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HomeMy WebLinkAbout07-30-09 (2)- f. ~. _ _ a .. ~ - - - PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE NO. 21"~1'~7~~ PO BOX 280601 ~ ~``T?,~,.~T,p~(PAYER RESPONSE ACN 09133140 HARRISBURG PA 171za-o6gl ~ DATE 06-08-2004 _, ~.;~ m:V-I543 ~ M?~`f9MUe~ ' ' ~ `-'~ i~v~ J!.~~ 3Q ~ ~ ~ ~?~ ~3 C" ~~ < ~~ ~~ ~ ~ { ~ ~' , t~~. PAUL M WISDA 20b JONES ROAD CABOT PA 16023 EST. OF ELEANOR B WISDA SSN 190-18-3747 DATE OF DEATH O1-o8-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FgRMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. WA CHOVIA BK NA provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the 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. please call (717? ?8?-837 with ^_uestions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 1010084283395 Date 02-05-2004 Account Balance Percent Taxable Established $ 44,992.22 X 16.667 To ensure proper credit to the account, two copies of this notice must accompany payment to the Register of Wills. Make check payable to "Register of Wills, Agent". NOTE: If tax payments are made within three Amount Subject to Tax $ 7,498.85 months of the decedent's date of death, TaX Rate X . 15 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $ 1, 124.83 nine months after the date of death. P~T TAXPAYER RESPONSE I ~ LU~,,_, R~Sf'~OH L2L ~' IH~AN OF ~fr IAL TAX AS5fS5MF-NT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or 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. C ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y be filed by the estate representative. C. The above informs ion is C t PART ~ d/ l incorrect and/or debts and deductions were paid. PART ~ b low e an or omp e . e PART If indicating a different tax rate, lease state relationship to decedent: .S~ TAX RETURN - COMPUTATION LINE I. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 Off` ~~ 0~" 2 ~` ~ ~ 4 q a. ~ ~ d`Z-. 3 X 1lv . 4 s 7 ~ 98 . ~ s$ ~,~ 0 3 S. 7 1 7 X .©'f 5' a $ ,Z 71.'?~ OFFIC~TAL U5E ONLaY ~AA~ PA DARTMENT i)fi REVN PAD 1 7 3 4 5 6 7 8 PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL CEnter on Line 5 of Tax Computation) S Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best f my knowledge and belief. 4~ HOME C "7' 2`1' ) 3.~~-° ~~' 1 WORK ( ) c2 09 TAXPAYE SIGNATURE TELEPHONE NUMBER DAT v ,.~ ~~__~~~-ate _ _._~~1/7~,' .___..