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07-15-10
i 1,5D561,01,D1, ~ V ~~ ~ ^ /~ ~` / - ~ RE OFFICIAL USE ONLY P~ Departr,~~~nt of R_•,~nue Pennsylvania - _ ~ ~ ..~ r ~~',i~ ,u a "..:^7ba, B.ireau or' IrJi•r idea: Taxes P~ RO>, z8o6o1 INHERITANCE TAX RETURN !! ~ I ~ (~ ~ a ` ` Harrisburq. PA. i7~28-oboe RESIDENT DECEDENT a ( 6 ~ 1 ENTER DECEDENT INFORMATION BELOW S~;lai S°~.Gri' V'~ir?~`~•r Date Ci D~~i'1 rr.• __ '~~~ Dae 1f 3lftil ~ 'x.- 197-22-6710 12/26/2009 02/19/1929 DeccCe~ .s ! as'. ~~:a„-,~ Suf~~x D~~ecenf 5 First NaR".., P:11 Maughan Marilyn R (If Applicable) Enter Surviving Spouse's Information Below Spouse s ~ast 'Jc^'.e Suffr: Spcus;'s First Narnv Pr11 ~..,,~;.:sr s Sochi Ses,,n:;, N::rMber THIS RETURN MU5T BE FLED (N DUPLICATE WITH THE REGISTER OF WILLS FILL I N APPROPRIATE OVALS BELOW C!~ Orinir~~l Rat_.m O L. JUJ~iI~f,~antal R~:urn O 3 R~r~aind:~r Return (sate or death prior to ' 2-' 3-3" Q Lim-,;,... state O 4a. Futuna irlterast Cc~~romi~e {uat o` O ~ =~dera' Estate Tax Return Recuired Beath of~r . ~-^ ~-3% ~] ~~. ueu„den; Diet estate O De::a~~nt ,lain' :rya _. L!.~in, 'n..st 'ur~de " ~~a`~ '~epr;sit Bcxas ~a ~ Taal r~ r cr i ~.t.as . C~ :;f t!: i,l; ;attach CctiY of Tr ~_;sti O ~; ~~ ^~ .,.. L it gate n Prc.. ~evs Re;,~l,.,-~ O ~•. re -, ~~, ,:r Sec. -~.,3 ~) "J..,pousai P,;ert;~ C dit ._cUte ~~` aath O Election tc pax 7a:;r (: .. :qt'r': 1:e'.n ?L-.. I-`~i, Ui~'J I-~-.~i5! ~.. f'itt'3l.ll vrh. C,1 CORRESPONDENT - THIS SECTION ~~tUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD 13 E. DIRECTED T0: NGme Daytime TElephon~ Number George R. Maughan (812) 219-9881 REGISTF~ OF WILLS U ONLY C J ,- ~ = ~ "` First Ilt'io C` a:;ur~SS ~ ~ ~ ° I ~ ~.,,i ~ ~ i':3 7880 N Stinesville Rd - - x I ~ r _~ ~ 1 t_.:+ ~ ~ .._ ~ -~- ~ i _ ~ r. Cit cr Pcsi G"ic~ State ZIP Code ~ ,,, ~~~ ~ Gosport I N 47433 ~ Correspondent's e-mail address: gmaughan@Indstate.edU ~.I` ..., .-. u _... .. .=t' ~~" :C':,~~~i"., t"•_:l I u'. .. EX« 1'i'.~ i .. .'}..1, (1 I~..., _~.. ~,_.,i".:: c] .r: S:, ., _,Ji.: ., a.'ld ~~u;~f'~C..~ .., _ '~:y ~.~ F. ....~ S, ., r. v.r: ~'1 .: (, ~t r'~~~ vc~IC `. !~ :i2. ~~ v~r :r.~ ~.. 'I.,.~. :JC~.I.7~allri=l Gt'EN ,r~l ~i .. •f'.fl I`1~ 'SUn3~ y. ~a°~ .... ,.. IS UaS~~:~ C1 8il I^`C"7'.ct`~'. ^,` .. 3., wre.;or,., f'.aS a" ~:~ O.:Icu~~~. S~G~;' ARE= C~ PERSON RESP r<'IEL.Ey.~Jf3,FILlt•,G RE`URt`.' ~ C<~. _ ==.D~RE~c v 8~ v~ ~ re /~- ~ ss orT ~~ '~ 3 3 SIGI~:h~URP fir. PREP~.RER OT'-iER T•~{~.~; ~EpRESttv'-;'-.Tl'•JE ~F,~ -.CDri'=emu PLEASE USE ORIGINAL FORM ONLY „/L 1,50561,0101, Side 1 1,50561,01,01, `b J 1,50561,01,5 RE1-1 BOG EX Dec~Gent s Social ~~~;,urity Number c~~::~~~~~~: ~ r:a~-:: Marilyn R Maughan 197-22-6710 RECAPITULATION ~. St.,~KS ~,nd Ba,.,,vs (Schecule B : ...................................... . ~.. CI~JeI; r!~i',., ... `.'rl~'.^. ra :. ~: r. Parts ~~~r~N Gr SQI G'IJ r~prlC t~i~sl~'p t~:,ne'.. u... L~ ~. a. r'/~vri :'?~&5 anc ``~G[eS ~',eCc~'~'cabiE ,Crrl°:;l~lc (JJ . ~. Cass. Bank G°p~~i'S ar,, ~~:'isceil ne e-..~n_ P .-,erF„ ~:S hed~:i~ B;....... ~ 926.39 a ous P -a rGN ,, . c ,.. Jointly O~~r,r~ec Prcpertrt ,Schedsie F) ©Sep~rate Rillina P,e~_,uestea ....... .,. 2,31$.72 inter-'.%ivGS Tans ers & l:iisc~iian~ou.. NGr!-Prcba`e Proper.;, ~S'~hcduie Gi O Separate Biilin~ Requeste~u........ 7 65,652.05 8. Total Gross Assets (total Lines 1 through 7; ............................. 8. 68,897.16 9. F~:neral Expensss and ~.rn-!inistra,i•:re Cosa iScheaula Hi ... y. 16,595.94 1~. uebts cf De.edCnt, i,largags Lia~:litias. any Liens !Schecr.la I) ........ .. ... ". G. 1,764.76 1'. Total Deductions ;tota. Lines a ~,r!d 1Oi ........................... ..... 11. 18,360.70 12. Net Value of Estate;Lire 8 min"s Line i1 ~ ........................ ...... 12. 50,536.46 13. Cha~itabVe anc ~o:~ernn-~antal Ee;..uesa.~Sec °.13 Trusts for ~~.~hi.,~. c.n clc~.'Gn .., '.at: has (lGt ~Een mace lSCheG~i° Jl ... . . . . . . . . . .. . . . . . . . . i~. ~. Net Value Subject to Tax ~ Line 12 mn!;s Line ? 3 ............ .. ? 4. 50,536.46 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. ~mGl:nt Ci Lira "!. -t taXB:alc at t'~E Sj:G'.~5o' .aY. rate. cr Van~`2r; _,nc~r SY ~11~ _ !e'~ ~ } x~ o s-,~$~ 0.00 i t~ 1 at ~~nea~ rtr:~~ x .~`~ 50,536.46 1 1? Amon; c~` Line 1-+ taxabis; at siblinC r tG ): 1 L ~. Ar,:ount Gf i i".. i V taxable at COilaefai r~„_, ~~ 1 ~ 1 h. 1 ~. TAX DUE ......................................................... 1 ~. ~_-. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1~5~561,~1,05 Side 2 1~50561,~1,CI5 0.00 2, 274.14 2,274.14 0 J ,._.-.~...-. E.~ Decedent's Complete Address: File Number Tax Payments and Credits: TaX D,,., ;Faye L...:.~; ' ~~~ v- D ,mentJ ~. E:. ,_ ~ a'~, . ~ ,-. ~ ; n, ,;, 'j, ~I'~~OJr!` ... 'nic ~~t if ~ ne % sate , ., I _.., 1 ~ ~~,~ ., .,etc ~e ~ rte~en~~ ~, ~ ~ the OVERPAYMENT, Fiii in oval on Page 2, Line 20 to request a refund. ~. ii L~:ne ~ .. i >ne „ Qrc~..," i'-in i „ L °"ate' ,... :'lie"enG., T"'... .. t^., TAX dUE. TCI ('re.Ji iS , ~, ~ i (~i ,: ~~! ,~i ~~I Make check payable to: REGISTER OF WILLS, AGENT, 2,274.14 0.00 0.00 0.00 2,274.14 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS ~. '1'd Oe'~e~c'i: "~~~ ~ tranSfe tine. TES tiC ~ ,.~i1 t~'c J,:., G"n:;0^'~ Of i~"!., :.rvp~ri}' tr'u;ISf.°,:' ,,~~! . ........................................................................ ........... ~~ ~x/~ rpr FZ r~-. Y~f `,. ~~ I O r. r~np~ yr r'R`p' I I ,`J ., ~aln t. ., ~y ~ t~ ~., ~'l.~t.. ..Cv ~nc1 JS ,, ., tj' t~ariSl ~d or io' i'lw ......... ............ ......... ... ~. '~. .~+?I'. ~ ~c~. GiJ~Qr'd ntereJt v~ ........ .......... ..................... .................... .......... ........... ..................... ....... i '~X~ ~. ~~e : G +i - ~'rJr'~~SG tJr ~:le of '.tr',~r /G;1 Mont.,, ,",ier'IGfit.", o~~ ~.d~ ~ ... .. .................... ................................ .. ..... i ~' x ! 'F n ,.~„-.. ii r ~. 1 ~`a~ ^''~ f;e'."r~ nC(,~r -lrv~,-rf~; nl: i e ~ .^~~ ''1 ~. ~~ de4t '~.,_., Feu ane sac _ ~ :, ~.~ent tra ~., ., ~~ ,. . t. n ~~ gar of . ~at _ _ ..',t"~Jt ...,... n"y %0„~Jai....OnSI:~.~i:"at0"~~ ................................... ..........,. ......,........,..................... .. )C. _i ~. 1 ~ de_~~e !. _.:n nn i~ t~'u~t fn.,r G' n;'s,a:;`•e-JUC^.-~BdI^ ,:~'lK d~~uU' t ~ Sc,,,. !' ~t ^;., C~ ~' Cea'lh? ......... _, 'X 1:d ~cC:;d~ ~. _ '+n d'~I I`ldl`~ ~Ja, cI'rc;;ie~~t aCCO'J ~. ?"1'''J't'ti' Or Ctner'1Gn ~v~t~ie ~',~., i. ., ..,~ C li fit.. .,,, d ~.).. 1., 1', ..i7, '.iE~y:i~i~U1~ ........ .......... ............. ........................... .............. .J............... ..... .,.... .. _~~,X~ 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 JI~~IJ' ". i994. and be`~re Jan. 1, 1995. the tax ra,e impc~sec on n~ net ~~,-alue o trans ars :o or for `he use o he sur~~i~~ing spouse is ,-,,, ~~~erCent r~P. .