HomeMy WebLinkAbout04-0622
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate o/f,4 -r {.Z.l (I A- r+rJ. II t;L:,4,(
also known as 11 ~ -r 7'-1 1)[:: A tZ-
No.
To:
21- 01- ~ 2.2.
Register of Wills for thel
County of C.J. J!#1 b1" r ~ rfId in the
Commonwealth of Pennsylvania
Deceased.
Social Security No. / ~3-,5a 7t>2 ~ d
The petition of the undersigned respectfully represents that:
Your petitioner(~, who is/are 18 years of age or older, apply / '" 5
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decendent was domiciled at death in
h -e. or last family or principal residence at
Decendent, then - -:3-7
at
years of age, died
d 7 J.4 19-1
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Decendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows: /I (J A I (~
$ ~ "0 t1
$
$
$
Petitioner~ after a proper ~earch haS- ascertained that decedent left no will and was survived by
the following spouse (if any) and heirs:
Name
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CU-VYl RlZRLIhJ b
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The petitioner(s) above-named swear(s) or affirm(s) that the
statements in the foregoing petition are true and correct to the best
of the knowledge and belief of petitioner(s) and that as personal
representative(s) of the above decedent petitioner(s) will well and
truly administer the estate according to law 0
Sworn to or affirmed and subscribed
before me this /0 day of
J"'~LY~. .d9~. '1
~U l_AJJ OuLJ.iw
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No. ~l"O 4 .., ~LL
Estate of ~A-rKl tl ft-AN!\J B~
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k1<.A- , Deceased
"-fA 1 T"1 B ffi1<-
GRANT OF LETTERS OF ADMINISTRATION
uro1
AND NOW r LU.- Y t.p )4'-, in consideration of the petition on
the reverse side hereof, satisfactory prCW! haviRg been presented b~f~ me, B -,-J)
IT IS DECREED that ~ ~ ~ '-Y/h.U.. :r: - C:::Pr:P- ~
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to .:1 fhAL .:z- S ~ Sf<-
FEES i
Letters of Administration $ I 000
Sh C of' (";:l,,) $ Y . 0 0
ort ertl lcates '"" ...~... 0 . -
R:".tull"~al~ull ., 0 . . ...;J:"'~ . . . 0 .. $ l [) - 0 n
Filed....... ~O~AL.. A~~~
in the estate of
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
Ii 105.X05 REV 91~6
"T:lis is to certify tllat the information here given is correctly copied from an original certificate of death duly filed vitI- me as
Lucal Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
~
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
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10371907
No.
HIOS.I4JAe" 2117
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Date
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Co-
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COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH' YITAL RECORDS
CERTIFICATE OF DEATH
TYPE/PRINT
IN
PERMANENT
Bl ACK INK
NAME Of DECEOENTIF.,.. MIdcIe.l_1
..
AGE (lHl BII1tIOaW UNDER t YEAR
- !:, Do,.
57,,"
SEX
Female
UNDER 1 OM
Hor.n i Win&da.
IWrrHPLACE Ie..... and
saa"OlfeteognCo..ouyj
Harrisburg.
COUNTY OF IiJeAl'H
Cumberland
DECEDENT'S USUAl OCCI.INJK)N
(Give ~ 01 wen donecb':zt1hOll
oIworking-.~UN011~)
".. Upp Y ..
DECEDENT'S MAILING ADDREss (SIr.., CIIv/'bwI. ... Zit) eoo..
2 i 3 'vVesi Main Sireei
Mechanicsburg, Pa. 17055
DECEDENT'S
ACTUAl.
RESIO€NCE
lSoo___
on~sidet
1l..s...
Pa.__u~ ...
-
.....
Cumberland _,
IT.. L"":':'i.'.::'.. Mech ani c sb u rg
YOTHER'S HAUl!: IFifa ......,......" Sur.......)
Helen L Paxton
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fRHER'S NAME (fir.. Mid<Ie. lilli'
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""''''''''''''.........,,-,.,
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METHOD OF 04Sf'OSfTION
O ......1iil1ti_O
00nM1DR ou.~l
0..
SlGNAY
2. .
JOU<:E OF
..0lIl0<_
Rolling Green Memorial Park
1..
Camp Hill, Pa. 17011
.....
Paul J. Bear, Sr.
