HomeMy WebLinkAbout06-02-10 (2)INVE1~tTORY
REGISTER OF WILLS OF
COUNTY, PENNSYLVANIA
COM)vIONWEALTH OF PEr ~ 5YLVANIA ~ SS
COUNTY OF File Number ~ ~~ ~~ (~
Personal Representative(s) of the Estate of Mat v~-1~na_ •~•~ . t
deceased, depose(s) and say(s) that the items appearing in the following inventory include all o e personal assets wherever situate
and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said
inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the
Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory.
I verify that the statements made in this Inven- ~%~~{ ~E?C
tort' are true and correct. I understand that false state-
ments herein are made subject to the penalties of (~'~ ,G ,
18 Pa.C.S. § 4904 relating to unsworn falsifzeation to
authorities.
.----
~'~Attorney -- (Named 1-'2obies't' L. CS~~r~E't/1 (Sz~preme Court LD. No.) ~~~~
(Address)_ (°1 (~.ti ~ 5-E- ~'c~ru`E1.1 ~sl-a• '~ Ca.~' ~i s ~,e ~~,~~ (~
(Telephone) ~ ! ? 7_ ~~ ~ ~ "7 2
D(A~~Ti_E ~OF DEATH LAST RESIDENCE [/1 DEC~EJDENTS SOC. SEC. NO.
o^"_, -{- • ~k «~ oa ~ .~ ~ !~ ~ ~Q ~ rf` • \ Q t/' ~ t S. ~ e ~'(~A ~ ~ ~ E .5~ %~.. {I G " Z.'6 " c~ l 73
FIGURES MUST BE TOTALED
House
Mutual Funds /Acct.896-13448-1-2/Edward Jones
Money Mkt./Edward Jones
Stocks, Mutual Funds/Acct. 896-08529-1-4/ Cotenant/Edward Jones
Stocks, Mutual Funds/Acct.896-08538-1-3/ "
Stocks, Mutual Funds/Acct. 896-08537=~4/
US Savings Bonds
Mutual Fund/Acct. 896-09501/ Edward Jones
Checking Account, Members First FCU plus Dividends
Money Market, Members First FCU plus Dividends
Savings Members First plus Dividends
Personal Property
Auto: 1991 Toyota Camry
Furniture
Jewelry
Piano
Unearned Insurance Premiums, Tax and Misc. Returns
(Attach additional sl:eels as needed)
v
140,000.00
98,949.80
56.48
35,672.56
35,587.80
35,554.16
7,329.61
32,305.50
15,559.47
21,934.61
60.02
~ ~'','
_ _~
Z. ~0.0~ ,._ ,
--~s~0.00~ ~ - -
...~ _
~0.00~ _.;. , _
7 ~5.OQ~. ~...' _
~ 8686.61; ' - _
-~" .~, ~,....-J
N ~'-=~~
AL: ~ 439,731.67
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative include the value of each
item, but such figures should not be extended into the total of the Inventory. (See 20 Pa. C.S ~ j301(b))
Forn: R 63~ 09 rev. 10.13.06
Martha H. Shufflebarger/ Furnishings, Jewelry
Vanity and Mirror: 200
Oval Mirror: 75 .
Dresser and four drawers: 50
Two steel bedframes; one wooden bedframes 60
Cedar blanket chest: 200
Two analogue TVs 20
Composite board TV stand 10
Coffee table and two small end tables 200
Reproduction china, four settings 100
Doughboy 150
Walnut Hutch (damaged) 200
Single drawer stationery table 50
Two captain's chairs 300
Two dining room chairs 100
Four old table lamps (cords not code) 20
See addl. attached: 5325
To#al Furn. 7060
Jewelry
Assorted costume jewelry 250
Two zirc. Fake diamond rings 50
Total Jewelry 3Q0
HiCH VALUE INVENTORY FORM
~~', ATLAS VAN LINES, INC. • "'
~~® i212 ST. GEORGE ROAD, P.O. SOX 509
EVANSVILLE INDIANA 47703-05pB
AT f y~ GlSTRATION NO.
U.S. DOT No. 125550 (800) 252-8885 / (812) 424-2222 ""'-"--
Customer ~
Be sure to complete the description and estimated value sections on this form fdr all items in your shipment idered to
be of high value or that may require additional attention special packing, crating or Handling. If no items are considered to
be of high value or in need of additional attention, write NONE. Examples of High Valale Items or items needing additional
attention -Antiques, Art (wall or standing), CDs or DVDs (quantity), clocks, collectibles, collections, computer hardware or
software, customized items, designer clothing~or wardrobe accessories, exercise equipment, fiine china, firearms, high end
appliances/fiurniture, home audio/video system, hot tub, memory foam mattress, piano/musical instruments, silverware,
tanning bed, or other high value goods exceeding $~ U04.U0 in value.
tNYENTORY
No. " DESCRIPTION OF HIGfH VALUE ITEMS ESTIMATED
VALUE NOTES / CONDITIQNt
~` i ~~.~ ~C,.~~as3r~~ ~fn 5 ~ C~ oo D
R~:~S -~
2 ~; a~` ~t~~~~~ C~ - ~ C~~~
C~NL~ Cure CSA ~ i d ~ ~" k"xC~~..~~~rJ, e
4
~
~2- •~ ~cm c~,le ~ (,~..e~s G~,r,
~. 'T, ~
~Z~-C~C.t ~ £, ~ ~ i ~ ~... ~~ O D
i s E ~~ t ~ - ~4~ ~
~! ~~. `
~...
"'1"O BE COMPLETED BY TOTAL ~ ~
et~es r~o~s~*trarns_ ~~• i
AT ORIGIN
! CERTIFY THE ABOVE LISTED INFORMATION TO 8E TRUE, CORRECT AND
COMPLETE TO THE BEST OF MY KNOWLEDGE. I HAVE READ AND
UNDERSTAND THE STATEMENT OF CUSTOMER RESPONSlBlLITIES FORM.
SIGNATURE OF CUSTOMER OR S R£PpESENTAtIVE WtTE
SIGNATURE OF ATLAS REPRESENTATIVE AGENT/PVO CODE DATE
AT DESTINATION
! AClV~OWLEDGE RECEIPT OF ALL ITEMS LISTED ABOVE. ALL REMS ARE IN
THE SAME CONDI[lON AS WHEN TENDERED'iO ATLAS, UNLESS EXCEPTIONS
ARE NOTED ABOVE.
SIGNATURE OF CUSTOMER OR CUSTOMER'S REPRESENTATIVE GATE
Si~NATURE OF ATlA3 REPRESENTATIVE AGENTlPVO CODE GATE
ESTIMATED VALUE DOES NOT DETERMINE THE ACTUAL VALUE OF THE GOODS. SHOULD A LOSS OCCUR, THE ACTUAL VALUE MUST
BE ESTABLISHED BYTHE OWNER OFTHE GOODS.THE PURPOSE OFTHIS FORM IS TO ASSISTYOU IN DETERMININGTHETOTALVALUE
OF YOUR SHIPMENT AND TO ASSIST ATLAS IN DETERMINING WHICH ITEMS NIrED SPECIAL HANDLING AND PROTECTION.
Dc 22sooe
Rev. 2107