HomeMy WebLinkAbout05-14-12PETITION FOR GRANT OF L11ETTERS
REGISTER OF WILLS OF G (/f~ Q C,~/77Y )l COUNTY, PENNSYLVANIA
Petitioi - (s~ ~r.:med beic~,v. mho ~s a:= 13 fears of a_~ or alt er. apply(iesj 'r: Latter as s'pecifiad balo~.v, and in
supoort thereof aver(s) the following and respectfiilly reques;(s tl:e grant of Lat:ars .n the appropcinte form:
Decedent's Information ^~~~ ~ 'r' ~qv+s ~ ~ ~~
Names ~r ~l~ f~EL, ~~~' L~' File No:
~'k.'a: assigned by Register)
a/Ic'a:
a/k/a: _
Date of Death:
Decedent was domiciled at death in G (
principal residence at ~~ LDSG7 !'
Street eddr~ce and Zip Code
Decedent died
Stree[ address, l ost Office and Zip
V Social Security No:
~ Age at death: 75''
County, /'~U/!//SYL1~'~F/1.S.~Srnre) with his/her last
City, Township or Borough County
City, Township or Borough Coonty Stale
Estimate of value of decedent's property at death:
Ijdamiciled in Pennsy(vania ....................
........ Atl personal property / Op0
$ J
Ijnot domiciled in Pennsy[vnnia ................ ........ Personal property in Pennsylvania $
/jnot domiciled in Pennsy(vania ................ ........ Personal property in CounTy $
Vrtfue ojrea[ estate in Pennsylvnnia .............. .......................................... . $
TOTAL ESTIMATED YALIJE.. , . $ , e~DO
Real estate in Pennsylvania situated ar
(Attach additiana! sheets. ijnecessaryJ Street address, Post Omce and Zip Code City, Township or Borough County
A Petition for Probate and Grant of Letters Testamentary 7
etitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated _ 7 2 U t~ f and Codicil(s)
thereto dated
State relevant dreumsmnces (e.g. renunciation, death ofexecumr, eM.)
Except as follows: after the execution of the instrument(s) offtted for probate Decedent did not marry, was not divorced, 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), and did not have a child born or
ad led; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
[~NO EXCEPTIONS [JEXCEPTIONS
B. Petition for Grant of Letters of Administration (If applicvble)
c.ta., d.b.n., d b.n. c. t.a., pendente (ice, durance absentia, durance minoritate
If Administration, e.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds fbr divorce had been established as defined
in 23 Pa. C.S. § 3323(8) and was neither the victim of a killing nor ever adjudicated an incapacitated person.
^NO EXCEPTIONS ~ EXCEPTIONS _
Petitioner(s), after a proper search hasPoave ascertained that Decedent :eft no 6'rll and was survived by the following spouse (if any) atpl,¢eirs (attach .
adclitionut sheets, if necessary): ~-?
N ~1
Name Relationshi Address X17 a
^
b~
~
~t~,
-
.
S~
f> C:
~ _y ~ r~
:zi
enrm Rw-nz rev. rnnvznrf Page 1 oft
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
' s ss
COUNTY OF V.ryt~ ~~
vc .,
hE t.a,, ~ c
~~f2 SAY 14 APi 9~ 58
Pe:idc n, rr;; Printe
Sama
C Peti[io,~ettSi Pnn[~ i
' ~
;
~~ (A~ t lYF t/ i S ~ ~ C~U U CQ~,Aq (' 7 3
The Petirioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are tale and correct to the best of the knowledge and belief
of Petitioner(s) and that, as Personal Representative(s) of the Decedent, the Petitioner(s) will well and truly administer the estate according to law.
Sworn to r ffitmed a subscribed before ~ ~a~ Dare -5' ~i' /Z
day of ~ Date
y Date
r the Re ' Dale
BOND Required: AYES
FEES:
~NO
Letters ......................
( ~) Sltort Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commissiopp .~................ .
Other GUr /~ ........
$~
Automation Fee ........ ..... . . 5
JCS Fee .............. .......
