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OA'rn m' "IC"HUN^" RIWRWnlN'I'Ann:
COMMONWIZALTlI 01' VENNSYLV AN1A SSI
COUNTY o!"CUMlmRLANU
Uol'oro mo, Iho Itolllslor I'orlho I'robl~to 01' Wills IInd grllnllng 01' Lollm or ^dmlnlstrntlonln und ror thoColln!y. of
Cumherlnnd, Ilor8onnlly ollmo___llliLUJ..iLll,l_..1l'wl n ,..dJ.:.., Imd Horr,o I' '13, l1'w:l n
who, bolng duh'.......Jll'i.Q1.'.1L-1 do_.._doI'080 und suy tllRtus...;;..~"E xo 0 U t01'1.I
of tho last WllIund TostnmulIl 01'
'.J'holll1n 10:, POP1'
deconlod ,
__will wullnnd (ruly IIdmlnlslor tho goods and chattols, rights nlld crodlls of said dooollsed lIecordln8 to IIIW, 'And
'RIHO will dlllgenlly comply. wllh tho provlslolls of tho law rollllln8 (0 Transfer Inh rllan 08, fl W () I'll IInd subscrlbod boforo me,
Junl 0 ' 1981
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Be It romembered thai 011 the
21St, day or
DECREE
July
,A,D" 19.J1L..., Ihere WIIS probilled aM
reclllded the last Will nnd Tostament of'
Sbut;'h Middleton Township
............-.. ..... " " '. --'.._~'
Thelmb. E, Derr'
lalo of
DocclIsed. ,Lellors TflEl\;l1lnentat~_were granted t,o
'Wllnesilmy hnnd and offlclnl seal the day and year nroresald,
1(1.2
, Cumberland counly, pennsylvania,
Hal'oldS, l1'win, ,Tl',EtI1d Rog~r B, Il'w1.n
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COMMONWIALTH 01' PINNSYLYANIA
COUNTY 01' CUMI.llLAND
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III
_ ..'.~_m' lIul'old I.l, T.l'wln. Jl' ,,~r!d_~.l5)_~(~~13~I!'.IY.L'~____,...,..._., ... "_
being duly .___~W_~E'!I u_ uoordlng to law,doplllOl and laYI th.t '{,ht' .._....:1J,l'\L.\1)lQQ.b\,t<iJdL_...u_..
_H__~'~_'_"'__"" '. 0/ tho Eltalo 0/ "..1~!WJ.IIIIl...I~..Qfn:!:.______......._~_
Ilt(o/ l~l'll3tJ'l;Jnnllb(jl'o 'l'OWIlfJl1:Lp I ..-...,.,..., Cumborland oounty, Pa" dm...'d and Ihlt thl
within II an !,nvlnlory mado by Hm'Q;f(j.{31.1r'lt1n,.ili'UU\Q!'mcJ3,-ls:l'I;!tL~, the laid eX0oL!.i12.!:!:L__
ollh.' onllr,.... t4to o/Iald duoedont, ocnllltlng 0/ alllho pOrlonal prop."rty and realllhto, uoopt real lltolll outlldo
thl COlT1monwealth 0/ Pennlylvanla, and that tho /lgurcl OppOlltO oaoh Itom c/ 11,11 Invonlory "prOlent lt'l hlr valUI
II 0/ tho dato 0/ dooodont'l death, '
SWOl'~~ and ,ublcrlbod b%ro mo,
_JQ\lemhQ.V' ,l;lS~
19_fl:L-
. I..~~tor, l!'1!I Itl '-It
, .~..^HOj,P b, l~'2',N, <TII.
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R Yl,;I} . lIiWl
.~L!:L_!,?g.l.\tI1_11ll.n(L'loUJu::oat. Carlisle,. P^,
Add"" 1 '7 OJ. 3
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~;';;IEI\I;IiO,":IIoIIlIIIiMmCIIIJN1Y
t.\Y {\II.\MI.;lIIlN nl'IHr,~ 11f,C, 15, '984
M"muul, l'ollOl\'lvollia A"OCi,lJqn of Notarlol
Palo 0/ Dulh ____"_ ..LQ._____..._._____.._..___.2l1c1y._...._..___
'Coy Mijnth
1981
Vu,
INSTRUCTIONS
I, An Inve~tory !!lUll. bl /lied within three mcnthl a/lor eppolntMent 0/ Plrlonel reprellntatlve.
