HomeMy WebLinkAbout11-26-13 (3) J ,� 150561,0149
REV-1500 �`�02_">�F'>
P���� OFFICIAL USE ONLY
PA Department of Revenue °`�"`""°"`
Countv Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX 280601 21 13 D 9 6 9
Hanisburq,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYW Date of Birth MMDDWW
09 OS 2D],3 11 17 1920
DecedenYs Last Name Suffix DecedenYs First Name MI
Henry �leo F
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Socia�Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original Retum O 2. Supplemental Return p 3. Remainder Retum(Date of Death
Prior to 12-13-82)
O 4.Limited Estate � 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
� 6.Decedent Died Testate p 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
p 9.Litigation Proceeds Received Q 10. Spousal Poverty Credit(Date of Death Q 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT—THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone N�er
Elyse E • Rogers, Esquire 71 6 2 58�1, �+ �°
� � � nn
� � � c�
�E� F SU
r M �
�� � � �' �o c�
First Lme of Address ;� � �
Saidis, Sullivan 8 Rogers ° � c� � `'� ..`�',�
� � � �
Second Line of Address � � �,,� �— �
.
635 North 12th Street, Suite 400 ��'. c� c �
DATe"�It.ED
City or Post Office State ZIP Code
Lemoyne PA 1,7043
Correspondent's e-mail address: erogers@ssr-attorneys.COm
Under penalties of peryury,i declare that I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and corr�lete.Declaration of preparer other than the personal represerrtative is based on all information of which preparer has any knowledge.
SIG U OF PERSON ESPON LE FOR FILING RETURN DATE
�s��/3
ADDRESS 2 Fairway rive
Camp iil, PA 17011
SIGN OF PREP R ER THAN REPRESENTATNE DATE
ADDRESS 35 Of�h re t
Lemoyn PA 17043
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1,50561,01,49 1505610149
�
��
�
� 1505610249
REV 1500 EX(FI)
Decedent's Social Security Number
Cleo F Henr
DecedenYs Name: Y
RECAPITULATION
1. Reai Estate(Schedule A).......................................... 1. � • ��
2. Stocks and Bonds(Schedule B) ........ ............................ 2. � •�0
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0 • ��
4. Mortgages and Notes Receivable(Schedule D) ...................... ... 4. � •��
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E) . ..... 5. 2 4 ,4 8 9 • 4 8
6. Jointly Owned Property(Schedule F) p Separate Billing Requested .... 6. 8 2,819 • 1�
7. Inter-Vvos Transfers 8�Misceilaneous Non-Probate Property 5 4,21,6 • 7 6
(Schedule G) p Separate Billing Requested .... 7.
8. Total Gross Assets(total Lines 1 through 7) ........................... 8. 161,5 2 5 • 3 4
9. Funeral Expenses and Administrative Costs(Schedule H) ................. 9. 9,9?4 • 6 7
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I) .............. 10. 2,0 2 8 •2 3
11. Total Deductions(total Lines 9 and 10) .............................. ��. 12,0�2 � 9 0
12. Net Value of Estate(Line 8 minus Line 11) ............................ �2. 14 9,5 2 2 • 4 4
13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ....................... 13. � -0�
14. Net Value Subject to Tax(Line 12 minus Line 13) ...................... 14. 14 9,5 2 2 • 4 4
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a}(1 z)X.0 0 0 -0 0 ��. � •0 0
16. Amount of Line 14 taxable
at lineal rate X.0 45 � � �� 16, 0 • 0�
17. Amaunt of Line 14 taxable
at sibling rate X.12 0 • 0 0 �7, 0 • 0❑
�s. AmountofLine14taxable 149,522 • 44 22,428 -37
at collateral rate X.15 18.
19. TAX DUE .................................................... �s. 22,428 •3�
20. FILL IN THE OYAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Side 2
� 15056],0249 1505610249 �
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address: 21 13 0969
DECEDENT'S NAME
Cleo F. Henry
STREET ADDRESS
521 Fairway Drvie
CITY STATE ZIP
Camp Hiil PA 17011
Tax Payments and Credits:
�. Tax Due(Page 2,Line 19) (1) 22.428.37
2. Credits/Paymer�s
A.Prior Payments 21,306.95
B.Discount 1,121.42 22,428.37
Totai Credits!A+B 1 (2)
3. Interest (3) 0.00
4. If Line 2 is greater than Line 1+Line 3,enter the difference.This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4)
5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00
Make check payable 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 .............................. ❑ Q
b. retain the right to designate who shall use the property transferred or its income ....... ❑ �
c. retain a reversionary interest. ................................................ ❑ �
d. receive the promise for life of either payments, benefits or care? .................... ❑ �
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?.... .......... .................... � ❑
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 dea�h on ora�ter 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(T2 P.S.§9116(a)(1.1)(i)J.
