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Home My WebLink About06-20-11` ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA REGISTER OF WILLS PETITION FOR PROBATE AND GRANT OF LETTERS Estate of a/k/a: a/k/a: a/k/a: DORIS H. SHEERER DORIS H. SHEARER SS NO: 188-20-6023 Petitioner(s) who is/are 18 yrs of age or older, apply(ies) for: COMPLETE SECTION `A' or `B' AND "C" as applicable: D A. Probate and Grant of Letters Testamentary or ^ Administration c.t.a., or d.b.n.c.t.a. (complE~te Part C also) and aver that Petitioner(s) is/are entitled to the aforementioned Letters TESTAMENTARY _ under the last Will of the above-named Decedent, dated _ 10/12/2000 and codicil(s) dated _ _ __ JOHN W. SHEERER, HUSBAND AND NAMED EXECUTOR OF THE DECEDENT PRE-DECEASED THE DECEDENT ON 09/21/2003. STEVEN J. SHEERER, NAMED ALTERNATIVE CO-EXECUTOR RENOUNCED TO CINDY L. JONES. (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 establisched as defined in 23 Pa. C.S.A. § 3323{g): ^ B. Grant of Letters of Administration (lf applicable, enter d.b.n., pendent lite, durante absentia, durante minoriitate) Deceased ESTATE NO: 21- •- ~~r~ 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 pc~nding divorce proceeding wherein grounds for divorce had been established as provided in 23 Pa. C.S.A. § 3323(g),~cept as fonts: ~~ ~_ :~ Name Address Re o~~t~hi to De '_' J,. -~ : r-~- ~ .c~~ ~ ~: ~~ z ~ .." USE ADDITION 1I SHEETS IF ~iECE - nt ~~g-; ~_.~ .~_ ~ f .._.,r . ~•" ~:~;:.t; ~. " _ -~.~ ~~:: = r ~ 1 SSARY ~--- ."1`~ THIS SECTION MUST BE COMPLETED: `~°` -~j Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or princiipal residence At 283 SKYLINE VIEW CARLISLE PA 17013 NORTH MIDDLETON TWP. _ (Street address with Post Office and Zip Code, Municipality: Township, Borough, City) Decedent, then 85 years of age, died 12/29/2010 at CARLISLE, PENNSYLVANIA (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 $ 7'3()0.00 _If not domiciled in PA Personal property in Pennsylvania $ _If not domiciled in PA Personal property in County $ _Value of Real Estate in Pennsylvania $ --- - Total Estimated Value $ 7,300.00 Location of Real Estate in Pennsylvania: (Provide full address if possible.) NONE. Signature(s) ~~ . :z~, ,f , Name(s) & Mailing Address(es) 283 SKYLINE VIEW, CARLISLE, PA 17013 Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court - Page 1 of 2 OATH OF PERSONAL REPRESENTATIVE Commonwealth of Pennsylvania ~ SS County of Cumberland The Petitioner(s) herein named swear or affirm 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 bef re me this ~"' ~' ..day of ~ ~ . ~ -~ ~~ s-' - - ~7 ;'~"1 ~'~,' For the Register ~ - ~ ~~ DECREE OF PROBATE AND GRANT OF LETTERS:`:-~~ ~~-~, `? - ~~= -:: ,, _ ~ rW Estate of DORIS H. SHEERER ,Deceased File Number: 21- ~ ~'-~~'' `-~`~ .._._, AND NOW, this da of in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED ghat Letters x Testamentary of Administration are hereby granted. to: (If applicable, enter c.t.a., d.b.n., d.b.n.c.t.a., etc.) CINDY L. JONES in the above estate and that instruments(s) dated l0/12/200o described in the petition be admitted to probate and filed of record as the last Will and Codicil(s) of Decedent. Signature of Counsel Required to Enter Appearance FEES: Letters ....................