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02-0990
This is to certify that the information here given is correctly copied From an original certificate c>f death duly Filed with one as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. ~.,~ ~,. ', -~ ,- -, ~„-,,- Fee for this certificate, $~..00 ~,,~~"NTH Of p ~ Sharpe A. Brenize, Jr. Cumberland County PETITION FOR GRANT OF LETTERS Estate of Sharpe A Brenize Jr. No. ~ (' n ~ " 990 also known as Deceased Social Security No193-24-1302 Ronald Brenize Petitioner(s), who is/are 18 years of age or older, apply(ies) for (COMPLETE "A" OR "B" BELOW:) A. Decedent, dater+ Probate and Grant of Letters and aver that Petitioner(s) is/are the execut and codicil(s) dated 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 incapacitated: B. Grant of Letters of Administration (c.t.a., d.b.n.c.t.a.: pendente life, durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained the Decedent left no Will and was survived by the following spouse (if any) and heirs: Name Relationship Residence Carla Hess dau hter 25 Oak Lane Shi ensbur PA Karen Carr dau hter 127 Forest Rid a Sterlin VA Cind Booz dau hter 1207 Kin sbrid a Terrace Mt.Ai MD Richard Brenize son 1054 Ashton Dr. Shi ensbur PA Randall Brenize son 728 Roxbu Rd. Shi ensbur PA (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or principal residence at 121 Walnut Bottom Rd. Shippensburq (Shippensburq Township), PA (list street, number and municipality) Decedent, then 78 years of age, died September 3 , 2002 , at Chambersburg Hospital,_Chambersburg, PA (Location) Decedent at death owned property with estimated values as follows: (if domiciled in PA) All personal property ....................................... (if not domiciled in PA) (If not domiciled in PA) Personal property in Pennsylvania .................... Personal property in County .............................. $ 1,500.00 val~~P of raal estate in Pennsylvania ........................................................................................ $ 0.00 Total ..................................................................................................................... $ 1,500.00 Real Estate 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: named in the Last Will of the Signature Typed or printed name and residence Oath of Personal Representative Commonwealth of Pennsylvania COUnty Of Cumberland The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate accord g to law. Sworn to and affirmed and subscribed Fna.e,C~l „~~-utter/ 4tr: Ronald Brenize before me this- -_ day of TlO~'EMBER 2 0 0 ~ U DECREE OF REGISTER Estate of SharoeA. Brenize. Jr. Deceased No._~ ~' ~a - QQO also known as Social Security No: 1932241302 Date of Death: 9/3/2002 AND NOW, NOVEMEER 6 , 2 0 0 2 2002 , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters Q Testamentary ~ of Administration (c.t.a., d.b.n.c.t.; pendente life; durante absentia; durante minoritate) are hereby granted to Ronald Bren in the above estate and that the instrument(s), if any, dated described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters ................................ .... $ 2 5 . 0 0 Short Certificate(s) ............. .. $ 9 . 0 0 Renunciation ...................... .... $ 2 5 . 0 0 Affidavit ( ) ................... .... $ Extra Pages ( ) ........... ... $ Codicil ................................ . $ JCP Fee .............................. ... $ 1 0 _ 00~~~ Inventory & Tax Forms ........ ..... $ Other ................................... ... $ TOTAL .............................$ 6 9 . 0 0 g;p~x Attorney: Joel R. Zullinger I.D. No: 17516 Address: 14 North Main Street Suite 200 Chambersburg PA 17201 Telephone: (717)264-6029 DATE FILED: 10-6-2002 mailed to atty 10-6-2002 RW-7A tUiRli~ kliV'9;8g _ This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the Stare Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. -~ ~, Fee for this certificate, X2.00 ~/ ~ocal Registrar __~ 8474~~8 N~. R« 21ST COMMONWEALTN OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VtTAI RECORDS CERTIFICATE OF DEATH •• ~~c~ Dare • nnaRNUlCGDENTIFng.Mgdalavl -_-- -- SEX SOCIAL $ECURITYNUMSER DATEOF DEATNM M.[ ~+a~l - - ' SHARPE A. HRENIZE JR. ~~ P' 193 _ 24 - 1302 ' 09 03 2007 AOE ILap S.meaYl UNDER 1 YEAR UNDER 1 DAY DATE a •IRTN t/UTTNPIACE tC•h ane ~MOnM Oa `barl $rb M F D C M P A a DEdN ICN U only - nn• +N nNrueMan nn nlnar _ ~•+ _ _ _ '~--- Yn. pKM ana Ilalaa t MUIaa . y d aag~ OwwY) E D'bWpSSV]-112, ___.__ OTNER~ __. -- _ __ .__. IrpaMM ® ERIOVpMbrK ^ DOA ^ N~"1• 1 Otlw 78 • ~ ~~r,k7 in lvF.. Nunn ^ RwWnn 1J ~SOrrM1 ~~ COUNTY OF DERN CrtY, 8080. iWP OF OFATN FACERY NAME PI nd Mpmnam, qwe WM arW manear~ O EGEDEM Oi NF$PANIC OPoGIN9 RAGE ~ Am•ncan Inaan, RM[+ w~na .