HomeMy WebLinkAbout06-01-09ORIGINAL
FILL INAPPROPRIATE OVALS BELOW
~~~ 1. Original Return
4. Limited Estate
~~ 6. Decedent Died Testate
(Attach Copy of Will)
,.,~ 9. Litigation Proceeds Received
2. Supplemental Return
C 4a. Future Interest Compromise (date of
death after 12-12-82)
7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
10. 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)
~ 5. Federal Estate Tax Return Required
~_ 8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
Linda J. Olsen, Esquire (717) 232-1581
Flrm Name (If Applicable) -- -- ------
_... REGISTER OF WILLS U5E OryLI(
,.
. Killian & Gephat, LLP
_...
First line of address ~ ,.. ~ •
,.
i 218 Pine Street ~ -
Second Ime of address "' ---
_. r ;
P.O. Box 886
-_____.. _..._....... _..._..._ . .. ............... _.. .. ........... ... ......_...._. OATEFILED
City or Post Office State ZIP Code ----- ---~-•-~ --- ---.-r---r -I
Harrisburg PA 17108-0886
Correspondent's a-mail address: lolsen@kllllangephart.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. Declarationpf preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE ~ERSON RESPONSIBLE FOR FILING RETURN DATA
/'~/ ", o s~~ 3~~ r
~~~b}Xfl4^'.
ADDRES ~
Arleen E''~Diamond, Executrix, 541 Mill Road, Sidman, PA 15955-3516 ~%~~~ d
SIGNAT{1 OF PREPAR OTHE REPRESENTATIVE DATE
. -- ~ .~~
-ADDR
Linda J. Olsen, Es ., Killian & Gephart, LLP, 218 Pine Street, P.O. Box 886, Harrisburg, PA 17108-0886
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056051058 15056051058
REV-1500 EX
EDNA
Decedent's Name:
RECAPITULATION
15056052059
K KONKLE
Decedent's Social Security Number
159-09-5735
1. Real estate (Schedule A) ........................................... .. 1. ' 0.00
2. Stocks and Bonds (Schedule B) ..................................... .. 2. ' 66,270.16 '
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. (((( 0.00 j
4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. 0.00
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. 23,463.02
6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ..... .. 6. ' 0.00
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property " ~ ~""' "
(Schedule G) Separate Billing Requested...... .. 7. ' 0.00
8. Total Gross Assets (total Lines 1-7) .................................... 8. 89,733.18
9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. 5,392.02
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. 476.19
11. Total Deductions (total Lines 9 i~ 10) ................................. .. 11. ' 5,868.21 '
12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. !, 83,864.97 ':
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which "" °'
an election to tax has not been made (Schedule J) ...................... .. 13. 65,178.23
14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. ! 18,686.74
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 .0 4 ', 0.00 ! 15.' 0.00
16. Amount of Line 14 taxable
at lineal rate X .0 0_ 0.00 16. ''; 0.00
17. Amount of Line 14 taxable
at sibling rate X .12 0.00 ', 17. ', 0.00 ',
18. Amount of Line 14 taxable 18,686.74 '
at collateral rate X .15 '
18. 18,686.74
19. TAX DUE ......................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056052059 Side 2
2,803.01
15056052059
REV-1500 EX Page 3
Decedent's Complete Address:
Ftle Number
21 09 00244
DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER
EDNA K KONKLE 159-09-5735
STREET ADDRESS
20 N. 12th Street
Apartment 233
CIN STATE ZIP
Lemoyne PA 17043
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments 0.00
A. Spousal Poverty Credit
B. Prior Payments 0.00
C. Discount 147.52
3. InterestlPenalty if applicable
D. Interest
E. Penalty
0.00
0.00
(3)
(4)
(5)
(5A)
(56)
Total Credits (A + B + C) (2)
Total Interest/Penalty (D + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
2,803.01
147.52
0.00
0.00
2,655.49
0.00
2,655.49
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.
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) ()].
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. §9116 (a) (1.1) pi)]. The statute does not exem~ a transfer to a surviving spouse from tax, and the statutory requirements for disdosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only benefdary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twentyone 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 zero (0) percent [72 P.S. §9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or far the use of the decedent's lineal benefidaries is four and one-half (4.5) percent, 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 twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling isdefined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
~a~t ~iCC anb ~Ge~taritent
OF
EDNA E. KONKLE, a.k.a. BETTY E. KONKLE
I, EDNA E. KONKLE, a.k.a. BETTY E. KONKLE , of Cumberland County,
Pennsylvania, declare this to be my last Will, hereby revoking all prior wills and codicils.
FIRST: The expenses of my last illness and funeral shall be
paid from my estate.
SECOND: I make the following specific bequests:
(a) The ownership of all stocks which I own at the time of my death shall be
transferred to OUR LADY OF LOURDES CATHOLIC CHURCH, Enola, Pennsylvania.
THIRD: I hereby give and bequeath, absolutely and
in fee simple, to my good friend, ARLEEN E. DIAMOND, all my household furniture and
furnishings, books, pictures, jewelry, silverware, automobiles, wearing apparel and all other
articles of household or personal use or adornment, provided that if the said, ARLEF.N E.
DIAMOND dies before the thirtieth (30th) day following the day of my death, this gift shall lapse
or be divested and I direct that all the items hereunder shall be sold and the proceeds distributed
to OUR LADY OF LOURDES CATHOLIC CHURCH, Enola, Pennsylvania.
Page 1 ~'/ ~~' /~~
FOURTH: I give and devise the residue of my estate, real and
personal, to my friend, ARLEEN E. DIAMOND, if she survives me by thirty (30) days. If she
does not survive me by thirty (30) days, all the rest, residue and remainder of my estate shall be
distributed in cash, and not in kind, to OUR LADY OF LOURDES CATHOLIC CHURCH,
Enola, Pennsylvania.
FIFTH: If OUR LADY OF LOURDES Catholic Church,
Enola, Pennsylvania is no longer in existence at the time of my death and there is no successor
parish, all the rest, residue and remainder of my estate shall be paid to my heirs who would be
entitled thereto under the intestate laws of Pennsylvania in effect at my death.
SIXTH: No provision of this Will is intended to exercise any
power of appointment.
SEVENTH: All taxes, interest and penalties thereon payable by
r~aiGn vvf my"~ a*u~' rw•itu r:.sp~.~;t iv pr~pctiy t";Gnipil5ina my b.L`°,St»t.°., ~rl:~`tl:° LSF §1Gt p~SS?ng
under this Will, shall be paid from the principal of my residuary estate.
EIGHTH: No interest of any beneficiary under this Will or any
codicil hereto shall be subject to anticipation or voluntary or involuntary alienation, and the
Page 2 ~i ~,
personal receipt of such beneficiary shall be the sufficient and only discharge of my Executor
unless otherwise provided herein.
