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Home My WebLink About02-07-07 ~ --.J 15056051047 REV-1500 EX (06-05) PA Department of Revenue . Bureau of Individual Taxes. PO BOX 280601 Harrisbu ,PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT Suffix (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix lID MI o THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW _ 1. Original Return c::>> 2. Supplemental:Return c::) c:::> 4. Limited Estate c::) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 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: Name Daytime Telephone Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received o 8. Total Number of Safe Deposit Boxes c:::> N/If ............. City or Post Office .::- Correspondenfs Ermail address: be'ltmet'(!S cID~ix, net DATE 7 tP '" " PA IIOSS HI/R,/JS m~aUAAJJl!.5;auR(j., PA 170S~ PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 --.J --.J REV-1500 EX 15056052048 Decedent's Name: RECAPITULATION V. L luflElIE ~()ttJ~S .. Decedent's Social Security Number '" 1. Real estate (Schedule A). .. '. . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .'. . . . . . . . . . .'. ~ 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . . . 4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . . . 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested . . . . . . . 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested. . . . . . . . 8. Total Gross Assets (total Lines 1 :7)~. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Funeral Expenses & Administrative'Costs (Schedule H). . . . . . . . . . . .. . . . . . . . . 'r ~ -. 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/Sec 9113 Trusts for which an election to tax l1as 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(2- 16. Amount of Line 14 taxable at lineal rate X.O '15- 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X. 15 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . 19. 15. 16. 17. 18. 20. FILL IN THE OVAL'1F YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 15056052048 Side 2 c::::> 15056052048 --.J ., REV.,500 EX ~ge 3 Decedent's Complete Address: File Number DECEDENTS NAME V, /&JU)~S LbUJe€III€ .~ STREET ADDRESS AD #. /.:lfIJ 5-rA!EET CITY J.E/YJ()YAJ€ I STATE /'A I ZIP /7/)t{-,3 Tax Payments and Credits: 1. Tax Due (Page 2 Une 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) f #; 761 If. b () o e; &' Total Credits ( A + 8 + C ) (2) f) 3. InterestlPenalty if applicable D. Interest E. Penalty t:J o (3) 0 (4) 0 (5) ~Ll 7''', f)() (5A) , /t8',7(, (58) , Lf, Cls~. 7' TotallnterestlPenalty ( 0 + E) 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. 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 Une 5 + SA. This is the BALANCE 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 property transferred or its income; ............................................ 0 IXI c. retain a reversionary interest; or.......................................................................................................................... 0 IXl d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 IX] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 /Xl 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 !