~9`1~(a!(1.11'. ~Or dates pi ueatn On Or allot .air. 1, 19G5. :". taX. r8te !mpOSed On he ne. ~'~'oiUe Of trcnSierS t0 Or for the USe Oi the SUrti~iVing apOUSe IS ~' ~efC=C ~7% P.S. ~9,~C !;al X1.1 i il?;,. The statute cos.. not exempt a transfer to a sur;~i!fir;g spouse ?,ol, ax. and ,l~~e stautor;- requirements for disclosure of asses a!id Ind a taX reiUrn ar„ vtill ~~;pi'CaC'i~ ,,,,,n 'f he ~Ur'~r ,Ing SpOUSe iS he OnIV ber'~eilClai,~ 'vr dates Cf deal, On or a%er ~ l~,i~~.' 1. 2~~~': • The tax ra';e Im~OSed On the net ,'a`U8 C~ ,ranSferS irOm a deceased Child L1 ;Bars 0' ace Or '~OUnger at death t0 Or fGr the Use of a rl t f I a a U a par~n; a . adopti~e parent or a stepp~ren: cf he child is ~~ percent .'72 P.S. ~9116ia)i 1.2;]. Tne to 1 rase imposed on he net ~r~alue of transfers to or for he use of the decedent s pineal beneficiaries is 4.5 uercent. except as noeu in 72 P.S. ~9'1b!;1.2 i~72 P.S. ~~1116!a!(1;]. The tax rate imposed on the net ~~;~alue of transfers to or for the use cf the dececent~s siblings is 12 percent [72 P.S. ~9116(a)(1,31], A sibling is del+ned. under Section 9102, as an individual ~.vho has a leas: one parent in common ~,a~ith the decedent, :vhether by blood cr adoption. R~'~.- =~~~ EX- -..~ ~~~ ~~ ;w. C~~F4t~"O'~~`:':'~f,LTH QF ~E~JNSYL`dANIA ~Nr-~~~r~,NC~ ~.ax K~T~.~N ~~S:G~N?G~~FDcNT SCHEDULE E CASH, BANK DEPC)SITS, & MISC. PERSONA!. PROPERTY ESTATE OF FILE NUMBER Marilyn Maughan 2010-00049 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ~ ~~ ~ ~ ~~~ ~ ~ru~~ ~~ i iccucu. n i~ci t auoniun2i meets or the same size) REV-~5og ~X- (oi-io) -_-i, pennsylvania IN~EkIT:;NC"c T~:X R~ UktJ RESIDENT DECEDEh SCHEDULE F ]OINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: Marilyn Maughan 2010-00049 ]OINTLY OWNED PROPERTY: n,,^ ER __ ~ _R CR Joel\T ENS.^i" ~ ~ ~ DESCRIPTION OF PROPERTY ^ ~E i t •1.. ,DE t nt C' i~Hivi C:n (_ h~T;'~ TiOiJ nt' Cni'K r+CCo~~J~ J^ _" C.R _. L-R :Ciir~ I l.,_rv Yitv'v tiUh16~i..+``AC-~ E_EC .^~R ),`,It; _1 ~ R L _:i~'= ~ ~:T~ Qr ~En~,, \~AL'J~ 0 E~- ~ CF i'1 -~)EtJT~S ~t~?"cR_5' SATE Or DE4T4 Un~ lJE o' DtCEDEhT'E INTEREST 1. i A. 04,'03108 i F&M Trust. Account Number 35-43242 i i i I ~, I I I I I 4,637.43 50 2.318.72 ~ I I i I I I TOTAL (Also enter on Line 6, Recapitulation) $ 2.318.72 If more space is needed, use additional sheets of paper of the same size, If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. ~'~ lvania SCHEDULE G pennsy- - ~~- -~~-_ INTER-VIVOS TRANSFERS AND - ~~-~ - - ~ MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBED Marilyn Maughan 201 G_00049 : . ..._ . .. ~ - - - - , -~~~- Or .T YT. ~ _ _ ~~. - -. Nancy G. wlessich. Daughter, 4117!2009, F&M Trust No. 014-2993650 ~ 33,294.00 ; 50 3,OOG.0O 2- ~~' '~:~~~ Nancy G. Messich, Daughter. 4!17!2009. F&M Trust, No. 71-49921 i 84 13 120 50 i "3 2 , , . I Nancy G. Messich, Daughter, 4/17/2009, F&M Trust, No. 014-299481 i 231 21 j 25 50 25 ~3 3 . . j i I 65.652.05 TOTAL ;,=!5~ ent~. on Li ~` %, P,ecapi~uia~ un S pennsylvania - --L~,`~ SCHEDULE M FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ----_ ESTATE QF FILE NUMBEI~ Marilyn Maughan 2010-00049 Decedent's debts must be reported on Schedule I. Beatty-Rich Funeral Home, Inc. -Funeral 2 ~ Tombstone Engraving i • _ . - .., - -" ~.~~-_ ~,~- :~,~~ Geor e aug an - ~-•~=- =~~~~-~__ 7880 N Stinesville Rd - -, Gosport ~-~~` IN ~~ 47433 i ~ - -~- ~-~ NA ,v v ~, ~ ~ : Nancy rdl e ss i ch -- --- ---- ------------ ~. -.~~r__, 102 Independence Drive `;, Shippensbur ---- _ _ :-~ PA ~~ 1.725_ ___ .- - -- g- -.._. ,_ ~ _ _ , .._~ _ r- ~ _~ ; - - ~-- au .ter -. --- -- - i _ _ .- George Maughan -Postage and Thank You Notes George Maughan -Executor Expenses/Travel Costs Cumberland Valley Legal Journal -Advertising the Estate Notice THe Sentinel -Advertising the Estate Notice 9.036.00 800.00 1.000.00 3.500.00 198.50 20.00 1,232.00 75.00 134.44 -~--_--_ - ~ ~ 10 , 5 9 5.94 TOTAL ~,~. ~o ,.ntcr cn Line °, Recap+tuia~~s ~ ( S „-i ~ pennsy[vania SCHEDULE I DEBTS QF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Marilyn Maughan 2010-00049 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. _ ,. ._vC .~I iJhT~ -- ~: ~~ ~ ~"'J~^ ~ y~ 1 ;Pinnacle Health Hospital ' 4"8 00 2 Chambersburg Hospital 3 ! Preffered Health Staff 4 ~ Cumberland Valley Medical Services n. 1.053.18 144.00 99.58 --- -- TOTAL ~;~'SO ~ner ~.~ Line ~~, r^.e~apr.:i~;ion; ! 5 1 .764.76 pennsytvania ', iPvHERI~AhCE ':;X RETUR~~ RESIDER" DECEDEN' SCHEDULE J BENEFICIARIES ESTATE OF: FILE NUMBER: Marilyn Maughan 2010-00049 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NU~~15ER NAME ANC ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(sj OF ESTATE I TAXABLE DiSTRiBU T IONS :In,iude outright spousal distribution; and trans`ers under Sec. 9116 (a) (1.2). 1. 2 3 4 5 6 7 II 1, I Lauren Messich. 1200 S. Washington Street, Apt 703, Easton, MD 21601 Rachael Messich, 102 Independence Drive. Shippenburg, PA 17257 Bryan Maughan, 521 W King Street, Shippensburg. PA 17257 Dennis Maughan, 36417 Antone Drive, Grand Island, FL 32735 Nancy I~lessich, 102 lndependence Drive. Shippensburg, PA 17257 Barry Maughan, 119 N 5th St, Apt 1, Ft. Pierce, FL 34950 George Maughan. Jr. 7880 N. Stinesville Rd, Gosport, IN 47433 Granddaughter Granddaughter Grandson I, Grandson I j Daughter Son Son 1000 1000 1000 1000 C)neThirdC)fResidue C)neThirdOfResidue OneThirdOfResidue ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHO~NiN ABOVE ON LIiVES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE CiSTRiBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR 4'dNICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE A'vD GOVERNMENTAL DISTRIBUTIONS; TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, +$ I` more space is needed, use add«~onai sheets o` paper o` the same size. LAST WILL AND TESTAMENT I, MARILYN RUTH MAUGHAN, of Box 63, Madison Borough, Westmoreland County, Madison, Pennsylvania, being of sound mind, memory and understanding, do hereby make and declare the following to be my Last Will and Testament, hereby revoking all former wills and codicils heretofore made by me. FIRST, I direct that all my just debt and the expenses of my last illness and funeral be paid from my residuary estate as soon as practicable after my death, as a part of the e;tpense of the administration of my estate. SECOND, I give, devise and bequeath that all of the rest, residue and remainder of my estate, real, personal or mixed, wheresoever situated, whereof I may be seized or possessed, or which I may be in any way interested in or entitled