HomeMy WebLinkAbout95-0381RE:-tSOOEx~ (II-9t) .~ ~ S Y FOR DATES OF DEATH AFTERI4l31I91CHE[KHERE
~, :~ , ~~ - ~~ ;-~ ~,-~ ~ ~~ ~, INHERITANCE TAX RETURN IF A SPOUSAL
'~' ~~~'•;~+ ~ ~ ~ ~,! ~!' `~ ~~ RESIDENT DECEDENT POVERTY CREDIT IS CLAIMED ^
•- .c, :~- FILE NUMBER
COMMONWEALTH OF PENNSYLVANIA TO BE FLLED IN DUPLICATE
DEPARTDEPT.T2B060jVENUEWITH REGISTER OF WILLS °~,~ ~j ~~ ~ J
HARRISBURG, PA 17128-06ot _ _ _ COUNTY CODE YEAR NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIALI DECEDENT'S COMPLETE ADDRESS
F
W
Z
Lehman Donald W.
1434 Three Square Hollow Road
V SOCIAL SECURITY NUMBER DATE OF DEATH DATE OF BIRTH Newburg
PA 17240
W ,
O CouNy
"' ^ 2.
1. Original Return
pp 3. Remainder Return
Su lemental Return
Q ~ (for dates of death prior to 12.13-82)
wav ^ 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax
=00 (for dates of death after 12-12-82) Return Required
vam
^ 6. Decedent Died Testate ^ 7.
Decedent Maintained a living 7rusi _ 8. Total Number of Safe Deposit Boxes
a
Q (Attach copy of Will) (Attach copy of Trust)
`ALL CORRESPONDENCE AND CONFIDENTIAL 7AX INFORMAt 10N SHOULD B.E DIREG7ED T0:
I NAME COhIPIETE MAILING ADDRESS '
o H. Anthony Adams, Esquire 128 E. King Street
C! O TELEPHONE NUMBER Shlppensburg, PA 17257
a ( 717 ) 532-3270 r
Z
O
f-
Q
J
t^
a
Q
V
~J ;J
r":
_}
~J _
I
-~J
_7
t-,~
:; ~.
GG
• 9 9
11. Total Deductions (total lines 9 8~ 10) :~ ,, (11) 3 458.60
€ s
12. Net Value of Estate (line 8 minus line 11) 6 (12) - - ~~_,
.,
13. Charitable and Governmental Bequests (Schedule J) ~ (13) i
C ~/ ~
14. Net Value Subject to Tax (line 12 minus line 13) (14) -0- \ ~, ~~tT •!n a'
1. Real Estate (Schedule A)
( 1) ~ --
-~-
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Stock/Partnership Interest (Schedule C) (3) -~-
4. Mortgages and Notes Receivoble (Schedule D) (4)
5. Cash, Bank Deposits ik Miscellaneous Personal Property( 5) -~-
(Schedule E)
6. Jointly Owned Property (Schedule F) (6) _ .--
7. Transfers (Schedule G) (Schedule L) (7) '~-
8. Total Gross Assets (total lines 1-7) (8)
9. Funeral Expenses, Administrative Costs, Misce-laneou s (.,,4t`'~ 3
/ ~L+58 •60
Expenses (Schedule H)
10 Debts Mort a e Liabilities Liens (Schedule I) (10)
15. Amount of line 14 taxable at 6% rate (15) x .06 = -n-
(Include values from Schedule K or Schedule M.)
16. Amount of line 14 taxable at 15% rate (16) x .15 =
Z (include values from Schedule K or Schedule M.)