Carol Ferenz
DAlE Of DEATH ,MCnIh Oa~.'hfl
May 27, 2004
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RACE. A"'-"Can IncRn, 8Mck. While ~
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MANIA&.. IlTATUS.....".
Hewr u.r.ied. Widowed.
--
Neyer Married
10.
White
SURVMNG SPOUSE
(1f......."....tn;MOfInnamel
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II<FOAMAHr.__..lSo....~._.lJp"-
117 North Hanover Street Carlisle, Pa. 17013
.,..,.. ot~ C,...." lOCAfION. C~f1Own. SUe., ZrpCOdli
Jun 2, 2004
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DAlE OF tNJURY
(Wonh, Day. ...,
ow lOtoA AS' CONSEOUfNCE Of)o
ow lOtoA AS' CONSEOUfNCE Of),
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IMNHER OF 0lAJH
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INJURY IfI WORK? DESCRIBE HCrN NJURY OCCUMEo
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PlACE OF INJUAV. AI home, 1amI...... ~ OffIce
buildInQ._.lSpec.ly,
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CEATIFIER 1Ch<<2 ~ oneJ
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.PRONPUNCaHQ AND cun.....1NQ HfYlIM:IAH l~ tloIrl Pl'0I'\0unc.ng 0ltaItl and ceR/fyIrIQ lOc.use ol ~.alhl
To..... bnt oI.W knowINge. dulhooc.," ........... .... and pIac.. MId due 10 Ihe u~.) and menn.r.. .'.Ied
.MEDlCAl EXAMINER/CORONEA
On the b..ie OI..amlN'1on WNMO#lnve.Ug.tion,ln mW optnion, d...h OCcurred., th.llme. d.... .nd plac., MId dU.lo (he CaUN(S) and
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REV.' 500 EX (6-00)
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
OFFICIAL USE ONLY
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FILE NUMBER I /
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COUNTY CODE YEAR
INHERITANCE TAX RETURN
RESIDENT DECEDENT
1l~~~~
NUMBER
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DECEDENT'S NAME (LAST, FIR T, AND MIDDLE INITIAL)
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DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
05.... 2. 7 - J..oo 10 -/2. -/91f('
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
AI/A
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER I J
- -/'ItA
SOCIAL SECURITY N~BER
Ic.?>- ~O
72'10
,
~ 1. Original Return
D 4. Limited Estate
D 6. Decedent Died Testate (Attach copy of Will)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (date of death after 12-12-82)
D 7. Decedent Maintained a Living Trust (Attach copy ofTrust)
D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
D 3. Remainder Return (date of death prior to 12-13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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FIRM NAME (If Applicable)
COMPLETE MAILING ADDRESS
:1:{ L -eb R~ ·
C~('-I:~k
pI}- , 17013
(1) ~ QC
(2) gS g
(3) N/A C' (/)
rr:
HI/I -0
(4) I
(5) -n IJP'JO.sS- \0
filA --0
(6) .J' (f{
AI/Ii 0"1
(7)
.
TELEPHONE NUMBER
/
-/327
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r. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4, Mortgages & Notes Receivable (Schedule D)
/~.
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
~
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
(9) fJ 7Q 1(. 0 0
(10)
(8) J$128(J ~ \,\5-
:l1'I~7~2/
- (11) It 85/3 . 2 f
(12) -#7,;,3).r ,~
(13) a
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14) ~i1 7:l3~, (:~
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax b 0 (1)
rate, or transfers under Sec. 9116 (a)(1.2) x.O_ (15)
16. Amount of Line 14 taxable at lineal rate 0 d (16) C)
x.O_
17. Amount of Line 14 taxable at sibling rate 6 x .12 (17) 0
18. Amount of Line 14 taxable at collateral rate ~ x .15 (18) 0
19. Tax Due (19) (JJ
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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Decedent's Complete Address:
STREET ADDRESS
CITY
STAT It
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
/VI,.
1/;;
~0
(3)
(4)
(5)
(5A)
o
Total Credits (A + B + C )
(2)
o
3.
Interest/Penalty if applicable
D. Interest
E. Penalty
4.
