HomeMy WebLinkAbout09-26-08LAW OFFICES OF
MILLER & ASSOCIATES, PC
William E. Miller, Jr. 1822 MARKET STREET • CAMP HILL, PA 17011
Alicia S. Miller TEL: (717) 737-9210 • FAX: (717) 737-9215
25 September 2008
-~
HAND DELIVERED
Glenda Farner Strasbaugh, Register of Wills ~ ~` '-%
Cumberland County Court House ~ ~:'_
One Courthouse Square - -
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Carlisle, PA 17013 _
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Re: Estate of Dana M. Friedman, Deceased `'
Estate No. 21-08-0044
Dear Ms. Strasbaugh:
Of Counsel:
Michael L. Bangs
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We represent the Co-Executors of the Estate of Dana M. Friedman, Deceased.
Enclosed herewith for filing in duplicate is the Pennsylvania Inheritance Tax Return,
Form REV-1500, for Mr. Friedman's Estate. You will note that the enclosed REV-1500
also includes a complete copy of the Federal Estate Tax Return, IRS Form 706, which
is being filed concurrently for the Estate with the Internal Revenue Service.
Also enclosed is the Estate's check made payable to the Register of Wills,
Agent, in the amount of $7,124.00, representing payment in full of the balance due of
Pennsylvania transfer inheritance tax. As you can see from the REV-1500, the Co-
Executors previously paid $105,000 on account of the tax due within the discount
period, thereby receiving credit for $110,526 on account of the $117, 650 amount due.
Please acknowledge receipt of the enclosed Pennsylvania Inheritance Tax
Return and the enclosed payment check, by stamping the additional copy of page 1 of
the Return and the photocopy of the check. For your convenience in returning the
receipted copies to us, enclosed is aself-addressed stamped envelope.
If you have any questions, please give me a call. Thanks.
Very truly yours.
WEM/mlj
Enclosures
cc: Margaret T
Foster, Co-Executor
MILLET & ASSOCIATES, PC
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William E. Miller, Jr.
LAW OFFICES OF
MILLER & ASSOCIATES, PC
William E. Miller, Jr. 1822 MARKET STREET • CAMP HILL, PA 17011 Of Counsel:
Alicia 5. Miller TEL: (717) 737-9210 FAX: (717) 737-9215 Michael L. Bangs
25 September 2008
CERTIFIED MAIL-RETURN RECEIPT REQUESTED
Internal Revenue Service
Cincinnati, OH 45999 ~ ' ~'' ' ~`
Re: Estate of Dana M. Friedman, Deceased
Date of Death: 27 December 2007 ,~~
Decedent's Social Security No. 161-32-342;: ~~~
Dear Sir or Madam:
We enclose herewith for filing, on behalf of the Co-Executors for the Estate of
Dana M. Friedman, a United States Estate Tax Return, IRS Form 706. Mr. Friedman
died on 27 December 2007, a resident of the Commonwealth of Pennsylvania, and his
Last Will and Testament and Estate are being probated through the Office of the
Register of Wills of Cumberland County, Pennsylvania. Also enclosed is the check of
the Co-Executors made payable to the United States Treasury in the amount of
$276,422, representing payment in full of the estate tax due in accordance with the
enclosed IRS Form 706.
Please acknowledge receipt of the enclosed Return and check by so signing as
received the enclosed copy of page 1 of the IRS Form 706 and the photostatic copy of
the enclosed check. For your convenience, we are enclosing aself-addressed stamped
envelope for you to return the acknowledged documents to us.
If you have any questions, please contact the undersigned.
Very truly yours,
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MILLER & ASSOCIATES
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Enclosures
cc: Margaret T. Foster, Co-Executor
Glenda Farner Strasbaugh, Register of Wills
69/261285 11:50 7177379215
MILLEF~ASSDCIATES
PAGE 61162
Lavv Offices of
11~LEER & ASS~DCZA.'~'ES, P~
William E. Miller, Jr. 1822 M.A R~.ET STREET ~ CAMP I~t P , I'A 17~ 1. t ~ C7f Couiasel.:
Alicia S. Miller ~ TEL: ('717) 737-9210 • ~'A~: (717) 737-9215 Michael L, Hangs
E.~ CU'VER SHEET
FR41V1: W~~~ZAM E. M~I.LE~i, JR., ~SQLT~~E
DATE ; ,~ CQ ~..W~ ~J ~p c.~ ~
N0. S~-IE~TS ~3EING SENT: ,including coyer sheet. ~,
~f you do not xece~ve a71 of the pRges being seat, please call 7'37-921.0 anal ask
Moir 1V~alrji.
*'~***COI~FIDENTIALZT'Y P~'OT~***'~*
'T'he doellmen.ts accompanying this teleCOpy transmission contain information fronn the law f~ of Miller & Assooiates,
PC, which is conf~der~,t#al andler lcgall~y privileged. The information is inttndad only #or the use of the individua] or cnt%ty
aQmed on this TPStismi.S&ibn shcct Tfyou arc not the inlEnded recipient, poa err, herby noiifcd that airy disclesurc, copying,
distxibutiomor tbs taking of any action in reltance bn the contents of this te]ccopicd inirrzgstiott is strictly pirohibited, and that the
documents should be returned to this f rrn, immed,latcly. In tlus reg~.rd, if yon have received, thss telecnpy in error, please notify
us by t~lcplanne irnmadiately so that vve can. grrAngc far the rcntrn of the origrinal dacumcn~ to us nrt no cost to you.
