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HomeMy WebLinkAbout06-26-08COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 28060'1 HARRISBURG, PA 1 7 1 28-0 601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT KELLY SONDRA J 52 DREXEL PLACE NEW CUMBERLAND, PA 17070-2204 fold ESTATE INFORMATION: SSN: 177-24-x323 FILE NUMBER: 2108-0687 DECEDENT NAME: PRITTS RUTH H DATE OF PAYMENT: E-Er~6AS (.0~2 (~l dB n POSTMARM: DATE: 06/ 1 2/2008 COUNTY: CUMBERLAND DATE OF DEATH: 03/ 1 9/2008 ACN ASSESSMENT CONTROL NUMBER AMOUNT 08128161 ~ $868.64 TOTAL AMOUNT PAID: REMARKS: CHECK# 1402 SEAL INITIALS: AJW RECEIVED BY: 5868.64 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REV-1162 EX(11-961 NO. CD 009939 REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT DF REVENUE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 6~ b~~1 DEPT. 280601 ACN 0$12$161 NARRISBURG, PA 17128-0601 TAXPAYER R E S P O N S E REV-1543 Ex APPC09.09) DATE 06-11-2008 TYPE OF ACCOUNT EST. OF RUTH H PRITTS ^ SAVINGS S.S. N0. 177-24-9323 ^ CHECKING DATE OF DEATH 03-19-2008 ^ TRUSr COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FORMS 70: SONDRA J KELLY REGISTER OF WILLS 52 DREXEL PL CUMBERLAND CO COURT HOUSE NEW CUMBERLAND PA 17070-2204 CARLISLE, PA 17013 PSECU has provided the Department with the information listed below which has been used in calculating the potential tau due, Their records indicate that at the death of the above decedent, you were a point owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions ^ay be answered by calling (717) 187-8327. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0177249323 Date 09-29-2003 7o insure proper credit to your account, two Established (2) copies of this notice must accompany your 2 3 3.4 4 payment to the Register of Wills. Make check Account Balance 40, payable to: "Register of Wills, Agent". Percent Taxable X 50.000 1 1 6 .7 2 NOTE: If tax payments are made within three Amount Subject to TaX 20, (3) months of the decedent's date of death, Tax Plate X , OQj you may deduct a 5% discount of the tax due. Anv inheritance tax due will become delinquent Potential TaX Due 905.25 nine C9) months after the date of death. PART TAXPAYER RESPONSE ^ '~•: r:.~x~r~::~en~:::::~r~~~:::~^a'~'~t~naitx;ft~ii~;'c~:~~ssit~t°r<~x#ia~?t~=.~:~t~~i°~,A~+,.:ln:e.~.~r*~~~:E=:,::•era~€!x~~:~x~°+a~c~r^e~€t~neor~~naa:-rbi€re.,...ua;y~rz~.c ' A. ^ The above information and tax due is correct. :~_~ ~--~ ~-~ 1. You may choose to remit payment to the Register of Wills with two copies of this notice tor..ol,tain ' a discount or avoid interest, or you may check box "A" and return this notice ;o.?t'he-Register of CHECK C ONE ~ Wills and an official assessment will be issued by the PA Department of Revenue :. , ;~. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inherit'arLce Ta~`return 0 N L Y to be filed by the decedent's revresentative, _ __. - ~ - C. ^ The above information is incorrect and/or debts and deductions were paid by you. _' _ You must complete PART ~ and/or PART 3^ below. 7 :1 . , PART I1' you indicate a different tax rate, please state your ___~•~~••~ ~• ~ ~ ,,::,::• ..::::..::::: LlFICiAL i1S~ O~II.''.,^ A ~ •~ •'•'' Z relationshi to decedent: tir~ ~:::::i::•::.:t~ ~ r......,..,..., .... ~...~,..-,..R .~:.... ,...,-..,a..:,, .,.. TAX RETURN - COMPUTATION LINE I. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due PART DATE PAID PAYEE A OF TAX ON JOINT/TRUST ACCOUNTS i;~~jE;~ `; 1 .?11 ~ 9 1 ~ ~ ~ ! °, . i 2 y a f '2. 3 3 -° ~ 3 p `7 J ~ ... I . 4 a ~~ l , O ~' 6 / 9,L3o3.oa ~ B 8~ . ~y ~ ~ ....~...:...:. ,. .. DEBTS AND DEDUCTIONS CLAIMED DESCRIPTION AMOUNT PAID ~,~ Off' O t-m 3 D~ Bs r h Er /O o a p M v~ e- ~ .v1 /.~ ~~ u y..e.. r ~ cs ~ S 4 . D O ~ o ,j r G v , ~ f- , 1-e r t n e.v~ e ~ ~ 3 e o Z; G, ,'i+,..r t -p o ~ ~-t r u r i A~- ~ 5 / a D,~ iDiAL center on Lsne 5 of iax computation) a g /y,o v nder penalties of pgrjury; L declare that the facts I have reported above are true, correc and com t:e to the be t I o y k wled a and belief. ~7 g HOME C~~l ~ 7 ~/ 77-~I~77~ \ J~ n. Or w ~. ~© ~~. _ _ l //2 /~Sll WORK C ) JAI IL! Harr Darryl K. Guistwite, D.O., Inc. - Sc , , - . 56 Ashton Street ~'S~ ~~SU Carlisle, PA 17015-6914 S~L~ 4 ~ Darryl K. Guistwite, e.o., Inc. 56 Ashton Street (717) 609-2639 ~ ~I ~ Carlisle, PA 17015-6914 03/13/08 03/13/08 RUTH H. PRITTS ~ ~- C/O SANDRA KELLY 52 DREXEL PLACE 143.0(1) 143.0 NEW CUMBERLAND PA 17070 Detach this stub and return with payment. `~- _, _ _~ . - ~Descript~o ~+~-- =`'"`~'~Charge ~-~ 'z ~ - ~ Credit ~ ~ ' rBatance -~ - Date RUTH H. PRITTS ( 143.0) 143.0) 01/05/08 NURSING HOME EST. PATIENT 75.00 02/02/08 Ins Pmt-MEDICARE 42.21 $3.53 was applied to your de uctible 02/02/08 Adjustment 18.71 02/12/08 Ins Pmt-HIGHMARK PA BLUE SHIELD 10.55 $3.53 was applied to your de uctible 3.53 01/05/08 TO AL FOR RUT H. PRITTS 3.53 60 D s 31 61 - 90 Da s 91 -120 Days Over 120 Days Total Due 3.53 ' Current 0.00 . - ay 3.53 y 0.00 0.00 . - 0.00 3.53 Please pay this amount! ~ . ~ -- _ _ _..._._ 3397& MAIL ~rC40 2N001496 _~ _~~~" I - . _ ;~ PRITTS, RUTH 98916 CARLISLE i DATE ~ 3/09/2008 J 3/09/2008 3/09/2008 3/09/2008 3/09/2008 3/09/2008 3/09/2008 3/09/2008 3/09/2008 3/09/2008 3/10/2008 3/10/2008 3/12/2008 3/12/2008 3/13/2008 DR GUISTWITE, DARRYL, MD RX NO. 2933302 2933305 2933303 2933309 