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HomeMy WebLinkAbout04-14-11IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA REGISTER OF WILLS PETITION FOR PROBATE AND GRANT OF LETTERS Estate of ~) ~}r~ y .~"~ ~ ~ ~ F ~ /1} ,~,(~- ~ ,Deceased ESTATE NO: 21- ~('' ~ ~ `~ ~' ~~'~ ~~' a/k/a: a/k/a: a/k/a: SS NO: ~ Ca `~ ~°' 1 ~ -' ~~~~ Petitioner(s) who is/are 18 yrs of age or older, apply(ies) for: COMPLETE SECTION `A' or `B' AND "C" as applicable: ~1A. Probate and Grant of Letters Testamentary or ^Administration c.t.a., or d.b.n.c.t.a. (complete Part Calso) and aver that Petitioner(s) is/are entitled to the aforementioned Letters under the last Will of the above-named Decedent, dated ~° C') ~ ~' ~d ~+ ~ 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 instruments offered for probate; was not the victim of a killing, was never adjudicated an incapacitated person, and was not a party to a pending divorce proceeding at the time of death wherein grounds for divorce had been established as defined in 23 Pa. C.S.A. § 3323(g): ^ B. Grant of Letters of Administration (If applicable, enter d.b.n., pendent lite, durante absentia, durante minoritate) C. Petitioner(s), after a proper search, has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs (If Administration c.t.a. or d.b.n.c.t.a., enter date of Will in Section A and complete list of heirs); was not the victim of a killing; was never adjudicated an incapacitated person; and was not a party to a pending divorce proceeding wherein grounds for divorce had been established as provided in 23 Pa. C.S.A. § 3323(g), except as follows:- Name Address elati h' `~ d ors ~ to,:. ice _ i,~7 ~~_ ?:~ \ / ~ p ~~~ I. W,' --.~-. ent -~~ ,_1 ~ -, -, __a "1 i USE ADDITIONAL SHEETS IF NECESSARY ~ = ti-- ~,~ _ `r_} .. THIS SECTION MUST BE COMPLETED: -~ ';'~ === .;~j.:~ Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or princip~r jresidenc At lU4 ~~.~T ~:. (z ~'1C.iL ~~-~ D , f~'1 ECI~. ~'-~ 1?~~ S~ ~1~v -t~ ~ S P_l2IwU ~w{~ (Street address with Post Office and Zip Code, Municipality: Township; Borough, City) 'J Decedent, then ~ years of age, died l~_3 ~-.~ (~ -..20 l C at _ e=19 ~ f k,! I L L.. , (a -~ (Month, Day, Year of death) (City and State where death occurred) Estimated value of decedent's property at death: _If domiciled in PA All personal property $ ~, ,~-„J ~'} ~ _If not domiciled in PA Personal property in Pennsylvania $ _If not domiciled in PA Personal property in County $ -Value of Real Estate in Pennsylvania $ _~ Total Estimated Value $ ~ ,5 ~~ Location of Real Estate in Pennsylvania: (Provide full address if possible.) Signature(s) Name(s) & Mailing Address(es) ' .SHIa2~lr.:i Gf~Brj /7G-GL~S ~ ~ ~Ls L-1~ ~~ ~ L~ ,f ; ILt,~ ~-J91 t.-... c__~ naa~ nn _ «~~~~~ - ~~~~~ ~w-~< ~cv-xu i~.co. ~u oy ~umoenana ~ounry penaing action by the Court Page 1 oft Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF _ C_. ~1$~~2L~ ~~ SS The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and con•ect 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 ~, . f ~ l Signature ojPersonal Representatwe before .re tli~ __ 1 ~ ~ day of ~ I - ~ '~~ ~ d Signature of Personal Representative For the Register Signature vJPersonal Representative "=w ~ ,~. ~ °-`::-T-; _~ .~'~7 ~r ,7 ~y E~ ~. File Number: ~:~ ~~a ~ ~-~ --a ---- ._ :-r Estate of _f'~ /~}/Z `/ Sl~l'U~E. ~} E De ~ -~~} ~ , Decea`~d ,a ~..~~ ~ ~:~ _r i Social Security Number: ~ U °1 "~' ),~, ^ 9 ~ y~ Date of Death: .