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Home My WebLink About04-0166Register of Wills of CUMBERLAND County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of ANNA V. SHEARER No. o~/- {~/~-/~' also known as , Deceased Social Security No. 255078552 BARBARA BROBST, TRUST OFFICER, ORRSTOWN BANK Petitioner(s), who is/are 18 years of age or older, apply(les) for: (COMPLETE "A" OR "B" BELOW:) A. Probate and Grant of Letters and aver that Petitioner(s) is/are the execut OR ~'~ Decedent, dated 813/95 and codicil(s) dated named in the Last Will of the State relevant circa.~[ances, e.g., renur-~-- T;~, ,;,-~-.;~. of e~, etc Except as follows, Decedent did not man'y, was not divorced and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incapacitated: B. Grant of Letters of Administration (c.t.a., d.b.n.c.t.a.: pendente lite. durante absentia; durante mino,;~,;.=) Petitioner(s) after a proper search has/have ascertained the Decedent left no Will and was survived by the following spouse (if any) and heirs: Name Relationship Residence (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in CUMBERLAND County, Pennsylvania, with his/her last family or principal residence at 129 WALNUT BOTTOM RD., SHIPPENSBURG, PA 17257 (SHIPPENSBURG TWP.) (list street, nu~-iber and municipality) Decedent, then 98 years of age, died JANUARY 25 2004 , at 129 WALNUT BOTTOM RD, SHIPPENSBURG, PA · (Location) Decedent at death owned property with estimated values as follows: (if domiciled in PA) All personal property ......................................... $ 110,000.00 (if not domiciled in PA) Personal property in Pennsylvania .................... $ (If not domiciled in PA) Personal prop~,, rty in County .............................. $ Value of real estate in Pennsylvania ........................................................................................ Total ..................................................................................................................... $ 110,000.00 Real Estate situated as follows: Wherefore, Petitioner(s) respectfully request(s) the probate of the Last Will and Codicil(s) presented with this Petition and the grant of letters in the appropriate fon~ to the undersigned: Signature Typed or printed name and residence BARBARA BROBST, TRUST OFFICER, ORRSTOWN BANK ~.O. BOX 250, SHIPPENSBURG~ PA 17257 Oath of Personal Representative Commonwealth of Pennsylvania County of CUMBERLAND The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estat~--°~~~ ~~_Z~ Sworn to and affirmed and subscribed //I~ARBARA BROBST, T~UST OFFICER, ORRSTOWN BANK before me this / ~['f~) day of FEBRUARY, 2004 DECREE OF REGISTER Estate of ANNA V. SHEARI~R also known as OF WILLS, CUMBERLAND COUNTY Deceased Social Security No: 255078552 Date of Death: 1/25/04 AND NOW, FEBRUARY ~'~-,~ , 2004 , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters ~ Testamentary [~ of Administration (c,t.a., d.b.n,c.t.; pendente lite; durante absentia; durante minodtate) are hereby granted to ORRSTOWN BANK in the above estate and that the instrument(s), if any, dated AUGUST 3~ 1995 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters .................................... $ Short Certificate(s) ............... $ Renunciation .......................... $ Affidavit ( ) ....................... $ Extra Pages ( .~ ) .............. $ Codicil ................................. $ JCP Fee ................................. $ Inventory & Tax Forms ............. $ Other ...................................... $ TOTAL ............................. $ ~,0 ~) Attorney: SALLY J. WINDER I.D. No: 24705 Address: 9974 MOLLY PITCHER HWY SHIPPENSBURG PA 17257 Telephone: 717 532-9476 DATE FILED: his 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. Fee for this certificate, $2.00 WARNING: It is illegal to duplicate this copy by photostat or photograph. .~' Local Registrar P 9913235 No. H1D5.143 Rev. 2/87 TYPE/PRINT PERMANENT BLACK INK COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH ~ STATE FlEE NUMBER NAME OF DECEDENT (First, Middle, Last) I SEX I SOCIAL SECURITY NUMBER I DATE OF DEATH (Manlh, Day, Year) s. Anna V. Shearer 2. Female 13. 255 --07 --8552 [4. January 25~ 2004 AGE (Lest Birthday) I UNDER 1 YEAR ~ UNp~R 1 DAY DATE OF BIRTH BIRTHPLACE City end [PLACE OF DEATH ICheck only one - see inslructions on oth~r I Mo~ths ~ Days I Hours I Minutes I (Month, Day, Year) IState or Foreign Country) I HOSPITAL: I OTHER: ,.,8 Y='l I I IB.01/03/1,06 ?.'Jl'~na~e G~ aa. [] [] [] ..=llkq I I No [] Y.. [] ,, ps..~ cub... Bb. Cumberland I~.Shippensburg Twp.J,. Outlook Pointe I~, ..... P ....Rlcen, el¢. IS0 White DECEDENTS USUAL OCCUPATIONI KIND OF BUSINESS / INDUSTRY IWAS DECEDENT EVER iN DECEDENT'S EDUCATION MARITAL STATUS - Mamed, SURVIVING SPOUSE sl,.Clerk ISlb. Grocery Store i~z. ss. (~*) 9I 0~o~5*) s4.Widowed DECEDEN'PS MAILING ADDRESS (St~et, CJ~, S~le, Zip ~) [ DECEDE~S ~Tm. State Pennsylvania . 129 Walnut Bottom Road RESIDENCE dec~enlDid17c.~ Yes, de~entl~d~ Shippensbur9 se. Snippensourg, PA I/zS/ Ionothers~e) 17b. CounW C~berland to~p? 17thD No,~entll~ ~a, Euel Olin Walker ~, Adaline Elizabeth Duncan za,.Edna M. Roundtree ~0~. 13750 N.E. 238 Court, Fort McCoy, FL 32134 21a. ~ ~h~(S~) ~ _ ~ ~lz~,. 01/30/2004 2~c. Sprin9 Hill Cemetery 12~. Shippensburo, PA 17257 SIG~E~ ~~ ~ ~ON ACTING ~ SUCH I LICENSE NUMBER ~ ~E ~D ADDRESS OF FACIL,~ ~ IMMEDIATE CAUSE (Final --~0 + WAS AN AUTOPSY I WERE AUTOPSY FIND}NGS MANNER OF DEA~TH PERFORMED? AVAILABLE PRIOR TO -- COMPLETION OF CAUSE Natural OF DEATH? Accicienl YesD No~ Yes[] N~ I Suicicle [] 25l. 2Bb. 29, Homicide Pending Investigation Could nol be delenllined ; onset and death DATE OF INJURY TiME OF INJURY (Monlh, Day. Y~r) [] 13o.. 13ob. ~, IPLACE OF INJURY - At home, farm, street, factor, office butting, elc (spec~y} 30e. Other a~,,ir,~,lt conditions contributing to death, but not resulting in the underlying cause given in PART I. SIGNATURE AND TJ'T'I:E/~F~/CERTIFIER . .- !