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HomeMy WebLinkAbout06-02-10 (2)15056041046 REV-1500 EX (05-04) OFFICIAL USE ONLY PA Department of Revenue County Code Y~C~ File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Dept. 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~l ~~ ~ 1 ©Z, ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth a0 ~ ~'3 sq 9 © ~9 io3 aoo 9 0~' / o ~ 92D Decedent's Last Name Suffix Decedent's First Name MI C~~~~~ Y. ~~ ~-~ }cs (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N / /~ 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) ~ 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 T0: Name Daytime Telephone Number Firm Name (If Applicable) /~ / /9" First line of address 6 C~ o u~E~p_ ~o.¢-v Second line of address ~~ City or Post Office State ZIP Code ~i ,_ ;.._~ .-; -r.:r ~__~) .; ~ Correspondent's a-mail address: C eS~~ L° ~~~~ w~/ICQS~i /f t,°~ 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. SIGNATUR P SON RES O SI F ILING LURN X~ ~~ ~... A ~ ~ DATE S/J~! / /D G¢~tiv~ y `y Ctrl,/ ! / ADDRESS ~'~~~,N~Cd G ~ ~~(~K/7~,¢,~/1 T /4~/ /yi fy iPd•, ~i//s~~s~h4. ~i~ X70/ SIGNATURE:BFiPREP~ER OCHER /¢/l1~U~S ~°ATN uJFST, /,~i~rI~LS~ur~¢, ~if DATE s ~ZD.fD licr/f ~- - -~ G -~ Z! /U ADDRESS C,iS//~~LE.$ F SFfI S, ~ - 7~. CQ C;/ouSt~ ~1~1, /ylP.~ia~~~s6uv~, /Di9~ /7oSS' PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 15056041046 J J 1505604204? REV-1500 EX Decedent's Social Security Number G~D S // • ' /~'/'~ ~~/ ~/ a o y O ,3 S g 9 0 s Name: / Decedent ,l I C, RECAPITULATION 0 ~ '' 1. Real estate (Schedule A) . ............:............................ ... 1. ~ 2. Stocks and Bonds (Schedule B) .................................... ... 2. + ~ ~ 3. Closel Held Cor oration, Partnershi or Sole-Pro rietorshi Schedule C Y P P. P P( ).. 3 ... , d ~ 4. Mortgages 8~ Notes Receivable (Schedule D) .......................... ... 4. ~ ~ ~ 3 «; ~~ 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ..... ... 5. 3 ~ ~ « 3 C/ 6. Jointly Owned Property (Schedule F) C Separate Billing Requested .... ... 6. b 6 0~ 5 7 • ~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. L.f / 3 D (~ ~ I 3 , 8. Total Gross Assets (total Lines 1-7) .................................... 8. S D T ~ S ~p + ~ ~` 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. ~ ~ ~' ~ ~- . ~ 8 10. .. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ........... ...10.' 7 S3 07 11. Total Deductions (total Lines 9 8~ 10) ................................ ... 11. ~ S ~ 3 S. -~ S 12. ........................... Net Value of .Estate (Line 8 minus Line 11) ... 12~ ~ ~ ~ . ~ °Z' / `~ C 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. " ~ ~ ~ ~ ~` ` • 3 ~ 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 .ODD ~ ~ 15. . O ~' 16. Amount of Line 14 taxable at lineal rate X .0 ~~ ~ ~ ~ ~ ~ ~ ~ ~ 16. o~• ~ Q 9 ~ ~. • / CD 17. Amount of Line 14 taxable O ~ 17 • ~ G at sibling rate X .12 . 18. Amount of Line 14 taxable • © ~ 18 • ~ U' at collateral rate X .15 . 19. TAX DUE ...................................................... ... 19. ' _ o~ t q ,g 7 9 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 15056042047 15D56042047 J RSV-1500 EX Page 3 Decedent's Complete Address: File Number q~ /~ w G~~Dl~S /yl. Cam, i2~i~~yy - - - _ STREETADDRESS QIQ/D ~E3 •~T /~~tlT__Ca~~ ~f'T _ Z29 ? /DD__~CNT_- Cl~~~L!/y_ -- CITY /Jo ~x ~~~ /1?~C~.9~,i1//CSl3Ll~'~ ---- - - - - 1 STATE~~ __ ~ ZIP ~?os~' Tax Payments and Credits: ~ 1. Tax Due (Page 2 Line 19) (1) ,Z j , ~ ~7~ 2. CreditsJPayments D A. Spousal Poverty Credit - ----- - - -- B. Prior Payments 1j' p D~ C. Discount ~ ~ ~ ~~ , pD __ __ __-- t - _- -___-_ Total Credits (A + B + C) (2) al , 600. °1D 3. InterestJPenalty if applicable D. Interest ~ E. Penalty p Total Interest/PenaJty (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) D 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~ ~ 7, f A. Enter the interest on the tax due. (5A) 0 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 387, ~~ Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPR OPRIATE 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. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 7 1 28-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 012035 ELENAOR BURKHARDT 6226 CHARING CROSS MECHANICSBURG, PA 17050 ESTATE INFORMATION: ssN: 204-03-5990 FILE NUMBER: 2109-1 102 DECEDENT NAME: GLADYS CARMANY DATE OF PAYMENT: 1 1 /25/2009 POSTMARK DATE: 1 1 /24/2009 COUNTY: CUMBERLAND DATE OF DEATH: 09/03/2009 REMARKS: CHECK# 917 SEAL ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ $20,520.00 TOTAL AMOUNT PAID: INITIALS: DM REV-1 162 EX(11-96) 520,520.00 RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER REV-'1507 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN. RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. REY-1508 EX + (1-9~ SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN RESIDENT D EDENTRN PERSONAL PROPERTY ESTATE OF G,~~ /NON y FILE NUMBER ~! ~~~o ys ~. Indude the proceeds of litigation and the date the pn~ceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~~ Part: a.! Re~und ~~5{,Iwtark, ~~~.e sti.~d 1~`~,,38 .? . ~ecedtn~ was o~ 13 ri r~ q c s ~ ~'nti~ o~ d e4 f ~ , 5~ liar be..~ ~.t-e Sind ~Ar~ ~ nf' Zoo g. ~l~e ka.d -~o ~.~,w~irc1 I~~ r~ no ea s ~ . ~ hQd a bo ~--owed for;st r,~~ , ~~ a mock r~.dto .ccnd ~~u.~{c~ r,.n;ma,l. ~Z,oo ~ececQul.~ ~ // ~..~n ~S1-. ~ ys wera ~o r•~k~ o~ f~ ~r~'cL~cs , ~-n,~, NaTe : ~ceden~ av~ a~ al I -r` , ~ r n i s {-+ ~ MG' 4r ~ b .t~ n_ ~.0• cI . 'L~tC Ga1Cq l' ~ i Uc'~ w • ~iT c~ . i~wr~ -Han o y~ Vor>i o ~ s d ,~'owi ~ i7>le ~ ~'n~c. t~ ~,'1 Stie was r n need Qur~ of 2~ hour ~a re _ TOTAL (Also enter on line 5, Recapitulation) I $ ~ ~,~~ ,3'B (If more space is needed, insert additional sheets of the same size) ~~•00 5 9 3 30 5 7 L ~~' ~:0 6 1 L00 7 90~: 8800 60 9 14 4~~' IGHNV~RK~ ~ BLUE SHIELD M lndepmdent tkensee of the &ue Cross and 8lne Shield Assodafion Keep For Your Records EXPLANATION OF BLUE SHIELD BENEFITS (These Benefits Are In Addition To Your Medicare Part B Benefits) Page: 1 OF 1 PATIENT INFORMATION Date of this Explanation: SEPTEMBER 12 , 2 0 Name of Patient: GLADYS M CARMANY Member ID: 104825202001 Claim Number: 6092530211300 SERVICES WERE PROVIDED BY: ALERT PHARMCAY SRV INC TYPE OF SERVICE DATE (S) MEDICARE BLUE SHIELD (SERVICE CODE) OF SERVICE CHARGE APPROVED APPROVED DURABLE MEDICAL EQUIPMENT 08/20/09 22.50 16.91 16.91 ~~*~~ Total Payment Enclosed 53.38 See Note Note. 1 This amount represents the 20 percent copayrnent for each eligible line. Note 2 Our payment is enclosed. IGHh~RK° If ou have a l BLUE SHIELD ~ Y question, please call 1-800-367-656. wn Independent lkensee otthe 1Nue Cross and Nue Sheld AuodaNon Monday through Friday 8.00 a.tn . to 4.30 n Camp Hill, PA 17089 p' Please have a pen or pencil available to take note For text telephone users, please call 1-800-345-381 (TTY only). If you prefer to write, please send you question to Highmark Blue Shield, P.O. Box 89005 Camp Hiil, PA 17089-0052. ` #BWNDBQH To make changes to your address, please contact you #CO S89517 47 9 7 6213# local Social Security office. Your address shown of GLADYS M CARMANY P 0 BOX 145 •~ this EOB was sent to us directly from your Medicar~ MECHANICSBURG PA 17055 '~ Carrier. Any questions should be directed to th National Social Security Office at 1-800-772-1213 T ~...1, ~ ' ~ ~' ~~ n ~' ~ ' MNP200022 i~ 0001 0001 r'. n" ~~ ~,~~: ,~.. ,~.. ~., r ~~. '~~~~ ~~~ ~t~~rr~i~~~. c;~ ~~~i~r ~~r~~ . Dillsburg 5 Tristan Drive Dillsburg PA 17G?9 Inquiries Call: Acct XXXXXXX441 Eff: 09/18/09 Tlr: 0447 7:I.7-502-9992 Date: 09/18/09 Time: 12:21pm Deposit to CHECKING 11 Prev Sal: Amount: New Bal: Seq: Check Received Authorized by ID Source: ^ Drv Lic ^ SigCard ^ Known ^ Other 1,593.61 (\ ~ USA 33 .38 Q 1,596.99 #497852 Transfer your balances to a Members 1st VISA Credit Card and receive a low 3.99 APR introductory rate! Ask for details. 3.38 GLADYS M CARtdANY oW DEPOSIT TICKET ~ _~~_ oW GLADYS CAR1I~,ANY °~ ELEANQR B ~J T b $ 6226 CHARING CROSS MECHANICSBURG, PA 17050 o ~ ,~ g ~ DATE y '~-~- ~ c3 ~o DEPOSITS MAY NOT BE AYA/LABLE FOR tM EDIATE W[THDRAWAL Qo ai ~ U ~ SIGN MERE fOR CASM RECEIYEO (IF REOUIREO) ~~ o~ ~~ BARB '~ ~ ~x ~~.~ ..~ I~I011i u u p~ ~: 23 i38 2 24 i~: 00ti it,t,t,t, i5e= ®cASH s * LESS CASH RECEIVED ~ .. .