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HomeMy WebLinkAbout04-06-10 (3)• ~ 1505607121 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Coun Code Year File Number Bureau of Individual Taxes tY PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 0 0 0 6 8 Hanisbur9, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 2 5 2 2 1 8 0 9 0 1 0 7 2 0 1 0 0 7 1 3 1 9 1 6 Decedents Last Name Suffix Decedent's First Name MI K U S C H K E M A R Y C (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL INAPPROPRIATE OVALS BELOW ® 1. Original Return 4. Limited Estate ® 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust _ (Attach Copy of Trustl 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number R O G E R B I R W I N E S Q U I R E ~~ 7 1 7 ~2 4 9 52 3, 5 3~, ~ ~ ~ ~ Finn Name (If Applicable) - '° ~ _ . REGIS WILLS CIiE ONL'Y~ I R W I N li M c K N I G H T P C- r-rz ~~ ~ ~ ~ ~ ~ First line of address { . , ~ ~ ~ ~ r C,rj ~ ~ - ' ' ~., .. ~ 6 0 W E S T P O M F R E T S T R E E T ~ - r; © ~ Second line of address W ~ ~ ' --~ r ~~ a p J City Or POSt Office State ZIP Code DATE FILED C A R L I S L E P A 1 7 0 1 3 Correspondent's e-mail address: 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 O S N RESPONS~ FOR FILjtJG RETURN ~/ p~TE d ADDRESS 60 WEST_POM R T STREET CARLISLE PA 17013 SIGNA7U F PRE 0~-R THAN PRESENTATIVE . i AT® `' CARLISLE PLEASE USE ORIGINAL FORM ONLY Side 1 15D5607121 1505607121 J 15D5607221 REV-1500 EX Decedent's Social Security Number Decedents Name: MARY C• K U S C H K E 1 2 5 2 2 1 8 0 9 RECAPITULATION 1. Real estate (Schedule A) ........................................ 1. 2. Stocks and Bonds (Schedule B) .................................. 2. 9 5 7 3 8 8. 9 2 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages 8 Notes Receivable (Schedule D) ........................ 4. 5. Cash, Bank Deposits i3< Miscellaneous Personal Property (Schedule E) ....... 5. 2 5 4 1 D • 3 9 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8 Miscellaneous N -Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1-7) ........................... 8. 9 8 2 7 9 9. 3 1 9. Funeral Expenses & Administrative Costs (Schedule H) ................ 9. 6 7 8 3 7 . 7 8 10. Debts of Decedent, Mort a e Liabilities, ~ Liens Schedule I 9 9 ( ) ...... ... ... 10. 9 9 2 3 . 8 6 11. Total Deductions (total Lines 9 i;< 10) ..................... ... ... 11. 7 7 7 6 1 . 6 4 12. Net Value of Estate (Line 8 minus Line 11) ................... ... ... 12. 9 D 5 D 3 7 . 6 7 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............ ... ... 13. 1 7 1 D D 7 5 3 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. 14. 7 3 4 0 3 0. 1 4 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.o _ 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .0 _ 0. 0 0 1 g. D. 0 0 17. Amount of Line 14 taxable at sibling rate x .12 4 7 7 5 1 8. 8 4 17. 5 7 3 0 2. 2 6 18. Amount of Line 14 taxable at collateral rate X .15 2 5 6 5 1 1. 3 0 18, 3 8 4 7 6. 7 0 19. Tax Due ................................................ 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 9 5 7 7 8. 