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HomeMy WebLinkAbout06-17-11 (2) I REV-1500 EX OFFICIAL USE ONLY PA Department of Revenue Pennsylvania - Bureau of Individual Taxes DEPARTMENT OF REVENUE Caunty Code Year File Number PO BOX 28o6oi INHERITANCE TAX RETURN ~ ~ ~ ' Harrisburg, PA RESIDENT DECEDENT ~ ~ ~ Z ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY l l l0.~8:~ ~ 9 ~ aa~:.Zo ~ o Decedent's Last Name Suffix Decedent's First Name MI ~osT~4 ~uDQ~Y ~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI wr. ~ ~ 3 /Y / Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ Original Return O Supplemental Return O Remainder Return (date of death prior to O Limited Estate O 4a. Future Interest Compromise (date of O Federal Estate Tax Return Required death after Decedent Died Testate O Decedent Maintained a Living Trust ~ Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O Litigation Proceeds Received O Spousal Poverty Credit (date of death O Election to tax under Sec. 9113(A) between and (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone NumbeL CN A-,eL ~S F SH i ~~DS ~ ~ ~ ~ 7 6 ~w . REGIS. t41~ILLS ONL~~''' A~ I t ~ ~~T t.°.:.'~~ First line of address W+.~ `;"7~j Second line of address C.~? City or Post Office State ZIP Code DATE FILED ~nF~H~N~ cS~3u~~- P~. j 7 o,~~Sg7 ifs Correspondent's a-mail address: CeSh~ ~ ~d$ 3 C'ym~asfi 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 inforrriation of which preparer has any knowledge. SIGNATUR BRSON P BLE FO FILING ETURN DATE X ~ ~ ADDRES L~S~F J', NE~~Q HODI~, ~o NCa~hoo~ ~ar~e /17~//ers {~~v ~ / 0 6 .Z SIGNATURE EP ER O~R TH P T DATE ADDRESS C }~E} F J ~//ELDS (>z Clouser ~2oad, j11eehanrCsbc~r~i , P~ /"7os5" PLEA USE ORIGINAL FORM ONLY Side 1 ' REV-1500 EX Decedent's Social Security Number / Decedent's Name: ~ D 5 / ff'i ~ ~ n E/ v • ~ / ~i ~ ~ ~o ~ (E~ RECAPITULATION Real Estate (Schedule A) ~ 3 D ~ ~ ~ L7 Stocks and Bonds (Schedule B) © 7 5 * ~ Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) * O D Mortgages and Notes Receivable (Schedule D) " ~ Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E}....... ~ ~ ~ ~ q ~ 3 ~ Jointly Owned Property (Schedule F) O Separate Billing Requested * ~ Inter-~vos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Biding Requested........ 9 (p ~ 7 5 « O Total Gross Assets (total Lines 1 through a, ~ a-~ ~ q , Funeral Expenses and Administrative Costs (Schedule H) (D S ~ Z ' ~ g~ ( ) Debts of Decedent, Mort a Liabilities, and Liens Schedule t ~ Q 7 ~ ~ 9 Total Deductions (total Lines 9 and q 9 ~ . D O ~ ~ ` C~ Net Value of Estate Line 8 minus Line Charitable and Governmental Bequests/Sec Trusts for which an election to tax has not been made (Schedule J) # ~ ~ Net Value Subject to Tax (Line minus Line . TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES Amount of Line taxable at the spousal tax rate, or transfers under Sec. (a)(1.2) X .0[Z . p D O D Amount of Line taxable ~ at lineal rate X ~ / Z ~ cJ ~ • ~l ~ ' 3 ~ ~ ~ S , Amount of Line taxable Q b O D at sibling rate X ~_t. _ Amount of Line taxable at collateral rate X « O ~ ~ ~ O TAX DUE ~i ° 3 ~ ~ ~ 9 FILL tN THE OVAL IF YOU ARE REQUESTING A REFUND. OF AN OVERPAYMENT O Side Z 3 ~a~/~l COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE , BUREAU OF INDIVIDUAL TAXES OEPT.280601 HARRISBURG, PA PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD NEARHOOD LISA J NEARHOOD LANE MILLERSTOWN, PA ACN ASSESSMENT AMOUNT _ CONTROL NUMBER fold ~ ESTATE INFORMATION: ssrv: ~ FILE NUMBER: ~ DECEDENT NAME: COSTA AUDREY JEANNE DATE OF PAYMENT: 1 ~ POSTMARK DATE: 1 COUNTY: CUMBERLAND ~ DATE OF DEATH: I TOTAL AMOUNT PAID: REMARKS: LISA NEARHOOD CHECK#108 INITIALS: WZ SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER REV-1500 EX Page 3 File Number a. I ~Q --/Z 8 Decedent's Complete Address: DECEDENT'S NAME ~ u D,~Ey ~ CDs STREETADDRESS !S w!L T~SiyI~ZE ~FST CITY STATE Q ZIP / ,7D Tax Payments and Credits: Tax Due (Page Line ~7i 9S CreditslPayments ~ ~ 7J , ~D A. Prior Payments - ~ B. Discount ~ a ~ o _ Total Credits (A + B) .S DD • ~ D Interest D If Line 2 is greater than Line 1 + Line enter the difference. This is the OVERPAYMENT. ~ Fill in oval on Page Line Zi! to request. a refund. ff Line 1 + Line 3 is greater than Line enter the difference. This is the TAX DUE. ~ a, ~f, ~S Make check payable to: REGISTER 4F WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 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 ar its income : ? c. retain a reversionary interest; or ? d. receive the promise for life of either payments, benefits or care? ? If death occurred after Dec. did decedent transfer property within one year of death without receiving adequate consideration? ? Did decedent own an "in trust for" or payable-upon-death bank account ar security at his or her death? ? Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ~ ? IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on ar after July and before Jan. the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent P.S. (a) (i)]. For dates of death on or after Jan. the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent P.S. (a) (ii}]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements far disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only ber>efiaary. For dates of death on or after July The tax rate imposed on the net value of transfers from a deceased child 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 P.S. §9116(a)(1.2)]. • The tax rate imposed an the net value of transfers to or for the use of the decedent's lineal beneftciaries is percent, except as noted in P.S. P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or far the use of the decedent's siblings is percent P.S. §9116(a)(1.3)]. Asibling is defined, under Section as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ • SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is Jointly-owned with right of gurvivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Co n ~ 0 X11 n r u,»~ ~t ~ (S D t ~eQ G~OIt~ rid 2 (,t,~ ~ ,cep le 5 ~ {~i~~la e Co~i~o/~in;u~n `ri oSvu~i /I1%ddle~vrl T~vtls~:/~> y , d ~SC~i ~x~ ~ /ar ~ oaf G'erfain ~ce~/ ~~7ea~ y ~ av, ~r~ rPcor~le~ il/o~, ~ ~ ~ D~ liu ,~~C'dr~/r o~ ~eCcfs ~h a~~~i~ ~'urx~b er/a,~9/ C~G~In~ , ~h~q, ~Liic/ /rl~Ghac/ ~ Gee, ~ y Si,~ /e `h~ n, ran~cl ltd C'U/1Vey~u~ err Said y 9 ~r~M i sus ~%scp~i ~o~f, Lsr, ~~r iS Gv~ T!~ S~ c~ ~ `r ~D~, Sr. ~0.~~~c~Qse y ~ ~ so% ~ ~e ,~ol~l~ ~a ~ s~~c/ ~o/~/yi~~s. ;f was ~ o?d ~ eo n ~ e,~,e.~ ~ J'o y e e M. oe,-c~ctba ~ ©n IYlar~,L, ZD11 ~or a c,onSrG~era~'oti e~ I . ~se~ ~~~tlement ~~e~fi a,-H'a~hed~ 0 TOTAL (Also enter on line Recapitulation) $ ~ of 3 , DDO. ~ (If more space is needed, insert additional sheets of the same site) A. Settlement Statement U.S. Department of Housing and Urban Development B. T of Loan ~ OM8 royal No. FINAL ?FHA OFmHA OConv. Unins. Fie Number Loan Number Mortgage Insurance Case Number VA Cony. ins. 2011.161RAUDABA C. Note: gems maAced "(p.o.c.>^ w°«. pad outsids the ao.:p; they are stwvm hero far irNormatbn purpaes and aro not k,ck,ded in the totab. TitleExpfesS Settlement System WARNING: K a • crime to know~irgly make fahe statements ~ 1M UrrNd Statss on this a other simtler Ibnn. Penatliss upon conviction can i~ckids a tins and m For details see: Title U. S. Code Section and Section t D. NAME OF BORROWER: Joyce M. Raudabaugh ADDRESS: Old Stone House Road Mechanicsbur PA E, NAME OF SELLER: Estate of Audrey J. Costa ADDRESS: Wiltshire W Carlisle PA F. NAME OF LENDER: ADDRESS: G. PROPERTY ADDRESS: Wiltshire West, CarOsle, PA South Middleton Townshi H. SETTLEMENT AGENT: Baric Scherer, Telephone: Fax: PLACE OF SETTLEMENT: West South Str Carlisle PA I. SETTLEMENT DATE: J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLE 'S TRANSACTION: GROSS AMOUNT DUE FROM BORROWER GROSS AMOUNT DUE TO SELLER Contrail sales 1 Z3 Contract sales Personal Personal r Settlement ch to borrower line 2 Ad ustments for items aid b seller in advance Ad'ustments for items aid b seller in advance C' /town taxes Cit /town taxes Coun taxes to12131111 Coun taxes to12131111 School Tax to06130111 School Tax to06130111 GROSS AMOUNT DUE FROM BORROWER GROSS AMOUNT DUE TO SELLER AMOUNTS PAID BY OR ON BEHALF OF BORROWER REDUCTIONS IN AMOUNT DUE TO SELLER or earnest crane 2 Excess it see instructions Prirai I amount of new loans Settlement cha to seller line Existi ban s taken su 'ed to Existi loan s taken su ' to Pa off:36561081 BAC Home Loans Servicin LP Ad ustmettts for items un id b seller Ad'ustmertts for items un aid b seller Ci /town taxes Cit Rown taxes Coun taxes Coun taxes School Tax Sc~tool Tax Y19. TOTAL PAID BYIFOR BORROWER TOTAL REDUCTION AMOUNT DUE SELLER CASH AT SETTLEMENT FROM OR TO BORROWER CASH AT SETTLEMENT TO OR FROM SELLER Gross amount due from borrower line Gross amount due to seller line Less amounts b /for borrower line Less reduction amount due seller line CASH FROM BORROWER CASH TO SELLER f 1O•~ U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT File Number: 2011.161RAUDABA FINAL PAGE 2 SETTLEMENT STATEMENT TitleEx Settlement S stem . L. SETTLEMENT CHARGES PAID FROM PAID FROM TOTAL SALES/BROKER'S COMMISSION based on rice = BORROWER'S SELLER'S Division of commission Nne as fellows: FUNDS AT FUNDS AT to Prudential Thom on Wood Real Estate SETTLEMENT SETTLEMENT to Hooke Hooke Eckman Realtors LLC Commission id at Settlement ITEMS PAYABLE IN CONNECTION WRH LOAN Loan 0 ' ination Fee % Loan Discount % A sisal Fee Credit R REMS REQUIRED BY LENDER TO BE PAID IN ADVANCE Interest From to /d Mort insurance Premium for 0 most to Hazard Insurance Premium for 0 morrt to RESERVES DEPOSRED WITH LENDER FOR Hazard Insurance mo. Imo Mort Insurance mo. Imo Ci Tax mo. Imo Coon Tax mo. !mo School Tax mo. Imo A ate Anal is Ad'ustment TITLE CHARGES Settlement or Closi Fee Nda Fees to Cash Attome s fees includes above items No: Title Insurance to