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PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Deceased,
No, tOl~ ~ - L4-~
To:
Register of Wills for the
Counly of Cumberland in the
Commonwealth of Pennsylvania
Estate of Claire E. Myer"
also known os
Social Security No, 1 RlI_C;R_n1m
The pelition of lhe undersigned respeclfully represents that:
Your petitioner(s), who is/arc 18 years of agc or older, appl i ""
for lellers of administration
on the eslale of
(d.h.n.: ptndcnlc Iile: durante ab1>cnlla: durante minorilalc)
lhe above dccedenl,
Deeendent was domiciled al death in Cumberland County, Pennsylvania, with
~ er lasl family or principal residence al 62 Circle Place, Camp Hill Borouoh, PA.
(list SUet'I. number and municipalilY)
Decendenl, then 33 years of age, died Januarv 6
at Hershev Medical Center
,1996
Dccendent at death owned property with estimated values as folllows:
(If domiciled in Pa,) All personal properlY
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa,) Personal property in County
Value of real eslate in Pennsylvania
situated as follows: 62 Circle Place. Camp Hill Borouoh
Cumberland County. PA
$
$
$
$ 95,000.00
Petitioner_ after a proper search h~ ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Namc Relalionship Residcnce
Husband
Samuel M. M ers
Son
62 Circle
Cam Hill
62 Circle
Cam Hill
Place
PA 17011
Place
PA 17011
THEREFORE, petitioner(s) respectfully request(s) lhc grant of lellers of administration in the
appropriate form to the undersigned.
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62 Circle Place
Camp Hill, PA 17011
PUIlI'OU: 01'
NOTICE.
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To fulfill the requlr...nts 0' Section 2140 0' the lnhe,.lt~. and E.tat. Tax Act, Act ZZ 0' 1"1. (12 P,S.
Section Zl40).
Det.ch the top portion of this Notice end .~It .,Ith your pav-ant to the R.gllt,,. of Will. p,.lnted on the
ra....r.. aide.
.... ltIka cMck or IIOMY o,.der ,.vetlla tOI MeISTER OF WILLS, ACEHT.
AU p.~t. rec.IYM IheU first be applJed to ."y Inb,...t which ..y be due, with ...y r...lndllr 1IPP1Ied to thII tax.
A raf\n:l of a tu cr.cllt, which .... not requastad on the talC retu,.n, ..v be requested by coeplatlng an "application
fo,. R.fund of P....yl..,."l, InMrltWIC' WId Eatat, r-.- CREV"13lS), Appllc.Uons Ir. av.11lbl, .t \hi Dfflca of
the AIIIsta,. of Will., ~ of the Z5 RIYInUI DI.trlct Offlc.s or by calling the .paclaa Z4ahou,. .......'1"1 'Irvlce
~r. for for.s orderlngJ In Pannlyly,"l. laIOO"S6ZaZ050, outslda Pennswlvanla and ..Ithln local
~,.rlsbur. ar.. (711) lI1aI094, TDDI (111) 77Z-ZZ5Z CHaarlng lap_Ired Only).
OIJECTJONSI Any party In Int.r.st not ..tl.fled .,Ith the ...,.alseaent, allowanca or disallowance of deduction. 0,. ......-.nt
of to (Including dbcDlllt 0,. tnter..t) .. shown on thh NotlCI ..v objact ..lthln .ixty (60) .)'1 of receipt of
thh Notice bVI
--..rltten prot..t to the PA DaplrtHnt of Revenue, Bo.rd of Appe..., Dept. tllOU, Klrrhburll, PA 1112'-1021, OR
..a.lectlna to have the nth,. dehr.lned at thll MIdi t of the KCCU'lt of the pe,..onal repr..ent.tlv., Olt
_aIlPPlII to the DrphWl.' Court
AlIIU.-
IITIIATI\/!
CQRRECTlONSI
DISCOUNTI
PEKALTVI
INTERfST I
'actUll .rrors dhcoy.rM on thll ....spent should be add,....ed In ..rltlng tOI PA o.part-.nt of Rayanue,
au,.aau of Jndlyl~1 T...., ATTNI Po.t A.....sent AeyI... unit, DEPT. 210601, Har,.lsburg, PA I11ZIa0611
Phone (111) 711-6505. See page S of the booklet "In.tructlon. for Inhe,.ltanca Ta. R.tu,.n for a R..ldant
Decadent" (REV-lSOI' fo,. ~ ..,lln8tlon of edalnl.tr.tlv.ly correctable .rro,...
I' InY ta. due Is paid ..Ithln thr.. CJ) cal~ar -.nth. aftar the decadant'. death, a flv. percant CSX)
discount of the tax paid I. allowed.
The 15:C ta. MMSty non"partlclpatlon PIf\Ilty 11 COllPUted on tM tot.1 of the ... and Int.r..t ''''UM, and not
p.ld before J.nuary II, 1"', the fl,..t d.~ .ft.r the and of the t.. MM.ty period, Thl. nonap.rtlclpatlon
penal ty I. .....Ilbl. In the s... .ama,. and In the the .... tI.. pe,.lod .. you ......Id appa.1 the talC and Int.r..t
that hII. bean a..e..ed III IndlcatM on thh notlc..
Int.r..t I. charged bqlnnlnt with first d.y of dIIllnquMCy, or nine (9) .w1th. WId OM CU d.~
fr~ the data 0' de.th, to the dlita of p.ynnt. T.x.. ....Ich bee... delinquent before J.....ry 1, 1911
baa,. Intara.t at the rat. of .1. C6:c) percant par ~ calcul.ted .t a d.ll~ rat. of .101164.
All t.... ....Ich bee... delinquent on or .ft.r Jenuar~ 1, 19.2 ..111 bI.r Intar..t .t a ,..t. which will y.ry f,...
calendar vear to c.lendar y.a,. ..Ith that r.t. ennounced by the PA Dap.rtaant of R.ylnUe. ThI appllcabl.
Int.,.a.t rates for 19.2 th,.ough 1991 ar'l
Yaar Inter..t R.t. nally Int.,...t Factor "..r Jntl,...t Rat. DailY Jnta,...t Factor
19Ir rox .00un 1917 OX .010241
1915 lOX .01011)1 19Ual991 IIX .00lSOI
1914 IIX .00lSOI I9n 'X .OIDZ41
1915 UX .0ODS56 I "Sa 1994 n .GODl9Z
1916 lOX .010214 1995-1997 OX .OODZ41
--tnt.relt I. c.lcul.ted a. foll....1
IHTEREBT . IALAHCE OF TAX UNPAID X "UHlER Of DAYS OELIHQUENT X DAILY INTEREST fACTOR
"'Anv MoUe. luued .ftar the t.. beCOM' d.lInquent ..111 r.flect .... Inter..t c.lcul.tlon to flft.., US) day.
beYond the data of the ..........t. If paVMnt II aect. .ft.r the Int.r..t cHPUtaUon dait. IIhowt on the
Notice, additional Int.r..t sust be calcul.ted,
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NOTICE I
To fulfill the raqulreaent. of Section 2141 of the Inharltenc. and E.t.t. T.. Act, "ct It of 1991. C71 P,S.
Section 2140).
PAYttDITI
DetKh the top portion of thl. NoUc. Ilnd IUbIIIt ..Ith you,. p.yunt to the Reght... 0' Wllh prlntM on the
.......r.. aide.
.... flak. chack 0,. __v order p.,.I. tal MOIITtA OF WILLS, Ac[HT.
..11 ,.panta rec.lyacl shIIll lint be sppUM to MY Intlr..t which ..v be dull, .,lth any r...lnder 1iPP1Iact to the ta..
RU\ICD cau I .. nh.nd of a t,. crMlt, which .... not requa.tM on the t.. r.tu,.n, .ay be r.....tact by caplaU"I ." -Appllcatlon
for R.fund of Pann.ylv...l. Inherltanc. ~ E.t.t. Tax" (REYaISIS), applications .,.. ,....Illbl. at the Offlc. of
the R....tar of Will., MY of the 2S A.venue DI,trlct Dfflc.. or bV calling the ,pecl.1 Z4ahou,. ."....,.Ing ..rylc.
~r. fo,. fo,... ordering I In Pann.Ylvanl' lal'laS4ZaZOSO, out.lda Pann.vly."l. and ..ithln local
H8r,.lsburl .r.. (111) 111-1094, TDD' (111) 712-2152 CHa.rlng 1.,.lrad Only).
OI.ECTlDHSI IIrJ p.rty In Int.,...t not IIthf1H ..Ith the appr......,t, .UCNWIC. 0,. dh.Uowenc. of deduction. or ........,t
of tu Clncludl". dhcOW1t or Inte,...t) .. Ihown on thl. Notlc. uy object ..Ithln .lxty (60) day. of rec.lpt o'
thl. Notlc. byl
--written ,,.ot..t to the ,.. Dap.rtaant of R.ylnUl, loard o' App..l., Dept. Z110Z1, "-,...I.burl, P" 1112.-1021, OR
--.lacUng to heYa the ..tt.r dat.r'lned at the MJdlt of the account of the pa,.,.".1 rapr..."t.U..,., OR
--~1 to the Orphan,' Cou,.t
ADMIN-
ISTRATIVE
CORRECTIONS I
F.ctulll .rrors dhcoy.rM on thl. ...........t should be add,....ad In writing tOI PA Dap.rtaent of R.ylnUl,
au,...u of Indlyldual T.x.., ..TTNI Po.t .......alnt R.vleM unit, DEPT. Z10601, H.rrllbu,.., P" 1112a-0611
Phone (111) 711-'505. S.. pegs 5 of the bookl.t -In.tructlon. fa" Inhe,.ltanc. T.. Return fo,. . R..ldant
Decedent" (REV-1511) for an .xpl8n8tlon of adllnl.tratlyely co,.,..ctlbl. .,.ror.,
DISCOllfTI
If ~ t.. due I. peld ..Ithln thr.. (5) c.lend.r aonth. aft.,. the decedent'. death, . flY. p.rcant (SX)
discount of the tu p.ld I. eUowed.
PEKALTYI
The lSX tu .....ty non-p.rUclp.Uon penalty II CoeputM on the total of the tu Met Int.r..t ......ed, Met not
p.ld before Jenua,., II, I"', the flr.t d.y .ft.r the and of the t.. .....ty period. Thl. nonap.rtlclp.tlon
panelt, II ."..Iabl. In the .... ....r Met In the the .... U.. p.,.lod .. you would ."..1 the tu and Int.r.1t
thet has bean ......ed .. Indlc.t.d on thll noUc..
IHTERESYI
Int.r..t II charted betlmlnt Nlth fl,.st d.v of delinquency, 0" nine (9) .w1th. and OM (1) d.V
free the det. Df de.th, to the det. of P'YHI1t, Tu.. which bee.. delinquent before Jllf'lUllrv 1, nl2
betr Int.r..t at the ,..t. of .1. (6X) p.rcent p.r annua calcul.ted .t . d.lly ,..t. of .001164,
All tu.. which bee... delinquent on or .ft.r Janua,.y I, 1"2 ..III be.r Int.,...t .t a rate which ..Ill v.,.y fro.
c.IMdar y..r to c.lenda,. v.ar ..Ith that rat. 8rnM\Ced by the P" D.p.rt.....t of R.yenua, The eppllclbh
Int.r..t r.t.. for 1"Z through 1991 .,..1
Y.." Int.r..t Ret. D.llv Int.r..t Facto,. Y.'" Int.n.t R.t. D.lly Int.rut Factor
1'12 ZI% .001541 I'll n .GODZU
19U 16% .ODDUI 1'''-1991 11% ,GOOSOl
1914 11% .DDOSOl 1992 9% .DIOZU
1915 U% .0DUS6 1995al994 7JC .DOOI9Z
1916 lOX .000214 1995-199' n .DOOZ41
ulnt.r..t I. calcul.ted .. foll....1
INTEREST . BALAHCE OF TAX UNPAID X HUKlER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Hotlc. I.,ued .ft.r the tax bee.... delinquent ..111 r.flact an Inter..t calcul.tlon to f'ftaan CIS) day.
beyond the date of thll ..........t. If p.v-ent II .ad. .fter thll Int.rut coeputetlon data IhoMn on the
NoUce, IIddIUonal Int.r..t .."t be celcuhtM,
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Ralph A. Germak
Attorney at Law
4\ Wellfall Slreel
1'.0. 800 249
McAllllervllle,l'A 17049
Telephone (717) 463-3686
Pax Number (717) 463-2578
E-mail: rsermakOlrlcounlyl.nel
May 2, 2002
Mary C. Lewis, Register of Wills
Cumberland County
One Courthouse Square
Carlisle, PA 17013-3387
Re: Estate of Claire E. Myers
Estate No, 2] -96-00146
Dear Ms. Lewis:
Enclosed herewith please find an original and one copy of a Proof of Claim for the above-
referenced Estate. 1 would appreciate your filing the original Proof of Claim and returning a
sll1mped copy to my office in the enclosed, stamped, self-addressed envelope. Also enclosed
plCllSe find Check No. 8329 in the amount of$5.00 for filing fees. If you should have any
questions in this regnrd or need additional infonnation, pi case do not hesitate to contact my
office. Thank you for your assistance in this maller.
