HomeMy WebLinkAbout11-10-09 (3)J 1505607120
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes county code Year File Number
Po Box.28o60~ INHERITANCE TAX RETURN
Harrisburg, PA 17728-0601 RESIDENT DECEDENT 2 1 0 9 0 0 5 0 3
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
198 22 9985 05 07 2009 04 06 1922
Decedent's Last Name Suffix Decedent's First Name MI
DEITCH JUNE p
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
XD 1. Original Retum
C 4. Limited Estate
L~ 6 Decedent Died Testate f-1
(Attach Copy of Will) ~J
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
2. Supplemental Return ~ 3, Remainder Return (date of death
prior to 12-13-82)
qa, Future Interest Compromise ~ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
~ Decedent Maintained a Living Trust 8. Total Number of Safe De sit Boxes
(Attach Copy of Trust) I~
L~ 9. Litigation Proceeds Received ~ 1 p. Spousal Poverty Credit (date of death r -l 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) ~-J (Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JAN M WILEY 717 432 9666
~,
Firm Name (If Applicable)
THE WILEY GRC]UP , P C
First line of address
130 W. CHURCH STREET
Second line of address
City or Post Office State
DILLSBURG pp,
Correspondent's a-mail address:
ZIP Code
17019
REGISTER 0,,~„~pLS USE LY ~ ; `
1
~~ ~ c~
~ z ~ .~ ~-,
Q ~Y. „%
~~ '
~ _
.....
'`
.-
~~
.
.
c~~
• • V-
DATf~FILED W
:.~„
_..,_.
:._
=~=
t~ ~:
.y
.._~. ,.
'` r"i
t...
;~ ~
unaer penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSO RESPONSIBLE FOR FILING RETURN DATE
____/__ Arlene Myers ~~_ ~_~c~
175 Farm Valley Road, Wellsville, PA 17365
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
.... ~~ Jan M Wiley ~~ ~ 6~
nie erar..
130 W. Church Street, Dillsburg, PA 17019
-~ Side 1
1505607120 1505607120
PA Inheritance Tax Return
Signature of Additional Fiduciaries
ESTATE OF FILE NUMBER
Deitch, June P. 21-09-00503
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information
of which preparer has any knowledge.
Signature #2
Name
Address1
Address2
City, State, Zip
Date
Carol Smith
168 State Road
Mechanicsburg, PA 17050
~~- ~"
J
REV-1500 EX
Decedent's Name: June P. D e l t c h
Decedent's Social Security Number
198 22 9985
RECAPITULATION
1. Real Estate (Schedule A) .......................................................................................... 1.
2. Stocks and Bonds (Schedule B) ............................................................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3.
4. Mortgages & Notes Receivable (Schedule D) .......................................................... 4.
5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5.
6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ............. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ~ Separate Billing Requested ............. 7. 2 5 6 5 2 6 4 4
8. Total Gross Assets (total Lines 1-7) ....................................................................... g. 2 5 6 5 2 6 4 4
9. Funeral Expenses 8 Administrative Costs (Schedule H) ......................................... 9,
10. Debts of Decedent, Mortgage Liabilities, 8~ Liens (Schedule I) ................ ................ 10.
11. Total Deductions (total Lines 9 & 10) ...................................................... ................ 11.
12. Net Value of Estate (Line 8 minus Line 11) ............................................. ................ 12.
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 .00 0 0 0 15.
16. Amount of Line 14 taxable
at lineal rate X .045 7 7 1 7 5 4 8 16.
17. Amount of Line 14 taxable
at sibling rate X .12 0 0 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 1 5 4, 3 5 0 9 6 18.
