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HomeMy WebLinkAbout02-24-12Reset PETITION FOR GRANT OF LETTERS REGISTER! OF WII.,LS OF ~,urn(3ER-l-At.10 COUNTY, PENNSYLVANIA Petitioner(s) named belolN, who is/are 18 years of age or older, apply(ies) for Letters as specified below, and in support thereof aver(s) the following and respectfully request(s) the grant of Letters in the appropriate form: Decedent's Informatioh Name: Do N Act.D '~..} . A t_+-+ S a ty a/k/a: a/k/a: a/k/a: Date of Death: I ~ 3~t) Zo t Z File No• ~ ~ _ ,~ (Assigned by Register) Social Security No: a- 01 - (b ~ L SO `7 Age at death: ~S Decedent was domiciled'at death in (' ur+nRl=l2t.ian~A County, ~_ (state) with his/her last principal residence at '?O (~c.~ D ~ n N ~G',2 QD CA/ni' u-t.(, ~ QA- GurngE2LA~o Street address, Poat Office and Zlp Code Cfty, Township or Borough County Decedent died at Street Post Office and Ztp Code City, Township or Borough County State Estimate of value of decedent's ~roperty at death: / !f domiciled in Pennsylva*ia ............................ All personal property $ / 7 ~ 1 0 b ~ IJnot domiciled in Penn lvania ........................ Personal property in Pennsylvania $ If not domiciled in Penns~y,lmnia ........................Personal property in County $ ~-' Value of real estate in Peal nsylmnia ......................................................... $ / t. C1 i O U O p TnOTAL ESTIMATED VALUE.... $ 3 3 ~ ~ v oc~ 0.00 Real estate in Pennsylvania situhted at: `? b ~~ f ZON 2~2 lug C./~1-'-P )d fLt- ~ P r~ 1 Z(~1l CI.~W~6~~G/4-~D (Attach additions! sheets, if necessary.) Street address, Poat Office and Zip Code City, Township or Borough County A. Petition for Prol>Iate and Grant of Letters Testamentary Petitioner(s) aver(s) he/sheVthey is/are the Executor(s) named in the last Will of the Decedent, dated _ ~~al~/~d b ~/ and Codicil(s) thereto dated State relevant circumstances (tg. renanclatlon, deat/~ of executor, eKC) Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not divorced, was not a party to a pending divorce proceeding whereiq the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g), and did not have a child bom or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. NO EXCEPTIONS ~ EXCEPTIONS Q B. Petition for Gra>#t of Letters of Administration (If applicable) c.t.a., d.b.n., d.b.n.c.t.a., pendente life, durante absentia, durante minoritate If Administration, Goa or db.n.c.za, enter date of Will in Section A above and complete list of heirs. Except ac follows: Decedgnt was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g) at~d was neither the victim of a killing nor ever adjudicated an incapacitated person. Q NO EXCEPTIONS b EXCEPTIONS Petitioner(s), after a proper search has/have ascertained that Decedent left no W ill and was survived by th,e following spouse (if any) and heirs (attach additional sheets, if necessary): ri..a C7 ~' Name Relationshi Address ~~ ''"i +~i C7 t7t7 r __~°' ~_ .C' - ? ~ ~ _ ~i ~ __ ~ D ,~ L ~ C`3 C.:~ r-i' t,J ~:.__) Y7 Farn e w o2 rev. ron inoi i Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF __~~,tmC3E2LAU D } Official Use Only .r +~ .,R Petitioner(s) Printed Name Petitioner(s) Printed Address J A /J IL K t..t `t'N ~ ~/ la I I D A U.-EUN ~~- m ~~ A~+ ~ G ~ 0 ~CNnl~l%C'Q. K iSs>/ u2orv 0 MELF6Aty- ~, CI~.IP~0.S7) The Petitioner(s) above-named swear(s) or affirm(s) 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, t etitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before - ~ i'~ Date ~- ~ ~ dU/~ me this day ` ` ~ Date By: Date For the Register Date BOND Required: ©YES Q NO FEES: Letters ..................... . ( / o )Short Certificate(s)..... . ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commissio ................ Other ~ ~ ...... s~ Automation Fee ............... ~ ~. JCS Fee ..................... TOTAL ..................... $ -A:BA ~~y~-~ To the Register of Wi!!s: Please enter my appearance by my signature below: Attorney Signature: Printed Nsme: Supreme Court ID Number: Firm Name: Address: Phone: Fax: Email: DECREE OF THE REGISTER Estate of N At,o >~ . s a,~ File No: ~ ~ ~ I ~ ' ~- a/k/a: -+ I . AND NOW ~~ ~ ( ~t 1 1 ~ , in co id ration of the foregoing Petition, satisfactory prof ing been pr se ed before me, IT S DECREED that Letters e hereby granted to -1-- i the above estate and (if applicable) that the instrtunent(s) dated described in the Petition be a itt d to probate and filed~ef~~cord as the lash W}~1(and Codicil(s)~ygf Decgdent. , Re'gfster of Will _ Form RW-Ol rev. 10/I1/2011 ~ P e 2 of 2 H 105.805 REV (9/11) LOCAL ~rR;~~ CERTIFICATIOI\I OF DEATH WARNING~~j~"irlega~ ~`~k~i~licate this co b py y photostat or photograph. Fee for this certificate, $6.00 F 1160200 Certification Number TYPe/Print In Permanent ' ZC~lZ FEB 24 AM f! ~ ~. This is to certify that the information here given i i p ~ corrl~ctly copied from an original Certificate of Deat CiLEtI~ Q1` duly tiled with me as Local Registrar. The origin ~~p~ls v~(}~1 certificate will be forwarded to the State Vita C«M~r~J f~i1}~~ (;(~ ~ Records Office for permanent filing. ~ FEB 3 Z Z Local Registrar Date Issued COMMONWEALTH OF PENNSYLVANIA . DEPARTMENT OF HEALTH .VITAL RECORDS CERTIFICATE OF DEATH as[, Suffix) state File Number: m'an Allison 2. Sex 3. Social Security Number 4. Dafe of Death (MO/DSy/Yr) (Spell Mo) s ~ d 1 D 6 D Male 201 16 - 6807 Tsa,,..e-__ -„ .. _ _ _ 1 1 Apr i1 2 Id nce (Street and Number -Include Apt 70 Old Pioneer Road Y qF O (~. R$~ S Yes [] No D Unknown Ir antai 5ta Q Divorced ~ Never Married Q Vnk o(wn Q Removal from State u 9lu rrsr ~ Cremation 16b. _~ Other (SDecIM I ~ Donation 1'•@ 92 6 76. Birthplace (Coun >y r~ur YA Bc. Did Decedent Live In a Township] ty) Dau hin fives, decadent nYed in _ Hampden ~P- ~ No, decedent Ilvetl within limits of 402 Dr3.ve 17050 I _. __...___ r. .. ~,.,a.°rv. or Evans Crematory SChae f f erg t0 wn , PA 17088 re ne ~~~~ ral Service Licensee or Person In Charge of Interment 17b 17c. Name and Complete Addr . License Number ess of F Parthemore ne I Facility 6 C - F' S 012 849 L I0. Decedent's Education -Check the S, Inc., ox that best d P.O. Box 1, NaW Cumberland highest degree or level of school comp escribes the clad at the time f d , PA 1 7070 19. Decedent of His i 0 l O Bih grade or less o eath. 20. Decedent's Race - Ch k box that best tlescribes wh eth c ONE OR MORE ra er the deced [] No diploma, 9th - 12th grade ent ces to Indicate what the deceden t considered hl If h Is Spanish/HlzpanlULatino. Check the "NO" a or e self to be ~ High school graduate or GED m~ ~ Some college er dl pleted _ Q White box If decedent is not 5 O Korean Panlsh/Hlspe nic/Latino. ~ Black ar Afri Q No not S e et, but no degr Q Associate degroe ( g Aq q5 e , can American panish/Hlspanlc/Lat1no ~ gmerican Indian or gla ~ VleTna mesa ~ Yes, Mexican Me k i . , , J Q Bachelor's degree (e.g. BA q0 g ) , s x a NatlYe can AmeNCa n, Chicano ~ gglan Intllan ~ Other Asian Q Yes, Puerto Rican , , ~ Master's degree (e.g. MA M5 M n M ~ Chinese Q NatlYe Hawaiian 0 Yes, Cuban , , 0 Doctorate (e.g. PhD EdD) or Pr f g, Ed, MS W, MBA) 0 Flllplno [] Guamanian or Chamorro ~ Yes, other Spanish/Hlspanlc/Lati , o e. MD DDS DVM LLB JD ssional de .gran no 0 Ja pane::e 0 Samoan (Specfy) Q Oth P 21. Decedent's Single Race Self-Desi g^ er sciflc Islander 0 Other (Specify) tio Ch Q White ~ Black or African American n - eck ONLY ONE to In ~ Ja pa nesa dicate what the decedent considered himself or her ~ Samoan self to be. 22a. Decedent' U Q American Indian or Alaska Native) ~ Korean ~ Vletn s sual Occupation -Indicate TYPe of worl Q Other Pa Clflc Islander done during most of workin Ilf D Q Asian Indian ameae ~ Other Asia e g O NOT USE RETIRED. [] Don't Know/NO[ Sure ~ Chinese n Q NatlYe Haw ii $81e S RE! r E! 0 Refused p sentat ive ~ Flllplno a an Guamania Q Other (Specify) 22b. Kind of Business/Industry