HomeMy WebLinkAbout03-05-08
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15056051058
REV-1500 EX (D6-05)
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
21 07
000693
Date of Birth
224-20-9376
09/13/2006
08/16/1924
Decedent's Last Name
Suffix
Decedent's First Name
MI
Eshelby
Elizabeth
E
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WillS
FILL IN APPROPRIATE OVALS BELOW
'.:: 1. Original Return
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
o
8. Total Number of Safe Deposit Boxes
Luther E. Milspaw, Jr.
Filrm Name (If Applicable)
(717) 236-3141
REGISTER OF WILLS USE ONLY
Harrisburg
PA
17101
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DATE FILED 8 c:: 'TI ::r:: ~ R
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First line of address
130 State Street
Second line of address
P.O. Box 946
City or Post Office
State
ZIP Code
Correspondent's e-mail address:luthermilspaw@milspawlawfirm.com
Uncler penalties of perjury, 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 pre parer other than the personal representative is based on all information of which preparer has any knowledge.
ILlNG
SE USE ORIGINAL FORM ONLY
D'6
Side 1
L
15056051058
15056051058
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15056052059
REV-1500 EX
Decedent's Name:
Elizabeth
E Eshelby
224-20-9376
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 Govemmental 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_
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
0.00
15.
0.00
16.
0.00
17.
0.00
18.
19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . .. . ., .. . . . . . . . . . . . . . . . . . . . . . . . . . . 19.
.20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056052059
Side 2
L
Decedent's Social Security Number
0.00
0.00
0.00
0.00
1,550.00
2,863.46
0.00
4,413.46
6,151.00
10,595.54
16,746.54
-12,333.08
0.00
-12,333.08
0.00
0.00
0.00
0.00
0.00
15056052059
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REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENT'S NAME
Elizabeth E Eshelby
STREET ACORESS
~File Numbe~
000693
DECEDENTS SOCIAL SECURITY NUMBER
224-20-9376
CITY
STATE
ZIP
Tax Payments and Credits:
1. Tax DUi3 (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
0.00
Total Credits ( A + 8 + C ) (2)
0.00
3. Interest/Penalty if applicable
D. Intemst
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 + 5A. This is the BALANCE DUE.
(5A)
(58)
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
f'LEASE 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;.......................................................................................... 0 [KJ
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 [KJ
c. retain a reversionary interest; or.......................................................................................................................... 0 [iJ
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [iJ
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 [KJ
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 [KJ
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0 ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. ~9116 (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. 99111> (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 dleath 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. ~9116(1.2) [72 P.S. ~9116(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. s9116(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.
STATE OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SHORT CERTIFICATE
I,
GLENDA FARNER STRASBAUGH
Register for the Probate of wills and Granting
Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
the 23rd day of July, Two Thousand and Seven,
Letters of ADMINISTRA TlON
in common form were granted by the Register of
said County, on the
estate of ELIZABETH E ESHELBY , late of SILVER SPRING TOWNSHIP
(First, Middle, Lastl
in sa:id county, deceased, to BARBARA LEIGH BAIR
(First, Middle, Last)
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 23rd day of July
Two Thousand and Seven.
File No.
PA File No.
Date of Death
5.5. #
2007-00693
21- 07- 0693
9/13/2006
224-20-9376
, ~U'\(~ ~~~;,~6rlA'~
~ ~,vE Deputy
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
REV-1508 EX+ (6-98) '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Elizabeth E. Eshelby
FILE NUMBER
21-07-0693
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
1. 1990 Buick Park Avenue (does not run)
DESCRIPTION
VALUE AT DATE
OF DEATH
2. Clothing and miscellaneous household items (donated to Goodwill)
1,000.00
250.00
3. TV and VCR (approximately 7 years old)
4. Costume jewelry (donated to Goodwill)
100.00
200.00
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert addnional sheets of the same size)
1,550.00
REV-1!509 EX+ (6-98*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
E/izatleth E. Eshelby
FILE NUMBER
21-07 -0693
If an asset was made joint within one year of the decedent's date of death, It must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. Barbara L. Bair
77 Beechcliff Drive
Carlisle, PA 17015
Daughter
B.
C.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 07/26f73 PNC Bank Checking Account 5,726,91 50% 2,863.46
TOTAL (Also enter on line 6, Recapitulation) $ 2,863.46
(If more space is needed, insert add~ional sheets of the same size)
l~oV.LI, LUUf L:~lrlYl
~NC ~ANK 412-705-2747
No. 5955 P. 1
o PNCBAN<
November 21, 2007
Tara L. Ebright
130 State Street
P.O. Box 946
Harrisburg, PAl 71 08-0946
RE: Estate of Elizabeth E. Eshelby, deceased
SSN: 224-20-9376
000: 9/13/2006
Dear Ms. Ebright:
In response to your request for Date of Death balances for the customer noted above. our
records show the following:
Checking Account
Account #5070079511
Established 07/26/1973
ELIZABElli E ESHELBY
BARBARA L BAIR
DOD balance: $5.726.56 + $.35 accrued interest
Please note that this office only provides date of death balances for deposit accounts
(lRAs, CDs, Checking and Savings accounts). We do not p~ess any finandal
transaetions or provide statements. H you need assistance with any of these items,
please caJ11-888-PNC-BANK (1-888-762-2265) o.r stop by your local PNC Bank branch
office.
6f~ {))Jft-
Rachelle Wells
1-800-762-1775
P7-PFSC-04-F
500 first Ave.
Phtsburgh P A 15219
Member FDIC
REV-1511 EX+ (12-99)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
21-07 -0693
ESTATE OF
Elizabeth E. Eshelby
ITEM
NUMBER
A.
Debts of decedent must be reported on Schedule 1.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
Hetrick Funeral Home, Inc.
960.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
2.
3.
4.
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
State
Zip
Year(s) Commission Paid:
Attomey Fees
1,250.00
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant Barbara L. Bair
Street Address 77 Beechcliff Drive
3,500.00
City Carlisle
Relationship of Claimant to Decedent Daughter
State PA .Zip 17015
5. Accountant's Fees
Probate Fees
86.00
7.
6. Tax Retum Preparer's Fees
8.
9.
10.
The Patriot News - publication fees
Cumberland Law Journal. publication fees
Glenda Farner Strasbaugh, Register of Wills - Filing Inheritance Tax Return
Glenda Farner Strasbaugh, Register of Wills - Filing Petition to Settle Small Estate
250.00
75.00
15.00
15.00
6,151.00
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
HETRICK CREMATION SERVICES
OF CENTRAL PENNSYLVANIA, INC.
3125 Walnut Street, Harrisburg, PA 17109
(717) 671-1289 Fax (717) 545-2325
Patty J. Garb<!r, Sul"'rvisor
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
Funeral Expense Agreement
This is an explanation of charges as well as a sales agree-
ment presented in accordance with the regulations of the P A
State Board of Funeral Directors.
Charges are only for those items that you Selected or are required. If we are required by law or by a cemetery or crematory to use any items, we
will explain the reasons in writing below. If you selected a funeral which may require embalming, such as a funeral with a viewing, you may
have to pay for embalming. You do not have to pay for embalming you did not approve, if you selected arrangements such as direct cremation
or immediate burial. If we charge for embalming we will explain why below.
Legal, cemetery, crematory or other requirements compelling the purchase of any items listed below:
Reason for Embalming: Ai A .
Funeral Services for t:-;;'z-,.0.2.i-A.- C. .!S}u/ /;v Date of Death q /1' .I *
GOODS dD SERVICES SELECTE~ I
TYPE OF SERVICE AUTHORIZED TO BE PROVIDED Prayer Cards. .............................
DTraditionalFullService a Viewing day of Service Crucifix..................................
,0 Graveside servia" only 0 No Viewing Temporary Grave Marker. . . . . . . . . . . . . . . . . .
~Crernation a Immediate Disposition Memorial Board Rental. . . . . . . . . . . . . . . . . . . .
o Public Viewing o Anatomical Gift Casket Rental. ............................
o Private Family Vi,ewing a Memorial Service Clothing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
o Evening Viewing o Shipping Service Flag Case. ................................
o Receiving Service Other
A. Pa~:'~::i,,:~~~en(r~/,,_ h J>..... Total of Merchandise Selected (C). . . . . . . . . . . . . .
$ ~ 7 5' D. Special Charges
Forwarding Remains to
Date of Service
$-
$-
$-
$-
$-
$-
$-
$-
$-
B. Charge for Services Selected:
1. PROFESSIONAL SERVICES
Basic Services Fee .....................
Embalming .. . .. .. . .. . .. . .. . .. . . .. .. ..