$ f will ....................... l~5 C~ Codicil(s) .............. . (~) Short Certificates ~ - C; ~ ( 1) Renunciations.......~~ ~ ~`~ Bond ............................ Other ............................. Automation FEE......... 5.00 JCS FEE .................. 23.50 1 ~' TOTAL ................ $ 0 ~-~ ' "Glenda Farn re Strasbaugh, ~~ r rX~ . ~~~ Register of Wills >> ~~~ Atty s Slgnature __ PRINTED Name: ANDREW J. BENDEIR, ESQUIRE Supreme Court ID No.: 205763 __ Address: 61 WEST LOUTHER. STREET CARLISLE, PA 17013 Phone: (717) 249-1177 __ Fax: (717) 249-4514 Interim Form RW-02 revised 1226.10 by Cumberland County pending action by the Court Page 2 of 2 OAL REGISTRAR'S E `"" ~ ~)~' EA•~- 1N~AF~iVING: it is illegal to dupliCat= ~~a~ P:a~, g": i~~~;:~<t~~~~s;} cap ~i~~~t~~~~~;~~~~ _ I~- --x._7.12.2 3 7 ~' ~ ~'!~1`~1L~,Llrtl~ ~'~'t11111r,,, ~MlpS•143 REV 112006 TYPE /PRINT IN PERMANENT BLACK INK l t. Name of pecetlenl (Post. mddk, 4st. sulfa) ~.f 4 u i ,. ~ i~, ,,, :.'li:l „l - ~jr.~ }'ld,~t~111itICL~11 ~i+~t~~.' ii~'cil 1~ .. r ~, t~ttltt'~..b "a~ z _ =A ~s~,~ 'r, ,~ z,k~~T t~l~ ~~CI1(~IiCillt,' C~~ ~)t'~it}1 d ~, ~, ~~'o'~, ~_ I ~ ~) k~l' ' l l ~ ~ V "L r~,i~~,~rit~~. I~I iL° L~r)~in~tl ,`~~' ~~ °jlit l~l ~~ r,~i ,1 ;~~ ti~IL~ `~~t~)t(.~ "~'il.)1 v ~ , . ? ~ , t j l ,, I t r ~ `~9 i 3 Ij~1j]:.' (( ~j fd'~ [/gyp ~(~j ~ .,,, ~ a IyE -~- --_ ___a ..._--- ` _ _____ t \~ ~. ~ •a ~t ~~ _ ~O C..._ _ ~ "1 C~_ 7 ~ C~ ~ n ~? - :_.. _ ~- ' •-ri 11 ,.~ ---I • .. c "" r r - --- - - n r„ ~ C COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH • (See Instructions and examples on reverse) STATE FILE NUMBER 2. Sex J. Social Seaaay Number 4. Dale d Deem (Month, dey, year) rj 5 ~f . 5 h~~;~e~ ~rj - :~~ -cuc`~ 3 ~ ~ Imo,-- ~~, ~ to 5. Ape (Lett Bumdayl Under t ar Under 1 as 6. Dale of Binh Monet, da ear 7. & lace Ci and state a laei count ea. Place d Deam Check one A ~5 Yrs. xbnMr Days Roars Aenuter _ ~ r. ((-~ IG~S -'~~ ll~CJIY~ SC)(l~~:n P~ 1Hdspital' tplnpatiem ^ER1OulpabeM ^DOA Other-. _^ ^NuningHorne ^Reskbnce ^Omer Spedly: &. County d Doam & C4Y Bao, Twp. d Deam ed. Faciiry Name Ill not insuNbon, give street and number) 9. Was Decedent d Hispanic Orpin? No ^ Yas 10. Race: Artwrlran IMian, ®ladt, While, eb • (.ul~~ l~~ ~ f e~;°u1 (`cu I i.s l~ i C.c~rl i ~ I,/ (~ i ones I IT1.¢d - Ce.r~ l~r (U yea. specey Cuban. Mewn. PueAO Rican. etc.) ISpeaM ~~ h 1 •f e..