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OATH m' P'~RSONAI, RI~PRI~SI~NTATIVE
COMMONWEALTI-I Ojl PIlNNSnVANIA SSI
COUNTY OF CUMLlBRI,ANI)
Beforo me, the Reglsler for the probale of W\l1s and Ijrnnllng of Lelters of, Admlnlstratlcm In and for tile county of
cumberland', personnlly Cllmo
MARY 0.' \l,I\LIll8
who, being duly SWORN ,do illS depose IInd sny lhnl ns_----1n1<Ocutril)
of the Ins I Will nnd Testament of
MARY'B, HJ!lRMAN
deoonsed
she ..,:.:wlll woll nnd truly ndmlnls\or the goods nnd chllltels, rights nnd credits of snld deceased according to Inw. And
. sworn
alsQ will dlllgenlly comply \vlth the provisions of th~lnw rellltlngto Transfer Inherltnnces. ,to and subscribed boforo me.
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<-,.,' AprU' 24:, ,I\,D., IL_.JLl
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DECREE
Bo It remembered 'that on the' 24th dny of April
recorded tho IlIst Will nnd,Toslnment of.. MARY B. HERMAN
EAST PIllNNSBORO TOWNSHIP'
,A.D,,19~, thero was l'robated and
_late of
"cumberlnnd C;ounty, Pennsyivanla,
"
Deceased.Lelters TIlISTAt<IIllN'l'ARY werogrnnted' to
Witness my hnnd nnd ofrlclnt'Senllhe day, nnd yenr nforesnld.
MARY O. ZALIilS
1~,~ .
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GENERAL INHERIT ANCE TAX INFORMATION
Unsatl.f1ed Ilabilltlos Incurrod bf tho dncodont pilar to his/her (loath me doductlblo o"olnst hla/hol taxable
estoto, In oddltlon to dobts Incurro(1 bf tho docodont or ostato, othor itoms mo clolnlllblo Including tho oost 01
administration, otlonHlf loes, Iiduclorf looa, lunollll and burial oxponsos Including tho cosl 01 0 burlellot, tombatone
or grove merkor ond othor relolod,burlol oxponses,
All debta being clolmod ogalnst on ostoto tlro aubloct to tho approval 01 tho Roglstor 01 WiI,ls with whom tho
Inhorllonce Tax Roturn Is III0d,' t'!vldenco.to support tho dOGedont's or tho ostoto',a liabllllf,lor the debts baing
claimed should be attaohed to thl. schodule" ' " ,
A lamlly exemption may be olalmed bf a spouse of a decedent who died domiciled In Pennsylvahlo, If there II
no spouse, or If tho SPOUIO hallor/elted his/her rights, then any child 01 the decedent who la 0 memborof tho same
household con claim the exemption, In tho e,yont thoro Is no auch apoUaO 1>1 child, the ex,",ptlon can bo claimed by
apare"t or parents who are monibera of tho ao,,,o houaoholll 01 tho docedent, The family exemption Is allowable only
against ouels wlilch pall by 0 will or by the Pennay,lvanlo Intciatoto Lawa, '
NOTE1 Compensation paid to on estatoroproaentotlvol namely, an, exe,cutor or admlnl.lrator, for services
pel'lormed In adiT1lnlsterlng an e.tate,la reportable lor Penns Ivonla Inoome Tax purpesea, This taxoblelnoome
Item should be roported on form PA.40.lndlvlduollncOnle To Return.
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LNSTRUCTIONS FOR COMPLE!l.t!G SC~"
I. If the family exemp on Is being claimed, Indicate tho claimant's "ame, oddreaa and hls/herrelatlonahlp to
the decedent. Ertte Ilfamlly exemption" In tho remnrka colul11n and, the amount claimed In the omount column,
2, A~slgn conuoullvfl numllera to each Itom Ilatod. , .
3. Entor tho dato on which oach debt was Incurrod and/or paid,
4, Ent.r the namoa of eachpciyu.
