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Home My WebLink About01-1033 . '. Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of Albert C. Gavlak No. ~1-Cl-ID~3 also known as , Deceased Social Security No. Judy A. Gavlak 184-32-2717 Petition... who Is 18 yeera of ege or older. app/yliea) for: (COMPLETE" A" OR "B" BELOW:) IJ[J A. Probate and Grant of Letters and aver that Petitioner is the executrix named in the Last Will of the Decedent, dated Seotember 18 2001 and codicil(s) dated NONE State relevant circumatances. e,g., renunciation, death of executor. etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: No Exceptions D B. Grant of Letters of Administration ld,b.n.c.t.a.: pendent. lite; durante absentia; durante minoritatel Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: I Name Relationship Residence I . . (COMPLETE IN ALL CASES:) Attach additional sheets If necessary. Decedent was domiciled at death in Cumberland County, Pennsylvaniar with his last family or principal residence at 101 Hollv Lane Mechanicsbura. PA 17055 (Silver Soring Townshio) (list atr..t, numb81 and municipalityl Decedent, then 59 years of age, died Seotember 25 Dauohin Countv. Pennsvlvania , 2001, at Milton S Hershey Medical Center Derrv Township (Location) Decedent at death owned property with estimated values as follows: (If domiciled in P A) All personal property ............................................................................ $ 20 000 00 (If not domiciled in PAl Personal property in Pennsylvania .......................................................... $ (If not domiciled in PAl Personal property in County.................................................................. $ Value of real estate in Pennsylvania .......................................................................................................... $ Total................................................................................................... $ 20 000.00 Real Estate situated as follows: NONE Wherefore, Petitioner respectfully requests the probate of the last Will presented with this Petition and the grant of letters in the appropriate form to the undersigned: Typed or printed name and residence Judy A. Gavlak 101 Holly lane Mechanisburg, PA 17055 4crnwt':'f'-1 Page 1 of 2 (Dauphin County) - Rev. 9/92 \ l - dO - b . .. Oath of Personal Representative Commonwealth of Pennsylvania County of CLlMBERLAND The Petitioner(s) above-named swear(s) and affirm(s) that 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, Petitioner(s) will well and truly administer the estate according to law. before me this 8TH Sworn to and affirmed and subscribed NOVEMBER ~/f2. i .. . 'fU) tu, MJl.RY CLEWIS' No. day of ~ a :>U~ 21 - 01 - 1033 Estate of Social Security No: ALBERT C GAVLAK Deceased 184 - 32 - 2717 Date of Death: SEPTEMBER 25, 2001 AND NOW, NOVEMBER 13.. , 20 01 , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters g Testamentary 0 of Administration are hereby granted to d.b.n.c.t.; pendente lite; durante absentia; durante minoritate JUDY A GAVLAK in the above estate and that the instrument(s) dated SEPTEMBER 18, 2001 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters........................... $ 50.00 Short Certificate(s)... !.~J.. Renunciation................. . Affidavit ( )................. Extra Pages (6 )............ Codicil........................ .. JCP Fee........................ Inventory...................... . Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . TOTAL.... ....... ..... Form RW.1 Page 2 of 2 {Dauphin County' . Rev. 9192 $ 12.00 $ $ $ 18 . 00 $ $ 5 . 00 $ $ MARY CLEWIS Attorney: Stanley A Smith I.D. No: 33782 Address: Rhoads & Sinon LLP. PO Box 1146 1 South Market Square. Harrisburg PA 17108-1146 Telephone: 717-233-5731 $ 85.00 Mailed letters to attorney on 11-13-01 Register of Wills of Cumberland County, Pennsylvania OATH OF SUBSCRIBING WITNESS Estate of Albert C. Gavlak also known as No. 21 - 01 - 1033 , Deceased Stanlev A. Smith and Yvonne R. Durham each subscribing witness to the l&Iwill presented herewith, each being duly qualified according to law deposes and says that each was present and saw the above Testatrix sign the same and that each signed as a witness at the request of Testatrix in his presence and l&I in the presence of each other. 436 Wood crest Drive, Mechanicsburg, PA 17055 (Address) .~ 1010 Hemlock Lane, Enola, PA 17025(Address) Sworn to or affirmed and subscribed 'I day of Notarial Seal I Jo Am Saker, ~ Public I HarrI~, P&uPhIn Ccu1tv My CommIssion Expires JlI18 3Cf, 2003 Member, Pennsylvania ASSOCIatIon of Notaries ,2001. J (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTE: To be taken by officer authorized to administer oaths. Please have present the original or copy of Instrument(s) at time of notarization. Form RW-2 (Dauphin County - Rev. 9/92) 407365.1 ~'(l';.,~0::: ':"i"":"\" '':/;':() rhis is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Rt:;gistrar. The original certificate will be forwarded to the State Vital Records Office for permanent tHing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 p 7691233 No. ~j{JLVl ~~ Local Registrar 0 () ~1JP;-~ ;;'1, ~()o / 7---......