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Home My WebLink About03-25-08 \J"' , . Pa. O.C. Rule 6.12 STATUS REPORT REGISTER OF WILLS OF !/umhN /al?CJL COUNTY, PEN~SYLVANIA Name of Dececlent: . J1);/ j/& rYJ If ;fo.s::; Ie r Date of Death: 1-;.< () - () ~ File Number: ;;j tJo ~- {)tJ I;;; d- pursuant to Pa. O.c. Rule 6.12, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration ofthe estate is complete: . . . . . . . . . . . . . . . . . . .. ~es 0 No 2. If the answeris No, state when the personal representative reasonably believes that the administration will be complete: 3. lfthe answer to No.1 is YES, state the following: a. Did the personal representative file a final account with the Court? . . . . . .. m es 0,.... ,TO !. ..i. ~,; b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account infol111ally to the parties in interest? . . . . . . . . . . . ., . . . . . . . . . . . . . . . ., ~es DNo d. Copies of receipts, releases, joinders and approvals of fonnal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Dille 3-.J~--C<; a --A In J'L 3a/7 nt nha u rYL Si", ature of Person Filing this Form Capacity: ~rsonal Representative D C0U11sel J{a fh III ,,-;;/7 n N7ht?i it rYJ Name of Person Filing this Form /,;,1/0 -.5~lF?7m('rl{)n j)r. Addnss fY)ctha/7/tdh u ,t( PA 17oS-{) J 7/1- 514- 6 q Z-b Telephone .... ..) Form RW-IO rev. 10.13.06 ESTATE OF WILLIAM R KOSSLER DISTRIBUTION STATEMENT Total Value: -less charitable contributions: 81. Therese Church Our Lady of Grace Church $100,026.23 - 1,000.00 - 1.000.00 Total taxable value: Tax @ 4.5% less .5% 98,026.23 4.179.02 Total: 93,847.21 Final Filing Fees: - 215.00 93,632.21 Disbursements: Laura Tannenbaum Alex Tannenbaum 1,000.00 1.000.00 Total 91,632.21 Remaining equal disbursements to: Thomas R Kossler Kathleen Tannenbaum 45,816.11 45,816.1 0 PROBATE FORM IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENN S YLVANlA ORPHANS' COURT DIVISION, REGISTER OF WILLS Estate No. 001220f2008 Estate of William R Kossler, Deceased RECEIPT. RELEASE AND INDEMNIFICATION AGREEMENT Background Information The circumstances leading up to the execution of the Agreement are as follows: 1. William R Kossler (Decedent) died on January 20, 2008, a resident of Cumberland County Pennsylvania. 2. Paragraph three of Decedent's Will, dated 29 August, 2003, provides that the residue of Decedent's Estate be paid to Thomas R Kossler and Kathleen Tannenbaum (which this agreement complies with). 3. I, Thomas R Kossler, the undersigned, desire that the Estate assets to which I am now entitled be distributed to me without the formality of a court audit in order to save the expenses, publicity, and delay of such audit. I also understand that Kathleen Tannenbaum, Personal Representative, is willing to make such an informal distribution upon execution of this Agreement. Agreement I, the undersigned, am a party in interest in the above Estate that is now distributable for the reasons set forth above. For the purpose of inducing the personal Representative to make distribution without seeking a court audit to release and discharge her from liability for her administration of the Estate, and in consideration of its distribution without any such audit, I hereby: 1. acknowledge that I have read this Agreement, and represent and warrant that the facts set forth above are true and correct to the best of my knowledge, information, and belief. I further acknowledge that I am familiar with the provisions of the Will of William R Kossler, Deceased; that I have examined the First and Final Account of Kathleen Tannenbaum, Personal Representative, specifically approve such Account and acknowledge receipt of the balances shown in the Account as distributed to me as being my entire interest in the above Estate that is now distributable as shown therein; 2. waive the filing with any court of any Account concerning the assets shown in the First and Final account; 3. release and discharge the Personal Representative of the above Estate, in her individual capacity and as Personal Representative, from any and all liability , including specifically but not limited to liability arising in connection with any mistake of fact or law or negligent or careless act or omission by such Personal Representative in connection with the administration and distribution, including the present distribution, of the assets shown in the First and Final Account; 4. to the extent of the value of the Estate that has been or is being distributed to me, agree to indemnify and save harmless the Personal Representative of the above Estate, in her individual capacity and as Personal Representative, against any and all liability. Loss, or expense (including, but not limited to cost and counsel fees) that may ever be incurred by the Personal Representative, including specifically but not limited to liability, loss, or expense resulting from any mistake of fact or law or negligent or careless act or omission by the Personal Representative as a result of the settlement upon this Receipt and Release; 5. agree to refund to the Personal Representative such part or all of the Estate or the value thereof that has been or is being distributed to me, if it is hereafter determining by a court of competent jurisdiction, after notice to me, that I am not legally entitled thereto; 6. acknowledge by these presents that, if said distribution