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11-08-10 (2)
-~ ~ 1505610101 REV-1500 °`~~-~°' ~' Y ~~ Bur~tr of 1rtdlvidual Tatoes C~ INHERITANCE TAX RETURN Cas~r Fie INaober ~~abwaPA s~sze-o6os RESIDENT DECEDENT ~' ~ IO~' ~ ~ I ENTER DECEDENT N~FORMA?10N BELOW Sodeil Seaxily Number Date of Deafh MMDDYYYY Date of BMh MMLX)YYY1' 223-38-1091 12/122009 02n08/1915 Deoedenrs Last Name Su(flx Deoederrt's First Name ~ MI Ulletzel Mary E (Ir Appxcabls) ErtMr SruvlMrtp Spoua~'s Irrformatiort Bsiow Spouse's Last Name SuNix Spouse's First Name ' MI Spouse's Social SecurNy Number THIS RETURN MUST BE R,m M DUPLICATE MII~N , REGISTER OF WILLS FlLL IN APPROPIlIKTE OVALS BELOW m 1. Oripkrd Rstum O 2. Supplemental Relum O 3. Remei~ i I ~et um (dabs of dsalh O 4. LFrtdMd Estabs O pr or to 12 4a. Futuro Interest Compromise (dabs of O 5. Federal Es 1 ~6s Tax Retum Required death 81tar 12-12-82) O 6. Dsoederk Died Testate O 7. Dsosdsrrt Matrrtafrred a Lhrkg Trust 8. Total Numt~ sr ~ Safe Deposit Bones (Attach COPY of Wis) (ANach Copy of Tnist) O 9. Liligalton Roossds Received O 10. Spousal Poverty Credit (date of death O 11. ElscNan to Sec. 9113(A) balween 1231-91 end 1-1-96) (Alladr . O l~Itl~P01NXGIT - TINS fLC710p rUST NE f:OM!'LEfED. ALL COOIIDBICE AID COIN~DRfItAL TAX MrFONMATiON DMNeCIED 70: Name _ Daytime T Gwendolyn E. Plt~t (703) 361 i ~TEI! IISE ~Y ~,.. ~. First Sne of address O Z , .~ 1oos2 ~ oak Terlaos _ _ ~' ~,° d rs ' ~ t3eoond lkre of address _' a o m ~` ~ ' ..... _ ~- ~ .. _~ r. City a Post OINoe State... ZIP Code ~ r ~"' ' ~•l~ ~~~ VA 20110 .~ ~''' ,~ e....,.........~...r~ ~~ - ..~. lhrdar panNtlas d per)ury, i dadanl that I haw axarnirrad this return, aooorrganyinp actrsdYss and , and to the d k Y tors, oorract and cortKflsM. Dadaradon d aMisr sisn the psrsarN ropreaer~tlw N hsssd an aN hdortrmtlon d which. ' Imowlsdps and belief, any IoioNAadps, 3KiNA OF q~ pjp RN 1!1/05110 1 ost Terrace Manassas, VA 20110 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE I ADDRESS 'LWE LNNE ORIGINAL FORM ONLY i Side 1 III 1505610101 1505610~0~ I, 6 J __ __ . -_ _ _ ____ I I 1505610105 REV 1500 FJ( DecederM's S{x~l Secueity Number Dsa~tenKs NrrN: AAery EliZtabeth Wetzel 223-3&1091 RECAPITULATION 1. Reel Fatale (Seiredule A) ............................................. L 2. Slocka and Bonda(Schedule B) ....................................... 2 i _ __ 3. Closely Held Corporation, Parbiershlp or Sde`Proprfelorstrip (Schedule C) ..... 3. ,.._ 4. Morlpepes and Nolen Raoeivable (Schedule D) ........................... 4. i 5. Cash, Bank Deposits and MisoeNaneous Persarel Properly (Schedule E)....... 5. ~' 5,770.00 8. Joirply Owned Property (Schedcrls ~ O Separate BiBrep Regcreated ....... 8. 24,819.67 7. Irrler-VNos Trarrdfera 3 MfsoeNerreous Non-Probate Properly _ ~L . . (Schedule G) O Separate BlBrq Requested........ T. _ j ~ 18,338.44 8. Total Groan Aaasls (total Ones 1 tlxargh 7) ............................. 8. ~~, ~~ 48,$28.11 9. Funeral Experroea and AdmirriabatNe Caste (Schedule H) ................... 9. } 9,340.00 10. Debts d Decedent, Mortpege LfabNltles, and Dena (Schedule i) .............. 10. { 8,744.82 _ 11. ToM Deductfores (total Linea 9 and 10) ................................. 11. 18,084.82 ; i 12. Net VaNre of EstaN (Line 8 mines line 11) .............................. 12. 30,843.29 13. Charitable and GoMemmental BequestslSec 9113 Trusts for wtrich an ebc8on m tent has not been made (Schedule J) ........................ 13. 14. Nst 1laNw Subject to Tax (l.bre 12 nines line 13) ........................ 14. -- ---- TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Anrourrt d Line 14 taxable at the aporwd tax rate, or trarrslers under Sec. 9116 (ax1.2) x .o_ 18. Amaent d Line 14 taxable at heal rate x .0 ~' 30,843.29 17. Amourk d Line 14 taxable st sibNrrp rats X .12 18. Arrrount d Line 14 taxable _ at coNeteralrate X .15 30,343.29 19. TAX DUE ......................................................... 19. 7,.16~.ir.7 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 1505610105 Side 2 I i I i 15056.101~~1 5 I! ~, O J REM-1500 EX Paps 3 Decedent's Complete Address: Mary Elizabeth Wetzel ', sTR~r~oDR~ss 5225 WNson Lane CRY Mechanicsburg STATE PA ' Z~ 17055 Tax Payments and Credits: 1. Tax Due (Page 2, line 19) 2. CredilsrPayntertts A Prior Payments B. Discount 3. Ingest 4. ff Wte 2 is greater tlren line 1 + Line 3, enter the digerence. This is the CVBtPAYMENT. FNI In oval on Pape 2, Wte 20 b request a refund. 5. M LMe 1 + LMe 3 id greeter than t.irte 2, enter the dfRerenoe. This is the TAX DUE FIN Nunbsr (1) ~, 1,387.95 Total Credits (A + B) (2) 0.00 (3) ~ 8.24 (4) __ (5) II i 1,396.19 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSYYER THE FOLLOWING QUESTIONS BY PLACING AN'7(" IN T'1# APPR(~P~tIATE BLOCKS 1. Did decedent nmloe a trer>sfer and: es ' No a retain the use or income of fhe property tr~sterr~ed :.......................................................................................... b. retain the right to designate who shall use the properly Uanaferred or its income : ............................................ c. retain a revetaiorrary interest; or .......................................................................................................................... ^rc d. receive the pnxrtiee for Nfe of either payments, lrertefits or care? ...................................................................... ! Q 2. ff delMtr ooatrred after Des 12,11t82, did deoedeM transfer property within one year of death ~' without receiving adequaN consideration? ............................. ..... ...... ................................. ~ Q ................ ........... .......... 3. Did decedent own ~ art trust tor' or payable•Itprxr-death bank account or eectaity at his or her deadr4 .............. ^Q 4. Did decedent own ar individual retirement aoccrurt, armuity orother nat-probate iy~ whirr corrtafns a benetidery d~grration7 ........................................................................................................................ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE. G AND FILE R X13 PART OF THE RETURN. Far dates of death on or after July 1,1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers b or ~ ~ use of the survivir~ spouse is 3 percent)72 P.S. §9116 (a) (1.1) ml• For dates of death on or after Jan. 1, 1965, Ute tax rate imposed on the net value of transfers to or for the use of Iii surviving spouse is 0 peroertt (72 P.S. §9116 (a) (1.1) (ii}]. The statute does not exempt a Uartsfer to a survivir~ spouse from tax, and lire statutory ro~ for disdosrme of assets ~d flNng a tmc ratan are stAl appNcaYble even r<the surviv~tg spouse is the only benafictiary. For dates of death on or after July 1,2000: • The tax rate on the net value of transfers from a deceased d>ild 21 years of age or younger at death to or ~ ~ use of a rratur~ parent, an adopthre parerd or a stepparent of the child is 0 percent [l2 P.S. §9116(a)(1.2)). • The tax rate l on the rret value of transfers b or for the use of the decedents lineal beneflaaries is 4.~ percent, except as noted in 72 P.S. §9116(1P.S. §9116(a)(1)). • The tax rate imposed on the net value of lrartsfers to or for the use of the derredent"s ' e 12 peroerd)72 P.S. §911~(s)~1.~)). A sibling is defined, under Serdion 9102, as ~ htdhridual who has at I~st one parent in connrton with the decedent by blood or adoption. ~! i I I v~ j~RiTAN~ TOES ~~ ~~ ~ •F'1 R, s~.......r~ ESTk'TE ~ ~~ ~ ~ ~, the p~eede ~ eMe ~ ~. ~ry E.1~~ ~,e p°`e°es ~ ~ ~ of ~ awl N~ 1 ~ 2 F~ 3 Je~ekY 4 ~~ 941.00 I 1,410.00 ~ ~~ 2,500.00 919.00 ?s Wheels ei tl+e aee+e ~) ~I ~~ I 5,77'0.00 1 a s pennsylvarria DEPAitTMENT OF REVENUE rra~ettrnMCE nuc R~+ RE~oeR oECEOEnr ~ E JOINTLY-0WNED PROPEIRY ESTATE OAF: Mary ElQabeth VMelzel It an greet tin ~eUMlr twrner teMYn aM ~r d HM deoaderrC~ t1a4e d tNNh, R swat tse ~dnrlrie O. StNtVMNG JOINT 7ENANT(5) NAME(S) ADDRESS ONSFHP TO DECED9~(1' ~ Staam Wetzei Sublett 5225 ttUilaon Lane Room 323 f~a 111er Mecharriceburg, PA 17055 j ' B. , I i ~I ~ G I I ]OZNTLY OWNED MlO0E1tTY: ttrret DaE ot~crtsrwrr of cTY pl-7E of or~ort fret rrR Doerr MADE eKiuoE rotME OF FewK7111. asrrnngN AND alwc ~oootNrr Mlrret OR SaetAR DIttE of DFxnt 1pILtIE of raateet 7BMNr NuMeeR. argot D® 70HflLr F6D ttSK esnae. rruale OF DE®BfIS an~sr 1. A. 04103189 PMC Beek Checking Acodrtt X61.4027-2561 21,994.87 i 50 10,997.44 2 A 091'16106 Neyr Federel Credit Urrion 800142351620004 27,634.47 ~, 50 13,817.23 3 A 09/16A6 ~ Federal Credit Union 80014235106 10.02 ~ ~~ ~i i i I I 50 5.00 TiOrTAL (also ember on Llne 6, Recapitulation) ~ 24,819.67 If more space is needed, tree additional streets of paper of the carne size. it Performance Checking Account Statement F« tlhe perbd 11n m 12N4fZ80p For 24fiour kNontgltlort, eqn on to PNC Bank ONins Bank~B MARY ELQABE7'H Primaryacaourrt ~ C1-40R7-2581 ~~~ Paps 2 of 2 PNC pOkrb is a service mark of The PNC Finandat Servioss C,rouP. Ina PNC BsMc reserves the riDht b dtarge or .the PNC . See Terttae and CatdiBons for tlelaYs. P®rtormance CMcking s~i,ran w Interest Checking Account Summary Aooourt nunrbM: 51-A027.861 . Overdraft PioiecYon Provided By: Conbct PNC to eeEabttah Ovendralt Pro~sction ' Bsiancs S1rKtmlary Baairrikrp Dapoaae and Clydet and aver Endni berara~s dheraddeane dadudo~r ~~ ' 19,900.51 18,110.81 18.303.99 21,707.33 AvoaO! ,~ s dtaaes 19.954.82 .00 Transactlort Statntnary ' , cararaaidi a,.d~crdPOe cnrakcara~e.ar.nd wa,a~.wras etan.e trr.