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Home My WebLink About03-01-11 1505610148 REV-1500 EX (01-10) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po Box 28oso1 INHERITANCE TAX RETURN ~ ~ , ~ (~ ~ ~~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 205-09-4804 08112009 07281917 Decedent's Last Name Suffix Decedent's First Name M I DURBOROW JAMES A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M I Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE - - REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW ® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-82) ^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) ^ ^ ^ 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number CRAIG A • HATCH, ESQ • - - _ ~=a First line of address 10],3 MUMMA ROAD Second line of address SUITE 7,00 City or Post Office State ZIP Code LEMOYNE PA 17043 Correspondent'se-mall address: C • HATCHb1GATESLAWFIRM • COM n ._. REGISTER S USE ON1~Y - ~E .r, . r ~ ::t:t - - r_~ ~ ~~~ I`r`I 1 L J :. ~:..{ .. _:, _ _ '.. "~ DATE FILED ;-.-~, ':°-~ f"" ':.:. - -._~ :..f ~'.~~ t'~`- a Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNA RE OF PERSON ESPONS LE FOR FILING RETURN DATE ~. a I' ~ ADDR SS 170 BOBBY JONES DRIVE ETTERS, PA 17319-9510 SIGNA OF P ~, ER THAN REPRESENTATIVE DATE ADDRES 101 MUMMA ROAD, SUITE 100 LEMOYNE, PA 17043 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610148 1505610148 9M4647 4.000 /"~ji~j ~/' .i J 1505610248 REV-1500 EX Decedent's Social Security Number 205-09-4804 Decedent's Name: D U R B O R O W JAM ES A RECAPITULATION 1. Real Estate (Schedule A) 1 0 • 0 0 2. Stocks and Bonds (Schedule B) . 2. 0 • 0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) , 3. 0 • 0 0 4. Mortgages and Notes Receivable (Schedule D) 4 0 • 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5. 10 9 • 0 0 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested g. 3 , 0 4 9.0 0 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. 0 . 0 0 8. Total Gross Assets (total Lines 1 through 7) 8 3 ,15 8.0 0 9. Funeral Expenses and Administrative Costs (Schedule H) , .9 6 6 8.0 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) . 10. 2 , 2 2 6.0 0 11. Total Deductions (total Lines 9 and 10) , 11 2 , 8 9 4 •0 0 12. Net Value of Estalbe (Line 8 minus Line 11) 12, 2 6 4 •0 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) , , 13. 0 • 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) , 14. 2 6 4.0 0 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers un~er Sec. 9116 (a)(1.2) x .o _ 0.0 0 15. 0.0 0 16. Amount of Line 14 t xable 0 4~ at lineal rate x . 2 6 4. 0 0 16. 12.0 0 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0. 0 0 18. 0. 0 0 19. TAX DUE 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505610248 12.00 Side 2 9M4648 4.000 1505610248 J REV-1500 EX Page 3 Decedent's Cemnlpte d-rlrirRCC• File Number DECEDENTS NAME DURBOROW JAMES A STREET ADDRESS M R A CITY CARL S E STATE pA ZIP _ Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments Q . Q Q B. Discount Q . Q Q 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) (1) 12•QQ Q•QQ (3) 8.OQ Q•QQ 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2 Q . Q Q 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 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)J. 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)J. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Total Credits (A + B) (2) 9M4671 2.000 REV-1502 EX + (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF: FILE NUMBER: James A. Durborow All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is Jointly-owned with right of survivorship must be disclosed on Schedule F. swass5 2.00o If more space is needed, use additional sheets of paper of the same size. REV-1503 EX+ (Cr98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS 'ATE OF FILE NUMBER James A. Durborow All property jointly-owned with right of survivorship must be disclosed on Schedule F. 3wasss ~.ooo (If more space is needed, insert additional sheets of the same size) REV-1507 EX + (6-98) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHI~SIDENT DECEDENTRN RECENABLE ESTATE OF FILE NUMBER James A. Durborow Ali property jointly-owned with right of survivorship must be disclosed on Schedule F. 3wa6AC ~.ooo (If more space is needed, insert additional sheets of same size) REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER James A. Durborow Include the proceeds of litigation and the date the proceeds were received by the estate. 