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1505610105 REV-1500 Ex (oz-ii) (FI) ~ PA Department of Revenue OFFICIAL USE ONLY Pennsylvania Bureau of Individual Taxes PO BOX z8o6oi °"""TM`"'°"~°'~° Count Code Year y INHERITANCE TAX RETURN ~ r File Number ~~ ~ Harrisburg, PA 1'7128-0601 RESIDENT DECEDENT I ' ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYYY a-ao -~~- ~1 ~~ 0~~~1~/~\\ ~~ ~ ~~~-~ Decedent's Last Name Suffix Dece nt's Ftrst Name MI A~v~,s nn~r~~~~~_k M (If Applicable) Enter Surviving Spouse's Information Below _ Spouse's Last Name Suffix Spouse's First Name __ MI Spouse's Social Security Number FILL INAPPROPRIATE OVALS BELOW ® 1. Original Return O O 4. Limited Estate ® 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 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 5. Federal Estate Tax Return Required 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) 8. Total Number of Safe Deposit Boxes O 11. Election to Tax under Sec. 9113(A) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number First Line of Address __ ~~ l~.c_i,.~ovc~ _ I~ _ _ __ Second Line of Address City or Post Office State ZIP Code __ p Ca~~-s~c.._ 1A 1l~ 13 REGISTER OF V(~LZS USE ONLY~_=;? ~ ~ _._. ~~ C '~ ~r C"~ ~ n .~ ~~ t ~~ ~-, t-t C7 d ~~~~ ::~~ -~~ neTk^ni cif t::~ ~: 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. SIGNATURE PERSON RE~'~~Lff OR FILING RETUR DATE ADDRESS ~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ,,,,r ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505610105 Side 1 1505610105 rl'?', ~~ `, r7 f , ,_, c., ~ -- J, 1'- r~*~t C~ ["~ ti U 1505610205 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: f \ t ~~ a ~(~ 1~ , p (~~ y~~ O ~f~ ~ r~- d- ~,~ 1 ~ l RECAPITULATION 1. Real Estate (Schedule A) .......................................... ... L 2. Stocks and Bonds (Schedule B) .................................... ... 2. ~ - ,O m 1 L . `'~ Y 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. ~ Q ~ ~ ~ q 7 -__,_ ~.v_,n ~ _r..~.__- j_~ .. _ _._ __ _. 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 ' ~ ~ ~ !i ` ~ /,_ U f 0 8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. ~ __.w..e._ .__. ( r ~~ 6 -~ ~~ 11 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. ' ~ `I ~~~, ~ y T I 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ ... 10. ' 11. Total Deductions (total Lines 9 and 10) .............................. ... 11 ~,~ ~ ~(,~' ~ 1 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. ..__ ~. _ j..-- _ 1 fl ' ~ /~~ ~~~ ' 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which , ..1 `-~~~~ "`-""--"~° " " - ~- w-- ~- _~ --_ _-- -~- an election to tax has not been made (Schedule J) ...................... .. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........... ........... .. 14. ~' ~ ~ ,~,~. 3~ 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 to able ~ ~ ~ ~; ~~" ~ at lineal rate X .0~ ~ 18 V ~ -. _ _ -- 41, ~ .~ 3 , 1 t 17. i Amount of Line 14 taxable ~ _ ~~~ ~- , ---"--'--~--~ "~"` _.._. ~.~ ` at sibling rate X .12 17 18. Amount of Line 14 taxable at collateral rate X .15 18, 19. TAX DUE ....................................................... ..19. _ LJ, ~ 7J 3. 1J 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number ~~ t` o ®3 L 1 DECEDENT'S NAME (~f ~ ~ < d ~~. k ~ . ~~ a ~-1J STREET ADDRESS ``~~ ( ~`~~i~~o~ ~. CITY ` ~fi~' L S 1 t2_ STATE ~A Zlp i'10 l 3 Tax Payments and .Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount ~ (o . (0'1 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) ~ I ~~.''~~ Total Credits (A + B) (2) ~,pL , L ~ (3) (4) Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred ......................................................................................... . ^ b. retain the right to designate who shall use the property transferred or its income ........................................... . ^ c. retain a reversionary interest ............................................................................................................................. . ^ d. receive the promise for life of either payments, benefits or care? ..................................................................... . ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ............................................................................................................. . ^ 3. Did decedent own an "in trust fol" or payable-upon-death bank account or security at his or her death? ............. . ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ............................................................................................... ........................ . 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(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. 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. COMMONWEALTH OF PENNSYLVA""" COUNTY OF CUMBERLAND estate of MARGARET M ADAMS SHORT CERTIFICATE I, GLENDA EARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 21st day of March, Two Thousand and Eleven, Letters TESTAMENTARY in common form were granted by the Register of said County, on the 1 a t e of CARLISLE BOROUGH /First, Middle, Lasfl in said county, deceased, to BARRY WADAMS (First, Middle, LasU and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 21st day of March Two Thousand and Eleven. Fi 1 e No . 