HomeMy WebLinkAbout03-30-06
1lEV - 1500 EX .. (11-0O)
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
D 2. Supplemental Return
D 4a. Future Interest Compromise (date of death after
12-12-82)
6. Decedent Died Testate (Attach copy D 7. Decedent Maintained a Living Trust (Attach
of Will) copy of Trust)
9. litigation Proceeds Received 0 10. Spousal Poverty Credit (date of death between
12-31-91 and 1-1-95
THIS SECTrON MUST BE COMPLETED.. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED .TO:
NAME COMPLETE MAILING ADDRESS
I Hamilton C. Davis
, FILE NUMBER
21 05
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
00672
NUMBER
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
OEPT 280601
HARRISBURG, PA 17128-0601
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i DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
IlVIILLER, WOODROW W.
I
I DATE OF DEATH (MM-OD-YEAR) I DATE OF BIRTH (MM-DD-YEAR)
107/15/2005 I 03/10/1913
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
189-18-6664
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Retum (date of death prior to 12-13-82)
o
1
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
20 East Burd Street, Suite 6
P.O. Box 40
Shippensburg, P A 17257
(1 ) None
(2) None
(3) None
(4) None
(5) 181,007.75
(6) None
(7) None
(8)
(9) 20,961.43
(10) 551. 04
()FFJC:IAE.. USE C:'NLY
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181,007.75
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1. Original Return
4. Limited Estate
(11 )
21,512.47
159,495.28
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IRM NAME (If applicable)
Zullinger - Davis, PC
ELEPHONE NUMBER
717/532-5713
(12)
13. Charitable and Governmental Bequests/See 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)
159,495.28
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely 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)
o 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)
12. Net Value of Estate (Line 8 minus Line 11)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
7,177.29
7,177.29
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
15. Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a){1.2)
z 159,495.28 .045 (16)
0 16. Amount of Line 14 taxable at lineal rate x
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Q. 17. Amount of Line 14 taxable at sibling rate x .12 (17)
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)( 18. Amount of Line 14 taxable at collateral rate
< x .15 (18)
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19. Tax Due (19)
>>BESURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH<<
Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
210 BIG SPRING ROAD
CITY
STATE PA
i ZIP 1 7241
NE\VVILLE
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits (A + 8 + C)
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (0 + 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.
Make Check
to: REGISTER OF WILLS, AGENT
(1)
7,177.29
(2)
0.00
(3) 0.00
(4)
(5) 7,177.29
(5A)
(58) 7,177.29
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "XU IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
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?............................. ......................... ...............................................................
Yes No
~ I
D IZI
D IZI
o IZI
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 pe~ury, I declare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration
of pre parer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATU OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
NAt~ W. MILLER
114 VIRGINIA AVENUE
CARLISLE, P A 17013
ADDRESS
ADDRESS
20 East Burd Street, Suite 6
P.O. Box 40
Shippensburg, P A 17257
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alue of transfers to or for the use of the
For dates of death on or after July 1, 1994 and before January 1, 1995, thl
surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on th,
[72 P .S. 99116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a s
of assets and filing a tax return are still applicable even if the surviving sp<
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 991
The tax rate imposed on the net value of transfers to or for the use of the '
1.2) [72 P.S. ~9116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the P.S. 99116 (a) (1.3)]. A sibling is defined,
under Section 9102, as an individual who has at least one parent in comn lUll VVIU I U'''' .........,,,........, ... -- - - -" by blood or adoption.
DATE
DATE
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. the use of the surviving spouse is 0%
the statutory requirements for disclosure
nger at death to or for the use of a natural
is 4.5%, except as noted in 72 P.S. ~9116
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEAL 7H OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
I FILE NUMBER
! 21 - 05 - 00672
ESTATE OF
~IILLER, WOODROW W.
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.
