HomeMy WebLinkAbout96-00931
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MARY C. LEWIS
Rogl,'or 01 Will. a Clerk 01 Orphon.' Cou,'
Cumbe,lend Counly Courthouse
CaMlsle, Pennsylvdnla 17013
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~TA1J!~-B.~I)(J!l1'..._ UNDr:;R_. HUI'J::__L,J;1
Name of Decedent:
Date of Death:
Will No.
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 auove-captioneu estate:
1. State whether 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. I is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes No
b. The ,;epal'ate Oq,hiln,;' C,,"rt No. (if any) for
the personal representative's accollnt is:
c. Did I.he personal repres~ntative state an
account informally to the parlies 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:
Signat.ure
Name (Please type or print)
Address
Ll
Tel. N'J.
Cap"" i I y:
Personal Representative
Counsel for personal
l'epresentat i ve
(MAH:rmf/AM3)
PETITION Hm pnOnATE IIl1d C;nANT OF u:rnms
Esta/,. oJ _L2__ brlf:f. -~~ . . _ (' _ No" c;J /- C; ~-. 93 L. -.-..
alsf) kllOll'1I aJ Lll&uac.-'Y. ~~'ft.1Si.. "'"':'. To:
_________.__J l{e~i\ler 01 WII" lor Ihe
..__.__.... ))'....'11"". ('ollllty of CUHIlj-;III,,\Nll___ ill Ihe
Social S,.t'IIrit,l' No, _"21-1.. -::_CJ"l.::.._~q '2..~ ('ollllllonl,",'"llh 01 I'enl\\ylvani"
The pelilion of Ihe undersigned re\peclllllly rel1le\enl\ Ihal:
Your pelitioner(s), who is/arc 1M years 01 a~e or older anlll(.CJeCUI___________lq~ed
inlhe laS! will of Ihe above deecdelll, dated __. ~.O'I_L.!..:';~ ,19 -
and codicil(s) daled ._______________.___
1~lal(' rclt'\imt dWIl1l\IJII(l.'\, t'.~. rt'nllnl:ialion. dc;uh uf e\CCtlhlr I CIC.)
Decendenl was dOllliciled al dealh in _L'-'~blt~.Q~ County, Pennsylvania, wilh
II '''' lasl family or principal residence al _\..~ ~, ':) '0 """\
t..>AMC t\, \..\... r~A. _ tlbc<t..o
(Ii\! \!recl, number and munclJlalily)
Derlndenl. Ihen ~":L- years 01 age, died _~P'l: 'm~'2. ::to;:)---. 19'1 ~, ,
al "....~~dL\l r\~L~i?t.L.-., .
Exeepl as [tlllows. dece,jem did nOllllallY. was nol divorced and did nol have a child born or adopled
after execution of the will otlered for probate; was nOllhe victim of a killing and was never adjudiealed
incompelent:
Decendenl al dealh owned pr~'r1Y with cslimaled values as follows:
(If domiciled in Pa,) All personal properlY")
(If not domicild in Pa.) ClSonal properlY in I>cnnsylvania
(If nOI domiciled in Pa.) Personal properlY in CoulllY
Value of real eslale in Pennsylvania
situated as follows:
s lilq) '-110, O(
s
S
S
WHEREFORE, pelitioner(s) respectfully requeS!(s) the probat of the last will and codicil(s)
prr<Cnled herewith and the grant of lellers_fr'C, 1 tl Mel)
(tt~lamt'nlary: admmlma ion ":.1.3.; administration d.b.n.r:.l.a.)
Iheron.
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OATH OF PEHSONAL REPHESENTATlVE
COMMONWEALTH OF I'ENi'iSYLVANIA J'1 "
A H::;
COUNTY OF.r;!!~!~ERI. ND
The peliliolll'ris! 1llnvemo:nrd swear(,) or affirm(s) Ihallhe slatemelllS in Ihe foregoing pelition arc
Irue and mrrcu to the be>: ul 'l.e kilOwledge ;llId belief of petilioner(s) and Ihat as personal represen-
Ialive(s) of Ihe alluve dccedclll pe1ilillller(s) will well and trllly adminisler the estale according to law.
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Sworn ...> or amrn.leda nd. SUbS. crined 1.
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COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
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3liast 1[1i11 attb Qreshuuent
uf
CIIARLES P. LAFFERTY
I, CHARLES P. LAFFERTY, of the Borough of Camp Hill, Cumherland Cuunty, Pennsylvania,
make, publish and declare this to be my Last Will and Testament, hereby revoking and making void any
and all Wills by me at any time heretofore made.
I.
I direct that all my legal dehts and funeral expenses, including my grave marker and all expenses
of my last iI1ness, shall be paid from my residuary estate as soon as practkable alier my decease as a part
of tbe expense of the administration of my estate.
II.
I give and bequeath as follows:
A. My table saw, wuod lathe, drill press. tahle muter, wood lathe chisels, two
coffee tables, one desk and the wood in my shup in the garage at 119 North 28th
Street, Camp Hill, Pennsylvania, to my grandsun. MARK LAFFERTY.
B. My planer, joiner, hand saw, power mitre saw and hand router in my shop in the
garage at 119 North 28th Street, Camp Hill. Pennsylvania, tu my daughter,
MARY C. WAGNER, and her hushand, KERRY A, WAGNER, SR.
C. My wood clamp and carving chisels in the garage at 119 Nurth 28th Street,
Camp Hill, Pennsylvania. to my sun, CIIARLES I'. LAFFERTY, JR.
007371.00003/Novcmhcr 10. 19NIIIAJ/PAR/32565
III.
I give and bequeath all of the rest residue and remainder of my tangible personal properly and
insurance thereon to my daughter, MARY C. WAGNER.
IV.
If one of the assets of my estate is a One Hundred Thousand Dollar ($100,000.00) note payable
to me by my daughter, Mary C. Wagner and Kcrry A. Wagner, Sr., her husband. I give and bequeath
said note to said daughter and husband it heing my intention to thereby canccltheir obligation to pay said
note.
V.
I give, devise and bequeath all the rest, residue and remainder of my estate in equal shares to my
daughter, MARY C. WAGNER, and my son, CHARLES P. LAFFERTY, JR., provided, however,
if an asset of my estate is the note mentioned in Paragraph IV hercof and thc balancc duc on said sote
is One Hundred Thousand Dollars ($100,000.00), then my son, CIIARLES P. LAFFERTY, JR., is to
gel Fifty Thousand Dollars ($50,000.00) more of the residue and remainder of my estate than my
daughter, MARY C. WAGNER.
VI,
I appoint my son, CHARLES P. LAFFERTY, JR. and my daughter, MARY C. WAGNER,
Executor and Executrix of this my last Will. Should both fail to qualify or cease to so act, I appoint
DAUPIlIN DEPOSIT BANK AND TRUST COMPANY, Execulllr of this, my Last Will.
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT 0' REVENUE
OFFICIAL RECEIPT. PENNSYLVANIA INHERITANCE AND ESTATE TAX
'*'
o NO. AA 146957
RECEIVED FROM:
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ACN
ASSESSMENT r:'I
CONTROL ...
NUMBER
AMOUNT
MARY C WAGNEH
101
t3,300.00
119 NORTH 28TH STREET
CAMP HILL, PA
17011
ESTATE 'NfORMATION,
~ filE NUMBER
l:I 21-1996-0931
~ NAME Of DECEDENT (LAST)
I:iI LAFFERTY C P
l'I DATE Of PAYMENT
Iii 11118/96
EJ POSTMARK DATE
COUNTY
SSN 222-09-0926
(fiRST) (Mil
CUMBERLAND
DATE Of DEATH
09/20/96
REMARKS MARY C WAGNER
m TOTAL AMOUNT PAID
$3,300.00
CW
REGISTER OF WILLS
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RECEIVED BY /i." . 1.... ""':.- ".,:.
/ $IGNATUAi. I " ,.1 ...-
MAf-lY c. LEWIS 4/ ./ 'j/i/"'j..
REGISTER OF WILLS I ~
SEAL
CHECKII 1205
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CEH1'! F I C..^I.! ON (~~.JI():!, Lr:l'~.lJND1':1~u~I~II!!t;2~.!i L!!.l.
Nome of Decedent: t ,e La.ffc'rc.r'1___
Date of Death: 5 Cf-t. ~ CJLl!j CtlP
Will No. I tlqtp - ooq 3 , ^dmin. II".
To the Register:
I certify that notice of benelicial interest required by
Rule 5.6(a) of the Orphans' Court Ruleg wag served on or mailed to
the following beneficiaries (J( the nbovn-captioned estate on
Name
~~~t~.sA~'rh S1": C/tmflfif{,!A ,I7all
Jlf5'(<"fD5TD~6"QR. RD?- YdZd+A~G~, fA-.
