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Home My WebLink About04-0696 Keglster ot WillS ot County, I-'ennsylvanla CUHBERLAND PETITION FOR GRANT OF LETTERS Estate of Doris K. Owens No. :t, I - 0 4 -OLeCt Lc also known as , Deceased Social Security No. 174-20-5190 Petitioner(s) who is/are 18 years of aCe or older, apply(ies) for: (COMPLETE "A" OR "B" BEL W) El A Probate and Grant of Letters Testamentary and aver that Petltloner~) 's~the execute~named in the last VVil! of the decedent, dated F~bT']1r~r 15, 7007 and codicil(s) dated Husband, Joseph Mark Owens, was named Executor in said Will, however, he predeceased Doris K. Owens whereby the alternate executor, Richard C. Martin, shall serve 25 E2'ecntor. (State relevant circumstances, e_g_ renunciation, death of executor, etc.) Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: 0 B. Grant of Letters of Administration (d.b.r1.c.ta.: pendente lite; durante absentia; durante mmorilate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: I Name Relationship Residence I "<t ': u ':-' , ~ --.,- , N .... :=:> . . -, (COMPLE.:FE,IN ALL G&SES:) ~ach additional sheets if necessary ;1''':;: 0 ,........ Decede~was domi~iled at ~~ in Mechanicsburg, Cumberland County, Pennsylvania, withX1is/her last family or principal residence at 222 Messiah Circle, Mechanicsburg, PA 17055 (list street, number, and municipality) Decedent, then 80 years of age, died July 15, ,20~,at Hessiah Village (Location) Decedent at death owned property with estimated values as follows: (If domiciled in PAl All personal property $ 200,000.00 (If not domiciled in PAl Personal property in Pennsylvania $ (If not domiciled in PAl Personal property in County $ Value of Real Estate in Pennsylvania $ situated as follows: Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of letters in the appropriate form to the undersigned: /1. Signature Typed or printed name and residence ".<' ::<',/c,/:'" ,/ G:~- " -e' artin ./ , < " ~ - ,. :.'; , , -, /' )/ 1510 Breezeview Drive ~ York, FA 17404 snaceJWillsPetGrantl t/200 1 Oath of Personal Representative Commonwealth of Pennsylvania County of' CUMBERLAND The Petltloner~ above-named swear(x) or affirmL"lil that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief or,PetitionerIDl and that, as personal representativeNil of the Decedent, Petition(~) will well and truly administer th~ estate according to law ,/ . Sworn to or affirmed and subscribed ____----c'/ /,-- - - ~/;- ~': --( U//' . '. ,'--C Zu; RicharA C _ Martin day of /",,{ m ~ , - I (" 20 /. C , )lJU.t . 1..1' '>L, Ul__ - _ v,-. ~ i r'~ &1), i (l]i) )LU(JcP.~ er . ~lt,'l '\ _ - ....._'::;1' l)---- " . . , ~ v Zi-D1-uJllt No. Estate of Doris K. Owens Deceased Social Security No.: 174 - 2G - 5190 Date of Death: July 15, 2004 AND NOW, ,20 . in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters 121 Testamentary 0 Of Administration Richard C. Martin d.b.n.c.ta.; pendente lite; durante absentia; durante minoritale are hereby granted to in the above estate and that the instrument(s) dated February 15, 2002 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES /, -~ Vu 1 L Letters. . . . . . . . _ . . . $ 135 DC ,~LUH d[rtzL\.JlfL;: lLUJ.cU/.+j' KlLL Short Certificate(s) . . .$ 15 DC / I i / Register of Wills V rh;. " ' ( , " CA).1I../U Renunciation....... $ Att D",bthy r.~ '! 1\ .~ =~ c~ Affidavits ( )....... $ 1.0. No: 26204 ' ": I Id-OC J Extra Pages ( ).....$ Address: 32 South Beaver Street York, PA 17401 Codicil. . . . . . . . . . . . $ JCP Fee. . . . .$ IO.C C Telephone: (717) 846-4818 Inventory _ $ Automation Fee. . . . . $ Other. .. . .$ TOTAL. . ... $ al :ACe snaceflNill sP etGran tL 11200 1 II 4].- ~Cj lo (/-.. -l.-,-" ~1-" f'- . '.... ~-~ I':: ,~,~ ,.., .1 0U,- ;C. cUU~ -~,. QC: d JJ A CD n '- c:: , N G'I ".L8? COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH a co" ~ -- ---------- - - - - ----------- srAlf O-'lE "_"'"!lEA (: 'lAME OfDECED{~'ITil ' . u_.._u.________ ____ _.__~_ SEX---------r::AL;iCL;fi;ry. NU;;1&iil~ ---- -----,----~_. -~.----:--- -- -.---- I M..l<l'e. ,~"') [1AfEUtLJE),~G"~lDa,.'ea'l Doris K. Owens ,female ,174 - 20 - 15,200L_J AGEiLJS'B-nna.yl UNDEFltYE,o.A ""0'"' '" '[""0"'""'-1--"'''''''''''' "',;,,, PlACE 01' O~ATH ,(, ec. MI, ,",~ ..... or-,' ,.(;1",," "" ,-"~'" ""~I --I Mc~-;;;--:D-"-;S- H--r-~'~ ' '_',,'.'1\ d...,. '@d'l . J..,";",."r~"J",<(~..r,a".1 l-msprlAl - - -.---. ---- -- - ".- . -- -- OUi', .,,,,... Oth.' 80 ,,, ; e July 24, 2 ~_!.!~n:isburg Pa Inpah"n,[_; U-\iOLIlpaW>n' L_-" [}()An ,Spoc,tyIU , ~. COUNTY OF DEJJH CI rY. BORO, TWP OF OEATH F"CllITl NAME ;" "C" "..".~.""., "'~ "'''''' d"~ ",-"~t.,,, RACE - Am"oo&n Ir'l<\I~n, 81ac~. Wh~, siC ~~~~~~EDUCATION IS""",r-y1 .. Cumberland ...Upper Allen Twp ". Whi te DECEDENT"S USUAL OCCUPAJIO'" KIND OF BUSINESSIINOUSTRV WASDlCEDENTE'IERIN MARITAlsrATUS_Ma",..d SURYIVINQ SPOUSE IG'v..',!>'lol..or,,,,,,,,,du'"''-I'''''''' US.ARMEDFORCES'> ._.___~'t.2!C't,~.:X,~"'Jf.'Jec"""I"..r"~'1 N,ve<M.,,_.WOlo..'d ;11 ...~.., 'J<""ma'()"'~""'~1 ol""''''ngl,I.. 00 nOluse'eh'~'<l1 v61[1 ~DC EI6me~I.f)'IS""ond.ry Col,....e i)",o<<ad'Spec,ov) Secretary 121G'21 1,4",5'1 Widowed " " ... ... 222 Messiah Circle 17, State----.E?_____~___ Dod 17c.e;lv...,d4Ic_nlllvedin Upper Allen .." --. Mechanicsburg,Pa 17055 '".,na 17b. Co"my Cumber land___ '''''''n.~,p? 17dO:;,':":.oI'iwn"'::Ol " --~ C'lyll>o<t> FATHER'SNAME IF".t. M,~,jJ" L~"I MOTHER'S NAME ,F"so "',d~",. M.,<J,.,.,S",".,-"el " Frank Kerlin " Anna Hanmelbau h INFORMANT'S NAME 11 dP'''") INFORMANT'S MAiliNG AOORESSIStre<>!. C,tyfTO-wn. Sldl.. lip CWtI) 20.. Richar E. martin ,.. 1510 Greezeview Drive York Pa 17404 "flHOO OF DISPOSITI~ PLACE OF DISPOSITION - Name ot Cemels'Y. Clomatory lOCATION ,C'ovfT<>wn,SlaI6. l'JlICodo. Sonal Cram.allOOO RamO'o'all'omSlalaO Of OIl>8rPI.ca i:lo<la"onO OU""ISpecrtl' [J Rolling Green cemetery Camp Hi 11 , Pa 21a. 21e. '" , ,." , flPEASON "CTlNG "S SuCH LICENSE NUMBER N"ME AND ADDRESS OF FACILITY root '" 011654-L ne.M ers Harner Funeral Home Hill Fa 17011 To 1M olmy knowlodge, deal!l occufled ~IIMe',m.. aal.anoplaCeSO~\ed liCENSE NUMBER IS'\Ir\<1Me.ondT,tiei '" 'k Ileml24-2timUSlt>ecomple'adby OATE PRONOUNCED DEAO iM(",,~, D.~, Ye~') WAS CASE REFERRED ro MEDICAL EXAMINEflJCORONEA? ~I'i p&<son..llop<on<>UflCu<lesIM () , J f :, 0'/ leaD ". " ~ 27,PAl'ITI: En..' IMd d,SUSU. .nlu,"u or compioca''''n. ..MicM caused Irte <leal~ 00 nol enl.r '~e modo 01 <ly'''\!, ""eM "sc,,'d,..o or 'e.p"~IOf)' ."esl_ shoe" or he..~ la.lvre ,Appro"ma.a PART II: OlI\""o<"Ik&nlc<JndiIoonoconl"bolinglo~,,'t..b<II L'slonlyonacao....onuctlhne :'nlorva/!>e'....n nell r6'O~'n;,J ,n lh& ondio<iy1ng c&uu g"'.... In PART I ,0.....'nddota1h IMMEDIATECAUSEIF,n", Ce~'" -""-~,., Ac....-,'ewl !.:z...~ ALlf DIY! J'''''''''OfCOnd,'''''' ,/l. reoollJ"9",oealh!_ . DUE TOIQR AS ACONSEOUENCE Of) ~ " Stoquanua~y Ii.. cand~ions , ____ . ..___,~_~~ ________4--- ,lrlny,laadl<1gfO"""""',al" l O",m,oo""oo,"OI""'OO , catJH Enutf UNDERLYINQ , CAU!Klo.""'SIlot.n",ry c__._____,__._~__~____,__._ , It<al ""~..ted e....nls DUE TO lOR AS A CONSEQUENCC Of) : rewlllng In d....lh) LAST . ---'---. WAS AN AUlOPSV WERE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TLME OF INJURY INJURV AT WORK? DESCRIBE HOW INJURY OCCURRED PERFORMED? AllAlLASlE PRIOR TO 111.I01....' Day.Yea<i COMPLETION Of' CAUSE g Hom,c,da 0 OF DEATH? NallJ<al YOIS 0 NoD Ace,<len1 [] Pend,n\lln""'''~a,.,n U "o~ [] [J :O~CE OF INJURY Al h<>n'~ ..r~,O::'eo'. t..CIOlY, offico . ,~ ". ~, 0 Yes 0 '00 Sooe"'.. CCuldn<>ll>\Ode'.rm,ned LOCATIONI"St''''''C'OVlTown.Sldlel tou"d'''9_lt1c. 'S~"""v\ ,~ 28b. ". ,.. ,~ CERTIFIERLChockoo1,yooel SIGNAT AND TITLE OF CERTiFIER /If; 'CERTIFYING PHYSICIAN ,Pt.,51e"'n ce",ty"''l caL'" 0' deall1 "ner ."o'~e' D~v=,.n ~.5 p,c~Q(,nLed Cea" .oM C",,'''~'~~, "",n 231 .'!I131b /nO ToU.aballolmy~nowl""\le,de.lho<:co".odualulhac.ule('l.ndm.nna'al11al&4_, .e4... LICENS- UM EA DATESIGNEDIMooll1.0ay.Yean .PRONOUNCING AND CERTIFYING PHYSICIAN ,P"I>'C'~o1 l>"" ~r~"OU'Ie""J Ue.W, ""0 c""""""1 "-'c'~u>e cr d~.,"'" '-I ",.d'~!7.!.8 ':J >" ~ 31d, 0 1 4 /t;-~#04 aI To 'he bee_ 01 m~ Icno..lad",,,, dea'h O<;cu".... a. '''e 11111.. dOle, .nd placa, and do. 10 I~. closels) a~d "'.M~<.' .1..led NAME "NO "'ODRESSOf' ARSONWHOCAL2;,DCAU~ DEATH 'MEOICAl EXAMINER/CORONER l'te"'21\T~P9orP"nl J""~~ N~::f /t^<iJ On Ihe balll 01 uamlnalion and/or Invesligallon, in my opInion. de'lh occutfed atlhe lime, dal'. and place, and doe 10 lhe cao$e($l and I I z,J.,~ F.J.A..