201 1- 00361 PA File No. 21- 11- 0361 Date of Death 3/14/201 1 S . S . # 200-22-5759 NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL LAST i~TILL AND TESTAMENT I, MARGARET M. ADAMS, of 3700 Sharon Street, Harrisburg, County of Dauphin, Pennsylvania, do hereby make, publish, and declare this to be my LAST WILL AND TESTAMENT, revoking any and all Nrior swills and codicils, in manner following, that is to say: FIRST, that I direct that all of my just debts and funeral exrenses shall be paid by my Personal Representative as soon as this shall be practicable. SECOND, that upon my deati~ I give, devise, and bequeath all of my estate, real, personal, and mixed, to be divided equally among my children, SHERRY LEE LACZKOWSKI, ROBERT E. ADAMS, JR., and BARRY W. ADAMS, per stirpes; that is, if any of my children have predeceased me, then the share of said predeceased child shall pass to his or her surviving children, in equal shares. If said predeceased child is not survived by any children, then his or Tier share shall be divided equally between my surviving children. THIRD, that I hereby appoint my son, BARRY W. ADAMS as the Executor of my estate. If he is unable or unt~,rillina to perform in this capacity, then I appoint SHERRY LEE LACZKOI~~SKI and ROBERT E. ADAMS, JR., as the Co-Executors of my estate. I direct that my Personal Representative sl~iall serve without the necessity of Hosting bond in this or in any other jurisdiction. IN WITNESS WHEREOF, I have hereunto set my nand and seal this 13t« day of November, 1992. MARGARET` M . ADAMS WE, the witnesses whose names are hereto subscribed, DO CERTIFY that an the 13th day of November, 1992, the Testatri.: above named did subscribe her name to the foregoing instrument in our presence, and, in our presence and hearing, declared the same to be her LAST WILL AND TESTAMENT, and requested us and each of us to subscribe our names thereto as titnesses to the execution thereof, which we hereby do in the presence of the Testatrix and of each other on the date of the said Will. WITNESS WITNESS -" OCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. ~ee for this certificate, $6.00 P 17296657 Certification Number This is to ceriif} that the int~irmat;on hcre ~ivei con-early copied Crom an original ('ertificate of Dea daly filed Witt? me as Loca1_ Re=;stlar. ~~he ori«il; certificate wilt be forwarded to rl~e State Vii Records Office for permanent I-~lin~~. i t/ Local Registrar i},,(~ I°,sue~~ HtdSl13 REV ,IP2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS TYPE !PRINT IN PBLACK NK CERTIFICATE OF DEATH (See instructions and examples on reverse) -~~ 0 ,. Name a Deceuanl (Frsl, mdse, teal. aal6a) z. se. J. sdaal secunry rnmher ~ ..~~ ..„... e. Data a oaae, (Mints, day. rear) Margaret M. Adams Female 200 _ 22 _ 5759 3/14/2011 5. Age (Leer &Mdayl UMer 1 Ureter 1 M 6 Date a aM MmN, der , a ?. Bi MCB C' aM state or torei Ba Piece a Deem Check me + MorMS G"+ YS Noun ken9eS Upper Turkey Foot Hospital: OMer: 5/ 30/ 1922 88 vrs. ^ mpatiard ^ ER / Oulpatiant ^ DDA Nwsirg Homo ^ Residerxx ^ Other Speaty Bb. Comry a Death &. Cey. Boro. Twp. a Death 6A Fadity Name ftt Iwl kseNOOn, g'IVe street and mrmAer) 9. Was Decatlent of Hispans OrigM? ~ ~ ^ yaz ,n. Race: Arrenran Indian, Bla t, WNIe. act C~mlberland Carlisle Church of God (n res. r times IspaaM Ratite Mexl®n, Plsrb Rican, etp.) White 11. DeceOenYS Usual alias KiM a work done alai most of world lee. Dona stale rairetl ,2. was Damdem ever in Ne 13. DecedenYS Edummn ($pelaly oMy hgtwst graee mrtpleled) 1A. Mantel StaNS: Manilm, Never Marred, 15. sunivng Spouse In wee, give megm name) Kira a Work Kintl d Bustrress/ US. Armed Forces? k~slry Elem Homemaker Own Herne Widowed. DNOmstl (Speoyi entary I Secdr~ry 10.,2) CWlege (ti or S.) ^ Yea C~Nd 1 Wild 16. DecedenYS Maikrg Address (Sheet cd1' /town, state, np code) Decetleru's Did Dracetlent 31 Kenwood Dr Actual Ratlderrz ,7a slate ~'-nT,SylVanla live ins t7c ^ves Decedent Livee in . Carlisle PA 17103 ,>o cd~ntr . Tw (~nberland T°""~'~' ,7d. C~N D~e~ alNadw~n~n Carlisle p ~ ciy / mrd 16. Fathers Name (Frs[ rrvdae, last, Sulh.) 19 MoNefs Wme (F L mitltlle, maiden sulrNme) Wilson Maule Della Ansel) 2ga. Inhumanfs Name (Type / Pnnl) 2nb InformanYS Madi Adtlress Str rl9 ( ea, dly / k,wn, slats, zip Cotle) W. Adams 31 Kenwood Dr. Carlisle, PA 17103 2, a. Me7rod a Dis{ws f ^ Cremation ^ Dmabon i 21 b. Dale of Dspovbm (Mints. derv. Yawl 2tc. Plaza of Dsposilion (Name al Ixmetery, crematory or olhar pade) 21 d. LaaliOn (City/lawn. scare, dp code) Burial ^ Renwval ham sMte was cremation w Dovnon Authdraetl ~ h N tli lE i , ^ ^ ^ 3 / 19 / 201 1 y e ca x.m ner cdmne~ Diner-s Yea Nd ~ Woodlawn Memorial Gardens Harrisbur PA 17109 22a. Signature a F~ perso - 22b. License Number 22c . Name erne Address of Fa tity N 11 F',tulerall H r II ~F ~~ ~ FD 013239 L 3401 Market . Camp Hiil, P 17 (1 Compete M1ems mly when reneyxg id ' s 239. To Me best d my krwwtetlge, tleaN ortmed ar Ise Mie, date aM pMCe statetl. (Signature aM Idle) 230. License Number 23t. Date Signed IMOnN day year) pys an is va atde al ume a deem [o ~Ittr cause a deals _ ~ ' / `~ j Iv ~ ~ ~ ~ ~ ~ /7!