HomeMy WebLinkAbout04-0773PETITION FOR PROBATE and GRANT OF LETTERS
also known as ~%~.~ ~ 0 ca o 0
Deceased.
Social Security No. 0~_ lB "--01 - ~ -.q'O Lfi
No.
To:
Register of ~W, ills f r t e
County
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the executa ~c'
in the last will of the above decedent, dated ~Aa_~-el,~ 3_~ i c9~O(')~
and codicil(s) dated
in the
named
.,--1~
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
, Decendent was domiciled at death in C~t ~.~v-[~/~ County, Pennsylvania, with,.
Inset fam. ily or principal residence at g ~e)~'Zl~ [ (~0_~,-4-/ ~-~-~ ~tt~ex'/~oeaAsdflt~o
xJ (list street, number and ~uncipality) ! ' '
Dec. ende~nt, then g~ ,years of age, died . 0'''''~ "~"z- ,-~) ~
Except as follows, decedent d'id'n/ot marry, was not divorced and did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent: .k[.~ ..
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
WHEREFORE, petitioner(s) respectfull.y4.~equest(s) the. probate of the last will and codicil(s)
presented herewith and the grant of letters ' g'~ O Vvxa~
(testamentary; adt~inistration c.t.a.; administration d.b.n.c.t.a.)
theron.
OATHOF'PERSONAL REPRESENTATIVE.~, --'..
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF ~"u. vvtbel/~e.t/~e,,~ . ~ ss
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of petitioner(s) apd that as personal represen-
tative(s) of the above decedent petitioner(s) will we~ truly atdn~st~_the estate according to law.
Se~Oo~~ mtO or affirmed and subscribed ,-~.t~.~jf~,.~/na~.x.//~]tSr[ OL~ ~.
be ~ e e this /~ d~ of] ' t ' ~.
. (~, ~ .. ~ ~oo ~J ' · ~
Estate 0-ft/fl.)~~ ~ ~ ,r&ATf/O- , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW/)1,. ~ . . ~Z-~. 1~'/~ q~O0~i in consideration of the petition on
the reverse side hereof, satitfactory proof having been presented before me,
IT IS DEC~ED that the instrument(s) dated '~~ ~/ ~ v ~
described therein be admitted~o probate and filed of record as the last will of
are hereby granted to ~ ~ ~ ~
FEES
Probate, Letters, Etc .......... $
Short Certificates(,/D) .......... $
s
,Zc? s
TOTAL__$
Filed ...................................
Register of ills
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
105.112 REV. 8/88
(FEE FOR THIS
CERTIFICATE $2.00)
WARNING: IT IS ILLEGAL TO ALTER THIS COPY OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH VITAL RECORDS
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
CERT. NO.
T 5691O77
July 23. 2004
Date of Issue of This Certification
Name of Decedent An'l--~.h~t nv W. Rc.m=o
~ Middle Last
Sex Male
Social Security No. 060-01 -2504
Date of Birth May ]1. !9~9 Birthplace
Newburg_h: N%'
Date of Death July 22, 2004 .
Place of Death VA Medical Cent;er Lebanon S. Lebancr~ Twp.
Facility Name County City Borough or Township
Race White Occupation Prop~.ietor/Auto Repairs Armed Forces? (Yes or No)
Decedent's
Marital Status Widowed Mailing Address 439 Nicholls Road Deer Park
Numbel Street Cib/or Town
Informant Joseph B. C-orini Funeral Director Ha~' Jo Griffin
Name and Address of
Funeral Establishment Rohland Funeral Home, Inc, 508 Cumberland St, Lebanon, PA,
Part h Immediate Cause
(a) Endstaqe Cardiomyopathy
Part I1:
Pennsylvania
Yes
State
17042
Interval Between
Onset and Death
(b)
(d)
Other Significant Conditions
Manner of Death Describe how injuw 8cc~red:
Natural ~ Homicide
Accident ~ Pending Investigation
Suicide [] Could not be Determined []
Name and Title of Certfier Shubha R. Acharlra, MD
Address VA Medical Center, Lebanon, PA, 17042
(M.D., D.O., Coroner, M.E.)
This is to certify that the information here given is correctly copied from an original certificate
of death duly filed with me as Local Registrar. The original certificate will be forwarded to the
State Vital Records Office for permanent filing.
"lLc..~¢x~ .--~ ~-F.~,~~ 38-355
/ Lo~al Registrar of'Vital~o~ds / - District NO,
July 23, 2004 ~685-Mi11 Rd, Lebanon, PA, ~7042
Date Received by Local Registrar Street Address City, Borough, Township
3 a6t Dill e tament
ANTHONY W. ROMEO A/K/A ANTHONY ROMEO
I, ANTHONY W. ROMEO, a/k/a ANTHONY ROMEO; resi~ling ~
439 Nicolls Road, Deer Park, New York 11729, do hereby make, publish
and declare this to be my Last Will and Testament.
FIRST: I hereby revoke any and all Wills and Codicils made by me
at any time heretofore.
SECOND: I direct that all my funeral expenses and lawful debts be
paid as soon as practicable after my decease.
THIRD: All the rest, residue and remainder of my estate both real
and personal, of every nature and wheresoever situated, of which I may die
seized or possessed, I give, devise and bequeath in equal shares by
representation to my grandchildren surviving at the time of my decease, who
are on this date, by name, JENNIFER A. ROMEO, JOSEPH
LaCALAMITA, CRYSTAL LaCALAMITA, AND ANTHONY
LaCALAMITA.
FOURTH: I nominate, constitute and appoint my nephew, JOSEPH
B. GORINI, residing at 2 Foxtail Court, Mechanicsburg, Pennsylvania, as
3/26/2004 1:52 PM 1
EXECUTOR of this my Last Will and Testament. In the event my nephew,
JOSEPH B. GORINI, shall not survive me, or shall fail to qualify, die,
resign or cease to act for any reason as EXECUTOR, then I appoint my
niece, VERONICA GORINI, residing in Mechanicsburg, Pennsylvania, as
substitute EXECUTOR.
FIFTH: I direct that my EXECUTOR or substitute EXECUTOR
shall not be required to give bond or security for the faithful performance of
their duties.
SIXTH: If, pursuant to any provision of this Will, or if at the
termination of any trust created by this Will, all or any part of my estate or
portion of the principal of such trust as the case may be shall vest absolute
ownership in a minor or minors, I authorize my Executor in its absolute
discretion and without authorization by any court:
(1) To defer in whole or in part, payment or distribution of any or
all property to which such minor may be entitled, holding the whole or the
undistributed portion thereof as a separate share for such minor with all the
powers and authority conferred by the provisions of this Will, including,
without limitation, the power to retain, invest and reinvest principal without
being limited to investments authorized by law for trust funds.