Total Interest/Penalty ( D + E )
If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT,
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE,
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
o
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PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;.......................................................................................... D
b. retain the right to designate who shall use the property transferred or its income; ............................................ D
c. retain a reversionary interest; or.......................................................................................................................... D
d. receive the promise for life of either payments, benefits or care? ...................................................................... D
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? . ........................ ... ................... .............. .............................. ..... ... ........... 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ D
No
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
SIGN
ADDRESS 0.1
SIGNATURE OF PREPARER OTHER THAN REP ESENTATIVE
ADDRESS
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. 99116 (a) (1.1) (i)].
For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [72 P.S. 99116(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%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1 )].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116(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.
REV.1508 EX + (1-97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ANN 13 l:: R I<.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
~
It! R l ( I A
FILE NUMBER
2.<,ol( -OO~ Z 2
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
~.
..3.
},
<;.
I.
1.
~.
Ie.
I It
t~t
\3..
t, "I (
fS.
DESCRIPTION
c.\cA"':",\ J A$S~ ~~+ ~ :C"-hl -r- ~ :A'5J S (t~S~~oc,t'S/
U w'\~.q- t.XJ.e'b..r Su..re..~~~/ ;.J~~~
e."I\~~:^~ (~~-\c.r P-e stN)~A-/LJv\(j.52J'ol-e..,
" 'Dr))~"" 1)l'e5Se.(" W)wo~("' ~h.~6S---
~ .(Y\~ '" 13 r.'O )C-'lA ~ f\ 1:> ( C \
U rrt~~ " d~v dresSer 11J\(:)\.U'6(t~ Co(\<~.
fr\. \ Se, ~~~.s 0 '" ~~4~ ''1oo~ Co ~ ,1t>(J~ brdK4A
I 3 l' "1: V. ~ 0\-- (. a 'ok re.~~ I ~l LUot'iI'.
dll " 1: v. G&bk re.~J-, I lJ...te-.\\ W-o-t"l\.
C<- to ~ \I <:... R. t..) I G~.b \-<.6 w-e \ l UJO f'1/'.
~ Co~tY\~ j~/~ J\~~L~ ?(()~:-<. b-.e&l.s
AsS+- Cb1>~ ~~5
~";> ~. V~ 1>bo ;t\ j\t<; j\JCf2..
~\~ 1~~^~:~
7~~ AlhLih15 Wi fho~J
o 'f-v (":So( .s
C~td<~~ ~ C<dvn-\
VALUE AT DATE
OF DEATH
IS I()O. 0 a
tJo.oa
I ~a. ~Q
JI /0 (0 (]
Jj 10. () ~
J$ .5.00
.Jtfl5.oo
"/(1.60
~~... oc
Jt Ie ~ t:J CJ
Ii 0'" (jC
~ 3,60
JJo ~\~
<is SlOe>
l/oSo ( 55
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
.~65
REV-1511 EX+ (12-99) .
.~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE~ -I 4-
1J(~rc)
ITEM
NUMBER
A.
B.
1.
2.
AAJ ;V
FILE NUMBER
dOcJq -'- ()d6 Q~
OE~
Debts of decedent must be reported on Schedule I.
1.
DESCRIPTION
FUNERAL EXPENSES: A \ \ r-r ~ C l ~... r",\ ,...",. -'" (J _
· .,).. U ~ ,,~ "-.:1,) \~ <!- U-.Q.1l ~ "j \J '2!.U j +
c.~~ 1<<: \-- ), r "_ I J
I e.M do. ~.vt-5) 'Y;<}~7of/ 5 ~~S~ ~<- -t-eVl~ d 06: ^-9
JJ "t61" ,00
AMOUNT
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal RepresentatiVe(S)rr A~ \ -:}\ ~~, 0n '
Social Security Number(s)/EIN Number of Personal Representative(s) 2 c" - t3c, - 2" l~
Street Address 2 2 L<-.>o 0 ~ l ,
City C~I"\ :5\-L State~Zip (70J ~
Year(s) Commission Paid:
a%
Attorney Fees
N/A
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
4.
5.
6.
7.
Claimant
Street Address
N/A
.
City
State _ Zip
Relationship of Claimant to Decedent
[; [lJ rt~~
Probate Fees
d'3 7. od
AI 1ft
~/A
jp37.dO
Accountant's Fees
Tax Return Preparer's Fees
TOTAL (Also enter on line 9, Recapitulation) $ 70 5 ~ ,,0 0
(If more space is needed, insert additional sheets of the same size)
Credits Granted: $264.00 Goodwill Adjustment
If there are any questions or concerns
that remain unanswered, please call
me
$1
TOTAL OF SERVICE RENDERED
LESS: Credits granted
LESS: Total Payments
CURRENT BALANCE
,695.0
Package Price Discount
$8,975.00
1,959.00
7,016.00
$0.00
SUMMARY OF EXPENSES
Myers Funeral Home, Inc.
