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GOMMONWEALTH OF PENNSYLVANIA' OEPARTMENT OF NEALTH . VITAL RECOROS
CERTIFICATE OF DEATH
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
851
LEE R., BURGETT
bolng duly. . 9.\'!.'lTIL .,
,,_.,,_.. .-.~. .-----~ ----.----.,.-...-.--'..- ..-....
,_ according 10 law, deposel and says Ihat ho".is..the ..Exec.uto.r,,,' uu_ ,_uu
. . 01 the Estale of ......~INA._hJl.9!lKJJlL_._____u.,____.._u
lato 01, Souch Ni.ddlecon Township, _, Cumberland Counly, Pa" deceuod and that the
within II an inyenlory made by , LEE R. BURGETT__". ""_' tho said __~~e_c:..~tor,__..__
01 tho entire eslal. 01 laid decedenl, conslsllng 01 all Ihe personal prop.rty and real eltate, except real ollote outside
Ihe Cemmonwealth 01 Pennlylvanla, and Ihal Iho ligures opposlle each Item 01 tho Inventory repro sent It's lair value
as 01 the date 01 docedont's death,
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19 ,9_~_
,- t..~J?.'..a(~u~;'~i"r.'Ui -CEER ;"-ifuifG-ETT
Sworn
and ,ubscribod belnre me,
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814 Onkville Road
Not,1J1al8eaJ
. 8,IM1n.I'IotilryPl.tj:;
C ;~e Boro, CurrtxJf\nj Co.<<1!y
My CommisOOn E.'pren Ctt 3. 1900
tvllJrr,b:,H, )annsy:Yania f' nUon 0 klllulOs
Newville. PA 17241
Add,,"
Date 01 Death ,.__
...Q:1...
DIY
.__ _......06. '"
Month
"._u_,_, ___.9..4._..._..______.__.._,_
Vur
INSTRUCTIONS
I, An Inventory must be IlIed within three months alter appointment 01 personal reprosentatlve,
2. A supploment Inventory must be IlIed within thlrly days 01 dlscovory 01 additional aSlots,
3. Additional sheels may be attached as to personalty or realty
4. 500 Article IV, Fiduciaries Act 011949,
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Inventory of the real and personal estate of
EBB" J. nOOKINS
____ deoeased
1. 1993 PA Incomo Tax Refund............".,."",.,...,....".,....",.'.""I'~'
241 28
2. Farm~rs Trust - all accounts in dpcodent's nama alono
Chocking account 11-52106 openod 08-06-92. Date of Death balance
24,930.26 plus 4.22 accrued intcroBt.~.. 1'111" 11'111 It I "'f' I It' I' f..,.t I It.
CO #77627 opened 08-22-88. Patoof Death value 10.784.38
Interest from Ol-Ol~94 to 06-03-94 (213.65)""""""".,t""""""i...
24.934 48
10,784 38
CP #100954 oponed 08-06-92. Pate of Poath value 12,400.00
Interest oarned from 01-01-94 to 06-03-94 (29.49)...... ...............,....
12,429 49
3. Capital Blue Cross & Blue Slliold premium rofllnd.. l'III.I..I~t....II..'.f.'.1
186 40
4. Penn Trenty Life Insurance Co. Policy 203621 ~ unused premium.,...,.........
53 34
5. Personal Property - coins nod jewelrY'lt' III.'" 11""'f"I"";"'I"f'f~"1
TV anel Hisccl111nco\ls, , I t I . I I I . I I . , I t.' . It. . . . , , . , I I I , I , , .
99 92
160 00
6. Adams Electric Co-Op Inc. Pntr,onage Cnpi~111tt q tt. 1'1 tI ~",., I'" H H.......
488 08
7, United Telephone Co - credit"".",,,.,.. '''' ,','... II I" "" 1'""""."""'"
