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HomeMy WebLinkAbout11-22-10 (2) ~. S 1505610140 REV-1500 ~` `°'-'°' PA DepaMrent of Revenue County Code Year F'~le Number Bureau of Ind'nridual Taxes INHERITANCE TAX RETURN Po Box 2110601 2 1 1 0 0 7 3 6 Harrisb~m+ PA 1712&0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MiADDYYYY Date of Birth MiADDYYYY 0 3 9 1 8 6 2 3 5 0 7 0 8 2 0 1 0 0 9 0 5 1 9 1 9 Decedents Last Name Suffor Decedent's First Name MI H I N D E R L I T ER M A R Y R (M Applicable) E.rrbr Sra'vivfrrp Sparse's Information Below Spouse's Last Name Suffoc Spouse's First Name Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS MI ® 1.Original Retum ~ 2. Supplemental Retum ~ 3. Remainder Retum (date of death prior to 12-13.82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Retum Required death attar 12-12-82) ® 6. DeoedeM Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Wip) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty CredR (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-~) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD LIE DIRECTED T0: Name Daytime Telephone Number S U S A N J H A R T M A N 7 1 7 2 4 9 ? 7 8 0 First line of address 1 I R V I N E R 0 Id Second lure of address City or Post Office C A R L I S L E State ZIP Code REGISTER ~YYILLS 113E (~Y C ~ r,. -~ ~Sr , " ('V ~~~~ N r r ,"; ~ '~ U~ ~'` L .. ~-~~ ~ ~ -rr '? ~> ~~ N _: P A 1 7 0 1 3 CorroaponderlCs e-mail address: S U S A N H A R T M A N N P A• N ET w under perraNies of perjiNy,1 declare Ural 1 have examined ibis realm. IrxA,dinp accortiparyirq schedules and atebrrierNS, and to tare test d my krawlsdOe and be6sf, it is titre. correct and ooniplele. Dscleratlori of preperer oUier than Mie personal represarrtatlve is based on ant iritorrrianori a1 which preparer has any lurowledpe. SIGH/~T~itE OF PERSO~1 LtES~'QNS~E~OR FILING RETURN DATE ii.,s., i. Di ~ A /Sl/ //~ 9 7 --IlS PARTRIDGE CIRCLE ,TURIQOF PREPARER OTHER ThJk L 15D5610140 PLEASE USE ORIGINAL FORM ONLY Sidle 1 1505610140 ~ ~-i 1505610240 REV-1500 EX Deoeder-Cs Name: MARY R• H I N D E R L I T E R Decedents Social Security 0 3 9 1 8 6 Number 2 3 5 RECAPITULATION 1. Real Estate (Sd~edub A) ........................................... 1 • • 2 8 2 0 5. 6 3 2. Stocks and Bonds (Schedub B) ... • • • • ............................... 2' 3. Closely Field Corporation, Partnership or Sob-Proprietorship (Sc~edub C) ..... 3. 4. Mortgages and Notes Reoeivabb (Schedub D) .......................... 4. 8 8 0 1 1. 2 8 5. Cash, Bank Deposits and Miscellaneous Personal Property (Sc~edub E)....... 5. s. Jointly Owned Property (Schedub F) ^ Separate BiNing Requested ....... 6. 1 8 5 5 8. 8 7 7. Inter-Vivoa Transfers b Mbcellaneous N~Pro~te P~~Y uested Re BiNi t S 7 • ....... q n9 epara e (Sd~edub G) u . 8 1 3 4 7 7 5. 7 8 8. Total Gross Assets (total Lines 1 through 7) ........................... . 9. Funeral Expenses and Administratnre Costs (Schedub H) .................. 9• 7 9 8 2. 2 0 10. Debts of Decedent. Mortgage Liabilities. and Liens (Schedub I) ............. 