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WARNING: IT IS IllEGAL TO ALTER THIS COpy OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH VITAL RECORDS
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
CERT. NO. 2120658
J2..wM~J I, / r9V
~-'":'"O'IQOI' lIF1QITfI'IIClIr\lhutlon
'7AChfttS. J?J. /rJ=C~
HI~1 , Mldl1lll . Las!
Sex /?1 SociaISecurityNo..2-0~ -/0' P'~9'f' Date of Death /-2-Y'-7'f/'
Dale 01 Birth /4 'r~ 1-.-2.3 Birthplace 4:4:/6~t2; all;::.0
Place 01 Death ,16~~.4a?7#;/ ~aJt.bwc..A,<Jd -
. 1"~Clltl~N'1TNI ~ County
Rece t(:/ADrn: .Occupation ~:;vt-4c.-. Armed Forces? (Yes or No)
. 1 / Dec~ /J.../ ()
Marilal Status U/.&~,.,.-~ Mailing Address /~ d /VflH,.,.dJ)~L,
Number Sll&ul .
Inlormant ~~ / ~kL'" Funeral Director ~d~~
Name and Address 01 J) . /'
Funeral Establishment YiA/~.z\ ~~ .20(.,
Name 01 Decedent
a /7cJLJ .,;
Still!
Part I: Immediate Cause
(a) ~A.drAc.. 4~
" (b) Co P.lJ
.
(c)
(d)
Part II: Other Significant Conditions
Manner 01 Death:
Natural .Jit
Accident 0
Suicide 0
Homicide
Pending Investigation
Could not be Determined
Describe how injury occurred:
o
o
o
Name and Title of Certifier /7;j-~~"""~J
.
Address./,f"'?(j (;,od+ /~~ .c:Ao!~.4,J!'fl /7cJ2-J-
(M.D.:E:2,.. Coroner. M.E.)
This is to certify that the information hero given is correctly copied from an original certificate of
death duly filed with me as Local Registrar. The iginal ccrllticatc wiil be forwarded to the State
Vital Records Office for permanent filing. J LA
""~'{~""""~~ L."f.,=:LJ1-
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1M3
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'OR DATIl O'D AfTlR 12/31/91 CHICKHIRI
" A IPOUIAL. .
POVIRTT CRIDIT II CLAIMID 0 .
'Ill NUMBlR (' q
1'1- /'tCJ.C),
INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
NUMBER
,. .
. ,
-,,!iJ.l500 EX. {11.qlj
1. Real E.tate (Schedule AI \ ( I)
2. Stack. and Bond. (Schedule B) \ ( 2)
3. Clo.ely Held Stock/Partnership Inle".1 (Schedule q (31
4. Mortgage. and Nole. Receivoble (Schedulo D) ( 4)
5. Cash, Bank Deposits & Miscellaneous Perlonal Property( 5)
(Schedule E)
6. Joinlly Owned Property (Schedule FI
7. Tronsfe" (Schedule G) (Schedule l)
8. Total Gran Anets (Ictallin,s 1.7)
9. Funeral Expenslts, Administrative COSh, Miscellaneous (9) -<!&5A. cO
Expen... (Schedule H)
10. Debt., Mortgoge liobililie., lieno(Sch,dulel)
11. T 0101 Deductions (Iotalline. 9 & 101
12. Net Value of Estale (line 8 minus line 111
13. Charitable and Governmental BequOlI' {Schedule JI
14. Net Value Subioct 10 Tax (lino 12 minuoline 131
15. Amoun. of lin. 14 taxable 01 6%rol.
(Indudo valu../rom Schodulo K or Schedule M.I
16. Amount of line 14 taxable at 15% ral.
(Indudo valu.. from Schedule K or Schedule M.I
17. Principol tax duo (Add tax from line 15 and from line 16.1
1 B. Credits Spoutal Poverty Credit Prior Poymenh
+--+
19. If lin. 18 is greater than lin. 17, .nt.r th, differ'"CI on lin. 19. This is the OVERPAYMENT.
aD
20. If lin. 17 il gr.ater than lin. 18, .nt.r the diH.r.nc:. on lin. 20. This i. the TAX DUE.
A. Ent.r the Int.r..t on the balance due on line 20A.
B. Entor tho total ollino 20 ond 2DA on line 2DB. Thi. I, tho BALANCE DUE.
Make CIlock Payablo '0' Rogl,'er 01 Will., Agont
.. II sun TO ANSWER ALL QUunONS ON IMISE SIDE AND TO IECHECIC MATH.... . "";l .