3/26/2004 1:52 PM 2
(2) To pay, distribute or apply the whole or any part of any net
income or principal at any time held for any such minor, to or for the
support, education and general welfare of such minor, either directly or by
making payment or distribution thereof to the guardian or other legal
representative, wherever appointed, of such minor or to the person with
whom such minor shall reside (without obligation to see the proper
application thereof) or to such minor personally, or by distributing the whole
or part of such share to a custodian under the Uniform Girl to Minors Act of
any state, including a custodian selected by my Executor, and to pay and
distribute any balance thereof to such minor when such minor attains
majority.
The receipt of the person or persons to whom any such payment or
distribution is so made shall be a sufficient discharge therefore even though
my Executor may be such person.
My Executor shall not be required to render and file annual
accountings with respect to property so held under this Article of my Will
and shall be entitled to receive compensation with respect to any property
held for any minor pursuant to this Article at the same rate and in the same
manner payable to the testamentary trustees trader the laws of the State of
New York.
3/26/2004 1:52 PM 3
For purposes of this Article, a minor shall be deemed to be a
person who has not attained the age of twenty-one years.
IN WITNESS WHEREOF I have hereunto set my hand and
seal this 26th day of March, 2004.
ANTHONY W. ROMEO
SIGNED, SEALED, PUBLISHED AND DECLARED by the said
Testator as and for HIS Last Will and Testament in the presence of us and
each of us, and who at HIS request and in HIS presence and in the presence
of each other have hereunto subscribed our names thereto as subscribing
witnesses this 2~th day of march, 2004.
4
Name of Decedent:
Date of Death:
lrt I¢ Wo ; oo -oo
Will No.
CERTIFICATION OF NOTICE UNDER RULE
Admin. No.
To the Register:
I certify that notice of (benefid~l interest) ~ required by Rule 5.6(a) of the Orphans' Court Rules was
served on ~ to.~the foll~,wi~g beneficiaries 9f the abov.e-capt, ioned estate on D-'~t~Ct4 9.~.~1.~90~. e~n '~lan:
.Name Address
r/
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date:
Telephone(
Capacity:~ Personal Representative
__.Counsel for personal representative
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717)240-6345
Date: 11/01/2004
GORINI JOSEPH B
2 FOXTAIL COURT
MECHANICSBURG, PA 17050-8501
RE: Estate of ROMEO ANTHONY W
File Number: 2004-00773
Dear Sir/Madam:
It has come to my attention that you have not filed the
Certification of Notice Under Rule 5.7 (a) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES,
NO. 103 SUPREME COURT RULES DOCKET NO. 1, for decedents dying on
or after July 1, 1992, the personal representative or his
counsel, within ten (10) days after giving proper notice to the
beneficiaries and intestate heirs as required by subdivision
(a) of Rule 5.7, shall file with the Register of wills or Clerk
of the Orphans' Court his/her Certification of Notice.
This filing will become delinquent on 11/29/2004
Your prompt attention to this matter will be appreciated.
Thank You.
cc:
File
Counsel
Judge
GLENDA FARNER STP~ASBAUGH
Clerk of the Orphans' Court
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
8UREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
GORINI JOSEPH B
2 FOXTAil COURT
MECHANICSBURG, PA 17050-8501
-told
ESTATE INFORMATION: SSN: 060-01-2504
FILE NUMBER: 2104-0773
DECEDENT NAME: ROMEO ANTHONY W
DATE OF PAYMENT: 03/08/2005
POSTMARK DATE: 03/07/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 07/22/2004
NO. CD 005034
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $416.80
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TOTAL AMOUNT PAID:
$416.80
REMARKS:
CHECK# 98
SEAL
INITIALS: JA
RECEIVED BY:
TAXPAYER
GLENDA FARNER STRASBAUGH
REGISTER OF WillS
REV-I;11EX (I}.OO)
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT 280601
HARRISBURG, PA 17128-0601
REV-1
-, N.fi. Pb
500
OFFICIAL USE ONLY
FILE NUMBER
dL-~'::L tl3__
COUNTY CODE YEAR NUMBER
S9.\IAL SECURITY NUMBER J I
U(pV - eJ - 'd--5o ...,
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 3. Remainder Return (dale afdeath priarta 12-13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (AtlachSch0)
~ fO~( I Court-
M-eCC\o.V\lcsblA!j fA- /7050-85o(
(Jon 0
c; 1--), ~ to 0
(3) 0,.[1' 0
(4) 000
(5) _I B I 10 5 : Ii d....~
&, 0 ()
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
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W
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DATE OF B TH (MM,DD,YEAR)
(!)C?;- {I-(Cue
(IF APPLICABLE) SURVIVING SPOUSES NAME (LAST, FIRST, AND MIDDLE INITIAL)
'~._..)
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{ 6 ,788
.
3.1
19
~1.0riginaIReturn
D4.LimitedEstate
~6. Decedent Died Testate {Attach copy afWill)
D 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date aldeath after 12-12-82)
D 7. Decedent Maintained a Living Trust {Atll'chcopyofTrust)
o 10. Spousal Poverty Credit (dale of death beho,een 12-31-91 and 1-1-95)
(11)
(12)
(13)
J'~t15.
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FIRM NAME (I/Applicable)
TELEPHONE NUMBER
- l'd-B-
558
(14)
(17)
() OC)
.
.<j!&.8&
tJrvOO
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~/'.tT Bp_
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(18)
(19)
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Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
v
(6)
(7)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
(9)
(10)
, (8)
Q(5a5"Qfr
I).... ()(!)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
0_00 xO _ (15)
CJ ( ;)..bdl. G4f xO '15 (16)
t)t/JlJ x12
(,l 00 x 15
I)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
STREET ADDRESS &-
CITY
Tax Payments and Credits:
1. Tax Due (Page 1 Une 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
&.00
Oad()
O~,1 0
Total Credits (A + B + C)
3.
InteresUPenatty if appiicabie
D. Interest
E. penaily
() ,,/J ()
IJ.I11/
4.
TotallnteresUPenal1y ( D + E )
if Une 2 is greater than Une 1 + Une 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5.
If Une 1 + Une 3 is greater than Une 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Une 5 + SA. This is the BALANCE DUE.
ZIP/70S"O-t!. ()
(1)
~!b'~ 81
(2)
tleOIJ
(3)
(4)
(5)
(SA)
Q 00
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1-116.80
(58)
Make Check Payable to: REGISTER OF WILLS, AGENT
l!lInl!~~,llllllllt. II~ J '~.l!__JlIJlllllIlI JI __d.....1inrn r ii__
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
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; or.........
d. receive the promise for life of either payments, benefits or care? .. .......... ..
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .m
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 nan-probate property which
contains a beneficiary designation? ..... ............ ....."........ ........ ......
Yes
o
o
o
o
........0
.......0
o ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN,
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9
Under penalties of pe~llry, I declare thai I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct
and compkte.
Declaration of prepa erthanthe personal representalive is sed on all inlormation of which preparer has any knowledge.
SIGNATURE RET
ADDRESS
0'::> DATE!)