10. 9 1 5 . 5 3 11. Total Deductions (total Lines 9 and 10) ............................... 11. 8 8 9 7. 7 3 12. Nst value of Estab (Line 8 minus Line 11) ............................ 12• 1 2 5 8 7 8 . 0 5 13. Chartiabb and Governmental BequestalSec 9113 Trusts for which an ebd'an to tax has not been made (Schedub J) ...................... 13. 14. Net Value Subject bu Tax (Line 12 minus Line 13) .. .................... 14. 1 2 5 8 7 8 . D 5 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxabb at the spousal tax rate, or transfers under Sec. 9118 0 0 0 15. 0. 0 0 (a>(1.2> x.o _ . ts. Amount of Line 14 taxabb 1 2 5 8 7 8. 0 5 1s 5 6 6 4. 5 1 at lineal rate X •~ . 17. Amount of Line 14 taxable 0 . D 0 17 0 . D 0 at sibkng rate X .12 . 18. Amount of Line 14 taxabb D • 0 D 18 0 • D 0 at collateral rate X .15 . 19. TAX DUE ...................................................... 19. 20. FN1 IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 1505610240 Side 2 5 6 6 4. 5 1 150561024D J REV-1500 ~X Pape 3 Plsrwrls~n*'s Cemnlete Address: File Wwnber 21 10 0736 ~~~~..~. -----r--- - ---- DECEDENTS NAt~ MARY R• HINDERLITER - STREET ADDRESS CHAPEL POINTE AT CARLISLE ??0 SOUTH HANOVER STREET _ ctrr CARLISLE PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 5 , 6 6 4.51 2. CreditslPayments A. Prior Payments B. Discount Total Credits (A + B) (2) 0.0 0 3. Interest (3) 4. ff Line 2 is greater than Line 1 + Line 3, enter the dfffererice. This is the OVERPAYMENT. Ftil in oval on Page 2, Une 20 b rcqued a refund. (4) 0.0 0 5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE (5) 5 , 6 6 4.51 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes tVo a. retain the use or income of the property transfemed : ...................................................................... ^ b. retain the right ~ designate who shah use the property transferred or its income; ............................... c. retain a reversionary interest; or ................................................................................................ ^ d. receive the promise for life of either payrrierits, benefits or care? ....................................................... ^ 2. ff death ocarrred after December 12,1982, did decedent transfer property within one year of death .. ............................................ X withal receivxig adegrrale consideration? ........................................... 3. Did decedent awn an 'in mist for ar payable~on~ealh bank account or security at his or her death? ......... ^ ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beriefiaary designation? .................................................................................................. ® ^ IF THE ANSWER TO ANY OF THE ABOVE taUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R AS PART OF THE RETURN. For dates of death on or after July 1,1994, and before Jan.1,1995, the tax rate imposed on the net value of transfers in 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, Ute lax role imposed on the net value of transfers in or