Loading...
HomeMy WebLinkAbout96-00299 . ! - .~ ..a C ..... . ~ 0 E CI) . 4 .. Q.,;; Z C Q. . ~ 0 .. VI Z ~, Will PETITION .'OR I)ROnA TE and GRANT m' LETTERS Will !:.:\{atc ?(, ,~i)\l,l" 9,... !I.4~9.t1! p,C? 1;1 , .."......."", also klloll'n as .1'.il,l,I~, ,r;.., .I.1~,~<;11.1, ::;P,t),. ,!) r.., , , , , , , , late. .of. .Sh,l.pp,gJ)p.Ql,lr.g, :r,Ql'llV,tl.l.P"."""., No, ,~.I.-:-lqq(.Q~ ;).,qq, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , [)('('{'us(J(I. Social Sccurity No, ..., .LOll,., 1 D,.,O.1.'J(l"""".,.,., To: Register 01 Wills lor the County 01 muakhrxinlll'lP Cumberland Commonwealth 01 Pennsylvania The petition ollhe undersigned respectfully represents that: Your petitioner(s) is/are 18 years 01 age and the execut Q r, , , . . , , , . , , , . . , , , " named in the last will 01 the above decedent, dated , ,(lugI,lP.t, 3.1".."", .19 ,07, ,XIlIcbMulli(ll~,."."". ",.."""",." ,.J}I/ P,gti,t io,ner, ,.I::;, ,ep.1e, ,~lCeC;\l.l;Qr, ,l)illT)'i!d,. in. . !;/1,e, ,~1 p" ".',:~ .1<'.,>:". F, J(" :I,d..",~~,J,:~4, If' ,~l'., .~'~-!'+" y~ I, \~C/P ,;, ~,f1~" ~v'~~,,:41<e, :-l'~,<~f;'., ~f. ,Je,(!:..I~--:'i:} ",~d,c.,~ht',....'h-Il\. ISldln Ifllevanl cllcumalrmccs, p q Renunciation. deitlh 01 fUIOCl.ltor. elc ) Decedent was domiciled at dealh in Cumberland Counly, Pennsylvania, with h .i~.lastlamili or principal residence at ,Sbi.ppe,nsb.u rg ,lI.l~ill,tb. ,Cil r,e . C,eo,t,~r." , L2,l, ,1~ill,I'j\l;:, BpI; !;P'I1J, .R.d, .'. ." .i.ppe.nshurg" P.A, .172.5.7..""".,.,.,."""""".,.,.".,."..,.,..,.,."".",.,."",., (hsl.lreel. numbt., dnd mUnlclpdllty) Decedent, then.&L, ,yearsolage, died """""'..",..,.,,,.., Nilr,c;o, ,2(;"...,.""., 1951('>,., at .Shippensbu.r:g, .Health .Care. ,Centex" ,1 n. loJa1o,u,t ,I1Qt,~Q{l1, ,RP,.", .!1\1,i.l?pel)s,ql,Jr1~257 Excepl as lollows, decedent did not marry, was not divorced and did not have a child born or adopted alter execution 01 the will ollered for probate, was not the victim of a killing and was never adjudicated incom, petent ,.",. Non,e , . , , , . . . , . , ' , , . . , . . , , , , . , . , . , , , . , , , , , , , , . , , . . , ' , , , , , , . , , . , , , , , , ' , . , . . . . , . . , , ' . , , Decedent at death owned property with estimated values as follows: (If domiciled in Pa.) (If not domiciled in Pa.) (If not domiciled in Pa,) Value 01 real estate in Pennsylvania situated as fellows' ,,;'~,11. ,Or,r:!> t,Q I>' n, ,RP.ig1", All personal property Personal property in Pennsylvania Personal property in County . Orrs,l;owl'j,. .F'.l\. .1, 7~,'11,., , " , ,. $, ,O2.l.2 .Q,Q, $.....,...... $..,......, .. $..........., " ,?2,,4~P,.,OP WHEREFORE, petitioner(s) respectfully requesl the probate 01 the last will and codicil(s) presented here. with the grant ollcltors , . , , , ,t'il.!'; till1Jli!n,t;a.r.y , , , , , , , , , , , , , , , , , , . , , , , , . , , , , . , , . , , , , , . , , , . , ' , " therecn. (Tt~51,lm"nl,HY, ,HimmlSlftllion c I ,l ,.ldmml!tralton d b n c I il ) / --..-) 1 Slqn,tlurl'('ll .mll RI'Sldl'ncl'(!;) ~~.,<!, >1.,':-:~':"/.""! .'t-""'~/ , " ., " , . "IP""""n..~r~I, . . " " " , " . " , , . . . obert'!... Summer,!; ;',r~56.0, .o,r5 tP,Wl) , Mad, ,Orrst.o"!n,'. ,PA, 1.724,4, . 15-9(0-5 ~ if?~ (,) ~) ~ ".-, fi; r: ~ ~~ Q d, :~ \', COMMOMWEALTH OF PENNSYLVANIA l SS f] (, ~ ;;;~ COUNTY OF ,~l1M~r;~~N~p""". i ~8 N \I> Q. The petitioner(s) above named, swear(s) or affirm(s) that the statemenls in the forego{~~ petition are true and correct to Ihe best 01 the knowledge and belief 01 petitioner(s) and tbal as personal representative(s) of the above petitior.er(s) will well and truly administer the e~reyccording 10 la" ,~ f ~, /o(~/,?~>..'<~,,~)~ Sworn 10 or alhlmeo dnO sub, ~.i,.:~.:...,.. ,..-;, "...,..., '"...,' ."...... scrihed befom me this. " ddY 01 ,P,~':'f..''.. !",';~ IIUI.1 0'/. ,y.~.", , ' " , , ".' '--17"" /lP~~,~ ,./3".. 19 'fll)h~ ~ . .lCJ.MI(lry.+~Y!o#'-:'i:;.". I((f..~) MARY C. :.EWISFflrtheRegister VJly OATH 01: PERSONAL REPRESENTATlVi~ rr ' '" ................................................. ................................................. ................................................. No,;tJ-: Jqq~ .-).qq Estate 01. . , . . . , . . . . . Pau 1. .c. , Hu tc:hi son, , . . . , , . . . . , . . Deceased DECREE OF PROBATE AND GRANT OF LETIERS AND NOW, ..,..., ilp.J;'U . .1,~ . . , . , . . . , , " 19, .