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06-02-09
15056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Coun Code Year File Number Bureau of Individual Taxes ~ INHERITANCE TAX RETURN ~ " PO BOX 280601 ~ \ G ~j, ~(~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT V ENTER DECEDENT INFORMATION BELOW ! 09/07/2008 ' 12/12/1918 Decedent's Last Name.. Suffix Decedent's First Name MI _ _ ' DIVEN ;Florence _ G . __ _ . (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE _ __ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~,~: 1. Original Return ,,._, 2. Supplemental Return 3. Remainder Return (date of death ~._,_, 4. Limited Estate n.!•.: 6. Decedent Died Testate (Attach Copy of Will) „,,, 9. Litigation Proceeds Received ~ .m,„~ 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) prior to 12-13-82) 5. Federal Estate Tax Return Required 1._ 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 Patricia J. Eckman ', (717) 486-7902-~ ': Firm Name (If Applicable) ~ ..__ ___. ,...m._~. -.. _....__...___~..__... , _ ..._ ~ .,._ REGISTER OF WILLS USE dNUY + ; } _.. ~ _ _.... First line of address ; - ' ; 1 Tioga Ln _ Second line of address' _ _ _ _ City or Post Office :, Carlisle Correspondent's a-mail address: _ _ _ . __ _ _ _ _ State ZIP Code - PA :17015-7509 _ - DATE FILED i Under Wallies of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my k ledge and belief, it is tr e, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer s any knowledge. OF PERSON FILING RETURN __ -- A 1 Tio~L~t, C~rli~l A 17015-7509 _ OTHER THAN REPRESENTATIVE ADDRESS ~. ~ " ~ 26 State ve., Suite 103, Carlisle, PA 17013-4457 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 J REV-1500 EX Florence Decedent's Name: RECAPITULATION 15056052059 G DIVEN 1. Real estate (Schedule A) .......................................... ... 1. 2. Stocks and Bonds (Schedule B) .................................... ... 2.L 9,376.87 ; 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. '' 4. Mortgages i~ Notes Receivable (Schedule D) .......................... ... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. 1,988.88 ': 6. Jointly Owned Property (Schedule F) Separate Billing Requested .... ... 6. ' 52,141.80 '; 7. Inter-~vos Transfers & Miscellaneous Non-Probate Property ._ _ .... (Schedule G) Separate Billing Requested..... ... 7.: 136,459.18 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ' 199,966.73 '' 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. ', 12,069.97 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. 3,454.93 11. Total Deductions (total Lines 9 i~ 10) ................................. .. 11. 15,524.90 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. ' 184,441.83 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 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 45 184,441.83. 15. ., . r.. _ .M.... .. .._ .... . 16. Amount of Line 14 taxable at (meal rate X .0 _ ' 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 ' 18. 19. TAX DUE ................................... ......................19. 20. FILL IN THE OVAL IF YOU ARE R ERPAYMENT 15056052059 Side 2 184,441.83 8,299.88 8,299.88 Q 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Number ,.._...._._..,~ ._ ., .. _ ... ._<... . e.. . tI ~, ~£ DECEDENT'S NAME STREET ADDRESS 1000 W. South Street CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 8 299 88 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments 5,000.00 C. Discount 263.15 Total Credits (A + B + C) (2) 5,263.15 3. Interest/Penalty if applicable D. Interest E. Penalty Total InterestlPenalty (D + E) (3) 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. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 3,036.73 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 3,036.73 Make Check Payable to: REG/STER 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? .................................................................................................................. ...... 0 ^ 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) (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 zero (0) percent [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 zero (0) percent [72 P.S. §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 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 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-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Florence G. Diven FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) OST ~~visc~r~+~mp~a~s Online Service and Transactrans Account Profile -TAX-EX BOND FD - B ~"'} r- ~:m~r rise ~'~ t'"' 1~°ntr~t~,'c~l Training Close Window Account Profile ~ Activi ~ Checks Issued ~ Arrangements Transaction Wizards ..~ ~.~._~., _.~..~.~. .. a..~.. ~.. ~ _ .....T .,~_~.~ ~_ . .. ~. _ . Move Mone ~~Move Money r New Money In Systematic Out of Account Within Account ` Move Money Previous Account Next Account ®v~rnership Information Account #: 0000 0010 1297 6700 9 002 Account Status: ACTIVE Opened Date: 03/10/2006 Ownership: FLORENCE G DIVEN TOD Plan Type: NON-QUALIFIED Associated TIN: 204-03-8163 Taxpayer's Current Age: Deceased Associated Group IDs - Select Group Account List Group ID Group Type 0083 0468 5 001 HOUSEHOLD Associated Client IDs - Select Client Profile Client ID Client Name Role Beneficia Information PRIMARY BENEFICIARY Request Correction DAVID LEE DIVEN SON QfLT 171!'+l~ JrA-1 ~JICVCCQ 1"1A11!'`lJT - 1 'T1 1 ITrGTPC-J~-CT's 7ViL`I Cf'CQ-DTT~TTI i Value as of 11/11/2008 ©9/07 og ` Account Opened Date 03/10/2006 Good Funds Amount $4,336.67 9, 37~ ~87 ~'~ ~42 i~oM ~ll,L/M0 ~ S'~ nIBE.+~C ~ r 0 /~ `~'~b g. ~ff- ~ https://www8.ex.is.ameriprise.com/Ost/Secure/AccountProfile/AccountProfile.asp?a1Key... 11/12/2008 ~ ~1 OST At Risk Amount $0.00 Amount available for 336 67 $4 redemption: , . Approximate amount available 336 $4 66 without CDSC: , . Collaterally Assigned: No Liquidation Information as of 11/'11/2Qa8 Shares: 1268.031 . NAV: 3.420 Principal Value: $4,336.67 . Plus Accrued Dividends: $6.44 Gross Value: $4,343.11 . Less CDSC Amount: $0.00 . Less Withholding Amount: $0.00 Liquidation Value: $4,343.11 investment Information Ticker Symbol: ITEBX CUSIP Number: 76931 P603 Asset Value: NO Cost Basis: $5,043.16 Combined ROA Value: $49,545.91 Letter Of Intent Commitment Amount: $0.00 Purchases within 90 days: $645.72 Repurchase Credits: $0.00 LOI Escrow Shares: 0.000 New Money Shares: 0.000 Fund Progress Report Fund Progress Report Fund As-Gf Vaiues AS-Of Date ,11/11/2008 Fund As Of Values Tax. Information Current Year ~~ ~. ~ -, _~ REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Florence G. Diven Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sneers of ine same size ~. W i ~d 1-888-910-4100 ~aU. Citizens' Phone Bank anytime for aaount information, current rates and answers to your questions. US002 BR319 FLORENtE G DIVEN 1 TIOGA LN CARLISLE PA 17013 Savings Account Statement OF 1 Beginning July 01, 2008 through September 30, 2008 ~_----- Savings SUMMARY Balance Calculation Balance Previous Balance 1,017.53 ~ Average Daily Balance 1,017.70 Withdrawals .00 - Interest Deposits & Additions .00 + Interest Paid 5P + Qment Interest Rate .20°0 Annual Percentage Yield Earned .20"0 'urrent Balance 1,018.05 = Number of Dnys Interest Earned 92 Interest Earned . 