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HomeMy WebLinkAbout02-08-11E ~ 1,50561,01,01, REV-1 soo ~x co~_~o, OFFICIAL USE ONLY PA Department of Revenue Pennsylvania -- '~' P,a,~t~,oF~E~E..~E County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN ;~~, ; PC> BOX 280601 , ~ ~ k~ - Harrisburg, PA 1'7128-o6oi RESIDENT DECEDENT -~ k ~~} `_ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 201-16-2829 04!29/2010 12/28/1926 Decedent's Last Name Suffix Decedent's First Name MI SOUTNER FRANCES A (If Applicable) Enter Surviving Spouse's information Below Spouse's Last Name Suffix Spouse's First IVame MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW (*j 1. Original Return O p 4. Limited Estate O O 6. Decedent DiE~d Testate O (Attach Copy of Will} O 9. Litigation Proceeds Received O THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 1Q. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95} C- 3. Remainder Return (date of death prior to 12-13-82} Cr 5. Federal Estate Tax F',eturn Required __ 8. Total Number of S~rfe 'deposit Boxes O 11. Election to tax under ~~ec. 9113(A} (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Numk~er CYNTHIA PETR,ASNC (717) 763-9544 First line of address 86 HILLSIDE CIRCLE Second line of addres:7 City or Post Office CAMP HILL Correspondent's a-mail address: State SIP Code PA 17011 .., REGISTER OF~LLS USE ONLY. c~ ~-->_. ': ~-7 ._ r- ~_. =~7 ,,~. ~_ ~; -- -~ -,`J f_ ,~ DATff~iL1 D c.~ _~ -*-• :_ ~~ - J - ~ ~? __.~ ~~1 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowiedge and belief, it is true, correct and complete. Declaration of prep er other than the personal representative is based on all inforrnation of which preparer has an}~ knowledge. SIGN RE OF PERSON RESPON , ~~~FOR F I G RETURN DATE± r" _ ~!~;~- ADDR 86 H LSIDE CIRCLE CAf1~P HILL, PA 1.7011 M _ S OF PREPARrR OT ,Q(;1 REPRESENTATIVE DATE ADDRESS i 430 N ENOLA DRIVE ENOLA , PA 17025 PLEASE USE ORIGINAL FORM ONLY 1,50.561,01,D1, Side 1 1505610101 .,,F. J R1=V-1500 EX decedent's Name: FRANCES A SOUTNER Decedent's Social Security Number 201-16-2829 RECAPITULATION 1. Real Estate (Sc:hedule A)..... ...................................... 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages arrci Notes Receivable (Schedule D) ................. ..... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 1 ~'~,709.80 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos l"ransfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 13,709.80 9. Funeral Expenses and Administrative Costs (Schedule H) ............. ...... 9. 1 1,782.42 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........ 10. 1,957.65 11. Total Deductions (total Lines 9 and 10) ......................... ..... 11. 13,740„07 12. Net Value of Estate (Line 8 minus Line 11) ........................ ...... 12. -30.27 13. Charitable ar~d Governmental Bequests/Sec 9113 Trusts for which an election tc, tar, has not been made (Schedule J) .................. ...... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. .... 14. -30.27 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line '14 taxable at the spousal tax rate, or transfers unde- Sec. 9116 (x)(1.21 X .0___ 15. 16. Amount or LinF~ ^4 taxable at lineal rate ~:.(i _ 16. 17. Amount of LinE~ 14 taxable at sibling rate ?,: 12 1 ~. 18. Amount of Line 14 taxable at collateral rate X .15 1 g. 19. TAX DUE ............................................... .... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15Ci561,01,05 1,5D561,01,D5 1,5D561,01,05 0.00 O J r i REV-1500 EX Page 3 nar_Arlant'~ C:mm~letP Address_ DECEDENT'S NAME FRANCES A SOUTNER STREET ADDRESS 86 HILLSIDE CIRCLE; CITY ----- ---- STATE -_---Liles - - - CAMP HILL PA i_^ 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments 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. File Number Total Credits (A + B) (2) (3) (4) (5) Make check payable to: REGISTER OF W1LL~~, AGENT. 0.00 0.00 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIA-TE 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 ................................................................................................................... ...... ^ x 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 receivir-g adequate consideration? ........................................................................................................ ...... ^ 0 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 beneeficiary designation? .................................................................................................................. ...... