HomeMy WebLinkAbout08-24-091505607121
~'' REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 0 9 0 5 2 1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
1 7 1 3 0 7 0 5? 0 5 2 4 2 0 0 9 1 2 2 8 1 9 3 7
Decedent's Last Name Suffix Decedent's First Name MI
S T O N E R M A R Y A N N
(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
D 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
Q 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 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 INFORt~TION SHOULD DIRECTED T0:
Name Daytime Teleq>lir~ Number' _
J A N L B R O W N
~,,~ `~ 5 '.; 5 0
? 1 7+, $~~ _ 1 ~
Firm Name (If Applicable)
1'. i_1~ f~J
REGISTER C1-,F~LLS U§4E ONLY. ~'
J A N L B R O W N & A S S O C "- ' <'~ ~-; -~~
~~
First line of address ~~-
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8 4 5 S I R T H O M A S C T S T E 1 2 ~> tv '.
0
Second line of address
City or Post Office
H A R R I S B U R G
State ZIP Code DATE FILED
P A 1 7 1 0 9
Correspondent's a-mail address:BRENDAJLB@VERIZON.NET
Under penalties of perjury, I declare that 1 have examined this return, including accompanying scheduk;s and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Dedaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON~#ESPON I LE FOR FILING RETURN n DATE _ ..
ADDRESS \J '
133 DEERF ELD RD CAMP HILL PA 17011
SIGNATURE OF E R N REPRESENTATIVE DATE /~
. _ - -- Q'- ~ n _ ~ /-1/1'7
845 SIR THOMAS CT STE 12 HARRISBURG PA 17109
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505607121 1505607121 J
J 1505607221
REV-1500 EX
Decedent's Social Security Number
~eceeenrs Name: MARY ANN STONER 1 7 1 3 0 7 0 5 7
RECAPITULATION
1. Real estate (Schedule A) ........................................ 1-
2. Stocks and Bonds (Schedule B) .................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages & Notes Receivable (Schedule D) ........................ 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ....... 7.
8. Total Gross Assets (total Lines 1-7) ........................... 8.
9. Funeral Expenses & Administrative Costs (Schedule H) ................ 9.
10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ............ 10.
11. Total Deductions (total Lines 9 & 10) ........................... 11.
12. Net Value of Estate (Line 8 minus Line 11) ......................... 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) .................. 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ............ ...... 14.
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 _ 0 D 0 15.
16. Amount of Line 14 taxable
at lineal rate X .045 6 0 2 0 4. 9 3 1s.
17. Amount of Line 14 taxable
at sibling rate X .12 D 0 D 17.
18. Amount of Line 14 taxable
at collateral rate X .15 D D o 1 g
19. Tax Due 19.
...............................................
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505607221
3 0 D 0. 0 0
4 5 6 1. 6 6
6 7 4 5 4. 4 1
? 5 D 1 6. 0 7
1 2 9 6 1. 5 2
1 8 4 9. 6 2
1 4 8 1 1. 1 4
6 0 2 0 4. 9 3
6 0 2 0 4. 9 3
D. 0 0
2 7 0 9. 2 2
0. 0 0
0. 0 ^
2 7 0 9. 2 2
1505607221 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 09 0521
DECEDENTS NAME
MARY ANN_STONER_ _ _
STREET ADDRESS
1100 Crandon Way _ _
Hampden Township
CITY
'Mechanicsburg
STATE ~ ZIP
PA _ .17055
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit -
B. Prior Payments
(1) 2,709.22
C. Discount 135.46
Total Credits (A + B + C) (2) 135.46
3. InterestlPenalty if applicable
D. Interest
E. Penalty
Total InteresUPenalty (D + E) (3) 0.00
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. (4) 0.00
5. If Line 1 +Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2, 573.76
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 +SA. This is the BALANCE DUE. (56) 2,573.76
Make Check Payable to: 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 : ................................................................. ..... ^ 0
b. retain the right to designate who shall use the property transferred or its income; ......................... ...... ^
X
^
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? .................................................................................