':>-Glo<- ~
/70 (),
ADDRESS
DATE
,...... -, --
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
172 P.S. S9116 (a) (1.1) (i)J.
For dates of death on or after January 1, 1995, the tax rate imposed on tAl'net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. S9116 (a) (1.1) (ii)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are 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 twenty-one 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% [72 P.S. s9116(a)(I.2)].
The tax rate imposed on the net value of transfers 10 orlor the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. g9116(1.2) [72 P.S. g9116(a)(I)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. s9116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
1La~t Will anb ~t~tamtnt
- of-
ANTHONY W. ROMEO AIKIA ANTHONY ROMEO
I, ANTHONY W. ROMEO, a/kIa ANTHONY ROMEO, residing at
439 Nicolls Road, Deer Park, New York 11729, do hereby make, publish
and declare this to be my Last Will and Testament.
FIRST: I hereby revoke any and all Wills and Codicils made by me
at any time heretofore.
SECOND: I direct that all my funeral expenses and lawful debts be
paid as soon as practicable after my decease.
THIRD: All the rest, residue and remainder of my estate both real
and personal, of every nature and wheresoever situated, of which I may die
seized or possessed, I give, devise and bequeath in equal shares by
representation to my grandc)Uldren surviving at the time of my decease, who
are on this date, by name, JENNIFER A. ROMEO, JOSEPH
LaCALAMITA, CRYSTAL LaCALAMITA, AND ANTHONY
LaCALAMlTA.
FOURTH: I nominate, constitute and appoint my nephew, JOSEPH
B. GORINI, residing at 2 Foxtail Court, Mechanicsburg, Pennsylvania, as
3/26/2004 1 :52 PM
1
EXECUTOR of this my Last Will and Testament. In the event my nephew,
JOSEPH B. GORINI, shall not survive me, or shall fail to qualify, die,
resign or cease to act for any reason as EXECUTOR, then I appoint my
niece, VERONICA GORINI, residing in Mechanicsburg, Pennsylvania, as
substitute EXECUTOR.
~UTII: I direct that my EXECUTOR or substitute EXECUTOR
shall not be required to give bond or security for the faithful performance of
their duties.
SIXTH: If, pursuant to any provision of this Will, or if at the
termination of any trust created by this Will, all or any part of my estate or
portion of the principal of such trust as the case may be shall vest absolute
ownership in a minor or minors, I authorize my Executor in its absolute
discretion and without authorization by any court:
(1) To defer in whole or in part, payment or distribution of any or
all property to which such minor may be entitled, holding the whole or the
undistributed portion thereof as a separate share for such minor with all the
powers and authority conferred by the provisions of this Will, including,
without limitation, the power to retain, invest and reinvest principal without
being limited to investments authorized by law for trust funds.
3/26/2004 I :52 PM
2
.'
For purposes of this Article, a minor shall be deemed to be a
person who has not attained the age of twenty-one years.
IN WITNESS WHEREOF I have hereunto set my hand and
seal this 26th day of March, 2004.
~ ~/~?"'6
ANTHONY W. ROMEO
SIGNED, SEALED, PUBLISHED AND DECLARED by the said
Testator as and for IDS Last Will and Testament in the presence of us and
each of us, and who at HIS request and in HIS presence and in the presence
of each other have hereunto subscribed our names thereto as subscribing
witnesses this 2'Lth day of march, 2004.
S ~O--h e~"i(A P"ItA.kttsl... residing at 14- '2 !Nt '(1'2- vt'! / e R...clJ.Jl
f-/VtDI~ PA I1D'JS
~~ ~MX residing at 1YR vhrt'Uj)le.~
~ PA l7~,
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.. .. ............ HalIn NIle
a.- Au. N. ~ Coullty ,"
.., "'" . I Ba I!xpinws Mar. 1. 200f.i 1.
3/26/2004 1 :52 PM
4
t'10511? REV, 8/88
:FEf: FOR TillS
CER Ilf ICi\TE ,'02,001
WARNING: IT IS ILI::EGA'L-rO AL TER THIS COPY OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH VITAL RECORDS
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
CERT. NO. T 5 6 91 0 8 2
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ate Issue 01 Ilis ertlication
Name of Decedent
Anthony
w.
Romeo
Firq
M,ddle
LJst
Sex
Male
Social Security No.
060-01-2504
Date of DeathJuly 22, 2004
Date of Birth May] 1. 1919
Birthplace __.
Newhllrgl1. NY
Place of Death
VA Medical Center,
Facility NAme
Lebanon
COLJ'1Ty
s. Lebanon Twp.
City, BorolJghOr Townsh,p
Pennsylvania
Race Whi te
Marital Status
wi dowed
Occupation Proprietor/Auto Repairs
Decedent's
Mailing Address
Armed Forces? (Yes or No)
YP-~
439 Nicl1oll.. R=d
NtJrl11er Streal
T')p,p,r Park'
CitymTcwn
NY
Stale
Informant JosePh B.
Name and Address of
Funeral Establishment
Gorini
Funeral Director
MaI:}' Jo Griffin
Rol11and Funera 1 Horne. Tn"'. SOH CurnhF!r1 ;mil St, T ",h;mon.
FA, 17M?
Interval Between
Onset and Death
Part I:
Immediate Cause
(a) Endstage Cardiornyopat)"ly
(b)
(c)
Part II:
(d)
Other Significant Conditions
Manner of Death
Natural e9
Accident 0
Suicide 0
Describe how injury occurred:
Homicide
Pending Investigation
Could not be Determined
o
o
o
Name and Title of Certfier
Shubha R. Acharva, MD
Address
VA Medical Center, Lebanon, PA, 17042
(M.D.. D.O., Coroner, M.E.)
This is to certify that the information here given is correctly copied from an original certificate
of death duly filed with me as Local Registrar. The original certificate will be forwarded to the
State Vital Records Office for permanent filing.
JUly 23, 2004
38-355
District No
Ilal" Rece'v",J n\, Local F1eglslri\<
PA, 17042
.street Addrm;<;
City, Borough. Township
,,-,
STATE OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SHORT CERTIFICATE
I,
GLENDA FARNER STRASBAUGH
es ta te of ROMEO ANTHONY W
Register for the Probate of wills and Granting
Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
the 19th day of August, Two Thousand and Four,
Letters TESTAMENTARY
in common form were granted by the Register of
said County, on the
, la te of HAMPDEN TOWNSHIP
(Lest, First, Middle)
a/k/ a
ROMEO ANTHONY
in said county, deceased, to GORIN! JOSEPH B
(Last, First, MiddleJ
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 19th day of August
Two Thousand and Four.
File No. 2004-00773
PA File No. 21-04-0773
Date of Death 7/22/2004
S. S. # 060-01-2504
~(L'1~,fi~~ fU<-
Reglste' Of Wills ~ I
~
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
REV-1502 EX+ (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
A.II real property owned solely or as at nant 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 survivorship must be disclosed on Schedule F.
