HomeMy WebLinkAbout11-28-12PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS 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
Name: Roy C. Wender _ -
a/k/a: - --
a/k1a:
a/k/a: _ --
Date of Death: 11!7/2012
_ File No: ~~ I _~~~_~
_ _ (Assigned by Register)
Social Security No: 174201492_
Age at death: 85 - __ ___
Decedent was domiciled at death in Cumberland _ County, Penns t~a_nia _ _ __ (State) with his/her last
principal residence at ?.West Main Street. _ _ 17240 Newburg-_ - -_ Cumberland
Street address, Post Office and Zip Code City, Township or Borough Couuty
Decedent died at 2 West Main Street. 17240 Newburg __ - _ Franklin _ PA
Street address, Post 0t5ce and Zip Code City, Township or Borough County SmYe
Fstimate of value of decedent's property at deazh
Ijdomiciled in Pennsylvania ................................All personal property $ __ _5 ~DO.I)0
Ijnot domiciled in Pennsylvania .............................Personal property in Pennsylvania $
ljnot domiciled in Pennsylvania .............................Personal property in County $
Value ojreal estate in Pennsylvania .............................................................. $ -___ 700.00
TOTAL ESTIMATED VALUE.... $ _ 8.0000.00
real estate in Pennsylvania situated at. 2 West Main Street _ 17240 Newbu~ - _ Cumberland
(Anach additional sfieets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough County
® A. Petition for Probate and Grant of Letters Testamentarv
Petitioner(s) aver(s) he/she/they is/are [he Executor(s) named in the last Will of the Decedent, dated ~/~ 0%197 __ and Codicil(s)
thereto dated n0n~
State relevant circumstances (ag. renunciation, death ojerecutog 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(8), and did not have a child bom 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 lire, durante absentia, durante minoritate
If Administration, c.ta. or tLb.n.r~t.a., enter date of Will in Section A above and com plete 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 defir>~t;_'
in 23 Pa. C.S. § 3323(8) and was neither the victim of a killing nor ever adjudicated an incapacitated person. , ~
^ NO EXCEPTIONS ^ EXCEPTIONS __
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Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the following spous~if~ry~d heirs attack{ V
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Name ~ Relationship ~
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Form RW-oz rev. too uz°it Page 1 oft
- _-
Oath of Personal Representative o~e~ai use omy
COMMONWEALTH OF PENNSYLVANIA }
} ss: RECORDED CFFFCE CF
COUNTY OF CUMBERLAND _ -_ } ~-R_EGISIE~OF~~~
- _ _
__
Petitioner(s) Pnnted Name ~ Petitioner(s) t e
40 Shuman Road ~ '
Kim H. Wenger - --_ - _ Newbur -CL-ERK-~_PA 17240
P.O. Box 82, 11 South Water Street ORPHANS CO ~
Keith R,_Wenger _ - _-- - -iNewburo• -_ -_ _ ~ U~aT 17240 ~~
E-RLAND CO., PA
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition aze tme and correct to the best of the knowledge and belief
of Petitioner(s) and that, as Fersonal Representative(s) of the Decedent, the Petitioner(s) wivll /well~and~truly administer the estate according to law.