~6. . in consideration 01 tbe petition on tbe reverse side hereof, satisfactory proof baving been presented before me, IT IS DECREED tbat tbe instrument(s) dated " , ." , .,... ,';!l.g\ll>,t;, ;3,1" ,19,8,7..".".....,..,. ..,...". ,....,...". "" .." , .". "" "..,.."" described therein be admitted to probate and filed of record as tbe last will 01, .P.ilU,J" c.~, Hu tc.his,on.,.,., ................................................................................................... and lelters. , l;.esl;,"UJlgntary..... "..., ".,...". .,...... ,. ..,.",....".,. .,...., , " ."."".. ,'" are hereby granted to , , , . .11QP.eJ;'l;, '~'" . S!J.r\lI)1~.r~, .'?~... , , .. . . , . ' . .. .. , , . . ' .. . , , , . . .. . . .. . , , .. . . . , . , , . ..................................................................... ,..,.,.."..".",..",.,.,.....".,..,.,",.."., '~~l;i'~Jf~~;j.';j;.~LC0j1l1j~i'" . Documents AlIacbed: MARY C. LEWIS Register a! Wills Oath 01 Subscribing Witness(s) 0 Oath of Non,subscribing W,tness(s) r-' Oath 01 Witness(s) to mark r! Renunciation(s) L J FEES TESTAMENT^RY X- PAGES SHORT CERTIFl^CTES ~5t^L ,<lP,E!E;!p,l], "",.., ~I,1H:,a).'~.:;,'i/.3,$;2q~",. A'ITORNEY (Sup. Ct. I. D, No,) $ 200.00 6.00 6.00 Q. 21 ~:iHb ,96.14, ,Row,e, Run. ,Loap"Shipp,ens,bur.g, PA ADDRESS 17257 "".,.,171l',532~4a32", PHONE 11 I.' TIII~ 1\ III It !lll\ 111.11 1111 1111,011110111 ilL Ill!' \'!' ,I. 11H..1IHq:t\II.1I Ihl"II~'IIl,t1\'lldl\i1\ ..\till!II'I\' ij I'" II' 111 t!l;'lliil '1~1111,.IIC lei ,It.I!ll .!I.L Itlt'! '.\111. !Ill t" ;l! \ 11 ! I;, \' 1\ lljlh t 1'.1 1" Till 'Ilt III Idlll.: WARNING: Ills IIlcgnllo dupllcnll! this copy by photostnt or photogrnph. ~o ,,;.......,..~....... !/'::'\~\l.!!j1!..L'(t". I'!f!.~/ - . ,~'(r.;,~ ,;/$1_.' .'!NIl ." '\;;,~' It~f, .... \!:.~ \ .' II ;'''' . . ~- %, ~'~". i'."' /~ "(-p.' _"', /0$>1 '/4/ENl ~\ ~~,,.../ ....~/ 1J~ 13 'tlqf;11l<,""",,, Fu.lnl rlll'\tlllll,.ll{. 5.'011 34820)/ :J'~1-/7ft' Il.lIl' '..,IP t:!llA'-II)tIWIAIJll Of 1'(tltl'iYIYAPIIA .1" I'AIU'AI tlI or 111'041111. ',HAt I1rt:Pnll't Crllllnr.^1 r ()r IlE^," ':"'j';\I;L"'o.T;;=';'~;';.".'-;I;ITI'I/J~I"i . 'bl,' I, ;'", IV 01",( j:;;,';~'l~"';:"': OJ. "''''=;:;-\'':::':'i';::: .,,':::'i ;~=,~ I ,~.;, ;'...." I~.' . i~:'~:.::'t' '" 'f 'I' .:.~~~:~ '; .;;':.~,~~,w':~~ -.... ':'~'l-"~~ M.l':'::~ [) .........; I ~:" I 1 L--'-'-"': i ."/1 I', """, "'. 1'\ ,h '--~'------':::~'-I'- - . ~;r.;- --~- --;;I~"'~'."'i;;;r..".. "' r"'~""""" ........ .,.._.',....-.., . "'If(IlI'''L#I~ ..,............. ".,. ._.......~...t--. ......... _1'1 ...II...._..,..~ ,_0" dll fl' !' Cumb.'"iatld ..Slltn)"",I'rj't~1 It\':l, ,,'1111 """q"l~.j ~fI'''T' II: ~,la~.~ _r!-'~l_r,:..,. _. ........::--:....: - --- ".-. NOl'4.."'....'I.'.....r....d..,.. .~- ..",:..<t<.......,;;.i.,..;;.; 1.""""""_"'.'\ ,.."...!~J!..'"'' I ........'\'.',,,,,... I ~,.,.....,., .,0'- -,;,:,:,~',:,'~,~::::;j:~~ l'lf(I',1 "'.::',",':~",.;'" '-r~"';:.:'~''':-:;':II'.,..~;:~ ".~':...~~:~.:~I ". ,. .., !It t::u.:1: d_'1_(_t'tl._____~_ "I.. (i.ll.t.!,I. l' I" ,II .. .._ ., II'trl.\'.'~ -"-- ------.- "'(fl..."'....U.Il.I'C.....................'..-'.... 1';."1"'" /'.\ ",I 1_.....___. 3SJI O.'l:.U (I WI R,',lll ~~ ";:"~I ... :::.':'" It t"VI~ t('~'II. PA 11~'JJ 1 ~.l,:h j II -........ ".!~ :;,:."~",,,,:'::.I.. C''l~ (\,\\'11 . . .~'...""'i r.h""',..... .... ;;:;;;7;;,---- .._- .....,., ".;,..., ~..; ...-;-";',i..';' .".... " Ra~,,"l'tHf C. Hl(tdll~j'll Il.'!.~(,' II. ~,!.1':(1I1 ~..;:tiw.r.riii.iiI,T.;;~;;--. .. _.. :~. .:.....!~...~..i...;..:._..._..;;;;,:c~;.r....:;.,-.---_._. ___u__' ..--_.~_. I J?L.lldH.,t l.~__SHfI""l"~'~_. /_ l',tl. 1'., f!...l'~':~',~t.". p". t.1~~J._.___ ..-.-----.-- -... j '''''.~'';;;'~.. .. .. I;....'.. .:,-.,.:~.~........'............. 1....r....,.............1.,.... i _1\1 (,_.....11...-...._,,1.11 .... j (_I] I..... ,......,1.__. _ _ .- _.... ~ 1 , 11: ,I ~~i-,~,:i'I.:~.. ~!'.'I.I~,': 1~'~I~. ~:.~:(t~..',:~ " P/.'...~l.~. .!!..l.c.:!.!.:r:1..I_'~f~.I!..~.--*_!..\: ~~~d;.;;.:"""r$~~"'..;.,.,,;' "'. t::".'i;':::' I'i:;,::.:.,,~;',."r,;;~~:.~ r,II,Io1<,,/'(1 ~'. 1l.\,~llll'''''I...~.r,\_':;.,.,1 :~;~..::.~.~~,-::;::l;f" . i,~.~~:~)M..;'~.~.~"')." ..,., .... '...,. I "'t::."J" '1] / ~ 3r '-l":':.~.':'~" I _"'._...._ "'_,,, __J_-'(~ \...