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Home My WebLink About08-15-07 (2) --1 15056051058 REV.1500 EX (06-05) PA Department of Revenue '* Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 ~. ENTER DECEDENT INFORMATION BELOW Social Number Date of Death OFFICIAL USE ONLY ~?untyC?de Year INHERITANCE TAX RETURN RESIDENT DECEDENT 21 07 File Number 0536 May 20,2007 Date of Birth May 6, 1910 MI (If Applicable) Enter Surviving Spouse's Information Below Last Name Decedent's First Name Harriet Decedent's Last Name Garside First Name MI Spouse's Social Security Number ,..",..",.. """, ""'" " ' 'I \ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW C8J 1, Original Return c:::> 2. Supplemental Return c:::> 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required c;:J c:::> 4a. Future Interest Compromise (date of death after 12-12-82) c:::> 7. Decedent Maintained a Living Trust (Attach Copy ofTrust) 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 PClytiI11El!ElIElP~()~et'Jul11~Elr c:::> c:::> 4. Limited Estate 8. Total Number of Safe Deposit Boxes ca:> 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received '717-697-7050 C. Sheely, Esquire REGISTER OF WILLS USE ONLY C. Sheely, Attorney at Law ~ity()r ~()st <?ffi~El.. ..,. Mechanicsburg State ..~w........._.._..._m'l r-.... ..J e~.. ZIP Code 1'...) c:-~ r:-::) _J ~ils ,- c-~. ..; ~-.., Second line of address First line of address 27 South Market Street en Box 95 ~ W \.0 \....,1 ) Correspondent's e-mail address:~ndrewc.sheely@verizon.net Under penalties of pe~ury, I declare that I have examined this retum, 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. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN 17 .;U~U Ivr t ~ ,AnnRFRR Russell W. Lutz, 28 Chestnut Street, Camp Hill, PA 17011 PREP TH REPRESENTATIVE i'fI~ I D, ". nRi=C::C:: Andrew C. Sheely, 127 South Market Street, P.O. Box 95, Mechanicsburg, PA 17055 _ PLEASE USE ORIGINAL FORM ONLY ~ tt/a7 Side 1 15056051058 .-J L 15056051058 c " -.J 15056052059 REV-1500 EX Decedent's Social Security Number f..n-'_r___c......".""..,.......m.."......o,._.__._._._c..c._...."''"._,.",,.'.'.'.'.'.'.w_.._._..._................____.c Decedent's Name: Garside, Harriet J. RECAPITULATION 1189-03-0718 1 I 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. 71,191.81 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. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 71,191.81 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . . . 9. 11,892.46 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10. 2,707.98' _m".,~"_~NN^,,","=. ,wc,_,'h'..'_=m._,'^ 'W"pN -,-v'~,_-^,,~=wm1 14,600.44 I 11. Total Deductions (total Lines 9 & 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. I 13. Charitable and Governmental Bequests/See 9113 Trusts for which rw an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. I r-'--~' 14. Net Value Subject to Tax (Line 12 minus Line 13) ............. . . . . . . . . . . . 14.1 56,591.37 56591.37 i i TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers unct... C::ec. 9116 (a)(1.2) X .0, 16. Amount of Line 14 t"v~ble at lineal rate X.O 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 16. 