NINTH: hi addition to powers given her bylaw, my
Executrix and her successors shall have the following discretionary powers applicable to all real
and personal property held by her, effective-without court order and until actual distribution:
(a) To retain all property received by her including the stock of any corporate
fiduciary acting hereunder, provided such property remains productive;
(b) To invest in all forms of property without restriction to investments authorized to
fiduciaries, so long as such investments are productive;
(c) To join in any incorporation, partnership, recapitalization, merger, reorganization
or voting trust plan; to delegate authority with respect thereto; to deposit investments under
agreements and pay assessments; and generally to exercise all rights of investors;
(d) To compromise controversies;
(e) To exchange or sell for cash, property or credit, publicly or privately, or to lease,
even for a term exceeding five {5) years; v~ithoutliahility on the purchasers er lessees to see fo
application of the consideration, and to give options for these purposes without obligation to
repudiate them in favor of a higher offer;
(f) To borrow money, including the right to borrow from any corporate fiduciary
acting hereunder, and mortgage or pledge as security;
(g) To hold investments in the name of a nominee;
Page 3 ~' ` , ~ ` "
(h) To assume continuance of the status of any beneficiary with reference to
marriage, divorce, illness, incapacity or other change in the absence of information deemed
reliable without liability for disbursements made on such assumption;
(i) To elect to value my gross estate for Federal estate tax purposes as of the date of
my death or as of the alternate valuation date as allowed for such purposes, and to claim as
income tax deductions expenses that would otherwise qualify as estate tax deductions and other
elections allowable under law;
(j) To make interim distributions during the course of administration of my estate;
and
(k) To undertake any and all acts deemed necessary and proper by it for the proper
and advantageous management of the settlement of my estate.
TENTH: Any person who shall have died within thirty (30)
days of my death shall be deemed to have predeceased me. Any person (other than myself) who
shall have died at the same time as any then recipient of income or in a common disaster with
Such beneficiary, Cr under-such circumstances that lY ?s_dlffict.alt.:or impossibt_e to e ermine w~-
died first, shall be deemed to have predeceased such beneficiary.
ELEVENTH: I appoint my friend, ARLEEN E. DIAMOND, as
Executrix of this Will. h1 the event ARLEEN E. DIAMOND cannot act or continue to act as
~, ~~' ~~ ,
Page 4
Executrix for any reason, I appoint my sister, FRANCES E. KEPLER to act in her place. No
fiduciary acting hereunder shall be required to post bond or enter security in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 5~-- day of
~/a-~ 2007, to this page and to the preceding four (4) pages, and I have also placed my
initials on-each preceding page for better identification and greater security.
~~ ~ ~'~ ~~ (SEAL)
EDNA E. KONKLE
SIGNED, SEALED, PUBLISHED and DECLARED by the above-named Testatrix,
EDNA E. KONKLE, a.k.a. BETTY E. KONKLE , as and for her Last Will and Testament, in the
presence of us, who at her request, in her presence and in the presence of each other, have
hereunto subscribed our names as witnesses:
Residing at ~~~~~{,(,6~ ~ (G~ ~JI S'~~
nr~ (~,. ~~ / 7Ga S~
--
-- - c~~M ,~ Residing at .-~Z`.~) / c ~ /~:./ .~ ~~~°rcT
e
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF DAUPHIN
I, EDNA E. KONKLE, a.k.a. BETTY E. KONKLE ,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 instrument as my Last Will and Testament; that I signed
it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed.
~~ ~ ~~~
(SEAL)
EDNA E. KONKLE
Sworn to and subscribed
before me this day ~
of ~~t.~tc~~~ 2007.
Notary Public
My Commission Expires: _~;-~ r,_:.-`'a';'~~'~'.' '?;,_ rr;;~:-:<~_i-__-=
~I,....•;; ;~;~i
Pltttc} :. t j a htotzry ?ublic
(SEAL) ~ C t,rLrt~~! Daupphin Co~~~ty
,,,
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF DAUPHIN
We, ~ C C~and ,/ ~.~/ ~. ~ff~r' c~ ,the Witnesses
whose names are signed to the attached or foregoing instrument, being duly qualified according to
law, do depose and say that we were present and saw Testatrix, EDNA E. KONKLE, a.k.a. BETTY
E. KONKLE ,sign and execute the instrument as her Last Will and Testament, that Testatrix signed
willingly and that she executed said Will as her free and voluntary act for the purposes therein
expressed; that each of us in the hearing and sight of the Testatrix signed the Will as Witnesses; and
that to the best of our knowledge the Testatrix was at that fime eighteen (18) or more years of age,
of sound mind and under no constraint or undue influence.
Witness
Sworn to and subscribed
before me this day15~
of ~ 2007.
E,LC(..~t ~ • f
Notary Public
,I
y publican
r4TY CpClAaa•~
My Commission Expires:
(SEAL)
!' ['.. ,:i I ~" lii~idil~i ' ~a0"~I'1' .:iC
L `y Co:r±n~s~ion i?-;tt , Aiov. S. ~. '
REV-1503 EX+ (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
EDNA K. KONKLE 21 09 0244
All property jointlyowned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
t. AT&T Stock (1654 shares) -Liquidated value as distributed to Charitable Beneficiary 42,589.96
2. Verizon Stock (640 shares) -Liquidated value as distributed to Charitable Beneficiary 19, 904.30
3. `Alcatel/Lucent Stock (64 shares) -Liquidated value as distributed to Charitable Beneficiary 136.66
4. LSI Stock (19 shares) -Liquidated value as distributed to Charitable Beneficiary 41.43
5. ` Comcast Stock (186 shares) -Liquidated value as distributed to Charitable Beneficiary 2,505.88
6. E Bonds 1,091.93
TOTAL (Also enter on line 2, Recapitulation) $ 66,270.16
(If more space is needed, insert additional sheets of the same size)
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Please Note: The "Check Date," noted below, represents the settlement date of this transaction. Under normal market
conditions, sale transactions are traded 3 business days prior to the "Check Date".
/~
BNY MELLON
SHAREOWNER SERVICES
MAY 0 5 2009
SHAREHOLDER OF
DESCRIPTION
INVESTOR ID CUSIP ACCOUNT KEY CHECK NUMBER CHECK DATE CHECK AMOUNT
124942031!69 00145101390430 KONKLE-EDNAKOF00 98842312 05/01/2009 $136.66
SHARES/UNITS SOLD PRICE PER SHARE ($) TRADING FEES PAID BY SERVICE FEES PAID BY
64.0000 2.2916000
GROSS PROCEEDS TAX WfTHHELD COMPANY SHAREHOLDER COMPANY SHAREHOLDER
$146.66 $0.00 $0.00 $6.40 $0.00 $10.00
NET PROCEEDS SHARES HELD BY PLAN
$136.66 0.0000
PLEASE DETACH BELOW CHECK NUMBER: 98642312
• . ~
6D-160
CHECK DATE CHECK NUMBER 433
ALCATEL-LUCENT 05/01/2009 98842312
PO BOX 358014
PfffSBURGH, PA 15252 -BO14 PAYABLE AT THE BANK OF NEW YORK MELLON
IN U,S. DOLLARS
1020378 01 AB 0.351 ''AUTO T5 1 6088 17108-0888 867 DOM00000101
'111'I~111'111'III111'11'III111'11'1'1II11'III III~III'IIIIIII'
PAY TO THE
ORDER oF: A R L E E N E DIAMOND E X U W E D N A PAY***************$136.66
K KONKLE
ATTN LINDA J OLSEN
218 PINE ST ~ ~-^")
PO BOX 886 ~~~
HARRISBURG PA 17108-0886 `"rte
AUTHORIZED SIGNATURE
11'9884 23 L 211' x:04330 L60 1~: 0 L L111004011'
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Investor ServiceDirect® ar
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0 Comakers + 0 Papro0: I 0 Plastics , 2 Comments I 0 Joints I 1 Misc Codes I Relation: I 0 Appficatiorrs ~ Score: NEW
? I®1$' ~t,lt~l~i llTnr~
TakelTransfer funds ~+' ~~'
Cert~icate, New a ~..