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART 01= THE RETURN. For dates of death on or after July 'I , 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spout>e is 3 percent [72 P.S. §9116 (a) (1,1) (ii]. 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 an the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent; e>;cept as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed an 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)]..4 sibling is d~afined, under Section 9102, as an individual whc has at feast one parent in common with the decedent, whether by blood or adoption. REV-15o8 EX+ (11-ZO) pennsytvania SCHEDULE E oEF>AF~TM~ NT of iiE ~E:NUE CASH, BANK DEPOSITS & MISC. INHERITANCE TA); RETURN PERSONAL PROPERTY RESIDENT DECEDENT -- ESTATE OF: FILE MU~+IBER.: FRANCES A SO~TNER ^ Include the proceeds of litigation and the date the proceeds were received by the estate, All property jointly owned with right of survivorship must be disclosed on Schedule F. If more space is needed, use additional sheets of paper of the same size. R~V~-1511 ~X~ (1.~-`i-{.f~)~ ~ pennsylvania DEPARTMEN' OE REVENUE INHEf2ITANCE TAX RETURN RESIDENT DECE=DENT SCHE®ULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER FRANCES A SOUTNER Decedent's debts must be reported on Schedule I. If more space is needed, use additional sheets of paper of the same size. TOTAL (Also enter on Line 9, Recapitulation) $ 11,782.42 S f2~L-1.51 ~ ~X;. i l ~-'"i~'j r, pennsytvania SCHEDULE I DEPARTMENT ~~. ~aE~EN~E DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECED=NT ESTATE OF FILE NUMBER FRANCES A SOUTNER ___ __ _ Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed ineciical expenses. If more space is needed, insert additional sheets of the same size. l'=~97 Buick Lew ~~a'~~re -Private fart}~ Pricing Report - Kelley Blue Boole Page l of ...:, -.~ , ..:; ".~ :~~ belle 8~~ Ba®k _ _ _ _._ SEARCH '~ THE TRUSTED [tEi(~FUKCE i^:;Er°rr~ ha~u=' .,;»~"s `£~° ~i :,e< ~rF-_;FCrarw~~` Used Cars Rs~~~~br''~"t'. Pdf d8?"°§dSA, ~; ~a63A1~ Lbw .»5!:#'.` .erkt` _ tat , b° ¢.t.rr"~- ~ ~ a . aRB,~ Used Car Values ~earcr £~s~,=, Car Classif!eds ~ Certified Pre-Gwned ~ Compare Vehicles '! 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'~, I =:¢ r'. ..or 1C Back-to-School Car; 2010 _D Most ComfDrtable~ Cars Under ~3C',000 Best SePt~mber ruBance Deah; ACr. ,=.u~~:.i~.: S c;reat Car Deals Couple Stranded By Nav System - r!;_ kuo~: __....... Fe ~ : i~1ore Average Consumer Rating (253 Reviews} tread keviews ;' __ _ 4.4 out of 5 Revle~~: the 1.997 i3uiCk t_e~abre Vehicle Highlights Mileage: 68,000 Engine: V6, 3.8 Liier Transmission: Automat!c Drivetrain: =WD Selected Equipment Change Equipment Standard Air Conditioning Power Door Locks Dual Ai- Bags Power Steering Tilt Wheel ABS (4-Wheel) Power Windows AM/FM Stereo Steel Wheels Blue Book Private Party Value Kelley Blue 6ooK Private Party' 1~aiue is the amount a buyer can expe= tc Day when buying a used car fron-~ a private party. The Private Party Value assumes the vehicle is sold "AS Is" and carries nc v.arranty (other tnan any ~ema,nno factory warranty] The final sale pace maq varq depend!nc on the ~~enicle's adua' condition and local market condi[!ons. This value ma;' alss ne usec to Derive Fair Macke: Value for insurance and vehicle Bona*,~cn http:; /uwv~-.kl~b.ccinvused-cars/Buick/lesabre/1997iprivate-part~~-value%p~ric~ng-report?con~:f... 9i?2~:?O10 145329 -123 ~ 8 FRANCES A SOUTNER CYNTHIA S PETRASIC 86 HILLSIDE CIR CAMP HILL PA 1 701 1-2522 Santander Strong--- Sovereign is part of Santander, "Glob~~l E3ank of the Year."* Statement Period 013122/10 TO 04/21/10 SOVEREIGNI PREMIER CHECKING For ;your convenience our Customer Contact Center is available from 7 am - 8 prn EST, 7 days a week. CaU us at 1-877-768-1143. Hearing impaired may call 1-800-428-9121 (TTY/TDD). ww~n~. sovereignbank. com ~ ~~~" ~` ~~~f A~~~~ 1S "EEC. Get the conf idenc-e that comes from knowing that your checks, debits and payments will be covered if you averdra~r your account. When you attach an Overdraft Line of Credit to your Sovereign checking account, Hands are automatically transferred from your line to your checking account to cover the arnount that is overdraw ~ F ands are transferred up to the amount of the available credit limit on your line. To learn more about this great way to protect your account, call the number at the top of this statement or visit your local branch. ~:~0,7~)LO~= onon ~o~~ o zr~oo~r~9~~~ '.sovereign Bank is a Member FDIC and a wholly owned subsidiary of Banco Santander, S.A. ~ Sovereign and its logo and Santander ar~d its ~~CI,~~C' ~ ()~ -! ~ logo are registered