ITEM
NUMBER
1
DESCRIPTION
VALUE AT DATE OF
DEATH
10,009.90
ADAMS COUNTY NATIONAL BANK CHECKING - ACCOUNT NO. 221066
2
ACCRUED INTEREST ON 1
4.28
3
ADAl\IIS COUNTY NATIONAL BANK CERTIFICATE OF DEPOSIT - ACCOUNT NO. 160400
10,000.00
4
ACCRUED INTEREST ON 3
12.4 7
5
ADAMS COUNTY NATIONAL BANK CERTIFICATE OF DEPOSIT - ACCOUNT NO. 162689
10,175.79
6
ACCRUED INTEREST ON 5
25.28
7
ADAMS COUNTY NATIONAL BANK CERTIFICATE OF DEPOSIT - ACCOUNT NO. 3991011
6,000.00
8
ACCRUED INTEREST ON 7
64.18
9
PNC BANK CERTICA TE OF DEPOSIT - ACCOUNT NO. 21001054250
3,000.00
10
ACCRUED INTEREST ON 9
6.72
11
PNC BANK CERTIFICATE OF DEPOSIT - ACCOUNT NO. 31000262548
3,000.00
12
ACCRUED INTEREST ON 11
7.76
13
PNC BANK CERTIFICATE OF DEPOSIT - ACCOUNT NO. 31000261016
3,000.00
14
ACCRUED INTEREST ON 13
11.28
15
PNC BANK CERTICATE OF DEPOSIT - ACCOUNT NO. 31300263631
22,000.00
16
ACCRUED INTEREST ON 15
82.72
17
PNC BANK CHECKING ACCOUNT - ACCOUNT NO. 5004752958
5.00
18
PNC BANK SAVINGS ACCOUNT - ACCOUNT NO. 5004085382
826.15
19
PNC BANK SAVINGS ACCOUNT - ACCOUNT NO. 50047354162
110,414.83
20
ACCRUED INTEREST ON 19
175.39
Total of Continuation Schedule(s)
TOTAL (Also enter on Line 5, Recapitulation)
2,186.00
181,007.75
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY continued
COMMCNWEAL TH OF PENNSYL'JANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
i\tIILLER, \VOODRO\V W.
I FILE NUMBER
! 21 - 05 - 00672
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.
ITEM
NUMBER
21
DESCRIPTION
VALUE AT DATE OF
DEATH
100.00
AMERICAL"I LEGION DEATH BENEFIT
22
FAILOR - WAGNER DEATH BENEFIT
1 00.00
23
PRESBYTERIAN HO!vlES REFUND
1,496.00
24
ADAMS COUNTY NATIONAL BANK CERTIFICATE OF DEPOSIT INTEREST
121.00
25
ERIE INSURANCE REFUND
369.00
I
Page 2 of Schedule E
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SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRA T1VE COSTS
COMMONWEALTH OF PENNSYLVANIA
INt-<ERITANCE TAX RETlJRN
RESiDENT DECEDENT
ESTATE OF
!vIIlLER, \VOODROW "V.
FILE NUMBER
21 - 05 - 00672
Debts of decedent must be reported on Schedule J.
ITEM I
NUMBER. DESCRIPTION
AMOUNT
A. FUNERAL EXPENSES: I
1 Egger Funeral Home 6,214.50
2 Eby Granite Works 95.00
3 Wayne Noss Flowers 135.68
B. ADMINISTRATIVE COSTS: 7,240.00
1. Personal Representative's Commissions
NANCY W. !vlILLER
Social Security Number(s) I EIN Number of Personal Representative(s):
184-38-2208
Street Address 114 VIRGINIA A VENUE
City CARLISLE State PA Zip 17013
- I
Y ear( s) Commission paid I
Hamilton C. Davis, Esquire
2. Attorney's Fees 6,500.00
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 Cumberland County Register of Wills 125.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Legal Advertising - Cumberland County Legal Journal 75.00
2 Legal Advertising - The News Chronicle 76.25
Total of Continuation Schedule(s) 500.00
TOTAL (Also enter on line 9, Recapitulation)
20,961.43
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Schedule H
Funeral Expenses &
Administrative Cos1s continood
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
l'vlILLER, WOODROvV VV.
i FILE NUMBER
i 21 - 05 - 00672
3
Reserve for contingencies
500.00
Page 2 of Schedule H
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SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
~HLLER, WOODRO\V W.