51 Interest Paid this Year 1.53 TRANSACTION DETAILS Interest Date Amount description 07/31 .18 ~nterest pg/2g .17 Interest - 09J30 .17 Interest Daily Balance Date Balance Date Balance Date Balance 07/31 1,017.71 08/29 1,017.88 09/30 1,018.05 ~ NEWS FROM CITIZENS --IMPORTANT NOTICE/CHANGE IN TERMS Effective November 1st, 2008, when you request a single copy of a check, document, or statement, we will waive the $25 per hour / $25 minimum Research/Reconciliation fee. All other research or reconciliation requests wilt be subject to this fee. --IMPORTANT NOTICE/CHANGE IN TES MS FOR ACCOIINTS THAT RECEIVE STATEMENTS QUARTERLY Effective November 1, 2008 for accotmts that receive statements on a quarterly basis, our handling fee for certain court orders and legal processing will be $90 for each item lhat we process against your account. This includes court orders, garnishments, attachments, tax levies, executions, and similar types of legal process. ELORENCE G DIVEN Basic Savings 6140-210518 Previous Balance 1,017.53 n Totallnterest Paid .52 Current Balrnce ].0].8.05 003 1017.53*+ 0.18 + 0.17 + 1'017.88 ~ t ~~ ~ n ,., t t'rit ~~ Jl~j:}°t~ ~SC ~c~;r ~~ --~ ! L tip _''"a/l4n 5 ~m ,, f r~y~ ~~ /~7~~ - i ~~~-sl 1 ~y~ ~ //ii j~~`r - //J Cs) rfa.~ - I ~' ~ ~ - i/ .,~L;~ - - ~~~ ~`~~~ - i r ~ ~.= - l r %, ~ s) / S;~i ,~ i,~~ - ~ ~~.o~ ~i ~ f ~= c'- I ~ ~~ ~~ -~ ", G~ ~' ~G , cc ~ ~.°c I~l,~`' 3~, ~~~; ~~, j~'; c` ~C.c 1~1~~'~ I~,cz ~`~ .o-~ 5 S , ~; ~; i ~f , ~"~ ! ~ ~~~~ rn r'1_ (s ~) i y~~ - i~ ~:~a ~ ~ Z~ ( C~ ~ J~11 ~ - / ~ ~l . o ~. ~~~ i~Ir - ~i! ~5 y. u~ v ld 0~~ - ~ ~ ~"' GI L~ l~G~ o - -~ !v C. U c / / ~/~c/~~ . iS~~ ~rh~~,c i %.o~ C~ ~ /t~ %~'~ III" ~ `' __--- ~-;- . ~ q7 ~'~ __ ,_ ~~~ ,~ ~ ~- n c-~ ~~ V 1 V ~~ SCHRACK &LINSENBACH e LAW OFFICES 124 W. HARRISBURG ST. P.O. BOX 310 DILLSSURG, PA 17019-0310 PHONE (717) 432-9733 FAX (717) 432-1053 October 14, 2008 Attention: Lana Hughes Pennsylvania Department of Revenue 140 North Duke Street York, PA 17401-1110 Re: D/D: File # Dear Mrs. Hughes: The Estate of Florence G. Diven September 7, 2008 21-OS-0975 Attorneys WM. D. SCHRACK III BRIAN C. LINSENBACH v-,:. You will find enclosed herewith a copy of the Safe Deposit Box Inventory that was ~- completed in the Dillsburg branch of Citizens Bank on Friday, October 10, 2008. Thank you for facilitating access with the authority dated September 30, 2008. Sincerely, WDS/jsg enc. cc: ~atricia J. Myers Eckman COPY Wm. D. Schrack III SCHRACK &LINSENBACH Sat ~ ~ Z °~ ~" SAFE DEPOSIT -BOX INVENTORY INSTRUCTIONS \SH: REPORT TOTAL ONLY. STOCKS: LIST IN DETAIL EVERY COMMON OR PREFERRED CERTIFICATE, WARRANT OR OTHER RIGHTS FUND 1N BOX. STOCKS ARE TO BE DESIGNATED BY NAME OF COMPANY, CERTIFICATE NUMBER, DATE OF :RTIFICATE, NAME IN WHICH STOCK IS REGISTERED, AND NUMBER OF SHARES AND CLASS OF STOCK. OBLIGATIONS OF U.S. GOVERNMENT: NUMBER OF ITEMS, DATE OF ISSUE, FACE VALUE, NAMES IN WHICH :GISTERED AND TYPE OF OWNERSHIP, ie.. JOINTLY HELD, PAYABLE ON DEATH, ECT. BONDS: DESIGNATE BY NAME, AMOUNT, SERIAL NUMBER, OR OTHER DESIGNATION. (BEARER BONDS) BANK AND SAVINGS AND LOAN PASSBOOKS: STATE NAME OF DEPOSITOR, NUMBER OF BOOK, LAST DATE 'PEARING IN BOOK, NAME OF BANK AND BRANCH, AND BALANCE. JEWELRY, COINS, STAMPS, MANUSCRIPTS, ECT: LIST AND DESCRIBE AS FULLY AS POSSIBLE. DEEDS, MORTGAGES, CURRENT INSURANCE POLICIES OR OTHER EVIDENCES OF INDEBTEDNESS: LIST AND .SCRIBE AS FULLY AS POSSIBLE. ~ ALL OTHER CONTENTS. .M NOy ITEM DESCRIPTION .~CLrS ~~~ % ~/v~lQ CCrC ^t%GSSJ ~e G' 0 ~~ ; ~ L ILi ~ Utr :ERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE~PERSON RECEIVING COPY OF SAFE DEPOSIT BOX INVENTORY: ECORD !S CORRECT AND COMPLETE TO THE BEST OF MY NOWLEDGE AND BELIEF- - ~._,.,,..-- -~-----~.----~,~,-- --~ ~~~E =z~•r~- ~i51GNATURE ____- - ._. --~;-r-~ p"~tj' .~ Ei4M3°.~ ~t>' ~.f/'BO 6EL0 J:.-.~ L, L/~-/' C.l ~G !~/,~- c-~r ~~' ~.c Y~ i ~ , mac... ~~~-,~G v, ,. - _ ~. ~ kr k. v ~, ~ ,. - \TE REPR~SENTf~TfVE~,~~~;;;'" OTE: ATTACH ADDITIONAL 81/2" x 11" SHEET(S) IF NECESSARY OR USE DUPLICATES OF THIS PAGE OF FORM. REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY OWNED PROPERTY ESTATE OF FILE NUMBER Florence G. Diven If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A• Patricia J. Eckman 1 Tioga Ln Daughter Carlisle, PA 17015 e' David L. Diven 6200 Marshall Rd Son Centerville, OH 45459 C. JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY _~` INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 05/02/85 Ameriprise Tax Exempt Hi Inc Fund A 0000 0031 5083 0468 5 002 42,091.80 50 21,045.90 2 B. 01/25/89 Ameriprise Diverse Bond Fund A 0000 0011 2083 0468 0 002 52,192.55 50 26,096.28 3 A. 11/02/06 Member First FCU Certificate of Deposit 295135-40 5,430.07 50 2,715.04 4 A. 11/02/06 Citizens Bank Checking Account 610074-573-2 4,569.15 50 2,284.58 TOTAL (Also enter on line 6, Recapitulation) I $ 52,141.80 (If more space is needed, insert additional sheets of the same size) NUV-'L5-'LUU~ IUt Ub~'LI fM OST A~lvisor~Cornpass~' Online 5er~lce and Transa~tlons Account Profile -TAX-EXEMPT HI IN - A Account Profile ) Activity ) Checks Issued r. uuuiuiu Page 1. of 3 Ameri rise .~. 17r~~ir~~ic~1 Tralning Close Window ) Arrangements Transaction Wizard . inr, s;~t;rr,-rrrrcunr~r~s~ ._ ~rnar~,++~-~ .. .... Move Money Move Money ~ ~ New Money In i S~ y emetic Out of Account Within Account , i Move Money Ownership Information . Account #: 0000 0031 5083 0468 5 002 Account Status: INACTIVE Opened Dafie: 05/02/1985 Inactive Date: 10/28/2008 Ownership: ~ FLORENCE G DIVEN PATRiCIA J MYERS Plan Type: NON-QUALIFIED Associated TIN: 204-03-8163 Taxpayer's Current Age; Deceased Associated Group IDs - Select Group Account List Group ID Group Type 0083 0468 5 001 HOUSEHOLD Associat®d Client IDs - Select Client Profile Client 1D Client Name Role Value as of 17!2412008 0 07 ~8 Account Opened Date 05/02/1885 Govd Funds Amount $0.00 ~ ~ rfZ o9 f. 8p At Risk Amount $0.00 Amount available for redemption: $0.00 Collaterally Assigned: No S~ t~i!4.2 Ff2-OM c~.-tticA~n-D ~: S-r~..s~f.24 r7~U it ~~~ rzao~. ~+- ~ . g ~ ! hops:l/www8.ex.is.amexip~rise.comJOst/Secuxe/A.ccountPxofile/AccountPxo~ie.asp7alKey... ///25/2008 7ST Y~I~Q ~.~.., A~vis~~c~mp~l~ Online Service and Transactions Account Profile -DIVERSE BOND FUN - A Account Profile ~ Activity ~ Checks Issued ~ ~. I•~-arr~~c-crl Trainina Close Window Arrangements Transaction Vi€izards M,._..M....__..~._ ---....__ ......._,,. _.-.~ ~,...~a..._~,..