Ralph A. Gcnnak
Enclosures
Ce: Mr. and Mrs. Chester L. Adams
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PROOF OF CLAIM
ORPHANS COURT DIVISION
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
NO. 21-96-00146
ESTATE OF CLAIRE E. MYERS
Deceased
Dale ofDcalh: 01/06/1996
.' ,'_.1
Ralph A, Gcrmak. Esq.
P.O. Box 249
McAlislcrville. P A 17049
(717) 463-3686
.
. .
HAROLD E, POWELL, JR.
.
^ TlOnNE'r AT l.AW
HeRe3 ISTAR ROUTE!. Box~e
MIFFLIN TOWN. PA 170~'
'''''3e,8'80
April 4, 1996
William C. Vohs, Esquire
11 Ileat Ppmfret'Street
Carlisle Pa. 17013
In Re: The Estate of Claire Elise Osborne ~Iyers aka Claire Elise Osborne
Cumberland County. Pennsylvania.
Dear Attorney Vohs:
Please treat this letter as notice of a claim against the above referenced
estate The claimants are Che~ L.Adams and He2en S.Adams, husband and wife, of
RD04, Box ~~2, ~lifflintown, Pa. 17059. The amount of the claim is $55,700.00
plus interest at the rate of 6% per annum. The source of this claim is a Note
dated April 24, 1990.
I had previously sent a letter to Stephen R. Hyers notifying him of said
claim but it was before the issuance of letters.
If you need additional information , please advise.
.. your RETURN ADDREBB,oomplatacl on tha rev"" alda?
Very truly yours,
;7r5w/ ~/1-
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COMMONWEAL Hi OF
PErmSVL VANIA
DEPARTMWT OF REVENUE
DEPT 780601
HARRISBURG. PA 171780'm
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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MYERS, CLAIRE E.
PA1( Of OfAIlllVI,4 r.r rl','-
rl~a 11flll1ltt1VI,4O[JVU'!
01/06/1996
05/28/1962
llf APPlICAlJl[l !jl!fNI'JII.G ~,P()I.J~,( S 'j,\VI (l AS1 U~~, 1 A',n I,4IDDtr l!dIAl)
MYERS. STEPHEN R.
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l&l1 Of9lOcll Return
o 4 llfTllled ESL"I~
o 6 Oeccdenl 01N1 Tcsl.1!f' I'~"~(""'~\"'I
00 9 Lrt.gitbOn PrOCPI!dS R{'Cw'!'mj
o 1 Supplemtmtal Return
o 4a F ulure lnleresl CompromIse (d. rJ 0"1"" 11 , 1 all
o 1 Decedent r,1alnlalned a llYlfl9 TruSllAut~c~, rJ Trw\!J
o 10 SpousJIPo....er1yCfe(MI"...oI"'."tJttaMl\12llJ;1~1.1~~l
OI'ICJ~U!olQlfl'
FILE HUMBER
21 -96 00 1 46
~.7"'7' --;j,~ - - =..--
~OCiAL :iECtJRlh' 'j'J,-,O(H
1 8 4 - 5 8 - 0 301
TRIS RETURN MUST BE filED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITy tllJIJBER
03 Remainder Relum (GhcolOutllpollOlllHl1
o 5 Federal ESlate Tal Return Required
_ 8 Total Number 01 Sale Deposit Bales
o 11. ElectIOn total under Sec 9113(AlllllA'lScIlOI
THIS SECTION MUST BE COMPLETEO, ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED 0,
NAME COMPLETE MAILING ADDRESS
R. MARK THOMAS. ESQ. 101 S. MARKET STREET
FIRM NAME pI Art-.. ,t.,,)
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TELEPHONE NUMBER
717.796.2100
MECHANICSBURG
I Real ESlale lSch<dll~ AI
III
7 Slocks and Bond. ISchC<1ule BI 121
3 Closely Held Corpol3hon Pal1nershlp or SOle.PrOpnclo~hlp l31
4 Mor\gages&NolesRe<:e..b~IScI1elluIeDI 141
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11.
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5 Cash. Bank OePO!.I:S & Miscellaneous PCrMlnal Property
IScI1edu1eE1
15)
6 JOintly Owned Propel1y ISc.h~ule Fl 16)
o Separate Billing Requested
7 Intcr.Vrvos Translllrs & r.llsooll.lncous tlollProbalc Property (7)
ISchellule G or LI
8 Total GIOII Allels lIotallmes 1.7)
9 Funeral ErpensC!o & Adnllntstratlve Costs (SchPdule HI 191
10 OeblsolOcccdenl MortgagcllJblhles & llCns(SChedule II 110)
11 Tol.1 D.ductlonl IIOlitl lInes 9 & 10,
12 Net Value 01 Eltal. (line 8 mlnusllllC 111
13 Chanlablo and Gnvernnlcnlal Bequests'See 9113 TruSlslor I'l'hlCh 11n elecl<!n 10 tal has not been
made ISchellule JI
14. N.t Value Subjecl to T.I1LlOc 12 mInus line 13f
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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1!> Amount olllOe 14 t.lIable allhc spouSitlt3l
ralc. or trans'c~ under ficc 9116litll111
82,936.60
82,936.60
16 Amount ollme 14 t"lithle at lineal tale
17 Amount of line 1.4 titlitbw! alslbllng rale
18 Amount 01 line 14 litlable at col13lcral rate
19 bIOU'
20 0
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
x !L..- {151
X ,045 1161
X 12 {171
X 15 1161
1191
PA 17055
90.000,00
OFFICIAL USE ONLY
241 ,000,00
Ie}
331.000.00
99,634.79
65,492.00
(II)
(121
(131
165,126.79
165.873.21
{141
165,873.21
3.732,15
3,732.15
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. Decedent'8 Com 18te Addre8s:
~IR[[I AOORESS .
. 62 Circle Place
(JIY
Carn Hill
SlAtE PA
l,P
17011
TalC Payments and Credits:
1 Ta. Duo (Page lUne 19)
2 Cred,lsJPaymenls
A. Spousal Poverty Cre<t.I
8 Prio! Paymenls
C. Dlscounl
(1)
3732.15
Tolal Cred,ls (A - 8 - C) (2)
3. InleresVPenally " appl,cable
o mlerest
E Penally
5
TolallnleresVPenally ( 0 - E ) (3)
IIUne 2 is grealerlhan Une 1 -lIRe 3. enler Ihedlllerence Th,s is Ihe OVERPAYMENT.
Check box on Page 1 Line 20 to request. refund (4)
II line 1 -Une 3 is grealer Ihan Une 2, enler Ihe dlllerence This 's Ihe TAX DUE, (5)
A Enler Ihe inleresl on Ihe la. due (5A)
8. Enler Ihe 10lal olUne 5 - 5A. This 's Ihe BALANCE DUE, (58)
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 Iransler and Yes No
a. relain Ihe use or income 01 Ihe prope~y transferred; ..,....,............,..............,................,........,............' 0 00
b relaln Ihe righllodesignale who shall use Ihe prope~y Iransterred or ilS income; ..........,...................,......... 0 00
c retain a reversionary inlerest or ...................................................................................................... 0 00
d. receivelhe promise for hie of ellher paymenls. benel,ls or care? ..........,....,..........,..........,..................,.... 0 00
2. II dealh occurred alier December 12, 1982, d,d decedenllranslC! prope~y wllhin one year ofdealh
wilhoul receiving adequate consideratIon?,..... ..... ..... ......... ...... .... ................. ........... ............... ..... .... ........ 0 [X]
3. D,d decedenl own an ',n Irusl for" or payable upon dealh bank accounl or secunly al his or her dealh? ......,..,......' 0 00
4. D,d decedenl own an IndiVidual Relllemenl Account, annUlly, or olher non.probale prope~y which
conlains a benellciary desi9nalion? .."....,....,..,......'..'".."....,..,......,............................,........,........,........ 0 00
3732.15
4
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES. YOU MUST COMPLETE SCHEDULE r. AND FILE IT AS PART OF THE RETURN,
lbelllf,IIIStrve.wrettandtQtTllltle
lJnderpen.1he$oI~.Ill!darelhallhaveel~It\lS'el~_If'ICII.d'"9~J'"95Chedultsa'ldl~ts,~.....
~al.on 01 prepa'et' othot '* Ihe rersM~ ttPC$ffttatlyt II based on a/llnlormatql oI-.t11Ch preparer hJlf - .
SIGNATURE RE P I FOR FILING RETURN ~ \OS. ()O
~ ,~~?1\\f;-
\).l~ '
;:;;:--
;I; DA~
6' 5'" tJ.'i'
62 Circle Plac
Carn Hill
SIGNATURE OF P R
TATIVE
PA 17011
~/~~i~
ADDRESS
10 S, Market Street
Mechanicsburg
PA 17055
For dales ot dealh on or aller Jllly " 1994 and belore Janualy 1 1995.lhe la. rale ,mposed on Ihe nel value 01 translers to or for Ihe use oflhe surviving spouse is 3%
172 PS ~91 16 (a)(! 1}(1)}
For dales of dealh on or aller January I, 1995, Ihe la. rale ,mposed on Ihe nel value 01 Iranslers 10 or for Ihe use of Ihe surviving spouse's 0% 172 P.S. ~9116 (al (1.1) (ii}J,
The slalule does nol e.emol a Iransler to a survIVln9 spouse from la., and Ihe slalulory requiremenls for disclosure of asselS and fil,ng a lax relurn are slill applicable even if
Ihe surviving spouse is Ihe only benefiCiary
For dales of death on or aller July 1, 2000
The la. rale imposed on Ihe nel value of IranslC!s from a deceased child twenly-one years 01 age or ycungC! at death 10 or tor Ihe use of a nalural paren\. an adophve parenl,
or a slepparenl ollhechild is 0% 172 P.S ~9116(a)(1 2}J
Theta. rale imposed on Ihe nel value 01 Iranslers 10 or tor Ihe use 01 thedecedenl's I,neal beneficiaries is 45%, e.cepl as nOled in 72 PS ~9116(1.2) 172 P.S. ~9116(al(l}J.
The la. rale imposed on Ihe nel value of Iranslers 10 or for Ihe used Ihedecedenl's siblings 's 12% 172 P.S. ~9116(al(l.3}J. A Sibling is defined, under Section 9102, as an
'nd.v.dual who has alleasl one parent in common w,lh Ihe decedenl, whelher by blood or adopllon
.
...,"",.,.,".
COUMCltM'f.'L lH or Il(N"SYLIJAfM
INI~R1lANC( UXR[lURN
R I NT CfOfIn
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
MYERS CLAIRI= E
FILE NUMBER
21
QA
00146
Debts or dKedenl mUlt be reported on Schedule!.
:rEM
NUMBER
A
DESCRIPTION
AMOUNT
1
2.
