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HomeMy WebLinkAbout10-03-08 (2)t ~ y • Cq~y 15056041158 REV- 1 ~.1VO EX (06-05) OFFlCIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 21 08 ~~~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 175-50-4142 01192008 07091910 Decedent's Last Name Suffix Decedent's First Name M I DUNLAP ROSE S (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M I Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE - - REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW 1. Original Return ^ 4. Limited Estate 6. Decedent Died Testate (Attach Copy of Will) ^ 9. Litigation Proceeds Received ^ 2. Supplemental Return ^ 4a. 7. ^ 10. Future Interest Compromise (date of death after 12-12-82) Decedent Maintained a Living Trust (Attach Copy of Trust) Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 3. Remainder Return (date of death prior to 12-13-82) 0 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes ^ 11. Election to tax under Sec. 9113{A) (Attach Sch. O) c:URRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number AQUANETTA WASHAM 215-553-2176 t`~ c~ ~~~-, Firm Name (If Applicable) REGIST WILLS U NLY - " THE BANK OF NEW YORK MELLON, N - A - -'"~';_--; First line of address r ~~, P - 0 - BOX 7899 `. ~~- rT Second line of address -•- `~{ . RM# 193-0205 ~~ P- c~ City or Post Office State ZIP Code DATE FILED PHILADELPHIA PA 19101-7899 Correspondent'se-mail address: AQUANETTA - WASHAMaBNYMELLON - COM 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 per~nal representative is based on all information of which preparer has any knowledge. ~(SN y NEU~ ~ ~ ~ ~~ ~ ~ ~,~,~ r o_ ~ - v F aiunwi urtt car F'HtPARER OTHER THAN REPRESENTATIVE DATE JVI"1CJJ PLEASE USE ORIGINAL FORM ONLY Side 1 15056041158 15D56041158 6M4647 3.000 f REV-1500 EX 15056042159 Decedent's Social Security Number 175-50-4142 Decedent's Name~D U N L A P R O S RECAPITULATION 1. Real estate (Schedule A) 1, 0.00 2. Stocks and Bonds (Schedule B) . 2. 0 - 00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . 3, O • O 0 4. Mortgages & Notes Receivable (Schedule D). 4. 0 • O O 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . 5. 18 0 8 7 • O 0 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested 6. 0 • 0 ^ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. 4 0 814 6 8 • 8 7 8. Total Gross Assets (total Lines 1-7). . .. ... .. ... 8. 4 O 9 9 5 5 5 • 8 7 9. Funeral Expenses & Administrative Costs (Schedule H) . 9. ], 6 2 3 7 6. 5 4 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). 10. 3 8 0 2 0' • 21 11. Total Deductions (total Lines 9 & 10) . 1 1. 2 0 O 3 9 6.7 5 12. Net Value of Estate (Line 8 minus Line 11) 12. 3 8 9 915 9 - 12 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................ 13. 3 7 6 813 9 • 12 14. Net Value Subject to Tax (Line 12 minus Line 13) 14. ], ~ ], 0 2 O - 0 0 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 .O D- 0 , 00 15. 0.00 16. Amount of Line 14 taxable at linealratex.oli5 104370.00 16. 4696-65 17. Amount of Line 14 taxable at sibling rate X .12 0 , 00 17• 0 • 00 18. Amount of Line 14 taxable at collateral rate X .15 2 6 6 5 0. 0 0 18. 3 9 9 7. 5 0 19. TAX DUE 19. 8 6 9 4 • 15 20. FILL IN THE BOX IF YOU ARE REGIUESTING A REFUND OF AN OVERPAYMENT r] Side 2 15056042159 sMasasz.ooo 15056042159 REV-1500 EX Page 3 Decedent's Complete Address: Fle Number ~i. nA DECEDENTS NAME DUNLAP ROSE S STREET ADDRESS CUM ERLAND CITY MECHANICSBURG srATE zIP Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 0 . 0 0 B. Prior Payments Q . Q Q C. Discount 0 . 0 0 3. Interest/Penalty if applicable D. Interest Q . ^ Q E. Penalty 0 . 0 ^ (1> 8694 •15 Total Credits (A + B + C) (2) 0 . 0 0 Total Interest/PenaMy (D + E) (3) 0 . 0 0 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) o • 0 0 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 8 6 9 4 • 15 A. Enter the interest on the tax due. (5A) 0 • 0 0 B. Enter the total of Line 5 + 5A This is the BALANCE DUE. (56) 8 6 9 4 •15 Make Check Payable to: REGISTER OF WILLS, 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; ~ ^ b. retain the right to designate who shall use the property transferred or its income; c. retain a reversionary interest; or ^ ^X d. receive the promise for life of either payments, benefits or care? ^ 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . ^ ^ 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? ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FlLE 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. §91 16 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(x)(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(x)(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(x)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. 