tradernark~; of Sovereign Bank and Santander, respectively. or their affiliates or subsidiaries in the United States and other =~~ I ~ / ~~ ~ S 9 ,,, rountnes 'According to The Banker. pecernber, 2009 FRANCES A SOUTNER CYNTHIA S PETRASIC' Deposit Accounts Account Number Average Daily Balance C:tir•rent Balance -SOVEREIGN PREMIER CHECKING __ __ ,__ 461070359 __ __,___ ______~ $2,336.26 _____________$2,948.00 STATEMENT SAVIN_G_S ACCOUNT 1714046149 $7,881.80 __ $7,881.80 Total Deposit $1o,s29.so FRANCES A SOUTNER Cl~'NTHIA S PETRASIC Acrour~t ~# 46107G'359 Balances Beginning Balance _ $2,058.01 Current Balance __ $;2,948.00 Deposits/Credits `_ + $1,935.78 Average Daily Balance __ g>2,336.26 Withdrawals/Debits - $1,045.79 Interest Paid this Period ~ $ 0.02 Annual Percentage Yield Earned `_ 0.01% Earned this Period ~ $ 0.02 Paid Last Year `_ $0.37 Paid Year-To-Date $ 0.06 __ '`The interest earned <and the interest paid may differ depending on when interest is credited to your account. service Fees -Itemized Date # Transactions Fee Total MONTHLY MAINTENANCE FEE 04/21/10 1 30.00 __ $30.00 Total $30.00 Checks Posted Check # Date Paid Amount Reference 03;2'2 4945 $12.97 635786430 __ 04114 4946 $12.00 _ 979493850 ___ 4951" 03122 $1.3.69 997652505 __ 0312 4953 $217.00 997098970 _ _ 4954_________ _ 03124. ___ _$217,00 _ 998645065 4955 03/24 $40.00 998901430 11 Check(s) Posted = $947.63 An asterisk (*j indicates a skip in sequential check numbers. Account Activity Date Description 03-22 Beginning Balance 03-22 CHECK. 4953 Check # Date Paid Amount Reference _ 4956 _ ! 03131 _ $205.OU 972765490 4957 ___ __04/01 $12.9 i' ___ ~ 630690890 _ 4958 _ ~ __ _ 04/07__ ____$50.00 975790550_ 4959 04/07 _ $50.00 632684500 4961* 04/12 $117.00 977732855 An (E) indicates check was converted to an electronic. item. Additions Subtractions Balance $2,058.01 $217.00 $1,841.01 03-22 CHECK 4951 03-22 CHECK. 4945 03-24 CHECK. 4954 03-24 CHECK. 4955 _ 03-26 CHK CARD _ _ PIMP 483994 RITEAID RITEAVDSTORE LEMOYNE PA 0?~-31 CHECK 4956 04-01 CHECK ~9`.i7 $13.69 $1,8:27.32 $12.97 $1,814.35 8217.00 $1,597.35 840.00 81,557.35 818.00 81,539.35 8205.00 $1,334.35 $11.9% 81,321.38 ->t~l(I~(~359 Jur,~c> ~ r~/-l Seller. tieill Funeral H.~me_ lnc 3401 b1arket Street X501 Dern Street Camp HiIL PA ] 7(11 1-N28 l~amsburg- P.A 171 I I (717)73?-8726 -I~-564-263, Kevin J Shillabeer . ~upervtsor Srapl~en J W'ilsbach. Jupervisor (.bntract it - 741 ] U 1000167 Case. #~ -20864282S Part (lnr~ of Thr~r F statement of Funeral Goods and Services Selected/Purchase Agreement ' Date of Death 04~29' ?O10 _ _-_ Uate of Service OSr03~010 Name of Deceased Frances A SoutTier ___ Dare of Birth ]?'2$/] q;>6 Deceased's Last Address g6 Hillside Circle ___ City Camp Hill gate pq zip Code ~ 70 j Purchaser's NameCyIlthla PeTr3SIC ______ Phone Number 1717) 76~-954 Purchaser's Home Address 86 Hillside Circle-_ cite Camp Hill state pq zip code 1701 1 Co-Purettaser's Name ___-_ Phone Number _ ~_ Co-Purchaser's Home Address __ C:tty' state ztp Code In this Agreement the words you and your refer to the Purchaser and the Co-Purchase:, if any, signing this Agreement. The words we. us and our refer tr the [~uneral Provider or Seller whose name and address appear above F.~r goo d and valuable consideration , which each party acknowledges receiving. you agree to buy the goods and services described below. You authorize us to prepare and care for ~he b ode of the decedent named i n this Agreement and to conduct the funeral and services and incur tine charges listed in said P.greement We have the right to collect the total amo unts due under this Agreement from any person who signs this Agreement as Purchaser or Co-Purchaser. (NiA indicafes~ riem.r ofservice andor merchandise that arc not prwrded ~ Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain the reasons in writing below. If you selected a funeral that may require embalming , such as a funeral with viewing, you may have to pay for embalming. l~ou do not have to pay for embalming you did not approve if you selec ted arrangements such as a direct cremation or immediate burial. If we charged for embalming, we will explain why below. SECTION I -SERVICES AND MERCHANDISE MERCHANDISE FUNERAL DIRECTOR AND STAFF SERVICES Basic Professional Service Fee ____ __ W -.680.00 Casket or Alternative Container: Manufacturer/Supplier Batesville PACKAGE OFFERINGS Duect Cremation ______-_____ _______ f n:a _ Model Name/Number Antique Blue - Immediate Burial _-______-_ ----- c .. n a Material - Forwarding Remains ____ e ~. n~a Species of Wood .