HomeMy WebLinkAbout10-17-07
-.J
15056051058
REV-1500 EX (06-05)
PA Department of Revenue
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
County Code Year
File Number
a\ D1
tfi2JlP
Date of Birth
201-26-5035
07/12/2007
07/31/1933
Decedent's Last Name
Suffix
Decedent's First Name
MI
Roeder
Paul
S
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
MI
Roeder
Bernadette
A
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
.. 1. Original Retum
2. Supplemental Return
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
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 Daytime Telephone Number
4. Limited Estate
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
Mark W. Allshouse, Esq.
Firm Name (If Applicable)
Christian Lawyer Sol.
(717) 582-4006
REGISTER OF WILLS USE ONLY
First line of address
4833 Spring Road
')
Second line of address
r)
.;
City or Post Office
State
ZIP Code
. "
DATE FILED
Shermans Dale
PA
17090
-.,~
~"- '?
Correspondent's e-mail address:mark@christianlawyersolutions@comcast.net
- ,,__J
.--j
t<,,~
Under penalties of pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowle~.!:>and beBef,
it is true, correct and complete. Declaration of preparer other than the personal representative IS based on all information of which preparer has an
SIGNATUR~Ffl~IL/(~ IO//sE/()7
ADDRESS I' '/.
1 Hellam Drive, Mechanicsburg, PA 17055
SIGNATURE oo:rA00~HER~AN REPRE~
ADD~(
4833~~pr~g Road, Shermans Dale, A 17090
PLEASE USE ORIGINAL FORM ONLY
10/15/07
Side 1
L
15056051058
15056051058
---l
--.J
15056052059
REV-1500 EX
Decedent's Name:
Paul
S Roeder
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 Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14.
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2)X.0~ 104,584.15
16. Amount of Line 14 taxable
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.
17.
18.
19. TAX DUE. . . . . . - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
L
15056052059
Side 2
201-26-5035
Decedent's Social Security Number
0.00
0.00
0.00
0.00
23,009.31
0.00
96,753.77
119,763.08
14,719.93
459.00
15,178.93
104,584.15
0.00
104,584.15
0.00
0.00
15056052059
...J
REV-1500 EX Page 3
File Number
Decedent's Complete Address:
DECEDENT'S NAME
Paul S Roeder
STREET ADDRESS
1 Hellam Drive
DECEDENT'S SOCIAL SECURITY NUMBER
201-26-5035
CITY
Mechanicsburg
, STATE
PA
ZIP
17055
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits ( A + B + C ) (2)
0.00
Total Interest/Penalty ( 0 + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in avalon Page 2, Line 20 to request a refund. (4)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5A)
(5B)
0.00
0.00
0.00
0.00
0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
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 [K]
b. retain the right to designate who shall use the property transferred or its income; ............................................ D [K]
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 [K]
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D [K]
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ [K] 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 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 PS. 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 PS. 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-15G8 EX+ (6-98) '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Paul S. Roeder
FILE NUMBER
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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Cash 42.00
2. 2004 Honda Odyssey 19,545.00
3. Irish Setter dog (Devereux's Red Blaze of Glory) 800.00
4. Omega wrist watch 500.00
5. Nittany Lion Football 100.00
6. Gold wedding band 150.00
7. Oil painting 50.00
8. Train set 150.00
9. Clothing 400.00
10. Desk and chair 250.00
11. Coins - 14 silver dollars @ $20 each 280.00
12. Coin set - Bicentennial silver proof set 25.00
13. PNC Bank checking account number 5080386996 717.31
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
23,009.31
REV-1510 EX+ (6-98)
*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
Paul S. Roeder
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.
DESCRIPTION OF PROPERTY
ITEM INCLUOE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACH A COpy OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. Financial Network Investment Corporation Individual Retirement Account 96,753.77 100
Account No. 5FN-607611 96,753.77
TOTAL (Also enter on line 7 Recapitulation) $ 96,753.77
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99)*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Paul S. Roeder
FILE NUMBER
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
2.