Certificate, Withdrawal $0.00
Certificate, Add-on
Certificate, Renew
Cert~cate, Adjustment 0 @ $0.00
Miscellaneous Items $Out
Journal Adjustments
s ~ e
Bonds
0 Redemption $0„0~
0 Purchase -~
~' 0 @ $O.OD
To
Qty
Bond Amount Issue
mm
Series ';
Earning: Redeiription
Value-
1 1 $25.00 1OJ1976 Series~E $117.57 $136.32
2 1 $25.00 06/1976 Series E $117.59 $136.34
3 1 $25.D0 07J1976 Series E $117.57 $136.32
4 1 $25.00 08J1976 Series E $117.57 $136.32
5 1 $25.00 08J1976 Series E $117.57 $136.32
6 1 $25.00 09J7 976 Series E $117.57 $136.32-'
7 1 $25.00 11 J1976 Series E $118.90 $137.65
8 1 $25.00 06J1976 Series E $1
1
7.59 $136.34
9 .
.
.
10
11
~~
Total• ~`
Disbursement Method
QK ~ Undo ' cancel
ms el
~ ~~
AT THE ORIGIN}A L~,MATURITY HEREOF WILL PAY
7v 159-09-5735 `
IRS EDNA K KONKLE
=~ 544 WALNUT ST APT7
LEM~YNE' PA 17043
ISSUE DATE '
. WHICH IS FkiE~FiRST DsAY~Of~._•
N 0V_ _:,_ _I-9:7 b ::
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AT THE ORIGINAL MATURITY HIE R~EpO~F WILL PAY 1~.~
AL 7976- .?l ~ ~~ 3~~~ ~ ~ ISSUE DATE
~`.- r .WHICH IS TkLE. FIRST DA1' OF _ -
T~pp(`15g tAA19~-/573fi C~CT.' 1976
~ ~R~-. ~~1TIH K: KQNKLE I -(MONTH) -_ t <ral ..
544 WALNUT ST APT7 ` ~ ,TNE BELL" ,
LEMQYNE PA ~.?{343 .,_ .' TE,~.~~S~,~I~~;~~C.Os
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1776 BICENTENNIAL 1976
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MRS DNA K- KC1NiCLE `(MONTHI ~_. ;FEAR;. -
544 _WALNtIT' ST ,.APT7 :;' '~`, ,SHE ,:BFLL~;
t~M~YNE PA : 1704 ..
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AT THE ORIGINAL MATURITY HEREOF WILL PAY~~~~1
1078 BICENTENNIAL 1978 ~ 1~ h'~G.~~.s`za~.,?i wHCS STxeFDST~E DFa ~
T .159-fl9-5735 - ,~: SEPT~~19,'T6 <~_
~~ ~tF~S, EDNA K KDNKLE
- (MONTH>--.- ~ IYE~RI _~-
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AT THE ORIGINAL MATURITY HEREOF WILL PAY
1778 BICENT NIAL 1978: ~~ / ~ y B ~ i~j~~ ISSUE DATE- - " •~
~.s.~.i~~~ .
;WHICH IS TNE:_FIRST DAY_OF --
~ ,.. ~a i59-(1{3 ~-735 :-> ~' ~ 'AUG. 19TH
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1778 BICENT N AL 1978 + • ~. ~' ~~ I ~l4/ ~~1 i - 1 S S U E DATE...
WHICH IS TF~E FIR57 DAY OF
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REV-1508 EX+ (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
EDNA K. KONKLE 21 09 0244
Indude the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with fight of survivorship must be disdosed on Schedule F.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
1. Belco -Savings Account 10,906.02
2. Belco -Checking Account 1,309.59
3. Belco -Certificate of Deposit 8,682.41
4. Bureau of Unclaimed Property 1,845.00
5. IRS Refund
720.00
TOTAL (Also enter on line 5, Recapitulation) S 23,463.02
(If more space is needed, insert additional sheets of the same size)
BELCO COMMUNITY CREDIT UNION
DECEDENT ESTATE INFORMATION
1. Name(s) in which the account was held:
EDNA K KONKLE
2. Account number: 37380
3. Balance as of date of death: $20,898.02 Total of S1,S4 & CD
Balance Accrued Dividends YTD Dividends
For
Regular Savings: $ $10,906.02 $ $2.74 $ $19.50
Christmas Club: $ $ $
Whatever Club: $ $ $
Checking: $ $1,309.59 $ $
Money Market: $ $ $
Certificates: Balance Accrued Dividends YTD Dividends Certificate Number
For
opened 1996 $ $8,682.41 $ $20.35 $ $59.45 18369
$ $ $
$ $ $
$ $ $
$ $ $
4. Date the account was initiated: S1 SAVINGS 10/1965 AND THE S4 CHECKING 04/1987
5. Name(s) in which Safe Deposit Box was held:
6. Date the box was initially rented:
7. Branch address at which the box is located:
8. Loan Information: Balance
Unsecured Loans:
Line of Credit
B. Secured Loans:
Accrued Interest Per Diem Int
C. Mortgage Loans: $ $ $
$ $ $
Miscellaneous:
PROPERTY DESCRIPTION
,Prop. °/ Hoider,tniorrnation ° ~ ~ Prope ID 8428648
(A) Original Owner's Name (B) Original Owner's Address as Reported
KONKLE EDNA K C/O COUNTRY MEADOWS CAMP HILL PA 17011•
(C) Holder Reporting Funds (D) Last Transaction Date
CINGULAR WIRELESS LLC 1 0/2 612 0 04
(E) Holder Address and Contact (F) Type of Funds Reported
AUDIT SERVICES US LLC 212 W 35TH ST SUITE 600 REDEMPTION
NEW YORK TX 10001-0000 (G) certificate, Policy or Check Number
CINGULAR WIRELESS LLC
(800)522-6645 (H) Amount Reported $1,845.00
Total Shares Claimed 0.0000 Total Cash Claimed $1,845.00
RETURN CLAIM FORM AND DOCUMENTATION TO:
Bureau of Unclaimed Property P.O. Box 1837, Harrisburg, PA 1 71 05-1 837
~~, s ~ ~: 15-51.' ~•
~~: S 497, 520 09 5 ~~;~r:
~ ~ ~ ' o00 ~ ~. s
ti ~~r Y . rt.
~~
a. s,,., Check No.
~~~.~ ~.-Y~~~~ 04 03 09 45 AUSTIN, TEXAS 2309:-72254622
~`~~~ '" ~`°~ ,`'"b';``~, 23.09„- 72254622 20090900 I30 OKONK KANS CYTAX REFUND
.: ~s
x ': ~ .Pay to ~ni~~~i ~~~n~~~~ui~n~i~~~u~~i~~~~~~~i~~iv~n~ii~~~i~n~~~
. ~ thco'derof ARLE.EN E DIAMOND EXEC- 12/08-:
EDNA K KONKLE DECD 22 -
N` 4~ ~ ~. , . PO BOX 886 ~****720*00
'~~ HARRISBURG PA 17108-0886
~~~ ~ ~~
F~u. aeaot~u oisuu~+swooraicea VOID AFTER ONE'YEAR
~~° I I- I ! -t I 11= I I I I-
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REV-1511 EX+ (12-99)
SCHEDULE N
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FlLE NUMBER
EDNA K. KONKLE 21 09 0244
Debts of decedent must be reported on Schedule L
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Gilbert L. Dailey funeral Home 1,700.00
2. Milton Cemetery -Borough of Milton 250.00
3• Father Acri -Priest 100.00
a. Rev. Stephen G. Shirk 100.00
5.. .Organist..... 100.00
6. Soloist 50.00
B. ADMINISTRATIVE COSTS:
1. Personal Representafive's Commissions
Name of Personal Representative(s)
Social Security Number(s)IEIN Number of Personal Representative(s)
Street Address
City State `Zip
Year(s) Commission Paid:
2. Attorney Fees Killian & Gephart, LLP 2,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State ' Zip
Relationship of Claimant to Decedent
4. Probate Fees 287.00
5. Accountant's Fees
6. Tax Retum Preparer's Fees
~. The Sentinel -Estate Advertising 230.02
s. .:Cumberland Law Journal -Estate Advertising 75.00
TOTAL (Also enter on line 9, Recapitulation) $ 5,392.02
(If more space is needed, insert additional sheets of the same size)
~.