to at the time of my death, I give, ,and bequeath, divided in equal shares to my following children, and/or the heirs of my children: GEORGE MAUGHAN, JR., my son, per stirpes One-third share NANCY MAUGHAN MESSICH, my daughter, per stirpes One-third share BARRY D. MAUGHAN, my son, per stirpes One-third share All of my belongings are to be divided equally by agreement between my children. All monies are to be divided equally. If any of my children shall predecease me, their one-third share be divided equally among their children, per stirpes. THIRD, if all the foregoing named beneficiaries and their issue are at the time so fixed for distribution deceased, all remaining principal and accumulated income shall be distributed to the person or those persons who ~~~ould be entitled thereto under the intestate laws of the Commonwealth of Pennsylvania then in force, as if I had died at that time, possessed of such property, intestate and unmarried. Pa~c ! of 4 FOURTH, I give, devise and bequeath the sum of FOUR THOUSAND DOLLARS ($ 4,000.00) to be divided equally, share and share alike, among my grandchildren loving at the time of my death: Dennis Ryan Maughan $ 1,000.00 Bryan Scott Maughan $ 1,000.00 Lauren Marie Messick $ 1,000.00 Rachel Lynn Messick $ 1,000.00 FIFTH, I direct that all federal state and other death taxes of any kind whatsc-ever, together with any interest and penalties thereon, payable on the property compromising my gross estate for those purposes, whether or not such property passes under this will, shall be paid out of the principal of my residuary estate. SIXTH, I nominate, constitute and appoint GEORGE MAUGHAN, JR., my son„ the Executor of this, my Last Will and Testament. In the event he is unable to serve in this capacity because of death, incapacity or refusal to act or continue as my Executor, I appoint NANCY MAUGHAN MESSICH, the Executrix 'rereof SEVENTH, if a member of my family is a daily caretaker of me during the time of my final illness and at the time of my death, that person shall receive payment equal to what the average rate of a Home Health Care Agency in the community would receive. This amount shall have been determined by the holder of my Power of Attorney. EIGHTH, the Executrix or the Executor of this my Last Will and Testament or any fiduciary hereunder shall not have to post bond or other security in any jurisdiction. ~`~ IN WITNESS WHEREOF, I have hereunto set my hand and seal this ;T day of ~~ ~~: ~.-v , 2000. ~~ ~~~~~z~ ~ -~ ~~~ ;~, ~~?'?/try ~.~~~ - -~ ~sEAL MARILYN UTH MAUGHAN Page 2 of 4 Signed, sealed, published and declared by MARILYN RUTH MAUGHAN, the above- named Testator, as and for her Last Will and Testament, in the presence of us, who at her request, in her presence and in the presence of each other, being present at the same time, who have hereunto subscribed our names at her request as witnesses. ~ ~-~ ~ ~ ti~ Address Address ~ • U ( G ,~ ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF WESTMORELAND I, MARILYN RUTH MAUGHAN, the Testatrix whose name is signed to the attached instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ~" • :/ / MARILYN' RUTH MAUGHAN SWORN TO or affirmed and acknowledged before me by MARILYN RUTH MAUGHAN, the Testatrix, _~~. this day o ~ ~~~~~~~~~ _~, 2C~~10. t~;c~4a~iaf Seat •~ ~ / ~ Eileen Chgllman Billet', Notary PubI~C ~ ~' ` ,~•~.~,~., U ~~ ~4:~ ' ; ~~~~~ - - eal~ Gr~~nsburg. Westmor~iand County My GorrtrrEission Exp+res. Frl2rctr 26, 2~(Jt Notary Public Memb~F. Pennsylvania A~s~cia.iori o± PJo!aries ~ Paae 3 of 4 '~ 1 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF WESTMORELAND SS: We, the witnesses whose names are signed to the attached instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her Last Will and Testament; that the Testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness, in the hearing and sight of the Testatrix, signed the Will as a witness; and that to the best of our knowledge the Testatrix was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. - G, -_ ~~ .,~~ ti'.~ti - ~ Z'~ ~'~ -- (SEAL) r - ~ SEAL ~ _ Sworn to and subscribed before me by r~-z- ~~ ~ ~ ~~ sand ~' I ~ , ~ ,witnesses, this ~ day of _ ,~-~~,~^-Z/~ , 2000. ~ ho!arial Seal ~ / Eileen Che!iman Bille;;, FJotary Puolic ~~~ ~'% ;C~~~C--'~ S"e ~_ .. ~r,sburg, VVestmo~~i~nv ~c~unty Notary Public ^~v Commission Expires ~,~arch 26, 20Gt Member Penn sy;vania AssociatiCn ~f iotaries Pace 4 of 4 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 May 26, 2010 GEORGE R MAUGHAN JR 7880 N STINESVILLE ROAD GOSPORT IN 47433 Re: Marilyn Maughan SSN: ###-##-6710 Dear Mr. Manahan: Pursuant to your letter dated May 06, 2.010, the Department of Public Welfare (DPW), Estate Recovery Program, has reviewed the information you provided regarding the above-referenced individual. It has been determined that this individual did not receive any type of assistance during the questioned period. Therefore, according to the information you provided, the Department's Estate Recovery Program will not seek any recovery from this estate. If your client applied for Medical Assistance and had an application and/or hearing pending at the time of death, please advise us and provide any additional information that may affect a recovery by our Department. If you have any questions, please feel free to contact me. Sincerely, ~ ~~~ ~ ~~ Vince A. Porter Recover.~r Section Manager (717)772-6604 Walker, Connor' c~ Sp~tng, LLC 247 Lincoln ~~%a~ East Chambersbur~. P:~ 17201 Telephone: 717-262-? 1 ~> Fay: 717-262-? 187 ti-1a~~ "?8. 2010 Geol'«e tau<_ha11 7880 N. Stines~ illy Road 1=i1~ -=: ?=I37-OOl Gosport. I\ 474 ~ ~ I11~ =. 1 l 149 Re: EStat~ Questions for Professional Ser~~ices Rendered: DATE DESCRIPTION' LA«'~'EIZ I-i0[1R~ A1~IOUNT Mai-04-10 Re~~ie~~ Inheritance Tal Return and make M.iC 0.>0 100.00 su«~~ested re~~isions: draft Estate Notice for ~d~'f'_rtlSln~,? ii~1a~~-13-10 Prepare ad~-ertisin~~ and letters to ad~-ertisers to MJC 0. ~0 100.00 ad~~ertise the estate >\-1a~-- 19-10 Telephone call «-ith George re: status oI~ MJC 0.20 40.00 Estate '~1a~~-28-10 Re~~ie~~~ supportin~~ documentation: prepare ~~1JC ?.>0 >00.00 draft of Inheritance Tai Return: scan and -111ai1 to 1/aecutor Totals x.70 5740.00 Total Fee & Disbursements 5740.00 P1'e~~ious F3alance 60.00 P1'e~ ]OL1S Pa~~lnentS 60.0() Trust Transferred at Billin~~ 330.6 Balance No~.~ Due ~~~~.;~,+ Walke~~, Contzol• ~ Sp~rnb, LLC X47 Lincoln Wav Last Chambersbur~~. P~ 17201 Telephone: 717-262-? 18~ Geor~~e \'Iau<~han 7880 1'. Stinesville Road T , --~ , -, ~Z~ ; ~ State ~)L1eSC1(lI1S Fay: 717-262-? 187 E=ile ~ . 1i1~ %Iav 7. 201 2-X37-00] l t)09 For PI-ofessional Services Rendered: DATE DESCRIPTION .