~~ ~~ ~ ~ _ .. ~Z ~ ~~v~ u v v vw~~,~ BLUE SHIELD ~,~ M Independent Lk~e°see of fhe Blue Cross and 81uE Sh dsl°'Assocq-lon Keep For Your Records EXPLANATION OF BLUE SHIELD BENEFITS (These Benefits Are In Addition To Your Medicare Part B Benefits) PATIENT INFORMATION Page: 1 OF 1 Date of this Explanation: SEPTEMBER 12, 20~ Name of Patient: GLADYS M CARMANY Member ID: 104825202001 Claim Number: 6092530211300 SERVICES WERE PROVIDED BY: ALERT PHARMCAY SRV INC TYPE OF SERVICE (SERVICE CODE) DATE (S) MEDICARE BLUE SHIELD OF SERVICE CHARGE APPROVED APPROVED DURABLE MEDICAL EQUIPMENT 08/20/09 22.50 16.91 16.91 Total Payment Enclosed *~**~ $3.38 See Note Note. 1 This amount represents the 20 percent copayment for each eligible line. Note 2 Our payment is enclosed. ~~~~~ '~H~v V ~~` ~ If ou have BLUE SH 1 ELD ~ y a uestion ease q , pl call 1-800-367 6565 "''°~"°"""""_°°°'""'~"~°""d ~'"SbM~""~°""'°" Monday through Friday 8:00 a.m. to 4:30 p.m. Camp Hill, PA 17089 Please have a pen or pencil available to take notes. For text telephone users, please call 1_80tI`3g5-3816 (TTY Doty). If you prefer to write, please send your question to Highmark Blue Shield, P.O. Box 8~ 52, Camp Hiil, PA 17089-0852. ` BBWNDBQH To make changes to your address, please contact your tkCOS8951747976213B local GLADYS M CARMANY ~ia1 Secunty office. Your address shown on P 0 BOX 145 ~ .M this EOB was sent to us directly from your Medicare MECHANICSBURG PA 17055 ~~ Carrier. Any questions should be directed to the National Social Security Office at 1-800-772-1213 THIS I S N T MiP2000222 C~ A BILL Oo0~0o0~ REV-1509 EX r (1-9n SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF C,r ~ ~ h1 /~/V y~ ~, L~ y~ ~ FILE NUMBER ~~ ff 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. ,~LF~I/D/i~ ~: /3U/QK,y~4il'D"j" /~f/ /5l/C/CD~Z~/ /lo~-.D .1~/1~~.tG/yT,~ ~ /[lse'3 ~lpG, p•~ / T~ ~' B..7"o A~N/t!~ L . /yl~~~ /S Sot 9 ~'/~1E~,/i¢S P~ T/~/ ~t/EST ,l~,¢l~Gy7~ ,/,YI~C'iS/i9~/!~!C.s.E3u~~, ,pilr /70.SD c. s u 2~ivNF C'. Cp~l.~Y ! 9'a3 Co~/.~ cit~c~' /3ayiVTo~Y /.3~'~e'i',/, ~L 33 y~ 7 'D'~~6y1~ JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar idenfrfying 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., t~ /v/s/gS n1 ¢M bcrs F; r~ l~aftn~l C~~al •~ Gtn ~ on /~e~. ~ J~'p ~. ~D a$~ ~~ ~ G. /8 C N~. 5~'f ~! Y I - D a? ,¢, B, c 3/ic,/~ Me~ba-s ~ i^s~ ~~1err~,/ C!r~ct~f Gcar- ~w~+ A~.c~: ~SS 36~. ~ ~ ~ as ~ ~ x.11 &~,l t 3 No, y~{ yy /- vS , 3. ~iB,C ~/it~ff /1?P~/1e~lers ~/Sf I~i~~~n/ Cr~i1~ k./-ioN ~'. ¢'/~ 799. G6 o?Sfo ~S1~9. `j.Z ~0. ~f~~ /- / / ~. A~, D,C. ~/a/s4 /Ylemlacrs first ~tde~r/ Cwt un;on ,~ Zos 79~f, 4~( ds~ ! ~ / y~~ ~ No. ~ v~/- ~~ , ,D . . , a J.' iq- ~ c ~/Gtfog ~'lernbers #"i',r5~ ~~P.1'arl C,rrd;f union ~: ~/, /6/. ~a c~lo ado. 3S ~n~>~ No, 3a9 53g-~r ~~~ ~ ~~' ~~~/ua J~cn o~afa T~~C+'1 ~rOrN ~ ; I [; p ~rmS Y ~Zoo~ S W Vi ~ nt ~'1Q.Jt~ TOTAL,(Also enter on line 6, Recapitulation) S ~ ~~ a 5 ?- ~$ (If more space is needed, insert additional sheets of the same size) 'i REV-~s~o Ex • ~i-sn COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS ~ MISC. NON-PROBATE PROPERTY ESTATE OF Cf~~~~~Yi ~~~~s ~~ FILE NUMBER ~~.,.. © 9 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENTAND THE DATE OF TRANSFER ATTACH A COPY OF 7HE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IFAPPLICABLE TAXABLE VALUE ~ . ,q,~-EQ/P~c'/SE FiNi9~ve~~4+c ~e~ co u n t /~,~ ~/VF ~i~74,ncia~ /¢C~DU~f; ~' DODU DOOD ~, 36 567 I 10 01' -' -- ~ a6 / 56 36 ~ 038 cr69 ~ off/ . , ~ to 0 o , 1. TranS~r on dtalf !tii lyart~ ~~~ ~ual S~iurrs ~' ~'/panor G, ,akr~har~dt, ..7"oannc ~• II?ardif, ait~ Suzanne C:' ~pru/ey, a/4u9hh~rs ~ ~eeer~~af ,/~~ ~/Y~sD[IiPG'F L, ~{c /5~n~ k; ty, ~~•X c~/ IPG~i'rr- /1tc~tt ffnnHi~y o~c (i~ yr'ar'; -;~ DDOD 0930 fl Zl~, 98,x. 79 I oopa -~ o - flab, 98~. 79 D~39 311 S ~ DD~ puyab/e ,~y ,bux~St.~cry ~Ps,;hahons ~. Meaner (~ ~3urKhar~d t, .T"oanne L • /1~ar,~is, ~ ~ ~z~.~>n~ c . Epp~~y, ~ta~ht~s ~ d~t~t. ~"~d%~, l0/an : iii ~~^csaur>rc ~~~~ ) T. ~.~4 C C ~y/ 963. F~ I oo~o -- o -- ~l, 963.8'S~ . . ,/~nnu,~y, ~a~ /¢~ay~ 3 ~ ~ oa~o , o g3/ oT/7 549 '~i~ pad /~a~ab7e 6t. bP-yIC~iC~4jy ales~~nulio/ts ~ ~/eahor G • ~3unkl~,r,~f , .Tot~nne ~. ~11~tr~•s, a~i~t.d su Za„ne ~ . ,~ p~/~ , a~du9h krs o~ y d ecegltrlt . ~se~ I~alua~'on da~'a Q,~c.heol ob~+u",mil ~roM 'David Lyd„, lo+*al ,~'rnr,~, prise ~?cpr~scnt'- ~~ VG) TOTAL (Also enter on line 7, Recapitulation) S ~30 J~~3 Q ~ (If more space is needed, insert additional sheets of the same size) , 10/19/2009 0 r : 42 September 1 ~_ 209 7174414808 DAVID R,A,~YIw[OND LYON .sr~ ~.~~ 4905 1.OUISE DR MECHANICSBURG, PA 17(155-6y0(1 Dear DAVID RAYMOND .LYON: AMERIPRISE FINANCIAL PAGE 01 We ha~-c rcxei`ed notification of GL,A,DYS M CARMANY's dedth. ThE deceaSCd's name appears on the following accounts_ Accotmt values as o£~9/03/2()09 are listed below. At ~i~e end of this letter. you will find a list of beneficiaries shown in our initial rcvictiv of the accounts Account :fnfortnation Anm~ities -Post 198,'4 Account Numb~r_ Owncrshin 93U11Z.'193615 4 A04 Individual 9310'7175989 4 (104 iRA - t~cneficiaty- designated Arneriprise ONE ~n:tncial .