2933312 2936568 2947730 3030556 3094017 3135440 3157922 3159118 3030556 3030556 3005203 pESCRIPTipN Medicare D P an: MEDCO YOURX PLAN DIPYRIDAMOLE 25 MG TABLET METOPROLOL SUCC ER 25 MG TAB ALLOPURINOL 100 MG TABLET EFFEXOR XR 75 MG CAPSULE SA AMIODARONE HCL 200 MG TABLET SEROQUEL 25 MG TABLET ARICEPT 5 MG TABLET FUROSEMIDE 20 MG TABLET FERROUS SULF 325 MG TAB EC GABAPENTIN 100 MG CAPSULE LOPERAMIDE 2 MG CAPSULE ENULOSE 10 GM/15 ML SOLUTION FUROSEMIDE 20 MG TABLET FUROSEMIDE 20 MG TABLET NITROGLYCERIN 0.6 MG/HR PTCH DAYS GUTSTANDINGj 1 - 30 AG~~D BALAwCE I 0.00 7010 SNOWDRIFT RD ~u ~4~~ m~6~r - 60 67 - 90 I 91 - 0.00 ~ 0.00 I 0.00 ALLENTOWN, PA 18106 NDC NO. 00904-1086-61 00185-0281-10 00378-0137-10 00008-0833-22 00185-0144-OS 00310-0275-39 62856-0245-41 00172-2908-80 00182-4030-10 00228-2665-50 00378-2100-05 00472-1360-16 00172-2908-80 00172-2908-80 00378-9116-93 QUANTITY 54 EA _= 18 EA 18 EA 13 EA 13 EA 22 EA 23 EA I 4 EA 10 fA 21 EA 30 EA 473 ML 30 EA 30 EA 30 EA AMOUNT CCDEITYPE j 8.00 C RX 8.00 C ! RX 3.83 C RX 50.00 C RX 8.00 ! C RX 20.00 ; C RX 20.00 C RX 0.56 ' C RX 0.15 ~~ oTC ~, 8.00 I C RX ~ ~ 6.88 ~ C ~ ~ RX i 8.00 C , RX 6.31 C !. RX ': 2.31 CR RC RX 8.00 C i RX L~.-- -- +-- ---~-- --- --- -- - -- 4/30/2008 121 + DUE DATE. S 153.42- -- ' 0.00 AA'IOUN': DUE: 800-270-6351 ~~~'"6~bosED: I--- - - -- _ _-__i htESSAGES .Finance c arges are ca cola a mon y peso Ic ra eTz ofi'f-5°r(or~ of $1.00 per month) for a total annual rate of 18%. The charges listed on this invoice do not reflect any balance billed to your insurance. ~>lIl 8 ~ ¶~ll]~CIl(~~]Cb V~i~g~i~'g'' 11J1ll~/. To Funeral Expenses of RUTH H. PRITTS Apr . 9 , 2008 Sondra Kelly I ~ j ~~ - (~Q, 52 Drexel Place f.~~ 7I fa~3 New Cumberland, PA 1.7070 ~l ~ r 2008 March 24 - FOR ITEMS.'.-NOT COVERED. IN GUARDIAN PRE-NEED PLAN Flowers $238.50 Death certificates 14.00 Newspaper death notice 247.42 Tip fora honor guard 50.00 Established 1895 TOTAL $ 549 .42 Brian C. Musselman, F.D: {County VA Benefit.) -$100.00 Supervisor William G. Pegan, ED. SUB-TOTAL DUE $449 .42 P.O. Box i37 324 Hummel Avenue Lemoyne, PA 17043-0137 (717)763-7440 Fax: 717-730-9798 www.musselmanluneral.com FOR APPOINTMENT PHONE 717-763-7440 .. 4 ~- •._ +' ~: ?;= i~ ,_ -.:.. Xt. rs, .. ,.,.. r i _. :;;. ~- . r.,... ..,,,,,,,:, ,, ~~ ~` ,, ~~ .' ~~ ~ BOSCOV ~ S ~~~ '~ 'SCOV ~ S ~ ~t~~ - 016497 03/15/2008 16:05 REG SALE ~ ~ ' 294101 03/15/2008 15:47 REG SALE '~~ ~~ ~~ 33'b3 1010980 INTIMATE APPRL ~, 1228 1102168 MISSES SPRTSWR UPC 7613-2179-2790 '_> UPC 8 50-3352-2141 .REGULARLY 76.00 57.00 REGULARLY ~ 36.00 27.00 TOTAL 57.00 AC;CT # *************6369 S VISA 57.0 APPROVAL 01603400 ~~ Kf:LLY/SONDRA J