~~pr-23-10 Telephone dill re: estate matters Totals Total Fee ~ Disbursements LA'~~'YER HOtRS MJC 0.30 0.30 :~1~[OL'~'T 60.00 560.00 S60.00 Balance No«~ Due Pease make p~~~ments to: Walker. Connor R Span~~. LLC ?~17 Lincoln ~~~`a~~ East Chambersbur«. PA 17?Ol The account is due and pad able in full a maximum of ~0 da~~s from invoice date. Interest of l.?~°~o per month ma~~ accrue on unpaid balances. S60.00 Summit Physician. Services - an a~liate of Summa Health 785 5TH AVE STE 3 - CHAMBERSBURG PA 17201-4232 RETURN SERVICE REQUESTED PATIENT: MARILYN R MAUGHAN MARILYN R MAUGHAN 102 INDEPENDENCE DR SHIPPENSBURG, PA 17257-8217 I ~ Please check box if above address is incorrect or insurance information has changed, and indicate change(s) on reverse side. If !'M 111\V 01 Vf1L/11 VMIIY~ ~IL.L VV I YVVV •I. 1... ~.» J'7 Y.y.. .I~NG~ V~~ ~ r V~ ,VY ~.cv~ .~~. CHECK CARD USING FOrR PAYMENT D n-M ~Rt~N L~ MASTERCARD _ VISA "~`''RE5` AMERICAN EXPRESS ®DISCOVER CARD NUMBER TVIN # AMOUNT SIGNATURE EXP. DATE STATEMENT DATE PAY THIS AMOUNT ACCT. # 02/05/10 99.58 D00011808169 PHONE: 717-263-9555 SHO~NAMOUNT PAID HERE CUMBERLAND VALLEY MEDICAL SVCS 785 FIFTH AVENUE SUITE 3 CHAMBERSBURG, PA 17201 PLEASE DETACH AND RETURN TcJP PORTION WITH YOUR PAYMENT 01/04/10 ADJ MEDICARE -6~+.84 01/21/10 PMSAETNON -18.83 TRACE# 810012510001489 0.00 X 12/02/09 Morel M.D.,Dan SUBSEQUENT HOSPITAL CARE 136.00 01/04/10 -PMT MEDICARE -52.56 01/04/10 ADJ MEDICARE -70.30 01/21/10 PMSAETNON -1:6.14 TRACE# 810012510001489 0.00 X 12/03/09 Dhar M.D.,Sanj SUBSEQUENT HOSPITAL CARE 159.00 01/04/10 PMT MEDICARE -7-`i.33 01/04/10 ADJ MEDICARE -6~i.84 01/21/10 PMSAETNON -18.83 TRACE# 810012510001489 o.ao x 12/04/09 Dhar M.D.,Sanj HOSPITAL DISCHARGE DAY 179.00 03/04/10 "PMT MEDICARE -7~i.69 01/04/10 ADJ MEDICARE -8~i.39 0:1/21/10 PMSAETNON -18.92 TRACE# 810012510001489 0.00 X ....... ~ ~ . ~ ~ :~ ~: .: :::~ ~:: ~: ": .:: . . : ~ 9 9.58 0. 0 0 . . . .. . . . . . . . . . . 9 9."58 .......... ....... ................................ ...:...~:E7Ft~~1!~'1` ........ .........~:I7•.~~'S :.:~:~:~:~:::: ~:::~:~:::~:~:~:64~:~,~Y~:..::.":..~. ....:::.~."~t#. ~.A.~ ~~.~..":..:.~: .~::: ::::... .. .......... :~~Bt~i;~~lil~~,'~E;3s:: 9 9.58 9 9 .58 Your account is seriously past due. Send your payment in full to avoid 381920 placement with a collection agency. Summit Physician Services PLEASE PAY BALANCE DUE . an affiliatE~ of Summit Health If paying in person our office is located on the 2nd Floor * ITEMS MARKED WITH ASTERISK HAVE BEEN BILLED TO YOUR INSURANCE COMPANY For Billing Questions call Summit Physician Services at (717) 263-9555 Eileen Chellman Billey, Attorney at Law 206 North Main Street Greensburg, PA 15601 BILL TO George Maughan, Jr. 7880 N. Stinesville Rd. Gosport, Indiana, IN 47433 _--- DATE ITEM 1 1 /30/09 O 1 /OS/ 10 Legal 03/09/10 j Legal DESCRIPTION Balance forward Phone call with George In office conference !, i Sta to m e n t --- ~ DATE ~ -- - ~' 3/31/2010 i ~ ~ 1 ~ ___ __ _ _- - AMOUNT DUE AMOUNT ENC. - - _ t- -- $180.00 ---- _ - ----- --- - -~- '~ QTY RATE ~ ANIOUNT BALANCE --- - - - - - -- - - ' --------- 0.00 0.2 150.00 ~ 30.00 30.00 1 150.00 I 150.00 180.00 Iolta A count Activity as of 3/31/2010: Depos t 2/25 - Retaine Estate of Marilyn Maughan +500.00 Ck 15 0 lolta - transfe to General -180.00 lolta b lance/retainer r maining $320.0( CURRENT 1-30 DAYS PAST 31-60 DAYS PAST ~ 61-90 DAYS PAST i OVER 90 DAYS DUE DUE DUE ~ PAST DUE _ - ---- 180.00 0.00 0.00 ; 0.00 0.00 i AMOUNT DUE $180.00 ~ - TM MEMBER FDfC ACCOUNT: DOCUMENTS: MARILYN R MAUGHAN 102 INDEPENDENCE DR SHIPPENSBURG PA 17257-8217 15-0 0 0 FIRST NATIONAL BANK TELEPHONE:800-555-5455 4140 E STATE ST HERMITAGE, PA 16148 First National Bank would like to thank you for your business and the confidence you have placed in us. It has been a challenging year in the economic environment and FNB remains strong and secure. Because we know the economy has been a factor for many, we reviewed our service and fee strucLULe and 'nave limiter the changes for 2010. Effective March 1, 2010, the following services and their associated fees will be effective: Deposited Items} Returned - $12.00 per item; Fee for Non-FNB ATM trans- action - $2.00 per transaction. A complete schedule of services and fees is available at any FNB branch or by contacting the Customer Service Center at 1-800-555-5455. LIFESTYLE 50 ACCOUNT 701190977 MINIMUM BALANCE 526.39 LAST STATEMENT 12/15/09 526.39 AVG AVAILABLE BALANCE 526.39 CREDITS .00 DEBITS .00 THIS STATEMENT 01/15110 526.39 - - - ITEMIZATION OF OVERDRAFT AND RETURNED ITEM FEES - - - * TOTAL FOR TOTAL * THIS PERIOD YEAR TO DATE * * TOTAL OVERDRAFT FEES: .00 .00 * TOTAL RETURNED ITEM FEES: .00 .00 PAGE: 1 701190977 01/15/2010 0 RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Receipt Date: 1./15/2010 Cumberland County - Register Of Wills Receipt Time: 11:05:07 One Courthouse Square Receipt No. 1059658 Carlisle, PA 17613 MAUGHAN MARILYN RUTH Estate File No. 2010-00049 Paid By Remarks: GEORGE MAUGHAN JR SAP Receipt Distribution Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 135.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 20.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS ~ CNTR M.D AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN ---------------- Cash 198.50 Total Received......... 198.50 ~ ~~ 5 L- i~ ~~ i Summit Physician, Services an affiliate of Summa Health 785 5TH A VE STE 3 - CHAMBERSBURG PA 17201-4232 RETURN SERVICE REQUESTED PATIENT: MARILYN R MAUGHAN MARILYN R MAUGHAN 102 INDEPENDENCE DR u, SHIPPENSBURG, PA 17257-8217 N I~~~III~~~I„I~I~I~I~I~„II~~I~~~I~I~~~III~~~III~~~~~I~IL~LI -^ Please check box if above address is incorrect or insurance mformation has changed, and indicate chanoe(s1 on reverse sides ................ ............. ........::......................................:.:..:............................................................. ........:~~~...., .....,....~..~.x~~~ . : ~a:z~,e~..:.. ~ti.:;~.... 08/06/09 Dhar M.D.,Sanj INITIAL HOSPITAL CARE 333.00 _ 09/15/09 PMT MEDICARE -142.21 09/15/09 ADJ MEDICARE -15.5.24 09/28/09 PMSAETNON 0.00 TRACE# 809265570001415 COINSURANCE AMOUNT 35.55 X 08/07/09 Morel M.D.,Dan SUBSEQUENT HOSPITAL CARE 159.00 09/15/09 PMT MEDICARE -7!5.33 09/15/09 ADJ MEDICARE -64.84 09/28/09 PMSAETNON iD.00 TRACE# 809265570001415 COINSURANCE AMOUNT 18.83 X 08/08/09 Morel M.D.,Dan SUBSEQUENT HOSPITAL CARE 136.00 09/15/09 PMT MEDICARE -52.56 09/15/09 ADJ MEDICARE -70.30 09/28/09 PMSAETNON I~,00 TRACE# 809265570001415 COINSURANCE AMOUNT 13.14 X 08/09/09 Morel M.D.,Dan SUBSEQUENT HOSPITAL CARE 136.00 09/15/09 PMT MEDICARE -52.56 .09/15/09 ADJ MEDICARE -70.30 09/28/09 PMSAETNON 0.00 TRACE# 809265570001415 COINSURANCE AMOUNT 13.14 X 08/10/09 BekeN,Emre HOSPITAL DISCHARGE DAY 179.00 09/15/09 PMT MEDICARE - -7;,69 .09/15/09 AllJ MEDICARE -84.39 09/28/09 PMSAETNON 0.00 TRACE# 809265570001415 .COINSURANCE AMOUNT 18.92 X 11/3.0/09 Sharma MD,Kirt INITIAL HOSPITAL CARE 180.00 01/04/10 PMT MEDICARE -711.84 01/04/10 ADJ MEDICARE -91..45 01/21/10 PMSAETNON -17'.71 TRACE# 810012510001489 12/01/09 Morel M.D.,Dan SUBSEQUENT HOSPITAL CARE 159.00 0.00 X 01/04/10 PMT MEDICARE -75.33 ..................................................: ..