~tceoant Account Number Ownecsh~ Ull(KQ3I;0169 7 U21 Individual - TOD Annuities -Post 1985 Accc-uxtt Number Total Value I30~2393615 4 U(>4 S 126,982.79 ~~ 1A717s9R9 4 a~4 X41_)63.84 Atncriprisc ONE Financis~ .Account Account Nurnbcr Total Value 0C106t)380169 7 U21 $201,567.36 Acd Narne:N~iprlse ONE F1n~r~hl /~ocount C31.AD't's M1 CARMIINY TDO I1ect No~t106a3do1~ 021 ~- .. .. .... -• . ... .. ~. . ...•, . ..: :~,,i - ` ~V E7~LOM ~C11~'ORIOIC~N E7Cfr C~4P 4,91 OD 4S T2 23~,MtiA6 PR/U~ INC PX 5 ~ GP ~~ T6:11 ~ 18.~!~0 ~261,5b738 10/19/20@9 07:42 7174414808 AMER2PRiSE FINaNCiAL PAGE 02 The date of death ~~alues prohidod ar.E [or estate t<~x pucpoScs and are not. 3 val~ac to be paid. Accrn~nts may be s~~bject to rnarkct ^uctvation as governed by each Product. Please note that tl~e valves indicated for act} Life TnsurancE products with the insured deceased reflect tl~e gtos.S death beneRt at date of death and not the cash value. Vah~es indicated for Life Tnsurance products with only ~tlie owner deceased reflect the cash valve as of the date of death_ Values for any proprietary mutual. funds include accrued. dividends as applicable. Values provided for brokerage products arc manually calculated, and should be used. as estimates curly. The prices used to provide values are cstimat~ obtained from outside cowrces believed to be reliable. Ameriprise Financial provides these values as a service to its clients. Actual values used in preparation of tax returns or for planning purposes should be verified try ,your legal and acoouuntit-g advisors. Account Disposition Account disposition is based on how an account is owned (the ownership type). The following information will help you understand tl-e process that will be used to sEt.tle the accounts. Accounts maybe subject to market fluctuation as governed by each product.. Disposition for individoal ow-nerahip Upon the death of the owner and anrroilant, account proceeds typically pass to tl~e named beneficiaries. 1f no beneficiary is named and the contract includes a default bcneftciary- provision the proceeds will be paid according to the beneficiary default language. Ttt all other where no benefciary was designated, the proceeds become paint of the owner's estate for distribution. DEFERRER ANNUITY NOTICE: Tf tl-e ben~ciary{s) wishes to elect an anntrity payment plan we must receive written notice a[ this election within C~() days of our rexipt of complete requirements from any individual t~eneficiary. The conrtract value will nrmain irrv~ted in. the separate account until R~ receive a conrtpleted claim. lif them are multiple beneficiaries, each claim will be processed separately and each beneficiary's share will remain invested in the separ~tc aceaunt until it is claimed. The beaefciaries bear the market risk during this tirnc. Disposition for TRA - beacficiary designated o~wncrship The deceased was the annuitant on at least one annuity account previously listed. Upon the death of the ~-nuitant account proceeds typically pass to the ben~ciaries named at the time af. death. Jf no beneficiary was designated the procxeda become part of the estate for distribution. DEFERRED ANNUTt'Y NOTICE. If the benef~ciary(s) wishes to elect an annuity ~ymcnt plan, we must receive written notice of this cfection within 60 d~ of our receipt of complete requirements from any individual beneficiary The contract vah~c will remain in~elst~ in the scpararc accrnmt urrtil w~c receive a completed claim. TC there arc multiple bencficrancs, each claim processed separately and each beneficiary's share wif.l remain invested in the separate account until it is claimed. The beneficiaries bear tt~e market risk during this time. Dispo9itian for Tndividual -'FOD ownership Upon the death o[ the owner, all accov»ts registered as individuaf transfer on death pass to the named bcncficiarics. Although the assets do not become part of the estate for distribution, we understand they should. be included for inheritance and/or estate tax Aurpos~. [f the brokerage account holds limited partnership or RETT invc.Stments the general partners mtr.