/7310
JiJB~y C" t>>f\-lON t:f{
t had.(~ Ph; I/i f LfifFeR.,IY
Notice has now been given to all persons entitled thereto under
Rule 5.6(a) except
Date: a" '3- 9 .,
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Address 1\ q /J. ~ ~~ <;'T
LAmp +till. PIt.I7OI1
Telephonel'ILlL:l.k 3 0'51)4
Capacity: ~--- Personal Representative
counsel (or personal
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FilED IN DUPLICATE
WITH REGISTER OF WillS)
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IlI:l.l1JINrS NAMlIlI.ASf.I1UT. ANII A-'DIUUl INrnAl.I
FFETY, CHARLES P
111 ('I JIINI"" I'OMI'WII! AJllllh\S
19 NORTII 28TH STREET
AMP HILL, PA 17011
SOCIAl. S[('t'lny Nt'MRUI
222-09-8926
09-20-96
II" 11! 01 flllUll
08-28-12
FrLE NUMBER
21
1996 0931
f'UI'Nl)' "(Jill! VI!Al
III' Af'I'I.lCAIUJil,lol'l\'I\'ISU 11'Jl!.\I;'s NAMli
lLuT, !-lAST ANtI "'lnUll! L~rn^1.1
,\I)("'AI. .un 'MIIY.'" 'Mnu
CUMBERLAND
^"lill'N'Jll.I:nrvInIUJ!INSIl1.l'f"l10NSI
IllIl. O'iginll! Roluln
o 2. Supplomon'ol RO'lIIn
o 3. RomolOdor ROluln
(lor dolo. 01 dOOlh pllor 10 12-13-02)
o 5. Fodo,ol E,'olo Tll)(
ROlurn Roqulrod
8. TOlal Numbor 0' Safo Doposit Boxos
N,um
RY C. WAGNER
'ALl;CORRE5PONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
t'lIMF'l.J:ll: MAIWW AU(JR[.U
19 NORTH 28TH StREET
AMP HILL, PA 176i1
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13,266.00
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55,537.00 0,
0.00
(8)
10,235.00
3,009.00
(11)
(12)
(13)
(14)
x. .
55,559.00 x .06 ,
x .15 ,
~
68,803.00
13,244.00
55,559.00
55,559.00
3,334.00
+ 3,300.00 + 174.00-
20. II 'Ina 191. rootor thon Ilno 10. onlor tho dillaronco on lino 20. Thl. I. tho OVERPAYMENT.
~ IllI Check here If 011 ere r U""Un . relUnd 01 your ov a ment
21. II Ilna 181. gro.'or thon IIno 10. on'or tho dllloronco on IIno 21. Thl.I. Iho TAX DUE.
A. Enlor tho Inlora.t on tho bll!onco duo on rino 21A.
B. Enlor tho totll! ot IIno 21 ond 21A on lil10 21B. Thi. i. Iho BALANCE DUE.
Moke Check Pa able to: Re I.ter 01 wnr., Agenl
.. -+ BE SURE TO ANSWER AU OUESTIONS ON PAGE 2 AND TO RECHECK MATH
o 4. Urnlod E.lo'o
o 4i. Futuro InlOfO:il Compromiso
(lor dolo. 01 doo'h ollal 12-12-02)
o 7. Doeodonl Maintoinod 0 Uvll1g T'U,I
(Moch 0 copy 01 Tru,,)
(18)
lultfnll
(19)
(20)
3,474.00
140.00
IllI 6. Docodonl Dlod TO'lolo
(Moch copy 01 Will)
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(717)-763-5504
1. Roll! E.toto (Schodulo A)
2. Stock. ond Bond. (Schodulo B)
3. Clo.oly Hold S,ock/PlIr1nOlShip '"10ro91 (Schadulo C)
4. Mortgogo. ond Noto. Roeoivoblo (Schodulo D)
5. Co.h, Bonk Dopo.its & Mi,collonaou. Pomonll! Propol1y
(Schodulo E)
6. Jointly Ownod Propol1y (Schodulo F)
7. TrBn,rO,. (Schadulo G) (Schodulo L)
8. Totll! Gro.. AssOI. (Iolll! IIno.,-7)
9. FuneraJ Expensos, AdministratIVo Costs, Miscollaneous
Expon.o. (Schodulo H)
10. Dobl', Mortgogo UObillllo.. Uon. (Schodula I)
11. TOlll! Doducllon. (IOlll! IIno. 9 & 10)
12. Nal Valuo 01 E.toto (Iino 0 minu,"no 11)
13. Chlllitobla ond Govornmonlll! Baqua'l. (Schadulo J)
14. Not Vll!uo Sub ocllo Tll)( (IIno 12 minu,"no 13)
15. po us rans ars (for dalos 0 death aftor 6-JO-94)
509 Instructions lor Applicable Percontago on Pogo 2.
(Includo voluo.lrom Schodulo K 0' Schodulo M.)
16. Amount 01 Ilno 14 taxable at 6% rate
(rncludo vll!uo.lrom Schodulo K or Schodulo M.)
17. Amount of line 141axablo 8115% ralo
(Inc'udo vll!uo. 'rom Schodulo K or Schodulo M.)
18. Prtnclpll! tll)( duo (Add Ill)( lrom Uno. 15. 16 ond 17.)
19. CnI1lu Sp:1W11'I7mty CtaJil Prior 1'I)lIl1:f1U
UiW.lUlI
(21)
(21A)
(21B)
l'DSttpmaltla oIper;uI)',Id<<:llfe UltlllVlvt a&ftlinN tbU tdLlm,lrd.klq t<<"I~Ir1IdD1i1n ard ll&tnl.-rilJ, lid luUIt torIl otnO' .no:....ll'lI4t lid torlirl, II UINt.
ccna:t aN ~t. I dediit' lilli_II ml rlllII hu btom rrrM'l1'd IlINe m.ft.rt u~t'. UfIl':laralicu 0' r"t'trt' Ol./lI'f UlaJIlIlt rorn"1I1 f\1'fftfUltiV1' iI has.. ulan inf'onnllioQ at
lII'tlkJI prtp.tTt bu &ll)' tm.1l'd<<t.
SIGNA'1lJlIiOFPE SON REsI'ONSIBU?FOR Fl SI1Ri.ItN A1l1lRf;.\S
)/',1\.119 N 28TH ST CAMP HILL PA 17011
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(9)
(10)
(15)
(16)
(17)
.. ..
AllllltUS
4811 JONES TOWN RD HARRISBURG PA
Act .40 011004 ployldos lOf tho loductlon ollho tax lolo9lrnpo9ud on Iho nol yolun olllun~lms 10 01 101
tho uso 01 1110 spOU90. Tho 10109 as ploscllbod bV lhu ololuto will bu:
. 3% (.03) WIll bo oppllcoblo 101001010001 docodonto dyll'g on 01 01101 7/1/04 ond bolo,,, 1/1/00
. 2% (.02) will bo oppllcoblo 10' 001010001 docodonlo dying on 01 01101 1/1/00 ond bolo III 1/1/07
. 1% (.01) will bo oppllcoblo lor ootoloo 01 docodunlo dying on 0' 011011/1/07 ond bolo,o 1/1/00
. SpousoltronslOfs occunlng on or altm 1/1/00 will bo oxampt fromlnhmilol1ca lox.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING A MARK (X) IN THE APPROPRIATE BLOCKS.
YES NO
1. Old docodont mako atranolor and:
.. rolaln tho uoo or Income of Iho p'oporty tronolorrod .
. . . . . . . .
b. rotaln tho right to doslgnalo who shall usa tho p'OpOlty translorrod or 110 IIlcome
c. rotaln a royorslol1luy InlolDst or. . . . . . . . . .
d. rocolvo tho p,omlso for lilo 01 ollho, payments, bonolits 0' cora?
2. II dealh occurred on or belOle Docombor 12. 1992, did docedont wllhln two yoars p,ocoding doalh
transler proparty wllhout rocolvlng adoquato consldolotion?1I doath occurrod allor Docombor 12.
1992, did docodonttranslor proporty wllhln ono yo.. 01 doalh wllhout rocolvlng adoquato
consldoration? ................
3. D,d docodont own an 'In trust 101' bank account at his or hor doath? .
IF ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
c~ ClaIM Mkrot)'lltll.Int.. WubirWll1t, IJ.C.. 199)
x
x
x
x
x
x
..
3rrClst lIill Club illestClment
of
CHARLES P. LAFFERTY
I, CHARLES P. LAFFERTY, of the Borough of Camp Hill, Cumberland County, Pennsylvania,
make, publish and declare this to be my Last Will and Testament. hereby revoking and making void any
and all Wills by me at any time heretofore made.