^"-' " manne,aa.laled.. .'H d"I<t..J......,.,<#'<6 ?AI74J-~J '" / REGISTRAR'S, ATUREAN: .6 Ft. ':'-';'L{/?:,:.rJZ--. p{,/p(,/i' I DA1~ FILEDi'"''''''''' D~v "ean II //} 'n~.'.; ,> .-,-. (/ 'l11-/'1 d/7{J </ ----~-----_.._---._. J LAST WILL AND TEST Alv1ENT ~ , . _,:0 OF d _,_.' (1\ -C> ~jJ ~-; C- ' ,_.., VORIS K. OWENS c= r- N a, -" - I, DORIS K. OWENS, of Mechanicsburg, Cumberland County, Penns~vania;'~ing -.J of sound mind, memory and understanding, do hereby make, publish and declare the following to be my Last Will and Testament, hereby revoking any and all Wills and Codicils heretofore made by me. 1. I declare that I am married to Joseph Mark Owens, and that any references in this Will to "my husband" are references to him. I further declare that I have no children. 2. It is my intention by this Will to dispose of all of the property which I may own at my demise. 3. I direct and authorize that all of my just debts and burial expenses be paid as soon as convenient after my death, said obligations to be paid out of my estate by my Executor hereinafter named. 4. All estate, inheritance, succession or other taxes, imposed or payable by reason of my death, and interest and penalties thereon, with respect to all property comprising my gross estate for death tax purposes, whether or not such property comprising my gross estate for death tax purposes passes under this Will, shall be paid out of and be borne by my residuary estate. 5. It is my intention to maintain a list of certain personal items of little or no monetary value, which list I will maintain with my Last Will and Testament. I direct my Executor to deliver said items to the persons on said list pursuant to my instructions. 6. I hereby give, devise and bequeath all the rest, residue and remainder of my estate of whatever nature and kind, and wheresoever situate, to my husband, Joseph Mark Owens, provided that he survives me by thirty (30) days. A. In the event that my husband, Joseph Mark Owens, shall fail to survive me by thirty (30) days, I give, devise and bequeath all the rest, residue and remainder of my estate to Richard E. Martin, of York County, Pennsylvania, provided that he survives me by thirty (30) days. B. In the event that Richard E. Martin, shall fail to survive me by thirty (30) days, I give, devise and bequeath the rest, residue and remainder of my estate to Joy C. Best, of York County, Pennsylvania. 7. If any beneficiary under this Will in any manner, directly or indirectly, contests or attacks this Will or any of its provisions, any share or interest in my estate given to that contesting beneficiary under this Will is revoked and shall be disposed of in the same manner provided herein, as if that contesting beneficiary had predeceased me without issue. 8. If any provision of this Will or of any Codicil hereto is held to be inoperative, invalid or illegal, it is my intention that all the remaining provisions thereof shall continue to be fully operative and effective so far as is possible and reasonable. 9. I hereby nominate, constitute and appoint my husband, Joseph Mark Owens, as the Executor of this, my Last Will and Testament, and direct that no bond or other surety is required of him in this or any other jurisdiction for his performance of this office. 9. In the event that my husband, Joseph Mark Owens, is unable or unwilling to act as Executor during the administration of my estate, I then appoint Richard C. Martin, of York County, Pennsylvania, in his stead and direct that no bond or other surety be required of him in this or any other jurisdiction for his performance of this office. In the event that Richard C. Martin is unable or unwilling to act as Executor during the administration of my 2 estate, I then appoint Joy C. Best, of York County, Pennsylvania, in his stead and direct that no bond or other surety be required of her in this or any other jurisdiction for her performance of this office. 11. In the event that any beneficiary under this, my Last Will and Testament, is a minor at the time of my death, I then appoint the Guardian of said minor child as Trustee of said minor beneficiary's share of my estate, unless otherwise provided in this Last Will and Testament. I hereby further direct that my said Executor and any Trustee appointed, shall have full power, at their discretion, to do any and all things necessary for the complete administration of my estate, including the power to sell, at public or private sale without Order of Court, any real or personal property belonging to my estate, and to compound, compromise or otherwise to settle or adjust any and all claims, charges, debts and demands whatsoever against or in favor of my estate as fully as I could do if I were living. IN WITNESS WHEREOF, I have hereunto set my hand and seal this / :;-If! day of February, 2002, to this, my Last Will and Testament, consisting of three (3) pages plus witness and Notary pages. -' .---"~/l ',.) ~ <;1- / c'-'.'>;---:"--<.1 DORIS K. OWENS 3 SIGNED, SEALED, PUBLISHED AND DECLARED by DORIS K. OWENS, the above-named Testatrix, as and for her Last Will and Testament, in the presence of us, who, in her presence and in the presence of each other, at her request, have subscribed our names as witnesses hereto. " , of 32 South Beaver Street _' f (\ ~ . York, :'A ~401 ,< ,_J,. Ht'tL\C"-L:( d,' 'Lt. {lkj Of;! ~ !~ "~Uy( 0"\CLL{ K~ :LC~. '~LULYI\o.-: l.J !(Q.(J( ) PO' I') L C( _. COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF YORK We, DORIS K. OWENS, Dorothy Livaditis, and -? od-~~c- A. 6h~t'~ the Testatrix and witnesses respectively, whose names are signed to the attached instrument, being first duly affirmed, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and Testament, and that she signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witness, and that to the best of our knowledge, the Testatrix was at that time eighteen (18) years of age or older, of sound mind, and under no control or undue influence. f '._ _ ,.--1 o--'i'" ,{-(' - ?_ 1-.-,y_ )I\l\TN S r +1lti-~C~jJ: Ct tJlu,~j WITNESS I 4 COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF YORK +J.t On this 1'5 day of February, 2002, before me, the undersigned, personally appeared DORIS K. OWENS, Dorothy Livaditis, and ~c.c\\Uu<>- 'R. 0h~(. who are known to me or satisfactorily proven to be the persons whose names are subscribed to the within Last Will and Testament, and acknowledged that they executed the same for the purposes therein contained. ~l ci! ~oo~ NOTA~BLlC n Iy /estates/owensk. wil '''~'''.._.''_______--O"-- '~""_____~".; I I'~() T!\; "_. ,,)I..:./\L I . r'~x 1(;', l ';":' :;,1:_"/ :-':J.'i-~ 1 !': , ,-, '"'i' ,1 ~ 5 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Doris K. Owens, deceased Date of Death: July 15, 2004 Will No. 2004-00696 Admin. No. To the Register: I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on September 15, 2004. ~ Address Richard E. Martin 1510 Breezeview Drive, York Pennsylvania 17404 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except N Date: c; -(b--O t Signature: Name: i . . Address: Law Offices of Dorothy Livaditis 32 South Beaver Street. York. PA 17401 Telephone: (717) 846-4818 Capacity: _ Personal Repre~~tive . J:) --1L Counsel for peJ:SO:llaI re~sent~Vll ~. ., {J '." (.., VI rn -0 N 0 -0 - l:I3 (J; -.J 0-- Law Offices of Dorothy Livaditis Attorney At Law 32 South Beaver Street York, Pennsylvania 17401 Teler.hone: (717) 846-4818 Te efax: (717) 854-2256 October 13, 2004 ~~ :", ... l. ~ :;; (~\ g ::0 '-i :-:-: ~~ Register of Wills fi~ ,. ,. CJ Cumberland County, Pennsylvania " ...... ~ One Courthouse Square ..,. Carlisle, PA 17013 ';, 0 Re: Estate of Doris K Owens N No. 2004-00696 PA No. 21-04-0696 To Whom It May Concern: Enclosed please find check #1014 in the sum $45,000.00 for prepayment of the inheritance tax due and owing on the above-referenced estate. Please provide verification that the payment was credited to the Estate. I have enclosed a self-addressed, stamped en\elope for your convenience. Thank you for your cooperation in this matter. r , f Dorothy Livaditis by: Doro y Ivaditis, Esquire DL:n Enclosure (check #1014) pc: Richard E. Martin, Executor Federal Express No. 846723135398 V' COMMONWEALTH OF PENNSYLVANIA REV-l 162 EX(1 1-96} DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 004495 MARTIN RICHARD C 1510 BREEZEVIEW DRIVE YORK, PA 17404 ACN ASSESSMENT AMOUNT CONTROL NUMBER u______ lold nu~_____ ______n 101 I $45,000.00 ESTATE INFORMATION: SSN: 174-20-5190 I FILE NUMBER: 2104-0696 I DECEDENT NAME: OWENS DORIS K I DATE OF PAYMENT: 10/14/2004 I POSTMARK DATE: 10/13/2004 I COUNTY: CUMBERLAND I DATE OF DEATH: 07/15/2004 I I TOTAL AMOUNT PAID: $45,000.00 REMARKS: CHECK#1014 INITIALS: JA SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS "_ ____ ___~"__'_'___~__ ______ ____________n_____ ~o::T~ Ls> ~f-- '-U ~~ .