HomeMy WebLinkAbout97-00573
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OATlt Of PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA 1 5S
COUNTY OF CUMBERLAND
The petlliDner(s) above-named swear(s) or afnrm(s) that the statements In the foregoing petUlon are true
and correct to the best of the knowlEdge and belief of petitioner(s) and that as personal representatlve(s) of
the abo~'e decedent petltloner(s) wll1 well and truly administer the estate according to law,
/-.J~h.(D MCl)!J1 ,) /
Sworn to or afllrmed and sub- -g
scribed before me lhi~..2.!.taay of i
,1tll,Y _19 --U j
'-..~U\J~ (\, ~ii'A'~rHV I\lA1).lW}~Mq
MARY C, LEW\llS For tiiid~e,lster
No. 2.H'fq'1-D~13
Estate of _ Daleter A. Shaffer
. Deceased
'GRANT OF LETIERS OF ADMINISTRATION
AND NOW
JULY 10
19 97
. In consideration of the petition on the reverse
side hereof, satisfactory proof havll1ll be~n presented before me.
:'
IT IS DECREED that Tvlice Mark"
r)r'J
C':: ~:. J J
~ I "C"i ,.~
is/are entitled to Letters of Administration. and in accord with such finding. Lelters of Administration
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are hereby l1'anted to Tylice Marks
l<
1>
in the estate of
n.RiYrAt" a
. Q,h.::tof'-FIOY"
MARY C.
r~,r,C~J (1\ "J jf;)~L.VfV)~4Jy-
I.EW,S Register af Wills
FEES
,
Letten of Administration S 25.00
Short Certllicates ( , S 24.00
Renunciation S 15.00
JCP 5.00
S
69.00
TOTAL ~
Filed JULY 10 19 91
Scott W. pohlman~~suire. 78004
ATTORNEY (Sup. Ct. LD, No.)
ROBINSON & GERALDO
P.O. BOle 5320, Harrisburg, Pennsylvania
ADDRESS ! I U U
(717) 232-8525
PHONE
ThiJ il\ to twtil}' thai till' itll(ll'IlIillioIlIH'I(, gi\'~'ll is ltllll'ld:l' ((lI'I('d (IOlll ;11\ /llil',lld :ndflt;IH' of d~';llh tllIl)' lill~d with 1I1l' ,I"
I.ol.:al H<'l~i"'lfill', Th(: llriglllill u'lIilil';H(' will hl' /;lIWMdl'd In Ihl' SLUL' Vit.t~ 1{('UIIII" ()H!(,' 1;11 pnl1l;uH'1I1 filing,
WAI1NING: II Is llIogal to dupllcato this CDPy by photostat or photDgraph,
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/ Date
No.
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COMMONWEALTH 01' PENNSVLVANIA' DEPARTMENT Of HEALTH' VITAL REC(lMDS
CERTifiCATE Of DEATH
(Colon..)
f'l'fMIfIlN'
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sn SOCIAl.IIQUlllfYNlMNIl
Sholl.. , H.h 198-74-8183
iMIlO1iiRtil~'~l~lAl;IIC~I"d l'I.ACI llIAhtICNd"'ctt"''' "'''''''''''''''''OUOll''''']
11Juo..04,.....'l ~..'w'"f,,~'C..W1'11 ~~ . o~
July 11.1980 tarrishurg. Pa "'PI1......Ll IlIIo..q..,...~~ 1lQt,(1 :::'CI
tlI:Aftl F'ACir. ,.....MAMll~r"~...""'..., lJ""''''''''''''';;t:..) OIHlOl'HI .
I'Cllusboro Splr it llosp1tal
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'OIDI,qH(Mc>I"'~_""')
4 June 16. 1991
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~- _~M__' WOIlIfA.IN"IoIil!f...-......."..""'...1
Ha~~Shaff.r , Carolyn Marks
..rryP':>lri's~~affer ~~Ila;r:rket,~;~'~;than~csbur9. PI 17055
ial5fDllPOtl,~ 4 .~. 5mofoi,jiijjiTIOfl iiWiif!OO,JOtmeQlc_....c,_y l~.......I.~
. . ..,...111 "_I....U f\4'......h..n...,.l} 1......,11.1_) Ofoo..l'\to;.
~LJ "'4l>i*"I~..~.-..~--_.____.1 j June 19 199'1 Gate of Heaven Cemetery
"AL" lH).....-.'1 L~IIC.HII!~" -- -,HAr:iii!AAOAiiOiinotMClln, Myers
_.____1... -olllili~~,--1u.--;11-
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pa 17,055
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......MAU1QHV'If'llllHO. IWAHNI"OI~IIH
d; 'Htily Spirit Hospital
e. West Shore EMS
f. ~obinson ~ Geraldo
(Elltate Reimbursemsnts of
Robinson & Geraldo
(Estate Administration
Administratrix Fees
g.
$1,436.~0 (See Exhibit "E")
$ 747.03 (see Exhibit "F"~
$ 69.00 (See Exhibit "G')
CostBfor the Estate)
$ 2,000.00
Fees)
$ 5,000.00
$18,754.83
h.
TOTAL
8. The following settlement has been proposed: payment of the
poUcy Uability limits offered by State Farm Insurance of
$100,000.00, and payment of the policy Uabi li ty limits offered by
Allstate of $25,000.00.
9. Counsel is of the professional opinion that the proposed
settlement is reasonable based upon the foilowing: The insurance
liability limits maintained on the driver's vehicle were ,
$100,000.00/$300,000.00. The driver of the vehicle was negligent when
he wrecked his vehicle, causing the decedent to to be ejected from the
vehicle and causing his death. The Insurance policy provides for a
maximum of $100,000.00 to be paId to the Decedent's representatives.
In addition, the Decedent's Mother maintained an underinsured motor.1st
benefit with a prlicy limit of $25,000.00. There are no other parties
against which negligence may be attributed. Therefore, according to
20 Pa.C.S. Sec. 2103, the representatIve of the Decedent are entitled
to $125,000.00 under the insurance policies.
10. Petitioner is of the opinion that the proposed settlement is
reasonable.
11. Counsel requests counsel fees in the amount of $41,250.00, an
amount which represents thirty-three (33%) percent of the net proceeds
of the settlement, an amount less than that agreed to by the parties
in the original retainer and fee agreement attached hereto aB Exhibit
ItH".
12. The reason for the requested allocation is aB follows: the
costs aris.1ng from the decedent's death have been allocated to be a
survival claim. Part of the settlement will be used to satiBfy the
costs listed in paragraph 7. All of these costs arose directly from
the decedent's death.
13. Pursuant to the Wrongful Death Statute (42 Pa.C.S. Sec.
8301), the beneficiaries of the Wrongful Death Claim, and the
proportion of their interest, are as follows:
~
Harry Shaffer (father)
Carolyn Shaffer (mother)
M\Q.unt Due
50%
50%
Register of Wills of CUMBERLAND County, pennsylvania
Certificate of Grant of Letters of Administration
No. 1997-00573 PA No. 2197-0573
ESTATE OF SHAFFER DAXTER A
{1.oI\l:j'l', r !Kln', 1'111)1)1.01:; ,
Late of
HAMPDEN TOWNSHIP
~U"~~~LAAU ~UUN'rl,
Deceased
social security No. 198-74-8183
WHEREAS, SHAFFER DAXTER A ' late of HAMPDEN TOWNSHIP
\~^~~, f~~~,~,'"!uuu~J ---
CUMBERLAND COUNTY , died on the -1!~ day of ~une 1997;
and
WHEREAS, the grant of letterll of administration
required for the administration of the estate.
, Register of Wills
, in the
Letterll of Administration___
" 'I~"
THEREFORE, I, MARY C. LEWIS
i
I in and for the county of CUMBERLAND
I -
icommonwealth of pennlly1vania, have this day granted
I to TYLICE MARKS
\ ( 1.01\::1'1', r 1 K::l'l', 1'1 1 lJlJL>r. ,
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\ who has duly qualified all administrator(rix)
,- -
1 of the above named decedent and has agreed to administer
, -
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i to law, all of which fully appearll of record in my Office
I
i COURT HOUSE, CARLISLE, PENNSYLVANIA.
! IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my Office on the lOth day of Julv 1997. '
ll1~~Jn~
..NOTE"
of the estate
the estate according
at CUMBERLAND COUNTY
ALL NAMEIIIiIiIiiii (LAST,
FIRST, MIDDLE)
(.
ADDITIONAL TftAMS AND CONOITION8
Seller aOfl'l lhat upon reoelpl of Ihe deferrecl payment price' set out herein, uponreQu..t of the Buver, hll
helt. or ...Ignl, S,lIer will oellver 10 th, Buy,r, hl$ tleir\!l or III"gnl, Ihe lIems enumoraled and Mslonate<l ..'
Ilu,ch..ed hereunder, !ublecllo the following Itrms and condltlonl:
1, INTIIlMINT II'ACIS (InClUdes ground and cryptS): II il distinCtly underotood lh.1 . .um will be .e' aside
wilh Clther similar sums, by the Seller. In I genera' pe'mam~nlllll oare f\lnd, Thelnaome ',om Ihll t~nd II to be used
lor Ihe general aare and pr..ervatlon of thili Cemelery'l grounda, and for the maintenance, repair, ,enewal end
repleDement 01 all Improvement, bullcllngs and properlY of aald Cemeterv, Including admlnlslratlve ove,htad
applloable 10 luch Dare,
2, MIMOllIALS: Seller aorees to Inslall, upor, full paymenl of Buyer, his halre or "llgns, memorial I II enum.
erated Indd..lgnaled as purohllsd her,under Said memoriall shall oonllll ola bronze marker afllMed 10 a base,
.uah as la aommonly lold by Seller, Slid memorial I mav bfar Ihe name end year of birth and dealh Ollhll
Individual and inltallatlon Ihall be macle In the Cem..ary of Seller,
3, IUAIAL VAULTS: ThaI upon order 01 the Buyer, nls helro or assigns, il enumeraled and designated as
purchased, Ihe Seller will provide and Inllalllor Interment In Ihe cemete.y 01 Seller, burl,1 vaultl 01 adult Ille, Said
burial vault. sn.1I be made ot relnforoed concrete, lid, and sealed, Seld burial VIUUS Shall be coaled wllh an
IIphalt bile or llnal oOllllng,
4, C"VPT SPACE: Upon complellonol all paymenls by tne Buyer, tne cemetery aOtlol to Issue to Ihe auver an
I!asement to the above burial rights, but subject to.1I of the RuleS and RegUlations ollne,cemetery now exlsllng 0'
which may hereallsr btldoptect 10' lhe government 01 the cemetery end the crypt.