____--- _ __ -_ ' steel Type of Metal Receivrng Remains _ __ $ n a W'eighUCiauge 18 ga - -- - na - ere e lntenor P ~ n a Blue _ Exterior Color $ I,i9~.00 CARE AND PREPARATION OF REMAINS Outer Burial Container. Embalming ___-________________ ______ _ _ _ _ _ _ _ ___ g 79j.00 Manufacturer."Supplier Evans Eagle _ Other Preparation (specify i Model Name'Number Sentinel _ Dressm~ and Casketine of Deceased S 39.00 Material concrete-lined $ [.395.00 - - - ~ n;a Urn- -- $ tvlanufacturer Supplier _ n.a c n%a Model Name;Number - - _ c na Material $ ni - a ---------- ----- _at. in° $ 125.00 -- -_ - USE OF FACILITIES AND RELATED SERVI(ES - __ $ nia Visttauon __------_ -----.--- -- 5 nia $ rya _. __ Funeral Ceremonc S 495.00 ____ _-_____ $ t.14i.00 TOTAL SECTION I____ _ Memorial Serene-_ -___ __ _- 5 na _ ______ _ Graveside Service $ Na SECTION II -CHARGES TO BE INCURRED BY US ON Other tspecifi~i -_-- YOUR BEHALF (Certain charges maybe estimated -"e" means $ ; estimated. g y ) We char a ou for our services in obtaining those items - - - _ - - - _ _______ - - n a - $ n/a - marked with an ..X~~ $ n/a - Cerneter}'__ - ----- - -- - S 95O_00 - Crematory $ n/a RANSPORTATION ______ - - - Clergy /Religious Facility $ >00.00 = .- - Transferring Remains to Funeral Homy ____ 495.00 _ - Musicians or Sinters _ -- $ 175.00 Funeral Vehicle~Tfeazse__ _____ $ 395.00 Certified Copies __ -____ $ 36.00 Chher (specific): Newspaper Notices $ n/a e Vehicle eryic,- - - $ 395.0(? News a _er Notice ~ t 7 q2 P_P- $ n/a - _ n/a n/a tea ~ n/a tea S n/a $ ~ n/a ~ Na OTHER GOODS AND SERVICES Memorial Booklet ____ ____- $ n/~+ Service Folders------ -------_-- - _ _ __ ~ nia Prayer Cazds -- - -- ---- ---- -- - _ - . $ n/a AcknowledgementCards._ -___ ____ S Na Memorial Package-.____ - - _ - _- $ - - 80.00 Flowers - - - S 300.00 ~ n/a ~ nia __ __ - ~ 4 _ - n/a nia rt ~a - - - - _ -- -- ~ c -- $ ~ _ e nia nia nia n/a ~ ~ n;'a n/a na n,a - nia Hairdressing ~_ g, p0 ~hnerBurial-Container_I_nstallation $ I~9.00 Aha) ~~rve[~_____ $ -- -- S !5.00 ~ -- - - $ rya n/a $ - - r>/a $ -- -- _ - -- nia $ -- - n/a 4 - nia ' - -- $ nia - $ n/a ~ TOTAL SECTION II_ ______ ~ '-'-37.42 TOTAL SECTION I CHARGES ___ __ _ ____ _ -___ ~ U 145.00 TOTAL SECTION II CHARGES ___ 2.237.42 TOTAL SECTION 1 AND SECTION II CHARGES ___ W 11.382.42 i r~ ~ ~ ~ / ~' ~ ~,/,~~ ~ - ~ '~'- ,~.~J r ,.' ~ PURCHASER'S INITIA LS. Ai NI>"DATE TNES~' I1\'ITI i AL.!A'v' DATI: sz;io ;, :ans Part T wo of'Three Pvt~ Contract. # - 74t 101000167 Natne of Deceased Frances A Soutnet __~_ Statement of Funeral Goods and Services Selected/Purchase Agreement TOTAL SECTION I AND SECTION II CHARGES _ - ~ 11382.42 SECTION III -ALLOWANCES ~ - - _ - nia -- - ~~ - _ - - - - - - - - n; a - ~~ J nia - - - -- ~~ _. _ n; a - _ ~~ ~~ n a nia nia - - - - `~ n; a ~~ tUa ~~ 0.0(~ TOTAL ALLOWANCES_--______ SECTION IV -TAXES Taxable Items Section 1 t or -Section 111 ~'- - - ~~~`~ ~, Less Deductibles _ - - - - - - - - - _ _ - a `> C.00 TOTAL TAXES _ °i~ __ + + + TOTAL CHARGES: Section (I} (II) or - (III) (IVJ _ ~> 11382.42 Less Cash Received - - - _ _ _ - - - - - - - _ _ _ 9; n,%a ~; Less Assignments of -- - - - - - - - - - - ~ _ _ _ - I ._ ). ) Unpaid balance due by: 05/03!2010_.. - 9, 93.42 PAYMENT TERMS: You understand that no extension of credit by us, suhject to federal or state credit disclosure, installment sales, or other consumer credit s tatutes, is contemplated by this Agreement You have no right to defer payment of am amount due under this Agreement. You agree that you are personally liable for pay ment of the applicable balance due shown on the Statement of Funeral Goods and Services Selected by the due date indicated on the Statement_ Such payment will be made to us at the address set forth in this Agreement. Where the iua amount due will not be paid prior to the performing of the services called for by this Agreement, you authori ze us to inquire into your credit histon. IDENTIFICATION AND DESCRIPTION OF MANDATORY ITEMS AND EXPLANA71ON OF EMBALMING CHARGE: W e have identified ar~d descr ibed below any legal, cemetery or crematory requirements that compel the purchase of any items listed in Part One and we have explained why we charged for embalming. You acknowledge a~~d erforn~ed at the faciliq~ of the above-referenced funeral home or at another facilit}~ that is duly l s ma be f th m i i d icensed and p e re ain y on o /or preparat ng an agree that embalm equipped to pro~~ide such services- Emha]minR Expressly Authorized By C,<nthia Petr~3sic - Cemeterv Requires Outer Burial Container __ You confirm that you have examined the service and merchandise items listed in Part One and found them to be correct and according to the arrangements