-I '"'''' "''''' ON "-0> CO ~ 0) - C'? Vl an ~ :"\~> NO POUCH NEEDED. :; ~) C'? a. I " See back for peel and stick application instructions, 0 ... ~ I ~. I C'!:) i RECIPIENT: PEEL HERE \ <<="I I Co:! N - ~I In.,, ,,~n Z~ ~ < n I:: . n z~ 0 i J I r- - I" j ~ 8:.~. ~ ~~. 0 I!! ~ ~ 3 &. If . 'll-' "1lI 1:1 <1>""" CD "'<t> I CD ;!:l g:iii' II> !ii' - '" II> ......- ,.. .. ~ ,,;;. () '" ::> '" r...~ - -- .. ... .. \j.. 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UOlle~!ldde ~~!\S pue laad JOI ~~eq aas Q ~ S '03033N H:mOd ON ~. . ,J . . . . . t~ . ~ . --..~~- "......~_.- Law Offices of Dorothy Livaditis Attorney At Law 32 South Beaver Street York, Pennsylvania 17401 Telj.hone: (71 7) 846-4818 Te efax: (717) 854-2256 April 14, 2005 Cumberland County Register of Wills Cumberland County Court House One Courthouse Square Carlisle, Pennsylvania 17013 ~, ' _....., Re: Estate of Doris K. Owens ';1 File No. 21-04-00696 (:.~) C) To Whom It May Concern: Enclosed please find the Inventory and Inheritance Tax Return regarding the above-referenced Estate. Also enclosed please find check #1022 in the sum of $5,885.76 for payment of the tax due on the above- referenced estate and check #1024 in the sum of $65.00 for payment of the filing fees and additional probate fee due on the estate. Please file said documents and return a copy to our office in the enclosed, self-addressed envelope, Thank you for your cooperation in this atter. Very truly y, ur,s, La ffi, rf Dorothy Livaditis by: . ILl---- Do th ivaditis, Esquire DL:n Enclosures pc: Richard E. Martin, Executor Federal Express No. 84649311 6986 N Iy/estates/owens. est "~...",.".., .. I REV-1500 I CF"C;r,LU;'C", I ~ ,<OMMONWEAmO"'NNmVANFA I INHERITANCE TAX RETURN IFlLE-NUMBER- DEPAR6~~~T,~:;~~V'NU' RESIDENT DECEDENT , 21 04 00696 _________.~__ HARRIS8URG. PA 17128-060~___ ~_ _____________ _'~____________ ~__90UNTY CODE YEA.R___ ___ NUMB~._~ --,- : DECEDENT'S NAME {LAST.FIRST, AN'O MIDDLE INITI.ii."Lj---- --.- ---'----- -- ---.---- SOCIAL SECURITY NUMBER ----- -----. i Owens, Doris K. 174-20-5190 . ------- -'~--'-~---_._---- ---- z I DATE OF DEATH (MM-DD-YEAR) ----- DATE OF S-IRTH (MM-DD-YEAR) w i THIS RETURN MUST BE FILED IN DUPLICATE WITH THE c 1(~-}~~l;;A~~E~~RVIVINGSPOUSES NAME ! cA~~/F~~~ ~~~ ~'DDLEiNITIAll -- u___ - W , u REGISTER OF WILLS w --,'---'. c -.----..--- SOCIAL SECURITY NUMBER -- I --------.,'------ ------.., 181 1 Original Return 0 2. Supplemental Return --0'-'3 Remainder Return (date of death prior to 12-::i3-82Y-- w . D 4. limited Estate D 4a Future Interest Compromise (date of death after o 5. Federal Estate Tax Return Required lI::~(Il u~~ 12-12.82) w~u 181 0 1 xoo 6. Decedent Died Testate (Attach copy 7. Decedent Maintained a Living Trust (Allach 8. Total Number of Safe Deposit Boxes u~~ ~m of Will) copyofTrust) ~ < 0 9. litigation Proceeds Received 0 10. Spousal Poverty Credit (date of death between o 11.Election to tax under Sec. 9113(A) (Attach 5ch 0) .~_._~_ 12-J1-91"and1-1-9S) . __~..~_~.. .'. '" ".,.._.., __~_',_____~__".__ THliis~CTiOlH.lUST B~ COMPL~T~D. ALL CORR~SPONDENC~ AND CONFIDENTIAL TAX INFORMAT10N SHOULDB~OlRECTED TO: AME COMPLETE MArLING ADDRESS .;, Dorothy Livaditis w -.--------.-- -----.,,_.~---- ~ IRM NAME (If applicable) 32 South Beaver Street ~ Law Offices of Dorothy Livaditis 0 u --.--- York, PA 17401 ELEPHDNE NUMBER 717/846-4818 ---- --~-- -------- ----. --_....~-~-- ..,--,---.~-~._._--- _.._---~------ --- .- -~~--- -- ----- ... ".-..---- ---..----- .---.---------...-- i 1. Real Estate (Schedule A) (1) -0- (,Ff'ICIAi --.----, ------ 2. Stocks and Bonds (Schedule B) (2) 133,920.77 -----. --....- 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) None --.----...- ------- 4. Mortgages & Notes Receivable (Schedule D) (4) None --------._-- 5. Cash, Bank Deposits & Miscellaneous Personal Property .--:'. i (5) 137,586.90 (Schedule E) -...._------.._-- 6. Jointly Owned Property (Schedule F) (6) None z D Separate Billing Requested -----_._~_._~"- 0 ~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) 108,546.54 CCi ~ ~ (Schedule G or L) . " 8. Total Gross Assets (total lines 1-7) (8) 380,054.21 < u -.---------.- w 9. Funeral Expenses & Administrative Costs (Schedule H) (9) _~,026.33 ~ i 10. Debts of Decedent, Mortgage liabilities, & liens (Schedule I) (10) 11. Total Deductions (total lines 9 & 10) (11) 25,026.32 12. Net Value of Estate (line 8 minus line 11) (12) __~55,(J27.~JI 113. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (line 12 minus line 13) (14) 355,027.89 --- ~ ---.--- ----_...._---~..." .______..,.____..._m____. ..___.____ .~-...- SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of line 14 taxable at the spousal tax rate, x .00 (15) or transfers under Sec. 9116(a)(1.2) ------._--- - ---~... z .045 (16) 0 16.Amount of line 14 taxable at lineal rate x ~ "--- - ~.._..-._-------_._--- ~ . ~ ~ 17.Amount of line 14 taxable at sibling rate x .12 (17) ~ 0 n .---- ----- u ~ 18. Amount of Une 14 taxable at collateral rate 355.027.89 x .15 (18) 53,254.18 . --...._---...._- 19. Tax Due (19) 53,254.18 -.--- ._--_....,,~._--- i 20. 0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. >> BE SURE TO'ANSWERALLQUESTIONS'ON REVERSE SIDE AND RECHECK MATH<< Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS - . 222 Messiah Circle CITY Mechanicsburg ---------rTATE ~-;-- izIP~~5;_---- Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 53,254.18 ---~----" 2. Credits/Payments A. Spousal Poverty Credit ----,'--'-.,- B. Prior Payments 45,000.00 _..~--_._- C. Discount 2,368.42 -----_.__..~----- Total Credits (A -t B + C) (2) 47,368.42 --_.~---- 3. Interest/Penalty if applicable D. Interest ---_.-~----- E. Penalty ---,.._~-'-- TotallnterestlPenalty (0 + E) (3) 0.00 ---_..~---_.- 4. If Line 2 is greater than Line 1 + line 3, enter the difference. This is theOVERPAYMENT. (4) ---,----'-- Check box on Page 1 line 20 to request a refund 5. If Line 1 + line 3 is greater than Line 2, enter the difference. This is theT AX DUE. (5) _-0'" 5,885.76 A. Enter the interest on the tax due. (SA) --_.----_..._-~ B. Enter the total of Une 5 + 5A. This is theBALANCE DUE. (58) 5,885.76 --"--"- 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;.. ......... ......n.. ......0 ; b. retain the right to designate who shall use the property transferred or its income~.. -- ~ C. retain a reversionary interest; or ............ ..-.... ....n..... .......... ...... d. receive the promise for life of either payments, benefits or care?.. . . . . . . . . . . . . 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without ~ receiving adequate consideration? ........ ............ .........--- ...........n.. P..... 0 3. Did decedent own an ~in trust for" or payable upon death bank account or security at his or her death? ....... 0 ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which ~ 0 contains a beneficiary designation?.. p' ........-... ..........n.. ................. IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. .~~-~--~_. --- _.._~--"--~--_._.__._~ DATE A!~A~3 .--'..--- ,-----~---_... DATE' -.~ --'---ADDRESS ---.----,'.----' ----' ---"-- .~-..---.'- DATE-~" 32 South Beaver Street York,PA 17401 'I-I ,/-OS .W?;" ,~.. , .A'<'....""-.,," For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. 99116 (a) (1.1) (i)j. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 59116 (a) (1,1) (ii)l. The statutedaes not exemota transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even jf 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 twenty~one 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% [72 P.S. 59116 (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%, except as noted in 72 P.S. 99116 1.2) [72 P.S. 99116 (a) (1 )]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 59116 (a) (1.3)]. 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. , I - . '* I SCHEDULE A REAL ESTATE COMMON\r\'EAL TH OF PENNSYLVANIA I INHERITANCE TAX RETURN RESIOENT DECEDENT ~u_L_~_ --- .- -- ---- --.-------'---------- ----.-. .,_u.__. __~___ _________ - 0'___- '. _______~_,.~__._.._ -- ESTATE OF i FILE NUMBER Owens, Doris K. , 21 - 04 - 00696 .....- -----.---... ...------- All real propertY owned solelh or as a tenant in common must be re~orted at fair market value. Fair market value is defined as the price at which property would be exc anged between a willing buyer and a wil ing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on schedule F_ ~ --------- ---,-,---- _.~- --'------------ ---------- -------------.---- ITEM DESCRIPTION VALUE AT DATE OF NUMBER DEATH - ---.-----------,----.------.- -----.-..- -------.----'--- -------- -- ~----- I None 0.00 ------ ----".'0_____,,- ------.------, ..------ ------- TOTAL (Also enter on Line 1, Recapitulation) 0.00 *' I SCHEDULE B ,- . I I STOCKS & BONDS COMMONWEAll"H OF PENNSYLVANIA I INHERITANCE TAX RETURN ~-_.._-~---~_.~ RESIOENT DECEDENT I ESTATE OF -- i FILE NUMBER-- -- ~~ Owens, Doris K. , -.---- ._------~-- ____________..L_~_l - 04- 0069~_________ All property jointly-owned with right of survivorship must be disclosed on Schedule F. "," r --- - - - - -~"O;,~,O~- - -- ----= \ c,~ v^';~1 V^,C", D^" Dc NUMBER' DEATH .___ 1.---- - ---~-.----------- --.------.--+-------------- 1 I American Express - Mutual Funds.. Account No. 011258553996002 - 6486.448 i 31,193.55 I shares I I , 2 American Express - IMA Account - Account No. 000204081830021 97, I 57.26 3 Krupp Funds Group, One Beacon Street, Suite 1500, Boston, Massachusetts 02108- 2.59 647.50 Account No_ AlC I 174205192 (Government Income Trust) 250 shares @ $2.59 , , 4 MetLife, c/o Mellon Investor Services, P.O. Box 4444, South Hackensack, NJ 34.381 3,334.86 07606-2044 - stocks Investor ID No. 8064 8026 8551 - 97 shares @$34.38 5 Prudential Financial, Inc., c/o Equiserve Trust Company, NA, P.O. Box 8006, I 45.36 1,587.60 Edison, NJ 08818-9320 - 35 shares@$45.36 i I I I J_ _u_ -- .._______ .____._____ _____________l_ ~ .____ TOTAL (Also enter on line 2, Recapitulation) 133,920.77 Page 1 of2 ~ Nancy From: "Richard L Mccarthy" <richard.l.mccarthy@aexp.com> To: < na ncyy@livaditisatlaw.com> Sent: Monday, October 18, 2004 9:21 AM Attach: plc16423.pcx Subject: Doris Owens Thank you for your recent inquiry regarding DORIS K OWENS's accolmts. These me the values of the accounts as of 07/15/2004. Mutual Funds Account Number Total Value # of shares Asset Value Per Sharc o I 1258553996002 $31193.55 6486.448 4.800 lMA Account Number Total Value 00020408 I 83 0 021 $97157.26 (Embedded image moved to file: picl6423.pcx) Thc date of death values provided are for estate tax purposes and are not a value to be paid. Accounts may be subject to market fluctuation as governed by each product. We appreciate the opportunity to be of service to you. Please contact us if you have any questions. Richard L. McCarthy, MBA, CFS Financial Advisor American Express Financial Advisors IDS Life Insurance Company 55521 Carlisle Pike Mechanicsburg, P A 17050 Phone: (717) 591 -1800 Fax: (717) 591-181 I American Express made the following annotations on 10/18/0406:22:01 ------------------------------------------------------------------------------ ****************************************************************************** 'This message and any attachments are solely for the intended recipient and may contain confidential or privileged information. If you are not the intended recipient, any disclosure, copying, use, or distribution of the information included in this message and any attachments is prohibited, If you have received this communication in error, please notify us by reply e-mail and immediately and permanently delete this message and any attachments. Thank you." :1:***************************************************************************** I 0/1 8/2004 - C::<:OOOD~FUno'; Group Or\e Beacon S~t Slllre 1500. BMJcm, MSSSllChU$S!lS Gll<la 'taJephano (aoo,<'.S~AUPP(500-2S5-7l371J November 22, 2004 Nancy 7\7-854-2256 RE. DORIS K. OWENS 1. MARK OWENS JT WROS (AlC 1174205192 GovenunentIncomeTrus12) 1n response to your request for account valuation. we provlde a net asset vaJuation, We have enclosed a statement confirming shares owned on July 15, 2004. The Net Asset Value (NA V),is calculated without factoring in the shared appreciation in the underlying properties. The value is estim..sted using quoted market prices fot the Mortgage Back Securities (MBS) and carrying value for its Participating Insured Mortgage (PIMs), Participating lnsured Mortgage lnvesnnents (:PIMIs), and certain other assets ao.d llabtlities.. The appreciated value on the PIMs and PIMIs cannot be ascertained until the mortgages arc refmanced by the borrowtfl the underlying property is sold, Or if the mongage is called. The NAVis adjusted with each" Special Dividend". Please find listed below, the net asset value in the quarter e-/osest to date of death as possible Net Asset Value as of June 30. 2004 $2.59 There can be no assurance that you (or <my other onitholderl could realize such value if you were to attempt to sell your shares, Should you have any further questions or conc~rns regarding this informatlcn 'jJleas-::. do not hesitate to contact our Investor Communications Department at J-SOO-25-KRUPP. Investor Communications Department .'I,^['r,\ ',",',',,', ,"'" ",\ __. '", 71 ',In', , - KRUPP 1:.~:ijm~~:~J~:j\'\1~~~:~~~~i!,~~~~:ir1'1r[~1 KRUPP GOVEI<NHENT INCOHE TR II I(RUPP ACCOUNT NUMBER SOCIAL SECURITY I TAXPAYER 10 BROKER I OEALER NUMBER I""., """"'\'Z;'J'r:ffl"]'i:~>""""6\"'1 l:::n,~~.i,~,;,~~i~#~~f~:Vr.4:~ia.~!~;;}:~;;~~~;:,;;i:~l ! ;;,i",'"'' .\:',03%69,"';:':', ':""'1 INVESTOR REGISTERED REPRESENTATIVE P-NGEL4. M. CAMPLESE DORIS !(. OWENS MORGAN STANLEY J. MARK OWENS IT WROS 4TH AND WAlliUT STREETS 581 HESSIAH PO BOX 12053 HECEANICS8URG PA 17055 HARRISBURG PA 17108-2053 !U~5~1!l!~~1~;~~t~~~!~~-f$~i~~~~6f~ TRANSACTION SUMMARY _;ii;1l!~!fifl,*r.r,~~l!*l&:~:!i~ DATE TRANSACTION GROSS AMOUNT FEES NET AMOUNT SIlABE SBARES ~--- ~~~~ ~=-==""== ~~......- =----...-...... -'"'.._""~"" =-=.....,.,,-~ 01/01/04 Opening Bal 250.00000 02/17/04 Cash Div 35.00 0.00 35.00 05/15/04 Cash Div ]2,50 0.00 12. SO 08/14/04 Cash Div 12.50 0.00 12.50 11/14/04 Cash Div \2.50 0.00 12..50 - - - - - - - - - - ~ -- Ending Bal 250.00000 -------- Total Cash Dist 72.50 DRP Purch 0.00 AddressQUU1,onssboulyoIJraeeouflllo: Or call: KRUPP InVUlor CC>I't\I't\Unlco:Itiont: 1-800.25.KRUPf> Alln; lnvnlor Communie;olion5 One BueonSI.,Sullil1S00 BO/;ton,Motiti-1.e;hUlJell,0210B " I ~, ",. ','.r'd'. ,(\,nJ )JC'V, '\:.1: ~ 7 ~r. {, I ., i '''',i, . SCHEDULE E , . CASH, BANK DEPOSITS, & MISC. I I PERSONAL PROPERTY COMMONVolEALTH OF PENNSYLVANIA I I INHERITANCE TAX RETURN I l RESIDENT DECEDENT ______ __ - __ 1_- __ ~___.~__.__~._____..._____._________..~__....__ ___..___.___ ESTATE OF~--~- ---- .~------------ -1 FILE NUMBER-------- ~wens, Dons K. ____ ._~ _ _____ __ __._.__ _ i 2] _ 04 - 00696 . -- .... - -. .. -..-- ---'--------.-, 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 DESCRIPTION VALUE AT DATE OF NUMBER DEATH ,----- __,___ ______~_____..____._.._u._ ___._____._'__._'.___ -----_.-.~_._- 1 AF&L Insurance Company, P.O. Box 368, 1800 Street Road, Warrington, PA 18976 - Nursing Home I] ,970,00 Policy 2 Personal Property -- see attached appraisal from Kelly's Used Furniture 313.00 3 ]991 Ford Taurus - 4-door Sedan - see attached appraisal from Kelly's Used Furniture ] ,000.00 4 PNC Bank, Messiah Village, Mechanicsburg, Pennsylvania ] 7055 - Certificate of Deposit - Account No. 11,472.63 21001015277 5 PNC Bank, Messiah Village, Mechanicsburg, Pennsylvania 17055 - Checking Account - Account No. 19,715_91 5070101934 6 PNC Bank, Messiah Village, Mechanicsburg, Pennsylvania ] 7055 - Savings Account - Account No. 92,115.36 5002056385 7 West Shore Lodge B.P.O.E. #2257,108 North Street, Johns Church Road, Camp Hill, PA ]70]]- ] ,000.00 Ownership Certificates in the amount of$250_00 each (4) - see attached, - ----_._-.._--~^-------- ---- --- ---._---- -- -- --- ---- ~ ~--- -"--- ----- ------- TOTAL (Also enter on Line 5, Recapitulation) 137,586.90 u ~: L ~,. I. UU" "l .;I V c...., ~ V J ,,~, VV J 0 ... ,.