I.
t
"
I
,'~
,
I direct that all my legal debts and funeral expenses, including my grave marker and all expenses
of my last illness, shall be paid from my residuary estate as soon as practicable after my decease as a part
of the expense of the administration of my estate.
n.
I.
, l
.
I
,
I:
I give and bequeath as follows:
A.
My table saw, wood lathe, drill press, table router, wood lathe chisels, two
coffee tables, one desk and the wood in my shop in the garage at 119 North 28th
Street, Camp Hill, Pennsylvania, to my grandson, MARK LAFFERTY.
I
"
C.
My wood clamp and carving chisels in the garage at 119 North 28th Street,
Camp Hill, Pennsylvania, to my son, CHARLES P. LAFFERTY, JR.
I
I
l
\
,
i
,
i
B.
My planer, joiner, band saw, power mitre saw and hand router in my shop in the
garage at 119 North 28th Street, Camp Hill, Pennsylvania, to my daughter,
MARY C. WAGNER, and her husband, KERRY A. WAGNER, SR.
.. ...,. _..... '~'./ 1'." ...... ''''_._ ,.'- " ",,;.t"" \.....~,\t :"';,f.t..:-!:
"~i'.~::'~').~"r,..:'.' ;.>-:.. .'::l"~~"P."': -~~ :l\fo';j ~-:,.~~::. :~, '.~ ':r~~- ,,'J?:~;~ ~- fF:J-y~..~K'.~l.~.....~.~t\l"'~' "I;~'~. ::.'
...~.....~;......J..:__.:',.,,.~.. /'.....". ....-:.,. .,"f:;::...~.",:"Jo':."'. t -:.":' c~ ~"""".""'''='-''''''''.J.'''''''~'-.''''___
,
IN WITNESS WHEREOF, 1 hereunto set my hand and seal this /i.'day of
/kl/~ht!.y ,1994.
Signed, sealed, published and declared by the above-named Testator, as and for his Last Will and
Testament, in the presence of us, who at his request, in his presence and in the presence of each other,
have hereunto subscribed our names as witnesses.
..~
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IsIIUrr"'...(11 TAX "'m'll....
JUnlf']n (JI'(11IrNT
SCHEDULE F
JOINTLY-OWNED PROPERTY
Plom;u Punl Of T II
FILE NUMBER
21-1996-0931
ESTATE OF
ESTATE OF CHARLES P. LAFFERTY SR
Jolnttonant{I):
NAME
AMARY C WAGNER
ADDRESS
119 N 28TH STREET
AMP HILL, PA 17011
RELATIONSHIP TO DECEDENT
AUGIITER
B.CHARLES P LAFFERTY JR
45 REDSTONE DRIVE
ORK HAVEN, PA 17370
ON
c.
JornUv-ownod p,opor1y:
LETTER DATE DECE- DOLLAR VALUE
rTEM FOR MADE DESCRIPTION OF PROPERlY TOTAL VALUE OF DECEDENTS
NO. JOINT OF ASSET DENTS
TENANT JOINT % OF INT. INTEREST
1.00 B 04-20-94 oUTNAM TAX-FREE HIGH YIEU 55,346.00 .33 18,447.00
A ~12-1222098926BBDG
2.00 A 02-01-94 ~NC CHECKING ACCOUNT 24,005.90 .50 12,003.00
151-4003-6454
3.00 A 02-01-94 ~NC MONEY MARKET 50,174.71 .50 25,087.00
TOTAL (Also onter on lino 6, Rocopitul.lion) $ 55,537.00
(If mora spaco i~ neoded. tmlOI1 additional shool3 01 samo sizo.)
Cll')n,.tA t"I'I'.IIM Mkrm)ltC':lIIlIIlC:.. WWWCIlfl,D.C,. 199'
.
.
12-1-222-09-8926-BBDG
*
ORID, EI2
ACCOUNT TRANSCRIPT
occ...... ,,,,"0' AI2-1-222-09-8926-IIDO .....0. PUTNAH TAX-FREE HIOH YIELD CL-I ""~
N:Ct ()litH ~TCI 04/13/94 ''''''AYU Lo.1 222-09-8926
CHARLES P LAFFERTY I HIHLTC SALES CORP
HARY WAONER . R 141 IROADWAY
CHARLES P LAFFERTY JR JTWROS 0 STE 320
119 N 28TH ST K HANOVER PA 17331
CAHP HILL PA 17011-2929 E
R
PHOfI[ ......8[111 1\7-737-9914 " PIICO IH"T UCI
TARot.JlOUAHAL 'liNt ACT all
DATC DATC COU111(11.. ~ 'IIACe .
04/20/94 04/20/94 TRANSFER OF SHARES FRDH
AI2-122209B9261..E
0095332330
05/20/94 05/19/9~ ACCRUED DIVIDENDS
PAID TO SPECIAL PAYEE
06/20/94 06/17/94 ACCRUED DIVIDENDS
PAID TO SPECIAL PAYEE
07/20/94 07/19/94 ACCRUED DIVIDENDS
PAID TO SPECIAL PAYEE
08/22/94 08/19/94 ACCRUED DIVIDENDS
PAID TO SPECIAL PAYEE
09/20/94 09/19/94 ACCRUED DIVIDENDS
PAID TO SPECIAL PAYEE
10/20/94 10/19/94 ACCRUED DIVIDENDS
PAID TO SPECIAL PAYEE
CCRTIrICAu:a ISSUCDI
IMMel OH DePOSIT_
10TH. IHAAClI
2,401:458
2,401.458
2114 253 HARHDH
MOUfIT "lIlce
tour "" . BAlCH'
34,028.66 14.17
162.10
163.07
179.46
172.78
171.12
167.32
MAaCT UAl,.UC "lor.
DIViDeND OPTlQfIl C
CAP/GAIH OPTION' C
... ACCOUHT PIIQrILC ...
'teAR 10 DAIC
IHlJC8TI"CHT81
PCOCI'fITIOtCUI
DIVIDeHO TOTALI
- TAXABLe Diva I
.. HOHTAXABLC DIVdI
. R[YUAN or CAPITIC.
CAPITAl. JAIH TOTolL'
.. SHOAT TtR" CAIHS.
- LOHO TeR" GAIHS'
- "CYUAN or CAPITAL,
S\.IP DOLlMS.
0.00
0.00
1,363.42
0,00
1,363.42
0.00
0.00
0.00
0.00
0.00
0.00
COUTAlBUTIOflB
"""
'011'
TOA.
ROl.lOV(lI1
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
C)(CHAHCC8 IN I
[)l.CHAHC[1 CUT I
PReVIOUS '{CAR DCCLMCO/l,Jftl'ID
DIVlDeNDD I
.. TAXABle DIva.
.. NONTAXABLe DIUBI
. RCTURN or CAPITALI
PRCUIDU8 VCAR DeClAReD,UNPAID
CAPUM. OAtHS.
.. SHOAT T[R" GAIHSI
.. LOHO T[R" CAIHS'
- RCTURH or CAPITAL,
... ACCOUHT RCTIReMeNT PROTll[ ...
RepORTABLe ~T
ReocnP T IOtIB I
DIVIDeNDIU
CAP CAlfl. I
RCTURH or CAPl1At.1
0.00
0.00
0.00
0.00
0:00
0.00
0.00
0.00
U 9 C D H l V ...
CVST tVptl
ACCT tVPCI
. ..
tOTALS I
r 0 R PUT HAM I H T C R N A L
seRVICC. Ot'flOtl9 I DDP
STATUS COOCSI TPRV
MILItia ADOACB91
CHARLES P LAFFERTY
NARY WAGIlER .
CHARLES P LAFFERTY JR JTWROS
119 N 28TH ST
CAMP HILL PA 17011-2929
L
... ncCOUtl1 R[SCAPCH DATA ...
0" "'" 00H812302
601 NO' 000000000
CAP NOI H
HAU RSH I
UN CCAr COI CTIH
U1114HOlD CD I
HRA IHDI H
tAX RUI US crRV Res I US
C()I1PAffVl
PMflCIPAHr 101
PC11
GCH DOLLARS I
1 OF
2
'~C8
IAICH 1["'
64696 097
IALN<C
o PAveD PO AC
. 0
2,401.458
2,401.458
2,401.458
SPH
2,401.458
SPH
2,401.458
SPH
2,~D1.458
SPH
2,~01.~58
SPH
2,401.458 ,
IIHI
tC:tWORl LlA.1 DO
WltloMJLDIHO
rDACIONI 0.00
""""... 0.00
~ DIsrRlsutlOHSI 0.00
- RCDtnPrtOHB I 0.00
. VCAACHQ .