for the use of the surviving spouse is.0 percent (72 P.S. §9116 (a) (1.1) (k)l. The statute does riot exempt a transfer to a surviving spouse from tax, and tits statutory requirements for disr~OSUre of assets and fdaig a tax return are stiN appNCable even if the surviving spouse is the only beneficiary. For dates ~ deaUt on or oiler July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased childd 21 years of age or younger at death to or for the use ~ a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(aK1.2)). • The tax role imposed on the riet value of transfers to ar for the use of the decedent's lineal beriefiaaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [/2 P.S. §9116(aK1)I. • The tax role imposed on the rret value of transfers b a for tits use Of the decedent's siblings IS 12 percent [72 P.S. §911li(a)(1.3)]. A SibNng is defined, uttdE Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1503 EX + (8-98) SCHEDt/LE B cowwoNwEAUH of PENNSYLVANIA STOCKS Bi BONDS INHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MARY R• HINDERLITER 21 10 D736 IN prop«it/ joirNy-owrnd wNh right of wrrivaship mud be discbsed on ScMduN F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. VANGUARD ACCT- •0021-09936112898 24,275.48 [SEE ATTACHED STATEMENT] 2• NORTHWEST SAVINGS 340.273 SHARES X 11.59/SH 3,930.15 TOTAL (Also enter on line 2, Recapitulation) ~ t 2 8 , 2 0 5.6 3 REV-1508 EX + (8-98) CONNAONWEALTH OF PENNSYWANIA INHERffANCE TAX RETURN SCMEDVLE E CASH, BANK DEPOSITS, 8~ MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER MARY R• HINDERLITER 21 10 0736 Irrdude the proceeds of ' and of =rsvinorsh ~ be discload o~n ScMduN F. AM propery- joMHh-'owrwd rift VALUE AT DATE ITEM NUMBER DESCRIPTION OF DEATH ~. ORRSTOWN BANK CHECKING ACCT• 5143000718 9,053.80 [SEE DOD LETTER ATTACHED] 2• ORRSTOWN BANK C•D• 54000035734 35,039.42 [SEE DOD LETTER ATTACHED] 3. ORRSTOWN BANK C•D• 54000035735 [SEE DOD LETTER ATTACHED] 43,918.06 TOTAL (Also enter on line 5, Recapitulation) ~ i _ _ 8 8 , 011- REV-1509~EX+ (01-10) Pennsylvania DEPART1iEHT OF REVENUE INHERRANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: - - FILE NUMBER: MARY R• HINDERLITER 21 10 0736 Man asset was node jointly owned wffhM one year of the decedents date of death, it must be reported on Schaduk G. SURVMNG JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT a BRUCE HINDERLITER 76 PARTRIDGE CIRCLE SON CARLISLE, PA 17013 s. ERIC HINDERLITER c. .JOINTLY-OYIINED PROPERTY: fTEM NW6ER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FHrANCIAL INSTiTUT10N AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER ATTACH DEED FOR JgNTLY-FOLD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDENTS INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A. 11/94 NORTHWEST SAVINGS BANK 13,881.15 50• 6,940.58 CHECKING ACCOUNT X024036741 2• A•ILB• 11/94 NORTHWEST SAVINGS BANCSHARES INC 34,8b9.77 33.3 11,618.29 3020.76 X 11.55/SHARE 106 S• PINE STREET ISON WARREN, PA 16365 TOTAL (Also enter an Line 6, Recapilulabon) I t 18 , 5 5 8.8 7 REV~151f EX+ (10-09) Pennsylvania ~~~~ ~ ~~ INHERRANCETAXRETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE Ir1UMBER MARY R• HINDERLITER 21 10 0736 o.ad«rrs d~ mrat e. reporMd on Srdredule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~. MORNINGSIDE CEMETERY - BURIAL 515.OD 2• MORINGSIDE CEMETERY - STONE 1,025.00 3• GEORGE'S FLOWERS 56.18 4• EKEY FLORISTS 63.60 B. 1 2. 