HomeMy WebLinkAbout03-17-09COMMONWEALTH OF PENNSYLVANIA
DEPARTM EINT OF REVENUE
BUREAU 01= INDIVIDUAL TAXES
DEPT.280~601
HARRISBUI~G, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 01 1007
LAUGKS DIANE E
103 SOUTH LOCUST STREET
SHIREMANSTOWN, PA 17011
--- fold
ESTATE INFORMATION: SsN: 174-20-1592
FILE NUMBER: 2109-0259
DECEDENT NAME: NESS LOIS V
DATE OF PAYMENT: 03/ 1 7/2009
POSTMARK DATE: 03/ 1 6/2009
COUNTY: CUMBERLAND
DATE OF DEATH: 12/25/2008
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
101 ~ 53,487.50
TOTAL AMOUNT PAID:
REMARKS: RECEIPT TO ATTORNEY
CHECK#7374
SEAL
INITIALS: AJW
REV-1162 EXI11-961
53,487.50
RECEIVED BY: GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
CHARLES E. SHIELDS, III
A7`TORNEY-AT--LAW
6 CLOUSER ROAD
Corner of Trindle and Clouser Ronds
MECHANICSBURG, PA ]7055
GEORGE M. HOUCK
(1912-1991)
March 16, 2009
Register of Wills
Cumberland County Court House
1 Courthouse Square
Carlisle, PA 17013
Ike: Estate of Lois V. Ness
Dear Register of Wills:
"TELEPHONE (717) '766-0209
FAX 1717) 795-7473
As per Michelle's discussion with Wanda today, please find enclosed the completed
Estate Information Sheet and death certificate for Lois V. Ness. This Estate has not been
probated as all significant assets are in joint names. It would be appreciated if you would assign
this Estate a Docket No.
Please find enclosed Check No. 17374 in the amount of $3,487.50 for estimated
Inheritance Tax for the Estate of Lois V. Ness.
Thank you for your kind attention to this matter.
Very truly yours,
r
Charles E. Shields, III
Attorney-At-Law
CES/mjj r~
Enclosure
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+®CA~. REGISTRAR'S CERTIFICATIU[V GF DEATH
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
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(See lnstructtons and examples on reverse) STATE FILE NUMBER
~G~ C1 `~ ~iaV
edent (First, mkldle, last. suAlx) 2. Sex 3. Social Security Number 4. Date of Death (Month, tlay, year)
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Nam
e of D
ec
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V
L_.:/ i S "Z CS ~ I ~ - Zc:~- )5`i~ ~Z December 25 2008
5. Age (Last Birthday) Under 1 year UrMer 1 day 6. Date of Birth (Month, tlay, year) 7. BiMplace (City and stale or foreign aunlry) Ba. Place of Death (Check only one)
t
her:
Mourns Days I+ours Minutes HospitaC O
rr
gq
84 Yrs. December 14 1924 Harrisbur PA ^Inpatient ^ER/Outpatient ^DOA lp Nursing Home ^Residence ^Other Specily.
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County of Death &. City, Bore, Twp. of Death
8b Bd. Fadllry Name (If rrot institution, give street and number) 9. Was Decedent of Hispanic Origin? No ^Ves 10. Race: American Indian. Black. While. etc.
.
Cumberland Camp Hill (If yes, specHy Cuban, (Specily,
Manor Care Health Services Mexkan,PuenpRien,ek) White
11. Decedents Usual Occu lion Kind of wtMc done dodo most of workin life. Do not state refir 12. Was Decedent ever in the 13. Decedent's Education (Specity ony highest grade completed) 14. Marital Status: Marred, Never Martied. 15. Surviving Spouse (11 wife, give maiden name)
Widowed
Divorcetl (Specilyf
Ki of Work K' d pt Busi ss / Intlustry
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l
s
b
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US. Armed Forces?
Elementary /Secondary (0-12) College (1-4 or 5+)
oo
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ic
eacher Pu
School ^vea WNp 4 Widowed
tfi. Decedent's Mailing Address (Street, city I lowq state, zip code) Decedent's Dld Decedent
PA Live in a 17c
Decedent Lived in Twp.
^ Yes
1700 Market S t . .
,
AcMUaI Residence 17a. Stale
Township? 17d ®No, Decedent Lved wilhm
Cumberland
Camp Hill
c
' Cam Hill , PA 17011 ,7h.
p~mty
city / Bnm
Aptual umfla pl
16. Father's Name (First, middle, Iasi, suplx( 19. Mother's Name (First, middle, maiden sumarne(
-Frank R. Zimmerman Alice Seebold
20a Informant's Name (Type I Print) 20h Inlormant's Mailing Address (Street, city /town, slate, zip code)
Shiremanstown
PA 17011
Locust St.