3wa6AD 1.000 (If more space is needed, insert additional sheets of the same size) REV-1509 EX+(01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: James A. Durborow ff an asset became jointy owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVNINGJOINTTENANT(S) NAME(S) RELATIONSHIP TO DECEDENT A Krone, Victoria A 170 Bobby Jones Drive, Etters, PA 17319-9510 Daughter JOINTLY OWNED PROPERTY: ADDRESS rt,~ NUMBET~ LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME aF FINANCIAL INSTITUTION AND BANK ACCOUNT NLNYBER OR SIMLAR IDENTIFYING NUM9ER. ATTACH DEED FOR JgNTLY HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDEIYI'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1 A 3/23/2004 MST Bank Checking Account #9836644535 6,098 50.0000 3,049 TOTAL (Also enter on Line 6, Recapitulation) S 3,049 swasAE 2.00o If more space is needed, use additional sheets of paper of the same size. REV-1510 EX + (08-09) SCHEDULE G pennsylvania DEPARTMENT OF REVENUE INTER VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER James A. Durborow This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBS DESCRIPTION OF PROPERTY INCU.DETI-EW+MEOFTFETRANSFEREE,TI-EIRREIATIONSHIP TO DECEDENT AND T1-EDATEOFTRfNSFER.ATfACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD~S INTEREST EXCLUSION IFAPPIJCABLE TAXABLE VALUE ~ • None TOTAL (Also enter on line 7, Recapitulation) $ 9W46AF 2.000 If more space is needed, use additional sheets of paper of the same size. Rf=V-1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE ~.~~ ~~n~Tw.~nc Twv ocri loot SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF Jam s A. Durborow Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: ~ None B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address Citv State ZIP Year(s) Commission Paid: 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer Fees: 168 7. 1 Gates, Halbruner, Hatch & Guise, P.C. 500 AMOUNT TOTAL (Also enter on Line 9, Recapitulation) ~$ 668 swascc 2.00o If more space is needed, use additional sheets of paper of the same size. REV-1512 EX + (12-08) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF James A. Durborow SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. awasAH 2.00o If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FILE NUMBER: James A_ Durborow RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [InGude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Thomas E. Durborow 113 E. Areba Avenue Hershey, PA 17033-1404 16.6666: 44 Son 44 2 Patricia L. Christensen 1050 E. 7625 S Midvale, UT 84047-2957 16.6666: 44 Daughter 44 3 Stephen B. Durborow 603 Rose Petal Lane Mt. Joy, PA 17552-1404 16.6666: 44 Son 44 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 1 8 OF REV-1500 COVER SHEET, AS APP ROPRIATE. [I NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0 It more space is needed, use additional sheets of paper of the same size. 9W46AI 2.000 Estate of: James A. Durborow Schedule J Part 1 (Page 2) Item No. Description Relation Amount 4 Cynthia E. Durborow 513 Bridge Street, Apt. 2 New Cumberland, PA 17070-1955 16.6666: 44 Daughter 44 5 Victoria A. Krone 170 Bobby Jones Drive Etters, PA 17319-9510 33.3333: 88 Daughter 88 LAST WILL AND TESTAMENT OF JAMES A. DURBOROW I, JAMES A. DURBOROW, of Dauphin County, Pennsylvania, declare this to be my Last Will and Testament. I revoke all other Wills and Codicils that I may have previously made. Article I My just debts and expenses of my last illness, funeral, and