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Home My WebLink About11-17-10 (2)~r 1,5056],01,01, REV-1500 Exto~_~o, . OFFICIAL USE ONLY PA Department of Revenue Pennsylvania UfPARTNEN! pE PE VENUE Count Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN ~, Y PO BOX z8o6o1 Harrisbur , PA 1'7128-0601 RESIDENT DECEDENT J ~s Q ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 164-28-0089 05/07/2010 04/28/1933 __ __ Decedent's Last Name Suffix Decedent's First Name MI ...._.......... ROMBERGER II WILMER .... _ ... _ __ .. _ _ ._ _ ... _. ..~_... _.._ ~_..... . _._ . : __ _ _.. ~.... L (If Applicable) Enter Surviving Spouse's Information Belvw Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number __ FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 4. Limited Estate O 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received _. __ __ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS O 2. Supplemental Return O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) O 3. Remainder Return (date of death prior to 12-13-82) 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. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number _. ..... ............................. RONALD K MOORE ............................... ...................... . ... ............................................. . . (717) 732-4435 ................. ...................... .............................. . ....... ......... . __ REGISTER OF WILLS USE O~Y C-? .a:..-. .. ~ r~ First line of address ~ ~ O ~~_ :' _ _ _ ___ _ _ __ _ _ --' -t 601 TOWER ROAD - = n ~ .~ ~n ~ , _ __ _ ___ _ 1_~. _ -a .,J ~_ ___ rr ' Second line of address # ._.~ _ ~ % ~ c --., --- . -~ t,~:~ ~, 47 -r, --, . _ City or Post Office __ - C~ ~ ~ _r _, _.._, State ZIP Code DAT TC1tD •• ENOLA ,... __ _ W PA 17025 Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGN URE OF P RSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS 601 TOWER ROAD ENOLA, PA 17025 S ATURE OF PREPARER TH R T REPRESENTATIVE DAT~ ADDRESS 430 N ENOLA DRIVE ENOLA, PA 17025 PLEASE USE ORIGINAL FORM ONLY Side 1 1,50561,01,01, Lsos61o1o1 c~~ 1505610105 J REV-1500 EX Decedent's Social Security Number ......................... . __ __ Decedent's Name: WILMER L ROMBERGER II 164-28-0089 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. ..... ........ .................... 2. Stocks and Bonds (Schedule B) ....................................... 2. 469, 374.54 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 92,952.58 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property - - - (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 562,327.12 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 57,400.92 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 8,463.07 ................................: . __ _ __ 11. Total Deductions (total Lines 9 and 10) ................. . ..... . .. . . . . . . . 11. 65,863.99 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 496,463.13 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which - -- an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 496,463.13 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable __ at lineal rate X .0 45 495, 798.13 16. 22, 310.92 17. Amount of Line 14 taxable - at sibling rate X .12 17 18. Amount of Line 14 taxable at collateral rate X .15 665.00 , 0 99 75 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 `,~, 1,50561,01,05 1,50561,01,05 22,410.67 O J REV-1500 EX Page 3 Decedent's Complete Address: 20, 900.00 DECEDENT'S NAME WILMER L ROMBERGER II STREET ADDRESS 601 TOWER ROAD cIENOLA STATE PA ZIP ~ 17025 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 3. Interest 1,120.53 File Num~ (1) 22,410.67 Total Credits (A + B) (2) 22, 020.53 (3) (4) (5) 390.14 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :................................................................. b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ x^ c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ x^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 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 contains a beneficiary designation? ........................................................................................................................ x^ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)). The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary, For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(x)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(x)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(x)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF WILMER L ROMBERGER FILE NUMBER 2110-0514 All property jointly-owned with right of survivorship must be disclnspci ~~ Srho~~do r ~~~ ~,~~,~c aNaw w uccucu, swell dUUIIIUfIaI Sf18BTS OT the SBRIe SIZE REV-1508 EX+ (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, of MSC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF WILMER L ROMBERGER FILE NUMBER 2110-0514 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ~~ ~ ~ ~ wi c aNa~e is neeaea, insert aaaiuonai sneets of the same size) Rt=.V-:i.5a.1 E:x•f (1U••U9) ~~~_~~ pennsylvania ''~' DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER WILMER L ROMBERGER II 2110-0514 Decedent's debts must be reported on Schedule I. ITEM - NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: - 1' RICHARDSON FUNERAL HOME 6, 523.32 2 ROLLING GREEN CEMETERY 405.00 3 PATRIOT NEWS -ADVERTISING 204.60 B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: .. Name(s) of Personal Representative(s) _RONALD K MOORE Street Address 601 TOWER ROAD city ENOLA __ Year(s) Commission Paid: 2010 State PA ZIP 17025 2~ Attorney Fees: 3~ Family Exemption; (If decedent's address is not the same as claimant's, attach explanation.) Claimant 4 5, 6. 7. Street Address City State Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: APPRAISAL FEE ZIP 47, 000.00 535.50 950.00 500.00 1,282.50 TDTAL (Also enter on Line 9, Recapitulation) I $ 57,400.92 If more space is needed, use additional sheets of paper of the same size. REV-1512. EX+ ;12-08 j ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER WILMER L ROMBERGER 2110-0514 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1~ AMBULANCE SERVICES 797.50 2 BONNIE K MILLER, TAX COLLECTOR 10.00 3 MANOR CARE HEALTH SERVICES 3,950.00 4 LATSHA WESTGATE APPARTMENTS -RENT 1,611.00 5 PENN DOT 28.50 6 ERIE INSURANCE 46.00 7 HEARTLAND PHARMACEUTICALS OF PA 147.48 8 WORLEY MOTORS 40.00 9 ANDREWS AND PATEL ASSOCIATES 15.00 10 CRYSTAL SPRINGS 24.87 11 CITICARDS -AT&T 142.72 12 MOVING EXPENSE/APARTMENT CLEANOUT 1,600.00 13 MISCELLANEOUS EXPENSE 50.00 TOTAL (Also enter on Line 10, Recapitulation) I $ 8,463.07 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) ~ pennsyLvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: WILMER L ROMBERGERII NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).) 1~ RONALD K MOORE 601 TOWER RD ENOLA PA 17025 STEP SON 2 BEVERLY EDWARDS 240 DELL ROAD HEGINS PA 17938 STEP DAUGHTER 3 ROBIN ZYDALLAS 421 S BROAD ST JERSEY SHORE, PA 17740 STEP GRANDAUGHTER 4 KENNETH MOORE 310 LANCASTER AVE ENOLA, PA 17025 STEP GRANDSON 5 VIRGINIA MOORE 601 TOWER ROAD ENOLA, PA 17025 STEPDAUGHTER 6 ELLEN PALMER 132 COLLEGE AVENUE CHAMBERSBURG, PA 17201 NIECE FILE NUMBER: 2110-0514 AMOUNT OR SHARE OF ESTATE 280,371.56 276,535.56 490.00 630.00 3,635.00 665.00 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN; 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS; 1 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ 562, 327.12 If more space is needed, use additional sheets of paper of the same size. COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 7 1 28-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 013168 MOORE RONALD K 601 TOWER RD ENOLA, PA 17025 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold TOTAL AMOUNT PAID: $20,900.00 REMARKS: CHECK# 109 INITIALS: SAP SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER i ~~r~ ~~ - ~~1~~ 1 L'~, L~.F :~'., JANUS July 15, 2010 RONALD MOORE 601 TOWER RD ENOLA PA 17025-1331 REFERENCE: 02000030 JANUS GROWTH AND INCOME FUND D SHARES JANUS SHOI:T-TERM BONi, FLING D SHARES ACCOUNT NUMBER 102163549 WILMER L ROMBERGER Dear Mr. Moore: Janus received and processed your request to re-register the above-referenced account. Confirmation will arrive separately. The account information provided below is unaudited Date Fund/Account Number Transaction Share Price Shares Dollar Amount 05-07-10 40/202163549 Balance $27.31 1,602.566 $43 766.08 05-07-10 52/202163549 Balance $3.09 8,459.344 , $26,139.37 We appreciate the opportunity to be of service. If we can be of additional assistance, please give us a call. Sincerely, ' ~ ~ / r r ~ ~ ~}j [s 3 ~ r ~~ £ I Amanda Hottovy Investor Services • • _-_. i '' ~ Name ~und~& Account Date PncePer - ;4cci•ued Number Opened Shares Shace Value* `Dividends `. 