Baric Scherer includes above items No: Lender's Pdi Owner's Pd' - GOVERNMENT RECORDING AND TRANSFER CHARGES Recordi Fees Deed • Mort • Release C' ICoun tax/ Deed • Mort State Tax/stam Deed • Mort 1 Deed • Mort Deed 'Mort 'Release ADDRIONAI. SETTLEMENT CHARGES Coun Taxes to Robert Cairns Tax Collector Inheritance Tax Esaow to Banc Scherer Tax Certification Fee to Robert Cairns Tax Collector Resale Certificate to Pro Mana emerrt Inc. Assoddion Initiation Fee to Meadowri d at M a le Villa a Condo Ass Find WatedSewer to South Middleton Townshi Munici I Authors TOTAL SETTLEMENT CHARGES enter on lines Section J and Section i n.ve d~H reviewed ttw Huai Settlement stakrttent and b M. t»a a my knowMdpe and txfef, it ie. trw aoarete statematx a ap r«~a /fin ~,~{/fir and d'abtreerttstMe made on my acaairri in . I funMr dnM Mat I have received a copy of Me Statement. ~ OI N ' / ~ c The HU 1 Stal I Mve a and acawate acoourx of Mss trarnadion. 1 have dosed wip cause funds b be d'abureed VWIRNING: i• • crime b knowinyy make f gaterturMS United States on Mie or yoMSr similr form. Penalties upon canvidion can krdude a ffne and i Far : reb ~e u. s. code seaiona10o1 and Section tofo. REV-1503 EX+ - ' SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STV~.KS & BC~?NDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ail property jointly-owned with right of survivorship must be disclosed on Schedule. F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH /Yl ALL ~ YiY~~ ~ ~E T~~L ff CC T. ldo. ~ - 5S S ee va~uQ~oh ~~4cle~~ ~ ~ o7S °g TOTAL (Also enter on line Recapitulation) $ ~ d ~ ~ q (!f more space is needed, insert additional sheets of the same size] 0 0 0 v v 0 6t C ~ ~ ~ trp eDi r O N o:; 0 u n ~ i , N ~ ~ ~ ~ Q ~ ~ ~ ~ N ~ 3 ~ N Ga Qv ~ Z ar Q~ 7C -i o. 1 q N ~ 2 ~ ~ C_o ;C`o ~O-<~ O r-m ~ © z~ Gov ~ ~ ~ ~ ~ t°n o Z ~ ~ w S ~ ~ f~ O A~~ v d o ~ " o, n s j S v a ~ as ~ ~ o r ~ a, o d g vo ~ Q, ~ ~ ~ a m y Of 3 ~ c ~ ~ o_<~' c ~ c Dm ~ n ~ ~ N ~ c~. ~ c ~ ~ ~ ~ r. ~ Q N ~ ~ ~ a ~ ~ Y ~ ` v ~ U Y! ~ ~ _s ~ n ~ Q1 ~ ~ ~ ~D 2 A a ~ c a ° a ~ o ~ n ° ~ ~ -mC MN NNN ' _ A A w~ v m t1 .a~i a o ~ ~ ~ ~ C m °m ~ ~ o ~ mod ~ ~y ~g a o 'v Z ~ O m g i~. ~ ~ ~ en to ra Q~,,' ~ a ~ 4 m ~ ~ m C ~ ~ ~ ~ ~ N ~ ~ ~ ~ ~ b l0 ~ - o g~ ~ ~a~ c b ~ o'er ~ ~ ~ ~aa~ y mac-, g~c~~.~ x Z ~r ~ y to a~ ~ nr a m 'a o ~r ~ ~ a ~ ~ y ~ ~ A 3 m ~ ~ C ~ a p O aci S o~ ~s ~ g D cn as a o ° ~ ac 'o m o • ~mm~~ '~i' ~c~~ oQa a ~ a ~ ~~Qa~~. c~~ 2 g ~ ~ ~ C ~ ° ~ ~ m ~ s~ 8 m ~ ~ ~ E' ~f c a M_ C C ~ n w~ ~ m ~ ~ ~ ~ ~ ~ ~ ~ ~ Y1 ~ n ~ ~ O ~ C ~ ~ ~ a - a 3 o a o ~ ~ ~ ~ ~g ~g N ~ ~ ~ ~ m a ~ _ ~ a ~ ~ ° ° c -It fl ~ ~ o ~ ~ ~ ~ ~ o ~ ~ ~ ~ 8i' ~ o~ ~i a ~ m ~ 3 as g~ ~ a ~ ~ A ~ C~ p a ~ o ~ a ~ S~ W _ ~ 9 ~ ~ a a ' ~ ~ ~ 's ~ r ~ a o Q z ~ o ~ ~ ~ ~ ~ ~ ~ ~ o ~ Q ~ ' o ~ ~ ni na ~ N (Q N A O V tlti O m r ~v fsoe Ex. t+-sn SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHRESIDEN7DECEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER CosT~~ ~r~/~,eEy aZ /-X0--/28/ Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must lie disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ . M ~'n18~'12S lst 1~~d era.t G-~e d ~ n ~ oh ul ar ~'~:.s s ~.esf /t/v. 3 o y~ - o t~ ~S. a O f l3.) Cdr eck; A-~-r,~ ~/o. ~ 3 0 ~ 5Z (Tlt2iZ° wad /~Q aCG~ec1 ltd. ~ a°. o. Q! o~ e ~ ~r~ ogee ~/~lr~a~iv`t /~~r ~~a c~~~ ~a/Q vl" C~i OI~/rll~rJ ~ ~l~ ~ ~e ~~it ,L~@~~/!lA' . Sapp , Do a o ~ ~ Su ba r~{ , ~//N S ~ Q Pb I GX 7 7 3 ~f / 6 ~f S' SQIa~ ~ ~ Cf1 r is lTir'S ~ Su f /i•~'F 6lSeq~ Cat /'S (SCE I",~/SQ d D00", / ~irc cS~~c ~ ~'s sorf'l~ t~%yIS ~ C~,oenhaver' Corn ~k~~it~~ of f~u~l~tte/s~~. t~see ~eee~pt awl ~`~e.~k ~ac~ed~ '~a~`b~ o . ~ ~ ~,Q,~ ! lea/I~ end ~ 1 ~ ~ ~a b. yh ~Q~ k GC~e~.t,n d yo, o~ f.(n ~ fe.~ ~ earn Care !~~-~un d ~ 1 a . 4~e f MbK~sem~~fs ~ro-~ka,~,'ohs ~ ~a~c o~ deal ~sfa~e ~e>r ~'~>l+I~men~ Shut ~4ffa~l~~ A G.; ne ~f o~ C'oun T~s ~ ~ fir, 8S L.; rye X08 Sc.ltoo~ 7~.2c~s l ~ ~~~s7~ ~ Z ,~a ss ~e~nd lb. ~ ~ ~ m ark ya ~ ~~4nP ~Ne a /f~ {fie ~n~ ~ /}-~-nn JN~a~l~i ReF~n~ ~'bd, oa ti ~~~j n~ ~a 1~f . ~Iy! Cash ~e~xna~ 1E f oo ~g IS loo • a % ~ - bm low (sce co~~n sue) ~ ~d. C Ski 9 ~ ~n~ /v D - ~ ~ TOTAL (Also enter on line Recapitulation) $ ~ ~ ~ 9 (If more space is needed, insert additional sheets of the same size) 1 s~r-D . C, ~~d. ~o ~e c ~ / _ _ _ _ _ _ _ - y'_ _ ~i~a ~.tu~~ ~i?r -~Zu J^G~i~s~- __b~ ' ~T _ T_ur/1 ~5~?i ~t!1_ _ _ _ _ _ - _ _ _ _ ~l 9 9 _~~tu~~ __G.~. Ta-~X.~on~-___/YalSonw.a!c _ ~ ~ J3, / ~cJ~i~rh a~ ~Sl:1~eJ_ ~nr,~ o~ /ylbr~t~e__Loan__an_ ~llur~asc _ ~__.C_''~ruCo,1_ __l~ 9p _ t- _ r. i I MEMBERS FEDERAL CREDTT iJNION REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner None CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner None M BERS 1ST FEDERAL CRE IT UNION ~Q.