5, ,Provldo 0 brlol oxplanatlon In tho romark&oolumn lor eaoh debt 'claimed,
6. Enter the amount 01 each debt being claimed.. ,
7. Tho lorm must be signed by' tho porson who.haa assumed tho responalblllty for paying the debtl.
IF ADDITIONAL SPACE IS NECESSA~Y. USE BVa" x l1"SHEETS,
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!:EtlliliY.L v AWAJ.~H Efll.I]NGILLilKJ1J~Nr0i~U Nlll.l1M^I.LQ!i
1, fiBiQ.tlrRESPo.NSIBLE FO!LKETUIlN
SeQtlon 70.1 of tho Inherl,tflnce and Estalo Tux Act of 1961 Pfovid(l'; IhotllHllollowlnll pnrsdils shall propnfn fiud fllo
a relllrl1: . . .
a. Tho porsonal roprnsontollvo of tho ostlllo of tho doc(l(Iol11 mi 10 PI\lpnrlypf tho docmlollt nduflulsluroll hyhilll
and suchmhllllonol proporty which Is or II10Y ho suhjoet 10 lulWfltllueolll~ of whic.h hohiho Shill I hovo fir
acqul ro knowlodgo;
b,' Tho transforoo 01 pro/lorty UpOI1 1110 trrnsfor 01 which luhorlloucn Tax I!i or lIIay hu Imposod hy tho 1961 Statuto, . .
I'ncludlnfl.8 trustee.o proporty trousfor.rod In !rust, provldod thot uo sIJpnfoln rolillllllood hlllllodo by tho troilslcroo
of property Incllidod In tho return of 0 porsonfll roplo80ntnlivu. .
,.. .'.' .. ,- '
2, PLACE F'ORFILlNG
Tho loblln Is to ho Illodln dupllcalo with tho Ruglstor of Wills 01 tho COlllltV whoruln UIO{IiIClldoul rosldod.
3, TIME FOR FILING
The roturn Is dUllnlno lIIonths.aflor Iho docodoul's doath, \11I1088011 oxlousiou lor IIllng hilS hooullppllod for afl(l
granted hy tho SocfOtary of Revonllo within lho nlno'lIIonth Ilorlod.
4, fAILURE TO. FILE RETURN
Soollon 7910f tho 1961 Statllte provides lhal" . , ,allnOlSOIl who willfully 1IIIIs to filo a ralum or olhor rnporl
reQuired of hlnl. . .sholl bo porsonally Iloble. . ,to aponolty 012!i% olllllllax ultlnlnloly found to be dllo or $1,000
Whichever Is Iho lessor 10 bo rorQvored by lhe Depnrtmont of 1l0vollUo fiB dobts of Ilko olllount ororocovOlahlo hy
law,"
5, TAX RATG~
10!lBrltnnce'ra~ Is payahleat Ihe .rate 016% on tronsfors to Iinoallloscflndonts, such llS lalhor, mother, 11lisband, wife,
spn, dauilhtor, grandchlldron, grandporent, sOIHn.luw oncl dallghtor-In-Iow flnclal tho rote of 15% as IQ 011 othors,
,
6, PAYMENT DF TAX
,
The tax assossod on the translor 01 property roporlodlll tho relum IS duo 911\unlhs nltor lho docedolll's dealh, Intorosl
at the ra, te, of 6% pe,r annum aocrues thoreaflor ulIlll pOYll1onll,s II\lldo, All pUYlllonls loculvacl Ora f1rslnppllod 10 an,Y
Interesl wl1lch maybe due with anY,rOl\lalnder al'Pllod to tho tux. If TAX IS PAID WITHIN 3 MONTHS AFTER THE
"DECEDENr'SOF.ATH, A DISCOUNT DF 6% 0.; THE TAX PAYMr:NT IS ALLOY/[D, ,
All checks Shollldhe ;nado Ilayablo to IhoRoRlstar of Wills Of, 1110 Cllllnty whoro!n lbc doco(lont rosldad lllld oro '
, received subject to lho lInal delorl1llnutlon of the Dopmtll\onl 01 flovunno.
