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HomeMy WebLinkAbout96-00301 PETITION nm IJlmUATE IInd (;I{ANT OF LETTlms ;;tl-Iqqlt> -J() I. bl,l/e' 01 Sidney H. "/\1,11.1101"" u\ Sidney, Andersen Ilonid ^ndersen No. 1"0: /,(.,.(.(/\(.,/. Ik~i'll'r ,,' \\,ill, '''I Ihe CllIIIIIY ,,' Cl1lllbe.rl.~_n_(!.__ ill Ihe ('OIlHI101l\\l'allh of Prnnsylvania SociaIS..../lrityS". 101-.22-.3963 1'lIl' p,,'lil itH) e,r Illl' IIIUkl ..i!!IIl'd Il'''pl'l'llllll~' fl'P' l""'III.. l1lal: " . . I' I' II I ors 0111 1'"'1I110Ill'I('). \\ III 1'1 ,Ill' N Y"'ill' ul OI!!l' tll n ll.'l allJ Ill..' l"t;.\.'~196 inlhl' la" \\ill of I I h.' aho\l'dl'\"l'dl'lll. dall'd January ]u._ J .~_~ and codicill') dall'd n/a ._~_______ nilmru ,19_ t'I,l1l' .dl'\,lJl1 ~lInll1l\I.II'~'~", \'.~. 1\'lllllh:I,lIitlll. dl';llh tlll'\\:\."lIlur. l'll'.) 11e,endl'lIl \\;1' dOIlli.:i"'''. al <ll'alh in ..Cumbef+anrlhi d. St.-"~liu,nlcJ~Ble't'nlli'lI ~'ilh h .!~. 101'11.111111\ 01' prllll'lpalll',IUl.'I1I.'l' ill _ j, T .r__~ ____ _.' h__.,..~ __I'^' ... New Cumbel"liJnd Cor~ugl.:.u___._ _u_____u_ (11" 'II~'~'I. 1111111"":1 ,lIhlllllll1~'lp,dll~1 , Ik~~"IC'~e~'t':'ritlt ~L , ~tl~k'~ af{a~~~n~~..r~~ 7carboncounty--' 19 96.., .11 _ _ ____.._ _..~~ _....__.~__.._~._._._+_.._ _ __,..~ _ _.______....__ r'I.'l.'pl ;1" lilli,"'.... dl'~l.'dl..11I did 1101 marry. \\0,... nol di\'ofl'l'd and did nol have a I,.'hiltl horn or adopled aft",'1 ""\,,'l'ulioIlOf 111.., \\ ill offt.'rl.'d fOf prohah.': \\a... 1101111,,' \'klim of a ~illing and Wit... nc\'cr adjudicated ilh:lllIIPl'Il.'IlI: _ .~nla ___ ...___.____.~ _________.___.~_____~~ Dl'(l'lHknl ~:I t.kalh tH\l1l'd propl'l'IY \\ith c...till1i.1ll:d \'alllc..... 01\ rollo\\\: (If dl1lll1':iled in I'a.) All per'"nal prnper1~ (If Illll uomil.'ikd in PII.) P'-'f\onal prOflt,'fty in PCIH1\yh';Jllia (1111111 \hHllh,:ih:d ill 1'01.) 1)"'f\tlll~11 propc.'rly in t"HI111y \allll" tlf fl.'al "'....(;11". ill Pl.'IlIl,,~hania \ilUah,:d ii' lulhm...: __n/a $ __9...o.llQ._0J>_ $ $ $_ \\ IILKU(lIU., pelilioller(,) re'pe,lfnll~ reqne,'(\) the prohar.: 0' lite la'l will and eodicil(,) pre"'lned herell;.h allll the ~ranl of Ielll'r, ._ t(:!s_tCJmen_ti'lry_ .. Ih""I'HI. li~'.I,llll~'lII,II\, ,ldllllllJ'll,lthllll'.I.;I.; ,hhnini,tr.uuln d,h,n.l',I,a,) -1 - " [' , ......- Janet Ruth Peler~on -~. /, , , J .. i! ,...!. i.,_.. ,_'.1, . I, -. ;- c j OATil OF PEnSONAL nEPnESE\TATIVE (,O\'\'O:\WE:\I.T11 OF I'E:\:\S\'I.\':\:\I:\ I .. Cot :VI'\' OF Cilrbon ....____ j' "" I Ill' I'l'l lIii.llll.'l b) ;lbtl\l'-II;t~lIl.'d "'\\\,',11("') 01 allirl11('I th.1I lhl.' 'lal\,'I1I1.'II'" inlhc fOfcgoing petition arc II Ill' ,1Ild ~'IHln:1 Itllhl' b\,....ll'f Ihl' ~lItl\\kd!!l' alld hdid (If pl.'lilitllll.'rhl and Ihal a.. pCf~(lnal fcpr,,"cl1- 1;tII\l'f'.1 "llIIl' ;111tl\l' dn.'nll'lIll'lIilioll,,'n,) \\ill \\l'lland lIuly allrtlini'ln Ihl.' C,WI,,' .h.,"l,.'oruing 10 law. , S\\llTll hi III hl.'lt'll' I1h: Illi... t '. . ,. '.. ~ R'uth' Pett!rson-- ;; --.----- ::: '" :: ~ 2 &l11I11I1\,d and c_,o;:.' __, _ .~(. ( 'ulh,,'lih,,'d da~ 01 1'1 :". , ,.../ -'." . - -:.:."r; . " I . /U:'e<iwr 1 Janet No. ~~\iOI Estllle of SlDNEY HOM.D ANDEIlSEN {Ilk la SI DNEY 1l,'I~~F<<Sl!(fN nEClmE ()J-' PRonATE ANn GRANT ()J-' LETTERS AND NOW APIlI L 11 ..__ 192L, in consideralionof Ihc pClilion on Ihe re"me side hereof, salisfaclory proof hi"i3,^~'URRlfse~bed h~fg!f6ne, IT IS DECREED Ihal Ihe instrllmelll(sj dmed____._... '... dcscrihcd Ihcrein he admillcd 10 prohale and filed of record as Ihe la,1 will of SlDNEY ROALD ANDERSEN a/k/a SIDNEY R. ANDERSEN and lCllers TESTAMENTARY arc hercby grmlled 10 _JANET_RU'l'Il_PE-T-ERSON_AND-KARID4_J~.cE-SM-l.!t'-Il-a+kla- KAREN SANDNES SMITH ajJ5.ja KAREN s........sMITH ~-1?li.y.cl{iU.1 :\<Ie .~};'l~~wV Rcgi\lrf ~r Wilh /1 C. LEWIS /- MARY FEES Probalc, lCllcrs. Elc. ......... $ 40.00 Shorl Ccrtiliea!csU j .. . . . . . . .. $_..3"'88- x.page~ ~. RcnllncmllOn ................ $____ JCP $ 5.00 TOTAL _ $ 51.00 Filcd . APRIL .l.l...1.996............. .\HORNEY (Sup. Ct. I.U. No.) ,\I>DRESS PIIONE ~ szt .... ~ OtJl 1>:;;: I""l 0 a.. .) . .~> ~8 ~ (.) t.. I '0 r.) .. .~ w (:" ~ t.J :-i: .- . ii o ~.., ; .0 uC) ~ ~E ClIa: a: ~8 MAILED ORDER. LETTERS TO KAREN S. SMITH ALONG WITH /:'."il/(' II/ '~di, ,(" a/w All,;"" 1/\ . -.':., II I ,le. " PETITION FOlt 1-lmUATE lIlId G1tANT OF I.ETTEltS ~I-Iqq(o - ~Ol I, , '..(\.'1 I f( I '...' 1-, 'i/lLl{I~(1 , SIl, 10: 1)I'I't'O\I't!. Ilq",le, ,,' \\,ill; 1111 Ihe ('tHIIII\- of ' , ,,_ j, I'J,1 J,_~_ ' ('olUlIloll\\c:allh 01 Pl'lIn'yl\'allia ill Ihe Sot'wl ,\'I'('IITIlY.\'o. I I: '. " - ',11.., ::l nil' PC:llliOIl ,.1' Ihl' t1lHkl\Ij!lIl'd Il"pl'I..'lllIlh Il'pll"l'l1l\ Ih,lI: YOlll Pl'lititUll'r('J, \\IHlI' ;lIl' IS n',lI' ulll~l' 01 llldl'1 ;llIllIl'l'\l'I..'1I1 C" .... in Ih\.'la'l \\ 111,'1 Ihl' aht1\l' dl'I..'nklll, dall'd ,/ :."1'/ ". - ,.- ---. ami (odh.:ill\) dall'd ._ llilll1l'd ._______.1')..______ 1'I.lI~' rdn.11l1 ~1I.lI111'I,lII.I:\.~'}'. 1\'t1l1nn,tlilm, d~"l1ll III 1'\l'(llllll, l'kl' { lFlr>._k,,-,- (' (d. ,~)C'" C,n( IkL'l'IHh.'1I1 \\iI' dOl1lidll'd ill d\.'i1lh in ,_~__<_._ .____. County. Penl1'yl\';mia, wilh It J:-J__ _ la... fOl,lt1ily (II prinL'ipal Il....idl.IIL'\.. al _ I j ..J':_~ r.I:\,~~__r_' _~l J___:.i_u--L1-......L!~j.=!.LJ..iL" t-''''.,c'_-'',j'}l,lL'./ "J..I ,/.1' .1.( ~"_1",l!,_.__L:Jl~______.__ 111'1 'lI~'I'I, IIUlllh1'1 ;111.1 1I11111~lpOlht~ I I!,wmklll, ,h,'n It~' /. ~,'ar' ", a~",dk" _ __v '_\.\.1<:.. L~1i .:_L~___..~.. PI Ii (; . at.)'..- (,,':..11.,-,1 ':'l, Lu/u./l"luL>_'.41__J.12.L"-ILl~!.L.LJ14_r_/~. r\,,:l'pl a.. h,IIO\\\, dl'...'l'"kl1l did 1I0t lIlilrry. \\iI'" h~lI di\tlfl'l'd all{l did not ha\'e a l'lIild horti or adopted ~':~':':II~I~~~'~:::~'n "I the" ill "I !e'~\I\'~""b;oI";\:"~ n:,'I~e.\kli~lllla_~illil~~__a~~_\:'" nem adjudicated IkL'l'ndl'lll al lk:llh \,l\\I1\.'d IH\,lpl.'lt~ \\ilh l'...lirnall'd \lIllIl.'\ a... Itlllt1\\'\: (If dlll11idkd ill 1'01,1 ,\11 Jll.'r"ollal propl'ny fllllPl dOl1lkih:d Itl Pa,) Pl'r""'l1~11 pltlpl'rt~ III Pl'IHI'yh.lI1ia (II lIot llol1lil'ikd III POI,) Pl'I't1l1al pruPl'llY 111 County \'altll' "I' I'l'al ...''':all' 111 I'l'1II1,~hal1ia \illlall'd iI.. 1 \.1l1l1\\': /r1 LJ,( ((, (' (' $ $ $________ '/1. \\ IILRlJlllIL. I'eli'h,nel(') re'pe,lIl1l1~ prl'''l'l1ll.:d IIl'fl'\\llh and Ihl' glanl (llll'lll'l' leque,I\,) I Ill' probate II! Ihe la', will amI wdidl(s) -tL~IJ;. '1.1_"_n~fa-'-L/____~n_ 111:,I,UlIl'nl.If\; .tdlllll:l.lI.I!f.lll ~',1.;I,; ;UI11l1m\lraliOIl d,tl,n,~:.l.a,) Ihl'I"II, - i: ~! i' , ,/ .. ; } '-1 \.0 (C.l '\ '. (\"i (''',..')tl:[ Il.. c:J~c XII 'l.!-t,-, -'V,,-,,, 'f ' . ....;j.'J;d0..y-~.: :UI ,'(~'~J~,(.j,:' ,)."jr.. ,< :~I ~-L:"~":..:1/)Ju.~-!z., .. _ ,,-_..!/ '--- /':'-,_1(/:>.]":'1'-' (, a:ulL),. o..L~', L',-IC-"1.~)-.:.:)..._6-S I-Lu_LJ:' __'''CLlcCLLlL.:. ()) It '/ ~, ({('!...J. ~ t , "Ie k~j1-c..i._!L_____ }-'". , .- .s. .' ,) -, 'l;,4-l L~l.l ...., .;;,/.1.1_1--'1 3(1 sn a ' f f "- _ .c_ _,-JLLl'1 c. CL_'--l.r.. . (',) ",p illll, PP'J'7C'" ~:.. ." i ----~_._---~.~-,._------- -- - --.- _...__.~-~_._.__._-- OATil OF PEltSONAL REPRESENTATIVE (.'O:\IMO"i\\'EAI.TII OF l'I':'''iS\'I.\'A:\IA COl:'iTY OF Cumb'"r l'ln_d..____.______ I j' tiS IS,LlLP-8 I IIl'I'l.':llit1I1l'I(') abO\l' n:lll1l'd '\\l'arh) l'l' allirlllt') Ihallhl' \lall'I1I\.'II"" in thl.' foregoing. pl'lition arc tllll' ,lIId .:Il!I\.....1 lullh: hth.ll" fhl' ~Ihl\\kd~l' alld hl'lil.'f or f'll'liliolll.'r(!\) and lhat a... pl'r!\llllal rcprcsen. lali\l'(..,.d Ihl' .lIhl\\.' lkl..'l'dl'lll Pl'I:liplh 1('1 \\ill \\\.'11 i.lI1d Intly .Jt.ll11ini\tl'r Ihl' 1..'\10111..' al'l'urding 10 1a\1\;. ! L /' ..-/ S\\tHII ill tt! ,t:llIl1Il'" ,:lld ..Uh'l"lhl'd I J(LLLJ~..(.(_'-IC~~___j~_L~J~__ r.r. hdllll' Ilh 111I" 21st d," 01 .; J C. L'__ L'AJ.J~ >.!._f'i._-:. -(---- -~--- ~' __March, _ J"96{) 1c..-<..L/.I_/tL,<J::L'U<"'_:__J,fJ..,t..lLr_ ~ ~fI/CLLY (;*<M~-fi \ o,.lI))'jL,u "u.J!j'l : L7'r....') {-U"A.Pf; --, =t-- -- - ---- ~ Mary c. Leln:; 11.'