7 95
8. Leaders Nursing Home - 2,079.84; 54.83. I" ,....", ".., "...".., ,.j"~,, ""
234 67
49,619 99
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
COMMONW'''''' 01 PitH/III v.",, (TO BE FILED IN DUPLICATE
OIPAR1M[1H or RI'IINUI I )
Hm'lfJnWI"i:180601 WITH REGISTER OF W LLS " COUNTY_COP!,"" .___.YEAR___..
,.. '-fu;mf""NAMilLtlcfii\t'AND M,~ii\nfiffiAil~==cC,," ClOfNticoM'ITTfADfimr---'
LEAIJEK NtlKSING IIOME
BOIlK I NS. EMMA .J. 940 W 1 t II l t Ron I
ro~i"-SICO;if'NUMi(i'----mn nnlO'A110fPfAIH-"nnIOAirOfiiRtH--- CuI f~I:" p/ 17~~\ (
179-12-4681 06-0]-94 06-21-1920 c:. Cl1m~"rJ~p~
_ ____nnn._'...____ ___,,____'_"'m_.u_____nn__.unn _1...__"...._
[]i 1. Original Rolvrn 0 2. Svppl.monlal Rolvrn 0 3, R.maillder Rolvrn
(for dolo. of doo.h prlo, 10 12,13,821
o d, lIml..d EIIol. [J do, Fvlure Int'''" Comp,oml" 0 5, Fed"al E.lal. Tax
lIar dol.. 0/ dealh oh" 12,12,82) R.lvrn Reqvi"d
o 6, Dec.denl DI.d T..lole I] 7. Decedonl Molnlained a living T,v.1 u_ 8, Tolol Numb., of Sof. Dopo.i180xo.
(Alloch copy 01 Willi IAlloch copy of T,v.11
-------- Ale CORRESPONOENCE-ANDco"NFioENTJALTAX INFORMATION SHOUl.DBE[iiRECTEO'TOl
t~AM[ - ---- -_.~-------- -- ------36MPmCM-,(mNGAfillRE~S
fI1IRt.lil~f~.~_c.K~_I{;f1T ~..!.ly_r.III~~___,______..__ (~O WI"fAlt poml'Afr"17tOSI3trcct
L PHON tWM8U ,nr He,
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lOR OATI$ 0' OIATH AmR 12131~1 CHECK HIRI
If A SPOUSAL
POVI R Tl'.CR IOIl!!_ C.LA1M_IOD__..__
Fill NUMBIR
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1. R.ol ElloleISch.dul. AI 111______.._______
2, Slock. and Bond, ISch.dvl. 81 I 2) __ '.________
3, Clo"ly Hold Sloek/Ponn",hlp Inl"e.1 ISeh.dvl. C) (3) ____
A, MOrlgogOl and NOle. Recelvobl. (Sch.dvl. 01 ( AI______..______
5, Co.h, 80nk Depo.i" & Miteellanoov. Po"onol P,openyl 51 .__~.2.,,,6J 9.99
(Schadvl. E)
6. Joinlly Owned P,operly ISchedvl. FJ ( 61
7. T,oOlI", ISch.dvl. GI (Sehodul. LI ( 7).._.._._____
a, Tolol G'OIl AIl.II Ilolollln" 1.7)
9. Funeral Expen.o., Adminitl,alive Co.lI, Mitcolloneoul I 91
Exp,"", (Sehedvlo HI
10. Debl., Mongog. LiobililiOl, lien. (Sch.dvl. II (101__--1.47.00
11. T 0101 D.dvclloOl Ilolalllno' 9 & 101
12, Nol Volv. a' E,lol. (line 8 minv.!iM 111
13, Cho,"oblo and Gov"nmonlol 8.qv.." ISehodvl. J)
Id, N.I Volv. Subi~~o Tax (line !?--",~"!.I,~3L_
15, Amount o/lIn. ld loxabl. 01 6% '010
(Inclvd. valvo. f,om Sch.dule K a, Seh.dvlo M,)
16, Amovnt 01 II no ld laxobl. 01 15% ,ole
Ilnclvd. voluo, from Sch.dvle K 0' Sch.dvlo M,)
17, P,inclpollO' duolAdd lox f,om line 15 and /,om line 16,1
18. Credih ~poulal Poverty Credit Prior Poymenll Oil(ounl
<%
h.___.___.._o._u_o.._._ 1- ..,...___.____ +.,_~_ - ._______
19, If II" 18 is greol" Ihon line 17, en'" Ih. diff"once 011 II no 19, Thit it Ih. OVERPAYMENT.