` , , ~ ~ 3 I 2 O t 1 Items za.26 must lK competed by persm wroprdrlolmcesseam 2a. Time W DBaA ~ 25. Dale Pmrwurvea Dead (MOs .day. year] 26. was Case Raen ro Medcal Examner I Cdrorrer for a Realm Other roan Cremation or Donalton? ~ . 1 G aM. I -1 ~ i ^ vee No CAUSE OP DEATH (S inswctions antl examples) r Approximate keenal' Item 2]. Part I'. Enter ate GAain of events -diseases, inludes, or compkraeens - Vial dreclly raised the death. DD NOT enter terminal events such az cartlix arrest. Onset to Death Pan II: Enter other sionif~aa rnm%o ~ tr9v d n In hN ltd resulting in the rrvkryn9 cause given in Part I. 26. D'd Tobacco Use COnlnbute to Death? ^ Y ^ P respratory arrest, or venlnwlar fibrdMtim without slwwing ds aeobgy. tat mly me cause m eam Ixte. -~ IMMEDN7E CAUSE IFnal tisease a es rotuby ~ No ^ Unknown t~ 1 rnrrtlitl fi0rl resulting'n death) `(\6 Sl a'~-~ ,J~~\Y\ SC;Y, S 29. M Female , z. ~ . ® Due m for as a crosegueme ~. Na pregnant whin past year $equenliallIyy Yst COMrkons, 6 aM. b kadirg to the Wuse tilled m line e. ^ Pregnant al time a dears Due ro Enter the UNOEflLYING CAUSE (or as a Ixmseouence of). ^ Nd pregnant, but pragranl wiplm a2 days Idsease err injury ewt'vdearotl the a death events resWUng'm death) LAST. ^ Due to (or az a wnsequence ol): Nol pregnant bW pregnant 43 days id 1 year d belwe tleaN ^ Unknown A pregnarq within Ne pall Year ~. Waz an AWOpsY Perfm T 3nb. Werra Autopsy Endings 31. Manner a DeaN 32a Date of Inlury (MOMh. day. year) 320. Describe Haw Iryury OxuneO J2c. Place of Inryry Home Faun SVeel Facro ry re Availaae Prior ro Completion Natural ^ Homicide , , 01&;e Buimin t . 9~ • c_ (spealy) of Cause of IJeetn7 ~ ~/k ^ Yes Ip/ No ^ves ^ No ^ Attident ^ PenMg Invesugatim 32d. Time of In(ury 32e. Irryury at WoMd 321. tt Transportation Inpuy (Spealy) 32g. Loraum of inlwY ISlreet, oy I mwn, state) / ^ Suicde ^ C ld NW m D t ^ves ^ No ^ Driver/Operator ^ Pessmger ^ Petlestrian ou e ermrne0 M Other Speedy: 33a. Certifier Ire k mty one) Cartttying physician IPnysiaan cenilying cruse of dears when anWter physidan has prorwirtee deem and competed Item 23) 33b. SgnaNr~id T o CeNf L TO Ise bW a my knowletlge, deeN occurred eue to the ousels) and manner es stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ :~ r^ - • Pronouncing and certihyfng physician (Physiaan ban prmourkxg death and ceralyirg 1b cause a Death) 33c. License Number 3:3d. Dale Signed (Monts, day, Year) To the hest d rtry krrowledge, death oaurtetl at Ne lime, date, and pMO, antl tlue to the oase(s) and manner az stated_ _ _ • Medical Examirxx/ mo ner o ^ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , y '\ O ~ ~ O C (y r '- ` U C J CT L_. 311 ~ 1 z ~.~ ~ 1 ^ a on Ina hash of axe ' non and / or iwestigatlan, m my opinion. deem occ~rree err cite nine, mte, erne place. antl see to cite o~sH:) elm manner as slaled_ ^ x Noma and Amrgs a P^ woo co`mp~t~d cease a Deem Inem 2ll Type r Penl R - s S i r N 36 ~ ~ \ ~ !h ~~~ i1 r 1\~ i gnaNre and umber . st ~{ / I~ I / ICI - I 3 re Filed IMOnm, day, year) l~ N y3 ~ - 3~3 ~. +vnct~ ~cLti N1 t1,<;ll ~~,-~v,. P,~ 1ZG~~S Dispositron Permit Nc S: ~l E ~~ /O REV-1503 EX+ (g-gt3) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. QGp,i~t~~,~c~ ~..~2~1 S ~~ac_'~u~ t7 ~~~~'i1O.7to n ~D~~y Ma~'I,~~ ka~L ~~ ~occ~L~.el-rr~L- P~,~~.i\ ~ ~s~UC-~~~ ~~~ a-ra.t1 ~.c.~t~b ~todlr~~b~t~ F~v,,L _~, ~~~~~~~r~ ~. ~Po~~l~ 4 Aga<<,~~ ~~ , ~~.a~ C~P~t-~. t~.orl~ broL~~ `~ I~~o~ FLL~& acc~t.~\~~ v._._ L. `a~,.~tl~ T ~s~~~"~ci~~ l`t tDS1.~Y .~ ~.; ~.~.~ J~~~,~~~~, ~ ~. Pa,~~~ ~ also ~ 1,~-I~.s ~ n ~r~ ,~~1 ~ ~ e ~ l ~ ~1-~. .~A~~~ c~.:: ~ , r` l..~uv~ ~u, va. t~ u ~ ~ t ~ L - -Co v-~~\~ ~`, ~ Spa Lt C>`~e.~ 'f i ,nn c~ D'~-tll~Q 1~.t.T~,.-(rn Y u.. v.~ ~t~,,~ ~~ ~~~~ ~ ~~.~~ TOTAL (Also enter on line 2, Recapitulation} I $ ~ I p j pt (o, ~~ (It more space is needed, insert additional sheets of the same size) O o ~ r ~ . ~ioFi 0 O CD 1~ ' ~ r ~ O) O c~ g O N EA 0 1~ CD N 1~ Imo- I~ l.t) cD ~ M b9 0 O Cfl CC V in d' ca ~ r ~- ~ 0 r Q~ 00 V O ~- T- N ~n O ~- $H 0 C") O M t~ CG ~ r N rn O r 43 0 la r M S''') T O~ r ~ tr, +- r 6R 0 .- Q~ 00 r .- 00 r CD i~ t,[) N ~-- N O t~ ~ O O ~.1~ Q N O O 00 +- n M ~ ~ t~ D tf~ r Q~ L[1 O oo N O N cA op O ~ Cfl ~ +--- 0 0 r r r r r N N EA Efl fR ER Ei? fR Eg U U U _ ~ ~ U m ~ ~ ~ E U ~ U_ °' U c ~ ~ _ dy U ~ U U Ii U Cn U LL ~ ~ ~ c . 0 o u. o > m C~ ~ a' ~, n ~. a i ~ . a~ ~ ~ -a ~ ~. - ~ ~ ~ ccL O 2O ~ ~ ~ N . ~ .~ .~ p ~ .~ ~ ~ ~ g U U u. u.. 0. a w c a~. 'S 0 d O C N ti C lU N .~ [D ~ r O m O 3 T b r a .J f~ C .~ g m Q k ~ ~, ~ ~ c~ ~ c t0 ~ O H d ~~/~IJ 39Jd cSETb HJN~J~3 TcLE85?LTL L~ ~BI~ TLI~~,'9~/bt~ REV-15o8 EX+ (u-IO) =~~, r ~., Pennsylvania ~, SCHEDULE E DEPARTMENT OF REVENUE CASH BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: 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. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH ~- n 1~ll0~ 1~YN.4/,c,._- 1.2~~-r~ ~~a~ ~ ~6711.aa ~~ ~3~~y a ~ - << ~~~~ 3 q~,~3 RIB ~ ~~a~-~~ ga~~v~s ~3s.36 ~/~ ~ 3a~~8 ~ - ~~ ~t~iG; ~~ ~~ ~~~SI~ I a~s.S~ Q/C ~ ~~a-~1 B t - ~U l..i?