administration of my estate shall be paid by my Executor from the principal of my residuary estate as soon as practicable after my death. Article II All inheritance, estate, and succession taxes (including interest and penalties thereon, but not including any generation skipping tax) payable by reason of my death shall be paid out of and be charged generally against the principal of my residuary estate without reimbursement from any person. This provision is not a waiver of any right which my Executor has to claim reimbursement for any such taxes which become payable as the result of any property over which I have the power of appointment. Article III I give, devise and bequeath in accordance with any memorandum which I have either handwritten or signed, located with my Will or with my valuable papers and found within 30 days of the probate of my Will. Gifts may only be to persons who survive me or to organizations which exist at my death, and if there is a conflict, the memorandum having the latest date shall govern. e,~;~~P rv All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, I give, devise and bequeath according to the following schedule: A. ONE-SIXTH (1/~ to PATRICIA L. CHRISTENSEN, of Midvale, Utah; B. -ONE-THIRD (1/3) to VICTORIA A. KRONE, of York County, Pennsylvania; C. ONE-SIXTH {1/~ to STEPHEN B. DURBOROW, of Mount Joy, Pennsylvania; D. ONE-SIXTH (1/6) to THOMAS E. DURBOROW, of Baltimore, Maryland; E. ONE-SIXTH (1/~ to CYNTHIA E. DURBOROW, of Dauphin County, Pennsylvania. If any of my beneficiaries predecease me or fail to survive me by thirty (30) days, I give, devise and bequeath his or her share to his or her issue who survive me, per stirpes, or if he or she has no issue, the share(s) are to be added equally to the other shares. If a beneficiary under this Will has not attained the age oftwenty-eight (28) years, the„share. __ of the beneficiary shall be placed in a separate trust, for the benefit of that beneficiary according to the terms in Article VI. -2- Article VT In the event that a Trust is created by or as a result of any part of this Will, the terms and conditions of the Trust shall be as follows: A. To expend and apply so much of the net income and so much of the principal of the Trust as the Trustee shall consider advisable for the support, health, care and education (including college, trade school, or other similar training or education) of the child until the child attains the age of twenty-eight (28) years. B. Upon attaining the age of twenty-two (22), one-third (1/3) of the principal and accumulated income, of the child's share shall be distributed outright to the child. C. Upon attaining the age of twenty-five (25), one-half (1/2) of the principal and accumulated income, of the child's remaining share shall be distributed outright to the child. D. Upon attaining the age oftwenty-eight (28), the remaining principal and accumulated income of the child's share shall be distributed outright to the child. E. No beneficiary or remainderman of this Trust shall have any right to alienate, encumber, or hypothecate his or her interest in the principal or income of the Trust in any manner, nor shall any interest be subj ect to claims of his or her creditors or liable to attachment, execution, or other processes of law. Article VTT I hereby appoint VICTORIA A. KRONE, as Trustee of any Trust(s) created in this Will. In the event of the renunciation, death, resignation, or inability to act, for any reason whatsoever of __ _ - - __ ___ VICTORIA A. KRONE, I nominate and appoint PATRICIA L. CHRISTENSEN, as Successor Trustee of any Trust(s) created in this Will. -3- Article VIII In order to carry out the purposes of the Trust established by this Will, the Trustee, in addition to all other powers granted by this Will or by law, shall have the following powers over the Trust estate, subject to any limitations specified elsewhere in this Will: (a) to retain in the form received and/or to sell either at public or private