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HomeMy WebLinkAbout06-28-12Res~_ PETITION FOR GRANT OF LETTERS REGISTER OF WII..LS OF CUMBERLAND COUNTY, PENNSYLVANIA Petitioner(s) named below, 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 Information ~-7 Name: ELMER H. WERTZ File No: (j~~ ~ ~~ - ~ / ~~ a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: 204-OS-1408 Date of Death: Mav 14, 2012 Age at death: 92 Decedent was domiciled at death in Ctmberland County, penngylvania (state) with his/her last principal residence at 5525 Wilson Lane. Mechanic sbure 17055 Lower Allen Township Cumberland Street address, Pod Onlce and Zip Code CHy, Township or Boroag6 Coaaty Decedent died at 5525 Wilson Lane. Mechanicsburg , 17055 Lower Allen Township Cumberland PA Street address, Pmt Olflce anti lip Code Clty, Township or Boroogh Connty State Estimate of value of decedents property at death: If dontk!!ed in Pennsylvania ..................... ....... All personal property $ 500.000.00 If not damkiled in Pennsy[vania ................. ....... Personal property in Pennsylvania $ ljnat damkiled in Pennsylvania ................. ....... Personal property in County $ Value of real estate in Pennsylvania ............... .......................................... $ TOTAL ESTIMATED VALUE.... $ 500 000.00 Real estate in Pennsylvania situated at: None. (Attach additional sheets, if necessary.) Street address, Pod Otflce and lip Code City, Township or Boroueb Couuty A. Petition for Probate and Grant of Letters Testamentary Petitioner(s) aver(s) hdshattitagis/awths Executor(s) named in the last Will of the Decedent, dated March 17, 1975, and Codicil(s) thereto dated N/A . Carah Mnr~h~ Warn rlir~l nn l~rrrmhrr 10,~fMR. Stste relevsat circumstances (eg. renunciation, death of execator, eta) Except as follows: after the execution ofthe instrument(s) offered for probate Decedent did not marry, was not divorced, was not a party to spending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(8), 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. Petition for Grant of Letters of Administration (If applicable) c.t.a., d.b.n., d.b.n.c.t.a., pendente life, durance absentia, durante minoritate If Administration, c.tm or rLb.n.c.ta., 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 for 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 hes/have ascertained that Decedent left no Wilt and was survived by the following spouse (if any) and hytg(attach additional sheets, ifnecessaty): ° tv Name Relationshi Address ,- rr ~ C ~ ` (_ .,y lT ~~ rTl Farm nw-oz rev. l0/71/201 / Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } ss: COUNTY OF CUMBERLAND } REGIS;Eri ~~~ tM,~ kc 2Ut2 JUt128 AM 8~ 5? Petitioner(s) Printed Name Petitioner(s) Printed Addres' ':.C ,i . -. RobeR H. Wertz 'v 900 Cocklin Street Mechanicsbur PA 17055 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 lmowledge and belief of Petitioner(s) and that, es Personal Representative(s) of the Dce tt, the Petitione s) wil well at tnrly administer the estate according to law. Sworn to or trmed subscribed before Date~- me thi ay t~~" Date By: Date or Re ' r Date BOND Required: Q YES Q NO FEES: Letters ...................... $ 410.00 ( 5) Short Certificate(s)...... 20.00 ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( ) Affidavit(s)........... . Bond ........................ Commission ................. . Other Will ........ 15.00 ........ Automation Fee ............... 5.00 JCS Fee ..................... 