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Home My WebLink About07-06-09 (2)COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 7 1 2 8-0601 RECEIVED FROM: WELLER CHERYL RD 2 BOX 2278 WAYMART, PA 18472 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ACN ASSESSMENT CONTROL NUMBER fold ESTATE INFORMATION: FILE NUMBER: DECEDENT NAME: DATE OF PAYMENT: POSTMARK DATE: COUNTY: DATE OF DEATH: SSN: 202-20-1712 2109-0626 WELLER ANNA M 07/06/2009 07/02/2009 CUMBERLAND 02/21/2009 TOTAL AMOUNT PAID: REMARKS: RECEIPT TO ATTY CHECK#1192 SEAL INITIALS: CJ RECEIVED BY: REV-1162 EX111-96) N0. CD 01 1448 AMOUNT $493.30 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS LAW OFFICES OF GATES, HALBRUNER, HATCH & GUISE, P.C. 1013 MUMMA ROAD • SUITE 100 • LEMOYNE, PENNSYLVANIA 17043 (717) 731-9600 • FAX: (717) 731-9627 LOWELL R. GATES, LL. M. CORRESPONDENCE ADDRESS: BRANCH OFFICE. LL. M. in Taxation Lemoyne Office 3 WEST MONUMENT SQUARE, SUITE 304 Also Admitted to Massachusetts Bar WEB SITE: LEWISTOWN, PA 17044 MARK E. HALBRUNER _ (717) 248-6909 CRAIG A. HATCH, CELA www.GatesLawFirm.com Certified as an Elder Law Attorney by the National Elder Law Foundation CLIFTON R. GUISE Also Admitted to practice before the U. S. Patent & Trademark Office SARAH E. McCARROLL Cumberland County Courthouse Office of the Register of Wills One Courthouse Square Carlisle, PA 17013 RE: Anna M. Weller, deceased Dear Register of Wills: STACEY L. NACE Paralegal/Office Manager TRACI L. SEPKOVIC Paralegal VALERIE LONG Paralegal TRACI L. SHERIDAN Paralegal July 2, 2009 Enclosed for filing with your office are a Petition for Settlement of Small Estate and Pennsylvania inheritance tax return. An original death certificate is enclosed for your records. I am enclosing a check in the amount of $30.00 as the filing fees. A second check in the amount of $493.30 is enclosed as payment of the inheritance tax liability. Please time-stamp the photocopy of the Petition and return it to my office in the enclosed envelope. I am enclosing a second envelope for you to return the signed Order to my office. Please notify me if you need any additional information to process this filing. Sincerely, MEH/tls Enclosures cc: Cheryl L. Weller Mark E. Halbruner r..~ 1 ~r~~ r-r'S ' ~ : - : C O ~z •..t LOCAL REGISTRAR'S CERTIF1CATtON OF DEATH WARNING: It is illegal to tiuplicate this copy by photostat or photograph. )~,°e lt?r'I?i~ r I i~i.~,tc `~tr.tl{i <,';nitlt~r•irtn ''~i;)ahr~ _l.).tt. i~ au t_Lr(li~ '.?:it tiie i„1i>nn~tt~lt~) ii';~.' r_'I~CrI ): rorrertfv ruder: ~~,-v)? X117 cr)i:~m:;i CW~ :li,i~:~ite of I)Lath duly ~ilei x;"!~ ~.' a~ Lt~ct;; iZ ~i<t l:u. T:~~e ur in_:l ate x,AI~ X71.^,ardc~l rr~ r .°~rt~l~ir ts~c ~la~e Vital 77 )~le(Yl lit (iE)lrl` ~i. '' i~t.'i~IT liil1Cl11 ll~li5. . ~' 2 4 009 --+F'tt - ---- - - -- a, ,.~ -- -- t.,,<.ai ~~,,~ ,,,', .,.3 ~ a ~ __ C C~ ~, " ? - ` r rE,- r' ~ ''TT77 ~ '~ ~~-. ~-.~r.