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PETITION FOR ..ROllA 1'E and (~RANT (n' I,ETTERS
Estate oj _h.2!ltfN.,,-5., (11/l~n_ .... No, ,aL=qrL::-_.LS:~_
also known as _.___..._.".,.. .".._. ....,.....". To:
___,,,. ,_.,,_______.._._.n__ Registor of Wills for the
_______.........__. _~ Deceased. County of .Ci/.ftjfj:.'Cf:!LAIQ...__ In tho
Social Security No. .1R.'l.:aS_ -:6J?.) '/._ .'n'.'_ COlllmonwealth of Pennsylvania
Tho potltlon of tho undorslgned rer.pectfully I'epre'onts that:
Your petltloner~ who is~18 years of IIge or older,an the exceut~___,
in the last will of the above decedent, dllted _~Cf'~_J.i
aud ,",vdldl(.1) ~ftted~
named
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(sIBle relevant clrcumSlances. e.g. renunciatIon. death of executor, etc,)
Decendent was domiciled at death in (' v 1"1 11(',(' I..lf.,fJ
~ last family or prin~ipal reside~e at ...-L.1 ~ -IS. LINE.
r (OU rlf /II'/neW 7U/1' I 7 if 5' 7 "
(list SHeet, numher and munclpallty)
Decendent, then 8-L ~ y-e~rs o~e, died R:/;{'",f'I''f) J , , I~_,
at __-L.1 7 Kl-ltVf' tJ1W Dt)"tIfI""'~l7JN Tw!'. -rX;;'i7f'r'-,/JW) ,
Except as follows, decedent did not marry, was not divorced and did ~v'e a child born or adopted
after execution of the will offeA1!f probate: wa,~ not the victim of a killing and was never adjudicated
Incompetent:
Decendent at dealh owned property with estimated values as follows:
(If domiciled in Pa,) All personal property
(l.f not domiciled in Pa,) Personal property In Pennsylvania
(If not domiciled in Pa,) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
County, pennsYI~anla"lth
f!()A () I r h ,(,w''''J !:i--
'),$0
S
$
$
$
WHEREFORE. petitloner(s) respectfully
prr<ented herewith and the granl of letters
theron.
requcst(s) the probate of the last will and codicll(s)
-r".s 7 >lMf C N'7'Itti?/
(leStamcmtarYi administratIon c,l.a.j administration d.b.n.c.t.a,)
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OATH 01<' PERSONAL REPRESENTATIVE
COMMONWEALTH 01<' PENNSYLVANIA }' 88
COUNTY OF -':.~r,V1l3e/0.JO__
The petitioncr~above.named swear(n or affirm(s) that the statements in the foregoing petition are
true and correct 10 the best of the kilOwledge and belief of petitioner~ and that as personal represen.
tative,l<lf of the above decedent pClitioner~ will :Vd\Zd ~uIY, ad,i,nij7I'thC es.tate according to law,
Sworn to 01' affirmed and;l; subscribed ,t~c.lbdl-;/r LY,.'<<'j'A:! __ Vl
before me this..:;::"r_LJ To _ dil of ' ~.
'~Av"1Mffi,;"~~~1J12/ ~:giSI c ~=_.._.__ !
No. __2=--?2..:J..~.__
Estate 0*' ~d.11tJ t ~', QI)/ de....
, Deceased
DECREE 01<' PROBATE AND GRANT OF U:TTERS
AND NOW --li~.b.'^~4~...l ~........~_.. 19. 77., in considcration of thc petillon on
the reverse side hereof, sallsfactory proof having been prcscnted before OlC,
IT IS DECREED lhal thc instrumcnt~ datcd_~/ha.ee. -13.1 179,)- ."
described therein be admilled to probate and filed of record as the last will of I-/'/(,;"~ $, (j,1';1l:"'~
and Letters J~(1.II1t",v7/J~L
are hereby granted to rI ef' bl'l'( 0. G?VIU<::
FEES
Probate. Letlers. Etc, " , , , , , ,. $ 25. 00
Short Certlflcates( 3) , , , , , , . . " $_ 9.00
Renunciation ...,....,.,.",. $
X-PAGES $15.00
JCP ~.OO
TQTAL_$ ij4.0Q..-,
Flied""" F,~mA~Y, ?Q\, m?,...."
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Mailed letters 'and order to attorney on 2-21-97.
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LAST WILL AND TESTAMENT
OF
LILLIAN s. QUICK
I, LILLIAN S. QUICK, of Cumborland County, pennsylvania,
being of sound and disposing mInd, memory, and understanding, do
hereby make, publish and declare this as and for my last will and
testament, hereby revoking all other wills and codicils hereto-
fore made by me.
FIRS'1'
I direct the paym9nt of my debts and expenses of my last
illness and funeral from my estate as soon after my death as
conveniently may be done.
If there be no cemetery lot available
for my interment, owned by me at the time of my death, I autho-
rize my personal representative to purchase such cemetery lot
wit.h a contract for perpetual care, using therefore funds from my
estate, in such amount as my personal representative shall
consider necessary and desirable, and I authorize my personal
representative to cause title to or ownership of such lot so
purchased to be vested in such person as my personal representa-
tive shall designate.
Further, in this connection, I authorize my personal rep-
~ resentative to expend funds from my estate, in such amount as my
J
personal representative shall consider necessary and desirable,
for the purchase, erection and inscription of a suitable marker
for my grave.
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SECOND
I give and bequeath all tangible personal property owned
by me at the time of my death, together wi th all insuranoe poli-
aies thereon, unto my spouse, HERBER'l' G. QUIC!( I if he survives me
by siKty (60) days.
Tl-IIRD
I give, devise and bequeath all the rest, resi,due and
remainder of my estate unto my spouse, HERBERT G. QUICK, if he
survives me by sixty (60) days. In the event he fails to survive
me by sixty (60) days, I give, devise and bequeath all the rest,
residue and remainder of my est.ate unto my daughter, LILLIAN F.
QUICK, if she survives roe by sixty (60) days. In the event she
fails to survive me by sixty (60) days I give, devise and be-
queath all the rest, residue and remainder of my estate, in equal
shares, unto such of my daughters [MARGARE'l' A. GILMO,U R, JUDITH M.
JEFFERS and STARR E. QUACKENBUSH] as survive me by sixty (60)
days.
FOURTH
I direct that any and all Inheritance, Estate and Transfer
Taxes imposed upon my estate passing under by will or otherwise,
shall be paid out of the principal of my residuary estate.
FIFTH
In addition to the powers conferred by law, I authorize my
Executor I in his or her absolute discretion:
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(a) to retain in the form recei vod, and to sell eHher at
pUblio or private sale any r.eal or. personal property;
(b) to manage real estate;
(c) to invest and reinvest in all forms of property
without bei.ng confined to legal investments, and without regard
to the principle of diversification;
any option or rights arising from
(d) to exercise
ownership of investments;
(e) to compromise claims without court approval, and
without the consent of any beneficiary, and to abandon any pro-
perty which, in my Executor's opinion, is of little or no value;
(f) to join with my spouse, HERBERT G. QUICK, or my
spouse's personal representative in the filing of any state or
federal income tax return for any year for which I have not filed
such return prior to my death, and to consent to the treatment of
any gifts made by my spouse as being made one-half by me for gift
tax purposes notwithstanding the fact that such action may result
in additional liabilities for my estate. Any income or gift taxes
,,\
~~_~ due on such returns and any deficiencies, interest, penalties or
.)
refunds thereon, shall be allocated between my estate and my said
spouse or my spouse's estate, or all to any of them, in such
manner as my Executor and my said spouse or my spouse's personal
representative may agree.
SIXTH
Any and all payment or payments of any sum or sums,
whether in cash or in kind and whether for principal or income,
payable to the said beneficiaries or any of them, shall be made
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upon the sole receipt of the respectiv~ individual to whom the
payment is made, and free from anticipation, alienation, assign-
ment, attachment, and pledge, and free from control by the
creditors of any such beneficiary.
All shares of principal and
income herein given shall be free from anticipation, assignment,
pledge, or obligations of any beneficiary, and shall not be sub-
ject to any execution or attachment.
SEVENT;H
I nominate, constitute and appoint my spouse, HERBERT G.
QUICK, Executor of this my last will and testament. In the event
of the renunciation, death, resignation or inability to act for
any reason whatsoever of my said spouse, I nominate, constitute
and appoint my daughter, LILLIAN F. QUICK, Executrix of this my
last will and testament. In the event of the renunciation,
death, resignation or inability to act for any reason whatsoever
of my said daughter, LILt,IAN F. QUICK, I nominate, constitute and
appoint my daughter, JUDITH M. JEFFERS, Executrix of this my last
will and testament. In the event of the renunciation, death, res-
ignation or inability to act for any reason whatsoever of my said
daughter, JUDITH M. JEFFERS, I nominate, constitute and appoint
my daughter, MARGARET A. GILMOUR, Executrix of this my last will
and testament. In the event of the renunciation, death, resig-
nation or inability to act for any reason whatsoever of my said
daughter, MARGARET A. GILMOUR, I nominate, constitute and appoint
my daughter, STARR E. QUACKENBUSH, Executrix of this my last will
and testament.
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
(OMMONWr^lTH Of l'f_NN$YtVAt~I^
I1fPARlJMNl 0' krVrNUr
pCF'l1nOtm
11ARR1SeURO, PA \11'9.060\
.------ -tMtolNi-;~--N1Mf--iiAil.' iOO1~^-~DMli,bir--iN;I;Alj- -=.::~----;
(,luick, Lillian S,
~('^;~~~Q~~~_~O~ ,_ ',_,' " _..r~;~D)~~~
11' AmlcA'111 ~VRVlVlNu $POl/M'$ NAMlllA.~! ".SI ....Nt> MllllllllNlllAl1
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Full/fit Inhmat Compromito
lfor dole$ of cleolh af10r 12.12.82)
Decedent Died T eUalo [] 7 Oocodllnl Maintained 0 living Trull
(AHoch copy of Will) (AtICl<h <::opy of TrUll)
llRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO,
.. ----- -- coMmh MAILING ADDR~5S
Richard L, Bushman, Esquire 1",0. Box !jl
ffi{~HONfNUMiER""-"'" ~----._-"---------------------- Spr i ng Run, PA
717 349-7657
.J _ L __ _-cc,,""~__~_~=-====_=,=_==_=,==,~,_~_~_"
(1)___
(2) ._.".___
13) _._____ _~_
14) n _ _____ _____,___,,____._ ,__,_
15 J - -.4339....5S..-------c-
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Original Return
IJ 2
[J 40,
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I 'OR OATIS 0' n.Alli IInlR 12/31191 CHICK HIRE
IF A SPOUSAL
POVIUV cUlm IS CIAIMID I I
fill NUM~IR
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YIAR
01',2
limited Estate
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ColJUTY (OPI
NUMBER
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1. R.ol "'0'. (Sch.dul. A)
2. Slocks ond 8ond. (Schedule B)
3. Closely Held Stock/Parlnership Inter".t ISchCldule q
4. Mortgages and Nole. Receivable (Schedule Dl
5, Cash, Bonk Depo5ih & Mi.collaneous Penonol Property
(Schedul. EI
6, Joln.ly Owned Prop."y (Sch.dul. f)
7, l,onll." /Sch.dul. GI(Sch.dul. l)
S, Total OroH Aueh (Iotal Unes 1-7)
9, Funeral hpemes.. Administrative COSh, Miscellaneous
EKpenStlS ISchedule HI
10, I>ebh, Mortgage liabilities, liens ISchedule 1)
11. Tolal Deductionl Itotol lines Q & 101
- n. r;[i'j-Mtil';<;.rol.;:rlt"i,. '\ilil~i' ~~
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12, Net Value of Estate lline a minus line 11)
13, Cnorltablf) and Governmentol BequllSts ISchedule Jl
14, Nel Value Subject to Tax (line 12 minus line 13j
15, Spoulal Tron.ferl (for dales of dflolh aftll 6-30.94j
See Insfruclio", for Ar,plicobll! Percentage on Reverse
Side, llndudo values rom Schfldule K or Schfldul" M.l
16. Amounl of line 1.4 tOKoble 01 6% role
(Include volues from Schedule K or Schedule M.)
17. Amovnt 01 line 1-4 IOKclbll) at 15% roJle
(Indud0 values from Schedule K or Schedule M.l
18. Prlncipalta)( due (Add lox from lines 15, 16 ond 17.)
19. CredIts Spousal Povllrly Crfldil Prior Payments
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12;:3/1',
I""''''''''''''''''''"''
Supplomllntal Return
13') 1\] jll" l\(lolL!