~t be contacted directly by tl~e beneficiaries for the transfer of ownership instructions and paperwork. ONE Account Features - Acxvu»t Restricted For Ameriprise ONE Accounts. features are suspended until we have received all requested documents to re-regstEr the accxrunt TF the claimant wc)uld like to continue tre Fcattires and open a new ONE account please complete the Additional Account Features Fornn. (l SU28). Failure to complete this form will result in the remrn~l of features when the account ownership is re-rcgisteced. Required Documents REV-1511 EX+ (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF /yM. n /~~ ww,, //~'~/ y~y^/V- ~`+ /~,/y/~ FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. ,. FUNERAL EXPENSES: /~'la/~e2ti ~untrrcl Nonce o~ /hechaniesbur9 rt /0,~~9,,~7 ~. Honararikrn fo ~s~r Shover, C~m~ Hi I~ L°1~t~r~L~ o~` (>od ~! SO.00 3. ~onorccr-u.rn ~ /~' as~r S~anc~ler, Carn,}~ H-11 ChurcL, of God ~1 S'o~do f/oitm~it,r~ u n~ ~ La a~i ~s ~f u. xi li c ry -- ~-C.~-i~rn, f !1?~al ~l so • o0 S. ~S~iyips, ~,/11~C10,~lCS~ erc •, ~l ,"t3~.lle has ~ar lYkmor~a.l ~erv;c.~ '°'Sb. 00 6. ~e;~r, b ~ rse~e~f' ,4, ~'r,'s Shover, {~,oal ~ar^ ~'rcrera,~ mea.~ ~ao~ . o s 7• 73 looms by ,(/i c,~'rt~ , Ieicnarnl $pra~s, /~rrar,9 ewtet~~t, eta . ~-7~ 5~• Z( B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) (,~~~VE~ Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees ChCt,r"IQS ~ J/jl p~fL~.s ~ (e5 ~~-Ili,~ d r~~ ~S'Q • do 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant /1~ C,N/E ~"L~G/$LE' /~/D/~/F Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees ~loy~l ~tines~k ~.r pr,~p ~ncor~~ ~rA.,c rolurns ~a pC). b0 6. Tax Return Preparer's Fees ~. St, T has C'emrf'ery, ~nzv~ ~tlafcd, e~'. ~~'oD•D~ 1. G~__'~~OtL~at2~I /~./r~'1 ~Q I (~,LL t'wrVy~' fia 1I'aLT'N~ 4S~ -LLa M ~' A'hd. i » P• D. ~bX a.~' ~~1- p~~ !~r 6a.~cwbt,t ~ ~ eSt'a:~2 GG~1M ~ 1'~ 1SPµ~~oh f,~s'. oD lo. 6~e;~n6u~strne~tf r C~~-l,~,s E. Sh;~lals .7r ~,r p1~ol~leo~p;es, pos~.~e, ee~~ he~P rna~l,~,rys, ~r . ~esx~) a~, sr> TOTAL (Also enter on line 9, Recapitulation) $ /~ QB~~ ~,8 (If more space is needed, insert additional sheets of the same size) d"" Y, fi 6 f i v ,' i ' ,' ~. Carlisle Plca 6280 Carlia~a Pike Mechanicsburg 1 17050 - Inquiries G~~=~: 7X7.~69'1~4.432 ~ i Acct ~ G ,~Y . GUYS ~ £ff c a9i~.0`3 `L~;a#~~C Q9~03/09 Tlr: t~675 'Ti;ma: 11:4Y1aat . .,=. Withdrwl~,trcm MODIFY MA~f~1G~NT Q5 ~~ ~evr Ba 1: 53 , 6i4~,,, 21 $er-~ : #3751I5 ____..__ :_,_ D.e ~ 00 - d -500 -• ~ ~ des c ~. . . Cash Qisbu~se Hundre~d~ ~?isbursad •~ ~ 2Q0.00 • Via.,- l~ift~.es Ds>sbur~ad 20.0.00 ~ 's~ . Dy t/ Twenties Disbursed 100.00 /~'~ ~~ .: ~..~~w~~af~~--- ~~/ /T~ Cash Etecs~ived by _, .. ~ ~ v V ~~ ID Source . ~ ~ ~~~IG~~~~~ ~f~~2~ i ^ Drv Lac Y ~ ^ :~~rd ^ Kti+~wn ^ Other Got bills? Dieed cash fast? Signature Loan t3pecial: Rates as low as 8.90 APR with terms up to 60 months! i I GLADYS M CARMA~'Y ~~-~ ... / Track Yaar Expenses.;: ? ~ . b ~ TA ' O98aReM• T 1 ^ rar~sportetlon []Entertaimnent &'Tievel D O X.; EUUCTJ6IE ITEM .- NOT USE + t ^ +~~s i E~ ;~,~cremc cad ~Mi ~~ Fy4 R R E O R D E R I N~ ~$.'f +'..y. f ~ L J'~ePhone "QTakes `ye "~ ^ Dependent Care ' ~ ~ too ~ ' trn ~ ~~ ^ ~ r Q ~_ ~ ~ & tnves ent 17 ; ,. G, - O +~ FoR'D ,?±'~ PAYMENT ~ V ~S~` ,• ~`~ c , k • 1YPe: ~ e~enae _ add detaNs en w,e :I'~'~{~U~CH~8 6 D.~9t{l%BC+t18CICbOX ~ r:~2" ~i, r j/ ~ ~ .b t ~ i~ . Merno •r = .. .:E •. 81 . /ww~Ti,,," r,.7F. 1n, i •r ;~" . _} >" Great Entertaining Order Tracking -Detail ~~~ Er~~ea~~r ~~~~~~ ~r~~c~r~g ~~e~ t')rder # itJ 1457213 Order Date: 09/03/2009 Order Time: 01:57PM Order Origin: Store Payment Type: Store Pick-up Information Pickup Store: #0269 Sched. Pickup Date: 09/05/2009 Sched. Pickup Time:. 09:OOAM Invoice Details Customer Information iris Shover Giant Camp Hill, PA 17011 Phone #: (717) 737-7963 Fax #: Email: crgiant@aholdusa.com PAYMENT DUE Qty Product Department Price Ext. Price 2 Instant Party Tray -GIANT Brand Meats ;Deli (153127) (2647) -Large Tray i $69.99 1 $139.98 1 Veggie Tray (153128) (2643) -Large Tray i Produce $26.99 $26.99 Sub-Total: $166.97 Total Item Qty: 3 Total: $166.9 Page 1 of 1 http://wsl.aholdusa.com/jginet/cfappldata/greatent/tracking/orderdetail.html?order id=10105720 9/3/2009 `'-- , .. 181 'Quc+lity.5election. Savin~s~ Every Day. ' •Visit us on the Internet www.GtantFoodStores.com My coal is to ensure your satisfaction every time you shop with us. If there is anythins ,more I can do to improve sour experience Please call or write. Mike Youne, Store Mannser Giant Food Store #269 3301 Trindle Road Camp Hill, PA 17011 Store Telephone: C?17) T24-1166 Pharmacy Teaephone: 0717) 72~-1170 09/05/09 09:04AM THANK YOU 48003640980 PARTY. TRAY 69.99 F PARTY TRAY 69.99 F RELISH TRAY LG 26.99 F TAX PAID .00 ee**TOTAL 166.9? VF GIFT-CARD 100.00 CARD 1t 6051980921512668 ', PREVIOUS BALANCE: t 100.00 AVAILABLE BALANCE: t .00 ` CASH 66.97 CHANGE .00 TOTAL NUMBER OF ITEMS SOLD = ;; 9/05/09 9:05 AM 0269 50 0002 162 ~**#~* BONUSCARD SAVINGS SUMMARY ~**** 2009 BONUSCARD SWINGS ~~9,96 j **~~~~~ REWARDS POINTS SUMMARY ~~*~~~~ * Earn Redeem Balance Expire GAS 167 0 790 09/19 J,~ NOW EARN AND REDEEM ~ GAS EXTRA REWARDS EVERY WEEK.! GAS EXTRA REWARDS POINTS EARNED TODAY WILL EXPIRE 9!19/09. START EARNING NEW GAS POINTS WHEN THE NEXT PROMOTION BEGINS 9/10/09. 