HomeMy WebLinkAbout11-20-08PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA
Estate of Blanche G. Fromm
also known aas
File Number 21-08- `~
Deceased Social Security Number 162-07-3154
Mark D. Meabon
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE= `A' or `E3' BELOW)
~X A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the Executor named in the
last Will of the Decedent, dated 11/25/1992 and codicil(s) dated 07/28/1995
Decedent's son, Thomas L. Fromm, died on l~'~' ~i~y
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
app Ica e, en er: c..a.; . . n.c. t.a.; pe en e i e; uran e a sen ia; uran a moron a e
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: (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.)
Name Relationship Residence n ~'
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(COMPLETi5 IN ALL CASES:) Attach additional sheets if necessary. ~ -~ -
iy to
Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal residence at ps
Church of God Home, 801 N. Hanover St., Carlisle, Carlisle, Cumberland, PA 17013
(List street address, town/city, township, county, state, zip code)
Decedent, then g7 years of age, died on 06/25/ at ~'~~dt11>
Decedent a1: death owned property with estimated values as follows:
(If domiciled in PA) $ .~ V ~~
(If not domiciled in PA) -
(If not domiciled in PA)
Value of real estate in Pennsylvania
situated asfollows:
All personal property
Personal property in Pennsylvania
Personal property in County
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:
- ,Signature Typed or printed name and residence
Mark D. Meabon 130 Fairway Drive
~r ..- rj Dillsburg, PA 17019
Form RW-O?' Rev. 1t)-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc. Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA } SS
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 representatives} of the D d~'nt, Petitioner(s) will well and truly
administer the estate according to law. r-'' ~ ,,~~ ~ ,
Sworn to or affirmed and subscribed
Signature of Personal Representative Mark D. Meabon
before me this ~
day of ~ rr~`',~-
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Y~tt J_~ Signature of Personal Representative S
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Far the Register Signature of Personal Representative ~
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File Number. 21-08- "~=Zj
Estate of Blanche G. Fromm ,Deceased
.moo-, ~ ~ ~_
Social/l ecurity Number: 162-07-3154 ~/~~}Date of Death: 06/25/~9A8-
AND NOW, ~~U rr ~ , G2~ , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters Testamentary
are hereby granted to Mark D. Meabon
and that the instrument(s) dated 11/25/1992 07/28/1995
in the above estate
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
~,F~FjEES
Letters..........,,~t {,fix' .................. $ `166
OL
Short Certificate(s)...........~....... $ / ~,
Sc~ 0
Renunciation(s) ...................~........ $
$ _ /S
$ /n
t,/
$ ~~"
$
$
$
$
off'
TOTAL .................................... $
Supreme Court I.D. No.: 28078
The Wiley Group, PC
Address: 130 W. Church Street
Dillsburg, PA 17019
Telephone: 717-432-9666
Form RW-O? Rev. 10-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc. Page 2 of 2
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REV 11/2006
PRINT IN
ANENT
,K INK
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH `
(See instructions and examples on reverse) STATE FILE NUMBER ~ 1 ~j [~ \`r~.
1. Name of Decedent (first, middle, last suffix) 2. Sex 3 Social Seariry Number 4. Date of Death (Month, day, year)
Blanche G. Fromm Female 162 - 07 - 3154 June 25, 2007
5. Age (Last Birthday) Under 7 year Untler 1 day 6. Date of Birth (Month, day, year) 7. &rthplace (City and stale or loraign country) be. Place of Death (Check only one)
MonaS Deys Hours Minutes Hospital: Otner.
96 vra 9-25-1910 SllIIbu , PA ^ Inpatient ^ ER I Outpatient ^ DOA ®Nursin Home
g ^ Residence ^Other ~ Speciy'.
