HomeMy WebLinkAbout02-23-10 15056051058
REV-1500 EX
06
05
PA Department of Revenue (
-
) OFFICIAL USE ONLY
Bureau of Individual Taxes
PO BOX 280601 County Code Year File Number
INHERITANCE TAX RETURN Z
r
Harrisburg, PA 17128-0601 ~
1 ~ ~ U ~ Z
RESIDENT DECEDENT 1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
188-12-5666 12/06/2009 02/05/1924
Decedent's Last Name Suffix Decedent's First Name MI
Horn, Sr. Sr. Glen R
(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 IMITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~~ 1. Original Return ' 2. Supplemental Return 3. Remainder Return (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 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
Mark W. Allshouse, Esq.
. ' (717) 582-4006
Firm Name (If Applicable) .~
' REGISTER WILLS USE LY
0
Christian Lawyer Sol. a
.7
rC
First line of address ~
~~. ~, ~~
i_~~n ~ r` s ~~
-- CU
~~
4833 Spring Road .
r
Cr; .tJ
,
` + ~ ~ W f'~?'7 .`~ i
•>.~ .--~
~:~
Second line of address ~~ r`~ ---,
--~ A„
L Q ~
7
'..1 C i -'f-'7
-'~ "v
r' -_ .)
....
City or Post Office ZIP Code ~ E FILED
cap
State
__ ...
Shermans Dale IV
', PA 17090 j
Correspondent's e-mail address: mark@christianlawyersolutions.COm
unaer penames or pequry, 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.
URE OF PERSON RESPONSIBLE FOR FILING RETURN
f ~ - _ V
DATE
nvvnCJJ
167 Overcash Road, Chambersburg, PA 17202
SIGNATURE OF PRE ~THER T N RESENTATIVE DATE
Spring Road, Shermansl(Dale, PA 17090
PLEASE USE
15056051058
Side 1
ONL'
15056051058
J 15056052059
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Glen R Horn, Sr. 188-12-5666
,.""" __. ....._..__.. ..._.._... _._... __..._.......__
RECAPITULATION _.....___.__M.....,_._.~. ,... ~ ~..~........__~.__~...
1. Real estate (Schedule A) ........................................ ..... 1. ' 0.00
2. Stocks and Bonds (Schedule 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 Owned Property (Schedule F) Separate Billing Requested .. ..... 6. 0.00
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested... ..... 7. 0.00
8. Total Gross Assets (total Lines 1-7) ............................... ..... 8. 0.00
9. Funeral Expenses & Administrative Costs (Schedule H) ................ ..... 9. 12,112.27
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ........... ..... 10. ,, 0.00 ii
11. Total Deductions (total Lines 9 & 10) .............................. ..... 11. 12,112.27
12. Net Value of Estate (Line 8 minus Line 11) .......................... .... 12. -12,112.27
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) .................... .... 13. ', 0.00
14. Net Value Subject to Tax (Line 12 minus Line 13) .................... .... 14. ' -12,112.27
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_ ', ', 15. ' 0.00
16. Amount of Line 14 taxable
at lineal rate X .0 _ 16. ' 0.00
17. Amount of Line 14 taxable
at sibling rate X .12 ' 17. ' 0.00
18. .... .
Amount of Line 14 taxable
at collateral rate X .15 18, ! 0.00
19. TAX DUE ..................................................... ....19.1 0.00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056052059 Side 2
15056052059
REV-1511 EX+ (12-99)
SCNEDt~LE N
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
tstatt yr FILE NUMBER
Horn, Glen R. Sr.
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Osiris Holding of Pennsylvania, Inc. a. Internment ($1,400) b. records and processing fee ($95) 1,495.00
2. Fogelsanger-Bricker Funeral Home, Inc. 8,664.71
a. Professional services, facilities and equipment ($8,025)
b. Newspaper Notices ($320.71) and certified copies ($60)
c. Clergy ($100) and flowers ($159)
s. Vet's Canteen Association -funeral luncheon 952.56
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) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
C~~' 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)
1, 000.00
12,112.27
IrS Q/15 fir. ~~(l.. //r^ r i _
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
P 16085975
Certification Number
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
1 certificate will be forwarded' tp the State Vital
Recor ice for a t f rig.
m
Local egistrar Date Issued
Htos.tu REY nnBa
TYPE I PRY1T NJ
PERItlANEHT
aAacrx
S
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See InttdructlDne and exemolee on reversal
t. Hams a DacadwA (FM, ntleb, lest eueW 2. Sax s. SodM Secuny Numbu m ~. Dre a Death 1, M. YMr)
Glen R. Horn Sr. Male 188 - 12 - 5 D
5. Ape (LaM BWasy) IAitler 1 lAitler 1 Q !ke d Sktlr 7. rM akk a M. Pkoe a Daab ChrA ae
Nah 0•Ye llwae aaadea
NaWW: Olher.
