HomeMy WebLinkAbout03-1073 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
also known as To:
Register of Wills for the
Deceased. County of ~tr,~<~,~,b in the
Social Security No. ~0 ~ -~6- qq ~ Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, applt~ for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decendent was domiciled at death in ~3~ ~-~ ~-~ County, Pennsylvania, with
h ~ last family or principal residence at I0~ A~
~0~?~- ~ ~ ~' (list street, number and municipality)
3E' ye~s of age, died : ~c~ i~9 ., ~ ~6~ ,
Decenden~ then
Decendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property $
(If not domiciled in Pa.) Personal prope~y in Pennsylvania $
(If not dOmiciled in Pa.) Personal property in County $
Value of real estate in Pennsylvania
situated as follows:
Petitioner.__ after a proper search ha 5 ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name Relationship R~s~denc4.'
I
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
~,~ PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 28060 INHERITANCE TAX RETURN
HARRISBURG, PA17128-0601 RESIDENT DECEDENT oou,, coDEI --
DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
III DATE OF DEATH iMM-DD-YEAR) (3 [ DATE OF BIRTH (MM-DD-YEAR THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
U.I ~,7.. '~0- l.Oo3 I 0'3 [0~-~ ~"'tZ.~ REGISTER OF WILLS
U.J (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
I-~1. Original Return I'---] 2. Supplemental Return [~ 3. Remainder Return (data of death prior to
12-13-82)
LLI
,Z, O:: '"' I~ 4. Limited Estate [] 4a. Future Interest Compromise (date of death after 12-12-82) [] 5. Federal Estate Tax Return Required
,,~ ,', o
I---] 6. Decedent Died Testate (Atiach copy of Will) [] 7. Decedent Maintained a Living Trust (At~ach copy of Trust) __ 8. Total Number of Safe Deposit Boxes
C)
,-,
Il.
< [~ 9. Litigation Proceeds Received [] 10, Spousal Poverty Credit (date of death between12-31-91and1-1-95) [] 11. Election to tax under Sec. 9113(A)(AttachSchO)
I-
Z
Z""LU NAME ~1.~'~$ ¢~,,t,.~_,,~,~ COMPLETE MAILING ADDRESS
FIRM NAME (If Applicable)
TELEPHONE NUMBER
o
1. Real Estate (Schedule A) (1) ~
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) ~ '
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5) ~ I~).'-~-~
(Schedule E) .._,
6. Jointly Owned Property (Schedule F) (6) ~ ~-~ ~
~ [] Separate Billing Requested
~) 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) --~--
I-'" (Schedule G or L)
,~ 8. Total Gross Assets (total Lines 1-7) (8)
UJ 9. Funeral Expenses & Administrative Costs (Schedule H) (9) /J~'7.
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 (13)
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
Amount of Line 14 taxable the
1
5.
at
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 __ (16)
I~. 17. Amount of Line 14 taxable at sibling rate x .12 (17)
O
(.) 18. Amount of Line 14 taxable at collateral rate x .15 (18)
X 19. Tax Due (19)
Decedent's Complete Address:
STREET ADDRESS
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments (1) ..,~._._.,
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Interest/Penalty if applicable Total Credits ( A + B + C ) (2)
D. Interest
E. Penalty
Total Interest/Penalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT,
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due.
(5A)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (SB)
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.. . ................................................................................... [] []
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?
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 FILE IT AS PART OF THE RETURN.
Under penalties of perjury, 1 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.
S 6N^TURE OF PERSON RESPO,S B,E FOR F L N6 RE -URN
ADDRESS
,U a.
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
ADDRESS
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 3%
[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 0% [72 P.S. §9116 (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 the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [72 RS. §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 4.5%, 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 12% [72 P.S. §9116(a)(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.
