HomeMy WebLinkAbout02-10-11I 1505610140
REV-1500 EX (01-10)
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 1 0 0 5 4 7
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 8 8 2 0 7 5 7 5 0 5 1 7 2 0 1 0 1 2 0 4 1 9 2 6
Decedent's Last Name Suffix Decedent's First Name MI
E L L E N B E R G ER V I O L E T H
(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 WITI-I THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Retum ~ 3. Remainder Return I;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)
QX 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 INFORMATION SH~DULD BE DIRECTED TO:
Name Daytime Telephone Number
M~
D A V I D H R A D C' I T F F 1- c~ 7 1, 7 ~ ~"~, 9~ ~T:~° R
- ~-~ ~~~
~~~
First line of address
1 0 1 1 M U M M A
Second line of address
S U I T E 2 0 1
City or Post Office
L E M O Y N E
State
P A
ZIP Code L
1 7 0 4 3
REGISTER OFY ~E ONLi'tn"j
s ....i
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DATE FILED
Correspondent's a-mail address: DHRAD@IX.NETCOM.COM
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Under penalties of perjury, I declare that I have examined this return, inGuding accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. DeGaration of preparer other than the personal representative is based on all information of which preparer hags any knowledge.
SIGNATURE OF P RSON RESPONSIBLE FOR FI ING RETURN DATE
ADDRESS ~~
404 WEST STRAWBERRY AVENUE MECHANICSBURG PA 1~~055
SIGNAZ~kJh2E'~PREPARE OH,~HAN.REPF~ ENTATIVE ATE'
ADDRESS '~
1011 MUMMA RD #201 LEMOYNE PA 1~~043
PLEASE USE ORIGINAL FORM ONLY
L 150561D140
R 0 A D
Side 1
1505610140
.-h~
1505610240
REV-1500 EX
DecedenYsName: VIOLET H • ELLENBERGER
Decedent's Social Security Number
1 8 8 2 0 7 5 7 5
RECAPITULATION
1. Real Estate (Schedule A) ........................................... 1 • •
2. Stocks and Bonds (Schedule B) ...................................... 2.
6
1.
i?
3 .
0
8
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. •
4. Mortgages and Notes Receivable (Schedule D) .......................... 4. •
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6 6 .L 4 . 0 1
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 1 4F '3 5 . 1 0
7. Inter-Vivos Transfers 8 Miscellaneous N -Probate Property
~
1 7 8
~i ,
3
4
8
5
(Schedule G)
Separate Billing Requested ....... 7. . .
8. Total Gross Assets (total Lines 1 through 7) ...........................
__ 8. 1 9 2 r' ~ 7 . 0 4
9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 1 1 ~I I~ 1 • 4 9
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 2 6 0 7 . 2 0
11.
Total Deductions (total Lines 9 and 10) ...............................
11.
-r '
~
• 6 9
12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. 1 ? 8 1 '9 8 . 3 5
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. 1 7 8 1 '9 8 . 3 5
TAX CALCULATION -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 0 Q 15.
16. Amount of Line 14 taxable
at lineal rate X .045 1 7 8 1 9 8. 3 5 16.
17. Amount of Line 14 taxable
at sibling rate X .12 0 0 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 0 0 0 18.
19. TAX DUE .............. .............................. ... ..... ..19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
0. 0 0
8 CI .1 8 . 9 3
0. 0 0
0. 0 0
8 CI :1 8 • 9 3
Side 2
1505610240 1505610240 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 10 0547
DECEDENT'S NAME
VIOLET H. ELLENBERGER
STREET ADDRESS
805 NORTH WALNUT STREET
CITY
MECHANICSBURG STATE
PA ZIF'
17055
Tax Payments and Credits:
~ ~ Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments 7,000.00
B. Discount 368.41
3. Interest
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.
