HomeMy WebLinkAbout03-03-15 J REV-1500
Ex cot-„> 1505610143
PA Department of Revenue OFFICIAL USE ONLY
p pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO BOx.280601 INHERITANCE TAX RETURN 21 14 .01220
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
12 16 2014 07 20 1919
Decedent's Last Name Suffix Decedent's First Name MI
HESS JAMES W
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
HESS DOROTHY M
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return ❑ 2. Supplemental Return ❑ 3.Remainder Return(Date of Death
Prior to 12-13-82)
❑ 4. Limited Estate ❑ 4a.Future Interest Compromise ❑ 5. Federal Estate Tax Return Required
(date of death after 12-12.82)
® 8 Decedent Died Testate ❑ 7• Attach Copy of Trust)
a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of will)
❑ 9. Litigation Proceeds Received ❑ 10.Spousal Poverty Credit(Date of Death ❑ 11.Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
ROBERT P KLINE 717 770 2540
REGISTER OF WILNUSE-qNR
c O rr1 C->
First Line of Address =0v3
714 BRIDGE STREET rrn w —I
r-1 r n
Second Line of Address
`r1
PO BOX 461 C? t
DATE)FILED c�
City or Post Office State ZIP Code
NEW CUMBERLAND PA 1.7070 _I o Cl p
cr1
Correspondent's e-mail address: rkline@klinelawoffice.com
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SI F PERSO ESP IBLE FOR FILING RETURN DATE
Gerald L. Hess 1
ADDRESS
2440 East Bayberry Drive, Harrisburg, PA 17112
SIGNA` E OF REPA THER THAN REPRESENTATIVE DATE
1 1� Robert P Kline Z,
ADDRESS
Kline Law Office
714 Bridge Street, New Cumberland, PA 17070
Side 1
L 1505610143 1505610143
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: HESS, JAMES W
RECAPITULATION
1. Real Estate(Schedule A).......................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................... 2. 3 , 389 . 60
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C).......... 3.
4. Mortgages&Notes Receivable(Schedule D).......................................................... 4.
5• Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5.
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6. 164 , 569 . 71
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............. 7. 93 , 343 . 1 4
8. Total Gross Assets(total Lines 1 through 7).......................................................... 8. 2 61 , 302 . 45
9. Funeral Expenses and Administrative Costs(Schedule H)..................................... 9. 9 , 686 . 22
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................. 10.
11. Total Deductions(total Lines 9 and 10)..................................................................11. 9 , 686 . 22
12. Net Value of Estate(Line 8 minus Line 11).............................................................12. 251 , 616 . 23
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J)................................................. 13.
14. Net Value Subject to Tax(Line 12 minus Line 13)................................................. 14. 251 , 616 . 23
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)x.00 251 , 616 . 2 3 15. 0 . 00
16. Amount of Line 14 taxable
at lineal rate X .045 16.
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18•
19. TAX DUE.................................................................................................................:19. 0 . 00
20. FILL IN THE OVAL IF.YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21 - 14 - 01 220
Decedent's Complete Address:
DECEDENT'S NAME
Hess, James W
STREET ADDRESS
24 Amherst Drive
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A. Prior Payments
B. Discount
Total Credits(A +B) (2) 0.00
3. Interest
(3) 0.00
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 20 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 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;.................................................................................. F
b. retain the right to designate who shall use the property transferred or its income;....................................❑
c. retain a reversionary interest;or...............................................................................................................�.� ❑x
d. receive the promise for life of either payments,benefits or care?..............................................................� 0
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.....................................................................................................................1-7
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?......... 1-1 O
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary designation?...................................................................................................................fil 7'
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[72 P.S.§9116(a)(1.1)(i)].
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 retturn 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)(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 bloo or adoption.
