HomeMy WebLinkAbout80-00394
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NO. 21.80 ;~~:H
IN ~:I;~~~~~' (~I?,~~~~lg~..3~4t.m.'.~;~j~~~W/~~;Il.
To . .,I!!~~.Y.....~,:....".?P~!.1.~,...... ...",...".", ....."""" ""..." .... ."" ",...,.", """,
~~~i;:;i t~:1l \~ ~ I~., .A:~,Y" ,(o:t~::: t,~: K ~:V (tfd)?~~: ,I,', I" t, I:~..:: ~:~~.',',',(,J,Il,::',~,'.d,~~" I: I:, I,~~,~ ::~,j: ~:: :~:: ~~:'"..,
"...."."....,..,,,,..,,,,,,...,,......,,....,",.,,,,.. reHpectfully showel h !lml ..r;:p:o/.-1,g'p..,..C/:f1.g~12,..B!.g4t.(~., JR.
'd CAfT pel/fir 1>.0 Jt 0 TOWllship '1'1 I" . S' t 'P > I
WIIS II res I ent of ".....,..,,,,,,... "~:....,,,,11.,.."''''''..'''..'''~ I}, . (um leI 1l1l1 Coullll, ' t,. e 01 enllsy -
otlillg .
vania, and a Citizen of United StllteH, IInd departed thiH life illtestllte ill the Coullty of ..c.J!.t1"~:.".",,,,..
,...',."..'",.""""."".."""'" Illld State of ."."PA.,...."",.,.. ,.,....','. "",... ..' ",..' '" "...', ....."".....'",.'".. ..,.."".."" '" 'P1j'"
on "",,,ftJ..!.,,~1.t.,,..,,,,,.. the ",..,...J..P"~",,,,,,......,.. tlllY of I11Ay.."..""'..""'''''..'''..,..,,.. A, 0" 19Q..~...,
at the age of .~.?::,,",.., years. V (?
That the said "EJ?!I.,1,~P."..(1I:1,(?;,~,~....r.u.P.~.o,<<q,!.. de~eased, left Hurvivillg the following
named widow or husband, heirs and next to kin, to wit:
II
t!). 9 / J wRe"lt'Jfj r.
"!fI",,,/,.;;(J.v..f?f.g.'?11,~,L...f.J.A.,}3 d 61'
/12]. J'A)((}NY CT, /ntl/Z FI28J'.I110eo
"....' ",...,."...' ,,'..... ",...,..',.." I. ,,,.... ".."..." T/!:7"A/ I
').3JIHlNDERS Jr. PdJ<:rLNID,I'-lE:.
"'''o,iO''''jj/(;;P~R'D'';r.''''1~i' ... ~Nrc
".."",..,,,,..,,...,,,..,,,,,,,,,,,,,..,,,,....i.,,,,,.lif'foI'6 I ,:~
I.
Name
.f.I~.Y.""L..,)?.'.'..V.!.ftp,(J~.".,",.
,,?..t!.'!RL~..,,;.1..,......~f~,~t.,',..,'
"f?.P.!I.~,~P..,,,.~,:...,f.y.F.:,~.~~,I.f.!f...
..J!1J.1.."!.!?...J.:""..f,~~,~~.'Y.~."".
.""J?!,~/:!.~.~"..\L"""P..\!..!'?,~,1.,0,
RellltionHhip
.,.,..P.~.v.,f!.H,f.IK"....,,'"
............................................
JON
...................................,........
,.,"p.tly~,~.,'"~"l~..",,,,.,'
1\
............................................
................................................................
................................................................
........................,...................
................................................................
................................................................
............................................
................................................................
................................................................
............................................
................................................................
................................................................
............................................
................................................................
That those above named include all of the next of kin, so far as known.
The said decedent was possessed of personal property to the estimated value of $,q~P.~:,~".....,..
and of Real Estate, less incumbrance. to the estimated value of $,..Q!!P.",.-:::::...",...... as near as can be
ascertained.