I FILE NUMBER
21 - 05 - 00672
Include unreimbursed medical expenses.
ITEM
NUMBER
1 GRAHAM lVIEDICAL CLINIC
DESCRIPTION
AMOUNT
56.53
2 CENTRAL PENN MEDICAL
3 BAXTER WOLLMAN, P.H.D.
4 BLUE MOUNTAIN ANTESTHETIC
5 CtThtIBERLAND - GOODWILL FIRE RESCUE
6 OMEGA lVIEDICAL LAB
7 APEX ASSESSEMENT MANAGIvIENT
8 CV NEPHROLOGY ASSOCIATES
33.00
7.71
12.67
407.00
6.53
13.80
13.80
TOTAL (Also enter on Line 10, Recapitulation)
551.04
~EV-1513 EX+ (9-00)
.
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
l\tIILLER, \VOODRO\V w.
I FILE NUMBER
I 21 - 05 - 00672
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
NANCY W. NELLER
114 VIRGINIA AVENUE
CARLISLE, P A 17013
I RELATIONSHIP TO
I DECEDENT
I
IDAUGHTER
AMOUNT OR SHARE
OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
1/2 RESIDUE
2 JOY DYSON
20 HOPE TERRACE
I CARLISLE, P A 17013
I
!GRANDDAUGHTER
1/4 RESIDUE
3 JILL GETTLE
166 KERRSVILLE ROAD
CARLISLE,PA 17013
GRANDDAUGHTER
1/4 RESIDUE
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
I
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET[
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t-'N\"...t\HNK.
41 ~ . (be: ,j4::'o
P.01
o PNCBAT\K
October 25, 2005
Zullinger Davis PC
Attn: Hamilton C Davis
20 East Burd St., Suite 6
POBox 40
Shippensburg, P A 17257
scp/ a1
RE: Estate of Woodrow W Miller (Deceased)
SSN: 189-18-6664
DOD: 07..15-2005
Dear Mr. Davis:
In response to your request for Date of Death balances for the customer noted above, our
records show the following:
Certificate of Deposit
Account #21001054250
Established 05.24-1988
MJr..R Y H MILLER
WOODROW W MILLER
nOD balance: $3,000.00 + $6.72 accrued interest
Account #31000262548 Established 06-06-2005
WOODROW W Mll..LER
DOD balance: $3,000.00 + $7.76 accrued interest
Account #31300263631 Established 05-18-2005
WOODROW W MILLER
DOD balance: $22,000.00 + $82.72 accroed interest
Account #31000261016 Established 05-18-200S
WOODROW W MJLLER
DOD balance: $3,000 .00 + $11.28 accrued interest
Checking Accouot
Account #5004752958 Established 06-24-2005
WOODROW W MILLER
DOD balance: $5.00 +- SO.OO accrned interest
Page 10f2
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412 '/bd ';:4:'8
P.02
Savings ..~CCOUDt
Account #5004085382
Established 11-08 -2002
MARY H MILLER
WOODROW W MILLER
DOD balance: $826.15 + $0.00 accrued interest
Account #50047354162 Established 06-24-2005
WOODROW W MILLER
DOD balance: $110,414.83 + $175.39 accrued interest
Please note that this office only provides date of death balances for deposit accounts
(IRAs, CDs, Checking and Savings accounts). We do Dot process any financial
transactioDs or provide statements. If you need assistance with any of these items,
please call 1-S8S-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch
office.
