HomeMy WebLinkAbout07-15-11 (2)' 1505610140
REV-1500 EX (°'_'°'
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
2 0 2 2 4 6 4 6 7 1 0 1 5 2 0 1 0 0 8 1 2 1 9 3 2
Decedent's Last Name Suffix Decedent's First Name MI
B A R K E T I R E N E M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED 1N DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
Q 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A}
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT -THIS SECTION MU5T BE CoMPLET EU. ALL GVFtFttSF'UlvutrvVt Anu Vunr~utn i iP-~ i /~~ mrvrcmHi wry ~nww oc u~n~~. ~ w ~ v.
Name Daytime Telephone Number
D A V I D H S T O N E E S Q U I R E ? 1 7 ~ 7 4 ? ~I 3 5~
REGISTE , ILLS US LY '~ '
~ rn r-~ , r--„~~
First line of address ~ C!7 ~ ~~ '~-~' ~`'`
4 1 4 B R I D G E S T R E E T ~.~ ~~ --~ --i-z
'] L~ ~~
Second line of address ~ ~ ~? ? :~`t
~ ~ "~
CM:
City or Post Office
N E W C U M B E R L A N D
Correspondent's a-mail address:
State
P A
ZIP Code ~-
1 7 0 7 0
DSTONEBSTONELAW•NET
DATE FILED
Under penalties of p rjury, 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 an omplete. claration reparer they an the personal representative is based on all information of which preparer has any knowledge.
SI SON ONSI E R FI N DATE „~„ ~ , , ~
ADDRESS ~ "
530 PARK U NEW CUf1BERLAND PA 17070
SIG RE ER THAN REPRESENTATIVE DATl~r ~ !r
414 BRIDGE ST EET NEW CUMBERLAND PA 17070
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140 ~~
1505610240
REV-1500 EX
Decedent's Social Sec urity Number
Decedent's Name: I R E N E M• B A R K E T 2 0 2 2 4 6 4 6 7
RECAPITULATION
1. Real Estate (Schedule A) ........................................... 1. •
2. Stocks and Bonds (Schedule B) ...................................... 2. •
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. •
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 2 4 6 3 7 . 5 5
7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property
(Schedule G) ~ Separate Billing Requested ....... 7. 3 0 7 5 0 3. 7 0
8. Total Gross Assets (total Lines 1 through 7) ......................... 8. 3 3 2 1 4 1 . 2 5
9. Funeral Expenses and Administrative Costs (Schedule H) ................. . 9• 1 2 0 5 3 . 0 0
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ... ......... . 10. •
11. Total Deductions (total Lines 9 and 10) ..................... ......... . 11. 1 2 0 5 3 . 0 0
12. Net Value of Estate (Line 8 minus Line 11) .................. ........ . . 12. 3 2 0 0 8 8 . 2 5
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. 3 2 0 0 8 8 . 2 5
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 0 0 0 15. 0. 0 0
16. Amount of Line 14 taxable
at lineal rate x- 0 4 5 3 2 0 0 8 8. 2 5 16. 1 4 4 0 3. 9 7
17. Amount of Line 14 taxable
at sibling rate X .12 0 0 0 17. 0. 0 0
18. Amount of Line 14 taxable
at collateral rate X .15 0 0 0 18. 0. 0 0
19. TAX DUE ............................................. ........ . 19. 1 4 4 0 3. 9 7
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610240 1,505610240
REV-1500 EX Page 3 File Number
Decedent's Complete Address: 21, 11 0
DECEDENT'S NAME
IRENE M• BARKET
--- -
STREETADDRESS - --------- -------- ----- ---_------ -------------------
530 PARK AVENUE
CITY STATE ZIP
NEW CUMBERLAND PA 1,7070-
Tax Payments and Credits:
~• Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
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.
