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Home My WebLink About96-00950 PETITION FOn PIWBATE lInd C;I{ANT OF LETTERS Blate of -#-4)/ ~ f? 1(.~tl..L,IJz(&,r),1 No, ,rJl : 9"_-=3' 5 0 also kllOll'1I as Z--_____.. ..,._. _... _. . To: Social Security No, ,.zz1_::j;=3=~::' f*'0/'" I(e~bler of \,\I)lt- I' oJ Ihe, , Couuly of .l'{iJl)be~/f( /U III Ihe CUl1ItIIOIl\\'calrh of Pennsylvania The pelilioll of Ihe ulldersi~lIed re,speelfully 'CJlIe,el\lS Ih'lI: Your pelitioller~ who b/-.IH years of 'I}\e or ulder alllhe exeelll/l..lJ~,. illlhe lasl :-viII of Ihe above deeedel\l, dOlled /t:."'I.~~-t::-...tlf--:- '~ ---,..------,--...------ muned .19p:::- (\!;lIe: rcl(,\;1II1 d'(lllll\lancC'\, ('.il. rc:nlln~'ialinll. dr;]th of C:'C'CllItH, tiC.) Decendelll was dOllliciled OIl dealh ill -C~~2~6~j I; ni, , ' Cou, . ' P~nmylvani . wilh h J,i;l lasl !allJily or principf-G'I re il1~nec al _-P. ,JLYl, J {' ,e o".ut: Y Ph 1~J:J.sLL .J,:!~J1t-{:LI71 f:?J1~r .~ /a:, 70// . 11'1 \lree'I, n~mht'r and lIlunclpalil)'J ~e~~denl,. Ihc9 _'IS" years of agc .'licd J1/.., '1-"-:..!2lk~'Y ~ ' 19 tZ,~' atJ{I:L.tJeJ..t_f..iLL_r.;re "'C'~Y44.efLtV1~J_::1Jd~ '~/')L n,'n '. P/l Excepl as follows, ,Ieeedcn, did nOlmallY, was 1101 divorced alld did 1I0t havc a child born or adopted after execuliDn of Ihe will offcred for probate; was 1101 the viclim of a killillg and was never adjudicated ineompclenl: ____ Decendelll at ,kath owncd pr\lperlY wilh estimated valucs as follows: (If domiciled in I'a.) All persollal properlY (If nol domiciled in l'a.1 Pcrsollal properlY ill Pennsylvallia (If nOI domkiled in ?a.) Personal propcrlY in County Value of real estate in pcnnsYIN/.A. SItuated al follows: '-LJ_ s /00, 0=, O~ S S S WHEREFORE. pClitillner(s) rcspectfully prrsented herewilh and Ihc grant of ICllers r':S~J::'I(S) Ihe probale of Ihe last will and codicil(s) I (~5 CO- 111(2.'1 l' d_ Y Y IhO\13mcntar)': admini\trJlion c.l.a.; 'adminimation d.b.n.c.t.a.) theron. i ~ " -,- G~ 0:" c -,0 C": 1"2.= -" ~~ ;; c ~ :ii V.(~-f 7: .;tf'-tt-('.t) F /> ~ (Ih~(!y'~ .;7;- 't:(;!~/7:on , "-Ll'//.!i-=.:<-fol OATH OF PEHSONAL ImPRESENTATIVE COMMONWEALTH OF I'ENNSYLVANIA l~. .. ~::; COUNTY OF ___ClL~IillRLANI) ) The pelilionerl'l ~bllve named ",ear(,) or amnnls) tltatlhc statcments in the foregoing petition arc truc and cullec; III Ih,' hesl of Ihe kilOwlcdgc and bclicf of petilioner(l) and Iltat as personal rcpresen. talive(s) "I' Ihc a!Jove ;leced"l1I relldoIlCr(s) will well alld trnly admi=er Ihe esta::Jding to law. Sworn to or ilffirn,,'ed >nd $uhscribed { .n4.-u /, '~7-<--1' '" before mc this .___ _J,~'=.t,-__ day of ~' , ~_QY~h~L__. 19-21i..... !: 11)(1 lA\ . J..J.'(" 1; ( i" 'J ' f-R"~lWer ~ 1',,1 rJ l"fl" "1 ' ..... .. / tf ' ,.- -"--:"..lIftI __ 1 :. , --.. -. -.- -, No. 21-9&-950 Estate of AGNF:S WAL13UHN , Deceased DECREE OF I)ROBATE AND GRANT OF LETTERS AND NOW NOVr,M13ER 2 2 19~. in consideration of the petition on the reverse sidc hcreof. satisfactory proof having been presel1led bcforc mc, IT IS DECREED thatthc instrumcnt(s) dalcd AUGUS'f 27,1995 describcd thercin be admittcd 10 probate and filcd of rccord as thc last will of AGNF:S WALBURN TESTAMENTARY DOLORF.S T. LONCAR and Letters are hcreby gral1led to ~.---.l~~, {I" {J~ ~rrL:L~ o Rr.gi~fcr of wids \ FEES Probale, Lctters, Etc. ..".,.,. $ 200.00 Short Certificates( 21 .. .. . ..... $ 6 .00 Renunciation ..............., $ x-pages 3.UU JCP $ 5 00 TOTAL _ $ 21400 Filed .,.... .~Ryr;f1!3.~~.. ?,~! .~~~,~..... ATIORNEY (Sup. Cl, 1.0, No,) ADDRESS "HONE 00. L co ~. ~ ;~( - -. .. ~ ,,> '. ~- " ~: (: l'I ... ~ ':~ f_:;! .- ..~ , g >. '.., ,- C.\l~ ~i\ "-) :3 a: Uu . :. l z II: ~ ::>> III .... ~ 0- ~ r.. 0 l III r;. ro:l Z CI I ~ - <0 - ' . " . - - .... '. ,- '. "- iEast ]UIill aub Ql"estatueut I, AGNES WALBURN, of Lower Allen Township, Cumberland County, Pennsylvania, being of sound and disposing mind, memory amd understanding, hereby declare this instrument, to be my Last Will and Testament, revoking any and all wills by me heretofore made. ITEM I, I direct my hereinafter-named Executrix to pay all my just debts, funeral expenses and administration expenses, including inheritance and succession taxes, as soon as may be convenient after my decease. ITEM II. I give and bequeath the following: A. The sum of Ten Thousand Dollare ($10,000.00) J Yl1to I1)Y godda~ghter, Helen J, B,9tchifil' (11" /:ffn:~o<:cx(~.se. /. -ctJe'l} C"lJ I}d /J~btl n{l, -:'jf\!icph jJ), iJct(!-/jI'e, ) J} \ \ {11If",t B. The sum of Ten Thousand Dollare ($10,000.00) u.nto my goddaughter, Dorothy ,'ruccJ:/r cT:- ~!j t)"(!:'~c. ei\..se, J ,/. -C/~n W oeY' l;iiSbind, tV/IIII1_WI "CLH:', r-J \1 f/9-71'1r c. The sum of Ten Thousand Dollars ($10,000.00) Unto my goddaughter, Dolores T. Miller. D. The sum of Ten Thousand Dollars ($10,000.00) unto my nj,ece, Dolpres T. Loncarj('>/'"b1f :('re.leeed6~91.. ./q.- 'then ~ /J.er /J4.~(/tj)hI, ~h)} -r. t. nct'<t.r, d \ \, ll;.1(/~ ITEM III. All the rest, residue and remainder of my Estate, real, personal or mixed, of whatsoever nature and where- soever situate, I give, devise and bequeath unto my sister, Cecelia M. Hale, A. In tteeven~y sister, Cecelia M. Hale, should predecease me or die within thirty (30) days from the date of my death, or we should hoth die in a common diDaDter, then I give devise and bequeath all the rest, residue and remainder of my Estate, real, personal or mixed, of whatsoever nature and wheresoever aituater in equal shares, unto my goddaughters, Helen J. Botch~, Dorothy Tucci, and Dolores T. Miller. \ \ i, \ ; I _~, I '- ~~ 1 '"'(SEAL) Agnes 11i'llburn .. . . '" ITEM IV. I hereby nominate, constitute and appoint my niece, Dolores T. Loncar, as Executrix of this my Last Will and Testament. In the event my niece, Dolores T. Loncar, is unable or unwilling to serve as Executrix of my Estate, then I hereby nominate, ~Onstitute and appoint my goddaughter, Helen J. Botchie, to serve i1her stead as Executrix of this my Last Will and Testament. ITEM V. M~xecutrix is hereby authorized and empowered to sell at public or private sale or sales all of the personal property of which I may die seised and t 0 likewise sell all real estate of which I may die seised, and to convey the same by fee simple deed or deeds to the same effect that I could personally do, if living. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and Testament, this clffj day of ll/L.ttl....7-t , A.D. 1995. f.' ,,'} I ",",": l,.. t ; L,...... \- , Agnes/Walburn \.-1 t ""(,l ~, / I(S~AL) WITNESSES: __&Le/4------ ~ig~~1a:~t~-- 21-96-950 REGISTER (W WILLS 01: -CUHHRRI"-ND COUNTY OATH OF sUnSCRIIJlNG WITNESS Robert P. Kaskie1 and Kathtf!e!L.t:lL_~<lSKicl *~~* (cach) a subscribing witncss 10 thc will prcsclllcd hcrcwith. (cach) bcing duly qualificd according to law, dcposc~) and sa~ that t.hs:YJere prcscnt and saw l\GNES WM.BUlW Ihc tCltal or ,sign thc samc and that they signcd as a witncss atlhc rcqucst of Icslat..Q&- in h g r prcscnce and (in Ihc prcscncc of cach olhcr) (iI'i~'k\l!JC'\li~flkM1;f1 ~~~~~~~). Sworn 10 or arnrlc:9,Q?d lubscribcd beforc mc this -yv\ day of November 19~ (Nal:}27tf 3::(::1 2323 Scarborough Dr., Harrisburg, PA17112 -J. ) I Addr~s) - I I r; :'_~fLeC('_ ,(---7JI.' .'M,.L h, c e (Nallll') Kathleen M. Kaskiel 2323 Scarborough Dr., Harrisburg, PA 17112 (Adtlress) Register ..---- -\ ~. .\ '. "" I~ . " , , ' .' " , " P,l<';)l'I,1 H ~J. 1",-' .!i'!1 ,"' .> . . _, ',:. ._,!~.._~.,/_.! ._,;_',: 'c'.' ~ REGISTER OF WILLS OF COUNTY OATH OF NON-SUBSCRIBING WITNESS (cach) a subscribcr hcrcto, (cach) bcing duly qualificd according to law, dcpose(s) and say(s) that familiar with thc signaturc of codicil will that prcscnlcd hcrcwith and codicil bclicvcs thc signaturc on thc will is in Ihc handwriting of Icstal_ of (onc of thc subscribing wilncsscs (0) thc ------ knowlcdgc and bclicf. to Ihc bcst of Sworn 10 or affirmcd and subscribcd beforc mc lhis day of 19_ (Name) (tltltlft'S5) Register (Nallll') '1("; (tltltlft'SS) CE~TTFICl\TION OF NOTICR lINDRR RULF. 5.n 11 Name of Dec~dent: l\GNES \ll\LllURI~ Nov~mber. 1, 1996 Date of Death: 1996-00950 PA No. 2196-0950 ., l\dnin19tration No. To the Regl<::ter: I certifY that notice of ben~Cicial interest reqllir2d hy Rule 5.6(a) of the OrF~ans' COllrt Rules was served on or mailerl to the follouing bcneficlnries of the above-c~?tion~d estate on January 7, 1997: 1\ddress Name ~ \38 Wheaton nrive, ~ittleBtown, p~ 17340 Helen J. Botchie 800 E. nobier Drive, l\pt. 0-3, Vista, cr. 92084 DorothY TUCci Dolores ? Miller ~273 SOllt~ Highlands circle, Harrisburg, pl\.17111 See evidence of such mailings, attacheD hereto and narkec1 r.XHIBITS NOS. "1\", "U", and "C", respectivelY. Notice has now been given to all persons entitled thereto Ilnder Rule 5.6(a) except for Ce~elia M. Hale, who predeceased the Decedent on August 13, 1996. Date: January 24, 1997 , L. Jtl/~( ,'.11 'j; , signature .... ./ /t)l\.I1 A./1 / --r Dolores T. Lonc~r o.