TOTAL .............. ....... $
To the Register of Wilfs:
Please enter my appearance by my signature below:
A ey Signature:
Pri ame: ~-t S><t fN lik,rz t t l.Q, -//~ C
Supreme Court
ID Number: ~R~'[$
Firm Name: Co ~ i+ t-6-...nr~ ~ C
Address: ~T
Phone: `1 l1 - 7 3'7F 0 `'{ b ~
Fax: ~-r - T'S? - Y"f b t
Email:
DECREE OF THE REGISTER ~`
Estate of ~I('~_°~- ~,CL)~ S File No: ~ ~ ~~ _ J
allc/a:
.n~ f
AND NOW, _
satisfactory proof
the instrument(s) dated ~
described in the Petition be
Form R4K@ rev. In/l1/2n1/
~1 ~ihUl ~ , in co tder tion of the foregoing Petition,
presented before me, IT DECREED tt}at Let rs ~~
are hereby granted to A~Rtipl~ A~ ~1 t
~ f in the above estate and (if applicable) that
to probate and filed
as the list bVill (and
_~
n~~
~ofz
p .)„,. :
LO,,,~~{± ~, R~RAR'S CERTIFICATION OF DEATH
IO~o~:~ It i I al to duplicate this copy by photostat ar photograph.
Fee for this certificate, $6.O~~i2 MAY ~ 4 A!1 9~ ~J$ This is to certify that the information here given is
,, „ correctly copied from an original Certificate of Death
P
duly tiled with me as Local Registrar. The original
- - certificate will be forwarded to the State Viral
,(~~1QRPFWIv a Iv'vU~1~ Records Office for permanent filing.
18 3 8 91 CgMBERLANO CQ.. PA ~ln, yyyl~~~i~c._ y~AY 0/12011
Certification Number
z~?/print In
s
Q
W
Q
i
Local Registra~ Date Issued
COMMONWE4LTH OF PENNSYLVTNIA • DEPgRTMENT OF HEALTH VITTL PECOROS
TLC•!•ATC !lC fICATY
[41n k
ace en[ a a I Nante (Flrst Mleele, Lest 9uiHZ) P. sex gclal seta HtV IJUmbet a. Dale pi Deetn (MO/Day/Vr115pe11 Mol
35
204-30-9141 Ma 1 2012
a. q[e-LVrt Blrtntl•y (Yta) Se. V near 1 Vear c. V ntl• 1 6.OVte ei glrtn (Me/DaY/Yeerl (bpell Men[M1) e. Birthplace (EIN and Sb er FarelHn Councryl
s
74 pnma Dava Xen Inut
Dec~nberl2 1937
b Blrmpl.a (county) a t more
e=laen=e (sore pr GOrasn ~pmrv) Hb. Ream.n=. stree<.na Number-mnmeAp<Ne.)
a. eDe=eaent ur<In. ewnanipa
e=
F
Pa ampd r< twp.
•. a.=.eent Ilyea m _
Y
3620 Lo an Ct A t 3C
Ba. Reamn[• tce~mvf
Cumberland a.. R.am.n=. (np epa.l O Ne, a.=.aent ny.a wimm ammo eF =lN/ep.e.
n vs .m.a F rcen lo. .r <a s pr D .m O M e gtwmewee ss. s„rvroing spo Na a Pi wl e, give name poet m nrn mar legal
rrl
tJ TI
a V N/A
O N er Marrle
p V ][f No O Vnknown ~ DIVOrcetl
w
u. Faner•a N.m. tFl Morale. L.n, s..nlx) 13. M .me at Mana[e IFb:<. Mldme. Loral
aN prlpr <e Gt
Paul A. Kunkel let
Kat
aet of
nrorm.nra Nam. lab. R .emnahw m D«ea.nt 3m mrorm.nra M.uma Petra=. tsc ana N~mee., clN, s e, np cote)
lq..
9E a tt
HII<e9 W rJ8V18
~
O
`
t'F
~ <_.. .. ec a_n yona ....
... ...
.................... ........ .................... ................. ere Otner iM1an HosPlt•1:............. ................ .......... ........yY __
I
Decedent x Xome
.....-.•••••.