Sid VPUllf:.:')\H'~_1' PA
(O~lIlf' CumLH.'!:] dlld
-AM6IiNl ~U.fIVl'ilm ~ -it~~fIiU(ti6~ii) - - - nn -,-,---
"- .- -. ----"._--------~--<-~----------------- --...
r 1 3, RemaInder Relurn
/10, do.., of d.o.h prlol 1012.13,821
[] 5. Federal Estate Tax Return Required
+
] 7257
__ a, Total Number of 50fo OoposlI 80llen
n; t~,:,t);.,:-! _'J.-\!l \'~i ", i
17262-0051
16) -_._,,,__.___,_____
1 7 ) ________
1 9 ) __!.~~_!9~~.,.____ _.__
(10) '..m~,284. 25
18)
2,339.58
(111
(12)
(13)
(14)
5,394.7L______
0.00___
----.-----. '\
0.00
115) ____________~,_,..
(16)________,,_.~__.___,_,_,_~ ,06..
(17) .._
.~~__._l( .15 =
(18)
Discount
Inlerest
+
(19)
120)
20, If Untt 191s grflotor than line 18, enter the diffftrenc(J on line 20. This Is Ihe OVERPAYMIiNT,
m
~ C eck hllre if you orc rl!' uesting 0 rcfvnd of your overpoymer,t
21, If line 18 i. groohn than Une 1 Q, enler the difference on line 21, Thi~ i. the T AX DUE, 121} 9 !'_Q9______..
A. Enter the inlfHflst on the balance dU6 on line 21A. (2IA) "U"._ __ __________
B, Enter lhl'l lotal of Un/! 21 ()nd 21 A on Une 21 e, Thi, is Ihe BAlANCE DUE. (218) _ __ _ __ _____D...QO...
Ma~. C~~.~_k,,~_~y'~~bl. tOI _RIgl~!~! of Willi, AGln' _ ._. _ ...
rr<-'~--::' ~'v,:" ~)o- - BE SURE TO ANSWER ALL QU~STIONS ON-liEVEiiiE~'ID~ AND TO RECHECK MATH <0( <0('",;'1:'
Undftr penallitu of perjury, I dedorB thot I hove eKomlned this relurn, inclllding Q(Componylng $Chodu/lls and Uotemenh, and 10 thfl bel' of my knowledge cmd belie
It is true, carr eel and complete. I dedof, tlHlt 011 rfHlI I'15tole has been reporlfld ot Irllfl marke! volvo Declarallon of preporer olhor lhon the personal repreil'lnlolive
~~~_~.on alllnlormotlon..et~i,\'hich prep Hit tlm ony knowledge,
SlONA1"UIl Of rf,,~SON-;:>=o1bH~ltt~'fO.fflf-- G!if"fl!RN;----- - -:---AOO.RES-f------ ,,-- --_----- - -- o-":lr ..... --...-.....,. ._._,..~~_.._-. .
i ,- I"d! ,; . ',_ f ,'I, ",;C 139 I\J im' Hc1" Sid 1'1"'l1sbury, I'^ J 72',7
SIONATUlH Of PR ~fR 0 fll T "~" " 1\1IY[ .L -A[IORTSS-'---
If? PO Box 'ii, SIJr1n(1 l~lJl1, I'^ 172(,)
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Act '48 of 1994 provide. for the reduction of the tax rate. Impo.ed on the net value of tran~fer. 10 or for
the u.e of th. .pou... The rate. a. pr..crlbed by the .tatut. will b.1
e 3% (.03) will b. appllcab1. for ..tale. of decedenll dying on or after 7/1194 and b.fore 111196
· 2% (.02) will be applicable for .states of decedenll dying on or after 1/1196 and before 111/97
· 1% (.01) will b. applicable for ..tat.. of decedonll dying on or after 1/1197 and before 1/1/98
· Spousal tran.f.,. occurring on or after 1/1/98 will be exempt from Inher!tance tax.
PLEASE ANSWER THE FOLLOWING QUESTIONS
BY PLACING A CHECK MARK (~) IN THE APPROPRIATE BLOCKS,
1. Old decedent make a transler and:
a. retain the use or income 01 the property trunslerred, .......................,........,........,............,
b. retain tho right to designate who shall use the property translerrod or its income, ....,....".."
c, ret.:Jin a reversionary Interest; or ....,....................,....,..,......,........................"..........",..,
d, ,receive the promise lor Ille 01 either payments, benelits or care~ "",....,.."",.."....,,,,,,....,...
2, If death occurred on or belore December 12, 1982, i did decedent within two years preceding
death tronsler property without receiving adequate consideration' II death occurred alter
December 12. 1982, did decedent transler property within one year 01 death without receiving
odequate consideration' .,.,..,',..,',.,.,.,',..,........,.,......,..,...,......"."........"".."".,.., '" ........,..,
3, Old decedent own on 'in trust lor' bank account at his or her death"'........,..............""'.."""
YES .1:!Q_
x
x
x
x
x
.
x )
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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LAS']' W .II,']. ANI:> '.I'Ii:S'I'AMF;N'I'
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QUICI<
I, LILLIAN S, QUICK, of Cumberland County, Pennsylvania,
being of sound and disposinq mind, memory, and understanding, do
hereby make, publish and declare this as and for my last will and
testamont, hereby rcvokinq all other wills and codicils hereto-
fore made by me.
FIRST
I direct the payment of my debts and expenses of my last
illness and funeral from my estate as soon after my death as
conveniently may be done.
If there be no cemetery lot available
for my interment, owned by me at the time of my death, I autho-
t
rize my personal representative to purchase such cemetery lot
with a contract for perpetual care, using therefore funds from my
estate, in such amount as my personal representative shall
consider necessary and desirable, and I authorize my personal
:.;
'" representative to cause title to or ownership of such lot so
..~
~ purchased to be vested in such person as my personal representa-
tive shall designate.
"
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Further, in this connection, I authorize my personal rep-
resentative to expend funds from my estate, in such amount as my
personal representative shall consider necessary and desirable,
for the purchase, erection and inscription of a suitable marker
for my grave.
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I give lInd bequeath all tllngible pon;onaJ proporty owned
by me at the time 01 my death, together with all Insurance poli-
cies thereon, unto my spouse, HERBlm'l' G. QUICK, if he survives me
by sixty (60) days.
'rHIH.D
I give, devise and bequeath all the rest, residue and
remainder of my estate unto my spOllse, HERBERT G. QUICK, if he
survives me by sixty (60) days. In the event he falls to survive
me by sixty (60) days, I gIve, devise and bequeath all the rest,
residue and remainder of my estate unto my daughter, LILLIANF.
QUICK, if she survives me by sixty (60) days. In the event she
fails to survive me by sixty (60) days I give, devise and be-
queath all the rest, residue and remainder of my estate, in equal
shares, unto such of my daughters [MARGARET A. GILMO,U R, JUDITH M.
JEFFERS and S'I'ARR E. QUACKENBUSH] as survive me by sixty (60)
days.
FOURTH
I direct that any and all Inheritance, Estate and Tral1sfer
Taxes imposed upon my estate passing under by will or otherwise,
shall be paid out of the principal of my residuary estate.
FIFTH
In addition to the powers conferred by law, I authorize my
Executor, in his or her absolute discretion:
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(II) t.0 r."toll1 ill tho lorm l"""o!vo<l, /J11c1 to /loJJ ofthOl" lit
public or private sale any rOll I or porHonu1 proporty;
(b) to manage real ostllte;
(e) to invest and reinvest in all forms of property
without being confined to legal investments, and without regard
to the principle of diversification;
(d) to exercise
any option or rights arising from
ownership of investments;
(e) to compromise claims without court approval, and
without the consent of any beneficiary, and to abandon any pro-
perty which, in my Executor's opinion, is of little or no value;
),
(f) to join with my spouse, HERBERT G. QUICK, or my
spouse's personal representative in the filing of any state or
federal income tax return for any year for which I have not filed
such return prior to my death, and to consent to the treatment of
any gi.fts made by my spouse as being made one-half by me for gift
tax purposes notwithstanding the fact that such action may result
in additional liabilities for my estate. Any income or gift taxes
due on such returns and any deficiencies, interest, penalties or
refunds thereon, shall be allocated between my estate and my said
spouse or my spouse's estate, or all to any of them, in such
manner as my Executor and my said spouse or my spouse's personal
representative may agree.
SIXTH
Any and all payment or payments of any sum or sums,
whether in cash or in kind and whether for principal or income,
payable to the said beneficiaries or any of them, shall be made
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upon the nola receipt of tho ronpectivo Individual to whom the
payment is mads, and free from anticipation, alienation, assign-
ment, attachment, and pledge, and freo from control by the
creditors of any such beneficiary.
All shares of principal and
income herein given shall be free from anticipation, assignment,
pledge, or obligations of any beneficiary, and shall not be sub-
ject to any execution or attachment.
SEVENTH
I nominate, constitute and appoint my spouse, HERBERT G.
QUICK, Executor of this my last will and testament. In the event
of the renunciation, death, resignation or inability to act for
any reason whatsoever of my said spouse, I nominate, constitute
and appoint my daughter, LILLIAN F. QUICK, Executrix of this my
last will and testament. In the event of the renunciation,
death, resignation or inability to act for any reason whatsoever
of my said daughter, LILLIAN F. QUICK, I nominate, constitute and
appoint my daughter, JUDITH M. JEFFERS, Executrix of this my last
"
,
will and testament. In the event of the renunciation, death, res-
ignation or inability to act for any reason whatsoever of my said
daughter, JUDITH M. JEFFERS, I nominate, cons,ti tute and appoint
my daughter, MARGARET A. GII.,MOUR, Executrix of this my last will
and testament. In the event of the renunciation, death, resig-
nation or inability to act for any reason whatsoever of my said
daughter, MARGARET A. GILMOUR, I nominate, constitute and appoint
my daughter, STARR E. QUACKENBUSH, Executrix of this my last will
and testament.
4
, -~-.
. , ~ '
RECEIPT FOR MISC. INCOME
~~_~~~~~~~~~n=~~~~~~=~~~
2/13/97
9120149
1010513
cumber.land county - Register Of Wills
Hanover and High street
carlisle, PA 17013 '
Receipt Date
Receipt Time
Receipt No.
HOUSE ACcoUNT
File Number 1997-99999
RemarkS COPIES
------------------------
Distribution Of Receipt ------------------------
payment Amount Payee Name
1.50 CUMBERLAND COUNTY GENERAL FUND
-n.:lO
$1.50
,
I
\
Transaction Description
MISC. INCOME
Chec1dl 4757
Total Received.........
<,,, -
c1 ' ~.li,:-~'''':' - :U.n"'~:;rH..:,'thc;r.:-:l-,~iTr;..;';';Xt';'~. +L;"-i,', ~;,
,..;'/ _,' .fl., : ,':ii.;.- ''''" , ' ,': FlW',~_""""_' ,",:1>, ;,_;:~",,-,:'":,
,',' "',"1',0,110)( looe8 ,,' ','''' ,"."'( ';
(" ' AUGUUAi' QA i":1I0.0I~08U ,'; H.!, ",c. ''" .
, 1:' """: i:,i;f;';i:!,FV:Y' '"
O:ll:r '\:-' i'N~_ '- '" ~ML~;>tt}-~,~I;(_:t:4""<;i?"'::::' ",i}.:~~-;_~,:,h.,..1tl-~~r
':~~:~-"i.;,'"",""'l':~'- 1~' f: ti.t~::O': t-::Vo;';:'-u:-"';;';~,.~;,:'<(ii~r:(""" ,
(,t"lf:!U" '_.JXP (lll.t Oll,.b'WM~t%,:;.,f.,}i:;!;.:.'?)~,,;~^,,,,
':i Mcdicare:J)ad n13eild'its" '::',~k.i..
, _ ,_. 1lIii\!~1
, ,;', ! ,,', i, " . r ", \ ' , I, ~ . "1\ ' ,," L
'f ,< vi
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Sllfl111lnl~' oflhl~ nollcr dnll'd Mn.' 05 1997
.,,-,..,-~--'~~~---~-
",
,
LI LLI AN S QUICK
139 KLINE RD
SHIPPENSBURG, PA 17257
(.',<:,/
'-;'~i' ,Ii,.
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t1
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~.iY,
'i'(.Y:'
73,84
18.46
i'",
," "~ -, " "
$21",00';-,
$ 92.30
Tola1 chnrRes:
TOlal Medicare approved:
,'.\ '_I; ',.
We paid your provider:
YOtll' totnl I'e~ponsibllity:
Ii
',' :1'1
"1.111"
$
$
,
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.' 1 ;~,', r\, 1 _',
. l' !, ,_I,,',
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YOIII' Mcdknrr number Is: MA.063.03.4II9
YOIII' provider nccepled n~slgnment.
-
I)etlllls eboul tbls 1I0llce (See the back for more lnformntlon.)