to me is or is hereafter found to be erroneous or improper in whole or in part under the governing instrument and applicable law for any reason, including but not limited to any mistake of fact or law or negligent or careless act or omission by the Personal Representative, I will refund such amount improperly distributed to me on demand, and if so, then this obligation shall be void; otherwise, it shall be in full force and virtue; 7. specifically waive hereby any Statute of Limitation that might be applicable against a claim by the Personal Representative and her attorney or assigns, for refund or indemnification under this instrument; 8. declare that this Agreement shall be governed by the law of the Commonwealth of Pennsylvania and shall be legally binding as an agreement under seal upon me and my heirs, personal representatives, and assigns. RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17G13 Rece~pt Date: Rece+pt Time: ReceJ.pt No. : 3/05/2008 09:08:04 1051808 KOSSLER ~'lILLIAM R Estate File No. : Paid By Remarks: 2008-00122 ESTATE OF WILLIAM R KaSSLER AJW ________________________ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name INH TAX RETURN. ADD PROBATE FEE Check# 106 Total Received......... 15.00 200.00 ---------------- $215.00 $215.00 CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT, 280601 HARRISBURG. PA 17128-0601 HtV-l 'I bL tXIII-~bl RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT TANNENBAUM KATHLEEN KOSSLER 6110 SOMMERTON DRIVE MECHANICSBURG, PA 17050 ___n___ fold ESTATE INFORMATION: SSN: 190-09-5824 FILE NUMBER: 2108-0122 DECEDENT NAME: KOSSLER WILLIAM R DATE OF PAYMENT: 03/05/2008 POSTMARK DATE: 03/05/2008 COUNTY: CUMBERLAND DATE OF DEATH: 01/20/2008 NO. CD 009372 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $4,179.02 I I I I I I I I TOTAL AMOUNT PAID: $4,179.02 REMARKS: CHECK#107 SEAL INITIALS: AJW RECEIVED BY: TAXPAYER GLENDA FARNER STRASBAUGH REGISTER OF WILLS PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Troy Whitesel, Classified Advertising Manager, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th, 1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): February 9, 16, 23, 2008 COPY OF NOTICE OF PUBLICATION EXECUTRIX..~ Letters Testamentary on the Estate of WilLIAM R. KOSSlER, late of the Township of Hampden, Cumberland County, Pennsylvania, deceased, have been granted to thEl und~rslgned. All persons knowing themselves to be indebted to said Estate will make payments Immediately al1dthose having. claims will present them for settl~ment. Kathleen..Tannenbaum Executrix 61.10 Sommerton DrivEl Mechanlcsburg;PA 17050,. Affiant further deposes that he/ she is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are true. ~~-- Sworn to and subscribed before me this 25th day of February, 2008. C~L4j;J.~fltV ~~ Notilly Publl7 My commission expires: OJ/I/oi' COMMONWEALTH OF PENNSYLVANIA Notarial Seal Christina L. Wdfe, Notary Public Carlisle Boro, Cumber1and County My Commission Expires Sepl1, 2008 Member. Pennsylvania Association Of Notaries Please Note: Your Sale Proceeds Check is Attached > ,'}' \ O\J ~\)\~ ~. ..~~ \~ l'" f ,^I" iiiiiiiiiiiiiii - _. iiiiiiiiiiiiiii - ~ iiiiiiiiiiiiiii iiiiiiiiiiiiiii iiiiiiiiiiiiiii BNY MELLON SHAREOWNER SERVICES - - === - - - - ~ - ~ - ~ iiiiiiiiiiiiiii ~ ((~~:~Y6i~~i~~6eil~fi~t::~witft\:~@~!:g'S~:f:\\t~??it::?itt:?::::tttttt::::::~t:::::::::t:t)::':::::?::::::=: ...... ::::::::::::::::::::::::::::::::::..... Login to Investor ServiceDirect@ at www.bnymellon.com/shareowner/isd ",' .............. .............. ........................... . . . . . . . . . . . . . . . .. .. .. . N t:: N 8 o t:: N o o ~ .. ... .. .. .. .. .. .. .. .. .. ... ... .. .. .. ... .. .. .. .. .. .. .. ... .. ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ... .. .. .. .. .. .. .. ... .. .. .. .. .. .. .. .. .. .. .. ... .. .. .. D~.lUN .. ~::::::::::~t::~:::::::::::::::::~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::Mt..itibi::Qifmij:::r::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::r::r:::::::::::::::::::::::::::.:::::::::: .... ................................ ...... ........... .. .. ...,................................'........ .. : .:.:.;.:.;.:.;.:.:-:.:. :.:.:.;.:.:.:.:.:.;.;.:.;.;.:.:.:.:.:.:.;.;.:.;.:.:.:.:. : . . ... ......... ... . . . . . . . . . . . . . . . .. . SHAREHOLDER OF DESCRIPTION ALLEGHENY ENERGY, INC. SHARES SOLD INVESTOR ID I CUSIP I ACCOUNT KEY CHECK NUMBER I CHECK DATE I CHECK AMOUNT 124842647906 001 750 01 7361 10 KOSSLER--WILLROFOO 6551348 02/19/2008 $34,910.91 SHARES/UNITS SOLO PRICE PER SHARE ($) TRADING FEES PAID BY SERVICE FEES PAID BY 667.9986 52.2844090 GROSS PROCEEDS TAX WITHHELD COMPANY I SHAREHOLDER COMPANY I SHAREHOLDER $34,925.91 $0.00 $0.00 $80.16 $0.00 $15.00 NET PROCEEDS SHARES HELD BY PLAN $34,910.91 0.0000 1"'11 .......... ---..--.-.. --. -... ....,....._" a., I...