9 6 Side 2 L 1505607221 1505607221 J Continuation of REV-1500 Inheritance Tax Return Resident Decedent MARY C. KUSCHKE 21 10 0068 Decedent's Name Page 2 File Number Correspondents Name M A R C U S A Firm Name (If Applicable) I R W I N & First line of address 6 0 W E S T Second line of address City or Post Office C A R L I S L E Correspondent's e-mail address: State ZIP Code P A 1 7 0 1 3 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, oorrecl and plate. Dada ' n of preparer other than the personal representatNe is based on all information of which preparer has any knowledge. SIGNATURE /RS~ON RES IBLE F FILING R~E~TURN //,~~ j DATE ADDRESS ~ ~ ~ ' 60 WEST POMFRET ST ET CARLISLE PA 17013 Name Daytime Telephone Number Firm Name (If Applicable) First line of address Second line of address City or Post Office State ZIP Code Correspondent's e-mail address: Under penaltes 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 infomlation of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE Daytime Telephone Number M c K N I G H T P C 7 1 7 2 4 9 2 3 5 3 Mc K N I G H T P C. P O M F R E T S T R E E T ADDRESS REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 10 0068 DECEDENTS NAME MARY C. KUSCHKE STREET ADDRESS 210 BIG SPRING ROAD CITY NEVWILLE STATE PA ZIP 17241 Tax Payments and Credits: ~~ Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 4,788.95 3. Interest/Penalty if applicable D. Interest E. Penalty (1) 95,778.96 Total Credits (A + B + C) (2) 4, 788.95 Total Interest/Penalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 90,990.01 A. Enter the interest on the tax due. (5A) B. Enter the total of Une 5 +SA. This is the BALANCE DUE. (5B) 90,990.01 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 property transferred : ...................................................................... ^ b. retain the right to designate who shall use the property transferred or its income; ............................... Q c. retain a reversionary interest; or ................................................................................................ d. receive the promise for life of either payments, benefits or care? ....................................................... 2. 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 "intrust for" or payable upon death bank account or security at his or her death? ......... Q 4. Did decedent own an Individual Retirement Acx:ount, 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 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 p2 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 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 p2 P.S. §9116(a)(1.3)], Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1503 EX + (8-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MARY C. KUSCHKE 21 10 0068 All properly jointly-owned with right of survivorship must be discbsed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. MERRILL LYNCH ACCOUNT #872-22477 957,388.92 27 SECURITIES -DATE OF DEATH VALUATION ATTACHED TOTAL (Also enter on line 2, Recapitulation) ~ ; 957 (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER MARY C. KUSCHKE 21 10 0068 indude the proceeds of litgation and the date the proceeds were n:ceived 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. WACHOVIA BANK, N.A. -CHECKING ACCOUNT XXX)CX6879 13,978.50 2. WACHOVIA BANK, N.A. -CHECKING ACCOUNT XXX)CX8868 11,431.89 TOTAL (Also enter on line 5, Recapitulation) ~ S (If more space s needed, insert additional sheets of the same size) REV-1514 EX + (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE H FUNERAL EXPENSES ~ ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER MARY C. KUSCHKE 21 10 0068 Debts of decedent must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES; 1. HOFFMAN-ROTH FUNERAL HOME 169.74 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) See Attachment Page(s) Street Address City State Zip Year(s) Commissbn Paid: p, AttomeyFees IRWIN & McKNIGHT, P.C. 3, Family Exemption: (If decedenPs address is not the same as claimants, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees REGISTER OF WILLS 5 Accountants Fees 6. Tax Retum Preparels Fees 7, REGISTER OF WILLS -FILING FEE 8. NOTARY FEE 9. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 10. THE SENTINEL - ESATTE NOTICE 11. REGISTER OF WILLS -SHORT CERTIFICATE 12. LAW OFFICES OF ROBERT E. DANIELSON -ATTORNEY FEE -MAINE 13. 33, 250.00 616.50 30.00 5.00 75.00 187.54 4.00 1,000.00 TOTAL (Also enter on line 9, Recapitulation) I E 67.837.78 (If more space is needed, insert additbnat sheets of the same s¢e) Continuation of REV-1500 Inheritance Tax Return Resident Decedent MARY C. KUSCHKE 21 10 0068 Decedent's Name Page 1 File Number Schedule H -Funeral Expenses ~ Administrative Costs - B1 ITEM NUMBER DESCRIPTION AMOUNT B. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) ROGER B.IRWIN 16,250.00 Street Address 60 WEST POMFRET STREET city CARLISLE State PA Zip 17013 Year(s) Commission Paid: 2• Name of Personal Representative (s) MARCUS A. McKNIGHT, III 16,250.00 Street Address 60 WEST POMFRET STREET City CARLISLE State PA Zip 17013 Year(s) Commission Paid: SUBTOTAL SCHEDULE H-B1 ~ 32,500.00 REV-1512 EX + (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES ~ LIENS RESIDENT DECEDENT s ESTATE OF FILE NUMBER MARY C. KUSCHKE 21 10 0068 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. MILLENNIUM PHARMACY SYS -MEDICAL 1,412.31 2. CUMBERLAND-GOODWILL EMS -AMBULANCE 38.00 3. DARRYL K. GUISTWITE, D.O., INC. -MEDICAL 155.00 4. GREEN RIDGE VILLAGE -NURSING 8,056.11 5. ATBT UNIVERSAL CARD -CREDIT CARD 160.71 6. PP8~L -ELECTRIC 66.29 7. KUHN COMMUNICATIONS -CABLE 10.25 8. CENTURYLINK -TELEPHONE 25.19 TOTAL (Also enter on line 10, Recapitulation) I S (If more space is needed, insert additional sheets of the same size) REV-1513 FX + (9-00) . SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MARY C_ KUSCHKE ~~ ~ n nn~R RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [indude outright ssppoousal distributions, and transfers under Sec. 9116 (a) (1.2)j 1. ARTHUR W. KUSCHKE, JR. Sibling 50,000.00 3263 ASTON ROAD MAINE REAL ESTATE DRESHER, PA 19025 2. JUNE E. STEVENS Collateral 256,511.30 133 BIRCH TREE CIRCLE 30% OF RESIDUE NEWVILLE, PA 17241 50% OF RESIDUE 3. DAVID L. KUSCHKE Sibling 142,506.28 107 LANDRY DRIVE HOLLIS, MAINE 04042 4. JOHN C. KUSCHKE Sibling 142,506.28 88 MOSHER ROAD GORHAM, MAINE 04038 5. MARGARET KUSCHKE COWELL Sibling 142,506.28 3091 COLONIAL ROAD DUNCANSVILLE, PA 16835 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS; 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. GRACE BAPTIST CHURCH (20%) 171,007.53 777 WEST NORTH STREET CARLISLE, PA 17013 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S 171 007.53 (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT I, MARY CARSON KUSCffi~, of the Borough of Camp Hill, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, hereby expressly revoking all Wills and Codicils heretofore made by me. 1. I direct my executrix to pay all of my debts, funeral and administrative expenses as soon as may be done conveniently after my decease. 