. ~'
15056041181
06
05
REV-1500 EX
(
-
) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
INHERITANCE TAX RETURN
PO BOX 280601
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2' I O' $ Od ~'~-~'
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
161-32-3423 12272007 06221938
Decedent's Last Name Suffix Decedent's First Name MI
FRIEDMAN DANA M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
FOSTER MARGARET
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate 0 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
6. Decedent Died Testate 0 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death 0 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
GREGG HAMM 717-761-7210
rU
Firm Name (If Applicable)
BOYER & RITTER
First line of address
P.O. BOX 8300
Second line of address
City or Post Office
CAMP HILL
Correspondent s e-mail address: ghdmm@ Cpabr . COIri
,~~ WILLS U~ONLY
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`'DATE FILED =~
State ZIP Code L
PA 17001-8300
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE ERSON RESPONSIBLE FOR FILING R URN --"' ~~t DATE
'`, ~~' Z 0
ADDRESS
_ l~LL j1,/i~~r s; c~u P 1.1l t l - ~8 y~
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
~ G.Q aor.~ Na~vh~... 9~2 Y ~QS
enno~ec • -_-- --
P.O. BOX 8300, CAMP HILL, PA 17001-8300
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056041181 15056041181
WK4T FAOl05-001 107
REV-1500 EX
Decedent's Name: DANA M FR I E DMAN
Decedent's Social Security Number
161-32-3423
RECAPITULATION
1. Real estate (Schedule A) ............................................. 1.
2. Stocks and Bonds (Schedule B) ....................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages & Notes Receivable (Schedule D) ............................. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5.
6. Jointly Owned Property (Schedule F) t~Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested........ 7.
8. Total Gross Assets (total Lines 1-7) .................................... 8.
9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10.
11. Total Deductions (total Lines 9 & 10) ................................ ... 11.
12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ...................... .. 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14.
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0 15.
16. Amount of Line 14 taxable
at lineal rate X .0 9 5 2, 614 , 4 4 4. 0 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.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056042182
0.00
2,732,299.00
0.00
0.00
16,870.00
0.00
19,753.00
2,768,922.00
124,472.00
30,006.00
154,478.00
2,614,444.00
0.00
2,614,444.00
0.00
117,650.00
0.00
0.00
117,650.00
Side 2
15056042182 15056042182
WK91' PA0J05 -Q~2 ~~,
REV-1500 EX f.'age 3
Decedent's Complete Address:
File Number 21- 0 8 - 0 0 ~~
DECEDENTS NAME
DANA M FRIEDMAN
STREET ADDRESS
1962 CHESTNUT STREET
CITY
CAMP HILL STATE
PA ZIP
17011
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. InteresUPenalty if applicable
D. Interest
E. Penalty
(1) 117, 650.00
Total Credits (A + B + C) (2)
Total InteresUPenalty (D + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference, This is the TAX DUE.
A. Enter the interest on the tax due.
110,526.00
(3) 0 . 0 0
(4) 0 . 0 0
(5) 7, 124.00
(5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 7 , 12 4 . 0 0
Make Check Payable to: REG~sTER of wi~~s, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :.......................................................................................... ^ ^X
b. retain the right to designate who shall use the property transferred or its income :............................................ ^ ^X
c. retain a reversionary interest; or .......................................................................................................................... ^ ^X
d. receive the promise for life of either payments, benefits or care? ...................................................................... ^
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. ^ ^X
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. ^
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ............................................................................ ^X ^
............................................
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
WK9T PA0305-003 10"1
105,000.00
5,526.00
REV-1503 EX+ (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FRIEDMAN, DANA M.
FILE NUMBER
21-08-00~
All property jointty-owned with right of survivorship must be disclosed on Schedule F.