For dates of death on or after Jan.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 retum are s�11 appl�able even if the surviving spouse is the only beneficiary.
For dates of death on or�fter 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 per�ent[72 P.S.§9116(a)(1.2)).
• 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[72 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 decedent,whether by blood or adoption.
REV-1508 EX+ (08-12)
• p�n,u�van;a SC H E D U LE E
DEPARTMENT'DFAEYENOE CASH� BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
Cleo F. Henry 21 13 0969
Indude the proceeds of litigation and the date the proceeds were reoeived by the estate.
All property jointly owned witl�right of survivorship must be d'�sdosed on Sd�edule F.
ITEM DESCRIPTION VALUE AT DATE
NUMBER
1 Wells Fargo Account 4861-009033 OF DE2O,032.18
Per 11/1/13 letter
2 M&T Bank Checking Account 9852657742 4,457.26
Per letter
Interest on above item accrued as of decedent's death 0.04
� TOTAL (Also enter on Line 5, Recapitulation) 24,489.48
If more space is needed, use additional sheets of paper of the same size.
REV-1509 EX+(01-10)
r pennsylvania SC H E D U LE F
: pEP11FlTMENT flF AEVENUE
INHERITANCETAX RETURN �OINTLY-OWNED PROPERTY
RESIDENT DECEDENT
� ESTATE OF: FILE NUMBER:
Cleo F. Henry 21 13 0969
If an asset became joiMiy owned within one year of the decedent's date of death,it must be reported on Sd�edule G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A. Cheryl E. Hoerner 521 Fairway Drive Friend
Camp Hill, PA 17011
B.
c.
JOINTLY OWNED PROPERTY:
LETTER DATE DECSRIP'TION OF PROPERTY %OF DATE OF DEATH
��M FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR DATE OF DEATH ECEDENTS VALUE OF
NUN�E .�NANT JOINT SIMILAR IDEM'IFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE VALUE OF ASSET ��REST DECEDENTS INTEREST
1 A 3/19/13 M&T Bank Money Market Account 85,819.10 � c 100% 82,819.10
15004229573983 joint with Decedent's friend,
Cheryl E. Hoerner
Per letter
This account was opened on March 19, 2013,
within 1 year of Decedent's date of death;
therefore, the total value of the account
($85,819.10)is subject to PA inheritance tax
minus the$3,000 exclusion
TOTAL (Also enter on Line 6, Recapitulation) 82,819.10
If more space is needed, use additional sheets of paper of the same size.
REV-1510 DC+ (08-09)
� p����i� SCHEDULE G
OEPIIRTMENT OF AEVENUE
INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Cleo F. Henry 21 13 0969
This schedule must be o�mpleted and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
�pq DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
NUMBE INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT uq�UE OF ASSET INTEREST IF
AND THE DATE OF TRANSFER.ATTACH COPY OF THE DEED FOR REAL ESATE. ( APPLICABLE) VALU E
1 TransAmerica Life Insurance Company Annuity 54,216.76 100 54,216.76
Beneficiary: Decedent's friend, Cheryl E.
Hoerner
Per 10/23/13 letter
TOTAL (Also enter on Line 7, Recapitulation) 54,216.76
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
. penns�rlvania S C H E D U L E H
OEPIIRTMEI�[T OF REHENUE
FUNERAL EXPENSE AND
IRESID NTNDEC DE T�RN ADMINSTRATIVE COSTS
ESTATE OF FILE NUMBER
Cleo F. Henry 21 13 0969
DeaedenYs debts must be reported on Sd�edule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
1 Bitner Memorials, headstone 2,145.00
2 Cheryl Hoerner, reimbursement for payment to Hetrick Bitner Funeral Home 6,127.67
B. ADMINISTRATNE COSTS:
1. Personal Representative's Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
2. Attorney Fees:
1,000.00
3. Family Exemption: (If decedenYs address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees:
303.50
5. Accountant Fees:
6. Tax Return Preparer Fees:
7 Saidis, Sullivan &Rogers, reserve for out of pocket expenses 100.00
8 Cumberland County Register of Wills, filing fees 30.00
9 The Sentinel, legal advertising 168.30
10 Cumberland Law Journal, legal advertising 75.00
11 Check order 25.20
TOTAL (Also enter on Line 9, Recapitulation) 9,974.67
If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
� pennsy?L�an�a SCH EDU LE I
II'EPIIRTMENT�F REVENUE
DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Cleo F. Henry 21 13 0969
Report debts incun�ed by the decedent prior�death that remained unpaid at the date of death,indu�ng unr�imbursed medical expenses.