REV-1511 EX+ (12-99) _ ~
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE (::OSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES: r~
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. Attorney Fees
3. Family Exemption: (If decedenrs 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.
TOTAL (Also enter on line 9, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
Nationwide
"The Simple Digrtified Choice" 1-800-722-8200
12-11-2003 231393 JL-5
Mr. Charles E. Bartch
48 Butter Road
Dover, PA 17315
Beverly J. Bartch - Deceased
X Direct Cremation $995.00
Special 48 Hour Or Weekend Cremation Service
Nationwide Guarantee Program
Worldwide Travel Protection Program
Private Family Viewing/Witnessing Cremation
Cremation Container
Medical Documents/Courier Fee
X Meadow Green Marble Urn with Engraving $255.00
Urn Burial Vault
Arrange For Burial
Personal Delivery of Cremated Remains
Arrange/Deliver Remains To A National Cemetery
Scattering Charge
Packaging And Forwarding Cremated Remains
Express Mail
X Certified Copies 5 @ $2.00 $10.00
Register Book
Memorial Folders
Thank You Cards #
Memorial Service Package
Flowers
Newspapers
X Harrisburg Patriot $112.85
X Cumberland County Coroner Cremation Approval Fe $25.00
DNA Preservation
Other
Other
TOTAL $1,397.85
1-14-2004 PAID $1,285.00
BALANCE DUE $112.85
www.cremationsocietyofpa.com
~v.,~E×.<~.9,, ~ ,,,,ou SCHEDULE E
BANK
&
MISC.
COMMONWEALTH OF PENNSYLVANIA ~,on,
INHERITANCE TAX RETURN
RES,DENT DECEDENT PERSONAL PROPERTY
FILE NUMBER
Include the pro~eds of I~gaaon and ~e date ~e p~eds were re.ired by ~e es~te. All pmpe~ ]oint¥o~N ~ the ~ght of su~ivomhip ~ust be disclosed on ~hNule F.
ITEM VALUE AT DATE
NUEJBER DESCRIPTION OF DEATH
TOTAL (Also enter on line 5, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
12--22-2003 Checking Account Inquiry Next display: ,0,5, 20-0700-4
11::05:11 Current Statement for: 100283472 DSPBR01818
Bal as of 11-30-03 466.47
BEVERLY J BARTCH +Dep/CR: 1 675.00
1065CALLENDALE RD
MECHANICSBURG PA 17055-4464 -Chks/DR: 7 722.70
-Service charge: .00
+Interest paid: .00
Current balance: 418.77
Pst Dt Serial Number TC Description Amount Balance
Str/Run/Bat/Seq#
X Elf Dt
120103 1264 081 CHECK 37.55- 428.92
120103 1270 081 CHECK 20.15- 408.77
120303 018 US TREASURY 303 675.00 1083.77
120503 058 AARP HEALTH CAR 127.00- 956.77
120503 1268 081 CHECK 77.00- 879.77
120803 1273 081 CHECK 300.00- 579.77
120803 1271 081 CHECK 126.00- 453.77
121003 1272 081 CHECK 35.00- 418.77
Bottom
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA ~
COUNTY OF ~~ ss i/i~ ~-~-:
The petitioner(s) above-named swear(s) or affirm(s)that the
statements in the foregoing petition are true and correct to the best
of the knowledge and belief of petitioner(s) and that as personal
representative(s) of the above decedent petitioner(s) will well and
truly administer the estate according to law.
Sworn to or affirmed., and subscribedf ~ 6-~--
befm:e me this ~t ~ 6~? day of I
No. ~/-t~,.~o/~ 7~,
Estate of ~v~ t,0 .~ I~g ~.~ .1~ , Deceased
GRANT OF LETTERS OF ADMINISTRATION
ANn NOW c', c~ ~ ~ ~ <? ~ ~ ~~, in consideration of the petition on
the reverse side hereof, sat~factory proof havi~been presented before me,
IT IS DEC~ED that (~L~ ~ ' ~T~
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to
in the estate of
FEES
Letters of Administrmion ..... $
Short Certificates( ) .......... $ ~. ~ A~ORNEY (Sup. Ct. I.D. No.)
iation ................ $
TOTAL ~ $~ ADD.SS
PHONE
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Local Registrar
P 9 8 1 1 7 0 8 ~~~~ DEC i ,5 2003
No. ~ Date
R~ ~a7 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
NAME OF DECEDENT (F~rs~. M i~,e, La~l) ISEx ISOCIAL SECURITY NUMBER E]~F ~H~ __' . ~. '~}
,. ~ *~. ~ ,,.