&J 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 I){l 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 (O) percent [72 P,S. ~9116 (a) (1.1) (ii)). The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are stiH 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 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 four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(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 decedent's siblings is twelve (12) percent [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. ________________~_____V~H LnJl~~E_ _.&uJb~__ -- ~~~------===~~~~-- ---------~-------- ~_=--==~ 7k;;r;_-~f;;3;/~~==;~L~~-i~~-==-==-==-~-==-=-~---.----.. -- _____________ ..-.--. I -------..--.-.-.--------.......-------------".-.-.------..----..----.---.-.------..---..------.------..... -.-...---.--...---..------.-----.. ........-- -----. -....-. -=-==--~-=~ Iki- -;--;j;;~_7~ ~3.it.-_:L~~==-=-=-==~==~=::====-=====- --_..._.._._---_._--------~-----------_._----------------..---..---"..------...--.-.-.---.---.-.--.--.---.- --. - .-- - ..-..----.---.--.-.--...--..-.-- ___._._.._______!!t-2JJ1LP ~_.__~_.~__~~Q__~.l_~___~__._'1_~_Q._!L__~_J_~~_1___--..~-_~~_ ~ ~_____.__._._____ .. /8'8. '7~ . _._"___~_----.--~__._.-_--_---------..---~_.-_.~.---..--_"___'~n~_~.__._____. ___~,..__.__~_,.,..__~_.._._ __ _._...'""' _', n_..__..__...___._'..__._._n.'.~.._~_~.___.~_,_.__.._.____.d._....___._~~._.__--'~~.__~__~___._~ RI."J.1509 EX. (1.97)' '* COMMONWEALTH OF PENNS) L.VANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF V. L ()U.ItEN~ 13()tcJst& SCHEDULE F JOINTLY-OWNED PROPERTY FILE NUMBER If an asset was made joint within one year of the decedent's date of death, It must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME RELATIONSHIP TO DECEDENT ADDRESS A. ~/) Nil-(./) €. 71 PI'E rr B. c. 31'01) (;.oLFVIE"ttJ ./>Iz.. IH E ~N AN It!. S~ leG-.1 1'11' /7 ~SD 13/UJ 7Nse JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY 0/0 OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar Identifying number. Attach DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deed for joindy-heJd real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 7/2/D2, cASr SIDE /)r 2. Y. S~I!Y Fit!AMG "%1, 2. 9(). 00 ~ ~ ~Jr,q.~tJf) ;;;JIIE~Nt;,. HouSE .#t{Jl/JJ8t.ED 133 E: ~AIN.57:, SN/eE/IIAA'snkllfl ~"", C tl J1118E1t.JJMJ> &/,/'" TV ~ ,0 FAIN/!;, /JUA!e fJA-,erl(!~L.AIf!LY 'PES(!I&4J~ /A) mAr ~rA/" ZJetJ lJATIiD ..)/.U. Y .2, 2.P".2 , ~AI KArNlt)'AI X. TIP/JE7'1; J1A1I2EMIIre /l!nJ IfIIt)PIf)/ 7D I&dAUJ E. 771'/l~rr; 4~ I'l E 77JfJ,E7-t;,fw,d y, LtJ/ttI'tBll~ ~kI/I9t$ lieS ,:;plAiT 71fW/MIn M),r# /<I~T ~r ~IdlVJvpLSI(If1~ ~(!/)IUJEt)IAJ 7#E /)FF/IJE D;:- ~ /<&f!bIUJse. IJF f)~ /J) AN4 t91t aulHiJERJ,AN1J DOSIA/TV 1# L)E/!1) Ikx* ~5.:J, PA-6E ..-- a,98Cf.. (.s~E C!/;IJy OF 1JEl:tJ A'T'OIUI- 151>) .. / SEE VALUATION flf./N'F()u r In II--rl9tIA-l- oRJrAlNEJ) fielht 7J1-1 ~>s.