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HomeMy WebLinkAbout08-21-12~F,J{c-.~~~~~~ ;~~;c~ fay PETITION FOR GRANT OF LETTERS `l." 12 AUG 2 ~R~'~I~F WILLS OF ~'U~IQ~,V2.~ aI~J ~ COUNTY, PENNSYLVANIA Petitioners}:named below, who is/are 18 years of age or older, apply(ies) for Letters as specified below, and in sup~~~ ~~ Xhe following and respectfully request(s) the grant of Letters in the appropriate form: D~s'l~i~tyttiati~ t Name: ~~~(1 .~ OAS ~~(l l~ U~ a~ ~ File No: _ 02 ~ ~ ~ ~ - t~ a/k/a. a/k/a: (Assigned by Register) a/k/a: Date of lleath: Social Security No: 2,.Q 2 - y 2 - ~ `~ Aga at death• ~~'" Decedent was domiciled at death in M~0•C~2 1~ ~ County, Q~ ~ 1VQl^i )Ol (state) with his/her last principal residence at - ~ ~ 1t ~ C Street address, Post Office and Zip Code ~ "~~ Clty, Township or Borough ~ " County Decedent died at ~~~y~ C.~~xtij ~ ~ ~d ~~ 1P~°Sld~ C.ei ~~-~S~/Jl,1~g 1~aUp~11 N '~' Street address, oat Office and Zip Code Crty, Township or Borough Count Estimate of value of decedent's roe Y State p p rry at death: Ijdotniciled in Pennsylvania ............... .All ersonal ro e ............ p P P rt3' $_~OO O . C3G If not doneiciled in Pennsy/vania ........................ Personal property in Pennsylvania $ Ijnat domiciled i'n Pennsylvania ................ . .......Personal ro e Value of real estate in Pennsylvania ............................. . I? P ~ to County $ TOTAL ESTIMATED VALUE.... $~-(') n ~ Real estate in Pennsylvania situated at: (Attach additional sheets, if necessary.) Street address, Post Office and Zip Code Clly, Township or Borongh County (~ A. Petition for Probate and Grant of Letters Testamentar / `Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated ~~ Z~ ZG }Z- thereto dated_~ r and Codicil(s) State relevant circumstances (eg, renunciation, death ojexecuwr, etc.) 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 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. ~~;0 EXCEPTIONS ^ EXCEPTIONS ^ B. Petition for Grant of Letters of Administration (If applicable) c.t.u., d.b.n., d.b.n.c.t.a., pendente life, durante absentia, durante minoritate If Administration, c.t.a. or db.n.c.l~a., enter date of Will in Section A above and com lete list of heirs. Except as follows: Decedent was not a parry to a pending divorce proceeding 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 ro Vb if l and was survived by the following spouse (if any) and heirs (attach additional sheets, iJ'necessary): Name Relationshi ~i~da 1Cu1n(~~i~ V~~~ ~-C., ~.~ V~Ov ~L~Address V /~ ~ SUV~1~(~da I ~ ~ ~G~ ~ ~~~aw2- C, pQv~ 11~~c. ~ ~ ~ ~~~d ~ d Ca ~ ~ ~ ~ ~~~ ~-• 1C t1~1n C~~.-i C. Sb~N ~ ~ - $0~ 32 3 SU.rn~ ~dalrt; Forni RW-OZ rev. /0////101/ Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } COUNTY OF I ~ } SS: ___ } Printed Name ---_. ~U~a~~~ '~~;`~~~~~.~ '~~F~~~/1 /OBE ~j~~t.',T x'7'1 ~ ';V1~I f ~w~~,tif L.. v .: ..4.`~ Official Use Only f~~I2 AUG 2 I PM 3~ 5~ L^ 'etitioner(s) Pri e A ress ~d ~1t «~II The Petitioner(s) above-named swear(s) or affirm(s) the stateme of Petitioner(s) and that, as Personal Representativ s of the n the foregoing petit' re true and correct to the best of the knowledge and belief ~) eden a Petitio s) wi I an truly administer the estate according to law. Sworn to or affirmed a d subscribed before me ~ day of 2 ~ ~ Z 13y Date ~ ! Date For the Register Date Date BOND Required: QyES fiN0 FEES: `''t' Letters .............. , ( o~ )Sh , S v • d~ ort Certificate(s)..... ( ~ )Renunciation(s)........ ( . , (~-© . ~~~ )Codicil(s) ............ - )Affidavit(s)....... . . ---~-_ Bond.......... ............. Commission....... . --~_ ... . Other ........ .. Automation Fee ...... ~_ ........ . 1CS Fee. ---~_ TOTAL ..................... S~~(~- Estate of a/k/a: File No: ~ f ~ _ ~ ,,~ _ ~~ AND NOW, ~+ satisfacto ~ ~t t °~~ ~ ~G ~ , in consideration of the foregoing Petition, ry proof =,av,t,g peen presented before me, IT IS DECREED that Letters are hereby granted to ~` the instrument(s) dated in the above estate and (if applicable) that described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s) of Dec edent. Regtster of Wills Forne RW-02 iev. !Il//!/20l! ~~~ ~ i Page 2 of 2 To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature: Printed Name: Supreme Court ID Number: Firm Narne: Address: Phone: Fax: Email: DECREE OF THE REGISTER H105.805 REV (9/]I) -- -- - -- LOC G R'S CERTIFICATION OF DEATH WA ~. ( ~s~~'~11 duplicate this .copy by photostat or photograph. Fee for this certificate, $6.00 ~~ ~ ~ ~~~ Z I ~ ~ 1 ,,,,,,, „~,,,,,,, M 3~ 5 i ~ .III:~a~jH oFPF .~ r~ ~~ ~H~S vdil~il ~" ~' '~ P 18 6 514 ~~ ~uMS~~~atvo co., ~ ~- ~~,, ~~~ ~ ~~~~~ ~~,1~~~': =: q.~. , .~a.,, _ This is to certify that the information here given is correctly copied fron;~ an original Certificate of Death duly filed with me as. LocaC Registrar. T'he original certificate will be forwarded to the State Vital Records Office for pl„rmanent filing. ~:'MFNT O~~I~IIIr y~l Lam/ Certification Number """""PI Local Registrar Tyw/Print In PermarNnt COMMONWEALTH OF PENNSYLVANIA . DEPARTMENT OF HEALTH .VITAL RECORDS ° ' CERTIFICATE OF DEATH 1. Deud•nt's Lepl Name (Riot, Mlddie, fart, BuMx) SteN FI JOHN J . KUHAFtIC 2. ux 3. Sxlel s•arley Number Male 202-42-7118 Sa. Ate-Last BlrthdaY (Yn) Bb. Un r 1 Y ar C. Under 1 M 6. Date 01 Birth (MO wy Nr) (Spell MOnM •. BI Plaes (City •n SS Months D•y. Noun. Minutes Sept . 10 , 1956 Jsa. Residence (SfaN or Poreiin Country) b. esl rip Street arW Number - In ode Apt No) k Did 76. BlrthPleee (Cpuntt PA Date Issued ao/a.. _ 651 Erford Rd . D ~d.^t LN. 1^ .Township b. RH ~]N ~'es, decedent IN•d in l+^A t- PE1ATTlct l"> Y(f eN,P. Cum~sr and Be. RNidenp (LP Code) QNO, decedent Ilwd wKhln IlmRa of 9. !wr In US Armed ForcesT 10. MerRa SNtus •t Tlme ONth Married ow 11. Surwvini SpouN•s Neme 1 wife, Blw name Prior N rat marrlaie dry/boro O vo pcNO O unknown O ohrorc.d O N•wr Mottled O unknown 12. tether's Name first, Mid •, Laa4 Su ) a JOtm K 8r1C 13. M er • Name prior to Ir•t Marnaq (First, Middle., Lest 14a. norm t• me Mary Gustin 1~arJa~e ~.. KutJaric ~aug~Jl°terN D .m 1•~1~ ~•'.r•LOr~ dpsa sl(..~ .rid {~~'~-, chypA Ni~ . ....... ................ .........:........ ................... n a 1~ D•et}I~CSCUrred in s Flosphal: ~ ~' InP•CI•rK ...............................!:...•C!.......................4. 4. n• ...... ...................'.............. ~ _ Emer H De•M Occurred Somewhei• OeMr Thin ~~NOSpRi~: •.•.••.•.••..~( MoWic• F•eil ••.••• •• •••.•.••.•...•... n Room Out teem Dead on ArrWal Nunl Nome -Term Can Feclll ~ ~ ~•cb~^t'+ Home 1Sb. Facil ty Neme not nstRUtlon, Bhre itreee and number, lie. Other I ) CRy or Town, State, M 21p ISd. County o Death ~, lBa. Met Dlsposmon Burial r•matlon Sib. O•N Dlspesitbn tic. Plaq of Dis DaV hin Q Rem Ot^~ S fNN Q Donation A1.7 PosRlen Nam• 07 um•t•ry, crematory, or then plate) g 1,' 2012 Hoover Crematory lid. LOUNOn of DisPOSmon C1ty or Town, Se~N, end 21P) 17a. 5lineture of Fu nl E-IerriSburg PA 1711E uwnaeeorpenonlnch.r..,,r~...