~ ......)_ f' /.' .... 1.../ j. l . I~ 0 .."'( If. _,,"-...............04... t~.".,..," I "" I'" .'~"'H'.. ,;.....-.,;..,."i",,'-'.",iIii I ~___..-......~ ,.,.. ,," "', " "':".1) ..,1 I .....J I .' ,.." 1 ,....... ........ .~_......,. ........ . _. ....... . .. .,.. ...... ,. .... ..":' -. "'" . ... ,'.... ,I.~. .,.....~. ...i;; - ~..;;.; ;..';;"-;;';;;;':-~;:;;';' ;;.q~; ..;:;;...; ... \ ....__............._. ;....~..'._. .._..,.~I....~.............,......n" I ............ .....,.--." ~........,--, ........-1.-'... ..._I....lI4fO........... uuU~_..,..... ....~....h_.. _~....__Il1' \: . -- ;;~il- M~......;';J..." .....'".. ".,',., .......,....1>' ;,-,:,::::.'::::,'''.'"., __ ,..,.,..' I..... rl ...11... ...11 ....!I "'"," !!!...--'.!!._- " U..I....J.......... n.'..'_".......'........M... ......"...-.~... "" ........~ ,'" ,. I........-'...._.,...,.J....._...........................-'.. r~ t...,..'-" ,.., "0-. ,.. . .. ,.., l...r I) ,^ _o....c.uuJ.... .........,...-.. -..........., ,,,,,,,,.,,,, ,.., ''','''' ..1" ! .1.. .~ , I I' ,- ~: ;,., .;. ;. ;..~; .;;;:. . . ". --. ,,;;;., 11...11 ~.,j.~.'~'! .. ~ ~ 1:~""" -".'.- ".. ,-."","i-i.'r"J.i "..,;;;-..---- ..... "t,. ',1 "',-.J () O~-:o. ,'I::.'~.~;1~j<Jj~f L,. .1',;:"-;,0.01;",';.," '\....., "~'.~":~" . 'i"., :'IT"'/::'::',\';".:';., .\"1" . I '1 ",.,.;",. .1 1,(".,1."..., 'tlo/,.I- I.. ;'l);:';/:' It"?? ~' i. -. ,."OOOUIOI:_."".,.'.......I."...'.,,-...w..'. ................_...............,........,..._. .",.. .',-M. ...,...."~.'..."... '",.noc:&tll."'''''''(,)tI0''''' (1..-"....'''.-.......122;...... ....... ,,,.~"'...,"::;: t / ,: 7l~;ar ' ,~,,:- ,_ft .--." ~"".,..".,. ... ,>~, .... . " .h".......'.,.., 1?~c.1 COMMONWEALTH OF PENNSYLVANIA COUNTY OF FRANKLIN ss ",W.e, Paul._<;:~ tch.lson, Sr., C"'):;<",...:- ,,\.(.\.,.(~.,..-(, and '-""', .. ,. .Y':.., , the testato;:r;~d the witnesses resp t1vely, whosc numes are slRncd to thc attachcd or foregoing Instrument, being first duly sworn and qualified according to law, do hercby declare to the undersigned authority that we wcre prcscnt IInd saw thc tcstator sign and execute the Instrument ns his w\1l, and thllt he had signed willingly (or wllllngly directcd another to sl~ for him), and thut he executed It us his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hcarlng of the testator, signed the will as witness and that to the best of their knowledge the testator was at that tlmc elghtcen ycars of age or older, of sound mind and under no constraint or undue Influencc; and 1, the said testator, do herehy acknowledge that 1 signed llnd executed the Instrument as my last will, that I signed It willingly, and that 1 signed It as my free and voluntary act for the purposes therein expressed. , . . / " , ~. :/ . ,~I ./" ~ ,'/f/j/:.A.4 <~ ..'-- ) ./ '/.-1/ I ilv LLiU- cr /J..L,wo-- V /3)d;0 X ~( , Acknowledged, sworn and subscribed to he fore me this.,z;':!r day of // "~_. ,1987 ~ ~ ''-..;-~_. '<y;;'" ./ ~~,--~/r~d.'-,: ". /" /////....-' otary Puhlie ~",' I ,I::~' :'I": .', '; ,I. ;- . i'I'''; " .1 '1.. r .' .."11",_,1,-,- ,<< . , ." ~',' ~. ~.." ,-" . rl ,. (\ r /:,)-/U'--:) 1-- .'VHOO(lt pl<.,ll) 19. If line 18 is groaler than line 17, onlor tho difference on line 19, This is tho OVERPAYMENT. r!ljQ 20. If line 17 is greoter than line 18, enler the difference on line 20. This is the TAX DUE. A. Enler tho interest on the balance duo on Iino 20A. B, En'er ,he '0'01 01 line 20 ond 20A on line 20B, Th,. i. ,he BALANCE DUE, ~a~_l!.,~h.dc Payable to: Register of Will" Agont .. BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND TO RECHECK MATH"" Under penalties of pcriury. I declare thol I have ollomined this return, including accompanying schl,dules cnd slolements. and 10 the best of my knowledge and belief, it is)l~c1 cnd comptete,.' do.dare thai all real eslale has been reported olltue market \lolue. Doclarolion of proparer other thon the pena I to ~'!,nloli...e is bpi"ed on alii formation Ol.whi<f preparcr hos ony ~nowledge. . ,/ "..(';)- '1/ ~'GNAfDiEc5 PPt~9i.rRHP6fl!lrn6ffiiTNG-R1lrRN ADc:iRE~~ - DATE :t~~'''~~;;t .;;;;,:"~",__35'~?T>f n, ,0.' .'e." - 0",,'""' ,- ~A_' 7244 "'" I f ~~<~t:;_ft):((:....._:.~,,~~~g.. 110x 83, Orrst~w..'1!..,.!?^-_J7244 1/');,rO .. Z w o w V w o w ~ ..