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Home My WebLink About04-0296 PETITION FOR PROBATE and GRANT OF LETTERS also known as To Register of Wdls for the -- ~:~ County of CJJ~I9~4V-[O~/ld ~n the Soctal Security No ') 0 .~ ~ TO'-'Dec,~ __ a~> Commonwealth of Pennsylvama The petmon of the undersigned respectfully represents that Your pet,ironer(s), who ,s./~. 8 years of age or older an the executF/X ~n the last wdl of the above decedent, dated ~ I- ~)- ~- Cl ~t , 19__ and codicil(s) dated (state relevant clrcnmstances, e g renunclanon, death of executor, etc ) Decendent was dom~cded at death tn Q~ f'~ k:~__.~[~d County_Pennsy. J,vanla,, wtth h ~ last fa~/hty or prlnclpaJ4esq:lcnce at (hst street, number and muhclpahty) Excel{as follows, 3ecedent dM not marry, was not divorced and d~d not have a chdd born or adopted after executzon of the wdl offered for probate, was not the victim of a kdhng and was never adjudicated mcompetent Decendent at death owned property with estimated values as follows (If dom:cried in Pa ) Ali personal property $ (If not dom]cried (lf not dom:cried ~n Pa ) Personal property ~n County ',~ Value of real estate ~n Pennsylvama s~tuated as follows m ' - - WHEREFORE, petmoner(s) respectfully reqqest(s) the probate of the ,last2 wdl ~d codiEll(s) presented herewith and the grant of letters (testamentary, admm~stranon c t ].2~mm~str~n d b nj:t,a ) theron OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF ) (..~Az~_~ ~:0_ / The pctttmncr(s) above-named swear(s) or affirm(s) that thc statements tn thc foregomg peUtton arc truc and.~orrcct to the,best of thc knowledge and behef of pctmoner(s) and that as personal rcprcsen- tauve(s) of t,h~ a~ decedent pctmoncr(s) will well and truly adm~mster thc estate according to law Sworn to '~r afl.med, and subscr,bed ~ ¢~ ~ befor%meth,s_ [~ 1~ h ~'~ '~ ~.day°f { ~ ~~ X ~~ This Is to cer[ify that the mformat~on here g~ven ~s correctly cop~ed from an original cemficate of death duly filed w~ me as Local Registrar The original certificate will be forwarded to the State Vital Records Office for permanent fihng WARNING: It IS illegal to duphcate th~s copy by photostat or photograph. ,,.~ CERTIFICATE OF DEATH O ~ - -- ,, Susan Shu~har~ Elaine Mellen [~ 328 south P~tt St.t ~rl[sle, Pa 17013 PA 17013 OF LEANA E. McCOY I, LEANA E. McCOY, of 511 South West Street, Carlisle, Pennsylvama, declare this instrument to be my Last Wall and Testament, in manner and form following: FIRST: I hereby expressly revoke all W~lls and Codicils heretofore made by me. SECOND: I hereby direct my EXECUTRICES to pay all my just debts, funeral and administrative expenses out of my estate, as soon as practicable after my death. THIRD: I d~rect that all taxes which may be assessed in consequence of my death of whatever nature and by whatever jurisdiction imposed shall be paid out of my estate as a part of the administration of my estate. FOURTH: I devise and bequeath the remainder of estate to my children, share and share alike, with the chdd or children of any deceased child taking ~e?share~their ~fi~nt would have taken if hmng. ~-, ,, -- FIFTH: I nominate and appoint my daughters, JOANN E. BAKER and ELAINE L. MELLEN as executrices of this my last will and testament; and I direct that my said executrices shall not be required to file bond or security in this or any other junsdxctlon. IN WITNESS WHEREOF, I hereunto set my hand and seal this day of/~ ~ ~o.,~ , 1994. Leana E. McCoy SIGNED, SEALED, PUBLISHED and DECLARED in the presence of: 2 COMMONWEALTH OF PENNSYLVANIA : : SS. COUNTY OF CUMBERLAND : I, LEANA E. McCOY, Testatrix, whose name is signed to the attached or foregoing instrumem, 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 the purposes therein expressed. Sworn, or affirmed to and acknowledged before me, by LEANA E. McCOY, Testatrix, this q~I~L~ day of ~~~: 1994. Notary ~ - COMMONWEALTH OF PENNSYLVANIA : -' SS. COUNTY OF CUMBERLAND : We, Roger M. Mor~enthal and Becky H. Mor~enthal , 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 Testatrix, LEA/WA E. McCOY, 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 purposes therein expressed; that each of us in the sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge the Testatrcx was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before m.e by Roqer M, Morqentha]and Becky H. Morqenthal .witnesses, this~_~:)-~-dayof~ .~.~'¥L~k~3J~l~94.~ x,-x Witness ~itness /J -'-- Notary Public~ NOT~ttll. S~L 4 CERTIFICATION UNDER NOTICE UNDER RULE 5.6(a) Name of the Decedent: Leana E. McCoy Date of Death: March 20, 2004 Will No. 00296 of 2004 Admin. No. 2004-00296 To the Register: I certify that notice of a beneficial interest required by Rule 5.6(a) of the Orphan's Court Rules was mailed to the following beneficiaries of the above- captioned estate on April 29, 2004. Name Address Joann E. Baker 22 Kreider Avenue Lancaster, PA 17601 Elaine L. Mellen 328 South Pitt Street Carlisle, PA 17013 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: April 29, 2004 S~~ Name: Kathleen K. Shaulis, Esq.. Address: 44 South Hanover Street Carlisle, PA 17013 Telephone: (717) 243-6655 Capacity Personal Representative X Counsel to .~.e~rsonal Representative.. S ~ ?~ ir= ?-,3 NOTICE OF BENEFICIAL INTEREST IN ESTATE BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND In re Estate of Leana E. McCoy, deceased No. 2004-00296 TO: Elaine L. Mellen 328 South Pitt Street Carlisle, PA 17013 Please take notice of the death of decedent and grant of letters to the personal representative named below. You may have a beneficial interest in the estate as follows: You are named as one of only two beneficiaries under Mrs. McCo¥'s Last Will and Testament. Name of the Decedent: Leana E. McCoy Last Known Address: Forest Park Health Center 700 Walnut Bottom Road, Carlisle, PA 17013 Date of Death: March 20~ 2004 Place of Death: Forest Park Health Center County of Grant of Original Letters: Cumberland Decedent dies X testate __ intestate A copy of the will __ is X is not attached. Name(s), address(es) and telephone number(s) of all personal representatives appointed Name Address Telephone Joann E. Baker 22 Kreider Avenue (717) 569-0578 Lancaster, Pennsylvania 17601 Elaine L. Mellen 328 South Pitt Street (717) 243-0549 lJancaster, Pennsylvania 17601 Name(s), address(es) and telephone number(s) of all counsel Name Address Telephone Kathleen K. 44 South Hanover Street (717) 243-6655 Shaulis, Esq. Carlisle, PA 17013 Additional information may be obtained fi.om the undersigned. Date: April 29, 2004 Signature:"~..t~~/~~ Name: Kathleen K. SHaulis, Esq. Address: 44 South Hanover Street Carlisle~ PA 17013 Telephone: (717) 243-6655 Capacity: __ Personal Representative X Counsel for Personal Representatives NOTICE OF BENEFICIAL INTEREST IN ESTATE BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND In re Estate of Leana E. McCoy, deceased No. 2004-00296 TO: Joann E. Baker 22 Kreider Avenue Lancaster, PA 17601 Please take notice of the death of decedent and grant of letters to the personal representative named below. You may have a beneficial interest in the estate as follows: You are named as one of on1¥ two beneficiaries under Mrs. McCo¥'s Last Will and Testament. Name of the Decedent: Leana E. McCoy Last Known Address: Forest Park Health Center 700 Walnut Bottom Road, Carlisle, PA 17013 Date of Death: March 20, 2004 Place of Death: Forest Park Health Center County of Grant of Original Letters: Cumberland Decedent dies X testate intestate A copy of the will __ is X is not attached. Name(s), address(es) and telephone number(s) of all personal representatives appointed Name Address Telephone Joann E. Baker 22 Kreider Avenue (717) 569-0578 Lancaster, Pennsylvania 17601 Elaine L. Mellen 328 South Pitt Strec~ (717) 243-0549 Lancaster, Pennsylvania 17601 Name(s), address(es) and telephone number(s) of all counsel Name Address Telephone Kathleen K. 44 South Hanover Street (717) 243-6655 Shaulis, Esq. Carlisle, PA 17013 Additional information may be obtained f~om the undersigned. Address: 44 South Hanover Street Carlisle, PA 17013 Telephone: (717) 243-6655 Capacity: __ Personal Representative X Counsel for Personal Representatives CERTIFICATION UNDER NOTICE UNDER RULE 5.6 (a) Name of the Decedent: Leana E. McCoy Date of Death: March 20, 2004 Will No. 00296 of 2004 Admin. No. 2004-00296 To the Register: I certify that notice of a beneficial interest required by Rule 5.6(a) of the Orphan's Court Rules was mailed to the following beneficiaries of the above- captioned estate on April 29, 2004. Name Address Joann E. Baker 22 Kreider Avenue Lancaster, PA 17601 Elaine L. Mellen 328 South Pitt Street Carlisle, PA 17013 