3. 4. ADMINISTRATIVE COSTS: Personal Representative CORNf113S10r13: Name(s) d Personal Represe~Ure(s) Street Address Year(s) Cam~issiai Peid: State ZIP AtlorneyFees: DUNCAN 8 HARTMAN, PC F~niy Exemption: (IF decedenCs address is not the same as daunts, attach explanation.) Claimant Street Address ~~ State ZIP Relatiorahip d Clairnard b Deoaderd Probate Fees: REGISTER OF WILLS 5. Acroorxrfant Fees: 6. Tax Return Preparer Fees: 7. ( CUMBERLAND LAW JOURNAL - LEGAL NOTICE 8• THE SENTINEL - LEGAL AD 75.00 176.92 5,750.00 320.50 TOTAL {Also enter an Line 9, Recapitulation) I : 7 , 9 8 2.2 0 REV-1512 EX+ (12-08) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETINiI~I RESlOENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, S LIENS ESTATE OF FN.E NUI~ER MARY R• HINDERLITER 21 10 0736 Report det>Rs incurred ~ the decedent prior ~ death tlrlat remained unpaid at the dale of dealh~ indudMg unreimbun>ted medkal expense. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t. MILLENIUM PHARMACY 17.80 2• PUBLIC SCHOOL EMPLOYEES RETIREMENT SYSTEM 851.39 3• HARTZELL EYE MDS 10.0D 4• GEORGE BRANSCUM MD 36.34 Tt7TAl (Also enter an Line 10, Recapitulalioll)) i 915_. H more spaces needed, insert additional stieeb of the scene sae. RE1~-1513 EX~ (01-70) Pennsylvania DEPARTMENT OF REVENUE INHERfTANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FR.E N1J~ER: MARY R• HINDERLITER 21 10 0736 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Lint TrusMa(s) OF ESTATE I TAXABLE DISTRIBUTIONS (hidixle p~ht sPaoal ~ and trer~siers under ' • Sec. 91 T6 (a) (1.x•1 1 BRUCE HINDERLITER Lineal . 76 PARTRIDGE CIRCLE 25~ SHARE CARLISLE, PA 17013 2• ERIC HINDERLITER Lineal 106 S• PINE STREET 257. SHARE WARREN, PA 16365 3• CARL HINDERLITER Lineal 23 EVERGREEN DRIVE 25i SHARE GREENVILLE, PA 16125 4• BECKY STEIS Lineal P•0• BOX 2383 25% SHARE CLEVELAND, OH 30528 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART )(I -ENTER TOTAL NON-TAXABLE DISTRIBUTKNS ON UNE 13 OF REV-1500 COVER SHEET. i ff rtwrn cnar~a, is r~r1 ~~a arkitimal ctwRtc rf rwnr+~ of Iha carrw~ ci~w ~~f lJ~ee~«JT ~.v.~t- ~~ ~X~~ t% c~j ~~ ~e z~ ~ ~~~~a~ f {mot d:r~n<..e ~d~,,,.~,..,~~ j../"'"~"` Est X +d~ ~~~~9~ June 30, 2010, quarter-to-date statement P.g.>> ~~ Vanguazd' Client Services > 80062-2739 RUTH K HINDERLITER yyWW.valgWtrd.tOm 76 PARTRIDGE CIR ~g CARLISLE PA 17013-8746 ~~~ r~N w.ui~ton wed i„v ooQ~-os~as~~~s Average Cost Total Cost 128.65 525,298.34 Date Transactbn Amount Share Prove Shares Transacted Total Shares Owned Beginning balance on 3/31/2010 129.72 875.897 06/28• Income dividend .23 5201.46 28.10 7.169 883.066 Emlin/ balance on 6f30i/201/ 127.49 883.066 Value =26,031.66 =24.275.,1 ' Northwest