HomeMy WebLinkAbout08-30-101505610140
REV-1500 ~` ~°'-'°'
PA Department of Revenue OFFICw. USE O~ILY+
Bureau of Individual Taxes INHERITANCE TAX RETURN CO~~ Code Year File Number
Po Box 260601 2 1 1 lD 0 6 3 0
Harrisburg PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date Of Blrth MMDDYYYY
2 0 1 0 7 5 2 9 7 0 6 0 4 2 0 1 0 1 2 1 7 1 9 1 6 ~!
Decedents Last Name Suffix Decedent's First Name MI
M U R T O F F B E R T H A ', W
(If Applicable) Enter Survivirtp Spouse's Information Below
Spouse's Laat Name Suffix Spouse's First Name MI
Spouse's Soaal Security Number
THIS RETURN MUST BE FILED IN DUPUCAT~ V~IIfiH THE
REGISTER OF WILLS
FILL INAPPROPRIATE OVALS BELOW ',
® 1. Original Retum ^ 2. Supplemental Retum ^ 3. Remaindler m (date of death
pnor to 112-1 )
^ 4. Limited Estate ^ 4a. Futuro interost Compromise (date of ^ 5. Federal ~ Tax Retum Required
death after 12-12-82)
® 6. Decedent Died Testab ^ 7. Decedent Maintained a Living Trust 8. Total Nulnb~
r of Safe Deposit Boxes
(Attach Copy of WUQ (Attach Copy of Trust)
^ 9. Litigation Proceeds Received ^ 10.3pousal Poverty Credit (date of death ^ 11. Election ~ I, under Sec. 9113(A)
between 12-31-91 arM 1-1-95) (Attach $ch O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTUIL TAX INFORMA, $NOULD BE DIRECTED TO
Name Daytime TelepFhon 14umber
R O G E R B I R W I N , E S Q U IRE 7 1 7 2 'i 4 9 p3 5 3
~
....
REGIST ILL8 USC~itJLY ~"i ~ ~.~-
~
' ~ S ,
.
First line of address
~-A~ ~ ~ Q R_ ' "
6 0 W E S T P O M F R E T S T R E E T ~ ~ ~ ~ ``'
~
Second line of addroas C { ~ ~ W
~~
~
,
W
State ZIP Code D
Off
P TE FILED G7
City or
ost
ice
~L A R L I S L E P A 1 7 0 1 3
~
Corns s e-mail sddnss:
Under pergddes of perjury, l declare that I have examined this realm, brdudkp aooorrrparrykg schedules and ste~emeMs, and to my knowledge and belief,
it le true. cXr~ rrecx and complete. Dsclaradon a proparer other than the personal represer~live b based an as iMormation of which has any knowledps.
SIG ER RE NSIBLE F FI NG RETURN DATE 8- ~~
J
ADDRESS
119 HILL DRIVE CARLISLE T ~' 17013
TIiAN RJt~PRESENTATNE
SIGNATURE OF EP ER OTHER v
3
~(,G~- 3, `
ADDRESS
60 WEST POM T STREET CARLISLE ~F ~A~ 17013
PLEASE USE ORIGINAL FORM ONLY !~
Side 1
1505610140 1505610 ~r40 ~`
J 15O561O24D
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: BERTHA W• M U R T O F F 2 0 1 0 7 5 2 9 7
RECAPITULATION
1. Real Estate (Schedule A} ......................................... .. 1.
2. Stocks and Bonds (Schedule B) .................................... .. 2.
3. Closely Held Corporation, Partnership or Sofe-Proprietorship (Schedule C) ... .. 3.
4. Mortgages and Notes Receivable (Schedule D) ........................ .. 4.
5. Cash, Bank De osits and Miscellaneous Personal Pro e
p p rty (Schedule E).....
.. 5. 7 8 1 8 2 . 0 1
6: Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6.
7. Inter-Vivos Transfers 8~ Miscellaneous N Probate Property
(Schedule G) ~ Se
ar
te Billi
R
t
d
7
p
a
ng
eques
.....
e .
..
