HomeMy WebLinkAbout11-16-05
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REV-1500 EX (EHlO)
OFFICIAl USE ONLY
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV -1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
~L
-2L 0187 ___
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Dixon Eleanor
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
2/16/2005 5/4/1918
(IF'APPLICABLE) SURVNlNG SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
F
COUNTY CODE YEAR NUMBER
SOCIAL SECURIIY NUMBER
202-01-4943
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
~ [X] 1. Original Return
~ ~Ul D
fil f~ 4. Limited Estate
(J% ~g [X] 6. Decedent Died Testate (Attach copy 01'11I111)
11.111
~ D 9. Litigation Proceeds Received
D 2. Supplemental Return D 3. Remainder Return (date of death prior to 12-13-82)
D 4a. Future Interest Compromise (date of death after 12-12-82) D 5. Federal Estate Tax Return Required
D 7. Decedent Maintained a Living Trust (Attach copy of Trust) _ 8. Total Number of Safe Deposit Boxes
D 10. Spousal Poverty Credit (dote of dooth botween 12-31-91 ond 1-1-95) D 11. Election to tax under Sec. 9113(A)(AttochSchO)
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NAME
Peter J. Ressler Es ire
FIRM NAME (If Applicable)
Mette, Evans & Woodside
TELEPHONE NUMBER
717-232-5000
COMPLETE MAILING ADDRESS
3401 N. Front Street
PO Box 5950
HarriSburg, PA 17110-0950
1. Real Estate (Schedule A)
(1)
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6. J~ Owned Property (Schedule F)
U Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
(6)
0.00
336,449.45
0.00
15,645.58
155,863.80
0.00
OFFJYlAL USE ONLY
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~ 11
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
(4)
(5)
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2. Stocks and Bonds (Schedule B)
(2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
372,332.56
8. Total Gross Assets (total Lines 1-7)
(8)
43,693.80
12,296.20
880,291.39
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
(13)
55,990.00
824,301. 39
0.00
(11)
12. Net Value otEstate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
(12)
14. Net Value Subjectto Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
824,301. 39
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
18. Amount of Line 14 taxable at collateral rate
0.00
824,301.40
0.00
0.00
x.O L(15)
X.o 45 (16)
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19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
(19)
0.00
37,093.56
0.00
0.00
37,093.56
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
x .12 (17)
x .15 (18)
> > BE SURETO~NSWER AU; QUESTJONS ONREVERSE.SIDEAND RECHECK MATH < <
3W4645 1.000
ece en s ample e ress:
STREET ADDRESS
822 Oak Oval
Cumberland
CIIY I STATE I ZIP
Mechanicsbura PA 17055-
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I t Add
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1 )
0.00
32.000.00
1,684.21
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits (A + 8 + C) (2)
0.00
0.00
Total Interest/Penalty (D + E) (3)
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 (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (SA)
37.093.56
33.684.21
0.00
0.00
3.409.35
0.00
8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (58) 3.409.35
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes
D
D
D
D
without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . .. D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. lXJ D
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 penelties of pe~ury, I declare that I have examined this return, induding eccompanying schedules end stelements, end to the best of my knowledge and belief, ~ is true, correct and complete.
Declaration of preperer other than the personal representative is based on all informelion of which preparer has any knowledge.
SIGNAlURE OF PERSON RESPONSIBLE FOR FILING RETURN
~~
ADDRESS
No
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DATE
11 /1I,/el')
,
112 S. 27th Street, Camp Hill, PA 17011
DA
/
Peter J. Ressler, Esquire
3401 N. Front Street, Harrisburg. PA 17110-0950
It I~
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. ~ 9916 (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% [72 P.S. ~ 9116 (a) (1.1) (ii))
The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum ana 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 a natural parent, an adoptive parent,
or a stepparent of the child is 0% [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%, except as noted in 72 P.S. ~ 9116(1.2) [72 P.S. ~9116(a)(1)J.