GII,BERT L. DAII,EY FUNERAL HOME, INC.
"CJuiding Your 'Way"
Mario A. Billow, RD. Clifford D. Forester, Sr., ED. Timothy J. Dailey, RD.
Supervisor Funeral Director President
650 S. 28th Streel, Harrisburg, PA 17103 • 717-233-1933
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
Charges are only for those items that are used. If we are required by law to use any items, we will explain in writing below.
If you selected a funeral which required embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to
pay for embalming you did not approve if you selected arrangements such as a direct cremation or immediate burial. If we charged for
embalming, we will a aim why below.
For the Servicere of~J/1~ ~ ag~c~ r Date of Death 3.~`~f etJ"1
Charge to: Yt~LUI~ I/.T:En'I,W~ ~/bL~.riiLSd
Name ' Address Ciry State
A. CHARGE FOR SERVICES SELECTED: Other clothing
1. Professional services $
Services of Funeral Director/Staff $ $
Embalming $ Cremation urn ..................... . $
Other prepazation of body
(Description)
Cosmetology, dressing and casketing $ ______ ..__ ~
Sanitary caze when embalming is not elected- $
Dressing and placing in casket or $ OTHER $
alternative container only $
SUBTOTAL OF PROFESSIONAL SERVICES .. $ $
TOTAL MERCHANDISE SELECTED . ......... $
2. Facilities and equipment
Use of facilities for viewing C. SPECIAL CHARGES:
(Visi[ation/Wake) .................. $ Forwarding of remains to
Use of faciliries for funeral ceremony .... $ $
Use of administrative areas, reception (Funeral Home)
areas and arrangement rooms ......... $ Receiving of remains from
Use of Preparation room .............. $ $
Ocher use of facilities (Funeral Home)
Immediate Burial ................... . $
Direct Cremation .................. . $ I ~~
...... .. ... ... ...... $
SUBTOTAL OF FAC[LITIESIEQUIPMENT ... $ SUB TOTAL OF SPECIAL CHARGES ......... $
3. AUTOMOTIVE EQUIPMENT D. CASH ADVANCED
Vehicle to transfer remains to Funeral Home. Opening Grave .................... . $
Local .............................. $
Cemetery Equipment ...............
. $
Hearse (Casket Coach) Lot and Deed ...................... . $
Local .............................. $ Newspaper Noticesl..ocal ............ . $
Limousine Newspaper Notices-Out-of--Town ...... . $
Local .............................. $ Telephone 5t Telegrams ............. . $
Family car
Local ..............................
$ Airfare ...........................
Clergy/Mass Offering............... . $
. $ ~:~,~
Flower car or floral disposition Pallbearers ............... i ~f~CC
C . $
Local $ Certified Copies of the Death
ertificate . $
Lead car/clergy car Police Escort ....................... . $
Local .............................. $
Flowers ...........................
. $
Car for pallbearers
Vaul Service Charge ...............
. $
................
Local ...........
.
$ r~ Ir $iaJ
.
.
Out of town transportation ...........
$
`~' r'+' e ft $
$ $
$ $
SUBTOTAL OF AUTOMOTIVE EQUIPMr"NT $ $
TOTAL OF PROFESSIONAL SERVICES, SUBTOTAL OF ADVANCES ........ ......... $ r._Z~-°
FACILITIES AND AUTOMOTIVE
EQUIPMEN•I .......................... ....... $ SUMMARY OF CHARGES
A. Professional Services, Facilities and
B. CHARGE FOR MERCHANDISE SELECTED: Equipment, and Automoxive Equipment .. . $
Casket ............................ $ B. Merchandise ......................... . $
(Desctintionl- ---- --- C. Spe~:af C!:a-e=' ....................... .. $ 9 :2ra
D. Cash Advances ................ ~~ ~
$ ~~
Other Receptacle .................... $ TOTAL OF ALL SELECTIONS ....... $ i
....... .
(Description) PAID AT TIME OF OR PRIOR TO
`
ARRANGEMENTS .................. ~ .
......... $ }
Outer burialconcainer ............... $~
BALANCE DUE .................... /~
......... $
(Descriprion) r~! ri2 "' yYU+t1R.:aRn/
REASON FOR EMBALMING
Acknowledgementcards .............. $ '~ ``~' - '~ c
Register book(s) ..................... $ jE any law, cemetery, or crematory requirements have required the
purchase of any of the items listed above the law or requirement is
Memory folders ..................... $ explained below.
Prayer cards ........................ $
Temporary grave marker .............. $
Burialclothing ...................... $
I hereby agree that I have examined the above stated items and found them rn be correc[ and according to the arrangements requested and I
hereby acknowledge receipt of a copy of this memorandum and agreement I hereby represent that I have sufficient assets legally availabie for
payment of the cash price and hereby agree and covenant jointly and severally ro make payment of $ within days.
A late charge of per month amounting to per year is applied to the unpaid balance beginning days from the
date of this agreemrnt. Any additional services or merchandise ordered or requested after the date of this agreement will be considered part of
this agreerent and the cost thereof will be reflected on the final statement.
(seat) ~ ~ - ~ j~a/~ ~
.. (Purchaser) ~'1 (Date)
E ~ d
(Seal) / ' „~:.^ -__ _.
(Purchaser) (Licensed Funeral Director)
Milton Cemetery -Borough of Milton
2 Filbert St
Milton PA 17847-1708
Bill To
The Estate of Edna Konkle
%Atty Linda Olsen, Killian & Gephart
218 Pine St
Harrisburg PA 17101
MAR '~ S 2009
Invoice
Date Invoice #
3/23/2009 2009-1
Description Quantity Rate Amount
Cremation grave opening for Edna Konkle 1 250.00 250.00
TOtal $250.00
Phone # Fax #
570-742-8759 570-742-2322
~~~- U
I~~
MAR 2 0 2i1C9
The First Presbyterian Church
Of The Presbyterian Church (u. S. A.)
~ °
cS, .:,
~' Walnut Street - P. O. Box 255 -Milton, Pennsylvania 17847
Rev. Stephen G. Shirk, Pastor
Estate of Edna Konkle
Attention Linda Olsen
Killian & Gephart
218 Pine St.
Harrisburg, PA 17101
Dear Friends,
Church: 570/742-4491
Manse: 570/742-9875
March 18, 2009
i am the pastor who led the committal service for your client Edna Konkle on
Wednesday, March 18th at 4 PM. I was instructed by the family to report this to you
and say that I usually receive between $50.00 and $100.00 for such a service. I have
enclosed the service program I prepared. Thank you for your kind attention to the
matter.
