HomeMy WebLinkAbout08-12-08COMMONWEALTH OF PENNSYLVANIA /QT~
DEPARTMENT OF REVENUE INFORMATION NOTICE FILE ND. 21 O" ~~~
BUREAU OF INDIVIDUAL TAXES AN D
DEPT. 280601 ACN 08135638
HARRISBURG, PA 171zB-0601 TAXPAYER RESPONSE DATE o8-08-2008
REV•1543 EX 11FP (09-00)
TYPE OF ACCOUNT
EST. OF DAVID ZAGORIC ® SAVINGS
S.S. NO. ^ CHECKING
DATE OF DEATH 07-29-2008 ^ TRUST
COUNTY CUMBERLAND ^ CERTIF.
REMIT PAYMENT AND FORMS T0:
EMILY ZAGORIC REGISTER OF WILLS tva
149 NORTH 25TH STREET CUMBERLAND CO;~OURT HC~E
CAMP HILL PA 17011 CARLISLE, PA ~}Qp13 °7 -_-
'"I7 ~.,,
7 'ta C~
G7
- n~ ~ -_
- -,~,~,
MEMBERS 1ST FCU has provided the Department with the information listed below which harJ;2n=wed i
calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a Point owner/bene+ficiary of,,._
this account. If you feel this information is incorrect, please obtain written correction from the financial instit3ution, atk+agh a copy '-'
to this form and return it to the above address. This account is taxable in accordance with the Inheritance TaR-7Law~s of the Commonwealth_
of Pennsylvania. Questions may be answered by calling (717) 7B7-8327. "` `~°
COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIC~1t'$
Account No. 27230-00 Date 05-28-1981 To insure proper credit to your account, two
Established (2) copies of this notice must accompany your
payment to the Register of Wills. Make check
Account Balance 628.13 payable to: "Register of Wills, Agent".
Percent Taxable X 16.667
NOTE: If tax payments are made within three
Amount Subject to Tax 104 • 69 (3) months of the decedent's date of death,
Tax Rate X , 00 you may deduct a 5Y. discount of the tax due.
Any inheritance tax due will become delinquent
Potential Tax Due .00 nine (9) months after the date of death.
PART TAXPAYER RESPONSE
~:: :::::
~;::::: ~ ~~ ' . ::, ::::;~;; :: ~~::;~ ~ _ s: ~R~ItAE.i'CAXisA~~E~~~1ENfi~A~E~#;;~f~l~fiNIB~'fiIE:
:::~:~ ~k~I~Il~.....°['D.....~~I?"•~fl~1D..:.~1 ~~~.-:.:R:E~;E~,~fi:.:.:I..:: A~.:._~1! ~.._ :..................................................................................................................................................................
A. ^ The above information and tax due is correct.
1. Yau may choose to remit payment to the Register of Wills with two copies of this notice to obtain
CHECK a discount or avoid interest, or you may check box "A" and return this notice to the Register of
Wills and an official assessment will be issued by the PA Department of Revenue.
C ONE:
B L D C K B. ^ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return
0 N L Y to be filed by the decedent's representative.
C. ^ The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ^ and/or PART ^ below.
PART If you indicate a different tax rate, please state your
relationship to decedent:
TAX RETURN - CDMPUTATION
LINE 1. Date Established
2. Account Balance
3. Percent Taxable
4. Amount Subject to Tax
5. Debts and Deductions
6. Amount Taxable
7. Tax Rate
8.. Tax Due
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
3 X
4
5
6
7 X
8
PART DEBTS AND DEDUCTIONS CLAIMED
0
DATE PAID PAYEE DESCRIPTION AMOUNT PAID
TOTAL (Enter on Line 5 of Tax Computation3 8
Under penalties of perjury, I declare that the facts I have reported above are true, correct and
complet to the best ~f kn 1~,~q~,}(rydf belief. HOME C )
~~ .~ `.C{~ / v'~ WORK C )
rri rounNF NIIMRFR DATE
1U5.8U5 REV fUl/07l
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
P 14542295
Certification Number
This is to certify that the. information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will be forwarded to the State Vital
Records Office for permanent filing.
