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HomeMy WebLinkAbout04-13-10PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND Estate of Dorothy J. Priset also known as Deceased COUNTY, PENNSYLVANIA File Number c~ ~ ' 6~ ~~~ Social Security Number 179-12-3104 Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE 'A' or 'B' BELOW.) A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the Executrix last Will of the Decedent dated March 26, 2008 and codicil(s) dated January 17, 2010 __ _ r~ _~ ., (State relevant circumstances, e.g., renunciation, death of executor, etc.) ~ Q c~ -.-- ' ~~ 3 Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of tl~ ~nt(s)'ered ~'.' ~"7 for probate, was not the victim of a killing and was never adjudicated an incapacitated person: _ -='rn `" ~;.TMl :=` . r..~ B. Grant of Letters of Administration c: ~ ~ ~ ~~ P.t (If applicable, enter: c.t.a.; d.b.n.c.t.a.; pendente life; durante absentia; durant~' i'n~itate) '~ '- Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spot (if any) anc~eirs: (If '~% C~ Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) ~.J (COMPLETE I1V ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal residence at 274 Mooreland Avenue Carlisle Cumberland County, Pennsylvania 17013 (List street address, town city, township, county, state, zip code) Decedent, then 91 years of age, died on March 25, 2010 at 274 Mooreland Avenue, Carlisle, PA 1701.3 Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ 150,000.00 (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: or urinted name and residence f ~ ~ + ,. , ``; I Joan West Jones - 274 Mooreland Avenue, Carlisle, Pennsylvania 17013 W named in the Fvrm RW-02 rev. 10.13,06 Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF ~~( ~~_ The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me the ~ day of ~ , ~ r~ For the Regis er ~... ~--° ._ c.-v . Si atur oJPersonal Repres~nL e Signature ojPersona! Representative Signature of Personal Representative ~ ~- ,~ ~~°; ~C7 .: ~.~ ~ p -ter- '?fit ~,,, ~:,~ } ~:`~~ ~ ~ ~~ try: Cwt , ~ x .,.~ File Number: O ~ ~ - ~ ~ ~~, ~ ~ ~ ~~`-~ ~-~ Estate of Dorothy J. Priset Deceas~d r 1~.~. ; . , . , r+ .y '"Y' } Social Security Number: 179-12-3104 Date of Death: March 25, 2010 AND NOW, ~ ('~ ` (~ d ~ o in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters Testamentary are hereby granted to Joan West Jones in the above estate and that the instrument(s) dated March 26, 2008 and January 17, 2010 described in the Petition be admitted to probate and filed of *ecord as the last Will (and Codicil(s)) of Decedent. FEES Letters ............... $ 2 _ Register of Wills Short Certificate(s) ........ $ ~~ + ~ Attorney Signature: _..