Sworn to ~ffirmed anbscri ed be#gre ~~ ~ /~' . ;!~/p ~ _ Daze ~~ ~~ ~v~-
- ,
me thi ! -day of Y ~_ ~~ ~° -
- ~ -`~ - Dale 1 ~~~d-
By. '~ __`~ r~-Q-`tom _ _ Date -
F Jfre Register - - Date -
BOND Required: ^ YES ®NO To the Register of Wills:
FEES: Please enter my appearance by my signature below:
_ - --
Letters .................... .. $ _ 210_00 A ey Signature:
(4 )Short Certificates(s) ...... __ 1_6.00 ~
( )Renunciation(s) ....... .. -_._ ~ ~ ;
--
( )Codicil(s) ........... .. °~~ '~~~-~_ ~'
- - - ~ ~T
( )Affidavit(s) ............. -
Bond ......................... P' i ed Name: .JO I . ZUlll~er
Commission .................... _ .Supreme Court
--
- -
Other Will. _-_ , , , .. , , , . - 15,00 ID Number: 17516 _ _
J__CS_fee 23.50 _ - I'
Automation _ _ _ _ _ , , , , , , , , , _ 5.00 Firm Name: Zullin~c er-Davis. P C. _
Address: 14 North Main Street, Suite 200
Chambersburg - _ _PA 17201
-- ' ' ' ~ ' ' ' ~ ~ Phone: (717 264029
- ......... Fax: ~17~264-1884_
- -
aromatton Fee ................. - Email: 'z1 ullin~er ullin er-davis.com __-
JCS Fee ....................... - - _
TOTAL ......................$ .269.50 _ _ - - - _-
DECREE OF THE REGISTER
Estate of Ro~C. Wenger ~~ f - /y~
- - -- File No: ~~~'
AND NOW, - `~ ~C~(.'t ~_i~_l ~"< ~~ ~~~ i J -_ , in consideration of the foregoing Petition,
satisfactory proof having beAn presented before me, IT IS DECREED that Letters Testaments
ry - -
-- --- - - - are hereby granted to Kim H. Wenger and Keith R. Wen er
_~ -
- - - - - in the above estate and (if applicable) that
the instrtunent(s) dated January 1Q 1 _977 _-
- - _ - -
described in the Petition be admitted to probate and filed of record as the last Will (and Codicils)) of Decedent.
.,
1 <_
egister of Wills f'~' ~i ~
~~~~
Form RW-02 rev. 10/11/207] ~ l'l~a` .~1'
a/k/a:
~ ~ Page 2 of 2
~x ;~~y',C~1~T;~~~~~~l.~S
2~l? NuU 28 P(~ i2 ~3
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CLERKO~ -
ORPHANS'000RT
CUMBERLAND CO , t:;t~~ ~'~~~~} r.,,
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P i90663t~9
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Types/Print In COMMONWEALTH Oi PENNSYLVANIA
Permanent DEPARTMENT OF HEALTH -VITAL REC00.D5
_ _ /-'C ~Td CSrATr n
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' - State Flle Number:
1. Dlmtlln['s 4gal Nam! (Firs[, Mltldle, Lest, Sutflx) 2. SGx 3. SOC1a15ecurlty Number q
0
.
a[e of Oa![M1 (MO/Day/Vr) (SpIII Mp)
Ra C_ Wen eh
. MIZZe 774-20-1492 Nov ember 7 2012
5e
A
e-tee[ Blrthd
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g
aY (
r3) Sb. Untler l Year Sc. Vndar 1 Ov 6- Drta Of BIRh (Me/OSy/Yeer) (Spell Man[h) ie. Birthplace ICIN antl State Or Foreign Country)
M
M1
on[
S Oays HOVIS MIn VIGf NQ~IrDV(/JL '~jA
85 ecembP.JE. 28 7926 Tb. alnhpma (cepnN)
8a. Residence (3iat< Or Foreign Country) Bb. ResltlGn<e (Street and Number- Includ! Apt No.) Hc. Dld Decedent LIVe In v Townships
2 W 26X Ma.i,n SXlLeeX Ove:, decedem Ilesed In
Bd. Realdenee /eer,nN)
twp.
L
CumbeJC.eand g<- Resld Gnc<(ZIp Cede) 2 ENO, tl<catlen[ Ilyltl within limits ^I 1¢4114 (.IfLQ
city/born.
9. Ever In U5 Armed FOrcasi 10. Marital Stitus at Tlme Of Daa[h Marrl<d WIOOwetl 11. Surviving 3puusi s Name (If wise, glue nsme prior [o Rrs[ marriage)
O
Yes ~ N
O U
k
~
i
.
o
n
n
D
vorced ~ N r Marrle0 O UnknO
w
12- Fa[h!r's Name (FIrS[, MlOdle, Utt, Suffix)
HcvuL L
W¢n
n 13. MO[M1er's Name PrlOr [O FIrSi Marriage (Perot, Middle, Last)
.
e
14a. In[erman['s Name 14b
ReletlOna M1i
[
D
d Ruth L. Coleman
'
.