The ceme18ryshell nave full control 01 all of the del,lIs of design, arrangement of crypts, speClllcatlono 01
materlol, and conetructlon of the crypt, The purchasepflce includes all charges lor continued care, m,lnlenanee
and edmlnlalrallon ollhe c,ypt and of tne oemetery,
- -
-
- ,-"-- ---
.--
,- ~,-
The Oioceaan Oalhollo Cellleterles Office Is available to assist you In cllrnelory mailers, SlIouldyou have any
problem 0' quesllohs with pavments 0' ooncerns about you, pu,cn,,,, ple..e contact u. al:
Olllee 01 Flnanol,l Admlnlslrellon -. (717) 657,4804
Ollloe 01 C,tMlIc Cemeteries - (717) 657.4804,
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...
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Mejor Olooe..n Cemelerles:
All Saln's, Elyabu,g - (7171672,2872
aate 01 Heaven, Meonanieoburg - (717) 697.0206
Holy Crols, Lebanon - (7t7) 273,7541
Holy Saviour, York - (717) 764,9685
Resurr.ollon, HlIrrleburg - (717) 54504205
St. Josepn's, Lancaster - (717) 394.2231
-ry,
7?u.::;.f..5~"" .:f,,~N 4C'Y'1',
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IlA$EMEN1 NO,
NAME ESrllfrE lJF )).,.qX7"e.e ,:J. S'h'A,,:'~1Z PHONE (
AODRE"~/.AI?h*'~/t#y
CITY .P--~I($v~'
$AI.E$ CONTIlACT AND
TEMPORARY BURIAL AGREEMENT
DATil '7)1~-7~ 7,. ~~' 1 22'
cEMmA~F~/A/;w16N _ NO, .a
SALESMAN NO, AIN JL'IN _
A/fl.,
~9?~
DIoa. .. of """"1Ibwg
tm PoM ClftIDe 1!Iol( 3851
HBrT1lillrg, Pema)llv"",,, 1 71M
Office d Colt1ollc Cemeteries
In.elm.lIIS",.. ",. , ,. ___ S
1, ,riOt. . . . . . . . . . . . . . . . . . . . , . . . , . . . .
2. D' "1t, .JItiFtnA'U"~
own .ym.nt... .V. . . . . . . . . . . . . . . , ,
lI, Unpoid 1.1....11'21 ,.,., . , , , , , ' , , , , , .
", Fln...oe Ch.... ' , , ' , . . . , , , . . , , , , , , , . ,
6, 0.1.,,,,,, '.ym.nt Amount (3'''' . . , , , . , . , .
e, TOIlI P,loe (I....' ' , , , , . , . , , , , , , , , , , , . .
_ FAMILY PROTECTION
"lATE.A 2IPCODI L.:lJ.J".5'
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1r0ll.. MtlllOfiolt ,(, , , .
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Fo.Ad.tion. .. ..I.. , ... S ~~ ~O
U1X ItGr64A/Hd
8uIllll Voulta . , . , , , , , , . S
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CtYPlS_. .,. ,.,.. ..
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7, App,o_lmot. Monthly Poym.n. , . , . . , . , . , ,
1i.'lIIum,*ol MOIIthly '.ymonll . , , , , , , ,. ,. ,
t, Filtt Monthly P.vm"'t Ou. .""",,'..,
10, Annu.I'.retnt". RIl' ". . . , , , , , , , , , , ,
Othel~4f~",.., $ 71P: a'J
.2
Lal 27 / c"..(s)L_
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C..h
1.71a""
Seelion
Block
_Clypl(Il ,
gO DIY'
S.loctlon mu.. b. modo wilhin 30 dlY. 0' o....t.ry will m.k. choice,
Intt.llm.nl
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_ The poym.ntl. duc on th. dote .tIled aboVll ,nd th. r.mllnlng p.ym.nll on th. ..m. day of e.oh .u....ding month,
_ lIuyer nuy preplY in ad.lnce the IoJ I Imount due wlthou, pen.lt. ond will b. entilled to . propOr1lon.te r.fund or I'" unumod
finance chor9l. ,
_ Upon d.I....11 In th. p.ym.nt of .ny in.Ullmont due here"nder 10' . PIII.d in OKCO" 01 on. hundrld lwen,y , 1201 d.y., SoIl..
"'IV. .111. option, .old Ihil .gr"ment and retain .11 plym."t. mid< by 8uye, .. liquid..ed d.megel,
_ Buye, ""eby ocknowltdge. re..lpt 01 .n '''<I..~utod copy of Ihi. '9""".nl II Ih. t 1m. of ox"ulion h..tol,
_ B.fore illY burl.1 I. p.,mllltd In Ihil 101, or .ny m.mod.1 pllOOd on thlllot, th. ,,'lot 01 Ihq gre.. .nd momo".1 mUSI be pold
,,,lull.
_ The PUlch...r(s1 ogroo(.) 10 sbld. by .11 rul.. .od IIOul.lion. 01 Ih. comelery now in fcre. at woll "' Ifty ruin Ind "'9~IIIon.
Which m.y horelfter b. .dopt.d, S.id rul.. Illd regulatloll. m.y "" 'el" upon reoun' .1 tho Soli,,'. of lie.,
_ Upon lulflllm.nt or Ih. ennditionl 01 Ihl. .o,..m,nt and rece'pt 0' .lIlh. Ibove do.crib.d p"tntnll, S.lIo, ogre.. and bln<l.llI.lf
10 co"wV to the Buy.', bV III e1lmelery ..'.nllnl, tor Int.rment pu'po... only, tho .bollO m."tionod number 01 .ite.,
_ YOU, THe PURCHASeR, MAV CANCEL THIS TRANSACTION AT ANV TIME PRIOR TO MIONIGHT OF THe THIRD
BUSINESS OAY AFTER OATE OF THIS TRANSACTION, seE THE ATTACHED NOTICE OF CANCELLATION FOIIM fOR
AN EXPLANATION OF THIS RIGHT,
8'1'
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(Authorllld I'Iep
('urehlt"" Slgnlllurel
NOTICE, Se. other .ide for tddilionlllnformltlon,
(Co'purch....'. Slgnalult)
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see I SEe L I L oeH .:K1::lSdV HO~.:l
H~19'01 L661-LI-L
9'd
-~yer~
Funeral Home, Inc.
BOYD L, MYERS, JR" Supelllltor
37 E, MAIN STAEET
MICMANIOSIURO, PENNSyLVANIA 11055
(117' 7ee.~2t
BOYD L MYIA'
P,..ldlnt
TO
Harry P. Shaffer
6121 Hay~rket w.~
---.
Meehanlesburg PA 170SS
FOR THE FUNERAL OF
Daxter Shaffer
- ,
June 19
1lf)~
i\emlzedAcccunt On InSide pag.,
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1~'>t19'I!H LeehLI~L.
\~;~)~i~\W@U..~"~-;-':J'i\,~---
CUMBERLAND l,;OUN1'V, PENNSVLVANIA
/Iv' 'IT PROBATION lINU PAROLE O~ CE,
1 COURTHOUSE SQUARE
CARLISLE, PA' 17013
April 03, 1997
liE I CASE NO.
PROBATION NO.
PROB OFFICER NO.
30009"'1996
198748183
bAXTER A SHAFFER
6121 HAYMARKET WAY
MECHANICSBURG PA 17055
865.67
50.00
100.00
4/03/1997
TOTAL AMOUNT DUEl
AMOUNT PAST DUEl
NEXT PAYMENT AMOUNTI
DU,E DATE:
..,.. .,... I
Dear Mr. SHAFfER I
You have tailed to remit the amount that was due on your court imposed
tinancial obligation. Thus, I will expect a payment of 100.00
no later than 4/19/1997.
It i8 imperative that you comply with the payment schedule that was
previOusly established.
It is expected that you will give this matter your immediate attention.
Sincerely,
BARRY E. HAIR
Collections Supervisor
'.'10
','
_.' ..,
..,....
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PAYMENT INSTRUCTIONS
CHECK OR MONEY ORDER PAYABLE TOI
MAI~ PAYMENTS TOI
(InclUde Ca.e No.
on payment)
CLERK OF COURTS
CLERK OF COURTS
1 COURTHOUSE SQUARE
ROOM 205
CARLISLE, PA 17013
CLERK OF COURTS
COURTHOUSE
IN-PERSON PAYMENTS:
Exhlbll
PA 17013
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I ~[[]iiM~S;'~m1 CIIO..ROI DA~B
HOLY'SIIt/lIT HOSPITAL
IiOJN al8T IT '
CII"I' HILL, I'll
111 1n~llt41
Ftl' t~-jI1e147
T. & 'AlI""""'-
SHAFFER ;"DIIXTER
_-=E^T!INT ....".
-l
-:O~B,.... iN UAAII;.JI COMIIA,NY NAUI
. HWtttll POUC H . A
IIWoAA-nOIll
HARRY SHIIFFER 1 AUTO INS
6121 HAY"ARKET YeAY J' _2" BLUE CROSS J61
"ECHANICSBUR;,~II 11055 _.
ED GROUP
PLEAse ReTuANTgl;~~T'I~t;'~,iTH'<OUA PAYMeNT,7~"'~1 '=!~~)',
OI"."lION o. aEIVIO. TOTAL .." COVI...Ol ur, covr......r 'ST, eow.....1 lIT, ClO'/IIV.QI
Hc)P1l'AL SlAVIC" 0001 CK'I"QI!S iN$ co NO.' IN::o. 00, NO.' IN' co NOa 1Nt. -eo, NO,4
,,,,,IN1'
AMOUNT
..",..
BOt 6436145
...
