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Home My WebLink About06-06-07 (2) ---I 15056051047 REV-1500 EX (06-05) PA Department of Revenue '* Bureau of Individual Taxes . PO BOX 280601 Harrisbur , PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT Date of Birth Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW _ 1. Original Return <:::) 4. Limited Estate <:::) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required <:::) 2. Supplemental Return <:::) <:::) <:::) 4a. Future Interest Compromise (date of death after 12-12-82) <:::) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) <:::) 10. Spousal Poverty Credit (date of death <:::) 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 Da ime Telephone Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received o 8. Total Number of Safe Deposit Boxes - REGISTERc()F WILLS Usei)NLY :: 0 --.. '-" .~-: ~ (" ---'" C') I (jl J r,,) Correspondent's a-mail address: he~lYIercs (j)epiX.l1et /71J1/ Side 1 L 15056051047 15056051047 -.-J ...J 15056052048 REV-1500 EX Decedent's Name: 0 !till L Y h1 M #. RECAPITULATION 1. Real estate (Schedule A). .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3. 4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5. 6. Jointly Owned Property (Schedule F) <::) Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) <::) Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10).. ... .. .,. .. . .. ... .. ... . . . .. . .. .. . . 11. 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. 14. Net Value Subjectto 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 .OCL 16. Amount of Line 14 taxable at lineal rate X .0'iS 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 19. TAX DUE.. . . .. . ., ... .. ... ... .. . .. .. . . . . .. ..... . .. . .. .. ... .. .... . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056052048 Decedent's Social Security Number 15. 16. 17. 18. <::) 15056052048 ...J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENTS NAME ___________ '-1 IJ1I/-N _ JI.~/ll(____ ______d _____ ____ --- --- -- - - ----- STREET ADDRESS /J/ ANpL eAt!E e--------- ___ ___________________________ ----------- _________n_________ - ~----- /100 IJIA-It-J{E T Sr: f------------ - ----- ---- CITY /l- A~~ L7 LAMr HILl.. ----------- ----TSTATE;;- i ZIP -- /7 ~ -;;- Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) '1 I ~ J 0.33 o --~~-_.._--- o ----------------------- o Total Credits ( A + B + C ) (2) () 3. Interest/Penalty if applicable D. Interest E. Penalty () -----U-- ----- ---- B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) 0 (4) () " (5) I, ~ 10.3.3 (5A) 0 (5B) , - f, g'/O,.33 . - -------- -- -- -- ---- Total Interest/Penalty ( D + E ) 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. 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 of the property transferred;.......................................................................................... 0 ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 ~ c. retain a reversionary interest; or.......................................................................................................................... 0 ~ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 r&I 2. If death occurred after December 12, 1982, did decedent trahsfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ ~ 0 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. 99116 (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. 99116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return 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. 99116(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. 99116(1.2) [72 PS. 99116(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. 99116(a)(1.3)]. A sibling 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-l508 EX + (1-97) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF OI2./l, L.)