That the said Real Estate in so far as is known iH located in ..,f.~!.T.......P.f.~~?..~.~,~,~....!,,:,:!,P,
............~y.~,!?....."~,9,.I..,..T'Y.I?r...'......"..,'"....,''',...,,.... ....,.,.""",.,..".""".."",.....,..,,,.,,...,,.,,.,.,,..."""....".."""...,...
Therefore, your petitioner(s) respectfully apply(ies) for Letters of Administration in the above
named estate,
Dated ....."""....,..,..,,9f.v.~(~,?:,",,. A. I)" 1!l.(q" a; y"--:J,' . .
Slgnature and Address X...,:?;,:?,..."w.,..,:",.;(/i..,:6./.,-:/,I:J.r4.,.",,,,..,.....
of Petitioner(s) AM 'r/ L, J> [I/,'tf 0 ri 0
'."'j"iq.;'.....'j,"W':".'."J.fji...'ff.""..."..'....."..'..
........................................................................................
}I, LALll>E'R'DALE ) pI-A 330"!'
........................................................................................
COMMONWEALTH OF PENNSYLVANIA 1
f ss:
COUNTY OF CUMBERLAND I
,,,.A,':'!:X,',..~.:.,,,,]?,:,Y. ~:fu,(I:O'"..,""',....,",."..,",." ",.""",.."""",., ...,. "..... .,..,..,...,."".'"", .."",..',.,. ""., named
in the above application being duly ...IW.fl..R:.tY."......".."......".."" accOl'ding to law, sa~' thllt the facts set
forth in ~ abo,'e application are true to the best of h,u:....." knowledge and belief.
,....."".....",,,t!..PPJ:L..,,..,,.,,,,,,, "...., and subscribed 1 ..:;;,..';Z"'''''......~~''');~''':'....:''''''''....''''''
before me, June 3 80 t (.~,.L!:h:/,,,"<...!,,::/......,:.L(. "..,r<:.c""'.",,,..,,..,...
....,..,.."....",...,."...",...,,',.,.,"""" ,.",.". A, I)" 19"",."" I "",........ "'~" ,,,.,.,,,,,,,,, ,.",,,, ."",. ,..",.. ,..,.."."'.',,., ,,,,,..'.,..
0'1' .q;l!.:;:~~R;;i;;;;.. ..................~~~.~.......................,...~;........~
Filed, ",.."",,,,......,,,,,....,,..,,..,,.."',,,,....,..,,...,,",..,,.... '.. AtlOll1c~ '3th(.. ~//[;lt~.~(f:..,..'''....''''..
';;1-1J~-3?y. /1- ,/.2-.3 (o\Cl) (A;lt.f' H ILL Ph frllJ If
.. ...........
21 80 ')(.4 "
. u.....~.~
Es tate No. ...............................
BOND
. Amy L. DiVittorio
KNOW ALL MEN BY THESE PRESENTS, Th.t we, "......,......,..""......,...."....,....................,.........................
.................................................................................................................................................................."..., principal........,
INSURANCE COMPANY OF NORTH AMERICA
.nd ................,............................,..........................................,..., ......",....,..................,................,....................,...........
of 1600 Arch Street, Philadelphia, PA. 19101
........................................................................................................................................................................., suret.Y..........1
.re held .nd firmly bound unto the Commonwe.lth of Pennsylvania, in the ,um of ........~.~.s..!..n.~.~.........................
.E..~.Q~.~.~,~.r1....I.~.~u..~.!1n.A......................... DolI.rs (S...1~.!..O'.O''O..........,), to be p.id to the s.id Commonwealth,
her certain attorney or assigns, to which payment, well and truly to be made. we do bind ourselves, jointly and
severallYI and our and each of our heirs, executors, administrators, succcssors and assigns, firmlYI by these presents,
for .nd in the whole of the s.id sum.
SEALED .nd d.ted the .),r.~...........................................d.y of
June
....................................................,
80
19.........