2. I authorize and empower my executrix to sell any realty owned by me at my death and not specifically devised herein, at either public or private sale, and to give good and sufficient deeds therefor, in fee simple, as I could do if living. 3. I devise all of my interest in and to that property situated in Prouts Neck, Town of Scarborough, Cumberland County, Maine, known as "The Towers" and more fully described in that Deed recorded in the Registry of Deeds for Cumberland County, Maine, in Book 3008, Page 284, et sea.. together with the sum of Fifty Thousand ($50,000.00) Dollars, to my brother, Arthur ~ W. Kuschke, Jr., if he survives me, and if he does not survive me, to my sister-in-law, Charlotte M. Kuschke, if she survives me, and if she does not survive me, to my said brother's issue, per stirpes. 4. I give and bequeath to my friend, June E. Stevens, all of my tangible personal property including without limitation, furniture, furnishings, clothing, jewelry, objects of art and decoration, and the like, and any motor vehicles which I own, together with the insurance thereon, if she survives me. 5. I give, devise and bequeath all the residue of my estate of every nature and wherever situate as follows: (a) 20% to Grace Baptist Church, of Carlisle, Pennsylvania, (b) 30% to June E. Stevens, and, (c) 50% to David L. Kuschke, John C. Kuschke and Margaret Kuschke Cowell, share and share alike. 6. I nominate and appoint June E. Stevens to be the executrix of this my Last Will and Testament; they are to serve as such without bond. Should she die before my death, renounce or refuse to serve for any reason, or die leaving any of my estate unadministered, Inominate and appoint Roger B. Irwin and Marcus A McKnight, III, as substitute executors, also to serve as such without bond, with the same powers as are given herein to my executrix. 7. I hereby suggest that my personal representatives retain the services of Irwin, McKnight & Hughes, as attorneys in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this /o~ day of February, 1997. SEAL ~tA Y CARSON KUSCHxE ( ) Signed, sealed, published and declared by MARY CARSON KUSCHI~, the testatrix above named, as and for her Last Will and Testament, 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. 2 ACKNOWLEDGMENT AND AFFIDAVIT WE, MARY CARSON iKiTSCHI{I;, BETZI A. MORRISON and CHERYL L. CLELAND, the testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last Will and that she had signed willingly, and that she executed it as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the Will as a witness and that to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. L. CLELAND COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS: Subscribed, sworn to and acknowledged before me by, MARY CARSON KUSCHI~, the testatrix herein and subscribed and sworn to before me by BETZI A. MORRISON and CHERYL L. CLELAND, witnesses, this ~o" day of February, 1997. ~~ Public Notarial Seal Roger B. Irwin, Notary Public Carlisle Boro, Cumberland County My Commission Bxpires Oct. 3, 20x00 ~- _ Y CARSON KUS'CHKE res-nc5ilsmrfx2-1 e 2/2/2010 12:38:21 PM PAGE 1/002; Fax Server WHO~VIA Rerenmee m: 2427641 wachovia rink N.A. Balance ConOmlatitm Services P O Box 40028 Roanoke, VA 24022.7313 FCbrusry 2, 2010 IR~VIIV c~ MCKNIGIiT PC ATTN: ROGER B IRWIN ~+ SUBJECT: Verif>cet~ / Confirmation of Aooount and Balance I~ormatian providod for: Caattoma: MA1tY C KUSCNKE (SSNA~ XXX XX-1809) Dube