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HomeMy WebLinkAbout12-27-10i 1505610101 REV-1500 Ex ~O1.1°' ' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes oEOAATME"'"F RE°E"~E County Code Year File Number Po Box Zso6o1 INHERITANCE TAX RETURN Harrisburg, PA 1'7128-0601 RESIDENT DECEDENT .~ ~ ~ ~ ~ ~ a, ~ 3 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY J~~ 7o y~ 7 s 0/ l 9 ~o ~ o 0 9D(o ~ q 63 Decedent's Last Name Suffix Decedent's First Name MI G~ISCo~ ~~~z/~tiwF (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N/'~ 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 p 2. Supplemental Return ~ 3. Remainder Return (date of death Q 4. Limited Estate O 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received Q 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) prior to 12-13-82) O 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes ~ 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 ~ lI ~4 /~ L E~$ [' ~ y / ~"L DS /°! / ~ ! 7 7~ (Q DSO 9 First line of address 6 czou5~~ Ro~~ Second line of address ~~~ , City or Post Office State /11,x- C H~ y/ C 5 8 u~ G P ,i¢ ~ REGISTEIL.LS US~dNLY' • . ~~ _. _.~ r-n ~, ..~ rl_7 ......, s r~~`-~-~ ~~ rf ; 1. ~~i 4`~ ~ ~ ~~.~ ZIP Code L~ 7 D ~ S~ 7 r..,., ..~.:-- ~ DATE FIILED ""'`~ ~ 3 S" Correspondent's a-mail address: c lesh- plds3~ Comca st ,~~- 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 anv knowled°e. SIYNATI,J~ZE Q~PERSON RESPONSIBLE FOR FILING RETURN ADDRESS -GoiLCFLC~l1 ~ SF/~~ DATE X99 ~~st bane, Dtl~{>,~n~ ,pA /70/9 SIGNAT F P EPAR OTHE IAN P ESENTATIVE ~ ~ M DATE x _,~ ~~ ~' ! z/zr/ifl ADDRESS C'H~-'+2LE'S ~. SHIr'YL)S TIT .-. ___.~._...~ ~_~~.__-._.-.~m~.__._o_~___ ~ ~3!? , !Q Clouser I~o~aca°, /nelC~i aln acs b~ pi4 ! 1 ~ S~' PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J 1505610105 REV-1500 EX h~ ~+ Decedent's Social Security Number Decedent's Name: I l i Q r 1 Qh ne h 1" 1~ ("p/yl ~ T~ ~ 0 ~ 6 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. • ~ D 2. Stocks and Bonds (Schedule B) .................................... ... 2. ~ Q O 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. s ~ D 4. Mortgages and Notes Receivable (Schedule D) ........................ ... 4. ~ ~ p 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5. ~ 0 (0 7 ~ • ~ d 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. . ~ Q 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) p Separate Billing Requested..... ... 7. . 0 Q 8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. ~ ~ 6 7 ~. ~ a 9. Funeral Expenses and Administrative Costs (S~hedule H) ................ ... 9. ! ~ 6 ~ 2 , 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... ... 