Amy L. DiVittorio
WHEREAS, the above n.med ..........................,......................................................................................................
..................................................................................................................................................................................................
has or h.ve m.de, or is or .re about to make, application to the Register of Wills of Cumberland County,
Administration
Pennsylvania, for the grant of letters ...............................,.............................................................................................
on the estate of ............~.d.IlI.a..r.~....~~.~r..1.,~.~....r..u..r.1.~.~,~".....J..r..: late of .X,~...p..e.n.n.13.~l?E,~...................,
Cumberland County, Pennsylvania, deceased:
THE CONDITION OF THIS OBLIGATION is, that if the said personal representative ............ or any of
them shall well and truly administer the said estate accord ing to l.w, this obligation shall be void as to the personal
representative or representatives who shall so administer th e soid estate; but otherwise, it sh.1I remain in force.
SEALED and delivered in the presence of
~~..~_jd~~~-
~~., .,~, /P-ri'U'A
_._tA_?_" _,):f:....Lz--:U.-"-L'J-<o.m
/
..
----~----------------------------_.----
(SEAL)
(SEAL)
---------------~-----------------------_.._.
_ _~ _7'__ ;_n.._ _ __ __ n-n..--,r-;- __....__ _ _ _ _. ____non ..nn_ -- ---. ----- - - - --- -- -- -- - (SEAL)
,~/-:.,..._L.~--.~ /,' W /,,'~@' In ~al1ce Co. of No. America
/1_!!;qI.{:t./;.~:-:.<:::."c-~'n..r.::'~~--?X*'--7/. _ _n; __________.. ___~~---n-n-:.m (SEAL)
____________.___n______un_________......(. ____-'m.':::...jk-:--:=~-- (SEAL)
David O. Lillich, Attorney-in-fact
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND 55:
Personally appeared. bd orc mc, :1..
...................................
................................................... in and for the county and
state, aforesaid . ............... ... .......... ................. ". ..... .....,.. ......... ........ ........... ..... ......... ................. ..... ... ........................ ............ ........ ....
of............................................................................................,and........,.......
...................................................................................
.................................................................................................of.....................................................................................................
surities on the above bond who being duly sworn (affirmed) according to law, depose and s.y th,t they each own Real
Estate worth the whole of the penal sum n,med in the above bond, over and above their debts and the debtor's exemption.
Sworn and subscribed before me this
..................................................................................... (Seal)
..................................................................................... (Seal)
..................................................................................... (Seal)
.................................................................................... (Seal)
....................................................... day of ..........................
A.D. 19..........
...............................................................................................
. . . .
POWER OF AnORNEY
. . fIo-...
INSURANCE COMPANY OF NOHTH AMERICA
I'IIII,AIIEI.I'III,\,I'A,
1\no\11 all IIItn bp tl)tllt prtlltntll: That the INSURANCE COMPANY OF NORTH
AMERICA, a corporation of the Commonwealth of Pennsylvania. h:i\'in~ its principal office in the City of
Philadelphia, Pennsylvania, pursuant to the fnllowing Resolution, which was adopted by the Board of Directors
or the said Company on June 9, 1953, to wit:
"RESOLVED, pursuant to Artich's :I.ti and &.1 of the By. Laws, that ~he followin}! Rules shall Kovern the execution
for the Compan}' of bonds, undcrtnkilll{s, I'CCO}!lli1.allCeS, l'olltl':Icts and other wl'itinKs in the nature thert!of:
(1) I'Such writings shall be signed u~. the President, a Vice President, an A~$istant Vice President, a Resident Vice
President or an Attorncy-in-Fact.
