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HomeMy WebLinkAbout08-30-10 1505610148 EX (01-10) REV-~ ~OO OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN 2 ], 10 0 3 5 0 PO BOX 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 188-18-7896 03152010 1,2241924 Decedent's Last Name Suffix Decedent's First Name M I WASSELL ~1ARY E (If Applicable) Enter Surviving Spous e's Information Below Spouse's Last Name Suffix Spouse's First Name M I Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE - - REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-82) ^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) ^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date of death ^ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number CRAIG A • HATCH, ESQ • 71,7-731-9600 First line of address 1013 MUMMA ROAD Second line of address SUITE 100 City or Post Office LEMOYNE State ZIP Code PA ],7043 Correspondent'se-mail address: C • HATCHa1GATESLAWFIRM - COM _.j _~_ i , i - : -=, -"'s" i 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. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN /~ ~ ~ D TE 7 SPRING VIEW COURT MECf+AN-ICSBURG, PA 17050 SIGI~PrTl~1FE OF E ___._ DATE ~c' _.~ ~ "~.. _._ ~ ~r~ 1 r~~ 10~ MUMMA ROAD, SUITE 1,00 1505610148 REGISTER OF~LLS USE ONLI! . - ~ r ..~ • ~ ~~. .i ~;.. :~ C.. - ---i ~ ~ ,.. y" -~~ ' .r ---~ .. DA~FILED - - ~..~ LE~10YNE, PA 17043 _ FORM ONLY Side 1 9M4647 4,000 15 0 5 61014 8 ~''~L., Estate of MARY E. WASSELL Executors (Page 1) Name Linda J. Johnson Address 7 Spring View Court 188-18-7896 Mechanicsburg, PA 17050-7811 Tax ID 299-44-7012 J 1505610248 REV-1500 EX Decedents Social Security Number 188-18-7896 Decedent's Name W A S S E L L fr1 A R Y E _ RECAPITULATION 1. Real Estate (Schedule A) 1. 0 • 0 0 2. Stocks and Bonds (Schedule B) . 2. 0 • 0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) , 3. 0 • 0 0 4. Mortgages and Notes Receivable (Schedule D) 4. 0 • 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5. 3 6 , 9 5 2.0 0 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested 6, 0 • 0 0 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property Requested arate Billin ~ Se 7 5 8 , 8 8 9.0 0 g p (Schedule G) . 8. Total Gross Assets (total Lines 1 through 7) g. 9 5 , 8 41.0 0 9. Funeral Expenses and Administrative Costs (Schedule H) , ,g, 10 , 4 4 7.0 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) 10, 11 , 717 • 0 0 11. Total Deductions (total Lines 9 and 10) , . 11. 2 2 ,1, 6 4 •0 0 12. Net Value of Estate (Line 8 minus Line 11) 12. 7 3 , 6 7 7 . 0 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) , . 13. 0 • 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) , 14. 7 3 , 6 7 7 • 0 0 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers un~er Sec. 9116 00 0 (a)(1.2)x.o- 0.00 15. . 16. Amount of Line 14 t xable 4~ at linealratex.o 73,677.00 16. 3,315.00 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0' 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0. 0 0 1 g, 0' 0 0 19. TAX DUE 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610248 1505610248 9M4648 4.000 3,31,5.00 J REV-1500 EX Page 3 nnnnrlnnt'c ~`mm~lntn Arlrirocc• File Number DECEDENTS NAME WASSELL MARY E STREET ADDRESS UMBERLAND CITY CARLISLE STATE PA ZIP 17013- Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 3, 4 0 0. 0 0 B. Discount 16 6.0 0 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) 3, 315.OD 3,566.00 (3) 0 • D 0 251.00 (5) 0.0 0 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes ^ No a. retain the use or income of the property transferred; ^ ^X 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 Dec. 12, 1982, did decedent transfer property within one year of death ^ without receiving adequate consideration? . " " ^ or payable-upon-death bank account or security at his or her death? in trust for 3. Did decedent own an 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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. X9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. X9116 (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 21 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 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 4.5 percent, except as noted in 72 P.S. X9116(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 12 percent [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Total Credits (A + B) (2) 9M4671 2.000 REV-1502 EX + (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF: FILE NUMBER: MARY E. WASSELL 21 10 0350 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. swasss 2.00o If more space is needed, use additional sheets of paper of the same size. REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MARY E. WASSELL 21 10 0350 All property jointly-owned with right of survivorship must be disclosed on Schedule F. 3wasss ~.ooo (If more space is needed, insert additional sheets of the same size) REV-1504 EX+(6-98) SCHEDULE C COMMONWEALTH OF PENNSYLVANIA CLOSELY-HELD CORPORATION, INHERITANCE TAX RETURN PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER MARY E. WASSELL 21100350 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM I VALUE AT NUMBER DESCRIPTION DATE OF DEATH None 3W4697 1.000 TOTAL (Also enter on line 3, Recapitulation) (If more space is needed, insert additional sheets of the same size) REV-1507 EX + (8-98) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FIt_t Numl~tlt MARY E. WASSELL 21100350 All property jointly-owned with right of survivorship must be disclosed on Schedule F. 3Wa8AC ~.ooo (If more space is needed, insert additional sheets of same size) REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDEI~fT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY `ESTATE OF 1-11_t NuMt3tK MP,RY E . WASSELL 21 10 0350 Include the proceeds of litigation and the date the proceeds were received by the estate. 