85 YrB. Feb. 5, 1924 Letterkenn ®kpatlem ^ERlouquem ^DUA ^Nunb Han ^liaaMrtp ^gINr. Spedly:
eB. Cautly d DeeN Sa Cry, Sao, Twp. d Dauh 8E. Parlay Name (r rid hrYkdlon, phe atnet and nuMr) 9. Wm Decedam d ?
Hkpnlo Unpin No ^ Yea 10. Race: Amrkan Indian, Skck• WNk, eb.
Franklin Chambersburg („ Yea. weaur coven. ISp•d'i1
Chambersburg Hospital ~ R~• ~) White
11. Dandera's tkad ~ d rrak dw ~ mwl a Ma. Do not un ~ 12. wr Darrtdrp ova b tle 13. Deadra'e Eduatlan (sPedrY a~A' h9Mn Braga mspkted) 11. Mrae sows: Mertlad Nwer Married 1s. Sunivirro Spun (B wea, pre rrWden rwn)
l6M d WoA KYW d eebneunany
su
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n (atz) Capepe (t~ a u)
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Married Janet G. Souders
18.Dxsdere'a MawpAmeee (sbeet,dryltam, eee,~weel
38 Horn Rd. DeeedeM•a Penns 1Van1H Db Deatem
AeuWReebenn rn31eb Y
DeadeMUaedb N. Newton
17c
~Yn
M
l
Shippensburg, PA 17257 .
,
Twp
T
w~y?
aw
,yy ~y Cumberland t7a.^NO, Decedra Lived wiNn
AduM Umika CirylBoro
18. Fatlene Noma (FIM, middle, Ya4 eulfu) 1B. Mdher's Hems (Fin, nddde, nwCr, wrap)
Morgan Horn Fannie M rtle Newman
20e. Naamera'e Name (yype /Prim) 2Bb. kdormem's Maep Meaea (glnal, dY / bwn, sIW, r1P mdal
Janette Washin ton
' 929 N. West St. Carlisle PA 17013
21e. MMhodaD
upoeitlm r ^Cranwim ^,
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(~'/bwn, sere, zip area)
as CramMbn a 0prtbn Autlenaad
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~ --- -
~ 014831-L F.H. Inc. 112 W. St. F{7 HaK 336 PA 17257
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Y Dlepositlolt~Permd No. ~yV ~ ~~
LAST WILL AND TESTAMENT
OF
GLEN R. HORN
I, Glen R. Horn, of Shippensburg, Cumberland County, Pennsylvania, being of sound
and disposing mind, memory and understanding, do hereby make, publish and declare this as and
for my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made
by me.
FIRST
I direct the payment of my just debts and expenses of my last illness and funeral from my
estate as soon after my death as conveniently may be done.
I direct my remains be buried in my prepaid cemetery lot in Memorial Gardens, Carlisle,
Cumberland County, Pennsylvania. If none exits, I authorize my personal representative to
purchase a contract for perpetual care of my cemetery lot, using therefore funds from my estate
in such amount as she shall consider necessary and desirable.
Further, if none exits, I authorize my personal representative to expend funds from my
estate, in such amount as my personal representative shall consider necessary and desirable for
the purchase, erection and inscription of a suitable marker for my grave.
SECOND
I give and bequeath certain articles of my tangible and personal property in accordance
with a hand written list made by me during my lifetime and attached hereto. In the absence of
- ~ such a list or designation on said list, said articles of my tangible personal property shall be
y added to the residue of my estate.
~.
.~~.
THIRD
-tea
I give, devise and bequeath all the rest, residue and remainder of my estate to my beloved
spouse, Janet G. Horn, absolutely and in fee simple if she survives me by thirty (30) days and
she is not institutionalized in a health care facility or nursing home, or receiving benefits through
the PDA Waiver Program or any other public benefits program.