O
Q 17. Principal tax due (Add tax from line 15 and from line 16.) (17)
~ 18. Credits Spousal Poverty Credit Prior Payments Discount Interest
~ + + - (18)
~ 19. If line 18 is greater than line 17, enter the difference on line 19. This is the OVERPAYMENT. (19)
x ~^ - .,
~" 20. If line 17 is greater than line •18, enter the difference on line 20. This is the TAX DUE. (20) -~-
A. Enter the interest on the balance due on line 20A. (20A)
B. Enter the total of line 20 and 20A on line 208. This is the BALANCE DUE. (20B) -n-
Make Check Payable to: Register of Wills, Agent
tt* u-'BE SURE TO ANSWER'ALL QUESTIONS ON REVERSE SIDE AND TlO RECHECK MATH~$ ~'
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. I declare that all real estate has been reported at true market value. Declaration of preparer other than the personal representative is
based on all information of which preparer has any knowledge.
SIGNAT.ItRE OF PERSON RESPONSIBLE F FILING RETURN ADDRESS DATE
~ \' 1434 Three Sguare Hollow Road, Newbury, PA 2-27-97
SIGNATU F PRE OTHER TH R ENTATIVE ADDRESS DATE
_ 128 E. King Street, Shippensbur~, PA 2-27-97
COMMOr7WEAUH OF PEtnJSYLVANIA
INIIERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE
SCHEDULE "A"
REAL ESTATE
LE NUMBER
--------t?.O.>s~~.d_W. _.~ehman _ _ . ..._ _.... .. _ __-.._ - ----. .....--------- 2195-0381_
(Property jointly-owned with Right of Survivorship must ba disclosed on Schedule "F") All real estate should be reported of fair morket
value which is deiinad as the price at which property would be exchanged between a willing buyer and a willing seller, n•{ther being
compelled to buy or sell, both having reasonable knowledge of the relevant (acts.
ITEM DESCRIPTION VALUE AT DATE
NUMBER OF DEATH
1.
N/A
TOTAL (Also enter on line 1, Recopilulation) $ -~-
(!( more space is needed insert addilionol sheets of same size.)
~~ a S(;HEIaULE li
~~~5~ FUNERAL EXPENSES,
COMtAONV/EAlill OF FErltrSYlVAN1A ADMINISTRATIVE COSTS AND
INVIERIIANCE rAX RETURN MISCELLANEOUS EXPENSES
RESIDENT DECEDENT Please Print or Type
ESTATE OF FILE NUMBER
Donald W. Lehman 2195-0301
ITEM DESCRIPTION AMOUNT
NUMBER
A. Funeral Expenses:
1. Fogelsanger-Bricker Funeral Home, Inc. 3,422.60
B.
C
Administrative Costs:
1. Personal Represenlalive CorTtmissions
Social Security t~urnber of Personal Represenlalive: _
Yeor Commissions paid
2. Attorney Fees
3. Family Exemption
Claimant Relationship
Address of Claimant at decedent's death
Slreel Address
City Slate _
A. Probate Fees -Register of Wills "
Mi:cellaneous" Expenses: ,
1.
2.
3.
Q.
5.
6.
7.
8.
Zip Code
36.00
TOTAL (Also enter on line 9, Recapitulation) $~:~"r 458.60
(IF more space is needed, insert additional streets of same size.) ~
~Ev.I$I: FX• ~e.ee~
~:"~.~
. ,:,..
COMM QtJV/E AItN Ut rf I11 J$~IVAIlIA
IIJ11(OIIAIICf to%OE IVRN
PE LDUJI U(CfDUII
ESTATE OF
SCHEDULE .!
BENEFICIARIES
FILE NUMBER
Donald W. Lehman 2195-0381
ITEM
NUMBER tJAh1E AND ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR
SHARE OF ESTATE
~ A. Taxable Bequests:
~, Barbara Lehman Wife 100%
1434 Three Square Hollow Road
Newburg, PA 17240
(If more :pace is needed, insert odditionol slseels of same size)
I-q5 C~3~i
H105.144 Rev. 1/91
TYPEIPRINT
N~
PERMANENT
BLACIL INK
v~
ti
Z
w
U
O
0
z
This is to certify that the certificate hereunto attached is a true and accurate copy of the original
death record on file with the Division of Vital Records, and that Frank Yeropoli, whose name is
subscribed thereto, was at the time of subscribing the same and now is Director, Division of Vital
Records of the Department of Health, for the Commonwealth of Pennsylvania, duly appointed
and commissioned as directed by Act 66 of the General Assembly, approved 29 June 1953, P.L.