-
..TO
"","0
'ETIII OF CURRENT CHAII;ES, PAY ENTS AND ADJUSTIIE 'TS
/16 TRap O.ll1a SYII0144120019 S,OO 5,00
/16 PI 0,1110 SYRIN06441204tB 15'1,80 tS'I.80
/16 PI Ilia/tilL 10"0144120"6 It,OO 1 t ,00
/16 EKTROSI! III 5001161'0502 8.00 8,00
/16 EXTROSE ill 100116 t 301002 $,00 8,00
/16 KG PADS FOUR'SO"410547! 4,00 4,00
/16 OLDER ENDO TUB011411e37' 8.00 8,00
/" AI; ADUl.T CPR 01141208tO 53,00 53.00
116 PONGE OVER ~X401141e3038 1. 00 1,00
'\6 11TH ~L SOCT 180114te5l!64 t ,00 1,00
'16 ORTUARY PACK 1I01141e6296 J~, 00 32,00
'16 NDO TUBE 9.0""0114t28961 8.00 8.00
,,. liS 1060 0116130614 11. 00 11.00
'\6 RS 1000 0316tJ0684 '3,00 :13,00
'u 1'0 IV sn 021613t03" ~2, 00 42,00
'16 TYLET lNT 14FROlIT20440S \3,00 13,00
'16 AIIDIAC ARIIEST 0121200005 tea.oo 1ee,OO
'16 ~OOD GASES otllaOa601 146,00 ''16,00
'16 TilT HIINDLlN~ FOI2S103'.0 13.00 13,00
'16 RTERIAL ~UNCTUOI2StOl)06 ",00 ".00
'16 XYGEN PER HOUII0150101047 19.00 19,00
'16 D VISIT LEVF.~ 01tl104019 252,00 as!!,OO
'16 ON-EVA EAR/PULOll?J055Se It,OO 19,00
't6 HYTH" ECG t-J 0ItTl0?J! 43.00 43,00
'03 AIIDIQPULH,RESUOl11J014S :145,00 345,00
0,00
Y OF CURIIENT CHARGES
~HARHACY 250 nO,80 110,80
IV THERAPY 260 16,00 16,00
'il>IMl. i~N' NO. 2)'1~\~''''
, :'q'v;, *'i'.lI': ._l.,~ "';'.:1';' (~'I~' .:' ',. '1'<::,-,',\',
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, \'. "
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o ~ NO ST 0 \HHI" T.~...L 'tV" PMtA
o. .. ,...u....... C,,",,'. lOOT "y AIN ',M
'HI .\40UNT. SHOWN ufolOf,., "11oll~U~ INI""A~C!
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,A'hIN't'fil\.tA.....
REFER AI..l.. QUESTIONS m TH~
IUSINESS OfFIQTi
(t11),a-ma,
E.hlbll
E d
PLEASE SEND PAYMEtn TO:
AL
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88
:)Sdv ~~O;>j.;j
I
INVOice
INVOloe II: (7ooS7m)
IiMf,~(1, "1"1' \I~, I(,AIQ~
,()) NQnh 2!tl $1,..,. Camp HIll, PA 17011-2204
(717) 761-1038. 1-800-367-0SI2 (PA Only)
I'1QlftA~ IQ. lI.a._
OATE: (. 06/1 51t 7)
-
ooal 07/11/81 .aN. 1'8-74-8183
PATIENT: IHA""IR, DAXTSR
.131 HAYMARKST WAY
~ICHANICI8URO, ~A 17055
BILL TO:
HARRY SHAP'FBR
6131 HAYMARKIT WAY
MBCHANICSBUftO, PA 170~~
POLICY NAME:
INS. II:
INS, II:
ACCOUNTII: 14619 TRIPII: 700!l7371
PATIENT PICK EO UP: LOCUST POINT RD
DAle OF SERVICE: 06/15/97
PATIENT TAKEN TO:
HOLY SPIRIT HOSPITAL
OESCRIPTION OF ILI.NESSIINJURY:
427.' CARDIAC ARREST
E819.9 HOTOR VEHICLB ACCIDBNT
OESCRIPTION UNIT COST QTY, ' AMOUNlOUE
HOIILI INT8NftIVI CARB (ALSI 456.8:2 I 4!l6.82
Ambul.now HIlv_a_ Charg- AI.S 5.0 10 50.00
CARDIAC MONITOR 60.00 I M.OO
MID BLIlCTRODES 77.63 I ?7 .1D3
ANOIOCATH (14-24) 4.14 ;) 12.42
:lOee SYRING8 !l.1 I 5. If.
oxv,sn Adalnl5tr.tlon 40.00 I 40.00
STI "NICK COLLAR 45.00 1 45.00
COMMENTS: ... "'eo wer. \In.bhl to obt.1 n .'Jit I 0 I vnt
lnfor..tlon .t the tlfte .ervio.. were rendered,
Pl.... coaplete the enclos.d fora .nd r.t~rn to
,u. &s soon a. possibl..
SUBTOTAl.
CREDIT
TOTAL
747.03 .
o..L-
E xhlbll '
u
l:'cI
RECEIPT FOR PAYMENT
c=~c===~===========
Cumberland County ~ Register Of W~1ls
Hanover and High Street
Car11llle, PA 17013
~:gitlt ~!;:7qbHiU
SHAFFER DAXTER A
File Number
Remarks
1997-00573
ROBINSON , GERALDO ATTYS
-------~----------------
Tranllaction Description
PETITION LTRS ADM
SHORT CERTIFICATE
RENUNCIATION HEIRS
JCP FEE
ChecU 004263
Total Received.........
,.'
Distribution Of Receipt --~-~-------------------
payment Amount Payee Name
25.00 CUMBERLAND COUNTY GENERAL FUN
24.00 CUMBERLAND COUNTY GENERAL FUN
15.00 CUMBERLAND COUNTY GENERAL FUN
5.00 BUREAU OF RECEIPTS' CNTR M.D
$69.00
$69.00
'i
I
. EKh1b11
CONTINGENT FEE AGREEMENT
JIWo, thotllldonlanod, do IppOint Gorald S. Robinson, Esquire of tho law fino ofl......OB
&. Oeraldo to iItIdtuto and m.slntain an action apiNt any penon ~ ~ or corporation who
may be I'OIpOIIIIblo for my/our claim or damaaCllU8tained on (0 / 11 or to
offllCt an amicable 8Ottloment. ~~.
JIWo aarco that out of whatever sum ia secured by my/our attomoys or by molus rrom;o A1h~~I;r' f, oJ-"-
above (capoIIIIblo parties, oiIher by way of sottloment or verdict, that sttomoy shaI1 rot
tl, ~C> porcont (.t()II~ of tho arou rocovory and in addi1ion thoroto, tho ClllpOIIIOI of tho IIIit, pretrial
;y diacowry, inYoItiption, modicaI export ovaluation(s) and 10JI0a1l, and tho fool and lOlpOftlIllI of
'wimelIOl, and otbor IlXpOIl8OI paid in handling tho fIlo, if any, shaI1lbon be rolmbunod to tho
raid attomclyI.
AD modical blDa lncurrod . a I'OIUIt of tho acoidontllncidcnt, whether oxponded by coUIIICI on
bohalf ofmolul or not, shaI1 be cbargoablo to my/our share oxclusivoly, ifnot prmoualy paid
by lnauranco. '
CoUIIICII'ClOl'YCl tho ri&bt to withdraw i( after lnvcatigation they beHove that thoro iI no morlt
in puI'lIUiDa my/our claim.
SbOilJld DO money be recovencl by .uIt or aettlement, said aUorneys sbalI bave no claim
....UJt me/ualor 80rvlces nndered, except u agreed upon In lIdvance.
CoWllOl iI not roquirod to tako appula either from llbitration or trialllllder tbi.a 19I'OOtIlent.
J/Wo horoby authorize tho raid attorneys to pay billa for modlca1 and hoIpltal treatment by
paymont dkeotly to phyliclans or hoepita/l concomcd from tho procooda of anymodica1
iItIuranco bonefitl recoiYod by tbom.
J/Wo horoby acknowlodae that Robinaon &: 00taId0 has undertaken thia roproacntatlon on a
contingent Coo aarooment . atatod abow. All a I'OIUlt, this Firm ia aharina in both tho riak and
rocowry roprdloI8 of tho number of holUl inwIted and baa vcatod intoroat in tholl' work
product and tho fllo and procoocla of tho CAICl. J/Wo autborizo raid sttornoys to notifY tho
appropllato inIurIMo carrier of their claim for foo and that tho inlurance canier shaI1lncludo
tbom . payee on any draft.
J/Wo f\uthor undontand that part of the foo . sot forth above wiD be paid to referral COlIIlMl
VlDari and 00I0mb.
J/Wo horoby ICknowIodp recolpt of a dupHcato copy of this Conlinaent Foe Aarcoment.
Dato; tD ,.f), L\ ,~
(717) 232-8525
"
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~T2 31997
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CERTIFIED TRUE
AND CO...R~E.9LQQP}
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'~.'~f1T 9, :ljq97
.-OERf)FIE[JTFll'.t1: ("J
AND CORRECT COPY
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
o 2, Suppltmtnlol R,'u,n
o Aa, Pu'u,. In'.'4I' Comp,omlt.
(10' dolt. 01 dooth ah.. 12.12.121
o 6, Ooe,d,n. Dl,d T,IIolt 0 7, Ooe,dtnt Molnlaln'd a LI.lng T,ul'
(Allach copy 01 Will) (Allach capy 0 T,u.')
ALL CORRSSPONDINCI AND CONPlDINtlAL TAX tN'ORMATION SHOULD.I DIRlalD TO, , "";';'" or
NAMI ;gM'~ MAII.lN ADOUU
Scott W. pohlman, ESyuire P.O. Box 5320
LI'HOHIHUMtll Harrisburg, PA 17110
717 232-8525
~~
COMMONwe..~rH 0" 'INtdy",.NIA
oe,.U'MIN' O' ..veNut
DC" 210001
H..UISlUIlO,'A 11131,0001
N 'S H"M I~A . "In', "NO MIOOU INIfI^"
Shaffer, Daxter, A.
OCI"~ "Cu.Uy NUMI"
O. . 0' 0 AIH
1/16/97
20, If Un' t~It, ""'n u... 11. ,n'or lho dIN....c. on Un' 20, ThI.I. Ih. OVIRPAYMINT.
II O--.z:"...._.-..._.l.............._DIU-._.IIIwnn_~I.a..,...._.....".UI&......... -
21. If lIn. 1111 .roalt' Iha.Un, 19. ,nit' th, dIN...nco an Un, 21, Thll I.,h. TAX DUI.
... En'.' ,hl'n'I'''' on the balan" dUI on lInl 21...
I, Inlt, Ih. latal al Lln. 21 and 21 A on Un, 211, Thl. I. Ih, BALANCI DUI,
M.k, Ch,.k,. "ilia ,., Ro I.,.." Will., A..'
II SURI TO ANSWIR ALL QUISTlONS ON RIVI.SI 5101 AND TO RICHICK MATH I
Und" p."oIU.. of pe'lury. I decla,e thai I hove ..amlned thi. 'I'''''", lncludln'1 accompanying tchedull' and lIatl"'I"'" an" to Ih.ltl.' of Ifty knowl.d,1 a l
It I, "U', C,.."ec I and comple'e, I d.clall ,hal all ,101 I.ta'e hell beln 'Ip.'" ll" I'UI ma,"" value. Oecla,allon .f Pllpa,., .,hlt ,ttG" ,h. ,.,....~I ,.P'IIII !