10. / ~p ~ ~ q ~ (~ 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. ~ $ ~ '~ ,~ , 9 9 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. . © ~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. • Q ~ 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. , ~ (~ TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0~ . D D 15. O D 16. Amount of Line 14 taxable at lineal rate X .0 ~ O Q 16. . d~ D 17. Amount of Line 14 taxable at sibling rate X .12 . Q ~ 17. ~ t7 18. Amount of Line 14 taxable at collateral rate X .15 • Q ~ 18. • O Q 19. TAX DUE ...................................................... ...19. ~~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 J REV-1500 EX Page 3 Decedent's Complete Address: File Number a, ~.~ l D ,_ ~~ DECEDENT'S NAME mCLr i a..h n ~ Gr i S C~rrl STREET ADDRESS DD ~Ou1lP.Yl Co tart CITY rYj ~1 . unt,t ~ sb ~ STATE J~ ~ ZIP ' ~ O Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments O A. Prior Payments ___-_ _-----_-___-----__ -_---_._-_. B. Discount ~ 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval 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) (2) (3) (4) (5) Make check payable to: REGISTER OF WILLS, AGENT. O O O Q O PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No 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 Dec. 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? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ................................................................................... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT 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 to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan, 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX * (1-9n , COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER G~ri seQ,m, 111~.r- anne a ~ -la -- 203 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~~ Sale oE' 1=airmont lnob;l~ Home , I?~8, v/N~ b39~z ~ p,~y!/~s ~: [;e6 , ~' ~!v t~trnf ~4/.%/ ~c~, ~herr~. /ll/, NT~~o~ ~~Se~ ~~%/ Bf sa/c which i.tclaal~s screra/ a~u/.fidr~/ i~i~zs B~' pens o ~ ~ lt' in ~t Sa/~ . /.g.%/ o~ ~/~ is a f~ac~A/ ~i «r/O~ ~/ 7 ~QQ• Go y - o~. ~ ~f'rp- /cJ~11 k Chc~K; nr~ ,A~+,~.t': No. S 3(0 7 3 S S ~ 9 ,. o c1 S-ti~v ~tofie : 7h:s A-~Counf ~~s o`~,/arQs~h . ~i ~'s ~f~i~r as becn r?.ross-r~erute~ ~ Scher' . ~ •~ ~. Vel vD ~dan, 194(0 Utz ~ yV.i I.SS 7aoT ~~q g3~ o ~ eti-I d ~ I~ti-v ~ d 1~. e C~ r ct.n d C.h a.m(~ ~o?~ SDO.Oo Q ~~n d oh ~ r• e T-r s w~. /~u~'o ~o (~ c ~ 13 ~. o 0 ~; ~~~d e~ Dve,,r~ stir Erie ~nS u-r: ~b ~~ ~~'~~ ~~ ~ 6, $ule o~ an ~ sc. pcrs o n a.lf fiy ~r ~ lens ~} u.~,or, ~ ~'ne G-o ve, /~ ~~3 ~~ /n ~ a ono ~ ~ ~ ~ ~ ~ 7~ ~flS, a0 7, of p.~ ~~ 071'1'l Gtr' u.p r~q ~t' 7~ZG' / t tt t.