56,591.37 17. I 18. i 8,488.70 8,488.70 19. TAX DUE. .. ... ... ...... ... ............... .......... .............. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT c:::> $~ L 15056052059 Side 2 15056052059 -I R'EV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME Harriet J. Garside 36 DECEDENT'S SOCIAL SECURITY NUMBER 189-03-0718 STREET ADDRESS 1700 Market Street CITY Camp Hill STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 8,488.70 8,064.30 424.42- Total Credits ( A + 8 + C ) (2) 8,488.72 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + 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) 8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5) (SA) (58) 0.00 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;.......................................................................................... 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 [i] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D [i] 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. 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 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. 99116(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-1508 EX+ (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER HARRIET J. GARSIDE 21-07-0536 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly.owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. PNC Bank Savings Account #5130088533 68,493.68 2. PNC Bank Savings/Checking Account #5140022714 1,488.13 3. Manor Care - refund 1,210.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 71,191.81 t"- ..... 0 ..... 0 \0 N 0 V) V) 00 ~ \0 0 g ~ 0 ::l 0\ ~ ~ . 00 0 .s \0 Z co:l Q Y} IJ) ..., >. c Q) Co. u 0 ..., U ..c '05 l-l , Q) '" e .8 ..., 'c;; .~ 0 ~] (J) ~ tf.l "0 = C U ~~ <( IJ) ~'g L.. C1J ui 0 Q) 0 - .c ~~ Q) C': Q) .- L.. ~ ..c 0 +;' bJ) ~ ..., Q) Q) Z ~ .!:: I z = r:5' Cl "0 ~ ~ ..... ",' tI) ~ ~ ~ "0 ",'J ",<5 < C ~ 0 ::J I ...., L.. ~ ~ ::J U 0 Q.) ..... LL ...c::: ~ "0 ~ c E U < C1J .. :r:: IJ) a: ::J U'.) '- 0 ..c ... 0 I- ~ .... (. <1.) ..., Q.) " 0 ..c .- r"> >- ...c::: <1.) "'P r"> ",,'" -B "... ,~ U'.) 00 ,,'" cd 8 00 v ..., 8 .," U ~ X IS ::: ~ p.. (J) c.< "... ,,+'~t~: '';;:,,< 0090-9E60Z I V'JtlO;3 ro-,.'- r- ...... 0 N 0 \0 N 0 II) II) ~ "<t 0 Q) ...... 0 !:l 00 ;j ~ 00 "<t 0 Q) ...... ..... Z ell Q ~ >. Q.. 0 U (/) l-l ..... Q) c S c:: Q) .9 U 0 :;; 2] c ...- Q) (I) Q) ::l ..... U ~~ .... .c P:)'~ I- "0 Q) u: c <( - .J::j. ~~ ~ ~ co .... ...- 0 0 0 bl) 6) ..... Q) .c Z I ~ := Cl 0 ...... Z \.Ii 0::: ~ i.i:i Cl "0 ....., Q) .... ~ E-o "0 ~ C U - ::l ~ 0::: I ...c:: 0::: .... ~ ::l U 0 ::r: LL CZ) '- "0 " 0 c .... co ~ <U ~ "0 (/) 0 ::l ....... 0 :!: ...c:: <U .c -5 r-- l- N CZ) 8 8 ro Q) >. C U cd ::!; "" 0 V) ~ 0090-9860<: L V'I!30~3 .. !, \\, ,It\ \ .. \" ~ \ '\~ 11\ \ ,,~\ ,\ \\ < '.~" '\' ., \ \! , ' ", , \ \" \ \\1 , t, Check Date: 06-12-2007 Invoice Number Invoice Date l88 06-06-2007 Patient Refund-Invoice: l88** Vendor Number 0000359995 Check Number 0090562946 Russell Lutz Date 06-12-2007 Name Gross Amount l2l0.00 Total Amount 1210.00 000168 P1 2320377 Check No. 0090562946 Discount Available Paid Amount .00 l2l0.00 flEr/lIlE-/.J Total Discounts .00 Discounts Taken PUMD~ r=:qIJAJ AIJ/<< REV-1511 EX+ (12-99)* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF HARRIET J. GARSIDE FILE NUMBER 21-07--0536 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: 1. DESCRIPTION AMOUNT MUSSELMAN FUNERAL HOME ROLLING GREEN CEMETERY $ 5,960.87 $ 1,195.