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Home My WebLink About08-01-07 (2) --.J 15056051058 REV-1500EX( PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death ,----~- I 194-14-~~~___ I November 11,2006 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Year File Number 1045 ! Suffix I Mrs. Date of Birth 1 October 30, 1924 Decedent's First Name r;arie ] ] ~ Decedent's Last Name I J (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name ---1 ----~ MI Inl. R. ! Fontenoy : i ~__----.J -, I I Suffix r---------' ] J I Spouse's First Name I ~ MI n ~-~ None Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS -~~---~ FILL IN APPROPRIATE OVALS BELOW eX::o 1. Original Return c::o 2. Supplemental Return c::o 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required e::o 4. Limited Estate c::o c::o 4a. Future Interest Compromise (date of death after 12-12-82) c::o 7. Decedent Maintained a Living Trust (Attach Copy ofTrust) c::o 10. Spousal Poverty Credit (date of death c::o 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: eX::o 6. Decedent Died Testate (Attach Copy of Will) Attachment A. c::o 9. Litigation Proceeds Received o 8. Total Number of Safe Deposit Boxes Name I .~ Daytime Telephone Number 1717-737-6789 (-)-~ I REGISTEft~ILLS US~N~~- - , ~ ""D 'TO c: ; .,..,./- GJ ::'-'::m I " () ?:J _ ~ .......... Cir, '(~~..J -0 r= 11 ::It :.0 "OATE FILED N ).;: -.. . W -i (1) .~ S. Berne Smith, Esq. Firm_~~_~e1If AJ>Plica~.~ First line of address _J --=--._J ] 107 N. 24th Street Second line of address <2i!y ()r Post ()ffi~.____ Carnp Hill State ~ jPA ZIP Code 117011-3602 Correspondent's e-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. _~:~:~~:o~;~Sx~;u~~:PONS~BLE F R FILING RETU~aaL,} flt~--------------lJ31;~_1-_-_- 17 S. 26th Street, Camp Hill, PA 17011 _________u______ .. ~IG;~~R~~~;h~~::~RER OAA6j=T~_~______. ADDRESS . 107 N. 34th Street, Camp Hill, PA 17011-3602 DATE ~lJ-~""1. - PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051058 15056051058 --.J ~ 15056052059 REV-1500 EX Decedent's Name: Marie R. Fontenoy Decedent's Social Security Number I 1194-14-7665 RECAPITULATION 1. Real estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) CJ Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) CJ Separate Billing Requested 8. Total Gross Assets (total Lines 1-7) 1.~' -= - ~~~o 2. I $19,811.27' l _________ 1 I 3. ~_~------_ $O.~O~ 4. I $0.00 5. 1 $18,846.681 f--- -~ ---l 6. L-- $11,649.78 7. L- _~5,689.631 8. I $125,997.361 I .~-_._--~----; 9. $14,697.74 L--_ 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) Net Value Subject to Tax (Line 12 minus Line 13) 13. I $0.00 I-~----------- ---.~--- ~__~~___ __ $104,796.85 13. 14. TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES Amount of Line 14 taxable 15. at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X O. 16. Amount of Line 14 taxable at lineal rate X 0.045 17. Amount of Line 14 taxable at sibling rate X .12 18 Amount of Line 14 taxable at collateral rate X .15 $0.00 $104,796.85 l__ _.=-I 19. TAX DUE 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056052059 L 10. __~6,502. 771 $21,200.51 ! 11. 12. $104,796.85 I --- $0.00 :: ~ "~_.-~'~~I 18. , r----- ---------- 19. $4,715.86 L C::) 15056052059 --..J REV-1500 EX Page 3 File Number ~I 06 111045 Decedent's Complete Address: i ~ ~ DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Marie R. Fontenoy 194-14-7665 STREET ADDRESS 4837 E. Trindle Road CITY I~TATE IZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit (1 ) $4,715.86 B. Prior Payments C. Discount $4,000.00 $210.52 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits ( A + B + C ) (2) $4.210.52 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. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) $0.00 (4) $0.00 (5) $505.34 (5A) (5B) $505.34 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; 181 b. retain the right to designate who shall use the property transferred or its income; 0 181 c. retain a reversionary interest; or 0 181 d. receive the promise for life of either payments, benefits or care? 0 181 2. If death occurred after December 12, 1982, did decedent transfer property within one 0 181 year of death without receiving adequate consideration? 0 181 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? 0 181 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? 181 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. S9116 (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 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. S9116(1.2) [72 P.S. 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-1503EX + (6-98) . SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Marie R. Fontenoy FILE NUMBER 21-06-1045 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION Edward Jones Account - Mutual funds. 660.389 shares of Columbia Fds Ser Rt 1 Fed Sees CL A. Date of death value - $6,904.37. See Attachment B, being letter of December 18, 2006, from Edward Jones and the supplemental pages thereto. VALUE AT DATE OF DEATH $6,904.37 2. PNC Investments - (Account #33494427) Mutual funds - 766.233 shares of Dreyfus Premier St Mun Bd Fd PA Series CL A. Date of death value - $12443.62. See Attachment C, being letter of December 19, 2006, from PNC Investments and the supplemental pages thereto. $12,443.62 3 U.S. Savings Bond # R1171 0130-EE Redeemed 11-30-2006. See Attachment D, being a copy of the Redemption Receipt $463.28 TOTAL (Also enter on line 2, Recapitulation) (If more space is needed, insert additional sheets of the same size) $19,811.27 REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Marie R. Fontenoy FILE NUMBER 21-06-1045 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. DESCRIPTION Country Meadows refund. See Attachment E. State Farm Insurance - Refund of Medical Insurance Premium. See Attachment F. PNC Bank - CD Account # 31600258569 - See Attachment G. PNC Bank Accrued Interest to 000. See Attachment G PNC Bank - CD Account # 31000263819 - See Attachment G. PNC Bank Accrued interest to 000. See Attachment G Federal Income Tax refund for 2006. There was no cash on hand at 000, no jewelry, no furniture. The clothing was donated to the nursing home Prepaid Funeral- Kevin A. Beardsley Funeral Home, Clearfield, PA. See Attachment H. PNC Bank Money Market Account # 33494427. 