()j ~Heo
FILE NUMBER
ESTATE OF
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
KJOY\.9
Vlo-ne
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
~
""""""'1"".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
FILE NUMBER
CD. Kot'\l\'t'v
All property' . Uy ..
Jom -owned with ngh. of sUNivorship must be disclosed on Schedule F
IT~ .
NUMBER
1.
DESCRIPTION
\13 ~~V'e.Q lh WQ~ Ar~ t;'old (Vl(~1(Vl1
CDWvpa1:^j, Ltot, (IV trfZ ~ y)
C'tJ<sxr q 'i7b~t.f'-"U) \fl4 kr-cou~ 1f
c6 88 ;)6 q'~, 77 '-rvv 1?>~4:. 0 f NQW yb\~<'1
C1A1AA~'\ (\r evt- ~~ ( l\J ,V ( fJ y' I Dv8 b
C~ - rJJ-cf- LfLf58)
V<tl L( e. ~<l- O\~ f ~ r :r ~ \.- ,-/lJV~
[S InSMt"er X $3-06 -=- 5t1~;J-dj~~
(see a!Jp ~ cttft,vt7
VALUE AT DATE
OF DEATH
I 6 J.;), go
. TOTAL (Also enter on line 2, Recapitulation)
(If more space IS needed, insert additional sheets of the same size)
$ 6)..-"'2-,&
~""""'('..".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP or SOLE-PROPRIETORSHIP
ESTATE OF
M@
FILE NUMBER
Schedule C-1 or C-2 (Including all supporting infonnation) must be attached for each closely.held corporation/partnership interest of the decedent, other than a sole-proprietorship.
See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
WOY\~
IL <?IT\.Q
TOTAL (Also enter on line 3, Recapitulation) $ ~
(If more space is needed, insert additional sheets of the same size)
""'''''''.".''.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATEOF ~
1. Name of Corporation
Address
City
2. Federal Employer 1.0. Number
3. Type of Business
SCHEDULE C-1
CLOSELY-HELD CORPORATE
STOCK INFORMATION REPORT
UJ . ~VVtGD
f\J D 'Y\V
FILE NUMBER
Zip Code
State of Incorporation
Date of Incorporation
Total Number of Shareholders
Business Reporting Year
State
Product/Service
4.
TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE
STOCK Voting I Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK
Common $
Preferred $
Provide all rights and restrictions pertaining to each class of stock.
5. Was the decedent employed by the Corporation? 0 Yes o No
If yes, Position Annual Salary $ Time Devoted to Business
6. Was the Corporation indebted to the decedent? 0 Yes o No
If yes, provide amount of indebtedness $
7. Was there life insurance payable to the corporation upon the death of the decedent? 0 Yes 0 No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was prior to 12-31-82?
DYes 0 No if yes, 0 Transfer 0 Sale Number of Shares
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
g. Was there a written shareholders agreement in effect at the time of the decedent's death?
If yes, provide a copy of the agreement.
Consideration $
Date
o Yes
o No
10. Was the decedent's stock sold?
DYes
o No
If yes, provide a copy of the agreement of sale, etc.
11. Was the corporation dissolved or liquidated after the decedent's death? 0 Yes 0 No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
12. Did the corporation have an interest in other corporations or partnerships? 0 Yes 0 No
If yes, report the necessary Information on a separate sheet, including a Schedule C-1 or C-2 for each Interest.
A. Detailed calculations used in the valuation of the decedent's stock.
B. Complete copies of financial statements or Federal Corporate Income Tax retums (Form 1120) for the year of death and 4 preceding years.
C. If the corporation owned reai estate, submit a list showing the complete address!es and estimated fair market value/s. If real estate appraisals have been
secured, attach copies.
D. List of principal stockholders at the date of death, number of shares held and their reiationship to the decedent.
E. List of officers, their salaries, bonuses and any other benefits received from the corporation.
F. Statement of dividends paid each year. List those declared and unpaid.
G. Any other information relating to the valuation of the decedent's stock.
REV-1506 EX+ (9-0W
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-2
PARTNERSHIP
INFORMATION REPORT
ESTATE OF
~#L~ uJ,
L Name of Partnership
Address
KDMW
r\OV\€-
FILE NUMBER
Date Business Commenced
Business Reporting Year
City
State
Zip Code
2_ Federal Employer LD_ Number
3_ Type of Business
Product/Service
4. Decedent was a 0 General 0 Umited partner. If decedent was a limited partner, provide initial Investment $
5_
A.
B.
C.
D.
6. Value of the decedent's interest $
7_ Was the Partnership indebted to the decedent?
If yes, provide amount of indebtedness $
8. Was there life insurance payable to the partnership upon the death of the decedent? 0 Yes 0 No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
_ . . . . . . . . . . . . . . _ . . . . .. 0 Yes 0 No
9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was
prior to 12-31-82?
DYes ONo
If yes, 0 Transfer 0 Sale
Percentage transferred/sold
Consideration $
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
10. Was there a written partnership agreement in effect at the time of the decedent's death?
If yes, provide a copy of the agreement.
Date
DYes 0 No
11. Was the decedent's partnership interest sold? ....
If yes, provide a copy of the agreement of sale, etc.
12. Was the partnership dissolved or liquidated after the decedent's death? _ _ . . . . . . _ . 0 Yes 0 No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
DYes 0 No
13. Was the decedent related to any of the partners?
If yes, explain
14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . .. 0 Yes 0 No
If yes, report the necessary information on a separate sheet. including a Schedule C-1 or C-2 for each interest.
_ . .. ... 0 Yes 0 No
THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A. Detailed calculations used in the valuation of the decedent's partnership interest.
B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years.
C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/so If real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
REV-15D7 EX+ (1-97)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
W.Rf)Wl
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.
n OV'\..e
f'vQ\sL
TOTAL (Also enter on line 4, Recapitulation) $ n)JI\.L-
(If more space is needed, insert additional sheets of the same size)
--=--~. ~
"".,..".".n *'
COMMONWEALTH OF PENNSYLVANIA
lNHERlTANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
f;o
ESTATE OF
FILE NUMBER
Include the proceeds of litigation and th date the proceeds were received by the estate. All ro e . in wn .. ..
ITEM P P rty JO tly.o ed with the right o!survlvorshlP must be disclosed on Schedule F.
NUMBER
1.