6M4671 1.000 r REV-1508 EX + (8-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF FILE NUMBER Rose S. Dunlap 21 08 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 County of Cumberland Burial Allowance 100.00 2 Highmark Refund of Health Insurance Premium 514.31 3 Hospice of Central PA Refund 3,900.00 4 Miscellaneous Jewelry Per appraisal attached 2,120.00 5 Personal Property Appraisal (attached) 975.00 6 United States Treasury 2008 Economic Stimulus Payment 300.00 7 Accrued income from David Dunlap T/W "B" A/C# 101706728N8 7,297.98 Interest accrued to 1/19/2008 1,987.10 8 Accrued income from Rose Dunlap T/A Charitable #10172653BN6 311.48 9 Accrued income from Rose Dunlap CRAT #101730716N0 259.56 10 Prudential payments 62.01 11 Accrued income from Rose Dunlap CRAT #10177325BN0 259.56 TOTAL (Also enter on line 5 Recapitulation) $ ~ 18, 087.00 3Wa8AD 7.000 (If more space is needed, insert additional sheets of fhe same size) REV-1510 EX + (6-96) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE Rose S._Dunlap 21 08 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 is yes. ITEM NUMBS DESCRIPTION OF PROPERTY INCLLpE7}~µM~EpF7}E7FiAN5FEREE,THEIRRELATIONSMP70DECEDEMMD TFE DATE OF TRPlSFE3i ATTACHACJR' OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE ~• BNY Mellon Tr U/A Dated 3/2/1981 As Amended Date of Death Assets per Attached Schedule 4,051,918.87 100.0000 0.00 4,051,918.87 2 Gifts within 1 year of death: Mildred Hikes $25,650.00 James Roach $5,500.00 Sharon Roach $5,150.00 Carolya Dunlap $5,250.00 41,550.00 100.0000 12,000.00 29,550.00 TOTAL (Also enter on line 7, Recapitulation) I $ 4,081,468 87 (If more space is needed, insert additional sheets of the same size) 3W46AF 1.000 ESTATE OF ROSE S. DUNLAP ATTACHMENT TO SCHEDULE G FI LE# 21-08 FACE/SHS DESCRIPTION OF SECURITY SIP # EXCHANGE MAN DEATH 1 210, 034.860 CASH 210, 034.86 2 74,565.038 BNY MELLON FDS TR 58551 X736 NASDAQ 12.66000 943,993.38 3 174,748.901 BNY MELLON FDS TR 58551 X678 NASDAQ 12.75000 2,228 048 49 4 326.465 BNY MELLON FDS TR 58551 X603 NASDAQ 18.98000 , . 6 196 31 5 4,094.112 BNY MELLON FDS TR 58551 X504 NASDAQ 13.84000 , . 56,662.51 6 65,446.745 BNY MELLON FDS TR 58551X108 NASDAQ 9.04000 591 638 57 7 995.215 BNY MELLON FDS TR 58551 X306 NASDAQ 10.82000 , . 10 768 23 8 410.819 BNY MELLON FDS TR 58551X405 NASDAQ 11.14000 , . 4,576.52 TOTAL 4,051,918.87 101707746N2 -DUNLAP, ROSE T/A REV-1511 EX+,(10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER _Rose S. Dunlap 21 08 Debts of decedent must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~. W. Orville Kistmtel Funeral Home Funeral Bill 2,007.00 B. ADMINISTRATIVE COSTS: t. Personal Representative's Commissions 120, 000.00 Name of Personal Representative(s) BNy Mellon, N A & D Mark Thoma Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees 38, 750.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach e~lanation) Claimant Street Address 4. 5. 6. 7. 1 2 7W46AG 1.000 City State Zip Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees John Wesley/SMM Payment for Personalty Appraisal Munn's Diamond Gallery LTD Payment for Jewelry Appraisal Total from continuation schedules . TOTAL (Also enter on line 9 R (If more space is needed, insert additional sheets of the same size) 135.00 350.00 1,134.54 $ 162,376.54 REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Rose S Dunlap 21 08 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE 1 OF DEATH Alert Pharmacy Services Final Bill 240.37 2 AT&T Final Bill 43.45 3 Messiah Village Balance Due 984.23 4 Pennsylvania Dept. of Revenue 2007 Pennsylvania State Individual Income Tax 2,668.00 5 Thomas, Armstrong & Nissen Legal Services prior to death $5,988 & Expenses $439.84 6,427.84 6 Travelers Indemnity Payment for Personal Articles Policy 79.00 7 United States Treasury 2007 Federal Individual Income Tax 27,548.00 8 Verizon Final Bill 29.32 TOTAL (Also enter on line 10, Recapitulation) $ 38, 020 .21 3W46AH 2.000 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+(9-00) ~ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENTDECEDENT ESTATE OF FILE NUMBER Rose S. Dunla 21 08 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 Mildred Hikes 419 Apple Tree Road Camp Hill, PA 17011 Taxable Gift within 1 year of death $22,000.00 None 22,000.00 2 James Roach 2 Rusty Drive Mechanicsburg, PA 17050 Taxable Gift within 1 year of death $2,500.00 None 2,500.00 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEEP 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 See Attached TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET I $ 3, 768, 139 12 3W 46AI 1.000 (If more space is needed, insert addltlonal sheets of the same size) Estate of: Rose S. Dunlap Schedule J Part 1 (Page 2) 21 08 Item No. Description Relation Amount 3 Sharon Roach 2 Rusty Drive Mechnicsburg, PA 17050 Taxable Gift within 1 year of death $2,150.00 None 2,150.00 4 Estate of Robert Dunlap C/o David C. Mize, Esq. 1045 Cascade Avenue, Ste 202 Colorado Springs, CO 80903 Specific Bequest $100,000.00 Son 100,000.00 5 Carolyn Dunlap 202 Castile Circle Panama City Beach, FL 32413 Bequest TTP-Jewelry $2,120.00 Taxable Gift within 1 year of death $2,250.00 Granddaughter 4,370.00 Estate of: Rose S. Dunlap Schedule J Part 2B (Page 1) Item No. Description 1 Four Diamonds Fund of the Hershey Medical Center Hershey, PA 1/3 of Residue 2 Hershey Medical Center of the Pennsylvania State University Hershey, PA 2/3 of Residue 21 08 Amount 1,256,046.25 2,512,092.87 Q1/22J2008 11:40 FAX. 717 236 8278 RECEIVED 01/22/2008 TTAN FIRST CODICIL OF ROSE DUNLAP 11:37 I~ 002/005 f, ROSE DUNLAP, of Cumberland County, Pennsylvania, do hereby make this a First Codicil to my Wi11 dated March 6, 2006, WHEREAS, I have provided for certain beneficiaries during my lifetime in lieu of their inclusion in my last will; I, ROSE DUNLAP wish to make, publish and declare this First Codicil to my Will dated March 67, 2006 as follows: 1. ITEM FIRST of the will is hereby amended and restated to n3ad in its entirety: FIRST: I bequeath the following personal property to the person indicated, provided that such person survives me. In the event said person predeceases me, said bequest shall lapse and the property shall revert for disposition under the remaining provision of this Will, All taxes incident to this bequest shall be paid from the residue of the estate. Accordingly, I bequeath: A. To my son, Robert Dunlap, 410 Bear Creek Road, Colorado Springs, Colorado, 80906, One Hundn3d Thousand ($100,000.00) Dollars in cash. 2. In aN other respects, I hereby ratify, confirm and republish my Will dated March 6, 2006 as and for my last Will and Testament. Executed ~~ ire ~ , 2007 l~ - ~ ~-; ~ ~ (SEAL) Rase Dunlap 01/22/2006 11:40 FAX ,717 236 8278 RECEIVED 01/22/2008 11:37 TTAN 1~j003/005 SIGNED by ROSE DUNLAP as a First Codicil tv her Will dated March 6, 2006, in vur presence, who at her request, in her presence and in the presence of each other have signed as witnesses. ~.aw L ~ -c14r e g Address ~i~~b~t.