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HomeMy WebLinkAbout03-01-10 (2)15056041046 REV-1500 EX (05-04) ~~~ ~ ~~ PA Department of Revenue Coun Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN ~ Dept. 280601 ff`` Harrisburg, PA 17128-0601 RESIDENT DECEDENT oZ. ~ ~ ® (~- V ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth d2/o ~~ 9~8~ of ~3a,ooo ©7oS' /q1 ~'-" Decedent's Last Name Suffix Decedent's First Name MI ~ c c Q M d s P ~,~ ~. c. (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 WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 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 C/~~-Q~~s ~" ~~ ~ ~~~s i ~ ~ ~1 7 7~ 6 0~0 9 Firm Name (If Applicable) ~~ /T First line of address CL o~SE~ ~o~~ Second line of address ~` City or Post Office State ZIP Code r' ,_ ,-~ ~~ ~,~ .~ r:.::.y ~`..,... a'-~ 't ~~~ _:~~ /1?EC,y~N/CS~u~QG ~~ l7oSS973~ Correspondent's a-mail address: e eSh %P.lds 3 nComeQSt'• ~'1 er 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. SIGNATy~'~ OF PERSOf RESPO.N~SIBLE F R FILING RETURN D9TE ADDRESS C/Q'/ZO~H L. ~~~'~~ ~ O(~ ~i/'d~ •~ ~ Ei70~Q~ /Did / 70 •'t s SIGNATU F PR PAREfj,~OTHE REP E E~TIVE Cf'._ DATE << / 1 ~ ADDRESS l~/~,~Z[E5 F S/y/~L17S~ ~o C/at~er /Q~% PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 15056041046 J ~'v' 15056042047 V 1500 EX RE - Decedent's Social Security Number ~hc Co~~3s . ~ PE ~-sec _ . H ' _. _ .,. ~ ~ > ©.z ~ ~ -~ 7 ~9 ~ . , s Name Decedent REC APITULATION 1. Real estate (Schedule A) . ............................................ 1. + d d 2. Stocks and Bonds (Schedule B) 2. , O b 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. • ~ ~ • D D 4. 9 9 ( ) ............................. Mort a es ~ Notes Receivable Schedule D 4. ~ 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. • 6. Jointly Owned Property (Schedule F) C Separate Billing Requested ....... 6. °~ 3 °~ ~ -S • 2 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) 0 Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) .................................... 8. ~J ~ S S • ~ 5 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. 6 4 1 3. 8 Co 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. . ~ O 11. Total Deductions (total Lines 9 & 10) ................................... 11. ~ ~ ~ 3 . 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. ~ C/ ~ y ~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ~ ~ an election to tax has not been made (Schedule J) ........................ 13. • 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ~ ~ ~ 7 ~ .3 g TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ~ ~ 15 O O_ (a)(1.2) X .OQ_ . l . . 16. Amount of Line 14 taxab e q at lineal rate X .0 ~ ~ 6 ~ y ~ . 3 I 16. ~ ~ ~ ~ • 17. Amount of Line 14 taxable at sibling rate X .12 • d ~ 17~ • 0 ~ 18. Amount of Line 14 taxable • D ~ 18 ~ ~ , ~ at collateral rate X .15 19. TAX DUE ........................................................ . 19. ' ~ T.~c Rate {,~- L.atac/ ~ c~. a • ~- wds six ~` ~.