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Home My WebLink About10-29-09 5056051058 REV-1500 ~ (os-o5) oFFICU4L USE ONLY PA i>epartment of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO sox 280601 21 09 ~ ~ ~-3 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Soaai Security Number Date of Death Dat® of Birth 202-20-1901 07/02/2009 01 /11 /1928 Decedent's Last Name Suffix Decedent's First Name MI SHAULL K. RICHARD (M Applicable) En1Der Surviving Spouse's Infi~rmation Below Spouse's Last Name Suffix Spouse's First Name MI SHAULL YVONNE B Spouse's Soaal Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER QF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Retum 2. Supplemental Retum 3. Remainder Retum (date of death prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of _ 5. Federal Estate Tax Retum Required death after 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number YVONNE B. SHAULL r.s (717) 766-4001,h ° - Firm Name (if Applicable) _ac7 ~ ~? :-~~~ -• ~ ~? ' ' REGISTER OF WIt1S USE ~~ . " 7 ~ r ~ i ~_~ ~ ~ :.x : ~ First line of address "~ ~,.. _ 's -- 5225 WILSON LANE #2117 , .~_ ~~'~~ ~::' . -- ~ ._ -rte ~ Second line of address ..~,: ,._.. , -7~ ~ • ~ ~ _;r) 4-? r . O City or Post Office .~ State ZIP Code DATE FILED G... MECHANICSBURG -- ~;., PA 17055 F,. Correspondent's e-mail address: Under penalties of pery'ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, oDrnect and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any kno RE OF PERSON RESPONSIBLE F FI RETURN DATE ~o z AD ESS 5225 WILSON LANE #2117, MECHANICSBURG, PA 17055 SIGNATUR 4F PREPARER OTHER THAN REPRESENTATIVE / ~ - ~~-- DATE ' /a ~ ~ ADDRESS 120 STATE STREET, HARRISBURG, PA 17101 PLEASE USE OR161NAL FORM ONLY Side 1 15056051058 15056051058 J 15056052059 REV 1500 EX Decedent's Social Security Number Decedent's Name: K. RICHARD SHAULL _ 202-20-1901 RECAPITULATION 1. Real estate (Schedule A) ............................................. 1. 0.00 2. Stocks and Bonds(Schedute B) ....................................... 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. 0.00 5. Cash, Bank Deposits ~ Miscellaneous Personal Property (Schedule E) ........ 5. 0.00 6. Jointly Ovvned Property (Schedule F) Separate Billing Requested ....... 6. 34,171.00 7. Inter-Yvos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested........ 7. 187,195.00 8. Total Gross Assets (total Lines 1-7) ................ .................. 8. 221,366.00 9. Funeral Expenses ~ Administrative Costs (Schedule H) ..................... 9. 5,495.00 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ................ 10. 11. Total Deductions (total Lines 9 8~ 10) ................................... 11. 5,495.00 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 215,871.00 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. 215,871.00 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (ax1.2) x .o_ 215,871.00 15. 0.00 16. Amount of Line 14 taxable at lineal 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 REQUESTING A REFUND OF AN OVERPAYMENT 0.00 15056052059 Side 2 15056052059 REV 1500 EX Page 3 Decedent's Complete Address: File Number 09 DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER K. RICHARD SHAULL 202-20-1901 STREET ADDRESS 5225 WILSON LANE, #2117 CITY MECHANICSBURG STATE PA ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 0.00 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 0.00 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) 0.00 5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 0.00 Make Check Payable fo: REGISTER 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 :.......................................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ Q c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ................................................................. ..... ^ 2. ff death ocaiired after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ......................................................................................................... ..... ^ 3. Did decedent own an "intrust for" or payable upon death bank acxount or security at his or her death? ......... ..... ^ 4. Did decedent own an Individual Retirement Account, annuity, orothernon-probate property which contains a beneficiary designation? ................................................................................................................... ..... ~ ^ IF THE ANSVI~R 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 nqt exemot a transfer to a surviving spouse from tax, and the statutory requirements for disdosure of assets and filing a tax return are still applicable even if the surviving spouse is the only 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)j. The tax rate imposed on the net value of transfers to or four the use of the decedent's lineal benefidaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of Vansfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)j. 