500 Index Fund Inv 0040-09899816956 04/10/1996 343.059 $102.48 $35,156.69 - :Totals $35,1'56.69 $0:00 'Doesn't include accrued dividends. 1173329958 06/18/2010 13:55:49 ~~ I. Pa e: 1 ~ • g c ment Name: Op enheimer & Co. Inc. A09-0 0 0 USD RR=128 WILMER L ROMBERGER PAGE: 1 DATE- 0'/1 /10 1141 COLUMBUS AVE, APT #1 TEL # 717 -761-0593 TD-6P~EN O.OODR PRIME CASH SERIES TDBL 0.00 MKT VAL 356,-066 EQUITY ~C' 3 6, 066 TYP-1 0.00 SDBL 0.00 HSE-EXCS 231,395 CASH-AVL~-~-~~- 0 TYP-2 0.00 MFUND 73.39 HSE-CALL 0 BUY-POWR 0 TYP-9 0.00 CS/EQ 0.00 FDL-CALL 0 SMA-BAL 0 OTHER 0.00 MULTI-CURRENCY PLATFORM: HOLDINGS IN --> US $ LONG/SHORT S E C U R I T Y D ESC R I P T I O N PRICE MKT VAL *** TYPE 1 *** 62.930 ADVANTAGE BANK DEPOSIT ABDXX * 1.000 62.93 FDIC INSURED AT VARIOUS BKS ACCRUED INCOME -------> .00000 10.460 ADVANTAGE PRIMARY LIQ ADLXX 1.000 10.46 27,811.984 FIDELITY ADVISOR 5894 FAHIX 12.800 3 55,993.39 MUNICIPAL FUND CL T REINVEST CODES (D/S/L) RRR UNPRICED ITEMS 0 PRICED ITEMS VALUE 356,066.79 NEXT (P)REY PAGE# /ACCT (MF) TYP(T1-T9) (S:)SEC (E)ND <F2>N&A <F3>MONEY <F4>HIST <F6>ALFA <F8>CUST <F9>FAIQ <F11>PREV <F12>MENU Name: crousem - Date: 5/19/2010 Time: 2:09:45 PM Pennsylvania State Employees Credit Union 1 Credit Union Place Harrisburg, PA 17110 717-234-8484 WILMER L ROMBERGER Account: 0164280089 Post --------- ---------------------- ------ _________ Effect Transaction Description _______________ ______ ---- ____________ Amount ___________ New Balance 05/01 05 17 ____ ________________________ ID O1 REGULAR SHP.RES Balance Forward ----------- i ___________ ----------- ___________ ----- 52.14 End ng Balance ----------- ---------------- --- -------- - -----52.14 05/O1 05/03 ID 04 CHECKING Balance Forward ----------------- Withdrawal by ATM: #00005399/PE0110 ----------- - 39,046.91 05/03 ATM PSECU 2301 N CAMERON ST HARRISBURG PA 300.00- 38,746.91 05/04 05/04 Deposit Check Deposit Check 5, 273.94 44, 020 .8:5 05/04 0o Check hold release 05/13/10 5 657.94 10,384.00 54,404.85 05/06 J5/06 , Withdrawal: PPL EU TYP 96.40- 54,308.45 )5/09 E: ELEC SVC ID: 1230959590 C0: PPL EU i )5/09 W thdrawal by ATM: #00002758/DU0109 AT 400.00- 53,908.45 )5/10 M PSECU 2301 N. CAMERON ST HARRISBURG PA D f )5/10 ra t: 005237 Draft: 005236 51.00- 53,857.45 )5/10 Draft: 005238 494.50- 805.50- 53,362.95 52 557 45 )5/17 )5/17 Withdrawal: VERIZON TYP 41.17- , . 52,516.28 E: PaymentREC ID: 9783397101 )5/17 Cn: VERLZON )5/17 Ending Balance --------------------------- ---- - -52,516.28 )5/01 ID O1 PSL LOAN Balance Forward ------------------ ------------ - ---- 0 00 )5/17 Ending Balance ------------------------ ---- ----------- . ----- 0.00 )5/O1 )5/17 ID 09 VISA LOAN Balance Forward ----------------- ----------- ----- p,00 Ending Balance ---------------------------- --- -- ----- 0.00 • Worley Motors, Inc. Susquehanna Avenue • Enola Road • Enola, PA 17025 • Phone (717) 732-2051 L~ ~ ~ ~ ~ ,. -t1r. ~ ~ c c~ ~ r~-~ W U ~.~. ~ ~ ~-2. ~ J~~ Jam' 7~ , y~„~ ~u< y~ r~ • CORDIER ANTIQUE S ~-' fine art r AUCTIONS APPRAISALS ESTATES Appraisal Report Estate of Wilmer L. Romberger, II c/o Ronald Moore, Executor 601 Tower Road Enola, Pennsylvania 17025 (717) 732-4435 Prepared by: David J. Cordier Ellen E. Miller Cordier Antiques & Auctions 2151 Market Street Camp Hill, Pennsylvania 17011 Phone: (717) 731-86.62 Fax: (717) 731-9830 • • Summary On July 15, 2010, at the request of Ronald Moore, I personally inspected the assets of Wilmer L. Romberger, II, 1141 Columbus Avenue, West Gate, Lemoyne, Pennsylvania. Value Fair Market Value The Fair Market Value for the property in total is: $12,916.00 This is not the appraisal report. The appraisal report must be read in its entirety. Page: 3 of 16 • • Analysis Analysis All items in good condition unless otherwise noted in Appendix. Page: 4 of 16 • • Conditions of Appraisal The value stated in this Appraisal Report is based on the best judgment of~ the appraiser given the facts and conditions available at the date of the valuation. The use of the report is limited to the purpose of determining the value of personal property for Insurance purposes. Any additional research or testimony required by the client or the court will be billed at the current rates. Disclosure of the contents of the report is governed by the Standards and Practices of the Certified Appraisers Guild of the America. Certification of Report No prohibited fee was accessed for this report. David J. Cordier and Ellen E. Miller of Cordier Antiques & Auctions have successfully completed the personal property appraisal certification program with the Certified Appraisers Guild of America and are members in~good standing. This report was prepared in accordance with the Uniform Standards of Professional Appraisal Practice and with the Standards and Practices of the Certified Appraisers Guild of America which has review authority of this report. David J. Cordier and/or Ellen E. Miller have personally examined the subject property. The statements of fact contained in this report are true and correct to the best knowledge and belief of the appraiser. B :David J. Cordier; C.A.G.A. Cordier Antiques & Auctions By: Ellen E. Miller, C.A.G.A. Cordier Antiques & Auctions Page: ~ of 16 Purpose of the Report • The purpose of this report is to determine the value for Estate Tax purposes for Ronald Moore, Enola, Pennsylvania. Method of Valuation The method of valuation used for this appraisal is the Fair Market Value. Definition of Value Fair Market Value Under the United States Treasury regulation 1.170-1 c Fair Market value is defined as: The price at which the property would change hands between a willing buyer and a willing seller, neither being under compulsion to buy or compulsion to sell and both having reasonable knowledge. Basis of Appraisal ` Valuation Date The date of valuation for determining the value estimation is August 4, 2010. Date Appraisal Conducted This appraisal was conducted on July 15, 2010. Limitations of Property There were no limitations on use or disposition of this property. Description An itemized list with descriptions is in Appendix A. Page: 6 of 16 CORDIER ANTIQUES & AUCTIONS r ~ Cordier Antiques & Auctions was established in l 984. The company specializes in appraisals of antiques, fine art and personal property, estate liquidations and the auction and sale of fine antiques, art and real estate. Cordier Antiques & Auctions maintains memberships in the Certified Appraisers Guild of America, the Al~tiques and Collectibles Dealers Association, I-~c., the Antique Dealers Association of Pennsylvania, tl~e Pennsylvania Auctioneers Association and the National Auctioneers Association. Cordier Antiques & Auctions has conducted appraisal clinics for such organizations as the Harrisburg Area Community College's Older American Days, the Questers, Rohrer Bus Antiquing Road Show Tour, Millersbut•g Historical Society, Friends of Fort Hunter, West Shore Country Club and the Friends of the Pennsylvania State Museum. Cordier Antiques & Auctions is an underwriter for the Antiques Road Show on WITF Public Television. DAVID J. CORDIER, C.A.G.A. CERTIFIED APPRAISER David J. Cordier is co-owner of Cordier• Antiques & Auctions located in Camp Hill, Pennsylvania. Mr. Cordier• has been an antiques and jewelry dealer since 1980 and an appraiser since 1990. David Cordier of Cordier Antiques & Auctions has successfully completed the personal property appraisal certification program with the Certified Appraisers Guild of America. Mr. Cordier is a graduate of Winterthur Museum's Winter Institute, a graduate level program in American Decorative Arts. David Cordier has attended classes in the fine and decorative arts at George Washington University, Washington D.C. and