-'" V"',, w"'v :00 v"'... ...... ... <l I.. ::Jz ",w "'0 oz VO ... fOR DATES Of DIATH Ann 12/31191 CHICK HIAI If A SPOUSAL POVI~TY CAlDI,T IS C.LA!Io\II~.JJ _ _ ____ fill NUMBIR L .~ ~ ,.... '.... . ~., ~:. INHERITANCE TAX RETURN RESIDENT DECEDENT (TO BE FILED IN DUPLICATE WITH REGISTER OF WILLS) 21 COU'HV CODE M I A 96 YEAR 0299 NUMBER (OMMOt4WI AllII 0' ~ltH."HYArjIA OIPAIIIMlIll 01 ~IYttfUl Of 1'1 JllOWl IlA.llllt!)IWIlG rA lJ1JtlOf..'1 0'4 tlAMI (tAJ III . AND MI I lNllALJ " Hutchison, Sr., ~O(IAl.~((Ullll'1 tfUM8I R Paul C. -..IDATCOfOfA1H-- IDAU Of B-IRlIl 3-26-96 01-11-15 - ------.-..-.--- .-_.~-- -_..._-------~- ._._--~.. 121 Walnut l1ottom Road Shippensburg, rA 17257 Cumberland -- ~.~.~!- - --.-----.---,----...----- 188-10-0198 I X 1. Original Return [J.4 limited E\lale I I 3, [.J 5, 1'"1 2. Supplemor,lal Return Romainder Relurn (for dole' of deo,h prior 10 12,13,821 Federal eslato Tax Relurn Required Total Number of Safe Deposit Boxes ['] 4a. Fuluro Inlere" Compromise (for do'e,ef deo,h aher 12.12.B21 [X 6. Docodent Diod Toslate [J 7. Decedenl Maintained a living Trust IAllath tapy of W,III IAlloth tOpy 01 Tru"l ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO. NAME COMPlETE MAIliNG AODRE~~ 'LB, ___Joseph l\..!,IJCil1_uso._,__,._.__ HUPHOtH t4UMB[R P.O. Box 83 Orrstown, PA 17244 '" r- , " ::-J z o ;:: :3 ::> .. A: <l V w '" _ L c2P L 5,l2dJ!32 1. Real EI'olel5thedule A) I 1) 69, 000_. OO~~ 2, 510tk. and Bond. (5th.dule 81 ( 21 3, Clo..ly Held S'otk/PorlnOtlh;p In'ere" 15thedule C) (31.~.. - ~- ~ 4. Mortgoges and Notes Receivoble (Schedule 0) ( 4) 5. Cash, Bonk Deposits & Miscellaneous Personal Property( 5) ___.____6_1.7..4 5_________~__ (Sth.dule E) 6, Join,ly Owned Property 15th.dule F) 16) ,__7 ,25~L.36._______ 7, Tronlle" 15thedule Gl15thedulel) ( 7) on,_____ - .-.-- ,.-.-,.--, 8. Tolal Gron Anels Itolallines 1.7) ( 81._ 7 6,_8_68-,_81 ~ ~ e' 191_1J,.9.7.7._8.7_.______ (l01__L.OL9.27______,___ 9. Funeral Expenses, Admini\trotive ColIS, Miscellaneous Exp.n.e. 15thedule HI 10. Debls, Mortgage liabilities, liens (Schedule II 11. T otol Deductions (totallinos 9 & 101 12. Net Valuo of estate lline 8 minus line 11) 13. Charitable and Governmental Beques" ISchedule J) 14. Net Value Subiect 10 Tax (line 12 minus line 13) (II) ,~lJl"S~L'Z...J,4 (12) ,-5.7_,,8.21.._61 (131 0 (14) ........5.7n8.21...67 ..5,7., 87L67_~__.x ,06 = 3,472.30 (151 z o ~ ::> ... ~ o V )( <l .. IS. Amount of line 14 taxable ot 6% role (Include values from Schedule K or Schedule M.) 16. Amount of line 14 taxable 01 15% rote (Include values from Schedule K or Schedule M.) 17, Principal lax due (Add lax from line 15 and from line 16.) 18. Credits Spousal Poverty Credit Prior Payments Discount __0________ + 3,_711. 57 +...1,9,5.3<1 (18) (191 " ..,__3,90.6.._9J__._. 434.61 (l6)....__,._0___,__..,__._.__x ,15 = o (171 ..___ 3,.4.7.2...30______ Inlere" o Check here If you or. requesllng 0 refund of your overpayment. (20) 120A) (20B) PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING A CHECK MARK (1"") IN THE APPROPRIATE BLOCKS. 1. Did decedent make a transfer and: a. retain the use or income of the property transferred, ....................................... b, retain the right to designate who shall use the property transferred or its income, c. retain a reversionary interest or .................................................................... d. receive the promise for life of either payments, benefits or care? ....................... 2. If death occurred on or before December 12, 1982, did decedent within two years preceding death transfer property without receiving adequate consideration? If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................................. 3, Did decedent own an 'in trust for' bonk account at his or her death?...................... YES NO Ix x x IX I I x x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. .IV,'~U'12'1) ~ SCHEDULE E CASH, BANK DEPOSITS AND MISCELLANEOUS PERSONAL PROPERTY Pleale Pr;nl or Type FilE NUMBER COMMONWUUH 0' ,tNNSYlVANIA INHIIITANCI1AX IITUIN ..S1DINT DICIDIN1 ESTATE OF Paul C. Hutchison, Sr. 21-96-0299 (All prop.rty lolntly-own.d with Ih. Righi 0' Survlvouhlp mull b. dllClo..d on Sch.dul. FI ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH See continuation schedule attached hereto and made part hereof. TOTAL (Allo enter an line 5. Reea ilulation) S 617.45 IAltach additional B'h" )( 11" ,heel' if more 'poce i, needed.) PENNSYLVANIA INHERITANCE TAX RETURN Estate of Paul C, Hutchison, Sr. File # 21-96-0299 CONTINUATION SCHEDULE SCHEDULE F - JOINTLY OWNED PROPERTY Joint Tenant: Robert L, Summers ADDRESS P.O,BOI11 3560 OrrslOVln Road OrrstOVll1, PA 172<<.0011 RELATIONSHIP TO DECEDENT ~ A. step-son Dolar Valle of "em Letter for Date Made Total Value Deed's Deed's Number Joint Tenant .!2In1. Deseripllon of Asset ~ !!l1. 