100 POINTS= $0.10 PER GALLON DISCOUNT YOU HAVE EARNED A DISCOUNT OF 1`gl Qu,tiility~5election'Sclrvin~,}s.~Every Day. Visit us on the Internet www.GiantFoodStores:com My coal is to ensure your satisfaction every time you shop with us. If there is anythins Wore I can do to improve your experience .please call or write. Mike Youns, Sfore Manager Gi,an~ Food .-Store it269 ..3301 7rindle'Road CifAp Hill, PR 17011 Store Telephone: f71?) 724-1166 Pharmacy Telephone: (717) ?24-1170 09/03/09 2:13PM THANK YOU 48003640980 ~ 2 @ 2.39 MTOLV CHIPS 24Z BC 4.78 F 2 `~ . z0 SC BONUSBUY SAVINGS .40-F Price for 2 4.38 MARTINS CHIPS BC 7.99 F SC BONUSBUY SAVINGS .40-F Price you Pay 7.59 3 @ 1.27 GNT FORKS 24CT 3,81 T ' 1.6$ !b @ 1.49 /lb EASTERN PEACHES W BC 2.50 F 1.68 lb @ .99 11b = 1.66 SC BONUSBUY SAVINGS .84-F Price you Pay 1.66 IN7,,';L DELIGHTI6 BC 1 .69 F 5C BONUSBUY SAVINGS .70-F Price you pay .99 SWSS PCH TEA128Z _ 9.00 F i { TOTAL BEFORE SAVINGS 29.77 'YOUR TOTAL SRUINGS 2.39 TOTAL AFTER SAVINGS.;: 27.43 TAX PAID . Z`3 aee*TOTAL 2~~(~~G ., x:27.66 CASH ~ 5-~ 30.00 ".CHAN'GE ~' „ 2.34 .2 ~" ~ ~ TOTAL N-UMBER OF ITEMS SQLD = 12 '9/43/0.9 215 PM .0269., 07 91.44 293 ~***~* BORUSCARD SAVINGS SUMMARY ****~: BONUSCARD SAVINGS 2,34 TOTAL SAVINGS 2.34 2009 BONUSCARD SAVINGS 629.96 ****~'** REWARDS POINTS SUMMARY ~*~*~:** * Earn Redeem $alance Expire ~ GAS 27 0 623 09/19 C NOW EARN AND REDEEM ~ cac :FXTRA__REWARDS EVERY WEEK E ~0~ ~~~s~a ~~A - . ~, s` .. _ _:::_ ~N~st Sh~r~3 Pic`~~c7 '~ C~ P E f~l 7 [~ cd y s .~ tic- •. A Vir`U~k .t •~. h o ? cr rr~ - 1 C~ ~-..~ rY-~ fi Q O KARNS CARES WITN 1 FOR THE Si;i-IGOLS TOM MALESIC STORE MANAGER 763-0165 GARY BARNA MEAT MANAGER 763-0173 0004 07 07393479 09/03/09 2:38pm 453 19 PF LAYER CAKE $1.74 F (EVERYBODY SAVES $1.75> 19 PF LAYER CAKE $1.74 F (EVERYBODY SAVES $1.75> ~ 19 PF LAYER CAKE $1.74 F (EVERYBODY SAVES $1.75) * 19 PF LAYER CAKE $1.74 F (EVERYBODY SAVES $1.75) ~ 19 PF LAYER CAKE $1.74 F (EVERYBODY SAVE5 $1.75? 19 PF LAYER CAKE $1.74 F (EVERYBODY SAVES $1.75? 19 PF LAYER CAKE $1.74 F (EVERYBODY SAVES $1.75> * 19 PF LAYER CAKE $1.74 F (EVERYBODY SAVES $1.75> SUBTOTAL $13.92 TOTAL $13.92 CASH $20.00 CHANGE $6.08 FRESH REWARDS # 041617920528 ~~~k~~~C~C~~~C~~~~~~~C~~~C~K~~~~(X~f ~~C ~ VOU SAVED: $14.00 ~ # OF ITEMS: 8 REG 7 ~~* UI5IT OUR NEW WEBSITE AND VIEW OUR. WEEKLY ADt www.KARNSFOODS.coM~X~ ~I~~DYS CP.-I~MANY 6~;r5?2;l2373 -~ /' s f e 1 ~~w 912 ~- ~ DOLLARS ~ *~ ~ Oven cn ars. ~~ • L~i~ l~i~.:Zt7 it v-Yti .2C..te:..: E..^~ i ~:~3~3~~~~~~; 004L~~.4~.Z5~~' 0912 "1` 2Z` ~\e~~ ~ I°~ ~L 8 Market Plaza Way (717) 697-4696 Mechanicsburg, PA 17055 www.mal ezzifuneralhome.com Jeremy J. Shartzer, FD Michael J. Malpezzi, Owner, FD Kyle C. Knipe, FD September 25,~ 2009 Eleanor G. Burkhardt 141 Hickory Road Dillsburg, PA 17019 The Funeral Service for Gladys M. Carmany We sincerely appreciate the confidence you have placed in us and will continue to assist you in .every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES Services of Funeral Director/Staff $4275.00 3. AUTOMOTIVE EQUIPMENT Limousine $335.00 FUNERAL HOME SERVICE CHARGES ~ $4610.00 SELECTED MERCHANDISE: Golden Sand Guardian Burial Vault $3840.00 Register Package $990.00 THE COST OF OUR SERVICES, EQUIPMENT AND MERCHANDISE THAT YOU HAVE $95.00 , SELECTED $9535.00 AT THE TIME FUNERAL t~-RRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. CASH ADVANCES Cemetery Equipment Certified Death Certificates $190.00 Newspaper Notices -Patriot $90.00 Monument Engraving $224.67 TOTAL CASH ADVANCES AND SPECIAL CHARGES $150.00 $654.67 SUB-TOTAL $10189.67 INITIAL PAYMENT /DISCOUNT /CREDITS _ _ _ _ _ _ TOTAL AMOUNT DUE $10189.67 Malpezzi Funeral Home ~~~. t . ~ .rrRa~.r,. ~.r~.r?urr u~~ Dillsburg 5 Tristan Drive Dillsburg PA 17019 Inquiries Call: Acct ){}{}{}{}{){}{441 Eff: 10/01/09 Tlr: 1712 717-502-9992 CARMADIY, ~LADYS M Date; 10/01/09 Tiros: 4:13pm Withdrwl from Prev Bal: Amount: New Bal: Seq: Deposit to CI Prev Bal: Amount: New Bal: Seq: Withdrwl from Prev Bal: Amount: New Bal: Seq: Deposit to CH Prev Sal: Amount: New Bal: Seq: REGULAR SAVINGS 00 3,485.50 3,400.00 85 .50 #964361 ~CKING 11 720.55 3,400.00 4,120.55 #964362 MONEY MANAGEMENT 05 53,901.69 6,200.00 47,701.69 #964363 CKING 11 4,120.55 6,200.00 10,320.55 #964364 Authorized by ID Source: ^ Drv Lic ^ SigCard ^ Known ® Other Transfer your balances to a Members 1st VISA Credit Card and receive a low 3.99 APR introductory rate! Ask for details. ~ ~ ~~ ~u~~~a~ ~~• l~ GLADYS M CARMANY d ~r i ~' a ~~ ~~` a O ici Z 3i,~ c ~ ~ ~ ~ .