~...~.~........:.....:.:......~.~.~::......~:.~....:::.p~~.1~~Y~:.~~1~~1.1~T'~:~.~:~~L!~~.:.:<.:::.;: .:.:.:~;:~: ;:....:..:::.....~ ......:....: T~.1'~#.Is.llrxl;~l~G:~;:;~:.:.:...:.::...~........... i::i:-:~ (.' ~~. ~y~~:•:•i::~:~ .<':: -. .. .... ................................. ...._ .•_~_•_':.•:.•.•:::.~::::. :.•::::.~:_':.~:.~.~.•:::.~.~.•.•.~`:•:~:: ~:•:•:~:•:~: .~:•:•:•i:•:~::J«f,.~~,JC.~_::.•.•.~::::. .•.•.:.... ........_ t~~.:ll~:T.a1:::::::::::::::~:: D Summit Physician Services an affiliates of Summit Health ~r rM t ava o- ~,neui i ~,Nnu, n~~ vv ~ eewrr. iv.i.n.x o-y aigic namcer on ine oacK or your creak carat. M^ASTERCARD CHECK CARD USING F013 PAYME=NT ~~ ~ V^ISA owr~e'¢ ,AMERICP,N EXPRESS DISCOVER CARD NUMBER ~ VIN ~ AMOUNT - SIGNATURE EXP. DATE STATEMENT DATE PAY THIS AMOU~dT ACCT. # 02/05/10 99.58 1)00011808169 PHONE: 717-263-9555 SHOW AMOUNT PAICI HERE CUMBERLAND VALLEY MEDICAL SVCS 785 FIFTH AVENUE SUITE 3 CHAMBERSBURG, PA 17201 ~ ' ` ~~~iii~~~i„i~iii~„~„li~i~,f~~i~l~~li~~~l~lli~„~~ii~~i~i~i ~ j PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT 361920 * ITEMS MARKED WITH ASTERISK HAVE BEEN BILLED TO YOUR INSURANCE COMPANY For Billing Questions call Summit Physician Services at (717) 263-9_555 ` Hospital '" an affiliate of Summit Health 760 E. Washington St. Chambersburg, PA 17201 - SUMMARY OF CHARGES MESSAGE ~~ We did .not receive your payment of $200.00. However, if you made a payment within. the past 5 days, it may not be reflected on this statement. In order to continue the terms of your contract, please make payments every 30 days. Room & Board $ 6720.00 Pharmacy $ 119.88 Supplies $ 657.50 Laboratory $ 2672.00 Radiology $ 263.00 Blood Storage/Processing $ 910.00 Respiratory Services $ 453.00 Emergency Room $ 2040.00 Pharmacy $ 152.30 Cardiology $ 184.00 Physician Fees -Emergency Room $ 319.00 Physician Fees -EKG $ 66.OD PATIENT SERVICE CHARGES $ 14556.68 An itemized copy of your bill is available upon request. - INSURANCE INFORMATION nmary nsurance: MEDICARE Policy Number: 168220030D Secondary Insurance: AETNA Policy Number: W018254512 PLEASE RETAIN THIS PORTION FOR YOUR RECORDS PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT ® Hospital an affiliate of Summit Health 760 E. Washington St. Chambersburg, PA 17201 AMOUNT PAID: PATIENT NAME: MARILYN R MAUGHAN ~c* ACCOUNT NUMBER: H00036161503 r- ti 0101 Illllllil~llllili1111'I111i1111111111111111111t1111111I1II1111111 MARILYN R MAUGHAN 102 INDEPENDENCE DR SHIPPENSBURG, PA 17257-8217 - ACCOUNT SUMMARY Statement Date February 08, 2010 Date(s) of Service 08/06/09 - 08/10/09 Patient Name MARILYN R MAUGHAN Guarantor MARILYN R MAUGHAN Account Number H00036161503 Patient Service Charges $ 14556.68 Tota I Transfers $ 0.00 Insurance Payments $ -5270.76 Adjustments $ -8232.74 Patient Payments $ 0.00 Balance Due - $ 1053.18 Amount Due $ 1053.18 Date Due March 10, 2010 - 6ZUESTIONS t If you have questions regarding your bill, please contact us by calling: (717) 267-7169 (Insurance-related questions) (717) 267-7129 (Patient payment questions) If a payment plan is necessary, please call to set up an agreeable arrangement.. Office hours: 8:00 AM to 7:00 PM Monday -Thursday 8:00 AM to 4:30 PM Friday 8:00 AM to Noon Saturday Our business office is located at: 760 East Washington St. Chambersburg, PA 17201 You may pay your account online al: www.summithealth.orq. SEE BACK FOR ADDITIONAL INFORMATION IF PAYING BY MASTERCARD, VISA OR DISCOVER, FILL OUT BELOW. M^ASTERCARD VISA V^ ~ ^ OVER CARD NUMBER SECURITY CODE AMOUNT TO BE CHARGED TO CREDIT CARD EXPIRATION DATE SIGNATURE bb,SULbN IIII IIIIII~IIiilllilli111iIII~111111111111111i11~ll~llliiillll111 CHAMBERSBURG HOSPITAL 760 E. WASHINGTON ST. CHAMBERSBURG, PA 17201 Make check payable to Chambersburg Hospital 34931 *TVIOMENGP000437 COM PUTEf~ CREDIT, I I~IC. . CLAIM DEPT 083307 640 West Fourth Street . Post Office Sox 5238. Winston-Salem, NC . 27113-523a .336-7E>1-153a AC~ INTBRNATIt>NAL The Aasociuion of Credit and Collection Pro!'euimak February 15, 2010 Mr,~, Pinnacle Health Hospitals 143 SH1 35000 0567564993 Marilyn Maughan Attention: Jane 102 Independence Dr Telephone: (7171 230-3419 Shippensburg, PA 17257-8217 or 1-800-603-6064 Acct. No. 290298809 A ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~«~~~ Date of Service: 05-22-09 AMOUNT DUE: ;~4fiS.O Dear Marilyn Maughan: PLEASE SEE IMPORTANT NOTICE ON BACK Your overdue balance with Pinnacle Health Hospitals has been referred to Computer Credit, Inc. (also referred to in this letter as CCI) for collection. Our records` indicate that this debt is your responsibility. This letter will serve to inform you that your account remains unpaid and we expect resolution of your obligation to the hospital. Computer Credit, Inc. is a debt collector and a member of ACA International, the Association of Credit and Collection Professionals. This communication is an attempt to collect a debt and,any inforniation obtained will be used for that purp~>s~esumel that you notify our office that you dispute the validity of this debt within 30 days of receiving this letter, we wll the debt is valid and expect it to be paid. Pa the amount due to prevent further collection activity by Computer Credit, Inc. We appreciate your attention to this Y matter. Payment in=fuH is expected. Partial ~aymenfs uvill notsfop the collection process. tf / you have recently paid your balance in full, thank you. You maybe eligible for,assstance through a financrai support care program. You C. Jordan may call the number above if you have questions or if you think you maybe eligible. Director of Operations To learn more about why you received this letter, you nay contact CCI: u-' i~'ti`v' ~~T.iifOlii-lc"iilvil~Cl.COm iv^~,l:i cv~'~..i°,: OC~7C~~ jC/13 MAP Return this portion with your payment VIS4 ~ ~ ^ - - _ ~ ~cayEx CARD NUMBER EXP DATE SECURITY CODE AMOUNT SIGNATURE PRINT CARDHOLDER'S NAME BILLING ADDRESS BILLING ZIP CODE I H1 Z=35000 35000 Computer Credit, Inc. CCI KEY: 0567564993 GUAR-NAME -Marilyn Maughan- ACCOUNT NO 290298809 A AMOUNT bUE $408.00. You may make check payable to: Pinnacle Health Hospitals PO Box 2353 Harrisburg, PA 17105-2353 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SHORT' CERTIFICATE I, GLENDA EARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for C~BERLAND County, do hereby certify that on the 15th day of January, Two Thousand and Ten, Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate of MAR/L YN RUTH MAUGHAN late of SOUTHAMPTON T-OWNSH/P a/k/a (First, Middle, Last) MA RlL YN R MA UGHA N in said county, deceased, to GEORGE MAUGHAN JR (Fi~sC Middle, Lastl and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office a t CARLISLE, PENNSYLVANIA, this 15th day of_ January Two Thousand and Ten . Fi 1 e No . 