~. --. ---.'").... Please Note: Your Sale Proceeds Check is Attached > iiiiiiiiiiii !!!!!!!!!!!!e iiiiiiiiiiiiiii iiiiiiiiiiiiiii - !!!!!!!!!!!!!!! BNY MELLON SHAREOWNER SERVICES ---- iiiiiiiiiiii - - - - ,)/ ~. J ct' - - === - - - == - - iiiiiiiiiiii !!!!!!!!!!!!e Login to Investor ServiceDirect@ at N ;.::: ~ o f'. N 8 ~ '. .. .. .... .......................... .................................................................................................................................................................................................................................................... - - :\:::\:~::':':::m~::\m:~:\\::'::\\\:~\::@:::::::~":~:::~~~:::::::~~~rr::\~~:::::::~\~~:~~~~~:~~::m:@::::m:::::~:'::::\\:::::\::::::::::~::@:::::::::It~,::@:::~::;:::~:I::r:::::::::I:::~:::::::l_lAm!q~UlniT.mW~::::::::~~~':':~f::~:::~~::::m:::::::m:t:I':::r:::::::~::~'~'::::::::::::::::~::m:::::::~:::~::'~:::~::~:::::::':::::::~:'~:~::::::~:::::::::~::~~~::~~~:%:::I:::,:.::~r:' ..' . SHAREHOLDER OF DESCRIP'TlON ALLEGHENY ENERGY, INC. SHARES SOLD INVESTOR ID I CUSIP I ACCOUNT KEY CHECK NUMBER I CHECK DATE I CHECK AMOUNT 124842647906 001 750 01 7361 10 KOSSLER-WILLROFOO 6551348 02/19/2008 $34,910.91 SHARES/UNITS SOLO PRICE PER SHARE ($) TRADING FEES PAID BY SERVICE FEES PAID BY 667.9986 52.2844090 GROSS PROCEEDS TAX WITHHELD COMPANY I SHAREHOLDER COMPANY I SHAREHOLDER $34,925.91 $0.00 $0.00 $80.16 $0.00 $1 5.00 NET PROCEEDS SHARES HELD BY PLAN $34,910.91 0.??oo PLEASE DETACH BELOW' -. . CHECK NUMBI:R: 6551348 _ :'111"":1 ::(....1 =- 'I'II{III'J I ::I~..: r.\.... :l" ~U'IOi:"':I: I ;1::('111':18.: 1:11 :"11{ :.'1" I: 1I.....I.lotlll'JI::I~. .ot'I~. '.UN.....' ~Ir.,:. U :llom, ."'/-'.::1 :fIU-':I:.-: [OIl ..-, ..,~ !r-' ~ I Oi 1...10 .'J, ~'l'_ ALLEGHENY ENERGY, INC., PO BOX 358014 PITTSBURGH, PA 15252 - 8014 CHECK DATE 02/19/2008 CHECK NUMBER 6551348 60-160 433 PAYABLE AT . MELLON BANK N.A. PITTSBURGH, PA. 'IN U.S. DOLLARS 100271001 MB 0.380 "AUTO Tll 0 603617050-7305101 - DOMOOOOO101 1,111 II 11I11111..1.1.1111.1'1111111.11'1111.11 i i 11111 ;11111111 . PAY TO THE ORDER OF: KATHLEEN TANNENBAUM EXUW W.ILLIAM R KOSSL,ER 6110 SOMMERTON DR , MECHANICSBURG PA 17050-7305 I PAY...............$34,91 0.91 1 ?!~ t AUTHORIZED SIGNATURE III 0 b 5 5 I. :l ... 8 III I: 0 ... :l :l 0 I. bOLl: o I. 1.111001..0111 Fideli'ty Brokerage Services LLC VOUCHER NO.914511214 72,873.68 02/25 CREDIT BALANCE y fI I ob 0\"> 't t'D c,)Vt (iJvV ACCOUNT NO. X179103091 OET ACH THIS PORTION BEFORE CASHING CHECK "~T::j~~ti::ii~~RK ~E~~~~~\'\\ i ; FIDELITY , " 'N~'.91:4511214 , "" " : ", . BROI<ERAGESERVICES LLC ' .' '., I" :- .," /' .62-351311, ' "'//~' . ~. . .." " ", '. , . ~.,'; '.- ",-, February 25;2008 I EXACTLY *$72,873.68 .. . >: ",.:.," is Ii ~ ,PAY iSJllentll Two Thousand Eight Hundred Seventv Three Dollars arid 68 Cents Not Valid After 90 Days ~ TO THE ORDER OF 0000912 KATHLEEN TANNENBAUM EX EtO WILLIAM R KOSSLER 6110 SOMMERTON DR MECHANICSBURG PA 17050-7305 National Financial Services LLC ~~.~ AUTHORIZED GNATURES THE ORIGINAL DOCUMENT HAS AWHITE REFLECTIVE WATERMARK ONTHE BACK. HOLD AT AN ANGLE TO SEE THE MARK WHEN CHECKING THE ENDORSEMENTS. 11-9 ~~5 ~ ~ 2 ~~II- -:031 ~ ~003l5 .-: 1I-03l009?~ 20 ~II- Fidelity Brokerage Services LLC VOUCHER NO.914511214 .~~t~';':' ':.:i:'~~~~~I~~"~~~~~~~~~I.::i::ji:i,:'j:'.,:'jji.,jj,', 02/25 CREDIT BALANCE p ;) t"b)- 72,873.68 ACCOUNT NO. X179103091 DETACH THIS PORTION BEFORE CASHING CHECK p....Q ~, Kelley Blue Book ~~ THE TRUSTED RESOURCE . , k~b.(om Send to Printer advertisement 1991 Honda Accord DX Sedan 4D advertisement BL:JE BOOK lRALiE.IN VALL;: Condition Value Excellent $1,600 Good $1,375 $985 Avel'age ConsumeI' Rating (148 Reviews) Read RevieWs 4.6 out of 5 Review This Vehicle Vehicle Highlights Mileage: Engine: TrlInsmission: Drivetrain: 95,000 4-Cyl. 2,2 Liter Automatic FWD Selected Equipment Standard Air Conditioning Optional Power Windows Power Door Locks Power Steering AM/FM Stereo Tilt Wheel Cruise Control Cassette Close Window B~ue Book Trade-In Value Trade-in Value Is what consumers can expect to receive from a dealer for a trade-In vehicle assuming an accurate appraisal of condition. This value will likely be less than the Private Party Value because the reselling dealer incurs the cost of safety inspections, reconditioning and other costs of doing business. Vehicle Condition Ratings 1of2 2/14120086:53 PM Excellent $1,600 . Looks new, is in excellent mechanical condition and needs no reconditioning. . Never had any paint or body work and is free of rust. . Clean title history and will pa" a smog and safety Inspection. . Engine compartment is clean, with no fluid leaks and is free of any wear or visible defects. . Complete and verifllble service records. Less than 5% of all used vehicles fall into this category. Good $1,375 . Free of any major defects. . Clean title history, the paints, body, and interior have only minor (if any) blemishes, Ind there are no mljor mechanical problems. . Uttle or no rUlt on this vehicle. . Tires match Ind have substantial tread wear left. . A "good" vehicle will need some reconditioning to be sold It retail. Most consumer owned vehicles fill Into this category. ./ Fair (Selected) $985 . Some mechlnical or cosmetic defects Ind needs servicing but Is stili in reasonable running condition. . Clean title history, the paint, body and/or Interior need work performed by a professional. . Tires may need to be replaced. . There may be some repairlble rust damage. Poor N/A . Severe mechaniclllnd/or cosmetic defects Ind is in poor running condition. . May have problems that cannot be readily fixed such as a damaged frame or a rusted-through body. . Branded title (salvage, flood, etc.) or unsubstantiated mileage. Kelley Blue Book does not attempt to report a value on I "poor" vehicle becluse the value of these vehicles varies greatly. A vehicle in poor condition may require an independent appraisal to determine its value. * Pennsylvania 2/14/2008 2of2 2/14/20086:53 PM To: Kate Tannenbaum, Executrix for the Estate of William R Kossler RE: Date of Death Balance for checking account #437247 Account owners: William R Kossler and Kate Tannenbaum, Joint owners with rights of survivorship Date of Death Balance is $418.39 with all checkS; having cleared Free checking account, with no interest. First National Bank of Marysville Four Generations... .