HomeMy WebLinkAbout07-20-12 (2)150561143
-~ REV-1500 Ex(°'-'°' .:
PA De artment of Revenue -~ OFFICIAL USE ONLY
p pennsylvania County Code Year File Numbar
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO 80X.280601 INHERITANCE TAX RETURN 21 12 0 0 7 3
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
168 14 3600 01 06 2012 05 21 1923
Decedent's Last Name Suffix Decedent's First Name MI
GOOD MARY A
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return
^ 4. Limited Estate
® g Decedent Died Testate
(Attach Copy of Will)
^ 9. Litigation Proceeds Received
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
^ 2. Supplemental Return
^ 4a. Future Interest Compromise
(date of death after 12-12-82)
^ ~ Decedent Maintained a Living Trust
(Attach Copy of Trust)
^ 10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
^ 3, Remainder Return (date of death
prior to 12-13-82)
^ 5. Federal Estate Tax Return Required
~ 8. Total Number of Safe Deposit Boxes
^ 11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephgrt4 Number c~
HAMILTON C DAVIS 717 53213 ^' ~~
First line of address
20 EAST BURD STREET
Second line of address
SUITE 6
City or Post Office
SHIPPENSBURG
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j{,S` USE 01~_Y
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DATE FILED
State ZIP Code
PA 17257
Correspondent'se-mail address: hdaVlS@ZUllinger-DaVIS.COm
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE F; FILIN RETURN DATE
(~t,{ry"~, ~ ~`,~-~~-~, WAYNE A. GOOD ~~t~ ~ Q. ~lL.
ADDRESS ~ U U ~
12724 STONEWALL ROAD, SHIPPENSBURG, PA 17257 v
SIGNAT E OF PREPARER OT R THAN REPRESENTATIVE ATE
~1 C ~ ---~-- Hamilton C Davis 7 ~ b
ADDR SS
20 East Burd Street, Shippensburg, PA 17257
Side 1
1505610143 1505610143 J
i
n~~
REV-1500 EX
150561243
DecedenrsName: GOOD, MARY A.
RECAPITULATION
1. Real Estate (Schedule A) .......................................................................................... 1.
2. Stocks and Bonds (Schedule B) ............................................................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3.
4. Mortgages & Notes Receivable (Schedule D) .......................................................... 4
5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............ .... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ......... .... 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ......... .... 7.
8. Total Gross Assets (total Lines 1-7) ................................................................... .... 8.
9. Funeral Expenses & Administrative Costs (Schedule H) ..................................... .... 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................ .... 10.
11. Total Deductions (total Lines 9 & 10) .................................................................. .... 11.
12. Net Value of Estate (Line 8 minus Line 11) ............................................................. 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ................................................. 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................. 14.
Decedent's Social Security Number
168 14 3600
47,689.45
5,400.75
53,090.20
3,058.25
4,163.11
7,221.36
45,868.84
45,868.84
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 4 5, 8 6 8. 8 4 16.
17. Amount of Line 14 taxable
at sibling rate X ,12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. Tax Due ................................................................................................................... .. 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1525610243
2,064.10
2,064.10
1505610243 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21 - 12 - 0073
DE ED N NAME
GOOD, MARY A.