3Wa6AD ~ .ooo (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: MARY E. WASSELL 21 10 0350 If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVNING JOINT TENANT(S) NANE(S) JOINTLY OWNED PROPERTY: RELATIONSHIP TO DECEDENT ~~ NUMBER LETTER FOR JOINT TENANT DATE WADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAHE OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUM3ER OR SIMLAR IDENTIFYING NUM3ER. ATTACH DEED FOR JgNTLV HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DEC~I'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST None I TOTAL (Also enter on Line 6, Recapitulation) S 9W46AE 2.000 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX + (08-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER MARY E. WASSELL _ 2i In ~35n This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBS DESCRIPTION OF PROPERTY INCU.DE Thf NOME OF 7FE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER ATTACHACOPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE ~~ Edward Jones Account #896-10103-1-4: Polaris II A-Class Variable Annuity Contract #P13A3406999 58,889 100.0000 0 58,889 TOTAL (Also enter on line 7, Recapitulation) $ 58,889 If more space is needed, use additional sheets of paper of the same size. 9W46AF 2.000 REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE SCHEDULE H FUNERAL EXPENSES AND enMINIISTReTIVF rC~STS ESTATE OF FILE NUMBER MARY E. WAS SELL 21 10 0350 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ Neill Funeral Home, Camp Hill, PA 3,996 Total from continuation schedules . B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Linda J Johnson Street Address 7 Spring View Court City Mechanicsburg State PA ZIP 17050-7811 Year(s) Commission Paid: Waived 2,206 2. Attorney Fees: 3 , 500 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 158 5. Accountant Fees: 6. Tax Return Preparer Fees: 210 7. 1 The Sentinel - Publication of Notice of Estate Administration 302 Total from continuation schedules ~ 75 TOTAL (Also enter on Line 9, Recapitulation) ~ $ 10 , 447 9wasAC 2.00o If more space is needed, use additional sheets of paper of the same size. Estate of: MARY E. WASSELL Schedule H Part 1 (Page 2) 21 10 0350 Item No. Description Amount 2 Neill Funeral Home - Additional Funeral Expenses 126 3 Dodd's Monuments 1,780 4 Fairfield Cemetery, Fairborn, Ohio - Cremation internment 300 Total (Carry forward to main schedule) 2,206 Estate of: MARY E. WASSELL Schedule H Part 7 (Page 2) 2 Cumberland County Law Journal - Publication of Notice to Creditors 21 10 0350 75 Total (Carry forward to main schedule) 75 REV-1512 EX+(12-08) SCHEDULE pennsylvania DEPARTMENTOF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER MARY E_ WASSELL 21 10 0350 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. awasAH z.ooo If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FILE NUMBER: MARY E. WASSELL 21100350 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [InGude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1, Linda J. Johnson 7 Spring View Court Mechanicsburg, PA 17050-7811 100 of Residue: 73,677 Daughter 73,677 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. 9W46AI2.000 ' Estate of Mary E. Wassell Pennsylvania Inheritance Tax Return Form REV-1500 EXHIBIT A Copy of the Certified Death Certificate of the Decedent ~~ ~ ,~r~~ `~I~C~~l~t~~o [t i~ il6ec~~l Ica ~~I~~~rat~ t~t~~ ~cz~~~ ~~~ ~,~~~cm~c~~~i~# ~~~ ~l~~t~;~~l'I~~, P 1624414 i ;N l rrJ, i;T,.', ~,~ t •~ \V J_' ~ ~ , ,. .~ ~"'~ ` !a e~ .Yb]- ~' ,i r_ ~ ~.;,~~EI~S O~rtf,ti `f it(~ i~ tv (~ly~ttt~~ Tl~~ I~~}!I2fol~rll~iti<!Il I2f_~¢{e /~~~~r~-~~{~2 L(}~f~.-Lti}~ (. 1.3 L~iL. ~t 1)t [~ Cit6 l,i (`.1-Y 11 C1~ ~}~l lt~t ~-Cill. l~/-LL.t (lili~' 3IC-l~ \~ !'t~"i !i1U _I~ ~.()f;'~il ~'e°1Sli'~!I-. rr~le Oi-I-yii c~ t ufif:`<lt(v ~~ li? ~,~ ~~€_)r«~ar~led to tl--e State V t ~t~~i3-C.< ~~f~i e ~(?1 ,2C:F!?Ii:3;i2ePt t1~111~. 2 i ~ ( ~~~ ~~ x_()~4Li Re,<_=ist~-t~r Date Issued C'ertif7c~~tit~!~ Nu(ll~er FUOrrl43 REV 17!2006 TYPE /PRINT IN PERMANENT BLACK INK ,~ z 0 U 0 0 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) .._.__ _.. _ ......___ 1. Name of Decedent IFrrst, middle, last, suthz) 2. Sex 3. Social Security Number 4. Dale W Oeam (Month, day, year! Mary E. Wessell Female 188 _18 _7896 3/15/2010 5. Age (Last Birthday) Under t ear Under 1 da 6. Date Of Binh (Norm, da , ear 7. BiM ace Ci and state or tor e munt ) Ba. Place of Dea[h (Check on one) Mmlhs DeyS Hours Minwes Hospital: Omer. 8 5 vrs 1 2 / 2 4 / 1 9 2 4 Pittsburgh P A ^ ^ ^ ~ , Inpatient ER f 0utpat+em DO0. Nursing Nome ^ Residence ^ Other -Specify: 8b. county W Deam Bc. Ciry. 00,0. Tvrp. 01 Death Bd. Facility Name QI rat institution, give street and number) g Was Decedent W Hispanic Ongfn~ ~ No ^Yes 10. Race: American Indian, 0lack, White, etc. Cumberland Carlisle Ilt yes, specify Cuban, Sarah Todd Memorial Home Mexican,PuenoRican,elci (S~]hite t t. Decedent's Usual Occ tion Kind of work done Burin mast of world tile. Do not slate retired 12- Was Decedent ever n me 13. Decedent's Education (Specify only highest grade completed) 14. Marital Staas Marred. Never Marred t5. Surviving spouse (If vnte, give maiden namo) Kind of work Kind of 0usire;s/Industry V.S. Armed Fcrces? Elementary /Secondary (0-72) College (1-4 or S.) Widowed. Divorced /SpecityJ Homemaker Own Home ^Yes ~J Nd 1 2 widowed t6. Decedents Mailing Address (Street dry /town, slate, zip code) Decedent's p e nn s y 1 v a n i a Did Decedent i S ] A l R 1 V e r S r i n C 7 Springview Ct . _ cua es dence 17a. Stale lJVe in a ,?c ~ v,. n..,....,,. p g Twp ~__ " "°""``'L'"`d"~ Meehanicsbur PA 17050 g mwnshp? 