~lllc. 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 in writing below. If you selected a funeral that may require 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 YOjl sJllecltd arrange~e~~uch as a dir~cremation o~media~ burial. If we charged for embalming, we w' ~ e!Q.laln .~h~~~. , For the Service f l,/L/ I CC I rI"'J7Vl ". IC.sS c-~~ Date of D ath ~ ~ Charge to: I"IrtE' ~/.J<,,J ,.., t;,1I0 JE, n;J;-O Name Address A. CHARGE FOR SERVICES SELECTED: I. PROFESSIONAL SERVICES Services of Funeral Director/Staff . Embalming , . . Other preparation of body ..,~ s -o/A- SUB-TOTAL OF PROFESSIONAL SERVI~.... Al 'T..,rL 2 FACILITIES AND SERVICES Use of facilities and services for viewing (Visitation/Wake). Use of facilities and services for funeral ceremony , Use of facilities and services for Memorial Service Use of equipment and services for graveside service. . Other use of .facilities $ .-/ s~ $~ $ ....- $~ L .. . A2 ;t;a- SUB-TOTAL OF FACILITIES/EQUIPMENT. . ' :1 AUTOMOTIVE EQUIPMENT ~~~~~ie ,to transfer ,re~ainslO, Funeral H~~ Hearse (Casket Coach) Local, $~ Limousine Local, Family car Local, , , , , , , . . Flower car or floral disposition Local, ' , , , , , , , ' Lead 'car/clJ:gy car , ~) Local, , ' <I\(...\.. , ,., ("I'-I ,1,~, , ' Car for pallbearers Local Out of town transportation , $ ..-' $'- $--- s1;IcL- $,- tr~ S $ SUB-TOTAL OF AUTOMOTIVE EQUIPMENT, , TOTAL OF PROFESSIONAL SERVICES, FACILITIES AND AUTOMOTIVE EQUIPMENT A3~ A $:I;..c(. B. CHARGE FOR MERCHANDISE SELECTED: Casket, "",.., ' , , , , .. $ (Description) Other Receptacle, , , , . , , , ',', ' , , .. 'A ' !~~ :,' '..." (Description) ~~f1~ ~""........v Outer burial container , . , . . S BOYD L. MYERS, JR., Supervisor 37 E. MAIN STREET MECHANICSBURG, PA 17055 (717) 766-3421 Cremation urn (Description) 5 55 ~ "t9' 5' tL'i4 OTHER 5 $ S TOTAL MERCHANDISE SELECTED. . . C. SPECIAL CHARGES: Forwarding of remains to s (Funeral Home) Receiving of remains from $ (Funeral Home) Immediate Burial, Direct Cremation, . , , S '...... s7~ s SUB-TOTAL OF SPECIAL CHARGES D. CASH ADVANCED Opening Grave .. . $ Cemetery Equipment, $ Lot and Deed. , . , . , , . . . , , , . . , . . . . 5~ Newspaper Notices-Local . ....... $~ Newspaper Notices-OUl-of-town. . . . $_ Telephone & Telegrams . . $_ Airfare $ Clergy/Mass Offering. , ,. . . . $_ Pallbearers , , . . . . . , . . . . .. $ ~~~::~:~~t;oPiel ~ t~~t;:~ , S~ Police Escort . , $ Flowers $ Vault Service Charge. . . . . . . , . . , . . . S $ $ 5 $ $ $ SUB-TOTAL OF ADVANCES...., We charge you for our services in obtaining: (specify cash advances that are marked-up) ^ 0 -19. '''' ,- .B$* 209,r-''.!:? CS~. 2/r~ DS~. SUMMARY OF CHARGES A, Professional Services, Facilities and Equipment, and Automotive Equipment . . . ' ~ B. Merchandise , , , , . . . . . . ~_ C. Special Charges . , , . . . . . . . , , . . . . . . $~ D. CashAdvances.., ....... . . ... $~~ TOTAL OF ALL SECTIONS. . . . . . . , . . . , . , . . . . , PAID AT TIME OF OR PRIOR TO A DO A. ""Tr,la.lr1\'T~ s23Id!t& o RECEIPT FOR PAYMENT ~------------------ ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17IT13 Rece~pt Date: Rece=!-pt Time: Recel.pt No. : 2/04/2008 09:14:28 1051445 KOSSLER WILLIAM R Estate File No. : Paid By Remarks: 2008-00122 AJW ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST WILL RENUNCIATION SHORT CERTIFICATE JCP FEE AUTOMATION FEE Check# UNNUMBERED Total Received......... 60.00 15.00 5.00 40.00 10.00 5.00 ---------------- $135.00 $135.00 CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D CUMBERLAND COUNTY GENERAL FUN REMITTANCE ADDRESS I BILL TO THE SENTINEL - LEGAL KATE TANNENBAUM P . O. BOX 13 0 , CARLISLE, PA 17013 AD NUMBER I CLASS SALESPERSON BILLING DATE LINES 343694 10 PUBLIC NOTICES shoet 02/25/08 30 * 2 AD DESCRIPTION START DATE STOP DATE EXECUTRIX NOTICE LETTERS TESTAMENT 02/09/08 02/23/08 PUBLICA TION INSERTIONS RATE NET AMOUNT GROSS AMOUNT 3 THE SENTINEL - LEGAL 3 LGL 119.70 TOTAL AD CHARGE 119.70 3 PROOF OF PUBLICATION 01PRF 7.00 PREVIOUSLY PAID -126.70 DA YS RUN PURCHASE ORDER PAY THIS AMOUNT .00 .00* william R. Kossler * AFTER 03/26/08 MESSAGE: Thank you for advertising with The Sentinel. Deadlines for in-column legal advertisements: Monday is Friday at 11 a.m.; Tuesday is Friday at 4 p.m.; Wednesday is Monday at 12 Noon; Thursday is Tuesday at 12 Noon; Friday is Wednesday at 12 Noon; Sunday is Thursday at 12 Noon. If you have any questions regarding your Legal bill please call Tammy Shoemaker 717-240-7176 Fax your legals to 717-243-3754 attention Tammy Shoemaker You can also EMAIL yourlegaltoClassifiedads:classified@cumberlink.com Please send a cover letter including your name and address as an attachment DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT THE SENTINEL - LEGAL . . POBOX 130 CARLISLE PA 17013 Wl.IIl.am R. Kossler . . AD NUMBER CLASSO START DATE STOP DA TE 343694 PUBLIC NOTICES 02/09/08 02/23/08 AD