~, .. -_.W . Outo., .. ......._ oney Move Money z New Money In Systematic of Account Within Account ~ Move Money First Account Next Account O~,rnership Information Account #: 0000 0011 2083 0468 0 002 Account Status: ACTIVE Opened Date: 01 /25/1989 Ownership: FLORENCE G DIVEN DAVID LEE DIVEN Plan Type: NON-QUALIFIED Associated TIN: 204-03-8163 Taxpayer's Current Age: Deceased Associated Group IDs - Select Group Account List Group ID Group Type 0083 0468 5 001 HOUSEHOLD Associated Client IDs - Select Client Profile Client ID Client Name Role Value as of '! 11'I'1/2Q08 pQ~o7 g Account Opened Date 01/25/1989 Good Funds Amount $45,209.24 SZ IgZ.55' At Risk Amount $0.00 Amount available for redemption: $45,209.24 Approximate amount available without CDSC: $45,299.99 Sim- ~~ Fi'LDM Lt~rc.t.rA-,z0 S ~rErn1',s£?G , ~rn /I~i. `Zoos". ~ft httros://www8.ex.is.amerinrise.com/Ost/Secure/AccountPrcfile/AccnuntProfile_asn?alKev___ 11/12/2~OR ~ °~i' ^ST Collaterally Assigned: INo Liquidation Information as of 'i 1l'I'11200 Shares: 10321.745 . NAV: 4.380 Principal Value: $45,209.24 . Plus Accrued Dividends: $90.75 Gross Value: $45,299.99 . Less CDSC Amount: $0.00 . Less Withholding Amount: $0.00 Liquidation Value: $45,299.99 Investment Information Ticker Symbol: INBNX CUSIP Number: 768912602 Asset Value: NO Cost Basis: $50,419.96 Combined ROA Value: $49,545.91 Letter Of Intent Commitment Amount: $0.00 Purchases within 90 days: $645.72 Repurchase Credits: $5,200.00 LOI Escrow Shares: 0.000 New Money Shares: 0.000 Fund Progress Report Fund Progress Report Fund As-Of Values AS-Of Date 11/11/2008 Fund As Of Values Tax Information Current Year Address Address: C/O PAT ECKMAN 1 TIOGA LN CARLISLE, PA 17015-7509 Scat F ~ Z ~ 2 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AN D DEPT. 280601 HARRISBURG, PA 17128-0601 TAX P AY E R R E S P O N S E REV-3543 IX qFP (09-00) FILE N0. 21 ACN 08143650 DATE 09-18-2008 EST. OF FLORENCE G DIVEN S.S. N0. 204-03-8163 DATE OF DEATH 09-07-2008 COUNTY CUMBERLAND TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. REMIT PAYMENT AND FORMS T0: PATRICIA ECKMAN REGISTER OF WILLS 1 TIOGA LANE CUMBERLAND CO COURT HOUSE CARLISLE PA 17015 CARLISLE, PA 17013 MEMBERS 1ST FCU has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions may be answered by calling (717) 787-8327. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AIVO PAYMENT INSTRUCTIONS Account No. 2951 35-40 Date 11-02-2006 To insure proper credit to your account, two Established (2) copies of this notice must accompany your payment to the Register of Wills. Make check Account Balance 5,430.07 payable to: "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are ^ade within three Amount Subject to Tax 2, 715.04 (3) months of the decedent's date of death, Tax Rate X .045 you way deduct a 5% discount of the tax due. Any inheritance tax due will become delinquent Potential Tax D ue 122.18 nine C9) months after the date of death. P T TAXPAYER RESPONSE ~ ~ FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT EkSED ON THIS NOTICE A. ~ The above information and tax due is correct. 1. You way choose to remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you may check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONE B L 0 C K C B.~The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y ,to be filed by the decedent's representative. C. ~ The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. PART If you indicate a different tax rate, please state Your DFFICIAL USE ONLY ~ AAF relationship to decedent: PA DEPARTMENT OF REVENUE TAX RE TURN - COMPUTATION OF TAX ON JDINT/TRUST ACCOUNTS PAD ~iric I. Deie c5 iaui13ile ii i 2. Account Balance 2 2 3 Percent Taxable 3 X 3 . 4. Amount Subject to Tax 4 4 5 Debts and Deductions 5 - ~ . 6 Amount Taxable 6 6 . 7. Tax Rate 7 X 7 S Tax Due 8 8 . PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID WORK ( ~ TCI CDLI niJC MIIMIICD TOTAL CEnter on Line 5 of Tax Computation) 8 Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. unMr r ~ '® MEMBERS 151 FEDERAL CREDIT UNION Send inquires to: SD00 Louise Drlve PO Box 40 Mechanicsburg, PA 17055 www.membersl st.org Main Switchboard: (717) 697-1161 or (800) 263-2328 EZ Call: (717) 697-4372 or (800) 283-4372 TDD: (717) 697-5312 or (800) 283-2328 ext. 5312 TeleBranch: (717)795-6049 or (800)237-7288 Statement of Accounts Jun 25, 2008 thru Sep 24, 2008 Account Number: 295135 Account Balances at a Glance: Checking: o . 00 Savings: 25 . o0 CertltlCateS: 5 , 426.87 Loans: o.oo Money Management: o . 00 Page: 1 of 1 FLORENCE G DIVEN PATRICIA J ECKMAN C/O PATRICIA J ECKMAN 1 TIOGA LANE CARLISLE PA 17015 Your aggregate balance as of September 1st is $5,451.87. An aggregate balance of $2,500 and having 3 products will place you in the Silver MLR level. Access over 25,000 surcharge-free ATMs in the United States. See the enclosed insert for more details. SAVINGS ACCOUNTS 00 - REGULAR SAVINGS Date Transaction Descri tion Additions Subtractions Balance Jun 25 Balance Forward 25.00 Sep 24 Ending Balance 25.00 CERTIFICATE ACCOUNTS 40 - 18 MONTH CERT Maturity Date - Aug 02, 2009 Date Transaction Descri tion Additions Subtractions Balance Jun 25 Balance Forward 5,378.05 393.92 87 5 15 Jun 30 Deposit Dividend 3.590% , . Annual Percentage Yield Earned 3. 650% from 0&/01/2008 through 06/30/2008 Jul 31 Deposit Dividend 3.590% 650% from 07/01/2008 through 07/31/2008 16.45 5,410.37 Annual Percentage Yield Earned 3. 426.87 50 5 16 Aug 31 Deposit Dividend 3.590% , . Annual Percentage Yield Earned 3. 650% from 08/01/2008 through 08/31/2008 Sep 24 Ending Balance 5,426.87 YTD SUMMARIES TOTAL DIVIDENDS PAID 00 REGULAR SAVINGS 0.00 40 18 MONTH CERT 134.52 Total Year To Date Dividends Paid NOTE: Total includes closed shares 208.74 Don't forget about our new Member Loyalty Rewards Program. The more products you have with us, the more benefits you'll receive. Ask an associate for details or visit our website at www.members1st.org for details. ~cr-f- F 3~ Z ~, 3 °' ~ ~ ~ L ~a o N ( 6 MOM NO CO • O N ~' V' N N N ~ v rn rn rn N ~ Q ~n v v v O T ~ Q. O O c v o o m ~ Q- L cn ca o V ~ ~ ~ O ~ O ~ D LL- ~ M O U o0 O d' O ~t ~ O p 0 M~ N f6 ~Y '~ N ~' m ~ ~ ~ Z 0 N, 0 O 000 ~ 0 0 0 O O O T O O O O O O C Q. O O O O O O C N u O m aO O V ~ d W U ~riM~ooocfl U ~ ~ ~ O M c ~~ to to O 6~ (O N ~ ~ p ~ ~ O O m 00 ~ ~ O O ~ -~7O r ~ NNN r ~ d' V ~O~Op0 (p Q 'O COMMp00~O c v~ ~ (O sY d ~ O r C c ~ V' V ~ ~ ~ ~~n~n~n~ ~ ~ ~ N cD c0 fn D (~ M ~ ~ ~ a ~ ~ a~ ~ v ~ v fl- F- so a~i m ~ m -~ ~ to ~ p 3 >- ~ ~ ~ v ~ _ ~ O ~ N~ c C d C v U u~-aQ~~Qv ~ w ~ L ~ ~ ~ ~ ` ~ ~ o o ~~ ~ ~ SS o.. .. o.. L. UUF-7o ~Do ~ ~ F- W 00 0 ~ o00 Z (0. NNN NN N W O M O O OO O O O W 0 0 0 0 0 00 J LL Z W ° ° ° > v v °o oo p ~ cn cn cn cn cn cn ° ° ° 0 ° m o o o 0 o o V ~ ~] NNN NN C~ M 0 O O O O a 0 O O o00 00 0 0 O ScH- ~ ~ 3 ~ 3 N 6i (6 K I J~ f k ~ i ~ r ~~,`£ ~w_ 1-885-910-4100 Call Citizens' PhoneBank anytime for account information, current rates and answers to your questions. US259 BR319 FLORENCE G DIVEN 1 TIOGA LN CARLISLE PA 17013 1 Checking Account Statement Of 2 Beginning August 12, 2008 through September 10, 2008 Checking SUMMARY FLORENCE G DIVEN PATRICIAJ ECKMAN Balance Caiwlation Basic Checking Previous Balance 8,147.85 610074-573-2 Checks 8,257.68 - Withdrawals 7 ,129.70 - Deposits & Additions 5, 808.68 + Current Batarxe 4 , 569.15 = TRANSACTION DETAILS Checks' 7hrle is a break in drecP sequence Check A Amant Date Check i j~ 7 , 59~ . 