HomeMy WebLinkAbout10-19-101505610143
REV-1500 EX (01-10)
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania County Code Year File Number
Bureau of Individual Taxes °~""T"~NT0F1~"~
PO 80X.280601 INHERITANCE TAX RETURN 21 10
Harrisburg, PA 17128-0601 RESIDENT DECEDENT (~~~~
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
176 40 3850 11 22 2003 11 09 1947
Decedent's Last Name Suffix Decedent's First Name MI
MILLER YVONNE S
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
MILLER RAYMOND E
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise
(date of
death after 2-12-82) ~ 5. Federal Estate Tax Return Required
g Decedent Died Testate
(Attach Copy of Will) ~ rrl1
~• (Atta~cheGoMaof~rus a Living Trust
PY ) 0 8. Total Number of Safe Deposit Boxes
9. Litigation Proceeds Received ~ 10. ~~~ P~ 31 ~j~a dt Idat8e5~f death
1 ~ 11 • Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
REBECCA A HOBBS 570 322 2077
... =,
First line of address
413 WASHINGTON BLVD
Second line of address
City or Post Office
WILLIAMSPORT
State ZIP Code
PA 17701
c__.
REGISTER OF Vf1tLl~ USE O
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DATE,FILED
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Correspondent's a-mail address: rhobbs@steinbacherlawpc.COm
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 DATE
i + \
'.~'lti~~r:~,~1~. r` r=~-r:~ ~ Michael P. Croyle l(..' ~ 1 ~ i 1 i'~_ i~
ADDRESS
8157 Route 654 Hwy., Williamsport. PA 17702
.S~N URE OF PREPARE OTHER THAN R ESENTATIVE DATE
j ,, - .
~ ~''' ~ ~- ~~~~~ ~_~~~, Rebecca A. Hobbs ~ r, ~ ,'
ADDRESS
413 Washington Blvd., Williamsport, PA 17701
Side 7
L 1505610143 1505610143
. ~
J
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Miller, Yvonne S. 176 40 3850
RECAPITULATION
1. Real Estate (Schedule A) ....................................................................................... 1.
2. Stocks and Bonds (Schedule B) ............................................................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3.
4. Mortgages & Notes Receivable (Schedule D) ........................................................ 4.
5• Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ............... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6.
36,331.95
7. Inter-Vivos Transfers 8 Miscellaneous -Probate Property
(Schedule G) Separate Billing Requested............ 7.
8.
........................
Total Gross Assets (total Lines 1-7) ............................................. g• 36 , 331.95
24.00
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9.
10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .............................. 10.
2 4 . 0 0
11. ( ) ...................................................................
Total Deductions total Lines 9 8~ 10 11.
12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12.
36,307.95
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.
36,307.95
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
0
0 0
15
~• ~ ~
.
(a)(1.2) X .00 .
16. Amount of Line 14 taxable 9 0 7 6. 9 9 1 s 4 0 8. 4 6
at lineal rate X .045 r .
17. Amount of Line 14 taxable 2 7 2 3 0. 9 6
at sibling rate X .12 r 17. 3, 2 6 7. 7 2
18. Amount of Line 14 taxable
0
0 0
18
0
0 0
.
at collateral rate X .15 . .
19. Tax Due .................................................................................................................. 19. 3 , 67 6.18
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^
Side 2
1505610243 150561D243
Z
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-10
DECEDENT'S NAME
Miller, Yvonne S.
STREET ADDRESS
6339 Bennington Road
CITY
Mechanicsburg STATE
PA ZIP
17050
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
3. Interest
4,991.00
0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 2 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.
Total Credits (A + B)
(1) 3,676.18
(2) 4,991.00
(3) 1,346.10
(4)
(5) 31.28
Make Check Pa able 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:
a. retain the use or income of the property transferred :...............................................................................
b. retain the right to designate who shall use the property transferred or its income :..................................
c. retain a reversionary interest; or ...............................................................................................................
d. receive the promise for life of either payments, benefits or care? ............................................................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ....................................................................................................................
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.......
Yes No
^ ^x
0 0
^ a
. 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.