•c . - ~~ yy , (SPxMI Na ml w ^ K ya apacKT CuMn . .. Franklin •a. Chambersbur •a Chamberabu Hos -ital. Mreer,.rlapbinrrl'pP. White • ,•. DECEDEM'S USUAL OCCUPRION KIND Of BUSINESSRNDUS}RY WAS DECEDENT EVERM OECEDENI"SEDIMJ•10N MAlMTAL ,4TATU8. "'!- Manrd SURVIVING SPfMI lGn'a anddagrM dPM OUruu mop U S ARMED FORCE37 ~ qq . . N.rlr Mahbd, Wfmwa. mwe,~mab d wMin•Mr: do nd uM rafirep) 1 w^ NP® SleonOary Colala DhaandlSpecMT • ,,. Baker ,,.,Valley Baking Co. ,,. ~~ g '~s • n ~«$.1 It Divorced ,!. __.___.__I DECEOENT'SMAILIN(i ADDRESS tSIraw;CMnu•n, Star. IO Codel DECEDENT'S - • Acruu na.sbu_lvennsvlvania Dra na.Gdw.an.a.Mw.eln Shippensburg Twp. 121 Walnut Bottom Rd. ~,e~„~I,d„ d•~ w.m. ,a Shi ensbur , PA 17257 °"d"°fe'dp Cumberland 1D"'""4T "'~°`aY0"'E"° ,Tb. na^ •aMl.rnrlmwd FATHER'S NAME (Fief. MXlda. Laxl __.Mmao MOTHER'S NAME Ifap. Mdflla. Mptlan Swnama) -__- .. - 1 u. Shat a A. Brenize Sr. ,•, Pearl; E. Kuhn •6OIMAANT'4 NAME (tyPwriXl INFtDRMANi' MAKJaIp $618aaa1.. .91ab. zp COdq ..----- " Ron L. Brenize 27 Nort Acorn Dr,. Boilin S tin s PA 17007 METNOOOF DISPOSITIDN _~.__. p8M91T10N ar 0•w PtlP• ~ LOCIEgN -CKy/ban., Stpa. Zn Copa ~ • ~ ~~^ ~~~~Q ~ ^ Lurgan Township Dp.aletl^ a Fl .arc . ma ,n, 09-07-2002 „e.Otterbein Cemeter :t•. Franklin Count PA OFF RAL SERVICEL FOR RS011 ACTING A99lIG11 ICFNSE NUMBER NAME AND AOORE98 .012984-L - F.H. TnC. P.O. HoX 336 PA 17257 . a.ma zo..e en .rbn n.ml ONYpcrn p r1d avaaa0la N IKlla eI dNm ro IM EaN d my Mnowbdla~ A M•M al tM nma, Pala ane dsro alpap. LICENSE NU ER ---~-' -'"' ,Sgrpure arM Tmal~ v GATE SIGNED l ~ t'N-3'lEC7~L ^- 3-O ti , . .Dw. •earl - e.MY Ue..aa.pn. /~/ I !alto T42B rIXM MCanPbttl PY TIME D<pEATN DATE PRONOUNCED DEAD IMenM, Oay. yaerl Vl1.4 FERRED Ip MEDICAI E%AMINERICORONERf - --{ - Parson wlr 0•erlP+•ICw dapA . n. MRT L EMN Kb daaaaaa, xyurief a compafatorb wni;n caused IM W atA Do net aMar tM naM al Oyirq, fucA as urdb<or raelnntory asap, snxX a Mar, Iplun t Applomwa PAIIT M: dMr --- -r Lip oNy orb uuv on sang Nb. ai•ru,ICa1K dAYAOena amtMapvgro Matn. ha ~ ; jpRM aaW drN nK nweiepn uJe^Y'n4 u~rss Tv'+^ F'nRt YI[OMT[ CAIIlE IFwI '~FML'+~',~ __ 7----- • f i ouEroIDRASAC ouENCEOF~: -- -------- --- s.IAbMIrYrYanelorb e. C~df ~ + ~ K•IM.I••dWbamn0lpa rola+ASacaNS E oFl: ~ -------. ~~ _ °"" Enbr IROERLr•tD ~ I: ` ~ _.... • Inp abpep avada pIEN A ENCE -.--_ CONSf1W OFI: rmlrq n dapAl LA•T , d _ __.-__ WAB AN AUtOPSY WERE AUTOPSY FINdN09 ER OF DEATH DATE OF INJURY iIME OF INJURY INIURYQ WpIKT DESCRIBE NOW INJURY OCCURRED PEAFORMEDT MAVIABLE PFiK%i 7p IMmM. DaY Berl ~NETION OF CAUSE NpurN .YJ Mdnld.a ^ ACCiMM ^ PaMIn• InyaallVMlon ^ w ^ No ^ I 70a. M. w ^ w ^ N• ^ Sukia ^ Coub mlMdala.minsp ^ PUCE DF IN RY --.-_ JU .MMm•. !arm, praM. tadery, o111Ea. LOCATION ($bew. Cay/TOwn.$rtel _...- E ilAr S u pecMl q, aK. I 1•a. 2b. !•. i0a. 9Pf. fJERTIF1ER tCMdaNyorol 'CFIITIFYIIIG MIYSICIAM IPnys¢an umeyaq nay d plain wMn andlror plryscan nas parounce0 pealn arw competed Item 2J1 -.. SK31aAT CERTIFIER -.__. Te UIa Mal ei mY Xrowrd•a, MaM attlKnd dIr b sM cauae(sl and mambr n al•W ..................................................... . ~ I 'tM1pMOUNCNq AND CERTIFYING aMYlICIAM IPIIys~an exun;a>rrd;•cne uaetn xW CMnysp to causedneatnl LK:F N4MItlFR DATE SgNEDIMdnn Dav'aea~l ______- ~ va ~L: /~~ ~~ 2 db eaat d my Ynearbdgw, aaN oecurrad M ura Blna, pate, arq plaea, arM dua b tAa cWaa(a) and manner as sbtad .. ................. ~. 71C. ~('•J 7 0 ' 714 • 'MEDICAL EkAMINER/CORONER NAME AND OF RSON WIIO COMPLETED CAUSE~OF DEATN Otnn 2717yp! a RIM ~i.i! ~~ ~ A~ ~~ ~Y ^ p R A. S Y !T /7T V On iM Mtla of aaamlrotlon and/a Imaatl•alion, In my ppinien, dlatR aecunad M IKe Ilme, daN, and pbea, aM tlu• to IM eau a(Q ArM manner as atatw ~ , - . ` _ ~/~ ~ - K.N' 7777~ 6 7/¢ ~` ~ ................................. ..... ............ .... ...... ......... ..... ^ REGI$TRAR'$$IGNATVRE AND NUMBER ~- /(//~~ G) ~ / I ]l _ 23 /~a2 ~- j~q ~ -~_~_.LTxdJf ~ ' DATE FILEDIMenM Day Y/eF//~J/~ / -' •-- ~ ~ J _ - Cumberland County Sharpe A. Brenize RENUNCIATION Estate of Sharpe A. Brenize No. _ r~ ~ - ~ ~ - ~C3© also known as ,Deceased The undersigned,Carla Hess, daughter (Relationship) (Capacity) Of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration be issued to Ronald Brenize Witness mV hand this '2U'h day of ~~ ~ °~~`'~ , 2002 Carla Hess ~ v -~ 25 Oak Lane, Shippensburg PA 17257 (p (Address) ~s~~'~~~~'~ Af~`la,,~~l.