Bb. County of Death ea Ciry, Boro, Twp. of Death 60. Facility Name (If not Institution, give street and number) 9. Was Decedent of Hispanic Origin? ~ No ^Ves 10. Race: American IMian, Black, White, etc.
pl yes, specify Cuban, (Speciryf
Cumberland Carlisle Church of God Home Mexican, Puedo Rican, etc.) White
11. Decedent's Usual lk al'on Kind of work d one Burin most of woddn INe. Do not state retired 12. Was Decedent ever in the 13. Decedent's Education (Specify onty highest grade compl eted) 14. Mental Status: Married, Never Married, 15. Surviving Spo use (If wife, give maitlen name)
Kind of Work Kind of Business I Industry U.S. Armed Forces? Elementary / Sewndary (0-12) College (1~4 or 5+) Widowetl. DivorCetl (Speciryl
Operator Education ^Vea ®Np 12 Widowed
16. Decedent's Matting Address (S1reeL city I town, state, irp code) Decedent's Did Decedent
Penns lvania
y
801 North Hanover Street
Live in a ^Ves, Decedent Lived m
AcNalResitlance 17a.Slate
,7p
Twp.
Carlisle
PA 17013 Townshp?
rn. cpunty Cumberland 17tl.~ ~~o
a~souyed w;min Carlisle
, ~
ciglBom
18. Father's Name (First middle, last, suaixj 19. Mother's Name (First, midtlle, maiden surname)
H.S. Gass Clara Tha
20a. Informant's Name (Type r Print) 20b. InfornwnYS Mailing Address (Street dry I town, state, zip cotle)
Curtis Fromrm 4201 Gett abut Road, Lot # 10, Cam Hill, PA 17011
27 a. Melhotl of Disposttion ~Cremalim ^ Donator 21 b. Date of Dispositbn (Month, day, year) 21c. Place of Disposttion (Name of cemetery, crematory or other place] 21d. Lxatlon (OUy /town, state, zip code)
^ Burial ^ Removal from Slate i Was Crematlpn or Donation Auttanzed
• ^ Other-Specify: ~j byMedlcalExaminerlCororter? vas^Np
6-27-2007
Cremation Soeiet of PA
Harrisbur PA 17109
' 22a. $igna of Funeral ice Licensee (or Parson acting es such) 22D. License Number 22c. Name orb Address of Pecilit~uer MemOria Home and Cremation Services , Inc .
. ~ ~~,~-~ ~,a. /I,,.~--- FD 013376 - L 4100 Jonestown Road, Harrisburg, PA 17109
Cm,ple tams 23a< only wfien certifying
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' 2 To the best I m~knowledge, tlealh occunetl at the time, tlat antl place slated. (Signature and atlej
J 23b. Lcense Number
` 23c. Date Signori (Month, tlay, year)
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ysician
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_ certfly cause of death. l.~Va..
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Items 24-26 must be completed by person 24. Time of Death ~'" ,
~ 25. Date Pronoufnced Dead (MOnlh, day, year)
~
~~~~ ~ 2fi. Was Case Refereed to Medical Examiner /Coroner for Reason Other than Cremation or Donation?
who pronounces death. / 7
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~ ^Yes ^ No
CAUSE OF OEATH (See Inatruetlone an0 a pies) r Approximate interval: Pan II: Enter omer signifcam condilipns contribmirw Ip death, 28. Did Tobacco Use Contribute to Death?
Item 27. Pen I: Emer the ~pw30S;; - tliseases, injures, or camplicatians -Mat Grectly caused Me tlealh. W NO7 enter terminal events such as caNiac artest Onset to Death but rwl resulting in the undedying cause given In Pan I. ^ Yes ^ Probabty
respiratory angst, a ventricWar fibnpation wimal showing the etiology. List only pre cause on each line. i Q•~NO ^ Unknown
IMMEDIATE CAUSE ffFnal tlsease or t
condition resultingm d~th) _' a SE~S'Y ~ ;
~ti 4..4.L.~ A.~..l V\CEf1_
29. 1If; Fye,~male.