~ ~ ~c~ /,7fatrrc~P ~n~ir~~./ Address,_m±~lrr~L~~ ~~F -2- 0.1/22/2008 11:40 FAX X717 236 8278 TTAN RECEIVED 01/22/2008 11:37 • f~ 004/005 ~- ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVAN{A : COUNTY OF CUMBERLAND I, RASE DUNLAP, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the two page instrument as a First Codicil to my Last Will and Testament dated March 6, 2008; that I signed it willingly; and that I signed it as my free and voluntary act for tfie purposes therein expressed. Rose Dunlap Affirmed tg,and acknowledged before me by ROSE DUNLAP, the testatrix, this ~ day of ('" I c~rc~ , 2007. coax orvw rH o~ P NN VANIA IvaMW aw ae~y e.n~1,~, ~ N°n' Gard Lebrnan ~Y ayc~~rr~„ 6~.1~.27, 20,0 M°'^~~ ~w+nsvw.rda ~sioc;.uon a NoyiryW N ry Public My Commission Expires: J ah~.~ ~7, aor a 01/22/2008 11:40 FAX • 717 236 8278 TTAN RECEIVED 01/22/2008 11:37 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND , I~j 005/005 We, the undersigned, the witnesses whose names are signed to the attached foregoing instrument, being duly qualified according to law, do depose and say that we are present and saw testatrix sign and execute the instrument as a First Codicil to her Law Will and Testament dated March 6, 2006; 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 hearing and sight of the testatrix signed said Codicil as witnesses; and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. ~. a ~' day of Swom or affirmed to and subscribed tp before me, by _ r~Q,~( ~~ ~0 ro.~yn.-~ ~,,,q~„ ar Nor.~es and ,/1` c~ ,witnesses, this Cx~ ~ , 2007. ONwEA~7r~ of PEhM~sYLv~uu~n sir -'^ c~.a ~w.r°~rnlr'rt' N°~'r~ac Na, Lrbenon o~ Notary Publi My Commission Expires: } ~~- 4Ar i+.. ~, •. ~ ..~.. .v ~~ „ .A ~, ~.~. LAST WILL AND TESTAMENT OF ROSE DUNLAP I, ROSE DUNLAP, of Upper Allen Township, Cumberland County, Pennsylvania, make this my last Will and Testament, thereby revoking all prior wills and codicils made by me. FIRST: I bequeath the following personal property to the persons indicated, provided that such persons survive me. In the event any of the persons indicated predeceases me, said bequest shall lapse and the property shall revert for disposition under the remaining provision of this Will. All taxes incident to these bequests shall be paid from the residue of the estate. Accordingly, I bequeath: A. To Mildred Hikes, 419 Apple Tree Road, Camp Hill, Pennsylvania, 17011, Twenty-five Thousand ($25,000.00) Dollars in cash; B. To Sharon and Jim Roach, 2 Rusty Drive, Mechanicsburg, Pennsylvania, 17050, jointly or to the survivor of them, Ten Thousand ($10,000.00) Dollars in cash; and C. To my son, Robert Dunlap, 410 Bear Creek Road, Colorado Springs, Colorado, 80906, One Hundred Thousand ($100,000.00) Dollars in cash. SECOND: I bequeath to my son, Robert Dunlap, if he survives me, any of my tangible household items he may desire, except those which are specifically -1- March ~ , 2006 bequeathed in this will and have not lapsed. Any taxes to be paid on such items shall be paid from the residue of my estate. THIRD: I bequeath to my granddaughter, Carolyn Dunlap, if she survives me, all of my jewelry which I own at the time of my death. Any taxes to be paid on such items shall be paid from the residue of my estate. FOURTH: I devise and bequeath all the rest, residue and remainder of my property, both real and personal, of whatever kind and wherever situated, including but not limited to all assets derived directly or indirectly from my late husband, David Dunlap, or his estate, including any property over which I hold power of appointment (which power is hereby exercised) in the following manner: One-third (33'/3%) to the Four Diamonds Fund of the Hershey Medical Center and two-thirds (66tis%) to the Hershey Medical Center of the Pennsylvania State University, Hershey, Pennsylvania ("Hershey Medical Center") to be used for cancer research. My preference is for Hodgkins and pancreatic cancer research but this is not a requirement. FIFTH: The exercised power of appointment referred to in Item FOURTH above shall include, but not be limited to, the power of appointment contained in Item II (Disposition at Death) contained in Deed of Trust from me to Commonwealth National Bank (now Mellon Bank, N.A.) dated March 2, 1981, as amended, and I hereby appoint the sum remaining (if any) in said Trust in accordance with Item Fourth. SIXTH: I hereby appoint Mellon Bank, N.A., with an office at 2 North Second Street, Harrisburg, Pennsylvania and Carroll F. Purdy, Jr., of 211 Briarcliff - ,..:._, ., ,. -2- March `~~ , 2006 Road, Harrisburg, Pennsylvania, 17104 as Co-executors of my estate and direct that they serve without