//S%7~ _~ Il7a 3~- ~ o ,~' /-- ~~~ ~3 J (~,~,,~ 3 ~~ 3 P~ ~o-~ K~ . ~_ ~'~ C.J. L UCAS FUNERAL HOME, INC. FAMILY AFFILIATED SINCE 1891 Over 100 years of Continuous Service MAIN OFFICE 27 North Vine Street Mt. Carmel, PA 17851 Telephone: 570-339-4110 Fax: 570-339-1890 Supervisor, C.J. Lucas, IV BRANCH OFFICE 1053 Chestnut Street Kulpmont, PA 17834 Telephone: 570-373-3202 Supervisor: C.J. Lucas February 5, 2009 Patricia Semick 505 Ellen Road Camp Hill, PA 17011 Dear Ms. Semick: Please find cash charges due for the burial o f the late Eleanor B. Wilda which were not included or were not covered by her pre-arrangement: Pre-arranged price Current price Balance • Grave Opening & Ck-sing $ 750.00 $ 900.00 $150.00 • News-Item Obit & Notice $ 28.00 $ 115.00 $ 87.00 • Death certificates $ 12.00 $ 36.00 $ 24.00 • F~wers $ 212.00 $ 254.40 $ 42.40 • Harrisburg Patriot $ .00 $ 288.37 $288.37 • Butler Eagle $ .00 $ 123.00 $123.00 • Hired Pallbearers $ .00 $ 180.00 $180.00 • Pallbearers Car $ .00 $ 200.00 $200.00 • Mileage $ 140.00 $ 230.00 $ 90.00 • 2 Additional Death Certificates $ .00 $ 12.00 $ 12.00 • Tent Service $ 175.00 $ 120.00 - 55 00 Total Amount Due $1141.77 Upon your review of the above information if you have any questions, please feel free to contact my office. Sincerely, C.J. Lucas, IV, Supervisor C.J. Lucas Funeral Home, Inc. P~ ~~ a la~ln 9 C.P~ /i~a. c~ WEST SHORE EMS -BLS 205 GRANDVIEW AVE SUITE 211 = CAMP HILL, PA 17011 ~~ Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ,~Z' ~0~ EMERGENCY MEDICAL SERVICES PATIENT NAME: ELEANOR WISDA PATIENT NUMBER: 49873 WCS CALL NUMBER: 184053W NONE INSURANCE: MEDICARE B 190183747A DATE OF CALL: 01/03/2009 STATE FARM HEALTH IN; H37290953838 TIME OF CALL: 02:50 PM CALLER: HOLY SPIRIT HOSPITAL 1$4053W FROM: HOLY SPIRIT HOSPITAL TO: ACUTE REHAB HOSPITAL ELEANOR WISDA 2100 BENT CREEK BLVD REASON(S) ROUTINE TRANSPORT MECHANICSBURG, PA 17050 FOR TRANSPORT INVOICE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT Wheelchair One Way -Member A0130 1.0 46.52 46.52 Transport Van Mileage A0999 5.0 3.74 18.70 Total Charges 65.22 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT ~ -~ ~-3 po 9 i E d z R C N C~ C~ H All Sa~~ts Cemetery Diocese of Harrisburg 172 AU Saints Road Elysburg, PA 17824-9736 Phone: 570-672-2872 January 22, 20D9 Patricia Semick 505 Ellen Rd. Camp Hill, PA 17011 Dear Patricia: Please sign the enclosed contract ~~2160 for refinishing your parent's bronze memorial and re-install on a new granite base and return the white and yellow pages, along with your check of $725. made out to and sent to All Saints Cemetery; the pink page is for your records. You will be notified upon re-installion of your parent's refinished bronze memorial an a granite base for Memorial Day, if not sooner. A polaroid photo will also be mailed to you. Thank you for giving us the opportunity to be service to you and if we can be of any assistance in the future, please don't hesitate to contact us. Sincerely, ` ~~ Michael S. Rugalla, Jr. Manager Enclosures Office of Catholic Cemeteries Diocese of Harrisburg PO Box 3651 Harrisburg, Pennsylvania 17105 Phone (717) 657-4804 SALES CONTRACT DATE ~` ~~_ ~~ i<'j~ CEMETERY~~ 1 rJ~ CEMETERY# ~ A/N~F'/N A/R i NAME A~j~e C ~, y~~V` ~~~ PHONE (~l lf1) ~ z `~- 1 `-"..