Bancshares, Inc.: NASDAQ:NWBI historical prices -Google Finance Page 1 of 1 Web Images Videos Maps News Shogaing Gmail more ~,c~-z: ~1 finance Example: "CSCO" or "Google" Northwest Bancshares, Inc. historical prices Watch this stock Help ~ Si n in Get quotes Historical chart Show: Daily ~ Wee Jul 8, 2010 _ Jul 9, 2010 Update 11.00 Date Open High Low Close Volume Jul 9, 2010 11.62 11.71 11.60 11.69 397,357 Jul 8, 2010 11.56 11.63 11.47 11.60 704,425 :~ I I .SS 11.00 Show 30 1 - 2 of 2 rows rows: 11.00 Jul 8, 2010 Jul 9, 2010 Export Download to spreadsheet Google Finance Beta available in: ~~{~ (Hong Kong) -Canada - U.S. -1~4~~~ (China) - U.K. Information is provided 'as is' and solely for informational purposes, not for trading purposes or advice, and may be delayed. To see all exchange delays, please see disclaimer. ©2010 Google Google Home - Blog -Help - Privacy Policy -Terms of Service ,_ ~., ~ ~«~.ono--~--1~_~--r-_~_-~oni~n~~nino___ ~nf~ni~n~n ~~~~ ORRS"Z'OWN ~'INANCIA~L SERVICES, INC. A T-udition of F.rcellence Susan J. Hartman, ESq. buncan Lie Hartman, FC One Ir~;ine llo~v Carlisle, PA 17013 Fax 249-7800 August 2, 2010 Re: Estate of Mary Ruth Hinderliter Sdeial Security Number 039- X S-G235 Date of Death July $, 2010 1?' IS HERERBY CERTIFIED THAT" THE ABOVE NA1~fED DECEDENT, ON THE ABOVE DATE, HAD TFIE F'DLLOWINGACCOUNTS bil77'H ORRSTOWIV BANK: C.HECKIIVC ACCDUNT Account Na. - Account Type - I~ate 4pered - Joint Account (dame Jdate) - Balance - accrued Interest - 143000718 50+ Interest Check 3/29f06 None $9,053.80 $o CERTIFICATES' OF DL~'YOSIT Account No. - Account Typc - Date Opened - Joint Account (ri:~mC/date) - E3alance - A~crued Interest - 400003:i73~ 12-17 Mont_:4 Growth 1'/1/09 iVone ~35,039.~12 $20. I6 '~ Cast Fang Street, ;hippcrsburg, Penr.aytvar:uz I73S7 Accou.tit Na. - 4000035735 Account 'lope -- 30-35 Month Urowth Date Opened -- 11 / i 9 j 09 Joint Account (name/date} - None Balance - $43,9.13.06 Accrued Interest - $50.03 Best Regards. Vicki L. Gullixan Customer Service Specialist ~r'~I E:ISL Kt1~j S[CCCC, ~~I3~7j)C:13bl1IR, F':'.:1:15`~'t~:iriW i %~5i RE: Estate of Mary "Ruth" Hinderliter Duncan & Hartman, P.C. One Irvine Row Carlisle, Pennsylvania 17013 In regards to the Estate of Mary Hinderliter, the account # 24036741 was opened on 09/28/1993, and is an interest-bearing account. The names that are listed on the account are Ruth K. Hinderliter or Bruce A. Hinderliter. The account was originally opened in only Mary's name and Bruce's name was added 1/13/2005. The balance in the account as of the date of death on 7/8/2010 was $13881.15. Thank you If you have any questions please call Randi 814-723-9696 1~~= ~- NORTHVi/EST SAVINGS BANK Where people make the difference. f tn~ttt~utttnnuttntt~tnt~tu~t~tut~t~t~tu~t~ttlnnttt $ ~ RUTH K HINOERLITER w OR BRUCE A HINDERLITER w ~ 76 PARTRIDGE CIR "' ~ CARLISLE PA 17013-8745 0 w V N 0 $ 0 CHECKING ACCOUNT STATEMENT [~ ~ ~~ ~ ~ ~ ~~ ~~ a~~ t"1/~` ~ ~e~b~erM ms's' 024036741 8/16/2010 _ ,: Y. .; • .. ,.: Mlb :x ~.: y r > ~. 13,800.73 2,437.00 1,436.38 0.00 1.01 12,601.10 }~~ ~ _ .