bond or surety. If Carroll F. Purdy, Jr. is unable or unwilling to serve as Co-executor, I appoint D. Mark Thomas, of 100 Walnut Street, Lemoyne, PA 17043 as my Co-executor in his place. SEVENTH: The Co-executors may receive reasonable compensation for services as co-executors hereunder. The corporate Co-executor's compensation may be, but shall not exceed, its standard schedule of compensation in effect when the services are performed, notwithstanding the facts that bequests are made to charities. I, the Testatrix, am fully aware that I may nominate any person or corporate entity to serve as Co-executors, but have on my own initiative specifically requested Carroll F. Purdy, Jr. and Mellon Bank, N.A. to serve as Co-executors to assure implementation of her goals and objectives. The individual Co-executor shall receive compensation in an amount equal to 50% of my corporate Co-executors compensation, but shall not reduce the amount to be paid to the corporate Co-executor. EIGHTH: Executors, Co-executors or other personal representatives under this will shall have the following powers in addition to those provided by law: A. To sell, grant options to purchase, exchange or alter assets of the estate; B. To enter into any contract without personal liability thereon; C. To invest and reinvest principal and accumulated income in any property which they may deem suitable, without restriction to legal investments, including any common trust fund and to keep cash uninvested; ,, .~ ,~; ~~ -r . ~-f~ -3- March G .2006 i D. To purchase, sell, exchange, lease, mortgage, partition, or in any other way deal with real property; E. To retain, without liability for loss or depreciation resulting therefrom, original property, real or personal, for such time as they shall deem advisable, although such property may not be of the character prescribed by law or by the terms of this instrument for the investment of other estate assets and although it represents a large percentage or all of the estate; F. To delegate powers, discretionary or otherwise, for any purpose to one or more nominees or proxies with or without power of substitution and to make assignments to, and deposits with, committees, trustees, agents, depositories and other representatives; G. To retain any investment received in exchange in any reorganization or recapitalization; H. To settle, compromise, contest or abandon claims or demands in favor of or against the estate; I. To vote and exercise all stockholder's or other rights with respect to any share of stock or security held by the estate; J. To retain property in any form for such length of time as the personal representative may in their sole discretion deem proper; K. To subscribe for stock and bond privileges and join in any merger or reorganization; -4- March ~, 2006 L. To lease and sell property of all kinds for such prices, on such terms and i at public or private sales as they may deem proper and grant options for the purchase or lease of property; M. To pay any death taxes, which may arise from any charitable remainder annuity trusts I may have entered into, from the residue of my estate. N. To retain and compensate attorneys to advise in the administration of said estate. -5- March , 2006 ++ .~ , _ _' I• IN WITNESS WHEREOF, I have hereunto placed my hand and seal to this, my Last Will and Testament this ~ day of March, 2006. This is page six (6) of a six- page will. I have signed and dated the first five (5) pages. ~;, _ _,:_,z_ ~ ,,, Rose Durr~ap - Signed, sealed, published and declared by the Testatrix as and for her Last Will and Testament in the presence of us. s ~. ('' _ ~ r ~, ~t , -6- March .2006 COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND Each of the undersigned, being duly sworn, says: The within will was subscribed in our presence by Rose Dunlap, the Testatrix, on the~,°~ day of March, 2006, at Upper Allen Township, Cumberland County, Pennsylvania. At the time the instrument was so subscribed, the Testatrix declared such instrument to be her Last Will and Testament. The undersigned thereupon signed their names as attesting witnesses at the end of such Will, at the request of the Testatrix and in the presence of the Testatrix and in the presence of each other. At the time of so executing such Will, the Testatrix was over the age of eighteen (18) years, of sound mind, memory and understanding, under no restraint and in no respect incompetent to make a Will. In the respective opinions of the undersigned, the Testatrix was able to read, write and converse in the English language and was not suffering from any defect of sight, hearing, speech or other physical impairment, or from any mental impairment, that would prevent the execution of a valid will. Each of the undersigned was acquainted with the Testatrix and makes this affidavit at the Testatrix's request. The within will was shown to the undersigned at the time this affidavit was made, and was examined by each of them as to the signatures of the Testatrix and the undersigned. Such Will was executed as a single, original instrument and not in counterparts. The formalities or execution and attestation were supervised by Patricia Armstrong, an attorney-at-law. ,cam-" itness ,~ ~~ ~ ~ _u~ itness Sworn to and subscribed before me this C.