~.-_~ .-.~ ..---- -. - s ~ 17c. Name end ComPleN Addreu of Funeral Feeilhy ~~ 1B. O•oad•nt's Eduotlon - Ch tM box that beat descri b the hliheat deir.e or fowl of school eempl•Nd at the time of death. Q Bite i°. Dep ant Nis a 77 box that best descnbwes Whp ehl~~ ~ « rA grade or ley Q No dlPlema, BM - 12th Br•d• t ti• d.C Ont b Sp•nbh/MlsPank;/Ledno. Check the "NO• ® NIBh aehool BraduaN or 6CD comPlegd box If decedent is net Spanish/Nlspenl4L•tlne. Q Beme eo11N• credit, but no dNr•• ' No, not SpanishMlsPenk:/Letlno Q As•OUete decree (e, •' M' ~) yes, Mexlun, M•xlun Amerlun, Chlune Q MchNOr's degree (•.F BA, AB, BS) Q Mesgr' d Q' Yo, puerN Rlun Q Y•s, Cuban s NrN (e.B. MA, MS, MHni, MEd, MSW, MBA) Q DoctoreN (e•B• PhD, EdD) or profeulenal de°r•e Q Yea, other SPanlsh/Nisp•ni4tatlno e. . MD D Jp (Sp•eHy) 21. De nt'a SInBI• R•Ce S•If-O•slinadon -Chock ONLY ON[ N Indicate whet the decedent tonal • hlmsetf o ~Whft• Q Japanese Q Blacker Afrlun Amenun Q Konen •,~ Amerlun Indian or Alaska NKI r 0 Samoan Q ether P•Nflc Islander w Q Vletnam•ae Q Aden Indian Q Other Mien Q Don't Know/Not Sure Q FIIIP no O NatNe N•wallan R O Ot eh r (9peCNy) Q Qwmanlen or Chamorro .yE*~ P•R 1. Engr tM eh•1n of w GUSE OF DEATH ------~ '~' ~'- rlO went.- lte•a•a, Injuries, or ~mPllutlonhMK dir•etN uus•d the death. 00 NOT •nNr Y• respiratory arrest, or ventricular flbrlllatlon without showing the Klel D ProxMl•N s`P rmin•1 •wnb such b Grdl•c •r t srt IMMlOIATE GUSE -> • / . 7Y~S oBy- O NOT ABBREVIATE. Enter only one uuN " r•y , on • IIM. Add additional Iln•s If neussary OnaK to Death ' > / (Final dIMaN or Wndltlon ~_~ ~ ~7 L ~..^~a f,..~ resultin° In death) D • N ( as w sequence of). b. SegwntiallY Ilst wndltiona , If •rh., ludini N the eawe Dw N (er as a cont. quanta 019; Ilsbd on IIM •. Engr the UNDBRLWNO CAUiE (ma•a.• or Injury en•c Du. to (or mn..qu•nee on: InRi•Nd she events reauRlnE d. In death) LAST. .a a Oue to 0 ( r Cona u nu on: 26. /art 11. Enbr other n . but not re•ultini In the u ni cause Blwn In Part 1 27. WM an autopsy W orm•d7 ' 2B. Were wtopsy n inq awllable 28.1 .male: t0 rnmpleN the uua• of death? Q Net pre Bnant within pert year Q Pr•Bn•nt R time of Wath .Did Tob•ceo Us• CentrlbuN to ON T Q Y•s Q Probably 31. Mtn r o/ Death y No c 0 Net ProinMt, but prainant within 41 days or death Unknown Q Ne [~ oral Q Accident Q Nomlelde Q Net Pr•inaM, but prein•nt 43 d• ri to 1 Ye•r before deKh Q Unknown If Preinant wthin the Past year 32. Date o Injury Mo Day r Spe 1 Mont Q P•ndlnB Investlietl0n Q SWcide Q Could not W tlet•rmin•d ~ Yes Q Driver/Operator ~ Ped•Rnen Si' D••crib• How Injury Occurred: Q No Q PessentK Q Other (SP•clfY) •• r C on one rtMylrti PhWleian - To the bert of mY knowledie, death eceurre0 due N eh• yuse(a) end manner •t•ted Q Prernounclni i. 4rdfNn° physlelen - Te tha Wat of rnN knewNdf•. dpth oecurr•d at the time, daN, end _ Q Medlin Examiner/Coroner - O b b p} ex•minagon, •ntl/er_ Inw•tli•tbn, In Plat., end tlw to the uup(s) and manner sceUd my opinion, dbth occurred et the time, date, •ntl piece, and d W N the GuN(s) and m SlBnatura of prtMer: TRIe of artlMr: .Name, Address and 21P Code of Person ComPletlnB GuN Of Oeath (Kern 2q) LIC•na• Number: S_ ~y ~~~~ l,~tr\ OS ~` ~ ~ D~ Signed (M aY r) r • 1" j i) ~ r 4 BMWre '7rrT, aj 4 e Y uj 43. Amendments " •(~ _~ ~: ~ ~',~~ Dlaposmon Permit No. 0796919 ~ H1os-l~s REV o7noal -- ONE OR MORE npato Indlut• whet 1 decedent consitlered hima•H or h•rpM to be. White Q Korean clack or AMUn Am•rlun Q VletMmese Amerlun Indian or Alaska Native Q Other /oleo Aden Indian Q NatN• Nawailan d11n"• p Duam.nian or ch.morro FIIIPino Q Semwn JaPaneae Q Other P•ciflc Islander Other (SP•clfy) ' N be. 22a. Decedent s usual OceupaNOn - Indiut• type of won done durlni most of workini life. DO NOT USE RETIRED. Carpenter 22b. Kind Or euamesu lnauae.., r.: LAST WILL AND TESTAMENT n ~ ~ ~ ;~: ~~ ~' ~ ~ t- } ~3 OF : ~ JOHN KUHARIC ~~~; ~ ~ ~ - ~. --' c-~c~ - , ..p , ~ . -r--~ -~ D ~ ~; w ~'-~ Ti ~ _; }_~ I, John Kuharic, of Camp Hill, Pennsylvania, revoke my former Wills and Codicils ~d declare~is `"' to be my Last Will and Testament. ARTICLE I IDENTIFICATION OF FANIILY I am not currently married to anyone. The names of my children are Randie Lynn Kuharic and John Lawrence Kuharic. All references in this Will to "my children" are references to the above-named children. ARTICLE II PAYMENT OF DEBTS AND EXPENSES I direct that my just debts, funeral expenses and expenses of last illness be first paid from my estate. ARTICLE III DISPOSITION OF PROPERTY Residuary Estate. I direct that my residuary estate be distributed to my children in equal shares. If a child of mine does not survive me, such deceased child's share shall be distributed in equal shares to the children of such deceased child who survive me, by right of representation. If a child of mine does not survive me and has no children who survive me, such deceased child's share shall be distributed in equal shares to my other children, if any, or to their respective children by right of representation. If no child of mine survives me, and if none of my deceased children are survived by children, my residuary estate shall be distributed to . If such beneficiary does not survive me, my residuary estate shall be distributed to my heirs-at-law, their identities and respective shares to be determined under the laws of the State of Pennsylvania, then in effect, as if I had died intestate at the time fixed for distribution under this provision. ARTICLE IV NOMINATION OF EXECUTOR I nominate Randie Lynn Kuharic, of Camp Hill, Pennsylvania, as the Executor, without bond or security. ARTICLE V EXECUTOR POWERS My Executor, in addition to other powers and authority granted by law or necessary or appropriate for proper administration, shall have the right and power to lease, sell, mortgage, or otherwise encumber any real or personal property that may be included in my estate, without order of court and without notice to anyone. My Executor shall have the right to administer my estate using "informal", "unsupervised", or "independent" probate or equivalent legislation designed to operate without unnecessary intervention by the probate court. ARTICLE VI MISCELLANEOUS PROVISIONS A. Paragraph Titles and Gender. The titles given to the paragraphs of this Will are inserted for reference purposes only and are not to be considered as forming a part of this Will in interpreting its provisions. All words used in this Will in any gender shall extend to and include all genders, and any singular words shall include the plural expression, and vice versa, specifically including "child" and "children", when