HomeMy WebLinkAbout02-01-13PETITION FOR GR+~AN ' OF LETTERS
REGISTER OF WILLS OF ~~ 1 ~ COUNTY, PENNSYLVANIA
Petitioner(s) named below, who is/are 18 years of age or oider, appty(ies) for Letters as specit3ed below. and in
support thereof aver(s) the following and respectfully.request(s) the grant of Letters iu the appropriate form:
Decedent's Information
Name• _ Q t
a/k/a:
a/k/a:
a/lc/a:
Date of Death:C~1 ~Z S.~i
Decedent was domiciled at d~e~aqth. ~in~~
principal residence at ~ZFJ ~' l ll
Street address, Post Office and Zip Code
File No: ~~~ I~ ~ ~~-l
(Assigned by Registerp(),, p,
Social Security No: ~Q~~ ~OC>° V~~
Age at death: ,fin
~~' (State) with his/her last
Clly, Tawhsh-p or Borough
County
Decedent died at 11`~ ~~~ ~ ~~ (1>~ IUI~C 1.51 ~ ~-
Street oddrcss, Poat Office and Zip Code City, Towaship or Boroogh County State
Estimate of value of decedent's property at death:
ljdomiciled in Pennsylvania ............................ All personal property S ~n~V~
Ijnot domiciled in Pennsylvania . . ...................... Personal property in Pennsylvania S
IJnae domiciled in Pennrylvania ........................ Personal property in County $
Value ojnalestateirt Pennsylvank ......................................................... S
TOTAL ESTIMATED VALU S
Real estate in Pennsylvania situated at: ~~ .~~~ i/l~- riL.+~ lJ~j(7 1~ ~ n~
(Attach additianalsheev, ifneceuary.) Street addreu, Post Office and ZIp Code =~-City,-Township ar Borongh County
~A. Petition for Probate and Grant of Letters Testamentary //~~
Petitioner(s) aver(s) he/shehhey is/are the Executor(s) named in the last Will of the Decedent, dated `1 , and Codicil(s)
thereto dated
State relevant circunutaacn (eg. renunciation, death ojaecumr, etal
rv
0
Except as follows: after the execution ofthe instrument(s) offered for probate Decaient did notmarry, was tvorced, was ~ pa Winding
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 33~g~tnd did not~ive `il6~1om or
~ad[opted; and Decedent was neither the victim of a kitting nor ever adjudicated an incapacitated person. Od' BOO rn
'{Q] NO EXCEPTIONS ^ EXCEPTIONS ~ ~ ~ ~~-t c-
^ B. Petition for Grant of Letters of Administration (If applicable) ~D` ~ ~ p
c.t.u.,d.6.n.,d.b.n.c.t.a.,pendentelitr>~u~pttga~sent' uranl2 ritate
O --~
If Administration, ~t:a or db.n.c.ta., enter date of Will in Section A above and c~d~te list tlf heirs m
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for dibrce~tad been ,~(gblis}ip af8lefined
in 23 Pa. C.S. § 3323(8) and was neither the victim of a killing nor ever adjudicated an incapacitated pers~Ti .' t~ ~
~1V0 EXCEPTION3 ^ EXCEPTIONS
Petitioner(s), after a proper search has/ltave ascertained that Decedent left no Will and was survived bythe following spouse (ifany) and heirs (attach
additional sheets, i/necessary):
Porn Rw-nz ,Y~, lnauzntt Page 1 of 2
Oath of Personal Representative
COM110N`,VEALTH OF PE~'~Sk'LV.aYfA }
4 SS:
C' :' i C `: T'r' O F
Official Usc Only
i~':(i;Ci ::~;, '•._ . G,;;r. i 'e~:-.u~ ;.Cdtss i
, ~
The Petitioner(s) above-named swear(s) or affirm(s) the statemenu in the Foregoing Petition are true a c rrect to the best of the knowledge and belief
of Petitioner(s) and that, as Personal Representatives} of th a dent, a titioner(s) will 1 ly administer the estate according to law,
Sworn to aff~med a d subscribed b~re Date~7~~L~~
me thi ay o ai- /3 Date
BY~ Date
or he Register Date
BOND Required:OYES NO
FEES:
L tters ...................... S ~
(~ )Short Certificate(s)...... • -~-
("`~~~"' )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)... , ....... .
