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HomeMy WebLinkAbout04-07-11PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of ROBERT L . BURLES01~ File Number ~ ( ~ ( ~'' ~ ~"~ "t also known as ,Deceased Social Security Number 4 6 4- 2 4- 9 5 4 9 JOHN E- BURLESON 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 E X E C U T 0 ~ named in the last Will of the Decedent dated ~1+ / ~~Q 10 and codicil(s) dated (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, was never adjudicated incapacitated, and was not a party to a pending divorce proceeding at the time of death wherein grounds for divorce had been established as provided in 23 PA C.S. section 3323 (g): B. Grant of Letters of Administration (If applicable, enter: c. t. a.; d. b. n. c. t. a.; pendente liter durante absentia; durante mtnoritate),, .. Ems: Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following s~~t~Cj(if any) a heirs;-~1'~~,~ Administration, c. t. a. or d. b. n. c. t. a.. enter date of Will in .Section A ahnve and cmm~lete list nfheir.c 1 -.y --~ ~~^°• ~..7. ~- Decedent was domiciled at death in CUMBERLAND County, Pennsylvania, with his /her last principal residence at 3 7 5 5 SULLIVAN STREET MECHANICSBURG PA 17050 HAMPDEN TOWNSHIP (List street address, town/city, township, county, state, zip code) Decedent, then $7 years of age, died on 4/2/2011 at HOLY SPIRIT HOSPITAL CAMP HILL pA Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ 13 , 2 0 0.0 ^ (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania $ 8 5 , 0 0 0.0 ^ 3755 SULLIVAN STREET, MECHANICSBURG, PA 17055 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 fonri to the undersigned: nature Typed or printed name and residence JOHN E• BURLESON 497 WOODCREST DR:LVE M HA R PA 17050 Page 1 of 2 Form RW-02 rev. 10.13.06 (COMPLETE INALL CASES:) Attach additional sheets if necessary. 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 representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirred and s~?bscribed _" o~L~e.~e~~. before rr~e the ~ day of Signatu of Personal Representative Q J ( l i, ~ ~ ~'{ ~' ~ C7 ~: , ~~: ~~ ~~ - - ~ Signature of Personal Representative a ~ ~ ~ "~ `~ ..," 7 ~ For the Register Signature of Personal Representative - - ~''~ ._-,~ _- „J ' ' ~ '~' _-,'' _ .... _~ 1 _. _ _ File Number: c~- i - ~ ~ ' ~ ~ ~ ~ • + ~`'~ ti.~ ~~ ° ' ~ Estate of ROBERT L • BURLESON ,Deceased Social Security Number: _4 6 4 - 2 4 - 9 5 4 9 Date of Death: 4_/ 2 / 2 011 \ i AND NOW, ~ ' (, ~ ~ ~ , 2011 , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT I S DECREED that Letters T E S T A M E N T A R Y are hereby granted to J O H N E• B U R L E S O N in the above estate and that the instrument(s) dated NOVEMBER 2 , 2 010 _w described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. FEES ~- l C~ . Letters ............................. $ ~ ~ ~' ~ Short Certificate(s) ............ $ `~ ~ - C1 Renunciation(s) . • • ............. $ TOTAL ......................... Form RW-02 rev. 10.13.06 .... $ .... $ .... $ .... $ .... $ .... $ Attorney Signature: Supreme Court I.D. No.: 70241 Address: 2331 MARKET STREET CAMP HILL PA 17011 Telephone: 717-763-1383 Page 2 of 2 Attorney Name: SUSAN H• CONFAIR G~AL RE.GISTRAR'S CERTIFI~AT•I~N GF E:A" 1~'J~RNNNG: lik Is Illegal to duplicate tI~IC> ~'~:~~~ b~ ~a~~c~to~~~~~t ~I' ~hc~t~.~~I',°°~~:)#~~ }'t't' ~lll- thl~~ ~_`s:'('U~IL'~llc.- ''s~'.~lii ~', )y`, I' ... ._ il4i±?4-f~l~rlt(~I'i ;1. ;+, 4'I1~'1'I 1`~ rr'~~ ~ ; ,. , a~ (l~ ~ _ _ ~y r `... ~ k , ~rt~"~ - ~ip,..:: _((%.'l •+r) :i ~ ~ to it l~ i_ ill.~ll' 1~ .' ^.?I 1;~.C~1 ~ ~',` J' i `~~"~/ .~ ~~~~ E~`~ i ~ .~ ~1~ ~~=. ,.s °~~~,`~1)'~t1d;~ ) 1t" t~fl .11faLl 4 ~ ~ t';. y .~~1 -~' I(~) ..I'.. ~ I1 t. .'i~(l~'l1 (l ~1)i.~ ~~(,.3i. ~~i):.II ,: o, ~ ~ ~v i=~~ ~x, i~~t_;,}) i ~)t i ~ t,.,~,;,t'f~i SlI1l~Yz ~,~ - ~° ~~~ ~ ~; ~,pR Q 4 2011 ,r ~~~ ` P 17298771. ~~ ~ , _ __ ,~_ M~~~ `° '' ..__ ~~C'I-t19i( ~Il)11(1 ~''rtllTih ` ::.