RCtURH or ~, 0.00
ReAl.LDC Olval 0.00
ReAlLDC CAIHBI 0.00
rOACICH tAlC CRI 0.00
DOLLARS wITHHeLD
0.00
0.00
0.00
0.00
REO
sus rvpc I
P\.H DATCI
11/06/95
LAsr ClCRlCAL Dr,
"'lOA 01'
04/13/94
l.IIPAID DIva,
- rA)lABLel
- NOH rAXABle I
- PCT or tAPl
"'IPAID CAItIS I
- SHORr TC'"11
- L')IlO TCAI1I
- ACT or CAPI
74.82
0.00
74.82
0.00
0.00
0.00
0.00
0.00
Annual Statt!nwnl
JUllllur~' 1 - D,'ceml",. :l\. 1'll)6
CHARLES P LAFFERTY
MARY WAGNER &
CHARLES P LAFFERTY JR JTWROS
119 N 28TH ST
CAMP HILL PA 17011.2929
SUIllmary of your Putnam
Account(s) ycar-to-date
Investment Account!
Putnam Tax-Free High
Yield Cl-B
ACCOUNT, AI1.1-122.09.8916.BBDG
CHARLES P LAFFERTY
MARY WAGNER &
CHARLES P LAFFERTY JR JTWROS
Date
I
I
: Account Activity Detail
01/01/961 Beginning Balance
01/22/96 Dividends Paid To SpeCial Payee
02/20/961 Dividends Paid To Special Payee
03/20/96 Dlvidendl Paid To Special Payee
Q.l/22/96I Dividends Paid To Special Payee
OS/20/96 Dividends Paid To Special Payee
06/20/96 i Dividends Paid To Special Payee
07122/96 DIvidends Paid To SpeCIal Payee
08120/961 Dividends Paid To Special Payee
e
IJ,iI. /1.11 "~'(ll
/""'''/'''''''. Hhfl",'I.I""""~'jlJl./~'flt
PUTNAM INVESTMENTS
Statemr.nt Date: DECEMBER 31, 1996
Client number. 01l89SS410
Investment f,nn: MIMLIC SALES CORP
Representative: PLEASE PROVIDE
For Putnam asllStance: '.800.115-1581
For help durrng L1X leason. Putnam offers The 1996 Putnam Sharehorder
Tax FIling Handhook. To order your free copy. call a Putnam cUltomer
lervlce reprelentatlve at 1.800.752.0040.
You Ihould have already received a proxy package soliciting your Vote on
a number of Imporunt proposars. Your vote II very Imporunt. If you
have any quest,ons please contact your financial advllor or Pumam at
1-800-225-1581.
Amount Share Number Share
Pel'" Share A.nount Price of Sh~res BaJ:1ncc
3.9lJ.603
.067418 526S20 3.933.603
061282 24104 ].9]].603
.070Q.l0 27S.S2 3.933.603
.067696 266.29 ],933.60]
.060672 23864 ].933.603
.071731 282.r8 ].9]].603
06S077 2S600 ].93].603
.067401 26S.11 ].9]]60]
PLEASE SEE DEFINITIONS ON OTHER SIDE
P....GE I OF 2
CDtft)HW(Al TH Of P[IOtSYlVAHIA
D[PAAT~NT Of' REV(HU[
IUR[AU Of IHDIVIDUAl TAXES
D[pl. 1I0UI
HARAISIURC, PA 111:1.0'01
*
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
EST. OF CHARLES P LAFFERTY
5.5. NO. 222-09-8926
DATE OF DEATH 09-20-96
COUNTY CUMBERLAND
FILE NO. 21 96-0931
ACN 97108336
DATE 02-26-97
TYPE OF ACCOUNT
o SAVINGS
IXJ CNECKING
o TRUST
o CERTIF.
In-,"'III'" 1'-"1
MARY C WAGNER
119 N 28TH ST
CAMP HIL L
PA 17011
REHIT PAYHENT AND FORHS TO.
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
PNC BANK h.. provld.t the aap.,t..,t with the Infor.aUon lltt~ balow which h.. b..n u..d In ulcul.Unt tha
potential t.x due. Their record. Indlcat. that at the d..th of tha above dacad.nt, you wer. a Joint owner/benaflclary of thl. account.
11 you f..1 thlt Infor..tlon I. Incorr.ct, pl.... Dbt.ln written corractIon froe the financial In.tItutIon, attach. copy to thlt fa...
~ ...hl"" It to tile ahov~ aritl,.." Thl. _r.,....t I. tA.......,.. I., ~,.r...,.......-.r.... ..It.. t... ,~..It-. T... I".." Itf ,~ CO...:I~.lth,..f P.Ms'llvanl..
Due.tlon. .ay b. an....rad by c.lllno (717) 717..1317.
COMPLETE PART 1 BELOW II II II SEE REVERSE SIIIE FOR FILING AND PAYMENT INSTRUCTIONS
Account Ho. 5140036454 oat. 02-24-94
Eohblhhod
Account Bolonco 24,026.41
Par cant ro.oblo X 50.000
AIoount SubJoct to Tox 12, 013 . 21
Tox Rot. X .15
Potontl.l To. Duo 1,801.98
PART TAXPAYER RESPONSE
COI FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSH!HT BAS!DOH THIS NOTICE I
..
To In.ure prGp4r cr.dlt to your account, two
(l) copl.. of thl. notlc. au.t .ccoapany you..
p.~t to the R.ght... of Wills. H.a ch.ck
p'Yabl. tal ~aglst.r of Wills, Agent".
NOTE: If tax paYIIlltlts ar. .8de within thr.a
el) aonths of the dacadent'. d.ta of d..th,
you .ay d.duct a 5% discount of the tax ~.
Any Inh.,ltenc:. tax due ..111 bua.. d.Unquent
nln. (9) aonths aft.r the data of d.ath.
~
[CHECK ]
ONE
BLOCK
ONLY
o ™ Ilbova Info....tlon end tax dua ls carract.
I. You .ay choo.. to r..lt p.yaant to the Aagl.t.~ of will. with tva copla. of this notlca to obt.ln
. discount 0' avald Int.r.st, or you aay check box "A" end raturn thl. notlc. to the Aagl.t... of
Will. end an official .....s..nt ..111 be Is.ued by tha PA C.part-.nt of R.venue.
.. 0 The abav. ....t h.. ba." o~ ..Ill be r.po..t.d and tax paid ..lth the Pam,ylvanla Imarltlnca Tax r.turn
to b. filed by the decadant'. rapruant.Uve.
C. r=J The abova Info..a.tlon I. Incorract and/or dabt. end daductlon. ..a'. p.ld by you.
You IIUSt caapl.t. PUT 0 endIor PART lIJ b.low.
If you indic.t. a diff.r.nt tax rat., pl.... .tat. your
r.lation.hip to d.cadant:
OFFICIAL USE' ONLY . [JAAF
PADEPARTHENTOF/REVENUE
PART
[!]
fAX ltr.1URN - COt1I'U'UiUON
LINE I. Data Estobllsh.d
2, Account Balance
3. P.rcent Taxabl.
4. Aoount SubJoct to To.
5. D.bt. .nd D.duction.
6. AIoount To.obl.
7. Tax Rat.
8. Tax Du.
iAX Oh JOINT/1KU5T ACCOUNT~
PAD
1
2
3
4
5
6
7
8
DEBTS AND DEDUCTIONS CLAIMED
U~'
1
2
3 X
4
5 -
6
7 X
8
PART
[!]
DATE PAID
PAYEE
DESCRIPTION
AMOUNT PAID
I I
TOTAL IEnt.r on Lin. 5 of Tax COMPutation) t
Und.r pen.lti.. of perjury, I decl.r. th.t the fact. I have reported abav. ar. tru., corract and
co~leta to the be.t of ay knowladg. and b.lief.
PNCIBANK
Central P A
101
C P LAFFERTY
MARY C WAGNER
119 N 28TH ST
CAMP HILL PA 17011-2929
state.ant Nunber 51-4003-6454
st~t End Data
10-07-96
Enclosure.
Pa a
11
1
INTEREST CHECKING
ARTY
MARY C WAGNER
AccQun Nuaber
Tax ID NUI'Ib.,.
Last stat End Data
51-<<003-._5_
222-09-8926
09-03-96
PREMIUM PLAN
For CUS oner Service or curren
1-800-762-3581
ACCOUNT SUMMARY
~
~
23,304.41
Withdrawals/Debits
262.94
Hew ealance
57,318.18
Previous Balance
25,469.14
DeDosits/Credits
55,416.39
Humbe,.