Due to (or as a Consequence of): ~ rvol pregnant within past year
Sequentially list rnnditions, if any, b ~ R„Z('tq Z rLJ9 a- r
~f ~• Z~ ~ ~'°~• ~ _ i
Lz1~/ ~ UL ~ ~` y ~ 01 ^ Pregnant at time of death
laaarg to me cause listetl on line a.
Enter the UNDERLYING CAUSE Due !o (or as a cpnsequence ^ Not pregnam, but pregnam withn 42 tlays
(disease or injury that inidatad the C ~
events resulNrK
in death) LAST
r of deem
.
)
Due Ip (or as a consequence oQ: Nof pre rant, but pre nt 63 da t
^ g gna ys o 1 year
d- belore tleatn
^ Unknown if pregnant within the past year
30a, Was an Autopsy 30b. Were Autopsy Findings 31. Manner of Death 32a. Date of Injury (Month, day, year) 32h. Describe How Injury Occuned 32c, Place of Injury: Home, Farm, Street Factory,
Penormed? Available Prior to Complelim ~Metural ^ Hpmictle Ofike Building, etc. (Speciy)
of Cause of Death?
^ Ves [~.NO ^Ves ^ No ^ Aaitlenl ^ Pending Investigation 32d. Time of Injury 32e. Injury at Wodr? 32t. It irarisponation Inury (Specity) 32g. Locatlon pf Injury (Street city I town, stele)
^ Suitide ^ Could Not be Determuted ^Ves ^ No ^ Driver I Operator ^ Passenger ^Petlestnan
M ^Other- Speciy
33a. Cenifier (check onty one) 33b. Signature and Title of nifier
• CenNying physldan (Physician certirying cause of deem when another physidan has protwuncetl tleam and completed Item 23) ~~ C P ~ o
To the Feat of my knowbdge, r1eaN occurred due to the cause(s) antl manner as slated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .. _ _ _ _ _ _
• Pronouncing and certitying physician (Physkian both pronouncing death and cenilying to cause of death)
To the bast of my krrowledge, death occurred at the time, date, and place, and due to the cause(s) and manner es slated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. License Number 33d. Date ,gne Month, tla year)
~
• Medical Examiner /Coroner U ~.
~ SO ~ ~ ~ ~a - L ZC
On the bests of exeminatlon and I or Investigation, in my opinion, deelh occured at the time, date, end place, and due to the cause(s) and manner as slated_ ^ 34. Name and Address of Person Who Com~letatl Cause of Death (Item 27) Type I Print '
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35. Registrar's Signature a 'strict Number ~
I o71 tl ~ /I / I
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LAST WILL AND TESTAMENT ~
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OF -~
~„ _ _ __..
. r- "'
BLANCHE G. FROMM y'~ ~
BE IT REMEMBERED that I, BLANCHE G. FROMM, of Le Tort honor, 80~,nHannove~
tT
Street, Carlisle, Cumberland County, Pennsylvania 17013, being of sound mind,
memory, and understanding, do make, publish, and declare this as and for my
Last Will and Testament, hereby revoking and making null and void any and all
Wills and Testaments, or writings in the nature thereof, by me at any time
heretofore made.
1st: I direct that all of my just debts and funeral ext,~nses be paid and
discharged as soon as may be convenient after my dece~:,e by my executor or
alternate executor, hereinafter named.
2nd: All of the rest, residue, and remainder of my estate, of whatsoever
nature and wheresoever t,ie same may be situate, whether real, personal, or
mixed, ~ give devise and bequeath unto my beloved husband, T. LYNN FROMM, to be
his a~solutely and forever, provided that he survives my death for a period of
thirty {30) days.