/ /JIA-P H FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH ~- ~ ~ '1.2, IJD ~. HC~ IJ/Al/Pi t!Ihtt,. ~ AIl7i At.. R5At IIJD (~ (!;9py OF iJA-Ym@JT A -rnt-MGZJ) f<,E-FkNl) ~JJ f/aesOAl,fl JIJ&JIHE: TA-y,ec-r/,fA!.JiJ ~ If, 0 30. "'" 11JFf) A/P~: IJ€CElJeir HAJJ f!1EE/I) /AI /JI,fM)R (!/VIE FiJf/ d~Y 7NItEF YG7hfl.$ iIhIlJ NA() ~ ~ Q"Y'QI bJItI-Y Sallfk /71S1Jtf 'r /lBl..SalVAt..ry 8e::b/2,F #/.5 ENT/l.Y lAin 11/ bPplf' t!.Ihe& TOTAL (Also enter on line 5, Recapitulation) $ G, I , 7:(, , "eo (If more space is needed, insert additional sheets of the same size) Gross Amount 2642.00 005061 P2 1293326 Check No. 0004515496 Discount Available Paid Amount .00 2642.00 [-'Check DatE;: 12-13-2006 --Invoice ~~~~'-'Invoice Date Facility Name 1552 11-27-2006 Manor Care of Camp **************************** I I -- .. .. Vendor Number Name Total Discounts 0000342114 SUSAN BRAND FOR LYMAN ORR .00 Check Number Date Total Amount Discounts Taken Total Paid Amount ---~----_. 0004515496 12-13-2006 2642.00 I 2642.00 v REMOVE DOCUMENT ALONG THIS PERFORATION v HCR Manor Care 333 N. Summit Street Toledo OH HCR.MallorCare NO. 0004515496 56-1512 441 43699-0086 VOID AFTER 60 DAYS DATE 12-13-2006 AMOUNT PAY Two Thousand Six Hundred Forty-Two and NO/100 Dollars SUSAN BRAND FOR LYMAN ORR 611 FAIRWAY DR $**********2,642.00 TO THE ORDER OF CAMP HILL PA 17011 A#.-H-;, s-: ~ ____l~~_~____ _ ___+_ Allthnri'7~rl ~inn~hlr The Hunlin!llon National Bank REV-t509 EX + (1.97) SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNS) LVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF p,(~ ly AI/I# ~ FILE NUMBER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Sus,fA) ~UAil> ~/I F".IHItIII-JI IJR. ClJ6IfJ IIN..L" /JA /7/)11 2>~HT~ B. c. JOINTLY-OWNED PROPERTY: LETTER ITEM FOR JOINT NUMBER TENANT DATE DESCRIPTION OF PROPERTY MADE Include name of financial institution and bank account number or similar identifying number. Attach JOINT deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 5("/11 M7iJ Au.- ,I. t!elllA/15 ,for INEAI.~I:7fcJ /ST P1n>BI!IH- e/lsJlT ~p": ,fE~u.LJl.It Sv~ A~T.. /II,. ~3-t)D Ih4l/~At.''Is.SI /N?:. D2. ~ lfs,53 (!/lECKlN& /l-tCT. lilt:>. Lf/)f-I/ ~ l4AJA'e//lA/. ~'1~ 3.1/1 /At: .51 ~ /, l.J z 'I. ,'/ htlAJI?y Al4~"'6Rlllb7VT ~ r. /.ff;1-DS A" ~ r',(fA/f!./J#,f(. .3, ili/. S"S ,./i T 7./pS- (SEE rAUlIf1iIJN LE 7YeR ~1fI 1ST A-1YAeNefJ) ~ 3, Iff; ~() ~~ 3t" 8. /7 MBUJ8t5 svl ! ..:I, " elf. 0' TOTAL (Also enteron line 6, Recapitulation) $ 2, "~ of REGULAR SAVINGS ACCOUNT: Account Number/ Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established MONEY MANAGEMENT ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established Estate of: LYMAN A. ORR Date of Death: October 20,2006 Social Security Number: 183-12-1108 fvl- MEMBERS 1st FEDERAL CREDIT UNION 408 -00 09/11/1950 $45.51 $.02 $45.53 Susan E. Brand 05/19/2001 408 -11 12/31/1979 $1,423.47 $.57 $1,424.04 Susan E. Brand 05/19/2001 408 -05 10/01/1985 $3,891.55 $7.05 $3,898.60 Susan E. Brand 05/19/2001 JJB~R~SST F DERAL CREDIT UNION . ~4.U / ~i: D nise A. olfe Insurance Services upervisor January 2, 2007 5000 Louise Drive · Po. Box 40 . Mechanicsburg, Pennsylvania 17055 . (717) 697-1161 . www.members1st.org REV-1510 EX . (1-97) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF III 01( IC., L Y /J1 /fN fI. FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER 1. DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECO'S INTEREST EXCLUSION IF APPliCABLE \ TAXABLE VALUE .5/N&l€ NlEMJUIH ~E1!.1t.EtJ .If-NAlIJJ1'y .#: 2/bbO/ .3/,Z7 TNE INTE~JtITV UFE 1/tIJ",RAIle.F &IIPANY DF t!JNt!/AlNII-T/, o/llD D/t'TG IJF /JeIJ'1"I/ JlA-/.M.1: (S~E riJ,f./JJ 7/l If,. 77;if-t!He:D/ ~t>iU/NG J)A-rE a= tJBl-7N J',ft.tlTf) I 3.2, 052..sf, /'/)lD -0 - II ..J;Z~ /)SZS/;, TOTAL (Also enter on line 7, Recapitulation) $ 3.2, () S .:l # st. (If mnr~ c:n~f':~ Ie:: n~~rlQrl mC::Qrt ~rlrlitinn~1 chootc!: nf tho C':3m.o C!:J"7.o.