'J!l;
"..
BILL SUBMITTED BY:
Mailing address:
RWC EMERGENCY PIIYSICIANS,
13 BROOKWOOD AYE, (/3,
CARLISLE, PA 17013
Sl'r
Notes
Del~'
Dntes
Services end Sen'lee Codes
Control ilUmber 970,,9:0218600
GERALD FRONKO M,D.
1 Emergency dept visil (99284)
1 Rhythm Ecg;report (93042-WJ )
Total
~. Medlenre
Charg€:,..Illflll\1lf\.pprnved
.~
$
;
$
82.79 a
9.51 ,a
92.30
Dee 11,1996
Dee 11, 1996
$
+
$
180.00
37,00
2 'i7.06
NOTES:
l'c(, [- 3- /11,
(I.k, ;-11 /;,3
;1.t/6
II The approved amount is base,d on the fee schcdule,
GENERAL INFORMA TlON ABOUT MEDICARE
\
If y,ou make a permnnent change in your addrcss please contact your local Railroad Retirement Board Office,
--1'\ ,
Medkafe covers vaccinations to prevenl pneumococcal pneumonia. If you've never had a pnc,umocoeeal
pneumonia shOI, protc,et yourself and gel one now, If your provider accepts what Medicare pays, there
shouldn'i be n charge 10 yon. " '1' '
,:!
The Medicare Division of MetraHealth has become the Medicare Division of United HealthCllre
Insurance (:Ompany, You will notice the United HealthCare namc being uscd in sla(emeQts
and mailings from lIS, Office locations, phone numbers, and starr members will remain the same,
This ehllnge will not a[[ect your coverage. " ,
IMPORTANT: H)'ou hlll'c qucstlons ahoulthls nollCI', call thc Medklll'I' cllITler al {Jolted HcaltltcAI'c Ius CO, III
1.800.~3"44SS or srI' liS IIt27431'erlmetrr l'nrk\\'lI)', Augusta, GA 30909.4S76, You will need this notk!'
II you contact us,
To uPPI'RI OUI' dt'dsloll, )'011 mUst I\Tltc loU, brlo!'r SI'ptrlllbl'r OS, 1997, St'r #2 outhl' bark.
-
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,\,:'~":\ ,r~I;;j.fI~J:li~<"i: R,l!!n.tll,1 ",(I $1 0" '"i AC,I,I
" "I,il, '.'\ "tlI" 0;,',
~"', h "t:~':'i";. .. ~:':"- '1'" ~_,oIl ;', ':"\!l.'<'., ' 'I'" ' ':,j(',:~
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, .' ~/ Unt t.d HealthCaNl 11'.00., \'i~r~ij' /, .
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-
THIS IS NOTA lULL
Explanation of Your
Mec1ieare'P~lI't n Benefits
"
SumIllUI:L''i!!!!,-~!!lIee dl!h'd M..!,,' 05LI991
LILLIAN S QUICK
139 KLINE RlJ
SHIPPENSBURG, PA 17257
Total ('har~~e!): $ 54,00
To'al Medica", approved: $ 54.00
We paid your provider: $ 43,20
Your tolal re'pon,ibilily: S 10.80
, ;.,1,.,
Your Medleore number ISI MA.0l\3.03.4119
'Vour provider ~('cepted osslgnmenl,
.
Detolls about Ibis notice (See IbtbaclU!t..maHl tnformnllon,)
BILL SUBMITI'ED BYr BELVEDERE MEDICAL CORPORATION,
Mailing address: 850 WALNUT BOTI'OM RD,
CARLISLE, PA 17013
~ ,;i t'/ ' See
'I.' Medicare Nutes
Dules Services und Service Codes Cltu!'1l.!', Approved Below
(;onlrol numl)er 97037.3145800
IIAROLD G KRETZING
Jan 08, 1997 1 Nursing facility cnre (99301) $ 54.00 $ 54.00 a
. "
NOTES:
" JJ /,t, 0~Y t? 1/
a The approved nmount is lhe provider's nctual ehnrge for this service. (L:,:J / /
'l .
GENERAL INFORMATION AIlOUT MEDICARE ef{., /;'//6;/
,;, /c. 'i?o
H YOlllllake a permanent change in your nddress please contact yollt local Railroad Retirement Board Office.
'\;'1'
J!
";':, Medicare covers vaccinations to prevcnt pn'eumococcal pneumonia, H you've never hnd a pneumococcal
pneumonia shot, prolect yourseIr and get one now, H yom provider accepts whllt McdiCare pays, there
shouldn't be 8 charge to you. ' '~~''-''''__ ..'~
, . ~
The Medicare Division of MetraHealth has become the Medicare Division of United HenlthCare .
Insurance Company, You will noHce the United HcalthCare name being used in stntemenlS
and mailings from us, Orrico locations, phone numbcrs, nnd Slnff members will remain the same.
This change will not arrecl your coverage; 'I' .
. "
'J;'~n~:1it\i::'~.',J:~!\ ,. i~~~'i II' ;r; \",' ;\/~~:~,~t~3v~:1'
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"!~~'TM~bk~AN1::tr{ou ~nv~~~~~II~~~~(b~:I:;:i;~:'~~;tl~;~~J;~~'~~'~nrr'er at Jolled ~Iealtht~~ti;~~'~a,~iii k::.",
:.\' :,1.80o..!l3J-4455 or lee UI,I\1274.' ~erlUlelt~ I'Arkway, AugualA, GA 30909-4576, You will need thlinollee:/ii\"i:Cj , "
. "-",\ "ifyiJu tohtild "R.<::':-\:/',::)i::}:\L;X';Xr;C~;t7(tYF>-,::t~?~(~::.,':';-:,::': "'_:-', .', ,>,'" , ,'),::::< '_ :-.> t~rS;<i~(~"/r'::.':'
To appeal our decl8Iol\;}<iUf'lIl&t.m-lle toils before September 05, 1997, Set #2 on lite back, '"
""'~\\"'~;~I'" :'W~
ME"'''AHEAlTH'''
. .. ,
LXI'LANA TlON OF MEDICAL OENEIITS 1II1IIII11IilfliIIIIHiilliiliillli'iili'iil'l'llj'llllililiflfilll//"""'"
,".
I,^TE PROCESSro:
EMPLOYEE NUMOlR:
CI.AIM NtIMOER:
GROUI' /SUO:
CI.AIM YEAR:
PArIENT'S RIRlIIDATt:
PAGE 01 OF 01
MAY I, 1997
PAO03034119
KI70424339Hl-99
0030500/0090
1997
12/03/15
DEAR MR. fL QUICK,
WE RECEIVE~ A MEDICAL CLAIM rOR LILLIAN,
INFORMATION ON THIS FORM EXPLAINS THE 8ENEFITS PAYARLE UNDER YOUR STATE Of NEW YORK PLAN. SAVE
THIS rORM FOR YOUR TAX RECORDS. IF YOU HAVE ANY QUESTIONS AUoUT THIS CLAIM, PLEASE CALL OUR
TOll-FREE NUMOER 18(lo) 842-4840, OR WRITE TO THE ADDRESS AT TIlE BOTTOM OF THIS FORM, IN YOUR
LETTER, PLEASE REFER TO YOUR EMPLOYEE NUMBER, Cl.AIM NUMOER AND OROUP NUMOER StlOWN IN THE UPPER
RIOHT-HANo CORNER OF THIS FORM,
TOTAL EXPENSES SUBMITTED ON THIS CLAIM
OUR PAYMENT ON YOUR CLAIM
54.00
,DO
-~
;"'expense. ,,'::'e~p'~;.er Rttuctn LO.' . Ballnto Pl,n
III.erlpUo" of Sorvlco SUbtfJltt.d . I!xchldod' ,IS.. Not ooducUbl. CllIlIldorod % Baneflts
ITffilEll '~ . OOlowl ",,",,-, -
DR'S VISIT 54.00 54,00 245
U
L
r--
---.00
ll..\l.
o
NOTE 245 Pl.as. Submit the Medicare VOucher Indicating theIr payment or rejectIon on this charge,
Ple..e Ittlch I copy of thll statement to expedl te prooesslng of thll charge,
PLEASE NOTE IMpORTANT ADDitiONAL INFDI1MATlClNON REVER!lG SlOG;
, " "-"'<':,',',,:,,'-:::,; -,-- ,:"-"":::";:::,',;,-:-:,:,:,-:,,,,,,,,:-'" ", ,,'.., ',',',"
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NEW YORK STATt CLAIMS UNIT
METRAHE'AL TH SERVICE CORP"
ADMINISTRATOR FOR METLIFE
1', O. BOX lBOO
KINGSTON, NY 12402-1800
, .
LPSlF8 8W 02,,~
,y. ST.ATE OF .NEW. YORK
..;J'" 'I"~ '"
, METRAHEAL TH SeRVICE CORP.,
. AOMINISTRATOR FOR METLIFE
E...Q.. nnx L60Q
KINr.qnN, ta 12"M-lIlnQ
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H QUICK ...,. .
139' KLINE ROW
SHIPPENSBURG PA
',I
1725'7
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CUSfOMfR Sf:lt\lltE
ro DOX 09003.
CAMr HILL rA 17009-003.
Pcnl1sylvunla
Illll~~III~I(l
EXPLANATION OF BENEFITS
KEEP FOR YOUR 'I AX !{[COrlOS
.'
11111I Ihl.14tn4 ftlu.Cro.."ltnlo''''Mtyl''.IlII."lndlp'rldtm
I In".." \lllh. l'Hu. r'~""1d !lllll "hl.ld /l,uncJ.lI"" ."
Subscriber, IlERBERT QUICK ID Number, 06303(,119 Pagel 1 of
Patient, LILLIAN S QUICK ClAim Nu",hf>r I 9706(,062325 Dsh, 03/27/9'1
Provider. BELVEDERE MEDICAL CORP
(000037595)
__n,__
PROCEDURE DESCRIPTION
PROCEDURE CODE SERVICE PROVIDER'S ALLOHANcE AMOUNT PAID AHCUNI REIIARKS
(NUHBER OF SERVICES) DATEISI c!tARGE NOT PAID
---
HEOICAL cARE (001) 01/08/'7 54,00 ,00 ,00 5(..00M 50026
IUD1
,09
SD026
unable to identify' the patient from the identification number reported
Ploose verify the nome and numbor indicated on the identification cord,
patient is covered by us, please resubmit the claim,
We ore
above,
If the
M Vou owe THE PROVIDER for those amounts in the AMOUNT NOT PAID column followed by en
asterisk (M), Those amounts total $54,00 for this provider, Send this amount directly
to the provider.
-"
T',.
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IlERBERT QUICK
700 WALNUT BOTTOM RD
CARLISLE PA, 17013-3631:.
, '
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THIS IS NOT A BILL
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H~VE~A~QU~STION?
(Servito for the
N0010915
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1-800-3(,5-3806.,
at 1-800-3(,5-38(,8,)"
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: "r.' 'tW ~l,' ....v I'''' ",. . ," ., -,t ~f" I I 'I' .1,t1"','. , '
f' ~Vl'\r.,./(I ;" '." .<(+"1' ' I .,~r',',' t"::;"I":::,~',.",
, "1..1 I, ,ii" I,' ,,-(I (I " J 1',11. I ~\j'\"A '\ ' ,:1/,'-i...'~8(,!~I:I~~~:ir', ,;,
': ,~~:~ \l;'l~' ~L ,,',q;CUS,TOMER'S PUnCIiAS[: CONTRACT ,<\.:'" 'f;.\,!, ". "i~",/:~h ';:",,':""
. ,II ~ , 1/, ,W' "l"lt, "I'l' \ ' [) I ',.0.,'" Q'7
I~ ':. ,:,::;:m~~~~~~,.';;~i{~}AL 1I};~'; ING Am"SlmV;6;i:'-r-'-~~~~'i~~t-.
Stollelledge Square SIIoppl,1g'Ct'llIl'f, 950 Wt//1II1! !Jot/O/ll /I"tld, CmIiJII', PA /7013
I ~, "1
\ Ii:;; " :/4i,n;-/~;-, I'll, (7l(J 249.5436
I hereby purohase ItOm lho above Seller. now Hoarlng Aid and/or equlpmonl as follows:
" ' . . ,y' r ~
HEARING AID MODEL ,;' .' SERIAl. NUMBER BATTERIES
'"
(,
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.. '
, ,
ACCESSORIES
"
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For which 1 agroo to pay tho lo"ta.L~urr"'~I':'~! ' t -z _ 2.- i.. ~ -- SS ,~j
. - - ~jS;O.
---"::::':::":i~', ,"\1,',' Not purchaso prlco payable S [:.. 'if), ".~_.