p
o
ece
ent lqc. Informant
3 Melling Atldress (Street and Number, CIN. 5[a[!, Zip Code)
Li
eQ W¢n vJ
g -
L Dau. G~tvL 7
z
° If DGa[M1 Occurred In a HeaPital: ~~~~~~-~-~' ~Inpa[lent ~ ?If DeatM1 OCCUmed Som One ............................. .... ...... ty... .
ewhere OMer Than a HOSpltil: Lf' ~NOaplce Fvclll ~~~~~~ ~~~~~- ~ -~'
LKS o
o:
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lesaenra H
,,
Q Emergln Cy Room/OUtpaflent Q Oead On ArrlVal ~ NVrSing Hem!/Long-Term Cere Faclllry Q OMer (SpeclN)
F
11
6
•
~ 15
-
ac
1N Name (If not Inrtl[utlOn, give rtrcet and number;
15c. CIN Or Town, Stg[e, and 21p Code SSd, County of OlatM1
2 W¢.bZ' Mcun S~icee# N
vb
_ u
un PA 17240
16a
Me[ISOd Of Dl
C~-F^benRRnd
ltl
.
Spos
on Burial ~ Cr<ma[len 16b. Date oT Ois
position 160. Place of Dlsposltlen (Name a( cemetery, crema[pry, Or O[M1er plate)
Q Removal from State ~ D
tl
ena
on
Oth
I
$
er (
P.c
N) J Zo~y Z Q.
16d. LOCeCion oT DISpOSItIOn (City Or Town, State, antl Zlp) 1 a- $IgnatV re of FVneral ServIC! LlClnslG Or PGnOn In Charg! Of In[Grment 1]b. Llcens! Number
Pie-a.b a.wt ffa-Q.e PA 17246
014837-L
1 Nam d Cempla[e q2dregs of Funeral Fac111N
€`o
~
~ ge
¢ng en-73tu.eheh F. N_ Znc. 112 W. K.Cn Ste. Sh,i.. en66LUr
PA 1
.
18. Decedent's Educa[len -Chick [he box tM1a[ bart tlescrlbes [M1e 1B. Decedent Of Hlapanlc Odgln - CM1e<k [M1e 20. OCCttlent'f Races -Check ONE OR MORE races fe Indicate what
M1lgM1est tlegree or level of School comple[etl a[ [he time Of tl
a<h
b
th
t b
<
.
oz
a
est describes whether [M1<d<cedenl tlse~r[cedent condltlGretl hIm3G11 er M1erself [o be.
Q Bth grade er less I
g SpanlSh/HISPenlc/Latlno- CM1eck the "NO'Cinyhl[e 0 Ker<an
O JIe tliploms, 9th - 12th gretla bozJf decedent Is not SpgnlsM1/HlSpenlc/Latlno. ~ Bieck Or g1r10an AmerlOan ~ VletnamesG'
Q HIgM1 sche0l HreOUat
GED
l
t
tl
I
e pr
cemp
e
l
($
NO, no[ $plnlsM1/Hispanic/La[Ino ~~gmerlcen Indian or Alaska NatlVe ~ O[M1<r gxlan
0 Seme college credit
but no tlegree
V
M
,
Q
az,
ezlcan, Mexlcen Amarlcan, Chicano 0 gslan Intllan O Na[We Hawallan
Q Associate degree (e.8, AA. AS) O YIS
Puerto Rlcsn
,
~ CM1lneae
O GVBmanlan or Ghamorro
Q Bachelor's tlegree (a.g. gA, qB, 05) Q Yes
Cuban
,
~ Filipino Q Samoan
Q Marter s degree (l.g. Mq, M5, MEng. MEd. MSW, MBA) Q Yes, O[M1ar Spanlah/HlsOenlc/latino ~ JapOnfi!
~ OCM1er P<01}IC Inlander
~ Doctorate (e.g. PhD, EtlOI Or PrOtlEilOnal tlagrle (5paclTy) ~ OH.Ir (SpeclN)
. MD DDS OVM LLB JD __
21. D~~IeEBtllnt'S Single Race Self-DeSlBnation -Check ONLY ONE to Indicate what [he decedent conslderetl hlmaelf er M1erself [o be. 23a. pacetlln['s Usual Occupation - Indlq[! NPG of work
~whlte Q lepanese
~ Samoan tlone during mart of working lHl. OO NOT USE RETIRED.