d`~ ~ 0 2008
oca eg tier Date Issued
C1
C Q c~ ,
- ~~ :~~. 1
_-'-r) N _
-; ~.,;
~:~
-_ ~ fiJ
C~
3 REV ttnoo6 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
/PRIM IN
iMANENT CERTIFICATE OF DEATH
ACK INK (See instructions and examples on reverse)
STATE FILE NUMBER
i. Name of Decedent (FrsL mkMle, Iasi suffix) 2. Sex 3. Bodal Security Number 4. Date of Deam (Month, day, year)
lj{a~ } ~ ~ , •Z~1C-,OR1G ~Y1 198 - 18'- 1076 .~~:+t,,`t' ~~l 2~Y
6. Age (Last Binnday) Under 7 year Under t day 6. Dale of Birth (Harm, day, ear) 7. Bjrthplace (City and state or faeign Country) Ba. Place of Death (Check only one)
Monde Daya Hours xMwulea I H06pifal: QtIkY:
~7UGfi~N ~~ r~./fi
9a 3
1 y
~
,
.
84 ys, A u
Pittsbur h PA
g y ^ Inpatlenl ^ ER /Outpatient ^ DOA ~ Nursing Home ^ Resdence ^Odlar ~ spetily.
Bb. County of Deem &. City, Boro, Twp. of Deam Bd. Faa3iry Name (If nW insMWbn, gNe street aM number) 9. Was Decedent of Hispanic Origin? ~] No ^ Yes 16. Race: American Indian, Black, White, etc.
(II yes, speriy Cuban, (Specityl
Cumberland E. Pennsboro Golden Livin Center Mexican,PUertoRican,eta) White
17. DecetlenCS Usual Occu frxn Kind of work done Burin most of workin Ida. Do not state rear 12. Was Decedent ever in the 13. Decedents Eduption (Specify omy hkghest grade completed) 14, Marital Sutus: Married, Never Marred, 1 B. Surviving Spouse QI wife, give maiden name)
Kind W Wodr Kind of Business I Intluslry U.S. Armed Forces? Elementary /Secondary (D-12) College (1-4 or 5+) Widowed, DNOmed (Specify)
®Y~ ^r+° 12 Married Finil E. Scrimshaw
16. Decedents Ma91ng Adtlrmss (Street, cry /town, state, zip code) Decedent's PA atl Decedent
149 N
25 tl1 S t Actual Residence 17a. Slate Tox
o 17c. ^ Yes, Decedent Lived in
s
i 7,~.
.
.
Hill PA 17011 m
h
p
,ro.connty Cumberland ndf~N
o ~em'Nedwghin CAP Hill
" ciylBOr°
18. Famer's Name (First middle, Iasi sumx) 19. Mother's Name (Flrsl, midtNe, maiden surname)
Jose h Zap oric
20a. Inbnnanl's Name (Typa~ I Pnnt1 20b. InfarmanCS Mailing Adtlrasa (Slreei city I town, state, zip coda)
7 149 N. 25th St. Hill PA 17011
21a. Memotl o Disposd'an ~ ~ Cremation ^ Oonatbn 21h. Date of Disposaian (Month, Bey, year) 21c. Place of Disposition (Name d cemetery, crematory a omer place]
lli 21d. Lxaaon (City I town, state, zip code)
^ Banal ^ RemovalfromState ~ WaacromatbnorDaraNonAuthortred 08-O1-2008 Ho
nger Funeral Home & Mt
Holt
S
i
^ Omer - spedly: M Madkel Examiner I Coronerl ®Ves ^ No .
pr
y
ngs , PA
22a. ~ 'era F 22b. Litense Namber 22t. Name and Addmas of Fatdiry Myers-Harner Funeral Home
- 014819 L 1903 Market St. Cam Hill PA 17011
Complete Items 23et only when ceniFying 23a. To me best of my knovedge, death occurred at 8w lime, date aM pace stated. (Signature and title) 23b. License Number 23c. Date Signed (Mmm, day, year)
physician rs not avaNahie at tlme of tleam to
cer6ly cause a deem.