000 value - 42.37 shares = See Attachment C, previously identified. VALUE AT DATE OF DEATH $2,764.27 $2,790.52 $2,813.84 $4.41 $1,982.71 $5.56 $3.00 $0.00 $8,440.00 $42.37 TOTAL (Also enter on line 5, Recapitulation) (If more space is needed, insert additional sheets of the same size) $18,846.68 REV-1509 EX + (6-98) SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Marie R. Fontenoy FILE NUMBER 21-06-1045 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. Barbara A. Poole 17 South 26th Street, Camp Hill, PA 17011 Daughter B. C. JOINTLY-OWNED PROPERTY: ITEM LETTER DATE DESCRIPTION OF PROPERTY DATE OF DEATH %OF DATE OF DEATH NUMBER FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. VALUE OF ASSET DECD'S VALUE OF TENANT JOINT Attach deed for jointly-held real estate. INTEREST DECEDENT'S INTEREST 1. A 2-3-2004 Sterling Financial Corporation - Checking Acc # 10501591 $7,615.43 50_0% $3,897.72 Accrued interest to 000 on this account $3.05 50.0% $1.53 (See Attachment "I") 2. A 9-1-2004 Sterling Financial Corporation - Money Market Acc # 21014501 $15,461.53 50.0% $7,730.77 Accrued interest to 000 on this account $39_52 50.0% $19.76 3. (See Attachment "I") 4. 5. TOTAL (Also enter on line 6, Recapitulation) $11,649.78 (If more space is needed, insert additional sheets of the same size) REV-151Q EX + (6-98) '* SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Marie R. Fontenoy FILE NUMBER 1045 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 DESCRIPTION OF PROPERTY % OF DECD'S TAXABLE INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO OECEDENT AND THE DATE OF TRANSFER. DATE OF DEATH INTEREST EXCLUSION NUMBER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET VALUE (IF APPLICABLE) 1. Allstate Financial Annuity Contract # GA16871788 $54,119.06 100.0% $0.00 $54,119.06 (See Attachment J) 2. IRA Account held by PNC Bank Acc. # 55000002463 - Date of death value $14,639.15 100.0% $0.00 $14,639.15 plus accrued interest of $1.86 (See Attachment G previously identified) 3. IRA Account held by PNC Bank, Acc. # 75000027892 - Date of death value $6,931.42 100.0% $0.00 $6,931.42 plus accrued interest of $21.09. (See Attachment G, previously identified) 4. Prudential Financial Insurance Policy # 610900269 paid to estate for benefit $2,413.41 100.0% 100% $0.00 of decedent's three daughters. 000 value - $2,413.41. See Attachment K. 5. Prudential Financial Insurance Policy #042 801 872, paid directly to the $4,364.91 100.0% 100% $0.00 beneficiaries, decedent's three daughters. 000 value - $4.364.91. See Attachment L. TOTAL (Also enter on line 7, Recapitulation) $75,689.63 (If more space is needed, insert additional sheets of the same size) REV.1511 EX + (12.99) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Marie R. Fontenoy FILE NUMBER 21-06-1045 ITEM NUMBER A. 1. 2. 3. 4. 5. B. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Debts of decedent must be reported on Schedule I. DESCRIPTION FUNERAL EXPENSES: Kevin A. Beardsley Funeral Home - See Attachment H Transporting body to cemetery - See Attachment M Funeral flowers """ Funeral dinner """ Engraving headstone - See Attachment N ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address City Year(s) Commission Paid: Attorney Fees - S. Berne Smith, Esq. Camp Hill, PA 17011 Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address State Zip City Relationship of Claimant to Decedent State Zip Probate Fees - See Attachment 0 Accountant's Fees Tax Return Preparer's Fees Estate Notice - The Sentinel Estate Notice - the Cumberland Legal Journal Additional expenses of executrix in conjunction with the funeral Postage Filing fees (.s~ a,t(~ 11) TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) AMOUNT $8,440.00 $552.00 $116.60 $464.16 $105.00 $0.00 $4,000.00 $0.00 $152.00 $0.00 $0.00 $129.77 $75.00 $621.69 $6.52 $35.00 $14,697.74 REV-1512 EX + (12-03) '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Marie R. Fontenoy FILE NUMBER 21-06-1045 Record debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION Final payment of nursing home expenses to Country Meadows, Mechanicsburg, PA _ Ck 172 State Farm Medical Insurance payment - Ck 173 AMOUNT $3,831.77 $2,671.00 1. 2. 3. 4. 5. 6. 7. 8. 'I! TOTAL (Also enter on line 10, Recapitulation) (If more space is needed, insert additional sheets of the same size) $6,502.77 REV-1513 EX + (9-00)) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Marie R. Fontenoy SCHEDULE J BENEFICIARIES FILE NUMBER 21-06-1045 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List T rustee( s) OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] Barbara A. Poole, 17 S. 26th Street, Camp Hill, PA 17011 Daughter 1/3rd of residue of estate 2. Donna L. Franz, 1045 Newton Ave., Erie, PA 16511 Daughter 1/3rd of residue of estate 3. Suzanne M. Madia, 3102 Liberty Street, Erie, PA 16508 Daughter 1/3rd of residue of estate 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 0.00 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 0.00 TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $0.00 (If more space is needed, insert additional sheets of the same size) 2.lJtl!IUJ1~11.fj.._, I, MARIE R. FONTENOY, of Clearfield Borough, Clearfield County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. ITEM I: I direct that all my just debts and funeral expenses shall be paid from the assets of my estate as soon as practicable after my decease. ITEM II: I devise and bequeath the residue of my estate of every nature and wherever situated to my husband Paul C. Fontenoy providing he shall survive me by sixty (60) days. ITEM III: Should my husband Paul C. Fontenoy predecease me or die on or before the sixtieth day following my death, I devise and bequeath the residue of my estate of every --~.... nature and wherever situated to such of my children, Barbara Breon, Donna Franz and Suzanne Modlo, as may be living at the time of my death and to the issue then living of such of my children as may then be dead per stirpes. ITEM IV: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. f'-...) I appoint my husband Paul C. Font~gj' Ex~~ut?r, :"-~ :::0 === of this my last will. Should my husband Paul C. 