."10" l IfLL-t<-JJ-JUL _L,-_ ~ .. . LAST W 11.1, allll 'I'ES'I'ANEN'I' of S IIINEY HO,\l.1J ANIJEH:;I'::~ I, Sidney Hould Andersl'n, a resillenL of New Cumherland, Pl!nnsylvunlu, declare thut this is my Last \~i II und Testament 111111 I revoke all prevlons wills and codicils. I. 1 huve never heen murrled and I have no children or grundchll- ren. :.1. J make the following specltic gilts: To any relative who desires a phOLO . photos, slide or slldes of themselves or Lheir family, they may take such slides or photos as they wlsh. 3. 1 give nil the rest of may properLY, whether real or personal, wherever locnted, to John Edward Andersen, my hrother, or if not surviving, sell nil properLY and distribute the ussets equally to my sister, Astrid Elizabeth Solberg,and my deceased siblings children, my nieces and aephews, Per Sterlpes. 4. All beneficiaries must survive me by thirty days to receive any gift under this will. If nny beneficiary and 1 should die simultaneously, I shall be conclusively presumed to have survived that beneficiary for purposed of this will. 5, I appoint Janet Huth Peterson, my niece of 7 Scarlet Oak Hood, Callfon, N.J. 07HJll, and P.O. Ilox 77:.1 Lake Harmony PA. 18"24, and Karen Joyce Smith, my niece of 3415 Bedford Drive, Camp- hill PA. 17011, as Executors, to serve without bond or com- pensation. , , , 1 Hrnnl my EXtll:ulorH filii powt'!" to perlorm allY nelH, ill thel r Bole d I Hcrl'll on lInll wllhoul courl lIJ1provlI I, for Ihl' mnnlll\emenl nnd dlBlrlhnLlon 01 my l'slllll', includlnl\ Indl'pen- dent ndmlnlstraLion of my eslllte. b. I hnve mnde fnnernl nrrnngements ,dth Parthemore Fnnernl Pnrlor, New Cumherlnnd, Pennsylvania for hurinl at Hollinl\ Green Nemo- rinl Pnrk, Camphill, PennHylvnnia, and 1 direct my I~xecutors to carry ouL such arrnngements. I puhlish nnd sil\n this Last "i II nnd Testnment, conHistinl\ of :l (two) typewritten IHII\es, on I I'!> 0 / '( (., I and declare thnL 1 do so freely, for the purposes expreHsed, under no constraint or undue influence, nnd Lhat I am of sound mind and of 1('801 age. /. i '1'"~J' I~. ol.,.--I' '- Andersen \ ~ C, LC I ' above-named Testotor presence of oIl of us, the this Last "ill and Test- On in the publiHhed and signed ament, and then, nt Testator's request, and in Testator's presence, and in each others presence, we all signed below ns witnesses, and we declare, under penalty of perjury, that, to the best of our knowledge, the Testator signed this instrnment freely, under no COll~tralnt or unlluc Illflucllcct UII~ Is uf soulld m1n(1 an(l legal age. l ~C"'( 2\( J.... IL'II \\,~V'\..\., ~o(,--h \. , of !JfJ/lI~J (" " ;/,/'). /!/7//Jidl 1""t)/)f) () (' ).',; ~ , of REGISTER 01' WILLS 01' COUNTY OATH 01' SUnSCIUUlNG WITNESS ~ ~odi~i1 (ca~h) ;;-'ilJ~ibing witncss 10 Ihe will prcscntcd hcrcwilh, (cach) b" law, dcposc(s)'ii'nd" (s) that g duly qualificd according to prcscnt and saw the Icstat , signlhe samc , n~t signcd as a witncss at Ihc rcqucSl of teslat_ in 11- prcsclite-.;t~inlhC prcsence of ca~h Olhcr) (in thc prcscncc of thc olhcr subscribing wilncss(cs)), / '- / Sworn to or affirmcd and subscribed.tiCfore mc this ~ day of , 19_ / / / R('}!,;.'iu', /," (Nome) (Address) REGISTER 01' WILLS OF Cumberland COUNTY OATH OF NON-SUBSCRIBING WITNESS Karen S. Smith (each) a subscribcr herclo, (cach) being duly qualilicd according to law. dcposc(s) and say(s) that 1 am familiar wilh Ihc signaturc of SidnHY Roalil AnilHr'''''11 -ndl will Ihal 1 prcscl1lcd hcrcwilh and codWiI- bclicl'cs thc signaturc onlhc will is in thc handwriting of tcslat-.Q.L of (onc of thc subs~ribing witncsscs 10) Ihe Sidney Roald Andersen -_.~-- to thc bcsI of mv knowlcdge and belief. Sworn to or affirmcd and suhs~ribd beforc ; )i (" ,:.J.... J /)i ( ('- ( (t mc Ihis _ 21 s t ""yoI' .fir ' , ~'J) "-,. (Nome) ~ n' It' t .\ ~~ 199.6_ () -'ilr") /";>'cr {!c, r/ lh- \...{J'fJJJ..<+. 1.~J..c;_}d::/Jii?lUittlJl;fyf'~ 1'/./)/,/1, . (Mdress) /)1/ r'1rJ II M~ryJ C . eW~s Ifellisler (Nome) (Address) REGISTER 01; WILLS 01; COUNTY OATH 0'" SUBSCRIBING WITNESS ./ " '" ',,-- '-- -.....,.... codicil " (each) a subscribing whness'lo Ihc will presenled herewith, (each) " law, depose(s) and say(s) that . 'ng duly qualified according 10 present and saw " the teslat , sign the same and that request of testal_ in h presence a~ olher subscribing wilness(es)), / Sworn to or affirmed and subscribel\-llefore me this / day of / / 19 / - // Re~;sler / signed as a witness at the thc,presence of each other) (in the presence of lhe " ". , ",--- '- "" (Name) " " I Add'rcssl '" ..... (Nume) ".... , ....,. -........ ...... (Address) '. REGISTER OF WILLS OF Cumberland COUNTY OATH OF NON-SUBSCRIBING WITNESS Rachel Smith (each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that 1 am familiar with the signature of c;; nn...y Iln" 1 n ^nn",""",n -'lei! will thaI 1 presented herewith and .~ believes lhe signature on the will is in Ihe handwriting of testat-OL- of (one of lhe subscribing whnesses to) the S..i_~-"eyyoald __~_ndersen to the best of _!ll~-- knowlo:dge and belief, " K_~'he~ ~~~~ me this __ _~t:~____ day of 2j-1 \r ~V(NU"\e)..-\' '.' r I ,r\.\ \\ ~~ \1"\1 March. _~; 19- ~_6_ _ ) ~ Inn ~n\:L.-)~g\~' \ rlU "--11~1 ~,=/,-.J)--I'.L~tii.i4.w"/J.I (Address) M ry C. I\ewls R!/' .Jf'({;- f!~'S((J .,- .{/ _ Sworn to 01 affirmed and subscribed b,'fore (Nume) (Address) ,REV.IS00":. P' QAt. W ... ~~'" U",,, w~U :<;00 U"'~ ~'" ~ .. ,... ..z Ww "'C> "'z 8~ ~ ~ J .- ci'/ - (~, ,. 5 . 1<., c) '" INHERITANCE TAX RETURN RESIDENT DECEDENT (TO BE FILED IN DUPLICATE WITH REGISTER OF WILLS) Ol(lOfNT'!l NAMt ltA~T. IIR~T. AND MIOOLt It4111AII OICllJItt'" COMrlll1 AOONI!il" ~J?.Sl?-~"F.;.JIJ-. S-'-Qf'~\c--f' -r .- n ;, ?) TIII~() ~... ~ n 1;.1\ IT,'.le. Mi~ !llCURITV NUMa!R DATI O"tO!ATtl DAft 01 81Rhl ? . 1J~i..(.) ( Ll/",r:se (2' L...J.J,J I", 1'/1 ..... lul-.1~...:..nr.3_- 3/1 (9_"'j___-'-.J..Jcl)-:-!i.- co'o'l' (Y-MBI=~"f"NO--- --------- I" ......"" "';;;"'0 '000>1' ..., "'" '''' ,., .,,,,, '~:'___ ::A' "~~~,,:,,t_~.~~__ __ A.~:~'~: ,,,,,","U'"O"" I] 4a. Future Intere" Compromise (lor dotes of death alter '2.12.821 Decedent Died Testate [J 7. Decedent Mainlained a liying Trust (Anach copy 01 Willi IAtlach copy 01 Trustl ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO. COMMONWEAlTH Of PENNSYl....ANIA OlPAIl:TMENT Of RE....WUE OlPT 180bOl HAIl:Il:I!lIIURG, PA 17118-0001 ... Z W lil u W C> )Cl'1 04. %6. [] 2 If line 19 is grealer Ihan line 18, enler the difference on lino 20. This is the OVERPAYMENT. a D.II:T:'n'll.I,u,.I.'.l'l'.,u'."I'l".UIIiI~.'.I'Im':'r.Ir.1.Tj'III..rj.U!l!1'~IlI,"1 If line 18 is grealer than line 19. entor Ihe difference on line 21. This i5 Ihe TAX DUE. A. Enler Ihe inlerest on the balance due an line 21 A. 8. Enler the lotal of line 2' and 2'A on line 21B. Thi5 is the BALANCE DUE. Make Check Payable 10: Regls'er of Wills, Agenl ~ ~ BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND TO RECHECK MATH .... Under penallie5 of periury, I declare thot I haye e.r.amined Ihis return, including accompanying 5Chedule, ond ,stolements, and to Iho best of my knowledge and belief. il is !rue, torrett and complete. I declare that all reale,tale has been repolled at true mar\.;et value Dedorahon of preparef olher than the personal representatiYt! i5 ~:,~.~ ~~ ;;:~~:a;~~o:,;~;~~;:~::~~:'"h"~~ any k~aiol~.d,~~_ ~n _ H -. - - .... ... .... -. 6,"--------- -.:.Ct~r~(~.I..L/" --.c_. '1 <~'::.-I.'_....L-c.. (U..:.\~) C,.L.. ~:( 1\; S ':':Yji' II: ~.'i<i{..'__.._ s~r~".lto,"1.,1'~~t.II\j'. Au=-:gl..'> .,' . 1 [1 ! --4tLt...LJ.l.-~)/.~-;{ I.. ;:;/'1 J.:/,<!;t1.J';). :.. r 'j) 1:,C It //1." ~',/L Ill.~' Original Return limited Estate NAME t<AR.EtJ 5.-.tvL)I\lF-C THEPHOUE NUMBER <". .)(\o\I'I'L I' z C> ;: :5 => ... ;;:: .. u W '" 1. R.al h'a', (Sth,dul. AI 2. Slacks and Bond, (Schedule B) 3. Closely Held Slack/Partnership Interest (Schedule q 4. Morlgages and Noles Receiyable (Sthedule D) 5. Cosh. Bonk DeposiU & Miscellaneous Penonal Property (Sth.d,l. E) 6. Jolnlly Owned Property (Schedule F) 7. T,and". (Sch.d,l. G) (Sth.d,l. l) 8. Tolol Grou Auets (talallines 1.7) 9. Funeral Expenses, Admini5troliye Ca5U, Mi5Cellaneaus Expense5 (Schedule H) 10. Debts. Mortgage liabilities. liens (Sthedule I) 11. Total Deductions (Iotallines 9 & 10) Net Value of Estate (line 8 minus line 11) Charitable and Goyernmental Bequests (Schedule JI Net Value Subject to Ta.r. (line 12 minus line 13) Spousal Transfers (lor dales of death aher 6.30.94) See Inslrudions for Applicable Percentage on Reyerse Side. (Include yolues from Schedule K or Schedule M.I Amount alline 14 laKable at 6% rote (Include values from Schedule K or Schedule M.) Amounl of line 14 taKable 01 15% role (Include value5 Irom Schedule K or Schedule M.) Principal tax due (Add tall. from linos 15, '6 and 17.) Credits Spousal Poyerly Credit Prior Payments + ~ -,_.._--'--- + 12. 