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Home My WebLink About01-18-07 .....J 15056051058 REV-1500 EX (06-05) PA Department of Revenue '* Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Number Date of Death OFFICIAL USE ONLY Cou~tyC(xle Year INHERITANCE TAX RETURN RESIDENT DECEDENT File Number 21 06 0391 Date of Birth 196-48-4298 04/21/2006 Decedent's First Name MI Decedent's Last Name Petty Donald s (If Applicable) Enter Surviving Spouse's Infonnatlon Below Last Name Suffix First Name MI Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW <e:> 1. Original Return c:::> c:::> 4. Limited Estate c:::> 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 2. Supplemental Return c:::> c:::> c:::> 4a. Future Interest Compromise (date of death after 12-12-82) c:::> 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c:::> 10. Spousal Poverty Credit (date of death c:::> 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NameDaytime1"~lephOf'l~ Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes <.:::> · (717) 724-0266 ;~.~-1 ------~-~C5:.:.=~:~--~.~..--, '.1 ! REGISTERQ~LLS US~LY t i I ~ ! co l DATE FIL.E[), '~mm J en Firm Name First line of address State ZIP Code 17011 Correspondent's e-mail address: Under penalties of perjury, I declare that I have examined this return, induding accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNA URE OF PERSON RESPO I E FOR FILING RETURN DATE i- I .0 SIG~4~RESENTATIVE ADDRESS DATE 1-11-01 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051058 15056051058 ....J -1 15056051058 REV.1500 EX (06-05) PA Department of Revenue '*' Bureau of Individual Taxes .' PO BOX 280601 Harrisburg, PA 17128'()601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY County Code Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT 21 06 0391 Date of Birth 196-48-4298 04/21/2006 09/11/1958 Decedent's Last Name Suffix Decedent's First Name MI Petty Donald S (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW . 1. Original Retum 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 4. Limited Estate 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received o 8. Total Number of Safe Deposit Boxes Elizabeth J. Goldstein (717) 724-0266 Firm Name (If Applicable) REGISTER OF WILLS USE ONLY First line of address 355 N. 21 Street Second line of address Suite 202 City or Post Office State ZIP Gode DATE FILED Camp Hill PA 17011 Correspondent's e-mail address: Under penalties of perjury, 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, oorrect and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 --.J L 15056051058 --.J 15056052059 REV-1500 EX Decedent's Name: Donald S Petty RECAPITULATION 1. Real estate (Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3. 4. Mortgages & Notes Receivable (Schedule D). . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5. 6. Jointly Owned Property (Schedule F) Separate Billing Requested. . . . . .. 6. 7. inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested. . . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 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). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11. 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable at lineal rate X.O 45 57,885.42 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 16. 17. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 L Decedent's Social Security Number 196-48-4298 81,000.00 0.00 0.00 0.00 13,998.24 0.00 0.00 94,998.24 11,110.72 26,002.10 37,112.82 57,885.42 0.00 57,885.42 18. 0.00 2,604.84 0.00 0.00 2,604.84 . 15056052059 ---I REV-1500 EX Page 3 Decedent's Complete Address: 21 File Number 06 0391 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Donald S Petty 196-48-4298 STREET ADDRESS 74 Oliver Road CITY I STATE I ZIP Enola PA 172025 Tax Payments and Credits: 1. Tax Due (Page 2 Une 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 2,604.84 0.00 3,200.00 168.00 Total Credits ( A + B + C ) (2) 3,368.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E) (3) 4. If line 2 is greater than line 1 + line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 763.16 5. If Une 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE. B. Enter the total of line 5 + 5A. This is the BALANCE DUE. (5) (5A) (5B) A. Enter the interest on the tax due. Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.......................................................................................... 