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Home My WebLink About04-0564 LAW OFFICES OF STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 IN RE: JOHN K. MCKEEHAN, SR. : COURT OF COMMON PLEAS ALLEGED INCAPACITATED : OF CUMBERLAND COUNTY PERSON : PENNSYLVANIA : ORPHAN COURT DIVISION : : NO.: : PETITION FOR GUARDIAN AD LITEM The undersigned brings this Petition through her Attorney, ::.:S: tephen J. Hogg, Esquire, seeking appointment as the Guardian Ad Litem of John K. McKeehan, Sr., alleging the following: 1. The alleged incapacitated person is John K. McKeehan, Sr. born October 27, 1941 and whose last known address is 1668 Douglas Drive, Carlisle, Cumberland County, Pennsylvania 17013. The alleged incapacitated person is currently an inpatient at the Holy Spirit Hospital, 503 N. 21st Street, Camp Hill, Cumberland County, Pennsylvania 17011 and has been deemed by his treating physician to be unable to safely travel. 2. The alleged incapacitated person is married to Sandra J. McKeehan. The alleged incapacitated person has two children: Mary K. Spanos 23 East Oakwood Drive Carlisle, PA 17013 John K. McKeehan, Jr. 10 Meadowview Drive New Bloomfield, PA 17068 LAW OFFICES OF STEPHI~N J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 and also three stepchildren: William M. Kronenberg, III 236 D. Avenue Coronado, CA 92118 Christopher E. Kronenberg 1886 Douglas Drive Carlisle, PA 17013 Erin L. Kronberg 2151 Penn Street Harrisburg, PA 17110 The alleged incapacitated person is currently being treated by Dr. Robert Baily, Holy Spirit Hospital 503 N. 21st Street, Camp Hill, Pennsylvania 17043, whose records are attached as Exhibit 1. The Petitioner is Sandra J. McKeehan, residing at 1668 Douglas Drive, Carlisle, Cumberland County, Pennsylvania who is the spouse of the alleged incapacitated person. The Petitioner has no interest adverse to the alleged incapacitated person and seeks to be appointed Guardian Ad Litem to ensure the alleged incapacitated person's continued physical health treatment and to ensure that his financial matters are properly and timely addressed. The Petitioner alleges that the alleged incapacitated person is unable to adequately care for his own needs or manage his financial matters. LAW OFFICES OF STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 10. Date: The Petitioner requests that she be appointed Guardian Ad Litem of the alleged incapacitated person to assure continued needed physical health treatment and to assure that the estate of the alleged incapacitated person is not wasted or squander. The Petitioner alleges that she is the most qualified individual to act as the Guardian Ad Litem of the alleged incapacitated person and has his best interests in mind. The Petitioner seeks to be appointed the Guardian Ad Litem of the alleged incapacitated person only so long as the alleged incapacitated person is determined by his treating doctor, Dr. Bally, to be unable to take care of his own needs. The Petitioner estimates that the gross value of the estate of the alleged incapacitated person is $150,000.00. Petitioner seeks to be appointed the guardian of the alleged incapacitated person's estate and of his person. Respectfully Submitted, ~tephen J. H~'g//Esquire Attorney for Petitioner EXHIBIT ADM. DATE: 05/18/2004 SS #: 161-32-3927 REASON FOR CONSULTATION: Evaluation of fever. The patient is a 62-year-old male who was admitted to the hospital on 5/18 after having an acute cardiopulmonary arrest in the field. The patient was resuscitated and brought to the Carlisle Regional Medical Center and then transferred here to the Holy Spirit Hospital. He has been in the ICU on a ventilator since-admission. He had been running a Iow grade fever, however today he spiked a fever to 103 degrees. He has been on Zosyn at 3.375 grams q6h since admission. He has not had any significant sputum production. There has been no reports of diarrhea. He does have an indwelling Foley and a PICK line in his right upper extremity. PAST HISTORY: Significant for hyperlipidemia and hypertension. SOCIAL HISTORY: Negative for smoking but only an occasional drink. FAMILY HISTORY: Unknown. REVIEW OF SYSTEMS: Is otherwise not obtainable. PHYSICAL EXAMINATION: On examination he is presently on the ventilator. He is unresponsive. T-max is 103 degrees. NECK Supple. LUNGS Clear. HEART Without a murmur. ABDOMEN Soft. EXTREMITIES With slight edema. LABORATORY White count is 7,800, hemoglobin 14.0, platelet count is 190,000. His creatinine is 0.7 with a BUN of 19. The blood cultures were negative. Tracheal aspirate had a rate staph aureus. Urine count had a strep species. Chest X-ray has shown some atelectasis or infiltrate in the bases with a small effusion. IMPRESSION: Status post cardiac pulmonary arrest on 5/18/04. Post cardiac arrest anoxic encephalopathy. Post arrest respiratory failure. HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 CONSULTATION REPORT Page I of 2 NAME: Mckeehan, John K MR#: 298173 ROOM: ICU 831 01 DR.: ROBERT J KANTOR, MD ORIGINAL NAME: Mckeehan, John K *'MR#: 298173 Fever with the possibilities including (A) a nosocomial infection such as pneumonia, udnary tract infection, less likely a Line sepsis, (B) essential fever or (C) a DVT or (D) drug fever. RECOMMENDATIONS: Change antibiotics to Cefepime I gram q12h and Vancomycin 1 gram q12h. Follow up chest X-ray. If his cultures are negative and the fever persists despite' the antibiotic change, then we will do a CAT Scan of his lungs to include emboli. RKJjs DOC #: 459584 D: 05/26/2004 T: 05/27/2004 12:21 P 000681369 cc: ROBERT G BALLY, MD ROBERT J KANTOR, MD ROBERT J KANTOR, MD HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 CONSULTATION REPORT Page 2 of 2 NAME: Mckeehan, John K MR#: 298173 ROOM: ICU 831 01 DR.: ROBERT J KANTOR, MD ORIGINAL CONSULTATION REPORT ~i~ONSULT (WITH CARE) [] CONSULT ONLY REPORT REQUESTED REGARDING · -- NOTIFtED BY ' ~ w DATE HOLY SPIIIIT iiOSPITAL ~~:~: CAMP HILL. PENNSYLVANIA TIME MCKEEHAN , JOHN K 161-32-3927 62 M 10/27/1941 BAILY ROBERT G 298~73 05/18/04 2'2~3C87% ADM. DATE: 05/18/2004 CHIEF COMPLAINT: Cardiopulmonary arrest. HISTORY OF PRESENT ILLNESS: Mr. McKeehan is a 62 -year-old obese white male without prior history of coronary artery disease, who presented this evening to the Cadisle Regional Medical Center with acute cardiopulmonary arrest. The spouse states that the patient was watching a movie with her, at which point in time he developed an acute onset of unresponsiveness, fell to the floor, and immediately his spouse contacted the ambulance service, who within five minutes began to administer CPR. Patient was brought to the Carlisle Regional Medical Center, where he was found en route to be in PEA. He was placed on Lidocaine, and the patient was now in normal sinus rhythm with widened QRS complex. He was found initially to have a potassium of 3.1. This was normalized, and patient had no further rhythm disturbances. An electrocardiogram was obtained in the emergency unit, and the patient was intubated and placed on volume and ventilatory support. Electrocardiogram demonstrated sinus tachycardia with lateral upsloping ST depressions and poor R-wave progression in the antedor precordial leads. On closer observation, it appeared the patient was actually in atrial flutter with variable block. Later cardiogram sinus rhythm at a rate of 86 beats per minute. Patient is now transferred to the Holy Spidt Hospital for stabilization post cardiopulmonary arrest and to determine whether patient sustained a myocardial infarction and will require catheter intervention. PAST MEDICAL HISTORY: Significant for hypertension, hyperlipidemia. The patient takes Zocor for the hyperlipidemia. He has no prior history of cerebrovascular accident or myocardial infarction. He had shoulder surgery on the dght in the past. CURRENT MEDICATIONS: Tiazac 420 mg, p.o., q. day; Claritin 10 mg, p.o., q. day, p.r.n.; hydrochlorothiazide 25 mg, p.o., q. day; Zocor 20 mg, p.o., q. day; Patanol ophthalmic solution, I drop, b.i.d., both eyes; Flonase nasal spray, 50 mcg, 1 spray, q.. day; Ativan 0.5 mg, q.h.s.; Allegra 180 mg, p.o., q. day, P.r.n.; and Cozaar 50 mg, p.o., q.h.s. FAMILY HISTORY: SOCIAL HISTORY: Significant for being a nonsmoker, and he drinks only on occasion. REVIEW OF SYSTEMS: Provided by the family members, indicates that the patient has had no decreased exercise tolerance and no chest pain or shortness of breath either at rest or with exertion. He also denied any paroxysmal nocturnal dyspnea, orthopnea, or peripheral edema. He also denied hematemesis, hematochezia, or melena, hematuria, pyuria, or dysuda and had no complaints of neurologic symptoms. PHYSICAL EXAMINATION: He was noted to be an obese white male who was intubated on volume and ventilatory support and unresponsive. Most recently, the patient was reported as Pacje I of 3 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 HISTORY AND PHYSICAL EXAMINATION NAME: Mckeehan, John K MR#: 298173 ROOM: ICU 831 01 DR.: ROBERT G BALLY, MD ORIGINAL NAME: Mckeehan, John K MI~: 298173 having decorticated posturing. Blood pressure was 125/85 mm/Hg, pulse of 116 beats per minute. HEENT: Grossly unremarkable, other than mild facial plethora. NECK: Neck veins were not distended. No carotid bruits were audible. LUNGS: Lung fields were surprisingly clear. CARDIAC: Showed a rapid rate, regular rhythm without S3. PMI was not displaced. I heard no rubs. There were no significant murmurs audible. ABDOMEN: Soft, globoid, nontender, and mildly tympanitic. Bowel sounds were audible but distant. EXTREMITIES: Without clubbing or cyanosis, and I noted no significant edema. Pulses were present, full and equal bilaterally. RECTAL/GENITALIA: Deferred. NEUROLOGIC: Significant for decorticate posturing. His pupils were 3 mm on the right, 4 mm on the left and reactive. LABORATORY DATA: Electrocardiograms were as described above. Chest x-ray was reviewed and appeared to be an under-penetrated film with an increase in perihilar haziness suggesting the presence of increased pulmonary vascular congestion. Cardiac silhouette was increased as well suggesting cardiomegaly. Laboratory values from Carlisle Hospital showed an initial CPK of 253 with an MB of 1.0 and a troponin I of less than 0.04. Sodium was 139, potassium was 3.1; chloride was 99, carbon dioxide was 21.5 with a fasting blood sugar of 206, BUN of 13, creatinine of 1.2, calcium of 8.5, and a magnesium of 2.0. Prothrombin time was 11.6 with a partial prothrombin time of 25.9. White count was 9.3 with hemoglobin and hematocdt of 15.6 and 44.8, respectively, and a platelet count of 196,000. IMPRESSION/PLAN: It is my impression that Mr. McKeehan probably suffered a cardiopulmonary arrest related to an arrhythmic event. Subsequently, I believe he has developed cerebral anoxia of undetermined extent and undetermined reversibility. The patient will be kept on topically nitrates and intravenous beta blockers to maintain his rhythm in a normal range and also will be given intermittent doses of intravenous ACE inhibitor to reduce blood pressure if necessary. HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 HISTORY AND PHYSICAL EXAMINATION Pa(:je 2 of 3 NAME: Mckeehan, John K MR#: 298173 ROOM: ICU 831 01 DR.: ROBERT G BALLY, MD ORIGINAL IN RE: John K. McKeehan, Sr. An alleged incapacitated person IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-2004-0564 IMPORTANT NOTICE CITATION WITH NOTICE A petition has been filed with the Court to have you declared an Incapacitated Person. If the Court finds you to be an Incapacitated Person, your rights will be affected, including your right to manage money and property and to make decisions. A copy of the petition which has been filed by Sandra J. McKeehan is attached. You are hereby ordered to appear at a hearing to be held in Court Room No. 2, Cumberland County Courthouse, Carlisle, Pennsylvania, on June 28 ,2004, at 9:00 A.M. to tell the Court why is should not find you to be an incapacitated Person and appoint a Guardian to act on your behalf. To be an incapacitated Person means that you are not able to receive and effectively evaluate information and communicate decisions and that you are unable to manage your money and/or other property, or to make necessary decisions about where you will live, what medical care you will get, or how your money will be spent. At the hearing, you have the right to appear, to be represented by