13. 14. 15. 16. 17. z C> ~ 18. ... 19. => ~ :E C> u >< 20. .. ... 21. ; fOR DATES Of DEATH AnER 12/31/91 CHECK HERE , .f A SPOUSAL . POVERTY CREDIT IS ..cLAIMED [ I fiLE NUMBER COUl 111 CODE .2[ YEAR <./ (, ::(.1/ NUMBER Supplemental Relurn [] 3. [J 5. OB Remainder Relurn (for dates of dealh prior to 12.13.82) Federal Eslate Tax Return Required T 0101 Number of Safe Deposit Bous (OMPUl( MAlllNQ ADOAH!l 3'-/1-5 .3cf.,r=o~/') C. A.Mr-> diLL O~((J /: p,,,- I 70 /I (ll__Nr"wE_._________.__, " (21 _Nu~JC:.____~______ (3 I _loJUAJF: (4 )__t>J..:.~NE_____.___ (51 _.d:j'I:ll~LLoI.:<"--- (6 )_/I.1()_I;J:=._____ ( 71_N_uN.~__- (9) _J.OG._o.:...l.5_- (101 __ 5<'1..1.. ~-- (81 ~r-'U.~-<-'-<: (11) ..---8-1 (,5:'5 . i 3 (12) .20-,-.ll(".,. 5~ (131 -C>- (141 ;1.D,.2./4-..~)?' -() - (15) _______.__x._= (16) _______ .__ _______ ________ x .06 = (171 L:2_c..,,;l]G~LSj,---.. x .15 = - c,- (1 B) ___ 3..,_O!-iL.=lJ'-------- .._ _~__,,,.~Ll..':l8 _ ~___ Discount Intere~1 . 0- (191 1201 (21) (2IA) 121BI :3 o-/l."-{g ...' ,...' -,---- -" ---..--- - 0.-..__ 3,Q..~ I ,l,18_ , I Hl'ant illY E",,('Ulll.-'i lull po"..!. to lll~rfunn illIY BetH. in Lhld.. :1oll~ dJ~ltrl'llOII 111111 wlthuut cuu,l ullpruvul. for tile m 1111 UK" In" II L all.1 .It:>I I' I 0 II l I nil" 1 I" Y ,,:!t U t ", 111 C lu d i Ill! 1 n d C I' e n - tll! n t II d 1:1 j II l 'j trill i (>:t U fill\' 1.':1 t d t l' . tJ. 1 havl! made fUllt'ral Jrralq..~I'lIIl'nl;. \./it.h Purllll!n1Ure I,'uneral Parlor. New CumlJl'rlalld, )'cllll:lylvani.. lur hurial lit H.lllillg Green Ncmo- riul Park. CilllIl)hill. I't'1l1l1iyivUlli,l. HUll [ lliruct my gxecutoru to carry ont ~Juch IIrraIH~"ruelltH. .., . I p1l011:;h uud ;;\1\11 11:1;' 1.11,;1 \,i11 al!.1 Tp"I,a::Il'IIL, (,01l,II:;lln8 of '.. .-.o20'(IWU) Lyp,owril'I"1I 1'''1:'''''' UII _L(7) o"/r!c,.....--.-.-. --.-.--'- I .' and declare thllt 1 do ,;" free] y, [or Lhu I'UrI'O:lc:! "xpre:l:led, un,:er no conslraint or ulldll" ill[luellcc, and thot I om of :;ound mind and of legul age. j~. , ) (.1 I . .~ J ,(1",~I.J .., ,-.. And c r :;t'11 On \ ~1c,1.J' in the pre:lence of 011 of us, the u!Jove-named Tc:;latolo Iluhli:;I",r\ allll signe" this LO:lt hill and Test- unwut I und then I at: i'estatorl ~i rClllJe~;l, tlutl ill 'l'c9lul.Or '9 presence, und in cuch othcr~ preHCllce, we all &iglled helow an wltnc&scs. and we <.Ieclare, uuc!cr I'ella 1ty 01 perjury. that. to lhe O(':lt of our kuowledl;c. th(' Tl.'.'I,'IClr "igllc'c! lhis i""lr\l;"'lll (reely, undcr!lo r.OIl:::;LfH1nL U1" UIHli.,I' .lId Jllt'lh I.', ..lad 1:1 oJl :,ound minu ,IIIlJ legul il~~~. -.... , ( .-:l:.c:" .!....J/\_._~_~~"- \{,lL- __, "f _-\, \ OJ '-"\.~ " 0\\.1(.":-\'1 \ Ii , -r"r11 . /' :J ,nl.--WL:.;t/""d .. , ~/..o /} ,. o' n '( ,~ i11~1 , . 11.1\".1'.,,'1) SCUEDULE E CASIi. BANK DEPOSITS ANn MISCEllANEOUS PERSONAl. PROPERTY ~ ',~o,l It" ~'" of\ - l/'o;* (OM...OI.....'411.l (.f H.j~".fl,I\.,I... U4If1llllA"n I^, '11111'" !.l\IOWI0ICtUIr" 1 P!"me Pont or T,'lJo ..--.. -flit ':IJI.'I<[I:---- ---.- ----- ESTATCX---..---------- /--....-.--.. ___. _2~I_t)I__.lL'0'( t,',,' !.IU "(' .,1..'1-1 {All prop.,ly jolntly,own.d with th. Right of Su,wi...oralllP ,"uti tl_ ~11,(lot"d <on Slh.dt.I.., .---.- ---.-,.-- ---..----. ITEM I NUMBER VALUE AT DATE OF DEAltl DESCRIPT ION I p /.:,{,' . [:, A I., ;.; (~, " (\~u ':.".>(' Lt'l C [;:"'iJ1(~'b...l_ tJ E'lc.-' (.~( N 8 i~C:'< ,:V,) (.:) , " (\'\EC(;U,.:,- (,Cl l' i)/l ,,\ ./1 5i-4c)(L' - '-1'-111 tv, 6:':,. II ,J. PA." -7 . IVl. t:).<V;'~ ~:'vu:li'( '- C6Jlt'.I\L 1~1.l O<'lc b01:::LU C < t 1"1/:; r" l:' U'AH".' (~ "- Ae t 1 '/f S/. 3i:'i"-( ..:.\1 ~I-I .~Allll0...<'.. 10 <:(1 ?,. C:;{ I 3 I ' " C "',,"' ,- ". ., ().SI;:D ,-i..c('f1'L'(~, Ii" f[.,', 1\,/\,0,<"., . .....,., 1;)r.:~'" (::..I::G ,'\;7Ac ("E' IJ '<\Jl..'C~:l ,",/.'(( .' ~'21,(, ;;.:'_(",) (Ai,. ".{"lv.,/":'(!</. I" (,',d.", - t.~,(,. 1'~OiOl::.'.F,,; ;.I\..J""I~ iiu ,. f:;JC;"~JI' HED 14/',..:, .'{ (,I.( . ,;t. ^t 1'-' 7 " F \ u -~. [...: lJ i ~ l;""~\f\) .o:'\. 0 f\ :::~~;c.. CiD .5 PI? E r~'~,r l'~ F(l.}..;l': t. /\ ( /-' '\ - J ..- ." ../-1'( ,....~I...), " I ( '. I~ " . ''- r. 'J L '" C r-= ,~O"':I- . < ~ . 1'-' .. 'I~I':: ,i.)':-II~,-.r~ -::":.'t'/ 1\-U:'ll.,(lL~((3E.r2l '-\1'.).) !"~ - .-;EPUI"(.=:'" c, I" CLI-J.-:J/:;t::'1.-\j:f=i;: i - Fi...Q\,'cO-I:::) l\ .:.: l-EI::L"'1 ., - L:: j.'/{I)tC. Ct~e'(vIAJ L (1/;,,:, f'/lllJ C,=-I.W d\f~'( l:.c T <.'1 fvl/'~:'/i.l<.:.[,:,:lL. J:~3>7,<lC, rf>.!:II~1 13.:s t.(7G.?.,o() .:Z (,'1,00 ~,70,(jO '. ' f) . . . \()I'--'-(,J.~C-. C~I:!t::EIv: ( .."..:,..tC:'Tr~...R'-( ( .)/ I (.' f.\/(L/-)LC R.t. C'<'~.l/ t~ILI... ,."'/\ I I L__ TCTAL ('.1'0 c.'oron Jino ~,_ Rec!'eilulolio.~U L_~S I ~ .2 .:!..~ '~'_~~_ ('\'!n;~ 011 i l.c~rJl 0'.1" )t, n" ,h...." ,t ",:-,.. ';"HII ,\ t\t'.tJ..,11 . . ( .- (-- .~' , . ( \. ~. 'I.' 1'\ . ' ... '..., ,c' \. /.J Z ((:Co' \ \.. 0 jJ' i (-..t n' (? .'0 ( /- ,7 ) (,,'- L' -'-,.' )" .~..... ....., . \1 . v . ' '1',' . "II Ii , , ... /'c~ t)L_~' Dlj dJ.fII (....:1 i',t-{,:,) I C::o\ C:r Fe: ' -) '() Vcw~{.Y :v!c-ll.Q ') ./}<0;.;r1...... ~'5o, ) -- ~"') ( ,'I V6 0('";):'--1 J - -, I 8-t<oA:JS , Lvr."- t4---u( LO\.. /'.](c. "", " ~ 'v'.".::> ,Dl h'..) .:.jkl/i ts lJ..~~{ L ~ h ~\ (.s, L,.-J G.'l Ie / rc..1/C I::z- /A)LltL'!.,,1 o,~)d~J:\ ((~:ps J '-1: u ~1 C'L~ (O~~-f- -3 Wi-IS , ? PCU.;l du '5:-:',('1- Jt-{-;~ I pet....) S)lL~..'CL-') .:;[ (tit 1..:-:::tWy-.., ( (~\. C(__{..) ,S '/eels, ---;., ){<}-~C.'LJ...4""'1..."l\..ntJ;"'u...c..Oh..e:.l {z:A.lC-: ..' " eILL~I\ .....- .. . h ,.' <r:.r...' u' lre'_. ,,-,1_: S . \ . 4 ~'-~l)__tot._. C") n~jc., rt:f/, L0Jltl}/(' c..~ !-. ,~'d/~J Ji;t'Lt.I7~;'p IO[..uIn,'A. (~\...OL"-- t d~~ VI' <:...u\ (j , I S,?")YlCr (). (:tdLc:jr(l~/ .- () dD 10 It) J. I- Cede! s\ '2.~ 3!cj::l'6 ) IOTA L- VAl.-l.( ~ 4:2 S (, 010> (-(.1 <. -, ... , I~..' .. .' .;' 'C f / a{.',-, 6 () c~ d ('c6-'f !;Lv~ stGl~ 'Y\ 6ufdo-tlO !1~ cI ;:r1.'L Lf\ (I c;; D.9f f(~ Rrc:Y\ dell/.- Cw~ 11 O-(of I s~ 0,,-(;:1, f13(W J) 1111-1:/(- ./;//;, ," FUNl:ltAL., 'mUST .tt-s rRI~-NEED AGIUmMENT / 1.'1 O&/.; A~'r 'I. .' ,1". _'._, 11.11' HJNI'ltAI, 1I0~1I., ._,-.jJJ,- N)~:n\uY..~_. /}Ooi/~, iil/'l,._L"..:. ~ --r', .f.(}",_,.. 1-", . II . ,I)", I .. '" . f/. .1.-. ..,_ .l... '-. ". N.IIIII' !ir:,J.j,;: ;:,1._ 1./ .L(J,Jl"A!j}/1J../'LL~'Z~ JllI'ill\'" .\dllll") ,.- I I! () j l'llIlCIIASEIl,__i_l.l.DLl,'c..'/'_ J:_.Ub '-:/.:';_::(. ._- . "...' (lIl'1dllJflcr "Yuu") i'oiJIIU' 1L;l 7tU.:J~. /0 .!.Loj (1J,~ ~6~~h.:l ,/ !>~_. Alhln',"'/ /,'. I ,7.' .~,). . .._L.'-_...I__.... .,_,_.~i":'-.__.._ ~tll:I.l1 ....n llrll}' NUlllhl'r IlENHICIAIlY, ___..___ III diUI'n'nl frum PurdIJ!rot'r) - - .----. - -.". ------ - -. - -_._- -. -_._.-. ~lId;a1 ~1'l'uri1)' Nl'lIIhl'f ~.IlIU" ---- -------- .----....------------------- ^,lllrn~ ANNUAL l'EHCI,Nl'AGE !lATE l'INANCE CHA!lGE 'I'"lal "r l'a)'llIl'n,s Illr IllIlIllUI ,nil \lolll hl'r ".ll,1 "flCOf )Utl !,Ht' Il\JlkJllllJlli,,-,'t,n 'lhnl.llld IlII" lllul,-u\IUf llllll 1'1Ildu,r IIn tltll'l, IIIdmllplI)lIu.t IIUV.II' I'..)mrlll"'. _L~_-- - j\Jt1uuut 1'11I311lC<I T"t". Sale Price lilt '1/'1 ul pmr u('lliI .I'" )r"'I)' lur, 1111" .lullH ..lm'u'II 'ht 1((',111 \\'.lIlu'l \"U lilt' 3111ullllloI ....'111 l,"u'jllnl to' '"11111,,1\ 11>111 It. lull O.OO'X, SO.OII .-- YOUf I'nna'nl ~lllrlltl:t' \\1111.(' I' 1'It)lI' HI t\UIIl.lU :-.;" "' .&\:lIrllh '\nll1l1l11 "II'.4'"Il'llI' \\1l1'IlI'.l\lllnll\ .\[,' 11111' ItC'lIIlzatlon (If Amuunt 1.1'" l"ut. 'J ., ,< (., '/ ~I, 1IIIhlr, l.t''''llIlll't~ I" .....(' plllr lUUU.III IIdow lilt ..111\ JII&IIIIl'IUlllllu,:IUlilll1 .lhUllt 1I11llp.l)llll,:nl .Ilhl ,ld.lLlII. . lut.lII).'