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" " I,:' /: .\ , "I' .' :i~: '", , , ," \', ,,'t' " ; '.."" , ," " ',Il "., .. , " ,'I"~ f"" " 0\ . :"<""" >I"r;',..!.,' ': ,;, 'I' "~Ii :1, ,~ ' \. r,', " f" /, PETITION J<'<)R IJROIJATE and GRANT ()Ii' LETTERS 1::\'11111' of 'lh'/.'J( (,' Jd r!~J.( ~~":~.' r t,' No, .....c21::h_1ft.-::.....r:o'3.!;:Xl.-._ 111,111 kl/oll'l/ f/J ." ..' ..,.._..__..._~_h_.. To: _........., .m'"'''''' Rcgisler of Wills for lhe ..'_"h"'_""" _ h' /)1!('('II,\('d, County of ..,JUMBERLilliL. in Ihc 80dlll 81'('lIrlIY No, . ,"2,.[1 /:h..J..;J.~ :..!d.0.<:J.:... COllll11onwcllhh of I'cnnsylvllnlll Thc pelltloll of lhe undersigncd rl!Speclfully rcprescnts Ihlll: YOllr pL'lltloncr(s), whols/mc IN YCllrs of l~l!.c or older ,llnlhc cxcelll_,'J.~p_._. Ir,lhc IlIsl will of lhe IIho\'e dCCl'dcnl, dlUL'd ._.7.!,...Ll.!~"....(j:..YJl__.. IInd codleil(s) dlllL'd _.._.,... .h___..U__.....__u_...____...____ .__.... IIl1l11ed . 19_ ___....._u____......__._.~._.__.. _________.___._._._.._...._..__.______~__________._. (\lllIl' Il'll'\'lIllll'ir\'lllmllllll'l''I, ~',ll, r~'IlIl11dlllltln, dl'lllh Ill' 1,.''(Cl'lIlnr, 1.'11.',) Ilccclldenl WIIS dOlllidlcd III dCllth 11I..C'L-':"J<\.,':..u..L',(: ,~.J.~: .(1- . C(JlIIUY, 1'~_n!ls~lvl\JlIII))y,lth h...L:",..._ IlIsIIIIllllI>' or l,rindpIII resldcnce III _,1.(L':L~:..:JLc ___.1 III ~ /1.1 ( ,:/..1L I ' (Ii'll \trccl, 1I1111111cr lIlId IlHll1dp"IlI)') IlcS~lIdenl, IhcnJu.YI.,,.. yellrs of IIge, diCd7..4/ r"I'~~').2,,_.____, 19....1L., 1II ,2J.,~,+-_..>fJ..~u.[_. ..C.~_D "f:::jid:r..L...:.L~.-.-- . , Execpl n'(follows, dceedL'lIt did nOlmnrr>, wns not divorecd IInd did nOI hllvc II child horn or ndopted nfter cxcdlllon of the will offered for prohnlc; \\'IIS not the vlellmof 1\ killing IInd WIIS ncver IIdJudlellled ineompctent: ___.._.....~......___.__._ ___...___.... [)ceendcnl III dcnlh owned propcrty with cSlimlllcd vlllucs ns follows: (If domiciled In I'll,) All pcrsonlll property (If not domlcllcd In I'll.) I'ersolllll propCrlY In I'ennsyl\'nnill (If not domiciled In I'n.) I'crsonnl propcrlY In Counly Vnluc of rCIII cstllle In l'ennsylvl'lIln sitllntcd ns follows: _._.____..._...._.__. $.Ja C' c', " () $ $---- $------- _ WHEREFORE, pClilloner(s) rc~pcclfully re\LllPj\(i\~~~~J1InhnIC of Ihe IIISI will IInd eodlcll(s) prcscnlL'd hcrcwith IInd lhc grallt ollcllcrs_... I t~ II ilK Y . (IC'illllllcnIlHY;lUllIIlnl'ilrlllloll C,I.II.; lldl1llnislrllllnn d,h.I\.\",1,II,) lheron, 7- 11 6 'tl_ 'B~ '" 0 C "O,g ~. 'ii~ lt~ ~ 0 g, Iii , .')", "''',.It _,.1 'J?I ,')1.[ :~~1J~~.e~~:=--=-LtI~ ~--- ,) ^ '/,{ J' O( .. ,/. ,j. ,. .J Lt:...L'4_c1.f:!~{ ..C tt-'I\"Q,/Vd('~ ~,Ir,' .. .._-.-_._--------~.._------_..---.. ....-- - ---------- .----- - ____..._0______________.___._____ .~._ ... .._.