-. Date' H '0,. :43 Re, 2187 COMMONWEALTH OF PENNSYLVANIA. OEPARTMENT OF HEALTH e VITAL RECORDS CERTIFICATE OF DEATH TYPE/PAINT IN PERMANENT BLACK INK AGE (La.. S.v>daYI UHOER 1 '\'EAR -.. Daye IlIRTHPLACE 1C.ly ...4 S~outz'~g~Jl. STATE FIl.E ~U"'BEA SOCt~UAIT'\' "U~ 3. PlACE OF DEATH (CNIck Of'lfy 0I"le -- ... I('ISlruca.c.toj on othet .... HOSPiTAl; -- I"""".", ttl ERIOulpall.'" 0 EJ'J b-..~L/l.. L)" Zoo Albert C. Gavlak SEX Male NAME Of DECEDENT If... MICl<lI8. Las, 59 VIS ,. COUNT'\' Of OERH Dauphin ec. . .... DECEDENT'S USUAl OCCUPlVION I~:"'~.~~::~:f """'S DECEDENT EVER IN U S. AA~D FORCES? VesO NoO la. Cumberland =olvlO RACE .. Arnenc:an InCIIan.III8c" _e. 8lC t!ip<<olv) White ". SUfMVING SPOuSE 1.:rucJY~e 0icI - .... WI . -..e/Ilp? hip 1.. "RHEA'S NAME (1'0". MoOdIe. LasI) .lb. Cou ccy_ ". INFORMANT'S NAME (T ypelf'IInl) 11. INfORMANT'~l!"~~, Pa. 17050 _. PlACE OF 0l5P0liIT1ON. _ 0I~. 0.........., LOCRIOH . C~. St.... Zip eo. orOlll8t~ate of Heaven Cemetery Mechanicsburg, Pa. 17055 Ze. 27. I'AIlT I: ERIe' Ihe _._. inl"'ies or cornplocl..ona _ CIUS8d the dll'" 00 LOll only one CIUM on elCl\ line DATE PRONOUNCED DEAD (Mon"'. DIY. Year) M D. S [1'1 E;v>Jre-1L ent., the mode of dying, such as cardiac 01 resptfalOly an e ('rIi2-lJ/orc..4..t./4-tc.v...,..-Jf2.y' ti!l.zL t.A./Ii?-.e DUE 10 lOR AS A CONSEQUENCE OF): b C_ E .L-~ .:? d.A L L:- /) L"', .4 I DUE 10 (OR AS A CONSEQUENCE OF): :-oiJf 10 tOR AsA CoNSEOUENCEOf}'-------- WERE AUlOPSY FINIllNGS MANNER OF DERH AIMULA8lE PRIOR TO COMPlETION OF CAUSE OF DEATH? DATE Of INJUR'\' IMonlll. Day. _.., NII",oI ~ o o Could 001 b4I determined Z,<I. NAMEAND~Pi?fJ,tliNJl.tome, Inc. 37 East Main Street Mechanicsburg, Pa 17055 ZZc. LICENSE NUMllER DATE SIGNED fMonll.Dey. _, 2311. Z3c. MS CASE REFERRED TO MEDICAl EXAMlNERICOAONER? A "" 0 "",U D. I AppIolUlhall '-- :--- , I PART .: au. .iQnillcanl....-... CORI'lIluIing 10 _. bul .....-.ng in....ldIlI8t1ying..- given in ""'" I TIME OF INJURY INJURY R WOfU<? DESCRIBE HOW INJURY OCCURRED Accodenl Pending IR,,"I~lton o o r.J PLACE OF INJURV _ AI ""mto. 'arm. ..._. taC1ory. office M. bu~. "c. 1Spec.IM 308. LOCRION r.;._. Clv/Town. Stale) HomICide 'I'M 0 "",0; Suocode 288. Z". CEll'TIl'IEft IC~""" CRy onel "CERTIFYING PHYSICIAN fPh)'SCtilfl CefWycng cause c:J. death wh8fl .JnoIner phySIC.an hdS pronouncea lJealh ana complele<J lIem 23) To..... be.' 0' PI' kno....~ de.'" QC;CunN.. lIt"'e c.u..(a) liArd mMlMr.. .'.led. . . . . 29. ~ ~ o o w ~ Z .PRONOUNClHG AND CERTifYING PHVSICtAH tPhys.c.an boItl j.}IOflOl.,tf.c;lI'Ig Oedth and l.:etb.ylfl9 10 cause ot death} To &he ~. 0' my knowtedg., de.'" occwred .. .... ....... dtll.. and ptace, and due to lhe cau..(a) and manne, .. alilled., .MEDICAL EXAMINER/CORONER On the heal. of ..amination andIOI' inve.tigabon, in my opinion, d..th occurred al the lima. dale. and place, and due 10 Ihe cau..(a) and manner as ....M.. . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1" ; c/l~ ~Leh;;11 / / Jj II I:}..I 1 I ) I 'I'M 0 "",0 3Z M. S. Hcrshe Medical Centcr Hers ORE FILED (Month. Day ...arl ,..5e PI.J? dl iJI',cJ -'2 7 c~c'k-) I I '7 LAST WILL AND TESTAMENT OF ALBERT C. GAVLAK I, ALBERT C. GAVLAK, of Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time previously made. I am married to Judy A. Gavlak (hereinafter referred to as "My Spouse") and the children born of our marriage are Allen J. Gavlak and Christopher J. Gavlak. 1. TANGIBLE PERSONAL PROPERTY. I give and bequeath all of my household furniture and furnishings, automobiles, other motor vehicles, books, pictures, jewelry, china, crystal, appliances, silverware, wearing apparel, articles of household or personal use or adornment, collections, artworks, boats and recreational equipment and vehicles, together with all policies of insurance thereon, to My Spouse, if My Spouse survives me. If My Spouse does not survive me, I give such articles to my children living at my death in as nearly equal shares as they shall select under the supervision of my Executor. Any cost of packing and Page 1 of 7 Pages 40\451.\ shipping said personalty to the beneficiaries, including insurance, shall be paid by my Executor as a general administration cost. If any such articles cannot be fairly divided or distributed in kind in the opinion of my Executor, such articles shall be sold and the proceeds thereof shall pass as a part of my residuary estate. 2. RESIDUE. I give, devise and bequeath all of the rest, residue and remainder of my property, real, personal and mixed, not disposed of in the preceding portions of this Will, including all property over which I hold a power of appointment (which powers of appointment I hereby exercise in favor of my estate), to My Spouse, if My Spouse survives me. If My Spouse does not survive me, I give, devise and bequeath said residue to my issue living at my death, per stirpes. 