Total Credits (A + B) (2)
(3)
(4)
(5)
1,4,403.97
0.00
0.00
0.00
L4,403.97
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 : ...................................................................... ^ Q
b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q
c. retain a reversionary interest; or ................................................................................................ ^
d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q
2, If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ^ X^
3. Did decedent own an "in trust for" 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? .................................................................................................. 0 ^
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
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(1.2) [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, undE
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1509 EX+ (01-10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
IRENE f"I • BARKET 21 1,1 0
If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
530 Park Ave
New Cumberland, PA 17070-
A.Arthur F Barket
B.
c
JOINTLY-OWNED PROPERTY:
Son
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTERESI
L• A• 2009 Integrity Bank-Time Deposit Acct 41,61,4.99 50• 20,807.50
#1,029517 joint w/Arthur F Barket
and opened for more than 1 yr
2 A 2DD6 Sovereign Bank-Savings Acct joint 7,660.09 50• 3,830.05
w/Arthur F• Barket dtd 7-12-2006,
Princ • $7,659.1,9, Int • $ • 90
TOTAL (Also enter on Line 6, Recapitulation) I $ 2 4 , 6 3 7 • 5 5
If more space is needed, use additional sheets of paper of the same size,
REV-1510 EX+ (08-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
IRENE M• BARKET 21, 11 0
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 RELATIONSHIP TO DECEDENT AND
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
% OF DECD'S
INTEREST
EXCLUSION
(IF APPLICABLE)
TAXABLE
VALUE
1, Property located at 10 St Johns Rd 1,66,125.00 1,00.00 ,000.00 63,125.00
Camp Hill Lower Allen Twp, Cumberland
Co•, PA Irene Barket, Grantor (and
Decedent) sold to Arthur F Barket on
July 27, 2010 (within one year of
decedent's death)
2 Wachovia Bank-IRA Acct #13433058 36,534.17 100.00 36,534.17
w/Arthur Barket beneficiary
3 Western National Life Ins Co-Annuity 1,D7,844.53 100.00 07,844.53
#VP235138 w/ArthurBarket beneficiary
TOTAL (Also enter on Line 7, Recapitulation) ~ $ 3 0 ? , 5 0 3 • 7 0
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
IRENE M• BARKET 21 11 0
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1• Lord-Bixler Funeral Home, Inc-funeral expenses 8,848.00
2 Funeral dinner expenses 460.00
3 Blue Mountain Memorial & Cemetery Serv-serv rend. 130.00
B
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
2•
3.
City State ZIP
Year(s) Commission Paid:
Attorney Fees: David H Stone, Esquire
Family Exemption: (If decedents address is not the same as claimants, attach explanation.)
Claimant
Street Address ___
4•
5-
6•
7•
2•
City State ZIP
Relationship of Claimant to Decedent
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees:
Register of Wills-filing Inheritance tax return
Reserve for closing expenses
2,500.00
15.00
1,00.00
TOTAL (Also enter on Line 9, Recapitulation) I $ ], 2 , 0 5 3 - 0 0
If more space is needed, use additional sheets of paper of the same size.
REV-1513 EX+ (01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
SCHEDULE J
BENEFICIARIES
ESTATE OF: FILE NUMBER:
IRENE M• BARKET 21 11, 0
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. 9116 (a) (1.2).]
1• Arthur F Barket (Son) All accts on Lineal 320,088.25
530 Park Avenue Sch "F" and "G"
New Cumberland, PA ],7070 less exp
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 $
If more space is needed, use additional sheets of paper of the same size,
2011-Jul-fl$ 09:1 RM
July 8, 2011
Integrity Bank 7179204904 1
Stone LaFaver & Shekletski
414 Bridge Street
Post Office Box E
New Cumberland, PA 17070
Re: Estate of:
Social Security #:
Date of Death:
Dear Ms. Burkey
Irene Barket
Z02-Z4-6467
10!15/2010
Date of Death Balance on Time Deposit 1029517 was $41,614.99. Irene was on the
account at time of death, and removed from the account on 11 /24/2010.
Please let me know if you need anything else.
Sincerely,
Debbie Painter
Integrity Bank -Camp Hill
Customer Service Representative
Sovereign
Court Ordered Processing \ Decedents - MA1-MB3-02-10 - P. O. Box 841005 -Boston, MA 02284
May 3, 2011
David H. Stone
Stone LaFaver & Shekletski
414 Bridge St
P.O. Box E
New Cumberland, PA 17070
RE: Estate of Irene M Barket
Date of Death: 10/15/2010
Dear Sir or Madam:
~ Per your request, enclosed please find the account information as of the date of death
~ for the above-named decedent. For your information, accrued interest is not included in
~ the date of death balance.
Please feel free to contact me if I can be of any further assistance.