11
DAILY ACTIVITY
ReferenclI Checks and Depasi ts and
gm Explanation of TranSAction Nu"bar Othe,. Debits Other Credits Balanclt
09-03 YOUR PREVIOUS STATEMENT BALANCE 25,469.14
09-05 ACH DEBIT 007352B20004242 13.50 25,455.64
CNA BOO-252-214B INS. PREM
09-10 CHECK 1179 2B150964 14B.00
CNECK 11BO 28147831 116.70
CNECK 1182 2B164614 37.46 25,153.4B
09-16 CHECK 1183 26615508 1,000.00
CHECK 1181 24416796 32.25 24,121.23
09-18 ACH DEBIT 0000022947 115.33 24,005.90
TRANS OCCID LIFE POLICY PMT
09-24 CHECK 1186 22408010 1,500.00
CHECK 1184 23350875 320.00 22,185.90
09-26 CASHED CHECK 1188 21248294 100.00 22,085.90
09-27 DEPOSIT 28008853 20,262.81 42,348.71
09-30 ACH DEBIT 521-0778-060 12.00 42,336.71
PA POWER I LIGHT ELEC BILL
ACH DEBIT 1069052500 31. 93
PAWC - CAPITOL D PAYMENT
CHECK 1190 28598218 10,000.00 .~;-~
CHECK 1189 23620674 10,000.00 22,304.78
10-03 ACH CREDIT 22209B926A SSA'
US TREASURY 303 SOC SEC
DEPOSIT 23379774 34,005.91
ACH DEBIT 521-077B-050 90.1B
PA POWER I LIGHT ELEC BILL
CHECK 11B5 25328995 50.00 57,273.51
10-07 INTEREST PAYMENT 44.67 57,31B,lB
ACCOUNT INFORMATION
, AVERAGE BALANCE 31,259.07 INTEREST PAID THIS PERIOD 44.67
.. AVG COLLECTED BAL 30,23B.74
CHARGES AND FEES .00 INTEREST PAID THIS YEAR 1,144.B7
RELATED ACCOUNT BALANCES
The followIng were rovIowed 1n an attelllPt to offset the SOr-ViCD chargos on this account.
Account TVDe Account Nu~ber5 Balance Type AL!!! Balance
Interest Checking 5140036454 This Cycle Avg DeIoneD 10-0B 31,259.07
Honey Harket Account 5080592327 This Cycle Avg Balance 10-07 50,21B.05
C~AlTH Of P[HHSYlVAHIA
Df:P&ATHt:NT Of A[Y[NU[
.URtAU or INDIVIDUAL 'AX[5
DOT. laU01
HARRIS'URG, PA 1711'-0'01
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
EST. OF CHARLES P LAFFERTY
5.5. NO. 222-09-8929
DATE OF DEATH 09-20-96
COUNTY CUM8ERLAND
FILE NO. 21
ACN 971 08337
DATE 02-26-97
TYPE OF ACCOUNT
!Xl SAVINGS
o CHECKING
o TRUST
o CERTlF.
....IUI..." 11,"1
MM MARY C WAGNER
119 N 28TH ST
CAMP HILL
PA 17011
REHIT PAYHENT AND FORHS TO.
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
PNC BANK hat provld.d th. D.p.rb~t with th. Infor..tlon 1ltt.d b.low which h.. b..n uud In ulcul.tlna th.
potentl.1 t.x due. Their r.cord. Indlc.t. th.t .t th. d..th 0' th. abov. d.c.d-nt, you w.r. I Joint ovn.r/b.n.flclary of this .ccount.
If you f.. I this Infor..tlon I. Incorr.ct, pl.... obt.ln wrltt." corr.ctlon fro. th. flntnel.l In.tltutlon, .tt.ch . copy to this 'or.
..,... r.'''''n I' ." ~M ~..., ~"'1.. 'Ioo!. ~o:roro~ ,. .....1001.. I,. _-:0......___.. ..1.100 ~~': t...Ioo...'.....,... T.., 1_. 0' t..., ,...~"'I'.. ... O_.~I.,_I..
OUt.tlon. ..y b. tn.w.r.d by c'lllng (111) 117-IS21.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 5080592538 Doh 08-22-96
estobllahod
Account Balance
Percent Taxabl.
loount Subjoct to To.
Tax Rat.
Potontlol To. Duo
x
47,192.85
100.00
47,192.85
.15
7,078.93
'0 In.ur. prop.r credit to your lecount, two
Il) copl.. 0' thlt notlu ~...t ICco.pBny your
ply.tnt to th. Aegl.t.r of Willi. HIk. ch.ek
p.y~l. to: ".gllt.r of Wills, Agent-.
x
NOfE: I' t.. p.y.~ts .r. ..de within thr..
Cl) tonth. of the dtetdtnt., d.t. of d..th,
YOU ..y deduct . 5~ dl.count of lht ta. ~.
Any lnhtrltanc. t.. due wIll b.e~ d.llnquent
nl", (9) aonth. .ft.r the date of d..th.
~
PART TAXPAYER RESPONSE
QOI FAILURE TO RESPOND WILL ResULT IN AN OFFICIAL TAX ASSESSNENT BASED ON THIS NOTICE I
..
o ThI above In'or..Uon ~ tIX dull It cornet.
1. You ..y choa.. to r..lt p.y-.nt to th. A.gl.t.r of wills with two cop I.. of thl, notlc. to abt.ln
. dllcount or .vold Int.r..t, or you ..y ch.ck box "A- and r.turn thl, notlc. to t~ Aegl.t.r of
WIll. and en offlcl.1 """tent will bt I,.ued by the PA D~.rt.tnt 0' A.vtnUl.
[CHECK ]
ONE
BLOCK
ONLY
a. E:J The &bov. ..I.t he. b.tn or will b. r.port.d and t.x paid with the P.nnlylvtnl. Inherltanc. T.x return
to b. fll.d by the d.c.dentO, repr.l.nt.tlv..
C. c:J Th. above Infor..tlon I. Incorr.ct end/or debts and d.ductlon. N.r. paid by you.
You ault cotpl.t. PART 0 tndior PART [I] b.low.
If you indicat. a different tax rate, plee.. .tate your
relationship to decedent:
. OFFICIAL .USE ONLY 0 AAF
PA DEPARTMENT OF. REVENUE
PART
~
lAX RETURN - COI1PUTAHO!i
LINE 1. Doto E.tobll.hod
2. Account Balance
3. Percent Taxabl.
4. A.ount Subjoct to To.
5. Debt. and Deduction.
i. AMount Taxable
7. Tax Rat.
8. Tax Due
TAX UN J01NT/lRUST ACCUUN1~
PART
~
DATE PAID
DEBTS AND DEDUCTIONS
PAD
1
2
3
1\
5
6
7
8
CLAIMED
OF
1
2
3 X
4
5 -
6
7 X
8
PAYEE
DESCRIPTION
AMOUNT PAID
I I
TOTAL CEnter on Line 5 of Tax COMPutation) .
Undar penaltia. of perjury, I declar. thet the fact. I haya report ad above are trua, correct and
cOMPleta to the belt of .y knowledga and balief.
stato.ont Nuabo. 51-4003-6454
am
01-07
01-16
08-19
01-21
08-22
08-23
08-30
0,.03
PNClBANK
Central P A
101
C P LAFFERTY
MARY C WAGNER
119 N 28TH ST
CAMP HILL PA 17011-2929
~
Enclosure.
Po .
stat End Dote
0"03-96
Accoun Humbe,.
Tax ID NUllIb_,.
Lost st.t End Dot.
Sl-.a05-bLfStt
222-0,.8926
08-07-96
PREMIUM PLAN
For Cus Ollie,. Serv1ce or curren
1-800-762-3581
ACCOUNT SUMMARY
C~.ek s
Alnaunt
7,377.52
Wlthdrnwals/Deblts
50,313.38
Previous Balance
81,553.33
Deposlt~/Cr.dlts
1,606.71
NUllber
10
DAILY ACTIVITY
Reference Checks and Deposits and
EXDIBnatlon of Transaction Hu,.,be,. Din.... Debits Other Credits
YDUR PREVIDUS STATEHENT BALANCE
ACH DEBIT 0000022947 115.33
TRANS DCCID LIFE PDLICY PHi
CHECK 1171 23606698 148.00
DEPDSIT 28662074 100.00
CHECK 1173 24870554 52.99
CHECK 1172 24858798 1.00
CHECK 1170 24813695 35.88 ,
DEBIT HEHO 28384653 50,000.00-n(lkE..-G' e Vi:. '\) ,('0
CHECK 1178 28233125 68.00 5c,,?c":;<;? S-~R
CHECK 1176 23552315 6,900.00 ,.
CHECK 1175 23561325 96.95
CHECK 1177 23549806 50.00
CHECK 1166 23190407 14.70
DEPDSIT 24074530 340.11
ACH DEBIT 1069052500 35.85
PAWC - CAPITDL D PAYHENT
ACH DEBIT 521-0778-060 7.91
PA POWER & LIGHT ELEC BILL
CHECK 1174 25864723 10.00
ACH CREDIT 222098926A SSA 1,103.00
US TREASURY 303 SOC SEC
ACH DEBIT 521-0778-050 154.29
PA POWER & LIGHT ELEC BILL
INTEREST PAYHENT 63.60
ACCOUNT INFORMATION
54,235.03
54,226.14
.00
INTEREST PAID THIS PERIOD
AVERAGE BALANCE
AVG COLLECTED BAL
CHARGES AND FEES
INTEREST PAID THIS YEAR
The following Wlr8 reviewed In an attelllPt to offsot the servico charges on this account.