304.
Date
AUG 16 200T
f
Fran Yeropoli, `' act
Division of Vital Records
P.O. Box 1528
New Castle, PA 16103
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
r r1 r
-'IJC-.3
NAME OF DECEDENT (Fksl, Middle. Lest) SEX SOCIAL SECURITY NUMBER DrVE OF DEATH (MOMh, Day. Year)
,. Donald W Lehman :. Male ,- 190 - 42-.3519 .-January 26 , 1995
AGE (Last Bkmday) UNDER 1 YEAR UNDER I DAY DATE OF BIRTH BIRTHPLACE (City and PLACE OF DEATH (Ch Jc Doty one - see iretructroru on omen sitle)
4 3 Months Days (burs Minutes (MO^m, Da ,year)
~ 8
J Slatew Foreign Country) HOSPIUL DTHER:
Yrs J
19 51 S h amok i n , PA ~ ti.nt ^ ER/Otapatient ^ DQA ^ Hom; g ^ Ra~e,nta~ O1^°'
(spetiry) ^
Is T
COUNTY OF DEATH CITY, BOR DEATH FACILITY NAME(d ratinstilution, give slreM and number) WAS DECEDENT OF HISPANIC ORIGIN? RACE-American Indian, Black, White, alt.
- Cumberland Ho ewell 1434 Three S uare Hollow Rd. " ~ '"^"y°°'~eCHyBUban' (Spat~y)
P q
t
_
k
eakan,PUen Rkan,alt. White
Lb. 9a aA- 9. 10.
DECEDENT'S USUAL OCCUPI{TION KIND OF BUSINESSANDUSTRV WAS DECEDENT EVER IN DECEDENTS EDUCATION MARRAL STATUS-MamieO SURVIVING SPOUSE
(Give kind d worts done Maap r~ U.S. ARMED FORCES? h' eat c Never Martied, Widowed, (If wile, give maiden name)
N working life; do not use refaed.) 1'ea^ No EMmeraerylSecondary Cosege Diwrcad lspetify)
(a,z) (,r°rs+)
~ioadway Trucking
Truck Driver
~
~~
„a
,z
,3
,eMarried ,s~arbara Givnin
DECEDENT'S MAILING ADDRESS (Street CiryROwn, State, Zip Code) DECEDENT'S
Hopewell
17 s'°ta Penngylvania
®
14'i4 Three Square Hollow Rd. M ,Ta.
vea,eetedentlivedin
Mro
ESIDENCE
Newburg, PA 17240 (see in,o-nttiona IM in a
on aher side)
Cumberland bwnslYp7
~
~
d
~
n
l
mm
ta 1Tb gun
Td^ w
Itf
xn
eM
ua
l
i
a
ttymom.
FATHER'S NAME (Fk9. Midde, Lag) MOTMEA'S NAME (Kral. MidAe, Maiden Surname)
,a. Geor a Lehman ,s- Theaesa Tapolski
INFORMANT'S NAME (TypelPnnt) INFORMANTS MNLING ADDRESS ISlraet. C' lkwn, Stale, Zip Code)
~
Barbara Lehman lollow Rd., Newburg, PA 17240
X1434 Three Square
METHOD OF DISPOSITION D/UE OF DISPOSITION PLACE OF DISPoSRION -Name of Cemetery, Crematory LOCATION - CNyROwn, State, Zip Code
yy,~ II
Bwlal ^ Crematbn y~ Removal from State (Monet, Day, Y ) a Other Play
DonNitn^ omer(spetiTy ^
. z,a.
z,b. 1 29/95 Smithsbur Cremator
z,e. S Y aSmithsbur MD
x1. 8,
' SKiNATUR fU MLSER~y~ E ACTING AS SUCH LICENSE NUMBER NAME AND ADDRESS OF FACILITY
~' dam- !' 01 1776-L ~
elsan
erBricker F
H
Inc
P
Box
336
Shb
PA 17257
O
_
zza. pg
g
.