2. A. $upploment 'Inventory mUlt be 'lied within thirty daYI 0/ dllcovory of additional Ullh. '
. Additional. lho'hmay be eltached U to potlonalty or roalty
. Sel Artlell IV, Flduol.rlu Act 0/1949,
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Inventory ollhe real and pereonal eelale of
'['helma g, Dol'P
deooaeod
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PBRSONAL I'HQPBR'l'Y
1975 Aat~o VBllayb~o6k Mobile Homo (12 X 70)
sold privataly------~----------------~~--..-~__~~__~____~-
Cumbavland Vulley .Savings, and Loan ASDOO~'
savingB aoaoun~ H159609---~--~--.----.------------_--__~__
Certifioate HOh-68eh39--------------..-----------_----_-__
Fa~'mel'B 'l'nuBt Co,
Cheoltingao ooun t 11/1-09537.- ---------_----______,___________
Blue.Tdde;e Haven West Convalesoent Center
Retund----~~~~-~--~-------------------------------~--M____
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9,00 00
111,25 ' 8'7
'7 I 01 65
1,08 75
J,,81 76
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33,170 03
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P.1ilitiS1J..YJ\.t:IL8..lliJitIUli1iQ.1: T AX OEfiEIl~kIN ro RMATION
I. WSONllt~SPONSIUL~ FOR_RETUHN
Section 701 orilla .Inheritance and Eslalo Tux Acl of 1961 provides Ihat tllO 101l0wlnH persons sholl pfopar ~md Hie'
aroturn: ' , '
a. Tho personAl ropresontatlve of tho ostato of tho dOI;ndonl [IS 10 pronl1rly of tho decedonl sdmliilfllerndby him
and such oddltlonl1l proporty which Is or ml1Y bo subjocl to Inhorllonco Tax of which holsho shl1ll havo or
ocqul ro knowl edgo;
"
b. Tho transferee bl prollftflY IIPOlllho, transfur of which Inhorltl1l1co Tax Is (Ir may be Imposod hy Iho 1961 Stnluto,
Including 11 ttusloo 0 proporty transforrod III trust, provldod lhatno soparato rolllln nood ho IIli1do by tho Irar\sfereo
of property h\cludod In tho relum of 0 pOlsonol nlprosontotlvo.
2, I:hACE FOR FILING
TllO retumls to be f1lod In dllpllcale with 1110 RnRister'of Wills of Iho cOllnty wherolo tho docodent resldod.
), I\Mi;.FOR FILING
..
Tho rolurn Is due nloo months ottel,II10 docodonl's,doalh, unloss on oxtonslon,for filing hAS booll appllod for and
grAn lOCi by 1110 Secretory of Rovonllo wllhlnlho nlno-monlh poriod.' , '
;;
4, EAlJJ'wLIQ. FILE RETURN
section 791 of tho 1961 Slotuto provides that" . . .ony porson who Willfully fllils to fIlo 0 relurnor ol~orraport
rO(llIllOd olhlm. . .sllall bo porsollolly Ilohle, . .to a ponalty of 25% of. tllo tax ultln\l1lely found 10 be due or $1,000
wlllchover I s the lessor to Ile recovered by tho Dopartment Of Rovonue os dehts of like amount arorecovorabl e by
lAW.'" "
5. JAX RATES
Inherllnnco Tax is paynblo allha rote of. 6% on trnnsfers 10 IInool doscan\lanls, s\lch as father, motrer, husband, wlfo,
son, dauRhtor,llrandchlldron, gralldparent, son-In.low and daughter.ln-Iaw and at tile rato of 15% as toal,l olhers. '
6. p,AYMENT'OF W
The tax assossed onlho transfor of property roportodin the return Is duo 9 months alter tile decedent's death. Inlorost
atthe rato pf ,6% por annumaccrlles llIerealter until payment Is ',nOdo. All 110ymenls roc, el vild Are .II rst ,nPPl1 ed, to any
Interesl whlcll may bo dllo with any romainder applied 10 Ihe tax. I F TAX IS PAID WITHIN 3 MONTHS AFTER T,H E
"'DECEDENT'S DEATH, A DISCOUNT OF 5%OF THE TAX PAYMENT IS ALLOWED. '
Allcllecksshould bo modo payohle to,lho Register of Wills of Iho countyWhereln.lhe decedon\ resldedandare
re90lvod,gubjocllo Ihe final dotermlnotlon ollhe Department of Revonue.