77tt Gounry Cumberland 77d ^NO. Decedem !rued within / ActualLimitsd City/Boro 78. Fathels Name (First middle, IazI, sufhx) 19- Momefs Name (First middle. maiden surname) John Feeney Helen Boot 20a. tnlormanYs Name (Type 1 PdnQ 20b. InfortnanYs Mailing Address (SVeeL say I bwn, state, zp coaej Linda Johnson 7 Springview Ct. Mechanicsburg, PA 17050 2ta. Method of Disposition + ~ Cremation ^ Donation 27b. Date of Disposition (Norm, day, year) 27c. Place of Disposition (Name of cemetery, crematory or omen place) 27d Lucalion (Ciry! town, state, zip code) i ^ Budal ^ Removal from State r Was Cremator or Donatlon Authorized ^ Other - S ` by Medical Examinerl Coroner? ®Yes^ No 3 / 1 7 / 2 01 0 Evans Cremation Service L e c,1 a , P A 1 7 5 4 0 22a Signet M R~nera! Service Licenses (-r pars -ding as welt) ~ 22D. License Number 22c. Name arxl Address d Facility Nei 11 F u n e r a 1 Home , I n e -Gzy L .-- ~~+ D 012122 L 3401 Market St. Cam Hill PA 17011 Complete items 23ac only n certifying 23a. To the best of my knowledge, Beam occured at me time, date and place stated. (SignaNre and title) ^ 23D. Lx;ense Number 23c. Oale Signed (Norm, day, year) physician is rat avaaable at fime d death a cemty cause of Beam } -'t ~,~? ~~ ~ , f~(.C% fi'(~~~( f'~IL~ h ~'~Tu' i1 J • 1"J T ~! ~ ,l .~ / ~ S~OcU 1 U Items 24-26 must be completed by person who rora ruzs death 24. Time ot~am '~" 25. Date Pronounced Dead (Norm, day, year) 26. Was Case Reterrea to Medical Examiner / Cortmer for a Reason ONar tltan Cremation or Donation? p u ~ , ~ ~ M. ~ ~ S ~V l (~ ^Yes ^ No CAUSE OF DEATH (See instructions and examples) i Approximate interval: It 21 P n I~ E t h Part IL Enter other sigrtificant conditions conVibuAna to Beam 28. Did Tobacco Use Conbibute to Death? em n er me c a ain of evenly -diseases, injuries, or complications - mat directty caused me Beam. DO NOT enter terminal events such as cardiac artesi, + Onset to Death i lwt not resulting n the underlying cause given in Pan I. ^ Y es ^ Probably resp ratory artest, or venNicular fibrillation wimax showing the etiology List only one rouse on each line. ~ r IMMEDIATE CAUSE (F nal di ea FF ~~ ''77 L7tvo ^ Unknown i se or s condition rewNirtg in Beam) (~'rC ~ i3~ Z V li$ r -~ a. Cx.. t~ AC C r O ~ + Z ~`-) S ~; ~ i I ~ J r ~ ~~ 29. FIt -Ftem ale. Due to i« as a consequence o() r _ ~~ LTNpt pregnant wimin past year Sequential Est conditiens, a any, b ~ leading a the cause Nsted on line a ^ Pregnant at time of death . Due to (or as a copse tierce o Enter the UNDEALYING CAUSE q 0 ~ ^ Not pregnant, but pregnant within 42 days (disease or injury mat initiated me r events resulting in death) LAST. c r of Beam Due to for as a consequence o0 + ^ Not pregnant. but pregnant 43 days to t year d_ + before death ^ + Unkrawn it pregnant wNttin me past year 30a. Was an Autopsy Pedormed? 30b. Were Autopsy Endings Available Prior to Completion 37 Manner of Death 32a, Date of Injury (Norm, day, year) 32b. Describe Flow Injury Occurred 32c. Place of Injury: Home, Farm, Street, Factory, ONice Buildir etc (S edtyJ of Cause of Death? - Natural ^ Homicide g, . p F~1~ ^ Yes LJ rb ^ Yes ^ No ^ Accident ^ Perrdng Investigatiorn 32d. Time of Injury 32e. Injury at Work? 32f. It Transportation Injury (Specify) 32g. Location of injury (Street city !town. slate) ^ Suicde ^ Could Not be Determined ^Yes ^ No ^ Driver/Operator ^ Passerger ^ Pedestrian M ^ Other -Specify: 33a. Certifier (shed onfy one) 33b. Signature a Tale of tier // • Certifying physician (Physician certifying cause of death when anomer physician has proraunced Beam and cortpteted Item 23) ,7,~ To the best of my knovvladge, death occurred due to the cause(s) and manner as stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Pronouncing and certlfying physician (Physitan Born pronouncing Beam antl cetifying to cause of tleam) 33c. thence Number 33d. Date Sgned (Norm, day, Year) To the best of my Imowledge, death occurred at the time, data, and place, and due to the cause(s) and manner as stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ ( ~ -,~ ~ ( ( ' J • Medical Examiner/Coroner M ~ v ~ ~ ~ ) ~ ~ ) 1 On the hasls df examination and / or Investigation, in my opinion, death occurred at the time, date, and place, and due to the causes} and manner es stated_ ^ 34. Name and Address of Person Who Completed Cause d Death ptem 27) type / PriN R¢9is(gY. I ature~n ~ N 'ber ~2 I % ~ 7 4 ~ I~ i r / t°. / f) it vs I I Date Fit (hknN, day. Year) ~ 4 ~ Q /- t L ~ ~ 1 W ~..rC l , r~6.} v ~ ; ~ Z ~ S F ~ i ~. r~ C ca-~ f ~ j°t~ `-~ ~ ~ ~ 1~ 1"~ 1 T Q i 3 Disposition Permit No. V ~ ~ Estate of Mary E. Wassell Pennsylvania Inheritance Tax Return Form REV-1500 EXHIBIT B Copy of the Last Will and Testament of Mary E. Wassell Dated August 5, 1997 <' L~ V W ,~~~~' l t 7 ~ ( ~' ~ j ~ ~~~, ~ ~ ~ s,~ .~~~.~ _, ~,- ~~s4~~ ~ o ~~T~~S~~~, ~ ' - -.~,~--~ ~ Wig- ~ 8- ~~9~, o~ rr~ yy~' r' K;j~ t ca_~r0i r;L ~, y; n~~'~ =~c f r --~'•~r=~ ~.,~ ~J ~~~~?~~~dy~~ o`.S 'i1__~ ?E rSCY!c~ ~~V ~~~v'~L~L JC ~?"•("~ Y'Y;li_J __ C i i ~ i- T~~i •~.:.~Z.:.Q__LCY'r -!~t~~~_ T ' 1-T ~~ _ TrQy _ i_ .~ _ ~ _.. ~:1 .=C-~'..- ! - ~'--^rl :,_!-..~~o ~ __~ ._' ~_ t~-C?G~. i.;.~n-C_', U~`Nl\~-~'.~Z a.. _ ~.:.,G~~US ~ _'!~~ ~-'`~ =='c ~`':Or_~_ ~`.~r~S='•~'~~~ ~ `~ c'' !~E ~~ ('r?1 ~ ~tE~ .C ,.:c V~ vv __ Ci:~ ~OI~d O Si:~_:..L; L. .,_.._C _ -- h ' :Jr __i ~ T1-l ;7 "~ 4~ C~_ C L~~~, E_ ~ C__ O~ LZ~v l.,CarL - ^.