~L - , anielle A. Kline Lending Insurance Support Specialist March Estate of: AUDREY J. COSTA Date of Death: Social Security Number: Louise Drive P.O. Box Mechanicsburg, Pennsylvania wwwmemberslst.org VEHICL=APPRAISAL c~T~ ~t`v JATi~ / DATE ausvECtioM~ f j ~k25 ' .n~~:':ir.:SL•y / t / fl TRADED / / t:xrlRes { v . _ MA MOOI:f. 80DY ~ T LEV~L 1 r~0 ]u INTE OR <:O.OH(S) ~ COLOR O LEATHER f sl ~,TE +yQ. PLATE EXP. TITLE #i ~ t - ~ ) Y .Ni ' 5 Dtt3lT C] 6 DIGIT MILES [_._J _ tf._ ~ ..__..l ~ _ ~;,t~~1tWf)t-~iS :.f1'ER TAANSAAISSION DRIVE ` y _ 5 i C T J MANS 'J M v FRONT {J REAR :J 4X4 D ~ ~ WtcR ITEMS EYLESS ~!'!K-t'CRI;~;G t S ~pCKS NDOWS SEAT ~IRROR J ANTENN REM071: _ . - AUDW ii ERAS _ - 1~~vJFy. CAS.Sc ~ IE~CU £.l CHANGER 'J ONSTAR ~_i XM :J DWD ' .iA~ r,OND ITEMS AEt BAQS a~,~.Ft ' riEnt t AHi VnNF NEEDS WORK J t3LOW9 COLD ~1AL G DRIVER •J SIDE b9i, L!~?. t~'~' I ~a;~QEAR .~i LT •r~itJISE U I1t~Sr PICKUP TFtUGK 1TEWS . 4Jvt~t _ ~ !DEFOG j~Vl•tEEL CONTROL > REG CA8 u TRAILER FNTCH + - - • ---'Jtll:dl VAN IlERAS U' XCAB u SHORT-BED ~ , 3 i ~ :]a POWt..R OR 'J SHORT 'J EXTO 0 3 OR 'J LONG t3ED I - - ,c7;...?, . f'~I+VCF~ J ROOt= J T TOP J REM_ '-t 4 OR ~I f3E0 LINER • rztXl ' Suvf+GJt' RACK ~~~P U SLIDER U CAP ' RAILS U BOAf30S 1 ~ v q„v ; -~tt>EO WAliRAf~iTY? Y ; N (WARRANTY EXPIRED? Y ! N ) ' .:a.riP ft~• U r:.:S ~ 7 -;vt i AREA OF e:~ t~ r r?n p:.,(,'tF)i;+'?ti Y / N - DAMAOE? . S _ _ A fPP ,ISA I,I~C~,~ ~ MMa ~ .L ~;:7n _ . _ _ u PAOE ~rit5 _ SUTt.~FFTRADE? Y/ N BAuNC~ :~~~~F:A!cs:.-1 ~,,J~91'~/~ OWED: S_... TO WHOM' ~F:c VAV v" 3 ,,'_'p~ SALF~PERSON'- - - - FACTORY ~ OROEF tx STOCK Q LOG TEVAL • rr ti~rr-f•rvarrvf r'~wf vV'76.~/'iMilh f'ttil i'k - l~.fi.-^r:.~~: ~ ~ ~ 13th & P~xi~'~~#"~eet~ Bob,"i307 5t?t)1 Jonestov~t~::~ i.~'''~ 1-1~rrisburg, PA i Q~ t~trisburg. PA ~ Tf .~aevroiet ~~ri~l./ j_j717} 234«~t444 ~*8~$'I;'L,1F~ 1-8+~5~F~ (NAME) FWSr MIDDL£ ' - ~ ET''ADbRES~I ~ CITY ~iir~ ZIP ~ ~A~ i~~ ~ : i~ 1~1I~T FaR QELNERY ON DESCR1PT1aN ~ ~ i.~ SRI s.~LEsCf1~$ULTANT ~ AAODE ` N[i~S ~ ~.f ~ .,i ~ ~utcE _ ' ~ tiC1f~' - ~ 71rir' Ir tie, r,,. ~ EXPIRATION OIITE MILES , e+ t AMOUNT +u7WA G000 TIL ~r~' STATE ' : Z1P YERiFIEDBY. `~la t~aa~kf ~~0err unrbte Za verty the amount owed or tjw vthicie being`traded. Therefore, yoel w~3itt~ listtte Mr any srwrtage and the tsardc w4 reflura any excess when the amoum is verified. GM. Karranted items added: PuACrIAS~a's SIGNATURE ~ BATE . ` ` ' IN3UfUNCE AGENCY. ty0[t•Q14{ WaFf8fit8d 1t8m8 2lddAd: ADORE53 PHONE NUMBER CirY STI(rE IlP ORNER'S LICENSE • WE t9MIlE YOU: {pease rssotve rrkn~n 2 weelce) ~NSUc~ ~~crlvE ExPIRArION °COMPANY DATE DATE `POLICY ' ~ COMP. ~>f4ti1G>~1.~c ' NUMBER ' COLL. DEDUC11Al1k ~:0~~"tl~lt. !~15:'.LOti>r# STATEMENT.FORlJ&Et3'UEfi1CLE ONLY CREOIT LIFE & D1SAt31LITY INSURANCE (optional) was offered- 'T~.~a Irtlormatian you see the wfndaw form f~?r vehicle part of this t~OCftfBGt, Iniormatfon on the v~ndow form C1rlr~trtk4;~ c~v y;rovisions (rti thEt I CHOOSE 7p [t PUAGHASE ? QECLINE t_XTLNDF.[3 WARRANTY:PAOTEC'f°ION cu:~ract of she ^ Purchaser ~I~rs~x that This crifd~tr i~~~dt~'aIS qt territi~ erxi conditions iraft~ ihfa find rerr+etss~ ttk~v herLsGt~ t~~t ~tµs c~::ier ~t1~ls end ~~t supersedes prior agreement ~trd. a~ c~f,i~ hereof ~rrrt;r~„~y thA complote exclusive statemehs of m~ ti?strtis cxt tcgreemertt. fsiatrs-~ to ~ ~b~ect matter& covered ttHie!ry~_ Ti~S >~ttyef ~t?aii nct l.~# , _ ~fixa't~~,~fn~t e~if3d bv' t~fi ;i~r car ~s authorized sGt~rASentativer 'mss ~ ~C~t~is > ase~ ~ #;~i r~t~ may. '~ApS!~t AMOUNTCiF DESCRIBED 1iEI~~CLE S ;gip ~ ~'t i~tti~ad - t.~ a t-~, dpi LESS TRADE-tN VAGUE ~ ti `~n~~tti~ ~ ~ ~rrrs ~a,:'I~li'~ ~s~l~ir_~ri the c~3i~te~t~ ~~.•.as..~/ r>i~ execLftfion Gt.tfrj~ t~~e+' adcnowiedges brat Ice TAXABLE AMOUNT $ ' :~~.r~ ir~~t, t;~d conditions ~c~ ~,:;s received ~ flt.rl~ t'°:r'! t,~f" ~~ti~ order f F~ SALES T,t?~ s~ ~t~~'~ ~ ATE 1 E ACCEPTEp B DOCUMENTARY FEE qtr 'i`1~'t„~ EYltvit~' t=_ -i~E ~A ~ ~ NEW t_1CENSE PLATE i _ ` Y~33 Al1~C~,it~'~` 11+tCi,~31~~N~a~~:~.1STEQ $ . AMOUNTCIWED ON TRADE-tN . LESS DOWN PAYMENT AMC?UNT:DUE OPl DELtVEAY $ E i . ,,,.:fyr ttY :.A 7~MaN0 C-wI Cr CI1D~~ GH~CK tttiff Chevrolet Co. CfJIVrROt_ NtJ. ISSUED BY: BRENDA WASHING PAGE 1C arnsbur , PA INVpICE tNVOiCE PURCHASE COMMENTN.I.N. AMOUNT DISCOU[+ITI NET STOCK NO. DATE ORDER NO. ACCOUNT NO. AMOUNT O1G41I PURCH~ISE SUBARU I2, NEARWOOD t i E t t ~ ~ t t TOTAL 12404.Oa DETACH Al' PERFORATION BEFORE DEPOSiTI1VG CHECK REMITTANCE AOVICE , t:.~t; u,~~~7t..~'.Q ;t ~r eti+et r t3i~ > # ~ ~;~:t!'t' • ~ L1:~~ :'r~ f„i~~ ; . - istt.. Iff,P1 CHsmi::titt ~a;tit:... ttl _.i rR i .~-5t.,.s,r , t.~kf 4,'#lt~4: L r~is :z~it,t ,si:. z v SUT~IFF GHr=VRdLET CO. P.o. sax , ~ 0 4 8 6 ~ tc # ~ t & Paxton sts. nn~rRO sar~x ~1/t____.lY~~~'"" H$fflSbUfg, PA ~7~Q~J tiARRiSBURG,PA $Q•isa/313 eras ~a~t i717! 