~ (4) ~~..: (", .< .. .," N~me C', r.~c1rp.~, 394 ehambers street, stenlton, p~ 17113-2801 ~:. .~ , c, r-.J Telephone (717) 939-6145 .~ .~ ":..' or:; Ofl) lU(C a: .,': .", -, caoacity ExecutriX of the Estate oC l\GNES H1\LPlIRN, DECE;'\SED r- P' G0 BEFORE THE REGISTER OF WILLS, eOUNTY OF CUMBERLAND, PENNSYLVANIA In re Estate of AGNES WALBURN, Deceased No. 1996-00950 of PA No. 2196-0950 TO: HELEN J. BOTeHIE 138 Wheaton Drive Littlestown, PA 17340 PI ease take notice of the death of decedent and the grant of letters to the personal representative named below: You may have a beneficial interest in the Estate as follows: Ten Thousand Dollars ($10,000) outright bequest and a one-third (1/3rd) share of the residue of the Estate. Name of decedent: AGNES WALBURN Last known address of decedent: B Columbia Drive, Camp Hi 11, PA 17011 ~ Date of death November 1, 1996 Place of death: Medical Center, County of grant Pennsylvania Lebanon Valley Veterans I Administration 1700 S. Lincoln Avenue, Lebanon, PA 17042 of original letters Cumberland County, Decedent died testate. A copy of the will is enclosed herewith. Name, address and appointed: Name Dolores T. Loncar telephone number of personal representative Address 394 Chambers Steelton, PA Telephone Street 717-9396145 17113-2801 . No counsel has been retained to represent this Estate. Additional information may be obtained from the undersigned. ,- Date: December 2, 1996 ,. Ll'/. ,--:/1'l{.6'd J Do ores T. Loncar 394 Chambers Street Steelton, PA 17113-2801 Telephone: 717-939-6145 Capacity: Personal Representative Executrix of Estate EXHIlHT "l\" P 2:14 b35 026 SpoOII [)eINery r.. RMtndod [)ebeIy r.. on m Relurn Reeetpl Showw'IO t .... 'MM:lm & Dale Oeivered 'E """,~&wrQ~_, :t Oalt,lldt.......A4t...' c:i ' g ;:!TAl. PO$fA & p..' $ e;- M PottrUr\OfO f' " 8 " ' i,I07 :.'-;, u. . l . \1 " en' .~.--,...' " a. ' POI\agO CertlfiedFe8 ,.-, -:J ------- ." .. _...r' 3. Ar1Ido Addressed to: l(r.5, ;k/~n ~ 6d'd,/e 13>1 kJ/,.erd:oI1 j)r, ;,/t;t-(e& i'acv(), f# /1 &~(; I olso wtsh to rocolvo tho following servlcos (lor on extra 100): . 8 1. 0 Addressoe's Addros~ ~' @lJostricted Oollvery~ ell : COnsult postmostor lor fee. :e. ' 4a, AJlI,da Numbor ~ " f./ ~ eJd(, e, 4b. Sorvlca Typa :l ' o Roglsterod ~Cartlfied ~: o Expross Mall 0 Insured .5. i" Rotum Recolpllor Morthandiso 0 COO ~ I 7. Data of Ool.Ory .!! . ,c. 5' I >>. oss (Only /I requo.roa. l' \t \1 I " ,5 I Ii \1 1- ,'" ifi I I I I I J i \ I "I !l I~ I.!I I . .eompa".It;mt1 ~ot 2 tor addit\OMIHrv\etI. .eompaet.lteml3,.a.and 4b. .Pr\r'4 your nIR'lId add,..' on IhI rtverll 01 1h1t form 10 IhII M can return Ihls card \0 you. _AnKh this tonnlo the tronI at IhIi maI1p1ece. Of on ,he back illplce doeS not .e;:!ilttum Rocoipl ROll....''''' on \"" malplocO btlow thO Il1Ido nurrller, _lhI Retln Receipt wtl thaW to whom the article was dtivtrtd and the dill dtltvorod, Domestic Return Receipt PS Form 3811, Oocombor 1994 . ; BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND PENNSYLVANIA In re Estate of AGNES WALBURN, Deceased No. 1996-00950 of PA N,. 2196-0950 TO: DOROTHY TUCCI BOO E. Bobier Drive, Apt. D-3 Vista, CA 920B4 Please take notice of the death of decedent and the grant of letters to the personal representative named below: You may have a beneficial interest in the Estate as fOllOWS: Ten Thousand Dollars ($10,000) outright bequest and a one-third (1!3rd) share of the residue of the Estate. Name of decedent: AGNES WALBURN Last known address of decedent: 8 COlumbia Drive, Camp Hill, PA 17011 . Date of death November 1, 1996 Place of death: Medical Center, 1700 County of grant of Pennsylvania Lebanon Valley Veterans' Administration S. Lincoln Avenue, Lebanon, PA 17042 original letters Cumberland County, Decedent died testate. A copy of the will is enclosed herewith. Name, address and appointed: Name Dolores T. Loncar telephone number of personal representative Address 394 Chambers Steel ton, PA Telephone Street 717-9396145 17113-2801 . No counsel has been retained to represent this Estate. Addi tional information may be obtained from the undersigned. , Date: December 2, 1996 A-jj..J~ '7:-'~t"'~ Dolores T. Loncar 394 Chambers Street Steelton, PA 17113-2801 Telephone: 717-939-6145 EXHIBIT Capacity: Per~onal Representative "nO Executnix of Estate . -"',~ r t ID,d) / ''I Inventory of the real and persDnal u5tatu of l\GNES WM,IIURN (tecoasmJ PERSONALTY Checking l\ccount No. OOB036B069 witll Dauphin Deposit lIank ~ Trust Company, Harrisburg, PA 17101, in the name of the Decedent, by Dolores T. Loncar, Agent, opened 9/18/96 Interest on the above to date of death Savings l\ccount No. 5700559350 with Dauphin Deposit Bank & Trust Co Harrisburg, Pl\ 17101, in the name of the Decedent alone, opened 8/2B/95 Interest on the above to date of death Cash on hand Ph Funeral Trust with wiedeman Funeral opened October 7, 1996 Fufund from Wiedeman Funeral Home, Inc., re and cred its pension Check, dated November 1, 1996, from K-Mart Corporatior., Troy, MI 48084-3163 Home, Inc., Steelton, PA. I \ adjustments of eXpenSB&" Benefits received from Department of Veterans Affairs, FA 19101, as follows: Burial Allowance Plot of Internent Allowance Transportation Expenses Burial Benefit received from Department Dauphin County, Pennsylvania I I . 1\ Philadelphlul I I :$ 0 00 , I I 2,52B 2B 3 56 l41 534 01 I ., 74 I 96 15 00 3.'3R3 61E 5a 00 50 17 300 00 150 00 270 00 of Veterans Affairs of 100 00 TOTAL PERSONAT,TY 5 tt" . 26 TRANSFERS Transfer of cash from Savings Account of Decedent to John T. Loncar or Dolores T. Loncar on 9/18/96, invested in afore-mentioned indi- viduals in Certificate of Deposit #200145R69-Rl01101 with CoreStat Bank, N.A., Harrisburg, PA, on same date Interest on the above Certificate to date of death Transfer of cash from savings Account of Decedent to Helen J. Botch e on 9/18/96, invested in aforementioned individual in Certificate 0 Deposit No. 800-0025771 with York Federal savings & Loan Assn., Hanover, PA, on 9/20/96 Interest on the above Certificate to date of death Transfer of cash from Savings Account of Decedent (with PNC Bank, Harrisburg, PA, No. 5130074254, closed out 10/8/96) to Dolores T. Loncar or John T. Loncar, Jr., invested in Certificate of Deposit No. 8140520071 with Dauphin Deposit Bank & Trust Co., Harrisburg, PA, in the aforementioned individuals on 10/9/96 Interest on the above Certificate to ~ate of death s 30,000 195 I \10,000 56 I \ 115,000 52 00 17 00 20 00 18 TOT~L TR~NSFERS 55,303 55 JOINTLY-OWNED PROPERTY CheCking Account 10010595910 with Dauphin Deposit Rank & Trust Co., Harrisburg, PA 17101, Made joint 5/22/95, in names of Dececent and Sherry Hac Skimming (Grand Niece); Total Value- $1,991.07; ona-hal 995 54 (~) share Taxable Interest on abovP Account to date of death; Total Value- $.92; one-half (~) share ta~able 46 "OTAL JOINTT.Y -OlmED PROPERTY ~ COMMONWEALTH Of PENNSYLVANIA COUNTY Of elnd.~ DAUPIIIN II: DOl.ore,,-1', l./oncar ------ - ----- being duly __ __13.\10.rO_ _, __ eccording to lew, dopolol end "YI Ihel she --- __l~_ t_I1Pm______ -- __ ______ -EX9cut.r 1 X 01 tho Ellete 01_ __l\GNES_WALDURN--------------- Ie" 01 _,_ Lower Allen Township _, Cumborland Counly, Pe., deceelod end Ihat the within II en Invonlory modo by, _ _ Dol.or98 -T.--I.oncar --, tho lald_Exoc~J:-ix----_ 01 Iha onllro ..1010 01 ..id decodenl. conlilllng 01 ell Iho pel\onal propdrly end real OItale, oxcept real ellalo ouhlde tho Commonwoalth 01 Pennlylvenie, and thaI Ihe ligurol oppolite each ltom 01 Iho Invontory roprolont it'l lair value a, 01 Iho dolo 01 docodent', deelh. RWORN and ,ublCribed bolore mo, P~~~~l;i(~-- "-- ~A:~. ~ 19 q7 394 _Chambers Street , HaWialSoo , F1errnce U [~;r~al11an, Ilal.1 I PublllS ee 1 ton. PAl. 7 1.1 3 - 280 I. '~~'N;;,.,f" I''',p, O;1Uph1n r.: lunty- ------ u. (".,. .. ~'\pim~. SI'P . J. 1998 . , .~ r.~~~I:.; ",: ;~-~1~'(,;~.ill.1~1 01 Not.'Vd Addr... Dale of Oe.lh ______18.t Day NovembeJ:-- Month ,qqf; Vu, INSTRUCTIONS I. An invontory mull be flied within threo monlh, alter appoinlmont of pOllonal reprelontallve. 2. A ,upplement inventory mull bo flied within thirly day' 01 dilCovery of additional a..oh. 3. Additional ,hoeh may be attachod a, to pellonally or roalty 4. Seo Arllcle IV, FiduciariOl Act of 1949. ~ o co N I l"1 ~ ~ r- ~ ..: Po 0- ... .c Ul l:: r- :- ,; 0> ~ 0 0> 0 w E-< .. ~ M It1 ~ "" S .. 0> W ! l:: " 0 l1. OJ U .. 0 III " 0 0 w "" w ~ C '" I :t ~ .. I- l1. l1. \0 ... ...J LL ..: .. 01 Z LL ...J < 0 l1. 0> W 0 < w cl \.4 ,;. :>. ~ > Z "" OJ - \.4 Z 0 :- c co c " III Z 0 0 ::> 0 "" Z o-l U l:: Z w < .... l1. ~ "" co c ..., .. ... -;: 0 " ..0 ... .... " E - ..! 0 .. " 0 ...J U u: lD l:: o X.oJ .",~ \.4 OJ .oJ OJ ::>.oJ UUl OJ X . iii ' .oJ iUl I~ E co .c CJ '<l' 0> l"1 . --,- D NO. AA 185120 COMMONWEALTH OF PENNSYLVANIA DIPARlMlNT OP RIVINUI OFFICIAL RECEIPT · PENNSYLVANIA INHERITANCE AND ESTATE TAX . uv.nu 111''''1 RECEIVED FROM: D ACN ASSESSMENT P:' CONTROL iii NUMBER AMOUNT DOLORES T LONCAR 101 SI;:I. ;:!