___ OATH 01.' IJERSONAL REPRESENTATIVE COMMONWEAI.TII OJ! I'ENNS\'LV ANIA }- ~s COUNTY O...____.~UMBERhAN~__.__.__. .. Thc pelilloner(s) lIho\'c.nnllled swcar(s) or !,ffirm(s) thlltlhe sllllelllcnlsllllhe foregoh1ll pel it Ion nrc trllC nnd cOlrccltolhL' hcsl of Ihe knowledgc nnd hcllcf of pelilloncr(s) nlld Ihlll1\S pcrsonnl rcprcsen. 11I11\'e(,I) of IhL' nho\'L' dCL'edcnl pClllloner(s) will wellllnd trllly IIdminislcr the esllUC neeordlng loinII'. SIWIII III '~I nl:rilmcd ~lId snhselihcd ~ ~~,.-4-""f.t I L(~,..~,:__ql:G.L~~ ~ hci III L' lIle Ihls t./f'l..'/1 daya __ -,. --. --, .......-' "._u_,..... ~ .717f/."ie:t~,u~,oflc.'~tJif!.r .7.1!J;IJ,i : _, .:h_::-._h:-:~~ ~ M~RY It. LEWI S 1I('g;I/I'1 (; (I -... - - -- ~ ! , I, Ill05112mv ~'llll (Fl'[ fOn IIIIS Cr.nlllIC/III: IlWI WM1NINc;: II I', ILII(;I\I II' 1\1 (';1 !(II:; I III'\' "II Tn UIIPIIL,l\11. Ill' 1'11()dl~i'fj\1 ili( f'11()jl)(tll,l\jIIL COMMONW[AlTll or PI:fINDYlVM41A DEPAntMENT or HI'AI.TiI VHAI.Ilf,COflDO LOCAL REGISTflAR'S CERTIFICATION OF DEATH CERT. NO. 2025729 / '! ~ll~Z,l~. .u.... ~'J' ~.(ll,(I'lr't,Cllrllh"!'dll I I N.m. 'l'l>"""' -. _Ck1<0,~;'t:;. (} /Yrt4~L- _ _~~___~ ________~_ (), ( ,,,,' 0 ~'" t tfJ. "" Sex tI..vf.!l~_.Soclal Socurlty No' .16 ,~). - a )~, .Dato 01 Doath .../L. "J.L.:. ,Zs. .__ Date of Blrth'].::jJ..jfl_~ ....... Blrthplaco. . rJ::!:!'t'~ c.~), ,R. .. .....;'.._______.__._ Placo of De/lth A /_p ')1.J~,~UYl/,... t.. ......t~'-R(VV~<l;.C1-1"d?jM__..--..u...l"jJD.Jl.~YJ~gD!!!. 1. D ~,~,;-= ~,..,'r' ""', ('1""""'''''''"'''''''> Race__.~ldi....occupatlon ~'-~~><"4.jz..,A..~'. Armod rorC05? (Y05 or NO)~t.(Jn._...___ lJ 'n Docodont'5 17' '1.. / ~J 1 I ~.. j.? /'Z Marital Status ....-L.cX.QU<..., Mail.lng Addros;l tJ .. 5.. J Iv CM''1f}Ic.fvtf.. ..<1,.L. ,P..!I._..__ (1.. A .. "'''''''. t" ,11/. '~'''';;; ';"", ~l~~~:~~~~T~/nf~I1'V. . .. Fl0W:Orill DllfJC,t.OI . r(.j'~~'~'1,~,~.I;~J:'hno~J~(?:'-'-- Funeral Establishment "\X.a.:vt.;..,J 11D:1'/I..c.>'1 . 'J..f, Ii fl. "(~~<' .11 ~1 .. '''y"vr4.c..L.....it'C' ___ I : Illlerval Betwoon Part I: Immodlato Cau50 : Onnet and Death IJ.k. -}:. /" --r '(j,' , / (~J~(k~t;:D!..{'14~ (.&i"'I& ...Jr?~I1.i... .ud--.~f""-"--- (b)0.U.lW,I.k.""~l,j!t&~..l-f.tJ..t"lch-"].'"tl.a-~Cl.'lI'c'.'."~~"'i_'~~'L""",,'_. (c)........_.___.. .__....__............, '. .. .... . .... . ... .... ...... ......u..: ..........._______._....._ , , I -..--.,....__ .._~._u_____I____..____._._~_._,._.._ (d). --.-__.._.__._.__...u...... Part II: Othor Significant Conditions -.____~______h_n.__"__~___~..__..____ ... ..___,______~.__ -- '---...-..,~_,__... __.....__._____n________________ Manner of Doath: Natural IX Accident 0 Suicide lJ Doscrlbo how Injury occurrod: Homicide Pending Invostigatlon Could not bo Dotormlnod [] o n - -----..-~---~.-..-- ...~._....._..- --....-.--.--____.____u_____ .-----.__... _n.__ -__.,~_.'