RELATED ACCOUNT BALANCES
Account Type
Inter.st Checking
Honey Hark.t Account
Account Nu,.,ber~
5140036454
5080592538
ll.JU.
0,.04
0,.01
Butnne. Type
This Cycle Avg BalancD
This Cycle Avg Balance
,
11
1
ra ..,e.1
H8w B.lance
25,4".1~
Balance
81,553.33
,
81,290,00
81,336,01
81,300.13
31,232.13
24,185.18
24,170.48
24,466.83
24,~56.83
25,469.14
63.60
1,100.20
Balance
54,235.03
50,000.00
Il.I:V.UIOI:X . (1.r1)
C'UMMONWI:AJ.lll OIl I'f:NNSYLVANIA
~llnrrANClI TAX .lm~N
RIJ;DIINT UU'lWNT
SCHEDULE G
TRANSFERS
Ploaso Print or TVpo
FILE NUMBER
ESTATE OF
THrs SCHEDULE MUST BE COMPLETED AND FILED IF THE ANSWER TO ANY OF THE QUESTIONS ON PAGE 2 IS YES.
ITEM DESCRIPTION OF PROPERTY TOTAL VALUE 8~~f~, .:!!<LI~';.
hbSe NnW dlht IrlndtlN', llwi. EXCLUSION OF DECEDENTS
NO. ItlllQll.llir 10 4<<.11. ~I' oIull.rft. OF ASSET X.OFIN INTEREST
1.00 CHARLES P. LAFFERTY III 3,000.00 2,500.0m 00.00 2,500.00
GRANDSON
-
-
TOTAL (Also ontor on hno 7. Rocapilulation) $
~
(If moro spaco is noodod, Insort additlonaJ shoots 01 sarno sizo.)
C'l')'ri&IlI CmtiYt Mkn.)1lftl1llrE.. W~IlU, D.C.. 199'
aEV. UIl DC . (1.QI SCHEDULE H
FUNERAL EXPENSES,
CUMMONWI!Al.lll ni' rU~NSVlV""-'IA ADMINISTRATIVE COSTS AND
L"IIUrrAN(11 TAX Rlnt'aN MISCELLANEOUS EXPENSES
RESDIIMlln']II~vr PIOB!iO Prinl or TVpo
ESTATE OF FILE NUMBER
CHARLES P. LAFr'ERTY SR I;n-1996-0931
ITEM DESCRIPTION AMOUNT
NO.
A. FunoraJ Exponsos:
MYERS-HARNER FUNERAL HOME 5,458.00
HELPING HANDS 100.00
-
B. AdmJnistrativ8 Costs:
I. PersonaJ Representative COmmissions
Social Security Numbor 01 Personal RepresontatlVo: - -
Year COnvnlsslons paid
2- Attornoy Foes
3. Famrv Exomption 3,500.00
Claimanl MARY C. WAGNER Rolationship DAUGHTER
Address ot Claimant at decedont's dealh
StroolAddross 119 N 28TH STREET
CityCAMP HILL Slato PA Zip Codo 17011
4. Probate Foo9 135.00
C. Mlscollaneous Exponsos:
BSTATE ADVERTISING CUMBERLAND LAW JOURNAL 60.00
ESTATE ADVERTISING PATRIOT NEWS 142.30
f{ & R BLOCK PREMIUM FINAL 1040 & PMO 265.00
f{ & R BLOCK PREMIUN 500.00
PA DEPARTMENT OF REVENUE 1996 BALANCE DUE 25.00
UMBERLAND COUNTY PROTHONOTARY FILING FEES 50.00
TOTAL (A/50 ontor on Iino 9. Rocnpitulalion) S 10 235.00
(If mora spaco is ncodod. insert addllionaJ shools at sarno sizo,)
Clt't~ CfT.li" Mktl.)IIG." II",. .....UllU..,"-O.C.. 199)
lEV, UU D: t (I.U)
SCHEDULE I
COMMONVo1!ALnI OP rtNNSYLVANIA DEBTS OF DECEDENT,
L\lll!RlTANCl! TAX nm\,~
1lr,.sQ.1I:N'T U1:C1])I!NT MORTGAGE LIABILITIES AND LIENS Ploaso P,io1 or Tvpo
ESTATE OF FILE NUMBER
CHARLES P. LAFFERTY 21-1996-0931
ITEM DESCRIPTION AMOUNT
NO.
1.00 lEAST PENNSBORO AMBULANCE SERVICE INC 80.00
2.00 i\LAN CHUFF DDS 68.00
3.00 IBLUE RIDGE HAVEN WEST 148.00
4.00 SEARS 68.89
5.00 MONTGOMERY WARD CK II 1184 320.00
6.00 HECKS NOT CLEARED AS OF 09-20-96
K II 1186 CHARLES P. LAFFERTY II I 1. 500 . 00
7.00 ,ELL ATLANTIC FINAL PHONE BILL 50.00
8.00 'PL - FINAL ELECTRIC BILL - GARAGE 12.00
~PL - FINAL ELECTRIC BILL - HOUSE 90.18
9.00 'ENNSYLVANIA AMERICAN WATER COMPANY FINAL PAYMENT 31. 93
0.00 jLUE RIDGE HAVEN WEST 600.00
1.00 "ORRISON EYE ASSOCIATES 40.00
.-
TOTAL (Also onlo, on lino 10. Rocopil"lolion) S 3,009.00
1
1
(If moro SpBCO is noodod, Insor1 additional sheots 01 sorno sizo.)
c~ Cmtin MIt"')"Ilcm 1<<., Wuhqlll\ O.C., l~)
,.\ '~PATIENTNAME ;'11.1'1","',;:" .',~~.',,~'.:"I .....,'l,..,,;
ACCOUNT NUMBER. ~Ilh '.
. STATEMENT DATE " .
285 96877 10/01/96
OVERED ,I, n IOCC '.'I. III 'll~Ii~{jI~~I'''''~OJ:,.I~'~:DESCRIPTION .~1'1.'1;1I" ',\'IIIli/,",~gIP lt~:. .. Q1Y I DAYS. 'iT';rl.AMOUNT ~h'l'
! 8~1 !91! 8~1'!
I ~i~ ,I ~ 091996
31
1
1
3 46
1~s!50
52
00
-6900r:00
-3 :46
l3Q.OO
2
'"
IF NOT RECEIVED BY TIlE 10TH. PA NTS
RECEIVED AITER TIlE 10TH MAY NOT BE
.'
:.
,
,.
Payment due by the 10th of each month
i
;ot Billing Inqurries pl.... call:
1
! ..'
:i;'*i:n;:;lf~liil!}!; .'
." ... \"h ....., ,..,I " .' ... .. .~..;r.:.t:';l'tl II.. ,.. 'I.t.. ..
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.....'.. .... ,,, .... ..... ..",1"". .. ~.- .. .
. I"~;'. {,"' . \,,: ~; '.: , .' ;./ ~.-: ." '.:' ).;."f~' .~l~.;:~~. .
.......... ..' II' .., .... .. ~ ,'.. ,-:),. 'I':} .
'.};I;!!~:::.':'.:'" ," .::?~:~~~:t~~H~:~f:,;~f;:,.::.
(717)
763-7070
':. .
", '~..'J ."':.', '..:..'i".;.aCln;::.~
.... !... r ., "':'J,\~?:"l'., . .' .
. ;::;'if;;tk;tt~?,;:~::: .
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ITEMIZED RESIDENT STATEMENT .
II!IEVlERL Y
-
REIIOlH' H.u.tE AESIO[H, NO.
r_UQ l2,,\..E~ l A~ER\Y q~'gl\
FAClUrt NAME , AOUrv NO.
t:>\..uX.. "'""I.DGE. 'MAVE..I\:) U,)E~'" ()Q~5
t ~INTERIM DISCHARGE o ITEMIZED DA'E ~EPARED
STATEMENT TYPE 00 \.Qu,\C\,
DATE I PERIOD COVERED I DESCRIPTION I DAYS CHARGES CREDITS
('n\Q""'\ \ql (\ ~Lll. F c..ROs~ D.e." J:fl..LE IOQI IOn.Nl
-\0 C,le\ Iqln ~, II s: r 12. . ~ r C'l _ i'\-."", 1C: I\'YT I r'\C'\ '.0 <=" .on
,
,
BALANCE FORWARD CHARGES CREDITS AMOUNT DUE
01$ls1 00. 00 IS' tslX). 00
BE Xle (7~11
STATUS IU:I'OIl~LILND~!L.!i~-',,~:-.&,-11
Name of Decedent: ( I \C(..LLt~ rJ ), ~ttvtij SIC.