\\'IlIU)mrtll -I ')t.'7 Thl' Il'rm.' ,!tUWIl ill the hllll .1.(111\1" Jr,' !"ltl "r llii\ ^l:IU'Illt"tll Sl~n\'ICllS, Ml~ItCII^NI)JSE AND I'IUCES: ~'n' l'ulll'r.:1 "WU'II., II rl.rul IIr Hlhn Ilt'1l11/Jlillll ,&11.11 hl'd hnl"lu ;1\ hluhil A, IU~\'OC^Tl()NI "11\1 hnt'll)' dnl 1lr..lllhi~ ,-\jI.(('nlll'lll .&lIlllhl' I ru\t III hl" l'M,lhlhhnlll) 1:11' l'ullrullJi'n'tH ,hill hl' (f.hnk IIlll'.: Ll J~c\'ncahle hy "'UlI and at \'uur o(lllulI "r ~Il tllllt.~" ItJ"Irrcvnl':lblc UPOIl P;I)'lIll'llt in ruHlIr 1111,' Toul ':';&k "(1(<<.', Sl'C I'.:u}:r.ljlh~ j ;lntl.j 1111 U'\LHC 'HIl' fur ItlUl\ ):,o\t'lnill)( 1l'\.IIJlltlll (It'llHllI..Ilillll, 1'lllCE (llUn'[CTJON: 1'hl' I:ullrl.ll Oln'l.lor .111111111' ,"Uti hndl) J.,::ct" .lutllll' I'rn'o ,hmlllllll hlllhil It. .1fl.' Idll'I!. line', i.Y'Nnt nuar;antl'C'd hr thl' I:IIl1l'f,11 llirn'lor [J (;u:lr:&I1(r'cd hl' IlIl' rUIlt'I;lI Uin'rltlr Upllll p,l)'llll'lll ill Jullllf IlIl' TulJI '"lit !'(llC ~l"(' l'u"";IJl1h \ I'll Ihr n:\'l"Hl' 'loll' lllr It !Ill' )<tlnl"'lIl1l;'; I'; III 1't11lnllun ^GnEE~U~:'<ri 1': You h('rl'h~' ;t~1 ['I' III hllY .lllJ 1111' hUll '.1111111 Ilnr hnl"hl ,H~ClT' III ,("11111\' hUH'1 JI 'l'f\"ln:' C"'t'flh:l'\'" Hili )l.PHI" ("~ll'U 1I,IIUh,('''1 whhh .&11' Ill"H'rihl'tl1111 Ilw ih'nll/JllllI\ ..IlIJI f,:J tll Ihi\ ^t-!lHI'lnn 1\ I "llhll ",\' '1 hi' ".:It'l'IIlI'1l1 I' ~uhlt'O Willi" tl'IlII\ ;llId t I IIllJlllun\ \1'1 luflll ;lhIlU: :JlIlIIII1 lilt' 1(:\'(""" ~hh' ,.lllIh I' ,~t \ULllll'l\ll',n 1111 1,,1.11 ".,1\- 1'111'1' ,1111\\ II JI,"\,' .11,,1 .411 "I!ln 1l.&\11U'lll\ fl'llllUcd inlhh ^Rrel'lIIl'llI A'lt", \'11\1 ItA\" pJll1ll1l' Tlll"l ~,lk 1',1l1' 1..lIlO\I:) JIIllllI ulht"r 1'J\'lIIt'1ll\ (t"lllllttl tllhlt-r 1111\ AplTIIU'lll. IIIl' It:iln",llJln'tlur will (nukr 'ur 1111' Jhtl\'I' t1lJlIlnl Ikndid.ll)' ..lIul tilt, IUII!'f 11 :wni.n ;lml ~It"', 11.111,1,.. dl"\II1I'nlllll b.h.hil ,\ t'XCI,tJ~ION 01' \\'^IlIl^:"III'~, Till' 1-I1:"I'.IlAI. IlIIlHTOIlIS :"llr 1'110\'11111\;,;'10 \'Ill' .IN\' W.\JIIl,INTI' 0/' .\lUlU/AN. TAIlII.r!'\' Oil "'AnIlANn' 01' I'ITNI'SS 1'011 A ",Ill nCl!I..\\II'\:llI'O~I: "'lTllln~I'I,<'T Tlll'lm MI\IlCIIANIIIS~..I". unly ~';lrr;lntl('.. Yuu ;atc n'l'chln): rur tht' ~'adl;lntll:\t' ;IH' IllI' t'lII11' t'"'' ..rll't"n W,UUlllkfil,II,&l1r, "hkh ;lrc I'rcl\oldtd h)' Ihl' m;an"(;&llurcn tit lht' :'oh'hll"l1dl..~ ~llhlltl "I'lllIlIl1IlI'r thl\ .\~rI'CUIl'III, (111)' Ihl' lII~nlll.llllu('t ,,'11I h..lll' "11)" lI~hllll)' 10 \'uu untJcr 'Iud' .';uunllcl, IN \\'I"'l\E~~ \\,Jlt:ltEOt:, YIl~I"1l1\11111 I '"u'rJlllil"111 r hJ\I' "~I\l'd 1111\ ,\J.:rt'('lIlC11l1l11 lilt' .I,. ,tllIl ~"H Iml w.illt"n ",hUH Ynll Jlhl 1111' I ulltul 11111'1'11'( inll',,,t I" I'l' h'~,111\ 11(. 'HI 11\ Ill" ,\~IHlIInll ~\nJ\,\~(,t~'E:'\T lU:; $,___ Ihl' iiI I'. "1'.11,1,( ..11.1 \h\lll',II'"111lhl Illl~j 'oJI'" Pill' Jlhl "III hi' thI'" ,lit tlIII Iht" 1111'1 H/:o.l'Itoll.IIIIlECIllIt __ C;/tc....LY'.L/2J J'..!I] (-,:U,:..L "/1' [. ~1It" , . '1/'//.4 L./. I ..:.. .:t..::----; II)' ..>'-f.d/~d~w- _.:./':.i..1- ~-.~ _~J.,_._ I.ln'mrd IUlll'l,lllhrulll' l'I;IlUI.\~L11 :L. /: i' , ',' I. {, , , ',- ..~ l'unh.l\t'I l'urdlJur L"/1 Q 0\ -:..-(/ L ,____..___ __ L!.._ _1L-l:2..:J.-r----.------ l.h.("I1~': l'itl. SIIIIJI:Cr TIl TEIlMS ANI) UINIlITlIlNS IlN IlESI'JlVF, Sill!, You ;ll'knuwlnl)tc r4.'rclpt 01 :I CUII1I,1l"tct!l.'uPY ht'rtnr. Y I.. 1 '" 111,1_ 1""'.'\"'1,", "I all)' tlUlt' (lrlor tn II1ldnl~lIt lIr tin' Ihlrd bu~lnc~' d;l)' al'lcr thl" (!:ate or thla out ICuU)'Cf. U;')'Cll'C' -.. .-.... .. trJu!'t:lctlun. SC'e Ihe :llIadlcd Nntkc ur C;Ull'ell.ulon r.lrlU Cor :In cxp1an:atlun ul thb rl~hl. UI\lII'I"P~ rlU\ \',1111\00 U'I') lilOu"..1 U"rlhl' l'lIl~ tUI't l'ullh.l\u li)I'l'lll",I~~lll.l IIl"",1llhu .111" A\',,,lll'llll 1'I'l",iHI .~ );11,1.11111.,11/;, ' \" FUNEf{AL 'j) , 'mUST " ~rtv PRE-NEED AGREEMENT lJ.111' / '/ ,:.J.,~ II A: I: I) '", IlIlIl.II-\1- 1I0~1I', ___ . .. " I" ., I. .' J I / I '/ .UI.:",/(. I.. //1.,::"./),:,/:..::.. /"Ii,,:',:.1 /.'""__',,... .:z~'-.__.._. ._ :\.11111' , l I I. I' . / ' I, . /. 1-" .) 1")4: .11 ,1.'1.. ' ~..i\i'I...'.~./J'::L _t~~'I_,,_.L -L/!:,/.. (/ Ihl\IIIl" "thill'" ) :,>.IIh.Y ;1, ;;.~J.', I,'." I N.lllll' ( ./ .' ./ I I' 'r" . I i", I ._ _. ;-_'j"_ _ ._':"._L-'WJ'I.:. '~.._I ~~"-/ I" A.hlrt,,, / _____/L:' I _'2-.. .A ~tH.IJI "l'lurily J\'ulllht'r I/o ._ _' 1____ . ___~ l'IIIlCII'\SI.II, 1IIl'U'III.lllf'l "\'IIU"I -/~ 7X;'{ III,NHICIMn', _._._____ _.. III ,Jincrnll tWill l'urdl,l:'l'r) ;~;ll1I\' ~odill ~l'(uril r :'\:umhl'f -----------.-...---.-----------.- ,\dclrl'.\!t ANNUAl. J'E1lCENTAGE HATE I'INANCE CHAHGE Amount I'III'II<'C<I "'"1:11 of I'.YIIICIIIS Ihr ~1II"UUI )1111 \\111 hur pI hi ,,'lrf ,"U hHr uu.lr "Ull.l)llIrl\l\ ,n \lln,IIIIrIJ Tor.1 Salc I'rlce: lilt' e"'l ul }'HlIt unlu J\.I lc,nlt' nu. lilt' Ilull" .UlIuul1lthr uulit "lllll"l )tllI 1111' ,..m'llnllll,rrllll Ilfll\lIlr,II'. lHUII' uti tuur hdulf Tilt lUul ('''' III )'lIUt pUll hnf un IrrLlII, Il1du~;llll;uut \llUt,n. 1''')lIltnl tit. ~!...-_. 0.00'::, S(l.lIll Yllur II.lrll1l'l1l ~dll:c1l1k wi:l hi" t. Iljt'~II' In c\lInlJlr N'l II' 1:&\'1111'111\ AlIlIllIlll 'It I'J\llIl"1ll\ \\!lntl',1111H"1" ,\".'1111' J ~1'1II1hlr. hl'},'!llllllt: 1'/ IIcmll.aIlolI of Alllnlllll 1'1 II a liCe: Ll\h I'rllt' I. 7/' -'u' lUU' nlll!fJII 1>1'1"" I\.r "Ill)' ;uJilUhlll.llllll' lI,ullIlI .111'"11 nUlllu) tllt"1I1 .lllIi lld.wll 1"',11 U,,"",,")lIltfll -. (~'IO I :Ululd n,,'..nrt" III C.:Jo\h I'flu. A AlI1l1unl IlU.lllU"d . S J..;r- 1111' Icun' ~hll\nl iil thl' hll'\ ..IIlI\"(' :11,' 1'.1(1 III rhi\ .\).:I\T'lH"lIl sun'ICES, MEItCll.\~I>JSE Ai\l> I'IUCES: "l't" rUlli't.l1 ^~fll'lllnll Illtllllll III Ill" Iln'II,.uillll ,illJdll'd hUC'III:1\ hlrihll .\. IlI~\'OCATIO:-l: Yllllllnt'll} l'In'l Ih,ll lhi\ .\~ln'I1WI1' .111111111' TlII\1 11I1.t. r"l..bll..lu:d It}" Ihl' 111I1<"111 Uirnlm ,lull Ill' (tlln k 1I11t" iJlc\'ucahlc h)' \'UII ~lIlcJ ..I luur uption al Jlllllllt..\. ,,) IrrC\'(Jc~thlc UpOIl p:I)"lllnlt III full ur lilt' '1\11.11 ....IlL- I'dl:t' :'n' 1',.uA~I;al'h.. ,\ <llltl' Ill) r1.....rn. ..Ilk for It'UII'' ~Ol"'llIlll,! rn"I.lIi"" tlnlllill.uillll/ l'nlCE "HO'l'l:CTIU:i: 'lh...l'llll~J.lllljln:IU' ;,Lnllllw )"otllllrd" .I~u,(, IIIAllhc'lllill" ..!i.," II 111I hlllhll ^:.nr (lhn~ IIIlt'l l/Nut ~:uaralllced h)' 1111.: FUlll'rJlllirl'<<.:llIr, f] Guaralll("nl hy lilt.' 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IiiI' rUI1C"ut I)irnlul will Hlhkr lur thl' .IIMI lumt'd Ih:nl'lid,ur ;lIlur IIIl IUlIl'I.l1 !'oulin" ;llltl,\kft""11li\l'l'I''''ral,t',llIlll~hjhil ^ J;;!H:I.IISION 01' W'\I.II^NTII'S: I'IIE l'IIl'\I'IL\I. IlIllH:TOIl IS l'\OT 1'1l0VIIlIN(; TO \'011 ^NY W^IlIlMo/TY 01' ~1l:IlCII^ T.\/II1,/TY 1lI1 W,\IlIL\l'\ rv or nnil.ss 1'011 .\ 1',\IlTlClII^IlI'IIIlI'lISE WITII IlI'SI'I:T TO 1'111: ~IUICII.\NIlISI:, Tlor '" warr:ulllc!'l YIIU :arc rCl'rh'llIjoC rllr 111f' ~1C'rdl.llUlI"r ,Ut' lilt' 1'11'ft'" \\'rllll"ll \\"urOllllln, ir OIlIt', "hJell uc: prm"dctl h} ,llr f1l"f1Ur~I'ur ur 'he ~h'rdl"lull\r.' :"111111 lu )"1111 uudn Ihl"" ^~n'rllll'''I, 0111, Iht' IIIAUU'", luru "'111 "..\t. i&ll)' IIAhJllly In \'UII umJer ,ul:h wuunll IN \\-fITNESS \\'IIE1U:Or. ,"'HI .Imllllt' lunn.llllllnll" IIJ"" "'t',u\llhh ^J.:lu'lllrlll Ullll... II... 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I'E:\t'\S\'I.\'A:'iI.\ Ii II: \'Oll CAM'El.lIl1S A(aIlT~IE:'iT, TilE SEI.I Ell ~I'\\' '01 Kll:i' ,\1.1, 0I1N,lT OF ,\:\\' I''\SIIIlO\\':\ 1'^\'MF:'iT, AN EXI''',\:-;,\'I'IO:-; Ill' TillS IlIlalT, SI.I';:'ilrl ICE OF (,'\:'i('EII.,\ 11O:'i nlltM \\'1111'11 \'Ill; \\'11.1, IIECElVE ,\I.O~(; \HI 1'01'\' OF 1I1l~ '\1;JlI.:::,UXr. I't:II('II,\SEIt'S A,'KNIIW! Ulla,,~n.\T II\' SH;NI:'i(; IIEW\\', 1'l'IIl'I\,\SUllllJ'IlI:,ISIS '\:'iIl,\I'I\~O\\'l.lll(a'~S '111,\'1 1'l'IH'IIA~EIlII.\S IlE'\Il,\:'illll:-;IIFII~T, '1'111,; TEIlMS OF'IIII~ Al;llI,:nU:NT, '1'11,\'1' ,\II.IlH.EV.\:'iT 1II,\:'iK ~I',\(TS 11,\ \'10: III'.EN 1 '()~II'I.ETEIl, ,\:-111 TII,IT I'I'/ll'll. II'\S IIECElVElI ^ 1'1l1'\' OF '111I~ ,\r;JlI'E~IE\T .\'.11 1'llIOIt 10 IllS< 1'~'17'o'; l'lt /l'1'.S, ~"IIJ('/':S OIl ,\I/':U(,I/,\,\I)/"E, ,\ ,. OF 'I'm: '\I'I'I.II',\III,E 1'llIn: I.IST AS IlHJI'IIlEIlII\' '1 liE H,',U1:Il.