~~, /"'7 ®~/Z~. ~ ~(~..) j ~ AND NOW, -; ~ j v I ~ i ~ ( ,'~ _ j ~ , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters r ~ ~-C{F y"l.r: (~-(~ ~'~ f are hereby granted to _ ~"` , ~ ~ (^~ ~ {~~' .r",l L (~ ~'(~('! in the above estate and that the instrument(s) dated ~ ~l - ~{ - ~ Ci ~~(~ described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. ~~ i FEES ji `' ~ ~`{- ~~~ ~~ Letters ............... $ ~;~ ~~ Register of Wills ~~ ~ ~ ~ ~~.~ Short Certificate(s) ........ $ ~ ' _ _>~' ~ Renunciation(s) .......... $ j (~ „ ... $ ... $ ... $ ... $ ... $ ... $ ~J TOTAL .............. $ c ~ Fvnn R ~V-U? rev. l U.13. U( Attorney Signature: Attorney Name: Supreme Court I.D. No.: Address: Telephone: Page 2 of 2 _ _ _ _ - - _ il(15.81)S ttE~ I(I1J11"'i - - - - FLe fc>r this ~L~rtit~sc<)<<:. `ti(•~1' L~~AL RI~GISTRAR'S GE~T~I~°~~~~AT'iC.~l~ C)F C~,~ 1~V~FiNING: It is illegal to duplicate this ~c)lK~1~ iar~ pl~otc:,~a~at o~ phat®t~r{~~-)l. tll`f e~,ifl j~r ~~~/ .. l {j) ~ . ~`..,~)) il(1 ~) ` ) t). i ' r ~ i `S'S ~~ ~ A~Y\ ~ +l ~ .., , St S {..9 it )r ) - 1 t i j) ~) 1 t ) l 91, ( t,' `.(( ~ , ,, ~~~~ 4~ r ~ 1 ~ I r, r I•°~l '!i ~ i t1r ,j ~ ~ " ~.ezz) il~.!°~. '',~jt' t~9t'_'lil:l~ _ ~ I~ ~' ~ i` °' r ~ ~q~ ~, ~ til.tl I ~I )~ s.l+_ ,.~ [~ 1~~c' '~i~llc' `w )!~'a( . INV. 'Jn1 2]r.±; ..~{ri 1{~ d„It'i,.. l' ~ 1` 1i .)S'1:'f 1~ i~!)-iSr P 1726859 -~ /v ~~ ~ ~~,~ -~ - C e)'lltNC.lllr)11 '~1--1)(lt'~ n,rr '"' 1 _l -----_ ., .,, - ,~ r r ~ , } t? _~ : ~ : - . .. ~ ~ rn I'= ,~ _ I.,',I p~~, / \ 1, ~ ...) ~.,.~ _ ~. (. i r 1 i' ... ...-i ....,.t .. f -. t~ (~ ... .. .n._t.,~. ... . v- 1 1.. .... . .. ;. - I l \ • e - r...... ~ .1. Y rr ~."~~ ~r . ; i H10S143 REV 11/L006 TYPE /PRINT IN PERMANENT BUCK INK 1. Name of Decedent (Fret, middle. last, suffix) Mari 5. Age (Last Birtltdey) under 1 Montha 84 vrs. 8b. County of Death Cumberland COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) STATE FILE NUMBER 2 Sex 3. Sadal Security Number 4. Date of Death (Marxh, day, year) Jane Hern'ak Female 209 - 12 - 9645 3/26/2011 Under 1 da 6. Date W BiM Month, da , r 7. B' and stale or coon Be. Place d Death Check one ys Hours Minutes lHo~spital: Other 11 26 1926 Harrlsb PA ~jrpetient ^ ER !Outpatient ^ DOA ^ Nursing hlame ^ Residence ^ Deter . sper9ly: &. City, Boro, Tw~. of Death 8d. Fadliry Name (If not irtstihrtien, give street and raxnbar) 9. Was Decedent of Hisparkc Origin? ~ No ^ Yes 10. Race: American Irvllan, Blade, White, ek. (n Yes, specify Cuban, iSPeGM East Pennsboro Holy Spirit Hospital Mexican, Puerto Ryan, etc.) White 17. UeatleflCS Usual lion Kind of work done Kind of Work du ~ most of kte. Do rat state ~ 12. Was Decedent ever M the U S A 13. Decedents Education (Specify ony highest grade completed) 14. Marital Status: Married, Never Marred. 15. Surviving Spouse In wife give maiden name) Anal st Kind of Btrskress /Industry Na De t . . rced Forces? ^ Elementary2econdary (0.12) College (1-4 a Sa) Widowed, Divorced (spea'yl , Yes ~ No W1d04Jled 16. Decedent's Mailing Address (Street, city /town, state, zip code) Decedent's Did Decedent ~~u.~ 2520 r .