Boyd L. Myers Jr" Supervisor
3 7 East Main Street
Mechanicsburg, Pennsylvania 17055
(717) 766-342 Fax (717) 795-7291
,. A standard of excellence in Central Pennsylvania since 1910
Monday, June 28, 2004 t
~1."':~:~~~ic,.. 0 e:;~
i\ov , -a~+~ 71/t..
~~Ubc ~,
Carlisle, Pa. 17013
Dear Ferenz,
Thank you for selecting our funeral home to provide services for your family during your bereavement. I
hope that you found our services to be of the highest standards and that they met your needs and those
of your family and friends.
The following is a summary of the service charges as previously explained and provided in written form
and herein indicated as PAID-IN-FULL.
Patricia Ann Bear
Newport Ambulance league, Inc.
50 South 3rd Street
*
NEWPORT, PA ot 7R7A.
Phone#: (800) 367-0512 INVcJJe~1 Tax ID: 23-7359121
PATIENT NAME: PATRICIA BEAR PATIENT NUMBER: 653 NMI
CALL NUMBER: 1M400228 INS1
INSURANCE: HEALTH AMERICA 16350724001 DATE OF CALL: 04/14/2004
TIME OF CALL:
CALLER: PolicelFire/911
W0400228 FROM: 70 MONTABLEO RD
TO: HOLY SPIRIT HOSPITAL
PA TRlCIA BEAR
213 W MAIN ST APT 4 REASON(S) ABDOMINAL PAIN
t/ECHANICSBURG. PA 11050 FOR
TRANSPORT
DESCRIPTION OF CHARGE
QUANTITY
UNIT PRICE
AMOUNT
BLS EMERGENCY
MILEAGE
CONVENIENCE BAG
A042Q
A0425
A0382
'l.0
22.0
1.0
300.00
7.00
1.30
300.00
154 .00
1.30
~\ D j<(-jJ tV z et.j
e-keJ,L 6:L
otal Charges
455.30
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
y
,
Total Credits 0.00
PLEASE PAY THIS AMOUNT ~ $455.30
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE 455.30
PATIENT NAME: BEAR. PATRICIA CALL NUMBER W0400228 AMOUNT $
PATIENT NUMBER: 653 BILLING DATE: OS/20/2004 ENCLOSED
A CLAIM FOR THIS INVOICE HAS BEEN SENT TO YOUR
INSURANCE.PAYMENT MAY BE MADE TO YOU. PLEASE REMIT PAYMENT
TO US. THANK YOU.
...1________"""" .._L..~.I____ I ____~.._ 1__ s::.r. C"'_...LL.. 1"1--1 C""I.__"'" r..1r-lAII"\.I""\.n"T" n. .~.i"""
.~I-bLY
SfIJMI
The Spirit of Caring
Holy Spirit Hospital
C:~-i\~:~i'l.w~"'~~~~!;l'iL; ,;'.;&.;:';;,;,;W)j..:~p;;<,~bi1;;.'i~':!'X~:,,',~,.; ;;'l'l-'~;~,::-,c
';,' -<Lg~':i:;;i:' ,',:;; '::.'iI!1:j~~ :',
503 N 21ST STREET
CAMP HILL PA 17011
#
717-763-2141
. . . . '. . . . . . . . . . . . . . . .
.................................................. ................
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::\}\~~ij@t:.Nij~{}:~~12'~Q8,.......... . ... .... .....