~;:!. ~3 394 CHAMBERS STREET STEELTON, PA 17113-cBOl - 'ota Hit' ESTATE INFORMATION: fJ fiLE NUMBER 21-1996-0950 r:. NAME Of DECEDENT (lAST] ~ WALBURN AGNES II DATE Of PAYMENT B POSTMARK DATE COUNTY SSN 187-03-8B:H (FIRST] (MI) CUMBERLAND DATE OF DEATH REMARKS DOLORES T LONCAR m TOTAL AMOUNT PAID S13,323.S3 SK SEAL CHECKII 011 REGISTER OF WILLS ,/ RECEIVED BY ,I".',. , 'I',' ,1/ , /'1,~/ r SIGNATURE . ~.' . . ",," ~'ll r, ~.... MARY C. LEWIS ...- J;lc) ,,1.,' REGISTER OF WILLS ',~ " J '. .? . . .. ./ .__1 ---.~ -.. , ~~., - - 1" . , _'+'__'_+_"'+'6~~ ,- I 1')'1 \ ';, (.,,) . " ' JUV.Uo..lfh I1q"l w ~ ,,:!cn ..,,,,>< w",U ",00 U"'~ ",,,, '" .. /11_ /1// - /1 INHERITANCE TAX RETURN RESIDENT DECEDENT (TO BE FILED IN DUPLICATE WITH REGISTER OF WILLS) IJf~ffl;!l,W~"'ii~GNE:'J . 'IV'" 0">1''';. 1"'" 00 ."", __JJ!.7-.:-.03:-.66 31 .,. 11/1/961,., !i/18 /0 1 "_'~:'~~:_~'"''''":' ....,.." ,,,. ......"" ...." ... _ '0(<'1 \fCU"" ,1"M'" r~ 1. Original Relurn j 2 Supplemenlal Return [] A. limited Eltate [ .J 040 FUlure Inlerelt Comptomiu, (for dalel of deoth olter 12.12.82) LX 6 Decedent Died Tellote [J 7 Decedent Mainlained 0 lilling Trult (Attach COpy of Wiltl (Attach copy of Trult) ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: ,,~,:J~:~(\ ...,.'ffI_ (OMMONwfAlht Of P(r---lH!lYlVANIA ofPARTM(NI O. IUVWU( Of" 180WI IIAUIUUIlG. Pol I" 111 01\01 01(100.1 ~ r~AMI lIA~I. Illl~1 AIm "'IOlllllttlllAII ~ ffi o w u w o .~ "z Ww "'0 "'z 8~ -- =L7J,d-J _9,39...6145--_=_-..-._ 20. If line 19 is greater Ihan line IB, entor Ihe difference on line 20. This is the OVERPAYMENT. aD Chode hero if you are requesting a refund of your overpayment. IlAMf Dolores T. Loncar ffil'HONI NU~-~-------~--'-- ..------~----.- z o ;:: S => ~ a: .. .., w '" 1. Real Eltale (Schedule A) 2. Stach and Bondi ISchedulo B) J, Closely Held Slock/Portnership Inlerest (Schedule C) 4. Morlgages and Nolel Receivoble (Schedule 01 5. Cosh, Bank Deposits & MiICellaneous Personal Property IS,hed"le EI 6. Jointly Owned Property ISchedule F) 7. Tran,fen ISchedule G) ISchedule LI B. Total Gran Anets (tolollinel 1.7) 9. Funeral hpenses, Admini,lratjve Co,ts, MiICetloneous Expenles (Schedule H) 10. Debts, Mortgage liabilities, lien, (Schedule II 11. Total Deduclions Itolal lines q & 10) 12. Nel Value 0' Estote (line B minuslino 11) 13. Charitable and Governmenlal Bequests (Schedule J) 14. Nel Value Subject 10 Talt lline 12 minus line 131 15. Spousal Transfers Ifor dote I of death after 6.30.941 See Instructions for Applicable Percenlage on Reverse Side. (Include value, from Schedule K or Schodule M.) 16. Amount of line 14 talloble 01 6% role (Include values from Schedule K or Schedule M.I 17. Amount of line 104 taltable 01 15% role (In dude values from Schedule K or Schedule M.) 18. Principollolt due (Add 101t from line, IS, 16 ond 17.) 19. Credits Spoulol Poverty Credil Prior Poymenh ---0..00-- + ----0.00_ L', fOR DATlS Of DIATH Anu 12/31/91 CHICK HUI If A SPOUSAL " _ POVIRTY CRIDIT 15 ClAIMID [ I fill NUMBU - .;/ COUNIY COOE 'ISO NUMBER z o ;:: .. ~ => '" IE o .., ... .. ~ lie, Y[AR 01 (I (.Iltll~ (0"'''1111 AIlOII ~\ 8Co1umbla Drive, (Camp 11111), Lower ^11en Township, P^ 17011 CO"Or.y(Jil'WI\\J'~Ii' ~}t \J'~'U,,'O'''I_ r . 3 Remainder Return (for doles 01 death prior 10 12.13.82) 115. Federal E,tote Tolt Return Required 0- B Total Number of Sole Deposit BOltes (OMPHIf MAllltlG "OOlll!>!. 394 Chambers Street Stee1ton, P^ 17113-2801 ..- ....- .-- -~_.__.~--- ---"~---"'-'---'-'--~- (I) 121 PI (41 (5 ) 161 (7) 0.00 0.00 0.00 0.00 51,355.26 996.00 55,303..55 I Q I 110) _ 10,004.36 ( 81 107, 6 54&L~_~,___ 4,152.00 111) (12) (13) 1141 14,.156,..3_6____ 93,9'l.El-'..1i...___ . - ---__O.OO~___ _9.3, 498_. 15 1151 116} (171 0.00. x, -- 0-.00--.-- --- 0.00------ l4,02..4~.?'L___ x .06 = 0.00. 93,498.45 x ,15 = 118) 14,,024,77 Discounl InlorcII +_70L24_ - ,___ 0.00_ I1QI (20) .701. 24 .... ___ 0.00..__ 21. If line 18 i, grooter thon line 19, entor the difference on line 21. Thi, i, Ihe TAX DUE. ^-- Enter Ihe interest on the bolanco duo on line 21 A. B. Enter the tolal of line 21 and 21A on line 2'B. This is the BALANCE DUE. Malee Ch.ck Payobl. to: R.glster of Will., Ag.nt ~ ~ BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND TO RECHECK MATH -<-< U~der penalties of porjury. I declore Ihat I hove 8Itomined this return, including accompanying "hedulel and slatementl, and 10 the best of my ~-;~~I;d~;;-d~belief, .1 IS true, correct and complete. I declare that 011 real estate has been reporled otlrue mor~et lIalue. Declarotion 01 preparer olher Ihon Ihe personol reprolenloti~o is oosed noli information of which preparer has ony knowledge. \I N U 'O'~"'ON":i.'~'t'V'''NG'''UON I 'VD'''' 394 Chiinlbe-rs Street ~--------- 0.'.--.--------- . ~~ -L$~~-~ S_teel_tOD,__P1'L1J..lU,,_2JlOl____ ~___ _1/;('1L'LL___ SI NAtulll 0' '"I'''"fIl 0 HU THAN IfnlllS(NIAl,vI "'OOlll!>~ OAf( .,. Dolores T. Loncar, Executrix of Estate 121) 121A) 121BI 13,323.53 0.00 13,323.53 --~----~------- -.-.-.------- I Act #48 of 1994 provldn for the reduction of the tax rates 1m pOled on the nel value of tranlfers to or for the ule of the spoule. The ratel 01 prelcrlbed by the Itatule will be: e 3% (.03) will be applicable for ellalel of decedents dying on or afler 7/1/94 ond before 1/1/96 e 2% (.02) will be appllcoble for ellalel of decedents dying on or after 1/1/96 ond before 1/1/'n . 1% (.01) will be applicable for estolel of decedents dying on or ofter 1/1/97 ond before 1/1/98 . Spoulol transfers occurring on or after 1/1/98 will be exempl from inheritance tax. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING A CHECK MARK (....) IN THE APPROPRIATE BLOCKS. _1ES_ ~9., 1. Did d.c.denl make a Iranlfer and: a, retain the ule or income of Ihe prop.rty tranlf.rr.d, ............,..............,..,......,.............,... x b, r.tain the right to designDte who shall us. th. property transf.rred or ill income, ............... x c. retDin a reversionary interest; or ........,............,......,........,............,....,.......,......,............ x d. r.ceive th. promile for lif. of eilher paymentl, benelill or car.? ,...............,....,..",............ x 2. If deoth occurred on or before D.cember 12, 1982, did decedent wilhin two yeors prec.ding death transfer property without r.ceiving adequate considerDtion? If death occurred alter December 12, 1982, did dec.denttransf.r property wilhin one year of d.ath without receiving adequale cOnlideration? ..... ..See,.:l'.r,ansf e.r.s.. re,p.arte.cl,.,an..S.c.HEnU,t.E..:~ Q.':........, X x 3. Did decedent own an 'in trult for' bank account ot his or h.r d.ath?..................................... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Cl - ,.~ '- , ,'- ., ,',. ~, 1 It; C) ..." ',- a, N :=j (' - r- ,-' OJL- 9' ,~ ;:J a: au AccoUnt No. Typo Date Opened or Issued Date Closed or Matured D Dauphin Deposit Bank and Trust Company 'M'" o,roCE 213 ",^".n Oll'EH IiAIII\ISDURQ. PEUN8VlVANIA '''0' 7l11l~,1111 Aevised Decodont Confirmation Nomo: Agnes Walburn Social socurity No.: 187-03-8831 Onte of ()ooth (000): 11/01/96 0010595910 0080368069 5700559358 ------------------------ ------------------------ ------------------------ Checkin9 Checking Savings -------------------- ---.-------------------- -------------------- 03/28/94 09/10/96 OB/28/95 ------------------------ ------------------------ ------------------------ 11/18/96 (Closed) 12/02/96 (Closed) 12/02/96 (Closed) -----------------...-- ------------------ -------------------...- Date of Death Balance .$1,991.07 $2,528.28 $43.534.01 PWS ------------------~----- ------------------------ ----------- Date of Death Accrued lnt. $0.92 $3.56 $96.14 __w______________ ------ --------..-------------- ------------------- ...... Joint Owners (if any) or Sherry MacSkimming None None -------------~---------- ------------------------ ------------------------ Date of Joint ownership OS/22/95 ------------------------ ------------------------ ------------------------ --..---------- --------..~-_..---_....__.._-- ------------------------ ----------------------- Special ConmCnls: N/A -------...---..-- .- Additional in(orm~tion AVdildblo at $20.00 per hour. One hour minimum. Ollte Prepurod: January 24, 19!rI Prepared by: Cheryl A. Bowers Cus lom"r Mnnllgemont Informal ion Dopt. (Ooll) Telephone No. (717) 255-2054 ----------- form 00-020-216 lRHV 7/93) I'age 1 of 2 . ..,.._. ,,_ ......,.0-.._ O. .. \. , c PLEASE DETACH llErORE OEPOSUlNG COUNTY OF DAUPHIN VDUCHE~ INVD ICE CHECK # 0 1819 6 NeT HARRISBURG, PA _ DESCRIPTION 00018196 GRDS S " 96411337 A WALBURN 100.00 --------------------------------------------------------------------------- 100.00 I,-t.:.\.\) ,t- 1,"(ltt1 nATr- 1;t/1Q/V" NFl A"4t1:JNr: --------------------------------------------------------------------------- 10J.lIll , '. ';'" 'I " .