REV-1503 EX+(6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Hess, James W 21 - 14 -01220
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE VALUE AT DATE OF
NUMBER DEATH
1 Prudential Financial, Inc. 84.74 3,389.60
TOTAL(Also enter on line 2, Recapitulation) 3,389.60
REV-1509 EX+(01-10)
Pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hess, James W 21 - 14-01220
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
Dorothy M. Hess 24 Amherst Drive Wife
A Camp Hill, PA 17011
JOINTLY OWNED PROPERTY:
LETTER DATE C#EfSCRIPTION C�F PRO�'ERTkY %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name o Inancla,Instltu Ion an ban account numb rDATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT or similar identifying number.Attach deed for jointly-held real VALUE OF ASSET estate. INTERES DECEDENT'S INTEREST
1 A 24 Amherst Drive, Lower Allen Twp, 185,130.00 50% 92,565.00
Cumberland Co, PA(Assmt$187000 x CLR
.99)
2 A Santander#1200441877 24,623.57 50% 12,311.79
3 A Metro Bank#2843758349 11,092.62 50% 5,546.31
4 A Metro Bank#833059199 39,564.94 50% 19,782.47
5 A PNC Bank#5140223225 8,295.98 50% 4,147.99
6 A PNC Bank#5004889997 60,432.29 50% 30,216.15
TOTAL(Also enter on line 6, Recapitulation) 164,569.71
REV-1510 EX+(08-09)
�) " f pennsylvania
` DEPARTMENT OF REVENUE SCHEDULE*G
INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS &
RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY
ESTATE OF Hess, James W FILE NUMBER
21 - 14-01220
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF EXCLUSION TAXABLE VALUE
Include the name of the transferee,their relationship to decedent VALUE OF ASSET DECD'S IF APPLICABLE
NUMBER and the date of transfer. Attach a copy of the deed for real estate. INTEREST ( )
1 Santander Brokerage Annuity#QG2-522438 93,343.14 93,343.14
r
I
TOTAL(Also enter on line 7, Recapitulation) 93,343.14 .
REV-1511 Ex+(10-09)
pennsylvania FM
gy�pp/��H�EDULE��+HC��A/�w�tm
DEPARTMENT OF REVENUE rV1 MAL BIG) MS MD
INHERITANCE TAX
RESIDENT DECEDENT RETURN AN1mwn I ATMECO �
/'1LJIY111�1h71rV1 1�./�7��7
FILE NUMBER
ESTATE OF Hess, James W 21 - 14-01220
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT
A. 1 Parthemore Funeral Home &Cremation Services, Inc. 6,945.72
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(s)Commission Paid
2. Attorney's Fees Kline Law Office 2,500:00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills 240.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1
TOTAL(Also enter on line 9, Recapitulation) 9,686.22
REV-1513 EX+(01.10)
Pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF I FILE NUMBER
Hess, James W
21 - 14 -01220
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
I� TAXABLE DISTRIBUTIONS[include outright spousal
distributions and transfers
under Sec.X116(a)(1.2)]
1 Dorothy M. Hess Wife ALL
24 Amherst Drive
Camp Hill, PA 17011
Enter dollar amounts for distributions shown above on lines 15 through 18 on 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 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
RECORDED OFFICE OF'
R=EG-1STE Or WILLS
ZOIy ��C 30 PM I fu AST WILL AND TESTAMENT
OF
CLERi� OF JAMES W. HESS,
ORPI104S' OOUilIT
CUIi>!C1�'0'A'LL"MEN`8Y THESE PRESENTS, That I, JAMES W. HESS, of the
Township of Lower Allen, County of Cumberland, and Commonwealth of Pennsylvania, do
make, publish, and declare this instrument to be my Last Will and Testament, hereby
revoking and making void any and all former Wills by me at any time heretofore made.
FIRST: I direct the Executrix hereof to pay all my just debts, funeral expenses and
costs of administration as soon as conveniently may be done after my death. I further
direct the Executrix hereof to pay all inheritance, estate, transfer and succession taxes
which may be levied or assessed upon any property which is included as part of my gross
estate for the purpose of any such tax.
SECOND:I give, devise and bequeath unto my wife, DOROTHY M. HESS, rest,
residue and remainder of my estate, realty and personalty, howsoever designated
wheresoever situate provided that she is living on the thirtieth (30th) day after the date of
my death.
THIRD: In the event that my wife, DOROTHY M. HESS, does not survive me or
does not survive by the said period of thirty (30)clays, then in that event, I give, devise and
bequeath all the rest, residue and remainder of my estate in equal shares, share and share
alike, to my Children, GERALD L. HESS, CYNTHIA A. MINCE, THOMAS J. HESS, LORI
J. FARRO, and LAURI J. BEYER. All of my children with children take under this my Last
Will and Testament, per stirpes. Only my daughter, LORI J. FARRO, who does not have
any children, takes under this my Last Will and Testament, per capita.
J - 1 -
FOURTH: I appoint my wife, DOROTHY M. HESS, to be Executrix of this my Last
Will and Testament. I do, hereby give to the Executrix hereof full power, discretion and
authority at any time or times to sell, at private or public sale, mortgage, lease, pledge,
exchange or otherwise deal with or dispose of the property comprising my estate as
deemed best, to settle and compound any and all claims in favor of or against my estate as
deemed best and, for any of the foregoing purposes, to make, execute and deliver any and
all deeds, mortgages, contracts, leases, bills of sale or other instruments necessary or
desirable therefor.
FIFTH: In the event my wife, DOROTHY M. HESS, fails or refuses for any reason
to serve as Executrix of this my Last Will and Testament, then in that event I appoint my
son, GERALD L. HESS as Executor of this my Last Will and Testament.