FUNERAL EXPENSES
Beaver.Urich Funeral Home
Foster Monuments
7,102,00
1,418,00
B ADMINISTRATIVE COSTS
1. Personal Represenlalive's CommiSSions
N.me 01 Person.1 RepreSenlal.e,sl N/A
Sooal secunly Numbe~.) I EIN Number 01 Personal RepresenlatJve,'1
slreet Addrell
Coty Slate Zip
Yea~.) Comm;,son Paid
2 Anomer Fees R. Mark Thomas, Esq, 2.500.00
3. Famoty E.empbOn (II decedenr. add'ess ~ not !he same e. dalmanr.. alt.1ch e.pIanation) 3.500.00
Claimanl Stephen R. Mvers
51'eel Add'es. 62 Circle Place
Coty Camp Hill slale PA ZiP 17011
Relatoonsll'P of Clalmanf to Decedenf Spouse
4. Probale Fees 325,00
5 Accountanrs Fees
6 Tal Relum Preparefs Fees
7. Litigation Counsel Fees (10% of $622,166.66) 62.216.66
6. Litigation Costs (10% of $25,731 .34) 2.573,13
TOTAL (Also enter on line 9. Recapilulatlon) S
III more space IS needed. Insen addlllonal sheets of Ihe .ame "ze)
99634,79
lSenber- ~ricq ~ ulternI ~Utl1e
305 W. FRONT ST. . BOX 287
LEWIS BERRY. PA 17339
PHONE 717,938-8172
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
0",... .re only for thooe II."" th.tlr. um If.... .r. rrqulml by I.w to UK .ny II."", .... will upl.ln In wrlllnl below,
If you ..Iec.od. fun<r.1 which requlml.mh.1mlna. ,uch.,. fun...1 wllh vl<wlna. you m.y h.v. IU p.y for .mb.lmll.. You do not h.veto
ply for cmhalm1n, you di .no Dve If you IClccled...r~.nanncntlluch I" dircct eremllhln or Immtdlltc burl.1. If we charaed (or
embolmlna, .... will ..pl n why low, >:. "'1
For tho Service 01 .. c., I I' -1",' <, D.t. of On.h' / - {;' Q (
, - , f.'
.',>" ~ ,.'c..o ~..I
$-
$-
$-
SUB-TOTAL OF SPECIAL CHARGES ....,..,C$_
D. CASH ADVANCED
OpenlnlG"ve ..................,.. $ -:tOo. 00
C.m.,ery Equlpm.n. ..........'..,.. $ --4:S' 00
LollndDeod...."......,.......... $_
Ncwsplper Notlc...Loc.oI "",."",.. $_
Ncwsp.p<1 Notlccs-OU....,Town...,... $_
Telephon.&.Tdesr''''' ........,...., $_
Alrf... ..............,..........,.. $_
CI.rly/M.uOfferlnl..............., $_
P.llbe..ers ................,........ $_
CcrtlfiodCoplesof.h.o.llhCcrtlRCI.e. $~' 00 :.---
l'oliccEscort...... .... ......... ..... $_ ._---.
Rowen..................,......... $~OO
V.uhSnvlc.Ch.... """""",." ,$~
f_
$-
$-
$-
$-
$-
SUB-TOTAL OF ADVANCES .."""...... ..D$_
SUMMARY OFCHAROES
A, Prof",lon.t S.rvices, F.cilitles .nd
Equlpmen.,.ndAu.omodveEqulpmcn..., $ ::'5'/7
8, Merth.ndile '....................,.... $..!J..1..fO
C, Specl.ICh....."""""".""....... $~/i:--'
D, C..hAdvances....,.................., $---=--
TOTAL OF ALLSELECl10NS .",'.',,'. ''-7' -I ~
PAID AT TIME OF OR PRIOR TO
ARRANGEMENTS,........ ....,... ........,:.$_
BALANCE DUE ....,..,.............,....,.. $_
REAS()~r,9.R,~.~tBA~~f~r-y'. ;,..J,'
l( any l,wl cemetery. or trem.tory requlrcmenu hive rrqulmJ the
purchase ur any~o( the hems listed alx.we the taw or requirement Is
c:xpl.lncd ~Iow, \ .. )
/ ,...
\ ,"n-.!". I (",{"tf~
, . I
I
I htrt'by 'arte thltl hlV~ (..mined the .ho~ JiliN hems and (ound them 10 he (ornet Ill<! accoroinlllo the .rr.naemcntl requesced .nd I
her.by ocknowlodl" receipt 01. c"t"l oIlhll mcmollndum and 'Il'CCmenl, I hereby rcpresen. .h.. 1 hIVe lufficlen. .....,I...lly available for .
plymcnt of the cull price .nd herttly Ilfre .nd coveNnt J~ndy and Iever.lI., to ml~(, payment or S . within dayta
A Ill. ch.... of pcr mon.h .moun.lna to per yell II .ppliod '0 .h. unpaid h.l.nc. bcsinnlna day. from .he
d1te of this Il'mnc:nt. Any ,dditlonallefviccs or mef(:hanwK urdna.l or requetted .rl~ the dste of lids IlI'rtmcnl wdl hc coruldcttd Pi" of
.hl. .Il'......n. .nd Ihe c""thereel will be "Rotlod on Ihe finol..."melll, .
(Seal)
A~ ". (rwchlled
(Sca>>"'" /;;" ~ ~ /1-j~."<!A./
, , Jl'I1reh..erl
a..... ...
N.me
A. CHARGE FOR SEI\VlCES SELECTEOI
I. PROFESSIONAL SERVICES
ServlmofFunero!Direclor/S.aIl' ...... $_
Embalmlna........,....,..,..,...., $_
Other prepalltlon 01 body
,..........,......................$-
1 SUB-TOTAL OF PROFESSIONAL SERVICES ..AI $_
I 2. FACIUllES AND EQUIPMENT
I U.. of fodll.les for vlewlna
I (V1~...lon/W.ke)"..........,...., $-
: U.. of f.cllltles for funero! ceremony .... $_
U.. of .dmlnlm.tlv. .".... reception
.reu and arungemcnt rooms. . . . . , . .. $_
U..ofl'repar.lIonroom"",.,....'" $_
Other we of facilities
1 SUB:rorAi.'Oi:'FAcii.iTiES/EQuij,MEk ",A2 $-
3. AUTOMOTIVE EQUIPMENT
Vehicle '0 trans/er remllno to Funer.1 Hom.,
\\;. Loco!....,..,................,...., $_
,~ ~ca:.,(~~.~,~~~............,.. $_
tt ~r~:..,..,..,....,..,........, $-
" LoClI..,............,.............. $_
"'.Rower Cll or Roro! dllpo.hlon
Loco!,......,...............,...... $_
Lnd Clf/clerav cor
Loc.I............,..",.""""". $_
Car for plllbeJrers
Loc.I......""".....",..,."". ,
Out c:l town transportation ..,........
$-
$_
$_
$-
SUB-TOTAL OF AUTOMOTIVE EQUIPMENT A 1$_
TOTAL OF PROFESSIONAL SERVICES,
FACIUTIES AND AUTOMOTIVE
$, .~ oJ') 'I
EQUIPMENT..,..,..............,..........,A ~
B. CHARGE FOR ~RCHANDlSE SELECTEOt
Caskcl ....,(~:..:...,..i'/,~......, $~O""-~
lOesalptlon) _ . " (I ' LIi- '''''' cl::l f '-'
Oth.r Recept.c1e.................... $_
lOesalptlon)
Otller bull.1 conlllner '..,...,.... (1., . ,
(Dcsalpllonl .t -f, u
. e;..u
$~/~
~':Ii~. 0
$_
$_
$-
$_
$_
Acknowlodl"men. ellds , , , , , , , . , . , . , ,
Rcatllerbook(l) .."..,.. ....,......,
M.moryfoldm ..:...............,..
I'r.yerca.ds ........,..,...."......
Tnnpoflry lP'.vem.rkrr..............
Durl.lclothlna,..""""""""" ,
.'
CI.y
State
Other c1o.hlnl
$
$-
Crm.tlon urn.....,.....,.,........ $_
(Dcsalptlon)
$-
$-
$-
TOTAL MERCHANDISE SELECrED. . . . , , , ,,8 $_
C. SPECIAL CHARGES.
Forwarding of remains to
OTHER
$-
(Funer.t Home)
R<cclvl"8 of r.m.IN from
$-
(Funer.1 Homel
Immcdi... Durl.1 .. .. .. , .. .. .. , .. .. ..
DirectCrmatlon .....,.."........,
or
. ."
" (Do.e)
....
," I';~',. . . ~~.
'. ... - (Uccmcd Furie,,1 Dlrec.or)
.'tUTI. F__" Dm"... YlLlOW. FvMII Dtt-,,,.
IlHK,C-
'.
.,
.'1
, .
.-, .,
/v r/ '
I.. , C;'
ANNUAL' .
PERCENTAGE.
RATE
~=.~u
Amovt;',iinoncod
1"".,\.t;j.,lolaedII"O_
10"",.. on """bohall.
8ocurlly: You III g1w.g a MMiIy In",..t In.... goodl
.. pn>pIfty boIng purtt\aJad,
" -'
"i. ....J
'l', ...... .. ~i
. t .,
lalICllarvo:"_I~_lf""0dOYllala,you_lbolNrgad5%0I""_l.butm_I,,"I$500 .A...; I (t.?{.,:." ~l ,..,..J~:
'Prlpa"""nl: lyoupayohll1y,,,,,,"'nol,,,,..lopayapona/ly. ~'f J ,I.' 'r, " "Jl..yf.:.....t
Boa.... _bolow lor InJ 1Iddllionollnlocmallon obo\A "",...,,,*,l dolaoJl, InJ __ad ropoymonlln fUl bobl f.. clal.,
rttunil am pINlIl... '
FINANCE
cHARGE
The do....",oll'llha aedl
....~ 0---'
'lCo .
./ j)/)()
v... PIpl8nl Sdladl/...tl 1>0: .
No,oIP. AInountolrll"'!l"IJ
.' . .A.C' ~c..'J-I.. ../.
\WoInroy,,*,~A..()JI
IolonlNy,boglMro
--
Toto' 01 Poymants
lho """""I",,,... 110.1
""Ida"" "'" 114.. macla..
ochoduIod poymonll.
..
I / /] /)/1 ..-
l../t./V
,10
In 11110 Conklct
: ;':.." FOller Monumenll, 702 Wesl Fourth Slreel, Lewlslown, PA 17044 I (7171 248.5322
f. NIIme RUllnsa Add,... ' I P /VII
~':';:;'~I),~t.p/w.' 4/4ft.J {e>/}. Vt..cA. /.'1:""(' Ch'l'}IJ4i,')
y Neme(I)L Addle...
If Ihlll9ls mOl1llhon onO lluYar, aoch,.1 you wll ba obllgolod, IOparstoly and tooof,Of, lor aU su",s due us and 1110
pIrlormancf 01 oIl1QO_1o IS p<ovldod In thll Con~acl1ho IormslhoWn In Iha 'be... aro pOll 01 fli. Con~acI.
U~o Ionn. ollhl. Controc~ you hovo ogroad 10 purd1aso Iha lollowlng p<<>porly and Its a,lro aqulpmon~ which
Is Iha'Goodo'InIl1I1Con~:icI.
~ '!> WE REQUEST THAT YOU PROVIDE THE FOLLOWING MARKER
~+ Design D- /0 75" P,k:o / "// J :.-::
Y Die 'l.' / X . V / I Q' Base J . I .
. . Slzv' ~ tJ. Go ^ . 0 Slza;' . t. I. 0 17' ~
~ AND SET IT ON OUR LOT IN ( 0. .. .. /~W{ ~(;':;;r7::v, o' )
,~~ II
~ InacripUon 10 be "' 101l0wl:
.1
~.
Tolal Sala Price
1ha Iotal COIloI""" pun:hua
onaadllnd~YCUrdoon-.