Cremation. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other Preparation of Body
$-
Receiving Remains from
$ ~"-
$-
$ -;(,.,<..-
$-
$-
$-
$-
$-
Immediate Burial. . . . . . . . . . . . . . . . . . . . . . . . . .
Equipment Rental. . . . . . . . . . . . . . . . . . . . . . . . .
Direct Cremation. .........................
Total of Special Charges (D) . . . . . . . . . . . . . . . . . . .
E. Cash Advances
Opening of Grave. . . . . . . . . . . . . . . . . . . . . . . . .
Cemetery Equipment. . . . . . . . . . . . . . . . . . . . . .
Clergy/Mass Offering .. . .. . .. . .. .. . .. . .. . .
~~=:d'C~~i~~ '~f'~~fu Ce~~~t~' (io)::
Newspaper Notice . . . . . . . . . . . . . . . . . . . . . . . .
Cemetery Lot and Deed....................
Pallbearers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Airfare. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .
Vault Service Charge. . . . . . . . . . . . . . . . . . . . . . .
Honor Guard. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Organist. fl' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other I o('Q/\Je_/.5 faz....
$ ..--L
Transfer of Remains to Funeral Home . .. $--L
Sub-Total of I"rofessional Services (B1) . . . . . $~
2. ADDmONAL SERVICES AND FACILITIES I
VIsitation. .. .. . . . . . .. . .. . .. . . . .. .. .... $..--L
Funeral Service. .. .. .. . . .. . .. . .. .. .. '" $-L
Memorial Service. .. .. .. . .. .. .. . .. . .... $ +
Graveside Service ..... . . . . . . . . . . . . . . .. $---L-
Sub-Total of Additional i
Services and Facilities (62). . . . . . . . . . . . . . . . . $~
3. AUTOMO'ITVE EQU1PMENT I
Funeral Coach ........ . .. .. .. .. .. .. ... $--r-
Lead/Clergy Car. . . . . . . . . . . . . . . . . . . . .. $--t-
Flower Car............................ $
=y ~i~~~ 20'~~ Tr~~;t~ii~~:: ~ T
Sub-Total of Automotive Equipment (B3) . . . $ \
Total of Professional Services, Additional Services ~
and Facilities, and Automotive Equipment (B) . . $-115-
C. CHARGE FOR MERCHANDISE SELECTED
Casket
Description
Other Receptacle
Description
Outer Burial Container
Description $ _
Urn
Description $ ~
Acknowledgement Cards .................. $_0
MemorialFolders ......................... $_
RegisterBook............................. $ - 'R- Total of Funeral Home Ch"[8esand 3i.e!2-
CASH ADVANCES MUST BE REIMBURSED PRIOR TO SERVICE DAY ~ \e 7<t;tf1dV'f~t"6 . . . q 1iZ! i O~. . '~.i-~' . . . . . . $ (/
AGREEMEJ\IT: I agree that I have inspected the goods and services selected above and found them to be accurate and according to the ~ai1.gements rh~;-; selected. I admowledge receipt
of a copy of this Statement of Goods and Services Selected. It is understood that the total charges shown above may be estimated and reflect only that agreed upon at the titM of this
agreement. Any additional items of service or merchandise ordered or required after the time of this arrangement shall be considered part of this agreement and the cost will be reflect-
ed on your Final Statement which we provide.
TERMS: TI1is is a cash transaction due in full in 30 days. and in all events becomes past due and delinquent after the 3D days date. A penalty of 15% per annum (1.25% monthly) will be
charged for unanticipated late payment effective on the 31st day.
WARRANTIES: The only wananty of the merchandise sold in connection with this agreement is the express written warranty (if any), provided by the IlWlufacturer. The funeral direc~
tor makes no warranty (expn!ssed or implied) with respect to any funeral merchandise. .
AUTHORIZATION: I or We ,authorize and ratify prior consent to the funeral director to take possession of the body, give care to and carry out the arrangements hereto specified and
agreed to. I or We represent ourselves as the person(s) having the legal right to arrange for the final disposition of the above named decedent. and do hereby grant authority to the funeral
directOr to supply the services and merchandise as listed above. I or We guarantee the payment of this contract according to the above terms, and also agree to pay any attorney fee or
legal jud~ment imposed upcln the collection of the cost of this service agreement. ~ /-; L /." ~ 7") ,~_ , ? . ./
Oral Permission to Embalm the above named decedent o Was granted aWas refused by rof. 1"/ I?er --A!_A-!"- !'")("'( 1:;<;( '4.....- L) ~ I -
<, '<1;7 Na
i ") (f_~ ..t....~---e._ ..,--~ on / I at approx. (am) (pm) a by phone Q in person,
, Rela . hip
FINAL ACCEPTANCE: I or We accept and appro~ the above selections and terms, and acknowledge that the general price list effective / II 10';;' casket price
list effective II / J;;h and outer b. urial'price lisl'effective r" II lo(pwere made availabl'e pJ:i'or to selection of services.
X- ... :I _ ~__ qj/y/o~
'" SignatUre of P\u1:ba&er' I Da~ Signature of Co-Purchaser
I Statement To:
$-
$-
$-
$-
$~
$~
$-
$-
$-
$-
$-
$-
$ ;;? S-
For your convenience, we will advance the cost of the foregoing items; however, any
error made by any supplier of services shall be the sole responsibility of that suppliet'
and our funeral home is relieved of liability therefore by acting as your agent. Hetrick
Cremation Services is entitled to take and retain any discounts offered on the purchase
of a cash advance item.
$~
$~
$-
$-
$-
$ 27s-
$ ---'BS
Total of Cash Advances (E) . . . . . . . . . . . . . . . . .. . .
A. PACKAGE ARRANGEMENTS .............
B. ADDmONAL SERVICES / FACILITIES. . . .
C. MERCHANDISE..........................
D. SPECIAL CHARGES .. . .. . .. . .. . .. . .. . .. . .
$-
$-
Total of Funeral Home Charges. . . . . . . . . . . .
E. CASHADVANCES.. '" .., '" .., '" .., ....
tl-15ti~
/-/
~.>e.j//:;.J.<-
/ Title
Accepted By
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cunilierland County - Register Of wills
One Courthouse Square
Carlisle, PA 17013
Rece~pt Date:
Rece~pt Time:
Recelpt No. :
7/23/2007
10:49:13
1049261
ESHELBY ELIZABETH E
Estate File No. :
Paid By Remarks:
2007-00693
B L BAIR
JA
------------------------ Receipt Distribution ------------------------
Fee/Tax Description
PETITION LTRS ADM
AUTOMATION FEE
SHOET CERTIFICATE
RENlJNCIATION
INVENTORY
JCP FEE
Check# 3230
Total Received.........
Payment Amount
30.00
5.00
8.00
10.00
15.00
10.00
----------------
$78.00
$78.00
Payee Name
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
CUDmerland County - Register Of wills
One Courthouse Square
Carlisle, PA 17(J13
Receipt Date:
Receipt Time:
Receipt No.:
9/24/2007
11:19:16
1049983
ESHELBY ELIZABETH E
Estate File No. :
Paid By Remarks:
2007-00693
AJW
Fee/Tax Description
Receipt Distribution ------------------------
Payment Amount Payee Name
SHORT CERTIFICATE 8.00
----------------
Cash $8.00
Total Received......... $8.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, P A 17013
November 16,2007
-,
,
Cumberland Law Journal is published every Friday by the Cumberland County Bar
Association and is designated by thre Court of Common Pleas as the official legal publication for
Cumberland County and the legal newspaper for publication of legal notices.
TO:
Luther E. Milspaw, Jr., Esquire
Elizabeth E. Eshelby Estate
'i01k
RE:
Legal advertisements must be received by Friday Noon. All legal advertising must be
paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on the following dates:
November 2, November 9, and November 16,2007
Advertising Cost $ 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Payment received $ 0.00
-------------
Total Amount Due $ 75.00
---------
-------
Payment received by
REV-1!i12 EX+ (12-03) '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF
Elizabeth E. Eshelby
FILE NUMBER
21-07-0693
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
'I. Discover Card - Printable year-end summary shows payment of $8,831.31 after 000; Final statement
10.
11.
12.
13.
14.
15.
shows a remaining balance of $232.33.
8,985.64
641.52
'"'
to..
West Shore EMS - unpaid medical bill
3.
West Shore Pathology - unpaid medical bill
43.53
4.
Burick Azizkhan, M.D. - unpaid medical bill
254.44
5.
Spirit Physician - unpaid medical bill
31.36
6.
7.
Zlotoff, Gilfert, & Gold - unpaid medical bill
66.28
PA Orthopedic Institute - unpaid medical bill
26.99
8.