3. SPENDTHRIFT PROVISION. No interest in income or principal of my estate shall be subject to attachment, levy or seizure by any creditor, spouse, assignee or trustee or receiver in bankruptcy of any beneficiary of my estate prior to the beneficiary's actual receipt thereof. My Executor shall pay over the net income and the principal to the beneficiaries herein designated, as their interests may appear, without regard to any attempted anticipation (except as may be specifically provided Page 2 of 7 Pages herein), pledging or assignment by any beneficiary of my estate and without regard to any claim thereto or attempted levy, attachment, seizure or other process against said beneficiary. 4. SURVIVAL PRESUMPTIONS. Any person who shall have died at the same time as I or under such circumstances that it is difficult or impossible to determine who shall have died first, shall be deemed to have predeceased me. 5. FIDUCIARY POWERS. In the settlement of my estate, my Executor shall possess, among others, the following powers, exercisable without prior court approval, but in all cases to be exercised for the best interests of the beneficiaries: (a) To retain any investments I may have at my death so long as my Executor may deem it advisable to my estate so to do, including securities owned, issued or underwritten by any corporate Executor or any of its affiliates. (b) To vary investments, when deemed desirable by the Trustee, and to invest in every kind of property and type of investment, including securities owned, issued or underwritten by any corporate Trustee or any of its affiliates, or as to which such Trustee or its affiliate acts as investment advisor, as the Trustee shall deem wise. (c) In order to effect a division of the principal of my estate or for any other purpose, including any final distribution of my estate, my Executor is authorized to make said divisions or distributions of the personalty and realty partly or wholly in kind. If such division or distribution is made in kind, said assets shall be divided or distributed at their Page 3 of 7 Pages respective values on the date or dates of their division or distribution. In making any division or distribution in kind, my Executor shall divide or distribute said assets in a manner which will fairly allocate any unrealized appreciation among the beneficiaries. (d) To sell either at public or private sale and upon such terms and condittons as my Executor may deem advantageous to my estate, any or all real or personal estate or interest therein owned by my estate severally or in conjunction with oth~r persons or acquired after my death by my Executor, and to consummate said sale or sales by sufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title, free and clear of all trust and without obligation or liability of the purchaser or purchasers to see to the application of the purchase money or to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings which may be necessary or desirable in carrying out any of the powers conferred upon my Executor in this paragraph or elsewhere in this Will. (e) To mortgage real estate and to make leases of real estate for any term. (f) To borrow money from any party, including my Executor, to pay indebtedness of mine or of my estate, expenses of administration, Death Taxes or other taxes. (g) To pay all costs, expenses, legally enforceable debts, funeral expenses and charges in connection with the administration of my estate. (h) To vote any shares of stock which form a part of my estate and to otherwise exercise all the powers incident to the ownership of such stock and to actively manage and operate any incorporated or unincorporated business, including any joint ventures and partnerships, and to incorporate any such unincorporated business, with all the rights and powers of any owner thereof. Page 4 of 7 Pages (i) In the discretion of my Executor, to unite with other owners of similar property in carrying out any plans for the reorganization of any corporation or company whose securities form a part of my estate. (j) To assign to and hold in my estate an undivided portion of any asset. (k) To hold investments in the name of a nominee. (1) To compromise controversies. (m) To disclaim, in whole or in part, any and all interests in property owned by me at the time of my death, including those passing to me by Will, intestacy, contract, joint ownership, operation of law or otherwise. (n) To employ and compensate from income or principal, in the discretion of my Executor, investment and legal counsel, accountants, brokers and other specialists, and, whenever there shall be no corporate Executor in office, a corporate custodian, and to delegate to investment counsel discretion with respect to the investment and reinvestment of any or all of the assets held hereunder. 