~ ,vcr een t 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15056042047 15056042047 REV- i 500 EX Page 3 Decedent's Complete Address: File Number ~! " ~ ~' -~- Tax Payments and Credits: ~ , ~~ 1. Tax Due (Page 2 Line 19) (1) ~~ D 1 O 2. Credits/Payments O A. Spousal Poverty Credit B. Prior Payments ~ C. Discount Q Total Credits (A + B + C) (2) ~ 3. Interest/Penalty if applicable D. Interest ~ E. Penalty Q - -_ _ _ _ _ O Total Interest/Penalty (D + E) (3) 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) fl 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~~ D ! O • ~ ~ ,• A. Enter the interest on the tax due. (5A) ~ 7 8' 6U B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) ~ ~ ~' 8 , 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 : ............................................ ^ 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 "in trust for" or payable upon death bank account or security at his or her death? .............. ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1509 EX + (1-97) SCHEDULEF COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~h c ~a~r~s, ~c=~~ y a l- 0 9 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. C',~'~OLYN L, I,rJE/1-YL-7C' !o D~ TAY//L~ S7. ,3~/~-u,~~! ?~1 ~NOL ,~¢, ~~ / 7 0 ~ B. C. JOINTLY-OWNED PROPERTY; ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE NT JO DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. I f ~•!~~ lof of ground W. t'~ri i tnproVem e>n~s {'~,eCoh a#' l 98x1 Co 0(0 1 ti r ~ d 5~ : E~rta~ a, ~-~s ~-n+~.v l~ ~S f ' ~'i-i rvi ~kl ~a /a~ , ~t3>f' ''1'Insdoro Twp. , C ~.Mn1.¢,~-InM.~ L3oro~y~~ n Cotu+~ ~ Penn s. (sce copy o~ deed a~r.>h~.~ h ~rr/ ~~ Cc,~.mlo~-land ~ouh~'y Asses s ~t tt.s d>~ ~'an . ~,ooo teas ~ 3, 070. eo sec C ~x>r-b. Co . A~ssessm - ~~ (Jri nt 6u~ ~.-~'ac!^c.o~ C ~.,mb. ~. ~-~,I~h'pl ~ eY ~ J'a~, . 2oao) as P~ Converso~.~'dh w. ~. G,~,mb. Ce, . ~ec . ~ ~.ds was - 5', ~ S Ca~Cc.~ah~ oh ~3, o~D. ~° x t $. I S .~ ~ 5-p ~(~, 5/a. ~ S 10 ~ ~3l ,~55, ~ TOTAL_(Also enter on line 6, Recapitulation) $ 0~.3, a$5• ~~ (If more space is needed, insert additional sheets of the same size) ~~ YY.P. S1MPL6-PHNNA. DSBD-7080 I ..}~.rm 7e. rl~nkmhoro Ca. wW4mpo~A ra. t:ounty Parcel N0. (`~~t~ ~1n~r>extt~tr~e, MADE the <l~;~day of December In the year ainetoea hundred and Eighty-nine { 1989 ) BETWEEN PEARL H. MCCOMBS, of West Fairview, Cumberland • County, Pennsylvania, Grantor, Party of the First Part, -AND- PEARL H. MCCOMBS and CAROLYN L. WEAVER, as Joint Tenants with the Right of Survivorship, of West Fairview, Cumberland County, Pennsylvania, Grantees, of tho s~tiwnd part, WI7'NESSETI3, That said part of the first part, for and In oansidcratlon of tha sum uf -=-------------------One ($1.00)-_________--..-----__..