~ ~~ .,~s ,~. ) - _,~ .~.~~ .., r ~% ) ':7 ~ c ,.i :'c17~ - REV lt/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS !PRINT IN MANENT CERTIFICATE OF DEATH 1CK INK (See instructions and examples on reverse) ..r,r~ _„ ~ ,,,,,,,,~„ 1. Name of Decedent (First, middle, last, suffix) 2. Sex 3. Social Security Number 4. Date of Death (Month, day, year) Robert L. Burleson Male 464 - 24- 9549 A ril 2, 2011 5. Age (Last Binhday) Under 1 ar Under 1 des 6. Date of Birth Month, des 7. Birth C and state a forei count 8e. Piece of Death Check onl one Months e Daya Hours MinNes HOSpltal: Other: 87 vrs. Ma 5 1923 y I Centerville Tx r ®Inpetlent ^ ER /Outpatient ^ DOA ^ Nursing Home ^ Residence ^ Other - S i I~ N 8b. County of Deets Bc. City, Boro, Twp. of Death 8d. Facility Name (If not Institution, gNe street and number) 9. Was Decedent of Hispanic Odgin? [~ No ^Yes 10. Race: ATencan Indian, Black, White, etc. • Cumberland East Pennsboro Holy Spirit Hospital (If yes, specify Cuban, Mexiran,PuertoRican,etcJ (Spec/yl White 11. Decedent's Usual Occ lion Kind of work d one dudn most of world INe. Do not state retired 12. Was Decedent ever in the 13. Decedents Education (Specify only highest grade comp leted) 14 Madtal Status: Marded Never Married 15 Survvin S o use pf if N id Kind of Work Electrician Kind of Business/ Indust ry R il d U.S. Armed Forces? Elementary /Secondary (D•12) College (1-4 or 5+) . , , Widowed, DNorced (Specify) g p w e, g e ma en name) a roa ^Yea~Ne Widower - 16. Decedents Mailing Address (Street, city /town, state, zip code) 3 7 5 5 S u 11 I v a n Street Decedent's Did l~cedent H a m Dde n Adual Residence , 7a. state _ P e n n s y 1 v a n i a Live in a 17c ®Yes Decedent LNed in T Mechanicsburg Pa . , wp. Township? 17b.County Cumberland 17d.^No,DecedentLivedwithin , Actual Limits of City/Boro 18. Father's Name (Frst, middle, lest, suffix) Roy Burleson 19. Mothefs Name (First, middle, maiden surname) Elizabeth Lynam 20a. IniormanYs Name (Type I Prirn) John E. Burleson 20b. InfortnanYS Mailkg Address (Street, city /town, state, zip code) 497 Woodcrest Dr M h i b ., ec an cs urg, Pa 17050 21 a. Method of Disposition r ^ Cremation ^ Donation • r 21 b. Date of Diapasikon (Month, day, year) 21 c. Place of Dispasitlon (Name of cemetery, crematory or otfrer place) 21 d. Location (City/town, state, zip ccda) ® Budel ^ Removal from State t Waa CremMbn or Donation Authorized ^ Other - r by Medal Ezaminsr/Caorrer7 ^Yes^ No • Apr 6, 2 01 1 W o o d l a w n Memorial Gardens H b q, P a 22a. S' of Fu ref Service Liven (or person acting es such) 22b. License Number 22c. Name and Address of Fadiity S u 11 i v a n F u n e r a 1 H o m e - - ~ FD011897-L ,~ Complet 23a-c any when certifying 23a. Tot of rtry knowledge, death occurred at the time, date and place stated. (Signature and tdle) 23b. License Number 23c Date Signed (Month da ear) physiden is not available at fine of death to . , y, y certNy cause of death. • S ~ ~ a a ~ Items 24-26 must be wmpleted by person 24. Time of Death 25. D Pronounced Deed (Month, day, year) 26. Was Case Refe rr e d to Medical Examiner /Coroner for a Reason Other than Cremation or Donation? • who pronourrcea death. - M. r - ~ / ^Yes l~ No CAUSE OF DEATH ( es Instructions and examp s) r Approxknete interval: Item 27. Part I: Eller fife chain of events -diseases, injuries, or complicetbns - that rxredty caused the death. DO NOT enter terminal events such as cardiac arrest, i Onset to Death Pert II: Enter other ;dgni8cant mndftior~ rxNttdhudnc to dea[b but not resulting in the underlying cause given in Pan I. 2E. Did Tobacco Use Ccotribute to Death? ^Yes ^ Probabl respiratory arrest, or ventricular fibdllation wltlwut showing the etiology. List Doty one cause on each line. r y ^ N ^ r IMMEDIATE CAUSE (F n l di ~ o Unknown n L i a sease or condition resulting in Heath) V . , ~ f - `/' l ~ ~~ ~C ~ ~ ~S Pl -~(~ ~' 29. If Female: ~, ~ ~ ` _~ a l Y ~i ^ i Due to or as a ce quence ~p ~ ~~ ~ ~ ~ Not pregnant within past year ^ Sequentlelly list conditions, if ary, b , G(,L L ~ Q ~ ~ GC L. wl v C_-- i lea ' to the cause listed on line a. \\\ ~~• Pregnant al time of death Due to sequetnce of): ~ Enter Bre UNDERLYING CAUSE (~~ ~ (disease a in th t I iti r t d th ^ Not pregnant, birt pregnant within a2 days f ~ n ju y a n a e e ~ l r events resulting m death) LAST. c' ~ o death ^ - Due tO (Dr~$ n~que~ Lfk _ ~U~ ~ ~h / sj~, r - ~ ; 5 n Y / ~ . /-~ ~ Not pregnant, but pregnant 43 days to 1 year betas death C ~ ~ ~+l l • d. _ L I ( / I , f.