sale, any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, (c) to invest and reinvest in all forms of property without being confined to legal investments, and without regard to the principal of diversification, (d) to exercise any option or right arising from the ownership of investments, (e) to compromise claims without court approval and without consent of any beneficiary, (f) to file fiduciary/income tax returns and pay the tax due for any year for which such a return is required, {g) to make distributions in cash or in kind, or in both, and to determine the value of any such property, (h) to employ any attorney, investment advisor, or other agent deemed necessary by my Executor; and to pay from my estate reasonable compensation for all their services, (i) to conduct along with or with others, any business in which I am engaged in or have an interest in at the time of my death, and (j) to receive reasonable compensation in accordance with heir standard schedule of fees in effect while their services are performed. -4- (i) to conduct along with or with others, any business in which I am engaged in or have an interest in at the time of my death, and (j) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed. Arti~1P TX I nominate, constitute, and appoint VICTORIA A. KRONE Executrix of my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any reason whatsoever of my Executrix, I nominate, constitute and appoint PATRICIA L. CHRISTENSEN successor Executrix of my Last Will and Testament. I direct that my Executrix or successor Executrix be permitted to serve without bond and in addition to those powers granted by law, I grant them power to distribute in cash or in kind in like or in unlike shares and to file any qualified disclaimer I could have filed if living. My Executrix and successor Executrix shall receive reasonable compensation for services rendered to my estate. Article X In addition to the powers conferred by law, I authorize my Executrix and successor Executrix, in her absolute discretion: (a} to retain in the form received and to sell either at public or private sale, any real estate or personal property except that which I specifically bequeath herein, __ (b) to manage real estate, -5- (g) to make distributions in cash or in kind, or in both, and to determine the value of any such property, (h) to employ any attorney, investment advisor, or other agent deemed necessary by my Executor; and to pay from my estate reasonable compensation for all their services, (i) to conduct alone or with others, any business in which I am engaged in, or have an interest in at time of my death, and (j) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed. IN WITNESS WHEREOF, I, JAMES A. DURBOROW, hereby set my hand to this my Last Will and Testament, on 1~_ ~ ~ , 2003, at Harrisburg, Pennsylvania. AMES A. DURBOROW In our presence, the above-named JAMES A. DURBOROW signed this and declared this to be his Last Will and Testament, and now at his request, in his presence, and in the presence of each other, we sign as witnesses. Name C~.t Address ~~ S~r7~anas ~f . l~~ I71~~ ~~5Sr171a~s f~., ~~ p~ i71U9 -6- I, JAMES A. DUR.BOROW, Testator, who signed the foregoing instrument, having been duly qualified according to law, acknowledge that I signed and executed this instrument as my Will, and that I signed it willingly as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by JAMES A. DURBORO~V, the Testator, on ~15 ,2003. No ~ blic AMES A. DURBOROW ~r~i~ au~ cw~nr ~ ~~ We, the undersigned witnesses who signed the foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the Testator sign and execute this instrument as-his Will; that he signed and executed it willingly as his free and voluntary act for the purposes therein expressed; that each of us in his sight and hearing signed the Will as witnesses, and that to the best of our knowledge,.that he was at that time eighteen (18} years or more of age, of sound mind, and under no constraint or undue influence. Sworn to