HomeMy WebLinkAbout03-22-13 J 1505610143
REV-1500 EX(ozi 1) tu
PA Department of Revenue OFFICIAL USE ONLY
Pennsylvania County Cade Year File Number
Bureau of individual Taxes Ws^a+ .
PO 80x.280601 INHERITANCE TAX RETURN 21 13 0064
Harrisburg,PA 171284601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
i
12 25 2012 10 12 1929
Decedent's Last Name Suffix Decedent's First Name MI
HEARN SHIRLEY R
(If Applicable)Enter Surviving Spouse's Irdormadon Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW _
�X i. Original Return C 2, Supplemental Return l g Remainder Return(Date or Death
Prior to 12.13-82)
qa,
q. Limited Estate O werw b. Federal Estate Tax Return Required
(data Fw�e ord 1Baer 2-12.82)
8 D edenDie a �a d ruNlLiving Truat
(Att �&WRI) 7. � a, Total Number of Safe Deposit Boxes
9. Litigation Proceeds Received F7 10. bSlrao'aeni2-31 S jtt0a j 1 Deem 11,Election to tax under Sec.9113(4)
(Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATIC111C3HOULD VIRECTED TO:
Name Da@Irle Totepho8 I uffmf r1
MICHAEL L BANGS 7 730 731 n
BEGOT tna OF KLS (*LY
w O, t
First Line of Address
429 SOUTH 18TH STREET
m
Second Line of Address r� u2 0
City or Post Office State ZIP Cade DATE FILED
CAMP HILL PA 17011
Correspondent's e-mail address: ntikebangs@verizon.net
R is hue neel and cartlpbte.Daere caratdon O,t prePerer oel�ei than!mhelpeudrson�al r sa�inta ve Thad ai a8 stta�am�nts,and to the bast of my knowledge and belief,
formation of which preparer has any knotNadis
SIG NATU E pF PERSON RESPONS FOR FILING RETURN J DATE
ADDRESS 7Z a = Kathy J.Hanson
122 South 31st Street,Camp Hill, PA 17011
SIGNATURE OF PREPARER OTHER TF(/W REPRESENTATIVE DA _
� Michael L. Bangs S' ,Z,
ADDRESS
429 South 18th Street, Camp Hill, PA 17011
Side 1
1505610143 1505610143 J
1505610243
REV,l 500 EX
Decedent's Social Security Number
Hearn, Shirley R.
RECAPITULATION
1. Real Estate(Schedule A),... .............................. 1
2. Stocks and Bonds(Schedule B).......... .. 2.
3, Closely Held Corporation,Partnership or Sole•Prophetorship(Schedule C).....
4. Mortgages&Notes Receivable(Schedule 0)...- - .. .....- - __ -........ 4-
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)....._.-_._..... 5. 87,848. 62
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 3,460. 17
7. Inter-Vivos Transfers&Miscellaneous Non;Probate Property
(Schedule G) �j Separate Billing Requested-...._.... 7 3,444 . 60
8, Total Gross Assets(total Lines 1 through 7)... ...... ............. 94, 753 .39
9, Funeral Expenses and Administrative Costs(Schedule H)... 9. 13,784. 67
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 10. 174. 80
11. Total Deductlorm(total Lines 9 and 10)_.-.....__..._.......___..._ ...... 11 13, 959 . 47
12. Not Value of Estate(Line 8 minus Line 11)......... 12. 80 ,793 . 92
13, Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J).................-................ 13,
14. Not Value Subject to Tax(Line 12 minus Line 13)............................................... 14, 80 ,793 . 92
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
16. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under See.9116
(a)(1.2)X ZO 15. 0 . 00
16, Amount of Line 14 taxable
at lineal rate X .045 80,793. 92 16. 3, 4535. 73
17, Amount of Line 14 taxable
at sibling rate X.12 0.00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0. 00 18. 0 . 00
19. TAX DUE, ... ...... ............. ...... ...... ....... ......... 1 .......1111...1., 19. 3 , 635 . 73
20, FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT, 0
Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21-13-0064
Decedent's Complete Address:
DECEDENTS NAME
_ Hearn, Shirley R.
