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' In the Estate ot:
J cc v, 2 I~ re-~- f rte- s-s
Estate No
~l-oa -/o ~~l
Date /a ~ ~ ~~~
CLAIM AGAINST DECEDENT'S ESTATE
The claimant certifies that there is due and owing by the decedent in accordance
with the attached statement of account or other basis for the claim the sum of
$ l /y3~ yy
I solemnly affirm under the penalties of perjury that the contents of the foregoing
claim are true to the best of my knowledge, information, and belief.
Pharmacare
Name of Claimant
Jeanne Zaladonis, Billing
Name and Title of Person Signing Claim
(301) 777-1773 Ext.i17
One James Day Drive
Address
Cumberland, i!ID 21502
Telephone Number
FILED:
RECORDED:
Claims Docket Liber
Folio
Instnictions:
~. This form may be filed with the Register of Wills upon payment of the filing fee provided by law. A
copy must also be sent to the personal representative by the claimant.
2. If a claim is not, yet due, indicate the date when it will become due. If a claim is contingent, indicate
the nature of the contingency. It a claim is secured, describe the security.
M.~~
Signature of claimant or person authorized to make
verifications on behalf of claimant
RW 28 PS-3
1 R ^ ~•
~ PHARMACARE
ONE JAMES DAY DR.
CUMBERLAND, MD 21502
PHONE: 301-777-1773
09/30/2002
30 DAYS.. 16.65
60 DAYS.. 147.90
90 DAYS.. 961.99
AMT DUE. 1143.44
PHARMACARE
A LATE CHARGE OF 1.5~ PER MONTH (18.0$ ANNUALLY)
WILL BE ADDED TO AMOUNTS 31 DAYS PAST DUE
SCHOLL, MARY SCHOMARY
FOR JANE FRENTRESS C/0 SH GRP-GS
WALNUT BOTTOM RD PAGE 1
SHIPPENSBURG PA 17257
ONE JAMES DAY DR. CUMBERLAND, MD 21502
**** PREVIOUS BALANCE
** THIS AMOUNT PAST DUE **
1126.54
133.47
YTD MED
DEDUCTION
.00
16.90 1143.44
1126.54
.00
00
1143.4