"I have been tVls cl1';:t my basI interests would be servod If I had a medical oxamlnatlon by an otologlsl
or otolaryngologist or any IIconsed physician belore my purchaso 01 a hoarlng aid, ,
(' "q J, l-V I (\; It,ll ~1 (\IJh.s IUlly and clearly Informed me 01 the ulua 01 auch medical
examination. Alter such explanation, I vOluntallly sign this waiver. I chooso not 10 leok a madlcal oxarnlnatlon
belore the purch.se 01 tho hOlrlng .Id." '
, . '...; . :~;'J'!
':The purchaser has boon advlsod allha out sot of 1.ls rolallonshlp wllh Iho hearing aid dealer thaI
any examlnallon or ropresentallon'madll by a roglstorodhearlng aid dealor and flttor In connection with
the pracllce 01 fitting and soiling 01 this hearing aid, Is not an oxamlnatlon, diagnosis, or prescripllon by a
person IIcensod to practice medicine In this Commonweallh end therofore must not be regarded as
medical opinion," " '. "~'~,,
. I .:,
"If your rights aro violated you may contact the Slalo Buroau 0' Consumer Proloctlon or the
Pennsylvania Department 01 Health In Harrisburg or your local dlslrlcl attorney,"
Exocute In Duplicate Signature of purchaser
IhIS,~_ day of _::rfl'\) 19:11 Namo of purchasor --1 \('l<'i..I",/ 'i Dill I" II
IN tH\r\ ~NC O~ Homo Addross ..(:5.1- 1/ lll>,1 l~ (i (~ Sb':i!" ' \,
~uriE REGISTRANT'S REGISTRATION CERTIFICATE /I -Zllii..
C' 'oC\AA' , ',7,{"
~'rf-"':'"' '.rf!':.PI/'
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",:\.n ;.',,~. Thank you 'for "using Walnut"'Bottom'Rad,iology; ,
___"_---:~ 1 .' "',.1 , '
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ACCOLlNT NO '.. "",',..,A':"'1;\' S'ATEMEf<jTDATE: .,' ~'''t,'''''''': ' '" ACCOUNT BALANCE
_..~- -----.-.--.:!7'OG343 -------~_CJ/-J.4In..-,~-
()V oll,lel VIGil OH. OUT PAlILNl HOSPI1Al.
III "IN PA llf'.Nl 1I0SPl"1 Al Nli " r~unSltKI HOMe
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30,77
INSURANCE PENDING
.00
WALNUT BOTTOM RADIOLOGY
850 WALNUT BOTTOM ROAD
CARLISLE PA 17013-3698
PHONE (717) 245-2821
FED IV NO. 25-1675580
PA TlEN1 DUE AMOUNT
I'AYMEN1 DUE BY
30.77 I
04/04/9'1
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THIS IS NOT A HILL
Expl.anation of Your
Medicare Pnrt n Benefits
-
;II'? :
-
LILLIAN S QUICK
139 KLINE RO
SHIPPENSBURG, PA 17207
>)'.
I{
---_.~-<..._--'"...- -,...-.._-~----._._----
SU!!!!J1l1)'} of th!!.!1~1I,c,~II!!!l'J!J:"-~.lq1..19~1.
Total eh"r~cs: S 232,00
Totul Medicare "1'1""ve": S 0,00
We p"id your plovi"er: S 0,00
Your total rcsponsihility: S 0,00
, r,,"
Your Medicare number Is: MA.063.03.41l9
Ottftll~ abolll tbls notlc~ (Ste tho back for mol't Information,)
Your provider ~'c.~'~~~,l('~~ RsslRnmrnl.
~ '~,. '
BILL SUnMIITED ny: RONALD M SCHLANSKY MD,
Mailing address: 220WILSON ST, MED ARTS DLe; #106,
CARLISLE,' PA 17013
See
Medicare Noles
Dates Services and Strvlce Codes Charge Approved nel<:w
Ciiiilrol number 97041.3117600
RONALD M SCULANSKY M,D,
Nav 14,1996 1 Office/outpatient visit, cst (99213) , S 45,00 $ 0.00 a
Nov 14,1996 1 Drain/iaject joinl/bursa (20610) 50.00 0,00 b
Nov 14, 1996 1 Methylprednisolone 40 Mg inj (J 1030) + 5,00 + 0,00 b
''''I Totnl $ 100.00 $ 0.00
'(\'
Control number 97041.3117900
May09,1996 1 Office/outpatient visit, est (99214) S $ ,
55,00 0,00 a
May 09,1996 1 Drain/inject joinl/bursa (20610) 50,00 0.00 b
May 09, 1996 1 Metbylprednisolone 40 Mg inj (Jl030) 5.00 0,00 b
May 09, 1996 1 Dexamethosone sodium phos (J 1100) 10.00 0,00 b
May 09,1996 1 Rbc sed rate, 'nonauto (85651) + 12,00 + 0,00 b
" ~';, . "~,'I Total + 13f.Ocj + 0,00
"J': $ - S 0:00
,~: Total 232,00
NOTES:
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,T\", ';IMPORTANT: Iryou have questlona hb'ouflhts'illitlce, call the Medkare carrfer at United lIenlth,nrr Ins CO, aI, ;'" .
'<"'1.800.833.4455 or are us al2743l'erhneter Parkl\ll)', Augusta, GAJ0909-4576, You \\ilt need this notice . 'i""'" .
It you eontnct Us, . \\'....<,1,/ . v'' ""i"
To appeal OUI' decision, yon must ,",lie to~. before August 19, 1997, See #2 on the ba,'k.
ft;'(' '. I"~
,\" a Medicare does not separately pay for these charges because the cost of related care before and after the
,,' :N' surgery/procedure is part of tbe approved,~mounl for the surgery/procedure. You cannol be billed separately
~' -'" I ( , , , " .'~, ." I .,.' I J
";~,.. or Ihls servtce, "'~'" "ill "'3i~\\'~'I'.h~)~~, II).: # '
'.: ,~, ':',';( )/.;'1,:' i: '~'I'-> ,,',, ,:_-.
.:b This is a duplicate of a charge we have pr6cessed, .'
:k,I'"qi:1 . I ",: *~,fm:4N'<. ,:!I'
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'GENERAL INFORMATION ABOUT MEDICARE
:\"""(
If you make a permanent change in your address please conlacl your local Roilroad Retirement Board Office,
""~"""""''''''''''~~~''''''-.''''
\ ' I '44 .00(l~8Q'a-8703' "4-7 -oe-oe-N-2-N-N-N"N I)
, "..tOIChAt' , ,'J,
'Unl tad ....lthe.... In. Co, ' "~
p,O, 80)( looee
AUGUSTA, QA 30888-0889
THIS IS NOT A HILL
Explanation of Your
Mcclicarc Part B Benefits
t
" '
..,-',-.....~-~--'. "--~-------.~--_._--_.~
S !'"! III,",')' ....ul!~~~I.!~~!!I'!<.<ll!'!'-'lI.L 199'1.,
LI LLI AN S QUI CK
139 KLINE RD
SHIPPENSBURG, PA 17257
Total rhill'grr.:
Total M('dk~afl' appro\'L'd:
$ 100,00
$ 0,00
\\le paid yom provider:
Your 101111 re'l'oosibilily:
$
$
O,OIl
O,OIl
Your MediCAre numbr.r Is: MA.063.03.4119
YOllr pruI'ld.r !~~cel'te~1 A;slgll",en!.
DelAlls nboullhls nnlletJSee lhe back for mn~!!I..!!!I,~.!!,)_____u.,______________
OIL!. SUBMI1TED BY, RONALD M SCHLANSKY MD,
Mailing address: 220WILSON ST, MED ARTS BLO #106,
CARLISLE, PA 17013
See
Medicare Not.,
illites Services And Service Codes Chllrge Approved Bel 01\'
Conlrol number 97021.0953200
RONALD M SCI/LANSKY M,D,
No\' 14, 1996 1 Office/outpatient \'isit, esl (99213) $ 45,01l $ 0,00 a
Nov 14, 1996 1 Drain/inject joint/bursa (20610) 50,00 0,00 b
No\' 14, 1996 1 Methylprednisolone 40 Mg inJ (J 1030) t 5,00 + 0,00 b
, TollII $ 100:00 $ o,no
NOTES,
a Medicare does not separately pay for these charges because the cost of related care before and aCter the
surgery/procedure Is part of the approved amount for the surgery/procedure, You cannot be billed separately
for this service, .~
h This Is a duplicnle of a charge we have pr,ocessed,
GENERAL INWRIltATION ABOUT MEDICARE
1 :'f"
If you make a.permanent change in your address please contact your local Railroad Retirement Board Office,
'11'i'"
Medicare covers vaccinations to prevenl pneumococcal pneumonia, If you've never had ~ pneumococcal
pneumonia shot, prolect yourself and gel ?~e now, If your provider accep:s whlll Medicare pays, there
h I., 'I h h ge IOyou '(lIP"'", { .' "
S ou un e a c ar " -,' "~';--:'i\~t~" . .;, J ,^ I , .' '~
j '.,"'-M'i1":'
The Mcdicare Division of MelmHealth bas become the Medicare Division of Unhed HeallhCare
Insurance Company, You will nolice lhe United HealthCare nanw being used In statements
and mailings from us, Office locations, phone nllmbers, and staff members will remuln Ihe same,
'. This change will not affect your coverage/',I
, ,.','
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1~I~ORtANT: 'rryouhave (tUUllon! aboUllhls DO lice, call1heMrdlcal'e carrier alllnltrrlllrllllhra,'. InsCO~a '
!1~800.833.4455 or In u~ a1274:1 Perlme'erParkIl1lY, AuguHta, GA 30909.4576, \'ou will need this notice .>"; J
"lIyo\i'contacl us, ,l(~;\,' . . ,..k" "
To appeal our declsloa, yOIl musl wrlle lous beft'r. July 31,1997, See #2 on lhe hUl'k, ".',:~':j/'"
,>It:''''i,,,J
.
'UtB' 000:10 18D-U"iOJO"4-2.0~"oe'N"2 "N N
_ ,M!Dlr;AAt
United IIe.HhC.,.. 1M Cc>, '
P,O, e(l~ 100es
AUGUSTA. llA 30891-0891
-
NN 1I
-
TillS IS NOT A HILL
[~xplan:ltioll of Your
MedicarePm'f B Benefits
!
SI!!.".!'!!"'.t!>!"II!h n".lIel!_!!!lI.I'd Feb 05, 1997
LJ LLI AN :; QUI CK
139 KLINE RD
5HIPPENSBURG, PA 17257
lOlal ('''nl~'(''l;,:
lollll ~kdkall' .IPPlowd:
S D",OIl
S II, Oil
We paid ~'lHH prodder:
Your tolal responsibilily:
S
$
IU)II
0,00
Your Medlenrt' number III MA.063.03.4119
\'onr pro\'ldrr ~~('~:l:QI~~~ n!lsl~nml'nt.
,~tI!.!!!.!J!.!>~~1!!'.!!.."0tl'!, (See the Mfor lII.ore Infol'mnllon.)
nll.t SIJllMllTED Ill':
t\'iniling addrc!;!\:
RONALD M SCIILANSKY MD,
no WILSON ST, MrD ARTS lJl.(i IIlO!"
CARLISLE, PA 17013
Mal' 09. 1996
Ma~'09, 10%
~lay 09, 1996
Ma~' 09, 1996
May 09,1996
Sen'lte!; nnd Sen'lce Codl's
COlllrol number 97021.08954110
RONALD M SCIlLANSKY M,l),
1 Officc/outpatient visil, cst ('19214)
1 Drain/inject joint/bulSa (20(>10)
1 Methylprednisolone 40 Mg inj (J 10311)
1 Dexamcthosonc sodium pho; (J 1100)
1 Rbc sed rate, nonaOlo (H~('51)
~.!:S.!:
See
Medlenre Noles
AllllrO\'ed II e II",
$ 0,011 "
0,110 "
0.110 b
0,00 "
t U,OO b
$ 0,011
Dull'S
Tolnl
$ 55,IlO
50,011
~,Oll
1(1.(1\1
t 12, Oil
$ 132,00
NOTES:
a Medicare does not separ"tely pay for tbese charges because the cost of related care before and ufler the
surgery/procedure is part of the approved amount for the surgery/procedore. You cannol be bilkd separatcly
for this service,
b This is a duplicate of a charge we have processed,
GENERAL INFORMATION ABOUT MEDICARE
If you make a permanent change in your address pleasc contact your local Railroad Retirfment Board Offlce,
'I"~ ,-, ,;" ~:! '. ,'"
f'~~t~ . ,
;~'~~,. Medicare eovcrs vaccinations to prevent pneumococcal pneumonia, Ifyou'vc neve~ had a pneumococcal
\:.f?, pneumonia shot, protect yourself and get one now, If your provider accepts what Mcdicare pays, Ihere
"f~': shouldn't be a charge to you,
.f\~
"
· The Medicare Divisiou or MelraHealih has heconw the Medicare Division or Uniled HealthCnre
'*:ii Insurance Company, You will notice the United llealthCare name being used in statemcnts
1V'~' If,! n .