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. ~ 9116(a)(1.3)]. A Sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
3W4646 1.000
c'oMMONWEAlTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 2B0601
HARRISBURG. PA 171 2B-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
RESSLER PETER J
3401 NORTH FRONT STREET
HARRISBURG, PA 17110
-------- fold
ESTATE INFORMATION: SSN: 202-01-4943
FILE NUMBER: 2105-0187
DECEDENT NAME: DIXON ELEANOR F
DATE OF PAYMENT: 05/10/2005
POSTMARK DATE: 05/10/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 02/16/2005
NO. CD 005307
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $32,000.00
I
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TOTAL AMOUNT PAID:
REMARKS: ESTATE CHECK
CHECK# 1023
SEAL
INITIALS: RSK
RECEIVED BY:
TAXPAYER
$32,000.00
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
C,OMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
RESSLER PETER J
3401 NORTH FRONT STREET
HARRISBURG, PA 17110
-------- fold
ESTATE INFORMATION: SSN: 202-01-4943
FILE NUMBER: 2105-0187
DECEDENT NAME: DIXON ELEANOR F
DATE OF PAYMENT: 11/15/2005
POSTMARK DATE: 11/15/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 02/16/2005
NO. CD 006001
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $3,437.96
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I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS: P J RESSLER ESQ
CHECK# 3673
SEAL
INITIALS: VZ
RECEIVED BY:
TAXPAYER
$3,437.96
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REV-1503 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE B
STOCKS & BONDS
FILE NUMBER
Eleanor F. Dixon
21 05 0187
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTlON
1.Merrill Lynch Account #838-10L72
VALUE AT DATE
OF DEATH
336,449.45
3W4696 1.000
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
336,449.45
REV.1507 EX + (6-98)
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Eleanor F. Dixon
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
FILE NUMBER
21 05 0187
All properly Jolntly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION
VALUE AT DATE
OF DEATH
1 Camp Hill Distributors Note
Receivable
15,645.58
TOTAL (Also enter on line 4, Recapitulation) $
15,645.58
3W46AC 1.000
(If more space is needed, insert add~ional sheets of same size)
REV-1508 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX REl'URN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Eleanor F. Dixon
FILE NUMBER
21 05 0187
ITEM
NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on SChedule F.
DESCRIPTION
VALUE AT DATE
OF DEATH
1
Auto insurance refund
102.00
2
Blue Cross/Blue Shield - refund of
unearned premium
195.45
3
Homeowner's insurance refund of
unearned premium
58.00
4
Messiah Village - refund of value
of occupancy right for residence
at Messiah Village
34,510.00
5
PA Department of Revenue - refund,
state personal income tax
88.15
6
Patriot News - refund
29.16
7
Pennsylvania Personal Income Tax
Refund
2,793.56
8
PPL Electric - refund
4.18
9
Pennsylvania State Bank Checking
Account #10011815
97,201. 78
10 Pennsylvania State Bank Checking
Account #26018188
11 Talbot's - refund for returned
merchandise
12 Tangible Personal Property
13 Toyota Camry
12,527.14
417.38
4,937.00
3,000.00
3W46AD 1.000
TOTAL (Also enter on line 5 Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
155,863.80
REV-1510 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Eleanor F. Dixon
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
FILE NUMBER
21 05 0187
ITEM
NUMBEF
1.
3W46AF 1.000
DESCRIPTION OF PROPERTY
N:U...OE TrE Nt.ME OF ll-E TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT Afo.D
11-E DATE OF TRANSFER. ATTACl-lACOPY OF TI-E DEED FOR REAL ESTATE.
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
Fidelity Guaranty Life Ins. Co.
Annuity #L9045994
2
Fort Dearborn Life Ins. Co.
Annuity #P00000030047
3
Fort Dearborn Life Ins. Co.
Annuity #P00000030048
4
Hartford Ins. Co. Annuity
#310135324
5
Hartford Life Insurance Annuity
#255721
6
ING Usa Annuity & Life Ins. Co.
Annuity #NG90155313
7
Integrity Life Ins. Co. Annuity
#2100081091
8
~dland National Life Insurance
Co. Annuity #8500181011
DATE OF DEATH
VALUE OF ASSET
% OF DECD'S
INTEREST
TOTAL (Also enter on line 7, Recapitulation) $
77,934.50 100.0000
30,581.60 100.0000
36,610.88 100.0000
37,507.72 100.0000
54,178.32 100.0000
70,557.76 100.0000
26,057.76 100.0000
38,904.02 100.0000
(If more space is needed, insert addttional sheets of the same size)
EXCLUSION
OF APPUCABLEl
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
TAXABLE
VALUE
77 , 934 .50
30,581.60
36,610.88
37,507.72
54,178.32
70,557.76
26,057.76
38,904.02
372 332.56
REV-1511 EX + (12-99)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Eleanor F. Dixon
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
21 05 0187
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Funeral Expenses
7,869.00
B. ADMINISTRATNE COSTS:
1. Personal Representative's Commissions 20,000.00
Name of Personal Representative{s)
Social Security Number{s) I EIN Number of Personal Representative{s) - -
Street Address
City State Zip
Year{s) Commission Paid:
2. Attorney Fees 12,500.00
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 548.00
5. Accountant's Fees 640.00
6. Tax Return Preparer's Fees
7.