19. Tax Due ....................................................................................................... .............. 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505607220
1505607220
25,000.00
25,000.00
231,526.44
231,526.44
0. 00
3,472. 90
0. 00
23,152. 64
26,625. 54
1505607220 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-09-00503
DECEDENT'S NAME
June P. Deitch
STREET ADDRESS
168 State Road
-
CITY
--- -
Mechanicsburg STATE -~--- ZIP
PA 17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Interest/Penalty if applicable
p. Interest
E. Penalty
22,942.50
1,207.50
Total Credits (A + B + C)
(1) 26,625.54
(2) 24,150.00
(3)
(4)
(5) 2,475.54
(5A)
(5B) 2,475.54
Total Interest/Penalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 2 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF W/LLS, 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 :.................................................................................. [~ 0
b. retain the right to designate who shall use the property transferred or its income :.................................... ^ 0
c. retain a reversionary interest; or .................................................................................................................. ^_ 0
d. receive the promise for life of either payments, benefits or care? .............................................................. [__~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? .......................................................................................................................
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... []
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...................................................................................................................... ~ ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
. .. ~.
....
.... a :.:: .. ;.
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)]. A
sibling 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-1610 E7C+ (g.98)
COMuIONWEALTH Of PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
Deitch, June P.
This schedule must lie 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 DESCRIPTION OF PR DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
1 Remainder interest of the John W. Deitch Trust, 256,526.44 256,526.44
under Will dated 11/14/2001, which was "spouse
only" property not taxed at his death. Assets
held with Janney Montgomery Scott Account
6129-7491:
FILE NUMBER
21-09-00503
TOTAL (Also enter on Line 7, Recapitulation) I 256,526.44
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98)
REV-1151 EX+ (12.98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ESTATE OF FILE NUMBER
Deitch, June P. 21-09-00503
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City State Zip
Year(s) Commission paid
2. Attorney's Fees The Wiley Group, PC
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
12,500.00
4. I Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 12,500.00
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 25,000.00
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Deitch, June P. 21-09-00503
ITEM
NUMBER DESCRIPTION AMOUNT
Other Administrative Costs
1 Trustee termination fee (Arlene Myers and Carol A. Smith) 12,500.00
H-B7 Subtotal 12,500.00
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
REV-1b13 EX+ (9-00)
SCHEDULE J
COMMNHER TANCE TAX RETURNANIA BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Deitch, June P. 21 _n9_nnsn~
NUMBER
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO
DECEDENT
SHARE OF ESTATE
d
W
AMOUNT OF ESTATE
Do Not Llst Trustees or
s)
( ($$$)
I
' TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116(a)(1.2)]
1 Arlene E. Myers Niece 154,350.94
175 Farm Valley Road
Wellsville, PA 17365
2 Carol A. Smith Daughter 77,175.40
168 State Road
Mechanicsburg, PA 17050
Tota I 231,526.34
Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropri ate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTA L OF PART II -ENTER TOTAL N(~N_TAXARI F nISrRIRI ITICIAIC nn~ ~ i~i~ ~~ nc ow ecnn ~nvco cu~c~r n nn
c;opyngnt (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98)
Estate Valuation
Date o~ Dea?-:r~:: 05/07/2009
ValuGt~on ~~.:_e: 05/07/2009
Processir.c ~Gte: 07/06/2009
Share:: Security
cr_ Par Description
1) 1 1 0 `~~ __<.~ 7 MASSACHUSET'
CL A
Mutual Fund
05/07/2009
Estate of: John W. Deitch Trust.
Account . 612 9-^' 4 91
Report Type : Date of Deg: t h
Number of Securities: 4
File iD: John W. Deitch Trust DOD 050709
Mean &/or Div & Int Security
High/Ask Lew/Hid Adj'ments Accruals Value
TS :INNS GROWTH STK (575719109; MIGFX)
(as quoted by NASDAQ}
10.53000 Mkt
10.530000 11,639.41
2) 35406.8%7 AIM INVT SECS FDS INC (008879835; AMHYX)
HI YIELD CL P.
