Loading...
HomeMy WebLinkAbout07-08-11 1505610148 REV-1500 EX (01-10) PA Department of Revenue OFFICIAL USE ONLY County Code Year Fil a Number Bureau of Individual Taxes Po sox 28oso1 INHERITANCE TAX RETURN 2 ], 1, L 0 2 41, Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth nnMDDYYYY ~-~ ~ 1,74-20-8303 021,1,201,], 05],91,927 Decedent's Last Name Suffix Decedent's First Name M I BLESSLEY EVELYN K (If Applicable) Enter Surviving Spous e's Information Below Spouse's Last Name Suffix Spouse's First Name M I Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE - - REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW ® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-82) ^ 4 Li it d E t ^ 4 F I t C i f ^ . m e sta e a. uture n erest omprom se (date o 5. Federal Estate Tax Return Required death after 12-12-82) 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 ^ 10 ^ . Litigation Proceeds Received . 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 SHOULD BEpaJ,RECTED TO: Name Daytime Telephdlr~ Number ".,., RICHARD C • SNELBAKER 717-6978 ~= First line of address 44 WEST ~1AIN STREET Second line of address P•0• BOX 318 City or Post Office MECHANICSBURG Correspondent's a-mail address: 4S USEIONLY :~; . `~. ,,,~ ~ OD ` :.? i~. t!> ~ _7 ~ ,_ _ ,: ~- , ~ ~ `~"' ~~ ~, .. State ZIP Code L DATE FILED PA 1,7055 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG OF PERSON R PQNSIBLE FOR FILING RETURN DATE 20 CYNTHIA~• WARNER, EXECUTRIX SIGNATU OF REP ER THAN REPRESENTATIVE DEBRA L- SPARKS, EXECUTRIX a/k/a Deborah L. Sparks DATE ADDRESS - ' RICHARD C- SNELBAKER 44 WEST MAIN STREET, MECHANICSBURG PLEASE USE ORIGINAL FORM ONLY Lsas61o14a Side 1 9M4647 4.000 1505610148 ~'' J 1505610248 REV-1500 EX Decedent's Social Security Number 174-20-8303 ~ecedent'sName: BLESSLEY EVE LYN K RECAPITULATION 1. Real Estate (Schedule A) 1 0 • 0 0 2. Stocks and Bonds (Schedule B) . 2 0 • 0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) , 3. 0 • 0 0 4. Mortgages and Notes Receivable (Schedule D) 4. 0 • 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5. 1, 3 2 , 7 O L , 6 0 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested 6. 2 , 310.12 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. 2 51, 9 L 5.0 2 8. Total Gross Assets (total Lines 1 through 7) g, 3 8 6 , 9 2 6.7 4 9. Funeral Expenses and Administrative Costs (Schedule H) , , 9 6 , 5 21.9 3 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) 10. 21, 9 3 6.0 5 11. Total Deductions (total Lines 9 and 10) , 11. 2 8 , 4 5 7.9 8 12. Net Value of Estate (Line 8 minus Line 11) 12. 3 5 8 , 4 6 8.7 6 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) , , 13. 0 • 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) , 14. 3 5 8 , 4 6 8.7 6 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers un~er Sec. 9116 (a)(1.2) x .o - 0.0 0 15. 0.0 0 16. Amount of Line 14 t xable 4~ at lineal ratex.o 358, 468.76 16. 16,],3], • 09 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0. 0 0 18. 0. 0 0 19. TAX DUE 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610248 1505610248 9M4648 4.000 16,131.09 a J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 L7~ ^241 DECEDENTS NAME BLESSLEY EVELYN K STREET ADDRESS VILLAGE, UPPER ALLEN TOWNSHIP CUMBERLAN COUNTY CITY STATE ZIP MECHANICSBURG PA 17055- Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 1 4, 0 0 0. 0 0 B. Discount 7 0 0. 0 0 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) (1) . 16,13],•09 14,700.00 (3) . 0.0 0 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1 , 4 31 • 0 9 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred; b. retain the right to designate who shall use the property transferred or its income; c. retain a reversionary interest; or . d. receive the promise for life of either payments, benefits or care? . Yes ^ ^ ^ ^ No 0 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . 3. Did decedent own an "in trust for" or payable-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? ® ^ 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. X9116 (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. X9116 (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. X9116(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.~~. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Total Credits (A + B) (2) 9M4671 2.000 REV-1508 EX+ (11-10) Pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS, & MISC. R sl~ir ~c ENTTURN PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Evelyn K. Blessley 21110241 Include 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. Capital Blue Cross 201.57 premium refund due the decedent 2 Internal Revenue Service 299.00 refund due the decedent on 2010 income tax return 3 Med-co 15.60 RX refund due the decedent 4 Readers Digest 56.96 subscription refund due the decedent 5 Wells Fargo Advisors 79,167.81 investment account #1597-9905 6 Wells Fargo Advisors 52,960.66 IRA account #1597-9922 TOTAL (Also enter on line 5, Recapitulation) $ ~ 132 , 701 . 6C ow46AD 2.000 If more space is needed, use additional sheets of paper of the same size. REV-1509 IX+(01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: Evelyn K. Blessley 2,111 0241 If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVNINGJOINTTENANT(S) NANE~S) ADDRESS RELATIONSHIP TO DECEDENT A Sparks, Deborah L 27 Oakwood Avenue, Mechanicsburg, PA 17055 Daughter JOINTLY OWNED PROPERTY: ~~ NUMQER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIP110N OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUM9ER OR SIMLAR IDENTIFYING NUM9ER. ATTACH DEED Fq2 JgNTLY HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET °/° OF DECEDENTS I~fTE~2EST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1 A 7/16/1993 Sovereign Bank 4,620.24 50.0000 2,310.12 checking account #1681715902 TOTAL (Also enter on Line 6, Recapitulation) $ 2 , 310.12 swasAE z.ooo 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 Evelyn K. Blessley 21 11 0241 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 yes. ITEM NUMBS DESCRIPTION OF PROPERTY INCLIAETI-Er14MEOFTi~ETRANSFEREE,TFEIRRELATIONSHIPTODECEDENTAt~ TFEDATEOFTRAISFER. ATTACHACOPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD~S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE 1. John Hancock 251,915.02 100.0000 0.00 251,915.02 annuity contract #8098548. Benficiaries are decedent's three children. TOTAL (Also enter on line 7, Recapitulation) $ 251,915.02 If more space is needed, use additional sheets of paper of the same size. 9W46AF 2.000 REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Evelyn K Blessley 2:1 11 0241 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ Deborah Sparks reimbursement for funeral expenses 1,343.41 B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: 2. Attorney Fees: Snelbaker & Brenneman, P. C. 3, 700.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 15 8.5 0 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. 1 Cumberland Law Journal advertising Executrices Notice 75.00 Total from continuation schedules 1,245.02 TOTAL (Also enter on Line 9, Recapitulation) $ 6 521.93 swasA~ z.ooo If more space is needed, use additional sheets of paper of the same size. State ZIP Estate of: Evelyn K. Blessley 21 11 0241 Schedule H Part 7 (Page 2) 2 Register of Wills filing fee for Inheritance Tax Return 15.00 3 The Sentinel advertising Executrices Notice 230.02 4 Reserve for filing fees, accountant fees and other costs associated with the administration of the Decedent's estate 1,000.00 Total (Carry forward to main schedule) 1,245.02 REV-1512 EX+(12.08) SCHEDULE pennsylvania DEPARTMENTOF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Evelvn K. Blesslev 2]L 11 0241____ Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. 