1. fAILURE TO PAY
ThQlaxlls Imposed, togolhor with any Intorosl thereon, aro allon upon real proporty, Whlch,lIen.remalns 111 effoct until
t~e taxes and Interest hove been paid in full. The taxes may bo suod for aRAlnst any roal proporlY Intllo decedent's
estato or against any propetty bolonglnR to a Iransferee lIablo .for the lox.
a,PILING OF FALSE RETURN
--., '
Any porson who Willfully makosa lol,to r,otum or roport required of 111m shull, Inaccordm\co with Section 793 of the
1961 Stalulo, bo gllllty of 0 misdemeanor and, on conviction thereof, sholl bo sontonced to pAY a fino nol exceeding
$1,000 or undergo Imprisonmont not e~ceodlng ana year at, Wth.
qUESTIONS CONCERN~G PROPERTV..lRANSFEHS
1. Old docadel\t~ wl\hlnlwo yoms of donlll, f1\nko nnytrnn~lor of nny IIInlo!iiil pnrl 01 his OSllllo wllhout rllcelvlnp,
'vnlunble and adeQuato consldomtlon? (Answor "Vos" or "No" ,).-NO-- '
2, Did docedont, within two Yllnls of donlll, IrllnslOl plOportyholll hililsolf/ 1\orsoll to hill1solf/iHlrself ond IIrlolhor party
or partlos(lncludlnp, n spauso) in joinl OV/IIlHShip? (AlJsV/ur "Vos" or "No".) ..._No. '
3, If tho onswor 10 ana or lwoohovo is "Vo~;" ,lIId lho. lrnnsf!)I!. i1[O clailllod 10 fHlllOlllaxohlo, p,rovido Iho (olltlwltlp,
In(orll1otlol);
a, ARO of docodollt altlll10 01 Il<<lIslol, ..Ji1A-
h. Copy of dooll) cortl.flcoto.
e. Aflldavll hy tho atlolldlnR pllysleloll indicating Iho !;lolo 01 rlncodonl's 1I001lh ot !jIlHl ot Irollsfor.
(I, All athol in(orlllatioll sllPlll1llinp, nonlnxniliIi Iy of IliIlIsfnr. '
4, Old docodont, In ills/hor Ill0limo, rnol<o ony Ir,lnslm III propmly witllollt locolvlng a vnhwblo oradoQualo consldornllon
{harofol which wns 10 lako olloel III possossion 01 olljOYlllonl ill or ollpl 1115/1\01 r1(Jath'l (AlIswor "Vas" or "No",) ..tlO-
a, Was,lhoro any possibility thollho propelly lr<lIls(ullod mlghl rnlurn tOllilllSlolOl or his/hor oslntoor ho subiocl
10 hls/hol POWOl of dlsposltlon'l (AnswllI "Yos"or "No",) _!ilL... '
h. Whol wns the tral1sforoo's ano al till1a of dllcollonl's doalh" -NtA-:.
5. Old docodol11 111 hls/hm Illotlmo lIlal<o nny tmnslol wllhnnl rocolvlllf\ n volllob!o an(1 ,1110\lnalo consldorollon Ihorolo['
tinder l'illlch tronslorol oxprosslY or Impliodly IO'JOIVOS fOI hl''/hor 11(001 ,my plJliorl which doos in lacl and bolore hls/hor
doath:
n, Tho 110sso$s1011 or 1IIljoYlllonl 01 or tho rlghllo IncollIO from 1110 plOporly llilll:.;ftlflorl'l (AnDwor "Yos" or "No" ,) _..liO-
b, The rlRht \0 dosignato the porson!; who. slwllllOSSO!;SIH onjoy lho proplnly IransfollOlI or incomo lhorofrom?
(Answor "V os" or "No",) _NO.-
6, If tho answor \0 five h, (11)(1\10 Is "Vas," slalo whothor tho ri'ghl WilS rosolvml in r1ccOlhml 010110 or othors, N/A
,
7" Old decodont iii his/horlllotl\Ho \HaKOn lml1s(or, Iho consldornlion. for whl.ch was Ironsloroo's prollllso \0 poylncomo
\0 or for thll hllnefll or coro 0 I transloror? (Answor "Y os" 01 "No".) NO ' ,
, '
8, Old do'codonl, otal)Y limo, Ilonsfor prol1orty, lho brnoflciol onjoymont 01 wllich was subject 10 chonp,o, bocouse of
arosorvod powor to altar, omond, or rovollo, or which could rovrirllo docorlonlundor 10rlll~ 01 transfer or by oporotlon of
low? (Answor "Yos" or "No" ,)!iQ....- '
'9. If tho answor to oi~hl obovo is "Yos," wos Iho POWl1l 10 allor, amond or r(\voKo lholnlerost of lho bonoflclnry resorved
in tho docodOlll olono or tho docodont nnd olhols'I (Answor "Vas" or "No" ,) ..lliL___
_~__..--.--.._..___-~----_.---_._~_......_,~._.n_~~-.._.""'"