234-~k444 x.44 8 6 6 www.sutri#tchavrolet.com OATE PAY 7NIS AMOUNT- AMQUNT OF CHECK 2 4 JAN 1 t ~ # ~ * * tJOIt.ARS CENT'S * * * 12,40Q OQ T O THE. LISP? J NEARWOUD EXEL EST. OF - OFtUER AUDREY ti7 COSTA BY , OF NEARWOOD LANE M I LL,ERSTOWN PA 0 6 2 tf" ~D~B~~il' ~;D 3 i ii$~,6~ 5 3B'$ 3$D 5i1' two Q~`-"'~ ~ 7r' tt ~ ~ v ~ r 1r ¢ ~ M ~ ii t+ t! O K s r~ p M tt 't ~ ~ r ~ ~ rc1 ~ to ~ • . N Ti ~ ~ ` ~ ~.d J y ~ O. M Ja O W'~-Y4 ~ N O~ N p p ~ p s V~p ~ p. fi O pOµwGl~ A.rt~7 ~ r K ~ O O N O O Q ~ Y• s ~ - t ' ° s ~ ~,w s< d. ~ ~ C ~ p k, ~ w.. o b ~ a~ h~ ~ ` ~ v .,.y , , ~ ~ ~ CC1 • y: ~ ~ ~ ~ ~ Q wl YF. THI ~ ~ ~ ~ ?rr~ Y ~ ~_g ~ ° ~ ~ " Ra 'd "O > V? - vi b p, ~ ~ _ as ~ .x x r ~ O,~ ~ Ox0 tV O U .N O O ~ O N P'"` ~ ~ q ~,x ~ 'j ~ V ~ ~ G r o ~ b ~ y • c> ~ ~ ' ~ ~ Q ~ .n at H V) Q i Q " z% *.f.. ~iMiAY n~sadi.-+=tfo-iia...»,-.N ~..a Y.~».~._.. ~._.~....,...~a..,r<«~F~+~«.eu-w:.~...«a,.,.~~..._...._ .,...r...~ • t - - 4 RAY A. COPENHAVER ~ DOGWOOD DRtV£ f HUMMElSTO1AM, PA 17U36 ~ m ~ fi0-142-313 DATE . RAY a To TiiE ORDE F" I ~ ~ - ~ YA , USTEN1N61S JUST'THE BEGtNNtNG ' FOR n'004? 8u¦ i 2 L6 n¦ - r - x f . COPEI~HAVER COI1~T EXCHANGE East Main Street Hummelstown PA Established S ~ F., ~ Date ~ Paid b DOE rhoto ID Y ~ ~ i x Seller ~ "a w.._ ~ ~ f,~ - ~ s 1Ok 14k' 16k i 18k 22k ~ ~ gold coins N, ' gold coins/bullion , l~ . misc. r._`~ ~.~°"~f~ silver coins .SOO silver coins "a ' Canadian coin ~ U:S. silver coins X sterling Trade out ~ ~ Net TOTAL . ~ ` Distinctive marks, initials, odd shapes, rarity, etc. i~ k. ~ ~ i. '.i i ~ ~ I, (the undersigned) am the legal. owner/trustee of this item ~x items and understand that I can t be held legallyresgonsible to Copenhaver Coin Exchange for damages through`loss of inventory and court costs iri the event.. this property becomes the subject of THEFT BY UNLAWFUL ` TAK1N by ..taw enfolce$nent agency y ~ ; is Si e i~c~~ seller ~ Date :w~ ! RCV-IJ IV Gr,I•JI~ ~ ~ ~ SCHEDULE G ' INTER-VIVOS TRANSFERS ~ COMNOERTANCEOAXERETURN NIA 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 the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY % OF ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE ATTACH A COPY OF THE DEED FOR REAL ESTATE . NUMBER VALUE OF ASSET INTEREST IF APPLICABLE (Nod : sUaS _ ~'ef upo ~ e~s~% ski ~ ~1SOZ /o o ~o V ~ ~ ~gG, o,~ oo~ ~i~c ~r a ~ire~ ~~s,~~- ~ de~clica~~ s ~ ~A~ ~ ~c~~ ~r~f~r Co~?r0%~o`r ~'pr~~ ~~pe`'w~rK. Ya la a Pion shce,~ ~rar~'c~cee' by f~ei'ri~~~ ~y~r~l! ~llaS~ i~ ~11y`aG~feq~ `J~~7c ~3~N~F/C/f1-/~~E3 DFG'~D~~/TS Cf//c d~E-~! Lisp T, /(lear~tvod, dau~h~r /Yl v~~ ~ (~s~~ c~a u~~ter ,ran l~l, Casta, ~ ~1~r ~ose~(~ C~s~, .Ti:~ sdrr TOTAL (Also enter on line Recapitulation) S ~'~S; Q2 (If more space is needed, insert additional sheets of the same size) Feb 18662~1~i Merrill Lynch Page N r o e ~ a aY W v ~ i N N s pAi r W ?W+ NN~+ Otp I op~I N ~ ~ W N Id t ~~nys o cs W e a m v J p o a 1 q m nc ? ~ w r e ~ N o m N a 1 m 1 N 0 u ~~p! 1 A N rqq+ ! b . tD N N _b ~ O b J:. N M 1 OOGG~~ W W M O W m .I N E1 M N. 1 N A bOb a dl W p ~gl v1 o ~ o S ~ b S o o d ~ S 1 N ~ _ ~ ~ a ~ CCCC~'"' ~rye~ ~ _ ~ ~ ~ ~ ~ CMS _ ~ ~tD1 _ ~ V ' ~nS W~ l9 kl ~ M Nn} ~~~~yyy ~M ~ ~ M 1 M n a y ~ ~ ~ O ~ ~ ~ ~ ~ ~ s ~ ~ ~ ~ ~ 1 ' ~ ~ l u0 ~ M : b j ~ ~ ~ i ~ ~c r t+ r r N r S . bb tt~~ N N -N- N N N N N~ N N -N N N-1..,~l~ ~ h/. N N N NN N N N N N N N N t Ap pl. m .o M m oe m m m m m m s m l It p rAR K o ~ t~~ ~ ~ 1 ~ ti g 1 1N QQ V m JN W A m A r. J W O- 1~pp W -q p~ b N N Nl b 0 0p?l O. 1 1>r ~ O C O p O Q o O o O q O P D 1 v t N1+ N• w 1 y~ ~ O O ? s V a m ti ~.q t~+ V j jl~y 8 S ~ $ so g~A q O OdO 1 1 l ~A Ot ~ Ill lJf - I ~ A YI 1YppI `O 1 GG~h~~tt1 A Iy? O IN W J N: ~ O N o o ~ m ? u a W e b N a m o f p 1 N W ~ W ~ ~ a ~ Q a ~ ,rA i - t 1 O l MI i t ~a ~ ~ ~ ~ ~ ~ ~ ~ ~ 8 ~ ~ I Feb - lferrilL Lynch Page ,p W b ~O M r r i ~ , a" :o "d ~M11 w ~~p ~ pp r A ~ ~ i wm y ~oK z ~b ° r :i ~ M ~ iD~y~ ~ ~e Y R . ?t ? u i _ _ a Q ~ s , ~ ~ ti: o ~~~&t a~~y~y7 ~ ~ M ti p k. ~Me 1 1 ~~g~` d ~ ~ ~~~a ~ ~ ~?~Y K b d ~ ~ ~ 1 Z ~ ~ ~ ~ F j o ~ ~ ~~x( ~ 1 ~ ~HH w ~n~ 1 ~ h . 1 fpa i? ~ 8 ~A g ~ " I !!~~eeo ["pf o Y ~ eedd 6 CK i ~ ?i ~ ~ ~ Q~ . ~~p ~ ~ o Q ~ p~ d r ~ ~ ~ o oA o O I 1 , ~ ' ~ e 1 ~ _ . 1 Yr N :N I m p i M ~ ~ - I i. _ i i t1.~~ y 1 j 1 O~ 1 o t i "o 1 ~jq1 ~i i N 1 REV-1511 EX+ SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF C,DS7~i n~E~ J. FILE NUMBER ^ /D Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: !?ti cr5 ~urteral Nome PF ~leC~ian~ cs6u ~ l y , ~P~pdr,~~ior ~ Li~~ D,nner ~!/~t a~a' vsagy~%os ~~s'~rQn7e `~y; 7~f ~Scc re~ei~ l~~a t6iea!) /1I~ino~~a/ ~aweys fists Qdra~ 6 fjto/y Cow ~ ~'D,~o B. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) L/~A ~ ~~r~od~ ~ ~ p DO Street Address ~eQi'`! Dock L!~/JC City ~~C~-s7~W/I State ~ Zip ~ Year(s) Commission Paid: Attorney Fees Cha fle.S ~ Sl~liu~S Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant ~ fVD ~ L/Gl/3 /VD/1/~ Street Address City State Zip Relationship of Claimant to Decedent Probate Fees ~kcG~ Ot i q • ~Jli ~ ~ ~1G ~ ;.s~'~`i~f ' ~~°r f 1~i~~Q fG.s' ~ / S ~L,, Accountant's Fees Y/GGS , ~ /D~~/ Qf~-~D r p 5 w o daes T~ p Tax Return Preparer's Fees ~,UQ~Q S J~/'` ~/`~~O (~S~/17~~ QQ r ~9dYer~is~n Cc[n~bcrl~~ ~~ti1 .Tokr~ta~ f7~'.00 i9-d ?e+~ f: s. C'u ~!%s ose~ f,'r~e I itleuls paper ~s~ m~ q. .