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HomeMy WebLinkAbout04-01-13 PETITION 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: Mary E.Roberts File No: JlD a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: 213-01-6116 Date of Death: i:Q o�'�-?' �Q /`� Age at death: 94 T Decedent was domiciled at death in Cumberland County, Pennsylvania (State) with his/her last principal residence at 92 North Old Stone House Road,Carlisle PA 17015 Silver Spring Township Cumberland County Street address,Post Office and Zip Code City,Township or Borough County Decedent died at 92 North Old Stone House Road,Carlisle PA 17015 Silver Spring Township Cumberland Co. Pennsylvania Street address,Post Office and Zip Code City,Township or Borough County State Estimate of value of decedent's property at death: If domiciled in Pennsylvania.... . .. ... . . . . . ... . .. . . . . .. . All personal property $ 5,000.00 If not domiciled in Pennsylvania. . . . . ... . . . . . . . .. . . . . . . . Personal property in Pennsylvania $ ` If not domiciled in Pennsy lvania. . . . . . . . .. . . . . . . . . . . . . . . Personal property in County $ Value of real estate in Pennsylvania.. . . . . .. . . . . . . . . . . . .. . . . . . ... . . . . . . . . . . ... . . . . . . . . . . . .. . . $ TOTAL ESTIMATED VALUE. . . . $ 5,000.00 Real estate in Pennsylvania situated at; N/A (Attach additional sheets, if necessary.) Street address,Post Office and Zip Code City,Township or Borough County A. Petition for Probate and Grant of Letters Testamentary Petitioner(s)aver(s)he/she/they is/are the Executor(s)named in the last Will of the Decedent,dated January 30,2009 and Codicil(s) thereto dated N/A State relevant circumstances(e.g.renunciation,death of executor,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. Q NO EXCEPTIONS ©EXCEPTIONS N/A Fri C7 c'' rn C 7 © B. Petition for Grant of Letters of Administration (If applicable) � °� c.t.a., d.b.n., d.b.n.c.t.a.,pendent�te�utapte crb3�entia,q�u me minoritate Ts s If Administration,ca.a. or db.n.c.t.a., enter date of Will in Section A above anAaai bete Hst of RiH. x, CP C:, - Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds f6Rivdre?7had b=esf 5lis d as defined in 23 Pa.C.S. §3323(g)and was neither the victim of a killing nor ever adjudicated an incapacitated pe`TssoR Q Q NO EXCEPTIONS 0 EXCEPTIONS ' C-0 e Petitioner(s),after a proper search has/have ascertained that Decedent left no Will and was survived by the f(dlomg spou"'Iif any n3heirs(attach additional sheets, if necessary): '- Name Relationship Address Form RW-02 rev. 10/11/2011 Page 1 of 2 Oath of Personal Representative Official Use Only COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF CUMBERLAND } Petitioner(s)Printed Name Petitioner(s)Printed Address Betty L. Lehman 92 North Old Stone House Road Carlisle PA 17015 The Petitioner(s)above-named swear(s)or affirm(s)the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s)and that,as Personal Representative(s)of the Decedent,the Petitioner(s) '11 well and truly administer the estate according to law. Sworn to oraffirmed a d sub cribed before /emu Date J me S day Date gy AMA Date For the Register Date BOND Required: Q YES Q NO To the Register of Wills: FEES: Please enter my appearance by my signature below: Letters . . . . . . . . . . . . . . . . . . . . . . $ • Attorney Signature: ( (Q ) Short Certificate(s). . . . . . PT-an ( )Renunciation(s).. . . . . . . . ( ) Codicil(s). . . . . . . . . . . . . ( )Affidavit(s).. . . . . . . . . . . Bond.. . . . . . . . . . . . . . . . . . . . . . . Printed Name: Mark E. Halbruner Commission. . . . . . . . . . . . . . . . . . Supreme Court Other . . . . . . . . ID Number: 66737 . . . . . . . I S . . . . . . . . Firm Name: Gates,Halbruner,Hatch&Guise, P.C. . . . . . . . . Address: 1013 Mumma Road_ Suite 100 . . . . . . . . Lemoyne PA 1704 ! rn Phone: (717)731-9600 C:, Automation Fee. . . . . . . . . . . . . . . D Fax: (717)731-9627 r— JCS Fee. st� r— �' �o- Email: m halhnmPr(a�u tPa� cnr>w"'' TOTAL. . . . . . . . . . . . . . . . . . . . . CD C� DECREE OF THE REGISTER c^ = ;-•t �1 1 Estate of Mary E.Roberts File No: 02 I -) —oaA a/k/a: AND NOW, in consideration of the foregoing Petition, satisfactory proof having been presented before me,IT IS DECREED that Letters Testamentary are hereby granted to Betty L. Lehman in the above estate and(if applicable)that the instrument(s) dated January 30 2009 _ described in the Petition be admitted to probate and filed of record as the last Will (and Codici (s)) of Decedent. r Register of Wills ) Form RW-02 rev.10/11/2011 Page 2 of 2 � C> C p q W :::o LAST WILL AND TESTAMENT rn wn r 1 OF M ►� MARY E.ROBERTS -n ..