DESCRIPTION
P-ef50fW ~'t'~ ~ rN R { ~
~# 7otJ6g/60j f:;cyci-CaMtd'j'5D(O FM/
.3 c!.I. #.1 ([3\. I (~,g--Dper Ptf'i({~,4vR 'I
~~r~ INY' 1/7V1 (63(- fob7--86W)
(S"-e Q~tk>kdJ
2-- ~ \ .# 5o~ q'ooo70IS5 'R05(~V\
i ' / 'v5:/ ~rfl{rKAver
N~~hyl~ NY 11703 (631-~-60y87)
3, Ckck-(~kf ~-# OS-366b Cf/~~
~-e,:(e ~( i86fJ uU-{lJle fJlro.r
M-ece{a~cMJ r'A-17$o (71/-075-7~%)
1. [~ckt:0f fTc~~ It q8 3~811t>b
M6f't~<!.. s-,J.-B G~/yi1PIF Af4".
u\~cl~~S'b4J fA:- l7035 (7r7-6~7- ~7
6 ChU:fLUY~~# Qrf357c97()(L
(\-:sw CJ ~ 'B(((y f~()) I ~6:,1s+/
o t;?--g carnirle Pl~ r~cM1M0-f'i(;v(S V'~
l7asJ (7f7-b97- 35;)7)
VALUE AT DATE
OF DEATH
11,) I '1c;0J ?J
II (J y -r: 1- "Z.-
I( '/d-3, tB/
IIr 8 d' ;)/f7
1/ :d96Qtr
. . TOTAL (Also enteron line 5, Recapitulation) $ It. 1100-
(If more space IS needed, Insert additional sheets of the same size)
R""''''''I'm,.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTL Y.OWNED PROPERTY
ESTATE OF
u).(LoMfD
FILE NUMBER
year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S} NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A.
(VJN
B.
c.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of ~nancial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. ~ VUJ\;u fUIlAp
TOTAL (Also enter on line 6, Recapitulation) $ vi L\)<,.L
(If more space is needed, insert additional sheets of the same size)
REV'''''''''.''''.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF t'\ _ _ lA. " ({)';d\ .
1~VV\l4A~~'U'V~W
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
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
FILE NUMBER
DESCRIPTION OF PROPERTY %OF
ITEM INCLUDE THE NAME OFTHE TRANSFEREE, THEIR RELJ\TIONSHIP TO DECEDENT AND THE DATE OF TRANSFER DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE
ATTACH A COpy OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IFAPPLlCA8LEl
NUMBER
1. rLb1f\Q MY&
VW\tV-
TOTAL (Also enter on line 7, Recapitulation) $ Y\)5)U
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99) .
'*
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
ITEM
NUMBER
A.
B.
1.
2.
3.
4.
5.
6.
7.
~\tJ
~V\tEo
FILE NUMBER
Debts of decedent must be reported on Schedule 1.
1.
DESCRIPTION
?;RA1:~+()3)O(O ~fi~{ ttoYT-e,
([0 t I ( ~).. ;)o( 000 iU 18 (fee blU atloctwJ)
ADMINISTRATIVE COSTS: ~ - -
Persona! Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
State _ Zip
Year(s) Commission Pa'rd:
Attorney Fees
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
Probat~lfe~ ~tV"~('-"'A_L ~~,ndW;(~ ~r
L~ ~:) t:i 'stye-e ~ Cat-(cf;;Pft7/0\~ \ftl' ~~)
Accountant's Fees /
....................................-- -- -----~
Tax Return Preparer's Fees. _
~
~
TOTAL (Also enter on line 9. Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
AMOUNT
u C?( r.tJ/p~ 1j
VW~
./\(\...ID~
"'" ~
99 ~ 0 Ci
-~
~_.~
REV-15'2EX~(1-97) tt
W
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF ~
Include unreimbursed med-:::~;Lses.
ITEM
NUMBER
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
(jJ\~
FILE NUMBER
DESCRIPTION
AMOUNT
1.
now
fL (fY\Q
TOTAL (Also enter on line 10, Recapitulation) $ h.1SM
(If more space is neede<!, insert additional sheels of the same size)
NAME AND ADDRESS OF PERSON IS) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS {include outright spousal distributions, and transfers under
_ 11\ Sec. 911"\ loJ (12)]
,. 1"-\' I~YlQe ()
~l(IVM<<q A!~
M-e rc{ NY 11763
L :k'fPh. G- CfA la f1t -(t~ '
~~~t~rrt 17J-~-{80S-
3 erikl ~ (1oJa~~ - -
'-(2:;9 'NtCd,lls R&.
'~~r Pct~ [\J '( f /7V1- (~1 ~
Lf ~rv.1 ~Ca{Qtt((~_ _ J~c&M., t)-1 .
\..t~q N\LC! (tr ((..& .
~y- pCt(1::- f\J V I (7LJt -ISoS- . /O(). 0 to
ENTER DOLLAR AMOUNTS FOR DISTR~UTIONS SHOWN ABOVE ON LINES 15 THROUGH IB, AS APPROPRIATE, ON REV-150~ET
REV-l~13 EX+ (9-00)
'*
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
r~Ntw
NUMBER
!
FILE NUMBER
RELATIONSHIP TO DECEDENT
Do No! L10! T,.oIOO(o)
JVMJot&~ ,
arwwJC'~td -
J~(1~lJ ,
,.
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
,.
AMOUNT OR SHARE
OF ESTATE
~~t
~2'
, ,
" .+,rt
- .. "(\.~
VlCJ0A-SL-
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REY-1500 COYER SHEET $
L>oC)D
(If more space is needed, insert additional sheets of the same size)
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
Check Box 4 on Rev.1500 Cover Sheet
ESTATE OF \<.of'\\~ W. FILE NUMBER
This schedule is to be ed for all single life, j int or.successive life estate and term certain calculations. For dates of death
prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit.
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5 -1-89.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
D Will D Intervivos Deed of Trust 0 Other
L1FE'ESTATE'INTEREST'CALCULATION
REV.''''''''''." *'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS
LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE
f\ .^ 0 o Lile or 0 Term 01 Years_
K r~
o LileorD Term 01 Years _
o Lile or 0 Term 01 Years _
o Lileor 0 Term 01 Years _
1. Value of fund from which life estate is payable
2. Actuarial factor per appropriate table
Interest table rate - D 3 1/2% 06% D 10% D Variable Rate
3. Value of life estate (Line 1 multiplied by Line 2)
ANMlI'rY,IN1'EREST.CAl..CULA'l'ION
$
~
%
$
I'UYI e
NAME(S) OF NEAREST AGE AT TERM OF YEARS
l~ ANNUIT ANTIS) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE
\\L~ o LileorD Term 01 Years _
o Lile or 0 Term 01 Years _
o Lileor 0 Term 01 Years _
o Lile or 0 Term 01 Years _
1. Value of fund from which annuity is payable
2. Check appropriate block below and enter comesponding (number)
Frequency of payout - 0 Weekly (52) D Bi-weekly (26)
D Quarterly (4) D Semi-annually (2) D Annually (1)
3. Amount of payout per period
4. Aggregate annual payment, Line 2 multiplied by Line 3
5. Annuity Factor (see instructions)
Interest table rate 0 3 1/2% D 6% D 10% D Variable Rate
6. Adjustment Factor (see instructions)
7. Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period,
calculation is : Line 4 x Line 5 x Line 6
If using variable rate and period payout is at beginning of period, calculation is :
(Line 4 x Line 5 x Line 6) + Line 3 $ V\ IfJ'0J<.