6. CUSTODIAN OF ESTATES. If at any time any individual under the age of twenty-one shall be entitled to receive any assets free of trust by reason of my death, whether payable hereunder, by operation of law, contract or otherwise, I appoint my Executor hereinafter named as Custodian for such individual under the Pennsylvania Uniform Transfers to Minors Act. 7. TAX CLAUSE. All inheritance, estate and similar taxes becoming due by reason of my death, except any taxes Page 5 of 7 Pages relating to generation skipping transfers imposed under Chapter 13 of Subtitle B of the Internal Revenue Code, as amended ("Death Taxes"), whether such Death Taxes shall be payable by my estate or by any recipient of any property, shall be paid by my Executor out of the property passing under ITEM 2 of this Will as an expense and cost of administration of my estate. My Executor shall have no duty or obligation to obtain reimbursement for any Death Taxes paid by my Executor, even though paid with respect to proceeds of insurance or other property not passing under this Will. 8. EXECUTOR APPOINTMENT. I hereby appoint My Spouse, JUDY A. GAVLAK, as Executrix of this Will. If for any reason My Spouse should fail or cease to act, I appoint my sons, ALLEN J. GAVLAK and CHRISTOPHER J. GAVLAK, as Co-Executors. If for any reason either of them should fail or cease to act, the other shall act or continue to act with all of the powers granted to the two of them. All references in this Will to my "Executor" shall refer to my originally named Executrix, to my successor Co-Executors or to my sole successor Executor, as the case may be. 9. WAIVER OF BOND; FIDUCIARY FEES. My Executor shall qualify and serve without the duty or obligation of filing any bond or other security. Page 6 of 7 Pages IN WITNESS WHEREOF, I have set my hand and seal to this, my Last Will and Testament, consisting of this and the preceding six (6) pages, this c) / c day of c _ ../.tl t/ [ 2001. cc ( C' {>" (t, (' Albert C. Gavlak (SEAL) We, the undersigned, hereby certify that the foregoing Will was signed, sealed, published and declared by the above-named Testator as and for his Last Will and Testament, in the presence of us, who, at his request and in his presence and in the presence of each other, have hereunto set our hands and seals the day and year above written, and we certify that at the time of the executi the eof, the said Testator was of sound and disposing min . an ( SEAL) Residing at: 43t; cJ<IT?i2atf ~ ~Uc,C" fl ReSi:ing at: /hd ~ ..z..<-<...... J~~ ~ ( SEAL) ~ f?A " / 7 d ,:2 .s- Page 7 of 7 Pages COMMONWEALTH OF PENNSYLVANIA COUNTY OF SS: We, ALBERT C. GAVLAK, and , the Testator and the Witnesses, respectively, whose names are signed to the foregoing instrument, having been sworn, do hereby declare to the undersigned officer that the Testator, in the presence of the Witnesses, signed said instrument as his Last will and Testament, that he signed voluntarily, that each of the witnesses, in the presence of the Testator and of each other, signed said Will as a witness and that to the best of the knowledge of each witness, the Testator was at the time of sound mind and under no constraint or undue influence. Albert C. Gavlak Witness Witness Subscribed and acknowledged before me by ALBERT C. GAVLAK, the Testator, and subscribed and sworn to before me by and , the witnesses, on this day of , 2001. Notary Public My Commission Expires: (SEAL) 208778.1 't.. /' CERTIFICATE OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Albert C. Gavlak Date of Death: September 25,2001 Will No. 010330f2001 Adm. No. To the Register: I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court RUle~as served on or mailed to the following beneficiary of the above-captioned estate on DV 17. ~oo/. I Name Address Mrs. Judy A. Gavlak 101 Holly Lane, Mechanicsburg, PA 17055 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except No Exce tions Date: November 19,2001 Signature: Name: Address: Stanley A. Smith Rhoads & Sinon LLP 1 South Market Square, 12th Floor PO Box 1146 Harrisburg, P A 17108-1146 (717) 233-5731 Telephone: Capacity: Personal Representative X Counsel for Personal Representative o o~ ;:,~, ~~: ":": 'SC r:L: N CL ~~, ()(J) OJ a: 0:: - N :::::::- 5! ~2 ;~f~ ',;:: , (l) ~.o li...~ ~; UU - p 408634.1 I_~ Register of Wills of Cumberland County, Pennsylvania r- , INVENTORY Estate of Albert C. Gavlak also known as No. 01033 of 2001 Date of Death September 29, 2001 , Deceased Social Security No. 184-32-2717 I, Judv A. Gavlak Personal Representative of the above Estate, deceased, verify that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I verify that the statements made in this Inventory are true and correct. I understand that false statements herein are made subject to th enalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. ~:;t;:;:a ~~ Name of Attorney: 1.0. No.: Address: Stan 33782 Rhoads & Sinon LLP, P.O. Box 1146 Harrisburg, PA 17108-1146 (717) 233-5731 Telephone : Dated: Description Value 59,838.33 See attachment ....... ..- ~ "t..... '. o ~"""J r~ (Attach Additional Sheets if necessary) Total: $59.838.33 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. Fo,m RW-7 (Dauphin County - Rev. 9/921 418893.1 ,.. ~ Estate Inventory Valued as of Date of Death No. of Shares Stocks 960.5790 AXP Global Ser, Inc., Innovations Fund CL A $ 1,392.84 207.9000 Black Oak Emerging Technology Fund 573.80 286.5900 Harley Davidson, Inc. 11,817.54 Dividend at date of death 8.60 110 International Business Machines Corp. 10,417.55 319 SAIC (employee owned company, stock not traded on open market) 11,356.40 146.8200 White Oak Growth Stock Fund 4,524.99 Total Stocks $ 40,091.72 Money Market/CMA Accounts AXP Cash Management Account Fund $ 10,803.66 AXP Market Strategy Investment Certificate 5,059.78 AXP Stock Market Investment Certificate 3,883.17 Total Money Market/CMA Accounts $ $ 19,746.61 Total Inventory 59,838.33 ----------------- ----------------- Page 1 /'?