Silver Spring Ambulance - unpaid medical bill
71.96
9.
Kantor & Ktach, M.D. - unpaid medical bill
27.50
Central Pulmonary - unpaid medical bill
242.20
19.12
Kunkel Associates - unpaid medical bill
Heritage Medical Group, Inc. - unpaid medical bill
14.32
Camp Hill ER Physicians - unpaid medical bill
40.27
Holy Spirit Hospital - unpaid medical bill
109.50
20.91
Physicians of Rehabilitation, Industrial & Spine Medicine - unpaid medical bill
10,595.54
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
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-
Discover Platinum Card Account Summary
==
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~
!!!!!!!!
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-
Cardmember since 1986
Account Number 6011 002293001244
Payment Due Date January 24, 2007
Minimum Payment Due $22.00
Credit Limit $15,500.00
Credit Available $15,267.00
Cash Credit Limit $11,700.00
Cash Credit Available $11,502.00
Closing Date: December 25,2006 page 1 of 2
Previous Balance $21 3.44
Payments And Credits 0.00
Purchases + 15.00
Cash Advances + 0.00
Balance Transfers + 0.00
Finance Charges + 3.89
New Balance $232.33
You may be able to avoid Periodic Finance Charges, see the
reverse side for details.
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-
-
-
-
-
==
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==
-
-
==
.Cashback Bonus@
Opening Cashback Bonus Balance
New Cash back Bonus Earned
$
+
15.87
0.00
15.87
0.00
Cash back Bonus Balance
Available to Redeem
$
$
Cc.:~bcc~ ~..::::;:~ ,~"iii-:"'~;Aii'i
Date: June 25
How Can We Help You?
Please have your Discover Card avaaable.
Manage your account online at Discovercard.com
Customer Service: 1-800-DISCOVER (1-800-347-2683)
For Account Inquiries, write to us at:
Discover Platinum Card, PO Box 30943
Salt lake City, UT 84130
TOO (Telecommunications Device for the Deaij:
For assistance, see reverse side.
==
iiiiiiiiiiOi
~
Transactions
$0 Fraud Uability Guarantee Use your Discover Card with confidence.
Trans. Post
Date Date
Dee 25 Dee 25 LATE FEE
15.00
Other/Miscellaneous
$.
Information For You
~ While we are permitted under the Cardmember Agreement to increase the APRs on your Account because your payment
was late, we have chosen not to do so at this time. We hove terminated, however, any introductory or promotional rote on
purchases and any special balance transfer rote, and applied the standard APR for purchases to your outstanding balance of
purchases and balance transfers. However, we reserve the right to increase the APRs on your Account if you foil to pay the
minimum payment due by il,e p..ymenj~Jue d..ie. See ihe Default Roie Plull sedioll of the Cordmember Agrlolemeni for
details.
... ATfENTlON ... Your account is post due. Please pay the post due amount now, or contact us to make other
arrangements.
Cut back on mailbox c1utterl Sign up for Paperless Statements and simplify the way you manage your account. We'll send
you an e-mail as soon as your statement is available online. And,whileyou'reatDiscovercard.com, you can pay your bill
quickly and easily. Sign up at Discovercard.com/ps
I/~
I L)
Ij)/CJ7
It pcIy$ ...
DISCeVER:
Discover Card: Printable Year-End Summary Statement
Page 1 of3
DISC()VER'
CARD
...
etO:';(1 Window
2006 Year-End Summary
ELIZABETH E ESHELBY
77 BEECHCLlFF DR
CARLISLE, PA 17015-9098
(717) 691-0761
Last 4 Digits of Account Number:
1244
2006 Year-End Summary
Statement
Note: Totals may not reflect your
current balance
Total Purchases, Cash
Advances and Balance Total Payments -
Transfers $ 891.47 and Credits $11,724.17
Totals for All Categories
Payments and $ - Gasoline $ 107.90
Credits 11,724.17
Merchandise! Retail $ 690.57 Other! $ 93.00
Miscellaneous
Transactions for this Summary
Trans, Post
Date Date Description
01/06/06 01/06/06 0195 SHEETZ00001958498
MECHANI
01/15/06 01/15/06 PAYMENT - THANK YOU
Amount Category
$ 36.25 Gasoline
$ -279.35 Payments and
Credits
01/19/06 01/19/06 MEDCO HEALTH FT WORTH $ 40.00 Merchandise/ Retail
80088870
01/26/06 01/26/06 MEDCO HEALTH FT WORTH $ 18.63 Merchandise/ Retail
80088870
02/17/06 02/17/06 MEDCO HEALTH FT WORTH $ 7.34 Merchandise/ Retail
80088870
https://www.discovercard.com/cardmembersvcs/statements/ app/yesPrint?sortColumn=tra... 10/21/2007
Discover Card: Printable Year-End Summary Statement
Page 2 of3
02/19/06 02/19/06 PAYMENT - THANK YOU $ -449.57 Payments and
Credits
03/01/06 03/01/06 MEDCO HEALTH FT WORTH $ 53.42 Merchandise/ Retail
80088870
03/09/06 03/09/06 MEDCO HEAL TH FT WORTH $ 36.52 Merchandise/ Retail
80088870
03/21/06 03/21/06 MEDCO HEALTH FT WORTH $ 40.00 Merchandise/ Retail
80088870
03/21/06 03/21/06 PAYMENT - THANK YOU $ -325.97 Payments and
Credits
03/29/06 03/29/06 MEDCO HEALTH FT WORTH $ 40.00 Merchandise/ Retail
80088870
03/31/06 03/31/06 MEDCO HEALTH FT WORTH $ 13.35 Merchandise/ Retail
80088870
04/03/06 04/03/06 MEDCO HEALTH FT WORTH $ 20.00 Merchandise/ Retail
80088870
04/16/06 04/16/06 PAYMENT - THANK YOU $ -429.94 Payments and
Credits
04/17/06 04/17/06 MEDCO HEALTH FT WORTH $ 40.00 Merchandise/ Retail
80088870
04/19/06 04/19/06 TURKEY HILL #0268 Q69 $ 36.75 Gasoline
MECHANIC
04/20/06 04/20/06 MEDCO HEALTH FT WORTH $ 27.11 Merchandise/ Retail
80088870
04/21/06 04/21/06 MEDCO HEALTH FT WORTH $ 20.00 Merchandise/ Retail
80088870
05/16/0605/16/06 MEDCO HEALTH FTWORTH $ 7.34 Merchandise/ Retail
80088870
05/18/06 05/18/06 PAYMENT - THANK YOU $ -497.21 Payments and
Credits
06/15/0606/15/06 MEDCO HEALTH FTWORTH $ 18.66 Merchandise/ Retail
80088870
06/16/06 06/16/06 PAYMENT - THANK YOU $ -307.34 Payments and
Credits
06/26/06 06/26/06 MEDCO HEALTH FT WORTH $ 40.00 Merchandise/ Retail
80088870
07/07/06 07/07/06 MEDCO HEALTH FT WORTH $ 35.79 Merchandise/ Retail
80088870
07/08/06 07/08/06 MEDCO HEALTH FT WORTH $ 13.42 Merchandise/ Retail
80088870
07/13/0607/13/06 MEDCO HEALTH FTWORTH $ 40.00 Merchandise/ Retail
80088870
https ://www.discovercard.comlcardmembersvcs/statements/app/yesPrint?sortColumn=tra... 10/21/2007
Discover Card: Printable Year-End Summary Statement
07/16/06 07/16/06 PAYMENT - THANK YOU
07/26/06 07/26/06 MEDCO HEALTH FT WORTH $
80088870
07/31/06 07/31/06 MEDCO HEALTH FT WORTH $
80088870
08/03/06 08/03/06 MEDCO HEALTH NETPK $
8002822881
08/07/06 08/07/06 MEDCO HEALTH FT WORTH $
80088870
08/08/06 08/08/06 MEDCO HEALTH FT WORTH $
80088870
08/21/06 08/21/06 MEDCO HEALTH FT WORTH $
80088870
08/22/06 08/22/06 PAYMENT - THANK YOU $
08/23/06 08/23/06 SHEETZ 00001958498 $
MECHANICSBU
08/24/06 08/26/06 MEDCO HEALTH FT WORTH $
80088870
09/02/06 09/02/06 TWX* J692WR*GD $
HSKEEPNG 800-607
9393645A-0000008
09/25/06 09/25/06 LATE FEE
10/25/06 10/25/06 LATE FEE
10/28/06 10/28/06 PAYMENT - THANK YOU
12/25/06 12/25/06 LATE FEE
~~
Page 3 of3
$ -318.66 Payments and
Credits
9.65 Merchandise/ Retail
40.00 Merchandise/ Retail
20.00 Merchandise/ Retail
7.34 Merchandise/ Retail
20.00 Merchandise! Retail
40.00 Merchandise/ Retail
-284.82 Payments and
Credits
34.90 Gasoline
20.00 Merchandise/ Retail
22.00 Merchandise/ Retail
'i7S 3.3 /
$ 39.00 Other/
Miscellaneous
$ 39.00 Other/
Miscellaneous
$ -8,831.31 Payments and
Credits
$ 15.00 Other/
Miscellaneous
gg3/.3/
.3~-
2j7-9--i ' 3 i
3/
<Z7 ,5"3 . 3 I
@ 2007 Discover Bank, Member FDIC
https ://www.discovercard.comlcardmembersvcs/ statements/ app!yesPrint?sortColumn=tra... 10/21/2007
Date ICD9 CO PL* Description Amount Balance
Balance forward last stat 0.00
09/12/06 518.81 IH 99291 CRITICAL CARE, (74 NUTES) 400.00
10/04/06 MED MEDICARE PAYMENT -161.10
10/04/06 MCDS MEDICARE DISALLOWANC -198.62
11/03/06 INDN INSURANCE DENIED 0.00
09/12/06 -
09/12/06 518.81 IH 99292 CRITICAL CARE, ADDL o MIN 800.00
10/04/06 MED MEDICARE PAYMENT -323.30
10/04/06 MCDS MEDICARE DISALLOWANC -395.88
11/03/06 INDN INSURANCE DENIED 0.00
09/13/06 518.81 IH 99291 CRITICAL CARE, (74 NUTES) 400.00
10/04/06 MED MEDICARE PAYMENT -161.10
10/04/06 MCDS MEDICARE DISALLOWANC -198.62
11/03/06 INDN INSURANCE DENIED 0.00
09/13/06 -
09/13/06 518.81 IH 99292 CRITICAL CARE, ADDL o MIN 800.00
10/04/06 MED MEDICARE PAYMENT -323.30
10/04/06 MCDS MEDICARE DISALLOWANC -395.88
11/03/06 INDN INSURANCE DENIED 0.00
A
~/\l\ \.v
Current Amount Past Due Amount I Please Pay This Amount :1 $ 242.20
$ 242.:20 $ 0.00 CENT
Place Codes: IH=ln Patient UH=Uut Patient I::K=l:.mergency Koom
RAl PA PULMONARY ASSOC.