\l.ll(,\Il1, 1 OSI~ll~SIIl:\, 1'(,1"\-:1(1\1. l'II'\ClICES'\ 1\ """"1 1'1'1"'" 1Il'I r, ..' I.... "'1111"".\1 .1IU\'....""c.O'illIIlO\Si ;; ill',II/II~/:I(;" , FUNEHAI.., , THUSr cr~9 PUE-NEED AGH.EEMENT IJ.llt' /.; " .II! /. ..." ....- .... -- ,I'}..I.' I'I'NI'IIAI, 110Mb __j~:, Ill-i,.u" lu.E. \ I I J (' ., I : ! .. ~.lIl1t. /;- I' .. // I I /"; I :;~. ...../ ,. I .', 1/.:/ 1/ , .I'll \ 'I)' l'IIItCII^Smll _.._.. t1lndIlJlu:r "YIIII") j 1 ")-:Z1:,'. .J I I, 1I11~'IIIl""\ ..\,hlll" ././1_- .t,),., :'~, . :'. i N.lllIC - 'I') . . .J _/"':'.LI. (.. f" {t~". /,...., ~ .\lhllt"" ../-::' / ~ ~uLl'" ~C\.Utl\'" Numhc:. I.N' j'/ ! '/ . .... _.,:.J -_. _. .__. --..--.. -------- IIENHIClAlIY, ._.____. (if t1illl'rt'l1I rrom l'urdl.1~n I - --'------'---' .----- -"- . _.- ._---_._----~- -----.- SlIdal ~('t lITlI)' ~ul11hl'r r\.llIll' ---_._-------- ..--_...~-~.----_..- --- I\,hlu',' ANNUAl. \'mlCENTAGE RATE FINANCE CHARGE ,\mnllnt 1'1"'"<<',1 Tut~1 of Pa, ments I Ill' J'!lou:ll "III "lllIU\f !,"I(IIIlCf !"1I h...r lIl.!ll, .1111'.11111<111'''' \.11111111.,1 TOI~1 S~le l'rlce IlIc:cu\It11 lUllt Ue'1111 .I' .I,("JII) UtI' lht' .Iull" JlllllUlll;l1l Hr.lll\ulllll\I)11l1 "Ihr .Il11llll1l1 ,.1110-,1,. IlfU\ hlnllu }'lIIl "I ..II ) "lit IodlJII li't" llIul 111'1 III \Ollf l'lluhnc: un In.III, 1l1l11~IJV)1l 1IIIII.dlllloll' l1JpllrUlllr I J-4_t./~n.._: o.onl;:. SO.OO L- , Your 1'.IPIlI'1l1 Sdll't!U1l' witllll', l'U,.",III\.l'II'ltlllJll' ~~II III \.I\'I1U'I1I\ .\nu1UlIl IIf 1'01\"111('111\ \\ 11111 1'.I\"IIII'lIl\ .\fl' D,tl' Jt("nll7.:ltinn (If '\ml)lI'lI nn:lllced t.,,1I "ril r f Momltl). hq:'llllhlt)l ,I" . .... ?(.Z. ~n' )'UUl 11lltlr.J11 lid,," lur 0111' .l\Jditiwullllh,lln.lllilll ",hlllll 1I1111IU'IllI'IlI,UIII,kl.llllc '"'IIA\ IJuwnfl.l}'nlt'n\ _I 1!?(.2.-- 1llllUlllll.ll.llll.r '" (.'.I..h ('rhr II. ^mllUlll IlIumnl 1 /"','-- . ,'_. 'I hi' h'fm" !llIel\\'n l..lllI" Illl' ;.Ihll\l' ;Hl' IUrI III Ihl" .\~f1'l"lIu'nl SI~It\'ICliS, ~tl~llLn^NUlst ANI> 1'IUCES: ~IT l'ulll'r.A1,\~H't'IIIt'nl rlllnl tlr 1I111t'r IhlllilJlillll .ul.ld...d IIl'n'W;I" I~klllllll ^. ItE\'OCATIONr YUtl Ill:,rh)' 1'h:l'I 111.11 thb ^):U:e..'l1lI'1I1 ;Ilhl the..' TIU\1 In hi' nlJhlhlll'c1 h~ IIII' l"ullt'IJllhu:e..ltlr ..h.dl ht' {I !In k tlUt.), n ItC\'lu.:ahlc hy Yuu ;lIltl al Yuur Ul'llul1 ,11 ;11I1imn, Ll....lrrc\.m::.hh. UPUIl p.I)'IlIl'1l1 hi full of llH' 'filial S;th' I'rill:. ~1'e..'I'.Ol:lKUI'Il~ j JUtI" un rn.t'rn' ~llk lllr Inlll\ }.:ll\'t'llIlIIK rnut.Uillll (hIU"llJlllllll, PIlICE I'ItOTI!C'f10N: The hunl.11 Uifl'llur ,Iml the lull Iwn:h} ;ll~rt'l' Ilul lllr 1'1111'" ..hll\lll nil I',xlllhil ^ ;uc (dll'd.. lilli" U NUl gU3r:1I1lCCll h)' I11L' I'UlIl'r,11 llia'dor. lij'(,U3falllccd hr thl' l"lIunal DirC:lltJr \lplll1 IlJlIlll'II1 111 flllluf I Ill' TlIlal ~;lk Prin', ~IT 1',uJ~r;lph Ii un Ihl' rrn:r..t' ..hII' fllr II'flll" ~III'I'rnIIlK I'rin: 1'llIlnliulI A(I1U~I!MI::"i"'1 \'tIll hcrrh)' ;I;:ln'llI 1111\' ,lllilllll' I'II11rl.llllulIlllf 'n'" 11)' ,1,:rn \ III ~dlllu' IUIU'I ,II \l'l\'iu'\ :"~l'flllt\'" .111I1 ~lllld\ I"Mt'ft h.lmlilt'" whll h ,Ill' tlnnihnllll1lhl' 1Il'IIII/.HIIIII JII 'I III ,1111 Ihi\ ^1l11 "llI~'III ,1,' 1.\llIhll '..\' '1IIi\ ^J.tItTllll'lIl 1\ \111111'11 IH lhl' Irml\ .I11,llluu!tlitm\ 't'l '11111 ,1110\1' ;llHllllIllll' fl'ITr"I' \ilk III Ihi' P,I;.!I' "'I,U 1U1I'1 p,I~' Iht, '1'1,1;11\,111' I'lnl' \llllwlI.llul\l' ;lIHI,dl nlht'l P.I}'llIt"lIl\ rl'lllllllllllllhl\ ^~II"'lIll'lll. AIII'1 'lllI hJ\I"luul Ilu' llll;lll\Jh' IIWl' plllUtl ,111,1 ;ltllllhn 11,1'111""1\ (l'11111'I'11 wult'r lhi\ ,\~ln'Ho-"I, lilt' l'UlIl".III)Irl'l'llIr "III u'l1tlt'r lur II... ,1111I\'1 111.I11Il",llIclIdl":IJI)' .Il1nl Ilu: 1I/Ill'I,II !'ot r,-j,j'\ .11111 ~h'rllt.llllh',t' .\1 \\ rll".1 .,11 I ,1111111 ^ EXCI.\ISION 0\' \\'^IIItA~TIE\, 1'1I1: IlINI;IIA1: IlIltECTlllt I~ ~OT 1'1I0\'IIlI~IO'\ ,) \'011 ^NY \\'^ltIt.\N1'\'OI' MI:ItClI^N T,\ItIl.lT\' 011 \\'^llIt.\NT\ 01' HI'NJ:\S I'OIt ,I 1'.1111'11.111.,111 l't'IlI'O\[ WITIIIlI'~.I'I'CT TO Till, MI'IlCIIMill/.~Ji. 'IIor ,ull) \\;.Irr01l1tlc... ,"UII 01" rt"l'~h'III~ (ur lhc' ~lr(l h;lI\lU\~ ur Ihr r'''I'u'''I\ "'I hlC-II "'Oil unllr.., II ;Ill'" \",hlt II O1r~ 1)fIl~hJcl1 It) Ihl.' 1I1.1II1I(,nlurc,. ul Ihl" ~h'rd);llldhf.: ~uhllH '"tlUlulcr Illh ^~n'rll1t'lIt. '11I1y Ihe 1I1.1Ilu[,nlUu'r will h;lVl' ..ny Il.lhUlly tu VIlU under \u"h ....';uuntlu. IN WITNESS WIIEnl~Ul. Y'II' .111111111 11llUIJII1illlll" 11,1\1' \1.;111',11111' ,\~U't'I1lt'llllln 1111' tlJ} JIIlI )t'U Ilr'l wrilll'l1 ;IhuH, ".1lI ,Inti Ihl' runt'u I"'nlur IIl1l'lUllul1l' IqpU~ IlI'llllll hi Ihl\ \t~11C IIlt'lI1 ,\IlU,\Nta;:\t1:,:"i'l' N:l:: l~.__ 1111' In' I'. ''i'H,1Il ,('Ill.h\' III IloUlII\(' lultl ".Ih\ 1'/,,1' .Ilhl will 1.1' tlquI'!11'l1 llllhl" frultl I'IlNI:Il^1. IlIllECTlllt 'I CJI6~_l~_L'I!L:'i. /f:"-..'.: ,;.l__ , 1111110 ,I.. I /1/ /; . II)' ,>,~:~:._:.JL_ .:".~,U,-;.-;.--.-. I H,t'll\l'lI l'ulll'ui llll~\ IlIr __.LI}_Jj...t5.L '[.':L(~._.__ -.---.- . Uti'''',' :-". 1'11\1.11,1>1.11 , .~ '. , " ~ I ~ t... ..l___ -~,- ,,:...lL..,.LLEL', "urd1.l\cr I l'urt'h;l~l"r SIJIIJECI' TO TI'ItMS ,INIl CONIlITIONS ON ItI;smtVE SIDE '\'uu a(knuwlru):,c rn:rlpl ur :I t'CllI1lllellod l'UI')' hercof. \',,"lhe hll)'cr, ""')' cann'llhl, Ira,,,actl..n.t an)' tI,m' I'rllIr I.. mldnl.:hlllf the third hu.lne.. d~)' .fter the d.te "f II. Ir..ns~l'llon, Set' lhe :luadu',1 Nulkc of C:lfll'e1I:,1I11111 form fur all eXl1bU311nll of lhls rlKhl. IIInl,dW' \\llllr ,UI'} I'll'" 'CUll'" ~1I1') 11I1'I'ullhlrlll1f I'm'" "'It' I'uldu'" (<'I"llw\)'h.lIll,lIUIU'I.l1 1,"",101\ ^,,'IiI.llIUl1 I'll ~ltll , ___.. ,._ __..._.,._ _o~'._ . J 11l//J1'!'1II11; . ,,. FUNt:RAL.., , TRUST' c ~;g) PRI~-NEED AGREEMENT {'/ Or!JLA>;:r__, 1'1-'1.1"'- I)JIt" I'IINUl^1. 110m, __'..fJJI~ .{/):::'{>k.Jf~_ I" [;;I)~, ! 1.1_,(, \.; 7;;.j.-:-______ . . i\.IIIU' jJo./i. \' ,/,'1.,. I' I..:("/.J.-:. .-:;;'.//...dlu;,:A_r..h/1J.l/_.!"x1j, 'J chl\HU'" I\ddrn.... l'III1C11^SI,II, __~~_j{)~:o _.6: [lih/I S' t" (lklc:lnaflcl "YIIU") I t-o'Jlllt' ..IL)_:111I"L{ :1...IL..j CJf . 6~n I.:,.',,<ll.. .\ddu':'o\/ /~! .7 /"' .-:. )/ ~ . - .. -' . -.._.., ._.L.__ ~1I11..tl ,""'Ulrll}' ,'\;IIIIII,t,( III,Nlil'ICI^IIY, ____.._ _ (if dilfc.-rl'lH (wm I'url"h;.....l'r) N~lIu' ~UI,:i31 SC:l'IJril)' NUlllhrt Alhln"" ANNUAL I'E!tCENl'AGE !tATE I'INANCE 1;IIAltGf. ,\muunl nnanced TlIl:a1 ur l'a)'lIlcnIS 111(' ;111I1111111 '1111 ".111',1\(' 11;1111 diu }t1l11.HI' llI.ulr .Il1lu~'lllfllU ,1\ \tIIl'dull'.1 '[utal Sale I'rlce lilt" IlullJI Jlllllllllllhr ut'llll Will UI'I }UU Ilir,1IlIlIUIII""U','tl 1"IH"illltllll rllUll' till lour IIdl;!11 TIll' lUull'u" ur )Ul1f l"llllu\(' IIn ucdit,lndudipJJ"Uf dillion' iU)'1Ilt'1l1 HI S ---,'L"/_ Tht lml ur )uur Hetllt ..,.. )'C.llly f.l1C' 1l.l)O% SO,OO . ""\11 1';l)'I1Wlll Sthrllulr \\ilI ht"; Nil ul .nl1lrnl' ^1ll1l1l1l1 "II'.I\IlH'l1I' \\ h"1I 1'.I\'1I1l'nl' '\fl' IIl1c' C' Il1r.lll\.I11 r'IUIl..lr Itt'mlz:ulull Or Amuunt , L.I'h "tiu" '.11'111111,.. hC);llllllllt-: ,11) ....1, ,'I '.f"'''/ "_. '141111Ih,wnp.I)'mtlll '1/":' -. ., (... I I lllJuM 1I.11,III4,.-C ur (:.I\h I'rot t.''' AlIllIUIll hIUlllrd., .V:j"' ~c't' )t1ur t'llIllr.ull...llIw ,",r .111\' .alclllulll.l1 ...lllllll.UUln JhUl' II11UP.I)lllt'III;,1ll1ltld.l1l11 . Tilt" Il'rlll~ ..!IuWII III 1111" h"x Jhuu' .If! lUrI III Ihio; ,\~Il'I"nH'I'I. SEltVICES, MlmCIli\NI>ISE AND flItICI!S: ~cc hllle'.Il ,\pl't'llU'1I1 r"f11l tlr 1Ilhn Ih'11l1/.l1ltll1 ;,Iludll'tlllnt:lo ,1\ I:\hihll ^ lU~\'()C^ TION: )"Utl IIl'reh)' clrc:1 lllJl IlIio; '\KU'Cl1U'1II .Illd IIII' 'IrU\1 It. h. 1'\IJI,li'hl'tI It\' llu' I um'ullJill'l'lur \Iull ht' (dink tllll'): U I}cvm::ahlc by Ynu ;11111 at Your (JJlIlon .11 :all lim('t" [U'1rrcvocahlc UJlUIl P;l)'I1\I'111 in hili of the Tol.ll S;lIe I'rkl', SlOt 1',u:r.J.;rJph:o. j ;Jnd ,lUll rl'.