7, f.AILURE TO PAY
"l.,T, he.taxeslmposod, tOg, lither wl.lh anYlnlere"st Ihoreon; Ole Ii Illlllupon roalllflJpO,rlY,' wlllch 11011 rOlllolns In ofloc\ until
lho toXos and Interest have been pald,ln full. Thl/laxos lIIay bo suod for anulllslill1Y fOal proporty In ,tho deoedont's
" estate or against any properly holonglnR 10 a IransfOluo lIablo lor ,tho tn~. . '
8, FILINfl OF FALSE RETURN
,
Any person who Willfully lIIak.os a lalso rolurn or roport roqulrlJd of 11111I Shflll, In nncorclall(;o wllh Sor-lIon 793 of tho
\~61 Slatuto, bo gullly 010 mlsdollloanor find, oncollvlollolllhoroof, ~l1nlllJf) S(1I1toIlCl)(llo pay nflllolloloxcoodlng
$1,000 or undergo I IIIl1rlSOlllnont not o~ooodlng ono yoar or hotil. '
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The H ~ A FlI S Saving.. A..~clatlon
\,Hl0~IP IIIW l'tI'II'~!lill.l;' .IIIIIIIII':\llIill(1, "I'NNiiVI V/,NI^ 111iI1
O/,IICfS
IJClWNIOWN', (:Ill (IN/M /'AIIK , eMil' /1111. , I,/il/ANON ,lINI(}N/lUl'O~11
nAl'/fA/. (1/11' , NIW(,'UMI/I,IIIANIJ , YClIIK ,sUMMUWA/.I!
"IUIIOlHhI/11'.1aIlHIl1ol1
Jun. 10, 1981
Myer/J I Myerll I. Flower g, Johnl3ol1
%JerryR. PUffie
1'.0,' Bo,x 12~ '
Lemoyne I. '1'1\ 17011 ~
'1'hll informut:!.llnwhioh
lIermon
YllU requcated on the /Jooount(s) of.' Mary B.
-
(Sooinl'Seourity'# 172-01-8878
4.6 liS folloWS I DOP '.-11-81
'Aooount Number(s) 1.888'2
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Oluss of Aooount h41sbook
II.
Datl),Openod' 12-a9~8o
Principal Balanoe U4. "'315.1~
Aoorued Interest 106.77
BlIlurice at
DatI) of Death U't.461.?3
"
Aooount
OWllenhip Individual
Name of Joint
OWller I. if ony ....,...............
. ,
,
!;late Ownership 12-29-80
was j!Jstablishel\
-
Addi tional Infor..
mation requested ......--......-
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(C~LJIt. :d\ 1 l(':1' 1"/ C,,')
Be te:! " NordLil
Bllvl ngo Coun\1(,lor
W,dll Oftice
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2Y!llIONS CONOERNIN1ilfiOPERTY TRANSFg~~
1. Old decodent,wllhlrl twoyotlrs of death, makoMY translor ofnny matorla1llnrl of his estate wlthout,rooolvl,nH
valUllble an.d adoQuato conslderaUon? (Answer "Yes" or "No".) hi" "
2, Old dooedont, wlthlntwayoars of'doath,tr~nsfer property frol1l hlmsolf! herself to himself/herself and another party
or parUes (Inoludlng a spouse) In lolnt ownership? (Answer "Yes"or "No",) ...J>lO-. .
3, If the answer to one or two above Is liVes" and the transfors are clallllad to be nontaxable, prOVide the foliowlns
Informallon:.' .' .