2010- 00049 PA Fi 1 e No . 21- ~ 0- 0049 Date of Death 12/25/2009 S . 5 . # 197-22-6710 NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAJ OCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, ~(~.00 ~ 1~!~~~4 Certification Number This is to certify that the information here given is correctly copied froml an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records ~ ice for pl° an t filing. ~ ~~ Loa egistrar Date Issued H105-143 REV 11/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS TMPERMANENTIN CERTIFICATE OF DEATH BLACK INK (See instructions and examples on reverse) CTATF FII F NI II.ARFR ~~ w °w W 0 0 w Z 1. Name of pecedent (First, middle, last, suffix) 2. Sex 3. Social Security Number 4. Dale of Death (Month, day, year) Marilyn k2. Maughan Female 197 - 22 - 6710 Dec. 25, 2009 5. Age (Last Bidhday) Under 1 ear Under 1 da 6. Dale of Birth Month, da , ear 7. Birth lace Cit and stale or total n count Ba. Place o1 Death Check onl one Months Days Hours Minutes Hospital: Other: $0 Yrs. - Feb. 19 1929 Greensbur PA ^Inpatient ^ERlOutpatient ^DOA ^NursingHome ®Residence ^Other Specify: o1 Oeath Count Bb Twp. of Death rk. City Boro Bd. Facility Name (If not institution, give street and number) 9. Was Decedent of Hispanic Origin? ®No ^Yes 10. Race: American Indian, Black, White, etc. y . , , (t1 yes, spedfy Cuban, (Specily~ • Cumberland Southam ton Tw 102 Inde endence Dr . Mexican, Pueno Rican, etc.) White 71. Decedent's Usual Occu anon Kind of work d one Burin nest of work li{e. Do not state retired 12. Was Decedem ever in the 13. Decedent's Education (Specify only highest grade completed) 14. Marital S1atU5: Marled, Never Married, 15. Surviving Spouse (It wile, give maiden name) Divorced (SpeciyJ Widowed Kind of Work Kind of Business/Industry U.S. Armed forces? Elementary /Secondary (0-12) College (1-0 or 5+) , Homemaker Own Home ^ Yes ~ No 12 Widowed • 16. Decedent's Maikng Address (Street, city 1 town, stale, zip rode) Decedent's Did Decedent Decedent lived in_~~uthamptori Tom. Pennsylvania Liveina ilc ®Yes 102 Independence Dr. , . Actual Residence 17a.State Township? Livedwilhin D de l 17d^ Shippensburg, PA 17257 ILce ~ o nb.CountyCumberland City/Boro Ac1 18. Father's Name (First middle, last, suffix) 19. Mother's Name (First, middle, maiden surname) John Sell Mollie Moorehead 20a. Informant's Name (Type /Print) 20b. Informant's Mailing Address (Street, city /town, state, zip code) Nancy Messich 102 Independence Dr. Shippensburg„ PA 17257 21a. Method of Oisposilion r ^ Cremation ^ Donaton 21b. pate of Disposdion (Month, day, year} 21c. Place o1 Disposflion (Name o1 cemetery, crematory or other place) 21d location (Cityltown, state, zip code) • I ® Burial ^ Removal Irom Slate I Was Cremation or Donellon Authorized ^ Ottrer - s ' by Medical Examiner/Coroner? ^Yes^ No Dec . 29 , 2009 Madison Union Cemeter P4adison , PA 15663 ~ 22a. Signatur ,off ~ Service L' (or person ailing as such) 22b. License Number 22c. Name and Address of Facility - - - ~ 014831-L el er-ffii F.H. Inc. 112 W. St. PO Box 336 Shi PA 7257 Complet ems 23a-c only when ying physician is trot available al time o1 death to 23a. To the nowledge a trail ,dal ~n il/pl/a/ceys~t/a~/~te/d~J.~S\i)gnatur/e~and lick) //~ ~ /~fJ 23b. License Number ~~ / ~~l ~ -1 ~1 ~ 23c. Date Signed (Mo~~Jfnth, day, year) f~ // -~~ ~S ~ / cerlity cause of death. Lev ~ c _, ' / Items 24-26 must be completed by person 24. Time of Deal 25. Data Pronounced Dead (Mon day, year) .y 26. Was Case Relened to Medical Examiner /Coroner for a Reason Other than Cremation or Donation? ~ ^ • who pronounces death. ~ `~ ~ ~S M. ~~ ~ ~ ~c•~ j No Yes CAUSE OF DEATH (See instructions and examples) r Approximate interval: Pan II: Enter other sjgnilicanl conditions conttibutino to death. iven in Part I nd rl in muse lti i th b t t 26. Did T cco Use ConiribNe to Death? Y ^ P b bl Item 27. PaA I: Enter the chain o1 events -diseases, injures, or cromplications -that direclty caused the death. DO NOT enter lerminat events such as cardiac arrest, ~ Onset to Death ' . g g resu ng n e u e y u ra ro es a y me. , respiratory arrest, or ventricular tibriflation without showing the etblogy. Llst only one cause on each I ^ No ^ Unknown I tMMED1ATE CAUSE (Final d+sease or ~ J~ r / / ~ ~ ~ L./ ' ~ condition resulting in death) r ~~ / ~E;c- •~ ~~_ 29. II Fe 1e: ~yrt1d l~ Not pregnant within past year _~ a, uence oQ: , Due to (or es a conse r ^ P t rime or death nt q fl any Se uenliallyy list renditions J S,~~ ~ `'C D" - ~'~~ ~~ regna a ithi 42 d b t ^ N , b , ~ leading io the reuse tilled on lira a. ~ w n ays ut pregnan ot pregnant, Due to or as a copse uence of Enter the UNDERLYING CAUSE ( q ) ~ of death (disease or Injury that initiated the _ regnant 43 days to i year but ^ Nol re nant events resulting m death) LAST. c' ~ Due to (or as a consequence ol): I p g , p before death i Unknown 0 pregnant wihin the past year • d. 30a. Was an Autopsy 30b. Were Autopsy Findings r o1 Death 31 32a. Date o1 Injury (Month, day, year) 32b. Describe How Injury Occurred 32c. Place of Injury: Nome, Farm, Street, Facbry, OAice Building, etc. (Spealyf Pedomred? Available Prior to Compielion f D th? f C ~ ~ Natural ^ Hanktide ~(/ ause o ea o ^ Accident ^ Pending Investigation 32d. Time o1 Injury 32e. Injury al Work? 32!. 11 TranspoAalion Injury (Specify) 32g. Location of injury (Street, city 1 awn. state) ^ Yes Ll No ^Yes ^ No ^ Yes ^ No ^ Driver/Operaar ^ Passenger ^ Pedestrian ^ Suictide ^ CoukJ Nol be Defertnined M. ^ Other - S PAY 33a. Cedilier (check only one) 33b. Sig lure and Title of Certifier ) /~ ~"'YV l/U ~ ~" G~~ CeAkying phyaiclan (Physician ceAityxrg cause of death when another physician has praaurrced death and completed Ikm 23) d . ~i ~ , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ To the best o1 my knowledge, death oauned due to the cause(s) and manner es state 33c. License Number Month, day, year) 3£td. Date Signed ( • Pronoundng and certtlying physician (Physician both pronouncing death and certifying to cause or death) To the best o1 my knowledge, death occurred at the time, date, and place, aril due to the cause(s) and manner es statetl_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ n ~ ^ /1 !: '?