0 ~ b. retain the right to designate who shall use the properly transferred or its income; ............................................ 0 ~ c. retain a reversionary interest; Of.......................................................................................................................... 0 [i] d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [i] 2. If death occurred after December 12, 1982, did decedent transfer properly within one year of death without receiving adequate consideration? .............................................................................................................. 0 ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ [K] 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. ~9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax 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 a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 PS. ~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 four and one-half (4.5) percent, except as noted in 72 PS. ~9116(1.2) [72 PS. 99116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. 99116(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. REV-1502 EX+ (6-98* COMMONVVEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF Donald S. Petty FILE NUMBER 21-06-0391 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 74 Oliver Road, Enola, Pa 17025 81,000.00 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 81,000.00 A. Settlement Statement U.S. Department of Housing and Urban Development OMB No. 2502-0265 B. Type of Loan 1. o FHA 2'OFmHA 3.IiJConv. Unins. 4. OVA 5.0Conv.lns. D. Name and Address ot Borrower Hichael J. Vickery Wendy L. S. Vi ckery c. Name and Address 01 Seller Donald S. Petty C. This form is furnished as a statement of acrual sertlement costs. Amounts paid to and by the settlement agent are shown. Items marked (p.o.c) were pwd outside the closing; they are shown for informational purposes and are not included in totals. 1'. Name and Address at Lender Mi d Penn Bank 0. l'roperty LocatIOn 74 01 ive,. Road Enola. Pennsylvania 17025 East Pennsboro Township. Clhberland County . ...h.SUM:MARY}Jl'BORROWER:S.TRANSACTION: 'o:J(JO,J]ROSS'AMOU:NTDUE F'ROM..OORROWER 101. Contract sales price 102. Personal property 103. Settlement charges to borrower(line HOO) 104. overai ght 105. Mid Penn undisbursed funds Adjustments for items pwd by seller in advance 106. City/town ta.xes to 107. County taxes 08/15/200fu 12/3112006 108. Assessments to 109. sewer/trash 8/15.9/30 ($1l5/qtr) 110. 111. 112 :: ."'.0" ...... .:::: 81. 000.00 4.113.59 25.00 97.55 57.50 ,.':.,,'.,'- ,-".-.,.; ,,",,' . ,".",_.- .,..... .C,' ...... . ...... \120.GR.OSSAMOUN1"DUE FRbM BORROWER .85.293.64 i,,:Zoo;::'AMOUN1'S pAID.BY OR IN BEHALF OF BORROWER '.. 201. Deposit or earnest money 1. 000.00 202. Principal amount of new loan(s) 203. Existing loan(s) taken subject to 204. 1st mortgage ($77800) $64800 disbursed 64.800.00 205. $13000 held back. by Mid Penn 206. Open End Mtg ($25000) - $18092.32 dsbsd 18.092.32 207. $'" i n fees pd on open end See 2nd HUO 208. ~8 held back by Mid Penn~ ~&'f/ ,tv 209. seller credit pest inspection 500.00 Adjustments for items unpaid by seller 210. City/town taxes to 211. County taxes to 212. Assessments 07/011200fu 08/15/2006 118.32 213. 214. 215. 216. 217. 218. 219. .220. ,,~(JO. "... . );OTAL)> AID BY /FOR BORROWER C;!'SHA"f;SETILEMENT~ROMITO BORROWER 84.510.64 '.. '., 85.293.64 84.510.64) 301. Gross amount due from borrower(line 120) 302. Less amount paid by/for borrower(line 220) ';',"; ;':.-":::.."";"':::;.;:;:::"..i:-:'.'. ",,;::;':':::.:..' ':'. ':':'.. - '" '." -':'.' " ":~.'.';' .'; ;". ~fu:~;;;(OOt~6~ct3:rb}g6kib\\>eR 783.00 H. Settlement Agent Great Road Settl ement Servi ces. LLC Place at Settlement J. Settlement Date 2157 Harket Street Camp Hill PA 17011 08/15/2006 K.SUMMARYpF..SE~Eg!:lT%\NSA9:rlbN;ii 4(JO;..<GR.qsS..A'MO!JN1'..D!JJ:lTq~.BI"J".JJR...{...'."'."".... 401. Contract sales price 81. 000 . 00 402. Personal property 403. 404. 405. ~... Adjustments for items paid by seller in advance 406. City/town taxes to 407. County taxes 08/15/200fu 12131/2006 97.55 408. Assessments to 409. sewerltrash 8/15-9/30 ($115/qtr) 57.50 410. 4] 1. 412 .. .....) .i)i~ bt.J~fb~IL~~. ........ 81.155.05 "i":i{/ i . 501. Excess deposit(see Instructions) 502. Settlement charges to seller(line 1400) 503. Existing loan(s) taken subject to 504. Payoff of tirst mortgage Joan 505. Payoff of second mortgage loan 506. 