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) RUSSELL W. LUTZ, EXECUTOR Social Security Number(s)/EIN Number of Personal Representative(s) - - Street Address 28 CHESTNUT STREET $ 3,507. 09 City CAMP RTT.T. State ..R.A...-- Zip 17011 Year(s) Commission Paid: 2. Attorney Fees ANDREW C. SHEELY, ESQUIRE, PER AGREEMENT $ 537. 50 3. Family Exemption: (If decedenfs address is not the same as claimant's, attach explanation) Claimant Street Address City State _Zip Relationship of Claimant to Decedent 4. Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS $ 177. 00 5. Accountanfs Fees 6. Tax Return Pre parer's Fees 7. FILING FEES FOR INHERITANCE TAX RETURNS $ 15.00 Reserves to conclude administration of Estate, including preparation of decedent's final income tax return, costs, pos age $ 500.00 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) $11,892.46 Musselman Funeral Home & Cremation Sernces, Inc. Established 1895 Brian C. Musselman, ED. Supervisor William G. Pegan, ED. P.O. Box 137 ; 324 Hummel Avenue Lemoyne, PA 17043-0137 (717) 763-7440 Fax: 717-730-9798 www>musselmanfuneral.com To Funeral Expenses of HARRIET J. GARSIDE Russell W. Lutz 28 Chestnut St. Camp Hill, PA 17011 2007 May 23 PROF.SERVICES,FACILITIES,AUTOS "Spencer" Metal Casket Reinforced concrete vault Cash Advanced Items: Flowers Copies of death certificate Newspaper death notice TOTAL FOR APPOINTMENT PHONE 717-763-7440 / June 5,2007 $3,745.00 1,050.00 900.00 $106.00 24.00 135.87 ,; I~ '- ~, $5,695.00 $265.87 $5,960.87 eAil;,~H' it~/ ., tJ~j{,r KriJ.. '1> "tin .. \~ln)"'"~4t<i'tf> Contract ,r,', F r-- "'" ' )i:, i J ~,'~ r '~. [k1, \,.J!' .," ,~; '<"c" Q''''' File Folder Name/Number CEMETERY INTERMENT RIGHTS, MERCHANDISE, AND SERVICES PURCHASE/SECURITY AGREEMENT THIS AGREEMENT PROVIDES FOR PERPETUAL/ENDOWMENT CARE. The undersigned, referred to as 'Purchaser', hereby agrees to purchase the Interment Rights, Merchandise and Services described herein, subject to acceptance and approval of the above named cemetery, hereafter referred to as 'Seller', Purchaser: Last Name: , First: I f,'.I\} IS , ! Middle: It. Lt. I~j "11_1 I I I I I I I I I I I I I I~, I:: lei I I I I I I I "')1 I I I I I Telephone: (: !7 )7 ~-; _ C) f:j.,~ '.~y-"l SSN: DaB: ; Email: - - - / / , Address: I;,IYI ICeI)\I< I' 1~"I'\I"d'H ISII-I I I I I I I I I I I I City: 1(1(,j1!'"'d(~ I IHI: 1\ 11 I I I I State: IhA, Zip: J '~l (~) f \ Co-Purchaser: Last Name: I I I I I I I I I I I I I I I I I I First: I I I I I 1 I I I I , I I I Middle: I 1 I I I 1 I Telephone: c-)_- SSN: DaB: / / Email: - - - Address: I I I I I I I I I I 1 I I 1 I I I I I I I I I I I I City: I I I I I I I I I I I I I State: I I I Zip: Deceased: Last Name: Ie 1,c'_I" I <, I, Ii'lli' I I I I I I I I I I I First: If~ 1(;\ I t' I <!"-- I I~,l~\' I I I I I I I Middle: 1'\1 I I I I I DaB: k-; / i / f crl{; DaD: C"'.