FOURTH
In the event that my spouse, Janet G. Horn, fails to survive me by thirty (30) days or in
the event she shall be institutionalized in a health care facility or nursing home, or receiving
benefits through the PDA Waiver Program or any other public benefits program, I hereby give,
devise and bequeath my estate to my children, Glenda J. Branthafer, now of Orrstown,
Pennsylvania, Janette L. Horn Washington, now of Carlisle, Pennsylvania, Patsy A. Martin,
now of Chambersburg, Pennsylvania and Glen R. Horn, Jr., now of Chambersburg,
Pennsylvania, equally, share and share alike, pro rata. Should any child predecease me, their
share shall pass to my surviving issue, pro rata.
These provisions also appear on my spouse's Will and are intended by both to be
reciprocal, each providing the consideration for the other.
FIFTH
I direct that any and all inheritance, estate, and transfer taxes imposed upon my estate
passing under this Will or otherwise shall be paid out of the principal of my residuary estate.
SIXTH
_ _ In addition to the powers conferred by law, I authorize any personal representative acting
under this instrument, in his or her absolute discretion:
(A) To retain in the form received, or to sell either at public or private sale any
-- real or personal property;
(B) To exercise any options to subscribe for stocks, bonds, or other
investments;
2
(C) To join in any plan of lease, mortgage, consolidation, exchange,
reorganization or foreclosure of any corporation in which my estate or any trust may hold
stocks, bonds or other securities;
(D) To sell, transfer, convey, mortgage, pledge, lease or exchange any
property, real or personal, which at any time may form part of my estate, for the payment
of debts or taxes, or for any puzpose of administration or distribution, for such prices and
upon such terms as my personal representative, in his or her sole discretion, may deem
wise, and to execute and deliver deeds of conveyance or transfer thereof;
(E) To make settlements and compromises on such terms as my personal
representative in his or her sole discretion may deem wise without the necessity of
obtaining any court approval thereof;
(F) To make distribution hereunder either in cash or kind, as my personal
representative in his or her discretion may deem wise.
SEVENTH
I do hereby nominate, constitute and appoint my daughter, Patsy A. Martin to act as
Executrix of this my Last Will and Testament. Provided, however, that if she is unwilling or
unable to act as Executrix, I direct the duties of Executrix to be performed by my daughter,
Janette L. Horn Washington.
~.~ EIGHTH
1 direct that no personal representative, guardian, trustee or other fiduciary appointed
under this instrument shall be required to give bond for the faithful performance of their duties in
~'- any jurisdiction.
3
IN WITNESS WHEREOF, 1, Glen R. Horn, have hereunto set my hand and seal to this
my Last Will and Testament, consisting of five (5) typewritten pages, the first three (3) of which
bear my signature in the margin for identification, this ~;~ ~ day of ~}~ ~ ; ,_,~.r~ :.,.2008.
Glen R. Horn, Testator
Signed, sealed, published and declared by the above-named Glen R. Hom, Testator, as
and for his Last Will and Testament in the presence of us, who have hereunto subscribed our
names at his request as witnesses thereto, in the presence of said Testator and of each other.
,:. ~ f:, <- ~~ ~ ~ ~ t ADDRESS ~~~`, !'. ~~. F~~~-~' ~!`~`
;, ~,
/ r:~./t" } ~~ `` ~'~.?~~ f~i ~~' is/~:3
~.-• -,-e ~ ,L ~~~
_~
~r i ; ~ --:.... -r%~ ;._. ADDRESS 'r~ ~ R t ,- ,ff :.~..~ ,~ f ~ :,
A p ~! ']
~ ~ ~~ ~
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF ,_- ;,~~ ~~`~`"l ,~`~~;~~_'~`
.~ ~ ~ ~,
We, Glen R. Horn, ; f.~ ~„~ ;~ , i,, i''~.,^;~ ~ °:~~ and ~~~r~f~>r~~,fis-. ~ °"% ,~~ ~,~;,;~ ~-~..,~
the Testator and witnesses, respectively whose names are ssigned to the foregoing or attached
instrument, being first duly sworn, do hereby declare to the undersigned authority that the
Testator signed and executed the instrument as his Last Will and Testament and that he signed
willingly and that he executed as his free and voluntary act for the puzposes therein expressed,
and that each of the witnesses, in the presence and hearing of the Testator signed the Will as
witnesses and that to the best of their knowledge the Testator was at the time eighteen (18) or
more years of age, of sound mind and under no constraint or undue influence.