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: May 4, 2004 .q~~'~~ Signature Name: Kathleen K. Shaulis, Esq. Address: 44 South Hanover Street Carlisle, PA 17013 Telephone: (717) 243-6655 Capacity Personal Representative X Counsel to Personal Representatives NOTICE OF BENEFICIAL INTEREST IN ESTATE BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND In re Estate of Leana E. McCoy, deceased No. 2004-00296 TO: Joann E. Baker 22 Kreider Avenue Lancaster, PA 17601 Please take notice of the death of decedent and grant of letters to the personal representative named below. You may have a beneficial interest in the estate as follows: You are named as one of only two beneficiaries under Mrs. McCoy's Last Will and Testament. Name of the Decedent: Leana E. McCoy Last Known Address: Forest Park Health Center 700 Walnut Bottom Road, Carlisle, PA 17013 Date of Death: March 20, 2004 Place of Death: Forest Park Health Center County of Grant of Original Letters: Cumberland Decedent dies X testate intestate A copy of the will __ is X is not attached. Name(s), address(es) and telephone number(s) of all personal representatives appointed Name Address Telephone Joann E. Baker 22 Kreider Avenue (717) 569-0578 Lancaster, Pennsylvania 17601 Elaine L. Mellen 328 South Pitt Street (717) 243-0549 Carlisle, Pennsylvania 17013 Name(s), address(es) and telephone number(s) of all counsel Name Address Telephone Kathleen K. 44 South Hanover Street (717) 243-6655 Shaulis, Esq. Carlisle, PA 17013 Additional information may be obtained fi.om the undersigned. Date: May 4, 2004 Signature:~' ~e/~_.~/~//-~~~-~ Name: Kathleen I<L Shat~is, Esq. ~ Address: 44 South Hanover Street Carlisle, PA 17013 Telephone: (717) 243-6655 Capacity: __ Personal Representative X Counsel for Personal Representatives NOTICE OF BENEFICIAL INTEREST IN ESTATE BEFORE THE REGISTER OF WILLS, COUNTY OF CUMBERLAND In re Estate of Leana E. McCoy, deceased No. 2004-00296 TO: Elaine L. M¢llen 328 South Pitt SU'eet Carlisle, PA 17013 Please take notice of the death of decedent and grant of letters to the personal representative named below. You may have a beneficial interest in the estate as follows: You are named as one of only two beneficiaries under Mrs. McCoy's Last Will and Testament. Name of the Decedent: Leana E. McCoy Last Known Address: Forest Park Health Center 700 Walnut Bottom Road, Carlisle, PA 17013 Date of Death: March 20, 2004 Place of Death: Forest Park Health Center County of Grant of Original Letters: Cumberland Decedent dies X testate intestate A copy of the will __ is X is not attached. Name(s), address(es) and telephone number(s) of all personal representatives appointed Name Address Telephone Joann E. Baker 22 Kreider Avenue (717) 569-0578 Lancaster, Pennsylvania 17601 Elaine L. Mellen 328 South Pitt Street (717) 243-0549 Carlisle, Pennsylvania 17013 Name(s), address(es) and telephone number(s) of all counsel Name Address Telephone Kathleen K. 44 South Hanover Street (717) 243-6655 Shaulis, Esq. Carlisle, PA 17013 Additional information may be obtained t?om the undersigned. .. i ~/,, ~' Date: May4, 2004 Sign ature :"'~L~-~tx-]'-~ Name: Kathleen K. Shdulis, Esq. Address: 44 South Hanover Street Carlisle, PA 17013 Telephone: (717) 243-6655 Capacity: __ Personal Representative X Counsel for Personal Representatives COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 004041 SHAULIS KATHLEEN KRISE 44 SOUTH HANOVER STREET CARLISLE, PA 17013 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold .................. 101 $4,500.00 ESTATE INFORMATION: SSN: 203-10-8490 FILE NUMBER: 21 04-0296 DECEDENT NAME: MCCOY LEANA E DATE OF PAYMENT: 06/14/2004 POSTMARK DATE: 06/14/2004 COUNTY: CUMBERLAND DATE OF DEATH: 03/20/2004 TOTAL AMOUNT PAID: $4,500.00 REMARKS: CHECK# 117 INITIALS: JA SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV-1162 EX(11-96) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17~ 28-0601 PENNSYLVANIA INHERITANCE AND ESTATE TAX RECEIVED FROM: OFFICIAL RECEIPT NO. CD 004718 BAKER JOANN E 22 KREIDER AVE LANCASTER, PA 17601 ACN ASSESSMENT AMOUNT CONTROL N'UMBER ........ fold 101 $128.40 ESTATE INFORMATION: SSN: 203-10-8490 FILE NUMBER: 2104-0296 DECEDENT NAME: MCCOY LEANA E DATE OF PAYMENT: 12/1 O/2004 POSTMARK DATE: 12110~2004 COUNTY: CUMBERLAND DATE OF DEATH: 03/20/2004 TOTAL AMOUNT PAID: $128.40 REMARKS: MCCOY CHECK//128 INITIALS: CCP SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURN 2-1-o O& HARRISBURG, PA17128-0601 RESIDENT DECEDENT COUN, CODE DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) ~ SOCIAL SECURI~ NUMBER DATE OF DEATH (MM-DD-Y~R) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~ -- ~0 -~ 00~ ~ - ~ -- I~ 17 REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (~ST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURI~ NUMBER ~1' Origi,al Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death pr,or to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of death after 12-12-82) 5. Federal Estate Tax Return Required ~. Doco0ont Diod Tostato (~uacn ~py of Will) 7. Docodont Maintained a Uvin~ lrust {~mch copy of lmst) 8. Total ~umBer of Safo Doposit Boxos ~ 9. Litigation Proceeds Received ~ 10. Spousal Pove~ Credit (date of death be~n 12-31-91 and 1-1-95) ~ 11. Election to tax under Sec. 9113(A)(A,ach Sch O) COMPLETE MAILING ADDRESS FIRM NAME (If~plJ~ble) 1. Real Estate (Schedule A) (1) OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) ~ ~ ~ 7 ~ ~, O O 3. Closely Held Co~oration, Padnership or Sole-Proprietomhip (3) 4. Me,gages & Notes Revivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Prope~ (5) ~ ~ 9 ~ I. O ~ (Schedule E) 6. Jointly Own~ Pmpe~ (Schedule F) (6) ~ Separate Billing Requested 3 OO 7. Inter-Vivos Transfem & Mis~llaneous Non-Probate Pmpe~ (7) i (Schedule G or L) 8. Total Gross Asse~ (total Lines 1-7) (8) 9. Funeral Ex~nses & Administrative Costs (Schedule H) (9) ~ ~ O ~ . O 10. Debts of Decedent, aoAgage Liabilities, & Liens (Schedule l) (10) ~ ~ ~ 11. To~lBedu~ions(totalLines9& 10) (11) / I / 73 12. Net Value of Es~te (Line 8 minus Line 11) (12) 13. Charitable and Governmental Bequests/Sec 9113 T~sts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE ~TES 15. Amount of Line 14 taxable the at spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0 ~ (15) 16. Amount of Line14 taxable at lineal rate / 07 ,/ ~ ~3~.. ~x.0~ (16) ~ ~.~ 17. Amount of Line 14 taxable at sibling rate x .12 (17) 18. Amount of Line 14 taxable at collateral rate x .15 (18) 19. Tax Due (19) SCHEBULE E COMMO.w~^Lm OF PENNS¥.V^N,^ CASH. BANK DEPOSITS. & MISC. .N.ERIT^NC~ ~^X RETUR. PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER ~TE~ VALUE AT DATE NUMBER DESCRiPTiON OF D~TH ~3( oo3q TOTAL (Also enter on line 5, Recapitulation) (If more space is needed, inser~ additional sheets of the same size) SCHEDULE G INTER-VIVOS TRANSFERS 8, COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ......... '" 'FILE #UMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET s es, DESCRIPTION OF PROPERTY % OF ITEM INCLUDE THF NAME OFTHE TI~NSFEREE. TflEIRREI. ATION~I~PTODEC(EDENI'ANDTHIE ~A'm OF TRA~SFe'~ DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUI ATtic. ^ co~ OF n~E ~em mR ~L NUMBER VALUE OF ASSET INTEREST 0F ~UC~LE) TOTAl (Also enter on line 7, RecapitalaJon) $ 3 3 Z.~ 0 i. ~ (If more space is needed, insert additional sheets of the same size) RE~V-1511 I~X~- (12-99) ~ SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT FILE NUMBER ESTATEOF LC. eX Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A, FUNERAL EXPENSES: B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State ___ Zip Year(s) Commission Paid: 2. AttorneyF~s ~I2~"~\'~.~.,V~ l~. ~ [.~ )F__~iyl¥.,~.~,~ qff o~-~ ¥~~ ,~q~-, ~,,,r~,,~.,/~A. ~o~'3 12-.¢0. O0 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State __ Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees '7~ oo TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) ~ SCHEDULE ! coMMo.w~m~'~War'~'~oF PE..SYLV^.,^ DEBTS OF DECEDENT, ~..~,~.~ ~.x .~u.. MORTGAGE LIABILITIES, & LIENS RESIDENT DECE~NT , . , , ,, ESTATE OF FI~E NUMBER Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT ~0 ~X qloo~ eoe~~ P~ TOTAL (Also enter ~ line 10, R~apitulation) $ I ~ 0 ~. 7 E×*, 9-oo SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DO Not List Trustee(s) OF ESTATE 1 TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a)(1.2)] 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 1I- 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) May 13, 2004 The Law Offices of Kathleen K. Shaulis, Esq. 44 South Hanover Street Carlisle, PA 17013 RE: Estate of Leana McCoy Date of Death: M~xch 20, 2004 Social Security Number: 203-10-8490 Dear Ms. Shaulis: In response to your request, please be advised that at the time of death, the above- named decedent had on deposit with this bank the following accounts. 