____nd____ __O__._.'.____.._n__._.____ __. ....____ Namo and ~f Corllflorji#~'\,:?:::'L~jL.~d~v.....u...-.-..--........ Addross -d!-B,-.1.r..Z&"!-pu.-: . I ~i, I] ffi!; ... 'P' . .nn'.p ... ..._.....~u.. _'m....... ___ ~ D.O., Coron(jr~"M,E~) This Is to certify that tho Information horo [llvon 15 corrocliy coploel from un ori9inal corlillcato of doath duly fllad with mo as Local Rogi5lrar, Tho mlnlnnl cortiflcato will bo forwardod to tho Stato Vital Rocords Offlco for pormanont 111111(1, ~ Il I ';71 .1\'4,LJu/ 5-/.',3./). .l~,~LZ.~.p.. ,d :> 't~,'s[:'fiI7"'UI'~L ,&)f??/c'p ,,,,,,,. ,,,,",,,., ,,, """"'"'''' 'I)",,,,, f'"'''''' """""1' '. :,3 F; ~g 1"0. I o U 1'1 \,)' ,'-- 12 1-1 . (.>tJ. r,./ l~/ REV.1500 INHERITANCE TAX RETURN RESIDENT DECEDENT M'I I!OOEX' (1 III j~t. COMMOllW~SVLVANIA OEPARTMENT OF REVENUE OEPT 2eooJI IMRRI B R PA 1712 1 OECEOEljl'SN,A,ME (lAST. FIRST. ,AND ~IIOOIE INIl!All u\e. ~w bb:1.1) ~M* ~~I rJ k ,', I,' ;','> FU NIIIl8ER f/ 0.3 '~9' . socw. &CCUHI1'i NW6~R V) ell II ~&.~/)E~J T.E" (] OA1~OFOE lit o,mOf IJjRHt / I T IS RETURN MUST Bf FILED IN DUPLICATE WITH THE REGISTER OF WILLS 1. Original Rolum 02 SupplomontalRetum 0 3 RornalnderRelumtiUlo~d...,,,,,,.Il.Il!71 o 4, limited E,tate 0 4a Fulure Intor,,1 Compromise Id"~""'''' 17-17871 0 5. Federal E,tate Tftx Relum Required o 6. Decedenl Died TeslatOlAtt.>:h"Of,'W'1 0 /, DCcedenlMalntallled a L"ing Tru't (AlIa:hC'" 011""1 _ 8. Total Numoor01 Sele Depo'it Boxe, o 9 Litigation ProceOO, Roceived 010. Spousal Poverty CrOOil(d"~""'''''''o 12,3'.1'... ',',111 0 II, Election to tax under See, 9113(A) (,lJl."So;hOI THIS SECTION MUST BE COMPLETED, ALL CORRElIPONDENOE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAJ,tE CQ6.IPlEJEM.AJlINOA.OORESS tJ~ - 7' I-{!J/(,~ / c,rlJ, 36~,..u: ~1y1.J,~9Q, 17e)// (II (2) (3) (4) (5) (61 (71 (8) . () t" (9) (10) (11) (12) (13) . () t' 12 Hit Value 01 Elt.lle (Line 8 minus line II) 13, Charitable and Govemm,ntal Beque'tslSec 9113 Trus~ lor which en election 10 Ia.I ha, oot beeo made (Schedule JI 14. Nel Velue Subjtcllo Tax (Line 12 minus Line 131 15, Aroounl ollin, 14 talable al ~"pou,"1 tax rele I I See In,truction, on reverse ,Ide lor eppl<able per~nlage 16. Aroounl 01 line 14 talabl, al6%rale 17, Amount ollioo 14 taxabl, all5%"te () ~ ~I~ I. Real E'tal' ISchedule A) 2, Stocks and Bonds (Schedule BI 3. Ciose~ Hold Corporation,Partnership or Sole,Propileto~hip z o 5 E ~ ~ 4. Mortgages & Notes Receivable ISchadul. 0) 5. Cash, Bank Depo'i~ & Miscellaneou~ Personal Proi'lrty (SchOOule E) 6. JoloUy o..ned Property (Schedule F) 7, Inler,Vivos Trenslors & Miscellaneous Noo,Prob<llo Property ISchOOule G or L) 6. Tolll GrOll Amls (total Unes \.7) 9, Funeral Expense, & Admlnl'trative Cos~ ISchOOu~ HI (14) Ot! 10, Deb~ 01 Decedent, Mortgage LlabillUas, & Lien, ISrJ1edu~ I) II, Tot.ll Oeductlool(lotal Lines 9 & 10) 16 Tax Due 19 , x ,0 (15) x ,06 116) (17) (16) .