'Fj~no~ ,-.. .J ;;;: r-; 1'0 fail to qualify or cease to act as Executor, I app~i~ mY' .n~~~Q -0 daughter Barbara Breon Executrix of this my last :~t1i~ -- ~:.:'.:i ITEM V: N W );~:_;:-, ,/-' ~l' ~_ A ~ffiRIE R. FONTENOY ~1"AcPllE"JJ" A .~~ ,/'" i ./ // / ITEM VI: I direct that my personal representative shall not be required to give bond for the faithful perfor- mance of his duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand this ',\ toy day of November, 1978. /'7, -1/1//' 'j I . / / (' d-<.-~:..<.;; /\ '7-1) " uiC~--_ MARIE R. FONTENOY , /:/ /", The preceding instrument, consisting of this and one other typewritten page each identified by the signature of the Testatrix was on the day and date thereof signed, published, and declared by Marie R. Fontenoy the Testatrix therein named as and for her last will, in the presence of us, who, at her request, in her presence, and in the presence of each other have subscribed our names as witnesses hereto. ~. '-fl ~. ,/~~ ::/-->)./ ~,(A> FYLl"C,'f--" - I I I, , -2- 2501 W 12th Street Ste 20 Yorktown Centre Erie. PA 16505 814-833-7370 www.edwardjones.com Mark J. Madia Investment Representative EdwardJones December 18, 2006 Attorney S. Berne Smith 107 N. 24th Street Camp Hill, PA 17011 Dear Attorney Smith: Per your request, I am writing to provide valuation for the following security belonging to Marie R. Fontenoy, now deceased. Please let us know if you need any other information or assistance. I can be reached at 866-860-7980 The values were obtained from an outside historical pricing service and while we believe that they are reliable, we do not guarantee their accuracy. Sincerely, "'~~"\, .'. ". ~ \.\ . ,',,~ r----- Mark J. Modlo'- Investment Representative CC: Barbara Poole, Executrix A 7'/ A C 1./ n C ~"l QS Estates - Historical Date of Death Valuation Worksheet Account Registration: Marie R. Fontenoy 17 So. 26th Street Camp Hill, PA 17011 Account Number: 213-09820 Date: Dec 18, 2006 Date of Death: Date of Death Valuation: Alternate Date of Valuation: Nov 11, 2006 .:tJ C:t 9 c:, "'4 ,'37 HIlA Use the additional worksheets (pages 2 - 8) to determine the total value and dividends / interest due for stocks, bonds, and mutual f person's account. Then use those totals to complete section Band C to determine the overall total account value. r A. Total Cash Held: 1. Cash 2. Money Market B. Total Value of Assets Held: 3. Stocks 4. Bonds 5. Mutual Funds 6. Miscellaneous Securities C. Total Dividends I Interest Due: 7. Stocks dividends 8. Bonds interest 9. Mutual Funds dividends 10. Miscellaneous distributions D. Total Account Value: $-0- $ - 0- $ ...-- c> - $ -- Q --... $ tp <tC>4. 3, $ - G- $ - 0- $ - C1 - $ - Cl> $ - 0 - $&90~,31 Edward Jones, its employees and Investment Representatives do not provide tax or legal advice. This information is believe~ to be r completeness are not guaranteed. You should consult with a competent tax specialist or attorney for professional advice on tour spe Date Printed: 18-Dec-2006 IR Name: Mark J. Modlo Phone: 814-833-7370 Page 1 of 1 Edward Jones Historical Pricing for Marie R. F ontenoy Symbol Descriptionrrype Date Value CFSAX COLUMBIA FDS SER TR I FED SECS CL A Net asset value (adjusted) 10-Nov-2006 10.4600 USD CFSAX COLUMBIA FDS SER TR I FED SECS CL A Net asset value (adjusted) 13-Nov-2006 10.4500 USD This report is provided by Edward Jones. The report was calculated uSing third party information. This report is not intended to replace official ! documents such as confirmations and/or account statements that should be retained for tax purposes. Past performance is no guarantee of future I results. Edward Jones does not provide tax or legal advice. You should consult your tax and/or legal advisor for your particular situation. The historical cost basis information furnished herein ("Information") is for use by customer ("you") only and is based on the purchase and sale information provideq. While Edward Jones believes that the information was obtained from reliable sources, Edward Jones does not guarantee the accuracy or completene~s of the Information and is furnishing the Information to You on an "as-is" basis. EDWARD JONES MAKES NO WARRANTY OF ANY KIND, EXPRESs! OR IMPLIED, WITH RESPECT TO THE MERCHANTABILITY, FITNESS, CONDITION, USE OR APPROPRIATENESS OF THE INFORMATION. Edw.rd Jones is supplying the Information on the basis that the Information will be used by You for Your own use and benefit and not for resale or other transf~r to, or use by or for the benefit of, any other person or entity. : o PNC1NVESTMENTS Member NASa and SlPC December 19,2006 S Berne Smith 107 N 24th Street Camp Hill, PA 17011-3602 Re: Estate of Marie R Fontenoy Dear Mr. Smith, Ms. Fontenoy's account, #33494427, was established at PNC Investments on March 15, 2004 as a single account. Attached, please find date of death balances as November 11, 2006. Also, Ms. Fontenoy held an annuity policy in this account. The information on her policy will be forwarded to you directly from the annuity company, Allstate Life Insurance Company. If you should have any questions, please, feel free to contact me at (814) 231-1646. Sincerely, The infonnation contained herein bas been obtained from sources we believe to be reliable but do not guarantee it to be accurate, correct. complete, or timely, and shall not be responsible for the results obtained from its use. A member ofThe PNC Financial Services Group 1601 South Atherton Street State College Pennsylvania 16801 www.pncinvestments.com Important Investor Information: Securities and brokerage services are provided by PNC Investments LLC, member NASD and SIPC. Annuities and other insurance products are offered by PNC Insurance Services, Inc. a licensed insurance agency. IJ 'lr Ilc fIn ~ IV.,. lmD .May Lose v.uue ~ .No Bank GuaIantee C- -'~'--"P~j)iC/l e7~UUb/MON UJ: U6-'P~M -~,,--,- - p, 002 I I ESTATE OF MARIE FONTENOY (000 v AlUA liON NOVEMBER 11, 2006) The information provideq in this report is believed to be reliaple, but its accuracy cannd,t be guaranteed. , , , , I A mean price is calculat~d as an average of the high and low on ' I the yaluation date when