507. 508. 509. seller credit pest inspection Adjustment. for items unpaid by seller 510. City/town taxes to 511. County taxes to 512. Assessments 07/01l200tD 08/15/2006 513. 514. 515. 516. 517. 518. 519. 520.T()f.h. ~Bgc#8.J~~.~~~~E~~~fr~. 600.... .CA$JI.A'I;~EJTm!~w:.q:9l:F:g9tv1'..~B~W~R....).. 601. Gross amount due to seller(line 420) 602. Less reduction amount due seller(line 520) ( ......~ 5,820.00 500.00 118.32 6.438.32 ,ii . ','....,.,{.<<" ',','i.,..'.". 81,155.05 6,438.32) 74.716.73 The information conrained in Blocks B, G. H and I and on line 401 or. if line 401 is asterisked. ines 403 and 404 is important tax information and is being furnished to the Internal Revenue Service. If you are required to file a return, II negligence 'enalty or other sanction will be imposed on you if this item is required to be reported and the IRS determines that it has not been reported. IUD-I SETTLEMENT STATEMENT Q Brain.torm Software 1-540-665-0800 WARNING: It is a crime to knowingly make false statements to the United States on this or any other similar form. Penalties upon conviction can include 8 fine and imprisonment. For details see: Title 18 U.S. Code Section 1001 & 1010. SETTLEMENT STATEMENT PAGE 2 L. SETTLEMENT CHARGES ..... ........ .......... .......... PAID FROM PAID FROM 700. TOTAL SALES/BROKER'S COMMISSION based on price $ 81.000.00 @ 6.0 % = $ 4.860.00 BORROWER'S SELLER'S Division of commission (line 700) as follows: FUNDS AT FUNDS AT 701. $ 2,405.00 to Straub & Associ ates SETTLEMENT SETTLEMENT 702. S 2,455.00 to Remax 703. Commission paid at Senlement 4.860.00 704. Transacti on Fee ....>800/ITEMS PAYABLE IN CONNECTION WITH LOAN .. .. .... ....... >>..>.>. ... .<> ....>>............ 801. Loan Origination Fee 0.7500 % Hi d Penn Bank 583 . 50 802. Loan Discount % 803. Appraisal Fee to 804. Credit Report to 805. Lender's Inspection Fee 806. Mortgage Insurance Application Fee to 807. Assumption Fee 808. Hi d Penn Bank - f1 ood cert 11.00 809. Mi d Penn Bank - real estate evaluation 150.00 810. Hi d Penn Bank - doc prep 285 . 00 81 I. .900,. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE ...... ..... '. '" ..... ........... .<<< < ............ 901. Interest from to @$ /day 902. Mortgage Insurance Premium for months to 903. Hazard Insurance Premium for years ro 904. 905. .>1000, . RESERVES DEPOSITED. WITH LENDER ...... ..i ..><. .'.<<< >.... ... . ..... , -. 1001. Hazard insurance months @ $ per month 1002. Mortgage insurance months @ $ per month 1003. City property taxes months @ $ ~,"'" per month 1004. County property taxes months @ S 21. 56 per month 1005. Annual assessments months @ S 80.20 per month 1006. months @ S per month 1007. months @ S per month 1008. '1100.' TITLE CHARGES . ....... .. ................... ><<>. ".<.>', 1101. Settlement or closing fe. to GRSS 2nd Htg Fees 266.00 1l02. Abstract or title search to GRSS Coon & Co POC $155.50 1l03. Title examination to GRSS 1104. Title insurance binder to GRSS 1105. Document preparation to Remax . deed 125.00 1l06. Notary fees to cash 1107. Anorney's fees to GRSS (includes above items Numbers: ) 1108. Title insurance to GRSS (Stewart Title Guaranty) 744.75 (includes above items Numbers: ) 1l09. Lender's coverage S 77 ,800.00 Mid Penn Bank 1110. Owner's coverage $ 81.000.00 Vi ckery 1111. endorsements 100. 300, 900 150.00 1ll2. closing service letter 35.00 1113. Debbie Lupo1d-tax cert (adv by GRSS) $5: school tax $962.34 962.34 5.00 )200: '.GOVERNMENTRECORDING AND TRANSFER CHARGES . . ..... ><.>. << >.......... 1201. Recording fees: Deed $ 38.50 ;Mortgage $ 52.50 ;Releases $ 91. 00 1202. City/county taxlslamps: DeedS 810.00 :Mortgage $ 810.00 1203. Slate taxlslamps: Deed S 810.00 ;Mortgage $ 810.00 1204. record assi gnaent of rents 25.00 1205. .4300' )\DDlTIONALSETl'LEMENT CHARGES ... < ....... ..<> <. < 1301. Survey to 1302. Pest inspection to 1303. Tri County Abstract . deed copy 15.00 1304. Remax - tax cert 5.00 1305. ']400:.. TOTAL SETTLEMENT CHARGES (emer on line 103. Section J andline502.Section 4,113.59 5.820.00 ~ . ~: ceRTI"CAnON ~~e careful rev' ed Senleme Statemem and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and lis rse~n~ o~'}jffr by me' this ion. I further certify that I h~ve received a copy 0~~-1 Settlement Slatement. V ~ . r.'/)/ M1JaIJ) . /;} ",,/7. \.. 'U ~.