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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 05
COUNTY COOE YEAR
SOCIAL SECURITY NUMBER
COMMONWEALTH OF PENNSYlVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
00584
NUMBER
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OECEOENTS NAME (LAST, FIRST, ANO MIOOLE INITIAL)
BARRETT, GEORGIE R.
~A~~ ~~ ~:A~~ ~M.OO.YEAR) uu 'r~A;~~~~I:;~~M'OD'YEAR)
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST ANO MIOOLE INITIAL)
REGISTER OF
SOCIAL SECURITY NUMBER
174-05-1974
THIS RETURN MUST BE FILED IN D PLICATE WITH THE
181 1. Original Return
D
181
D
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D 2. Supplemental Return
o 48. Future Interest Compromise (date of death after
12-12-82)
D 7. Decedent Maintained a Living Trust (Altacl1
copy of Trust)
D 10. Spousal Poverty Credit (date of death between
1 -31-91 and 1-1-95
THIS SECTION MUST BE COMPlETED. ALL C6RRESPO!,!~ENCE ANDi<:PNFIDI!NTlAL TAX:INE.a.TIONSHOULDBS'DIRECTEDTO:
AME COMPLETE MAILING AOORESS
Ivo V. Otto III, Esquire
4. Limited Estate
D
D 5.
o 8.
3. Remainder Return (date of death p or to 12-13-82)
6. Decedent Died Testate (Attach copy
of Will)
9. Litigation Proceeds Received
IRM NAME (If applicable)
Martson Deardorff Williams & Otto
Ten East High Street
Carlisle, P A 17013
(1) None
(2) 25,788.26
(3) None
(4) None
----
(5) 66,360.67
(6) None
(7) None
(8) 92,148.93
(9) 18,438.87
(10) 12,394.81
ELEPHONE NUMBER
717/243-3341
1. Real Estate (Schedule A)
2, Stocks and Bonds (Schedule B)
3. Closeiy Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9, Funeral Expenses & Administrative Costs (Schedule H)
10, Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
(11)
30,833.68
12. Net Value of Estate (Line 8 minus Line 11)
(12)
61,315,25
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14, Net Value Subject to Tax (Line 12 minus Line 13)
(13)
(14)
61,315.25
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15,Amount of Line 14 taxable at the spousal tax rate. x .00 (15)
or transfers under Sec. 9116(a)(1.2)
z 61,315.25 .045 (16)
0 16.Amount of Line 14 taxable at lineal rate x
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0. 17,Amount of Line 14 taxable at sibling rate x .12 (17)
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0
0
~ 18, Amount of Line 14 taxable at collateral rate .15 (18)
l- x
19, Tax Due (19)
2,759,19
2,759.19
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
'b11ls'ofj':REVERSE:liID
Copyright 2000 form software only The Lackner Group, Inc.
RK.
Decedent's Complete Address:
STREET ADDRESS
442 Walnut Bottom Road
CITY
Carlisle
STATE PA
ZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
,759,19
137.96
Total Credits (A + B + C)
(2)
137.96
3, InteresVPenalty if appllcabie
D, Interest
E, Penalty
TotallnteresVPenalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 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.
A. Enter the interest on the tax due,
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3) 0.00
(4)
(5) ,621.23
(5A)
(5B) 2,621.23
Make Check Payable to: REGISTER OF WILLS, AGENT
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 desig nation?........,.,.,.............,...,..........,.,.""".,.,.,.,...""...,.,.,...........,.,..............,..............
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;.................................................................................. 0 ~
~: ~:::~ :h~e~~~;i:~:~s:~~~~s~~~..s.h.a~~.~~~.~~~.:.~.~.~.~.~:.,~:~~~.f~r~~~..O~.i,t.S.I~~~~~;:::::::::::::::::::::::::::::::::::: B ~
d. receive the promise for life of either payments, benefits or care?.............................................................. 0 ~
2, If death OCCurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? .,.,...........,.,.,..............,.,............,.,.,.,.,.".,.,.,.,.,.,."""" .,...........,..............,........ D ~
D ~
D ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF
Ten East High Street
Carlisle, PA 17013
preparer gther than the personal representative is based on all information of which preparer ~as any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN AOORESS
Marjorie B. Dutrey 504 West South Street
Carlisle, PA 17013
AODRESS
SIGNATURE OF PRE PARER OTHER THAN REPRESENTATIVE
IVO~, Es u'
AOORESS
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. !l9116 (a) (1.1) (ill,
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 s 0%
[72 P.S. !l9116 (a) (1.1) (ii)]. The statute does not exemDt a transfer to a surviving spouse from tax, and the statutory requirements for dis losure
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 of age or younger at death to or for the use of natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. !l9116 (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%, except as noted in 72 P S, !l9116
1.2) [72 P,S, !l9116 (a) (1 )].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. !l9116 (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.
*' SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF I FILE NUMBER
BARRETT, GEORGIE R. 21 - 05 - 00584
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE V "LUE AT DATE OF
NUMBER DEATH
1 69 shares AT&T CORP., common new (001957505) 19.355 1,335,50
2 1 share AGERE SYS INC, CL A (00845V100) 12.30 12.30
3 40 shares AGERE SYS INC., CL B (00845V209) 12.20 488.00
4 12 shares A VA Y A INC, common (053499109) 8.285 99.42
5 396 shares BELLSOUTH CORP" common (079860102) 27,12 10,739.52
6 112 shares COMCAST CORP NEW, CL A (20030N101) 31.80 3,561.60
7 152 shares LUCENT TECH INC, common (549463107) 2,96 449.92
8 198 shares QWEST COMM INC" common (749121109) 3.7 732,60
9 348 shares SBC COMM INC" common (845333103) 24,05 8,369.40
TOTAL (Also enter on line 2, Recapitulation)
25,788.26
*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA.
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
BARRETT, GEORGIE R.
I FILE NUMBER
21 - 05 - 00584
Include the proceeds of litigation and the date the proceeds were received by the estate, All property jointly-owned with t e right of
survivorship must be disclosed on schedule F.
ITEM
NUMBER
1 M&T Bank Checking #401803
DESCRIPTION
Vf.LUE AT DATE OF
DEATH
63,043.25
2
Travelers, homeowners insurance, refund of premium
486.00
3
United Church of Christ Homes, refund
2,812.48
4
Philhaven, refund
18.94
TOTAL (Also enter on Line 5, Recapitulation)
66,360.67
I
*' SCHEDULE H
FUNERAL EXPENSES &
COMMONWEALTH OF PENNSYLVANIA ADMINISTRATIVE COSTS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF BARRETT, GEORGIE R. I FILE NUMBER
21 - 05 - 00584
_.
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
--. . ---
A. FUNERAL EXPENSES:
1 Ewing Brothers Funeral Home, Carlisle, P A 9,360.20
2 Westminster Cemetery, interment fee 1,045,00
3 Westminster Cemetery, grave marker 730,00
4 Rillos, funeral reception 1,524.17
B. ADMINISTRATIVE COSTS:
1, Personal Representative's Commissions
Sociai Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City State Zip
-
Year(s) Commission paid
2, Attorney's Fees Martson Deardorff Williams & Otto (estimated) 5,350.00
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 of Cumberland County, PA 179.00
5. Accountant's Fees
6, Tax Return Preparer's Fees
7. Other Administrative Costs
1 EVP Systems, Inc., Stock valuation report 15.50
2 Register of Wills, filing fee, inheritance tax return 15,00
Total of Continuation Schedule(s) 220.00
-
TOTAL (Also enter on line 9, Recapitulation) 18,438.87
ESTATE OF
Schedule H
Funeral Expenses &
Adninislratiw Costs continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
BARRETT, GEORGIE R.
3
Register of Wills, additional probate fee
4
Stock transfer fees, postage and filing fees
I FILE NUMBER
21 - 05 - 00584
Page 2 of Schedu e H
120.00
100,00
COMMONWEALTH OF PENNSYLVANIA LIABILITIES, & LIENS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
.