~soir PoB PIN trairac/ons 9 0 0 I Tale/ ATM PIdC Bank Derr Bank Ywracegr ATM YanplCeOna ATM bniaCeone 0 0 0 _ AB d 1?114, 8 bt ~ iSt in iMeroet was Inbre:t tn+mary P~ this AiaadPOaeAaae Mraberddays AvaapaoAaelad Ir~IseetWid nNd tcanrd (APYfS) b ir~lraal aalod balrra bA~YE rrs veaod 0.15a 32 19.076.43 2.45 ACtlvlty DataN Depoeke and Other AidcNtlons TtrMS weie 7 ---,- ana oMsr Aaaflone IotalYg =i 11 1 Dale Arnonk ~~ 11/18 3.798.98 DaposN Rel'erenoe No 522811805 11/18 205.00 Branch Ospoeit Tel 0400058804 0180 11123 &1304.00 Deposit Reference IVo 523310359 11/30 1,95125 Deposit Rderenoe f+lo 524880355 ', 12101 3.537.45 Diced Deposit - CivY Serv ' US Treasury 312 F 3083013 W CSF 12!07 13.70 Deposit Rsferenoe Nlo 520812788 ' ' 12114 2.45 Interest Payment Checks and Subadtirte Checks. prdc oala RaAwnoa ~aex nunnsr Amgrnt a.b i.sn+n.r ~ Rarnwioe rMmbar 7071 45.00 12107 aese3nas 7076 140. 11!27 oeesttasr 7072 4,440.00 11/18 52oee9BO6 7077 48. ~ 12108 Oee67stt4 7073 10,713.00 11123 7078 23. 12/04 oe~la7ae 7074 478.59 11/19 Oe~Uet04 7079 289. 12/14 0 7075 128.49 11/30 otgM3est 1 • Gap kt check ssglrarros Thsrs were 8 IfeYrd bfaling 1 Wi Balr+w Galt Ba>.r~os tJ~! eair~oa 11 /13 19,900.51 11!23 18.878.88 12/01 22,1)88.29 1 BalanOa 1 .87 11/18 19,482.47 11!27 16,738.08 12/04 23,074.87 11/19 18,985.88 11/30 18,580.84 12107 22.043.37 Signature Card Image Page Page 1 of 1 ~J• 1taG1" 7~.~ua"~~E ~ ,B~.w+. ____ :~ ~~_ v5140?72 3b; ~ ' ~ . ? _ 2 nrr~ofACCOUrrR or' GlfCIpOKi- O RDi11LAR D i1~t708ET D NOW O S~ NOW O C1d1B i ~i CLtlS PLUS D CLt1~ SUPER PLUS D UlT1MATi C1~ SAV11iGS- O PA:i8S001C O +301' D STAN _ O ~OihB, $"IA7S, O , k ~~~ " .•w •.~c• xa•u.. 5140'272581 ~•waew....b+.rN~a t a..w~ w~ ~n,r ~.w. A..we w,r ~ +~+••rs a•...~«.w•.y.M..+wM..a..nr. ~ ~ ~~w ..+it.~wa wr .. . +ru..r.n~r- ~` +~~ ~ ~ « ...~ wr• jq i ~f ~. ~+~~ ~ ~.•~ ~i ~~ ~ ~~ ~. .r. - - •~• Ke... .ss~^ ~rnr i~YQ ACCOgMt- PA1MifN 5+11 EltrliR OR WaMlMOS eStatement ~' '~ r.... ~ ~ STATBNBN'T OP ACCODITT ACCBSB NOMBBR ', 00777032 i 'i, STATBNBNT PERIOD PtOal 10-01-09 it 'Through 12-31-09 ieNNLi.eV ACCOWf[ BWIBBR 9000000PON7MP82A1i000OQR752 00000014235105 ~ ~', MARY 8 NBTSBL I. 10082 POST OAR '!~ 'I ', NARASBAS vA 20110-271e Merbsrahip Bhare Savings--0014235105 ~ Joint Owner(al-- SOEAN M SOBLSI'T GNRiDOLYN [ PICOT ~ ' ~ W1TS TRANSACTION DHSCRIPTION ~.... A}I(ARTt BALANCE ~ 10-O1 BB(iIRBrI11G BALANC= 10.02 ', 11-09 TRARSP~R PRON CBRTIPICATB 10,000.00 10,010.02 ' '. 11-09 NITIBNtANAL BT CN6CR 10,000.00- '~ ~ 11-31 6NDIN(i BALBIiCB ' ', 2009 Year to Data Federal Zneowe Tax Inforwation i, ii SBARB SAVINGS DIVIDRNDS 0.01 '~ '~, i I Page 1 of 1 eStatement ., .., ., . .. ~ .. • s' ~ SRARR CBRTI /ICATS/IR11 9TATEIB3Rl' OP ACCO04R w-RY a Nararl, loofa Doer oAR TSR M11~1ssAB vA 20110-271e IMPORTAN'~ 1038S1Ni8 STATLIRNP DATE 12/31/09 ACCHSS MOWHR 777032 Update your tea withholding iastzuctlons for your IRA dietributiana whine. 9uhmit your instructions at the Lifs Stages s Retiresrnt Center - navyfaderal.org/ire/. Belect •On11ns Applicatime.• Seleat the •Pederel and virgiaia State Ineawe Tax Nithholding Por*.• STI'Tg181P1' SOMIARY SOINARI POR 8lD1X1t CRRTIFICATR ACCOOR'PS ACCOOIPt N7ITORIT! CwtRdfl' YTD YTD YTD FBD CORRiIrI' 1NRIRER DATB Div RATS DIV PAID POWLTY TAX HAIdNCH 0014235120004 06/2t/11 3.15 1,274.23 175.97 .00 27,708.50 00142351620005 12/22/10 2.47 321.06 .00 .00 10,330.73 Total 1, 5!5.29 175.!7 .OD 38,039.23 S01MaRY POR STATOIi[!1' Total BalaACV: Sher! Certificates 38,039.23 Total Balance: Retiresunt Accounts .00 Total Stateseat Balance 38,039.23 SRARN CRR7TPICATB/IRA STAT818slT1' OP ACCODIT!' M11RY 6 NRTELL /' eNARS csRTIPICATSS ~ ~/ Account 001423S1f20004 Purchase/Renewal 06-28-OB 45,867.95 JOINT WEILLi N SwI,S1T Nith Survivorship DATt DLBCRIP7'ION D9A3IT8 CRBDITS HAI.7111CI Pcior StAteelaflt Balance 47,721.27 10/1! Penalty 49.23 47,672.04 10/19 Mithdriwl 10,000.00 37,672.04 lO/31 Dividend Credlt 39.04 37,711.08 11/09 Penalty 126.64 37,584.44 11/09 Transfer -Share Saving 10,000.00 27,584.44 11/30 Dividend Credit 50.03 27,634.47 /~ 12 re 74.03 ~-^!~r'7IlE.50 Total 20,175./7 163.10 Page 1 of 2 • eStatement I Page 2 of 2 . ~~t ~ ~1~ Dividends Paid Ibis Period ~ 163:10 31000Unt 00142351620005 Purchase/Rene+-al 06-22-09 10,197.38 Ylf ! PICOT Nith Snrvivarsbip D11T! DlSCRIP12O! D818IT8 C!lDITS BN.i1MCB '~ Prior StataeNnt Balance 10,266.61 10/31 Dividend Credit 21.56 10,288.17 11/30 Dividend Credit 20.91 10~309~08 ~- ' - v d rc 21.65 ""'r'! ,D-a30 73 i Total .00 64.12 Dividenda Paid this Period 64,12 I REV-1510 EX+ (08-09) E INFI~rANCE TAX RETURN RESIDENT DeC~ENf SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE Mary Elizabeth Wetzel Tlds sdR~ule must be aompleOed and iNed H the answer to any of questions 1 throu~l 4 on page three of the REW-1500 is yes. DESCRIPTION OF PROPEIRY ITEtt a~auoE TiE NAIE a TlE TI®t RaWR1115lV W occmert ND pATf OF DEATH 16 OF DECD"5 CLUSTON TAXABLE NUMBER TILE DAZE a TRMlIQ.. ~arAOl ~ car a tIE a®roR 8611 ~. VAWE OF ASSET INTEREST VALUE 1. Nagy Federal CreditUnion Ii100142351620006 - GwerWolyn E. Picot 10,309.08 100 j 3,000.00 7,309.0! ~G~) - ~~ 1 ~~ 2 X0815.7381- Gwendolrt E. Pioait (Cxanddatgttler~ 14,029.38 100- ~'i 3,000.00' 11,029.3E ~~ ~~ I ~I i ii ', i I I ', i I~ TOTAL (Also enter on Lilte 7, Recapitulation) # 18,338.44 If more span Ls needed, use additional sheets of paper of the same size. _~ .• • SHARE CER7iF~ATE CONFlRMATION NOTICE MARY E METZEL BMENDOLYN E PICOT 10082 POST OAK TER MANASSAS VA 20110-2718 Dear Member. 22 December 2008 Account No. t)01423516~00~5 A share certificate with the following terms has been issued in your name. If intention or if you have any questions, please contact Navy Federal's Share Certifica! as pos4ible, You may do so by calling toll-free in the U.S. 1-88$-842-6328. For toll-f __ove~ea_4, .v~.cit. ni--~'ederal~larrrseasl. ll~e.l.~7Q3~25.S-RR3_Z _for-collect- iatematiaaal you may write b Nagy Federae arCredit Union; PO Box 3000 , Memfield VA 221 f9-3000 John Owner: BitENDOLYN E PICOT ~~ ~~ 12/22/08 PtwcMee Amount: = 10, 000.00 Term: 26 irEEKS pis not your pitch as soon tubers when ~fyou.prefet;.--.._._ aK a branch. MetlxitY Dste: 06/22/0 Oividsrld Rste: 3.920X~ Arlnuel Perl:erltape Yhfld: 4.Oj0Y. DISCLOSURE STATEMENT DIVIDENDS: Ttte share cerMlk;ala itas a ttritinttm valance be cartcebd and the above penalties imposed en -equkemertt and w# earn divioerbe for each ~tIIyy dividend aatortrn. (n) in aooorcrartce wiMt Federal perbd at the dividend isle -and amaral peroerttges~yield (APY) wMtdratrrals made within Mte first 6 ~ d a sper9ied. ~ held b ntalrxily. Rates d non-Variable mate purchase are ~ b a 7 day early Certltit~les do not dtartgs before mentally. Rats for 3-Year perte~r. This reg`riatiort does not apply b Variable Ita19 C remain in affect for one year and Mten renewed. Mte drviderM vale wit charge on Mte certtifcala~ anniversary dabs (at 12 and 24 monMq) b Mte most rocar~t yyrteel1d PENALTY EICCEPTIONS: NFCU penalties wIM nl (every Monday) d Mte 1-Year CtortstaM klaNxily T-eastxy (t~tTj, arty d the (a) Nlihdrawels d except that Mte dividartd reb wi never 1aM more Iran ane-haM (b) Nlitlidrawals b the tieatir d ppaoenttt below Mte cerilicatek dividend rab al Mrs tlrrte slue certiFcale or nrede prrrstterd b Article MI ~~purrdtased a rertawed (Mtere is rto intieiort on Federal C~redi Untat Bylavrs. (c) V/ititdrawals dhriderM rate dtttrtges). Dividends are comprrledn day-or Mte voksMary or:wohnttary igtridaion d the l b day-of-withdrawal on the acfuM dotiar value d Mrs oerl~ ~tne deity l)alwtce method, comporatded daffy and 1MATiIR~iti CERTIFICATES: at list 20 b tits shore oerMficale monlltly on tine