-n.n � cz I,MARY E.ROBERTS, a resident of Cumberland County, Pennsyly ih i�;do pu sli�h aFA declare this to be my Last Will and Testament, hereby revoking all other prio6 wills andwodicff made by me. FIRST: Family Background and Appointment of Executor. (A) Family and Background Information. I am not married. I am the widow of HARRY L. ROBERTS. I have three children, HARRY E. ROBERTS, BETTY L. LEHMAN and PAUL M. ROBERTS, and they will be referred to as"my children"throughout this Will. (B) Appointment of Executor. I appoint my daughter, BETTY L. LEHMAN, to act as Executor, and if she dies, becomes incapacitated, resigns or does not complete the duties of Executor, then I appoint my granddaughter, TERESA GILBERT, to act as Executor. The aforenamed persons are all hereinafter referred to as"Executor",and they shall serve without bond and without being required to account to any court. The Executor shall serve as Trustee of all trusts created under this Will, and when acting as Trustee, the Executor shall have such powers as are otherwise granted under this Will to the Executor. SECOND: Funeral and Last Illness Expenses: Taxes. (A) Expenses of Funeral and Last Illness. I direct my Executor to pay my funeral expenses and the expenses of my last illness from my estate. (B) Taxes. I direct my Executor to pay any and all estate,inheritance,succession,legacy, transfer and other death taxes or duties,by whatever name called,including any and all interest and penalties thereon, imposed under the laws of any jurisdiction by reason of my death,upon or with respect to any and all property included in my gross estate for the purpose of such taxes, whether such property passes under or outside of this Will,out of my residuary estate,without being prorated or apportioned among or charged against the respective devisees,legatees,beneficiaries,transferees or other recipients of any such property or charged against any property passing or which may have passed to any of them. The Executor shall not be entitled to reimbursement for any portion of any such taxes from any such person. THIRD: Tangible Personal Property. Except for those items excluded below and those items enumerated in the Letter of Instruction,I bequeath all my tangible personal property,including but not limited to clothing,jewelry, furniture, household furnishings, household goods, personal effects,motor vehicles,and all other similar articles which I own,and the insurance thereon,to my children and the then-living issue of any child who does not survive me,to be divided among them as they may select in as nearly equal shares,per stirpes,as is practical. If there is any disagreement LAST WILL AND TESTAMENT OF MARY E. ROBERTS PAGE 2 as to distribution,the decision of my Executor shall be binding. Any items not selected may be sold, donated to charity,or discarded in the sole and absolute discretion of my Executor,and if sold,the net proceeds therefrom shall be added to the residue of my estate. Tangible personal property shall not include: (1)any and all property used by me in any business, (2)cash on hand or on deposit in banks, (3) stock or securities, (4) any type of evidence of indebtedness and (5) any life, health or accident insurance policies. The reasonable costs of protecting, appraising, packing, storing, shipping,cleaning,delivering and insuring all items distributed in this Article THIRD shall be paid as expenses of administering my estate. Notwithstanding any other provisions in this Article THIRD,I may leave a separate, dated and unsigned Letter of Instruction,which I shall place with this Will, containing directions for the ultimate disposition of certain items of my tangible personal property,and the Letter of Instruction shall determine the distribution of such items. FOURTH: Residuary Estate. (A) I give,devise and bequeath all the rest,residue and remainder of my estate,of every kind and character, real, personal and mixed, tangible and intangible, and wherever situated, including any lapsed or renounced legacies, devises or residuary bequests and any property over which I may have a power of appointment,in equal shares to my children who survive me;provided, however,if my daughter,BETTY L.LEHMAN,does not survive me,her share shall be distributed to her then-living issue in equal shares,per stirpes. (B) The shares of my sons, HARRY E. ROBERTS and PAUL M. ROBERTS, shall each be held in separate trust according to Article FIFTH,below. The share of any other beneficiary who is at least twenty-five (25) years old shall be distributed