~'~ (Signature) Sworn to or affirmed and subscribed before me this day of Notary Public My Commission Expires: (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) (Address) (Signature) (Address) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 Cumberland County Sharpe A. Brenize RENUNCIATION Estate of Sharpe A. Brenize No. _ L~ / - (', -~1 - ~~ (~ also known as ,Deceased The undersigned,Karen Carr, daughter (Relationship) (Capaaty) Of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration be issued to Ronald Brenize Witness -nY hand this ~_ day of ~~ OfJe t"' , 2002 Sworn to or affirmed and subscribed before me this day of Notary Public My Commission Expires: (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) Karen Carr ~-' 127 Forest Ridge, Sterling VA 20164 (Address) (Signature) (Address) (Signature) (Address) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 Cumberland County Sharpe A. Brenize RENUNCIATION Estate of Sharpe A. Brenize No. ~ I - ~ a - ~~{ (3 also known as ,Deceased The undersigned,Cindy Booz, daughter (Relationship) (Capaaty) Of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration be issued to Ronald Brenize Witness mY hand this~_ day of ~~ 2002 Sworn to or affirmed and subscribed before me this day of Notary Public My Commission Expires: (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) J ~.~~yi~gyaia/ Cindy Booz 1207 Kingsbridge Terrace Mt Airy MD 21771 (Address) (Signature) (Address) (Signature) (Address) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 Cumberland County Sharpe A. Brenize RENUNCIATION Estate of Sharpe A. Brenize No. `~ ~ - ~ ~ ' ~'~ ~t (~ also known as ,Deceased The undersigned, Richard Brenize son (Relationship) (Capacity) of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration be issued to Ronald Brenize Witness mY hand this ~0 tk day of ~c~r~'~`t , 2002 Sworn to or affirmed and subscribed before me this day of Notary Public My Commission Expires: (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) (Address) (Signature) (Address) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 (Signature) Richard Brenize Cumberland County Sharpe A. Brenize RENUNCIATION Estate of Sharpe A. Brenize No. ~ ~ - ~ :~ - ~ 1 C~ also known as ,Deceased The undersigned, Randall of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters of Administration be issued to Ronald Brenize Witness mV hand this ~ TH day of ~~ ~~ , 2002 ~. i ~ ~ n Randall Brenize ~v ~ y ~ y~ 728 Roxbury Road, Shippensburg PA 17257 (Address) (Signature) (Address) (Signature) Sworn to or affirmed and subscribed before me this day of Notary Public My Commission Expires: (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) (Address) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3 Cumberland County Este of Sharpe A. Brenize, Jr. CERTIFICATION OF NOTICE UNDER RULE 5 6(a) Name of Decedent: Shar e A. Brenize Date of Death: 9/3/2002 Will No. 2002-00990 Admin. No. 21-02-990 To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphan's Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on 10/2/2002 Name Address Ronald Brenize 27 Acorn Drive Shi ensbur Randall Brenize 728 Roxbury Road PA 17257 Shi ensbur Richard Brenize PA 17257 1054 Ashton Drive Shi ensbur Cindy Booz PA 17257 1207 Kingsbridge Terrace Mt. Ai MD 21771 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: no exce tions Date: 2/12/2003 "'~- ~ ~~ t ~ , /,.~a ", a~ 1 7 Signature Name: Joel R. Zullinoer Address: 14 North Main Street Suite 200 Chambersburg PA 17201 Telephone(264) - 6029 Capacity: X Personal Representative X Counsel for Personal Representative Continuation of Certification of Notice Under Rule 5.6(a) Sharpe A. Brenize Names and addresses Page 1 9/3/2002 Name Address Carla Hess 25 Oak Lane Shi ensbur PA 17257 Karen Carr 127 Forest Ridge Sterlin VA 20164 REV-1500EX"(6-00) '* COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-{)601 REV -1500 INHERITANCE TAX RETURN RESIDENT DECEDENT I- Z W C W U W C w .... ~:!;U) 0"'''' w"o ,,00 og:~ .. " z o ~ <C ...J ~ l- ii: <C U w a:: z o ~ <C I- ~ II.. ::!!! o U >< ~ DECEDENT'S NAME (LAST, FIRST. AND MIDDLE INITIAL) Brenize Shar e A. Jr. DATE OF DEATH {MM--OO-Year) OA1E OF BlR1H (MM-OD-Year) 09/03/2002 12/04/1923 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) [Xl 1. Original Retum o 4. Limited Estate o 6. Decedent Died Testate (Attach copy of Will} o 9. Litigation Proceeds Received o 2. Supplemental Retum o 4a. Future Interest Compromise (dale of death after 12-12-82) o 7. Decedent Maintained a living Trust (Attach copyofTrustl o 10. Spousal Poverty Credit (date of death between 12.31-91 and 1.1-95) OFFICIAL USE ONLY / 1"/-9';;- /~ FILE NUMBER 21 -0 2 0990 ""CciUNTY""CciDE ---VEA;r--- - - NUMBER- - SOCIAL SECURITY NUMBER 193-24-1302 THIS RETURN MUST BE FilED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER o 3. Remainder Retum (date of death priorto 12-1J.82) o 5. Federal Estate Tax Return Required _ 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) {Attach Sch 0) .... z w c z o .. <II W '" '" o o '\!