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on
Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on
Lines 13, 15, 16 and 17.
$ l'Ief'^l.
D Monthly (12)
DOther( )
$
VLtf"\N
%
$
Y\...-tCW
(II more space is needed, insert additional sheets of the same size)
REV-16.4.4 EX+ (3-8.4)
~ii-
COMMONWEALTH OF PENN5YlVANIA
INHERITANCE TAX RETURN
RE51DENT DECEDENT
INHERITANCE TAX
SCHEDULE "L"
REMAINDER PREPAYMENT OR INVASION
OF TRUST PRINCIPAL FILE NUMBER
I. Estate of
(First Name) (Middle Initiol)
This schedule is appropriate only for estates of decedents dying on or before December 12, 1982.
This schedule is to be used lor 011 remainder returns when an election to prepay has been Iiled under the pravi.ion.
01 Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal.
Remainder Prepayment:
A. Election to prepay liled with the Register of Wills on
(attach copy 01 eiection)
B. Name(s) of L,le T enant(s) Date of Birth
or Annuitant(s)
II.
(Dote)
Age on date
of election
Term of years income
or annuity i. payable
~
C. Assets: Complete Schedule L- 1
1. Real Estate
2. Stocks and Bonds
3. Closely Held Stock/Partnership
4. Mortgages and Notes
5. Cosh/Misc. Personal Property
6. Total from Schedule L-l
D. Credits: Complete Schedule L-2
1. Unpaid Liabilities
2. Unpaid Bequests
3. Value of Unincludable Assets
4. Total from Schedule L-2
5
5
5
S
S (/)J'rJ2-
S
S
S
S
III.
E. Total value of trust assets (Line C.6 minus Line 0-4)
F. Remainder factor (see Table I or Table II in Instruction Booklet)
G. Taxable Remainder value (Line E x Line F)
(Also enter on Line 7, Recapitulation)
Invasion of Corpus:
A. Invasion of corpus
s h~
s (\l\Y1f
s r1 tf\1.P
(Month, Day, Vear)
B. Name(s) of Life Tenant(s)
or Annuitant(s)
Date of Birth
Age on date
corpus consumed
Term of years income
or annuity is payable
C. Corpus consumed
D. Remainder lactor (see Table I or Table II in Instruction Booklet)
E. Taxable value of corpus consumed (Line C x Line D)
(Also enter on Line 7, Recapitulation)
$
S
S
/"vlf'v'J
r'\ ()\f
-
'\'Ul Y\.9
REV.1646 EX + (3-84)
*
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE L-2
REMAINDER PREPAYMENT ELECTION
-CREDITS-
W,
FilE NUMBER
I. Estate of
(first Name)
{los\ Nome}
II. Item No.
Description
A. Unpaid Liabilities Claimed against Original Estate, and payable from assets
reported on Schedule L- 1 (please list)
Total unpaid liabilities S
(include on Section II, Line 0-1 on Schedule L)
B. Unpaid Bequests payable from assets reported on Schedule L-l (please list)
Total unpaid bequests S
(include an Section II, Line 0-2 an Schedule Lj
C. Value of assets reported an Schedule l-1 (ather than unpaid bequests listed under
liB" above) that are not included for tax purposes or that do not form a part
of the trust.
Computation os follows:
Total uninc\udable assets
(include on Section II, Line 0-3 an Schedule Lj
III.
TOTAL (Also enter an Section II, line 0-4 on Schedule Lj
(If more space is needed~ attach additional BY2 x 11 sheets.)
(Middle Initial)
Amount
("USN
~
S
S
REV;"7EX"'."*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE M
FUTURE INTEREST COMPROMISE
Check Box 4a on Rev.1500 Cover Sheet
ESTATE OF ~ (jJ, (<0 fu~ FILE NUMBER
This schedule is appropri e only for estates of decedents dying after December 12,1982.
This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession
and enjoyment cannot be established with certainty.
Indicate below the type of instrument which created the future interest and attach a copy to the tax return.
o Will 0 Trust 0 Other
I. Beneficiaries
NAME OF AGE TO
BENEFICIARY RELATIONSHIP DATE OF BIRTH NEAREST BIRTHDAY
1. Y\J\ 'f'Jl
2.
3.
4.
5.
II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months
of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such
withdrawal right.
o Unlimited right of withdrawal o Limited right of withdrawal
III. Explanation of Compromise Offer:
IV. Summary of Compromise Offer: ~
1. Amount of Future Interest
2. Value of Line 1 exempt from tax as amount passing to charities, etc.
(also include as part of total shown on Line 13 of Cover Sheet) $
3. Value of Line 1 passing to spouse at appropriate tax rate
Check One 06%, 03%, 00%
(also include as part of total shown on Line 15 of Cover Sheet) $
4. Value of Line 1 Taxable at 6% Rate
(also include as part of total shown on Line 16 of Cover Sheet) $
5. Value of Line 1 Taxable at 15% Rate
(also include as part of total shown on Line 17 of Cover Sheet) $ ruJM
6. Total value of Future Interest (sum of Lines 2 thru 5 must equal Line1) $
(If more space is needed, insert additional sheets of the same size)
, REV~ 1648 EX (1~921 .
COMMONWEALTH OF PENNSYLANIA
INHERITANCE TAX DIVISION
ESTATE OF
SCHEDULE N
SPOUSAL POVERTY CREDIT
AVAILABLE FOR DECEDENTS DYING AFTER 12/31/91
I FILE NUMBER
This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet.
PART I - CALCULATION OF GROSS ESTATE
1. Taxable Assets total from line 8 (cover sheet) .................................................................... 1.
2. Insurance Proceeds on Life of Decedent ............................................................................ 2.
3. Retirement Benefits ................. '....................................................................................... 3.
4. Joint Assets with Spouse ................................................................................................. 4.
5. PA lottery Winnings ...................................................................................................... 5.
6c.
6a. Other Nontaxable Assets: list (Attach schedule if necessary).. 6a.
6b.
6d.
6.
SUBTOTAL (Lines 60, b, e, d) ...........................................
6.
7. Total Grass Assets (Add lines 1 thru 6)
.............. 7.
8. Total Actual liabilities.... ..... ..... ........... ............... ....................... ..................................... 8.
9. Net Value of Estate (Subtract line 8 from line 7)................................................................ 9.
If line 9 is greater than $200,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Port II.
PART II - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income
Tax Returns for decedent and spouse. )
Income: l. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19
o. Spouse..................... . 10. 20. 30.
b. Decedent................. .. lb. 2b. 3b.
c. Joint .......................... Ie. 2c. 3c.
d. Tax Exempt Income..... ld. 2d. 3d.
e. Other Income not
listed above ........... le. 2e~ 3e.
f. Totol.......................... H. 21. 31.