Very truly yours,
~ Donna M. Long
_ Lead Specialist
~ Phone:617-514-5189 --
Fax: 617-533-1931
Sovereign Bank
ESTATE OF
SOCIAL SECURITY #:
DATE OF DEATH:
202-24-6467
October 15, 2010
Account #: 0574401808 Type: Savings Open date: 7/12/2006
In the name of: Irene Barket or Arthur F Barket
Date of Death Balance: $7,659.19
Int.(YTD) from 1/1/2010 to 9/30/2010 $3.59
Accrued interest to date of death: $0.90
Other info:
Irene Barket
Page 1 of 1
~~ ,
`~
;~~~~~
001 WOD
F',D4CS1R~`,D~D`Barket.[rene - .0 St. 1c~tais Road.wpJ
TAX PARCEL NO.: 13-24-0799-055
t1DDRESS: 10 Saint Johns Road
Camp Hili, PA 17011
THIS DEED
MADE THE o~ day of i~..~
BETWEEN IRENE B.4RKET, single woman
in the year of our Lord two thousand ten (2010).
Grantor,
and ARTHLjR F. ~AR3~_>`;-f~; :adult individual
Grantee,
WITNESSETH, that inconsideration ofONEand NO/ 100 ----------($ l .00)-----------.Dollar, in hand
paid, the receipt whereof is hereby acknowledged, the said Grantor does hereby grant and convey to the said
Grantee, his heirs and assigns,
ALL THAT CERTAIN tract or parcel of land with the buildings and improvements thereon erected
situate in Lower Allen Township, Cumberland County, Pennsylvania, more particularly bo~.inded and
described as follows, to wit:
BEGINNING at a point on the Western line of St. John's Church Road at the intersection of St.
John's Church Road with Rosemont Aven~~e; thence along the northern tine of Rosemont Avenue, South
?8 degrees =I0 minutes West a distance of 86.98 feet to a point on the eastern line of Lot No. 115 on the
hereinafter mentioned Plan of Lots; thence North 61 degrees 2U minutes West a distance ~of 95.? feet to a
point; thence Norrth 35 degrees 3 minutes West a distance of 10.86 feet to a point on the southern line of Lot
No. 1 13; thence North ~ 1 degrees 5? minutes East 1 ZO feet to a point en the western line of St. John's
Church Road; thence along the Western line of St. John's Church Road, South ~5 degrees 3 minutes East
a distance of 58 feet to a point, the place of BEGINNING.
<,'
_1_
. =~.
BEING Lot No. 1 ! 4 on Plan of Lots known as "Keewaydin", recorded in the Oftce of the Recorder
of Deeds of Cumberland County, Pennsylvania, in Plan Book 4, Page 41.
HAVING thereon erected a one story frame dwelling house known as No. 10 St. John's Road.
UNDER and subject to restrictions of record.
BEING the same premises which Irene Barket and Arthur F. Barket, her son, by their Deed dated
November 11, 1985 and recorded on November 13, 1985 in the Office of the Recorder of Deeds in and for
Cumberland County, Pennsylvania, in Deed Book "O", Volume 31, Page 1089, granted and conveyed unto
Irene Barket, Grantor herein.
THIS IS A CONVEYANCE BETWEEN PARENT AND CHILD AND IS EXEMPT FROM ALL
REALTY TRANSFER TAXES.
AND the said Grantor hereby covenants and agrees that she will warrant specially the property
hereby conveyed.
IN WITNESS WHEREOF, said Grantor has hereunto set her hand and seal the day and year first
above written.
' p,~`~a"_°r ~~'L..~i~' (SEAL)
IRENE BARKET
-2-
CO1~iMONWEALTH OF PENNSYLVANIA:
SS:
COUNTY OF `~~~~
Un this, the ~~~~~`' day ot`=~~ , 2010, before me the undersi ned officer
~ ,
a Notary Public, personally appeared, IRENE BARKET, known to me (or satisfactorily proven) to be the
person whose name is subscribed to the within instrument, and acknowledged that she executed the same
for the purposes therein contained.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal the day and year first
above •Nritten. y
,f 1
COMMONWEALTH OF PENNSYLVANIA Notary Public
NOTARIAL SENAI~ry Public
CAROL L. TROXELL,
Cumberland Co.