l: t~ Inp•[lent X OCath Occurvae SomewF ~~~ v ~~ ~ t~ Hospice Faculty y
lt
tl I
H
%
••••.a
S (
oap
e
D•atn Occurre
n a
1
NU.aln Home
Emar en Reem/OU<pv[lent Oe•e on grrlvl )Lpn• Tetm O.e Gacll OtM1er ISpe<I N)
~ SSb. FecIIIN Name Ili opt lnatl<uVan, HNe street and number:
is
c. Oty or Town. 5!•<e, one 21p Coae tV of •tF
Cumberland
Hill Pa 17011
D
a. M•tM1Oe e1 posl<lon rlal rematlon
Be
6 16 b. Dvte oI DNpoaltlon lbs. Place eI OlsposRlon (Name ar cemetery. crematory, o other pla<el
o Denalen
° R. omt.~m E-.<e
F(sp pIN) Ms 3 20 2 Hollin er Cremator
6e. LoceVen of DlspaflVen IClty or Town, septa, ana Zip) r er,en n m r
e n
of Funeral SeMCe tens P in CM1nrHe llnterma t lib. Lice ore Nu ee
'
011654-L
v=. = ana c mplae gaeaaa of an.r I wcnM
o
un al
~ uc• n Cne[k Me box toot best eaecebez <ne 19. Oecetle of Xlsppnic Onaln-CM1eck Ne 20. Oeceeent'S 0.ace-Ct.eck ON£OR MORE ra cav Inel<e[e whaC
a ce en['a
nl8nea<deHr• rlavela school completed vc [nenme of death, box [net bee abet e[M1e [he a=cede h tl ceeent consrtleretl hln+seli or rsel/<e ee
n=
nt
i
0 Korean
p~~mNnlte
Ia SpvnlaM1/Xispanl4Letlno CM1eck [M1e "NO'
0 HeF Hretle er less
-
Black nr grn=.n gmen=.n O vl.mameze
p np alplem., xn-uma+•ae boa lfemeaentm nos sp.man/Hlspml4La<Ine. d
O XIHn scnopl gretluate or GED [a<nplebd ONO, net sp•nlsn/XI=p•nlc/LaVnq O vnl^tllan at Alaska N•tlve DOtnet gAan
\
Inelan ~ Nv[Ne Hawvilan
O Some college credit but no aeg.ee O VeG. Mexlcen, McKlcan American, CM1lcano ~ gslan
•pona[e eee.m p.a. Aq, qsl O vas, Puertp Rm.n O cnm.ae p w^ a.^ Ian or cnamorre
e
.cnelor•a a.eree (e.a. BA. Aa, Bsl O v cub.n O Flllpmn p s•
p Mvaer'a Beare. P~e. Mq. Ms, MEna, m6a, Msw. Mbq) p v , pcn.r sp•man/XXpanr=/<.<ma p tapan=ore O Omer want Isl.mer
e
(sp•=IN) O Dmer lspe=IN)
O Donate. le.a. PnD, Caw er Pmfessiona eear<e
MD 00E D
1 O•c•tlen<'a 51n[Ie Race self-DealanatIon-chec40NLV ONE<o lnelce<ewn•f Me ae[eeen[canilaerad M1lmsali or nersel/[o ee. Deceaent'x VSUVI OCCUpa< Indlcvte Npe of work
W nlte Q Japanese Q E e tlunng moat eI working IIFe. DO NOT VSE RETIPED.
n
or an ~ Kor 0 Other c Islanue
~ BI•ck o n P
Housewife
K~ „y
`~.
.
~~.,
a
o
Nets ..
m.,. open.
,k. Nanye oyla
n rnl
o qm.r .
o
e
l
33b. ntl of Business/industry
~ OMer Palen ~ Refused
0 gylan
lnelvn
O ebmeae p N ~ Dore. tse.=lM
'C
namUrro
p Flllpinn o O
+
p
nce Mo Day 3 . blgneture pI troth pronoun ing Devt Only w eM1 appllca le c- Vicenae Num er
p renew
EMg age - 39 MV BE CO 33a. 0•te
ED
D
MA' t
GERTEIFI gOEgTN PRONOVNCEBOp
Z~r2
23tl. De[e sl[nee lMe/Day/Yr) a. Time fD•atn
Yes
O~ c•I Eaamineror coroner coma=teaa/c'p 0
CAUSE OP OEATM
j gln
~
aL[
rv
c
z6. Pank E rm.cnannie a--mae.a... mNrlea, oc compn=alon:-mat dlreRly =aurea me aeon. DO NOT enter cermlmll oxen<=:u=n. arela=arre
me
o
z
~
c
n
, o D
l
nal Imes e,
.
pesvarv mace apt
aapo-.cery.meat er.,eno-l cu l.. nbruucmn wrtnpm abewlna cne e<mioav. pD NDT gBBRgylgTe. Emar only one =aeae on. ana. qaa aael
G~
..C
~ I~'R1LV
t M)NyT`~
)r s
Ye~~
7
IMMEDI/TE CAVSE ----------> a.