~ ~ ~ cn ^ ~ ` ^ ~ .~ X m ~i -v v ~ -a cv ~ .a m U ~ m s ~.. ~ L o c6 p ~._ ~ ~ ~ ~ ~ a ~ a~ 'Q y ~ .. ~ p ~ ~ a ~ - = c ~ `~" p 'D X ~ ~ V ~ ~ ~ m N ~ .~ L ~ .3 ~ ~ ~ w w`` ~ ~' ~ O W OO W W iJ W ~ A 1~ d 0 V.. O m O ~. N 7 m N M U O Z ~; ~~ ~ ~., ~ ~ ~. ,; ~ ~' C° ~ ~~ ~ ~i ~ ~ `~ ~ ~' ~ ~~ U ~~ ~ ~ W `~ ~ ~ Q -~` a- 0 r. i1~. ,~ J ~` }.~ l ~ a r N I -a ;: X ~ J ~ ~ o ~~ ° ~. '' ~ ~~ v~ ~ ~ ~ ~ ..~ e9 ~ ~ ~ ~ i~ w~ ~ ru i U ~ ~ w "! .~ ~~~ c0 U O ,~ y ~ ~ Z Zd O~ ~ p ~ '' Q ~ x ~, a~ ~ W ,~ a'~ 31wa~dno no ia~xM 3xmaa a .~~,.~, 9:: •~ ! .. } .., `~ • .. REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF C ~~/~~~Ily GL/~ ys ~' FILE NUMBER a?/ - Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. +;a ~~ Y t ~ ~ , . ~.a / / ~Zo6~ ~+d paw,- ~ ~~ G~ • ~ ,.~, 0 914 f` ~- 7 y 8 ~~ .~ st ~: 2 3 138 2 24 i~: 004 14444 1 5 ' 09 L4 GLADYS so-a~a~~,s Ei.EANOR BIJRIQ~ARDT ooa~4aaas ~ R3oX ~4J- MECHAIVICSBURG, PA d 7d3 ~- nn~ ~"'~ ~"'a~ }. ...... WSEMS -Chambersburq ALS/BLS - - 205 GRANDVlEW AVE f;~=-~~ ~~~ SUITE 211 ~~~~_~ CAMP HILL, PA 17011 ~~~r=` Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 _ ~ - :. ,~_ PATIENT NAME: GLADYS CARMANY PATIENT NUMBER: 82714 " CDIS CALL NUMBER: 190585W NONE INSURANCE: PALMETTO GBA WA203i00383 DATE OF CALL: 06/17/2009 HIGHMARK ZAL104825202001 B TIME of caLL: 01:16 PM CALLER: HOLY SPIRIT HOSPITAL 190585W ~°M= HOLY SPIRIT HOSPITAL TO: BRIDGES AT BENT CREEK GLADYS CARMANY P O BOX 145 REASON(S) Hypertension '~ .. MECHANICSBURG, PA 17055 FOR TRANSPORT -. °..';, _ .~. ~-~ "~~~ 1!V VOICf' ti - F::~ DESCRIPTION OF CHARGE QUANTITY UNIT PR ~ . jam.. ~ OUNT Transport Van Mileage A0999 8.0 ~_ 3 74" y`~P Wheelchair One Way -Member A0999 1 0 . ... ~ ~ 29.92 ~ ~ x. . ~. ~ 46,52 ,V 46.52 _: ~~ ~ 33, .dn`3 ~ u t ~ " i~.~ .~ti. ~ i _ f C - '... .. '~'`~:W .y. ..y x.4u' ~.l.. ^~. !y~ y: J~_ L~ ~ ~~~ _ .~.: ~~ .. Totai Ch 76.44 DESCRIPTION OF ~ RECEIPT .PAYMENT DATE AMOUNT PLEAS .,; , AY THIS AI~10[~NT ; II~#VOICE DICE I.tPON RECEIPT --~- a'T6.44 ~;,.z_G t~ETI~RI'~IED CHECK PEA - ~3#=00 ~~=` ~, __ ....._ DETACH ai:ONG~ PERFORMATION AND RETURN STUB WITH PAYMENT - - AMOUNT DUf~ 76:44 PATIENT NAME; C~4RMANY, GLADYS I+it -CALL. NUMBER 190rJ85W AMOUNT $ . . PATIENT NU1VfI3ERi 82714 - BIL~:lNG. DATE: 09h4l2009 ENCLQSEb ^~7~0. y ~! . aND MASTER CARD ACCEPTED WSEMS -Chambersburq ALSlBLS 205 GRANDVIEW AVE CAMP HILL, PA 17011 REV-1'513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER o2/ .~ C~i2~~vY, GL~OYS /l1. NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)) 1. ~G~i~NOR G- ~uIZXH~ipt~T ~R-~ldNl~ y3 /~/ N/CKd/!y /~0~4D 'D t i~ 4 N R G, p~- /70lR ~. .~-D/FNNE' L. /1//~/~L~IS ~/}ll6f/T~,7Q 73 .SD 2 g ~/slE~~9S PiS~ Tiy G/JE~ T /I~E'C~.4ivr~S,t~~~G, P~ ~7oso 3, Su Z~4NNF' C'. E~i~LES/ 1~uGiSIT~7'? y3 6 Qo3 ~o,~~.¢ ~i~~cE ~oY~vTO~-/ ,~4~~5/, ~"c 3 3 ~ 3 7 ~~NFD /Ydr'~: ~ 7h~iI~EF .~i¢~IGHT~S ~'~ ~~T ~~ s~a~~.~c ~'~~t/n~r~~~,Ts ~ ~ T~ir~ 3 AF T~F L~sT' cv~« ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. 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) LAST WILL AND TESTAMENT ' OF GLADYS M. CARMANY , I, GLADYS M. CARMANY, of 6226 Charing Cross, Mechanicsburg, Hampden Township, Cumberland County, Pennsylvania, revoke any prior Wills and Codicils and declare this to be my Will. ITEM 1. (a) I give my household and personal effects and other tangible personalty of like nature in as nearly equal shares as practical to my children, ELEANOR G. BURKHARDT, SUZANNE C. EPPLEY, and JOANNE L. MARDIS, subject to the survival provisions of this Will. I direct that my Executrices take into account the wishes I have expressed in making distribution of my household and personal effects and other tangible personalty. ITEM 2. I give all the rest, residue, and remainder of my estate in equal shares to my children, ELEANOR G. BURKHARDT, SUZANNE C. EPPLEY,-and JOANNE L. NjARDIS, subject to the survival provisions of this Will. ITEM 3. If any of my children is not living on the thirty-first day after my death, I give that child's share to that child's issue per stirpes who survive me by thirty days, but