The URL can be used to link to this page

Home My WebLink About05-14-07 -.J 15056051058 REV-1500 EX (06-05) PA Department of Revenue . Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFOttMATlON BELOW Social Security Number Date of Death ,----.-----..-------.---..-----.--- --.--".-..---.--..., -.-.-. OFFICIAL USE ONLY ,County_~de Year INHERITANCE TAX RETURN RESIDENT DECEDENT File Number 21 07 S'7 Date of Birth · 174-20-0943 01/07/2007 02/25/1927 Decedent's Last Name Suffix Decedent's First Name MI McCurdy Daniel D (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name _...._. ... _'0 ___._._._._~_ Suffix ~Pc:l~~~'~.~i!!l_~_~!".:l~. MI ~p~s~'s Social Security Num~!~.... THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW (8) 1. Original Retum c::) 2. Supplemental Return c::) 3. Remainder Retum (date of death prior to 12-13-82) 5. Federal Estate Tax Retum Required c::) 4. Limited Estate c::) 4a. Future Interest Compromise (date of death after 12-12-82) c::) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c::) 10. Spousal Poverty Credit (date of death c::) 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name .Dayti.r:ne Telep_hon!_N~~~_______...__.....__, c::) ca> 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes c::) Daniel D McCurdy, Jr Firm Name. (If ~I:l~cab~e).._ i (717) 576-7200 ,-.-.---..... ....--_...__.._.......__ r:",;>.__.__....-' (~ .~ I REGISTE~ ~LLS USE~LY i" 'I ~3 ':::-f~;c: ~ !;~~ ~~ . ~. ~ .&'" -.:;,...... First line of address -n Second line of address C~ty or Post Office New Cumberland State ZIP Code OAt! FILED 0' PA 17070 ,---.-.-,. ..,_.._,.._-,..,--,,--,---~._"~,-_.. --~--'--_.,._,_._-_._-_._-,~_.._,._--_._~~-------~-_.., Correspondent's e-mail address:damccurdy@comcast.net ADDRESS 1331 East Chocolate Ave Hershey. PA 17033 PLEASE USE ORIGINAL FORM ONLY 7 L 15056051058 Side 1 15056051058 --.J .....J 15056052059 REV-1500 EX Decedenfs Name: RECAPITULATION Daniel D McCurdy Decedent's Social Security Number --,.-.----,-,--.------~- .----- --...----------------1 174-20-0943 1. Real estate (Schedule A). ............................................ 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. . .. 3. ----i 4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. >----~-- 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5.' i 26,661.23 I 6. Jointly Owned Property (Schedule F) c:::> Separate Billing Requested . . . . . .. 6.! 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ~ (Schedule G) c:::> Separate Billing Requested.. . . . . .. 7. ~ 26,661.23 i 9,133.89 ! 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8.. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. i ----: I 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10. . ---.j 11. Total Deductions (total Lines 9 & 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. i 9,133.89 i 17,527.34 ! 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. , u__------! 14. Net Value Subject to Tax (Line 12 minus Line 13) ..... . . . . . . . . . . . . . . . . . . . 14. . TAX COMPUTATION. SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2)X.0_ 16. Amount of Line 14 taxable at lineal rate X .045 17,527.34 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 17,527.34 i 15. 16. 788.73 17. 18. 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C,) L 15056052059 Side 2 15056052059 .....J REV-1500 EX Page 3 Decedent's Complete Address: 0~L.r .