\1!iI~\!JMIlS,il!le!e~I!_.;i'.lWill~ NAME Joel R. Zullin er FIRM NAME (If A"'<abIe) Zullin er-Davis P.C. TELEPHONE NUMBER 717 264-6029 ND Hlle! Chambersbur (1) (2) (3) (4) (5) 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedeni Mortgage Liabilities, & Liens (Schedule I) 11. T alai Deductions (total Lines 9 & 10) 12. Net Value of Estate (LineB minus Line 11) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) (6) (7) (9) (10) 14. Net Value Subject to Tax (line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of line 14 taxable at sibling rate 18. Amount of line 14 taxable at collateral rate 19. Tax Due X _(15) X _(16) X .12 (17) X .15 (18) (19) 20. 0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT _Yi_lllitltiiii PA 17201 OFFICIAL USE ONLY 994.421 1 1 1 I I I ___I 1.__- (8) 994.42 6,736.14 18,390.21 (11) (12) (13) 25,126.35 -24,131.93 (14) -24,131.93 , i..>'i>' .BE'SUR!TO:ANSWE~:AI:J!'QtlESTIONSi(!)N,RElIERSE'SIDe;AND ~ECHeCK.M:ATH(;,::",j;,...... .'. .' ' D d . C I t Add ece ent s omDle e ress: STREET ADDRESS 121 Walnut Bottom Road CITY I STATE I ZIP Shippensburg PA 17257 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits ( A + B + C) (2) 3. InleresUPenalty If applicable D. Interest E. Penalty T otallnteresVPenalfy ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the total of Line S + SA. This is the BALANCE DUE. (SB) Make Check to: REGISTER OF AGENT 0.00 0.00 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; ........................................................................... 0 00 b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 00 c. retain a reversionary interest; or ...................................................................................................... 0 (Kl d. receive the promise for life of either payments, benefits or care? ............................................................. 0 00 2. If death occurred after December 12, 1982, did decedenl Iransfer property wilhin one year of death without receiving adequate consideration?............................................................................................... 0 00 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. 0 00 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................... .......................... ..................... 0 00 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and 10 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. SIGNATURE Of PERS~SIBLE FOR FILING RETURN DATE ;t tf~ /oZ/tJ/.lPl), ADDRESS 27 North Acorn Drive Boiling Springs REPARER OTHER TH ~ PA 17007 DATE /Z I 0" 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 orforthe use of the surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)]. 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. ~9116 (a) (1.1) (ii)]. The statufe does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are stili applicabie 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 twenty-one years of age or younger at dealh \0 or for Ihe use of a nalural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. ~9116(a)(I.2)]. The lax raleirnposed on the nel value of transfers to or for the use of the decedent's lineal beneficiaries is 4.S%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(I)J. The tax rate imposed on the net value of transfers to or for the use at the decedents siblings is 12% [72 P.S. ~9116(a)(1.3)1. 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. RE"~"'I''':.. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENl SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FilE NUMBER Brenize Shame A Jr. 21 02 0990 Include the proceeds of fttlgation 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 NUMBER 1. DESCRIPTION Checking Account #334626, Orrstown Bank, including interest accrued to date of death VALUE AT DATE OF DEATH 994.42 TOTAL (Also enteron lineS, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 994.42 """"""'I'.,,!.. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RES1DENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Brenize Shame A Jr. FILE NUMBER 21 02 0990 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Fogelsanger-Bricker Funeral Home 6,357.14 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) 0.00 Social Security Numbe~s) I EIN Number of Personal Representative{s) Street Address City State Zip Yea~s) Commission Paid: 2. Attorney Fees Joel R. Zullinger 300.00 3. Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation) 0.00 Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Mary C. Lewis, Register - Letters 25.00; renunciations 25.00; short certifi- 79.00 cates 9.00; JCP fee 10.00; filing return 10.00 5. Accountanfs Fees 6. Tax Return Preparers Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ 6736.14 (If more space IS needed, Insert additional sheets of the same size) REV'''''''''''''''._ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF Brenize. Shame A. Jr. FILE NUMBER 21 02 0990 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 284.00 1. Shippensburg Health Care Center 2. Commonwealth of Pennsylvania. Department of Public Welfare; CIS #810107352 18,106.21 TOTAL (Also enteron line 10, Recapitulation) $ (If more space is needed, Insert additional sheets of the same size) 18390.21 TO Law Offices Zullinger-Davis 14 North Main Street Suite 200 Chambersburg, PA 17201 FROM ORRSTOVVN BANK P.O BOX 250 SHIPPENSBURG PA 17257-0250 RE: ESTATE OF Sharp A Brenize Jr. DECEASED DATE OF DEATH: September 3,2002 IT IS HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD, ON THE ABOVE DATE, THE FOLLOWING ACCOUNTS WITH ORRSTOWN BANK: (1) CHECKING ACCOUNTS ACCOUNT NO. TITLE OF ACCOUNT DATE OPENED 334626 Sharpe A Brenize 7/1/79 DATE OF DEATH PRINCIPLE & ACCRUED INTEREST 994.3012 (2) SAVINGS ACCOUNT DATE OF DEATH ACCOUNT NO. TITLE OF ACCOUNT DATE OPENED PRINCIPLE & ACCRUED INTEREST (3) CERTIFICATES OF DEPOSIT DATE OF DEATH ACCOUNT NO. TITLE OF ACCOUNT DATE OPENED PRINCIPLE & ACCRUED INTEREST Date: 11/19/02 By: Timothea Customer Service Operator "'_' S " ":;'~ " r-:' ; ; : ,~ ~ ~~ cmllMCNWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS ESTATE RECOVERY PROGRA1I.1 PO BOX 8485 HARRISBURG, PA 17105-8486 November 19, 2002 ZULLINGER DAVIS LAW OFFICES JOEL R ZULLINGER ESQUIRE 14 NORTH MAIN STREET SUITE 200 CHAMBERS BURG PA 17201 Re: SHARPE BRENIZE CIS #: 810107352 SSN: 193-24-1302 Date of Death: 09/03/2002 Dear Mr. Zullinger: Please be advised that the Department of Public Welfare maintains a claim in the amount of $18,106.21 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $~8,l06.21, was incurred during the last six months of the decedentrs life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $.00, is to be entered as a priority Class 6 claim against the estate. ---- Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed~ the latest tax assessment, and a current appraisa~~ if available. Sincerely, ~a.}~ Debra A. wiest TPL Program Investigator 717-772-6713 717-772-6553 FAX Enclosure . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTiON - CASUALTY UNIT PO BOX 8485 HARRIS3URG PA 17105-8486 November 19, 2002 STATEMENT OF CLAIM SUMMARY Estate of BRENIZE, SHARPE 810107352 INPATIENT OUTPATIENT LONG TERM CARE DRUG .00 .00 .00 .00 .00 16,690.85 1,415.36 .00 16,690.85 1,415.36 .00 .00 18,106.21 .00 18,106.21 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLle WELFARE November 19, 2002 STATEMENT OF CU\JM NAME BRENIZE, SHARPE ID 810107352 PHARMACARE INSTITUTIONAL SERVIC ONE JAMES DAY DRIVE CUMBERLAND MD 21502 ~AYM~~+DAj~ 04103/02 - 04/03/02 07/01/02 215673404201 000000000000 11.10 8.01 DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 04/06/02 - 04/06/02 07/01/02 215673404401 000000000000 17.25 9.B5 DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 04111/02 - 04111102 07101102 215673421401 000000000000 17.25 9.85 DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 04116/02 - 04116102 07101102 215673440501 000000000000 17.25 9.85 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 04122/02 - 04/22/02 07101102 215673440701 000000000000 17.25 9.85 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 ; PROCEDURE: 04/30/02 - 04130/02 07101/02 215673338601 000000000000 39.05 33.74 DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 04/30/02 - 04130/02 07/01102 215673450101 000000000000 10.15 7.39 DIAGNOSIS 1 : PREse PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 04/30/02 - 04/30/02 07/01102 215673338501 000000000000 57.19 48.43 DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELF,~RE Noyember 19, 2002 STATEMENT OF ClAlM NAME BRENlZE, SHARPE 10 810107352 PHARMACARE INSTITUTIONAL SERVIC ONE JAMES DAY DRIVE CUMBERLAND MD 21502 DATE OF SERVICE PAYMENT DATE ",MOUNT APpROVED 04/30/02 . 04/30/02 07/01/02 215673399401 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 9.28 6,19 04/30/02 . 04130/02 07/01/02 215673338301 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 59.1'1 51.80 04/30102 . 04130102 07/01102 215673450301 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 12.88 10,19 04/30/02 . 04/30/02 07/01102 215673450201 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 00000000??oo 11,84 4.84 04/30/02 - 04/30/02 07/01/02 215673378801 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 10,30 5.31 04/30/02 . 