~ t 1. Decedents Usual Occu atron Kind d work tlone d ur most d work Ne. Do not slate ret ired 12. Wu DBCedenl ever b me 13. Decedent's Educalbn (Specify Doty hiyfMSl grade cornpl elad) 14. Mandel Status: Married, Never Married, _ 75. Surviving Spo use (If wile, give maiden tadN! Kind d Work Kind d Busmesslmdushy U.S. Armed Forces? Elementary I Setardary (0.12) College (1-4 or 5+) Widowed. Oivorad (SpeuYyJ ~ 1 . ~~ (L ^ Yet Nd r ~, W jG~1%i,~` i 16.Oecedenfs Mailing Address trees, cry !town, state, zip code) I n l~; ~ . j ~~ ~ 1 Y _ DBCaderlt't (l /l Did Decedent Actwl Residence t 7a. Slate Y 'C Liva in a ' 17c. ^Yes. Decedent Lived in Twp. ` Qll l ~1 C C ~ { ' \c , _„ C~C~ Township. y„ , ro. l`AUNy +~~•.1~ l I na. ~ No. Decedent Lived wilNn ( ~i l - (~ (i./.i \ 1 1 V Actual Limits d Cily / Boro 18. Fadtr?F's Name ass, middle, last, suHixl 19. Moma's Name (Fesi middle, maiden sumeme 20a. mlarmanfs Name (Type I PnnO 20b. Intomanfs Mailing Address (Street, city I bwn, state, zip ) t~~t~ .IUi~S ~„ ~ J ,nom ~i~u.r. ~cc'rliSl.1? P~ 1~1U13 21a. Method of Diapdsitipn r ^ Cremation ^ Donation .t-I r i l ^ R l I B 2tD. Date d Oisposeion (Monet, day, year) 21c. Place of Disposabn (Name d cemetery, crematory or other pWCe) 21d. Locaoon ICiry!bwn, slate. zip code) ~ - ur a emova 09 rom State r Was Crenaatbn a Oonalbrt Authorize ^ Omer.S ~ ' by Medial Examiner/Coroner? , d ``/~ ~ ~,, ` / /~ ~ `7~(,, s-~~~ ~ (~ y~ /l/~ ^ Ves^NO J~1 ~ l ~~!~` 1 I1~ 5~n ~i(J„m ~'Fry~• lJ`~-V l~ ~ l Ilril ll..l/SE..~n~ ~V'1 f et ~" IV~'1~ 22a. Sgn1a'~~~re of Funeral Service Licenseyy~~' person acting u wch) - Y Yl 1 ~!~i'.L(Jl,l{~ i~1 I Yt, .%.~ 22b. License Number 22c. Name antl Address of Fadliry -t 1 .~ U.a Ci J - /~:, i l ~.. 1-~I.F ~!`, ~ ?~ ~ ~~'_ (1`l . Cl~: n 1'r„ ,,,,1 ~J~ lv7/"'11~f Complete items 23at only when certdymg 23a To lne bast d my knowledge, loam Oocuned M the tune, date and Place stated. 16ignature and mk) 230. license Number :?3c. Date Signed (Monln, day, year) a physician is not availabN a1 time d deatn to uroty cause d deem. Items 24-26 mutt be completed M person ' wi ron m B 24 lpn¢ of~p-e7am _ 25. Date Pr d Dead (Monet, day, ar) ~ Z • ~ 26. Was Case Referpred w Medical Examiner I Coroner br a Reason Omer Than Cremation a Donation? , q p owbes ea . ~ G~'~ ~M. ~ ~ C.~ ` Q ~ ^Yes /s.J No CAUSE OF DEATH (See Instructions and examples) I Approzimale inKNal: Pan 11: Enter other sjg(tilicant torlditians contrihuano to dean. 28.Oid iobawo Use Conhibtde b pea ? Item 27. Part 1: Enter tae then of events -diseases, xyurws, a twmplications • Ihat direcry caused the deem. DO NOT enter tarrtinel events such u ardiac arrest, ~ Onset b Deam Out cwt reauakg b the ruNedyetg ease given in Pan I. CJ Yes ^ Probably respiratory anesl. or ventrit;ular fibralation witlgd showig the etiobgy. List ordy orb cause on each line. IMMEDIAT n r vvII - ,os No ^ UMrown E CAUSE IFinal disease or , ^- ^- condition resu4ing in cash) ~~~~1~ . ~ 29. II F emale: ~ ~ \Q Y a. ~ O l N i hn Due b u a trartG oQ: ~ C r ( Saquen0ally ass condibau. it any. D. _- ~ ~V~ 1 Q~~ ~ ~ 1 ~`,,1~ T~ leading b e cause listed on 6te a. i ` ' ~ y r Y- d pregnara w t put yea I~,I CJ Pregnant at 0me d deem Dw to or u a rte ~ Enter me UNDERLYING CAUSE ~ ~ ~ ' ~ ~ ~ ^ Not pregnant, but pregnant we0in 42 days s ~ (bsease a Iry ur~ that ni0ated the ~(V\ ~ v~~ ~ \(.J V~ event resulting r tleatn) LAST c r ,~p ~/ ~ r .