>~~ r~T G S ~'CC1il ~~~ ~ J i LN !-' _ ,~- ~ ~ Y ~^'V' ?'i ~.cOfc''S~Z=~G~=vim ~.C~ ~?"~ l.zy?Sl.t{~=-\j1ScC,t o^ri:..r_,~~rc.:+_~CT2 St: ~S LO ZCQ!:t1niSL~_r my ~S ~aL~ ;f~Tt~ a m,-;~ mur_ of coact Su~~r~-s ~ cn . ~f ~ ~ becCm~S r~C~SS~.fV `~-p ?a~.%.._ ._._.!il^. _- ~ ,...('~}~ ~(a~-i =t i S~ ('r-.~~_,.:.'3: C=''i_r' CSC ._~t-_.~ ~"~ .`'..~f1~i ] l~' S!.~1C1~1Cr? 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(~ / ..._ '~'_' v^_~~~ L . ,`. - - ~ t_ ~"? c ~ti~ ? ~ r'i c S S e S ~ S ~ g ='_ O 1:i r L`1 a'T! 2 S L O i_ ~"'_ S -~?S ~--~''UI?'le1_~r" ~ hC~ nGr' dU~ y t7,t~a ~ 1' ~ cd aCCO ("Q_Z~u ~C ~ a~~r~ d0 C1ep05° c~?2Ci SaV ~~~.~ tNe ~vc~-E _~_ESEr!L ca?iCc SaN~ ~'•"?2 L~SL~~ (-fix .~=g?~ a?"1Cd 2~~CULz L~r1E _ v- ~ -r - L ~ -: T ~ I i ',^ ~ i ~ r' = '!,~ ~ ~ .~ ~ i" ~ C l Tl l ~ l 1"1 ~ -;,,~~_~.~~:;~rt a~ ~~_ ~a ~,ti__ ~ _-~ __~ ~ _ ---- g--ed w_s gay and cX?C~LcC_ _ ~ aS rle_ ~ r'ec .:.tP_Q =.~_ll='-%- ;` _ ~ ~ `! ~c ~1:~ ~'pOSeS i~ ~?es'ei t~ c~~~''eSBeQj _!lc_... CaC~ Cu.r.JSCr~ h_rg ~l.T! `~_~~~ --- .-rl` ('Car'1'C"?g a?~Q S1g~`?L C~ ~-~e ~eC~at f__x"_ C c .r-r;-~GQ ~~~~ ~,rV' ~ ~ i ~,~ ._.. 4^:' ~ `?-'i~~.~ ~ .._'_~!~ L_'1~L LO LiiC ~~Sl.. Cf C~..L~ J - _ ~~o;tir~ edge L~~e ~es~.~~~-~ ~~a~ ~_c trat ~- _8 _ o_~ vea_ age, c SGl.1~?d t1T'!Q czl`'_Q ~_1iQC r ~^v Co~SL''a---L ._. %' lii`?^~'~ ---' -licliCe . 3 _ __ ~.~., '._._,.^. ~ C r ~ u e C_ .` i=^; l^.. - ~ ~ 'v ~ ~'_ v_ G. C ''~ `, J :` _. ~ 'u l..T = '~ ._.. ~ - U~ (- .~ ~~ ~ j' ! ~' I %-i ~ ~ _ - - - Ir~~e' .- _ _ .--~ 1 ! C .~ ~ ~...~ I J I. - - I r ~ /. ~ ~ ~ ~%'ri~ ~ C _ ~ .~.% C ~L .i_ _^ ~ ~ ~'~T ~ - ~ ~ C !J C LJ ~^ L- : t ~ C A./ v ~~% 1 _ Estate of Mary E. Wassell Pennsylvania Inheritance Tax Return Form REV-1500 EXHIBIT C Copy of the Certificate of Grant of Letters issued on April 5, 2010 REGfSTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA No. Estate Of : MARY E WASSELL CERTIFICATE OF GRANT OF LETTERS PA No . 2 ~ - ~ 0 - 0350 (First, Middle, Last} Late Of : SlL VER SPRING TOWNSHIP CUMBERLAND COUNTY Deceased Social Security No : ~ 88- ~ 8-7896 WHEREAS, on the 5th day of April 2010 an instrument dat=ed August 5th 1997 was admitted to probate as the last will of MARY E WASSELL /First, Middle, Lastl 1 a to of SILVER SPRING TOWNSHIP, CUMBERLAND County, who died on the 15th day of March 2010 and, WHEREAS, a true copy of the wi 11 as probated i s annexed hereto . THEREFORE, I , GLENDA EARNER STRASBAUGH Register of Wi 11 s in and for C ~~1tsERLAlvi~ County, in the Comm. onweal th of Pennsyl vani a, hereby certify that _I have this day granted Letters TESTAMENTARY to: LINDA J JOHNSON who has duly qualified as EXECUTOR(R!X) and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CA RL lSL E, PENNS YL VA NlA . IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 5th day of April 200. A !' ,` ~ V _ / Regis ter is ~~ _ n 7 ~! J / Deputy Estate of Mary E. Wassell Pennsylvania Inheritance Tax Return Form REV-1500 EXHIBIT D Copy of PA Inheritance and Estate Tax Official Receipt No. CD 012908 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 REV-1 162 EX(1 1-96) NO. CD 012908 JOHNSON LINDA J 7 SPRING VIEW COURT MECHANICSBURG, PA 17050 I -------- fold ESTATE INFORMATION: ssty: ~ 88-~ 8-7896 FILE NUMBER: 2110-0350 DECEDENT NAME: WASSELL MARY E DATE OF PAYMENT: 06/ 14/2010 POSTMARK DATE: 06/ 1 4/201 0 CouNTY: CUMBERLAND DATE OF DEATH: 03/ 1 5/2010 REMARKS: ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ 33,400.00 TOTAL AMOUNT PAID: $ 3, 400.00 CHECK# 95 INITIALS: CJ SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER Estate of Mary E. Wassell Pennsylvania Inheritance Tax Return Form REV-1500 EXHIBIT E Documentation of Assets St MEMBERS 1St FEDERAL CREDIT UNION SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death 1 Principal and Accrued Interest Name of Custodian CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Custodian INVESTMENT SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Custodian 342992-00 11 /10/2008 $2,618.00 $.30 $2,618.30 Linda J. Johnson 342992-11 11 /10/2008 $9, 076.11 $.35 $9,076.46 Linda J. Johnson %~4 `~ ~~ ~`~2, 342992-05 09/18/2009 $2,668.44 ,1f,~ $.41 $2,668.85 Linda J. Johnson ME ERS 1sT FEDERAL C IT UNION ~' ~ ~Z._' Danielle A. Kline Lending Insurance Support Specialist May 7, 2010 Estate of: MARY E. WASSELL Date of Death: 03/15/2010 Social Security Number: 188-18-7896 5000 Louise Drive ~'O. Bow 40 Mechanicsburg, Pennsylvania 17055 (800j 283-2328 wwwmemberslst.org p-ccount Molder(s) Mary E Wassell Account Number 896-10103-1-4 MARY E WASSELL 7 SPRING VIEW CT MECHANICSBURG PA 17050-7811 Financial Advisor Sean Ferguson, 717-731-5432 1300 Market Street, Lemoyne, PA 17043 Statement Date Jan 30 -Mar 26, 2010 When you celebrate Tax Freedom Day is really up to you. ~` ' J!~t ~* ~~~ `A .