2250 MilLENNIUM WAY,#400
ENOlA, PA 17025
STATEMENT
1/111111111111111111111111111111111111111111111111111111111I SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION
Tax 1.0.562382216
Tel: 888/624-3704
Patient: ESHElBY,ELlZABETH E
0308 . 386
t:'HYSICIANS OF REHABILITATION, INDUSTRIAL & SPINE MEDICINE, P.C.
175 Lancaster Boulevard
P.O. Box 2028
Mechaflicsburg, PA 17055
(717) 691-375!)
Billing Dept: (717) 691-4879
A.NSACTlON DATE INV. NO. POS.
4310 Londonderry Road
Bloom Bldg. Suite 106
Harrisburg, PA 17109
(717) 561-4242
Tax 1.0. #25-1651500
Michael F. Lupinacci, M.D.
William A. Rolle, Jr., M.D.
Eric E. Hansen, M.D.
www.prismdrs.com
4950 Wilson Lane
STATEMENT
PATIENT
DR.
PROCEDURE
Mechanicsburg, PA 17055
(717) 691-4847
Christopher Royer, PsyD
Amy J. Kurcirka, PsyD
Usa A. Eaton, PsyD ACCOUNT
Please retain this portion of statement for your records. NUMBER ()435IZl0
DESCRIPTION OF SERVICES DIAGNOSIS AMOUNT
STATEMENT DATE
PAGE
0E./ 13/0E
0J.
5/;:~3/06 RE EL r ZAE EEl- 9931215 SKILL NRSG, INIT~ LEI.,.I 3 781c~ i::~ 2 5;: ~::HZt
5/0'3/1215 EL I ZAE EH. 10 PAYttJENT --tr1ED I CARE 8,311 65-
5/1219/1215 EL I ZAE EEl- L~0 j'71ED I CAI:;:E D I SALLO\.oJ 120.4A.-'
YOU Hf=VE ~NY QUESTICNt:"), PLEASE CALl.. 591-'-487'":3
ET\.-JEEN f:: 30 Atr1 AND 4: v.. ILi ~ tr1.
PLEASE CALL OUR OFFICE WIn ANY
ADDITIONAL INS JRANCE INFORMATION
CURRENT
OVER 30 DAYS
OVER 60 DAYS
OVER 90 DAYS
OVER 120 DAYS
..oIIlIIII-. ACCOUNT
........ AGE
ANALYSIS
TOTAL ~
AMOUNT ..,......
DUE
20.91
;::~0. 91
r"L.t:M,:)t: Ut:IM\"".n MI"iU nt:IUn.I"i IUt'" "'Ul"{IIUI~ YYIIM TUUI"( t'ATMt:NI
09/13/2006
09/13/2006
09/13/2006
10/18/2006
10/18/2006
01/03/2007
ELIZABETH E ESHELBY IDi 225614/STANLEY B LEWIN MD
ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE D
DOPPLER ECHOCARDIOGRAPHY. PULSED WAVE AND/OR CONTINUOUS
DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING CL
SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE
PAYMENT FROM MEDICARE
PATIENT RESPONSIBILITY - UNITED HEALTHCARE DENIED CLAIM STATING THE
--> POLICY WAS TERMINATED ON 9/13/06. PLEASE REMIT PAYMENT. THANK
--> YOU!
119.00
50.00
31.00
-128.44
-57.24
-14.32
119.00
50.00
31.00
BALANCE TICKET iIH053186
.00
Make Checks
Payable To:
HERITAGE MEDICAL GROUP, LLP
For Billing Questions Call
(717) 972-2829 x 20
PLEASE DO NOT SEND CASH THROUGH THE MAIL
EG2651-32
Jr.OOl014GOO*
PAGE 1 OF 1
01 462
0.00
0.00
0.00
0.00
0.00
14.32
14.32
14.32
.00
14.32
~LY
~
The Spi'nt of Caring
Holy Spirit Hospital
503 N 21ST STREET
CAMP HILL PA 17011
#
717-763-2138
1111111
For Account Information, Please Call717-763-2138
t-
08/24/06
08/24/06
08/24/06
08/24./06
08/24.1'06
10/02,(06
10/02./06
10/10I06
Description
PREVIOUS BALANCE
PROTHROMBIN TIME
SPEC COLLECT FEE
SPEC COLLECTION FEE
CT ABD W/WO CNTRS
CT PELVIS W CNTRS
MEDI PVMT-HOSP OP
MEDI CIA HOSP-OP
UNITED HEALTH CARE
MID MEDICARE OP A
MID MEDICARE OP A
P Q15 UNITED HEALTH
Amount
.00
7.25
11.00
3.00
2,939.00
2,250.00
333.11-
4,662.73-
104.91-
Transaction Date
u- '1,-\:S LP
Estimated Insurance Due; .00 Total Patient Credits:
YOUR INSURANCE HAS BEEN BILLED.THIS IS YOUR CURRENT
BALANCE. YOUR PAYMENT IS DUE UPON RECEIPT. THANK YOU.
M10 MEDICA,RE OP A .00 Q15 UNITED HEALTH .00
PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID.
Account Balance:
109.50
Please, detaCh and return with your payment
.Z=."--.~
_...__~r:III1~-""''''
..........,.. .....-..... ...~.
..111'=1-1.-'1_ _.... L- ra.......:.U ..~ .r:..-:1......
09/13/0623 Elizabeth
10/06/06
10/06/06
11/10/06
99253 Inpatient Consult,low
Adj:Medicare Writeof
Plan Payment:l076877
Plan Payment:OOOO
038.10 190.00
94.42-
76.46-
0.00
19.12
! y(;;fu
MAKE CHECKS PAYABLE TO:
Kunkel Surgical Group
PROVIDER/ .
PRACTICE NAME Kunkel SurgJ.cal Group
I . AN ASTERISK APPEARS ON ACCOUNT ESHEEl- 00
CHARGES FILED FOR INSURANCE NUMBER
11/29/06:
STATEMENT DATEI
DA TE OF LAST
PAYMENT
FOR BILLING
INQUIRIES,CALL 717-761-7244
CURRENT
0.00
OVER 30 DAYS
PAYMENT
DUE DATE
0.00
OVER 60 DAYS
0.00 19.12
OVER 120 DAYS PLEASE PAY THIS AMOUNT
TRANSACTIONS AFTER THE CLOSING DATE WILL APPEAR ON YOUR NEXT STATEMENT
"e"'Z'%~.