Total Credits (A + B) (2) 7, 368.41
(1) 8,018.93
(3)
(5)
(4)
0.00
Make check payable to: REGISTER OF WILLS, AGENT
650.52
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 : ...................................................................... ^ Q
b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q
c. retain a reversionary interest; or ................................................................................................ ^ 0
d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ^ Q
3. Did decedent own an "intrust for" orpayable-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? .................................................................................................. 0 ^
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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for thE; use of the surviving spouse is
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 21 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 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 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 12 percent [72 P.S. §9116(a)(1.3)]. 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-1503 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
VIOLET H. ELLENBERGER 21 10 0547
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
(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, & MISC.
IN REST DAENT DE EDENTRN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
VIOLET H. ELLENBERGER 21 10 0547
__ __-
Indude 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. 1992 CHRYSLER LE BARON 650.00
2. M&T CHECKING ACCT #30556708 5,499.21
3. 5 - $20 TRAVELERS CHECKS 100.00
4. REFUND -STATE FARM INSURANCE 6.80
5. REFUND -STATE FARM INSURANCE 41.55
6. REFUND -UNITED WATER 15.87
7. REFUND - COMCAST 19.13
8. REFUND - BANK OF AMERICA 18.75
9. PA DEPT TREASURY 262.70
TOTAL (Also enter on line 5, Recapitulation) I $ 6,614.01
(If more space is needed, insert additional sheets of the same size)
REV-1509 EX+ (01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF: FILE NUMBER:
VIOLET H. ELLENBERGER 21 10 0547
If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME(S)
A. BARRIE ELLENBERGER
13
C
JOINTLY-OWNED PROPERTY:
3480 GRANDVIEW DRIVE
YORK HAVEN, PA 17370
ADDRESS
RELATIONSHIP TO DECEDENT
SON
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 ;~a OF~
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTERESI
1. A. PSECU REGULAR SHARES 2,220.49 50. 1,110.25
2. A. PSECU CHRISTMAS SHARES 769.69 50. 384.85
TOTAL (Also enter on Line 6, Recapitulation) I 9~ 1,495.10
If more space is needed, use additional sheets of paper of the same size.
REV-1510 EX+ (08-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
VIOLET H. ELLENBERGER 21 10 0547
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is ye`,.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
% OF DECD'S
INTEREST
EXCLUSION
(IF APPLICABLE)
TAXABLE
VALUE
1. AMERIPRISE BROKERAGE ACCT #12792242 98,012.04 100.00 98,012.04
2. RIVERSOURCE LIFE ANNUITY #0930082467570004 54,379.94 100.00 54,379.94
3. AMERIPRISE IRA (ACCT #0011236359078002) 26,142.87 100.00 26,142.87
TOTAL (Also enter on Line 7, Recapitulation) I $ 178,534.85
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
VIOLET H. ELLENBERGER 21 10 0547
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. PARTHEMORE FUNERAL HOME 3,984.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
2, Attorney Fees: RADCLIFF LAW OFFICE, P.C. 7,700.00
3. Family Exemption: (If decedent's address is not the same as daimanYs, attach explanation.)
Claimant
Street Address
4
5
6
7.
8
9
City State ZIP
Relationship of Claimant to Decedent
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees: BROWN SCHULTZ SHERIDAN FRITZ (2009 PERSONAL
RETURN PREPARATION)
FILING FEES -INHERITANCE RETURN & INVENTORY
CHECK PRINT FEE (ESTATE ACCT)
ADDITIONAL PROBATE FEE
TOTAL (Also enter on Line 9, Recapitulation) I
If more space is needed, use additional sheets of paper of the same size.
114.50
100.00
30.00
17.99
15.00
11.961.49
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
VIOLET H. ELLENBERGER 21 10 0547
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (01-10)
pennsylvania ~ SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
VIOLET H. ELLENBERGER 21 10 0547
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. TRUDY E. MERRILL Lineal 44,549.59
404 WEST STRAWBERRY AVENUE
MECHANICSBURG, PA 17055
2. SERLA E ROSS Lineal 44,549.59
510 LAMP POST LANE
CAMP HILL, PA 17011
3. BARRIE L ELLENBERGER Lineal 44,549.59
3480 GRANDVIEW DRIVE
YORK HAVEN, PA 17370
4. EILEEN E OSBERG Lineal 44,549.58
1109 INDIANA STREET
GLENWOOD, IL 60425
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
It more space is needed, use additional sheets of paper of the same size.