"
" ...... ^
~ 0
^
or payable upon death bank account or security at his or her death? ...
in trust for
3. Did decedent own an ......
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, an
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)J. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1507 EX + (6-98)
SCHEDULE D
COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES
INHERITANCE TAX RETURN RECEIVABLE
RESIDENT DECEDENT
ESTATE OF rac ivumocrc
MARY ANN STONER 21 09 0521
All property jointlyowned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Note receivable between Kurt B Stoner and Mary Ann Stoner; 3,000.00
unpaid balance $3,000; 0% interest rate
TOTAL (Also enter on line 4, Recapitulation) ~ S 3, 000.00
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MSC.
IN RESIDENTEDECEDENTRN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
MARY ANN STONER 21 09 0521
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F,
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. M&T Bank Checking Account 1951580 1,468.26
2 M&T Bank Savings Account 015004208638386 490.35
3 E I DuPont; final pension payment 489.05
4 Loyalton of Creekview; rent refund 258.00
5 MetLife; dental benefit ck dtd 5/11/09 740.00
6 United States Treasury; Social Security ck 4/09 866.00
7 United States Treasury; Social Security stimulus ck 250.00
TOTAL (Also enter on line 5, Recapitulation) I $
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX + (6-98)
SCHEDULE G
INTER-VIVOS TRANSFERS &
COM NCHERITANCEOTAx RETURNANIA MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
MARY ANN STONER 21 09 0521
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 THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIPTO DECEDENT AND
THE DATE OF TRANSFER ATTACHACOPYOFTHEDEEDFORREALESTATE.
DATE OF DEATH
VALUE OF ASSET
°!° OF DECD'S
INTEREST
EXCLUSION
(IF APPLICABLE)
TAXABLE
VALUE
1. Edward Jones Account 22311792 67,454.41 100. 67,454.41
TOD to Kurt B Stoner, Tina L Lebo, Craig A Stoner, children
TOTAL (Also enter on line 7 Recapitulation) ~ $ 67,454.41
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (10-06)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES Hr
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
MARY ANN STONER 21 09 0521
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Musselman Funeral Home Inc 7,317.57
2 Suburban Memorial Gardens; open/close grave 1,125.00
3 Funeral luncheon 377.95
4 Memorial marker 1,000.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
SVeet Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees Jan L Brown & Associates 2,500.00
3. Family Exemption: (If decedents address is not the same as claimants, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills, Cumberland County 141.00
5 Accountants Fees Parks & Company; 1041 preparation 300.00
6. Tax Return Preparers Fees
7. I Edward Jones transfer fee I 200.00
TOTAL (Also enter on line 9, Recapitulation) I $ ,, ,, oa, ~,,
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (12-03)
SCHEDULE I
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT ~
ESTATE OF FILE NUMBER
MARY ANN STONER 21 09 0521
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Associated Cardiologists 78.44
2 I Internists Of Central PA ~ 29 78
3 IOmnicare Pharmacy Services of Eastern PA I 1,346.35
4 (Pennsylvania Gastroenterology Consultants ~ 25.00
5
126.16
6 I West Shore EMS -BLS ~ 114.76
7 (The Weston Group Inc ~ 129.13
TOTAL (Also enter on line 10, Recapitulation) I $ 1 849
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (g-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
MARY ANN STONER 21 09 0521
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. Janelle A Reall, granddaughter Lineal
5 Pine Ln, PO Box 89, Plainfield, PA 17081 2.5% residuary estate
2 Jennifer A Stoner, granddaughter Lineal
333 S Main St, Edwardsville, IL 62025 2.5% residuary estate
3 Jessica A Sindler, granddaughter Lineal
5649 Hunters Valley Ct Apt I, St Louis, MO 63129 2.5% residuary estate
4 Michael V Lebo, grandson Lineal
133 Deerfield Rd, Camp Hill, PA 17011 2.5% residuary estate
5 Megan C Lebo, granddaughter Lineal
133 Deerfield Rd, Camp Hill, PA 17011 2.5% residuary estate
6 Kevin S Stoner, grandson Lineal
1874 Continental View Dr, Louisville, CO 80027 2.5% residuary estate
7 Kurt B Stoner, son Lineal
768 Lime Quarry Rd, Gap, PA 17527 28 1/3% residuary estate
Sch G
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
MARY ANN STONER 21 09 0521
Decedent's Name Page 1 File Number
Schedule J -Beneficiaries - 1
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT
Do Not List Trustee(s) AMOUNT OR SHARE
OF ESTATE
I TAXABLE DISTRIBUTIONS (include outright spousal distributions)
8 Tina L Lebo, daughter Lineal
133 Deerfield Rd, Camp Hill, PA 17011 28 1/3% residuary estate
Sch G
9 Craig A Stoner, son Lineal
1874 Continental View Dr, Louisville, CO 80027 28 1/3% residuary estate
Sch G
LAST WILL AND TESTAMENT
OF
MARY ANN STONER
I, MARY ANN STONER, of York County, Pennsylvania, declare this to be my Last Will
and Testament. I revoke all other Wills and Codicils that I may have previously made.