1. A. 2-1-82 Checking Ace\. 5,174,45 50 2,587.23 134 086 3 Orrstown Bank 2, A. 3-3-82 Savings Ace\. 9.328.26 50 4.664.13 #7001 Orrstown Bank TOTAL $7,251,36 .l~ l~lll" 1'"1 ESTATE OF ITEM NUMBER A. 8. Il~ij;} COMMONWEALTH Of P[NNSYlVANIA INHUltANC[ lA' RnURN RESIDENt O[([D(Nt - ~-~-- - - " - .-. --- -..-- SCHEDULE H FUNERAL EXPENSES, ADMINISTRATIVE COSTS AND MISCEllANEOUS EXPENSES --- - -.. -. -_.--- PleasoPr!n! or Typo jFILE NUMBER 21-96-0299 ->---------- - Paul C. Hutchison, Sr. DESCRIPTION AMOUNT 1. Funoral Expens..: See continuation schedule attached hereto and made part hereof. Administrative Casts: 1. Personol Reprosonfntive Commissions Social Security Number of Personal Repre.ental;ve: Year Commissions paid 2, Attorney Fees 3, 4, C. 1. 2. 3. 4, 5, 6, 7. 8, Family Exemption Claimant Addren of Claimant 01 dece'!.n!', dealh Slreet Addr... City Probate Fe.. Miscollaneous Exrense.. ~Qlationship .::''''. __ Zip Code TOTAL (AI.a onler an line 9, R.capitulatian) S 17,977.8?_ (If moro spaco Is needod, insert additional shoets of sarno sizo.) T r- ,- \ PENNSYLVANIA INHERITANCE TAX RETURN Estate of Paul C. Hutchison, Sr. File # 21-96-0299 CONTINUATION SCHEDULE - PAGE 2 SCHEDULE H - FUNERAL EXPENSES. ADMINISTRATIVE EXPENSES AND MISCELLANEOUS EXPENSES C. Miscellaneous Expenses Legal Advertising - News Chronicle $ 56.50 Cumbo cty. Law Joumal 60.00 Lawn maintenance - 230.00 Danny Strayer Roof repair to residence - Dean's Roofing 1.175.00 P.O. Box (No. 121)- Orrstown P.O. B.OO Advertising auto - Kuhn Comm. (cable TV) 14.00 Advertising auto - Newspaper 24,75 Sewer - CFJMA Joint Auth, 141,00 Heating 011 - Timmons Oil Co, 376.65 Trash disposal - R&A Bender 124.50 Dumpster - Kelly Dump BoxlCumb, cty. Landfill 208,55 Electricity - Penelec/GPU Energy 236,25 Real estate taxes - Thomas Dick 686,91 Settlement costs -residence Realty Transfer Tax - 690,00 Real Estate Commission - RElMAX 4,140.00 'Ivl~'J 'I. 1'''1 \ SCHEDULE I DEBTS Of DECEDENT, _ MORTGAGE LIABLlTIES AND LIENS 1 PI.a.. Print ~! Typ. FILE NUMBER '!~@~ COM....Oflwt All" Of "NtlillV"UI" INMII.'''N(lI.U "lUlU IUlotNt OlCIOIN1 .- --_.---- --- ^ 21_96-0299 ~- ESTATE OF Paul c. Hutchison, sr. AMOUNT DESCRIPTION ITEM NUMBER -'-----'-- I. See continuation schedule attached hereto and made part hereof. TOTAL (Also enlor on line \0. Recapitulalion) (II mar. .poc, i. n..d.d, in.ert oddilionol .h..ts 0' .ame .i.e,) S 1,019.27 Item Description Amount Real Estate 1. Residence at 3541 Orrstown Road, Orrstown, PA 17244 (as per HUD -1 settlement statement, a copy whereof Is attached hereto). Jointly OWned Property - Bank Accounts 2. Checking Account #34 086 3 Orrstown Bank ($5,174.45 x 1/2) $69,000,00 2,587.23 3. Savings Account #7001 Orrstown Bank ($9,328.26 x 1/2) 4,664,13 Personal Property 4. Automobile - 1981 Chevrolet sold 600.00 Miscellaneous Property 5. Insurance refUnd - State Farm 17.45 $76,868.81 TOTAL H i'" :;l -go tl !=' ro- r- = # : ",:" ~ ' UlO'l,O - LoJ . :r......(I>> ~ 0 ....,.,b,.ro .. GO i Po N :'0 ~ !. 0'1 .'0 :o:f N olD O' . => 0: '> th - "en ", IS : tJ"rD: . c:: :tt"X a. - . ., 'llI ~ : IS 'lQ C :n '" >_ ::3.A1 ~ II . C"... 0 IS - 00 - . 'tl 'C 0 > ::I>08)n III -< _' 'C D .... ........ . 8 o...,J . a'N . CD : U1 : K' '<.-.J : ~~ :t s ~ ~ iD 'tl :c e 0 "" - . h 0 Q ',Ul . ~ ~ ~ .'::1' . ~ .1..... ~ :'tJ ~ N "0 ,.,. 0 . III g. 'tl ... t-' :=> 0 ~ = . ... 0 & \0 .en .... i!; pl '0' (Jl 'tl Q 'C ~ ~ . :., t;J ~ '0 ..0 . 'N . . '" '''l :Ul '" '0; .1'\ ~ ~ Iii . '. . - to a. lI: ~ III $. INVEN'I'ORY IN RE Estate 01 ;..~'!\l}.. .l;:,. .lil!-\:~M ~PJ\.. I)x,.. late of ,. ~."~I?P!,~l)!?P.4J;'9...'I;Iit>................ Franklin County. Pennsylvania. STATE OF PENNSYLVANIA. COUNTY OF ~K&IN; Cumberland 55.: I verify that the statements made in thh Inventory are true and correct. I understand that false statements herein are made subject to the penalties of 18 P. A. C. S. Section 4904 relating to unsworn falsifications to authorities. 