<- , t. '~.#> " .{ 'I ,.\ ,. ,t. " . 0." :", '4" t ; ; -. . .' .... ... . " .r .' . '! t'.~. ;"".. (\ .. - l to. .. t. ~ ." , ,j J t- -, ~. \ Y -, :'," .. " .. - -.-- V""'~--'O r......'" ~, )',,-, )', , . ..,..-. , ,p-- i .. . -:,,:.w1I r-= ! , . ) i , . , . IIV.UOP 11+ 11Ut) . COMMONWEAUH Of 'fNNSYlYANIA INHfRITANCf TAll: R!TURN .fSIDfNT DfCfDfNT ESTATE OF SCHEDULE F JOINTLY-OWNED PROPERTY Joint tononl(II' AGNES WALBURN, DECEASED NAME A. Sherry MacSkimming B. C. Jolntly-ownod proporty. FILE NUMBER 2196-0950 _ ..__ _.n__u__ ADDRESS RELATIONSHIP TO DECEDENT 6273 South Highlands Cir. Grand Niece Harrisburg, PA 17111 ITEM LmER DATE FOR TOTAL VALUE DECD'S DOLLAR VALUE OF NUMBEI JOINT MADE DESCRIPTION OF PROPERTY OF ASSET % INT. DECEDENT'S INTEREST TENANT JOINT 1. A. 5/22/9! Checking Account #0010595910 with Dauphin Deposit Bank & Trust Company, Harrisburg, PA 17101 $ 1,991.07 ~ sh. $ 995.54 (al. A. 5/22/9 Interest on the above to date of death .92 sh. .46 TOTAL (AI.a onlll on lin. 6, Rocapitulalion) S ""G.OO '.)>o~io:tW"':':;';~\';-!:_,/~'-'i" '",;"JiJ,-_'~j"..c- (II more space is ",~eded inslf' additional sheets of same size) \. CoreSlalos Bank. N A Repo~,"g Services FC 6.90.3.235 PO Box 1102 ReadIng PA 19603.9987 6106553353 ~ January 21, 1997 CoreStates Mrs. Dolores T. Loncar Executrix 394 Chamber Street Sleellon, PA 17113.2801 RE: Estate of: Agnes E. Walbum Date of Death: November 1,1996 Dear Mrs. Loncar: In response to your lener, please be advised Ihat the decedent held the following account(s) With our bank as of the date of dcalh: DATE DATE DATE OF DEATH ACCR. ACCOIJNTII ACCOl JNT TlTI.R OPENED CLOSRn BAI.ANCE lliL Cenlfieate of Deposit John T. Loncar or 09/18/96 30,000.00 195.17 200145869-810110J DolDres T, Loncar I trust that we have been of assistance to you in this maUer. Sincerely, CORESTATES BANK, N.A. JUn." tLJ~)tL~, Brian K. Harvey BKH/hbl141 IN REPLY REFER TO: REPORTING SERVICES Fe 6.90.3.235 POBOX 1102 READING, PA 19603 610.655.3353 Ih,,"I.. .111, SCHEDULE H FUNERAL EXPENSES, ADMINISTRATIVE COSTS AND , MISCELLANEOUS EXPENSES! Plea,e Print or Typo , . ' -----------"---- -------jFII.E NUMBER DECEASm I 2196-:0950 ---- ---,---- ~, '!~ v ,,, , ".", ;t\ , ,h (OMMONWIAI1H Of PfNU!l'WAUIA IUH(III1A'K( I..., Ie( lUlH4 R(510lHIDfClDI1H i-STATE OF ITEM NUMBER A. 1. 2. 3. AGNBS '''ALnURN, DESCRIPTION .-_. ------------ AMOUNT Funllal Expens..: wie~eman Funeral Home, Inc., Steelton, PA $ (Prepaid Arrangement AgreeMent; see SchedUle "E") ROlling Green Cemetery, for Opening Grave Harding'S Restaurant, Camp Hill, PA, for Funeral Luncheon B. Administrative Casll: 1. Personal Representati....e Commissions Sociol Socurity Numbor of Persanol Represenlolive: _, .2.00.__-=-.2 2 __-=--2.01lL 1997 Year Commissions paid ----------.------- 2. Atlarnoy Feos _ Not Appl icable - None 3. 4. C. 1. 2 . x23. 4. x25. 6. xx1. x:llB. :(:1.1. xJt 9. x 11,1 0 . It. Fomily Exemption _ Not Applicable Claimanl __.....__________ Relolionship Address of Cloimonl 01 decodonl's deolh Stroot Address ------- --.------.. City ._,_Slole __._ Zip Codo_ ProboteFees - Reg. of IHlls of eumberland eo., PA, for Probate of Will, Letters, Short Certs., etc. Mlscollaneaus Expenlos: Robert P. Kaskiel, for Witness Fee Kathleen M. Kaskiel, for Witness Fee CUMberland Law Journal, for Advertising Letters The Sentinel, Carlisle, PA for Advertising Letters Reg. of Wills, for Filing Inv. & App. Reg. of WillS, for Filing Releases (2) Reg. of Wills, for Filing PA Rev. Dept. Inheritance Tax Return outstanding Check #104 on Checking Acct.f0060366069 with Dauphin Deposit Bank & Trust Co., at time of Decedent's death. (CheCk issued to Reg. of Wills of Cum. Co., in payment of Inh. Tax due by Decedent on Joint Acct. vith PNC Dank with Cecelia M. Hale) Postage and Certified Mail (Notices) Traveling Expenses (Mileage-trips toCarlisle & Lebanon) Notary Fees TOTAL (Also enler on lino Q, Rocapilulalian) (II maIO spa co is noodod, Inler! additional she ell of same lilO.) 3,663.00 695.00 256.96 3,675.00 214.00 15.00 15.00 60.00 56.90 13.00 14.00 15.00 1,199.46 30.00 50.00 10.00 S 10,004.36 WIE:DE:MAN fUNE:RAL ijOME:, INC. , fACKLE:R-WIE:DE:MAN fUNE:RAL ijOME: 351 South Second Street Ste.lton, PA 11113 939-2344 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Ctu.rxcs arc only 10lthooc IIclOl thai you ld<<tcd or that uc rcqulrcd, II "c uc rcqulrcd by b" or by . ccmctcry or crcmatory to .... any IIClOl, "c "iii npWn In "rillll3 belo", II you sclcctcd .luncnlth'l nuy rcqulrc cmbalmlll3, luch 1l.luncral "lib vlc"lng. you m.y havctof'y Iur cmhalmlna Yuu du nnlhavcto p,y lur cmbalmlna you dJd nUI'pprovc" you sclcctcd IIIIllRcmcnll ,uch II I dJrcct <<cm.tiun or Immcdblc burial, I ..c cblliCd lor cmbalmlll3, "c "iii capl.ln "by belo", 'orshcScnlcc01 ~ t. uJtLtI~~ D.tcoIDc.sh .p4 ~ CIw1e 101 -ww M,.4..J.o -r. ~~ ~ '1'1 t.k....tw,,~t ~ Namc Addrcsl City 5111C 2lrd and Dcrry Slrcetl Harrisbura, PA 11104 564-1434 A. CHARGE FOR SERVICES SELECTED, I. PROFESSIONAL SERVICES Smiccs 01 Funcnl Olrcclotl5u1ll f/'I.5'. (J(' Embalming.. ......... .... 1 LlS() ,<)0 Dmllna, cllkcllna and cusmclology............. 1 /9S."" Otbcr prcpmtlon 01 body , " . . SUB.TOTAL OF PROFESSIONAL SERVICES" Al I I~I,/(I,(),. 2, FACIUTIESI5ERVICES/EQUIPMENT Usc ollaclUtlcs and scrvlccslor vlc"lna (V1s1t.tlonIWakc) "I 1 9.5= ()() AddhlonalltaIC and cqulpmcot lor vlc"lna In churcb or mldcncc ..............,. Use ol'aclUll.. and servlm lor Ionctal ecrcmony ".., . Addltlonallllll and cqulpmcol lor scrvler In churcb or mldcnec".."".."",. 4')5 o/)() Use oll.clUtl.. and servlm lor Mcmorial Scrvlcc .. , .. .... . Use 01 cqulpmcnl and servle.. lor Gl2vcsldc Scrvlcc "". 1 PI2Ycrwds ,..,..,..,..,.1 Tcmporary Rl2vc mukcr ' , " I Burl.1 clothing ,.... .. ' .... . Olbcrdulhlna ,..,,'..',.. 1 Fiuwcn,~V~': Crcmallonum ......,...... (Dc>cripllon) Intcrior & Eltcrior Cruclfl.cs 1 JJll'.L)O Otbcr ....,.............. I TOTAL MERCHANDISE SELECTED""..", B 1 11./'1. ()O C. SPECIAL CIIARGES, For\\'udlng 01 rcmaln> to 1M. 00 I (Funcralllomc) Rccclvlng 01 rcmain> Irom 1 SUB.TOTAL OF 'ACILlTIESIEQUIPMENT "A21 t, ?O.C~ 3, AlITOMOTIVE EQUIPMENT Vchldc 10 tl2tulcr remain> to Functalllomc, 'S LoaI .........,.. .....,.. I Ir1o~ .(J" Go .()O HclllC (c..kct Coach) /~i'gg LoaI ..,....,............ 1 UmOUllnc LoaI ......,..........,.. I ~". 00 Family w LOC2I ,,,..,.......,...... 1 Fiowcr C1r or flotal disposition LoaI ................,..,. .J(J.~ Out ollo\\'n 1I.00pon.tlon ,. I I I SUB.TOTAL OF AlITOMOTIVE EQUIPMENT, A3 I TOTAL OF PROFESSIONAL SERVICES, ~t~I~~E~,.^~ ,~~,~~,~~~~.. .. ' .. .. A I 116 ~/). CO .$ 1l'tJ. cc ~ 'h?Jo- (Functalllomc) ImmcdJatc Burtal ..,......, I Olr<<t Crcm.tlon ... .. , .... 1 1 SUB.TOTAL OF SPECIAL CHARGES,."", C 1 D. CASH ADVANCED Opcnlng Gl2ve ...'.'",.', I ~f!-;.';f'- A Cemetery Equipment....... . A~:.JI I~ Ncwlp.pcr Notlcco-LoaI ("llmatc)..........,.... I NC\\'lpaptr Notlcco- Outo()l,town ........,... I Tclcphonc & TclCJlt2IIU ' , , " I AlrIarc............,...... 1 Clc'BY 1I0not2rium........, I I~<J" P~ .'"".'.'",., I Ccnillcd Copl.. 01 thc Dealh CcnlflC1lc .. ..t .. .. .. . .... 1 II. (>0 VaullScrvlccCtu.rxc .""..1 Crcmatory Ctu.rx.. . , , , , . , .' I Organist,... ..,..,.., .... I 5(J.(J0 Solols!..........,........ 1 1 1 SUB.TOTAL OF ADVANCES",..."""..", D 1 '8''19.00 SUMMARY OF CHARGES A, ProlClllonal Scrvlc.., FaclUII.. and EquJpmcot. and AUtOlDotlvc Equlpmcnt .............., 1 tlfto94.00 B, Mcrchandilc , .. .. .. .. .. ..' 1 ILI'rl ()O C, SpcclalCharg....,.........1 0, CllhAdvanc.. ...,........1 'ii4'100 6'.a TOTAL OF ALL SECTIONS.............., 1 3' . d" PAID AT TIME OF OR PRIOR TO ARRANGEMENTS.,.",....,..,..".,... 1 BALANCE DUE....................,.... 1 B. CHARGE FOR MERCHANDISE SELECTED, Cllkct ,................., 1 (1)cscrlptlon) Olhcr Rcccptadc.. .. .. .. ,.. I (Dc>cripllon) Acknowlcdacmcnl cuds , . ' , , 1 Rcglstcr book(l) , ",..""" 1 Mcmory loldcn"""""" 1 :lUSC:' rOil EM3W.:tr.:G W II an b". ccrnmry. or crematory rcqulrc cots havc rcqu1rcd thc purclwc 01 any olthc I~VC thc b" ~ rcqulrcmCOl1s ~Wncd belo". ~ ...J () -""_~~ . Outa burial conta.ln<< ...... , (1)cscrlptlon) I agrct thai 1 havc cnmJncd thc Italll or aoods and smiccs ..kctcd aIsovc and lound thcm 10 be corrccl and .ccordlng 10 Ibc: arnnacmcnll I b..c rcqucstcd, I acknowlcdg< rteclpt 01. copy or lbil SUt.....t 01 Funml Goods .nd Smiccs ScIC<lcd, I rcpltSCllt thatlhavc luffieknllunds avaibblc lor P'ymcnt or thc asb prier lor thc SOOth and scrviccs ..Icctcd, I also agrct to makc P'ymcnl 011 within cla)'1, I agrct to bc jointly and scvmlly IJabIc with IO)'OOC cIsc wbo sign! belo", A btc ehalJC 01 " pcr OlOnth amountlna 10 " ptr ycar wIiI be applkd to thc unpaid balancc IqInnIng cla)'1lrom thc clalC ollhls 'armncnl. I wIiI also P'Y 10 lbe Funcnl Dirtc10r all rc2!Onablc COlli paid by lbc Funcnl Dirtc10r to colkct amounts I 0'" undcr this qrccmcnl. 