- ~~~._.._.. --. OSl2SI200409:J1 AM ATBlll_24/.jij . EXPLk~AT~ON OF 82NEF:T8 :D NtJr..1BER: 'c. SHOU:""D YOU HA.'v"E ANY QUESTIOtJS PLE..~,Sr:: CONTACT OCR O::'?lC;:; AT (800) 659- 9206. TO: DORIS OwE~S A:&L INSURANCE COMP~~Y MI;:SS:A.H VILLAGE 1800 STREET RC MECEl\NICSBURG, PA 17GS5 'o'JARR :~~GTON, ?l, :8976 INSURED; DORrS O~ENS POLICY N:..JHBEF.: 652.7 PROCESS ;:lATE: 09-09-04 SU?FIX: 2 - - - - - - - . - - - - - - - - - - - . - - - - - - - - - - . - - - - - - ~ - - - - - - - ~ - - - - - - - - - - - ~ - - - - - - ~ - - - - - - . - - - - - - - - POLICy ~O. .~I\N BENCD SVC . FROM SVC.TO BEN'2Fl'T AMT. COIN\- NETS DX ~ _~___ _ ____~ __ _ ~_ _~ _~ w_ _ _ ___ __ _ ___~_ __ _ __ _____ _ __ _ __ _ _ ___ __~ ______ __ __ _ ._~____ __ 6527 11 NH 02/29/0Q 07(03/04 11, J4C. 00 0 1l,340,OO 6527 11 NH 0-1/04/04 07/0'7/U1 ,Gu u .vv 5527 11 NH 07/08/04 07/15/~<1 630.00 0 630.00 - ------- - --- - - --------- -~ - ---- - - - ----- - - - ~~ - ~- ~- - ~- - - - - - --- - --- --- -- -- - - ---- TOTALS , S;l~.97C.OO $11,970.00 - - ~ - - - - - - - - - - - - - - - - - ~ - - - - - ~ - - - - - ~ , --------------------------------- -------- CHECK ISSUED TO: DORIS OWENS crr;;:CK .b,~17 , $"-1,97D.00 TOTAL ~~OUNT ?AIO TO DATE fOR TH:S CLAIM $41,850.00 POLICY SERViCE NOTES, 637 EF.N8FITS UNDER THT~ POLICY ARE NOT PAYABL~ ?OR DAYS ON WEICH YOU ARE CONF'HJED TO 'tEE HOSP! TAL DORIS OWENS f'olESSJAS VILLAGB sa1 DOGwOOD DRrVE MECHANICSBURG. PA 17055 i '--. ----- 09/29/100409:31 AM A7BS7_24740 - llt(oll,"SURANCECQ.,CLAIMS 236318 1""'>lIC.NO ~Hf"cNct .....oUNl j),'SCQUNl ",,......1 Ci..AIN:6527 11970.00 .00 1.1970.00 , OATE 09-/.8-04 Cl-/fCll: NUM8~A 236318 CHfC!( AMOuNT C .- $H,970.00 PAVE! ESTATE OF DORIS OWENS ,-,;_..,s. ",,"D"'.O>oI"O". .OC.'. ;"'G'J'~OO''''"'9...'O.. 'I U..NOW. (AC\ ""c.,,, "" ~~_'!OIl" <~- @~ff(;1J4lI".""o,'" ''''''~(''Ib<'')" - _.~--- ~-~.~ -"- .- COlPr , ELLY'8 " :J' U:_IBY.R.E i\ ~_NI~rk P^ 17401 " F W MarketSt. 01'023 of- ii 228 (717) 848. II 8-/~?- ,i " Ii I \11 .:J1I.1OICC i\1 ' R,€T 0,,", oweNS tf 52 (>0 / D. : /Y.J1t'>. InA ~/2.J5 1<. ' . E of '\ E:;;,A7 ,J I. il?/I/'_-r/ 84C- .3111 :, LX eCl-lfiA'1) u rHo/,)C 'I c? -0 I A. I _ Vie !\ 5/0 fjIfG~7-t:. i\ I ~ 17!-~'+ !: jtJPc, Il. " l' ,\ , :1 II .jti~l(r"'- i " I <(Jl~~ ~ r Lv.L II f-)2.L~ CO~~ ~~'., ~ )f".,J . ..<5fs /.if! . qi-c z- cJ-ex. ~c :s?3 -139J' .I (;547 7r - 1\ ii, ,!I ,.: i;i H! Iii ,1 :\j ';1 ill !il Iii I" ili -J 5'500 WDe,5'<. ,[ " ill 5l= ii:t:tles:r of=" J:>~uJel?s III iiiI;8JtTI'1.8UT ij/ -0- :',j iliC;-lA/~ (KtJCKec) I!(cc 1.1 /'i \ \\\.6,,)) ~~ 2'"'' "1 ii' iil~"'TT7 C;<In"" J.t1C III ./ ii,s,-A..vU .:7,CO if! 11'4 L f'7V,N! Iii' x: OTJ \11 . I" l I(M i\\HOo/t !hP.s. i'i 2t:J. (10 '11!lF;I?t?'v ii' ,,1 .4 1::>mo.e ~04,.J (.0;/0<::'5"0 /11/<.E 5) " \i/'11' f'i,el> '"r'AuEuS I /?On r(l hi ,,. \)1 ~771<- /3.13 co il! I.. !il Iii ,II il. Iii ili 'ii !i "I i' .li (1. di l ' 1 1" Iii 1\, "~I ill 1\ " I:] \Ij :11 I" ill ili 'ii 'q 'I :! illl ili 11\ Ii! 'I 'il 1)1 ':i ':1 .11 II! 'i " i\\ , , ~ ':i r~u'_'-u,:::,-.::>::,,,-,.... - ~ -- "" ....~~ ,... c...._.,.-, "".....N"nAN< . '\:<<' n ,-D November J 0, 2004 Dorothy Llvodilis ./~cp :n South Beaver S1. York, PA ]7401 RE' Estate of Dons K Owens (Deceased) SSN; 174-20.5190 DOD: 07-15-2004 DeM Ms. Li,'adi:is: In rC5ponsc to your request for D<1tc of DCl1L'1 p<1lnnces for tbe customer noted above, our records ~h(lw the following; Cutlficate of Deposit Account #21001015277 Established 01-03-1995 DORlS K OWENS DOD balance: 5J 1,472.63 + $9.31 accrued interest Checking Accouut Account #5070101934 Established 03- J 8-1 988 DORlS K OWENS DOD baLance: SI9,715.9] T S2.W accrued interest g"viDg8 A(~o"n~ Account #5002056385 Estab!isl:ed 03.25.2004 DORIS K OWENS DOD bl1lance: $92,115.36 + $46.61 accrued interest Pase 1 of 2 '-',-IL.'-,-":-'--,,",_,,~...). ...,: ,'-< >-"_!1 HW'" ...l1'::' cS2 :::~1':",2 p. ~I? . Please note that this office onl)' pmvides dale of death balances for deposit accounts (IRAs, CDs, Checking and Savings ~ccounts). Wt do not proc~s any financi..1 ~ransactions or provide statements. If you need assistance ",-jIb any of these items, please call 1-88S.PNC-BANK (1.888.762-2265) or stop by your local PNC Bank bran{:h office. Sincerely, 2~ ~ Erica L Schlegel 1-800.762-1775 P7-PFSC-04.F 50DFi~IAyo:. f'iltsbu'llhPA l5219 Member FDIC Page2.of2 TOTAL P. 02 ~ "D\i 0:;;' Jl--l " ~ 00 " o m--l l Jl Jl~ , 0\11 "\ ("1 ~ .,,~ ~i ~rnil ~(/l" -..... I~' rn~(/l ~.,'I. :t "\ 01,,\ ~;o 'ii rn rnl~ orn .~ ;0 1"",11 . ~ M c:,q" e-~ 0:> (/l III -s. I"" ~ ~:t} ~I"" .~~\ n (/l00 "'I o '~ B 1>(;) I.' (/lrnl] (/l... ~'. 0" ~\ o$) I:I.~..,. );...,~ -I..., ~' g!!q "'~I ,,!(%. ~\ 0\" .... llil 1"\ o ~I If' ~ \1 ~~~, .~ ,.-> 0 ~.~ ~ - , ~\ - I ~ V \; ~ ~ I. ., 't w, I ~ {J~) .L '~I Ie-, -- ::~\ -Ill r. ill ~ "".'. "V , ~'j, ^ ~ (.0 ''J,\ v _ r'V"'I .~, "'l O!l;;; 'i::. ,I\! Ii .~. _ I ' 8"_0 ,n, . Q 4 I, l'\'o~ ~. ,~ 'h" \!',. ~ z ,.~ . !~ - "", i~ . ""_ " %~ ' ,~ 'ill .~ \~~ '. I SCHEDULE G i INTER-VIVOS TRANSFERS & COMMONWEALTH OF PENNSYLVANIA INH~RITANCE TAX RETURN J MISC. NON-PROBATE PROPERTY I RESiDENT DECEDENT --._~ - ------ ._-_.._.._-.---_.__..__.__._~----.._. _.------~- -.- ---"---'----- -...---'----------.-.--.---------..---".--- ------~-,----_.__._-- ESTATE OF i FILE NUMBER Owens, Doris K. ! 2] - 04 - 00696 -----.'-- .-..-___~_._.______L_____~_~_.__ ___ _,!his schedule must be completed an<l.flled ifth~answ-".rto an~ of qUestions_'UhrOUt~C)"-Pa e 2 is es. ___ i DESCRIPTION OF PROPERTY I DATE OF DEATH! % OF , ITEM I '"",dolh. Mm. ofth.t,,",""., """"""",h" to d".'eo"""h. ,," 011""""1 S \ DECO'S I EXCLUSION TAXABLE VALUE NUMBER Allach a copy of the deed for real estata VALUE OF A SET IN ER (IF APPLICABLE) , . I TEST + _~______.______.___L__.___.______ ____.-_,._____ _ _. _ I New York Life Insurance and Annuity Corporation, P.O_ I 48,763.331 I' - -48,763.33- Box 69]6, Cleveland, OH 44]01 - Policy No. N3100526- beneficiary: Joy Best I I I 2 New York Life Insurance and Annuity Corporation, P.O. 24,334.171 I 24,334.17 Box 6916, Cleveland, OH 44101 - Policy No. N31015 12- beneficiary: Richard Martin \ I 3 New York Life Insurance and Annuity Corporation, P.O. 35,449.041 I 35,449.04 Box 69] 6, Cleveland, OH 44101 - Policy No. N3118774 - beneficiary: Richard E. Martin I ' I I _J__ ______~__._______ ___u_ 1______.___ -- _ ____.L___..n.__ _ _ _ __ _ 'n __ TOTAL (Also enter on line 7, Recapitulation) 108,546.54 .D (") n '0 E" " '" ~ -0 " C" N N Q " :1,;' '" " ' E Z '0 ,-, C) ~ "' ro'" U'J U) <1>'0 - C c-, " 0 " Or. r- r- "- ~ .c~ ~ <1>;;1- u~ o.t::- t::- C::- o " m [\jVJ ~ [L u ~ GU.2 ill " u . ~ . C --~D '- ro ~ E ~ (lj~:JE2 ." _~ gO:;):::1 -~ 0 8 ,--oDCo '" ~1 i ::10nJQl>> C ~Ci:Q~~ ro ~ '--flJOC<<j ill ')' u E . ~ QJ w Q) o~.~ Q)..c \f _. - :::> 'K-.) Q, -~= -- ---1 (/l ifI~ ro '" 1,.0 ~ . ~ ~-cg;w IT "l QJ >. 0 <;'3oaE't: " " w W ~ 0->--. >- 0 () ~ '," L t.o <ll c~o " ~ Qi Qi ~ ~ 'g ci S cu ~ QJ :-0~ C C I Q.3!n. ill ~ > ~-" 6Z~o~ '" en en en ',..., l <Jl ~ <-I " '" ~ oj - . > 0 >-''---{'JQ}---. [t:'!: '!: \...... QJ <::: <II :::J.c ill Q " 0 _ 0.0 ," ~ c2' 2' 2' - . " Q) >-:J~ ~ :.\ (J ~ '" ill C C C ' " 0 .s;::..'- 00 QI "'''' '" '" " dJ 0 .- 0>--<--, c: 'U <iT T T .c >-<11 25OCOJf~ t-..-- I---m:J ~ ~.-"\ ou >- (\.) ,:S __ \.' -;j:; U) ',~ ~ .~'> 0).......... .... '1'" -~ lIJ"TI 0 C (1).;::: 0 ~ \) "- c; ~ ~ t ::J~...... --4-' C:Q)Q) <D co ., e- m- Ql ~ QI "C'_ IT! ill r;q ~ M o~'" ~ '" <D ~. '< E-o- om......c J::: :'::::00""': ~ Q) Q. 0 () o..C~O-8t M '" ~ '" T (V-, ~ . >-~ l' ~>cn U'J '" .... <tI ~ _.... M 0-0 --<---,.-.Q. :> UC "'~ "" "!. ('f\ :;>,.:'00 0 o~~{l).2~ V) E cO ~ ~ '" \l~ >-..0.- <.) l~ m \"'. ~ '" 7:~o-B CD IlJ ro Ci 3. illU :> " '" M '" N -:5 Q~~ ~ ru ill 0 U> '? U> If) 0 ~:~J: ~ a 0 ) ['I' <'1 C :::> (J) ~ (f){IJ 0'---:-.;:: <i ! ~1 t~ rn (lJunj::Ih 0 0 E.~~c~Q) ""- ! n --;;j-o >..!: 0 0- (})O'iJ)~ , 2 ~ ~ ";;; N o::Q U; 0,__ -1 OJ 1 ~ '" >-c 0 - ~.- ill > .Y. U \, \ <Tl~~<l} "n Q) OJ -'-- 3: 0 Q)(f),-o U C)<J <.0 ",VI ill :0 ..--~ij~ U 11> L.