\ Form 712 (Rev. April 2006) Department of the Treasury Internal Revenue Service Life Insurance Statement OMB No. 1545-0022 Decedent-Insured (To be filed by the executor with Form 706, United States Estate (and Generation-Skipping Transfer) Tax Return, or __ Form 706-NA, United States Estate (and Generation:Skipping Transfer) Tax Return, Estate of nonresident not a citizen of the United States.) Decedent's first name and middle initial 2 Decedent's last name 3 Decedent's social security number 4 Date of death LYMAN ORR (if known) 183-12-1108 10-20-2006 5 Name and address of insurance company INTEGRITY LIFE INSURANCE COMPANY 400 BROADWAY CINCINNATI OH 45202 6 Type of policy 7 Policy number SINGLE PREMIUM DEFERRED ANNUITY 2100013627 8 Owner's name. If decedent is not owner, 9 Date issued 10 Assignor's name. Attach copy of 11 Date assigned attach copy of application. assignment. LYMAN ORR 03-03-1999 NA 12 Value of the policy at the time of assignment NA NA 75,000.00 13 Amount of premium (see instructions) 14 Name of beneficiaries SUSAN BRAND, PATTI BROWN, JO ANN FIELDS 15 Face amount of policy 16 Indemnity benefits 17 Additional insurance 18 Other benefits. 19 Principal of any indebtedness to the company that is deductible in determining net proceeds 20 Interest on indebtedness (line 19) accrued to date of death. 21 Amount of accumulated dividends 22 Amount of post-mortem dividends . 23 Amount of returned premium 24 Amount of proceeds if payable in one sum 25 Value of proceeds as of date of death (if not payable in one sum) 26 Policy provisions concerning deferred payments or installments. Note. If other than lump-sum settlement is authorized for a surviving spouse, attach a copy of the insurance policy. 27 Amount of installments 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits . 30 Basis (mortality table and rate of interest) used by insurer in valuing installment benefits. 31 Were there any transfers of the policy within the three years prior to the death of the decedent? 32 Date of assignment or transfer: / / Month Day Year 15 $ 16 $ 17 $ 18 $ 19 $ 20 $ 21 $ 22 $ 23 $ 24 $ 25 $ 32,183.70 NA NA NA NONE 32,052.56 DYes 0 No 33 Was the insured the annuitant or beneficiary of any annuity contract issued by the company? . 0 Yes 0 No 34 Did the decedent have any incidents of ownership on any policies on his/her life, but not owned by him/her at the date of death? 0 Yes 0 No 35 Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your records. opriate federal agency or retirement system official) hereby certifies that this statement sets Cat. No. 10170V Date of Certification ~ Form 712 (Rev. 4-2006) REV-1511 EX+ (12-99}~k COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF ,n A ~ I LJ tJ,i.tt., L Y At /'f7V rr . FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: /JdEPAIJ). 1. DESCRIPTION AMOUNT ~. I="kN~ /JU:1I{,,, /7l!:7H.5 /Jtt/JYlA-s~ A-7 WA-A/T CS~ ~ 9/': /;0 . B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) SUSA-AJ ~AA'-Al.D Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State _ Zip Year(s) Commission Paid: I(;JI'I-I/le:f) Attorney Fees (!HA-IlL.E5 F: 5#/ tz..D$ 1iL: 6S~. UJA-/J,/61> 'I> 8 ~5. &0 2. 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant AlI1A1r E"L./t&/dL.E #'AlG' Street Address City State _ Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees J,fex St'Jp- NE"1U/77 - ~SG" t::Ur ~ AJ , I~i'. 80 7. Flt.I~ /1#1IE1llrAN~ 7A,r' .l/Elil/i.N .rEF ::JAOJ(so/ll-HEWIf'r- PRGP bF=" ,fIl(FN/)e-iJ ~ RG'Tll,eAJ ~ s: /)0 173 .00 ,. TOTAL (Also enter on line 9, Recapitulation) $ J) J 1'1 . ()O (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) * COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF Ofl/(,} L Y hJ A-N 1/. NUMBER I NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] Sits J..A/ ~If!A-K 1> {,/ / J::AI,f/IJ,l-y.i1t'. CIMfP HI/.L, Jf7A 170ft 1. ~. Jo A-NN F'EU>~ 3S'-/fD ttJINAlIF~ /JI('. ElII2Fk.A-1 /WJ. {,34aS"" /JA77"1 LYAlIV I!Jbtt)AJ 51 . /(/tyF S7: fbrrSTbtl)/II/,.