ITEM523a _2 MUST BE COM LETED n or Chamo rro BY PERSON WHO PRONOUNCES OR CERTIFIlS DEATH 23a. Date Clothing & Auto Mfg ' ^~u^ d Dead Mo Day Yr 236. re o 3d. ~ [ igr:ed ( /Da.,/yr) ~~ ^3 / ~' ' J , ~ 24. TI of D . p unclog D a[ (On y when applica le 23c. Vicensa Number , I J ea h ~~ ~ ~~~ / mine .Was Medical a r r Coroner Contacted? ` ° 26. Part 1. Enter the ch 1 f ~ L `'Iseases injuries CADS F DEATH e5 O No respiratory arrest, or ventricular f~ , , or compllcatlons--that direc[I' Y caused the tleath. DO NOT enter ter lbrlllstlon without showln [he APProxim tl i t l l g IMMEDIATE CAUSE e m na a e o o events such a BY- DO NOT ABBREVIgTE. Enter onl ardiac arrese ~ Interval: Y one cause on a Il ___ z (Final disease or condition # ~~ /' ~' nc. Add atlditional lines if n c sary 1 Onset to Death n ~ ~Qr es resulting In tleath) '.~ ~ D t ( s consequence of): Sequentially list conditions, If any, leading to the cause Due to (or as a conse listed pn Ilne a. Enter the 4 quence of): - VNDlRLYING CAUSE (disease or Injury that ~ initiat d h Due to (or as a consequence of): e t e events resulting In death) LAST. ~- ' 26. Part 11. Enter oth glgnlfl t Due to (or as a Consequence of): t tl th b t gerlying cause given In Part 1 ' 27. Was a autopsy pertormed7 Q Yes ~6 9. If Female: 26. Ware autopsy findings available [] Not pregnant within past year 30. Dld Tobacco Use Contribute t D to complete the cause of death? 0 Ye ~ Q Pregnant at time of death ' Not ~ o eath? Q Yes [] 31. Man r of Deat P obably s ~_t h pregnant, but pregnant with Q Not pre n b n 42 days of death ~ No (a~tl nknown ~ Homicide cc de~ g ant, ut pregnant 43 d Q Unknown if pre na t ys to 1 year before death A l t ~ [] Pendlhg Investigation 32 Dat S i id f g n within She ast year - e o u c Injury (Mo/Day/Yr) (Spell Month) ~ e ~ Could not be determined 1. Place of Injury (e,g_ home; constructio n site; farm; school) 33. Time of Injury 35. Location of Injury (Street and Number, Clry, State, Zip Code) ,. Injury at Work 37. If Transportatl Injury, SpecHy: Q Yes 0 NO ~-.Driver/Operator " ~ Pedestrian 38. Describe How Injury Occurred: Q Passenger I 0 Other (Spec) fY) Certifier (Check o nly one): O fying nhyslclan - To th zt of &. ertif ^c ln y knowledge, death occurred du e ° T : X? y aiclan - (] M dleal E In r/C - On th 'ause(s) and m stated To best o c Y knowledge, death c u ed at the ti e Signature of certifi ination, and/o me, date, and place, and tlue to the cause s stigaHon, In my optn ion, death ( )and manner stated occur er tyyaw J e, Ad ass p C~of perso Co plating Cause of Death „ s at the time, date, and place, and due to the ca Title of certlFler ~/C7~.L/J~ (/) d m one rated rem 26 License Number / ~3d ~_ ~ ~ : / . Registrars District Number 41. Registrar' ! 39c. Datp 51 ed (Ma/ Y r) / 7Q f/ Si s grlatpre ~w O Disposition permit No._~arjn ~~ H105-143 REV 07/2011 LAST WILL AND TESTAMENT OF ~ "' DONALD H. ALLISON ---o ~~ ^, ~ ~' jv ~ C7 ~ C1D ~ r_i~ ~i3 ~C7 ~ ~ x ,~- -~ f~ ~ ~ I, DONALD H. ALLISON, of Hampden Township, Cumberland` ty,~ ~~~~~~ c„ ,~~ - Penns lvania,~, bein of sound mind, memor and Y g Y u.nderstan ~ ~~, dcS: `"~ ` .a- ~ hereby make,l publish and declare this to be my Last Will anc~" Testament, helreby revcking an}' and all former Wills and Codicils by me at any tittle heretofore made. ITEM I: I direct that all my funeral expenses and estate or inheritance tlaxes be paid by my hereinafter named Executrix as soon after my death as may be found convenient. '~ ITEM II:', I give all my tangible personal property, together with all polijcies of insurance thereon, including but not limited to, any and a]~l automobiles, furniture, furnishings, china, silver- ware, jewelry',, ornaments, works of art, books, pictures and wearing apparel, but' excluding cash on hand and tangible evidences of intangible personal property, to my wife, GENEVIEVE L. ALLISON, if she survives~hne by sixty (60,1 days_ If she does not survive me by sixty (60) days, I give all of the aforesaid tangible personal property to m~ children who survive me, to be divided among them as they shall agree. ITEM III: I give, devise and bequeath all t:he rest, residue and remainde~ of my estate, both real and personal, wherever situate, to t~hy wife, GENEVIEVE L. ALLISON, if sh.e survives me by sixty (60) days. -- _ _ ~_ ITEM IVd If my said wife does not survive me by sixty (60) days and pr©vided that my gross probate estate exceeds Three Hundred SixtylThousand Dollars and No Cents ($360,000.00) in value, then in such events I give the sum of Ten Thousand Dollars ($10,000.00)~Ito each grandchild of mine who survives me by sixty (60) days. I~ the event that any such grandchild is under 21 years of age, this gift shall be to his or her parent who is my child as Custodian fclr such grandchild under the Pennsylvania Uniform Transfers to Minors Act. In the event that my child who is the parent of such minor grandchild is not living, my personal representati~re shall pay this gift to such minor grandchild to one of my chil ren as Custodian under the Pennsylvania Uniform Transfers to Minors Act. ITEM V:I~, If my wife does not survive me by sixty (60) days, I give, devise land bequeath all the rest, residue and remainder of my estate, both!, real and personal, wherever situate, in equal shares to my childr n. If any of my children predecease me, I give that child's shar to his or her issue, per stirpes. Provided, however, that except 'gas otherwise provided herein, if at the time of my death any ofl my property should pass, either under this Item of Will. or othe wise, to a beneficiary who has not attained the age of thirty-two ( 2) years, I give, devise and bequeath the share of such beneficiary to the Trustees hereinafter named, in Trust, for the followin uses and purposes: 2 A. Until the twenty-first (21st) birthday of said beneficiary, the Trustees shall expend inrome and, to the extent necessary, principal to such extent and in such manner as the 7lrustees, in their sole discretion, deem advisable for the sup~ort, maintenance, medical care and education of said beneficiary, and shall add any excess accrued and undistrib- uted in~ome to principal and invest it as such. B. From the twenty-first (21st) birthday of said beneficiary until the Trust terminates as hereinafter pro- vided, 1~he Trustees shall pay to or apply for the benefit of said eneficiary, in quarterly or other convenient instdll ents, all of the net income from the trust estate. In additio~, the Trustees may expend any principal as, in their sole diiscretion, is necessary to provide for the support, maintenance, medical care and education of said beneficiary. C.' In addition to the provisions of subparagraphs A and B of t~is Item V, the Trustees shall make the following distributions: (l,) Upon the twenty-first ( 21St ) birthday of said beneficiary, the Trustees shall transfer and de- liver one-fourth (1/4) of the then principal and any accrued an undistributed net income to said beneficiary, free of trust. (2!,) Upon the twenty-fifth ( 2 5th ) birthday of said beneficiary the Trustees shall transfer and deliver 3 one-half (1/2) of the then principal and any ac- crued and undistributed income to said beneficiary free of trust . (3 )I Upon the thirty-second (32"d) birthday of the ''~ beneficiary the trust shall terminate, and the I ii Trustees shall transfer and deliver the then prin- cipal and any accrued and undistributed income to said beneficiary free of trust. D. The Trustees hereunder shall have the following powers ~n addition to, and not in limitation of, those granted by 1 aw : I (1~ Management of Trust Property - The Trustees shall I, with respect to any and all property which may at I any time be held by them in trust, have the power, ~' exercisable at the Trustees' discretion at any time and from time to time on such terms and in such ~' manner as the Trustees may deem advisable