[1'l~S ~ t S L' ~8 S. d0 TOTAL (Also enter on line 5, Recapitulation) $ a ~i 6 ~ ~• °~~ (If more space is needed, insert additional sheets of the same size} ERIE fNSURANCE EXCHANGE Erie Insurance P.O. BOX 1699 ERIE, PA 16530 NAMED INSURED COPY Exchange CANCELLATI~JN NOTICE Member Erie Insurance Group 100 Erie Ins- PL Erie, PA 16530 MAIL DATE 07/O1/IO CANCELLATION EFFECTIVE BAL: $139.00 CR POLICY NUMBER QO1 1609671 H 05/12/10 12.01 AM POLICY EFFECTIVE DATE 01/16/10 STANDARD TIME PIONEER FAMILY AUTO POLICY NAMED INSURED ESTATE OF MARIANNE GRISCOM 300 RAVEN CT AA7518 MECHANICSBURG PA 17050 WE ARE NOTIFYING YOU THAT THE ABOVE POLICY IS CANCELLED AS OF THE CANCELLATION EFFECTIVE HOUR AND DATE SHOWN ABOVE. IF WE HAVE BEEN ASKED TO PROTECT OTHER INTERESTS, WE ARE REQUIRED TO ADVISE THEM OF THIS CANCELLATfON. THE REASON FOR THIS ACTION INSURED DECEASED ~'ti~~FORMERLY - GRISCOM, MARIANNE PREVIOUS BALANCE $.00 UNUSED PREMIUM $139.00 CR PRESENT BALANCE $139.00 CR REFUND CHECK ENCLOSED 00009 FETR AA7518 FETROW INS ASSOC LLC 932EXC 6/00 Erie° I nsu rance Group 100 Erie Ins. PI. •Erie, PA 16530 NOTICE OF PREMIUM REFUND DATE MO_ DAY YR. 02I03I10 REFUND AMOUNT $35.00 POLICY NUMBER QO1 1609671 H AGENT NO. AA7S 1H AGENT'S NAME FETROW INS ASSOC LLC REASON 4 REF. No. 2619731 CHECK No. 26619731 MARIANNE GRISCOM 300 RAVEN CT MECHANICSBURG PA 17050-2084 AA7518 NON-NEGOTIABL-E A REVIEW OF YOUR ACCOUNT REVEALS AN OVERPAYMENT. WE ARE PLEASED TO ENCLOSE ERIE'S .CHECK, WHICH INCLUDES POLICY NUMBER IDENTIFICATION. DP164G 101 -~ IF YOUR RECORDS DO NOT AGREE, PLEASE NOTIFY YOUR AGENT. ~~ Bill of Sale BE IT KNOWN, that for payment in the sum of $17.500.00, the full receipt of which is acknowledged, the undersigned Colleen M, Seace ,administrator for the estate of Marianne Griscom, deceased [Seller) hereby sells and transfers to Phyllis E. Lieb (Buyer), the following described Mobile Home: Make: FAIRMONT Year: 1988 VIN #: 63972 The sale is subject to the following conditions and representations: Seller acknowledges receipt of $17,5fl0 in full for the Mobile Home. Seller warrants to Buyer that Seller has good and marketable title and registration to said property, full authority to sell and transfer said property, and that said property is sold with a free and clear title. Said mobile home is sold in "as is' condition, with no expressed or implied guarantees or warrantees, and where currently located at 300 Raven Court Mechanicsburg, PA 17050. This sale also includes the 10' X 16' shed/workshop located on the lot and other appliances and furnishings including 2 window air conditioners, electric clothes dryer, and other items not listed. Taxes are paid through 2009. Buyer will be responsible for real estate taxes for 2010. The mobile home has been inspected and approved to be sold, and the buyer has been approved by RVG Management, the managers of Hampton Village. Date signed: ~~ 'Z,~ ~.01~ Seller: (~ -Q~o-v~- ~ , j ~©~ ~~ ~-t ~ j ~-C~. Address: 7 ~ a ~"~ L~-~- I ~ ~ C>! Buyer: - :1~ Address: ~`~ 2/ v r 4g' In the presence of (With Print name of witness: ~ ~ ~ ~ ~ ~ 1~ Small upright freezer -Newer