~V' uona I a ::.retty ./ ~orrowers . Vl cl(erv .......... Sellers The HUD-I Se.ttle",!,nt Sla~IC\~ prepared is a true and accurate aCCllunt of this transaction. I have caused or will cause the funds to be disbursed 1 accordance With thiS statement. ' ~ --- August 15, 2006 ~ etnement Agent ent Servl ces. LLC Date -- ~ -= REV-1508 EX+ (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Donald S. Petty FILE NUMBER 21-06-0391 Include the proceeds of migation 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 . Belco Savings Account 708270 DESCRIPTION VALUE AT DATE OF DEATH 3. Belco Accrued Dividends 7,233.28 3,613.13 17.07 2. Belco Checking Account 708270 4. Belco Bond 134.76 5. 1996 Jeep Cherokee 83,000 miles - value based upon sales price 3,000.00 TOTAL (Also enter on line 5, Recapitulation) $ (If mote space is needed, insert additional sheets of the same size) 13,998.24 '"-'" -- BELCO COMMUNITY CREDIT UNION 1. Name{s) in which the account was held: DECEDENT ESTATE INFORMATION DONALD PETTY 2. Account number: 708270 3. Balance as of date of death: 4/21/2006 Balance Accrued Dividends YTD Dividends For 4/21/2006 Regular Savings: $ $7.233.28 $ $17.07 $24.59 Christmas Club: $ $ $ Whatever Club: $ $ $ Checking: $ $3,613.13 $ $0.00 $ $0.00 Money Market: $ $ Certificates: Balance Accrued Dividends YTD Dividends Certificate Number For $ $ $ $ $ $ $ $ $ 4. Date the account was initiated: 6/4/1992 5. Name{s) in which Safe Deposit Box was held: N1A 6. Date the box was initially rented: N/A 7. Branch address at which the box is located: Balance Accrued Interest Per Diem Int 4276.5 $ $ $ $ $ $ 12285.76 $ $ $ $ 8. Loan Information: VISA Unsecured Loans: B. Secured Loans C. Mortgage Loans: Miscellaneous: BOTH LOANS PAID IN FULL REV-1510 EX+ (6-98. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Donald S. Petty FILE NUMBER 21-06-0391 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. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COpy OF THE OEEO FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. Exel Profit Sharing Plan 453.40 100 0.00 0.00 2. Exel (401k) 93,032.94 100 0.00 0.00 Items on this schedule are reported for information only. These are qualified retirement plan benefits, exempt from inheritance tax under 72 p.s. 2111 (r) TOTAL (Also enter on line 7 Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) Exel2 ~ ~- Exel Human Resources Dept. 570 Polaris Parkway Westerville, OH 43082 Telephone 614-865-8500 Facsimile 614-865-8871 August 17, 2006 Amy Lacomba c/o Elizabeth Goldstein, P.C. 355 North 21st Street Suite 202 Camp Hill, PA 17011 Dear Ms. Lacomba: I have received your letter regarding the Estate of Donald Petty. Donald Petty did have a 401(k) account with Fidelity Investments through Exel. Ms. Irma Petty contacted this office directly in May to inquire about his retirement account. Donald did not have a beneficiary named, and had no spouse, so per our plan document, the account is paid out per stirpes, first equally to the children; if no children, then equally between the surviving parents. Mrs. Petty was the surviving parent. The balance of Donald's account was transferred into Ms. Petty's name and she withdrew the funds on May 25, 2006. If you have any additional questions, please feel free to contact me at 614- 865-8559. Regards, ,Gl, (~j/'- J Susan Adelsberger Retirement Benefits fjministrator Exel, Inc. ...... ~. _ __I ........_11.. "-.............. www.exel.com Ex~1 ~~ EXEL RETIREMENT SAVINGS PLAN TOTAL DISTRIBUTION STATEMENT 74401 OP4K IRMA M PETTY 5 LENOX COURT MECHANICSBURG. PA 17050-0000 EMPLOYEE NO.: 196-48-4298 DIVISION NO. : Xl TYPE ; DEATH BENEFIT - NON-SPOUSAL BENEFICIARY EMPLOYMENT DATE PARTICIPATION DATE TERMINATION DATE TRANSACTION DATE : 01(02(1979 : 07 (01j1994 : 01(12(2006 : ..95-I2S~OO~ FUND INFORMATION FID EQUITY INCOME FIDELITY INVST GR BD FID BALANCED FID MGD INC PORT PRICE $54.5100 $7.2200 $19.2800 $1.0000 SHARES WITHDRA WN 2.508 12.572 4.645 136.360 CASH WITHDRA WN $136.71 $90.77 $89.56 $136.36 SOURCE INFORMATION EXEL PROFIT SHARING OS/25/2006 BEGfNNING BALANCE; $453.40 VESTED PERCEN1: 100.00 AMOUNT WITHDRA WN $453.40 DISTRIBUTION SUMMARY TAX INFORMATION BEGINNING BALANCE LESS WITH D RA W ALS ENDING BALANCE $453.40 ( $453.40) $.00 TOTAL DISTRIBUTION $453.40 $453.40 $453.40 TOTAL TAXABLE AMOUNT ORDINARY INCOME AMOUNT CHECK INFORMATION IRMA M PETTY 5 LENOX COURT MECHANICSBURG . PA 17050-0000 CHECK DATE OS/25j2006 CHECK NUMBER 227416500 GROSS AMOUNT FEDERAL TAX NET AMOUNT $453.40 $45.34 $408.06 A!!v~t/JlfW September 6, 2006 ~ Elizabeth Goldstein, PC Attn: Amy Lacomba 355 North 21 st Street, Suite 