ESTATE OF I FILE NUMBER
BARRETT, GEORGIE R. 21 - 05 - 00584
Include unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER
1 Marjorie B. Dutrey, reimbursement for personal funds advanced on 4/28/05 for nursing home care 12,000.00
2 PP L, final bill 16.13
3 UGI, final bill 54.62
4 Pharmerica, account payable 13,30
5 Thornwald Home, account payable 82.71
6 State Employees' Retirement System 228,05
I
-
TOTAL (Also enter on Line 10, Recapitulation) 12,394.81
*'
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
I FILE NUMBER
21 - 05 - 00584
RELATIONSHIP TO NT OR SHARE
DECEDENT FESTATE
DIU
.' REV~1513 EX+ (i-oO)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
BARRETT, GEORGIE R.
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
John W. Dutrey
336 Wilson Street, Carlisle, PA 17013
Grandson
2
Mary Ann Kidd Thewlis
405 Rainbow Drive, Creve Coeur, IL 61610
Granddaughter
3
Marjorie B. Dutrey
504 West South Street, Carlisle, P A 17013
Daughter
4
Sue Ann B. Greco
509 Pinney Road, Huntingdon Valley, PA 19006
Granddaughter
5
Steven W. Barrett
194 Beagle Club Road, Carlisle, P A 17013
Grandson
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTiON TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Spec' fic bequest of
stock $25,788,26
Cash equest of
$5,0 0.00
1/2 e tate residue
1/4 e tate residue
1/4 e tate residue
~,
ACCOUNT NO. ACCOUNT TYPE STATEMENT PERIOD PAGE
401803 H&T SELECT WITH INTEREST JUN.04-JUL.01,200S 1 OF 2
00 10 04319M H 021
- 371
GEORGIA R BARRETT
104 W POMFRET ST
CARLISLE PA 17013-3218
-
INTEREST PAID YEAR TO DATE 7.26 HIGH STREET-CARLISLE
ACCOUNT SUMMARY
BEGINNING .' DEPOSITSS .' , ....., OTHER '....... CuRRENT, lENDING
BALANCE .'. .. OTHER . ADDITIONS . . ' ., " tHetKSpAIO ..." I SUBTRACTIONS INTeREST ,PI) '. 'BALANCE' .'
NO.1 AMOUNT NO.1 AMOUNT NO. I AMOUNT
11,665.81 21 105,389.52 101 56,530.07 o 1 0.00 3.65 60,528.91
ACCOUNT ACTIVITY
POSTING . ,'.... .,.. DEPOSITS, INTEREST CHECKS SaTHER I DAILY
DATE ,... TRANSACTION DESCRIPTION & OTHER ADDITIONS ' . . ' SUIlTRACTIONS ' . '1 ALANCE ...
06-04-05 BEGINNING BALANCE $11,665.81
06-06-05 CHECK NUMBER 3860 150.00 11,S15.81
06-08-05 CHECK NUMBER 3857 100.00
06-08-05 CHECK NUHBER 3859 100.00 11,315.81
06-09-05 DEPOSIT 104,606.52 l1S,922.33
06-10-05 CHECK NUMBER 3858 100.00 115,822.33
06-14-05 CHECK NUMBER 3863 46,489.28 69,333.05
06-15-0S CHECK NUMBER 3862 6,251. 94 63, 081.11
06-16-05 CHECK NUHBER 3861 39.68 r 63,041.43 \
06-23-05 CHECK NUHBER 3866 - /Ct/I,,-=- ' fZu<-erAf2 1'0.:4' fG,.., 1,524.17
06-23-05 CHECK NUHBER 3864 - /,J.lt:snr,/ t1.s.kr ~ ---'kr(f - tr I-L"''''' 171''''''';kO 1,045.00
06-23-0S CHECK NUHBER 3865 - Iv' ~sf>." 'ASokr {' ~n1'C-k'i1- r>1 " LLIY1 c...:r 730.00 59,742.26
07-01-05 US TREASURY 303 SOC SEC -rct.....- 'x<.{, 7 IDs 783.00
07-01-0S INTEREST PAYHENT 3.65 60,528.91
ENDING BALANCE $60,528.91
I ..,. . CHECKS !'AID SUHMARY .. ... ,. '. .'.
, . .'. '. .'