Article I
My just debts and expenses of my last illness, funeral, and administration of my estate shall
be paid by my Executor from the principal of my residuary estate as soon as practicable after my
death.
Article II
All inheritance, estate, and succession taxes (including interest and penalties thereon, but not
including any generation skipping tax) payable by reason of my death shall be paid out of and be
charged generally against the principal of my residuary estate without reimbursement from any
person. This provision is not a waiver of any right which my Executor has to claim reimbursement
for any such taxes which become payable as the result of any property over which I have the power
of appointment.
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Article III
I give, devise and bequeath in accordance with any memorandum which I have either
handwritten or signed, located with my Will or with my valuable papers and found within 30 days of
the probate of my Will. Gifts may only be to persons who survive me or to organizations which exist
at my death, and if there is a conflict, the memorandum having the latest date shall govern.
Article IV
I give, devise and bequeath FIFTEEN PERCENT (15°l0) of my estate IN EQUAL SHARES
to my biological grandchildren. By way of explanation, step-grandchildren and adopted
grandchildren shall not be included in this group. If one of my biological grandchildren predeceases
me or fails to survive me by thirty (30) days, I give, devise and bequeath the share he/she would have
received to my remaining biological grandchildren who survive me by thirty (30) days, PER
CAPITA, NOT PER STIRPES.
Article V
All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever
situate, I give, devise and bequeath IN EQUAL SHARES to my son, KURT B. STONER, of
Lancaster County, Pennsylvania, to my daughter, TINA L. LEBO, of Cumberland County,
Pennsylvania, and to my son, CRAIG A. STONER, of Louisville, Colorado.
If any of my children predecease me or fail to survive me by thirty (30) days, I give, devise
and bequeath his or her share to his or her biological issue who survive me, per stirpes, or if he or she
has no issue, the share(s) are to be added equally to the other shares. By way of explanation, no
portion of my estate shall be given to any stepchildren or adopted children of my children.
-2-
Article VI
If a beneficiary under this Will has not attained the age oftwenty-one (21) years, the share of
the beneficiary shall be placed in a separate trust, for the benefit of that beneficiary according to the
terms in Article VII.
Article VII
In the event that a Trust is created by or as a result of any part of this Will, the terms and
conditions of the Trust shall be as follows:
A. To expend and apply so much of the net income and so much of the principal of the
Trust as the Trustee shall consider advisable far the support, health, care and education (including
college, trade school, or other similar training or education) of the child until the child attains the age
oftwenty-one (21) years.
B. Upon attaining the age oftwenty-one (21), the remaining principal and accumulated
income of the child's share shall be distributed outright to the child.
C. No beneficiary or remainderman of this Trust shall have any right to alienate,
encumber, or hypothecate his or her interest in the principal or income of the Trust in any manner,
nor shall any interest be subject to claims of his or her creditors or liable to attachment, execution, or
other processes of law.
Article VIII
I hereby appoint my daughter, TINA L. LEBO, as Trustee of any Trust(s) created in this
Will. In the event of the renunciation, death, resignation, or inability to act, for any reason
whatsoever of TINA L. LEBO, I nominate and appoint my son, CRAIG A. STONER, as Successor
Trustee of any Trust(s) created in this Will.
-3-
Article IX
In order to carry out the purposes of the Trust(s) established by this Will, the Trustee, in
addition to all other powers granted by this Will or by law, shall have the following powers over the
Trust estate, subject to any limitations specified elsewhere in this Will:
(a) to retain in the form received and/or to sell either at public ar private sale, any real
estate or personal property except that which I specifically bequeath herein,
(b) to manage real estate,
(c) to invest and reinvest in all forms of property without being confined to legal
investments, and without regard to the principal of diversif cation,
(d) to exercise any option or right arising from the ownership of investments,
(e) to compromise claims without court approval and without consent of any beneficiary,
(fJ to file fiduciary/income tax returns and pay the tax due for any year for which such a
return is required,
(g) to make distributions in cash or in kind, or in both, and to determine the value of any
such property,
(h) to employ any attorney, investment advisor, or other agent deemed necessary by my
Executor; and to pay from my estate reasonable compensation for all their services,
(i) to conduct along with or with others, any business in which I am engaged in or have
an interest in at the time of my death, and
(j) to receive reasonable compensation in accordance with their standard schedule of fees
in effect while their services are performed.