~c ~ Renunciation(s) .......... $ _ l d l . ~ . _ . $ ~ ~ -UCH Attorney Name: Anthony L. DeLuca, Esquire ~--- - (~1G{,1 C ~ ~ • • • $ ~ ~ V d Supreme Court LD. No.: 18067 ... $ ~~i! ~~ C S ~ d $_r~ ~ Address: 113 Front Street ~jr5-~-1'1~`~L~-L•71~.3Y~ • • $ ~.C~ ~ P.O. Box 358 ... $ $ Boiling Springa, PA 17007 ' ' ' $ Telephone: 717-258-6844 ... $ TOTAL ..........:... $c~~9-86 Form RW-02 rev. 10.13.06 Page 2 of 2 OCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. ~ Fee for this certificate, $6.00 P 16252008 Certification Number 9 n H106.143 NEY 1 ti70D6 TrPt:lPtiNT iN PtEtlwAtlNBfy t~t.Aac Ndc This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. 3 00 ocal Registrar Date Issued COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See laeln,die,n,e ae.ri .ar,.xn.,r..n ..w .a..aw-1 r-a CJ r-~ ~/ ~ 1 ~ 'r"1 .X " . - ' ',=-(--I rt7 7 ~~ .~ ~ _~ C" YT7 -.,.. .~~;::~,:.~ ~i ~ ~ "'' r.._..1 ~+• ~... L:' 3 ~....1 '- ~ ,~' Y7 • 3rnrC rrLt NVeA9Ep f. Name of De:edent (F.~, rrst9, .last. sutaxl 2. Bex ~. S:cgt Setatrily Mamba d. Date of Oeath (GbrtfD. day. year) toroth J. Priset Female 179 -- 12 -3104 March 25, 2010 S. Ape (fast &rehffiYI undst 1 Dcder t d,v B. Doled 6M IeAarah. Wu 7. ; and 9*ele a (C cempYj 8a. Pfeon d De,Bt tCA,c1c ane) t,Y,r+~q D,p+ Nets ,~•.aca -ioaDilat p~ 91 vim. November 7, 1918 Charleston Twp., P p,,~,d~, ^~;~,~,, Q~ QNn,bprtanr Ra,:clence pather•spet:ity: 6 C D. OUny a DOath ec. Gry. Som. 7uq. o! Desn ht. Fatly lhyrn (M rbt nsiir.at. pins sleet and r,rnberl 8. YUU t>oe,der d tacpan~c Ort9h? ~ No [] vas 70. Roca: American Malian. 8!ark. Y+nae eft , . ~ Cumberland Carlisle 274 Mooreland Ave. ~'~a~~rDa°'• c e~uaean watt Flan. era Whit e tt. Oeced,nh Usual d imp dqt, due` most d mr. Dona wale rceraat 72 Mtas Detmbtk ever n Nn t9.0ebrdatTe E6rtrGatt (~fedty atry ttylnal pray, te. Nbrtll thorn; lfafiod. Never IartrMe. 15, St,vix6lq Spouse id xa1o. give maWan rums) K,rra d Y1ork U S AnnW F ? am . . aoea t a hHe 1 p,m, 1 p>•tz) Calps (t•4 or 5«) M'tdewed. DNaoed ISpaaM Packer, Quality Cn Ma~u~eactu`i°"r ng p,a, ®N, ~.2~toA°"y Widowed ------ ts. Deaaerr, r4aan9 Adana 1SDen, ui moat, tdab, a+v taeadonl ofd Deeaderd PA 274 Mooreland Ave. Adoetnrlu.tb. na.aw Uwha ~~~,^ Ya.DeoedaaUsdh rn,, T°"'"hip? tzd.~] No.Dee,dertJredredert Carlisle, PA 17013 t~~"b__[_+._s_h_orlan,i Carlisle Aerwtiwd CNylBao t6. FoNsr', Name (F'tral. tntaate. last sulk) ~ t6. Mdnst N,er IF,ta. taddr, ttrddat rlrretrq Iva Smith z~. trdartbtd'o Nrtr~Type! PMt) r Joan W. Jones - z6b. rdattbtttt Maieladdresls~. Wltsre-ffib, rpabdN 274 Mooreland Ave., Carlisle, PA 17013 21a. MNhod a Dtspa,yoet ~'~'~"[1 Gentauat ^ Obrwiat 21b. Daae d Ditposaton IMontt. clay. yYari tte. Place d Otsposdion (Nstns a eetttwy, txemgayar otter tom! eta lopeon (Ciy; teem slate, zip code) ^ 9utiN ^ RemoeM teen Stan ' ; tw t SimWrn or Dalbdat AWtrtkrdl-~ 01~'' ' hrtratrl~+ t,gYtlOrb March 22, 2010 $uckheit Crematory Mansfield, PA 16933 d~`"rat~`"~ ~0f0"'~` tlt~! ~'~A8°""Aba ~'e'~~AaF++~Jacquelyn A. uc e t Hera ape , rams ory 637 S. Main St., Mansfield, PA 16933 a0y cMilyMq 73a. Ts tlb Dal d my inbsbdpe. riper at the ~, tlw ,bbl {Sand tilt) 136. liorw lirtthrr 23b. Dab 