For Account Information, Please Call 717-763-2141
Transaction Date
02/27/04
02/27/04
02/27/04
02/27/04
02/27/04
02/27/04
02/27/04
03/25/04
06/02/04
06/02/04
Description
PREVIOUS BALANCE
DISC ELECT AD 4
IV CATH
TRANSPARENT DRESSING
ED LEVEL IV. PC
LEVEL V 1-4 HRS COMP
NON-EVA EAR/PUL OX FOR 02SATUR
RHYTHM ECG 1-3 LEADS INTERSREP
HAMER CIA HOS-IP Q02 HEALTH AMERIC
HAMER PYMT-IP Q02 HEALTH AMERIC
HAMER CIA HOS-IP Q02 HEALTH AMERIC
Amount
14.674.60
5.00
14.00
1.00
259.00
933.00
35.00
79.00
1. 326.00-
12.881.00-
1.741.20-
Estimate,. Insurance Due:
.00
Total Patient Credits:
Account Balance:
52.40
Q02 HEALTH AM ERIC ,00
PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID.
.-----------------------------------------------------_____________~L._a!!_ot~IJ.!!!'!_~_I'!!_Ii'!I!I:!.1!!!!!:.mT!!!!.________________________________________________________________
For HlIlIpltal U.a Only Account Number:
22726608
Pattent Name:
BEAR ,PATRICIA A
0.0==0 ~"~~R
HOLY SPIRIT HO~ITAL
S03 N 21ST STREET
CAMP HILL PA 17011
#
ADM DT: 022804
DSH DT: 030904
S8: KOOOO
717-791-9063
Due By:
06/22/04
Card Number:
CVVJ No:. Bxp, Date:
ADDRESS SERVICE REQUESTED
HR: HSG
789.09
Signature:
Amount Paid:
Make Check Payable To HOLY SPIRIT HOSPITAL
. The CVv:I Number Is the lut 3 d11ltl on lhe bact of your credit card, by your Ilgnature
1...111...111....1.1..1.1..1111I.1.11..1....1111....1111.11111
00002555 1 AT 0.292 01
22726608
PATRICIA A BEAR
213 W MAIN ST APT 4
MECHANICSBURG PA 17055-6281
I, ..III, ..111....""...",,1.1..1,1"....1,, III..." ~f,l'~~ \) '?- ~3
HOl V SPIRIT HOSPITAL ()lJ
503 N 21ST STREET J_ J
CAMP HILL# PA 1?01l ~ :]0"';---
o Please check this box If your address or Insurance Information has changed and record the changes on the back 0' this statement
- rt?~lb .Q<t jJ,0 d'(
---
- 111I11I11I11I11111.1
- .
~"'
====1 65880 AT 0.292 C\v.?d,LU{ L)~
-Q PATRICI A BEAR TROO023
-..
-'"
=.. 213 W MAIN ST APT 4 lS4-~\~ML'f(
MECHANICSBURG, PA 17055-6281
-
-
Dear Patient/Guarantor:
Thank you for choosing HOLY SPIRlT HOSPITAL for your health care needs.
Your account has a balance of $144.72. If you are unable to pay this amount in full. or have
any questions,Slease contact our Patient Fmancial Services by calling (Toll Free)
1-877-254-923 .
If you have insurance coverage. please contact us inunediately so that we can bill your insurance for
you.
If you have already paid the balance, thank you, and please disregard this letter.
Sincerely,
Patient Financial Services
If you have multiple accounts, please indicate the account numbers and the amount applied to each on
your check. Payments received without an account number may be applied to the oldest account.
_~..._ ..,_~ _ .., If !~t !I~ bl!~t~_!'1~~ Please Disre2ard This Lette
HOl V SPIRIT HOSPITAL
503 NORTH 21ST STREET
CAMP Hill, PA 17011-2288
IIIII1IIIII11III
Patient Name: PATRICIA A BEAR
.#'atient
Responsibility
ServIce DlIlIl Account Number Amount
03/19/04 22862767 75.00
03/23/04 22881650 69.72
MAY
18 2004
Dear Patient/Guarantor:
Payment has not been received in response to our recent requests. Your account is now past
due. Please rem.it payment in full, or contact our Patient Financial Services at (Toll Free)
1-877-254-9239 if you have any questions.
If you have already paid the balance, thank you, and please disregard this letter.
Sincerely,
Patient Financial Services
If you have multiple accounts, please indicate the account numbers and the amount applied to each on
your check. Payments received without an account number may be applied to the oldest account.
If !~!!t .!I~ ~!~t ~1:1~!p.!e.28e Disre2ard This Letter
-
-
-
____lU
===16
-0
~t;
iiiiiiiiiiiiiOi"'
~
-
~
111I11I11I11I11111.1
53760 AT 0.292
PATRICI A BEAR
213 W MAIN ST APT 4
MECHANICSBURG. PA 1
Patient
Responsibility:
7055-628
::!!!I!I:!II!!III!!:!!!llll!!:!:!!:i!i::I:!:!:I:li!.