04130/02 07/01/02 215673389901 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 13.98 8,28 04/30/02 - 04130/02 07/01/02 215673338401 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 46,05 40.04 04/30/02 . 04130/02 07/01/02 215574785901 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 13.75 10.37 I '- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE ~ NO'lemb9r 19, 2002 STATEMENT OF CLAIM NAME SRENIZE, SHARPE ID 810107352 PHARMACARE INSTITUTIONAL SERVIC ONE JAMES DAY DRIVE CUMBERLAND MD 21502 ~AYMENT DATE AMOUNT APPROVED 05/18/02 - 05118/02 07/01/02 215574748101 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 25.38 15.94 05/19/02 - 05119/02 07/01/02 215673412601 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 11.10 8.01 05/31/02 - 05131/02 07/01/02 215474875201 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 12.65 7.57 05/31/02 - 05/31/02 07/01/02 215474874901 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 9.91 5.19 05131/02 - 05/31/02 07/01/02 215474892801 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 21.20 15.75 05/31/02 - 05/31/02 07/01/02 215474892701 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 43.88 43.48 05/31/02 - 05/31/02 07/01/02 215474875601 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 38.28 33.05 05/31/02 - 05/31/02 07/01/02 215474875101 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 9.11 5.54 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WElFA.RE Nov:ember 19, 2002 STATEMENT OF CLAIM NAl\.lE.\8REN1ZE, SHARPE 10 810107352 PHARMACARE INSTITUTIONAL SERVIC ONE JAMES DAY DRIVE CUMBERLAND MD 21502 DATE OF SERVICE' PAYMENT DATE: 05131/02 - 05131102 07/01/02 215474875501 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 05131102 - 05131/02 07/01102 215474875001 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 05/31/02 - 05131102 07/01102 215474892601 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 05131/02 - 05131102 07/01/02 215474875401 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 05131/02 - 05131/02 07101102 215474892501 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 06/21102 - 06/21102 07122102 217674531001 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 06/29/02 - 06/29/02 07129/02 218270174401 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 06130/02 - 06130102 07/29102 218370694901 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 54.87 12.57 56.73 12.32 23.66 17.25 38.28 "..,1 AMOUNT APPROVED 47.98 8.98 5.99 9.90 49.65 4.91 19.89 9.85 33.05 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE Nov~mber 19, 2002 STATEMENT OF CLAIM NAME BRENIZE, SHAR?E ID 810107352 PHARMACARE INSTITUTIONAL SERVIC ONE JAMES DAY DRIVE CUMBERLAND MD 21502 DATE OF SERVICE ~ ~ PAYMENT DATE 06/30/02 - 06130/02 07/29/02 218370547901 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 06/30/02 - 06/30/02 07/29/02 218370618501 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 06/30/02 - 06/30/02 07/29/02 218370618301 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 06130102 - 06130102 07/29/02 218370618401 DIAGNOSIS 1: PRESC PRESCRIPTION D~UGS DIAGNOSIS 2 : PROCEDURE: 000000000000 06/30102 - 06130/02 07129/02 218370695001 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 06/30/02 - 06/30/02 07/29/02 218370547801 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 06/30102 - 06/30/02 07/29/02 218370694801 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE; 000000000000 06/30/02 . 06/30/02 07/29/02 218370547601 DIAGNOSIS 1; PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 ; PROCEDURE: 000000000000 >",:','i,.\.,"'., ',;\,',:<,\:"t USUAL CHARGES 'AMOUNT APPROVED 8.98 12.57 7.18 11.84 54.87 12.98 62.07 8.86 5.99 9.90 5.06 4.84 47.98 7.75 54.45 6.57 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WElF~RE "~ , i , I November 19, 2002 STATEMENT OF CLAiM NAME BRENIZE, SHARPE 10 810107352 PHARMACARE INSTITUTIONAL SERVIC ONE JAMES DAY DRIVE CUMBERLAND MD 21502 'DATEOF SERVlCE PAYMENT DATE 06/30/02 - 06/30/02 07/29/02 218370694701 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 06/30/02 - 06/30/02 07/29/02 218370618601 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 06/30/02 - 06/30/02 07/29/02 218370547701 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 07111102 - 07/11102 08/12/02 220073383301 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 07[17/02 - 07117102 08/19/02 220674011001 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 07/17/02 - 07/17/02 08/19/02 220673938701 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 07/24/02 - 07/24/02 08/19/02 220671394301 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 