~ I - DECEDENT'S NAME DECEDENrS SOCIAL SECURITY NUMBER Daniel D McCurdy 174-20-0943 STREET ADDRESS 1646 Lowell Lane CITY I STATE I ZIP New Cumberland PA 17070 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 788.73 Total Credits ( A + B + C ) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( 0 + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill In oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5) (5A) (5B) 788.73 A. Enter the interest on the tax due. 788.73 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income ofthe property transferred;.......................................................................................... D ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ D ~ c. retain a reversionary interest; or.......................................................................................................................... D [i] d. receive the promise for life of either payments, benefits or care? ...................................................................... D ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ D ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. ~9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. ~9116 (a) (1.1) (ii)). The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)].Asibling is defined. under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+ (8-98) *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDaNT DECEOENT .eNIDULI I CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTAtE OF Daniel D. McCurdy FILE NUMBER ITEM NUMIER Include the proceeds of litigItion and the date the proceecls were received by the estate. All property jolntty-owned wtItI r1tht of survivorship mUlt lit dllClosed on Schedule F. DESCRIPTION VALUE AT DATE OF DEATH 10,492.40 528.18 9,745.65 5,227.00 668.00 1. Members 1 st Federal Credit Union Acct # 174356-11 Checking Acct. 2. Members 1 at Federal Credit Union Acct # 174356-00 Savings Acct. 3. Members 1st Federal Credit Union Acct # 174356-05 Money Management Acct. 4. 1999 Buick Regal 5 Miscellaneous Personal Items TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 26,661.23 REV-1511 EX+ (12-99* COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT sca.DULI a FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTAt! OF Daniel D. McCurdy FILE NUMBER DIbIa of decedent must be reporlecl on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Malpezzi Funeral Home 8 Market Plaza Way Mechanicsburg, PA 17055 Meal Expenses Following Services 8,569.72 2. 104.17 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Soclal Security Number(s)/EIN Number of Personal Representative(s) Street Address City Stata Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedenrs address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent State . Zip 4. Probate Fees 110.00 5. Acc:ountenrs Fees 6. Tax Retum Preparer's Fees 350.00 7. TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 9,133.89 REV-1513 EX+ (9-00) *' leN.DULI , BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DanielD.McCurdy FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Lilt TruatH(I) OF ESTATE I TAXABLE DISTRIBUTIONS Pnclude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Unda K. Nokes Daughter 1/3 21 Longview Drive Mechanicsburg, PA 17050 2. Suzanne L. Sassamon Daughter 1/3 Lot 10 967 West Trindle Road Mechanlcsburg, PA 17055 3 Daniel D. McCurdy, Jr Son 1/3 1646 Lowell Lane New Cumberland, PA 17070 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON- TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space Is needed, insert additional sheets of the same size) , st Send Inquires 10: 5000 Louise Drive PO Box 40 Mechanlc.burg, PA 17055 www.membera1.lorg M11ln Switchboard: (717) 697.1161 or (800) 283.2328 EZ Call: (717) 697-4372 or (800) 283-4372 TOO: (717) 697-5312 or (BOO) 283-2328 ex!. 5312 Tel.Branch: (717) 795-6049 or (800) 237-7288 MEMBERS 1st FEDERAL CREDIT UNION 14865 1 AV 0.293 29729-14865 1",111",111,1,1",11111I,,1,1,,1,1,,11,1,11,,1,,',11111,1111 DANIEL 0 MCCURDY CIO DANIEL 0 MCCURDY JR 1646 LOWELL LANE NEW CUMBERLAND PA 17070 . -. .~ ~iIi .=== - > .- -- Statement of Accounts Dec 25, 2006 thru Jan 24, 2007 Account Balances at a Glance: Checking: 0 . 