.....d .n .lllft'.,ma"." 0', which r. Q',' hot a" kftowlld I. -
~AIU" Of ..._ ...oo.. I , ,,,.. U .. A' DAN
I,j';, '~} ,[ 211 Schuyler Hall, Harrisburg, PA 17104 fjj~~';' '
"".N N .. IV . 01 ....;.7t"'JGO"
P.O. Box 5320, Harrisburg, PA 17110 ~,
198-74-8183
l" ...,,,1("""1 IU."'''INQ 'KNU" ......"". I\"U, 'II" ......0 ""100" 'NlII"'lI
~ 1. O"glnol R,'urn
o ~. Llmll.d hlott
I
I
1, R,ol E,'.I. ($chodul, Al
2, Slock. and tond. ISch,dul, II
3, Clo..ly H,ld SloclcIPa"ftO"hlp Inl.'OI' ($chodult q
~. Mo~.o....nd Nat.. R.....altl. (Schodul,.ClI
$, COlh. "'nk Otpo.lt. & MI..,llonaou. p,,,o.ol P,op'l1)'
(Sch,dul, E)
6, Jolnlly Own,d p,op'l1)' ISchodul, F)
7, T,onll,.. ISchtdul. GIISch.dul. L)
8, Tolal G'OIl ""... (total Un.. 1.7)
9. fune,al Exp.,..e., Admlnl'lrallvl COI", Mllc.llaneou.
Exp,n... ISchadul, H)
10, D.b", MO"go., L1ablllti.., U,n' (Sch,dult II
11, T 0101 D.ductlon. (tolol LI".. 9 & 1 01
12. Not Volu. 01 hlo" ILln. 8 mlnu. Lint 11)
13, Cho,lIobl, and Go.ornm,n'ol Ioqu.." ISch,dul, J)
U, Not Volu, Subl'ct to To. IUn, 12 ml.u. Un' 13)
15, Spou..1 T,an.'," 110' dot.. 01 daolh ohor 6-3o.9~)
k, '.",....10.. 10' Af,pllcobl. Porconl." on Roy,,,,
$Id" (tnclud, ..Iu.. ,om $ch,dul. I( or $chtdul, M,)
16, "m..nl ollln, 14 t...bl. ., 6~ '0"
(lnclud. ..luOl f,om Sch.dul, I( 0' Sch.dul, M,)
17, "moun' 01 Un, U lo..bl. 0' 15~ r.'.
Ilnclud, .olu.. f,o.. Sch,dul, I( 0' Sch.dul, M,)
II. P,'nclpoIIO' duo (Add I.. I,om Lln.. 15. 16 ond 17,)
19, C'ld1.. Sp",ulal '0'11"" C,edl' P,lo, Paymln"
.'
I
s
0"" O' 'I.'"
7/11/81
COY'
(I) -0-
(21_-0-
(3) -0-
(4) -0-
(5) $22,056.83
(6) -0-
(71 -0-
(9) $14,708.05
(lD) -0-
(15)
(16)
117}
$ 7,288.75
Ol,counl
+
\::.
-'
.0_ DAns o. DIATH A"I_ 12/31/91 CI'
IP A I'OUSAL
POYI_u.sUIIIT "CLAIMID 0
FILl HUMII_
e;2/
COUNTY CODE
ON "",un 4DO~CU
6121 Haymarket Way
Mechanicsburg, PA 17055
Cumberland
.I.MOUN .. .llveo I' INS RUe tON I
"'1
YIAR
,f;,1! :5
"
o 3, Rtmolndor R,lu,n I
(10' do'.. 01 d,a.h plio' 10 '.
o 5. ,.dotoll".t, To. Relu,n R ;
,
_ 8, Total Numbor 01 Sal, Otpe ;
- (8)
p2,056.83
(11) $14,768.05
(12) - $ 7,288.75
, (131 -0,-
(1~) $ 7,288.75
M,_- -0-
-
-;c -:n6 . 437.25
Ie ,15. -0-
(11) 437.25
Int.,...
(19)
(20)
-0-
-0-
(21)
(21A)
(211)
$ 437.25
--1-- 4.86
$ 442.11
... -
II.Ylto,".I'''1
~
SCHEDULE E
CASH, BANK DEPOSITS AND
MISCELLANEOUS
PERSONAL PROPERTY
COMMONWIA!l!I, 0' P1NNI\WANIA
IN'1fm:iHtl.:tc\lfNVRN
Shaffer, Daxter, A.
(All ",~.rty 10"'11,._..4 with tho Illhl .f ,""'IVOllhl~"~'1 ~. 41..1...4 .. S.h.4ul. 'I-~
ITEM
NUMBER
1.) Survival Claim
2.) stereo
3. ) Computer
4. ) Television
5. ) Cash
DESCRIPTION VALUE AT
DATI OF DEATH
$18,754.83
$ 2,000.00
. $ 1,000.00
$ 250.00
$ 52.00
056.83
l"'"",h .ddlllo.ol I...." . II" ,ho." If ,.0" 'Fo,.I. ......d,1
....
,,\Utllll_I""
ITIM
HUM.11l
~
COMMONWIAIIH 0' 'INNIYl\IANIA
INHIRIIANCI rA. RITURN
.UIOINr OICIOINT
5CH.DULI H
PUNERAL IXPINSIS,
ADMINISTRATlVI COSTS AND
MISCILLANIOUS IXPINSIS
Shaffer, Daxter, A.
DISCIlIPTION
A. Puneral "pen.e.1
I,
.. ,
2,
Myers Funeral Home - 37 E. Main Street, Mechanicsburg
Mechanicsburg, PA 17055
Catholic Diocese of Harrisburg - P.O. Box 3651
Harrisburg, PA 17105
Gate of Heaven Cemetary
Catholic Shop
.
I.
Admlnlotratlve Co.h.
Personal Rep,.eenlatr.. Comml..lon. l' y I ice Mar k s
SocIal Security Number of Personal RepresentatlwlI 1 94 - 64 - 1 2 6 7
Year Comml..'on. polc:l, 1 998
Attorney /'ee.
Robinson & Geraldo
31 FQmlly Exemption
Clalmont Relatlon.hlp
Addre.. of Claimant at decedent'. death
Street Add,...
City
.Stote
Zip Code
Probote /'ee. Cumberland County
MIHellaMaU. Ill...n.l.
TOTAL (141'0 enter on line 9, Recapltulotlon)
(If m.re lfNI.e I. _ded. ",..rt a...IIII....1 ......... ..I ..._.. .1__ 1
AMOUNT
$
$
$
$
5,032.00
1,070.00
710.00
87.05
$ 5,000.00
$ 2,000.00
$
69.00
S 14,768.05
IN REI Estate of Dexter
Shaffer
IN THE COURT OF COMMON Pl,EAS
CUMBERLAND COUNTY, PENNSYLVANIA
No: 1997-00573
ORPHANS COURT DIVISION
ORDER
AND NOW, this ~3'~day of D~ , 1997, upon
consideration of the Petition to Compromise Wrongful Death and
Survival Action Filed on , 1997, is hereby ORDERED
and DECREED that Petitioner is authorized to enter into a
settlement with defendant, State Farm Insurance Companiell, in
the gross sum of the one hundred twenty-five thousand dollars
($125,000.00). Defendant shall forward all settlement drafts or
checks to Petitioner's counsel for proper distribution.
IT IS FURTHER ORDERED and DECREED that the settlement
proceeds be distributed as follows:
A. To Villari & Golomb (Reimbursement of Costll):
B. To Villari & Golomb (counsel fees):
C. To Robinson & Geraldo (counsel fees):
D. Wrongful Death Claim (to parents):
E. Survival Claim (to administratrix of the estate):
TOTAL
$ 150.64
$ 13,612.50
$ 27,637.50
$ 64,844.53
$ 18,754.83
$125,000.00
Within sixty (60) days from the date of this final Order, Counsel
shall file with the office above Civil Administration an Affidavit
from Counsel certifying compliance with thill Order. Counsel shall
attach to the Affidavit copy of the Certificate of Deposit and/or bank
account containing the required restrictions.
BY THE COURT:
f.J:
~~...... '1'.~"~''"''''' ,.." ......'..':ifl{lYX
;,._~ '1'::I,{>lt,.,/, . -'t!lii;4"~.i'~.I.
. t. ;.;',.. ,', - ~".. ., ,.' !; \, 'l~ r:'I,-""",;.. . ; ...
IN REI Ellt~te of D~xter
Sh~!fer.
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No: 1997-00573
ORPHANS COURT DIVISION
PETITION TO SETTLE WRONGf'UL DEATH
~URVIVAL ACTION
TO THE HONORABLE, THE JUDGES OF THE SAID COURT:
The Petition of Tylice M~rks, Administr~trix of the Estate of
Daxter Shaffer, Decealled, by and through her attorney, Scott W.
Pohlman, Esquire, and Robinson & Gera1do, respectfully requestlll
1. Petitioner is Tylice Marks who was appointed Administratrix
of the Elltate of Daxter Shaffer, deceased, on July 10, 1997, by the '
Register of Wills of Cumberland County: a copy of the decree of the
register is attached all Exhibit "A",
2. The Plaintiff Decedent died on June 16, 1997, as a rellult of
a one car motor vehicle accident.
3. The claim was settled without institution of court action,
therefore, notice of the institution of the action as required by
Pa.R.C.P. 2205 was not sent as a Complaint was never filed.
4. Petitioner hall served copies of this Petition on the
intestate heirs of the Plaintiff Decedent as provided in 20 Pa.C.S.
Sec 2101 et ssq., who ~re as follows:
Harry Shaffer:
Carolyn Shaffer:
Tracie MarkS:
6121 Haymarket Way, Mechanicllburg, PA 17055
6121 Haymarket Way, Mechanicsburg, PA 17055
3610 Brookridge Terrace, Apt. 101, Harrisburg,
PA 17109
5. The heirs of the Plaintiff Decedent are all of the age of
majority.
6. The Decedent did not have a will.
7. The following unpaid claims have been raised and/or are
outstanding in Decedent's estate. See Exhibits "B" through "G".
Creditor
Amount Due
a.
b.
Diocese of H~rrisburg
Myer's Funeral Home
Cumberland County Probation
$1,070.00
$8,332.00
$ 100.00
(See Exhibit "B")
(See Exhibit "C")
(See Exhibit "0")
c.
d.
e.
f .
Holy Spirit Hospital
West Shore EMS
Robinson & Geraldo
(Elltate Reimbursements of
Robinson & Geraldo
(Estate Administration
Administratrix Feel
$1,436.80 lsee Exhibit "E")
$ 747.03 See Exhibit "F"\
$ 69.00 (See Exhibit "G')
Costs for the Estate)
$ 2,000.00
$ 5,000.00
g.
h.