TR00020
1r!JY[
eNK 01
Serv.... o.c. Account Number Amount
02/28/04 22726608 52.40
03/19/04 22862767 75.00
03/23/04 22881650 69.72
1.t1l? J..<6;;Jv'.v<~
CkcK (!)~
Patient
503 NORTH 21 ST STREET
CAMP Hill. PA 17011-2288
1111111111111111111
HOLY SPIRIT HOSPITAL
Name:
PATRICIA A BEAR
JUN
12 2004
OS/20/2004
---\ (" BEAR PATRICIA
75.75 J I CPARC MAIN ST
53.41 I 213 W. MAIN ST
L MECHANICSBURG PA
---- -------- ----~
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
--------.. ..".. ..--- -- -.- --..-....-..".---.--- - -
ALERT PHARMACY SERV.,INC.219 NORTH BALTIMORE AVE. MT.HOLLY SPRINGS,PA
17055
17065
BEARP
GRP-32
PAGE
1
Amount pai~
Daa
STATEMENT OF ACCOUNT
-~
THANK YOU
-l
___J
..
..
Alert Pharmacy Services,
219 North Baltimore Ave
Mt Holly Springs, PA 17065
800-266-9954 . (717) 486-8606
Inc
A FINANCE CHARGE OF 1,50 % PER MONTH
(AN ANNUAL PERCENTAGE RATE OF 18.0%) WILL BE
CHARGED ON ALL AMOUNTS 30 DAYS OR MORE PAST
DOO
30 DAYS.
f>c() DAYS.
:90 . .DAYS.
#'
Date
06/18/2004
~~--) I ~EAR PATRICIA I BEARP
41.94 I CPARC MAIN ST I GRP-32
75. 75 J 213 W. MAIN ST J' PAGE
53.41 L_ MECHANICSBURGu~_~~_1705~____
PLEASE Di:TACH AND RETURN TOP PORTION WITH YOUR PAYMENT
ALERT PHARMACY SERVo INC 219 NORTH BALTIMORE AVE. MT . HOLLY SPRINGS, PA 17065
THANK
YOU
1----
hm:pa;d I
,
~l
-STATEMENT OF ACCOUNT
~
,.dert Pharmacy Services,
219 North Baltimore Ave
Mt Holly Springs, PA 17065
800-266-9954 . (717) 486-8606
Inc
A FINANCE CHARGE OF 1.50 % PER MONTH
(AN ANNUAL PERCENTAGE RATE OF 18,0%) WILL BE
CHARGED ON ALL AMOUNTS 30 DAYS OR MORE PAST
DUE
o PNC13AN<
040
MECHANICSBURG (041)
2 EAST MAIN STREET
MECHANICSBURG PA 17055
Cashbox 10
* Deposit Check
14:58 JUN282004
Account Number 5004639162
..Iran Amouri.. ~L $1.725.22.L,i.fo
'Jv ^~ r-e-f. ~trr ~hf b~~""'" ~ Cl
W/S 10 WWSH0412 Sequence Number 00289
Batch 403 N...ew3~"lo ~O.{
This deposit or pay lent is accepted subject to
verification and to the rules and regulations of
this bank. Deposits lay not be available for
il.ediate withdrawal. Receipt should be held
until verified with your statelent.
..
CERTIFICATION OF NonCE UNDER RIJJ_E 5.6(8)
Name of Decedent:
.v1t-11!.1(1~
,..foJN
"ie-I? R..
Date of Death:
J..7 M ~( f).,CJCJ'I
Will No.
Admin. No. ;},) - 0 Y - c;" ~ ~
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on
l'WM
~
:L
(b~I1-(..
3fL
;d;SSleb~) Kt
C~r \ :~\;:4-. 9~, 170/3
,
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date: q 5<-(1+ c200r
~n
o
N
N
0...
0\
I
n.
w
Vl
Qrot~ %_
Signature U
Name ? A-vl '::J, ~C:~ f.. j<,-,
Address;2:). L.... be. K ,L
,
C~....\~~~ __ [114 /7rf 13
Telephone 7/'5/ .1<.lf>'- 13..2.. 7
Ci ",.,:)
Um
Q..'i""'
c: '....