availal;lle. If these prices are not available, suc~ as on weekends or holidays, the mean price is the inversely weighted average of the high a~d low on the nearest trading dates befo're and after, when these prices are available within one week of " the valuation date. If actual tra:des are not available, the nearest bid and ~sk prices are substituted.!Note that securities traded on the I , T orQnto Exchange are in Canadian dollars. I , If an equity is ex-dividem;J for a cash distribution on or before the 'f'aluation date but is of rec<;}rd after the valuation date, the divi~end is included in the valuation report and is added to the secu:rity's value. This is reported as an adjusted value on the report. If th~ date of death is on or aft~r the record date and the dividend is pay~ble after that date, the acc~ued dividend is listed separately on the r;eport and added to the POr,tfolio's total value. I ; Prices for which daily up~ates are not available are priced accqrding to a Corporate Pricing Cycle. These pricing dates occur on the last business day of the week, and the last business day of the mo~th, unless the end of the w~k update falls within three business days. or less, of the end-of-month update. Prepared 1 8 December 2006 .- .._... ...... __...._.....r ....__. UtL/l~/LUUb/MUN U~:Uj PM P. 003 Bat:&t:e ValUAtiOll. Date of Death. 11/11/2006 Valuatioa Da~.: ~1/11/200' Ptoce..il19 Date: .13/11/200& Share. or Par : Seclaity ~lpt1cm lU9biAlt LotI/Bid ItItate of: MARI. POIftIl*W AcCOUDt: 33494427 Report Type: Data of Dath N\iN)er of s.cudti..; 2 File %I): J'OlmDIOf.1WU1 IIeul ud/or Diy ADd Int S~lty Mjuet~. Accrual. Value 1) "".an IlIIYPUI !UllI1l Sf .. ID PD (2f102D1f9' 'PASIICLIo : I Nlatual I\lIld (u quot_ by ~) : 11/10/200' 16.24000 IIllt If .2<10000 12,<l6J.n :II 42.11 PIa MONIY MlRlIT (BVP01) ; 11/11/200' 1.00000 1.00000 1. 000000 42.37 total Value, Total Accnal: TOtal, $~. 48S . tt to.oo su.Ut." PAge 1 Thili report wu iproclucecl with htat.Val. . product of Betate VillutiOPe . Pricing Sy.t.... IDc:. If you ~~ queetiOl1ll, I plea.. COII.t&ct BVP sy.teas at 18181: 313-'300 or www.evp-ra.co.. (levielOll. 7.0.4' u.s. Savings Bond Redemption Receipt Branch ID: 10 Transaction Number: 0611-301859229110 Estate of Marie R Fontenoy 17 S.26th St. Camp Hill, PA 17011 20-7160965 Redemption Date: 11/30/2006 Teller ID: csterner Issue Interest Redemption Serial Number Series Denom Date Issue Price Earned Value Rl1710130-EE $200 07/1982 $100.00 $363.28 $463.28 Total number of bonds redeemed: 1 Total Total Total Price Interest Value $100.00 $363.28 $463.28 &u ~.<+~ Ct .:k . C~(~; Customer Signature Customer ID: 13785461 Sterling Financial Corporation 1097 Commercial Ave PO BOX 38 East Petersburg, PA 17520 800-225-5252 j1,r/lCflne ~T D Page 1 Of 1 ~~~~:~~~:dOW~~$OClate~{ : :\,::}:~~:~:::~, " Hershey P A ) 7033" ,,' '" ; ..' l " Amt: $2,764.27** NET AMOUNT 2,764.27 125122 1:'>;""" _\,',";;1, ,.:.,'. ,.. '. ",';'i: ;-:1 :::~':::., . ::":-,,: "': '.;, . ': ',,' ,," , ,.,<,;,,;, ':'i:12h 1i~bb6 125122 , .i.. :;i;:,;:>0y;'~f~:>;;' ,h:~ .'\:':(,<,:{,:~:,:..' "" , , . TWO THOUSAN[Y'SEVENHd~6RE6' S'JXTY-FourfAND27 i1 OODOLLARS ,"-. . ...... -. '1" _,'J1 ..~, ::i::';':~"<';"""'~'::J~:::" ',\~,~~,;t:.'~:r -, . , " '. " "',',.. AMOUNT $2,764.27** Pay I ~ SECURITY FEATURES iNCLUDED. DETAILS ON BACK. to 1110.25.22111 \1:03.0005031: 20.~ 20.2 '7088 Sill ~,,~ I ) TO THE ORDER OF ",:,-".'_.:.-,,',' ..... ..........(. "","- ....,.-. .. "":'::':'''' ,.",," BARBA~ POqLE . 175 26]H ~T~E~T:, . CAMPHll.k,~A1701.1 , BORDER CONTAINS M1CROPRINTING .1J7"/ACfJn~tJ'I E "' Mead Living Ctr West Shore .4 Meadows L~ving Ct~West Shore . ';>.';, ,483,7/East!Trindle.('Road. ..... .,;.,;ir\;';';;,,::':',Mec~ariic~burg ,..PA';:J.7Q5 0.. :'... ,: ,:~~ :' ~',~,7',: .... ,~.,,:<,_.: .:. ~t::":1 'l:..;:_,;.:"J::~:<;'~,~ .~,):~ ';;", ,;:': '. '..:/ ',. ";;;}:'/,'>.'_~)~",' "t' ;::' ~ . ';'!!:'>:R~f:H"der:it"'Statemeht' .. / ';';. { :<:, ,~-,:'.i>i'~', .':~'. ", Date: 12/01/2006 Re: Marie Fontenoy Account#: 66546 Balance Due: -2,764.27 Barbara Poole 17 So. 26th Street Camp H~ll, Pa 17011 Amount Enclosed ~".::':~:'-'-'~____4~~'::"___;_ ~___.._,.__.'. _..__,' __._ DATE BALANCE FORWARD 3,831.77 11/10/2006 PAYMENT 12/06/2006 PAYMENT 10/27/2006 Wash & Set, . 11/01/2006 .ROOM. &: BOARD~BILLED"':, ::,.' 11/01/2006,' RObM.&'.".BOARD' B'J:LLEP,':-"':'~: ,;',. 11/03/2006' wash !&':se,t.~";",':";:' :;,,' '.'.'.' ,:" 11/21/2006 'Pharmacy'Charges! CURRENT MONTH. CHARGES CREDIT BALANCE - DO NOT PAY 14.00 (3,650.00 ) 1,200.00. ".' .', 1'4,~ 00 15.7.73 (3,831.77) (500.00) (2,264.27) (2,764.27) Thank you for choosing Country Meadows of West Shore 4! . '.". .~.' ..,:.: "';' ..\. i~' "~. Please' inchlde,:the :'):6p;ip6'i-tion of this bill with you:r;p~yment by the . 15th usipg t:h~;:enc1.:o:Si;~~ 'Jny.e,~.ope. '. Make your check, .payapl,e to Country Meadows 'Ass6F~iites ~~;;s.ta,t~~e~.t::~.questions contact Bonn.ie 7],.7 - 975 -3434 ForpharmacY'qUestioris-please'con"tact "Alert" direct 'atl-aOO-266-9954 :;~.- ". Resident :t{~me: Marie Fontenoy .. '{ Account#: 66546 Statement Date: 12/01/2006 r&1~ ~- Stale Farm Mutual Automobile Insurance Company P.O. Box 3080 Newark, OH. 43058-3080 - AGENT COpy 3036-38 THE.ESTATE OF MARIE R FONTENOY C/O BARBARA POOLE 17 S 26TH ST CAMP HIll PA 17011-4612 1...1" 11.1" 111111" 11.11.1..1.11'111111111.111111111111.1111 96204 11222006 NOTt CMrc-ANCEttAnO~" Policy Number Type of Policy Premium Refund . HB880402 3838 Medicare Supplement Plan 'C' $2790.52 ., As requested, this policy has been cancelled as of 12:01 a.m. standard time, November 12, 2006. Premium refund has been sent to the agent for proper disposition. Agent: RAY COUDRIET Phone: (814) 765~9676 951-94108.8 (Olh5711a) , ( II' ~ :I ~ It ~ 2 2 ? 