~'
',j' ':"J\IIIORTANT: If you have qu;.'ilo~5 abo~f';;,;: ~~lIce, calltht Medicare r~rrler ntl1nlted lIenlthrare Ins CO, III
,:.;;' . 1,ROII.Il.J3.445S or le~ U8 1112143 Perimeter Parkwn)', Augllsta, GA 30909-4576, You will need this notice
II you eon tad us, '
: ' To npptRI our decision, you mDst write to os bclore August 05, 1997, See # 200 the ba,'k,
,
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~?/11/97
02/11/97
10/02/% L E WI S
728.9
11/18/90
11/18/96
0;'/12/97
" "
"
11/06/96 LE.JIS
332,0
12/19/96
12/19/96 ,"
1\;'/12/97
:"'~: "1:-:,'. '.; ',I
11/16/96 LEl,aS
421,31
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12/:'li/%
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411 .1
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~' ' '~..o< (" 14800'OOOUHa.U7034"4"U'Ol"02"N"1"N"N.Ii"~..P)", ""11 I S IS N()l"',A '\'nI"L ',,'" ,
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,;~",fJJI :i'~'IS~~X'\~"':';'.8I:om ,/,1.: :~~; "",; ExplanatIon on'l o,u]'l;j.:.. ,':,':
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139 '<LINE RD 'I"""''''
SHIPPENSBURG,',lA 17257
",':.~,k"~; ~II.<
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W.' paid ~'our p,r9,I'ider:".J;,Jka,,$,
YOllr 10tnll'Cfip6'li'sibllity~$' .
\'our MedleRre number Is: MA.063.06.4119
'< 'll""'IJ;;.K:' r.'ll;~"""',:i,..\~ll.\1
'\-:;.4 "k~\)"\l*
\'nllr prnl'ldrr R(:!!plrd os~l~nmrnl. " '(;11.
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.------. . ------.~---..' _.,_.' ., ..-__._0______---.
1111.1. SIIllMITTEIl 11\':
Mailin~ uddre,,,
CARLISLE CARDIOLOOY INC,
13 BROOKWOOD A \'C, STF 3,
CARLISLE, PA 17013
Ilnle,
"
~s nnd Srrrler Codes
Conlrol number 970(17.2,177500
DA \'10 KANN M,D,
I Initial inpatient consult (99254)
I SUbsequen,t hospital cnre (99232)
1 Elcctrocardio~ram teport (930IO,\\'J )
Totul
See
Medica.. Note,
ehnr.&!: .:M>.E!.<!.l'ed lIel'!.":
a
$ 15(1,OU $ 0,00 b
60,00 0,00 b
,I 27,00 ~ 1l,lllJ h
$ 2,<7, Oil $ 0,00
Dee 11, 1996
Dc<' 12, 1996
Dec 13, 1996
NOTES:
II Medicnre cI'nnol pay you lor the money YOII mllsl puy eRch year lor the Medicllre Part II dedllclible, See tbe
explanalion beloll' for the amollnt YOII have noli' paid 10Wllrd the deductible, See #4 on Ihe buck,
h Medicare records sholl' Ihat either Ihe name or Medicare number sholl'lI on Ihis claim is incorrccl. If Ihe
information ~holl'n is II'rong please contact your prol'ider 10 make sure thatlhe provider's reeord~ arc
enrreet and Ihal a new claim will be filed, If you think Ihe information i~ C0trCet. piense contncl
YOllr Social SeeurilY Office,
GENERAL INFORMATION ABOUT MEDICARE
IfY0u make a permanenl change in your addre~~ plen" conlncl your local Railroad Relirement Board Office,
,
Medicare coverfl \'accinati()n~ to prevent pneumococcal pncumonla, If you've 1ll'\'t'1' had n pnruflwcoccnl
pnenmonia ~hot, prolect yourself nnd p.el one noll', If YOllr !,"'l'iderllc('epI; II'hnl M,t:dirare pllY'. Ihete
,hou/dn'l be a charp.e to you,
The Medicare Division of MetrllHenlth ha~ become the Medienre Dil'i,ion olUoiled HellllhCnrc
Insuraoce Company, Yon 1I'i1lnotice the United HelllthCllre name beinf used in Sialements
and mlliling~ 110111 us, Office locntions, phone numher" nnd filnff members lI'ill remain Ihe ~ame,
IMPORTANT: If)'oll hnve IlllfRtlons phout Ihls nollce, rRlllhe Medicare curriei' Rllllllted I/caltll('pl't Ins CO, al
I.R(lO,8,'3.44~S or stl' 115 r.1274~ Perhnch'r l'ark\\11)', Augu8la, GA 30909,4~76, \'0'11 will nred lhl~ lwtler
II you conlact us,
Tn uPflcul our dcel8loll, )'oumll~1 write 10 115 heforr AII~U~I OJ, 1997, ~('" /I, 011 fill' hllek,
,-;-.. 00588-??oo1401.87043" 1'1.~3.0.-N-l-N.N.N.N 0
. , '/, \. M!OIIAH! ,..\:,~,. ,,,
Unl tell t..lttiC.,.. In. CO ,l ',:\.~ \"
P,O, 110)( 10008 '."'/ .;
AUQUSTA, CIA 30U8-0U8:~ "
\ ' .' ,
.' ~I"'-:
,. I\:t+y
THIS IS NQT A lULL
Explana lion of 'your
McdicHrePar.t n Benefits
-
I'"
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-,...--____ff.____,__...~.~______
~.l~!!!!'!'y of Ih!!o-'!~!!E~A!'!~I~!:!!!_I_~J.J..
HERBERl G QUICK
139 KLINE RO
SHIPPENSBURG, PA 17267
')'o'aJ ('h"r~cs: ~
Total Mcdican' llppro\'cd: \
'15,110
77,11(0
,
"
lVe paitl YOUT provider:
YOUI' lolal rcsponsihilil)':
~
$
0,00
WI,06
Vour Mr'dlrAre number Is:' A.06J.03.'4119
UetAlls aboulthls Rotlte (See th!!,batk for,mol't! InlormAllon.)
, ':I~ .;
Vour prol'ld"I' ~"c!"J>led a"lgumfnt.
IlILL SUBMITIEU BV,
MAiling address:
DA VID L HARTZELL MD,
850WALNUT DOTTOM RD, STE 109/MED ARTS OLD
CARLISLE, ~A 17013
. "
Sef
Mfdlcarf Noles
Approvrd Beloll
a
$ 50,35 h
2(l, 71 h
+ 0,00 e
$ 77.06
',"
Uales
Senlces and Senlcr Codes
Cooll'ol oumher 97030-1119100
DA VII) L HARTZELL M,/),
1 Eye eXAm & Ireatmenl (92014-ZP )
1 Eyc exam wllh phOIOS (92250-ZI' )
1 RefrAction (92015-ZP )
ChArgc
$ 53,00
30,00
+ 12,00
$ 9Diii
Jan 14, 1997
Jan 14, 1997
Jan 14,1997
,
'folal
'1('1'" ~,1)1'-'
NOTES:
,,'
a Medicare cannot pay you for the money YOII must pay each year for thc Mcdieare Part B deductible, See Ihe
explanation bclow for the amount you have now paid loward the deduelible, Sec #4 on lhe back,
'!rJ "I.
h The approved amount Is based on lbe ree schedule.
c Medicare does 1I0t pay for roullne eye examinations or eye refraellons,
GENERAL INHlRMATION ABOUt MEDICARE
.,,'
, ";".'
If you mal:e a permancnt change in your address please contact your local Rllilroad RClircment Board Office,
~'i...; ,'.,1",', I " .,',)",:)~~t! .. '." . .". ~
" \(0" Mcdieare covers I'accinntiorls'to prel'ent pncumococcal pneumonia, If you've never had a pneumococcal
jf') pneumonia ShOI, pmtect yourself and get one now, If your provider accepts, whal ~edicare pays, there
~~I\ ~:u:::I~:r: :i:';~i::O :fo:eit;~Heah~:~::b~':~~" the M~dic!:i;~Llon of United HealthCare
~~1 Ii' Insurance Company, You will notice the United HeatthCare name bring uscd in statcments
" and mailings from us, Office IOClltions, phone numbers, and staff members will remain lhc same,
\t~.jl.7" ','.-'r:':'" I',:.~'..o..j"f~,l,,!, " '\hr~',~;":l'll:,,' , "~'. '
"t(~l-, ".,",,, J";" ,_''''\' ,;";.ki'.o/",'li(,,,' .",
i~~!.,~.: {, ':::".', ,'. ", """"~.;';'1:". J:'.'\{"'.~\t. '1j~..:.',/,.'::i..~!SiM.~,". "~I~'1:';It:~'i.'f,'lrl'-Wril'~)":-f'~~i~:i>; .;-., , .' .
..~-",l\'li'" ,1:_ ,'; . ",:,'_I,,'...\;lr.l.1;rljl~.,,,~;"":"", ""."-V,,' "~'" i; ',!_,: ,,'" ". _ ,
:l, ' IMPORTANT: Uyou ha~e 'lj1Jf8l1obs .bout this nollce,caU tile Mfdlcure ('nrrler lit United Ilealthcul't! Ins CO, 01
..: . 1.800.113J.44SSom~u! 1I1~743I'~rhJ\~ttr'Parkwny, AU8u81~1 G1-30909-4576, You wtll need this 1I0tlce
' . Iryou contact II!, .'. '" )"~i"Fi\( " 'r . '" . .
To .ppelll our dcclsloll, you musi wrlle to us berore August 12,1997, Sce #2 olllht bllck.
~~,
r '~" ,~.,
. 281Q,-OOO73108.U70aU-.-a -03'-,OlI-N-2"H"H-H"H 0
MeDtcAltt ,,; ~
UI'l't.d ~.UhC.rtlln. Co. ,,,.,
I',D. lOX lDOeO '
AUGUSTA, OA 30U8-0un ;:, l'
THIS IS NOT A HILL
" I. ,
[;:xplan:ltion of Your
Medicare Part B Bl'l1efit:~
--
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:",'1,1
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"'-'--"---~'-'._-""--"'-------- ."-'--"-'---
S !!!l!'II_"rY.!'!J!II'.llQ!!~!.!!" led,,! Il Il21...!.~~
LI LLI AN 5 QUI CK
139 KLINE RD
SHIPPENSBU~(i, PA 1 '/257
~, I
Tul/l1 ('harg('s:
Total Medicare apprO\'l'd:
$ 1,'/49,00
$ HII8,,',O
We paid YUill plO\'idn:
YOllrlolalre,lpoll,libility:
$ 718,80
$ !'I 9 , 70
.,:1, \',
Your Medicare number 18: MA.063.03.4119
Detallll about this notice (See the back for'lnorHnrormotlon,)
YOllr provlll.., ~~<:'Cjl.t,ed a,~IRnrn.nt.
BILL SlJBMITfED BY:
Mailing add, ess:
,
'!
DA VlD L HARTZELL MD,
SSO WALNUT BOTTOM RD,
CARLISLE, PA 17013
"";
-----,--
Q!!lli
Medicare
~rov.d
Sen'lces and Sen'lc. Codes
Control number 97002.2123100
DAVID L HARTZELL M,D.