LASTLY: I direct that no fiduciary appointed by this, my Last Will and Testament,
shall be required to give bond and that if, notwithstanding this direction, any bond is
required by any law, statute or rule of court, no surety shall be required thereon.
IN WITNESS WHEREOF, I have set my hand and seal to this, my Last Will and
Testament, consisting of two (3) typewritten pages on the margin of which (except this
page) I have affixed my initials this 16th day of February, A.D. 2001.
Ja s W. Hess
-2 -
Signed, sealed, published and declared by, the above-named Testator, as and for
his Last Will and Testament, in the presence of us, and each of us, who at his request, and
in his presence, and in the presence of each other, have hereunto subscribed our names as
attesting witnesses.
eth Myers Amy Knauer j l
- 3 _
County of Cumberland
SS.
Commonwealth of Pennsylvania
ACKNOWLEDGMENT AND AFFIDAVIT
We, James W. Hess, the testator, and the undersigned witnesses to the Will, the
'attached or foregoing instrument, having been qualified according to law do depose and
say:
(a)that 1, the testator, do hereby acknowledge that I signed the instrument as my.
Will, that I signed it willingly and as my free and voluntary act for the
purposes therein expressed; and
(b)that we, the witnesses, were present and saw the testator sign the instrument as
his last Will, that he signed it willingly and as his free and voluntary act for
purposes therein expressed; that each of us in the hearing and sight of the
testator signed the Will as a witness and that to the best of our knowledge the
testator was at that time 18 or more years of age, of sound mind and under
no constraint or undue influence.
Sworn to or affirmed before me by James W. Hess, testator, and Beth Myers and
Amy Knauer, witnesses, this 16th day of February, 2001.
JamQs W. Hess o- Beth Myers
4Z
4
By: David W. Knauer Amy Knauer
Attorney I.D. #21582
-4 -
WARRANTY DEED Printed on Plankenhom's 100%Linen Record Paper
`I TI= 44'7-1-S
I �
I
lRubf the S day of
in the year nineteen hundred and ;seventy-three (1973). �!
Wptumptt J. ALLEN DUFFIELD and E. LOUISE DUFFIELD, his wife, of Lower
i Allen Township, Cumberland County; Pennsylvania, GRANTORS and partie�
of the first part,
-AND -
JAMES W. HESS and DOROTHY' M.. HESS, his wife, of the same
place, GRANTEES and parties of the second"part,
11f1tt9999t4, That in consideration of THIRTY-FIVE THOUSAND THREE HUNDRED-----
($35,300.00)--------------------------------------- -----------Dollars,
in hand paid, the receipt whereat is hereby acknowledged, the said grantor 5 do hereby grant
and convey to.the said grantees, their heirs and assigns,
All THAT CERTAIN piece or parcel of land situate in Lower Allen Town-
ship, Cumberland County, Pennsylvania, bounded and described as
follows, to wit:
BEGINNING at a -point on the western s-ide of Amherst Drive, which point
measured along the western side of Amherst Drive is one hundred sev- j
enty-five (175) feet North of the northwest corner of Amherst Drive
and Citadel Drive and which point is also.at the northeast- corner of
Lot No. 12 on Plan No. B-3, Cedar Cliff Manor hereinafter referred. tc ;
THENCE along the northern line of Lot No. 12 aforesaid North eighty-
four
ighty four (84) degrees eleven (11) minutes West one hundred twelve and sell
enty-two one-hundredths (112.72) feet to a point at the eastern line
of Lot No. 181 on Part of Plan No. 2, Cedar Cliff Manor as recorded
in the Office of the Recorder of Deeds in and for Cumberland County,
Pennsylvania in Plan-Book- 7, Page 13; THENCE along the eastern line
of Lots Nos. 181 and 182 on Part of Plan No. 2, Cedar Cliff Manor a-
foresaid North five (5) degrees forty-nine (49) minutes East eighty-
five and three-tenths (85.3) feet to a point -at- the southern line- or
Lot No. 14 on Plan No. B-3, Cedar Cliff Manor hereinafter referred to:
I�
THENCE .along the southern line of Lot No.-:14 aforesaid South eighty
(80) degrees thirty-one (31) minutes thirty (30) seconds East, one
hundred thirteen and thirteen one-hundredths (113.13) feet to a point
BOOK 25PAGE 89
at the western side of Amherst Drive; THENCE southwardly along the
western side of Amherst Drive by an arc curving to the left, having
radius of 90 feet, a distance of five and seventy-four one hundredths
(5.74) feet to a point; THENCE continuing along the western side of
Amherst Drive, South five (5) degrees forty-nine (49) minutes West,
seventy-two and thirty-four one-hundredths (72.34) feet to a point,
being the Place of BEGINNING.