8. Total Gross Assets (total Lines 1 through 7) ........................... 8. ~ 8 1 8 2 . 0 1
9. Funeral Expenses and Administrative Costs (Schedule H) ................ .. 9• 5 5 1 D . 6 6
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule l) ........... .. 10. 1 D ~ 7 • 1 2
11. Total Deductions (total Lines 9 and 10) ............................. .. 11. 6 5 8 7. 7 $
12. Net Value of Estate (Line 8 minus Line 11) .......................... .. 12. 7 1 5 9 4 . 2 3
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) .................... .. 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) .................... .. 14. 7 1 5 9 4 . 2 3
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2)x.o _ 0. 0 D 15. 0. 0 0
18. Amount of Line 14 taxable
at lineal rate X .045 7 1 5 9 4. 2 3 1s. 3 2 2 1. 7 4
17. Amount of Line 14 taxable
at sibling rate X .12 0. 0 0 17. D. 0 0
18. Amount of Line 14 taxable
at collateral rate X .15 0. 0 0 18. 0. 0 0
19. TAX DUE .................................................... ..19. 3 2 2 1. 7 4
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505610240 1505610240 J
__ - _
~,
Continuation of REV-1500 Inherit~lnce Tax Return Resident Decedent
BERTHA W. MURTOFF 21 10 0630
Decedents Name Page 2 File Number
Correspondents
Name Daytime Telephone Number ' '
R O G E R B I R W I N E S Q U I R E 7 1 7 2 4 9 2~1 3 5 3
First line of address
6 0 W E S T P O M F R E T S T R E E T
Second line of address
City or Post Office State ZIP Code
C A R L I S L E P A 1 7 0 1 3
Correspondent's e-mail address:
Under penaNles of perjury, I declare that I have exami-led This return, including aoa7mpanying sdledules and statements, and tD the best of my kr
N is true, coned and comple6e. Declaralbn of preparer other than the personal representative a based on all information of which preparer has ai
SIGNATUR~'F PERSON RESPONSIBLE FOR F11L,IN,G,
ADDRESS
BOX 72
Name Daytime Telephone Number
R O G E R B I R W I N E S Q U I R E 7 1 7 2 4 9 2
First line of address
6 0 W E S T P O M F R E T S T R E E T
Second line of address
City or Post Office State ZIP Code
C A R L I S L E P A 1 7 0 1 3
Correspondents e-mail address:
Under penalties of perjury, l declare that I have eucamined this return, kxiuding ao3ompanying schedules and statements, and to the hest of my kna
it is true, oorect and cortlplele. Dederaton of preparer otiler than the personal representative ~s based on aN information of whk:h preparer has any
belief,
7 - /~
3 5 3
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
ADDRESS
BOX72___ GARDNERS PA 17324
REV-150tl EX Page 3
Decedeht's Comalete Address:
File Number
21 10 0630
CEDENTS NAME
BERTHA W. MURTOFF
STREET ADDRESS
770 S. HANOVER STREET
CITY
CARLISLE STATE
PA ZIP
17013
Tax Payments and Credits:
~. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
B. Discount 161.09
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the dfffarence. This is the OVERPAY~NT.
FIII in oval on Page 2, LMe ZO fio request a refund.
5. ff Line 1 + line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
I
(1) ', __ _ 3,221.74
Total Credits (A + B) (2) 161.09
(3)
(4) 0.00
(5) 3060.65
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING pUESTIONS BY PLACING AN "X" IN THE APPItaP~tIATE BLOCKS
1. Did decedent make a transfer and: Y No
a. retain the use or irlconle of the property transferred : ......................................................................
b. retain the right to designate who shall use the property transferred ~ Its income; .............................
c. main a reversionary interest; or ................................................................................................
d. receive the promise for life of either payments, benefits or care? .......................................................
2. ff death occurred after Decerrlber 12,1982, did dec~derlt transfer property within one year of death '
without receiving adequate oonsideration? ......................................................................................
3. Did decedent own an'in trust fol' orpayable-upon-death bank aa;ount or security at his or her death? .........
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a benetaary designation? ............................................................................. .................
IF THE ANSWER TO ANY OF THE AfBOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R AIS 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
3 percent [72 P.S. §9116 (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 sur~ivi g~spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory re~ui rlierlts 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 far th~ use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. i
• The tax rate imposed on the net value of transfers to or for the use of the decedents lineal beneficlaries is 4.5 percent, e~Cgept as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedents siblings is 12 percent [72 P.S. §la116~a)(1.3)]. A sibling is defined, uncle
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-150$ EX + (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, 8~ MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER! ',
BERTHA W MURTOFF 21 10 0630 ~I
Include the proceeds of Ntlpatlon and the date the prooeeda rye reoeired by the estate.