~••,t~S ~ap RDad Adual Residence 17a. State p -n~l~a 17c' [,Yes' Decedent Uvetl in .S11Ver Spring T 17b. Corny ,~ Townshi ~ D. 17d. ^ Na, Decedent Lived within Actual Omits of 18. Patter's Name (First, midde, last, suffix) John H Schmidt City / Boro 19. Mother's Name (FrsL middle, maiden surname) . Lillian Fujara 20a. Informant's Name (Type /Pant) Sharon Cabs 20b. IMannant's Mailing Address (Street, dh' /town, state, zip code) 2520 Lambs Ga Rd. Enola, PA 17025 21 a. Method W Disposition r ~] Cremation ^ Donation 21b. Date of Disposition (Month, day, year) 21 c. Place of Disposition (Name of cemetery, cremabry or other place) 21 d. Location (City/town, state, zip code) ^ Burial ^ Removal from Stat r e Was Cremation or Dortatlort Authaaed ^ Doer- ~ .~ ~ r by Msdkal Fxaminar/Cororwr? ®Yee^ No 3/30/2011 Evans Cremation Service LeOla PA 17540 z2a signature of F Pa 22b. License Number ~~ , 22c. Name and Address of Fadliry Neill Funeral Home IriC ~ FD 013239 L , 3401 Market St. Camp Hill, PA 17011 Complete kemc ony wlen rtilying 23a. To de best of my des rted at ne tkne, date and lace slated. S p (gnature and title) 23b. License Number goad (Month physician is ailable at time of deem to 23c. Date S' day year) _ certny ca deem. ~'~__ .~ i ` ~~ , . ~ ~'v Z~'3 SJ L L ~~ Z~~ ~ ~ C CJ Kerns 24-26 must be completed by person 24. Time of Deem 25. Date Prarauroed Dead (Monet, day, year) 26. Was Case Referred to Medical Examiner /Coroner for a Reason Other man Cremation or Donation? who ponourtas deem. ~~ ~ 2 y M k /q M. r c. r = Z (:. ,~ O t ` ^ Yea ~ No CAUSE OF DEATH (See Instructbns and examples) Item 27. Part I: Enter the Ltlalo of events - diseases, injuries, or carrtpliCetions .that drectly caused the deem. DO NOT enter temknal eve r Approximate nterval: Part IL Enter other ' 28. Oid Tobaao Use Camribute to Deem? nts such as cardiac amrest r respiratory arrest, or ventricular fibrillation witlaut stowing the etiobgy. list oMy one cause on each tine. , Onset b Deem but not resulting in the underlying cause given in Part I. r ^ Yes ^ Probaby IMMEDIATE CAUSE Enai disease or j~/~ _IL. I I oondnion resultrg in ~fh) _~ a ' ' `~' \ l Q l ~ (f1Y ~ ~N Ott ll ~(~~ t ^ No ~ Unknown r ~ 2 If F .( . _ _ ~ Due to (or as a consequence Dry: 9. emale: r r Q Not pregnant wghin P~ Y•ar ~ ~~s' 4 ~'~ b. _C Q D.S~~S' ~m cause kated on tine a ~ ^ Pregnant at time of deem . Enter UNDERLYING CAUSE Due to (or as a consequence oQ: (dpease a krjuurY that initiated the r r ^ Not pregnant, but pregnant wkhin 42 days every resulting m deem) LAST. c. Due to (a as a consequence of); r of deem r ^ Noi r pregnant. but pregnant 43 days to 1 year d. 30 W A r r before deem i ^ Unknown n pregnant within the past year a. as an utopsy 30b. Were Autopsy Endings 31. Manner of Deam 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Ocarred Pedomed? Available Prar to Completion 32c. Place of Injury: Home, Fartn, SVeeL Factory, ^ Homidde of Cause of Deem? Natural Office Building, etc. (Speriryj ^ Yes ~No ^ Yes ^ No ^ Accident ^ Pendng lnvestigatan 32d. Time of Injury 32e. Injury atWorkT 321. If Transportation Injury (Spec/Y1 32g. t.ocation of injury (Street, city /town, state) ^ Suicide ^ Couk1 Not be Determined ^ Yes ^ No ^ Driver/Operator ^ Passenger ^ Pedestrian M ^ Omer - Speciy~ 33a. Certifier (check only one) • Certifying physician P ( Mrsidan prtirying cause of deem when arather physician has pronounced deem and completed Item 23) To the best of know my ledge, deem occurred due to the cause(s) and manner es stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 33b. Signature and Tide of Certifier ~ ~"))) ~ / ~, ~~ ~~ i ~ . _ _ • Pronouncing and artffying physician (Physician both pronouncing death and certifying to pose of deem) To the bast of my knowledge, death occuned at the time, date, and place, and due to the pose(s) and manner ss stated _ • _ _ _ _ _ _ _ _ _ _ ~---- 33c. License Number 33d. Date Signed (Monet, day, year) _ _ _ _ _ ^ - - Medial Examiner/Coroner -'--'-'-'- ,M, y~~'-t ~ C6L .