`. ~c i .~ ADDRESS ~~, ~l~nl i`~~ o r~ 1~i ~.~ ~4..`- `~ L~~ ~~ CITY ~, i STATE_ZIP CODE / A/ G ~ Interment Spaces ... $ .~ ... $ 1. Price... ............ r~ c;' , i ~ Bronze Memorials....... ~ - $ ~ 2. Down Payment......... r~T-,~,3{~ Size ~ .:.:, .~,~., .. Granite F unda 'on ~ ~ $ I- 3 Unpaid Balance(1-2) ~U N~. _...k.. ..:; . , :. , ~ Burial Vaults........... @ $ 4. Finance Charge... .... ~ - _ Crypt Spaces .......... ~ $ 5. Deferred Payment (3+4) . . Niche Spaces .......... ® $ 6. Total Price (1+4) ....... . Other ~; r.# i ~~,, {~Z~, $ ~ ~~ 7. Approx. Monthly Payment Section ~ Lot~QGrave(s)~_ 8. Number of Payments ... . Building Side Crypt or Niche 9. First Monthly Payment Due Selection must be made within 30 days or cemetery will make choice. 10. Annual PefCentage Rate Th~-e- payment is due on the dates ted above and the remainin payments on the same day of each succeeding month B yer m~y prepay in adv~nce the full amount due without penalty and will be entitled to a pro ortionate refund of the P unearned finance charge. I Upon default in the payment of any installment due hereunder for a period in excess of one hundred twenty (120) days, Seller may, at its option, void this agreement and retain all payments made by Buyer as liquidated damages. , Buyer hereby acknowledges receipt of an exact executed copy of this agreement at the time of execution hereof. ~' Before any~burial is permitted. in this lot or any memorial placed on this lot, the price of the grave and memorial must be paid in full. . ,. , , _,, ........ _ i j The Purchaser(s) agree(s) to abide by all rules and regulations of the cemetery now in force as well as any rules and regulations which may hereafter be adopted. Said rules and regulations may be seen upon request at the Seller's office. Upon fulfillment of the conditions of this agreement and receipt of all the above described payments, Seller agrees and binds itself to convey to the Buyer, by its cemetery easement, for interment purposes only, the above mentioned number of sites. ~'. YOU, THE PURCHASER, MAY CANCEL THIS TRANSACTION BY WRITTEN NOTICE AT ANY TIME PRIOR TO MIDNIGHT l :: ~ OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. (Authorized Representa i e) ~` (Purchaser's Signature) NOTICE: See other side for additional information. (Co-purchaser's Signature) U.S. Posts! Service,,. CERTIFIED MAIL,:, RECEIPT (Domestic Mai! Only; No Insurance Coverage Provided) For delivery informnt;~....:~:. _.__ ~~° u~~ Postage S r ~~;~~f= ~!_ijj Certified Fee ~ s; 4 jr r 7 ~y, Retum Receipt Fee ~ , / p t* (Endorsement Required) ~ / ~-, ;t! 1 ^~ ~ (Endorsemen~eegwred) ~1],ill ? ~~` ~^ \ ' , Total Postage & Fees ~ J ' , v _ i ~ f , 1. _ '^ 3 1.''