---____-- Dull~u•s, luwhil money of tba Udted States of America, well and truly paid by the said part i e s of the seeoncl port to the said party of the first part, at and before the sealing and delivery of these lirrscn~s, ilu rrccipt whereof is hereby acknowledged, granted, bargained, sold, alicncxl, enfeo[Ied, released, rnnveyed and con9rmed, and by these presents do es grant, bargain, Sall, alien, cafcofl:, release, convey and coa6rm unto the said part ies of the seoond.part, heirs and assigns. AI.L TIiOSE two certain lots or pieces of ground situate in the ;Borough of West Fairview, County of Cumberland, and State of ;Pennsylvania, more particularly bounded and described as follows; to-wit. ~ - DaCINNING at a point on the West side of• Third Street (Thirty five •,(35) Feet wise) said point being the center line of the centre ;partition wall between houses No. 606 Third Street and the house ~iadjoining on the South; Thence Westwardly through the center of said ;partition wall and beyond, a distance of one hundred (100) feet to an '!alley; thence Northwardly along said alley; a distance of seventy-five p~c~34 racr1~003 (75) feet to a point at land now or formerly of Henry R. May; thence, Eastwardly on a line at right angles to Third Street, a distance of one hundred (100) feet to the Westerly line of ~, .; ~i ,~ Third Street; thence along the Westerly line of Third Street Southwardly, a distance of seventy-five (75) feet to a point, ~ (~ the place of BEGINNING. i BEING LOTS NOS. 53 and 54 in May's Second Addition to West Fairview. Being the same as surveyed by p.P. Raffensperger, Registered Surveyor, ~. August 15, 1956. ~ I~ HAVING THEREON ERECTED the North One-half of a two and one-half story frame dwelling house known as No. 606 Third Street, West Fairview, I Pennsylvania. ' BEING the same premises which Dolores F. Ruby and and Gurney B. Ruby,Jr~i, her husband by deed dated April 25, 1958 and r.pcordpd in r'hp ~I ~ Cumberland County Recorder's Office in Deed Book "J", Volume "18", ~ Page "462", granted and conveyed unto Robert Charles McCombs and Pearl ~ H., McCombs, his wife. Robert Charles McCombs died on September 24, 19 0, thereby vesting title in Pear H. McCombs, his widow, by operation of I':, law. Said premises were granted sub~eet to tt~e life estate of Elizabeth L. Blacker, as bequeathed unto her by Wi:11 recorded in Lhe Cumberland County Recorder of Deeds Office in Will Book "50", ~ Page "41". Said Elizabeth L. Blacker died in October, 1958, thereby ~~ extinguishing said life estate. '~ NOT taxable since transfer between parent and parent and child. bGD~1 3~ "~sEi009; r~ ~~ io v ~ ~ C h7 ~ m ~ ~ ~ c•~ Q 1"' ;1~ 17i ~ ~ l7 Q •li ~~t 1 ~~ C: :) C~ .t" ~• 'TI ~ LA $ . i i . ;; ,. i TOCETIiZ:R +vith all and singllJ»r tho tenements. hereditnments and appurtenances to the same be- longing, or In aay+vise appertaining, and the reversion and reversions, remainder and remainders, tents, • i~xclcrs nr,d profits tllcrcof; AND ALSO aD the estnte,'rigbt, title, interest, property, claim and demand +vhatsncvcr, bath in low and cguity, of the said part ies of the first part, of, in, to or out of the said pre- - -uisus, :u1d every part and parcel thereof, ~: '1'c) EIAVIs ANU