of Deat>t; January 7, 2010 Denolit Amt Information Aeaoaat Ammad Ilydc ofl)esth Avaagc 1)a~ Mata~ Lfete~ A~ucd Y'lY) Uatc Trne NmnUa Aalanee t3alena* Glaaed Hate Rah Tnbered inEe~at Paid Cloned C'~I11iC;KiN(i XXXXXXXXX6879 513,978.50 lh/1')50 50.40 50.00 1/Z6/2010 1~YiAL7T'fLL+: MA[IY I:ARBAN KUBCHKL~ CLOSIDK' BALANCE: $13979.24 CHECKWG J~Dt}{8868 $11,431.89 4J30l2004 $0.64 50.00 1!26/2010 IEGALTPrLE: MARY CARSON KUSC~ CLOEla1G DALANCI;: $11433.14 PE;S-17C51151RY'tXL-1L/'L/"LV1V 1L:3i3:L1 1~P7 YAIrE G/wG rax vcivca a -., WHOFVIA No 3a6e Deposit Hox found for customer. 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Kensinger Drive, Suite r~500 Cranberry Twp., FA 16066 F: 724.940.2490 F: 724.940.2499 ' W: www.urpsrx.cam -~s: ------ nnn7AC Invoice Date:12/31/2009, Acct#:GRVA1282, KUSCHKE, MARY-CARSON, Green Ridge Village AL -PHI, A, BOWER, DOUGLAS 12/09/2009 6005944 35.00 Ursodiol Oral Capsule 300 MG $ 90.93 $ 0.00 $ 90.93 RX 64980-0139-01 12/09/2009 6005980 .00 DOK Oral Capsule 100 MG $ 0.71 $ 0.00 $ 0.71 OTC 00904-7889-80 12/09/2009 600598 18.00 Lipitor Oral Tablet 20 MG $ 85.59 $ 0.00 $ 85.59 RX 00071-0158-23 12/09/2009 4000279 12.00 Hvdrocodone-Acetaminophen Oral Tablet 5-500 MG $ 7.35 $ 0.00 $ 7.35 RX 00406-0357-01 12/09/2009 4000280 12.00 Lorazepam Oral Tablet 0.5 MG $ 8.37 $ 0.00 $ 8.37 RX 00591-0240-05 12/09/2009 6005984 12.00 Mapap Oral Tablet 500 MG $ 0.25 $ 0.00 $ 0.25 OTC 00904-1988-80 12/10/2009 6005940 17.00 Citaiopram HYdrobromide Orel Tablet 40 MG $ 43.78 $ 0.00 $ 43.78 RX 55111-0344-01 12/10/2009 6005941 17.00 GlipiZlDE Orai Tablet 5 MG $ 8.73 $ 0.00 $ 8.73 RX 00781-1452-10 12!10/2009 6005942 17.00 Pantoprazole Sodium Oral Tablet Delayed Release 4o MG $ 65.20 $ 0.00 $ 65.20 RX 00008-0607-01 12/10/2009 6005943 17.00 Triamterene-HCTZ Oral Capsule 37.5-25 MG $ 9.89 $ 0.00 $ 9.89 RX 00378-2537-01 12/11/2009 6013345 30.00 Risperidone Tablet 2mp $ 74.13 $ 0.00 $ 74.13 RX 50458-0583-50 12/14/2009 6008739 15.00 Nystop External Powder 100000 UNITlGM $ 30.09 $ 0.00 $ 30.09 RX 00574-2008-15 12/15/2009 6009613 30.00 Triple Antibiotic External Ointment 3.5-400-5000 $ 4.36 $ 0.00 $ 4.36 OTC 51872-2016-02 12/16/2009 6010077 255.00 PoNethylene Glycol 3350 Oral Powder $ 21.17 $ 0.00 $ 21 17 RX 51991-0457-58 . RECErVE~ n ~ l~1 ~h~l~aC .IAN 2 5 ~, JI ~e n ~ 200 tRi~N & ~+FcNNIGHT LAW OFFICES ~j; $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 445.23 $ 5.32 $ 0.00 $ 0.00 450 55 ' Mill~nn~ < a Pharmacy Systems Inc Cranberry Business Park, BuiIcting 120 100 I/. Itensinger Drive, Suite #500 Cranberry Twp., PA 160b6 P: 724.940.2490 F: 724.940.2499 V~: wwR'.inpsrx.com Q1Te notice that your account is past due. If you have akeady mailed us your payment, please disregard this notice. Please notify us if there is insurance coverage or other third party coverage we should be billing. However, you are responsible to pay on a timely basis until. coverage is verified and activated Overpayments after coverage will be reimbursed.' If there is a problem regarding this matter, please contact ane of our billing specialists today @ 1 866-466-7779, extension 2826 or 2852. Otherwise, please remit your payment immediately. For your convenience we accept Visa and 1Vlastercard. d--.:,, ~ ------------------- Invoice Date:03/01/2010, Accl#:GRVN1483, KUSCHKE, MARY CARSON, Green Ridge Village NC -PHI, A, GUISTWITE, DARRYL - - RESfD~ENTSTATEMENT-FROM------- --------:----_----------- --------- ----- GREEN