Rev-1509 EX+ (6-98)
SCHEDULE F
COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Miller, Yvonne S. 21-10
If an asset was made j oint within one year of the decedents date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Benjamin H. Croyle (DOD: 7807 South State Route 44 Hwy. Father ~ Mother
10/24/2007) ~ Jane Croyle Williamsport, PA 17702
B. Michael P. Croyle 8157 Route 654 Hwy. Brother
Williamsport, PA 17702
C. Kathleen L. Mertz 265 Edmonds Ave. Sister
Northampton, PA 18067
JOINTLY OWNED PROPERTY:
ITEM
NUMBER
LETTER
FOR JOINT
TENANT
DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT
NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR
JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
ALOE OF ASSE o
~0 OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1 A B C D 5/6/2003 1/5 interest in real estate located at 7807 181,659.76 20.000% 36,331.95
South State Route 44 Hwy, Limestone
Township, Lycoming County, PA, as more
particulary described in Deed Book 4567,
Page 191. Clean and green assessed value
$119,513.00 x common level ratio factor (1.52)
_ $181,659.76
TOTAL (Also enter on Line 6, Recapitulation) I 36,331.95
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98)
I
SCHEDULE F
JOINTLY-OWNED PROPERTY
Attachment Sheet
ESTATE OF
Miller, Yvonne S.
SURVIVING JOINT TENANT(S) NAME
D. Thomas B. Croyle (DOD:
6/15/2007)
FILE NUMBER
21-10
ADDRESS RELATIONSHIP TO DECEDENT
29 Miller Road Brother
Montoursville, PA 17754
5
REV-1151 EXt (10-06)
COM INHE~IT E T ~ECER~RN ANIA
R IDN D DN
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE DOSTS
ESTATE OF FILE NUMBER
Miller. Yvonne S. 21-10
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
A, FUNERAL EXPENSES:
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(sl Commission paid
2. ~ Attorney's Fees
3, I Family Exemption: ()f decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Ziq
Relationshio of Claimant to Decedent
4. I Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 24.00
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 24.00
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Miller, Yvonne S. 21-10
ITEM
NUMBER DESCRIPTION AMOUNT
Other Administrative Costs
1 Register of Wills -Cumberland County -filing fee re: inheritance tax return 15.00
2 Vital Records -death certificate 9.00
H-B7 24.00
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
-~
.i`
SCHEDULE J
GOM IN~ESITDEN~DECEDEN~R~ANIA BENEFICIARIES
ESTATE OF FILE NUMBER
Miller, Yvonne S. 21-10
NAME AND ADDRESS OF RELATIONSHIP TO
DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY (Words) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
• distributions, and transfers
under Sec. 9116 a 1.2
1 Benjamin H. Croyle Father St Mother 1/4 of Sch. F,
(Date of Death: 10/24!2007) and Jane Croyle Item 1
7807 South State Route 44 Hwy.
Williamsport, PA 17702
2 Michael P. Croyle Brother 1/4 of Sch. F,
8157 Route 654 Hwy. Item 1
Williamsport, PA 17702
3 Thomas B. Croyle Brother 1/4 of Sch. F,
(Date of Death: 6115/2007) Item 1
29 Miller Road
Montoursville, PA 17754
4 Kathleen L. Mertz Sister 1!4 of Sch. F,
265 Edmonds Avenue item 1
Northampton, PA 18067
Total
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 15 00 cover sheet as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI
Copyright (c) 2009 form software only The Lackner Group, Inc.
Form PA-1500 Schedule J (Rev. 11-08)
r
X105.905 RLV.(3/091
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with
the Vital Statistics Law of 1953, as amended.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
554964
No.
Linda A. Caniglia
State Registrar
~1AY ~ 4 2010
Date
Ht05.,43Rev. Z'87 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH ~ VITAL RECORDS
CERTIFICATE OF DEATH 115 2 0 ~
TYPElPRINT
IN STATE FILE NUMBER
PERMANENT NAME OF DECEDENT (Fast, Middle. Las) SEX SOCIAL SECURITY NUMBER DATE OF DEATH itdcnm.0ay,'rear)
BLACK INK ,. Yvonne S. Miller 2.Female 3. 176 - 40 - 3850 4. November 22, 2003
AGE (Last Birthday) UNDER t YEAR UNDER, DAY DATE OF BIRTH BIRTHPLACE (City and PLACE OF DEATH (Check only one - see inalruchona on Deter sx,e)
Months r Days Hours , Minutes i,Momh.Oay,'lear) SlaleorFore~gnCournry) HOSPITAL
OTHER:
' ~ Nursing Other
5 6 Yrs. ~ ~ Inpatient ^ ERIOutpatient ^ DOA ^ Home ^ Residence ~ (Specify) ^
' s. e,11 9/194' 7. PA ~,.