1 Remove cataract, inscn lens (66984.R TZP)
:1'
--9!arRe
Nov 25,1996
$ 1,749.00
$ 89B,50
NOTES:
"Il'
a The approved amount is based on the fee schedule,
GENERAL INFORMATION ABOUT MEDICARE
If you make a permanent change In your address please conlact your local Railroad Retirement Board Oence,
I " '.~ ,#,(1 ;
Medicare covers vaccinations to prevent pneumococcal pneumonia, If you've never had a pneumococcal
pneumonia shot, protect yourself and get one now, If your provider accepts what Medicare pays, there
shouldn't be a charge to you.' ..: ,'- " , '
i
The Medicare Division of MetraHealth'hlis become the Medicare Division of United HealthCare
Insurance Company"You will notice the United HealthCare name being used In statements
and mailings from us, Oence locations, phone numbers, and staff members will remain the same,
This change will nol affect your coverage, , I
, ,I '~} ",
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'IMPORiANT:lryou bave qunlloo, about thlnollce, call1he Medlcal'e cnrrler at United ilenllllcare In' CO, at
1.80Q.833...4SS or ICe us lit 2743 Perimeter Parkwny, Augusta, GA 30909.4576. You will need tbls notice
If you cotltact u,; " "
To IIppeal our declslon, you muH wrlle to 'us hefote July 29, 19'17. Scr #2 on the buck,
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' ',,' '" " ,,', " [UPlo,i"r' ' " PA B"034118 l ,':j'!
i , " , :; :'\ ' , 'Iii" 'I', ' ,~ , ,. NUMB.R I ,10" 0.., ',.j, '
, " ',', ":,~\",,,\, CLAIM '''UMBER: ;,.',', :"1<10042298614-88. 'Ii: :t,
" :,'(" .:, "J,:V', ;,GROlJP/SUB:, :' ,.' 0030600/0~88 Jldl "j,;',\ , ';r)
I: " ,,~( "'Il, CI.AIM YEAR, . '" IQ08 ,,,,,}~L',,\~, \ ' ",
'f \, ., ':.,'j ~;'/t'~.:... "rATZtNT'S PIRTHDAT[:' 12/03/tti I . ,,' ",' \,_ '(', \~\', j"",
",I' '~' ~'~\~ 'r~' "I' It., ~"
""'rt,' , " ::1. 1.1" , I'''-~; i" ; ,I I '''I . j '., ".I" it"'I"" ~ "', ,:
oeAR MR, H, QUICk, ''''';'''',j".,j, l:r'""j "~Of ":" ,1, !,,'.':'i; . ,';{:'~(,,'il\'
WE mEIV[O A MeDICAL CLAI~}~::~~~LVAN",J!. "'(M;~~M~;.{;
INrORMATlON ON THIS rORM EXf'!.AINS\YHE'BENrrITS' PAYABL[ UNDER YOUR STAl[ or NEW YORK ,I'LAN,'SAVt",
TillS rORM rOR YOUR TAX RECOROS,dr YOU HAVE ANV QUESTIONS ABOllT THIS CUUM, PLEAS!. CALL';;OUR,'
TOLL-rREE NUMBER (BOO) 942-4B40'WITHIN NEW YORI< STATL Ir OUT or THIS AREA, 'PLEASE CALL';.\('BOO'
431-4312, OR WRITE IO IHE ADDRESS AT TH[ BOHOM or TlUS rORM, IN YOUR LETTER"Pl,tASE:REnR. O',j OUR
EMPLOYEE NUMOER, CLAIM NUMBER ANP GROUP NUMBER SI10WN IN Tl1C UPPER RIGHT-HANP CORNER or :f IS ' 0 14:
f' ' '~l;" t~:,.
TOTAL ExrtNsES SUBMITTEO ON IHIS CLAIM ,:105.00 '::"l"
TOTAL PAYMENT MAPE BY ANOTHER CARRIER ,,'(~4;09 j
OUR PAYMENT ON YOUR CLAIM . ';00' .'~
-----~-_.- ----.- ROllinn
El<pollGot [JO; fHt" &tl5 leu ttalanca % Pltlll
llescrlptloll a1 Service Submitted E<eluded (Soo Note OeduC\lble Ctltl,lderlld Benefit'
-'--- Baluw
-mITSLrTMAaING ASSOCIATES"'
PIAO, X-RAY 01/16/8B 105,00 9B.48 418 B.62
G , 4;-
~ 0
"., ...
NOTt 418' Ille amount ...cluded Includes any amount paid by Medicare, It M8Y also Include the
dtfference between the prOVider's charge and the Ilmount Medioare approved. If the
provider accepts Modtcar-e 8$S'gnment, he/She has agreed to limit his/her fee to
Medic.re's approved amount.
Your benefits are provided by. Health Plan insured or admtntstered bY MetLtfe, Ple8se see your
plan booklet for dehlls, MetraHealth Service Corp, Is a new company formed by Metllfe and The
Travelers. 10 cards and forms WIll be valId for use wIth or without the new name. We remaIn
committed to provIding the highest level of service.
rLEASE NOTE IMPOR:fAN:f APOITIONALINfORMATION ON REVERSE SIDE
NEW YORK STATE CLAIMS UNIT
METRAHEAL TH SERVICE CORP"
ADMINISTRATOR FOR METLlrE
P,O, BOX lBOO
KINGSTON, NY 12401-0000
LP51FO OW 02/95
STATE or NEW YORK
METRAHEAL TIi SERVICE CORI'"
ADMINISTRATOR FOR METLlFE
P_1L BOX IIiOO
KHIGSIDH., ti.Y, l.2ltJlI:::.O./iilll
ON9
.
Ii QUICK
139 KLINL ROAD
SHIPPLNSOURG PA 17257
, METRAIIEALTH'.,\'\,
,- I" ;, l'~~'~ ,. ' :
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, EXPLANA TION OF ,MEDICAL .BENEFITS ' "I., ',! ' , " ' ,
, " , I'fl',q l ' , , ,
:,r DATE.I'ROCESSED: I,PR, 2a,:,,1087 , PAGE Of OF 01
" EMPLOY[E NUMBER ') ", PAOoaoa4118 ')", '.<!. , ',-Ii' I
'I' CLAIM NUMBER: "',T'! ~1704161U88-08 rV . '. ':'J"",
:~, : i .d'", i g~~~:/~~~~: } V;,: m~5~~/:;~~f,~t~lf#! ; 1'1,r"','
'j, r 'I"~ ' "X r," ';'~{:'I :' I'~T1,ENTIS B1RTHDATE;1'''2/03/,'!~l',.;:~''' (,~~, ': \,;,;:< \
I H "QUICK ';'I":~\"1 ~'('/i ^\,' d ", ".\Jr\h',~ ",'1 . ',',
OCAR MR. <I' '/</ .''''1 1r.;:1 i', ,. " ,~\'''' "'Itf 1." "I
j, "
WE RECEIVr,D A MEDICAL CLAIM FOR LILLIAN, , ",," , . . "ti1,';~'.li'
INFORMATION 'ON THIS FORM EXPLAINs THE !ENErm PAYABLE UNDER YOUR ST'AtE'OFNEI/~OR~*,;t~~!~ttJ~, '
THIS /'ORM FOR 'YOUR TAX RECO/IOS.' IF YOU HAVE ANY QUESTIONS ABOUT THIS CLAtM'.'PLMtE CAl.L' OUR :/'"il 1'"
TOLL-FRH NUMBER (800) i42-4B40, OR WRITE TO TliE ADDRESS AT TH[ 1I0nOM OFTH%S~ORM, 'IN YOllR ,"~', ,
LETlER, PLEASE REFER TO YOUR [MPLOY. [E NUMBER, CLAIM NUMBER AND aROUP NJMIl..E. R",.'SHOWN., IN THE UPPER,':.!, ';~,'iil\:i,
RIGHT-HAND CORNER or THIS fORM, ' " ":"'ii" :,,~,I,. '~~~,
' TOTAL EXPENSES SUBMITTED ON THIS CLAIM ' .. '20.00 ,,;,j " ":,,~{,t,
lOTIIL PAYMENT MIIOE BY ANOTHER CARRIER ,'7,04
OUIl PAYMENT ON YOUR CLAlfll 1,41
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Expflns;u. f..p~n'.. Reuan . l&u . . .1I~I.neo
'D..crlptlon 01 Sorvloo Sybmltt.d belUtled (Soe Note Doductlble Con,Iaored %
- Below .
A :tlWij-
DIAG, X-RAY 20,00 lB,24 418 l. 76 80
Piau
1I~"eflt.
1. 41
TAL
20. 0
1. 6
1.41
/,41
AM
NOTE 418 ,The amount o.cludod Includes any amount paId by Medfcano. It .~y also InclUde the
dlf/eronoe between the provider's charge and tho amount MAdloare approved, If the
provIder accepts Medica... asslgn..."t, he/she has agreed to limit hIs/her fee to
Medicare's epproved Mmount,
I'LEASENOTE IMPORTANT ADDITIONAl. INFORMATION ,ON REVERSE SlOE
I11III111I1IImm1llm1l1l I IIIWI 11I1 11111111111I11 1111 , ,','
NEW YOR~ STATE CLAIMS UNIT
METRAHEAL TH SERVICE CORP,.
ADMINISTRATOR FOR METLIFE
1',0, BOX lBOO
~INGSTON, NY 12402-1Boo
lP'IFD ew 02"&
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lPf I:'fC-...._......_-V_~-"~._...",,~_-.,--. -~, :,:
MtDltAAE ' ., ., ,,'\ f ii'i~ ,) , ,
unftlMl HeaUhCD,..llla t(>"it~<Jfi';i'"
p , 0, 110)(.' OOOB' " ' ,', ::t"'ll'.;r.~\"(:J
AUGUSTA, W.,;f\,om.oo~o !'~l""I~; ....
~ ,---- t'~; ':: ;i" ': ,.:~;~~:i\ ','. ,..'~~:*;:iJ~(; ;f;~;I~~ki;.!~_: )!,(,
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LILLIAN S QUICK . <'
139 KLINE RD .'
SHIPPENSBURG, PA 1726'1
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Your Medlenrt number Is: MA,063.03.4119
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lletlllls obollllhls Mtlee (See Ihe buck for ml!!:t Inf,,!!!!..utlon,L
llILL SlIIIMIlTEll8Y, CARLISLE IMAGlN(i ASSOC,
Mailing address: 1'0 BOX 100,
CARLISLE, I'A 17013
Senlces and Se,."lee Clldes
Control number 96365.4135600
CIIARLES K LOll M,D.
1 Ches' x-ray (71010,2(, )
Professional Charge '
I Echo exam of abdomen (76700-2677)
Professional Charge
1 Hepatohiliary imaging (78223-2(,
Professional Charge
D1I1.-
Dec 13, 1996
Dec 1:1, 1996
Dre 14, 1996
.,
$
,
See
Medlcnre Notes
Chnrl!! Approl'ed lido",
20,00 $ 8.80 a
119.00 40,06 n
114,00 , 41, (,3 n
25:l,OO $ 90.4'1
Totnl
$
Control number 96:\65.4135700
RANDJ CllTl\lIERTSON M,lJ,
'1 Chest x.ray (71010.26 )
Professional Charge
Del' 11, 19%
NOTES:
, ~~'
a The approved amount is based on the fee 5ehedulc,
GENERAL INFORMATION ABOUT MEDICARE
1
20,00 +
8,80 a
TOIlII
$
273.00 '$
99.29
If you makc a permancuI change in yaur address please contael your local Railroa~ Retiremenl Baard Office,
Mrdicf\fC covel's vaccination!; to prn'cnt pncumo('oc('ul pneumonia, If you've never had a pneumococcal
pneulllonia ,hul, prolecl yuurself and gct one now, Ir yom prol'ider accept' whal Medicare pays, there
shuuldn'l be a charge 10 you,
-
I ~IP()RTANT: Jr ~'ou have (1\I(.~tlon5 about this nolk." ('all the Mt'dlcal'e ('III'1'II'r III United Ih'nllhClII'c 1115 CO, III
1.800.8,\3,4455 or tiel' \IS lit 2743l'el'imctcr l'ul'kwn)', Augusta, GA 30909,4,76, You will n('ed this uollee
If )'Oll contact us,
To apPI'al our d\~c1sloll, )'OUlllust "Tile 10 lIS hrlnn' July 24,1997, St't' #2 tlnlhe bark,
"""""
'lore dt'tul Ii bout ChtH II()Uct~ Jr;!:<d;;i::;'MW:(~1,;1bni:' ", ~!{,~~,-_~;.,~-~,:' '!' '_)r~;l'~~_"'-"'" '1, :"1 ',', ":",-'/;" ':.J(li",'~!,\I',/U-r.j~;tUq '/',1',\ '
-"---';-"" ' --'- ',"',""i,'k!fjl'/f:ll"r' -:;\''',i/l:','','"I'.,'''' -----'---':"'.------;,
,i 'r J ' ,~I"- ,.",~:'"'~";.~,I}~;1"- " tWq~'o-",' "~I
The Medicare Divi5ioll of Metrai~~al;i; h~I'b~~~e IheM'cdi~ore Divi\ioll of Ullited lIenlthCorct'i,
In\\lrallce Company, You will notice the l!,nlted /l1'lIlthCAle nome beillg u\o,d iu 6totemenll
and mailing,\ from\l\, Ornee locations, ph~~e,h.umber5, nnd 5taff memben will remoin the 5nme,
This Ch~~~7~i\~t. ~0t nffee,t you'r eo\'ernge,'!~i,n,(i ' '
:"11':',' ,'I-t.~Wlh:
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"', ,'I""',~Wtr.#:,1 ".
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lIere II an explanation of this notice: ," ;, ..,',,: '
'" /:\'
Of the tolal chargCl, Medicnre npproved $
Your 20% ",
The 80% Mcdicnre pnYI " ~: $
Medicare owe,1 , $
We arc puying the provider ,.,$ .'