Sincerely,
Rev. Stephen G. Shirk
65 Walnut St
Milton, PA 17847
.r
`~~ iC~.e~~''
~~: -~-.
_.~~ ~~ ~,
To Know Christ and To Make Him Known
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17613
KONKLE EDNA E
Estate File No.: 2009-00244
Paid By Remarks: ARLEEN E DIAMOND
JN
-------------------
Fee/Tax Description
PETITION LTRS TEST
WILL
SHORT CERTIFICATE
AUTOMATION FEE
JCP FEE
INVENTORY
Check# 3183
Check# 3184
Total Received.........
Receipt Date: 3/13/2009
Receipt Time: 09:36:48
Receipt No.: 1056052
Receipt Distribution ----- -------- -------- ---
Payment Amount Payee Name
210.00 CUMBERLAND COUNTY GENERAL FUN
15.00 CUMBERLAND COUNTY GENERAL FUN
32.00 CUMBERLAND COUNTY GENERAL FUN
5.00 CUMBERLAND COUNTY GENERAL FUN
10.00 BUREAU OF RECEIPTS & CNTR M.D
15.00
-- CUMBERLAND COUNTY GENERAL FUN
--------------
$
$15.00
$287.00
PROOF OF PUBLICATION
State of Pennsylvania, County of Cumberland
Erica Peterson, Classified Manager, of The Sentinel, of the County and State aforesaid,
being duly sworn, deposes and says that THE SENTINEL, a newspaper of general
circulation in the Borough of Carlisle, County and State aforesaid, was established
December 13~, 1881, since which date THE SENTINEL has been regularly issued in
said County, and that the printed notice or publication attached hereto is exactly the
same as was printed and published in the regular editions and issues of
THE SENTINEL on the following day(s):
March 27, 2009, Apri13, 2009 and Apri110, 2009
COPY OF NOTICE OF PUBLICATION
LETTERS TESTAMENTARY on the Estats of EDNA E. KONKL6, Nkh'
EDNA K. KONK7_E; a/k/a BETTY E. KONKLE, lath of Lemoyne Borough,
Cpmberland County, Pennsylvania, deceased March 4, 2009, have been
granted to the undersigned.
All persons knpwing.themselvas to be indebted to sold Estate+~q may
payment immedletely, andtMese having-oleima wfll preaenttftom for
settlement:
Arleen E. Diamond, Executrix-
• 20 North 12th Street
Apartment 233
Lemoyne, PA 17043
Linde J. Olsen, Esquire ""
Killian $ Gephart
288 Pins Street '
P.O: 8px 886
Hamsburg, PA 17188
Affiant further deposes that he/she is not
interested in the subject matter of the
aforesaid notice or advertisement, and that
all allegations in the foregoing statement
as to time, place and character of
plu~blication are true.
_L
Sworn to and subscribed before me this
~~
~~
Notary Public
My commission expires:
COMMONWEALTH OF PEryNSYLV. NL
NOTARIAL SEAL
gAM81 ANN HECKEN[XIiINs ~y
Camp Hill Boro., CurtiOedend 10
My C~mIY,,:<;inn Expires Jams 27,
RETAIN THIS PORTION FOR YOUR RECORDS
REMITTANCE ADDRESS BILL TO
THE SENTINEL - LEGAL KILLIAN & GEPHART LLP
P.O. BOX 130, CARLISLE, PA 17013
AD NUMBER CLASS SALESPERSON BILLING DATE LINES
366402 10 PUBLIC NOTICES cartc 04/10/09 42 * 2
AD DESCRIPTION START DATE STOP DATE
EXECUTRIX NOTICE LETTERS TESTAMENT 03/27/09 04/10/09
PUBLICATION INSERTIONS RATE NET AMOUNT GROSS AMOUNT
3 THE SENTINEL - LEGAL 3 LGL 223.02
TOTAL AD CHARGE 223.02
3 PROOF OF PUBLICATION O1PRF 7.00
DAYS RUN
` PAY THIS AMOUNT
Est. Edna Konkle
230.02
276.02*
~ER 05/10/09
MESSAGE: -~- G
~ ~ . (~~1
Thank you for advertising with The Sentinel. r~ (~
vl
Deadlines for in-column legal advertisements: Monday is Thursday at
5 p.m; Tuesday is Friday at 5 p.m.; Wednesday is Monday at 5 p.m;
Thursday is Tuesday at 5 p.m; Friday is Wednesday at 5 p.m Saturday
is Wednesday at 12 Noon; Sunday is Wednesday at 5 p.m.
If you have any questions regarding your Legal bill please call
Classified Manager at 717-240-7176
Fax your legals to 717-243-3754 attention Classified Manager
You can also EMAIL your legal to Classified ads: classifiedCcumberlink.com
Please send a cover letter including your name and address as an attachment
DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT
THE SENTINEL -LEGAL Est. Edna Konkle
P_O_ BOX 130_ CARLISLE PA 17013
AD NUMBER CLASSO START DATE STOP DATE
366402 PUBLIC NOTICES 03/27/09 04/10/09
AD DESCRIPTION BILLING DATE TELEPHONE NUMBER
EXECUTRIX NOTICE LETTERS TESTAMENT 04/10/09 717-232-1851
KILLIAN & GEPHART LLP
218 PINE STREET POB 886
HARRISBURG, PA 17108-0886
I~~~III~~~I~~~1111~~~1~~1~11~~~1~~1~1~~1,I~~~I I
GROSS AMOUNT OF
276.02
DUE AFTER 05/10/09
TOTAL AMOUNT DUE
230.02
ENTER AMOUNT ENCLOSED
20200000003664020000000000000002760200000230023
='I~t00F OF PUBLICATION OF NOTICE
iNT C'U'MBERLAND LAW JOURNAL
(Under .~~ci No. 587, approved May 16, 1929), P. L.1784
COMMONWEALTH Gr; i'I~,~:~=-NSYLVANIA
COUNTY OF CUMBET~.I.AND
ss.
Lisa Marie Coyne., 1~1sc,uire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being dul~,~ sworn, according to law, deposes and says that the Cumberland Law
Journal, a legal periodical {published in the Borough of Carlisle in the County and State aforesaid,
was esCablished January 2. 19_S2_ and designated by the local courts as the official legal
periodical for the publication o ~ all legal notices, and has, since January 2, 1952, been regularly
issued weeiay in the said '`~~un«-, and that the printed notice or publication attached hereto is
exactly the same as was p~ u,!~~i ~n she regular editions and issues of the said Cumberland Law
Journal on she 'following c~:~ acs.
viz:
i~/[al'Ch 27, Aprl: _= a_ui ,apnl 10, 2009
A I~iiant fiu-thcr- dei~~~:~~cs +-+I~at he is authorized to verify this statement by the Cumberland
La~>`- .lournal, a legal peria:_lical oPgeneral circulation, and that he is not interested in the subject
mater of the aforesaid no~:~„ or :.advertisement, and that all allegations in the foregoing
stateu~ents as to time, play _~ <u~~i character of publication are true.
~-
Li Marie Coyne, Editor
SWORN TO AND SUBSCRIBED before me this
10 day of April, 2009
Konkle, Edna E. a/k/a Edna K.
Konkle a/k/a Betty E. Konkle,
deed.
Late of Lemoyne Borough.
Executrix: Arleen E. Diamond, 20
N. 12th Street, Apartment 233,
Lemoyne, PA 17043.