STREET ADDRESS
824 Lisburn Road,Apt.411
CITY..__..------- -- -----, —.._.�..�STATE —. _ I Hill PA 17011
I
Tax Payments and Credits:
1 Tax Due(Page 2, Line 19) (t} 3,635.73
2. Credits/Payments
A. Prior Payments 3,453.94
B. Discount 181.79
Total Credits(A +B) (2) 3,635,73
3. Interest (3)
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 ZO to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This Is the TAX DUE. (5) 0,00
Make Check Pa able 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;................... .......I....I.....,__,.......,..1.1,...11.,............. xx'
b. retain the right to designate who shall use the property transferred or its income c.....
.......,...._..........-.
c. retain a reversionary interest;or...................._..................._.......___............_.........._......_..__..._.......... '� x
d. receive the promise for life of either payments,benefits or care?.,...-......---.................. ....... � x
2. If death occurred after Dec. 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?....... ❑
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary designation?..........._...._.........._...._..........._.......__..........._,__..._......._....._........._.., 5
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 172 P.S.§9116(a)(1.1)(1)],
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 return 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)(12)].
• 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
172 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). A
sibling is defined under Section 9102,as an individual who has at least one parent in common with the decadent,whether by b or adoption.
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Rev-IWO EX.(11-1e)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
oorsloRne��,tioF PErwsnvwu PERSONAL PROPERTY
iN1iERIT�eCE Tr1%RET
RE910EM OECE W
ESTATE OF
Hearn Shirle R. FILE NUMBER
21-13-0064
IndWe tM proceeds d uupetion ens Ure tlele Ne proceeds were received tM estate.
AlI property platlyownee wIM tlro G
rlyM d wMVO,Mip nwst tlIaUOSad
by on seMdula F.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
1 FEdward nes -sing le account 957-11503-1-8;this is an individual account maintained by 84,811.21
nt The estate is the beneficiary of the account
2 Refund from Comcast Cable
29.40
3 Refund from Erie Insurance
55.00
4 Refund from United Health Care
36.60
5 Refund from The Woods
259.86
6 Susquehanna Valley Federal Credit Union
2,656.55
TOTAL(Also enter on Line 5, Recapitulation) 87,848.62
(If more space is needed,additional pages of the same size))
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 11-10)
Rev-1509 EX.(01,101
SCHEDULE F
�w «w A „aF�NNaY YANiA JOINTLY-OWNED PROPERTY
INHERITANCET"REMAM
RE910ENiDECEOEM
ESTATE OF FILE NUMBER
Heam,Shirley R. 21-13-0084
If an sweet wea ewde IWM wlWn one year of the domdenYe date of death.N R 1 be mPQ0*d on schedWe G.
SURVIVING JOINT TENANT($)NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Kathy J. Hanson 122 South 31st Street Daughter
Camp Hill, PA 17011
i
B.
C.
JOINTLY OWNED PROPERTY:
NAME DESCRIPTION OF PROPERTY a DATE of DEATH
ITEM LETTER DATE INCLUDE ER OR SS1MtWY1DENTfY1NG N�Uk19ERAATT SANK ACCOUNT OPkOR DATE OF DEATH OECD'S DECE VALUE MERESr
NUMBER FOR JOIN MADE ALUE OF ASSE
TENANT JOINT JOINTLY-HELD REAL ESTATE. INTEREST
1 A 12/03/2012 M&T Bank-Account 9859753593 3.410.17 100.000% 3,41017
2 A 12/28/1981 M&T Bank-Account 41898788 100.00 50.000% 50.00
TOTAL(Also enter on Line 6,Recapitulation) 3,460.17
(N more space is needed,additional pages of One some Size)
Copyright(c)2010 form software only The Lackner Group,Inc- Form PA-1500 Schedule F(Rev.01-10)
Reu-1510 EX.(0849)
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
C011W ofN�S�u.TH OF PENN511YAraat -
INHERRANCETA%REIVRN
RE910@!T OECEOENi
ESTATE OF FILE NUMBER
Heam, Shirley R. 21-13-0064
This adhadula must be completed and filed if 0te nnawer to any of questions 1 Wough 4 on page fuse of ft REV-1500 is yes.
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ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % DECUS EXCLUSION TAXABLE
NUMBER THE DANE OAF TRAANSFERSATfACII A CIOPY OF THE DEED TO FODEC EAL ESTATE VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1 Edward Jones-IRA 957-92473.1.4;this is an 1444,64 3.444.68
individual Retirement Account maintained solely in
the name of the decedent The beneficiaries on this
account are the decedents three daughters, Kathy J.