selected and that pnor to signin~ this Statement. you reviewed and approved a completed copy of this Statement. You also confirm that you have been informed of v_ our rigi~t to select onh~ such services and merchandise as ~°ou desire, attd that you nave the legal right to arrange the funeral services for the deceased named above. Acknowledgement of DisclosuresiDisclaimer The Federal Trade Commission 'Trade RegulaUOn Rule on "Funeral Indusm~ Practices" requires certain disclosures and prohibits misrepresentations. The following is a checklist we ask those we serve to read and sign n~ verify that the funeral arrangement conference was conducted i^ compliance with the Rule. You, who made the arrangemems for the funeral and final disposition of the above-named decedent. do herebq attest to the fallowing: I 1"ou were given a General Pace Lisr effective on _ 03i30i2010 pnor to discussing funeral arrangements or the selection of airy funeral goods or services. ~. You were shown a Casket Price List effective ~n~ 03!30i'_010 prior to discussing caskets. .You were shown an Outer Burial Container Price list effective on 0;{30!3010 prior to discussing outer burial containers 4. 1'ou were advised that the law does not require embalmin_ except in certain special cases. ~. 1'ou were not advised that embalming: is required Erie direct cremation, immediate burial or a closed casket funeral without viewing or visitation if refrigeration is available, where state or local law does not require embalmm~~ m such cases. 6. Fou were not advtsed that any law requires a casket for attest eremadon or that a casket, other than aft alternative container, is required for direct cremation. Z y"ou were advised that state law does not regwre the purchase of an outer burial container or any of the funeral goods or services you selected, except as set forth on your Statement of Funeral Goods and Services Selected. 8. No claims were made to you as to the merchandise or services (embalming, casket. outer burial container) to the effect that embalming or the use of any merchandise available from us would delay the decomposition of the remains for a long term or indefinite time.. or that any such merchandise would protect the body from gravesite substances_ No representations or warranties were made to yuu about ate protective features of caskets or outer burial containers other than those made by the manufacturer. 9. You were advised that the funeral fim~'s c~~st tax the items listed in Part One. Section l1, may be different based on volume or cash discounts or other protessionaVtrade customs where permitted by state or local lay,. NOTICES TO PURCHASER/CO-PURCHASER SEE PART THREE FOR TERMS AND CONDITIONS THAT ARE PART OF THIS AGREEMENT. DO NOT SIGN THIS AGREEMENT BEF=ORE YOU READ IT OR IF IT CONTAINS ANY BLANK, SPACES. YOU ACKNOWLEDGE RECEIPT OF AN EXACT COPY OF THIS AGREEMENT. BY SIGNING THIS AGREEMENT, YOU ARE AGREEING THAT ANY CLAIM YOU MAY HAVE AGAINST THE SELLER SHALL BE RESOLVED BY ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A COURT OR JURY TRIAL AS WELL AS YOUR RIGHT OF APPEAL. Executed this ~ day of MaV _ '_010 Purchaser's Name CVrlt]ll p2t1'151C ;'~__ Purchaser's Signature ~~ ~~~~~-1 Social Security' ~ - - F3y. k:evin S ~ abeer _ _ FD Ol X239 L C~~-Purchaser's Name Tv ~~1 e ~~ ~ License Number __ Co-Purchaser's Signature __ Co-Purchaser's Social Security # - - d~ Signature i I attest that I have completed/reviewed this document as required by the Company's SOX Key Control Checklist: Pert dame: Title: MCHS CAMP HILL '1700 MARKET SIRE. E:-1 CAMP HILL PA 17011 717-737-8551 Account Summary I~ $150.00 $1,255.50 $0.00 $1,405.50 ~ $1,405.50 Transactions Detail BALANCE FORWARD $150.00 04/20/2010 ROOM & BOARD CHARGES APR 20-24 2010 $1,255.50 f' ~ ~ ~~ ~ ~ ~ ~,1 ~, ~ ~ ~ ~ ~ f ~,p .~ ~ i~ V I ( " ~ ~~ We thank you for your prompt attention to this statement. Please notify the business office of any changes to your benefi~!s or insurance. Patient: FRANCES :SOU-fI~ER Patient tVumber: 0058:x-298i/~ Statement Date: 0501 x'201 ~:? ~~~~r~_~~~ _«an~~~ 0 G PENNSTATE ~! Milton S. Htershey ® Medical t;:enter PO Box 643291 Pittsburgh. PA 15264-3291 FRANCES SOUTNER 86 HILLSIDE CIR CAMP HILL PA 17011-2 522 1V00488 Patient Name SOUTNER FRANCES A Statement Date 07/18/10 Service Date(s) Type ofi Sen,~ic Account Number New Charges/Adj ,_ _ New Payments/Adj`_ Account Balance Amount Pending Insurance Amount You Owe ~.J/i L" ~`~, ~ ~ ~ ~ ~ ~ st S1:atem~r~t Pa e 1 of 2 i~ This bill represents the portion remaining after your insurance compan4~ has processed your claim. Please send your payment for the full amount