1bosc COlli IOIY Include '"OffiC)'1' I.... coun COlli and othcr COlli. Any .ddltlonalscrviccs or mcrclundisc ordcrtd or rcqucstcd ahtr Ibc: dalc 01 this qrccmcntwill be coO!ldcml pan or lb~ qrccmcnt ~nd thc COli t1xrrol wIiI be rclkC1cd 00 thc full! bill or lUt.....l.~ 9 (Sa( /.;yr.d~c:'. /c-~~ _ _~. 1'1 " '_ / , 11/',' .JrIll<~I. ) 11.,' r C"'\. (Scall'L" Jt"j/ N.d-t? /. . h.<~ ~ J-...,JJ.,,, .~ oJ. iJ . I (Purclul<r) 'lr t:( (IJccnl<d Funeral Oircctor) WHm Dtm10f _ ' YlUOW' ,.-nJ DftnOf PIJU c:.u.- Contrlc:lNo, A8010l, 'lIISI INTERMENT ORDER AND AUTHORIZATION Inllnnenl No 14,784 Dill 1111 /96 Nolnllrrnenllhlllllkl pll.1 unllll wrlnln lulho~ly, Ilgnld by IhI propll ...IIIIvI or Ilgllrtpr..lnllllvl cllhI elI.....d "" ....n glY1n 10'" elmlll plrlormlng Ihl Inllrmlnl. The undelllgned hlreby rlqulIl Ind luthorlzl: NlmeofClmlllry ROLLING GREEN K1!KCl'I1AL PAR!': In eccordenoe with In IU jl 10 'II ru II en rlgu Il,onllo 'nlor AGNES E. ~RNEC WALBURN Dill of Dllth November I, 1996 Vel..,? Sex No Female NAME OF DECEDENT 0111 of Birth Ka)' 18, 1901 AQ8 9S In thefollowlng c1esaibed Intorrnenlapace, Block: G FUIlIIlIIHome Wiecleman Section: 609 Dlreclor Grave: 14 Denn)' PlA'dlased PN rn AN 0 Tel, 939-2344 Addrell Steelton R.G. 01}' lvf' 0 . Olte" I {, / ~ (, T1meofServlclll 1/ '. t' (' Day WcdneedaYDal1 11/6/96 TlIIl8ofServlc:e /~ : ;3{J Supplier R.C. ' Memoriel Base Supplier PII.. of Servl.. f.; i n~ t 0.( ?"O(' t"_ Type of Clmelery Slrvlce Type of Outer Burial Conlalner eoncrcte Memorial 24x12 v/v Gorhem Supplier Vintage Bron~e Calket lnterment [J..)/ -{:e.n'( REMARKS INTERMENT rEE S ;: 1/..5'7 t'> C/ Match gov' t on G-609-14 OVERTIME CHARGES Jonea, Lillian B. 1 2 OTHER CHARGES open- I~'-,,,o 3 4 TOTAl. S Tho undeBigned hereby certify thaI they are the legal l>JSlodian(sl oIlhe herein named deceased, having the fulllegol authority to dinlcI u-e Oltenmnt. entombmonl Of lnummont 01 the remains 01 the deceased. and hereby authorizo the _.named cemolery to make disposition of the remains 01 u-e dP- lld "" rd_ ' _, The undel$igned hereby further certify and represenllhallhey are the <>WI1l>I1s) or authorized representative(s) 01 the ownerjo) 01 u-e abcMHlesaibed Interment Rights and hereby authorize use of said Inlem,",,1 Rights for lhe Intermenl entombment Of Ioommonl 01 the remains 01 u-e herein named do< s d Cemelery is hereby authorized 10 Install 81fi outer burial container purchased In connection with this intermenl in u-e Inlermont RV1t de.Dtbed herein, Tho undersigned hereby agree 10 indemnify and hold harmloSS the cemetery, Its alfiliDlos. and \heir reapeclMl agents, Sha,oI.o1dors. 0fIicer.I, lJiredDrs lW1d .......- tmm 81fi and aIlliabilrty, including reasonable ollorney'o fees, and against 81fi loss It Of Dnf of them may lklSIain In connection with u-e W8rmenl, entooob,,~' Of lnumment authorized hereunder, Further. the undersigned agree that oemolery oI1aII hlMl u-e ri\t1Ilo correct 81fi orrcr In this i""',,~.I, oJ Is own_. without 81fi liabil such orrcr, ) d~;:: W~ Dolorea T. LODe are Niece (AulhonztdRlp'...ntt1JYt1 Pm_ R.........."'lo~ .~-u 394 Chamberl Street Brelller Steelton PA 17319 939-614S """'. TII.No. - ay - ZJp Slgnaturl (Authonztd R'p'_l 4": I PmI...... I R-'otI;plo~ TII. No. Addrsu - ZJp - ay . Ham. oIlnlsrmont Righi own.r,11 dill...n! thin Aulhorilld R'pnllontlliYl: / OFFICE USE ONLY ~~1Et .~ FtIl'Ir'M ~, ~" ;1,"""k~ " OnItrTtIltnlly , - /,'," /~ , :' , ./ -,~Y,//J , 9.o-,..do.tlw........... " _IlyKL _Ctnl UlII1oc1c UlI Ctnl """ --- FORIoA 23 REV. "/83 / >> IIAL.Net; ."'l-AI'4CI ,OMW...ltU ~ 11""& ....'INI...CIl oa,..n. - ",,"'''._MI enAKG!. eNID" .--" I/k/f. d?' #.I41t@ J.~ /P7 ~ Jl~ k~~{/~ . 31 f1 I b zq , -v II J{ d.~ ~3 ~ ~ J,5, ~ 17~. qto..i<u~ 1t 4- 05 ~, L WIt, I ~ . Its ~ -' ~5o. \q.g r'\ . t1 lLf /1 ~ ICfJIo -~ I I \.l IVI W./ I ~5 f(. Iqg .~ l . , . 7 TERMS: NET 30 DAVS A FINANCE CHARGE OF n.lO PER MONTH WILL BE ADOEO TO UNPAID BALANCE, HARDING'S RESTAURANT.INC.. C.mp H,li PAY LAST AMOUNT &.. IN BALANCE COLUMN I . , " "Jot 1 " " . . --, -.....,.."..- . -~._,_._. .-.~..)f. -- .,:. II..-',Iillt"'" ESTIlTE Of SCHEDULE I ~ '~V ^",JJ ','1\ -:t UP COMMONWlAUH O' P[NN~YlVANIA INHUltANCllAllltUlt~ lUIOINT otelOINt I \ D!!IIT!l 01' nBCEOBN'r , J _' .__ PI.a~..~r.lnt or !VP' , fiLE NUMBER , , AGNES WAL!1URN L-!>~_CE_~!!F'D_______________,L-_2196=_095 N~T::ER DESCRIPTION AMOUNT . ut !Ita nd-i_ng_Debt-s-or-Decedent-a rti mtrot-demt's'[!,rs follo\l" . 1. Internists of Central PA, for balance of medical expenses $ 8BO.00 2. 3. 4 ~ The A.Z. Ritzman Associates, Inc., for balance of nedical expenses 1,000.00 Moffitt, Pease & Lin Associates, Inc., for balance of medical expenses 300.00 PA Neurological Associates, for balance of medical expenses 410.00 675.00 5. Kunkel surgical Group, for balance of medical exps. 6. Pinnacle Health Hospitals, for payment of Medicare Deductible amount (this was not paid since' Decedent did not have Medicare B., or medical supplement insurance coverage) 887.00 I ..--- .-.- TOTAL (AI.o onlor on lin. ;. Rocopilulalion) S 4 152. III mall spac. \. n..d.d, Ins.rt additional sh.." 01 sam. I....) :' /,', '--"'----" I'tll, I --_.--_._-_._.~--'- , INTERNISTS of Central Pa. ,,==--=::-:-::'~~-::,:=-=:'llll '-,:'::::-. --,':::,:.-.'"::. I.....,M n"",MII MlChHI L ()IU1~, M II JalnM A Tyndall. M U ~rhard t4rhtyllot', M U 013444 Ira J I'alkman, M II 09M1't4 L 1.)11"" nnllnn, M IJ mUIt. L"l''I'lK"f U 1.lmmm"an, M n 1&M3!1 ,.litha,l A I),MlIh,l" M II 41411.11 11atl~ (NMltJh !If'1fi!f'JJ PLEABE DETACH AND RE. TURN THIB PORnON WITH YDUR PAYMENT. PLACE IN INVELOPE PROVIDED. WI! WILL GLADLY BILL YOUR CREDIT CARD. BEE OTHER BIDE. IRS. 23,2146427 IWUUS\1P' MlOFtS.IHONA1.CE~j[R _lOll LU\l.TlIr.Rst _ III bOX 101. LEMm'NI:.I'A 110U{lI01.11111114,IWl f',U 11111 714 42,12 . fH.I,I ,; U ( I'III~I~ ,: r nl (lI'I! I n Ill' :.11 I nt'1I' II II I f'fo t;' (,1 DIAG CODE SERVICE DATE PROCEDURE REFERENCE /1 : : Of, " 'J (~ . II", . .-;'J ,'~.', I i'J / (, ,'J" ,j '~ (" I' . " r;" ~,,~ .~ i.', . fl '; . '.J,I, :, '1" Ii r;,'. II;' .' It:. ,'.,' ;... 1 '; '. . " (,I ~. ..1,.., 1 ( , ,~' , " I': ,) (, , ',; ::i, ... ;',., .~' ,~I:- ~-I" . II'~ 'r; /, '/ H I. r~ p '~ ." -\' ' ';",1, IJ ",: :, I to: ',', 'j ';- .' '; ... ~j':Y,OO ORil~/~~ Q9~';7 0"-,. /1 ,I,/fii r,"','l (I (d, /i. rl ~. ,. 9 '-,' t :1 i' 0)' , ~ .-, "f', 'fJI, STATEMENT 1 (i I "I /1 / '. STA11'MENT DATE ACCOUNT NO I, PATIENT NAME AMOUNT ( $ ENCLOSED ATTENDING PHYSICIAN'S STATEMENT 1 t,; "'_': ) DESCRIPTION CHARGES I PAYMENTS I AOJ PATIENT INSURANCE i ,d' b,' r l' : I I " I I ! ....p " I ,f'. r. il '1 r', ~ ~~ , " h' I~I I n f" , I I, I',j .i! i II, 11. f'f r IIIAI H()t,f'i'lld ,IHITLEMENT [I- 7~,OO IIHrl'. lHII~I: "nil 45,00- ,I i .-, 11 L r. '.Ii i ~. I III! I '';f , I ~ I, t . I I,' I 95.00 111" H, ", ,';', j I r lli I 1'".1 I, ~ ( ,', T' r I' ~l Yt'li . i ; 7~,O(l f'- \, d II S F' I.; t s : 1 I r '~il , 1""1:' I;' t'; f I') ,':'. .. : 75.00 "1, i. h . ',1' 11r i. ' 1)1-.; 111.;1 r .,i'!1 7~.00 ., -, , tll.t !"'" I" '.., t I) i' 'I I I ~q I , i. I,' t "(:1:: 7<,.00 I',! I~ H (, r., f' ;,1 ",: r i r ','I I '-II :' I \ j.j.:i f'(,'t"!'V,j '.i I,Vii'i if ;Ir; I',rl,'r,.~~r FIHITLEMEIH E~"'i I, 75.00 mI. 1I,,',r' V,c,ll Ill"l MI "i I ,,;,f ,'lIYMi 1~1 ',lhl'IU .11 II Ii I'll PUrd,E ENTITLEMENT VI-i: 75.00 rl: r~ i-; It l, i U;~, i I I f I.If, / Mt.I;I'i1hf r'~jr"l.~iNl 75.00 f': , .,. , 08 '71,' f,';.. '\.-,,. 1 t. I Q (J 99 ' \ 7 i I ,: IHi !;f' l: I ,; I r I 1 'J' I MFl'lr..rn. r'H,'i:r1n 1-,INI"iid'l ['lln1fl'! [,H: ,-'; :,11 PATIENT NEW BALANCE ~ NEXT f'Rr.V .\ ot. , III Q~ (,0 on ("I nn 71 (I() (j() ;'1; n:, Oil II, '-1(, (1(, / I~ Ii'", l'I(; 7 ~'. (J'I or, ,,1; (10 ~" , " tld (J'.' PATIENT BALANCE DUE PATIENT INSURANCE IS YOUR RESPONSIBILITY * LOCATION CODES I.INPATIENT HOSP, 2.0UTPATIENT HOSP, 3, DOCTOR'S OFFICE 4,PATIENTS HOME 7.NURSING HOME e,SKILLED NURSING MAKE CHECKS PAYABLE TO i III i INTERNlsrs of Central Pa. 1111 1"101 M lIlIff.MII M"I,...II. Ulll4~. ~III J.n..... It. 1)ml.1I, ~III Ihflumttlch",ihfo,. M II tI1.1444 h.J 1'.I~I1'I"I,MlI UMltllt I. 1.'ftn.IIIIllllll, M II crJI~Ir. IA."m. II i'.lnllll.lnI.lII, Pot It II\M~" MIt.,..1 It. I~M'IIII,II-. M II 11'1111 Ill,.'tll Irl',l~lh ",.,'I't11 PLEASE DETACH AND RE. TURN THIS PORTION WITH YOUR PAYMENT. PLACE IN ENVELOPS PROVlDEO.' ,WS WiLL GLADLY BILL YOUR ',.CREDIT.; CARD.(BBB~OTHEA ~BIDE. " " :V;.f\ 1 IRS_ 23.2140427 llAKIU!l\'U:W r.mrt:......IIISAI.nNlUl. 'llIll~ly"ilU:H HT .1'llltlX 101. LUtrl\'NI:, IIA I1GUOIU1'111l11H 1.1'.1".0: 11111 114 U.1l -'1,11, 1\1;111 ,; I. I'd I: 111;/1 STATEMENT STATfMENT DATE I ()( \.'1, II rdl Ill-Ii:; fI 111\ i I. I I ;,I'li' H II I j'll I ,j j I ACCOUNT NO, :'.' PATIENT NAME 111;141 ' AMOUNT ( $ ENCLOSED " :-,~..' ,",1' ". DIAG, SERVICE PROCEDURE DESCRIPTION CODE DATE REFERENCE '}2/(.9 OIJI22/96 9~J252 LtC HDSr VI S IT I. [('EL " , 09/16/96 MEDICnri[ ('AYMf Ii I 1131. OOn31'f6 99230 t LtC D I SCIIAriGE MANAGEl1J:tH 09/16/96 MEDICARE PAVMENl :~ ~"":'I"~"~;,.