23.50 TOTAL ..................... $ 473.50 To the Register ojWilis: Please eater my appearance by my signature below: Attorney 'nature: Printed Name: Marlin R. McCaleb, Esq. Supreme Court ID Number: 06353 Firm Name: Address: Law Offices -Marlin R. McCaleb .219 Ee_at Main Street P_ n_ Rnx 230 Mechanicsburg. PA 17055-0230 717-691-7770 117-691-7772 marlinmrraleh ~ man rnm Phone: Fax: Email: DECREE OF THE REGISTER Estate of ELMER H. WERTZ Ftle No: ~~ ~~~- Q /~~ a/k/a: ~ AND NOW, satisfactory proo 2Q ~ , ~~ ~C/ , in consideration of the foregoing Petition, been presented before me, IT IS DECREED that Letters Testamentary are hereby granted to Robert H. Wertz in the above estate and (if applicable) that the instrument(s) dated March 17. 1975, described in the Petition be admitted to probate and filed of record as the last Wil (and Codici s)) of Decedent. Reg' er of Wills For,„ RW-oz rev. ioainoJJ Page 2 of 2 vine 2n< REV tq/~'\ _ _. _ _ _. __. _ _ _ is LOC ~~AR'S CERTIFICATION OF DEATH W i~,a,~~~to duplicate this copy by photostat or photograph. 1 C. '~~ t Fee for this certificate, $6.00 Z~~2 ~UH 28 AM a• ~J This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original l.rl.t; li ~ certificate will be forwazded to the State Vital ~ ~'IS t..~~T Records Office for permanent filing. P 18 3 8 9 6 0 3 RIAN~ ~~~~ ~ ~~~ ~Q_ MANY 1 71012 ~\ Certification Number 't ] Typ./Pnm In ..// p.r... .nt 3g Local Registraz Date Issued COMMONWEALTH OF PENNSYLVANIA . pEPgRTMENT OF NEgLTN ~ VITAL RECORDS l`COTf lit wT __._____ _-_ __- ~. ~~. .. .. Stab Flls NVmber: 1. Oepdem's Ls{il Nams (First, Mltldls, Lest, Suffix) 2. Sa% i. Social SacuNN Number 4. Date eI DeeM fMO Ow/Vr) (Spell Mo) Elm H W t er _ er z Male 204-05-1408 May 14, 20'12 Sa. A{e-last {IKhdw (VR) 9 . UnWr 1 Year Sc. Untler 1 De {. Date of Birth (MO/Ow ear (Spell Mon[h ) Irth ap (City tl StaL or F Country) Men<M D ~ •o ~ ~g 92 r nest wn, ~ iy, Heur, MmYte. December 21 , 1 91 9 7b. BlKhpliee (County) gi. ReN nqi (Sbtf or FeMI{n <oun[ry) R 1 nce Street entl NVmber - Inslutls Apt No.) {c- Did Deptlsnt LIVe In • 1 T Pen> ® lv 5~~25 ~ 711 i 'Y3'~ a;°i" ~ an r1 a i r Allen son Lana (aYU, dapeent lived In { rvp ~`umber~ and M. Roltlsncs (ZIP COdi) Q No, d«adsnt Ilyetl wlMln OmIK of sIN/hero. 9. Ewr In US Armed orces 10. MarMl {ti[Yf et Tlme of DeaM Mart a WI owe 11. SurvNln{ Spouse's Name (If wNS, {Ne name prier <O first m+rria{e) ® Yea Q NO Q Unkltgwn Q DHerced Q Nwsr MirHSd Q Unknown 1 t • • Nam Flrsy Itl le, last, Stdflx) 1 Mo[h 'f Na 1 p FI Mirtli{e (Flat, Middle, Lart ~~mer ~. Mertz 3us~n '€'fgBS@;~t 14 In tine f Name 36 gala[lOns Ip t0 Decedent 14q. IMerm+nt's Melling Atldreff (Street entl Number, Ctty, SLSN alp Cpdef i~io art H_ Wertz bSon 900 Cocklin St Mechanics~ur4 n . ~He 1/Death Occurred ~In a HotpMl: ~( InPi[lent .I~Death OccVrrstl SpmlWMre other Then • NosPital: Pipe Rlty ~Oewd t' en sNeme -~~~ E rne sn App OVt etlsrK Deed en Amlysl N Vrsln Heme/Len -Term Ore Fadlity Other (SP4gl ) 13b. Fad Ity Neme I et Inrtttudpn, tNS atfeet entl numwry SSc. tty or awn, State, Pnd 21p Cotla 13d. County v Dsat Lebanon VA Medical Center Lebanon PA 17042 ~, , , Lebanon 1 +. Met o1 Dlspvfltlon puHal demat on 1{b. Dab W Difpqs1 ~Ion Igc. plea o Dlaposttlon (Nsme of cemetery, crematory, or ether place) p wemewd rrom eta:. pDeneelon Mayl 6, LOl2 HFH Crematory O[hsr 5 ) igtl. LOp<lon OHpefttlon (<Ity or Ow ,Stab, and 21p) 17 nature pf u re srvlce Licenses r Pfffpn In Ch+ Interment 1 b. LIp Grantvi116, PA 1 