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HomeMy WebLinkAbout01-30-09 (2)15056041046 REV-15 0 0 EX (05-04) OFFlC1dL i1SE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Dept. 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 0 8 '1 0 9 7 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 1 0 2 2 0` 0 8 0 2 2 1 1 9 2 0 Decedent's Last Name Suffix Decedent's First Name MI M i l l e r L u c i l l e K (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) f 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1=1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATIOpI-a~HOULD BE DIRECTED T0: Name Daytime Telephorie,PlUmber ~' f A n t h,o n,y L. D e L u c a E s q 7 1 7 2 5,~_ 6~$ 4: Q~ Firm Name (If Applicable) First line of address P O B o x 3 5 8 Second line of address 1 1 3 F r o n t S t r e e t Cit or Post Office State ZIP Code ,_ Y B o i l i n g S p r i n g s P A 1 7 0 0 7 Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowle RS N RESP..9NSIBLE FOR FILING RETURN DATE i .~ /`. E 3U Zou~ ADDRESS ~o~. = cu ~/ L ~ ~ © ~~Gr ~M (•! .cti j 7v6 ' r 3~ z~'.c~ SIGNATURE OF PREPARER OTNE&iTHAN.~E9RF~ENTATIVE ~ _ DATE ~ ~ ~ tf ~ AD R SS ~ '~//,~ r i / ~ (.~ PLEASE USE ORIGI L ORM ONL Side 1 15056041046 15056041046 15056042047 ,. REV-1500 EX Decedent's Social Security Number Decedent's Name:. _.. _ _ .. .. ~_ .. .. -~~ -_., RECAPITULATION 1. Real estate (Schedule A) .......................................... ... 1. 0 0 0 2. Stocks and Bonds (Schedule B) .................................... ... 2. 3 4 9 6 0~ 0 0 3. Closely Held Corporation, Partnership. or Sole-Proprietorship (Schedule C) .. ... 3. 0 0 4. Mortgages & Notes Receivable (Schedule D) .......................... ... 4. U 0 0 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. 2 4 0 , 1 7 5 2 3 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested .... ... 6. 0 0 0 7. Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. 6 1, 7 3 2 1 8 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. 3 3 6 , 8 $ ? 4 1 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. 2 4 , 9 3 8 . 8 3 10. Debts of Decedent, Mort a e Liabilities, & Liens Schedule I 9 9 ( ) ............. ...10. 1 0 r 9 8 4 1 11. Total Deductions (total Lines 9 & 10) ................................ ... 11. 2 6 , 0 3 7 ~ 2 4 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 3 1 0 , 8 3 0 . 1 7 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 0 .0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. 3 1 0 . 8 3 0 •1 7 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_. 15. 16. Amount of Line 14 taxable ' at lineal rate X .0 _ 16. , 17. Amount of Line 14 taxable at sibling rate x .12 1 5 5 4 1 5. 0 8 17. 1 8, 6 4 9 •8 ` 1 18. Amount of Line 14 taxable at collateral rate X .15 1 5 5, 4 1 5 •0 9 18 2 3 , 3 1 2 • 2 6 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 4 1,9 6 2.0 7 O Side 2 15056042047 15056042047 REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME _________ __- Luci_1_l~_ K_ Miller ____ _ ____ ______ _ ___ STREET ADDRESS D-~--B-•~^r ~' ng V i 11 e pia ~--- - -- - -- - -- -- _- -- -- -- - - - - CITY - -- - ---- STATE ZIP Boilin S rin s PA ~ 17007 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit _ - 0 - _ __ B. Prior Payments ~_ C. Discount 2, 0 9 8. 1 0 3. InteresUPenalty if applicable D. Interest _ - 0 - __ __ E. Penalty (1) $41 , 962.07 Total Credits (A + B + C) (2) _ ~ _ - Total InteresUPenalty (D + E ) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. (3) (4) (5) (5A) 2,098.10 -0- -~v 39,863.97 -0- B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 3 9 , 8 6 3.9 7 Make Check Payable fo: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ d, receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ [~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ X^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ ...... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ...... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, are adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling isdefined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV;1502 EX+ (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Lucille K. Miller 21-08-1097 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ~~~ w~ic sNace is neeaea, msen aaamonal sheets of the same size) REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Lucille K. Miller 21-08-1097 All property jointly-owned with right of survivorship must be disclosed on Schedule F. to ine~e space Is neeaea, Insert a~slanal sheets of the same size] REV-1504 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Lucille K. Miller 21-08-1097 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ter more space is neeaea, insert adtlitional sheets of the same size) REV-1507 EX+ (1-97) SCHEDt~ILE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER Lucille K. Miller 21-08-1097 All property jointly-owned with right of survivorship must be disclosed on Schedule F. i~~ nixie sNece is neeaea, insert aaamonal sheets of the same size) REV-1508 6X ~ (1.97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC. INHRESIDENT DECEDENT RN PERSONAL PROPERTY ESTATE OF FILE NUMBER Lucille K. Miller 21-08-1097 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ Time Deposit, #1101288, at Commerce Bank $22,674.53 2. Time Deposit, #1101290, at Commerce Bank 21,337.96 3. Time Deposit, #1102294, at Commerce Bank 20,436.33 4. Checking Account, #33-09657, at F&M Trust 2,185.22 5. Checking account, #70-66570, at F&M Trust 29,795.85 6. Certificate of Deposit, #31003917714882, at M&T Bank 26,647.16 7. Certificate of Deposit, #31003915940520, at M&T Bank 24,932.15 8. Certificate of Deposit, #000031900287484, at PNC Bank 10,064.95 9. Certificate of Deposit, X4000027680, at Orrstown Bank 15,117.12 10. Certificate of Deposit, #247402053541262, at 25,344.91 Wachovia Bank 11. Certificate of Deposit #247402063757572, at 23,169.28 Wachovia Bank 12. Certificate of Deposit, #247402303205735, at 13 369.77 Wachovia Bank 13. Miscellaneous items of personal property, including 5,100.00 1986 Cadillac Motor vehicle. See attached appraisal. TOTAL (Also enter on line 5, Recapitulation) I$ 2 4 0, 1 7 5. 2 3 (If more space is needed, insert additional sheets of the same size) ' REV~1509 Ex ~ 11-971 SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Lucille K, Miller 21-08-1097 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. NONE B. C. JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET o~ OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1, A. NONE -0- TOTAL (Also enter on line 6 Recapitulation) I $ - 0 - (Ifmore space Is needed, insert additional sheets of the same size) ' REV4510 EX ~yL97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF Lucille K. Miller FILE NUMBER 21-08-1097 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THENAMEOFTHETRANSFEREE,THEIRRELATICNSHIPTODECEDENTANDTHEDATEOFTRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE ~~ Annuity, #FJ225988, at AIG Annuity $14,340.02 100 -0- $14,340.0. Insurance Company 2. Annuity, #XV216314, at AIG Annuity 15,623.31 100 -0- 15,623.3 Insurance Company 3. Annuity, #940012154, at Met Life 30,768.85 100$ -0- 30,768.8! 4. Balance of Pension at Boeing Company 1,000.00 100$ -0- 1,000.00 TOTAL (Also enter on line 7, Recapitulation) I $ 61 , 7 3 2 . 