Association of Notaries 2 Conseco Services LLC 7/x/2007 1:40 PM PAGE 3/006 Fax Server PHYSICIAN'S CLAIM FORM Pt~ASE ANSWER ALL QUESTIONS, AND SIGN BELOW 1. PATIENTS NAME: ~~~ )~r~ ~ ~ y~ ,f 1 j ~ y~ 2. PRIMAR~~:.O[~DITION(S) CAUSING THIS L05S? 3. DATE OF FIRST TREATMENT FOR PR1MA17Y CONDITION: MO ~ DAY ztv YEAR o s' BY WHOM? (DOCTOR'S NAME & ADDRESS) 4. DATE OF PRIOR HOSPITAL STAY: DIAGNOSIS: HOSPITAL NAME & ADDRESS: MO QAY YEAR 5. ANY NURSING HOME STAY OR (Na-IOME CARE WITHIN THE LAST 5 YEARS? YES NO_ IF YES. DATES: NAME AND ADDRESS OF PROVIDER OF CARE: 6. IS PATIENT COGNITIVELY IMPAIRED? YES_ND_ , (If yes, please attach the resuUs of any tests used th determine this.) 7. DO YOU CERTIFY THAT THE PATIENT IS CHRO~CALLY ILL (expecl8d to require help wtth ADL's for at least SO days due to functional incapaitity or due th cognitive i )? YES VV NO IF YES, DATES: FROM: Y~ ! O: 8. IS THE CARE YOU ARE RECOMMENDING MEDICALLY NECESSARY? YES NO_ 9. WHAT TYPE OF FACILITY ARE YOU RECOMMENDING? Nurs~g Home ARemate Care Facifdy Asalsted Livng_ Other (Pleaseexpialn): DATES: From: ~ / ~~ ^To: WHAT IS THE LEVEL OF CARE~CERTIFIED? SKILLED_INTERMEDWTE_"OUSTODIAL RESIDENTIAL OTHER (IF OTHER, PLEASE EXPLAIN) 10. 1F PATIENT 1S IN AN ALTERNATE CARE FACILITY, WOULD NURSING HOME CARE OTHERWISE BE NECE55ARY? YE5 NO EXPLAIN: 11. INDICATE THE LEVEL OF HUMAN ASSISTANCE YOUR PATIENT REQUIRES WITH THE FOLLOWIN G ACTMTIES: AGTNt'i{>=S OF DA{LY L{V WG NO ASSISTANCE STANDBY ASSISTANGE HANDS ON ASSISTANGE MOBILITY/AMBULATING ~ TRANSFERRING ~ CONTINENCE ~ BATHING ~ DRESSING TOILETING -~ EATING GETTING IN OR OUT OF BED OR CHAIR PHYSICIAN'S SIGNATURE ~ ~ // ADDRESS ~ ~ Z V ~A ~~ ~ ~ ~T``~`~~- PHONE NUMBER 7 31-x' c~'~~ AT•1 X342 PAGE 2 of 8 DATE ~„~/ U ~ ! 7 TAX 1D FAX NUMBER PAGE 318 • RCVD A7 7f3/2007 1:40:Q8 PM [Eastern Daylight Time) • SVR:EAFAX01115 • DNtS:3'137 • CSID:COnsecO Services LLC' Dt1RAT10N ~mm-ss):03A2