ITEM DESCRIPTION VALUE AT DATE
NUMBER OF DEATH
1 Pulmonary&Critical Care Med.Assoc. 85.19
2 Pinnacle Health Hospitals 250.00
3 Discover 0.18
4 Holy Spirit Hospital 212.50
5 Quantum Imaging&Therapeutic Assocs. 30.34
6 Internists of Central PA 232.00
7 Hershey Kidney Specialists Inc. 83.68
8 Charles R. Imus, M.D. g.gg
9 Physical Rehab&Spine Medicine 49.57
10 Pinnacle Health Cardiovascular Int. 56.55
11 West Shore EMS-ALS 967.62
12 Quantum Imaging&Therapeutic Assoc 51.64
TOTAL (Also enter on Line 10, Recapitulation) 2,028.23
If more space is needed, insert additional sheets of the same size
REV-1513 EX+(Q1-10)
. penrisylvania S C H E D U L E J
DEPIIRTMENT flF AEVENUE
IN HERITANCE TAX RETURN B E N E FICIA RI ES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Cleo F. Henry 21�.3 0969
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) F TATE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and
transfers under Sec.9116(a�(1.2).]
1 Cheryl E. Hoerner Friend 145,522.44
521 Fairway Drive
Camp Hill, PA 17011
2 Daniel Burkett Cousin 4,000.00
2 East Main Street
Walnut Bottom, PA 17266
ENTER DOLLAR AMOUNTS FOR DtSTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET.
If more space is needed, use additional sheets of paper of the same size.
November 1,20�.3
To Whom !t May Concerned,
This letter is verification that Cleo Fay Henry, now deceased, had an account with Welis Fargo.
The account number ending in 7168 was closed on September 13,2013 and had a balance of$20,032.82
upon closing. The account was yieiding 0.1590 interest. Her date of death was September 5,2103. The
per/Diem.interest on the account was approximately 0.08 cents per day resuiting in a date of death
value of approximately$20,032.18.
If you have any additional questions feel free to contact me at 717-610-9261.
Sincerei ,
t
:
; j ,� ,I�
�
Angela M Campiese
Personal Banker li,Silver Springs Square Store
Together we'll go far
.�.;
_�:��
� M&T Banlc
5528 Carlisle Pike,Mechanicsburg,PA 17050
Cheryl E Hoerner
5Z1 Fairway Dr
Cam p H ill, Pa 17011
Re:Estate of Cieo Faye Henry
Social Security numb�r 205-09-9125
Date of Death September 5,2013
Dear Cheryl:
Per your inquiry on October 31,2013, piease be advised that at the time of death,the above named
decedent had on deposit with this bank the following:
Checking account#9852657742
In the name of Cleo Faye Henry
Opening date 9/10/2010
Balance on date of death $4457.26 plus accrued interest.04 for a total of$4457.30
Money market account#15004229573983
In the name of Cleo Faye Henry or Cheryl E Hoerner
Opening date 3/19/2013
Balance on date of death$85810.87 pius accrued interest$8.23 for a total of$85819.10
Eor any additional information on the above accounts please call me at 717-766-0507.
Sincerely,
��;�;�f.-� �-�.���V
4
Margie H Fealtman
Relationship Banker Hampden Branch
� M&T Banlc
5528 Carlisle Pike,Mechanicsburg,PA 17050
Cheryl E Hoerner
521 Fairway Dr
Camp Hill,Pa 17011
Re:Estate of Cleo Faye Henry
Social Security number 205-09-9125
Date of Death September 5,2013
Dear Cheryl:
. Rer your inquiry on October 31,2013, please be advised that at the time of death,the above named
decedent had on deposit with this bank the following:
Checking account#9852657742
In the name of Cleo Faye Henry
Opening date 9/10/2010
Balance on date of death $4457.26 plus accrued interest.04 for a total of$4457.30
Money market account#15004229573983
In the name of Cleo Faye Henry or Cheryl E Hoerner
Opening date 3/19/2013
Balance on date of death$85810.87 plus accrued interest$8.23 for a total of$85819.10
For any additional information on the above accounts please call me at 717-766-0507.