Date of Death: 1\~ 20 - CJJt2
Will No. ~ I~ /c/q(., - () 73 / IIdmin. 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 whether administration of the estate is complete:
Yes No v
2. If the answer is No, state when the personal
representativ~ reasonably believes that the administration will be
complete: jVf\t' 2-D J l'1tt,
3. If the answer to No. I is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes No ~ .
b. The sepal'ilte Ot"phans' Court No. (if any) for
the personal representative's ilccount 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.
, .
n)~vt C I/Ja:ti,jU/
Signa ure .
.I; 1
,. L . yk!.-1
Name ( leas'e. ~~ o~r i'}t ) . 1/./;(:4 _
. lIq /u )t ) .S/ ( f)Yv'f,1/1t,
Ad ress /7())(
Jr1 -1~3 s'Su i
Tel. No.
Date:
11!11?f7
'~ ,~
r-
c..::
-
I
r~~
\1' .
c.: I..
!'-,
~:h
,., .~.
;,,-:
.... '-'
Capacity:
Personal Representative
Counsel for personal
representative
(MAH: rmfl AM3)
I-"'~ I '/O. Y
BUREAU OF INDIVIDUAL TAXES
IHII(AIUHC[ fAIt DIVISION
DlPf. :lobOI
IlANAISlURC. PA 11l:a.ObOI
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
~~
1I"lhlllll'lIl.tll
CttARLES
P
NOTICE OF INHERITANCE TAX
APPRAISENENT, ALLOWANCE DR DISALLOWANCE
OF DEDUCTIONS AND ASSESSNENT OF TAX
MARV C WAGNER
119 N 28Ttt ST
CAMP HILL
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
06-23-97
LAFFERTV
09-20-96
21 96-0931
CUMBERLAND
101
MAKE CHECK PAYABLE AND REMIT PAVMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ....
ifEV:iSlin:if-jij:p-nli-:97rNoYicE--oTYNHEifii'ANCE-YA'x-APiiiiiiiSEHENT-,--jiii.-owiiifcE-iflim---m-----m
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF LAFFERTV CHARLES P FILE NO. 21 96-0931 ACN 101 DATE 06-23-97
If an assessment was issued previouslY, lines 14, 15 and/or 16, 17 and 18 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. AMount of Line 14 at Spousal rat. (15)
16. AMount of line 14 taxable at Line.I/Class A rat. (16)
17. AMOunt of Line 14 taxable at Collateral/Class Brat. (17)
18. Principal Tax Due
AMount R...itted
PA 17011
TAX RETURN WAS: (X) ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN 8ASED ON: ORIGINAL RETURN
1. RooI E.toto ISchodulo Al III
2. Stocks and Bonds (Schedule OJ (2)
3. Closely Held stock/Partnarshlp Intarast (Schedule CJ (3)
4. "artD.gal/Nota. Raceivabla (Schedule DJ (4)
5. Ca.h/Sank Deposits/Hisc. Parsonal Property (Schedule E) 15)
6. Jointly Owned Property ISchedule F) (6)
7. Transfers (Schedule G) (7)
8. Totel Asseh
I CHANGED
.00
13.266.00
.00
.00
.00
55,537.00
.00
18)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Ada. Costs/Misc. Expense. (Schedule H) (9)
10. Debts/Mortgage liabilities/Liens (Schedule I) (10)
11. Tot.l Daductions
12. H.t Velue of Tax R.turn
13. Charitable/Governmental aeqUelts (Schedule J)
14. Het Value of Estate Subject to Tax
10.235.00
3,009.00
(11)
IIZ)
113)
1141
NOTE:
.00 X .00=
55,559.00 X .06=
.00 X .15=
1181
TAX CREDITS:
PAYNENT
DATE
11-18-96
DISCOUNT (+1
INTEREST/PEN PAID (-I
166.68
RECEIPT
NUNBER
AA146957
ANOUNT PAID
3,300.00
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
HOTE: To insure proper
credit to your account,
sub_it tha upper portion
of this form with your
tax payaent.
68,803.00
13. ?44 no
55,559.00
.00
55.559.00
.00
3.334.00
.00
3,333.54
3.466.68
133.14CR
.00
133.14CR
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN '1, NO PAYNENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR). YOU NAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FDRN FOR INSTRUCTIONS.)
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
0...
*
BUREAU OF INDIVIDUAL TAMES
...tUUAHC[ TAX DIVISION
DEPT. lIDU.
HARRISBURG, Pi 11111'0601
MARV C WAGNER
119 N 28TH ST
CAMP HILL
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COIJNTV
ACN
11'.11"11'" III.".
00-04-97
LAFFERTV
09-20-96
21 96-0931
CUMBERLAND
101
CHARLES
P
PA 17011
AMount R..itt.d
MAKE CHECK PAVABLE AND REMIT PAYMENT Tal
REGISTER OF WILLS
CUMOERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTEt To inlure proper credit to your account, subnit the upper portion of this forn with your tax pay.ant.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS .....
iiiv:i6-oTE1C,\FP-iiij':mm----iiiiii-iNHERI7fAiic'E-fiix..sTAfEiiiNf-oTr.c-COljiif--iiliii--m-m-m---- .---
ESTATE OF LAFFERTV CHARLES P FILE NO. 21 96-0931 ACN 101 DATE 00-04-97
THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHEO ESTATE. SHOWN BELOW
IS A SUHHARY OF THE PRINCIPAL TAM DUE, APPLICATION OF All PAYHENTS, THE CURRENT BALANCE. AND, IF APPLICABLE.
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT, 06-16-97
PRINCIPAL TAX DUE ....._.
PAVMENTS (TAX CREDITS),
PAVMENT
DATE
11-18-96
07-00-97
RECEIPT
NUMBER
AA146957
REFUND
DISCOUNT (+)
INTEREST/PEN PAID (-)
166.60
.00
3,333.54
AMOUNT PAID
3,300.00
133.14-
TOTAL TAX CREDIT
3,333.54
BALANCE OF TAX DUE
INTEREST AND PEN.
.00
.00
.00
TOTAL DUE
. IF PAID AFTER THIS DATE. SEE REVERSE
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS lESS THAN fl.
HO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRI,
YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.
" '
.." ,
PAYl'lEHTI
o.tKh the loti portion of thh NoUe:. Bnd lub.lt with your p.)'.~t lad. p..,able to the ntIH Bnd eddr...
printed on t~ rlv.t.. llde.
If RESIDENT DECEDENT ..... check Dr .oney order plI)'able tOI RECISTER OF WILLS, AGENT.
If NOH-RESIDENT DECEDENT ... chick or .onl., order plyable tOJ COHHONWEALTH Of PENNSVLVANIA.
REf\I(D (CAh A r.'LRI of . tlX credlt, which .... not requested on the TalC Return, NY be t~.ted by coepl,Ung ."
"AppllcltJon for R.fund of Pennl.,lvenle lnn.rJtanc. and E,t,t, Tlx- (REV.l11]). applIcation, .t. IVlll8bl. .t
thl OffICI of thl Rlgllt.r of Will., any of thl 21 R.venue DIstrict O'flc.. or fro. the a.p.rtl."t', Z~'hOur
en'~rlng ..rvlc. ~r. far for., orderlngr In Pennl.,lvenll l-IDO-]62-2050, out,lde Penn,ylvanla
end within lOCI. Harrl~rg .t.. (717) 7'7.aD~, TOO' (717) 77Z-l152 IHelrlng 1~.lred only).
REPLY TOI Du..Uon. r",rdlng .rror. conblMd on this notlu .hould be addr....d to: PA o.part...,t of R.venue, BunllU
of Indlvldu.1 h..., ATTN: Post A......ent R.vl." Unit, D.pt. za06Dl, Harrisburg, PA 17121.0601, phone
(717) 717.6505.
DISCOlIfT:
I' any tax due I. p.ld within thr.. (]) calendar ~th. a't.r the dt<ed..,t'. death, a 'Iv. percent (5~) dl.count
0' the tu p.ld 11 allowed.
PENALTY:
The ISle ta. ~.tv non-participation penalty Is CMPUt.d on the total 0' thll tM end Inbr..t ......~, end not
p.ld o.for. J8nU8ry 11, 1996, the 'Ir.t day aft.r the end 0' thll t.. aene.ty p.rlod.