Attorneys: Linda J. Olsen, Es-
quire, Killian & Gephart, 218 Pine
Street, P.O. Box 886, Harrisburg,
PA 17108.
Notary
N!~iP,42iAL Sc;'~L
DEB(7RAH .o C:.GILINS
Votary P~~ta1!c
CARLISLE BORO, CU14~~~ERLANrD COUNTY
My Cemmissi~n Expires Apr ?.8, 2010
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tele: (717) 249-3166 Fax: (717) 249-2663
April 10, 2009
Cumberland Law Journal is published every Friday :by the Cumberland County
Bar Association and is designated by the Court of Common Pleas as the official legal
publication for Cumberland County and the legal newspaper for publication of legal
notices.
TO: Linda J. Olsen, Esquire
Edna Konkle, aka Betty Konkle Estate
RE:
Legal advertisements must be received by Friday Noon. All legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on the following dates:
March 27, April 3, and April 10, 2009
Advertising Cost
Proof of Publication
Second Proof Request
Payment received
Total Amount Due
$ 75.00
$ 0.00
$ 0.00
$ 0 .00
$ 75.00
Payment received by
REV-isiz Ex+ ;~z-oa
i~~ Pennsylvania SCHEDULE I
~, DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF PILE NUMBER
EDNA K. KONKLE 21 09 0244
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
1. West Shore EMS-BLS 107.99
2. West Shore EMS-BLS 161.71
3., ;Spirit Physicians Services 6.57
4. Holy Spirit Hospital 199.92
TOTAL (Also enter on Line 10, Recapitulation) ~ 476.19
If more space is needed, insert additional sheets of the same size.
WEST SHORE EMS -BLS
205 GRANDVIEW AVE
• ~ SUITE 211
CAMP HILL, PA 17011
Phone #; (800) 367-0512 Federal Tax ID: 23-2463002
PATIENT NAME: EDNA KONKLE I
INSURANCE: MEDICARE B 159095735A
UNITED I-IEALTHCARE 820942922
HIGHMARK BAP159095735
186030W
EDNA KONKLE
1700 MARKET ST
CAMP HILL, PA 17011
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
REASON(S)
FOR
TRANSPORT
INVOICE
~~
~~ ~~
~~5~ ~~
49277 WCS
186030W NONE
02/19/2009
12:40 PM
MANOR CARE CAMP HILL
MANORCARE HEALTH SERVICES
HOLY SPIRIT HOSPITAL
BONE SCAN
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
WHEELCHAIR MEMBER 2 WAY ', A0130 1.0 93.03 93.03
Transport Van Mileage A0999 4.0 3.74 14.96
I
~
i
~~ C
~ ,~
`~ `~~
~~
Total Charges 107.99
DESCRIPTION OF PAYMENT RECEIPT. PAYMENT DATE AMOUNT
Total Gredits
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~
RETURNED CHECK FEE - $31.00 $107.99
`
DETAG~H ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE 107.99
PATIENT NAME: KONKLE, EDNA K ! CALL NUMBER 186O3OW AMOUNT $ f~ 1 ,(~
PATIENT NUMBER: 49277 BILLING DATE: 03/03/2009 ENCLOSED Iy 'T ' Q!-~
THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL VISA
ASSISTANCE. V/SA~ i n~a5tercar_'
AND
MASTER CARD
ACCEPTED
WEST SHORE EMS -BLS 205 GRANDVIEW AVE CAMP HILL, PA 17011
WES"(- SHOi~C EMS -BLS ~ 1 6 COpg•...~~..__
205 GRANDVIEW AVE ~%~.
SU{TE 211 sib",.
CAMP HILL, PA 17011
Phone #: (80U) 367-0512 Federal Tax ID: 23-2463002 wE~T SH®~~
PATIENT NAME:
EDNA KONKLE
PATIENT NUMBER:
CALL NUMBER:
159095735A DATE OF CALL:
820942922 TIME OF CALL:
BAP159095735 CALLER:
FROM:
TO:
REASON(S)
FOR
TRANSPORT
49277 WCS
186439W NONE
03/02!2009
01:55 PM
HOLY SPIRIT HOSPITAL
HOLY SPIRIT HOSPITAL
MANORCARE HEALTH SERVICES
Sepsis
INSURANCE:
MEDICARE B i
UNITED HEAt_THCAREi
HIGHMARK ';
i
186439W
EDNA ILONKLE
1700 MARKET ST
CAMP HILL, PA 17011
INVOICE
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher One Way Transport i A0999 1.0 96.06 96.06
Transport Van Mileage A0999 1.0 3.74 3.74
OXYGEN ADMINSTRATION A0422
i 1.0 61.91 61.91
i
~~~
~~1
: ~
~
` `~/
Total Charges 161.71
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE- AMOUNT
Total Credits ~ 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -->o-
w r-r-r" A~~1 AA $161.71
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT 161.71
i AMOUNT DUE
KONKLE, EDNA K CALL NUMBER 186439W AMOUNT $ {/~
PATIENT NAME: ~ (lSl l •~~
PATIENT NUMBER: 49277 ~ B{LLING DATE: 03/09/2009 ENCLOSED
THIS SERVICE IS NOT COVERED BY MEDICAKE UK tvlEUlt;A.l. VISA
ASSISTANCE. visa ~~
® AND
MASTER CARD
ACCEPTED
WEST SHORE EMS -BLS 205 GRANDVIEW AVE CAMP HILL, PA 17011
SPIRIT PHYSICIAN SERVICES
205 GRANDVIEW AVE STE 210
CAMP HILL PA 17011
EDNA KONKLE
20 N 17TH ST APT233
LEMOYNE PA 17043-1451
ACCOUNT ## 161214
-~' IF ANY QUESTIONS, PLEASE coNTACr: SPIRIT PHYSICIAN SERVICES 717-972-4490
I'130GEI?URE DlAG ``
DATE GOD> CODE QTY DESCRIPTION
2 D~ 2
STATEMENT
DATE: 03/14109
LAST STATEMENT
DATE: 02/07/09
FED TAX ID # 251766971
INS CHARGE PAY141ENTt' GUARANTUR
- ADJUSTMENT-.BALANCE'
/^~
~~J
~ ~~D~p~
~,~
/A7PORTANT~PLEASE DETACH ~iND RETURN BOTTOIIA PORTION Df STATEMENT WITH YOUR PaYMEN7
STATEMENT DATE GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT:
sl2 43/14/09 ~ 6.57 $ 6.57
SPIRIT PHYSICIAN SERVICES
205 GRANDVIEW AVE (HP)
STE 210
CAMP HILL PA 17011
...III~~~II1.~~~~~U~~~Ii~~~lll~.~ill~„I~~I~~It~~t1~~~1~~1.1 00001864 02
Mafl SPIRIT PHYSICIAN SERVICES EDNA KONKLE
ra 205 GRANDVIEW AVE STE 2I0 20 N 12TH ST APT233
CAMP HILL PA 17011 LEMOYNE PA 17043-1451
7FF7CE USF pNLY PDR CREDIT CARD PAYMENT, PLEASE FlLL IN INPDRMATION BELOW -===_=_= -==~~-}~- - - -,-~~1fI.