1. Account Type ........................... Certificate of Deposit Account Number. ...................... 31003910172681 Ownership (Names of) .............. Leana McCoy Opening Date ........................... 08/25/98 Year to Date Interest ................. $0.00 Balance on Date of Death. ......... $7,100.85 Accrued Interest $ 111.58 Total ....................................... $7,212.43 2. Account Type ........................... Certificate of Deposit Account Number. ...................... 31003910176279 Ownership (Names of) ............... Lea_ua McCoy Opening Date ........................... 08/28/98 Year to Date Interest ................. $0.00 Balance on Date of Death_ ......... $14,835.22 Accrued Interest $ 229.75 Total. ...................................... $15,064.97 Schedule · Page 2 May 13, 2004 3. Account Type ........................... Certificate of Deposit Account Number. ...................... 31003910176287 Ownership (Names of) .............. Leana McCoy Opening Date ........................... 08/28/98 Year to Date Interest ................. $0.00 Balance on Date of Death- ......... $14,725.99 Accrued Interest $ 207.72 Total ....................................... $14,933.71 4. Account Type ........................... Certificate of Deposit Account Number. ...................... 3100391414097 Otvnership (Names of) .............. Leana McCoy Opening Date ........................... 11/12/91 (account closed 03/29/04) Year to Date Interest ................. $0.00 Balance on Date of Death. ......... $6,276.86 Accrued Interest $ 26.86 Total. ...................................... $6,303.72 5. Account Type ........................... Chectdng Account Account Number. ...................... 500429 Oumership (Names of) .............. Leona McCoy Opening Date ........................... 11 / 01 / 72 Year to Date Interest ................. $94.03 Balance on Date of Death. ......... $6,375.35 Accrued Interest $ 2.09 Total. ...................................... $6,377.44 May 13, 2004 · Pa,::je :3 Smccrely, Charlene Warrington, Records Nlanagement 1-888-502-4349 Corn m on wealth of Pen n sylvan ia Department of Reven tee Bttreau of Collections attd Taxpayer Services May 3, 2004 Attorney Kathleen Shaulis 44 S. Hanover St. Carlisle, PA 17013 Dear Attorney Shaulis, Pursuant to your request that a representative of the Pennsylvania Department of Revenue appear and inventory a sate deposit box in the name of Leana E. McCoy deceased, attthorization is hereby given for you to access the safe deposit box without the presence of a representative of the Pennsylvania Department of Revenue. You are hereby attthorized to access the safe deposit box on or after May 3, 2004. You should present this letter to M & T Bank as evidence of your authority pursuant to 72 P.S. § 9193. This actthorization is made only to Atty. Kathleen Shaulis and may not be delegated to any other person. In ~'anting this authorization, Atty. Kathleen Shaulis a~ees to prepare and submit an inventory of all contents of any safe deposit box accessed and to submit said inventory on the form provided by the Pennsylvania Department of Revenue, to the Pennsylvania Department of Revenue within seven i'D clays, from the access date, by mailing to: Pennsylvania Department of Revenue Harrisbur~ District Office Attn: Deanna Williams Lobby, Strawberry Square Harrisburg, PA 17128-0101 (717) 783-1405 Very truly yours, Rebecca Barrick District Administrator Co~MO""'~A~T"T~7~'A~' SAFE DEPOSIT BOX ' ' iE~A~ MENEX^~,.^T,O" A I~vEHTORY DX / IP CODE) lAME AND ADDRESS OF pERSON REOUESTING THE oPENING OF ~HE sAFE DEPOSIT BOX NAME, ADDRESS AND RELATIONSHIP ~IF ANY1 TO DECEDENT, OF pERSON{S] (STREET A~ ~ ~t' jRELATIONSHIP) b. (NAM~J (STATE) JCITY) ~STREET ADDRESS) [RELATIONSHIP) izm CODE) c. ~NAMEI )STATE) (STRAIT ADDR[SS) EPOSIT BOX IS LocATED. ~ , , . NAME ~ND ADDRESS OF FINANCIAL ~ ~ i ~ :~. ~ .... ~C~ ~~~ ~ ' '(ZIPCODE) (CITY1 (STREET DDRESSl ENTRY 1~ '~ ~0 V'~ V"~ ~ ~ ~ BOX ~ME AND ADDRESS OF pERSON(S) HAVING ACCESS TO BOX ~RESSi name and address of a~torney, il any c, ~NAME) / ~CITYJ ~DRESS~ Page of .4/ SAFE DEPOSIT BOX INVENTORY INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stack is registered, and number of shares and class of stock. (3) Obligations of U. S. Government: Number of items, date of issue, face value, names in which registered. (4) Bonds: Designate by name, amount, serial number, or other designation. (5) Bank and SavJngs and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. ,J,~Jewelry, Coins, Stamps, Manuscripts, etc: Ust and describe as fully as possible. (7~dDeeds, Mortgages, Current Insurance Policies or other evJdences of indebtedness: List and describe as ? fu y as possible. (8) All other contents. ITEM DESCRIPTIOH Icertify under penalty o[ perjury that the above recordls correct and complete to the best of my knowledge Print Name and Title NOTE: Use ~eparate ~heets if necessary. Page SAFE DEPOSIT BOX INVENTORY File No. 21-04-0296 Estate of Leana E. McCoy DOD 3-20-04 3. Series E U.S. Savings Bonds - Decedent was joint owner with Bruce McCoy, husband, deceased Serial No. Date Issued Face Value Q 5237588044E 1/75 25.00 Q 5249473800E 4/75 25.00 Q 6016237675E 8/75 25.00 Q 6043372444E 11/75 25.00 Q 6350207931E 6/79 25.00 Q 6374111440E 10/79 25.00 Q 6390750700E 1/80 25.00 Q 6403823933E 5/80 25.00 Series EE U.S. Savings Bonds - Decedent was joint owner with Bruce McCoy, husband, deceased Serial No. Date Issued Face Value L21441425EE 4/80 50.00 L40790038EE 2/81 50.00 L69140105 EE 7/81 50.00 L61740694EE 12/81 50.00 4. No bonds. 5. A. M + T Bank statement dated 9/13/02 showing 2 CD's: CD 31003910176279 Value $14438.60 CD 31003910176287 Value $14336.72 B. AIlfirst Certificate of Deposit statement dated 11/2003 showing w/drawal of Acct. No. 8-700-800-0689472 fixed value $6000; deposit slip for $6000 and letter noting that CD will mature to $7,084.82 with notation in Margin that $6000 was reinvested in another CD and a check issued for $1084.42 at maturity Page ~ of ~ SAFE DEPOSIT BOX INVENTORY File No. 21-04-0296 Estate of Leana E. McCoy DOD 3-20-04 The following are older documents showing investments that have since been reinvested or cashed in: C. Allfirst deposit slip dated 11/12/1993 for $4500 CD for 2 years at 5.55% D. Statement for Financial Trust for CD issued 8/28/98 for 24 months with an automatic renewal. (31003910176287) ($11,719.46) E. Statement for Financial Trust for CD issued 8/28/00 for 24 months with an automatic renewal. (31003910176279) ($11,661.12) F. Statement for Financial Trust for CD issued 8/25/99 for 12 months (31003910172681) ($5,784.99) G. Statement for Financial Trust for time deposit issued 8/28/95 for 24 months. (10,000.00) H. Statement for M + T Bank for CD issued 8/6/2001 for 9 (31003910193992) ($9,820.36) I. Statement for M + T Bank for CD issued 11/8/2000 for 9 (31003910193992) ($9,820.36) J. Legg Mason - investment notice dated 9//1/95 of $20,000 in Provident Bank 6. No jewelry, coins, stamps, manuscripts 7. No deeds, mortgages, current insurance policies or other evidences of indebtedness 8. A. Copy of will, birth certificate, social security card, marriage license B. Receipt from sale of 1186 Newville Road, Carlisle, PA on 8/15/95 C. AIIfirst letter $100 Bonus coupon expired 7/15/02 D. AIIfirst G-B-L Privacy letter - no date E. October 3, 1994 - Fraternal Order of Eagles death benefit for Bruce McCoy F. Authorization for SS payments dated 6/5/82 for both decedent and husband Page ~ of V SAFE DEPOSIT BOX INVENTORY File No. 21-04-0296 Estate of Leana E. McCoy DOD 3-20-04 G. Renewal on homeowners policy for 501 B South West Street, Carlisle 8/16/95 from Plough and Lillich agency H. Undated receipt for 27 Savings bonds with face value amount of $775.00 to be held in Carlisle West Office of Dauphin Deposit bank. I. Notice of merger of Allfirst into M+T Bank 10/25/2002 J. Undated notice of inactive accounts at AIlfirst K. Homeowner's insurance policy from Fickel Insurance for 501 South West Street, Apt. B, Carlisle 9/12/02 Savings Bond Calculator Page 1 of 1 Savinc: l°3/2°°4J ~ [ I Series Denomination Serial Number Issue Date Bo_.n_.d_s_ ...... ~ $!5o I I l i # Bonds Total Price Total Interest Total Value YTD Im 27 $531.25 $2,507.54 $3,038.79 $28/ Issue Interest Next Final Serial Number Issue Date Series Denom Price Interest Value Rate Accrual Maturity 11/1977 E $25 $18.75 $90.58 $109.33 4.00% 05/2004 11/2007 08/1977 E 25 18.75 102.84 121.59 4.00% 08/2004 08/2007 04/1977 E 25 