~JtAEN7 ~J:RtE A7'1"A{J,HS) ) TOTAL,(Also enter on line 6, Recapitulation) $ JH;:b~S.I)'D (If more space IS needed, insert additional sheets of the same size) 02/09/2007 16:54 71 72~5t:E1BE,2 TPI CDUI'.fr\" ABSTPACT PAGE 01 FacetWin Screen Print for: recdeeds, from lICA!G._Login" 2/5/2007 10:43:29 .AM CUMBERLAND COUNTY ARCHIVE SYSTEM HS:03/01j200S T PARCEL: 37 37-23.0555-136. BXLLING B~gTORY ----LAND Last COUNTY Eill AV; 16200 Last SCHOOL Bill AV: 16200 OWlJER: BLDC 65090 65090 gHIRE~SANS'I'OWN TOTAL~ r1S'74 81.2 51 0 I 1M:. V . 81290 I I --.J I Land: Bldg: TOTAL: 12600 - 4J7~O :;;63~O New 11/28/2006 1(;200 65090 ~.IL DATE Why FAV :LoA.ND FAV BLDG 11/30/2006. 01 16200 56360 05/10/2004 05 16~OO 65090 05/09/2004 12600 43740 10/07/2002 01 12600 4.3740 07/01/2000 05 12600 ., '7670 06/30/2000 440 24'70 81290 TOTAL CG LAND CG aLDG TOTAL 74560 I 81290 (; 56340 I 56340 I 90270 i 2910 -~ Screen 9 Enter Selection > Number .Switch Screens, X -Exit, J -Jump Mode, Down Arrow -NQxt Entry, Up Arrow .Pr@vious Entry, Record: 31464 F -Forms, r -Image ? -Sor~~ns, B -Br:owse Dncx \IL *~ Gnn"~ ~ \)~\ U.( MsS86smen-t, u.::>c>~d hdJJe ~ cyl\e;- Co--:S'SD ~'(1 ~' ~ fY'On \.e ue \ ~ Mnd~ ~r(le- 6..D ) n @()C)q - i\ <(5\ CAG e~ \; cr ,~~~ ~~ ~na_\ l - U~ UC \ .5 s ~ry1 e:: $ S\'C;)q~ .. - Tax Parcel No. 37-23-0555-136 ~14-a \ C S~\t\~ THIS DEED Made the d I/.j day of ~r in the year two thousand and one (2002). Between KATHRYN I. TIPPETT, unremarried widow, currently of the Borough of Shiremanstown, Cumberland County, Pennsylvania, Grantor, to RONALD E. TIPPETT, a.k.a. R. E. TIPPETT, her son, currently of Hampden Township, Cumberland County, Pennsylvania and to her daughter, V. LOURENE BOWERS, their heirs and assigns, as joint tenants with rights of survivorship and not as tenants in common, Grantees, WITNESSETH, that in consideration of the sum of ONE and No/lOO (S1.00) DOLLAR, in hand paid, the receipt whereof is hereby acknowledged, the said Grantors do hereby grant and convey to the said Grantees, as joint tenants with rights of survivorship and not as tenants in common ,their heirs and assigns: ALL THAT CERTAIN lot of ground situate in the Borough of Shiremanstown, County of Cumberland and State of Pennsylvania, bounded and described as follows, to wit: BEGINNING at a point on the north side of East Main Street, at corner of property formerly of Joseph A. Willis, now owned by the Evangelical United Brethren Church of Shiremanstown; thence by said property northwardly one hundred sixty-seven (167) feet to a post on the south side of Strawberry Alley; thence by said Alley westwardly twenty-two and five-tenths (22.5) feet to an iron pin; thence southwardly through the center of a frame barn and beyond, along other property now or formerly of Mildred P. Sauve and James W. Sauve, ninety and two-tenths (90.2) feet to the center of the cesspool; thence southwest- wardly along the same property thirty-four and five-tenths (34.5) feet to a point at the rear of the partition wall of the double frame dwelling house erected on this and the adjourning lot of ground; thence