the appraisal studies program at New York Univel•sity, New York. Mr. Cordier studied the arts and decorative arts in Pennsylvania at Penn State University and holds a Master's degree in Business Administration from Penn State Capital Campus. Mr. Cordier is a writer for the Harrisburg Patriot News reporting on antiques and related events in central Pennsylvania. He also wrote a bi-weekly feature column "Eye on Antiques" for the Sunda}~ Patriot News from 2001 to 2006. ELLEN E. MILLER, C.A.G.A. CERTIFIED APPRAISER Ellen E. Miller joined Cordier Antiques & Auctions in 2000. Ms. Miller holds a Bachelor's degree in Marketing from Shippensburg University and a Master's degree in Business Administration from Temple University. Since joining Cordier Antiques & Auctions, Ms. Mi11e1• has been the Director of Internet Sales, conducting research and documentation of inventory, maintaining client relationships and managing an international customer base. She has been responsible for the sale of several large collections via Internet auction including classic automobiles, antique to}~s, sports memorabilia and autographs. Ms. Miller has successful]}~ completed the personal property appraisal certification program with the Certified Appraisers Guild of America. Prior to joining Cordier Antiques & Auctions; Ms. Miller worked in the printing industry in sales and administration. Page: 7 of 16 • • Appendix A Fair Market Value Living Room 1. $600.00 5 Cut to clear stems. 3 Clarendon emerald hock stems and 2 Clarendon ruby hock stems. Each 8" high. All with the Waterford Cr~~stal label. 2. $100.00 Curio cabinet. Wood cabinet with glass pane door and one drawel• with brass hardware. Modern. ~. $5.00 Pair of Picadillos. Wood and cloth. 19-3/4" long. Souvenir quality. 4. $75.00 Contents of curio cabinet. 1.2 Porcelain plates with floral decoration. 2. Blue decanter with stopper and three small shot glasses. 3. 3 Pieces of cut glass -two clear and one incandescent. 4. Asian rice bowl and spoon. 5. Snow globe. 6. 2 Porcelain shoes. 7. Cut egg. 8. Glass cup. 9. Rolmonica. 10. 2 Ceramic landscape scenes under glass domes. 11. Bust of a woman with a green shawl. 5. $400.00 Atmos clock. Jaeger LeCoultre Swiss made clock. 9-1 /4" x 8-1 /4" x 6-1 /2". Brass case. 6. $15.00 Ceramic lamp, White and iridescent ceramic lamp depicting three children holding up a pineapple cut top. 19-1 /2 high. 7. $240.00 2 Cut to clear stems. Clarendon ruby hock sterns. Each 8" high. Both with the Uaterford Cr}~stal label. In original box. 8. $15.00 Ceramic Christmas tree. Hollow white tree with multicolored plastic pieces. 17" high. 9. $150.00 Living Room suite. Hallagan Mfg. Company, Inc. suite that includes 2 three seat sofas and 1 armchair. Floral velour upholstery. 10. $0.00 2 Upholstered armchairs. 1 Reclining mauve colored chair and 1 rocking swivel yellow chair. Page: 8 of 16 • • 11. $75.00 Pair of end tables. Wooden tables each with a shelf and one drawer with brass hardware. 12. $75.00 Drum table. Wooden table is a pedestal base and four feet. There is a drawer with brass hardware. 13. $75.00 Drop leaf end table. Wooden table with wheels and two drop leaves. Two drawers with brass hardware on each. 14. $50.00 Pair of tables. 1 round coffee table with a faux green marble top and 1 rectangular hall table with a shelf at the bottom 15. $0.00 Pair of alabaster table lamps. White lamps with a square marble base and a cylindrical white cloth shade. 16. $125.00 Mechanical coin bank - "Always Did 'Spise A Mule." Reproduction from the original in the collection of The Book of Knowledge with a certificate of authenticity signed by Ellen V. McCoughlin. 7" high. Cast iron. 17. $400.00 8 Franklin Mint precision die-cast model cars. 1. The 1930 Dusenberg J Derham Tourster. 2. The Mercedes SOOK Special Roadster. 3 . The 193 8 Alvis 4.3 Litre. 4. The 193 5 Auburn 851 Speedster. 5. The 1907 Rolls-Royce Silver Ghost. 6. The 1928 Stutz Black Hawk Boat-tail Speedster. 7. The 1937 Card 812 Phaeton Coupe. 8. The 1912 Packard Victoria. 18. $600.00 Music box. Wooden inlay music box. Cylinder mechanism. Har Zither that plays 8 airs, 5-3/4" x 17" x 8". 19. $65.00 Glass pitcher with cover. Yellow glass pitcher with lid. Red to yellow coloring. 12-1/4" high. 19th/20th century Czechoslovakian. 20. $70.00 7 Porcelain animals -National Wildlife Federation. 6 from the National V~~ildlife Federation that are titled and inscribed "By RWGVi~ Limited Signautre Editions. Fine Porcelain -Hand Painted," on the bottom. First Adventure, Forest Discovery, Raccoons at Play, In the Meadow, Woodland Companions; Chipmunks in Autumn. 1 bird that is inside of a glass dome on a wooden stand. 21. $50.00 Edward M. Boehm porcelain Goldfinch. Page; 9 of 16 • • Titled and inscribed "40167 Made in U.S.A." with the Boehm hallmark, on the bottom. 2-5/8" high. 22. $100.00 10 Model truclcs and cars. 1. 4 John Deere model truclcs, 4710 Sprayer, 9420 Tractor, 9420T Tractor, and the 6220 Tractor w/ 1590 Grain drill. Each with their Certificate of Authenticity. 2. 6 Model cars in a red case including, 1911 Ford "T" Tourer, 1909 Ope14/bhp Coupe, 1910 Benz 14/30hp Landualet, 1912 Packard Model 30 Landaulet, 1911 Daimler A1.2 Tourer, 1911 Maxwell "Gar" Roadster. 23. $150.00 Miscellaneous items. 1. Framed decorative reproduction print. 2. Pair of ceramic white dogs, one with an opening at the back. 3. 3 glass mugs. 4. YamaJi white porcelain vase with a bird and stem decoration. 5. Black china bear key holder. 6. Black china ashtray with an image of a bird in the center. 7. Black decorative plate with an image of a duck. 8. Black sculpture of a dog. 9. White plastic plate depicting Mary, Jesus, and Joseph, in a wooden frame. 10. Hollandomold ceramic lidded egg in pastel colors. 11. Leather covered glass decanter with wooden and plastic stopper. 12. Etched glass decanter with stopper. 13. Plastic wind-up musical piano - Mozart Austria. 14. Wooden wind-up musical San Francisco trolley car, Powell & Hyde Sts. 24. $150.00 Miscellaneous furniture/electronics. 1. Upholstered top footstool with wooden legs. 2. Framed mirror. 3. White china table lamp with a raised design of flowers and a white cylindrical cloth shade. 4. Zenith Television. 5. Zenith 4-Head VHS player. 6. Wooden table with four legs and a glass top with glass sides and a glass pane shelf, the knob is marked "The Franklin Mint" v~~ith an image of Franklin. 7. Vi~ooden wall case with three inserted shelves and two glass doors that open at the front. 25. $30.00 Ceramic dog. Sculpture of a bulldog. Approximately 8" high x 14" long. Master Bedroom 26. $400.00 Bedroom suite. Including a double bed headboard, two night stands; a chest of drawers with seven drawers and brass hardware, and two dressers each v~~ith eight drawers and brass hardware with one also having an attached minor. The Sterlingworth Corporation -Jamestown American Furniture. Maple. 27. $125.00 Wicker furniture set. White wicker love seat and a pair of matching armchairs all with pin Page: 10 of 16 • • striped cushions, and a small coffee table with a glass top. 28. $80.00 4 Alabaster table lamps. A pair of alabaster table lamps with a white cylindrical cloth shade. Each 3 0-1 /4" high. A separate pair of alabaster table lamps with a white cloth shape and a braided top and bottom rim. Each 4" high. 29. $100.00 8 Decorative plates. W.S. George fine china plates from the Xerces Society that are each designed by Lean Liu for the On Gossamer Wings series. Each is fully inscribed on the back with plate information - "The first collector's plate series ever sponsored by The Xerces Society. Edition strictly limited to 150 firing days. Titles are: Malachites, White Peacocks, Red-Spotted Purples, Eastern Tailed Blues, Zebra Swallowtails, Red Admirals, Western Tiger Swallowtails, Monarch Butterflies. Each plate is framed in a round wooden frame. Plate size: 8-1 /2" Frame size: 11-1 /4" 30. $100.00 Miscellaneous items. 1. Table lamp with a glass top and bottom and with a hand painted floral design. 2. White porcelain bowl. 3. Etched stainless steel vase. 4. Tray with a mirror at the bottom and a decorative rim. 5. White porcelain bowl with a sea green lid. 6. Framed dried flowers. 7. Mug. 8. Framed print reproduction of Native Americans watching a plane flying. 