18.75 101.42 120.17 4.00% 04/2004 04/2007 01/1977 E 25 18.75 103.82 122.57 4.00% 07/2004 01/2007 10/1976 E 25 18.75 102.30 121.05 4.00% 04/2004 10/2006 06/1976 E 25 18.75 104.74 123.49 4.00% 06/2004 06/2006 03/1976 E 25 18.75 105.75 124.50 4.00% 09/2004 03/2006 [View AIl',[ Viewing Bonds 1-7 ~-~-~> i Note Description NI Not Issued NE Not Eligible for Payment P5 Includes 3-month interest penalty ME Matured (Exchangeable for HH) MN Matured (Not Exchangeable for HI-I) Please rate this service. (Please print and/or save this page before submitting your survey) Service Excellent Good Fair Poor Savings Bond Calculator 0 http://wwws.publicdebt.treas.gov/BC/SBCPrice 6/10/04 Savings Bond Calculator Page 1 of 1 Savinc Io3/2oo~ ~ l "~'~ J Series Denomination Serial Number Issue Date lEE Bonds $l5° I t # Bonds Total Price Total Interest Total Value YTD lnT 27 $531.25 $2,507.54 $3,038.79 $28.' Issue Interest Next Final Serial Number Issue Date Series Denom Price Interest Value Rate Accrual Maturity 04/1975 E $25 $18.75 $105.23 $123.98 4.00% 04/2004 04/2005 01/1975 E 25 18.75 107.71 126.46 4.00% 07/2004 01/2005 09/1974 E 25 18.75 108.72 127.47 4.00% 09/2004 09/2004 01/1974 E 25 18.75 109.73 128.48 01/2004 10/1973 E 25 18.75 113.01 131.76 10/2003 12/1968 E 25 18.75 118.53 137.28 12/1998 01/1979 E 25 18.75 70.08 88.83 4.00% 07/2004 01/2009 10/1978 E 25 18.75 69.00 87.75 4.00% 04/2004 10/2008 06/1978 E 25 18.75 70.73 89.48 4.00% 06/2004 06/2008 03/1978 E 25 18.75 76.19 94.94 2.34% 09/2004 03/2008 [~tl ~-~-. Viewing Bonds 8-17 I.~,~>>I Note Description NI Not Issued NE Not Eligible for Payment P5 Includes 3-month interest penalty ME Matured (Exchangeable for HH) iMN Matured (Not Exchangeable for HH) Please rate this service. (Please print and/or save this page before submitting your survey) Service Excellent Good Fair Poor Savings Bond Calculator 0 0 0 http://wwws.publicdebt.treas.gov/BC/SBCPrice 6/10/04 Saving. s Bond Calculator Page 1 of 1 Savinc lo3/2oo4 ! ~ ~ Series Denomination Serial Number Issue Date lEE Bonds $!50 I I I i E # Bonds Total Price Total Interest Total Value YTD In~ 27 $531.25 $2,507.54 $3,038.79 $28.' Issue Interest Next Final Serial Number Issue Date Series Denom Price lnterest Value Rate Accrual Maturity 12/1981 EE $50 $25.00 $82.00 $107.00 4.00% 06/2004 12/2011 07/1981 EE 50 25.00 84.14 109.14 4.00% 07/2004 07/2011 02/1981 EE 50 25.00 91.28 116.28 4.00% 08/2004 02/2011 09/1980 EE 50 25.00 104.40 129.40 4.00% 09/2004 09/2010 05/1980 E 25 18.75 67.63 86.38 4.00% 05/2004 05/2010 01/1980 E 25 18.75 68.47 87.22 4.00% 07/2004 01/2010 10/1979 E 25 18.75 67.66 86.41 4.00% 04/2004 10/2009 06/1979 E 25 18.75 69.39 88.14 4.00% 06/2004 06/2009 11/1975 E 25 18.75 105.47 124.22 4.00% 05/2004 11/2005 08/1975 E 25 18.75 106.72 125.47 4.00% 08/2004 08/2005 lw~A~I J L << Pr.] Viewing Bonds 18-27 Note Description NI Not Issued NE Not Eligible for Payment P5 Includes 3-month interest penalty ME Matured (Exchangeable for HH) MN Matured (Not Exchangeable for HH) Please rate this service. (Please print and/or save this page before submitting your survey) Service Excellent Good Fair Poor Savings Bond Calculator 0 0 0 http://wwws .publicdebt. treas.gov/BC/SBCPrice 6/10/04 5 North Orange Street Suite 4 Carlisle, PA 17013 www.proiectshare.net September 14, 2004 Joanna Baker 328 S. Pitt St. Carlisle, PA 17013 Dear Joanna, Thank you for your donation of your mom's belongings as well as your recent gift of $100 to Project S.H.A.R.E. Your support is much appreciated, especially during this difficult time for your family. What a thoughtful way to honor your mom, by giving to those who do not have the basics. During August's food distribution, we served 592 local families including 166 senior citizens and 506 children. We are able to provide groceries valued about $160 per family for about $12 food costs. I hope you have heard that if you shop Giant Foods Stores in September, please save your receipts! Giant will donate $1.00 for every receipt dated in September. Turn in your receipts at WIOO Radio Studio, 180 York Rd., or to the SHARE office before Sept. 30. Thank you for your generosity and support You and Elaine remain in our thoughts and prayers. Elaine Livas Director Check # 125 Pursuant to Internal Revenue Code requirements for substantiation of charitable contributions, no goods or services were provided in return for the Tax Deductible contributions. Sponsored by The Carlisle Area Religious Council FIDELITY AND GUARANTY LIFE INSURANCE COMPANY 201 Brookfield Pkwy, Ste. 301 Greenville, SC 29607 1.800.638.2255 April 16, 2004 _loanne Baker 22 Krieder Avenue Lancaster PA 17601 Re.' Policy No: I683959 Annuitant: Leana McCoy Beneficiary: Joanne Baker & Elaine Mellen, equally Dear Ms. Baker: We were sorry to learn of your loss. On behalf of Fidelity and Guaranty Life Insurance Company please accept our sincere condolences to you and your family. The policy provided a monthly benefit of $373.61 guaranteed for :~0 years beginning February 17, 2003. Our records reflect there are 106 guaranteed payments remaining. As beneficiary, you may receive the remaining guaranteed payments as scheduled or the commuted value. The commuted value of the policy is $33,401.26. The commuted value is the present value of the future payments and is less than the single premium. The interest rate used to calculate the commuted value is 1% higher than that used in determining the single premium. The difference in the interest rates is a charge for the risks and expenses associated with the asset liquidation required for a lump-sum payment, and a recoupment of expenses, for example, commissions and overhead, which must be paid from the single premium. Please complete the enclosed form and return it along with a certified death certificate. you have any questions or concerns, do not hesitate to contact this office. Sincerely, Claims Examiner Schedule G w w ~,v . 0 m f n . c 0 m ADMIN 5184 (10-2003) RIGINAL 286 ] ~ ACCT. NO. ~ral Services ~~ ' CREDITS ~x~. I - Name of Deceased 3THER NEW BALANCE $ ¢583 ~ateful acknowledgment is made for the recent payment of your account. We also wish to express our sincere thanks for the friendship and good-will you have accorded US. It is our purpose at all times to render a considerate and thoughtful service that may ScheduleH continue to merit your highest esteem. WILLIAM E. HOFFMAN, Supervisor i,~. .... Move-outDocUment ~ ' . Unit 627 MIDWAY1545 HOLLySELF STORAGEpiKE Move In Date ~. 10/11/2003 CARLISLE, PA 17013 ~ ' ~ ' ' ~ '~ "~ ~'" ~: ?'~:'''' Move Out Date ':-7/29/2004 (717) 258-9000 Paid To Date ~ .' 'i:.-. 8/1/2004 7/29/2004 Leana McCoy 328 S. Pitt Street ComPlete Tenant History CARLISLE, PA 17013 Eff Date From Unit Billed Paid Balance Ck # Comments .~.9(.!.~./_27~ ...................................................................................... .6._~ ........................................... $..1.9:9.9 ........................................................... ~?_:~.0 ....................................... SCt~P..?.e~e 10/11/2003 10/11/2003 11/1/2003 627 $61.00 $71.00 Rent / Prorated 10/11/2003 10/11/2003 11/1/2003 627 $3.66 $74.66 Sales Tax / Prorated 10/11/2003 $90.00 $164.66 Rent 10/11/2003 $5.40 $170.06 Sales Tax 10/11/2003 $170.06 $0.00 Check 12/1/2003 12/1/2003 1/1/2004 627 $90.00 $90.00 Rent 12/1/2003 12/1/2003 1/1/2004 627 $5.40 $95.40 Sales Tax 11/25/2003 $95.40 $0.00 3672 Check 1/1/2004 1/1/2004 2/1/2004 627 $90.00 $90.00 Rent 1/1/2004 1/1/2004 2/1/2004 627 $5.40 $95.40 Sales Tax 12/30/2003 $95.40 $0.00 3676 Check 2/1/2004 2/1/2004 3/1/2004 627 $90.00 $90.00 Rent 2/1/2004 2/1/2004 3/1/2004 627 $5.40 $95.40 Sales Tax 1/29/2004 $95.40 $0.00 3684 Check 3/1/2004 3/I/2004 4/1/2004 627 $90.00 $90.00 Rent 3/1/2004 3/1/2004 4/1/2004 627 $5.40 $95.40 Sales Tax 3/1/2004 $95.40 $0.00 3688 Check 4/1/2004 4/1/2004 5/1/2004 627 $90.00 $90.00 Rent 4/1/2004 4/1/2004 5/1/2004 627 $5.40 $95.40 Sales Tax 3/29/2004 $95.40 $0.00 3695 Check 5/1/2004 5/1/2004 6/1/2004 627 $90.00 $90.00 Rent 6.!. !./2..P0..4; .................. ..6_~!.(~(~0~ ..... 7( .1.!.2_07~ .................... .6..2_7 .......................................... .$_?O:(~Q ..................................................... $?~:~.0. ....................................... R.e_nt. ................................................. 7/1/2004 7/1/2004 8/1/2004 627 $90.00 $90.00 Rent ~7_(.~(2-0..-04- ............... ~!/2(~0~ ............ ~(_1./20~ ................ ~2.~/ ........................................... $.5.~40 ............................................ ~95:.40.__ ................................... .S_~_es...~'_ ~a~... .................................... 