Mutual Fund (as quoted by NASDAQ)
05/07/2009 3.30000 Mkt
3.300000
3) 38387.686 DELAWARE GROUP INCOME FDS INC (DHOAX)
HIGH YLD OPP A
Mutual Fund (as quoted by NASDAQ)
05/07/2009 3.26000 Mkt
3.260000
4) 2900.48 Cash (CASH)
Accrual
Total Value:
Total Accrual:
Total: $256,526.47
Page 1
11.6,842.69
125,143.86
2,900.48
0.03
$256,526.44
$0.03
This report was produced with EstateVal, a product of Estate Valuations &
Pricing Systems, Inc. Janney Montgomery Scott LLC assumes no responsibility for
accuracy or completeness of the information provided, the Date of Death and the
specific securities, which are valued. While we deem this information to be
reliable, we do not warranty or guarantee its accuracy. This service is not
intended to constitute legal or tax advice. You should consult with your tax
professional and attorney to discuss estate settlement and any legal matters.
21-2002-346
LAST WILL AND TESTAMENT OF .1OHN W. DEITCH
I, JOHN W. DEITCH, of Monroe Township, Cumberland County, Pennsylvania, being of
sound and disposing mind, memory and understanding, do make, publish and declare this my Last
Will and Testament, hereby revoking and making void any and all prior Wills by nne at any time
heretofore made.
1.
I direct the payment of all my just debts and funeral expenses as soon after uZy decease as
the same can conveniently be done.
1 a.
My good friends, LARRY E. CLIPPINGER and SHERRY A. CLIPP[NGER, his «~ife,
are currently paying down a debt oc~~ed to me which is secured by a note and mortgage which they
executed in my and my late first ~~~ife's favor. In the event that my now wife survives me, the
payments of principal and interest shall continue to be made to my now ~~c~ife for and during the
term of her natural life. I authorize and empower my executor to arrange for and to provide for the
making of such payments as he deems best under the circumstances as they then exist, including an
assignment of the debt upon condition or the like.
In the event my said no«~ wife has predeceased nne or upon the end of her life, if she has
survived me, then I bequeath,a'iny then remaining balance on said debt to the said CLIPPINGERS.
Any inheritance or estate tax which might be assessed against the value of this debt shall be paid
from the residue of m}~ estate.
I hereby nominate, constitute and appoint ARLENE MYERS and CAROL A. SMITH,
Co-Trustees, in trust, for the following purposes, and to have the following duties, as is more fully
set forth below:
(A.) In the e~~ent that at the time of my death, my wife, JUNE P. DEITCH, is occupying
my residential real estate situate at 258 Stoner Road, Monroe Township, Cumberland County,
Pennsylvania, then I give, devise and bequeath the said parcel of real estate and the residence and
other buildings and improvements thereon, and all the appurtenances thereto, and all the rents,
issues and profits therefrom, as well as all the household contents thereof to my said Co-Trustees.
l.) My said Co-Trustees are to allow my said c~Jife, for and dwing her
natural life, the foil use and occupation of, to, and in my right, title and interest in
and to that certain real estate aforementtoned as well as the free use of the household
contents therein.
~2«zzCeG ~o~2GGG'c~ ~
~~ !~ ~
L='L~ s~1tL~~ ~~-~ uc1-~
?.) So long as, in the good (with and reasonable opinion of my said Co-
Trustees, m}~ said ~~~ife is financially capable of doing so, she shall pay for the
maintenance, utilities, repairs, upkeep, property taxes and the like associated «~ith the
said real estate. In the event that it is determined that my said wife is not financially
capable of making such payments, my Co-Tn~stees are to use the funds of this trust,
as more full}~ set forth below, to assist her in part or in whole to make such
payments.
/i- ~ y-oi
~~~~
3.) In the event my said wife is institutionalized or is placed in some
other long-tens care facility or situation, upon certification by an attending
physician that the likelihood of her being able to return to the premises is virtually
nil, my said Co-Tnistees shall consider her right of occupancy and use herein to be
terminated and shall proceed to sell the said real estate and household furnishings
which have not been othen~~ise specifically bequeathed at public or private sale or
sales as the}~ deem best, and shall take the net proceeds therefrom and place them
into trust as is more fully set forth hereinbelow.