5 0 II' I: 0 b ~ ~ ~ 2 ? a a I : :I 2 q q ~ ~ :I 5 :I 2 II' It "'r rA < I'Inc'JV 7" r DEC-21-2006 22:31 PNCBANK 412 768 3458 P.01 o PNCBAN< December 22, 2006 S. Berne Smith Attorney at Law 170 N. 24111 Street Camp Hill, PA 17011-3602 RE: Estate of Marie R Fontenoy, deceased SSN: 194-14-7665 DOD: 11/11/2006 Dear Attorney Smith: In response to your request for Date of Death balances for the customer noted above, our records show the following: Certificates of Deposit }\ccount#31600258569 Established 03/30/2005 MARIE R FONTENOY DOD balance: $2,813.84 + $4.41 accrued interest Interest Paid 1/1/2006 - 11/11/2006 - $90.34 }\CcoWlt #31000263819 Established 06/23/2005 MARIE R FONrENOY DOD balance: $1,982.71 + $5.56 accrued interest Interest Paid 1/1/2006 - 11/11/2006 - $65.70 IRA Accounts Account #55000002463 Established 04/1111988 MARIE R FONTENOY DOD balance: $14,637.29 + $1.86 aCCIUed interest Interest Paid 1/1/2006 - 11/11/2006 - $580.63 Account #75000027892 Established 01/19/2005 MARIE R FONTENOY DOD balance: $6,910.33 + $21.09 accrued interest Intercst Paid 1/1/2006 - 11/11/2006 - $261.57 For IRA or Beneficiary information, please call1-888-PNC-lRAS. The decedent maintained Investment Accounts (INV #33494427), and (INV #36488823). For further information, you may contact the Brokerage Department at 1-800-762-6111. Page lof2 p1J "rAC-Idn efVr c DEC-21-2006 22:31 PNCBt=lNK 412 768 3458 P.02 Please note that this office only provides date of death balances for deposit accounts (IRAs, CDs, Checking and Savings accounts). We do not process any financial transactions or provide statements. If you need assistance with any of these items, please call1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch office. ~UJPft- Rachelle Wells 1-800-762-1775 P7-PFSC-04-F 500 first Ave. Pittsburgh PAl 5219 Page 2 of2 Member FDIC TnTOI 0 fA..., '~""':"',"','".,.l.'",', . ~'>i .."ii< BEAAoSLEY'.' ~~~. STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges are only for those Items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain the reasons in writing below. If you selected a funeral that may req.uire embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve If you selected arrangements IIch as a di t cremation or immediate burial. If we charged for embalming, we will explain why below. FOR FUNERAL SERVICES OF Fo NO 113 North Third Street Clearfield, PA 16830 : (814) 765-5731 15 State Street Curwensville, PA 16833 . . (814) 236-1281 ~TE OF; Death AtrIngemenIs :~ ~bS" {;f~~ Kevin A. Beardsley Supervisor . Aaron D. Westover Supervisor Social SecurIty NlI'I1ber A. ALTERNATE PRICING METHOD Ollering T) C. CASH ADVANCES Cemetery Charges.. .. .. . .. .. . .. .. .. .. .. .. .. . .. . .. . .. .. $ 360- Cemetery Equipment .............. 'J' '~."""""'" $ Death Certlflcates.--15- 0 $ b .. .. . .. .. . $ q 0 - Fees to o.ther Funeral Homes.. .. .. . .. . .. .. . .. . . .. .. . . .. . $ Florisl Charges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Honorarium ...,.. ...................................... $) 0'0 Obituary-Local....................................... . $ Obituary - Out 01 Town. . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . $ Telephone I Telegrams. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Transportation Fees Common Carrier . . . . . . . . . . . . . . . . . . . . . $ Weekend I Holiday Cemetery Charges .. . .. .. .. . .. . .. .. .. . $ Weekend I Holiday Vault Company Charge ................ $ Other aa.(,A~'I:tt' .............:. $ 100 ~ <;~ ............... $ I ~ \fJ - ~ 0 .. .. .. .. .. . .. .. $ 3 1 c ~ We charge you for our services In obtaining: (specify cash advance items) (A) $ A. CHARGES FOR SERVICES SELECTED PROFESSIONAL SERVICES Non-Declinable Services 01 Funeral Director and Staff. . . . . . . .. $' 1N CL Embalming ...................................,......... $ IMC 1 . Sanitary Care ...... . . . . . . . .'. . . . . . . . . . . . . : . . . . . . . . . . . . . .. $' Restoration, Cosmetology. Dresslng,Cesket Placement ,.,. and Hairstyling. . . . . . . . . . . . . . . . . . .. .. . . . .. . . .. .. . .. . .. $1 tiC L Other.... ...... ........ '" ..... ........................ $ TOTAL .................. .r. . . . . . . . . . . . . . . . . $ ADDITIONAL SERVICES AND FACILITIES Shelter of Remains ....................................... $ Use of Facilities and Stall Services lor VIewing. . . ; . . . . . . . . . ,. $' l NtL... Funeral at Facility or Other Locatlonand Staff services ........ $ I N"U . Memorial Service at Facility or other Location and Staff Services $ Graveside Equipment and Staff Services.................... $ Refrigeration of Unembalmed Remains. . . . . . . . . . . . . . . . . . . . .. $ Other $ TOTAL .................................... $ AUTOMOTIVE EQUIPMENT . Transfer 01 Remains to Funeral Home. . . . . . . . . . ; . . . . . . . . . . .. $ 'J IJ tl. .. Funeral Coach ..,.........,............................. $ l Nfj . Limousine ...,................................;......... .$ , Family Sedan.".... .'......................... ......... ~ $ Sedan for Funeral Procession ............................. $ Utility I Service Car ',....,....,........,................. $ Flower Car,..... ,'.,... .'.........'....................... $ Sedan for Pallbearers ....,............................... $ Other $ , TOTAL .................................... $ TOTAL CHARGES FOR SERVICES SELECTED....... (A) $ ~q" S'- B. CHARGES FO MERCHANDISE SELECTED $ 2!::l..95- - $ ~1~- TOTAL OF CASH ADVANCES ............. (C) D. SPECIAL CHARGES Forwarding of Remains . .. .. .. , .. .. , .. .. . .. . . .. . .. .. .. . , Receiving Remeins .....................,...........,.. Immediate Burial ...................................,.. Direct Cremation............................ ......,.... , TOTAL SPECIAL CHARGES ............... (D) E. ITEMS ORDERED LATER Death CertifICates.......,........................,.,." TOTAL OF ITEMS ORDERED LATER . . . . . .. (E) SUMMARY OF CHARGES A. Charges lor Services Selected or (. Charges lor Alternate Pricing. . . . . . . . . . . . . . . , . . . . . , (A) B. Charges lor Merchandise Selected. . , . . . . . . . . . . , . . . (B) C. Cash Advances ..................,.............. (C) D. Special Charges ................,............,... (D) $~qC)<)- $~ $ .31L $ $~- $ Casket Outer Burial Container SeA~~ Cremation Urn $ . ~~~ $ Sundry Items: Acknowledgment cards'_ ........ ~ ....... $ I W CA. J Register book(s) ................,..... ~ .. .. ... $ l Nt l Memorial Folders ..................... ....... $ Prayer C~rds ......,...............;... . $ I NU Temporary Grave Marker ............... TOTAL OF ALL CHARGES .................. PAID AT TIME OF ARRANGEMENTS. . . . . . . . . . BALANCE DUE ............... ~ .. .. . . .. . . .. $ E. Items Ordered Later ............................. (E) $ TOTAL ACCOUNT BALANCE................ $ :~ $ Total of Sund.ry.,1tema . . . . . . . ~ AC. /1111 e"" r Mileage " ( $ Other $ TOTAL CHARGES FOR MERCHANDISE SELECTED.. (B) $ ~ Reas~ for Embalming: 1 The undersigned hereby states that II we have the authority to arrange for the funeral ceremonies of the above named deceased and hereby authorize Kevin A. Seardslay Funaral Home, Inc. to furnish the merchandise, professional services, special charges and cash advances as selected; and doas hArAhv nUAr::.ntAA tho n~",.o."t .. lta....;"AIf ........_u_ A6 .~_ ___..__& __.... ~_ L._LL_U _11. a"_ .. . . _ . Transfer of Remains to Funeral Home. . . . . . . . . . . . . . . . . . . . . .. $ Funeral Coach .......................................... $ Limousine .............................................. $ Family Sedan. . . .. .. .. .. . .. .. .. . .. .. . .. .. .. .. .. . .. . .. ... $ Sedan for Funeral Procession ............................. $ Utility I Service Car ...................................... S Flower Car ............................................. S Sedan for Pallbearers .................................... $ Other $ TOTAL .................................... $ TOTAL CHARGES FOR SERVICES SELECTED....... (A) $ ~q c.; S' - B. CHARGES FQ~ MERCHANDISE SELECTED Casket H! ~bV\ $ 2..B..95'- - (-,MLt/\ .outer Burial Container $ Y 1 <;'- SeA~ Cremation Urn $ ~~~ S Sundry Items: Acknowledgment cards 11_ ................ $ Register book(s) .............................. $ Memorial Folders ............................. $ Prayer Cards................................. $ I NU Temporary Grave Marker. . . . .. .. .. . . .. . . .. . . ... $ $ $ Total of Sundry Items . . . . . . . . . . . . . . . . . . . . . . $ ~~ $ Other $ TOTAL CHARGES FOR MERCHANDISE SELECTED.. (8) $ ~ Reason for Embalming: The undersigned hereby states that II we have the authority to arrange for the funeral ceremonies of the above named deceased and hereby authorize Kevin A. Belrdsley Funerll Home, Inc. to furnish the merchandise, professional services, special charges and cash advances as selected; and does hereby guarantee the payment as itemized above. At the request and In behalf of the undersigned and for and in consideration of Kevin A. Beardsley Funeral Home, Inc., agreeing to perform certain funeral services for the above named deceased, and the furnishing of the materials, etc., as above specified, the undersigned hereby promises and agrees to pay for said funeral services, materials, etc., the cash sum of $ as above stipulated and assumes full personal liability therefore; provided, however, Kevin A. Belrdaley Funerll Home, Inc., reserves the further right to collect all or any part of this funeral claim from the estate of the above named decedent. It Is further agreed that any additional items ordered later or cash outlays authorized by the undersigned shall become part of this Agreement and the undersigned hereby promises to pay for the same. This is a cash transaction. The undersigned jointly and severally agree to pay Kevin A. Belrdsley Funerll Home, Inc. the balance due on this account, plus the reasonable or agreed value of such additional services, materials and cash advances as may be furnished by Kevin A. Beardsley Funeral Home, Inc. Such payment shall be made within thirty days from date of the funeral service. A late penalty of 1'/2% per month (18% per year) will be assessed on the unpaid balance for materials and services, beginning 30 days from the date of this Agreement. If placed in the hands of an attorney for collection, the purchaser agrees to pay reasonable attorney's fees and court costs. DISCLAIMER OF WARRANTIES: KEVIN A. BEARDSLEY FUNERAL HOME, INC. MAKES NO WARRANTIES OR REPRESENTATIONS CONCERNING THE PRODUCTS SOLD HEREIN. THE ONLY WARRANTIES, EXPRESSED OR IMPLIED, GRANTED IN CONNECTION WITH THE PRODUCTS SOLD WITH THE FUNERAL SERVICE, ARE THE EXPRESSED WRITTEN WARRANTIES. IF ANY, EXTENDED BY THE MANUFACTURERS THEREOF. KEVIN A. BEARDSLEY FUNERAL HOME, INC. HEREBY EXPRESSLY DISCLAIMS ALL WARRANTIES. EXPRESS OR IMPLIED, RELATING TO ALL SUCH PROD- UCTS, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. II We, the undersigned, acknowledge that the foregoing statement has been read to me / us and II we hereby acknowledge receipt of completed copy. Purchaser f ~ ~~ fJ.J.~lj~ltA f-r~ Embalming ............................................. Sanitary. Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Restoration, Cosmetology, Dressing,Casket Placement and Hairstyling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other................................................. . TOTAL .................................... ADDmONAL SERVICES AND FACILITIES Sheller of Remains ...................................... Use of Facilities and Staff Services for Viewing. . . . . . . . . . . . . . . Funeral at Facility or Other Locationand Staff Services ........ $ Memorial Service at Facility or other Location and Slaff Services $ Graveside Equipment and Staff Services . . . . . . . . . . . . . . . . . . .. S Refrigeration of Unembalmed Remains. . . . . . . . . . . . . . . . . . . . .. $ Other $ TOTAL .................................... $ AUTOMOTIVE EQUIPMENT s I 1\1 [ 1 ~ $ siN'LL $ $ $ $ I NtL. INU. IIJU . , Me, . IWCL INCl Address Date N O\J l -, , 1.fl{-, f'^^ Time 1(,36 Honorarium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ I OD Obituary - Local . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Obituary - Out of Town ................................. $ Telephone I Telegrams. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Transportation Fees Common Carrier .. .. .. .. .. .. .. .. .. . .. $ Weekend I Holiday Cemetery Charges.............., .... .. $ Weekend I.~ollday Va~1l Company Charge ............ '.- : ... $ ~r C)lL..~t.J\ -tr' ........ ...":,, $ 1':;0 U€.