202 Camp Hill P A 17011 Dear Amy Lacomba: We are responding to your request for information regarding Donald Petty's Fidelity account. Account Number: 348-626910 Registration: DONALD PETrY - ROLLOVER IRA Value on 4/21/2006: See attached valuation report G61656 All information in the enclosed valuation report(s) is based on assets in the above-listed Fidelity account(s) as of the date indicated on the report(s). Valuation information for these accounts is provided through Evaluation Services Inc., a third party valuation service provider. Fidelity does not warranty the accuracy of this information for any particular purpose. In addition, Fidelity does not provide legal or tax advice. Consult with an attorney or tax professional regarding any specific legal or tax situation. We hope this information is helpful. For questions concerning account holdings or instructions on how to transfer the ownership of the accounts, please call our Inheritor Services Group at 800-544-0003 between 8:00 A.M. and 6:30 P.M. Eastern time Monday through Friday or visit our website at www.fidelity.com. Sincerely, Fidelity Investments Our File: W020404-31AUG06 Brokerage Services provided by Fidelity Brokerage Services llC Member NYSE, slPe Clearing, custody, and settlement services by National Financial Services LLC Member NYSE, SIPC PO Rnx 770001 Cincinnati,OH 45277-0034 ~~ III ..... .....11I ~ 1'\ o CD s::'tl 1'\ 0 1'\ :Ii ~ CD tr:li III III III ..... ~'tl CD 1'\ CD 1lI'tl ~ III 1'\ 1& . s:: ?;;~ 'tl ::s ~lQ H"'l CIlo-! 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'" -..I ~ o-! ~ H "l ~ a In H 'tl Z o 'tl ~ In ~~ ~..... ~ In o :D H 'tl "l H o Z ~~ 1."l0 I."l = 'tl H :IIQ H = ~;; In :>; t' 'tl 0 :II~ H..... ~~ tl ~~ In I."l ~a ~H ~ tl >- H 0 <0 .....~ H~ ~tl o o I :i In >- o o ~ Q 01 ..... 01 U1 01 ~ I."l o "'l ~ = 15 >- ~t;1 I."lln III I."l ~a CD H .. "l H 8~ ~~ tld 'tl>' I."l"l "lH ~i "'l 1'\ ..... Q. 1lI :.< ~ 1'\ ..... ..... '" ..... '" o o 01 'tl ~ z o ..... REV-1511 EX+ (12-99>* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Donald S. Petty FILE NUMBER 21-06-0391 Debts of decedent must be reported on Schedule L ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Funeral and Cremation 1,159.00 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions 0.00 Name of Personal Representative(s) Social Security Number(s}/EIN Number of Personal Representative(s} Street Address City . State Zip Year(s} Commission Paid: 2. Attorney Fees 4,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 0.00 Claimant Street Address City State . Zip Relationship of Claimant to Decedent 4. Probate Fees 495.72 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 221.00 7. Real Estate Commission on sale of Descendant's Residence 4,860.00 375.00 8. Skip's Hauling ( removal of items in Descendant's Residence) TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 11,110.72 A. Settlement Statement U.S. Department of Housing and Urban Development OMB No. 2502-0265 B. Type of Loan 1. DFHA 2.DFmHA 3.IiJConv. Unins. 4.DVA 5. DConv. Ins. 6. Filo Number GR06.121BJAM C. This form is furnished as a statement of acrual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked (p.o.c) were paid outside the closing; they are shown for informational purposes and are not included in totals. F. Name and Address of Lender Mi d Penn Bank 1). Name and Address of Borrower Mi chae 1 J. Vi ckery Wendy L. S. Vi ckery E. Name and Address ot Seller Dona 1 d S. Petty G. J:'roperty LocatIon 74 01 iver Road Eno1a. Pennsylvania 17025 East Pennsboro TONTlship. CUnber1and County J. SUMMARYOFBORROWER'S TRANSACTION: ..lO<LGROSS:AMOUN1'DUE FROM. BORROWER 10 I. Contract sales price 102. Personal property 103. Settlement charges to borrower(line 1400) 104. overn i ght 105. Mid Penn undisbursed funds Adjustments for items paid by seller in advance 106. City/town taxes to 107. County taxes 08/15/200m 12/31/2006 108. Assessments to 109. sewer/trash 8/15-9/30 (S115/qtr) 110. 111. i 112 ....... ......: 81,000.00 4.113.59 25.00 97.55 57.50 1:\120. (OROSS:AMOUNT-DUE FROM BORRO\VER 85.293.64 200. . AMOUNTS PAID BY OR IN BEHALF OF BORROWER 201. Deposit or earnest money 202. Principal amount of new loan(s) 203. Existing loan(s) taken subject to 204. 1st mortgage (S77800) S64800 disbursed 205. S13000 held back by Mid Penn 206. Open End Mtg (S25000) $18092.32 dsbsd 207. S_in fees pd on open end See 2nd HUD 208. ~ held back by Mid Pennoo;g. ~(;'I/ .tV' 209. seller credit pest inspection Adjustments for items unpaid by seller 210. City/town taxes to 211. County taxes to 212. Assessments 07/01/200m 08/15/2006 213. 