New Cumberland Bo%s Dec• 27, 2013
M Commission Exp,.
I hereby certify that the precise residence and complete post office address of the within named
Grantee is: 530_Park_Avenue, New CumberlandtPA I7('~~
DATED: _ ~_ Z~- ~ ~
-3-
~l,`~s
/ ~ M
.ROBERT P. ZIEGLER
RECORDER OF DEEDS
CUMBERLAND COUNTY
1 COURTHO~JSE SQUARE
CARLISLE, PA 17013
717-240-6370
Instrument Number - 201021851
Recorded On 8/9/2010 At 11:24:10 AM
* Instrument Type -DEED
Invoice Number - ?0576 User ID - ES
* Grantor - BARIiET, IRENE
* Grantee - BARKET, ARTHUR F
* Customer -STONE
* FEES
___._
STATE WRIT TAX $0.50
STATE JCS/ACCESS TO $23.50
JUSTICE
RECORDING FEES - $11.50
RECORDER OF DEEDS
PARCEL CERTIFICATION $10.00
FEES
AFFORDABLE HOUSING $11.50
COUNTY ARCHIVES FEE $2.00
ROD ARCHIVES FEE $3.00
WEST SHORE SCHOOL $0.00
DISTRICT
LOWER ALLEN TOWNSHIP $0.00
TOTAL PAID $62.00
RECORDER O D EDS
* -Information denoted by an asterisk may change during
the verification process and may not be reflected on this page.
Certification Page
DO NOT DETACH
This page is now part
of this legal document.
* Total Pages - 4
I Certify this to be recorded
in Cumberland County PA
iiiiuiuiiioiiii~iiui~i
TaxDB Result Details Page 1 of 1
Detailed Results for Parcel 13-24-0799-055. in the 2010 Tax Assessment Database
DistrictNo 13
Parcel_ID 13-24-0799-055.
MapSuffix
HouseNo 10
Direction S
Street SAINT JOHNS ROAD
Ownerl BARKET, ARTHUR F
C/O
PropType R
PropDesc & ROSEMONT AVENUE
LivArea 892
CurLandVal 29600
CurImpVal 103300
CurTotVal 132900 ~ /, a S
CurPrefVal
Acreage .17
C1GrnStat
TaxEx 1
SaleAmt 1
SaleMo 08
SaleDa 09
SaleCe 20
SaleYr 10
DeedBkPage 20 1 02 1 85 1
YearBlt 1950
HF File Date 11/03/2004
HF_Approval_Status R
C~ ~ ~ ~ 1 ~S, (~~
r
~~V4 f'~ S '~ S S
~t1~
~ ~'~ c-e
http:/Itaxdb.ccpa.net/details.asp?id=13-24-0799-055.&dbselect=l 4I~(/x(11 1
Wachovia
Retirement Statement
146320 RLY2f014
-~-r--~ ARTHUR BARKET BNF
OF IRENE BARKET
i 530 PARK AVE
~'~""" NEW CUMBERLAND PA 17070
~...~~
.r..~.
~ For Customer Service
Call (800) 669-2136
Or write to:
WACHOViA BANK
2801 MARKET STREET
ST LOUIS, MO 63103
Plan Overview -IRA
Tax Information: Contributions & Distributions
Contributions
For tax year 2009 $ 0.00
-- For tax year 2010 $ 0.00
Rollover Deposits $ 0.00
11/17/2010 thru 12/31/2010
2010 Distributions
Amount (gross)
Federal tax withheld
Net amount
Important Information Regarding Your IRA
REVIEW THE PRIVACY STATEMENT CONTAINED IN THE ENCLOSED INSERT.
FOR INFORMAT{ON ABOUT YOUR RETIREMENT PLAN ASSETS, CONTACT
YOUR BANKER.
$ 36,534.17
$ 0.00
$ 36,534.17
:~3a i
Wachovia Bank is a division of Wells Fargo Bank, N.A. Page 1 of 2
14632001418?_21:;i~3'fNNNNNNNNNNN rvvmn~ uivcaorn
WESTERN J NATIONAL
Life Insurance C o m p a n y
P.O. Box 871
Amarillo, Texas 79105-0871
1.800.424.4990
May 31, 2011
STONE LAFAVER & SHEKLETSKI
ATTORNEYS AT LAW
ATTN: DAVID H STONE
PO BOX E
NEW CUMBERLAND PA 17070
Re: Contract #: VP235138
Deceased: Irene Barket
Dear Mr. Stone:
Thank you for your recent inquiry regarding the referenced annuity contract. It is our pleasure to
be of service to you.