~\U~~U\O ::::::::::::::: : 31 d- We charge you for our services in obtaining: (specify cash advance items) TOTAL OF CASH ADVANCES ............. (C) D. SPECIAL CHARGES Forwarding of Remains . .. .. . . . . .. . . . . . . . .. . . . . . . . . . . . . . Receiving Remains .................................... Immediate Burial ...................................... Direct Cremation ...................................... TOTAL SPECIAL CHARGES . . . . . . . . . . . . . . . (0) E. ITEMS ORDERED LATER Death Certificates...................................... TOTAL OF ITEMS ORDERED LATER . . . . . .. (E) SUMMARY OF CHARGES A. Charges for Services Selected or Charges for Alternate Pricing. . . . . . . . . . . . . . . . . . . . .. (A) B. Charges for Merchandise Selected................. (B) C. Cash Advances ................................. (C) D. Special Charges ................................ (0) $ 7:>q~ <)- $~ $~ $ $~- $ TOTAL OF ALL CHARGES ............... . . . PAID AT TIME OF ARRANGEMENTS. . . . . . . . . . BALANCE DUE ............................ S E. Items Ordered Later ............................. (E) $ TOTAL ACCOUNT BALANCE ................ s If any law, cemetery, or crematory requirements have required the purchase of any of the Items listed, the law or r uirement (s explalne belo~~ Purchaser Address KEVIN Signature 01 llceneed Funeral Director z o i= ~ o a.. IX: o o ..J <( o z <( z u. C) Z ..J IX: w l- V) ..... e e ('II cO ~ ns ~ l: ns ..., >..n OeDeD l:eDe (1).....e 1:...t~ 0........ LL...t~ " en .... 0:::........ CI) .. 0" 'i: Z CUcnO :Ecno w 0::: ('II e eD M I .... .... e .c ~ . ~ ~j(j)<1: E_.cQ. cncu....= CI) >-'''It ,- l:CI)('II:I: lii E z Q. m~.....E cri<1:~~ e en .... M ('II tn cO en OW eD ('II ~ffi .,. co .,. .... ~ lI) ('II 0.... ~ lI) wtn C'? en :JW .,. C'? D::D:: .,. OW 0.... e(~ M M W 'Ill: ~ 0 lI) .... OZ .... eD 0:5 ~ '''It ..... .n- Oe( .,. .... a:l .,. Z 0 i= CI) CI) ~ "0 "0 0 0 .... Q. Q. tn <C (3 <1: W ns ns D:: .. .. CU CU .c .c .. .. CU CU m m .. .. 0 0 >- >- 0 0 l: l: CI) CI) - - l: l: 0 0 LL LL 0:: 0:: CI) CI) "i: 'i: ns ns :E :E 0 '''It '''It w e e Z - - W M .... Q.. e e 0 - - ('II en w e e l- e( 0 .... .... en e 1-0:: lI) lI) Zw .... '''It =>lll e .... O:e lI) e ()=> e .... ~Z .... ('II u..1- 'Ii: O~ ~ .. WO Cl CQ I, Q..() :e .A T ~ c ~ II 11 'EI JT ~() ~ ~ ., II ~ r-t( e( U I- CIl C .c 0 () :e r-...: c.o en It) I It) C"') ..... I ..... ...... ..... - CO Q) E - () CO - c: 0 () Q) CIl 'j CO Q) a. - <Ii ~ CO () .0 c: CO Q) - Q. CIl CI) "00 - CIl ~ c: CO Q) ..... E Q) .I::. ~ t .0 .2 ~ ..... c: >- ~ Q) 0 Q) () c: "~ Q) CO 0::: .... 0::: -- 0 Q) Q) :2: u .0 >- c: ~ CO .!!1 c: c: a. CO Q) c: u u ~ CO E c: Q) 0 :!:: U5 0 u 12/18/2006 12:32 PAGE 003/003 Fax Server Allstate Life msurance Company 544 Lakeview Parkway Vernon Hills, IL 60061 Telephone: (877) 499-6418 Facsimile: (866) 635-4523 ~AlIstate. FINANCIAL December 18, 2006 S. Berne Smith Attorney at Law 107 N 24th St Camp Hil~ P A 17011-3602 Re: Contract No: Marie E. Fontenoy GA16871 788 Dear Ms. Smith: We have been requested to complete IRS Form 712 with regard to the above referenced contract. The purpose of Form 712 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a certain date (usually the owner's date of death or date oftransfer of the contract). This contract is an annuity contract, which is not reportable on IRS Form 712. The following information is provided for estate purposes only as of the date specified: Date of Death: Annuity Value* as of Date of Death: Cost Basis: Named Beneficiary: November 11, 2006 $ 54,119.06 $ 50,000.00 Barbara Poole, Donna Franz and Suzanne Modle *The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender Charges. If you have any questions, please contact our Customer Care Unit at 1-877-499-6418. Sincerely, Loreau Webster Sr. Claim Examiner A '7~rJC;l" IE J.Jr J Addressee ,.....-:.....,-.". " BARBARA> A POOL:EE'XEC'lJTOR"i'OF7';THE TATE OF MARIER FONTENOY*- ESTATE OF MARIE FONTENOY 17 S 26TH ST CAMP HIll, PA 17011 Statement of Benefit ~ Prudenti8I .. : . Financial . Check no. ~F W JAOD SCH J DEC-11-2006 0269454 I Ben;f~ATH Policy Numbers Certificate no. Certificate amount -~, ,,;.:.....:;.,:~ ~~~~~;' I Claim Number J I 09524= EXECUTOR OF THE ES: R FONTENOY* INCLUDE SURANCE,,,'(INClUDING -PAID UP ONAl INSURANCE) RACT INTEREST :-' '.~-";"'':-_.'-... , .~-:. ", "'--'-- 1. '. ;~. . '..'" :~;~.- , { ,..,Itq--rItCHk1~I.J1 1<: I Comb 34771 A I .... " '\,~. ; '. .' -;'.' ;>;:'':L';<;~~;;,::;'c~:~_:;''..;,1 ..,.-,; ,.".to:. ',' .; .--::~ : Prudential ~ Finan~ial' ._,' i'.j.;',':. PRUDENTIAL INSURANCE COMPANY OF AMERICA CUSTOMER SERVICE OFFICE PO BOX 13069 PHilADELPHIA PA 19176-3069 , l-BOO-575- 77BO ..... BARBARA A POOLE EXECUTOR OF THE ES TATE OF MARIE R FONTENOY, ESTATE OF MARIE FONTENOY 17 S 26TH ST CAMP HILL, PA 17011 ~ DECEMBER 11, 2006 CLAIM NUMBER: 952455 INSURED: FONTENOY MARIE R POLICY NUMBER(S): 610900269 DEAR BARBARA A POOLE EXECUTOR OF THE ES: ,. y',.: ,......", '.. :'.':-,....._-...,.:,',,'.;,..,.. I am enclosing a check for $ 2,420.9~,whichisfor.life insurance benefits under the p(jlicy-C-hurriber{sfSliown)above~''''-~~--'------i'Cc-._-,-- ._. "--. '.." ~. If you' have any. questions,' 'please call our Customer Service' Office at 1-800-575-7780 Monday thr.oughFriday,a~QO_a..~;JoJLQQ p:m. Eastern time.. Sincerely, Manager IWP Division Enclosure .;~", , ( ....- '.~ '~ .. '~'\ {~ t'fUaenLlal ve Financial The Prudential Insurance Company of America P.O. flox 13069 Philadelphia. PA 19176-3069 www.prudential.com Reason for Check: Death Claim Check Number: I 1880269454 Check Amount: $2,420.92 Date of Check: DEC 11 2006 Policy Type: Life Insurance Insured: M FONTENOY Claim Number: 952455 : Policy: 610900269 " BARBARA A POOLE EXECUTOR OF THE ES TATE OF MARIE R FONTENOY ESTATE OF MARIE FONTENOY. 17 S 26TH ST CAMP HILL, PA 17011 YOUR CHECK STATEMENI Pa~e 10f 1_ - --- --~ -"'.,. ---_..'--._,~...._...~"-..:..-.~-~...... -rl'" .~',J'''''~,'\'-l '\I ".:.:."",,.o\.;.:.;-"';";'~,~~'~.._,_._.. If you have any questions, please call our Customer Service Office atl-800-575-n80, Monday through Friday, 8:00 a.m. to 6:00 p.m. Eastern Time or write to: Customer Service Office P.O. Box 13069 Philadelphia, PA19176.3069 o;;i~hbefO;. ~hinO or deposltingciiec:k. Please ;etalntlli~ ch~ statem8~f'fottuiUrirefei.nCe. - P67400 . 5160000-_______.__ _. 