Sincerely,
~~~
Erica L Schlegel
1-800-762-1775
P7-PFSC-04-F
500 First Ave.
Pinsburgh PAl S2 J 9
Member FD1C
Page 20(2
F. CHARLES EGGER, Supervisor
~Y~~h.
1 5 Big Spring Avenue
NEWVILLE, PENNSYLVANIA 1 7241
717-776-3414
FRANK C. EGGER, Funeral Director
August 2, 2005
Funeral Bill for Woodrow W. Miller
Date of Death July 15, 2005
Professional Services $2,375.00
Cemetery Opening $380.00
Hearthside Oak Casket $2,350.00
Burial Vault $895.00
1 Death Certificate $6.00 a piece $6.00
Clergy Offering $60.00
Carlisle Sentinel Obituary Charge $126.00
Patriot News Obituary notice $22.50
Total
$6,214.50
~ ADAMS COUNlY
N..\TION.:\L Bi\l~K
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August 18, 2005
Hamilton C. Davis
Attorney at Law
20 Last Burd Street
Shippensburg, PA 17257
Re: Estate of Woodrow Miller
Dear Mr. Davis:
The following information is being provided as per your request:
Acct. Type Account Account Accrued Ownership Date
No. Principal on Interest to Account
D.G.D. D.G.D. Opened
Checking 221066 $10,009.90 $4.28 11. wi Mary H 2-10-86
Miller
C.D. 160400 $10,000.00 $12.47 J1. wi Mary H 7 -2-02
Miller
C.D. 162689 $10,175.79 $25.28 Indi vidual 5-19-04
C.D. 3991011 $6,000.00 $64.18 J1. wi Mary H 1-2-01
Miller
Inquiries concerning ACNE Corporation stock information should be directed to the Registrar and Transfer
Company at 1-800-368-5948. If you need any additional information, please contact me at (717)339-5116.
S incerel y,
fJ ~ /~ ~
Lois Kime
Deposit Services
LAST \VILL A.l~D TEST4~'IENT
I, WOODROW VV. MILLER, of Nevvville Borough, Cumberland County, Pennsylvania,
declare this to be my Last \Vill and Testament and revoke any vVill or Codicil previously made by
me.
ITEM I: I direct that all my just debts (except as may be barred by a Statute of Limitations)
and my funeral expenses (including my gravemarker and expenses of my last illness) shall be paid
from my residuary estate as soon as practicable after my decease as a part of the administration of
my estate.
ITEM II: I bequeath those articles of my household furniture and furnishings and those
articles of my personal effects and personal property as I have or may set forth in a separate
memorandum (which is or will be signed by me, dated and make specific reference to this \Vill and
memorandum, which I shall place \vith my Will or deposit \vith my attorney), to the persons therein
designated.
ITEM III: I devise and bequeath all the residue of my estate of every nature and \vherever
situate to my wife, MARY H. MILLER, providing she shall survive me by thirty (30) days.
ITEM IV: Should my wife, tvlAR Y H. MILLER, predecease me or die on or before the
thirtieth (30th) day following my death, I devise and bequeath all the residue of my estate of every
nature and wherever situate as follows:
A. One-half (1/2) thereof to my daughter NANCY w. ~nLLER.
B. One-half (1/2) thereof in equal shares (one each) to my granddaughters, JOY DYSON
and JILL GETTLE (the children of my late daughter, Susan B. l\IIcKeehan).
;IVy jt;YIlIi1,
ITE~1 V: Should my daughter or my granddaughters predecease me or die on or before the
thirtieth day following my death but leaving descendants who so survive me, such descendants
shall receive, per stirpes, the share that such person would have received had she so survived me.