1 Cumberland Law Journal
Legal advertisement 137.03
2 Shipping/Packing/Misc. 1,924.77
Total from continuation schedules 75.00
TOTAL (Also enter on line 9, Recapitulation) $ 43 693.80
3W46AG 1.000
(If more space is needed, insert additional sheets of the same size)
Estate of: Eleanor F. Dixon
202-01-4943
Schedule H Part 7 (Page 2)
3
The Sentinel
Legal advertisement
75.00
Total (Carry forward to main schedule)
75.00
REV-1512 EX + (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERfTANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Eleanor F. Dixon
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
FILE NUMBER
21 05 0187
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
Final Credit Card Statement
537.78
2 Medical Expenses
50.26
3 Messiah Village
2,299.88
4 PA Dept of Revenue
8,760.00
5 US Treasury
412.00
6 Utili ties
236.28
3W46AH 2.000
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
12,296.20
REV-1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Eleanor F Dixon
NUMBER
I
1
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers
under Sec. 9116 (a) (1.2)]
Nancy Chandler
3236 Page, #302
Virginia Beach, VA 23451
25% Residue: 206,075.35
2 Robert Dixon
1300 Hill top Road
Leesport, PA 19633
25% Residue: 206,075.35
3 Sandra Dixon
120 W. Third Avenue, #308
San Mateo, CA 94402
25% Residue: 206,075.35
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Daughter
Son
Daughter
FILE NUMBER
21 05 0187
AMOUNT OR SHARE
OF ESTATE
206,075.35
206,075.35
206,075.35
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
3W46A11.000
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
(If more space is needed. insert additional sheets of the same size)
$
0.00
Estate of: Eleanor F. Dixon
Item
No. Description
4 Susan Kemble
112 S. 27th Street
Camp Hill, PA 17011
25% Residue: 206,075.35
Schedule J Part 1 (Page 2)
Daughter
202-01-4943
Relation
Amount
206,075.35
METTE. EVANS & WOODSIDE
ATTORNEYS AT LAW
HARRISBURG, PENNSYLVANIA 17110-0950
1Jlast
Dlill
Anb
Wtstamtnt
OF
ELEANOR F. DIXON
I, ELEANOR F. DIXON, of Camp Hill, Cumberland County,
Pennsylvania, declare this to be my last Will, hereby revoking all prior wills and
codicils.
FIRST:
funeral shall be paid from my estate.
The expenses of my last illness and
SECOND: I hereby give and bequeath, absolutely
and in fee simple, to my issue, per stirpes, living at the time of my death, all my
household furniture and furnishings, books, pictures, jewelry, silverware,
automobiles, wearing apparel and all other articles of household or personal use or
adornment, to be divided among them as they shall agree. If they cannot agree for
any reason, my Executor shall make the decision and its decision shall be final.
My Executor shall represent any minor child in any division of such
property and shall deliver to the person standing in the place of a parent to such
minor, without bond, such portion of the minor's share as my Executor, after
considering the minor's wishes, deems appropriate.
THIRD: (a) I give and devise the rest, residue
and remainder of my estate, real and personal, equ.ally to my children, NANCY
Page 1
E -;J lJ.-
CHANDLER, SANDRA DIXON, ROBERT DIXON, and SUSAN KEMBLE. If any
said child predeceases me or dies within thirty (30) days of the date of my death, that
child's share shall be paid to his or her issue, per stirpes, otherwise to my surviving
children or their issue, as the case may be.
(b) If no said issue survive me, my estate shall be paid to my heirs who
would be entitled thereto under the Intestate Laws of Pennsylvania in effect at my
death as if I had then died Intestate.
FOURTH: No provision of this Will is intended to
exercise any power of appointment, including any power of appointment granted to
me by my spouse's estate planning or other documents.
FIFTH: No interest of any beneficiary under this
Will or any codicil hereto shall be subject to anticipation or voluntary or involuntary
alienation, and the personal receipt of such beneficiary shall be the sufficient and
only discharge of my Executor unless otherwise provided herein.
SIXTH: All taxes, interest and penalties thereon
payable by reason of my death with respect to property comprising my gross estate,
whether or not passing under this Will, shall be paid from the principal of my
residuary estate.