61prd WIaNA. day. ysad a Web d death b ~` tiJ etatiq au,e d dtmh. R.rv sfl 8~ 3-as- (~ Dams 14-26 must M camplebd DI perca+ ~. Tine al OtlW 15. Date Ftatouttxtl tfead dry, ytrar! i0. Mon tba ytebmd to tl6ritll tr.,atatnerf Catrrrbr a keaeort Drnr fleet ~Tanerort a Oosrtbttt wtnprdgteKS,dealh. ~~ 1 M. r ~~~ "~~ ~ ) ^Y ( f ~ L7 es No CAtI¢E OF OEATN (8ae ImNrueYo„s sad eatsntptss) s Appttsireb hbnak Pat ~ Ede a6w ' 2& 010'bbaeco Uss t+'olMdbtde b Oeat? Nam tI. PtN l: Prker Nts ~~-dbetltl. iItJIMe1. oro+snptearar-mat direr9y caused 6b dtWA DO tIDT atlr bmrnal eve:ds a+ttt tl cardaeara,l . , mpkMtkyMSM4orswMair(OnllYmrwWMrKiglDaado~.tiatoNyanetpwacnettDfir. s OwibDrlh Dwtnla~npb6aubny(npcrnNpNMhPael. ^ ria ^pAbsDly ~,~s~~ / ~ ^ i4r ^ INtRnb+ut ~~~~ - ~ .-y.. a. _ ~i~..... V i 26. N FemaM: Dw b for tl s amepratp oq, t ^ Not preptuM sit pe,t ye,r ~~Ibt oartdone. N Wt• b, t ^ Pregrnt M imr a dtl11+ a' Otn b la tl a eamagrnca elk s ^ bttt preptttrA saw @ drys C. ~~ . d Dar b la tl ^ aonsaqusttCa i ~ ^ Nat pnMrn6 Dtd pn9tbte tl aryt b t y,ar d. s ^ trNtro,etN sitlthorp,tayaa 30a. Y+as?aPsY 30b. bua,rgs 31. Manna d Death 97s. Dab d teprlr (Rkdh. day, yw- 310. f)txaD, kaa Ntpey Oeeuned 0~ d Ctrse d ~C?aay:krrn ~ tiYnrt ^ lCetirlde 370. H~otlb. FemltSlnel. F~mry. © Yee ^ ro ^ Yea [] Ne ^ arau~+t ^ Pe.~t9 Std. Titr a Miry 32e. trsu y et tYak? a;~. a TArtgrotmtion injtry {~ebay+ 379. totstcrt of ~' oty bran. aaafe! ^ 5ucd, ^ Could tbt be ~bm8ned ^ Yes [~ Nc ^ Ori<~er: Qpentor ^ Pas„n9er []Pedestrian M Oder. Spedy. 37a. CaeYfer kluot sty ar) ' ~MyhM IPtpsiciur ad~Shp user ddtttM attest ar. tar F.hysiden l,r ptaetrfceddeedt am tonprbd Nan 23) mw6>,na*ear.6l~e.dw.rewwea.wwea«rturaaettlNwta.---------- 33D. St9n,haa and - ------------ • -nrprtt~m+qM!{it/pltysicb.(PDyairitlDatpnnpnc,9aaab>naoatityitgteauseadnNd ---------- TafhrDeddllgbrwblpi.atWhoeCWndMwMr40ffa.mMphtl,anddlnroNratre~a~aMwtrmeraastaYd-----------„------ O • hledieel6rrrhwltbtooa 31c. NaraDa t1 11-~ ~d.~ 59ted~~ yyear ~ ti On w htlb a saathrtlrn rtdt a iMoq b mY opinion Oath ottumd N the tlme date and rt d d b w ^ ~ 3 ... ( j . , p tl. sa ue cxwW ud entata a, awed. 3a, ttrte and Address d Persm lbto d t?a~ (Nw o 2ri type; R:-t Pa ar's S~ rya and NsnYM.. I.5• ~ 9 iS i ~ 131 3S. D~ Fled tiknl, 4ax }=at! 7acf~n l ~ !~ ~~ e-1 O ~5~~ G - ) C~w 1-~ ~1~ w 110 J ~ tT;spnsrimrtPennuno "`*-''+~~~ N G ~, :~C7 i... ~ ~ ~ LAST WILL AND TESTAMENT ~'°~ ~ ~m -" ~ 9 Y~, y^ _~c ~~~ ~ `~^~ ~ 4 ---1 I, Dorothy J. Priset, of 21 Grant Street, Apartment D-202, Wellsboro, County o:~Tioga, ~ State of Pennsylvania, being of sound mind, and not acting under duress, menace, fraud, or undue influence of any person do hereby make, publish and declare this instrument my Last Will and Testament and do hereby revoke any and all other Wills and Codicils heretofore made by me. FIRST: I order and direct that my just debts and funeral expenses, expenses for administration of my estate and