southeastwardly through said partition wall forty-five (45) feet to a point on the north side of East Main ' Street; thence by said street eastwardly twenty and five-tenths (20.5) feet to a point, the place of BEGINNING. ~ HAVING ERECTED THEREON the east side. of a two and one-half (2-1/2) story frame dwelling house numbered 123 East Main Street, Shiremanstown, Pennsylvania. BEING THE SAME PREMISES which Mildred P. Sauve and James W. Sauve, her husband, by their deed dated December 31,1952 and recorded in Deed Book "E", Volume 15, Page 293 granted and conveyed unto William C. Tippett and Kathryn I. Tippett, his wife. The said William C. Tippett departed this earthly life in December of 1980 whereupon full and complete title vested in the said Kathryn I Tippett, his widow, the grantor herein, according to the laws of the Commonwealth incident to tenancies by the entireties. The Grantor further grants and convey unto the said Grantees the right, so far as may be necessary or usable, to use the cesspool which is located partly on her property and partly on the adjoining property, subject, however, to the same right of use by the owners of the adjoining property, the care and maintenance of the same so far as applicable to be borne in equal shares by the respective owners of this property and the adjoining property. THIS IS A TRANSACTION BETWEEN PARENT AND CHILDREN AND IS, THEREFORE, REALTY TRANSFER TAX EXEMPT. IN WITNESS WHEREOF, the said Grantor has hereunto set her hand and seal the day and year first above written. , " AND the said grantor does hereby covenant that she will WARRANT SPECIALLY the property hereby conveyed. Signed, sealed and delivered in the presence of: # ~~ tJdu g L --11'ati .~ KATHRYN I~TT ... o ,: ',',:! N .,:~. ." :'\ t;;:J c~~ 1'_:' ~ rnc,fJ I ;o.;it P1 I Cl 7} ;po. - -1 c.o(S~~ :--J -:D Cl ',:.,~ ~.': :3 ~ ," j i~.: t--' :z: Pi I c::::> ---4 r1l rr. CJ1 -< Cl ::0 , u> ex:> ..1 J;>>- BOOK 25:2 f'AGE2984 COMMONWEALTH OF PENNSYLVANIA , : SS. COUNTY OF CUMBERLAND On this, the CJmi day of , A.D. 2002, before me the undersigned officer, personally appeared KA R I. TIPPETT, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto' set my hand and official seal. (~g~~ . . Notary Public Chatfea NOT~AIAl SEAL MontoeL.~Publc My Comnulon E.,.. June =. CERTIFICATE OF RESIDENCE I HEREBY CERTIFY that the precise residence of the Grantees is: 123 East Main Street, Shiremanstown, Pennsylvania . ~hC'~Ji) Attorney for Grantees ( 1fI~) 2 BOOK 252 PAGf:(:985 ,r-"" Cumbel"land ClJtmty Recorder of Oeeds Instrument Filin3 Rec~ipt# 371140 . Instr~ 2002-027421 7/09/2002 10~J7~L2 Remarks: C SHIELDS ~ 5 l' (~. (J tl "vtf DEED ~~ DEED - WRIT DEED - RTT STATE MECHANICSBURG SHIREMAHSTOWN BORD DEED - AiH CO IMPROVEMEr~ FND REC. IMf'RVMT FUND Checkit 530 T obi Received....... :t2450 ~50 ~ ~jO ,i){j ~oo ',t t ,~50 2~\)O :; :"ifl 'J t ""\01 $29~50 $29,50 a)()/aq~1 REV.15<pj EX+ (12-99) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF V. L t>Ul!EflJE 6tJUJees FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: 1. DESCRIPTION AMOUNT