3rd: In the event that my husband, T. LYNN FROh4M, should predecease me or
LAW OFFICES
FETTER, NESSLER 6 PERSING
B NORTH THIRD STREET
P. O. BO% 512
LEWIS BURG, PA I7B3J-0512
jin the event that he should fail to survive my death for a period of thirty
{30) days, then I direct my executor or alternate executrix, hereinafter namad,i
I
to convert all of the rest, residue, and remainder of my estate, of whatsoever
nature and wheresoever the same may be situate, whether real, personal, iir
Blanche G. Fromm
mixed, into cash, at either public or private sale, whichever my- said executor
or alternate executrix may deem to be for ttte best interests of mL F~state; .:,nd,
for this purpose, T do hereby authorize and empower my said eaecutcr or alter-
pate executrix to make ~gcod and sufficient deeds, in fee sirr,ple, fc~r :~i~~- ,~r.d
all real estate, which I may own a.t the time of mti~ death, tl~e s;~me a,s l r~igl~t.
do if then living.
~lth: The cash fund so realized from the conti~er°sion of m estate, I ilir•ect
to be divided into two {2} equal shares, Which 1 do gi~•e and bequeath as
follows:
A. C?ne (1) equal sharz thereof unto my son, THO~i~S L. FROb1'~i, or to hi=;
{phi ldren ir, the ei~ent. treat he should mgt survive me, to be his or theirs
:.absolutely ar~d forever.
B. One 41) equal share thereof to be equally di~'ideci,rimong my then
living grandchildren, to be theirs absolutely and foretier.
LASTLY, I hereby nominate, constitute, r.-~,nd appoint my son, THGhi.AS L. FROMnI,
LAW OFFICES
"ETTER, KESSLER 6 PERSING
8 NORTH THIRD STREE-f
P. O. BOX 512
.EWISBU RG, PA 1783 ~-09:12
to be the executor of this, my Last Will and Testament. In the event that my
,son, THOMAS i.. FR0'!1h1, should not survive me or in the event that he should fail
to qualify°, then I hereby nominate, constitute and appoint my daughter-in-law,
', w. Y6`Oti\E FROAiM, to be the first alternate executrix of this my Last kill and
Testament; my named executor and alternate executrix shall serve without bond,
'.irrespective of his or her place of residence at the time of my death.
IN WITNESS WHEREOF, I, the said BLANCHE G. FROMM, have to this, my Last
!Will and Testament, written and contained on three (3) pages of paper, sub-
J=~ ~d, `= rr,>rrvr,.,, , (SEAL )
Blanche G. Fromm
- 2 -
scribed my jjn``ame and affixed my seal to each of the three t3) pages thereof,
this ~~__ day of /~-lcj~c°'~ `~ may, one thousand nine hundred ninety-two
(1992).
,~'~r,vi.t-~c,~ ~ ~ZrT~'~`'' Y t SEAL )
Blanche G. Fromm
* * * * * * * * * * * *
The aforegoing instrument, written and contained on three (3) pages of paper,
iwas subscribed by the said BLANCHE G. FROAg1 on each of the three (3) pages
thereof and sealed, published, and declared by her, the said BLANCHE G. FROMM,
as and for her Last Will and Testament, in our presence and in the presence of
each of us, and we, at the same time, at her request, in her presence and in
the presence of each other, have hereunto subscribed our names as attesting
witnesses, this ,~ of ~~a~~rh ,/-`~~,.' one thousand nine hundred
ninety-two {'`1992) . .,,~
'~` residing at 5 Jefferson Ave.,_Lewisburgy, PA 17837.
l
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residing at RD 4~1 Box 409C, Mifflinburg, PA 17$44.
l~W OFFICES
FETTER, NESSLER 6 PER5ING
8 NORTH THIRD ST RE~ET
P. O. BOX 512
LEWISBU RG, PA 1783)-OS12
- 3 -
COMMONWEALTH OF PENNSYLVANIA }
SS
COUNTY OF UNION )
We, BLANCHE G. FROMM ,
W. ROGER FETTER
and KAREN L. WATTERS , the testatrix and the witnesses, respecti~~e-
ly, whose names are signed to the attached or foregoing instrument, being first
duly sworn, do hereby declare to the undersigned authority that the testatrix
signed and executed the instrument as her Last Will and Testament, and that she
signed willingly, and that she executed it as her free and voluntary act for
the purposes herein expressed, and that each of the witnesses, in the presence
and hearing of the testatrix, signed the will as witness and that to the best
of his or her knowledge the testatrix was at that time eighteen (18) years of
age or older, of sound mind, and under no constraint or undue influence.