Bond..----...
Commissio ................ _
Other ,
• ~•
-~
Automation Fee .............. .
1C5 Fee .....................
TOTAL ..................... S ~- -
To the Register ojWi!!r:
Please enter my appearance by my signature below:
Attorney Signature:
Printed Name:
Supreme Court a
""' ~
~ t91
ID Number: c
.~
S7 "*'t ~ O
Firm Name: ~' ~ Pr"! rl1 ~
Address: Ys1 y
~^ ~ tTf t~ 7t7
1> N C ~
'
Phone: Q -r
t
Fax: O --~'
Email: _ _~ t,~, fA n
~ ~
DECREE OF THE REGISTER
Estate of ICJ 1 ~O~ ~mma~ns File No: 07~ ~ ~ 3 ~ d ~g
a/Wa:
AND NOW, ~ ~ ~~ (3 , in conside ation of the foregoing Petition,
satisfactory proof having been pres to efore me, IT I~ TnECREED that L tern f~
are hereby granted to Y (1_fKxSSct, ~i mrn ar7
in the above estate and (if applicable) that
the instrument(s) dated ~
described in the Petition be admitted to probate and filed of record as the'last Wil1(ant~,S~odicil(s)) of Decedent
.!_
of Wills - J ~yjl
- _. _.. Fnr~u QW_lU ..-...iaci~iui~___ _. _ _ _... __ _.. __.. __.. _. _ _ __ ~_.. __. ~._. .... n~ _.
HIOSROS RP_V rq/111
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
RECORDED OFFICE OF
Fee for this certificate, $6.00 REGISTER OF WILLS This is to certify that the information here given is
m correctly copied from an original Certificate of Death
zal3 FE8 1 ~" 1 duly tiled with me as Local Registrar The original
certificate will be forwarded to the State Vital
CLERK OF Records Office for permanent filing.
P 19 0 6 5 4 3 9 ORPHANS' COURT ~~~ JAN,17 2013
"~'SERLAND CO..
Certification Number Local Registrar Date issued
Type/Print In COMMONWEALTH OF PENN3VLVANIA .DEPARTMENT OF HEALTH ~ VITAL RECORDS
P•r^`•^•n° CFRTI FICOTF ~F ~EOTM _ _. .. .
~'
1. Dacatlent • Lgal Name (Flrft, Mitltlle, Lai[, SVMz) 2. SeX 3. oriel SacurlN N V mbar 4. Oatn Of Death (MDfOiy r (Spell Mo)
on emale 1 6- -8707 a uar 12 201
5a. A{e-UaR {In ay (Vn Sb. Vn er Y er 3<. Under 1 Da 6. Da[a Of Birth (MO Dry ear) (Spill Mon<h) Ja. Birthplace CIN aafq1O Sqq or Forcl{n Country)
Menthe Days Hour. Minutes orK, YA
36 Jul 20, 1976 ]b. glnhplace (coYnNl York
gi. Rask[ernci qq or Ferol{h [:ountryl eb. Residents (Street and Number-IncWde Apt NO.) 8c. OIO Decadent LNa In • Township]
O Yas, decitlent IWed In twp.
ea. R.n enc. (COYnN) 125 Ha rman.~~-Avenue
L'.Llmbarl.8nd ga. R!lldlnq! (Zip COdn) ~ ND, decedent Ilvld WI[hln limits Df Lamovne [IN/bo.e.
9. EVar In U ArTad Feruai SO. Marhal3gtUl at Tma of Onath ~ Married ~ WI Owad 11. SV rvlVln{ SpoV[n'c N. m! (11 wire. gWa names prior tD nrat marrlag!)