~ r ^ Unknown if pregnant within the past year 30a. Was an Autopsy Pedesmed? 30b. Were Autopsy Findings Available Prbr to Completion 31. M~rrner of Death , ~ / 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occured 32c. Place of Injury: Home, Farm, Street, Factory, of Cause of Death? /( Natural ^ Homidde L J Office Building, etc. (Specify) ^ Yes No ^Yes ^ No ^ Accident ^ Pending Investigation 32d. Time of Injury 32e. Injury et Work? 32f. If Transpodation Injury (Specify) 32 L g. ovation of injury (Street, city I town, state) ^ Suicide ^ Could Not be Determined M ^Yes ^ No ^ Driver / Operates ~ Passenger ^ PedesMan ~ ^ Other• 1 33a. CertlBer (check Doty one) 33b. SI to Title of Certi r • CertMying phyaleien (Physician certifying cause of death when another physician has pronounced death and completed Item 23) (~~ CM. ~ To the best of my knowledge, death occurred due to the cause(s) end manrxr es slated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - • Pronouncing end cerNlying physician (Physician troth pronouncing death and cer8fying to cause of death) 33c. License Number 33d. Data Signed (Month, day, year) To the best of my Imowledgs, death occurred at the time, date, and place, and due to the ease(s) and manner ss eteted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ • Medkel Examiner/Coroner ~ ~ Z ] / j_ f ~1 1 T I -` ~ ~ I / On the basis of ezaminatlon sod / or Investlgetlon, In my opinion, death occurred at the time, data, and piece, and due to the ceuae(s) end manner as stated_ ^ 34. Name and Address of Person/"y~yh~o ~Complet Cause ofD e ath (Item 27) Type i P 5nt ~ `' ' ~ 35. Registrar's S' ature end Diatr~l N ~ ~''~ . I d l ll ~ I / i ~ I ~ p ~ r ~ ~~~~' .. l V (S `J C7 ~ r {'1L~ t ~ ~ '~ / r ~ D ~~~ ~+ ; %~ 1 ~;•• 1; c,/~~~ [-> (c.~ > f~~ P ~ N -~ ~ N vK( rd ~~~ ~'~ c ~ ~ , , fJ6 <UIJSa ''" '' Disposition PermN No. Evaluation Only. Created with Aspose.Words. Copyright 2003-2010 Aspose Pty Ltd. LAST WILL AND TESTAMENT OF ROBERT L. BURLESON I, Robert L. Burleson, a resident of Mechanicsburg, Pennsylvania declare this to be my Last Will and revoke all former Wills and Codicils. ARTICLE I Identification of Family At the present time I am unmarried. In making this Will I have in mind my children, Robert E. Burleson, born 1944, and John E. Burleson, born 1949, but does not include any children hereafter born to or adopted by me. Any reference to a "child of mine" or "my children" shall include the persons named or referred to in this Article. A. Disinheritance Provision. I, intentionally and with full knowledge of the consequences, disinherit and omit any provision in my Will for the following children: my son, Robert E. Burleson, and my son, John E. Burleson. Further, I intend that this disinheritance specifically defeat the application of any statutory heirship interest or ;any reference to child, children, descendants, heirs, or issue, in this Will, with respec~ hese children. .~ _-~ ~~, J l~ { , , %~ ` ' t t ~~' ARTICLE II Appointment of Fiduciaries ~ ; ` ~' ~- :.