`'
A `~ ~" Test t~1x
C ~~ , ,.;
~.
Wi Hess
i ~
UW OFFICES
FETTER. KESSLER d. PERSING
_'( ~ ,~ ,L(~ b'1
Witness
B NORTH TRIRO STREET
P. O. BOX !~ i 2
LEWISBU RG, PA 17837-0512
Subscribed, sworn to and acknowledged before me by BLANCHE G. FROMM, testa-
trix, and subscribed and sworn to before me by W. ROGER FETTER
and KAREN L. WATTERS , witnesses, this 25th day of November
one thousand nine hundred ninety-two (1992).
N4~ry M. [1r~hr;~s!~<<, ivotary P~hc
L,~`Jt^~i:l!"~,~ E~C:~G, ~!iIOY] (i0Urlly
Nty Corr!mis~;!cn Gxp!rc& Jan.16,1994
,`'• ~
Notary Public
- 4 -
N
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CODICIL ~?~
..
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I, BLANCHE G. FROMM, of Carlisle, Cumberland ~~~ty~ :_ ;
,? ~ __
Pennsylvania, having made my Last Will and Testament.--dated ~ _~
November 25, 1992, do hereby make, publish and declare t~s ;~o
J ..
Cl1
be a Codicil to my said Last Will and Testament. cs~~
FIRST. Whereas in Paragraph LASTLY of my said Last Will
and Testament I appointed W. YVONNE FROMM to serve as an
alternative executrix of my estate, I now hereby revoke such
appointment and in lieu thereof I hereby nominate, constitute
and appoint PAMELA S. MEABON and MARK D. MEABON, to serve as
alternate executors in place of W. YVONNE FROMM as provided in
Paragraph LASTLY aforesaid, with the same force and effect as
if the same had been originally named as alternate executors in
my said Last Will and Testament.
SECOND. In all other respects, I hereby ratify, confirm
and republish my Will dated November 25, 1992, together with
this codicil, as and for my Last Will and Testament.
IN WITNESS WHEREOF, I, BLANCHE G. FROMM, have hereunto set
my hand and seal to this Codicil to my Last Will and Testament
UQ1..CU 1V :~VCmbGi L,J, iJJG., mil i.J uu~ Vf - w/~ ,
A.D., One Thousand Nine Hundred Ninety-Five (1995).
wry,:: ~ ~.~I?,2<:'~-~•."~`- (SEAL)
-~,W ~,~„~ ~_;
M AHLIN R- McC FILEH
The preceding instrument, consisting of two pages, was on
the date thereof signed, sealed, published and declared by
BLANCHE Ge FROMM, the Testatrix therein named, as and for a
codicil to her Last Will and Testament dated November 25, 1992,
in the presence of us, who, at her request, in her presence and
in the presence of each other, have subscribed our names as
witnesses hereto,
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MAfi LIN f3. McC l1l C. E3
-2-
RENUNCIATION
REGISTER OF WILLS OF
Estate of Blanche G. Fromm
CUMBERLAND COUNTY, PENNSYLVANIA
,Deceased
C~ rv
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i. Pamela S. Meabon in my capacity/relat~or~sfitp asa ,
'- (Print Name) C_~ '-~; ; ~" ~ ~ .
~~ ~_~ ~
co-executor under Codicil dated July 28th 1995 of the above Decedent, hereki~ ~nounce<~e right to`~~
- r -:
ut
administer the Estate of the Decedent and respectfully request that Letters be issued to rn
Mark D. Meabon.