any inheritance, State or Federal taxes upon said estate, except those, if any, which are secured by mortgage or deed of trust, shall be paid as soon after my death as may be practical. SECOND: I am a widowed person. My spouses, Claude M. West and Oscar Priset, are deceased and Joan West Jones and Dora West Logan are all my natural children. THIRD: I hereby make the following specific bequests to my grandchildren: Kevin Patterson $6,000 Linda Kent $6,000 Todd Patterson $6,000 Jamie Logan $6,000 Susan Logan $3,470 ($6,000 less $2,530 loan balance not repaid) Penny Fassett $2,205.23 ($6,000 less $3,749.79 loan balance not repaid) Patty Chilson $10 ($6,000 less $5,990 loan balance not repaid) FOURTH: I hereby give, devise and bequeath all of the rest and residue of my estate, all property over which I have power to dispose to Joan West Patterson Jones, her heirs and assigns and Dora West Logan, ber heirs and assigns. FIFTH: I nominate and appoint Joan West Jones as Executor of this Will. In the event that the Executor named above shall predecease me or fail to serve as such Executor of this Will, I nominate and appoint Dr. Kevin L. Patterson as Executor. I further direct that no appointee hereunder shall be required to give any bond for the faithful performance of their duties. SIXTH: I hereby authorize my Executor to exercise all power, rights, discretion and duties deemed necessary for the proper administration and disposition of my estate. }-'} ~y.i fir.` :~z~y. ~.~:..~ ~, ..1 .:~..,: ~' '_ ~-e-~ .-a C' 3 .~. -~ I subscribe my name to this Wi1I this ~(~ day of March ?008. Signature: D y J. Priset On the day written below, Dorothy Jelliff West Priset, declared to us, the undersigned that this instrument, consisting of two {2) pages was her Wi11 and she requested us to act as witnesses to it. Dorothy Jelliff West Priset thereupon signed this Will in our presence, We novv in her presence subscribe our naumes as witnesses. It is our belief that Dorothy ~eiliff West P'riset is of sound mind and under no ~nstraint or undue influence. whatsoever. We declare under penalty of perjury that the foregoing is true and correct and that this declaration. was executed on the ~ day of March, 2008. J~~ ~~ Witness Wi e f !. ~a~~~ O/~ /~ 9~ ~ Aa~s 02027'3 ~jjcrr~/ ~/l~fd` ~ ~'YJ~s~;~~d P~ i~9.~ Address APR-7-2010 02:33P FROM:MARANATHA 258-1000 v+i v i• vv ~v .T ~a~. . ~.n T0: 5707242323 P.5 ~ vv..r vrv f'r•.~ ~~ (~ -.~,,. C~ 1 ," ....~ ,._.. ~~,, ~ . a ~ C;i~J ~'~ `~ ~ S.._r. t ~i ' ti...% " UAT~ ~~ SUBSCR~ING R~IT'NESS{L~~ ~~~ ~ ~ t ,~_, ;.~,_, ~~ ..' `~:' ~~~ w ~,~.:,t ~ .,'..~ W L~ ~~ r ~`-~.. ~ 1~-G~~J ~. ~ ~ ~ iw i~ ~~w ..r.~r ' ,~ , , ~~ I _ ~ O - ~ J Estate of ~~~Y ~'. Prises - ,-.._..~.,_~.._,.._.._..~..,,...,...... .._.__.