..." ~ .~.... , :1
, ,
ASTSTA1'EMENT YOUR PAYMENTS IIISURAltCE PATIENTS ADJUSTMENTS
35.39 0.00 -55.00
_=".'.'h-' . . . , .....--." . .
YOUR RESPONSIBILITY 30.51 0.00 30.51
INSURANCE PENDING 0.00 0.00 0.00
29580
ROSSO
P9/18/06 IN?MEDI .
~~/18/06 MEAD,)
ll/27/06 CHECK
'8/30/06 11041
ROSSO
'9/18/06 INPMEDI
'9/18/06 iMEADJ
'9/06/06 11041
I~OSSO
'9/26/06 INPMEDI
'9/26/06 11EADJ
'9/11/06 99213
HOSSO
l0/06/06 INPMEDI
l0/06/06 NEADJ
~BOOT
l.INSUR . BILLED. AMOUNT DUE
fIIf+DICARE PAYMENT
M~D!CARE ADJUSTMENT
PATIENT CHECK PAYMENT
m~~~~D SKIN. FULL THICKt~ESS
~t~'i(INSUR. BIL LED. AMOUNT DUE
~EDICARE PAYMENT
MEDICARE ADJUSTMENT
'9.~aRID SKIN. FULL THICKNESS
~.~I INSUR. BILLED. MOUNT DUE
MEDICARE PAYMENT
MEDICARE ADJUSTMENT
{fSTABLISHED PT. INTER~1 VISIT
'SAtANCE INDICATES PTS COPAY
MEDICARE PAYMENT
MEDICARE ADJUSTMENT
[S IS YOUR STATEMENT FOR SERVICES RENDERED. THE PERSONAL
_ANCE SHOWN IS YOUR FINANCIAL RESPONSIBILITY AND IS NOT
IERED BY YOUR INSURANCE. YOUR PROMPT PAYMENT IS EXPECTED.
lTOFF, GILFERT & GOLD
717/761-3161
-27.57
-20.53
-3.38
115.00 payment 5.67
-22.68
-86.65
115.00 payment 11. 34
-45.35
-58.31
55.00 payment 9.98
-39.91
-5.11
r----"
--1~Cv)
30.51
PLEASE PAY
THIS AMOUNT
. ,TI ~
ASTSTATEflEHT YOUR PAYMENTS INSURANCEPAYlENT$ ADJUSTMENTS
0000 223068 -285039
:' ,
07/20/1,:)()
07/20/06
08/01/0r;
(1t~/?1/('6
08/21/~H)
0BjQ)9/(l6
08/;:8/M,
08!2f:;/r,;,6
~m/lf:)1';j6
(19/05/06
09/05/06
29580
ROSSO
INPMEDI
MEAD,]
11041
ROSSO
INPt~EDI
MEAD,]
29580
ROSSO
INPMEOI
I~EAOJ
YOUR RESPONSIBILITY
INSURANCE PENDING
;OEB~lOEMENT NAILS, SD:
ALL XNSUR. BILLEO. M10Ui'n~ !'J:i
MEDICARE PAY~IEtn
MEDICARE ADJ US11"iErrr
UNNA BOOT
ALL INSUR. BILLED, AMOUNT OU
MEDICARE PAYi'lEiH
MEDICARE ADJUSTi'1Ei'H
SKIN, FULL THICKN
INSUR. BILLED, PJiCiI)l'lf UU:
MEDICARE PAYMENT
MEDICARE ADJUSTHE~l
UNNA BOOT
ALL INSUR. BILLED, MiOUI'!1 1.11
MEDICARE PAYMENT
MEDICARE ADJUS1ME~T
J' (~;'1 \( ou r~~ ST f\ TC i'll !:-" Nl-- F: 0 e (::; :~. f?\/ I C [' ~~,; P E r.j D E F? C' D ~ 'i"'l-! [
r::: C) 1,1 Pi Ie
L Pi j',\C', E~ S },.\ C:\/..\j'.-l I ~::) V 01....1 f~ F .1)',1 Pi I'.) C' I (\ L f;~ ESP 0 )'.-1 ~:::; I 8 T 1.._ :,{ T \/ (\ [\! [J
j'l!C!T
h:F,LJ e\/ 'y'OUP, },j\!SUnr11',!CF " 'y'f)tJr? F:>pOf'IPT Fl-\"/i"lE'i'.1T' J: F'x'P C'T'C
I)TU "CILi P I;, C IJ
)'-1:/ ,/761---:::; 161
5 ~::) ~ ,? (1
l1S.00
~:)s" 0(')
7if
. . .
35.77 0.00
0~C'~) O,(iJc/!
-:;:;0. i j
./ ..
paYlTl Ii
-3\) ., f;~
--16,. /~
pay;il'.'11 i
1 J
__.q !-"~! ., 'j C"
~~ :~;o ~::;
paYl1Ic'>I!
, i
-9 0"1
:35. T?
PLEASE PAY
THIS AMOUNT
U.J,..,c..c..-~
1...111...111......11.1.1.1.1..11...1.1..1..1.1...11...1 ,11..1
082516-0000028439040-06
#BWNJFDB
#0000000HYP335565#
ELIZABETH E ESHELBY
77 BEECHCLlFF DR
CARLISLE PA 17015-9098
, 1*'1'\
Ot-- '7V:k
STATEMENT OF ACCOUNT (
Statement Date: MARCH 18, 2007
ACCOUNT NUMBERI
CUENTAS DEL PACIENTE: HYP28439040
S
Tax ID #: 20-4667340
Account Balance: $40.27
Amount Pending
Insurance: $20.21
Amount Due from
Patient (Current): $40.27
Amount Due from
Patient (Past Due): $0.00
I Pay this Amount: $40.27 I
PLEASE REMIT PAYMENT BY
"PAYMENT DUE BY" DATE. THANK VOll
Plea.. refer to coupon below for paym..,
Instnlctlons.
N
CAMP HILL EMERGENCY PHYSICIA
PO BOX 13693
PHILADELPHIA. PA 19101-3693
Account Detail
PATIENT
Paid By Paid By Paid By Amount Due From BAI.ANCE
Date . Charge FIrst Inl. Other Inl. PatIent AcIJullled Insurance
09112/06 1 99291-25 CRITICAL CARE, FIRST $926.00
HOUR PITAL
DX:7S0.09 DR. MAGUIREJHOL Y SPIRIT H01
01118107 MEDICARE CONTRACTUAL ALLOWANCE $724.62-
01/18107 MEDICARE PAYMENT $181.10-
03I131f17 INSURANCE PAYMENT $0.01- $40.27
09112/06 2 99292 CRITICAL CARE fA. 1/2 HOUR "" $483.00
DX:780.09 DR. MAGUlRElHOL Y SPIRIT HO TAL
01/18107 MEDICARE CONTRACTUAL ALLOWANCE $381.97-
01/18107 MEDICARE PAYMENT $8o.s2- $20.21 $O.OC
/\
Totals $1.389.00 $241.112- $0.01- $0.00 $1,086.59- $20.21 ( $40.27
Important Messages: .~n
this lta\!ement Is for \he dnc.t treatment and/or 1=:'1on of care r::. recent~1ved from an Emelge~ ~ Holy SplIt HoaplaL The '- for this prt,Iate
_ billed aeparal8ly from any hoIpIIal ell es or profeaalonal for wh you may allo be reaponable. . should you recelve a biB from \he IlaJ or' olI1er.
phyalclana for charges ~ corinectiQn wllh ~ viall, l will not InWde \he lteml Raled on this atatement.
ho8p
"Payment Plans" Accepted I Aceptamos "Planes de Pago"
Question about this statement? I L1ame de Lunes a Vlernes?
Call 1-800-355-2470 Monday through Friday 9:30AM - 4:00PM.
Your automated system access code Is 801-28439040, or you can send emall to
billing questions@emcare.com.
Please detach and reTurn bottom portion with your remittance.
