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HomeMy WebLinkAbout05-18-12PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAN_D_ COUNTY, PENNSYLVANIA Petitioner(s) named below, who is/are t8 years of age or older, apply(ies) for Letters as specified below, and in support thereof aver(s) the following and respectfully requests the grant of Letters in the appropriate form: Janet K. Culp Decedent's Information Name: Helen D. Kopp alk/a: a/k/a: a/k/a: Date of Death: 03111!2012 Fite No: 2i - ~ ~~ - ~~) 'i ~~ (Assigned by Register) Social Security No: Age at Death:. 87 Decedent was domiciled at death in Cumberland County, pA (State) with hislher last principal residence at 28 Westfields Drive, Mechanicsburg 17050 SilverSpring Cumberland Street address, Post OHice and Zip Code City, Townstp or Borough County Decedent died at Hamsburg Hospital Harrisburg County PA Street address, Posl Office and Zlp Code City, Townsh~ or Borough County State Estimate of value of decedent's property at death: !f domiciled in Pennsylvania ...................... All personal properly $ 5,000.00 If not domlclled In Pennsylvania ................ Personal property in Pennsylvania $ Knot domiciled in Pennsylvania ..........:..... Personal property in County $ Value ofreal estate in Pennsylvania....... TOTAL ESTIMATED VALUE $ 5,000.00 Real estate in Pennsylvania situated at (Aftach add;Nonal sheets, if necessary) Street address, Post Office and Zip Code City, Township or Borough County © A, Petition for Probate and Grant of Letters Testamentary Petitioner(s) aver(s) that he/she/they is/are the Executor(s) named in the Last Will of the Decedent, dated 05124!2006 and Codicil{s) thereto dated Stale relevant araanstartces (e.g., renunciation, death of executor, etc.) Except as follows: after the execution of the instruments} offered for probate, Decedent did not mar 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 adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. ® NO EXCEPTIONS ~ EXCEPTIONS ^ B. Pekj„d,Qn for Grant of Letters of Administration (If applicable) c.ta., d.b.n„ d.b.n.c.t.a., pedentelife, du2nteabsentia. duranfeminoritate If Administration, c.ta or d.b.n.c.ta., enter date of Will in Section A aboveand cQgrnlete list ~f hpir~. Except as follows: Decedent was not a party to pending divorce proceedin wherein the grounds for divorce had been established as defined in 23 Pa. C.S. §3323 (g) and was neither the victim of a killing nor ever adjudicated an incapacitated person. NO EXCEPTIONS ~ EXCEPTIONS 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 {attach additional sheets, if necessary): Name Relationship Address ,-- ~--- r-;, i:~:, - ct' ~, ~ ~!, ~' ' _~ ~.'i- , O,_ _. ~? r _ " ~:~ ~-_ t r ~ ~,~ a ~ -T, Form RW-02 rev. f0-11-20f i Copyri~'tt (c) 2011 form software only The Lackner Group. Inc. page 1 of y Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF Cumberland } Petitioner(s) Printed Name Petitioner(s) Printed Address Janet K. Culp 3608 Golfview Drive Mechanicsburg, PA 17050 Official 0.Jse Only -~, ~ -~ ~4 - ¢~ __ •. r ~~ i _ ~ - n7 __ 1 ~ .. r» C; --r ~', 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 thg D~e/cede~nt~etitloner(s) will well and truly administer the estate according to law. ''hh (~. . n _.~, Date 5 ( g ~-' Sworn tc or affirmed and subscribed before _ "'""`~jr _ Date me this ~ ~ day of ~~ I ~S~ yy (`~1 -~ L1 ( ' I r ~ `~,C 1 ~~1 ~ ~ ( ~ ~ \ >l ~ ~ Date By~ _..~-c•-.--~~~ _ Date For the Register BOND Required? ^ YES ~ NO """'~~~ FEES: Letters ..................................... ..... $ ~L ~) ~~ ( ~``i< )Short Certificate(s)..... .... _~ I •: f ~~ \ ( )Renunciation(s) ......... ..... ( )Codicil(s) .................... .... ( )Affidavit(s) ................. ..... Bond ....................................... ...... Commission ............................ ...... Other Automation Fee ...................... ...... `) ~~ L~ JCS Fee ................................. ...... ~:~ ~ ~. TOTAL ................................... ...... $ ~ C~ . r~(,. To the Register of Wills: Please enter my appearance Dy my stgnawre oetvw: Attorney Signature: Printed Name Ga . Ja es Esq. Supreme Co ~ ID Number: 752 Firm Name: James, Smith, Dietterick & Connelly, LLP Address: 134 Sipe Avenue Hummelstown, PA 17036 Phone: 7171533-3280 Fax: 7171533-2795 E-mail: glj@jsdc.com DECREE OF THE REGISTER Date of Death: _03111/2012 Social Security No: _ Estate of Helen D Kopp File No: _21 a/k/a: AND NOW, ~ ~(, `. ~ _ , in consideration of the foregoing Petition, satisfactory proof having beer/ resented before me, IT IS DECREED that Letters Testamentary are hereby granted to Janet K. Culp in the above estate and (if applicable) that the instrument(s) dated 05/24/2006 _ described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. , 'Register of Wills ~ -~ I ~ (/ ' i~ ` ~ i (~ i IrrI- Copyright (c) 2011 form software only The Lackner Group, Inc. '- ~'a9e 2 ~ 2 ,: , L+~~~~4L I~ECaISTR'AR' ~w~"~`~.~`°~'~C.a> ~" ~~,.~r ~~'f~.,; ~~'/`~.~NIN~iG: !t ins iller~a9 to du~:>iir~tc3 ?~~~~ .. ~ra,1, ~~=;r -ak~e~tl~~„~f - a ;2~1, ax~;;,1-~ Fc~~ (~,r tLr~ ~-rtili9~,1/ ° rii _~ ~~ '.~ pe/vrml in em ~~~ ~ It k .. I.I . - , `: ~~ ~ , ~-~ r - t _ „- ~ „~tl~,l~~„ ., J `r r~ ix~ -, - ~~'~ ~><1s.`N (",s ° ti ~" ~,~1.[,7,J(,FZ- ~~ ~, CX,',{ tiZ. ~ ~ a~ 7 .I ~i COMMONWEALTH Of PENNSYLVANIA • DEPARTMENT Of HEAIiH • VITAL pECORpS ~eorlua-Rr --~•"' Stale File Number: I. Decedent's Legal Name (First, Middle, last Suffix) , 2. Sex 3. Social Security Number 4. ate of Death IMO/Day/Yr) I$pell M l Helen D. Kopp f l gna 200-16-9108 Sa A L Bi h . ge- ast rt tlay IYrtl 56. Untllr l Year Sc. UIMlr 1 pa 6. Date of Birth (MO/Day/Year) (Spell Mpnthl ]a. Blrthplage lClry and Slate or Foreign Country) Months Dayi our Minutes Du9o1s PA 87 H s July 9, 1924 )h Binh lan lCOUn I p ry ga. Rnitlence (State or Foreign Country) Bb. Resltlence (S[rnt and Number - Include q t No l B p . c. Ditl Decedent flue in a Township? PA Bd. pnmentr keunryl 28 Westfields Drive rn, aecedent ri..ed in Cumber) ~o ge. Rnldence IZlp fodel ^NO, detttlen[ lived within limits of c 9. Ever In US Armetl Forcn] 30 Marital Sbtus at time of Oeath ^ Mardetl ~ Widowed Il. Surviving Spouse i Name (If wile glue name rior to n st ^ Ye l ® , p r marr f agel No ^ Unkrawn ^ Dhrorcetl ^ Never Married ^ Unkiww 1z. father i Name (FInL Middle, lest SuRix) 13. Mother's Name Prim t° First Marriage (First, Midtlle, Lastl Simon Dereskavich Tamosaitis lAa. Informant's Name 14b R k l . e t onship to Decedent Jan t E 1 lac. Informant's Mailing Atldrns (Street and Number, City, State, ZID Codel 1 g e . 012 dau ter 3608 Golfview Drive Mechanicsb P ` ° ................ wr ... ..... ..:. R Oeath acNnre m a Hosptal: mpalent . .. of pram atprrrtl somrwnere otne. man a Hoe nal: ... []~~ u ~sgce Faclli ' p ~ ry Decedent s HOAgJ ^Eme ry oorrs/putpatknt ^ Dead on ArrNal ^Nuning Home/Long-Term Care Faciliry n<n R (sDnlrrl ~ Other g _ 1sb. Farnlry Name pr not matmrtlon, gNe greet and number; ut. sty Dr Town, state, ana zip ceee 1sa. cDNnry or Dnth Harrisbur H it l osp a Harrisburg, PA DAU in ~ +__ 16a. MRMOtl of DlNwsltlon [~BU I ^ Cremation tfib. Date of Disposltlon l6c Plxe or Dl l l O . spos t on(Name of cemetery, crematory, or Dther place) ^Removal from State Donation ~ ._ _ anerlsprclryl Mar. 1 S, 201 St. Joseph Church Cemetery '~ Z ]64. Location of Dlsposkbn lClry or Town, State, arM Zipl 3)a. Signature of Funeral5ervke Licensee pr Person In Chxge °/Interment 1)b. llcenu Number $ DuBois, PA 4 F'D 011667 L 1)c Name and C k dd c . omp te A mi of Funeral Faclliry Mal zzi Funeral Hane 9 Market Plaza Wa : Mec i ~ cs PA 17055 Ig. Deatlent's Etlucatlon-check the box that best deuHbesthe 19. Decehnt of HlsWnic Or4ln -Check the 30. Decedents Race-[heck ONE OR MORE r l M h d xes to n g itate what ert degrn or level of school completed >t the Hme of tleath. box that best descHbee whether the decedent Me decedent consltlered himself or hersel to be ^ eth tl l . gra e w ess Is SDanish/Hlspanic/latlrw. Check [he "NO' White ^ Korcan ^ No di bma 9th 12th d p , - gra e box if tlxedent Is opt Spanish/Hispanic/Latlno. ^ BIacF or Alrkan American ^ Vietnamese ~Hlgh school rcduat GEO g ew COmpletetl Nn, not Spanish/NlspanlA)Latlno ^gmerican lndlanor Alaska Nature ^Other Nlan ^ Some college aedll but n° tle r , g ee ^ Yes, Mexican, Mexican American, ChlcanD ^ Asian Indian ^ Na[IVe Hawaiian ^ Asspciate degree le.g. M, Ail ^ Yes P rt 0.1 , ue o can ^ Chinese Guamanian or Chamono ^ Bachelor's tlepee (e.g. BA, AB, BS) ^ Yes Cuban ^ , ^ Flliplnp Samoan ^ Master's tlegrce le.g. MA, MS, MEnL MEd, MSW, MBA( ^ Yes, other Spanish/Hispanic/Latlnp ^ ^ Japanese ^ Other Pacifk Islander ^ Doctorate le.g. PAD, EtlD) or prafnslonal degne Ispearyl ^ goer fspeclNl .. MD DDS DVM LlB 10 Zl Decedent's Single qa¢Self-Des4nation~Chxk ONLY ONE to intlicate what the decedent considered himself or herself [o be. 22a.Decedent's USUal Occu ation-Indic t Whi p a e type of work te ^ IaDarieu ^ Samoan done tluri t f ng mos o working life. p0 NOT USE RETIRED. ^Black or Afrkan American ^Kpre ^Other Paclnc Islander ^ American Indian or Alaska NatMe ^ Vlet amese ^ Don't Know/Not Sure haEnernaker ~la^ ^ anrr AElan p Rrmeee ^ zzb. Kmtl or e~smreapntlNetry enmrer ^ ^Native Hawanan ^oeh<r lsp<dryl ^ Filipino ^ Guamanian or Chamono h~ REMS Zia-tgd MUST BE COMIlF1ED 23a. Date Pronouncetl Dead (MO/Day/rrl 23b. Signature of Perspn Pronouncing Death (Only when applicable) 33c. license Number BY PERSON WHO PRONOUNCES OR CERTIFlES DGTN 23d. Date Signetl IMO/Oay/Yr) 3a. Time of Death ::/// fitt ,~aN , // (( 1~ / W zS. Was Metllcal Examiner or Coroner COnlacted2 ^ Yes No CAUSE OF DEATH 2fi. Part 1. Enter the Shah of events-diseases, inlurles, or complicatlens~-that direct) ~ AD^`ovima[e y caused [he death. DO NOT enter terminal events sucn as cardiac arrest l i ~ resp erva . n[ory arrest, or ventricular Hbrlllatlon without s howing the etiology DO NOT ABBREVIAtE. Enter only one cause on a Ilne. Add adtlitipnal lion II n O ecesury nset to Death / / ' IMMEDIATE GUSE --------~-~-x a. %/~/~~ -- g ] ~/ /~ (Final tlisease or coMition D for uf [o ass consepu ofl -- resulting in death) ~r % y / /~ // Sequentially Ilst conditions, Due t° (pr as a nsequence ell: '~ -- LO if any, leading to [he cauu Ihted on Ilne a. Enter Me UNDERLYING GUSF Due to for as a wns -- e f quence o f. (disease or Injury roar F inlHrt<d the vents resuRlnB d. in tleath) ld {T. Due t° Ior az a consequence pN. -- S 36. Part II. Enter o[hrr5 vnifln t MItl t buts t d but not resulting In th<underlyiry cause given In Part I 2). Was an autopsy error etl) F ^ Yes No Zg. Were autopsy nn available tq complete the cauu of tleath) ~ Z9. II Female: 30 ^ Yes ^ Np Di . tl Tobacco Use Contdburc to Death? 31. ner of DeaN k,NN ,~9-/~NOt prcgnantwithln pas[year ^Yes ^Probably ,{ t l ~ a ura Homicide ~ ( ^ Pregnant at time or death No ' Q Accidens ^ P ^ ^Unknown N ^ ending invest) tlon Ot pregnant, butpregnant whhin a3days of death Sukide ^COUW not bedetennlnetl ^ Not pregnant, but Drcgnant 03 days to 1 year before death 33. Dale o/ lnfury lMD/DaY/Yr) (Spell Mpnth) ^ ^ ^ Unknown II pregnant within the pxt Year 33. time of Injury 34. Plate pf Injury Ie.g. home; conetruttlon site; fxm; school) 35. IncaHOn of Injury (street and Number, Ciry, Slate, Zlp Codel 36. Injury at WorN 3I. Ir transportation lnfury, SpeclrY. 