Y~fIEYTE, EVANS & WOODSIDE
ATTORNEYS AT LAW
^~ i-1APRISBURG, PENNSYLVANIA 17108-0729
~~~# tX~ ~z~~ C~e~#~~te~t~
OF
VIOLET H. ELLENBERGER
I , VIOLET H . ELLENBERGER, of the Borough of ramp H:i.l1 ,
Guiliberland County, Pennsylvania, de make, publish and aecla~re
this to be my Last Wi11 and Testament, hereby revoking all
Wills and Codicils by me at any time made.
ITEM I: I direct that all inheritance <~nd
estate taxes becoming due by reason of my death, whether such.
taxes may be payable by my estate or by any recipient of any
property, shall be paid by the Executor out of the pxope.r_ty
passing under ITEM III of this Wi11, as an expense and cost of
administration of my estate . The Executor shall have T~to dusty
or_ obligation to obtain reimbursement for any such ta~~ so p<~id ,
even though on proceeds of insurance or other property not
passing under this Wi11.
ITEM II: I give and bequeath to such of my
children, BARRIE L. ELLENBERGER, TRUDY A. MERRILL, SEP,.~A F.
ROSS and EILEEN OSBERG, as are living at the time of my death,
absolutely and in fee simple, all of my household furniture and
furnishings, books, pictures, jewelry, silverware, au1umobi:les,
wearing apparel and all other articles of household or personal
use or adornment and all policies of insurance thereon, to ibe
divided between them as they shall agree. Should there be 7ilc~
agreement, such property shall be divided among them '_~y the
Page 1 ~ ~ `-~;' ~?~ .
Executor in as nearly equal portions as is deemed practical in
the sole discretion of the Executor, having due regard to the
personal preferences of such children.
ITEM III: I give, devise a~
the rest, residue and remainder of my estate,
in the preceding portions of this Wi11, to my
equal shares. If any of said children is not
death, the share of said deceased child shall
then living issue of said deceased child, per
:xd bequeath all
not disposed of
children, in
living. at my
be paid ~o thf?
StirpeS.
ITEM IV: In addition to powers given by
law, the Executor shall have the following discretionary
powers, effective without court order:
(a) To retain any property received by the
Executor;
(b) To sell real estate for any purposes,
publicly or privately, for such prices and on such
terms as the Executor deems proper, without liability
on the purchasers to see to application of the
purchase moneys;
(c) To compromise controversies;
(d) To distribute income or principal in cash or
in kind, or partly in each, at valuations fixed by the
Executor at such times as are deemed appropriate;
(e) To hold investments in the name of a
nominee; and
,;
Page - - ----
(f) To undertake all other acts in the
Executors judgment deemed necessary for the propez:
and advantageous administration and settlement of my
estate.
ITEM V: Any person who shall have died at
the same time as I shall have, or in a common disaster with me,
or under such circumstances that the order of our deaths cannot
be established by proof, or within thirty (3C) days of my
death, shall be deemed to have predeceased me.
ITEM VI: If at any time any beneficiary
under the age of twenty-one (21) years shall be entitled to
receive any assets hereunder, the living parent of such
beneficiary shall receive such assets as Custodian under the
Pennsylvania Uniform Transfers to Minors Act for that
beneficiary. Such Custodian may receive and administer_ all
assets authorized by law, and shall have full authority as
provided in the Pennsylvania Uniform Transfers to Minors Act to
use such funds in the manner it deems advisable for the best
interests of such beneficiary. In addition, said Custodian
shall have all the rights and privileges as to the
Custodianship and its assets as are herein granted to the
Executor as to my esta~l-.e and tree assets therein. I also
designate said Custodian as successor Custodian of any property
for which I am custodian under any Uniform Transf ers to Minors
Act.