D Yea $1 No O Unknown ~ Dizorcetl W/ NWer Married ~ Unknown
13. Fathar•a Nami Rirat, MItldN, Uat Sufnx) 13. Mother's Nama Prier w Flra[ Manh{a (First, Middla, Last)
t arils L. 31Ttmona Jr. Detests Ka a Parthemer
14a. Inferment'a Nama 14b. R9latlonahlp [e Decedent 14c. Intormant'a Mallln{ Address (Strait and Number, GIN, Sta[a, alp Cotle/
Mother
Darnace Simmons 208 H Remsa Place Naw Cumberland
PA 1707
'
- - - - _
_ _ sat _ r~ en YDn _
_<ae
Il DeaTh OCturntl In a Hpspltel ~ InDlLlant 11! Daat11 OttYrnE Smm~whlr! O<hir Than R Hosplfal; d HOSpi<e Fa<~i1N ~ ~ D~ceAent's Hcme
Ems an Ream out atlent O Dsad en Mrlwl 1 0 NVnin NOmULOn -Term Uro Fa<Iltty 0<h!r 3 ace )
lSb. Fic111N Name (If not Institution, {Wa ,troet end nYmbir) 13<. CIN or Town, State, and alp Gpda lStl. County of Dea<h
er an
ffi, 16s. Meths of Dlaposi[lOn Burial Gromitlon S6b. Oat! Of Olsgpf [Ion 16c. Plape of DlsposRion Name Df <lmgfery, crematory, Or other plate)
LU 13
~ RamgVSlTrom Sgti ~ Denatlon 14
~, s nay) anuary
,
usea Cremaro
1g . locatlen o101sOOSlden (City or Town, Sgta, and Zlp) na
1Ta. 31 naiV of Fu r aryl as Or Person In Charge o Interment 1]b. License Number
Schea£feratown, PA 17088 FD 013 340 L
1]c. Nam! amt Complete Aetlresf of funarol F4GIIN
r a ore FH6 In PO ox New Cumberland PA 17070-0 1
~ Sg. Dacedant'a EdYCa[lon -Check [he bon [ at bia<tlNerlbef the 19. Dace ant of Nispsnle On{In - Chec [he 20. Deeedint's Raci -Check ONE OR MORE rscea to Indlcat! wMt
r hl{heat de{roe or lawl of school <Omplegd a[ <M Hma of death. box the[ beat tleacribaa whether the deciean[ the Decedent conaltleretl himself or herself to be.
Q g<h {nde Dr leas Is Spanish/Hlspam4Latlno. Check the "NO" ~ Whha Q Korean
~ NO diploma, 9th - 12[h {reds beX if decadent Is no<Spenlah/Hispanic/Latino. D Black Dr AfHCan Amedcan ~ Vietnamese
)~.I HI{h school{rodwq or GED COmblegtl (${NO, m<spanish/Hfapanlc/LaBno DAmarican lntllan or Alaska NatlVa ~ O<her Alan
Q Soma rolls{s crodit, but no de{rae O Yns, Mazlcen. McXI<en American, CFlcano ~ Aalan lndlan O NatlVa Nawailan
O Assoclaq d!{roa (e.{. M, AS) ~ Yea, Puerto Rican Q Chine[! O Guamanian or Ghamorro
~ gaphflDf'a tlgrci (i.{. BA, Ag, {S) D Yas, Cuhan O Filipino ~ Samoan
O Mas[ar's dagria (a.{. MA, M3, MEnF MEd, M3W, MBA1 ~ Vea, o[her Spanlah/HlsPinlc/LaTlno O lapanlae ~ Otnnr eerier I:lands
O Doctorate (e.{. Ph O. EtlD) or prefesslOnal degree (speclNl ~ O<her (SpecIN1
MD DDS OVM LLB JD
21. Dawdent'a Sin{IS Racs S!M-DeslgnaHOn • Check ONLY ONE to Inelcate what the decedent cDnaltleratl hlmaell or hnrHM t0 be. 22a. Dacedant'a U,VaI Occupation - In IcaCa NPe of work
WNIq 0 lapanace - ~ Samosn dOni dYrln{ moat Df workln{ Ilfa. DO NOT USE RETIRED.