nttp:~~narrisburg.craigsnst.orgiappil ~~~1~~~~~.nLn ~~~ ~~~ ~d harrisburq craigslist > for sale /wanted > appliances email this posting to a friend Avoid scams and fraud by dealing locally! Beware any deal involving Western Union, Moneygram, wire transfer, cashier check, money order, shipping, escrow, please flay with care: or any promise of transaction protection/certification/guarantee. More in o miscategorized Small upright freezer -Newer - $85 (Dauphin) Date: 2010-05-13, 3:02PM EDT Reply t0: sale-g7xsp-1739144934@craigslist.org (Errors when replyin~ to ads?1 prohibited spam/overpost best of craigslist This is from a relations estate. It's an Avanti upright freezer. It works very well and keeps the temperature at 15 degrees below zero on the normal setting. It's nice and clean, runs on regular .115/120 volt house current, and has pull out drawers which makes it easy to find items in the freezer. Easy to load or move. Please reply through craigslist email or phone 717-921-8547. -Dave • Location: Dauphin • it's NOT ok to contact this poster with services or other commercial interests 1 of 2 5/13/2010 6,:27 1 REV-1511 E,X+ (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER ~r-SCam, C1'lari an~~ ~ l- /n - Z.o3 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ,. /~-uer ~I'~/lta~lon ~erivi~es d~ ~~nns ~va~wc4 , ?~,e., C~+un~.ort, ~fi. ~~, Sao. o0 f~s ee t"t.Ce.i ~" °~~'~ iPt ~~`~ ~ ¢ p, 00 S' L~S ~J -- 1.G~r~rl ~ n1DAyU7~/w ~Q.I'•1~Gr ~°.3 .~, d~, T. Hall, ~~'- t . , pri . ~`f' Scr3 ~~'em~rrt a--tf~~r~ly~ 3, ~ G~ f /nCa/ a.~ yslip~Q f ~1 ~t, G ru~'ti ~Y: ! fit, l~/4 ~ see rec.~y~" ab x]'.33. ~ ~. C'.f.~ 6~ax ~ H.~.'.~~y ~.,, G~-a,~.h~,'«e, ~~ ~'~'i /I?R~rta r ~Sce rY,ce,;~Dt` a~Gt cl~e`l~ f ~{dr'o, o v B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions .~,Q 77'' ~~ ` Name of Personal Representative(s) ~ ~~GCXI olr[.(J~C P~ ~) B DO' a0 Social Security Number(s)/E{N Number of Personal Representative(s) Street Address _ 1 ~9 ~K.S~ ~11 °~ - ~Ot~u-.~ ~ ~ n state _'~'~" Zip 17 6 I $ City _T Year(s) Commission Paid: 2. Attorney Fees ~ {~ a r ~ ~ ,F ~ ~ e I c~S ~ '~ ~~©BD.oo 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant /V'D ONE ~L/L //3 GE' _ '~~'~~ Street Address City State _ Zip Relationship of Claimant to Decedent A. anncl ',,,~,{ 's ssc~c o~ st,o~f ~a•t- ~ c.~"~ s Probate Fees uryc~t ~ 83 SD ' 5. Accountant's Fees ~a n `~. ~~~ ~ 6 ~ ~' , ~~ ~ I~(L ~~' ~~ / ~, ~D K Z ~ r~$ o~/~ P ~Fl y u ~ ~S,d ~ 6. Tax Return Preparer's Fees 7. ~u~~'oneers ~vMmiss~on eln Sol. v~ ~e,Fs~nalt~ ~ ~b ~c~jer, /~"uch'onecr, Pane G~vve, ,p~, #~ D3, 80 $. /dal."~i'ohQ/ /~roba~e des x.30. o0 g ~i ~l % /? ~~ ~ ~O /~eq'i 5~'/' 6~ Lt/~ %iS ,~r' ,~i ~C~¢ r. Tjc ~~~r'~? / ~ J $'. D O ~° • . /~ ~/~d,r1~.'sing iry ~'t~/~ s /c sup {~r~ t/ ~ 13 y. ~~t U ~~ ~~1~r~ a ~c~ :n s'~ie~~ TOTAL (Also enter on line 9, Recapitulation) $ f ~, 6 Z ?, S'9 (If more space is needed, insert additional sheets of the same size) n. ~. se~E~ ~ SST. o~=_ ~,~2/s Cony, /jii~~'r~F _ _ _ _ _ ~'~t-F No . _ _ _ ~ /-/©.