~_1 ~ ~ ~ ~ a 1 . ~ r-: ~ t ,.:t COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ',aaiNT'i°06 CERTIFICATE OF DEATH IMANENT (See instructions and examples on reverse) srnrE FILE NuMRER ACK INK _ 2. Sex 3. Social Security Number 4 Dale of Dealn (MOn(h, day. year; 1. Name of Decedem (First, middle. last, sufllx) Anna M. Weller 5. Age lLasl Birtntlay) Under 1 year Under 1 day Moan: p.rs Hours Mmwes 81 yin I LVU Bb. County of Death 6c. City, Boro, Twp. of Death Cumberland. Pennsboro Klntl of Work Kind of 0usiness I Industry Homemaker Own Home ]fi.~}eS~dpnYS t~yiling Atldress (,St rat. clggl tqw., state, zip code) 1 / 11 (.ornej.l LCQ Camp Hill, PA 17011 78. Father's Name (First midtlle, Iasi, sufllxl Paul L. Dunn 20a. Informant's Name (Typo /Print) Cheryl Weller 7 ~ 7nT Aonth, day. Year( ,, o„,,,m^,.~ ~.,~,r ..,._ _._._ _. _. _., .. Hospital. ter' 1 2 Inpatient ^ ER / Outpatient ^ DOA ^ Nursing Home ^ Residence ^Other Speclly. 6d. Facility Name (11 not institution,'gdive street ntl number) 9. Was Decedent of Hispanic Origin? ~ No ^ Ves 10 R~Sayc~ec ~ encan Intlian, Black, White, etc. (If yes, specify Cuban, W [~ 1 t e Mexican, Puerto Rican, etc.) Holy Spirit Hospital 12. Was Decedent ever In me 13. Decedent's Education (Specity only highest gratle completed) 14' W dowed~DWOrced (Spec ty) Monied. 15. Surviving Spouse ('I wile. give maiden .name) U.S. Armed Forces? Elemen;ry IOSecondary (D12) College (1-4 or 5+) ^vea g]Np 1 Widowed Did Decedent Two Decedent's pA Live Ina 17c. ^ Yes, Decedent Lived m Actual Resitlence 17a. Slate Township? r'_ l 7 17tl. ~ N0, Deoedenl Lived wifmn (`nrrn~ Cli l1 Cay I Boro ,76 cpnnrv Cumberland Acmaltimdant ~~~~~k' 19. Mother's Name (First mitldle, maiden surname) Florence E. Hale 20b. Informant's Mailing Atldress IStreet, city I lawn, state. zip code) 23 Lakeshore Dr., Waymart, PA 18472 21 d. Location IC'ny I town. state rip cotlel ^ Cremation ^ Donation 21 b. Date of Disposition (Month, tlay, year) 21c. Place of Disposition (Name of cemetery, crematory or other place) ~'"""r ~ 11, PA 21 a. Memod of Disposition ~ Burial ^ Rempvaummstate '' waacretnahonprDpnahpnAumprixed February 27,2009 oiling Green Memorial Park ~! by Medical Examl orrer? ^ Yes ^ No 1 Home ^ Omer-Specity~ 22a, 0igpehge of Funeral Service Licensee or rson a - as such) Complete Items 23e-c only when cenitying 23a. Ta [he bast of~ my kn°vAedga. physician is not available at lime of death to ~~\I(~~, J,`J~((',,` certiy cause of death. 22b. License Numbe• 22c. Name and Andress of Facility Myers-Hamer Funera,^I , 0174819 1903 at Ole time, date and place slated. (Signature arid !ilia) 2 Dale Pronounced Deadd (i~ay, year) Items 24-26 mull be completed by person s deem 24 Time of Death p i O , ~~ T YY~ M `- F~J 1p'~'...t~ ~) r d~V . who pronounce CAUSE OF DEATH (See Instru ctions end examples) Approximate Intarval~. t r Onset to Death s cardiac arrest h Item 27. Pan L Enter the rho n of events - diseases, Injuries, or complicallons -that tlirem oceuone causeeaoth.eDO NOeT enter termi the eeobgy IY l snowin im , a nal events suc respualOry arrest or venlnc g ou ular Ilbnllation w t ( IMMEDIATE CAUSE (Final disease o~ m B ~ y~ 'yI '. - y/,,~ J I r7 ~ ~ ~ I J `^ G Y A'" - ~ Y c .! 