BEING Lot No. 13 on Plan No. B-3, Cedar Cliff Manor, which Plan was
approved by the Lower Allen Township Planning Commission on January
4, 1958 and by the Lower Allen Township Board of Commissioners on
January 6,- 1958 and which Plan was recorded 6n May 6, 1958 in Plan
Book 9, Page 36, Cumberland County records.
HAVING THEREON ERECTED a dwelling house known as No. 24 Amherst DRive.
The aforesaid Lot being under and subject nevertheless, to the terms
and provisions and conditions and restrictions contained in the
Declaration of Willard F. Keiser, Jr, and Anna M. Keiser, his wife,
dated May 6, 1958 and recorded in the Office of the Recorder of `Deeds
in and for Cumberland County, Pennsylvania in Plan Book 9, Page 36
and to the set back lines and utility easements as shown on the afore-
said Plan.
BEING THE SAME PREMISES which M.R. Campbell, Inc. , a Pa. Corp. , by
deed dated October 4, 1958 and recorded in the Cumberland County
Recorder's Office in Deed Book "U", Volume 18, Page 505, granted and
conveyed unto J. Allen Duffield and E. Louise Duffield, his wife,
grantors herein.
iownshi �G'/if•'.v' i':�� ° /a .
Cumb. Co., Pa. School Dist. Cumb,Ce., Pe I i
A
176 Real Estate Transfer TerCD
% Real Estate Transfer Tax ro Ao
Date -/y-�3 ��k!•-S U y .S v .L
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.. .. Am},... Date �m�m
um b.C..Dist.C.I.
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BOOK 2SPAGE 90
Auh the said grantors will GENERALLY Marrant.antl Narturr Brftnil the property
+� hereby conveyed.
I inn witurris nllttrtof, said grantors have hereunto set their hands and seal S ,the
day and year first above-written.
gzate t anh bektiere3 in f4z pretence of .
z _
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BEAL
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LOU Duff eld-l'
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----------------------------------------•--_-.----------•------—._. -----------------------------------------------------------
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(9jertifiratt of Xrothettrt
I hereby certify, that the precise residence of the grantees herein is as follows:
��f l-Zv,..•Gti�1�-` 17h� , �-�,.�� Jd�,CO P, X70�1.�-. • <<�..�,�2�--�---�, -
•-....................... ......•-•••----.
Attorney or Agent for Grantee
s1 r
17 1�2 o nI12e
�sU6n 444• tns +ma
On this,the � day of /-,—, c< 1 19 7 3,before me a Notary Public,
the undersi ned officer,personally appeared J. ALLEN DUFFIELD & E. LOUISE DUFFIELD,
his wife, are
known to me (or satisfactorily proven) to be the person S whose name S subscribed to the within
instrument,and acknowledged that they executed the same for the purpose therein.
contained.
IN WITNESS WHEREOF, 1 have hereunto set my hand and notarial
Notary Public,'tate.of-gorida air Garge ,. _
JJ =
__6aV_C �gssion,Expiees July 15;a9 a S �I
MY Com�l �z t a samerica'1'n`siu2 zp'Co=
' �lo':ttntUllS,ittti�fiQll of'�t11nEaJluatttu ;: .'''�•� �,..�`
Qtountg of _...._..__
--- ss,
On this,the day of 19 ,before me
the undersigned officer,personally appeared
known to me (or satisfactorily proven)-to be the person- - whose name subscribed to the-within
instrument,and acknowledged that executed the same for the purpose therein
contained.
IN WITNESS WHEREOF, I have hereunto set my hand and seal.
_......_.._.._..............
- --- - -- -----------
-----
.- - -
MY Commisdon Expfree
600KA 25671 A
elate of
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'Zounty of
j On this,the day of 19 ,before me I�
I
j the undersigned officer,personally appeared
iknown to me(or satisfactorily proven) to be the person whose name subscribed to the within
i
{ instrument,and acknowledged that executed the same for the purpose therein
I contained. I
i IN WITNESS WHEREOF, I have hereunto set my hand and seal,
MComadssioa Espires~�---..—.��.�..�..•.•
$face of
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Mountg of )))
IOn this, the day of 19 ,before me
the undersigned officer, personally appeared lI
Iknown to me (or satisfactorily proven) to be the person whose name subscribed to the within
instrument, and acknowledged that executed the same for the purpose therein
contained.
IN WITNESS WHEREOF, I have hereunto set my hand and seal,
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ietDY�e� in the Office for Recording of Deeds,etc.,in and for said County,in Deed
Book No. -o. ,Page ry�
11MMSS my Hand and Official Seal this 1�) d df
Recorder of Dads