~ (F x 15 > > BE SURE TO ANSWF.R ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < U~I penalt~' ofpo.WIY, I declare that I have e~amined 11'115 lelllrn. including occompany,ng $Ch<<1u~' and slalemen15, and 10 the besl of my kr'oOYlloOge and belief, ilis lNe. COffee! and complele Declarllbon of pl'epilill/ ottlet ltlan!t\eDeI~alfe[)fe'entallvei$basedooalllnformilbOOof""hichoreD,ye'~a'lMVln(htledae SIGNATURE Of PERSON RESPONSIBLE FOR fiLING RETURN ADDRESS DATE / ?vf~/j'/\/ /07~ J{;"tf,..!.r UAU .4;Vtg/~ . .?/~.vp- SIG ATURE OF PR ARER OTHER THAN REPRESENTATIVE ADDRESS 'r . . Om- Decedent's Complete Address: ~Tl ^(l[)RiS:;-------~--.-------. . ell) .......h.______._......_...._......_~---. -.----.. -~.- , - EO-.--' .-----I/IP--- - ----- .~--- 'fax Payments and Credits: 1 Tax Duo {Page Il1no lAI 2 CfI!dlWP,lYIlll'nls A. Spolls" Pavony Cre.dll ,___._______ 8, PfI(>! Paym'JOIs G Diswunl (II Tolal Crodits (A . B . C) (2) 3 InlArosWenally if appllcablo D, tnlorASI E, PenallY . ' '. " . ,. t ~~ ' '\ . ,1\' . . . " TOlallnleresVPonalty (D' E) (3) 4, II110e 21s grealer Ihan line 1 . line 3, enler Ihe difference This Is Ihe OVERPAYMENT, Check box on Pege1 Llne1S to (eqUllt e refund (41 5. II line 1 .lino 31s greater Iban line 2, enler Ih~ difference ThiS Is Ihe TAX DUE, (51 A, EnlAr Ihe Inlerest on Iho lax cue. (5A) 9. EnlAr Ihe lOlal of line 5. 5A Th's is the BALANCE DUE, (591 Make Check Pay~b/e..IE.:REGISTER OF WILLS, AGeNT ~~ . '-1 .~__-.m~""'t:Illlll._1II PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1, Old decedent make a trensfer and: Yee No e, retAin the use or Income of the property Iransferred:""",,,,,,,,,,,,, '" 0 0 b, retAin the right to designAte who shall use the property Iransferred pr ils Income: ""'"'''''''' [J 0 c, retnln a reversionary Inlerest: or..",,,,,,,,,,,,,, "........",,,,,,.. """"""..,.." ""'"'''''''''''''''''''''''' 0 0 d, receive the promise for life of either payments, benefils or care? ..,..,,,,,,,,,,,,,,,,,,,,,,,,,,, "",0 0 2, If death occurmd on ClI hefore December 12,1982, did decedenl within two years preceding deAth transfer property without receiving adequale consideration? If death occurred after December 12, 19R2, did decedent transfer property within one year of death WlthOlil receiving adequate consideration?.... ....""""..""..""""".."".. "........""".."""""..""""""", 0 0 3, Old decedftnt own An "in trust for" or payable llpon death bank account or security at his or her deAth? . .....,......,........"" ......,,,..,,,,,,, "" 0 0 4, Old decodent own An Individual retirement account, annuity, or olher non.probate property?.... 