_10I'~
, //,,/''':'
Th. Conlroclls be'-n Sellar ond
Buyer. AI dsdosltrea haw been moda
by Seller,
Phono I. ~/-o &,;2. I
"omllOtion 01 Amoult FNnoad
Cuh Price
$ / ;// (f
I '
-
U.(I'ld Dob"",
S I " M Y f.. f\ 5 ^"","/.I FIo;ctdA ()' ~.
o l:;tJl\fVE.) C/..ult'( tHE I'll rtlC f/IT/tt ~ s (/ V
J i'\ fA/.It:I-';/ ." 'rJ/:' r: AI Ro t:.r
~fH r.. t t"" 1st. -.) T J.: I h,. (V -.. r:" t. . MARKER WILL HOT BEcollE PART
MAY" 0' jut.1- ~'II'('Io"I'II>~L Of-c., If. ~11'f.'J 1, OF THE PERMANENT LOT UNTIL
,. I '" a 1 7 ' ... PAID IN FULL AND CAN BE
;r It N - ,,, I / 99 (, p 1i1.&J: q -1/ REMOYED FOR NONPAYllENT,
, BUT yOU WILL snLL BE LIABLE
NO MARKER WILL BE SET UNTIL HALF PAID FOR FOR PAVlIENT.
r1lU.daU... Cod
," /"
-- ....-
s
Down r'ym.n'
/-1/ f -
'N.t.~...,~
. ,
PAVlIENT SCHEDULE: You &gloa 10 pay U. f18 To~ll Sale PrlcG for Iha Goods by making f>o Tala/ Downpoymenl and paytng .. Iha Total 01 Payments In Ihe
number II1d amounl of monll1ly poymanls Ihown In Iha Poymenl Sctoodtlo. Payments Dnl We on '" 001..0 110..". day 0' ooch monll1 II Ihe IIrIt payment dais,
Poymanla mUll 00 mado allha offtco QI
PREPATIIEHT: Vou may 1"0"" Iha TotII 01 roymonIJ, In fUl .. In IJIl1 w;1houI
ponoIlr .. 1"_ . you 1"_ In fUl. what. In colh .. br rormlVldng, .. II ...
...."'.Ia tho malurlly 0I1hI1 Conhcl bocauM 01 ""', dol....I, IOU will ,ocol.. a
flF\rd c:rtclt of I,NlfNd FInInce Chlrgt. th..mount 01 flI rel\.nd credit w. elrn II
clolorminad by U1Iro Iha ocbJaololmalhod. How..... you wi' nol racal.. a..1\lnd 111111
Itlllhan '1.00.. ......10 In Oil allooo a mlnlC!Ull Flnan~ Chllgo olio.. _ 1.70 a
""'"" kit a 11111 8 rnonlhl.
UTE CHAROU: You ..... 10 pay UI a ling'" 1010 <I>..go d 5% 011nJ mr"*"
_11han 10dOYllo'o, butmmclfIlhan $6.00.....10.. hln 1100.
SEcunrn AOREEIIENT: To loa.. Iha paymonl 01 .. ouml <l.Ja lrd Iha
perl......... 01 .. fI<IUl<ad cbIIo.tionl U>dIt .i. Conted. "'" ""'eby ll'",t UI .
'IGIrity Intort.tln'" Goods, I" .. parl'lcaI~d ...Mlllons,anached to 'II Good'_1
any I..... time, Md In IIff proceods 01 flo Good., Indudlng InsUfIla Pfoc:Hds. If .
lOOJtUy 8gfHmonl Dr mortgagt to....ring OlMr prop.wfy you own now .slall between
~ou snd UI, WI walvelh. right to tJII11ha1 ofl" property II lIarlty Jot ttpeymlf\1 of
IhI.ConkllCl. YouadU1ow4odga our r\lhl 01 Ml<>Wlnllf/ .IIO..~wI1IcI1lo InllUf
pou.nlonalM"f lme.
NO WARRANlIES: TIlE'" ARE NO WAnRAN11ES, EITHER EXPRUSEO
OR lIIPlIEO, INCUJOINO THE WARRAKTIES OF IIERCHANTAelLITT OR
FI1NESS FOR A PARTICUUR PURPOSE, OIVEN IV eElLER III
CONNECllOII WrlH TIlE &ALE OF THE GOOOS AND SERVICES
COVERED OY THIS ComRACT, UNLESS TOU HAYI lEEN OIYEH A
SEPARAIE wnmEH WAnRAHlY,
AOOlllOllAl TERIIS AHO COHOrlIOllS: nlls COHlRACT OONIINUl:S.OH
lIl( n[vrn~[ SIOC. YOU AI1E OllI.lOAlEO TO ALL M TERMS OF TIIS
COll1l1ACr W1llClI APl'EA" ON mE F1IOIIr j\N() IlEVERSE !lIlES,
NOTICE TO BUYER: (1) DO NOT SIGN THIS AGREEMENT BEFORE YOU READ IT OR IF IT CONTAINS ANY BLANK SPACE. (2)
yOU ARE ENTITLED TO A COMPLETELY FILLED IN COpy OF THIS AGREEMENT, (3) UNDER THE LAW yOU HAVE THE
RIGHT 'IO'PA" OFF IN ADVANCE IHE FULL AMOUNT DUE AND UNDER CERTAIN CONDITIONS TO OBTAIN A PARTIAL
REFUND OFTHE FINANCE CHARGE, (4) NOTICE: "YOU THE BUYER, MAY CANCEL THIS TRANSACTION AT ANYTIME PRIOR
TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTiON, SEE THE ATTACHED NOTICE OF
CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT."
By 11gn~'ll boIow wa agr.. b ...1 f18 Goodalo you uodor Iha bnnl 01 f,ls
Con~acI.
"::} ~. JJ I --;:t- .
SELLER ,/O.l..l...\_///{/'/~fJI '0""'\:.:'- (SEAL)
RY:...._ ' l:'Ja....(/~1 ~")~ ~
/ -
(SEAL)
VOU ACKNOWLEDGE RECEIVING A COMPLETED COPY Of THI8
CONTRACT AND IN lEND TO DE LEOALL Y BOUND BY ITS TImMS,
NO 11/1 L BE SI!!.UN L ALF PAID fOR.
DUYEn
(/
NOTler: 5EE II(VEnSE SIDE FOR IMPORTANT INFonMATION,
BUYER
(SEAl)
(SEAl)
,
,
"
..
I do b",b," r"riA rb.r rb, p"ri.. ,,,id,.,, ..d rompl", po" offir, .dd"..
oflb,.'ilhi.n.m,dR'..'" i, 62 Cir,le Place, Cant> lIill, Pa. 17011.
January '9,
/990.
-~'Yi~(~/~ltsq.
Grantee
A"o,n,y fo,
I I
:>c
~ ~~ E-t . m
. ~ . 0
~ I I!;l !:i
~ II .
~ rx: !ffim
~ ~ .0
. .~ ~
~I .
0 ~. J,
~ i~: ~
~~
COMMONI1'EAL7'Il OF PENNSI'LI'AN/A
I'"
Co"nryof
IIECORVEV o. Ibi,
d.y of _
A. V. /9_, in Ib, R,ro,d,,', olfir, .f,b".id Co"n'y, i./I"d noo1
/'.1,
,P.R' ___'
Giv,n "nd" m)' bo.d o.d ,b, ...1 ofrb, ..id afflict. ,b, do', .110." ""i",n,
-----.--,
R,r.,d".
. .
T..,
lZ34~e/e::'iJ
03/06/04 04,:Zpm F. OCz.
. .
STEPHEN R. MYERS, as the Administrator
of the EST ATE OF CLAIRE E. MYERS,
DECEASED, and STEPHEN R. MYERS,
Indh'ldually and in his own right,
Plaintiff
COURT OF COMMON PLEAS
DAUPHIN COUNTY, PENNSYLVANIA
No. 5343 S 1997
vs.
N
......
.r...
.1.:-
. '
'.,.
r_
".
N
C';J
JOHN BOTTI, M.D.,
MATTHEW DAVIES, M.D.,
CAROL COULSON, M.D., THE MILTON:
S. HERSHEY MEDICAL CENTER,
PENNSYLVANIA STATE UNIVERSITY,
Defendants
"1:-.
p.:-"
,....-.
~ .: .:" )
'......-.,
. c"'-;
.-1
".
JURY TRIAL DEMANDED
91!J1ER
AND NOW THIS J21... day of July, 2004, upon consideration of the Petition for
Approval of Wrongful Death and Survival Settlements, it is hereby ordered that the
Petitioner is authorized to enter into a settlclllent in the gross sum ofTwo Million Four
Hundred Thousand Dollars ($2,400,000).
Petitioner is authorized to sign the attached Release. tile terms of which are
incorporated by reference Into this Order, and to mark this matter settled, discontinued
and ended as to the Defendants.
Petitioner is also authorized 10 mark as settled, discontinued and ended the prior
action in this matter, docketed to numbcr 5124.5.1997, Dauphin County, as to all
Defendants therein.
The settlement proceeds shall be distributed as follows:
A. From the initial pa}ment of$I,400,000.00 payable upon execution of the Release:
TO: Costopoulos, Foster & Fields, and Catherine M. Mahady-Smith,
attomeys at law, $422,166.66 for counsel fees;
r:~
-..
...
}J
i ;~~...n
l."ro-,
. -in
,. ., t';:j~:J
'~;l:n.<
.. ,....."1
:', ;.,
a
..
U1 .
CJ
./
T.st
lZ?4r:6:"~;O
03,'0';,'04 04,3'Z!:", F. ('04
B. From the final MCARE pa)'I\1ent of $1,000.000,00 payable on December 31, 2004:
TO: Costopoulos, Foster & Fields and Catherine M. Mahady-Smith, attorneys at
law, $400,000.00 for counsel fees;
The balance of the final MCARE payment (representing the balance of Samuel
Myers' share of the Wrongful Death proceeds) shaH be utilized by the MCARE Fund to
purchase a structured settlement in favor of Samuel Myers, as set forth in the attached
Release, which is incorporated herein by reference.
The distribution of the proceeds us sel forth herein has been calculated by the
apportionment of the claims arising from the death of Claire E. r...lyers as 10% arising
from the Survival Action claim and 90% arising from the Wrongful Death claim.
Counsel shaH provide to the Court, within ten (10) days from the receipt of the
initial payment of $1,400,000.00, proof of the deposit of $39,546.64 for the benefit of
Samuel Myers as set forth above.
BY HIE COURT:
~1J(t~
J.
1/1" f,-> ,', .., "",n ~
~'~.h t. i) do"~
,t.vJ,aI
.. ...., . : _.... '-'.. ..... ...~.. ..~,
I f'~' ,.-v" :'. ., . ..._,-,......
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DISTRIBUTION SHEET
STEPHEN MYERS. INDIVIDUALLr
AND AS A1JMINISTRATOR OF THE ESTATE QF CLARE MYERS
v. HERSHEY MEDICAL CENTER
REMAINING FUNDS IN 10LTA ACCOUNT
AMOUNT OF ERC CHECK
AMOUNT FOR CURRENT DlSTIUBUTION
$ 10,430.98
$8110.000.00
$810,430.98
CATHERINEMAHADY.SMITII. P.C. EXPENSES
- 13.988.97
$796,442.01
- 11.742.37
$784,699.64
-642.475.00
$142,224.64
COSTOPOLOUS, FOSTER & FIELDS EA1'ENSES
STEVE MYERS'S WRONGFUL DEATH PROCEEDS
SUR VIV AL ACTION PROCEEDS:
TO: Stephen Myers, Administralor of the .
Estate of Clare E. Myers (Stcphcn Mycrs' Sharc)
- 79.909.83
$ 62,314.81
. 62.31Hl
-0-
(Samuel Myers' Share)
BALANCE
On this 24th day of August, 2004, I acknowlcdge and agree that ( have received a
copy of this Distribution Sheet, rcviewed its contents and agree with it. I understand that
if there Bre any outstanding bill, including medical bills. or if any third pat1y has a right to
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subrogation, I understand thai ( am resJlonsible for those obligations.
I have again been advised by illY attorneys 10 consult with an accountant or tax
attorney regarding thc lax consequences of the proceeds, including Pcnnsylvania
Inheritance Tax. I understand that a Pennsylvania Inheritance Tax Retum needs to bc
.