4. Average Joint Exemption Income Calculation
4a. Add Joint Exemption Income from above:
(H)
+ (21)
+ (31)
=
(+ 31
4b. Average Joint Exemption Income ..................................................................................... =
If line 4(b) is greater than $40,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part III.
PART III - CALCULATION OF SPOUSAL POVERTY CREDIT FOR RESIDENT AND NONRESIDENT
ESTATES
1. Insert amount of taxable transfers to spouse or $100,000, whichever is less.......................... 1.
2. Multiply by credit percentage (see instructions) ...................................................... 2.
3. This is the amount of the Resident Spousal Poverty Credit. Include this figure
in the calculation of total credits on line 18 of the cover sheet. ................................ 3.
4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the
decedent's gross estate........................................................................................... 4.
5. Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal
Poverty Credit. Include this figure in the calculation of total credits on line 1 a of the cover sheet. 5.
,'<'" --.....-"... .",..,-,,\,-~
BUREAU OF INDIVlDUAI,:TAX~S""
INHERITANCE TAX DIVISION
PO BOX Za0601
HARRISBURG PA 171Z8-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE DF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
DF DEDUCTIONS AND ASSESSHENT OF TAX
7r\t1t;Mrtv,",0
....Uv:... 1'1;-\! i.
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
05-23-2005
ROMEO
07-22-2004
21 04-0773
CUMBERLAND
101
AlIOUnt He.1tted
Prl12: tlO
CLERK OF
ORPHNfS COURT
JOSEPH il.MlflNI'
2 FOXTAIL CT
MECHANICS BURG PA 17050
*'
REV-1547 EX AFP (03-05)
ANTHONY
W
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CD COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ...
1t!V-"MIl,."tf."'\wm~'tI!'.'lmtm.W.!wtItWlM!l!'.'m!'.lmlmMMf~.'la:tWlM!l!'.lIW'.............. ...
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF ROMEO ANTHONY W FILE NO. 21 04-0773 ACN 101 DATE 05-23-2005
TAX RETURN WAS: I X) ACCEPTED AS FILED
) CHAIIIlED
I~ an assessment was issued previously, lines 14, IS and/or 16, 17, 18 and 19 will
r~lect ~igures that include the total o~ Abb returns assessed to date.
ASSESSMENT OF TAX:
15. AlIO\Int of Line 14 at Spousal rate (5)
16. A~nt of Line 14 taxeble at Lineal/Class A rate (16)
17. A.ount of Lin. 14 at Sibling rate (17)
18. A.ount of Line 14 taxable .t Collateral/Class B rate (18)
19. Principal Tax Due
IT :
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Kortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposlts/Hlsc. Personal Property (Schedule E)
6. ~ointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
IS)
(6)
17l
.00
622.80
.00
.00
18.165.42
.00
.00
IB)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule X)
11. Total Deductions
12. Net Value of Tax Return
13. ~rltable/Governnental Bequests; Non-elected 9113 Trusts (Schedule ~)
14. Net Value of Estate Subject to Tax
(9)
(10)
9,525.95
.00
NOTE:
.00 X
9,262.27 X
.00 X
.00 X
+
AHOUNT PAID
416.80
DATE
03-07-2005
NUMBER
CD005034
INTEREST/PEN PAID 1-)
.00
~
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
NOTE: To insure proper
credit to your account,
suai t the upper portion
of this for. Nith your
tax PBYIIlHlt.
18,788.32
(11)
(12)
(13)
(14)
g.~?~ g~
9,262.27
.00
9,262.27
00 =
045 =
12 =
15 =
.00
416.80
.00
.00
416.80
(19)=
416.80
.00
.00
.00
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FDR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YDU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FOHN FOR INSTRUCTIONS.)
Register of Wills or Cumberland County
Name ofDecedent: 1\ n.'\ltv. n y vJ,
7 -- 1... 1... - ;) DO Lf'
,
d DO 4 - 00 7 7 3
Estate No.:
STATUS REPORT UNDER RULE 6.12
'D
hOlYleo
Date of Death:
Pursuant to Rule 6.12 ofllie Supreme Court Orphans' Court Rules, I report the following
with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes)& No 0
2. If the answer is No, state when the personal representative reasonably believes that
the administration will be complete:
~ e ~e. G>tt$ ~-4hl&ttu
3'. If the answer to No. 1 is Yes, state the following: -tti\.~ act:.currll ~, ~l \ tA;h&
a. Did the personal representative file a final account with the Court? h.A ~bee,'\.pA.l~ ( l~~~e
YesD .No~ . !.s\C.J;e.~~f€\'":S'(j. .
. ~~~~~~ ~thL
b. The separate Orphans' Court No. (if any) for the personal representativ ~ l~LUf't~~lU ,",
account is: Hit XJ;, L~~~r.et\\"t"ctu\A.
~ ~~ 1larJ...~(':J LAj1-
c. Did the personal representative state an acpount informally 19 the parties. lAJ'll\ ~"'T't"5t6'~..d-
interest? Yes 0 No ~ G.~ h~l("" r~~'eA+helt- ~\'4:.re cffh, I '
~1iSC&..veyeJ..tJy 0... c~m\o-; Th.t'tV~ree~~(e((/~(
c. Copies of receipts, releases, joinders and approval of formal or informal (hedc.s~~t("
accounts may be filed with the Clerk of the Orphans' Court and may be J~,tt~ ~
attached to this report r ~ l)lInor w,t.(' I i\:f; 'L~
Date: ~,/4 Jf) ObI., t~ t1~,(t\~J+,I~
~ ature tl ~o<<.'('C~r\t
M~~ B.~ot\~; ~~~~
Name C\.tlIi~(~ ,l~~
J.. ~, j - ~ t ~ r-r w:f\- Mil ~1ILL
rw ~, ::l 4J"r\.-tN
\n,~ ; (r 4.~
-&e~\Rc.l blUj rA 17050- Q\lo ~t<{J
Telephone !J~ --, fiSo I ~~CM-t) iv\ '7
-:-1\(-7.R;--7 ~>S " _
Capacity: ~ersonal Representative_ ~t'~Y-cf( {<;cftx..-k..
o Counsel for personal representative
Address
(1
L"\ \J ;
-~/
kh0t
Anthony W. Romeo Estate
Joseph B. Gorini, Executor
Two Foxtail Court, Mechanicsburg PA 17050-8501
Tph: 717-728-7558 Fax: 717-728-7473
July 24, 2005
Jennifer A. Romeo
202 Pennsylvania A venue
Medford, NY 11763
Dear Jennifer,
Pursuant to the wishes of Anthony W. Romeo, your grandfather, as stipulated in
his Last Will & Testament, you are an heir to his liquid estate, in equal shares with
your cousins Joseph, Crystal, and Anthony. A copy of his Last Will & Testament
was provided to you at the time of his internment.
As Executor of the Estate, I am instructed to consider both your financial need
AND your ability to manage money in the timing of distributions from the Estate.