~f :- ~ 07/19/10 CHECK 1636 100.00 13,500.73 07!20110 CHECK 1640 250.00 13,250.73 0721!10 CHECK 1837 100.00 13'150'73 07/23110 CHECK 1643 320.50 12'830'23 07/27/10 CHECK 1642 1,025.00 11,805.23 07/27/10 CHECK 1634 100.00 11,705.23 07/27/10 CHECK 1638 50.00 11.655'23 07/27/10 CHECK 1641 20.00 11'635'23 07/30/10 PA TREASURY DEPT ANNUITANT 920.87 12,556.10 07/30/10 PA TREASURY DEPT ANNUITANT 515.49 13,071.59 ~ 07/30110 CHECK 1621 100.00 12,971.59 07/30110 CHECK 1622 100.00 12'871'59 08/02/10 CHECK 1639 2'46.50 12'825'09 08/03/10 CHECK 1632 25.00 12,600.09 08/16/10 INTEREST i .01 12,601.10 Total ratumed item fees Total overdraR fees Total fees c~ta~ged b of returned i6em fees ~d of paid ibm fees fees refunded INTEREST EARNED FROM 7/192010 THROUGH SN62010 DAYS IN PERIOD 29 AVERAGE BALANCE 12,652.43 ANNUAL PERCENTAGE YIELD EARNED 0.10 INTEREST PAID THIS YEAR 8•~ INTEREST WITHHELD THIS YEAR 0•~ ~~Q~b~ ~~ This Cyde Y~ 0.00 ~ 0.00 ~ 0• 0.00 0• This Cycb Y' 0.00 0. o.oo o. o.oo o. 1621 100.00 1622 100.00, k 1632 25.00 k 1634 100.00 k 1636 100.00 1637 100.00 1636 50.00 1639 246.50 1640 250.00 1641 20.00 1642 1,025.00 1643 320.50 NORTHWEST RANKED "HIGHEST IN CUSTOMER SAT15t=AG ~ iVn WITH RETAIL BANKING IN THE MID-ATLANTIC REGION" J.O. POWER 2010 RETAIL BANKING SATISFACTION STUDY ...._-- ~~166 C~~zoN ~ Mo ~~T~ 15Ni ROUtE 3?t EAgt ~ f2AtEQ1~ pA 1fTl4 • Plt (ef4jT~1-~3 ~+0~rlbrwrseM~co~ PURCHASER BRUCE HiN~ERLRER ADDRESS 7f PARTMp~ GRCLE CARLISLE, PA 17pt3-8745 PHt~IE Tt7-249-8966 .. ErA/.-ph lt~~~nderihK4T ~u...~,,, Clarion 11~tvnumsnts a9~ees to seR to purchaser a msmoriat descxibsd -. and condltlona as Indicated. AS worltmanshlp and materlab ~~ with lettertt~ ~ ~, tames TYPE ~~ Matk~Y provided by Ciarlon Monumsrrts aro puarantsed. ~~ ~~ Bxt~ G~+ SIZE Y-0' x t'-0"x0`-8" Dis~f CMisHna Kk! FROSII Polhhei! BDVe~ed Top, BRP BASE WA -_ «) OTHER Si(ETCN ! tET?'ERINg OESCpIP?lD~t ,. .__ HINDER~ITER 19~g Rt1TH K. zoo t9zo MEADE E. t994 LITIIv i ~_ FOlAp ~ f'EAi AT LOT FOlMD IM-- aASE IN------- ^ CORNER POSTS ^ F/N ON BACK ^ INSCRIPTION ON BACK fsEE spECULL MATES tip at ~ ~~ tit hi. wMc aha/ amain pasonaf O~ ~ b anM- trpp- said kM b ~ M~ wak and ~wIM r~nwrt r~no! p~ifd b In ao~ ~ ~ ~ o~Ya d 1 tt~ (arr~1 n1r tit p, ~ soootr* owr ~Q p~*' any raaaor~ N ooffa~tton rasa aid aaortrir 1~aas as pryabla by iM p~rrhaaw~ A ~ d dxQ Mi ba dw~ b aff e~drs rNrn~ by M bank br TT+it vewr it nd w~ot ip crpoEaf<on aAar TTda oniK dON not t+duda ~ ooat or adding wys CEMEfiERY: MORNINGSIpE f0u80K) ~ !OT INFO.: FUNERAL DIR.: ALCOAAI EST. COMPLETION: UT'E SUMMER 2010 PRICE i --+ FOUNDATION i 185.00 F/NON el1CK t CORNER POSTS i i TOTAL i 1,025.00 PAYMENT i BALJINCE = 1,025.00 MSITi-Otl~c~ / FOOTER Tb tiE tNSTALLEp BY MQRNWGSIOE CEMETERY wE wlLt t~sT,~tL w~l FooT>~ ~ PAYMENT METH00~ ~ ~ ~ I P~J Paid fa f~ ~ ' ~~~ ~ ^ 1 /1 Dove. Bai. Dw oe CompleEian ^ CreditCard - Circle ~ MC a Y1 • o ~ o AC Ak ®® .t D~it Y~~~ban ~ an bed of ca-d: AGnae at arr qrd` BillinpAdbress (~f~}; SIGNED DATE ~~ 19, 2010 YlLLOw-Frodr7ctio~n / PZIiR-Fttrch~s~r t~~ ~~ ~