~~a/ifl vna/ ~,rrt6Q1~ fee ~ I D. ~ v ~;%~q ~e f ,G~c i~sJEr' off' Lrii%/S ~ J /s oa !l - ~XG ~l,~f~iuS G?~/%'L~ ~J~Ji,~ir~sy~ ~i ?4SDy1 ojlA~/~h/ c~ ~"D r' ~ ~e ~ (sce CD/Jfi`ttia/SO~ ~P~~ TOTAL (Also enter on line Recapitulation) $ ~ -S~'Z, (If more space is needed, insert additional sheets of the same size) i E-ST: o~- C®STi~- G~ul~~-'E3~ J - ~l LE Z- . _ _ ~s~~!~-___~___~~Z~!_____ _ - _ _ ----a~- ~e__-~~ - --~~.e_~~~~rSG_mc~f__~ _.LSQ_~Y~r/jen~ _,~'•--.-_~CI~,~~~~_ _ ~~r_- neGeS~~~-------_----- _ - ~,~a~rS. _/YktC~e_--..__-~~S~Zoll _ ~5ee_---6~~1i _ invo~ce_ _~tf_I_'r~cl~rf~ _ - _ 6O / -----~~S~s_- ~t v%1_!1l_~!P~ SSv G c~fec? _ G~!a_~_J - a~lG_-o` ~~f . _ _ . _ _ _ _ _ - _ _ _ _ _ _ _ - - - - - -See __._~~te~~~ ~ -_~~i. ct~" _~c _~i~_a clr~ _ _ - _ _ _ - - _ _ _ _ _ _ _ _ _ - - _ _ _ . _ _ _ _ _ - , ~ ~ / ~ Do L.ihe ----7r7.~___-- _ ~c°2, ~!'S !-Di1~~'/S-Soy _ . _ _ . _ _ . _ . _ ~ S~D~ L~~G---.~_-_----------- _ _ _ _ _ _ - C'1 _ L,~c ___/~ql---- _ _GPo6~ _ _C'a~'ns,.__ -lax __lol/ec~i,-- _~?.oil.l~a T.~x.__ _ ---~Zg~. s _ _ _ C' , - - - ~;~_--L%/le . ~d ~ - ~~%'rl.s_ r~_ _ _~/_~flGr~_..~'--------7r~ _.C'er~~z-~ _ . _ . _ - _Ln~ _ _,/3v f~ - --~~.~a~e.__ ._.,,Dip~O~r_ . ~ ¢Ls v. go. s S9 - _ - - _ _ _ _ _ _ - _ _ _ _ _ - • _ __._._~r~ ___.~~~~~~__-__D_r_~'^~__ _ _ _ ~ %,S" o0 6 / 7 - _ _ _ _ - - _ - - - - q - ~ ^ s~ ~ncr_ _ - _ D~C~-- - _ - - _ - g~3 _ ----._~I,_ /DO'_~____--L~15_.!' ,~v_/1~_ _ C-._ ~bG_-_ ~P~.. JC/~cG~~ ~_Z!~/Y1 ~S) -6J_D ??,,r__t°_--_.._ . __¢,~OD~OD__---___ ~=xeeccf~~x- - as_ _ ~%~i 6ursc~rc~ t _ .~.w~n~ __~osr _ _ ~~',~~nc~~-- ~ ~c._c_c_rr.~~~x _ - - _ _ _ _ L _ - _ - _ - --`rbr_-. __G(G/.----~,_/I • ~tA_ _~Sc~-- /.~,//iI~ a1` -~c-~t_e_u - - ~ ~ ~ - _ s-_ _ _ _ _ _~~.~h~ b_~r~~n~~cy_i,~`__ _ ar-lc s_ F_ ___S h_~ c~la!s Z _ _ /~~s fx~c,__ -Qa~.1~c~_,_cs.,_ _ _ _ _ - - _ - ~_r-!'~_~ e~.- ~Za fin - c~~ Sce_ _ _ _ _ ~e S~%n- ~ - _ _ / 7S;_a~_ _ - - - - r - i RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date: Cumberland County - Register Of Wills Receipt Time: One Courthouse Square Receipt No.: Carlisle, PA COSTA AUDREY JEANNE Estate File No.: Paid By Remarks: CHARLES E SHIELDS III HMW Receipt Distribution Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST CUMBERLAND COUNTY GENERAL FUN WILL CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE CUMBERLAND COUNTY GENERAL FUN JCS FEE BUREAU C>F RECEIPTS & CNTR M.D AUTOMATION FEE CUMBERLAI~TD COUNTY GENERAL FUN Check# Total Received......... . • VISAGG~O'S hISTOl~ANTE GASTEL. GA3TAGNA BALLROOM V T SAGGI Cl ' S f2I S-I"C7i~A t~Jl- E E-0100 ~ TABLE # 4 Party O CASTEL GASTAGNA BALLROOM JOHN L SvrCk: 1 f11/03/11 C3~t347a TABLE ~ t Party t~ i PARTY DEPO`iiTS, amoun# 5CX3.O0 JOHN L Sv r'Ck : 2 : Q5 Sri Tots 5[1U . O0 1 OPEN FOOD, amount SuE~ To#a1: 500.G0 FOOD, NA BEVERAGE 3t3.5i.i UI/03 .T-OTAL : 50p _ OO 1 pPEN Ff~D , a~~otrt~t G . , 6ElEST 1NERT~'V I L LE f~OAD N0135E ~fHITE - 266.5f? ENDLA PA 17f~25 SPEGiAL RED - WY#N.VISAGGiOS.GE~ ~ 1 OPEN LIflUOR, amount 18D.QU, DRAFT BEER Sirs Total : TAX : _ Sub Total: 20X GRATUIT 01/Oft TOTAL : AMT-TEND CHANGE TALLY cases ~oo.oo V~EE2-C~~1LLE 1~:C3AE3 _ E NO L A PA 1 ~,y I.YISAGGIOS.COM j ~jr 717-697--SQ82 ~ Me~o: GQSTA 1 /~~~c~ -~-e ~wwrt<< .,.T Tr.?~n rYa~t:N~; TALLY . . _ . ,:ri,_„, LiSl~t J NEARNOQfl EXEC ~ EST OE AUDREY J Ct3S7A ~I~~~~ Cash A9'anag~ementA~ccoWn#" NEARHUI~Q UV tu1sLLERSTQWN, PA 1TU82-9063 l ORDER ~ ~ ~~//J 1 $di d`: . r MBti~ i~1~1G~! irk of Amer~p 1'9bli?Cl .~vl .v _~~tYL~ i,~~lEslJ+-~i~_.. (I"-L~ Y ~.~843C1 a~ ~ 29~i'0 ~G y r _ . ~w ti z :U.. . CJ l?~;3' ~ t~ ~ ! t~ ~ ~ y J~ i.,t Irt, ~#.C~ L~ C1 i~ C~~ ~ ~ C~ ~ ; ~ ~ C~if~ 3~t1 ~~©C7 {^L~~ a ~ ~7.~T i~~ , kC? t~ +~CI C3 ~ Z r ~ ~ ~ ~ CI ~ ~ ~ t~ ~ ~''a A FrG "g tit ~ F, 4 av ~ ~ ~ ~ ~ ~ ~ , p,, ~ CZ p ~ CI ~ ~ ~ D c~ x ~~bQ ~ a°e ~ ~a:~S t~ 0 1 ~ ~ ' ~ , ~ a ~ a ~ ~C7 .~o~z ~ ~ . u jai ~ ~ g ~ b ~ Z t~ «wr•W , i ~ ~ ~ ~ ~ ~~~°Q~~~ ~~Y~ ~ ~ c ~ ~ : ~ ~ ~ ` m ~ ~ ~ p. i r~ ~Q~r"'~~~ ~ y~ ~ D ~ ~ ~ ~ rri ~ ~ ~ O ~ ~ia ~ ~ r i w .,,r..;.. s . cam,, U ;a F _ i v f^a.., t~s.~ A c7 ~ 'D ~ 1 s ~ ~ ~ ~ ~ fe ~ C ~~~r ~ " ~ m _ ~i ~ v d oo ~ m Cj ' m ~ as , r A ~ ~ ~ ~ i ~ ~ i ~ ~ ~ o ~ ~ _ ~ ~ y. ` Y s ~MAMMMM~ ~ Z~)' t ~ ~ m ~ ~ ~ ~ ~ . ~ - ~ ~ ~ i ~ A~~ ~ x~$ ~ t~ r t~ ~ Q ~ ~ * ~ ~ x ~ ~ ~ ~ ~ ~ j `Y ~ k ~ .q r I R ~ 7R ti` 'M1 ~ ~ f -a t 1 ~ ~ ; ~ uP gpl.~g 5 Cam _ . 't'uLl YY I ~ ? cX~ I trr ~ v tw tc ~:R.. i vT Four Generations... Celebrating Life, HonoringTi'aditions ~ r~ds ~r~~S IVt~ , BOYD L. MYERS, JR., Supervisor Ce ~ ~ . E. MAIN STREET R f ~Qq~ll ~ ~ MECHANICSBURC~ PA `funeral C`~6me, inc. ~s..~f~ D'e~ou~ USC~I ( STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges are only for [hose items that you selected or that are required. [f we are_required by law or by a cemetery or crematory to use any items, we will explain in writing below. if you selected a funeral that require embalming, such as a funeral t viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if yo~cted a e rat uctt~s~direct a riot[ or t mediate burial. If we charged for embalming, we will exp in wh elow. For the Ser 'ce of ~'sT`~ Da o Death i Z 2 4 e7 Charge t~~ L°f,~• `y ~L~.