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FAX NO. :7174632578
Nov. 05 2004 03:22P~1 P3
RELEASE
FOR the sole consideration of Sixty-five thousand four hundred ninet)'-two
($65,492.00) dollars, the receipt and sufficiency whereof 15 hereb)' acknowledged, the
undersigned, In his own right and on behalf of thc Estate of Hclen S. Adams, hereby
releases and forever discharges the Estate of Claire E. Mycrs, Stephen Myers. both as
Adminislrator of the Estate of Claire E, Myers and in his individual capacity, and all
other persons liable, or who might be claimed to be liable, none of whom admit liability
to the undersigned, from any and all claims, demands, damages, actions, causes of nctions
or suits of any kind or nature whatsoever, and particularly with regard to certain Articles
of Agreement dated April 24. 1990, by and between Claire E. Myers, deceased, and the
undersigned along with Helen S. Adams, deceased.
,
The undersigned her.eby declares That the terms of this settlement have been
completely read and are fully und.mtood and voluntarily accepted for the purpose of
making a full WId final compromise, adjustment WId settlemcnt of W1Y and all claims
disputed or otherwise, on account of the said Articles of Agreement above-mentioned,
and for the express purpose of precluding forcver any further or additional claims arising
oUI of the aforesaid Articles of Agreement.
.3rd
IN . WITNESS WHEREOF, Chel L. Adams has sel his hand and seal this
day of November, 2004, in the presence of:
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Chet L. Adams
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;OMMOHWlALTH OF PENNSYLVANIA
L\:MATMENT OF AEVlNUE
.... BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG. PA '712'-000'
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
RECEIVED FROM:
REV.1162 EXlll.961
NO. CD 005520
STEPHEN R MYERS
62 CIRCLE PLACE
CAMP HILL, PA 17011
ACN
ASSESSMENT
CONTROL
NUMBER
........... loId
101
ESTATE INFORMATION: SSN: 184.58.0301
FILE NUMBER: 2196-0146
DECEDENT NAME: MYERS CLAIRE E
DATE OF PAYMENT: 07/05/2005
POSTMARK DATE: 07/05/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 01/06/1996
TOTAL AMOUNT PAID:
REMARKS: S R MYERS
CHECK# 204
SEAL
INITIALS: VZ
RECEIVED BY:
AMOUNT
$2,800.00
$2,800.00
GLENDA FARNER STRASBAUGH
8\ '1 \05 - REGISTER OF WILLS
VOID-NSF
REGISTER OF WILLS
C1'ecfc AHorne.-'-)
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COMMONWEALTH OF PENNSYLVANIA
C!:PAATMENT OF REVENUE
BUREAU 0' INDIVIDUAL TAXES
OEPT,280801
HARfUSBURG, PA 171211.Ql'OI
REV.IIC2 EXIII,9CI
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 005681
THOMAS R MARK
101 S MARKET STREET
MECHANICSBURG. PA 17055
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
..-_.. 'old
101
$2,800.00
ESTATE INFORMATION: SSN: 184.58.0301
FILE NUMBER: 2196-0146
DECEDENT NAME: MYERS CLAIRE E
DATE OF PAYMENT: 08/12/2005
POSTMARK DATE: 08/11/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 01/06/1996
TOTAL AMOUNT PAID:
$2,800.00
REMARKS: R MARK THOMAS ESQ
CHECK# 2469
SEAL
INITIALS: VZ
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WillS
REGISTER OF WillS
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R. MARK THOMAS, ATTORNEY AT LAW I:; { A rJ 60-726912313
IOLTACUENTTRUSTFUND V\Jt 0
101 S. Mar1tot Sl
Mochanlcaburg, PA 17055 "I~A. II -
(717)796.2100 DAm ~. ;'~~...
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BUREAU OF INDIVIDUAL TAXES . '
INHERITANCE TAX DIVISION
PO lOX 280601
HARRISBURG PA 171Z&.0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
... ~: APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT OF T~X
*'
REV.lS'l EX AlP ID6.D5)
09-26-2005
MVERS
01-06-1996
21 96-0146
CUMBERLAND
101
APPEAL DATE: 11-25-2005
(See reverse .ide IIl1der ObJeetilln!)
Amount Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE .-. RETAIN LOWER PORTION FOR YOUR RECORDS -
REV: i54=r EX' AFi>- (0;':05 i' NoTicE- OF- iNHERiTANcE- TAx" APPRAisEHENT~ - ALLowANcE" OR-' -".""" - - - - -.,
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
CLAIRE E FILE NO. 21 96-0146 AcN 101 DATE 09-26-2005
TAX RETURN WAS' I I ACCEPTED AS FILED I X) CHANGED SEE ATTACHED NOTICE
", !
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DATE
ESTATE OF
DATE OF DEATH
FILE NUHBER
COUNTY
ACN
CLAIRE
E
R MARK THOMAS ESQ
101 S MARKET ST
MECHANICSBURG
PA 17055
ESTATE OF HYERS
RESERVATION CONCERNING FUTURE INTEREST . SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. R..l E.t.t. ISc~dul. A)
2. stock. and Bond. ISch.dul. B)
3. Clo..ly H.ld stock/p.rtn.r.hip Int.r..t ISch.dul. CI
~. Hortgag../Hot.. Receivable (Schedule 0)
5. CaSh/Bank napa.lts/Hise, Parsonal Property (Schedule E)
6. Jointly Qwnad Prop.rty ISch.dul. FI
7. Transfars (Schedule 0)
8. Tobl Au.b
HOTEl To insure proper
credit to your account,
sub.it the upper portion
of this for. with your
t.x p.yaent.
90,000.00
.00
.00
.00
241. 000.00
.00
.00
181
III
(2)
(31
141
15)
(6)
171
331,000.00
99,634.79
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funaral Expen.../Ad.. tosts/Hisc. Expanses (Schedule H) (9)
10. Dabb/Hodg.g. Uabiliti../U.n. (Sch.dub II (10) 65.492.00
11. Total D.duction. 1111
12. Hat Value of T.x R.turn 1121
13. Ch.ritabl./Gov.rna.nt.l B.qu..t., Non-.l.ct.d 9113 Tru.t. ISch.dul. JI 1131
14. N.t V.lu. of E.t.t. Subj.ct to T.x 1141
NOTE: If an assessment was issued previouslY, lines 14, 15 end/or 1&, 17, 18 end
reflect figures that include the total of ~LL returns assessed to date.
1;;1;.1'" 19
165,873.21
.00
165,873.21
19 will
ASSESSMENT OF TAX:
15. A.aunt of Lin. 14 .t Spou..l r.t. 115)
16. Aaount of Lln. l~ taxable at Lin..l/Cla.s A rat. (16.
17. Aaaunt of Line 14 .t Sibling r.t. 1171
18. Aaount of Line 14 t.xabl. .t Coll.t.r.l/CI..' B r.t. (18)
19. Principal Tax Du.
82,936.60 X 00 c
82,936.60 X 06 0
.00 X 00 0
.00 X 15 0
(19)0
.00
4,976.20
.00
.00
4,976.20
HUHBER
. WRITEOFF
"' CD005681
INTEREST/PEN PAID 1-)
.00
.00
AHOUNT PAID
2,875.62
2,800.00
DATE
OB-25-2004
08-11-2005
INTEREST IS CHARGED THROUGH 10-11-2005
AT THE RATES APPLICABLE AS OUTLINED ON THE
REVERSE SIDE OF THIS FORM
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
2,800.00
2,176.20
240.83
2,417.03
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION DF ADDITIDNAL INTEREST.
IF TDTAL DUE IS LESS THAN fl, NO PAYHEHT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FDRH FOR INSTRUCTIONS.I
~
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PAvttENTI o.bch ...... top portion of this Hotlc. end ...,..It with your pBy..nt to the Reghter of w11l1 printed an ...... raver.. ,Id..
ntIK. ctMck or RMY order payabl. tOI REGlSTER of WILLS, AGEST.
Failure to pay the t.., lnt.r..t, and panalty due ..y result In the filing of . lien of record In the ~ptoprl.t. county,
ar the luu..,ca of an Orph"'.' Court citation.
REFUND (CR)I A refund of . tax credit, which w.. not r.~.t.d on the 'a. R.turn, "Y b. r.~.t.d by co.platJng an
"application 'or R.fund of p.nnlylvanl. Inherltanca end E.t.t. Tlx" (REV-1S.S). application. ata Ivall8bl.
online at vww.ravanua.stata.ol.UI, any R.glltar of Wills or Ravenul District OffiCI, Dr fr~ the D~.r....,t..
Z'-hour enlWlrlng service for for.. or~r'l 1-SDa-S6Z-ZDSDJ ..rvlc.. for ta.p.yars with splcla' hearing end/or
speaking n..dll 1-800-"7-1020 1fT only).
Any party In lnt.r..t not ..tl.fled with thl appr.I....nt, .llow.ne. or dl..llow,nc. Df deduction. or ........nt of t..
(including discount or Inter..ll .. IhOwn on this Natle. "31' obJ.ct within 60 d.y. of the d.t. of recllpt of thl. notle.
bv flUng on. of the fDllowlngl
A) Prat..t tD the PA D.p.rt..nt of R.v,nu., la.rd of App..l.. You "31' obJ.ct by filing. prDt..t online .t
wvw.bo.rdafBDO..l...t.t..a..ul Dn or b.far. the .~plr.tlon Df the .I.ty-d.y IPP..I p.rIDd. In order far
1ft Il.ctronlc prDt..t to b. v.lld, you .u.t rlc.lvl . canflr.atlon nueb.r end proc....d d.t. fro' the
laard of App.al. w.b.lt.. VDU ..y also .end a wrltt.n prat..t to PA D.p.rt..nt of R.v,nu., lo.rd of Appe.l.
P.O. ID. 281021, Harrisburg, PA 17128.1D21. p.tltlon. "31' not b. f..ed.
I) Election to hav' the ..tt.r d.t.nelnld at the eudlt of the .ccount of the p.r.anal r.prl..nt.tlv..
C) Apreal to the Orphen.. Court.
RERAYAUDHI
PUIIPIlSEllf
NOUCEl
OIJECTIONSI
....,"-
ISTRAUYE
CORRECT UltS I
DISCOUNT I
PENALTYI
INTEREST 1
)~
E.tat.. of dlc.dlnt. dying on or ~for' D.c..b.r 12, 1982 a. If any future Int.r..t In the ..t.t. I. tren.f.rr.d
In po.....lan or enJDY'ent tD CI... . (collatlr.11 b'nlflclarll' of thl dlcadlnt aftlr thl I~plr.tlon of eny I.tat. for
Ilf. or for y.ar., thl Co..onwe.lth h.reby .~pra..lY r...rv.. the right tD IPpr.I.. .nd ...... tren.flr Inherltanc. Ta~"
It the llwful Cl... I (cDllat.rall r.t. on any such future Int.r..t.
To fulfill the r.qulra..nt. of Sactlon 21~a Df tha Inh.rltanc. and E.t.t. T.. Act, Act 25 of 2000. (72 P.S.
Sletion 91401.
Feetual Irror. dlscovarad an thl. .......ant should bl addr....d In writing tal PA Deplrtaent of R.venul,
lur.au of Indlvldu.l T...., ATTHI po.t A.......nt R.vl.w unit, P.O. ID. 280601, Hlrrlsburg, PA 17128aa6al
Phone (717) 787.6505. S.. pig' S Df tha boOkI.t "In.tructlon. far Inherltanc. TI. R.turn for. R..ldent
Decadent" (REVaISOII for an I~pl.n.tlon of Idllnl.tr.tlv.ly corr.etabl' .rror..
If any". due I. p.ld within thr.. (51 c.l.nd.r .onth. .ft.r the d.c.dent., d..th, . flvl p.re.nt (5%) dl.count of
the t.. p.ld I. .l.owed.