RIDGE VILLAGE • SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE, PA 17241-9486 717-776-8256 Statement Date Due Date ACCOUNT NUMBER 12/31/2009 Upon Receipt 61428GRV AMOUNT PAID $ Please make check payable to GREEN RIDGE VILLAGE MARY CARSON KUSCHKE Remit To: c!o MARY CARSON KUSCHKE GREEN RIDGE VILLAGE 133 BIRCH TREE PO BOX 34309 NEWVILLE, PA 17241 NEWARK NJ 07189-4309 Please detach and return this portion with your remittance to the address above. Comments f ou have an uestions ardin our statement lease contact the Business Office at 717 776-8256 Balance Forward $14.40 01/06/10 - 01/06/10 PMT FRM STMT 11/09 Check # 1758 $14.40 12/20/09 -12/31/09 Room/Board-Self Pay 12 $267.00 $3,204.00 12/21/09 - 12/21/09 Brief Pull-On Super X-Large 1 $31.32 $31.32 12/22/09 -12/22/09 Secura Ointment 1 $5.01 $5.01 12/23/09 - 12/23/09 Hairbrush 1 $1.44 $1.44 12/23/09 - 12/23/09 Comb dresser 8" blade 1 $0.42 $0.42 12/25/09 - 12/25/09 SUPPOSITORY BISACODYL 10M 1 $0.33 $0.33 12/27/09 -12/27/09 Staple Remover 1 $4.11 $4.11 01/01/10 - 01/06/10 Room/Boani-Self Pay 6 $280.00 $1,680.00 TOTAL BALANCE DUE: $4,926.63 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER SWAIM HEALTH CENTER MARY CARSON KUSCHKE 61428GRV - -Rf51DENTSTATEMENT-FROM------- -- -- ------ .- - -- - ------ GREEN RIDGE VILLAGE SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE, PA 17241-9486 717-776-8256 Statement Date. Due Date ACCOUNT NUMBER 12/31/2009 Upon Receipt 125221GRVAL ~ AMOUNT PAID $ MARY CARSON KUSCHKE c/o JUNE STEVENS 210 BIG SPRING RD. NEWVILLE, PA 17241 129.24 Please make check payable to GREEN RIDGE VILLAGE Remit To: GREEN RIDGE VILLAGE PO BOX 34309 NEWARK NJ 07189-4309 Please detach and return this portion with your remittance to the address above. Comments f you have any questions ngarding your statement please contact the Business Office at (717)776-8256 12/10/09 - 12/10/09 Toothpaste 1 $3.24 $3.24 12/10/09 - 12/10/09 Syringe TB 25 G X 5/8 1 $0.93 $0.93 12/10/09 - 12/10/09 Body shampoo royalmed 8 oz. 1 $2.97 $2.97 12/15/09 - 12/15/09 Laricet 26G 1 $46.17 $46.17 12/16/09 -12/16/09 Syringe TB 25 G X 5/8 1 $0.93 $0.93 12/16/09 - 12/31/09 Room/Board-Self Pay 16 $145.00 $2,320.00 01/01/10 - 01/05/10 Room/Boani-Self Pay 5 $151.00 $755.00 TOTAL BALANCE DUE: $3,129.24 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER SWAIM HEALTH CENTER MARY CARSON KUSCHKE 125221 GRVAL IQWIN. R. MrKAIIf:NT_ P_C_ FS~TETRLICT.Af.C(]L1NT ~~ .... FUNERAL HOME ~ CREMATORY, INC. DECEIVED 219 North Hanover Street Carli~e, Pennsylvania 17013 717.243.4511 toll free 1.866.451.4511 fax 717.243.3723 www.hoffmarroth.com info@hoffrnanroth.corn FEB 0 5 2010 February 3, 2010 Irwin 8~ McKnight Attorneys At Law IRWIN & McKNIGHT 60 West Pomfret LAW OFFICES Carlisle, PA 17013 Statement of Funeral Expenses for: Mary Carson Kuschke Date of Death: January 7, 2010 Account Id: 15823-4 PACKAGE: Traditional Funeral Service TRADITIONAL FUNERAL SERVICE PACKAGE $ 4,350.00 Sub Total: = 4,350.00 MERCHANDISE: Casket: Provincial $ 2,990.00 Sub Total: ; 2,990.00 TOTAL FUNERAL HOME CHARGES: ; 7,340.00 CASH ADVANCES: 10 Certified Death Certificates at $ 6.00 each $ 60.00 Newspaper Notice -Sentinel $ 108.15 Flowers $ 159.00 Sub. Total: ; 327.15 Total Funeral Expense: ; 7,667.15 Total Payments Made: ; 7,497.41 Payments made: Madison National Llfe Check 344436 F~Ib 3, 2010 7,397.41 Cumberland Co VA Check 751611 Feb 3, 2010 100.00 Total Balance Due: ~