(It more space is needed, insert additional sheets of the same size)
ESTATE SECIIRITIES VALUATION PAGE NO. 1
ACCOVNT: 880837 Name of Estate: DANA FRIEDMAN
DATE OP DEATB: Thursday, December 27 2007
ITEM CUSIP NO. SHARES/ DESCRIPTION PRICE HIGH/ASK LON/BID MEAN SECURITY ACCRUED COh4IENT5
PAR VALUE DATE PRICE
_ _ PRICE
_________ PRICE
__________ _ VALIIE
____________ DTV/INT
____________
________
____
1) _________ _
G6359F103 _____________
750 __ ______________________________
NABORS INDUSTRIES LTD _____
12/27 _________
28.3800 27.8300 28.10500 21,078.75 NYSE
sxs
2) 025816109 2,000 AMERICAN EXPRESS CO 12/27 52.7399 51.0200 51.67995 103,759.90 NYSE
COM
3) 026874107 950 AMERICAN INTL GROUP INC 12/27 59.2900 57.8000 58.54500 55,617.75 NYHE
COM
4) 037411105 2,540 APACHE CORY 12/27 108.8200 106.2500 107.53500 273,138.90 NYSE
COM
5) 05518E202 1,600 BAC CAP TR III 12/27 23.4700 22.6300 23.05000 36,880.00 NYSE
CAY SEC GTD 7%
6) 060505104 4,741 BANK OF AMERICA CORPORATION 12/27 42.0300 41.3200 41.67500 197,581.18 NYSE
COM
DIV $0.6400 EX 12/05/2007 REC 12/07/2007 PAY 12/28/2007 3,034.24
7) 171798101 1,500 CIMAREX ENERGY CO 12/27 42.3700 41.8700 42.12000 63,180.00 NYSE
COM
8) 172758102 1,500 CISCO SYS INC 12/27 28.3800 27.6800 28.03000 42,045.00 NASDAQ
COM
9) 172967101 2,200 CITIGROUP INC 12/27 30.0590 29.4800 29.76950 65,492.90 NYSE
COM
10) 25243Q205 500 DIAGEO P L C 12/27 87.2800 86.1300 86.70500 43,352.50 NYSE
SPON ADR NEW
11) 285512109 1,000 ELECTRONIC ARTS INC 12/27 60.0500 58.6400 59.34500 59,345.00 NASDA4
COM
12) 302316102 500 EXXON MOBIL CORP 12/27 94.9800 93.6700 94.32500 47,162.50 NYSE
COM
13) 368710406 450 GENENTECH INC 12/27 67.9100 66.8800 67.39500 30,327.75 NYSE
COM NE9a
14) 369604103 2,500 GENERAL ELECTRIC CO 12/27 37.5400 37.1100 37.32500 93,312.50 NYSE
COM
DIV $0.3100 EX 12/20/2007 REC 12/24/2007 PAY 01/25/2008 775.00
15) 437076102 1,550 HOME DEPOT INC 12/27 26.9600 26.7100 26.84500 41,609.75 NYSE
COM
16) 458140100 4,400 INTEL CORP 12/27 27.4200 26.7700 27.09500 119,218.00 NASDAQ
COM
17) 478160104 775 JOHNSON & JOHNSON 12/27 67.9600 67.0100 67.49500 52,308.63 NYSE
COM
18) 502424104 1,000 L-3 C064R7NICATIONS HLDGS INC 12/27 107.9600 106.2500 107.10500 107,105.00 NYSE
COM
19) 517834107 75 LAS VEGAS SANDS CORD 12/27 110.4500 105.6200 108.03500 8,102.63 ~ NYSE
COM
20) 548661107 1,250 LOWES COS INC 12/27 23.1900 22.9000 23.04500 28,806.25 NYSE
COM
21) 57772K101 1,000 MAXIM INTEGRATED PRODS INC 12/27 26.0800 25.5600 25.82000 25,820.00
COM
22) 714046109 1,100 PERKINELMER INC 12/27 26.1300 25.8500 25.99000 28,589.00 NYSE
COM
ESTATE SECURITIES VALIIATION PAGE NO. 2
ACCOIINT: 880837 Name of Estate: DANA FRIEDMAN
DATE OF DEATH: Thursday, Decambnr 27 2007
ITEM CUSZP NO. SHARES/ DESCRIPTION PRICE HIGH/ASK LOW/HID MEAN SECURITY ACCRIIED COMMENTS
PAR VALUE DATE PRICE PRICE
___ PRICE
__________ - VALUE
____________ _ DIV/INT
___________
__________
____
23) _________ __
717081103 ______________
1,800 _____________________-________ _____
PFIZER ZNC 12/27 __________ __
23.2800 _____
22.9000 23.09000 41,562.00 NYSE
COM
24) 742718109 900 PROCTER & GAMBLE CO 12/27 74.2600 73-6200 73.94000 66,546.00 NYSE
COM
25) 882508104 1,500 TEXAS INSTRS INC 12/27 34.1600 33.5400 33.85000 50,775.00 NYSE
COM
26) 913017109 2,800 UNITED TECHNOLOGIES CORP 12/27 78.2000 76.5300 77.36500 216,622.00 NYSE
COM
27) 91324P102 2,100 UNITEDHEALTH GROIIP INC 12/27 59.4400 58.2000 58.82000 123,522.00 NYSE
COM
28) 931142103 1,350 WAL MART STORES INC 12/27 48.3000 47.0`205 47.96025 64,746.34 NYSE
COM
DIV $0.2200 EX 12/12/2007 REC 12/14/2007 PAY 01/02 /2008 297.00
29) 3133M36V2 30,000 PEDERAL HOME LN BKS 12/27 100.3438 100.34380 30,103.14 - GVT AGENCY
CONS BD 5.7859608