SEVENTH: In addition to powers given them by law,
my Fiduciaries and their successors and any guardian acting hereunder shall have
the following discretionary powers applicable to all real and personal property held
by him, effective without court order and until actual distribution:
Page 2
g~b-,
(a) To retain all property received by them including the stock of any
corporate fiduciary acting hereunder, provided such property remains productive;
(b) To sell real estate for any purpose, publicly or privately, for such
prices and on such terms as he deems proper, without liability on the purchasers to
see to application of the purchase moneys;
(c) To compromise controversies;
(d) To distribute in cash or kind or partly in each at valuations fixed by
them;
(e) To hold investments in the name of a nominee;
(f) To assume continuance of the status of any beneficiary with reference
to marriage, divorce, illness, incapacity or other change in the absence of infonnation
deemed reliable without liability for disbursements made on such assumption;
(g) To make income or principal distributions during the course of
administration of my estate or trust created hereunder; and
(h) To undertake any and all acts deemed necessary and proper by it
for the proper and advantageous management of any trust and the settlement of my
estate.
EIGHTH: Any beneficiary hereunder who dies at
the same time as me, within thirty (30) days ofme~ or under circumstances wherein
Page 3
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(,~ ,,1 )!J..,
it shall be difficult or impossible to determine who died first shall be presumed to
have predeceased me.
NINTH: I appoint my daughter, SUSAN
KEMBLE, and my son-in-law, MELVIN CHANDLER, or the survivor of them, as Co-
Executors of this my Will. No fiduciary acting hereunder shall be required to post
bond or enter security in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
(7:tiL
'1_ day of ..7'nC....t.l- , 1995, to this and the preceding three (3) pages
' . if ,
and I have also placed my initials on each preceding page for better identification and
greater security:
.el .' -:tt h '
f.. /? . -'" ' ,,/'.
b..~ ~,,"l{~, ~,'.., .~-,t'f.__ 'f...,.."---'
ELEANOR F. DIXON
(SEAL)
SIGNED, SEALED, PUBLISHED and DECLARED by the above-named
Testatrix, ELEANOR F. DIXON, as and for her Last Will and Testament, in the
presence of us, who at her request, in her presence and in the presence of each other,
have hereunto subscribed our names as witnesses:
j1 ~
(J~ (), --L~
{
SA/-" jrJ/J 4l'~/#O-O
Residing at 2-';'0 c:tA.....-!..I"Yl""..... ji/2.e!€..
,," . /J
~'-i!.r~.. l,; ~, jC" ;7,. { ~ .
~sidi~g at /<;L/<f ~'("M2 A? fl.?
Llh'J.d-7bf'~;t/(/, (?4 7zdrr
ACKNOWLEDGMENT
COMMONWEAL TH OF PENNSYL VANIA )
) SS.
COUNTY OF DAUPIDN )
I, ELEANOR F. DIXON, Testatrix, whose name is signed to the attached or
foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I
signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and
that I signed it as my free and voluntary act for the purposes therein expressed.
Cry .' ..7: r,
6 k t1':4U<'I::.- 'V' :r.k,{.6__....
ELEANOR F. DIXON
(SEAL)
Sworn to and subscribed
before me this 9l11J day
of Ii1&t.J ' 1995.
~d~ \\. .tv~,
tary Pub~
My Commission Expires:
Notarial Seal
Unda J. Oisen, Notary Public
Harrisoufc, Dauphin County
My Commission Expires Sept. 8, 1996
1'I'18rnC'9f, Penr1sylvaruaAssociation of Notanes
(SEAL)
AFFIDA VIT
COMMONWEAL TH OF PENNSYL VANIA
COUNTY OF
DAUPHIN
SS.
We, -:[;,r dfi /1-1 A- 77ft}> e{.}~:' , and f:i i?l tL 7- /(~ S" s k ,the
Witnesses whose names are signed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw Testatrix, ELEANOR F. DIXON,
sign and execute the instrument as her Last Will and Testament; that Testatrix signed willingly and
that she executed said Will as her free and voluntary act for the purposes therein expressed; that each
of us in the hearing and sight of the Testatrix signed the Will as Witnesses; and that to the best of
our knowledge the Testatrix was at that time eighteen (18) or more years of age, of sound mind and
under no constraint or undue influence.
r\ i"") / ).... ,7
'~a,)(2 j LmiJ"""'J.
;\Wittless
(f
t^
y:J ..."
/,LI...~ /G--1-~.-d'--\
Witness '- -
Sworn to and SUb9Cribed
before me this ~ day
of ?'ba.;; , 1995.
~~~~-~
otary P IC
My Commission Expires:
Notarial Seal
Linda J. Olsen, Notary Public
Hamsburu, Dauphin County
My Commission Expires Sept. 8, 1996
Member, Pennsyivanie, Associat<on of Notaries
(SEAL)