8W46AH 2.000 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FILE NUMBER: Evel n K. Blessle 21110241 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Cynthia A. Warner 1870 Spring Road Carlisle, PA 17013 John Hancock Inventory Value: 83,971.59 One Quarter of Residue: 26,060.97 Daughter 110,032.56 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. 9 W 46AI 2.000 Estate of: Evelyn K. Blessley 21 11 0241 Schedule J Part 1 (Page 2) Item No. Description Relation Amount 2 Deborah L. Sparks 27 Oakwood Avenue Mechanicsburg, PA 17055 Sovereign Bank Inventory Value: 2,310.12 John Hancock Inventory Value: 83,971.59 One Quarter of Residue: 26,060.97 Daughter 112,342.68 3 Ellen L. Merrill 8605 Spruce Run Court Elliott, MD 21043 John Hancock Inventory Value: 83,971.59 One Quarter of Residue: 26,060.97 Daughter 110,032.56 4 Nicole R. Warner 1870 Spring Road Carlisle, PA 17013 4.1666 of Residue: 4,343.49 Granddaughter 4,343.49 5 Robert A. Warner, III 1870 Spring Road Carlisle, PA 17013 4.1666 of residue: 4,343.49 Grandson 4,343.49 6 Jessica K. Sparks 27 Oakwood Avenue Mechanicsburgq, PA 17055 4.1666$ of residue: 4,343.49 Granddaughter 4,343.49 7 David L. Sparks 27 Oakwood Avenue Mechanicsburg, PA 17055 4.1666 of Residue: 4,343.49 Grandson 4,343.49 Estate of: Evelyn K. Blessley Schedule J Part 1 (Page 3) Item No. Description Relation 8 Matthew D. Merrill 8605 Spurce Run Court Elliott, MD 21043 4.1666 of Residue: 4,343.49 Grandson 9 Lauren Merrill 8605 Spurce Run Court Elliott, MD 21043 4.1666 of Residue: 4,343.49 Granddaughter_ 21 11 0241 Amount 4,343.49 4,343.49 J ra.J ~ ,.....~.,, ..... _.....~......,......,. T -, r ~ ~ ~ ,~ '~~ {~ ~` {~~Y~~ar~~_.~~~ ~~~~ ~ z~~l.,~,,,_a.r_,.~ :- ,. t. X. ('~ ,. i. _1•J t"l ~ x:11 ~ C; `. s: > s' s 1 ` ~ L _: _. ~~ C`iUUTl~iy o:~ Ci~1s+1~JE.'•a.'~.~.1"ld c.~l~;~, a'-~;~t~} C:'1 ~;.C~'~15~_J_'~ ~.:r~l.~~:.~ ~::":_?_. t~:i• ~~i71~.:~'~ a r~ c~. d i s ;~,~ s a_ :r., ~ z?~x~~. n d_ , 1,.~=~~ x~1c~ ~:' ~" ~ . l~ cl z;~.t~ r~ r~= ~~~ ~~ ~', ~, ~~9. ~~x ~J. ~`. n ~; ~ ~ ~. ~~., , ~ < ~~.. ~~~~ , ~ ~ ~ ~? ~~ ~- ~ ~ ; ~-~ and dec~..are th:z.s x~z„y ~'~~r:~t ~'~_~_?_ ~~.r~zc? ~~~ . ,... ~~;~~.~~..x}~•~r~~.x ~-, ,~ ,,d,;~ ~.~;~ -r~->'~~:.~_~~, ~':-1~'~. ' a~ ~~~.~~1 ~l~~:a_c~~:~ xnalg~. ng v o ~. d y aria. ~1~~i.."1-~._a_ ~~,~. r,~~ ~~-t', '-c~~;; ~~::_~,~~~~~; ',~~~~~t;oM~'~~r made . ;~., ,~ .J. ~ 'y'et /] // V 4/ ~ ~C./ ~^~ ~'-~ Y y J r~' 3.~ 2~ 1 ~ ,. ~,. - .. J ~9 I,:~ •° \ i~ ~ ~ ~~ I ~ ~, , 1 ~.. ~ I_ ... .... _~ •~ 1. "J i e~pe;t'lSe ra` a~7 s'o~~~ ~.J. l~'~..^.~•A t~`AaJ~ j.~ f' fi ~~, ...' ~i ~~II,i'~: ::Yi ., 4' ,-', ~~~ . .. `,~ `~i ~ r.'.~. _ done. :~ T el;~.re t~ ~ ~ ~- s a ~.~~- _. ~ ~ ~ ~ ~ e 1..7 ~.r J».fi.~. ~,u.~. d ~. ~r 8 ~=.:~~.E~`.~~ '~.. +.~1 " ~l r: !:^` ~.~ ~ ~ ... .I_, I I: ii ~_.1 "; '„~'. ~ i ~ ~ ~ , . ~ : , C:i ~ a ` ~. ~ 'l. A .i. 1.. ~.i ' t ";.a' .. -; '.1 .. e. ,L au Vho1~ J.. /tee GL.LA4A. V l~~lp 4..~~'~~ J. ~ k~~W~,~~ ..,~._~i~~.., (.~ ~..~ W ~.'~ (`., •A ~.. ~.i a~ 1 .~ r_ ..~ f: ..~. i ~~ .. ~.~ ~.ti ~~_~ 7 l.f ~f.~, t ~~ ~ ~.r ~..'} w, ~~ .~~_ _.. r~r ~:~ s is r:~.1. u~ aid a~.l r©al _._ ~~ r~' , z,~~- ,~ ~,~,.r°~ ~~~~r , _ .~ ~ a. ._. ~ :,. , .. "~~:~ ~~ n . ~~w.~: ~r~;~ .. i r,_E~_,.~< - :~+., , ~. ~F , a;~ ~,re11 ~ s j ~, .... ~ . ~ .~ , ..~ 'j ~.i ~ .. ~.., . . i i., T ii .~ _.. , .,..1, or sales. A f ~ e r ~~y e s ~ a~ c~ "~~~ ~ ~ ~ l~~zz:~a ~~a e e ~~~ ~~ c~ ~:~ ~ ~~~ r:~, -L~ ~~~ ~~~ c~ ~ r~~~~ ~~ ~~ w~± ~~~ ~ , ~:~. ~~xd upon payment of all rn~~r i'1~~~ 1, r~~:~1,~..rr~. ~::~.i -:air ~ ,, ~f.