3.
FUNERAL EXPENSES:
Parthemore Funeral Home & Cremation Services, Inc. total less $189.46 immediate pay discount
a. Funeral Services -- $5,390.00 b. Casket & Vault -- $4,083.00
c. Death Notices and Death Certificates-- $556.39 d. Clergy & Flowers-- $385.50
First United Methodist Church - funeral food donation
Rolling Green Cemetery Company - interment and recording fees
Gingrich Memorials - head stone
10,225.43
1.
4.
1,000.00
1,195.00
1,575.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s}/EIN Number of Personal Representative(s}
Street Address
City
State
Zip
Year(s) Commission Paid:
2.
Attorney Fees
724.50
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State
Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets 01 the same size)
14,719.93
REV-1512 EX+ (12-03)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Paul S. Roeder
FILE NUMBER
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
Visiting Angels Living Assistance Services
459.00
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
459.00
~~~ faa&,J, K~
&001 I~B~ 11/~5tf5
~~.~~ t~ (,/30/0.5) 800
j)11 e --<1 '-1-:-_ -c:f)..
N:~l~ ~~~
.~~~ 150
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~ 400
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AMERICAN KENNEL CLUB
NAME
DEVEREUX'S RED BLAZE OF GLORY
BREED
IRISH SETTER
COLOR
MAHOGANY
SIRE
CH HEA THERWOOD'S SWEET CRIMSON
SN37576805 10-97 OFA31G
DAM
KA THMAR'S DIAMOND LADY
SN7589870411-050FA38G
BREEDER
JAMES D COOK & KIM ALAN EIFFES
OWNER
PAUL ROEDER
1 HELLAM DR
MECHANICSBURG, PA 17055-6159
NUMBER
SR27696603
SEX
MALE
DATE OF BIRTH
JUNE 30, 2005
AMERICAN
KENNEL CLUB OM
CERTIFICATE ISSUED
SEPTEMBER 2, 2005
This certificate invalidates al/ previous certificates issued.
If a date appears after the name and number of the
sire and dam, it indicates the issue ofthe Stud Book
Register in which the sire or dam is published.
For Transfer Instructions, see back of Certificate.
This Certificate issued with the right to correct or
revoke by the American Kennel Club.
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STREET
CITY
FINANCIAL INSTITUTION NUMBER
NUMBER
Kelley Blue Book - Private Party Pricing Report - Honda, Odyssey
co
~"_.
IeleyBlueIaek
THETltUmo RESOURCE
"~_"~__h~_""_
advertisement
Page 1 of2
;;=.; Send to Printer
+ $1.ooO.....Cash AIlowuce
OR$2.OM~ CnftAllowalKe
+$1,ooo",u Cash AUown<e OD ChryslefPacIfka
2004 Honda Odyssey EX Minivan 4D
BLUE BOOK PRIVATE PARTY VALUE
Condition
Value
..I Excellent
$20,660
(Selected)
~
$1~
Fair
$18,025
Average Consumer Rating (8 Reviews)
Read Reviews
f~f~f~f~{ 4.SoutofS
Review This Vehicle
Vehicle Highlights
Mileage:
Engine:
Transmission:
Drivetrain:
19,833
V6 3.5 Liter VTEC
Automatic
FWD
Selected Equipment
Standard
Power Sliding Doors
Air Conditioning
Rear Air
Power Steering
Power Windows
Power Door Locks
Tilt Wheel
Cruise Control
AM/FM Stereo
Single Compact Disc
Dual Front Air Bags
Front Side Air Bags
ABS (4-Wheel)
Power Seat
Quad Seating
Roof Rack
Privacy Glass
Alloy Wheels
Optional
Cassette
Leather
Blue Book Private Party Value
Private Party Value is what a buyer can expect to pay when buying a used car from a
private party. The Private Party Value assumes the vehicle is sold "As Is" and carries
no warranty (other than the continuing factory warranty). The final sale price may
vary depending on the vehicle's actual condition and local market conditions. This
value may also be used to derive Fair Market Value for insurance and vehicle
donation purposes.