^ ~ ~ COUNTY OF DEATH CITY, BORO. TWP OF DEATH FACILITY NAME QI not inshNtion, give sleet and numberi WAS DECEDEIN~T OF HISPANIC ORIGIN? RACE -American Indian, Black, Witke. etc.
/((,,`/ No ~ Yes ^ If yes, specify Cuban, (SpecM)
e~ Twp. ~, 6339 Bennington Road Mexican, Puerto Rican, etc.
9b. Cumberland aITI en 9, ,a. White
DECEDENT'S USUAL OCCUPATION KIND OF BUSINESSIINOUSTRY WAS DECEDENT EVER IN DECEDENT'S EDUCATION MARITAL STATUS • Married SURVIVING SPOUSE
(Give kind of work done during most U.S. ARMED FORCES? S eci onl hi hest rode coin feted Never Married, Widowed, pl vnle. give maiden name)
of working life; do not use rested.) ElementarylSewndary College Divorced (Specry)
Yes ^ No ® (a,2) (t 4 or 5+)
• ,,.. LPN „b. Nursin ,2. ,3. 2 ,4. Married ,,.Ra rid E. Miller
DECEDENT'S MAILING ADDRESS (Street, City/Town, State. Zip Code) DECEDENT'S Penns lvanla
ACTUAL t7e. State Y Did ,7c.® Yes, decedent lived in Hampden h
6339 Bennington Road RESIDENCE decedent
(See utsiruclion5 live in a
Mechanicsburg, PA 17050 on otherstde) township? No,aecedeMlived
16• ,7b.County ('_tlmbErland 17d.^ within actuallimilsot citylbo
FATHER'S NAME (First, Middle. Last) MOTHER'S NAME (First, Middle. Maiden5urname)
,o. Ben' amin H. Cro le 19. Mary Jane Orphan
INFORMANT'S NAME (TypelPrint) INFORMANT'S MAILING ADDRESS (Street, CiryrTown, Slate, Lp Code)
2~. Ra and E. Miller 2Bb.6339 Bennington Road Mechanicsburg, PA 17050
METHOD OF DISPOSITION DATE OF DISPOSITION PLACE OF DISPOSITION • Name of Cemetery, Crematory LOCATION • City/Town, State, Zip Code
Burial ^ Cremation ® Removal Irom State ^ (Month, Day, Year) or Other Place
W _ 2Donatbn^ Other(Speciyt ^ 21bNovember 26 2003 2,~Hollin er Cremato 21d.Mt.Holly Springs, PA
7 SIGNATU f UNE I LICENSEE OR PERSON ACTING AS SUCH LICENSE NUMBER NAME AND ADDRESS OF FACILITY
rte. 22b. FD-014889 2z~.Ma1 zzi 8 Nit Plaza M3~T11 PA 17055
~ Complet tams ac ly when ce dying To the best of my knowledge, death occurred at the time, date and place stated. LICENSE NUMBER DATE SIGNED
physici is no vail at time o Bath to (SgnaWre and Title)
(Month, Oay, Year)
' certify cause of death.
23e. 23b. 23c.
Items 24.28 must be completed by TIME OF DEATH GATE PRONOUNCED EAD (Mo h, Day, Year) WAS CASE REFERRED TO MEDICA ERlCORONER?
• person who pronounces death. /~ //p
24. ~ ~ / M. 25. /// ~~ ~C7U 28. Yes No^
27. PART 1: Enter the diseases, injuries or complications which caused the death. Do not enter the mode 01 dying, such as cardiac or respiratory arrest, shock or hears failure. I Approximate PART II: Other significant conditions coniributirtg id death, twt
list only one cause on each line. ~ interval between not resuking in the underlying cause given in PART I.
IMMEDIATE CAUSE (Final t onset and death
disease or condition 1 , j
~ resulting in deam) -+ a. ~ ~' V %7/i<. ~ L- / • ,7 ~~ -~, H ~~ t
DUE TO (OR AS A CONSEQUENCE OF): ,
r
t
\ uentially list conditions b.
'^~ it any, leading to immediate DUE TO (OR AS A CONSEQUENCE OFI: I
y cause. Enter UNDERLYING t
• CAUSE (Disease or mpry ~, t
• that ineiated events DUE TO (OR AS A CONSEQUENCE OF):
resukinq in death) UST )
d. '
WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH OATS OF INJURY TIME OF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED.