ITENI VI: If any property passes outright (either under this \Vill or othenvise) to a minor
(which shall be defined as anyone under twenty-one (21) years of age) and with respect to which I
am authorized to appoint a guardian and have not othenvise specifically done so, I decline to
appoint a guardian but instead authorize my Executor to distribute such property to a Custodian
selected by my Executor (and my Executor may act as such Custodian) as Custodian for the minor
under the Pennsylvania Uniform Transfers to Minors Act. Provided, however, that this
appointment shall not supersede the right of any fiduciary to distribute a share where possible to the
minor or to another for the minor's benefit.
ITEM VII: I direct that all taxes that may be assessed in consequence of my death, of
whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as
part of the expenses of the administration of my estate.
ITEM VIII: I appoint my \vife, MARY H. MILLER, and my daughter, NANCY W.
MILLER, Co-Executors of this my Last Will.
ITEM IX: I direct that my Executors, custodian, or their successors, shall not be required to
give bond for the faithful performance of their duties in any jurisdiction.
ITEM X: The interests of the beneficiaries hereunder shall not be subject to anticipation or
to voluntary or involuntary alienation.
IN WITNESS "'lHEREOF, I hereunto set my hand and seal to this my Last \Vill and
~ ;-yr:m-
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Testament, vvritten on four (4) sheets of paper, dated this
,'+~
I b day of
,
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, 2 004.
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vVOODROvV vV. MIL ER
(SEAL)
The preceding instrument, consisting of this and three (3) other typewritten pages, each
identified by the signature or initials of the Testator, \-vas on the day and date thereof signed,
published and declared by the Testator therein named, as and for his Last vVill, in the presence of
us, who, at his request, in his presence, and in the presence of each other have subscribed our names
as witnesses hereto.
vjrJJJoy b) {}JkJ
residing at
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residing at
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CONt~fONvVEAL TH OF PENl'TSYL V A~nA
: ss.
COUNTY OF CUNIBERLAND
I, WOODRO\V W. NIILLER, the Testator 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 \Vill; and that I signed it willingly and as my free and voluntary
act for the purposes therein expressed.
A4(~~
WOODROW \V. MILLER
(SEAL)
Sworn to or affIrmed and acknowledged
before me by WOODRO\V W. MILLER, the
Testator, this 16 ~ day of
Vv"~ .CVt ' ,.1/\ , 2004.
;~--j 4vwJ liY"\. t. J. ~-'-
V Notaiy Public f'"
Notarial Seal
Hamilton C. Davis, Notary Public
Shippensburg Boro, Cumberland County
My Commission Expires Sept. 27, 2004
Member, Pennsylvania AssocIation of Notaries
COMMONvVEAL TH OF PENNSYL VANIA :
: ss.
COUNTY OF CUNIBERLAND
n~:' are ~~ ~~::~:lle~ i ~;~g in~~::rl ~~;g ~~"~{ifi~d~~C:::;St~ l;;'O~~
depose and say that we were present and saw the Testator sign and execute the instrument as his
Last Will; that the Testator signed willingly and executed it as his free and voluntary act for the
purposes therein expressed; that each subscribing witness in the hearing and sight of the Testator
signed the \Vill as a witness; and that to the best of our knowledge the Testator was at the time
eighteen (18) or more years of age and of sound mind and under no constraint or undue influence.
,!b-ruyidVlt!lf ,)
111~~ !-/.~Y;f:~L I
( ,
Sworn to or affirmed and subscribed to
before me by I'J AI/" C";' tv. t.r'\;' \ l. T't. and
Vf\ ~ A 11,. vYl ..., (J.It , w,itnesses, this
, ,~ Iday of .YV\ AA;'/~ , 2004.
,,1 / ,/' ,; \ r-." ,
--- /' ~" . ;---
li.~J-~Y 1::' ,". i ,
, otary Publi~V
Notariai Seal
Hamilton C. Davis, Notary Public
Shippensburg 8oro, Cumberland County
My Commission Expires Sept. 27, 2004
Member, Pennsylvania },::}SGG:ailCP ot 1'~otar!t)S
4