Sincerely,
����� ���� ,
Margie H Fealtman
Relationship Banker Hampden Branch
�A�ly���.{��� Adminisirative O ffice:
l 1 �,.L 433.3 Edgewood Road NE
�i LIFE INSURANCE CdMPANY CedarRapids,iA524�9
wwwtransamericaa nuiriP� n.r
October 23, 2013 _
CHERYL E HOERNER
521 FAIRWAY DR
CAMP HILL PA 17011
_-- RE: _ Aaauity _N�mber(s�_ 02CBT130002 _. . -
__�:� : - _ - . - - - � -- - _
Dear Claimant:
We have received notification of the death of Cleo F Henry. We extend
our sincere condolences to you for your loss . The information in this
letter is being provided to assist you in submitting death claim
paperwork. Our records reflect the following information regarding
this annuity:
Annuitant: Cleo F Henry
Owner: Cleo F Henry
Claimant: Cheryl E Hoerner 100�
Annuity value: $54,216 .76 as of 09/05/2013
Annuity type: Non-Qualified
Tax Inform�ation
This letter includes general tax information that should not be relied
upon for personal tax planning. Transamerica Life Insurance Company
does not give legal, tax, or accounting advice. You may' want to '
consult your attorney, tax advisor, or accountant with questions
regarding the direct tax consequences when s.electing an option.
Geaeral =aformation
The financial professional of record will remain on this annuity
unless we are notified of a change in writing.
Please be advised automatic operations such as Systematic Payouts and
Automatic Payments have been stopped.
an QEGON company
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: LAST WILL AND TESTAMENT OF :" `:' � =
�..,
: �., . �
CLED F, HENRY �'�� ' ,�,; � � ,
. �r j� r• �rt
: • I, CLEO F. HENRY, of 521 Fairway Drive, Camp Hill, East Pennsboro Township,
. Cumberland County, Pennsylvania, do her�by make this my Last Will and Tes#amen#,
revok�ng any former V1lills and Codicifs made by me.
FIRST: I am not married. I ha�e no children. I am naming my friend, CNERYI.E.
. HOERNER, as the beneficiary in �ny Last Wili and Testament.
: SECOND: t give my tangible pec�onal property and all casualty insurance that I �
, am carrying on sa�d tangible personal property#o my friend, CHERYL E. HOERMER. In �
� .i
; the event rny friend, Cheryl E. Hoerner fails to survive me, then 1 give sa�d tangible '
�
� personal property to my , in equal shares or as near equa� as possible,
� �
; #o be divided between them as t�ey might agree. If they are unable to reach a�ree-
. �
;
rr�ent,�or, �f they are unab�e to agree, then as determined by the Presiden#Judge af the �
� Court o#Common Pleas of Cumberland Coun#y, ;
' TH1RD: I presently own, and have �iving with me, twa cats. If one or both af my �
� ' cats sunrive me, fiy friend, CHERYL E. HQERNER, has agre�d to maintain them in her
�
household with her vwn animals. 1f Cheryl E. Hoerner�ails ta survive me, at my death, i
al! of our�nirnals shall be transferred to the care and facilifies of Dr. Cal�rin Clements
. ;
�
; and Palmyra Animal Clinic, Palmyra, Pennsyl�ania, for adoption and placement in a '
� ;
home or homes of appropriate individuals, who will agtee to such adoptians as de#er- :
� mined by Dr. Clements or his.designes veterinarian at the Palm a Animal Clinic.An �
Y� Y
�
� and all costs for the care and feeding of said animals by the Palmyra Animal C�inic, un#if ;
� such adoptions, sh�ll be borne by my estate. � ?
: ;
i F4URTH: I give the sum of Four Thousand Dollars �$4,0001 to Daniel Burkett, y
� of 2 East Main S�reet, INaln�ut Bottam, PA ��'266, to be depvsited into and used for the
� a
� account of the Burkett �'amily Reunion h�ld annually each June in Plain�eld, Penn�y!-
. �
� van�a, vv��h with�rawa�s from said account to be determined by said Daniel Burkett and =
;
� with the arnounts and uses of said funds to be used exclusive! for#he benefifi of the �
• � J
: � Burkett Fanaily Re�union as determined by Daniel Burket#. In the event DanieE Burkett �
� �
` � (•a_
� Last Witl and Tes#ament of Page 1 of 4 �-%�`
� C�.EO F.HENRY � CFH � �
; .
' fai�s to swrvive me, then his successor with the Burkett Farrtily Reunion shali make the
; determinations described herein.