Black O/ African Amedcan Q KOroan D Other PlUflc lslandlr
Q American lndlan Or Alaska Na[IVe p Vletnameaa ~ Don't Know/Not Sure Ma diC 81 Aeals rant
~ Mean lndlan 0 O[her Arlin D RlTUfed 26. Klntl of Business/Indus[ry
~ Chinese ~ NatlVa Hawaiian O OChar (3PacIN)
Q Fllkaln0 D Gusminlan or Cl.amorro Healthcare
aq roneunca sa Mo y 2 . 31 e<un o Person ronouncln{ Deat on Y w en app ca • 2 <. rouse um er
{Y PER60N WND eRONOV NC{{ OR ~~ ~~` ~
ClRTIFa3 M
q
9
()
a
TA
~t
~ / N3 ~0~5~/~
1c
„
r
~
"
V,a
/ I /
2 paq SI nag MD ~+q'/yr . Tme Of Oeat
~
1
/sL
~ ~
2S. Was Medical Ezaminlr or Coroner Gonta<[adt ~ Yns No
CAUSE OF DEATH ~ Approximate
26. Pan I. Engr tb chain DI ewnn--maiaus, in)udas, Or wmpllcaNOm--that diroctly caused she dlaM. DO NOT enter terminal eyentn such as cardiac arrest 1 Interval:
t
10
NO
T
ABBREVIATE. 6n[er only ens cause on a Iles. Atld agtlltienel Ilnes N nacacsary. 1 Ogsat to De1th
respiratory arras[, Dr yen[rlcular RbYlllatlDn wlthaut sHOw(ng the a
10
g
0
0
Y.
/
1
/
~
/~
1
~
/
t
~
IMMEDIATE GUSE --------> a. ~A~.ar~~1n~Z/A/ t/IAWI/IVKl~ 1
~~
-
• <o (of as a cpnsagw c of): 1
(Final dbgu! or condltlen
•
routting in death) l
...
~ /YhLT
b. ~
D
t
o
(or is • onsequan
ef): 1
Sequentl,lly list cpntll<lans,
e ^1=:Se
~ ~ /y ~ ~ ~y l
~~y
9
^
r
e
~
~
~M'~~r7 1/Mat /r170"r
listed on
Engrthe
^~L^~A Uyy~.y/
c. ~_(d.d{L( tti)1
tINDERLYIN® CAUSE Due [o (pr as a onsaquan<O of): 1
(disease or Inlury that I
Inltlatetl the iwnts nwRln{ e. 1
In death) LAST. Due t0 (er as a censngwnce of): I
36. Pan II. En[ar o[ it but net rcculUng In Cha underlylnt clues {Ivan In Pan I. 3>. Was en autopsy parformetl?
D Ye No
3B
l
to complete the eauae pf dea• h
?
$ 0 V!s Np
y
' 29. 11 Famalg: 30. Old Tobacco Uaa CoMtibu[a to D!a[hi 3 annlr o1 Onath
a
G ~] Notpro{nant within pest year Q yes ~ Probably ~Naturel ~ Homlcitle
O ~ Pr!{nan[at time of tlsath Q NV ~ Unknown Q Accident Q Pineln{Imnstl{aflOn
~' [] Not pra{nanL but pro{nant wRNin 42 data o} death [] Suielde Q Gould not be tlegrmined
ti ~ Not pre{nar^, but pro{nam 43 OaYa to i year bnfgri death 32. Oat! of Inlury (MO/D!Y/Yr) (Spell Month)
O Unknewn If pregnant within Mn past War 33. Tlm! of Imury
34. P ace of InIVN la.g. Rome; constructkan alq; farm: achoei) 35. LOCa[lon Of Inlury (SLr!![ and Number, CIN, COV nN. State, 21p Coda)
36. Inury at or 3]. I/Tnnsponatlen In)ury, 4piciN: 3H. Describe How Inlury Occurred:
~ Ysa ~ Oriwr/Operator ~ PadefMSn
Q Np ~ Paafangir O Other (SPacMy)
3 a seiner- Irises cartMed nYni practltlonar, medical examiner romper (Check only one):
~CenlNln{ onW - TO Mi beat Of my knowladp, dealR ocwrrad due to <M cause(s) antl manner a[a<etl.