Iss1 rxiartdar share oeriicete's rrsNUriyr, NFCU wr7 t day d the matlh in which they wee seised, uriess anoMter dfnrid- owrrar spe~yktp tits tarrrts order vNtich end dralrbtalort opMat Etas been clloeen. Tice APY asstanes b renew ire share oerMticale or rdi~vid~ertds it Mte axatnt anti mn~aiy. Early wiMtdrawals ~avalfettie b the otwter. Each share aubmelically rertev-ed ~ specified in ire ADDITIONAL DEP03115: (EasyStart Only) /WdWortal depocNs may be made b an EasyStart CerMticale at any tine by cxteit. transfer from a Navy Federal attars or rdter9cing aa:ortM, or direct deposilfaNWttentt. ldlwmirtitntm rNa~gvuyientsrtt ftx addiiortal s age ~ 8~or alder set rip direct deposNiablm~ernlp~erbdic transfer(s) b the EasySMrt Cettiicale. PENALT~B FOR EARLY wlTitDRAwAL: (a) M Mte term b rttafuriy is one year (ar less) Mte arrtotrrM brfeilerl is egtrel b the lesser d: (1) Alt dividends br eo days on Mte arrtorett wititdrarrrt. or (2) All dFridertrfa on Mte amaaN wMtdrawn since the dale d issttanoe or renewal. (b) N Mte term b ntalrtriy is grmAer Mtan one year. the amount forfeied is egrml b Mte testier d: (1) AI dividends br 180 days on Mte .arnaxN wiMtdrawn, a (2) M dividendst on Mte amoratt wihdrawrt sktce Mte dale d isswarwx: or renewal. (ci M the term b tttakvily is greater than tive years, Mte amount torleMtd is equal b Mrs lesser of (1) AI dividends for 365 days on the amount wiMtdrawn or. (2) AM tMvidettds on Mte amount w(titdrawrt since the dale d tssuartce or renewal. For Jumbo Share Certificates (city): (d) M term b maturity k 6 b 11 morNlts, the amarnt forfeited La equal b the lesser d: (1) Afi dvidends tOr 90 days On the amomrN wihdrawn, ar (2) Ati dividends an ttte wrtoun wititdrawn since the dale d issuance or renewal. (e) M the term b meatrfiy fs 12 b 59 momhs. Mte amotmt forfeited Ns egad b Mte lesser d: (1) AM dhridertds br 180 days on the amount wiMtdrawn, or (2) A/ dividends on the amount wiMtdrawn since Mrs dale d issrtertce or rertewai. (f) M Mte term b maatrily is 60 b 84 months. Mte amount forfeited is equal b Mrs lesser d: (1) Ai dividends for 365 days on the amortnl vrititdraYrtt, or (2) AN dNklertds on the amount withdrgwn since Mrs dale d issltertce d renewal. (g) b Mae case d early wahdrewral d prNrcipd on r:ertitiaete whiCtt redrrces the balance below Mte rttirrintum requirement, die share eerYNcate shah owrte, rtoliies MFC~U b the rwrttary on or dale. The owner has agr period d /4 ~ Mte maaailr date b vrltitdrew~Mte hrtxls in tl b~eir~ Viand early wihdrawal penally. N rrtaMrrily, and tte owner h share aooourtls, rtterrtbersttip in NFC:U wii termk MSURANCE: Share Cet1'licale acoourtt ti raider irtstaartoe coverage by the Netlc Administation up b al I~st i250,0U For more inbrrrteion about NCtIA sitars see "ktsurartce on Your Savings" bradtrrre (NFC JOINT OWNERSFIP: N issued writ a !t oerlitic:ate is jofnMr awned with hrA rights d oMterwise ragtresled. The member and eerlNkale epee Mtett Mtis share ceriRcat dfvidertds are srtltjer.M b wiMtdrawal or reeoo~~ii~~ payment b arty one d them ar Mte surviv disritarge WFCiI irartt any iaDirly for such path TRANSFERABrtTY: Share Certificates i and rtol rtegoMeble and may rte pledged as al Navy Federal C.redt Union only. RNAL PAYMENT: Ati non-emh share cart be cradled srtb)eG b fatal peytrterM. CHANGE IN TERMS: NFCU reserves the n change Mte terms d share oertlficale offer m~aY ~t d+arged wirioW owners copse GOVEfttlriG t.A1I11S: Share CerliRr~le Acd and governed in aooordanoe wilt Federal Mte Commorwreeltit d virgrtia. as atttertdad. certiticble dividend that have appied b rter d~Mte a result d x b each ice b the edit Union ~ melts Mte eta wii be artless Mrs days elm rxirtiticate titer NFGU incktded C Union individual. 11 1 Phase 't8r, a share share rt#I anon a~loen urclteses wiN b roue or 30 a yertifiCede meinmirted hlte taws d I~ ~_ Premium Money Market Account Statement Forthe pelod 11111 to 1~1f41Z90Y For 24~wur irdornMion, sign on b PNlC &rdc Onltns Banking MARY EL2ABETHn~. on pnc.oom. Pr4nary acoaaR 53.061b~7361 Pegs 2 of 2 Premium Mony- ilA~lricet A©count Summary ~y Afloourd rsrnrber: 53-081£s7361 oMSrdratt ProMction Provided By: CorNsct PNC do aelsblNh ovardrNt ProMctlon '~ Balance St~nary ~-I~! lglmMil ~~PoMt ane cn.as snd oew Enerq ', esrsebe aMrrsddeois dedreesrrs ssiwia t 14,029.38 20.75 .00 14,050.11 Avasps ewNdy Qrgst 'i '' ems snd Aa 14,030.00 .00 inbrest 31Nnlnary As of 12HIti d 5J0.11 in inbrsst was Mr.w?aanlp. Nunevofays AraO.eae.era Yrw.uPaie ~~ ' vlraEanea(APYE) inirr.wparfed eslr~or+l~rIIPYE eAsp«fod 1.70E 32 14,030.00 20.75 I ~I -- -__ - Activity Detail ~~ and Qths~' A~pn~ '17Nre was 1 o~dit ar Ottrer Addition w. 1Vnourt oasaipeon btsfing .73I . 12M4 20.75 k~f9ereat Payment Daily Balance DetaN Dsb tlsisnos osr Bspir~os 11!13 14,028.38 12/14 14,050.11 • 'Signature Card Image Page Page 1 of 1 ~~~ in~c ieaak I~latiiswx! Mr.~ CA0~1302 acrotasr asar~tti-Ttost ~ r ~. nTLE rat ~. ~ r weal Peon. ~e ~ccouerr ~oo~ss 10082 POST OA1C TOt MAMASSAS itA 20110 i C.earf~aitioa .~[ Oee+~r: Under panstr~es of perjury, I certify that: (1) 'tue member cm this mIr coanct ~Ym ideidificstion number (or I ata waiting far a cumber w be iwi~cd to rna), aid (2)1 stn not ' rvi$iholding boceuse: {a) I a~n e:etnpt $tom badatp withha, a (b) I have not been tioti8od by tLe: Intextaaal Service (IRS) that I am sabjesCt to baclrnp with6ulding ~ a nattOt of a faihuc to t+epott all inlwat or divideods, or (c) has notified coax that i am ao longer wbjast to backup wtthtbulding„ aaMd (3) I am a U.S. e~ize;n e>t' other U.S. peasai. '~ H you save bent aotlRed by tie [RS that yea are tarreeaNy wb~oet ter bae;Io~ ~ yott lxave f#Rei to rtport erg hstsrest sad dlvYeads ew year to rstaera, yea taunt crow oat Itatts (T) is mar t;boclc this boat ifyou ese a nomx-rasidmt alien. ^ Chec7c if Bxenxpt f'syee - StMns +rrpply to individuain. See imtruoiion Cot the WA fomt at ebe IRS websitc. Aeceaat Awe By sib this Acca~it R,tagistrat3on and A~oeaaeant and/ea by using daa by rogiieecing ewd/ar eaxing aadior latter adding auy sRaootmt related sesvica, i~ludiag but oot timiEed m I2ebit '~"M Ged, Overdraft Ptotectiott, PI+1C Heroic Oaiine servie;w,, I agroo to be bound by the teraaas avid eaeaaditiana o!' PNC s'.~-acoeait Agrrarnoot for Cheddng Acaenuxa cad Staviugs Aoooutrts, PNC Bsdc's Axount AO,reamant for CertiBades ' > or IRA CDs, as applicaW~ and Sched<elc of Service and Fcas. as well as other teams and conditions thsx y to aa<y 2'NC Hank aovoud, aoesaat feistui+ex andhar sexvicxss. I agt~ee that my acooeint Is subject tb appravttl by lyNC ~ceounrr • PRODttcr exuNCie r~eC'reve t>rtT'E nPKtc~rro~- oxa-~ wr~t.icr~lto~e r 5308157381 PWk 00586 09/Z1/2004 04/22/2009 1-KxPJY6 EI0R7 ELIZABETH ~TZEL 6iE1140LYp E PIi70 T i t>iis ttr. is W cJaar piatlc ~ tie rei ina~rt h eater also re >rsi.d.rh aacil n t~-~,a! &eg~ r7 PI~c https://www.cct.pncbank.tom/eaiws/EaiImaServlet?requestType=SCR&account=(~0(~0000... 11/2/2010 --- - -___. i I ; REV-1511 EX+ (10-09) '~Pr!sylvania 1lRieRTTAN(f TAX RETURN SCHEDULE H FUNERAL EX~NSES AND RESw~rr oE~r ADMINISTRATIVE COSTS ESTATE OF FILE Mary Elitabetlt Wetzel DeeaNR!'s /arts RNwt M raporte~ en Sdra/rrle L A. F1INERAL EXPENSES: 1' Seniioes provided by Fwieral Home, Inc 2 Riling Green Cemetery B. 1. ADMINISTRATIVE COSTS: Personal RepresdKative Commissions: Name(s) d Personal RepraeMative(s) Stmt Addre~ ~Y Year(s) Carnr~fon Paid: State 2. Attorney Fees: 3. 6cemptlon: (If deocddrt's address is not tfie same as claimant's, attach explanation.) CiaMnaM Street Addre~ 4. 5. 6. 7. ~Y State ZIP RdatlonsMp d Claimant to DeaederK ---~- II Probate Fees: AooorRdant Fees: Tax Retum P-'eDa-'er Fees: ! it FiTirig Fee 7,980.00 1,345.00 15.00 TOTAiL (Also enter on tine 9, Recapitulat~n) I ~ 9,340.00 If more spas is nailed, use additlonal shcets of paper d tfie same size. ~ Tr -T, REV-1512 EX+ (12-08) P~~varyia SCHEDULE I DEPIIRTMEN7 OF REVENUE ~BTS ~ ~, r"'~''"X n~rr oec®eNr NORT6A6E LIABILITIES ~ LIENS ES'TATte ot= FILE Elizabeth vYbfiZel ~ dells Nrctirrad ~ tM ~eee/Mt pier to redh tLet rewAeini ~ at tln fete d ~eetA, fecte~ ~meieN ~. AEM VAWE AT DATE NUMBER DESCRIPTION i OF DEATH i. ~ ~ 3.63 2 Hoy Sprit Hospital 4.43 3 ~~ 1,671.02 4 Phannarica 289.99 5 Cordinuing Cars 762.05 6 ~9 Care 56.85 7 Y viape Skied 9 1,780.01 8 Y ~~'~'!- 3,722.58 9 ~ ~ Retiab0itain, Iriduatrial d Spine Medidne PC I 14.14 10 East Perrrraboro Ambulance Servitres, trrc 58.00 11 East Pennsbdo ArnbWence Services, Inc 58.00 12 Hamp~dert Physician Aseoaailes 32.72 13 A.