O Black pr ACHCen Am Grlcan Q Kprlan ~ Other paclRC lslantlar -
Q gmerlcen Intllan Or Alaska Netlve ~ ylGtnameaa O Don't Know/Not Sure P1LO du.e~c.On SCL en,c.wt¢ndgn
~ ASlan Indian -
~t
H
.
Q O[
er gglen Q Refused 22b. Kind of Business/Intlusiry
Q CM1lneae O Na[IVe Hawallan O Other (SPedNI
O FIIIpInO ~ Ouamanlan er CllamOrrO Manu4a.c.tccn.i.ng
ITEMS 2
3a - 23d MUST BE COMPLETED 23a. Oa[e Pronpunced Oaad Mo Oay/Yr) 23b. SIgnB[Ur! of Person PronouncinH paath (Only when eOplicsblef 23c Llcang¢ Number
BY PERSON WHO PRONONNCES OR
CERT1ilE5 DEATH
23tl. Date Signed (MO Oey Yr) 24. Tlm! of DeatM1
Q ~ 35. Was MedlCal Examiner Or CorOnlr COntBC[ed? Q Yez NO
- CAUSE OF DEATH
26. Part I- Enter the cM1eln of even[¢-diSeas<5, In)urlls, Or cam Ilca[lonz-[M1V[ dlrcctl gpProxlmaie
P y ceuietl the death. OD NOT enter tGrminal events such
di
a3 car
ac arrest Interval:
reapira[ory arrest,orvlntrlcularflhrlllatlYn without sM1Owing [M1<et
lolegy. OO NOT AB
B
REVIATE. Enter only One cause onaline
gtld atltll[lonal lin
if
^
.
es
necessary _ Onset <o pee[M1
(
~
IMMEpIATE CAVSE ----> LO/LCN4.CY IIZ~~Y L(SS/JIS-
(Final dlaease nr condition Due t0 (or ai 8 CO^SeOYence Of):
rizul[Ing In tlee[h) _
b.
Sequen[lally Ili[ conOltlons, - OV¢ [o (er as a conuquence o!):
If any, leetling to the rauzn -
IHted on Ilne a. Enter She
c
VNOERLYING CAVSE
Due to (ar asaconaequencc Of): (
-mbevae nr InJury tha ~
-
,
,
Inl[latad [M1e evenGZ Ylsul[Ing d.
~ '
~ ~
In death) LAST. ~ Dues LO (Or a3 a COnSequ<nce Of):
26. Pert 11- Enter other;l¢nsflcen[ [ontl13 M1 but no[ resulting In the Vndlrlying ceuae given In Part I
2]. Waa en a V[Opay pertor~jrn~~ld]
I'
C-lLrf"/-ISnq` ,/4s c~u([.q!' ~/stAS~ Ovls Q'N
~' }l
O
l ~ f-T P~'r qty Y NYfar:~t-.~y,.6 r q'N 2g. Wer¢aV[epSy Flntlin
s
ll
bl
~i g
ava
e
¢
tO eOmpletG [h[ CaV
Se $$T deaths
Y ~
J9. If Female: 30
~ Yes Q~NO
pi0 T
.
o}}~se cu Usc Contribute [o peathi 31. Mannar pf DeetF
~ Not pregnant within part year [~C'
c
~ GS
~ prebably ~7ja[ural ~ HomlCltl!