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20, If IIn. 17 it g,eol" Ihon line 18, onl" Ih. difference on line 20, Thit it Ih. TAX DUE,
A. Enter the Inlere" on the balance due on line 20A.
1201
(20A)
(20B) __
9/.
553
( 81
12.056.98
(11)
(12)
(131
(lAI
(15)
37,416.01
K ,06 a
1,9,619.99
12,203.98
37,416,01
-IL4Ib.01
2.244,96
112.25
2.132,71
2.132..71
.. ..- iiE"iuRE -fC)A-NiWiiALi QUfSTlON.S ON REVERSE -SI[)E -At.{O TO'RECHECK MATH"'-
~nder p.nolliu 01 ptltillly:lde'cT~~~lh~lTh~~e-;;;mjn.d 'hi~- relurn, Including occomponyill9 ICt..duit;-;;d Itol.m.nh, and 10 th. bllt al my knowl.dge alld blli.l,
II II true, (orrecl ond cc1mplelfl 'd.c1ore Ihal 011 1801..101. hOI bun '.port.d' ollrVI mOlhl volue, D.cloration of prepot., other than Ihe p.rlonol "pr'lentall.... II
bo~.!.d '!..n 011 inlormoliCln 01 which ptepare' ho, any .nowl.dg.
1iCi'~AluRT6nfR~ci;~'R! ~PoN~j8frf6R 'j"I(lt~r.R(fuiit~.' .ou--':AMiRUr-----------..----.-----.--
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1161--_._____,..._K .15 a
(17) _
Inlerel'
(181___
(191
Chec" here If you art requeilinD 0 r.lund'of vour overpayment.
8. Enl" Ihe 10101 of lin. 20 and 20A on IIn. 20B. Thl. it '''e 8ALANCE DUE,
_..._ M_oko _C",ok PO,~~ble t.'-~OI!I!,~_.'_~II!..~!nt
fiAlr
OR- ,,/ -94
bAlf
08- 31 -94
IUY~nl1 '..17.11/
ESTATE OF
ITEM
NUMBER
~:J~'9~
_'~J.,;
COMMONWfAlttl m Pftna'l'lVANIA
INHUnANCf TAX R(lURN
R~SIO~NT DfCEpUH_ __..
SCHEDULI H
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
PleoN P,lnt 0' Type
EHHA J, BODKINS
21-94-553
DESCRIPTION
A. Funeral Explnllll
B,
2,
3,
4,
C,
1.
2,
3,
4.
S,
6,
7,
8,
1.
Gibson-Hollinger Funeral Home, Inc 1" '" . . "... " , , .,. I'.. I I'"
2.
3.
Carlisle Hcmorial Services I Inc " . , ,. "" . .., "'" ....., I"""
Westminster Cemetery. Inc... ""'" "... ... """", .,'...... ...
Admlnlstrotlve CClstll
Lee R. Burgett
1.
Perlonol Roprelentatlve Commllllonl
Social Security Number 0' Porlonal ReprelenlallYIl
Year Commissions paid
161 - 32 - 3704
AUorney Fees Irwin t NcKnight & Hughes .......,.. I . . . . . . . . , . . . . . . . .