TO IIOLD the said prclnises, with all rind singular the appm•tcnnnces, unto the said party of the second part, their heirs nnct assigns, to and for the only proper use and ~` Lchcu,f vI said part ies of tho second port, their heirs ;1nd nssigrls forever. '~ AND tho snid ;i ~, llclrs, executors, and administrators, do by these presents, covenant, grant and agree to and with ,~ flue .r,1id port ies of tho second part, their heirs and assigns, that the said I! j: h,:irs, alI and singular the horcditamcuts and premises bcrt;in above described and granted, or mentioned !I and inten,.iccf sv to bc, +vith the appurtenances unto the said part ice of the second port, ~~ heirs an<l assigns, against tbo said party of the first port and her heirs, aad against all and ~` every other person or persons, whomsoever, lawfully claimlug or to claim the same or any part thereof, ~ s11a11 and will, by theso presents, WARRANT AND FOREVER DEFEND. ~' IN'r~TTNCSS WIII:IiEOF, the said party of tho first part has hereunto set ;; bond and sent ,the day aad year first written above. I? ' , •~SICNED, SEAi.>iD' D it ~ '~ ,_ ~ ~Z`.7....~... ~..~... .z~-~.. .[..7: rZ.L ~ ~~~. .I.l.l.r.4ft:.?.l:t: ~t'C~ ..................~ '' ' ~ ~ ~~PEARL H. MCCOMBS ~II ............................................. .............. ............................................._..... ................_ ~~ . ~f ................:......................................................... ..........................................................................~ ~~ i `I CERTIFICATL' OF RESID-FENCE !~ I, hereby certify that the precise residence of the grauteo s / herein as fo o s , 606 Third Street, West Fairview,. PA 1702iy', ~ ~ ` ~j ...4~~::.....~.1.....L.~:~............j~ ~~'.. ~, `~ U ""~ Arloenry a Arent !oe Cnnw I~ • tCuunnuttfucnltlj of ~lettttaglbuntu i+ i I SH. 'j (Lrt+turtu of ~/~ %~ ., ..........~. 2liz! ..................... ~~ On this, the ;;;'?y~- day of ~c:2:»,(iiJ• 19 ~f'~, before me ~~ the unclcrsifined officer, personally »ppenred '.I known to me (or satisfactorily proven) to bo the person whose namo ,~a,' subsedbed to !be ~~ within instrument, anti acknowledged that b./t,(, executed the same for the purpose therein contained. ,~ IN ~VITNGSS W1IEt~);OF, I have hereunto set my ]land and ~~~ ~ci;. seal My •Commission Ex ices ..~ ~ XC,z`.....:` 'y "}~~......... .....~r~til.11...1...r,~S.~~~ ., ~ ...............,.. `:; HIQTARIAL SEAL •- ~ l.'t'•s ~ j~~; WANN P. GALLUP, Naary Pubib ~`. J'`; 3`#~. ,~ tt~l~ ~~ . , I ,v NarMsburp, Dauphin County O.k1.L 3~ f,;!~E~„oo5,,''~~.y : `'' ~J ~ •~~~,~~••~~ Commiselon Explree A i 29, 1991 ~~u-uu,+~~'' ' :~:.,,...,.He/ NOV-05-2009 09:41A1~ FR0~1- T-583 P.OD11001 F-225 --- - FacetWin Screen Print for publi~04, from "CAMA Login° 11/4f2009 3:15:57 PM CtJA~ERLAND GOUNTY ARCHIVE SYSTEM HS:11/24/2004 A PARCEL : 4 5 4 5 -16 -10 5 0 ~ 131. OWNER : IdCC03~S , PEAI2I, fl B xLLSNG FTISTORX BLDG TOTAL--, X197 4 Land : 22 S 0 0 ~ Last COUNTY Bill AV: 21600 45130 66730 ~ M.V. Bldg: 40630 Last SCHOOL 8111 AV: 21500 45130 66730 ~ ~ TOTAL: 63130 ~ -- ~ t J New 07/Ql/2004 21600 45130 66730 L~IL DATE Why FAV LAND FAV BLDG TOTAL ~ CQ LAND CG BLDG TOTAL. 