Int. From: 10/14/2007 to 12/27/2007 356.74
30) 3706AOV85 20,000 GENERAL MTRS ACCEP CORP 12/27 88.7815 88.78150 17,756.30 NASDAQ
FR 5.49612 15 0 9
Int. From: 12/15/2007 to 12/27/2007 39.00
31) 313392MJ8 35,000 FEDERAL HOME LN BKS 12/27 106.5000 106.50000 37,275.00 GVT AGENCY
CONS BD 6.19610
Int. From: 12/13/2007 to 12/27/2007 88.96
32) 3128X2V44 25,000 FEDERAL HOME LN MTG CORD MTN 12/27 100.0078 100.00780 25,001.95 GVT AGENCY
CALL 5.096040114
Int. From: 10/01/2007 to 12/27/2007 302.06
33) 61745ESW2 20,000 MORGAN STANLEY D W DISC SRMTNS 12/27 95.4530 95.45300 19,090.60 NASDAQ
VR 020105-020215
Int. From: 12/02/2007 to 12/27/2007 72.22
34) 36962GL69 20,000 GENERAL ELEC CAP CORD MTN BE 12/27 97.9775 97.97750 19,595.50 NASDAQ
CALL STEP 102816
Int. From: 10/28/2007 to 12/27/2007 137.50
35) 37042GTA4 25,000 GENERAL MTRS ACCEP CPSMARTNHE 12/27 73.9605 73.96050 18,490.13 NASDAQ
CALL 7.5096111516
Int. From: 12/15/2007 to 12/27/2007 67.71
36) 31331SG49 25,000 FEDERAL FARM CR BAS CONS SYSTE 12/27 99.8438 99.84380 24,960.95 GVT AGENCY
CONS SD 5.689620
Int. From: 12/22/2007 to 12/27/2007 23.67
37) 3128X1LM7 50,000 FEDERAL HOME LN MTG CORD MTN 12/27 96.4323 96.43230 48,216.15 GVT AGENCY
CALL 59612 0 9 2 2
Int. From: 12/09/2007 to 12/27/2007 131.94
38) 38374C3H2 20,000 GNMA REMIC TRIIST 2003-85 12/27 99.8686 99.88860 7,198.86 GVT AGENCY
20270920 4.50000
CMO Paydown Factor .36034442
CMO Accrual Rata = .3250 ~ 23.42
39) 316089507 3,449.5220 FIDELITY COURT STR TR 12/27 12.5900 12.59000 43,429.48 Manual
SPARTAN MIIN IN
Int. From: I2/O1/2007 to 12/27/2007 130.10
40) 316388303 3,630.8160 FIDELITY SCH STR TR 12/27 10.5500 10.55000 38,305.11 Manual
STRATEGIC INCM
int. From: 12/01/2007 to 12/27/2007 195.04
ESTATE SECURITIES VALUATION PAGE NO. 3
ACCOUNT: B80837 Name of Estate: DANA FRZEDMAN
DATE OF DEATH: Thursday, December 27 2007
ITEM CUSIP NO. SHARES/ DESCRIPTION PRICE HIGH/ASK LOW/BID MEAN SECURITY ACCRUED COMMENTS
PAR VALUE DATE PRICE PRICE PRICE VALIIE DIV/INT
41) 06324 BHRB 25,000 HANK LEUMI USA NEW YORK NY 12/27 91.0471 91.04710 22,761.78 NASDAQ
CD CLL Sk23
Int. From: 12/26/2007 to 12/27/2007 6.94
42) 143876041 25,000 CAROLINA FIRST BK GRVILLE SC 12/27 97.4237 97.42370 x4,355.93 NASDAQ
CD CLL 515
Int. From: 08/31/2007 to 12/27/2007 410.91
43) 2546782H0 25,000 DISCOVER BK GREENWOOD DEL 12/27 97.7673 97.76730 24,441.83 NASDAQ
CD CLL 5.518
Int. From: 12/12/2007 to 12/27/2007 61.11
44) 254678242 25,000 DISCOVER BK GREENWOOD DEL 12/27 98.2294 98.22940 24,557.35 NASDAQ
CD CLL 623
Int. From: 08/24/2007 to 12/27/2007 - 513.59
45) 25467H3 R7 25,000 DISCOVER BK GREENWOOD DEL 12/27 97.2738 97.27380 24,318.45 NASDAQ
CD CLL 5.2518
Int. From: 10/04/2007 to 12/27/2007 304.82
46) 33761KQ73 25,000 FIRSTHANK P R SAN JUAN 12/27 98.1713 98.17130 24,542.83 NASDAQ
CD CLL 5.12514
Int. From: 12/26/2007 to 12/27/2007 7'12
47) 428668BA7 25,000 HIBERNIA NATL HK NEW ORLEANS L 12/27 99.9475 99.94750 24,986.88 NASDAQ
CD CLL STP 11
Int. From: 12/14/2007.to 12/27/2007 40.64
48) 59I64TAC8 15,000 METROHANK N A HOUSTON TX 12/27 98.5504 98.55040 14,782.56 NASDAQ
CD 4.4510
Int. From: 11/30/2007 to 12/27/2007 51.92
49) 84603MGV2 25,000 SOVEREIGN BK FSB WYOMISSING PA 12/27 98.1024 98.10240 24,525.60 NASDAQ
CD CLL 514
Int. From: 09/26/2007 to 12/27/2007 319.37
50) 316114107 78,432.6200 FIDELITY MONI MONEY MARKET 12/27 1.0000 1.00000 78,432.62 Manual
Int. From: 12/01/2007 to-12/27/2007 171.82
Grand Totals
Total Principal plus Accrued interest and dividends
---------------- ------------
2,724,736.23 7,562.86
ss-=2x732 299'09
This report was Hrepared using FTPAPPRAISE Var. 7.2.402 software, an EVALUATION SERVICES, INC. product.
Visit our web site at WWW.APPRAISENJ.COM.