~._f~~l,i~~ t o %~ xb:; ---~o- ~ ---------~ x~-o orAp sox nlo. pis sieie",'zi~o'~~G ~ ---~~ __ ~ _~ _ J _O ~ - ----------------•---- DIVINE REDEEMER CHURCH MOUNT CARMEL, PA. gnat ly acknowledges a gift from f /D® IN MEMORY~F s - /~~~/ CAMP HILL POST OFFICE ~~ CAMP HILL, Pennsylvania 170113717 4134870011 -0097 01/16/2009 (800)275-8777 09:00:19 AM Sales Receipt Product Sale Unit Final ~j"J Description Qty Price Price a~ ~ PHILADELPHIA PA 19101 $0.42 ~~ Zone-2 First-Class Letter ~~ \, 0.60 oz. .~ Return Rcpt (Green Card> $2.20 ~O ~ r LabelfN d 7005182000071264790 70 Issue PVI: $5 32 $8.40 2 $8.40 $16.80 Forever Stamp PSA ~ Dbl-Sd Bkit Total : $22.12 Paid by: Cash $30.00 Change Dus: °$7.88 o ~'~ Order stamps at USPS.com/shop or call 1-800-Stamp24. Go to USPS.com/clicknship to print shipping labels with postage. For other information call 1-800-ASK-LISPS. B111M: 1000303375843 Clerk: 08 All sales final on stamps and postage Refunds for guaranteed services only Thank you for your business x~r~rx~**~rx~*~:~*xxxx:xzx:*xxx**z~*x~cxx~r~rx *x*xxxxtcxx>r~x*~~*xz~r~c*~tx~rxfcxx**~xxxx**: HELP US SERVE YOU BETTER Go to: http://gx.gallup.com/pos TELL US ABOUT YOUR RECENT POSTAL EXPERIENCE YOUR OPINION COUNTS xxx*x~r~xx~r**x*~xxxx*xtrzrr**xra******:*xxx xxx~cxrrxx~xxx*~trcx~r~x*ax,rx*x~cxxxrc~rxzrrzxxr~rr r, ~c+n,nur f nl'11/ ~ s l' lY 't; ~ ? i, y"( ~' s y _ .t ~ 4 1-~ r ;r4,~~ r 1410 - 1, Y K..?~,2, Y ~--`, II ~ ` S ~ T Y ~.}~ ~. r~ rJ+ ~F- ~. i'~1'gF '~ ~~ _ `'~ +fr ~~ `Jl ~ Sr.+F~ ~ ,~ ~ ~ z ar ~ ~ ~` '~` y~,~.~ ~ w + ~``~~e, ,~ """ "~ {K.1. ~ r. ' .i y ~S k ~ ty. j ' - Y ~ A -' i N -C 'S Y Nti.. ~'ySk ~^}_ ~ ftY } ~ 'c ) Y +'~'t~ ~ .35 -y ti i ~ ~~rIF ,~~ ~~ ~~ ~ y~ y `r ~ ,'eft ~ fj~t 1 4~J-~, f - y r .) - ~ :: f~ ~ 43 t 4 ~~ ' ~ ~' '' m ~ , ~. ,~ ~.. _ ~ t i i-+-+i+~i A FINANCE CHARGE OF 1.50 ~ PER MONTH PHARMACY SERVICES INC. (AN ANNUAL PERCENTAGE RATE OF 18.0$) OR A 219 North Baltimore Ave t Mt HollySpriags, PA 17065 MININtUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED 800-266-9954 (717) 486-8606 ON ALL AMOUN'YS 3 0 DAYS OR MORE PAST DIIE STATEMENT OF ACCOUNT =:~~rA "~ ' - kA,~N13W . INS1JftA23CE :CARD FOR YOUR ~~,SURE TO SUPPLY IIS WITS A COPY. Date 01/20/2009 ~~ ~ - ;;;DIE . 02 15 09 WISDA, ELEANOR WISDE ~~ BRIDGES AT BENT CREEK GRP-58 rat 2100 BENT CREEK BLVD PAGE 1 ~~-x'31 MECHANICSBURG PA 17050 Amount Paid PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT RUNT DUE 56.86 PHYSICIANS OF REHABILITATION, INDUSTRIAL & SPINE MEDICINE, P.C. STATEMENT :~~ ~ _----•_- "__,---_-, ,.,.,.. -- . _ -.