~' / ::U-) / Burial Date: ~ / .;;~,~~-:. / ;,~{(:'y) rj Veteran: 0 >'Le.. '_. ~"'")[j , - Description of Interment Rights to be used: fly .w"" -"J! ! Ii ","'~ --~, Memorialization Rights: I \.~f 1-1' , Issue Certificate of Interment Rights to: Address: City: State: Zip: INTERMENT MERCHANDISE & SERVICES . Interment Rights $ _="_",,w'"~'''''"''''''''''''' . Urn ~-=..,..~.-"~.- '^-.'-'.'-"""""."'..'.- (Includes PerpetuaJlEndowment Care of $ ) Supplier . Interment and Recording Fees \ \q5 "CO Type/Color . Outer Burial Container ~,,~,,~-"""~._'''' Design/Size Supplier . Admin/Processing Fee ....~,=-., ,.....~",.....-....,.-.~,...",.,........ Model/Design . Other .-"",~,_."",.""",,,....-......-- Material/Color . Other . .' ~".. ~~..-~- Outer Burial Container Installation -.0.,......---...'" Other _.,~._.",...'^-.,....--."'_. . . MEMORIALIZATION . Other ._.... ,-c~., ~',~~___~...__ ---",-,-,,,,"~=.,.,..,..-... Other f --~-~.,........,.,,-_. . Memorial . Supplier . Other ~=--'-"--'-"'-'-."-' Type/Color TOTALS, ALLOWANCES & TAXES Design/Size . Interment Rights...........................", ,.......,... .......,.. ,........,. ( '''--,.....-'~" ) Memorial Base ----.......-,.-.-......-=-.... Reason . ,. Supplier . Merchandise/Service,..,....."...".....,..,........,."....,....,."..... , ( ~.~"-,-,,,---,--- ) Type/Color Reason Design/Size Apply to Memorial Perpetual/Endowment Care -~,-----' ~-_.".~..."",,- . Merchandise/Service,.,....,.....................,.., ........,....,."..,.., ( -,.,..,-..,.."-.._-,,.,.~_...,,,,,. ~- ) . Memorial Installation Fee ---._~...,....~,-.--.., Reason . Memorial Inspection Fee ------~. ~-- Apply to . Nameplate/Scroll _...~_........~!:..- Sub Total ! \ c1 <::~ (~) CO) . Lettering --~.....~.""---,,,,,-,~,-~-.. Total Taxable . ~,._~...~.~,.,...~~.h . Sales Tax (if applicable) ,......................,........,.................. -..--..- . . Flower Vase TOTAL CASH PRICE $ ! '; c,' ~"~~. j( " Supplier Type/Color Less: Down Payment Design/Size Other Total Do~ Payment ( ,. ,. C'/.:-- ) . Vase Base -~---'-"""""'"""- , Size/Material Unpaid Balance of Total Cash Price $ '-r['?~ .'. -.- ,,"- Notes & Payment Terms (where applicable): /;'/y' :N * .., ~ TERMS The Total Cash Price is due and payable as of the date of this Agreement. A delinquency charge of _____ percent wiil be assessed monthly on any balance not paid within yr, .. r., .' , ~ ~_11__ _L_ll ...1_...1.._0- o-t..~ ~~~_..~A A""l:...........t:>o....ro" roh"rn-o -ft'nrn thp. -:l.rnAllnt rprpj,/prl '..Inri r<rorl~t thp. RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle{ PA 17G13 Rece~pt Date: Rece:;.pt Time: Recelpt No. : 6/01/2007 11:01:30 1048653 GARSIDE HARRIET J Estate File No. : Paid By Remarks: 2007-00536 RUSSELL W LUTZ JA ------------------------ Receipt Distribution ------------------------ Fee/Tax Description PaYment Amount Payee Name 1- PETITION LTRS TEST WILL AUTOMATION FEE SHORT CERTIFICATE JCP FEE Check# 1526 Total Received......... 