IlIy.4IH' 0-001
COMMONWEAL TH OP PENNSVLVANIA
DUl'ARTMENT OF REVENl,JE
rnANal'EIlINH"UITAN(\~l AX
I1BOIDBNT DBCEllENT
SCHEDULE "0"
PENllPIOIARlllS
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III/sIt/lOti,,,,, 1111 I/tworsu SIr/oJ
Estate 01 Tlle1!ll. m.D,%'~
..----
hl!Nl!FIOIARIIlS AND ADOReSSES RELATIONSHIP SURVIVED DATa OF INTeRDST OF BeNl!FICIARV
I'JIlOEOBNT PIRTH
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Blc\om~nl~oll, ILL 61101.___ -.--........,T1...._c~_.-......._"--. ........------..-
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Thfl above beneflolarlel are IIvlnp at this time except/or the following:
NAME
bATe DI' DEATH
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'AIJodoJd pouf\'\o AHUIOl aljl JO enl8^ la)jJoll.lIO\OI e41 GIOOIPU\ '~
'poqsllqa\5a saM dlqs.tGUMO\UIOI aql Olap aljl pUO (s) JOUMO.OO aljl!O lUnPOOaP,
a4\ 01 ctl~sUOllliI9.1 pUll SS9JppO 'GUJnualjrapnlOUI '"S" 9.lnpoqos .101 8Utl!\OnJl5U\Gq\ UI \lO\SO!PUI 58
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aq Ol./IJB A\JadoJtI OIQI6un\u\ pUO Blq16U8\ q\OS . '~114SJOAI^JIl5 !O ~401J 41lM B1U9Ua\ \UIOI 80 1911J9d .10 AlJ9d
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"a.. g1nOaHOs ElNI.LS1dWQO 1:10:1 SNOI10nl:l"'I.1m
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Qe~EAAL INl;1ERITANC~ TAX INFORM6!1~
UnBlltllflod lIobllltlo,9 Incurred by tl10 dooodent prior to hls/hor <loath ul'O dodlWtlblo oUlllnst hl8/her IMtoblo o8tato,
In addition to dobts Inourrod by tho deoedont 01' ostlllO, othor Itoms 01'0 olnlmuble Inoludll\utho cost of ndmlnl8trntlon,
attornoy foos, f1duolol'Y foos, funol'ul und IJurlul eKponso'slnollldln\l IhoooSI (JIll burial lot, lomb8\One'l1rqrllvo markoI'.
All debtl being 010lmedsoolt18t on08teto aro 8uUloot 10 tho approvol of tho Register of Wills with whom-tho
Inherltanoe TaK Relllrn Is filed. Evldenoo to 9upport Iho decodont's tlr tho 08tato's liability for the debts bolnq olalmod
should be ottaohod 10 thl8 sohedule.
A family AKamptlon of $2,000 lTlay bo olalmod by a spou811 of 0 decedont who diad domlolled In Pennsylvania.
If there 18 no spOU8e, or If the 8pouee has fOl'folted I1ls/hel',rlgl1\8, than eny cl1l1d of tho deoodont who 18 a member of
the seme hl1,usehold oon ololm the oKemptloll, In the event thero Is no SllOh spouse or ohlld, the aKamptlon oen ba
olelmed by a parent or peranls who ore mOl,nbers of the somo housohold os Ihe dooodont.
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,INSTRUCTIONS FOR COMPLETING SCHEDUI.E"F"
,: If tho fomllyoKomptlon 18 bolnq ololmod, Indlooto the 0lalmol1t's nomo, addross end hl8/hor relotlonshlPto tile
dooodont, Entor"famlly oKomptlon" In the romarks oolumn and tho amount olalmod In tho omount column.
2, AS81qn consecutlvo numbers to oach Itoln IIstod.
3, ~ntor tho dato 011 which eaol1 dobt was Il10llrrad and/or paid,
4. Entor tho l1ulnOS of each payoo. ,
1;, Provldo a brlof oKplal1otlon In tll0 remarks, 00luml1 for aaoh debt olalmed.
6. Enter the lln10unt of eaoh dobt being olalrned. '
7. Tho forlnmust bo slOl1od by the porson Who has ossumod tho rasponslblllty for paying tile dobtl.
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