3857 06-08-05 100.00 3858 06-10-0S 100.00 3859 06-08-05 100.00
3860 06-06-05 lS0.00 3861 06-16-0S 39.68 3862 06-1S-05 6,251.94
3863 06-14-0S 46,489.28 3864 06-23-0S 1,045.00 386S 06-23-0S 730.00
3866 06-23-0S 1,524.17
ANNUAL PERCENTAGE YIELD EARNED = 0.10 %
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F:\FILES\DA T ArILE\ WILLS\ 7284_COD
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CODICIL
I, GEORGIE R. BARRETT, sometimes known as GEORGIA R. BARRETT, of the Bar ugh
of Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memo
understanding, do make, publish and declare this to be a Codicil to my Last Will and Testa ent
dated April 9, 1990,
1.
I add the following paragraphs to my said Last Will and Testament:
2a,
I give and devise to my grandson, .TOHN W, DUTREY, my AT&T stock and
all shares of stock in the companies spun offfrom same by virtue of the Court Order,
i.e, Bell South, V,S, West, Southwest Bell and any similar company,
2b
I give and devise to my granddaughter, MARY ANN KIDD, the sum of Five
Thousand Dollars ($5,000,00),
2,
In all other respects, I ratifY and affirm my said Last Will and Testament dated April 9, 1
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~tJJI-..
~, ,1995,
~/j--en~ k &v1Af:$
Georgi . Barrett
JlfrA I!lAA~?7/7
Geor R. Barrett
(S
SIG!\TED, SEALED, PtJBLISHED p.1'ID DECLARED by the above-named Testatrix, as and
for a Codicil to her Last Will and Testament dated April 9, 1990, in the presence of us, who a her
request, have hereunto subscribed our names as witnesses thereto, in the presence of the said
Testatrix and of each other.
( , '< <:"
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COMMONWEAL TH OF PENNSYLVANIA
)
)
SS.
COUNTY OF CUMBERLAND
I, Georgie R, Barrett, sometimes known as Georgia R Barrett, Testatrix, whose n
signed to the attached or foregoing instrument, having been duly qualified according to la
hereby acknowledge that I signed and executed the instrument as a Codicil to my Last Will ated
April 9, 1990; that I signed it willingly; and that I signed it as my free and voluntary act fi r the
purposes therein expressed.
of
Sworn or affirmed to and acknowledged before me by the Testatrix herein, this
c 'YLi'-^'- , 1995,
, Notarial Seal
Corrine L Myers, Notary Public
Carlisle Bore, Cumberland County
My Commission Expires May 27,1999
"'aay
COMMONWEALTH OF PENNSYL VANIA )
. SS,
COUNTY OF CUMBERLAND )
We,,J/Zt.A.i!EA-J t>J i//i..iIA'/.k ,ii' {( ,./1~~~{: (:1/:1:U:'l~[;Z'1"---
the witnesses whose namd are signed to the attached or foregoing instrument, being duly qua ified
according to law, do depose and say that we were present and saw Georgie R. Barrett, the Test trix,
sign and execute the instrument as a Codicil to her Last Will dated April 9, 1990; that the Tes atrix
signed willingly and that the Testatrix executed it as her free and voluntary act for the pur oses
therein expressed; that each of us, in the hearing and sight of the Testatrix, signed the Codi il as
witnesses; and that to the best of our knowledge the Testatrix was at that time 18 or more ye rs of
age, of sound mind and under no constraint or undue influence,
~~{I '
Addre'ss
Sworn or affirmed to and subscribed before me this
"'d f
' ay 0
, 1995,
Notarial Seal
Corrine L. Myers, Notary Public
Carlisle Bore, Cumberland County
My Commission Expires May 27,1999
.'
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LAST WILL AND TESTAMENT
I, GEORGIE R. BARRETT, sometimes known as GEORGIA R. BARR TT, of the
Borough of Carlisle, Cumberland County, Pennsylvania, being of sound and
disposing mind and memory, do hereby make, publish and declare this to be my
Last Will and Testament, hereby revoking any and all former Wills r Codicils
by me made.
1.
I direct that all my just debts, funeral expenses, testamenta y expenses
and all inheritance taxes shall be paid from my residuary estate as soon as
practicable after my decease and as part of the administration of m estate.
2.
I give and devise my house at 104 West Pomfret Street, Carlisle,
Cumberland County, Pennsylvania, together with the contents ther of, to my
daughter, MARJORIE B. DUTREY, absolutely.
3.