Glen R. Horn, Testator
~;~ ~~~:
-a'-"
`~~`~' ° ~`,' `~-~' %` ~<"~~,~'~'~-~°~ ,Witness
~~a `A ~
~:
F ~ / ~/,
~:, < ~ 'J `~~~~ '~'~~~ ,Witness
4
Subscribed, sworn. to and acknowledged before me by Glen R. Horn, the Testator, and
subscribed to and sworn or affirmed to before me by ~~;}~~d-e, s:.~~ • ~~..~;<.~ ~ ~f ~ and
~ ~ ~ i.f ~f i s'". ~'a f ~ `!'~s'tr" , WitllesseS, t111S ~ day Of ~'F.~{'A"G` ef. ~ ` ~ ~` ~
2008.
r / ~ ~ ,i'
/~~ l ,~~
Notarq Public
~OMtVYONWEpF PEATNS V
lVota~ial Seal
SailleA~Gshonse, ~iotary Public
twanro9' Ywr~., Peery trounty
My' ~ommi~s(ors ~gpires Mar. 28, 20th
Osiris Holding oP Pennsylvania, Inc.
oalr. Retail IDSttallment Contract and Security Agreement
Ido111ioj of Pkawylr.ria Il.C ("[LC") ^'Iyi-Cau --...
Gains floWira of Peansylvavia Su mY Memwsd Oardem I.I,C ('1.LC") 'l -- ..
Cumbedarrd 6wdury LLC ("Comwny'7 TYi-Cowry Memorial Oardew S Wesmuanw Cemetery LLC C`LLC') Cantratt a ..
1971 Riurm~Highwa~ypCnidi ~t~/OU~~ TriLouory Meowrial pardeoa ( ~^j~ (^Com~Y~ W Cemeavy Subsidiary LLC ("Campwry')
717-243-3341 7~ 39 & Eaad, I.ewiabeny, PA.17339 1IW~59bN~evrvCil~k Ro~id~ Car1i~A 17013
1I7-20¢7029
LLC arr~Cottipany (sanetimes referred ro collectively in this Agreement as "$etier) are owner{s~
WITNFSSETH 7 PuRMsmaghes to qry rid LLC and ~ ~ . ` agrees b adl b Pamhxr, a
I. DFSCRIPITON OF BURIAL RIGH75. The Burial Right oovetd by the Agimrtm[am rho
_ Brrial Rfghd in: _ Cnve Spate(s)
_ Lawn Crypr: ~ Double Depth ^ Side-by-Side
O Single O Developed O Preconetruction
]rt Choice 2nd Choice
Garden _. _.. ---- Garden
$Kllon _..___.._ EeCtiw
La Lot
Space(s) -----... Space(s) _
L MERCHANDISE:
O Check here if merchandix is being purchased for ux at another cemetery.
Cemetery's Name:- .._„_
A. VAULT(S) pl. Description
p2. Descrp[ion
B. URN(S): pl. Description
p2. Description
C. MEMORIAL INFORMATION:
Memorial Design:
Vac: Y/N
Bmnu Size X Ganix Siu X
Location (Sation, tic.) ~~? -~ r, s~ _ , (i ( i- ti: `
,t
D. MONUMENT INFORMATION:
Tye' Color:
Size: x x p
Die: x x F
Bar. x x F
E. CASKET(S):
1. Model:
2. Model:
Gwge:
Gauge:
(G) Mausoleum Lettering/Crypt Plate E ~..
E
(H) MemaneVMonammt -'- --
E
(I) Grwih Bax(s) -
E
(f) Irw.lladw Charge _.-- _--
E
E
(K) Caskets __ E
~ .
(L) Ioiaai Fa Ew Irrrarnntt
__ r ! "'
--
S 1 r -R'.
(M)fiml InxrmenUF}ttombmeet/lwmment Fee
(N) Permurent Records @ Processin
Fee E ~~ ~ ..
E ~ I42f
00
g
(O) 001er _ .
- _ S ~s~
E
(P) Sales Tu -----
E E
.
TOTAL CASH PURCHASE PRICE (A THRU P) .
E F [„~ Q :t; ~ (}
ITEMIZATION OF THS AMOUNT FINANCED r
(d) ToralCachPna ...............................
(2) Ac Down Paymem O Cah d Cheek O Credit C
d ~
...f t t.i f3.!~ •.
~ `
~
ar
..
B. Trade In:
... .... ...E
~,
_
'
...5
OId Agreetnntt No. '
C. Total Down Pa
ment
2A+ 2B !f "
~ ~ ~ ~ ~.
y
(
) ...
..............
(l) Unpaid Balmee of Cash Price (I - 2C) ............. ...