, a. ARe of decedent at\lme of traasfer,
b, Copy of death certl lIcate, , "
'. c, AffldaVltbY, the attending physlolan Indicating the slate of decedent's health at lime of transfer,
d. All other Informll\lon supporllng nontaxablllty of transfer,
4. Old decedent, In his/her Ilfe\lmo,make,any transfefof property without recelvlnR a valuable or adequate consideration'
therefor which was to takeeffeot Inpossesslon or enjoyment at or after his/her death? (Answer '.Ves" or "No",)
a, Was there anyposalblllty that the property transferred mlflhtreturn 10 transferor or hls!her estate Or be subject
to his/her power of disposition? (Answer '.Yes" or "No ',) ,
b, What was the transferee's age atUme of decedent's death? ,
5, Old decedent In his/her IlfeUme make any transferwlthout receiving a valuable and adequate cOnsldera\lontherefor
under which transferor exprossly or Implledlyresarves for his/her life or any period which does In faotend befotehls/har
doath: .
a, The po~sesslon Or onloymentof or the right to Income from the property transferred? (Answer "Yes" or IlNo" ,)
b, The right to designate the persons who shall possess or enjoy the properly transferred or Income therefrom?
(Answer"Ves" or f'No",)
6. If the M~werto f1vQb, above Is "Ves,'1 state whether the right was reserved In decedlll1t alone or others,
7, Did decedent In hla/her Ilfellme make a transfer, the conslderaUon for which was transferee's promise to pay Income
to or for the mefltar Oft1'81lt transfomr?' (Answer "Yes" or "No" 0) " '
8, Old decedent, at any tlma, transfer property, the bmeflclal enjoyment of which was sublect to change, because of
a reserved power to alter, amend, orrevnke, or which could revert to decedent under terms of, transfer or by operallonof
law? (Answer,."Yes" or "Noll.) , '
9, If the answer to elllhtabove Is o'Y,es\" was the power to alter,' amend,er revoke the Interest of the beneflolary reserved
In the decedent alone or the deceden and others? (Anewer "Yes" or "No" ,), ..
IlI'V./H\:J (1,(101 '
llOMMONWDAI.TH OP,PONNSV\.VANIA
1Jr,!'AIITMUNT OP IIRVUNUO
1I\ANllrnn INlWlllTM(1I! TAX
IIIlRIOnNT IlUOQDUNT
SCHtiOULF- "0"
llENgPICIARlES
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IIl/mllot/o"'I OI/I1IIVllfS/1 Sir/II)
F-stslo of
Mi\RY Il. IIIDRMf\N
- T - sURVIVED
IlnNEFICIARIES AND AOORE8SES REI,ATION8HII' PATE OP INTERnST, OF BUNEFI'JIARV
OECeDllNT PIRTH
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The sbove bsneflolorles ore IIvlng'st this time exoept for thofollowlnOl
NAME
OATl!OF OIlATH
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It. ~I~;~! I"'}'f:t,': ',",' ,
~TIONS..POR COMP\.ETING BCHEDU\.E "!!"
, '
" .SOheduie"E" mUlt 'Include ell property, roe I And porlonol, oWliod by Iho deoodont lo\ntly with "nother
party or partlflll as lolnt tenentl with rluht of uurvlvor,hlp. BOlh terl"lblo ond Intol'lulblu properly 01'0 to bo
Inoluded. \.18t real eltete flrlt, .
2,
Oeaorlbe 011 reol propur\V ea Indlootod In the Inslruollonll lor Sohodulo "A", DOllotlba 1111 pordqnsl proporty
eslndlostod In the II18trLlotlol1s ff.\r Sahodulo "B", Inclludo tho nomo, Urldrollll ond rolutlllllllhlptu tho'
docodent of the ao.owner (sl,end thn'doto tho lolnt ownorohlp woo oslobllslWd.
Indleeto the total merkot valllo of tho lolntlyownad pr,opor\Y,
IndlOftlothe pereentalle of the deoedont'o Intaresl.
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j,11
(3,
4,
Indloate the market velua ollho decodel1t's Intoreol.