~ . . .... LICENSE NUMBER ~ ~'Jt'I~ATE SIGNED (Month, Day, Year) DATE FILED (~,h, Day: Ye~ ' ' O ' LOCATION (Street, Clty~'own, State) 3Of. CERTIFIER (Chec~ ooly one) '~ E .R, TIF~YIN~G .PHYS. ICIA .N (.Physi~iag. certifying ~ca.use of death when another physician has pronounced death end completed item 23) *PRONOUNCING AND CERTIFYING PHYSICIAN Physician both p~onouncing death and certifying to cause of death) *MEDICAL EXAMINER/CORONER On the basil of examlnatiml and/or Investigation, in my opinion, death occurred al Ihe time, date, and place, and due to the causes(a) and ......... llted ............................................................................................... ' ~'~ '" ' 7~ ........................................... [] REGISTRAR'S SIGNATURE AND NUMBER INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED. Y.sO NoUI 30c. 30d. I, ANNA V. SHEARER, of Shippensburg Township, Cumberland County, Pennsylvania, being of sound mind and memory declare this to be my Last Will and Testament and revoke any will or codicil previously made by me. ITEM I: I direct that all my just debts and funeral expenses, including my gravemarker and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my decease as a part of the administration of my estate. ITEM II: I give, devise and bequeath all of my estate of every nature and wheresoever situate to my husband, JOHN W. SHEARER, providing he shall survive me by thirty days. ITEM III: Should my husband, JOHN W. SHEARER, predecease me or die on or before the thirtieth day following my death, I give, devise and bequeath all of my estate of every nature and wheresoever situate to my issue per stirpes, share and share alike. ITEM IV: I appoint ORRSTOWNBANK executor of this my Last Will and Testament. ITEM V: I direct that my executors or their successors shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I hereunto set my hand and seal to this my Last Will and Testament, written on 1 sheet of paper, dated this ~ day of AUGUST, 1995. ANNA V. SHEARER The preceding instrument, consisting of this and one other typewritten page, each identified by the signature of the testatrix, ANNA V. SHEARER, was On the day and date thereof signed, published and declared by ANNA V. SHEARER, the testatrix herein named, as and for her Last Will, in the presence of us, who, at her request, in her presence, and in the presence of each other, have subscribed our names as witnesses hereto. residing at ]/L~lx-~.,¢ t~-'/,-~¢. residing at COMMONWEALTH OF PENNSYLVANIA : : SS We, ANNA V. SHEARER, the testatrix in, and the undersigned witnesses to, the will, the attached or foregoing instrument, who have signed the instrument, having been qualified according to law do depose and say: (a) that I, the testatrix, do hereby acknowledge that I signed the instrument as my will, that I signed it willingly and as my free and voluntary act for the purposes therein expressed; and (b) that we, the witnesses, were present and saw the testatrix sign and execute the instrument as her will, that she signed it willingly and executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testatrix signed the will as a witness and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. ANNA V. SHEARER ~SS Subscribed to and subscribed or affirmed and acknowledged before me by ANNA V. SHEARER, the testatrix and the witnesses whose names are signed above this ~ day of AUGUST, 1995. No~a~Pu~i¢ Notarial Seal I Sally J. Winder, Notary Public ] Shippensburg Twp., Cumberland County I My Commission Expires Feb. 13, 1999 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 _ 04 0166 DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I.- SHEARER, ANNA V. 255-07-8552 III DATE OF DEATH {MM-DD-YEAR) DATE OF gIRTH (MM-DD-yEAR) ~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE LIJ 01/25/2004 01/03/1906 REGISTER OF WILLS III (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) i SOCIAL SECURITY NUMBER ~:oo la, [~1. Odginal Return ~14. Limited Estate r~]6. Decedent Died Testate IAtUch copy of [~9. Litigation Proceeds Received [~2. Supplemental Return r~4a. Future interest Compromise Idate of dea~ seer 12-1242) E~7. Decedent Maintained a Living Trust (A~tach moy of Trust) NAME BARBARA E. BROBST, VP & SENIOR TRUST OFFICER FIRM NAME (If Ac~icable) ORRSTOWN BANK TELEPHONE NUMBER (717) 530-2614 Remainder Return [~5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes [~11. Election to tax under Sec. 9113(A) P.O. BOX 250 SHIPPENSBURG, PA 17257 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Propdek)rship (3) 4, Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, gank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Property (Schedule F) (6) E~ Separate Billing Requested 7. Intar-V'~vos Transfers & Miscellaneous Nen. Probete Property (7) (Schedule G or L) Total Gross Assets (total Lines 1-7) Funeral Expenses & Administrativej Costa (Schedule H) (9) Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)(10) Total Deductions (total Lines 9 & 10) Net Value of Estate {Uno 8 minus Uno 11) 9. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 121,528.3~'~ ~' 33,159.~.; 20,674.44 147.33 154,688.03 (11) (12) (13) 20,821.77 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 133,866.26 0.00 133,866.26 BEE INSTRUCTIONS ON REVERSE Sl0E 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) 16. Amount of Line 14 taxable at lineal rate 1 33,866.26 x .0 4.~ (16) 6,023.98 17, Amcunt of Line 14 taxable at sibling rate _ x .12 18. Amount of Line 14 taxable at collateral rate ..... x .15 19. Tax Due (17) (18) __ (19) 6,023.98 Decedent's Complete 'Address: STREET ADDRESS 129 WALNUT BOTTOM ROAD ClTYsHIPPENSBURG I STATEpA I ZIP 17257 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Phor Payments C. Discount Interest/Penalty if applicable D. Interest E. Pena~ 5,000.00 263.16 (1) Total Credits ( A + B + C ) (2) Total Interest/Penalty ( D + E ) (3) (4) If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (5) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. 6,023.98 5,263.16 760.82 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 760.82 Make Check Payable to: 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 properly transferred; .......................................................................................... [] [] b. retain the right to designate who shall use the property transferred or its income; ............................................ [] [] c. retain a revereionary interest; or .......................................................................................................................... [] [] d. receive the promise for life of either payments, benefits or care? ...................................................................... [] [] 2. If death occurred after December 12, 1982, did decadent transfer proper~y within one year of death without receiving adequate consideration? .............................................................................................................. [] [] 3. D d decedent own an "'n trust for" or payable upon death bank account or security a his or her dea h? .............. [] [] 4. Did decedent own an Individual Retirement Account, annuity, or other non-prebate preper~y 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. Un~r ¢enalties of perju~, I declare that I have examined this tatum, including accompanying schedules and statements, and to the bsst of my knowledge and belief, ~t is true, correct and complete. Dedaratton of preparer other than the personal representative is based o~ all informafon of which preparer has any knowledge. BOX 250, SHIPPENSBURG, PA 17257 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS 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 3% [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 0% [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemot 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 stepperent of the child is 0% [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 4.5%, except as noted in 72 P.S. §9116(1.2) [72 RS. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 ES. §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-1503 EX+ (6-98) COMMONWE~ALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SHARER, ANNA V. SCHEDULE B STOCKS & BONDS FILE NUMBER 21-04-0166 Ail probe~o/Jointly.owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 2 3 4 5 6 7 8 9 10 2228.22 SHS FEDERATED MONEY MARKET FUND, CUSIP 60934N625 ACCRUED INTEREST ON ITEM # 1 902 SHS ORRSTOWN FINANCIAL SERVICES, INC. CUSIP 687380105 ACCRUED DIVIDEND ON ITEM # 3 737.96 SHS VANGUARD GNMA FUND ADM, CUSIP 922031794 ACCRUED DIVIDEND ON ITEM # 5 1495.113 SHS VANGUARD IT CORP ADM, CUSIP 922031810 ACCRUED DIVIDEND ON ITEM # 7 2794.069 SHS VANGUARD S/T CORP ADM, CUSIP 922031836 ACCRUED DIVIDEND ON ITEM ~ 2,228.22 1.50 65,620.50 207.46 7,778.10 24.41 15,280.05 49.04 30,259.77 79.32 TOTAL (Also enter on line 2, Recapitulation) $ 121,528.37 {If more space is needed, inser[ additional sheets of the same size) REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SHEARER, ANNA V. SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21-04-0166 Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jointly.owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 2 3 4 ORRSTOWN BANK CHECKING ACCOUNT #330361, SOLE OWNERSHIP ACCRUED INTEREST ON ITEM #1 ORRSTOWN BANK CERTIFICATE OF DEPOSIT #30038416, SOLE OWNERSHIP ACCRUED INTEREST ON ITEM ~ 26,743.52 3.66 6,411.44 1.04 TOTAL (.Nso enter on Pine 5, Recapitulation) $ 33,159.66 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COUMONWE.~LTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SHE~RER, ANNA V. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE L ABIUTIES, &UENS FILE NUMBER 21-04-0166 Report debts Incun~l by the decedent prior to death which remained unpaid as of the date of death, Including unrelmbursad medical expanses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 2 ANDORRA RADIOLOGY, BALANCE DUE CARLISLE CARDIOLOGY, BALANCE DUE 91.00 56.33 TOTAL (Also enter on line 10, Recapitulation) $ 147.33 (If mom space is needed, insert additional sheets of the same size) EV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA iNHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SHARER, ANNA V. SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21-04-0166 Debts of decedent must be reported on Schedule l ITEM NUMBER DESCRIPTION AMOUNT 5. 7. FUNERAL EXPENSES: FOGELSANGER-BRICKER FUNERAL HOME, FUNERAL EXPENSES ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative{s) ORRSTOVVN BAN K Social Secudly Number(s)/EIN Number of Personal Representative(s) StreetAddress P.O. BOX 250, C~y SHtPPENSBURG Year(s) Commission Paid: 2004 AttomeyFees SALLY J. WINDER, ESQ. 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 Probate Fees Tax Re~um Preparer's Fees 23 0934350 SUe PA mp 17257 Zip 6,411.44 7,000.00 7,000.00 263.00 TOTAL (Also enter on line 9, Recapitulation) $ 20,674.44 (If more space is needed, insert additional sheets of the same size) REV-1515 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REEIDENT DECEDENT ESTATE OF SHARER, ANNA V. SCHEDULE J BENEFICIARIES FILE NUMBER 21-04-0166 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER DO Not List Trustee(s) OF ESTATE [ NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS ~nclude outright spousal dist~butions, and transfers under Sec. 9116 (a) (1.2)] EDNA M. ROUNTREE 1750 N.E. 238 COURT FORT MCCOY, FL 32134-6201 V. ERNESTINE MCDONALD 136 SOUTH FIFTH AVENUE CLARION, PA 16214 RICHARD A. WRIGHT 13633 N.E. 237 COURT DAUGHTER DAUGHTER 1/3 of estate residue: $ 44,622.08 1/3 of estate residue: $ 44,622,08 FORT MCCOY, FL 32134-6201 GRANDSON ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN £LECTION TO TAX IS NOT BEING MADE 1/9 of estate residue: $ 14,874.03 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET (If mom space is needed, insert additional sheets of the same size) 0.00 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYI.VANIA INHERITANCE TAX RE-DJRN RESIDENT DECEDENT ESTATE OF SHEARER, ANNA V. SCHEDULE J BENEFICIARIES FILE NUMBER 21-04-0166 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s} OF ESTATE TAXABLE DISTRIBUTIONS [include outright spousal disMbutions, and ffansfers under Sec. 9116 (a) (1.2)] STEPHEN W. WRIGHT 7806 CHEVALIER COURT SEVERN, MD 21144 KELLY WRIGHT 13640 N.E. 237 COURT FORT MCCOY, FL 32134-6201 GRANDSON GRANDDAUGHTER 1/9 of estate residue: $ 14,874.03 1/9 of estate residue: $ 14,874.04 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE BISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART I] - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 (If more space is needed, insert additional sheels of the same size) I, ANNA V. SHEARER, of Shippensburg Township, Cumberland County, Pennsylvmfia, being &sound mind and memory declare this to be my Last Will and Testament and revoke any will or codicil previously made by me. ITEM I: I direct that all my just debts and funeral expenses, including my gravemarker and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable aRer my decease as a part offlae adntinistration of my estate. ITEM II: I give, devise and bequeath all of my estate of every nature and wheresoever situate to my husband, JOItN W. SI:II~,ARER, providing he shall survive me by thirty days. ITEM m: Should my husband, JOHN W. SHEARER, predecease me or die on or before the thirtieth day following my death, I give, devise and bequeath all of my estate of every nature and wheresoever situate to my issue per stirpes, share and share alike. ITEM IV: I appoint ORP~TOWN BANK executor of this my Last Will and Testament. ITEM V: I direct that my executors or their successors shall not be required to give bond for the faithful perfom~ance of thek duties in any jurisdiction. IN WITNESS WHEREOF, I hereunto set my hand and seal to this my Last Will and Testament, written on I sheet of paper, dated tlfis ~ day of AUGUST, 1995. ANNA V. SHEARER The preceding instrument, consisting of this and one other typewritten page, each identified by the signature of the testatrix, ANNA V. SHEAREIL was On the day and date thereof signed, published and declared by ANNA ¥. SHEARER, the testatrix herein named, as