([Joel elvease or contlltlon Due [o (or as a comequence oV: t
reapldn[ in dotM1J b. N YG~ R ~A ~ E- A- ! OA-Ys
at <e tat as a [enaegPena mr
xw.nnaRy uac =ena¢lona, o
r
li env. le.amH tp me=auze
5
~ Y~112
-
I~NVk r~( y/L
ustea on ane a. Envr me c.
OERLV INfi EgVSE Oue <o (o. as v coniepuence of): {
tai:epa. er lnlerv tn.t µypEP-r~5.o~ iY~n->
tea me .vent: reaal<InH
~ m eeaM Loan Dee eo (or.. a cone. nor aq:
zs. pan u. Enter o<M1.r na..me~tnpt.e=wane \n me vnaa.wma =a~ae Hlvenmpam v. waG an piv penprmeaa
Ne
~ •. wean vnmm~ea nvalable
e<
z
n.=wae of aeamv
en
=e
p vas O No
39. li Gemale: Dle Tobacco VSe Cen<nbute tp Deatni 3 ero earn
iD
Not prC[nent wltnln psa<Vear Q V Q Probably
s ural
~ X mKlee
~i
~Pregnent at time of tleatM1 ~NO O Unknown ee
o n gallon
O Nc
n
t
n
a
l
ffi YS of tlee<M1
< eeterminaa
idv
Q Coultl
net
be
~ s Ic
eaya [e l
yepr bait+e tlev<M1
~ Not p.egn•nt but pregnen<43 ll Mon<M1)
32-OVCa of lnfury IMO Dey/Yrl lspe
p unknewnl.prem.nt wlmm[M1e p.at ve.. -nmep laurv
3a. Plea et Imprv t=... M1em., =.naovalen ,la, nrm, ==neon 3s. Le=aaen m mrvrv ts<ree<ana Nembe., oN, state. np cpeq
86. In)ury vt Wprk 32. Ii napertstlan ln)ury speclN:
e 3B. OeaCrlbe Xew In)ury Occurred:
r^op. tp p Peeescrs.
p Ne, p D
p e O P a ar p Dcn.N p•nM
H
1fla lChec4 anlY ane):
89 CeR
[
et o my knewletl[e, earn o suttee du [a uae[a[ and m nn tee
lnH PM1YSI an -T <M1e
0 C I
v
ryr
rtlrying pn s an -T a bas of mV knowl.age, eeKM1 o tee a e, eat ntl eu e(s) ane ma [ea
a~er
e a
n era
p
a
m
P n
o pl
O
ne =. 1:).na mann.r oral a
a me nor., moe..ne Pl.=e. and
t
mn, Bea
~ nor/oan...=e[.oon. m m np
ne b
r Inaa+e ~
m.m=a~e .r gl e~ico
-
e
C
d
m n
r
~
T
l I
eNUmber M~l.J Y)SS~-J L
lle //11/
Y oic
slgna rtina ~ n ~'~`Q~
T le r:
~~ 9, ~ 3s~<e nee tore Dav/y.l ,
B9b.ne..t. egda.ess.na xlP CeaemP~e~~c`emp~155•sel`~t~tem z6l
Sao a. [ :~ zo L
. Reglstrer a Inritt Num r Regl 3. Re[IStrar FII [e Mo Day r
43. gmenamen<a
DlpppaidpnPermltNe. ~ 7570 t+7`~7~1 Revo>i3oi3
ILA'][" ~VI[ILIL r~l~~ 'I['IE5'1[['
®IE
-i
6 lllldll~JiJ Llla llY~ v L~
~:;
__-n
-~
- ~..=
--;
_ <
--,
~- fir;
-~ r..
_
-~,
=~
r11 ~n
1, ALICE K. DAMS, of 3620 Logan Court, Apt. 3-C, Township of Hampden, Cumberland
County, Pennsylvania, declare this to be my Last Will and revoke any Will or Codicil previously made by
me.
ITEM 1: Upon my demise, I direct my body be released to Myers-Hamer Funeral Home,
.;
n
~'
J
1903 Market Street, Camp Hill, Pennsylvania where I have pre-ananl;ed and pre-paid cremation, funeral
and burial services. I direct my ashes be interred next to my beloved husband, William S. Davis, in a lot
which I own in the Davis Family Plot in Rolling Green Memorial Park, Lower Allen Township,
Cumberland County, Pennsylvania.
d
x
w
a
ITEM 2: I direct that my funeral expenses be paid as soon as practical after my death.