-- ~o3. _ __ ll, I ~dve~~is%n ,fy _ ~icx ~-{Q.;rtaf _ ~a~_ .wwr~r~l _ _ _ _ _ -___ _ _ _ _ _ _ __ - - - -_7S oo_ -_ _. _ . _ _ _ _ _ - l ~'. E ~D~t~~ . O/!J~ - ~~~ /~ttrfty_ _ _ ~ v(~ ~1~t 4~~'/~~'~ f~ ~~~±e~r~h.~_ G'' _ _ _ _ _ _ _ 35 9, ~'3_ C, . ~ 9 ~ 7T. /7 _i _ _ ~SpeGfi^k.m G(~i /t f c-5_ ~~u.}~'o~- 5~ _ __Gv~kr_ (3 ; l 1r _ _ _ . _ _ ___ _ _ _ _ _ _ __~_I S. _z? _ ~ar~sh ~tmi~ ~ ~f _Ca~cr~nc _s~ ~'. l4nne C~mef~r o _tta~n .v2r _ _ o - - __ _ _ - __ ~-_ P- _ _ S ' _ ~.a noru.riurn. ~_ ~t`i_tst- -um_ c~ _o_~ _ see Sf 'ernuvfi_ achod) _ _ _ oo.ao ~ ~o. __ _ __ 14e ~ -,~ bur:~:~ur~__ ~_ ~_/~~rles_ _F _ ~f ~'G_~_ ~r _~~~,_ e~y' ~ ~,~a.~ ~%~s', _ . -_ -l~ _- ___ o ( _ _ : _ , __ _ S%~ e /ot c~i~~4•~tte is ,t~c__ /..!~p - - ~° `mil ~ _ - 0 Q B ~ X ~_~ -'. ~jO~G~dS~' _ _ _ ~ ~8 7 9 ____ __ , _ . _ _ ___ _- _ __ _ . __, 1 _____ _ _ __ _ I _ _ _ _- _ _ i i - _ _ ____ - _ _ __._ -- ___ _ _ ___ __ __. _ _ _ ___ i i i __ ~ (-____ __ _ _ __ _- __ __ _ _ __ __ _ ___ __ _ __ _ ___ _ _ __ _ _ _ _ __ ' i I __ _ _ _ I _ - _ _ - __ E C__ _ _ _ _- _- _ _ 1: i _ _ _ _ _ _ _ __ _ r __ ..___ ___- _ - _. _ __ _ - __ _ I _.__ - _ _ _ __ __ ~~4~~MATION SER~jc~ .AVER CREMATION SERVICES OF PENNSYLVANIA INC. csP s O~ l~C>• 4100 Jonestown Road • Harrisburg, PA 17109 • 1-800-720-8221 • Fax 717-541-9943 • Shawn E. Carper, Supervisor pENNSYLSAI~t~' 100118 DAA Jan 29, 2010 Mr. Robert J. Griscom 18 Jones Mill Road, Apt I-7 Wrightstown, NJ 08562 Marianne Griscom - Deceased SPECIAL CNARGES X Direct Cremation $1,495.00 Nationwide Guara-ntee Program Worldwide Travel Protection Program TOTAL SPECIAL CHARGES $.1,495.00 PROFESSIONAL SERVICES X Services of Funeral Director & Staff Dressing/Cosmetizing Facilities & Staff for Memorial Ser~rice Staff & Equipment for-Memorial Service Private ID Family Viewing Witnessing the Cremation Packaging/Forwarding of Cremated Remains Personal Delivery of Cremated Remains Scattering of Cremated Remains TOTAL PROFESSIONAL SERVICES AUTOMOTIVE EQUIPMENT X Removal~Vehicle~ Lead CarjClergy Car Family Car Service Vehicle TOTAL AUTOMOTIVE EQUIPMENT Included Included $0.00 $@.@0 MERCHANDISE Register Book Memorial Cards Thank You Cards Remembrance Package Alternative Container X Cataline Stone-Toni Urn Urn Burial Vault Container Veterans Flag Case Grave/Memorial Marker TOTAL MERCHANDISE GASH ADVANCED ITEMS .--+ ® C \~ --~ C x V ~ A SS +~ 7 yC . ~~ ~ N C ~ d - X -^ S .® o x x ~ m r-- x ~ ~ ? ° z i .a n g~~m ~ ~ ~ O 6 ~ m~m~ -~ U r-• a to -~ .sx.T~ao 3 ~[Y m @ ~~~z° ~~ N /~ '7 ~ ~ ~ v Afn ~~~~ ~ ~ cr -..v ~ ~ r~~ ov S ~ ~" ~ ~~~o A d S ~ ~~ ?