. "
MD OTHER GREAT omRS
ON OUR AW.............
VEHICUS
advertisement
.elley Blue Book - Private Party Pricing Report - Honda, Odyssey
Vehicle Condition Ratings
.,I Excellent (Selected)
U'w:'Jt10 $ 20,660
"Excellent" condition means that the vehicle looks new, is in excellent
mechanical condition and needs no reconditioning. This vehicle has never had
any paint or body work and is free of rust. The vehicle has a clean title history
and will pass a smog and safety inspection. The engine compartment is clean,
with no fluid leaks and is free of any wear or visible defects. The vehicle also
has complete and verifiable service records. Less than 5% of all used vehicles
fall into this category.
Close Window
Good
$19,545
"Good" condition means that the vehicle is free of any major defects. This
vehicle has a clean title history, the paint, body and interior have only minor (if
any) blemishes, and there are no major mechanical problems. There should be
little or no rust on this vehicle. The tires match and have substantial tread wear
left. A "good" vehicle will need some reconditioning to be sold at retail. Most
consumer owned vehicles fall into this category.
Fair
$18,025
"Fair" condition means that the vehicle has some mechanical or cosmetic
defects and needs servicing but is still in reasonable running condition. This
vehicle has a clean title history, the paint, body and/or Interior need work
performed by a professional. The tires may need to be replaced. There may be
some repairable rust damage.
Poor
N/A
"Poor" condition means that the vehicle has severe mechanical and/or cosmetic
defects and is in poor running condition. The vehicle may have problems that
cannot be readily fixed such as a damaged frame or a rusted-through body. A
vehicle with a branded title (salvage, flood, etc.) or unsubstantiated mileage is
considered "poor." A vehicle In poor condition may require an Independent
appraisal to determine its value. Kelley Blue Book does not attempt to report a
value on a "poor" vehicle because the value of cars in this category varies
greatly.
W'm,:
t.......t
* Pennsylvania 7/24/2007
1-4-L~./'-_~__ t 1 1
Page 2 of2
Aug. 9. 2007 3: 05PM
PNC BANK 412-705-2747
No. 0770 P. 1
o PNCBAN<
The Thinking Behind The Monty
August 9, 2007
Mark W Allshouse, Esq
4833 Spring Rd
Shermans Dale, PA 17090
RE: Paul S Roeder (Deceased)
SSN: 201-26-5035
DOD: 07-12-2007
Deal' Mr. Allshouse:
In response to your request for Date of Death balances for the customer noted above, OlD"
records show the following:
Cheddng Account
Account # 5080386996
Established 01-19-1995
PAULSROEDER
DOD balance: $717.31 non interest bearing
P1~ note that this office only provides date of death balances for deposit accounts
(IRAs, CDs, Checking and Savings accounts). We do not pr0CC88 any financial
t:ransaetioDS or provide statements. If you need assistance with any of these items,
please call1-g8g-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch
office.
Sincerely, ~
co~ .
1-800-762-1775
P7-PFSC-04-F
SOO First Ave
Pittsburgh. PA 15219
Member FDIC
Page I ofl
Senior Checking Plan 1-\.ccount Statement
l'NC B:lIlk
For the period 01/12/2007 to 04/11/2007
Primary account number: 50-8038-6996
Page 1 of 1
Number of enclosures: 0
z
PAUL 5 ROEDER
I HELLAM DR
MECHANICS BURG PA 17055-6159
g For 24-hollr bClnking, and transaction or
&:::!. interest rate information, sign on to
1)' PNC 8ank Online 8i\l1king ilt. pnc.coln.