\,'f\'" \Itk fur Irllll\ )ttln'tl1ln~ u uu,IIIt1l1l1t'lll1ill;11i1l1l1 J)ltlCn l'ltOl'l<:TJON: TII,' hllu:tJll)iu',lur ;&Ilillht" \'Ull lint'll)' OIKrn"lh.lllhl'I'ru.:n \hU\\llllfl hhillll ,\ .IU' (rhl'd. tllW) iYNut gu;u2utccd h)' 1111': FUI1l'r;ll l>irL'l'ltJr tJ (.uar;antccd h)' 1111: l:ulIl'r,11 Dilc:,:lOr upon IU)'lIU'1I1 in rllll of 1111' TIIt,II ~,lk l'rilT, ~l'C 11,U;I)tuph -; un lilt" rC\'l;(\t" ..ilie' fur Il'rl1l\ KU\'c'll1in)( I'riu' PlUlnllun, ^(aU:E~mNl': YUllllL'rchr OI)(IlT III hll)' .lIId IlIl' 1:t111n.lI,hrn IlIr h."I'll)' OIK"'f~ III wlllhr 'l.lll'ul '1'(\ hC\ (""',,'llT\'" .11111 Wlllll\ (".'tIcnlumJi'(''' whld'OIr(' d"M:,ihl't1 flUlhl' ilCllIi/JllolI,uudlt'lllulhl\ ^~U'I'I11I'III;1\ r.hihll ",\'" TIII\ ^~u'''nll'l1I h 511hjrct It) tht" trrlll\ OIlhll'lImJllhlll~ \c'l hUll allll\'r :mu uUlh" n'\'I'r"I' 5111t" 1I'lhl, f1.1)tt'. Ylltlll1t1~1 pJy Ih" '1'111..1 ',lll'l'titc' '1..1\\ 11.111,,\1' .111<1 ,llll'lh," I'A"lI1rnl' rnl'lift'L1 1111hh A~nrl11"lll. ^'ll'l "I'tllI ha\'(' paid tilt: Ttll.ll ~;Ik Ilrln' IJ:un'l'IOIlhl;a1l uthl'r 1'.1)l1U'1I1\ U'll'llred IIlld.., Ihl\ {\~'I":1\I1'lIl, Iht" hllll,,..1 Uirnlllr will H'ntk, fut 1111' ;,IhmT fC1Jl11nJ IIcndld;lf)';l1I ur Ill" (tll1l'ul ~I'f\ln'~ JI111.\ktdl,lIull\(' t1nltllwllllll hlllllll ... I:XCl.IlSlON 01' W^ltIlANTII'S: Till: HINEIlAI.IlIllI;CrOIlIS Nln'I'1l0\'lllIN" TO \'OIl.\N\' \\',\llll.lNf'\' 01' .\l/JlC.Il^N. T^IIII.1TY Oil WAltIlMIT\' 01' ITrNESS 1'011 ,\ 1'^IlTlCIII.^III'l1IU'OS" WITIIIlI,SI'ECT TO TilE MEIlCIIANIlISlo. Ih"IIlI, ""arranllr..... \'tlU art' rCl:t'h'hl" eur Ihl;' Mrrdl:lI1dl,U" arf" lhc' c'XI'rt'!'I"" \1"rlllclI ,,';arr:&ullu,1I any. "hlt.h :au' f1rll\lde-d by Ihr w..nu(ac:lurc'r" ue Ihe- M(,flhalltlhe- ~uld IH \.111 Ullllrr Ihl.... ^s.;u'CIIH"nf, Onl)' lhr l1I;&nll'.ltlurcr will h..\'(, all)' lIahllll)' In Yuu lIlutrr ~ulh .';lrrallllu IN WITNE~S Wllmtt~()F, YIllI :11111111" IlIIwull)hn 1..,11.1\'" \1J.:Ilnlllll\ '\I:rnllll'lIll1l1lllt' 11.l~ JIllI ~'I'Jr ''''11\(1111 n..llu\(' "Uti Jlltllhl' t-UIU'fJ 1111t"lIHf Inl\'lhllll h,' Iq:'Jllr hllllllll h~ lhi' ^~r"tllll'lll ^1l1l^N(;J,~IIXr HI" ,_ Ihj, ,...." "'1''''''' ""I ,h.",,,, h..on ,h,' '1...., '".. I',,,, ",,' ,.." h,' ,hl""",.1 '" ,h" I".., HINI'Il^I. IJllllCnllt C;/i;:,..!.....Yo.L/}J.. (f,ct:l. :d,:' . /'/~J 1./ , I ~1" :1:._,-- i -' II)' -~I.:.~~L.CLlj 1:'.J:i1"..~'.:.:...- l.iumnlluIWfJllllflll'" l'I'Unl'\~ER '-;. '-~ft..11J;;--.----'~/-;-- --- ! , I,: 1\ ('1- ' 0... .. ' "urlh.l\,r _L]) -UIL.6:.1.'I_~__ li\t'lI,t''''''' Sl'n)I'CT TO Tr:(~.s MOl CO;o.,JI nONS ON IU'SI:l:\'I, SIUIl YOII .H.-kIlU\\ 1c:t1J.:l" H'l'c1111 of ;a rUl1Ipll"led \.'fll')' hercuf, Yuu the hU)'l'r. may t.';lfIl','llhh Ir,III't:ll'llon at ;111)' time prillr In IIIhtnllo:ht uf 111f: Ihlrd hu~lnc!'l~ d;l)' after the date uf Ihl- tr;ln~:tl'tlun. S("t' Ihe alCadu'd Nlllh:e n' (;.ll1ll'II..lluII furm fur ;an c'''I,I;&lI;allnll ur till.. rlKht, 1i)1'I'Il""I\'~I1I.1 11l1lI'f~' 1)", '1"1' "''''1''''1''1 I'll ,un \\11111'\1111\ f'II" \'t\l"" '''1'\ IUIHf.lllhfnl"r l'lll" '''11\ I'ur,h.l\u .t j i ! i t , ! , .' ) 11l"JY'f./"li, \','" FUNI:HAL,"' THUST I 8~~ pnE-NEED AGnEI~MENT 1'.lIl' , /" - /ZI::.lJt Ii:. I'.. _ 1l1Nlm'\I'II11.\IE:../!;, ~.1.6':::/1;-:":'::'. (:'fl..:.',;:/ i/.,........ 1\.1I1U" " .1. .'': j' I.., . L'-, /"" / / 1111\1111''''' .\;II'I~~"'" ... .... __a.....;...I~. "? .-, "-.- ~Z-;lC:M___' . I" I.a/J,~~L''- _ O.;J.:J~: ,./..... ,.' / i) /' I I} f'UIlCIIASI,Il: '__.. ...":""1.. f I)::.;v..--~L... {I>._':'-' f.::.':' (lh'n'jualln "You", I N,lllll' "Z"'- ( . I I, I -1-'- j'--.-- .-!.'~'.Ir :.-. .'~~l""~~~-':;' ~-,,.~.C',,,..II::..l. ~_-,. 1.JJ~d . " ^Ihlrn... / I. I ' 'J ", J'" I . . ", /' ..- --. ---;-,_ ____ n~_~ !'Iul"lJI ~l'tllril)' NUlllht'r I' , /' 1_....._.. IIENHIGI,\IlYI __..... __ _.. (it dUrerl'll1 (rulll Purrh.l~l'CJ ..-----.+.--- -+ N.lIl1l' ~'UJl'I..1 !'It:rurll)' Numhcr ------------.----.-.--.- Addrt'''' ANNUAl. I'ERCENl'AGI! HA'I'I: I'INANCE CIIAIlGE Amount Flnann'd TCllalnf l'aj'lIIrnls lilt' Jrl\HllIl1 )1'11 \\111 lint 1'.lI,I.I'ltr '"11 hnr m,uJr..III'J'lIlruI' ,n 'lllnlu!r.J Total Sale Prier 'I Ill' cl..lI", .I'lllllUlllhr (((\III "'lIlu"II'II\.! Iht "lIllllllll 01 IUIIII I'fll"..lnllll)UlIllr "II )1111"'1"11..11 III(' lul..1 11"1 !lr 1"11' Jlulllu'r un uul., hllllllhllllllJur L1.n,", pJ)mrlllur'L ','___, ThC' (11\1 III }"Inn urulI u.1)url)""lr 0,00% ~O.cIO , YlIlt' I'J)'lllrlll ~dlc.rllh," will hl'; N'I_ fir ';I\'lIl('IlI\ ,\'It"..m III 1',I\'IIU'II1\ \l'Ill"lI 1'.1 '11I1'111\ ,\fl' 0111' r Illnll'.Illnlinu/l' ItcmJ:r.allo/l of Amount (:J\h 1',1.r J MUlllhl)', hq:llIlliu;.; ,II) 1 /7/' '1"Jllhl\,n,',IIIII'"1 -I (~70 ~t"t' )'IIU, nunr.l.1 hdllw rnr JII)' ;r,d,lIlhIlUllllhltlU..1l1l11 ;lhullI IIUnp:l)Il11""1 JllIl d,'I;lull. 'I ht:' Ir,nn ~llImn illlh,' hll\ Jltll\'" .Ill" pHI III 11m '\~"nll('lII 1:IlI1.1ld IlJl.I'hr ur [:I,h 11,11'1' A AnlUullI 1 ill.ln...rd .. 1.,;r SElt\'ICJ;S, MI:nCllj\NI>ISI~ .\NU IIUICI;S: ~CT 1\IlIC"rJI \~IlTllU'1I1 I III III "' IIIIH" lIC'lIll/,III11" JII.llhnl hl'UllI J\ 1..\1111111 ^. 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Smith 3415 I?<;Jfcrd r':.oi\"c Camp Hill, PI, J7C'll .,. -- .-.-- ... -_..........."-i+- .. '.'- -.--- Fot' the S(.1"....iC~S of Sidr.L'Y R. hnu..:r:,(;:-,,: .....-.----. .. ..-..----- ;\~ !-....~:l(k.d -.---~_.._-. !,ctU.:11 c,-,st ---- . -...-...-..... Grave 0j,-'('l i: ;I~J 1'ranSror:dtic;1 :1'om Lake l::l:n'o;)', \ ~,') ,;,i @ S1.:,'1 miL~) ~670,O\l SGS'5, no ....-, . ' . . - .------ .. ._.n'_ ._ -.. .. .... . .~ : .~~~. $528.50 , - . !~. ..- 1'<.." :: ~ ;7- : --P----. $670.00 S158.S0 ----...- 5133. S} .-- .._- -..- Di. f: f-l"l.:-j,C8 l)~112: TI',anl: YO',I. . ( .J.. ~ ,'/ : ~It\' (r (" (.: ( L-'.;- '- -' ,,'- - -;- 10~1 ... _.._ __..~.,...._._~~"",~"1\1'.;'CT.J'~":'~'Ii.:\'::; ..~...~:T..a..~~~ri~7 ~~ * , ......~~~ ~~.-~"1.,~"Irtt~...l~'ZL.~-=~.:~j~... ~...m-.:.:j~~~~.l~~ l\ ~ ..~~.~:a~~__'~~~';.h"'''~~:- ........ 1'~;". ~.~!I.,..'t."...."...;~~.'.. ... 't..J _....~ .lr......._ '\1--. .... _\L..~'\o..... -... 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'(I) __ .<.:.-1./ - . -- l' ~OIIl'I: TO '1 m. l'IIll'lI,\;1 II · III I)Il :\IlT SIl;~' TillS ,\(;[nT\IISr III.HIIIE \Oll IIF \I) 11111111" IT ('0:>-1.\1':' \';\' III.,\:>-K s\'\l'l:, (!I \'Or AilE I "Tm Ell TII .\ 1'w'II'J.ETEJ.\' FlI.I.EIl.I" ('01'1' or TIII~ .\1;j11.J.\11.~ I. (,I) 1'''IIEII TilE 1.'\1\. \1Il: II.\\'E IIIE III I an TO 1'.\\ IIFF 1\ ,\II\'AM'E '1111.1\;11. .\\101.:-'1111;1': ASIlI.'IlEII (un ('O:'\I)ITlIlSS TO lIlI 1',\1:'\ ,\ (',\IITI,\I. llFlI:-.lIIlF Till. H",y:-.n: ('11,\\;1;(.. 1'('In'lI \SI'.II',; 1111;11 I' TO (' \:\1 ('I. (,\I'I'I.II:S 0'1.\ II' ~ \1 E slll.hTI EI) I' 1'11:1 '11.\<';1:1(', IIl1\lEI \'OU \lA\' <'A\Gl,Tllh ,\(;[tlr.II::, r II\' 1'1I0\'II1ISI; ,\ \\'11I11 E\ so nil: '1lIIl11:\I.I.I.EII.OIlII\ \E'III'.'; ,\ '11.I.n;t; 011 II\' M \11.. TillS :,\Oll('E \IIST IS\JI!,,\'I:'. TlI.\T \'or Il!l SOT \I ,\"1'111I'. (,1I01lS 011 SEII\'ln:s .\:>11 \IISI Ill' (. \'EIlElllllII'IlST\I,\II:\EIlIIEFlllll. \111);\11;11 I' "I' '1 liE T1II1W III SI"ESS 1),\ Y' ,\I'I'I-:1l nlll S1I;;\ TIll', '\\;IIEDII'.ST, l'ionn: AIl'S'( IIEMAII.EIlTOI\OI.1.1\1;1;1l1l.:.\<.I-.\IE11.Il\..INII(..\\:I.I\I\:IIO.\I).(..\\II.IIII\.. I'I.S:\S\'I.\ ,\\1.\ I IF \'011 C.\\CEI. 'I illS '\\;:l:-E\lE:\I'. TilE ;,1,.11.1-11 \1 \\ :sol' hEU' ,\\1. OIlI',\Il1 I,F A\\' I.\SIIIl()\\':'\ I',\\'~IES r. ,\:'\ EXI'I..\\,\'\'IO\ OF "illS lU:al\'. SEE MlTll'E 01' ('^:\<EI.I.I\II\):-; 1.0H\1 II 1\1('1\ \'OU \\11.1. lWei-WE .\\.0;\\; WI COI'\' OF TlIIS ,\GllEE\UXr. I'IIU'I(,\SEH'S '\('hs(I\\ IllIl;J'.\IIS\' u'" SIWil:,\!; IIEI.O\\', l'I;\U'II,\SFlI HEI'IlESL'\'IS ,\;\\1,\1",\011 ITIICES '111,\1 1'11ll'IIASEIIIIAS HL\I) A:-;1l11:>IlFIIST 1'lIIiTEIt\IS OFTIHS ,\\illn.\lI'XI','III,\l ,\I.I.IIEI (.:\'A:\T III,\SI, SIW"I'.\ II In. 1>1'1-:\ ('O\II'I.ETII), .\:\IIlIIA'I l'I'Ill'/I liAS llECEI\'EII ,\ 1'01'\' OF 'IlIIS .\1;JlI':E~lL\ r ,\'\111'1011I1 101llSl'I \-1\1; l'I(If" S, SI:J\\'/C/:s 01(.\/11/('11,\.\11/.'1-','\ I OF TilE AI'I'I.\(, 1'lt\('E UST ,\S IIElJl'IIlElJ 11\' 'I Ill'. H-JIEIto\1, TIl,\IlE nl~',~l1SS1ll:-;, l'U'\UlM,I'll,\UIU.s '1\ ,"'f'1 'I 'T,n"" Ie' ...' ,..... '"''111''''' 'IU"'''' .\'0 ('()~IHIIO"'~" ! ( -1--":': :/---- ... .- .', '." '" . I ...... b_... ... ..\~... -~::::::ucns::-'-~~:" _::':j'.'::"L>__'" ~~;-l~ur~~ ~ , 1 r II r; 1, ~! ':' '( c. "." ..'....."., "'" r lkcl,. ,.. 'i( . ~ "!