E
...E C>
(4) Finance Charge ................................ _ _
...E
' The LLC arM the Company shall mch remain setorldarily liable ro the other for the alts of items and services provided by orre arrotlter pursumt ro Nis A
1 (E) Total Ut¢wd &lanx (3 t 4) Beanent. however, Putthaser shall not be required to exhaust)
any remedies against the LLC or the Company before proceeding against tlx other.
the S11.[.EE for such righii In accorda'ice' .. _..._'"~-.._ ..•....,.... . _-.__.. _
wim Ne Polbwing dixbsum statement: m°~dY01f oedaaaywM ~. T4 dearummteraaglvia con yw.
YOUR PAYMENT
SCHEDULE WILL BE:
_ raYmnnm
S_
_ S
Date
O MonNly an the
`EECDRfTY: You are giving a seeunry inhrtn in the goods or pmpeny bring portlwsM a ro part of are !visa paid uMer Nis
17tEPAYMENT: tf yoo pay off lady, You wifi nd have ro pay a paralry and you rtiay be ewtled b a mfund o(port of the Finance ~k in a Machmagac Tout Fuod.
.NOTICE: See dh mmnMv of dos Agrament (irrdudirrg Owreral Proriaiom on are muse aide her>:.o0 far additioal information stool IWn
sclrWakd doh, and prepaymem mhards aM paWties. 1s7~k default drl'urquency Charge, aecunty imen:xu. any required payment in full before the
THLS AGREEMENT ARLSES OUT OF A CONSUMER CREDIT SALE AND IS SUBJECT TO TAE ADDITIONAL GENERAL PROVLSIONS CONTAINED ON THE REVERSE SIDE
OF TATS AGREEMENT, WIIICH ARE A PART OF THIS AGREEMENT,
This Agteerttem shall be binding upon Ute heirs, executors, adtninisvatora, suctbasors and aaigns of the par6cs hereto,
THIS AGREEMENT AND THE FAMILY PROTECTION CERTDrICATE, IF APPLICABLE, CONTAIIV ALL THE COVENANTS AND PROMISES BETWEEN THE PARTIES, AND
NO AGENT, SALESPERSON, OR OTfDi& REPRESENTATIVE OF EITHER PARTY HAS AUTHORTIY TO MODIFY, ADD TO OR CHANCE ANY OF THE TERMS AND
CONDITIONS CONTABNED IN THLS AGREEMENT AND/OR THE FAMILY PROTECTION CERTiFICATF.
NOTICE TO ACSfG-NESS OP CRt • M R
Arty holder of this consttmer credit eontnM k subject to alt claitta and defettses which Use debtor (Pnrcltaser) eadd aaett a
or with Use proceeds hereof. Recovery hercarder by fhe debtor (Ponchater) shaD not utaed the attttwnt ~~ the Seller of goods or services obtained pursuant hereto
paid by Use debtor (Purchaser) hereunder.
NOTICE TO m aACFR
(d) Do nor sign this Alpeettsent before you read i[ or if it txnaains any blank spaces.
(2) You are entitled to a completely filled in copy of this Agreetrlent at the time you sign it
(3) Under the law, You have the tight a pay off in advance the full attKwm due and wafer certain rxmditibrrs to obtain a partial refund of the finance charge; to redeem the property if repossesstd for
a default; to require, under certain conditions, a resale of the property if repossessed
PURCHAC .R~ 1 _arrlb sN('Rr
It Uris AgreenteM was sdidted at your residence and you do tat want the goods or servitxR you. ffie Patxtaaser, tmq aRtxl this
btrsinas day alter the date of this Agncement (For an explnutfon of this rl Agaeemmt at any time prior to ttridrtigbt of Ute (bird
Recovuy FLrKI: A Real Esttut Recovery Fund exists to reitnburse ~R m Ute attached Notice of CatraOathan totm )
persons who have suffered ttaaary loss and love obtained an utuollectible judgement due to feud, misrepresentation, or deceit in a
teal estate transaction by a Pentnylvartia licensee. For complete sktaik call (ll7) 783-3658 or I-806-822-21 t3.
S&E REVER.~R cI~E FORADDTTIONA RM Ah"1 rn- D1T10)VS
IN WITNESS WAERF,OF, Purchaser has executed this `~ t'^ (~. ~ o Y flog thla
_ Agreement thk ~_ day of 13=~+s_ .- oo s B eiecu
.. 1 r ~ Agreereent, Purchaser adcnowkdges receipt of a mpy of Chia Ai.'rament
Counselor. ~_,.,_ ~t ._ ~ > _ ._' ;, ~ NxMsa -^~ti.._ r..