-~-
Article X
I nominate, constitute, and appoint my daughter, TINA L. LEBO, Executrix of my Last Will
and Testament. In the event of the renunciation, death, or inability to act, for any reason whatsoever
of my Executrix, I nominate, constitute and appoint my son, CRAIG A. STONER, successor
Executor of my Last Will and Testament. I direct that my Executrix or successor Executor be
permitted to serve without bond and in addition to those powers granted by law, I grant them power
to distribute in cash or in kind in like or in unlike shares and to file any qualified disclaimer I could
have filed i f living. My Executrix and successor Executor shall receive reasonable compensation for
services rendered to my estate.
Article XI
In addition to the powers conferred by law, I authorize my Executrix and successor Executor,
in his/her absolute discretion:
(a) to retain in the form received and to sell either at public or private sale, any real estate
or personal property except that which I specifically bequeath herein,
(b) to manage real estate,
(c) to invest and reinvest in all forms of property without being confined to legal
investments, and without regard to the principal of diversification,
(d) to exercise any option or right arising from the ownership of investments,
(e) to compromise claims without court approval and without consent of any beneficiary,
(f) to file any federal income tax return for any year for which I have not filed such return
prior to my death,
-5-
(g) to make distributions in cash or in kind, or in both, and to determine the value of any
such property,
(h) to employ any attorney, investment advisor, or other agent deemed necessary by my
Executor; and to pay from my estate reasonable compensation for all their services,
(i) to conduct alone or with others, any business in which I am engaged in, or have an
interest in at time of my death, and
(j) to receive reasonable compensation in accordance with their standard schedule of fees
in effect while their services are performed.
IN WITNESS WHEREOF, I, MARY ANN STONER, hereby set my hand to this my Last
Will and Testament, on ~ , 2005.
MARY O E
In. our presence, the above-named MARY ANN STONER signed this and declared this to be
her Last Will and Testament, and now at her request, in her presence, and in the presence of each
other, we sign as witnesses.
Name
Cv ~~ Q ~ ~~e 5 ~`~
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Address
845 Sir Thomas Court, Suite 12, Harrisbure. PA 17109
_845 Sir Thomas Court. Suite 12 Harrisburg PA 17109
-6-
I, MARY ANN STONER, Testatrix, who signed the foregoing instrument, having been duly
qualified according to law, acknowledge that I signed and executed this instrument as my Will, and
that I signed it willingly as my free and voluntary act for the purposes therein expressed.
Sworn to or affirmed and
acknowledged before me by
MARY AN STONER, the Testatrix,
on ~ ~ ,2005.
'Not Public
COMAIONIMEAUTf of PENNSYLYIINM
NOTARf SLA~EAI'
1ACQUELINE A. KElL~ NOTARY PUBLIC
LOWER PAXTON TWP., DAUPHIN COUNTY
kIY COMMISSION IXPIRES QEC.1T 2607
• ~A ~ ~
MA Y A N STONER
We, the undersigned witnesses who signed the foregoing instrument, being duly qualified
according to law, depose and say that we were present and saw the Testatrix sign and execute this
instrument as her Will; that she signed and executed it willingly as her free and voluntary act for the
purposes therein expressed; that each of us in her sight and hearing signed the Will as witnesses, and
that to the best of our knowledge, that she was at that time eighteen (18) years or more of age, of
sound mind, and under no constraint or undue influence.
Sworn to or affirmed and
subscribed to before me
y
and 4~O,u1 >_.~ . L~.snile
witnesses, on '7 - f , 2005
otary ublic
t~~onwF~tnT DF PENNSrirANIA
NOTARIAL SEAL
IACQUEIINE A. KELLX NOTARY PUTlUC
AIY COMMlSS OM EXPIR~ESUDEC.I~T, 2Q0T
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fitness --
Witness
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