~f ..J ~ Name Address City State A. CHARGE FOR SERVICES SELECTED: Other clothing I . PROFESSIONAL SERVICES f Services of Funeral Director/Staff f pp Embalming i Cremation urn f 7 - Other preparation of body (Description) ~ -r OTHER _ f f f SUB-TOTAL OF PROFESSIONAL SERVICES A 1 icY, - f ~ ~ ~ TOTAL MERCHANDISE SELECTED B f_ ` FACILITIES AND SERVICES C. SPECIAL CHARGES: Use of facilities and services for Forwarding of remains to viewing (Visitation/Wake)......... f _ f Use of facilities and services (Funeral Home) for funeral ceremony f Receiving of remains from Use of facilities and services for i Memorial Service f (Funeral Home) Immediate Burial f ' Use of equipment and services for graveside service f Direct Cremation Uther use of facilities f SUB-TOTAL OF SPECIAL CHARGES C f!' v • ' _ D. CASH ADVANCED ! Opening Grave . . f SUB-TOTAL OF FACILITIES/EQUIPMENT A2 f ~ Ceme[ery Equipment f Lot and Deed f AUTOMOTIVE EQUIPMENT Newspaper Notices-Local f pa' Vehicle [o transfer remains to Funeral lie. - f Newspaper Notices-Out-of-town f o~~ • Local f ~ Telephone & Telegrams f Hearse (Casket Coach) ~ Airfare f Local f Clergy/Mass Offering i Limousine Pallbearers f Local f Certified Copies of /e!~ D~th Family car Certificate . !.`L.. .~P"`•.'.'......... S~~ • Local f Police Escort f Flower car or floral disposition Flowers S Local . f Vault Service Charge i Lead car/ e r l ~J f Local f f Car for pallbearers f Local i~~ f Out of town transportation f f f D f~~- ttss f ~ SUB-TOTAL OF ADVANCES . SUB-TOTAL OF AUTOMOTIVE EQUIPMENT........ A3 f We charge you for our services in obtaining: TOTAL OF PROFESSIONAL SERVICES, (specify cash advances that are marked-up) FACILITIES AND AUTOMOTIVE EQUIPMENT A i~ SUMMARY OF CHARGES B. CHARGE FOR MERCHANDISE SELECTED: A . Professional Services, Facilities and Casket . . i Equipment, and Automo[ive 1 v~ (Description) Equipment . f es2 B. Merchandise f.~t= ~ Other Receptacle f C . Special Charges , tf~i~, (Description) D. Cash Advances . c~-b~~ ~ ~f ~ TOTAL OF ALL SECTIONS " . E. Outer burial container f PAID AT TIME OF O PRip TO ~ ~ (Description) ARRANGEMENTS f d~• BALANCE DUF. Acknowledgement cards f REASON FOR EMBALMINQ )~h Register book(s) f ~ Memory folders If any law, cemetery, or crematory requirements have required the purchase Prayer cards f of any of the items listed above the law or requirement is explained below. Temporary grave marker f Burial clothing f 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 1 have requested. l acknowledge receipt of a copy of this Statement of Funeral Goods an curt I cted. I represent hai~I have sufficient funds available for payment of the cash price for the goods and services selected. 1 also agre~to ~yment oH' wit~}i days. 1 agree to be jointly and severally liable with one else who signs below. A late charge of_1-.? ~ ~ per month amounting to ` v per year will he 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 1 owe under this agreement. Those costs may include attorneys' fees, court costs and Dther costs. Any additional services or merchandise ordered or requested after the date of this agreement will be considered part of this agreement and the cost thereof will be reflected on the final bill or statement. (Seal) P ) ate) (Seal (Purchaser) (License Funeral Dir or) WHITE-Funeral Director' YELLOW -Customer ~d m~~-~s mc~~~ /~~rr~ 1 / . C ~ /~ch r,~~e ~CC v ~ >n~ . ~y ~z~. ~ • ''"i°'~~ ~ ~ ~~d ! red ~ i ~ checX. VISAGGIO'S R7STf)RANI"E 1 ~ ~ ~ ( Ch,eCJC ~ p Z CASTEL CASTAGNA BALI RODM V:I.SAGGtC)'S FZI:~i"i-UIZANTL F--()OOla TAEiLE q 0 ilParty{l CASTEL CASTAGNA BALLRiIOH JOHN L SvrCfc: 1 Ei1/U3/il 7a TABLE ~ 1 pParty O i PAF'TY DEPOSITS, a~~t SUO.t)0 5t~.00 JOHN L SvrCk: 2 S~~ Total: 1 OPEN FOOfi, aa~cx,nt Sut; To#al: 5Em.00 FODD, NA BEVERAGE 3a.5u Ui/Ot TOTAL ; 5 C"~U _ 0 0 1 OPEN FOOD, aniairtt GUEST fi9'.~O trJEF:TZ V L_ L_.t RuAt:U flt3t15E 1EHIfE ENOLA PA 1 iB SPECIAL RED - W4EW.UISAGGIOS.COM ~T~1 1 OPEN t_IAU(1R, a~oun# 717-Ei97-8082 _ - V DRAFT BEER 180.G0 Suh Total: TAX: Sub Total: GRATUIT U1/08 2U: TOTAL ; 4 6 . 7 4 AHT-TEND CHANGE TALLY CASH 500.OE) O.UU 5UO.OU fi9~10 IMtFt l-Z V 1 L l_E~F:OAD _ E N O L A P A 1 ~7~~~^C J+~ ~y NWW.UISAGGIOS.COM ~j~ ~ ~ Memr,: COSTA Z f O1/03/11 ~ -To dho~l.r< •ur Tr~,n Sip/('NN(i TALLY y ~-~t~. ~y REV-1512 EX+ SCHED~lLE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, Ot LIENS RESIDENT DECEDENT ESTATE OF C p sTA- ~Q-k,UI~EY f FILE NUMBER ~ /o `'/Z~/ Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Ch~.rles C-: Sh;G/ds ~ ~r CDn~SUlfafiorrs u~ ttc~i;~e G~!