~,,,,:IlJjt1i..;(I/:I"~.;' __ . __.. .. I 'b7;;2.~ot::.'G t ~~!f.';jj;"LJ ,1'';(;/1 c''''(~' d ~(--C-,'" , '" I ! ,~(~s~/~ N oc 1/)' j' _/; J. ,,'h""''''I'A . ""'. .:; '>.r'[(.l t.C. ,--,-:i -ill-' c t l.\.. ... :; . . ;~~~~~-;-~~~_. ~-~;-;~ 5 ~ 1.0 ~(j< g? ~Il' mT{1'JOO6~~&/~:?:J .......cL~~~~.-.:-.::!'~':..=-...:!'....:._.::o:~:--.;.':."'Z"'" '-:-'I."J":r) . P"!'}- FooD .f REFf!E:-SI-lI..fE.".J'~ Po ~_ l.JAK"t!:. -'--- =~== -j;4~J~~~0~/--.'..'~.__~lr~~' . _ _.J~-- ~~--(.~L~~ n_Cif'j{~~_.. .--. --_.!j'~ -- ----i.- - -..~ j-. . ---- ,.-.. '--[1' ------.-- ----. -----1---. -----...--- ----.- --.-.--(~tijfuCti-LjQht _ --1 . . L/~G;_ilfl -_oct :_t}d!.b.__ _____.!_ -.I. 0 :i!St;.:"-G: - --- !3"",J...s ,l'. ~, .. -.ce..,}~~.~ I'I\V U\',J i'U.'OUNT I.. IN LlALANCr CO'.Up".t~ I : . I Tlnr.,s ~~ti 3.1 u"'YS I.. ~Ir-.:.\NC[ CH..'\n'..;r \'1 ,.... i"(ll r.'or"T1i \'.'LL (j[ :.rJ:";L~ Ie- 'Y~i':'I:~ 11;.1. ;,';Ci HARDING'S RESU'+.UR/\/',:T. no:c.. c.amp tt.!1 .~ ~ o::;t- CD C\J '- ~ ~ :'i ~ -... <:J !I ~ ri. '.7'~ "' ':.J ~ ....... '- ....... = '\ .:: :-... '-u 3 ~ ~\N :: ....... ? . ~. ';).. ~ ~ ;: ~ :: ~. . -',,,, .~ '" ~ '" ~ R \ -1.1 ":::--'" '. ~ ~ ~ ~ (J EX ~ ""- 1\ \n ,.., ~. ~ '- ~ I \\.) ~ ~ "n ~ .~ ---( ~ ....j ~ ~ c;; ;.:0\ '.::J , ,~ ~ ~~ \ ,~ ~ /\~ ~ h. ~ --: G~ \1, ;oJ II " .\ " . .~ .. f'f7\ 1,1\ c...., ~ ...;. .~ Q. 'II r; -...:. ~ I ~ ) \....;j <1 l~ \,:; .....,\ \~ .. . , ." 'I) \/1 (~ ,:,:..... ....... <') ,~ .~ "- \ ....... ~~ \ Q ~ '):. ,~ ~ ~ .-...!.) "~ ~ ~J '.~ --.. :.;r:- Q c/) "<"\ ~ :-.l ,~~ ~J --=~ 8- VIi.,.. ~~ -.... ~ .~ .J1 '- - ,-,. .;:;:: X' . - <;:' ,~ (}. {, 1\ \" ~ ~:l ~ , . . ~,~,~ ~J!' SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES AND LIENS I PI.a.. Print 0' Typo 1__ . _ . . - -.'--- ---1 Filf liUiAnEi- _ 1 _,~__..__.___. _.'.._ _.___._. _""ISlll"!")l (1).....vNwl..\ll. II f1'j'.\rh~..'A 1hr41111"Un U'."t'Hf 10l"P.[\III(-I'.' _..!.-.._.....:......~--;.----'.- ...-..._.. --- ESTATE OF " A 5IDI\)I:\ (<;..'. _'~Jl)E"!',~'.r.:~..J . -.---------.--- -- -- ITEM NUMBER DESCRIPTIOll 1. lJ/!.11. Lr:siT:-;'''':'( I M,{), Po &0)(. 182.. ... _ dl?l~ {-t-{ ::;0 rLL.C fA '1 v/.,. -( -.., f'> .,- <. AJA,e.IALA/U' r:: L-_,\A)",,-Ol~ I " , I P,'\. 41..<1 ':l, l.~rlJ 3l, Cl3.kP (- Ir..L 3, /'/AR.R..(~ Bv. ~L:- !--I()';, ,",.Ai. PD B~,.. .z.SS.3 t-/ARI:!{ ~i3LlC.'C.- PI-\ i.(, ') SO!.LElJ nc~GEI2 COi-C)/) I\FcTf\L 15/1 I.J. h~''''\J '\ ,- I' , 'f" ", - ...-, .).. ~ -r~h' fo.:' l',U 1,(- I , :;, I ItAr;:I:I:' Bu..N- l ~)_".)fY(At.._ f-\' 8..,.. .23S~) tl,4J?F:tS ()<~(~ (__ (~ C" CA.Rj(IC(\IJ~, (c-,wICY eH/i~II\ACy {(T Clo'!> ALW':?IC-t-no;,VILLL?:, 1:;.\ _____L__ . - -T ---AI~~~;'---- ----.----- - --r------.-.---- I.f"M e. U,~it r I IS, '-0 I I I A,..4?t.u. 4.vc CO &., M~ .t 7't~:c.i.l E- SA"" n, <:'r' I , lJJij, (.\'. (vA;:;...... t1 , I.t..E{j~~TClk'l r!.j --, , CtJLC:::".{)I-,', Ej.(cR'-~r::....c: y t)rpl /\t\e b I un (~'.v<, TOTAL (Mho, "t'T 0."' IIn,' 10. RI~(<1f"'U!1 ',;:..r.) {II ":(1., DOC.' 1\ nN'cJt,a In',f'tl :'1dd.' ond ~h"l'h of \am~ S,/t:; '2 . "['j ,",J~, .J /"'9. &_ 1-526 3.2 (, ,(, ( 10,22. ;l. (), t'O i I I I , --: s--. 5-'i.i,-.3({ _L ____ __ ..- - --- l..~ THIS IS NOT 1\ HILL Explanation of Your Medicare Part B Benefits . - 1".111,"111".1,"111"...1.1...1111...1".1...11..:1....111 SIDNEY R ANDERSEN 113 3RD 5T HEW CUMBERLAND PA 170/0-2101 ~III11I1I:'IY ullhh lIutke .lal,,\ ;\Ialeh (19, 1996 'lut:.1 d1arl:('S: T..t:,' :, tl'tHr-..lrt' :1J1P"f"'OO: s s 78.0U 78,00 We I",hl )",111 (It'" id,'r: S ,"uUf tufal H" JI1\ihilit\: S YIIIII ;\I"limre nllmher h: l(:l.!~-J%JA "hur (lrfl\'i1lcr ~ln'l'lt!!:(! :1\\i~lInll:n1 -- . Delail. .houl Ihis lIolire (S<:..t.!'~ h:l':)( Inl IllUTe inlc~~m...linnL __._. __.__ __ _ ._ nIl.L SVn:\IIlTED IlY: :\hilin~ Addr..,.." :\,'il Lr,illl:y :\l.D. 1'0 11." IR~ Alblight~\'iUc I'A IS210.0182 :\ov 16, 1995 ScnkC'i :\lId Srnkc ('nd,.' Cnnlrll' nllmurr ~(..61143,lnR,4~.(lO :\,'il L,'Sit,ky ;\1,1>. (I Illume ,'isit, ne\\' patient 1993431 Sre :'I1"lir:m Sfll~ (".rCI" Anmo....tJ Belnw S 'IS.on $ 78.0n a nah.. :\ulc,,, '-;)1 t ;--t.. '. I--:r.-t 1--:, :'~__';~(O \ a '1,e approved amount is the provider's actu..1 charge for this !eIVire. ~_~ ,. lED . C\r)n.~.~~t. h.le t, / GE:-;ERAJ. r:\FOR:\IATIO:-; AIlOL :\ . I c'\It L: l1\(l:-X.~ 1'- !I U5l..g ~ Tclec";;:munieatj,,ns D,'vice for the Deaf (I DD), ;'\oa,e cai. I.RlIO.242.S4'!1 for Medicare Part II . 0:J I infonnahon. \ (1,\'- r. (J 'l1,e fiu ,ca"lll j, here! I'lc-ase remL:nbcr that :\Icdira,c now ('o\'ers nu ,hnls. I<:)l ~ J'L' )-',1.-'0 \~(.V , .f U J\\()C \, L.CL(J i~ , \\ \-'0 (, lL~ ~ \ \ U' \, \ ',1\ ~ \.; ~ \j'" 1Iar"I...... tfI&.._____--.___ li\I!'ORT,\:>iT: If )'(,U hare qlh"liollS ah'llIllhl~ nOlie" ""II X.l'1l\1..li,,,re &n'lre, ;\1...!ir:lI'C ParI n.t I,801l-.'82-1274 Dr . .i$illl~ al IR(lf1 Cenlel Slrl'CI, Camp 1li:1, PA (IlIne ShiLld IInildir.1! #1). Ynu will Ol't'd Ihi~ l,liCl' irynu conlaet liS. SP' To ;'l'~"'''llIur "lxisillll, wrile 11111< lit ;\1l'1!i'-:lrC, 1'.0. IIn, SQtl413. C.mp lliil, I'A 171189-11413 bernrr &ptemhl'r 09, 1996, S''C II. nn Ihe uack. (;cnl'l:,1 qlleltinns c:<n .Iso Uc .Ii"..II-d to Ihis .d'(r""'~ "' Ihe at",.e telephone number. 3,076 ..- -- ( ~ f..L.v- ~ -' L' 2) , THIS IS NOT A BILL Explanation of Y ollr [\1edicarc Part B Benefits ... . . .- SIIIIIIII'")"[ ,hil '1Ulin',bll'll I>n"'lIIh,', II;;, 1995 1,,,111,,,111,,,1,,,111,,,,,1,1,,,1111,,,1,,,1,,,11,,11,,,,111 SlllllEV R MWERSEII 113 3f/ll ST NEW rUMBERLA~D PA 17070-2107 Tut:11 lh:lr~(": '1'''':01 ~h',lir'"l' :01'1"11I",1: s s ~S1,OO ! ~.1.1>8 \\ \. I",id ) our I'ICI\ illl'r: S "Hilt 1111:11 U"fllI,"ihili"~ S YII'" ~"',Iir,"" "'"111,," j" 1lt(,Z1.J')(oJ,\ \'fllIl 11I(I\hll'r ~'llll'll :1\,i~l1Itll'lIt - ~_~',!~\ il'-. :~~.H~~!,.t 1~_i~_I~t~~ ~J~ !_I~~~ I!:l ~I~!~.~~.l~'" }n ~~!:!!!.:11 j !II~:L 11I1.1. SI'II"( 1'11:1) IIY: ~I:lilj,,!: .\<I,h,",,, :\rnhul.I:"f{, Tr,m'p"11S 1m: Cumbed:o.,d .\mb ~\'C.' 4:'1 S I:::h Sf (amp IJ':I 1',\ 1701:.51)'1:: 1>:11,,, St'l \ il"'s ;11111 St'nin' ("mil-, ('1111'11I1 ,"""h", 17,5JI.l."Il. ;(,.(11I ..\ntlllll:tllrr ol'r:IIl"IJUrrs III:': 01 Il:"ir emn "'P mik ,,< s"I'P1,' 1.\I1.\l>::.:\1J1 06 fl,,, Ie hI'" ml'P~rt nllk,~o 1 \'I..SIII 01 An,o"lanr" O~ life ,,,,t,,inillg 1,\0'1.'::1 '1',,':01 Uml:!} :'\0\' fJ5, 1'1')) :'\ov OS, I') 15 :'\0\' 0). I'J I~ ) ~.\5.liO ~ ::7110 ~__ __2_~ } ~S1.01l :'\1111:." a The approved amollnt is oa~"ll ~n the I',e,ailing ,Lr~". ,.-Ie c;",1y/" - ,-'.J If ....- _,/,I ~ .... V ~ ... b The "I'P:O\^d "Illollnl is oa,eJ un the ~\l>tumal)' ehlilg:. (K .- J.-.,-- Sc,' ;\1I1..'S IIdllw a " b _.._~_ . '0- ._ DlI'OIIT.\'iT: II )ollllalc q,"',linll' :l1",,"lhi, ,,,,'il-e, ,'"II 'iad .\I"li,',"e SCllin" ~h.t1i,'an' "21' B:oI 1.::rIIl,",S2, 1274 or lilill".1 ISOIl Cell"'r Slr,'d, Camp lIill, P.\ (Bille Shid.!lIl1ihlill!: 1111. \,,,,, II ill 11",,1 Ihi, IIl1lk" If )."" (lllllar! liS, SI' Tu "I'\"'al.",, ,I,'rbi,,", 'Hile I" '" al ~1",li,,",', ".0. HilS li~IIl'ID,l'a"'I.l!ill, 1'.\ 1:"S'/.(I,113IR'fu,e .Il1l1e !I5, j'NC" Sl't..lt.. un the h;ld\. (;"'l1n:,1 lJtn':.tiuns (.:111 :lI'lo I.... t1irl'l'lnllo IlIls ,Hltltl'.s....; (Ir th.., :\blJ\C Idqlhnnr numll\'r. (i,52tJ ~lr,lit-are !.\1'11l1l\'t.1 $ 1.1'). H, ~ 20, ~2 . 15lJU ~ 1 Sl.I>S C)lc..01L- 10'- ) ~"~~.":'~.:i.:-=.J"'~ -..- ~ , , ~ - ~ ,~I ___'__ _ __ . (\J Nl of' . I rn ~j I "=: ~ '<'~i l'- r-J ,.. 0 -r.)' Ln rI , ,. 0 ' 111 I ~ :'J ''':'~ 0 , i ~ ;. -~' ~ --:} g ", ~ -----, ~.. ,I ~ ~ ~1 ~t. )t-~ i ~ l ~i ,~)~- ):J; :;. .:t. 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I.... D NO, AA .1V.1l62 Ill""') RECEIVED FROM: 184915 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE OFFICIAL RECEIPT. PENNSYLVANIA INHERITANCE AND ESTATE TAX '* KAREN SANDNES SMITH AND JANET R PETERSON 3415 BEDFORD DRIVE CAMP HILL, PA 17011 ESTATE INFORMATION, ~ FILE NUMBER ~ 21-1996-0301 1:1 NAME OF DECEDENT (LAST) ~ ANDERSEN SIDNEY R II DATE OF PAV:ENT m POSTMARK DATE COUNTY 5SN 101'-22-3963 (FIRST) (Mil CUMBERLAND DATE OF DEATH REMARKS SEAL KAREN SANllNES SMITH JANET R PETERSON CHECK II 112 REGISTER OF WILLS D ACN m ASSESSMENT AMOUNT CONTROL J NUMBER 1 101 "'."v....l.LfB '01;0 Hflf-. fa TOTAL AMOUNT PAID "'3,041.48 CW (); . JI RECEIVED BY t,'jlr1/I...., L .;;(/'A../.oJ/. ~ J't.,. .J SIGNAUJRJ-- .. 