00 Savings: 347.69 Certificates: 0.00 Loans: 0.00 Money Management: 0.00 Account Number: 174356 - - - - Page: 1 of 2 Your current Member Loyalty Reward level is Gold Beginning in February, we will be adding additional security enhancements to Members 1 st Online. Please read the enclosed insert for additional information. CHECKING ACCOUNTS 11 - CHECKING Date D6c 25 Dee 29 Jan 03 Jan 05 Jan 05 Jan 05 Jan 10 Jan 11 Jan 13 Jan 22 Jan 24 Check # 000509 Transaction DescrOtion Balance Forward Check 000509 Tracer 122900nQ6 Deposit Transfer From Share 00 Withdrawal Deposit Withdrawal ACH AARP HEALTH CARE TYPE: PREMIUM 10: 1526069387 WID PRENOTIFICATION FROM CREDIT CRD PMT Withdrawal Deposit Cheek 000510 Tracer 0122015737 Ending Balance 2DM7JNidiii1iis. pilid .- CHECK SUMMARY Amount Date 160.00 Dee 29 2 Chscks CIBartKJ for 2,160.00 Additions SubIracIIons 160.00- 6.50- 163.50- Balance 852.40 692 .40 1,662.40 1,655.90 10,655.90 10,492.40 0.00 2,000.00 0.00 0.00 Date Jan 22 SAVINGS ACCOUNTS 00 - REGULAR SAVINGS Date Transaction De8crioIion OtIc 25 SalllnCffl FOfWIIrd Dee 31 Deposit Dividend 1.000% Annual Psrcenltlgtl YI6Id Eamsd 1.010J(, from 12/01/2006 Ihrough 12/31/2006 Jan 03 Deposit ACH sac SEC 10: 3031036030 Withdrawal Transfer To Share 11 Withdrawal Ending Balancs Jan 03 Jan 11 Jan 24 - - - Continued on following page _ __ 970.00 9,000.00 2,000.00 10.492.40- 2,000.00- O~()() Check # 000510 Amount 2.000.00 AdditIons Subtractions Balance 527.73 0.45 528. 18 970.00 1,498.18 970.00- 528. 18 180.49- 347.69 347.69 fv'1,~t. MEMBERS I' rtJ'EUI.(Jl~III"l,:.'lIQI< Sent;llnquires to: 5000 louise Drive PO Box 40 Mechanlc.burg, PA 17055 www.membera1.t.org MIIln Switchboard: (717) 697.1161 or (800) 283.2328' EZ Call: (717) 697.4372 or (800) 283-4372 TOO: (717) 697.5312 or (800) 283.2328 ex!. 5312 TeleBranch: (717) 795.6049 or (800) 237.7288 2''730''141'5 Dee 25. 2006 thru Jan 24. 2007 Account Number: 174356 Page: 2 of 2 Date Transaction DescriDtion 2006 Dividends Paid Additions Subtractions 5.25 05 - MONEY MANAGEMENT .. "- "-, :> .J_ :>1iIi! .-= Date Transaction OescriDtion Dsc 25 Balance Forward Dec 31 Deposit Dividend Tiered Rate Annual P8fC6flf8ge Y18Id Earned 2. (J()(M from 12/01/2006 through 12/31/2006 Jan 05 Withdrawal Jan 08 Withdrawal by Check Jan 11 Deposit Dividend AnflU8l P8fC6fl1ags Yield Eamsd 2.000J(, from 01/01/2007 through 01/10/2007 Jan 11 Withdrawal by Check MONEY MANAGEMENT CkJs<<I ..uThis is th8 final sfat8mtJf1t pl'8tltlntng inforrrwtion on this product..... ....... PltJaS8 Millin this final sl8t8m8nt fOr tax I8pOftiIg purpostJS .. U iixxJ l5iVidiJniJS PliliJ " '" '..p', Additions Subtractions 31.63 9,000.00- 1,210.00- 7.04 8,542.69- YTD SUMMARIES 411.26 TOTAL DIVIDENDS PAID 00 REGULAR SAVINGS 05 MONEY MANAGEMENT 11 CHECKING 0.00 7.04 0.00 Total Year To Date Dividends Paid NOTE: Total includes closed shares Total 2006 Dividends Paid Total Year To: Date Interest Paid NOTE: Total includes closed loans 7.04 416.51 0.00 Add Your Photo For Security Your personal safety and financial security are top priorities at Members 1st. ;As a result of increased scams and fraudulent activ~ tfiroughout the entire country, we are strongly encouragil"tg members to have their photos acfded to their account records. When visiting our branch offices1.You may be asked by one of our Associates to allow us to take your photo. This member identification program will assist in our fraud deterrence initiatives and will take our identity theft prevention program to the next level. We are experiencing an increasing. number of attempted fraudulent activities and as a result, we need to be able to verify your identity . im.mediateIv~r8triAving y(u"~.account~fQrmatiQn, _ _______________. !n ad~itio~ to having your photo in ou~files},.you may be re~Uired t~ show additional for'!"s of Identification basec:f on the type of trallSaction you are seeking. ThiS is for your protection and security and we appreciate your ongoing cooperation and understanding. . , ~ '.. ',"'- ~ ,,- co. ~~. . ~ ~l LAST WILL AND TESTAMENT I, DANIEL D. McCURDY, of the Borough of Mechanicsburg, County of CUmberland and Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void