~ ~ Favor de separar y mandar la parte de abaJo con el cheque. ~ ~
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT
DATE PROVIDER EXPLANATION OF ACTIVITY PATIENT NAME CHARGES PAYMENTS
NAME AND DEBITS AND CREDITS
062806 BaAL MO,
EaCH CPT: 99213 DX: 724.2, ELIZABETH E
OFFICE OUTPT VISIT EST
MEDICARE PAYMENT 881588185
MEDICARE ADJUSTMENT
$9.98 UNITED HEALTHCARE co INS TLA
60.00
080706
1080706
101806
I
-39.91
-10.11
I
I
I
I
I
I
I
I
I
I
t~~~-'-:~:Zi::~~:"i~O~:' ::ER W"E:O~~"G OORomeE
j 9.98 9 98
ISEND INQUIRIES TO: .. .. ...-.-.. ...-.-..-------'--.-.-
I OSL DBA ORTH INSTITUTE OF PA (717) 761-5530
I 3399 TEaNDLE ROAD
I. ~~ ~:~3~8755:.~: 7011 .. .........._......._..
lll~
I YC:3
13690
PATIENT BALANCE
PAY THIS AMOUNT
9 98
l..HAKbt:;:, AJ-'f-'t:AKIi'lb Ul'< I HI'::> ;:, IAI t:IVIt::,: AKt: NU I IN\.;lUUt:U UN ANY HU;:,t-'IIAl bill UK::; IAI t:Mt:.N I
DATE PROVIDER EXPLANATION OF ACTIVITY PATIENT NAME CHARGES PAYMENTS
NAME AND DEBITS AND CREDITS
083106
083106
112706
080206
080206 BOAL MO, RICH CPT: 99213 DX: 724.2, E849.6
OFFICE OUTPT VISIT EST
MEDICARE PAYMENT
MEDICARE ADJUSTMENT
$9.98 UNITED HEALTHCARE CO INS TLA
BOAL, RICHARD CPT: 72100 DX: 724.2, E849.6
LUMBOSACRAL SPINE, 2 VIEW
MEDICARE PAYMENT
MEDIClIRE AD.:i1JSTMENT
$7.03 UNITED HEALTHCARE CO INS TLA
ELIZABETH E
60.00
881610435
-39.91
-10.11
ELIZABETH E
81. 00
083106
083106
112706
881610435
-28.13
-45.84
'~l 7 tfG'7
STATEMENT
CLOSING DATE 12/05/06 PLEASE INDIC::rE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE:
CURRENT 30-60 DAYS 60-90 DAYS > 90 DAYS TOTAL
17.01
SEND INQUIRIES TO:
OSL DBA ORTH INSTITUTE OF
3399 TRINDLE ROAD
CAMP HILL PA 17011
IRS #: 231875547
17.01
PA
("117) 761-5530
09/01/2006
PAYMENTS AFTER THIS
DATE WILL APPEAR ON
YOUR NEXT STATEMEI\iT
BALANCE
AMOUNT DUE
ACCOUNT NUMBER
DATE OF STATEMENT
26*2619344
$30.98
PATIENT NAME
INSURANCE DENIED PAYMENT. IF YOU HAVE ANY QUESTIONS, CALL
YOUR INSURANCE COMPANY. PA YMENT IS YOUR RESPONSIBILITY.
PLEASE MAIL PA YMENT IN FULL TODA YI!
ELIZABETH E ESHElBY
BILLING HOURS ARE lOAM TO 4PM
iiiiii
!!!!!
-
!!!!!
iiiiii
iiiiii
~
iiiiii
iiiiii
!!!!!
Place of Service: HOLY SPIRIT HOSP IP
Referring Doctor: PAUL LICATA MD
MAKE CHECKS PAYABLE TO:
WEST SHORE PATHOLOGY
PO BOX 750
SCRANTON PA 18501-0750
800/238-3614
Date
Doctor
SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION
Code Description
88312 SPECIAL STAINS GROUP I
88305 SURG PATH SINGLE COMP
88307 SURG PATH GRS/MICRO CMPLX
1199 MEDICARE CONTRACTUAL ADJUSTMEN
1100 MEDICARE PAYMENT
UNITED HEALTH CARE
Page 1 of 1
Amount
05/19/200l3 HENRY J VENBRUX, MD
05/19/200E3 HENRY J VENBRUX, MD
05/19/2006 HENRY J VENBRUX, MD
06/14/2006
06/14/2006
08/04/2006
08/04/200€\
40.00
130.00
235.00
-250.11
-123.91
**"
s.2
~~~7
'l\!y?;\oLP +0
+1
For questions call, 800/238-3614 and when prompted enter your identification number as follows 2129*2619344
THESE SERVICES WERE PERFORMED BY THE PATHOLOGIST AT HOLY SPIRIT HOSPITAL.
PLEASE DETACH AND RETURN THE BOTTOM PORTION WITH PAYMENT
09/01/2006
PAYMENTS AFTER THIS
DATE WILL APPEAR ON
YOUR NEXT STATEM1:NT
BALANCE
AMOUNT DUE
ACCOUNT NUMBER
DATE OF STATEMENT
26*27746924
PATIENT NAME
$12.55
ELIZABETH E ESHElBY
INSURANCE DENIED PA YMENT. IF YOU HA VE ANY QUESTIONS, CALL
YOUR INSURANCE COMPANY. PA YMENT IS YOUR RESPONSIBILITY.
PLEASE MAIL PA YMENT IN FULL TODA YI!
BILLING HOURS ARE lOAM TO 4PM
iiiiiiiiiiiiiii
!!!!!!!!!
==
iiiiiiiiiiiiiii
iiiiiiiiiiiiiii
=
iiiiiiiiii
iiiiiiiiii
!!!!!!!!!
Place of Service: HOLY SPIRIT HOSP IP
Referring Doctor: DAVID S MIZE MD
MAKE CHECKS PAYABLE TO:
WEST SHORE PATHOLOGY
PO BOX 750
SCRANTON PA 18501-0750
800/238-3614
Date
Doctor
SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION
Code Description
SP112 CYTOPATHOLOGY SMEARS WIN
i 199 MEDICARE CONTRACTUAL ADJUSTMEN
1100 MEDICARE PAYMENT
UNITED HEALTH CARE
Page 1 of 1
Amount
110.00
-47.24
-50.21
05/19/2006 CHARLES EVANCHO, MD
06/12/2006
06/12/2006
08/04/2006
08/04/2006
***
For questions call, 800/238-3614 and when prompted enter your identification number as follows 2129*27746924
THESE SERVICES WERE PERFORMED BY THE PATHOLOGIST AT HOLY SPIRIT HOSPIIAL.
PLEASE DETACH AND RETURN THE BOTTOM PORTION WITH PAYMENT
Patient: ELIZABETH E. ESHELBY
Chart Number: ESHELOOO Services Provided at: HOLY SPIRIT HOSffiAl- WiC-SS
Amount Paid by Paid By
Insurance Guarantor Adjustments Remainder
-110.02 -132.48 27.50
Charge
270.00
Dates Procedure Procedure
09/13/06 9!~254 HOSP CONSULT
... NON COVERED BY UNITED
oj-
1'-\G
~
PAVMENT DUE BY:
l;tl Co pG
E:=
t Due 30 Day Past Due 60 Days Past Due 90 Days Balance Due
0.00 0.00 0.00 27.50
ENT HAS BEEN MADE RECENTLY, PLEASE DISREGARD THIS STATEMENT, THANK YOU
IFPAYM
Statement Number: 2129
Date of 1st Statement:
DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
~
9/12/06
__u....___,_.._._.. ___n" ,
9/12/06
9/12/06
9/12/06
9/12/06
9/12/06
10/17/06
1olfti06
Description
~a~i~ Life~upport Emergency
Mileage - .... . ....
Oxygen
. lSiscount,Medicare
Discount, Medicare
t:ii~c~~nI,Medicare
F>~Yrl1Emt
F>~Yrl1Em~
Total
Procedure
Code
A0429
.. A0425
A0422
Qty
1
12
Unit Price
390.00
,........___nm.......m_......_m_.....
7.50
45.00
/r- I
[/IL
-7Lj G?/
/5/,yk;G
We billed this claim, to YCJurin$f.imryce.; however, they have denied the claim. This balance is now
your respons. ibilit.y.... You mayc.CJ..n......t.a....c;ty. our insuarnce carrier regarding the denial. Please remit
. .. . I'.. ..... ". ...s....................
payment for the balance. Th~nk you.
Silver Spring Ambulance & Rescue Assn, 877214-6018
ESHELBY, ELIZABETH E. 06-49569
.---.,.
\
ie"'"
"\
PAY THIS AMOUNT 1111.
$71.96
AMBULANCE BILLING OFFICE: P.O. BOX 726. NEW CUMBERLAND. PA 17070-0726
Elizabeth E Eshelby(13474)/Theresa A l::lurlck mJ/n.:;Hi.n....lo4
Location: Holy Spirit Hospital
0511912006 Subsequent Hospital Care Level 2 $85.00 1.00 $85.00 $0.00
11110/2006 Medicare contractual Adjustment from Highmark Medicare Services 1077784 ($30.96) $0.00
11/10/2006 Medicare Payment from Highmark Medicare Services 1077784 ($43.23) $0.00
12/28/2006 Transfer from Insurance 1001566 ($10.81) $10.81
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility. Please remit payment.