Under penalti,. of perjury, I declare that I huv. .aamined this "'urn, iN:tuding accomponying Kh.dul.. and Ita'.ments, and to the btli1 of my bowl.dg. and betief,
it b tru., torr'd and co"'plt'" t dK'lar. tha, 011 r.ol..tOI~ has betn r'part.d ot true morhl volue. D.darotion of pr.pore1' oth.r thon the ptMftOl repr...ntotivI J,
bo..d On olllnforlftotion of whidl p~por.r halon)' howledg..
"~GN" II Of~P(lOON Il:~U'PONSII~f fOR fltlNG '(TURN AOD'~(~~~ /~, fJ' DA~'f A j {/~
~'t1. '4f):,U' . L~.i{1'L'11 (,;J"ltI p.-1 17(").''- ()(I
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COMMONWEAlTH Of PENNSYlVANIA
DEPARTMENT OF REVENUE
DEPT,2110601
HARRISBURG. PA 11128.0601
AM
,
I YEAR 9"(
COUNTY CODE
NT'S COMPlETE ADDRESS
'wO A-;h/~'I'-d Dt'lve.
Ff'lDlL, R'l1Itsylv'ClI1fQ.
MI
I All
1-11/1
.IA
li10>>1
URI YN M
170;;:l')-
26ft,
108 ~q
"E1' 1. Original Return
o 4. limi'ed E.lale
Count
o 2. Supple~ontal Relurn
o 40. Future 1~ler'll Compromise
(far dOl.. of deolh oker 12.12.B21
o 6. Decedenl Died Te"ele 0 7. Dec.dent M'Ointoinea' a living Trult
(Attach copy of Willi ,(Attoch copy 01 J rUlt)
AU. COUESPONDENCIAND CONPIDEN AL TAX INFORMATION SHOULD BE DIRECTED .TO.
AM I OMP f MAILING ADDRESS
qr;. dLl~t1
'Enla... VA
03. Remainder Return
(lor dote. of doath priarto 12.13.B21
o 5. Foderal E.tale Tox
R,'urn Required
_ g. Totol Number of Sofo Depo.i' Box..
" ';, ~':'; ~,t.:; ,"/;>:(<;'i~'~io'~,';~::;i,:,;).:ij~:~~@t, j
S7
)70',}.O-
z
o
S
E
a.
~
..
I CJ(X). (")(")
,
( 6)
( 7)
( BJ -1, CJC.CJ, 00
(10)
(11)
(121
(13)
(141
1(pPiA.O(')
-~("f3P,. 00
(l51--=...3~A 8 00
x .06 =
- 3{"FlR. 00
- :~~(. ~R
(16)
x .15 =
(17)
- :l~<I>, ;) lJ
Diltounl
Interes'
CheCk here if you {.lIe l('quc~I."9 a refund of you, overpoyme.,t.
(IB) 0
(191~~/.
~",
(20) r)
(2DAI --!J
(2DB)
'.. !
'1 .
: t'"
99. eJu.LM1 ~ .,--'
~"I PA /70::l{)
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"h
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G.;m&.u'iLl1d &111';/- (kJha-tw.R.J
Ca.~t.;, hi 170P3
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REVo1547 EX AFP (08094*
CO""ONWEAL TH OF PENNSVLVANIA
DEPARTM:HT OF REVENUE
BUREAU Of' INDIVIDUAL TAXES
DEPT. 2110&01
HARRISBURO, PA 17121.0601
NOTICE DF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEOUCTIONS AND ASSESSHENT OF TAX
ACN 101
DATE 01-24-95
FILE NO.
01-29-94 COUNTY CUMBERLAND
TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBHIT THE UPPER PORTION OF THIS FDRH WITH YOUR TAX
PAYHENT TO THE REGISTER OF WILLS. HAKE CHECK PAYABLE TO "REGISTER OF WILLS, AGENT"
REMIT PAYMENT TO:
PAMELA KILGORE
92 QUEEN ST
ENOLA PA 17025
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
L
Allount R...l Uld
CUT ALONG.7MIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV: iS4-j-EX""Fji-ioil"'.:94Y-iioTicE"-oF-YNHEiiifANcE"TAx-jipjiiiA'isE;.iE'iii'-,--"i.i."owANCnili"--m------- ---"
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF HILL THOMAS M FILE NO. 21 94-0119 ACN 101 DATE 01-2(,-95
TAX RETURN WAS I I X I ACCEPTED AS FILED
I I CHANGED
RESERVATION CONCERNING FUTURE INTEREST " SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: DRIGINAL
1. Rool E.tolo ISchodulo Al III
2. Stack. ond Band. ISchodulo BI 121
3. Clo..1~ H.ld stock/Partnership Int.r.at (Schedull C) (3)
4. "ort,lg.a/Hot.. Reclivable (Schedull DJ (4)
S. C..h/Bank D.po.lta/Hllc. Parsone1 Propert, rSchedull E) 15)
6. Jointly Own.d PrDperty (Schedule fJ (6)
7. Tron.for. ISchodulo GI 171
a. Total Alllt.