~ociabed Car6ologisls 43.00 14 (luarrium hnagirg and Theraper~c Asfopalea 5.18 15 f~luarttrun knagirrg and 1Therapetdic Assodaies ' I, 2.68 16 West Shoes EMS 25.68 17 West Shore EMS I ~ ~ 28.13 ' 18 OrMaped'ic of PA I 78.29 19 OAlgpedic of PA Ii 2.81 ZO Lackawanna Mobie X-ratr, Inc i 8.96 21 Mobie X-Ray I~i9 Inc 9.82 22 Space Mart (Shred itNrrilure vnhle in SklNed I~Nxsing betas peasir~g-One mores rent no bi) ~', 85.72 23 Space Mart (Shred fixrN'bas whie in Skiled Nurdng before passing-truck rental) 21.15 TOTAL (Also enter on Una 10, RewpitWation) # 8,744.82 If more space is needed, insert additional sheets of the same size. Car Aoaarat lasllriaa>~ea, Prose Cai 717 763-2135 _, Sra~rt ~}'~ 1 . >~ PREVIOUS UILANCE 10/19/09 COlPtETE Iit00D COUNT 10/19/09 sLO~ CULTURE 10/14/09 1LE~D CULTURE 10/19!09 _ _ _ sLtN1D CULTURE _.._ _-.--- _ _ _ - -- _ 10/19/09 SPEC COLLECTION FEE 12/01/09 .INSURANCE PYlIT Q02 HEALTH AMEBIC .~~. /aa fv~ .00 9.26 291.00 _21200 -32.Oi` 3.00 -32.62 YOUR INSURANCE HA8 BEEN BILLED.THRS IS YOUR CURRENT' BALAPICE. YOUR PAYMENT I8 DUE UPON REC©PT. TFb4r,MC YOU. doe HEALTH AMEBIC .oo PLEASE DiSREQARD THIS BTATEMENT IF YOU HAVE PAID. ADN DT: 101Y0o -~ _ 3585SIl99 DBH DT: 'NONE` Ire HQLY SPRIT HOBMTAL SB: ~~ 11E1"ZEL .MARY ~ S03 N 2lST STlI<IiNT 7t7-7s3amo CAMP HHL PA 1701 i ~ IrfR~l30Q4 A~RESS SERVICE REQUESTED ~~ --77 spur norm .I Nas Ooot ~ pN~ nrsbe °fgloiq ~ an~idc. won ~Aake CDaGc Payable To: HOLY SPIRIT t106PITA~ •'l'<r t:vY2lwver Is r. rc s r~lr.. tre ~ aryar aMkou,loryi.r~ 00013464 001 0.53 35858899 MARY E VVETIEL 770 POPLAR CHURCH RD CAMP HILL PA 17011-2302 I.aNId•.~..Nln~...l.ll HOtY SPIRR HOSPITAL P.O. BOX 822183 PHILADELPHiA,PA 1918.2183 ~kT~ nnnna~~ s Sr~ggnntnnnnnnnnar,~nntnn~a ~nnnnnnn~.~.ana ~-- Y L T7~e Spisit af' ~S .~ _ _ _ ,- - _ - - -- l~or Aeoee..t Iirau~iao, )rleose Ca0 Tl~'763-21~ St+~rtt o~~! . ~ ,. - PREVIOUS sALANCE 11/09/09 METABOLIC PANEL,s 11/09/09 PREALBUMIN 11/09/09 11/09/09 Nes ANB NCT NE T MA OCItIT 11/09/09 l~IM _ - - _ _ . 11/09719 - ---- - -- SPEC' LLECTYON' FEE - ~ _._ _ __ --- _._.. _ 12/04/09 INSURANCE PYMT Q02 l~ALTN AMEBIC YOUR INSURANCE HAS BEEN BItJ_ED.THIS IS YOUR CINtRENT BALANCE. YOUR PAYMENT' 18 DUE UPON RECEIPT. 'TtUWK YOU. aoz HEALTH AMEBIC .oo PLEASE DISREQARD THIS STAT'EMENT' IF YOU HAVE PAID. MM1r 1w art ors MIN DT: 110Y0o $~~~,L,_,.„_ DBH DT: `NONE' Ny~L MARY ~ .. HOLY 3M1e17' HOBPlTAL g~ ~p~ S03 N Z1ST 31'RB6T 717-7aQ-QZ79 ^ ^ CAMP HO.L PA 1701 I ~ AAR~906t AMRE3S SERVICE REQUESTED ~-R ^ i~~f ~ipad. nialea cnripe~ cn nick. moo ~ Check PsyoDle To: IiOLY SPtRtT tiOBPITAL • 7'e. CYVi ri~..~r r ur we i ryis.. n. ~.ec.tsr a~ ow.. 0001744b 001 0.53 3588e807 ~Y E ~~ I...NI.I....dll..l..d.it 5225 WILSON LN HOLY SPIRIT HOSPITAL IIAECHANICSBURG PA 170558863 P.O. BOX 822183 PHILADELPHU,PA 1918 000035b666070030000000044300100735000000011307 r ~,2/i e....~ ' .oo ~~ ' 12.25 ~, 20.00 4:S® ', 4.58 5.88 -39.82 $3 Isar A~ooorat iairdi~, Please C'a11717-'I63-21311 Traosrelloo Daole 10/13/69 16/23/69 11/25/69 11/Z5/89 11/25/09 ~~~~~ . ` PREVIOUS !AL ', 37A 6~SQ 30 PT THERAPEUTIC EXERCISE-15 ' 105.00 HMO LATE CHRBE C/A I Q02 HEALTH AMEBIC ~ -185.00 INSURANCE PYMT Q62 HEALTH AMEBIC -13,772.06 C/A OTHER COMM ~ N2 HEALTH AMEBIC II ' -19,987.22 C/A OTHER COMM OP Q82 HEALTH AMi:RIC !~ ', -2,226.00 cio2 HEALTH AIYERIC .oo PLEASE DISREGARD THIS STA1~Nf iF YOU HAVE PAID. 3~ AOM DT: 104TOY . 8si12 .. _ DSN OT: 101900 HOLY ~T H05PiTAL gg;, ~0Q0 tlETZEt. ,MARY ~'E S63 N 21ST S77l~T T77aaB-e05t ('.AMP HII.I, PA 17611 ~ ~AR~ad ADDRESS SERVICE REQUESTED a1~.1o Ceack box It~~r sddress or insurance uNOrmafion ----- ^ h/s d~M1pe0.Please make ctMnpes df Dack. Wake Ctiaclc Ps~rable To: t10LY SPIRIT tI06PITAL •'r~. crm iw.~rr w we s wrs s+~e ~ ors u.~~r, 00011146 001 0.53 AAARY E VYETZEL 6.d11.i.....N1..1..~1.11 52251MLSON LN HOLY SPIRIT HO3PRAL ~~ N~CHANICSBURG PA 1705S~9Q83 P.O. BOX 822185 PHILADEI.PHIA,PA 1918.2 e 0000356343020000000016710200100735000000011308 '~ __ __ ' ~harMerica USTOMER: MARY E, WE 1ZEL FACILITY: GOLDEN LIVING WEST SHORE ATE: l 1/21 /09 ACCOUNT: 5702-48-40504 ~,~~ p~L gip I~toCK1oN, MA 02301 PAGE: 1 of 2 PRIMARY PAYOR: INSURANCE POLICY#; 224605102 EFFECTIVE DAB 10/13/09-10/27./09 PRIMARY PAYOR: INSURANCE POLICY#: 00285 EFFECTIVE DA' 1(1/23/09-10/23/09 PREVIOUS PAYMENTS CREDITS: 1VEW B~„~~ $21~9 5~9 99 $289 BALANCE: RECEIVED: . CHARGES: . DUE: DATE I RX NUMBF,R I DESCRIP'T'ION I QTY B ', IriiS i > -NCE ~ I I U ~~~~ ~ J CRF.DI~ I ( Balance Forward: ~ ( ~ ~ I ~ ~ COPPiY OR DEDDCTIBLE PER 10~ER' 3 2>yI3T7R7lIIC8 10/13/09 2493212.00 DIPINE lOMG TAB 7.000 26.62 I 21.62 5.00 10/13/09 2493233.00 PROLOL TARTRATE 50 MG 14.000 17.62 12.62 5.00 10/13/09 2493235.00 CLONIDINB HCL 0.1 MG TABL 14.000 13.55 ', 8.55 5.00 10/13/09 2493236.00 LEVOTHYROXINE 75 MCG TABL 7.000 12.29 7.29 1 -5.00 10/13/09 2493239.00 LORAZI3PAM 0.5 MG TABLET 14.000 18.75 ', 13.75 5.00 10/13/09 2493242.00 TEMAZEPAM 15 MG CAPSULE 7.000 15.14 ' 10.14 5.00 10/14/09 2494216.00 LOVSNOX 40 MG PRBFILLED $ 2.800 260.58 159.7 48.85 52.03 10/15/09 2494735.00 VBLOX 400 MG TABLET 5.000 95.18 54.9 I 22.23 17.96 10/15/09 2495217.00 FBNTANYL 25 MCG/HR PATCH 3.000 53.26 20.4 27.81 I 5.00 10/17/09 2493212.01 DIPZNE l0t'IG TAB 15.000 45.61 I i 36.48 9.13 10/19/09 2493233.41 TOPROLOL TARTRATE 50 MG 60.000 42.66 ~ ! ~ 37.66 5.00 10/19/09 2493239.01 LORAZBPAM 0.5 MG TABLET 30.000 28.76 1.0~ i 22.76 5.00 10/19/09 2499155.00 RMAL SALINE FLUSH SYRIN 280.000 71.60 48.2 18.36 5.00 10/19/09 2499162.00 DAZOI,is' 500 MG/100 700.000 30.93 14.0 1 11.85 5.00 10/19/09 2499164.00 IPIME 1 CiM ADD-VANTAGB 5.000 127.43 75.4 I, 27.41 24.60 10/19/09 2499165.00 SODIUM CHLORIDE 0.9~ SOLN 500.000 20.20 5.0'~ 10.13 5.00 10/21/09 2499155.01 ORMAL SALINE FLUSH SYRIN 240.000 62.80 40.8 16.95 5.00 10/21/09 2499162.01 ONIIDAZOLB 500 MG/100 600.000 27.94 11.5' '~, 11.37 5.00 10/21/09 2499164.01 MAXIPIMB 1 GM ADD-VANTAGE 4.000 103.94 60.5 ', 23.62 19.77 10/21/09 2499165.01 SODIUM CHLORIDE 0.9~ SOLN 400.000 18.16 3.3~ ~ 9.81 5.00 -, BILLING QUESTIONS: MEDICATION QUESTIONS: P!~ ---. ADDRESS: 08:30 AM - 05:00 PM 09:00 AM -04:00 PM PC~ ~ ]644458 PHONE: 866-251-5966 PHONE: 800-994-6337 P BURGH, PA 15264-4458 ~A 1123 PEARL STREET BROCKTON, MA 02301 RETURN SERVICE REQUESTED 31111-9QAA CUSTOMER NAME: MARY E, WET ZEL i~'i Pk+rs clack box ff ~ddlsss ks illeorlect or ilalrwlcs U illfonnaRfon hp cMrlged..na irldicats cbange~s) on "verse side. o~zoz ulll{111111~~~ll~lillf~lll~ll~~lllll~•ll.llillll.l~li•liil•1••11 WENDY PICOT 101382 POST OAK TERRACE MANASSAS, VA 20110-2718 arMerica ~ M1fN3 eY DMCOIIOi. NQA OR FLL OUT 0801M. C-ECK CARDUbN6 ®~ ~~ wlsrmc~nD oiacD~n PA ~~ ro1Ewc+~111 Exw-ESs i slt;>M~upt: oa D~ OUE GATE 12/21/09 PAIY TH16 $289.1 9 ACCT. i 5702-48-40504 i Ilgan1111~4~1'~~nll.ll~ll{il~~~~ Itil~u~.dllull~lllllll~l PHARII~RICA 1 PO BOX 644458 PITTSBURGH, PA 1 ["111 -11~ p A1~11111'1 [1111 P~I~ f~1RR-1 a 000 f CClNTIitiiUTl~dG GARS RX 2s s s~corvD sT NEI~IFC3RT 4'A i.iG74 :~ ~ S T A T E M E Itif T~# Statamer,t Date: iir30fp9 Page Ac c ovn t #: 10005428b DVC3 MARY WEl'':ZEL. ilENDY F I ~:dT it~t~©82 FdST dAK i"ERRACE i~€A~IAAwA~;: VA 2t~i its C~ Date Descrip~:i+~r~ Qty Amount i 1!04/09 RX#-70f?CY04D CRAhIL~ERRY 4004"10 CAPSULES 28 4. 65 End irtg ba.lar±ce -- Pao this amount --------- Past Due Past Due Current 3i-60 days 61-90 days ___________ __"____-___w ___________ 762. 05 . 00 . 00 QUESTI01~4S PLEAS: C~~L.L i-SOCk-c~,75-2279 E?CT: 1304 -NPjease cut here and remit this portion With payment Femit to: ~:Csh4TTl14ilI4`~4G CARE RX 5 775 ALL.E1~4Tt3W1~1 ~L.V)? 5U I TE i C} i -tA~~~s~~~R~:~ PA i7~.iz 7~2. 05 Past Due 90+ days . 00 Statement date: 11/30/09 Account #': 100054286 B4 Ending balance!: 7b2.05 Hmount enclosed!,: 4'•4ame: 4'1AR`; WET~~.;~L WEIttDY 4' I CC2 10C7f~332' F4::lST dAl~t TERRACE CONTINUING GARS RX 28 S SECOND ST NEWPORT PA 17074 I ## S T A T E M E N T## Statement Date: 12131/09 Rage: 2 ', i Account #: 100054286 '~ MARY WETZEL WENDY PICOT I ! . 100082 POST OAK TERRACE ', MANAA5A5, VA 20110 Date Description. _ 12/12/09 RX# 712122b MORPHINE SUL SOL FOMG/ML I _ Qt_y___ _ -_ _. I!i A~n~oun t ___i ---~--IS 00 COPAY ~~ I i I Ending balance - Pay this amount ---------> ',5,,85 Past Due Past Due Pas bue Current 3i-b0 days bf-90 days 90+ d~ys 5685- -~- . 00 00 . p0 t3UE8TIONS PLEASE CALL i-800-675-2279 EXT:1304 II Please cute-here and.