07/01/2004 05 21600 45130 66730 ~ I 06/30/2004 22500 40630 63130 07/41/2000 OS 22500 40630 63130 06/30/2000 530 2540 3070 ~ , Screen 9 Enter Selection > Record: 56427 Number -Switch Screens, x -Exit, J -Jump Daode, F -~'ozu-s, I -Image Down Arrow -Next Entry, Up Arrow -Previous EritZy, 7 -Screens, 8 -Browse ,~ c,~~ REV-1511 EX+ (10-06) r SCNEDt~LE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF ~C ~~~~, ,~E~~ y, FILE NUMBER ~/-09 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ,~ ~~ ~ ~ Tnc. , ~ ~~ .~' SZl, S~ /f'1 K 55e~rn a n ~u.~-era N~w-e ~ L,emevy n c ~, ~; h9ric~ Mcmori gels , Cn~rY~t. ~i ny ~7s, o0 Caec a~~4„I!s 4~`acltea~~ B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions nn Name of Personal Representative(s) (~Q,I'D~,I/~ ~~~~~v~,l'' _ L ' (~-~c~.i Vecl , Street Address ~ D lP 7~~ ~''~! ~t City EnOla State ~~ Zip ~O Z S~ Year(s) Commission Paid: _ 2. Attorney Fees Char~e s ~. Sh ~'eJds JL ~ ~` s ~ , ~es}4',~.~ ~~--~1, ~~ 3. Family Exemption: (If decedent's address is not the same as claim/ant's, attach ex/pla~natio~n) / ~/ Claimant /I~'O,f'1 e ~lLti/!'KGir -/gyp /~55~15 CIjf~Q'/lQ~le //~ ~/7fi Street Address __ _ _ _ _ City State Zip ___ Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees ~. ,~,'/; n fie r4, ~ is f'r e ~ Liii//s ~/~-, 00 ~ ~ 8, ~s~~ m~ ~,~~ ~o~ Gl~d4 ~~~ n ~ aeD. ~o ~eint~G!/'~~~~ ~ ~liarlcs ~. ~ ~~e'~S~ ~Dr eea^~,~. M[u ~~ n.. PR' S q TOTAL (Also enter on line 9, Recapitulation) $ ~, ~~ ~• ~~O (If more space is needed, insert additional sheets of the same size) To Funeral Expenses o1 PEARL McCOMBS 2000 January 18 ~'""""1~!E~ PROF. SERVICES, FACILITIES & AtJ'I'OS $1 , 475.00 20-Gauge "Jackson" Steel Casket 1,350.00 ~.~~~~~~~~ #12 Guardian top-seal vault 650..00 1T~ 11 " `""""`'~`~~"(("" Cash Expenditures ~~II1Til1(~, llII11~. Flowers 132.50 Out-of-town FD Charges (total) 1_,279.06 Established 1895 Gratuity for Rev. Gettins 50.00 Grave opening & closing 505.00 Brian C. Musselman, F.D. Tent 80.00 Supervisor William G. Pegan, F.D. '~'~ P.0. Box 137 Jan. 19th Paid .by D. McKenzie 324 Hummel Avenue - Lemoyne, PA 17043,0137 dance due on account (717) 763-7440 /~ Billed to: Carolyn L. Weaver .606 Third Street West Fairview, PA 17.025 i~~ ~ ~ \~r~~ . Gam- / ~ ~o d FOR APPOINTMENT PHONE 717-763-7440 Feb. 18,2000 $3,475.00 $2,046.00 $5, 521 .5.6 1,279.06 $4,242.50 ' ORIGINAL `''~ ~~ ~/~~eceriuea!z,• Funeral Services . ' D Name of Deceased CHECK # CREDIT MUSSELMAN FUNERAL HOME, INC. CARD ^ OTHER pp o ~~: Vlurm~c n~osc./ ORIGINAL 3345 ~~: ~'ak Funeral Services ~'~/~C/~~!/1~c, i'/!C Cr ~Z~d.~ Name of Deceased CHECK # CREDIT MUSSELMAN FUNERAL HOME, INC. CARD ^ OTHER r ~t,~ a, a o0 0 ~~ ~~.. ~~~ ORIGINAL ~r~iea~~~rn~t. 3345 .