.00
.00
.00
.00
l.000.00
.00
.00
IBI
1,000.00
APPROVED DEDUCTIONS AND EXEMPTIOKS:
9. Funeral E.pen.../A~. Coltl/Hi.c. Expens.. (Schedull HJ (9)
10. Debts/Hortgoso LiobUiU../Llon. ISchodulo II 110)
11. Totol O.duction.
12. N.t Value of reM R.turn
13. Chorltoblo/Go.ornMOntol Boquo.t. ISchodulo JI
14. Not V.luo of E.t.to Subject to To.
4,688.00
.00
1111
1121
1131
1141
4.IlAR nn
3.6B8.00-
.00
3,688.00-
NOTE:
If an ........nt we. i..u.d previously, line. 14, 15 and'or 16, 17 and 18 will
rBfl.ct figure. th.t include the total of ALL returns ass.s..d to dat..
ASSESSMENT OF TAX I
15. Aoount of L~ 14 ot ~.ol rota 1151
1'. A~t of LLfta 14 ~~lo ot Lin.ol/Clo.. A roto 11'1
17. ~ of LIRa 14 ~~lo ot Callotorol/Clo.. I roto 1171
11. Pr~Ns1p'1 T& Duo ~~ /3
TAX CREDITS.J \D
'AvttE~i{ 0'
DATE c; ";;.
o t..~
uw
"'0:
0:
. DO X . DO.
.00 X .06.
.00 x.15.
I1BI
.00
.00
.00
.00
RECUPT,
2 NUll8E1._
DISCOUNT l+ 1
INYElEST 1'1
AHllUNT PUD
~
"
':'E
08
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST
TOTAL DUE
.00
.00
.00
.00
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCUl.ATION..M' ADDITIONAL ImREST.
S-Sf..-( V
IF TOTAL DUE IS LESS THAN $1, NO PAYftENT IS REOUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI, YOU I!AY IE DUE
A REFUND. SEE REVERSE SIDE OF TNIS FO~ FOR INSTRUCTIONS.!
i . ___..~ t.;;~li":':ll' '...
I ......-. .
I
JRD/June 30, 1992/17858
REGISTER OF WILLS
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
NOTICE PURSUANT TO RULE 6.12
PENNSYLVANIA SUPREME COURT ORPHANS' COURT RULES
To: Personal Representative
Counsel:
PAMELA HILL KILGORE
RE: Estate or THOMA$ MARTIN HILL
, Deceased, Lale or
Fa~T PFNN~RnRn TWP
Estate No.: 21-1994 -119
Date or Dec:edent's Dealh: JANUARY 24, 1994
Pursuant to Rule 6.12, the above named personal representative or the above named attorney, if
applicable, within two (2) years of the decedent's death, and annually thereafter until administration is
completed, is required to file with the Register of Wills a Status Report as required by Rule 6~ 12, in
substantially the prescribed form, showing the date by which the personal representative, or attorney, as
aPplicable, reasonably believes administration will be completed. loe purpose of this Notice is to advise
You that uoless the requisite Status Report is moo with the Register of Wills or Clerk of the Orphans'
Court, as appropriate, within ten (10) calendar days after the date of this Notice that the Register of Wills
is required to notify the Orphans' Court Division, Court of Common Pleas of such delinquency and to
request that said Court conduct a hearing to determine whether sanctions should be imposed upon the
delinquent personal representative and the delinquent personal representative's counsel, if any.
Accordingly, if the requisite Status Report is not filed by FEBRUARY 29 , 19 ~,6you are herdly
advised that a request will be submitted to the Court in accordlllCe with Rule 6.12.
Date: FEBRUARY 15, 1996'1) 'Ct 1.1 (,'~:- .1:l/j,..L<L..-
D ty egister of Wills
Distribution to Estate File