Hanson,Barbara R. McNulty and Nancy G.Millard.
TOTAL(Also enter on tine 7,Recapitulation) 3,444.68
pf more space is needed,additional pall"of the game size)
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule G(Rev.08-09)
aEV4151 EX.(10-0)
SCHEDULE H
ooti, A,a FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Hearn, Shirley R. 21.13-0064
Decedent's debts must be reported on Schedule 1.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedules)attached 9,774.18
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zia
Year(s)Commission Paid
2. Attomev's Fees Michael L Bangs 3,500.00
3_ Family Exemption: (if decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Do
Relationshio of Claimant to Decedent
4. Probate Fees 308.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7, Other Administrative Costs 201.99
See continuation schedule(s)attached
TOTAL(Also enter on line 9,Recapitulation) 13,784.67
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Heam,Shirley R. 21-13-0064
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ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Exp2rises
1 An Oide Towne Florist 148.40
2 Giant Foods-funeral luncheon 99.54
3 Parthemore Funeral Home 5,587.17
4 Rolling Green Cemetery-interment and recording fees 995.00
5 Rolling Green Cemetery-urn and headstone 1,283.18
6 Sophia's on Market-funeral luncheon 1,660.89
H-A 9,774.18
Other Administrative Costs
7 Barbara McNulty-miscellaneous expense re:funeral 17,47
8 Cumberland Law Journal-estate advertising 75.00
9 The Patriot News-estate advertising 109.52
H-87 201.99
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1600 Schedule H(Rev.6.98)
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ROV-1512 E%.(12.08)
SCHEDULE 1
DEBTS OF DECEDENT,
�oM.dN NoFReNNen ANw L TGAGE LIABILITIES AND LIENS
hNHERRNILE TNI RETURN
RE510EM dECEPEM
ESTATE OF
Heam, Shirley R. FILE NUMBER
21-13-0064
RePa1 Gbh indurred by the decadent prior to death that remained unpaid at 0M data W death,IncluW
ITEM tW unrsinhburaad madicai expenses.
NUMBER DESCRIPTION VALUE AT DATE
1 Discover Card OF DEATH
11.31
2 Emma Hanson-birthday gift from decedent
25.00
3 Lower Allen EMC
60.00
4 PSERS-Return of unearned benefit
56.25
5 Verizon
22.24
TOTAL(Also enter on Line 10, Recapitulation) 174.80
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group, Inc.
Form PA-1500 Schedule l(Rev. 12-08)
REV-1013".(Of-10)
SCHEDWLE .J
co o)W"'n BENEFICIARIES
ESTATE OF o1 FILE NUMBER
Heam Shirley R.
21-13-0064
NUMBER NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
PERSONS)RECEIVING PROPERTY DECEDENT (Words) ($$$)
I. TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.91 16 a 1.2
1 Emma J. Hanson Granddaughter 1,000.00
122 South 31st Street
Camp Hill, PA 17011
2 Kathy J. Hanson Daughter one-third of 24,928,81
122 South 31st Street residue
Camp Hill,PA 17011
3 Barbra R.McNulty Daughter one-third of 24,928.81
127 North 27th Street residue
Camp Hill, PA 17011
4 Alex S.Millard Grandson 1,000.00
623 Front Street
Catasauqua,PA 18032
5 Nancy G.Millard Daughter one-third of 24,93619
774 Mohawk Street residue
Allentown,PA 18103
See continuation schedule attached Continuation 4,000.00
Total 1 60,793.91
Enter dollar amounts for distributions shown above on fines 15 through 18 on Rev 1500 cover sheet as awwo 'ate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
S.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART ti-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REVA 500 COVER SHE
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01.10)
SCHEDULE J
BENEFICIARIES
(Part I, Taxable Distributions)
ESTATE OF:
Shirley R. Hearn 12/25/2012 162-22-7128
Item Name and Address of persons)
Number Receiving Property Share of Estate Amount of Estate
Relationship (Words) ($SS)
6 Rebecca M.Miller Granddaughter
4613 St. Davids Street 11000.00
Philadelphia, PA 19127
7 Aaron Piscloneri Grandson
5003 Seneca Avenue 1.000.00
Mechanicsburg, PA 17050
8 Elizabeth Piscloned Granddaughter
127 North 27th Street 1,000.00
Camp Hill, PA 17011
9 Jordon Piscloneri Grandson
501 Porsha Terrace 11000.00
Camp Hill, PA 17011
Total 4,000.00
1
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SUSQUEHANNA ✓339 Ea 11 Pa&D
339 East Park Yk H&niAgW&PA 17111-2130
ALLEY Local•717-737-4152
FEDERAL- CREDIT UNION Teff Free: &14$4
Fax 717-737-05;09
March 15,2013
Michael L. Bangs
Bangs law Office,LLC
429 South ISM Street
Camp Hill, PA 17011
RE: Estate of Shirley R. Hearn
The following is the Infomtat"that you requested regarding the awmmts that were held by Shrley
Hearn at Susquehanna Valley FCU. Mrs. Ham had account number 1389,which was a savings account
that was originally opened on April 30,1979. Her husband,Lloyd Hearn,was also on the accamt until
his death.