~, saarw Social Secud No. -
ry _.- Due of BiNr
Seger by: __ 2. Pumhaae _ '-
AudanaMReprmarire _.
NOTICE': AaLawged Reprawmrara it sdgdng on bekaljof back LLCand Cowpony.
Tk&Agrewrsar is aof wfid twtflsKlud byanAurhaited Reprerenrociw ofCx SsBn.
V gavial aighu Catifiah to b<pnned in Nar(p almr Nan pmahmca. d a provide Name(s) Ma:
State Licenx No
of the Cemetery. THIS AGREEMENT is made bf' and between Seller and
cgireed beaefieiaty in-amtdarce with the tams hemmtta alied da'Putthau~t'
the of suck baoof, Ne ~IOrs'brt ibms b be provided or wed u the above checked kKadon.
~P gatdr:rtlbmldittg onfile mthe of5ce mfthe CEMETERY, and are mere particularly desrn'bed bebw.
_+Mauwleam: O (:hapel ^ Garden O Tandem O Side•bySidc O Single ^ Devekped ^ Preconztruction
_ Nicie: ^ Clupel ^ Garden O Single O Companion O Developed O Precowaructiw
+,tWarwr av,aa exwrea, err: r«am ay °. »are m-. ergr ra^
]rt Chdee 2nd Choice
Building Buildin _
Section 8 .__... _._
- Section
No.(s) No.(a) ..._..._ ..
Level Level _..__ ---
3. ITEMIZATION OF CHARGES LLC• Company'
(A) &nial Rights (.4,mbea ~ M. t Worn) ___ E _
(B) Papearal Cue ___ E
~._ (C) Lea Certifiate Dieeowt g ---
(D) Sewnd Eight of (ntennmt E
_ (E) Vault(s) E ---
(F) Urn(a) ..
Socials Security No. Date of Birth ~~_.
Asldrca>~f)liR&-v rh ~`.~ i`-o 'q~ r I -
C~.~F-c,-t,+ r-~,. ~i I
Ffome Phone Number: ~ `)1~~. `) ~ i ~_ t , l'p_
WFarE C(WY-me Cwnpvnyy (aaMlCopy YELLOW COPT'-RemN, Caryone RNKCOPY-Nxdiwv'a Copy Goeorbpr. Pweeaara COPY
__ .. _.
anldcnW prwreaato Ydr Ina amen you as mve paq anw you rr»wur craw yrwrvuv wriuwa~iww
on yair vin hstlaa. ......I •hava mesa M payrnua as achadaad. I M dww Pal'meat d s _
~~ FOGELSANGER-BRICKER FUNERAL HOME,1[NC.
NORMAN H. BRICKER, F.D.
P.0. Box 336
112 West King Street
SHIPPENSBURG, PENNSYLVANIA 17257
Phone (717) 532-2211
Date December 15, 2009
No.
Funeral of Glen R . Horn , Sr .
Mrs. Janette Washington
To 929 North West Street
Carlisle, PA 17013
Personal, Staff and
Professional Services
Funeral Home
Facilities and Equipment
Automobile Equipment
Casket
Interment Receptacle
Monument Engraving
$4,950.00
53,075.00
News
paper Notices Tai A' 58,025.00
Clergy Honorarium $
$ 320.71
100.00
Certifie@ Copies $ 60.00
Flowers $ 159.00
Total `B' $ 639.71
Tota! `C'
Due January 16 , 2010 Complete Total * $8 , 664.71
Amount Paid $ 100.00
Balance $8, 564.71
.~_=
Vet's Canteen Association j ~'r ~ v~~2 ca s h ~ o ~ ~
130 West King Street ~' ~,n.~~cS~~~. ,`~. i "7'~~-
Shippeasbe~, PA !7257 J
(717) 530-?088 Fax (7!7) 532-7324 IIWOICE
Name of
~- - _
Date ~~ , / 1
Phone 1
Unit Price TOTAL
~/.
.. -
o c~ o c c~a
Nast
C(;~
o (deck # ~ Dit~
~` jl ~l
o ~ P~ by woe ~ ~k ~o:
VFW Post 6168 G
Dana
s~ Total
PA Sales teat
6%
Bar BOl
z
~f5,3~
Baited See
~~ x zio~
c~~~
TOTAb DUE: ~~~ . ~~
~ ~s'Od B-]!~S ~tlt 1~'~oOp32
We Th~mtiYau for ~r Patronage