D Pronpuncin{ 6 GRifyln{ - TO the boat o1 my knowledge, death eccurrid of the time, dap, antl place, end des to M9 cause(s) and m r stated.
Q Matllcal ExaminarJGe - On M bas of Ina<I d/or Investigation, In my oplnlen, du<h e<curretl at [he tins, date, antl Olace, and due <o the ea YSe(a7 and
m
r stated.
p
/
Slgna<Yr! Of clnlflir: TI[In of cenlner: M_ D Llcnnae NV mbar: ~ LJ Y 3 l to q S
99b. Na a, Adtlratt and Zlp Cod! Parapn CpmDlatln{ Cava D.a<h (I<nm 26) 39c. D to 51{n d (MO/Oay/Vr)
. Ra{Iatrar a aM [[ unbar 41. •g Kn acute { attar I a ate Me ay
- ~~ ~ ~
4S. Amandmanta
Olapesidon Permit No. dI O t !'JET' ~ ~ REV 0]/2012
LAST WILL AND YE$TAMENT Of Nichols D. Simmons
1, Nichols D. Simmons, a resident of the Stall of Pennsylvania, make, punish and declare this
to be my l.asft WIN and Testament, revoking all wifis and codicils at any tMne heretofore made by
me.
FIRST: t direct that the expenses of my last iNness and funeral, the expenses of the
adminislfation of my estate, and all estate, inheritance and similar taxes payable with respect to
property included in my estate, whether or not passing under this wiN, and any interest or
penaltip~ thereon, shah be paid out of my residuary estate, without apportiorrrrrerrt and with no
right of n3imbursemerrt from any redpient of any such property.
SECOND: I am not monied. I have the fdlowing children: Vanessa Simmons, lxxn on AprN 9,
1993, Leonna SirxTrons, bom on August 22, 2005 and Natasha Simmons, tx>rrr on July 23,
2007.
THIRD: I give all tangible personal property owned by me at the tone of my death, including
without lirr~tatiorr personal effects, clothing, jewelry, furniture, furnishings, household goods,
automobiles and other vehicles, together with aN insurance policies retorting thereto, to those of
my children who survive me, in substantiaNy equal shares, to be divided among them as they
shall agree, or if they cannot agree, or if any of them shall be under the age of eighteen (18)
years, as my Executor shall determine. If any of said children shall be under the age of eighteen
(18) years at my dea8r, my Exeartor may seN any property bequeathed to said duld under this
Article THIRD, as my Executor may deem appropriate, or my Executor may hold such property
or any proceeds therBOf, wthout bond, surely or other security, until said dull attains said age
or such earlier time as my Exeador may deem proper to deliver any such property or proceeds
to said child, or to said child's guardian or any person with whom said child resides for the use
of said drill. AN costs incurred by my Executor in connection with obtaining possession,
appraising, safeguarding, deNvering or seNing such property shah he paid a5 expenses of
administering my estate.
FOURTH: 1 give aN the rest, residue and remainder of my property and estate, both real and
personal, of whatever kind and wherever k~catted, that I own or to which I shall be in any manner
entitled art the time of my death (collectively referred to as my "residuary estate', as foNows:
(a) To those of my drNdnen who survive me and to the issue who survive me ~ those of my
children who shall not survive me, per stirpe5. If, however, any such chNd then shall be under
the age of eighteen (18) years (each such d'rild being hereinafter referred to as a "Beneficiary"),
the share of such Berrelidary shall oat be paid or disUibuted to such Benefidary but instead
shah be given to my Executor and held by my Fxeaitor, IN TRUST, pursuant to the foNowing
(ij My Executor shah hob, manage, invest and reinvest each share aside ~ ~
Beneficiary in a separate trust for the benefit ~ such Benefidary and shah mudti50f' all ~
the net income from each such trust to or for the benefit of the ~r 1tI~
health, education, maarhtnanoe and support of the Benefidary, to such end ~qt srlNlli tirrf,Q ~
or times and in such manner as may be deterrrdned in the absolute d' ~y Execulan m
Any net income not so paid shall be accumulated and added to prirrci ~~ a o 0
thereafter shall be held, administered and disposed of as a part thereof.