<JA /111'/f 3. FILE NUMBER RELATIONSHIP TO DECEDENT Do Not List Trustee(s) ::PA""7IT~ IJA-UQ.H7~ 7:)Atl&.NT~ AMOUNT OR SHARE OF ESTATE Y3 Y3 fa 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 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - 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) ...====' LAST WILL AND TESTAMENT OF LYMAN H. ORR I, LYMAN H. ORR, an unremarried widower of the Township of Lower Allen, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. 2. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, I give, devise and bequeath in equal shares, per stirpes, to my three (3) beloved daughters, to wit: JO ANN FillLDS; PATTI LYNN BROWN; and SUSAN E. BRAND. 3. I nominate, constitute and appoint my daughter, SUSAN E. BRAND, to be the Executrix of this, my Last Will and Testament. In the event that she should predecease me or for any reason be unwilling or unable to act as such Executrix, I nominate, constitute and appoint my daughter, JO ANN FillLDS, to be Executrix in her place and stead. In the event that she should predecease me or for any reason be unwilling or unable to act as such Executrix, I nominate, constitute and appoint my daughter, PATTI LYNN BROWN, to be Executrix in her place and stead. I further direct that they shall not be required to file bond or other security in the Office of the Register of Wills for the purpose of administering my Estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this /~~ day of ff ' A.D. 2001. . ~~"-- (SEAL) LY NH.ORR Signed, sealed, published and declared by the above-named LYMAN H. ORR, as and for his Last \Alill and Testament, in the presence of us, who at his request and in his presence, and in the presence of each other, have hereunto subscribed our name~~~es. ~~d~~ dU~ CHARLES E. SHIELDS, III ATTORNEY-AT-LAW 6 CWUSER ROAD Corner ofTrindle and Clouser Roads MECHANICSBURG, PA 17055 GEORGE M. HOUCK (1912-1991) TELEPHONE (717) 766-0209 FAX (717) 795-7473 June 5, 2007 Register of Wills Cumberland County Court House 1 Court Square Carlisle, P A 17013 Re: Estate of Lyman H. Orr Dear Register of Wills: Please find enclosed for filing 2 copies ofthe Inheritance Tax Return for the Raymond E. Wall Estate as well as Check No. 2569, in the amount of $15.00 for the filing fee and Check No. 2577 in the amount of $1 ,628.98 for the Inheritance Tax due. Thank you for your kind attention to this matter. Very truly yours, ~ f.~'ll Charles E. Shields, III Attorney-At-Law CES/mjj Enclosures \,~, 1 -......, - " ;-", .J f'...;.. H 105.805 REV 1/05 This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. thn-/J; ~ . .... , LOC"t~ .. -n '< .. -- ,.;:,,,,,,." OCT 2~;;:ZOO6 \ 0\ Fee for this certificate, $6.00 P 12840335 --r-"; Date .- ITEM /I '2-18 21 (! ..J.. '211:> _~~SHbUll:f~ATI"'~-SFQIHrW~::~__~....~.... ~~-~~~J~;F~~~~:t~: t;;/~ (!~tm~TlJ~ .........................................................................................................................__..........._...J--.......~................ ~-..,,) \".) ~fr;~ 143Rev.01AJ6 PElPRINT IN :RMANENT ILACK INK 1, Name of Decedent (FIst. middle, last) Lyman H. Orr 5. Aoe (lAst OOthd.y) 89 Yrs. 8b. County 01 Death COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH STATE FILE NUMBER 7. Dale of Birth Month, da , ear 3. Social Security NulTiler 4. Date of Death (Month,daV, year) 8. Birlh lace C' and slate 01' bre' . 183- 12 -1108 81. Place of Death Checll on one Hospital: Din Iienl 0 E 10-20-2006 Cumberland Camp Hill Care Health Services Other' lienl 0 DCA Nun;' Home 9. Was Decedent 01 Hispane Origin? Xl No 0 Yes (II yes, specily Cuban, Mell'ic8n, Puerto Rican, etc.) o Residence 0 Other. 