7/1/2oo4 $95.40 $o.oo 122 Check Syrasoft, LLC. / C:~m~w~mo,,~o~n,t Page 1 of 2 7/29/2004 Leana McCoy 328 S. Pitt Street Complete Tenant History CARLISLE, PA 17013 £ff Date From Unit Billed Paid Balance Ck # Comments 8/1/2004 8/1/2004 9/1/2004 627 $90.00 $90.00 Rent 8/1/2004 8/1/2004 9/1/2004 627 $5.40 $95.40 Sales Tax 7/29/2004 7/29/2004 7/29/2004 627 $6.36 $0.00 Customer Refund Leana McCoy $933.26 $933.26 (717) 243-0594 Refund Syrasott, LLC. / c:~.~m.~,o,,~o,,'.wt Page 2 of 2 THE LAW OFFICES OF I~ATHLEEN K. SHAULIS, EsQ. 44 SOUTH HANOVER STREET CARLISLE, PA ! 70 ! 3 PHONE (717) 243-6655 FAX (717) 243-6618 Invoice submitted to: Joanne E. Baker Elaine L. Mellen 22 Kreider Avenue and 328 South Pitt Street Lancaster, PA 17601 Carlisle, PA 17013 Re: Estate of Leana E. McCoy File No. 21-2004-00296 HrslRate Amount 12/4/2004 Preparation of Inheritance Tax Return 3.5 hr/S100 hr 350.00 Preparation of Informal Accounting and Family Agreement 2.0 hr/S100 hr 200.00 Preparation and Filing of Final Status Report .8 hr/S100 hr 80.00 Balance 12/31/04 $630.00 THE LAW OFFICES OF I~ATHLEEN K. SHJ~UUS, ESQ. 44 SOUTH HANOVER STREET CARLISLE, PA ! 7013 PHONE (717) 243-6655 FAX (717) 243-66 ! 8 Invoice submitted to: Joanne E. Baker Elaine L. Mellen 22 Kreider Avenue and 328 South Pitt Street Lancaster, PA 17601 CaHisle, PA 17013 Re: Estate of Leana E. McCoy File No. 21-2004-00296 HmlRate Amount 5/21/04 Inventory of Safety Deposit Box 1.5 hr/S100 hr 150.00 5/26/04 Preparation/mailing of Written Inventory 1.1 hr/S100 hr 110.00 Balance 5/31/04 $260.00 THE LAW OFFICES OF I~ATHLEEN K. SHAULIS, ESQ. 44 SOUTH HANOVER STREET CARLISLE, PA 1701:3 PHONE (717) 243-6655 FAX (717) 243-6618 Invoice submitted to: Joanne E. Baker Elaine L. Mellen 22 Kreider Avenue and 328 South Pitt Street Lancaster, PA 17601 Carlisle, PA 17013 Re: Estate of Leana E. McCoy File No. 21-2004-00296 HmlRate Amount 6/10/04 Consultation wi Joanne .7 hr/S100 hr 70.00 6/26/04 Preparation/mailing of Written Inventory 1.1 hr/S100 hr 110.00 6/10/04 Check #118 (260.00) Balance 6/30/04 $70.00 THE LAW OFFICES OF KATHLEEN K. SHAULIS, E$C~. 44 SOUTH HANOVER STREET CARLISLE, PA ! 7013 PHONE (717) 243-6655 FAX (717) 243-6618 May 4, 2004 Invoice submitted to: Joanne E. Baker Elaine L. Mellen 22 Kreider Avenue and 328 South Pitt Street Lancaster, PA 17601 Carlisle, PA 17013 Re: Estate of Leana E. McCoy File No. 21-2004-00296 Hm/Rate Amount 3/25/04 Arrange Advertising .5 hr/S100 hr 50.00 5/4/04 Reimbursement for Sentinel Advertising N/A 108.95 5/4/04 Reimbursement for CC Law Journal N/A 75.00 5/4/04 Preparation of Certifications and Notices to Beneficiaries/Filing With Register/ Mailing .9 hr/S100 hr 90.00 5/4/04 M+T Letter DOD Val. for Bank Accts .3 hr/S100 hr 30.00 Balance 5/4/04 $353.95 RECEIPT FOR PAYMENT Cumberland County - Register Of Wills Receipt Date: 3/26/2004 Hanover and Hiqh Street Receipt Time: 11:01:14 Carlisle, PA ~7013 Receipt No.: 1036068 MCCOY LEANA E Estate File No.: 2004-00296 Paid By Remarks: JOANN E BAKER JA ......................... Receipt Distribution ........................ Fee/Tax Description Payment Amount Payee Name PETITION FOR PROBA 18.00 CUMBERLAND COUNTY GENEPJtL FUN EXTPJt PAGES 9.00 CUMBERLAND COUNTY GENEPJtL FUN SHORT CERTIFICATE 18.00 CUMBERLAND COUNTY GENERAL FUN JCP FEE 10.00 BUREAU OF RECEIPTS & CNTR M.D Check# 3651 ........ Total Received ......... $55.00 CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 APRIL 23, 2004 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Kathleen K. Shaulis, ESQUIRE Leana E. McCoy, ESTATE 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 following dates: APRIL 9, 16, 23, 2004 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment Received $ 75.00 Total Amount Due $ 0.00 Payment received APRIL, 2004 by Becky H. Morgenthal/Executive Director PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L. 1784 STATE OF PENNSYLVANIA : : SS. COUNTY OF CUMBERLAND : Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, viz: APRIL 9, 16, 23, 2004 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. / ~sa Marie Con, piS, Editor McCoy, Leana E., dec'd. $~v'ORN TO AND SUBSCRIBED before me this Late of the Borough of Carlisle. 23 day of APRIL 2004 Executrix: Joann E. Baker, 22 Krelder Avenue, Lancaster, PA Attorney: Kathleen K. S haulis, ~) ~ _~_~ Esqulre. I lqO~A[ ~EAL I LOIS E. SNYDER, Notary Pubhc ! Carlisle Boro, Cumberland County ~ My Commission Expires March 5, 2005 RET/~Ii',J :['HI9 t~ORTI(:)N FOR Y'(:)bl~ RECORDS '~EMII-ltANCE ADDRESS I BILL TO ,~:--.~..z:~_:.z: .... · . ,.,..__, . THE SENTINEL - LEGAL I LAW 0~P.]iC~8 SHAU~I$; ~ATHLEEN P~O. BOX 130, CARLISLE, PA 17013 AD NUMBER J CLASS SAL E SlJ f'~.-'~ "~j G~-':-'~ -~' ~ ........ ' ' 1' I~l~_~ _ 262529 AD DESCRIPTION CO-E×ECUTRT×ES' NO?ICE ~.E?~ERS TES 04/13/0~. 04/27/04 3PU~LICAT~ONT~F: SENTINEL - LEGAL ~NSERTIONS]3 LGPz~:Tr"~ '"-'~i~r.102.60AMi)UN+ ........OF;--~SS AMOUNT TOTAL AD CHARGE I 102'60 3 PROOF OF PUBLICATION 101PRE 6.3~ DAYS RUN ,~,c,,s, O,D,, PAY THIS AMOUNT t08.95 ~30.74* leana e. mccoy ..... -.,. ..... "' ~!~ 05/28104 MI SSAGF: Thank you for advertising with The Sentinel. Deadlines for in-column legal advertisements: M~nda~ is ~riday at 11 a.m.; Tuesday is Friday at 4 p.m.; Wednesday is ~Onda~ at l~ Noon; Thursday is Tuesday at 12 Noon; Friday is Wednesday at 12 No~h~ Sunday is Thursday at 12 Noon. If you have any questions regarding your Legal[ bill pleas~ c~ll Tammy Shoemaker 243-2611, ext 203. Fax your legals to 243-3754, attention Tammy ShD~maker You can also EMAIL your legal to Classified adS~ ad~@cumb~rlink~com. Please send a cover letter including your nam~ a~d ~ddreSs a~ a~ attachment DETACH AND "ETURN THIS PORTION WITH YOUR PAYMENT~l./J_~t ~ 'HE SENTINEL - LEGAL .O. BOX130 CARLISLE PA 17013 l~ana e. mccoy AD NUMBER CLASS0 START DATE " ST'(J~P DATI~ ........ 262529 ?UB~,ZC NOTICES 04/~3/04 04/27/04 GROSS AMOUNT OF AD DESCRIPTION BILLING DA-I'~ ' TELEPHONE' NUMBER ' 130.74 CO-EXECUTRIXES NOTICE LETTERS TES 04/28/04 717-243-6655 DUEAFTER 05/28/04 TOTAL AMOUNT DUE / 108.95 ENTER AMOUNT ENCLOSED LAW OFFICES SHAULIS, KATHLEEN K. 44 SOUTH HANOVER STREET CARLISLE, PA 17013 20200000002625290000000000000001307400000108958 PROOF OF PUBLICATION State of Pennsylvania, County of cumberland Tam.my Shoema.ker, Customer Care Sales manager, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13% 1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following date(s): April 13, 20, 27, 2004 COPY OF NOTICE OF PUBLICATION CO-EXECUTRiXES' NOTICE Letters Testamentary on Affiant further deposes that he/she is not the Estate of LEANA E. MCCOY late of the interested in the subject matter of the Borough of Carlisle, Cumberland County, aforesaid notice or advertisement, and that Pennsylvania, deceased, have been granted to all allegations in the foregoing statement the undersigned. - - ~. ' All persons knowing as to time, place and character of themselves to be indebted to said Estate puotlcanon are tr~,~~ , will make payment immediately, and those having claims will present them for '%'-' settlement. Elaine b Mellen Co-Executrix 328 South Pitt Street Carlisle, PA 17013 Joann E. Baker Co-Executrix Swom to and subscribed before me this 22 Kreider Avenue Lancaster, PA 17601 28~ay of April, 2004 Kathleen K. Shaulis, ~ ,,~ 44 South Hanover Street Carlisle, PA 17013 Notary Public My commission expires: NOTARIAL SEAL DARCIE A. NELL, Notary Public Carlisle, Cumberland County My G. ~tllmi~lorl E. xplres Nov. 24, 200~J 'P~ilhaven 283 S Butler Road Phone- 866-276-3076 PO Box 550 Mount Gretna, PA 17064 ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, JOANNE BAKER /~ 22 KREIDER AVE DATE: JUN 28 2004 LANCASTER PA 17601-3610 DEAR' Joanne Baker: On behalf of Phllhaven, thank you for chooslng our facilities for your health care needs. In the process of aud±tlng our accounts we have noted that you have an outstanding balance for servlces rendered from 01/13/04 through 01/13/04. We apolog±ze for any delay in receiving thls notification as our buslness offlce was undergoing a computer conversion. You may pay the balance of $33.54 by returning a check, money order or charge card information wlth thls letter. Credlt card payments are also accepted by calllng (866) 276-3076. If you need to make other arrangements, had prevlous arrangements or feel that you had insurance that covered thls perlod, please contact our offlce at (866) 276-3076. Sincerely, Phllhaven Buslness Offlce Llst of Accounts: Name Acct Number Client Date Balance McCoy Leana 17933-408111 Phllhaven 01/13/04 9.57 McCoy Leana 17933-408111 Phllhaven 02/05/04 14.40 McCoy Leana 17933-408111 Phllhaven 02/19/04 9.57 WEST SHORE EMS - BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL. PA ~ 7n~ ~ E~IEROENCY MEDICAL SERVICES PATIENT NAME: ~ANA MCCC'~' PATIENT NUMBER: 224~5 CALL NUMBER: INSURANCE: MED{CA~E ~ ~0E:I~0A DATE OF CALL: TIME OF CALL: ~:0~ PM CALLER: CARLISLE HOSPITAL t I ~lW FROM: CARLISLE REGIONAL MEDICAL TO: FOREST PARK HEALTH CEN~R LEANA MCCOY 7~ WA LNUT BOTTOM RD REASON(S) MYOCARDIAL IN F.ARCTtON CA.ISLE. PA 17013 FOR BOWEL OBSTRUC:TIC:,N TRANSPORT Gl BLEED DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT Ss'etcher C:,ne ",,"..'