DESCRIPTION BILLING DATE TELEPHONE NUMBER EXECUTRIX NOTICE LETTERS TESTAMENT 02/25/08 717-514-6941 GROSS AMOUNT OF .00 DUE AFTER 03/26/08 TOTAL AMOUNT DUE .00 ENTER AMOUNT ENCLOSED KATE TANNENBAUM 6110 SOMMERTON DRIVE MECHANICSBURG, PA 1...111...111'1..1.1111"11...11 17050 20200000003436940000000000000000000000000000002 THE SENTINEL - LEGAL Printed on 02/15/2008 at 10:26 by shoet AWl 343b:i'l t'lrsc caKen DY Sfluec Last changed by shoet U~/U!ILUVO ~~:~V 02/08/2008 09:42 (717) 514-6941 KATE TANNENBAUM 6110 SOMMERTON DRIVE Acct# 77207 Given by KATE TANNENBAUM PO# William R. Kossler Start 02/09/2008 Stop 02/23/2008 Transient Bill Expir. MECHANICSBURG, PA 17050 Subscr? N Class 10 PUBLIC NOTICES Index: EXECUTRIX NOTICE LETTERS TESTAMENT Cols 2 Lines 15 Inches 1.51 Words 59 Box? N Comments: Pd check over the phone. tam Mail Info: Type Mail Affid N Sched Copies L 1 Sunday Comment William R. Kossler Pb# Code Rate Base-Charge Addl-Charge Total-Cost Ins Start Stop SMTWTFS 01PRF 7.00 3 LGL 119.70 7.00 126.70 3 02/09/2008 02/23/2008 TOTAL AD COST 126.70 lLQTh ;;;t.. ~ r 0\ "t- EXECUTRIX ~ Letters Testamentary on the Estate of WILLIAM R. KOSSLER, late of the Township of Hampden, Cumberland County, Pennsylvania, deceased, have been granted to the undersigned. All persons knowing themselves to be indebted to said Estate will make payments immediately, and those having claims will present them for settlement. Kathleen Tannenbaum Executrix 6110 Sommerton Drive Mechanicsburg, PA 17050 . . , , CERTIFIED MAILm RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) ":10':lFF'F'I"C I A L Postage $ Certified Fee Retum Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required) ~'u" ,~~U :0.. /. ! .~l it I"; (j" Total Postage & Fees $ USE 1,. U.)~, I.i; Postmark Here $enlTo " <. A.1 ..;). ..I. 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UI 0,00 ~ C>:o [!I :!1pm--s iI' P 3 a 0;;. :0 III [i 'S ~ ~ ! t i ;~_. f p. ::;:1.0 8TARJJJ:J CARLISLE - 717-243-3887 01/23/2008 12:54 PM RECEIPT EXPIRES ON 04/22/08 lllll\ll\l mIl lllll 1IIIlIllllIlIlIIl 081060076 081020593 4CT ENVELOPE T 2CT SHARPIE T SUBTOTAL 6 0000% on 3.19 . TOTAL CASH PAYMENT CHANGE DUE 1.47 1.72 3.19 0.20 3.39 5.00 1.61 T = PA TAX RECEIPT 10# 2-8023-2099-0078-5765-3 VCD# 750-288-851 TM#~~~~9261 ---------------------------------------- Win a $5000 OiftCard Tell us about your last shopping e~perlence at Targe.t for a chance to Wln a $5000 Target GiftCardl Locate the Gift Registry Kiosk and select GUEST SURVEY. Or at home, log onto: www,Taraet.conlsurvev User 10: 7197 6790 1992 password: 142 347 CU9ntanos acerca de tu ultima experiencla de compra en Target y tendras la oQortunidad de ganar una tarjeta de regalo Target GiftCard por valor de $5000. En el kiosco del reglstro ~e reQalos. selecciona "Guest Survey 0 vlsita www,target,com desde tu casa e Ingresa la contrasena Y N" de usuario de arriba,,, Normas disponibles en "5ervicio al hU9sped ONE WINNER PER MONTHl Guests must be 18 or older to enter. Sweepstakes runs from 01/01/08 through 03/31/08 Complete rules at Guest Service Desk and Target,com/s~r' (Target team and family not el ~~ol' ",(fV 02/05/2008 USPS. ENOLA ENOLA. Pennsylvania' 170259998 4134870025 -0097 (800) 275-8777 11:01:23 AM Sales Receipt Product Sale Unit Description Qty Price SOUTH HACKENSACK NJ 07606 Zone-2 First-Class Large Env 1.50 oz. Return Rcpt <Green Card) Certified Label #: Final . Price $0.97 $2.15 $2.65 70072680000106582574 ======== Issue PVI: $5.77 Total: Paid by: Visa Account #: Approval #: Transaction #: 23 903110047 Order stamps at USPS.com/shop or call 1-800~Stamp?4.. Go to USPS.com/clicknship to prlnt shIppIng labels with postage. For other information call 1-800-ASK-USPS. W******~*********~********************** **************************************** "LET US DARE TO READ. THINK, SPEAK AND WRITE. " . -JOHN ADAMS. 1765 www.poweroftheletter.com **************************************** **ww****w******************************* $5.77 $5.77 XXXXXXXXXXXX9509 221545 540 Bll1#: 1000302435242 Clerk: 01 All sales final on stamps and postage. Refunds for guaranteed services only. Thank you for your business. **************************************** **************************************** HELP US SERVE YOU BETTER Go to: http://gx.ga11up.com/pos TELL US ABOUT YOUR RECENT POSTAL EXPERIENCE YOUR OPINION COUNTS **************************************** **************************************** Customer Copy II ~ ~ ) 7 t,(}b Mechanicsburg Main Post Office MECHANICSBURG, Pennsylvania 170553459 4134870055 -0098 01/23/2008 (800)275-8777 01:16:53 PM Sales Receipt Sale Unit Qty Price Final Price Product Description CARLISLE PA 17013 Zone-1 First-Class Large Env 0.70 oz. Return Rcpt (Green Card) Certified Label #: $0.80 Issue PVI: $2.15 $2.65 70070710000387174990 ;;-====== $5.60 Total: $5.60 Paid by: $6.00 Cash Change Due: -$0.40 Order stamps at USPS.com/shop or call 1-800-Stamp24. Go to USPS.com/clicknship to print shipping labels with postage. For other Information call 1-800-ASK-USPS. BIll#: 1000203074983 Clerk: 16 All sales final on stamps and postage. Refunds for guaranteed services only. Thank you for your business. **************************************** **************************************** HELP US SERVE YOU BETTER Go to: http://gx.gallup.com/pos TELL US ABOUT YOUR RECENT POSTAL EXPERIENCE YOUR OPINION COUNTS **************************************** **************************************** Customer Copy 2 Old 30 Plaza / Greensburg, PA 15601-8320 Tel: (724) 830-5984 or (888) 462-2328 / Fax: (724) 830-5129 E-mail: AECU@comcastnet/Web Site: www AEFCU.coop Allegheny Energy FEDERAL CREDIT UNION February 8, 2008 Kate K Tannenbaum Executor for the Estate of William R Kossler 6110 Sommerton Drive Mechanicsburg, PA 17050 Dear Ms. Tannerbaum, This letter is to verify that the AEFCU Visa credit card account number 4148-8600-00025769 has been paid in full and closed in the amount of $570.19 as of 2/8/2008 by a transfer from AEFCU's share account number 0000000323. If I could be of any further assistance to you, please contact our office at the above number. Thank you! Sincerely, '-t..' !' .;.:1' .