Pregn Gn[ a[ Llme o} OeetM1 ~ No 0 Vnknewn
Q gccldent ~ pending InvesHgatlon
O Ne[ pirreegnenG but pregnant within 42 tlays o[ d<atY 0 SVICItlc ~ Could not be tletermined
N°[ B^an[, bV[ pregnant 43 tleys to 1 year before dee[f 32. Dat! Of Injury (MO/Oay/Yr) (Spell MOnthl
O Unknown If pregnant wltM1in [he pest year 33. Time OI Injury
3q. Place Of Inf Vry (e.g. home; canstructlon site: farm; icn0pl) 33. Loce<lOn O[ In)Vry (Street antl Numhpr, GIN, Sta[!, ZIp COd[I
36. Injury at Work 3i. If Tranypor[atlon Injury, SpeclN: 3B.lJlS<nb[ HOw In)ury Occurred:
Q Yea ~ DrlVer/Operator 0 Pedestrian
e r
No Q peas nge ~ Other (SPecINI_
39a. Certlller (Check only One)
[a~CertlNlnq plryslclan - Tn the boat o1 my knowletlRe. Oea[h occurred due tV the cause(s) antl Tanner stated
~ Prono
i
8
unc
ng
. CertlNin9 Physician - To the best o1 my knowletlge, tlesth oOCVrrcd at tM1e [Ime, date, antl plat ntl tlue t0 tM1e cause(s) antl manner statetl
~ Medical Examiner/Coro
ne
r -
O
n Che bas
is of
sn
l
t
¢
a
en, /Jtl~/o ~1^~ lstlgetlun, In my opinion, dea/t~hw oc/e~V rcd
/j
~
%
et Me time, date, antl place, and tlue to [M1e c e(s) and msnn r Stated
'
/
/~~
~
518^arure of certlli
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r
!
er:
l.
yNO
/G
rryfAr /% ~/~ Title Of cert[fler. /rr LJ
Llcenee Number; MA~~77~t~
39b. Name, Addresa and Zlp Code eT Person Cpmple[Ing Cause of DeatM1 (Item 2GI
39c. Date $IRned (MO/Day/Yr)
(/)raa.I rkm ~. Vc Nr'1H ~-/) i26 Lai rt.SON C-)1'j.L gT ({~24SC2
FF1 ITO I~
t
j Nc/rMA41C ~~ 201Z
40. Registrar s District Number 91
R<RIStr I
natur
~
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e
B
q2, Reg [rest Flle Oate (MO/Day/V r)
/~ -
43. Amnndmcntiz / -
Dlsposl[len nermlt Nn yytiL>c • 7~ H305-143
- REV O]/2011
..
4 ~. r .~ .. F''
~t?R~rt~ ~; ~pr~~ QF
LAST WILL AND TESTAMENT
CL~Ri( v
~~ r ROY C. WENGER, of the Borough of Newburg, Cumberland County,
A~~tS' Cw;~t~T
CU ~~~~$1a~r~Gbeing of sound mind, memory and disposition, do hereby make,
publish and declare this my Last Will and Testament, hereby revoking and
making void all wills by me at any time heretofore made.
FIRST. I order and direct the payment of all my just debts and funeral
expenses as soon as may be convenient after my decease.
SECOND. I give, devise and bequeath all my estate, real, personal and mixed,
whatsoever and wheresoever situate, to my beloved wife, PAULINE C. WENGER,
absolutely.
THIRD. In the event that my said wife predeceases me or is not living on the
60th day following my death, I then give, devise and bequeath my said estate
as follows:
A. I give and bequeath any antique items which I may own at my
passing and which are located in my home located in Newburg,
Cumberland County, Pennsylvania, to the persons whose names are
attached or affixed to such items at the time of my passing.
B. I give, devise and bequeath all the rest and residue of my estate
of every nature and wherever situate to my children, in equal
shares, on a per stirpes distribution basis.
FOURTH. I nominate, constitute and appoint my wife, PAULINE C. WENGER, to
be the Executrix of this my Last Will and Testament; if she be unable to
fulfill the duties of Executrix, I then nominate, constitute and appoint
KEITH R. WENGER of R. D. 1, Newburg, Pennsylvania, and KIM H. WENGER of
R. D. 1, Newburg, Pennsylvania, to be the Co-Executors of this my Last Will
and Testament.
FIFTH. I direct that my personal representatives shall not be required to
give bond for the faithful performance of their duties in any jurisdiction.