Family Ex~mpllon
Clalmont
Addroll 0' Claimant 01 decodont'l death
Slreol Address
Rblatlonshlp
City _
Slale
Zip Code
Probate Foel Le t ters Testamentary
AMOUNT
5.389.10
1,235.00
179.40
2,500.00
2,500.00
96.00
Mlscellaneoul Expenll..
Roger B. Irwin - Notary Fee..........,....,....,..".,.,..,..", 12.00
Filing 'Fee - Register of Wills.." II If It." tf..,,,,,,,,,,,,,,,, 25.00
Cumberland Law Journal - Advertising Letters Testamentary...... 40.00
The Sentinel - Advertising Letters Testamentary".............. 65.48
Roy Gottshall - Auctioncer- appraisal fee.,..............".... 15.00
TOTAL (Also enler on line 9, Recapltulatlanl S 12,056.98
III more space Is n..ded, Inlert additional sh..ts of tome sill.)
\ REV-1S47 EX AFP (08094)* / /
COMMONWEAl HI Of PEHHSYlVANIA
"\, DEPARTMENT 01 REV'MUE NOTICE OF INNERITANCE TAK
'\l SUREAU.f INDIVIDUAl lA,,, ~ ' ' APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
~i:~is::::~I"A 11118'0601 '1..~. OF DEDUCTIONS AND ASSESSMENT or TAK DATE 12-12-94
ESr-ATE OF'~~fj(iBiIT1iS=C"~~~~ -EMHl\=o ~"'~T'~"".""""'" ,,,., co..',, "FILE' NO'. "'c=2rt4~-055'r""~="'~=
DATE OF DEATH 06-03-94 COUNTY CUMBERLAND
)',1
"-1
c
ACN
101
NOTE I TO INSURE PROPER CREDIT TO VDUR ACCOUNT, SUOHIT THE UPPER PORTION OF THIS FORH WITH YOUR TAK
PAVMENT TO THE REOISTER OF WILLS, HAKE CHECK PAVABLE fO "REOISTER OF WILLS, AOENT"
REMIT PAYMENT TO:
IRWIN ETAL
60 W POMFRET ST
CARLISLE PA 17013
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
En". nAmount ~~~jii;iL~ '1
CUT ALONO THIS LINE ... RETAIN LOWER PORTION FOR YOUR RECORDS ~
R "eV: iscj; 0 EX "A j: p' 0 f 0 ii: 94 Y' NOY i c r 0' F 0 i"NHEiii;: A'tic E" TAX' A"P'1i RA" is EMENT ~"" A i.10'w A'N"C E 0 eiFi" -... -..""" - . 0 0 0
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF BODKINS EMMA J FILE NO. 21 9(,-0553 ACN 101 DATE 12-12-94
If an aSlessmant was issued previously, Hnes 14, 15 and/or 16, 17 and 18 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15, A.ouni of Llnl 14 ai Spou.al rail 1151
16, A.ouni of Unl 14 toxabll II UnoaI/Cla,,, A rato Ilbl
17, A.ounl of Llnl 14 iaxab11 al Collalara1/CI... 0 r.il 1171
18, Prlnolpal Tlx OUI
TAK RETURN WAS I 1 X I ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST 0 SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL
I, RI.1 E.llio ISchldul1 Al
2, Slooks Ind Sonds ISohldu11 81
3, C1011ly Hold Siock/Parlnarshlp Inloro.i ISch.dula CI
4. Harig.gat/Notes Rlceivable (Schedule OJ
S. C.sh/Bank Deposits/Misc. Personal Property lSchedule EI
b, JOlnl1Y O"nld Proparly ISchodulo FI
7, Transfers ISchftdul. OJ
B, Tol.1 A...to
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Fun.rul Exp.n.../Adln, Costs/Hisc. Exp.nses (Schedule H) (9)
10, Dlbil/Horlglgl Llabllltlas/Llon. ISchadul1 II 1101
11, Tolal DiducH on.