outright to such beneficiary as soon as reasonably practical. The share of any beneficiary who is less than twenty-five (25) years old shall be held by the Executor in separate trust for the beneficiary until the beneficiary becomes twenty-five(25) years old, and in the meantime the Executor shall use as much of the income and principal of the separate trust as the Executor,in the Executor's sole and absolute discretion,deems appropriate to provide for the proper health,maintenance,support and education of the beneficiary taking into account other resources available to the beneficiary. If the beneficiary dies before becoming twenty-five (25) years old, the balance of the beneficiary's separate trust shall be distributed to the personal representative of the beneficiary's estate. (C) Prior to final distribution of my estate,the Executor,in the Executor's discretion,may make partial distributions to one or more beneficiaries or trusts. As a consequence,the executorship LAST WILL AND TESTAMENT OF MARY E. ROBERTS PAGE 3 and any trusts created under this Will may exist contemporaneously. A distribution may be made subject to any indebtedness or liability of my estate. FIFTH: Trusts for Harry E.Roberts and Paul M.Roberts. The shares of HARRY E. ROBERTS and PAUL M.ROBERTS(each referred to as"the Beneficiary"in this Article FIFTH), shall each be administered by the Executor in separate trust according to the following terms: (1) This separate trust is established for the purpose of improving the Beneficiary's quality of life for and during all the term of his natural life. The Beneficiary may suffer from substantial disabilities that require medical care. The Beneficiary may be entitled to benefit from various governmental programs which provide for his basic or supplemental care. It is the purpose of this separate trust to provide the Beneficiary with a higher quality of life beyond that which would be provided by these public entitlement programs and to provide him with a proper funeral and burial. (2) I intend that the Executor use this separate trust to promote the happiness, welfare and benefit of the Beneficiary through income and principal distributions,without in any way reducing the services or financial assistance and basic maintenance, support, medical or dental care which the Beneficiary may receive without charge from any local, state or federal government agency or department thereof,and without using any portion of the trust income or principal to reimburse any local, state or federal government agency or department thereof for basic maintenance, support, medical or dental care received by the Beneficiary. The trust income and principal are not to be considered income, assets nor resources of the Beneficiary for any purpose,including but not limited to,the determination of income,assets or resources as stated in any rules or regulations set forth in any local,state or federal government agency or department thereof. If the Executor is requested by any department or agency to release principal or income of the trust to or on behalf of the Beneficiary to pay for equipment, medication or service which other organizations or agencies are authorized to provide, or if the Executor is requested by any department or agency administering such benefits to petition the court or any other administrative agency for the release of trust principal or income for this purpose, the Executor shall deny such request and shall defend at the expense of the trust estate,any contest or other attack of any nature. (3) The Executor shall distribute to the Beneficiary,or expend and apply for his benefit, so much of or all of the income and principal of this trust, as the Executor, in the Executor's sole and absolute discretion, determines to be advisable for the Beneficiary's LAST WILL AND TESTAMENT OF MARY E. ROBERTS PAGE 4 supplemental needs for happiness and comfort to achieve the purpose of the trust herein set forth. The"supplemental needs"which the Executor may provide to the Beneficiary include, but are not limited to, spending money, additional food,clothing,gifts on his birthday and major holidays, small appliances that would provide the Beneficiary with entertainment or amusement,computer equipment,camping excursions,vacations,athletic contests,movies, trips, money to purchase appropriate gifts for relatives and friends, any recreational items that would be of use to him and other monetary requirements to enhance his self-esteem or situation. "Supplemental needs" shall also include medical and dental expenses, annual independent check-ups,rehabilitation and physical