an attorney, and to request a jury trial. If you do not have an attorney, you have the right to request the Court to appoint an attorney to represent you and to have the attorney's fees paid for you if you cannot afford to pay them yourself. You also have the right to request that the Court order that an independent evaluation as to your alleged incapacity. If the Court decides that you are an Incapacitated person, the Court may appoint a Guardian for you, based on the nature of any condition or disability and your capacity to make and communicate decisions. The Guardian will be of your person and/or your money and other property and will have either limited of full powers to act for you. If the court finds you are totally incapacitated, your legal rights will be affected and you will not be able to make a contract or gift of your money to other property. If the court finds that you are partially incapacitated, your legal rights will also be limited as directed by the Court. If you do not appear at the hearing (either in person or by an attorney representing you) the court will still hold the heating in your absence and may appoint the Guardian requested. Clerk, Orphans Court Division Cumberland County, Carlisle, PA My Commission Expires 1st Monday, January, 2006 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION also known as To: Register of Wills for the County of Cumberland Commonwealth of Pennsylvania Deceased. Social Securit.v No. 161-32-3527 in the The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, applies ¢~ ~'~.~ (d.b.n.; pendeme lite; durante ab~entia; durante minorilate) the above decedent. for letters of administration on the estate of Decedent was domiciled at death in Cum_b_erla_nd C~_~)~ y, Pen.nsylvaniaej~yith his last family or principal residence at 1668 Douglas Drive, ~'~isle~__P~A ~i--' Ilist street, numbe~--~'~p, or ~oro.~ '"i'~ Decedent, then 62 years of age, died June 19 ~ at Holy Spirit Hospital Decedent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: ' $ 70,000.00 i~!:' - $ Petitioner after a proper search ha the following spouse (if any) and heirs: Name Sandra O. McKeehan Mary K, Sponos John K, McKeahan. Jr. ascertained that decedent left no will and was survived by Relationship Spouse Daughter Son Residence 1668 Douglas Drive, 23 E. O~kwood Drqva~ 10 Moadowviow Drivo~ Carlisle, PA1701 Cmrlisle, PA17C Now Bloomfield, PA 17068 THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF Cumberland The petitioner(s) above-named swear(s) or 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 above decedentpetitioner(s) wil)~well and truly administer the estate according to law. Sworn to or affirmed_and subscribed r- before__me this ~c~ day of. No. Estate of John K. McKeehan, Sr. , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW July lX)F. 2004, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that is/are entitled to Letters of Administration. and in accord with such finding, Letters of Administration are hereby granted to in the estate of . John It. McKeehan. Sr. FEES Letters of Administration ..... $ Short Certificates( ) .......... Renunciation ................ $ $. TOTAL ~ $. Filed ..................... A.D. 19 Register of Wills Patricia R. Brown 27474 ATTORNEY (Sup. Ct. I.D. No.) 10 W. Pomfret Street, Carlisle, PA 17013 ADDRESS (717) 249-3024 PHONE his is to certify that the information here given is correctly copied froln an original certificate of death dul'~ Iii Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanc,u l'ii~ ~,, WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this cerdficate, $2.00 No. H105.143 Rev. 2/87 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH ° VITAL RECORDS CERTIFICATE OF DEATH DECEDE~'S USUAL ~PA;ION 0~ Trucking ~zv,, ~O ~(~) andra 0~o 1668 Douglas ~r. INFORMANTS ~ME ~y~nt) Ra,daa O. MCg~¢hg8 7668 Doaq~as Dr. Carlisle PA 17013 ~ ~1,. ~(s~) ~,~ 6~22/04 ~,~o~lnger Cremator~ ~~' :~ ~ m~ ~ ~ ~ ~ PART I. IaaEma~ CAUSE (~nM WAS AN A~OPSY I ~RE AUT~Y FI~ ~l MANNER ~ATH I DATE OF INJURY I TIME OF INJURY I INJURY AT ~RK? I ~RIBE ~W INJURY ~CURRED. o I°'°~'"'I,~ O .~,~,~.,..