10. Rae.: American Indilln, Black. Whle, ele. (SpocHy) White 11 Oecedenfs Usual Occ lion r ne durin roosl of work!n ile; do nol slate relired puEClfta"'sing SPCC1BuS...",ndUstry 16. Decedent's Mailing Mdress (Slreel. cilyAown, slale, zip code) 13. Decedent's EducalOn S ec ime2tarylSecond.ry (0- t 21 h' esl ade c Ieled 14. Marital Slatus: Married, N....er marriecl, 15. Surviving Spouse (tfwile, give maiden name) CoDege (I.' or 5+) _. O..rced (SpocHy) widowed Did Decedent LNe in a 17c, 0 Yes, Decedent Lived in Twp. Township? 17d l){ :'~~::'o;.edwithin Camp Hill Ciyilloro 611 Fairway Dr. Camp Hill, PA 17011 17a, Slate pn. 'lb. Counry Cumber I and 18. Father's Name (Firsl, mkldle, lasl) " :~ 19. Mother's Name (Firs!, rriddle, maiden surname) Otis A. Orr Rebecca O. Klin 208. Informant's Name (Typelprint) Ms. Susan E. Brand 2Ob. Informant's Mailing Address (street, cilyl1own, state, zip code) 611 Fairway Dr. Camp Hill, PA 218. Melhod!)ID~ ~._ ~ 8urial _ "Cremation o OthOl'S .. ~ 223. Sig!1atur'ofFuneral_~~nacti such) W~ . C".on1MIe Ilems 23a-c only' when certifying 231. To the besl of physkian is no! available al time of death 10 certify cause 01 death. . bems 24.26l!1JsI be corTlIleled by person who pronounces death. o Rerrcvallrom Stale o Donalion 221. License Nurrber 011248 L 21c. Place of DispoGition (Name orcemelery, cren!ory or other piece) 21d. Localion (CilyJ\own, state, zip code) slateI:i:tll'semetery Camp Hill, PA ~il'~mes'~rmessa"g:a<: ii&CS Inc.324 Hummel Ave. ..Lemoyne, PA 23b. License NUrrDer 23c. Dale Signed (Month, day. year) knowledge. death occurred al the time, date and place stated. (Signature and tille) 24 Time 01 Death ~ ~ Is' CAUSE OF DEATH (Sellnstructtons and ex.amptesl Hem 27. Partt: Enter Ihe ~ - diseases. in~ries, 0' c~lbns -Ihat directly caused the dealh. 00 NOT respiratory arrest. or ventreuler fibrillation without showi\g thl! ef NOT abtxeviate. En,!r only one cause on 25. Date Pronounced Dead (Month, day, year) 26. Was Case Referred \0 a Medical Examiner/Coroner? IMMEDIATE CAUSE (Final disease or condilion resulling in death) ~ B. ~ M. O<.T. J,O, ~ool.. fl, Y No Part II: Enter olher sionificanl condilions contmutina to death, hut not r8Suning in the undertyino cause given in Part I. 28. Did Tobacco Use Contrbule to Death? DYes OPr~ o No ~wn 29. If Female: o Not pregnant within past year o Pregnanl allime 01 dealh o Not pregnant, bul pregnant within 42 days ofd9ath o Not pr~nt, but pregnant 43 days to 1 year bebre dealh o Unknown ~ pregnanl within the pas! year 32c. Place 01 Injury: Home. Farm. Street. Factory. OIlIee Buiding..~.(Specifj\ SeqUOlltialy ist condlions." any. Ieacmg 10 lhe cause listed on Una a. - Ent8l the UNOEAL YlNG CAUSE . (diseaseorinjurylhaliniliatedthe ....ents resulling in death) LAST. c. Due to (or as a consequence o~: 308. Was an Autopsy Performed? d JOb. Were Aulopsy Findings Available Prior to CoR1>>etlon 01 Cause 01 Dea~ o Yes ~o ooth o Hotricide o Pending Investigation o Could Not Be Detemined 32a. Dale 01 Injury (Month, day, year) 32h. Descrbe how Injury Occurred: 3S A~rs~""~ ~ I .21 I I ~I II II M. o Yes No 32d. TllTl8 ollniUry 32e. Injury at Work7 o Yes 0 No 321. 32g. Location (Street. eilyAown. ~ 0t1 \~l \4- 338. CerttfIer (check only one) Certifying physician (Physician cel'lifying Cluse 01 death when another physCian has pronounced death and COrf1)Ieled bem 23) To the best 01 rrrt knowledge, death occurred due to the cause(s) and nnnet as stated ,___..._......._..........m..................~...._..................'M..........-.......... Pronouncing and ctrttIying physician (Pttyslcian bolh pronouncing death and certifying to cause 01 death) To the best of my knowtedge, death occurNd at the UmI., date, ,nd place, and due to the cause(11 and manner as slated.......................................................................O IIed1caI examinerJcoroner On the basis o. examination and/or Investigation,ln my opnion, death occurred II the time, date, and place. and due to the cause(s) and manner as stated .........0 36. Dale F~ed (Month, day, year) 33d, Date Signed (Month. day, year) ~"'\04.. "")(.> ~