-remft~ this-portion with payment" -~ -- I ' - -- Remit to: CONTINUING CARE RX 5775 ALLENTOWN BLVD SUITE 101 HARRISBURG, PA 17112 Name: MARY WETZEL WENDY PICOT 100082 POST OAK TERRACE MANAASAS, VA 20110 Statement da~e Account)#. Ending balance Amount enclosed 12/31/09 100054286 Bt, 5b. 85 i I i i , Stalamarlt Data Dw Dada ACCOUNT NUMBER 12J31/Z009 Upon i 178 ~~-n~ouMr Pay ~ _____ Pis~ee m>Idce amac payable m BETt1ANY MARY E Raml! To: do wENDY BE7HIWY VS.LAGE 10052 POST' 325 VME~.EY DRIVE MANABSASr VA.20110 _ _.._._ __ _ _ -_ . _.. -MECHANIGBRIiRG, PA Please de4lch and return ~ potion wNh~ueour Comm~nh 1210~ifi9 -12101109 Balerioa Fawar+d xt+ar tr atl~ed Check 8 xfer 12MTA9 -12H 7A6 Py~nt fin stmt 11/JM09 GaNCk i 7t>~ 121t)?Jg9 -12l0"110R I~RAiNAiOE BA~t3 HOI.D~t 12A?109 -1210?J0O Bpi LEC3 TWIST VALVE MEO _ --1?It)4109.1?10~109 URSlE DRNOE 6AC3 COVERS POKEY 12/O~Ifi -1?IOA10i1 TRAY FOL NO CA'[WB14t' PVP 80G,C 12I0~1108 -1?IOU00 CATH FOL.EY 91L!-FLAB 1tlFR 9oC~C 12/10109 -1Z!'10109 URtt~ DRWt~E 8146 COVi;R. POSE1f 12/1 OA8 -12/11209 TRAY FOL NO cATt118~1k3 PVP 3000 12MOii~09 -12/101109 TRAY U18=~Fl~J4L RU88ER PVP 15FR 12/10109 -12/10100 CATH FOLEY Sll.l-FLAB 18FR SOCC 12H0106 -12H0109 CATH FOLEY 31L1-FLAB 18FR 3000 12N2lOt3 -12/12106 teofefon 12h210®-12/12AA SUcioNrrg 1?J12Ji0®-12112A8 (ietilletBl' Care . 12112100 -12I1210ti Irroorrtlrrerae t~s - ModA~leenry 12M2106 -12112N9 PR090URCE PROTEMI PWDR 9.7 OZ 12/12/09 - i2/i310f MontlMy Fee 12/12109 -12/31109 Montliy- Fee 12/31108 -14/31109 Ret+und: Monthly Fse TOTAL BALANCE DIJIE: 1 ;13.15 1 x.4(1 _-~. __- 515.25 1 ;8,06 1 ;7.80 2 ;15.25 2 ;6.05 2 =3.15 1 ;7.80 1 ;7.80 12 56.25 1 ;13.50 12 ~.~ 4 ;10.75 1 ;21.00 2 ;258.00 Ro) 5{256.00) SB,502.05 ;13.15 ~ --. ~A4-.III ;15.25 ~~ ;7.80 S~o.so ;12.10 56.30 57.80 57:60 57500 ;13.54''._.... ;75.00 543.00 52'1,0.0... 5518.00 5(5.160.00) 54306.95 b tle address above. '.05 ;0.00 FACILITY NAME RE3R)ENT NAME NIRABER ocn~wwrv evn r rn wa rnc~+-rn i aawov c urcr~~r 1 •+e case contact Donna Colon at 717-591-8029 with anv bile questions ..,..,,._ ~ ,k __ .,~~xvr. ~ ~ ig .v. x~ y v° ~ r cd' >*j,f `ifr1~3 ~y2 /22/09 - 10/22/09 PR Evaluation 1 $75.08 $75.08 /23/09 -10/23/09 OR Evaluation 1 $79.54 $79.54 X23/09 -10/23/09 PR Therapeutic Exerdses 1 630.09 630.09 "13109 -1 0/23!09 PR Therapeutic At~ivfties 1 $31.46 $31.46 '23/09 -10/23/09 O!f Therapeutic AcBvtties 1 x31.48 $31.46 '26/09 -10/29/09 PR Therapeutic Ac~ivBies 7 #31.46 $220.22 '27/09 -10130/ Pff Therapeutic.Exert~ses 8 $30.09 6240.72 ', 27/09 -10/30/09 O/T Therapeutic Exercises 4 $30.09 $120.36 28109 -10129109 O/T'i'herapeutic Actlvities 2 $31.46 562.92 30/09 -10/30109 OR SeIF Care Mgmt Training 1 531.49 $31.49 02/09 -11/02/09 OR Therapeutic Activities 1 $31.46 $31.46 02/09 -11/08/09 PR Therapeutic Exerdses 9 $30.09 6270.81 '' J2/09 -1 1/06109 O!f Therapeutic Exercises 8 $30.09 6240.72 12/09=11it1~ PlL.'Cfaerapeutic~ivities__ __.. __ _ ._-._ __~__ 531.46 .---____61~7_~`.,_._ .~ ' )3/09 -11/03/09 OR Self Care Mgmt Training 1 631.49 631.49 - -- -~~ -~ -___ _+- _... _ )9/09 -11/09(09 PR Therepeutic ActMties 1 $31.46 $31.46 )9109 -11/09109 OR Self Cate Trai '~ ~- 09 =11119109 OR Self Care Mgmt Tratning 1 631.49 631.49 09 -11!20109 PR Therapeutic Activities 1 $31.46 531.48 j d8 -11120109 O/T Therapeutc Activities 1 $31.48 531.46 ', ~09 -11/25109 PR Theta~peutic E~cercises 3 530.09 690.27 09 -11/25109 011` Therapeutic Exerdses 6 630.09 6180.54 09 -11/25/09 PIT Therapeutic Adivites 4 631.46 $125.84 ` 09 -1 1130109 P/T Therapeutic Exerr~ses 2 530.09 680.18 ' ~~ 09 -11/30/09 OR Therapeutic Exerdses 1 X0.09 630.09 ~. 09 -11/301D9 OR Therapeutic Activities 1 $31.46 $31.46 09 -11/30109 PIT Wheelchair Mgmt Training 1 $28.92 8. 09 -12/02/09 DRAINAGE BAG HOLDER 1 $13.15 513.15 09 -12/02109 BAG LEG TWIST VALVE MED 1 $3.40 53.40 09 -12/04/09 URINE ORNGE BAG COVER, P05EY 1 615.25 615.25 09 -12104109 PRAY FOI. NO CATHIBAG PVP' 3000 1 $8.05 $8.05 09 -1211)4/09 CATH FOLEY SILT-FLAB 18FR 3000 1 $7.60 $7.80 09 -12110109 URINE DRNGE BAG COVER, POSEY 2 $15.25 630.50 ~ .~_ . _ __ __ .._.__-- _- _...._v .__.. __..K~.. ~.._ _ _ _ -_ '~ _ __ 09 -12/10/09 TRAY FOL NO CATHIBAG PVP 3000 2 $6.05 $12.10 ~, (~~ ~ ~/L 09 -12/10109 TRAY URETHRAL RUBBER PVP 15FR 2 63.15 66.30 y Y,~j1'V`' 09 -12/10109 CATH FOLEY SILT-FLAB 18FR 3000 1 $7.60 $7.80 ', 1~ 09 -12/10ro9 CATH FOLEY SILT-FLAB 18FR 3000 1 $7.60 $7.80 rol 09 -12h2/09 Isolation 12 68.25 $75.00 I, `r 09 -12/12109 Suctioning 1 613.50 513.50 ', 09 -12/12!09 Catheter Care 12 $625 675.00 09 -12112109 Incontinence Care - ModMeavy 4 610.75 $43.00 09 -12/12109 PROSOURCE PROTEIN PWDR 9.7 OZ 1 621.00 521.00 TOTAL BALANCE DUE: :4,OS9.a3 «.~ i (S!C[ANS OF REHABIUTAT~N, INDUSTRIAL ~ SPINE MEDICINE, P.C. ~TATFMFNT aESOUlevard 4310 Lor>eml Roatl Michael F. Lupir-acci, M.D• STATEMENT DATE PAGE Box 2028 Bloom Bldg. Suite 106 William A. Rolle, Jr., M.D. ianicsburg, PA 17055 Harris~a:rrg. PA 17109 f 2f Q11 f 09 01 691-3755 (717 561-4242 www.prismdrs.com Lisa A Eaton, PsyD ACCOUNT ~ ~ Dept: (717) 591-4405 Tax LD. ~2a-1651500 Please retain the portion of statarient for your NttMeER 0536^c8 PION DATE INV. NO. POS. PATiEN-r DR I PROCEDURE DESCRiPT10N OF SERVICES QIAGNOSIS AMOUNT r 4frZl9 gR MARY IMFt~ . 993+D6 SKILL NRSG, INIT; LEV 3 7812 225.00 3f~19 MARY ~MF ~ 46 INS ADJUSTMENT tCR> 83.60- 3fCh9 MARY ~ jMF 6 PAY-INSUR 127.26- 3f~19 MARY MF -4 # 14. 14 Ct]PAYMENT ]U H VE NY QUESTI NS PLEASE CA L 691-3755 .EN :30 AM AND 4: 0 M. 14 ~ACCOUttr u ~ i 4. i 4 RENT OVER 90 DAYS- OYER 80 DAYS OVERlfO DAYS OVER 120 DAY8 ~~~ _- - _ __ ~ PLEASE DETACH AND RETURN THiS PORTION WITH YOUR REMITTANCE At;,CpUNT NO. 053628 12!01!09 MARY E WETZEL 5225 WILSON LN MECHANICSBURG,PA 17055 PLEASE MA E C PAYABLE T P I; s 14. i4 CHECK East Pennsboro Ambulance Service, Post O,,Qice Box 47 L Enolq PA 17025 - AX (717) 728-9501 Federal Tax Nwnber 23-2464545 invoice ~~ INVOICE ~ 111858009 09-2590 PATIENT NAtdE: Msry ~ tiz#beth Wetzel ADORESS: sus ~ '~ Lane I ADDRESS: PA 17050 PIgC UP: Bet6a~ L ' TAKEN TO: nr Fid,ds ' I DESCRIPTION: Whoel_ TRIP NUMBER ~ 09-21289 BATE ~ SERV... DESCRIPilON UNIT RA AMOUNT 111248009 Whceldtair Transport -Round Trip 1 ,,5$.00 58.00 Far yortr toweaieate. we am- accept Mastercard, Vies and Diooe!rer. Card Type: Naaee w card: ' Credit Card Ntiober !~_ ._.__-.-. ~-~.._ .~_~._._ Espirstlar____ / Amaaat b be ems: S i I atra to pay tre above fatal ataroast soardieK b card isomer a~aee.t. sipaares Coearee•tx Yanr payaee~t is dex apoa receipt Mediare acid cost iwraaees do ~ cover trio service. need a creek witr yNr iasetiraeee eo~piuay. pkrso aek iTyaar phut covers d~Ortation code Airl3ii. ', Pr:aee Nate: Unpaid aeeonts easy be cent is a eoBeetiea s~ey aRer 90 days. AL DUE $58.00 East Pennsboro Ambulance Service, Its. Post Office Box 47 Enola, PA 17025 (717) T32-5552 FAX (717) 72&9501 Federal Tax Number 23-24b4545 BILL TO wa~ryEa~ 5225 Wibon L~oe ~. PA 17x50 AMOUNT AMOUNT ENC. ssaoo ', ~ DATE DESCRiPT10N ~ AMOUNT ~ ~ BALANCE 11/25/2009: aw ~o~-zs9o. na i ~~sr~. o,~. Any ssa.oo. _-BVa..~cwx 2way t5aoo . s .oo ~, I ~~ ~I ;i I ~i~ ~',~ _ ~ ~I saoo CURRENT 1'30 DAYS 31-60 DAYS 61-90 DAYS R 90 Y AMOUNT DUE o.oo ooo ooo ssoo ooo II ~sa.oo PiBASB RB~M1T YOUR PAYM@TP TODAY! I~DICARB, MEDICAID AND MOST II13tJRANCES DO NOT P APPROPRU-TB COLLECTION ACTION WILL BE TAKEN ON ACCOUNTS OVBit 120 DAYS OLD. TEfANR VISA VBRCARDSACCEI'TED Y Y ~i TES SBRICB. ~ I, ~__I, Statement of Account HAMPDEN PHYSiCUW ASSOCIATES 3456 TRINDIE ROAD '~°~~''~" CAMP HILL, PA 17011 ° -~ ~ ~~ ~~ ~---- i Wendy Piet ~ 10082 Post Oak TeRaoe Manassas, VA 20110 Date For Description 12l02t2009 MARY ~ _ insurance Adjuslrner~t _ R Ref 31859 P ,..: _ # 2_ i $32.72 f $0.00 ~ $0.00 ~ $0.00 ~ $0.00 I ~ ~~2.7 ~ , i ~~~ Notes ~~ THANK YOU FOR YOUR PAYMENTS. BiLLiNG QUESTIONS CALL: (7i 7} 635-2073 ' 'I I ~~'~ Li,___ ~SSQ~4RB CARDIOLOGISTS ~6 CENTURY DRNE MECHANICSBURG, PA 17056 For BilNrp QwrHons CsN: (/17) 591-7122 ForToM FnsCaN: 1-80D~846-1742 Patlent Name: MARY WETZEL ADDRESSEE: MARY YETZEL 5225 WILSON LN 11ECHANICSSURG PA 17055-6663 12/07/2009 : 63.00 262714 CHARGES AND CREDtT8 h4ADE AFTER STATEP:9~NT SHOW AMOUNT DATE L;~ILL A?PEAR ON NS:CT Sl'A7EniEP1T; I ~ID HERE ~a MAKE CHECKS F#AYI ISLE / REMITTO: ~~ mzz-say ~n~~I~~~~I~~~U1~~~u~~~~~u111~~~~~~,tu ~~u~~~u~~u~~n~~ ASSOCIATED CARDIOLOt~IS~T'S 856 CENTURY DRIVE MECHANICS8UR6, PA 1710515 ~ I la~a"ana~dM°ea. ~a'+nac~e~ amoet i axe. °~ ReruRN ToP roRnou w~ UR IN ENCLOSED EMIELDPE Dal9 ~ ~ ~ ~ ~_ ~CrNK _... _ Barh~o~ 100@109 10J09r09 10/101Q9 10/11/x9 10V12/09 - - 98254 99232 99232 99232. 