1 8 SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY (If more space is needed, insert additional sheets of the same size) EV=1511 EX+ (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Lucille K. Miller 21-09-1097 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t Hoffman-Roth Funeral Home 219 North Hanover Street $990.25 Carlisle, PA 17013 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Ronald L , Tanger Social Security Number(s)/EIN Number of Personal Representative(s) Street Address _102 E. Springville Road City_ Boiling Spri nc~~, State~j~zip 1 7007 Year(s) Commission Paid: 2. Attorney Fees Anthony L. DeLuca, Esquire 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City _ State Zip Relationship of Claimant to Decedent 4. Probate Fees 11,000.00 11,500.00 314,00 5. ~ Accountant's Fees 6. Tax Return Preparer's Fees ~. Legal Advertising - Cumberland Law Journal 8. Legal Advertising - The Sentinel 9. Appraisal of Personal Property 10. Filing Fee for Inheritance Tax Return and Inventory (If more space is needed, insert additional sheets of the same size) 500.00 300.00 75.00 1 74.58 55.00 30.00 TOTAL (Also enter on line 9, Recapitulation) I $ 2 4 , 9 3 8 . 8 3 REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Lucille K. Miller 21-08-1097 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical exoensas t~~ more space is neetletl, insert atltlnional sheets of the same size) REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Lucille K. Miller FILE NUMBER 21 -08-1 097 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1, Ronald L. Tanger Nephew 25$- 102 E. Springville Rd. Boiling Springs, PA 17007 2. Elizabeth Dundore Sister 25$ 3588 Gray Fox Drive Chalfont, PA 18914 3. Joyce A. Boyer Sister 25~ 202 Penna Avenue Claymont, Delaware 19703 4. Jean Kopenhaver Cousin 7~ 405 Leearden Road Hershey, PA 17033 5. Cheryl Davis Niece 6$ 2479 S.W. Oak Ridge Road Palm City, Florida 34990-2037 6. Lujene Gerber Niece 6$ 720 Hillwell Road Chesapeake, VA 23322 7. Dar rel Dund O re Nephew 6~ ~ $l (A j1~ ~~ ~ f ~~ E DOL LAR A bU NS OR DI~~RIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. NONE -0- 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ - 0 - (If more space is needed, insert additional sheets of the same size) LUCILLE K. MILLER I, LUCILLE K. MILLER, a resident of 107 E. Springville Road, Boiling Springs, Cumberland County, Pennsylvania being of sound mind, memory and understanding, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils heretofore made by me. ITEM 1:. I direct that all my just debts, the expenses of my last illness and funeral. expenses be paid as soon after my decease as the same can conveniently be done. ITEM 2: I direct that there shall he paid out of my residuary estate all estate, inheritance and like taxes together with any interest or penalty thereon imposed by the goven~ment of the United States, or any state or territory thereof, or by any foreign govenunent or political subdivision thereof, in respect to all property required t iSl~ included in my gross estate for estate, inheritance or like tax purposes by any o:~~ z;,~~ ~Tt govenunents, whether the property passes under this Will or otherwise, excludi~~ however., any property over which I have a taxable power of appointment, prow however, that no residuary beneficiary shall by reason of this provision be denied. the benefit of any deduction, credit, favorable rate of tax or other benefit which bylaw enures to such beneficiary. I7_EM 3: 1 give, devise and bequeath all of the rest, residue and remainder of my estate, real, personal and mixed, of whatsoever kind and nature, and wheresoever situate rv `~' c~ c'_'s , ~- ~~ .z~ ..~ c~ !` 3 _- w ~.~__ :~,..: t__ t~Y t 1V cr7 r-) ..,« ~~. LUCILLE K. MILLER. 