if no issue survive me by thirty days, that child's share shall lapse and be divided among my other heirs as they take portions of my estate. Document #: 208493.1 ITEM 4. I note that at the time of the writing of this Will, my daughter, JOANNE L. MARDIS, owes me the sum of $7,193.30. If and to the extent that she has not paid this debt in full by the time of my death, her share of my estate,'or the share of her issue per stirpes if she does not survive me by thirty days, shall be diminished by any outstanding amount. of this obligation. ITEM 5. I direct that all my just debts and the expenses of my illness and burial, including my grave marker, shall be paid from my residuary estate as soon as practicable after my death as part of the expense of the administration of my estate. ITEM 6. In addition to the powers granted by law or by other parts of this Will, my Executors shall have the following powers: (a) To retain any and all assets of my estate, real, personal, or mixed, without regard to any principle of diversification, risk, or productivity, except as may be otherwise expressly provided herein; (b) To sell at public or private sale, to exchange, to lease, to pledge, to mortgage, to transfer, to convert, or otherwise dispose of, and to grant options with respect to, any and all property, real, personal, or mixed, at any time forming part of my estate or trust estate in such manner, at such time or times, for such purposes, for such price or prices and upon such terms, credits, and conditions as may be deemed advisable; (c) To invest and reinvest the trust property in stocks, bonds, mortgages, notes, insurance policies, annuities, common trust fund participation, or other Document #: 208493.1 property of any kind, .real, personal, or mixed, irrespective of any .statute, case, rule, or • custom Limiting the investment of trust funds, except as expressly provided otherwise herein; (d) To settle, compromise, contest, prosecute, or abandon claims in favor of or against my estate or any trust as may be deemed advisable; (e) To allocate .receipts and disbursements to principal or income or partly to both and to ascertain principal or income in accordance with the laws of the Commonwealth of Pennsylvania; (f) To make distribution or division of the trust or estate in cash, in kind, or partly in both, to postpone distribution by agreement with a beneficiary and to distribute articles of tangible property to a minor or to any person to hold for a minor within the limits authorized by statute or rule of law; and (g) To exercise any law-given option to treat administration expenses either as income tax or estate tax deductions, without regard to whether the. expenses were paid from principal or income, and without requiring reimbursement. ITEM 7. No bond shall be required by my Executrices, but if bond is nevertheless required, it shall be without surety. ITEM 8. I appoint my children, ELEANOR G. BURKHARDT, SUZANNE C. EPPLEY, and JOANNE L. MARDIS, Executrices. Document #: 208493.1 ITEM 9. For the. convenience of my Executrices, I note that this Will has been prepared by Jered L. Hock, Esquire, and the firm of Metzger, Wickersham, Knauss & Erb, P.C., Harrisburg and Mechanicsburg, Pennsylvania. Executed this ~ day of _ 2002. P ~d/ E'C ~ G~i~ Gladys M. C any Signed, sealed, and published and declared by the above-named Testatrix, GLADYS M. CARMANY, as and for her Last Will and Testament, in the presence of us, who, at her request, in her sight and presence, and in the sight and presence of each other, have hereunto subscribed our names as witnesses. Address Address ~~.~~~,_ ~ r' ` Document #: 208493.1 Commonwealth of Pennsylvania Cot}nty of ~~P~~~ ~ ss We, GLADYS M. C1~~lZMANY, and ~ ~~'~rco~ L, . ~ c-~-. ,and /-~r~~ (~ r1~1 ~ h'll l lP r~ ,the Testatrix and the witnesses, respectively, whose names are signed to the attached or 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 (or willingly directed another to sign for her), and that she. executed it as her -free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witness and that to the best of our knowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. .~ Testa ' Witness Wi ss SWORN tQ or affirmed and acknowledged before me by the above named Testatrix and witnesses this ~+~( day of ~u ~ +~ 2002. ~~~~~ Notary Public My Commission Expires: (SEAL) NOTAR{AL SEAL CAROL A. LYTER, Notary Public City of Harrisburg, Dauphin County My Commission Expires Dec. 28, 2004 Document #: 208493.1