(~-1~Le~.c air o~~~ ~ ~1, L-l~ .o`~ ~. `Oo~~~~ ~ns. Co - Q~-~~,tiIL~~ ~e~kers ~.~u.r~rt~ ~~.~o I C~~r~~ ~~ C,od. ~~~ - 1\ \fi~G~ Q2~i,-u`r~L.. /3 1133.1 ~ TOTAL (Also enter on Line 5, Recapitulation) $ I ~jpl Qj-~? C ~ If more space is needed, use additional sheets of paper of the same size. May. 11. 2011 11:46~M WOODLAVJN MEMORIAL GF~RDENG No. 254; F, ~ Woodlawn Memorial Gardens Statement of Current Property Value Today's Date: May 10, ZO11 Property Owner: Robert & Margaret Adams The Estate of Margaret M. Adams Property (Lot) Location: Gazden: Well of Samaria Lot: 138-D Spaces: 1&2 Current Value of Total Spaces: $1,835 each = $3,670 total r~ I . -~~ ~~o-~ etery Administrator Date 4855 Londonderry Road, Harrisburg, PA 17103 717-545-3777-PHONE 717-545-4241 -FAX POLICY' DATA P(~LiC~I idflV~'lfiEet I~a.~i.i:c'L1~ Ar'3~'t141d~~ ;tiVaVr~ili v$~vGO vy ADAf~>~ ~IAnGA§tEF !w. ~flL.ICY DA3'E R~~ rJL~f~'~1~8~.= AFC RP,PI.ZCATIQIV Ord RA4tl~1~7~IEiyT RT~ACFiED ~E~E;t7 P4~cE1`3$LINi= his-T~~l ~PA'YAF3LE: t~U~,}2TF~~Y f rcC+~lild~9 CLd185C a7"~kAt:~KEi- :~L'dEE3:Cs:#l~Y: Sit A~'YzICs~~T~aN a!ri AP`sEIV~F~~i~'i' A~ i AC1-!~D HERE1"C~ SCI-I~DULE O~ QEMEI;IT~ AhID P'R~NllUI4r6~ ~C~iti~ ~ f'~, LLEE Ate#S~Jn~'1UCc i~3.c~i E©F, i..ia=~ ~ c-5zn,a -; APR-2fi-~O11 TUE ~2.~5 PM MIST UvALNUT BGTTGM FAX ~,lo. 1172~91d16 FACSIMILE OVER SHEET -J o h~~ ~-~-,e-'~.. To: h~ Date: ~S/26/2D11 Company: ,,~ # Pages including cover; ~~~ - ~~ ~~ from: Oanlelle A. Kline, Insur9nne Services Specialist (717) 795-5139 or (8Q0) 283'2326 extension 5139 Fax: (717) 795-5176 klfrlea(8tmembQrs19t.vra l2e- Margaret Adams Attached is a copy of th® date of death values for this account. The executor, Barry Adams will be in today tp pick this document up ai your branch. Please make sure Barry shows his ID before picking this up, The account number is 325781, Thanks. Z This message contains information Prom Members 1st Federal Credit Union which m n ial and privileged. 1F you sre not an intended recipienk, please refrain from any dtsclosure, copying, distribution or use of this Information and note that such actions are prohibited. If you have received this transmis;.ivn fn error, please notify by email' postmaster(~.mcmborslat.org_ 6DDU Louise t)rly®, PO Box Att. Mechanicsburg, PA 171)55 www.memberslst.or(~ P, 001/002 ~.I'd 9TbI6bcLtiL=O1 BLTSS6LLt~ S.~I~1S SNI~aN3"1 15LW:~eJ,~ O~.~T ITOZ-92-~1dki P.PR-26-201 ? TIJE 02 ~ 45 PhA M1 ST wRLNUT BGTTOM F~,X PJo, 7112491416 ~$ mEMBERS 1,t PPPPRAT_C.RPnTT UNION SAVINGS ACCOUNT: Account NumbeflSuffix x26791-QO Date Account Eatrabllerhad 03l1BI2008 Frlnclpal 6alanc~ at Date of Death 59,46 Accrued Interest to Det~ of D®ath S,DO Total Principtal and Accrued Interest S9 A6 Nema of J^int Owner Nona GHEC,KJN~ ACCOUNT: Account Numbedstrrtiz 3257a~-tt Dale Account Establlshed 0311 Bl2006 Prlnc[pal Balance al Date of Death S3.B25,32 Accrued Inter®et to Date of Death Sr.21 Total Principal and Accrued Intrrryat S3,H25.53 Name of Joint Owner None INVESTMeNT sAV1N({$-BGGOUNT: Account NumberlSuffix S2GTg7-06 Date Account Establlshed 12!25!2009 Principal 9alance al Date of Death $234.3e Accrued Interest to Dete of Death S,Oa Total Principal and Accrued Interest $235.36 Name of Joint Owner Nvnv IRA GE.RTIFlCATE;, Acrnunt Numherl3uffla 326761-16 Dale Account Eet9blfshad 09!1412009" Principal Balance at Date of Death Accrued In[erast to Dtata of Daath 52,649,77 $1.D9 '1 ,~~~~~~ ~ ,-` Iota[ Principal and Accrued Inrrirest 52,650,80 Name of Beneflclary Barry W. Adams "Rollover (tom IR.4 cartl(icate 325701-15, originally 9stahlis hed 02/13/2009. CERTIFICATES OF OEPQ$ITt Account Numbtar15u7ttt< 325701-dd 325781.48 325787-5D Duto AccounE Established D4l152009 DBl28l2010' D9/26/2010" Pritlc[pal Balance et Dete of Death 51,025.29 $25,152.55 $28,G55,ea Accrued Inter®st to Dale or Death 5.27 53.66 514.15 Total P~ncipal and Accrued Interest 51,025,56 $25,161.21 $29,670.09 Name ^f ,loin! Owner Bony W. Adams Bany W, Adana Barry W. Adams Date Joint Ownership Established 04!15!2009 09!2812010 0912H/2010 'Opened by transfer of fundsftom 325781-00_ "Opened by transfer of funds from 325781-OD, VIS4ACCQUNT_ Acwunl Nwrrbar/Sufltx 4672090000167453 Dsta A~caunl Established D3/24/2DDt; Principal Belence at Dete of DmRth S.DD Joint CRMholder Nnne MEMB 5 1HT F~D~CRE tT U 10 ~~ lin® Lending Insurance Support Specialist April 26, 2011 Estate of. MARGARET M_ ADAMS Doto of Death: 03!14!2011 Social Security Number; Z00-22-57fi9 F.00~/002 5000 T-Ut11ML• T7ri.~r P.C). }3rrx ~0 - ~iecli'uursbur~;, YeiT[lsyl~allia 17055 (Fi(1fJ) 1.fJ:3-23ZR ww-wmcmhcrs1 sr.or~ z~2-d 9TbT6b~~TL-^1 HZ1:S56ZL1:~ l~Idf15.5NI~aN~1 1SZ4l:'lln~~ Gli=:~T ZtOZ-9z-Jdd REV-1510 EX+ (OS-09) ~~~, SCHEDULE G - ~ ~;1 Pennsylvania ~i DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR REIATIDNSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY Df THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION ([FAPPLiCABLE) TAXABLE VALUE ~. rt\.~~,.~~s ts' ~~a~.r~ G~~,~ U~~:,~. tiZR Q~C ".