~'ees )
TOTAL
$18,754.83
8. The following settlement has been proposed: payment of the
pOlicy liability limits offered by State Farm Insurance of
$100,000.00, and payment of the policy liability limits offered by
Allstate of $25,000.00.
9. Counsel is of the professional opinion that the proposed
Ilettlement is reasonable based upon the following: The insurance
liability limits maintained on the driver's vehicle were
$100,000.00/$300,000.00. The driver of the vehicle wall negligent when
he wrecked his vehicle, causing the decedent to to be ejected from the
vehicle and causing his death. The Insurance policy provides for a
maximum of $100,000.00 to be paid to the Decedent's representatives.
In addition, the Decedent's Mother maintained an underinsured motorillt
benefit with a policy limit of $25,000.00. There are no other partiell
against which negligence may be attr.ibuted. Therefore, according to
20 Pa.C.S. Sec. 2103, the representative of the Decedent are entitled
to $125,000.00 under the insurance pol.1cies.
10. Petitioner is of the opinion that the proposed settlement ill
reasonable.
11. Counllel requestll counsel fees in the amount of $41,250.00, an
amount which represents thirty-three (33%) percent of the net proceeds
of the settlement, an amount less than that agreed to by the parties
in the original retainer and fee agreement attached hereto as Exhibit
"Ji".
12. The reason for the requested allocation is all follows: the
costs arilling from the decedent'll death have been allocated to be a
survival claim. Part of the settlement will be used to satisfy the
COlts listed in paragraph 7. All of these costs arose directly from
the decedent's death.
13. Pursuant to the Wrongful Death Statute (42 Pa.C.S. Sec.
8301), the beneficiaries of the Wrongful Death Claim, and the
proportion of their interest, are as follows:
~
Harry Shaffer (father)
Carolyn Shaffer (mother)
Amount Due
50%
50%
"
,..__,.......;................,.'.....,..._ n
14. counsel hall incurred the following expenses for which
reimbursement is sought.
payable to Villari , Golomb
$ 150.64
15. cour.sel requelltll counsel feel in the amount of'41,250.00 to
represent thirty-three (33') percent of the net proceedll of the
settlement to be divided all folloWIl:
Villari , Golomb
Robinson , Geraldo
$13,612.50
$27,637.50
16. Petitioner requests allocation of the net proceedll of the
settlement (after deduction of COlts and attorneys feel) all follows:
17. The pecuniary losS suffered by the beneficiaries listed in
paragraph 7 is as follows: the amount requested fairly and adequately
compenllates the parents for the losS of contribution, society and
comfort the decedent would have given had he lived, including such
elements as work around the home, provisions of physical comfort and
serviees, and provision of society in comfort.
WHEREFORE, Petitioner requests that she be permitted to enter the
settlement reclted above and that Court enter an Order of Dilltribution
as follows:
Wrongful Death Claim (to parenti):
Survival Claim (to administratrix):
$64,844.53
$18,754.83
A.
B.
C.
D.
E.
To Villari' Golomb (Reimbursement of costs):
To Villari' Golomb (counsel fees):
To Robinson' Geraldo (counsel fees):
wrongful Death Claim (to parents):
Survival Claim (to administratrix of the estate)
TOTAL
Respectfully submitted,
ROBINSON , GERALDO
$ 150.64
$ 13,612.50
$ 27,637.50
$ 64,844.53
$ 18,754.83
$125,000.00
By, Svtt"-W. q> JJ?ot~,
scott W. pohlman, Esquire
4407 North Front street
P.O. Box 5320
Harrisburg, PA 17110
Attorney I.D.': 78004
(717) 232-8525
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Register of Wills of CUMBERLAND County, Pennsylvania
Cer.tificate of Grant of Letters of Admini.tration
No. 1997-00573 PA No. 2197-0573
ESTATE OF SHAFFER DAXTER A
\~~~, ~~K~~, "lUU~~1
Late of
~:~~e~e~~~I, ,
,
WHEREAS,
Deceased
Social Security No. 198-74-8183
SHAFFER DAXTER A , late of HAMPDEN TOWNSHIP
TLA~~, ~~n~4' R~UUu~J
"MBERLAND COUNTY
,d
, died on the _~ day of
19971
June
WHEREAS, the grant of letters of administration
required for the administration of the elltate.
THEREFORE, I, MARY C. LEWIS
and for the County of CUMBERLAND
mmonwealth of Pennsylvania, have this day granted Litters
to 'l'YLICE MAIUCS
("^~~, ~~nD~, "~UUu~J
, Register of WUl.8
, in the
of Admini.tration___
o h!!- duly qualified as administrator(rix) of the e.tate
the above nAmed decedent and h!!- agreed to administer the e.tate according
law, all of which fully appears of record in my Office at CUMBERLAND COUNTY
URT HOUSE, CARLISLE, PENNSYLVANIA.
IN TESTIMONY WHEREOF, I have hereunto let my hand and affixed the .e.l
my Office on the ~Oth day of July 1997.
m
VB APPEAR (LAST, FIRST, MIDDLE)
........ ,"'"",.. ,."MIlI ANII CONDITIONS
Sllllr Igrll. lhlt upon r,oelpt of the d",rr.el paym.nt prlc.. lit oul h.reln. upon reClu..t of lhl aUVII. hll
helll or 1..lgn.. S.1l11 wilt d.llver to thl Suyer, hll h.lr. or ...lgIII, the It.m. .numer.lld Ind dlllgnatldl.,
p\lroh..ld h.rtundll, lubject to Ihe 'ollowlng term. alld oondlllonl:
" INTI"MINT IPAC.I (InCI\ldng,ound and crypts): It I. dlltincUy und.reload Ihat . aum will bI.., "'d.
with "ther slmll.r .uml, by the SIII.r,ln I glner.' p.rmanunllct car. lund, Th.'ncom.lrom thlslund ,. to bl Uled
for 11'1. O.nerl' Clrt Ind pr...rvIUon 0' the c.m.t.ry" grOund., Ind lor th. m.lntenanol, rep,'r, r.n,wII .nd
repllclm.nt 01111 Improvlment, bUlldlngl and propeny 01 1.ld C.m.t.ry, Including IClmlnlltraUv. ovtrhtad
appllcabll to luch carl. '
2. MIMOJII'ALI: S.lIlr Igre'l to Insta". upon rull paym.nt of lIuyer. his h.lrs or "slgnll, m.morlals II .num.
.,.t.d .nd dlslgnlt.d as puroh...d h.rtunder, Said mlmo,'.'. sh.1I conllsl of. bronze marke, alflxld 10 I bas.,
!lUOh '1 II oommonly sold by S.lIer, Said memorial I m.y belr the name and year of birth .nd dlath of the
Individual Ind Inl1allatlon .h.1I bI m.el. In th, C.met.ry 01 Sell.'.
3, IURIAL VAULTS: Thet upon order of the Buyer, his h.I/I or ..alglll, II enulMltlld and dnlgll.lld ..
purOhlled, th. SlII.r will provld. and InetaUlor III10tnnent In the, o.lMt.ry of Seller, burl. I vaults of adult slz., SlId
burl II vlun. she" bI madl 01 r.lnlorcld concrete. lid, and ...'ed. Said burial v.ultll Ihell be boeted with an
aSphalt be.. or flnel ooallng,
4. OJIIVPT SPAOE: Upon oompl.tlon of all pevmenta by the Buyer, the cemet.ry ag,ee. to lelu.'o the Buyer an
Easem.nt to the lbov. b\lrlll rights, but .ubj.ct to III 0' the Rules and Regulallon. 01 the,cemet.ry now .xlSllng or
whloh may her.alter blt a40ptld lor th. gov.rnmenl of the c.metery and the crypt.
Th. o.mel'ry shall hllve full control 01 all 01 the <l.I,lIs 01 d.slgn. .rr.ngemenl 01 crypts, .peolllcallon. 01
",.terlals .nd conltructlon of the crypt. The pureh...'priee Includes.1I oharges for continued care. ""Interline.
Ind admlnl.tlttlon 01 the crypt and 01 the o.m.t.ry,
-
--
Th. Dloce..n C.lhollc Cem.terles Orneels available to assist you In cemetery matt.... Should you have .ny
prObI.m or qu.stlons with p.ymentl 0' eonotrn, about your puroh...., pl.... oontact us .t:
Offl08 01 Fln.nolal Admlnlstrlllon - (717) 857,4804
Olflee 01 Cathollo Cem.terl.s -(717) 857-4804,
-
Major Oloc...n Oem.tarl.s:
All Sllnt., Ely.burg - (717) 672.2872
Gat. of H,.'NI, M.ohanlosburg - (717) 69700206
Holv Cro.., L.b.non - (717) 273.7~1
Holy SlvlOur, York - (717) 784.lNI85
Rtlurr'ClIon, Hat1'lallurg - (717) 6450420S
St. JOI.ph'l, Lancaster - (717) 394.2231
.' .
7:Y,
,/?c$rl.5c.':"" $'F;.I' 4(d~,
~4"'$ <1"17" ,d"'rn-7 fZ)$
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// ~Q _1/4'"",^1' ~pt!<$7''-''$
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$l,.at~'~~:: '.,.....~".~'4'l~.",._,~......:...
r.g;nuer~
..., ii' Funeral Home, IDC.
10'1'0 I., MVIAB, JI'\, 'vll8fVl.or
37 I!, MAIN STAIlET
MIOHANI088UAO, PENNSYLVANIA 11OS1 .
(717) 7...3421
10'1'0 L, ItlVWlI
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TO
Harry P. Sha",1'
,S121 HI)I'lI\\Il'k.t Wi)'
Mechanlcsburg PA 17055
FO~ THE FUNERAL OF
Dallt.rl Shl11er
J","e19
1'1-..
, Itlmlzed Accounl On IIl,ald. Page
,~~I.. -
April 03, un'
IlEll CASE NO.
PROBATION NO.
PROB OFFICER NO.
30001l-UlII
118741113
DAXTER A SHAFFER
6121 HAYMAMET WAY
MECHANICSBURG PA 11055
TOTAL AMOUNT DUEl
AMOUNT PAST DUEl
NEXT PAYMENT AMOUNT:
DUE DATEI
861J. 67
50.00
100.00
4/03/1997
.,.,-........., ..._,...~....... f
I" ,
,
Dear Mr. SHAFFE~I
You have failed to remit
financial obligation. Thu..
no later than 4/19/1997.
It i. imperative that you comply with the payment schedule that was
previou.ly establi.hed.
the amount that was due on your court imposed
I will expect a payment of 100.00
It is expected that you will give this matter your immediate attention.
.