103 S
Diane Loucks ,
,
.
21 a. Method of Disposition ^ Cremation ^ Donation 21 b. Dale of Disposition (Month, day, year) 21 c. Place of Dispositon (Name of cemetery, crematory or other place) 27 d. Location (City I sown, state, zip code)
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~
Burial ^ Removal from Slate j WaS Cremagon or DOnatlon AUthodzed December 30 200 St. John's Cemetery Mechanicsburg, PA
~
y
^ Other -Specify: by Medial Ezaminar Droner? ^ Yes ^ No ~
22a. Si of Funeral Service Licensee (or person ac ~ as su 22b. License Number 22c. Name and Adtlress of Facility yers- arner unera ome
014819 L 1903 Market St. Cam Hill A 170
Complete Items 23ac anty when cerafyirg 23a. To the hest of my knowletlge, death occurred at me Ume, date aM place staled. (Signature and title) 23b. License Number 23c. Date Signed (Moo)n, day, year)
physkian k rot available at lime of deem to
cenity cause of tleath.
'
Time of Death
24 25. Dale Pronounced Dead (Month, day, year) +
26. Was Case Referred to Medical Examiner /Coroner for a Reason Other Than Cremation or Donation
Items 24-26 muss be completed by person . ^ Yes ^ No
' who pronounces death. M.
CAUSE OF DEATH (Sae Instructions and ezempies) i Approximate interval: Pan II: Enter other sionifcent contlitions conmbufne to tleath,
n 1
i
I
P
d
i 28. Did Tobacco U C6mnbute to Death
^ Ve~Probably
Part I: Enter the f~In of events -diseases, Injuries, or compliCatbns -that directly causal the death. DO NOT enter terminal events such as cardiac eras), i Onset to Death
Item 27 .
ven
n
a
y
ng cause g
but not recalling In the untle
.
respiratory arrest, or ventricular fibrillation withoN showing the etiology. List only one cause on each line. r ^ No ^ Jnknown
IMMEDIATE CAUSE (Final disease or ~
~
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contlition resulting in death) // + ~)
CGI~•~n/~ C,~~~~{ f_5i fi 0~:+~, ~-><•i 29. II Femal
re
nant within
est
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eet
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1 p
y
p
g
nseque of)-. _ ~
Due to (or as a go
^ Pregnant at hme of death
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it an
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4
leading to me ease listed on line a. Due to for as a wnsequence olj'. 1
Enter the UNDERLYING CAUSE
that initiated the
~
(disease or inju ^ of death nanl, but pregnant within a2 days
c
ry
events resulting in death) LAST.
~ t ^ Not pregnant, but Dregnant a3 days to t year
Due to (or as a consequence of
)- I before tleath
^ Unknown d pregnant within the past year
d
30a. Was an Autopsy 30b. Were Autopsy Fintlings 31. Man of Death 32a. Date of Injury (Month, tlay, year) 32b. Describe How Injury Occuned 32c. Place of Injury: Home, Farm, Slreel, Factory.
Olfce BuiMitg, etc (Speciryl
Pedomwd? Available Pnor to Completion
? ~ Natural ^ Homicide
,.
] ~
of Cause of Death
Q N
V ^ Accident ^ Pending Investigation 32d, Time of Injury 32e. Injury at Wak? 32f. It Trensponation Injury (Specfy)
^
i 32g. Localbn of Injury (Street, city I town, stale)
No
^ Yes [ c
es
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D
^ Vas ^ No Pedestr
an
^ Driver I Operator ^ Passenger
erm
ne
e
^ Suicide ^ Could Not be M ^Other - Specity'
ignature and T of enifier '
33a. Certifier (check ony one)
• Certdying physician (physkian cenitykg cruse rl death when another physician has pronounced death and ampleled Item 23)
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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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e
Ta the heat of my knowfetlge, deem ocamed due to the cause(s) and manner as s
• Pronouncing and certitying physkian (Physician bom Dronouncing death and cerlitying to cause of death)
^ 33c. Lcense Number
~ 33d. Da)e Signed (Month. day, year]
'
To me best of my knowledge, death occurred at the time, dale, antl place, antl due to the ease(s) and manner as staled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ f~
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• Medical Ezamirler I Coroner
On the basis o1 examinetlon and / a invesdgatlan, in my opinion, death occurred at the time, date, and place, and due to the cause(s) end manner as sm[ed_ ^ 34. Nam and Address of P,e/rson WhoJ~omple ed Caus/e,/gel D/e/a/t~h (Item 27) Type I Prim
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nd District Number - f
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35. Registral ~ur
I -~21 ~~ OV ~ ~ ~ ~ 36. Date Filed (Month, day, year)
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