~ ~,~. ~ D m ~~ ~~ m ~~~ ~ °'- Grave Opening Cemetery Equipment Newspaper Notice Newspaper Notice Newspaper Notice Clergy Church/Sexton/Organist/Soloist Flowers ~• X Crematory Charge X Cumberland County Coroner Approval Fee X 10 Certified Copies of Death Certificate TOTAL CASH ADVANCED ITEMS SUMMARY OF CHARGES Special Charges $1,495.00 , Professional Services $0.00 Automotive Equipment-- -$0.00 Merchandise - $250.0® Cash Advanced Items $85.00. SUB TOTAL $1-~ 830.00:: CREDITS _ $0.®®~ AMOUNT PREPAID Date ~ $0:,.00 TOTAL $1,830.00 AMOUNT PAID Date Feb 24, 2010 -$1,830.00 BALANCE DUE $0.00 $250.00 $250.00 Included $25.00 •.$60.00 $85.00 THIS STATEMENT MAY NOT REFLECT ALL NEWSPAPER CHARGES SEP-7-2018 13:39 FROM: H.1 HALL, Inc. 1716 HIGHWAY 71 SPRING LAKE HEIGHTS, N.J. on62 7324493447 T0: 7177957473 P.2~2 .~ 732-4495454.732-223-2323 FAX: 732-449-3447 • E-mail: hthatl~verizon.net www.hthailmonumertts.com ~._.._ _ .. , xo2o~ THIS lS TO CERTIFY that the undersigned ha-s this day ordered H.T. Hall. Inc. to famish: SPEClFICATION$ Design No. Matorrel ofe Style o/ Lettering Halo t/ Marker Approximate CornNletion Dato ~ ~ - ~~ `~~ ~~~ '~oric~~me r1 ~- ~ Can ~e ~~ Cemetery - _ ~ ~ - ~' ~- Nsm. Foundation Cost TERMS Memorial oontree~s_,A deposit of one-thirCt C/~ of the Connect price i8 required with the SlQninD of this contnd, and an addldonal ono-third (tiS) b duo and payabb when the foil Biza debil (biWprq'tt) is rat~xned approved. The balance of ttlp at~utated amount is due and payable upon notl00 to the buyer that the monumertit is t~mpleted, at the senOr's shop and ready Eor lnst8listion_ Lcdterins aor~SraCla.- The fuM sbpufated amount on aN feaeihig COnb~+cLs is duo end payafle with the siDNng of this aontrad. A f9nanvs Chatge of tyS96 per month w~ be added bo alI babnoz Past duo 30 days after notion to the t>uycr that t?le monument is oanpleted. at the seller's shop and ready for lnstsllstion This is an annusf plxaentaDe rate of t 896. T~tly to t1-e right or possession of saw monumtlntaf work Shall be and cement in the abava n~n~ed deekr until !hs fup purchase PrStx+ stipulated herein hea been paid. TOTAL AAAOUNT $ Yr~~ ' ~© CASH DEPOSIT~I~~~ ~/7~ '•r'O ~,(~ eALANcE ~6? Ail oontreCts are subject to delays occasioned by tiro. aCCidant, sUlke6, or oMer causoa beyond the control of the company YoU THE BUYER, MAY CANCEL TMts TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE TFtIRD 6lJSINESS t]AY AFTER THE t~i4'1'E OF THIS TRANSACTION, SEEATTACtiEp NOTICE CANCG.I.A- TiON FORM FOR AN EXPLANATIpN OF THIS RlGM' THE TERMS OF THIS CONTRACT SHALL NOT IN ANYWAY BE CHANGED, At_TERED OR MODIFIED NOR SHALT. ANY aGREEMENT COLLATERAL HERE70 BE 6-NDING, UNLESS MADE IN WRITING DULY SIGNED BY ALL OF THE PARTIES ALL CONDITIONS APPROVEDAND ACCEPTED JOINTLY. For the above specified Memorial Work as contract tinder then stl sled farms... I promise tb you file sum of -1 ~YYt. he oa~ars s• Name iPrintf~~.,/ ____~ ~"~~i\f'Xl~ 0 and `~ ~~.. ;~~ sold THIS CONTRACT SUBJECT TO APPROVAL BY MAIN OFFICE 3 ~~ ~" ~~ ~ ~ ~ ~; J4 ~. ~~ - ~ \/ ~~ P,,~ 1 .