9. Wooden hanging for plants. 10. 17 hardcover and paperback religious books. Dining Room 31. $600.00 Dining room suite. Includes 1. Wooden table. 2. Four chairs. 3. Breakfront with four square doors at the top, two at the bottom with three drawers, and two in the center with a shelf. There are also two glass paned doors in the center. 4. Buffet table with one drawer and two doors with wooden handles. 32. $250.00 Writing desk. Wooden writing desk with three drawers and brass hardware and a lid that opens to reveal a leather top and one small drawer with two openings on either side. Mahogany. 33-1 /2" x 27-1 /8" x 16-1 /8". 33. $50.00 Cuckoo clock and Mirror. 1. The American Cuckoo Bird clock that is inscribed on the face, "New England Clock; G Bristol Conn." With two long metal chain links that extend 51 " from the bottom of the clock to two 7-1 /2" long metal pine cones. 2. Coated wood mirror that is oval with a shelf below in the shape of a seat. 46" high. 34. $350.00 The Franklin Mint precision model display case with model cars. Page: 11 of 16 • • 1. V~~ooden wall case with three shelves. 21-3/4" high. 2. 7 precision die-cast model cars: The 1929 Rolls-Ro}ice Phantom I, The 1933 Duesenberg SJ Twenty CJrand, 1954 Mercedes Benz 30USL, The 1938 Jaguar SS 100, The 1953 Corvette, 1921 Rolls Royce Salver Ghost, The 1930 Bugatti Royale Coupe Napoleon. 35. $200.00 13 Beer steins. Various styles and sizes of beer steins with seven having hinged lids. Ranging in sizes from 4-1 /4" to 11-1 /4" . 36. $220.00 54 pieces of handpainted Limoge dishes. Consisting of 8 each of cups, saucers, large plates, and small plates, 1 each of salt shaker, pepper shaker, sugar bowl, and creamer, 7 small bowls, 6 pieces of service ware, 5 small condiment holders. Handpainted blue flower design. Inscribed "LBM," on the bottom. 37. $60.00 The Franklin Mint - Le Cordon Bleu Mould Collection. 6 Pieces of porcelain wall hangings in circular, oval, diamond, and rounded rectangle shapes. Each depicting either animals (ducks, lambs, and rabbits) or food (raspberries, lemons, and asparagus) 3 8 . $100.00 Miscellaneous items. Includes glassware, china, candle holders, table lamp, wall hangings, etc. 3 9. $40.00 Tulip lamp. Painted metal fixture with 3 frosted glass shades. Approximately 18" high. Late 20th century. Hall 40. $10.00 Pair of W.S. George fine china plates. 1. The Koala. Designed by Charles Frace. 1990. From the first issue in the Nature's Lovables series. Inscribed with information on the plate, verso including "A tribute to nature's most endearing animals. The edition is limited to a maximum of 150 firing da}~s. Sponsored by The Wildlife Society." 2. The Panda. Designed by Will Nelson. 1988. From the first issue in Last of Their Kind: The Endangered Species series. Inscribed with information on the plate, verso including "Sponsored and authenticated by The Wildlife Society. Edition limited to 150 firing days maximum. (Part of #47 and valued there). 41. $10.00 Edwin M. Knowles fine china plate. "A Chance Meeting: V~~hite American Shorthairs." Designed by Amy Brackenbury. 1987. From the first issue of Amy Brackenbury's Cat Tales Collection. Inscribed with information on the plate, verso including "The frrst collector's plate series sponsored by the Cat Page: 12 of~ 16 • • Fanciers' Federation, Inc. Created exclusively f or this limited edition by the artist and f red to the traditional standards of Knowles fine china in an edition strictly limited to 150 firing days." Plate size: 8-1 /2" Frame size: 12-3/4". 42. $35.00 Cabinet and Mirror. 1. Wood cabinet with a scalloped bottom and one door with a shelf inside. 26" x 26" x 12-7/8". 2. Wooden framed mirror. 33-7/8" high. Bedroom 43. $800.00 Bedroom suite. Including a double bed headboard, a night stand with a drawer at the top and two doors below, a chests of drawers with eight drawers and brass hardware, and a dresser with six drawers and brass hardware. Pennsylvania House. Storage Room 44. $35.00 Metal etagere. Etagere with five shelves. 79" high. 45. $30.00 Magnavox 8-Track and Record Stereo System with speakers, records, and 8-tracks 1. Stereo system with two speakers each 23-1/8" high (one in hall). 2. 21 Records of dance and Christmas music. 3. 2 Cases. One with 19 8-Track tape cartridges and the other with 21 8-Track tape cartridges. 46. $25.00 Microwave stand and Bookcase. 1. Pressed wood microwave stand with a drawer at the top and two doors on the bottom. 33" high. 2. Pressed wood bookcase with four shelves and a door that opens from the top with a shelf inside. 72" high. 47. Kitchen 48. $75.00 Miscellaneous. Including furniture, books, suitcases; linens, VHS, wall hangings, etc. $60.00 6 Decorative plates. W.S. George fine china plates that are each designed by Donald Schwartz for the Purebred Horses of the Americas collection. Each is fully inscribed on the back with plate information - "Crafted in fine china under the hallmark of W.S. George. This plate is produced in an edition strictly limited to 150 firing days maximum. Titles are: The Mustang, The Tennessee walker; The Appaloosa; The Morgan, The Quarter Horse; The Saddle Bred. Each plate is framed in a round wooden frame. Each 8-1 /2" diameter. Page: 13 of 16 • ~ 49. $100.00 9 Decorative plates. Vi~.S. George fine china plates that are each designed by Will Nelson for the Last of Their Kind: The Endangered Species series. Each is fully inscribed on the back with plate information - "Sponsored and authenticated by The Wildlife Society. Edition limited to 150 firing days maximum. Titles are: Przewalski's Horse, The Black-footed Ferret, The Slender-Horned Gazelle, The Snow Leopard, The Asian Elephant, The Vicuna, The Red Wolf, The Bridled Wallaby, The Siberian Tiger. Each 8-1/2" diameter. 50. $125.00 Harvest drop leaf table and two chairs. 1. Wooden table with stenciled decoration on each leaf. 29-1/4" x 36-1/4" x 45-1/2"~2. Pair of L. Hitchcock chairs with stenciling on the back and marked L. Hitchcock. Hitchcocks-vine. Conn. Warrranted," at the back of the seat. 34 a 16-1 /2 x 16 . 51. $110.00 Cupboard and server. 1. Server with one drawer and two doors with brass hardware. 33" x 37" x 19-3/4.2. Cupboard with six drawers, two wooden doors at the bottom and two glass paned doors at the top with two inserted shelves. Early American Temple Stuart Furniture. 73" x 40-1/2" x 21.1/2". 52. $125.00 Contents of kitchen. 1. Partial Johann Haviland Bavaria Germany porcelain dinner service. 2. Partial Corelle Livi~ngware by Corning dinner service. 3. Lenox serving bowl 10 long. 4. 6 Personal Fan. 5. Zenith Space Command Television 11 "wide screen. 6. Kenmore Microwave 7. Various pots and pans, mugs, cups, bowls, utensils, strainers, blender, beaters, popcorn maker, cake and cupcake pans, measuring cups, scale. 8. General Electric can opener. 9. Oster toaster oven. 10. Wall hanging spice rack with a hinged cover having a reproduction of apples in a tree. Jewelry 53. $650.00 Man's diamond ring. 14 Kt. yellow gold setting with solitaire diamond approximately .65 ct. Mine cut. Gold: 7grams / 4.5 dwt. Condition: Small chip to side. 54. $1;800.00 Phoenix pendant with 2 chains. 2-7/16 round pendant with phoenix bird and Chinese characters. Marked 18 k. Pendant: 56.6 grams / 36.4 dv~~t. 2 chains: 18" + 24" marked Krementz. Gold filled. Coins 55. $192.50 1 1 Peace silver dollars. Page: 14 of 16 • • 3: 1922; 7: ] 925; 1: 1924. About uncirculated. 56. $100.00 5 Morgan silver dollars. 1: 1879; 1: 1902; 1: 1889; 2: 1921. About uncirculated. 57. $150.00 15 Franklin halves. 1949-1950. About uncirculated. 58. $32.00 5 Franklin halves. 4: 1963; 1: 1960. About uncirculated. 59. $6.50 1942 Liberty Walking half. 60. $17.50 7 JFK 40% silver halves. 1967-1969. Uncirculated. 61. $25.00 U.S. Mint Set 1964 in Whitman Case. 1 cent - 50 cents. 62. $25.00 U.S. Mint Set 1963 in Whitman Case. 1 cent - 50 cents. 63. $20'.00 2 JFK Memorial sets in cases. 1964. 64. $85.00 1922 U.S. Grant Memorial commemorative silver half. (No star) AV. 65. $325.00 1881 $5.00 Liberty head gold. VG. 66. $200.00 1911 $2.50 Indian Head gold. AV. 67. $200.00 1914 $2.50 Indian Head gold. AV. 68. $30.00 1960 Proof set. Small date. 69. $20.00 1960 Proof set. Large date. 70. $10.00 1961 Proof set. 71. $5.00 1968 -Proof set. 72. $5.00 1969 -Proof set. 73. $15.00 2 - 1970 Proof sets. 74. $175.00 9 U.S. Mint proof sets. 1999, 2000, 2001, 2002; 2003; 2004; 2005, 2006, 2007. Page: 1~ of 16 • • 75. $90.00 10 U.S. Mint proof sets. 1989,1990, 1991, 1992, 1993, 1994, 1995, 1996, 1997, 1998. 