~.........: Deceased Daam Pletcher (each a aubaen`bing wiine~a to R`~+s Nam the ®Will Q Codicil(g} presented herewith, (eacch) behtg drily gnatiFed according to law. deposo(s~ and say(s) that she / he 1 they wee !ware prGSatt and saw the above Testator ! Trststri>~ aagn the same and that she ! he 1 they signed the ensue and that she ! he !they signed ~ a witness st the rec}uest of the '~estatar ! Testaticlx in hor 1 his presence sad in the presence of each. +~ther. i~~~~~~ ~~~ f3usa dlld/ar~ - -- --- ~Ils~r~ ~~ /~ o/ ~,~~ ,L~xecated !r~ ~e~~r'a Dice Sworn to ar armed and subscribed befo mo this ~ ~ ~y of ~ C~ 1 O . for Rcginer of Wills 21 Gmarrt Sbrect • A.pt. D212 Wcllaboro. PA 16101 ~creted eut o, f R~f,~tar',s 4f,~ce Swam to or a~rmod and subac~ribed before ma ttris day of ~,~~, Notary Pablic --- My Coma~1SSXCD Expixos: (Si~atur~ nd 9ed of Narary a tKhaalAaW ~~ to s~fi3nJ~r off. Shaw dzta oftxptrxtlaa afl+iaary'r Ca~arniwbn.) NGTE: Tn 1~ r;k1a by Ofi[aer stuhOrE~ b admfr~ittrar oatf~. a have this or~iaai p ~ pti~(i) ~t ZGgf Of nodtir~iph, Forar 1[W-03 rav. 1 D.13.85 OATH OF NON-SUBSCRIBING WITNESS(ES) REGISTER OF WILLS ~~1~ e~ ~~r1n~ COUNTY, PENNSYLVANIA Estate of ~~d'd ~i ~ `~ ~,~~.~~ ,Deceased ~7~a.i,~J 4~s''f ~~'~c.~r°S and (each) being duly qualified according to law, depose(s) and say(s) that she / he /they was /were well- acquainted with o~o~CT~".. ~/^jSQ`'f and am/are familiar with the handwriting and signature of the decedent, and that the signature of ,~a ~'' e ~h ~/ ~ /~e~ l s'~l" to the foregoing instrument purporting to be the Last Will and Testament/gel-of ~QS~oY~'y ~T'- ~/~/ SQ'f is in his/her own proper handwriting. ~~~ (Signal re) ~y ~~~2 ~~~~ ~-~~ (Sb•eet Address) (Cil}~. State, Zip) Execccted in Register's Office Sworn to ter; affirmed and subscribed before me this day of , ao l~ . Deputy fur Register of Wills (Signature) (Street Address) (City, State, Zip) ~ ~ ry _.~ p --- ~ ,_ ..._ .. f l ~ ~ ~ ~ } . _;.} ~ r , a . y r•l r...~ ~~y ~ ~ ~~ "i ~. ~ ~ > ~, " -+..! r ~ Form RW-04 rev. 10.13.0( CODICIL I, DOROTHY J. PRISET, of 21 Grant Street, Apartment D-202, Wellsboro, County of Tioga, State of Pennsylvania, being of sound mind, and not acting under duress, menace, fraud, or undue influence of any person do hereby make, publish and declare this addition to my Last Will and Testament. Since my daughter, Dora West Logan, predeceased me I hereby direct as follows: Any expenses I have paid on behalf of my deceased daughter connected with her burial will be deducted from her one-half portion of the remainder of my estate. A pre- paid funeral plan for Charles Logan wi11 also be deducted from her one-half portion of the remainder of my estate. No distribution will be made to the heirs of my deceased daughter until they present the executor of my estate with proof of obtaining this pre-paid funeral plan. If my deceased daughter's spouse, Charles Logan, is living and has not remarried, then I direct the remainder of my deceased daughter's one-half share of my estate be distributed in six equal shares to her spouse and children, their heirs and assigns. If my deceased daughter's spouse has remarried then I direct my Executor to divide my deceased daughter's one half share of the remainder of my estate in five equal shares to her children, their heirs and assigns. IN WITNESS WHEREOF, I have hereunto set my hand and seal this , z~_ day of ~JRuua~eu ,2010 i ~- i ~ ~. b Dorothy J. Prise ,~1 ~ . Witness - ~- ~ ~ - ~5,. t t 4 r _..