HomeMy WebLinkAbout05-15-08 (2)
--.J
15056051047
REV-1500 EX (06-05)
PA Department of Revenue
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
County Code Year
File Number
Date of Birth
Decedent's Last Name Suffix
Decedent's First Name
MI
(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
C)
2. Supplemental Return
C)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
C)
4. Limited Estate
C)
sJ5
8. Total Number of Safe Deposit Boxes
C)
C) 4a. Future Interest Compromise (date of
death after 12-12-82)
C) 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
C) 10. Spousal Poverty Credit (date of death C) 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Da time Telephone Number
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
-
REGIST~~WILLS U~NLY
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Correspondent's e-mail address:
SIGNATURE 0
ADDRESS
SIGNATURE OF PRE PARER OTHER THAN REPRESEN/
ADDRESS /'
r
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051047
15056051047
.-J
.-I
15056052048
REV-1500 EX
Decedent's Social Security Number
8. Total Gross Assets (total Lines 1-7).
8.
Decedent's Name:
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) c:::::> Separate Billing Requested . . . . . 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) c:::::> Separate Billing Requested.. . . . . . 7.
....... ..............
9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . .
. ..... .. 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . . . . . 10.
11. Total Deductions (total Lines 9 & 10). ..... ..... ..... .... .... ..... ... ... 11.
12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.
13. Charitable and Governmental Bequests/Sec 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 tr>flble
at lineal rate X.O ~ 5
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
18.
15.
16.
17.
19. TAX DUE. . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
-
Side 2
L
15056052048
15056052048
.-I
REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENT'S NAME ~ t:.: ~
STREETAD~REScS ~20~d= C1-fltc&N~_
.~- 111LL-. -
CITY . L'~_- ---:-F
File Number
s+(~-
STATE
Pt1-
tit
(1) I~ 1'15, 77
ZIP I 7 () /
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits (A + B + C)
(2)
-&-
3. Interest/Penalty if applicable
D. Interest
E. Penalty
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3) jf
(4)
(5) ~
(5A) ~
(58) /~ 7-1-5', '71
,
Total Interest/Penally ( D + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in avalon Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. ~.idr~~a~~~~:tu::~r ~n::~~:f ~~::property transferred;.......................................................................................... [] ~
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 ~
c. retain a reversionary interest; or.......................................................................................................................... 0 5
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 ~
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. 99116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. 99116 (a) (1.1) (ii)). The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. S9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. 99116(a)(1.3)]. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1503 EX+ (6-98.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ITEM
NUMBER
1.
t;. ~efi-
FILE NUMBER
d-.t-01- tofCf
ESTATE OF
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
VALUE AT DATE
DESCRIPTION OF DEATH
EP XfGI5H oYw/(SJ f.Le. LII-/B) ~'6/fJ3 ./0
GJ7o~ ~ @ 1Lf1105)La/ ~ QJD
TOTAL (Also enter on line 2. Recapitulation) S 3;;t'g
(If more space is needed. insert additional sheets of the same size)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
REV-f508 EX + (1-97)
ESTATE OF
'*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
~ \ lft-s erz FILE NU~R ~ rz - I 0 L
Include the proceeds 01 litigation a the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
j,
3,
VALUE AT DATE
OF DEATH
DESCRIPTION
nt~T P/rNK Uj09j07 CP
ac11F If 100 3 ~t.f;1A~/>~~9? '+iaPtHi-st-Bcn..k)
~~1 ~r""''-:~ftJ>( .
S~ (3(l1V1< IIfNf'? -S~
tUff:p::- 3 t5 Lf-o 0 J D~ tp . M' f>>TJ~)
{w~tfarrts cS.IW~ ~ C~T"-'--~ 7
vJ;rch~ ~ d.i./- 7</1- Jol/- 5f73S-ifJ
(~ F1 f"3 r iJJliOYl /3fnJ "- ) II /1'-//01
1l/DJS11/1S
~ I.y #.i=
,
Jcj7S3.56
4,
e~ ~~I1:t~~.
11/~ to) D ?