\,' ~.l,. / ,"" 'I "'-~ >. " "..... ~ j J .c..l t~J_,,)(/t.d7{Grd(t.t.,r>t Melissa Lenhart Member Service Rep. Allegheny Energy FCU ALLEGHENYENERGYFCU Account Number: 4148860000025769 Closing Date: 02/01/08 Credit Limit: $5,000 Available Credit: $0 AccOUOfhlq",iries ~ Customer Service: ~ (800) 433-0505 NA TL 800 (888) 462-2328 CARD COORD To Report a Card Lost or Stolen: (888) 462-2328 BUS HRS (800) 991-4961 AFTER HRS !~"".tl~ Please Direct Written Inquiries to: t.G, CUSTOMER SERVICE PO BOX 30495 TAMPA, FL 33630 A~countSummary Previous Balance Purchases Cash Credits Payments Insurance Other Debits Finance Charges NEW BALANCE Payment Information Total Minimum Payment Due Payment Due Date VISA $ 190.89 570.19 0.00 0.00 190.89 0.00 0.00 0.00 570.19 + + + + + $ $20.00 02/26/08 Minimum Payment Past Due Amount Over Limit I Fees ~."""" '> ~'~.~''''.' .- Mail Payments to: A.E. FCU PO BOX 4519 CAROL STREAM IL 60197-4519 '~.Important News . ........................-...........-...................................... . THE TOTAL FINANCE CHARGE PAID ON YOUR ACCOUNT DURING THE PAST YEAR WAS. . $ 4.04 ......,..""................................................................... $ $ $ 20.00 0.00 0.00 x ~ ~~.~~.~ ~{ . TO REPORT A LOST OR STOLEN CARD PLEASE CALL: 888-462-2328. CREDIT CARD COORDINA TOR LOST/STOLEN AFTER HOURS: 800-991-4961. TO FILE A DISPUTE OR INQUIRE ABOUT AN EXISTING DISPUTE CALL: 800-600-5249 Description MEINEKE 240 25202409 MECHANICSBURG PA 24692168005000162706082 GIANT FOOD #005 MECHANICSBURG PA 24226388008360791800748 WM SUPERCENTER MECHANICSBURG PA 24164078016346026000049 MEINEKE 240 25202409 MECHANlCSBURG PA _______________________________________________________ PAY M ENTS, ADJUS TM ENTS AND OTHERS-------------------------------------------------------- 01/14 01/14 0000 74148868014001630783793 PAYMENT - THANK YOU 19089. 01/05 01/06 5411 01/08 01/09 5411 01/15 01/17 7538 PLEASE DETACilcOUPONAND RETURN PAYMENT USING THE ENCLOSED ENVELOPE. AU..OWSDAysl'()RMA1CbWVERY ALLEGHENY ENERGY FCU 2 OLD 30 PLAZA GREENSBURG PA 15601 - 8320 Closing Date New Balance Total Minimum Payment Due $20.00 02/26/08 PaYment Due Date 02/01/08 $570.19 MAKE CHECK PAYABLE TO: WilLIAM R KOSSlER 6110 SOMMERTON DR MECHANICSBURG PA 17050 - 7305 ;;;;;;;;;;;;;;; -0> -;;; -N $ Amount 517. 08 891 9.68 34.52 VI ~. Account Number 4148860000025769 Check box to. indicate D name/address change on back of thIS coupon AMOUNT OF PAYMENT ENCLOSED $ - !!!!!!!!!! 1.11..11......111.1..111.1.1..1.1,11111111.1'1111111.1..1111.1 A.E. FCU PO BOX 4519 CAROL STREAM Il 60197 - 4519 1".111...111"..1.1.11..,111.1,.11.11"111.111.,1111"11..1II 19 4148 8600 0002 5769 00002000 00057019 3 ;;;;;;;;;;; !!!!!!!!!!!! ;;;;;;;;;;; ~ ;;;;;;;;;;; - ulscover More \..ara AccounT ",UIIIIIIUI Y Cardmember since 1987 Closing Date: January 17,2008 page 1 of 3 3285 Previous Balance $690.78 February 16, 2008 Payments And Credits 300.00 $21.00 Purchases + 268.92 $14,500.00 Cash Advances + 0.00 $13,826.00 \ Balance Transfers + 0.00 $7,300.00 (\ { . Finance charses + 13.76 $7,300.00 ~l- ~ New Balance = $673.46 C ()\k -,1"( .?Ov You may be able to avoid Periodic Finance Charges, see the \. ~\t.(,,'-b )9 \ ') ~ ~o't- ~~everse side for details. jJJ :V \) V \) 't\~ l\\ f)~VJ .,).~OS'\ = Cashback Bonuse ~ Opening Cash back Bonus Balance === New Cash back Bonus Earned j-2.'Z'Ol .Arn~ +rLlM~.( ~ _, fOhCl~~ ~ Cashbock Bonu:;(!) -/>.I'lniver:ary' " ,- . = Date: November 17 === Account number ending in Payment Due Date Minimum Payment Due Credit limit Credit Available Cash Credit Limit Cash Credit Available ;;;;;;;;;;; = - - === - - - - === ;;;;;;;;;;; !!!!!!!!!!!! $ 23.57 0.67 + Cash back Bonus Balance AvqiIQ~letQR~d""m ' $ .$ 24.24 ,20.00, pic 'IMitlrMec... ~ 'ry~'3. J' d-. "\. .;l'1af ~ 0, Ill) ~ e.e.- j-22.-" t . Ltt/}h back. ~ Lt~ tbk.. ~ rtcluV\f>-h~ ~Clr6tn u. : ~ .. /, '1 <t.:1 ;1 CONGRATULATIONS I Your Cashback Bonus(R) is waiting for you. Visit Discovercard.com or call 1.8()()'DISCOVER . (1.800-347.2683) to get your share of America's #1 Cash Rewards Program. How Can We Help YOU? Please have your Discover Card available. Manage your account online at Discovercard.com ,Customer Service: 1.800-DISCOVER (1.800-347.2683) For Account Inquiries, write to us at Discover More Card, PO Box 30943 Sa~ lake City, UT 84130 TOO (Telecommunications Device for the Dea~: For assistance, see reverse side. Transactions ~ o '" o (11 Payments and Credits Merchandise/Retail Gasoline ; Supennarkets $0 Fraud Liability Guarantee Use your Discover Card with confidence. Trans. Post Dale Date Dec 26 Dec 26 $ .300.00 23.62 90.03 Dec 29 Dec 29 Jon 5 Jon 5 Jan 15 Jan 15 Dec 20 Dec 20 Jan 4 Jan 4 Dec 21 Dec 21 Dec 28 Dec 28 Jan 12 Jan 12 Jan 15 Jan 15 PAYMENT. THANK YOU RITE AID MECHANICSBURGPA CMK*CARFJ.