~ ~~ ~~~'~~ t. J ~Pe l~a,~e °'~ '~'~ _.---- ~~ S ~' ~~ __ ~ ~~~ (1~~) S~~u;~ue _r____~.._.-- ~~,. i f~ /~ j, Syr i/ (fij'~jjj_i ^"~ ~J ~ ,~Oe ~;ep44i~ _ _ ~~~ ~, ~~ertt x-~~unr.~ ~ + ~,~ Gam s,~~ ~ ~ ~ S ,' ~'''`~`~' ~ 475 - ~ ' ~~ ~~~ . 5 73 -245 S _ ~ . nt! ~. ~c~ ,~~r'°n~. 09/07/2010 12:9 ~~~,X 1717697089 HOLIDAY INN Holidabinn -~ool~ool 101 09-07-10 ~ PA Bible Fellowship US Folio No. 138553 AIR Number ; Group Code Company Membership No. Invoice No. Room No, ; 901? Arrival 03-28-10 Departure 02-26-10 Conf, No. Rate Code HOUSE Page No_ 1 of 1 Date Qescrlptlon Charges CredltB 02,28.10 Banquet Brunch -Food 02-2810 Banquet Brunch -Food 0226-10 Banquet Brunch .Food 02-28-10 Banquet Brunch - FOOd 02-28-10 Banquet Gratuity 02-28-10 Banquet Tax 02-28-10 Banquet Aoom Rental 02-28-10 Banquet Tax 02-28-10 Visa 02-28-10 Visa 02-28-10 MasterCard xxxxxxxxxxxx7~ ~14iC~1tXg'~16half XXXXXXXXXXXX8001 146.93 151.92 90.93 1so.oo 102.56 38.54 50.00 3.00 X33.88 -242.21 242.21 Total 733.88 733.86 Balance 0.00 Guest Sig~ettu~e: have received tt-e goods and / or senrk;es In the amount shown heron_ 1 agree that my r~abllty for this bill Is not waived and agree to be Held personally liable in the event that the Indicated person, company, or associate fails to pay for any part or the full amount of the6e charges. If a Cretllt card charge, I further agree to perform the obligations set forth Ir~ the Cardholder's agreelfient with the Issuer. Holiday inn Harrisburg/HerShey ~ 604 Station Road Grdntville, PA 17028 Taleohone: (7171469-0661 Fax: (717) 469-7755~ p.2 'rHE PARISH FAMILY OF S T. C ATHAR INE AND S T. .A.1'JNE CEMETERY September 7, 2010 RE: Marianne Griscom- St. Catharine Cemetery- Sect. 4-AVM-1-1 Cre. To V~'hom It May Concern: Marianne Griscom ~~vas cremated and buried in St. Catharine Cemetery on Monday ,August 23, 2010. The cost for the opening of the gra~%e ~~vas $600.00 The stipend for the Priest; Fr. Joselito Noche was $100.00 The cantor was Ann Marie Allen and her charge was $100.00 If I can be of further assistance please, do not hesitate to contact me. Sincerely, l:~ C~ C~ 1Vlarion Ciecura, Secretary 1610 ALLE\`WOOD ROA.D~ WAZL~ 17Ftiti' JERSEY 0 7 ? 19 Pxo~rr (732) 681-6269 Fax ('732) 681-0338 REV-1512 EX+ (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT INHERITANCE TAX RETURN RESIDENT DECEDENT MORTGAGE LIABILITIES & LIENS ~ ESTATE OF FILE NUMBER Gam, scorn, lYl~.r«nn~ a/-~v- ao3 Re port debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH ~. Ll.S . TK4SUry, ~s end ~ic'onu ~~s ~0 9 ~!o a. do ~, ~Salanc t due on ~i ne 1'b ~'ccm~.s ,l~. ~..enker-, May iS~r~al ~A'~5~*~~~- ~'kdye, 17~s~. Ct. -~-I--o1, 2tzs P~-xtah Chu~~ti ~d. , ~-IQrr~ s6~-~, P~ I~ilp ~~ -- 6.s D 3 . CH ase F~^eco~ om Cr~cd ~f C'.a.rd Sr ~9 2 ~,v 4 (flood 18~f0 ~r ~~ 86 /, 2 7 "f. C~fi', PIa ~~n ~~- ered;+ Cad s~~Y lads ~¢so o~~r ~ a ~3, er ~• ~isCo~er Creolf' C/s~d ~~~ob ~ Se/. ~3 6, P%•,~a~/~ ~1~4/tti ~t~ ecoan} laclie~cd t" hrue bc,~r, `~C1ear~d."