~ ol I I ,..o ,oDI 'PRONOUNCING AND CERTIFYING PHYSICIAN (P~ysk:iafl heft1 pronouncing death and ca.rig to cause Of dealfl) ~ To the be~t of my knowl~e, ~eath ogcuned at the time, tiate, and place, and due to the ¢aus#(l) and manner a~ atated ...................... ~ *MEDICAL EXAMINER/CORONER "G'"NA.,'.A'U. ARO.UM.~ c~. ¢,._..&~~_~ I~,~, ~,01 NAME AND ADORESS ( (Itael~ 27) Type ~ Prinl DATE FILED (M~rmh, 0~/, Y CERTIFICATION OF NOTICE UNDER RULES 5.6(a) Name of Decedent: Date of Death: Will No: John K. McKeehan, Sr. June 19, 2004 21-04-0564 To the Register: I certify that notice of beneficial interest 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 August __, 2004: Sandra O. McKeehan 1668 Douglas Drive Carlisle, PA 17013 Mary K. Spanos 23 Oakwood Drive Carlisle, PA 17013 John K. McKeehan, Jr. 10 Meadowview Drive New Bloomfield, PA 17068 Notice has now been given to all persons entitled thereto under Rule 5.6(a) excel: No ex~tions.' Date: August-~7 , 2004 Patricia R. Brown, Esquire 10 West Pomfret Street Carlisle, PA 17013 Phone: 717-249-3024 Capacity: Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 TAX RETURN RESIDENT DECEDENT DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) McKeehan, John K. OFFICIAL USE ONLY FILE NUMBER 21-04-0564 ;OUNTY CODE YEAR NUMBER SOCIAL SECURITY NUMBER 161-32-3927 Z uJ DATE OF O DATE OF DEATH (MM-DD-YY) BIRTH (MM-DD-YY) THIS MUST BE FILED IN DUPLICATE '" 6/19/2004 10/27/1941 WITH THE REGISTER OF WILLS UJ IF APPLICABLE) SURVIVING SPOUSE'S NAME SOCIAL SECURITY NUMBER ° O ~ 1. Original Return '-] 4. Limited Estate ~] 6, Decedent Died Testate 9. Lirg'tion Prcceads Rec'd [] 2. Supplemental Return [] 4a, Future interest Compromise [] 7. Decedent had Living Trust Credit [] 3, Remainder Return [] 5. Fed. Est. Tax Return Req'd 0__ 8. Total number of SOB's i 11. Election to tax w/Sec. 9113(A) NAME: Patrica R. Brown, Esquire FIRM NAME: TELEPHONE NUMBER 117 249,.3024 3,OMPLETE MAILING ADDRESS: Patricia R. Brown 10 W. Pomfret St. Carlisle, PA 17013 $0,0t $0.00 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3.Closely Held Corporation, Partnership or Sole-Prop. (3) 4. Mortgages & Notes Receivable (Schedule D) (4) $0.00 5. Cash, Bank Deposits & Misc. Personal Prop.(Sch. E) (5) $72,745.37 6. Jointly Owned Property (Schedule F) (6) $0.00 D Separate Billing Requested 7. Inter-Vivos Transfers & Misc. Non-Propata Prop. (7) $36,105.12 8. Total Gross Assets (total lines 1-7) (8) $108,850.49 9. Funeral Expenses & Administration Costa (Sch H) (9) $13,289.50 10. Debts of Decedent, Mortgage liabilities, & Liens (10) $58,510.07 11. Total Deductions (total lines 9&1 O) (11) $71,799.57 12. Net Value of Estate (Line 8 minus Line 11) (12) $37,050.92 13. Charitable and Governmental Bequests/Sec 91 t 3 Trusts f~ which an election to tax has net bean made (13) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) $37,050.92 USE ONLY SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amnt of Line 14 taxable at the spousal rate, or trsnsfera under Sec.9116(a)(1.2) 16. Amount of Line t4 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due $36,105.12 x.O_ (15) $0.00 $945.80 x.04s (16) $42.56 $0 x.12 (17) $0.00 $0 x. t5 (18) $0.00 (19) $42.56 Z0 [] CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedent's Complete Address: ISTR~ET ADDRESS 1668 Douglas Drive c~ Carlisle Tax Payments and Credits: 1. Tax Due 2. Credita/Payments A. Spousal Poverty Credit B. Pdor Payments C. Discounts STATE PA ZIP 17013 $42.56 Total Credits (A+B+C> (2) $0,00 3. Interest/Penalty if applicable D. Interest E. Penalty Total IntereaL/Pentalty (D+E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. T~is is the OVERPAYMENT. Check box on Page I Line 20 to request a refund 5. If Line 1 + Line 3 ts greater than Line 2, enter the differenca. This is the TAX DUE A. Enter the interest on the tax due. B. Enter the total of Line 5 + SA. This is the BALANCE DUE. Did decedent rake a transfer and: a. retain the use or income of the property transferred: b, retain the right to designate who shall use the property tmnserred or its income: c ratain a revemiona~y interest: or d, retain the promise for life of either paymenta or