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tlllv.4ft4 u.41H01
INHERITANCE TAX SUMMARY SHE:ET
(SUREAU USE ONLY)
_.. -
21-01-0259
FI,I. Nu~ber
I;.tat. Nom. ~~.:.;-
-~--------
Gl Original
o Supplemental
o Remainder
Oat' af Death ^p~:l 1:_~:01
...........,..---......
Soolal Security Humber __u~!~~~~.~.1.:-~~?~--,----~
REPORT OF INHERITANCe TAX APPRAISER
I, th. und.rllgn.d dulV oppolnt.d Inherltan" To. Approlur In and lor th. County 01_ cumb~
P.nnlylvonla, do r..peotflllly report that I hove appralud the real and p,"onol prop.r 01 ,~I.~regol,nR
retum oUhe valu.. ut forth oppollt. taoh Item In the Iou column the right In 50 ul.. "A", "B", "e'!, and' e"
Diat.dl ~ovembet' 12, 1901,
-
-
ItlVIHTORV
, Real P1oP""V (Sohedull ")
,
Per.anal Prapertv (Schldull II)
Jalnt.Hlld "ropertv ("hi dull II
T.an.fll' (Schldull C)
TOT "I. OROSS A$SITS '
I.... Plbtl and bldulllonl
(SCHIPUI.I p)
CI.IAR VAI.UI OP ISTATI
o LIl. Eetat.
o Annuity
POR un OP RllplSTBR OHL. V
Td' on 5
Tu. on,5
To. on $
ra. on 5
'1'0' on 5
a".,pllo.'
T~lol B.tot.
(.'... Or.dlll
DArl 01' PAVMIHT
Mut'Y B, lIel'IlIUn
---~-~_..~~._--._.
~-
':""-"-'--T
AOJUI'l'MBHTS
(HAMMIIIUMO USI oHLV)
VALUR AS APPMAIUO
CODE
00+
20,31111 ,60 10+
3,016' \19 fIll+
None 10+
$ ,31,361 65
.___.~_.____.._.__.~._~.nn- ~. ._-~ -~~~
<40.
M!!
pAcrOR PRIHCIPI.I
--
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6%
15%
'faT A.\. rAX
IHURIlST pROM
IlAI.AMCB
TO _
"MOUMT PAID DlleoUMT
5 + 5
IHTBRIlST
5 .
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5
5
5
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+
IHrIlRBS.TpROM
IlAI.AMell DUB
BAI.AMeB
TO
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ReMAIHDeR APPMAluMeHT CODe
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VAI-UB
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cool
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COMPUT"TIOH Of TAX
5
5
$
5-
5
$
$
5
,TAX CRBDIT
$
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SJ. 8 ~
...--..._--r-o;._.........*-
.' ,
InYllntory of the real end personal eBlatD of
~__.~_J:l_1!r 0.., nJllRMAN ' ._.__"..._u__~~u.~ deQBaSed
--
........-......-,=-
- . -=-_~~~=:;,~~;;:,.::;;c;:;::-;:-;c:-~;::~~;~-":t:::.:c.:;;;'-';~_~L-~';;.~;:",'":.
......~
1. The nnrris Savings Asaooiation
Savings' 1\000untNo. l-BBB52
~atEl of death balanoe I pJ.us ,intereat
First Federal Savings & Loan I\aaooiation
savings AOGlount ,No. '1-1-31.6710
Date of death balanoe I plua interest
2.
lDstate of Paul B. Herman
Dauphin Deposit Bank !&, '.j'tust: comPany
Cheoking I\ooount No. 42-44~104B -
4B Shares - Amerioan Telephone &
Telegraph Common @ 54.6563 p/sh
6. Blue Ridge Haven - refund
7. Washington National Insuranoe Company - premium refund
3.
A .
5.
B. Mutual Life Insuranoe Company of New York
Prooeeds ,from!?ou.ioy No. DB 557 00 11
on. the life o,f PaulB. Herman, Mary W.