~ ~ ~.~~• a~ 7. C t~x+n 4atr ~ a,,~ d~ w Tw.sc. ~~ i hr1 ~ Ul.t' ~ q ~l 19 0, a~ ~. 1~ ~~rv - ~an k- overdr~a,~f' anol n e~ bail ~~ d ~ see /efk~ alfatlu ~j ~ a ~~. a3 TOTAL (Also enter on line 10, Recapitulation) $ I ~~-~ `gyp. (If more space is needed, insert additional sheets of the same size) 'METRO BANK 3801 Paxton Street Harrisburg • PA • 17111 mymetrobank.com 888.937.0004 April 27, 2010 Char{es E. Shields, ill 6 Clouser Rd Mechanicsburg PA 17055 RE: Estate of: Marianne Griscom Tax Identification Number: 144-70-4675 Date of Death: January 1, 2010 To Whom It May Concern: This letter is in reference to decedent account information you requested for the individual listed above. We are able to provide the following: Account Type: Checking Account Number: 536738529 Date Opened: 08/02/2004 Date Closed: 02/23/2010 Primary Owner: Marianne Griscom Date of Death Balance: $-123.49 Please be advised that the customer listed above had an overdrawn balance and the account has been closed. The customer owes a total of $219.23 and has been reported to Torres Credit Services. Please feel free to contact me at (717) 412-6127 if I may be of further assistance. Sincerely, Diana Reynolds Metro Bank Research Associate/Deposit Services CHARLES E. SHIELDS, III ATTORNEY-AT-LAW 6 CLOUSER ROAD Corner of Trindle and Clouser Roads MECHANICSBURG, PA 17055 GEORGE M. HOUCK TELEPHONE (717) 766-0209 (1912-1991) FAX (717) 795-7473 December 22, 2010 Register of Wills Cumberland County Court House 1 Courthouse Square Carlisle, PA 17013 Re: Estate of Marianne Griscom No. 21-10-0203 Dear Register of Wills: . Please find enclosed for filing 2 copies of the Inheritance Tax Return for the Marianne Griscom Estate as well as Check No. 1007 in the amount of $15.00 for the fili ng fee and Check No. 947, in the amount of $40.00 for additional Probate. Thank you for your kind attention to this matter. Very truly yours, Charles E. Shields III ~.-~ n ' .. Attorney-At-Law ~ ~ ~' ' >~~? ~,. M;.a ;, ~~ ~ ~ . ~ ~. Enclosures ~; ~ , ~ ~. - ~^ _ ` ~~~ r ,. ~' ~~ ---~ • • ~- . G, ;~.,,.~.1 -~.....~ :~i4 ,. ~ ~7._ v~ ~M.., ~ ~~ `~~' Vf~, ~ ~....+ ~ ~ ~ ~ O ~ J w ~ aN -o O a ~ ~ cn o ~ '- ~ Q 2 ~ W r- ~ o W -~ ~ I 1. ~_ ~ o ~ ~ - _ Zgo~ (n ~ CV O o _ UT ~ W `ca ~ ~+ / N ~ ~ ~ M .~ NMI ~ ..I ='O ° o CV ~ - RS o. ~ - -~~ ~ ~ w ~ ~ Cn r ~, ~ p ~ v Nw o ~ ~' Q rn OZOa o W~~J= ~r Li ~ f" W ~ N ~ LL ~ ~ m ~ J ~ ~ w?oa ~ ~ OCU.-V a wow =gym .. ~ ~~~ O w J ~ Q inf. O W 2 U ~ U ca ~ -.,:: e::.y, Y'"+. N ' ~ ~_'; r=`7 L~.~ ;` . . - ~ f.....,. l d ~ _ i'."v r.... -; ~......' 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