~Oh1~~tONWEALTH OF PE)`iNSYLVANiA Notarial Seal Carl Eugene Ginder, Notary Public Mt Joy Twp., Lancaster County ~~ Commission Expires Oct. 12, 2007 r,Aembe• a~~nsvwama Assaiation of Notaries C^~////day of March, 2006. ~~L ~ /~-~ f Notary Pu is My Commission Expires: /~-~ i 2- z ~~~ ~~ i- COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. I, ROSE DUNLAP, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the foregoing instrument as my Last Will and Testament; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. t.! i,yu ~C/.~,~ Rose Dunlap Sworn to and subscribed before me by the Testatrix this ~~, day of March, 2006. ~~'~y'+~'EAL:ri OF PENNSYLVANIA i Notarial Seal ! Carl Eugene Ginder, Notary Public Mt..loy Twp., Lancaster County ~y Commission Expires Oct. 12, 2007 .Member ?=nnsylvania Association of Notaries ~ a~~ Z.~ Notary Public My Commission Expires: io - ~ Z -zoo AMEAtQ~I'I' T'0 DEED OF TRUST I, Rose Dunlap, amend my trust dated March 2, 1981, under which ONWFKL,TH the fOo i~,~g:ls ~~ by yoking all the articles and replacing them with "I. Lifetime Trust: During my lifetime my trustee shall invest and manage the Property as a separate trust, and make distributions as follows: A. Payments: As much, even if all, of the net income and principal as I may from time to time direct in writing shall be paid either to me or as I may specify; B. Balance: Any remaining net inco~t~e shall from time to time be acc~mnalated and added to principal: however, C. Di_sabi_lity: If I am, in my trustee's opinion, disabled by advanced age, illness or other cause, as much of the net inco~rie and principal as my trustee may from bane to time think desirable for my or my dependent's welfare, oaanfort, support or emea.~gency needs shall be paid to either of us or pplied directly for those purposes, II. Disposition at Death: my death my trustee shall pay the then-remaining Principal and any undistributed net income to certain beneficiaries I name on a supplemental beneficiary schedule, If that schedule is not accepted by my trustee or if the schedule is not in existence at my death the principal and income shall be paid to or in mast for such one or more persons or on~anizations on such terms as I may appoint by a will specifically referring to this power of appointment or, in default of appointment or insofar as it is not effective, to my personal representative for distribution as part of mY estate. III' Ri4hts Reserv~• I reserve the follow' exercised whenever and as often as I may wish: ra.ghts' each of which may be A• ~ Add: The right to add to this trust with assets acceptable to my trustee; and B. To Revoke: The right by an i nGtnrnent in writing -other than a will - to revoke or amend this deed and the trust hereunder in part or in whole. However, rents must be approved by my trustee. ~' Ma~°e*'-t Provisions: I authorize my trustee: A. RetainJInvest: To retain and to invest in all forms of real and ~ ~l Pr~rtY. including common trust funds, mutual funds and Y market deposit accounts operated or offered by my corporate trustee or any affiliate of it, regardless of any limitations ~ by law on investments by trustees, or any principle of law ~g investment diversification; B. Corrm_ : To compromise claims and to abandon property which, in my trustee's opinion, has little or no value; ~ 1 i ~ • ~• Sell_ /7.~~; To X11 at public or lease for ~Y period of time Private sale, to exchange or to give options for sales or leasesy real or personal prO~y~ and to D- Capital c~am~; ~ join in trust plan or other co ~' ~~~' Organization, voting- delegate discz'etio ~ action of security holders, a~ ~ ~zy duties with respect thereto; E- Al-=te= Tb allocate any P principal or income or P~leach w thout chafe ~ to definim principal and income; and ~ regal to any law F- Distribute: Tb distribute in cash or in kind T~1eSe poWerS shall exte~j t0 all pro shall continue in full force until the as ~ t~ held by my trustee and property, All powers, authorities dual distribution of all such be ~ addition to those granted arad discretion granted by this deed shall authorization. ~' law and shall be exercisable without court V- eT.sation: accorr7ance with a letter amt ft~~ shall receive compensation in or as superseded or amended frown t sx~time-fee ~~ is already in effect a5r'eement in effect, the co ~ the event no separate fee acron~an~ with the standard ~~~ trustee shall receive -nsation in are Perforn-ed. edu]-e of fees in effect while its services VI. Sites and ~~r,,;,Y, Iaw: P~ermsylvania, and all The sites of this deed shall be in the administration of ~etions as to the validity or effect of this deed or Pennsylvania." trust hereunder shall be governed by the law of Executed Q ,..JL~ ~ 3 ~ , 19 9~ , WITNESSES: ~Z n ~S~) Rose Dunlap V The foregoing trus Pennsylvania, on ena~ent ~~ delivered~a~ is hereby accepted, in 2P132 rRn1EALZ~i NATZONAI, BANK By __ ~ • ~ S'L'ATE OF (~ OOL7NI'Y OF C . ~ i ss . public1 - Q ~ ~3 19 `."0, before me the undersigned Personally a'ed ROB flap and in due form of law ac~lawledg~ed the foregoing ent to be her act and deed and desired the same to be recorded as such. Witness my hand and notarial seal the day and year aforesaid. ~~~ ~ Notary Pub c MY Conmiission Expl.reS; RoDat Nodri~l Srd Upper Alm Twpry ~~h ~ ~ Expi-es AW.19,1a81 INf+nDa, P~ Assocatbn MNobriw Commornvealth National Bank _` i 0~1~1 ~;~ Date _-__ ~.`~ _-~-!z _ ~-!_-•------ Cash Amount S ._~~ ~_ _ `~~ ~ `~; Trust Agreement No. _--__!