38. Describe How Injury Occurretl: ^ Yee ^ DNVer/Operator ^ Pedestrian ^ No ^ Pasunger ^ other (Spnlry) 3 9a. Certiner (Check only one): Q'Lertifying physklan - To the best of my knowledge, tleath occurred due [o the causelsl and manner stated ^ PronountlngR[ertl(ying physlnan~To the best of de rred at the time,date, and place, and due to the causelsl antl manner stated ^ Medical Exa i f u m ner/ ofo / Is o/examina In inbn, death occurred at thy time, dale, aM place, antl due [a the cca u sels) and manner s[atM `e a signaurr ergertrer.: ~ ~ l a.~ 1-~' rHe of temper: .~l l ~~.~/ orange NU„Ipg/.lie iJ`-~~~~ 3 , 9b me, Addr n ZI ode o/Person Completing Cau th Z6 ' ~ , ~. 39<.D ned( o/DaY r) ,a 4 / / a/ // 0. Aegis[rars Distrkt Number a3 g ar' . u a2. Registrar FI a Oate IMo ay l 4 3. Amendments ~+sJ ~~ } , ~ ~ ice: -C CD -~ ~ C`~ `'~~ appa,e°n Permit N° ~7dy 3'75" H1Dfi.1A3 pkv D?/zav Article Two Appointment of My Personal Representatives Section 1. Nomination of My Personal Representatives I appoint the following to be my Personal Representative(s) in the order of priority in which their names appear: JANET K. CULP; THEN WILLIAM M. KOPP; THEN JAMES E. KOPP; THEN ROBERT C. KOPP If, for any reason, the Personal Representative(s) named above are unable or unwilling to serve, the next successor Personal Representative(s) shall serve in the order of priority listed until the list has been exhausted. Unless otherwise specified, if Co-Personal Representatives are serving, the next named successor Personal Representative shall serve only after all of the Co-Personal Representatives cease to act as Personal Representatives. Section 2. Waiver of Bond No bond or undertaking shall be required of any Personal Representative nominated in this Last Will. Section 3. General Powers My Personal Representative shall have full authority to administer my estate under the laws of the Commonwealth of Pennsylvania relating to the powers of fiduciaries. My Personal Representative shall have the power to administer my estate under the Pennsylvania Probate, Estates and Fiduciaries Code. Article Three Disposition of My Property Section 1. Estate Planning Letter or Memorandum To the extent permitted by state law and not necessary to fully utilize my Unused Applicable Credit Equivalent, my Personal Representative shall distribute such of my personal or household items to such persons as I may direct by a written instrument signed by me and delivered to my Personal Representative. Section 2. Distribution to My Revocable Living Trust I give all the rest, residue and remainder of my property of whatever nature and kind and wherever located to the then acting Trustee(s) of my revocable living trust of which I am a Trustor known as the: HELEN D. KOPP AGREEMENT OF REVOCABLE TRUST dated November 9, 1990, and any amendments thereto I executed said revocable living trust prior to the execution of this Last Will. Section 3. Alternate Disposition If my revocable living trust is not in effect for any reason, I give all of my property to my Personal Representative under this will as Trustee who shall hold, administer and distribute my property as a testamentary trust the provisions of which are identical to those of my revocable living trust on the date of execution of this Last Will, or as thereafter amended. Article Four Death Taxes Section 1. Definition of Death Taxes The term "death taxes," as used in this will, shall mean all inheritance, estate, succession, and other similar taxes that are payable by any person on account of that person's interest in the estate of the decedent or by reason of the decedent's