ThI 15% le. ..,..ty nonap.rUclpaUan pen.lly Is cOllput.d on the tDt.1 of the t.. .nd Inter..t .......d, and not
p.ld blfor' Januarv 18, 1996, the flr.t d.y .ft.r the .nd of the t.. ..nI.ty p.rlod. Thl. nonap.rtlclp.tlon
pen.l ty Is IIPP..lllbll In the .... .enn.r and In ttt. the .... U.. p.rlod .. you would .pp..1 the t.. and Internt
that has bien .......d .. Indlc.t.d an thl. nDtlc',
Int.r..t I, charged b.glnnlng with flr.t d.y of d.llnquency, or nln. (9) ~nth. and on. (II dlY frD' thl dlt, of
d.ath, to the dlt. of p.y..nt. T.~" which b.c... dlllnqu.nt b.far. Janu.ry I, 1982 b.,r Int.r..t .t thl tat. Df
.1. (6%) perc.nt p.r ennui c.lcul.tad .t a dilly rat. of .000164. All t.... which blc.,' d.llnquent on and .ftar
J~ry 1, 198Z will ba.r Int.r..t .t a r.t. which will v.ry fro. calender y..r to cal.nd.r y..r with that rat.
ennounc~ by the PA D'P.rtsant of R.venul. Th. .ppllc.bl. Int.r..t rat.. fDr 198Z thrDugh ZOOS .r.,
Int.nll D.l1y Int.rnt Dally Intere.t
R.t. Factor Vllt R.t. Factor Vllt R.t.
~ ':Inm tml-199' -rnr-:wmrr ml -,r
16% .000"8 199Z 9ie .0002"7 ZODZ 6ie
11ie .00nDl 1995al99" 7ie .Daa19Z zan 5%
lSX .000356 1995.1998 9% .aaazu un "ie
lOX .000Z74 1999 7iC .aaal9Z zoos 5%
9% .0002"7 zaoa aiC .aaaU9
V..r
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1985
1986
1987
D.lly
F.etor
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.DOOI64
.aaOlS7
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.000137
,
INTEREST ~ BALANCE OF TAX UNPAID X NUHBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
.aAny Hotlc. I.sued .ft.r t~ tl. b.cD." d.llnquent will r.fl.ct an Intar..t cllcul.tlon tD flft..n (15) d.y.
b.yond the dlt. of the ........nt. If p.y..nt I. .ldl .ft.r the Int.r..t cOlput.tlon d.t. shown on the
Hotlca, additional Int.r..t lU.t ~ calcul.ted.
..Int.r..t I. calcul.t.d .. fDllow'l
COMMONWEALTH OF PfNNSnVANIA
DEPARTMENT OF REVENUE
eOREAU OF INDIVIDUAl. TAXES
DEPT. 280&01
HARRISBURG. PA 17128.Q8D1
REV.1162EXlll.961
c
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 006228
R MARK THOMAS
101 S MARKET ST
MECHANICS BURG, PA 17055
--.... ,..,
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101
$2,449.55
ESTATE INFORMATION: SSN: 184.58.0301
FILE NUMBER: 2196-0146
DECEDENT NAME: MYERS CLAIRE E
DATE OF PAYMENT: 01/19/2006
POSTMARK DATE: 0010010000
COUNTY: CUMBERLAND
DATE OF DEATH: 01/06/1996
TOTAL AMOUNT PAID:
$2,449.55
REMARKS:
CHECK# 2569
SEAL
INITIALS: MG
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
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PLEASE RETURN THIS PORTION WITH YOUR PAYMENT TO
THE REGISTER OF WILLS LISTED BELOW
Estatc of:
HVERS
SSN:
Date ofOcath:
File Nurnber:
Datc of Asscssmcnt:
ACN:
CLAIRE E
184-58-0301
01-06-1996
21 96-0146
09-26-2005
101
REGISTER OF WILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17013
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auREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO lOX UDlIl
HARRISIURO PA 17111'0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
'*
REV-I'D' EX AFP (0'-151
., . r, I
I I': . ,J
DAT!
ESTAT! OF
OAT! OF DEATH
FILE NUHBER
COUNTY
ACN
02-06-2006
HYERS
01-06-1996
21 96-0146
CUMBERLAND
101
AlIOUI'It R.ltt.d
CLAIRE
E
(~
R MARK THOMAS ESQ
101 S MARKET ST
MECHANICSBURG PA 17055
MAKE CHECK PAYABLE AND REMIT PAYMENT TOI
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE I To In.ur. proper credit to your account, lub.it the upper portion of thl1 for. with your t.x p.~t.
CUT ALONG THIS LINE --+ RETAIN LOWER PORTION FOR YOUR RECORDS ...
---------------------------------------------------------------------------
REV-1607 EX AFP (03-05) ... INHERITANCE TAX STATEMENT OF ACCOUNT ___
ESTATE OF HYERS CLAIRE E FILE NO. 21 96-0146 ACN 101 DATE 02-06-2006
THIS STATEHENT IS PROVIDED TO ADVISE DF THE CURRENT STATUS DF THE STATED ACN IH THE HAHED ESTATE. SHDNN BELOW
IS A SUHHARY OF THE PRINCIPAL TAX DUE, APPLICATIOH DF ALL PAYHENTS, THE eURRENT BALANCE, AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT. 09-26-2005
PRINCIPAL TAX DUE. 4,976.20
PAYMENTS (TAX CREDITS),
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
08-25-2004 WRITEOFF .00 2,875.62
08-11-2005 COO05681 .00 2,800.00
01-19-2006 CD006228 272.91- 2,449.55
· IF PAID AFTER THIS DATE, SEE REVERSE
SIDE FOR CALCULATION OF ADDITIOHAL INTEREST.
I IF TOTAL DUE IS LESS TIWl U,
NO PAYltENT IS REQUIRED.
IF TDTAL DUE IS REFLECTED AS A "CREDIr' ICRI,
YDU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FO~ FOR IHSTRUCTIOHS. I
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
4,976.64
.44CR
.00
.44CR
~
.
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- --_.. . - ~- .
".~I.~~''!'o'''"''''''',.....~,._..,l..~", ~,^,_~"""'. .....
PA \1IENT I
Debch U. top portlon of thb MoUel Md -mlt ..lth ~r PIYMI'It lact. PtlyMiI. to the ~. Met ..wr...
prlnt.d an the rev.r.. .Ide.
If p~t If far I REIIDDfT DEC[O[JfT, ... check 0,. 1tOI'MY ont.r paylbl, tal
"'~I."'-'AI.I
If p~t If far I MOM-RESIDENT DECEDENT, -.kl ch.ck or ~y order p'vlbll tOI
C-..n "'.....'7"..10
,.Uurl to pay the t_, Inhrelt, Md peneltw .... _, ......U In ttMI flUng of . lien of record In the
IIppropr.,t, DOW1tr, Dr U. 1.....M. of ., Drph.,., Court alt,Uon.
RUlIII (tlh . rafwld of . tax credlt, IIhlch .... not requested on the 'IX Altum, _w tMI rMl'Mltlld by OOIIPl,Ung .,
-Appl1c.Uon for a.fw\d 0' l'em1V1"...al 1,.,."lt."cl Iind Estat, TIM" (REV-ISIS). ..",l1o"lonl In .."Uebll
onl1n. It wv..i.v~....t..a..u., ~ A.,l,t,r of Will, or Revenue al.trlal OffiCI, Dr fro. ttMI o.p.rtlent',
1:4.hour .....,. ng ..rvln far 'aMi' ardera. 1-,aD-lU-Z'SO, ..rvle.. for bxpQUI with speale1 he.rl", wdlor
.,..1"1 n.lldll 1-101-"47-"20 (IT only).
REPLY TOI
DISCOUNT.
PENALTYI
11ITEJl[ST,
-~~
,,4
~
au.ltton. regerdlna .rrar. cant.IMd on this notle. .tMNld tMt addr.....s tal PA Dep.r~t 0' Ravwu., aur...
0' lndlvlcLt81 Tu.., ATTNI Pa.t A...._~t A.vl... Unit, P.O. lox taD601, "'rrlaburll, PA 17121"0611, phDM
17171 7.7-6505.
If MY taJc ... h p.ld wIthIn thr.. (S) c.IMdlir IIDI1th. .ft.r tM dec:..s~t'. ...th, . flv. perc.,t (5%) dllOOW1t
of ~ taM p.ld I. .llow.d.
TM 15% tu .....ty nonoop.rtlalpatlon p...lty Is ~t.. on tM toul af U. tu IInd Int.r..t ......IId, Md not
p.ld befOr. J8nUary II, 1996, U. flr.t d.y .ft.r u. end 0' the t.M ~.ty perIod.
Int.n.t 11 cfw"'" NrilmJr'l ..Ith flr.t dly of d.Un.,.,cy, or nIne (,) IIDI1th. IInd DM (1) dIIy frw U. diu of
dl8th, to u. dIIt. of papent. Tu.. .....Ich bee.. dltl1nql1Wlt bI'or. J8nu1ry I, 1911 tMI.r Int.r..t .t tM rat. a.
tlx (62:) parc~t par .... e.lcul.tlld .t . dllb Mlt. af .00I1M. All u... Wilch tMIcue d.U~t on Md .ft'r
JlftUlry 1, 1'.2 ..Ill be.r Int.r..t .t . r.t. Wilch ..Ill v.ry 'ra. a.lMdlir ,..r ta c.lend'r ,..r ..lth thlt Mlt.
~ed by the PA Dep.rulnt a. A.v.... ThI 1IPP11c1b1. Intsr..t rat.. 'ar 1912 through 1106 .r'l
Int.r..t Dally Int.r..t D.lly Int.r..t DeIly
v_. A.t. F.ator V... ..ta F.otor v_. Alt. FlOtor
-
I9IZ 10% .101541 1911-1991 11% .111"1 2101 9Z .111247
1915 16Z .IIDOI I99Z 9Z .DlDZ47 un 6Z .10nM
19M 11% .IIOS01 1993.1994 7% .DD01'2 ZOOS SZ .0"157
1915 ISZ .DlOS56 1995-199. 9Z .IIU4? 2014 4% ..om.
1916 11% .111274 1999 7Z .lIl1n zoos SZ ....157
19.7 9% ..00141 21D1 IX . nun 1D06 7Z ."0I9Z
;"':;;.'::~
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INTEREST. BALANCE OF TAX UNPAID X NUMBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR.~}~
".Iony NoUe. SlIulld .fter the tme becOlll. d.ll~t ..111 rlfleet In tnt.rut c.lculltlon to fifteen UI) ..... ''', '\ ,,:~,'?~l
beyond the dllte of the ....n...t. If pap.,t 1. .1Ide .ft.r the Int...... COllpUtatlon diu IhoMn .. thI ',;I:~:::\~)<;-
NoUa., IddSUDnll Inte....t .....t be c.lcul.tlld. '.; ~~,,:'-!:,,:!,"".:il~
,_~;\,:~j',::~;.;'.l~
,:~,J~?1f~~
".',ry..o"~~
.-Int.r..t SI c81oul.ted .. '011ow'l
and Helen S. Adams, decedent's unele and aunt, in the principal amount of$S5,700.00, plus 6%
interest. (A copy of the Notice of Claim is allached hcreto and markcd Exhibit "B".)
7. The Estate of Clairc E. Myers was insolvcnt until thc selllement of its claim
against the Hershey Medical Centcr on August 24, 2004, at which time the Estate received
proceeds in the amount of$240,OOO.00.
8. Pursuant to a negotiated agrecment, the Estate paid $65,492.00 to Chester L.
Adams, to satisfy the lien set forth in paragraph number 6 hercin. (A copy of the Release Is
attached hereto and marked Exhibit "C".)
9. The vnlue of the real property at 62 Circle Place, Camp Hill, Pennsylvania was
estimated at $90,000.00 as of decedcnt's date of deaUI and U18t estimate was acccpted by the
Department of Revenue.
10. Petitioner has maintained the property since the death of dccedent and would like
to transfer title to the propcrty into his name as a portion of his intestate share.
II. A First and Final Account has becn filed on cven date herewith. (A copy of the
First and Finnl Account is marked Exhibit "D", allaehed hereto and incorporated herein.)