0 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 "'-~lAit;I~~~iI..,i1~lH~~:,N(~:;.lif~p~~wtl~~'l_!Nl!:1~ 72 P.8, ~9116 (a) (1,1) (i) provided for the reduction oflhe tax rale Imposed on the net value of Iransfers to or for the use ofthe surviving spouse from 6% to 3% for dates of death on or after July 1, 1994 and beforo January 1, 1995, 72 P,S, ~P116 (a) (1,1) (Ii) provided for Ihe reduction oflhft rate Imposed on Ihe net value oflransfers to or for the use of the surviving spouse from 3% 100% for dates of death on or after January t, 1995, The statute does.D.QWempt a transfer 10 a surviving spouse from tax, and the stalulory requirements for disclosure of assels aocl filing a lax return are stili applicable even If Ihe surviving spouse Is the only beneficiary. FOR DATES OF DEATH ON OR AFTER JANUARY 1, 1995. Please answer the following quesllon by placing an "x" In the appropriate space, Old the decedent create a trust or similar arrangemont which Is Bolely for the surviVing spouse's benefit for his or her entire lifetime? Yes [J No [] If you answered yes to tlie above quesllon, Ihe lax on tha Irust or similar arrangement is postponed untIl the dealh of the second spouse, at which lima it will be fully taxable at the raters) applicable 10 the remainder boneficiery(les), Enter Ihe value of the trust on Schedule J, Part II, in order to romove it from the calculallon of the lax due in Ihis eslale. You may wish to file Schedule 0 In order 10 make the elecllon available under Secllon 9113. If the election Is made, the trust or similar arrangement is taxed In Ihe estate of Iha first decedant spouse, tha ponlon of the Inlst or slmilnr mrnngement which banafits the surviving spouse is laxed at the zero tax rata, and the ramalnder Is taxed at the mte(s) applicable 10 tbe remainder beneficiary(lea), If you choose \0 make tlla election, you muet attach Schedule 010 a timely.filed lax relurn, along wilh Schedule(s) K and/or M in ordor to show Ihe apportionment of the trust or similar arrangemenl belween Ihe SlIlVlvin\] spollse and Ihe rormlndor ben"lIciary(ies). ... .,I, ~ UY.UIIIX"17,1I1 ,,~:'~:9~ ."" fflur COMMONWfAlHl Of PENN~YlVANIA INHEIUTANCt TAlC NfYUNN RISIDINl DECED~N' UTATI O' J SCHIDULE H FUNERAL EXPENSES, ADMINISTRATIVE COSTS AND MISCELLANEOUS eXPENSES - - -. PI.al. P"lnt or Tvp. _ jUMllR ITEM NUMBER A. Funeral Ixp.nl'" 1. / B. 1. 2. 3. DESCRIPTION jJ.,Vt~ -~ -~ ~~ 11 t9 ?1't..e.- "'--?~... -'&;7~~k kt/c~-tlb.O~ j ..,\ .. ~~'~0 Admlnlltratlve COI'I' Personal Represontatlve Commllllons Social Security Numbor of Porsonal RepreJentatlve, Vear Commllllans paid, Attorney Fees Family Exemptlan Claimant Addrell of Claimant at decedent/, death Street Addrell Relatla~,hlp , State. Zip Code City 4. Probate Fees C. ' Mllc.llan,oul Ixp.n"I' 1, 2. 3, 4. S, 6, 7, 8, , ' AMOUNT I/. 1 ~ J., !7 ) (If mort Ipac. II n"d.d, Inl.r1 additional Ih"h of lam. 11".1 TOTAL IAlso enter on line 9, Recapitulatlonl $ I-Ii /() ~I r i> ,