I se
~ C~b~land ..E~ Pen~boro Igl~
~065 Allend~e Road Apl. C,,~
,t Mechanrcsb~g, PA 17055 · . ·
,~.~ Cumberland
,,. Ch~les Wrl' f.(c~' H~k [,,. B~tha Elrzabeth' Shenk
~. Ch~les E. B~tch [~ 48 Butter Road, Dove, PA 17315
_ ~U ~,~ ~.~ P~.~,.~ I~ C~ema~ton ~oele~ o~ I
~~A ~~~' ~ J~. I~. 4100 Jonestown Road. H~r~b~O, 'PA 17109
~ IT~ ~ _. ~ I ( ~. ay. ~)
I~.
~(~y c.
~SY J~NER ~ ~ATH ]~URY TIME ~ ~URY J~URY~ ~? ]~ ~I~Y~D.
~ ,.~ c~ ~" I". I~. I
'MEDIAL ~AMINE~CORONER
~..~,.o, .... ,..,, .... ~o,, .... ,,..,,~.,..,o,,.,o.:,Tt,.UyyyF.~t,.,.~,.,~..,.,....~,, ..... ~,.~,.~y~y~).~
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Date ofDeath: ~. /iQ, ,~903
/
Will No. q~ ~ - 0 ~.~- [ 6~'~ ~ Admin. No.
To the Register:
I cegify ~m notice of (~nefiei~ intent) es~te a~ffistration required by Rule 5.6(a) of the O~h~s' Cou~ Rules was
served on or mailed to the following benefici~ies of the above-captioned estate on :
Name Address
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Signature
Name
Address ~ /~[0 *o~t
Telephone ( )
Capacity: ~( Personal Representative
__Counsel for personal representative
JRD/June 30, 1992/17858
t'l^Y 0 6 20114 ¢
In Re: Estate of BEVERLY J BARTCH · ORPHANS' COURT DIVISION
Late of UPPER ALLEN TOWNSHIP · COURT OF COMMON PLEAS OF
· CUMBERLAND COUNTY
Estate No.: 21-03-1073 · PENNSYLVANIA
NO. 21-2003-1073
NOTICE OF FAILURE TO FILE CERTIFICATION AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT
ORPHANS' COURT RULE
Personal Representative: CHARLES E BARTCIt
Counsel for Personal Representative:
Date of Grant of Original Letters: 12-30-2003
Date of Delinquency Notice: 04-09-2004
The undersigned, Glenda Famer-Strasbaugh, Clerk of the Orphans' Court, in accordance
with Rule 5.6, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court
Division, Court of Common Pleas of Cumberland County, that neither the above named personal
representative nor the above named counsel for the personal representative have filed with the
Register of Wills or Clerk of the Orphans' Court his, her or its certification required by Rule
5.6(e), Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 5.6(e),
Supreme Court Orphans' Court Rules, was given by the Clerk of the Orphans' Court on APRIL
9, 2004, and that the ten (10) day notice to file the certification has expired. Accordingly, in
accordance with Rule 5.6(e) the Court is hereby notified of such delinquency and the
undersigned requests that a Court conduct a hearing to determine whether sanctions should be
imposed upon the delinquent personal representative or counsel for the delinquent personal
representative.