HermaT\I benefioiary (paid after death of M:\ry HetTl'al1)
9. Blue Cross, Blue Shiele;! &, Medioare
refune;!s & reimbursements
10. washington National - premium refune;!s
& e;!eath benefit - Pal,\l B. Herman
11. MutlJal Li fa Insuranoe company Clf' New York
Polioy No. 716-~0-17 - paie;! to Estate
TOTAL
_.._-<~..-~..- ,;,. ...
4,461 93
5,963 01
,7/263 73
3,B~6 33
2,623 50
B20 10
, 3 75
l,5B3 09
557 35
125 30
1,076 57
2B,34466
COMMONWIALTH OP PI~NIYI.vANIA t
COUNTY OP CUMIIRLAND J
"I
f.',
'c"J.!1\IW".Oi,"~Ml11El, ~""" , '".~, .++, ~".,' ,,~-,,-,,-"'" -.,.--".."..."
~elng duly u<...~_..8wonN" Aooordlng to law, de pOlO I a"d uYI thAt aho ,is,,IJlxooul:..tix....
."...'- .._.___,..,"" ~__" . of tho e,hlo of ..._MARY..Jl...-I1lllnM1\NoO_.-~'n_'-----F---
lato of.....Eas,tl'ennsbol:o 'l'ownsh.l.p " .""'" .,,..-, Oumborland County, Po., daooOlod end thet the
v.ollhln II an Inventory made, by ,~"hel:.,__ ~.-,-""'-'- "'- . ",,,-. ..~, the lald".lil.lillp\.ltd.l;L.~_._
of the ,'ntlre utftto of laid deoodent, oonlhtlng of all the porlonel prop.~t,'Y end rOIl oltoto, oxoopt rU,1 ..hto ouhlde
tho Oommonwnolth of PonnlylvAnla" and that tho IIgurOl oppollta oaoh .llom of tho Invontory roprolOnt It'l fair valua
01 01 tho deto 01 dooodont'l doath.'
Sworn to -'- and lubtOrlbodbeloro mo,
a~t/ f' 19 n
, ,
\ '-~:-i-H;~i~-:-:"-~""-
. 5 25 South Front St.
r__.~__'___"_'~__.'___~""""'-' .........__~____n.--.--
r' ,,'
I....: l' ' " \':
.' - . .'-~6~~; PUBLlO ;~S.,...,>~
Il., ConunltalOlll:lpllu PlKl. ai, 19111
~, PI!, OUll\I,..laod Oouo~
._~lit~9J,j;Cal'n-l?h 17113,._..___________
Add,,,,
DAle 01 Death ____jl'1'lL,,_..c.___~_._~.-_____..__1\pr~.f~--
, DIY Month
1981
v..t ----.-.-,.
INSTRUCTIONS
I, ~n Inventory mUlt be fllod within threo monthl Allor appointment 01 portonel ropr..ontotlve,
~, ^ supplement Inventory mUlt be ftlod within thirty daYI 01 dllOovory 01 addltlonal oneh. '
3, \ Addltlo,6~1 ,lho"I may bo ftttfto'h,d a\ to porIonalty or rulty
4; ~,Seo Artkle IV,:,FICluolarlol Aot 011949.
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COMMONWEALTH OF PENNBVLVANIA
OEPARTMBNTOFREVBNUB
BUREAU OF EXAMINATION
OFflOIAL NOTloe Of '.'
INHeRITANoe TAX
AssessMeNT
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ESTATE
t'llE NO,
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COUNTY fila NO:
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DATe
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L. 1_ '1 .. ,I
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OOUNTY
(' r/( ( Ilffl(, 1j2r:Ld"r(, -
; /'L;'! ~./ 'f
, -'""----
DATe Of DEATH ,Illl/:: /~ /x,> I
I
::1
AppralaodValuo of ESIAlo:
Roal aa\ala
Porsonal ProperlV
e
",....._~,_._-.......-+~-.'--."..