B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions (71J.z>z, 7"IPF'E T7 IS A-(!'iltAl(i, AS mE: fl!E5/lf)/(s~iS~F ,o6RSIIf/, Sl!:I!F" /N~ SNGF7: Name of Personal Representative(s) 7D.l>J:J 77PPe:- r'r Social Security Number(s)/EIN Number of Personal Representative(s) ~~-, '1- 7f)J/, Street Address <</).3 S IIA~E~T ,[)/!!,/VE City IHIFMAIV/t!.S/JUJet; State & Zip J7f)~ Year(s) Commission Paid: :J.L;tJr ~ 2S7:J..DO 2. Attorney Fees C# /J.,(!LS Sf; SN/~ 7lZ t/M./.klJes 7RJh 7D C!MI.I/.r #Nt5e/ ~ ~~~lf!'tIr~;:;,q~ ,:7/6f!71I?GT~ 4:71:.) Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) ~"~,~ 3. Claimant A/()/YE A) J)PE Street Address City State _ Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. f;I;^! F~ -h l(~i6kr ,1 /lJ//ls ~5,OO TOTAL (Also enter on line 9, Recapitulation) $ 9 :IS: f) 0 (If more space is needed, insert additional sheets of the same size) 1II A-./J 1J/7i I;N I'N- I Ai fl;I&J1 J9.71 oAJ .sNGEr.' eS7lf~ ~. .....~ l..IJtllflf"l2I€ .lEbtvc~S 8lfA$~~o~_ ..~/SD"'!Liit'Stv".,..5 . .5'gltJ;'lf/~ ,6)1' Ne2Nu.fdlJ.Jf)l>J I<I!'tll1~~4 ..Ilf)A)~~.#~~I?J;"Ql., . /JIJ't .~JQb'?J$ TA.~/J/~~ WT/IIE .1?~etf&!7iNl" t:Jr 7J,'/s Ate ra,eN ;"1lA/~ mAN'.Er ,AJo ~1'~~l!1/r1:A-:7/~.s ~. 7?J /7,5' ,A-~aA~~~Y /A!MY~f!4J!C 7h'1..r /<~Ltllf!Alv J5 ~/lE"P'A-~!f:[) .,I./III)J/D</,QtfiZJ J$/(_O~l> ZLl!e€rr__M.I)~,7ilFS<<,t7€"gJ/).J'/~~ ..~. .~t:?_~€l1J~/fl1l!~ . j . p.E.tI/~... ,l/-r~/lA!€Y .a#~ ~ .€-m .~(t~~-!..!#2? ~..I' ~,/JJ> l5.__~_..S~l!!..'?FtYA!..1!::1! E; 7//J,lJE!~ LJE~. A::$/~ ZJ(S"l!J(~S/~~~/hf.ILJ~&f51!1)&J/)t:"/Vt!E tU/rN Ats.. _kAP.r&{~...,... ..72r~~?l?~{?/!!B!,.......,7kt.[.../4f!:u.~...r!:~~I{~!-J..V"h' t2f. ....!?k[~~l!!!f!!_~//V' ..@~~~{)7i~~ tp~t?l/ AJ..I'i!!~.1It~.... fi.€7lf~ ..6!€~(!I!!.~._...~rt..,~1lt!€._.q::. k'/lm,e}/N I. 7/1f1~E 77: /Uf;TH~ ~ J/. Lpu/eG7l/G" ......h.............._........ .... .............__..., ..'''', ......hh................ ..... ...............__..___...._...... ~f!_ftJ.~~~h....~#_._!Z~~~~~i......gZ~~-?.__~eNG E(f~__.?!fIJ.!t:€/!1.eR/{1~@g~{Y... .... .,;f~t()t77f/...~Qe.t:.~rg)_ .... . Ti? ....... AI~...h.:2I~f)'____4fl!_.. , /3.)./lJIliqf" 77tXRElil-lt.!/ bE/CftA//I-?415 7i ~.I!fr!; d~iP(~_ ~E...fh~Rl'~4!~_..&P..tf!if!f~. .../JI/l . 7Jl:J~€'T. 121t;i) ..~~t:_./'t_.~pp:r~_HII(~_..E~?2t~m. L.:s .;p~g~T~ ...Z22..LY~J_ ~=.. . .l!~..= .1~~~,._7!f€_..~Z!!/!~._I!!!/L4.~_EL~_/AI~~~~_..H ,/ EJtl r"f(<E,,,/T../S CNH/(,/ TIti3 L € 7b SA-y /){~ 7lf1..~~Tr~ ) If-pp/ftle.5 ~~ /1I.r!I/fsJ!J@l!JiG ])15/}J!.R1J.~ ?ill: 0EPTs fJkTt5NC€ t5 htb5t5?IN(!.tfl(!Ely. Af/I7IlR/II-~ .1 · REV-1"3 EX. 19-00. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER v. LIJu, UAl~ f1J/JltJ€TGS NUMBER I RELATIONSHIP TO DECEDENT NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee{s) TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] II/JT It.El€'V,fIVT. SEE St:HG/).. rAND hJF A-btJIT1D/tJAl.. /AlR/lH//rT(I)N .sNEEr ,4 /7M!J{E-b. 1. AMOUNT OR SHARE OF ESTATE 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 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - 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) H 10o.ROo REV 1/05 This is to certify that the information here given is correctly copied from an original certificate 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. Fee for this certificate, $6.00 ~931532 No. thm-/7l~ Local Registrar OCT 2 2 Z005 Date o (:;0 . -: ~~~;~ i-(-() i"-......