Aa Joi wNh of suryhronh mud be dhclaad on ScMduN F,
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. M8~T BANK -CHECKING ACCOUNT #9838892066 ~ 6,118.24
2. M8~T BANK -SAVINGS ACCOUNT #15004214150118 16,954.66
I
3. M&T BANK -CERTIFICATE OF DEPOSIT #31003912754370 II 55,109.11
TOTAL (Also enter on line 5, Reca~'itul~timn) ~ S
(If more space is needed, insert additional sheets of the same size) 'T_
REV-151h EX+ (10-08)
' pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
BERTHA W. MURTOFF 21 10 06~30'~
Decedent's debts must be reportod on &heduk L
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS: ',
1. Personal Representative Commissions:
Name(s) of Personal Repreaer~tive(s)
Street Address i II
Cfly Stale ZIP '~
Year(s) Commission Paid:
2, Atbmey Fees: IRWIN 8c McKNIGHT, P.C. 4,750.00
3, Famly Exemption: (If deceder-Cs address is not the same as riaYnanti's, attach explanation.)
Claimant - -
Street Address
Cdy State ZIP
Relationship of Claimant to Decedent
4. Proba~Fees: REGISTER OF WILLS 107.50
5. Aocamtant Fees:
6. Tax Return Preparer Fees: PATRICIA A. ROSENDALE, CPA '' 350.00
7. REGISTER OF WILLS -FILING FEE 30.00
8. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 75.00
9. THE SENTINEL -ESTATE NOTICE 198.16
TOTAL (Also enter on Line 9, Recapitulation) I i
If more space b needed, use additMnef sheets of paper of the same size.
REY-151'2 EX+ (12-08) .
. ' pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES, ~ LIENS
RESIDENT DECEDENT
ESTATE OF FILE N
BERTHA W. MURTOFF 21 1
Report debts incurred by the decedent prior b loth that remalnad unpaid at the dabs of death, including
ITEM
NUMBER DESCRIPTION
1. CUMBERLAND-GOODWILL EMS -AMBULANCE
2. MILLENNIUM PHARMACY -MEDICAL
3. CHAPEL POINTE AT CARLISLE -NURSING
TOTAL (Also enter on Line 10,
ff more space is needed, breert additlonel sheets of the same size.
medical expenses.
I VALUE AT DATE
OF DEATH
232.50
102.39
742.23
S
REV-1513 ~7(+ (01-10)
' Pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
__ FILE
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT I
Do Not List Tn~stea{s) ANIOUN I tm ~rlArtt
OF ESTATE
I TAXABLE DISTRIBUTIONS (Indude au~M spousal disbibulaa and Uanafers under
'
Sec. 91 6 (a (1.2).] I
1. JOY U. KNAUB Lineal '~ 8,949.28
188 BENTZ MILL ROAD ~ 1/8TH REMAINDER
WELLSVILLE, PA 17365 i
2. D. RICHARD MURTOFF Lineal ~, 8,949.28
119 HILL DRIVE ' 118TH REMAINDER
CARLISLE, PA 17013
3. LAWRENCE H. MURTOFF Lineal 8,949.28
2
BOX 7 I
~ 1/8TH REMAINDER
GARDNERS, PA 17324
~
4. DOUGLAS M. MURTOFF ''
Lineal 8,949.28
877 MYERSTOWN ROAD Iii 1/8TH REMAINDER
GARDNERS, PA 17324
5. LAIRD K. MURl'OFF Lineal '~ 8,949.28
179 FROST ROAD ~
~ 1/8TH REMAINDER
GARDNERS, PA 17324 I
6. DAVID O. MURTOFF Lineal
I 8,949.28
845 BUSHEY SCHOOL ROAD li 1/8TH REMAINDER
YORK SPRINGS, PA
7. JAY M. MURTOFF Lineal '~ 8,949.28
6340 OXFORD ROAD ~ 1/8TH REMAINDER
GARDNERS, PA 17324
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 CO E S EET, AS APPROPRIATE.
jj, NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1. ~
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER
If more space is needed, use additional sheets of paper of the same size
_ _ _ _ _
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
BERTHA W. MURTOFF 21 10 0630
Decedent's Name Page 1 File Number
Schedule J -Beneficiaries -1
NUMBER NAME AND ADDRESS OF PERSONS RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS pndude ~utr~ght s sal distributions and transfers under
i Sec. 91 i6 (a~(1.2).]