-1.ARK RX 80Q.,BA 1.5550 EI. 242005571 RITE AID MECHANICSBURGPA SHEETZ 0000 1958498 MECHANICSBURGPA GIANT FUEL #5 MECHANICSBURGPA 010059 GIANT FOOD #005 MECHANICSBURGPA 010079 GIANT FOOD #005 MECHANICSBURGPA 010019 GIANT FOOD #005 MECHANICSBURGPA 010039 GIANT FOOD #005 MECHANICSBURGPA 010031 10.46 30.63 31.16 28.68 26.59 20.12 \; \j ~: >;. ~ ~ ,\,-~/~ \ ry~ Wish you could sorl these purchases by amount, description or catego~ You can - register at Discovercard.com to view your purchases online as far back as 12 months. learn more at Discovercard .com / purchases It pcIyI to DISC.VEIl !i: w :IE z Cl u; .. < .... ~ No ~jo~ts(l A. Q WW ...I" u< -x Xu Wa: >:1 lL 1//10 rit. 2302 /{O VEHICLE IDENTIFICATION NUMBER /;/6 t!k3 7/",5" 9 Mil I zI2~.f LESS TRADE-IN B.a: W ...I ...I W .. AXABLE AMOUNT c ST NAME (OR FULL BUSINESS NAME) ---ran /) ~ /7);11 ) (/Yj a: CO-PURCHASER LAST NAME W ~ X u a: :I lL .... ~ FIRST NAME MIDDLE NAME PA DUPHOTO 10# OR BUS. 10# /"7 tJ7SZ PA DUPHOTO 10# FIRST NAME a e.. M OLE NAME STREET J-)f' c to 1/8 o::::;)6/77/77/?/ '6l/ STATE 2. TITLE FEE CITY 3. LIEN FEE DATE ACQUIRED/ PURCHASED r- j- 2.D.. () b . OF YELLOW COpy MIDDLE NAME PA DUPHOTO 10# DATE OF BIRTH OR BUS. 10# o fl/e fMrtlt'Jh)AI LAST NAME (OR FULL BUSINE;lS !i: a: CO-PURCHASER LAST NAME W W lE .. z < Cl x u; ~ STREET .. :I < lL Q Q Z Z N N 4. REGISTRATION OR PROCESSING FEE FIRST NAME MIDDLE NAME PA DUPHOTO 10# DATE OF BIRTH r+ FEE EXEMPT NUMBER AS ASSIGNED BY THE DEPARTMENT 5. DUPLICATE REG. FEE NO. OF CARDS CITY STATE ZIP CODE DATE ACQUIRED/ PURCHASED 6. TRANSFER FEE ( -lJ. REFER TO COUNTY CODES LISTING ON REVERSE SIDE OF YELLOW COPY E. MAKE OF VEHICLE VEHICLE IDENTIFICATION NUMBER WQ ..Jw uQ ffi ~ MODEL YEAR >.... 7. INCREASE FEE BODY TYPE (CP, TK. ETC.) CONDITION 8. REPLACEMENT FEE F. o GOOD o TRANSFER OF PREVIOUSLY ISSUED PLATE o TRANSFER & RENEWAL OF PLATE o TRANSFER & REPLACEMENT OF PLATE o TRANSFER OF PLATE & REPLACEMENT OF STICKER SEND ONE CHECK IN /' \.. \. -- '1 THIS AMOUNT -+ (-;::::; . ) \ I.. o FAIR o POOR 9. 10. OTAL PAID (ADD 1THRU 8) o PLATE TO BE ISSUED BY DEPARTMENT (PROOF OF INSURANCE MUST BE ATTACHED.) o EXCHANGE PLATE TO BE ISSUED BY DEPARTMENT o TEMPORARY PLATE ISSUED BY FULL AGENT 11. GRAND TOTAL (ADD 9 & 10) a: oz "'0 zi= ~g u!!l :Jffi ~a: < (-:, REASON FOR REPLACMENT o LOST 0 DEFACED 0 STOLEN 0 NEVER RECEIVED (Lost in Mail) NOTE: If "NEVER RECEIVED" blocl< is checked, applicant must complete Form MV.44. VIN iSSUING AGENT INFORMATION POLlC.:l.EXPIRATION, DATE 7. c:.,. C AGENT O. ISSUING AGENT SIGNATURE TELEPHONE NO. G. I/WE CERTIFY THAT I/WE HAVE EXAMINED AND SIGNED THIS FORM AFTER ITS COMPLETION AND THAT THE INFORMATION GIVEN IS TRUE AND CORRECT. IF ANY EXEMPTION IS CLAIMED. THE PURCHASER FURTHER CERTIFIES THAT HE/SHE IS AUTHORIZED TO CLAIM THIS EXEMPTION. I/WE ACKNOWLEDGE THAT I/WE MAY LOSE MY/OUR OPERATING PRIVILEGES(S) OR VEHICLE REGISTRATION(S) FOR FAILURE TO MAINTAIN FINANCIAL RESPONSIBILITY ON THE CURRENTLY REGISTERED VEHICLE FOR THE PERIOD OF REGISTRATION. I/WE ACKNOWLEDGE THAT I/WE MAY BE SUBJECT TO A FINE NOT EXCEEDING $5,000 AND IMPRISONMENT OF NOT MORE THAN TWO YEARS FOR ANY FALSE STATEMENT THAT I/WE MAKE ON THIS FORM. z o ~ !.1 ... i= a: W u Signature. of First Purchaser or Authorized Signe~ \:7/1 /"U /7 ha I { /Y\...- Telephone No. 1ST ASSIGN- MENT Signature of Co-Purchasermtle of Authorized Sign r V17} 5) 4- b if 2. to 2ND Signature of Second Purchaser or Authorized Signer ASSIGN. MENT ~~ Telephone No. H'.<i! ~ NOTE: IF A CO-PURCHASER OTHER THAN YOUR SPOUSE ISUSTED AND YOU WANT THE TITLE TO BE LISTED AS "JOINT TENANTS WITH RIGHT OF SURVIVORSHIP" (ON DEATH OF ONE OWNER. z W ~ TITLE GOES TO SURVIVING OWNER.) CHECK HERE D. OTHERWISE, THE TITLE WILL BE ISSUED AS .'TENANTS IN COMMON" (ON DEATH OF ONE OWNER, INTEREST OF DECEASED OWNER ~ ;:: ~ GOES TO HIS/HER HEIRS OR ESTATE.) g F= ~ NOTE: IFTHE VEHICLE IS TO BE USED ASA DAILY RENTAL OR LEASED VEHICLE, CHECK THIS BLOCK D. IF BLOCK IS CHECKED, COMPLETE AND ATTACH FORM MV-1L. < ;!; MESSENGER NUMBER: 3. APPLlCANrS COPY I TEMPORARY REGISTRATION (VALID FOR 90 DAYS) DAILEY HARVEY EYE ASSOCIATES 1857 CENTER STREET CAMP HILL, PA 17011-1703 (717) 761-3011 STATEMENT DATE I I IIiiii WILLIAM R. KOSSLER 6110 SOMMERTON DRIVE L MECHANICSBURG PA 17050 ~ 27495.0(1) WILLIAM R. KOSSLER (2749 12/05/07 EYE, ESTABLISHED PATIENT, 95.00 01/02/08 Ins pmt-MEDICARE BAL TO SECOND INSURANCE 01/02/08 Adjustment 01/16/08 Reject-HIGHMARK PA BLUE SHIELD PT OWES COPAY 12/05/07 VISUAL FIELD, EXTENDED 90.00 01/02/08 Ins pmt-MEDICARE 54.14 BAL TO SECOND INSURANCE 01/02/08 Adjustment 22.33 01/16/08 Reject-HIGHMARK PA BLUE SHIELD 0.00 PT OWES BALANCE 12/05/07 HRT 70.00 01/02/08 Ins pmt-MEDICARE 31.53 BAL TO SECOND INSU~~~CE 01/02/08 Adjustment 30.59 01/16/08 Reject-HIGHMARK PA BLUE SHIELD 0.00 PT OWES BALANCE 12/05/07 HRT 70.00 01/02/08 Ins pmt-MEDICARE 31.53 BAL TO SECOND INSURANCE 01/02/08 Adjustment 30.59 01/16/08 Reject-HIGHMARK PA BLUE SHIELD 0.00 PT OWES BALANCE TOTAL FOR WILLIAM R. KOSSLER 01/15/2008 01/15/2008 01/15/2008 01/15/2008 01/15/2008 01/15/2008 02/07/2008 02/07/2008 02/20/2008 02/20/2008 WILLIAM R KOSSLER ESTATE 10# 110670/KENNETH R HARM JR MD OFFICE / OUTPATIENT VISIT ESTABLISHED PATIENT DETAILED URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBI ADVANCE CARE PLANNING DISCUSSED AND DOCUMENTED; ADVANCE PNEUMOCOCCAL VACCINE ADMINISTERED OR PREVIOUSLY RECEIVE TOBACCO USE ASSESSED (CAD, CAP, COPD, PVll (DMl4 CURRENT TOBACCO NON-USER (CAD. CAP, COPD. PVll (DMl4 SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE PAYMENT FROM MEDICARE PAYMENT FROM BLUE SHIELD PATIENT RESPONSIBILITY - THE BALANCE IS YOUR COPAY WHICH IS NOT COVERED --> BY YOUR INSURANCE. BALANCE TICKET #GHFP125242 105.00 105.00 0.00 12.00 12.