(2) "Unless siKllrd bj' an Attol'Ocy-in-Fact, such writinKs shall have till' seal of the Company affixed thereto, duly
attested b~' the Secretar)", an Assistant Secretary 01' a Resident A!isistlwt St'ej't'tnrj', When such writin~s arc si~ned by an
Attorney.in.Fact, he shull eithl!\' Illlix, all impn':isioll of till' Company's sl!ul 01' ll~l! soow other ~enerally accepted Illl!thod
of indicatin~ use of a seal (as by wl'ltin~ the word "Seal" 01' till! letters "L.S." after hi::: silmnture).
(3) llResident Vice Prcsidl'r,ts, Resident Allsistant Secretaries and Attorneys.in.Filet may be uppointed by the Presitll.'lIt
01' an~' Vice PresHlent, witn such hnuts on their authorit>. to bind the Company as the appointing officer may see fit to
impose.
(4) "Such Resident Officel's and Attorneys-in.Fact shall have "uthol'it~. to act as aforesaid, whether or not the Pre:iident,
the Secretary, or both, be nbsent 01' incapacitatcrl; and shilll also have authol'it~' to certify or verify copies of this Resolu-
tion, the By-Laws of the Company, and any nffi(:avit or record of the Compllny necessary to the discharge of their duties.
(5) "Any such writing executed in ilccordance with these Rules shall be as bindin~ upon the Company in any ca:;e as
though signed by the pl'(~sident and attested by the Secretary."
docs hereby nominate, constitute and appoint
of Pennsylvania
DAVID O. LILLICH, of the Cicy of Carlisle, State
its true and lawful agenr and attorney -in-facr, to make, execute, seal and deliver for and on its behalf, and
as its act and deed any and all bonds and undertakings in penalities not exceeding FIVE HUNDRED THOUSAND
DOLLARS ($500,000,00 ) each in irs business of guaranteeing the fidelity of persons
holding places or public or privare trust, and in the performance of cnntracts other than insurance policies, and
executing and guaranteeing bonds or other undertakings not exceeding FIVE HUNDRED THOUSAND
DOLLARS ($500,000.00 ) each as aforesaid, required or permitted in all actions or
proceedings or by law required or permitted',
All such bonds and undertakings as aforesaid ro be signed for the Company. and the Seal of che
Company attached thereto by the said David O. Lillich, individually.
And the execution of such bonds or undertakings in pursuance of these presents, shall be as binding upon said
Company, as fully and amply, to all intents and purposes, as if they had been duly executed and acknowledged
by the regularly elected officers of the Company at irs office in Philadelphia, Commonwealth of Pennsylvania,
in their own proper persons.
IN WITNESS WHEREOF, the said
has hereunto subscribed his name and affixed
NORTH A.MERICA rhis.llth. .
HU.GH M. SINCLAIR, Vice-President,
rhe corporate seal of the said INSURANCE COMPANY OF
day of August., ,..19}O...
INSURANCE COMPANY OF NORTH AMERICA
(SEAL)
STATE OF PENNSYLVANIA (
COUNTY O~' Pll1LAD~;Ll'IIIA\'"
by
HUGH M.SINCLAIR.
Viee&}>residen'i'
On this 11th day of August ,A,I), W 70. bolorc the subscribcr, & Not&rY
Public of the Comtllonwl'lllth or I't'llnsylviUlill, in and for t.lw County l.lf PhihHld(llLlll, duly commissioned and qualified, came
..,..., ... ,.., . ,...... ..' ..' HUGH M. SINCLAIR .,... Vicc.President 01 the INSURANCE
COMPANY OF NORTH AMERICA to me personally known to hl: the individual Bnd officer described in, and who exccut.cd
tho preceding instrumt>nt, and he a.clmuwlt~d~l:d tbe mCt~C\ltinll of the Sa.I111', a.nd, heing by me duly sworD, deposcth a.nd 6a.itb.
tbat he is the oll\cer of the Company afon'said, and that the :i1'a1 at1ixed to the prl'ct'dill!: instrument is tbe corpura.te sea.l of lOaid
Company, and the saitl corpMalc sf'al and hi~ signatun' ns oflict'r were duly nffixcd and subscribed to the sa.id instrument by the
autbority a.nd direction (If the said corporation, a.nd that Hcsolution, a.dopted h~' the Boa.rd of Directors of said Compll.ny, re-
€erred to in the precedinc instrumt~nt, is IHlW in forcl~,
IN TgSTIMO}:Y Wln~RE()}O" I huvc hereunto sl't my hand and ul1ixed my official s(~1l.1 a.t the City of Phillldelphitt.,
tbe day.~~.~ yea.r first. auove written.