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-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDt~LE F JOINTLY OWNED PROPERTY ESTATE OF FILE NUMBER K. RICHARD SHAULL ff 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• YVONNE B. SHAULL 5225 WILSON LANE, APT. 2117 WIFE MECHANICSBURG, PA 17055 B' YVONNE B. SHAULL I 'SAME" I WIFE 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 DECEDENTS INTEREST 1. A. PNC BANK - CHECKING ACCOUNT - # 2009-328-0750 2,254.00 50% 1,127.00 2. g, MUTUAL FUNDS - PERSHING INVESTMENTS - #32184310 66,088.00 50% 33,044.00 TOTAL (Also enter on line 6, Recapitulation) ! s 34,171.00 (If more space is needed, insert additional sheets of the same size) REV 1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IED~ILE C INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER K. RICHARD SHAULL This sc~ule must be completed and fled if the answer to any of questions 1 through 4 on the reverse side of the REV 1500 COVER SHEET is ves. ITEM NUMBE DESCRIPTION OF PROPERTY ~NCIUDE THE NAME OF THE TRANSFEREE, THEIR RELATWNSFIIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A DOPY OF T}IE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION iiF APPLICABLE) TAXABLE VALUE 1• PACIFIC LIFE ANNUITY - #VR060$5301 100,000.00 100 100,000.00 2. ING ANNUITY - #167734 76,118.00 100 76,118.00 3. AMERICAN FUNDS IRA -#81729699 11,077.00 100 11,077.00 NOTE: WIFE IS 100% BENEFICIARY ON ALL OF THE ABOVE. TOTAL (Also enter on line 7 Recapitulation) s I 187,195.00 (If more space is needed, insert additional sheets of the same size) r RE1~-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCMEpt~LE M FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER K. RICHARD SHAULL Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' MUSSELMANS FUNERAL HOME 3,437.00 2• TRINITY EVANGELICAL LUTHERAN CHURCH 1,008.00 3- PASTOR & ORGANIST 300.00 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 Year(s) Commission 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 Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Zip Zip TOTAL (Also enter on line 9, Recapitulation) I ; (If more space is needed, insert additional sheets of the same size) 750.00 5,495.00 REV-1513 EX+ (11-08) pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER K. RICHARD SWAULL 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. YVONNE B. SHAULL WIFE 100% 5225 WILSON LANE, #2117, MECHANICSBURG, PA 17055 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 REV-1500 COVER SHEET. ~ It more space is needed, insert additional sheets of the same size. ep\wi'ils\SHAULLyvonne LAST WILL AND TESTAMENT OF R. RICHARD SHAULL I, K. RICHARD SHAULL, of the Borough of Camp Hill, Cumberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. ITEM I: I direct that my Executrix hereinafter named shall pay all my just debts and funeral expenses as soon as conveniently may be done after my decease from the residue of my estate. ITEM II: I devise and bequeath all the rest, residue and remainder of my estate of every nature and wherever situate to my wife, YVONNE B. SHAULL, if she survives me. ITEM III: Should my wife, YVONNE B. SHAULL., fail to survive me, I devise and bequeath all the rest, residue and remainder of my estate, of every nature and wherever situate, to my daughters, LISA S. ZOLL and LORIE A. SHAULL. Should either of my daughters predecease me, I devise and bequeath the share of such daughter to her issue, per stirpes; and should any daughter of mine leave no such issue living following my death, I devise and bequeath the share of such daughter to my issue, per stirpes. ITEM IV: I appoint my Executrix and her successors guardian of any property which passes, either under this will or otherwise, to a Page 1 of 5 minor and with respect to which I am authorized to appoint a guardian and have not otherwise specifically done so, provided that this ap- pontment of a guardian shall not supersede the right of any fiduciary in its discretion to distribute a share where possible to the minor