{rirl ~i~elS%nC. ~ / 6 S. 7S O a, m~~ on ~ar Loam ~ar Sw ~~ru ~Gr ~~m S c,(cr,~ F': ~cSa ppvrfi'n cloC ~{r~ en fQ/Soh i5 Q'~}ac~cl) ~ ~f, 6 ~ ~ S ~y sf r--„~,~Y aPCo. ~ 3 7 ss ~ ~-Z /ASS ~ 3 S ;oa /Il'Gdclou~r.'Q/9~ yso a 7 GCn~f~~ Zrlsura~~c ~`j ~ y~, ~a /V~t~iorl wi~~ ~S uran~e r ~o~r~as1` ~~ah~a/ ~ 6 S7 /.r/~ `V f i u c~ q, 6 9 ij. ~ Jl'!S~ ~l6NA-~u~~ Crcd;+ Ca~.rd ill, 1 a - ~ ~9-m ~r~ ca o ah ~ ~ ~z6, ~Z I _ ~ra~, ~z / i Gl, S, 7r~ctSctrJc ~u^a,~ ~~,tl1~ ~l 3 a o ~S• ~ ~l~Jy~ v,~ ,~IIfGt iGa J~D/?~ ~o ~n ~ ~z~, ~z /(o, j ~~a~ ~a~-vrt ~ ,~1~•,~1~C ~ ~/1tCrica ~/SCe ~G~~G~ ~fi~e~f ~ ffa Gl~e~! ~ ~ %rI t .Sb ~ ~ Sy' ~ Sok~t m; d~~ei~rn l~i~~r?sh,L~ ~ SGWP~' ~ l~a,~'eY ~ ~c q.13 ~ g . ~ ,f~~.~tz~I l ~y~ i ~lo.oa j9, ~ Centur•~ Link ~ a 3 G. i I TOTAL (Also enter on line Recapituiation) $ LO 3 a Cj'7, ~y (If more space is needed; insert additional sheet- of the same size} From:COMPUTER AID INC. P.0021003 . . ~4FFICIAL~~~CnE~K . . . . - - - - 3 0 - - - c ~L~ ~c h. r~ ~I e R - _ T,~. ~ - ~:DA 5 , - ~t~~om .S ° , e i . - w•`,•' • . PAY - = ~ . - • • _ - FOU<t . TiiOUSANO SIX HUNDRED TWENTY •.SEVEN • AND DOLLARS - - . *it~k ~t* - - 5 - 6 O ~'HE . - - T a~. - - - - AUT RD F F NANCE. ER O I o ~a~asE - . :r - - - D• - TA ITE .S TES UN - i ; _ ~ . t}RAWEt~ Bank of.,~mericd,.N.A :_<k ~ ~ ~ . • ~ _ ~ . - - - FOR: A PAY FF UD STA .CAR 0 REY. CO . NP tsgt~ed t3v $arili Of Arter+Ca N A. - ~ . Peyabta 7taot;ph C~tilxt~~Ic..NA, New CaaUe, Ddawero D ~ ~ _ . y - - ; n' 9 3 1000080n' 3 L i00 ? 5n' OFFICIAL CHECK ,ids d~c rlwnld6s teeuea.. p.a.na ar~sw~a win~.~y v 0 Nleriill Li~ynch^~ wry R t" dio. toes in.wneiaeo~e.o~aror d vat Y q ~ not ~ ebock. if not tad, rzarn it b Mcrrrll L tf yw lure . question pWw oowa you. idurill Lynd? rbuncia Advitoc oo not au Cit~bmkN A. ' DATE PAY FOlht TH~ISAND SIX HUNDRED TWENTY SEVEN AND DOLLARS TO THE $ ORDER OF CHASE AUTO FINANCE UNITED STATES • ~e~ DRAWER Bank of Am~~erica~p, N.A p J~ FOR: AUDREY COSTA CAR PAYOFF ~~`UJI{v ~L~UJ ~ ~ L~r- ?~~~,:.:a td.-,~:;. G~ ~rrttrr, ;a N.li CLIENT COPY ~ r~~•.f . ~:,..,,~;t~ ~ sir~r~:. N.k . tstnw cc~tt~. pr:a:vafr, ~~;za Authorized Sigytature(s) n'9 3 i000080f~' i:0 3 L i00'09~: ? Sn' - , _ OFFICIAL GHECK Customer verification information Check Number Account Number ~sa .l -e~hon • acknowied a recei t of a check N in the amount of $ CTn..af+i?n 1 ~ ~ ~ 5 0 - ~ a2 om;COMpU W N ~ x~ ~ ~ ~ ~ 4 ~ ~ 1 ~ ~ ~ ~ ~ ~ ~ ~ ~ c~ ~ ~ ~ a ~ ~ ~ ~ ~ N 's"~ ~ t~? ~ ~ ~ ~ ~ 1 C~ a~o ~ ~ ~ ~ Q ~ ~ • ~ ~ ~ S ~ - ~ ~ ~ i s ~ $ T i ~ ~ ~ ~ a ~ ~ ~ ~ ~ fl ~ _ ~ ~ a Q ~ ~ ~ ~ ~ ~i ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ . ; ~ ~ ~ a ~ ~ ~ ~ ~ _ ~ REV-1513 EX+ . ~ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIE~? INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF p FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. (a) L?sA- NE~F2Noo.A Neathnod Ln. , 1h~1/ers7~u1~, z ~ ~j~t~'" M~GLy F CoST~ I7o~r7b N3aKcr Cokrt San ~nc?sco, 4~f1z9 d ~,t~- y~ ~ ~ .Ti~ivey CosTi4 ~ a~~ G?~nsfi ~u,ncu,nnon, PA 1~o~Q ~ ,T o s FP,y c:~sT~, ..T~. TA-N Ey /yl, G'OST~- So,?~ a 2q sf. ~ dun cannnn~ ~f1- ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES THROUGH AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) I AST WIL•i AND TESTAMENT OF ALTDREY ~TFANNE COSTA I, AUDREY JCANNE COSTA, an unremarried widow, currently of South Middleton Township, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and aU prior Wills by me at any time heretofore made. I direct the payment of all my just debts and funeral expenses as soon aRer my decease as the same can conveniently be done. I give, devise, and bequeath all the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, to my four children, in equal shares, as follows, to wit: A. Lisa J. Nearhood; B. Molly F. Costa; C. Janey M. Costa; and D. Joseph Costa, Jr. In the event any of my said children predeceases me, then his or her share, as the case may be, shaA go to his or her issue, per snT~ve_s. In the event any of my said children predeceases me and is not survived by issue, then his or her share, as the case may be, shall go to my issue then living, ~ I nominate, constitute and appoint my daughter, LISA J. NEARHOOD, to be the Executrix of this my Last Will and Testament. In the event that she should predecease me or for any reason be unwilling or unable to act as such Executrix, I nominate, constitute and appoint my daughter, JANEY M. COSTA, to be Executrix in her place and stead. In the event that, for any reason she is unwilling or unable to act as such Executrix, I nominate, constitute and appoint my son, JOSEPH COSTA, JR. and my daughter, MOLLY F. COSTA, as Co-Executors, in her place and stead. I further direct that none of them shall not be required to file bond or other security in the Office of the Register of Wills for the purpose of administering my Estate. IN WITNESS WHEREOF, I have hereunto set my hand and seat this day of A.D. GGG ~L .~r~c. (SEAL) UDREY ~ STA Signed, sealed, published and declared by the above-named AUDREY JCANNE COSTA as and for her Last Will and Testament, in the presence of us, who at her request and in hey presence, and in the presence of each other, have hereunto subscribed our names as witnesses.