PERFORMED? AVAILABLE PRIOR TO (Monet. Day, Year)
COMPLETION OF CAUSE ~,/ ^
OF DEATH? Natural L°J Homicide
Accident ^ Pending Investigation ^ Yes ^ Na ^
30e. 30b. M• 30e. 30d.
Yes ^ No Yes ^ No ^ Suicide ^ Could not be detenninad ^ PLACE OF INJURY • AI home, farm, street, ladory, office LOCATION (Street. Ciry/Town, State)
• building, etc. tSpecity)
26e. 2Bb. 29. 30a. 10t.
CERTIFIER (Check only one) S NATURE AND TITLE OF CERTIFIER
'CERTIFYING PHYSICIAN (Physx;ian certifying cause d deem when anomer physician has pronounced death aria completed Item 23) ~~~ t ~~~~
To iha best of my knowledge, death occurred due to the cause(s) and manner as stated .................................. iY1 r/l'
................... 31 b. '
~ LICENSE NUMBER ~ DATE SIGNE (Monet, ay. Vearl
w 'PRONOUNCING AND CERTIFYING PHYSICIAN (Physx;ian both pronouncing death and cenify~ng to cause of deam) ~f h ~) /;C, i,.~~~ ~/L ,t , r
~ To the best of my knowledge, death occurred at the time, date, and place, and due to the louse(s) and manner as staled .......................... ^ 31c. ..// (/ (/ 31 d. - S
w
O NAME ANO ADDRESS OF PERSON WHO COMPLETED CAU OF DETAIN
w (Item 27) Type or Print < l
~ ~ 'MEDICAL EXAMINERICORONER ~--~Z,t~L•,LLI~~•-~~r~r~~~lrtr /,~~1/
p On the basis of examination andlor investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and l / t~
w manner as stated ......................... _
Z REGIST R'S SIGNATURE AND NUMBER
DATE FI ED (Month. Day, Year) /
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PENNSYLVANIA DEPARTMENT OF REVENUE
REALTY TRANSFER TAX
COMMON LEVEL RATIO (CLR)
REAL ESTATE VALUATION FACTORS
FOR
LYCOMING COUNTY
The following real estate valuation factors are based on sales data compiled by the State Tax
Equalization Board. These factors are the mathematical reciprocals of the actual common level
ratios. For Pennsylvania Realty Transfer Tax purposes, these factors are applicable for
documents accepted for the periods indicated below. The date of acceptance of a document is
rebuttably presumed to be its date of execution, that is, the date specified in the body of the
document as the date of the instrument. 61 Pa. Code § 91.102
ACCEPTANCE
DATE CLR
FACTOR ACCEPTANCE
DATE GLR
FACTOR
1~ROM TO FROM TO
7-2-1986 6-30-1987 2.75 7-1-2006 6-30-2007 1.10
7-1-1987 6-30-1988 2.91 7-1-2007 6-30-2008 1.16
7-1-1988 12-31-1988 3.13 7-1-2008 6-30-2009 1.25
1 1-1-1989 6-30-1989 1.33 7-1-2009 6-30-2010 1.19
1 7-1-1989 6-30-1990 1.33 7-1-2010 6-30-2011 1.21
7-1-1990 6-3 0-1991 1.48
7-1-1991 6-3 0-1992 1.66
7-1-1992 6-30-1993 1.60
7-1-1993 6-3 0-1994 1.65
7-1-1994 6-3 0-1995 1.73
7-1-1995 6-30-1996 1.80
7-1-1996 6-30-1997 1.82
7-1-1997 12-31-1997 1.86
2 1-1-1998 6-30-1998 1.33
2 7-1-1998 6-30-1999 1.33
7-1-1999 6-30-2000 1.43
7-1-2000 6-30-2001 1.48
7-1-2001 6-30-2002 1.44
7-1-2002 6-30-2003 1.49
7-1-2003 6-30-2004 1.52
7-1-2004 12-31-2004 1.60
(3) 1-1-2005 6-30-2005 1.00
3 7-1-2005 6-30-2006 1.00
(1) Adjusted by the Department of Revenue to reflect an assessment ratio change effective January 1, 1989.
(2) Adjusted by the Department of Revenue to reflect an assessment base change effective January 1, 1998.
(3) Adjusted by the Department of Revenue to reflect an assessment base change effective January 1, 2005.