Date: 05-06-2004 _~l..a.~M~~
Glenda Farrier Strasbaugh-~S~C')~
Clerk of the Orphans' Court
Distribution: Personal Representative
Counsel for Personal Representative
Estate File
A heating is scheduled fo at in Courtroom No. 3. If the Certification of Notice is
filed prior to the hearing date, the hearing will autom~
Geot~ge ~. I-toWer, ~.J: '
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF IND~I~'1~~~~iCE OC
INHERITANCE TAX ~QN:~..../L_--, .j. I . ;.... I
PO BOX 280601 l'~:"f\:':' '~ (I
HARRISBURG PA 171Z8~06iJ1i .'J
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
01-17-2005
BARTCH
12-10-2003
21 03-1073
CUMBERLAND
101
ZuGS J!\H I II Pi: 3: 14
C E~)I( r\:
L~I',i\ U,
~..R..'~'.' :.^'~'C',~ nl..i~.'.'T
'"",I,...... ",.. n i
CHAR,' .;'8 ~i;:fl,,'.
48 B 'fER RD
DOVER PA 17315
*'
REY-1547EKAFPI12-B4l
BEVERLY
J
Allount Rellitted
I CHANGED
III
121
131
141
151
161
171
.00
.00
.00
.00
418.77
.00
.00
181
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO CDURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
Ri.V' :r~~-Ei<--AFP--Cil1":cl'!".NiiT"icE.oF.i:NiiER-ii'Al(cl.'''Ax.A.PPRiiiSEMitl':..ALLowANclf-o'R......----- -- -...
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF BARTCH BEVERLY J FILE NO. 21 03-1073 ACN 101 DATE 01-17-2005
TAX RETURN WAS: I X I ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate {Schedule AJ
2. Stocks and Bonds (Schedule B)
3. Closely Held stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable {Schedule DJ
S. Cash/Bank Deposits/Misc. Personal Property (Schedule EJ
6. ~ointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Hisc. Expenses (Schedule H)
10. Debts/Hortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequestsj Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
NOTE: I~ an assessment was issued previously, lines
re~lect ~igures that include the total o~ ~
ASSESSMENT OF TAX:
IS. Amount of Line 14 at Spousal rate (IS)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
1,397.85
.00
1111
1121
1131
1141
191
1101
NOTE: To insure proper
credit to your account I
submit the upper portion
of this form with your
tax payment.
418.77
1 .397 8~
979.08-
.00
979.08-
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
.00 X 00 =
.00 X 045 =
.00 X 12 =
.00 X 15 =
(19)=
.00
.00
.00
.00
.00
.AX CREDITS:
~AY"EN~ "C~CH , 1+' AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID I-I
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
* IF PAID AFTER DATE INDICATED I SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
I IF TOTAL DUE IS LESS THAN $1, NO PAyMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI, YOU MAy BE DUE ~
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIDNS.I ~~
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 11/01/2005
BARTCH CHARLES E
48 BUTTER ROAD
DOVER, PA 17315
RE: Estate of BARTCH BEVERLY J
File Number: 2003-01073
Dear Sir/Madam:
It has come to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by: 12/10/2005
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
~~~
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
cc: File
Counsel
Judge
\Jb
STATUS REPORT UNDER RULE 6.12
Name of Decedent: {)e.\J{"'~ ,J 6Clttd1
Date of Death: UL,~ \w- l\9 "le;Q?>
Will No.: ~Go 3-0 \ 0/3
Admin. No.: ;,{ I- 03 -1073
,
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 administration of the estate is complete:
Yes M No 0
2. lithe answer is No, state when the personal representative reasonably believes
that the administration will be complete:
3. lithe answer to No.1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes No B
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 0 No G
c. Copies of receipts, releases, joinders and approval of formal or
informal accounts may be filed with the Clerk of the. Orphans' Court
and may be attached to this report.
Date: /I-IF-OJ
thtu.Lt~ 6udcA
Signature
(3ho.l 1M .~ (tr-tch
Name
'-1& t,-U.~ f~ - JIV{/ A 1731j'-
Address
('
L
, ,-)
7/7 -z92-tJ/;!.7
Telephone No.
Capacity: BPersonal Representative
o Counsel for personal representative
xlI+ :