'Y1o!...~.J I'),/J'-/- MARY C. LEWIS A. I REGISTER OF WILLS ..--- - - .-.-- -,..~J:...~" 4....~ .~:- ~ III .... . 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Print your nlme Ind Iddll.. on the "VII", or Ihl, form '0 Ih.1 WI eln CJ "tu," Ihl, clfd 10 you. = . Anteh Ihl, form to the front 01 Ih, m'i1pl.c.. or on the b'ck if 'PIC, .. do.. not petmlt. J . Wril, "R'lum Recllpt Requested" on Ihe mlllpi'CI below the 'r1I(:I. number .. . Th, R.tum RICllpt Willlkow 10 whom the .niel. WI. delivered Ind the dill 6 dllly.r.d. " 3. Artlelo Addr...od to: .. i E 8 m II: iC ,c c( , ~ 6. slgn.turo (Addr.....' 'ffi II: 6. , P 282 345 842 ~ - Rccci/II for Cortified Muil ......, , 10""0.1'11 I' f ,,\. ',1'1" /'I,,~ "j, flq! q',t ,J:I'!. ". II 1('11..1 ,..~, p' Ill.",.. -(&~5~N_<:~'HN_I'I -__n______,__.__~_..._ __"'__,'_. -----, .----.--- $ -- '-'--- ----- '" '" , " , -, 0 $ 0 <xl M E <; ~ V> ~ REGISTER OF WILLS CARBON COUNTY COURTHOUSE P.O. BOX 286 JIM THORPE, PA 18229 ATTN: JUDY MOON, REGISTER ~ ~..-J GPO: t~ DOMESTIC RETURN RECEIPT o >PS .!! I also wish to rocelvo ~ the fol/owlng services liar 8n extra r..l: 1. 0 Addro...... Addr... 4.. 2. 0 RO.lrlClod O.liv.ry Consult OSlmaster for foe. Articlo Numbor P 4b. S.rvleo Typo o Rogl.torod 0 In.ur.d Of C.rtificd 0 COO o Expr... M.il 0 ROlu," Rcc.lpt ror M , h ndis 7. O.t. of 0 . ~r'Z-'(.. '7(... I'~.. {)(, . y " , BUREAU Of INDIVIDUAL TAXES IHtl[RIlANC[ TAIt DIYISION D[PI. :aoftOl tlARRISBURC, PA 11126-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT. ALLOWANCE DR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX KAREN SANDNES SMITH 3415 BEDFORD DR CAMP HILL PA 17011 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN :\" 03-10-97 ANDERSEN 03-07-96 21 96-0301 CUMBERLAND 101 Allou"t R..,t ttad ~~* 11..lh' II'" Ill.hl SIDNEY R 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 .... iiEV:i54TEXuAFii-m-:9&Y"NOr-icEuOFuiNHER-ifAiicE-YAX-iiPPRiiiSEifENT-,--ALrOWAiicE-O-R----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF ANDERSEN SIDNEY R FILE NO. 21 96-0301 ACN 101 DATE 03-10-97 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. Allou"t of Line 14 .t Spousal 16. Anount of lina 14 t.xabl. at 17. Anount of Lina 14 taxable at la. Principal Tax Due TAX RETURN WAS: I X I ACCEPTED AS FILED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. R..I Est.t. (Schedule AJ (1) 2. stocks and Bondi (Schedule 8) (2) 3. Closely Hald stock/Partnarship Int.ra.t lSchedule C) (3) 4. Hortg.ga./Hota. Raceivabl. (Schedule OJ (4) 5. Cash/Bank Deposits/Hi.c. Parsonal Property (Schedule EJ 15) 6. Jointly Ownad Property (Schedule fJ (6) 7. Transfars (Schadule G) (7) 8. Total AII.t. APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expanses/Ad.... Costs/Hi.c. Expanse. (Schedula H) (9) 10. Debts/Hortgag. Liabilities/Liens ISchedule I) (10) 11. Total Daductions 12. Net Value of Tax Return 15. Charitabl./Gov.rnnental aequests ISchedule J) 14. H.t Value of Estat. Subj.ct to Tax NOTE: rat. Lin.al/Cless A rat. Coll.t.r.l/Class a rat. I1S1 116) 117) TAX CREDITS: PAYMENT DATE lZ-02-96 RECEIPT NUMBER AA184915 DISCOUNT It I INTEREST 1'1 .00 CHANGED .00 .00 .00 .00 28,929.66 .00 .00 IB) 8,060.75 592.38 Ill) 112) (13) 114) .00 X .00= .00 X .06= 20.276.53 X ,15= I1B) AMOUNT PAID 3,041.48 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE . If PAID AFTER DATE INDICATED, SEE REVERSE fOR CALCULATION OF ADDITIONAL INTEREST. NOTE: To Insure proper cr.dit to your account, subnit the upp.r portion of this forn with your t.x payn.nt. 28.929.66 R .6~3 13 20,276,53 .00 20,276,53 ,00 ,00 3,041.48 3,041.48 3,041.48 .00 .00 .00 If TOTAL DUE IS LESS THAN SI, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI. YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF TNIS fORM FOR INSTRUCTIONS.) In 'f.' co., 1-:- u: -. ~h ... '. c. ;, (J() RESERVAtION: E,tate, of deced.nts dying on or before Dec..b.r 12, 198Z -- If any future Intero.t In the ..tat. I. tran,f.rrld In POII..,lon or ,njoy..nt to Clal. B (collet.ral) b'n.flcl.~I.. of the decldlnt .ft.r the ..plratlon of any I.latl for 11f. or for y..rs, the Co..aRw..lth hereby ..pr.s.lv t...rv.. the right to appralsl and ...... tranlf.r Inh.rltancl Ta... at the lawful Cla,1 a (collat.ral) rat. on any luch future Inter..t. PURPOSE OF NOTICE: To fulfill the "qult..."t. of Section 2140 of the Inheritanc. and E.tate ta. Act. Act ZZ of 1991. 7Z P.S. Section 2140. PAYHENT: O.tach the top portion of thl. Hotlel and sub.lt with your pay..nt to the Rlgllter of Will, printed on the r.v.r.. ,Id.. "Hake check or .oney ordu payable to: REGISTER OF MILLS, AGENT All payeent. racelved .hall flr.t be appll.d to any Intere.t which eay be due with any reealndar appllad to the taM. REFUND (CAI: A rafund of a tax cradit, which was not raqua.tad on tha TaM Return, .ay be requ..tad by co.pletlng an "Application for Rafund of Penn.~lvania Inheritance and [.tate Ta." (AEY-1311). Application. are available at the Offlc. of the R.gl.tar of will., any of the 21 R.vanu. Ol.trlct Offlc... or by calling the .paclal Z~-hour an.w.rlng .arvlc. nuabar. for for.. ordarlng: In P.nn.ylvanla 1-800-16Z-2050, out.ld. P.nn.ylvanla and within local Harrl.burg area (7111 7el-8094, TOOl (711J 772-2252 (Hearing I.paired Only). OBJECTIONS: Any party In Intere.t not .atl.fled with the apprals...nt, allowance or disallowance of deduction.. or a..e...ant of tax I Including dl.count or Inters.tl a. shown on thl. Notlc. .u.t Object within .I.ty (601 day. of r.c.lpt of this Notice by: ..wrltt.n prot..t to the PA Depart.ent of A.venu., Board of Appeal.. n.pt_ 281021. Harrisburg, PA 17128-1021, OR ...I.ctlon to have the ..tt.r d.t.r.ln.d at audit of the account of the p.rsonal r.presentatlv., OR .-app.al to the Orphan.' Court. ADKIN ISTRATIVE CORRECTIONS: Factual .rror. dl.cov.rad on thl. a.s.....nt .hould be addr....d In writing to: PA Capart..nt of R.v.nu., Bur.au of Individual Ta.... A'TN: Po.t A.se.s.ent Review Unit, napt. 280601, Harrl.burg, PA 17128-0601 Phon. (7111 781-6505. 50. page S of tho bookl.t "In.tructlon. for Inh.rltanc. TaM R.turn for a R..ldant Dac.dent" (REV-IS01) for an ..planatlon of adalnl.tratlv.ly correctable errors. DISCOUNT: If any tax due I. paid within three (3) calandar .onth. .fter the d.c.d.nt'. de.th, . fJve p.rc.nt (5~1 dl.count of the tax p.ld I. allowed. PENAL TY: The 15~ ta. ..n..ty non-p.rtlclp.tlon pen.lty I. co.put.d on the tot. I of the t.. .nd Intere.t .s...s.d, .nd not p.ld before January 18, 1996, the first day aft.r the end of the t.. ..na.ty p.rlod. Thi. non-partlclp.tlon pen.lty I. app..labla In the .a.e ..nn.r and In the the .... tl.. p.rlod a. you would .ppe.l the t.. and Int.r..t that h.. b..n .......d a. Indlc.tad on this notlc., INTEREST: Int.r..t I. ch.rged beginning with flr.t day of delinquency, or nln. (91 aonths and on. III day fro. the d.t. of d..th, to the d.t. of pay.ent. Ta... which beca.e dellnqu.nt b.fore Janu.ry I. 1982 bear Int.r..t at the rat. of .IM (6~) perc.nt p.r annu. calculat.d at a dally rat. of .00016~. All ta.e. which beca.e delinquent on and .ft.r January I, 19B2 will b.ar Int.r..t at a rale which will v.ry fro. calendar y.ar to cal.ndar year with that ral. announc.d by the PA n.part..nt of Rav.nue. Th. applicable inter..t rat.. for 1982 through 1997 ar.: !!!! Int.r..t Rat. nalIY Int.rnt Fllctor !!!!' Inhlrnt Rllte Dally Int.rnt Fllttor 1982 20~ .000548 1987 .% .000247 1983 16~ .DOO~18 1988-1991 11;( .ODD301 1984 lli! .000301 1992 9;( .000247 1985 In .000356 1993-1994 1% .000192 1986 10;( .00OZ7~ 1995-1991 .% .000247 --Intarest I. calculated as follow.: INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR .-Any Notlc. I..u.d .ft.r the tax beco.es d.llnquent will reflect an Int.re.t calculation to fifteen (15J day. b.yond the data of Ih. a...s...nt. If pay.ent I. .ada aftar the Int.r..t coeputatlon data .hown on the Notlc., additional Int.re.t au.t b. calculaled. Il J ..... .J .y Q) .. J. !f} r{J r(1 W- I tl <!. f'(1 J l~ -.nQ - if) i () rj .J . 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