therapy equipment,programs oftraining, education, treatment, physical therapy and rehabilitation, private residential care, eye glasses,transportation(including vehicle purchase),maintenance,and insurance(including payment of premiums of insurance on the life of the Beneficiary) and other requisites for maintaining the good health, safety, and welfare of the Beneficiary when, in the sole and absolute discretion of the Executor, such requisites are not being provided by any public agency, office, or department of any state or of the United States. Nothing herein shall preclude the Executor from purchasing those services and items which promote the Beneficiary's happiness, comfort and welfare. (4) Any net income not expended for or applied to the supplemental needs of the Beneficiary shall be accumulated and added to the trust principal. (5) The Executor shall have no obligation to expend trust assets for the Beneficiary's supplemental needs, but if the Executor, in the Executor's sole and absolute discretion, decides to expend trust assets, under no circumstances should any amounts be paid to,or reimbursed to,the federal government,any state,or any governmental agency for any purpose, including for the care, support, and maintenance of the Beneficiary. This separate trust is created expressly for the Beneficiary's extra and supplemental care, maintenance, support and education in addition to, and over and above the benefits he otherwise may receive as a result of handicap or disability, from any local, state or federal government,or from any other private agency,any of which provides service or benefits to persons with disabilities. (6) Because the Beneficiary may be dependent on the support and aid of others, the Executor shall,in the exercise of the Executor's best judgment and fiduciary duty, seek support and maintenance for the Beneficiary, or request the guardian of the Beneficiary to seek support and maintenance for him,from all available public resources,including,but not limited to, Social Security Administration benefits, the Supplemental Security Income LAST WILL AND TESTAMENT OF MARY E. ROBERTS PAGE 5 Program (SSI), any such supplemental income program offered by or through the Commonwealth of Pennsylvania, the Old Age Survivors and Disability Insurance or successor programs,U.S.Civil Service Commission benefits,Medicaid,and Federal Social Security Disability Insurance(SSDI),and any other comparable programs,state,federal,or local. The Executor shall take into consideration applicable resource and income limitations of any public assistance programs for which the Beneficiary is eligible when determining whether or not to make any discretionary distributions. If necessary,the Executor may seek appropriate authority to collect, expend, and account for separately all such governmental assistance benefits, but shall not commingle them with these trust assets. In addition, in making distributions for the supplemental needs of the Beneficiary,the Executor shall take into consideration the applicable resource limitations of the public assistance programs for which the Beneficiary is or may become eligible. (7) The Executor shall not be required to make an accounting to any public official except to the extent otherwise required by law. All discretion conferred on the Executor shall be absolute and unlimited, and its exercise by the Executor shall be conclusive and binding on all persons. (8) The Executor shall pay reasonable burial expenses including a proper grave marker for the Beneficiary. (9) Upon the death of the Beneficiary, the remainder of this trust shall be allocated and distributed according to Article FOURTH, above. (10) When acting as trustee,the Executor shall have such powers as are otherwise granted under this Will to the Executor. SIXTH: Spendthrift Provision. No beneficiary shall have the power to anticipate, encumber or transfer his interest in the estate or any trust estate in any manner. No part of the estate or any trust estate shall be liable for or charged with any debts, contracts, liabilities or torts of a beneficiary or subject to seizure or other process by any creditor of a beneficiary. SEVENTH: Powers of Executor. In addition to such powers and duties as may have been granted elsewhere in this Will or by law,but subject to any limitations stated elsewhere in this Will, the Executor shall have and exercise exclusive management and control of the estate and shall be vested with the following specific powers and discretion: LAST WILL AND TESTAMENT OF MARY E. ROBERTS PAGE 6 (A) In the management, care and disposition of the estate, the