7 S ~~ ~ / j ) ~, ea condition resultng In a Due to (or as a consequence oft. ~ t ~ t Sequentially list condllions, If any, b. ~ leading fo me cause listed on line a. Enter the UNDERLYING CAUSE Due to for as a consequence ol): t f (disease or injury That Initiated me evems resulting m death] LAST. p, Due to (or as a consequence of): t t t d. f D ath 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occurred 3h. Ccense Numher RN 3~S1~s5 ~. r„rir o,y.~r:~ o.,,.,-~•~ ~~r, -.. Febr~c- a 1, aoo9 ?6. Was Case Referred to Medical Examiner I Coroner for a Reason Other Than Cremahor or Donation? ^Yas No Enter others, lg~(^°^' "^nd'to comr but n0 to de t Pant i 28. Dd Tobacco Use Comnbule Ic Death ^ Yes ^ Probably ven in but na resulting In the untlenying cause g ^ NO ^ Unknown 29. II Female. ^ Nol pregnant wdhm oast year ^ Pregnant a; Ilme of tlealn ^ Not pregnant. b i pregnam wnhin 42 days of tlealn ^ Not pregnant, out pregnant 43 days fo I year before death ^ Unknown ~. plepnanl whin Ina past year 32c Place of Inl~ry- Home- Farm- Slreel- Fac10N Ofllce BuJding. elC. %SpeCiW,i 30a. Was an Autopsy 30b. Were Autopsy Findings 3t. Manner o e Performed? Available Prior m Completion r•VNatural ^ Homicide of Cause of Death La 32e Ina at Works 321. If Transponetio I ry n Injury (Specily) 32g Location of Inlury IStreet cny /Iowa. stale) ^ Accident ^ Pending Investigation 32tl. Tine of Injury ^Yas ^ No - ^ yes ^ No ^ Driver I Operator ^ Passenger ^Pedeslrian a ^ Yes ~ No ^ Suicide ^ Could Nat be Determined M. ^Other ~ Specity: ' 336. Sign ature and Tile Certifier f ~ ~ I I, 1 k ~'I 1 33a. Certlfler (phe0k only One) • Certltying physician (Physician cenitying cause of death when another physician has pronounced death and completed Item 23) ------- t d l ' --------'------ ^ -- 33d. Date Signed (Month, day, y art ---------- e a To the best of my knowledge, death occurred due to Me ceuae~s)and manner as s • Pronouncing and certlrying physician (Physician both Oronouncing death and cenitying to cause of deem) ) and manner as stated- - 33c Lice - - - - - - - - - - - - - - - - ^ nse Number M D ~~ z~t ~ ~ ~ / G '( ~~ ~ ~Z To the best of my knowledge, deem occurred at the time, date, and place, and due to the cause(s • Medical Examiner 1 Coroner On the basis of examination and I or investigatlan, In my opinion, deem occurred at the dine, date, and plan, and due to th 34. Name arid Atldress of Person Who Completpp Cause of Death 1 m 271 Type I Prinll 1 (/ }~' ~ G t ~Gr I S ~ e causes) and manner as stalea_ ^ ~/ 1 I ~. ~ ~~ 36. Date Filed (Month, day, year) ~ ~~ (f I~ ,t~1 1 S f r 4 r I c ~ ~ ~ U 5 f 35. Registrar's Lure and Dlst' N bar, f,/ l ~ I ~I ~I ~ I ~ I U ~~) .. / , J K L/ 0332330 Disposition Permit No. a j , - ,~ ~ ~w~ _~".. ._. 1~.f~m ~'R # e~~ ~ ~« {..b~ n- ~ . $ ° :4 ,i~„ ~ . 3~ . ~ ~ 7.M a € __ _ Y 2Q~9 JUL -- 6 F'M ~= E~ U w M ~ ~ h f- Q ~ V1 ~ ~; Sy ~ 3 ~ ~ ~ ...I °o~ ~- o ~ U ~ ~Z ~ ~ ~ ~ w o ~ = x M O Z3 y ~ a x °W - ~~~ ~ J ~ O p Gy - w ~ ~ U ~ - = ~ ~ ~ c ~ UOOU = 0 H ~a