clue. If you have any questions concerning how your insurance company processed your Maim. please cal! them. 03/31/10 OUTPATIENT 14287363 $ 0.00 $ 0.00 $ 50.00 $ 0.00 S 50.00 I~ ~ This new statement has been specially designed with you in mind. Let us know what other improvements we should make. Please a-mail your ideas to: Statementideas a hmc.hs_u edu or write to us at: Penn State Milton S. Hershey Medical Center Statement Ideas. PO Box 854, MC A410 Hershey, PA 17033 j DATE DESCRIPTION AMOUNT 03/31/10 LIPASE 59.0() 03/31110 CBC W/PL.T AUTO 38.0() 03/31/10 MORPHINE SULFATE 4 6.3() 03/31/10 ONDANSE:TRON 2MG/ML 2ML 3.00 03/31/10 CT HEAD 'UNENHANCED 981.00 03/31/10 CT THORAX ENHANCED 2035.00 03/31/10 CT ABDOMEN ENHANCED 1404.00 03/31/10 CT C-SPINE UNENHANCED 1088.00 Continued on next page... f=ur billin~~ t~uestios~~ yr in~t.trat~ce vhan~~;~~s: Para preguntas acerca de su factura o cambios de seguro contamos con. representantes disponibles Para asistir a la com~~nidad hiispana. Phone: (717) 531-SOE9 or (800} 254-2619 Available Hours: Monday, Tuesday & Wednesday 8:00 am to 5:30 pm. Thursday & Friday 8:00 am to 4:30 p~m Written Correspondence: Penn State Milton S. Hershey Medical (enter Patient Financial Services Department. PO Box 854. MC A410 Hershey. P,A 17033-0854 Ple~xse ,time: I'oi~r plthsicirrns wiU bill se~xtrtrtt~l-~ ~~r their ~~~~ofessrnrrcrl seri~ic~E~,-. HERSHEYST-01 ............ ........ ......................... ....................... ..... ............. ......... .. .. ...... .......................... _ PEI"~NSTATE ~ ~ ~ ~ ~ :j~ Sta~~m~>iit ___ ~ Milton S. ~iershey Pa e 1 of 2 Medical Center i i This bill re resents the ortion remair~in afl:er our ~ p g y PO Box 643291 Pittsburnh, PA'5264-3291 IrlSUranr.E com~an}> has processed y+~ur c~aim. Please send your paymen~ for the fu11 amount clue. If you have any questions concerning how your in>urance company processed you°^ claim. please call trlem. FRANCES SOUTNER ivoos2~ 86 HILLSIDE ClR CAMP HILL PA 17011-2522 I~~~III~~~lll~~~~~~ll~~~li~~l~l~l~i~~~l~l~~l~li~~i~~ll~~~i~l~l ~ ~ Patient. Name SOUTNER FRANCES A DATE DESCRII~TION AMOUNT Statement Date 07/25/10 04/16/10 BLS NON-EMERGENCY TRANSF'T 960.00 04/16/10 Service Date(s) __ 04/16/10 OXYGEN 125.0(1 Tpe of Ce,nii~.e _ OUTPATIENT 04/16/10 BLS MILEAGE, PER MILE 252.00 Account Number 14384727 04/27/10 MEDICARE ADVANTAGE ADJ -125.OCi New Charges/Adj $ 0.00 06/03/10 AETNA HEALTH PLAN ADJUSTM -919.00 New Payments/Adj $ 0.00 06/03/10 AETNA PAYMENT -193.00 Account Balance $ 100.00 TOTAL 100.00 Amount Pending Insurance $ 0.00 Amount You Owe ~ 100.00 ~/ / ~ This new statement has been specially designed .For billing qu~.stic»t~ yr insurance ~har---;Ea: with you in mind. Let us know what other Para preguntas acerca de su factura o cambios c!e seguro contamos cor+ improvements we should make. representantes disponibles para asistir a la comuni+jad hispana. Phone: (717) 531-SOEi9 or (800} 254-2619 Please a-mail your ideas to: Available Hours: Monday, Tuesday & Wednesday 8:00 am to 5:30 pm Statementideas(a~hmc.hsu,edu Thursday & Friday 8:00 am to 4:30 pm or write to us at: Written Correspondence: Penn State Milton S. Hershey Medical Center Penn State Milton S. Hershey Medical ~~,encer PO Box 854, MC A410 Statement Ideas Patient Financial Services Department , Hershey, PA 1703:3 PO Box 854, MC A410 Hershey, PA 17033-0854 P~LQSL' :~OtE': ~Otfi"~~1~'SIC1lli1S WII~ b1j~SLf7lli"lllE'j)' ft3l" f{t['tY~~J"(I~E'SSIt)f?[I~SE']"i'IC!?:S. H YST 01 ........... .... ..................... ~ HERS E_ ........... Illfdll i Illlid 111 9111 ilVli! il~ 1111111 III Illii 11;111111 Iitll Illll IIIII Illi IIII r ~ • ~ s • ~ • SOUTNE~~, f=hANCES 297189 CAMP HILL 2988 s ~ ~ ~ e w I I DR BiND~.=R, ERIC, MD ~~~ ~f/30/2010 501563 ! ~ i 'r---- ------------ --- ____- GATE ~ RX NO. DESCRIPTION ^~ NDC NO. CaUANTI?'Y 1 AIViOUNT CODE TYPE 4/25/201G~ 500844671 LEVOTHYROXINE 75 MCG TABLET 00378-'1805-10 21 EA ~ 5.39 C RX 4/25/2010 500844674 DIl_TIAZEM HCL 240 MG CAP CD 00228-2578-50 21 EA ~ 10.00 C RX 4/25/2010' 500844677. k;LOR-CON M20 TABLET" 00245-D058-01 42 EA '~ 1D. DO C RX 4/25/20101 500870308' MORPHINE SULFATE 20 MG/ML SOLN 00527-'1425-36 30 ML 10.00 I C RX ~ 4/25/20101 500870314.. LORAZEPAM 0.5 MG TABLET 00781-'1403-05 2 EA 1.25 I C RX j 4/26/2010. 500865460 METOPROLOL 25 MG TABLET" 00378-0018-05 ~ 60 EA 4.63 C RX 4j26/2010~ 5008654~50~ METOPROLOL 25 MG TABLET" OD378-0018-05 j 28 EA 0.58CR RC RX i 4/26/2010' 5008654611 CARDIZEM CD 360 MG CAPSULE 64455-0799-42 ~ 3D EA ! 36.00 ~ C RX 4/26/2010 500865462: LEVOTHYROxINE 100 MCG TABLET 00378-'f809-10 30 EA ~ 8.09 !