~-' -' l~ of deem ^ Due to (or as a conteWNrta oq: r Nd Pregnant, bN pregnan143 days b 1 year d t r --r n 0elore deem ^ Unknown if pregnant within the past yea 30a. Wu an Autopsy 30D. Were Autopsy Findings 3t bWnner d Deam 32a. Date of Injury (Month, day. year) 320. Desttibe How Injury Occurred 32c. Place of Injury: Home Fann S0ee4 Facrory Performed? Available Prbr b fomPletwn n ~ Naturd ^ Ml d , , . Office Buiksng, ek. (Spaaly) of Cause of Deam ao o a t~ ^ Yes t7 y No ^ ves ^ Nu ^ Axidem ^ Pendap Irwesuganon ~o Tine d tryury 32e. Iryury al Wwk7 321. a Transportation Injury (Specify) 32g. Loation of kyury (SIree4 city /town, state) , • ^ SuiciOe ^ Coub Not W Determined ^Yes ^ No ^ Dnvr/Operator ^ Pascenger ^ Pedestrian M ^ Other ~ Sr»n!y 33a. Ceniher (Medc Doty me) • Cenhying physicFan Ipcrysxan cen4yiny cause of deem wren arother physkian has porwurved dean and conpieted hem 23) 33b. Sprat re and 7\~Ne d Cenilier ., C \ r C - ~~~-1~~ ~ ~ `~~~ ~~ To the best of my knowledge, death occurred due to the sore(s) and manner es staled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ - 7 VV Vi -~] V _ • Dronouncin and arti t h :icier Pn 9 h~n9 P Y I ysKian Dom pronouncing deem and anaying to cause of death) To the best o1 my knowledge, death otturred at the time, date, and plea, and due to the cause(s) and manner as staled _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ 33c. rise umber ~ ) l ~l~ L/ ~ ~ ~ 33d. Dale ;i rled Monet, l Y~ Year r ~ / '~ ~~`/'1 / \ • Medical Esamintr 1 Coroner i ~ G ( '~.J On the Oasis of enmination and / or investigauon, in my opinion, death occurred at the time, dale, and place, and due b the ease(s) and manna as stated_ ^ ~ 34. Name u~,d\Addresa d Pe Wlb Canpkbd Cause d Deam (hem 2T) Type ~ ~ I print 35. Regishals Spnature and Distr Number ^. ~ - `~ )~ ~~C ~~ s_ J p ~•Jr,N a O 5 ~l ~/ 9~ o __ Dispocilion Pemtit No. ~_ _ T /^~ ~ ..~ _ .'? \..J ~~ ~ ~...... d.~1 ~^~ (~T'i RENUNCIATION j`~ ~ ~U ~:~ ,~, ~ ' ` \~ ~ REGISTER OF WILLS ~ _~ ~'" ~;;- PENNSYLVANIA CUMBERLAND COUNTY ~ °~~ `-'mod , ~~~ Estate of DORIS H. SHEERER __, Deceased I, STEVEN J. SHEERER (Print Name) co-executor named in the last will and testament in my capacir~%relationship as of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to CINDY L. JONES (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. lOJ3.06 (Signatu3'eJ ,.