JO
-~„°~F R~ o~„o~ Application for Certified Copy of Death Record
DEATH Pennsylvania Department of Health • Division of Vital Records DEATH
_ _ .. _- . ° By my signature below, I state I am the person whom I represent myself to be herein, and I atTirm the information within
this form is complete and accurate and made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to
authorities. In addition, I acknowledge that misstating my identity or assuming the identity of another person may subject me to
misdemeanor or felony criminal penalties for identity theft pursuant to 18 Pa.C.S. §4120 or other sections of the Pennsylvania
Crimes Code. (Note: Signature must agree with name listed in Parts 2 and 5 of this form.)
Signature of person making request (Do notprint):
. .
{'.'_ -~ ~^ ~ ° PRINT or TYPE name of individual requesting record and his/her current mailing address.
~.~
,~~ ~ Relationship to Person , ~ :?-~~i~~~-~i ~~ ~'~.-I ~~~,' h ~ ~~~`~-~~~ ~'
Name: _~-~---7~.: -~ .; ~ ,,~~ - >,~~ ~ `~c'~ (. ~ l Named on Record: I"' i; .'~ +~ L"r r ~ r~ {~ _ ~- -i--~,
Address: - `~ ~. ~; ! ~;I i; ~~ (~`l~ ``~ ~ i 1 r ~ -~-_ r ~ _.
City: l~ ~ ~ i i -~'~„--~~ ~~ . ~; -~ ~~~` -' ~ ~' State:
_ `.-~ _ / ~ I Zip:
Daytime phone number: ('~ ) ~ 1 '".~', i~'
Intended Use of Certified Copy: ^ Social Security/Benefits
t3 Estate Settlement ^ Other (List reason:
E-mail Address:. ~~ ~ ~~,~~.-*~--. ~; ' y ~ '~ ~/~ -1
;`"
^ Insurance ^ Financial Institution ^ Genealogy
_ -__ ~ .. ~~ ~ PRINT or TYPE information below regarding person who died:
.: !~ / , ~
'_Same at Death: \ ~ ~;; !,; ; `~~,= ~ , ~ ~;~ r ~ ;'' ~~ s
Number of copies:
Sex: ^ Male C~~'emale
Date of Death: i ~ -~' - ~ L•~--= - % Place of Death:
(Month/Dav/Year -Records available from 1906 to the nresentl
Social Security #:
Full Maiden Name of Mother:
~,
Full Name of Father: ~ ~~r ~"1;1`'_~ ~-t ~ ~ ~~ ~ ~~_~^~,
Funeral Director:
Aye at Time of Death:
(Countvl (CitvBoro/TwD. in Pennsvlvanial
Date of Birth:
--~ - -. DEATH: 59.00 each. _ _ , _ ....:~= _ ~ _ .: ..,..,, _~~ ,,~._ ~: t _ ~: __. L _~~ ._' ~; ~~.
r ees will be waived for individuals who served or are currently serving in the Armed Forces and their dependents (complete the following):
Armed Forces Member's Name: Service Number:
Relationship to Armed Forces Member: Rank and Branch of Service:
• Individual requesting record must include a legible copy of his/her valid government issued photo ID that verifies name and
mailing address as listed in Part 2 above.
• Examples: State issued driver's license or non-driver photo ID (rf address has been changed, include copy of update tardy.
• If possible, enlarge photo ID on copier by at least 150% (copies of ID will be shredded upon reviewl.
* If acceptable ID not available, visit our website at www.health.state.pa.us/vitalrecords for further information.
DIVISION OF VITAL RECORDS (ATTN: DEATII UNIT)
301 SOUTH MERCER STREET
PO SOX 1528
NEW CASTLE, PA 16103
Print or type name and address in the space provided below
(must agree with name and can-ent address in Part 2 and lD documentation):
Name ~, ~ , % ii '"~
``--~j.:-~ ",~ t L. "1 ~ \~i i i~~ q~. I I :. /t il~'~ I C i,y l ~ 1
i~
street _ ~.` ~-~ , ~,1 ~,:. i=:{~~ ~ ,, .- . `1)i~~ r -
_, -
J
City, State, Zip Code 1 , +, - ~-~ ~-` "~ ,
~ Signed your name in Part 1 (do not
print)
`~ Listed your name and current mailing
address in Parts 2 and
/ Completed all items in Part 3 (enter
unknown i{information unavailable)
/ Enclosed payment (or completed Part 4
for waiver of fee)
/ Enclosed legible copy of ID (must agree
with your name and address in Parts 2
and 5)
For -.-. ~ _ ~ _~_ _~ -; ° - ~' - __;- -'° ~: or additional information, visit our website: - ~ ~ - = -, -
~~
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