3%.~1
~
TOTAL (Also enter on line 5, Recapitulation) $ 3 35;;; Q.t.3
(II more space is needed, insert additional sheets of the same size) /
I!~~
Hampden
November 9, 2007
hJi;~~
950
MARY E GLASER
2080 CLARENDON ST
CAMP HILL PA 17011-3827
Re: CD Account Closing Notice
Account # 31003915944837
Dear Mary E Glaser,
We are writing to confirm that on 11/08/07, Jour CD account was closed or transferred.
At that time, the balance was $10,557.95. V
We'd like to remind you that M&T Bank is committed to providing you with solutions to
all your financial needs. To find out more about the many ways we can help you with
those needs, simply stop by any M&T Bank office or call the M&T Telephone Banking
Center at 716-626-1900 or 1-800-724-3222. Or ifyou'd like, visit the M&T website at
www.mandtbank.com.
Thank you for banking with M&T Bank.
Sincerely,
M~~h~t~ Cot~-H~~to~
Michele Cole- Hector
Customer Service Manager
SMACCL AZRCSl
. Sovereign Bank
STATEMENT OF ACCOUNTS
('-
1...n-80V-eANK (1"'77-168-2285) www.soverelgnbank.COIQ
Statement Period 01101/07 TO 09130107
STATEMENT SAVINGS ACCOUNT
ST A TEr,iEN r SAVINGS ACCOUNT :,. ,', "- ;' -, ,-' ,"
MARY E OIASER
JuDItH APA KREBS ATTY IFF
Account I 354001026
Balancea
*The interest eamed and the interest paid may differ depending on when interest Is credited to your account
Account Activity
Date Description Additions Subtractions
01..Q1
BaIanc6
$1,114.49
.
-
..
.
..
11&
.
B!
.
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· ThIs baIaI1ce was -calcufated for the period beginning on 09101101 and ending on 09130I01
(
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page 3 of 3
354001026
"\VACHOVIA
TIME DEPOSIT WITHDRAWAL CONFIRMATION
Office Name
NE CNTRL PA 1 CAMP HILL
PA
Date
11/13/2007
CURRENT BALANCE: $20,736.48
+ ACCRUED INTEREST: $17.08
Availlnt WD/PenFree: $190.92
- PENAL TV AMOUNT: $0.00
- FEDERAL WIHD DUE: $0.00
- WITHDRAWAL FEE: $0.00
- OUTSTANDING PYMT : $0.00
~~~~-~~-;USTOMER : $20,753.56 /
"W"ACHOVIA
Opening Date
This Receipt Acknowledges That The Depositor Named
Below Has Deposited With This Bank The
SumO!
Depositor
Name And
Address
Term
Maturity Date
Interest Payment Disposition
Issued by
WACHOVIA BANK, N.A.
566594
Customer Name(s), Address and Taxpayer ID Number
MARY E GLASER
:1J(~
tk-c) .
2080 CLARENDON ST
CAMP HILL PA 17011
S208286581
FULL REDEMPTION
CD ACCOUNT NUMBER:
247412045973543
566594
TIME DEPOSIT NOT TRANSFERABLE
Account Number Taxpayer 10 Number
****************\I()I[)*****
Interest Rate Per Annum
Annual Percentage Yield Interest Payment F requency/Period
Account to Credit
PROD-TYPE:
PROMO CD:
1 ! ( 1 '" r7n
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REV-1511 EX+ (1O-06)W
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
ITEM
NUMBER
A.
B.
1.
2.
3.
4.
5.
6.
7
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
~ \ G{as~ FILENUMBER~/_
Debts of decedent must be reported on Schedule I.
DESCRIPTION
FUNERAL EXPENSES:
4i) U ~SeA' rY) ff1J5 huJ er& H-zmu-
~t=:~f!/~()vmite-(L
~ 0HcJcvL~ +-~dJ
5 os~4 St Nr Cdt 75.(JO-(-50,D6)
6 ~~rP~fos) p6S~
1.
ADMINISTRATIVE COSTS:
P~OO::~::::=:::::::::I') ~ JlliUW A- -K ~EBs
:~J:r~ ~Jff~Shcs~p::-~ If 070
Year(s) Commission Paid: .,er
Attorney Fees
Family Exemption: (~e..de.nt's add.ress is;mthe sam.. e as claimant's, attach explanation)
Claimant >>ttv ( P \.71 !tr> .~
Street Address d-6 ,3 O. Cia r~~ G+ ~
C;tv O~ IJ-i U .. i.7LJ-
State~ZiP
Relationship of Claimant to Decedent
J7())!