II
"
Sincerely,
BARRY E. HAIR
Collections Supervisor
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PAYMENT INSTRUCTIONS
CHECI; OR MONEY ORDER PAYABLE '1'01
,
MAIL PAYMENTS '1'01 '
(Include Ca.e No.
on payment)
CLERK OF COURTS
CLEM OF COURTS
1 COURTHOUSE SQUARE
ROOM 205
CARLISLE, PA 17013
IN-PERSON PAYMBNTSI
PA 17013
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IHA'll'llIl . DAUER
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HARRY 'H"PFEII
6111 HAYH"RKET UAY
"ECHIlNICS8URC.,.1l 17055
ID16436745
, ,1 AUTO IN'
e BLUE CRO" 361
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M:."~.:'GI W. A. 1J1.~" ":r..~r Ifa,r,,:="
'ETAI OF cUMRENT CHARCES, "AY ENTSAND ADJUSTtIE TS
116 TROP O.l"Q SYROt....120079 5,00 5.00
116 PI O.I"C SYRIN06....'eO..,8 15...80 15".80
116 PI I"G/l"L 30"01....,20'" 11.00 t 1 .00
116 EX1ROSa Ill: 50011613050 8.00 8.00
116 ElCTROSE 5lC 50011613050 8,00 8.00
/16 KG PADS FOUR'S011410S47 4.00 4,00
/16 OLDER !NDO TUIOI,,,,1!3.,, 8.01) 8.00
I" AC ADUl.T CPR 01 '4120810 53,00 53.00
116 PONGE OVER 4X4011..'23038 1. 00 1. 00
"16 ATH PI. SVCT 18011411S264 t. 00 1. 00
'16 ORTUAIIY P"CK AOI141262" 3t.00 32,00
'I' NDO TveE '.0""011"'2"'1 8.00 8,00
"16 RS 1000 0116130&1" 11. 00 11,00
;\6 ItS 1000 031 (, t 30684 3:5.00 3:1.00 'i"
'II TD III SET 021613103' ..e. O~ ' "2.00
'16 TYLET INT '4FR0117204405 t3.00 t'3.00
'16 ARDIAC ""REST 012710000 1.'.00 188.00
'16 LOOD QASES 012sa02607 > 146.00 146.00 ,\
'16 TAT HANDLING 11'011:5103":0 13.00 1'.00 ' '
'16 RTERlAI. PUNCTUOUlSI0r'IO',6 ,,' ,It.oo It. 00
'16 XYGEN PER HOVR015010104., 19.00 19.00
'16 D VISIT LEVEL 0117104019 ese.oo esa,oo
'16 ON-EVA EAR/PULOIIT30S55 1t.00 19.00
'16 HYTHK EC; 1-] 011130735 "3.00 "3.00
'03 AIIDIOPUL".RESUQt113014S 345.00 345.00
0.00
Y OF CU~RENT CHARCES
,.HARMCY 250 170.80 170.80
IV THERAPY 2'0 16.00 16.00
flDeM-IOIHT. NO, <holl"'.'
"
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REF.A A~~ OUUllOH1 1'0 THI PLEASE UNO MYMEtn TO: '~"\' ','i'~".t:"" ",:"~l", "', , , '
"~~~~I:'FICE A. :\,D,:, ';; :~I'.~"">"~',':,,:' ,;'i~'i';::>~. 't' '., ',..'
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INVOICE
INVOICE II: ( 700S7:l7li1iJ
DATE: (
06/ t 5/.1>
DOBI 07/11/11 IINI 1'1-74-8183
PATIENT: lHA"".R, DAXTBR
.121 HAYHARKST VAY
HICHANICIBURG, PA 110"
BILL TO:
HARRY SHAI"f'HR
6121 HAVHANKlr WAV
HKCHANIC58URO, PA 170S'
POLICY NAME:
INS, /#:
INS, II:
700S?3? DATE OF SERVICE: ' 06/15/97
AOOOUNT': I ..6 I . TRIPII:
PATIENT PIOKeo UP: LOCU6T POINT RD
PATIENT TAKEN TO: HOL Y SPIRIT HOSP IT AI.
DESORIPTION OF ILLNESSIINJURY:
427,5 CARDIAC ARRIST
8819.9 HOTOR Y8HXCLB ACCtOlNT
DESCRIPTION
UNIT COST
';. AMOu;.r.;ue,
" .' '. I .
QTY.
HOIILI INTINIIY. CARll (ALS'
Ambul.noe 1'I11..;a Ch.rg- ALS
CARDXAC I'lONITOR
ABD BLICTROOES
ANGIOCATH (14-24'
loce SYRINGI
Oxygen AdminIstration
ST%"'NICK COLLAR
I
10
I
I
3
I
1
I
456.82
50.00
'0.00
77.63,
12.42
5.16
40.00
4'.00
COMMENTS: ...We were un.bl. to obt.tn sufflolent
Infor",.tton at the tl.e ..rvloa. "'.ra r.nd.rad.
Pl.... ~o"'pl.t. the anolo.ed tora and r.turn to
u. a. .oon .. po..lble.
SUBTOTAL
, CREDIT
TOTAL
v
e'd
.~ ,'" '. ":T~ . ";.,->1~
. 11.- h' ~ ' . i '
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CONTINGENT FEE AGREEl\ofENT
VWo, Ibo undorsipod, do appoint OcraId S, Robinson, Eaqulro of tho law linn of .o.~ _
L C'..eraJdo to ina1ihue and nWntain an action aplmt any penon O! m~ corporation who
may be I'OIpOIIIibIo for my/our claim or damagOllUltJincd on _ W / Jj Lo/' I or to
, offcct an -.l.oablo lC'Idomcnt. (f;t:
, J/Wo agree dw out ofwbatcver IUID II lClCurod by my/our attomO)'l or by molul &om tho ."..,~..p~
~ aboYo RlIpOD8ibIo pII1ioI, oithor by way of sottICIIlCII1t or wrdlct, that IUomey sblllnot";" - a,v
\ tl. ~() ~ oftbo JI'OII rocovory and in .ddltlon Ihoroto, the ~... of the IUit, pnfriIl
;y diIcoYoIy, iIMItlpdon, -'ir'" aport DVIluatioa(l) and .~ IIId the feOIlUd 6it'O' II of
WimoaIoa, lIIld otbor apoa- paid in handllna tho fiIo, if 11I)', IhaII tboa be roimbanocl to 1110
Mid IUoIDGYI.
AD medical biDa lneurrod u a rcwIt oftbo accidenllincldom, wIulther ~ by couaael OD
behIIf of malus or DOt, IbaII be cblzpablo to my/our sharo oxcJuslvoJy, if DOt pN\Iioualy paid
by illluraaco. \ '
CouIIIolI'CllClnOl tho riabt to withdraw i( after lnwstlption they bcIlovo that there it no mcldt
in ptII'IUina my/our oJaIm.
Should DO money be rec:cnr.nd by luft or uttIem'Dt, said attoml)'llbaD have no cJabu
....1IIt me!ul tor aen1c:es reod.red, ncept u qreed upon In ..mmce.
Coimaol II DOt roquirocl to talco appeaII oithor from arbitration or trial \Illder tb/a qroomcnt. ,
J/W. hereby IUtborize tho IIid attorneyI to pay biDa for modlcal and hoapita1 treaaineat by
paymont dh-d)' to pbyIkUaa or hoIpiraIa concomcd from 1ho procoodI of lII)'.medioII
iaIuranco boaefita recoiwcI by tbcm. -
J/Wo horoby acblowIodp that Robinlon &: Genldo Jw \Illdcruken tb/a repI'flICDtation on a
contingent too saroement u stated aboYo.AI a reIUIt, tb/a Firm III11ariua in both tho !ilk mc:I
rocovcry roprdIca oftbo number ofhoun iJMtted IIld baa watod lnteroat in their work
product mc:I the fiIo and pnlC4lOdI of tho cue. J/Wo aulborim Mid IttOIDO)'I to notifY tho
....Opllate lnIuranco carrier of their claim for feo and that the inIIIrInce carrier abaD lncIucIe
them .. payee OIl III)' draft.
J/Wo &other lIIIderIund that pIIt oftbo fee..1Ot forth abow will be plid to referral coUDlOl
VlDari IIld Golomb.
-.
-..
J/Wc hereby ackno~1lcd&c rccoipt of. dupHcatc copy of this Conllnaont Fcc Agreement.
Date: {n-~~-q1_
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VERIFICATION
I, ---=sf li c.e: M, Ma..r K.s , am the peU Uoner in
this action and hereby verify that the statements made in the
foregoing Petition to Settle Wrongul Death and Survival Action
are true and correct to the best of my knowledge, information
and belief.
I understand that the statements in said Petition are made
Ilubject to the penal tiel of Pa.C.S. Sec. 4904 relating to
unsworn falsification to authorities.
DATE I -1gh:J./f.,
, . .
(1fr~ ,Jr{..Mah~
I.~ ',/ II"
I i 'q""""'~'.,t..',.;,r,...''''_'''.tfJ~.,, I
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NOI 1997-00573
ORPHANS COURT DIVISION
IN REI Estate of Dexter
Shaffer '
CERTIF~CATE OF SERViCE
I hereby certify the service of the true and correct copy of the
within Petition to Settle Wrongful Death Action was made to the
following individuals, by first-clalls, U.S. mail, postage prepaid, the
date below.
Datel
Allstate Indemnity company
Patricia A. DiCello
Market Claim Office
6345 Flank Drive
Suite 1000
Harrisburg, PA 17112
loJa-a}'1
. . ,
, State Farm
Sushma Vora
115 Limekiln Road
P.O. Box 257
New Cumberland, PA 17070
Villari , Golomb
121 South Broad street
Philadelphia, PA 19107
Carolyn Shaffer
6121 Haymarket Way
Mechanicsburg, PA 17055
Harry Shaffer
6121 Haymarket Way
Mechanicsburg, PA 17055
Tracie Marks
3610 Brookridge Terr., Apt. 101
Harrisburg, PA 17109
Respectfully submitted,
ROBIN~N .'~GERALDO
By ~W.~~
Scott W. POhlman, Esquire
4407 North Front Street
P.O. Box 5320
Harrisburg, PA 17110
Attorney I.D.': 78004
(717) 232-8525
. '1:1,1
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eState of
also knDwn II
Register of Wills of Dauphin County, Pennsylvania
INVENTORY
Shaffer, Daxter, A.