214. 215. 216. 217. 218. 219. ............... .<<. ...... . 220. TOTAL PAID BY/FOR BORROWER >3oo..CASH A1\SETTLEMENT FROMITO BORROWER 301. Gross amount due from borrower(line 120) 302. Less amount paid by/for borrower(line 220) .."............-.-.-_.......'... ...."..".,,".. .:',"-.. ',:.,'-:' -,:,.,:,:, ....., ....-..-.'..-........-. .----- ....... ....... ----- ........ ....... ..... "---",',' ,.,.....-.-,....-.-............. ','-' ....'-.-... ._....'.. ...-.-... ..............-.. .-'-'--' ...... .. .......-..- .-.............-. ..-..,-....-..... ""'. ,. .. ... ....303. CAsH([!]FROM)(D TO) BORROWER 1.000.00 64.800.00 18.092.32 500.00 118 . 32 84.510.64 ... 85.293.64 84,510.64) 783.00 H. Settlement Agent Sett1 ement Servi ces. Place ot Settlement Great Road LLC I. Settlement Date ...\ .. .. ..... ...... .. .. .: ...'.: 81,000.00 Q Brainstorm Software 1-540-665-0800 97.55 57.50 81.155.05 .. ..: 5.820.00 500.00 118.32 6.438.32 ~ 81,155.05 6.438.32 ) 74.716.73 The information contained in Blocks E, G. H and I and on line 401 Dr, if line 401 is asterisked. lines 403 and 404 is important tax information and is being furnished to the Internal Revenue Service. If you are required to file a return, lL negligence penalty or other sanction will be imposed on you if this item is required to be reported and the IRS determines that it has not been reported. 2157 Market Street Camp Hi 11 PA 17011 K...SUMMARYOF.sELLER.~S.:rI~AJ~.sAGTlON: 4oo;}GROSSAMOUN1'D1JIl1'o.~ELI.;ER 401. Contract sales price 402. Personal property 403. 404. 405. 08/15/2006 lUD-1 SETTLEMENT STATEMENT ,~ Adjustments for items paid by seller in advance 406. City/town taxes to 407. County taxes 08/15/200m 12/31/2006 408. Assessments to 409. sewer/trash 8/15.9/30 (S115/qtr) 410. 411. 412 .ion: 2./ ::....:....: ...:....) :..}:i i) 500; REDUCTIONS IN. AMOUNTPUE.TO SELLER. 501. Excess deposit(see Instructions) 502. Settlement charges to seller(line 1400) 503. Existing loan(s) taken subject to 504. Payoff of first mortgage loan 505. Payoff of second mortgage loan 506. 507. SOB. 509. seller credit pest i nspecti on Adjustments for items unpaid by seller 510. City/town taxes to 511. County taxes to 512. Assessments 07/01/2006> 08/15/2006 513. 514. 515. 516. 517. 518. 519. .. -.~ rn 520. TOTAL 600. . CASH AT SETTLEMENT.TO/FROM SELLER.. .. 601. Gross amount due to seller(line 420) 602. Less reduction amount due seller(line 520) ( -~- .- . ... ... .-:.- ......... WARNING: It is a crime to knowingly make false statements to the United Stales on this or any other similar form. Penalties upon conviction can include a fine and imprisonment. For details see: Title 18 U.S. Code Seclion 1001 & 1010. SETTLEMENT STATEMENT PAGE 2 L. SETTLEMENT CHARGES ..... ....... 700. TOTAL SALES/BROKER'S COMMISSION based on priceS 81,000.00 @ 6.0 % = $ Division of commission (line 700) as follows: 701. $ 2.405.00 to Straub & Associates 702. $ 2.455.00 10 Remax 703. Commission paid at Settlement 704. Transaction Fee 800,: ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Origination Fee 0.7500 St Hid Penn Bank 802. Loan Discount % 803. Appraisal Fee to 804. Credit Report to 805. Lender's Inspection Fee 806. Mortgage Insurance Application Fee 807. Assull1ltion Fee 808. Hid Penn Bank. .. 809. Hi d Penn Bank 810. Hid Penn Bank 811. '.900.} 901. 902. 903. 904. 905. JOOO; 1001. 1002. 1003. 1004. 1005. 1006. 1007. 1008. nOO:'l1TLE.CHARGES '. ....... II 0 1. Settlemenl or closing fee 1102. Abstract or title search 1103. Title examination 1104. Title insurance binder 1105. Document preparation 1106. Notary fees 1107. Attorney's fees (includes above ilems Numbers: 1108. Title insurance to (includes above items Numbers: 1109. Lender'scoverageS 77.800.00 1110. Owner's coverage $ 81,000.00 1111. endorsements 100. 300. 900 1112. closing service letter 1113. Debbie LupoId-tax cert (adv by GRSS) $5: school tax $962.34 .J200.': .;GOVERNMENT RECORDING AND TRANSFER CHARGES i .:. .....i 1201. Recording fees: Deed S 38.50 ;Mortgage $ 52.50 ;Releases $ 1202. City/county taxlstamps: Deed S 810.00 :Mortgage S 1203. State taxlstamps: Deed $ 810.00 :Morrgage $ 1204. record assi gment of rents 1205. '1300; 1301. 1302. 1303. 1304. 