~• ~x °+'~ soon . •° c8,:wiwv wt~- Page 1 of 2 Tax Freedom Day marks the day when, according to the Tax Foundation, average Americans earn their first tax-free dollar of the year, and it typically falls in April. Wouldn't you like to be above average? Implementing a few tax-efficient investing strategies could enable you to celebrate your personal Tax Freedom Day earlier. Call your financial advisor today to find out about strategies that may work for you. (Edward Jones does not provide tax advice. You should consult with a tax specialist regarding your situation.) This Period This Year Beginning value $0.81 $0.81 Assets added to account 500.00 1,000.00 Income 0.00 0.00 Assets withdrawn from account -500.00 -1,000.00 Change in value 0.00 0.00 Ending value 0.81 0.81 + Assets held outside of Edward Jones 58,889.00 58,889.00 Total Account Value $58,889,81 Ending Cash 8~ Money Market Balance Cash $0.81 Amount Annuities Purchase invested (Held at the Annuity Company) Value as of Date Since Inception Value Polaris II A-Class Variable An Contract # P13A3406999 3/25/201 0 1 1/24/2003 73,000.00 58,889.00 Total Account Value $58,889.81 Date Description Quantity Amount 3/01 Direct Deposit SunAmerica Annul Annuityach $500.00 3/02 Direct Payment to Acct No 47306416 -500.00 Account Type Single Account Holder(s) Mary E Wessell Account Number 896-10103-1-4 ;'~ ''; Q~' . ~. Financial Advisor Sean Ferguson, 717-731-5432 ~'~`'-''~'--' {yo s'aN+iu w+~ a 1300 Market Street, Lemoyne, PA 17043 Abort F.d~rd JoAes Edward D_ Jones & Co, L.P, is ~Y n~ista+ed with the Securities and Exchange Caa~mission (SEC) as a b~+ober-dealer and an invest advisor. Edward James is also a member ofFINRA. Statement of Floauciia! Co+iditton -- Prdward Janes shabanaat of tai condition is available ~ your personal review: • at your [anl lx~ oflioe at www edwardjoneaoaml® I]S/compa~nyfnndex.bbonl by mad upon written request Abort Your Acco~mt Account Wormation -- Your Acroount Age oontair~s the complete conditions that govern. your aaooun~ Plea9e caootnct your finamcdal advisor if you have airy changes to your financial situation, oor>daet in£or~tion as iavestinr~nt objectives AccountSAil~y-Please review y~r statement car~iilly. Ifyou believe there are emars an your accou~ you must notify us pro®p#1y ofyraur oanoems. Yoa nxy either contact our Client Relations drat or your fnancial advi.~or. You should c~ca®firm any oral oo~nnn~mica~ian by sending us a letter within 30 ~Ys ~ Pry y~ rights, ~~8 Y~ under the Se~rities Investor Pmbac~tian Act (SIPA~ Furors or Q.cstiooa abort poor F1~+onic Tnmsfers - Ca~ac# Client Relations at (800} 44i 2357. Commis about Your A~-~t - If you have a complaint please send a lettaer tp F~dwar~i Jam Attn: C~plairris Dept, t 245 JJ Kelley Il~inorial Dr,, St Louise MO 63131. Statement Date Jan 30 -Mar 26, 2010 Page 2 of 2 Withholding on 1Dlstrib~iaes ar Vfrft6drsnvails -Federal law requires Edward Janes to withhold inc;ame tax an distribntia®(s} farrm your retirenn~ent stets and other plans unless you elect not to have withholding apply. You may elect a percentage to be withheld from youcr distributim ar not to have the withholding apply by signing and dating the appropriate form and returning it to the address specified on the farm. Your election will remain in e117ect until you diaonge or revoke it by rehn~ning soother signed and dated form., ff you do not return the fan by the date your distn~utions are scheduled to begin, Federal inca~ t:tx will be withheld If you do not have enough income tax withheld firm your distn'bntia®s, you may neat to gay estimated tax. You may incur penalties if the amounts withheld and ymr esttimated tax are not eyual to the tax y~ owe. State witfiholdin& if applicable, is subject bo the state's withholding requirements. Fsiir Market VAlre for Individual Retir+eme~ A~oeo~ts - Ya~r fair marlret value as afDecember 31st will be repart~ed to ffie IItS as required by law: Rita to Yomr Free CYesHt BAlAnce -You may ask to withdraw your free credit balance clecing normal business hamrs, subject to any indebbe~ess in your arrant While yar fiords are sot segregated, they are properly accounted far an our boarlrs. Edward Jomxs may use ywr free credit balance to ooeduct business. Learn More About Youu~ Statement, Review A~itioosl Diacloaae-ea And Te~rnaina~ -Visit http:l/www.edwardjanescasn/ea. USJ ge center lindex.html Go Greed Did you know you can receive your s~teanents and other documes-ts online inste~rd of on `~ Paper? Vtsit www.edwardjones.raan/edeliveryfor morce information. Tol Free Phone '~ 800-A4123S7 dine Aoaaa Oder Contacts Zoi Pro~}rss Parkway ® Nimylamd Heights, MO b3443 '~ ()nlioe Account Access F.dwa~d Jones Mas~xCamd www.edvvaadjones.oo~n/aocess '~ 800-3fi2-b299 fidwat+d Jones OQlioe Support F,dwa~d Jones SSA Debit Card 800-041-5203 '~' 888-289-6635 Monthyy Frey lam -7p~n CST `'d Account Type Single ~-ccount rfoiaer(s) Mary t Wassell Account Number 896-10103-1-4 MARY E WASSELL 7 SPRING VIEW CT MECHANICSBURG PA 17050-7811 Financial Advisor Sean Ferguson, 717-731-5432 1300 Market Street, Lemoyne, PA 17043 Statement Date Jan 1 -Jan 29, 2010 ~` .:'~ -- , A~ a a. ,•t ra'K+wvK~6~ Page 1 of 2 The IRS deadline for mailing 1099s is now Feb. 15. The IRS has changed its deadline for mailing Consolidated 1099 Tax Statements from Jan. 31 to Feb. 15. While we expect to mail most 1099s by Jan. 31, we will not be able to issue some 1099s until mid- to late February. You may wish to consult your tax professional regarding when to schedule your tax preparation appointment. In addition, you may be able to view your tax forms sooner with Edward Jones Unline Account Access. For more details, see www.edwardjones.com/access or contact your financial advisor. This Period This Year Beginning value $0.81 $0.81 Assets added to account 500.00 500.00 Income 0.00 0.00 Assets withdrawn from account -500.00 -500.00 Change in value 0.00 0.00 Ending value 0.81 0.81 + Assets held outside of Edward Jones 56,576.57 56,576.57 Total Account Value $56,577.38 • • ~ 1 .