12. Pursuant to 20 Pa. C. S. A. ~ 3356, Petitioner Is required to obtain court approvnl
to have a deed executed which in effect would transfcr titlc ofrcal property from the Estate to the
Personal Representative.
13. Allached hereto as Exhibit "E" is the proposcd dced which Pelitioner seeks to
have signed by the Register of Wills pursuant to 20 Pa. C. S. A. ~ 3356.
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." "1llI~l111 Ilde of cite1. 1'1ace 60 foel: bl e l>Oin~ a al!l l:Ito lihe of Lo~ "," 11, ,",
. b1oc:k" of u,. hereihat:blr 1D1tIHcnlll Plan of Lo~., ~huv:e WOStllardlY elcn9 l:Ite
~ Ho.1! fllll~ bl e l>01h~ .., Un. of Lo~ Ib, 3, Diode .. of .aid I'lan, 1:It...,.
hoHI1II8h11y'IUinq u'e __ 61.2 ,...to a l>Oin~1 theOOl ..abl8rdly in a line a~
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:' ea1d P1an .,.illll ~d.s in Plan IlcoIc 3, .... U. Oolb.lllnd Coun~.l'_.
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ImLEASE
FOR Ihe sole considel'lltlon of Sixly-fivc thonsnnd' fonr hundrcd nincty-Iwo
($65,492.00) dollats, thc teccipt nnd suf/1clcncy whereof is hcrcby ncknowledged, the
ulldetslgned, III his own right nnd on bchnlf of thc Estntc of Ilclcn S. Adnms, hereby
relcoses and fotever dischargcs the Estntc of Clairc E. Mycrs, Stcphcn Myers, both as
Administrator of thc Estate ,of Clnlre E. Myers nnd In his individual capnclty, and all
other petsons IInble, or who mighl be clnbncd to bc linble, none of whom admllUability
10 the undersigned, from any nnd nl.1 clnims, demnnds, damngcs, net ions, causes of actions
or suits of any kind or naturc whalsoever, and particularly with regard to certain Articles
of Agreclnent doted April 24, 1990, by and between Clairc E. Mycrs, deccased, and the
undersigned along with Helen S. Adams, dcceased.
The undersigned hcrcby declnrcs thnt thc terms of this settlcment hnve becn
complel.ely rcad and nre fully understood nnd voluntnrily necepted for the purpose of
making 0 full nn~ finnl compromise, ndjustment nnd settlement of nny and nil claims
disputcd or olherwlse, on nccount of thc snid Articlcs of Agrccment nbove-mcntioned,
and for the express purposc of prccluding forcvcr nny flll'ther or ndditional claims nrising
out of lhe aforesaid Articles of Agrecment.
IN WITNESS WHEREOF, Chct L. Adnms hns sct his hand and scal this
.3,.d
day of Novelllber, 2004, in (hc presencc of:
r~ /?7~
Chct L. Adnms
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ESTATE NO. 21-02-0312
FIRST AND FINAL ACCOUNT AND STATEMENT OF PROPOSED
DIS11UI3tJ110N OF AND BY STEPHEN R. MYERS,
ADMINIstltATOR OF THE ESTATE OF
CLAllU! EI MYERS, DECEASED,
tATE OF tjOROUOH OF CAMP HILL
CUMBERLAND COUNTY, PENNSYLVANIA
Sleplten!t. Myel'll, AdmJnlsltalor, as aforesaid alld
Accounlaht Iteteln, avets lis folll1wS
DATE 017 DECEDENT'S DEATH:
OATE LEITElts OF ADMINISTRATION ISSUED:
OATES EXECtJ10R'S NOTICE AOVERTISED:
Ct1/t1berland Law Journal .
The SenUttel
]8IIUary 6, 1996
February 16,1996
March 8, 15, and 22, 1996
February 28, March 6"
and March 13, 1996
FIRST AND FINAL ACCOUNT
RECEIPTS OF PRINCIPAL
Fiduciary
AcquisitIon
Value
-
Cash: i
Cash In possessIon of decedent S 00.00
Check from West Shore Tax Bureau S 22.07
S22.07 .
r
Tangible Petsonal Property:
MIscellaneous pieces of jewelry , S500.00
Futnishlt1gs S500.00 '
S 1,000.00
Chose lJt AcUonl
Estate ofClalte Eo Myers v. $240,000.00
Hershey Medical Center,
(DaupWn Cty. No. 5343's 1997) S240,000.00
!teal Estate:
62 Citcle Place, C8I11p Hill, PA , S90,OOO.00
S90,OOO.oO
~~k(' b/f l{ b I(
..
.'
DISBURSEMENTS OF PRINCIPAL
Debts ofOecc!dellt:
11/16/2004 Chester L. Adams, mortgage on $6S,492.00
62 Circle Place, Canlp Hili, PA
Adm1tt1sltaUolI Exl1enses:
01/06/1996 Beaver-Urich Funeral Home, $7,102.00
Services
05/0211996 Foster Monuments, grave marker $1,418.00
07/24/2004 Catherine M. Mahady-Smith, Esq. $1,398.90
reimbursement .o'f IiUgalion expenses
07/24/2004 Costopolous, Foster & Fields, $1,174.24
Attorneys at Law, reimbursement
ofllUgaUon expenses
01/24/2004 Catherine M. Mahady-Smith, Esq., $82,216.66
and Costopolous, Foster & Fields,
Allotlleys at Law,
Lltigallon counsel fees
Iteglslet ofWl11s, I1ro~lIte costS:
02116/1996 Iteglster of Wills, probate costs $20S.00
01/0SI2005 Register of Wills, probate costs $ Is.OO
01/12/2005 Reglsler of Wills, probate costs $10S.00
081111200$ Depllrlmellt of Revenue $2,800.00
InherltBllce tax
01/1912006 Departtnent of Revenue ~i,449.SS
lnherilBl1cetax
09/j0/2004 ' R. Mark Thomas, Esquire $1,000.00
estate legal services
Bal8l1ee due: 51,500.00
1996 Property taxes 51,749.60
1997 Property taxes 51,782.00
1998 Property taxes $1,830.60
1999 Property taxes $I,8S4.90
2000 Property taxes 51,891.35
2001 Property taxes $1,986.22
2002 Property taxes $2,143.32
2003 Property taxes $2,2S3.25
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satisfactorily proven) to be the person whose name is subscribed to the within
instrument, and acknowledged that She executed same for the purposes therein
contained.
IN WlTNESSWHEREOF, I hereunto set my hand and official seal.
Title of Officer
I do hereby certify that the precise residence and complete post office addreBs
of the within named grantee is 62 Circle Place, Camp Hill, PA 17011
,2006
Attorney for
COMMONWEALTH OF PENNSYLVANIA )
COUNTY OF CUMBERLAND
Be.
)
RECORDED on this day of
the Recorder's Office of the said County, Deed Book
. A.D. 20-, in
. Vol. . Page
Given under my hand and the seal of the said office, the date above written.
. Recorder.
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I hereby certify that written notice ofthc filing of this Statement of Proposed
. Distribution, and of the date and time and place when the same will be presented to the
,Court for confinnation and of the IRSt day to file written objections to said Statement of
Proposed Distribution, has been given to every unpaid claimant and to every other person
known to the accountant to have or claim an interest in the estate as creditor, beneficiary,
heir or next of kin.
A "py .r... .............. mol""" wi" lb. ..U", ~
DATED: June 6, 2006 ~~
R. Mlirk Thomas
I hereby certify that written notice of the filing of this Account, and of the date, time, and
'place when the same will be presented to the Court for confinnation and of the last day to
file written objections to said Account, has heen given to every unpaid claimant and to
every other persOIl known to the accountant to have or elnim an interest in the estate as
creditor, beneficiary, heir or next of kin. '
~~~
DATED: June 6, 2006
R. Mark Thomas
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ESTATE NO. 21.()1IjO
FIRST AND FINAL ACCOUNT AND STATEMENT OF PROPOSED
DISTRIBUTION OF AND BY STEPHEN R. MYERS,
ADMINISTRATOR OF THE ESTATE OF
CLAIRE E. MYERS, DECEASED,
LATE OF BOROUGH OF CAMP HILL
CUMBERLAND COUNTY, PENNSYLVANIA
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Stephen R. Myers, Administrator, as aforesaid and
Accountant herein, avers as follows
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DATE OF DECEDENT'S DEATH:
DATE LETIERS OF ADMINISTRATION ISSUED:
DATES EXECUTOR'S NOTICE ADVERTISED:
Cumberland Law Journal
The Sentincl
January 6, 1996
Fcbruary 16, 1996
March 8, 15, and 22, 1996
February 28, March 6,
and March 13, 1996
FIRST AND FINAL ACCOUNT
RECEIPTS OF PRINCIPAL
Cash:
Fiduciary
AcquIsition
Value
$ 00.00
$ 22.07
$22.07
$500.00
$500.00
$1,000.00
$240,000.00
$240,000.00
$90,000.00
$90,000.00
Cash in possession of decedcnt
Check from West Shore Tax Bureau
Tangible Personal Property:
Miscellaneous picces of jcwclry
Furnishings
Chose in Action:
Estate of Claire E. Mycrs v.
Hershey Medical Centcr,
(Dauphin Cty. No. 5343's 1997)
Real Estate:
62 Circle Placc, Camp Hill, PA
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Chester L. Adams, mortgage on
62 Circle Place, Camp Hill, PA
Administration Expenses:
.
Debts of Decedent:
11I16/2004
01/0611996
05/0211996
07/24/2004
07/2412004
07/24/2004
DISBURSEMENTS OF PRINCIPAL
S65,492.oo
Beaver-Urich Funeral Horne, S7,102.oo
Services
Foster Monuments, grave marker S I ,418.00
Catherine M. Mahady-Smith, Esq. S 1,398.90
reimbursement of litigation expenses
Costopolous, Foster & Fields, $1,174.24
Attorneys at Law, reimbursement
oflitigation expenses
Catherine M. Mahady-Smith, Esq., S82,216.66
and Costopolous, Foster & Fields,
Attorneys at Law,
Litigation counsel fees
Register of Wills, probate costs:
0211611996
07/0512005
0711212005
08/11/2005
01/1912006
09/3012004
1996
1997
1998
1999
2000
2001
2002
2003
Register of Wills, probate costs
Register of Wills, probate costs
Register of Wills, probate costs
Department of Revenue
inheritance tax
Department of Revenue
inheritance tax
R. Mark Thomas, Esquire
estate legal services
Balance due:
Property taxes
Property taxes
Property taxes
Property taxes
Property taxes
Property taxes
Property taxes
Property taxes
S205.00
S 15.00
S105.00
S2,800.00
S2,449.55
SI,OOO.OO
SI,500.oo
SI,749.60
SI,782.00
SI,830.60
SI,854.90
SI,891.35
$1,986.22
$2,143.32
S2,253.25
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IN RE: EIlale of Claire E. Myers
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS COURT DIVISION
: NO. 21-96-00146
ORDER
AND NOW, this 71.11 day of v ~ ~ t
2006, having reviewed the
allachcd Pctitlon, and pursuant to 20 Pa.C.SA 9 3356, the court hereby authorizes the Register
of Will., or hcr dcsignee, to cxecute a dced transferring the Estate's interest in the real property
located at 62 Circle Place, Camp Hill, Cumberland County, Pennsylvania to Petitioner,
.
Stephen R. Myers.
BY THE COURT,
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ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
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In Re: CLAIRE E . MYERS
CUMBERLAND COUNTY
PENNSYLVANIA
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NO. 21.96-0146
CERTIFICATE OF SERVICE OF ORDER
ORDER DATE: 08-22-06
JUDGE'S INITIALS: JWO
TIME STAMP DATE: 08/22/06
IN RE: ORDER OF COURT
............................................................................................................................
SERVICE TO: R. MARK THOMAS ESO
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METHOD OF MAILING:
~ USPS
DRRR
D HAND DELIVERED
D OTHER_
ENVELOPES PROVIDED BY:
~ PETITIONER
D JUDGE
D CLERK OF ORPHANS COURT
MAILED: 08/23/06
............................................................................................................................