.,
.,
.
.
g.,
.
,
mob-
Complete itorne Sat ~~ry when Certifying To ltb best of my krawledga, deem occurred at the time, Gate arb place staled. LICENSE NUMBER DATE SIGNED
physician b not eveilabM at time of Beam to (SgnaNre antl Tale) (MOnlh, Oey, Year)
certih cause 0l death.
33a- 23b. 33e.
~
2W~~~1»»~~ e0 by TIME OF DEATH Aprx. DATE PRONOUNCED DEAD (MOnm, Day,Y ) WAS CASE REFERREDTO MEDIC LE%AMINERICORONER7
~
Januar
26
1995 ~ ~ "°
1
00 P
^
y
,
,..
:
. M. zs.
xe.
•
2T. PART 1: EnterlM diseases, injwias ar tomplitaliona which roused the deem. Do nd enter me mode at dying, SUCK as cardiac or respiratory arrest, slack ar heart fatlwe. ~Approsimate PART It: ONer signilkenl wrMHions conlribwing to deem, but •
Lis[ onryorb cause on each krre. ~ interval beMeen rat msukirg in me uMertyinq cause given in PART I.
RYiED1ATE CAUSE (Final ~ onset and deem
~°°~~~^~^ Myocardial Infarction
es„Ir gindaatm-+ a. Remote MI
r
DUE TO (OR AS A CONSEQUENCE OF7: ~
Occlu
ive C
A
t
Di
'
S,a„M,a,y,;~~,b;,;°,n b.
s
oroner
r
er
sease
dairy, beArg to immediate DUE TO (Oi AS A CONSEQUENCE OF):
tm. EMar UNDERLYING
CAUSE (Dreease or inNry c.
mat aJUated e+ants DUE TO (OR AS A CONSEQUENCE OF):
reR,kkg in Beam) usr
d
WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNEROF DEATH DATE OF INJURY TIME OFINJURV INJURY Rr WORK? DESCRIBE HOW INJURY OCCURRED-
PERFORMED7 AVAILABLE PRK)R TD (MOnm. Day. Year)
OF DEATMI70N OF CAUSE Nalwal ~ Homicide ^ Ves ^ No^
AccitleM ^ Pendlrg lmestigatbn ^ 30a. 30b. M. 30c. 30d.
Yes ~ No ^ Yes ~ No ^ PLACE OF INJURY-AI home, lean, street IaMOry, omce LOCATION (Skeet
CiryR wn
Stale)
saicbe ^ could rat t» aetermilad ^ Iwialrg, Nc. (Speciry) ,
,
zM. ztib. Z9. 30e. 3
CERTIflFJI (Check aMy one) SIGNATURE O RT
'CFMIFYING PNYSICIAN (Physician certitying Wuse of death when anomer physician has pronounced deem arts compleletl Item 23)
^
~
To foe bast of mY krawkdgv, deem occurred due to me eause(a) and manner ae wted ..................................................... C o r O n e r
31b.
LICENSE UM DATE SIGNED (MOnm, Day. Year)
'PRONOUNCING AND CFJTTIIYING PHYSICIAN (Physician both pronouncing deem arts certsying to cause d deem(
To the Dart of mY krawledge, deem rxcurtad al tM tirrM, da4, arW place, arts due to the cause(s) and manna ae slated .......................... ^
31e. Jan . 2 8 19 9 5
71d. J
NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH
'MEDICAL EXAMINERlCORONER (Item 27) Type or Print
Michael L. Norris, Coroner
On th. basis of esaminatbn arts/1x investigation, in my opinbn, death oewrretl at me time, date, and place, arW due to the cause(s) arts 4 0 5 Fairway D r i v e
3iamenn«ae atated ....................,- ........................-................................................ ~ 33. Mechanicsburg, Pa. 17055
REGIS GNATURE AN M R / DATE FILED h, Day. Year(
~ r