~t'¢' Tran~ort A0999 '1.0 75.26 75.26 Transport ',..tan Mileage A 09_~9 1.0 I. f 5 I. t 5 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Tnfat C, rPdif~ fl t'~ PLEASE PAY THIS AMOUNT ~, $76.41 ;TATEMENT DATE ACCOUNT NUMBER PATIENT NAME LOCATION OF SERVICE 04/07/04 ARA-7360065 LEANA E MCCOY CARLISLE HSP DP DATE DOCTOR CODE DESCRIPTION AMOUNT 02/09/04 GEORGE BRODER ~ 74160 CT ABDOMEN ENHANCED 199.00 02/09/04 GEORGE BRODER ~ 72193 CT PELVIS ENHANCED 181.00 03/16/04 0200 MEDICARE PAYMENT -97.57 03/16/04 9200 MEDICARE WRITE OFF -258.04 03/30/04 0399 DENIAL BY COMMERCIAL INS 0.00 24.39 IS PATIENT'S CO-INS YOUR I~SURANCE PLAN HAS REFUSED TO PAY FOR YOUR SERVICES. PLEASE CALL US SO WE CAN RESOLVE THIS PROBLEM. 610-459-3655. $ 24.39 DIAGNOSIS 5S3.3 ANDOR~A ~ADIO/OG¥ AS$OC PC PO BOX 892 This Billing office is open 8:30-4:00. CONGORDVILLE, PA19551 If you have questions concerning your Bill, please call the number shown above. Tax ~0#: 253016413 863 STATEMENT SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION Detach at perforation and retum above portion with payment. I J J Payments/ Service Date Service Provider Description Charges Adjus[Jiients Patient Account: 23668 - Leana E. McCo), Previous Balance: 0.00 02/16/2004 MEMO: 033004 AETNA PROCESSED -- PT RESP ChemicoffDO, David P. Lev 30V est pt 65.00 02/25/2004 FILED: Medicare HGSA 1 03/10/2004 AD J: Medicare Adjustment -14.52 PAY: Medicare HGSA I -40.38, Patient Balance: 10.10 BALANCES UNPAID AFTER 30 DAYS MAY BE ASSESSED A $5.00 BILL CHARGE EACH MONTH. Statement Date 1-30 Days 31-60 Days 61-90 Days 91-120 Days 121-150 Days Over 150 Days Due Date Total Due Apr 4, 2004 10.10 0.00 0.00 0.00 0.00 0.00 Apr 28, 2004 10.10 ndonderry Road. Harrisburg, P,~ 17109 · (717) 657-2599 Account Number: 23668 1.13,1,0 BEAZ20040404-00000572-00000603 Page 1 of 1 ASS~IA~IT~, LTD. !~'!Carh'sl~,241A~exar{~er Spring RoadpA} 17013 Patient Statement 717-24'5-~28 Wednesday, April 28, 2004 Page 2 of 2 Estateof:Leana E Mc Coy 700 Walnut Bottom Road Carlisle, PA 17013 wEstate of Leana E Mc Coy(23146)lRobert B Levy DO/041879 Location: Carlisle Regional Medical Center 3/07/2004 Subsequent-Focused Visit $90.00 1.00 $90.00 $0.00 3/29/2004 Medicare Adjustment from Medicare 1054324 ($57.54) $0.00 3/29/2004 Payment from Medicare 1054324 ($25.97) $0.00 4/13/2004 Transfer from Insurance 0096776 ($6.49) $6.49 Patient Responsibility $0.00 $6.49 wEstate of Leana E Mc Coy(23146)/Theodore Berk MD/042002 Location: Carlisle Regional Medical Center 3/08/2004 Subsequent-Focused Visit $90.00 1.00 $90.00 $0.00 4/01/2004 Medicare Adjustment from Medicare 1054442. ($57.54) $0.00 4/01/2004 Payment from Medicare 105~a. 42. ($25.97) $0.00 4/19/2004 Transfer from Insurance 0074149 ($6.49) $6.49 Patient Responsibility $0.00 $6.49 wEstate of Leana E Mc Coy(23146)/Theodore Berk MD/042003 Location: Carlisle Regional Medical Center 3/09/2004 Egd-W/Dir. Placement Peg Tube $1,112.00 1.00 $1,112.00 $0.00 4/01/2004 Medicare Adjustment from Medicare 1054442. ($881.79) $0.00 4/01/2004 Payment from Medicare 105~.~-~2. ($184.17) $0.00 4/19/2004 Transfer from Insurance 0074149 ($46.04) $46.04 Patient Responsibility $0.00 $46.04 ~'~0~ · ,o. o ",o.ao Carlisle Digestive Disease Associates * 241 Alexander Spring Road * Carlisle, PA 17013 * (717) 245-2228 wEstate of Liana E Mc Coy(23146)/Gregory Lewis MD/041747 Location: Carlisle Regional Medical Center 03/02/2004 Consult~Initial/Compri/Mod Sev $220.00 1.00 $220.00 $0.00 03/26/2004 Medicare Adjustment from Medicare ~.~ ~_..~.~ ~ 1054269 ($83.26) $0.00 03/26/2004 Payment from Medicare 1054269 ($109.39) $0.00 04/13/2004 Transfer from Insurance 0096776 ($27.35) $27.35 Patient Responsibility ~ $0.00 $27.35 wEstate of Liana E Mc Coy(23146)/Gregory Lewis MD/041748 \ Subsequent-FocusedL°Cati°n: Carlisle RegionaIvisitMedical Center.,,.., ,/ ' O 03/03/2004 ~ ~ $90.00 1.00 $90.00 $0.00 03/26/2004 Medicare Adjustment from Medicare v //,,-],,._,x/ 1054269 ($57.54) $0.00 03/26/2004 Payment from Medicare '~,j'ot,/ 1054269 ($25.97) $0.00 04/13/2004 Transfer from Insurance 0096776 ($6.49) $6.49 Patient Responsibility $0.00 $6.49 wEstate of Liana E Mc Co:y(23146)/Gregory Lewis MD/041749 Location: Carlisle Regional Medical Center 03/04/2004 Subsequent-Focused Visit $90.00 1.00 $90.00 $0.00 03/26/2004 Medicare Adjustment from Medicare 1054269 ($57.54) $0.00 03/26/2004 Payment from Medicare 1054269 ($25.97) $0.00 04/13/2004 Transfer from Insurance 0096776 ($6.49) $6.49 Patient Responsibility $0.00 $6.49 wEstate of Liana E Mc Coy(23146)/Robert B Levy DQ'041877 Location: Carlisle Regional Medical Center 03/05/2004 Subsequent-Focused Visit $90.00 1.00 $90.00 $0.00 03/29/2004 Medicare Adjustment from Medicare 1054324 ($57.54) $0.00 03/29/2004 Payment from Medicare 1054324 ($25.97) $0.00 04/13/2004 Transfer from Insurance 0096776 ($6.49) $6.49 Patient Responsibility $0.00 $6.49 wEstate of Liana E Mc Coy(23146)/Robert B Levy DCl/04'1878 Location: Carlisle Regional Medical Center 03/06/2004 Subsequent-Focused Visit $90.00 1.00 $90.00 $0.00 03/29/2004 Medicare Adjustment from Medicare 1054324 ($57.54) $0.00 03/29/2004 Payment from Medicare 1054324 ($25.97) $0.00 04/13/2004 Transfer from Insurance 0096776 ($6.49) $6.49 Patient Responsibility $0.00 $6.49 Carlisle Digestive Disease Associates * 241 Alexander Spring Road * Carlisle, PA 17013 * (717)245-2228 GRAHAM MEDICAL CLINIC, PC Statement 100 S. HIGH STREET NEWVILLE PA 17241 Tax ID · 232173798 Phone #' (717)776-3114 Date' 05/03/2004 Page' 1 LEANA E MCCOY JOANNE BAKER 22 KREIDER AVE ~~ Patient · LEANA E MCCOY Please pay this amount: $134.93 Insurance Patient Date Code Description Provider Diagnosis Location Amount Balance Balance Balance Forward: 0.00 0.01 33/01/04 99311 NH LEVEL 1 JAP 230.3 FP 50.00 5.9~ )3/29/04 MCCK Medicare Check -23.94 }3/29/04 MCDS Medicare Disallowance -20.07 ;)4/13/04 INDN Insurance Denial 5.99* ;)3/02/04 99311 NH LEVEL I JHH 789.07 FP 50.00 5.9! ;)3/29/04 MCCK Medicare Check -23.94 ~)3/29/04 MCDS Medicare Disallowance -20.07 ;)4/13/04 INDN Insurance Denial 5.99* 33/02/04 99223 ADMISISION, HIGH LEVEL 26H 786.50 CRI 200.00 24.2( 34/06/04 MCCK Medicare Check -97.06 34/06/04 MCDS Medicare Disallowance -78.68 ;)4/26/04 AETDD AETNA DEDUCTIBLE 24.26* ;)3/03/04 99232 SUB CARE, MODERATE LEVEL 26H 786.50 CRI 637.00 75.0~ ~)4/06/04 MCCK Medicare Check -300.10 ;)4/06/04 MCDS Medicare Disallowance -261.87 ;)4/26/04 AETDD AETNA DEDUCTIBLE 75.03' }3/10/04 99238 HOSPITAL DAY DISCHARGE 26H 786.50 CRI 99.00 13.6( ~)4/06/04 MCCK Medicare Check -54.40 ~)4/06/04 MCDS Medicare Disallowance -31.00 34/26/04 AETDD AETNA DEDUCTIBLE 13.60' 03/11/04 99312 SNF VISIT, MODERATE JAT 230.3 FP 60.00 10.0(~ 04/13/04 MCCK Medicare Check -40.25 04/13/04 MCDS Medicare Disallowance -9.69 04/27/04 AETDD AETNA DEDUCTIBLE 10.06' Current: $134.93 Past Due: $0.00 Total amount: $0.00 $134.93 pay : $134.93 Please this amount Your insurance carder has processed this claim and the balance is now your responsibilitv. Please remit promptly or contact our office to make payment arrangements. ' ~f~,,~a§o~ o~ly (Deductible & Denied) C~~C~]oNA~ PO Box 4100 ~o;c^~ C~t~T~t Carlisle, PA. 17013-4100 April 24, 2004 STATEMENT 002178395 LEANA E MCCOY 700 WALNUT BOTTOM ROAD CARLISLE PA 17013 PAT I ENT J~73~0065 DEAR LEANA E MCCOY Your insurance company was billed and has paid according to the benefits of your policy. However, there is a patient balance due which is indicated above. Please mail the balance in full today. For your convenience, you may pay your account with Mastercard, Visa, Discover or American Express by completing and signing the form below. Your prompt payment is appreciated. If you have any questions regarding the balance, please call our office at the number listed below. If you have already made this payment in full, please disregard this request...and thank you. KEEP THIS PORTION FOR YOUR RECORDS IMPORTANT .The balance ~is for you~..co-ins.urance a.mount. If you have additional .1,nsu,ran,ce, _p~,e.ase_provlae u?,.Wlth.,the ,lnformat_ion by completing and mailing ~ne..Dg.c~ oz. ~n~s zo.rm o.r ca--1.ng ~ne pnone number shown above. Unless additional information is provided, prompt payment of your balance is due. PO BOX 890418 CAMP HILL PA 17089 POL: 203108490A PLAN: GRP: SECONDARY INSURANCE AETNA PHONE: P.O. BOX 981106 EL PASO TX 79998 POL: 203108490 PLAN: GRP: 38501112002 DATE CODE DESCRIPTION CHARGES CREDITS BALANCE THIS IS ~ BILL FOR ~ROFESSIONAL LAB SERVICES, SUPERVISE£ BY A BOARD CERTIFIED PATHOLOGIST. THESE SERVICES ~RE REQUESTED BY YOUR ATT].NDING PHYSIIIAN. **** IF YOU ~AVE ALREADY MADE PAYMENT PLEASE DIS~F. GARD THIS ~OTICE. 