- 0 \li ",0 s~ojO>- VI ,,,! "' "' ~ g- E ~ ~nU) ill ,-OJ "' Cno ~';::; => 0-0. . s Q) 0>:'=' ~ ~ QiJos "'0, ~ ~-+- - $ Q) Q .o..:(ti <U '" lJ 0 <::: S" 0 -x c C Oz >,'.':) " ." :J. (jJ <=:-i- OU) '- :=: Ql ill if> >-0 0 0 ~.g'~ E y:9o o 0lQ).D0l '0 C'.' C >-uimE C ro:C C "0 ~.g E V)cn 3; ~ ~2"'2'~ :0 _0 0 0 0.2 2 2 _..0 ~ ;:J 'C ill '<--- D ft) ~ E {/} 0= ill Ql~ 0 ro...... IT! 0 - 0 " 000: z2 >-,V;~ E Q :::> U 0 '" .e co, '" 0,) '~m~~ .q roO,) <D 0,) .D G >-. ~ om rn Q) ;:;; Q) ,--'- :> >-.~ ~ :c:: "'.0;;;'"0 C <;1oQl~ C 0'" '" OJ "'<< << << Q c. g"5 O~ ~ '" C >-.- 0 C '" 0.0 co q '" n1 g.ti c - E - c (Il ~~ '" '" ". ~ 0 -o.~ E '" .... . 0 ~ D \0 10 .... e ~ ~ E E ~ ::>-g: C; <D -;:: > 0 0 ." ~ ill >-."0_ ~ '2'" c'::; ::J C 0 M <'J ill E <Tl ">- (f) 0 11. 2 2 ~ ~ E ~ if> 8 ::. E ilJ ~ C C Q ,--Iii =-" :::;:,U) il) ::J U; o ~ '" :': >- ~:.c UJ 0 OJ .2 ~ I- g- :0 0 IT i"~,~~ 0 Q) ~ U o III '';': J:: .~ ~'~ ~ : ~~ ill 1IJ 0 - i3 Co if> 1:) II 5 rl Q)o ~ '5 ';:: 0 ;:; 0 ~ ~ ~ {) .... () ::: EN - 0 U 0 LL '5 " 'S (L >- rJ () Q) .. c c c W~~~ C C C ~O <C <C <C <.I.l '" rj E (IlC') .n'D "" _ '" c c c o " ~ c '2 {.~ () OJ (f) ~ " ill " '" '" Q 0 > "'- QJ E E E c ;;:; to E. ~ c v.D S .~ .~ l" ill 'E "'" ~ ~ '" 0 S .D 0 '" o . ~'~ Q) E '" a; a; a; 0 ~:s;::i: ~ QJ ~ 0: 0:: 0:: "" en dJ-"6 g CO ~ (!) (; E E E ~ ~]~l v 0.. (l) " ~ :0 :=QJ 0 E E E 0 "0 0 N O(f) "-' 0 'Q ;:: ~ ;! ,- c '" lD '" "00 C ;; "0 (!)~ ::J ~ n: n: n: (; ~ ~~ ~ ~ - C 0 C '" "" '" - w v :> '" '" ro ': E ~ : '" 0 C c '" 0 ,,~ U (j) <t c C c c " _ _ 0 ::; <{ cG iii iii .;::; ::; ~,--; 0 ", <i if) f- l'. D.:; >- Q. . I FUN~& COMMONVI'EALTH Of PENNSYLVANIA! I INHERITANCE TAX RETURN AIJIVI NIS1'RA.T1VE COSl"S RESIQENTDECEDENT ------------------ ---- - ~-_._-~--- -. ----..-...-.-.....----..---.. --.----...-- ----- --_._-.~----- ESTATE OF -O--D .-;------------ -----------!FILENUMS-E'R--- ----- ___un _--",ens, ons ~_________ _______ .1__ _21:0~0()~9..6. _____ Debts of decedent must be reported on Schedule l. ~~~~ER FUN~RALEX~ENS~~-=- ~:~~RIPTI~~-=___ ____~~r-~MOU~~n~-= I Myers-Hamer Funeral Home, Inc., 1903 Market Street, Camp Hill, Pennsylvania 1701 I 4,415.00 2 The Reverend Charles Burgard, Messiah Village, 100 Mount Allen Drive, Mechanicsburg, 100.00 Pennsylvania 17055 3 The Reverend lanet Peifer, Messiah Village, 100 Mount Allen Drive, Mechanicsburg, 75.00 Pennsylvania 17055 4 Marilyn Ebersole, Messiah Village, 100 Mount Allen Drive, Mechanicsburg, PA 17055 - 50.00 organist 5 Messiah Village, 100 Mount Allen Drive, Mechanicsburg, Pennsylvania 17055 600.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Social Security Number(s) I ErN Number of Personal Representative(s): Street Address I City State _ Zip , Year(s) Commission paid 2. Attorney's Fees Law Offices of Dorothy Livaditis, 32 South Beaver Street, 5,655.00 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 Cumberland County Register of Wills, Hanover and High Street, Carlisle, 272.00 5. Accountant's Fees Judy Doviak, Kuhn & Doviak 375.00 1401 Mt. Rose Avenue, York, Pennsylvania 17402 6. Tax Return Preparer's Fees 7. Other Administrative Costs I Appraisal- Kelly's Used Furniture, 228 West Market Street, York, Pennsylvania 17401 150.00 2 Advertising - The Sentinel, P.O. Box 130, Carlisle, Pennsylvania 17013 105.53 Total of Continuation Schedule(s) 13,228.79 - ----- ----~---~-- . .----- ---------.--"---. ------~---._- ---~-------,._----.-~ - -- ---- --------~--- TOTAL (Also enter on line 9, Recapitulation) 25,026.32 .. I ScheduJeH I . COW;MON'WE.Al TH OF PENNSYLVANIA I Funeral Expet ~ & I INHERITANCETAX RETURN '1 Mninistrative Cos1s continued _ ___-----!3~S!DENT DEC~DENT__.~_____ ______.._____________~_____.._______.__'_____._~___ ____ ______~_ --.----'-.----. ..---.,.----- ----.--------."--..----.-----',.-------------,-, -------..----------..-.---,--- - --- ESTATE OF 0 D' K 1 FILE NUMBER wens, ons . I 21 _ 04 _ 00696 ---3-~ Advertising. Cumb~rland La~~urn~,32 South Bedf~rd Stree;,c;rlisle:P~nns~I~:~~~I-------75.00- 17013 . I 4 I Pat Shope, 231 Pisgah State Road, Shermans Dale, Pennsylvania 17090. wages for services 1,125.00 I rendered 5 Holy Spirit Hosiptal, 503 North 21 st Street, Camp Hill, Pennsylvania 17011 . hospital care 12.72 6 York County Solid Waste Authority, 2700 Blackbridge Road, York, PA 17402 10.08 7 MessiahVillage, 100 Mount Allen Drive, Mechanicsburg, Pennsylvania 17055 - SRC - 2,240.72 Juniata 07/01-07114 . nursing care & room and board 8 Messiah Village, 100 Mount Allen Drive, Mechanicsburg, Pennsylvania 17055. nursing 4,914,00 care, room & Board 9 Messiah Village - 100 Mount Allen Drive, Mechanicsburg, Pennsylvania 17055 - nursing 1,217.31 care, room & board 10 Messiah Village - 100 Mount Allen Drive, Mechanicsburg, Pennsylvania 17055. nursing 3,528.96 care) room & board 11 Sheperdstown Family Practice - medical bill 25.00 12 Cumberland County Register of Wills, Hanover and High Streets, Carlisle, Pennsylvania 15.00 17013 - filing oflnventory 13 Cumberland County Register of Wills, Hanover and High Streets, Carlisle, Pennsylvania 15.00 17013 - filing of Inheritance Tax Return 14 Cumberland County Register of Wills, Hanover and High Streets, Carlisle, Pennsylvania 35.00 17013 - additional probate fee IS Cumberland County Register of Wills, Hanover and High Streets, Carlisle, Pennsylvania 15.00 17013 - informal accounting I - I _ . . ~__ I - -. -- .-.--..--.- . .----.-. ____ __.L~.~ ._~ ____.____ Page 2 of Schedule H -i,:~~ _~ J -+:~~"-S..~,. MYERS~HARNER FUNERAL HOME, INC. ;' ..." , . ~ ,,,, ':' ," .>i,II'll1nnl Fil f;;$f 1'1113 \l.-\RKET STREU ROBERT H. HARNER /:;) FlI'1 '~'2:m 1'11'1 l!if-y, SlIPER\'ISOR 1;""'~,.~,- C\MP HILL. PENNSYLV..\'-'I.-\ 17011 .'~:~%:-~"" "~ <:,:-.'.-. - ~ TELEPHONE [.oeAL!.Y O\\'r\'FD :\Nll 7\7-7:n'l%1 OPERA TF.D Augus t 3, 2004 Mr. Richard E. Martin 1510 Flreezeview Drive York PA 17404 Services for Doris K. Owens July 20, 2004 Charges for Services Selected $ 3,975.00 Professional Services Use of Services Automotive Equipment $ 3,975.00 Charges for Merchandise Selected Acknowledgement Cards $ 10.00 Register Book 40.00 Memory Folders 40.00 $ 90.00 Cash Advanced Newspaper Notice/Local $ 117.00 Certified Copies 70.00 flowers 163.00 ~-_._~"---_....__... . $ 350.00 .' Total due within thirty days, please: $ 4,415.00 ~ \ ') Y \l) ,,~~. 04 I LJ~/ i6:{ {.J!to ~\ II\V ()S~10-")(;(1}c, -t ,/ :r ID ;/ etA /' (J U /' . 4'A-J 'J' /1 \ ,I' / ~--------_. ~ ,_.~-;:;<;\ 0;- ("'"':;; f~ '( 13 Richard E. Martin 1510 Breezeview Drive York, PA 17404-1720 August 9 , 2004 The Reverend Charles Burgard Messiah Village 100 Hount Allen Drive Hechanicsburg, PA 17055 Dear Pastor Burgard: Enclosed is check iF 1001 for $ 600.00 for a contribution to the church from Doris Owens. Also enclosed sre three checks for participation in the funeral of Doris Owens, as follows: Check iF 1003 for $ 100.00 for your services. Check iF 1002 for $ 75.00 for The Reverend Janet Peifer for her services. services 0A/2i. U-!IJ Check iF 1004 for $ 50.00 for her Erf! E'7(L soce) We appreciate your services. I would also appreciate it if you would give these checks to the proper persons. Tha~ very mU~h. -/~:4y/%{~vL Richard E. Martin Executor . . Richard E. Hartin 1510 Breezeview Drive York, PA 17404-1720 August 13, 2004 Pat Shope 231 Pisgah state Road Shermans Dale, PA. 17090 Dear Pat; Enclosed is a check for your wages for Doris for June and July. June--71 hours @ $ 9.00 per hour...... ....$ 639.00 July--54 hours @ $ 9.00 per hour.... ......$ 486.00 ------------- Total enclosed $ 1125. 00 ~c<<'.:tF/ct)g v~Yours, ~4.~-~/t;:;~~ l'?X Richard E. Martin Executor for the Estate of Doris K.Owens. III! \\\\\ II i 'I \ \ \ \ \ \\1 II' - I \ \ . ,\,.j ~yN~ S~~ \-"\_ 3 rc:: ... --3 -" -3 - \n ~ "'\-S:l - ~ \Jl .- r- r- \ f\l,i;_s:-_e- , " 0 ,.. 'U " -::. ~ - - - , ;,. =' '" \ r - ['f\ \ '". J v-,j r; ~ - {\j f'{\ '" \f\ VO CO ( \ ,() (i r'I,~ rf\ r<J - I. \ 0 \,0 I _ __ '-..J I I \ U' I <I ~ _'.\ \ ~;" Q (j oc!J \ \0\0 r WI a '-' '-..l U (V\ ('<\ (VI -- ."/1 fY' 01 M rf\ ~ - -' .," .. ~ ~. "'- <)0 c; V; en 'to (jo en ()O ~ V" <<1 ~6 \ \ /-\ c...