,,_.- -c'.. J ''''_ J
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Jolntlv Held ProPOrlV1Transfora
t :'J /1 / (/', :( I
,
TOlal Grou Eelalo
;'.';
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"
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Xi" ',"'..2.
Cloer Velue of Eslale
,./ ~';) ~IJ~ ) '7
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Tolel Approved Dqduotlona
lour Approvod Cherltablo Exomptlons
Olear Value of ESlalo Subjeollo Tex
1. '.- ;,/ . -->~~>.q,
,
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Amount TaKeble @ a'll> Rale
e
lox duo
e
Amounl T.Keble @ 1 B% Reto
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.~ I ~_/".-,- .;-- I') -/,; -
lax duo
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IV l~L L j,f I.',;~
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TOTAL PENN!lYlVANIA INHERITANCE TAX DUE
,// ) (~,"J' """
. " -, A/. );~
/
· · · " " · A five poroont dlsoount 10lallng e
, will bo granted If Iho Inherltanoo Tax Is paid bV __.
LeIS Credltsl
DArB OF PAYMEttl.
AMOUNT PAID DISCOUNT INTEREST TAX CReDIT
,
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--
I;) ~;;: ..)0
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/19 ...; ~.' t'l
Inlere8t aooruu al Ihe rele of .Ix Ie) poroonl por onnum
on tho unpaid bolonoe of Inherlt.noe TOK Irom
to dalo of pavmont, 'Inloroo\ duo lfilOld bv___, __ Is _
BALANOE OP rENNSYlVANIA'INHBRITANCB TAX DUe
.
.// ,~ 1.1)'
Auusadby: /), 2 ,>
Soo InlO/ln'II." 0" """10 Sid. Au,nl I., IH. corn~ '.~Ih
y).' .' ?', (;'-1
'l~/t .;.l~"' l-
i.J
'I (d,', il fl ii
llif.llliMAJ1QJ::L
To Inluro proper orollitlo YOIH ooooulII, Ihll '"1111" 01 Ihll '''1,1111 onll filII numbor Ihould bo olollrlv prlnl'
ad on Iho ohook Dr monoy ardor,
Tll11 ollollumDnllo modo In nooordonDD wllh SODllllh 700 of 1110 IlIllltlllnnOIl ond Eolo\(l TIIK Aol of
19G1172 P,S, ij 2406.70GI,
To Iho oKlonl Ihol Inhorllonoo 10K 10 pold wllhln IhrDD 131 mllnlho IIhllr IIW donlh of Iho ,deoodonl, e
dlloounl 01 flvo 161 poroonlll ofloWDd 172 P,S, G 2400. '/1 6},
Inl1orltonoo Tox, olhor Il10n 10K em '0 f"luro Inloroll, 18 duo 01 Ihll dOlO "I 11", doood''''I'1 ,doOlh ond booomol
dollnquonl 01 1110 oKpl<ollon .of nino 10} monlll1 ollar 1110 dueDdonl'. doolh 172 P,S, Q 24UO.71 11, Inlwllonoo
To. on 0 fuluro Inloroal II poyoblo wllhln IhrDD 13} month. ollor Iho Ironl'or lokou offoel In poo~o..lon and
enloymenl ond II dollnquon\ \horoollor(72 P,S, Q 24eo.7121, Coloulolo InlDrDII 111I01 Iho dDhll"uont dolo Ihown
on Iho fDOO of Ihll form 10 Iho dolo of aotuol poymonl uolng Iho f6f1oWIIlU Inlor.lllol,lu;
...---...--.......----...-.........-.. ...--.....-...--- ......- ..----...--------..... .....- ...-....... -........----....- ---- - -......-
1 m6nlh ,000 4 mon\hl mO 7 ,1nonltla ,036 10 mon\hl ,aGO
2 monthl ,010 o montho ,020 6 monlllo ,040 11 monlhl ,OG6
3 mOIlI"t ,010 6 monlha ,030 II monllll ,046 1 2 rhonlhl ,060
_..-~
1 dOYI ,00017 Hdoya ,00188 21 daYI ,00362
2 dOYI ,00034 ' 12 dllYu ,00203 22 dnya ,00369
3 daYI ,00001 13 dnyo ,00220 23daVI ,00366
4 daYI ,0006e 14 davo' ,00237 ~4 daVI ,004,03
6 daYI ,OOOe6 10 davo ,00260 25 daVI ,00420
6 daVI ,00101 10 dllVo ,0020'1 20 daVI ,00437
7 daVI ,00110 17 dnyo ,00204 27 daYI ,00464
e ddYI ,00130 10 dnyo ,00301 2e daYI ,00471
9 daYI ,00162 19 dllV. ,00310 29 dOVI ,00490
10 dny,1 ,00169 20 doyo ,00336 :\0 dnvu ,00600
, ' .'