13
l,ij
.0
.:~
(jJ:::::
0U
Capacity: ~sonal Representative
_Counsel for personal representative
0-
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
'*
BUREAU OF INDIVIDUAL ~:s .'.
INHERITANCE TAX DIVISION
PO BOX Z80601
HARRISBURG PA 171Z8-0601
f ,~ NOTICE OF INHERITANCE TAX
~PPRAISEMENT, ALLOWANCE OR DISALLOWANCE
". OF DEDUCTIONS AND ASSESSMENT OF TAX
REY-15~7 EX AFP 112-0~1
'"'..2.
L1
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
02-21-2005
BEAR
05-27-2004
21 04-0622
CUMBERLAND
101
PATRICIA
A
PAUL J BEARr,~Jf?'-'"
22 LEBO RD ..
CARLISLE PA 17013
Allount Re..itted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
iEV :rJ\"f-E;t-Ar:p--r~1-:6J'--':;o"icE-oF-jNHERYflN-E-"Ax-A-ppiAYsE'rfN'~--Ai:i.oQANcE-oR'-----_._----- - --.
DISALLOWANCE OF DEDU8TIONS AND ASSESSMENT OF TAX
ESTATE OF BEAR PATRICIA A FILE NO. 21 04-0622 ACN 101 DATE 02-21-2005
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
~. Mortgages/Notes Receivable (Schedule D)
5. CashlBank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Totel Assets
(1)
(2)
(3)
(~)
(5)
(6)
(7)
.00
.00
.00
.00
1,280.55
.00
.00
(8)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this forll with your
tax pay....,t.
1,280.55
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Ad.. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Govern.ental Bequestsj Non-elected 9113 Trusts (Schedule J)
l~. Net Value of Estete Subject to Tax
(9)
(10)
7,016.00
1.497.21
(11)
(12)
(13)
(1~)
8.513 21
7,232.66-
.00
7,232.66-
I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect ~igures that include the total o~ ~ returns assessed to date.
ASSESSMENT OF TAX:
15. Allount of Line l~ at Spousal rate (15)
16. Allount of Line l~ taxable at Lineal/Class A rate (16)
17. Allount of Line l~ at Sibling rate (17)
18. Allount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
NOTE:
.00
.00
.00
.00
X 00 =
X 045 =
X 12 =
X 15 =
(19)=
.00
.00
.00
.00
.00
~
TAX CREDITS:
ft"'''''', I (+J AMOUNT PAID
DATE NUHBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 3/29/2006
BEAR PAUL J JR
22 LEBO ROAD
CARLISLE, PA 17013
RE: Estate of BEAR PATRICIA ANN
File Number: 2004-00622
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103
SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after
July I, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by:
5/27/2006
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
k~A) ~/~//~/
Glenda Farner Strasbaugh
Clerk of the Orphans' Court
cc: File
Counsel
Register of "'Ii Us of Cumberland county
STATUS REPORT UNDER RULE 6.12
Name of Decedent::?a:t (': ( -\ A A ^ ^ ~t" ~ <'
Date of Death: Old.) 2-7'& tJXYt
Estate No,: 200 Y - 00(;2 'L
Pursuant to Rule 6,12 of the Supreme Court Orphans' Court Rules, I report the following
with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes 120 No 0
2, If the answer is No, state when the personal represen~tiJ~e reasonably believes that
the administration will be complete: j.J _/I
3, If the answer to No, 1 is Yes, state the following:
a, Did the personal representative file a final account with the Court?
Yes IZl No 0
b. The sepa:ate Orph~si.Court No. (if any) for the personal representative's
account IS: IYL-R
.
c. Did the personal representative state an account informally to the parties in
interest? Yes Iil No 0
c, Copies of receipts, releases, joinders and approval of formal or informal
accounts may be filed with the Clerk of the Orphans' Court and may be
attached to this report,
Date: 1/ fY\~J Zooh
~ture
, ;Y~\J\
Name
;<,~~ d ,'7 ~
Address
\\~ ~( ()r-:...:re-
'7/7- :;2/)"- ~O?l
Telephone No.
Capacity:
III Personal Representative
o Counsel for personal representative
- .- I,U
ty\'~~ \~-~~ '/
p6- /7(:)
tJ)