The value of the above referenced contract on October 15, 2010 was $107,844.53.
Should you have any questions or require further assistance, please contact our Client Care
Center by using our toll free number of 1-800-424-4990.
Sincerely,
s
Carolyn Smith
Annuity Claims Dept.
WARNING: IT IS ILLEGAL TO ALTER THIS COPT' OR
~~ ,.~,`
~~' ~?` ` TO DUPLICATE BY PHOTOSTAT OR PHOTOGR~-PH.
`' `" COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH VITAL RE.GORDS '~ ~,~,,,,
:~.'~
LOCAL REG'ISTRAR'S CERTIFIGA~ION <OF CEATH ~ ~
r _,. ..._ , ~--~
~ ~ZH OF p~11 wi ..~ , I
v ~ r ~ a --~ ;"T7
~~ ~ ~ *~ ~'~ , ~s October 15 10 ~~_
tt 9 jP~,~ Date of Issue of This Certt~tion
tlt~~ ~~ ~~~~~ ~w
r~ar~~~~ ~~ ~~~-t:t~xer,- _ _ ___--- Irene M: Barket
_ _ _ _ __
I~ es~ Middle Last
Sex Female ~, 2Q2-24-6467 October 15, 2010
_--____ ___--------------_._ ~~ocial Security No. --- _ Date of DE.ath -- --___--
c~~rc~, ~,f ~;,.t~, Augustl2,_1932 B;rthplace_-__ Buck Run,` Pennsylvania
~;~,~;~~ ,.,~ f~,t-zit-; - -Holy Sprit Hospital ---Cumberland _ Camp Hill Pennsyl~-an~~-
^+3,T,? County City, Borough or 7~wnship
Efface _ ____ Whlte_ ___ _ __ _ C?ccupation WaltreSS __ Armed Forces? (Yes or No) NO
Decedent's
r~~~~~rit i~ `7~~lr_lt.; W~dOWed_____ _____ Mailing address..-530 Park Avenue New Cumberland PA 17070
NwtrbOr Street- City or 7owri Sta!e
r~f;r.,~ar.,t __-_ Arthur F.__Barket ___ Funeral Director_Terry L. Bixler
I~iarra,~ t~r7d a~~~~«s~ >E 1818 Mahanton o Street, Pottsville, PA 17901
,~~~=,~.~i F_.,t~~,, .1r~~,~n.___ .Lord-Bixler Funeral. Home, Inc., g
Interval Between
Per" 'r ~:r~e+~liate C;au~;~~ Onset and0eath
Acute Renal Failure
~.
Obstructive Uropathy
r -~- -. -
~,
Pelvic Tumor
4E '
rj ~
Part i€: C.)th~}~ Si ~ nific,arrt Conditions
____ Isto_rY of .,Lung .Cancer ----~-- --_ ____
r~lanryer cf ~e~=i., Describe how injury occurred:
t~J a t r.~ r a. ~ X E-~ r~ m i c i d ~~ ['f - - __--__- -- - --
r'~~;t~iC~er~t P~_~nding Irwestigation C',
``~_.1'r;i'~f~? C;~auld not be Determined C'
Nar~~=~ anc~ ~ itle of Cektifaer._____--.Kenneth B. Conner, M. ~. _ _ _ _
(M.D., D.O., Coroner. IVI.E.~
a-~a,~r~~: -- -- _ 207 House Avenue, Carr~p Hill, PA 1701'1
T"!i~> is t~_3 certify that the information here given is-correctly'copied from an original. certificate
c,~ death duly filed with me as Local Registrar. The riginal certificate will be forwarded to the
State Vstal Rec~~~rds ~~ffice for permanent filing.
~ .-~'k~.cz~_ y _ 06-082
local Rr33istrar of Uitat Fleeords District No. -
October 15, 2010 11 Hill Road Lenhartsvlle
c~ .. I ..st~.:r Street,~.cldress Gty. Borough. To~rship