Executor shall have the power to do all things and to execute such instruments as may be deemed necessary or proper, including the following powers, all of which may be exercised without order of or report to any court: (1) To sell, exchange or otherwise dispose of any property at any time held or acquired hereunder, at public or private sale, for cash or on terms, without advertisement, including the right to lease for any term notwithstanding the period of the estate,and to grant options, including any option for a period beyond the duration of the estate. (2) To invest all monies in such stocks, bonds, securities, mortgages, notes, choses in action,real estate or improvements thereon,and any other property as the Executor may deem best, without regard to any law now or hereafter enforced limiting investments of fiduciaries. (3) To retain for investment any property deposited with the Executor. (4) To vote in person or by proxy any corporate stock or other security and to agree to or take any other action in regard to any reorganization, merger, consolidation, liquidation, bankruptcy or other procedure or proceedings affecting any stock, bond, note or other security. (5) To use attorneys, real estate brokers, accountants and other agents if such employment is deemed necessary or desirable,and to pay reasonable compensation for their services. (6) To compromise,settle or adjust any claim or demand by or against the estate and to agree to any rescission or modification of any contract or agreement affecting the estate. (7) To renew any indebtedness, as well as to borrow money, and to secure the same by mortgaging,pledging or conveying any property of the estate,including the power to borrow from the Executor at a reasonable rate of interest. (8) To retain and carry on any business in which the estate may acquire an interest,to acquire additional interest in any such business,to agree to the liquidation in kind of any corporation in which the estate may have an interest and to carry on the business LAST WILL AND TESTAMENT OF MARY E. ROBERTS PAGE 7 thereof,to join with other owners in adopting any form of management for any business or property in which the estate may have an interest,to become or remain a partner,general or limited, in regard to any such business or property and to hold the stock or other securities as an investment,and to employ agents and confer on them authority to manage and operate the business,property or corporation,without liability for the acts of such agent or for any loss,liability or indebtedness of such business if the management is selected or retained with reasonable care. (9) To register any stock, bond or other security in the name of a nominee, without the addition of words indicating that such security is held in a fiduciary capacity,but accurate records shall be maintained showing that such security is an estate asset, and the Executor shall be responsible for the acts of such nominee. (B) In making distributions from the estate to or for the benefit of any minor or other person under a legal disability,the Executor need not require the appointment of a guardian but shall be authorized to pay or deliver the same to the custodian of such person,to pay or deliver the same to such person without the intervention of a guardian,to pay or deliver the same to a legal guardian of such person if one has already been appointed, or to use the same for the benefit of such person. (C) In the disbursement of the estate and any division into separate shares,the Executor shall be authorized to make the distribution and division in money or in kind,or both,regardless of the basis for income tax purposes of any property distributed or divided in kind,and the distribution and division made and the values established by the Executor shall be binding and conclusive on all persons taking hereunder. The Executor may in making such distribution or division allot undivided interests in the same property to several shares. (D) The Executor shall be authorized to lend or borrow,including the right to lend to or borrow from my estate or any trust created by me during my life or by will at an adequate rate of interest and with adequate security,and upon such terms and conditions as the Executor shall deem fair and equitable. (E) The Executor shall be authorized to sell or purchase at the fair market value, as determined by the Executor,any property to or from my estate or any trust created by me during life or by will, even though the same person or corporation may be acting as executor of my estate or as trustee of any of my trusts. LAST WILL AND TESTAMENT