Probate Fees e- ~ lStw- 0 f will s <1/:3 (p 0 1 () 0
Accountant's Fees
~.
'1.
~~:;;:Ji.,tiJ<4 NM>~~ -~ yJ.fzCe-
Cwmb ~~~ 'H-~,,%~ - .
~ DO tlJdJLJ -JiIIJJ() -pu- ~~Ifvt-I&~
? - /Q)
AMOUNT
if fo O5D, t70
/765, OV
006,0t)
CJ-8CJ, g~
/JS", tJO
c3'8, 8 7
$;)fo~,ffD
d) ?oi),OV
iI> 350{) , (JfJ
:/I 3 b i), rJ-r:)
df
/ If~ ,(;&
-
7[. , DO
IS', criJ
$
TOTAL (Also enter on line 9, Recapitulation) $ / It; C/o f ' I
(If more space is needed. insert additional sheets 01 the same size)
lYlusselman
Funeral 1-lome
& Cremation
Sernces, Inc,
Established 1895
Brian C. Musselman, F.D.
Supervisor
William G. Pegan, ED.
PO. Box 137
324 Hummel Avenue
Lemoyne, PA 17043-0137
(717\ 763-7440
Fax: 717-730-9798
www.musselmanfuneral.coln
To Funeral Expenses of Mary E. Glaser
Aug.30,2007
Our Services $3745.00
~
(Lcd-,
Casket
Vault
CASH ADVANCE ITEMS:
Certified Copies (10)
Hbg Patriot Obituary
Lewistown Obituary
Tent/Grave Servicing
$1425.00
$ 900.00
$6070.00
$ 60.00
$ 484.28
$ 107.70
$ 125.00
$ 776.98
$6846.98 t \c1\
?L\ d- IJ'Y
J-{ . ~6' r
~ ~~V)
To tal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FOR APPOINTMENT PHONE 717-763-7440
".iI_.r-
f'
ESTATE OF MARY E GLASER
JUDITH A KREBS, EXEC
1724 CREEK VISTA DR.
NEW CUMBERLAND, PA 17070
-~ .. ..
F:!~~
~_Ob
60-295 61 09
313
202
~
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$foJ5Q, tJfJ
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East Harrisburg Cemetery & Cremation Services
2260 HERR STREET. HARRISBURG, PA 17103
PHONE: (717) 233-6789 - FAX: (717) 233-4600
ehbgcemetery@aol.com
o Pre-Need iQA( Need
Contract No:
/) t..-/
i,'i'
Purchaser's Phone: ~ ."
E-mail:
,'-/
THIS AGREEMENT is made the day of - - 20 ,--. i by and between you the Buyer,
C.: :-,';[ \~S of ;.=~~~{~_..- I
and us the Selier, EAST HARRISBURG CEMETERY & CREMATION SERVICES, 2260 HERR STREET, HARRISBURG, PA 17103.
AGREEMENT OF SALE
Subject to the terms and conditions hereof, we agree to sell and provide, and you agree to purchase, the burial space, cemetery merchandise and/or
funeral merchandise specifically enumerated below. Seller intends to assign this Agreement to the Assignee named on reverse side
BENEFICIARY
We shall deliver the burial space and/or merchandise enumerated below only upon your death unless you designate otherwise below, in which event such
burial and/or merchandise shall be delivered only upon the death of such designee
(Name of Designee, if any)
Social Security #
the term "Beneficiary" shall mean the person upon whose death such burial space is to be used and/or mer-
person is or Buyer's designee:
For the purpose of this Security Agreement,
chandise are/is to be delivered, whether
ff~RIAL RIGHTS QTY
RESERVED FOR'
,/
I!'f Ground 0
i
Sect
Sect
Prep Care $
Mausoleum
Lot
Lot
o Niche
...-;Or
(>\ i'
Space
spa~
Price$ ..-'
,~()
1/9
o MEMORIAUMONUMENT See Design Form
Price includes installation cost of $ _ and memorial care of $ ~
and cost of MonumenVMemorial. Price $
If installed at another cemetery these costs indicate
maximum coverage Seller will provide
o INSTALL STORE 0 TOTAL #
LOT OWNER'S NAME OR NAME OF CEMETERY IF OTHER THAN EAST HARRISBURG.