REV-1508 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
FRIEDMAN, DANA M. 21-08-00~~
- (If more space is needed, insert additional sheets of the same size)
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
,:F'r'ee ~laecl~.ing account Statement Pl'~I~~BA7V~
PNC Bank
For tho poriod 12/Oiit1~007 to 01/09/ZOO$
DANA M FRIEDMAN
1962 CHESTNUT ST
CAMP HILL PA 17011-5471
Primary account number: 50••0561-7643
Page 1 of 1
Number of enclosures: 0
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FI'96 C~116C~ng ~cd~0illtlt SICr~I11fa1'y ~ Dana M Fribdmal;
account number. 50-0561-7643
Balance Summary Please see the Activity Detail section for
additional information.
Beginning Deposits and Checks and okher Ending
balance other additions deductions balance
75.00 4,040.26 .00 4,115.26
Average monthly Charges
balance and tees
1,981.00 .00
o-ctivity Detail
)epoaits and Other Additions
rate Amount Description
.2/10 40.26 Deposit Reference No 028079287
.2/26 4,000.00 Deposit Reference No 019662147
There were 2 Deposits and Other Additions
totaling $4,040.26.
)ally Balance Detail
rate Balance
2/08 75.00
Date Balance
12/10 115.26
Date Balance
12/26 4,115.26
~ ~~
DANA M FRIEDMAN
MARGARET T FOSTER POA
1962 CHESTNUT ST
CAMP HILL PA 17011
Page 1 of 2
DATE 4/04/08
PRIMARY ACCOUNT 560006578
ENCLOSURES 1
------------------------------CHECKING ACCOUNTS--------------------------------
ACCOUNT TITLE: DANA M FRIEDMAN
MARGARET T FOSTER POA
Ask about our BreakFree Checking with Direct Deposit that
offers: no monthly service fees., no minimum balance
requirement & free Online Banking & unlimited bill payment.
BREAKE'REE CHECKING NUMBER OF ENCLOSURES 1
ACCOUNT NIJMBIIt 560006578 STATEMENT DATES 3/06/08 THRU 4/06/08
BEGINNING BALANCE 4,865.17 DAYS IN THIS STATEMENT PERIOD 32
CREDITS .00 AVERAGE LEDGER BALANCE 1,672.40
1 DEBITS 4,865.17 AVG COLLECTED BALANCE 1,672.40
SERVICE CHARGE .00
i INTEREST PAID .00
ENDING BALANCE .00
DEBITS
DATE DESCRIPTION AMOUNT
3/17 MISC DEBIT 4,865.17-
. BALANCE SUMMARY
DATE BALANCE DATE BALANCE
3/06 4,865.17 3/17 .00
Checks you deposit into your Chittenden account are your responsibility even after
the funds are made available to you, and you withdraw the funds. Checks returned
for any reason are your responsibility and will be charged against your account.
Two Burlington Square ~ P.O. Box 820 ~ Burlington, Vermont ~ 05402-0820 ~ 1-800-545-2236 ~ TTY Users: 1-877-318-0255
REV-1510 EX+ (6-96)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FRIEDMAN, DANA M. 21-08-0004
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the next page of the REV-1500 COVER SHEET is yes.
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
FILE NUMBER
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
% OF DECD S
INTEREST
EXCLUSION
(IF APPLICABLE)
TAXABLE
VALUE
1. VANGUARD IRA 19,753.00 100.0000 19, 753.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
WK9T PA0305-012 107
TOTAL (Also enter on line 7 Recapitulation)
19,753.00
~1f more space is needed, insert additional sheets of the same size)
Vanguard°
Julys, Zoos
Vanguard Windsor Fund
Investor Shares
VFTC -CUSTODIAN IRA
DANA M FRIEDMAN 800-662-2739 - Client Services
1962 CHESTNUT ST (800) 662-6273 - Tele-Account
CAMP HILL PA 17011-5471 ~ w Fund number: 22
~ Account number: 71613234234
ACCOUNT VALUE
on 7 iosi2oos
Trade date Transaction Dollar amount Share price Shares transacted Totai shares owned
Beginning oalance - i ,2,1.744
7/08 Transfer to 88028283892 $ -5,336.06 $ 12.79 -417.206 834.538
7/OS Transfer to 88028283915 -5,336.06 12.79 -417.206 417.332
7/08 Transfer to 88028283928 -5,337.68 12.79 -417.332 .000
Income dividends $ 184.39
~~~2~~a7
SNA22S IZSI_~`l~{
VAL~e IS_~S
i ~ ~S3
VANGUARD V4lINDSOR FUND FUND/ACCOUNT NO.
INVESTOR SHARES 0022/71613234234
• Do not alter or photocopy this Invest-ey-Mail slip. VFTC -CUSTODIAN IRA
• Visit www.vanguard.com or call to change your address. DANA M FRIEDMAN
Make checks payable to: The Vanguard Fiduciary Trust Company - 0022
2008 Tax year contr~ution ~ $ ~ ~ ^ ~ ^ . ^
2008 Rollover $ ^ ~ ~ ~ ^ ~ ^ ^ ^ . ^ ^ THE VANGUARD GROUP
^'^^^'^^^.^^ PO BOX 7800
Totalamount $ PHILADELPHIA PA 19101-9892
~u~~~~~~uu~~~~~uun~~~~~n~n~~~~~nn~~~~~u~~
IIRIIYflInV~I~I~YY V~IIIIININA~Vllllllllll
Page 1 of 1
REV-1511 EX+ (10-06)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
FRIEDMAN, DANA M. 21-08-00~`~'
Debts of decedent must be reported on Schedule [.