•~ • •- -. .. Ending Cash 8~ Money Market Balance Cash $0.81 Amount Annuities Purchase invested (Held at the Annuity Company) Value as of Date Since Inception Value Polaris II A-Class Variable An Contract # P13A3406999 1 /28/2010 1 1 /24/2003 73,000.00 56,576.57 Total Account Value $56,577.38 Date Description Quantity Amount 1 /27 Direct Deposit SunAmerica Annui Annuityach $500.00 1 /29 Direct Payment to Acct No 47306416 -500.00 Account Type Single Account Holder(s) Mary E Wasseil Account Number 896-10103-1-4 '~ i~*', d'. ,t~ Financial Advisor Sean Ferguson, 717-731-5432 a~c~'~'";£~{`a ~+*u K 1300 Market Street, Lemoyne, PA 17043 Statement Date Jan 1 -Jan 29, 2010 Page 2 of 2 About F.dvrard Jones Edward D. Janes & Co., LP. is dually r~istemd with the Securities and a Caaomission (SEC} as a ba+olaer~ealer and as inv advisor. FdwardJoaes is also anoember' ofFINRA. Stnteiaent of F~aeial Coraditioo -- Edward Ja>e~ stabe:nart of Emanuel condition is available ~ your personal review: • at your laical branch ofilce • at www:edwardion~esoaoolen USlcanpr+nyl' + by mafi upon written request About Your Accost AocoantInformasdlon-Your Amount Agreement co~air~ the complete cooditior>s that ®o~rein y9ouc acooru~ Please oo~ct your financial advisor if you have arty changes bo your financial situation, oanta~ infocaaation or iavestrmeat objectivr~s. Account Saik~- --- P}esse review your' staixxoent Illy. If you believe theme are emote on your acooamt, ynu must notify us pranrptiy ofyour oanoems. You may either caRrtact our Client Relatior~ d~ err your financial advisor. You should re-oo®firm any oral oar~mmimic~tiori by sending us a letter within 30 days to protect your ng~ts, n~duding your rights under the Seetaitiea Investor Probactian Alt (SIFA}. Faros or Quesiiona about your FJectranic Trsasfers - Ca~ct Client Relatias~s at (800}441 2357. Comfs abort Yom• Accomt -- If you have a caemplair~ please seed a letter m Edward Jones, Attn: Complaurts Dept., 1245 JJ Kelley Nlemarial Dr., St; Louis, MU 63131. Go Gcee» I Did you know you can receive your statements and other ~urnents online instead of on paper? Visit www.adward}ones.c~anledelivery for more mformahon. Witfrholding as 1Distril>otioas or Wfth+~rawals -Federal law requires Edward Ja~aes to withhold incoate tax on distribution(s) from your retirement a~oco~onts and other plans unless you elect sot to have withholding apply. You may elect a percxntage to be withheld fivm your distribution or not to have the withholding apply by signing and dating the appraprs'ate form and returning it to the address specified on the form. Your electiar will remain in effect until you change oc revoke it by rehn~ning anotl~ signed mid dated farm. If you do not return the harm by the date your distin'butiaes are scheduled to begin, Federal income tax will be withheld. If you do nut have enough inayme tax withheld fiam yarr disbn3mtians, you may veal to pay estimated tax. You may incur penaifies if the ainocmis withheld and your estimated tax payments are not equal to the tax you owe. State withholding, if applicable, is subject to the state's withholding requirements. Fs3r Maricet'i~idne for Isdividaal Retirement A~cco~ts - Yoca fair marloet value as ofDecember 31st will be reported to the IItS as required by law. Rigata fin Yom Free Credit Balance -- Yau may ask to withdraw yarr free credit balance during na®al business haute, subject to any indebbednc~s m your aooount While yrxr fiords are sat segregated, they are properly acoountaod for an oiu boots. P.dward Jones may use your free credit balance to conduct business. Learn Mare aborrt Your Statement, Review Additional D~o~ea and. Tern~inaiogy-Visit http•1/www edwardjanes_cam/en US/ ~ center /index.htiml One Acaaa Tel Tree Phome '~` $UO-X12357 Monday Fridgy lam -7pm CST ''d Online Aovoacrt Access www.edvvaEdjnnes. oo3n/access 20~ Prop}ess party ® Maryland Heim, MO 63443 '~' Edward Jones Odiie Support 800-411-5243 Outer Contacts F,dward Jones Mas6~x(,aud '~ 844.362-6294 Edward Jones VGSA De>~ Card ~ tt88-289-6b35 Account Type Single Estate of Mary E. Wassell Pennsylvania Inheritance Tax Return Form REV-1500 Schedule F Documentation of Expenses i ~,i. ~~{~~i~ ~t'' ;,=.w~fi ~,. ~ .. ~- I~'nn CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249-3166 Fax: (717) 249-2663 May 21, 2010 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Craig A. Hatch, Esquire Mary E. Wassell Estate RE: Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Lazti~ Journal. Advertisement inserted on following dates: May 7, May 14, and May 21, 2010 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director CSC C~ ,~ :~ -~-') J', ~' ~~~~ `~' t ^~4 ~`' ~ '~ _~-. `~ d3 1 d ~ ~ 4.~ ~ v ~v ~, ~; "` `~,.. r. ~ ~~ ,, ~~, ,~`-..~ "~\ w- CC3 ~J :;~`~.. F a-~.. _; `~~ ~J ~. ~~ t'-`~•~ `_~,~~ .~ U rJ (~ ~J r~Y~1£' ~~11~.i11~' wwv~.cumberlink.cam GATES, HALBRUNER, 8~ HATCH 1013 MUMMA RD. SUITE 100 LEMOYNE, PA 17043 717-731-9600 AD NUMBER PAGE NO. 383038 1 of 1 BILL DATE SALESPERSON 05/11/10 wolfc START DATE STOP DATE 04/27/10 05/11 /10 AD NUMBER AD DESCRIPTION CLASS LINES 383038 ESTATE NOTICE LETTERS TESTAMENTARY 10 PUBLIC NOTICES 46 * 2 cols Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL -LEGAL 3 LGL $244.26 TOTAL AD CHARGE $244.26 3 PROOF OF PUBLICATION 01PRF $7.00 Purchase Order Est.M.E.Wassell PAY THIS AMOUNT $251.26 $301.51* -- *AFTER 06/10/10 Thank you for advertising with The Sentinel! Deadline for in-column legal ads is 4:00 p.m. two business days prior to date of insertion. For questions, call (717) 240-7130. THE SENTINEL c/o LEE NEWSPAPERS PO BOX 540 WATERLOOIA 50704-0540 Return this portion with your payment Check # ~ Credit Card Acct #: Exp. Date: m m Name on credit card Signature THE SENTINEL c/o LEE NEWSPAPERS PO BOX 540 WATERLOO IA 50704-0540 Legal Ad Number 383038 Billing Date 05/11/10 Amount Due $ 251.26 Amount Enclosed $ Please make checks payable to: THE SENTINEL 000336 • GATES, HALBRUNER, & HATCH 1013 MUMMA RD. SUITE 100 LEMOYNE, PA 17043 THE SENTINEL c/o LEE NEWSPAPERS PO BOX 742548 