CUSTOMER COPY "~~ X1CYlYCYCY(Y(Yl7CYfYfY(Y(7C 7t 1C Yf 7t Yf YC Yf y(1C Yf 7k YC Y(Yf IC IC 1C YC Y(Yf YC Yl Yl YC y( * Feel the Mediterranean Glamour with * Island Capri, the Newest Scent from * * Michael Kors. Visit the Women's * * Fragrance Counter Today to Sample * * The Scent of Jet-Set Stylsi * *`a*~+rx*x********* ********************** ~~ `~ ,/~ C~,~ 12216~52~rOR3 n _ - Q_ Transaction Num er ff (~"~ , STORE 12 REG 2160 TRANS 12570 LAST YEAR, BOSCOV'S RAISED MORE THAN $2.5 MILLION FOR LOCAL CHARITIES "B" GENEROUS! ~ ° ° v rn rn ~ i n t n J O N N N N a F- O (n C7 O W ~ OJ O) I/n~ ~ O V / O F-- E"" H M ~ ~ L m N ~c li7 O ~ is Q .-i ~ O X ~ U o ~° ~ ~ o /A O Z U ~c ra -' ~ ~ ~ ~ '' ~ W ~ ~ O O W zp .-+ ~ In O O Y O f~ ~ ~ J O LS7 Q 4 Y a O U W O H U TOT{tt 27.00 ACCT # ************ 77 S ISA 27. ~ APPROVAL 01913700 ,~~ 1 KELLY/SONDRA J „n 1~C_+~~ CUSTOMER COPY ?`l `V ************** ************ *********** * Feel the Me lterranean Glamour with * Island Ca 1, the Newest Scent from * * Michael Kors. Visit the Women's * * Fragrance Counter Today to Sample * * The Scent of Jet-Set Style! * IIIIIIIIIdIINIIN Ilf II II Transaction Number STORE 12 REG 2171 TRANS 85623 LAST YEAR, BOSCOV'S RAISED MORE THAN $2.5 MILLION FOR LOCAL CHARITIES "B" GENEROUS! ~ ~ ~ * ~o °~ w ~ z _ L E ~ 3 Y -~ C S (!~ _ N (0 ~c F- W 7 C O ~ ~ ~ f~ W ~ O N E O T 9c r+ D: H E U +~ +r ~ 00 M O ~ (6 (n N (n i~ ~ O'~ f Q ~ ~ ~ _ O G7 ++ +r M O U (A 'D m ~ ~~ ~ N W ~' C m++ ON do W Z (nJ~• ', C Z -~ L m~ ,-+ ~- X 0 0 i6 > O7 ~ N J~ L 0) +~ is N Cn W H O ~ ~ ~ ~1c ++ N O ~ O U L U i-~ 3c E N U ~ ~ a Y U U Z m i c ' . W m H N ~ C U O~ d l 6 N J . tr "O U 0 ~ ~ ~ ( 6 1 - U ~--~ W ~ ~ l N ~' IS7 c N i c ~ I W c d !A ie C ~ F- N LLH ~ X60 Ei! Q }#185.905M5 REV. fi/06 This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records in accordance with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953. Military Status H,os,a3 REV nnoa> TYPE/PRINT IN PERMANENT BLACK INK WARNING: It is illegal to duplicate this copy by photostat or photograph. ~rQ Calvin B. Johnson, M.D., M.P.H. Frank Yeropoli Secretary of Health State Registrar 1379502 No APR02~ COMMONWEALTH OF IF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) Date 1. Name. of Dacemnl IFirst, mitltlle, la&, suffix) 2. Sex 3. Social SeCUdty Number 4. Data of Dealn (ftaEnth, day, year) Ruth H. Pritts female 177 -24 -9323 ar. 19,2008 6. Age (Last Blnhtlay) Untler 1 year Untler 1 my 6. Date of Birth (MOnM, day, year] ]. &rthplace (Ciy and slate or bra coumry) 8a. Place of Deam (Check mty one) Monaca P.y, Hours Mirwes Hospea: Omer. 8 8 yre Dee . 