~~w~ c;:~~:~~e.~°:~~ c7~' t dzn~.~.~~ ~ .~.. ,~. s.n~. a.ll ~"irz~~~~:~r~i~:,~7..~~~~.a~~; ~~~zc~. ,~7~~~;aes~~ ~ ~rz ~~,;.~;a, ~. Lion of xny estate, direct ghat my entire a~~esid~a.x~Y ~.y,~t:,~~..U~~ ~:;1~:rti~~ x°F.rxrla~.?~ai..i.~~~~~,~ ~>; di vi~~{ %nto four (~.~.) equal sh,<~re ~ ~~.z~.ca, tf~,~s.'~:~ ~~1;z~:~ ~~z,zrac~ 1.;e d. l..~~~, .;xx:~..~katz.~~~.~d ~r~ca, paid out as follows: ~•~. { a) T g~.ve and bequeath one (l) such equal share to my daughter, CY~ITHTA A. W.~RN~EFt. (b) S give and bequeath one (1) such equal share to my daughter, ~7EBRA L. SP~.R.~S « (c }T. ~.~.ve and. bequeath one (:~.) such equal share to xny daughter, x~Lfi,EN L« T'•~i~£~i.T~.ZI,L. {d) Z give and bequeath one (l) such equal share to my ,~~randch.ildre;r~ who are livin.~ at the time of my death, share and share ali~~e, and in th.e event that a.ny or all of my said grandch:~ldren are under the age of eighteen (18) years at such. time, T direct that tka.eir respective shares ~.n my estate be placed i n e.n ~.ntQrest bearing account ~Tith a local bankira~; i:r~s t itLtit i on until such time as they attain the age of eighteen (18) years, at which ta.m© the same shall be distributed and. paid over to them absolutely and unco:rlditionally« LAS~L~', I nominate, constitute and appoi;rxt my three (3) daughters, C~~'NT~IIA A. ti~IARNER, DEBRA L, SPAR~~S and ELLEN L. i~tER.RILL, Co-Executrices of this my Last Will and 1'estaxnent, and I d~.rect that they be excused from posting bond or other security for the faithful performance of their duties i.n any jurisdiction. .» 2~ I~1 ~°JITi~TFS~ ~~1Tr~1 JA ~aF', ~ have hereL~.nto set my hand and seal this~~„ day of/d~~~ , .A. D. , 1995 • (SEAL ly es,sley ~~ ,'vaned, se~a.7.ed, publ~.shed and dec~_s.red by the above .named, ~~~.~:L~L~`-~~~ ~"~• LL~~-'~~ST~, as acad. ~'or lxer Last ~r~ill and rrestament, ~.n the presence of us, who have subscribed cur naz~a.es hereto as w~,tnes;~es,~ at the request of said testatrix, in her Ares©nce and in tl:~.e presence o.f each other. r.-~°'~ -3~~ COMi~IONWEAL'fH OF YENNSYLVANTA ) : SS. COUNTY OF CUMBERLAND ) I ~ ~ wry L~'~~ ~~. xaLLS~L~~'~ the testat ~'~~ whose nazzie is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that T signed acid executed the instrument as my Last Will and Testament; t.tzat T signed it willingly; and that T signed it as my free and voluzl- t:tlry act and deed, for the purposes therein contained. Sworn and affirmed to and acknowledged before me by, ,' ".~ ,'"`,T Y~ * -~L~;,~" SI ~Vr h testat ~' ~ this i Id ; _:~ ~ .~..:..`~ ~,~.',. 1 ' I !..} i .1.X:.1 1 t e ~ ~.J...f » ~ ~ i .~` day o t - r:.i ,.~~~ ._..._ A . l) . ~ ~, t~ ~~~ ,~ -- /' ~.. /, .; _, 1 i ~ ~ ~~ ~,~ . - r ~, M ~~ ~ ~ Y Pubdtc COMMONWEALTH OF PENNSYLVANIA ) My~~~nC~ ~~ : SS. COUNTY OF CUMBERLAND ) ~ ~ ea . ~'0 a~':~' `S' :~'lx'~:G~~':L~~.~~t We, the undersigned, aild ±.=~~~. i w`-~'~ -~~. Il.~~;l "a.t~~Ti,i-~.~"r~!,l`~i , the witnesses w ose names are signed to the attached or foregoing instrument, being duly qualified according to law, depose and say that we were present and saw tYze testat ~''~.:~ '.~~i~ES~~rI~ Vii. BL:r_{~>~SL.' ~ sj_gn and exe- cute the instrument as L~her Last Will and Testament; ghat the said testat rim .~V'~~.;'~'~'T L. ~LFS~L~~'' executed it as /her free and voluntary act for the purposes therein Expressed; that each of us, in the hearing and sight of the testat.;t~;~x signed the Will as witnesses; and that to the best of our knowlE:dge, the testat r~.~ was, at the time, eighteen (18) or more years of age, of sound mind, and under no constraint, duress or undue ~Lnfluence. Sworn and subscribed to before me Lhis ~-'~ ~ day of ¢' ,~