~. (Street Address) ~ r ~ ~ ~ ~ ~ ~'OV~ ~. (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 Public My Commission Expires: m ~ ~ .3 ~j ~ ~ / ~ (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) COMMONWEALTH OF PENNSYUJAPIIA Notarial Seal Anna Mae Fultz Notary Public West Perry 'Twp. Snyder County My Commission Expires May 31, X112 Member, Pennsylvania Association of illotaries a LAST WILL I, DORIS H. SHEERER a/k/a DORIS H. SHEARER, of the Borough of Tho:mpsontown, County of Juniata and Commonwealth of Pennsylvania, declare this to be my Last Will and revoke any Will previously made by me. ITEM I: I direct that all my just debts, funeral expenses, gravemarker and the costs of the administration of my Estate be paid from the assets of my Estate as soon as practical after my death. ITEM II: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from the assets of Amy Estate as apart of the administration thereof, to the end that no beneficiary hereunder, or any c-ther person, shall be charged with or required to pay any part of such taxes. ITEM III: I devise and bequeath the residue of my Estate of every nature and wherever situate, including any property over which I may now have or hereafter acquire, a power of appointment to my husband, JOHN W. SHEERER a/k/a JOHN W. SHEARER, provided he shall survive me by ninety days. Should my husband, JOHN W. SHEERER a/k/a JOHN W. SHEARER, predecease me or die on or before the ninetieth day following my death: a. I bequeath such of my tangible personal property as is set forth in a separate signed memorandum, which I shall place with my Will, to the persons therein designated. b. I devise and bequeath the residue of my Estate of every nature and wherever situate, including any property over which I may now have or herf;ai.'ter G; ~_; ; ~ ~-- ~ acquire, a power of appointment to my children, STEVEN J. SHEERE~t and oc J ~:'- ;"R} ~, ~~~ CINDY S. JONES, in equal share, provided that the share of either c-f my ~ ~ ~ ~ ' --.. _ _. cv w ~ children who predecease me or die on or before the ninetieth day followir.-g my ~~a cz . ~:~ ~ c~ ~' ~ U u.: ~~ --. death shall be distributed to his or her issue, per stirpes, living on the ninety- ~ ~ ~ ~.., Page 1 o f 2 first day following my death. ITEM IV: I authorize and empower my hereinafter named Executor or alternative co- Executors to convert any property, not specifically bequeathed and devised above, that I may own at my death, whether real, personal or mixed, at either private or public sale, whichever in his/their opinion is deemed best, thereby vesting in said Executor or alternative co-Executors full power and authority to make, execute, acknowledge and deliver good and sufficient deeds or assurances of title therefore. ITEM VII: I appoint my husband, JOHN W. SHEERER a/k/a JOHN W. SHEARER, Executor of this my Last Will. Should my husband, JOHN W. SHEERER a/k/a~ JOHN W. SHEARER, fail to qualify or cease to act as Executor, I appoint STEVEN J. SHEERER and CINDY S. JONES, alternative co-Executors of this my Last Will. IN WITNESS WHEREOF, I have hereunto set my hand this r a- ~ day of G.