STREET ADDRESS
210 BIG SPRING ROAD
CITY
NEWVILLE STATE
PA ZIP
17241
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 2,064.1 0
2. Credits/Payments
A. Prior Payments 1 ,700.00
B. Discount 89.47
Total Credits (A + B) (2) 1,789.47
3. Interest
(3)
0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2 7 4.6 3
Make Check Payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :.................................................................................. ^ ^x
b. retain the right to designate who shall use the property transferred or its income :.................................... ^ 0
c. retain a reversionary interest; or .................................................................................................................. ^ 0
d. receive the promise for life of either payments, benefits or care? .............................................................. ~ 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ....................................................................................................................... ^
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... ^ 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...................................................................................................................... ^x ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of
assets and filing a tax re urn are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)1. A
sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF GOOD, MARY A. 21 - 12 - 0073
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE OF
NUMBER DESCRIPTION DEATH
1 M&T BANK CHECKING ACCOUNT NO. 97260169 (SEE ATTACHED VALUATION) 45,621.27
2 NEWVILLE FIRST CHURCH OF GOD DONATION 191.39
3 MILLENIUM PHARMACY REFUND 315.00
4 CHAMBERSBURG HOSPITAL REFUND 100.00
5 PRESBETERIAN HOME REFUND 348.79
6 2011 IRS REFUND FOR PERSONAL INCOME TAX RETURN 1,113.00
~ TOTAL (Also enter on Line 5, Recapitulation) ~ 47,689.45
COMMONWEALTH OF PENNSYLVANIA SCHEDULE G
INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS &
RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY
ESTATE OF GOOD, MARY A.
FILE NUMBER
21 - 12 - 0073
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM (
NUMBER DESCRIPTION OF PROPERTY j DATE OF DEATH I
Include the name of the transferee, their relationship to decedent
I VALUE OF ASSET I ~ OF EXCLUSION
DECD'S
(IF APPLICABLE) TAXABLE VALUE
I
~ and the date of transfer. Attach a copy of the deed for real estate.
~ INTEREST ~
~ --
1 ORRSTOWN BANK -IRA PREMIUM STATEMENT I~ ss2.2~ 692.27
SAVINGS ACCOUNT NO. 96563 (SEE ATTACHED
VALUATION) I
~ i
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2 I
ERIE FAMILY LIFE INSURANCE -DEFERRED a,~os.aa ! I
i
4,708.48
ANNUITY -ACCOUNT NO. EE557309 -PAYABLE j ~
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I TO ESTATE AS NAMED BENEFICIARY I i
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TOTAL (Also enter on line 7, Recapitulation) 5,400.75
°` SCHEDULE H
FUNERAL DCPENSES &
COMMONWEALTH OF PENNSYLVANIA 1~+ o/~ /~^~+~+
INHERITANCE TAX RETURN ADMINISTRATIVE ~VJ 1 J
RESIDENT DECEDENT
ESTATE OF GOOD. MARY A.
FILE NUMBER
21 - 12 - 0073
Debts of decedent must be reported on Schedule I.
ITEM
DESCRIPTION AMOUNT
NUMBER FUNERAL EXPENSES: !
A. 1 PRE-PAID
B. ;ADMINISTRATIVE COSTS:
~. ~ Personal Representative's Commissions
j Name of Personal Representative(s)
!
i
Street Address
i
City State Zip
Year(s) Commission paid ~'~
2. Attorney's Fees HAMILTON C. DAVIS, ESQUIRE 2,700.00
! i
3. ! Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant j
i
Street Address ~
City State Zip
I
Relationship of Claimant to Decedent
4. Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS 178.50
5. I Accountant's Fees
6. Tax Return Preparer's Fees
7, Other Administrative Costs '
I
1 LEGAL ADVERTISING -THE NEWS CHRONICLE i 104.75
TOTAL (Also enter on line 9, Recapitulation) 3,058.25
r
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF GOOD, MARY A.
Schedule H
Funeral E~gx~r~ses &
Administrative Costs continued
2 LEGAL ADVERTISING -CUMBERLAND COUNTY LEGAL JOURNAL
FILE NUMBER
21 - 12 - 0073
Page 2 of Schedule H
75.00
SCHEDULEI ~~
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSYLVANIA LIABILITIES & LIENS
INHERITANCE TAX RETURN ~
RESIDENT DECEDENT
- - __
FILE NUMBER
ESTATE OF GOOD, MARY A. 21 - 12 - 0073
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER
1 MILLENIUM PHARMACY 1,545.82
2 GREEN RIDGE VILLAGE 2,349.19
3 ~ ACME STORAGE ~ 128.10
4 ~ DR. DARRYL GUISTWITE ~ 140.00
TOTAL (Also enter on Line 10, Recapitulation) ~ 4,163.11
REV•1513 EX+111-081
'
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
I NHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
GOOD, MARY A.