OF MARY E. ROBERTS PAGE 8 (F) The Executor shall have discretion to determine whether items should be charged or credited to income or principal or allocated between income and principal as the Executor may deem equitable and fair under all the circumstances,to treat any part or all of the profit resulting from the maturity or sale of any asset, whether purchased at a premium or at a discount, as income or principal or apportion the same between income and principal, to apportion the sales price of any asset between income and principal,to treat any dividend or other distribution of any investment as income or principal, or apportion the same between income and principal, to charge any expense against income or principal or apportion the same, and to provide or fail to provide a reasonable reserve against depreciation or obsolescence on any assets subject to depreciation or obsolescence, all as the Executor may reasonably deem equitable and just under all the circumstances. (G) The Executor shall have discretion to disclaim on my behalf any interest, in whole or in part, in property passing(i)by intestate or testate succession, (ii)by inter vivos transfer, (iii) by joint tenancy or tenancy by the entirety, (iv) from any life insurance policies, annuities or other accounts having designated beneficiaries, "pay on death" beneficiaries or "transfer on death" beneficiaries,(v)under any trust,and(vi)from any other source. The Executor shall be authorized to execute an appropriate writing and to perform all acts necessary to make a qualified disclaimer as defined by the Internal Revenue Code and regulations. EIGHTH: Rights and Liabilities of Executor. No bond or other security shall be required of the Executor. This instrument shall always be construed in favor of the validity of any act or omission by the Executor. The Executor shall not be liable for any act or omission except in the case of gross negligence, bad faith or fraud. Specifically, in assessing the propriety of any investment,the overall performance of the entire estate shall be taken into account. The Executor shall be entitled to reasonable compensation for services actually rendered to my estate and reimbursement for reasonable expenses incurred in the performance of such services. NINTH: Tax Elections. In determining the estate, inheritance and income tax liability relating to my estate,the Executor's decision as to all available tax elections shall be conclusive on all concerned. In accordance with Internal Revenue Code§2632(a)(or its successor provisions)and without regard to whether a federal estate tax return is actually filed,the Executor shall allocate so much of the federal Generation Skipping Transfer(GST)exemption amount as will fully exempt any generation skipping transfer which may occur under this Will. ✓��r , LAST WILL AND TESTAMENT OF MARY E. ROBERTS PAGE 9 TENTH: Definitions and General Provisions. (A) Survival. Any beneficiary who dies within sixty(60) days after my death shall be considered not to have survived me. (B) Trust Estate. "Trust estate" means all assets, however and wherever acquired, including income,which may belong to a trust at any given time. (C) Issue. In making a distribution to the issue of any person, the property to be distributed shall be divided into as many shares as there are living children of the person and deceased children of the person who left children who are then-living. Each living child shall take one share,and the share of each deceased child shall be divided among his then-living descendants in the same manner. A posthumous child shall be considered as living at the death of his parent. (D) Other terms. The use of any gender includes the other gender,and the use of either the singular or the plural includes the other. (E) Captions. The captions set forth in this Will at the beginning of the various divisions hereof are for convenience of reference only and shall not be deemed to define or limit the provisions hereof or to affect in any way their construction and application. (F) Powers of Appointment. By this Will,I exercise any powers of appointment which I possess at the time of my death. [This space has been intentionally left blank. The signature page follows next.] �. t �� LAST WILL AND TESTAMENT OF MARY E. ROBERTS PAGE 10 IN WITNESS WHEREOF, I, MARY E. ROBERTS, the Testator, have to this my Last Will and Testament,typewritten on eleven(11)pages,including the Acknowledgment and Affidavit, set my hand and seal this _±yp411_N day of , 2009. MARY(4 ROBER S Signed, sealed,published and declared by the above-named Testator, as and for her Last