and for her Last Will, in the presence of us, who, at her request, in her presence, and in the presence of each other, have subscribed our names as witnesses hereto. residing at l/b~O:~ COMMONWEALTH OF PENNSYLVANIA : : SS /3/// We, ANNA V. SHEARER, the testatrix in, and the undersigned witnesses to, the will, the attached or foregoing instrument, who have signed the instrument, having been qualified according to law do depose and say: (a) that I, the testatrix, do hereby acknowledge that I signed the instrument as my will, that I signed it willingly and as my free and voluntary act for the purposes therein expressed; and (b) that we, the witnesses, were present and saw the testatrix sign and execute the instrument as her will, that she signed it willingly and executed it as her free and voluntary act for the purposes therein expressed; that each of us in the heating and sight of the testatrix signed the will as a witness and that to the best of our knowledge the testatrix was at that time 18 or more years &age, &sound mind and under no constraint or undue influence. ANNA V. SHEARER Subscribed to and subscribed or affn-med and acknowledged before me by ANNA V. SHEARER, the testatrix and the witnesses whose names are signed above tiffs ~ day of AUGUST, 1995. Notary Pt~ic Notarial Seal Sally J. Winder, Notary Public Shippensburg Twp., Cumbedand County My Commission Expires Feb. 13, 1999 his is to certify that the infornlation 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 O~ce for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 P 9913240 No. ~ Da~e- ' 98 Cumberland st Shippensburg, PA 17257 t8. Euel Olin Walker ~..Edna M. Roundtree COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH 2. Female 3. 255 -- 07 --8552 3//03/1906 ~aamasville Outlook Point e Store 9 /30/2004 ~*. Adaline Elizabeth Duncan ~0~. 13750 N.E. 238 Court, Fort McCoy, FL 32134 O RSTO K TO: Orrstown Bank Trust Department PO Box 250 Shippensburg, PA 17257 FROM: ORRSTOWN BANK P.O. BOX 25O SHIPPENSBURG PA 17257-0250 RE: ESTATE OF Anna V Shearer DECEASED DATE OF DEATH: January 25, 2004 IT IS HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD, ON THE ABOVE DATE, THE FOLLOWING ACCOUNTS WITH ORRSTOWN BANK: (1) CHECKING ACCOUNTS ACCOUNT NO. TITLE OF ACCOUNT 330361 Anna V Shearer DATE OPENED 2/1/77 DATE OF DEATH PRINCIPLE & ACCRUED INTEREST 26,743.52 3.66 SAVINGS ACCOUNT ACCOUNT NO. TITLE OF ACCOUNT DATE OPENED DATE OF DEATH PRINCIPLE & ACCRUEDINTEREST (3) CERTIFICATES OF DEPOSIT ACCOUNT NO. TITLE OF ACCOUNT 30038416 Anna V Shearer DATE OPENED 11/24/87 DATE OF DEATH PRINCIPLE & ACCRUED INTEREST 6,411.44 1.04 6/8/04 By Timothea Customer Service Operator CUSIP 60934N625 687380105 922031794 922031810 922031836 Anna Shearer DOD: 1/25/2004 SECURITY NAME Federated Fund Orrstown Finl Svcs ex-date 12/29/03 Vanguard GNMA Adm Vanguard IT Corp Adm Vanguard SFF Corp Adm SHS/PAR 2228.220 902.000 737.960 1495.113 2794.069 DOD PRICE 1.00 72.75 10.54 10.22 10.83 DOD VALUE 2228.22 65620.50 7778.10 15280.05 30259.77 DIV/INT 1.50 207.46 24.41 49.04 79.32 Report completed by: Wendy Bullock Date: 2/19/2004 Name of Decedent: Date of Death: CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Will No. To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on : Name Address Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: Signature Name Address Telephone ( Capacity: __ Personal Representative . Counsel for personal representative a Anna, den' _ rer s:~tat.~ · i on" ties Daughter · Edna M. Rountree :i i SSI: 25620-5683 1750 N. E. 238 Couri ! ~ DOB: 5/3111924 Fort McCoy, FL 321~ 62011 ; Daughter v. Em... i ss,: 138 South Fifth Aven~ i DOB: 11/12/1926 Clarion, PA 16214 3Ch,,.re. 1. Richard A. ~M'.t SSt: 22070-6682 13633 N. F_~7 ~!r DOB: Fort M~Coyi:,~.L 32!3 ~4-6201 2. stephen W..!~;MI ! SSI: a20-70-SS97 Severn, MD'.i~144 ! i ' 3. K~ty wrightif| 'i i ssi:. 2~?;2-4~2 Fort McC~yi{~. ACllVE MI~y.! mbil goes l~ mother's home '! COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF rNDJVIDUAL TAXES RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX(11-96) NO. CD 004468 ORRSTOWN BANK PO BOX 250 SHIPPENSBURG, PA 17324 I ESTATE INFORMATION: SSN: 255-07-8552 FILE NUMBER: 2104-0166 DECEDENT NAME: DATE OF PAYMENT: SHEARER ANNA VIVIAN 10/05/2004 POSTMARK DATE: 10/04/2004 COUNTY: CUMBERLAND DATE OF DEATH: 01/25/2004 ACN ASSESSMENT CONTROL NUMBER 101 AMOUNT $760.82 REMARKS: TOTAL AMOUNT PAID: $760.82 CHECK#018223 SEAL INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS BU.E^U OF ~.D~VIDUAL ~'T~-XES TNHERTTANCE TAX DZVTSTON DEPT. :)80601 HARRISBURG, PA 17128-0601 BARBARA E BROBST VP & SR ORRSTOWN BANK PO BOX 250 SHIPPENSBURG PA 17257 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLO#ANCE OR D]:SALLO#ANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DATE 09-27-200q ESTATE OF SHEARER DATE OF DEATH 01-25-2004 FILE NUMBER 21 04-0166 COUNTY CUMBERLAND ACN 101 Amount Remi'l:tad REV-1S~i7 EX AFP (01-OS) ANNA V HAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAHD CO COURT HOUSE CARLISLE, PA I70I$ CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV-1547 EX AFP (01-03) NOTICE OF ZNHER/TANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX ESTATE OF SHEARER ANNA V FILE NO. 21 04-0166 ACN 101 DATE 09-27-2004 TAX RETURN NAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schadule B) (2) 3. Closely Held Stock/Partnership /nterast (Schedule C) ($) ~. Mortgages/Notes Receivable (Schedule D) (~) 5. Cash/Bank Daposlts/Misc. Personal Property (Schedule E) (5) 6. Jointly Owned Property (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. To~al Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expanses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabillties/Liens (Schedule 1) (10) 11. Total Deductions 12. Net Value of Tax Return .O0 121/528.$7 .00 .00 :55/159.66 .00 .00 (8) 20,674.44 147.35 NOTE: To insure propar credit to your account, submit ~hm upper portLon of this form w~th your tax payment. 13. 