The value of the account on the date of death was: $2,W.55
Interest accrued from January 1—September 30,2012:S3.06
Interest that had not accrued as of date of death(October 1—December 25,2012):$0.06
An additional$0.01 was earned from December 26—December 31,2012.
Total interest eamed on this account for 2012 was$1.13.
Neese let me know If you have any additional questions.
Kind regards,
Kathy Jo McCabe
Member Services supervisor
WWW. S VFCU . org
® M&TBank
499 Mitchell Road,Millsboro,DE 19966 Adjustment Services
Phone 888-502-4349
Fa (302)934-2955
Bangs Law Office, LLC Januan 29,2013
429 South 18"' Street
Camp Hill, PA 17011
Re: Estate of Shirley R Hearn
Social Security- 162-22-7128
Date of Death: December 25 2012
Dear Sir or Madam:
Per your inquiry on January 22,2013,please be advised that at the time of death, the above-named decedent had
on deposit with this bank the following:
1. Type of Account Checking Account
Account Number 9859753593
Ownership(Names ofi Kathy J. Hanson
ShirleyR Hearn
Opening Date 1210312012
Balance on Date of Death S3.410.17
Accrued Interest S .02
Total S3,410.19
2. Type of A ccount Checking Account
Accorou Number 41898788
Ownership(Name'on Kathy J. Hanson
Shirley R Hearn
Opening Date 1212811981
Balarce on Date of Death 5100,00
Accrued Interest $ 00
Total $ 100.00
I�
i
For any additional information on the above accounts,including ownership and any changes,closures and/or reimbursement of funds,
pkase all the WWhland Park at 717-7373322.
We were unable to locate ROY safe deposit box for the above-mentioned decedent.
TNs ktter does not indude any accounts in which the deceased may have been listed as Power of Attorney,Custodian of Uniform Translem
Reptesentadve Payee,or Trustee under a Written Agreement.
Sincerely,
Valarie Mercer
Adjustment Services
Edward Jones Mark D. gl.
1433 Bridge Street Financial Advisor
New Cuanberland,PA 17070
(7I7)774-5475
Edward jane�
February 13, 2023
Michael L. Bangs, Esq.
Bangs Law Office, LLC
429 South 18th Street
Camp Hill, PA 17011
Re: Estate of Shirley R. Hearn, Deceased
Date of Death: December 25, 2012
SSN of Decedent: 162-22-7128
Dear Mr. Bangs:
In response to your letter dated January 22, 2013, regarding Shirley R. Hearn,
following is the information you requested.
Mrs. Hearn held two (2) accounts at Edward Jones:
1. Account No. 957-11503-1-8:
(a) This is an individual (single) account maintained solely in the name of
Shirley R. Hearn;
(b) The account was opened on December 11, 2006; and
(c) The date-of-death value is $84,811.21.
2. Account No. 957-92473-1-4:
(a) This is an Individual Retirement Account (Traditional IRA) maintained
solely in the name of Shirley R. Hearn;
(b) The account was opened on September 30, 2003; and
(c) The date-of-death value is $3,444 .60.
With respect to your request for the amount of interest earned on the
individual account from January 1, 2012 through December 31, 2012, 1 enclose a
copy of the 2012 Consolidated 1099 generated for the individual account. Also
enclosed for your records is a copy of the 1099-R generated for the IRA.
Under cover of a separate letter enclosed herewith, we are providing you with
the documents required by Edward Jones to liquidate Account No. 957-11503 and to
distribute the proceeds of the IRA account to Mrs. Hearn's three daughters.