0 VAULT(S) I URNS
Quantity
Type
Material
Price ($ Each)
0 CASKET FOR
Type
Price
0 CASKET FOR
Type
Price
~FESSIONAL SERVICE,
/
[0" OTHER
$
'''J;'''; c:~
{(\(\
$
LESS TOTAL TRADE-IN ALLOWANCE (CREDIT)
CASH SALE PRICE $
SERVICE FEE: For Document Processing
and Administration, Buyer agrees to pay a
non-refundable fee of $100,00 upon this
Security Agreement $
TOTAL SALE PRICE AND
SERVICE FEE
-,?-- .
't ~-,
i "\.-_
I (WE), THE BUYERS(S), HEREBY AGREE THAT IN CONSIDERATION OF THE
GOODS AND/OR SERYICES TO BE DELIVERED, THAT BUYER(S) INDIVIDU-
ALLY AND JOINTLY IS (ARE) HEREBY OBLlGATEO TO PAY ALL AMOUNTS
OWING AND SHOULO BUYER(S) DEFAULT IN THE AGREEMENT WITH
SELLER, IN ACCORDANCE WITH THE TERMS OF THE CONTRACT
BETWEEN BUYER(S) AND SELLER, BUYER(S) HEREBY AGREE(S) TO PAY
ALL COLLECTION COSTS, REASONABLE ATTORNEY FEES AND COURT
COSTS UPON COMMENCEMENT OR INITIATION OF ANY COLLECTION
EFFORTS OR LEGAL PROCEEDINGS.
YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR
TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS
TRANSACTION. SEE ATTACHED NOTICE OF CANCELLATION FORM FOR
AN EXPLANATION OF THIS RIGHT.
A Real Estate Recovery Fund exists to reimburse any person who has obtained a
final civil judgement against a Pennsylvania real estate licensee owing to fraud,
misrepresentation, or deceit in a real estate transaction and who has been unable
to collect the judgement after exhausting all legal and equitable remedies For
complete details about the Fund, call (717) 783.3658.
(Name of Designee, if any)
Social Security #
ITEMIZATION OF AMOUNT FINANCED:
1 CASH SALE PRICE $ ,<'~,
,_, t' r'
$
2, DOWN PAYMENT (Paid
3 AMOUNT FINANCED
FEDERAL TRUTH-iN-LENDING DISCLOSURES
Annual Percentage Rate FINANCE CHARGE
The cost of your Credit as a yearly rate. The dollar amount your Credit will cost you
% $
AMOUNT FINANCED TOTAL OF PAYMENTS TOTAL SALE PRICE
The amount of credit provided The amount you will have paid The total cost of your purchase
to you oron your behalf after you have made all pay- on credit including your down
mentsasscheduled paymenlot$_
$ $ $
Your payment schedule will be
Number of Amount of When Payments Are Due
Payments Payments
On the day of each month
beginning
Late Charge: If any payment is not paid on the due date thereof or within 10
days thereafter, you will be charged a late charge of $5.00 or 5% of the unpaid
portion of the payment, whichever is less, but not less than $100.
Prepayment: If you payoff early, you may be entitled to a refund of part of the
finance charge
See the General Provisions of this Agreement for additional information about non.
payment, default, required payment in full before the scheduled due date and
prepayment rebates and penalties
ATTORNEY IN FACT AND TRUST FUNDS
Buyer hereby appoints Seller as his agent and attorney in fact for the purpose of
creating an IRREVOCABLE Trust with part of the funds to be paid hereunder as
provided in the General Provisions hereof and for taking all proper, convenient,
necessary or expedient actions incidental thereto. This IRREVOCABLE Trust shall
be for the benefit of Buyer and Beneficiary, as their interests may appear, and
shall be created pursuant 10 an IRREVOCABLE Trust Agreement with Bank. Buyer
empowers and directs Seller to deal with and handle this IRREVOCABLE Trust,
and to change trustees, as permitted by such IRREVOCABLE Trust and income
from this IRREVOCABLE trust as provided in such IRREVOCABLE Trust
Agreement, and Seller shall have the right to withdraw principal and income from
this IRREVOCABLE Trust as provided in such IRREVOCABLE Trust Agreement
This power of attorney shall not be affected by Buyer's subsequent death, disabil-
ity or incapacibility.