~~~ ~,~/ ~0 11 On the baale of examination and / or investigation, in my opinion, death occurred at the time, date, and plea, and due to the pose(s) and manner u slated„ ^ 34 Nam e nd Add f P 35. R i ors SignaNre an D' Number ~ S l / . a ress o erson Vyho Completed Cause of Deam (Item 27) Type /Print ~} !'r N ~ a '~~ i ~ KS P~ ~-2 r . I ~ / I 1 /~ r~ I , ~~l ~,[ ^ Date Filed (Month, day. year),-r- 3 2- /v ~ F ~.+~.t ~ ~ + - ,/ /~ ~ , ~ T d tG4I L I r~ I IiJ ~, + nn I ~ "L S ~,iY"~ i ~ `r' !7 t,' tG / // ~-7 ~ ~ 7' l~ ~ Disposdan Permit No. G /-J,S. LAST WILL AND TESTAMENT .~ - y ,, , . ,..., ( , ~ _.... ___ ~ .. -~~-;, _~ MARY JANE HERNJAK ~ ' ' =~ ~ ~' .. - _. __;.a ~ a ~: I, Mary Jane Hernjak, now or formerly of Camp Hill, Cumberl~fid Coun#y:, ~_ e Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time made. ITEM I: I direct that all inheritance and 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 my Executor out of the property passing under this Will, which is not specifically devised or bequeathed, as an expense and cost of administration of my Estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax paid by my Executor even though on proceeds of insurance or other property not passing under this Will. ITEM II: I hereby exercise all powers of appointment which I may have at the time of my death in favor of my Executor, and all property subject to all such powers shall be included in my Estate. ITEM III: I give and bequeath all my household furniture and furnishings, automobiles, books, pictures, jewelry, china, linen, silverware, wearing apparel, and all other like articles of household or personal use and adornment to my husband, George J. Hernjak, if he survives me, or if my husband does not survive me, to my children, per stirpes, Sharon L. Caba, now or formerly of 2620 Lambs Gap Road, Enola, Pennsylvania, Cynthia A. Petroski, now or formerly of 2511 Vance Drive, Mount Airy, Maryland, and David A. Hernjak, now or formerly of 25 Cherish Drive, Camp Hill, Pennsylvania, to be distributed to them in equal shares by my Executor. ITEM IV: I give, devise and bequeath all of the rest, residue and remainder of my property, real, personal and mixed, to my husband, George J. Hernjak, if he survives me, or if my husband does not survive me, to my children, per stirpes, Sharon L. Caba, Cynthia A. Petroski, and David A. Hernjak, to be distributed to them in equal shares by my Executor. ITEM V: In the settlement of my Estate, my Executor shall possess, among others, the following powers to be executed for the best interest of the beneficiaries: (a) To sell, either at public or private sale and upon such terms and conditions as my Executor may deem advantageous to my Estate, any or all real or personal estate or interest therein, whether owned by me severally or in conjunction with other persons or acquired after my death by my Executor, and to consummate said sale or sales by sufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title, free and clear of all trust and without obligation or liability of the purchaser or purchasers to see to the application of the purchase money or Page 2 of 8 to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings which may be necessary or desirable in carrying out any of the powers conferred upon my Executor in this Paragraph V (a) or elsewhere in my Will. (b) To pay all costs, taxes, expenses and charges in connection with the administration of my Estate. My Executor shall pay expenses of my last illness and funeral expenses. (c) To distribute my Estate in kind or in money. If any assets are distributed in kind, they shall be distributed at their respective value(s) on the date(s) of their distribution. (d) To retain any investments I may have at my death so long as my Executor may deem it advisable to my Estate so to do. (e) To vary investments, when deemed desirable by my Executor and to invest in such bonds, stocks, notes, money markets, real estate mortgages or other securities or in such other property, real or personal, as he shall deem wise, without being restricted to so-called "legal investments." (f) To mortgage real estate and to make leases of real estate. Page 3 of 8 (g) To borrow money from any party to pay indebtedness of mine or of my Estate, expenses of administration or inheritance, legacy, estate and other taxes. (h) To vote any shares of stock which form a part of the Estate and to otherwise exercise all the powers incident to the ownership of such stock. (i) In the discretion of my Executor, to unite with other owners of similar property in carrying out any plans for the reorganization of any corporation or company whose securities form a part of the Estate. (j) To distribute my personal property directly to the Guardian of the person of any minor beneficiaries hereunder. (k) To elect such settlement options as deemed most appropriate by my Executor with respect to any pension, profit sharing or other retirement plan in which I am a participant. (I) To do all other acts in the judgment of my Executor necessary or desirable for the proper and advantageous management, investment and distribution of my Estate. ITEM VI: Any person who shall have died at the same time as Testatrix or in a common disaster with her, or under such circumstances that it is difficult or impossible to determine who died first, shall be deemed to have predeceased her. ITEM VII: I nominate, constitute and appoint my husband, George J. Hernjak, to be my Executor (herein referred to as "Executor"). In the event of the death, Page 4 of 8 resignation, refusal or inability of George J. Hernjak to serve as my Executor, I nominate, constitute and appoint my children, Sharon L. Caba, Cynthia A. Petroski, and David A. Hernjak, to serve together as Executors. My Executor(s) are specifically relieved from their duty or obligation of filing any bond or bonds. IN WITNESS WHEREOF, I have set my hand and seal to this my Last Will and Testament, consisting of this, the next three (3) pages and the preceding five (5) i pages this ~ ~~~ r day of ~~~ ~,~)~ ~-. 2000. ~~ ~~ ,~~ ~~ , ' /% ~ - ;. R/ f ~ ~. Page 5 of 8 SIGNED, SEALED, PUBLISHED AND DECLARED by the above named Testator, Mary Jane Hernjak, as and for her Will, in the presence of us, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as witnesses in attestation thereof. ,~:, ' ~~' ~" 1521 Penn Street Harrisburg, PA 17102 5115 East Trindle Road Mechanicsburg, PA 17050 i ~' - 5115 East Trindle Road Mechanicsburg, PA 17055 Page 6 of 8 ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA SS.: COUNTY OF CUMBERLAND I, Mary Jane Hernjak, the 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 Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed nd acknowledged before me by Mary Jane Hernjak, the Testatrix, this ~ ~J~, day of ~~~~ , 2000. ~''~ v ,~ ~ ',,, /' '~ ~' .