2~1 ~ 08%28 797 Re+rious Balance 8,147.85 Amt Date 615.47 ~ 09/02 n Total Checks 8,257.68 Wittxfrawals Ocher Withdrawals Date Amo~t 09105 1,OOg:Oo 09/08 1 ~ • ~ Deposits & Additions Description Withdrawal Uhti Ovations Premium 080905 0023141161 Withdrawal Date 08/12 Amornt Description 375.23 lAmeriprise Fine Amp Payout 080808 93007169009 Og/12 368.43 /Ameriprise Flnc Amp Payout 080808 93007169008 0829 08/29 Og/0Z 420.05 / A Treasury Dept Annuitant 08 1, 350.00 /Ameriprise Flnc Amp Payout 080827 01120830468 Og/02 1, 350.00 /~Mteriprise Finc Amp Payout 080827 03150830468 00 US Treasury 303 Soc Sec 090308 926 09/03 09/03 . 618.97 /"Arneriprise Finc Amp Payout 080829 93007537817 out 080829 93007272690 Pa c Am F i 09104 p y m prlse 400.00 mer . _~~.:,.. me ~ Ern:,,i a~.~~r~~~ ~ r~,a<~ ,tr1 Totsl withdrawals 1,129.70 n Total Deposits i Additions 5,808.68 ^ Wrrerrt Balaixe 4,569.15 ~~ ~ ~ / ~ ~ REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Florence G. Diven This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIRRELATIONSHIPTODECEDENTAND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 ~ Ameriprise Ret Adv Advtg Annuity T.O.D. 0000 0930 0727 2690 2 004 39,296.32 100 39,296.32 2 Ameriprise RVS RT Adv Advt Annuity T.O.D. 0000 0930 0773 2251 7 004 6,337.56 100 6,337.56 3 Ameriprise RVS RT Adv Advt Annuity T.O.D. 0000 0930 0773 3002 3 004 14,914.88 100 14,914.88 4 Ameriprise Immediate Annuity T.O.D. 0000 0930 0716 9008 3 004 20,026.38 100 20,026.38 5 Ameriprise Immediate Annuity T.O.D. 0000 0930 0716 90091 004 20,396.00 100 20,396.00 6 Ameriprise Annuitization T.O.D. 0000 0930 0753 7817 2 004 35,488.04 100 35,488.04 TOTAL (Also enter on line 7 Recapitulation) $ 136,459.18 (If more space is needed, insert additional sheets of the same size) OST ~~viS~r~~rnp~l~s Online Service and Transactions Account Profile - RET ADV ADVTG NQ ~I13~r1i~r15~ ~,, r l~iaau~-~in1 Training Close Window Account Profile ~ Activi ~ Checks Issued ~ Arrangements Transaction Wizards Move Mone Move Mone ~~ ~~....~. _ ..... ,._. ~ .~,_....~ _...~ _.~._ Y Y New Mone In Systematic Out of Account Within Account ~ Move Money Previous Account Next Account ®wnership Informafiion Account #: 0000 0930 0727 2690 2 004 Account Status: ACTIVE Opened Date: 12/24/2003 Ownership:. FLORENCE G D1VEN Plan Type: NON-QUALIFIED Associated TIN: 204-03-8163 Taxpayer's Current Age: Deceased Associated Group IDs - Select Group Account List Group ID Group Type 0083 0468 5 001 HOUSEHOLD 4ssociated Client IDs - Selecfi Client Profile client ID Client Name Role 3eneficiary Informafiion PRIMARY BENEFICIARY Request Correction DAVID LEE DIVEN SON 100.00% Value as of 11111f2Ot}8 oq o~ ~e~ Total Cash Value: ~ Zq6, 3Z $26,906.02 Loan Balance: NOT APPLICABLE Total Purchase Payments: $45,000.00 Purchase Payments within Last 10 Days: $0.00 ~! ~~~ Lei f~,2- ~~-vM l~(tt~4ft-~ 1T~ ~£JIf$EILt:" .~~'~ (I ~It f7Ab~p ~Cf~, C:~] https://www8.ex.is.ameriprise.com/Ost/Secure/AccountProfile/AccountProfile.asn?alKev... 11/12/2008 ~ °~ UST MVA: $0.00 Blended Interest Rate: 0% Money Fund Blended Interest Rate: 0% Surrender Value: $23,961.04 Surrender Charge: (includes contrac# charge of $30.00) $2,944.98 Amount Available w/o Surrender Charge: $1,357.39 Tax Information as of 11/11/2U0~ Taxable Income YTD: $1,600.00 Taxable Income TTD: $9,200.00 Pre-Tefra Contributions: $0.00 Pre-Tefra Earnings: $0.00 Tefra Contributions: $43,000.00 Tefra Earnings: ($16,093.98) TSA 12/31/88 Amount: NOT APPLICABLE State Tax Applies: N Surrender Amount YTD: $3;600.00 Surrender Amount TTD: $11,200.00 Year End Value: $48,825.50 RiderlCoverage Information No Riders OST ` A~v~o~~c~rnpass Online Service and Transactions ~, ~~n~r rise I~inur~~-cr1 Training Close Window Account Profile ~ .Activity ~ Checks Issued ~ Arrangements Account Profile - RVS RT ADV ADVT PL N Transaction Wizards ..~.~,,.~~.on~_~.x~~~w.. .__. ~ ~, .~. ,.~..~~...u. ~ ~ Move Money ~ a., ~Move~Mone~ y ~ New Money In Systematic ~' Out of Account Within Account ~ Move Money Previous Account Next Account ®wnership Information Account #: 0000 0930 0773 2251 7 004 Account Status: ACTIVE Opened Date: 05/15/2006 Ownership: FLORENCE G DIVEN Plan Type: NON-QUALIFIED Associated TIN: 204-03-8163 Taxpayer's Current Age: Deceased Associated Group IDs - Select Croup Account List Group ID Group Type 0083 0468 5 001 HOUSEHOLD Associated Client IDs - Select Client Profile Client ID Client Name Role Deneficia Informs#ian PRIMARY BENEFICIARY Request Correction DAVID LEE DIVEN SON 100.00% Value as of 11111!2008 oq/o7 2.oc,a Total Cash Value: ~ 33-7,5, $4,566.64 Loan Balance: NOT APPLICABLE Total Purchase Payments: $5,918.38 Purchase Payments within Last 10 Days: $0.00 Ste.- ~~ ~ ~s+K ~ ~ c.~.Aa-~ .T ~ ~rb~ ~ D iD ~~ ~r~ ~zo~s . ~c f+ ~~ ~? i ~ Z https://www8.ex.is.ameriprise.com/Ost/Secure/AccountProfile/AccountProfile.asp?alKey... 11 /12/2008 OST MVA: $0.00 Blended Interest Rate: 0% Money Fund Blended Interest Rate: 0% Surrender Value: $4,120.90 Surrender Charge: (Includes contract charge ofi $30.00) ~ $445.74 Amount Available w/o Surrender Charge: $721.64 Tax Infe~rrr~atic~n as of 11f11f200~ Taxable Income YTD: $0.00 Taxable Income TTD: $0.00 Pre-Tefra Contributions: $0.00 Pre-Tefra Earnings: $0.00 Tefra Contributions: $5,908.22 Tefra Earnings: ($1,341.58) TSA 12/31/88 Amount: NOT APPLICABLE State Tax Applies: N Surrender Amount YTD: $0.00 Surrender Amount TTD: $0.00 Year End Value: $7,400.97 ~tt~ G Q Zs ~ 2' OST t~ At~vs~~r~~p Online Service and Transactions Account Profile - RVS RT ADV ADVT PL N Account Profile ~ Activi ~ Checks Issued a"ti'"`",~.~ :~iCTI~'Tl T'YSt' ~. ~I~i~3crr~~-i~t Training Close Window Arrangements Transaction Wizards _... ~.. ~. ~..,~.~~.. _.. _ .._. x. e ._. ~.,...~...~~ ..: ~-.M...~.,~.~....,~a ~~~ ~_ Move Money Move Money New Money In ~ Systematic i Out of Account Within Account Move Money Previous Account Last Account ®vvnership Information Account #: 0000 0930 0773 3002 3 004 Account Status: ACTIVE ` Opened Date: 05/16/2006 Ownership: FLORENCE G DIVEN Plan Type: NON-QUALIFIED Associated TIN: 204-03-8163 Taxpayer's Current Age: Deceased Associated Group IDs - Select Group Account List Group ID Group Type 0083 0468 5 001 HOUSEHOLD Associated Client IDs - Select Client Profile Client ID Client Name Role Beneficia Informatian PRIMARY BENEFICIARY Request Correction DAVID LEE DIVEN SON 100.00% Value as of 111'1'1!2408 erg fo7~-~,ot Total Cash Value: ~ q~~~Bg $12,587.30 Loan Balance: NOT APPLICABLE Total Purchase Payments: $13,891.14 Purchase Payments within Last 10 Days: $0.00 g~ f.