8. STEVE S. MURTOFF
830 MYERSTOWN ROAD
GARDNERS, PA 17324
\TIONSHIP TO
Do Not List Tn
Lineal
AUNT OR SHARE
OF ESTATE
8, 949.27
1/8TH REMAINDER
-.
TA-~'~~
A-~ TES ''~
LAST ~~' c~
of D'~"Oa Tom'
Tpl"F~ ~ Tom,; ~~`'
c~~
t~~°'g ~ d~data, ~ I
my~to~~'of~ ~ ~ ~d
1 • T ~;ct ~,,~ de~'~. own~od by ~ '~' mSr
~ay~ dc~ G~~~n ,~ ~,~y te~-hY ~ ~ir;~
as ,my.~e ~, sad to ~ 8~
~'~'~
2. I ~~°°~ ~ ~ ~t~ ~hc °r e
not ~'~~ dew` ~ coin do if ll~' ~ ~
T ~ fee ale' ire and ~~
,tea tln~° ' mate of'~'~
. ~ ~ ~, of ~ e ~~ Y ~,ys.
3 i d~ tmridin8 ~ ~1V ham' ~ of t~
B°Yd g.. hh~°`~ P ~oct, I ~~ '~ I , tlr~
~bs~ tsl~+a s
h No• 3 not ~,
Shy .~ ~, ~ ~' ~ ~' cap '' h~ ° ~u,,;ms.
4 ~~~ ~ would
of w~Y ns~ ~ tlao per' `, ~ and
,mod L~
~~ of auY to be ~ tutor of ~'~ , r °s
o=
cbald 'Bo'!~ B,1r~turto~ ~ ~ ~,~ my
5• I ~ ~~ ~t mad. Shoed
sa ~ estate
~ ~ to ~° lea~B anY °f r~Y ~,utor~
T~ for ~ ,son, or ~ ~ ~uto~ as ~~
r tO gad M~off and ~
appowt D.
node a~
Igo to ~e ~
s<1ch without bond, with the sauce powers as are give~t hera~n to my exeartor.
II
6. I hereby t that my P~~ representative retain the savicxs o4f I~aviq Mc~ight
8t Hughes, as attorneys in the settlenne~nt of my estate.
IN WTTNE3S WHEREOF, I have hereunto set my head and
November, 1996.
BERTHA w.
11TH day of
Sighed, sealed, Published and declared by BERTHA W. MURTOFF,'~ above named
testatrix, as and for her Last Wdl and Testament, in the presence of us, who at mqueat, in her
pre~seuce and in the presence of each other have subscn'bed our naa4es as wig hereto:
2
.~
ACSNOA~LEDG111ENT AND AFFIDAYI~'
_~._._.~
wE, sERTHA w. MiJRTOFF, CHERYL z. CLELAND ~a ~. Nom,
the testatrix and witnesses respectively, whose names are signea to the ipg inahu~nt,
being first duly sworn, do hereby declare to the undersigned authority that the c signed and
executed five insbnutrerrt as ha Last will and that she had signed vvrlhngly, and she executed it
as her free and vohurtary act for the purpose herein expressed, and that each of witnesses, in
the presence and hearing of the testatrix, signed flay will as a witness and that Ito ~ best of their
knowledge the te~tattbc was, at than time, e3ghte~ years of age or older, of souiad nmrd and under
no constraint or undue influence.
COMMOhtwEALTS OF PENN3YLVANIfA
. ~.
COIINTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by BERTHA W. ~ TOFh', the
testatrix herein and subscn'bed and sworn to before me by CHERYL L. ' C~~~LAND sad
MA1tTHA L. NOEL, witnesses, this 11TH day of Navarnber, 1996.
~q ~I~f W~ ~M7YY'
MYLsbao, DE 19886
Mall Dods DE-Md-12
Phor~ 888x602-4349
~* Fax: 302.934.2966
a~
JYJGJ,S'fGOlYJ 1-L~l~ r~oe~a1/~e~onc r-1rL
Toe Roger B IMm'~ krona Sue Kimble
Tana 717 248.6364 oatbN July 2, 2010
Ilse Estate of Bertha W Murtotf 'area 2
•cen~s~ Attached, please find the lrrfortnatbn you requested eon the Estate d Berths V~t M~xoo6,
as of June 4, 2010.