death, including penalties and interest, but excluding the following: a. Any additional to the federal estate tax for any "excess retirement accumulation" under Internal Revenue Code Section 4980A. b. Any additional tax that may be assessed under Internal Revenue C"ode Section 2032A or 2057; and c. Any federal or state tax imposed on a Generation Skipping Transfer, as that term is defined in the federal tax laws, unless the applicable tax statutes provide that the Generation Skipping Transfer Tax is payable directly out of the assets of my gross estate. Section 2. Payment of Death Taxes Pursuant to the terms of my revocable living trust, all death taxes whether or not attributable to property inventoried in my probate estate shall be paid by the Trustee from my Trust. However, if my Trust does not exist at the time of my death or if the assets of my Trust are insufficient to pay the death taxes in full, I direct my Personal Representative to pay any death taxes that cannot be paid by my Trustee from the assets of my probate estate by equitably prorating and apportioning those taxes among the beneficiaries of this will. Unless specifically provided otherwise in my Trust, all death taxes incurred by reason of assets being transferred outside of my Trust or probate estate shall be assessed against those persons receiving such property. Article Five General Provisions Section 1. No Contest Clause If any person or entity singularly or in conjunction with any other person or entity, directly or indirectly, contests in any court the validity of this Last Will including any codicils thereto, then the right of that person or entity to take any interest in my estate shall cease and i:he demise of that person (and his or her descendants) or entity shall be deemed to have occurred prior to mine. Section 2. Captions The captions of Articles, Sections and Paragraphs used in this Last Will are for convenience of reference only and shall have no significance in the construction or interpretation of this Last Will. Section 3. Severability Should any of the provisions of this Last Will be for any reason declared invalid, such invalidity shall not affect any of the other provisions of this will and all invalid provisions shall be wholly disregarded in interpreting this Last Will. Section 4. Governing Law This Last Will shall be construed, regulated and governed by and in accordance with the laws of the Commonwealth of Pennsylvania. I signed this, my Last Will, on MAY 2 ~} Z~O6 HELEN D. KOPP ATTESTATION CLAUSE On this ~~~~ ~ ~~~~ ,HELEN D. KOPP, Testatrix, personally Published and Declared the foregoing instrument, as and for her Last Will and Testament, in the presence of each of us and all of us together, who, at her request, in her presence, and in the presence of each other, also signed the said instrument as witnesses. We further state that each of us believes that at the time she executed the foregoing instrument she was of sound mind and memory, of lawful age, and did so execute it as her own free act and deed and not under the constraint or undue influence of any person. r ~ls ~~ W1t178SS ~ 1%u ' /~u`~ '~ Stree Address C~ /~ l-7 ~ `~ ry Ci y, State, Zip ~~~ .,~,~.Q. ,_---.. ~; yv~mess j ~r~/ ~~x~h f' ~J~( Street Address City, State, Zip COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF DAUPHIN , We, HELEN D. ~l~ ~ KOPP, J~ - ~~.J~~ ~~~.~~ and r ~' L~ ~ ~ 1 ~C~ ~'~U~.