118 ~ 8 8 0 2 b ~ L, 5 L, III I: 0 3~ ~ 0 0 2 2 51: 20 ? ~ ~ 5 00 b ?3 L, 2118 , ~ rrUU~nL.la1 VlI/7J. Financial - . The Prudential Insurance Company Customer Service Office PO Box 7390 Philadelphia. PA 19178 www.prudentlal.com BARBARA A POOLE 17 S 26TH ST CAMP HILL PA ,..:BATCH NO:SN54 000000623 Reason for Check: DEATH CLAIM Check Number: . D 1201141215 !..~.' Check Amount:,. . . $1.454.97 ':;i:';:<,",~~tement Date: DEC 11 2006 ""~'<'''U'''''''''''. .. .. ........ , '.'''. ".;",j . Contract Number:' 042 801 872 ~l:" .. :\:"f'~< ": ':. " .... ",' .~i;h:'::)~;.lnsuredlAn. nuitant.: MARIE E FONTENOY .,.....'.'...,;...". t._ ".',.. .... C',"-' ;;r') , ":. ':'~',',~ '~'-~;~ ';',>>"" ' - 't~"~ :.,~ ;" . YOUR CHECK STATEMENT Page 1 of 2 ~:~ '-,.',~.", ':-"'::"'-':':'K<;<'F~:~":-,:::,,,~<':"'~T,,.F''',I,>_'.,.:"".,'",:,,~,' )',''"-'.,>.::,.,,:. :_', .. ..', ' . W~. h9pe.we._ ha~,been JOf' h~ 1~j,9J~QYi\d~~tlL~9j,ftl~u.45;tJ nl~~-..J.:'~':" ,""C'-"-., ~~~~r~~~c~4~080~'1 A~~~.,'Z:iir~,p'~;~~h,~!:~~~~t(..pr~r~ed.~>~r()f,\the death c 1 a I m on SOURCE OF FUNDS . ;'.....'... S2~OOO:.oo..r./.;0;..'LFACE>AMOUNT.. OF"INSURA.N. CE.... . . , .',i~~~,~~2~:~g !~~':~~~~~~i~TB2 '~'I~ I g~~g~..A,NDI~TEREST ':';.t"'~':IF:S4 ~5l;g~WI NTEREST: ,fROM DATE 'OF DEATH ~~g~~il g~s CHECK ',>n:~gg:~~X~~\~~~~~~T~;~tDEO~p'~~~.1 NG * * * * * * * * * * * * * * ie. * '*; ,*' *' it '~* '/( * * * ** * * * * * * * * * * * * * * - If the deceased was'name~~sa:benefici~ryon c:tnyother.insurance contracts, we suggest that a new beneficIary be named as soon as pOSSible. . - SOCial Security benefits may also be aV;1i lable.. For more information, get in touch with.the.appropriate,government.office in your area. ,. <,;",:-..:",";-..'i; ~";""";_""~'~!;~/";;"''..:'':'-'''~';-::' :.,,":'' ,'J_"'>-' ,. , .,-'.:,.;',',..' :f_';" ':;i"?:\\';:>~:;\'~:\ ,', ** CONT I NUED ON NEXT PAGE **. '., ,..-...;..:.........'..-...: For insurance service. get in touch with yourrepresentative or this office. .~6EBg~~~9~1~1~,I~~;'>y'f~" .......1-J rrfJ C )I h ~ tJl L . PHILADELPHIA PA'19176;:'/~:::" . '.:{~~~~rrj,~~~.~;.};'>:':~ei:~}>~ i '. .' IJ IliJ4,'? ':)~3.,.,':;",..;.\tl?d.iJfti!JfiY; >~r ....., .... .. '> ;;~lli~~~~\~!ii14!~.t~~ . i;. :'{.~~..t('~t'.;;i:;~:,,'~~~~t:i)~t~~~::~'}~~~~;~~)}~~::~r~t{,~~~~!t~f"!':~;; \;:::' -. II- ~20 ~ ~ 1, ~ 2~ 5u. ';1:0 ~~~0022 51:2 . .' ., FUNERAL EXPENSES MONDAY. NOVEMBER 13. 2006 Hotel- 2 connecting rooms - Donna & Missy Franz, Sue Modlo, Super 8, Clearfield Dick & Barb Poole $117.48 Dutch Pantry - Lunch - Donna & Missy Franz, Sue Modlo, Dick & Barb Poole $ 49.29 Clearfield Florist - Mom's funeral flowers $116.60 Hedges - Dinner - Donna & Missy Franz, Sue Modlo, Dick & Barb Poole $ 69.52 Beardsley Funeral Home - Mom's transportation from Mechanicsburg to Clearfield and obituaries $552.00 TUESDAY. NOVEMBER 14.2006 Super 8 Motel- Clearfield - 5 rooms - Donna & Missy Franz $293.70 Barb & Dick Poole, Sue, Mark, and Erik, Matt & Lauren Franz, Mike & Michele Breon, Daniel's Lunch - Donna & Missy Franz, Barb & Dick Poole, Sue Modlo $ 52.26 Fox's Pizza - Supper - Donna & Missy & Matt & Lauren Franz, $ 39.44 Barb & Dick Poole, Mike & Michele Breon WEDNESDAY. NOVEMBER 15.2006 Hedges Restaurant - Funeral Dinner - 30 dinners $464.16 $1,754.45 TOTAL ~ TTAc 1-1 nE~1 H Cuetara-fii!e memorial Center Cemetery LetterIng 1313 RIVERVIEW ROAD - CLEARFIELD, PA. 16830 - PHONE 814-765-7776 FILE NO, COMPLETION DATE: CEMETERY LETTERING FOR: MARIE E. FONTENOY NAME(S) ON MEMORIAL: PAUL C. AND MARIE E. FONTENOY FINAL DATE OR OTHER ENGRAVING: MONTH, DAY& YEAR, NOV. 11, 2006, DEATH DATE (Description of other Engraving) CEMETERY NAME: CALVARY CEMETERY LOCATION: CLEARFIELD LOCATION OF MEMORIAL IN CEMETERY: SEE OUR MAP INDIVIDUAL ORDERING: NAME: BARBARA POOLE ADDRESS: 17 S. 26TH STREET CAMP HILL, PA 17011 PHONE NUMBER: 717-763-0381 COST FOR ENGRAVING: 105.00 TO BE PAID WITH RETURN OF SIGNED CONTRACT WORK TO BE COMPLETED BY: BEFORE MEMORIAL DAY, 2007 I Have reviewed the above information and have confirmed that the Date listed in the "Final Date to be Engraved" is the correct date to be cut on the stone. The party or parties subscribing to this contract indicate thereby that the inscriptions as written hereon have been approved by them and therefore are correct. It being further understood, consequently, that in the event of an error in executing the inscriptions, the expense involved in making the corrections shall be borne by the purchaser, provided finished inscriptions correspond exactly with corresponding related sheet mentioned above. Please sign and date this contract and return it along with payment for the above amount. Signature: Date: J '/lcf/CG -J. t'15" IJ f'T lAC J-I n tf" i-l-r N RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17G13 Receipt Date: Receipt Time: Receipt No. : 11/28/2006 13:25:12 1046464 FONTENOY MARIE R Estate File No. : Paid By Remarks: 2006-01045 POOLE BARBARA A POA AJW ------------------------ Receipt Distribution ------------------------ Fee/Tax Description PaYment Amount Payee Name PETITION LTRS TEST WILL SHORT CERTIFICATE JCP FEE AUTOMATION FEE Check# 176 Total Received......... 90.00 15.00 32.00 10.00 5.00 ---------------- $152.00 $152.00 CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D CUMBERLAND COUNTY GENERAL FUN ~ 'T--J tfk:- jl It € jJ r o S. BERNE SMITH Attorney-at-Law 107 N. 24th Street Camp Hill, PA 17011-3602 PHONE: (717) 737-6789 FAX: (717)737-6783 July 31, 2007 In re: Estate of Marie R. Fontenoy; DOD 11-11-2006; SS# 194-14-7665; EIN: 20-7160965 PA File No. 21-06-1045 File: 206002 Ms. Glenda Farner Strasbaugh Register of Wills Courthouse 1 Courthouse Square Carlisle, P A 17013-3387 Dear Ms. Strasbaugh: The original and a copy of the Pennsylvania Inheritance Tax is enclosed. Also, please find enclosed the Estate's check in the amount of$505.34, payable to Register of Wills, Agent, as final prepayment of the Pennsylvania Inheritance Tax. My check in the amount of$15.00 is enclosed to pay the filing fee. Please acknowledge receipt of this filing. Thank you for your help in the case. It is a pleasure to work with your Staff. Sincerely yours, P- g~~l S. Berne Smith Enclosure: cc: Barbara A. Poole, Executrix o ;;0 <~::o :cv ':Co ,~~ , .10 O~ " C ::0 --.--, --i :1> -0 :x ~ w 0'\ '" = = ......., :z:". c::: G") , (J-(J~~ ~. 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