CINCINNATI OH 45274-2548 ~~~~~~~~~~~~i~~~~~~~~~~~~~~~~~~~~r~~~~~~~~~~~~i~ n ~~~~~i~~~~~~ 21,5402D000000383038000000DDOOOOD0030151,00000251,264 ~I~, Millennium Millennium Pharmacy Systems 100 E Kensinger Dr Building 120 Suite 500 Cranberry, PA 16066 Tel: (866) 466 - 7779 April 15, 2010 To: Linda Johnson 7 Spring View Ct Mechanicsburg, PA 17050 Re: Mary Wassell Facility: Sarah Todd Nursing Care Acct #: STMH1720 Total Balance Due: $0.00 Ms. Johnson, This invoice serves as a zero balance notice for the aforementioned account with Millennium Pharmacy Systems. We have received your payment of $195.12 on 4/15/2010 as payment in full. As of this invoice date there are no further monies due on this account. No further collection actions will be pursued. Please keep this invoice for your records. Thank you for all your cooperation in resolving this account. If you do have any questions or concerns feel free to call or email per information found below. Best Regards, Philip Rooney Collections Representative Tel: (724) 940 - 2826 Fax: (724) 940 - 2897 Email: PRooney@MPSRX.com RECEIPT FOR PAYMENT ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wil:1s One Courthouse S uare Carlisle, PA 1713 WASSELL MARY E Estate File No.: 2010-00350 Paid By Remarks: LINDA J JOHNSON SAP Fee/Tax Description Receipt Distribution Payment Amount Pay PETITION LTRS TEST WILL SHORT CERTIFICATE JCS FEE AUTOMATION FEE Check## 1032 Total Received......... 90.00 CUM 15,00 CUM 24,00 C 23.50 BU 5.00 C ---------------- 157.50 157.50 Receipt Date: 4/05/2010 Receipt Time: 13:44:16 Receipt No. 1060602 ee Name BERLAND COUNTY GENERAL FUN BERLAND COUNTY GENERAL FUN BERLAND COUNTY GENERAL FUN EAU OF RECEIPTS & CNTR M.D BERLAND COUNTY GENERAL UM R FUN UM Control No. ~=ORt~ l ~f,`0 (U7i(34j ArC, ~T, Ks, lam. Edo, GH, PA, SD, TPl, V i ,':V.4 A 3~ 4; ..~ ,d} f '°`~`r ~ n • {NSURANCE-FUNDED PREARRANGED FUNERAL AGREEMENT{TH{S {S N{3T A PURCHASE Ct~NTRACT~ i . STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Ghar~es are only for those items you selected or that are required. If we are required by law or by a cemetery or creme#ory to use any ifems, ll l i h i i we wi n wr exp a n t e reasons #rng below, df you selected a funeral thaf rrray require embalming, sucfi as a funeral with viewingr, you rr~ay have I`o for embalmin a You do not have to for embalmin a ! did if l t t d h t di p y g. p y g you approve no you se ec e arrangemen s s immed~afe burial, if we charged for embalming, we wilt exp am ~vhy below, uc as a rect ererrratron or SECTION i -SERVICES AND MERCHANDISE: MERCHANDISE CONTINUEt); ` MINIMUM SERVICES OF THE FUNERAL = ~~ s UrnlVase ;`~~ ~ ,~° ~~~ ~`~~ ` ° . ~ ~ xa- ' . . ~ DIRECTOR AND STAFF. ............................................ S , r Alternative Container . ~~ ~ ~~ Personae{ available 24 hours a day, 365 days a year to respond to initial - call' ~ OTHER GOODS AND SERVICES. ~~ Arrangement Conference. _v-~...~ Flowers ~~ Coordinating service plans with cemetery, crematory, andlor other S parties involved in the final disposition of the deceased. Grave Marker ,. ~ `n ~ ~~ Clerical assistance in the completion of various forms associated with Memorial Book -~ _ ~ a funeral. Service Folder (Prayer Cards -. ~ ~'" w -- ~ - ~5 ~ ~~ Securing and recording the death certificate and disposition permit. Acknowledgment Cards - `-:$ "` ~~ Also covers overhead, including facility maintenance, equipment and Cremation Fee ~ ~'~ inventory costs, insurance and administration expenses, and govern- Other `~ r ~ mental compliance. (Describe} ~'" ~ ~ ~~ ~ ~ ~ ~~ ~~ . .ARE AND PREPARATION OF REMAINS; .~ - _ __. - (Describe) = ~ •- ~ . `~ ~ . _. _ ,~ Embalming. ... ~ ............................................................... (Describe) ,: . ~ ° . .. ~. ~> Refrigeration ............................................................. S -~ _ ~ ~ r, S ~- Other Preparation. S - (Describe) : _ _ - :, S _ ~ . i~escr~~,ej (Describe) ~ - - !I~SE OF FACILITIES AND STAFF: ~~ Use of Facilities and Staff Serfices for Visitation _ (Per day) .................................................................... S ,~ t r~; t 1' rt +n 4F rinrnc~ far C. rn r2l sC VI 4cllltles ariU tall ~er'V II.GJ IVS t u:re, us Services in Our Chapel ............................................. ~ _ {~ Staff Services for Funeral Ser~rice in Other Facility ...................................................................... S = Use of Facilities and Staft Serrices for Memorial Service (without body} at Our Chapel ........................ S = Staff Services for Memorial Service (without body} at Other Chapel .............................................. S ~~ Equipment and Staff Services for Graveside Services .................................................................... ~ ............................... . Other Use of Facilities and Staff S . TRANSPORTATION: (within a mile radius of F uneral Home} ~~ Transferring remains to funeral home ........................ S `- ,. Funeral vehicle ......................... ~ ~. ,~. ,. Family vehicle ........................................... ,~ ower car .................................................................. . -.. ,. Servicevehicle ............................................................. ~• Additional Transportation ........................................... w - * iFor al! vehicles, additional distance will be charged at the per mile gate in effect at the time of need, MERCHANDISE; ` ~• Casket selected ............................ ............................... S Description Steel Gauge Wood (spec) ^Bronze ~St.Steef ^Copper oz. Shell style: Square Round Urn Exterior color: Interior Material: Velvet Crepe I nterior color: Outer Burial Container as Selected ....................... ~ Description l Describe} ~ - ~- .__ .... ~.. _ = Discount ............................................................. 'Less ~ (_ __ _ _ ) Total Section I .............................................. .................... S _ SECTION ll -THIRD PARTY ITEMS These charges are estimates only - rto Cos# guaran tee.) At the time of delivery of the third party items specified below, funds available shall be applied by the Funeral Home to t he prearranged funeral services and merchandise ar,d third party items in the same proportion as initially funded in this Agreement. Cemetery .......................................................... ........ a _ ^ Crematory .......:.................................. ............................................... ^ Flowers ....................... ._..: ,_. S - ^ Obituary~Notices ........................................................ _ ~ _- Escorts ...................................--..,................... S - ^ Certified Copies .............~:...................'......`..:...._......... S - ^ PublicTransportation ................................................ S _ ^ Outside Funeral Director's Expense .......................... ~ _ ^ Vault Installation ........................................................ ~ - , ^ CfergyiReligiousFecility ............................................ ~ -- ` S ^ f~-usicians or Singers ................................................. ~ - ^ Hairdressing .............................................................. S _ ^ Permits ~ . ............... ...... ...... ............................... S ._ _. Sales Tax .................................................................. ~ _ ^ Other ......................................................................... w _ _ we charge you for our services in obtaining those items marked with an "X". Total Section 11 ................................................................. $ - ,.: _ TOTAL CHARGES: SECTIONS i & It .............................. S (The initial face amount of life insurance or annuity benefit applied for is egg}a! to the Total Charges set forth above.} v A r-~L~ua.u..u Shape Carving ^ Hand Etching ^ Laser Etching ^ _ PSM/Dedo ^ ~~ Base Engraving ^ Vases ^ ;` f ~ f ~ °" `- Subtotal -.. ~"-',/F Tax . ~~ ~. "'~-~ F '= - .. *Foundation _r-f r. " ~r '~ ~. r Labor Charge r,> Total ~f ._ ~ ,/ ~ I3 i e os t -lance ~` ~~ Deposit Type ~TTACHM~NTS ..pictures ^ A.ft~vork ^ ~2ubbing . ^ Cemetery M ap ^ t)ther ~ VA Here ^ __ Origin: Dt Ordered Dt Received Mfg. invoice# Crate# !n Shop P~_ Vises: t t ~: R~ei~ci: PSM Ordered: PSM Received: Fdt~~t. Ordered Ck Fdtn. Completed Positions: Correct ~~ LOT.. SEC. Gr. . ; Est. distance off road - ~" ;, Direction Mont. F aces r ~ i,. Size: Finish: _ Shape of T`op: ~ ''..," Size: Finish: Size: Finish: Vase(s) Qty: Type: Color_ Size _ Mount Memorial is to be created in the following design: Lettering Style: ~ _ Famlhim=t.,. Ind. Names Verse ^ FuII Size ^ In Shop ~^ 8 x I O ^ Email This agreement between DODDS MONUMENTS Inc., party of the first part and by party of the second , r s at~ whp eside ~ :. . ~ ~:_.. r ,,. Witnesseth: The part of the first part agrees to erect the following describe Memorial work by ,- . ~ . _ ~ e .- ,r- ,,~ ~. - the lot of . in Cemetery near , in the County of _ _. ,State of upon a suitable foundation furnished by party of the second part. Said foundation is installed by the cemetery according to their specifications, with no supervision by Dodds Monument Company. . ~`~ Tax *Foundation f;~ ~ ~ ~' Labor Charge . Total _ Deposit T`', '/ Balance Deposit Type ATTACHMENTS Pictures ^ Artwork ^ Rubbing ^ Cemetery Map Other ~ VA Here ^ ~~# Qrigin: Df Ordered Dt Received Mfg. lnvoice# Crate# In Shop Pending Vases: Qrdered: Received: _ PSI'JI Qrdered: ~ !~ PSM Received: Fdtn. Qrdered Ck_ Fdtn. Completed Positions; Correct Reversed Verified By: ~ _ LQT_ ~ ~ ' SEC: Gr. Est distance off road ~ ~" ` ~ ` Direction Mont. Faces DfJDI}S M03~~~NTS ~'~C. CREATORS OF die Best In ~IemoriaC.Art MAIN OFFICE AND PLANT 123 West Main Street Xenia, Ohio 45385 (437} 372-4-408 Z oll Free (800) 77-DODDS (800-773-6337) Fax: (937) 374-4342 Email: doddsC voyager.net Website: wwFi°.doddsmonuments.cam Special Instructions " F ~, i - - - __ This agreement between DODDS MONUMENTS Inc., party of the first part and by party of the second part' ~ ~ - .. .. _ - - whp resides ate._ I - +r ~~ ~ ~ f - - --- Witnesseth: The part of the first part agrees to erect the following describe Memorial work by ,. _ . '~~ ¢ -~ , or as soon as possible, in a good and ti~~orkmanlike manner, on ~~ the lot of , in ~ Cemetery ~' near , in the County of ,State of _ 'yam upon a suitable foundation fiunished by party of the second part. Said foundation is installed by the cemetery according to their specifications, with no supervision by Dodds Monument Company. tae party cf the second part agrees that the above described work shall remain the property of the party of the fast part, with the right to remove, unless fully paid, even ~n the event of Bankruptcy. All contracts accepted subject to delays caused by strikes and contin- gencies beyond our control. "This contract is not subject to cancetlation_ APPROVED AND ACC +'PTED by: Memorial Consultant: f ,_ Phone Home Phone Cell Funeral Director I heard about your company through: Radio Newspaper TV Magazine Funeral Dir. Web Site Other CUSTOMER MUST INITIAL THE REVERSE SIDE OF THIS CONTRfi CT. 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