,ULA E.BAILEY
Not.&ry'Publin.
/
SB.2A "",,,,no IN U.I It.
REV.1500 EX + (9.81)
BUREAU OF EXAMINATION
PENNSYLVANIA DEPARTMENT OF REVENUE
P.O. BOX B327
HARRISBURG, PA 17106
11- '7;2. - .3
INHERITANCE TAX RETURN
RESIDENT DECEDENT
/2~
Decedent's Name (Last, First, and Middle Initiel) J
A ,.'. '<'~/"~ C?
.. ~.,.~" (I ,t"l t_.'I:A. ...,...:, -
Sociel Security Num r' Oete of O"th
,,<'. . -l}) cJF,J()',1j'O
1. Original Return [3l 2. Supplemental Return 0
DECEASED
CHECK
APPRO.
PRIATE
BLOCKS
" 07'/1 /l i!I";
File Number ~,.,,/ -".. /
Decedent's Addrasy; J ....,...- ,.J, f..
L-/:,r..;. /'f'/~'/If-~t?f)~(J (,~//,.I,'.I., 7fr'
(i",,;!.M///4Id /'O,/\I}j. JZ /'1(1;;'5'
3. Remainder Return 0
4. Ufe Estate 0 5. Federel EsteteTex 0
Return Required.
6. Decedent died tastete 0 7. Decedent maintained a living 0 B. Number of safe deposit 0
(Attach copy of Will) trust (Attach copy of trust! boxes inventoried
All correspondence and confidential tax informetion should be directed to:
CDRRE.
SPONOENT Name d
/-;/..,
Telephone No.
RECAPIT.
ULATIDN
AND
TAX
CALCU,
LATIDN
Computation of Tax
15. Amount of line 14 taxable at 6% rate
(include values from Schedule K)
16. Amount of line 14 taxable at 15% rate
(include values from Schedule KI
Principal tax due (add tax from line 15 plus tax from line 16)
Total Prior payment>'
(a) Amount Paid
(b) Plus Discount
(c) Minus Interest
19. Balance Due (line 17 minus line lB)
Meke Check Payable to: Register of Wiils, Agent
... PLEASE RECHECK MATH'.'
,
/-
P V:ft'()/~'tI
Recapituletion
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interast (Schedule C)
4. Mortgages and Notes (Schedule D)
5. Cash & Miscellaneous Personel Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
B. Total Gross Assets (tote; lines 1.7)
9. Funeral Expensas Administrative Costs/Miscailaneous
Expenses (Schedule H)
1 D. Debts/Mortgeges/Uens (Schedule Il
11. Total Deductions (totallinas 9 & 10)
12. Net Velue of Estate (line B minus line 11)
13. Charitable Bequests(Scheduie J)
14. Net Value subject to tax liine 12 minus line 13)
17.
lB.
Addrass
..~~" CO u -rt ~I.. ".1 p~f '
"
City ,-t...y',L /AII,IM""
( 1)
( 2)
( 3)
( 4)
( 5)
( 6)
( 7)
,;; 1,j,J () (j
7 7' :,., >''1
J ,.,..
( B)
/:7 "J? li' 'I
<"_~ / d r'"."
( 9)
(10)
C, (,u;n
(15)
I: J,J'/-.lF
.-'.