Will and Testament, in the presence of us, who have hereunto subscribed our names at her request, as witnesses hereto,in the presence of the said Testator,and in the presence of each other. Each of us further declares that he believes the Testator to be of sound mind and memory. The preceding instrument consists of this and ten(10)other consecutively numbered typewritten pages including the Acknowledgment and Affidavit. �_ esiding at Mechanicsburg, Pennsylvania Mark E. Hal runer, Witness residing at Boiling Springs, Pennsylvania Carol L. Frankland,Witness ACKNOWLEDGMENT AND AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF CUMBERLAND The Testator and the witnesses whose names are signed and subscribed to the attached or foregoing instrument,being first duly sworn and qualified according to law,do hereby acknowledge, depose and say to the undersigned authority, that the Testator signed and executed the instrument as her Last Will in the presence of the witnesses; that she signed it willingly or willingly directed another to sign it for her;that she executed it as her free and voluntary act for the purposes therein expressed; that each of the witnesses were present and saw the Testator sign and execute the instrument as her Last Will; that each subscribing witness in the hearing and sight of the Testator signed the will as witnesses; and that to the best of their knowledge the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. Mary oberts,Testator ��cf `� - (��,�,�-Q� of • ��J� Mark E. Halbruner,Witness Carol L. Frankland, Witness Sworn to or affirmed, subscribed to, and acknowledged, before me by the above-named Testator and witnesses, this � day of SSG.^ 12009. COMMONWEALTH OF PENNSYLVANIA otary ublic Notarial Seal Teri L Walker,Notary Public Lemoyne Boro,Cumberland County My Commission Expires Jan.20,2011 Member,Pennsylvania Association of Notaries _105.805 REV(9/11) LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. °ee for this certificate, $6.00 RECORDED F This is to certify that the information here given is s + r t� correctly copied from an original Certificate of Death REGISTER OF ',` N" yf`: l; duly filed with me as Local Registrar. The original p =- z certificate will be forwarded to the State Vital L013 RPR 1 tl , y Records Office for permanent filing. P 19474823 CLERK 0'( - - MENT OE ' Certification Number O R P H A N S COURT ""''III Local Registrar Date Issued rye/Print In C WEAL ENNSYIVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS ^en1 CUMBERLAND " "'° �eERTIFICATEOFDEATH Black Ink State File Number: 1.Decedent's legal Name(Fiat Middle,Last,Suffix) 2.Sex 3.Social Securing Number 4.Drte of Death(Mp/Day/Yrl(Spell Mo) Mary Elizabeth Roberts Prole 213-01-6116 March 7, 2013 5a,Age-Last Birthday(Yrs) Sb.Under l Year I St.Under 1 Da 6.Date of girth IMO/Day/Yean(Spell Month) 7a.8111plate(City and State or Foreign Country) Months Dm Hours Minutes t 9 marviand 4 November 21, 1918 71,.Birthplace(County) Be.Residence(State or Foreign Country) 81r Residence(Street and Number-include Apt No.) Bc.Did Oecedem live In a Townshlpi lvania 92 N. Old Stone House Road a KVhim,OgYey dedmt ed in Silver Spring t . Ed.Reaidenu(Couns"I Clnnberland Be.Resldence(Zip Code) 170155 ❑No,decedent lixed within limits of tlty/born. 9.Ever b USArmed Forces? 10.Marital Status at Time of DeaM ❑Manned Widowed 11.SuMSdng Spouse's Name(If wife,glue name prior to flrst marriage) 0 Yes ®No 0 Unk-n 0 Dlvorted 0 Never Married 0 Unknown 12.Father's Name(First,Middle,Last,Suffix) 13.Mother's Name Prior to First Marriage(First Middle,Last) Eugene McKim Clara Tinder lb.Informant's Name idb.Relationship to Decedent 14c.Informant's Mailing Address(Street a;d Number,City,State,Zip Code) 17015 i Betty L. Lehman Dau ter 2 N. Old Stone House Road Carlisle PA G ................ ....................... ......................................,..............: pate of Den ............... ccur..._..............n th e_one......ospital:............ a N Death Oauned in s Hapkal: ❑Inpatient ;lf Death Occurred Somewhere Othec Than a Hospital: 17 Hpspke faNllry �Decedent's Home O ❑Emergency Room/OutpeNent ❑Dead on Amval ❑Nursing Home/Long-Term Care faNIIN Other(SPKUy) ffiS 151b.Fatlgry Name(if not Institution,ghe street and number, I5c City or Town.State,and Zip Code 15d.County of Death 92 N. Old t CLm)berland 16a.Method of OHpotltlon X1 Burial 0 Cremation 16b.Data of Depalti0n ]&.wxe of D4posMpn(Name of cemetery,crematory,or other plan) E ❑Removal f pm state ❑Dmanon MarCh 11, 201 Rolling Green Cemetery € omec(spitting) 16d.Location of Deposition(City ce Town,State,and Zip) 17x.SI{natu nerel Service ee or Peron In Charge of Interment 17b.Liceme Number Camp Hill PA 17011 �C p �_ FD-138630 F 3 17cM1pe ed Complete Addr a Funeral facility zzi Funer Hone 8 Market P aza Na y, M41�cSbUra. PA Decedent's Education-Check the boa that beet describes the 19.Decedent of Hispanic Origin-Check the 20.Decedent's Rau-Check ONE OR MORE racec to Indicate what highest degree or eve of school completed at the time of death, boa that best descrlbes whether the decedent the decedent considered himself or herself to be. 0 Bill,grade or less Is Spanish/Hisp,Mc/Latino.Check the-No' White C Korean CX No diploma,9th-12th grade boa N decedent is not Spnish/Hispanic/labno. 0 Black or Afrkan American 0 Vietnamese High school graduate or GED completed No,not Spanish/Hispanic/Latino 0 American Indian or Alaska le- ❑Other blast ❑Some college credit,but rw degree ❑Yes,Mexican,Mexican American,Chicano 0 Aalen Indian 0 Nathe Hawalen 0 Auoelate degree(e.g.AA,AS) 0 Yes,Puerto inc- 0 Chinese 0 Guamanian or Cha norm 0 Bachelor.,degree Is.{.BA,AB,BS) 0 Yes,Cuban 0 FIIIPirw 0 Samoan ❑Master's degree(e.{.MA,MS,MfrL MEd,MSW,MBA) 0 Yes,other Spanish/Hlspenic/Latino 0 Uperese 0 Other Pacific Islander ❑DKtorate(e.g.PhD,EdD)or Professional degree (Specify) ❑other(specify) e..MO DDS DVM LLB ID Zl.Decedent's SIMIe Race Wf-Dedgnatlon-Check ONLY ONE to Indlate what the decedent considered himself or heael(to be.22a.Decedent's Usual Occupation-Indicate type of woA ]a White olapnese 0Samoa, done during most of-king life.DO NOT USE RETIRED, 0 Black or African American ❑Korean 0 Other Pacific Island., Htxnsnaker 0 American Indian or Alaska Native 0 Vietnamese C on Don't Know/Not Sum 0 Asian Indian 0 Other Asian 0 Refused 22b.Kind of Business/Indusny ❑Chinese 0 Nathre Hawaiian ❑Other(specify) 0 Filipino 0 Guamanian or Chamorro Own Hone REM&23x-211 MUST BE COMPLETED 23a.Date Pro munced Dead(MO Day/Yt) 23b.Signature of Person Pronouncing Death(Only when applicable) 121,License Number BY PERBON WHO PRONOUNCES Ose CERTIFIES DEATH 2211.Data Slpud jMO/DAy/Yr) 24.Time of Death 12:45 AM 75.Was Medical Examiner or Coroner COnacted7 0 Yes E No CAUSE OF DEATH Approximate 26.Part 1.Enter the chain of everts-diseases,injuries,or complkatbns--that directly caused the death.DO NOT enter terminal events such as Card arrest Interval. respiratory asst or ventricular fibrillation Wth,ut shpwing the�tiology.�DO NOT ABBREVIATE.Enter only one auu Praline.Add additional lines if necesury Onset to Death IMMEMATECAUSE (Final disease or condition .due to(or as a cp,�e0uena o0' refuhln,In death) b. SeOuentially list conditions, Due to(or as a mans rance on: If ant',boding to the cause listed on line a.Enter the 1. UNDEMYINO CAUSE Due to(or as a consequence of): (diseases or Mjury that Initiated the events resuhing d. In death)IAST. Due to(or a a-sequence oQ. 26.Part Il.Enter other simif-t conditions c-brihutina to death but not resullMg In the undeMing uuu given in Part l 27.Wass"autopsy performedl a C Yes Q No f 121.Were autopsy findings a,,liable s to complete the cause tdeaMi 9 0 Yes 'glo 1 29.If Female 30 Did Tobacco Use Contribute to Oeathi 31,f`1a near of Death Eo 0 Not pregnant within past year ❑r-,�Yes 0 Probably (�Natuai 0 Homicide C Pregnant at time of death 0 0 C Unknown 0 Accident C Pending Investigation 0 Not pre mmL but pregnant within 42 days of death C Suicide 0 Could not be determined 0 Not pre:re'L but pregnant 43 days to I year before death 32.Data of Injury(MO/Day/Y'r)(Spell Month) 0 Unknown If Pregnant Mthin the past year 33.Time of Injury 34.Place of Injury(a.,.home;construction site;farm;school) 35.Location of Injury(Street and Number,City,State,Zip Code) 36.Injury at Work 137.If Transportation Injury,Specify: 38.Describe HOw Injury Occurred: 0 Yes 0 Drher/Operator C PedesMan 0 No 0 Passenger 0 Other j5peclfy) 39,x,.C/ertBkr(Cheri onh one): p 6rtgying peZ.0 -To the best of my kn M dge,death occurred due to the cause(s)and manner stated -C Pronouncing B CertlMng physkbn the best of my knowledge,death ocarred at the time,date,and place,and due to the cause(s)and manner stated C Medial Eseminer/Coroner-On tine sit f {minatbn,and/or Investigation,In my opinion,death octuned at the time,date,and plate,and due to the cause(s)and manner stated Signature of ceMfln: % Title of certifier: 1A Ucense NUmber_AW y�9177 39b.Name,Addrm and 21p[a o Pe Completing base of Death Ilteln 261 �F'S r 39c.Date S red Mo/Day/Yrl a Ad eJallaas-Y, gYL.ng. �3o<• L<..da.-dr ��_ F7FOry 3 � /3 ID.R fs�stNtt Nu I ear 4I.Reglyrars naeurt 42.RegeUar Fne Da Mo Dav r) r^) /y1 X11 rw/ I('�7 3 r 8 ,a 43.Amendments D<„nn,mn P.-I Nn 0819594 .11105-143