} ~-':.~''') c:::,) -.... , , '" CD Rev. 2/87 COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS CERTIFICATE OF DEATH STATE FILE NUMBER -.C" SEX 2Female 3. BIRTHPLACE (City and PLAC F 0 TH h State or Forelr" Country) HOSPITAl.: amp Hi l, PA "...." IXI 7. a.. FACILITY NAME (If not institution, give street and number) . 76 Yrs. 5. COUNTY OFDEA TH E. pennsboro 8<:. KIND OF BUSINESS I INDUSTRY . Commonwealth of PA 26i02CNTS 17a. Slate P A RESIDENCE ~e~I~~~kjc:rs 17b. County Cumber land Old decedent live in iI township? SOCIAL SECURITY NUMBER 182 - 22 -8862 nloo-sein in n DCAD ::,~):.-tJ RACE - .can Indian, Black, White, at . (speCifyWhi te 10. MARITAL STATUS - Married. Never Married, Widowed, DIVCfced (Specify) l.married SURVNlNG SPOUSE (tfwtf.. giw maiden name) mond H. 17c. 0 Yes, decedent lived in Iwp. 17.orn ~"ti,=~~1i~~ of Lemoyne citylboro. 17043 PLACE OF DISPOSITION- Name of Cemetery. CremalOry or Other Place 2~on-O-Lite Crematory 'i~E AND AQDRESS OF Et&lLJ.lY.S 2*usse.lman l"H&C LICENSE NUMBER 2005 Items 24-26 must be completed by person who pronounces death. 24. 27. PART I: Enter the dl.......lnjuri.. or compncatlona whlth cauuct thti d.ath. U.I onty one cause on ..ch IIn.. IMMEDIATE CAUSE (Final disease or condition resulting in death)--' l.\{~ a. Sequentially list conditions I. b. if any, leading 10 immediate cause. Enter UNDERLYING CAUSE (Disease or injury c. that tnitiated events resulting on death) LAST d. WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF ?DEATH PERFORMED7 AVAILABLE PRIOR TO COMPLETION OF CAUSE Natural OF DEATH? Accident 0 Yes D No ~ Suicide D DUE TO (OR AS A CONseQUENCE OF): Homicide Pending Investigatior. Coukt not be determined D D D DAT~ OF INJURY (Month, Day. YlIsr) Ave. 26. : Approximate : interval between . onset and death PART U: Other significant conditions contributing to death. but not resuhing In the underlying cause given in PART I. TIME OF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED. 30.. 3Ob. M. PLACE OF IN.tURY - At home, farm, street. factory. office buIIdIng,ete. (Specify) 30e. Yo. D No D 3Oc. Yes 0 No 29. 280. 28b. CERTIFIER (Check only one) .~~~']t~:IGJ~~~~~3~~:~ ~~~u~ t~ g:~.::~(:~3r.g~x~~a~.h:~~?~.~.~~!~.~~.~.~.~~!~.I~~.~~).................. *pro~~:~'~r~N~;;,~s::~:.~~~~:=~: l~~~iu~n.~~.r~~~~~~.~th d~n: ~:ut~.c;(~):~~ ~:~~.r as stated.... ........ ..... ..... 0 'MEDICAL EXAMINER/CORONER On the bula of .xamlnatlon and/or Inve.tlgation, In my opinion, death occurred at the tIme, date, and place, and due to the causes(s) and manner a. .tat.d.... ...... .............. ...... ....... ........... ...................... ...... ............ ......... ..... ........ ......... ...... ............ ................... 0 318. . R GI R'S SI$N~~BER /1: 7~,:.." b.:1/ ~I/ Y' I 33. lie 'f Ol) cJr