or to another for the minor's benefit. Such guardian shall have the power to use principal as well as income from time to time for the minor's support and education (including college education, both graduate and undergraduate) without regard to his or her parent's ability to provide for such support and education, or to make payment for these purposes, without further responsibility, to the minor or to the minor's parent or to any person taking care of the minor. ITEM V: I appoint my wife, YVONNE B. SHAULL, Executrix of this my last will. Should my wife, YVONNE B. SHAULL, fail to qualify or cease to act as Executrix, I appoint my daughters, LISA S. ZOLL and LORIE A. SHAULL, Co-Executrices of this my last will. ITEM VI: No fiduciary acting hereunder shall be required to post bond or enter security for the faithful performance of her duties in any jurisdiction. IN WITNESS WHEREOF, I, K. RICHARD SHAULL, have hereunto set my hand and seal this ~~ day of ~ _.~ 2004. ~`j ~ ~-~. ~~~.~,, K. RICHARD SHAULL Page 2 o f 5 SIGNED, SEALED, PUBLISHED and DECLARED by K. RICHARD SHAULL, the Testator above named, as and for his Last Will and Testament, and in the presence of us, who at his request, in his presence and in the presence of each other, have subscribed our names as witnesses. ~ ~ ~ ~-- Witnes -s Address Witness Address Page 3 of 5 COMMONWEALTH OF PENNSYLVANIA: . SS. COUNTY OF CUMBERLAND I, K. RICHARD SHAULL, the Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law do hereby acknowledge that I signed and executed this instru- ment as my last will; that I signed it willingly and that I signed it as my free and voluntary act for the purposes therein contained. ~~_ : ~, K. IF D SHAULL Sworn to or affirmed to and acknowledged before me by K. RICHARD SHAULL, the Testator, this ~ ~ day of ~~.~~,~, 2004. ~~ ,~~~N~y Notary Public CARS. L TRO ee~o. Comb 2er1~a~~ New CumbMland ~ 0~. . ~ My r_.onxntssiat Page 4 of 5 COMMONWEALTH OF PENNSYLVANIA . SS: COUNTY OF CUMBERLAND t We , - t ~ ._- 1 and , the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, depose and say that we were present and saw Testator sign and execute the instrument as his last will; that Testator signed willingly and that he executed it as h.is free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the will as witnesses; that to the best of our knowledge, the Testator was at that time eighteen or more years of age, of sound mind and under no con- straint or undue influence. Sworn to or affirmed to and acknowledged before me by and l'~`e~ ~(,~.- witnesses, this fi!~ day of 2004. 1 Notary Public C4MNIONWEALTH QF PEI+~VSYIYANU~ C,AROI L TAOXEU_, Notary Pubic New Gwmberfand 8oro. Cwmb~tand Co. My Contraission Expbes Dec. 2T, 2005 Page 5 of 5 LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. P ~547f T~~ Certification Number d`.. JU 0 6 009 Local Registrar Date Issued I REV 1112008 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS /PRINT IN IMANENT CERTIFICATE OF DEATH ~CK INK (See instructions and examples on reverse) STATE FILE NUMBER 1. Name of Decedent (Prat, middle, lest, suffix) 2. Sex 3. Social Security Number 4. Date of Death (Month, day, year) K. Richard Shaull male 202 - 20 -1901 July 2, 2009 5. Age (Lest Blrtlaiey) Under 1 r Under 1 de 8. Date of Birth Month, da , 7. Bi ce and state a fo count 8a. Pbce d Death Check are 8 1 Months Deys lions MirxAes Jan . 1 1 , 19 2 8 Harrisburg , P A Hospital: Other: Yrs. ^ Inpatient ^ ER / Outpetlent ^ DOA ^ Nursing Home ~ Residence ^ other . speclty: Bb. CourHy of Death Bc. Chy, Sao, Twp. d Death 8d. Facility Name (If not instihttlan, give street and number) 9. Was Decedent of Hlspenic Ori~rt? No ^ Yes 10. Race: American Indian, Bieck, White, etc. Cumberland Lower Allen Tw P Bethan Villa e Y g (ayee,apecilycuben, (,~;/~ Mezicert, Puerto Rican, etc.) whit e 11. Decedents lhwel liar Kind d wok d ab dud most d tie. Do not state re8 12. Was Decedent ever in the 13. Decerknrs Education (Spedly only highest grade cemp bted) 14. Marital Status: Marred Never Married 15 Surviving Spo use QI whe ive maiden name KMd d Work Kind d Buskbss / 1 nd~ry school princip 1 school U.S. Amted Faces? ^ Elem I Secondary (0.12) ~~ College (1.4 or 5+) 6 , , Widowed, DivorrxM (Specify) arried . , g ) vonne Baiter Yee No 18. Decedents Mailing Address (Street, city /town, state, zip code) Decedent's Did Decedent state P e n n c Y l v a n i a Actual Residence , 7a Lower A 11 e n D d t Li d i ' 7 ~ Y 5 2 2 5 W i l s o n Lane Apt .2117 . c. es, ece en ve