- \II ':j-- \1) l';} '--' ()0 <r _ \0....Q,....... r-f\ _ _ _ '. \) ~ \l\ _ '.. t" , \) ~;-~ ct. ~ \ . N ~ ~ ~~ N c-,) ~ ~ - ::::::::::------.. ---- "rf'l - - ~ \"". CJ' ~ -S <:'IN -"- - , t:: c Q 9 ~ Cl 0 S" ~ \") \"-- ('Y\G~ . f"'l"-' I I M I\l \ <; \ \ CJ 0 1 '. ('(\ ~ ()0 - \ _ N ~ N ~ - . \ ~ \ _ _ a 0-- . ~ G - "- ! -::t: P (yo \ (~HOLY Holy Spirit Hospital SR~I 503 N 21ST STREET CAMP HILL PA 17011 The S/)iril fJ{ Caring - # 717-763-2141 - - For Account Information, Please Call717-763~2141 'S,; ,"i' "^.': "fJlJJJ1f,'Jl:c,1;;~'~i: . ,,;;;;",,;J~,iji'~?';;:;:::':':'" :-,:'-: '." .~. ';, .> ... -"_.-,, ';""" ',""i. <" ' .~ :J<",.. .r;" "',,,,, '()8.Y~Jql()4 .' ,: tateinelit/o /J";e.countt. ,-.' -, ,," ,,'j,_,' "_"l'f:.~>;-,:;;'c:<;>-l TrIlnsllction Dute Description Amount PREVIOUS BALANCE 9,647,17 I 07/13/04 MED CIA HOSP-IP M90 MEDICARE liP 3,843.30- 07/14/04 OTHER PATIENT NON CO M90 MEDICARE liP 15,60- I 07/29/04 MEDI PYMT-HOSP IP M90 MEDICARE liP 5,795.57- 07/29/04 MEDI CIA HOSP-IP M90 MEDICARE liP 3,445.28- 07/29/04 MED CIA HOSP-IP M90 MEDICARE liP 3,843,30 07/30104 MEDI PART B PYMT-IP M90 MEDICARE liP 116.81- 07/30104 MEDI PART B C/A-IP M90 MEDICARE liP 231,99- 08/11/04 NATL ASSOC. OF LETTE Z44 FIRST HEALTH 29.20- I "-.. 'A~' J~:;:J\","l! .) \ \l"V 6 (7 '1 -:/( \ ; Cf<'i\U '4 \ 'b Estimated Insurance Due: .on Total Patient Credits: Account Balance: 12.72 MSO MEDICARE liP .00 Z44 FIRST HEALTH .00 PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. _ _ _ _ _ ~ n__~_nn____ _ un__u__n__n nn__. _ -.__..n n_________ _ ___~!.9~~"!_d..e~l!o:!~_~~d..r~!..~, :'l-~i,!~ y~~~P::~r:!,." . . - YORK COUNTY SOLID WASTE AUTHORITY # 87053't 2700 BLACKBRIDGE ROAD 03/01/200Lf YORK, PA 17402 11:45-il:52 717-845-10108 DECAL: HAULER: '39'3 CASH TRUC~,: VAN TYPE: WASTE: 01 MS~.J UN ITS : 0.00 ORIGIN PCT TONS RATE 38 MANCHESTER TOWNSHIP 10e; :1. 0. i8 0.00 CUSTOMER: '39'3 CASH PAlO GROSS: 4320 LBS RATE: $ 55.00 TARE: 3950 LBS NET TONS: 0.18 ----~~----------- f:\MOUNT DUE:~08, NET: 350 LBS REMARKS lr 10 i I SIGNf:\TURE/c'.PC:LJ~/ :;;:f- WEIGHMf:\STER: DARINDf:\ ./ / / ~l' (> "I;' ~, P . ~ !, 5 ~~~~jah ..;1_.0. _<t'. ~~~I ~. ;! 100 MOUNT ALLEN DRIVE, MECHANICS BURG, PA 17055 QUESTIONS? CALL: (717) 697-4666 RESIDENT NUMBER I DATE 68204 I 07/3112004 RESIDENTIS) RICHARD E. MARTIN Mrs. DORIS K. OWENS 1510 BREEZEVIEW ROAD YORK, PA 17404 TOTAL AMOUNT DUE $2,240.72 DATE DUE 08/3112004 $ DATE DESCRIPTION UNIT CHARGES CREDITS BALANCE Balance Forward 3,528.96 07/30/2004 PAYMENT RECEIVED - THANK YOU!!! 3,528.96 0.00 *** Assisted Living *H 07/14/2004 SRC - JUNIATA 07/01-07/14 14 1,308.72 . 1,308.72 *** Nursing Care *** / _u_ _ .____ /' 07/07/2004 RMI BRD - NURSING - SEMI-PVT 07104-07/07 .' //4 2,240.72 / V6(() 6) s V'V\ ~u \ .~;f a U j(' \ /[,,<1- \ \ \ \ ~'" -- RESIDENT # CURRENT OVE R 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 68204 2,240.72 0.00 0.00 0.00 0.00 $2,240.72 RESIDENT NAME Mrs. DORIS K. OWENS Form P8-01 Ill}, A I % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! if you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! ~~~~~~Jah 1 DO MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055 QUESTIONS? CALL: (717) 697-4666 RESIDENT NUMBER I DATE 68205 I 07/31/2004 RESIDENTIS) RICHARD E MARTIN Mr. J. MARK OWENS 1510 BREEZEVIEW ROAD YORK, PA 17404 TOTAL AMOUNT DUE $6,131.31 DATE DUE 08/3112004 $ DATE DESCRIPTION UNIT CHARGES CREDITS BALANCE Balance Forward 6,131.31 /' / PI] tV l-zAc-Lf --~ ) P\ 12-- ) 601 <_->i( Ct-\ -If' Jt'.06 j/ A' \ RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 68205 0.00 0.00 0.00 0.00 6,131.31 $6,131.31 RESIDENT NAME Mr. .J. MARK OWENS FormPB-Ol lUll A 1 % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! )f you have any questions or concerns about your biB, please address them directly to Fiscal Services at 790-8220. Thank You! ~~~~Jah 100 MOUNT ALLEN DRIVE. MECHANICSBURG. PA 17055 QUESTIONS? CALL (717) 697-4666 RESIDENT NUMBER I DATE 68205 09/30/2004 RESIDENT(S) RICHARD E MARTIN Mr. J. MARK OWENS 1510 BREEZEVIEW ROAD YORK, PA 17404 TOTAL AMOUNT DUE $1,217.31 DATE DUE 10/31/2004 $ DATE DESCRIPTION UNIT CHARGES CREDITS BALANCE Balance Forward 1,217.31 mecUM Is shll pt'Dcet61 rYj +{u OefY'O.rJ ~I\\' /Va ~mmr due o.+' +W6 pofl'1.t. ~Kk You/ ~ RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 68205 0.00 0.00 0.00 0.00 1,217.31 $],217.31 RESIDENT NAME Mr. J. MARK OWENS Form PB-01 :tli A ll'l;, finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! ~~~~Jah ~) r--... ~1 >r. ,..,,,,34 ,};;'(cCr (10") 100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055 QUESTIONS? CALL: (717) 697-4666 RESIDENT NUMBER DATE 68204 06/3012004 RESIDENT(Sl DORIS K. OWENS Mrs. DORIS K. OWENS 22D 222 MESSIAH CIRCLE TOTAL AMOUNT DUE $3,528.96 MECHANICSBURG, PA 17055 DATE DUE 07/31/2004 $ DATE DESCRIPTION UNIT CHARGES CREDITS BALANCE Balance Forward 3,769.00 06/17/2004 PAYMENT RECEIVED - THANK YOU!!' 3,769.00 0.00 *** Assisted Living *** 06/10/2004 BARBER/BEAUTY SHOP I 19.00 19.00 06/1512004 MISC. MED SUPPLY - AL I 4.25 23.25 1 BOX GLOVES 06/1712004 BARBER/BEAUTY SHOP I 12.00 35.25 06/23/2004 SRC - JUNIATA 06/01-06/23 23 2,760.00 2,795.25 06/2412004 BARBER/BEAUTY SHOP I 12.00 2,807.25 06/3012004 SRC - JUNIATA 06/24-06/30 7 638.40 3,445.65 *** Nursing Care *** 06/2912004 TRANSPORT A T10N 1 83.31 3,528.96 HSH TO MV; MEDICARE NON-COV'D / ---- h ?~~ 1\<b[;,\ o &i,lP II ~tfv' /'/.; ~ C:~::f r1;) ? /,/ RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 68204 3,528.96 0.00 0.00 0.00 0.00 $3,528.96 RESIDENT NAME Mrs. DORIS K. OWENS FormPB-Ol "" A Ii finante charge may be assessed on accounts for which payment has not been received by the due date. Thank you! If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! 1Jt(J iiJ!Jf\ -I Account #: 253155 Please Pay: $25.00 Due Date: 09/28/04 DORIS K OWENS IDM 253155/BANANI SAHA MD 06/24/2004 OFFICE / OUTPATIENT VISIT ESTABLISHED PATIENT EXP PROBL 65.00 65.00 06/24/2004 TETANUS AND DIPHTHERIA TDXOIDS ITDl ADSDRBED FOR USE IN 15.00 15.00 06/24/2004 IMMUNIZATION ADHINISTRATIOH (INCLUDES PERCUTANEOUS, INT 10.00 10.00 07/30/2004 SYSTEH CONTRACTUAL ADJUSTMENT FROM MEDICARE -14.52 07/30/2004 PAYMENT FROM MEDICARE -40,38 08/20/2004 PAYMENT FROM HALe -10.10 08/20/2004 PATIENT RESPONSIBILITY - NOH-COVERED SERVICES. -25.00 BALANCE TICKET NSFPOO1444 ,00 25.00 ~-~'. " .~ "- " V~;L)ck' \ \ \~ 6(\lV'lO\U ~{\ .-'()~ C s' J> 1/' ---~ ...""..".._._--,-,,- .-.--....,,--,--...-----...--..--.--.. .--.....-..-..---.--.-.------...--.--.--..........----.....---.-,--_..-,._---.-.-............ ..,-.-..---..--.-.-.......-............."........."."...,.........,...".......,..."....",..,...,...,..,.,....,...,..........,...-".-",.-.....".....,."..,',.,",',.,.,',.,....,.,.. ......................................... ..... ................... ..............IMf!ORtAifIT MESSAtEAElOltri'OlJRACCOONT ......... ..................... . '-:"-:'-':-:--':-:':':':--':-':;:::::::;:\?::;::::::::~~::;:~:::~~:;...,: ''':-:'': ". :.::.:: :_,:..:..: )ii.,:....:...',;:..:>:'.. .', ::::-..,:.<_.::_:_.:.::, :\_,:_,-: ,:,:. .:. :<-:,:,::,,-:::_.::,.,: :.', .:, ::)2;::,:-:-:;.....'. . PROMPT PAYMENT WOULD BE GREATLY APPRECIATED. 25. 00 ":~ '. r;; .00::1':'::;: V" 'J': 25;00 :.,,__:.;'F:'. Make Checks SHEPERDSTOWN FAMILY PRACTICE For Billing Questions CalF f;.. Payable To: (717) 766-1795 '-'- PLEASE DO NOT SEND CASH THROUGH THE MAIL EG1521-J2 PAGE 1 OF 1 "' 51108 REV-1513 EX+ (9-O0) . ~ I - -- - ~ SCHEDULE J I COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES i ____~N~~~~AE~;1Th~~~I:_..._ ______ ___ ___ __ __~_________ EST.A.TE()F------n--~ .. _n____ ----- - --I FILE NUMBER-- --. ----- Owens, Doris K. . _____ . 21 _ 04 _ 00696 J-- I RELATIONSHIP TO --'1- --- .------ ___~UMBER NAME AND ADDRESS O~ PERSON(S) RECEIVIN~ PROPERTY _. t_O"~~;~~IS) AMO~~~~;A*~~R~_ I TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1 . 1 Richard E. Martin, 1510 Breezeview Drive, York, Pennsyvlania 17404 Nephew 1100% , , i ! Enter dollar amounts for distributions shown above on lines 15 through 18. as appropriate, on Rev 1500 cover she9t II. NON-TAXABLE DISTRIBUTIONS: IA. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE i lB. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS I i I I TOTAL OFPART II-_ENTERTOT~=_NON-TAXABLE DISTRIB~TIONS ON LINE 13 OF REV-1500 COVER SHEEt _____ _m" ,"_. Pm ",,'___ ___.._"_____.. _...____ __ _ _______________'_ ________..._... _______ .' __ __m__ ___"0_______ Register of Wills of Cumberland County, Pennsylvania INVENTORY Estate of Owens, Doris K. ____ ____ ._. ______. No. 21 - 04 - OD~~_,____ also known as Date of Death 7/15/20.0.4 - ----~----- , Deceased Social Security No. 174-20.