7028 F a'3r~'?3~ ~ O 2-L STC. Nsme entl Gmpiste Atldre+a of FunsM R+clitty ~ 08 w timberland PA 17070 U. Decedent's tlYeatbn - CMCk tM box toe[ st bcAMs [M1e 19. Deptlan<Of Hispanic Orl{In - C eck [he 20. Dsp cot's Rsca - Chs< ON! OR MORE reps t0 lntlicats wMt hyh+at de{rse or Iwsl of school wmplsted s[ th ri f tl th e ms o ee . box [hat best describes whether [ha tlspdem the decedent pnsltleretl himself or nerself to M. {th {rstle Or lea I 3 i h ^ " i Pen f /HlsPanic/Le<InO. check the NO ~ Wnl[! Q No diploma, Hth - 13th {tads hex If dwedsnt is net SpinlaNHlap+nic/4tlno. Q Black or Afrlpn Am i er can Q N tnamese Q HI{h uhpol {rotluaM or GED wmple[etl NO, not Sp+nish/Hlapsnic/4tino Q gmsrlc+n Indian pr AISSM NstlVe O[ner Aslen Q Some wIN{e erstllt but ne tle{ref . Q Vea, Ms%ICin, Msxlcsn American, Ghic+np AasoclaN tl Q Afisn Intllan Q Yree (a-{. M, AS) Q Y+F Puerto Rlpn Q ~im~ 1 a , Q Chin.se Ou n ~n o r CMTOffO Q B{pMlor'f tle{ree (s.{. AA, AB, BS) Q Vef, Cuban Q FIIiPIno ' Q Semean Q Master s degfN (a.{. MA, M3, MEnt. MEd, MSW, MBA) Q Vet, other Spenlsh/Hlapenl4LKlno Q JaPSnese O Other Pitlflc Islander Q Dettorip (s.g• PhD. E!O) or Profattlenal dgre+ (Specify) Q Other (SpsclN) OVM JO 21. Os en[ f SIngN Rap Ssl/-DSSi{nMlon -Check ONLY ON! tP In (cats whet the decetlen[ consltlerod hlmaslT or herself to be. 22a. piceden['z Usual Occupatbn _ Intlluts type Of work $) Whtti Q Ja anese p 0 Samoan done durlrtg mOrt Of workln Ilh. DO NOT USC RETIRED. Q Black orAMCan Amsltpn Q Korean Q Other Pscifle Islantlsr { Q AmeHpnlndlen or Al+aka N+<IVe oVietnem.,s pDe,:t«npw/Not sYr. Director o£ Pub11c Work Q Arlan Intllin Q Outer 4sian O Refused 22b. Kind of gwlnesa/Intlus<ry Q Chlnafe Q NPHVI HPwalian Q Other (SPecINj p Flllplno paY.m.nl.n pr rJlimpno Borough of New Cumbarla gY P[IS{ON tlllsl0 pgONOVNC{S OR D i. • roneunce ss Mo w r anon pouncing at On w M aPP My c. Upnse NVm er DlRTIN!! ~~J~ ~T ~ 3{d. Dip 31{netl (Mp pw/Yr) 24 t7 1 !/ ~/ _ . 0 Ossth tea ' , • "~ ~ O P of Medlcsl Eximinir Or Coroner ContaRadt Q Vef No CAUSE OF DEATH Appro%Im+te 26. Per[ 1. Enter<M chain el ~-_diseafea, Injuries, or complica[lons-that tliretrtly puptl the de+tn. DO NOT enter terminal wants fuck ss cartllec +rrs t E s interval: rispiratery arrest, or ventricular flbrlllatlpn wtthoVt showln{ the e[IOlow. DO NOT ABBREVIATE. Engr only ens puss on • line. Add atlditlonal Iinp N necessary Onset [o De+tn IMMEDIATE GUSE -•-•-------a a. C ^ ~~ 1 c- /4rr S~ ~:- ~ k .~ {-~ ~L f ~ ~I C ~t~F,,`}Ft Ls~~ ~!- ~ ~I l~ (Final tllNit! Or COndltlOn DY! LO for of a cpnsequlnp pf): rssulHn{ In death) jJ''''~~ b. IC.GGOI'r0.~f'J FaL1/H /LG~ J Sequentl+IM Iltt condttlont, Due to (er as • Consequence OI): i If anY, liitling [e fhs uuse , listed pn Ilne a. Einar the c UNOggLY1NO CI.US! Due tp (pr as s conflq Vence efJ: ' (tllsiife or INury that InIV+Nd the wenH risul[In{ tl. In tluth) LAST. Due to (vr as a confOquenpe ef): 1 26. part 11. Enter other but not roaulLtng In the underlyin{ cause glV+n In PaR I 27. Was an autoPri~Perfermetli Yes No 2g. Were eutoPw flntlings wal a $ to mmplste the cause p1 derth? 