2 0 , 1919 Lynn , AL ^ Inpahant ^ ER / Oulpaliem ^ DOA [J Nursing Home ^ Resieence ^Other - Spedfy: " 86. County of Death &. City, Boro, Twp. a Death Btl. Fadkty Name (end insMuaw, give sbem aM number) 9. Was Decedent d Hispank Origin? No ^ Yes 10. Race: American Intien, Sack, White etc , . Of res, specify Cuban, ~° Cumberland Carlisle M C anor are Mexican, PUedP Rican, etc.) t e 11. Deurtleas Usui Occu Bon NiM of work done dun most of worklr. life. Do wt slate retiretl 12. Wes Decedent ever in the 13. Dacetlea's Eeuwlion (Specify Doty highest grade complelsd) 14. Madta Sbtus: Marred, Never MameQ 16. SumMrg Spouse !If rode, 6Ne maiden name) KiM al Work Kintl of Busiwss / IMushy U.S. Annetl Farcas7 Elementary /Secondary (0-72) College jt-4 or 5+) Witlowee, Divorced (Specify) executive health ins. Yea ^NP 12 4 widowed 18. Deceeenfs Mailing Address (Steel, cdy /town, state, zip cotla) Derstlant's Did Decedent 52 Drexel Place Aclud ReaiaenPe na. Bata Pennsylvania Liva b a nP. ^ vea. Decemm Lived b T"e New Cumberland PA 17070 rownany? nb.connty Cumberland ,]a~~~i~~50Lwadwnnm , ra rt ; ~~ P an/gym 78. Famer's Name (Flrst mdde, last, suffix) 19. Mother's Name (Rod, mimle, memo surname) Joseph Hyde Anna Blackwell 20e. Inkxmant'9 Name (Type / Pdnt) 2Cb. InfomgnYS MaAing Adtlress (Brae!, city /town, stele, rip cafe) Sondra Kelly 52 Drexel P1ace,New Cumberland,PA 17070 21a. Memad a Dsposition ^ Cremef ^ Donation 21 b. Dale of Disposition (Month, tlay, year) 21 c. Pbca a Disposition (Name a cemetery, crematory a aher place) 21 d. Localbn (Cly /toes, slate, zip wee) Badal ^ amovelhomSbte ~w..crem.Neno<DOnenpnAamar~w Mar. 24, 2008 Rolling Green Cemetery Camp Hi 11 PA 171 Speuly: by Metligl Exsminer / CProneY7 ^ Yes ^ No , ore a Funeral Licensee (or person acting m suers) 22b. Lkenae Number 22c. Name antl Amress a Facdiry FD-013163-L Musselman FH&CS,324 Hummel Ave.,Lemoyne,PA 17043 r Ibms 23ac Dory when ceretyinp 23a. Toms bml of my Nriowl tlga, deaf etl at aw tlme, dale aM place sbletl. (SynaWra one title) 23b. License Number 23c. Dale Sigwtl (Month tlay year) phyddans na aveibble at tlme of seam ro wetly cease a mom. ~ ~ ~ ~ O.S" ~/ - <- , , M i eZ v ~ ~ Items 2428 must be wrtpbted by person 24. of Death 26. Date Prwauncatl Geed IMOnm, tlay, year) 26. Was Case Retenetl M Metlical Examiner /Coroner for a Reason aher than Cfematbn or Donation? wlw prCnwnces eeem. ~ L. ~ R . M iy ^ vas ~tdo . p r ~ CAUSE OF DEATH ($N Inslructione and examples) i gpproximeb mtetval: Item 27. Pan L Enter ere Chain a evenb - tli9e9aes, inplme, or complicalion6 - mai directly caused the math. DO NOT order terminal events arch as grdac arrest, grrsN to Deam i t d O Pad II: Eaer Omer.