12, Nil Vllue of Tax Rllurn
13. Ch.rjtlbl./Gov.rnm.nt~l Bequests (Schedule J)
14, Nil ValUI of E.lala Subjacl 10 Tax
NOTEI
TAX CREDITS:
PAVHENT
DATE
08-31-94
RECEIPT
NUHBER
MM91~886
DISCOUNT 1'1
INTEREST I- I
112.25
I J CHANGED
11 I ,00
12 I ,00
131 .00
141 .00
151_~,619.99
Ibl ,00
(7) ,00
(81
49.619,99
12,056,98
147,00
(11 I
1121
1131 _
1141
1?,?n3 9A
37,416,01
,00
37.416,01
,00 K'OO,_
37,416,01 X ,06,
~K,15,
1181
,00
2.244,96
,00
2,244,96
AMOUNT PAID
-------2;132:'71-
ETO-TAL TAX CREDIT 2'244'~6
BALANCE OF TAX DUE ,00
INTEREST ,00
, t=---
TOTAL DUE .00
-------- ---.--
I IF TOTAL DUE IS LESS THAN $1, NO PAVHENT IS REQUIRED,
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI, YOU HAV BE DUE
A REFUND, SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS, I
./
, IF PAID AFTER DATE INnlCATEO, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST,
RESERI/AltONI E,tAtu of dlClldlntt dYing on or boforll Oocllllblr Ii', 1982 .- If IIny futuro Intorost In tho OItrlto Is trantf.rrod
In POllllllon or enjoYVlont to Clan 6 (collnter"l) beneficiaries of the decOdent nftor the oKPlrfttlon of ftny Iltllte for
life or for years, the COllllllonwulth horoby eKprossly reterVOll the dght to npprlllu and III1"S trMlfer Inherltftllce TnKGI
at thl lawful Clall 6 Ccollaterul) rnte on nny tunh 'uture Intorut.
PURPOSE Of
HOTICE I
To fulfill the requlrellllntl of Section 2140 of tho Inheritance Md EstAte Tal( Act, Act ZZ of 1991, n P.S,
Section 21(.0,
PAVHEHTI
Dltach the top port Inn of thlt Notice ~nd tub~lt with your pllYllent to tho Reulster of Wills printed on tho rover.o side.
uHllke chuck or noney ordgr pllYflble tOI REGISTER or HILLS, AGENT
All paYllent, received thall first bg applied to any IMorost which I!IIlY he due with any rmlalnd,r applied to thl taK.
REfUND (CR)I A refund of n tal( crodlt, which WftS not roquostod on the Tal( Roturn, nlty be roquested by cOllplet1rlg an "Application
for Refund of Pennsylvllnlll Inhultnnce nnd Estllto TlIx" (RI:V-13l3), Appllcatlont llro nvallablu nt the OffiCI
of the Register of will., IIny of the 23 RovonllO District Offlcos, or by cnlllng tho ,peclal Zet-hour
anlwerlng service nu-.bllr, for forM ordllrlngl tn Ponnsylvllnln 1'600-.\6l-l050, out.ldo Ponnsylvanla find
within local Ilnrrlsbury arQA (7171 767-6094, TOO" (7\1l 171-U.52 Olellrlng Il'lplllrod Only),
OBJECTIONS I Any party In Intorost not Ilatlsfled with tho llPprnlse~ont, nllownnl;fiI or cllsallowntlcfil of cI.Jductlons, or nuulunt
of \nK Clncludlng discount or IntorettJ as shown on this Notlco MU.t Object within slKty (60) dllYS of rooelpt of
this Notlcfil bYI
--written protest to the PA Dopllrtl1ent of RfilvonulI, BOllnl of AproAts, DEPT, 7.81021, Iltlrrlsburg, PA 11128'1021, OR
~.Ilectlon to hAve the I1llttfilr dotunlned !It Audit of tho nccount of tho por,onal reprosentatlvo, OR
-.nppul to thll Orphnl1" Court,
ADHIN
ISTRATlVE
CORRECTIONS I
Faotual errors dhcovlred on this .1sseulllent should be nddrolSod In writing tOl PA Depltrtlllent of Revfill'lue,
Burfilllu of Individual TnKIS, ATTNI Post AUOSSllont Hovlow Unit, OEPT, 280(,01, Ilnrrl.burg, PA 17\28-0601
Phone (717) 787-6505. 580 pllge 3 of tho booklot "Inttructlons for Inhorltnnce TAlC Roturn for II Ruldent
Dlcfildlnt" (REV-1501J for an e)(plnnatlon of adrdnl,trntlvoly correctllblfil errors.