29. H Female: Y s No 30 Oltl Q Not Ph{pint within Past War . Tobacco Usi Contribute f0 DeathT 31. Manner of Death a Q prainant at Hme Ot dsKh Q Ves probably Q No ~ Unknown ~ Natural Q Nomlcltle Q A tl J Q Not Pregnant, bYt Pregnant wttM1ln 42 d+VS of deetM1 cpl ent Q pending Investl{a[lon r Q Not Pregnant, but Pregnant 48 tliYS t0 1 Year bebro deetM1 D Unknown K pro{nsnt wlCnln the past year S2. De<a e/ In u ) 1 ry (MO/DSy/Yr) (Spell Mont Q Suicide Q COUItl not be determined 33. Tlm! o11nJYry 34. play o/ Injury (e.g. hems; rons[ructlon sits; larrrt; schooR 35. Location of Injury (Street and Number, CIN. Seta, 21p Cotle) 36. Injury at Work 3>, I Trenspor[Klon InJury, SpeclN: 38. Describe How InJury Occurred: p Yea p Driver/Operator p Petles[nin Q No Q Piefangar Q Otnar f3peclN) 39a. Certmsr C eck Only One): ~1 CertlNln{ Pnyalclan -TO tna b+st vT mY knOWletlge. deaM xcurred due [o the c+useft) and Tanner statetl Q Pronounclry By GftlNln{ phytlclan -TO Ms best of my knowletlgs, death occurred at tns [line, dots, and place, and due tp the pace(s) and manner stated Q M tll l E l e p wm rter/COronlr- On <ne heels of wiminatlen, end/or Investl{ation, In my PpinlOn, deetM1 occurred st th. rim., d+p, and Paso, and dos to tM c.uslfs) +n d mennlf rtatld r ~ 31{nature O/ prtMer: Title o/ certlflert~ C LlceMe NumberQ t'~ O O R OQ>] 3Pb. Name, A NL an P <otle P peraen Cpmpletln! GYfe Of DeaM (Item 26). G~ 3PC. Oe<a Slgrted M ry a ( I ~ Z- e errs rtr Ym ~ /~ 1. eg attar t tore 42. egi r ~i~ } ~ / - / 7 tl i /~ 43. Amendments 3 / DispesltlonPSrmlt NO. ~T TLJ~~~ N105-143 REV 07/2011 d ~ . . . , !~ - 7t ~" LAST WILL AND TESTAMENT o N OF ~- - ~-, C ELMER H. WERTZ ~ ~:' wNw :4 w 8Ctl M~ ~."` uWr I, ELMER H. WERTZ, of 1003 Bridge Street, Stew Cumberlanehj Pennsylvania, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time made. ITEM I: I direct that all inheritance ~2 n^^~ 4I ~. ~ -_ ". and estate taxes becoming due by reason of my death, whether such taxes may be payable by my Estate or by .any recipient of any property, shall be paid by the Executor, from property passing as part of the rest, residue and remainder of my Estate, as an expense and cost of administration of my Estate. The Executor shall have no duty or obligation to obtain reimbursement for any such tax even though on proceeds of insurance or .other property not passing. under this Will. In the absolute discretion of the Executor, such taxes may be paid immediately or may be postponed on future or remainder interests until the time possession thereof accrues. to the beneficiaries. ITEM II: I direct the Executor. to pay expenses of my last illness and .funeral expenses from property passing under this Will as an expense .and cost of administration of my Estate. 'ITEM III: If my wife, SARAH MURPHY WERTZ, .. survives me, I give, devise .and bequeath to her alT my property, .real, personal and mixed. Page 1 of 5 pages. - v~" ITEM IV: If my wife, Sarah Murphy Wertz, does not survive me, all my property, real, personal and mixed, shall be divided into as many shares as required in order to make the following disposition, and (a) I give, devise and bequeath one such share to my son, ROBERT H. WERTZ, or to his issue per stirpes; (b) I give, devise and bequeath one such share to my son, JAMES M. WERTZ, or to his issue per stirpes; (c) I give, devise and bequeath one such share to my daughter, SANDRA WERTZ WALLACE, or to her issue per .stirpes; and (d) I give, devise .and bequeath .one such share to my son, NED C. WERTZ, or to his issue per stirpes. ITEM V: In settlement of my Estate, the Executor shall possess, among .others, the following powers: (a) To vary or to retain investments, when. deemed desirable by the Executor, and to invest in bonds, stocks, notes, real estate mortgages or other securities or in .other property, real or personal, without being restricted to so-called "legal investments" and