,.~ (SEAL)
i
WILLIAM R MARK
ATTORNEY AT lAW
9 MiPPEN39URG. Pq.
- 1 -
IN WITNESS WHEREOF, I, ROY C. WENGER, have hereunto set my hand
and seal to this my Last Will and Testament, written on two sheets of paper,
WILLIAM R MARK
gTTO RN FY qT LAW
9N~~'PEN89 LIRG. Pq.
the first one signed for identification purposes only, this /~::' ?~~ day
of ~.T,_ t,,,,~1,..,u.ti,~~ ~ 1977.
/ ,
r ~~-~.
Signed, sealed, published and
declared by ROY C. WENGER, the
Testator, as and for his .
Last Will and Testament, in the
presence of us who have at his
request signed our names as .
witnesses hereto in the
presence of the said Testator
and of each other. / `~„
///
.~ '~ ~~ ~ ~l~ ') r
J\
J .
~.- .
' ~~ I
„~1, /G~.---'`' SEAL
i
z
l .~ >
RECORDED OF¢lGE OF
OATH OF SUBSCRIBING WITNESS~~J~T~R of ~i~.i_s
20i2 i~OU 28 POl 12 05
REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLV CLERK C1=
`~~'PHANS' COURT
CUMBERLAND CO., PA
Estate of Rov C. Wenner ,Deceased
~errv A. Weigle
the X^ Will ^ Codicil(s) pre
say(s) that she / he /they
and that she / he /they
the Testator /Testatrix
(signature)
(each a subscribing witness to
(Print Name/s)
sented herewith, (each) being duly qualified according to law, depose(s) and
was /were present and saw the above Testator /Testatrix sign the same
signed the same and that she / he /they signed as a witness at the request of
in her /his presence and in the presence of each other.
C1 ~ a - (~
(Street Address)
(City, Stare, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
Deputy for Register of Wills
126 East King Street
(Street Address)
Shi~oensbura PA 17257
(City, State, Zip)
Executed out of Register's Office
Sworn to or affirmed and ubscribed
before me this day
of ?~/Z,
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.)
N01'E: To betaken by Officer authorized to administer oaths. Please have present the original or copy of instrument s) at ttme o no z tqn
~'o~anal Seal
Form RW-03 rev. 10.13.06 Linda K. Klein, Notary Public
Shippensburg, PA Cumberland Cour~r
M Commission E fires Autust 15, 2016
~L?2 NOU 28 P(~ i2 05 /~
/~_ .3<,
CLERK OF
ORPHANS' COURT
Gl1MBERLAND CO., PA
REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
No. 21-
Estate of \~ ~. ~~=~ ,Deceased
UNAVAILABLE WITNESS AFFIDAVIT
I, _ ~ ~ ~ ~ ~ ~ ~~ t-f CiT being duly sworn according to law, depose and s iy
that I, the 'Attorney ^ Personal Representative in the above referenced Estate, declare that
I~ol~~-~-u. ~ N ~' ~ ~ and
whose signature(s) appears as subscribing witness(es) to the ^ Will or ^ Codicil of the above
Testator is/are not readily available to prove the signature to the 'T'estator by reason of
r,.~l ~ vt .~:. N c~ c~.u~' ~ ~lU :~ ~ cc.t_ l l ~-t (,tu c.~.~ l~ ~} ~
Sworn to or affirm~ed a/,n~d subscribed
Be~~off e me this ~ daJ~y//7o7f
/VDd~/!I~ / , 201~.~
Suty for Register of Wills
ust sign in Register's Office)
~~ vL
Sig}~iature of Co nsel/Person Representative
OATH OF NON-SUBSCRIBING WITNESS
i
,yam ~ ~) btc~, ~`i~' ~ sttic%.t.c_~ and
(each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that
he is/she is/they are familiar with the signature of the above Testator of the ^ Will or ^ Codicil
presented herewith and that he/she/they believe(s) the signature on the ^ Will or ^ Codicil is in
the handwriting of the above Testator to the best of his/her/their knowledge and belief.
Sworn to or affirm~ed~ ,a~.nd subscribed
Bef me this ~ day of
~~ -' 2~~
l I M '-
uty for Register of 'ills
(:'lust sign in Register's Office)
Signature of Non-Subscribing Witness
Signature of'.~on-Subscribing Witness