kerns 2426 must be complNed by person 24. Time of Deam 25. Dale Pronounced Dead
(Month, tlay, year) 26. Was Case Referred to Medical Examiner /Coroner for a Reason Other than Cremalbn or Donation?
who pronamcas death. . ~ , S R M' ~y
0
.~ U ~ d H , •~~8 ^ Ves c^j No
CAUSE OF DEATH (See IneVUCUtms and examples) r Approximate interval: Pan II: Enter ottwr cif Amt c°ndd'mn. mnhaxmn g to deeLh, 28. Did Tobacco Use Contribute to Death?
Item 27. Pan I: Enter the ~g~.8ySp6t - tliseases, injures, a Wmplicakons - that directly pusetl the deem. DO NOT r term
respuatay areal, a vemncular fibnllalion adttwW ~ng the tblogy. List only one cause on each Foe. ants such as pMiac areal r Onset to Death
/ r fiat rmt resuki~ in me underlying cause given in Pan I. ^ Yes ^ Probe
End S tage M to r s i ^ No nknown
IMMEDIATE CAU$E (Final cksease a
condition resuping in m) -~ a ~ r 29. If Female:
^
Due to (or as a onsequence o0: i Nol pregnant within past
Sequentially gat candAions, d arty, b.
i
d
li r
r ^ Pregnant at lime of death
leading to the cause l
ste
on
ne a.
Enter Bye UNDERLYING CAUSE Due to (or as a consequence oR: r ^ Not pregnant, but pregnant witnm 42 days
(disease a injury mat inifialad me C
BVen15 resulting m Beam) LAST r of Beam
Due to (or as a consequence op: r ^ Nat pregnant Mrt pregnant 43 days to 1 year
d. r before death
^ Unknown If pregnant wgmn Ire past year
~
3da. Was an AWapsy 31M. Were AWOpsy Fallings 31. Maim~^r of Death 32a. Date d Injury (Month, day, year) 326. Describe How Injury Occurtetl --~
32c. PWCe of Injury: Home, Fann, SlreeL Factory, ~,
Pedormed? Available Prior to Completion r-.,/
~1 NaWral ^ Homi~ de Office BuiMing, etc. (6pecity)
of Cause of Death? ,
^ Ves No ^ Yes ~No ^ Accident ^ Pending InvesOgation 32d. Time of Injury 32e. Irmrcq at Work? 327. II Transponation Inuryy (SpeciyJ 32g. Location of Inlury (Street, city I tarn, state)
^ Suidtle ^ Cald Nol be Delermine0 ^ Vas ^ No ^ Driver I Operelor ^ Passenger ^Pedesman
M Omer - Specyty~
33e. Certirier (check Dory au) 3 ignature and Title of C
• Cerdtyfng physirian (Physiaan ceAtying puce of death when another physictian has pronounced tleath all completed Item 23) -
To Me bear of my knowledge, tleath occurred due to the cauaNa) end manner u sleted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
• Pronouncing and certdying physician (Physician troth pronandng death and cedgying to pose of death)
To the heal of my knowledge, tleath occurred at the time, date, and place, and due to the tease(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (i~ 33c. C Nymber ~~
~~(t (;
_ 33d Da S' netl ,day, year) ~ `
• Medcal Examiner I Coroner
tM the basis of examination end 1 or investigadon, in my opinion, tleam occurred al the time, date, a~ place, and due t0 the cause(s) and manner as stated_ ^ ~
~1 "1
~ Nam
e and Adtlress of Perso
Comp etl Cause
of
t
D
e
t
h
h
/I r
em Type I P 1
Regi r' S' nature arb '". ~ ~ / } ~ I / I ~I 3b Date fed ( m, daY. Year /
7
/
n
r
/
/
~
/
~9
-~y(,t / .~ ~~Vt~~ /v v>/ ' ~ l~l~ /(._.,1 .
Dlemifi°n Pennil No. 0220316