care? (3) $0.00 If death occurred alter December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? Did decedent own an "in trust for'' or payable upon death bank account or security at his or her death? Did decedent own an Ind~dual Retirement Account, annuity, or other non-probate property which contains a beneficial/dislgnation? (4) (5) $42.56 (5A) (5B) $42.56 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. yes no 4 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YF.5~ YOU MUST COMPLETE SCHEDULE Gl AND FILE IT AS FART OF THE RETURN, ADORESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS 10 West Pomfret Stroet, Carlisle, PA 17013 For dates of death on or after July 1, 1994 and before Januaq/1, 1995, the tax rate imposed on the net value of tmnstars to or for the use of the surviving spouse is 3% [72P.$ Sec 9118(a)(1 1 )(I)] For dates of death on or after Januarf 1, 1995, the tax rata imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P $ Sec. 9116(a)(1 1 )(ii)] only beneficial. SCHEDULE E CASH, BANK DEPOSITS AND MISCELLANIOUS PERSONAL PROPERTY ESTATE OF FILE NUMBER McKeehan, John K 21-04-0564 ~All pro[~y jointly-owned wi0a Right of Survivorahip must be disclosed on Schedule F) ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH 1 2 3 4 5 6 7 Orrstown Bank - checking acct no: 143000207 Arkansas Best Federal Credit Union - savings acct no: 1719900 1988 Corvette 2004 Chevrolet Tahoe $3,833.06 $1,762.31 $27,900.00 $39,250.00 TOTAL (also on line 5, Recapitulation) $72,745.37 SCHEDULE G TANSFERS ESTATE OF FILE NUMBER McKeehan, John K. 21-04-0564 This schedule to be cortt~leted and filed if the answe~ of the question on lhe reverse of thc cover is yes, ITEM DESCKIPTION EXCLUSION TOTAL VALUE DECD.% DOLLAR VALUE NUMBER OF ASSET INT OF DECD. IN~ 1 Prudential Financial 32,404.09 100.0%I $32,404.09 Contract E199590 Annuity IRA 2 Prudential Financial 3701.03 100.0% $3,701.03 Contract 99418559 (FIP) (NOTE: Spouse is named beneficimy on each annuity) TOTAL (al,o on line 7, Recapitulation) $36,105.12 SCHEDULE H FUNERAL EXPENSES, ADIvIINISTRATIVE COSTS AND MISCELLANEOUS EXPENSES ESTATE OF McKeehan~ John K. (All propet~y jointly-owned with Right of Survivorship must be disclosed on Schedule F) FlLE NUMBER 21-04-0564 1TEM DESCRIPTION AMOUNT NUMBER 1 2 1 2 3 1 2 3 4 5 6 7 8 9 10 Funeral Expenses: Hollinger Funeral Home and Crematoxy, Mt. Holly Springs Grave Marker Administrative Costs: Personal Representive Commissions Social Security Number of Personal Representative: Attorney fees to Patricia R. Brown, Esquire Family Exemption Claimant Sandra O. McKeehan Relationship: Spouse Address of Claimant at decedent's death: Street: 1668 Douglas Drive City: Carlisle Probate Fees to Register of Wills Miscellaneous Expenses: Miscellaneous Filing fees State & Zip PA 17013 $3,295.00 $1,307.50 $5,000.00 $3,500.0O $137.00 $50.00 TOTAL (also on line 9, Recapitulation) $13,289.50 SCHEDULE I DEBTS OF DECEDENT MORTGAGE LIABILITIES AND LIENS ESTATE OF FILE NUMBER McKeehan~ John K. 21-04-0564 ITEM DESCRIPTION NUMBER AMOUNT Arkansas Best Federal Credit Union (Loan L1 2004 Chevrolet Tahoe) 1998 Corvette payoff $33,010.07 $25,5O0.00 TOTAL (also on lin~ 10, Recapitulation) $58,510.07 SCHEDULE J BENEFICIARmS ESTATE OF FILE NUMBER McKeehan, John K. 21-04-0564 ITEM NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR SHAKE NUMBER OF ESTATE 1 Sandra O. McKeehan spouse one - half (1/2) 1668 Douglas Drive, Carlisle, PA 17013 2 Mary K. Spanos daughter one-fourth (1/4) 23 E. Oakwood Drive, Carlisle, PA 17013 3 John K. McKeehan, Jr. son one-fourth (1/4) 10 Meadowview Drive, New Bloomfield, PA 17068 ITEM NAME AND ADDRESS OF BENEFICIARY AMOUNT OR SHARE NUMBER OF ESTATE B. Charitable and Governmental Bequests: TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (also enter on line 13, Recapitulation} $0 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT 280601 HARRISBURG PA 17128 0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX(11 96) NO. CD 004688 BROWN PATRICIA R 10 WEST POMFRET STREET CARLISLE, PA 17013 fold ESTATE INFORMATION: SSN: 161-32-3927 FILE NUMBER: 2104-0564 DECEDENT NAME: MCKEEHAN JOHN K SR