135.00 15.00 5.00 12.00 10.00 ---------------- $177.00 $177.00 CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D / ~ /VI.. .Jh) REV.1512 EX .11.97} SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF HARRIET J. GARSIDE FILE NUMBER 21-07-0536 Include unreimbursed medical expenses. ITEM NUMBER 1. DESCRIPTION AMOUNT Burick Azizkhan Internal Medicine Associates $ 108.09 2 . West Shore EMS -ALS $ 622.22 3 . Verizon - final bill $ 17.39 4. Cumberland Apothecary $ 9.00 5 . Social Security reimbursement $ 1,075.00 6 . Holy Spirit Hospital - final bill $ 845.94 7 . Kantor & Tkatch Associates $ 30.34 TOTAL (Also enter on line 10, Recapitulation) ~ 2 707 98 1;> , . (If more space is needed, insert additional sheets of the same size) Patient Statement ivlOnday, July 02, 2007 Pay to: Burick Azizkhan Internal Medicine Associates 888 Poplar Church Road Camp Hill, PA 17011 (717) 724-2126 ~ Payment Type: o Cash DVisa Harriet J Garside C/O Russell W Lutz, EOE 28 Chestnut Street Camp Hill, PA 17011 Account # o Check o Mastercard Expiration Date _/_/_ Signature Date_/_/_ (Detach and remit with payment) Reflects transactions posted through 7/2/2007 for 16285 Date Descnptlon Check # Fee Units Insurance Pallent 05/13/2007 05/14/2007 05/15/2007 05/16/2007 05/17/2007 05/18/2007 05/19/2007 OS/24/2007 06/12/2007 . 06/12/2007 06/12/2007 . . . . Harriet J Garside(15851)/R George Azizkhan Jr DO/HSH015923 Location: Holy Spirit Hospital Initial Hospital Care New/Est Level Subsequent Hospital Care Level 2 Subsequent Hospital Care Level 2 Subsequent Hospital Care Level 2 Subsequent Hospital Care Level 2 Subsequent Hospital Care Level 2 Subsequent Hospital Care Level 2 Medicare contractual Adjustment from Highmark Medicare Services Medicare contractual Adjustment from Highmark Medicare Services Medicare Payment from Highmark Medicare Services Transfer from Insurance $185.00 $85.00 $85.00 $85.00 $85.00 $85.00 $85.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 $185.00 $85.00 $85.00 $85.00 $85.00 $85.00 $85.00 ($20.00) ($134.63) ($432.28) ($108.09) $0.00 ~'} $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.09 $108.09 $0.00 $108.09 $0.00 $0.00 $0.00 $0.00 rrnm~~;~:~~Tli~":~~~~~i:F.l.~~~l~I.~~ Rllr;"k A7i7kh;::m Intprn:'ll MArlir.inA ARRociates * R88 Poplar Church Road * Camp Hill, PA 17011 * (717) 724-2126 "1082208 1082208 1082208 , 1 .1 . 'I . . WEST SHORE EMS - AlS 205 GRANDVlEW AVE SUITE 211 CAMP Hill, PA 17011 Phone #: (800) 367-0512 Federal Tax 10:23-2463002 ~ , 1 WEST SHORE 'I; i ~: ....: (Y::'~C1 PATIENT NAME: HARRIET GARSIDE INSURANCE: MEDICARE B 189030718A PATIENT NUMBER: CALL NUMBER: DATE OF CALL: TIME OF CALL: CALLER: FROM: TO: 61871 3084740A 05/13/2007 MDEN MDIP 3084740A MANORCARE HEALTH SERVICES HOLY SPIRIT HOSPITAL HARRIET GARSIDE C/O RUSSELL LUTZ 28 CHESTNUT ST CAMP HILL, PA 17011 REASON(S) FOR TRANSPORT lOSS OF APPETITE WEAKNESS - MUSCLE INVOICE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT PARAMEDIC INTERCEPT A0999 1.0 617.52 617.52 EKG ELECTRODES (4PK) A0396 1.0 4.70 4.70 Total Charges 622.22 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Total Credits 0.00 PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT --.- $622.22 T RNED CHECK FEE - 32.00 RE U $ DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT AMOUNT DUE AMOUNT $ ENCLOSED . 