~g.. t mm ra b wryg t death ba wt resulting in the Immrkjxig cause given in Part I. 28. Did Taawo Use ConNhute to Daam? ^ Vea ^ Promdy resp 2 ary arses), a vem cWar brillation wdhwt ehow in g the aiobgy. Ue ! a nFy oneca use w each Nne. IMNEDUTE CAUSE IFnal tl' ~ ^ Unkiwrm ~ ( ( ~ ~ [ wntlllion resuMng in ) a ~ ~ iJ g.ST ` •"~ ~/.,~ 1 ~ r ~</ V 29. If Female: Dw to (or as wrwegwnre of): ^ Not pregnant wanin pact year Sequent' dty Ibl contlifians, a any, b. bada~g ro Ihs ceuea 9aee w kw a. ^ Pregnant et time a death Due to ar as a cans Em Bw UNDERLYING CAUSE ( epwnca of): ^ pregrwn Pregnant wi1Mn 42 tleys Not L bu! (eiseaee a injury Ihet ilifet me euxm resuMng In tlmm) LAT. c of tleem Dw ro (or as a wmegwnce oQ: ^ Na prepneni bM pregnant 43 days ro 1 year d, before mom ^ Unknown If pregwa within me pW year 3ga. Was an Autopsy 30b. Were ANapsy Findings 31. Manner a Deam 32a. Date of Injury (Month, my, year) 326. Descnm How Injury Owurtetl 32c. Pbce a Injury: Home, Farm, Breet Factory PeMrrtned7 gvailabb Prior M Complalan ~Naturel ^ Homkide , , Oflite BuiMag, etc. (SpeWly) a Cause a Death? y~ ^ Vas ~,NO ^ Yes ^ No ^ Acadent ^ Pendbg Investgatbn 32e. Tme a Injury 32e. Injury at WoM? 321. If TransPabfiw Injury (Specl/y) 32g. Lwaaw of Inlury (Shea), city / fawn, State) ^ Sukitle ^ DWM Na be Oetertninetl ^ yes ^ No ^ Driver / Operator ^ Passenger ^PemsYmn M. ^omer ~ speay: 33a. Cedlbr (check olay one) • CerlXying phyakian (Physician cedAying cause of meet when andher h sidan has mnouncetl deem aM com leletl Item 23) 33b. Signature TN diNer ~" p y p p To the beats m bw ktl e th tl d t ~ , ~ w ga, a oxurre ue Y o me cauee(a)end manrrer as sbted_________________________________ ^ , • Prarouneing eM rortaying phplelen (Physcbn both proraundng math and certiying to cause a math) To the best a my lorowlerlps, mom o,xumetl at the time, mte, and plRe, antl tlw to tM ceuae(s) and manner as efa[ad_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ • Mwlnl F.aaminerYCOmrtar 33c. License Nu ~ O~ (U ~-t $' - L 33tl. Date Signed (Monet, day.}rear) QJ 3 (I q (O On tlx beat a examirrtim and / ar Inwalgetbn, In my opinion, death occurretl st the time, mie, and place, antl dw to the cause(s) end manro r ae statatl_ ^ ( 34 Name antl Address a Perron Wno Completed Cause of Death (Ite m 2]) Type! Pdnl Registra dDi L ~ I , ~ ~I ~ ~ / I t p p - 36 UO ~~3~ ~ ,k d Disposition Permit No. D / / ,J ~ ~', FOREVER .. . ~~... !~,... .... ~ t .., ~ ... \\~~~~;, v F F-,` t t~' F~tr 'z^~ t ~ x n! t , .,`.), . ~~'~ ", ti ~ ~ ? ,,~~. ~„ :: ~y es~a~d~_ ;,, /~° rr ~~ Z Q Z ~ ~- ~ ~ ~ ~o ~ do Z ~ Sao r ,~ yyWoc~ ~ OZ ~+m et, a,,~a, ~ o m ct Q~Za= am ~~---- ~ a_ N N a a ~_ 4 a yG °' °~ 6 w p U o x4 W a , , Y O G Q