without being limited by any statute or rule of law regarding investments by fiduciaries; (b) In order to effect a division of the principal of my Estate or for any other purpose, including any final distribution,. the Executor is authorized to make said divisions or distributions of the personalty and realty, partly or wholly in kind, at a fair value determined at the date of division or distribution, and if it appears. desirable Page 2 of 5 pages . _ ~ ~ to partition any real estate,. the Executor is authorized to make, join in and consummate partitions of lands, voluntarily or involuntarily, including giving of mutual deeds, recog- nizances, or other obligations, with as complete powers as an individual owner in fee simple; (c) To sell, either at public or private sale .and upon such terms and conditions as the Executor. deems advantageous. to my Estate, any or all real or personal estate or interest therein owned by my Estate severally or in con- junction with .other persons or acquired after my death by the Executor, and to consummate said sale or sales by sufficient deeds or .other instruments. to the purchaser or purchasers, conveying a fee simple title, free and clear of all. trust and without obligation or liability of the purchaser or purchasers. to see to application of the purchase money or to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings which may be necessary or desirable in performing any power conferred upon the Executor in this paragraph or elsewhere in my Will; (d) To mortgage real estate and to make leases of real .estate; (e) To borrow money from any part, including the Executor, in order to pay indebtedness of mine or of my Estate, exgenses of .administration or .inheritance, legacy, Page. 3 of 5 pages . ~~~met~ 7" • V~~~ estate and other taxes, and to assign and pledge assets of my Estate therefor; (f) To pay all. costs, taxes, expenses and charges in connection with the administration of my Estate; (g) To vote any shares of stock, which form a part of my Estate, and .otherwise to exercise all powers incident to the ownership of such stock; (h) In the discretion of the Executor, to unite with other owners of similar property in carrying out any plans for the reorganization of any. corporation or company the securities of which form apart of my Estate; and (i) To do all .other acts, deemed necessary or desirable, for the proper and advantageous management, investment .and distribution of my Estate. ITEM VI: Any person who shall have died at the same time as Testator, or in a common. disaster with him, or under such circumstances. that it is difficult or impossible to determine who died first, shall be deemed to have predeceased him. ITEM VII: If, at any time, any minor shall be entitled to receive any funds hereunder, FULTON BANK (a bank with its principal office in Lancaster, Pennsylvania, and with an office in Harrisburg, Pennsylvania) or its successors, shall act as Guardian Page 4 of 5 pages. ~- G of the .funds payable to such minor .and shall have full authority to use such funds in any manner it shall. deem .advisable for the best interest of such minor. ITEM VIII: I hereby nominate, constitute .and appoint my wife, SARAH MURPHY WERTZ, to be the Executrix (designated herein, for. convenience, as "Executor"). In the event of her death or inability or refusal to serve, I nominate,. constitute and appcint ROBERT H. WERTZ to be the Executor. In the .event of his death or inability or refusal to serve, I