21 - 12 - 0073
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
I. TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116 (a) (1.2)]
1 WAYNE A. GOOD 'Son 1/4 OF RESIDUE 11,462.2'
12724 STONEWALL ROAD
SHIPPENSBURG, PA 17257
2 PATRICIA A. HOCKENSMITH 'Daughter 1/4 OF RESIDUE 11,462.2'
1601 WALNUT BOTTOM ROAD
NEWVILLE, PA 17241
3 JAMES W. GOOD ~ Son 1/4 OF RESIDUE 11,462.2'
1308 BALTIMORE STREET
PLEASAN HILL, MO 64080
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet, as appropriate.
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
REV•1513 EX+ (9-00)
' SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES continued
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
GOOD, MARY A.
21 - 12 - 0073
i RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
I~ TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116 (a) (1.2)]
4 GARY L. GOOD 'Son 1/4 OF RESIDUE 11,462.2
28832 VIA LEONA i
SAN JUAN CAPISTRANO, CA 92675 ~
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Page 2 of Schedule J
Q M8T Bank
499 Mitchell Road, Millsboro, DE 19966 Adjustment Services
Phone 888-502-4349
F ax (302) 934-2955
July 5, 2012
Law Offices of Zullinger-Davis
Hamilton C. Davis, Esq.
P.O. Box 40
Shippensburg, PA 17257
Re: Estate of Mary A. Good
Social Security: 183-18-6893
Date of Death: January 6, 2012
Dear Sir or Madam:
Per your inquiry on June 27, 2012, pease be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
l . Type of Account
Account Number
Ownership (Nantes ofl
Opening Date
Balance on Date of Death
Accrued Interest
Tonal
Checking Account
97260169
Wayne A. Good(POA)
Mary A. Good
Ralph E. Good
01!28/1980
$45, 621.27
$ .27
$45, 621.54
For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds,
please call the King Street at 717-532-4132.
We were unable to locate any safe deposit box for the above-mentioned decedent.
This letter does not include any accounts in which the deceased may have been listed as Power of Attorney, Custodian of Uniform Transfers,
Representative Payee, or Trustee under a Written Agreement.
Sincerely,
Valarie Mercer
Adjustment Services
lJtiKa 1 V VV 1V
BANK
A Traditio~i of Excelle~zce
June 28, 2012
Law Offices of Zullinger-Davis
Hamilton C. Davis, Esquire
20 East Burd Street
PO Box 40
Shippensburg, PA 17257
Fax: 530-5222
Re; Estate of Mary A. Good
Social Security Number 168-14-3600
Date of Death 1/6/2012
IT IS HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD THE
FOLLOWING ACCOUNT WITH ORRSTOWN BANK:
IRA ACCOUNT
Account No.-
Accowit Type-
Date Opened-
Joint Account (name/date)-
Balance-
Accrued Interest-
96563
IRA Premium Statement Savings
12/31/1993
No
$692.27
$0.05
Best Regards;
LUY~~~
fQ ~,~U(.e.l
J 1 R. Worthington
Deposit Processing Clerk
2695 Philadelphia Avenue
Chambersburg, PA 17201
1.888.ORRSTOWN
@J!!4lgPY~tra~ d"9'~~S&~f1~S"d.C63 0~'2
Erie Family Life
~~ Insurances
STATEMENT OF POLICY VALUES
STATEMENT PERIOD of JANUARY 01, 2012 -MARCH 31, 2012
CONTRACT INFORMATION
OWNER: MARY A GOOD
ANNUITANT: MARY A GOOD
POLICY NUMBER AY006103
PRODUCT NAME SINGLE PREM DEFERRED ANNUITY
TAX QUALIFICATION NON-QUALIFIED ANNUITY
DATE OF ISSUE FEBRUARY 05, 2008
THANK YOU FOR CHOOSING ERIE FAMILY LIFE AS A PARTNER IN BUILDING YOUR SECURE FINANCIAL FUTURE. IF YOU HAVE ANY
ADDITIONAL INSURANCE NEEDS, PLEASE CONTACT YOUR AGENT OR OUR OFFICE AT THE NUMBER LISTED AT THE BOTTOM OF THE PAGE.