~~ C RX 4/26/2010% 500865463'. SER.TRALINE HCL 100 MG TABLET 31722-0214-05 30 EA 16.00 C I RXI ' I i 4/26/2010; 5008654i~5' FENTANYL 100 MCG/HR PATCH 00378-9124-98 i ;.A 10.00 C i RX 4 26 2010 500865466' 41a!~FARIN SODIUM 2 MG TABLET 00555-0869-05 15 EA j 6.67 c ; Rx { / / ~ 4/26 2010; 500865475' LORAZEPAM 2 MG/ML ORAL CONCENT OD574-0163-30 ~ 30 ML ~~ 10.00 C ! RX i / i - - i ~, 4 26 2010 500865416.. ATROPINE 1~ EYE DROPS 61314-0303-01 ~ `> P1L 4.63 C i RX 4/26/2010; 50087D318 HYDROCODONE-APAP 5-500 TABLET 00406-D357-05 2 EA 0.39 ' C ~' RXI ~' ' i III ~ I ~ ~ 1 ; I! r ~~ ' ~ -I C i ~' - ---~ _--- _ I MESSAGES Finance charges are calculated @ monthly perodic rate of 1.5% (or a minimum II ~; of $1 00 per monthi fc>r a total annual rate of 18 ~o ~' I 0.00 - 0.00 i 0.58 - 0.00 ~~} 0.00 i`+ 31 - 6 0 61 - 9 0 I 91 - 1 2 0 0.00 ~ 0.00 ~ 0.00__ ALLENTOWN, PA 18106 DAYS OU + STANGIf~+a ~~, 1 30 AGEC~ 6~LAf~;~~ 0.00 ~ 7010 SNO`NDRIFT RD 1 27.05 i+ (7.00 I = ------, DUE DATE: 1 ~~ 1 + ~ -J-i AMOUNT DUi~: 0.00 _ ~~ AMOUNT ENC;LC~SE1]: 800-270-6351 EXT 605G 1 26.47 5; 301201 0 ~~, S 126.47 ', -- WEST SHORE EMS -BLS ~ ' - 205 GRANDVIEW AVE ~~ SUITE 211 ~~~~~ CAMP HILL, PA 17011 7;';'~ ~, Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 PATIENT NAME: FRANCES SOUTNER PATIENT NUMBER: 90932 'WCS CAt_L NUMBER: 202872W NONE INSURANCE: DATE OF CALL: 04/25/2010 TIME OF' CALL: 12:13 PM CALLER: HOLY SPIRIT HOSI'I1~AL 202872W FROM: HOLY SPIRIT HOS{'ITAL TC): MANORCARE HEALTH SERVICES FRANCES SOUTNER 86 HILLSIDE CIR REASON(S~ SHORTNESS OF BREATH CAMP HILL, PA 17011 FOR Tachycardia TRANSPORT ~~ Y ~~~G DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT STRETCHER One Way Transport T2005 1.0 108.75 108.75 Transport Van Mileac;f: S0209 2.0 3.74 7.48 OXYGEN ADMINSTR,4TION A0422 1.0 ~ 65.01 65.01 ~j ~~ ~~~ ' cJ ~ ' J l~C/ - Total Changes 1$1.24 DESCRIPTION DF PAYMENT RECEIPT PAYMENT DATE AMOUNT ~ f ----- ~~ ?~F,4~SE P~:~' ~"~IS ~r(t~C1~1NT -INVOICE ~3UE ~IP~I'~ ~ ECc.IF~' ~.-.- ~I^T~ >IaI~I=~ ~~F~~ ~F~ _ c'~~ fit;? -- $181.24 Nayment Amount $ i"ATEMENT ARE/DUE ON PRESENTATION. PLEASE RETURN THIS PORTION of s ~.. ~ _ __.. . Last Payment:$1`.~.00 Ori:1/26/10 PLEASE RETAIN THIS PORTION OF THE STATEMENT FOR YOUR RECORDS Date Services Description Charges Payments Adjustments Balance 1/26/2010 Office/Op Visit, Est Pt, 2 Key Components: Detailed Hx; Detailed Exam; Med C>ecis 2/4/ i 0 Patient Payment -Check-4996-Copay 3/22/10 AETNA--Deductible Applied 3/22/10 Adju~;tment 1/26/2010 Laryngoscopy, Flexible Fiberoptic; Dx 3/22/10 Insurance Payment - AETNA- 3122/10 AETNA--Patient Coinsurance 3/22/10 Adjustment 12'.4.00 15.00 18.40 381.00 120.46 256.70 Due From Patient: $ 90.60 :3.S~t 94.44 *~`IF this is a FINAL NOTICE, please pay within 10 days or account will go to COLLECTIONS** Page 1 of 1 his is ro certify that tlti~ is ~ uue cope of the record which is ot~ file i1) tl)c' I'cnns~~hania Department ,}{~ ~-I ca.th. its aca)rdance with the "~liral ~Sratistira Lam '~' 7 tr~.~, as a~nendc•d. WARNING: It is illegal to duplicate this copy by photostat or photograpf•~. ttr _ ,, p s~ . Linda ~. C.~uli~rlia 1:\`0 l2~ ~tat~' hCt„?1tiifLUb J 5~>~~158 tio. I H105-143 REV 11/2006 TYPE I PRINT IN PERMANENT BLACK INK 0 w Q Q ~G ~~ z w 0 0 LL' Z c-r ~ v• !ia ,~ * ; ~, I~`tatL COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ,n~~~~ n CERTIFICATE OF DEATHCERTIFICATE OF DEATH v`v Vf (See instructions and examples on reverse) STdTF FII F NI IA~RFR 1. Name of Decedent (First, middle, last, suffix] ,~` ~(~ (N~~ 2.5ex 3. Social 5ecudry Number 4. Date of Death ~ MonU, day, year] Frances A. Soutner ~ Female 201 -16 - 2829 4/29/2010 5. Age (Last Birthday) Uncer 1 ear Under 1 day 6. Date of Birth (Month, da , ear; 7. Bidh lace (City and stale or foreign count Ba. Place of Death (Check onl one ~ Months Days hour; Minutes Hospital: _ _ Other: ' 83 vr~. 12/28/1926 Harrisburg, PA r ^ Inpatient [! ER I Outpatient ,J DOA i ~ Nursing Home ^ Residence ,~ Other - SpecBy: 8b. County of Death Bc. City Boro, Twp of Death 8d. Fadliry Name (If not instilu8on, give street and number) 9. Was Decedent of Hispanic Origin? ~ No ^ Yee. ~ 1D. Race: American Indian, Black, Whit:, ate. ~ Cumberland Camp Hill Manor Care Nusing Home (II yes, specity Cuban, Mexican, Puerto Rican, etc.) (S ecil~ W~fite 11. Decedent's Usual Oceu ation Kind of work do ne during mast o' wodunq tile. Do not state retired 12. Was Decedent ever in the 13. Decedent's Education (Specify only highest grade com pleted) 14 Martial Status Mamed Never Married 15 Sun tyin ;i o u (If it i id Kind of Work Kind of Business; Industry U.S. Armed Forces? Elementary I Secondary (a12) College (1.4 or 5+i , , Widowed, Divorced (Specify) . g p se tr ve ma e, g en name) Purchasin Agent ;State o f P A ^ vas ~7 Ne 11 Widowed ' 16. Decedent's Mailing Address (Street, city /sown, state, np rode; 86 Hillside Circle Decedents Did Decedent Actual Residence 17a. State Pennsylvania Live in a tic Decedent Lived in East Pennsboro -f ~ Yes ' Camp Hi11, PA 17011 . , wp. Cumberland Tgwn$hip? 17h. County 17d. ^ No, Decedent Lived within - Actual Limits of ~ City/Boro 18. Father's Name (First, middle, last, suffix) 19. Mother's Name (First, middle, maiden surname) Samuel D. Rollason Winifred Dickinson 20a. Informants Name (type (PrinQ 20h. Informants Mailing Address (Street, city I town, state, zip code) thia Petrasic 86 Hillside Circle,. Camp Hill PA 17(111 _ 21a. Method of Disposition I "~ Cremation ^ Donation 21 h. Date of DisoosNon (Month, day, year) 21c. Place of Disposi8on (Name of cemetery, crematory o' other place) 21 d ~ocahon (Siry I town, state, Ldp code) Burial ^ Removal om Stale ~ Was Cremation ar Donation Authorized ^ Other-Sect: 'by Me xaminer/Coroner? ^Yes^No • 5/3/2010 Gate of Heaven _ r~eC~'1c.r11~SbL1]"_'g, F!1!'17055 - • 22a. Signature of ne ce Lice (or on i s such) 22b. License Number 22c. Name and Address of Facility Nei 11 ~.ineral Home, Inc ' ~ FD 013239 L 3401 Market St. Camp Hill, PA 17011 Complel to -c only w n cedifying 23a the hest of my Knowledge, death oceurred at the time, date ana place stated. (Signature and tine) physicia is n available at time of death to \ , n ~,, ~~ J certity tau of death 23b. License Number ; 23c. Date Signed (Month, day, year) . ~-J 1,. ~ ~ t-- ( Ile 4.26 must be completed by person i 24 Tlme o' Death 25. Date Pro ounced Dead (Month, day, year) 2fi. Was Case Referred to Medical Examiner !Corona- for a Fleason Other than Cremation or Donation? opronouncesdeath. i '~ ~ '1~ n,~ M L ~~ ~ p~~ X~7Ya5 ^No coroner n t fi d 08/05/2010 d o =_ e jp C AUSE OF DEATH (See instructions and examples) I Approximate interval: Item 27. Part I: Enter the chain of events -diseases, Injuries, o' complications - that directty caused the death. DO NOT enter terminal events such as cardiac anest, i Onset to Death Fart C: Enter other significant conditions contributlng to death 28 Did tobacco UsF; Contribute to Death? hat not resulting in the underlying cause given in Part I, ~`] '(es ^ Probabl respiratory arrest, or venlncular fibrillation witno!>t showing the tiology. List only one cause on each line. i y ~~ No ~ nown I IMMEDIATE CAUSE (Final disease or condifion resulting m death) _~ ~ ~ ~ ~ a -- ~ 29 ylf.F I Due to (or a a consequent off -, I S ti ll li t i di ~ ' ~l Not pregnant whhin past year _ i P equen a s con y t ons, if any, o i leading to the cause listed on line a. D t regnant at time of death ~ ~ Clot pre nant but re nant vnthln 42 d ue c ( , a onsequence of): i Enter the UNDERLYING CAUSE (disease or injury that initiated the i g ~ ~ , p g ays i of dealt events resulting in death) LAST. ~ Due to for a:~ a consequ ce og: i • I -- ~_~ Mot oregnant, but pregnant 43 days to 1 year tl i • ^i before dealt I Li Lmknown i1 oregnant within the past year 30a. Was an Autopsy Pedormed? 30h. Were Autopsy Findings ' 3 Manner of Deaft~ 32a Gate of Injury (Month, day, year) 32b. Describe How Injury Occurred 32c. Placr. of Injury: Home, Farm, Street, Factory, Available Prior to Completion - ~ Ho micide of Cause o DeaUi? ~ _~ tvatural ~ OYic~ Building, etc. (Specilyi ^ Yes No rr lI ,~ Accident tJ Pending Investigatlon Yes "I Nc 32d, Time o1 Injury 32e. Injury a( Work? 32L II Transportation Injury (Speci(yj 32g. Location of injury (Scree: cm !town, state] J Smcide ^ Could Not be Determined ^ Ves ^ No ^ DriverlG erator P ^ Passenger I`~ Pedestrian - M ^ Other - Specil}r 33a. Certifier (chect; only one] 33b. Signature and Title of Cediher • Certltying physician (Physician certrfymg cause o) aeair when another pnysician has pronounced death and completed Item 23) To the best of my knowledge, death attuned due td the cause(s) and manner as stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Ji 9 h' 9 P Y g ty • MedhcaExamaner CoiW ne9e death occurred at the fimendate, and placenand dueng to cause of death) to the cause(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. License Nu ~ ~ 33d, at 1_ _ Slgnsd ~, year) ~ On the basis of examination and i or nvestigation it my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner as stated_ ul -- d Address of Fersor Who Co plated Caus I Dean (Item 1 Typ e ! rirr 35. ~e Signature n~' D' tm~~~/ `~'~L ~ ~ ~ ~ ~ ~ I l ~ rL I 36 Date File M t, day, Year) l n ~ ~ ~ /~ ~ d'~A Disposikon Perm. No, b ~ ~ ~ xG yG ~ O