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LAST WILL and TESTAMENT
I, PAUL S. ROEDER, JR., of the Township of Upper Allen, Cumberland County,
Pennsylvania, hereby declare this to be my Last Will and Testament, and revoke all
Wills which I have previously made.
FIRST:
J direct my hereinafter named executrix to pay all my just debts and
funeral expenses as soon after my decease as may reasonably be done.
SECOND:
I give, devise and bequeath all of my property, real, personal and
mixed, of whatsoever nature or kind and wheresoever the same may be situate at the
time of my decease unto my beloved wife, BERNADETTE A. ROEDER, if she survives
me by thirty days; otherwise I give such property to my son, DOUGLAS R. ROEDER,
if he is alive at the time of the death of the survivor of BERNADETTE A. ROEDER and
myself. ill-E'q'lill shares
r.s.~.
THIRD: In the event that my wife does not survive me by thirty days and
we have no children surviving us, I give, devise and bequeath all of my property, real
and personal and mixed, of whatsoever nature or kind and wheresoever the same may
be situate at the time of my decease unto my surviving nieces and nephew, SARAH
JANE VIKNER, SUSAN RUTH SCHWARZ and ROBERT W. BOWDEN.
FOURTH:
If any of my heirs named in this document do not want my dogs
surviving me, I devise and bequeath them to the Humane Society of Harrisburg Area,
Inc. I specifically bequeath and devise $1,000.00 to the Society and request the
Society to find my dogs a good home. If the Society is unable to find a suitable home,
I request it to humanely dispose of the dogs.
?au~ ff ~~.f/V; r./.
(SEAl)
FIFTH: I nominate, constitute and appoint my beloved wife, BERNADETTE
A. ROEDER, executrix of this, my Last Will and Testament. In the event my wife is
for any reason unable to serve as executrix, I nominate, constitute and appoint my
son, DOUGLAS R. ROEDER, executor in her place and stead. In the event my son is
for any reason unable to serve as my executor, I nominate, constitute, and appoint my
nephew, ROBERT W. BOWDEN, in his place and stead. No executor or trustee named
herein shall be required to enter bond or furnish sureties in any jurisdiction.
IN WITNESS WHEREOF, I, PAUL S. ROEDER, JR., have set my hand and seal
to this and one preceding sheet of paper as and for my Last Will and Testament this
~~ day of April, 1997.
RJP ~.~ ~fr-
(SEAL)
The foregoing typewritten instrument was signed and sealed by PAUL S.
ROEDER, JR. in our presence on the day it bears date, and he stated, published and
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REV 1112006
. ?flINT IN
vlANENT
CK INK
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
STATE FILE NUMBER
1. Name of Deceden1 (Firsl. middle. last, suffix)
Paul S. Roeder
5. Age (lasl 8irthday)
73
6. Dale or Birth (Month. day, year)
July 31, 1933
y",
y. 8b, COunty 01 Death
.
ad. FaclTrty Name (If not insmution. give slreet and number)
Cumberland
Upper Allen Twp.
most of work' life. Do not state retired
Kind of Business I Industry
Law
. 15. Decedent's Mamng Address (Street. city 1l0000, slate, zip code)
1 Hellam Drive
Mechanicsburg PA 17055
1 Hellam Drive
12. Was Decedent ever In (he
U.S. Armed Forces?
DYes filo
Decedent's
ActualAesidenca 17a. Stale
13, Decedenl's Educalion (Spec;fy oo~ highest 9'ede oompIele<l)
Elementary I Secondary (0-12) College (1-4 Or 5+)
12 5+
Pennsylvania
17b. County
Cumberland
18, Falher's Name (First middle, last. suffix)
Paul S. Roeder
20a. Jnformanl's Name [Type I Print)
3. Social Securtty Number
201 - 26 - 5035
4. Dale of Death (Month. day. year)
July 12, 2007
14. Marital Status: Married, Never Marrie<l,
Widowed, Olvo<eed (Specify!