~~-t~-~LDM Gfu,LR~t.4 ~ ~n/b~.Qli ~~ r~~u~2o~$. S'Ctf ~-i ~ ~ 0{~2 V httnc•//wwwR ex is amerinrice nnm/Clot/CPenrP/A crnnntPrnfile/ArtcnnntPrnfilP acr~7alKPV 1 i /1 ~/~nnQ OST MVA: $0.00 Blended Interest Rate: 3.127% Money Fund Blended Interest Rate: p% Surrender Value: $11,572.59 Surrender Charge: (Includes contract charge of $30.00) _ $1,014.71 Amount Available w/o Surrender Charge: $1,582.28 'fax Infarmafiian as of 11111120~~ Taxable Income YTD: $0.00 Taxable Income TTD: $0.00 Pre'-Tefra Contributions: $0.00 Pre-Tefra Earnings: $0.00 Tefra Contributions: $10,000.00 Tefra Earnings: $2,587.30 TSA 12/31/88 Amount: NOT APPLICABLE State Tax Applies: N Surrender Amount YTD: $0.00 Surrender Amount TTD: $0.00 Year End Value: $15,789.47 RiderfGaverage Inforrnafiion No Riders Accounfi A#lacafiian Informsfiion Total Investment Value: $12,587.30 Total Fixed Value: $1,120.12 Total Money Fund Value: N/A Total Variable Value: $11,467.18 Portfolio Navigator: Moderately Conservative ~,~ ~ ~ z~~ OST Page 1 of 2 Advsc~r+~mpass Online Service and Transactions Allll~lrl3t']S~' I~i~~unc-i~a1 Training Account Profile -IMMEDIATE ANNUITY close window Account Profile ~ Activity ~ Checks Issued ~ Arrangements Transaction WiZardS ~~~ Move Mone ~. ..~...~...~ o ~~~~.,...~ _,.~~..,ror .~ ._. .~,~w___ _:,,~..~,....~. . y Move Money New Money In Systematic Out of Account i Within Account Move Money First Account Next Account Ownership Infc~rrrt!ation Account #: 0000 0930 0716 9008 3 004 Account Status: ACTIVE Opened Date: 06/02/2003 Ownership: FLORENCE G DiVEN Plan Type: NON-QUALIFIED Associated TIN: 204-03-8163 Taxpayer's Current Age: Deceased Associated Group IDs - Select Group Account List Group ID Group Type 0083 0468 5 001 HOUSEHOLD Associated Client IDs - Select Client Profile Client ID Client Name Role Seneficia Information PRIMARY BENEFICIARY Request Correction PATRICIA J ECKMAN DAUGHTER 100.00% o ZooB Payout Status. In Payout ~~, ate:. 3~' Payout Type: LIFE INCOME WITHIN 10 YR CERT Allocation -Fixed: 100% Allocation -Variable: 0% Percent of Stepped Increase: 0% ~'~ ~jr~4,CC- ~OrYI GJtGL~u~ T S'T£7,~/g~C~ (~1.1) II/ir~7.aP~ https://www8. ex. is. ameriprise. com/Ost/Secure/AccountProfile/AccountProfile. asg?a1Key... 12/ 10/2008 OST Page 2 of 2 Fixed Amount: $375.23 Federal Tax Withholding %: p% State Tax Withholding %: 0% Frequency: MONTHLY Next Payout Date: 12/10/2008 Payout Start Date: 06/10/2003 Value at Settlement: $44,196.83 Last Guaranteed Payout Date: 05/10/2013 Payouts in 2008: $4,127.53 Taxable Amount in: 2008: $2,175.25 Payouts to Date: $24,765.18 Delivery Option: CHECK TO OWNER Gflr~rnutable Valdes 'VALUES NOT AVAILABLE Address Address: C/O PAT ECKMAN 1 TIOGA LN CARLISLE, PA 17015-7509 Notes; • (There is a transaction pending for the account! See the Activity page. View Corporate Entities and Important Disclosures, Web Site Rules and Regulations, Privacy Statement and About E-mail Fraud. Copyright ©2003-2007 Ameriprise Financial. All Rights Reserved. Users of this site agree to be bound by the terms of the Ameriprise Web Site Rules and Regulations. https://www8. ex.is.ameriprise.com/Ost/Secure/AccountProfile/AccountProfile.asn?a1Kev... 12/10/200 R osT Page 1 of 2 AdV1SC~~`L}Cl'1~3~SS` ,~;1€Tle~`l 2'~S~ ., Online Service end Transactions ~l•,au~~c-c~t Training Account Profile -IMMEDIATE ANNUITY Close Window Account Profile ( Activi ~ Checks Issued ~ Arrangements Transaction Wizards ~,..~.~.,.e. ~~.. ~ ., ~ r_ ~.~.,,~ ..... . Move Money ~ Move Money ~ New Money In i Systematic Out of Account Within Account I Move Money ;~ Previous Account Next Account Grrvnership Information Account #: 0000 0930 0716 9009 1 004 Account Status: ACTIVE Opened Date: 06/02/2003 Ownership: FLORENCE G DIVEN Plan Type: NON-QUALIFIED Associated TIN: 204-03-8163 Taxpayer's Current Age: Deceased Associated Group 113s - Select Group Account List Group ID Group Type 0083 0468 5 001 HOUSEHOLD Associated Client 1C}s - Select Client Profile Client ID Client Name Role Beneficia Information PRIMARY BENEFICIARY Request Correction. PATRICIA J ECKMAN DAUGHTER 100.00% Aria'7 7,rnd Payout Status: In Payout ~ Zo 3Q(o. o0 Payout Type: LIFE INCOME WITHIN 10 YR CERT Allocation -Fixed: 100% Allocation -Variable: 0% Percent of Stepped Increase: 0% S~ Ih/~i ~ F~otvl Lc1(L~A24 .T. S'7~-~.tili3E.e~ ~N- C,i t '~ f (cry f~ https://www8.ex.is.ameriprise. com/Ost/Secure/AccountProfile/AccountProfile.asp?alKey... 12/ 10//2008 OST Page 2 of 2 Fixed Amount: $368.43 Federal Tax Withholding %: p% State Tax Withholding %: 0% Frequency: MONTHLY Next Payout Date: 12/10/2008 Payout Start Date: 06/10/2003 Value at Settlement: $43,396.19 Last Guaranteed Payout Date: 05/10/2013 Payouts in 2008: $4,052.73 Taxable Amount in: 2008: $2,103.42 Payouts to Date: $24,316.38 Delivery Option: CHECK TO OWNER ~amrr~utable Valdes VALUES NOT AVAILABLE Add lres~ Address: C/O PAT ECKMAN 1 TIOGA LN CARLISLE, PA 17015-7509 Notes: `There is a transaction pending for the account! See the Activity page. View Corporate Entities and Important Disclosures, Web Site Rules and Regulations, Privacy Statement and About E-mail Fraud. Copyright ©2003-2007 Ameriprise Financial. All Rights Reserved. Users of this site agree to be bound by the terms of the Ameriprise Web Site Rules and Regulations. ~~" hops://www8.ex.is.ameriprise.com/Ost/Secure/AccountProfile/AccountProfile.asp?a1Key... ~ ~Z 12/10/2008 U OST Page 1 of 2 AC~~ISC~~~arrn ~J~SS` Online Service and Transactions Account Profile - ANNUITIZATION Account Profile ~ Activity ~l1CTit~rl lt'lSe ~. t~inui~c~ial Traininct Close Window Checks Issued. ~ Arrangements Transaction Wizards .ReP~ .. e~~. ~. ~. - __ _ _ ,~,~..~,.~wa~4 ~ M Move Money Move Money New Money In Systematic Out of Account ~ Within Account ~ Move Money Previous Account Last Account O~rnership Information Account #: 0000 0930 0753 7817 2 004 Account Status: ACTIVE Opened Date: 05/20/2005 Ownership: FLORENCE G DIVEN Plan Type: NON-QUALIFIED Associated TIN: 204-03-8163 Taxpayer's Current Age: Deceased Associated Group IDs - Select Group Account List Group ID Group Type 0083 0468 5 001 HOUSEHOLD Associated Client 1Ds - Select Client Profile Client ID Client Name Role Beneficia Informatian PRIMARY BENEFICIARY Request Correction PATRICIA ECKMAN DAUGHTER 100.00% o` 07/~0~ Payout Status: In Payout 3S, ~{8'g _ o ~ Payout Type: LIFE INCOME WITHIN 15 YR CERT Allocation -Fixed: 100% Allocation -Variable: 0% Percent of Stepped Increase: 0% ('~ SE;~ i-~f c ~!z- ~2outi ccJ ~ cc~rn2o ~,i s'~in/Pa ~ ~ ,0 Tl~ ,r`~ /io o ~ ~' CM hops://www8.ex.is.ameriprise.com/Ost/Secure/AccountProfile/AccountProfile.asp?a1Key... 12/10/2008 r ~~ OST Page 2 of 2 Fixed Amount: $618.97 Federal Tax Withholding %: p% State Tax Withholding %: 0% Frequency: MONTHLY Next Payout Date: 01/01/2009 Payout Start Date: 06/01/2005 Value at Settlement: $85,139.71 Last Guaranteed Payout Date: 05/01/2020 Payouts in 2008: $7,427.64 Taxable Amount in` 2008: $3,149.28 Payouts to Date: $26,615.71 Delivery Option: CHECK TO OWNER Co~rrrutable Value .VALUES NOT AVAILABLE . Address Address: C/O PAT ECKMAN 1 TIOGA LN CARLISLE, PA 17015-7509 View Corporate Entities and Important Disclosures, Web Site Rules and Regulations, Pnvacy Statement and About E-mail Fraud. Copyright ©2003-2007 Ameriprise Financial. All Rights Reserved. Users of this site agree to be bound by the terms of the Ameriprise Web Site Rules and Regulations. ~.