all former wills and codicils by me at any time heretofore made. ~. I order and direct that all my just debts and funeral expenses be paid by my Executor or Executrices, as the i case may be, hereinafter named, as soon as conveniently may be done after my decease. SECOND. I order and direct that all the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situated, be converted into cash as soon as practical after my death, and the net proceeds thereof (after satisfaction of the obligations contemplated in Item First above and all death related taxes and expenses of administration) be distributed as follows: ,;, n;/ ,f/ 7/.;.Jr-tltl"'~ -1- . ~l.~~ ,,1)7 I\t. I give and bequeath fif1ay per centum of , -"1-07 A. said net balance of my residuary estate unto my ~. .') .f~....) daughter, namely, SUZANNE L. SASSAMAN, absolute~; r/r II-I 111-, 't: ...,./...- $.. cf' . B. I give and bequeath bw...'el ~...e per centum .~.J .Y~ ) of said net balance of my residuary estate unto my daughter, namely, LINDA K. NOKES, absolutely; and -;:/....#'1- fl.,..." ~I 60v #...,."l c. I give and bequeath w..'t':y fi". per centum ~.~.;. ) of said net balance of my residuary estate unto my son, namely, DANIEL D. McCURDY, JR., absolutely. If any of my said children should predecease me, I , _ .., .1>1 .' ,-...,-f> LAW OlflflCEM SNELBAKER & BRENNI!:MAN order and direct that the residuary distribution under this Item Second attributable to such deceased child shall be distributed unto his or her issue per stirpes by representation and not per capita, subject, however, to the protective provisions of Item Third hereinbelow. 1HlBQ. I order and direct that the 'residuary di~position pursuant to Item Second hereinabove which would be otherwise distributable to a beneficiary who has not attained the age of twenty-three (23) years at the time of my death shall be paid over and delivered unto PNC BANK, NATIONAL ASSOCIATION, in trust, nevertheless, to hold, manage, invest and reinvest until said beneficiary attains the age of twenty-three (23) years at which time said trust shall be terminated and the then remaining net balance of said trust shall be paid over and delivered unto the beneficiary, absolutely. During the existence of said Trust, I authorize and empower my said Trustee to use, expend or apply from time to time such amounts of income and principal as it ~ ., shall deem necessary and proper for the education of said beneficiary, including college or other post-high school training. LASTLY. I nominate, constitute and appoint my son, DANIEL D. McCURDY, JR., to be the Executor of this, my Last Will and Testament, but if for any reason he should fail to qualify as such Executor or cease so to serve, then and in that event, I nominate, constitute and appoint my two daughters, namely, LINDA K. NOKES and SUZANNE L. SASSAMAN, to be the Executrices of this, LAW OFFICE. SNEL.....KER 8: BRIlNNEMAN my Last Will and Testament, each and all to serve without bond or other security as a condition of qualification as DIY personal representative hereunder. IN WITNESS WHEREOF, I, DANIEL D. McCURDY, have hereunto set -2- LAW o"'c.. SNELBAKER lit BRl!'NNI:MAN my hand and seal to this, my Last Will and Testament Mhich consists of three (3) typewritten pages to each of which I have affixed my signature this 8th day of August A.D., One Thousand Nine Hundred Ninety-four (1994). 11-/;-< '/1/ .~" ./ ~ (SEAL) 1-- Dan:.r:el D. ~I"'~ ~/ The preceding instrument, consisting of this and two (2) other typewritten pages, each identified by the signature of the Te.tator, was on the date thereof signed, .ealed, published and declared by DANIEL D. McCURDY, the Testator therein named, as and for his Last Will and Testa.ent, in the presence of us, who, at his request, in his presence and in/~ pres ce of each other, have subscribed our names as witnesses .' .,. '? /' \..,.