7';))7 I I Date NO. /) , ~"_i?1~ ~i ",,< L.J/ Signature ITDl AMOUNT See reverse side \ ., , .,.- -'. .._ _.... -r'..... '" . Ret:,:' F/' " '0 ~ ,C oJUH 18 CIL" Cum'., .- \ t L':' .,':.!l:;, "'? "3 r"l........ ...., , ;'Jrl FA ...........- ~"~ ..._.-... ~--" ,row ,I t - " I"~ 1 i . ;. , " ,~ .., " , " \. -, t, . I ~. ~ .' ., ...,...-......31. r--- ~ - ... ,., r' -.-t - :.,' ',1, ~ ~l ," ,.--' --. --- .... -'" , - ROBERT L. SUMMERS 3560 Orrslown Road P.O, Box 11 Orrstown, PA 17244 ,....-~, . ',~' ". ') l' '.' / : I' \ I; J '~ ...rnl....1l1OOo ::::=::-::':_']j\?C~~< -: ~r'__"'_'___ '.. ~..- ..'.------- .- ~ .- _. ..--.... .. ......' - . ....--.- -...- .~ 02/- 9& -02Qcr Register of Wills Cumberland County Courthouse 1 Court House Square Carlisle, PA 17013 17en-'33-='2 132 ""/1/",11/"""1",1""1"",1,1,'",,1"",,,,,,1111,," .. ~""'.c. ''-'''''''''.~'_'''"''~-'' ~"'~. '. ,_ ,,,,._.,, ;:..-<__.~;"':.~,;~-,'._ '..J.~, ';;'.00 ",':: '. '~::'"~''' -,. ~._.-<...-.-~,--."._,-" ..,..<<..-'."',.(...... -,-~'.."......_-~. .'. ...l..".....-- , , " ';'" I " ~ .\ , ,,~~. ,. ~"'.It- I ' , t .' , f, ,~ ''''J " ~"t. )- .. . ~ .. ,I , " . r, ,: '. ,.; 0., . .,.,. Y' ..-.- ,r-'~ . . . , " , ~ _..l~ . , I -, ~. \' :< ., ',' r- ~- , . --~. to.. - 4"'-. ,._ _... .... << - ,....- ",-.. \ Re"'" ". ..'".,IL.. RJ '.1" ! :c: of I vilis '96 ~utl 18 P12 :33 Clark,;:: "'I. .1 C' '."beli<.n::l (" '.., ..-., .. . , -. . 'n ,I , . . . r.. ; " .. .... ,., f ,f . ;. . ~' 'J ._ .~ . t. \ ", ~. :< " . "',! " ~ -'-" ....--..-..--. .,--' .----' ---~' - ..~. -.;;.)f. 4.- - i,.. 1~,:~"" . / / / )0 . J /5-C)4' -S- COMMONWEALTH OF PENNSYLVANIA DEPARTHENT OF REVENUE BUR[AU OF INDIVIDUAL TAXlS 1~1'IWIIA"'f1 TAli Il1\1151l1'" {ltIIT, ,'lIOhOI ItAIIWI'.>flllWr., "" l/l:" tll,nt NOHt[ or INHf:HIlANCr TAX A"I'RAISUl(NT t AllOWANCt OR Ot5AllOWANC[ or olOUCI IONS AND A5SlSSMtNI or TAX JOSEPH A MACALUSO PO BOX 83 ORRSTOWN PA 17244 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN ; ( ~ 08-11-97 HUTCHISON 03'26-96 21 96,0299 CUMBERLAtlO 101 ^"ount Re.1i t ted ~~ ... ,. . ~.... "I~" ~",.:,Oo. " ',f~,.I'.'1.,.'rt ':'-.,,\\\ f.r.'..,......,1 '_ 't... i. ~~'!~' t>7 ~ . -. '" .101111" "lll. PAUL C 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 .... R'EV:isiii'EX'-AFii-io;i:97i--Nor-icE--OF-i-NHER-ifAiicE-ifAX-iiPPRiiisEtiENT~--ALi-oWAiicE-O-R----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF HUTCHISON PAUL C FILE NO. 21 96-0299 ACN 101 DATE 08'11-97 If an assessment was issued previouslY, lines 14, 15 and/or 1&, 17 and 18 will reflect figures that include the total of ahh returns assessed to date. ASSESSMENT OF TAX: IS. Anount of Line 14 1&. A~ount of line 14 17. Anount of line 14 18. Principal Tax Due TAX RETURN WAS: I X 1 ACCEPTED AS FILED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate ISchedule AI III Z. Stocks and Bonds (Schedule 8) (2) 3. Closely Held stock/Partnership Inte~est ISchedule C) (31 4. Mortgages/Notes Receivable ISchedule D1 (4) 5. Cash/Bank Deposits/Misc. Personal Property ISchedule E) IS1 b. Jointly Owned Property ISchedule FI Ib) 7. Transfers ISchedule G) (71 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Fun.~al Expenses/Adm. Costs/Misc. Expenses (Schedule HI (q) 10. Debts/Hortgage Liabilities/Liens ISchedule Il 1101 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governn.ntal Bequests ISchedule J) 14. Net Valu. of Estate Subject to Tax NOTE: at Spousal taxable at hxable at rate Lineal/Class A rat. Collateral/Class 8 rat. 115) 1161 117) TAX CREDITS: PAYHENT DATE 06-18-96 RECEIPT NUHBER AA112945 DISCOUNT I-I INTEREST/PEN PAID ('I 173.62 1 CHANGED 69.000.00 .00 .00 .00 617.45 7.251.36 .00 181 17.977.87 1.019.27 1111 112) 113) 114) .00 57.871.67 .00 X .00= X .06= X .15= AHDUNT PAID 3.711.57 , TOTAL TAX CREDIT i 1.---..- ' !BALANCE OF TAX DUE. INTEREST AND PEN. TOTAL DUE NOTE: To insure p~oper c~edit to you~ account, subMit the upper portion of this fo~" with your tax paynent. 76.868.81 1R.997 14 57.871.67 .00 57.871.67 liB) .00 3.472.30 .00 3.472.30 3.885.19 , 412.