- .. .... . _ - - _ 4950 Wilson Lane ~.. ~.c,n~a~ici ovuievaru wo iu ~onuvnaerry noaa Micnaei r. LuplnaCCl, M.u. Mechanicsburg PA 17055 STATEMENT D RTE PAGE , P O Box 2028 Bloom Bld Suit 106 Willi A IIA R J M D , . . . g. e am . o , r., . . (717) 691-4847 Mechanicsburg, PA 17055 Harrisburg, PA 17109 (717) 691-3755 (717) 561-4242 www:~rismdrs.com Christopher Royer, PsyD 03/03/OS ~i Lisa A. Eaton, PsyD Billing Dept: (717) 691-4879 Tax I.D. #25-1651500 please retain this portion of statement for your records. ACCOUNT NUMBER ~1F3234 TRANSACI'IONDATE INV.NOs POS. PATIENT, DR: PFiOCEIhURE D~SditIPTlO~{pFSEAVECES DIAGNOSIS AMOUNT ` F'REV I OUS BALAAJCE 67, 31 01/08/IZ19 AC ELEAN Mf" 99231 F/U HOSP VISIT, LEVEL 1 7812 1tZI2.Qlft1 O1/29/4~9 ELEAN M1= 1~ GAYMENT-t+IEDTCARE ~9.L7• 01/29/tZ~9 ELEAN MF 4tZ~ MEDICARE DISALLOW 65.41- 02/I~6/09 ELEAN MF 6 >='AY-INSUR 7, 32. ~1/t'~4/Q19 AC ELEAN MF 99223 INITIAL HOSP VISIT, LEV3 7812 252.00 01/07/09 AC CLEAN- MF '39:32 F1U HOSP VISIT, LEVEL :? 7812 122.00 02^/>T9/tZi'3 ELEAN MF 1QI PRYMENI--MEDICARE 165, 56- 02/09/+Zt9 ELEAN Mh 40 MEDICARE DISALLOW 167, 05• 0:'/17/09 ELEAN MF 6 PAY-INSUR 41.3'3• l~ IF YUU H BETWEEN VE : 30 NY RM I~UESTI RND 4 : N5, 0 t- !='LEASE L".A M. L 631-3755 ~'~ I FRIENDLY REMI PJD R! YOU A COUNT IS F' ST DUE. PLERSE REMIT ~ ~ BALANCE. THA F'. OU. . 67.31 ACCOUNT AGE TOTAL AAIOUN7 67.3 CURRENT OVER 36 DAYS < OVER 66 DAYS ' OVER 90 DAYS >OVER 1200AY5 ANALYSIS DUE PHYSICIANS OF REHABILITATION, INDUSTRIAL & SPINE MEDICINE, P.C. ATATFMFNT 175 Lancaster Boulevard 4310 Londonderry Road Michael F. Lupinacci, M.D. Mechanicsburg, PA 1'7055 STk7EMENS DATE PAGE P.O. Box 2028 Bloom Bldg. Suite 106 William A. Roll, Jr., M.D. (717) 691-4847 Mechanicsburg, PA 17055 Hartisburg, PA 17109 R P D QIE/@3!@'~ @ 1 oyer, sy com Christopher 4242 wwrN:prismdrs 717 561 . ) - (717) 691-3755 ( Lisa A. Eaton, PsyD Billing Dept: (717) 691-4879 Tax I.D. X1125-1651500 pose retain this portion of statement for your n3eords. ACCOUNT NUMBER @43234 TRANSgGTIt]N~ATE INY.NO. POS. PATIENT DR. PROCEDURE 'DE'SGRIPTIONOFSERVIGES DtAGNOSlB AMOUNT PREVIOUS RALANGE 88.81 @1/@5/@9 RC ELEAN MF 93231 F/U HUSP VISIT, LEVEL 1 781 i@~.@@ @1/@6/@9 AC ELEAN MF 99E31 F/U HOSP VISIT, LEVEL 1 7812 1@?. @@ @i/15/@9 ELEAN MF 4@ MEDICARE DISALLOW 13@.8~ @1/15/1219 ELEAN MF 8@ APPLIED TO DEDUCTIBLE 73.18 @i/261@9 ELEAN MF -4 PER STATE FARM THEY DON'T @1126/@9 ELEAN MF -4 LOVER MEDICARE DEDUCTIBLE @1/26/@9 ELEAN MF -~+ THIS YOUR BALANCE @1129/1219 ELEAN MF 1@ PAYMENT-MEDIGARE 29.27 x+1/29/@9 ELEAN MF 4@ MEDICARE DISALLOW 65.41 IF YOU H VE NY QUESTI NS, PLEASE CA L 691-3755 BETWEEN :3@ AM AND 4: @ M. 67.31 '~ '~cGOUNT '~' A6E ", ?taTAL _-~ AMOUIR ~' , `67. 31 ~~ .CUR1iENr " OYEA 30 DAYS OYEFF6Q [i'IRYS` =~ ~ ~ OYER 9P D0.YS, ; ~ ° "'DYER 120 GAYS - ,_~ ANAt:Y815 DUE PLEASE DETACH AND RETURN THIS PORTION WITt1 YOUR REMITTANCE -ACCQUNT N©: @43234 ELEANt7R R 41I SDA 21~@ BENT CREEK MECHANICSBURG,FA 17@5@ ~. @2/Q13/@3 •. 67. 31 PLEASE MAKE YOUR CHECK PAYABLE TO PRISM. LOCAL HOUSEHOLD ~ RENTAL AGREEMENT .