HomeMy WebLinkAbout01-0171
1 ' IS to cenif\' that the information here given IS correctly copied frum an original cntitlcatL' of death duly tIled \vith me as
['11.,,[ Registrar. The original cerrificate will be forwarded to the SUte Vital Records Onlce for p':rmanClH tlling.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
h,T for this c'Trifle,He. S2.00
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COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
BiRTHPLACE: (City and PlACE OF OE1JH (Chec" <lfVy one - ~ In9!ruCIIUft9 on oth~ SIde)
StaIB Of ForelQf\ Counlry) HOSPITAL
7rOtlt CAI't.&IJ PIJ ~~a".nl D
FACIUrv NAME (It nollnS1!fullon. gl.....e sfJeet and mJml)Qr,
MI. II CUU-, Ctl'.
TYPEiPRINT
IN
PERMANENT
BLACK INK
SEX
2. FPJ6j{
5~S-
COUNTY OF DEATH
UNDER 1 YEAR
Monlha Oaya
. ..,CUty18PlVlIV[)
ac.l)}T pf}JNJ&i\o
DECEDENT'S USUAL OCCUP.oUION
(Give lund otwork done dunflq mO$l
of WOfktng Itl.; do noI use rohred)
"0.11 OM mA k:~{\. "b.
DECEDENT'S MAILING ADDRESS (SIt.... p",lbwn StO'..LIp COde.
. lor- IfJ.JT ft~N >T
KINO OF BUSINESS/INDUSTRY
DECEDENT'S
ACTUAL
RESIDENCE
(See IIlSUUCIKmS
on arhar SIde)
C. (),/I'll) /In I--/'^ I)
17b. County
STATE FILE NUMBER
SOCIAL SECURITY NUMBER
3./'J.. -;1 0
MARITAL STATUS. M.,riod
Nava, Malfied. Widow~,
D_ced (SPElCotvl
1.. W, tJcX.u/t C
SURVIVING SPOUSE
ill -,""lie. 9'lfe m~1den namel
Did
decedenl
!twine
township?
rwp
17d.iM:;:::;'~O' I'1~CflA.A..Jlc1{1 IJI...
~,OTHERl1;n7K;'d~ MOIr<Li~tI
INFORMANT'S MAILING ADDRESS (Str...t OIyI1O",n. Stale. Z;p Code)
20..3 2. IJA-r, ~ I( . if /VOlA , 70 L j...J
PLACE OF DISPOSITION. Name 01 Cam.,ary, C,.ma,oty LOCATION. CilylTown. Sial.. Zip Code
Of Other Place
t V/lIlL I
M 25.
27. MAT I: EnI.' the diseasas. inJUries or comphcalions which caUS<<llhe dealh Do notenler the mode 01 dying, such as cardiac or respiratory arr851, shock or Man failur.
llsl only one caUM on each hoe
.)
(:5
J(.", c( th).,,- cAr r '" ~I
DUE TO (OA AS A CONSE~UENCE Of)
( O/, :> """"-::'2 ~f ff!'.J
DUE TO (OA AS A CONSE~UENCE Of)' r
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DUE TO (OR AS A CONSE~UENCE Of):
c1
WERE AUTOPSY FINDINGS
AVAILABLE PR/OA TO
COMPLETION OF CAUSE
OF DE.tJ'H?
MANNER OF DEATH
DATE OF INJURY
(Monrh. Day. Year)
Gr'
D
o
Could 001 be determmed
at.
I Approximate
: interval betw..n
I Onsel and death
I
I ~ v/
PART II:
Otner slgniftcanl condiliona ~nltlbutlllQ to de.rh, buC
nCJ( ,..uhing en the undettyulQ caUN grv4ln tn PART I
( .a~O
TIME OF INJURY
INJURY If:r WORK?
DESCRIBE HOW INJURY ()C{;URRED.
Accident
Pending In....estiIJalion
o
[J
o ;~ce OF INJURY - AI nome. tar~.O:;"I, lactory, orne.
bUIlding, .'e. ($ptlClly)
30e.
Natur~
Homidde
r-_
c
Yes [J
NoD
Sweuje
21a. 2.."
CERTIFIER (Check OOIy one)
.CEATtFYING PHYSiCIAN (PhY~ld.n cellJf'ylflg cause Of dt:!altl whtm anOII18f pt1'~'SlClan has pfonOlJnced dedIt! ana comple-Ied Hem 23)
To lhoe beat 0' m, knowledge, d..th occ::uned due to me CauN(I) and manne'.8 ,'ated. .