ITEM VII: I hereby nominate, constitute and
appoint my children, BARRIE L. ELLENBERGER, TRUDX A. T~ERRIL~L
and SERLA F. ROSS, to be the Executors, herein collectively
referred to as "Executor" . The Executor is spec~__f7 ca_11y
.,
Page 3 ;/%~ ~=~_4-
-ling any .~°.~~ °r
bllgation of f 1
am the duty or o
red-ie~ed f~ • t nd and seal to
other securr y have set my ha ~hls and the
SS WHEgEaF , I consist~'ng of o~ ~;hich T
I~ wI~NE nd T e s t a~1ent ' e
11 a end of each Pag be ~~=er
• s , my Fast W1 ages , at the r security and ,:-,.~jti,
thl ,three (3) P r Bate ~ 19
{
x e c e , ~~ ~.
ding initials for g
f
P also Set ray day o ~-., ! ~1 ,~~~, (SEAL)
h on .th ~ ,~ ;-~ ~ ~ ~~ , .z
c at i ~~ ~ -- ,'..
i d ent l f i ~~„ ~.~..>>~ ELL,EN$Eg~Eg
~ VI~LE~ K.
yQregoing
-~ t hE
eby certify tha tb.e aboVe~
ndersigned~ her and declared by en~ in .the
We ~ the u ed X11 and Testam.
seal Last W resenC~ and i.n
d ~ Pv`bl l sh
e
rll was Signed and fox hex t and in her p z~nd~ and
W ed Testatrix as at her xeques unto Set our ~~ ~~ify .that
here d ~ cc
nam ence of us , w o , other , have l.tten ~ an ~ ~- ~ 1,~. was of
Axes of each wr .~,esta_~.
e Presence ear first above f , the Saki
th day and, y there o
the ti°n
als irne of th eXecu and memory . .,
at the t ing mind ~ `~ ~ ~ ~. ' ' ~ ~ ' -
d and disP°S 1 at t.,-y~ ~
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ACKNOWLEDGEMENT
COMMONWEALTH OF PENNSYLVANIA )
~/J~ SS:
COUNTY OF .~~-+w'^ )
l/
I, VIOLET H. ELLENBERGER, Testatrix, whose name is
signed to the attached or foregoing instrument, having been
duly qualified according to law, do hereby acknowledge that I
signed and executed the instrument as my Last W~_11 and
Testament; that I signed it willingly; and that I s~.r.ned it as
my free and voluntary act for the purposes there~.n e~~pressed ,~
l
~~
-~.~ -t~~ ~ _.~ : C " ~-r:, ~' ~_.~- ~~~ ( SEAL )
VIOLET H. ELLENBE~GEP.
Sworn to and subscribed
before me-this oZ 199 day
of `~u U ~ y
Notary Publ
My Commission Expires:
(SEAL)
Nota~at Seal
Margaret M. Kenwortt7, Notmy PubOC
Susquehanna Twp., Dauphin County
My Commission Expires Sept 28,1997
tvian ;fir, i='ennsyNania Assoaation of Notaries
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA )
SS:
COUNTY OF li%~ l )
.: ,, _ .
and {~. -' ~~.~ k ~~~~ the Witnesses whose names are
signed to-~the attac ed or foregoing instrument, being duly
qualified according to law, do depose and say that we were
present and saw Testatrix, VIOLET H. ELLENBERGER, sign and
execute the instrument as her Last Wi11 and Testament; that
Testatrix signed willingly and that she executed sand Will .as
her free and voluntary act for the purposes therein expressed;
that each of us in the hearing and sight of the Testa~tr.ix
signed the Wi11 as Witnesses; and that to the best of our
knowledge the Testatrix was at that time eighteen (J_~) or more
years of age, of sound mind and under no constraint or. undue
influence .
a ~ ,
/ l
Witness
,t 1 /. ..
Witness
.~,
~`.' J,.
w. ,~ _
,•'
Witne$.s ~~
~ -.,.~..
Sworn to and subscribed
before me this o? y-f~i day
o f ~ ,~f , 19 9y.
`~i ,
otary Publ'c
My Commission Expires:
(SEAL)
No~,,1a- ~s~J
Nlarg~ret M. KerN~o~Y. Not1~ ~Pu ~c
SusquehannaTwP•, Dauph~t 28,1997
My ~,Y,rn+ssan Expires Sep
,a psscaaGon of Notaries
tviert ::,wr, Pennsylv~-