03-07-04 88305 LEVEL IV - SURG PATHOLOGY 150. 00 150. 00 GROSS AND MICROSCOPIC EXAM 03-29-04 PAYMENT P~f~-MEDICARE 32. 31 117. 69 03-29-04 ADJUST CONT LOSS-MEDICARE 109. 61 8. 08 AND MAIL TO: PLEASE PAY THIS AMOUNT $8. 08 CARLISLE ~ATHOLOGY ASSOC. P.O. BOX 188 LEANA E. MCCOY IRS#: 25-1645787 LANDISVILLE, PA 17538 ACCT NO: A126-0044391-04 8D CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT 030904 CHESS SERVICES RENDERED LEANA 481.00 051704 BZLLED:HGS ADNZNZSTRATORS 031704 BZLLED:AETNA 042104 HEDZCARE PAYHENT 042104 HEDICARE ADJUSTHENT SO.44- 0S1004 BLNCE PT RESPONSXDLX 417.95- 051004 AETNA CO-XNS$12.&! ,~(~ 0.0! 0.00 XHPORTANT: PAYHENT DUE ZN FULL UPON RECEZPT OF STATEHENT. ZF YOUR ZNSURANCE CARRZER HAS NOT HADE A PAYNENT PLEASE CONTACT THEH ZNHEDZATELY. ZF YOU HAVE ANY QUESTZONS PLEASE CALLOUR OFF/CE. THANK YOU, NDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: BALANCE PAYMENTS NEW ~ 11&48 FORWARD & CREDITS CHARGES 30 DAYS 60 DAYS 90 DAYS 120 DAYS PAY THIS AMO 0.00 468.39- 481.00 ~ 0.00 0.00 0.00 0.00 12.61 (800)827-3458 BLUE HOUNTAXN ANESTHESXA ASSOC P 0 BOX 249 GREENCASTLE PA 17225 5488 ** TAXPAYER COPY ** BILL DATE 3/01/2004 BILL NO 5488 2004 PERSONAL TAX NOTICE COUNTY OF CUMBERLAND DARLENE L. MOYER, C/O CTCB BOROUGH OF CARLISLE 19 S HANOVER ST, PO BOX 128 : CARLISLE, PA 17013-0128 UNPAID TAXES SUBMITTED TO DELINQUENT COLL 12/13/04 SSN 203-10-8490 ~ ].~0b CNTY P/C 5.00000 4.90 5.00 5.5C MUN P/C 5.ooooo 5.00 5.00~ 5.5C ~ 5488P/0004120 ~"~ MC COY, LEANA ?~ C/O MELLEN 328 S PITT ST ~'lf:~:~:~'i2~:l~ 9.90 10.00 11.00 CA'ISLE PA 17013 c~ ~/c 2.o~ ~0.o~ ~SCOU~ , FACg ~g~A~Y ~O ~e ~O~DAY 8:30~-A: 00~N A/30/200A 6/30/200A ~/30/200A ~s ~U~SDAY-~R~AY 8: 00~-A: 00~ C~OS~D ~HONg: (717) 2A3-3725 ~LOSE 8~LF ADDRESSED STAMPED ENVBLOPE IF ~ECEIPT IS DESIRED Case# 1 HOSP CONSULT 99255 HOSPITAL CONSULT 225 00 PAYMENT . 584.6 ' 37 61 $37.61 PATIENT'S RESPONSIBILITY PATIENT'S RESPONSIBILITY MCP MEDICARE PAYMENT -150.43 MCA MEDICARE ADJUSTMENT -36.96 99231 HOSPITAL VISIT SUBSEQUENT 130 00 PAYMENT . 584.6 · 12 98 $12.98 PATIEqT'S RESPONSIBILITY PATIENT'S RSSPONSIBILiTY MCP MEDICARE PAYMENT -51.94 MCA MEDICARE ADJUSTMENT -65.08 Your insurance company states this balance is yo6r responsibility. Please remit today! PLEASE PAY THIS AMOUNT ,- 50.59 ID# 25-1641662 STATEMENT CARLISLE CARDIOLOGY ASSOCIATES DAVID KANN, MD 850 WALNUT BOTTOM RD, SUITE 304 COLETTE LASEK, MD CARLISLE, PA 17013 BILLING INQUIRIES: 717-258-8862 VISA AND MASTERCARD ACCEPTED Leana E Mccoy 507171 05/17/04 3 MC JCPEN 700 Walnut Bottom Road Forrest Park ] Carlisle PA 17013 [- p~R~Ecr COPYRIGHT2002. STICOMPUTSR SERVICESINC ~ PLEASE DETACH HERE AND RETURN TOP STUB WITH YOUR PAYMENT ~ CARE Servicing Provider: COLETTE R LASEK 04/14/2004 HGSA ADMINISTRATORS 25.97 22.54 05/02/2004 JCPENNEY AETNA CLAIM OFF 0.00 0.00 MEDICARE COINSURANCE NOT PAID BY YOUR SEC INS MESSAGE: SEE REVERSE SIDE IF AN INSURANCE MESSAGE APPEARS~ PLEASE PAY ~, 84.85 1 Please pay within 30 days...thank you / Leana E Mccoy 507171 1,118.00 Carlisle Cardiology, Assoc, P.C. 850 Walnut Bottom Road, Suite 304 Carlisle PA 17013 151 ] 03/02/04 99254 HOSPITAL CONSULT-MODE1; CL 1.0 246.00 27.35 Patient: Leana E Mccoy - 507171 Servicing Provider: COLETTE R LASEK 04/03/2004 HGSA ADMINISTRATORS 109.39 109.26 04/23/2004 JCPENNEY AETNA CLAIM OFF 0.00 0.00 MEDICARE COINSURANCE NOT PAID BY YOUR SEC INS 03/03/04 99232 HOSPITAL FOLLOW-UP VISIT CL 1.0 88.00 10.72 Patient: Leana E Mccoy - 507171 Servicing Provider: COLETTE R LASEK 04/03/2004 HGSA ADMINISTRATORS 42.87 34.41 04/23/2004 JCPENNEY AETNA CLAIM OFF 0.00 0.00 03/03/04 93307 ECHOGARDIOGRAM 2D- INT CL 1.0 273.00 9.60 Patient: Leana E Mccoy - 507171 Servicing Provider: COLETTE R LASEK 04/03/2004 HGSA ADMINISTRATORS 38.42 224.98 04/23/2004 JCPENNEY AETNA CLAIM OFF 0.00 0.00 03/03/04 93320 ECHOCARDIOGRAN- DOPPL CL 1.0 131.00 3.94 Patient: Leana E Mccoy - 507171 Sen,icing Provider: COLETTE R LASEK 04/03/2004 HGSA ADMINISTRATORS 15.75 111.31 04/23/2004 JCPENNEY AETNA CLAIM OFF 0.00 0.00 MEDICARE COINSURANCE NOT PAID BY YOUR SEC INS 03/03/04 93325 ECHOCARDIOGRAM- COLOR] CL 1.0 105.00 0.79 Patient: Leana E Mccoy - 507171 Servicing Provider: COLETTE R LASEK 04/03/2004 HGSA ADMINISTRATORS 3.16 101.05 MESSAGE: SEE REVERSE SIDE IF AN INSURANCE MESSAGE APPEARS~ PLEASE PAY ****** Continue On Next Page Carlisle Cardiology, Assoc, P.C. 850 Walnut Bottom Road, Suite 304 Carlisle PA 17013 149 1 · STATEMENT CARLISLE CARDIOLOGY ASSOCIATES DAVID KANN, MD 850 WALNUT BOTTOM RD, SUITE 304 COLETTE LASEK, MD CARLISLE, PA 17013 BILLING INQUIRIES: 717-258-8862 VISA AND MASTERCARD ACCEPTED Leana E Mccoy /507171 05/17/04 2 MC JCPEN 700 Walnut Bottom Road ,'/~ -,d ~ Forrest Park Carlisle PA17013 // ~ ,,~o p~ERFECT ST'COM"UTEA SE"V'CES '~' PLEASE DETACH HERE AND RETURN TOP STUB WITH YOUR PAYMENT '~' CARE 04/23/2004 JCPENNEY AETNA CLAIM OFF 0.00 0.00 03/04/04 99231 IN-PATIENT FOLLOW-UP VIS CL 1.0 55.00 6.49 Patient: Leana E Mccoy - 507171 Servicing Provider: COLETTE R LASEK 04/03/2004 HGSA ADMINISTRATORS 25.97 22.54 04/23/2004 JCPENNEY AETNA CLAIM OFF 0.00 0.00 03/05/04 99231 IN-PATIENT FOLLOW-UP VIS CL 1.0 55.00 6.49 Patient: Leana E Mccoy - 507171 Servicing Provider: COLETTE R LASEK 04/03/2004 HGSA ADMINISTRATORS 25.97 22.54 04/23/2004 JCPENNEY AETNA CLAIM OFF 0.00 0.00 MEDICARE COINSURANCE NOT PAID BY YOUR SEC INS 03/08/04 99231 IN-PATIENT FOLLOW-UP VIS CL 1.0 55.00 6.49 Patient: Leana E Mccoy - 507171 Servicing Provider: COLETTE R LASEK 04/14/2004 HGSA ADMINISTRATORS 25.97 22.54 05/02/2004 JCPENNEY AETNA CLAIM OFF 0.00 0.00 MEDICARE COINSURANCE NOT PAID BY YOUR SEC INS 03/09/04 99231 IN-PATIENT FOLLOW-UP VIS DK 1.0 55.00 6.49 Patient: Leana E Mccoy - 507171 Servicing Provider: DAVID G KANN 04/08/2004 HGSA ADMINISTRATORS 25.97 22.54 04/23/2004 JCPENNEY AETNA CLAIM OFF 0.00 0.00 MEDICARE COINSURANCE NOT PAID BY YOUR SEC INS 03/10/04 99231 IN-PATIENT FOLLOW-UP VIS CL 1.0 55.00 6.49 Patient: Leana E Mccoy - 507171 MESSAGE: SEE REVERSE SIDE IF AN INSURANCE MESSAGE APPEARS~ PLEASE PAY ~ ****** Continue On Next Page ****** Carlisle Cardiology, Assoc, P.C. 850 Walnut Bottom Road, Suite 304 Carlisle PA 17013 150 I :DATE I DESCRIPTION i PAYMENT/ADJUSTMENTS 05/$0/04 MEDICARE PAYMENT 6,495.09- 05/50/0q MEDICARE CONTRACTUAL ADJUSTMENT 21,$78.46- PAYMENTS AND CHARGES RECEIVED AFTER THE STATEMENT DATE WILL BE REFLECTED ON THE NEXT STATEMENT. MESSA~--~ $876 . O0 The amount shown on this statement is outstanding at this time. Your prompt payment will be greatly appreciated. FOR BILLING QUESTIONS, PLEASE CALL: (717) 218-8852 05/2,~/200~ Date From To Code Description Amount Patient : Mccoy, Leana E Account : 0000011844 Diagnosis: 41071 5845 2761 1974 3,/09/04 3/09/04 CHG 00740 -Anesth, Upper Gastro Endoscopic $481 00 4/02/04 Medicare Filed... ' 5/12/0 PMT Medicare Payment $50.44- 5/12/0 ADJ Medicare Write-Off $417.95- Account Balance $12.61 Over 90 Days Over 60 Days ! Over 30 Days [ 0 - 30 Days TH~K YOU. 1-800-757-7288. ~ P.O.Box 619 E Petersburg, PA 17520 800-757-7288 Federal Tax ID: 23-3013255 t Please M~e Checks Payable To Pro¼der MDSSIB (0ESP)40:T012:002433:001:0000: : 04/09/04 1106 GUARP~AC PENNSYLVANIA MEDICARE 04/09/04 1106 GUARRAC INSURANCE WRITE-OFF -330.61 YOUR PAST DUE ACCOUNT REMAINS UNPAID AFTER SEVERAL STATEMENTS. TO AVOID FURTHER ACTION, PLEASE REMIT THE BALANCE INDICATED, OR CONTACT OUR OFFICE IMMEDIATELY TO MAKE ARR3~NGEMENTS FOR A SET MONTHLY PAYMENT AMOUNT. YOU CAN REACH US AT 866-247-3141. THANK YOU. Referred by GUARRACINO D.O., ANTHONY Please Remit Payment to: CENTRAL PENN MEDICAL GROUP EMERGENCY If yOU have questions regarding this bill please call PO BOX 619 1-866-247-3141 (toll free) or email EAST PETERSBURG, PA 17520-0619 patientinqui _ryC~_,mjca.net. THANK YOU. FOR YOUR CONVENIENCE, YOU MAY PAY ONLINE AT www. mjca. net *' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEHENT, ALLOWANCE OR OISALLOWANCE OF OEDUCTIONS AND ASSESSHENT OF TAX BUREAU OF INDIVI~UAL TAXES INHERITANCE TAX DIVISION PO BOX Z81160l HARRISBURG PA 17128-0601 REV-1547EXAFPI12-D4l 02-14-2005 MCCOY 03-20-2004 21 04-0296 CUMBERLAND 101 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN ......" / '" ..~ LEANA E r,-..' KATHLEEN,K SHAULIS 44 S HANOVER ST CARLISLE PA 17013 Allount Re..itted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CD COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ Ri:v:r!'l;".EX..