-02CJ -.s- ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG~ PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX STANLEY A SMITH ESQ RHOADS & SINON PO BOX 1146 HARRISBURG .O? DATE ESTATE OF DATE OF DEATH FILE NUMBER 1 9 r' :CqUNTY ". ACN 08-12-2002 GAVLAK 09-25-2001 21 01-1033 CUMBERLAND 101 AIIount Relli tted * REV-1547 EX AFP (ol-U21 ALBERT C ~. PA 17108C,l MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REY:is4j-ix-"FP-roi-:oz'r-NoYici--OF-i-titiEifiiANci-YAX-APPRAisiMENY-,--"LL'OWANCi-oi----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF GAVLAK ALBERT C FILE NO. 21 01-1033 ACN 101 DATE 08-12-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) ~. Hortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (~) (5) (6) (7) .00 40~091.72 .00 .00 19~746.61 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Hisc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax .00 .00 (11) (12) (13) (14) (15) 59,838.33 X 00 = (16) .00 X 045 = (17) .00 X 12 = (18) .00 X 15 = (19)= NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYll8nt. 59,838.33 00 59,838.33 .00 59,838.33 TAX CREDITS: . "'. ....... . R.."'..... . I (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIr' (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) , , " CI// STATUS REPORT UNDER RULE 6.12 Name of Decedent: Albert C. Gavlak Date of Death: September 25. 2001 Will No. 010330f2001 Admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: Yes a. No Did the personal representative file a final account with the Court? X b. representative's account is: The separate Orphans' Court No. (if any) for the personal c. parties in interest? Yes Did the personal representative state an account informally to the X No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court d may be attached to this report. Stanley A. Smith Rhoads & Sinon LLP 1 South Market Square, 12th Floor PO Box 1146 Harrisburg, P A 17108-1146 (717) 233-5731 Personal Representative X Counsel for Personal Representative Date: ~-I- D 5, Name: Address: :~ Telephone: Capacity: Cl ::;~ '-"1 P -- ., :7- . "r" '_o#'~ 482991.1 ,.... ~ L REV -1500 EX + (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA REV-1500 I 7 - .., 1 r/j,; DEPARTMENT OF REVENUE ~.C .- DEPT. 280601 INHERITANCE TAX RETURN FILE NUMBER HARRISBURG, PA 17128-0601 RESIDENT DECEDENT 21 2001 1033 COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER GAVLAK, ALBERT C. 184-32-2717 DECE- DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE DENT 09/25/2001 07/16/1942 WITH THE REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Judy A. Gavlak 8 3. Remainder Return CHECK r Original Return W Supplemental Return (date of death prior to 12-13-82) APPRO- 4. Umited Estate 4a. Future Interest Compromise 5. Federal Estate Tax Return Required ~ate of death after 12-12-82) PRJATE 6. Decedent Died Testate 7. ecedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach copy of Will) ~ttach a copy of Trust) BLOCKS 9. Utigation Proceeds Received 10. pousal Poverty Credit (date of death between 0 11. Election to tax under Sec. 9113{A) 12-31-91 and 1-1-95) (Attach Sch 0) ..tijt$$jQftQN.MO$t.ijl$..cifi,pUttji.j~M~~.~RijUlMilit;QW~~t@N..~\$.lij$..PjRl$$t$j.tQ~. NAME COMPLETE MAILING ADDRESS COR- Stanley A. Smith, Esquire P. O. Box 1146 RE- FIRM NAME (If Applicable) Harrisburg, PA 17108-1146 SPON DENT Rhoads & Sinon LLP TELEPHONE NUMBER (717) 233-5731 OFFICIAL USE ONLY 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 40,091.7..2" 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) , - ~. 4. Mortgages & Notes Receivable (Schedule D) (4) . '. 5. Cash, Bank Deposits & Miscellaneous Personal r Property (Schedule E) (5) 19,746.61 - 6. Jointly Owned Property (Schedule F) , 0 Separate Billing Requested (6) - RECA- PITULA- 7. Inter-Vivos Transfers & Miscellaneous TION Non - Probate Property (Schedule G or L) (7) 0.00 , 8. Total Gross Assets (total Unes 1-7) (8) 59,838.33 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage liabilities, & Liens (Schedule I) (10) 11. Total Deductions {total Unes 9 & 10) (11) 0.00 12. Net Value of Estate (Une 8 minus Une 11) (12) 59,838.33 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax (13) has not been made (Schedule J) 14. Net Value Subject to Tax (Une 12 minus Une 13) (14) 59,838.33 SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (aX1.2) 5 9 , 8 3 8 . 3 3 X .0 .00 (15) 0.00 TAX 16. Amount of Line 14 taxable at lineal rate o . OOx .0 .045 (16) 0.00 - COMPU- 17. Amount of Line 14 taxable at sibling rate 0.00x.12 (17) 0.00 TATION 18. Amount of Line 14 taxable at collateral rate O. OOx .15 (18) 0.00 19. Tax Due (19) 0.00 20. 0 t.~~ftiFl~n~~._~ert.:k:R~..