~ ~C3 -p C.~ ~ ~_-'. ;:~ z~~ ~~ ErJ Z~ t--7 "~` t t. `~ .. ` 1~ 1~. •Fl '~~- .~"' 'T i APR-7-2010 02:32P FROM:MARANATHA 258-1000 T0: 5707242323 P.3 c..a '~' _:~ ... ~y l BATH (~I' S~TB~CI~i~ri~G ~IT~~S~(ES) ~~ -~ ~ ~ ~ =, ~~~r ; c .~ ~i ~ ~~_°, ~ . t RECIISTER Ol~ WILLS ~7 c~ ~ ~ ~, CUMBEI~,A,ND C4LrNTY, PEbi1~T5~'YL1lAItTIA ';:~' ~ ~~, ~ _~- _ ~ ~= `s t.a f.. _ rn ,. ; Estate of Dorotl~ ). Prisct Deceased Maxine ~_ toy _ (each) a subscribing witness to /Pr~+-Arr~r~} tho pvv;u 0 ~odiail(a) printed herewith, (sash) beia,g duly qualified accor~g to I~w, depo$e(s} and say(s) that she ~l was f ro-erG prtsen# and saw the above ~Fes/ Testiirt~pc sign the earns and that sbe f ~-th~. signed the same and that she 1 ~a~ .signed as a witntsa at the ~qu~at of the -~~estatotl Tes#atrix in hc~t /his presancG aad in the presence of eacb Other. tsca~~•J r~~~~,s /arty, Srwr, z~J 1~acecvtdd tN Raistar's U~fee Sworn to or affiurmed and subscribed before me this daY of , Deputy for Rogistc~ of Willa Member, Pe-~nsylvania A$soclation of Notaries N 21(3rant Streck (S~il~i Wellsborn 1'~# 16941 t'GVy, StoK t~1 ~"zec~rtad o~rt of ~~itar'a ~cr Sworn to or ~renad sad subscribed bai'ore ma this to "-' ~y of ~i~ c. ?s~o , Notary Pu c My Ccmm~ssion Expucs: (slBnemra and ~ o! Nohry e~ other otflCial gWfflled to ad~a~ati,e ot+Rbs. Sba•v daea ofaa~gt(~du of Napa7's. Cp~~{~,? 1~OT8: ?o be takes by4ilicar sWd~p tdrt~la oaz~. r~tt Aavs pe~aaot tbs orf~iaat or of t rt tlme of noirti~odwu G M ~ ANN V MANIA Form RW.Q~ yv. ~0,I3.a6 Notat~l ~ Mark W. Wood, Notary Pubic wel~boro 8oro, ~iaga county ~ Commissbn Ex{~'ea Jw~e 23, 2010 OATH OF NON-SUBSCRIBING WITNESS(ES) REGISTER OF WILLS ~~'~u~~~~~-,~ COUNTY, PENNSYLVANIA Estate of -f 4 ~ o ~i u ~ ; ,r,~ / n~ ~ ,Deceased ~~~-~c.,/ CP~°-~ ~To.C.~ r°S and (each) being duly qualified according to law, depose(s) and say(s) that she / he /they was /were well- acquainted with ~d/~dyrCj (/ ~"~ ~/~rs~1~' and am/are familiar with the handwriting and signature of the decedent, and that the signature of .~rrd-d~~'v ~". /'~~-/..r- r'~ to the foregoing instrument purporting to be the Last Will and Testament/Codicil of ~d/~1~1 V ~' ~i~~sr~ ~ is in his/her own proper handwriting. /r Gv ~ ~='~ (S ~» tcu•e) (Sb•eet ddress) (City, Stale, Zip) (Signature) (Street Address) (City, State, Zip) Execccted in Register's Office Sworn to or affirmed and subscribed before me this ~~ day of ~ n ~ ~ ~-" Deputy for ~C,egister of Wills ra c~ -- "`~ -~ a~ ~• a.. ~ t w-, ~~ . : ~ . , _~.__ r- ~ r~-~ ~ t: T 7 C~ ~ ~.._i L-:.a ~ ~ ~ .... ~ '~ 1 ~.,i : ~ Form RW-04 rev. !0.13.01