CONTRACT ACTIVITY
ACCUMULATION VALUE AS OF DECEMBER 31, 2011 $4,682.50
SURRENDER VALUE AS OF DECEMBER 31, 2011 $0.00
PREMIUM RECEIVED DURING CURRENT PERIOD $0.00
ROLLOVER/TRANSFER/1035/RECHAR/CONVERSION $0.00
INTEREST CREDITED FOR CURRENT PERIOD $25.98
ROSS DISBURSEMENTS (INCLUDING SURRENDER CHARGES, FEES AND WITHHOLDING) $4,708.48
4000MULATION VALUE AS OF MARCH 31, 2012 $0.00
SURRENDER VALUE AS OF MARCH 31, 2012 $0.00
Agent name: MICHAEL A. STARR INS., INC.
1110 KENNEBEC DRIVE
CHAMBERSBURG, PA 17201-2809
(717) 263-1752
lF WE CAN BE OF ANY ASSISTANCE, PLEASE CALL YOUR AGENT OR CALL US AT 1-800-458-0811 OPTION 3.
MemUer Erie Insurance Group • Service Center ~ P.O. Box 83026, Lincoln, NE 68501 • Toll free 1-800-458-0811 • tax 866.567.1219 • www.erieinsurance.com
LAST WILL AND TESTAMENT
OF
MARY A. GOOD
I, MARY A. GOOD, of the Borough of Shippensburg, Cumberland
County, Pennsylvania,. being of sound and disposing mind, memory
and understanding do hereby make, publish and declare this as and
for my Last Wi 11 and Testament, hereby revoking al 1 other Wi 11 s
and Codicils thereto, heretofore, made by me.
FIRST
I direct the payment of my debts and the expenses of my last
illness and funeral from my estate as soon after my death as
conveniently may be done. In the event I am not the owner of a
cemetery lot at the time of my death, I direct my Executor to
J purchase such lot with a contract for perpetual care and to
improve the lot and have erected thereon a suitable monument and
' marker, using therefor funds from my estate in such amount a.s she
in her sole discretion shall deem advisable.
~`-_' J SECOND
I glue, devise and bequeath all my property, wlietli''cr re~.l yr
~~ personal, tangible or intangible, together with all insurance
t\C \ policies thereon, unto my husband, RALPH E. GOOD, provided he
shall survive me by thirty (30) days. In the event my husband
fails to survive me by thirty (30) days, I then give, devise and
bequeath all my estate whether real or personal property,
tangible or intangible, together with all insurance policies
thereon unto my children, provided they shall survive me by
unto my children, provided they shall survive me by thirty (30)
days, in as nearly equal shares as possible. In the event any of
my children fail to survive me by thirty (30) days, I give,
devise and bequeath my deceased child's share unto said deceased
child's spouse and children, in as nearly equal shares as
possible.
THIRD
I give, devise and bequeath all the rest, residue and
remainder of my estate unto my husband, RALPH E. GOOD, provided
he shal 1 survive me by thirty ( 3 0 ) days. In th.e event my husband
fails to survive me by thirty (30) days, I then give, devise and
bequeath all the rest residue and remainder of my estate, in as
nearly equal shares as possible, unto such of my children as
shall survive me by thirty (30) days, provided that the share my
oldest child, Gary Good, shall receive, shall be reduced by the
sum of Thirteen Thousand Dollars ($13,000.00) to reflect sums
1 paid by me for his college education. In the event any of my
children fail to survive me by thirty (30) days, I give, devise
and bequeath my deceased child's share unto said deceased. child's
.~
spouse and children, in as nearly equal shares as possible.