~, , 2000. Doris H. Sheerer a1k/a Doris H. Shearer The preceding instrument consisting of these two pages, identified by the signature of the Testatrix, the date thereof signed, published and declared by DORIS H. SHEERER ~~Ik/a DORIS H. SHEARER, the Testatrix herein named, as and for her Last Will, in the presence of us, who, at her request, in her presence, and in the presence of each other, have subscribed our• names as witnesses hereto. / ~ .~ _, Page 2 of 2 n C ~ ~,~ MEMORANDUM r~ ~~ . _,~ _. { 4, ._ .~ C7 ~~ -~-~ - DISPOSITION OF TANGIBLE PERSONAL PROPERTY ~~ ~-~ =~ ~_ ~~ ----i ; .~ ~..~ : -r~ 6 f ~ ~ ~ ~ ~r~' 4 ~~~~ ,. y ~~ ~ ^~ ~/ ~ ~, ~ ~ `f _ ,~ ~~ ~~ f'h Q G~ ~'- ~ ~l9 5 c'~j ~.~ c G Cc r 2 S ~CZ ~fC.~--r`) /c~ ~ ` -(.~. ,~ / r 1. / o n ~ -1'1 u-I ~ Ivy ~- r~ ~s r..vh~-~ SJ~~ 7~-Ilr~ . ~~~ ~.~`1-~..r 2 v' C 1 y ~ ~ ~~ ~ - ~ . - t . ~cw" r ~ S ~~'l CIS Gbh '7~ ~ QrJ' G' '`7 ~ ~•~LCc.~`'. .5~~ -~- .~ r'Q r• y ~ ~ ~~ ~a~ ~ ~ ,~ ~~s ~ ~ t ~o ~/ ~ ~ p/~~frP~ ~f Cc-i'hOh ~ j''/i'I - ~4SC~~ ~ ~-cJ~?,r ~ ~ S ~. f ~ Y y ~ L~r~. ~ ~~. a-~ ~ Y/~ fiv, ~ -f~, r j Q ,~- ~ GL~.S ~a-~~",-mot` ~s~~hc~s u.~-:`{z~ ~~ ~~ ,~ Doris H. Sheerer a/k/a Doris H. Shearer ,. y ~ ~-o /n. ~ fd cYo s r1 - ~ ~ ~ ~ cSLi ~~~ `~ ~ _ Y a-/- ~ r~u.ld a ~~ ~d ~pr~ ~~~2a s~- ~ e~ -~ ~i~i q,~:Je, d~ ~~s d- ,b~e ~ S ~cc; ~ ~/~c,Ea ,S 2 c~ e~ii /ads ~'~1 a~^.c ~v ~1 e r r ~ y ~ ~ ~, s~~~~ s/~~~ alike. ~~~;/v~' OATH OF SUBSCRIBING WITNESS(ES) REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA ~~ '='i~ ~~'>!~" ~_'} ~, -~ .~ t;r'~ ~ .:1~-.7 ...~ ~~ ?i ~..) C: z~ ~ ~' b r., r~ G °-,,; t»~ C` ~~_ ~~ f`~`~ C_~,,,7 c: %, :';~ (- -,- 4~ ~.~ p "~`7 Estate of DORIS H. SHEERER _ ,Deceased DANIEL F. CLARK, ESQ. & AMY C. BEWARD , (each) a subscribing witness to (Print Name/s) the ~ Will ^ Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that she / he /they was /were present and saw the above Testator /Testatrix: sign the same and that she / he /they signed the same and that she / he /they signed as a witness <~t the request of the Testator !Testatrix in e /his presence and in the presence of each other. 1 ` ~ ~~_ , (Signature) (Signature) ~0 ~o ~~t _~ a~ (Street Address) (City, State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed before me this ~ ~ day of o~~ ~ ~~' ~~~~~f I C~ ~i ~ ~ (Street Address) ~~i 1 ~ C~dt ~t~ ~!~ 1 ^~ '~ ~-t 2 (City, State, Zip) Executed out of Register's Offic°e Sworn to or affirmed and subscribed before me this of day -- ~~~~Register of Wil s Notary Public Juniata County My Commission Expires: ALICIAA. SEIGLER (Signature and Seal of Notary or other official qualitied to aEOisTEa of wiu.s administer oaths. Show date of expiration of Notary's Commission.) MY Commission Expires 1 ~3 Monde of Jan. 2014 NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of not;~rization. Form RW-03 rev. 10.13.06