° ~' o '° '*+~»
(u~ In addNion, my Executor may pay to ~ for the benefit of each piw theme ~
education, maintenance and support of each Benefidary, from the' of eadj[ rn
88nefidary's trust, such amounts, including the whole thereof, as date in the -ten
distx+artion of my Executor.
(rid When any Beneficiary shall attain the age of eighteen (18) years, the tout for such
Beneficlary shall temrrnate and any remaining prir>cipal and income stroll be paid and distributed
to such Benefidary, dudrarged of trust. ff such Beneficiary dies before said age, sud- prirKapat
and inc~rrre shall be paid and distributed to any then living issue of such Berrefidary, per stirpes,
or if such Beneficiary has no issue to my then Nving issue, per stirpes. ff any such issue is a
benefidary of a tout under this wiN, the same may be held in accordance witty such tout. ff
there are no then living issue, the same shall be paid and distributed to the berrefic~aries of my
residuary estate then in being as provided in this wiN, or if there are none, to those who would
take from me as if 1 were then to die without a will, unmarried and the absolute owner of the
same, and a resident of the State of Pennsylvania.
(b) If there shall be no issue of mine then Nving, I give my residuary estate to those who would
take from me as rt I were then to die without a wit, unmarried and the absolute owner of my
residuary estate, and a resident of the State of Pennsylvania.
FIFTH: If any property of my estate vests in absolute ownership in a minor or incompetent, my
Executor, at any time and without cxwrt authorization, may: distribute the whole or any part of
such property to the beneficiary; or use the whole or any part for the health, education,
maintenance and support of the beneficiary; or disbibute the whole or any part to a guardian,
committee or other legal representative of the beneficiary, or to a csrstodian for the benefiaary
under any gifts to minors or transfers to minas ad, or te.the person or persons with whom the
beneficiary resides. Evidence of any such distribution or the receipt therefore exetxrted by the
person to whom the distributie- is made shah be a fuN discharge of my Executor from any
liabiity with respell thereto, even though my Execwtor may be such person. If such benefidary
is a minor, my Executor may defer the distribution of the whole or any part of such properly until
the benefidary attains the age of eighteen (18) years, and may hold the same as a separate
fund for the benefiaary with aN of the powers described in Article SEVENTH heteof. tf the
beneficiary dies before attaining said age, any balance shall be paid and distributed to the
estate of the beneficiary.
SIXTH: 1 appoint Vanessa Sinanons to be my executor. ff Vanessa Simmons does not survive
me, or shall fail to qual~y for any reason as my personal representative, or having quaNfied shall
die, resign or cease to act for any reason as my executor, 1 appall Krmberly Jacoby as my
executor. To the extent pettailted by the laws of the State of Pennsylvania, this will is iMerrded
as and shall be t~rrstr'ued to be a nonintervention wiN and, after the probate of this wii, no
further proceedings in court shall be necessary other than to comply with the statutes resting to
the handling of estates under nonintervention wills. No bond or surety or other security shah be
required of any Personal Representative serving hereunder. The dertision to administer my
estate independently or under court supervision shah be made solely by my personal
representative.
SEVENTH: 1 grant to my Executor ai powers conferred upon executors wherever my Executor
may ad. I also grant to my Executor power to retain, seN at public or private sale, exdrarrge,
grant options on, invest and r+eimrest, and otherwise deal with any kind of property, real or
personal, for cash or on credit; to borrow money and encumber or pledge any property to
secure loans; to divide and distribute property in cash or in kind; to 6rrer+c~se aN powers of an
absolute owner of property; to compromise and release dairns with or without cxxrsideration;
and to employ attorneys, accountants and other persons for services or advice. The term
"Executor'" wherever used herein shall mean the executors, executor, execuCmc or administrator
in office from time to time.
EIGHTH: I direct that for purposes of this will a benefrdary shall be deemed to predecease me
un~ss such benefir~ary survives me by more than thirty days. The terms "dtid', "drildren" and
"issue", 8S used in this WIN, include dlildren and issue hereafter tom.