1~. NOTE: 154,688.05 (11) 20.821.77 (12) 13:5,866.26 .00 155,866.26 18 and 19 ~ill Char/table/governmental Bequests; Non-alec~ed 911:5 Trusts (Schedule J) Nmt Value of Estate SubSmct to Tax (1~) Zf an assessment ~as issued previously, lines 14, 15 and/or 16, 17, re~lect ~igures that include the total of ALL returns assessed to date. ASSESSHENT OF TAX: 15. Amount of Line 1~ at Spousal rate 16. Amount of Line 1~ taxable at Lineal/Class A rate 17. Amount of Line lq a~ Sibling rate 18. Amount of Line lq taxable a~ Collateral/Class B rata 19. PrAncApal Tax Due ~AX CREDITS: PAYMENT RECEIPT DISCOUNT (+) BATE NUMBER INTEREST/PEN PAID (-) 04-22-2004 CD005855 263.16 )AYMENT MUST BE MADE BY 10-25-2004~. IF PAID AFTER DATE /NDICATED, SEE REVERSE FOR CALCULATION OF ADDZT/ONAL INTEREST. (is), .00 x O0 = .00 (16) 15:5,866.26 x 045= 6,025.98 (17) .00 x 1Z = .00 (18) .00 x 15 = .00 (19)= 6,025.98 AMOUNT PAID 5,000.00 5,26:5.16 760.82 .00 760.82 TOTAL TAX CREDIT I BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT ZS RE~U/RED. ZF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU NAY GE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR /NSTRUCTIONS.) RESERVATION: PURPOSE OF NOTICE: PAYMENT: REFUND (CR): OBJECTIONS: ADNIN- ISTRATIVE CORRECTIONS: DISCOUNT: PENALTY: INTEREST: Estates of decedents dying on or before December lg, 198g -- if any future interest in the estate is transferred in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class 8 (collateral) rate on any such future interest. To fulfill the requirements of Section 2160 of the Inheritance and Estate Tax Act, Act Z3 of 2000. (72 P.S. Section 9160). Detach the top portion of this Notice and submit with your payment to the Register of Hills printed on the reverse side. --Make check or money order payable to: REGISTER OF NILLS, AGENT A refund of a tax credit, ahich was not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1313). Applications are available at the Office of the Register of Hills, any of the 23 Revenue District Offices, or by calling the special g6-hour answering service for fores ordering: 1-800-36Z-ZOSO; services for taxpayers with special hearing and / or speaking needs: 1-800-667-3020 (TT only). Any party in interest not satisfied with the appraisement, alloeance, or disalloaance of deductions, or assessment of tax (including discount or interest) as sheen on this Notice must object within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA iTlgS-lOgl, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. Factual errors discovered on this assessment should be addressed in eriting to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Revise Unit, Dept. g80601, Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident Decedent" (REV-lSD1) for an explanation of administratively correctable errors. If any tax due is paid eithin three (3) calendar months after the decedent's death, a five percent (SI) discount of the tax paid is allowed. The 15Z tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest that has been assessed as indicated on this notice. Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became detinquent before January 1, 198Z bear interest at the rate of six (6Z) percent per annum calculated at a daily rate of .000166. All taxes which became delinquent on and after January 1, 198Z will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 198g through 2004 are: Interest Daily Interest Daily Interest Year Rate Factor Year Rate Factor Year Rate ~ 20X .000568 ~)'~- 1991 11Z .000301 ~ 97. 1983 X6Z .0006:58 1992 92 . O00267 gOOZ 6Z 1984 IiZ .000301 1993-1994 7Z .000192 2003 52 1985 137. .000356 1995-1998 9Z .000267 2006 62 1986 IOZ . 000276 1999 7Z . 000192 1987 IOZ .000276 2000 7Z .000192 --Interest is calculated as follows: TNTEREST = BALANCE OF TAX UNPAI'D X NUNBER OF DAYS DEL/NQUENT X DAILY INTEREST FACTOR Daily Factor .000267 .000166 .000137 .000110 --Any Notice issued after the tax becomes delinquent will reflect an lnterest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. ORRSTOWN BANK' PO BOX 250 S HIPPENSBU RG. PA 17257 ~.037 BUREAU OF INDTVZOUAL TAXES INHERITANCE TAX DIVISTOH PO BOX Z80601 HARRISBURG, PA 171Z8-0601 COHHON~/EALTH OF PENNSYLVAN'rA DEPARTHENT OF REVENUE INHERITANCE TAX STATEHENT OF ACCOUNT REV-160? EX AFP C09-0~) BAR~ARA E BROBST VP &~ ORRSTO~N BANK PO BOX 250 SHZPPENSBURG PA 17;~57 DATE 11-15-200fi ESTATE OF SHEARER DATE OF DEATH 01-25-200q FILE NUHBER 21 0~-0166 COUNTY CUHBERLAND ACN 101 I Amoun~ Rem/~ed ANNA V HAKE CHECK PAYABLE AND REHZT PAYHENT TO: REGTSTER OF WTLLS CUHBERLAND CO COURT HOUSE CARLTSLE, PA 17015 NOTE: To /nsure proper credA~: ~o your account, submJ~c ~he upper portion of ~chis fore wJ~h your )cax payment. CUT ALONG TH'rS LINE ~ RETAIN LO~/ER PORT/ON FOR YOUR RECORDS ~ ESTATE OF SHEARER ANNA V F'rLE NO. 21 0~-0166 ACN 101 DATE 11-15-200~ THTS STATENENT TS PROVTDED TO ADV/SE OF THE CURRENT STATUS OF THE STATED ACN TN THE NANED ESTATE. SHO#N BELO# TS A SUNNARY OF THE PRZNCTpAL TAX DUE:. APPLICATTON OF ALL PAYNENTS, THE CURRENT BALANCE, AND, TF APpLTCABLE, A PROdECTED TNTEREST FIGURE. DATE OF LAST ASSESSHENT OR RECORD ADJUSTHENT: 09-27-Z00~ PRINCIPAL TAX DUE: .......................................................................................... PAYHENTS (TAX CREDITS): 6,023.98 PAYHENT RECEIPT DISCOUNT (+) AHOUNT PAID DATE NUHBER INTEREST/PEN PAID (-) Z65.16 0~-22-Z00~ 10-0~-Z00~ CD005855 CDO0~68 .00 5,000.00 760.82 ZF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( ZF TOTAL DUE ZS LESS THAN $1, NO PAYNENT ZS REQUIRED. ZF TOTAL DUE ZS REFLECTED AS A "CREDIT' TOTAL TAX CREDIT 6,023.98 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORN FOR INSTRUCTIONS. ) PAYMENT: Detach the top portion of this Notice and submit with your payment made payable to the name and address printed on the reverse side. -- If RESIDENT DECEDENT make check or money order payable to: REGISTER OF N/LLS, AGENT. -- If NOR-RESIDENT DECEDENT Bake check or money order payable to: COMMONWEALTH OF PENNSYLVANIA. REFUND (CA): A refund of a tax credit, which ams not requested on the Tax Returnj may be requested by completing an "Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-1315). Applications are available online at aww.ravanue.stata.pa.us, any Register of Rills or Revenue District Office, or from the Department's Iq-hour ansaaring service for forms orders: 1-800-362-ZOS0~ services for taxpayers with special hearing and/or speaking needs: 1-80g-4qT-30ZO (TT only). REPLY TO: DISCOUNT: PENALTY: Questions regarding errors contained on this notice should be addressed to: PA Department of Ravenuej Bureau of Individual Taxes~ ATTN: Post Assessment Review Unit, P.O. Box Z&0601, Harrisburg, PA 171Z8-0601, phone (717) 787-650S. If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (SI) discount of the tax paid is alloaed. The 15Z tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18~ 1996, the first day after the end of the tax amnesty period. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of death, to the date of payment. Taxes which became delinquent before January l~ 198Z bear interest at the rate of six (BI) percent par annum calculated at a daily rate of .000164. All taxes which became delinquent on and after January 1, 198Z ailZ bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for leBZ through ZOO4 are: Interest Daily Interest Daily Interest Year Rate Factor Year Rate Factor Year Rate 1982 lOX .000548 1988-1991 112 .000301 ZOO1 9Z 1983 16Z .O00q3B 199Z 9Z .000247 200Z 62 198~ llZ .000301 1993-1994 7Z .O0019Z 2003 SZ 1985 132 ,000356 1995-1998 9Z .000247 2004 qZ 1986 IOZ .000Z74 1999 7Z .00019Z 1987 9g .000247 ZOO0 BZ .O00Z19 Daily Factor .000Z47 .000164 .000137 .000110 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPA/D X NUNBER OF DAYS DELTNI;IUENT X DATLY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be caIculatad. cumberland County - Register Of Wills One Courthouse Square Carlisle! PA 17013 Phone: (717) 240-6345 Date: 12/16/2005 WINDER SALLY J 9974 MOLLY PITCHER HIGHWAY SHIPPENSBURG, PA 17257 RE: Estate of SHEARER ANNA VIVIAN File Number: 2004-00166 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 1/25/2006 Your prompt attention to this matter will be appreciated. Thank You. sincerely, .b~~,j~~ , ,. l GLENDA FAP~JER ST~~SBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge ~~' ..~ .' i -l~ .0~~~ f."f .\ ~~ ~ ~ R\eg].51Iei' ofV;Hl61IiJiK CiLii.tilb.e:iriand :COU:!G."[j7 Name of Decedent: STATUS REPORT UNDER RULE 6.12 ~J'- Vi VlJ/\A~~ Date of Death: Estate No.: ~DD4-DDi~b . Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Ru1es, I report the foHowing with respect to completion of the administration of the above-captioned estate: 1. State ~ether administration of the estate is complete: Yes~ No 0 2. If the answer is No, state when the personal representatIve reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a [mal account with the Court? Yes 0 No ~ b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the perso~epresentative state an account informally to the parties in interest? Yes J.2St No 0 CJ c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be frIed with the Clerk ofthe Orphans' Court and may be , . attached to this report. 0 ~ 1 .) . "- Date: J ~ 1-Yi ^~ . tlJ{;.v "- m ~ ~ SIgnature 0 ~l ~ ) [;0 i:Jd Nameq~l ;no1fJ!/Idu~ -~ .. & [ill Address Uti D I 111 <;~ Cjf7 '= iI!:" Telephone No. (:an"-Cl't-y.' Llrl Vp-~~~~ 1 D Q--esQ-+~+;"e .......- r""'" 1.- ~ ......l.::>vUa.l. .J..,-v}il ......1J.i..Ci.l.l v ~ Counsel for personal representative Vt REV.l500EXj6-00J . REV-1500 *' "..~~" PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX RETURN FILE NUMBER DEPT. 280601 21 04 0166 HARRISBURG, PA 17128-0601 - RESIDENT DECEDENT ----- COUNTYCQOE YEAR NUMBER DECEDENT'S NAME (lAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER I- SHEARER, ANNA V. 255-07-8552 Z W DATE DF DEATH (MM-DD-YEAR) ... ~~TE OF BIRTH (MM-DD~YEAR) THIS RETlJRN MUST BE FILED IN DUPLICATE WITH THE C W 01/25/2004 ,01/03/1906 REGISTER OF WILLS () W (IF APPliCABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER C w ~ 1. Original Return o 2. Supplemental Return D 3. Remainder Return (date of death prior to 12.13-62) ,., "':S.. o 4. Limited Estate o 4a. Future Interest Compromise (date of death after 12-12-62) o 5. Federal Estate Tax Return Required u"'" w..u ,,00 ~ 6. Decedent Died Testate (Attach copy of Will) o 7. Decedent Maintained a Living Trust (Attach copy of Trust) 8. Total Number of Safe Deposit Boxes u..... .... - .. o 9. Litigation Proceeds Received o 10. Spousal Poverty Credit (date of death between 12.31.91 and 1.t-95) D 11. Election to tax under Sec. 9113{A) (Attach Sch 0) " :t"'I&~~Mll$UII$;"PM lii;~L" . ~~Qli ~1i!II, I; ;!!!Ig!l~',I!I$,!!l8li ,., " z COMPLETE MAiliNG ADDRESS w NAME c BARBARA E. BROBST, VP & SENIOR TRUST OFFICER z P.O. BOX 250 0 FIRM NAME(IfA;:lplicabl~)"-"------"...-.- .. SHIPPENSBURG, PA 17257 [fi ORRSTOWN BANK .. n... .. TELEPHONE NUMBER 0 u (717) 530-2614 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 121,528.3f)Q g (~ - - 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) =:1 ~~: n- . 4. Mortgages & Notes Receivable (Schedule D) (4) ~l~ <- i F 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 33,159.~ W Z (SeIleduleE) Cl '..) 0 6. Joinly Owned Property (SeIledule F) (6) '!:) '''^'" ::g ~ D Separate Billing Requested 'r:, , N (7) p;:~ ~ ~ 7. InterNivos Transfers & Miscellaneous Non-Probate Property "" I- (Schedule G orL) ii: 8. Total Gross Assets (total Lines 1-7) (6) 154,688.03 < () 9. Funerai Expenses & AdministratillE1' Costs (Schedule H) (9) 20,674.44 W II:: 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 147.33 11. Total Deductions (total Lines 9 & 10) (11) 20,821.77 12. Net Value of Estate (Line 8 minus Line 11) (12) 133,866.26 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) 0.00 made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 133,866.26 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPUCABLE RATES Z 15. Amoont of Line 14 taxable at the spousal tax 0 ~ rate, or transfers under Sec. 9116 (a)(1.2) ,.0___ (15) 133,86(3,?~ ,0 ~ (16) 6,023.98 I-' 16. Amount of Line 14 taxable at lineal rate ::l ll.. 17. Amount of Line 14 taxable at sibling rate ---------- x.12 (17) ::i! 0 18. Amoont of line 14 taxable at collateral rate x .15 (18) () -~----_.- ----- .~- ~ 19. Tax Due (19) 6,023.98 20.0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedent's Complete :o\ddress: STREET ADDRESS 129 WALNUT BOTTOM ROAD ..-..- CITY SHIPPENSBURG I STATE I ZIP PA 17257 Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) (1) 6,023.98 2. CreditslPayments A Spousal Poverty Credil ---- 8. Prior Payments ~- ----- 5,000.00 C. Discount 263.16 ~-_.--.- --.---- Total Credits (At 8 t C) (2) 5,263.16 3. InteresVPenalty if applicable D.lnterest E. Penalty -----,..-..- TotallnteresVPenalty ( 0 t E ) (3) 4. If Une 2 is greaterlhan Une 1 tUne 3, enter the difference. This is Ihe OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Une 1 tUne 3 is grealer than Une 2, enterlhe difference. This is the TAX DUE. (5) 760.82 A. Enter the interest on the tax due. (SA) 8. Enter the fotal of Une 5 t SA. This is the 8ALANCE DUE. (58) 760.82 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Ves No a. retain the use or income of the property transferred;...................................................................... .................... D [i] b. retain the righl to designate who shall use the property transferred or its income;. .......................................... 0 [i] c. retain a reversionary interest; or............................................................................................................ ....... ..... D [i] d. receive the promise for life of either payments, benefits or care? ..........."'........................................................ 0 [i] 2. If dealh occurred after December 12, 1982, did decedent transfer property wilhin one year of death without receiving adequate consideration? ................ ............................................ ........... .......................... ............. 0 [i] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 [i] 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .......................................................... ................................ .................. ............ 0 [i] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN, Under penalties of pe~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, correct and complete. Declaration ofpreparer other Ihan lhe personal representaliveis based on all Infonnalionofwhich preparer has any knowl edge. SIG~~RE OF PERSON RESP~j8LE FOIR ~ILlNG ~ETURN . V; .. . ..... . . DATE ~ ;: ~:~:. S~I~PE~:B~~:::7::;LT- ~ / c~J}e'c, ,j e "J _7, oJB Uy -- -- -.--. ---.--. SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ---. ADDRESS --~ --.._----- -"---------_. --.-. .-.. .---.-- 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 3% [72 P.S. ~9116 (a) (1.1) (i)]. For dales of death on or after January 1,1995, the tax rale imposed on the net value 01 transfers to or for Ihe use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (iill. The statute does not axamot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum 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 0% [72 P.S. ~9116(a)(1.2)J. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)J. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [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-1503 EX+ (6-9.* SCHEDULE B COMMONv..EALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER SHEARER, ANNA V. 21-04-0166 All property jolntly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH I. 2228.22 SHS FEDERATED MONEY MARKET FUND, CUSIP 60934N625 2,228.22 2 ACCRUED INTEREST ON ITEM # 1 1.50 3 902 SHS ORRSTOWN FINANCIAL SERVICES, INC. CUSIP 687380105 65,620.50 4 ACCRUED DIVIDEND ON ITEM # 3 207.46 5 737.96 SHS VANGUARD GNMA FUND ADM, CUSIP 922031794 7,778.10 6 ACCRUED DIVIDEND ON ITEM # 5 24.41 7 1495.113 SHS VANGUARD IT CORP ADM, CUSIP 922031810 15,280.05 8 ACCRUED DIVIDEND ON ITEM # 7 49.04 9 2794.069 SHS VANGUARD SIT CORP ADM, CUSIP 922031836 30,259.77 10 ACCRUED DIVIDEND ON ITEM #9 79.32 TOTAL (Also enter on line 2, Recapitulation) $ 121,528.37 (If more space is needed, insert additional sheets of the same size) REV.1508 EX+ (6-98) *' SCHEDULE E COMMONW2ALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER SHEARER, ANNA V. 21-04-0166 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntty.owned with right ofsurvlvorshlp must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 ORRSTOWN BANK CHECKING ACCOUNT #330361, SOLE OWNERSHIP 26,743.52 2 ACCRUED INTEREST ON ITEM #1 3.66 3 ORRSTOWN BANK CERTIFICATE OF DEPOSIT #30038416, SOLE OWNERSHIP 6.411.44 4 ACCRUED INTEREST ON ITEM #3 1.04 TOTAL (Also enter on line 5, Recapitulation) $ 33,159.66 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) . SCHEDULE I COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE UABILITIES, & UENS RESIDENT DECEDENT ESTATE OF FILE NUMBER SHEARER, ANNA V. 21-04-0166 Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, Including unrelmbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ANDORRA RADIOLOGY, BALANCE DUE 91.00 2 CARLISLE CARDIOLOGY, BALANCE DUE 56.33 TOTAL (Also enter on line 10. Recapitulation) $ 147.33 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) *' SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER SHEARER, ANNA V, 21-04-0166 Debts 01 decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. FOGELSANGER-BRICKER FUNERAL HOME, FUNERAL EXPENSES 6,411.44 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 7,000.00 Name of Personal Representative(s) ORRSTOWN BANK Social Security Number(s)/EIN Number of Personal Representative(s) 23 0934350 StreetAddre" P.O. BOX 250, City SHIPPENSBURG .State PA Zip 17257 Year(s) Commission Paid: 2004 2. Attorney Fees SALLY J. WINDER, ESQ. 7,000.00 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 4. Probate Fees 263.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ 20,674.44 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) .. SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER SHEARER, ANNA V. 21-04-0166 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERlY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include oubight spousal distributions, and transfers under Sec. 9116 (al (1.2)] EDNA M. ROUNTREE 1/3 of estate 1750 N,E, 238 COURT residue: FORT MCCOY, FL 32134-6201 DAUGHTER $ 44,622.08 2 V, ERNESTINE MCDONALD 1/3 of estate 136 SOUTH FIFTH AVENUE residue: CLARION, PA 16214 DAUGHTER $ 44,622.08 3 RICHARD A. WRIGHT 1/9 of estate 13633 N.E. 237 COURT residue: FORT MCCOY, FL 32134-6201 GRANDSON $ 14,874,03 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, 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 TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ D.OO (If more space is needed, insert additional sheets of the same size) . . REV-1513EX+(9-00) '* SCHEDULE J COMMONWEALTH OF PENNSYlVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER SHEARER, ANNA V. 21-04-0166 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSONIS) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS ~ndude outright spousal distributions, and transfers under Sec. 9116 I') 11.2)J 4 STEPHEN W. WRIGHT 1/9 of estate 7806 CHEVALIER COURT residue: SEVERN, MD 21144 GRANDSON $ 14,874.03 5 KELLY WRIGHT 1/9 of estate 13640 NE 237 COURT residue: FORT MCCOY, FL 32134-6201 GRANDDAUGHTER $ 14,874.04 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, 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 TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00 (If more space is needed, insert additional sheets of the same size) II I . 9:ad.OfI/i/I wncI dTedanumI I, ANNA V. SHEARER, of Shipp ens burg Township, Cumberland County, Pennsylvania, I being of sound mind and memory declare this to be my Last Will and Testament and revoke any will or codicil previously made by me. ITEM I: I direct that all my just debts and funeral expenses, including my gravemarker and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my decease as a part of the administration of my estate. , ITEM II: I give, devise and bequeath all of my estate of every nature and wheresoever situate to my husband, JOHN W. SHEARER., providing he shall survive me by thirty days. ITEM ID: Should my husband, JOHN W. SHEARER, predecease me or die on or before the thirtieth day following my death, I give, devise and bequeath all of my estate of every nature and wheresoever situate to my issue per stirpes, share and share alike. ITEM IV: I appoint ORRSTOWN BANK executor of this my Last Will and Testament. ITEM V: I direct that my executors or their successors shall not be required to give bond for the faithful performance of their duties in any jurisdiction. 9':.w ~tfI~ c( a'aIty of. o/{/,;"k. --- ;(J( f__ dJrk, ri1i-t Qll.1'!'