76. $35.00 2 U.S. Mint sets Presidential $1 coin proof set. 2007 and 2008. 77. $30.00 2009 United States mint proof set. 78. $25.00 2009 District of Columbia and U.S. Territories Quarters - U.S. mint set. 79. $45.00 2008 U.S. Quarters - 50 State quarters proof set. Oklahoma, Alaska, New Mexico, Arizona, Hawaii. 80. $50.00 2008 U.S. Mint proof set 1 cent - $1.00 81. $45.00 8 United States proof sets. 1974, 1975, 1976, 1977, 1978, 1979, 1980, 1981. 82. $20.00 5 United States proof sets. 1984, 1985, 1986, 1987, 1988. 83. $30.00 2007 U.S. Mint proof set. $1.00 and 10 of 14 proof coins. 84. $7.50 2 United States proof set. 1982 and 1983. 85. $10.00 U.S. $1.00 Presidential proof set. 86. $50.00 Miscellaneous items. 1. 4 Susan B. Anthony dollars. 2. 2 2003 JFK halves. 3. 2 Bronze medallions Hershey Bears and Vietnam War. 4. 2 Pope tokens. 5. Copy U.S. token. 87. $400.00 8 American eagle 1 oz proof silver bullion coins. 5: 2006 and 3:2007. 88. $15.00 3 Sets World Trade Center silver clad. Freedom commemoratives. 89. $45.00 9 U.S. 1 dollar Twin Towers. Commemorative. Clad coins. ~ 12.916 00 Total Page: 16 of 16 • • 0127 Social Security Administration Retirement, Survivors, and Disability Insurance I171pOrtal~t Il1f0I'171at101"1 Mid-Atlantic Program Service Center 300 Spring Garden Street Philadelphia, Pennsylvania 19123 Date: September 04, 2010 Claim Number: 164-28-0089A ~Il~i~~liiii~liiiii~ili~iiii~i~il~~iln~~i~lilii~il~lll~i~l~~~i~~ 0000011 14 01 MB 0.382 T007,MAD,0830,PC2,I,PH, RONALD K MOORE EXEC OF rr+:r: EST ~ OF W ROMBERGER ~ h DEC D 601 TOWER RD ENOLA PA 17025-1331 We-are writing to give you new information about the retirement benefits which WILMER L ROMBERGER receives on this Social Security record. What We Will Pay You will soon receive a check for $764.00 because we owed money to WILMER L ROMBERGER. Do You Think We Are Wrong? If you disagree with this decision, you have the right to appeal. We will review your case and consider any new facts you have. A person who did not make the first decision will decide your case. We will correct any mistakes. We will review those parts of the decision which you believe are wrong and will look at any new facts you have. We may also review those parts which you believe are correct and may make them unfavorable or less favorable to you. • You have 60 days to ask for an appeal. • The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period. • You must have a good reason for waiting more than 60 days to ask for an appeal . • You have to ask for an appeal in writing. We will ask you to sign a form SSA-561-U2, called "Request f or C SEE NEXT PAGE T ~ NOTICE OF PREMIUM REFUND DP164G 1/01 Eriem Insurance ~\ Group DATE 100 Ene Ins. PI Ene, PA 16530 MO. DAY YR. 08 OS 10 REFUND AMOUNT $30 , QQ POLICY NUMBER QS $ 0408 749 H AGENT NO. AA7631 AGENT'S NAME CONSUMERS INS AGY INC . REASON 1 REF. NO. A022771 CHECK NO. 010227]1 WILMER L ROMBERGER AA7631 C/0 RON MOORE 601 TOWER ROAD ENOLA PA 17025 NON-NEGOTIABLE • fE ~~++.ps~cu.com 800.237.7328 717.234.8484 WILMER L ROMBERGER ESTATE RONALD K MOORE EXECUTOR 601 TOWER RD ENOLA PA 17025-1331 Account 8085XXXXXX ROMBERGER ESTATE EFFECT: 08/31/10 POST; 08/31/10 TLR: 0484 Deposit to CHECKING ID 04 PRE~1 BAL 17 623 39 TRAN AMOUNT , , 103 968.49 NEW B ALANCE , 121 591 88 SEQ: , . 1851854 Check hold to be released 09/10/10 93,998.49 Check Received '34 246 93 Check Received , . 43 244 84 Check Received 26,476,72 t wv~w. psecu. eom 800.237.7328 717.234.84$4 WILMER L ROMBERGER ESTATE Account 8085XXXXXX ROMBERGER ESTATE EFFECT: 08/31/10 POST; 08/31/10 TLR; 0494 Deposit to CHECKING ID 04 PRE~~ BAL 17, 593.39 TRAN AMOUNT 30.00 NEW BALANCE 17,623,39 SEQ : 1793B9~3 Check Received 30.00 • ~ ~ ~ a ~, act LL, ~ >M ~ ~ i• oo ~ ~ ~ ~ w Q ~ CV ~ ~~ O ~ ~ m O J ~' LLI _1 r-~ ~ ~ l~ v I ~ ~ TJ Ql l0 Lf") N I s t7 V l 0 Ol I I rU c7 . I I cY r"- Cpl rv ~ ' ' ~` rv , , ~ ~ ~ I L I, ' ° v .~ . , ~. I ~ T_ ~. V o I I I e I ~ F---1 I L I I r , I I x ~ ' ' ~ , X z H ' I 1--- 0 ~ I 1 Lf7 Crj ~ I I ~ ~ p W~~ U F--- W I I •~ .~ ~ ~ ~ '~ CD W ' U .~ Z I ~ ~ ' ~ N CTl C} r ~ f- C~ L.~ J -~--~ '~ ~ J I I U U ~ ~ W ~ ~ ~ ~'J Q ^CL ! I ~ ~ U UOLLp~ '~ ~ W Ll F- Q-W'Q3G3 ~ Q) (~ L~ W W i I U Q ) I ~ ~ D ~.... F- Z VJ I I U ~ PPL Electric Utilities Corp. Date 09/03/2010 Vendor Code 0000350044 Check No. 0011021105 Invoice Invoice Date Reference 08/30/2010 1390o72oonnn Cu; Service Address: 200001141 CC LEMOYNE, NA Allentown PA 18101 Print No. 74518000036 Total $**********492.20 ~ ~ ~ ~ ~C~~ 2~TH ENOLA DRIVE icl ar ovt unera ome ~.C. ENOLA, PA 17025 (7l7) 732.087 i.1ICHAEL G. MURRAY STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED SUPERVISOR Charges are onl}~ for those items that you selected or that are required. If we are required by law or by a cemet ery or crematory to use any items, we will explain in writing below. If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if you selected arrangements such as a direct remation or immediate burial'. if we charged for embalming, we will explain why below. For the Service of hi~N /' ~• C P G~ ~~~ ~,- ~~- Date of Death ~ ~~ 0 / ~' // , Charge to: L`/y a, /YJd o,''~ ~ d / G ~C/' /Qc~ .Crr'J c ~ (a / p ~ ~ ~~ ~~ Name Address City , State A. CHARGE FOR SERVICES SELECTED: Other clothing 1 PROFESSIONAL SERVICES f Services of Funeral Director/Staff .... f ~/l ~~ f Embalming .. .. l G Cremation urn .......... ........ . f Other prepara[ion of body (Description) ~ ~~ rt, ~ f ~ / ~ ~. v J> .~ C.~S . ,~ ~ -,~ ~ OTHER f ......... ... f ? Nei 1 SUBTOTAL OF PROFESSIONAL SERVICES......... Alf f TOTAL MERCHANDISE SELECTED .................. g f 2 FACILITIES AND SERVICES Use of facilittes and services for C. SPECIAL CHARGES: viewing (Visitation/Wake)......... f f l~i~i Forwarding of remains to Use of facilities and services (Funeral Home) f for funeral ceremony ............ fT/1/ C,~ Receiving of remains from Use of facilities and services (or f Memorial Service .... f (Funeral Home) Use of equipment and services Immediate Burial ........ ....... . f for graveside service ............. f Direct Cremation ....... , . ........ f Other use of facilities f ...... f SUB-TOTAL OF FACILITIES/EQUIPMENT ........... A2 f 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home. Local .. ..... ........... . f ~'t~C/ Hearse (Casket Coach) Local S .-'!/ Ci Limousine LUlat.. f Famil}' car Local.... ....... f Flower car or floral disposition Local ............. ............. f Lead car/clergy car Local.. .. 7i1/ v Car for pallbearers Local,...... ..... ..... f Out of town transportation ......... f f f SUB-TOTAL OF AUTOMOTIVE EQUIPMENT....... . TOTAL OF PROFESSIONAL SERVICES, FACILITIES AND AUTOMOTIVE EQUIPMENT ........... . A3 f A f_3y~o. B. CHARGE FOR MERCHANDISE SELECTED: Casket . ~Ta-"~? n ...~. i.~ .e .... f n? ? Y 7. `' `~ (Description) ~' /' G l 9 Other Receptacle ..... f (Description) Outer burial container f (Description) ~' ~ r!J~e~ ~, Acknowledgement cards ... ....... f~-`-'• Register book(s) f.:3 ~ c <~ Memory folders f o • ~~ °' Prayer cards f Temporary grave marker ...... .. f Burial clothing f SUB-TOTAL OF SPECIAL CHARGES ................ C f D, CASH ADVANCED Opening Grave ................ . f Cemetery Equipment ............ . . f Lot and Deed .................. .. f Newspaper Notices-Local ....... .. f i S~ 7..-7~ Newspaper Notices-Out•of-town . .. f Telephone & Telegrams ......... .. f Airfare ....................... .. f Clergy/Mass Offering ............ .. f ! d ~ , ~ '~° Pallbearers .................... .. f Certified Copies of the Death Certificate ......... .......... .. f y ~ - `' d Police Escort ..... ........... . f Flowers .:......... . f/~~ - ~ <_ Vault Service Charge ............. . f f f f f f SUBTOTAL OF ADVANCES ........ f _ ............... D f ~ ~ •S~1 We charge you for our services in obtaining: (specify cnsh advances that are marked-up) SUMMARY OF CHARGES A . Professional Services, Facilities and Equipment, and Automotive , Equipment ................... .. ~~ , c, v 13. Merchandise ..................... ~~7, [/ o C . Special Charges ........... ...... f D. Cash Advances ........ ........... f ~f ~! fC. ~ ~ // r~ TOTAL OF ALL SECTIONS ..... f k~ C~ ~ /1 ~ ~~ ./JtCGU .~.r:.. PAID AT TIME OF OR IOR TP C ~1 /f ' rn ARRANGEMENTS.... ~ ~ r _' - BALANCE DUE ....... - .. ~ J /.~~1.~'.~P .... f~~ 3 ' REASON FOR EMBALMING S ~~~~ ~~ //~ H J~ ~. !f any law, comet y, or cr natory requirements have required the purchase of any of the items listed above the law or requirement is explained below. I agree that I have examined the Items of goods and services selected above and found them to be correct and according to the arrangements I have requested. l acknowledge receipt of a copy of this Statement of Funeral Goods and Services Selected. 1 represen that I have sufficient funds available for payment of the cash price (or the goods and sen•ices selec[ed I also agree to make payment off /,i .7 ~ ~ ,within ~ days. I agree to be jointly and severally liable with anyone else who signs belop• A Isle charge of ~, i' ~ o per month amounting to ,,~;¢ 7 => .per year will be applied to the unpaid balance beginning days from the date of this agreement I will also pay to the Funeral Director all reasonable costs paid by the Funeral Director to collect amounts I owe under this agreement. Those costs may include attorneys' fees, court costs and other costs. Any additional services or merchandise ordered or requested after the date of this agreement will be considerr art of this~ment dd~he cost thereof will be reflected on the final bill or statement. (Purchaser) ate) iSeall ~ ~ y~~-7 (Purchaser) (Licensed uneral Director) •:. Ycnn>yl.ani~ Funcr~l D~rci rur~ A.suci aiiun VI'r11Tt Fun~~r~l pirc~~~or YELLOW Funcr~l Oirtcror . .. _., ,F....1" r .. ~ .v. .~.~~-~ NEED COUNSELOR SALES RECEI~ _~~ . V 1 f ,v~lr~~~~Lc KD v~.-I r. ,- ,;,- r ~ ~o.JJ.~~J~ ~ 1 .; . , ~ .~ - ~ .-. r'-~r1-40~`~' ft ~ 1/ ~ DATE __~ ~~~ ~ ~O RECEIVED FROM Aft ~. ... THE AMOUNT Name of Purchaser G1~ DOLLARS $ ~ 60 AS: DOWN PAYMENT ^ REGULAR PAYMENT ^~r CREDIT CARD CHARGE ^ CASH ^ b ` CHECF~ ~1 ~ U 1 C D TYPE ^ FOR THE PURCHASE OF INTERMENT RIGHTS AND/OR MERCHANDISE AN ERVIC RECEIVED BY CEMETERY SALES C` t[b ti,~Gr r~ O T ABOV NAMED CEMETERY. DATE BY NAME GEN 8002 (6/02) l.auuu~ ivv. L.1 PULL VI .1 L Memorial Color: (Additional Charge) I Jtvte t,luarn[[~, PLEASE PRINT CLEARLY OR TYPE THE ME1v10RIAL INSCRIPTION '1- ` ~` Famih' Her•it~rge Rel;istry~ Emblem ^ YES ^ NO (Initial) By checkin`s 1'ES and initialling the adjacent space, 1/We authorize the cemetery to aflix the '~PHR Emblem to the bronze base, granite marker, crypt iron) or niche front. 1/we (I) approve the above memorial design, size, lettering and dates; (2) represent that ]/we have the legal authority to order the placement or storage of this memorial and are the exclusive owner(s) or authorized representative(s) of the legal owners of the Interment Rights described above; (3) agree to indemnify and hold harmless said cemetery, its agents, and employees, agains( any liabilities ar damage in connection with the installation of the memorial if the named cemetery is not also the Installer. Upon full payment of this contract 1 direct that the memorial be rnanuf~actured, delivered, and (select onej ~ installed at the cemetery upon the Interment Rights, as described above ~! stored at a bonded storage facility. If the stored option is selected, I/we understand and acknowledge that. by signing below (I) the memorial stored shall he insured for all applicable risks (at no additional expense to purchaser); (2) upon manufacture and storage of the memorial, 1/wc will receive a Certificate of Title or receipt shaving the transfer of ownership; (3) upon written request from the undersigned or tither person having legal authority, the memorial will be delivered to the Seller for installation, and (4) if f elect to use another cemetery, other than an afliliatc of the Seller, unless already arranged, ]hve understand and acknowledge that I will be responsible for the costs associated with shipping the memorial to that cemetery. r ~~ r Signed this ~ day of ~ ~.._._~~..1 2O ~,LJ Accepted I3~.. .-, -~~ // p+-~'~ Jr"' /1 l•4luhuri=rl//fr/n~~~r,rrrun•r Purchaser: ~ /\ ~~~'~ (~~ p~`.C:emetery Na rc: i ~t Purchaser: Counselor. ke/urluneMp , ~ \ OFFICE USE ONLI' MEMORIAL ORDER Nlfg. Acct. No. .INSTRUCTIONS: Check Applicable Box `J Manufacture and Ship To: Manufacture and Store lN'VOICEAND SHIP TO: (MUST BE CUMI'LETED) \:lnlc' 111 C:~in~l~n A~cir~,s Cil~ -- .Sl:lll 7ir, PP TERM A10NTHS J DC ENCLOSED t3 v: - - Loc. Nc~. U~uc c~n~~~ nt;u,;ecr -- CIt'.N ()t)~t) (t()/(I~) ~rrl l•cl fl /~ Lt~itnc _ A k t~ f2 ~'A (`(1 [.I tl tr.l 1 n nAr~ n~r~ r.~r- r... ,.. ,-.. ~.... ,, • • RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Receipt Date: 5/17/2010 Cumberland County - Register Of Wills Receipt Time: 14:03:21 One Courthouse Sc{uare Receipt No.: 1061145 Carlisle, PA 17613 ROMBERGER WILMER II Estate File No.: 2010-00514 Paid By Remarks: RONALD MOORE DM ------------------- ----- Receipt Distribution ----- -------- ------- ---- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 460.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 32.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 -------- CUMBERLAND COUNTY GENERAL FUN Check# 1626 -------- $535.50 Total Received..... .... $535.50 ' ;' U}~})GI]~lCII11L'I' ~ CO. II]C. ~~.t~OC~'iE:~''S ~E:~~~~?-~ h PPENHEII`VLE 12i d Strccc, Nc~~~ 1'c~rl;, Nl' lUU(14, (? 12j 66;;-t;000 Mr~~of all 1'rincii~al F:xchant;es Ifrur,cl~ /wcnurn Nururn:~ Af Name ar / m ~ r•~ ~ L) , ~ l`` J ~ ~ 3 ~' ~ ~~>f ~ ~ ~ $ Address /n n / ~ nit ~ ~~~! El1D l~ l~ l ~ The following ^ Secur'ties~Check D Cash are D Received for~Delivered from your account D Debited to //^ Credited to Description (Checl; No., Bank/Branch) Dollars Cents l/~-~ ~? ~ (~ ~R ~ ~o C~ ~ ~ O C~ D D i i I i i Certificate Number lr l Client's ~~.L~1'~~~-~-- Augthorized Signature Si nature ~ GtM Date ~/~C~ P-14 PLEASE DETACH BEFORE CASHING ~ f-+• Ul 117 LU •n ~ 1 1"1 '~ ,f1 3 3 O W 1 J 3 ~ 3 4:, r31- rT ~ ,n to U'1 1-~ rL' 4n r ~y rt iu tD f--r m u1 N• 4 O ra ~ '~' 3 D w ~ {' ~ ~ ~ r i. C? t C[ 3 ~ - ~ ~ t '~ '~' W ~ r I ~, ~ r ~ . o i ~ ~ _O , ~ ~ r ~ ~ w ~ .~ ~ ~~ ~ I 3 U ~ -t. {~ i ,n I LU W r_,..I -,, ~ O 3-- -s ~ 11 i ,~ rr T p ~• r l 3 .u 1-.~ ISI x r~ In m 1-•~ ~. ,n fTJ m r•~ ~ ~ w • W ra m .-1 ~ # --i ' m u.. -r ~ .~ ul 3 w• i v L' r :S i-•r -i- G7 ~. S ~ 4J r-t- f u~ rj ~~ •-O •j,F # ~ r • rr . .u w • r-t ro ~ ~ -~ .~ ~ u~ u., n r~ o ~ ~ r r~ t~ O _ r~_ -n ,:.: HCR Man orCare ~ Z ~ s/ ~o MANORCARE HEALTH SERVICES -CAMP HILL 1700 MARKET STREET CAMP HILL, PA 17011 (717) 737-8551 Ronald Moore 601 Tower Rd. Enola, PA 17025 Wilmer Romberger # 2166 04/24/10 Room and Board 4/24-4/30/2010 $258.00/da @ Y $1,806.00 04/24/10 Level 2 Mattress with Pump @ $48.00/day $336.00 04/08/10 Beauty and Barber $20.00 PAYMENT DUE UPON RECEIPT $2,162.00 $ AMOUNT DUE f'~''~ $2,162.00 • Sheet2 "' HCR ManorCare ~/Z Z / C~ MANORCARE HEALTH SERVICES -CAMP HILL 1700 MARKET STREET CAMP HILL, PA 17011 (717) 737-8551 Ronald Moore 601 Tower Rd. Enola, PA 17025 Wilmer Romberger 05/01/10 Room and Board 5/1-5/6/2010 @ $258.00/day 05/01 /10 Level 2 Mattress with Pump @ $48.00/day PAYMENT DUE UPON RECEIPT AMOUNT DUE # 2166 $1, 548.00 $240.00 $1,788.00 $ $'1,788.00 Page 1 CD ~ - iU vii ~ cD cn Q m ~ ~ ~ ~ ~ ~ ° ~ < C ~ m ~ ~ -p sv o Q m C CD ~' _° ° ° ~ -p ~ ~ ~ ~- ~ ~ ~ 0 3 D ~ ~~ ~ ~ Q~ ~ ~~ ~ m cn o ~ N 0 ~ o ~ ~ ~ ~ ( ~ ~~ ~ 3 N 0 n ~ ~ ~ ~ ~ c~ N ~ ~ , , o CD ~ o ~ ~ ~ v ~ ~ ,~ ~; ~ ~ ~ O o ~ ~ oo ~ ~ ~ ~ ~ ~ ~ ? 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Romberger, II c/o Ronald Moore, Executor 601 Tower Road Enola, Pennsylvania 17025 Inventory, inspection, photograPhY 6.5 hours Research, Report preparation 5.0 hours Beneficiary Letters 2.0 hours Total hours $95/ hour 13.5 hours TOTAL $1282.50 - Please return a copy of this invoice with payment in the self addressed envelope provided. - Payments not received within 30 days of billed date will be subject to 1.5% interest per month. S/~onsor RI 'I I I • REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS No. 200- 0054 PA No. 2~- ~D- 054 Estate Of : W/LMER L ROMRFRrFR // (First, Middle, Last) Late Of: LOWER ALLEN TOWNSHIP C(JMBERLAND COUNTY Deceased Social Securi ty No : 7 64-28-0089 WHEREAS, on the 17th day of May 2 010 an instrument dated March 25th 2009 was admitted to probate as the last will of WIENER L ROMBERGER 11 (Firs!, Midd/e, LasJJ late of L O WER ALLEN TOWNSHIP, CUMBERLAND County, who died on the 7th day of May 2010 and, WHEREAS, a true copy of the wi 11 a s probated i s annexed hereto . THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsyl vani a, hereby certify that I have this day granted Letters TESTAMENTARY to: RONALD K MDORE who has duly qualified as EXECUTOR(R/X) and has agreed to administer the estate according to law, all of which fully appears of record in my office a t CUMBERLAND COUNTY COURT HOUSE, ~aRLISLE,, PENNSYL VAN/A. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 77th day of May 2070. c l ~ r Register of Wi//s • eputy * *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) • . LAST WILL AND TESTAMENT I, Wilmer L. Romberger, II of the Township of Lower Alen, CumbErlar~d County, Pennsylvania, declare this to be my will, ~i~eby ~ , -~;~ revoking all prior wills and codicils . ~-;_~r._. .,~ , _, , r, `~' `-=_-' ~ _~- Cry ~ .~ !. ~' . ' ~' 1 FIRST: Regardless of any other bequest made here,~3,~ I-~ ~";::~ ~ _+ speci fi call ath ~ - y beque to my st,.p son, Ronald ~ --- Moore of nog a -• ~=~ ---'~'~ , Pennsylvania, 9~: ~ ~ ~~ _~ ~' ~' .. ~ ;~ _~S~~.~caxrll~~.e~m~a,n~~~~ ~; - - ~ , f; ~,R. , . ~, ~ -, ;n .. -, - e. -, _ ., '¢ '~ . , ,: y ., .. ,. -~r: ~,i ro _ . '~ °e~o ~ =~ Virginia Moore, wife of Ronald Moore, all Waterford crystal except the ~'JGO Christmas present for Beverly Edwards, my mother-of-pearl lamp, my tulip lamp, my small cherry desk, all Bradford Exchange plate collections, my jade marble top tables, my Pennsylvania House oak bedroom set- (back bedroom) , my Chinese gold medallion and neck chains; to my step-granddaughter, ~R;obt~n Zydal as`~ of Jersey Shore, Pennsylvania, my~cer~amcVTChristmas, tree:, my living room sofas,- ends, ,. eta b 1' e~, r, ~, _:~~~~a~~r;s ~ ;~ n d ~ =~a~m~~s~~o;~f ~~~ he ~~~c h oF.c e ~ t o m - .,,~~:,.~. ,. ~ . ,~~~, • ~ ,~ Y s t e-p- gr a n d on , Vie'-~'~l~a~?~~s °~s' ~,,.:~. ~ j `Kenneth - Moore of Enola, Pennsylvania, my oak dining room furniture, including breakfront table, chairs and sidebar, my_ cerarnc bulldog.; to my Step-daughter, Beverly Ed`war..cls~ `~f Heg ris_:' Fennsy.lvania, ~my, ~~-atmos clod and Sher 2000 Waterford :_ crystal E ,.. _ ~. Christmas presen to my niece, ~~~lkale~nt~;. 1~alme° of Chambersburg, • ~ S enn ylvania r.~ __ .. . , . ~, - ~ ~ °' t;- ? t s ~' y~.. r '~ SECOND: I give the rest and residue of my estate in equal shares to my step-son, Ronald Moore of Enola, Pennsylvania, and my step-daughter Beverly Edwards of Hegins, Pennsylvania, per ca~~. to . THIRD: All income which is undistributed and accrued at a beneficiary's death shall be treated as if accrued thereafter. FOURTH: My executor and his successors shall have the fol)_owing powers in addition to those given by law to be exercised by them in their absolute discretion, which powers sha 11 be applicable to ail property held by them, effectiT.re without the order of any court and until the actual distribution of all. sucr~ property: A. To retain any investments at discretion including stock of a.ny corporate fiduciary hereunder or of a holding company controlling it; B. To invest and reinvest at discretion without restriction to so-called "legal investments" with the spe::ific right tc invest in common and preferred stoc~s and in sLlch common trust, diversified, money market and mutual funds as they deem appropriate; C. To sell, to grant options for the sa)_e of, or otherwise convert any real or personal property or interest, at pttbli c or~ private sale, for such prices, at such time, in such / 1 u • manner and upon such terms as ~chey may think proper, and tc exe%:ute and deliver good and sufficient conveyances, assignments and transfers without liability of any purchaser to see to the application of the purchase money; D. To borrow money and to secure its repayment by mortgage of re~~ or personal property, pledge of investments or othe?~t-wise, without liability on the part of the lenders tc see to the application thereof; E. To compromise claims by or against my estate or any trust created in my Will; F. To make distributions in cash or kind, or partly in each; G. To register investments in the name or". a nominee c>r to hold the same unregistered in such form that they will pass by delivery; H. To reorganization or deposit securities privileges, and g holders; join in any recapitalization, merger, voting trust plan affecting investments, to under agreement, to subscribe for stock and bond enerally to exercise all rights of security ./ I. To manage, operate, repair, alter or improve real estat~ or other property, and to lease real estate and other propez~ty upon such terms and for such period as my executo ~ and trustee deem advisable even for more than five years and bey~orid t:he • • duration of any trust; J. To deduct administration expenses upon either the estate tax return or fiduciary income tax return, with cr cV~ithout adjustment as between principal and income, as my executor shall determine; K• To join with my spouse and file any income tax or gift tax returns that may be due on my behalf and to pay so much of such taxes as :ry executor may deem appropriate and to consent to any gifts made by my spouse being treated as having been made one-ha?.f by me; I~ , To associate with them ir. the absence of a corporate fiduciary, an investment advisor, accountant, custodian grid other agents and to compensate them out of principal or income or bosh as my executor or trustee shall determine, such comper~sati on to be a reducti ~~~n of the compensation of my executor or trustee; M. To associate with them at any time, in their absolute discretion and of their choice, a corporate fiduciar w ' y filch shall have the same powers as my executor or trustee, such desicrnation by my executor or trustee and acceptance by a corporate fiduciary to be ire writing; i~?. To delegate to a corporate fid~~ciary the exercise of any powers, yrith the same effect as if the executor or t~,~~~stee delegating such power had joined in the exercise of such power; and to rec.Toke any such power, provided, however, that the revocat~er of • ~ any such delegation shall be in writing delivered to and accepted by the corporate fiduciary; 0. To exercise any stock options which they may receive, including my stock from any source as my executor or trustee may deers necessary for the exercise of such options; and to pledge assets as my executor or trustee deems appropriate for this purpose; ' P. To do all other acts and things riecessar.y or appropriate in the management, administration and distribution of my estate or trust, including incorporation of my estate. FIFTH: My personal representative is further authorized ill its disc~:~etion to make such loans, advances or expenditures out of the princi;~ai of the trust as trustee may consider desirable in order to facilitate the settlement of my estate. In exPrr; ~; r,n ~„~~, authority, trustee ma~~ pay in whole or in part the expenses of my last iil.ness and burial, debts, income taxes, estate or r ' Y inne~itance taxes, iec~acies, commissions, counsel fees and other administration expenses, owing by me or by reason of my death, which payments may be made directly by trustee or to my executor, and nei_t~~e~~ m y executor r~or any beneficiary shall be required to r eirlbur_ se the trustee for any funds so loaded, advanced or expended. SIXTH: No interest in income or principal shall be assygrable by a beneficiary or available to anyone having a claim agair:st a beneficiary before actual payment to the beneficiary. • ~ SEVENTH: All estate, inheritance and other death taxes, together with interest and penalties thereon, payable with respect to property or interests passing under my Will or any codicil thereto shall be paid out of the principal of my residuary estate jaithout apportionment. EIGHTH: I appoint, Ronald K. Moore as executor of my estate. If Ronald K. Moore is unable or unwilling to qualify as executor, or rlaving qualified is unable or unwilling to continue to act, I appoint as executor, the following person: Virginia Moore. If Virginia Moore is unable or unwilling to qualify as executor, or having qualified is unable