NINTH: I appoint Kimberly Jacoby to be the Guardian of the person and property of any dakiren
of mine who have not attained the age of majority. ff Kimberly Jacoby does not survive me, or
shall fail to qualify for arty reason as the Guardian, or having qualified shah die, resign or cease
to ad for any reason as my Guardian, I appoint Thomas Barton as my Guardian. No Guardian
shall be required to fie or famish any bond, sur as my Guardtan.
No Guardian shall be required to tits or famish any bond, surety or other security in any
jurisdiction.
IN WITNESS WHEREOF, 1, Nichols D. Simmers sign my me and publish a~ declare this
instrument as my last wit and testament this `~ day of ~gp,~, ZO~, I also have
affixed my initials on the bottom of each of the preceding pages hereof.
Nichble D. Simmons
We, the witnesses, at the Testatrix's request, sign our names to this instnanent, being first duly
swum, and do hereby dedare to the undersigned authority that the Testatrix signs and executes
this instrument as the Testatrix's will and that the Testatrix signs it wiYingly, and that each of us,
in the presence and hearing of the Testatrix, hereby signs this wiH as witness to the Testatra's
signing, and that to the best of our knowledge the Testatrix is eighteen years of age or older, of
so nd mind, a unde no oorrstraint or undue influence.
~ of n)C~N Vil ~~, P~ - ,)essic2 M~ C-~an-t~
~5 r fl
ess~
P of rr'
AFFIDAVIT OF WITNESSES
STATE OF Pennsylvania, COUNTY OF ~
ss.
Before me the undersigned authority, on this day personalty appeared:
the Testator, l f[
i Gh O I P_ _ i m m n.5 having an address at, ~ S ~l2 ~`morl ~y-e- ,~' m°~-~nC ~ ~ 7 ~ 3
and each of the undersigned witnesses,
. ~ ~4 A ('~1'1 _ having an address at, 2 ~D ~y5~~,,~Wv I ~ ~ ~ ~~ ~~Z~~
and ~n
~S~\CO.~~~~~h^a~vin~lg~a,,naddress at, 3y~ C C~~c~c,~o ~ ~..c~ , ~~~C~ Q ~ \1 \ is
and ~~~IY~CAYI ~ G` ~ havr~'ng~an,address at, ~ C~~fYl;n 1 Qom. ~ b .JI A ~ ~ ~ U q
respectively, being irrdividualty and severally duly swum, did depose and say that:
e foregoing last wiN and testament was subscribed in our presence and sigh by
j~rrl the Testator named therein. The undersigned witnessed the
execution of said will of i Gh n 1 Q. I m m On S , on this day.
At the time the instrurrrerrt was so subsdibed, the Testator declared said instrurrrent to be their
last will and testament. The undersigned thereupon signed their names as witnesses at the end
of said wNl at the request ~ the Testator, in the presence of the Testator and each other. At the
time of so executing said wiN, in our respective opinions, the Testator was at least eighteen
years of age, and was of sound mind, memory and understanding, under no constraint, duress,
fraud or undue influence, and in no respect incompetent to make a valid wiN. In our respective
opinions, the Testator was able to read, write and comrerse in the English language, and was
not suffering from any defect of sight, hearing or speech, or from any other physical or mental
impairment which would aged then capaaty to make a valid wiN. Each of us was acquainted
with the Testator, and we make this affidavit at their request. Said wNl was shown to us at the
time this affidavit was made, and we examined it as to the signature of the Testator and our
signatures. Said wiN was executed as a single, original instrument, and nct in counterparts.
Subscribed, sworn to and acknowledged before me by IC 2 0 the Testator,
and subscribed and sworn to before me by the said t and
~ I 1c8 Y c and'('111r~dA fh~Fi~en, as witnesses, this ~ day of ,,~~~
,-,
_ ~~1~~~~~ ~M~~MK NEK
N ry PubNc kM10~Mrtp1
MY comrrussion expires on m~ 1 I-I ~ a~~F lOwEll M>?'I~ON ~. pAUp1~ ~~,
"~ Mi Cam ~ ~ t. TO15
LAST WILL A , D TESTAMENT OF ~ (C~ nI ~ ~~~
Dated: , 20~.