~ ' ~ ~,. ~. UbIIC My Commission Expires: (SEAL) t~OTARir~~. ~cAL CONNIE R. SHULTZ, Notary Puk~lic Mechanicsburg, CuaAbe+iand County Commission E ss Au . ~ f~, 2.002 Page 7 of 8 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA SS.: COUNTY OF CUMBERLAND We, Mark K. Emery, John R. Fenstermacher and Margaret A. Fenstermacher, the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the instrument as her Last Will; that the Testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness, in the hearing and sight of the Testatrix, signed the Will as a witness; and that to the best of our knowledge, the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn to or affirmed and subscribed to before me by Mark K. Emery, John R. Fenstermacher and Margaret A. Fenstermacher, witnesses, this ~.~. day of C~fa1~,'; 2000. %~ ~ ~.~- Wit~ess ,_.~.~-, Wig: -~..~--- 1/~Ji~r~ess ,. ~ -!f e r~ _ . ._. . Witnes _ ~.- __ Public My Commission Expires: (SEAL) ----..-------------~ iJOTARIAL SEAL e CONNIE R. SHULTZ, Notary Public Mechanicsburg, Cumberland County M Com!~;SSi~Jn Ex ire Au~t~. 1 ~, 2401 W Page 8 of 8 RENUNCIATION x ~ ~ j REGISTER OF WILL , ? ~_? -~ ~ ~ \ ~ ") S ~ ~,.: _, f .~.~ ._.... _ _, Ly ~ ~~~L~~ n COUNTY, PENNSYLVANIA ~~;~ -" .., . . ~-' ::....._ _..,, i ,~, _ _ : ,_ _. . '~7 ~ i ~. ~ t.: ~. Estate of_ (~1 f~ /Z`/ ~ j~,~ /~ /-f ~=~~~'~.k Deceased (PrtntName) , in my capacity/relationship as -!~ ~ U ~ ~ ~~ ~- ,/ ~ X ~C t,.J T~ i)C of the above Decedent, hereb renounce the ri ht t Y g o administer the Estate of the Decedent and respectfully request that Letters be issued to ~~ 0 7 ~ o~/ (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of -. , Deputy for Register of Wills i ~ , ,- -_~. ~, (Sigfra re) ~~~~~ ~ ~ ~ L t". (Street Address) ~~ ~ 7~ (city, state. zip) Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he c?r she executed the renunciation for the purposes stated within on this _ ` - day of /~lr ~ ~ ' - / ,/, ~~ .. A•.., iB -~ e ~ `~"'4 G .~ ~ I .. , . ~;, i .f^`~ ~i s '-~ Public emission Expires: S"~ / ,~ -~~'~ ~~ and Seal of Notary or other official qualified to oaths. Show date of expiration of Notary's Commission.) Form RW-06 rev. 10.13.06 RENUNCIATION REGISTER OF WILLS ~-~ rL1. ~.1 c s 1 a.w---~~~- COUNTY, PENNSYLVANIA Estate of •_ C7 -- ,.._ y.,.~ ~ ... ° _. , ~..y _--~ __-_ - ..=. .~ i ~~ T 9 _.,1 . ~~ ~,-, yM^~ -- :~ =_ .gip;-~ __ ._ _ ~,~ _.. _ i ,. - - . ~. _.. .~. - ---. r _ - ` .% ~. ~ L>eceased _ in my capacity/relationship as (Print Name) ° ~ -~ ©tu / ~ X E Z'O of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to ~1 ~' - ~, (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills Form RW-06 rev. 10.13.06 C (/////Y/j~ -P ~ .-t.., \__ jam. ~ (Signature) 'C (Street Address) ~- (City, State, Zip) Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation for the purposes stated within on this ~~ ~ `~"~`~ day Notary blic My Commission Expires: (Signature and Seal of Notary or other official qualified tc administer oaths. Show date of expiration of Notary's Commis;~ion.) COMMONW~AL~~ {~~ pENN3YLVANIA Notarial Seal Holly P. Siekerman, Notary Public Lower Swatara Twp., Dauphin County My Commission Expires Aug. 23, 2012 ~!lemher Pennsylvania Association of Notaries