_k.",fTW (7(7) 552..9476' I I ! , I IN WITNESS WHEREOF, I hereunto set my hand and seal to this my Last Will and Testament, written on I sheet of paper, dated this 3- day of AUGUST, 1995. I , I ~ Cl- 71 ,&--'JL-~EAL) ANNA V. SHEARER The preceding instrument, consisting of this and one other typewritten page, each identified by the signature of the testatrix, ANNA V. SHEARER, was on the day and date thereof signed, published and declared by ANNA V. SHEARER, the testatrix herein named, as and for her Last Will, in the presence of us, who, at her request, in her presence, and in the presence of each other, have subscribed our names as witnesses hereto. . residing at 1~vJ>;JJJ? fA residing at fJL ~ Lx- J~(r/f11 I . , ; , Ii Ii I ! COMMONWEALTH OF PENNSYLVANIA I : COUNTYOF ~~ : SS I : We, ANNA V. SHEARER, the testatrix in, and the undersigned witnesses to, the will, the attached or foregoing instrument, who have signed the instrument, having been qualified according to law do depose and say: (a) that I, the testatrix, do hereby acknowledge that I signed the instrument as my will, that I signed it willingly and as my free and voluntary act for the purposes therein expressed; and (b) that we, the witnesses, were present and saw the testatrix sign and execute the instrument as her will, that she signed it willingly and executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testatrix signed the will as a witness and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. ~~.~~. G- ,J::'f ANNA V. SHEARER .,(,<VW &11- I Subscribed to and subscribed or I affirmed and acknowledged before me by ANNA V. SHEARER, the testatrix and the witnesses whose names are signed above tins ~ day of AUGUST, 1995. ~b"i - )[)J iJh Notary P ic , Notarial Seal Sail); J. Winder, Notary Public Shippens urg Twp., Cumberland County My Commission Expires Feb. 13,1999 I r l'''~_~I\; 'try "(~(, 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 cerrificare will be forwarded TO the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this cenificate, $2.00 .~ cal Registrar , p 9913240 ~-<-, .{'~ ~#r' No. ~ I)ate Hl05.143 Rev. 2187 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS TYPElPRlNT CERTIFICATE OF DEATH $T"'TEFILENUMB!;R " NAME OF DECEDENT {Flr6t, t.4kldle. La,l) SOCIAL SECURITY NUt.4BER DATE OF DEATH (Monlh. D,y. Year) PERMAHENT BLACKIHK 1. Anna V. .. 255 - 07 -8552 4. Januar 25 2004 AGE (Lasl Birlhday) BIRTHPLACE [Cltyend " St&leor Foreign Counlry) HOSPITAL: 98 <B. 7. 'Ib::masville GA l"POIio'" 0 E~Ipo1I.",D ~D ReoId"...D ~)D .. ... COUNTY OF DEATH FACILlTYNAt.4E (lfnollneU1utlon,glve.lreeland number) RACE. American Indi,n, Bleck. Whita. al . (Speolfy) 811. Cumberland Ic.Shi ensbur Tw 'Id. OUtlook Pointe ". White DECEDENT'S USUAL OCCUPATION KIND OF BUSINESS I INDUSTRY AS DECEDENT EVER IN t.4ARITALSTATUS.Manied. SURVIVlNGSPOUSE (~~":,go!~"::"J'':ri~1 U.S. ARMED FORCES? Nev6lv:-C:~:d. (h.IIe.g;..m.lO.n,,"mo) YHD NO[XI 11..Clerk 11b. Grocer Store ". u. 14.Wido DECEDENT'S MAILING ADDRESS (SInteI. CltyfTown. Stete. Zip Coda) DECEDENT'S 17..S~1e Pennsylvania D. 17c. J[] Y8I.del:edmllMldin Shipoensburq ACTUAL ... 129 Walnut Bottom Road RESIDENCE decedent (s.eln'ItUClion. live In. 17d.D~Ii=a1~i::::::oI 16. Shippensburg, FA 17257 on alherUde) 17b.Cowrtv Cumberland town.hjp? ""_. FATHER'S NAME (Fnt, Middle, LuI) MOTHER'S NAME (Fnt. Middle. Maklen SUlNlma) 11. Euel Olin Walker 19. Adaline Elizabeth Duncan INFORMANT'S NAME (Type/Pool) INFORMANT'S MAlLfNGADDRESS (Street. CltyfTown. Stl~, ZIp Code) 2aa.Edna M. Roundtree 20b. 13750 N.E. 238 court, Fort MeCo . FL 32134- . METHOD OF DISPOSITJON PlACE OF DISPOSITION. Neme 01 Cemetery, Cre~ LOCATION. CnyfTlOWn, Slate. Zip Code c BurIeI[XIc.-e""'tion~movelfromS"laD or OlhllrPlllce Cumberland County, . Olh8f{Spedfy) 21c. S 21d. Shi ens bur FA 17257 ~ ~ 'ON 0 . '" .~ .~ ~ ". ". -n. PART I: EnIO'lI>Odl.......lnjUt\H Dr ......"Ucolkln..IIl.hcou..d.... dooth. D<I n04.nl.,tho .,....oldyl"ll, ..oh.. COrdl.O '" ..."Irol"')"....." ohocl< D' ....rtlollu... 'Approxim.te ? LIohnIyD.........on_II.... :lnlatValblllween ]) vnr"t.",- ~ :on,81.nddeath :J .. ~ DUE O(llIllIS ACOtl.EQUENCE OF) ~ $eq""nbdyn.tconditions F n.ny.lHdlnglolmmediete OlIETO(ORA....C~EOUENCEOF) ~ cau....EnlerUNDERLYING CAUSE (DiIlea!Ie or injury OUETO(O!lASACO~EOUENCE F): lIwdin",-lIIdewmll rasuhina 00 dNth) lAST d. WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER Of DEATH DATI:': OF INJURY TIME OF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED PERFORMED? AVAIlABLE PRIOR TO (Monlll.O.y,VHf) COMPLETION OF CAUSE N.lural \ZD Homlckle 0 OFOEA.TH? 0 0 Ye,D NoD """.. I'1mdlnglnve,Ilg.llon Ye'D Nofll" YnD N<<EJ Suiclde 0 Could nol be d.wnrnnad o ::CEOFINJURY .... "'. b<Ji1dl"ll,OIO.(Spool!jl) LOCATION (Slreel. CllylTtlWn. State) ". 'Ob. ". .... ,.. " CERTlFIER (Check only one) , P;PCERTIFIER Z w ,~'M:~tGJ:=.lFu'r'~~UJ:t~lI:t~~(:r=r~~~a~h:~'f.~~.~~~.~~.~?~~~.~~.~.~~.~.. '/ /' 0 ~ w u w 'PT~~OU~.~I::'Gm~~~;:r~:~.~~'::~c.= ~~r.~::.n.~:~;~~~,c:,~.U:.dl:;et':,~J~.".{~~~d",":::'~.r.. .IM.d.... 0 ~ w 'MEDICAL EXAMINERlCORONER ~ On It!. bal. ol.~....ln.llon ..ldIot lnvullg.otlon, In my opinion, d.Mh oc:culllld llt tlHlllm., d.kI, end pl.c'.lII1d due loth. c'u....(.) .nd Z m._....tat.d.................................... ............... 0 ". REGISTRAR'S SlGNA.TURE AND NUMBER 1'1'1"/([ u. " " " " " " " " '.1 'i W C , " " D " I" I'," , 1,' I ~~ " , " , " ~1 W V./ C' ,., , .. " . ORRSTO~ BANK TO: Orrstown Bank Trust Department PO Box 250 Shippensburg, PA 17257 FROM: ORRSTOWN BANK P.O. BOX 250 SHIPPENSBURG PA 17257-0250 RE: ESTATE OF Anna V Shearer DECEASED DATE OF DEATH: January 25,2004 IT is HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD, ON THE ABOVE DATE, THE FOLLOWING ACCOUNTS WITH ORRSTOWN BANK: (1) CHECKING ACCOUNTS DATE OF DEATH ACCOUNT NO. TiTLE OF ACCOUNT DATE OPENED PRINCIPLE & ACCRUED iNTEREST 330361 Anna V Shearer 2/1/77 26,743.52 3.66 SAVINGS ACCOUNT DATE OF DEATH ACCOUNT NO. TITLE OF ACCOUNT DATE OPENED PRINCIPLE & ACCRUED INTEREST (3) CERTiFICATES OF DEPOSIT DATE OF DEATH ACCOUNT NO. TITLE OF ACCOUNT DATE OPENED PRINCIPLE & ACCRUED INTEREST 30038416 Anna V Shearer 11/24/87 6,411.44 1.04 6/8/ 04 By Timothea Customer Service Operator on Cf"\YI)c:.n . ~~...uCPI=f\I~RII~~ PA 17?r;7 . TI=I 1717\ Ci.~"~R11 A . <<> <<> <<> '" '" n '" '" '" ex> 0 c: '" '" '" ..... <<> In 0 0 0 '" '" '" '" '" ex> .j>. 'ii ~ ~ ~ 0 Z ex> ex> ..... ~ '" '" ~ <<> 0 '" '" 0 .j>. 01 01 0;0 ~ < < 0 " In ., CD ., ., ~ CD m ~"O ::J ::J ::J iil Q. n ~ 0 CO CO CO CD ~;:l. c: c: c: 6" ~ c: ., ., ., :; ., ;0 ~" a. ~ ~ ::J co ~ <<>0 Q. Q. Q. ;;:,3 (f) =i G) " " 0'2. ==1 n z 2: c: z OCD s: (f) ::J )> .j>.co n 0 Q. Q. 0 ~ )> < s:: ~ "0 " m C7 "0 )> )> '" ':': )> Q. Q. 3 CD Q. 3 x ~ 3 . C)> Q. CD ., O::J ::J co c::J Q. .. 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