622.22 PATIENT NAME: GARSIDE, HARRIET J PATIENT NUMBER: 61871 CALL NUMBER BILLING DATE: 3084740A 06/28/2007 THESE SERVICES ARE NOT COVERED BY MEDICARE AND ARE YOUR RESPONSIBILITY. WEST SHORE EMS - ALS 205 GRANDVIEW AVE I VISA J ~~: [.J MASTER CARD ACCEPTED ~ CAMP HILL, PA 17011 - it'e- 1 ~" veriZ9.p 00000190 01 AT 0.334 Eel' 158 ] 1 0002 F HARRIET J GARSIDE RUSSELL W LUTZ 28 CHESTNUT ST CAMP HILL PA 17011-5603 1"111"1""""..1,...".1,..."..1,.....1,...,.,,..1""'" AccoLlnt: 717737-967428039Y 210'HRRDAI oonuo 190 I TOtJoon00937 33-PA I'U63 ;17i379674 060707 AmoLlnt Paid: $ 00.00 Verizon PO BOX 28000 LEHIGH VALLEY PA 18002-8000 ,..." ,..,."...".....,."..,."..." ""'1"'11'" J;' f1, t:. -it..,. 11771707379674280802802130999991000000180770000001739200000 I.' \ " \ \ , ,,"I' : \ \t~.,:\ il \ 1'1' \\ r. ' . ~\ ; \\1',1 \"~ , i ,.\ CUMBERLAND APOTHECARY 3300 MARKET STREET C(li'iP HILL..! P(;.. 1)'0:1.1 ('I F' If".lf::'lf".iC~[: C'J"!{:'!I:;.~C':iE:: C)t:;" :L u ~.:5(~) :x; i)E::F: I"! (31'..' '({"I (('d..j (lj..ji'.il.j('li._ PEFd:::E::i'..j"frIC;E j:;;((IT: (jF :i.t:L DCi :.:n 1...11'< (':1 i"'i I f"'{ I j"il..Ji"-i ~:::;E:F~i..) I (::E: C:j..i(IF:C;E: [JF' ~f;. II :.:.:.;(.:,) i..:.J I i...l... E.:E: C:I"i{:iF~CJE:):> j ,"p..'j '....1' "'!":i'-n p...";">:::, .:;:.;::: .....'I'..'.Jc (,'i':;' 'y"'''i':;'J::' 'I"'j'\';::'"'' 'i",' "1::' ... " H... ,... H, I...... d I ..... ,... '..! .'....., I ..... ... I.. 1 ".. I '.1... .. .......' j ...-1...1 ... 3T A TEMENT DATE L:ILLb i::ir~E DUE Ii..j FUL.L. BY THE f:::~:.iTH DF j..iE:>Cf I"H::Il...rrH L U T :.;:: ~i h: I..r:;; :;;:: E i... L. j::::f:. C:HE::;:;'I"I...ji..,iT '3Th:E::ET J c:: ('j !Y! J::l j..; I L.I... pn :l.;';':-'(j:1. :L i...u'rZF: :L ...... .,. ... 1.:.i!.<I.......l..; Pi:iC:iE :L - -- AMOUNT PAID CUMBERLAND APOTHECARY .j.jljl:.:1 1"j(IF:i<.E:'r :;:;TF:i::ET PLEASE DETACH HERE AND RETURN TOP PORTION WITH YOUR PAYMENT C:(ii'jj::' HI L.i."'J P(I" :i. ':?(~':i 1 :I. '~~~~~'!J]~~!_NU~BER Q!Y. _~~~ESCRIPll~ . :D~' NIL ~~g: >AMOUNT \ _~SALES TAX -ITEM TOTAg. ~4/30/07' i e* ACTIV TY FOR GARSII "J5/07/0"; 62544~~j.1 3R ,* ACTIV TY FOR L81Z, , Pymi:;.... _.. ((j[:Jl4314:1. HI::iF<F:IET . OJ'VWII''~ HCT :!.1:;,(ZV :1. ;.;:: u GEL.!... "1 "'f " {::p.. .. {n .J... I 9.. ({.I(~J :1. / l7" :I. 9... " if.)f.) '::}.. ({.n;;:ic ;:) ... IZiff.) 4!:5 . ({)!Zi I I 'lED.. .I..!J::..I.J" "('f)) j"IED I.... 'OR MONTH CAL OED.. )i;;l;I""J('l'J:II.:':'.:,m~~ ~ej:r,l;[ej:!"IU~III-"IIi:~~~:./~':j r-:m,,'/[ej=-ol:r";~.~.71 I . :1./.. :1.'::' + L '::." 1::.1::'\ _ + L ,,'::'.l~ =. l')f"~ol~.r,':(~~~" Il'lf"Ill:H"I\j;/~~''IlOl~.I~;~~.i "'j" 1..1 I I' I. 1......11: " .,' - __ .. I II " ,.' J)u i.-:'Ji..:',i = EN/... 4~ Holy Spirit Hospital ..,- ".".. .~~.-._",.,.....,.,............. r ". "".........-"...o\II-~,-"II~~Il~II!~tl.n,l..-J flit lIIIiUl!IUfll_~IIiIMIIII"'"ItJ~JUI.W lWIIIJll'!I'JIll~.nIltUJ I .It n l ..Ift!IJ.....U!! . "..I.~~ tJ I". _ ..IfIU U ll\.1~L~,...IP_141 J! .~!N ,_ . Jf~lDill~.m~...._n".a._,4.,.IlIf8l,lMJrll'~Jl'm~U1lt. tlroe;:m..,~~.~ ~ A.llltr'4)...,~_J..."" 503 N 21ST STREET CAMP HILL PA 17011 # 8000887-8573 l The SfHrit of Comag For Accauat Infbrmation, PIeue OIlUJH...,7-8S73 I _:1 Tra..dicm DIde 05/31/07 06/18/07 06/18/07 : 06/18/07 -D6/liI,'87 ...... 