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.PAONOUNCING AND CERTIFYING PHYSICIAN {Ph.,.s.cldn bolt! PIQflOUflClng dedlh dnd certJIYlng 10 causa of death}
To the beet o. mY' knowledve, d..th CKcurred at the lime, date, And place, and due to the caul'(s) and manner 1.ltaled.
....EDICAl EXAMINER/CORONER
On the b.... 0' examinatton andlor investigation, in my opinion, death occurred It the time, date, and place. and due to the cau'.(I} and
manner a. Itated
110
621 (611 (1..:>1
Yes D NoD
IA. 300:.
'(;;>'.-~, "-'l.-;
D 31b.
LICENSE NUMBER DATE SIGNED (Moo"', Day, fear.
31c. r-v? ,,..l1j'Jl )-C Jld. J ev"~~~L~ 1;-;
NAME AND ADDRESS OFjPERSON WHO COMPLETED CAUSE OF DEATH
(Item 27) Type 0< Pnnl j1-<> r.-. c~ ~_ '(?, r) '-'/7
f''r ",,40/1,.., C"--~....A.. ~ I
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
/ t: d(J j'~W
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG. PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEKENTL ALLOWANCE OR DISALLOWANCE
OF DEDUCTION~, AND ASSESS KENT OF TAX ON
JOINTLY HELD OR TRUST ASSETS
Recc:
Fif'~
REY-1548 EX AFP 112-00l
.02
JAN 11
DATEl
EST""TE OF
DATE OF DEATH
FILE NUMBER
=~
ACN
01-07-2002
ANDREWS
09-16-2000
21 01-0171
CUMBERLAND
162-20-7747
01104071
EMMA
J
CHARLES S ANDREWS
32 NATHAN DR
ENOLA PA 17025
C;clh
CUlTlb,:,
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
RE-v:is~i-Ex--AFP--(i2-:oo1------------------------------------------------------------------------------------
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF
DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS
DATE 01-07-2002
ESTATE OF ANDREWS
EMMA
J DATE OF DEATH 09-16-2000
COUNTY
CUMBERLAND
FILE NO. 21 01-0171
TAX RETURN WAS:
S.S/D.C. NO. 162-20-7747
(X) ACCEPTED AS FILED () CHANGED
JOINT OR TRUST ASSET INFORMATION
ACN
01104071
FINANCIAL INSTITUTION: PNC BANK
ACCOUNT NO.
5140459625
TYPE OF ACCOUNT: () SAVINGS (Xl CHECKING ( ) TRUST ( ) TIME CERTIFICATE
DATE ESTABLISHED 05-18-1985
x
8,404.93
0.500
4,202.47
.00
4,202.47
.45
189.11
NOTE: TO INSURE PROPER CREDIT TO
YOUR ACCOUNT, SUBMIT THE
UPPER PORTION OF THIS NOTICE
WITH YOUR TAX PAYMENT TO THE
REGISTER OF WILLS AT THE
ABOVE ADDRESS. MAKE CHECK
OR MONEY ORDER PAYABLE TO:
"REGISTER OF WILLS, AGENT."
Account Balance
Percent Taxable
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate
Tax Due
X
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
02-12-2001 AA478009 .00 189.11
TOTAL TAX CREDIT 189.11
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
. IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .
( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CR), YOU HAY BE DUE A REFUND.
SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. )
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
'*
/ Ir -- ~ () q -I L
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 - 0 / - / 11
01104071
02-06-2001
REY-1543 EX AFP (09-00)
EST. OF EMMA J ANDREWS
S.S. NO. 162-20-7747
DATE OF DEATH 09-16-2000
COUNTY CUMBERLAND
TYPE OF ACCOUNT
o SAVINGS
[XJ CHECKING
o TRUST
o CERTIF.