B.) All the rest, residue and remainder of my estate, real, personal and mixed,
whatsoever and wheresoever situate, shall be placed in mist by my said Co-Trustees and
administered and distributed as follows:
1 ~) M}~ said Co-Tnistees are to invest the same i n good and safe
im~estments such as Certificates of Deposit, U. S. Government Bonds and Treasury
Bills, High-Rated Corporate or Municipal Bonds, Good Quality Corporate Stocks,
Common or Preferred, or in Stock or Mutual Funds of a high quality and good mix,
as they deem best. The income generated by the same shall be paid over at
reasonably timed intervals to my said wife for and during her natural life or until her
remarriage. In the event of such an event, this trust shall be deemed to have fulfilled
its purposes and shall be divided and distributed as provided for belo«~.
~.) In the event that during the teen of this trust, my said c~~ife's os~~n
estate has been so depleted as to render her needful o(- assistance in addition to any
that may be rendered to her in connection wish the said real estate as provided for
abo~~e, my said caife shall have the right to request in wilting that the said Co-
Trustees pay over to her an amount or amounts ~~~hich may go as high as ten (10010)
per cent of the previous year's balance in the mist's Cinancial account or accounts
as of December 3 ist of said previous year. This right shat] be exercised and
attended to in all good faith but shall not be cumulative.
3.) Upon the death or reman~iage of my said wife, the tntst estate, its
corpus and an}- interest accumulated thereon, shall be divided and distributed as
follows:
a.) Two-thirds (?/3) thereof to ARLENE MYERS er
strr es;;
~! ~ b.) One-third (fC3) thereof to CAROL A. SMITH,~r
~ >~- °~ ~~
~~ ~~~ ~.f_ ~~
~~
•,
stir es.
In the event that the said CAROL A. SMITH predeceases me or dies during the term of this trust
and is not survived b}~ issue, then her share shall lapse and shall go to the said ARLENE MYERS,
der stir es.
3.
I nominate, constitute and appoint LARRY E. CLIPP[NGER and SHERRY A.
CLIPPINGER, his wife, and BLAINE MYERS and ARLENE MYERS, his ~;rife, to be the Co-
Executors of this, my Last Wiil and Testament. I further direct that they shall not be required to file
bond or other security in the Office of the Register of Wills for the purpose of administering my
Estate.
4.
I authorize and empoc~~er my Co-Tntstees and/or personal representatives, in their sole and
absolute discretion, to purchase or othen~~ise acquire and retain any investments of «~hich I die
seized, or any real or personal property of any nature; to sell, lease, pledge, mortgage, transfer,
exchange, dispose of, or grant options in regard to any or all property of any kind forming a part of
my Estate for such terms and such prices as they may deem advisable; to borro«' money for any
purposes connected with the protection and preservation of m}~ Estate; to mortgage or pledge any
real or personal propeny iornting a part of my Estate; or to Join in or secure the partition of same;
to compromise any claims or demands of m}~ Estate against others or of others against m}~ Estate;
to make distribution in hind and to cause any share to be composed of cash, property in undivided
fractional shares in property different in kind from any other share; and to execute and deliver such
instruments as may be necessary to carry out any of these powers.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this /yf~ day of
--~ °~~ , A. D. 200.
,J HN W. DEITCH --(SEAL)
Signed, sealed, published and declared b}' the above-named JOHN W. DE[TCH, as and
tot- his Last Will and Testament, in the presence of ns, ~~~ho at his reduest and in his presence, and
rn the presence of each other, have hereunto subscribed our names as witnesses.
4
.
' LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
for this certificate, $6.00
Certification Number
This is to certify that the infoi7nation here given i
correctly copied from an original Certificate of Deat
duly filed with me as Local Registrar- The origin
certificate will be forwarded to the State Vita
Records Office for permanent filing.