~~~lPl- 11, ~-,b~b.va toy°~ - a- ~Sa.f3 ~ ~' I~r•11A_ ~~na,,~c_~ ,~- ~, - ~ c ~ 1(~w~, ~ w. ,~;nu~ ""~ ~ ~~ ~ a-1.3 b l coo °r~ - o (~ t X1.3 I e TOTAL (Also enter on Line 7, Recapitulation) $ I 1'~,1~>3.1 to .~~BtT If more space is needed, use additional sheets of paper of the same size. 0 North American Company for Life and Health Insurance r Since 1886 Apri15, 2011 °~ ~ L,,~+/l\,~ a _47~\An T, r,_.A 'C~~ J~~ ;n~~ a 4350 ~~festown Parkway West Des Moines, IA 50266 d `~`~y ~ g ~, ~ ~ ~ - ~' ~ Annuity Service Center Barry Adams ~~ ; ~-~ ?" .p 31 Kenwood Dr. Carlisle, PA 17013 C~ f ~y ~ ~,a~ ~ - ~ ~ ~ 1 ~-, ~ ~-'I . ~fo Re: Margaret Adams, deceased Policy: 8000046873 Dear Mr. Adams: Enclosed please find our check in the amount of $4,098.37 which is payable to you as a primary beneficiary of this contract. The total amount of-the death benefit was $4,091.29 plus $7.08 death claim interest. The amount of $757.96 will be reported to the Internal Revenue Service at the end of the year as a ta~a131e distribution. Also enclosed is the certified death certificate that was submitted to us as a requirement for processing the claim. We have retained a copy of the original death certificate for our files, and are returning the original to you. If you have questions, please call us toll-free at 877-880-6367. We are available Monday through Thursday from 7:30 am to 5:00 pm (CST) and Friday from 7:30 am to 12:30 pm (CST). A service professional within the Claims and Benefit Department will be happy to take your important call. Sincerely, Connie Baker, ACS, ALHC, AAPA Sr. Claims and Benefit Specialist Claims and Benefit Department cc: File The Marketing Alliance Inc. 12310 Emmet St. Omaha, NE 68164 Ph: 800-519-1801 A Member of the Sammons financial Group Annuity Service Center j P.0. Bax 79405 j Des Moines, IA 50315-0985 ~ Phone: 866-322-1065 ;Fax: 8bb-322-7015 j swww.nacannuity.com REV-1511 EX+ (10-09} ~1' Pennsylvania DEPARTMENT OE REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER M a ~garc~ 1~(\ . ~ ~ ~ w~S .~ t ~ - ~3 b l Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: e. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: ^~ `.' ('~` Name(s) of Personal Representative(s) L"JC~~\r U l . tt ~O_ti~nS Street Address ~ I ~ 2v~ tr~oo 61 1d City ~ ~ C t l .S, ~ State A ZIP ~7'y (3 Year(s) Commission Paid: ~b t Z• Attorney Fees: 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State Relationship of Claimant to Decedent 4. 5. 6. ~. 8 ZIP Probate Fees: Accountant Fees: Tax Return Preparer Fees: ` 3wr'~~.,.~ n~ v~ ~ ~ cs ~ ~k ~ (rp f c~no . ~ 3,~ a~ 33CS1.Sv -I O ~ TOTAL (Also enter on Line 9, Recapitulation) I ~ .~ ~I ~y ~', ~..~ If more space is needed, use additional sheets of paper of the same size. 4 ~ ~~'~ ~~ ;;4~"'~'S".*'~ '' .t. ~ ~T._~;i. ~ Y ySYkh xT~i b' . ., - - ~ ~. .:, -. ~ ~ ~, . e _J .' '.- -.~. >~ ~ ~ 9~,t1~ ~~"1~lSlipg-.ilf PgDRS}'~y'tlAia, IIIC w fa,=~ e~..r A,.., .,~~"~+ilw`n~~ ~ ~ ~ ~ _ .' 11nlcnt Gontrnct ttnd SeCUrily AgP~e~4ent ~; :; -,..~s ; -,~~ ~,''. _ a t-, gfllpgV}t ~r~e 6 t$~{ ~r ~ i t ~ °^.Prospect Hill Cemetery~TLC ("L7,~ /~ ?~+" t~ ~} .'~'Si ~~ '°,Ip 5a~~ ~ tonCM'9g~~ )<u ~~~54bBLS11er5?LL~ (HS -~m~ r - StoneMor PennsylVAnla Substdtary LLC II C nl~;~n i '' st,' r 7 Vy+ ~ryw,gyi "r ~v ~~N erg ' , ~ ``((~~ mGt~ i ~_ Psos ect Hill Cemete "Ce etc ~~ ~ °~,~t"!'r'I°jtit`=~`-'t ~~AtYde 1.611I~ ".^1~'- r48S5Londonderry~toad,'`HarnSburg~I+1I~sF~-....- ~+~`h~^'-~+~ b ,r t ~1rt '~ ~ ~~ ' 717-$'I5 3" 7 '~' y ~ r ,~ ~.~ ,~u}u~*~aa..~G m~p~kz~~opite;~`~~-'-•.i~i'fg °a,_ r. .rq~cr ~ an0.'o etq~gz5 oT the CemeteD. TIIIS:~GI2EFMENT IS made b yrtd betRgeP S~oll~c cl ~ •r `~~~ ~~~ 4~ . _[}}''TTN>;$SETH~TTIAT-Pu[GhdSCI"aBr~pb ko-buyQ ~I~ ~fL"..... ,..~ - r tq, F-,,,h~Se~ oc`his~desl~atecl~bengfieiah~ in accordance «ith ihprterms hereof, the following jiemsto he provrded flriued'at the abdV9 e~ 'R Q ,~n Tag J, ,~E~t~"~TF~'jON~ kU~ RLCf~s ~~ ntIhawn;l?y thgmgp of su~h'gardan/bupoing on file m t)?c office of the GEMETFItY apt] aze uTOre partlcglaify descnbp}I baIPW~2 `"~ ~, ~~ }gi.........°t=Cit'PUe~Ftppe3(s~ S ' ~ ~ "~khlapsoleum; ^ Chapel O Garden ~ Tandem C7 Srde.by Stde•: O'Stnglo ~7`Dev~lopad'a'C7,Ptep~ r i n" , ~-5,` t~~ir3'E~g~a.4'ryp~bi~A~t ~... ~ ~-~c~dd ~.>, ~`~~'xNiche..' ;.. C7~Chapel ~ C~ de' ^ Sm le'^ Com ar' g g pantos ~ DevelopedJ~ (?r`aeonstFlfeti~ ~9c' Ii ra - ~~. ~ , s ass "r y;,~~,r.,> tx+- ~; •. F, -~ 1-- ~~~"~ n ~ ~ ~ ~ +N~zimtrm casAef drmensrorts a ~ length 8f 1 ~dth f'9 }~Igryr ~6 ~ ,. ~ ~ , itx+,.w s~.k~tf-.,, "~Vlq~ ~euiC~` R ~ ~"" ~' Ist ~.hoicQ ~, zicy+ e -t ~,nd e i t. ~i, xr -~t~ G t1 n _ ~ ~~~ ~,' ~ i ,~ a BWldmg ~ - :+: ~~ F,ruilJm ,[ ~~t i ~ ai ;;- tieyuon., ~ Y ~ ..~' ~it+..e , , ,Sept:°4 ~ tilt[ ~n~ _ -k~F.~~ ;.~sw~` iii .t y_ ~ 'v,•i ~ ~ ~rtti ~? 1 t .rte ~~'"~~~ -z'. Na(s) - s5 '.t ~S ace(s) ~wb ~ ,u. '' a ~ Level ~ s` LGv~I~ ~ H~-r' Fes' _ a ,_~ s ~ *•~' r~~ ti r'I ~ -~rri'' ~ ~ ;~ `~ `I .' ' 3. ITEAIIZ~TIfJlq OF CHARGES ~~~:~ ~ t"'`•sH~~~ K ~,~MEAGILANAISE}~' ff~a ~` ~ ~ ~~ ~ _ ~ ~ (A) Burial Rt^ht6 (ap desenbed m Para 1 above)' $" r --. ~ ~~~~h4~~1f1t1@~~ rD ~~~~y~L'~~, i f~ ~ - (B) Perpetual Gwe~~ ' , ~ - _ $: > ~,4 ,~ ~' r; e , .~em9te~'Is~~e~'r}` , ai 4 ~, ~~ }~ ~ r (C) Less CemficateDiscounY - S .'