-~~~'ZS-_-v`~~ This TRUST is established between The Commonwealth National Bank as Trustee and the undersigned as settlor. The settlor hereby grants & conveys to the Trustee all right, title and interest in the cash amount indicated above and to any other assets or liabilities set forth on Schedule "A", which may be attached to and made a part of this agreement. In managing these and any other assets subsequently transferred to this TRUST, the Trustee is charged with the following duties: keep the assets safely; use the care and attention which a reasonably prudent man would devote to the management of his own financial affairs considering the economic conditions of the time; advise the settlor monthly of the past month's transactions and the valuation of assets held at month end, and annually of any neces- sary information for the preparation of the settlor's tax returns; transfer the net income each month to the principal of the TRUST for reinvestment, to or for the use of the settlor, to the settlor's checking account as indicated below, or to other persons in amounts described in a separate letter delivered to the Trustee. In addition to those powers granted by law, the Trustee may exercise the followin the above duties: receive proceeds from the sale, maturity, call or conversion of TRUST asosetssinves~ n and buy or sell assets (including real or personal property, common funds managed by the Trustee, and obligations, de accounts, or stock of the bank or its affiliates) subject to the settlor's guidelines indicated below; borrow money at reasonable rates and pledge TRUST assets as collateral, should it be prudent to do so; pay any necessary expenses, including reasonable Trustee's compensation; allocate transactions between income and principal as the Trustee deems best; and handle routine matters according to the Trustee's best judgment, including but not limited to making timely exchange of temporary issues for permanent, executing proxies or voting shares, buying or selling fractional shares, and exercising, holding, or selling warrants representing rights received in corporate recapitalizations or reorganizations. The settlor may alter or amend this TRUST in any way provided that such change does not result in making the TRUST irrevocable or creating diapositive provisions to take effect at or after the settlor's death. The settlor may add to or withdraw from the TRUST'S income or principal at any time, subject only to providing reasonable notice, and may provide for automatic funding by indicating below. The TRUST shall terminate upon the settlor's death with principal and undistributed income bein income or 9 Paid into the settlor's estate. The Trustee may expend TRUST principal in behalf of the settlor at his direction or in behalf of any named beneficiary to the extent of his beneficial interest. Only the settlor shall have the power to assign or encumber his interest in the TRUST or other- wise cause its assets to become liable for the payment of a beneficiary's personal obligation or debt. The Trustee is responsible for losses caused by its gross negligence but not for other losses such as, but not limited to, those created by fluctuation in market valuations. The Trustee is not required to account to anyone, except as described above, unless expressly directed in writing by the settlor or his personal representative. Either party may terminate this TRUST at any time, subject only to providing reasonable notice. This agreement is not binding upon the bank until such time as it has been accepted by an administrative officer, who will be assigned to the TRUST; this officer will be in contact with the settlor and may be called upon by him ~ „1 at any time. r Trustee's discretion ~~~INVESTMENT GUIDELINES Commercial paper ._________- Treasury bills ~(~:~:-__ Taxable bonds ___ Tax exempt bonds ~"'_ :--_:~, Common stocks INCOME TRANSFER ______.___. For reinvestment ---- To checking A/C ----~__ To address shown AUTOMATIC FUNDING ()The Trustee is to charge my checking account S _••-___ --•-----•------•------._ on the -------------•----------. of each _ and add it to this TRUST for investment ~ 3~- /2 G Phone No. -"-' 7-9-io Date Oi Birth Soc. Sec. No. Occupation ---- -•------ --- igriature -- Printetl name -- - Slreei address ---"-'-"--"------- City. State ~-------------- ~p Code ~~ --------------- Checking Account IV O. - -'-" O~YOUR ATTORNEY CAN PROVIDE LEG ~DVICE MUNN'S diamond gallery Appraisals Prepared For: The Estate of Rose Dunlap July 3, 2008 1•, 1203 Market Street Lemoyne, PA 17043 R (TT7)- ~ax (717~- 1-87~'-;p C~ t_' ~.,. ~~. : ~. ~... 4~. ,:.ye_ d r µ ~t ~ MUNN'S diamond gallery ESTATE APPRAISAL INFORMATION The enclosed appraisals are ESTATE APPRAISALS. Estate appraisals are formal evaluations that are used only when an estate is being settled and a fair market value determination is needed for tax purposes. Fair Market Value is a term that is reflective of an item's current condition and demand in a second-hand market, resulting in a value considerably lower than the item's purchase price. Fair Market Values differ from the more common Insurance Replacement Values which are used to insure and/or replace items with like kind and quality at an average retail price. *Estate appraisal values should not be used for insurance purposes. ~['he Federal Trade Commission defines Fair Market Value as; The price at which a jewelry item would change hands between a willing buyer and a willing seller, neither being under any compulsion to buy or sell the item, and both having reasonable knowledge of the relevant facts. Note that all jewelry appraisal determinations are limited to the extent