1305. If 00:: to f10Dd cert rea 1 estate eva 1 uati on doc prep ITEMS REQUIRED BY LENDER TO BE PAlD IN AnY ANCE Interest from 10 @$ Mortgage Insurance Premium for months to Hazard Insurance Premium for years to RESERVES DEPOSITED WITH LENDER Hazard insurance months @ S Mortgage insurance months @ S City property taxes months @ S County property taxes months @ S Annual assessments months @ S months @ S months @ S to GRSS GRSS GRSS GRSS Rem ax cash to to to to to to GRSS GRSS Hid Penn Bank Vi ckery .:ADDITlONALSETILEMENT CHARGES Survey to Pest inspec tion to Tri County Abstract - deed copy Remax - tax cert . . 4,860.00 PAlO FROM BORROWER'S FUNDS AT SE'ITLEMENT PAlO FROM SELLER'S FUNDS AT SETTLEMENT 4,860.00 , '. . .:. . ......... ....... ..' 583 . 50 11.00 150.00 285 . 00 .:" .:.,. ..... /day . :...:..::., '. .... .:.. '.. . .' '.' .. . ..' i.:' .. per month per month ~,'" per month 21. 56 per month 80.20 per month per month per montt! : ." '. ..... 266.00 ...... 2nd Htg Fees Coon & Co POC $155.50 - deed 125.00 ) (Stewart Title Guaranty) ) 744.75 150.00 35.00 962.34 5.00 ...t ..i 'iii'" 91. 00 810.00 810.00 25.00 . '.: ." '. .:. .... .... . 15.00 5.00 TOTAL SETTLEMENT CHARGES (enter on line 103. Section J andlind02, Section ~~ ~ CERTIFICATION I!'tve careful rev' ed .l.. m.'.... Sellleme Statement and to the best of my knowledge and .belief, it is a true and accurate statement of all receipts and Iis,\\"emen on m'Ul1i{olrllr"r by me' this ion. I further certify that I h~ve received a copy OV"~~I Settlement Statement. -:7J.//U . r..'/)/ !/}1Jc:i.f)') . ~}d/7 \..... \!J ~~. ~ UOnalQ ~etty '" .. IOrrowers . V1 c~rv -... Sellers The HOO-I Settlement Sta~.' ',ch.\~have prepared is a true and accurate account of tt!is transaction. 1 accordance with this statement. '\ ~ -.' ~ ent 5erVl ces. LLC ernement Agent -- - 4.113,59 5,820.00 I have caused or will cause the funds to be disbursed August 15, 2006 Date REV-1512 EX+ (12-03) '*' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF Donald S. Petty FILE NUMBER 21-06-0391 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 1. Ambulance 535.00 2. American Home Medical Equipment 150.00 3. Amazon Visa 4640182011788738 757.27 4. 5. Belco Mortgage Belco Visa 708270 12,285.76 4,276.50 6. Bill Me Later 5049902003668182 166.42 7. BMG Music 8715068-667 190.62 8. Buy.com 4266841086907456 Capital One 4121742279378973 80.95 38.42 9. Cingular 58.12 Cumberland Family Practice 25.00 Discover card 6011002800734709 820.73 Discover card 6011002420394058 2,289.00 1,402.00 107.80 East Pennsburo Township Petty05001 Heritage Health Holy spirit Hospital 26844968 318.65 MBNA 4313030064005557 1,359.45 180.01 Medical Bills Penn Credit Corporation 36.50 Pennsylvania American Water 24-0663724-5 83.61 Pennsylvania Power and light 460.23 Per Capita tax bill No. 9445 Real estate tax Bill No. 5417 4.90 273.79 Verizon 101.37 26,002.10 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) -- -- BELCO COMMUNITY CREDIT UNION 1. Name(s) in which the account was held: DECEDENT ESTATE INFORMATION DONALD PETTY 2. Account number: 708270 3. Balance as of date of death: 4/21/2006 Balance Accrued Dividends YTD Dividends For 4/2112006 Regular Savings: $ $7.233.28 $ $17.07 $24.59 Christmas Club: $ $ $ Whatever Club: $ $ $ Checking: $ $3,613.13 $ $0.00 $ $0.00 Money Market: $ $ Certificates: Balance Accrued Dividends YTD Dividends Certificate Number For $ $ $ $ $ $ $ $ $ 4. Date the account was Initiated: 614/1992 5. Name(s) in which Safe Deposit Box was held: N/A 6. Date the box was initially rented: N/A 7. Branch address at which the box is located: B. Secured Loans Balance Accrued Interest Per Diem Int 4276.5 $ $ $ $ $ $ 12285.76 $ $ $ $ 8. Loan Information: VISA Unsecured Loans: C. Mortgage Loans: Miscellaneous: BOTH LOANS PAID IN FULL "~ _.. ..__mm_.___ __ _ __ ___~_ REV-1513EX+(9-00) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF Donald S. Petty FILE NUMBER 21-06-0391 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Ust Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Irma M. Petty Mother 100% 5 Lenox CT Mechanicsburg, Pa. 17050-8215 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV.1500 COVER SHEET If NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 00 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 00 TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 00 (If more space is needed, insert additional sheets of the same size) This is to certify that the information here given is cOITectly copied from an original celtificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ~!?