to: I (a) sell, convey, exchange, convert, improve, III repair, manage, operate and control such property; (b) lease for terms within or beyond the term of I ~~~ said trust and for any purpose, including the ~i ~II exploration for removal of gas, oil and other II, minerals, and enter into any covenants and agreements relating to the property so leased i I~ 4 or any improvements which may then or hereaf- ter be erected on such property; (c) encumber or hypothecate real or personal property for any trust purpose by mortgage, pledge or otherwise; (d) carry insurance of such kinds and in such amounts at the expense of the trust as the Trustees may deem advisable; (e) commence or defend at the expense of the trust such litigation with respect to such trust or any property of the trust estate as they may deem advisable; (f) invest and reinvest the trust estate funds in such property as the Trustees may deem advis- able, whether or not of the character permit- ted by law for investment of trust funds; (g) vote any securities having voting rights held by them in trust, in person or by proxy, in favor of or ~~gainst management proposals; (h) pay any assessment or other charges levied on any stock or other security held by them in trust; (i) exercise any subscription, conversion, or other rights or options which may at any time attach, belong or be given to the holders of 5 any stocks, bonds, securities or other instru- ments held by them in trust; (j) participate in any plans or• proceedings for ' the foreclosure, reorganization, consolida- ' tion, merger or liquidation of any corporation I'~ or organization that has issued securities held by them in trust, and incident to such i participation to deposit securities to any protective or other committee established to ' further or defeat any such plan or proceeding; !, (k) enforce any mortgage or pledge held by them in trust, and at any sale under such mortgage or pledge to bid and purchase for the trust created herein, at the expense of the trust, any property subject to such security instru- ment; ~'~ (1) compromise, submit to arbitration, release II with or without consideration, and otherwise adjust any claim in favor of or against the trust; (m) subject to any limitations expressly set forth herein and the faithful performance of their fiduciary obligations, to do all such acts, ~~, take all such proceedings, and exercise all II!, such rights and privileges as could be done, 6 taken or exercised by an absolute owner of (2)i (3D (4; trust property. Power to Borrow Money - The Trustees shall have the power to borrow money from any person, firm or corporation, for any trust purpose, on such terms and conditions as the Trustees' may deem proper and obligate the trust to repay such :borrowed money. Determination of Principal and Income - Except as otherwise specifically provided herein, the Trust- ees shall have full power and authority to deter- mine, in their discretion, what shall constitute principal of the trust estate, gross income of the trust estate, and net income of the trust estate. Taxes and Expenses of the Trust - All property taxes, assessments, fees, charges and other ex- penses incurred by the Trustees i.n the administra- tion or protection of the trust shall be a charge on the trust estate and shall be paid by the Trust- ees prior to final distribution of the trust estate in full out of th? principal or in full out of the income of the trust estate, or partially out of principal and partially out of income of the trust estate, in such manner and proportions as the Trustees may deem advisable. 