~~~~ ACCT. NO. FEDERATED ~~~~~ AMEp~ i~~~ 1 C FEDERATED '~~'. AMER~ ACCT. NO. a ~~ d ~~~ Q`fl`°r~ FE`D_E~RA~T~ED ~~'.y ~, AMEa~ ACCT. NO. s~ LAST BALANCE $ F~ ~~~ ^ INTEREST LATE PAYMENT CHARGE SUB TOTAL CREDITS Q L~ LESS PAYMENT ~ ~ ~ ~~ Sd NEW BALANCE ~~ ~ /'a 7 004722 O LAST BALANCE $ ~,/~' ~~~ ^ INTEREST LATE PAYMENT ^ CHARGE SUB TOTAL C LESS PAYMENT d ~~6j~ 8~ u~.L B 8./~ D ~~ ~ a~,~ o 'VC ~ C1.Ol~Q//~J ~~ Funeral Services ~ C C '~ .~~~ ~~ulaxec~• Name of Deceased CHECK# ~ CREDIT MUSSELMAN FUNERAL HOME, INC. CARD ^ OTHER ~Ci¢lt~ i'AL~'i~i ( J ~ ~ ~~ . ~~u~re~ ~ce/ NEW BALANCE $ / L/~j ~ / 7 004755 LAST BALANCE $ ~ ~ ~~ L `f ^ INTEREST LATE PAYMENT CHARGE SUB TOTAL CREDITS >~ a LESS PAYMENT ~ / 7 ~ , t ~C ~r ~~ NEW BALANCE $ 004793 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDt~LE J BENEFICIARIES ESTATE OF ~ C ~ ~ c~s ' ~~~ L ~~ FILE NUMBER 2 / ~ ~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. ~,r,~ was no G(1% 11 ~robaf -c..d r~r 1,c~cx~ ,~.~re a~ a ss~~'s ~, d ; Sir; .6 ~e 0 ~I~ reCi P; t°nf a{' any ass~~ wa,~ r~c~rol/~t L . !.~ eav~t'' ~i S ~~r S c~e~l F . ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 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. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) i G, / 1; STATE FILE NUMBER COUNTY OF SAN DIEGO CERTIFICATE OF DEATH STATE OF CALIFORNIA UBE BLACK INK ONLY/NO ERASURES, WHITEOUTS OR ALTERATIONS VB-1 I IREV. 7/97) LOCAL REGISTRATION NUMBER 1. NAME OF D!C[DlNT-FIRST (GIVEN) 2. MIDDLE 3. LAST (FAMILY) Pearl Brant McCombs 4. DATE OF BIRTH M M / D D / C C Y Y 5. AGE YRS. IF UNDER 1 YEAR IF UNDER 24 HOURS 6. 9E% 7, PATE OF DEATH M M / D D / C C Y Y 8. HOUR 07/05/1915 MONTHS GAYS 84 ; ~ HOURS MINUT[B ~ F 01/13/2000 0005 DECEDENT 9. STATE OF BIRTH 10. SOCIAL SECURITY NO. 11. MILITARY SERVICE 12. MARITAL STATUS 13. EDUCATION-YEARS COMPLETED PERSONAL pA 210-26-9786 ~ © ~ Widowed ~ 12 DATA YES NO LINK . 14. RACE 15. HIB PANIC-BPECIFY 16. USUAL EMPLOYER Caucasian ^ YE6 ~ NO Self-Employed 17. OCCUPATION 18. KIND OF BUSINESS 19. YEARS IN OCCUPATION Homemaker Own Home UNK 20. R881DENCE-(STREET AND NUMBER OR LOCATION) uauAL 606 Third Street RESIDENCE 21. CITY 22. COUNTY-- - - - 23.. ZIP CODE 24. YR9 IN COUNTY 25. STATE OR FOREIGN COUNTRY West Fairview Cumberland 17025'. 84 PA 28. NAME, RBLATIONBNIP 27, MAILING ADDRESS (BTlleeT AND'NUMBER Oft RURAL ROUTE NUMBCR, CITY OR TOWN, STATE, 21P/ INFORMANT Deanna McKenzie ~- Daughter ~ _ _ _ 7819 Tommy Drive, .-440:,,. San Diego, CA 92119 26. NAME OF SURVIVING SPOUSE-FIRST 29. MIDDLE - - 30. LAST (MAIDEN NAME) SPOUSE 31 . NAME OF FATHER-FIRST - 32. MIDDLE. - 33. LAST - - - 34. BIRTH STATE P RENT Robert --:_-_ -=: - UNK _ _-.-Brant -- _ UNK INFORMATION 35. NAME OF MOTHER-FIRST ."~ 36. MIDDLE ~-- 37, LAST (MAIDEN( -~: 38. BIRTH STATE Clara` UNK UNK UNK 39. DATE ,M:'M / D D / C C YY 40. PLACE OF FINAL DISPOSITION - -_ DISPOSITION(S) O1/14/20~00 ~ Stone Church Cemetery, Enola, PA 1.7025 41 . TYPE OF. DISPOSITION(S) 42. SIGNATURE OF EMBALMER . 43.. LICENSE NO. : - TR/BU - .- G ; Q~ ~ ,- - a ~~ --=8535 D RECTOR . .. / LI , : ~.