or unwilling to continue to act, I appoi r:t as executor, the following person : Kenneth Moore . I further direct that my executor shall not be required to furnish security in any jurisdiction. NINTH: Words used in the singular may be read to include the plural or the plural may be read as the singular. Similarly, the masculine form may be read to include the feminine and neuter; the feminine may be read to include the masculine and neuter; ar~d the neuter may be read to include the masculine and feminine. I have signed this Will this ~ ~ da of Y , 2009. WIENER L. ROMBERGER, II, TE ATOR • ~ Signed by, Wilmer L. Bomberger, II, The testator, as his ~~lill, in tree presence of us, who, at his request, in his presence, and in the presence of each other, have signed our names as wit'nPRcPc • ~ COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN SS: Tile, Wilmer L. Romberger, II, the testator and undersigned witnesses to the Will, the attached or foregoing instrument, who have signed the instrument, having been qualified according to law do depose and say: a.) that I, the testator, do hereby acknowledge that I signed the instrument as .my Will, that I signed it willingly and as my free and voluntary act for the purposes therein expressed; and b.) that we, the witnesses, were present and saw the testator sign the instrument as his Last Will, that he signed it willingly and executed it as his free and voluntary act for the .purposes therein expressed; that each of us in the nearing ar~d sight of the testator signed the Will as a witness and that to the best of our knowledge the testator was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence. WILD~R L . ROMBERGER, I T , TESTp.I't~R S WITNESS Sworn and subscribed before me this ~~~ ' C~~~- a a ~~' o f 2009. "• P LIC (SEAL) Y ~O!41f~7Oi~v'U~~L i t-~ OF PFPdP•J~Y± Vp;~i(,~ M commission expires: I~oia~~al Soal A!felis~a ~. i'vlv~~, Pdoiary Public ~liy tai" Hanui:urr;, Dauphin Jaunty i1AyCc:~tr,7~~,icr~ `:~ir~ . Wu~ 11, d~::,~r~,~•, ,~'Lnn: ~___._...._____„'v t1~ 2.011 .:f1i, ..'il'•, /~c.;n;:r.~tinn nF nina~,,,, ,_, L®Cl~L REG~~R'S ~EI~TI~6 A ~ TI~~~ ~E~~~ WARNING: It is illegal to duplicate this copy by photostat or photograph. :(; for this certificate, $6.00 P 16177740 Certification Number This is to certify that the ini'ormation 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 Stat(; Vital Records Office for permanent filing. Ld~~ %~ ~ ~ M~ 1 2 01 ~ Z1 Local Registrar ~' Date Issued REV 11!1006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH a VITAL RECORDS PRINT IN KNN~ CERTIFICATE OF DEATH (See Instructions and examples on reverse) t. Name of Decsdrlrtl rat, middle, last, aulfoc) STATE FILE NUMBER 2 Sex 3.6adel Sawdry Number 4. Date of Death (Month, day, year) / ~/' L c t/ ~ ~ - fir' ; - - t'}q O /~ 5. Age (Leaf Bkddey) Under 1 wr Under 1 de 6. Date of Month, M , ear 7. &M end elate or Ion Doan nor. PWp of Death Check on me ~ Montle pays Floras Maaeu f/~' / Hoepnel: ~O~ther/: ~ ~ ~ YfS. ~'"l r• /~ ~ ! 9~ 6~ (,/f ^ Inpatient ^ ER / oaweoent ^ DOA U Nurakrg Home ^ Realdence ^ Other • Specny - ' 80. Calory of Death &. City, Bao, Twp. d Death 8d. Fed9ry Name QI not Usetlhrtlon, give sue end number) n. Wes Decedent d Hbpertk Odgin? No ^ Yes 10. Rep: Amedcen inden, &erk, Whna, etc. e / ~ (II yes, epedy Cuban, (~ r ~~' ~G r ~~ /7 j~v /" ~ /~ ~ C~ // ~ ~~ Mexk~n, Prredo Rican, elo.) G 11. DeatlanYs Uarl tion grsd of work done du moll wodtl nle. Do rot stele nW 12. Wea Deoedenl war in the 13. Decedenre Eduanon I~h highest Ands corrrdetsdf t4 Medtel Sm • M - KrM d Work ' '~ fandol Bueirtees/Indueuy U.S. Amsed Faces? us. erred, Never Merced, 15. SurvrvlnA Spouse (II wile, gne maiden name) Elemenlery /Secondary (d12) College (I.4 of bt) Widowed, DNOrpd (Specly) C C ey Yes ^ No 1L.JiG~QryG ' 16. DeeeduenYa Malbrip Address (SUeel, dry /town, stele, rip code ~~ '7 ~ ~ O `~ y ~ ~ ~ w DecedenYa Actual Residence 17a Stele ~/ Did Decedent ` " T ~ j , ~ f J n O . 17b. Count' To swnahi 1 p 17c. ^ Yes, Decadent Lived In T ~ w7 17d. ^' '~lo, Decedent LNed wllhln / 18. Fettsere Name ( ,middle, lest, atrffix) O Actual Umds of L City/Borc 19. Motherc Neme (Firol, Mddle, maiden eumeme) - 20a. Inlorrtlanra Name ype/ PMI) lob. InlornlenYs M°~ Address (SUeet, dry /lawn, able,f/p cod~e)s / /~Or~ q. ~Cl /YO o /' ~ ~ U~ /b c..c>Pr /~o of d ,Girl d `4~ ~i~` / ~ a oZ ~ - 2fa. McUgd~pbposUion r ^ Cremation ^ Daretlon 21h. Dale of DupoelGon (Month, day, year) 21c. Place of Dbpwibon (Name d cemetery, aemelory a other dace) 21d. Location - rLvJf ~ (Cfy/lows, ata18, Lp rode) BudN ^ Removal Iran 6ble i Wes Cremation or OoneUon Authorlud ^ yy~ (~ ~~ ~Q~~ l /~ ^ Olhar • S by Medlcel Examiner/CoroneA ^ Yes No / ,~ d ~/~~ G/~,/~ /1L°/f'jC~~~, /y~ ,(/ /~ y~jr /~Q ~/, 22a. 9igrselure d Furor Se Llceroee (a parson actlnA rv sad,) 22b. Lkenea Number 22c. Nemec ' , , , u of Far@I C~ (J /, / /'/ Complete nevus 23e~ aNy when certllyksA 23e. To the al arawledge, death aaaure el tlr to end place cteled. (Slgne a and tltle a ~ ~~, ~~ G , ~ ~ ~ I J ~ ~~ ~~ , ~ ~tl ~~ " ' / ~~ phyalden b nd evefledo el tirtre d deelh to ) ~~ ~ ~ O ~ ~ ~ ~ 23c.~e Signed (Month, deY, Y ar) artily cause of Meth. /) , _ 5 D ~ D Items 2426 must be canpleted by person 24. Tsme of Death 25. Dale Pronorrrpd Deed ( N, My, yser) 26. Wes Case Relened to Medical Exeminer /Coroner la a Reason 0 r than Cre lion or Donetion7 who prorrourxea Math. i ~ •~ ~ 5 ~ M. ~ ~ rJ / O ^ Yes ^ No CAUSE OF DEATH (See Inalrucllone end examples) l r Approximate Inlervel: Pert II: Enter other 28. Did Tobacco Use ConUbNe to Deetil? rem 21. Pad I: Enter Ure rdtein of evems - duseases, Irdudes, a mrttptications • tlrel dredly eased the Meth. DO NOT solar IermirW evenb such as cer6ec enesl, r Oruel to Deelh but not rasa b Iha undo ' resdrolory ertesl, a ventricubr fibrMetion w1tlsad Ore e' r ltinA !lying cause given in Pad L (~ Yes ^ Probebry slwwing bdogy. Llsl ally one cause on each Noe. r IMMEDIATE CAUSE IFinel dsease or f /~ ~ I'] ~ l r ootsdrtion reerdtirp in stn) _} e. 1/ V~ N I 7 1 V I y ~ r tare to (or es a preequa o r ngno~~~ ~,~a. N. m~~_A S~"1~-~l G ~ ~x~-o n ~ C f~-~v Eller the UNDERLYING CAUSE Due to (or es a consequerxx oQ: r (duease a iry'ury tlsal Ydtlaled the r evanb reaul6q n deelh) LAST. c. r Due to (or es a corssequersp oF): r d. r Spa Was an Autopsy 30b. Were Atopsy Frsdvsgs 31. Mercer of Death 32a. Dale of IMury (Month, day, year) 32b. Descrbe Her Iryrrry Oaurted Pedom,ed7 Avafleble Prior b Canpletion d Cause of Death? Dial ^ Homidde ^ No ^ Unkrravm 29. II Female: ^ Nd pregnant within pall year ^ Pregrenl al time of death ^ Not pre9nan4 but pregnant witisin 42 days of death ^ Nd Wegrranl, but pregnant 43 days to 1 year belore Math ^ Urrkrsown U pregnant within Use past year 32c. Piece of Iniury: Name, Farm, Street, Factory, Otf~ce Buildusg, etc. (5peoyyJ ^ Accident ^ Persdn Imes ation 32d. Torre of Iryury 32e. Irr)ury al Wor1CJ 321. II T ^ Yes ~ ^ Yes ^ No A bA ransporlation Inryry (SV~`h') 32g. Lophon d iryury (SUeel, ary/sown, slate) ^ Srridde ^ Could Nd M Determined M ^ Yes ^ No ^ Driver/Operola ^ Passenger ^ Pedestrian ^ Other • Spedfy 39a. Certifier (crredc arvy ore) 33b Sgna ~ Tu V -~J er ' ~d~nA physldan (Physicians certilyrg cause of deatir when eratirer ptrysidan has proraurced death end mrripkled hem 23 io the Neat of my knowledge, death oxuned due to the puee(e) and manner es atefed _ _ _ _ _ _ _ ~ ' Pronoundng and ceNfying phplclen (Physician both prorsouairsg Math and prUlyksg to pose of deaN) - - - - - - - - - - - - - - - - - - - - - - - - - - 33c. Lice Number 33d. Dale S (Monti,, day, year) To the best of my knowledge, death oceuned al Use flme, dale, and place, and due to the cause(s) end manrser ea aleted_ _ _ _ _ _ _ ^ ^ ~ ~ ~ ~ ~ I ' Medlin Examiner/Coroner ~ - - - - - -' -' ' f-1- ' 1 On The baste of euminetlon and I or In/veys~tlg~aUon, In my oplnlon, death occurred al the Ilme, date, and place, and due to the rouse(s) end manner ea sleted_ ^ 34 arcs and A1ddress o1 Ppason Wna Car>jYetedvCause of De/ath y(a~em~ 2/~ T ~/ Prilm~ i Regkuala Siena and Distrkl Nu r t~ /t / ~ / ~ 36. Dale~Md (Month, day, Year) `-' ~ "~ F-,f ~' ~ ~ 1 ~ n ~ L~~J"t~1 ~j r vY r T U I oL i I I I i ,SCC's~//q~7 -7 J 3 '~ TMl'~-G{) ~ I c. ~(,~C;{ ~In Disposition PemsN Na. _- ~ T / ~ / ~ / ~~ , ,J'1J I ,