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -26.27 0.00 -4.43 0.00 -51. 30 0.00 -35.00 35.00 .00 35.00 35.00 .00 35.00 .. .. ~ .. '" .- .. Make Checks Payable To: HERITAGE MEDICAL GROUP, LLP For Billing Questions Call (717)-732-8877 PLEASE DO NOT SEND CASH THROUGH THE MAIL EG2651-32 1II601014GOO' PAGE 1 OF 1 01 2498 683 1...111...111.11.1.1.11...1.111..11.11..111.1. ...1111.... ..111 WILLIAM R KOSSLER 6110 SOMMERTON DR MECHANICSBURG PA 17050-7305 BE INFORMED: Pfotect your Medicare. number as you would a credit card number. CUSTOMER SERVICE INFORMATION Your Medicare Number: XXX-XX-5824A If you have questions, write or call: Highmark Medicare Services (#(}0865) P.O. Box 890413 Camp Hill, PA 17089-0413 Call: 1-800-MEDICARE (1-800-633-4227) Ask for Doctor Services TTY Users Only Should Call 1-877-486-204~ Business Hours: M-F; 9:00 - 4:30 EST. This is a summary of claims processed from 12/11/2007 through 02/04/2008. PART B MEDICAL INSURANCE - ASSIGNED CLAIMS Dates Medicare You See of Amount Medicare Paid May Be Notes Service Services Provided Charged Approved Provider Billed Section Claim number 11-07340-809-610 Dailey Eye Associates PC, 1857 Center Street, a I~)Z' Camp Hill, PA 17011-1703 " Dr. Harvey, Todd J. M.D. 2 )- 12/05/07 1 Eye exam & treatment (92014) $95.00 $86.0Q $68.83 $17.21 t." 12/05/07 1 Visual field examination(s) (920&3) 90.00 67.67 54.14 13.53 12/05/07 1 Opthalmic dx imaging (92135-RT) 70.00 39.41 31.53 7.88 12/05/07 I Opthalmic dx imaging (92135-L T) 70.00 39.Q1 31.53 7.88 iJ. \l) '..) Claim Total $325.00 $232.53 $186.03 $46.50 ~~~;''''~-~';;1!;';;;;';';:~1i~Jt:.:,~i!...~ii!.~..ili~M'~~in'~El';;;;;:!i~~~M;~'~'~~~'l8:fft_~;'~';'~~_~;i;~,,'\i,~,,';M;:;'g'~'<<~.;;~;;:';;;'il~;;';i'.:';.;..~~.;;;.;~;;;;*;!;~.;;~.~ift';;)';1Y';'Bi!';~'~'~i.;'~'~~~';';e:;~';'~'-!!';;-.(i';-M;;'~';;';!'~,:;';'~;'p.';;',~;-~?';;~;;~'~;';;:1;~~ Claim number 18-07340-519-690 Heritage Medical Group LLP, POBox 12942, Philadelphia, PA 19176-0942 Referred by: Dr. Harm Jr, Kenneth R., M.D. Dr. Sangillo, Cathleen M.D. 11/30/07 1 Office/outpatient visit, est (99213) 11/30/07 1 Decis mkr/advncd plan doc'd (1080F) Claim Total a $75.00 0.00 $75.00 $56.68 0.00 $56.68 $45.34 0.00 $45.34 ,Dd. o~ $11.34 r ,\A1' 0.00 b $11.34 THIS IS NOT A BILL - Keep this notice for your records. 000222965 Your Medicare Number: XXX-XX-5824A 41217268: Page 2 of 4 February 26, 2008 PART B MEDICAL INSURANCE - ASSIGNED CLAIMS (continued) Dates Medicare You See of Amount Medicare Paid May Be Notes Service Services Provided Charged Approved Provider Billed Section Claim number 19-08022-198-910 Heritage Medical Group LLP, POBox 12942, a Philadelphia, P A 19176-0942 Dr. Harm Jr, Kenneth R. M.D. 01/15/08 1 Office/outpatient visit, est (99214) $105.00 - $86.30 $0.00 $86.30 c 01/15/08 1 Urinalysis, auto w/scope (81001) 12.00- 4.43 4.43 0.00 d 01/15/08 1 Office service (l123F) 0.00 0.00 0.00 0.00 b 01/15/08 1 Office service (4040F) 0.00 0.00 0.00 0.00 b 01/15/08 1 Tobacco use, smoking, assess (1000F) 0.00 0.00 0.00 0.00 b rJ. 01/15/08 1 Office service (1 036F) 0.00 0.00 0.00 0.00 b Claim Total $117.00 $90.73 $q.q3 $86.30 ~~-~'M,-1!';-~-~;iilf~~':;!;'~1!! ~;~'~;;:,~i'~'!ii\';;~'M;:;!~'E1'i!'~:;'~~';;-;fi';;';-;;'~-;";fE~~;ji;'';-1i~M'1!;';'~';~;i;';':lt;;;;t;-!;';(;ir;;i!-;;;:;'.~';r-~~;';n-;.~'~~;';;,,;~!;-;;,'_;;~:;;:;'~'~';-~i~';;-:Y~i!i';;!~';"~';~~';';"~;';;'~;';:'~ii'~';';;;.:;!;; ;~'~'i;;;;';;;~~~";;>;;;';;;;M :;;;: i~ ~i1 ;.~ :;~; ;:'~~,: ;r,::;;-:-:.r.~;;-e;';;-;; :;~'~.~;;: ~;; ~- ~;; r;;:,~~ ;;- Claim number 11-07332-478-210 Urology Of Central P A Inc, POBox 4963, Lancaster, PA ]7604-0000 Referred by: Dr. Harm Jr, Kenneth R., M.D. Dr. Dowling, Keith J. M.D. 11/27/07 1 Office/outpatient visit, est (99212) a $60.00 $34.56 $27.65 pd. i-"3-D( $6.91 Notes Section: a This information is being sent to your private insurer. They will review it to see if additional benefits can be paid. Send any questions regarding your supplemental benefits to them. Your private insurer is HIGHMARK INC. b This code is forinformationaljreporting purposes only. You should not be charged for this code. If there is a charge, you do not have to pay the amount. c This approved amount has been applied toward your deductible. d This service is paid at 100% of the Medicare approved amount. II 7. riD I L 2~.27 Lj.tG 51.30 3,-t;iJ ~. 111,0C> ~~ ()u#~!!/~WJN) ~ 1011 Mt. Pleasant Ro:td . Greensburg. PA 15601 Phone: 724-838-9480 . Fax: 724-838-1842 March 17,2008 Estate of William R. Kossler Kathleen Tannenbaum, Executrix 6110 Sommerton Dr. Mechanicsburg, P A 17055 Dear Ms. Tannenbaum, On behalf of Our Lady of Grace Parish I would like to express to you our gratitude for Mr. Kossler's generosity in remembering his former parish in his will. Please know that we will make sure that his generous $1,000 bequest is put to good use here at Our Lady of Grace. In Christ's peace, ~ ~L.~ Msgr. Raymond E. Riffle, Pastor