SERVICE TO:
METHOD OF MAILING:
D USPS
DRRR
D HAND DELIVERED
D OTHER_
MAILED:
ENVELOPES PROVIDED BY:
D PETITIONER
D JUDGE
D CLERK OF ORPHANS COURT
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and Hclen S. Adams, decedent's unclc and aunt, in the principal amount ofS55,700.00, plus 6%
interest. (A copy of the Noticc ofClairn is allachcd hcreto and marked Exhibit "B".)
7. The Estate of Claire E. Myers was insolvent until the sclllement of its claim
against the Hcrshey Medical Center on August 24, 2004, at which tirne the Estate rcceived
proceeds in thc amount ofS240,OOO.00.
8. Pursuant to a negotiatcd agreemcnt, thc Estatc paid S65,492.00 to Chester L.
Adams, to satisfy the Iicn set forth in paragraph number 6 hercin. (A copy of the Release is
attached hercto and marked Exhibit "C".)
9. The value of the rcal propcrty at 62 Circle Place, Camp Hill, Pennsylvania was
estimated at $90,000.00 as of decedcnt's date of dcath and that estimate was accepted by the
Department of Revenue.
10. Petitioncr has maintained thc propcrty sincc thc dcath of dccedcnt and would like
to transfer titlc to the propcrty into his namc as a portion of his intcstate share.
II. A First and Final Account has becn filcd on evcn date herewith. (A copy of the
First and Final Account is marked Exhibit "0", allached hcrcto and incorporatcd hcrein.)
12. Pursuant to 20 Pa, C. S. A. ~ 3356, Pctitioncr is required to obtain court approval
to have a deed executed which in cffect would transfcr title ofrcal propcrty from thc Estate to the
Personal Representative.
13. Allached hereto as Exhibit "E" is the proposcd dced which Pctitioncr seeks to
have signed by thc Rcgister of Wills pursuant to 20 Pa, C. S. A. ~ 3356.
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SA'tltUN tw. H. DE WlTrIE and ClAIRE O. DE lIITrIE, husband and wUe, of the
O:lII1alWee1th of l'ennsylvanie, .
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.AIL 'I1IAT amAIN lot or tract of land situate in the Borough of carp Hill, County
of ClJlWland and Stste of pennsylvanie, nme particularly bounde:l and describecl
sa foU""", 00 witl
~mINNIOO st a point on the wlStcrn side of Circle Plece, W.3 feet South of the
, s",thwClIt corner of Circle Place and Beverly Road, thence 8OIJtJ1..oardly elong the
w...tEl'll side of Circle Place EO fo<t: 00 a point along tho line of Lot No. 11, ,
Blcx:k F of tho hereinaCter mmUcne:l Plan of Lots, thence w...twardly elong tho
'lI1Il! 140.75 feet 00 a point on line of Lot lb. 3, Blcx:k F of said Plant thence
rmthwardly along the ..... 61. 2 fe~oo a point, th....ee eastwardly in e line et
riVht AIl\Il. 00. circle Place, 128.6 f_ 00 a Point the place of BEXlIllNIllCl.
BEII<<I parte of Late !be. 12 ancI 13, B1ocJ< r on Plan of Late of _e:ly Park,
aa1d Plan beinv recarclad in Plan Ilool< J, Pave 19, ~e:loncl CClunq.. reca&'cle.
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DISBURSEMENTS OF PRINCIPAL
Dcbts of Dcccdent:
11116/2004
Chester L. Adams, mortgagc on
62 Circle Placc, Camp Hill, PA
Administration Expenses:
S65,492.00
0110611996 Beaver-Urich Funcral Home, S7,102.00
Services
05/0211996 Fostcr Monuments, grave marker $1,418.00
07/24/2004 Catherine M. Mahady-Smith, Esq. S 1,398.90
reimbursement.oflitigation expenses
07/24/2004 Costopolous, Foster & Fields, SI,174.24
Attorneys at Law, reimbursement
oflitigation expenses
07/24/2004 Catherine M. Mahady-Smith, Esq., S82,216.66
and Costopo1ous, Foster & Fields,
Attorneys at Law,
Litigation counsel fees
Rcgister of Wills, probate costS:
02116/1996 Register of Wills, probate costs S205.00
07/05/2005 Register of Wills, probate costs S 15.00
07/1212005 Register of Wills, probate costs $105.00
08/11/2005 Department of Revenue S2,800.00
Inheritance tax
01119/2006 Department ofRcvenue S2,449.55
Inheritance tax
09/30/2004 R. Mark Thomas, Esquire SI,OOO.OO
estate legal services
Balance due: $1,500.00
1996 Property taxes $1,749.60
1997 Property taxes $1,782.00
1998 Property taxes $1,830.60
1999 Property taxes S 1,854.90
2000 Property taxes S1,891.35
2001 Property taxes SI,986.22
2002 Property taxes S2,143.32
2003 Propcrty taxes S2,253.25
.
. .
2004
2005
04/3012006
Property taxes
Propcrty taxes
Steve Myers, husband
family exemption
$2,656.30
$2510.33
$3,500.00
DISTRIBUTIONS OF PRINCIPAL TO BENEFICIARIES
$ 0.00
PRINCIPAL BALANCE ON HAND
Estate Checking
Real Estate
Misc. PersonaUJcwelry
$50,487.50
$90,000.00
LI.OOO.OO
$141,487.85
PROPOSED DISTRIBUTIONS TO BENEFICIARIES
Legal Fees - R. Mark Thomas, Esquire
Stephen Myers - Spousal Share
Stephen Myers - 50%
Samuel Myers - 50%
$ 1,500.00
$30,000.00
$54,993.92
$54,993.92
STEPHEN R. MYERS, Adminlstmtor of the Estate of CLAIRE E. MYERS, deceased,
hereby declares under oath that he has fully and faithfully discharged the duties of his office; that
the foregoing First and Final Account Is true and correct and fully discloses all significant
transactions occurring during the accounting period; that all known claims against the Estate
have been paid in full; that, to his knowledge, there are no claims now outstanding against the
Estate; and that all taxes prescntly duc from the Estate have been paid.
sre~~t:r
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
: ss:
I, Stephen R. Myers, Administrator of the Estate of Claire E. Myers, whose name is
signed to the attaehed or foregoing Instnunenl, having been duly qualified acconllng to law, do
. .
. . .
hereby acknowlcdjJl thai I signed and executed the First and Final Accountj thai I signed It as my
free and vobntary acl fur the pwposes therein expressed.
Si~y~91f/M/
5/ Sworn l}Ij am~ed 10 and scknowled!J:d befure me by Stephen R. Myers
thIs I day of ~ .2006.
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co,,,,DHWULTtl M NHHIYLVANIA
NOTARlALllEAL PubIc ;, /J 6tary
JOHN D. GRIOS8Y~ Coooty 1/
MedItl~.. 25.2010 .
Tax Parcol No.
THIS DEED,
MADE THIS
six (2006)
day of
, in the year of our Lord two thousand and
BE'lWEEN
GLENDA FARNER STRASBAUGH, Register of Wills
and Clerk of the Orphans Court, by virtue of
Order of Court dated
Grantor,
and
Stephen R. Myers,
Grantee:
WHEREAS, CLAIRE E. MYERS, deceased, previously known as CLAIRE O.
DE WITTIE, on January 6, 1996, died seised as owner in fee simple of the herein
described pr.operty; and
WHEREAS, the court, by Order dated authorized the transfer of
this real property from the Estate of Claire E. Myers to Stephen R. Myers, her
widower and Personal Representative of her Estate, by deed pursuant to 20
Pa.C.S.A. S 3356; and
WITNESSETH, that in consideration of ONE ($1.00) DOLLAR, in hand paid, the
receipt whereof is hereby acknowledged, the said grantor does hereby grant and
convey to the said grantee, his heirs or assigns,
ALL of the Estate's interest in that certain lot or piece of land situate in the
Borough of Camp Hill, Cumberland County, Pennsylvania, bounded and described
as follows, to wit:
BEGINNING at a point on the western side of Circle Place, 69.3 feet South of the
southwest corner of Circle Place and Beverly Road; thence southwardly along the
western side of Circle Place 60 feet to a point along the line of Lot No. 11, Block F of
the hereinafter mentioned Plan of Lots; thence westwardly along the same 140.75
feet to a point on line of Lot No.3, Block F of said Plan; thence northwardly along
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satisfactorily proven) to be the person whose name is subscribed to the within
instrument, and acknowledged that She executed same for the purposes therein
contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
Title of Officer
I do hereby certify that the precise residence and complete post office address
of the within named grantee is 62 Circle Place, Camp Hill, PA 17011
,2006
Attorney for
COMMONWEALTH OF PENNSYLVANIA )
COUNTY OF CUMBERLAND
ss.
)
RECORDED on this day of
the Recorder's Office of the said County, Deed Book
. A.D. 20-, in
. Vol. . Page
Given under my hand and the seal of the said office, the date above written.
. Recorder.
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Tn Parc.1 No. 01-21.0273.268
THIS DEED,
MADE THIS ~y of ~/. in the year of our Lord two thousand and
six (2006)
BETWEEN
GLENDA FARNER STRASBAUGH, Register ofWilIs
and Clerk of the Orphans Court, by virtue of
Order of Court dated August 22, 2006,
Grantor,
and
Stephen R. Myers,
Grantee:
WHEREAS, CLAIRE E. MYERS, deceased, previously known as CLAIRE O.
DE WITTIE, on January 6, 1996, died seised as owner in fee simple of the herein
described property; and
WHEREAS, the court, by Order dated August 22, 2006, authorized the transfer of
thiB real property from the Estate of Claire E. Myers to Stephen R. Myers, her
widower and Personal Representative of her EBtate, by deed pursuant to 20
Pa.C.S.A. ~ 3356; and
WITNESSETH, that in consideration of ONE ($1.00) DOLLAR, in hand paid, the
receipt whereof is hereby acknowledged, the said gran~or does hereby grant and
convey to the said grantee, his heirs or assigns,
ALL of the Estate's interest in that certain lot or piece of land situate in the
Borough of Camp Hill, Cumberland County, Pennsylvania, bounded and described
as follows, to wit:
BEGINNING at a point on the western side of Circle Place, 69.3 feet South of the
southwest corner of Circle Place and Beverly Road; thence southwardly along the
western side of Circle Place 60 feet to a point along the line of Lot No. 11, Block F of
the hereinafter mentioned Plan of Lots; thence westwardly along the same 140.75
feet to a point on line of Lot No.3, Block F of said Plan; thence northwardly along
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the same 61.2 feet to a point; thence eastwardly in a line at right angles to Circle
Place, 128.6 feet to a point the place of BEGINNING.
BEING part of Lots 12 and 13, Block F on Plan of Lots of Beverly Park, said Plan
being recorded in Plan Book 3, Page 19, Cumberland County records.
Tax map No. 01-21-0273.268.
BEING the same premises which Hal M. De Wittie and Claire O. De Wittie,
husband and wife, by their deed dated March 16, 1990, and recorded March 29,
1990, in Cumberland County Deed Book Volume M34, Page 92, conveyed unto
Claire O. De Wittie, now aIkla Claire E. Myers, deceased.
THIS TRANSACTION IS WHOLLY EXEMPT FROM PENNSYLVANIA REALTY
TRANSFER TAX SINCE IT IS A TRANSFER FOR NO CONSIDERATION FROM
THE ESTATE OF A DECEASED SPOUSE TO THE WIDOWER, WHO IS ALSO
THE PERSONAL REPRESENTATIVE AND LAWFUL HEIR OF THE
DECEDENT.
And the said grantor does hereby covenant and agree that she will warrant
Bpecially the property hereby conveyed.
IN WITNESS WHEREOF, said grantor has hereunto set her hand and seal
the day and year first above written.
Signed, Sealed and Delivered
in tbe Presence of
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Commonwealth of Pennsylvania
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ss.
County of Cumberland
On this, the JJrJ day of a,u; I~....t- , 2006, before me, the undersigned
officer, personally appeared GLENDl FARNER STRASBAUGH, known to me (or
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