9330626 --- H03P CONSMOD-HIGF180 SUBSHOSPMOD CCNNPLEX25 SUBSHC)SPMOD COMPLEX25 SUBSHOSPMOD CCMAPLEX25 ECHOM-MOOE2DW/DOPNt_ERCFINTE 401.9 401.9 754.31 794.31 786.50 .00 125.00 1125.00 ' 1,25.00 14Q.00 248.72 118.43 118.43 118.43 132.99 1628 6.51 8:5 6,57 7d' _ _ _._ .._._ _ 'PoM OrrnN 31-M it-M l1-1i9 09er 1b O N al w: 543.00 9w PaYMk ~~ 43.110 .00 .00 _00 OGIATED CARDIOL0013T3 ~NTURY DRIVE A9e9wt id99C9 S 43.00 ICSBURG, PA 17055 L. Snp~ ArAawa, M.D.. F/IpC (1941-19r~ OavW L. SdNr. M.D., F/ICP, RAL'C, FHR8 An4~as U. YVir, MA., fACC, fSCAI Don/d C: Durbaok, M.D., F/ICC, RETriED Jq C. L CoMon, M.D., FACC MioAaM D. Oosww MD„ RACC, FSCA! Ja9hry S. FupAa, D.O.. FACC Ya Saaiotin, M.D., FACC lanNa EdY, MA. Slawt S. PM~Ic, M.D.. FACC. FSC.I{I RobM D. AP~nclt, M.O., FAArC, FSCAI Aywh M. Dww M.D., FACC. FSCr11 Kanna9~ J. May. Jr., M.D., RACC, fSCN Orvid C. Man, M.D., RACC Sarp K. lOrn, MA„ FACC Ropnt A. SdoAlntcid. D.O.. fAOC, FSCAI Edvand C. Bew~naa, Jr., O.O., fACC 8aiwal A. Oaaais, MA, FACC ClMlalophar L. Spirsiati, D O, FACC ±r qu..wn. wn oe nn~o. owwsen nN d x90 AM and 4:Op PM. Quaadona Car: (717) 591-i1Zt fnaa CrM:1-A00.816~1i42 llnna:MARYINET2EL i._~_ ~"`'^DO NOT SEND PAYMENTS TO THIS ADDRESS Uep .19687 P O BoY 1259 Oaks. PA 19456 s ~~ ~ an aroolRn. raL. our Corr lJ+neA D ~ ^owoovER ..~ ttueTUfcura~autstr s~atrax,s_~nutt brat a awo c•~a~aa~aar way w... .,c, aaa....-.r .wwA.:~ For billing questions call: (717)932-5955 or: (877)932-5955 Fax: (717)932-4855 Office Hours: 8;00 AM - 4:30 PM ADDRESSEE: MARY E WETZEL 5225 WILSON LN MECHANICSBUR6 PA 17055-6663 ~ Ats~i~np~eA, aRd~ d) side. Patient: MARY E VYEIZEL ____ Aflemut~te 89TH f98T'08 c~uanunn Imaging P O Box 621G5 Baltimol!re, MD 21 ~1t~f~fti~Iftli'ff~fri~fl SHOW AMOUNT PAID HERE 3LE / REMITTO: sal il~[tGrA~EUt1C AS90C18t8S ~f1f~t'it~~iif't'1"tit' ~~~ YOI~R ~TF~ !N ENf~.~ E~MIEIO~PEw~ ____. ___. --_- -_ -- -+--r.._ _. _.__~.___ __ Ssrvicaas R~tdar+ad A~ HOLY 3P~R1~' H~SPFTAL Dab! (,per Description t r/ qW 10RlZ009 73030 SHOULDER MIN 2 VWS 36.00' ~ 1 0/7/2009 7 170 Z PELViB AP 34.00* f~~ 10?1Y006 71010 CHEST SINGE MEW FRONTAL 10Al2009 70450 CT SCAN BRAIN WIO CONTRAST , ~ 12!312009 PMT HEALTH AMERICA ~ 38.60 12/31/2009 CR Adjustment HEALTH AMERICA ~ ~~ 155.11 10/9/Z009 71010 CHEST 81NCaLE VIEW FRONTAL 36.00 ~ 12/312009 PMT HEALTH AMERICA e ' 7.99 12!312009 CR AdjustmeM HEALTH AMERICA . ~ ~ 27.12 ~. i . ~ ___. _ i _ .__ . _ . Current 31 - 60 61 - 90 91 -1 ZO O~rer 1?A BALANCE =5.18 5.18 0.00 0.00 0.00 0.00 PAY BY January 30, 2010 THIS ACCOUNT BALANCE ~ YOUR RESPONSIBILITY. PLEASE REMIT PAYMENT tN FULL OR CALL OUR OFFICE IF PAYMENT ARRANGEMENTS AND/OR IN8URANCE INFORMATN311! IS NECESSARY. Those charges shown with an "'" indicste pending ir-suranoe. @'TATCfa/Lr-IT I 1v31~2o09 f s$.18 1 s97v CHARGES AHD CREDITS tM1ADE AFTER STATEAI DATE WILL APPEAR ON NEJfT STATEMENT: ^~~ MAKE CHECKS I ii For billing questions call ('17)932-5955 Fax (717)932-4856 Office Hours: 8:00 AM - :3~0 PM Tax 10: 251792 I I - - eFwu~rrsrttnrti ae .FU.arrre.ow DO NOT SEND PAYMENTS TO THIS ADDRESS De t. 19687 ~" ~ ~~"~RD ~ ~01'00"~ l P O Box 1259 Oaks, PA 19456 ~T.«x~~~, ~~~ ~~rr~r~~r~r ,~~F~, .. .'.f .`~ l~ffV NR ~ APltAY~ .. For billing questions call: (717)932-5955 or. (877}932-5955 Fax: (717)932-4858 Office Hours: 8:00 AM - 4:30 PM ADDRE.9I:EE: ~~ NARY E YETZEL 5225 YIt_SON LN 11ECHANICSBURG PA 17055-6663 Plaee olNdc boot M ebore eddTOOes is ircoTrw:t or NrouTeooce MEonTalioR bee ehatigod, end ind'Ne>tie claoopels) an isveose side. Patiset: MARY E YIfE1ZEL Reindered At: HOLY Daaibe Code ~~PA' 10/T/200ti 73030 SHOULDER MIN 2 VWS 2/152010 PMT HEALTH AMERICA 2/15!2010 CR Adjustment HEALTH AMERICA 111A/2009 72170 PELV18 AP 2/152010 PMT HEALTH AMERICA 2h 52010 CR Adjushnent HEALTH AMERICA 1017/Z00® 71010 CHEST $MI~.E VIEW FRONTAL 2N52010 PMT HEALTH AMERICA 2h52010 CR Adjustment HEALTH AMERICA Current 31 - 80 61 - 90 2.66 0.00 0.00 AND RETURN TOP PORTION MATH ~p IN ENCLOSED ENVELOPE w ~- --- -- ~T MOSPITQ ~iRr?' H08PITAL ~_ '. Charp~ Chalrge Ad u s 08.00 36.00 8.30 8.30 26.18 26.78 J1.00 34.00 7.67 25.48 36.00 7.99 27.12 91 -120 Over 120 BALANCE U 62.88 0.00 0.00 PAY BY I March 18, 2010 THiB ACCOUNT BALANCE IS YOUR RESPONSIBI!_I'TY. PLEASE REMIT PAYMENT iN FULL OR CALL OUR OFFICE IF PAYMENT ARRANGEMENTS AND/OR INSURANCE INFORMATION IS NECE,$BARY. 2/16/2010 ~ X2.66 I 8970 CHARGES AND CREDITS MADE AFTER STATEN{~t~T AMOUNT DATE wiu. APPEAR oN NexT sTATEMENt. ', PAID HERE ~~ MAKE CHECKS P -YI~BLE ! REMIT TO: ~w ~s~o-22 tZuantwn Imaging a~d ~7terapeutic Associates P O Box GZI65 Baltimore, TvID 212GkI-165 ~~~~~~ue~~u~~~~~~tu~t~~~~~t~~~r~~~~~ui~~~u~~~n~~~~~'u~' For billing questions ca;~li: 17)932-5955 cbr. 77)932-5855 F :(717)932-4856 Office Hours: 8:00 AM 430 PM Tax ID: 25178 c~-rwxururr i WE T SHORE ANESTHESIA ASSOCIATES BOX 947 CHAMBERSBURG, PA 17201-0947 (800}827-3458 X407 8AM-4PM WSA ADDRESSEE: ne~a-34 MARY E WETZEL • 5225 YILSON LN MECHANICSBURG PA ].7055-6663 Plpse diedc boot M above add-e.a is Noconect or inslaanoe fnbmMdon has . and Yldieele claxipe(s) on reverse side. ~i~~: Pn~oadure Patient Date Cale Name DeacNption 10/08/09 01630 MARY E ANES ARTNRS NUMERAL N/N ST 11/24/09 MARY E Payarent GEHA 11/24/09 WIRY E MEDIGIRE NMO AlUST1ENT /~ M~ala M11asA OII AJ.OIif MLOw OMan ~ Ooa~stancwoo M ~ IM$T WIIpE 9 DIGIT BECUIYIYCmEffM7Y 8A49C OF CND sTaTaaMr ~-~ PAY a NT aCCOUN'r No 11/28J09 ~5. 28739-G CNAiiGES ANd CREDfTS Ps9ADE A'rTE6i STATEAdEPJI! HOW AMOUNT @@ Oc1TE 1VILL APPEAR ON FJEXT STATEF,7EM. ID HERE `p ~~ MAKE CHECKS PAY~ABI~E / REMIT TO: ~~ WEST SHORE ANESTHESIAIiAS~SOCIATES PO BOX 947 CHAMBERSBURG, PA 1720 -x947 6..111...1.,6111......1111...61...1..11..1N.i..i RETUR1i TOP PORTION WITH IN BVCI.OSED Bd11ELOPE Amount Balance P hysicianJ 5H 1,148.00 25. 8~ Git`EEINE'RE M 231.14 - S 31N 21sT ST 891.18 - i I ', I _ _,-._.- _ _ ~_ _ ._. _ - -- I YOUR CLAIM HAS BEEN SUBMITTED TO YOUR INSURANCE COMPANY. THE REMAINING BALANCE IS YOUR RESPONSIBILITY. PAYMENT IS DUE WITHIN 30 DAYS. '"'"'`~ YYEST SHARE EMS -BLS ~„_ 245 C3tRANDVIEW AVE SUITE 211 Phone 6: (800) 367-0512 ~~ PA F 4ede1ral Tax ID: 23-246300,2 ~ ~~; ~_ ~~Q~ E',iLRGE'~;CY RFEDIC.~1__ ~=t~~`~'~t`f PATIENT NAME: MARY VVETZEL PATIENT NUMBER: 48880 IBAL CALL NUMBER: 195488W NONE INSURANCE: DATE OF CALL: 10/1312009' TIME OF CALL: 04:35 PM CALLER: HOLY S PITAL 195488W FROM: HOLY 3Pt ChSPITAL TO: GOLDEN L MARY MIE7ZEL . C~ YrENDY FMC30T REASON(S) FRACTURE }HUMERUS -CLOSE 10082 POST OTT TERRACE FOR i MANA>SSAS. VA 20110 TRANSPORT ' n 1~.~ i 1Y tNVOiCE DESCRIPTION OF CHARGE l,UANTIIY UNIT PRICE ~ AMOUNT STRETCHER One Way Transport A0999 1.0 108.75 ~, i 108.75 Transport Van MAeage A0999 1.0 3.74 3.74 I I T 112.49 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Insurance Paymerrt - GOV EMP - f30X 4665 Its 22949147 01104/2010 84.36 ___, _._ --84,31 PLEASE PAY THIS AMOUNT - tNVOtCE DUE UPON RECEIPT --~•- ~, ~~ 528.13 RETURNED CHECK FEE - $31.00 DETACt! ALONG PERFORMATION AND RETURN STUB MATH PAYMENT ~ A E 28.13 PATIENT NAME: ~' MARY E CALL NUMBER 19~w PATIENT NUMBER: 48880 Bg,V~ pA~; 01107/2010 ENCL Thb is the arnoulnt due attar your Ilnsuranos Carrier's • vrSel VISA (~ I AND MAR CARD ....„~< !t c »z~t-i-x.~r-.i~tc: s~~-rr-e.rs-[_ "~= I'~iV3V;SYLVAi~I7A STATEMENT ADWiESSEE: ~n~~~~n~~~~n~~~~~~~~~~u~~~~~ Wstrl, Mary E 5225 Vlfilson lane STATEMENT DATE PAY THIS~` ACCOUNT NSR ~ oirosno I $78.2: 85230 ~ SNI AMOUNT PAID~HERE REMT T0: Ortiwpsdic Institute Of PA '', 3399 Trindle Road Mechanicsburg, PA 17055 Camp 111, PA 17011 - Pkasle deck bnlc ~ aboti~a addiets is inoomect a insualloe Infamwlion has dla~ged, and PLEASE DETApI AMD RETURN TOP IMiH YOUR PAYMENT IndM~1e dlaige(s) an reverse aide. i 'roe-aso _ ~-_ - _ _ ._ - - - - - -- -----__-__ __ ___ _. _ --- --C~ 7? DATE AMOUNT 1811 I PABAInANCE I BALANCE ;0727109 ENCOINrTtER AStt3>s4 lrOR MARY WITH POLACHECK JR MD WILLIAM ; n, ,. _ ~ 09/17109 PPO 3 Amount .~~.~~_ ~~~ T -:31.74 .. t_T _ -- - ..: ,.. 12/031108 -- ~' Mf'C --- _____. _ . .__ _ _ - _ $20.00 __~~... _ 0~ ~..,-~..,._ ~_ ., `_.. , T ----~ yv 3 p~ ~, - ._ _ 09/17/09 PPO - ----- _ _ ---- _ ~ __ _ _ __ ~< - - ,~ - ~ ._ ~ _ -- _ _ 12/03/09 - - --. -T.---_ ~- _~-~,.~ ---~ - - - .. _ $3.62 ~ _ _ *..lcnF~!~S.SR ti +EaHRR H'- J~y~j (~ ~/~ /_~... - ` '^._ _~Lf.VV $IIt. V~j . _. J...` ` 10/07/09 23615 -TREAT HUMERUS FRACTURE 51,653.00 $78.29 ; _ . ~ .:.. .~ ---. ~__ __.____ __ _ _ __. .~ HA 12/28/09 _._.__ ~:; " ~ -- -~ o~" L _ _ __ __ _ _ -$870.14~i _T_ a~s s - . _ ~~ : : ___. _- _~~ ~_ _~~oo _ aw _ __~~ _ -- - _ _ _ ~~ ~~-.r-r-----.~- ..-----.~- ~.~. -T-------~---.- ~--- - --,____-____..~ _ ., ...~.w~.___ _._~_.~~,.~ - --- -- 'I ACCOUNT MBR ! CURRENT 30 DAYS QO DAYS 90 DAYS ~ 120 DAY8 ~ ; 7~O~TAL ACCOUtiT BALANCE 85230 ~ $78.29. ~ $0.00 j - $0.00 _-_T_J $0: ~___.