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Of the approved amount
L06\ what Medicare owel
Nel responsibility
YOUI' total responslblllt)'
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,I $
$
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1\, \;~"It.l'~\ t~"'/l;l<I~tll"!~., 't"'ft''i;'t2'~o''r''~''\i ,.-
(.., , 'W::~':l~j)J.t;~'i t~' r~\~ ' '." l''' 011 >)"fr .
, 1 :~'~" ,,;' 't.~ i'rO~~fi.\.~~il~I,}~; I :' 'I~' '1:1 '~d'.l ',:,~:A 1\ I 'Ii:'
,<t, "" .} \ "" ~'lli LI NS U
"I;''''') \lr:q, ': ."'-t.:\j~r ,;" ,\,~, oJ 4 A lQ ICK ,'l~',-
Vour.1\'edlcure'n,umhel'l~: ,MA.063.0J.4H9 ',:Ii ,rJ,
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99.29
19,86
79,43
'79.43
79,43
YOlll' provider ugl'eed to accept this amounL See #4 on the back,
We pay 80% of lhe approved amounll you pay 20%.
You IlI\I'e met the deductlhle {Ol' 1996,
,$
99,29
79,43
'i9.8ii
19,8(, The provider moy bill you ror this alllonnL If you have othel' ,
insurance the other In,nl'unee may pay lhls amounL
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IMPORTANT: Ir)'ou hnvc questions about this notice, call the Mrdl(:AI'C cAl'rlel' nt lInlted Heal(hcAl'e Ins CO. 01
1,800.833-4455 ot see us nt2743I'el'lmcterParkwul'. Augusta, GA 30909.4576, \'011 \\iIIueed Ihls Mllce
Urou contact \1&, :\,;,;;>:
To nppe.nl our decision, )'OU IUUSllI'rllelo:?s,bctore JulJ' 24,1997, See #2 un lhe huck,
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o~~e7"OOOU6~7'U7037'3-I'OI"O~"N'" -N"N-N"N 0
".MI!f)ICA'U: ,.,."l' ,'~',,\;1\',,;:,'_. h .
UnIted Ht.UhC.,.. I". eo, ",,':'\, ",
P,O, 110)(10088"'",:, . /'.': " "
AUGUSTA, Q,\' 1l08U'08P8' .'" i';
::\ :~:$ I '_~ I' ':;!,~:~':" ,;{l~~):'~;;:,:~~" ~/ ,;/~ ,i;.
:'I"THIS IS NOT ABILL'i'
.' Explanation ()fyg~,':,;r'li,
, , ' , i!l~ I ~ ,c. ~/;'. :' ' i
Meclicarc"pfll'f n ;B(~llerits'"
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,\\l!'IlH'IfI!,f.!l!lu!olle!:.dlitcd Feh O(i,19?1~
, ,'~::'fr:~;::~.:~;~:"\t: ".;,t'/(
'\,,'al ,'lIalf""' "IIV;tj;ls;:~p9,:oo,
'1,,1;11 Medicale llpprol'ed:iIi,.it,,'il. 4R,HII,,,
, ",'~ "~t'\, l'~'" \ ,.',1/,
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tif /, "}" -.
We paid ~'''lIr prol'ider: ;Mi''i$~.~I'~,',;~9,09
y"ut lolal re,p(ln'ihilily:~!.~'s.'IjI,f'r'9 :77','
LI L LI AN S QUI CK
139 KLINE RD
SHIPPENSBURG, PA 17207
'1,
Your Medico.. number Is: MA.06~.O~.41J9
YOIII' prlll'lllcr !'ec,l:J"r~ IIs,l~nmclI',
UI'IIIII, obout Ibis nolice (See the back for 1II0I'e IlIf(jI',mollo~:.L.......___,_____
I\lLL SUBMITTEl) B\': CARLISLE IMAnIN(i ASS(JI',
tvlniliog add res,: PO BOX 100,
CARLISLE, PA 170I3
-
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Medicare
Appl'ol'cd
SI'"
Nnl('!i
111'1,,"
Sen'lces olld Sen'lcc Codes
COlltrol number 97010.1~6~,'(H1
RANDJ ClITIIBERTSON M,[),
I Chest x.ray (71010.26 )
Professional Charge
_..JJ"I'~e
Dee 27,19%
$ 20,00
S g,RO
a
Dcc 2R, 19%
Contrulllumbcr 97010.126~4110
ROIIERT F HALL M,[),
I Echo exam of abdomen (7Ci70ll,26
Professional Charp.c
"
~<I
119,00
TollIl
$
4R, Hr,
n'l,OO
$
NOTES:
a The approl'ed amount is ba,ed on the fee schedule,
GENERAL INFORMATION AIIOUT MEDICARE
If you make a permanent chaoge ill your address pleaseconlllel your local Railroad Retlremelll Board Office,
Medicare cOl'en vaccinal ions 10 prevent plleumococcallllwunHlnill, If YOll'l'e lIel'cr hlld II pncuOlCleoeclI1
pneuOlonia ,"ai, proleet )'our"lf and gel ooe no\\', If )'Ollr p:ol'idet aceepl' what Medi('lIle Pill'" Ihere
,houldn't he a charge to you,
,
The Medicnre Division of Mclrlll-Iellllh h<ls hecol11e the Medicm,' Dil';';"" olllnited Hellllhl'a"
Insurlln('(' COl11pnn)', '\'ouwill notice Ihe lIniled Hellllh( 'lire nllllle Iwiog IIsed in """'l11ellls
and Illailing' from u" Office location" phone numbers, and "all mcmhm will rcmain Ihe same,
Thi, change will 110' affcclyour eOl'erage,
-
IMPORTANT: If~'on hnn (IUesll"n, "boulthls notice, clIllth(' MNHellt'e cllnll'I' nt lIlIllcd Hrllllheol'c Ins CO, lit
I.HOli-8,'~.44~~ ur see us nl 274,\ l'crlm.lt!' l'ark\\'II), Augustll, (it. ~{)9(J9.4~76, \'ou 1I11111('('d this IInt"'l'
If you contoct us,
To 11 PI'('II I our d('dsloYt, )'0\1 IIII"t wrlle to II' lll,ron' AII!!u,' 06, 19'17, S,'(' #2 Oil till' hlll'k,
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. "1'1'.:IlCOICllllc '\ ': ,!,:t:C/., 'l.i
,h;: Untt.d H..1thC.... In. Co, ""i" , ,
, ,I;'tl',i P.O, ~OX 10006 ' , .,,~: 'i'l.,";"
"I,\>' 'AUGUSTA, GA ~ODU8.0808 ,/ ,]Hi.'
" 1" ;';O'!"'I)- i
~ "i'OI;t;"~'('i\!'i
,rnnS:IS NOT A ~l'f~'} ;~ "J~~t.~((':'
J"" 1 ' t' V II~~ ~~~,~I'
~~p analIon Oil <?: :'\:' ,~f,I.~,~;h:
Medlcar(1)art n Beneltts"~l!L.. "
io',
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LILLIAN S QUICK
130 KLINE RD
SHIPPENSBURG, PA
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17257,:"
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YOllr Medlcnre nllmber Is: MA.063.03.41l9
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\'0111' pl'''I'I<I''I' IIcerl','!" nssIAn"..,,!.
U"lnll, nbolll \hls nntlee (Se~~r more Inrol'''lllll~!'l..._________,_._____.".,_
IlILLSlIllMITrEllll\': CARLISLE IMAGIN(i ASSOC,
MAi1in~ addre,,: PO BOX 100,
CARLISLE, I'A ] 7013
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See
Medlcnre Noh.'!>.
{,hlll'ge Approl'e~ lid""
$ 34.00 $ 10,77 a
',{..i:'" "
Dnte,
Sen'lees nnd Son'lce Cnde,
Control number 9701~.1530900
DA'm R ROYAL M,D,
] Chest x-rny (71020-26 )
I'rofe"ional Charge
" I.'
Dee 29, ]996
Nonos,
a The approved amount i, ba,ed on the fee schedule,
GENERAL INFORMATION AIIOUl MEDICARE
If YOII make n permanent change in your address please contact your local Railroad Retirement Board orfice,
Medicare cOl'ers I'accinations to prel'ent pneumoeoecnl pnellmonia, If you'l'e nel'er had a pneumoeoccnl
pneumonia shot, protec, yourself and get onc noll', If yonr provider neeepts what Medicare pol", there
,hollldn'l he a charge to you,
The Medicare Dil'i,ion of MetraHenllh has become the Medicare Divisin" of United HenlthCare
In,urnnce Company, You will notice the United HenlthCare nnme heing lI,ed In statements
and mnillng' from "', Office locations, phone numbers, nnd ,taff memhers will remain the 'arne,
This chnnge will not affect your coverage, " I
,
.' '
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IMPORTANT: II )'OU hlll'e qllestlons nhoullhls notIce, culllhe Me,II,'nl'e ('lIrrler ntlJnlted l1eolthcn,'e IllS CO, III
1 'ROO.SJ3.44SS or see UH 1112743 l'eI'i1neler Porkll'lI)', Augusta, GA 30909-4576, You wllllll'ed thl\ notice
If you eonlnel liS,
To uppeal our derision, )'OU mU!IIlTlle 10 us before Auguslll, 1997, SI'e #2 on the huck,
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1"~III1IlY!VIIIIIII
D1U(~Shleld
EXPLANATION OF BENEFITS
KEEl' rem YnUfl TAX flFCorWS
rrNNfoYlVAHlA BI Uf: SltUI.D
U}SToHr" SfRVICF.
"0 no)( a'OO!6
CANP HILL PA 170e"0016
filII' 11'11.14 11\41 nlu. r'll" r!~n. IIf f'''III'V!~lnl. ~II Indl>rtndl"t
Ill''''''. nfthe nil" ':,.". ...41111,. UI.I~ ^"nrl~llnn "
Subscriber, ItI:RBERT 0 QUICK III Numhnrl 063031<119 PogO, I of
Pntlel1t, UlllAN S QUICK Clnim Numbarl 9'/03'i03816/ Dote , 02108/'1
Provider, BLUE MT ANESTlIESIA ASSlIC PC
(000191123)
_R__ '~'- -. ..~~--- ---. R~_.
PROCEDURE DESCRIPTION
PROCEDURE CODE SERVICE PROVIDER'S AllOWANCE ANOl/NT nlo ANOvNT RENARKS
lNUNeER OF SERVICES' DATEISl CItARGE NOT rAID
ANESTftESlA' FOR
CATARACT SUROERV (003) 11/25/" 495,00 .00 .00 4'!i. OOM S002'
'''83 ---
-1JUA -& eM
S0026
We are
abave,
If the
unable t. identify the patient from the identification number reported
Pleose verify the name and number indicnted on the identification card,
patient is covered by us, please resubmit the claim,
II You owe TIlE PROVIDER for those amounts in the AMOUNT NOT PAID column followed by an
asterisk (II), Those amount. total .~95,OO for this provider, S~nd this amount directly
to the provid.",
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HERBERT G QUICK I,
139 KLINE RD
SHrpPENSBURG PA 17257-9649
, ".
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ItA VE A'~'~;~k;~~~iM~~it~i1f~:;'c1}(/( 71;')
(Service far. theiD.sfJYie TOO Equipment
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THIS IS NOT A BILL
j';,:
(,1((. ~ '
'\/.' ~:
731-8080 OR 1-800-345-3806.
is bvailnble at 1-800-3~5-38~8,):
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N002387~
155 15-00031 t8~-17038"4-tl-Ol-0fI-N-2-N"N' N
"'!D~C,~AE . ;;',;'l:
Unltltd H.ulthC.". In. Co, ':''',:''
1',0. tlOX 10000
AUClUSTA, 1IA 30981-0U99';~" .
-
THIS IS NOT A HILL
Explanation of' Your
Medicare' Part BBenefits
'N 0
t
;j\
-
-...______.'__.____..don__
s!!.'!'.!!!!'n_'!UIII~IJ!~tk,~,d" t.~!J:<<.:!'JI&.!~
LI LLI AN 5 QUI CK
139 KLINE RD
SHIPPEN5BURG, PA 17257
Total charge\:
Tolal t\1cdll';H'l' ilppr(l\'cd:
$
$
411,011
211,04
We paid VOl" ,"()\'ider:
Your totnl rc~p{)n~ihHily:
s
s
1<,,04
,l.OO
f '!