~~ .00 412.89CR' . IF PAID AFTER DATE INDICATED. SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. I IF TOTAL DUE IS LESS THAN ~1. NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR1. YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FDRH FOR INSTRUCTIONS. 1 .:.., " . ~v RESERVATION: E.tate. of deced'nt. dying on or before Daca.ber lZ, 198Z .. If any future Interest In the a.tate I. transferred In po.se..lon or enJoy.ent to Cia.. a (collateral I beneflclarle. of the decadent after the expiration of any e.tat. for life or for years, tha Co.eonwealth hereby e.pre.sly re.erve. the right to appral.e and a..e.. tran.fer Inheritance Ta.e. at the lawful Cia.. a (collataral) rate on any .uch future Intera.t. PURPOSE Of NOTICE: PAYHENf: REfUND (CR): OBJECTIONS: ADHIN ISTRATlYE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: To fulfill the raqulraftant. of Section ZI40 of the Inharltance and E.tata To. Act, Act ZI of 1995. (ll P.S. Section 9140). Datach the top portion of thl. Hotlca and subalt with your pay.ent to tha Pagl.tar of Will. prlntad on tha rlver.a .Ida. ..Haka chick or .0nlY ordar payobla to: REGISTER Of' MILLS, AGENT A refund of a tax cradlt. which was not raquastad on tha Tax Paturn, .ay ba requa.tad by coaplatlng an "Application for Rafund of Pann.ylvanla Inharltanca and E.tata la." CREY.1313,. Application. ara available at tha Office of the Regl.tlr of Will., any of the 23 Pevenue District Offices, or by calling the .peclal 24.hour answarlng .ervlce nueber. for fora. ordering: In Pennsylvania 1-800-36Z-l0S0. out. Ide Penn.ylvanla and within local HarriSburg arIa 11111 181-8094, TOOl 111/. 17Z-2ZSZ IHlaring tnpaired Only). Any party In interl.t not .atlsflad with the appro!'a.ent, allowance or disallowance of deductions, or a..e...ent of tax (Including dl.count or Intere.tl as shown on this Notice nust objact within .Ixty (60l days of receipt of this Notice by: .'wrlttan prote.t to thl PA Depart.ant of Revlnue, Board of Appaals, CIpt. Z310Z1, Harrisburg, PA 17128-1021, OR ..elactlon to have the .atter datar.lnad at audit 0' tha account of the parsonal rlpre.entatlve, OR --appeal to the Orphan.' Court. factual arror. dl.covered on thl. a,.a...ent .hould be addre..ad In writing to: PA Oapart.ant of Ravanue, Buraau of Individual Ta.es, ATTN: Post A..a...ant Ravllw Unit. Capt. Z80601, Harrllburg, PA 171Z3.0601 Phone (717) 787-6505. Se. page 5 of tha booklet "In.tructlons for Inharltanca Ta. Raturn for a Ra.ldent Decadent" (REY.lS01) for an explanation of ad.lnl.tratlvely corractable arrort. If any tax due I. paid within thrae (3) calandar eonth, aftar the decedent", death, a ,lvI parcent (5~) discount of the tax paid Is nllowld. Th. IS~ tax a~e.ty non'partlclpatlon penalty I. co.puted on tha total of the tlx and Intara.t a"ess.d, and not paid beforl January 18, 199b, the first day aft.r the and of tha tax a.nesty period. 'his non.partlclpatlon penalty I. appoal"hla In the sa.e "&nnlr nnd in the the sa.. tifta parlod as you would appeal tha tax and Int.ra.t that ha. b.en a..I"ld as Indicated on thl. notice. Interast Is charged blglnnlng with first day of d.llnqu.ncy, or nine (91 .onth. and one (I) day fro. the date of d.ath, to the date of pay.,nt. Ta.e. which becaae delinquent before January I. 19BZ bear Int.rest at thl rata of six (6XI p.rc.nt per annue calculated at a dally rate of .00016~. All taxI' which beca.a dellnquant on and after January 1. 198Z will baar Interest at a rate which will vary fro. calandar year to calendar year with that rat. announc.d by the PA Depart.ent of Revanue. 'he appllcabla Intare.t rat.s for 198Z through 1997 ara: t!!! Inter.st Pate Dally Interut ractor !!!! Intarut Rate Oally Interl.t ractor 1982 ZOX .00054B 1981 .~ .000Z47 1985 IU .000438 19B8-1991 lU .000301 19B~ ll~ .000301 1991 .. .000Z47 19B5 U~ .0003S6 1993-1994 n .00019Z 19B6 lOX .0aoZl~ 1995-1997 .~ .00al~7 uInterut Is calculated .. follow.: INTEREST = BALANCE OF TAX UNPAID X NU"BER OF DAYS DELINQUENT X DAILY INTEREST FACTOR .-Any Notice Issued aftlr the tax blco.es dellnqulnt will reflect an Int.ra.t calculation to flft.en tiS) day. b.yond the date 0' thl a..ess.ant, If pay.ent i. .ad. after the Int.r..t co.putatlon dati shown on the Notice, additional Interllt IllUst bl calculated. PAV"ENT I D.tach the top portion of thl. Notlc. and .ub.lt with your pay.lnt lIIadl paYftble to the na.e and addrl.. prlntld on the rlv.r.. .Ide. I ~ ~ If RESIDENT DECEDENT .ak. ch.ck or .0n1Y ordlr payable to: REGISTER OF WILLS, AGEHT, If NON-RESIDENT DECEDENT .akl chick or 1II0ney ordlr p.yabl. to: COHHONWEAlTH OF PENNSYLVANIA, REfUND (CR)I A refund of a ta. cr.dlt. which was not r.qu..t.d on thl la. R.turn, .ay be r.que.t.d by co.pl.tlng an "Application for A.fund of p.nn.ylvanla Inh.rltanc. and E.tat. 