-.,l,........... r A< <;.,-~~-.... .f ~.., "r ./" -3- <' LAW' OP'l"ICf!:. SNELBAKER 8< BRENNEMAN COMMONWEALTH OF PENNSYLVANIA SSe COUNTY OF CUMBERLAND We, DANIEL D. MCCURDY, RICHARD C. SNELBAKER and JANET R. STEGNER, the Testator and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and Testament and that he had signed willingly, and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, siqned the Will as a witness and that to the best of his or her knowledge the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. (. , . )' . .h......,r~<. . ;-~..'-"'--- / W tn'"Os 1/ . V SUbscribed, sworn to and acknowledged before me by DANIEL D. McCURDY, the Testator, and subscribed and sworn to before me by RICHARD C. SNELBAKER and JANET R. STEGNER, witnesses, this 8th day of August, 1994. <9~~v 2' ~~~. Nary Public NalariaI S80I PaIri::Ia J Thr.mson, NalIry NIle ~~~J\l !'<lru. Ci.tml:sIinI CcllI1lY l/;oJ~,n ~>oo Cec. 31, 1994 .~.;n~' -. HIOS.CJ05MS KEY. 6106 This is to' cenifY.that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records in accordance with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953. WARNING: It Is Illegal to duplicate this copy by photostat or photograph. /2 J -// ~ ~ ~~ t[wyoL H105.1.t3REY.0'ln006 TYPE 1 PRtfT.., -.err IUQ( N< 1._"_ ""'_ Daniel D. 5.19> _ 79 Y~. No. Frank Yeropoli State Registrar Calvin B. Johnson, M.D., M.P.H. Secretary of Health 1006110 JAN 2 4 2007 COIIIIIONWEALTH OF PENNSYLVANIA. DEPARTIIENT OF HEALTH. vrrAL RECORDS CERnFICATE OF DEATH Date fl. 1. ",". Cllr/Bov DllitID{ar_.~aIt: 21.""__.__, o Y. XiI No PatIl:BWoIw .........~ID.... at TCIIIIaDoUIICcnlllltIDOIIM boll..._....-._.........". 0 v. 0-.- 0'" 21.,_ B~=:-_G_ O..=-~_~_..,_ lJfWloMIl",..,........,... lIII:. '-""""_.__F_. c-.......... ~ em..-..... "'_IIIidCII"& ---- =-~':...~ .. ... w....\IIqIIy - .. 311>.__ 3t._YI =~-. ~ 0- Oy. :::/ 0- 0-._ V"" 0 _ 0 ClUdNolbo-"- I i 331. _...anol . .........--ClWII'lq-..----..--...__....Z!l To.................... --........-.--.IIIeIf-..._............................................ __... ""......... _'__ __... __... . ~-::==-.=:=:::::"...--=-=::::.c."i".!.._.___________________.o . =.::..:.....:=..,..""-'.....---.....--..-..........-...-......._.0 ~.1 35.~_... .. W~ R.. ... I'd... 1-' I ~ l.l I?. I ..j ct.JIf. q, ~o'1 (SM lnatructloM and _111M on -J 8/?r"7s-eJ U:i Q) o "~ Q) I/) Q) I/) Q) .r= - ... .2 Q) a. o Q) > C Q) I/) ;s Q) I/) ~ (5 C o Cl ~ Q) .~ Q) Cl (ij= '- l1:l c:2: Q)- "Ol1:l "w .g Q)- o::(!) 1iQ) ~ E1:: o l1:l -o.r=E c;@CI) ~-I-I eJ:J: (!)ClCl '. . . \ '-o~ go:: -:'"0('1) <('C('I) Cl)l2-1 =:>..!!2LL.\ - Q) - ~.5 ,~ ~e; ~ \ Xc l1:l' we-I -IN~ \ \ t,jt,jt,jt,jJ l)~l)t)l)t)t)t)l)l) 1-0 C~ :I~ i:j ., 1: i::i: a., 'I: 1; 00 0:) ...."..- .....-,~ L.._ t~ LL e, 0... - - - 211)ii." - - - ~. ~- =- N ..- i- ...::t '-..... _......:... (C ~~~ Ll.{ ~~~: Gtt, cr~ . c5::S o -0 Q) "1;: l1:l'~ ~ .91/)- Q).2'iQ)c;c l1:l - g l1:l c; ~ ~ O)a.E '0.. 5 ~ ~ >'~:e-go X C'-OOl1:la." .Q :5' -g iii -g ~ ~ ~ iii 1;) Q) l!! 5t B -g~o=l1:l OEl1:lI/)Q):;l1:l g "0 I/) U .Q c; ,- - 3: Q) :; '> e a E ~ = ,9- ~ :; ~ fij Q)..c ~ e l1:l-g I/) 8:c~~ >.:t:::;::3:;.r= ~ "j a.1/)l1:ll1:l '>.1/) l1:l...;- -E I/) l1:ll1:l~dEI/)~a;oi ~ ~~~~~3:=C!c~fij~5g 01 ,- x a; l1:l :E -I ..c coo- I/) 1:::;::3 '6 ~ W I-' .~ ~ ~ ,S!! ~ ~ e ~ ~ ~ 5i s :r: aa ::J < CI :I: r--. r- u X u I- '~ ., C VI ~lJ 'iI ~~ '~ u ., ... Q. & VI VI QI WI ::I ..:! " " Lt'l t WI .. - M ::I - 8" I ~ I ,-0 a-:;M 0.... ..N .1: ::11""4 !..!. 8~cn .~ l""4 " l""4 LI.I E! '0'" ~ l:::Iift;; .0 -"I: .. ~ "t::.!63 J ::I,~", c ... 0 EO-_ '€ ., ::IU "z "ul""4d:::3 c ILl 0 {!. ;: If C e o X o X o ~ E Q .... ...., 'B~ P4"'~ ., 0 ~ l- i::'; i .21:0 E.. a. 1: .. Q. 'ti '1:- "'i:= U~~Vl Q. =:: 11.,='- o!li5:iio; ~ ~ ~I'I'I 01'1'I UO ...0....."" ~z:...1IJ UU!!C~ ZI-Q;:!: ~ '" ~'''' L&:~z:e ..!:"'~laE E::!l'I'IlrJz fC"'Z::::l u.. ~~ II I \0 III \0 o . f'/'l _1'1'I ,- III <(I Ii..... Q~ ..... 1;., 1:5 ~f E o ... .e. .c ... ~ ., ., Q. i 1 Q) I/) e s .r= 0) 'C <( ,;~:{. l> In