I am aware of your financial need with regard to maintaining your home, due your
college burden and the untimely demise of your mother. Also, I am witness to
your ability to handle your affairs with maturity, dignity, grace, and courage.
In consideration of the above, I am herewith rendering a partial distribution of your
share of the Estate. The final value of the Estate is not yet known due to pending
resolution of tax matters. However, I am certain that after tax matters are settled,
there will be another, smaller, distribution to you.
Therefore, attached is a check for $6,000.00. Please call me to confirm receipt.
Also, please cash the check within thirty (30) days.
I remain available to consult with you on financial and other matters.
seph B. Gorini
Executor, Anthony W. Romeo Estate
t-~~
Anthony W. Romeo Estate
Joseph B. Gorini, Executor
Two Foxtail Court, Mechanicsburg PA 17050-8501
Tph: 717-728-7558 Fax: 717-728-7473
December 30,2005
Jennifer A. Romeo
202 Pennsylvania Avenue
Medford, NY 11763
Dear Jennifer,
As you know, pursuant to the wishes of Anthony W. Romeo, your grandfather, as
stipulated in his Last Will & Testament, you are an heir to his liquid estate, in
equal shares with your cousins Joseph, Crystal, and Anthony. A copy of his Last
Will & Testament was provided to you at the time of his interment.
As Executor of the Estate, I was instructed to liquidate the Estate, settle debts and
taxes, and distribute the net Estate to heirs. The purpose of this letter is to inform
you that all known debts and taxes have been settled and the liquid Estate is being
fully distributed at this time.
Your full share in the Estate is now valued at $7,629.80. Since you were advanced
a partial share of $6,000.00 on July 24, 2005, a check for $1,629.80 is enclosed.
This check represents a final and full distribution of your inheritance from the
Estate of Anthony W. Romeo.
Please call me to confirm receipt. Also, please cash the check within thirty (30)
days.
I remain available to consult with you on financial and other matters.
'~~YI
Anthony W. Romeo Estate
Joseph B. Gorini, Executor
Two Foxtail Court, Mechanicsburg P A 17050-8501
Tph: 717-728-7558 Fax: 717-728-7473
December 30,2005
Joseph LaCalamita
239 Woods Road
North Babylon NY 11703
Dear Joseph,
As you know, pursuant to the wishes of Anthony W. Romeo, your grandfather, as
stipulated in his Last Will & Testament, you are an heir to his liquid estate, in
equal shares with your sister and brother, Crystal and Anthony, and your cousin,
Jennifer. A copy of the Last Will & Testament was provided to you at the time of
his interment.
As Executor of the Estate, I was instructed to liquidate the Estate, settle debts and
taxes, and distribute the net Estate to heirs. The purpose of this letter is to inform
you that all known debts and taxes have been settled and the liquid Estate is being
fully distributed at this time.
Your full share in the liquid Estate is in the amount of $7,629.81, and a check for
that amount is enclosed. This check represents a full and final distribution of your
inheritance from the Estate of Anthony W. Romeo.
Please call me to confirm receipt. Also, please cash the check within thirty (30)
days.
I remain available to consult with you on financial and other matters.
Yours truly,
......
omeo Estate
~~
Anthony W. Romeo Estate
Joseph B. Gorini, Executor
Two Foxtail Court, Mechanicsburg P A 17050-8501
Tph: 717-728-7558 Fax: 717-728-7473
December 30, 2005
Crystal LaCalamita
c/o Joseph LaCalamita
239 Woods Road
North Babylon NY 11 703
Dear Crystal,
As you know, pursuant to the wishes of Anthony W. Romeo, your grandfather, as
stipulated in his Last Will & Testament, you are an heir to his liquid estate, in
equal shares with your brothers, Joseph and Anthony, and your cousin, Jennifer. A
copy of the Last Will & Testament was provided to you at the time of his
interment.
As Executor of the Estate, I was instructed to liquidate the Estate, settle debts and
taxes, and distribute the net Estate to heirs. The purpose of this letter is to inform
you that all known debts and taxes have been settled and the liquid Estate is being
fully distributed at this time.
Your full share in the liquid Estate is in the amount of $7,629.81, and a check for
that amount is enclosed. This check represents a full and final distribution of your
inheritance from the Estate of Anthony W. Romeo.
Please call me to confirm receipt. Also, please cash the check within thirty (30)
days.
I remain available to consult with you on financial and other matters.
Yours truly,
.....
'-....
r~
r-J-e Uo,
Anthony W. Romeo Estate
Joseph B. Gorini, Executor
Two Foxtail Court, Mechanicsburg PA 17050-8501
Tph: 717-728-7558 Fax: 717-728-7473
J Gorini8 7@alumni.gsb.columbia.edu
December 30, 2005
Anthony LaCalamita
439 Nicolls Rd
Deer Park, NY 11729-1805
Dear Anthony,
As you know, pursuant to the wishes of Anthony W. Romeo, your grandfather, as
stipulated in his Last Will & Testament, you are an heir to his liquid estate, in
equal shares with your brother and sister, Joseph and Crystal, and your cousin,
Jennifer. A copy of the Last Will & Testament was provided to you at the time of
his interment.
As Executor of the Estate, I was instructed to liquidate the Estate, settle debts and
taxes, and distribute the net Estate to heirs. The purpose of this letter is to inform
you that all known debts and taxes have been settled and the liquid Estate is being
fully distributed at this time.
Your full share in the liquid Estate is in the amount of$7,629.81. This amount
represents a full and final distribution of your inheritance from the liquid Estate of
Anthony W. Romeo. Pursuant to the Will, since you are a minor,} intend to place
this amount in an account in trust for you and serve you as trustee. I will inform
you when this account has been established.
I remain available to consult with you on financial and other matters.
Yours truly,
~~'
J s ph B. Gorini
Executor, Anthony W. Romeo Estate
*: (w.ct No" l500'-f;?-j 3 S.S'-l611'
M~Tt~ JiNh'JJ..~ dVv
~lAj(,"')- "0, JOO~
~~"u...J'-".1..-"-CU1U. \...UUlll..-Y - KeglS1:.er or Wllls
One Courthouse Square
Carlisle, PA 17013
phone: (717) 240-6345
Date: 5/31/2006
GORINI JOSEPH B
2 FOXTAIL COURT
MECB~~ICSBURG, PA 17050-8501
RE: Estate of ROMEO ANTHONY W
File Number: 2004-00773
Dear Sir/Madam:
This notice is to serve as a reminder that the Status Report by
Personal Representative under Rule 6.12 is due on the below listed
date.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NOo 103
SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after
July I, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
wills a Status Report of completed or uncompleted administration.
This filing 1S due by:
7/22/2006
Please feel free to contact this office with any questions you may
have. If you have already filed your Status Report, please disregard
this notice.
Sincerely,
~~~~
Glenda Farner Strasbaugh
Clerk of the Orphans! Court
cc: File
Counsel