~__ j _$0.00 ~ $78:29 ; ._-. MESSAGE:.. ,. PLEA P Y if You Have Questions Catl 717-761-5530, Option 3 TMLq _ ice,,,, $78.29 "PAYMENT DUE UPON RECEIPT • THANK YOU " ~. w nom. • ,_ __ _ _ _ _ _ _, ~. _ c .riz i'i-K ~lil-_t rlc ~ 1 NS.'T'!7'R.:'I'L STATEMENT ADDRESSEE: ~n~~~~in~~~nu~t~u~i~in~i~~ Wetzel, Mary E 5225 wlson Lane Mechanicsburg, PA 17055 ~ PAYIN G BY CREDIT CARD, F~L OUT BELOW CHECK CARD USING FOR PAYMENT ', ..... - ~~OISCOVER ~MASTERCARD ~ (C.ARD NUMBER _ __ 1tiSA _----- __ _ _. --- -- ---- AMOUNT SIGNATt1RE :EXP. DATE -- STATEMENT i - PAY THIS AMOUNT AC-COUNT N~ 02/08/10 I $2.81 85230 3HOMV AMOUNT PAID HERE REMIT T0: Orthopedic Institute Of PA 3399 Trindle Road Camp Hill, PA 17011 irl sl al adder b ilx~ollxt a ilauarwe iniomlation has cAenged, and PU=AS'E DETAGI AND RETURN TOP PORTION MIRI~I 1f00R PAIIMENT p17~ 761-6Ef,10 . __ __. '"` PAYMENT DUE UPON RECEIPT • THANK YAII " .ackawann --~aobile X-Ray, Inc. :orporate Office - 1229 Monroe Avenue ]unmore PA 18509 questions call 1-800-789-7082 between 8:00 a.m. to 4:30 p.m. 4AKE QiSCKS PAYABLE TO: LACKAWANNA MOBILE XRAY STATEMENT FtaR PROFESSlON~~L ~ERVtGEa Place Of Service WEST SHORE HEALTH REHAB Amtwnt Encbsed Bill To WBTZEL MARY ~~ No. P28529 O CHECK HERE and See Reverse For Change of ~~cl~ Ir~ss, I~L'iUr3nCE! Information a id; : • Credit C MARY WETZEL T_ ---_-- -. ~ w~oy p~~- ~ o aS~ ~Pos~- oA-~ ~~~.~ ~-~cc !~!r! f~-N ~ SS {~S ~ 1'~1 ~;t r~ ~ t ~ PagE>. N~a. 1 Ret irn 7! pis Acrtion 'dVit ~ 1'cu ~ ~aynzen4 Billing Date 01/25/10 Amount Due 8.9ti r t: CURRENT 30-60 DAYS 60-90 DAYS > 90~ DAYS '1'O'k'AL INS PENDING TOTAL DUE 0.00 0.00 8.96_ ~~~~ 0.00 ._.8.96 0.00 8.96 cart Number II To ace of Service torre • LACRAWANNA ;NIO$ILB XRAY, INC PO BOX 512586 P28529 P$ILADffi,PHI.~. PA 19175-2566 WEST SHORE HBALT 800 789 7082 Refeminp Physician hL.ACE OF SERV. COf~ 11 Office 12 Patien['s Home 21 Inpel~lt Hospttel ~ ~~ 24 Arttbutaiory Sugicel CenH 31 Sled Ntlrsinp Fadl>ly 32 Nursig FecEly 61 Independeri Laboraf~y 99 Ofbet UnB~d Feciily 4a,.,.~orat,Q,....s>t~.~.,~,m,,,on r~o!zt>e~r:ROMALLSCRx~rs teaelc~~,~e~> Poaa~ns .wer~s HE~ITNAgERiC ~' , r......• n.rn r.....w ~_`AVL~~tURIIYR CRM~ f~VCM u~•w~ Tai •nwwti~w~~...... ~OBILE X RAY IMAGING INC 945 EAST PARK DR SUTTE 102 HARRISBURG, PA 17111-2804 35346 not PAGE:1 of 1 ADDRESSf E: "II'll'illNllll'III'1111I1i1i111111IIIIIIiI'IIIIIi•'lI1NII11" MARY E. WETZEL 325 WESLEY DR MECHANICSBURG, PA 17055-3511 F PAYMG Br Y18A AIERCAN RLL OUT ~OM1- CHECKCARDUSING PpR PAYMENT ®~ ~ ®~ w,srar~wo oeoaRn v,s~ ~.a~ 10/14/10 RP31202 . . ,82 ss~ REMIT TtD: Illlllillill'111111"II'I'II'III~1'1~1111111i1IhI111I1I11~~I1111 MOBILE X RAY IMAGING INC 945 EAST PARK DR ~l SUITE 102 ~/"" ~ 1. HARRISBURG, PA 171!11,2804 lQ~ ss~rn~sa ^ Please check box if incorrect or insurance information.has changed, and indicate change(s) on reverse side. _ ~ PLEASE DETACH HERE~AND:RETURNTOP PORTION WiTHYOUR', P/IYMENT T If you have any questions or concerns about you statement please call 1-800-420-9729 ext. 111. 11/27/49 MARY AbdomCn Side Vita Patient: WETZEL, MARY E -165412 01/04/2010 GEI3A 17.60. 39.84 11/27/09 MARY Trnnsportat3on Xray PatientA WETZEL, MARY E -165412 01/04/2010 GEHA 64.36 132.93 11/27/09 MARY Set Up Fee Patient" WETZEL, MARY E • 165412 01104!2010 GEkiA 1433 17.12 MAKE YOUR MOBILE X RAY IMAGING WC SEE REVERSE SijDl~ • CHECKS ~ 945 EAST PARK DR ,,~ 1F AN INSURAN~¢E' PAYABLE TO 102 - - - - - -- - - --- . MESSAGE APPPPEEAARS ~.$2 Please pay within 30 days...thank P~ RP31202 ~ ~ ~ 9.82 ~ ~ 7~" Space Mart -Mechanicsburg 4751 Westport Dr ~~~ Mechanicsburg, PA 17055 717-790-910(1 ~ ~'~ ~'~ Unit # Ai~02- Gate Access # LEASE ADDEND~11~ ' 8 and is due on the anniversary of your rental date. 2. We do not send out bills. Please mail your payment, bring it to the office or pay through our websi at a 3. We acxept Visa, Master Card, Discover and Am. Express as well as cash, checks, and money orders 4. If we have not received yon payment on or before the Sth day after the rent due date a 520.00 late f iv1 be assessed. If the payment is still trot raxived by the 10th day after the rent due date your unit will be overlocked, gate will be denied and a notice will be sent out to you. j 5. If your payrr~rrt is not received by the 30th day after the due date we will process your unit for publi ae ration and a fee of ~ 100.00 will be assessed, as well as a $20.00 cut lock fee. 6. A partial payment will not stop fees or official procedtt~es. Arty agreemmem between tenant and er 4iant to extend payment dates or defer sale of goods must be in writing and signed by both management and tenant to be binding. 7. A 535.00 fee is automatically charged for all returned checks. All future payments must be made by nor money order. 8. WED(? NOT ASSUME LIABILITY FOR THE GOODS YOU STORE. Addmg stored goods to e ' ' g policy is generally quite inexpensive; we recommend contacting your insurance agency. 9. Do not use the rental unit for anything but DEAD STORAGE. Do not store any flammable, explosi o k illicit materials. The unit is to be used for storage only. 10. The storage unit must be vacated on or before the last day of the month for which rem has been paid ~ all terms and conditions of this agreement are met by the tenant. 11. The storage unit must broom clean, emptied, in good condition -subject onty to wear and tear -and to re-rem. 12. Tenant's lock must be removed upon termination of occupancy. Failure to remove lock will result in o being charged the next month's rental and late fees. 13. Gate hours are 24 hour--daily. 14. Office hours are 9AM to 6PM Monday- Friday, 9AM to SPM on Saturday and 1 l AM to 3PM on S y. I5. We do not prorate when you vacate a unit. If your unit is not vacant on the fifth (5'~ day after the du e, a month's rent is due. 16. Only one lock is allowed per door latch. If more than one lock is found, you may be subject to a S20 00 cut lock fee for the removal of that lock. 17. Do not follow someone through the gate without first putting in your access code. The gate may cl o~ you or you may not be able to exit. 18. Please keep us updated of any address changes and/or phone number changes. Until we are notified ' v}~lting with your signature, the only valid address and telephone number present is on the lease. ~i 19. Please leave aisles clear, do not block other tenant's doors and remove all trash & boxes properly. ~ 20. Please meet delivery drivers promptly and see that they do not block the gate or driveways. '. 21. Speed Limit is 5 miles while on site-please follow one way -to avoid accidents. 22. If moving in after "DARK" -see Manager for lights and instructions. ~, 23. If you are currently in the military or the reserves please initial here 24. Fire Extinquishers are located in the rear of the "B" & "C" building and inside both "A" & "D" buildi 25. We require a 825.00 reservation fee on a major credit card when reserving the truck for rental. This ~s non-refundable if the truck is cancelled with less than 24 hours notice. 0 h 26. We are owned and managed by SPACE MART PARTNERS. If you have any comments or concern ase call 1-800-796-8 89. s p Thank you! We appreciate your business and look forward to you having a pleasant stay with us. ~~ Tenant Signature Date ctK Mart -Mechanicsburg 4751 'Westport Dr Mechanicsburg, PA 17055 ~i7-790-9100 a~ICYI.E'Ilt eC~~j31 Date Printed Jan 09, 2010 Tenant Gwendolyn Picot Paymcn~ Gate Janwazy 09, 2i3 ! (s ~ : ta:~ t~h~ Corapa~y Unit A502 Atid„<aa 10082 Post Oak Terrace Available rwretiit D.00 City,~tr,Zip Manassas VA 20110 Carrent Balance rJ.04 Paid Tura Jan 13, 2010 Receipt "Yumber 18568. 3y [=C~ Daft! 1lalit r~aCri tiOR1 Diacount Tit[ TptAi _ _P?A]~AIF:nt Methpd 1 A Truck Rental (1) ,- 0, 00~~~~ ~~ ~ ~ ' ~ . 15 V~sd- .. _ _._. _ Taxes __ '.C. ~i1 -- Payvtr~nt: (legs tdx) ; ~'•, 9`i Payment: 9ubtat,il ~l . i5 Cred:lt:e, Applied t) . CCU Refunds Applied t).i)0 Tota] Applied •~o Account: 41.1.5 Current Acc-ounr; Balance ~ _~~:~ Pala. 8~ , :,?w * ~ ***5960 Pala Thru :Date .~~ 1.'. 2,010 Transaction Type Sale Authorization 038963 Reference 000914005912 I agree to pay the above amount according to the card iasue: s'.atement. x REV-1513 EX+ (01-30) pennsylvarria SCHEDULE ~ DEPARTMENT OF REVENUE BENEFICIARIES ,,,~,~ T,,,r ~ REQOENf OECEOENi STATE OF: ~ ; IMa Eliz~betll We1~d ', RELJITIONSHIP TD DE(I:OHrT '~ ~ AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERiI' iDo Nrat L1et TtrrefDsra(s) OF ESTATE I TAXABLE DISTRIBUTONS (include outright spousal disbibrrtiorrs and transfers under ~ ~ Sec. 9116 (a) (1.2).] i• Suzan Wesel Sublelt Datlghier 10096 5225 Wison lane Doan 323 MecAanicsburg, PA 17055 ENTER DOLLAR AMOUNTS FOR DLSTRlsUTlOfiS SHOVYN ABOVE ON LUIES 15 THROU(li 18 OF REY-1580 COVER SF~T, II NOlKAXABIE D15IRIBUTIa1S A. SPOUSAL D15iRidlffIONS LNIDER SECTION 9113 FOR MIFHCH AN ELECfiON TD TAX 15 NOT 7AIQ>~1: 1. it I B. CHARITABLE AND (i0V8UM1e1TAl DLSTRIBIJTIONS: L it i TOTAL OF PART II -ENTER TONAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 CWl6t SHEET. ; if more space is needed, use addltfond sheds of paper of tfre same size. !