DATE OF PAYMENT: 12/03/2004 POSTMARK DATE: 1 2/03/2004 COUNTY: CUMBERLAND DATE OF DEATH: 06/19/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $42.56 TOTAL AMOUNT PAID: $42.56 REMARKS: SEAL CHECK# 1194 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX PATRICIA R BROWN 10 W POMFRET ST CARLISLE DATE ... ESTATE ~F DATE OF DEATH . FtLE NUMBER COUNTY . ACN.. 02-07-2005 MCKEEHAN SR 06-19-2004 21 04-0564 CUMBERLAND 101 ESQ '*' RH-15~7 EX AFP (12-04) JOHN K PA 17013 Allount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ Rlv:r~4".iic..AF"..rD1":6!')".Niii'.ifi.OF.i:lMiR.ifAN.fl.i'AX.iil5'PR".isiWNT:..ACLoWANC"l.Or................ DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF MCKEEHAN SR JOHN K FILE NO. 21 04-0564 ACN 101 DATE 02-07-2005 TAX RETURN WAS: I X) ACCEPTED AS FILED ) CHANGED If an assessment was issued previoUSly, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ~ returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 16. Allount of Line 14 taxable at Lineal/Class A rate (16J 17. A.aunt of Line 14 at Sibling rate (17) 18. Allount of line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX EDI : RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate {Schedule AJ 2. Stocks and Bonds (Schedule BJ 3. Closely Held stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule OJ 5. Cash/Bank Deposits/Misc. Personal Property (Schedule El 6. Jointly Owned Property (Schedule Fl 7. Transfers (Schedule Gl 8. Total Assets (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 72.745.37 .00 36.105.12 IB) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule Hl 10. Debts/Mortgage Liabilities/Liens (Schedule Il 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule Jl 14. Net Value of Estate Subject to Tex (9) (10) 13,289.50 58.510.07 Ill) (12) (13) (14) NOTE: 36,105.12 X 945.80 X .00 X .00 X . INTEREST/PEN PAID 1-) .00 AMOUNT PAID 42.56 DATE 12-03-2004 NUMBER CD004688 -/7 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax paYllent. 108,850.49 71 799 ~7 37, 050.92 .00 37,050.92 00 = 045 = 12 = 15 = .00 42.56 .00 .00 42.56 (19)= 42.56 .00 .00 .00 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. " IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. t..,\ IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU MAY BE DUE I A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) 2\\ ~ F AMIL Y SETTLEMENT AND FINAL RELEASE IN ESTATE OF JOHN K. MCKEEHAN (File No. 21-04-0564) '-0 w KNOW ALL MEN BY THESE PRESENTS. that WHEREAS, John K. McKeehan. late of 1668 Douglas Drive, Carlisle, Pennsylvania, deceased, died intestate on June 19,2004; WHEREAS, letters of administration on the estate of the said decedent were duly issued by the Register of Wills of Cumberland County, Pennsylvania, to decedent's spouse, Sandra O. McKeehan, hereinafter called personal representative; WHEREAS, the said personal representative has gathered the probate assets of the estate of the said decedent and the said assets consist of personal property to a total value of $72,745.37, as set forth in Exhibit A, which is a statement of account of the said personal representative, and which is attached hereto and made a part hereof, and marked Exhibit A; WHEREAS, the debts and deductions including the payment of inheritance tax in the said estate amount to $71,842.13, leaving a balance for distribution of $903.24, also as set forth in the statement of the said personal representative, which is attached hereto and marked Exhibit A; NOW, THEREFORE, KNOW YE, that we, Sandra O. McKeehan, Mary K. Spanos and John K. McKeehan, Jr., are the intestate heirs under Chapter 21 of the Probate, Estates and Fiduciaries Code, and being those persons entitled to inherit thereunder we do hereby, each of us, acknowledge that we have this date had and received from the aforesaid personal representative in full satisfaction and payment of all sum or sums of money as are distributed to each of us respectively under the said Code, which dictates the amounts due us for distribution of the decedent's estate, and which amounts are in the amount set opposite our respective names in the table and schedule of distribution