Signature(s) of Buyer(s)
GENERAL PROVISIONS-BUYERS AND SELLER RIGHTS
AND OBLIGATIONS-ARE PRINTED ON REVERSE SIDE.
PLEASE REVIEW BEFORE SIGNING.
E~st HBrrlsburg Cemetery & Cremation Services
f'i/, ?-<. / ,~__.;;.~__,:" .
By: P, / } ,"{~'/' _../>._/ (. /.r'l_
Memorial Counselor
Accepted By Title
IN WITNESS WHERE OF, Buyer and Seller have executed this Security Agreement for
Cemetery Services and Merchandise, the day and year first above written. We also
assign this Agreement to the "Assignee" named below, intending to be legally bound
hereby at
BUYER ACKNOWLEDGES RECEIPTS OF 1) A GENERAL PRICE LIST FOR RETENTION AND 2) A COMPLETELY
FILLED-IN AND EXECUTED COpy HEREOF SUBJECT TO THE GENERAL PROVISIONS OF THIS AGREEMENT ON
REVERSE SIDE.
.,-/ /
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,
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--- /
(Date of Birth) / (Signature of Buyer, IT more than one)
(Date of Birth)
(Signature 01 BUyer)
(Social Security Number)
/
/ (Social Security Number)
Any Co.SIDAer must receive and read a CODY 01 Ihls detachable notice belon becomlno oblloated to this Cnnlnlct
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SCHEDULE I
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT
IN~~~~ENNc,.EDT:6E~~~~RN MORTGAGE LIABILITIES, &' LIENS
ESTATE OF 11\1111 () n I
r ~ \kA..Av y t::'- . VlA'Dt::R FILE NUMBER
.'port ,.", ;,,""., by th. ,,,.,,,, ",,, '" ,..th wh'ch ..m,',,' "p,i' "oft, dl td . . . ~ / - 0 1 - tOt i
ITEM e a e 0 eath, mcludmg unrelmbursed medical expenses
NUMBER .
. DESCRIPTION VALUE AT DATE
/...-a.sri//tJess &~ OF DEATH
t-Ivs~ ~ ~ {bdy~fJ,q
P;r 11zpf 1J R~ ~. ~~ /I
P;t W ~ ~ J}.nJ - 1fJ? fJ.if dJXJ1 'if
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T rn~ ckkI-1J
REV-1512 EX+ (12-03)
1.
~
3
Jt,
cie-~-
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5:
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
~ liPh Jjo, 0-6
I 56, ;)ft;
cJ 16, tto
$
3 311 bO
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[JaftrlL2cf-
Hospice of Central Pennsylvania
98 South ~nola Drive
I?O. Box 266
Enola, PA 17025
Statement
Statement Date:
Aug 23, 2007
Voice:
Fax:
717-732-1000
71 7-7 32-5348
Customer Account 10:
GlaserM
Account Of: Mary Glaser
c/o Judee Krebbs
1724 Creek Vista Drive
New Cumberland, PA 17070
AIl}9... }Unt Enc.losed _,
$p.p ) tJ 4-0 I U V
Date
6/29/07
Due Date
-''7731)-07-- -
9/7 /07
9/6/07
Reference
Description
Amount
f~ -92-0~ bQ'-
9,920.00'
4,800.00
Balance
1 , 920 . 00
1l,840.0C
16,640.00
8/22/07
---;i:i.Ts
2135
.2136
7131/07
m1M!l.:~
,,;,.. -Ji{~ GI a~
I:O:l~:102q 51: qB~:lab5
~6109a
313
II/;u;h1 .;
$ /~)Co'fO, at)
~A-'-
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MBaSeh:t1ll
~~fj~
204
"
ESTATE OF MARY E GLASER
JUDITH A KREBS, EXEC
1724 CREEK VISTA DR. 'L"!
, ~EW CUMBERLAND, ~ .p1J70
...