$0.00 $10.81
Elizabeth E Eshelby(13474)/Theresa A Burick DO/HSH014044
Location: Holy Spirit Hospital
09/12/2006 Initial Inpatient Consult New/Est Le $240.00 1.00 $240.00 $0.00
09/27/2006 Medicare contractual Adjustment from Highmark Medicare Services ($20.00) $0.00
10/20/2006 Medicare contractual Adjustment from Highmark Medicare Services 1077222 ($30.41 ) $0.00
10/20/2006 Medicare Payment from Highmark Medicare Services 1077222 ($151.67) $0.00
12/04/2006 Transfer from Insurance ($37.92) $37.92
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility. Please remit payment.
$0.00 $37.92
Elizabeth E Eshelby(13474)/R George Azizkhan Jr DO/HSH014045
Location: Holy Spirit Hospital
09/13/2006 Subsequent Hospital Care Level 3 $100.00 1.00 $100.00 $0.00
10/20/2006 Medicare contractual Adjustment from Highmark Medicare Services 1077222 ($23.17) $0.00
1 0/20/2006 Medicare Payment from Highmark Medicare Services 1077222 ($61.46) $0.00
12/04/2006 Transfer from Insurance ($15.37) $15.37
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility. Please remit payment.
$0.00 $15.37
Ol~ (~7)
. ,;'v (Of 0
/' ,Il--
iI L'1
$0.00
$0.00
$64.10
$0.00
$0.00
$0.00
rf01f.1.:m"1iT~rrnJI:m~m~i:Fiill:f.l"II[ol:~
$64.10 $0.00 $64.10
. .. . .
1 1
,I
'I
. .
Burick Azizkhan Internal Medicine Associates * 888 Poplar Church Road * Camp Hill, PA 17011 * (717) 724-2126
Pay to:
Burick Azizkhan Internal Medicine
Associates
888 Poplar Church Road
Camp Hill, PA 17011
(717) 724-2126
Patient Statement
Tuesday, September 05, 2006
Page 2 of 3
Elizabeth E Eshelby
77 Beechcliff Drive
Carlisle, PA 17013
1 9D.?i-
I I ~
1!~')o y
I~S
-::fV
Date Description _ _ _ _ .:...__ _ _ _ _ ,_ Chec~ # - Fee - Units ' ,Insurance ~ Patrent
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility. Please remit payment
$0.00 $10.60
Elizabeth E Eshelby(13474)/Supriyo U. Ghosh MD/HTROOO878
Location: Healthsouth Transitional Rehab Center
OS/28/2006 Subsequent Nursing Facility Care $74.00 1,00 $74.00 $0,00
07/03/2006 Medicare contractual Adjustment from Highmark Medicare Services 1074870 $0,00 $0.00
07/03/2006 Medicare Payment from Highmark Medicare Services 1074870 ($59.20) $0.00
08/11/2006 Transfer from Insurance ($14,80) $14,80
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility, Please remit payment
$0.00 $14.80
Elizabeth E Eshelby(13474)/Supriyo U. Ghosh MD/HTROOO884
Location: Healthsouth Transitional Rehab Center
OS/29/2006 Subsequent Nursing Facility Care $53,00 1.00 $53.00 $0.00
07/03/2006 Medicare contractual Adjustment from Highmark Medicare Services 1074870 $0,00 $0,00
07/03/2006 Medicare Payment from Highmark Medicare Services 1074870 ($42AO) $0.00
08/11/2006 Transfer from Insurance ($10,60) $10.60
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility. Please remit payment
$0.00 $10.60
Elizabeth E Eshelby(13474)/Supriyo U. Ghosh MD/HTROOO893
Location: Healthsouth Transitional Rehab Center
06/01/2006 Subsequent Nursing Facility Care $53.00 1,00 $53,00 $0.00
07/07/2006 Medicare contractual Adjustment from Highmark Medicare Services 1074972 $0,00 $0.00
07/07/2006 Medicare Payment from Highmark Medicare Services 1074972- ($42AO) $0.00
08/18/2006 Transfer from Insurance ($10,60) $10,60
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility, Please remit payment
$0.00 $10.60
Elizabeth E Eshelby(13474)/R George Azizkhan Jr DO/HTROOO894
Location: Healthsouth Transitional Rehab Center
06/05/2006 Subsequent Nursing Facility Care $53.00 1,00 $53,00 $0,00
07/07/2006 Medicare contractual Adjustment from Highmark Medicare Services 1074972 $0,00 $0,00
07107/2006 Medicare Payment from Highmark Medicare Services 1074972 ($42AO) $0,00
08/18/2006 Transfer from Insurance ($10,60) $10,60
The primary insurance carrier information you provided the office is stating there is
another insurance carrier that is primary. Please call the office with the information
or this balance will be your responsibility,
$0.00 $10.60
Elizabeth E Eshelby(13474)/Steven A Prophet MD/HTROOO895
Location: Healthsouth Transitional Rehab Center
06/06/2006 Subsequent Nursing Facility Care $53,00 1.00 $53.00 $0.00
07107/2006 Medicare contractual Adjustment from Highmark Medicare Services 1074972 $0,00 $0,00
Buriclk Azizkhan Internal Medicine Associates * 888 Poplar Church Road * Camp Hill, PA 17011 * (717) 724-2126
.- 1 _ .... .._._..._i.ttf"'... - ----~
Elizabeth E Eshelby(13474)/Steven A Prophet MO/HSH013182
Location: Holy Spirit Hospital
05/16/2006 Initial Inpatient Consult New/Est Le $195.00 1.00 $195.00 $0.00
05/18/2006 Subsequent Hospital Care Level 2 $85.00 1.00 $85.00 $0.00
06/12/2006 Medicare contractual Adjustment from Highmark Medicare Services 1074419 ($88.44 ) $0.00
06/12/2006 Medicare Payment from Highmark Medicare Services 1074419 ($153.25) $0.00
07/21/2006 Transfer from Insurance ($38.31) $38.31
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility. Please remit payment.
$0.00 $38.31
Elizabeth E Eshelby(13474)/Theresa A Burick OO/HSH013183
Location: Holy Spirit Hospital
05/17/2006 Subsequent Hospital Care Level 2 $&5.00 1.00 $85.00 $0.00
06/12/2006 Medicare contractual Adjustment from Highmark Medicare Services 1074419 ($30.96) $0.00
06/12/2006 Medicare Payment from Highmark Medicare Services 1074419 ($43.23) $0.00
07/21/2006 Transfer from Insurance ($10.81) $10.81
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility. Please remit payment.
$0.00 $10.81
Elizabeth E Eshelby(13474)/Theresa A Burick OO/HSH013185
Location: Holy Spirit Hospital
OS/20/2006 Subsequent Hospital Care Level 2 $85.00 1.00 $85.00 $0.00
OS/21/2006 Subsequent Hospital Care Level 2 $85.00 1.00 $85.00 $0.00
OS/22/2006 Hospital Discharge Day Mgmt-30 Min & $90.00 1.00 $90.00 $0.00
06/12/2006 Medicare contractual Adjustment from Highmark Medicare Services 1074419 ($83.42) $0.00
06/12/2006 Medicare Payment from Highmark Medicare Services 1074419 ($141.26) $0.00
07/21/2006 Transfer from Insurance ($35.32) $35.32
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility. Please remit payment.
$0.00 $35.32
Elizabeth E Eshelby(13474)/Steven A Prophet MO/HTROOO866
Location: Healthsouth Transitional Rehab Center
OS/23/2006 Initial Inpatient Consult New/Est Le $195.00 1.00 $195.00 $0.00
06/12/2006 Medicare contractual Adjustment from Highmark Medicare Services 1074419 ($57.48) $0.00
06/12/2006 Medicare Payment from Highmark Medicare Services 1074419 ($110.02) $0.00
07/21/2006 Transfer from Insurance ($27.50) $27.50
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility. Please remit payment.