1680214
CIIECIC oNE I I I I l l l l l l i i l l l l l
M/C CARD NUMBER EXP DATE - - ~F ~ `- If 'f`===== = _ _____
VISA $ 6.57
__
~C• 12S0 CARDHOLDER NAME (PRINTS _~~T:_ ~, "J ~°
CREDIT CARD SIGNATURE SPIRIT PHYSICIAN SERVICES
LJ CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
STATEMENT OF PHYSICIAN SERVICES
SPIRIT PHYSICIAN SERVICES
205 GiiANDVIEW AVE STE 210
CAIVaP HILL PA 17011
EDNA KONKLE
20 N 12TH ST APT233
LEMOYNE PA 17043-1451
ACCOUNT #
IF ANY QUESTIONS, PLEASE coNTACr: SPIRIT PHYSICIAN SERVICES
PROGkt>URE . DtAG ~`".
QATE CODE CODE RTY QESCRIPTION ,
,; .-: ~;
»> PARENT: EDNA KDNCLE 1b8D214
1680214
STATEMENT
DATE: 03J14J09
!AST STATEMENT
DATE: 02 f0TJD9
~ of
717:972-4490 FED TAX ID # 257766977
INS CHARGE I~AYIVIENTI ';;GUARANTOR:
,ADJUSTMENT BALANCE
PERFORMED BY: SWARNALATHA NEEMA MD MD
PLACE OF SVC: 21
PERFORMED AT: HS
D1/24/04 99223 723.1 INITIAL HDSP CARE LEVEL I 148.D0
~ D2/17/04 MCARE ERA PMT 138.87-
~ 02!17/04 MCARE ERA CONTR/ADJ 20.24-
* 03/D3/04 COMMERCIAL PAYMENT 38.84- D.OD
PERFORMED AT: HS
OL25/09 94232 723.1 SUBSEQUENT HOSP, LEVEL II 73.00
~ 02117/09 MCARE ERA PMT 52.56-
~ 02/17/D4 MICARE ERA CONTR/ADJ 7.30-
~ 03/D3/04 COMMERCIAL PAYMENF 13.14- D.DO
PERFORMED AT: HS
D1/26/04 49232 723.1 SI~SEQUENT HASP, LEVEL TI 73.DD
~ 02/17/D4 MCARE ERA PMT 52.5b-
* D2J17/04 MICARE ERA CONTR/ADJ 7.30-
~ D3/03/09 COMMERCIAL PAYMENT 13.14- 0.00
PERFORMED BY: VIDA FARHI MD MD
PERFORMED AT: HS
DL27/D9 44232 723.1 StSSEQUENT HOSP, LEVEL II 73.DD
0?105I04 MCARE ERA PMT D.OD
02/05/04 MCARE ERA CONTRlADJ 7.30-
~ 02/24/04 COMMERCIAL PAYMENT 54.13- 6.57
PERFORMED AT: HS
OL28/04 44238 723.1 HOSPITAL DISCHARGE <30 MI 284 100.00
D2/05/D4 MCARE ERA PMT D.OD
02/05/04 MCARE ERA CONTR/ADJ 34.87-
02/05/D4 MEDICARE PAYMENT. 50.34-
* 02/14/09 6UARIWTDR PMT 14.79-
* 02/24!09 COMMERCIAL PAYMENT 58.b2- D.OD
BALANCE: EDNA KDNCLE $6.57
* INDICATES NEW FINANCIAL ACTIVITY SINCE LAST BILL.
OTHER CHARGES BILLED TO INSURANCE 224.00
PATIENT BALANCE SHOMN DN TNIS STATEMENT IS DUE FROM YOU. PLEASE
REMIT FULL AMOUNT PROMPTLY. PAYMENT IS DUE UPON RECEIPT DF THIS
STATEMENT.
3eeeeTHESE SERVICES WERE PROVIDED BY SPIRIT PHYSICIAN ~aeee
~eeeESERVICES AND ARE SEPARATE FROM ANY HOSPITAL FEES jeeee
3eeeePLEASE CALL 717-972-4440 WITH ANY QUESTIONS ~eeee
~eeeCONCERNING THESE CHARGES. 3eeee
CHECK BOX AND ENTER ANY ADDRESS OR f NSURANCE CORRECTIONS ON BACK
~ QLY
I~ZIT
HOSPITAL
The Spirit of Caring
Hol S irit Hos i
~' Pfi ~. p,~tal
503 N 21ST STREET
CAMP HILL PA 17011
800-997-8573
For Account Information, Please Call 800-9978573
~-
KONKLE ,EDNA K
Service Date: 03/01!09
Service End_
Last Statement Date: 03106/x9
Account No: 34059$81
Statement of Account 04J~S/49
Transaction Date Description
PREVIOUS BALANCE
03/01/09 CANNULA TUBING
03/01/09 CHEST PORTABLE
03/01/09 OXYGEN PER HOUR
03/01/09 LEVEL IV FC
03/01/09 INS TEMP $LADDER CATH
03/01/09 NON-EVA EAR/PUL OX FOR 02SATUR
03/01/09 EKG
03/01/09 IV INFUSION,THERAPY UP TO 1HR
03/01/09 IV PUSH,EA ADD NEW SUBSTANCE
03/01/09 IV INFUSION,HYDRATION,EA HR
03/02/09 INJ AZITHROMYCIN SOOMG
03/02/09 INJ CEFTRIAXONE SOD 250MG
03/02/09 KCL INJ 20MEQ
03/02/09 PROTONIX 40MG INJ
03/02/09 LIDOCA 1% 30ML
03/02/09 TRANS DISP 25
03/02/09 NACL .9% 250ML
03/02/09 NACL 0.9% 100
03/02/09 DEXTROSE 5% 1000
03/02/09 EKG PC-INTERPRETATION & RPT
03/02/09 PUMP SET 3Y TYPE
Estimated Insurance Due: .00
Total Patient Credits:
YOUR INSURANCE HAS BEEN BILLED.THIS IS YOUR CURRENT
BALANCE. YOUR PAYMENT IS DUE UPON RECEIPT. THANK YOU.
M10 MEDICARE OP A .00 Q15 UNITED HEALTH .00
PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID.
~ ~ ~~ ~
r (.~1
J,. -1
Amount
.00
2.00
418.00
54.00
804.00
118.00
55.00
158.00
457.00
64.00
156.00
238.85
231.75
1.05
105.00
3.75
65.00
79.70
78.30
82.50
33.00
54.40
34059881
HOLY SPIRIT HOSPITAL
503 N 21ST STREET
CAMP HILL PA 17011
ADDRESS SERVICE REQUESTED
ADM DT: 030109
DSH DT: 'NONE'
SB: 21020
717-737-8551
HR: HSG
Q38.9
nrsnunt Numcer_ Please Yiy This Amount:
Patient Name_ Due By-.
KONKLE ,EDNA K 05/03/09
^ ^ ^
r'-f Check box if Your address or insurance information Make Check Payable To: HOLY SPIRIT HOSPITAL
t_.l has changed.Pfease make changes on back.
• The CW1 Number is the Wst 3 digits on the bads of your aedit ord, by your signature
DDD45757 002 0.72
34059881
EDNA K KONKLE
1700 MARKET ST
CAMP HILL PA 1 701 1-481 7
I . t.l I I.I.....11 I..I...I.I i
HOLY SPIRIT HOSPITAL
P.O. BOX 822183
PHILADELPHIA,PA 1 91 82-21 83
'~99- ~~
ODDD34D598810D1DDDDDD19992DD10D73SDDDDDDD113D2
REV-:1513 EX+ ~I1-48}
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE
BENEFICIARIES
ESTATE Of FILE NUMBER
EDNA K. KONKLE 21 09 0244
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS {Include outright spousal distributions and transfers under
Sec, 9116 (a) (1.2}.]