ITEM
N MBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
~' MYERS HARNER FUNERAL HOME 2,457.00
2 ABBIATI MONUMENTS 663.00
3 MYERS HARNER FUNERAL HOME 300.00
4 COVEY AND ALLEN FUNERAL HOME 515.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s) MARGARET FOSTER/WILLIAM MILLER
Street Address 1822 MARKET STREET
City CAMP HILL State PA Zlp 17 011
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimants, attach explanation)
Claimant
4.
5.
6.
~.
Street Address
City State ZIP
Relationship of Claimant to Decedent
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
SEE ATTACHED
60,000.00
52,691.00
1,214.00
5,000.00
1, 632.00
TOTAL (Also enter on line 9, Recapitulation) S 124, 472.00
(If more space is needed, insert additional sheets of the same size)
WK9T PA03DS-013 107
Estate of Dana M. Friedman
File Number: 21-08-0004
Form REV-1511
Administrative Costs -Other
Mid Penn Bank -Check Fee 60
Verizon 20
The Sentinel -Legal Advertising 150
State Farm -Auto Insurance 67
Verizon 21
Mid Penn Bank -Trust Fee 759
State Farm -Auto Insurance 80
Margaret Foster -reimburse 1/2 tax prep fee 475
1,632
REV-1512 EX+ (12-03)
SCHEDULE I
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
FRIEDMAN, DANA M. 21-08-OO~f~f-
(If more space is needed, insert additional sheets of the same size)
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
REV-1513 EX+ (9-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA I BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
FRIEDMAN, DANA M. 21-08-00~~
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS (include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
JENNIFER L. FRIEDMAN BAILEY
DAUGHTER 33.33330
2 DANA H. FRIEDMAN
SON 33.33330
3 SARAH M. BRENNAN
DAUGHTER 33.3333%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUG H 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
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0 . 0 0
`~°J°J °'~ ' °" (If more space is needed, insert additional sheets of the same size)
LAST WILL AND TESTAMENT OF -_- - _
DANA M. FRIEDMAN - -~-
.-
I, DANA M. FRIEDMAN, of the Borough of Camp Hill, Cumberland Comity; ~:~ - -
Pennsylvania, do hereby make this my Last Will and Testament, revoking any-~former~' -
Wills and Codicils made by me. `''
FIRST: I am married to MARGARET T. FOSTER, a/k/a MARGARET T. FR1ED-
MAN, who has agreed to renounce any interest she might have in my estate. Accord-
ingly, (have purposely not provided for her in this Last Will and Testament. I have
three adult children from a prior marriage, JcNNiFER ~. FRlEDIti3AN BAILEY (born:
6 September 1963); DANA H. F-RIEDMAN (born: 11 May 1965) and SARAH M.
BRENNAN (born: 2 November 1967). These children are described in this Wiil as "my
children," or as "a child of mine." Any person born to or adopted by a child of mine is
described in this Will as "my issue." Provided, however, no adopted person shall
benefit hereunder unless the order or decree of adoption is entered before such
adopted person attains the age of twenty-one (21 }years.
SECOND: I give my tangible personal property and all casualty insurance that I
am carrying on said tangible personal property to such of my children who are living at
my death to be divided equitably among or between them as they may determine, or, if
they are unable to._agree.,_as_my.Executor-shall determine, after consider-ing-the-wishes -- ---- ------
of such children. Any such property not so distributed shall be otherwise disposed of or
sold, and the proceeds added to my residuary estate to pass as hereafter described. 1
have complete confidence that my wife, my children or my Executor will honor any
written instructions that I may leave with regard to said tangible personal property.
TH1RD: 1 give, devise and bequeath al! of the rest and remainder of my estate,
real and personal, in equal shares to my children, or their issue, per stirpes. In the
event any child of mine predeceases me without issue, her/his share shall be distrib-
uted in equal shares to my surviving children, or their issue, per stirpes. In the event all
of my children predecease me and die without issue, I give, devise and bequeath alt of
the rest and remainder of my estate, peal and personal, to the School of Medicine of
- ..
nnnG
Tufts University of Medford, Massachusetts, to provide scholarship funds for medical
students, in memory of my father, Sumner H. Friedman, M. D.
FOURTH: (1) 1 name my wife, Margaret T. Foster, and William E. Miller, Jr., or
the survivor of them, to be my Co-Executors and Co-Trustees, if applicable, herein
referred to as my Executor or Trustee, regardless of number or gender. 1 direct that my
Executor or Trustee, and their successors, regardless of number or gender, serve
without bond in any jurisdiction in which they are called upon to act.