-5.1,9.0__,_ Richard C. Martin, a/k/a Richard E. -~---~-- .- --------- ----.- .~._----------. The Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. INJe verify that the statements made in this Inventory are true and correct. INJe understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 490.4 relating to unsworn falsification to authorities. Personal Representative ~ ~. -./ _.Ji- Attorney: j)orot~y Livaditis_________ Signature:... ~~~ -_~$~~_____ Richard C. Martin, a/k/a Richard E. Martin 1.0. No.: 2620.4 ___ ___ _ ____ Signature: _______ _,~---, Signature: __, ,____________=:.=_______ Address: 32 South Beaver Street Address: 1510. Breezeview Drive ", York,PA 1740.4 York, PA 1740.1 -, Telephone: 717/846-4818 Telephone: (717) 846-3191 -------'- -- --. ---~.._- - -- . -.------.----- c:::: Oated: CD ---.. -------_..~- Personal Property American Express - Mutual Funds - Account No. 0.112585539960.0.2 - 6486.448 shares 31,193,55 American Express - IMA Account - Account No, 0.0.0.20.40.81830.0.21 97,157.26 Krupp Funds Group, One Beacon Street, Suite 150.0., Boston, Massachusetts 0.210.8 - Account 647.50. No, A/C 117420.5192 (Government Income Trust) 250. shares @ $2.59 MetLife, c/o Mellon Investor Services, P.O. Box 4444, South Hackensack, NJ 0.760.6-20.44 - 3,334.86 stocks Investor lD No. 80.64 80.26 8551 - 97 shares @ $34.38 Prudential Financial, Inc., c/o Equiserve Trust Company, NA, P.O. Box 80.0.6, Edison, NJ 1,587.60. 0.8818-9320. - 35 shares @ $45.36 AF&L Insurance Company, P.O. Box 368,180.0. Street Road, Warrington, PA 18976 - Nursing 11,970..0.0. Home Policy Personal Property -- see attached appraisal from Kelly's Used Furniture 313.0.0. (Attach additional sheets if necessary) Total Personal Property and Real Estate $271,507,67 Register of Wills of Cumberland County, Pennsylvania INVENTORY continued Estate of Owens, Doris K. No. 21-04-00696 ------ .'---- ---~-._------ also known as Date of Death 7/15/2004 --------,---------. , Deceased Social Security No. 174-20-5190 --..--..--- '--"-- 1991 Ford Taurus - 4-door Sedan - see attached appraisal from Kelly's Used Furniture 1,000.00 PNC Bank, Messiah Village, Mechanicsburg, Pennsylvania 17055 - Certificate of Deposit- 11,472.63 Account No. 21001015277 PNC Bank, Messiah Village, Mechanicsburg, Pennsylvania 17055 _ Checking Account _ 19,715.91 Account No. 5070101934 PNC Bank, Messiah Village, Mechanicsburg, Pennsylvania 17055 - Savings Account- 92,115.36 Account No. 5002056385 West Shore Lodge B.P.O.E. #2257,108 North Street, Johns Church Road, Camp Hill, PA 1,000.00 17011 - Ownership Certificates in the amount of $250.00 each (4) - see attached. Total Personal Property $271,507,67 2 COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT,280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 005210 L1V ADITIS DOROTHY 32 SOUTH BEAVER STREET YORK, PA 17401 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold ---------- -------- 101 I . $5,885.76 ESTATE INFORMATION: SSN, 174-20-5190 I FILE NUMBER: 2104-0696 I DECEDENT NAME: OWENS DORIS K I DATE OF PAYMENT: 04/15/2005 I POSTMARK DATE: 04/14/2005 I COUNTY: CUMBERLAND I DATE OF DEATH: 07/15/2004 I I TOTAL AMOUNT PAID: $5,885.76 REMARKS: CHECK#1022 INITIALS: JA SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS - ,; IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Re: Estate of Doris K. Owens No. 21-04-0696 Deceased, Late of Upper Allen Township, Cumberland County, Pennsylvania RELEASE I, the undersigned beneficiary, named in the Last Will and Testament of Doris K. Owens, deceased, late of Upper Allen Township, Cumberland County, Pennsylvania, do hereby acknowledge receipt of my respective shares, in accordance with her Last Will and Testament, dated February 15, 2002, in which Last Will and Testament, I was named Executor, and was named and duly qualified before the Register of Wills of Cumberland County Pennsylvania, to act as Executor on July 26, 2004. All Assets, Debts and Deductions were outlined in the inheritance tax return filed with the Pennsylvania Department of Revenue and the Register of Wills of York County, Pennsylvania. I hereby confirm that any informal accounting would contain the same information as set forth in the Inheritance Tax Return. All known claims and expenses have been paid. As the main beneficiary in this estate, I waive the filing of a formal accounting hereby acknowledging that I have received all assets remaining after the payment of all claims, debts, distributions and deductions. And I do hereby further agree to reimburse said estate to such extent as may be necessary from my share if any further claims for taxes or by creditors should be proved, understanding, however, that tax and debts of the decedent have been paid as presented to date. IN WITNESS WHEREOF, I have hereunto set my hands and seals this 19ft- , 2005, meaning to :7un: ~. , (~) . ~~~Co://7/o4~ a: c> c.._J Richard E. Martin LLJ (y- <. - . . . ~ PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Tamm . Shoemaker Customer Care Sales Mana er, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th, 1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following date(s) September 22, 29, October 06, 2004 COPY OF NOTICE OF PUBLICATION eXECUTOR'S NOTicE - Estate ot DORIS K. OWENS, late of Upper Affiant further deposes that he/ she is not Allen Township, Cumberland County, interested in the subject matter of the Pennsylvania, deceased. aforesaid notice or advertisement, and that letters Testamentary on the last Will and all allegations in the foregoing statement Testament of said decedent having been as to time, place and character of granted to the undersigned, all persons 3;;;;:;;;;~~ ~bt( indebted thereto are required to make immediate payment, and those having claims against the same, to present them without delay tor settlement. Richard E. Martin, Executor 1510 Breezevlew Drive York, PA 17404 Sworn to and subscribed before me this Dorothy livaditls, Esquire 06th day of October, 2004 32 South Beaver Street York, PA 17401 Attorney --~_. au. >fb~:t; . LUi~ My commission expires; C; /1 jar COMMONWEAl TH OF PENNSYLVANIA Notarial Seal Chnstina L ware, Notcvy Public CarlISle BOra, Cumberland County My CommISSIon Expires Sept 1 2008 Me be ' m r, PennsYlvania ASSOCiation Of Notaries - - . ~ PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 STATE OF PENNSYLVANIA : : ss. COUNTY OF CUMBERLAND : Lisa Marie Coyne, Esquire, Editor ofthe Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, VIZ: SEPTEMBER 24, OCTOBER 1, 8,2004 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. /~. ~)t;-~ V - SWORN TO AND SUBSCRIBED before me this Owens, Doris K., dec'd. 8 day of OCTOBER 2004 Late of Upper Allen Township. Executor: Richard E. Martin. 1510 BreezevJew Drive. York. PA 17404, Attorney: Dorothy Livaditis. Es- quire. 32 South Beaver Street. York, PA ] 7401. N 1\ SEAL LOIS E. SNYDER, Notary Public CEli!lsle Boro, Cumberland County ,'i'l' Commission Expires March 5. 2005 ":.~".-;:. 01':.' '" (Rev. 5/(2) CUMBERLAND Before the Register of Wills of mff County, Pennsylvania Name of Decedent: Doris K. Owens Date of Death: July 15, 2004 FileNo,: 21-04-0696 -~-~- Status Report under Rule 6. J 2 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above captioned estate: 1. State whether administration of the estate is complete: Y es:_~__No:_ 2. If the administration of the estate if not complete, state when the personal representative(s) reasonably believe(s) that the administration will be complete: 3. If the administration of the estate is complete, state the following: a. Did the personal representative(s) file a final account with the Court? Yes: -~- No: 'X b. Did the personal representative(s) state an account informally to the parties in interest? Yes:_~_No: Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: 1~ 1(-~()5' Signature Typed Name: Dorothy Livaditis, Esquire Supreme Court LD. No.: 26204 Address: 32 SOlltn R""ver Street York, PA 17401 N Telephone Number: (717) 846-4818 - Capacity: Personal Representative (._.'1 (-.:l .- - ---X-.. Counsel for .. .~"'" (1.- Personal Representati ve - ("',.1 . -' ==s t...~ C-:",) ~ c:.~::,~1 .:-.,