,~) I jf "1 -. ";'7 L"'::>
No, _.~ . ~ _2
, Deeelled
Data of Ooath _11 16 /97
Social Securitv No, 198-74-8183
Perlonll Rtpr...ntIUv.(.1 of Ihe,abovI EII'IIIl, d.o....d, vlrlfy thl' thl It.m. .pp..,lng in the folio wino Inventory inolude ,II
of the p.t.on.'...." wher,vI' IltuI'1 and III of"" "Illltl" In thl Commonw..lth 0' Penn...,I....n!. of ,"id Decedent. thl.
the Vllu'llon placid oppo.lte Itch it 1m of Slid Invlntory r.pt...nt. h, felt Vllu. .. 0' t~. dAta of thl Dlc.dent', d.ath, IInd
thlt Dlcld,nt owned no ,..1 "t"l outlld. of thl Com""onw..lth of PlnneY'",.nl. I)COlplth.. which .ppu,. in I memortndum
.. the end of thi.lnventory. I(W. verltv thllth. Illtemenll made In .hl. Inventory If' true end oorreot, IIVI/e understand thel
fat I' Itltemlntl hlrlln '" midi .ubl.at to thl penalU.. of 18 PI. C.S. Secllon 4904 r.I'tlng to un.worn felli.ioallon to
*Uthorltl...
N.m. 01
AUolnav:
I,D, No,:
Addr...:
Telephonl:
ParlOnol Raprllantetlve:
Scott W. Pohlman
78004
P.O. Box 5320
Harrisburq, PA 17110
/7171 232-8525
Tylice Marks
Oaled
OOlcrlptlon
Value
$ 2,000.00
$ 1,000.00
$ 250.00
~~ ,Ii! ::D
~Pl
(00
V~ ' ~ '.~" ....
',{If. C)
~; 0) W
", ;~ ~~
() -- f.\ ("',
0' N ""
0 C' 09 ,,~. ('j
, ~'Il
":og 0
)>;;> b: <l>S,
\0
1. stereo
2. Computer
3. Television
IAtl.oh Additional Sheet. If "eoeuarvl
Totll:' $ 3,250.00
NOTE: The Mtmor.ndumo' r"'ullt. OuUid. lht Commonw.a'th of '.n",.,IIII"11 me.,. 111 Ut. .hlloUon.ol the p.f.on.lllpt...n'.U..... includl
thl \,1.1",. of ..ch item, but IUGh lieu'" Ihould nol b, lIl"nd.d inlLllhft lot" 011h. In....nlol.,
RW-8
., 1,{./I9'-/;;?
UOMMONWIALTH OF PENNSYLVANIA
DIPARTMENT OF REVENUI
(.:./
*
IUREAU or INDIVIDUAL TAMES
INNERIIAMCr. lAM DIVISION
DlPT. 2....1 ,
HARRIIIURO, PA l'I,t-..I.
HOTICE Of INHERITANCE IAK
A~~RAlaENENT, ALLOWANCE OR DISALLOWANCE
Of DEDUCTIONS AND ASSESINENT Of TAM
....t..~ It '" CK.fPI
DATI
ISTATI OF
DATI OF DIATH
FILl NUIUIIR
COUNTY
ACN
APPROVID DIDUCTIONS AND EXIMPTIONSI
14,768.05
9. Funer.l Expen.../AdM. Coata/Hi.c. Expen... (Schedule H) (,)
10. Debt./Horte-ge Llobllltl../Llen. ISohodul. II (10) .00
11. Totol Doduotlon. (Ill
12. Not Vol.. of To. Roturn 1121
13. Chorltoblo/Gov.rnoontol aoquo.t.) Non-.lootod 9113 Tru.t. ISohodul. JI (13)
14. Not Vol.. of E.tot. Subjoct to To. 1141
NOTII If.n ........nt w.. i..u.d pr.vioualy, lin.. 14, 15 .nd/Dr 16, 17 .nd 18 will
refl.ct figur.. th.t includ. the tot.l of abk r.turn. .......d to dat..
ASSISSNINT OF TAXI
IE. ~t of Llno 14 ot Spou.ol r.t. IIEl
16. Aoount of Llno 14 to.oblo ot Llnool/Clo.. A rot. (16)
17. _t of llno 14 to.obl. ot Collotorol/Clo.. I roto 1171
la. ~rlnolpol To. Duo
SCOTT W POHLMAN ESQ
PO lOX 5520
HARRISBURG PA 17110
TAX CRIDITSI
~AVHEHT
DATE
10-31-1997
05-12-1998
RECEl~T
NUHIIER
RIlEOFF
AA270066
DISCOUNT 1+ I
INTEREST/~EN ~AID I-I
.00
4.S6-
MAKE CHICK PAYAILI AND REMIT PAYMENT TOI
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17U13
CUT ALONG THIS LINE ~ RITAIN LOWER PORTION FOR YOUR RECORDS ...
itiV:liW.ix.AFP"Cii9=f7Y.iio'fici.op.i"NHiiiiTANci.'i'"A'x-APpilAiiiiiiiir;.ALt'ciliANci-ij.C..............-
DISALLOWANCE OF DIDUCTIONS AND ASSISSNENT OF TAX
ISTATI OF SHAFFER DAXTER A FILl NO. 21 97-0573 ACN 101 DATI! 08-03-1998
TAK RETURN If AS. ( I ACCE~TED AS fILED I X) CHANGED SEE ATTACHED NOTICE
RISIRVATION CONCIRNING FUTURI INTERIST . SEE RIVIRSE
APPRAISED VALUE OF RETURN lASED ONI ORIGINAL RETURN
1. R.ol E.t.to (Schodulo Al
2. Stook. """ Bond. ISohodulo II
I. Clo.oly Hold Stook/Portnor.hlp Int.ro.t (Sohodul. CI
4. Horte-ge./Noto. R_hobl. (Sohodul. D I
E. Coohllonk Dopo.U./Hloo. P,,,'.onol Prop.rty ISohodul. E)
6. Jointly Ownod Proporty ISohodulo fl
7. Tron.for. ISohodulo C)
a. Totol A...to
08-03-1998
SHAFFER
01-16-1997
21 97-0573
CUMBERLAND
10.
t ~:t RIMlttod
lJAXTER
~
III
(2)
III
141
lEI
(6)
(71
.00
.00
.00
,00
22.056.83
..il.
.00
(al
HOTEl To inlur. proper
cracl1t to your aooount,
oubIIU tho uppor portion
of thl. for. with ~our
tax pavant.
22,056.83
'''.7~A n~
7.288.75
.00
7.288.75
.00 M' 00.
7.288.75 K.06.
.'00 M .15.
nal
.00
437.25
.00
437.25
AHDUNT ~AlD
1. 62
442.11
BALANCE OF UNPAID INTEREST/PENALTY AS OF 05-13-1998 TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTERIST AND PEN.
TOTAL DUE
437.25
.00
15.98
15.98
A
. If PAID AfTER DATE INDICATED, SEE REVERSE
faR CALCULATION Of ADDITIONAL INTEREST.
If TOTAL DUE IS LESS THAH fl. NO PAVNENT IS REQUIRED.
If TOTAL DUE IS REflECTED AS A "CREDIT" (CRI, YDU HAV IE DUE
A REfUND. SEE REVERSE SIDE Of THIS fORH fOR INSTRUCTIONS.I
"
"'V.14?O'It"'M~
'*
COMMONIYEAL TH OF PENNSYLVANIA
DEPAR1"MENT Of R~VF.NUE
IUREAU Of INDIVIDUAL TAMES
DEPT, 210t1U\
17 '
INHERITANCE TAX
EXPLANATION
OF CHANGES
IlE NU 8 R
2197-01173
101
I@VI!1WED 8Y
SCHEDULE I M
NO.
Outer A. Shaffer
Chari.. Wright
AeN
EXPLANATION OF CHANOES
Intereilt II flbated In the amount of $1.82 from the delinquent dats October 18, 1997 to
October 31, 1997, the date of receipt of the proceedl of litigation.
Inter..t II effectlv. November 1,1997.
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~arrisburg PA 17104
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Nary C.Lewis
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, Pennaylvania 17013
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COMMONWl:AUH 01 PfJmsVtVANIA
DEI'AR1MlNI OF "[VENUI
8UREAU OF INDIVIDUAL IA~ti8
Orf'l :'{\OQO\
HAI1IlIUlltJ!\O. PA 171;'0 OOql
WI'
. ,
)1
PENNSVLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. AA 296590
myUfI,' Ut llHlfll
RECEIVED FROM:
I
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
1.0.1.-
t&t~ QQ
TYLlCE MARKS
ell SCHUYLER HALL
HARRISBURG, PA 17104
--
~
fOlOflERe ..
fOlOtlFHf
---
ESTATE INFORMATION:
FILE NUMBER
______21--:-J'l.9.2"'-05'1.::L-- _SSIL1.9.B::c29.=9I 9::1
NAME OF DECEDENl (\A~ll (f1R811 ("'11
_Bl:IAEEER-DAlUER..J1--.~--------
DAlE OF I'AVMENl
____._..8J.2bJ.19.9B---.-.-.-.---
POSfMARK DAlE
---
TOTAL AMOUNT PAID
.115.98
... ...__.-8.ta.lL1..19-'lf.1-..--.-....---
COUNlV
"... PB
RECEIVED BV 1.1~"{()4-;Jt'V
MARY c. L IS ;I // /(! ')l;;
REGISTER (F WILLS /Ylll/-'. !..://.~
_.........-CUMBERLAND--.--.---...-.----.
DAlE OF OEA1II
-".
.-.-
REMARKSTYLlCE M MARKS
SEAr-HECK" 448
. HEGISTEJ\ OF WILLS
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IUREAU Of INDIVIDUAL TAMES
IIIlERIUHCE TAM DIVIIION
1IIP1. 1....1
~IIIURG. PA 17111-0'11
COMMONWIALTH 0' PENNSVLVANIA
DEPARTMINT OF RIVINUE
INHER%TANCE TAX
STATEMENT OF ACCOUNT
..
u
UW.IU1umlll-m
SCOTT W POHLMAN ESQ
pO BOX 5320
HARRISBURG PA 17110
DATE 09-28-1998
IBTATI! OF SHAFFER DAXTER A
DATE OF DEATH 06-16-1997
FILE NUMBIR 21 97-0573
COUNTY CUMBERLAND
ACN 101
F -~_t=od
MAKE CHECK PAYABLE AND REMIT PAYMENT TOI
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE. To lnour. propor orodlt to your ocoount, oubnlt tho uppor portion of thlo for. with your t.. p.yoent.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ...
itifv:i6iif-irX.APji.Coii:i7i----......-.iNiiiRiifA'iicif.TA)f.iT"ifiMifNT-iiF-Aircouiif-.ii...-....._.........-..-
E8TATE OF SHAFFER DAXTER A FILE NO. 21 97-0573 ACN 101 DATI! 09-28-1998
THIS STATEHENT IS PROVIDED TO ADVISE Of THE CURRENT STATUS Of THE STATED ACN IN THE NAHED ESTATE. SHOWN IEL~
IS A SUHHARV Of THE PRINCIPAL TAX DUE, APPLICATION Of ALL PAVHENTS, THE CURRENT IALANCE, AND, If APPLICAILF,
A PROJECTED INTEREST fIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT, 07-27-1998
437.25
PRINCIPAL TAX DUE, ..........