~ t•a~$ ~. _ ~~ s_ yti s ~~ ~ a. ~ s ' ~~~;~ (D) Second Rtght of Interment $ `ti z~ ~ !I VALTI.~'t5) #1 DesQ t1o ~r ~ gb.~ k t ,F.. esi~ 'r 12'~~` .~, ~~ (E) Vault(s) ~, '~r `IdF$ > ~~; ~y rr ~ ,#2 DesQnPt.}4~"~r zr_" 6~ ~:~, ~ (F1 Um(sl :~: ~- _t--- _ t t.1;~ ~ I= .-. + ;. ~~;aLIRN(SI ~i-)~~r ~~ $>~ ~. ~ - (G)MausnlerunLettenng,CryptPlate ~ a ~~ ~,~` , ~~ ~ ~ ~ + ~~ s~ (Hl Memonal/2rlonuntent 6 's Y_ sit s e ~- - M _ Y _ 1 ~ S ~• ~~ ~ ~ #o~l2escnpLO~n~ ' ~, 3 3 I' '"~ (I) Granite BaSe(6)"- ~°.:_.E~ :3c ><+..`~ .'t~'~s2 - ~ ~ ,r r ~ (J) Installatw~C~iaFBe ~~_ S'~ ~ ~ .r ~~~ ~tiiQRIAI~INFOFry~e*~Iq~[t ,..~~ ~ .. '` ~ (K)Caskets ,_ •~ t i~i-~ - ~ r$ s:; ,r~^ t _° ~ .. .'`~~~@u~ofia! pESlgnt ~ ~~ ~ r i ~ f ~ ~ -,^ (Ll, Initial I ee for lni@rmant :x s ~. ~~,Sc _ ,~ (iv~Final Intermett(~nYombmentllntunm°n_i Fpy~ '~'" ~+t ;¢ ~ _ ~; ,' r. ~$runzF She *',,' •'` 3„~ 't~~ A'-~~~~2~ t ~ ~r X ~ ~ r ~-~-y~ ,- ~ (NjPermanent $ecgrds d Processin Cez r ~ '`' '~ 3' 4"~ r +a(~i`~. ~f~~l~~~,~;x~, - t ~,.,~~-r ~ (0)~Other Y ~ ~ ~-~. .~ .d ri. ~ h ~y S i t ~ .. ~ ~ h -III r) :y ?el-, ~M ' , o ALGA ~. T S HA ' - H.RTJRC SE.R CE ~. RI (':THRL' Pl . .~.. v ~ & ~< ~- ,. " 1. I ~.~"`~`~' I ~ ~ _ not 4 i £ a ;, • ITEb117•ATIOlY QF THL AMQ~IVT ~I ~~' ~ ~ isiAN A ~ ~s ~: o ~q. ~I1~4 -- ,3t '„''q~x i ~ t~ ^~ roc _~ 6.. ~~ (Il TOt<71 C8S11 ~I(f~ rr * s ~-r r ~ ,.~. ~~ i ;f' F pt~ c • ,z ~ ; ~ ~ i , . ;c~+=t ~t*txc ry i A: Dpwm Paj?z`r~~,4t`~~t'#SbL'hadttfiC::. - Base. ~_ ~~~~ xt .s_,,,, : '" ~ ~ B.'Trade Ins' T t` s' .. xr~"- ' 9 , ` ,--_.~.~~• r :dS3,~.r~G~ ' t.~ ,- Old Agreem~ntNo '-„ a y ,_ ~ E CASKE'~(S) t ~ ' I C."total Dowv'~e~Inent (2P, k J~) ' t ~ ,~ x~ a '~ n~ M .~ c~ ~ , ~` ~ ~ ..` - ~ (3I Unpatd B~lap~rf ~ hkriPe (.L~ ~ x ^~`~~i`~F 4 ~t ~ r , I bfadel ~~ ~ ~~%'~ odel -~ ~ si(4) Ftoapcc Cb ~ c k s u ~y~rm #y~~~;+au ~ ~~ ~ ~,:, ~. ,. ~ I ~. . ..- ~ ~ ~ ' ~ ;.,~.. ~ ?s , ~ ~,rt„;a ~? ~ ~ , ~ (a)~Total Unpdtd'B~lance i3 d. +} .:i ~ r ; ~, € ~ ~ fhr~ I~LC and the Company Shs{I gach,r p ~~ b ~p~ thyrrr8 S of iten]s,4p '' rslc~s proYided b} une another Pursuant to this Agreed Rt ~9wever }?nT9ha;G ssh ~ A • ` ~; }°~~IENT The Purehasypsh~l~~ R ~E - :. AMOUNT FINAN E ~ TOTAL'0 AYAt 'rrn.~, ~Q]'})j,~~tS~t#);; tU4 . ~Ij. ~I,tr.;?Nch.rtglli~,,ttt r~rt~o}, t} uie redltrvlll opBt you , :Tf?a emeunt of pred! Prw ded tp yA~ Tha.ampurlt YPI; wID ha~e~tQ a_ftgr YPU ~~3~P~ ~ `s 141r~~;~o~1Q~4`IPSSl1S~IP;34n'$"~.9~ ~v,~,a 3r,~ y ~ ; T~ on your own t+eha7(si r~, f1~Yglnpde all pa~'~gnle p6 ~~du~ s YOUR PAYMENT ~ 'Amount of Pa ~ ' [ , ~ ~ I , ymenis First Payment pue pate , , T7lg one" Schepu~Ewt~4 a~. ~ f ~w~u, _ 'Q> >~'` ~~~~ ; ~~ ~~Y ~,e ,~~ i~~~-~ ~~' E, ,a ~, , . e lily '~ ~ , t a~+, I~ $ECURJTti': You arc giving a secunry'q[terest Ul ih~gogr o' ~gil~ ~ r ~¢`It~ of theiunds paid under this Agreement held in a Merchandise Trust Fund Pf~PAYivIE21T If ypu pay otFearly, yqu wdl Itq{Jl~s ~ ~t~[tk~ittg~;pfypd 4f part of the FinanFc Charge,. r ~' ~'' t ~ 'NQd`1Cj~ See thgrematn~eryf t~[;; AFBr„4,,q.Ilyeli~,~. ~~~t ~ditt nRl tntormatPog abopl non p menl ef?iult el>n acne gharge, spcunt}^ t4to[pg~ m t uirc~i - e ~'` , ~ ~ 'ti_ echeduleddate;andPrepay[negtTg(ttp ~,. .:* .•,~L,~ a_, .- - 'THI$AGREEMENTiAHTSE~O~~+~s~Q ~>~~~~ AND ~S SLI$JECT TO THE ADDITIONAL GENERAL. FROVI$IONS CONTA~1).`~i t~Q~' _. :. Q~' .TJ~15~A_GREEME'3T {'Ir#~~~~~lt R1~FAS'~8 I~ t.: , 1 ~~ ; ~ ; ~ ~. .~ ~; ~' ~ ~ r ,~'J'}tis~Agreementshakl,~~dit~~[t,~~e ,~~ ~ .~ A,~~i~cgiisor~~ndassignsofthepartieshereto. ~` °~ ~, THIS AGREEMENT AND Tk1EFA~vIIL~F~,R,,4`PF.~T~I `t'IFTC~1~, IF APPLICABLE, CONTAIN ALL THE COVENANTS A.'VD PROMISES BE~~ ~r~ ~~. , NO•AGE:VT, SAI,ESPE~~~~~~„~ ~ ~~ k' 1~~~'I~E#I P~1~tTY HA$.~UI'HORITY TO MODii''y, ADD TO „ r r ,°~ I ELL ; _ .:,. ; rOlt CHANIGE Q~I~, x ~ _ t CONDITIOIrS CONTAINED I~t T ~' >~ - `~ IH~~ A~ E~AIH.Y' FROTECTIOV CERTIFICATE ,~~ ~, .:.~ ~~~.w.,:u ~^~ :. t~,, ~'~' r ', "~t~.: a N9~~~~SS_C_-(L'tN~$ OF 5 ER fi .~ °- :Any holder of this consumer t C9q . g_~Q~',}~ e(p~ ~~ apSlllefgnses'wbI tithe debtor ~" £rgdl Fti~T~ ~. s C „ (purchaser} could assert agpipst the Seller pf goods or~~~ ~'~"Ip or with the Proceeds hereof ~eFoY~ r [ch!?~ol') ~ha11 not exceed the amount paid by the debtor (Purchdser) her~upder ~ ~ F" =~~„s rt ~ > ~ J ` t LYOT~C.~e ~52._Tl~.~3?RCHA4ER ~ E _ ~r F' .t.~- 2 3 -~_ ~ ~(1~ DQ not~sign thisAgreeme~i'befvr ~ `~" it " . } e ~ lai>)c spaces+ ~ i~. • ~~ ~ - . ~ ,-s_ ~: ~ ; t ~; f `,°,) 'You arC an>jtled to a c~y?Plgtel~'~ -~ ~ * ~ ~ ~th~ t[t~, You: stgn tt ~", ~`,~ ~ ~ I +, _ ~~r~ ~ z rRez (~} Under the Igw, you t~;iyp tha ngbt~ _~$ ount c[~te-and under certain conditions to obtain a partiah I~fun~ of the finapc~ charge; to rgdefln ~~,{t~ -~'f~ ~ f° t :t- a default to requue pnder,~pPt~g FRIG! < k41131~igpossessed. : • ,-.' - _ ~~~.~kh44 :~ .~` ~. - ~ ~, r '~~rlck~a4°4~ ,~ r ~' ~S~R'S RI~H~' TO CANCEL t '!