~~ ~- ~
Deal Registrar ate Issued
~E~ tIQ006
PRINT IN COMMONWEALTH OF PENNSYL'VANtA • DEPARTMENT OF HEALTH • VITAL RECORDS
WNENT
;K INK CERTIFICATE OF DEATH
(See instructions and examples on reverse)
t. Name of Decederx ~FUy, rtaddiB last sulfa) STATE FILE NUM6ER
2. S•x 3 Social Secretly Number 4 Date d Deatlt (Month, day. Year)
line P Deitch daY,yearf 7 & Female 198 - 22 - 9985 May 7, 2009
5 Aga Gast Birthday) IA,der , ear t,nd0! ,day 6. Data d Birtlr (Month,
-~ der Hut: Mrraes n~a f ~ and sate a bngl opx+n) Ba. Place d Deem fChetlc aav met
87 rr6
eb.Counry d Deem
1
& Ciry, Bono, Trop. a Death
Silver Snri
6, 1922 Si1V~ .".'"'° omen
6d. Facdly Name (tl rot G~pn, give street ant raariber) OulDalierK ^ DOA ^ Nursing home ~ Resrderlte ^OUter . ~~_
9. Was DecederM d Mispartk Origin? ~ No ^ y~ to. Roca: American
(tl ye:. spectly caber,, Indarti Badr, wrtit., •r.
168 State Road Mexican, Puwto Ritarl etc- f~'+M
• • ,z. was Oec•d•rtt ever ti me ,3 Decedent's Educafion White
U.S. Armed F«oes7 f~Y anN Kglwu pradp compMled) ta. MariW Sells: Married, twrer Married, ts. Survirirp Spouc• (tl wile, gNs rrtaid•n rwrts)
~Yas ®No E~°`"~'O~O"~Yla,2) CWsgsft.a«5.) vlfidowed,Drv«a•ofSp•ci/i1
1 Widowed
Dnceders's
AwralResidence t7astate - Pennsylvania DidDeC°d°'~
liveina 17c.~]Yes,Dea•dar,tLired„__ S11Ver Spring
,7a. c«wy Ctiimberland Township? Trop
,70. ^ No. Dewderx urea wimin
Awe arras a
19. Homer's Name (Fast rttidde maiden _ Cey / 8oro
~• s vsuar son Knd d cask dew most d ~ fie Do na slat. n
Kira a wont Ignd d Busness /
Cook Food Service
t6 Drxedartts Hairy Address fSTreel cdY / lorrrt stale zp coda)
168 State Road
Mechanicsburg, PA 17050
16. Famer's Name (Fvst, middle, last, sulfa)
Frank Potteiqer
zoo Irdomranrs Name (Type, Prra)
2 ta. Memod d Disposition
eurw Q Removal from state
~ ~ ~A7
zza «
cancans)
nessa EsheLnan
20b. Namartfs Mating Address (SUeet city / burl. staa, zip code)
168 State Road Mechanics
U Cranwion ^ Danaiiorl 21D. Dat• d Disposi9a, (Monet, day. year) 21c. Pas d oispositior, (Name d
Wu Gemstfon « Dorotlon Authortr•d Y. crerrwtory or otllx paca-
~r1sd1caE'""'""/c«~? ^Yes^Na Ma 11 2009 Trindle S tin Cemete
r awrtp as such) 22b. license Number 2zc Name end Adbess d Faalily
PA 17055
21a Location (Cty / bwn, atak, rip ands)
Mechanicsburg,PA
< wdY wnan 23a To m
b ~ - 014889 Mal zzi Funeral Home Mechanicsbnrga P~y17
ptrysidan u not avasabk a hrrre d m b
e
est my , seam o«uned at m• fim•, dab aro place stated (sigrrea
rre and tltl•) 05 5
prYry cause d Beam.
K 23b. Llcarla NumD•r
~
~ ~~ ~~.
Oaa Signed (Morith, day, Year)
eene 2x•26 mtsl be carglet•d by person
who Pr«tw+cet dean 2a. rm. d Deem
25. DaM P (Mmm, day. Y~1 / `/ V ~ ~ 0 Ci/
. a
r M.