07/26/02 - 07/26/02 08/19/02 220773627801 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 54.50 47.64 11.43 8.88 9.31 5.25 7.18 1.06 12.20 5.58 10.29 3.8S 12.87 10.17 17.25 9.85 r- COMMONWEALTH OF PENNSYLVANIA CEPARTMENT OF PUBLIC WELFARE November 19, 2002 STATEMENT OF CLAiM NAME BRENIZE, SHARPE 10 810107352 PHARMACARE INSTITUTIONAL SERYIC ONE JAMES DAY DRIVE CUMBERLAND MD 21502 < DATE OF SERVICE PAYNlENT DATE uifuAL CHARGES AMOUNT APPROVED 07/27/02 - 07/27/02 08/26/02 221174894401 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 10.49 7.18 07/30/02 - 07/30/02 08/26/02 221174917901 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 18.49 14.26 07/30102 - 07/30/02 08/26102 221174917801 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 33.49 26.86 07130102 - 07130/02 08/26102 221174894301 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 36.49 30.43 07130/02 - 07/30/02 08126102 221174885301 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 10.~9 7.09 07/30/02 - 07/30/02 08/26/02 221174875301 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 9.9~ 8.57 07/30102 - 07/30/02 08/26/02 221174856001 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 8.49 5.39 07/30102 - 07/30/02 08/26/02 221174950501 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 15.49 11.67 ~ , COMMONWEALTH OF PENNSYLVANIA DEPAClTMcNT Of PUBLIC WELFARE November 19, 2002 57 A TEMENT OF CLAH"..l NAME BREN1ZE, S;"lARPE ID 810107352 PHARMACARE INSTITUTIONAL SERVIC ONE JAMES DAY DRIVE CUMBERLAND MD 21502 DATE OF SERV1CE~ ~ PAYMENT DATE USUAL CHARGES~ AMOUNT APPROVED I 07/30/02 - 07/30/02 08/26/02 221174941801 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PRUCEDURE: 000000000000 10.99 4.49 07/30/02 - 07/30/02 08/26/02 221174931901 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 24.49 19.89 07/30/02 - 07/30/02 08/26/02 221174928601 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 32.49 27.03 08/02/02 - 08/02102 08/26/02 221473051101 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 18.00 9.85 08/02102 - 08/02102 08126102 221473048701 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 18.99 8.21 08/02/02 . 08/02102 08/26/02 221473023501 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 63.49 50.00 08/09/02 - 08/09/02 09/02102 222170716901 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 11.99 8.01 08/16/02 - 08/10/02 09/09/02 2228732'11901 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 18.00 9.85 COMMONWEALTH OF PENNSYLVANIA DEPil,R1MENT Or PUSUC VJELE'\RE J Nov~rnber 19, 2002 STATEMENT OF CLAiM NAME BRENIZE, SHARPE 10 810107352 PHARMACARE INSTITUTIONAL SERVIC ONE JAMES DAY DRIVE CUMBERLAND MD 21502 DATE OF SERVICE PAYMENT DATE ORIGINAL. CRN '>:<:.>>:: <.<:.'..:~.:.:...:.:'>': ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 08/16/02 - 08/16/02 09/09/02 222873204301 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 18.99 8.21 08/16/02 . 08/16/02 09/09/02 222873197301 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 45.49 38.07 08/24/02 . 08/24/02 09/23/02 224470331001 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 25.49 20.80 08/24/02 . 08/24/02 09/23/02 224470322801 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 13.49 9.84 08/24/02 . 08/24/02 09/23/02 224470314601 DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 45.49 38.68 08/24/02 . 08/24/02 09/23/02 224470314501 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 14.49 4.91 08/24/02 - 08/24/02 09/23/02 224470294701 DIAGNOSIS 1: PRESC PRESCRIPTiON DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 23.49 13.55 08/24/02 . 08/24/02 09/23/02 224470314401 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 70.99 51.1>7 I .J COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 19, 2002 STATEMENT OF CLAIM ----, NAME SRENJZE, SHARPE 10 810107352 PHARMACARE INSTITUTIONAL SERVIC ONE JAMES DAY DRIVE CUMBERLAND MD 21502 DATE OF SERVICE PAYMENT DATE USUAL CHARGES' AMOUNT APPROVED 08/24/02 . 08/24/02 09/23/02 224470304401 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 9.49 6.37 08/24/02 . 08/24/02 09/23/02 224470247001 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 64.99 53.87 08/24/02 . 08/24/02 09/23/02 224470304301 DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 15.49 10.75 08124/02 . 08/24102 09123/02 224470187301 DIAGNOSIS 1: PRESC PRESCRIPTION URUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 62.99 54.26 08125/02 . 08/25/02 09/16102 223770489101 DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS DIAGNOSIS 2 : PROCEDURE: 000000000000 12.99 9.32 PHARMACARE INSTITUTIONAL SERVICES 19 1538609 1,846.46 1,415.36 SHIPPENSBURG HEALTH CARE CTR 121 WALNUT BOTTOM RD SHIPPENSBURG PA 17257 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELF~RE November 19,2002 STATEMENT OF CLAIM NAME BRENIZE, SHARPE ID B10 107 352 DATE OF SERVICE PAYMENT DATE 04/03/02 . 