Should you have questions or require additional information, please telephone
this office at 774-5475.
Very truly yours,
ara Snsi" Z
ne
g
Senior Branc Office Administrator
/se
Enclosures
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LAST WILLMAND TESTAMENT
OF
SHIRLEY R. HEARN
I, SHIRLEY R. HEARN, of the Borough of New Cumberland, Cumberland
County, Pennsylvania, declare this to be my last will and revoke any
i
will previously made by me. ff
t
= death, I direct that my :portal remains be i
cremated and there be no public viewing of my body.
ITEM II : I bequest the sum of $1, 000 . 00 to each grandchild of
mine living at the time of my death.
ITEM III : I devise and bequeath all the rest, residue and
remainder of my estate, of every nature and wherever situate, in equal j
i
shares to my daughters, BARBARA R. PISCIONERI, NANCY G. MILLARD, and
KATHY J. HANSON, or to their issue, per stirpes .
ITEM IV: I appoint my Co-Executrices and their successors
guardian of any property which passes, either under this will or
otherwise, to a minor and with respect to which I am authorized to i
appoint a guardian and have not otherwise specifically done so,
provided that this appointment of a guardian shall not supersede the
right of any fiduciary in its discretion to distribute a share where
possible to the minor or to another for the minor' s benefit . Such
guardian shall have the power to use principal as well as income from
Page 1 of 4
9
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time to time for the minor' s supp_ort and education (including college
education, both graduate and undergraduate) without regard to his or
her parent ' s ability to provide for such support and education, or to
make payment for these purposes, without further responsibility, to
the minor or to the minor ' s parent or to any person taking care of the
minor .
ITEM V: I appoint my daughters, BARBARA R. PISCIONERI, NANCY G.
MILLARD, and KATHY J. HANSON, Co-Executrices of this my last will .
ITEM VI : No fiduciary acting hereunder shall be required to post
bond or enter security for the faithful performance of her duties in
any jurisdiction.
IN WITNESS WHEREOF, I, SHIRLEY R. HEARN, have hereunto set my
;r y
hand and seal this / I day of � : `-'L �`��' 2004 .
SHIRfEY R. HEARN
SIGNED, SEALED, PUBLISHED and DECLARED by SHIRLEY R. HEARN, the f
`es- rix abcve named, as and for her Last Will and Testament, and in II
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the presence of us, who at her request, in her presence and in the
presence of each other, have subscribed our names as witnesses.
fitness Address
Witness Address
Page 2 of 4
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COMMONWEALTH OF PENNSYLVANIA: _
SS :
CCtaNTY OF CUMBERLAND `
I, SHIRLEY R. HEARN, the Testatrix whose name is signed to the
attached or foregoing instrument, having been duly qualified according
j� to law do hereby acknowledge that I signed and executed this 'instru-
i
meat as my last will; that I signed it willingly and that I signed it
as my free and voluntary act for the purposes therein contained.
i
SHIRLEY HEARN
Sworn to or affirmed to and acknowledged before me by SHIRLEY R.
HEARN, the Testatrix, this �! day of 1Q��IC( t 2004 .
I !
�� II
NQTARM SEAT
ViTH uEN KEIM, Notary Fu5'ic Notary Pu 1 '
r:a:y Cumbef!md 6aro.,Cumb�erlar,'Co.
C0mlltis !on Expires Dec.5,4G6
I �
I
Page 3 of 4
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—_y! .CNWEALTH OF PENNSYLVANIA
: SST:
COUNTY OF CUMBERLAND
We, .l ! el�lf �c� and��4o`
the witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, depose and say that
we were present and saw Testatrix sign and execute the instrument as
her last will; that Testatrix signed willingly and "W-"r executed
�l
as her free and voluntary act for the purposes therein expressed;
i
that each of us in the hearing and sight of the Testatrix signed the
will as witnesses; that to the best of our knowledge, the Testatrix
was at that time eighteen or more years of age, of sound mind and
under no constraint or undue influence.
Witness
Witness
//
Sworn to or affirmed to and ackno edged before me by
andJ �-_._._��.,
witnesses, this _ day of 2004 .
Notary Publ
NO-TARIAL SEAL
KJ,I'ti Er4V PxOM, Notary Public
N.vi Cart>er!antl Bow,ComberllGr�d
ath�W C� oyy+..
N y Commission Expires bee.J,LU
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