$0.00 $27.50
Elizabeth E Eshelby(13474)/Steven A Prophet MO/HTROOO867
Location: Healthsouth Transitional Rehab Center
OS/25/2006 Subsequent Nursing Facility Care $53.00 1.00 $53.00 $0.00
06/12/2006 Medicare contractual Adjustment from Highmark Medicare Services 1074419 $0.00 $0.00
06/12/2006 Medicare Payment from Highmark Medicare Services 1074419 ($42.40) $0.00
07/21/2006 Transfer from Insurance ($10.60) $10.60
Burick Azizkhan Internal Medicine Associates * 888 Poplar Church Road * Camp Hill, PA 17011 * (717) 724-2126
Pay to:
Burick Azizkhan Internal Medicine
Associates
888 Poplar Church Road
Camp Hill, PA 17011
(717) 724-2126
Patient Statement
Tuesday, September 05, 2006
Page 3 of 3
Elizabeth E Eshelby
77 Beechcliff Drive
Carlisle, PA 17013
Date Descnptlon _ ~ _ _ _ _v" _ __~ _ _ _ ~_ Check.#-. _Fee - - -Units .-lnsurance--- - --PatierJt-
07/07/2006 Medicare Payment from Highmark Medicare Services 1074972< ($42.40) $0.00
08/18/2006 Transfer from Insurance ($10.60) $10.60
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility. Please remit payment.
$0.00 $10.60
Elizabeth E Eshelby(13474)/R George Azizkhan Jr DO/HTROOO896
Location: Healthsouth Transitional Rehab Center
06/08/2006 Subsequent Nursing Facility Care $53.00 1.00 $53.00 $0.00
07/07/2006 Medicare Payment from Highmark Medicare Services 1074972< ($42.40) $0.00
07/07/2006 Medicare contractual Adjustment from Highmark Medicare Services 1074972< $0.00 $0.00
08/18/2006 Transfer from Insurance ($10.60) $10.60
This amount is your coinsurance as stated by your insurance carrier. This balance
is your responsibility. Please remit payment.
$0.00 $10.60
$0.00
$67.80
$122.54
$0.00
$0.00
rrnr.1~~;~:~~T~:~~:~~'i:F.l.~~;~'.;71
I " . .
, I
.,
. 0'
Surick Azizkhan Internal Medicine Associates * 888 Poplar Church Road * Camp Hill. PA 17011 · (717) 724-2126
-
STATEMENT OF PHYSICIAN SERVICES
;PIRIT PHYSICIAN SERVICE
05 GRANDVIEW AVE STE 210
:AMP HILL PA 17011
-- .--_.~-.----~...._-- _._~-_._~..- ._._...~~--- ---.-.--. --~-~----
ELIZABETH E ESHELBY
77 BEECHCLlFF DRIVE
CARLISLE PA 17013
.. .. ...._~-._h.n.upAGE
1 of 1
ACCOUNT #
t IF ANY QUESTIONS, PlEASE CONTACT: SPIRIT PHYSICIAN SERVICE
808253
STATEMENT
DATE: 12/23/06
LAST STATEMENT
DATE: 11/18/06
08121106 99214
09/08106
09/08106
12108106
401. 9
2S
PERFORMED BY: MARGARET GROFF HD
PLACE OF SVC: 11
PERFORMED AT: SH
EP LEVEL 4
W;ARE ERA PHT
W;ARE ERA CCJlI1V ADJ
taPAYHENT XFER TO GU
BALKE: ELIZABETH E ESHELBY $1.6.68
103.00
62.74-
24.58-
15.68
INDICATES Nf:N FINKIAL ACTMTY SINCE LAST BILL.
PATIENT BALKE S~ CI4 THIS STATEMENT IS DUE FRIIt YClJ. PLEASE
REMIT FULL MI.tlr PIHJIPTLY. PAYMENT IS DUE UPC14 RECEIPT OF THIS
STATEMENT .
HHTHESE SERVICES NERE PRDYIDED BY SPIRIT PHYSICIAN HH
HHSERYICES AND ARE SEPARATE FROM ANi taSPIT AL FEES HH
HHPLEASE CALL n7-972-4490 NITH ANY QUESTIC14S HH
~ERNING THESE CHARGES. HH
'{ \
(It- -1 L\
~j ) /' \ [)-7
1 "'") .
..an"ft.,.Aa.'P.. .,., lI!".e-~ ftr...._..., ........ ............." ~__..._._ ,..___..._.. __ __...__.__..._ ....._.. ..-...._ _ ...__.._...._
STATEMENT OF PHYSICIAN SERVICES
,PIRIT PHYSICIAN SERVICE
05 GRANDVIEW AVE STE 210
:AMP HILL PA 17011
ELIZABETH E ESHELBY
77 BEECHCLlFF DRIVE
CARLISLE PA 17013
-- . -llA~e----~-
1 of 1
ACCOUNT #
1- IF ANY QUESTIONS, PlEASE CONTACT: SPIRIT PHYSICIAN SERVICE
.. -".... ".....
808253
STATEMENT
DATE: 10/14/06
lAST STATEMENT
DATE: 09/09/06
06126/06 99214<
07/14</06
07/14</06
10113106
08121/06 199214<
09108106
09/08106
09/D5I06 ~15
I01M/06
I01M/06
2.S0.01
PERFORMED BY: MARGARET GROFF MD
PLACE OF SVC: 11
PERFORMED AT: SH
EP LEVEL 4<
tCARE ERA PKT
Jt:ARE ERA CONTRIADJ
tDIIAYMENT XFER TO SU
PERFO_DAT: SH
EP LEVEL 4< Z90
Jt:ARE ERA PKT
Jt:ARE ERA CONTRI ADJ
PERFORMED AT: SH
BLD COLL FEE
Jt:ARE ERA PKT
Jt:ARE ERA CONTRI ADJ
BALKE: EUZABETH E ESHELBY $15.68
103.00
62.74<-
~.S8-
103.00
62.74<-
~.S8-
7.00
3.00-
4<.00-
15.68
4<01.9
4<27 .31
0.00
INDICATES NEN FINAtCIAL ACTIVITY SItCE LAST BILL.
PATIENT BALKE SIDfi ON THIS STATEMENT IS IIJE FRIll YOO. PLEASE
REMIT FULL AtIUlT PlDlPTLY. PA'fMENr IS IIJE UPON RECEIPT OF THIS
ST AratENT .
Q(l1SS-
......-.u:SE SERVICES NERE PROVIDED BY SPIRIT PHYSICIAN ..
~RVICES AND ARE SEPARATE FRlJ4 INf IaSPITAL FEES ..
"PLEASE CALL n7-972-449D NITH INf QUESnH iIBBBf
~ERNINS THESE CHARGES. iIBBBf
'HanD?..,?. at C.C!'I: I\CTIf.,.u A..I\ "'Il!T,tn., D",..,.,.",.. DnaTI"'.. ^r ll!'O'r...r...,ra... IoU'....... _"",,"' ...-A_...~..,_
WEST SHORE EMS - ALS
205 GRANOVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax 10: 23-2463002
td-IIh~,
\ i5
WEST SHORE
E:ViERGENCY ~lED!C/\L SERVICES
INSURANCE:
MEDICARE B
224209376A
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
51390 MDEN
3070747A ECAR
09/12/2006
PATIENT NAME:
ELIZABETH ESHELBY
3070747A
77 BEECHCLlFF DR
HOLY SPIRIT HOSPITAL
ELIZABETH ESHELBY
77 BEECHCLlFF DR
CARLISLE, PA 17013
REASON(S)
FOR
TRANSPORT
DIABETIC COMPLICATIONS
WEAKNESS - MUSCLE
INVOICE
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
PARAMEDIC INTERCEPT A0999 1.0 617.52 617.52
10GTT TUBING A0394 1.0 8.78 8.78
ANGIOCATH (14-24) A0394 1.0 5.50 5.50
GLUCOSE BLOOD A0394 1.0 6.42 6.42
NORMAL SALINE 500CC A0394 1.0 3.30 3.30
01- 1iSl
'1 )~'? o~
otal Charges 641.52
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ~ $641.52
RETURNED CHECK FEE - $31.00
\-
Hetrick Cremation Services of Central Pennsylvania, Inc.
3125 Walnut Street
Harrisburg, PAl 71 09
Invoice
Date
9/20/2006
Bill To
Barbara L Bair
77 Beechcliff Dr.
Carlisle, P A 17015
I Terms ,I Due Date
I Net 30 10/20/2006
Description Qty Amount
Death Certificates 5 30.00
?J ,Ill F" II C)" 2/~cPC
~
?-tft 7 '/ J~
Total $30.00
Payments/Credits $0.00
Ins oeen a pleasure WOrKIng wnn you. Balance Due
$30.00
REV-Hi13 EX+ (9-00) *'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
Elizabeth E. Eshelby
FILE NUMBER
21-07-0693
1
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
BER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
r TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
Barbara L. Bair Daughter 1/3
I Elizabeth Hoffman Daughter 1/3
..
:. Victoria Apple Daughter 1/3
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18,ASAPPROPRIATE, ON REV-1500 COVER SHEET
I 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 $
NUM
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(If more space is needed, insert additional sheets of the same size)