(2) For services as Executor and Trustee, my Executor and Trustee shall
receive reasonable compensation. !recognize that my Executor and Trustee ~nrill need
to use the services of an attorney and accountant as necessary to assist in the adminis-
tration, termination and distribution of my estate. It is my desire that my Executor and
Trustee use the services of these professionals who will charge for their services only
on the basis of a fee for services actually rendered and not be compensated for such
professional services on the basis of a percentage of the value of my estate.
i=1i=TH: If any share hereunder becomes distributable to a beneficiary who has
not attained the age of twenty-one (21) years, then such share shall immediately vest
in such beneficiary, but notwithstanding the provision herein, my Trustee, hereinabove
named, shall retain possession of such share in trust for such beneficiary until such
beneficiary attains the age of twenty-one (21) years, using so much_of the_net income
and principal of such share as my Trustee deems necessary to provide for the proper
medical care, education, support and maintenance in reasonable comfort of such
beneficiary, taking into consideration to the extent my Trustee deems advisable any
other income or resources of such beneficiary or his or her parents known to my
Trustee. Any income not so paid or applied shall be accumulated and added to
principal. Such beneficiary's share shall be paid over and distributed to such benefi-
ciary upon attaining the age of twenty-one (21) years, or, if he or she shall sooner die,
to his or her executors or administrators. My Trustee shall have with respect to each
share so retained all of the powers and discretions had with respect to the trusts
created herein generally.
- ._ ~ -
DMF
SIXTH: I give to any Executor and Trustee named in this Will or any Codicil
hereto or to any successor or substitute Executor or Trustee all of the powers enumer-
ated in this Will and al! of the powers applicable by law to fiduciaries in the Common-
wealth of Pennsylvania and in particular through the Pennsylvania Probate, Estates and
Fiduciaries Code, as effective and as in effect on the date of my death, during the
administration and until the completion of the distribution of my estate. I direct that ail
such powers shall be construed in the broadest possible manner and shall be exer-
cisable without court authorization.
SE1lENTi-i: No interest of any beneficiary under this V1,'ill, any Codicil h ereto, or
any trust created herein, shall be subject to anticipation or to voluntary or involuntary
alienation.
EIG! ITN: No person shall benefit hereunder unless such beneficiary shall
survive me by thirty (30) days.
NIN i H: All estate; inheritance, succession, and other death taxes imposed or
payable by reason of my death and interest and penalties thereon with respect to a-I
property comprising my gross estate for death tax purposes, whether or not such
property passes under this Will, shall be paid out of the residue of my estate, as if such
taxes were expenses of administration, without apportionment or right of reimburse-
ment, except as otherwise might be determined by.my_Executor in_its_sole discretion. i
authorize my Executor and Trustee to pay all such taxes at such time or times as
deemed advisable.
IN WITNESS WHEREOF, I have set my hand and seal on this my Last Will and
Testament on this 21St day of December, 2007.
yJC-. ~-~~..ti
(SEAL)
DANA M. FREEDMAN, Testator
-- -
nnnF
SELF-PROVING AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND
I, DANA M. FRIEDMAN, the Testator, whose name is signed to the attached or
foregoing instrument, being first duly sworn, do hereby declare to the undersigned
authority that 1 signed and executed the instrument as my Last Wiii and Testament and
that !signed wi;lingly, and that I signed it as my free and voluntary act for the purposes
therein expressed on this 21St day of December, 2007.
.~-, ,,
DANA M. FRIEDMAN, Testator
Subscribed, sworn to, and acknowledged before me by DANA M. FRIEDMAN,
the Testator, on this 21 Sc day of December, 2007.
Notary Pub4f~.
COMMONWEALTH OF PENNSYLVANIA
I NOTARIAL SEAL
MARJORIE L. JOHNSON, Notary Public
Camp Hill Boro., Cumberland County
;nmm~ssion Expires April 15, 2011
SELF-PROVI?~IG AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUM3ERLAND
SS.
We, the witnesses, respectively, whose names are signed to the attached or
foregoing instrument, being duly qualified according to law, do depose and say that we
were present, at his request, and saw DANA M. FRIEDMAN sign and execute the
instrument as his Last Will and Testament; that he signed willingly and that he executed
it as his free and voluntary act for the purposes therein expressed, that each of us in
the hearing and sight of DANA M. FRIEDMAN signed the Last Will and Testament as
witnesses; and that, to the best of our knowledge DANA M. FRIEDMAN was at the time
eighteen (18) years of age, of sound mind, and under no constraint,,or undue influence.
i~ 44.
~,~ ~. L ~
° ~'1,` ' ~ ~'' 1,,
~~~... ~i
J `~/ v ~.~.. ~.-.
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Witness
.~-r-
=-Witness
Y
--- -- - _-----Witness
Subscribed, sworn to, and acknowledged before me by ~"~ i Ch }~ C:.~ ~~. ~°~ ~ ~~~ ~'~~'
and ~~ CCZ ( -~~-~ ~ ~E:itthe witnesses, on this 215` day of
December, 2007.
Notary Public ~.
COMMON WEALTH OF PENNSYLVANIA
NOTARIAL SEAL
MARJORIE L. JOHNSON, Notary Public
Camp Hill Boro., Cumberland County
C:. ~~rT~ission Expires April 15, 2011
GS.SUS i2E`i (01/(77;
WARNING: It is illegal to duplicate this copy by photostat or photograph.