that stone settings and mounting characteristics many times obstruct the access needed to obtain exact carat weight estimations and quality gradings. ~~ ~` ~~ 1203 Market Street Lemoyne, PA 171143 t777)- ~ax CT17a- 7-877-;D ~#~~'ai~al MUNN'S DIAMOND GALLERY, LTD. LesdittQ to Diamond Styles 1203 Ma-lcet Street LEMOYNE, PENNSYLVANIA 17043 R1>? ~s~-es~o TO WHOM IT MAY CONCERN: This is to certify that we sn engaged is the jewelry business, •Pp~inB dianwnds, watdtea, jewelry rind precious atones ~ all descriptbns, We herewith certify that we have this day carefully examined the following listed and described ardcks, the property of: 1fie Estate of Rose Dunlap NAME ADDRESS We estimate the value as listed for insurance or other purposes at the current retail value, excluding Federal and other taxes. In malting this Appraisal, we DO NOT agree to purchase or replace the articles. ~~~ ~ ~ ,~t it [~ '~ } 7f -;i , 1 yr~ r~ ~ $o~"1 t~.,#.t~c ~ti ohm . ~~ i -!. r j - ~ ; . ~ let i. ~ !. a r' ~^4 t~ Y~ +~ ~~r~~ ~ c a 1t z ~ih ~ 1 r t ~ ,_. ,,. .. ~~y~ '~ yy'~ i. ~ t~ t ,~ A ~~ ':~ 1 I r -r~ib~'~-~~~ ~~§~}~~F,tikd ~.q~~ ~ ~,.~`~~ ~ '1,4 ~;~..511(1 ~. 5', ~~ t~ ~ ! ~ ~T~. ~:~r ~~k ~ ,Ft4 y, r {1~rtr Iri 4f. r ~ i ~ r ,~ ~ rho ~liS r ~N .'t} 4 sq.~,.~£ i, ~,,(j y r l~q]~j, f `~i-fr,i; r ~" +- ~ - ~~ s ~ '~1 ~~~"!~ t it ~J ~ 1 ~rll~,;+ f~ -3~~~iF J~R~;7~:~•- ! ~ F ~l~y ,.,~~. 1 ~r 1O4 ~s[iVig'if'~.1~{/t i! ~, ~~r~~'. 714 r ~;~.~si` ~.. ,, ay~Lr~ }~,~tA ~ o'r'tt~it~.'~ ~'1~r, 5i i J ~r7.^°'it ,. 1,~~~~~~4 ~{~~YS~ •~y~~ i'~ S~~y, ~.j~ ~ ~. ~ J { Ylts ~E_11~"7" ~~1T~`~~ ~7,i"'~1"f' ~ ~ r,{tv~ ~ .?VTV~ ~ L.'I ~u7 :."~• t~, ,y~..t r~ S ru~a t ti ~! ~ ~~y ~~ y t rj r,+ ~ fi .-, 4 " ~ ~ , 'ri'~f'f'd`F~t ,~~ sll~ ~~,,f tit + t '~1~~ t i ~ ,-,k t t ~~ r at y ~ ~ t ,b k~r ~ y {{~ r g ~ ~ ql"'1~ ~ i ¢ ( ~ '~'1~ 1 r t ~' ~g+~ tir ~'E }~ 't ~ ~ 4 [ ~a~ 7 • 7 ~i .f . ~ <''1 3"~a ~!J~ ~~t ~ -; z. 'ril ~+^'~i A ~" .;~~~ 'K ~i{i~~~ ! ~~ ~(i ~f ~~~ .i~~i°'~l t 'lr ~' 1 it ii `'e,NZ ~q~ ' ~~ir !yrK!~~1~7~4'~"`~~3r[~i ~. ~~ 'x~~ ~~ ~ 'ir;~t `Sl',,~~4~ E j ~{~+~~~`fi'+~'SY ..,ti.F. ,: ~' .. ''~~ ,.3>. i.t_ik' 3,,,e.,~" +~,~'[~',° `~ZLir ~ ~ {~~ ~i j~Lf3~'r. The foregoing Appraisal is made with the understanding that ttfe Appraiser assumes no liability rvidi respect to My ~~ that en on the basis of this Appraisal. P u`~ ~, ~.oc~ APPRAISER D TE ~ 3 ~ ~ ~ ~r~-oo-0e DSCN56~ ~' ~. - sue:.. ~,~ ,~~~_ ~ ~" ., , .~~,.~'` ~ t ~ ;~ „~ ~~ .. < ~ tC 7 ~' .. r _ / " ~, . DSCN5690.JPG 0000/00!00 00:00:00 ~ ~ ~ ~ ~~~ ~' ' ~~ ~ ~ '~`' ~`''~ /C ery 4Ls ~~ :4, F X203 ~Natk~tstreet ~emoyrne;~~~17t143 MUNN'S DIAMOND GALLERY, LTD. Leading in Diamond gtyMs 12x3 Market Street LEMOYNE, PENNSYLVANIA 17043 (717) 7$1$310 TO WHOM IT MAY CONCERN: 'T'his ~ to cxrtify that wt are enga;ed in the jewdry business, appr~~ precbus stoaua of all ~riptions, diamonds, watches, jewelry and We herewith certify that we have this day carefully examined the following listed and described articles, the property of: NAME The Estate of Rose Dunlap ADDRESS We estimate the value as listed for insurance or other Federal and other taxes. In making this Appraisal, weuDO NOTta ree to t retari value. excluding articles. 8 purchase or replace the z~, , o ~ ,. y t~ Ri r,~ ,. itt r s tt '~r ~(i ~7Y~7 u~ '<.f~ t~ r~~~ '~ E~'~ ~r ~~ `1'Tr~S~ ~~5~-~x ill fie ~5~'+s~~~ ~i ~~~! ~ ~ ' ~~~~ ~ ! . `~~ 11R]T[XA ~f1~ ~t' • l ~ 14 `F~ ~ y.µ- ~ ~ ~ ~ t L ~ I ~ F~ l ~ ~ t , ,,. ~ y y y ~ t ' ~ . VWI-J ai+r•~j}\A~, a , ~ K ~i `i~ y j, } t.~ t 4 ~ i l ~ ~ i ~ ~ ~ ~ ~ , , ~ z r ~ , s~ ~ ~, ~ >> `` ~ .9r, '^~'f . ~ ~ iii ~ ~~ r ' . ''` t t t ". t' .t ~ .' .T 1. `.t1 7~.~l. ~ ~ , 1 t ! ~ ~ t it t ~ ;, ~ '' j li~~i~{~~~ ~ ~ t T i7" ., i , ti .s ~ 3 y_ t , ~ , w ~~ ~ t s.. ~y, i _ .. ~~I SS~,i 1~`~yu~. ~f ~d y,~~~ ''p1 t~ ~ + t. }ryyi;y~ fts .'~ ~lr ~. J _ ~ i` ~ ~ . ~ ~ 1~ ~ ~~ ~ ~ ~~1 ~ f;4 ,, r f-d ~ ~f~l . ~x ~ (` ~ ;~~yy ~ Y , ~y 1 t Fr ~~~ ~ 4 tP ~ ~ }i f`I. d ~ 2 ~ ~: h t:.o.> ~' t t ~ ~f } t "Z rT'. ~.,}9 S a - 51 Ni -~~ ~ ` b ` ~~~ ~ ; ~'~._ . t ~.yy,~~ a lA t~~ s'P ~,~ ~ ~ t~ La~; tt" yz t "~ #~ ' "` ~ ~~ t r k~ r{iii fl1r ~ ,,. •~r i l. i t ~~ r~~' ~~ hid '~~°'~ ~C' ~ ~ ,4, ~h t w ~ ~' ~ , ~ ~ ~~ .t x ,~~~5S!! . ~ 9 ~~~ ~ ~. ~ .~, .~,. ta K ~ ~` ~~ y~ti '4#" y , ~ aArt'Id ~ ' ~~ +, i'Hj f '+ , i ~ ~~~ . ~ f ~. »c ,`, 7 ~~ 3"~ 4 .1 t e S'•.; i~k1't t ,' ~ ~ ~ fly! ' yr ,, :~ tc~ t _ 1 ~ ~ 1 I* .lr•~ a :)„ ~ ~ ',~.t~i t ~ jr ~- ~i N k t :(~ ~; -1 e ~ l !''i '~^' _ ~h ~ ~i 1. 4t t ,~[l ~ ~ ~ ~ ~ 5 . ,Yt ! ! s ~ r t ~ ;6ry f~5 c n .'i ~. , _ £ - I. 1~r l~ •ifF~a. ,~~~li~ ~_ {~ ~ Th f ,- g y '!'n'f ..~ ;~ c1 r . ~? e oregoing made 1Yith the wnd~andirrg that ~ ~ an A~~ s3somea no lia action th , . ~ . ,.. bnlrt ith y y w at pq respect to on tha basis of t#tis Appraisal. SER --~~~ DSCNSfi! DSCN56! /C '~y 105.605 RFV t01/07j a LOCAL REGISTRAR'S CERTIFICATION- OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. gee for this certificate, X6.00 P 14120807 Certification Number This is to certify that the information here given i. correctly copied from an original Certificate of Deatl duly filed with me as Local Registrar. The origins certificate will be forwarded to the State Vita Records Office for permanent tiling. ~r~i~-- JA Z 5 08 Local Registrar Date Issued I REV t120g6 !PRINT IN COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS MANENi iCK INN CERTIFICATE OF DEATH (See inatructlona and examples on reverse) 1. NuM al Detedsm (Flw, rnldt4. Ia«, sulfixl STATE FILE NUMBER U _ it , I A r L ~ ~ 2. Sav 3. Social Seanry NumWr 4. Data of Death lMonm. day, year) s. AAe (last annaey) Lhger 1 r lJ uUnm'rV1 m s. Dare a Blnn (Moan. da . r) 7. & ~ ~ ~•~ - ~ U- 'ii~>'S~,Z, JfI/1/,;/ f4;E'Y / 9 -Z C/Ud 9 Maaw Iby Naar rmplaz (Ci and stire a coax7) Ba. Place d Deem (Cnedt dny one) 7rra. Ju.