~ -. .. AND O 44. NAME OF FUN 6RAL DIRlCTOR 45. LIC£NBE NO. I 46.-. BIGNATURE.OF LOCAL REGISTRAR = 47. -DATE M M / D D / C C Y Y REG ISTRAR p:oway Ber>aardo 'Mor.tu'axy '`FD ''1`195 - ~~G~~r7 -- 0;.1 / 14 /2000 1 OI::sPLACE OF DEATH 102. IF HOSPITAL, BPECIFY ONE: 103.-'FACILITY OTMBR THAN HOSPITAL: 104„ COUNTY ;- Shar Grossmont Med Ctr '-® ~ 0 Q CONY. ~ FEB. [] --- San 'Die o PLACE p . . - - IP ER/OP DOA NOSP. CARE o7HER g OF DEATH 105...STREET ADDRESS-(STREET ANDNUMBBR~OR LOCATION) - -. ~.; ~ _ 106. CITY - _: 5555 Grossmont Center Drive ~ La Mesa. 'CAUBED BY: (ENTER :ONLY'ONE~.CAUSE PER LINE FOR A,-B, C,-AND-.D) - 107: DEATH WAB TIME INTERVA ` L ~. 1.08. DEATH-REPORTED TO CORONER --- - ~ BETWEEN ONS AND DEATH ET - ~ ~ - .YES No IMMEDIATE '- ~ - - CAUSE (A) .Congestive `Heart Failure. ];D Day REFeaRAL N~MSeR s .. 109. BIOPSY PERFORMED DUETO (B) a' ~ _ No YES '-, - - __ _: ~ _ --- - -- --.- - -- - - - 110.AUTOPSY PERFORMED CAUSE _:_ - - ;._ `_ - -.- -- ---- -- -. - ~ ~ OF DUE TO (C) YES No DEATH - - 1-1'1. USED IN DETERMINING CAUSE DUE TO (D) - ` ~ ~ _ " No YES 112. OTHERBIGNIF(CANT-CONDITIONS.CONTRIBUTINGTO DEATH.BUT NOT RELATED TO CAUSE GIVEN IN I D7 None :_ - - 113. WAS OPERATION PERFORMED FOR•ANY CONOITION~IH ITEMt07-OR 112? IF YES, LIST TYPE OF OPERATION.ANODATE. No 1 14. I CERTIFY THAT TO THE BEST OF MY:.KNOWL• 1 15. 6IGNATURE AND ITLE OF CEFjTAFIE 1 16. LICENSE NO. 1 17. DATE M M / D D / C C V Y PHYSI• EDGE DEATH OCCURRED AT THE NOUR,:DATE S ST E ~ t fti1 032313 01/ 14/2000 CIAN'S AND PLACE STATED FROM THE CAUSE D. AT DECEDENT ATTENDED 91N[E I DECEDENT LAST SEEN ALIVE- - - .. CERTIFICA- M M / D D / C C Y Y i M M / D D / C CY Y 1 18. -TYPE ATTENDING PHYSICIAN'S NAME, MAIL( ADDRESS, ZIP , osep cGreevy , M. D . TION 01/04/2000 ; 01/13/2000 5565GrossmontCenter Drive, 44455, La Mesa, CA 91942 1 CERTIFY THAT IN MV OPINION DEATH 1 20. INJURY AT WORK 121. INJURY DATE M M 1 D D / C C Y Y 122. HDUR 12 3. PLACE OF INJURY OCCURRED AT THE HOUR, DATE AND PLACE STATED FROM THE CAUSES STATED. YES No 119. MANNER OF DEATH 1 24. DESCRIBE HOW INJURY OCCURRED (EVENTS WHICH RESULTED IN INJURY) D NATURAL ~ SUICIDE ~ HOMICIDE CORONER'S ^ ^ PENDING Q COULD NOT BE USE ACCIDENT INVESTIGATION DETBRMINED ONLY 125. LOCATION (BTREET AND NUMBER OR LOCATION AND CITY, ZIP) 126. SIGNATURE OF CORONER OR DEPUTY CORONBR 127. DATE MM/DD/CCYY I28. TYPED NAME, TITLE OF CORONER OR DEPUTY CORONER - STATE A B C D E F G H FAX AUTH. M2OO 1167 CENSUS TRACT REGISTRAR A0435708 County of Ssn Diego -Department of Health Services - 3851 Rosecrans Street. Thb le to certify that, If bearing the OFFIC:fA~ SEAL OF THE STATE OF CALIFORNIA, the OFFICIAL SEAL OF SAN DIEGO COUNTY AND THEIR DEPARTMENT OF HEALTH - SERVICES EMBOSSED SEAL, fhb {s a true copy of the ORIGINAL DOCUMENT FILED. Required fbe paid. ~~~~~~ DATE ISSUED:Jstllu9ry 19, 2000 GEORGE R. FLORES, Il4.D. REGISTRAR OF VITAL RECORDS County of San Diego This copy not valid unless prepared on engraved border dbplaying seal and elgnature of Registrar s Zooo37 p00770 ,'