1. Arleen E. Diamond, 541 Mill Road, Sidman, PA 15955 -Residue +/-16,031.25
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN A80VE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1. Our Lady of Lourdes Catholic Church, Enola, Pennsylvania, Liquidated value of stocks as 65,178.23
distributed to Charitable Beneficiary
___.. __ _. __ ._ _..__.. _.._.~ .~...~ T.... r,l ~ I1iCTRT[]I ITT(1AIC (1~I 1 rnl[ ~~ nc Dc\I_1CM fr1VFR CNFFT 4(. 65,178.23
If more space is needed, insert additional sheets of the same size.
~~
A
:t~
._
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
Orphans' Court Division
ESTATE OF EDNA K. KONKLE
a/k/a Edna E. Konkle, a/k/a Betty Konkle
No. 00244, Year of 2009
NOTICE OF CHARITABLE GIFT
Honorable Tom Corbett, Attorney General
Pennsylvania Office of Attorney General Date: May 12, 2009
16th Floor, Strawberry Square
Harrisburg, PA 17120
Dear Mr. Attorney General:
Notice is hereby given of a charitable gift, as follows:
1. Charitable gifts are made as follows:
(a) All ownership in stocks shall be transferred to OUR LADY OF
LOURDES CATHOLIC CHURCH, Enola, Pennsylvania. Pursuant to the
request of the Church, the stocks were liquidated. The proceeds, including
the increase in value from date of death to date of liquidation, in the
amount of $65,178.23 was paid to the Church on May 12, 2009.
2. The name and address of the fiduciary is Arleen E. Diamond, 541 Mill Road,
Sidman, PA 15955-3516.
A copy of the instrument creating the gift is attached hereto.
4. If gift is other than pecuniary legacy which will be paid in full, there is attached
hereto:
(a) Not applicable. At the direction of beneficiary, the stocks were liquidated
and full amount distributed to OUR LADY OF LOURDES CATHOLIC
CHURCH, Enola, Pennsylvania.
(b) A statement of all compensation which has been paid or is being claimed
by fiduciary and counsel. Executrix is claiming no fee. Attorneys' fees to
be reflected on PA Inheritance Tax Return are billed on an hourly rate of
$175.00 and the total is expected to be less than $2,500.00.
Respectfully yours,
/j-,
..~-- ~ ~
Linda J. lsen, Esq ' e
Attorney I.D. No. 92858
KILLIAN & GEPHART, LLP
218 Pine Street
P.O. Box 886
Harrisburg, PA 17108-0886
Counsel for Arleen E. Diamond, Executrix of the
Estate of Edna K. Konkle, a/k/a/ Edna E. Konkle,
a/k/a Betty Konkle
Date: May 12, 2009
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
Orphans' Court Division
No. 00244, Year of 2009
ESTATE OF EDNA K. KONKLE
a/k/a Edna E. Konkle, a/k/a Betty Konkle, Deceased
CERTIFICATE AND RETURN OF SERVICE
I HEREBY CERTIFY that on May 12, 2009, notice was given by U.S. certified mail to
the Honorable Tom Corbett, Attorney General, Commonwealth of Pennsylvania, of the charitable
gift to Our Lady of Lourdes Catholic Church by Arleen E. Diamond, Executrix of the Estate of
Edna E. Konkle, a/k/a Edna K. Konkle, a/k/a Betty E. Konkle, deceased, in accordance with Rule
5.5 of the Orphans' Court Division, Court of Common Pleas, Cumberland County, Pennsylvania.
Respectfully yours,
-.~. 4. ~ ~
~t.~~- ~~i~_
`-Lind lsen, Es ire
Attorney I.D. No. 92858
KILLIAN & GEPHART, LLP
218 Pine Street
P.O. Box 886
Harrisburg, PA 17108-0886
Counsel for Arleen E. Diamond, Executrix of the
Estate of Edna K. Konkle, a1k/a/ Edna E. Konkle,
a1k/a Betty Konkle
Date:
^ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
^ Print your name and address on the reverse
so that we can return the card to you.
^ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
f~e~~~~P ~0/Y)~~/~~
~tfor~ ~
~f i~cXr~Q ~.~4 I ~ /z ~
A. Received by (Please Print Clearly) I B. Date of Delivery
9f~n~t#~ ~ y, ~~jj
,~, „~,~,s ~{ MQY'iJplgent
a). Is delivery address different from itemtl ? ^ Yes ,{,'
If YES, enter delivery address below: ^ No °"
3. Se ice Type
Certified Mail ^ Express Mail
Registered ~ Return Receipt for Merchandise
^ Insured Mail ^ C.O.D.
4. Restricted Delivery? {Extra Fee) ^ Yes
2. Article Number ~~~~
(Transfer from service label) -'~"l/~/V ~ ~ ~Q 0~ ~~ Q / ~d 13~
PS Form 3811, March 2001 Domestic Return Receipt 102595-Ot-M-1424
N
m
ra
0
t
Postage
$ 5 /;
~,,~ •~`/
I ~
}
0 Certified Fee ~
.
fTl Retum Receipt Fee d (7 Postmark
~ (Endorsement Required) Here
~ ResMcted Delivery Fee
~ (Endorsement Required} /
p Total Postage $ Fees ~ ~~ ~ Li
~ ///
~! Rec lQn N me lease Pr/n /early) (T be m lefed by mailer)
1~c'1~. r.~~------ ----- -- --------------------
~ Street, Ap . No.; or PO oz No.
~ City S t ~P/ 4 / / -y /
ESTATE OF EDNA K. KONKLE
a/k/a Edna E. Konkle, a/k/a Betty Konkle
LATE OF LEMOYNE, CUMBERLAND COUNTY, PENNSYLVANIA
RECEIPT AND RELEASE
KNOW ALL PERSONS BY THESE PRESENTS THAT OUR LADY OF
LORDES CATHOLIC CHURCH does hereby acknowledge that it has received of and
from Arleen E. Diamond, Executrix of the Estate of Edna K. Konkle, a/k/a Edna E.
Konkle, a/k/a Betty Konkle, the full specific bequest as set forth in Item SECOND of the
Last Will and Testament of Edna K. Konkle, a/k/a Edna E. Konkle, a/k/a Betty Konkle,
deceased, to wit:
The sum of $65,178.23 representing the liquidated value of all shares of
Stock owned by Decedent at the date of her death.
OUR LADY OF LORDES CATHOLIC CHURCH, by its authorized official,
hereby accepts and approves said distribution with the same force and effect as if it had
been duly awarded to the undersigned pursuant to an Account duly filed in the Office of
the Register of Wills and audited, adjudicated and confirmed absolutely in the Orphans'
Court.
OUR LADY OF LORDES CATHOLIC CHURCH by its authorized official
hereby releases, quitclaims and forever discharges Arleen E. Diamond, Executrix of the
Estate of Edna K. Konkle, a/k/a Edna E. Konkle, a/k/a Betty Konkle, of and from any
and all claims it has or may have under the Will against the said estate and the said Arleen
E. Diamond, Executrix.
IN WITNESS WHEREOF, as the authorized official for the OUR LADY OF
LORDES CATHOLIC CHURCH, Enola, Pennsylvania, I have hereunto set my hand and
seal this % ? ~ day of /~~ c'r ~' , 2009
OUR LADY OF LORDES CATHOLIC CHURCH
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WITNESS