INTEREST:
Inbn.t Is charged beGlmlna with first day of delinquency, or nine (9) IIOnth. and OM Cl) dey frOll the data 0'
d..th, to the data of pav-ent. T.... which ~... delinquent b.for. January 1, 1981 be.r Intara.t at the r.t. of
.1. (6%) ,.rclnt Plr ~ calcul.ted at a dally rat. of .000164. All t.... which bee... d.llnquent on end aft.r
January I. 1'8l will bear Int.r..t at a rata which will vary froe calendar yaar to celandar y..r with that r.t.
announced by the PA Dapart-.nt of R.venue. The appllcabla Int.r..t rat.. for 1911 through 1997 ar.:
v.... Intere.t R.t. Deily Int.....t Facto.. V.ar Int.....t Rat. Dally Int.r..t Fector
1912 m .000548 1911 'X .000lU
19n lOX .000'.58 1988-1991 IIX .000501
I." IlX .00030t 1992 'x .000lU
1985 In .000356 1993.1994 n .000192
I'''' lOX .aooll' 1995.1997 OX .ao02U
"Int.r..t It calcul.ted .. follow.:
IIITEIlEST = DALAHCE OF TAX UNPAIO X HUNDER OF OAYS DELINQUENT X DAILY IHTEREST FACTOR
..Any Hotlc. I.tuad aft.r the ta. bac~. delinquent ..Ill r.flact an Int.r..t calculation to flft-.n (15) day.
beyond the dIIte of the ...........t. If paYl*\t Is uda aft.r the Interast cHPUtatlon date IIhown on the
Hotlc., additional Intera.t au.t be calculated.
. -,_...,,--...~,.._>..
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PB Hnrn :
7158334 u.s. rOSTAGE :
MARY C. LEWIS
Regl,'e, 0' Will. & Clerk 0' Orph.n.' COU,'
Cumborland County Courthouso
Carlisle, Ponnsylvflnla 17013
MARY C. WAGNEll
119 NOlml 28th
CAMP HILL, PA
ST.,
17011
WAGN11Q 17011a001 1eQ7 17 11/a~/Qe
FORWARD TII1E EXP RTN TO ~END
WAGNERN b7TH LN
~t~~~ALE AZ eS30e-eQ.3
RETURN TO SENDER
rellt 1 ."t.~ -:: _._ ~.~: _..'E: : <lr. ~_
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STATUS REPORT UNDER RULE 6.12
Decedent I I 'lrr L(. J Y . ( "
Name of I
C 7" 'iL,
Date of Death I {
Will No. t ~C1G . UOL, 51
A/L)4
IA((t.'t~iY, (1),'''/''''
"
/,. SI
Admin. No. :) I</t,... u0 ">1
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 estatel
~;:te ~t~~r a~~~istrati~~f_ the estate is complete:
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete I
I.
3. If the answer to No. I is Yes, state the followingl
a. Did the per~al representative file a final
account with the Court? Yes No .
b. The separate Orphans' Court No. (if any) 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:
~'I~-~'1
~'tLL:f (' UJ, (/\i/
S.l:gnat.ure [)
f1lr1t l.J L LJ ~ ~,1,h f-
Name (Please type or print) .) , ~
,:). 11 D g' 10 l,o ) 't'h L i-J 0' ell cia L{'. . ). g'S',o
Address
IGJ3 :=)(.,'}' ;)G,).c.+
Tel. No.
Capacity:
Personal Representative
(HAH I rmfl AM3)
Counsel for personal
representative
"'._. 1- . ,.'. . ,'" . ,', . . ". " -', .' 'I ".l -- ,-", ,,' .
~ . ,. ....., Y~'.~_""""'. .._~ .....~.~ ......11.~ ...f'llll.........-~..-tt.:~.~...~-----..............
, . ,
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" " ,\'(:' ~ . . . ,.\, . . .
Register of Wills of CUMBERLAND county, pennsylvania
Certificate of Grant of Letters Testamentary
No. 1996-00931 PA No. 2196-0931
ESTATE OF LAFFERTY C P
\~A~~, rlK~~, M1UU~~)
a/k/a
Late of
LAFFERTY CHARLES P SR
CAMP HILL BOROUGH
(;UMIjl:;KLI\NU (;UUN'l'~ I
WHEREAS, on
dated November
was admitted to
the 18th
15th 1994
probate as the last will of LAFFERTY C P
(LA::"l', r .LK::i'l', M.LUULl:; I
Deceased
Social Security No. 222-09-8926
day of November
1996 an instrument
a/k/a LAFFERTY CHARLES P SR
late of CAMP HILL BOROUGH CUMBERLAND County, who died on the
20th day of september ~ and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, MARY C. LEWIS , Register of Wills in and for
the County of CUMBERLAND in the Commonwealth of pennsylvania, hereby certify
that I have this day granted Letters TESTAMENTARY
to MARY C WAGNER and CHARLES P LAFFERTY JR
who have duly qualified as Executor(rixl
and have agreed to administer the estate according to law, all of which fully
appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYLVANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my Office the 18th day of November 1996.
<-rJ1t11'1r' ,'f,.,,;, "y I. (Ui , .'\/ir..-h,w ~~lITI,
V ~eg.LsCe~~.Lxs ~
**NOTE** ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE)
STATE OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SHORT CERTIFICATE
I, MARY C. LEWIS
Register for the Probate of Wills and Granting
Letters of Administration &c. in and for said
county of CUMBERLAND do hereby certify that on
the 18th day of November A.D.,
one thousand nine hundred and ninety six.
Letters TESTAMENTARY
estate of LAFFERTY C P
\LA~~, rlK~~, M1UUL~)
in common form were granted by the Register of
said County, on the
, late of CAMP HILL BOROUGH
a/k/a LAFFERTY CHARLES P SR
in said county, deceased, to
CHARLES P LAFFERTY JR
\LA~~, rlK~~, M1UUL~)
MARY C WAGNER
\LA~~, rlK~~, M1UUL~)
and
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand
of said office at CARLISLE, PENNSYLVANIA, this 18th day
A.D., one thousand nine hundred and ninety six.
File No. 1996-00931
PA File No. 2196-0931
Date of Death 09/20/1996
S.S. # 222-09-8926
and affixed the seal
of November
'iYI!I..~(, (1. ?f'nr~ 'i'~' , (I (j ~'" 1; /1J>JJu..,,,J:i,
a U
Register
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
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WARNING: It Is IlIcgnlto duplicate this copy by photostnt (lr photograph.
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3783348
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CO......ONWEALTN OF PENNSYLVANIA. DEPART"'ENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
~ Of Of:tlDlNl',.,.. ...... \..,
.. rl P Laff
~.........." UCltAIYINl
- ....
...
'Wl..........-."
~51CU"'rrJoU..IlA
84 'f1S
CCIUJrt OfDIRH
Sr
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.. Male
. 222-
09- 8926
OoVIOfMtH
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_UtftAalCfw .-oJ
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Clf'f.~.
OJnberland
Fast Pennsboro
.....,..u....
..
Ml'HlIII'IIWIII.,-,.. UcUe L_
Lee N. Laffer
_ONIM '1IWIIl(1'~
Mary Wagner
OlClDlHTI
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n....... Pa
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Y.W1Al..WUl..........
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WIli te
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"....~---....
PI OINt' USUAL
.-=::::'O::::~:T
D.ner Laffert
DlQOlHT"WALlHO~"l$II_~.""lIICo111J11
119 North 28th Street
Canp Hill, Pa 17011
,..
Dol
-
....
CUrberland ---., "ilK] ::w.-"::'::1If
ItIOTHlA'INAWf"'.. Y4Je ~501....,....
, . Rebecca Bower
"'''lI~''''tbrt''h2Bth'St're'et ~ Hill,
ova ~
.--
Carp Hill
Pa 17011
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~TA~J~U~-'~EI'UH.:r.lJ.!lI?ER_.!.lyg ,fi,) ~
Name of Decedent:_~i~f.\U \;) cf
Date of Death:---3J. '2..0 l3-~ .
Will No._l ~o..~- OoC\,3J
~tWf\~~ C1t~~ ~
Admin.
No. "J-l. q,~ - CPv"3 L
Pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the lollowing with respect to completion of
the administratiun of the above-captioned estate:
1.
State wnh~ her administration of the estate is complete:
Yes V 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. I is Yes, state the following:
a. Did the per~al representative file a final
account with the Court? Yes-Y'__ No__.
b. The ,;ppa I'ate Oq>hans' C' ,urt No. (i [ any) for
the personal representative's accuunt is:
c. Did Ihe personal representative state an
account inlormally to the parties in interpst? 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:~~('1. ~'\t ~o.o~. L:?tto.~_ ,
Signature \JI~~
c.W\Il.~':. -Yo l..I\~~ 1""'e...
Name (Please type or p~int) ()
I "lS"" _ ~~C Sorct-:l ~ 'Th. Y'*L ~~}A \1 ~7~
Address
lit71 o.'af-d-.QI{3
'1'(.:.1. Nf).
Capac'ity:
j Personal Representative
(MAH:rmf/AM3)
Counsel for personal
l'epresenta t i ve