ITEM 3: I direct that all taxes that may be assessed in consequence of my death, of
whatever nature and by whatever jurisdiction imposed, shall be the responsibility of each beneficiary and
paid from each beneficiary's share at the rate then assigned to that beneficiary and in no event shall the
taxes owed by reason of my death be paid in a collective manner from the gross residue of my estate.
Furthermore, should there be any taxes assessed on property or assets which may pass outside of this Will
as anon-probate asset, I direct that all taxes which may be assessed on such an asset shall be paid by the
beneficiary or recipient of that non-probate asset and in no event shall the tax owed by reason of my death
be paid from the gross residue of my probate estate.
Page 1 of 6
r
ITEM 4: I give to the person or persons identified in any written statement which is signed
by me, whether prepared at the time of making this will or at a subsequent time, certain items of tangible
personal property described therein. This provision authorizing reference to such a separate statement
does not necessarily mean that such a statement has been made by me in connection with the making of
this Will.
ITEM 5: I give, devise and bequeath all the rest, remainder and residue of my estate of I
every nature and wherever situate, together with all insurance thereon, in equal shares, to my sons, PAUL
K. DAMS, M.D. of 736 Providence Road, Malvern, Pennsylvania 19355, per stirpes and JAMES W.
DAMS of 285 Whissler Road, Etters, Pennsylvania 17319, per stirpes.
ITEM 6: My Executor or his successor shall have the following powers in addition to
those given by law to be exercised by his in his absolute discretion, which powers shall be applicable to
all property held by him, effective without the order of any court and until the actual distribution of all
such property:
a. To retain any investments at discretion including stock of any corporate fiduciary
hereunder or of a holding company controlling it;
b. To invest and reinvest in the executor's discretion as permitted under Act 28 of 1999, as
.~
~-•~ ~
~ d
~ Q
x
u,
U
'~ Q
amended, the "Prudent Investor Act," with the specific right to invest in stocks, bonds and real estate,
including non-income producing residential real estate for the occupancy of any present income
beneficiary or beneficiaries, and in such diversified, proprietary money market and mutual funds,
including such mutual funds of any corporate fiduciary hereunder or those of any successor or affiliated
corporation or a holding company controlling it, as my executrix deems appropriate;
a To sell, to grant options for the sale of, or otherwise convert any real or personal property
or interest therein, at public or private sale, for such prices, at such time, in such manner and upon such
terms as they may think proper, and to execute and deliver good and sufficient conveyances, assignments
and transfers thereof without liability of any purchaser to see to the application of the purchase money;
Page 2 of 6
d. To borrow money and to secure the repayment thereof by mortgage of real or personal
property, pledge of investments or otherwise, without liability on the part of the ]enders to see to the
application thereof;
e. To compromise claims by or against my estate or any trust created hereunder;
f To allocate and distribute different kinds or disproportionate shares of property or
undivided interests in property among beneficiaries or trusts, in cash or in kind, or partly in each;
g. To register investments in the name of a nominee or to hold the same unregistered in such
form that they will pass by delivery;
h. To join in any recapitalization, merger, reorganization or voting trust plan affecting
investments; to deposit securities under agreement; to subscribe for stock and bond privileges; and
generally to exercise all rights of security holders;
i. To manage, operate, repair, alter or improve real estate or other property, and to lease real
estate and other property upon such terms and for such period as my executrix deems advisable even for
more than five (5) years and beyond the duration of any trust;
j. To deduct administration expenses upon either the f:deral estate tax return or fiduciary
~~
~~0,
ll
v
V
V
income tax return with or without adjustment as between principal and income, as my corporate or
disinterested executor shall determine;
k. To associate with them in the absence of a corporate fiduciary, an accountant, custodian
and investment advisor, and other agents and to compensate them from principal or income or both, as my
executor shall determine, such compensation to be a reduction of the compensation of my executor;
To associate with her at any time, in his absolute discretion and of his choice, a corporate
fiduciary which shall have the same powers as my executor, such. designation by my executor and
acceptance by a corporate fiduciary to be in writing;
m. To combine, without prior court approval, any trust herein with any other trust with
substantially similar provisions, although such other trust may have bE;en created by separate instruments
Page 3 of 6
and by different persons, and, if necessary to protect different future interests, to value the assets at the
time of such combination and to record the proportionate interest of each separate trust in the combined
fund; provided however, that no such combination shall be permittf;d if the effect of such combination
would be (1) to violate the applicable rule against perpetuities; (2) to disqualify any interest in one or'~
more of such trusts for a deduction for federal estate tax purposes which would otherwise be allowable; or
(3) to cause the loss of the exempt status of one or more of such trusts from the imposition of the
generation-skipping tax;
n. To exercise any stock options which they may receive; to borrow such funds from any
source as my executor may deem necessary for the exercise of such options; and to pledge assets as my
executor deems appropriate for this purpose;
o. No trustee shall be required to qualify before, be appointed by, or, in the absence of a
breach of trust, account to any court (and failure to account alone shall not be considered such a breach);
nor shall. trustee be required to obtain the order or approval of any court in the exercise of any power or
decision granted hereunder;
p. To allocate any generation-skipping transfer tax exemption from the federal generation-
~' >
d
'~-, Ca
~I
.v w
S~ a
V
skipping transfer tax to any property to which I am deemed the transferor under the provisions of Section
2652(a) of the Internal Revenue Code of 1986 and its successors, including any property transferred under
my will and any property not in my probate estate and any property transferred by me during life as to
which no allocation was made prior to my death, to the extent necessary to cause the inclusion ratios
applicable to such transfers to be zero;
q. To disclaim any interest in property without court approval; and
r. To do all other acts and things necessary or appropriate in the management,
administration and distribution of my estate or trust.