nominate, constitute and appoint, JAMES M. WERTZ, to be the Executor. The Executor shall not be required to give any bond or bonds. IN WITNESS WHEREOF, I have set my hand .and seal. to this my Last Will and Testament, consisting of this .and the preceding four (4) pages, at the end of each page of which I have also set my hand for greater security and better identification this / 7 day of ~~~, 1975. Page 5 of 5 pages. V, (SEAL) mer H. Wertz We, the. undersigned, hereby .certify that the foregoing Will was signed, sealed, published .and declared by the above-named Testator as and for his Last Will and Testament, in the presence of us, who, at his request .and in his presence and in the presence of each .other, have hereunto set our hands and seals. the day and year above written, .and we certify that, at the time of the. execution thereof, the Testator was of sound and disposing mind .and memory. EAL) Residing at: 3 /'~q ~~ ~~ \J~ Vim. ~ _ J ~' (SEAL) Residing at: ~ ~~10 ~ l (SEAL) Residing at: J`r3 S '-`~"~ ^~-~ /~- 7/ ~ f~~~EC? ~FiCE OF REC~~<<~, ~t ,YIIL~ 2012 JUN 28 AM 8~ 57 OATH OF SUBSCRIBING WITNESSES ~•~.~ ~~ 1'S COURT Ck1~lIBEFO.AN~ CO•. PA R,~GISTER OF WILLS C IMB R AND COUNTY, PENNSYLVANIA Estate of :Elmer H. Werti _ Deceased John Hav a s ) a subscribing witness to (Print Names) the ®Will ©Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that ~li1iX he /ltlig~ was /~~ present and saw the above Testator / T24d~itf~ sign the same and that ~( he / t~XX signed the same and that ~~~ / he /~q~ signed as a witness at the request of the Testator /x'6esfahu~c in 7txx~t his presence and it (Signature) (Street Address) (City, State, Zip) Executed in Register's Of)`ice Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills (~'treet.taaress/ Mechanicsburg, PA 17050 (City, State, Zip) Executed out of Register's Ojj`ice Sworn to or affirmed and subscribed before me this ~~ ~ day `~~ Notary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or ~ ~~Q~ Nohrld SeN Form RW-03 rev. 10.!3.06 Mi1Nf1 R' ~~~ ~Y ~'~ MedtNMaburp Boro, CulrtberlarM County My CamdaYon 0lt:. 14, 2014 s~teEa, peahsrwuw rassoo~rton of NdMR?>3 l ~ - ~/~ RF~O~?DcC) ~=FiCE ~ REGiS~cR ~~ ~1~1;.;5 2a~z ~uN Zs an s= s~ OATH OF SUBSCRIBING WITNESS(ES) ;,; ~; ,; _ ORPHAN'S COiJPsT REGISTER OF WILLS ~MB~LAN~ ~"' ~ CUMBERLAND COUNTY, PENNSYLVANIA Estate of Elmer H. Wertz ,Deceased James A. Ulsh ~lloh) a subscribing witness to (Print Name/sJ the ®Will ^Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that ~tt€X he i~il~dt was / ggp7~ present and saw the above Testator ~~€ sign the same and that ~'s1L~C/ he /X9iajr signed the same and that ~~/ he /~ signed as a witness at the request of the Testator / '1~rifc in $$rX/ his presence and in the presence of each other. (Signature) (Street Address) (City, State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed before me this of (Signature) James A. Ulsh (Street Millersburg. PA 17061 (City, State, Zip) Executed out of Register's Office Sworn to or affirmed and subscribed day before me this 12-x- day of 2b r zr . Deputy for Register of Wills N tary Pu My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) NOTE: To be taken by Officer authorized to administer oaths. Please have present the original copy of instrument(s) at tlme of notarization. ODMMAONWEN.TH OF PENNSYLVANIA Notarial Seal Form RW-03 rev. 10.13.06 Batty Mn Nd•7ullan, Notary PuWk Venn Twp., Perry t7ounty phr Gpnmissbn Expkes Jan. 28, 2014 Member. PenravNanla A~Odatlon of Notaries