~I i cns q5v ro?ron LQCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: tt is tttegat to duplicate this copy by photostat or photograph. Thi ' • to ce ~ tat the information here given ;for this certificate, $6.00 s is correctly copied from an original Certificate of Dez duly. filed with lme as .Local Registrar. 'Phe origir certificate will ~'~, beF forwarded to the State Vi' Recoils Office ~or~ permanent filing. i I ,~~ ~~ G P 16~301~4 '~. -Local Re stray' ~ Date Issued Certification Number; I, , 3 ,.MrrurmrlPor...Kra.~M _ [M>iry Elizal7et11 W9fZe1: ~ i~~>s-- -1051 - •. ~ iMO"'~II~r12.300! ,. SA'WMr11 - IYrt, - Wr1 i lalr ~ ~rrrrr 1 ~ ,~.., o,. ~.. "... February i,151s ~. P ~ "~" flM+r Ow/owrr Oow< Oarrrr Oor^-~ r. a~gca».*frar Y/drarrrrwry~r wrw~~1~~~ ~~, g awrararwwrrrayo it aw~wi~~ rr w,Yrir.+ewrrrcnarr..e _ IA./M Yllh#b lilly ~a~a~ Lower AtMn Ba CtM bsrlHld rwr,w.rnen.c- ,,, r.wrr .rr rr ~ u:wsa.rr,wwra. nOwrA6Werr urrrrarcrrw ,[ariwy~rrMii.l+rrr^wr ~ -~ Y.l.M~Iw~A 6rrrq a~rrros ~ ~Jri~ ~(~r Q~ 1'~!Y ,{;~ry!r~rrR l~rM - Or/M,r .. .. M/IYiMor 17a 1r - USir r~,: gc~11,.0,oIr0 -~ .. ,- Y- Mschagksbury. PA 17055 n.oow T""`~ ,xOano~rrr errrr- o-sa. r FrhM~~rrrir+rY4w:w1b Lear CAUMs fiarrOid srrr,r..tr.rr.~.r.ar.w a. rr.w..t4wrtiw Stl=~NI W. SubNtt a.w.mr,rn/rrr~~.~a . PA 17056 ' r-o-r~a.raraYr~rsM ncrro.rarwrMrrr.,rw...mt.rrM~,y 200! 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I rrr ~~.r.arM^~.r ~ tw. . ~ aMrYrrw iV,rliMw,fY~O~ ».r..rrorw aaorry.~a,~+,M,rM aaar+.~.rMr~r y ~ c °°`orra+~sr~aMrl+ar-wMy, PMI1rR AiilrllifbGSryYYO~ ~ ^~+ ~ Qwrw .[]rr~rr~~r ltirryR a-y~grw.e a~L.ww.rMNYwM >lirrr ~ al~rrrr.rM1 ~ I5~ ~, Q'6a ~ ~ a~ o. ^~.. odY„irwrwr.. oar,q.r. a~ Ohr+~ , , :~ >ti~.r~,,r» .~ ~' w ~ i ~ • ~tiM~+o~I-~rri.co.rrw.ra.~wMr+~acwr..,rmrarr~rr~rrra M l ~ v ~ • ~ _~ ............................ i AOrrrdgrYrrA4Yrew~~rrlrer~Ma/Mnrr . .~... rw - .rrr.r.d.,•.M~~rrr+~ptr,-d.~rr•r,wr.rwwbaMrdrrl rr~reSr~Mrr~r+rWrrwws,rrL___~~_~__~_..__~_ ^ w~rreYlY~ + ~ M+ ~29~ 3 M r ' . ioe wry.rM+- wr~ . 3 1D • rrrtrrrr/owr^ o~rlrrrwrY~r~wr/rrr/yrwrr/~M+a~rw~.arl~~.r.M+rMwsrrrsrrr~Mtirrrr~rA. t~ r1~rr~h~aM~~~d~r L•LNr1~hi~AG-VI . ~ .14'tf~l J ~ t. CODICIL TO WILL OF MARY ELIZABETH WETZEL I, MARY ELIZABETH WETZEL, of the County of Sarasota, State of Florida, make this Codicil to my Will executed by me on June 19, 1967, at Arlington, Virginia, before Betty Ann Mullican, Margaret Mullinix, and I. J. Crickenberger, as witnesses, and I now confir. and republish all of the terms of my Will except those that are i conflict with this Codicil. I amend the introductory clause of my Will so that. said clause shall hereafter read as follows: "I, MARY ELIZABETH WETZEL, of the County of Sarasota, Stfat of Florida, make, publish and declare this instrument to be my Last Will and Testament. By this instrument I revoke all former Wills and Codicils executed by me." I amend Article IX of my Will so as to make that part my Will hereafter read as follows: "I nominate and appoint my Husba{id, CHARLES MAYNARD WET to be Personal Representative of my Will, and if because of death o~ for any other reason my said Husband. shall fail or cease to act a~ Personal Representative under this Will, then I direct that my Daughter, SUZAN W. SUBLETT, Alexandria ,. Virginia, shall serve as successor Personal Representative of my Will, and if my said Daughte because of death or for any other reason shall fail or cease to alit as successor Personal Representative under this Will, then I dire t that my Granddaughter, GWENDOLYN SUBLETT, Alexandria, Virginia, shall serve as successor Personal Representative of my Will." ~!, IN WITNESS WHEREOF, I have subscribed my name and affix~d my seal below at Sarasota, Florida, this ~ day of May, 1982. I,II WETZEL The foregoing instrument was. signed, sealed, published and declared b_,~ MARY ELIZABETH WETZEL, the. above named Testatrix, as a Codicil to her Last Will and Testament in the presence o£ us, the undersigned, who, at her request and in her presence and in the presence of each other, have subscribed our names as witnesses after the Testatrix has. signed her name, this Jn~' day of May, 1982.; Sarasota, Florida Sarasota, Florida STATE OF FLORIDA COUNTY OF SARASOTA We, MARY ELIZABETH WETZEL, CHARLES W. WEBS and MARGARET W. WEBB, the. Testatrix and the witnesses. respectively, whose names area signed to the foregoing instrument,. being first duly. sworn, do here declare to the undersigned officer that the Testatrix signed the instrument as a Codicil to her Last Will and Testament and that shed signed. voluntarily, and that each of the witnesses in the presence i of the Testatrix, at her request, and in the presence of each other; signed the Codici]. as a witness and. that to the best of the know- ledge of each witness the Testatrix was at the time eighteen or mo~e years of aqe, of sound mind and. under. no constraint or undue influence. WETZEL; Testatrix . ~,~~.e-~-_ Witness Subscribed and acknowledged before me by MARY ELIZABETH WETZEL, the Testatrix, and subscribed and sworn to before me by CHARLES W. WEBB and MARGARET W. WEBB, the witnesses, on this 2 prt~ day of May, 1982. My..Commission expires: Notary Pubes, State rf i~f~n,~a ~1! Cowmissioa Expires Dec. ti, i9&4 aoad~d Tluu Troy FUo • Iotunoq, fnc, i -2- ~ i uw oFVtees CRIOK[N[[R[[R a MOO[[ 3t40D WiL[ON [OULEVARD AR4Ni'fON. VI[t{INIA 22101 [2A.4{ I 1 LAST WILL AND TESTAMENT OF MARY ELIZAEETH WETZEL ~I I, Mary Elizabeth Wetzel, .a resident of. .the Cou~t~i of Fairfax, .State of Virginia, hereby make, publish and de~l~re II this. to be my Last Will and Testament. I. ~ I I hereby revoke all Wills .and. codicils made by ~e at anytime prior to this Will. '~, ', II. I. direct .that all of my just. debts and funeral ~x~en- ses. be .paid as .soon as practicable :after my .death. I auth~r~ze my Executor, hereinafter named,ta expend such sums as he,li~ his sole. discretion, may. deem proper for my funeral and in~e~- went, regardless of any limitations fixed by statute, rule,o~ court, or otherwise. i III. 'I If my. husband, Charles Maynard Wetzel, survivesm I give,. .devise 'and bequeath to him all of my. estate,' real, p~r sonal and mixed. ~~ ~I IV. If my husband,- Charles Maynard Wetzel, does not vive me, I give ,. .devise .and bequeath all of my estate, rea personal .and mixed, to my daughter, Suzan W. Sublett, prow ..that she survives me. V. ', If my. daughter, Susaan W. Sublett,:predeceases m~, ..then I give,. ,devise and bequeath all of my estate, real, p~r- sonal and mixed, in equal shares, .to my grandchildren, Gwendolyn Sublett,,Cheryl Sublett and Charles Sublett, and tc VIII ~~I. I . e, , _,_ _ _ _T _ __ . _ _ _ --- - ~ _ i _ . . ., ~ . •, ;, ~ ». F" any other grandchilriren of mine. born after. the execution o~E this Will, .provided that they survive me. VI. If any grandchild who- takes. a share of my. estat '~ i under: Paragraph. .V of. .this Will. has. not .attained .the age of i twenty-one .years .at he time of my .death,. .then the share o ', .that grandchild shall be placed in trust and held by the Trustee, hereinafter named, until the grandchild .attains e age :of twenty-one .years. I authorize and direct .the Trust~eel to apply as much of the net .income and also the principal, i'~ required, as. deemed necessary, in the sole. discretion of ell Trustee, for the. proper education, support .and maintenance of each grandchild until the grandchild attains the age oft enty- one .years, ,at which time the Trustee shall release the residue of that grandchild's share of. the principal free from trust.) . VII . i I appoint as Trustee my son-in-law, Nelson M. _ Sublett. VIII. Any person mentioned in this [dill who. dies at t~el same time as I, or in or as the result of a common disaste~ with me, or under such circumstances that it is difficult or im I~- sible to determine who died first, shall be considered to ave predeceased me for the purpose of interpreting this Will. 1, IX. II ~'' I appoint my husband Charles. Maynard Wetzel, to be Executor of my Will, and as substitute Executrix, T appai t I, my. daughter, Suzan W. Sublett. I, uw orrtces ~ Ill GRIGK[NGSMRR •s MOOR[ l 3600 WILBON BOULEVMD ~ ~ '~ ARLINGTON. VIRGINIA 22201 ~ 534.4t1t '~ - 2 - ;,n'~+` ',I ' ~'~ I,