n Twp. Township? M e c h a n i c s b u r P A 17 0 5 5 7e. coon Cumber 1 a n d 17d. ^ No, Decedent Lived within ty- Aotual Umits o, c;ty, ern 18. Fatlter's Name (First, middle, lest, suffix) Fred Shaull 19. MolFter's Name jFirst, middb, maiden surname) Nellie Kemp 20a. Informant's Name (Type /Print) Yvonne Shaull 20b. Inlomrant's Mallkr~ Address (Street, city I town, state, zip code) 5225 Wilson Lane, Apt.2117,Mechanicsburg,PA17055 21a. Method of Disposition r remelan ^ Donaton 21b. Date of Disposhbn (Month, day, year) 21c. Place of Disposition (Name of cemetery, crematory or other place) 21 d. Location (City/town, slate, zip tale) 1 ^~ 0 6 5 ^ 13uriel ^ Removal ham state i Wes CremeHon a Dorbtlon Authorized r by Medcal Exeminer/caoner? ves^ No J u l 3 2 0 0 9 Y ~ H o 11 i n e r Cremator g Y M t. H o 11 S r i n s, P A Y P g tdle d Funeral rvice Lksnsee (a person acting as such) 22b. License Number 22c. Name arrf Address of Facility FD-013163-L Musselman FH&CS,324 Hummel Ave.,Lemo ne,PA 17043 Conpbte items 23a-c only when artilying phyaicbn Is not available et thne d death Io 23a. To the best of my knowledge, death rred at the ti ~ to a stated. (Sjgneture and tilt) ' L , C ! t 23b. License Number l ~ S G ` 23c. Date Signed (Month, day, year) rx•rufy cause d deem. N ~ l o ~ f ~ ~Cn < S , 1 l ' ~ `1 ~ ~ I ,a ( G` . ~ hems 24.26 moat be canpleted by person h d h 24. Time d Death c W 25. Date Pr ad (Month, day, year (J~ r ( ~ ~ ~ 26. Wes Case Relened to Medical Examiner /Coroner for a Reason Other than Cremation or Donation? w o prortouncea eat . ~ jj (r', M. ( /1~ q { -`•' ^ Yes ~No CAUSE OF DEATH (Sea Instructions and exa s) r Approximate interval: Pad II: Enter other .•torrific?nt conditions contnbcnklg !o = h 28. Did Tobacco Use Contribute to Death? Item 27. Part I: Enter the drain devents -diseases, krjunea, a contpllcetlons • that directly caused the death. DO NOT enter fermi events such as cardiac arrest, r poser to Death but not resultin in the undo 9 rtying cause given in Part I. ^ Y es ^ Probaby respiratory arrest, or ventricular fibdMation without showing the etblogy. Ust only are cause on each hoe. r r t 'I~ 1 ~ No ^ Unknown IMMEDIATE CAUSE (Final disease a condibon resulting in nth) p~ ~: k l (~ , ~~~ ~ ~ ~ ~, S ~ ~ r 5 L 29. If Female: `''~ -~ a ^ N ~ T Due to or 8a e ( consequence off: Sequentially hat cerMitlons, it any, b. i badlrq b the cause fisted an One a ot pregnant within past year ^ Pregnant at time d death ^ . Enbr Bte UNDERLYING CAUSE Due to (or ea a consequence oQ: i Not pregnant, but pregnant within 42 days (dfesue a hrµry that hddated the r events reeuhing m death) LAST. c. r of death ^ Due to (or as a consequence dl: i Nd pregnant, but pregnant 43 days to 1 year tl r r before tlealh ^ Unknown if pregnant within the past year 30e. Was at Auopsy P f d? 30b. Were Autopsy Findings 31. Manrwr of Death 32a. Dale of Injury (Month, day, year) 32b. Descdbe Fbw Injury Occurred 32c. Place of Injury: Home, Farm, Street, Factory, er omre AvaibMe Prior to Completion ~ NaNrel ^ Homicide Office Building, etc. (Speciry) d cause d Death? ^ Yes ~ No ^ Yea ^ No ^ Accident ^ Pending Imreatlgetbn 32d. Thee d Injury 32e. Injury at Wak? 32f. If Trenaportetion Iryury (Specyry) 32g. Locetion of Injury (Street, city /town, state) ^ Suidde ^ Could Not be Detemrirrred ^ Yes ^ No ^ Driver l Oparet« ^ Passenger ^ Pedestrian M Other • Speclly: ~• ~ ( ~' one) 33b. Signature and Tdb of Certifier • Certlrying physkbn (Physician certilyirq cause d death when arather physician has pronaxrced death and cortrpleted Item 23) To the but of my knoeAedge, death oatmsd dw to the atree(e) end mmrNr u hated _ _ _ _ _ _ _ _ .~ - - - - - - - - - - - - - - - - - - - - - - - - - •, ~ ~ ~ w'`'~~" f-z't ~'~f " N' 6, • Pronounel end ng osrtNying phyaiclan (Physkk;iaen both prorwuncktg dum and certhyktg to cause d death) 33c. License Nurt~er 33d. Date S' rgned (Month, ddY~ Yur) To tM but of my Wrowbdge, death occurred el the dma, date, and plea, end dos to the ause(s) and manner u stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ h~ -v c ~ , c1 ~ ~ ( -, , • Meelal Exsminer I Coroner y • ~ ~ f~ ~ Z. 1 t~ ''( ~ ~ ~ ~ On the bob of sxsminetlon end I a Imutlgstlon, M my oplnlon, death occurred at the time, date, and plsee, and due to the auu(s) and manner u stefad_ ^ 34. Name and Address of Person Who Completed Cause of Death (Item 27) Type I Print 35. Registrefs re and / 36. Da Fibd de , r N c1 c,n~-r~ f-.ry FI-G~ iG~, +~ ti" ? ( ~ U ( i V Disposition Permit No.