~ FOURTH
I give, devise and bequeath any minor child's share to be
invested in an interest bearing account at Dauphixi Deposit Bank &
Trust Company, Shippensburg Office, until such child is eighteen
(18) years old.
FIFTH
I hereby direct that all inheritance, estate or transfer
taxes imposed upon my estate, whether passing under this my Last
Will and Testament or otherwise,, be paid out of my estate.
2
SIXTH
Any and all sum or sums, whether in cash or in kind and
whether for principal or income, payable to the beneficiaries, or
any of them, shall be made upon the sole receipt of the
respective individual to whom the payment is made and free from
anticipation, alienation, assignment, attachment or pledge and
free from control by the creditors of such. beneficiary. All
shares of principal and income herein given shall be free from
anticipation, assignment, pledge or obligation of any beneficiary
and shall not be subject to any execution or attachment.
SEVENTH
I nominate, constitute and appoint my husband, RALPH E.
GOOD, Executor of this my Last Will and. Testament. In the event
of the death, resignation, renunciation or inability to act for
~~-~~ reason whatsoever of my said husband, I nominate, constitute
and appoint WAYNE A. GOOD and/or PATRICIA A. HOCKENSbSITH Co-
Executors of this my Last Will and Testament. My executors may be
compensated for their services up to three (3) percent, in total
of my estate, to be divided equally between them. I hereby
relieve my Executor from the necessity of posting security in
connection with his duties as such in any jurisdiction in which
he may be called upon to act, insofar as I am able by law to do
so.
3
IN WITNESS WHEREOF, I have hereunto set my hand and seal to
this my Last Will and Testament, consisting of three (3)
typewritten pages, the first two ( 2 ) of which bear my signature
in the margin for the purpose of identification this ~_ day of
19 8 (, .
~-
Ma y A. od
Testatri
SIGNED, SEALED, PUBLISHED AND DECLARED by the above named
Testatrix, MARY A. GOOD, as and for her Last Will and Testament,
in the presence of us who at her request and in her sight and
presence and in the sight and presence of each other have
hereunto subscribed our names as witnesses:
.~~~~.~ ~~~_ R~~~
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF FRANKLIN
I, MARY A. GOOD, the Testatrix whose name is signed to the
foregoing instrument, having been duly qualified according to
law, do hereby acknowledge that I signed and executed the
instrument as my Last Will and Testament; that I signed it
willingly; and that I signed it as my free and voluntary act for
the purposes therein expressed..
Mary A. G d
Testatrix `~
Sworn or affirmed to and
acknowledged before me by
Mary A. Good, Testatrix,
the ~_ day of
198.
Notary Public
~~I~R1~;~.~c'~i!r~~G~`~'s~l~., ~'~:s"c'f;f.~E' G~PlFdly,,
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF FRANKLIN
We , t a r~s ~ ~ /~ t~~°-rs and f~a ~~'s ,~>`i~..~r~
witnesses whose names are signed to the foregoing instrument,
being duly qualified according to law, do depose and say that we
were present and saw MARY A. GOOD, Testatrix, execute the
instrument as her Last Will and Test ament, th.a.t she signed it
willingly and that she executed as her free act and. voluntary act
for the purposes therein expressed; that each of us in the
G
hearing and sight of the Testatrix signed the Will as witnesses;
and that to the best of our knowledge the Testatrix was at the
time eighteen or more years of age and under no constraint or
undue influence.
v ~ ~- a,~
Sworn to and subscribed before
me by -- e~r~~~~" /~ ~~JA e~
and f~r,s ~f~,~~G witnesses,
this ~,~~( day of ~~~~~,~~;.-,~ ,
U
198 ~ .
Notary ~~lal c
My Ct~xnmission Expires:
~~ ~~~~~€~€s~E~r;~ `1 ~~E~~~ A ~~~. ~, ~~a~
rr,R~~:~b~r, ~~r~~zSyVbars€a !;~s~ociat'sosa of "votaries
6 ~