:e for this certificate, $6.00
P 139912~~
Certification Number
This is to certify that the information here given is
correctly copied from an original Certificate of DeatY
duly filed with me as Local Registrar. The origins
certificate will be forwarded to the State vita
Records Office for permanent filing. ~~~ 2 ~ ~oo,
LGr~rz.- ~ '.~r - l l
Local Registrar Date Issued
Eu 11rzoa6 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
viENrl" CERTIFICATE OF DEATH
K rNa See instructions and examples on reverse
1 STATE FILE NUMBER
1. Noma d Deeadenl (Rrq, ntiddh, ka4 eufial 2 Sea 3. Sodel Seeunry Number 4. Dale d Deam (Monty. uY. Yurl
Dana M. Friedman male 161 - 32 - 4
5. Aga (Lear BYthhY) Uma t year Urder t day 8. Dale of Sims pAaah, day, yaerf 7. Sinrgkre (ph ~ akk a lor eign caWry) Ba. Plea of Daam (Clkck ony am)
rber aay+ rwvn wvr Hoepiral: Diner:
69 Yra. June 22 1938 Bennin ton Vt ^mpalenl ^Efl/Oulpetlent ^DOA ^NUrnngFbme ®Rendence ^oder-spa~ay
+b. Damy a Deem ec. ciy, Sao, rWp. or Deem ad Faddy Name 01 red wmebn, We abeW and n.nbr) 9. was Decedent a NiaParrc oripn? No ^ Vea 10. Rare: Ameripn 41dan, emdc: wNh, nc
pr yes, apedh Cuban, (Seedy)
Cumberland Camp Hill 1962 Chestnut Street Mea;~n•w.r~Rieam.t~) White
11. Dautlnrs lhlud Idnd d vrak do ne moat d We. Do rlol nah ro 12 Wu Dsudald aver n me 1 3. Deeedenra Edueelion (Spadly a+N N9hat 9r~ hill 14. MMhI Sable: Monied, Never Martied 15. Surviving Spa we (6 villa, give maiden nnm)
16tl d Warp IOrd d dueku / pldleVy U.S. AmIM F
om
u
7 Ebrtlenhry / Sawndary (0.12) Co9epe (1r a &) YYlldOned. Dlvaced (Spadly)
Attorney Alcoa v
-
~
^ra p,1NO 5+ Married Mar aTet Trace
16. Addrou (Sasal, ' Y Imm, ahh, zip rmel
~°iestnut ~treet Decedsra's ~ Oecedod
,7e.^ Yea,D.~.aaaLiwdb Twp.
AWelRe~idence 17a.Sore Pa
Pa 17011
Camp Hill T
„~-D,~„y Cumberland ,70.0$1 llm d.,aNn Camp Hill
, ~,1~
1B. Faelare Name (Prat. niddh, hn, aldlbl) 19. MotlkYS Name (Fhn, mitlde, maiden aurtkrre)
Sumner H. Friedman Ruth Faitsch
20e. INOmwa'a Fame (type I Prim) 20b. mfamemk Meinq Addees (Broil, dF1 / men. ehh, rep eade)
Margaret Friedman 1962 Chestnut Street Hill Pa 17011
21a Maalod d Dhpmlion Cremeeon ^ Domtlm 21b. Dora d DYpcaltlan (Momh, day, your) 21c Phce d OigloeWOn (Name d a^IdM', cramatay a dmr place) T1d Lawlm Iciy! bxn, ekle, zip cads)
^ ^ emw ^ RamovalrranSlek i;~M;kr'~':I~n°ani"rc Ae'"~°d „ee^Np ,~ Hollin er Cremator Mt Holl S rin s Pa
SFgmaae Service ' a adelg ae such) 22b. Limma Nmtba Rte. Name endAddus d Pastry
- 011654-L Mors-Hamer Funeral Home Inc.1903 Market Street Hill Pa1701
ComplMa 7,itc omy wllwl artllyilg 29e. To ak WI or my ggvMtlga, tlaam axured at the ants dna oral Pkrs ahlad. (Si9man end tltle) 23b. License Number ~ 23c DW Sgrkd (Monet. daY. Year)
phyYden h M avalede M IMM d OuM m
early eew a aem.
pus 2426 msl M mrlglned q peroon 2d Time d^~aD/eavrh 26 Dora Pnelaaaxd Oaed (Mold, day, year) 26. Was Case RdartM h Mtlcal FxeMnar I Carakr br a Masan Omer men Cremation a Donalion7
alb pnmurcu duet. ~VV M. /~ ~7 ~' ~ ^Yp o '
CAUSE OF DEATH Sea InsWCtlane end sxamphs) , Appladnete WMVet: Part II: Enkr olller " 2S Did Tobxm the Comralde b Dud?
Dan 27. Pant: Erdsr dre CIBp.4ldIDWi-dneesas, injudu, aconpYCaeom - mat drily aueed the drN. W NDT enkr Nrmeln eruh such as rerdiec errui r Omer b Dead do not rondlirlg n Ik underyelg reuse given n PM I. ^ Yes ^ Probably
rupialay amen. a venbitldar watbd arowtiq me elbbgy. lhl only one Hues m each Mne. I
I
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30a Wn an Adopey 30b. Woe Aubpay Fhdirrgs 31. Mmner d Deem 32a Dale d bNaY (MOnm, day. year) 326. Dnmbe How N4eY Omarsd 32c Phm d Injury: Flume, Farm. Street, Factory,
Pedamed7 Avaiebb Pria b Camphlbn ~ ^ Horn ld Olke 9dkirg. Mc. (Spedly)
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To IM best of my Mowhdge, deNh occumd st FM tlme, doh, emi plan, and dos h ma auaa(e) and oromsr u shred_ _ _ _ _ _ _ _ _ _ ^
____ ____ A
33c. Ucuee Number 330.
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