06/18/07 06/18/07 06/18/07 Descriptioa PREVIOUS BALANCE MED C/A HOSP~IP HEDL PYMT~HOSP IP MEDI PART B PYMT~IP MEDI PART B PYMT~IP -.-.- --'- ----'.~. C~--HOS"'" f1I' MEDI PART B C/A~IP MEDI PART B C/A-IP MED C/A HOSP~IP ...'.-__...._._ __,._ '._.,,"._'__" .....,. .__...._...___ '_u_.,.'_._.m RECEIPT NO. RECEIVED FROM DESCRIPTION BALANCe Due METHOD OF PAYMENT CASH 0 . INPATIE;NT CHECK y" OUTPATIENT 0 MONEY ORDER 0 OTHER Q CREDIT CARD 0 ~ RECEIVED BY M90 MEDICARE I/P M90 MEDICARE I/P M90 MEDICARE UP M90 MEDICARE I/P M"o-'1IJEDICARI:I1"P"---'-'. "90 MEDICARE I/P M90 MEDICARE I/P M90 MEDICARE I/P Amount 22.998.82 1&,549.51- 5.457.25- 6..43~ 6.43- 1 ",-'i9l-;;S7..' 20.96~ 20. u- 16 . 549 . 51 ~ ,. 39228 DATE2k~ '1 $' ; ~ 995.21 Ie 9''1- rJ Thank you for your payment today. An exact balance is unknown at this time; however, we will apply this payment to your account. A final statement balance will be mailed to you in the near future. ,,,.t Balu.ce: REV-1513 EX+ (9-00) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATEffARRIET J. GARSIDE 21-07 -OS3~LE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116:8~.2)T Friend 10% Rest, Re THOMAS L ON 7930 Chambers Hill Road and Remainde Harrisburg, P A 17111 Estate per Wi LINDA G. ANDRUS Niece 4S % Rest, Res 33S Sherwood Manor and Remainde Mansfield, PA 16933 Estate per Wi) RUSSELL W. LUTZ Friend 4S % Rest, Re 28 Chestnut Street and Remainde Camp Hill, P A 17011 Estate per Wi) 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 $ sidue r of II idue r of I sidue r of I (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT OF HARRIET J. GARSIDE I, HARRIET J. GARSIDE, of Camp Hill, Cumberland County, Pennsylvania, make, publish and declare this as and for my Last Will and Testament, hereby revoking all other wills and Codicils heretofore made by me. FIRST: I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appoint- ment and together with any insurance policies thereon, as follows: (A) Ten (10%) percent thereof to my friend, THOMAS BOLTON, of 7930 Chambers Hill Road, Harrisburg, Pennsylvania, provided that should he predecease me, then to LINDA G. ANDRUS and RUSSELL W. LUTZ, as set forth hereinbelow, in equal shares. (B) Forty-Five (45%) percent thereof I to my niece, LINDA G. ANDRUS,. o'f, Mar1~ field, Pennsylvania, provided that should she prede- cease me, then to her issue per stirpes by representation. (B) Forty-Five (45%) percent thereof to my friend, RUSSELL W. LUTZ, of 28 Chestnut Street, Camp Hill, Pennsylvania, provided that should he predecease me, then to his estate. SECOND: In addition to all powers granted to them by law and by other provisions of this Will, I give the fiduciaries acting hereunder the following powers, applicable to all property, exercisable without court approval and effective until actual distribution of all property: (A) To sell at public or private sale, or to lease, for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms (including credit, with or without security) or conditions as are deemed proper. This includes the power to give legally suffi- cient instruments for transfer of the property and to receive the proceeds of any'pisposition -. of it. ~~ . - . 