PAVMENTS (TAX CREDITS),
PAVMENT
DATE
10-31-1997
05-12-1998
08-24-1998
RECEIPT
NUMBER
WRIlEOFF
AA270066
AA296590
DISCOUNT (+)
INTEREST/PEN PAID (-)
.00
6.13-
.00
AMOUNT PAID
1.62
442 . 11
15.98
TOTAL TAX CREDIT
IALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
453.58
16.33CR
.00
16.33CR
H If PAID AFtER THIS DAtE, SEE REVERSE
SIDE fOR CALCULATION or ADDITIONAL INTEREST.
( IF TDTAL DUE IS LESS THAN t1,
NO PAV"F.NT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
VDU NAV IE DUE A REFUND. SEE REVERSE SIDE Of THIS rORN fDR INSTRUCTIONS. I
If'
P_VMN1',
t..taoh the top porU~ _., thlt MoUaa end ..It with 1#00,. P,_1Iftnt ... pay... to the n-.. Met Mdt...
pr tntlld on the r'\l.~t~tdl.
If .SIDENT DECEDEN' Mk, check or IKJMY or.,. payllbl, tOI RBGISTER OF WILLS, AlENT.
If NOH"RESlDENT DECEDf."' "'" oheck or ItOMY Drder PIYHI, tOI COHHOHWEALTH Of PENNSYLVANIA.
REfUt4D CQUI A r.fWNt of II hI( credit, which "'.. not r.....ted on the '1)( Aaturn, HY be t..que.tMd by cOfIIplaUne en
-AppUoltlon for Refund of Pemlylventa InhlrJtllnol end liUat, TalC- (REy-nU), Application. at. .w1l8ble ~t
the Offl.. of tt. R...,ta" of WillI, RnY of the 23 Aevenue Dlstrlot Offic.. or frOl t~ o.p.r~t.. 2.-hour
In~rlng .."viae ou.ber. for for.. orderlngl In Pennsylvania 1-100-562-2050, outside P~.ylv"'J.
end within 10011 "-,.rtabur. ar.. (717) 7.7-I.ftl, TOO' (717) 77Z-ZZSZ (~.rlng J~'lred only),
REPLY TOI ctu.Ulon. regerdlng .rror. oontalrwd on thh noUc. should be IMtdr....cI tOI PA o-partHnt of RltVenue, lut'"
of Indlvldull ',x'" 4TTHI Po.t 4......-nt R.vieN Unit, Dlpt. '80601, Harri&bur., PA I1IZ'~0601, phone
(717) 717w650S.
DIItOUtfTI
If Iny t.w due i. paid wJt~in thr.. (]) calendar ~th. aft.r the dlc~t'. de.th, . fiv. percent (lX) dj~t
of the tu paid is aUowed.
PINAL TV I
The 10 t.w .....ty non~p.rticJpaUon ""al b 11 c~utad on the tot.l of the taw Ilnd Intl,...t ......ad, .... not
paid before J8nuary 18, 1996, the flr.t MY .ftar t.... and of the taw .....ty period.
INTEREST I
Intar..t I. chat.-cl beginning wJt~ first driy of da1!nqtMnCy, or nine (9) aonth. and \Jne (1) day fr" the dIIt. of
dHth, t9 ttwl deb of paltHnt. t.xa. Which No... delirMNenl Hfor. JlIOlHlry 1, 191' bear Int......t .t the rat. of
.IK (6Xl parcant par InnUa caloulated at a dally rato of .OooI6~. All taw., which bee... delinquent on Ind aft.r
Jlnuary I, 1~'2 Mill bear Int.ra.t at a rat. which will vary fr" calendar y.ar to c'lendar yaar with that rata
..w.unoed by the PA Departaant of R.VIlf1Ue;, The 1IlPP1Icabla Intar..t rat.. for 19" through 1991 aral
V..,. Int.r..t Rata DaUy Intar".t Factor
Vaar
lnt.ra.t R.t.
Dally lnt.r..t Faotor
190. 20~ ,OIOMI 1917 9~ .000l1l1
1905 I'~ . OO'~sa 1918~1991 Il~ .OOnOl
1904 Il~ ,'00511 I'" 9~ ,ODOZ~7
1905 15~ .00OJ56 1993~19t4 7~ .000192
I_ lax ,'10214 1995-199' 9~ ,.tOZn
.wJrtt.r..t I, c.lculated .. follw'l
INTDBST . IALANCE OF TAX UNPAID M HUllER OF DUB DELIHllUENT M DAlLY INTBRBST FACToR.
--Any MoUe. llIued aft'r the taM' baclOIII. del1,",,*,t wlll raflact If'! Intar..t c.lculation to fHtean'UiJ .)'11
bayond thl data of the ........,.t. 1f payunt h ... aft.r the Intat..t COlIpUt.Uon data Ihottn on the
Not loa, ~JtlDnll Intar..t .u.t be calculatad.
AdOO .lCl3l:Jl:J00 QN'v'
3ntll. 031dllH36
(HI IVlIl') . N()<;NIII(l}1
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t,
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DIPARTMIMT Of RIYINUI
INHERITANCE TAX
STATeMENT OF ACCOUNT
c,
-
IUREAU Of IMDlvlDUAL TAMil
IMHlaITAMCE lAM aIVI.ION
1IIl"f. .....1
_I...... PA 171f....OI
m.'.I,,,"'.I"."
SCOTT W POHL"AN ESQ
PO BOX 5320
HARRISBURG PAi17110
I.'
DATI
ESTATI OF
DATI OF DEATH
FILE NUIUIER
COUNTY
ACN
10-04-1999
SHAFFER
06 -16-1997
21 97-0573
CUMBERLAND
101
A_t RIMlttod ~
DAXTER
('>,
',""
r
NAKE CHECK PAYABLE AND RIMIT PAYMINT TOI
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
HOTE, To lnour. pr_r orodit to your oooount. ......U tho uppor portion of thlo for. with your to. p._t.
CUT ALONG THIS LINE ~ RETAIN LOllER PORTION FOR YOUR RICORDS ...
itiV:Uiij'f.ix-A;P-io.,.:Wf._.._.iiiiii.iiliiiiii'T"A'iiiiE'-fiiif.iTAfiiiiiNf-OF.AC-COUNfuiiiii..._..._......... ....
ISTATE OF SHAFFER DAXTER A FILE NO. 21 97-0573 ACN 101 DATE 10-04-1999
THIS STATEHENT IS PROVIDED TO ADVISE Of THE CURRENT STATUS Of THE STATED ACN IN THE N~~ED ESTATE. SHOIIN IELON
IS A ~RV Of THE PRINCIPAL TAM DUE, APPLICATION Df ALL PAVNENTS, THE CURRENT IALANCE, AND, If APPLICAILE,
A PIOJECTED INTEI!ST FIQUIL.....
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT, 07-27-1998
PRINCIPAL TAX DUE '.m
437.25
PAYMENTS (TAX CREDITS),
PAYNENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUl4BER INTEREST/PEN PAID (-)
10-31-1997 WRITEOFF .00 1.62
05-12-1998 AA270066 6.13- 442.11
08-24-1998 AA296590 .OU 15.98
09-20-1999 REFUND .00 16.33-
,
,
.
. ,
. ~
TOTAL TAX CREDIT 437.25
BALANCE OF TAX DUE .00
INTERIST AND PiN. .00
. If ~AJD AfTER THIS DATE, SEE REVERSE TOTAL DUE .00
. I
SIDE fOR CALCULATION Uf ADDITIONAL INTEREST.
( If TOTAL DUE IS LISS THAN Il,
ND PAVNENT II REquIRED.
If TOTAL DUE 11 REfLECTED AS A "CREDIT" (CRl.
YOU HAV IE DUE A REfUND. SEE REVERIE SIDE Of THIS fORM fOR INSTRUCTIONS. I
L__' ~lf~n'L"!t"_'-"!,\l
""..01->1-
~",;-f.'-'>"'''''!''-F''>-'''' ,~".' ~ 'J '," ~"".i_ __e_.~;, _-;-c' _'~,;,'-i--~'f -;,
A
STATUS REPORT UNDER RULE 6.12
Name of Decedent I Daxter A. Shaffer
Pursuant to Rule
Court Rules, I report the
the administration of the
Admin. No. 2197-0573
6.12 of the Supreme Court Orphans'
following with respect to completion of
above-captioned estatel
1. State whether administration of the estate is completel
Yes X No ___
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
campletel
3. If the answer to No. I is Yes, state the followingl
a. Did the personal representative file a final
account with the Co~rt? Yes_____ NO~__
b. The separate Orphans' Court No. (if any) for
the personal representative's account is: 0
c. Did the personal representative state an
ac~ount informally to the parties in interest? Yes.x No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
~)€~
Date: June 15, 1999
:0:-,
l,.()
\-'~
'-Y',
p\
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IJ
~iwn~h~ ~ ~rtg'Ar
Name (P~ease type or print)
4407 N. Front St., Hbg, PA
Address
ill.?) 232-8525
1'. l. No.
Capacity:
(MAHlrmf/AMJ)
Personal Representative
x Counsel for personal
representative
S,TA TVS RErQB1IJ~D.I:R~U~E 6.n
Namo of Decedont: Dlltor A. Shiffer
Dato of Death: June 16, 1997
Will No. :
Admin, No.: Zl97.0S73
Pursuant to Rule 6. 12 of the Supreme Court Orphans' Court Rules, I r~rt tho following
with respeot to completion of the administration of the above captioned estate:
1. State whether administration of the estate is complete:
Yes -X.... No_
2. If the answer is NO, state when the personal representative reasonably believes that the
administration will be complete:
3. If the answer to No.1 is Yes, state the following:
a, Did the personal representative file a final account with the Court?
Yes_ No~
b, The separate Orphans' Court No, (if any) for the personal representative's accoullt, is:
c. Did the personal representative state an account informally to the parties in interest?
Yes.x No _ (Family Settlement Agreement flied 6/16/99)
d. Copies of receipts, releases, joinders and approvals of formal or informal accounts
may be filed with the Clerk of Orphans' Court and may be attached to this report,
"
~\~: E~l-
. SlgnMure -~
Date: November 2, 1999
I '~\
I
Timothy T. Engler, Esquire
4407 North Front Street
P..O, Box 5320
Harrisburg, Pennsylvania 17110
(717) 232-8525
Capacity: _ Personal Representative
....x.... Counsel. for personal representative