(j't;."'bViaF'itM_....1 ..... ..............................................................................<<?......::;,iaJ;:$t;lmE1'OAN$.W~AUiQQe:$UQN$ON~I$~ANQaeCHeCl.i(titWlBg~r>)}................... o PA 15001 NTF 29755 Copyright 2000 Grea\\andINelco LP - Farms Software Only .- PA REV -1500 EX (6-00) D d C I t Add Page 2 ece ent s ample e ress: STREET ADDRESS 101 Holly Lane CITY I STATE I ZIP Me chani'c sburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 0.00 0.00 0.00 0.00 Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty 0.00 0.00 Total Interest/Penalty (D + E) (3) 4. If Une 2 is greater than Une 1 + Une 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Une 20 to request a refund (4) 5. If Une 1 + Une 3 is greater than Une 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the total of Une 5 + SA. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT 0.00 0.00 0.00 1. Did decedent make a transfer and: Yes a. retain the use or income of the property transferred; ....................................... b. retain the right to designate who shall use the property transferred or its income; ................. c. retain a reversionary interest; or. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. receive the promise for life of either payments, benefits or care? ........... . . . . . . . . . . . . . . . . . . . 2. If death occurred after December 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. 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 information of which preparer has any knowledge. SIG~.. URE C{ PERSON RESPONS~LE FOR Fu..ING~ETURN DATE ~r.LrtAJ' Z{. '-:'..J1/,'-'t-/..La.-/~ AD ESS . , cjoRhoads & Sinon LLP, P.O.Box 1146 Harrisburg, PA 17108-1146 SIGNATURE OF PREPA ER N REPRES NTATIVE No ~ ~ 8 m o ADDRESS Rhoads & 11 6 Harrisburg, PA 17108-1146 [72 P.S. 19116 (a)(1. 1Hill. For dates of death on or after January " 1995, the tax rate is imposed on the net value of transfers to or for the use of the surviving spouse is O'll> [72 P.S. 19116 (a) (1.1) (iill. The statute riDeR not exemot a transfer to a surviving spouse from ta)(, 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 twenty-one years 01 age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is O'll> [72 P.S. 191 16(aX'.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'll>, except as noted In 72.P.S. I 91 16(1.2) [72 P.S. 19"6(aX')]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12'll> [72 P.S. 191 16(aX1.3)]. 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. o PA 15002 NTF 29756 Copyright 2000 Greatland/Nelco LP - Forms Software Only REV-1503 EX +(1-97) COM MONWEAL TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF ALBERT C. GAVLAK FILE NUMBER 21-01-1033 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1 DESCRIPTION VALUE AT DATE OF DEATH 960.5790 Shares AXP Global Ser, Inc., Innovations Fund CL A CUSIP NO. 00245L843 1. 4500 1,392.84 2 207.9000 Shares Black Oak Emerging Technology Fund CUSIP NO. 671081404 2.7600 573.80 3 286.5900 Shares Harley Davidson, Inc. CUSIP NO. 412822108 Dividend accrued at 09/25/2001 41.2350 11,817.54 8.60 4 110 Shares International Business Machines Corp. CUSIP NO. 459200100 94.7050 10,417.55 5 319 Shares SAIC (employee owned company, stock not traded on open market) 35.6000 11,356.40 6 146.8200 Shares White Oak Growth Stock Fund CUSIP NO. 671081107 30.8200 4,524.99 TOTAL (Also enter on line 2 Recaoitulationl $ 40 , 091 . 72 (If more space is needed, insert additional sheets of the same size) Copyright lc) 1997 form software only CPSystems. Inc. Form REV -1503 EX (Rev. 1-97) REV-1508 EX + (1-97) COMMONWEAL TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ALBERT C. GAVLAK SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21-01-1033 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1 DESCRIPTION AXP Cash Management Account Fund VALUE AT DATE OF DEATH 10,803.66 2 AXP Market Strategy Investment Certificate 5,059.78 3 AXP Stock Market Investment Certificate 3,883.17 TOTAL (Also enter on line 5, Recaoitulationl S 19,746.61 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1997 form software only CPSystems, Inc. Form REV-1508 EX IRev. 1-97) REV- 1510 EX + 11 -97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DE EDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF ALBERT C. GAVLAK FILE NUMBER 21-01-1033 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE THE NAME OF THE TRANSFEREE THEIR DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE NUMBER R ELA 11~TN...~JP/,9n~~~W %~TDAENJlD V;.,E", ~<=TI. OI,,~~~~SF E R. VALUE OF ASSET INTEREST IIF APPLlCABLEl 1 See Attached Statement 0.00 100 0.00 0.00 TOTAL (Also enter on line 7 Recapitulationl $ 0.00 (If more space is needed, insert additional sheets of the same size) Copyright (e) 1997 form software only CPSystems, Inc. Form REV-1510 EX (Rev. 1-97) ESTATE OF ALBERT C. GAVLAK FILE NO.: 21-01-1033 Attachment to Schedule G The decedent owned an annuity account and a number of IRA accounts as follows. None of these accounts are reported as taxable assets because decedent was not 59 1/2 years of age at his death and none of the accounts was available to him without penalty until such time as he reached age 59 1/2. The beneficiary on all accounts is decedent's spouse, Judy A. Gavlak. American Express Account Numbers Value at date of death 010677190497002 (IRA) 011977190492002 (IRA) o 13177190496002 (IRA) 013877190499002 (Roth IRA) 022977190499002 (IRA) 930062025455004 (Annuity) 37,446.82 17,656.39 12,916.52 2,253.50 5,701.75 12,199.65 418891.1 REV -1513 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF ALBERT C. GAVLAK FILE NUMBER 21-01-1033 NUMBER I. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS (include outright spousal distributions) RELATIONSHIP TO DECEDENT Do Not Ust Trustee{s) AMOUNT OR SHARE OF ESTATE 1 Judy A. Gavlak 101 Holly Lane Mechanicsburg, PA 17055 Surviving Spouse 59,838.33 ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 17 AS APPROPRIATE ON REV 1500 COVER SHEET II. NON- TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS None TOTAL OF PART" - ENTER TOTAL NON- TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1997 form software only CPSystems, Inc. Form REV-1513 EX (Rev. 1-97) LAST WILL AND TESTAMENT OF ALBERT C. GAVLAK I, ALBERT C. GAVLAK, of Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time previously made. I am married to Judy A. Gavlak (hereinafter referred to as "My Spouse") and the children born of our marriage are Allen J. Gavlak and Christopher J. Gavlak. 1. TANGIBLE PERSONAL PROPERTY. I give and bequeath all of my household furniture and furnishings, automobiles, other motor vehicles, books, pictures, jewelry, china, crystal, appliances, silverware, wearing apparel, articles of household or personal use or adornment, collections, artworks, boats and recreational equipment and vehicles, together with all policies of insurance thereon, to My Spouse, if My Spouse survives me. If My Spouse does not survive me, I give such articles to my children living at my death in as nearly equal shares as they shall select under the supervision of my Executor. Any cost of packing and Page 1 of 7 Pages 401451.1 shipping said personalty to the beneficiaries, including insurance, shall be paid by my Executor as a general administration cost. If any such articles cannot be fairly divided or distributed in kind in the opinion of my Executor, such articles shall be sold and the proceeds thereof shall pass as a part of my residuary estate. 2 . RESIDUE. I give, devise and bequeath all of the rest, residue and remainder of my property, real, personal and mixed, not disposed of in the preceding portions of this Will, including all property over which I hold a power of appointment (which powers of appointment I hereby exercise in favor of my estate), to My Spouse, if My Spouse survives me. If My Spouse does not survive me, I give, devise and bequeath said residue to my issue living at my death, per stirpes. 3. SPENDTHRIFT PROVISION. No interest in income or principal of my estate shall be subject to attachment, levy or seizure by any creditor, spouse, assignee or trustee or receiver in bankruptcy of any beneficiary of my estate prior to the beneficiary's actual receipt thereof. My Executor shall pay over the net income and the principal to the beneficiaries herein designated, as their interests may appear, without regard to any attempted anticipation (except as may be specifically provided Page 2 of 7 Pages herein), pledging or assignment by any beneficiary of my estate and without regard to any claim thereto or attempted levy, attachment, seizure or other process against said beneficiary. 4. SURVIVAL PRESUMPTIONS. Any person who shall have died at the same time as I or under such circumstances that it is difficult or impossible to determine who shall have died first, shall be deemed to have predeceased me. 5. FIDUCIARY POWERS. In the settlement of my estate, my Executor shall possess, among others, the following powers, exercisable without prior court approval, but in all cases to be exercised for the best interests of the beneficiaries: (a) To retain any investments I may have at my death so long as my Executor may deem it advisable to my estate so to do, including securities owned, issued or underwritten by any corporate Executor or any of its affiliates. (b) To vary investments, when deemed desirable by the Trustee, and to invest in every kind of property and type of investment, including securities owned, issued or underwritten by any corporate Trustee or any of its affiliates, or as to which such Trustee or its affiliate acts as investment advisor, as the Trustee shall deem wise. (c) In order to effect a division of the principal of my estate or for any other purpose, including any final distribution of my estate, my Executor is authorized to make said divisions or distributions of the personalty and realty partly or wholly in kind. If such division or distribution is made in kind, said assets shall be divided or distributed at their Page 3 of 7 Pages respective values on the date or dates of their division or distribution. In making any division or distribution in kind, my Executor shall divide or distribute said assets in a manner which