on said statement attached hereto and marked Exhibit A: Page 1 of 5 AND, each of us does hereby stipulate that in order to avoid the expense and time involved in the filing of a formal account and schedule of distribution, we each agree that no account is necessary and we do hereby agree that we do consent to distribution being made without the filing of an account and schedule of distribution, the same to be with the same force and effect as if it had been filed and confirmed by the Orphans' Court Division of the Court of Common Pleas, Cumberland County. THEREFORE, we and each of us, do hereby remise, release, quitclaim and forever discharge the said personal representative, Sandra O. McKeehan, her heirs, executors, and administrators and assigns, of and from the said estate and from all actions, suites, payments, accounts, reckonings, claims, demands whatsoever for or by reason thereof, or for any other use, matter, cause or thing whatsoever, touching upon the estate of said decedent, and each of us do further hereby covenant and agree that should any liability come due to the estate of the said decedent after the signing of this agreement, we and each of us do hereby covenant and agree with each other and the aforesaid personal representative, that we will contribute pro-rate, our share of the estate to satisfy any and all claims demands, suits, or cause of action which may be successfully prosecuted against the said estate or the aforesaid personal representative after the signing, sealing and delivery of this Family Settlement Agreement and Final Release. IN WITNESS ~ d WHEREOF, I have hereunto set my hand and seal this /;(. day of ,2005. Witness: '.~T'-A-~ ~ ~ ~~ct2lt11'~EAL) 'IDo.."", ~ ~~ (SEAL) MARY K.<SP AN ~~'1(: ~ "-P ~<---J y~ )/~J (SEAL) Page 2 of 5 COMMONWEAL TH OF PENNSYL VANIA SS. COUNTY OF CUMBERLAND On this, the /c2tf day of /ll~ , 2005, before me, a notary public, the undersigned officer, personally appeared SANDRA O. MCKEEHAN (known to me or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. tL4.~ Notary Public COMMONWEALTH OF PENNSYLVANIA NOTARiAl EAL CA~~ri SENSENICH, NOTARY PUBLIC L MY COMM~~~~ &~~~~~~~i02UO~V SS. COUNTY OF CUMBERLAND On this, the 1& f.!:-day of M frKc 1+ , 2005, before me, a notary public, the undersigned officer, personally appearea MARY K. SPANOS (known to me or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. ukr cm,~== r-:'D\~~~;. ~~;~i.2::}~2E;'.; 2.~ arry L. M~:";::,!!, Not,.." Pli'.li" J Carhs;" Bem C\'",)v'rl~;;( C '~.;: M ....'.. ......,..... ~C!..j o~"n~ " . Y ComzP.!S}lOn Expires J":'3 10:" 2006 Member, Pennsylvania As~"''''o.;"., "1 I" , ~-~...."~ tv ~:.ilr;ea Page 3 of 5 COMMONWEALTH OF PENNSYLVANIA COUNTY OF PERRY- C cJrv/f3[(~L/TN:D SS. On this, the I;). -r~day of ;Y) It-fl-Ci+- , 2005, before me, a notary public, the undersigned officer, personally appeared JOHN K. MCKEEHAN, JR. (known to me or satisfactorily proven) to be the person whose name is subscribed to the within instru..'nent, and acknowledged that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. Page 4 of 5 COlv:'~/:- ="_~~ :"'/rF /~.'!-,T~"i QE~ ~'~:~1-,\ral1(~ -'-- Nc::~:J.1 Seal .1' J Larry L. t,k;:riscn, Notr.ry P\l1:,l~ C~~'1i~~e Eet,), Cr~~bcrlafo~. ~~~i~r: ~ ~ My Ch~,"~"i"" E,p"" ."" ,0, ":" . ~~~::~:::--;;;--i~,~~"~"" Member, pcnns~',varLd n...:.;..;,..;..;.,.....,..-.,.oll (v>; \,..,.......... STATUS REPORT UNDER RULE 6.12 Name of Decedent: McKeehan, John K. Sr. Date of Death: June 19, 2004 Will No.: Admin. No.: 21-04-0564 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes E! 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 t6 No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No 0 Filed Family Settlement Agreement March 22, 2005 b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes @ No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the. Orphans' Court and may be attached to this report. ~~Date: -Jjl-'IjZOOY . ~=r:;_ Ad"',':V(' ~ ... SIgnature Patricia R. Brown Name 10 West Pomfret Street, Carlisle, PA 17013 Address (717) 249-3024 Telephone No. Capacity: 0 Personal Representative Ga Counsel for personal representative .If