~'p..rB1":6'Jr.NiiTYeE-OF.iNIUR.ffAN.cl!-i"AX.APi5Rjii'SEH.Eln~-.Ar.towANCE.i1R.---.......__.... DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF MCCOY LEANA E FILE NO. 21 04-0296 ACN 101 DATE 02-14-2005 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: DRIGINAL RETURN 1. Real Est.t. [Schedule AJ 2. stocks end Bonds (Schedule BJ 3. Closely Held stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule DJ 5. Cash/Bank Deposits/Misc. Personal Property (Schedule EJ 6. Jointly Owned Property (Schedule fJ 7. Transfers (Schedule GJ 8. Total Assets .00 32.736.00 .00 .00 52.931. 06 .00 33.401.00 (8) NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax paYllent. ll) (2) (3) (4) (5) (6) (7) 119,068.06 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Exp.nses/Adll. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequestsj Non-elected 9113 Trusts (Schedule ~) 14. Net Value of Estate Subject to Tax 9,309.01 (9) 1l0) 1.905.72 (11) (12) (13) (14) 11.:71473 107,853.33 .00 107,853.33 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. NOTE: I~ an assessment was issued previOUSlY, lines re~lect ~igures that include the total o~ ALL ASSESSMENT OF TAX: IS. Allount of Line 14 at Spousal rate (IS) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rat. (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due .00 4,853.40 .00 .00 4,853.40 .OOXOO= 107,853.33 X 045 = .00 X 12 = .00x15= (19)= TAX CREnTTS: rAYN"N' 1+' AHOUNT PAID DATE NUHBER INTEREST/PEN PAID (-) 06-14-2004 CD004041 236.84 4,500.00 12-10-2004 CD004718 .00 128.40 TOTAL TAX CREDIT 4,865.24 BALANCE OF TAX DUE 11 .84CR INTEREST AND PEN. .00 TOTAL DUE 11 .84CR ~ IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRJ, YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.) . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX Z806Dl HARRISBURG PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT '* REY-1607 EX AFP (12-04) KATHLEEN K SHAULIS 44 S HANOVER ST CARLISLE PA 17013 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 03-14-2005 MCCOY 03-20-2004 21 04-0296 CUMBERLAND 101 LEANA E Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ ~~:r'~".!1:.I'~..rGl~.6!'........;..:rA~!~e1r~A1r.~'1"~Alnrf.o,r.l~l:60~...ii...................... ESTATE OF MCCOY LEANA E FILE NO.21 04-0296 ACN 101 DATE 03-14-2005 THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW IS A SUHHARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 02-14-2005 PRINCIPAL TAX DUE:. 4,853.40 PAYMENTS (TAX CREDITS): PAYMENT DATE 06-14-2004 12-10-2004 02-28-2005 RECEIPT NUMBER CD004041 CD004718 ~ REFUND DISCOUNT (+) INTEREST/PEN PAID (-) 236.84 .00 .00 AMOUNT PAID 4,500.00 128.40 11 .84- (.,,) (J."~ TOTAL TAX CREDIT 4,853.40 BALANCE OF TAX DUE INTEREST AND PEN. .00 .00 . IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. ) TOTAL DUE .00 Q~\<"" STATUS REPORT UNDER RULE 6.12 Name of the Decedent~ E. McCoy I L ~ Date of Death: March 20, 2004 Will No. 296 of 2004 Admin. No.: Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above- captioned estate: 1. State whether the administration of the estate is complete: Yes _X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to NO.1 is Yes, state the following: a. Did the personal representative file a final account with the court? Yes No b. The separate Orphans' Court No. (if any) for the personal representative's account is : c. Did the personal representative state an account informally to the parties in interest? Yes X_ No. d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the , orPha~ Court and may be attached t~ h~s;e:~rt. A . ) Dale~ /Ii ~5, ~~ Si nature .. - Kathleen K. Shaulis 44 South Hanover Street Carlisle, PA 17013 (717) 243-6655 - Capacity: Personal Representative _X_Counsel for Personal Representative cA IN RE : ESTATE OF LEANA E. McCOY, DECEASED Date of Death: March 20, 2004 Will No. 296 of2004 RECEIPT AND RELEASE The circumstances leading up to the execution of this instrument are as follows: 1. Leana E. McCoy died on March 20, 2004. Testamentary Letters were granted to Joanne E. Baker and Elaine L. Mellen, daughters of the Decedent and Executrixes of her Last Will and Testament dated November 21, 1994. 2. Pursuant to her Last Will and Testament, the following people were named as her beneficiaries, each of whom is entitled to receive an equal 1/2 share of the decedent's estate as indicated: Elaine Mellen 328 South Pitt Street Carlisle, P A 17013 Joanne E. Baker 22 Kreider Avenue Lancaster, P A 17601 3. An informal Accounting of the Administration of the Estate of Leana E. McCoy, has been prepared by the Executrixes, and is attached hereto as Schedule "A." 4. In consideration ofthe foregoing and intending to be legally bound hereby, Joanne E. Baker and Elaine L. Mellen: A. Do hereby waive an audit of an account of the administration of the Estate of Leana E. McCoy, deceased, by the Orphans' Court Division of the Court of Common Pleas of Cumberland County, Pennsylvania; B. Do hereby declare that they examined the attached informal account of the Estate of Leana E. McCoy, deceased, that they find it to be true and correct in all particulars; that they accept and approve it with the same force and effect as if it had been prepared and duly filed with, audited, adjudicated and confirmed absolutely by the Orphans' Court Division of the Court of Common Pleas of Cumberland County, Pennsylvania; C. Do hereby acknowledge that Joanne E. Baker and Elaine L. Mellen, Executrixes, have distributed the assets ofthe Estate of Leana E. McCoy, deceased; - D. Do hereby absolutely and irrevocably remise, release, quitclaim and forever discharge Joanne E. Baker and Elaine 1. Mellen, Executrixes, their heirs, executors, administrators and assigns, of and from any and all action, reckonings, liabilities, claims and demands relating in any way to her administration of the Estate of Leana E. McCoy, deceased; E. Do hereby indemnify and hold harmless Joanne E. Baker and Elaine 1. Mellen, Executrixes, their heirs, executors, administrators and assigns, from and against any and all claims, losses, liabilities and damage which they may suffer or to which they may be subjected by reason of their administration of the Estate of Leana D. McCoy, and the distribution ofthe estate without an account or the approval of the Orphans' Court Division of the Court of Common Pleas of Cumberland County, Pennsylvania, including but not limited to, any liability for any federal estate tax, Pennsylvania inheritance tax or any other death taxes, together with interest and costs incidental thereto, relating in any way to the estate; and F. Do hereby declare it to be there intention that this instrument shall be legally binding upon them and upon their heirs, executors, administrators and assigns. Witness: 7J~ [: ~ ~anne E. BakerX LA/J l'1 n _ ~ . f .Date _ ~~ f/r~ "fIOtt/o!:J Elaine 1. Mellen I Date D. Do hereby absolutely and irrevocably remise, release, quitclaim and forever discharge Joanne E. Baker and Elaine L. Mellen, Executrixes, their heirs, executors, administrators and assigns, of and from any and all action, reckonings, liabilities, claims and demands relating in any way to her administration ofthe Estate of Leana E. McCoy, deceased; E. Do hereby indemnify and hold harmless Joanne E. Baker and Elaine L. Mellen, Executrixes, their heirs, executors, administrators and assigns, from and against any and all claims, losses, liabilities and damage which they may suffer or to which they may be subjected by reason of their administration of the Estate of Leana D. McCoy, and the distribution ofthe estate without an account or the approval of the Orphans' Court Division of the Court of Common Pleas of Cumberland County, Pennsylvania. including but not limited to, any liability for any federal estate tax, Pennsylvania inheritance tax or any other death taxes, together with interest and costs incidental thereto, relating in any way to the estate; and F. Do hereby declare it to be there intention that this instrument shall be legally binding upon them and upon their heirs, executors, administrators and assigns. ~ ~~.16-Jld Jo E. Baker C-2 -(}S Date Elaine L. Mellen Date ESTATE OF LEANA E. MCCOY, DECEASED ASSETS Stocks and Bonds Cash, Bank Deposits, Personal Property Total Assets DISBURSEMENTS Funeral expenses Executor's Fee Attorney's Fees Probate Fees,Petition, Short cert. Legal Advertising Inheritance Tax Filing Fee Midway Self Storage Inheritance Tax Other Taxes Medical Bills TOTAL NET ASSETS EXPECTED DISlRIBUTION EXPECTED DISTRIBUTION PER BENEFICIARY 32,736.00 52,931.06 85,667.06 7235.10 0.00 630.00 247.00 183.95 15.00 387.96 4853.40 69.54 1736.48 74,452.33 74,452.33 74,452.33 37,226.16