- ~~.~.~~,~~, HORNUNG'S RENTAL CENTER (4517-41) Agreement 18937476 www.pensketruckleasing.com 6048 CARLISLE PIKE Check-out 01/23/09 09:04 AM MECHANICSBURG, PA 17050 USA Due-In 01/24/09 09:04 AM Voice (717) 761-8273 Fax (71 T) 796-2260 24 Hr Eme en Service. 800 526-0798 • ~- ~ Bill To LEONARD SEMICK 505 ELLEN RD Day (717) 737-9556 ~ CAMP HILL, PA 17011 USA C Unit Rented with Damage NO i f i t ~ . Name LEONARD SEMICK ~ NO HAZARDOUS MATERIAL BEING TRANSPORTED •• • • ~ Descri tion Quant Unit of meas Rate (%. 6010 -12FT SAG LIGHT HICUBE Fuel OutFULL ~ r Unit # 9903856 Plate # 1074848 St IN Exp 12/31/09 Owner 0723-10 ,, ~,~ `5 ~~i • .'f 'r Max. Payload 5,5441bs. Height 9 ft. 6 in. , f~~fr' `'~~, `' ~ Mileage Out 40273 20 MILE 0.59 }"~ ~t Days Used 1 1 DAY 19.95 '~-'; 1~. AAA Discount 10.0 °k DISC . ~- ~<-3L'~$~, LIMITED DAMAGE WAIVER / LDW Household *DECLINED* ~, ~; k:. SUPPLEMENTAL LIABILITY *DECLINED* ;. N::~ :.-~ ; - - .r: PERSONAL ACCIDENT INSURANCE *DECLINED* . .,,~~.;~~;~; . CARGO INSURANCE *DECLINED* :;, :K~re~;,' environmental fee 1.0 DY 1.50 , s ': ` <_'~'~'f: , ~_ ~ ~: S y. r Customers who return Vehicles with less fuel than when rented will be charged $S.IXilgallon to refuel the Vehicle plus an addidonai $15 Refueling ~k, ~ Service Charge 'rf a Vehicle is returned to a Penske kxxtbn that does not have fuel on site.X , ~ ~s?~ ~ ~' Initials ~`~!'~`; rr ~ T e Tran Date Details VI RUTH 01/23/09 Card# 6785 Appr 015298 on 01/23/09 for;34.47 a . ~ r ~ ' ~ • t HORNUNG'S RENTAL CENTER (4517-41) Created by J.RIVERA ITEMS i 6048 CARLISLE PIKE Completed by J.RIVERA PA $2/DAY RENTAL TAX MECHANICSBURG, PA 17050 USA Entered at 4517.41 PA 2% HH RENTAL TAX '~ Voice (717) 761-8273 Fax (717) 796-2260 Status OPEN PA 6% SALES TAX e si n n b l C t ESTIMATED TOTAL y g g e ow, us omer agrees that he/she received, read, understands and agrees with all terms, conditions and obligations shown on the rental folder and appropriate User's Guide. Penske k ' zk.,~~ ma es no warranties, express, implied or statutory, including but not limited to, the implied war- ranties of me h t bili fi ~~" ~ ' rc an a ty and tness for a particular purpose.in addition, ff customer is entering into a ~ ~~ his Agreement In FL, HI, MI or MN, Cus omer ackn ledges t elshe has read, understands and ; ;; ~~.~-~. agrees with the terms of the sta 's r red Ian ag a et o in Paragraph A Sections 1 - 4 of e rental folder. Minimum dri s 18 y s of . ustomer agrees that truck i cle dditional s rged ff truck of returned clean. 