FiFTH: I give the re�t and rema�nder of my estate, real and personal, to my
: friend C�IERYL E. HOERNER. in the event r�y frEend, Cheryl E. Hoerner, fails to
;
; �unrive me, ! give, devise and bequeath the rest and remainder of my estate, real and
<
; personal, #o or fhe sunr.ivor of#hem, or, if they fail to surviv� me,to
� fiheir issue per stipes.
� .
: SIXTH; t name my friend, CHERYt E, H�ERNER, as my Executrix. In#he
; �
; event, my�friend is unable or unwilling to senre, I name as my ;
� .
� � . Executar. � direct that rny Executrix or Executor, and#heir successors, regardless of � ;
,
� number or gender, serve without bor�d in any jurisdiction in which ca�led upon to act.
_
� SEYENTH: I give#o any Executor n�med in this 1Nill or any Codicil here#o all of
' the�pow�r� naw applicable by law to fduciaries �n�he CommQnwealth ofi Pennsylvania
� and, in particular, thrvugh the Probate, Esfa#es and Fiduciaries Code� as effective and '
;
! as in effect on the date hereof, during#he adminisfir�tion and until the corr�pt�tian of#he �
� distribut�on of rny estate, and unti! the#ermination of all frusts created hereunder and
' untif the complefion af the distribution of the assets of such trusts.
;
, :
; EIGHi'H: Mo inferest of an�r beneficiary under this Will or any CodiciE hereta or �
; any Trust created her�ein shall be subject fo ant�cipation or#o valuntary or involuntary �
' a{ienation. �
�
� - ;
ItV YVITNESS WHEREQF, I have se#my hand�and seal on this my Last Vllil! and �
,
� Testarnen�th�s 18«day of Nvvember, �01'f. �
. �
� ti ,
: . ��t��' tSEAL) :
� CLEC} .HENRY, Testatri �
�
; �
:
� Last Will and Testament of Page 2 af�
� Cl.EO�.HENRY CFH
� SELF-PROVINC AFFIDAVIT
CQMMOl�WEALT!-t QF PENNSYLVANIA :
. : SS.
� CaUNTY OF CUMBERLAND �
.
I, CLEO F. HENRY, Testatrix� �rhase name is signed to the atEached or forego-
; ing insfrument, having b�en duly sworn according to.law, dQ hereby acknowledge tha� I
� signed and executed the attached instrument as my Last VYiII and Tes#ament; �h�t i �
;
signed it willingly; and that I signed �t as my free and valuntary act for the purpo�es
� therein expressed, on this the 18'h day af November, 2�11.
'
1� �
. ,
CLEO F. HE�ERY, Testa�rix �
I 3
i
�` � SUBSGRIBED, sworn to, and acknowiedged before me by CLEO F. HENRY, the
m
� Testatr�x, #his 18� day of November, 2011. �
�
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� Notary Public
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i COMMONW�AL.T!-t OF PENNSYLVANIw i
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; MARJQR4E L.J4 C�N,►��ubNc �
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Last Wiil and Testament of Page 3 of�
; ' CLE�F.HENRY �
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. SELF�PROVi�VG AFFIDAVtT
� COMM�NINE14LTH �3F PENMSYLV�4NfA :
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i COUNTY C}F CUMBERLAND �
� WE,the witnesses, respectively,whose names are signed#o the at�ached vr
. , foregoing ir�strument, being dccly quali�ed acc�rding to law, do�depose and say that we
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; were present and saw CLE()�. HENRY�ign and execute�the instrument as�her Last ;
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� V11i11 and Testament; that she signed willingly{o�w�l�ingly directed another to sign for �
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� . her�, and that she execu#ed it as her free and voluntary a�ct for the purposes there�n
� expressed, and that each of the witnesses, at the t-equest of and in the presence and
hearing af C�.EO F. HENRY, and in the presence of each other, signed ths Last Will
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; and Testament as witnesses; and that, ta the best of Qur knowisdge CLEO F, HENRY �
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. trvas a#fihat time eighteen-�18) yeat-s of age or older, �f sound mind., and under no ;
� constraint or undue influence�.
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� Witness � � '
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Wi�nes �
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� SEIBSCR[BED, s�vorn to, and acknowledged before me, a nofary pubfic, �
by_t�t���?.U`�1�. � �Y1� ��.�, � , and �
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� �Q.. +T. � � , witnesses, this 18'"day ofi IYovember, 2411. �
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�.YN a���NsYt.V�►N� �
COMM�NVYEA � :
� NOTARIAL S�AN publ� �� �
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cam�t�11 Boro.�C ��°1�� �totary Public �
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Last Wi11 and Tesfament of Page 4 of � �
� CLEO F.HENRY � �
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