the context or facts so require, and any pronouns shall be taken to refer to the person or persons intended regardless of gender or number. B. Liability of Fiduciary. No fiduciary who is a natural person shall, in the absence of fraudulent conduct or bad faith, be liable individually to any beneficiary of my estate, and my estate shall indemnify such natural person from any and all claims or expenses in connection with or arising out of that fiduciary's good faith actions or nonactions of the fiduciary, except for such actions or nonactions which constitute fraudulent conduct or bad faith. No successor trustee shall be obliged to inquire into or be in any way accountable for the previous administration of the trust property. C. Beneficiary Disputes. If any bequest requires that the bequest be distributed between or among two or more beneficiaries, the specific items of property comprising the respective shares shall be determined by such beneficiaries if they can agree, and if not, by my Executor. IN WITNESS WHEREOF, I have subscribed my name below, this ~_ day of _~ ~ , ~ 2-. Testator Signature: Jo Kuharic We, the undersigned, hereby certify that the above instrument, which consists of pages, including the page(s) which contain the witness signatures, was signed in our sight and presence by John Kuharic (the "Testator"), who declared this instrument to be his/her Last Will and Testament and we, at the Testator's request and in the Testator's sight and presence, and in the sight and presence of each other, do hereby subscribe our names as witnesses on the date shown above. Witness Signature: r` ~4 t Name: Julia K City: Steelto State: Pennsylvania ..~ Witness Signature: Name: Jo Lawrence Kuharic City: Summerdale State: Pennsylvania Witness Signature: Name: Kathe ' e Kuharic City: Bressler State: Pennsylvania PENNSYLVANIA Self-Proving Clause COMMONWEALTH OF PENNSYLVANIA COUNTY OF UNITED STATES OF AMERICA I, John Kuharic, the Testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly and as my free and voluntary act for the purposes expressed in the instrument. Sworn to or affirmed and acknowledged before me by John Kuharic, the Testator, this Z~ day of ~~ V-~- ,2012 Testator Signature Johnaric Signature of officer Official capacity of officer (Seal) AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF UNITED STATES OF AMERICA We, Julia Kuharic and John Lawrence Kuharic and Katherine Kuharic the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the Testator sign and execute the instnunent as the Testator's Last Will; that the Testator signed willingly and executed it as the Testator's free and voluntary act for the purposes expressed in it; that each of us in the hearing and sight of the Testator signed the Will as a witness; and that to the best of our knowledge the Testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn to or affirmed and subscribed to before me by Julia Kuharic and John Lawrence Kuharic and Katherine Kuharic, witnesses, this 2°i day of ~~ U~ 2012 . Witness Signature: Name: Julia aric City: Steelton State: Pennsylvania ~. i Witness Signature: Name: John Lawrence Kuharic City: Summerdale State: Pennsylvania Witness Signature: Name: Katherine Kuharic City: Bressler State: Pennsylvania ,:; - ,, -~ I ~ AUG 2 I PIS 3~ 55 0~1"T ItUV,v VV~1flj Cl1M8ERLAND CO., PA RENUNCIATION REGIS ER OF WILLS -~~~~~ N ~OUNTY, PENNSYLVANIA Estate of_ ~~~ ~S~ ~V ` ~~Y 1~~ Deceased I' - "~ ~ ~' ~' in m ca aci /r p ~ ~ ~ y p ty elationshi as (Print Name) 1 ~ 3 ~~ of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to L© (Dat `~ ZO ~,O ~ Z ,~~-~~ f Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills Form RW-06 rev. 10.13.06 r e) reet Address) r•~ (City, State, Zip) ~ Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation for the purposes fated within on this ~_ day of ~ ~ .. , , . ,I- ,., ... ,-, votary-Public _ My Commission Expires: /Ud v~:s'~p/S (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) COMMONWEq~TM OF PENNSYLVgNIq Notarial Seal 71na M. Rob~~ Notary publk: East Pennaf~ro Twp., Cumberland Coun COmmisslon E~~ Np~,. 15, 2015ty MEMiRR, N~yANtA ~~TION OF gRIES t _L J ~~~I2 BUG 2 i Phi 3~ 55 ~~ OATI3 OF SUBSCRIBING WITNESS(ES) ORP~-`v~i~I~S "~`~r~~F REGISTER OF WILLS CUMBERLAND CA., PA. i..{m~atr)Ccn c~ COUNTY, PENNSYLVANIA _~1- t~ -o~`l~ Estate of ~ (3 n~ J 0 S t ~ {-. ~ 1.1 ~ G r t L ,Deceased Ju ~ t ~. ~ ~<u har 1,L , (each) a subscribing witness to (Print Names) the C~Nill u Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that sh / he /they ~~/ were present and saw the above Testat '/Testatrix sign the same and that / he /they signed the same and that he /they signed as a witness at the request of the estat Testatrix in ~ Presence and in the presence of each other. ~~ (Sign e) X00 ~- ~~ o~, (Street Address) ~ T-E~~.71a ~ ,~ A- I ? t l,3 (City, State, Zip) .Executed in Register's Office Sworn to or affirmed and subscribed before me this of day Deputy for Register of Wills Executed out of Register's Office Sworn to or affumed and subscribed before me this ~.1 5 T day of ~, ~C/~--. ~~ ~~~~ Notalry Public My Commission Expires:Np ~~ ~ 5'~,.p/,S" (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 copy of instrument(s) at time of notarization. FormRW-03 rev. /0./3.06 (Signature) (Street Address) (City, State, Zip) COMMONWEALTH OF PENNSYLVANIA Notarial Seal Tina M. Robertson, Notary PubUc East Pennsboro Twp., Cumberland County My Commission 6tpires Nov. 15, 2015 M[Ma6R, pEfINSYk.ViN1~P, A65043A'r~ON ®F RIES '' i~ ,~ '%[~I~ BUG 21 PM 3~ 5~ATH OF SUBSCRIBING WITNESS(ES) D~Pt'li,~`d'S i~u.Jf i j REGISTER OF WILLS CUM6ERI_AND CO., PA ~ COUNTY, PENNSYLVANIA t..{m~itr ~Qn ~~!~~ h Estate of ~ G ~ rl ~ Q S `P ,~ -'1 ~ ©~ C~, r 1 C.- ,Deceased a-~h vrN r ~'IC.. (each) 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 sh he /they ~a (were present and saw the above estato a Testatrix sign the same and that ~/ he /they signed the same and that sh / he /they signed as a witness at the request of the 'estato /Testatrix in her his presence and in the presence of each other. $_ nature ~ ~e l /-~) olUR o ~ ~,- (Street Address) ~T~~~~ low r~~~3~3iZ~_ (eiry, state, ZipJ Executed in Register's Office Sworn to or affirmed and subscribed before me this of day Deputy for Register of Wills (Signature) (Street Address) (City, State, Zip) Executed out of Register's Office Sworn to or affirmed and subscribed s ~" before me this ~) _ day of ~~ ~ C~) ~. Notary(Public _ My Commission Expires:r10 l) r' S oLolS (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 copy of instrument(s) at time of notarization. FormRW-03 rev. 10.!3.06 COMMONWEALTH OF PENNSYLVANIA Notarial Seat Tina M. Robertson, Notary Public East Pennsboro Twp., Cumberland County My Commission Expires Nov, 15, 2015 MEMBER, PENNSYLVANIA ASSOQATION OF N ES