~.It.';:l~1.1 r CHARGES I PAYMENTS I ADJ, PATIENT INSURAN ,75; 00' 7'" .' I Y;':' 75,00 ,'.-: ,'~ i~'1''::' : < '. GO "i ,'., ',.'.',. ' ',l'-I'..,r. \.;., :"- ,::.';: /'1 ~ . ',.., Boioo:;{ , ~. ":'-41.. ~_'_ .-"..........u.:. I" ;::" i 1(1' lli t ,I PATIENT NAME Id~1 H ~; iJfl.I;lil.!l PATIEtlT NEW BALANCE ~ U U 0 , 00 PATIEIlT BALANCE DUE PATIElll IN~U"AN IS YOUR RESPONSIBILITY . LOCATION CODES HNPATlENT 1l0SP ~,OUTPATIENT HOSP 3 DOCTOR'S OFFICE /09/96 /09/96 /11/96 /12/96 /19/96 /19/96 /21/96 /21/96 130/96 130/96 /30/96 /29196 0450 1010 1010 0470 6700 6710 2193 4160 THEAll UNENHANCEII HEST.l VIEW HEST[l VIEW, '. ..', '. THEAll UNENH ~,ENH CHOG AIlII COMP Ii-MOllE CHOG-RETROPERIT B-MODE T PELVIS W CONTRAST T ABIIOMEN ENHANCEII IECLI NE MElI ICARE ERV AFTER MC NTLMNT ENIIEII AYMENT SELF PAY 184.00 . '.29.00 '",29.00. 252..00 130.00 1 24.00 236.00 171.00 '.,"'.' 't' 157.00 Tllt"...-l. ":. .l,lf.,I"l.j..ln. POd... b~~ ('l.I,Jtll'P"",J'." YOUR CANCElLED CHECK IS 'l'OUR RECEIPT 1.000.00 ....... PlE.A5E.PA'f ....... nlls AMOUNT IRS,lJ1!)'j(1l . ." ~... " .._1 -~ . -;_-.-:---- ._._~H__"-:'.M. _ _ 1:' MOFFllT, PEASE & L1M ASSOCIATES, INC. 1000 NORTIl FRONT STREET WORMLEYSBURG, PA 11043 TAX 10 .23,1864122 To/I Fri' Numb., 1ft PA T".phOft. (717) 731.8315 1.800.148.0151 FlU (717/730-0693 George R. Motfrtt, Jr.. M,O. Wilham E. Paue, M,o. Hlng F. Urn, M,D, Mhu. J, Mull.., 0.0, 1'0111 Gu\ienlZ. ...,D, Paul A. PK:Cini. "',0, Claude Fanelli, "',D, Account ND. Thach N. Nguyan. ...,0, John p, lama... M,O, Roba~ G, Baily. ...,D, OlVld G. Pawlu'h, ...,D, Mdla., 1', Smrth, M,O, Dennlo E, Un.. M,O, Tadd A.BDhlman. ...,D, PI111nl Olllncl Duo walbag-00 IlI1a 300.00 Arnaunl Encfaoad Agn.. Walburn C/O Dolor.. T Loncar 394 Chambers Street Steelton,PA 17113-2801 12/12/96 p.Ulnl Ntme ,Agnes Walburn Make checks payable 10: MOFFm, PEASE & UM ASSOCIATES, INC. SEE REVERSE FOR PAYMENT INFORMAnOll ~ 08/09/9 93010 1 Ekg Interpretation & Report 0 786.l50 30.00 0.00 Paymentl102 30.00 08/12/9 9330726 1 Echocardiogram 2D Interp & Re 786.l50 22l5.00 6l5.00 10/07/9 Paymentl102 160.00 08/12/9 9332526 1 Doppler Color Flow Velocity M 786.l50 60.00 60.00 08/12/9 I 9332026 1 Doppler Echo Reading Interp & 786.l50 175.00 175.00 MOFFITT, PEASE & UM ASSOCIATES, INC. 1000 NORTH FRONT STREET WDRMLEYSBURG. PA 17043 TAX ID 123011&4722 SEE REVERSE FOR PAYMENT INFORMATION 300.00 Plllanl Nlma: Agnes Walburn I'UASI "ETAlN nus POPmON Of' ITAlDIEHT fOR YOUR "ICORDS Account Analyall TDlaI CUrrent ~.eo .1-110 Inoulln.. Bolin.. 0.00 0.00 0.00 0.00 Pl1Ilnt Balance 300.00 0.00 300.00 0.00 PAVTIlISAMOUNT '.-. 11-120 0.00 0.00 120. 0.00 0.00 At:Counl Ba~nce 300.00 pn HCUI(OLOG r en!.. nssoc Hi\rl'if,vi~w P'ruJos!:.;iOlh'\l 180 Lowther Stn?C't Leffioyne,rn 17043 717-77',--2202 FED 10 : 232441989 Cen (.(}'( Accounl No, Amounl Due walbag-0D 410.00 Dale Amount Encloaed 11 II Ill:'5 Walbu'rn II Columlli,i nor HJ/23/% C'''"fl Ifill.pn 17011 Date Patient Name: Agnes Walburn IF INS WAS GIVEN, CLAIM SENT' DILLIHG OFe 1I0UF(S 9 AM - 3 PI" Please remove and rei urn thIS panlon with your payment DEmI Dr. Pallenl Name Doscrlpllon ChrgsJCredils ' , 00/13/% ,iwh A!lnC's Wa 99254 Ini ti,il Con!'.ul tatio\l 1'10 437.8 175.00 178.B0 10/137/% P,iYOlent-Th"nl', You 0.00 , : 08/14/% clwh Agnes W" 99232 Subseqll(\nt lIos p i till Ca",'" ,,37.8 130.08 130.8B ! 08/1(;/% ,i~lh nqnCt> ~J,i 99231 Subsequent Ho,,-,pi t" 1 e,i'r '137.l\ 40.00 40.00 : 08/19/% csy Agnes W,i 99232 Subsequent Hos p i til I Ci\"r ,,37.8 (,8.00 (,5.00 , 5(~'f'V i\ft fflE'(]icc1"("C entit ,1/ tiA. i.' 1 9-11!f~ .7 J;.d ~ '" ()l-- PLEASE RETAIN THIS POnTION OF STATEMENT fOR YOUR RECORDS PAY THIS AMOUNT ~ 't10.00 Accounl Anal 81a Tolal D.GB 410.00 Currenl 0.DO 410.00 30.60 0.08 0.00 61-90 0.00 0.130 91-120 0.00 0.00 120 + PATIENT '" 13.00 BALANCE I 0.00 AMOUNT DUE Insurance Balance Pallent Balance 410.00 Charges/Credits lIem Dal.nee '08/12/96 99253 ! Inpatient Consult. Medium 433.10 175.00 175.00 1 09/30/96 I Plan Payment,OOO 0.00 08/13/96 99231 Subs.Hosp.Care.Low 433.10 50.00 50.00 , Utlf111fUI; IlU:I:H i Sube.Hosp.Care.Low 433.10 50.00 50.00 08/12/96 ,9388026 Prof.Comp.Carotid Aqd 11;:11; IIUIl.UIl IIUU.UU HlfUf fur; Plan payment.OOOO 0.00 we need new insurance in'fo (; *,V l . ; 'a~ C&' J;0. KUNKEL SURGICAL GROUP MEDICAL ARTS BUilDING CAMP Hill. PA ,7011 FED 1.0. .23.172B739 675.00 ! Patient Nam.: I Account Analysis Insur.nc. B.I.nc. I p.lI.nt B.I.nce PLEASE RETAIN THIS PORTION Of STATEMENT FOR 'fOUR RECORDS 3,.60 61.90 0.00 0.00 0.00 0.00 PAY THIS AMOUNT ... 120. 0.00 0.00 Current 910120 0.00 0.00 Tot.1 0.00 675.00 0.00 675.00 '--------'-1 -, " Account Balance b/ti.O I, i \ I 1 \ : I .. 'I I' " .._t v~ . -- ~-. ~.J< ....--:"'..N.'_ I""....,"" .~... \ , -. . ""0' No 1 .lctOuntNumber PalltnlNlme St~ltt Slln, SlllemenIOI'e: 970033056 WALBURN ,AGNES 08/09/96 S"..ceEM 1 0 /18/96 Lilt SlalOm,"! O'Ie. 08/23/96 08/30/96 QUESTIONS? Pi.... Call: (717) 782-3680 Conlacl: ACCOUNT BALANCE ESTIMATED INSURANCE DUE TOTAL PATIENT CREDITS .00 887.00 887.00 AMOUNT DESCRIPTION 22,525.50 16,713.47- 5,108.98- 183.95 TRANS DATE PREVIOUS BALANCE CTRADJ-MEDICARE 696 MEDICARE PAYMENT-MEDICARE A 696 MEDICARE CTRADJ-MEDICARE 696 MEDICARE 08/30/96 09/17/96 10/18/96 --_.---- .------- AJ J. ~01 I.jJ, -t-y~jJJJ1 fr~ H I R CO NU 1 000013682 ACCOUNT BALANCE 887.00 696 MEDICARE FC=A PT TYPE=S IF PAYMENT HAS BEEN .00 MADE, PLEASE DISREGARD. . , . UntIl your .nlurance has paid. the PLEASE PAY THIS AMOUNT represents the balance .....e estimate you o.....e. My balance unpaid by your Insurance will be due from you... Thank you. . -. ...-..------- . .j " J';",' ,/ .' > . ..-' -~ . _~-~.-..4-:- _~~ _ _ 1:" .,V Ulllhlll'l ~~ (OI,lM()t.j""'f"lltlQf'ftd4"j"''''11'' I..HI.nANCI 'AllnUIN IIIIDIHtC..ClDIHf SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER 2196-0950 AGNES WALnURN, DECEASED ITEM NUMBER NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP A. Taxable BequtUh: 1. Helen J. Botchie 138 Wheaton Dr., Litt1estown, P~ 17340 Niece and Goddaughter 2. Dorothy Tucci 800 E. Bobier Dr., Apt. D-3, Vista, CA 92084 Niece and GOddaughter 3. Dolores T. Miller 6273 South Highlands Circle, Harrisburg PA 17111 Niece and GOddaughter 4. Dolores T. Loncar Niece 394 Chambers St., Stee1ton, PA 17113-28 1 ITEM NUMBER NAME AND ADDRESS OF BENEFICIARY B. Charitable and Governmenfal Bequesh: 1. None TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Allo enter on line 13, Recopilulolion) (If more space Is n.edld, Insert addltfonalsh.... of sam I sill) AMOUNT OR SHARE OF ESTATE $10,000 nequest+ One-third (1/3rd) share of residue of Estate $10,000 Bequest + one-third (1/3rd) share of residue of Estate $10,000 Bequest + one-third (1/3) share of residue of Estate $10,000 Bequest AMOUNT OR SHARE OF ESTATE $ 0.00 s . e--- /s- IY/ ./,/ BUREAU OF INDIVIDUAL TAXES INIIERl UNC[ lAIC DIVISION DEPt. 180&01 tlARRISIURC. PA I1Ua-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE DF INNERITANCE TAX APPRAISEHENT. ALLOWANCE DR DISALLDWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX DOLORES T LONCAR 394 CHAMBERS ST STEEL TON DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 04-2B-97 WALBURN 11-01-96 21 96-0950 CUMBERLAND 101 Anount Ranitt.d PA 17113 c-- ;~~\ .r'.lhIU'" III.'" AGNES 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 ~ iiE'y:i5'4YEx-iiFi>ufo3":muNoricEuOFufNHEififilNCE-i''Ax-A"PPRA"isEHENr-.--iiL.i."owiiN'cE-olim---u--m-m DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF WALBURN AGNES FILE NO. 21 96-0950 ACN 101 DATE 04-28-97 If an assessment was issued previously, lines 14, 15 and/or 16, 17 and 18 reflect figures that include the total of Ahh rBturns assessed to date. ASSESSMENT OF TAX. IS. Anaunt of Line 14 at Spousal rat. 115) 16. AMount of Line 14 taxable at Line.l/Cla.. A rat. (16) 17. Anount of Lin. 14 taxable at Collateral/CI... Brat. (17) 18. Principal Tax DUB TAX RETURN WAS: I X I ACCEPTED AS FILED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON. ORIGINAL RETURN 1. Rool E.toto ISchodulo AI III 2. Stock. and Bond. (Schedule 8) (2) 3. Clo..ly Hald stock/Partnership Inter..t (Schedule C) (3) 4. Mortgage./Hot.. Receivable (Schedule DJ (4) 5. Cash/Sank Deposits/Hllc. Personal Property (Schedule EJ IS) 6. Jointly Owned Property ISchedul. f) 16) 7. Transfers ISchadul. G) 17) 8. Total Ass.ts I CHANGED .00 .00 .00 .00 51.355.26 996.00 55.303.55 181 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funaral Expens.s/Adn. Costs/Hisc. Expenses (Schedule H) 19) 10. Dobts/Hortgogo Llobllltlo./Llon. ISchodulo II 110) 11. Totol Doductlon. 12. H.t Valu. of Tax R.turn 13. Charit.ble/Govern~ent.l Bequests ISchedule J) 14. Het Valu. of Estate Subject to Tax 10,004.36 4.152.00 1111 1121 1131 1141 NOTE: .00 X .00. .00 X .06. 93.498.45 X .15. 