7 (5) Distributions in Kind or in Cash -- On any final or partial distribution of the assets of the trust estate, the Trustees may distribute such assets in kind, may distribute an undivided interest in such assets or may sell all or part of° such assets and make distribution in cash or partly in cash and partly in kind. E. In the event that a beneficiary of a trust created herein dies before final distribution as provided in subpara- graph C', of this ITEM V, the trust shall terminate, ana the Trustee shall distribute the principal and any accumulated income hereof to the estate of said beneficiary. F. No interest in income or principal of any Trust created herein shall be assignable by, or available to any one having ~. claim against, a beneficiary before actual payment to said beneficiary. ITEM VI I appoint my wife, GENEVIEVE L. ALLISON, Executrix of this, my ast Will and Testament. If she is unable or unwilling to qualify as Executrix, or, ~iaving qualified, is unable or unwilling to'',continue to act, I then appoint JENNIFER K. ALLISON and JAN K. ALLISON as Co-Executrices of my Will. If one of my said daughters isunable to so act, I appoint my son, JEFFREY K. ALLISON to serve as ~o-Executor of my Will. 8 ITEM VII: I appoint my children, JEFFREY K. ALLISON, JENNIFER K. ALLISON and JAN K. ALLISON, or the survivor thereof, Co-Trustees of any trust 'created hereunder. In the event any oz my Cl111uLC11 are unwilling or unable to serve as Co-Trustee, or having qualified are unable o~ unwilling to continue to act, my remaining children, or child as the case may be, shall serve as Trustee. ITEM VII: I direct that no custodian, guardian, personal representati~re or trustee hereunder shall be required to provide security, sulrety or bond in any jurisdiction for the faithful performance ¢f any duty under this Will. This clause is applicable only to such guardians, personal representatives and trustees as are specific lly named in this Will. ITEM IX~ All federal, estate and other death taxes payable on the propertyforming my gross estate for those purposes,. shall be paid out of '' the principal of my estate just as if they were my debts, and one of those taxes shall be charged against any beneficiary. This provision shall not apply to any property over which I have a general power of appointment for federal estate tax purposes. ITEM X:', Any word in the text of this Will shall be read as the singular~i or the plural and as the masculine, .feminine or neuter gender as ma~ be appropriate under the circumstances then existing. 9 IN WITN~SS WHEREOF, I, DONALD H. ALLISON, have set my hand and '~n seal to this'I, my Last Will and Testament, this ~ ~ ~ day of 2004. ~~ C~~~ ~ ( SEAL ) LD H. ALLISON Signed, sealed, published and declared by DONALD H. ALLISON, the Testator as and for his Will, in the presence of us, who, at his request, in his presence, and in the presence of each other, we believing hi to be of sound mind, memory and understanding, have hereunto sub$cribed our names as witnesses. \~. I ~ /lam OF ~•~+~ f ~~ 10 COMMONWEALTH 'OF PENNSYLVANIA SS COUNTY OF DAi~PHIN ~/t.z ~ - ~~/2 U 2a~S and We, DON~LD H. ALLISON, Testator, ~/j~~a j ~~~o~~ Witnesses, respectfully, whose names are signed t the attached or foregoing instrument, being first duly sworn, o hereby declare to the undersigned authority that the Testator sig~ed and executed the instrument as ]zis Last Will and Testament anc~ that he had signed willingly, and that he executed it as his free ~nd voluntary act for the purposes therein expressed, and that eac of the witnesses, in the presence and hearing of the Testator sig ed the Will as witnesses and that to the best of their knowledge, t e Testator was at that time eighteen (18) years of age or alder, of sound mind and under no constraint or undue influence. ` ~ DONALD H. ALLISON, Testator ~.~-~. ~. ill ~ ~^ ,~Q~~<`c~_. Subscr'bed, sworn to and acknowledged before me by DONALD H. ALLISON, th Testator, and subscribed~ and sworn to before me by n ~ E /i uu s and Lr~ aC~ ~'1~/~~. , witnesses, his ~O~ day of v _, 2004. ~i ~!, Notary Public NWEALTH OF PENNSYLVAAIIA 11 Notarial Seal public 4. Tobias, Notary. C;tiy~of Harrisbur8, Daupphin Co 2005 ly[y Commission Expites Ftb. 15, rlea Mstnber, pe~nav~ve"Ip ~ ~ Nots ~_ - -