- ~_:, A. Appointment of Personal Representative. I appoint my son, Join E. Burleson, as Executor of my estate. If John E. Burleson is or becomes unable or unwilling to serve, I appoint my daughter-in-law, Karen L. Burleson as alternate Executor. B. Bond; Court Supervision. My Executor shall have the right to serve without bond and to administer and settle my estate without the intervention or supervision of any court, except to the extent required by law. Nothing herein shall prevent my Executor from seeking the assistance of the court in any situation where my Executor deems it appropriate. ARTICLE III Disposition of Residue 1. Provision for Others. I give 50% of the rest and residue of my estate, wherever located (hereafter referred to in this Article as "residue"), to my Will of Robert L. Burleson Page 1 of 6 Initials: ~``'~~ Date: ~ a °- ~.-, .ie ,.o _ = __~ ."'1rE "~~.., 4,: 1 '7 -..•~ -, j __ _ J -;; ~ _. grandson, Eric L. Burleson. I give 50% of the residue to my grandson, Alan J. Burleson. If my grandson, Eric L. Burleson does not survive me then I give all of his 50% of the residue to my grandson, Alan J. Burleson. If my grandson, Alan J. Burleson does not survive me then I give all of his 50% of the residue to my grandson, Eric L. Burleson. If I am not survived by any party named in this provision, I give the entire residue to my heirs. ARTICLE IV Alternative Methods of Distribution A. Purpose of Article. Recognizing that under certain circumstances the terms of this Will may direct that property be distributed outright to a person who is under age twenty-one (21) or under a legal disability; I make the following provisions to facilitate the distribution of property to such persons. B. Alternative Methods. Whenever the terms of this Will direct my personal representative (referred to in this Article as the "fiduciary") to distribute property outright to a person who is then under age twenty-one (21) or under a legal disability, the fiduciary may retain pursuant to Paragraph C. of this Article or distribute all or any portion of that property in any one or more of the following ways: 1. Delivery directly to the beneficiary; 2. Delivery to the parent or stepparent of the beneficiary; 3. Delivery to the guardian of the beneficiary's person or property; 4. Delivery to any Custodian for the beneficiary under the Uniform Gifts to Minors Act; 5. Delivery to any then existing trust created for the beneficiary; 6 Deposit in a financial institution in an account established in the . name of the beneficiary alone pursuant to the laws of the State of Pennsylvania; 7. Storage of any tangible personal property in safekeeping with the costs of storage to be borne by the beneficiary; or 8. Sale of any tangible personal property and delivery of the proceeds in any manner permitted by this Article. Provided the fiduciary acts in good faith, upon delivery of any property in accordance with the provisions of this Article, the fiduciary shall be discharged from all responsibilities in connection with the property. a ~o ,~ Will of Robert L. Burleson Page 2 of 6 Initials: Date: i C. Discretionary Trust. Any property not distributed as provided in Paragraph B. of this Article shall be retained by the fiduciary in trust for the beneficiary on the following terms and conditions: During any period in which the beneficiary :is under a legal disability or under twenty-one (21) years of age, the fiduciary shall pay to or apply for the benefit of the beneficiary so much of the income and principal of the trust as the fiduciary, in its sole and absolute discretion, determines is advisable for the beneficiary's health, support, education and general welfare. At such time as the beneficiary is neither under a legal disability nor under age twenty-one (21), the fiduciary shall distribute any remaining trust assets to the beneficiary. If the beneficiary dies before all of the trust assets have been distributed, the fiduciary shall distribute any remaining trust assets to the beneficiary's estate. ARTICLE V Administrative Provisions A. Powers and Duties of Personal Representative. My personal representative shall have all of the powers and duties granted to or imposed upon personal representatives