~,+ j ~ ~ G, (,, (.~ 7 / ` ~ ~ /fit ~'/ ~-~ 7 f • Medical Examiner/Coroner On lire basis o1 exeminatlon end 1 or Investlgatfon, In my opinion, death occurred al the time, date, end place, and due to the cause(s) erM manner as stated_ ^ 34. a e and Address o1 Person Who Completed Cause of Oealh (Item 27) Type /Print ~> ~~ l,c~~ln,~-~-~~I-~m s- c~~ ~ lam ~C C d isiraCS Signature and District mbe ~ Re 35 th , day, year) 36. Dale Filed ( Mon ~ ~ { . .t;~ ai C ~ n,/~ ~ ~ g . p . , e ~ Disposition Permit No. QY~ ~ ~ I j~ ~j. COMMUNITY OFFICES IN STATEMENT OF ACCOUNT FRANKLIN, CUMBERLAND, 71-49921 FULTON AND HUNTINGDON STATEMENT PERIOD COUNTIES ~_ www.fmtrustonline.com FROM THROUGH 12-28-09 01-27-10 ~ ~ **'"****"*****AUTO**5-DIGIT 17257 4023 0.7150 AV 0.335 15 1 227 PAGE 1 of 2 i~~~lil~~~l~~i~l~l~l~l~~~il„I~~~I~l~~~lll~~~lll~~~~~l~ll~~l~l 2147 MARILYN R MAUGHAN NANCY G MESSICH 102 INDEPENDENCE DR SHIPPENSBURG PA 17257-8217 ENCLOSURES 1 5 MONEY MANAGEMENT ACCOUNT PERSONAL ACCOUNT: 71-49921 BEGINNING DEPOSITS/ CHECKS/ SERVICE BALANCE NUMBER CREDITS NUMBER DEBITS FEES 16,118.81 1 4.77 1 16,123.58 .00 INTEREST PAID THIS YEAR ACCOUNT INTEREST INFORMATION 4.77 ACTIVITY DATE DESCRIPTION CREDITS DEBITS 12-28 BEGINNING BALANCE 01-15 CLOSING TRANSACTION 00600007268 16,123.58 01-15 INTEREST CREDIT 4.77 01-27 ENDING BALANCE ''"'" ANNUAL PERCENTAGE YIELD EARNED DISCLOSURE FROM 12-28-09 THROUGH 1-27-10 *** ANNUAL PERCENTAGE YIELD EARNED .60 AVERAGE DAILY COLLECTED BALANCE 16,118.81 INTEREST EARNED 4.77 DIRECT F&M TRUST -SHIPPENSBURG OFFICE INQUIRIES TO: 13 SHIPPENSBURG SHOPPING CTR SHIPPENSBURG, PA 17257 TELEPHONE: 717-530-2100 OR 717-530-2101 ENDING BALANCE .00 BALANCE 16,118.81 .00 .00 C D C ~os~' vv @TDWTD OPR 180 TIME DEPOSIT WITHDRAWAL ACCOUNT NUMBER 014-2993650 WITHDRAWAL AMOUNT _ CLOSE ACCRUED ALL ACCRUED PENALTY AMOUNT 0 EFFECTIVE DATE _ CHECK NUMBER 30314.86 IK TRANSACTION CODE ACCEPT AS IS INQUIRY PROCESS x ENTRY ACCEPTED _> WTH AMOUNT 30,314.86 ALPHA KEY PENALTY 0.00 ACCRUED UNPAID COMPOUND VALUE 30,210.57 FED TAX WITHHELD AVAILABLE BALANCE 0.00 INTEREST ADJ AMTS 0022 01/15/10 x MAUGH:MR . O 1 104.29 0.00 0.00 ~~ ~t C~TDWTD OPR 180 TIME DEPOSIT WITHDRAWAL ACCOUNT NUMBER 014-2994851 WITHDRAWAL AMOUNT CLOSE ACCRUED ALL ACCRUED PENALTY AMOUNT 0 EFFECTIVE DATE _ CHECK NUMBER 25246.73 IK TRANSACTION CODE ACCEPT AS IS _ INQUIRY PROCESS x ENTRY ACCEPTED _> WTH AMOUNT 25,246.73 ALPHA KEY PENALTY 0.00 ACCRUED UNPAID COMPOUND VALUE 25,168.29 FED TAX WITHHELD AVAILABLE BALANCE 0.00 INTEREST ADJ AMTS 0022 01/15/10 x MAUGHMR.Ol 78.44 0.00 0.00 Summit Physician, Services an affili'~te of Su~rmit Health 785 STHAVE STE 3 - CH11M8ERSBURG PA 17201-4232 RETURN SERVICE. REQUESTED PATIENT: MARILYN R MAUGHAN MARILYN R MAUGHAN 102 INDEPENDENCE DR N SHIPPENSBURG, PA 17257-8217 o~ V III11111111111111111111111111111111111111111111111111111111111 CHECK CARD I,ISING FOR i'AYMF_NT ^ •~^~~ U nIVIERIChw L_1 u MASTERCARD ___ _ i VISA °Q~RI'S~~ AMERICAN EXPRESS DISCOVER CARD NUMBER VIN N -----~- AMOUNT SIGNATURE EXP. DATE STATEMENT DAT 01/06/10 E PAY THI S AMOUNT 99.58 ACCT. # D00011808169 PHONE : 717-263-9555 I SHI'JW AMOUNT ~ ~d' ~--~ PAID HERE ll CUMBERLAND VALLEY MEDICAL SVCS 785 FIFTH AVENUE SUITE 3 CHAMBERSBURG, PA 17201 1111111111111111111111111111111111111111111111111111111111111) ~~ /h ~~lv Z-r ^ Piease check box if above address is incorrect or insurance ~ PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMEN' information has changed, and indicate change(s) on reverse side. ~^.':. ~.T~..-r...~..'..".''~...- . -.'. ..~...-.-...~~.Tr. ~ _.»..~ :.~ ~.~..-.~T..T~..~:.~.-1.,~ .~r;tm .-.~.'_. ; .~ .; ..~~ ..,.»_ .. :~~~~':.':':~:.~::.':'.':•:'::~::': .':'.'.'.':.': ~::::•.':::'.':':~ •:::.'.'::. ..~ - : ... ~ . 1~ 1., tJ I14 ~: .'.:.. ....1J. , .....'. •.'.'.'.'.'.'.'.'.'~. ' . ~~'~Y.".~~.'.'.'.'.'.':.'.':'.'.'.'.'.'.'.:•.'.'.'.'.'.'.Y^.4fCS .Y.~L1~,:,~1 .l~Y,~ .......................................... ...•. •. •.'.'.'.'.'.'.'.'.'. ~. •.'..':.':.. .... D~1z ............ .;~~ _ _ _ _ _~- - - -~_.~~y__ s .~~ 106'10/08 ~ Dhar M.D.,Rach INITIAL HOSPITAL CARE ^ ~ 314.00 08/31/09 PMT MEDICARE 0.00 12/14/09 ADJ RESULT OF MEDICARE PRE-PAY -314.00 0.00 08/Ob/09 Dhar M.D.,Sanj INITIAL HOSPITAL CARE 333.00 09/15/09 PMT MEDICARE -142.21 09!15/09 ADJ MEDICARE -1.55.24 09/28/09 PMSAETNON 0.00 TRACE# 809265570001415 COINSURANCE AMOUNT 08/07/09 Morel M.D.,Dan SUBSEQUENT HOSPITAL CARE 09/15/09 PMT MEDICARE 09115/09 ADJ MEDICARE 09/28/09 PMSAETNON TRACE# 809265570001415 COINSURANCE AMOUNT 08/08/09 Morel M.D.,Dan SUBSEQUENT HOSPITAL CARE 09/15/09 PMT MEDICARE 09/15/09 ADJ MEDICARE 09/28/09 PMSAETNON TRACE# 809265570001415 COINSURANCE AMOUNT 08/09/09 Morel M.D.,Dan SUBSEQUENT HOSPITAL CARE 09/15/09 PMT MEDICARE 09/15/09 ADJ MEDICARE 09/28/09 PMSAETNON TRACE# 809265570001415 COINSURANCE AMOUNT 08/10/09 BekeN,Emre HOSPITAL DISCHARGE DAY 09/15/09 PMT MEDICARE 09/15/09 ADJ MEDICARE 09/28/09 PMSAETNON TRACE# 809265570001415 COINSURANCE AMOUNT 159.00 -75.33 -64.84 0.00 136.00 -52.56 -'70.30 0.00 136.00 -52.56 -70.30 0.00 179.00 -,75.69 -64.39 0.00 35.55 X 18.83 X 13.14 X 13 . l.4 X 18.92 X Summit Physician Services an affiliate of Summit Health 361920 ~ ITEMS MARKED WITH ASTERISK HAVE BEEN BILLED TO YOUR INSURANCE COMPANY For Billing Questions call Su~u~uit Physician Services at (717) 263-9555 -_ BEATTY -RICH FUNERAL HOME, INC. Ronald A. Rich, Supervisor MAIN STREET, MADISON, PA 15663 (724) 446-5511 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges are only for those items that you selected or that we are required by law ol• by a cemetery or crematory to use any items, we will explain in writing below. If you select a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if you selected arrangements such as a direct cremation or immediate burial. If we charged for embalming, we will explain why below. For the Service of Charge to: Address .. ., =ti Name A. CHARGE FOR SERVICES SELECTED: PROFESSIONAL SERVICES C"' -:` ~-°• ~~ ~~ Services of Funeral Director/Staff ....................... $ Embalming ........................................................... $ Other preparation of body Hairdressing ......................................................... ~~ $ g ....................... Dressing of Remains & Casketin $ ' ,.} ,. Date of Death " ~° > ~ > ~ ~'~ City State Other clothing Cremation urn ...................................................... $ (Description) Crucifix ................................................................ Other - $ Cosmetology ........................................................ $ ~., ' $ ..,, , ^ ~~ ~Y r ~~ $ , ....................................... ........,.......... ...... $ .....- TOTAL MF,RCIiANDISE SELECTED ............. ~ ... .................. B $.....r k SUB-TOTAL OF PROFESSIONAL SERVICES ....................... Al $ C. SPECIAL CHARGES: 2. FACILITIES AND SERVICES Forwardin of remains to a Visitation/Wake from funeral home th f iliti s f il id ili i f $ ~ ~a~ ..~. (Funeral Home) er ac e .. ence or o am y res t es, ac ... Use of factltttes for funeral ceremony ........... ...... ,,.,, .-... ...... $ -~~ , , . Receive g of rempins from. ,, r ,, , ..; -,. 7 - ~ r; 7 ~' ~~' ~~~,~ " °° '" ' $" j _ ,.,.~~,~'~,„,•. (Funeral Home) Immediate Burial .......................................... ....... $ ........................................................................ TOTAL OF FACILITIESIEQUIPMENT SUB ...... $ Y' '" --~ A2 r~.ai .......................................... Direct Cremation ....... $ $ ~-~°° ... - ........................ ~~~ SUB-TOTAL OF SPECIAL CHARGES . _ .... .................. C $ 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home. Local .................................................................. .. $ Hearse (Casket Coach) ,,,,,, " Local Limousine ......................................................... ... $ Local ................................................................. ... $ Family Car ........................................................ ... $ Local ................................................................. ... $ Flower car or floral disposition ,...~ ~. Local ................................................................. ... $ -~.;~ ... Lead car/clergy car ........................................... Local ................................................................. ... $ ... .. ~. a car for pallbearers Local ................................................................. ... $ r Out of town transportation ...: :.. ............. $ ' JJ.. $ ~,+' ~` SUB-TOTAL OF AUTOMOTIVE EQUIPMENT ...................... A3 $ +- r D. CASH ADVANCED .. '~''~ Opening Grave Grave Space(s) .................................................... Cemetery Equipment (Tent & Devices) .............. $ - ~..,~« $ p p ................................... ~. News a erNotices-Local $ ` Newspaper Notices-Out-Of--Town ...................... $ Telephone & Telegrams ...................................... $ Airfare ................................................................. Clergyllas Offering $ ,..,.w. $ ~,. Soloist .................................................................. Certified Copies of the Death Certificate ............ $ $ '~ .. '"`"'`~ ~ Pallbearers ........................................................... $ , Extra Vault Co. Charge for Sundays & Holidays _ $ Extra Cemetery Charge for Saturday, Sundays & Holidays Flowers ........................................... $ $ +~ _ $ ____ ~' $ TOTAL OF PROFESSIONAL SERVICES, ~~ ~~~ -,,, .»~. SUB-TOTAL OF ADVANCES ..................................................... D $ FACILITIES AND AUTOMOTIVE "" We charge you for our services in obtaining: EQUIPMENT ................................................................................. A $,~~~~ ,. (spec cash Advances that are marked up) B. CHARGES FOR MERCHANDISE SELECTED: /~ ~ Casket ar"~ ....................~...~~..., :....::.... ~'.'.................. $ ....~~ (Descrl tlon) rr p ~ - Other Receptacle .................................................. $ Outer burial c i e ........ '" (Descriptio ~~' Acknowledgment Cards ....................................... $ Register book(s) ................................................... $ """'"" ,...- Memory folders ................................................... $ .~ ~ Prayer cards ......................................................... $ Temporary grave marker ..................................... $ Burial clothing ..................................................... $ SUMMARY OF CHARGES A. Professional Services, Facilities and Equipment, and Automotive °s= ~ ~ ~ ~~~ Equipment ........................................................ $ B. Merchandise .................................................... $ ~ C. Special Charges ................. $ '"""'" ............................................... D. Cash Advances $ --~ TOTAL OF ALL SELECTIONS `~ « PAID AT TIME OF O PRIOR TO ............................ $ ' ARRANGEMENT .:...... ........;.........i. ... $ BALANCE DUE . ~{~iI~A!~}!~,. ..................... $ ~, ~~ ~ REASC~J~i. FOR E1V~B~L,iVIItyG i ,- . ~ , : l~ Fr.. ~",~/_ r rri ~. ' f. r~ f.: ~ d '.~ ~ { Y ~~ -' w ~9 ~ 7 ".!~ j ~ "..J~ If any law, cemetery, or crematory requirements have required the per ~^"' _. rr~ the items Listed af~ove the law or require ent is explained below, /// 1'~ ~~ f' s+ ,~ I agree that I have examined the items of goods and services selected above and found them to be correct and according to the arrangements I have requeste . I acknowledge receipt of a copy of this Statement of this memorandum and agreement. I hereby represent that I have sufficient funds available for payment of the cash price for the goods and services selected. I also agree to make payment of $ Within days. I agree to be jointly and severally liable with anyone else who signs below. A late charge of $ 1% per month amounting to $ 12% per year will be applied to the unpaid balance beginning days from the date of this agreement. I will also pay to the Funeral Director all reasonable costs paid by the F~neral Director to collect amounts I owe under this agreement. Those costs include attorneys' fees, court costs and other costs. Any ,a ~ ditional services or merchandise ordered,or reque after the date of this agreement will be considered part of this agreement and the cost thereof will be r Elected on the, al bill or statement. ,~~' ~ /j (Seal) urchaser) ,~:~ ~~',`) ~ (Date) r,, .~~ _ ~r,.. ~~ r ~ ~ , ,fir (Seal) G~'~ ~"~'~ :~ ,,,~..1'C~t'~ (Per aser) "`"~ `' '(Licensed Fu eral Director} © Pennsylvania Funeral Directors Association WHITE Funeral Director YELLOW Funeral Director PINK Castanet ` form - 600 Revised 4/94 ~ ,_, .~ ,~ .~ ~ ~_ ;, ~~ ~~ C`} ~r ! ,.: 1 +.. ~-~ .i Yr"~'~p ...~ ~=~ 1 ~ ~ / ~~ .. 1--- ~ s ,. ~ ~,' ,f r ~. ..i < .:; ~ ~ /'''~ sJA/ ~ii~4w. 5 ~~/ ~~~ 1~ I ~ I ~~ ass I~ III ~~ ^II~I•INI~I~IINIII~~~I~N~N INI~I ~ ~ ~~ ~ ~'p~,~ ~~~ ~~~~ ~ r~~ ~ ~ ~ III , • EO-8SE8I 000 !:, i OL i J'7~ G 00C 1 iNflOWki 3~~,rnar:r~ . wisod ~aivls :31~nrn nr •~r ~nr 6ZbLb NI `3~~IIIS11=-113 OIdd 3Jd1SOd ' S' fl ~ ~ /, ,- i~ iil- i~~