.. - ---....----- --- ..---.......... -,--- -...... - - ....-- _....-- ---... - -.' .............- -- - - -'- -.....-----.. -...- ....
Anv "orlV In InI0'.61, Including tho Cornm'onwonlih and IIH' "oroonol roprlloon\llilva; not O"llllInd ,wlih
Il1a allollmonl may olllool Ihorolo wlil1lo ol~ly 1601 doyo allor rooolpl ul, 11110 Nollun 01 provldod bV 9aotlon
1001 of Iha Inl1orltal1Counrl Ealoto TnK Aclof 1901 172 P,8, G 2406,1001\,
Make Chock or monllY order poyablo II,): .
"Reglstor of Willa, A~enl"
Moll 10 tile oddress IIs1ed below:
IIWO(llory of 1I111ll,wlllllllllUIROnl,ll.oolulu 01
.,,'
"
l'.1^.!~'!' n, ,,1.1,1':Il~^N
uuoeut)ed
;.;;;;;:-.1~,-' u.m__. --. ~;,:~~~;.::;.;..;.;...;o~.;...:..;t.;..;;'.':.o:,;.ta.;~-,;.,-:.:..;'.;.;;"'; 4'-.~~~. ~-;c:..,'. ,.;.;..;..;~,~---.;..~- "..._, ~
'.". --,- .....,..
t~..u_- ........ "D'_"~ ,-.-.
1. 'l'hll, \lards Savings /IS~uoi/;\t:.1Cln
Savings ~ooount No. 1~8B852
Oa,te of death balanoo, plus lntul'est
2. ,irst 'ederaleavings &. ,Loan Assool~tion
SavinGS ~ccount No. 1-1-316710
Pate, of death balance, plue intel'est
3. .state of Paul ~, Herman
,
4. Dauphin PlilPosit Bank & il'rust Company
" Cheoking Account No. 42..44~1048 ~
5. 48 Share,s ,~ American "Telephone &
Te le g raL,h common @ 54. 656310'/ sh
6. Bllle ~id'ile Ha ven ~ re fund
7. Washington National Insurance companY ~premium refund
Mutual Liflil Insurani;le Company of, NeW \lork
~roceeds from Policy No. PB657 00 11
0/1 the, life of Paul B. Herman, Mary W.
,Herman, benefioiary (paid after death of Mary Hemanl
9. Blue cross, Blue Shield & Medioare
refUpdEl& reimbursements
10. Washington National ~ [lremium refunds
&.. death benefit - Paul B, ,Herman
11 ,Mll!;ual Life ,Insuranoe Company of New\lork
Polioy No. 716~70-17 - paid to Estate
TOTAl_
1!1(~ 10'1I'M;E 73'
4,461 93
5,963 01
7,263 73
3 ,116 6 :n
2,623 50
820 10
3 7!i
1,583 09 '
657 36
125 30
1, ,076 57
28,3~4 66
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