serving with non-intervention powers pursuant to the laws of the State of Pennsylvania. B. Debts and Expenses. All expenses of administration chargeable to principal, the expenses of the disposition of my remains, and all my legitimate debts, if and when paid, shall be paid from the principal of my residuary estate. No debt need be paid prior to its maturity in due course and except as otherwise provided in this Will no interest in any property passing under this Will need be exonerated. C. Tazes. All estate, inheritance or other similar death taxes, together with any interest or penalties thereon, arising by reason of my death with respect to any property includable in my taxable estate, and any adjusted taxable gifts, whether passing under or outside of this Will, shall be paid from the principal of my residuary estate without reimbursement from the recipients or beneficiaries of such property, provided., however, that in the event any proceeds of insurance upon my life or any property over which I held a power of appointment are included in my estate for purposes of determining the federal estate tax liability of my estate, then the residue of my estate shall be entitled to receive from the recipients of any such proceeds or property the portion ~of such federal estate tax liability attributable to such proceeds or property determined in accordance with IRC § § 2206 and 2207. ARTICLE VI Miscellaneous Will of Robert L. Burleson Page 3 of 6 Initials: _ Date: ~~ ~ ,~~ A. Number and Gender. Unless the context indicates a contrary intent, the plural and singular forms of words shall each include the other, and every noun and pronoun shall have a meaning that includes the masculine, feminine and neuter genders. B. Survival. To "survive" me, as that term is used in this Will, a person must continue to live for thirty (30) days after my death. C. Descendants. The "descendants" of an individual include only the following: 1. All such individual's biological descendants, except any person not born in lawful wedlock and his descendants, unless the biological parent who would otherwise cause him or her to be a descendant has acknowledged paternity or maternity in legitimation proceedings, or in an unambiguous signed writing identifying such person by name, or by raising such person in the same household; and 2. Persons adopted by such individual or one of his or her descendants, and their descendants. If the parent, who would cause a person to be a descendant as defined above, is arreen~ced in an adoption proceeding, such person shall remain a descendant unless such p voluntarily consents to the relinquishment of his or her status as parent in connection with such adoption proceedings. ~~ D. Heirs. The term "heirs" shall mean those persons entitled to inherit under the then-applicable laws of the State of Pennsylvania governing the descent of an intestate's separate estate. They shall inherit in their statutory proportions. E. Exclusion of Pretermitted Heirs. Other than as set forth in this Will, I make no provision for any child of mine or descendant of a deceased child of mine. I specifically make no provision for any person (whether now living or hereafter born), other than a child named or referred to in Article I or a descendant of mine as defined in this Will, who may be entitled to claim an interest in my estate under the laws of the State of Pennsylvania. F. Legal Disability. A person is under a legal disability if my personal representative determines, in good faith, that the person is incapable of managing his property or of caring for himself, or both, or is in need of protection or assistance by reason of physical injury or illness, mental illness, developmental disability, senility, alcoholism, excessive use of drugs, or other physical or mental incapacity. G. Title to Real Property. Upon my death, title to any real property passing under this Will shall vest in