DISCOUNT I
If flny \llx due it paid wllhln threfil OJ cnlendnr 1II0ntt1. nftor tho decedent's death, II five Ilorclnt {5%1 discount of
th_ taK pllld Is allowed.
INTEREST I
Inhrost II charged beginning with first tlllY of delinquency, or nino (ql Mnth. and ono Cl) dAt frail the date 0'
death, to the date of pllYllent. TllKllS which becll,"" dollnqufilnt before JllnUary I. 198? bear Intor"st at the rlltl of
,ht (6%) percent per AnnUlll calculatod nt II dlllly roto of .000164. All tltlCOS which becarru dollnquent on and after
Janunry 1,1982 will bear Int.rut at n rote which will I/lIrv frnlll cnhndar yallr to cftlondar Y.llr with thAt rate
announced by the PA DepllrtlllGnt of Rel/enuu. 1ho nppllcnblo Intore,t r"'tos for Iq82 through 19tJ4 IIrel
~ IMorost Rate Onlly Interut fflctor ~ InttlrllSt Rllte Ollllv Intornt Fllctor
19SZ 20% .000548 1986 10% .000274
19S1 111% .000438 11)87 9% ,000247
1984 11% .000301 Iq88-19l)1 11% .000301
1985 13% ,000356 19l)l 1)% .000247
199.\-11)'14 7% .0001n
19115 1)% ,000Z47
~-IntarRst Is cftlculllted II' follow'l
INTEREST = BALANCE OF TAX UNPAID X NUHBER OF DAYS DELINQUENT X DhILY INTEREST FACT DR
'.Any Notice luuet! aftor the taK bRcollln. delinquent 101111 rnfloct ,m Intorolt calculntlon to f1ftaon ltS1 dnVI
btyond the dnte of thl n.....Il.nt. If pllv"ent It Made nftor the Inturnt cOllputlltlon ddte thown on the
HOtlCllj additional Interllt IIlU,t b. cnlculntod.
".,,/
c
STATUS REPORT UNDER RULE 6.12
Name of
I
. I f
Date 0
Decedent I
~:HHA ,I. IIIlIlKINS
Dea th l--.J!ft-03-94
Will No.
Admi n, No, 21-9/,-553
Pursuant to Rule 6,12 of the Supreme Court Orphans'
Court Rules, 1 report the following with respect to completion of
the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes-.2L._ No___
2. If t.he answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3. If the answer to No, 1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes______ No X
b. The separate Orphans' Court No. (if any) for
the personal representative's account iSI
c. Did the personal representative state an
account informally to the parties in interest? Yes_~ No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
Date I 12- t-
-94
(/)il)
Signat1f
RllGt:R II. IRWIN. F.SQ\J~____
Name (Please type or print)
JC'lL
, .
0\ S~
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I..J C'l .,"0
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......
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Ol ~ ~B
a:CI:
60 !ili.lIT....P.OliFRIi1' ST.. CARLISLE. FA 17013
Address
.LlJ1.U49-2353
Te 1, No,
(HAH lrmf/ AM3)
CapacitYI ____Personal Representative
XX Counsel for personal
representative