~~ G ~; hops://www8.ex.is.ameriprise.com/Ost/Secure/AccountProfile/AccountProfile.asp?alKev... 12/10/2008 REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Florence G. Diven ITEM NUMBER A. FUNERAL EXPENSES: t' Cocklin Funeral Home 2- Monaghan Presbyterian Churh FILE NUMBER Debts of decedent must be reported on Schedule I. 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) Cammission Paid: 2. Attorney Fees 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) NT 8,420.20 191.10 2,364.67 94.00 1, 000.00 12,069.97 REV-1512 EX+ {12-05) j i~ Pennsylvania SCHEDULE I ~ DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Florence G. DIVEN Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses, ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1• UCC Homes, Inc. -Sarah A. Todd Memorial Home, 09/25/08 invoice 2,261.09 2. Millenium Pharmacy Systems East, September invoice 582.93 3.' UCC Homes, Inc. - Sarah A Todd Memorail Home, final invoice 289.80 4. Millenium Pharmacy Systems East, final invoice 296.11 5. Paul M. Bouder, coin appraisal 25.00 TOTAL (Also enter on Line 10, Recapitulation) $ 3,454.93 If more space is needed, insert additional sheets of the same size. Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 West South Street Carlisle, PA 17013 Statement Date: 09/12/2008 Patricia Eckman 1 Tioga Lane Carlisle, PA 17015 Due Date: 09/25/2008 Re: Florence G Diven ------------------------------------------------------------------------------- Date Description Days Rate Charges Payments Balance Quant ------------------------------------------------------------------------------- BALANCE FORWARD 7,592.21 7,592.21 ~,./26/OS PAYMENT 7,592.21 .00 08/19/08 Beauty & Barber 1.00 15.00 15.00 15.00 08/27/08 Beauty & Barber 1.00 16.00 16.00 31.00 08/31/08 Personal Supplies 1.00 14.79 14.79 45.79 08/31/08 Medical Equipment R 1.00 629.10 629.10 674.89 08/31/08 Incontin ence Suppli 1.00 101.48 101.48 776.37 08/31/08 Medical Supplies 1.00 44.72 44.72 821.09 08/31/08 Personal Laundry Se 1.00 30.00 30.00 851.09 09/01/08 Room ~ B oard - Semi 6 235.00 1,410.00 2,261.09 ,~ 7ti" `~ q~ I~~ NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BUT NO LATER THAN THE 25TH OF THE MONTH ***** Please remit the LAST AMOUNT printed on your statement. Include the ACCT# from the statement on the MEMO LINE of your check. Payments after 09/10/08 do not reflect on statement. NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25% LATE CHARGE PER MONTH ** A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS ** QuantiE v pfion ,A - 1 mou nt ~ 4 08!05/2008 6518288 1.00 Cefuroxime Axetil Oral Tablet 250 MG $ 6.66 c $ 0 00 $ 6 66 RX 65862-0034-60 . . 08!07/2008 6324405 10.00 NovoLog Subcutaneous Solution 100 UNIT/ML $ 94.20 C $ 0.00 $ 94 20 RX 00169-7501-11 . 08/09/2008 6197294 60.00 Ben Gay Ultra Strength External Cream 4-10-30 / $ 3 83 $ 0 00 $ 3 83 i 74300-00535 . . . OTC 08/09/2008 6015342 240.00 Gerisilk Bath Oil External Oil $ 1.69 $ 0.00 $ 1 69 OTC 54162-0300-08 . 08/15/2008 6512876 20.00 Cefuroxime Axetil Oral Tablet 250 MG $ 38.23 c $ 0.00 $ 38 23 RX 65862-0034-60 . 08/19/2008 6290479 10.00 Lantus Subcutaneous Solution 100 UNITIML $ 94.21 C $ 0 00 $ 94 21 RX 00088-2220-33 . . 08/20/2008 6341784 8.00 Promethazine HCI Infection Solution 25 MG/ML $ 20.81 c $ 0.00 $ 20 81 RX 00703-2191-04 . 08/24/2008 6559520 10.00 Lantus Subcutaneous Solution 100 UNIT/ML $ 94.21 c $ 0 00 $ 94 21 RX 00088-2220-33 . . 08/25/2008 6553321 113.00 Calmoseptine External Ointment $ 5.42 $ 0.00 $ 42 5 OTC 00799-0001-04 . 08/28/2008 6264824 31.00 Cetebrex Oral Capsule 200 MG $ 119.21 c $ 0 00 $ 119 21 RX 00025-1525-31 . . 08128!2008 6264883 31.00 One-Tablet-Daily Oral Tablet $ 0.57 $ 0.00 $ 57 0 OTC 00162-4428-10 . 08/2812008 6264936 31.00 Ferrous Sulfate Oral Tablet 325 I65 Fel MG $ 0.31 $ 0.00 $ 0 31 OTC oo1s2-402a-1o . 08!28/2008 6264983 31.00 Lexapro Oral Tablet 10 MG $ 91.82 c $ 0.00 $ 91 82 RX oo45s-201o-01 . 08/28/2008 6364417 31.00 Lisinopril Oral Tablet 10 MG $ 11.76 c $ 0 00 $ 11 76 RX 00172-3759-80 . . SAN C ., ~~,C' ~ ~~ ~ ~, ` l..astl~vmt _Last-Pl9vment; ~tnance Chp, .,YTD Fln~Gf1g, Other ,~X '' ~L° .1'` P `~; JVRR ~} $ 0.00 $ 615.47 08/29/2008 $ 0.00 $ OAO $ 0.00 $ 571.11 $ 11.82 $ 0.00 $ 0.00 ' 582.93 l~; il.P.tY iYT~~L~SS~..v`~' ~6~G:sLaiJ- I~L~LYL Amou nt ~~:.~~~{~~' S ~~y~~ lV{QI 08/29/2008 6264936 5.00 Ferrous Sulfate Oral Tablet 325 165 Fel MG $ 0.05 $ 0.00 $ 0 05 OTC 00182-4028-10 . 08/30/2008 6484883 141.00 Aloe Vesta 2-n-1 Antifunpal External Ointment 2 % $ 8.13 $ 0.00 $ 8 13 OTC 00003-3251-05 . 08/30/2008 6451861 113.40 TBC External Aerosol Solution 650-72.5-0.1 MG/0.82ML $ 19.27 $ 0.00 $ 19 27 RX 53706-1001-01 . 08/31 /2008 6570506 60.00 Ben Gav Ultra Strength External Cream 4-10-30 °/ $ 3.83 $ 0.00 $ 3 83 OTC 74300-00535 . 09102!2008 6324405 10.00 NovoLop Subcutaneous Solution 100 UNIT/ML $ 84.20 C $ 0.00 $ 94 20 RX 00169-7501-11 . 09/05/2008 2029835 30.00 Morphine Sulfate Oral Solution 20 MG/ML $ 20.39 c $ 0.00 $ 20 39 f2X 58177-0886-01 . 09!05/2008 6581186 90.00 Albuterol-Ipratropium Inhalation Solution 2.5-0.5 MG/3ML $ 41.00 c $ 0.00 $ 41 00 RX 16252-0547-33 . 09/07/2008 6264824 14.00 Celebrex Oral Capsule 20o MG $ 56.58 c $ 0.00 $ 56 58 RX 00025-1525-31 . 09!07/2008 6264883 14.00 One-Tablet-Daily Oral Tablet $ 0.26 $ 0.00 $ 0 26 OTC 00182-4428-10 . 09/07/2008 6264983 14.00 Lexapro Oral Tablet 1o MG $ 44.21 c $ 0.00 $ 44 21 RX 00456-2010-01 . 09/07/2008 6364417 14.00 Lisinopril Oral Tablet 10 MG $ 8.05 c $ 0.00 $ 8 05 RX 00172-3759-80 . -_ 09/07/2008 _- 6564782 _. 9.00 Ferrous Sulfate Oral Tablet 325 f65 Fel MG $ 0.14 $ 0 00 $ 0 14 OTC 65162-0406-11 . . L j, J~ ~ 's ~c ~' ~~+ ~ t.~si ~y~ S~XIYI~~:; Finant~ Cha` S!TD din Cha. Othef ': -~ J,Vgp . '' Lp~ $ 0.00 $ 582.93 09/22/2008 $ 0.00 $ 0.00 $ 0.00 $ 283.70 $ 12.41 $ 0.00 $ 0.00 296.1 REV-1513 EX+ (11-03) pennsylvania SCHEDULE ~ DEPARTMENT OFREVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER a'`7i02£stJGf~ Ci . l~lJ~ 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. Daniel E. Myers, 34 Borbon Red Rd, Mechanicsburg, PA 17055 Grandson 1/g 2. Deborah E. Clark, 1602 Baldwin Ln, Harrisburg, PA 17110 Granddaughter 1/g 3. Patricia J. Eckman, 1 Tioga Ln, Carlisle, PA 17015 Daughter 1 /3 4. David L. Diven, 6200 Marshall Rd, Centerville, OH 45459 Son 1/3 5. Eric Diven, 2259 Bellfield Ave, Cleveland Heights, OH 44106 Grandson 1 /9 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S 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. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REU-1500 COVER SHEET. $ If more space is needed, insert additional sheets of the same size. NOV-15-lUU~ lUE U6~11 PM Novembez 11, 2005 DORIS E HILYTZ . STE 101 11 TRIPLETT CT DILLSBURa, PA 17019-9490 Dear DORIS E B1tYTZ: Thattk you l'or your recent inquiry regarding FLORENCE G D1VENs accounts. These are t>ae values o£ the accounts as of 09/07/2008. ,Account ba>Formation 1Vlutual Funds Account Number ~!3~C;!l~& 01012976700 9 002 Individual - TOA 01.120830468 0 002 Trustee/Beneficiary 03150830468 S 002 Trustee/8eneficiary Annultles -Post 1985 ~ccourat Number ~ Ownershio 93007169008 3 0041'/0 Indlvidual 930071690091004 P/O Individual 93007272690 2 004 Individual 93007537817 2 004 PJO Individual 93007732251 7 004 Individual 93007733002 3 004 Individual Mutual Funds ~lccptutt Number Total Value # o s ares ,Asset Value Per S sr 01012976700 9 002 $9,376,87 2,520.663 ~ 3.720 01120830468 0 002 $52,192.55 11,U64.696 4,710 03154830468 5 002 $42,091.80 10,055.612 4.180 Annuities -Post 1.983 Account Number 93007169008 3 004 P/O 93007169009 1 004 P/O 93007272690 2 004 93007537817 2 004 P/O 93007732251 7 004 93007733002 3 004 oT tal Va1Ue $20,026.38 $20,396.00 $39,296.32 $35,488.04 56,337.56 $14,914.88 Willard J Steinberg ~ Senior Claims Apalyst Death Settleurents Processing Team 70100 Ameripxise Finatacial Center ~ Minaaeapolis, IvlrT 55474 Office; 800.862.7919 option 5,1 Willard,J.SteinbergQampf.com amerprise.com P• 003/010 ~J ~ I° o t - ~" ]~' a ~611r'lt OF FLORENCE G. DIVEN I, FLORENCE G. DIVEN, domiciled and resident in the Borough of Dillsburg, York County, Pennsylvania, fully aware of the significance of my acts and intending to dispose of my entire Estate, declare this to be my Will. I revoke all Wills previously made by me. FIRST: I direct that all funeral expenses, expenses connected with my last illness, or other expenses connected with the administration of my Estate, be paid from the assets of my Estate as soon as after my death as can be done conveniently. SECOND: I direct that there shall be paid from my Estate all inheritance, succession, transfer and State taxes (both State and Federal) or like taxes, that may be assessed or levied against my Estate on property passing by reason of the legacies and devises herein made, or which may be in any way or for any reason enforceable against or collectible from my Estate, shall be paid not by the respective legatees, devisees, recipients or beneficiaries, but by my Executrix out of my residuary Estate without prorating, and should any tax be not due or assessable at the time of my death, I give my Executrix discretionary power and authority to compromise such future tax with the proper governmental officer or authority and to pay the amount so fixed and determined. THIRD: I give, devise and bequeath all of my Estate, all t~ ~~. ~.`,. r~ r• q ~~. ~. 4 ,. r'5. +. lY articles of personal and real property, of every kind and description and wheresoever situated, in three equal shares. One share I give, devise and bequeath to my son, David Lee Diven; one share I give, devise and bequeath to my daughter, Patricia ,lean Myers; and one share I give, devise and bequeath equally divided among my three grandchildren, Deborah Clark, Daniel Myers, and Eric Diven. In the event that any of my children are not alive at the time of my death, that child's share or bequest shall not lapse, but their issue, then surviving, shall take the share or bequest of their deceased parent, per stirpes. FOURTHa If pursuant to the provisions of this Will, all or any part of my Estate would vest in my grandson, Eric Diven, at such time that he is less than twenty-two years of age, I nominate and appoint his father, David Lee Diven, as the Trustee of the Estate with respect to all or any property passing to or vesting in my grandson, Eric Diven. I direct that the Trustee shall place my grandson's Estate into a Certificate of Deposit or other guaranteed investment in an institution which is insured through the Federal Deposit Insurance Corporation. The Trustee shall accumulate principal and income until Eric reaches the age of twenty-two, at which time the Trust shall terminate and the Trustee shall distribute all accumulated principal and income to my grandson. However, should my grandson attend a college or other program of instruction resulting in a bachelor's degree or other degree equivalent to a four year course of study, I authorize my Trustee ;;`~: ,~ ~.?: f; to use the principal and income of the Trust for Eric's eduction, tuition, room and board, school supplies, and support stipend, during the time he is so enrolled, and before he turns twenty-two years of age. FIFTH: I nominate and appoint my daughter, Patricia Jean Myers, as Executrix of this, my Will. In the event that she is unable or unwilling to serve as Executrix, I appoint my son, David Lee Diven, as Executor of this, my Will. I have not named my son, David, as a Co-Executor of this Will, not out of any love or affection for him, but because at the time this Will is written, my son, David, lives out of state, and I believe it would be cumbersome or difficult for him to participate in the administration of my Estate. I direct that my Executrix, or her successor, shall not be required to give bond. If, notwithstanding this direction, any bond is required by law, either by statute or by ruling of court, I direct no security be required thereon. SIXTH: By way of illustration and not by way of limitation, my Executrix and my Trustee, or their successors, shall have the following powers in addition to those vested in them by law or by other provisions of my Will; such powers shall be applicable to all property, whether principal or income, exercisable without court approval, and effective until actual distribution of all property: (1) To retain, invest and reinvest in all forms of real and personal property, without being limiting to what are known as "legal investments," or to the investments to which Executrixes are confined by statutes; (2) To sell or exchange and to give options for sales or exchanges or otherwise dispose of real or personal property, for any purpose, at public or private sale for case or credit; c;~ , ~' ;~; i .,. ''~.~ (3) To renew notes or debts of mine and to borrow money for any purpose for any person or persons, to execute promissory notes or other obligations for amounts so borrowed, and to secure the payment of any real or personal property; (4) To compromise or settle claims by or against my Estate without obtaining the consent of any beneficiary; (5) To make distribution in cash or in kind, except as to properties specifically devised or bequeathed; (6) To pay directly any payment to which the beneficiary shall be entitled hereunder for the maintenance and welfare of such beneficiary, should such beneficiary, by reason of illness or any other cause in the opinion of my Executrix be incapable of disbursing it. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and Testament this ~ ``~ day of ., ~: t ~~ '` "° 1994 1,~ f Florence G. Diven SIGNED, SEALED, PUBLISHED AND DECLARED by Florence G. Diven, above named Testatrix, as and for her Last Will and Testament, in the presence of us, who, in her presence and in the presence of each other, have hereunto subscribed our names as witnesses. .; ~` ~~-~fr.;~.~~~.. ~< ./~~~; -fir ~ ,~~ ,% : , COPY CODICIL OF FLORENCE G. DIVEN I, FLORENCE G. DIVEN, domiciled and resident in the Borough of Dillsburg, York County, Pennsylvania, fully aware of the significance of my acts and intending to dispose of my entire Estate, declares this to be the First Codicil to the Last Will and Testament executed by m~ on September 29, 1994, in the presence of Patricia Jean Myers and Victor A. Neubaum, Esquire. FIRST: I revoke the provisions of Paragraph Fifth of my Will, and substitute therein the following language: FIFTH: I nominate and appoint my children, Patricia Jean Myers and David Lee Diven, as Executors of this, my Will. I direct that my Executors shall not be required to give bond. If, notwithstanding this direction, any bond is required by law, either by statute or by ruling of court, I direct that no security be required thereon. SECOND: In all other respects I ratify and confirm all of the provisions of my Will dated September 29, 1994. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, the First Codicil to the Last Will and Testament this ~.S day of , 1996. ~~~~~~~ Florence G. Diven SIGNED, SEALED, PUBLISHED AND DECLARED by Florence G. Diven, the above-named Testatrix, as and for her First Codicil to her Last Will and Testament dated September 29, 1994, in the presence of us, who, in her presence and in the presence of each other, have hereunto subscribed our names as witnesses. 1 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND estate of FLORENCE G DIVEN SHORT CERTIFICATE I, GLENDA EARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 30th day of September, Two Thousand and Eight, Letters TESTAMENTARY in common form were granted by the Register of said County, on the 1 a to of CARLISLE BOROUGH /First, Middle, Lastl in said county, deceased, to PATRICIA JEANECKMAN A/K/A PA TRICIA JEAN MYERS a.nd (First, Midd/e, Lastl (First, Middle, LasrJ and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 30th day of September Two Thousand and Eight. File No. PA File No. Date of Death s. s. # 2008- 00975 21- 08- 0975 9io7i20o8 204-03-8 ~ 63 NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL 105.80 Fee i ,ws. r., 3 I 3 LOCAL REGISTRAR'S CERTIFICATION! OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. "' ~r this certificate, $6.00 ,,,iJ~ ~'°°'~' This is to certify that The information h 1~,,~~p,~SH OF pf~y correctly copied from an original Certific ~'~ ~ `'P ~~ O ~ _ duly filed ,with me as Local Registrar.: - _ ~ - ~ certificate will be forwarded to the _ °v yy~= , a Records Office for ~parpnanent filing. *~ ~ *~ __o~ ~~ ,~~; E~' 0 ~~~~M ~~~~ P 147~~~0~ ~ Certification Number ENT ~"'" """""' Loc egistrar Datl v rtv nme, COM~i1DI1WEALTH Of PENNSYLVANIA- DEPARiiAETIT OF HEALTH • VRAL RECORDS a pxxr ::.r~Jr CERTIFICATE OF DEATH xx,ac (See inatnxib7r and exsrnples on rarerx) S7AiE FILE fwwaER f. Wr a Dewda!eRl. -i14 bA, aA.41 2 5n i 5~si, ieoeiry Nrp ,. Dre dLbii MraA, ~.l 7rll i Florence G. Diven Female 'L04 - 03 - 8163 September 7, 2008 s.nv~yaem!1 J.r<.f7.r t+r.rlr7 nea+d e.f. yeo.n, ~. f. aN m,ee. fkweeea Deeq le.w ..t 89 r„ December 12, 1918 Shade Gap, PA Dlw.ry DenJOar«r, Dow CX+~h~•+ Df~. Da+.-salay_ !e. Ltwy d ilaM a a7 aw twp d Drb u fylf rwre A at i1wsm, qis aw.\.wsele.) i 1qe D...e.Y A ll'kcMifa{i.? ~ Me D'w we. /ada. rs,t e.nc Mw. t M m. sm4 oew SA Cumberland Carlisle Soro. Y! SaraA A. Todd Memorial Hone, a.rs~,Mblis~a,a Uhite n. 6.aarR dN6„ rHa M_0.,d O! nra> A b J YL 1Vee D,rsn, l.vbie 11 Deusn/s6lvfol(~edl, uYl -'OeeJ fab ar,4b4 HbeY Aielrebq Mr,rlrwC, fi. $en'h'611ee,r!r gar. Mlran ~,e'1 U S h...~1r ...1 rbw.~ o•.ew ( g.oAf ' bn sa riwa eswlr, Cook Food Service . . . Er.++~~ ~15~r,e„f P+e i ~il*aas•3 [~,e [}}a, / Yidoved xo..s+,.w,m..stsb~l+4rb.r,a.4e,ma; 1000 Y_-South Street ~~ m~ Pennsylvania w°r°"~'a ,n D,~~~4 ~•n Carlisle, PA 17013 -m.c..w Cumberland ~~t ~»~l ~w+*~1: Carlisle ~ M+B.n li febP3 Mr,e fib! uLS, Dtl, aid A Ikw, Ike /iqL ri0114raleettey Prank Snyder Li111an Snyder meael..nr...pp.rrs.S ~ as.I+errlr,r,»ye.r6ewt^4r+w•.fa~baze! rirs. Patricia Eckman 1 Tioga Lane, Carlisle, PA 17015 :w eedlee d0ip,%w ^GawMr ^Daalbr iV D ~.`~r,.aw j1 Owix'° r°"'""'"'b" .1,. Dae dDher#e,pbf,se7, 7eM M.Yr,dD„aeliw¢ne aar~r7,trn~er7yYeebr,j 2la uarr C7'1Mw. s4e.,.,.me~ i i D ~° preawe:w~a..Je..er± D+kC7u~ Se t. 10, 2008 P Dillsbur Gemeter - Mt. Rnad 8 Y DiLlsburg, PA 17019 ~+.~r,rfb wr.arr« ac ww.as~osecaFx», Cocklin Pbneral Aose, 1'c. FD-012975-L 30 N. Chestnut Street, Dillsb~rg, PA 17019 r,r rNar• ierlani~lJr arr. r a..r+r bnea rr ,noa..,dana...sr.w 7ro r.ra pyw,.rw> urr,r7use a D,rS~nw ir,n ds 7r.q o,~ae.aa... ~ 21~ /+',// Giy - L Sf.o-~c ni~ri' C7 o~1Gb rrrxxs e.rlbm.{Y.~e/r•e 27.7iraDarw _ 2S C1h ho.,se,~Rw .M.7ay a.YOeCw Rtlerfab ebsaibNVlLbartrellermaMenr perW.iooreor! r ' rrpmrsaM ~~ y5 i7 ~n+. SQ JO'~f i G.K 07 ~ ~L S Q~'" ®t! LYl6E OF pFATM t9r. A,rw,llorn am r„wp4e) , t~re+ee M...rR rrl c 6Ya ae. ~El~F~lLalt a.O,Alrwab Ct,eiae r Dsr' p2.At[6u,Oe<M!L,:~s-Aern.~P4•vme~t.+M¢-Ma lisrl~wOMbae.DO ND>'rM~1e•is stir rifaaeMe slael. OwasOM~ Ww,s14j47+w0~4~aeeprMl ^1s DH~7 reeVrYarel a..a4a,.ar.+.,a.aa.r:~,. rtib,e_lis.~ynrc..r a..a M1e. ~ DtM~be..• U16E deeerv "e~.°I114rr+y+~+ ; 1o S n 1 (` tiu u~ ~!~ ~ C }~ ~. ~ ~ a. vEe.rr +++ ~ D w .es+ +w.~., arbpee mse,+eaa! ~ l" y~e~yrm~absfe.{ D. S N C,•1 ~~`'1 ^~r~'K ela'aNSw~ -fer frJe W 4 .a,oEaLnesuusE orrar aacgeemrc~ ^ McRYes--ta~a,nr-eQbe . a~ s~ y y .~ c. l~ ~~ ~easr aa.a o»btsram.r.,».e.a D~e+v+r.wol.,.e.ao.4,ec1,... 0. We V D ua.e.eY,r,Mw~4rorw A~ b. ~*F Dy q Yr T ro d Dept. .m DMdMj/t ~eetd,Rf~l ]a, OrefrNti l~ry Qswtl SC bpllr/~ ~9aa Faa°F ~~ OQreaplMt ~~ rr ~~ ~'tl'~ DA~tlM F Dyr ~~ oyi ^A Drtap,r D~r«, re.+§~+» ]BOi aw,7 x. ~rlawn) JaflOgetsw rM'64i+,~N aID 1«ao,aMMry!Jrr1.d71wr,nM Dar/tA.a.e Dn. Dew r Qsar Dc...*,rDe.,,:w M .ra, a : pw, Dw .~ n.gMferryrtall/ey /~7eeModl//Y'eraAM.-derd/ OI/ea ~riQerte~l Ni Wa~Me~1Yi ~.3lgreer M•7eMer l^,• (~ UM Nf rtr/Y~R1-Sab Meww MbMC Vlaa wr~rrs,laL____--_. ~_-__-~---__~_-_~--____-, .,~ (4~ V 1 ~'~eY y~ ' Y- • rrreawearw~Ib~MJWIr IfNarr rl.prner4~Qr a1suM1414.1twea pest tiw,rrsl.lrerr4.,wna,e..waNa.~srr Wpryrdee bfrsrse}IMwrsreYrL_----______ ^ • MeatEM~lCrerl ------ IBe LbwellMrw 7dl.a! w~,~. ~!'~ r, p o l b a~ri S S5(~7 'i ,~ o ° a Abre,~d,rniM4e W7r4wd~,ere frre goioe.6i,eO~Maaear~M,aM aaRrYMb/M ~.wl,r.a.. r, weLD J ' e ar.adllYrrdrr,r ~rg~w• /ws -,n 272 >Yw Jrr ~ ~ ~ ~... ~ w.r.., .w Gc ~~ a+ . c2~SC..~>rt+ Jn M 6 L// QO ®SO W Ll..nt,,-j- ~~. iw L?lBlt,~ly GAL ere given ate of De. I'he origil State Vi Issued v ' u oz16a4a au,see win x, _