my personal representative in his fiduciary capacity and shall ',, ~ Date: ~/ ~ w Will of Robert L. Burleson Page 4 of 6 ~~ - remain so vested until my personal representative distributes or sells that property, at which time title shall vest in the distributee or purchaser. H. Disclaimer. Except as may be otherwise specifically provided in this Will, in the event that any beneficiary disclaims an interest arising out of this Will o:r any trust created herein it is my intention that the interest disclaimed shall be distributed in the same manner and at the same time as if the disclaiming beneficiary had died immediately preceding the event pursuant to the laws of the State of Pennsylvania. I. Governing Law. The provisions of this Will shall be interpreted in accordance with and in light of the laws of the State of Pennsylvania. J. Corporate Successors. Whenever a corporation or other business entity is referred to herein, the reference shall include any successor organization. K. References to Statutes. In this Will, the abbreviation "IRC" shall refer to the Internal Revenue Code of 1986 as amended. Will of Robert L. Burleson Page 5 of 6 Initials: _ Date: 1~ I have initialed and dated for identification purposes all pages of thiK,~y Last ill, and have executed the entire instrument by signing this page on that day of 0",E' /~~2, 20 ~d, at /~A®/l/5~5~~~0 ,Pennsylvania. s~~ l~ :...~~~~ Robert L. Burleson Attestation and Statement of Witnesses Each of us declares under penalty of perjury under the laws of Pennsylvania that Robert L. Burleson, the Testator, signed this instrument as his Last Will in our presence, all of us being present at the same time, and we now, at the Testator's request, in the Testator's presence, and in the presence of each other, sign below as the witnesses, declaring that the Testator appears to be of sound mind and under no duress, fraud, or undue influence. ;~ ~ ~'~~~ - 1 [ fitness Signature] 1 [With ignature] [Print Name] [Print Name] Residing at ~ - - ~ C~ Residing at 2 ~- ~ °~ C,or11 ~ ~irr~~rr ~~ i~7©~~5 Will of Robert L. Burleson. Pa e 6 of 6 Initials: '1 ~'~ Date: ~ ~ ~ ~ g SELF-PROVING AFFIDAVIT STATE OF PENNSYLVANIA } } ss. COUNTY OF LQ } I, the undersigned, an officer authorized to administer oaths, certify that Robert L. Burleson, the Testator, and _ Br~/~~ f ~•~~l~l~ S and F6~9~ a /1~~ S~i//l~s ,the witnesses, whose names are signed to the attached or foregoing instrument and whose signatures appear below, having appeared together before me and having been first duly sworn, each then declared to me that: 1) the attached or foregoing instrument is the last will of the Testator; 2) the Testator willingly and voluntarily declared, signed and executed the will in the presence of the witnesses; 3) the witnesses signed the will upon request by the Testator, in the presence and hearing of the Testator, and in the presence of each other; 4) to the best knowledge of each witness the Testator was, at that time of the signing, of the age of majority (or otherwise legally competent to make a will), of sound mind and memory, and under no constraint or undue influence; and 5) each witness was and is competent and of the proper age to witness a will. Robert L. Burleson .) ~' ~. c.~y~, ;. [Witness Signature] [Witness i a e] ~~ i~ ill r (' ~ l ' rr'r ~ ~ 1 ~ J [Pnnt Name] rint Name] Residin at _ ~~~ g ~ ~ ti ~ r-c.~z ~~~~ Residing at 2 ~ ~ ~ ~ ~ •- ~~ ~ 1 `~Q~~ (mow l , Section for Notary Public: Subscribed, sworn and acknowledged before me by the said Robert L. Burleson, Testator, and by the said Ij~ ~, ~~. ~ ~ ~, C_;,-- ,. ~ ,and .~ ~ ~'`"~~y~~ `~ f ~ ~ 5 -~ -~ ,witnesses, this ~ day of ~_~( ~ .,.~ ~ 20 ~ ~;; . r [Signature o otary] [Pnnt or stamp name of Notary] COMMONWEALTH OF PENNSYLVANIA Notarial Seal Donna B. Hummer, Notary Publk City of Hanislwrc~, Dauphin County My Commission Expires June 10, 2014 Member, Pennsylvania Assodation of Notaries