AUSE
~ O 26. Was Case Relamd b Me6ca1 Exarnrrer I Carver br a Roston man Cr ~ « Donarpn?
~-~( •r • tan
^Yes W No
OF DEATH (See Inshrsctlons end example.)
~txKOts -diseases.
Item 27. Pan I: Enter Ute siµeres, a wrtpGcalien5 - mat duewy caused me deem
DO NOT eritar 1 Approximate iaerval:
res
a Pan IL t:Nar Otlix ..
-
.
pe
ererxs such as cardiac arteat,
ory arrest, or renbiprar liDriAation wimaA i^9 me etrobgy. list oriy cause m earn 6ne. t Ortset b Deam
/
IMMEOUITE CAUS
Dal ~
rasWUW n the trld•rlyirrg cause given h Pan t 28. Did Tobacco Uce Caniribee b Deem?
^Yes ~ Probabry
E Feral assess or ~ 1
condition resulting b ~elh) r
-tl• a. r ~ ~ ~~
Due b (« es a rqe r
r
lW conditions. s any, b r
b cause fist
d
ti 29. tl sense:
^ Not ptegnars wNhin
ast
e
on
ne a. 1
Eriter UIIDEtiIYING CAUSE Due b (« a5 a cansequertce dl_ r p
y;r
^ PregrtaM M lerw d de
m
(assess a eM mar iriiuared the ~
events resuKAy r dean) UST. c e
^ IVot psgrwa. but preprad rndrn a2 days
Due b (or as a consequence d): j d deem
d. r
1
^ Nd pregrurit. Dra pregnaa ~ days b t year
30a. Was an AWOpsy
Perturrled? 30D Were AuKtpsy Frr6tgs
Available Prior b Compleeori 3,. Hamer d Deam
32a Date a bWY (Abrtm, day. Year) r
32b. Dascrae How NNrN' Ocaared Debr• loam
^ llraubatr tl pregrterx with me pall year
d Cause d beam? Natural ^ Homicide 32c. Paced apa7,
Yyuf! Homs. Farm. Sxaet, F
,
Office Buedrrg, etc (SPsc')1'1
^ Yes y~( No ^Yes ^ No ^ ~p~ ^ Pending Imes 32d. True a
(-t ~~ MMWY 32s. h}uy N Wwk? 321. M Tronapwalion kyury (SpaGyYl
^ SucW ^ could Not ba Detenritnad ^Yes ^ No ~ Driver / Operate ^ Pesserlper aoeseisrt ~ LacaYan a ~ (Steel, lily / load, state)
33a Cert~er (dlerit oriry one) M Oma . SPecAy
' CeN1Y4w phyciclan IPnysiaa, ceraryirg case a deem when arwurer 33b. Sigruaxe era 7
To the best d my M^o•'adin, deem Declined due to me eau W rYsician has pronounced dean and competed Keen 23) - ~`~ I` J n
sq:) and roamer ae rshted_ _ _ _ _ _ _ _ _ - _ _ rty ~ n/ / '
Prorlouneing arW tertilying physklan (Physician tom pronourxarlg Beam and rerGryirtg b rouse d assent - - - - - - - - - - - - - - - - ~ - - - - t~1 , i
To Ute Des( d my Mnowledge, deem occurred at tM Iwrie, dale, and place. and due to the causgs) and roamer as sated_ _ _ _ _ _ _ ~ "^~
' Medical Eaaminar / C«ontr - - - _ _ _ _ -' _ _ ^ ,/~~, Sgned .day, yea
On are baW a examinaUon and! or investlgadon, In my opinion, deem occurred at the time, dale, arM pace, and due to the cause(s) end manner as stated-, ^ { ~ ',G!
3s. Name era Address d ersan ad cause d Deem picm Z7- Type .
35 Regi 's Signature arq District "_-_
~ • ' ~ ~ 36. Data Fled (Moan. car. rte) cl 31 n t~~ C~ F~1 , ~ 17050
l.~.LL 1 I l I ~.- .
D~sposiuortPerrtWNO. 031862 -