Married
Bernadette A. Mahek
Upper Allen
Twp
Did Decedent
00 ir. a
Township?
17c. 0Cl Yes, Decedent lived in
17d. D No. Oec<denl LMld wffhin
ActuafLimitsof
City/Bora
f9. Mother's Name (First, middle, maldensumame)
Miriam H. Small
200. Informant's Mailing Address (Street city! toWn, slate. zip code)
1 Hellam Drive Mechanicsbur
21b. Oate of Disposition (Month, day, year) 21c. Place ot Disposition (Name of cemetery, crgmatory or olher place)
PA 17055
21d. localion ICily /lawn, sl"e. z~ code( 1 7011
Lower Allen Twp., PA
Rolling Green Memorial Park
22c. Name and Address of Faci~1y
FH&CS Inc., PO Box 431, New Cumberland, PA 17070-0431
23b. Ucensa Number 23c. Date Signed (Month, day, year)
PM.
24.1ime of ~
0:\0
CAUSE OF DEATH (See instructions and examples)
Item 27. Part J: Enter tl'le ~ - diseases, injuries, or complications - that direclly calJSe<l the deatl'\. 00 NOT emer terminal eventS sucl1 as cardiac arrest.
respiratory arres1, or ventricular fibrilla Non withOut showing tI'Ie etiolOgy. Ust only one cause on eacn line.
26. Was Case Referred 10 Medical Examiner I Coroner fOT a Reason Other than Cremation or Donation?
Dyes 1!(INO
~d1;~~~S~~t~~dise~ a. f1P..:tCL~-1' f1 ~ (:~J ~-i O-'~
Due 10 (or a5 a consequence of):
<-J 'j YS
Approximate interval: Parl II: Enter other sionifrearn condltions cootributir.CI to neath, 2a. Did Tobacco Use Contribute to Death?
Onsello Death bul not resulting in the under1ying cause given in Par11 0 Yes 0 Probably
.t;3->>o 0 Unknow'
Sequentially list concfi1ions, if any,
~~t~~O ~o~~v:~~~~ a.
(cfisaase or injury that initialed lhe
events reSU~irIg In death) LAST.
b.
Due 10 (or as a consequence of)'
Due to (o~ as a COl'\~uel'lCe of):
d.
3Oa. Was an AlIlopsy
Performed?
3Qb, Were AlIlOf)Sy Findings
Available Prior 10 Complel!on
01 Cause 01 Death?
DYes ~o
31. Manner 01 Dealh
~-atural 0 HomIcide
o Accident 0 Pending Investigation
o Suicide 0 Could Not be Determined
M
32d. Time of Injury
DYes~
33a. Certilier (check only one)
~7~:;$r:r::~~~:,n~:~== ~~~~I~::;u:~7;~h=:: ~~_~~th ~a~~~ ~~ ~~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
~~:u=~a: =~~:an~=~~ :~i~":.;n~::c~~:rtZei~~ca:~~~~~ man~r as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _.. _ _ 0
~~~::~;:~n;;,":~;~r:t:~ and I or i~stigatior., In my opir.\on, death OCCurred at lhe time, date, and p.Iace, and due to the cause(s) and manner 8S stated_ 0
I J.,I I ~ 1,1 I
35. Aegislrar'sSignal
~
f"""~
C4:/V\{<L....
,
29. It Female'
o Nol pregnanl within pest year
o Pregnanl at ~rne of death
o Not pregr.anl. bl1l pregnant wrthin 42 days
of death
o Not pregnanl, but pregnant 43 days to 1 year
before death
o Unknown if pregnant within the past year
32c. Place of lniufy. Home. Farm. SrQel. FatlwY.
Olflce Buil~ng, e~. ISpecjfy)
32g. Location olll'llury (Street, city I tOWll, slate)