- ~ ~ d r~ _ ,the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being duly first sworn, do hereby declare to the undersigned authority that we were present and saw the Testatrix sign and execute the foregoing instrument as her Last Will; that the Testatrix signed it willingly, or directed another to sign it for the Testatrix, that it was executed as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the presence and hearing of the Testatrix signed the Last Will as a witness; and that to the best of our knowledge the Testatrix was at the time of sound mind and memory, of lawful age, and under no constraint or undue influence. HELEN D. KO P ' _-- Wi ess ~ ~.~ 'rl 2. ~ 1~~ ~~~ ~ t.(~-~Q~ . W~ness ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN SS On this, MAY 2 4 2006 before me a notary public, the undersigned officer, personally appeared GARY L. JAMES, Supreme Court Identification Number 27752, known to me (or satisfactorily proven) to be a member of the bar of the highest court of said Commonwealth in which execution of the Will took place and certified that he was personally present when the foregoing acknowledgement and affidavit were signed by the testatrix and witnesses. IN WITNESS WHEREOF, I hereunto set my hand and official seal. ~, . ~ ~ ~ 1 N TARY PUBLIC OATH OF SUBSCRIBING WITNESS(ES) REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of Helen D. ~~ ~, ::~ J `" r~'s -x' -r-~ - .-~ -. ;: ;g.a ,Dec~sed ~i ~ ~ •--~ r'T ~: ~ --rs Jessica Multin -Q ~ + ~•'' D c-:; ..,,"! (each) a subscribing witness to (F'nM Namais) the ®Will ^ Codicil{s) presented herewith, {each) being duly qualified according to #aw, depose(s) and say(s) that she I he I they was /were present and saw the above Testator !Testatrix; sign the same and that she 1 he 1 they signed the same and that she / he /they signed as a witness at the request of the Testator /Testatrix in his /her presence and in the presence of each other, ~l r n , ~-~C.~ ~ Jessica Mullin 2785 Ranchview Lane North Unit 7 (sr*eea Address) giymouth, MN 55447 ~c~, scare, zpi rs~c~r~) (SheelAddrrsa) (City, Srek, zIp) Executed in Register's D;rfrce Executed out of Register's Office Sworn to or affirmed and subscribed Sworn to or affirmed and subscribed before me this-----._da - ~' Y before me this ~ `~' day of of A~ r~ 1 Z~ i Z Deputy for Register of Wi#Is Notary s'ubi~c My Commission Expires: ~~2.2 ~Z G i' ~' (Signature and seat of {yataty a other otfirlalq~ fified to adm inrsler oaths. Show date d expirati0rt of tJatPry a COntmisaron ~ MARISSA SULLIVAN Notary Public State of North Dakota My Commission Expires Sept 22, 2017 NOTE: To betaken by Officer authorized to administer oaths, Please have present the original or copy of instrurnent(sy at time of nofarizatlon. Farm RW-03 Rev. f0-13-YOO6 copyr~M (c) 200s tom, sonwa,e only T!ra lackr>g Grovp. Fnc, OATH OF SUBSCRIBING WITNESS(ES) REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of Helen D. M. Gail Geyer Name/s) n _. - ~- ~ ~ ~. r.~, --; ,, _,-' D~eased-~ z c'' '~- ~ c -I _~ L-i r _ . ~; -y r~ _ T r ~-~ l.~ (each) a subscribing w itne~s'`s to the ~ Wi~~ ^ 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 at the request of the Testator /Testatrix in his /her presence and in the presence of each other. (Signature) Palmyra, PA 17078 (City, State, Zip) (Street Address) (City, State, Zip) Executed in Register's Office Executed out of Register's Office Sworn to or affirmed and subscribed Sworn to or affirmed and subscribed before me this day before me this ~ ~~ day of of ~~ l Z v~ z- Deputy for Register of Wills Notary Public My Commission Expires: /1- $ -1 L (Signature and seal of Notary or other offiGal qualified to administer oaths. Show date of expiration of Notary's commission.) COMMONWEALTH OF PENNSYLVANW Notarial Seal Lisa R. Barker, Notary public City of M~Sburg, Dauphin County My Commission Ex ire N p s ov. 5, 2012 NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of notarization. Form RW-O3 Rev. f0-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc. 113 West Cherry Street (Street Address)