1181 TAX CREDITS: PAYHENT DATE 01-29-97 DISCOUNT 1+1 INTEREST/PEN PAID 1-) 701.24 RECEIPT NUHBER AAIB5120 AHDUNT PAID 13,323.53 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE HOTE: To insure proper credit to your account, subnit the upper portion of this forn with your tax paynant. 107.654.81 14.1~6 36 93.498.45 .00 93,49B.45 will .00 .00 14.024.77 14.024.77 14,024.77 .00 .00 .00 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCOLATIDN OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN .1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI. YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF TNIS FDRH FOR INSTRUCTIDNS.I .. ~. ... ~. r.......- ~ # ~ .' :l ~i 1 ,,' I':J ..j RESERVATION I E.I.tl. of dlcldlnt. dying on or b.forl O.c..blr 12, .982 -- If any future Int.r..t In thl I.tall I. tran.f.rrld In PO..I..lon or enJoy.ent to Cle.. a (collal.ra.) bln.flcJarJI. of the d.c.d.nt aft.r thl I.plratlon of any I.tatl for Ilf. or for YI.r.. the Co..onw.allh h.r.by ..prl..ly r...rv.. Ih. right to appral.. and a..... tran.f.r Inherltancl T..I. It the lawful CI... . (coll.t.r..) rat. on any .uch fulurl Interl.t. PURPOSE OF NOTICE: PAYJtENTI REFUND (CA) I OBJECTIONS: ADftIN ISTAATIVE CORRECTIONS I DISCOtltTI PENAl TV: INTEREST I To fulfill thl rlqulr...nt. of s.ctlon 2140 of Ihe Inh.rltanc. and E.tat. 'a. Act, Act 21 of .995. (12 P.S. S.ctlon 91"'0). D.t.ch the top portion of thIs Notlcl .nd .ub.lt with your pay.ent to Ih. R.gI.I.r of Will. prlnt.d on thl r.v.r.. .Id.. --"eke chick or .un.y ord.r p.yabla 10: REGISTER OF MILLS, AGENT A r.fund of at.. crldlt, which wa. not r.qu..I.d on tha Ta. Return, .ay b. raqu..t.d by coapl.tlng an ~Appllcatlon for R.fund of P.nn.ylvanla Inhlrltanc. and E.t.t. T..~ (REV-15IS). Appllc.tlon. .r. .vallabl. at Ih. Offlca 0' the Rlglstlr of Will., any of the 25 R.vlnu. District Office., or by calling the .p.cl.1 Z"'-hour an.werlna .ervlce nu.b.r. for for.. ord.rlng: In p.nn.ylvanla 1-800-362-ZD50, out.ld. Pann.ylvanle and within lac.1 Harrl.burg araa (111) 181-8094, TOO' (111) 112-2252 (H..rlng r.palr.d Only). Any p.rty In Intar..t not ..tl.flld with the .ppr.I....nt, allowance or dl.allowanc. of d.ductlon., or ...e....nt of t.. (IncludIng dl.count or Inl.r..t) a. .hown on thl. NotIce .u.t Object wlthJn .I.ty (60) d.ys of r.c.lpt of thlt Notlcl by: ..wrltt.n prot..t to thl PA D.p.rt..nt of R.v.nu., Bo.rd of Appe.l., D.pt. 281021, H.rrl.burg, PA -.Il.ctlon to have the .ettlr daleralnad at audit of Ihe account of Ihe parsonal rapr...nt.tlv., uapp..1 to the Orphans' Court. 11128-1021, OR OR Factual .rrors dl.COVlrld on Ihl. ........nt .hould bl .ddrl..ed In wrItIng tal PA Oep.rt..nt of Rlvlnu., Bureau of Individual T...., ATIN: Po.t A.......nt R.vl.w unIt, D.pt. 280601, H.rrl.burg, Pi I11Z8-0601 Phon. (111) 111-6505. S.. pagl 5 of the bookl.t ~rn.tructlans for Inherltanc. T.. Rlturn for a R..ld.nt DIC.d'nt~ (REV-ISOI) for .n ..planatlon of ed.lnlstratlv'ly corr.ctabl. .rrors. If any ta. due Is p.ld wllhln thr.. (3) cal.nd.r .onth. .fl.r Ihl dec.d.nt'. d..th, a flvl p.rc.nt (5X) dl.count of the t.. p.ld Is allow.d. The 15X t.. .~.ty non-p.rtlclp.tlon p.n.lly Is cOlputad on the tot.1 of the t.. and Interl.t .......d, and not paid bafar. Janu.ry 18, 1996, the flr.t day .ft.r the and of tha t.. a.n..ty p.rlad. Thl. non-participation penalty Is app.alabl. In Ih. .... ..nnar and In the the .... tl.. p.rlod a. you would app..l the t.. and Int.ra.t thet h.. bean .......d a. Indlcaled on Ihls notlca. Interut It ch.rged blglnnlng with flr.t d.y of delinquency, or nlna (9) .onth. and an. (1) day frol the date of death, to thl date of p.yaant. T.... which bee... d.lln~nt b.fora Janu.ry 1, 1982 b..r Int.r..t at the r.te of .1. ('X) percent par annul calculal.d at a dally r.t. of .00016.... All t.... which b.ca.. d.llnqulnt on and .ft.r January 1, 1982 will baar Int.r..t .t a rat. which will vlry fro. cal.ndar ya.r to c.lendar y..r with that rata announc.d by the PA Oapart..nt of R.v.nu.. Th. .ppllcabl. Int.r..t rat.s for 1982 through 1991 .r.: '!!!! Int.rut Rat. Dally tnt.rut FActor ~ Int.rut Rat. Dally Int.r..t Factor 1982 ZOX .00G54a 1981 .~ .000241 1983 1'~ .OOOUI 1981-1991 l1X .000501 1984 II~ .000301 199Z .~ .0002...1 1.15 IS~ .000356 1995.199lt 1X .000192 1986 lOX .000214 1995.1991 .~ .00020 --Int.ra.t Ie c.lculat.d .. follow'l INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X OAILY INTEREST FACTOR --Any Notice I"\lad .ft.r the ta. baeo.u d.Unquent will r.fl.ct an Int.rut clltculltlon 10 flfteen CIS) day. beyond thl data of tha .........,t. If p.~ent It .ad. aft.r the Jnl.rut co..,utatlon date ~ on tha Notlc., additIonal Intlr..t ault b. calculetld. l,' . i,~ _...i_, , " ,t~_ .".... ;i,-', . ' ~ ~ i.,' ~.','- ',. ~ .:~ Ii. ,.',~ . , ..; .~ d '/ .. ,~- ...', ,0 .,..-. '... ~.. '>'; .. :-;t.:,'", .. m '~ . CII a 't;l " ~ e Illo ~ 0 .~ ~ "'~ ",,' ,.,. .. ',' "'''''( . 11... ....1.- R( oj '.'.',1):; '97 JlIN 27 1111 :58 Ch::11 CUlT;!' IlQ CII IlIl IlQ t1 lIll , ': :.-u.U ':-ul1 " rJ'A l.,::'.! r ';, ~ ESTATE OF AGNES WAI,1IURN, DECEASED, late of Lover Allen Tovnship, Cumberland County, Pennsylvania IN TilE COllRT OF COMMON PLEAS CUM1IY-RI.AND COUNTY, PENNSYLVANIA ORPIIANS' COURT DIVISION No. 1991i-00950 RELEASE I, the undersigned, being an heir of the ESTATE OF AGNES WALBURN, DECEASED, do hereby acknowledge that I have examined and inspected the First and Final Account and Proposed Distribution of Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, and I hereby accept and approve such to be a true and accurate accounting with the same force and effect as if it had been duly filed in the Office of the Register of Wills and audited by t~e Court of Common Pleas of Cumberland County, Pennsylvania, Orphans' Court Division, and requirements of filing and advertising said Account. I also acknowledge that I have received of and from Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, the sum of $ 23,569.76, in cash, as per Account, in full satisfaction and payments of the amount inherited from the ESTATE OF AGNES WALBURN, DECEASED, with the same effect as if it had been duly awarded to me by the Court of Common Pleas of Cumberland County, Pennsylvania, Orphans' Court Division; and, therefore, I, for myself, my heirs, executors, administrators and assigns, do by these presents, remise, release, quitclaim and forever discharge the said Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, her heirs and assigns, of and from all actions, suits, payments, accounts, reckonings, claims and demands, whatsoever for or by reason thereof; anc I hereby agree that in consideration of the promise of the other heirs, to refund to the said Estate, pro-rata, any amount which may be necessary in the future to discharge any liabilities of the Estate of which we may hereafter receive any notice. IN WITNESS WHEREOF, and intending to be legally bound hereby, I have hereunto set my hand and seal this )/ day of June, ~.D. 1997. WITNESS: ,,~ + !,' 1,. 1.AA..:f-II.;1 ~jl/_~1_?,I/J . , 'oAZi . " \ " " _~c,.'-" lelen J. (, ))' \ ' - . . ~. ~. - 1-{~_/L-":"'-' (SEAL) chle .. -. ...-. COMMONWEALTH OF PENNSYLVANIA ) ) 55. ) COUNTY OF On this i I day of June, 1997, before me, a Notary Public, the undersigned officer, personally appeared Helen J. notcbie , known to me (or satisfactorily proven) to be the person whose name is subscribed to the within ReleaBe, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. I.., ! .j:; ( " ,jJt..... . . ~. ~lli;r /l? .I? la.A- Notary Public NOTARIAL SEAl. DAWN M. MUIR. Nola." "'hie Will Manheim Twp.. ,CMtl ~ Pol My Comr-t I~n &-.p&r. 1M, 11, 2000 ESTATE OF AGNES WALIIURN, DECEASED, late of Lover Allen TovnBhip, Cumberland County, Pennsylvania : IN TilE COUIlT OF COMMON PLEAS CUMlIEIlI,AND COUNTY, PENNSYLVANIA OIlPIII\NS' COURT IHVISION No. 1996-00950 RELEASE I, the undersigned, being an heir of the ESTATE OF AGNES WALBURN, DECEASED, do hereby acknowledge that I have examined and inspected the First and Final Account and proposed Distribution of Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, and I hereby accept and approve such to be a true and accurate accounting with the same force and effect as if it had been duly filed in the Office of the Register of Wills and audited by t~e Court of Common Pleas of Cumberland County, Pennsylvania, Orphans' Court Division, and requirements of filing and advertising said Account. I also acknowledge that I have received of and from Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, the sum of $ 23,569.76, in cash, as per Account, in full satisfaction and payments of the amount inherited from the ESTATE OF AGNES WALBURN, DECEASED, with the same effect as if it had been duly awarded to me by the Court of Common Pleas of Cumberland County, Pennsylvania, Orphans' Court Division; and, therefore, I, for myself, my heirs, executors, administrators and assigns, do by these presents, remise, release, quitclaim and forever discharge the said Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, her heirs and assigns, of and from all actions, suits, payments, accounts, reckonings, claims and demands, whatsoever for or by reason thereof; and I hereby agree that in consideration of the promise of the other heirs, to refund to the said Estate, pro-rata, any amount which may be necessary in the future to discharge any liabilities of the Estate of which we may hereafter receive any notice. IN WITNESS WHEREOF, and intending to be legallY bound hereby, I have hereunto set my hand and seal this ~~ day of June, I\.D. 1997. (SEAL) r:-~ ." - - ~~~I~- - -I ~ @ COMM.11D26912 iO i .... Notlll'f NlIc - Ccllorria ~ IAN DlE~ COUNTY J ~ ~ : .