or affirmed and subscribed to before me by and tnes with es, on ~ ~ - j , 2003. ~. -~ ~ tness ~_ Notary P>~ ' c lAN L BROWa NOtA~ PusuC - ~ M f tU'OMMiSS~ION D~~f3 MA~RCHG209U 2 04 5.805 REV (01/07) LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. , ~e for this certificate, $6.00 P 15728384 Certification Number This is to certify that: the information here given i~ correctly copied frorn an original Certificate of Deatr duly filed with me as Local Registrar. The origina: certificate will be forwarded to the State Vita: Records Office for permanent filing. ~ )Z ~ Local Registrar ate Issued ++,o,.u3 REV it120o6 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS TYPE ~ PRINT na PERMAHENT CERTIFICATE OF DEATH ~~ lNK See instructions and exam tee on reverse p ~ STATE FILE NUMBER i. Name d Oeoederd (Fist, niddk. last sdfix) 2. Sex 3 Saaad Seariry Numher 4. Dale of Death (A4oruh, day, year) James A. Durborow male 205 - 09 - 4804 August 11, 2009 S. Age (Last eitl+day) lkWer 1 under 1 day 6. Data d sift (Mash. ) 7. Bifrplece ( and ssh a 1 ea. Place d oeaut (Ctvactc Dory one) 92 rrs. rears taxyx Fu,x: ranges July 28, 1917 Camp Hill , PA Hospisl: ~,~,,, ~ ER / Outpatient ^ DOA rnner: ~ Nursing Home ^ R.sioente ^Other - Spedty: 8b. Counry of Death 8c. City. 8oro. Twp. d Death 8d Facily Herne (N not irWitu9on, give street and mxnberl 9. Was Decedent of Hispanic Origin? ~ No ^ Yes f 0. Race: American Indian. Buck. While. etc Cumberland Carlisle Forest Park Health Center or yes.specirycuban. Mexican. Puerto Rican, etc.i (Specir» white it. Detedem's Usual d wak d one moA d fk. Do net stab Mi 12 Was Oaceders ever in fte 13. DeaderN's Education (Speay ~y Mghest Drade cortrp hted) 14. Marital Status: Married, Never Married, 15. Surviving Spo use (fl wile. give maiden name) lGrd d Wak cad d easiness ~ tnducsy US. Anted Foroea? Eintaniry / SxaWuy (0.12) Cdlega (/-a « 5+) Widowed. Divorced (Specify) plate rtaker Printi Co. ~Jrea ~-~ t6. DeadanTS Maritg Addrar (SAaat WY l bwn, alias, iV cads) '170 Bobby Jones Drive DeaderMY ' l e in aid t 7c. Acid Fbeiderta 17a Sfae Aa ^ Yes, Decedere Lived'n Twp. ~ ~ dived ~~^ Etters ,~. ca.rr York , 7d. ® / Rao a 1f. Fadw's Natr (Fist, rttldAe, lest sriq 19. Nlafler's NYr (First, nidda. meidert strrtrne) William J. Durborow w n 20a. AdanrnCs Name (Type / Prbt) 20b. Hatnertra Wip Addtws (9rsM, dry ! lowrt star, ziP ~) Victoria ~~. A. Krone 170 Jones Drive Etters, PA 17319 21a Msftod d OYpoefWn ^crmtefart ^ Daleforl 210. OYe d DMpoefbn (MonMt dry, year) Ztk Pleas d DtspoMfat pima d arnewy, aenWoty «otlter plea) 21d toatlon (Qy / bwrt stile, bP Dods) [g BurW ^ Ranrowl ikon Stale • p P]IINr- saerr. IMsa rlaraatlsrl w Donetloa Aulhorlyd a rdedler EtnatileNCerors.t ^ Tr ^-~ August. 17 ~ 2009 Indiantown Gap National Cemetery Annville ~ PA 17003 • 22a - dPustal twig sudd 22A.UarwNlesibw 22e,NttaseMAddnlydFat~ly - - ; FD 014850 L Bach F.H. 21 Market Square Manhem~ PA 17545 Meer 23ae alter N1N1 23L lb fi baM d my hgwhdpe, daft fle 1ms, deb ittd pion lahled end tlia) 23A. ticerss Number 23a Dab 5gned ,day, year). physkin Y t161 avallbi et li+ts d dertfl b ~ !/a a~ ~ 36 L ~' / pAfy aw. d ewt- ,, - ~ Ilene 21,28 rlwq w aonphid M Perm _ ~. d 25.Ow der y+1 26. Wad Raterrsd b Me6cd Exan:rter /coroner fora fmrt Gsmation «Donarion? aAa proiiduww dpfl. • //, 3U >A M• /l - o~DOl Yes ^ NO CAUSE OF pEATH (s..InsAvetlom Held ) , ApproehsN idenal: Pan f: Erda omer ~ 28.Oid Tdtsoce use Caran~tta to Dean? Mm 27. Pan F. Enter fs ~.lyflli:-desree; frytahR a mttpkafps-fsl dtraly reread fN drR DO NOT irlr bmiW evani sltdt r aNae arter0. t Orret b Oaeft brd nil resuhirg in fs undenyirtg ease given n Pad L [] Yes ^ Pmbshly rll mfpiabry arpl, a vadnn/r fbr6lo n s h otA owi g fn Mobyy LM aiy one arse e lr h wilt Ins. _ ~ ^ ~ ~~ / ~ ~ U~E (Rrs(dkease « / J ~ ~ j , ~ / ~ ~J ~ ~ ~ ~ ~ ~~ 28. N Femab: g ) t / _ Lt/~ ~ /L ~ ` Yl/t/~ r ~~ a ^ Due b (a as a oatapsta dr i Not pregnard vAfta Past year ^ Pm wd at t d th b. _ ~ e i e ~ e g ans of ea s i ats a Entx