All the rest, residue and remainder of my estate I give and
follows:
One-half (1/2) thereof unto my daughter, MARJORIE
DUTREY;
and the
be
required to file a bond to secure the faithful performance of her duties in
one-fourth (1/4) thereof unto my granddaughter, SUE ANN B.
"
remaining one-fourth (1/4) thereof unto my grandson, STEVEN W.
4.
I hereby nominate, constitute and appoint my said daughter,
DUTREY, as Executrix of my estate and I direct that my Executrix sh
any jurisdiction.
5.
I authorize and empower my per-sonal r-epr-esentative, in her sole and
absolute discretion, to pur-chase or otherwise acquire and r tain any
-1-
LAW OFFICES - MARTSON, DEARDORFF, WILLIAMS /I; OTTO
~
investments of which I die seized or any real or personal prop rty of any
grant options in regard to any or all property of any kind formi
or
nature; to sell, lease, pledge, mortgage, transfer, exchange, di
a part of
my estate for such terms and such prices as they may deem advisabl
to boccow
money for any purposes connected with the protection and preserv tion of my
estate; to mortgage or pledge any real or personal property form in a part of
claims or demands of my estate against others or of others
my estate or to join in or secure the partition of same; romise any
to make distribution in kind and to cause any share to be compos d of cash,
property or undivided fractional shares in property different
from any
other share; and to execute and deliver such instruments as
necessary
to carry out any of these powers.
IN WITNESS WHEREOF, I have hereunto set my hand and seal th s
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day
of
/) I
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I
, 1990.
d:{> 1/'
. Barrett
SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Te tatrix, as
and for
request,
presence
at her
in the
her Last \^Jill and Testament, in the presence of U.;l,
have. hereunto ,subscribed our names as wi t, nt:;9s:~../, thrl ret
of saId TestatrIx and of each ot~er ./,/. ,
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l.AW OFFICES - MARTS ON. DEARDORFF, WILLIAMS & OTTO
..
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF CUMBERLAND
I, Georgie R. Barrett, sometimes known as Georgia R. Barrett, Testatrix,
whose name is signed to the attached or foregoing instrument, havi g been duly
qualified according to law, do hereby acknowledge that I signed nd executed
the instrument as my Last will; that I signed it willingly; and t at I signed
it as my free and voluntary act for the purposes therein expressed.
jL!:'( /;,<1 --:Tr-
/ /; ",<" /)/1 fl_/'Li::L''/-----
Georgi~?R. Barrett
,j
>/">') /,:1 __ h~L2-.!
GeorgiajR. Barrett
Sworn or affirmed to and aCknoWledged/before me by Georgie R. Barrett,
sometimes known as Georgia R. Barrett, the Testatrix, this day of
H().~i I , 1990.
C N'\::;:':\-;;;;:'; I
Corrina L t~l;~;'.Ii. N~'tatY . VlIk:
Carhs18 Bore, Cum~)6dar1d 'Olmty
My Gnmmi3~iDr [-::(~rf.f; "...~['.y 7. -!991
. ----
',yer,
1nstrwnent,
ere present
Will; that
as her free
us, in the
and that to
re years of
CO~~ONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND
We, ic// I 1/(:;'--rv'J .7-~ /)'-'"/.< /--~/-~~/'-'}I [~~~_,:l,_ ~[l.
the witnesses whose names are signed to the attached or
being duly qualified according to law, do depose and say that we
and saw the Testatrix sign and execute the instrument as her Las
the Testatrix signed willingly and that the Testatrix executed it
and voluntary act for the purposes therein expressed; that each 0
hearing and sight of the Testatrix, signed the Will as witnesses;
" the best of our knowledqe the 'l'estatrix was at that time 18 orim
age, of sound mind and under no constraint,. or/ jedUe in~e~ )
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Address
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Sworn
lip; 'II
or affirmed
, 1990.
to
and
subscribed
before
me
this
/"~ I
<-/i/{
day
of
LAW OFFICES - MARTSON.
',~(.'-/L,'!. .f.~'-l'l .J
Notary prCC;;;~~B~~'~f:b:~" j'
llF:ARDORFF. W LLM;M~.!!" F:.!::'''; 1k,y ], 1991 .