~ Local Registrar Fee for this certificate, $6.00 p 12410942 APR 2 4 2006 Date Rev. 01JU6 IlIHTIN ANENT :KINK 1. Name 01 Oecedenl (First. middle. last) COMMONWEALTH OF PENNSYLVANIA 0 DEPARTMENT OF HEALTH 0 VITAL RECORDS CERTIFICATE OF DEATH STATE ALE NUMBEA 7, Oal. 01 Birth Monlh da , eat 3. Social Security Nurrber 196 48 - 4298 J.{jO~ 8. Birth lace C and slale or be" 88. Place 01 Death Check on one ospital: In atient a ERIOuI 47 v". Bb, County 01 Deatft Cumberland ,.1",_1 OIhe,; lien! a OOA a Nursln Home 9. Was Decedenl 01 ~ispanl: Origin? :KI No 0 V...taV"'-"YCubon. Mexican, P\Jerto Rlcan,elc.) o Residence 0 OIner. 10. Race: American Indian, Black. WhMe, etc. iSpe~ White 14. Marlal Status: Married. Never m'IITie1. 15. Survivk10 Spouse (II wife, aive maiden name) Widowod, DiYorced (Spocifyj Sin le 171. SI,I, P A Did Decedenl livelna 17c.JC] Yss, Decedenl Lived in F:~J::.t ppnn~hnr() Township? rwp. 18. Father's Name (First, friddle, last) 17b. Coun~ CumbeJ;[land 19. MoIhm', Name (Ftrst, middle, maiden surname) 17d. 0 No, DecedenllNed within '&dualLimilsol CitylBoro John Maurice Pett 208. IntlM'1lnt's Nams (TypsIprift} Irma McGann 2Ob. Inlorfl'11nl's Malting Address (Slreet, cityAown, slate, zip code) 5 Lenox Court, Mechanicsburg, PA 17050 21c. Place 01 Oispos~lon (Name of cemel8'Y, cremalory 01' other place) Cremation Societ of PA 221;. N8",ondAddressolfacOly Auer Memorial Inc., Harrisburg, PA 17109 23b. license NuntHlr 230. DaI, Slgnad (Monlh. day. vaar) 25. Dale PrO/i.fId Dea~ (Month, day, 'year) riP!? I / ..;; I ,2r?O (~ CAUSe OF DEATH (See InstrucUOIll and examples) Item 27. PattI: Enler the ~ - diseases, injuries, or ~1bt1bns -lhat direcl:/y caused!he death, DO NOT eJlIer lerminal events such as cardiac anest, respiratory arTest, or venlricular fibrillation wilhoul showirlg the eliology. DO NOT abbrevlale. Enler only one caUSe on a line. IIIMEDIATECAUSE(F~8Id;s,.saor 8te A ;;~ E" tJe: fY1 A concI.lOnresulirlgndeathj --;. a. ..>.. m!..- D~(oI'~~U8ncaoQ: '(J : () n 11 SaqU8nliallyialcondi~ns.Hanv. b. CS:'] k! I 0 CJ_I I I,:V<./I ."v ktading 10 lhe causa Ilsled on Line a, Due to (o~as a consequence on: Enlar 1tl8 UNDERLYING CAUSE " (disease or injury thatinitiatecllhe events resuting in death) LAST. 204. nmeofDeafh 9:00 f'. M. ;$, ,as Case. Reletted kl a Medical Examiner!Coroner? '~il Yes 0 No : ~roximaleinI8rval: : onset 10 death Part II: Enter olher !lionlfbnl condtiions coofrnUllna 10 death, bul not ra&u~lng In Ille underlying eIIU1e given in PIli I. 28, Did Tobaa:o use Conlrinde Ie Death? oy.. O_b~ 1...er'No 0 Unknown 29, IfF.mala: C1 No! pregnanl wilhin past Y88l' o Pregnanl altm. of dealh CJ No! prlJVl8nl, but pregnanl within 42 days oldealh o NO! pregnant but pregnanl43 days 10 1 yeal beloTe dealh o Unknown If pregnant wtthin the past year 3.2c, Place ollnjury: Home, Farm. Street, Factory, Office Bulcllno,aI<:.(~ 7U ,/jI) QI<-- ". , . I r,a/COfl..i, t:.J.1 s ft1ltJ< ,f\. DE fJ.A..tS. s; 0 t4 Hyt'c(l.:/ErvS\VC Ctt-ISIS c. Due 10 (or as a consequence o~: 308. Was an Autopsy ""_1 o Vas .il\ No d. JOb. Were AulO(lsy Findings Available Prior 10 Conv\fltion of Cause of Dealh? Cl Yes 0 No 31. Manner 01 Dealh 'JIt Nalural [J Homicide o Accidenl [J Pending Investigation o Suicide 0 Could Not Be OelerlTlined 32a. Dale of tnjury (Month, day, year) 32b. Descrbt how Injury Oeeurred: 32d. Time at Injury J2e, Injury al WotX? o Yes 0 No 321. II Transportation In.kJry (Specit)1 o OriverlUperator 0 Passenger o Pad"I,.n 0 OIhel- Spocify. "natura and T1l18 01 Ce . 'fC-v: .... fC. 33c. l' nse Nurrb$r ,IV\. I) 0 2,..( 9 q 0 tC 3oI.~ame ~nd Address of .?arson ~.1IlKI Cj~, pi Oeali', (f'lvn 27) TYJ)8IPrint r<-O(~~ 1-'-. -VSI<Jf1j,ofL... fvooO 9;;lo c..S;.I-JTV,L-y O~,t/I: M .:(..L.( 11 IV'I COOS /1, cJ fl-.C, A { '1 0:( f 32g. location (Street, cityftown, slale) M. 338. Carttfler {check only one) ~::::'f:~~~=~n:~~~~~~= ~~:t~:c~n~~~:.~: ~=~~~~~.~.~.~~~.~~~w~!.,.w._".,._ww~~ww..".,ww.._~",~".".._w....~ Pronounclng anet certifying physlc:lan (Ptiysk:ian both pronouncing death and certi1ylng 10 cause 01 dealh) To lhe bett of my knowkKlge, death occurred al the time, date, and place, ~nd dUl to the cause(s) and manner iI' stattd...."w....'"...."..,....w_...,.._......_......_....w.....Cl Mtdk:alllxamh.rlcoroner On the basis of tumlnaUon anellor invesllgallon, In my opinion, death occurred at lhe time, date, and place, and due to the cause(lIland manner a. stated .........0 Regisirar's Signature and Ois.irict Nurmer I~I/ I~I/V