-. ~ _ dih,,r , ; a~ ~y • ,I r. If this A$reemept'was soGClfed ~~yAt~ ~esdd$n~ ~1t a~~ AQ[;pHl~t'the goods or sentices, you, the PurChaser,'ntay ca~cel this Agreement at any time pp(gp jo ,nil~nlghj. ' 't~~ t business da 'after WC date oP _ _~r ~ - ' ry y kh~ Aug ~ ~ ~~~f~1lh~a ~i~htt she the attlched~No6ee of Concellation fol-m d ~ u ~ , .. ~ ' , 5 ; ~ 1 ~ r ~ Aaco>,e Fund: A Real )~st~t $ pu ~:T ~ ~itt;hav~_suffeped mvne loss and have obtained att UnyoAectibJe 'ud intent du to frau ~ ~ c tta~l,tr r. gi t^' a ~` real astara napsacuoa by a~'ennsylvan}~ k~>~e ~ ~ ~ ~1ef~t~t3t1$'ga1J G717) 783;3658 or ]•800 8'x.3113., ~ ~ ~1 ,~ ~~ ~" ~ _~ ,.. _... '9' ~ T . w.: p', ~ - A h T - ~ ... Seller Neill Funeral Home, lnc. 3401 Mazket Street 3501 Derry Street Camp Hill, PA 170114428 Harrisburg, PA 1711 J (717)737-8726 717-564-2633 Kevin J. Shillabeer, Supervisor Stephen J. Wilsbach, Supervisor Contract. # - 741101000242 Case. # - 27560201 S Part One of T}vee Parts Statement of Funeral Goods and Services Selected/Purchase Agreement Date of Death 3/11/2011 Date of Service 03/19/2011 Name of Deceased MarQaiet M. Adams Date of Birth 05/30/1922 Deceased's Last Address 31 Kenwood Dr City Carlisle State p,~ Zip Code 1 701 3-2 1 1 2 Purchaser's Name $arrv W. Adams Phone Number (717) 243-1845 Purchaser's Home Address 31 Kenwood Dr City Caihsle State PA Zip Code 17013-2112 Co-Purchaser's Phone Number Co-Purchaser's Home Address CiN Slate Zip Code In Uus Agreement the words you and your refer to the Purchaser and the Co-Purchaser, if any, signing this Agreement. The words we, us and our refer to the Funeral Provider or Seller whose name and address appear above. For good and valuable consideratioq which each party acknowledges receiving, you agree to buy the goods and services described below. You authorize us to prepare and raze for the body of the decedent named in this Agreement and to conduct the funeral and services and incur the charges listed in said Agreement. W'e have the right to collect the total amounts due under [his Agreement from any person who signs this Agreement as Pumhaser or Co-Purchaser. 0`7/A indicates items of service andinr merchandise that are not nrovided.) Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we wiB eaplain the reasons in wrifing 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 cremation or immediate burial It we charged for embalming, we will explain why below. SECTION t -SERVICES AND MERCHANDISE MERCHANDISE FUNERAL DIRECTOR AND STAFF SERVICES Casket orAltema[iveContainer: Basic Professional Service Fee $ 2,680.00 Manufacturer/Supplier PACKAGE OFFERINGS Model Name/Number 148036 Misty Rose Metal 6 Direct Cremation $ n/a Immediate Burial $ Na Material Forwarding Remains $ Na Species of Wood Type of Metal Receiving Remains $ Na WeighUGauge $ Na Interior Moss Pink Drexel Crece Interior, Moss Pink DD $ Na CARE AND PREPARATION OF REMAINS $ 795.00 Other Preparation (specify) Dressine and Casketine of lleceased $ 395.00 $ Na $ Na $ Na $ Na USE OF FACILITIES AND RELATED SERVICES Visitation $ Na Funeral Ceremony $ Memorial Service $ 395.00 Na Graveside Service $ Other (specify): $ Na Na Na $ Na TRANSPORTATION Transfemng Remains to Funeal Home $ 495.00 F unemi Vehic!er.°.earse t 305.00 Other (specify). Service Vettiele $ 395.00 $ Na $ Na $ Na A Na $ Na OTHER GOODS AND SERVICES Memorial Booklet Service Folders $ $ Na Na Prayer Cards $ Na Acknowledgement Cards Memorial Package $ $ Na Na Memorial Package $ 80.00 $ Na $ Na $ Na $ Na $ Na $ Na $ Na Exterior Color Lieh[ Pink Painted Exterior Liehtb $ 1,695.00 Outer Burial Container: Urn: Manufacturer/Supplier Model Name/Number Std Graveliner Conce Material Concrere Constmeted Curve Liner, Conp $ 995.00 Manufacturer/Supplier Model Name/Number Material $ Na $ Na $ Nn TOTAL SECTION I $ 8.320.0(1 SECTION II -CHARGES TO BE INCURRED BY US ON YOUR BEHALF (Certain charges maybe estimated ='e" means estimated.) We charge you for our services in obtaining those items marked with an 'X' Cemete $ Na B Creroato $ n/a Cler / Reli ious Facili $ 150.00 Musicians or Singers $ 100.00 Certi ed Copies $ 60.00 n Newspaper Notices $ Na u Newspaper Notice 542.47 ^ Na Na Na Na Flowers 250.00 Outer Burial Container Installation $ 159.00 $ Na $ Na $ Na $ Na $ Na $ Na $ Na $ Na nia TOTAL SECTION II $ 1,261.41 TOTAL SECTION I CHARGES $ 8.320.00 TOTAL SECTION II CHARGES $ 1,261.41 TOTAL SECTION 1 AND SECTION 11 CHARGES $-.581.41 $ Na $ Na $ Na $ Na $ ~~,,,, ~ ~7~7/ ~ ~' ~~ ~~~ PURCHASER'S INITIALS AND DATE w1TN S' INITIALS AND DATE ~- Na Name of Deceased Margaret Nf. Adams Part Two of Three Parts Contract. # - 741 ]01000242 Statement of Funeral Goods and Services Selected/Purchase Agreement TOTAL SECTION I AND SECTION II CHARGES $ 9,581.4] SECTION 111 -ALLOWANCES S n/a ~ n/a $ n/a $ n/a $ Na $ n/a ~ Na $ n/a $ n/a TOTAL ALLOWANCES $ 0 00 SECTION IV -TAXES Taxable Items Section I - or -Section III $ Less Deductibles $ n/a ~a TOTAL TAXES 0 % ~ 0.00 TOTAL CHARGES: Section (I) + (II) + or + III IV = ( - ( ) ) S 9.581.41 Less Cash Received $ Na Less Assignments of $ 9,521.00 Unpaid balance due by: 04/15/2011 ~ 60.41 PAYMENT TERMS: You understand that no extension of aedit by us, subject m federal or state credit disclosure, installment sales, or other consumer credit statutes, is contemplazed by this Agreement. You have no right to defer payment of any amount due under this Agreement. You agree that you are personally