~C~~.~~l~I~.1 EST~TE OF ~GNES W~LnURN, DECEASED, late of Lover Allen TovnBhip, Cumberland county, Pennoylvania IN THE COURT OF COMMON PLEAS : CUMIlERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION : No. 1996-00950 RELEASE I, the uncersigned, being an heir of the ESTATE OF AGNES W~LBURN, DECE~SED, do hereby acknowledge that I have examined and inspected the First and Final Account and Proposed Distribution of Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, and I hereby accept and approve such to be a true and accurate accounting with the same force and effect as if it had been duly filed in the Office of the Register of Wills and audited by t~e Court of Common Pleas of Cumberland County, Pennsylvania, Orphans' Court Division, and requireMents of filing and advertising said Account. I also acknowledge that I have received of and frOM Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, the sum of $ 23,569.76, in cash, as per Account, in full satisfaction and payments of the amount inherited from the EST~TE OF AGNES WALBURN, DECEASED, with the same effect as if it had been duly awarded to me by the Court of Common Pleas of Cumberland County, Pennsylvania, Orphans' Court Division; and, therefore, I, for myself, my heirs, e:cecutors, administrators and assigns, do by these presents, remise, release, quitclaim and forever discharge the said Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, her heirs and assigns, of and from all actions, suits, payments, accounts, reckonings, claims and demands, whatsoever for or by reason thersof; and I hereby agree that in consideration of the promise of the other heirs, to refund to the said Estate, pro-rata, any amount which may be necessary in the future to discharge any liabilities of the Estate of which we may hereafter receive any notice. IN WITNESS WHEREOF, and intending to be legally bound hereby, I have hereunto set my hand and seal this /7tAday of June, A. D. 1997. (;;.. (" C,-,-,--.) ,J ") It R e L'- Dolores T. Miller (SEAL) ESTATE OF AGNES WALBURN, DECEASED, late of Lover Allen Township, Cumberland County, PennsYlvania : IN THE COURT OF COMMON PLEAS : CUHBERLAND COUNTY, PENNSYLVANIA : ORPHANS' COURT DIVISION : No. 1996-00950 RELEASE I, the undersigned, being an heir of the ESTATE OF AGNES WALBORN, DECEASED, do hereby acknOWledge that I have examined and inspected the First and Final Account and Proposed Distribution of DOlores T. Loncar, Executrix of the ESTATE OF AGNES WALBORN, DECEASED, and I hereby accept and approve such to be a true and accurate accounting with the same force and effect as if it had been dUly filed in the Office of the Register of Wills and audited by the Court of Common Pleas of Cumberland County, Pennsylvania, Orphans' Court Division, and requirements of filing and advertising said Account. I also acknOwledge that I have received of and from DOlores 'T. Loncar, Executrix of the ESTATE OF AGHES WALBORN, DECEASED, the sum of $ 23,569.76, in cash, as per Account, in full satisfaction and payments of the amount inherited from the ESTATE OF AGNES WALBORN, DECEASED, with the same effect as if it had been dUly awarded to me by the Court of Common Pleas of Cumberland County, Pennsylvania, Orphans' Court DiVision; and, therefore, I, for myself, my heirs, executors, administrators and assigns, do by these presents, remise, release, quitclaim and forever discharge the said DOlores T. Loncar, Executrix of the ESTATE OF AGNES WALBORN, DECEASED, her heirs and assigns, of and from all actions, suits, payments, accounts, reCkonings, claims and demands, whatsoever for or by reason thereof; anc I hereby agree that in consideration of the promise of the other heirs, to refund to the said Estate, pro-rata, any amount which may be necessary in the future to diSCharge any liabilities of the Estate of which we may hereafter receive any notice. IN WITNESS WHEREOF, and intending to be legally bound hereby, I have hereunto set my hand and seal this /;' day of June, ~.D. 1997. WITNESS: /1 ~ /(~/e~~_a , ,"---I / ,n ~ g~ -;r--" ' ~ ~-L/ . ~~ -(SEAL) Helen J. B6tchie :. ' ',~ ~~ ~ . 'r' u:: ~ ESTATE OF AGNES WALBURN, DECEASED, late of Lover Allen TovnBhip, Cumberland County, PennBylvania : IN TilE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPIIANS' COURT DIVISION No. 1996-00950 RELEASE I, the undersigned, being an heir of the ESTATE OF AGNES WALBURN, DECEASED, do hereby acknowledge that I have examined and inspected the First and Final Account and Proposed Distribution of Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, and I hereby accept and approve such to be a true and accurate accounting with the same force and effect as if it had been dUly filed in the Office of the Register of Wills and audited by t~e Court of Common Pleas of Cumberland County, Pennsylvania, Orphans' Court Division, and requirements of filing and advertising said Account. I also acknowledge that I have received of and from Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, the sum of $ 23,569.76, in cash, as per Account, in full satisfaction and payments of the amount inherited from the ESTATE OF AGNES WALBURN, DECEASED, with the same effect as if it had been duly awarded to me by the Court of Common Pleas of Cumberland County, Pennsylvania, Orphans' Court Division; and, therefore, I, for myself, my heirs, executors, administrators and assigns, do by these presents, remise, release, quitclaim and forever discharge the said Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, her heirs and assigns, of and from all actions, suits, payments, accounts, reckonings, claims and demands, whatsoever for or by reason thereof; ana I hereby agree that in consideration of the promise of the other heirs, to refund to the said Estate, pro-rata, any amount which may be necessary in the future to discharge any liabilities of the Estate of which we may hereafter receive any notice. IN WITNESS WHEREOF, and intending to be legally bound hereby, I have hereunto set my hand and seal this /~ day of June, ~.D. 1997. UIJ}<- ('lfJ-I1;\. (SEAL) ro. .- :,--1 ~ ' - . j - - ~ ~ . A ~~ ~~ - - "I ~ @ COMM.lflll26912 I :$.. Nolay NlIo - CalIon*I ~ , IAN DGOCOUNIY - J~ _ ~ .~~~~~l~l~( '. ~ - -. ,-' ESTATE OF AGNES WALBURN, DECEASED, late of Lover Allen Tovoship, Cumberland County, Pennsylvania IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS' COURT DIVISION : No. 1996-00950 RELEASE I, the undersigned, being an heir of the ESTATE OF AGNES WALBURN, DECEASED, do hereby acknowledge that I have examined and inspected the First and Final Account and proposed Distribution of Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, and I hereby accept and approve such to be a true and accurate accounting with the same force and effect as if it had been duly filed in the Office of the Register of Wills and audited by t~e Court of Common Pleas of Cumberland County, Pennsylvania, Orphans' Court Division, and requirements of filing and advertising said Account. I also acknowledge that I have received of and from Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, the sum of $ 23,569.76, in cash, as per Account, in full satisfaction and payments of the amount inherited from the ESTATE OF AGNES WALBURN, DECEASED, with the same effect as if it had been duly awarded to me by the Court of Common Pleas of Cumberland County, Pennsylvania, Orphans' Court Division; and, therefore, I, for myself, my heirs, executors, administrators and assigns, do by these presents, remise, release, quitclaim and forever discharge the said Dolores T. Loncar, Executrix of the ESTATE OF AGNES WALBURN, DECEASED, her heirs and assigns, of and from all actions, suits, payments, accounts, reckonings, claims and demands, whatsoever for or by reason thereof; anc I hereby agree that in consideration of the promise of the other heirs, to refund to the said Estate, pro-rata, any amount which may be necessary in the future to discharge any liabilities of the Estate of which we may hereafter receive any notice. . , . \ IN WITNESS WHEREOF, and intending to be legally bound hereby, . I have hereunto set my hand and seal this /7f/lday of,;,une, I\.D. 1997. c ~. I .... . .;:? -. WITNESS: 1?r~ ( f.- CJ~U.I ,,7 >hLAr.c~ Dolores T. Hiller (SEAL) -.J