04/30/02 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 05/01/02 . 05131/02 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 06101102 - 06130102 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 07101102 . 07/31102 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: OB/01/02 - 08131102 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 09/01/02 - 09/02102 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 06/10/02 06/10/02 07/22/02 11109102 11109102 10107/02 215688238201 000000000000 215688231001 000000000000 220086913601 000000000000 231310876701 221789215901 231310876801 224987507201 227590043401 000000000000 SHIPPENSBURG HEALTH CARE CTR 36 1550908 />, ,';c:<>.<:,:,<,)',:<,,>..X.', >, ",." :,',' ',.,:;,:,',';: ,;', ,', .-." USUAL CHARGES 'AMOUNT APPROVED 3,177.57 3,583.74 3,448.35 3,506.42 2,888.15 88.52 16,690.85 3,177.57 3,583.74 3,448.35 3,506.42 2,886.15 8B.62 15,590.85 Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (717) 240-6345 Date: 8/03/2004 ZULLINGER JOEL R 14 NORTH MAIN STREET, SUITE 200 CHAMBERSBURG, PA 17201 ]RE: Estate of BRENIZE SHARPE A JR File Number: 2002-00990 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS, COURT RULES, NO. 1133 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent,s death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 9/03/2004 Your prompt attention to this matter will be appreciated Thank You. ' Sincerely, GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge STATUS REPORT UNDER RULE 6.12 Name of Decedent' Sharpe A. Brenize Date of Death' 9/3/2002 Will No. Admin. No. 21-02-0990 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' Yes X No ~ 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court ? Yes No X b. The separate Orphans' Court No. (if any) for the personal representative's account is' c. Did the personal representative state an account informally to the parties in interest ? Yes X No ~ d. 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' 8/9/2004 /x... Si ~/)) ' Joel R. Zullinger Name (Please type or print ) 14 North Main Street, Suite 200 Chambersburg PA 17201 Address (264) -6029 Tel. No. ~;;' :~'; - ."~.!ai,.'3. Capacity · Personal Representative 6[: ~[d 0[ ~fl~ 170, X Counsel for personal representative ~' ~~ ~O~ COMMONWEALTH OF PENNSYLVANIA ti BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 NOTICE OF INHERITANCE TAX HARRISBURG, PA 17128-Ob01 APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 EX AFP (O1-OS) DATE 02-10-2003 ESTATE OF BRENIZE JR SHARPE A DATE OF DEATH 09-03-2002 FILE NUMBER 21 02-0990 COUNTY CUMBERLAND JOEL R ZULLINGER ACN 101 ZULLINGER DAVIS Amount Remitted 14 N MAIN ST STE 200 CHAMBERSBURG PA 17201 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~ _____________________ ------------------------------ -------------------------- ---------------------------------- REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BRENIZE JR SHARPE A FILE N0. 21 02-0990 ACN 101 DATE 02-10-2003 TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 00 NOTE: To insure proper 1. Real Estate (Schedule A) (1) (2) . .0 0 credit to your account, 2. Stocks and Bonds (Schedule B) 00 submit the upper portion 3. Closely Held Stock/Partnership Interest (Schedule C) (3) , 00 of this fora with your 4. Mortgages/Notes Receivable (Schedule D) (4) , 42 tax pay 994 ment. 5 Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) . . 6 Jointly Owned Property (Schedule F) (6) .00 . 7. Transfers (Schedule G) (7) .0 0 994 42 8. Total Assets ($) . APPROVED DEDUCTIONS AND EXEMPTIONS: 6,736.14 9 Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) . 10. Debts/Mortgage Liabilities/Liens (Schedule I) ( 10) 18,390.21 35 126 11. Total Deductions (11) . 25. 24, 131 . 93- 12. Net Value of Tax Return (12) .00 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) 24,131.93- 14. Net Value of Estate Subject to Tax (14) NOTE: If an assessment was issued previously, lines 14, 15 andior 16, 17, 18 ssed to date and 19 will reflect figures that include the total of ALL . returns asse ASSESS MENT OF TAX: .00 X 00 _ - .00 15. Amount of Line 14 at Spousal rate (15) 045 00 . 00 16. Amount of Line 14 taxable at Lineal/Class A rate (16) X = . 12 - 00 .00 17. Amount of Line 14 at Sibling rate (17) _ X 15 00 .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) = . X 00 (19)= . 19. Principal Tax Due TAX CREDITS• + AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. eFwF~uNn_DSEEIREVERSECSIDEAOFATHISEFORM FOR)INSTRUCTIONS,DUE