(11) ~,(",;!7./1'1
(12) C, 10 'I I)
(13) C,/{l'll~
(14)
x.06= ~//!/ 50
x.15=
(17) -Ils/;10
(16)
(1 B)
(19)
Under penalties of perjury, I declere that I have examined this return, including accompanying schedules and stetements, and to the bast of my knowledge
end belief, it is true, correct, and complete. Oeclerntion of praparer other than the personal representative is based on ail information of which prepa'" has
any knowledge.
SIGNATURE OF PERSONAL REPRESENTATIVE(SI
ADDRESS
OATE
QUESTIONS CONCERNING PROPERTY TRANSFERS
1. Did decedent, within two years of de~th, make any tr~nsfer of any material parI of his estate without receiving
valuable and adequate consideration? (Answer "Yes" or "No".) no
2. Did decedent, within two years of death, transfer property from himself! herself to himself/herself and another party
or parties (including a spouse) in joint ownership? (Answer "Yes" or "No".) ~
3, If the answer to one or two ~bove is "Yes" and the transfers are claimed to be nontaxable, provide the following
information:
a. Age of decedent at time of transfer.
b. Copy of death certi licate.
c. Affidavit by the attending physician indicating the slate of decedent's health at time of tr~nsfer.
d. All other information supporting nontaxability of \ransler. "
4. Did decedent, in his/her lifetime, make ~ny transfer of property without receiving a valuable or adequate consid'eralio~
therefor which was to take effect in possession or enjoyment at or after his/her death? (Answer "Yes" or "No".) no
a. Was there any possibility that the properly transferred might return to transferor or his/her estate or be subject
to his/her power of disposition? (Answer "Yes" or "No".)
b. What was the transferee's age at time of decedent's death?
S. Did decedent in his/her lifetime make any transfer without receiving a valuable and adequate consideration therefor
under which transferor expressly or impliedly reserves for his/her life or. any period which does in fact end before his/her
death:
a. The possession or enjoyment of or the right to income from the property transferred? (Answer "Yes" or "No".) no
b. The right to designate the persons who shall possess or enjoy the property transferred or income therefrom?
(Answer "Yes',' or "No".) no
6. If the answer to five b. above is "Yes," state whether the right was reserved in decedent alone or others. no
7. Did decedent in his/her lifetime make a transfer, the consideration for which was transferee's promise to pay income
to or for the benefit or care of transferor? (Answer "Yes" or "No".) no ,.
'. -..,.
8. Did decedent, at any time, transfer property, the bmelicial enjoyment of which was subject to change, becau~ of
a reserved power to alter, amend, or revoke, or which could revert to decedent under terms of transfer or by ~er~tion of
law? (Answer "Yes" or "No".) no .' ,
9. If the answer to eight above is "Yes," was the power to alter, amend or. revoke the interest of the beneficiary reserved
in the decedent alone or the decedent and others? (Answer "Yes" or "No".) - no
R,EV"~3 I'X+ (3-801
COMMONWEA~TH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIOENT OECEDENT
SCHEDULE "0"
BENEFICIARIES
*
-'
, f
~
""~
(Instructions on Reverse Side)
Estate of
Edward C. Furlong, Jr.
BENEFICIARI ES AND ADDRESSES
RELATIONSHIP
SURVIVED
DECEDENT
DATE OF
BIRTH
Le al
1 th Res idue
INTEREST OF BENEFICIARY
Am L D' . tt r' Dau ter
8291 SW Eighth St.
North Lauderlade, Fla 33068
e
Dau hter
Le al
1/5th Residue
Laurie A. Berr
1722 Saxony Court
Murfreyboro, Tenn. 37 30
Yes
. Edward C. Furlong III
23 Saunders St.
portland, Maine
Son
Yes
Lega 1
1/5th Res idue
Daughter
5/15/63
1/5th Residue
Jeanne L. Furlong
910 Sheopard Ct.
Altamonte Sryrings, Fla 32701
Yes
Dau hter
2/24/65 1/5th Residue
Dianne J. Furlon
910 Sheryryard Ct.
Altamonte Sryrings, Fla 32701
Yes
The above beneficiaries are living at this time except for the following:
NAME
DATE OF DEATH
INSTRUCTIONS FOR COMPLETING SCHEDULE "E"
Schedule "E" must include all property, real and personal, owned by the decedent jointly with another
party or parties as joint tenants with right of survivorship, Both tangible and intangible property are to be
included. List real estate first.