Vour M.dleor. numher I,: MA.063.03.4119
Your provider ~C(:"l'l,.d assignment,
.~I.II~ ai"l\Illhl!11n!;c! (S~'lh. ha~"ora Inl'nrl!IOllo~l.__,___.._____ _..___..,___,.,_____
BILL SUBMITTED BY:
Mailing add,c;s:
CIIAMDERSDIJRG IIUSPIT AL,
1'0 BOX 897, "
CHAMBERSDURG, "A 17201
!>Ule'
Medlcllre
_ A pprllved
S(,f
Not.,
11.11111
S.n'lee, IIl1d ServlCl' Clld.,
Clllllrol r,umb.., 97010.169H200
CIIAMBLRSBURG 1I0SP EMER
1 Che,t x-ray (71010-26 )
Professional Ch"rge
Chnrll!
Dee 26, 19%
S IH .110
$ 8,9~
Del' 26, 19%
COlltrlllllllmh.r 9701().21iM600
I EleClrocardiogram report (93010-WJ )
Totlll
f
S
11.12 a
20.114
22.00
40.00
f
$
NOTES:
a The approved amounl i, bn,ed on Ihe fee schedule,
GENERAL INf"ORMATION ABOUT MEDICARE
If YOII mnke a permanent change in YOllr address plea,e cOlltnetyour 10c,,1 Railroad Rrircm,'nt noard Office..
Medicare covers vaecinntioM to prevent pncumococcal plleumollia. If you've nev.r had a pneumococcal
'fl.;, pne'Jmonia ,hOI, prolect your,elf and get one, now, If your provider accepts what Medicare pay', there
,i:;';:' ,houldn't he a charge to you.
'''1/,1 '^ ' . ,
. ~ , '.' 1 " .
, ":' Tbe Medicnre Dil'i,ion of MetmHeahb bM become the Medicare Division of Ullited HeahhC'arc
, , i\,.lnsurallec Company, YOll will notice the Ullited HenhbCllre nnme being u,ed in !j/alemelll'
",:,and lIlai\in~' from u" Office loeatioll', pbolle number,. nlld ,taff members will remain the ,ome,
';,:1'bis ehllnge wi/I 1101 affect your coverage!;;:," , ., "r " ';
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l\" 'j-:: "', -' '., .'-,,' .'::~l./ ':, -;~r" '.. \ I' ,,/.// I , ,}
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t.~I:~(rr....'I..'..", f" ~l:'l.".;'.-,ll~, t;
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'li;IMPORTANT: lf~'olll;nve qUWlons'~~~i41~i~~*~G~~; call Ih~ MNII~~re cnr~l~r nllJnlted lIenlthcAre In~ g;~if~f~~~lJ:~"
':!'~;1.800.lm.44S5 or m liS ", t 2743 ptrlme, ttr P, ,ar~~IlY, Augusla, GA 30909.4576, Vou 11111 need Ihls notice ',.,);ilit:j;l',~;:<:,n",
...If you con lac IUs,. , ' ",:!,~;'\; " " "!'/>:I,lii';'",';"
, To appenl oU/' declsloll, yo~ musi wrlte.lo:us .bcCore AURII't 05, 1997, See #2 1I111he hnck, 'i":l: . :;';}'~~:4;~.,
a
[,==,:;====~~~=~r. --J
MAKE CHECK PAYABLE AND REMI'f PAYMENT TOI
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ... RETAIN LOWER PORTION FOR YOUR RECORDS -411
R 'EV: iS4"j "Eif" Af'ji"f of 97 T" NorY c r "oF" r NitER it ANCE - TAX - APPRA"isEifEN'r;" AL row Aifci!"' 'OR" - - - -- --" - -" - - - --
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TA)(
LILLIAN S FILE NO, 21 97-0152 ACN 101
If an assessment was issued previously, lines 14, 15 and/or 16, 17 and 18
reflect figures that include the total of ~ returns assessed to date.
ASSESSMENT OF TAX:
1S, A~ount ~f Lina l~ .t Spousal rete (IS)
1.. AMount of line 14 t.x.bl. at lin.DI/Cl~sl A rat. (16)
17. A.aunt of Lina 14 t~xabl. at Coll.teral/CI... 8 rat. (17)
18. Prlnclp~l Tax Du.
TA)( CREDITS:
PAYMENT
DATE
I"~ /./ /1(
,
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU Of INDI~IDUAL TAKES
IHUiRITANCf TAil DIVISION
Dn'T, 1I0601
UARNUIUftO, PA 11UI\"0601
NOTICE Of INItERlTANCE UK
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
Of DEDUCTIONS AND ASSESSMENT OF TAK
RICHARD L BUSHMAN ESq,
PO BOX 51
SPRING RUN
DAn
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
02-09-98
QUICK
02-03-97
21 97-0152
CUMBERLAND
101
PA 17 262
ESTATE OF QUICK
TAK RETURN WAS, (X) ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST- - SEE REVERSE
AI'PRAT.SED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. R._l Est.t. (Schedule A)
2. Stocks and Bonds (Schedule 8)
3. t.lol.ly H.ld Stock/Part~.rshlp Int.reG+ (Schedule C)
4, HortOMges/Not.s Receivable (Sch.dul. D)
S, Cash/Bank Oepolits/Hisc. Personal Property CSchedule E)
6" .JoinHy Owned Property (Schedultl F)
7, Trlnsfers (Schedula G)
8, Tobl Asseta
CHANGED
(11
(2)
(3)
(4)
15J
("
(7J
.00
,00
.00
,00
2 ,339,58
.0lL
,00
(8)
APPROVED DEDUCTIONS AND EX~MPTIONS:
9, Funaral ExpanseI/Ad~. Costa/Hilc. Expanses (Schedule H)
10, Oebta/Mortgage Liabilities/Liens (Sch.dula 1)
11, Total Deductions
12, Net Value of Ta~ Return
13. Ch.ritable/Governnantal aequests; Non~.l.ct.d 9115 Truste (Schedula J~
14. Net Value of Eatat. Subject to T_x
(9)_
(10)
1,110.50
4.28(,,25
(1l)
NOTE:
,00 K ,00=
.0l!.K,06=
,00 K .15=
(18)
RECEIPT
NUMBER
DISCOUNT (')
INTEREST/PEN PAID (-J
AMOUNT PAID
l..~
*
U1'1'~1 i~ '" llt."1
LILLIAN
s
DATE
02-09-98
NOTE: To insure propor
credit to your Mccount,
sub_it the upper portion
of this for. with your
tax payment.
2,33~
(12)
(13)
(14)
..5...32.."1...1.5..
3,055,17-
,00
3,055.17-
will
,00
,00
,00
,00
;00
,00
,_---.:~
,00
-- ,
If TOTAL DUE IS LESS THAN 'I, NO PAYMENT IS REQUIRED,
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND, SEE REVERSE SIDE ~F THIS FOR" fOR INSTRUCTIONS,)
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
. IF PAID AFTER DATE INDICATED, SEE REVERSE
fOR CALCULATION Of ADDITIONAL INTEREST.
RESERVATION, E.t,t.. of deo.o.nt. dying on or b.fore D'a.~.r 12, l'8Z ~~ If In~ future Inttrt.t In the t,t,te I. transferred
In po.....lon or enjoy.."t to CI,.. . (collet.,.el) beneflclarl., of the d.cedent .ft.r the IKP!r,tlon of ,"y ..t.t. for
11f. or fot y..,.I, the COIII.onwulth h.rtby I)(prulh r...,.v.. th. rllMt to ItPprlh. and ...... tren.fer 1nh'rltanee h)(e"
.t thll IItwf\11 Cl... D (coUat.rlll!) rate on My luch future Int.r..t.
PtJIlf'OIE OF
MOnCEI
To fulfill the ~oquir.~.nt. of Stet ion 2140 of th. Inh.rltance and Ewttt. T.~ Aot, Aot 21 of 1995, (72 P,S,
Stction 91401.
p~wtENr I
O.tach th. top portion of thl~ Hotlol and tub~lt with your pay..nt to th, R.gllttr of willi prlnt.d on the rev.r.. lid.,
--Hek. ch.ck or Mon.y ord.r pl'ilo'abl. to! REGISTER OF NILLS, AGENT
REFUND (eft) I
A refund of II talC oredlt, which wo, not requnted on tha hx Heturn, lIay be f'Clq~l..bd by cOllfl'htlng 8n "Appllcetlon
fo" Refund of PennlylvlInll!l Inherit&nCl and Elhlte Ta)(" (REV-Un). Appl1c.atJon, at. .vellnbl. nt the Office
of the R.;l.t.r of Will., eny of the 23 R.v.n", OJ.triet Offlc." ar by onlllng the sp.cial Z4-hour
"',"'r,tng ..rille. nu.m.rc for forM' ord.ring! In r.nnlylvenle 1~800-362-~050, outside P4tnn')llvani. (tfld
within loc.! Harrl'burg sr.. (717) 787.~094. TOni {717l 772-2252 (Heftrlng IMPair'd Only).
OBJECTIONS: Any pel'ty In Inte,...t not utIlfled with the appr~h"lInt, allowance or dh.llowam:. of deduction" or ....IIHnt
of tel< (Including discount lIr Interllt> fl. Ihnwn on this HatJu MUlt object w1thin ulKty (6R) day. of r,c'llI't of
thh N:ltlc. bYl
~-wr1tt.n protut to the PA D.pftl'tll'nt of R.....nu., BO!lrd of Appllah, DlIpt. l61021, HtlrrIsbura, rll 17121-1021, OR
--.I&-ctlon tn ha.... the llIatter deterllIn.d lit nudH af thfl account of tM p.r.onal r.pr...ntetlv., OR
--app.al to the Orphan.' Ccurt.
ADHIN
ISTRATIVf:
CDRRECTIOH.'\1
Factuel error. dl.co~.rwd on this a~"I...nt .hould be .ddr....d In ~rltJno tOI PA Depart..nt of Rev.nue,
Bur.au of Individual T.~.., lTTN! POlt AIs..,..nt R....I.w Unit, Dept. Z80601, Harrl.burg, PA 1712'~0601
Phon. (117) 787-650S. S.. pn". 5 of the bookl.t "In.truction. for Inh.ritance Tal< R.turn for II R-uldtnt
D.c.d.nt" (REV-ISOl) for an ."planation of ad.Jnhtrl!ltlv.b correctflbh IIr"orll,
Dl$COlIIT:
If WlY tal( dt.M is paid within thr.. el) cnl.nd." lIonth. IIft"r the d.ce.lt'. duth, a fl.... p.rcM\t (S'<:) dhcount of
the tax paJd I. allowed,
PENAL TV I
The lSiC tax I'M..tv non-partiolpatlon p4tnllb It 4'laflut.d on the total of thl tllX and lntllr..t .......d, end not
paid b.for. Jamlary 18, 1996, the Urllt day lifter th" and of tI'.. hi)! Illlfluh p.rlod, This non~p.rtlclpatlon
penlllty 1. ~pp'81.bl. In the I....ann.r and In the the ,e.. tl.. p.rlOd a. you would .~p..l the t~~ and int.r..t
thllt h.. b..n .......d .. indlclIbd on thlt n(ltloe..
INTERESV 1
Int.r..t I_ aharu.d beginning with flr.t dfty of d.llnqu.ncy, or nln. (9) ~th. and on. (1) day frO* the dllt. of
dt.th, to the det. of pay..nt. T.~.. which b.o... u.llnquant bafnrl Janu.r~ 1. 198Z b.ar lnt.r..t et the r.te of
.Il< (6:{) P."ClIflt ~r ~ cllcuht.d ot II dlllly rat. of .000164. All tau. which b.en. dellnquent an wid aft.r
JerRI.ry I, 1932 will bl.r Int.r..t at a rat. which will vlr~ frol oal.ndar y~ar to oal.ndar Y.lr wIth that r.t~
.,...lOUflC4td by tha PA Oepart..nt of Rav.nu., Th. IIppllcabla Interllt ,'.t.. fM 1982 throUifh 1998 Irll
~ Jntllut Rmha Dally Inh,."t Fnctor Y.!!! Inbr..t Rat. Dally Int.r..t Fnetor
1982 1.0:': .000~48 19&7 9% .000241
1983 1'" ,000438 1988~1991 11% .000301
19M 11% .000301 1992 .~ .0002'7
1985 13" ,OOnS6 1993-19~ ,~ .000192
1986 10iC .00027' 1'95-1998 ., .OOGZ41
R-Il'lte,...t II ctlcul.t.d .. follow'l
INTEREST. BAUNCE OF TAX UNPAID X NUNBER or DAYS DELINQUENT X DAILY INTEREST FACTOR
"'lny Notice i..uad .ft.,. the t.lC beooa", dellnqu."t will r.flact ." Int.rut r.alculatlon to fJftun OS) da".
blyond ths dilh of th. .....u..nt. If pl!lYlllnt 11 aIMN aftllr the Int.r..t COllf.'utlltJon d.h .hown on tM
NoUc., addJtlilnal Int.r..t ault b. a.loul.tad,