'a." (REY-ISISJ. Application. ar. avallabl. at tha Offlc. of the Ragl.tlr of Will., any of the ZS R.v.nu. DI.trlct Offlc.. or froe thl Dep.rt.ant.. Zit-hour an.warlng .arvlc. nuablr. for for.. ordarlngl In Pann.ylvanl. 1-800-S62-20S0, out. Ide Pann.ylvanla and within local H.rrl.burg .ra. (111) 181-8094, 100' Cl(1) 112-2252 CH.arlng I.p.lred only). REPlV TO: aua.tlon. ragardlng arror. cont.lnld on thl. notlca .hould be addra..ed to: PA napart..nt of A.v.nul, Burlau of Individual T...., ATTHI Po.t A.......nt R.vl.w unit, Dapt. 280601, Harrl.burg, PA 11128-0601, phone (111) 781-6505. DISCOUNTI If any ta. due I. paid within three (S) c.l.ndar .onth. aft.r the dacadant'. d.ath, a five p.rcant (5X) dl.count of the ta. paid I. allow.d. PENAL TV I Tha 15~ ta. aana.ty non-participation panalty I. co.put.d on the total of the ta. and Int.r..t a......d, and not paid bafore January 18, 1996, tha flr.t day aft.r tha .nd of the tax a.n..ty period. INTEREST: Int.r..t I. chargad b.glnnlng with flr.t day of dallnqu.ncy, or nine C9J 1II0nth. .nd one CI) day fro. the data of d.ath, to tha data of pay.ant. Ta... which bac... dellnqu.nt before January I, 1982 b.ar Intare.t at the rata of .1. C6~) perc.nt par annu. calculat.d at a dally rat. of .000164. &11 ta... which baca.e d.llnqulnt on and aftlr January I, 1982 will b.ar Intarl.t at a r.t. which will vary fro. calandar yaar to cal.ndar y.ar with that rat. announc.d by the PA D.part..nt of A.venue. Tha .ppllcabl. Intar..t rat.. for 1982 through 1997 ara: Vear Int.r..t Rata Dally Intara.t Factor Vaar Intar..t Rat. Dally 1ntarl.t factor 1982 ZO;C .000S48 1987 .~ .00DZ41 1981 16~ .0004S! 1988-19?1 11~ .ooonl 1981t lU .000301 1992 .~ .000247 1985 U:c .DOn56 1995-1994 7~ .000192 1986 lOX ,000274 1995-1997 .~ .00QZ41 --Intar..t 11 c.lculatad .. followll INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notlc. I..uad aft.r the ta. bacoa.. dallnquent will rafl.ct en Intar..t calculation to flftaan CIS) d.y. b.yond tha data of tha ........nt. If pay.ant I. .ada .ft.r tha Intara.t co.putatlon data .hown on tha Hotlc.. additional Intara.t lu.t b. calculat.d, CERTIFICATION OF NOTICE UNDER RULE 5.6 ( il) 00 ~fi? \(~ o. ,.)JJ " r, Name of Decedent: Paul C. Hutchison. Sr. Date of Death: ( ~ 3-26-96 Will No. 00299 of 1966 Admin, No, 2196-0299 N \:1 To the Register: ~, )>~ ;,.... c.) .,.'. <.' ('-:', 0\ I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries uf the above-captioned estate on 4-26-96 Name Address Robert L. Summers. Jr. P.O. Box 11 3560 Orrstown Road Orrstown, PA 17244 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Notice not given to two sons disinherited per article SECOND of will, whereabouts unknown to decedent as per will. Date: (, )';:).;)./% , ( . Macaluso ~ .~4-71~d .' Name Annress 9614 Rowe Run Loop Shippensbura. PA 17257 Telephone(117) 532-4832 Capacity: Personal Representative x Counsel for personal l'epresen ta t ive , STATUS REPORT UNDER RULE 6.12 Name of Decedent:____~ ~ I/ufr>/' ;.>DY? Date of Death: 0'> /;}""/9 G r J. ~ l~qro-()217 Will No. 00 2.'19 o -LJ:Lq4- Admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completIon of the administration of the above-captioned estate: 1. State~ether administration of the estate is complete: Yes No 2. If the 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 re~sentative file a final ac:count with the Court? Yes No . pe..,-s.,,'ht'\l R.~e-,y.."f,~ ~s :> ok be..-.e.h'v,''''''1_ b. Th~ sera l'a te Orphans' Cuurt No. (if any I for the personal representative's account is: 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: l.{ lJ7 j9g ./ co ~...: ..-:" ";..: a t.u e -To~~h A. fIIIc,c",Lu5l'l Name (Plea e type or print) Q(PII../j1owe ((<1'7 Loop,,5h.;ppen~ ~PA 17')\71 Address ' CJ I (7n 'S"3 '2. - 4 ~ 32- Te I. No. 15,/, ??": M 0.. N a: 'Z L. o'~ uu mC!: C!: 0Cl p' ._ I- ~::i r..)(j CapaciLy: Personal Representative ~nsel for personal representative (MAH: rmf/ AM3)