2 (B) To partition, subdivide, or improve real estate and to enter into agreements con- cerning the partition, subdivision, improvement, zoning or management of real estate and to im- pose or extinguish restrictions on real estate. (C) To compromise any claim or contro- versy and to abandon any property which is of little or no value. (D) To invest in all forms of property, including stocks, common trust funds and mort- gage investment funds, without restriction to investments authorized for Pennsylvania fiduci- aries, as are deemed proper, without regard to any principle of diversification, risk or pro- ductivity. (E) To exercise any option, right or privilege granted in insurance policies or in other investments. (F) To exercise any election or privi- lege given by the Federal and other tax laws, including, but not necessarily being limited to, personal income, gift and estate or inheritance tax laws. . .\;~ 3 (8) To make distributions to my herein named beneficiaries in cash or in kind or partly in each. (H) To borrow money from themselves or others in order to pay debts, taxes, or estate or trust administration expenses, to protect or improve any property held under my will, and for investment purposes. (I) To select a mode of payment under any qualified retirement plan (pension plan, profit sharing plan, employee stock'"ownership plan, or any other type of qualified plan) to the extent the plan or the law permits them to do so, and to exercise any other rights which they may have under the plan, in whatever manner they consider advisable. FOURTH: I direct that all inheritance, estate, transfer, succession and death taxes, of any kind whatsoever, which may be payable by reason of my death, whether or not with respect to property passlng under this Will, shall be paid out of the principal of my residuary es- tate. ~ ;' 4 FIFTH: All interests hereunder, whether principal or income, which are undistributed and in the possession of the fiduciaries acting hereunder, even though vested or distributable, shall not be subject to attachment, execution or sequestration for any debt, contract, obligation or liability of any beneficiary, and further- more, shall not be subject to pledge, assign- ment, conveyance or anticipation. SIXTH: I nominate and appoint RUSSELL W. LUTZ, Executor of this, my Last will and Testa- ment. In the event of the death, resignation or inability to serve for any reason whatsoever of the said RUSSELL W. LUTZ, I nominate and appoint JAMES D. BOGAR, ESQUIRE, Executor of this, my Last will and Testament. I direct that my Exec- utor, and his successor, shall not be required to post security or a bond for the performance of their duties in any jurisdiction. . ~~ 5 IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Tes- tamen t , thi S "l\\", day 0 f/'\jy'L<r(.' t 2006. '~j ( SEAL) Signed, sealed, published and declared by the above-named Testatrix as and for her Last Will and Testament in our presence, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as attesting witnesses. /) IS' // J i)'" / /" ! ' / I '., .. . "-, ,." ...--h'LU' j. V6k-f . IV (- , , \"~"/ Address {! /;{ . .iU-!' dJ?'_ . ( . , - . , . . . . ~ Address ,','" 6