CHARLES S ANDREWS
32 NATHAN DR
ENOLA PA 17025
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
PNC BANK has provided the Department with the information listed below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of
this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a COpy
to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth
uf Pennsylvani~. Questions ~ay be answai-ed by calling (717) 787-8327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 5140459625 Date 05-18-1985
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
x
8,404.93
50.000
4,202.47
.045
189.11
TAXPAYER RESPONSE
To insure proper credit to your account, two
(2) copies of this notice must accompany your
payment to the Register of Wills. Make check
payable to: "Register of Wills, Agent".
x
NOTE: If tax payments are made within three
(3) months of the decedent's date of death,
you may deduct a 5Z discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
Tax
PART
[!] !j!jli!!~~IM!:ill~~lijl~I~_li~!~~~~~!~I~'
.':~$::mMm~CE::m;
...................................................
[CHECK ]
ONE
BLOCK
ONLY
A. ~ The above information and tax due is correct.
~ 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or you may check box "A" and return this notice to the Register of
Wills and an official assessment will be issued by the PA Department of Revenue.
B. [] The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
to be filed by the decedent's representative.
c. c=J The above information is incorrect and/or debts and deductions were paid by you.
You .ust complete PART ~ and/or PART ~ below.
x
If you indicate a different tax rate, please state your
relationship to decedent:
PART
~
TAX RETURN - COMPUTATION
LINE 1. Date Established
2. Account Balance
3. Percent Taxable
4. Amount Subject to Tax
5. Debts and Deductions
6. Amount Taxable
7. Tax Rate
8. Tax Due
TAX ON JOINT/TRUST ACCOUNTS
OF
1
2
3
4
5
6
7
8
x
PART
@]
DATE PAID
DEBTS AND DEDUCTIONS CLAIMED
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line 5 of Tax Computation)
I
$
perjury, I declare that the facts I
and belief.
have reported above are true, correct and
( 71 7 ) 7? 1 - 7 7!>- /
WORK (7 I 7 ) 7? I - 6 Ie 7
TELEPHONE NUMBER
HOME
TAX
.2 -1' -() /
DATE
/ i - ~.,.' '-
COSHONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 - 0' - /7 I
01104071
02-06-2001
REV-1545 EX AFP (09-00)
I
EST. OF EMMA J ANDREWS
S.S. NO. 162-20-7747
DATE OF DEATH 09-16-2000
COUNTY CUMBERLAND
TVPE OF ACCOUNT
D SAVINGS
[X] CHECKING
D TRUST
D CERTIF.
CHARLES S ANDREWS
32 NATHAN DR
ENOLA PA 17025
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
PNC BANK has provided the Department with the information listed below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of
this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a COpy
to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth
of Pennsylvania. Questions may be answered by cal.a:ing (7ln 181-6327.
COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 5140459625 Date 05-18-1985
Established
Account Balance
Percent Taxable
Amount Subject to
Tax Rate
Potential Tax Due
)(
Tax
)(
To insure proper credit to your account, two
(2) copies of this notice must accompany your
payment to the Register of Wills. Make check
payable to: ~Register of Wills, Agent~.
NOTE: If tax payments are made within three
(3) months of the decedent's date of death,
you may deduct a 5Z discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
PART
[!] \lil!i~~l~~.li!l!,m!~'
"1I\~1~.::i1mXsjii:ji01TIICEi!!1i1
.......................-...............-.............'.......................................
.....................................-.....-.-.......-...-..".........-.---.....-.-.-.-.-.
.-.--.-.-.-...-.-..-.-..,........-................"..,....-...........................-.
.. - .
A. ~The above information and tax due is correct.
1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or you may check box ~A" and return this notice to the Register of
Wills and an official assessment will be issued by the PA Department of Revenue.
B. [] The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
to be filed by the decedent.s representative. .
C. c=J The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
If you indicate a different tax rate, please state your
relationship to decedent:
[CHECK ]
ONE
BLOCK
ONLY
PART
~
TAX
LINE
RETURN - COMPUTATION
1. Date Established
2. Account Balance
3. Percent Taxable
4. Amount Subject to Tax
5. Debts and Deductions
6. Amount Taxable
7. Tax Rate
8. Tax Due
OF TAX ON JOINT~TRUST ACCOUNTS
1
2
3 )(
4
.5
6
7 X
8
DEBTS AND DEDUCTIONS CLAIMED
PART
@]
DATE PAID
PAYEE
DESCRIPTION
AMOUNT PAID
I
TOTAL (Enter on Line .5 of Tax Computation)
I
$
facts I have reported above are true, correct and
HOME (7 I 7) 772 -- 77!:J 1
WORK (7/7) 731 -' &; 7c.J7 c1-9-0j
TELEPHONE NUMBER DATE