will fairly allocate any unrealized appreciation among the beneficiaries. (d) To sell either at public or private sale and upon such terms and conditions as my Executor may deem advantageous to my estate, any or all real or personal estate or interest therein owned by my estate severally or in conjunction with other persons or acquired after my death by my Executor, and to consummate said sale or sales by sufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title, free and clear of all trust and without obligation or liability of the purchaser or purchasers to see to the application of the purchase money or to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings which may be necessary or desirable in carrying out any of the powers conferred upon my Executor in this paragraph or elsewhere in this Will. (e) To mortgage real estate and to make leases of real estate for any term. (f) To borrow money from any party, including my Executor, to pay indebtedness of mine or of my estate, expenses of administration, Death Taxes or other taxes. (g) To pay all costs, expenses, legally enforceable debts, funeral expenses and charges in connection with the administration of my estate. (h) To vote any shares of stock which form a part of my estate and to otherwise exercise all the powers incident to the ownership of such stock and to actively manage and operate any incorporated or unincorporated business, including any joint ventures and partnerships, and to incorporate any such unincorporated business, with all the rights and powers of any owner thereof. Page 4 of 7 Pages (i) In the discretion of my Executor, to unite with other owners of similar property in carrying out any plans for the reorganization of any corporation or company whose securities form a part of my estate. (j) To assign to and hold in my estate an undivided portion of any asset. (k) To hold investments in the name of a nominee. (1) To compromise controversies. (m) To disclaim, in whole or in part, any and all interests in property owned by me at the time of my death, including those passing to me by Will, intestacy, contract, joint ownership, operation of law or otherwise. (n) To employ and compensate from income or principal, in the discretion of my Executor, investment and legal counsel, accountants, brokers and other specialists, and, whenever there shall be no corporate Executor in office, a corporate custodian, and to delegate to investment counsel discretion with respect to the investment and reinvestment ot any or all of the assets held hereunder. 6. If at any time any CUSTODIAN OF ESTATES. individual under the age of twenty-one shall be entitled to receive any assets free of trust by reason of my death, whether payable hereunder, by operation of law, contract or otherwise, I appoint my Executor hereinafter named as Custodian for such individual under the Pennsylvania Uniform Transfers to Minors Act. 7. TAX CLAUSE. All inheritance, estate and similar taxes becoming due by reason of my death, except any taxes Page 5 of 7 Pages relating to generation skipping transfers imposed under Chapter 13 of Subtitle B of the Internal Revenue Code, as amended ("Death Taxes"), whether such Death Taxes shall be payable by my estate or by any recipient of any property, shall be paid by my Executor out of the property passing under ITEM 2 of this Will as an expense and cost of administration of my estate. My Executor shall have no duty or obligation to obtain reimbursement for any Death Taxes paid by my Executor, even though paid with respect to proceeds of insurance or other property not passing under this Will. 8. EXECUTOR APPOINTMENT. I hereby appoint My Spouse, JUDY A. GAVLAK, as Executrix of this Will. If for any reason My Spouse should fail or cease to act, I appoint my sons, ALLEN J. GAVLAK and CHRISTOPHER J. GAVLAK, as Co-Executors. If for any reason either of them should fail or cease to act, the other shall act or continue to act with all of the powers granted to the two of them. All references in this Will to my "Executor" shall refer to my originally named Executrix, to my successor Co-Executors or to my sole successor Executor, as the case may be. 9. WAIVER OF BOND; FIDUCIARY FEES. My Executor shall qualify and serve without the duty or obligation of filing any bond or other security. Page 6 of 7 Pages ~, IN WITNESS WHEREOF, I have set my hand and seal to this, my Last Will and Testament, consisting of this and the preceding six (6) pages, this I ((~ day of ,- .~-"'. I / , 2001. /~( (I( ( Albert C. Gavlak (SEAL) We, the undersigned, hereby certify that the foregoing Will was signed, sealed, published and declared by the above-named Testator as and for his Last Will and Testament, in the presence of us, who, at his request and in his presence and in the presence of each other, have hereunto set our hands and seals the day and year above written, and we certify that at the time of the executign the eof, the said Testator was of sound and disposing min an em (SEAL) Residing at: C!Jt u(,,:-riJcl4f~ - /1 ( j,/ .' A at: /11/0 ~ r~ ~ (SEAL) ~ fJ,4 / 7d ,;2,5- " Page 7 of 7 Pages