liable for payment of the applicable balance due shown on the Stazement of Funeral Goods and Services Selected by the due daze indicated on the Statement. Such payment will be made to us at the address set forth in this Agreement. Where the full amount due will not be paid prior to the performing of the services called for by this Agreement, you authorize us to inquire into your aedit history. IDENTIFICATION AND DESCRIPTION OF MANDATORY REMS AND EXPLANATION OF EMBALMING CHARGE: We have identified and described below any legal, cemetery or crematory requirements that compel the purchase of any items listed in Part One and we have explained why we charged for embalming. You acknowledge and agree that embalming and/or preparation of the remains may be performed a[ the facility of the above-referenced fineral home or at another facifiry that is duly licensed and equipped to provide such services. You confirm that you have examined the service and merchandise items listed in Part One and found them to be correct and according to the arrangements selected and that prior to signing this Statement, you reviewed and approved a completed copy of this Statement. You also confirm that you have been informed of your right to select only such services and merchandise as you desire, and that you have the legal right to arrange the ftmeral services for the deceased named above. Acknowledgement of Disclosures/Disclaimer The Federal Trade Commission Trade Regulation Rule on "Funeral Industry Practices" requires certain disclosures and prohibits misrepresentations. The following is a checklist we ask those we serve to read and sign to verify that the funeral arrattgement conference was conducted in compliance with the Rule. You, who made the arrangements for [he funeral and fmal disposition of the above-named decedent, do hereby attest to the following: 1. You were given a Genera] Price List effective on 11/08/2010 prior to discussing funeral arangements or the selection of any funeml goods or services. 2. You were shown a Casket Price List effective on 11/08/2010 prior to discussing caskets. 3 . You were shown an Outer Burial Container Price Lis[ effective on 1 I/OS/20]0 prior to discussing outer burial containers. 4. You were advised that the law does not require embalming except in certain special cases. 5. You were not advised that embalming is required for direct cremation, immediate burial or a closed casket funeral without viewing or visitation if refrigeration is available, where state or local law does not require embalming in such cases. 6. You were not advised thaz any taw requires a casket for direct cremation or that a casket, other than an alternative container, is required for direct cremation. 7. You were advised that state law does not require the purchase of an outer burial container or any of the funeral goods or services you selected, except as set forth on your Statement of Funerai Goods and Services Selected. 8. No claims were made to you as to the merchandise or services (embalming, casket, outer burial container) to the effect that embalming or the use of any merchandise available from us would delay the decomposition of the remains for a long term or indefutite time, or that any such merchandise would protect the body from gravesite substances. No representations or warranties were made to you about the protecnve features of caskets or outer burial containers other than those made by the manufacturer. 9. You were advised that the funeral firm's cost for the items listed in Part One, Section II, may be different based on volume or cash discounts or other professionaVtrade customs where permitted by state or local law. NOTICES TO PURCHASER/CO-PURCHASER SEE PART THREE FOR TERMS AND CONDITIONS THAT ARE PART OF THIS AGREEMENT. DO NOT SIGN THIS AGREEMENT BEFORE YOU READ IT OR IF R CONTAINS ANY BLANK SPACES. YOU ACKNOWLEDGE RECEIPT OF AN EXACT COPY OF THIS AGREEMENT. BY SIGNING THIS AGREEMENT, YOU ARE AGREEING THAT ANY CLAIM YOU MAY HAVE AGAINST THE SELLER SHALL BE RESOLVED BY ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A COURT OR JURY TRIAL AS WELL AS YOUR RIGHT OF APPEAL. Executed this 16 day of March gy. Kevin J Shillabeer ~ ~ ~~3~3 9 L Type in Name License Number Signature ~~/~ 2011 Purchaser's Name Barry W. Adams Purchaser's Signature ~~ ~n~a-~ Social Security # 177 - 42 - Co-Purchaser's Name _ Co-Purchaser's Signature Co-Purchase>'s Social Security # ~ I attest that /have completed/reviewed this document as required by the Company's SOX Key Control Checklist: Print Name: Title: Signature: Date: REV-1513 EX+ (01-10) ;.,. y , P Y :i ~ ~ enns lvania SCHEDULE ] DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS (Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).) .~~ ~~~wo©a ~ C~r~~n`t, IA t'10Ib z. ~~~~k ~i~ Aa~~ ~ Q , ~~ ~ a~ ~ ~~. h.. l~,r~ . 3 ~ In e~~ ~, Le~~ ~L~L Z~~. o I,.~s~:, ~bcr` ~c~ f ~ 3 na Le.~ ~ N\a.skt~ri l__~_ ~ ti1c~~F,~,.~~~k~ -~.~ i l~ s-- ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S 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 $ ~~~_ If more space is needed, use additional sheets of paper of the same size.