1 ,. r ~` 54k~' F. ~~'.. ~. n ,... ';,,~ z LAST WILL AND TESTAMENT OF LUCILLE K. MILLER at the time of my death, as follows: A. 25% unto my nephew, RONALD L. TANGER, provided however, that he survives me and is living sixty (60) days after the date of my death. If and in the event that my said nephew, RONALD L. TANGER, does not survive me and is not living sixty (60) days after the date of my death, then and in such event, I give devise and bequeath his 25% share of my residuary estate unto his wife, MARIE M. TANGER. B. 25% unto my sister, ELIZABETH I. DLINDORE, provided however, that she survives me and. is living sixty (60) days after the date of my death. If and in the event that my said sister, ELIZABETH I. DUNDORE, does not survive me and is not living sixty (60) days after the date of my death, then and in. such event, I give devise and bequeath her 25% share of my residuary estate, in equal shares, unto the issue of my said deceased sister, per stirpes. C. 25% unto my sister, JOYCE A. BOYER, provided however, that she survives me and is living sixty (60) days after the date of my death. If and in the event that my said sister, JOYCE A. BOYER, does not survive me and is not living sixty (60) days after the date of my death, then and in such event, I give ~~ C LUCILLE K. MILLER 2 OF LUCILLE K. MILLER devise and bequeath. her 25% share of my residuary estate, in equal shares, unto my deceased sister's husband and the issue of my said deceased sister. D. 7% unto my cousin, JEAN KOPENHAVER, provided however, that she survives me and is living sixty (60) days after the date of my death. E. 6% unto my niece, CHERYL DAVIS, provided however, that she survives me and is living sixty (60) days after the date of my death. F. 6% unto my niece, LUJENE GERBER, provided however, that she survives me and is living sixty (60) days after the date of my death. G. 6% unto my nephew, DARREI: DUNDORE, provided however, that he survives me and is living sixty (60) days after the date of my death. I"fEM 4: I hereby nominate, constitute and appoint my nephew, RONALD L. TANGER, Executor of this my Last Will and Testament, with full power to do any and all things necessary for the complete administration of my estate, and direct that no bond or other surety is required of him in this or any other jurisdiction for his performance of this office. If and in the event that my nephew, RONALD L. TANGER, does not survive me and is not living sixty (60) days after the date of my death, or does not complete his ~ \ v, LUCILLE K. MILLER duties as Executor, then and in such event, I hereby nominate, constitute and appoint my sister, ELIZABETH I. DUNDORE, Executrix of this my Last Will and Testament, with full power to do any and all things necessary for the complete administration of my estate, and direct that no bond or other surety is required of her in this or any other jurisdiction for her performance of this office. ITEM 5: If any provision of this Will or of any Codicil hereto is held to be inoperative, invalid or illegal, it is my intention that all the remaining provisions thereof shall continue to be fully operative and effective, so far as is possible and reasonable. IN WITNESS WHEREOF, I, LLTCILLE K. MILLER, the Testatrix, have to this my Last Will and Testament, typewritten on five (5) consecutively numbered pages, subscribed my name and affixed my seal this ~. `~ =~1~ay of May, 2008. c~,~,~. a~ ..a ~~ , ,. ~ ~1..- SEAL) LUCILLE K. MILLER 4 .. LUCILLE K. MILLER Signed, sealed, published and declared by the above named LUCILLE K. MILLER, as and for her Last Will and Testament, in the presence of us, who have hereunto subscribed our names at her request, as witnesses hereto, in the presence of the said Testatrix, and of each. other. ~ _ '' ss ~ residing at ~ -~ .~.~ ~ ~ .. ~ Jr~ ~ ~~TTLL f ~~;G~ ~~ ,~'~ ~ ~, ~~ 1 ~l ~ residing at ~-~~-,-~~t'~:~= ~.--~ ~~ t~ v , °~I ~~ S s~f~ ~ // J~ ~ Jf. M ~~~~+F?A ~ ~~~J n/T ~,yt... //, ly+f... . , . h ~ rt j 1 7 ( ~ i ~4. ,w^M:~^,w,, C'~~ 'j °' ~., ~`` '.- ~) /,%/s~ f ~"3 . Ki'.y;J.~" ~i` ~3'•~1r fry ' ~~,r'°''~rrnIGF,,~. C ~' s~ _.. r. ~~ r _ r~ r ~- F ,~ . ~ t rr +, ~. ~ ~ ~" l /~/ jj i~' / G-i' 'Zr/~ /"'w~~%~"Y~rA~`~~ w~~+A~.i' ~r ~•- ~.~`°.. « F. d rfi FAG •~:J"s ~: .~>r ,:. 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