M I can be d furd'>ar assistance, Please do not hesih~te bo call me at 888-G02~348.
Thank you and have a great days
Sue lCunble ~ M ~ T BaMc
Thls ~ oonMk~s inbrnnelicn which may be car~ildentlsl and proprietary. You mtay not ,
dstrbrrle or Dopy al a any partotthla oonYrru~loetlon wt~out the e~rees ooneent d M b T Bank, FMrandal
Inc. orfhelr reepec~ue s<i6ald(erles or aBMelea. In adcMlon, ryou are not the addressee (ar~~~e 1o receNre
this Inibrrrrelon by the addroesee), ynu are not arrthorlaed b rooeMe or re+ilew the contents ol'thb
E you have rooei~ed Wia oomminicatlon to anon, pisses rehxn It Eo M 8 T Bank at P.O. Bax 1686, ~ , MD
2120a and ddsb any copy of thin aommuMcadon ltom your syaterrrs. Thank you.
- .ra+,r~ulfrtJiV 1 L`tt.l rrnv~c.l~tJ~L r-lrG
~ ~~ T~ JA~ ~~"i~V~N
Aa3ow~t Nwnber 983889?Oid6
~ (N ~ Berdw wMralv~'
~~ DaA~ U9/Y11/Y1b ~~
I
Balancea~ Date oJ'Drath 86,718.24
~!,
Aa~dlnrar~est 3 .10
Total 86,118.34 '~
2. Typeof'Aacwwrt SavinlytAawwrt
Aacaoit Nwnher 15UU421415U118
Owners)i~p (N~s v,~ Benha ~D4urroff
~~B Dare 09t~I1K16 i,
Balcrnae ar hate vjD~catJi
~I
a16,9S3.~9
~~~ 8 1.17
Tabl 816,95.66
3. 7}~e ofAaaowrt Cer~arte ofDspastt ''
Account Number 31003912754370
~ (N' un Bptha WMurtq,~'
~ 11/3Aro6 ~I
Boland an Date ofDieath SS5,108.5~4
Ac~crztcd lntenrst 8 -S3
Total SSS,10911_...-•__------------__._.__._..._..__ ~,
Rer hrdwr aoao~t b~rMo., ciewn+a wwdlor ~ d1Mnk pleas cell rile NoetU IYNddlegn ()IUa.~~'Y~{i-~0~~.
We were merle b leeyle a~ sde depedt box fiu rile abeveaneadsaed decedent.
Y~
Stl~mme M Kimble
Adjustrrlent Services
_ __
Chi ~`el Pointe F~ ~,
at Carlisle
770 S. HANOVER STREET, CARLISLE, PA 17013
Mrs. Bertha W. Murtoff
Joy Knaub
188 Bentz Mill Rd.
Wellsville, PA 17365
QUESTIONS? CAL ~ : 71 249-1363
RESIDENT # ' U IT STMT. DATE
13109 - 1-A 07/01/2010
RE I NT S
Mrs. Bertha W. M o
TOTAL AMOUNT DU $767.23
DATE DUE U on Recei t
DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE
_ _ - _ -
- __ - AMOUNT R~MLTTEQ.
DATE D~LRIfN~ ~ <~ CHA~R~E~ !GREtN1'S` BALA't~CE
Balance Forward 9
142.59
U6/041ZA10 Payment - Thaak Youi! ~ 9
142.50 ,
4.00
06/0.1/2410 HC Telephone Svc.-W/Long Distance 1 25.00 , 25,00
06/01-06/03
116/113/2010 Room. and Board Private-HC 06101=06/03 3 735.00 760.O
f
06/04/2@10 Medical Supply 1 7.2
3 ,
767.23
5/1110 Urethral Cath Kit 1
I
i
.I..J~G~ kc
'C '~a `y~. I
C~ 0
-N-,e, b ~ I ( ~'o ~ e, P 110 ~ e.
~" wa.~3
RESIDENT # CURRENT OVER 30 OVER 80 OVER 90 OVEF~ 1 0 TOTAL AMOUNT DUE
13109 767.23 '0.00' 0.00` 0.00 O.bO $767.23
RESIDENT NAME Mrs. Bertha W. Murtoff ' Fa,r, Pso,
CHAPEL POINTE AT CARLISLE, 770 S. HANOVER STREET, CARLISLE, P~. 17013
i
i
__ i
__ .