Page 4 of 6
ITEM 7: In the event any legatee or devisee named in this will dies under such
circumstances that there is not sufficient evidence to determine absolutely whether such legatee or devisee
survived me, I direct such legatee or devisee shall be presumed to have predeceased me and devise and
bequeath the gift in favor of that legatee or devisee to such persoxis and in such manner and in such
proportions as set forth in this will for distribution if the legatee or devisee predeceased me.
ITEM 8: Until distributed, no gifr or beneficial interest shall be subject to anticipation or
voluntary or involuntary alienation.
ITEM 9: I appoint my son, JAMES W. DAMS, Executor, of this my Last Will. Should
my son, James W. Davis predecease me, fail to qualify or cease to act for any reason as my Executor, I
appoint my son, PAUL K. DAVI5, M.D., first alternate Executor of this my Last Will. Should both my
sons, James W. Davis and Paul K. Davis, M.D. predecease me, fail to qualify or cease to act for any
reasons as my Executor, I appoint my daughter-in-law, JEAN B. DAMS, second altemate Executrix of
this my Last Will.
ITEM 10: I direct that my persanal representative or his successor shall not be required to
give bond for the faithful performance of his duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and
1
Testament, this .3 `- day of ~ u n G. , 2011.
_,~-~2uL ~S~ ~ ~ l uy
ALICE K. DAMS
Signed, sealed, published and declared by the above-named Testatrix as and for her Last Will and
Testament in our presence, who, at her request, in her presence and in the presence of each other, have
hereunto subscribed our names as attesting witnesses.
residing at
~ ~ d
esiding at ~~N
Page 5 of 6
PJ
~O~VIP/(~` ~~
(-~.a~.~ . ~ _I? X111 13
COMMONWEALTH OF PENNSYLVANIA )
ss:
COUNTY OF CUMBERLAND )
We, ALICE K. DAMS,
~~Or/'P ~. /~Ov~r and
~,itihry ~ Ci7Ne ,the Testatrix and the witnesses respectively, whose names are
signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the
undersigned authority that the Testatrix signed and executed the instrument as her Last Will and that she
had signed willingly, and that she executed it as her free and voluntary act for the purpose therein
expressed, and that each of the witnesses, in the presence and hearing; of the Testatrix, signed the will as I'i
witness and that to the best of his or her lolowledge, the Testatrix was at the time eighteen (18) years of
older, of sound mind and under no constraint or undue influence.
~) ~ t
ALICE,K. D.AVIS
Witness
Subscribed, sworn and aclmowledged before me Gl~s~ ~ if1G<~ ~Ne by
ALICE K. DAMS,^ _the Testatrix, and //,subscribed and sworn to before me by
_ ~hL° /? ~dry~/ and 9`~ ~ NE' ,the witnesses, this
___~ day of C~~ , 2011.
C"~
No ry Public (SEAL)
C M /lM1 ERN ti' Y 1-
t/dTA t SLAL
liss'Mlrie Coyna, Nptarµ pYbNe
Msmpq'sn toWrt4Ai0. ~wrtbertsntl, ' rtty
~Ytti ~; 14M IA,
Page 6 of 6