UNDERLYf1ti CAl1SE Des b (« a a oaMgtreroe dry: ~ ^ Not Ore9r~t brA pregnant within 42 days res~n~'~n~"aanliu Te' _ r a ~+ Due b (« r a oasequerwe d): ~ ^ Nil prsgnare, biA pregnant a3 days b 1 year • d' ~ ^ f prepmnt wfhin Cre past year 30a Was an Aubpsy 30b. Wen Aueopy Fitdrgs 31 fDeeth 3Z. DMe d ~ (Monl14 dl}: year) 32A Destrha How itjtry Otxunsd 32c. Phca d Mjtry: Home. Ferro, Seep. Feeley. Perbmted? Aniabh Prior b campMlbn C~~ ^ Hnnecide Ollke Buidng, att. (SPetAy) d Chun d Dedh4 ^ Ya ~lo ^ Yr ~ ^ Atthed ^ Patt6tq 32d. T(dr d MwY 32e, bjuty at Wak? 321. M Trespatstlon MaT (Spectlyl 32g. laca6an d InNY (Street dY I town, state) (] Suidde ^ Cor1d Not be Debrrrtisd ^ Yr ^ No ^ Dover / DDMabr ^ Passenger QPedmMan ~ Otter-S~ 33a Cerd4er (dteck mly as) 33b. Ttfe d Cerliier ,. CMMying pAyskin (Atysiain g sates of deeM ~ artofsr physkJet hasprarrourreq dWt and oarpMted fen 23) _~ ~ TopsbatdatybarsNdge.deAhxeunddueblM~s)tfedarrrsreaslsle~___.,__________ '~~~~~_-____.____ • ~~~DPbY*~I~pgdeelrndar9yhpbeaideddeMh) Ta Ys Asst al wry ImoeAedga, deatlt Doornail as fre cline, d+e, and pMa, and dw b the car(s) and nrrasr r ateid_ . _ _ _ .. _. _ _ . ^ _ _ _ _ - Yrr) 33c. i ~ ) ` / 93d.0eJeJ~g('sd ~~ ~ ~ ~ 1 • eeedleel Esamirr/ Corersr l V rJ U ~ (, On iMb~h of mrrrlrraLon and 1 or Yrveaflpation, b my opinion, drlh ooarnd d the drse, dale, and plea, tqd dud b the eeuse(a) and nrerwer r aiMd. ^ ~. Name and Address d Person yVla Cause d Oeas+ (hem 271 Type I Print ' 35 , ~ ~ ~~ J, G1 6'r - ~ ~, ~ Ic~ I~ I~ I ~ f ~ ~ ~ ~ o - - oisposhiort Permit No. 0378952 __ _ _ JAMES A DURBOROW VICTORIA A KRONE 170 BOBBY JONES DR ETTERS PA 17319 16623 ACCOl1NT SUMMARY ~~.,. U~', . (~ UNIGN DEPOSIT BEGINNING ;BALANCE .:::DEPOSITS $: :.. `::;f1THER:ADDITrONS CHECKS PAID OTHER. SUBTRACTIONS CURRENT INTEREST: P~ ENDING . BALANCE: N0. AMOUNT N0. AMOUNT N0. AMOUNT 5,919.12 5 3,776.06 5 3,597.56 0 0.00 0.00 6,097.62 ~CC'C1l1NT AC'T T V T TY ;PQSTxNG ;DATE> <:< <:: <' ;; ;TRANSACTION'DESCRZPTION'> DEPOSITS;INTER.EST &>OTHER ADDITIONS CHECKS >$. O'FHEt~ : SUBTRACTIONS::<: <DAILY: . BALANCE< 07-24-09 BEGINNING BALANCE 85,919.12 07-27-09 CHECK LIMBER 0477 ~ 15.70 5,903.42 07-30-09 CHECK NUMBER 0055 500.00 5,403.42 07-31-09 US TREASURY 220 VA BENEFIT 1,949.00 ~'`~~ 07-31-09 GCIU SUPP RET&DI PENSION-CK 129.65 07-31-09 ILPF - GCIU PENSION 67.04 07-31-09 NATIONWIDE LIFE NWL-EFT 47.37 7,596.48 OS-03-09 US TREASURY 303 SOC SEC 1,583,00 9,179.48 08-04-09 CHECK NUMBER 0478 25.00 9,154.48 OS-05-09 CHECK NUMBER 0480 500.00 ~~`` ~~~ i~tca~ 8,654.48 OS-06-09 CHECK NUMBER 0479 2,556.86 6,097.62 ENDING BALANCE 86,097.62 CHE£1C5.>PI4ID S~N1lIARX .. 55 07-30-09 500.00 477* 07-27-09 15.70 478 08-04-09 25.00 479 08-06-09 2,556.86 480 08-05-09 500.00 IMPRESSED BY THE SERVICE YOU RECEIVED AT M8T BANK? THEN PLEASE VISIT WM-b1.MTB.COM\EXCELLENCE AND COMPLETE OUR BE THE BEST NOMINATION FORM TO RECOGNIZE AN M&T BANK EMPLOYEE FOR PROVIDING YOU WITH AN EXCEPTIONAL CUSTOMER EXPERIENCE! WE APPRECIATE YOUR FEEDBACK! MEMBER FDIC ~r x ~ ~ MAD /R/n71 '.. ~h ~~t,.-.. _ A ...~.~ ccHn~w~Km Date: 08/18/2009 This Month Gross payment amount 108.63 Net payment amount 108.63 9274924 n'0 2 7 4 9 2 4~~' ~;0 3 60 7 6 L 50~; 6 20 5 ~. 5 2 58 Li~• 00004283 Forest Park Health Center 700 Walnut Bottom-.Road Carlisle,PA 17013 Questions Concerning This Invoice? Biller Name Dianna @ Ext. 833 Phone 1-888-880-7090 Fax 1-814-265-1377 Email dchittester@guardianeldercare.net Victoria Krone 170 Bobby Jones Drive ETTERS PA 17319 PAGE 1 Resident# 22506 Resident DCJRBOROW JAMES A Discharge Date 0811112009 Statement Date 09/30/2009 Payments Posted Through 09/30/2009 CALL 1-888-880-7090 IDIANNA EXT 833 IUSE MASTERCARD/VISA/DISCOVER PAYMENT ENCLOSED ~ , 'lease Detach and Return with your payment DATE DESCRIPTION UNITS REFERENCE AMOUNT BALANCE 09/11/2009 PREVIOUS BALANCE PRIVATE PAYMENT CHECK #481 2,225.75 -2,225.75 2,225.75 .00 F.NDtNG BALANCE ~ I I .OO YOUR PAYMENT OF 00 IS DUE UPON RECEIPT Forest Park Health Cent 1-888-880-7090 DURBOROW JAMES A 22506