1. Describe all real property as indicated in the instructions for Schedule "A". Describe all personal property
as indicated in the instructions for Schedule "B". Include the name, address and relationship to the
decedent of the co.owner (s) and the date the joint ownership was established.
2. Indicate th'e tota.1 market value of. the'jointly owned property,
3. Indicate the percentage of the decedent's interest.
4. Indicate the market value of the decedent's interest.
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GENERAL INHERITANCE TAX INFORMATION
Unsatisfied liabilities incurred by the decedent prior to his/her death are deductible against his/her taxable estate,
In addition to debts incurred by the decedent or estate, other items are claimable including the cost of administration,
attorney fees, fiduciary fees, funeral and burial exp~nses including the cost of a burial lot, tombstone or grave marker,
All debts being claimed against an estate are subject to the approval of the Register of Wills with whom the
Inheritance Tax Return is filed. Evidence to support the decedent's or the estate's Iiabiiity for the debts being claimed
should be attached to this schedule,
A family exemption of $2,000 may be claimed by a spouse of a decedent who died domiciled in Pennsylvania.
If there is no spouse, or if the spouse has forfeited his/her rights, then any child of the decedent who is a member of,
the same household can claim the exemption. In the event there is no such spouse or child, the exemption ca(l be '.'
claimed by a parent or parents who are members of the same household as the decedent. The family exemption is
allowable only against assets which pass by a will or by the Penl1sylvania Intestate Laws.
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INSTRUCTIONS FOR COMPLETING SCHEDULE ':F"
1. If the family exemption is being claimed, indicate the claimant's name, address and his/her relationship to the
decedent. Enter "family exemption" in the remarks column and the amount claimed in the amount column.
2. Assign consecutive numbers to each item listed.
3, Enter the date on which each debt was incurred and/or paid.
4. Enter the names of each payee.
5. Provide a brief explanation in the remarks column for each debt claimed.
6. Enter the amount of each debt being claimed.
7. The form must be signed by the person who has assumed the responsibility for paying the debts.
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------------
I ...--- -- ~ -- --- ""- z:a.:___....... ,...",.- --.
1~\"Ey.1'e21l(,'Q,""j'\,.I\;., I' I
Il~~\~'.\1~:':':'i~'::~1/: .', ,,' .' COMMONWEALTH OF PENNSYLVANIA
I 4 '~O:'K~;}29681 DEPARTMENT DF REVENUE '
,r>.':",:, :',', , "OFFICIAL RECEIPT. PENNSYLVANIA INHERITANCE AND ESTATE TAX
l \I w.
I =
.,
'I
a.
~ Henry r. Coyne, zeq.
~ RECEIVED Amy L. D1 vittorio
1[, FROM
,ADDRESS 3901 Market st.
,
-
TAX AT 6%
TAX AT 15%
TAXAT_%
ESTATE TAX
Oa aill PA 17011
'--~f~~T~[~E~~ATiO~C;; -30-,--i980'-----
TOTAL TAX CREDIT ,414.29
COUNTY
21-80-394
Auquet 4, 1981
ldwarCl Oharl.e Furlon
OulllberlanCl
TOTAL AMOUNT PAlO '414.29
FILE NUMBER
----------- -----
---------------------
,G.
m
LESS OISCOUNT
PLUS % INTEREST
IFROM TO_I
DATE OF PAYMENT
NAME OF DECEDENT
POSTMARK DATE
, REMARKS:
.~
"PAID ON ACCOUNT"
SEAL
RECEIVED ev
I
REGISTER OF WILLS
--.--------------.----'--.---------.--
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