~ Y 9 i 9/U />~Te.e ~ Sa ~r,~G N~ilal: soar: • ee. cam y dr D.am ~. c; , ~r°. T r ~ ti',v " ' UR n/ /R ^ lnpatgnt ^ ER / odpanem ^ ooA M w. of Deem Btl FeaMy Name (S M irubnaron, Aka street erM naMa) ^ Nursing Moms ^ Raeitlanca omen - Spaey NUS /' r::.L Fl U ~ H I ~ 9. Was Dacedml d Hispank Ongin7 No Vas - • `~~ N SQ U E h~ l~ /V r V s'{ ERR e aYrJ CQa X TU,J .S•A.R NE %1T(7-i/~TC E REI.'; ~aFN:-E (Me,ian~xto Rkan. «a) ^ io. Rec.: amancan In6en. Brace, won.. ea:. 11. Daaded's Usual (SOaaM Hind a wall done du mo« a We. po rp1 Wre re ~ 12. Wee Daoetlad ewr m ms 13. Dncedanr• Edueolion lL' H I '~ Kira a Work Nwle d 8u«na•s! htltulry U.S. Amlee Faces? (~°Cm' 0°y nrena°t Awe carpereo) 1 d. Mamal Sretua: Monied, Never Mertge, 15. Sumwn ~V /Yf C M /}KE~' EMrtlenlery / Secondary (P12) Co Widowed, Divorced 9 Spouse Ilt wqe, give maiden name ~C in c MR J~y~vll L- $(rea ^No Me9e (1~d as.) (Speciy) ) a t5. DerxdantS MeaktA Addr~e (Sire«, coy l tam. sate, zq coos) lZ C(// !~ G W Fd 7 c'O NI T. DecseenYS Did Decades h~ ll-[=N' +~,E' r' u c Acn,r Reaid.na na sure !~E N.V ~ ~'.i.U /j N i /a n Mcc:p/~,v/~ ~ Livain~a 77d.~v.e.DaeeentLwedn_ u/lf'E/P /7LL~-"/v r SL3U~'4 R /7C',-S 17bCounry_t,'(//77~C/~.(/~//r:) town z wp 18. Femer'e Name (Fist. middle, lat. sueik) 17d. ^ No, Decadent Lived waM - Adu« Limb of Csy! Born /tit G /~ kJ r S' S -/ /Vc t9. Modyr'e Name (Fr«, minddle, maiden wmame) 20a. InlormanCS Name (Typenr Pad) J- ~ A /3 L GI ['~ v? J !?E C..=//I/~ L ~ M /~. TZ lob. mlamrm's Meaaq Adae>s (StrsN, mY /Corm, stab, zp coda) 2te. Methods Dieposilipn aem.eon Daleown /`0 ~aX %S('Q /tfi-2r2/.~ !3 W,e C- >>yl r 7i C'( - epcelllon (Name a cam«ery c f Y SC C; ^ Burial ^ Removal Iran State ~ 27b. Dxe a Dlepoaltron (Napo, day, year) 21c. Place of Di remelay a amer place) 21 d. Ladlron (Gry I town, stele, zp meal ^ Omer. Spsay~ Wu Cralllatltrrl or Dolutlon AWnrWd C 'by Medeal EaranMNrrCaonely ^Yes^NO •.JANN Any 1S, :2 U.p ~rH Cy. N2E fr1AT0 k'_y' ; ~ 22a. Sigr. pl Funeral Service Ljceasee Paaon warp as such) 22b. Liprl•e Ntnlher G T-:r)N~ L•I t_rx T r/ ~ / ~ v Z tj. -?S~/~/ . JJ 22c. Nrro aM MM1eee d Fsoifily • -c'( J"-s'U.-,`%i 4.3L ti/. U~GrG[.~ /~/m~~,EL r-u.vt-~'~/J-L .~a~ r /Y7/a~ ~ T.~:~Ci=Gi Conpwe Nerrw 23eK when artXyaq 23a. 7° Igay~p a f-19i17 E r ptly«Iien a m avafeeb n ume a seam ro \, "'y ~"~°. ~ °~""~me . aw end pace awed. lSiplSUre and tinel '~/:. ~fhL~ / S f3 t f.~ C• PA / 7 , .,; aMy cause d deem. \'\ ~ ~ `A \\ 23b. Lioenee Number ~J 23c. Dale S 1--7 `V ~\ \ ~ 1 ~ ~ ~ \ 5neo (Monm, Tda+y~.' rear) ~ Irern• 2428 mule W mrrlp•ISd by penon 2d. Tana a Dwm 25. Dare Prmaatcad Ond Maas. d , N \~ `/ `~ woo Drortota¢m deem, i /\ ~ M \ Y ye«) 26. Was Case RelanW V \ ©~ edkal Examiner / Coragr !or a Reason r than tion or Donation? CAUSE OF DEATH (Sea Inatrucllona anal a:amph•) ^ Y•s No hem 27. Pan C Enter IM ~ d avast - r Appresimare mlav«: Pen II: Enter omen reapk«ory arteg, a venlriNer fibraewn - ~ ~tud1' ~~ the deem. DO NOT emer tanmal av«ge sum as cards( arrest, ~ 28. Did Tdseap Use Contribute to Deam7 (F'apI slKaaaq me emklgy. Lal ady one c«aa an each ins. Oreel ro Deem bd rat resume! In dk wlearMng cause gvan h Pert 1. Yes Pr m 6aoaui r~ewp~nUg~deodli assess a // r ^r~r~ ^ °o'aay -~ a. ~~ ~l,~Q~'~~~ ~ ~ L~ r rCJ ~ ^ Unknown `Jaen (a as a ~,,, r ~ r r 29 II Fertwre. s.a.mi+M i« i ~' 6' 1 ~ -~t Megnent wlmin pant yea, ro tlw twee feted m IFIe a. Enbr UNDERIyIIp~CAaUdSmE• Due to (a as a consepwlca of): ^ Pregnant a1 !Imo of oealn (w«~'m rewMg~n~d~m) {,AST. c. ^ Nd pegnan;, Inn pregnant wean 42 Days ore n la as a cornea,ence d1: a seam d r ^ Not pregnant. out pregnam aJ days Ia I year age. Wu an ' o«ore deem Porten A~dopsy 30D. Ware Alnmsy Fintings 31. Msnner d beam 32a. Date d I ~ ^ Unkrpvm it eAnan past AvalwlN Poor l0 Congssnan Mary IMmm, day, year) 326. OeecrAe How In Occurred M I wnnn tM year d Cause d Deam? ^ Naar« ^ Homiode 32c. Place of Iruury Home. Farm. Street. Fanay. DIN a B ^ res No ^ tae ^ No ^ Acudanr ^ Pen6ng Imesogatian 32d. rlme of I uwng. NC r~c''Nl ^ItM' 32e. Inasy al Nbk? 721. II Traneponatim Injury i$pw,yyy) ^ Suiade ^ case Na w Determmw ^ Y« ^ No fig. loglpn d Inlury jSlraet. m'y ;town. stare) M. C Dmrer l Operate ^ Passenger ^Pedestnan 77a. Cenitier jtnanA my one) Amer. $p~y.~ ' ~KYmA MY~lan (Ptrysipan cMirylnq Uuee of seam wMn ananer pnysloan nee prorlourlCad deem arq 336 Sipl6lixe Idle d Cenmx c To IM p•« a my krwMadge, dam attuned dw to tna G canpbled Item 23) ~ . • Pronotncmg and cerdryirg physklan Pn u•elel aM menrw a. •61er1, _ _ _ _ _ _ _ _ _ _ .Z L /,~~J. \l~,~ \ re lM beat of know ( Ystcwn ban prorpuraxp deem arts caNlyvtg to ceus•ddmtnl -----------------~~-- i(,L/ ~GL.. C~]V my I•dg•, deem occumd « the Nme, am. eM place. •nd due to the (suss(.) and manrwa ass - _ _ ~ - - - ^ ~. Ucense Numoer • MWkN Ex•mirrr / C roorwr t•tari_ _ _ _ _ _ - _ ~ 73d Dale Slgned rapxtm. Jay, yearl On tM Wais of esaml tlon end I or inve•ti ~ ~~ ~- / g«ion, in my °pinww, es«n occurred «In• gm., dau, and plan. •nd dus to the uuw(•l ana m,nnr w mterL ^ U 35. Regslrar's $ 34 Name and Address o aIM Dutnct par y / W/~o,C'o(rpkl/ao~C~ause I~\@a-mC{Jllam 211 Type I Pnnl ~~ I '~L-I ~ I ~ I / I / 36. Da1s R (Mm .say year) ~i7i71. / ~ylHG G~ .`T