_novE
Total
::'6,640.00
~~ ~~ J4-~uf {c.r-~ ~ % a-()~
Jeanette Moul
Manager
the
Bricker House
- Circa 1909-
Barbara Musselman
Manager
325 Hummel Avenue
Lemoyne, PA 17043
717-763-1640
www.brickerhouse.com
~ ~.R 'lrJJ.
ii '-- ~ Cr~c.(t.. Vif)-tJl. VI'.
AJlw L~ ~ (tv.). P4 11"10
6tt1- ('~8t
INVOICE
RENTAL DATE: ~~ r ;2.." ,.2.(;]0 l
RENTAL DEPOSIT: N lit
/5"0.00
I 3 OJ , ~~
C-616 '[, &? --!-oM
~
ROOM TOTAL 130 ,00
MATERIALS TOTAt=
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'~;I
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TOTAL DUE: l3o.oo
1 c9-D I Ct
-- -
~r~
1:56,00
~~I'.::ii~
ESTAtE OF MARY E GLASER
JUDITH A KREBS, EXEC
1724 CREEK VISTA DR. , .
. ~:w CUMBERLAND P1: ~ 0
60--2956109 --.
313
aa /I/~ /p 1 ..;
203
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REV-1513 EX+ (g-OO.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATEOF t^\\<1V'lA [, GkS'~
NAME ~D ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
NUMBER
I
, J \Ai') rr# A-. -f< (l..E!:>S I \'
[/;L,'f Cr~ \f L ~iu.-J.Jf-,
Nl2AtJ 0lVYY\b Jl'Lj~ Ptr 1707]D
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dfJ~'O ~~ 3trur
C 1hnf rh /I) P 6-- ('lo , I
FILE NUMBER'l I
ex -(J 7 - / ()) ~
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
AMOUNT OR SHARE
OF ESTATE
~
i5073
~
S' 0 10
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS .'
1.
,..
/
//
/"
/
/
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed. insert additional sheets of the same size)
/
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Notarial Seal Public _~ ~._' ~- '. .1Z~. K~ ~
Shelby A. Minich. N:nd County _
Cant Hill Born. Cum a 20 2005
P . 'on Expires Aug. . _ _
My Comm,ssl
~_"_nl~ AssoClatlonolNolal\eS
MemllGI'. r.... ~J"W-
./
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF CUMBERLAND
I, Mary E. Glaser, Testatrix, whose name is signed to the
attached or foregoing instrument, having been duly qualified
according to law, do hereby acknowledge that I signed and executed
the instrument as my last Will, that I signed it willingly, and
that I signed it as my free and voluntary act for purposes therein
expressed.
IN WITNESS WHEREOF, I, Mary E. Glaser, have hereunto set my
.fA... .
hand and seal this ~O day of .(l!A<L 2003.
717,~ Ii ~~
Mary E Glaser
SWORN or affirmed to and acknowledged before me, and Mary E.
,
Glaser, the Testatrix, this ,gO-/{.. day of tlfvup 2003.
NoIIrtII ..
SbeIby A. MIaIah, ~ NIIlI
~--""~i-&
;/~~~
Noeiiry P ic
........,....IiIljlqrAI~
, \
'. .',
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, ' ....
,,' ........
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF CUMBERLAND
We, /1C,rir. Jl..f'l,.-Jd,/ and
")a~1'~ Lov-...,,-,~:u , the
witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, do depose and
say that we were present and saw the Testatrix sign and execute
the instrument as her Last Will, that she signed willingly, and
that she executed it as her free and voluntary act for the purpose
therein expressed; that each of us in the hearing and sight of the
Testatrix signed the Will as witnesses; and that to the best of
our knowledge, the Testatrix was at that time eighteen (18) or
more years of age, of sound mind, and under no constraint or undue
influence.
r~
./
Sworn or affirmed to
/A~
t!~
and subscribed to before me by the witnesses,
vriltub;"mAu.J17 and ~ (I/U/Jjldl'
this JIJI<- day of ~j 2003.
NOlIIlII...
ShelbY A. MIaIah. ~ PDbIIlI
CImp HIli IIonI CIInIbIrIIiId CouaIY
M1 CclnIndIIIoI .pIne Au.. 20, 2Oll5
MemIlII'. PII.II't'MIIlfI.waaIIIlOnCltNDIIIIII
~~/Jb~~
N6tary P lic
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