567629 Customer's Signature ~~1 fwm m W_4 b"~ UC~~ , Hess 38285 4175 Market St. Cramp Hi 11, PA 17811 i/23/69 12:58 PM Term: JD42251544eB1 Appr: 655738 Seq#: 856216 PUMP# 16 CREDIT/ Unl RegulaQ #1.799/G VOLUME 3.34 GAL GAS TOTAL $6.86 Visa XXXXXXXXXXXX7538 61/23/2889 12:57'22 I agree to pay t1~e above Total Amount according to Card ' Issuer Agreement. ~ THAMK YOU FGR SHOPPING AT HESS i .M ~,_ ~,. B. C. 1 E. F. G. `h~~ ~~ \~,o H. A. February 2009 Dear Friend, Each spring a flower placement program is offered by the Diocesan Office of Catholic Cemeteries. This year, we are able to offer an expanded selection of silk floral arrangements and are pleased to be able to offer the selection at the same price of $30.00 (PA sales tax included) as we did last year. Selection of silk floral arrangements can be made at the local cemetery office or by using the mail order form (see reverse side). Unfortunately, we cannot accept phone orders. The completed form and your check or money order made payable to "Catholic Cemeteries" must be received no later than the dates listed below for placement of your floral tribute. If your choice is not available, we will substitute another floral arrangement. You may request arrangements for one or more of the listed dates. March 30, 2009 for Easter (April 12) April 27, 2009 for Mother's Day (May 10) May 11, 2009 for Memorial Day (May 25) June 8, 2009 for Father's Day (June 21) If you have any questions, please do not hesitate to call your local cemetery office. Sincerely, ~f' Patrick Miorin Director ALERT PHARMACY SERV.INC. 219 NORTH BALTIMORE AVE. MT.HOLLY SPRINGS,PA 17065 A FINANCE CHARGE OF 1.50 ~ PER MONTH (AN ADiNt'JAL PERCENTAGE RATE GF 18.0 $ ) OR A MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED ON ALL AMOUNTS 30 DAYS OR MORE PAST DUS PHONE: 800-266-9954 ' IF YOU RECEIVE A NEW INSURANCE CARD FOR YOUR PRESCRIPTIONS BE SURE TO SUPPLY US WITH A COPY. 12/20/ 2008 PMT DUE..O1/15/09 WISDA, ELEANOR WISDE BRIDGES AT BENT CREEK GRP-58 2100 BENT CREEK BLVD PAGE 1 MECHANICSBURG PA 17050 ALERT PHARMACY SERV.INC. 219 NORTH BALTIMORE AVE. MT.HOLLY SPRINGS,PA 17065 ** ACTIVITY FOR WISDA, ELEANOR -WISDE - -58 11%12/08 7439215 28 ISOSORBIDE MN 30 O1 8.00 .00 11/12/08 7439218 28 ASPIRIN 81MG CHEW O1 *. 2.93 .00 11/12/08 7439585 28 METOPROLOL 25 MG O1 5.80 .00 11/12/08 7439588 28 NEXIUM 40 MG O1 15.00 .00 11/18/08 7439587 28 DILTIAZEM CD 120M O1 8.00 .00 11/19/08 7439217 56 POTASSIUM CL 10 M O1 8.00 .00 11/19/08 7448951 14 FUROSEMIDS 20MG O1 4.79 .00 12/04/08 Payment-Thank You 59.07- .00 .00 49.59 2.93 LEGEND NON-LEGEND FOR MONTH FOR MONTH 59.07 52.52 .00 111.59 59.07 S.OOc 2.93 5.80c 15.OOc 8.OOc 8.OOc 4.79c 59.07- 52.52 Q O W S O OOCC N• •Z NCO fL~..f-om~ /1 IM 2CSC9N0 ` o •1Cp- E ~o ~ C] ~a o 7 ~ M d ~ U r ti O Fa o M N O p O ~_ ti 2 0 7 C ~..~-.~ 1 l.~~. ,+ L.i .. ~: ~.: l_.L 9,t ~.~ b.. `~~ ~ f.. ~~ .^, .~ N N N Rl jy N 11( ~ ~ ~ ..+ h Q 3 ca o _ ~~a Q~ NV tti}i ~ ~"~ ~~ ~: s, S >. S r ~~ y ~ r.,,.~. .. _ '! ._ ~.~ `~~ # ~ S et ? e f .1 K i E ~~~~ +. l ~5 +A )~ ~ k ~~