(Date)
~7~rc~L ~ ~? ~LZ 1 ~
(Signature) Pamela S. Meabon
130 Fairway Hills
(Street Address)
Dillsburg, Pennsylvania 17019
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
Deputy for Register of Wills
Executed out of Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purposes stated within on this t~~ day
of ~VCV 2{j~`.
__ ~ ..,~
Notary Public
My Commission Expires:
(Signature and seal of Notary or other official qualified to
administer oattasrSheW~ata gf,~xp~rationPf-NOtary;~ F~~4sV~~ir;
~.~v~ti_ _. - .__._.~, t.. .<c~9va 1 s. ..
i~ ~9:.vtr3i ":.~.
S. Dav~:n a',tt~~>;f;Ft, Iw~t~rr ~ubiic
DillsburgD~:~;.,., a'c,;i<(;auf~y y
I IVIyCommission w'.y~~fl;~ ;Uiay 37, 2609
Member, Pen~sylv~nia ~s~=.x;iation of Ngtaries
Form RW-O6 ~4ev. 10-f3-2006 Copyright (c) 2006 form software only The Lackner Group, Inc.
OATH OF SUBSCRIBING WITNESS(ES)
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA
Estate of Blanche G. Fromm , Decg~,sed
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Traci L. Water ~ -
(each) a subscribn~g~yvitriess
(Pont Name/s)"`~
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the ^ Will 0 Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and'4'
say(s) tl~at she he /they wa /were present and saw the above Testator /Testatrix` sign the same
,.~ - _~
and than sh / he /they signed the same and thatr'~she / he /they signed as a witness at the request of
the Testator /Testatrix in his /chef presence and in the presence of each other.
' / ~
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(Signature) (Signature) Traci L. ater
x l GI 3 ~ din e~~~ ~)~~ C-f
(street addres:y (Street Address)
(City, State, ZiEr) (City, State, Zip)
Executed in Register's Office
Sworn tc~ or affirmed and subscribed
before m~e this-day
of
Deputy for Register of Wills
Executed out of Register's Office
Sworn to or affirmed and subscribed
before me thi 1e~-day
of n.J d / ZtZ ~~ /~
Notary Public
My Commission Expires:
(Signature and sea( tyr3(pr~ot~er^q~cj- q~akried~Q~.yti,: ~~~! 4'r~Nir1
administer oaths,,t i tioa.' dtagt.° A~rci~fa:}-----~;
r•t_ * '
~, C~awn ~„ar~r~?t4~~~;, NoCra~r b~ubl'~:
Diilstxsrg 4a.,ro. '~'oa~ ~~c;urtty
My Commission ~:xi:~;r~s Nlay 17, 2009 1
Member, Pennsylvania Association of Notaries
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-O3 Rev. 10-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc.
OATH OF SUBSCRIBING WITNESS(ES)
R'.EGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA
Estate oaf Blanche G. Fromm ~_.~ Deceased
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Curtis M. Fromm (each) a subscribing_~yi~ss to ~
(Pont Name/sl , Zy ~ ~
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the ^ Will ~ 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 in his /her presence and in the presence of each other.
(Signature) (Signature) CUrtIS M. Fromm
(Street Address) (Street Address)
X __ ~ ~_ M~ Nd l I ,~`~ / ~ ~r ~
(City, State, L'p) (City, State, ip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of ,
Deputy lfor Register of Wills
Executed out of Register's Office
Sworn to or affirmed and subscribed
before me this /~~~" day
of N(~~~V,~~e-, ?~~~
~~ ~G~ ~_~`~'
Notary Public
My Commission Expires:
(Signature and seal of Notary or other official qualified to
administ `~~y'~agf'~f ~ ~F~~~sim.)
Na~ra1 Sea! ~V~A
S. [lawn C',adfe~i(Exr, Notary Public
Dillsburg t=sc>;;z, Y+~rk Courriy
My Comrn'ission Expires May 17, 2009
Member, PQnnsylvania N,sanciatian M Notaries
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. f0-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc.