HomeMy WebLinkAbout08-01-11 (3)1505610140
OFFICIAL USE ONLY
REV-1500 ~` (°'-'°'
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX 280601 2 1 1 1 0 3 2 9
Harrisburg PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYYY
2 0 4 2 6 9 5 8 1 0 2 2 6 2 0 1 1 1 2 2 0 1 9 3 3
Decedent's Last Name Suffix Decedent's First Name MI
W A G N E R L E O A
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
a 1. Original Return
4. Limited Estate
0 6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
2. Supplemental Return
4a. Future Interest Compromise (date of
death after 12-12-82) 1
7. Decedent Maintained a Living Trust _
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIREG I Eu I v:
Name Daytime Telephone Number
D O U G L A S G- M I L L E R 7 1 7 2 4 9 2 3 5 3
First line of address
6 0 W E S T
Second line of address
City or Post Office
C A R L I S L E
State ZIP Code
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
REGISTER Q~JVIIILLS USE ONLY
.-
7 =~7
r--
-~ cr, ~-~ __ .
.L`_, _~
~._ ..
_ l
a ..~
D~E FILED ~
P A 1 7 0 1 3
_,4~
Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF Pj?{tSON RESPONSIBLE FOR FILING RETURN ~ DATE ~
ADDRESS / ~ `
333 DRE SE STREET BEAVERTOWN PA 17813
SIGNATURE PIFT~~PARE~I OTHEF~)-HAN~2EPR~~NTATIVE ry D~T~' ,
60 WEST POM~RET STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
1505610140
P O M F R E T S T R E E T
Side 1
1505610140
"i
__.;.
L
J
1505610240
REV-1500 EX Decedent's Social Security Number
2 0 4 2 6 9 5 8 1
Decedent's Name: LEO A- W A G N E R
RECAPITULATION .
1.
1. Real Estate (Schedule A) .......................................... .
2 2 3 8 1. 0 8
2. Stocks and Bonds (Schedule B) ..................................... .
3.
3. Closely Hetd Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .
4.
4. Mortgages and Notes Receivable (Schedule D) ...... • . • • ~ • ~ • • ~ • • • • • • ~ • • ~ 2 1 0 0 6 . 8 4
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers & Miscellaneous N~Probate Property 2 0 9 2 . 6 9
(Schedule G) Separate Billing Requested ....... 7.
2 5 4 8 0. 6 1
............ a.
8. Total Gross Assets (total Lines 1 through 7) .............. .
6 5 0 9. 0 5
............ 9.
9. Funeral Expenses and Administrative Costs (Schedule H) ..... .
10. 9 4 6 0. 8 4
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .
11. 1 5 9 6 9. 8 9
11. Total Deductions (total Lines 9 and 10) ... • • ~ • ~ ~ • ~ ~ • ~ ~ • ~ • • ~ ~ ~ ' ~ ' ~ '
................12. 9 5 1 0. 7 2
12. Net Value of Estate (Line 8 minus Line 11) ........... .
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13.
lection to tax has not been made (Schedule J) .
an e
9 5 1 0.
7
2
14. Net Value Subject to Tax (Line 12 minus Line 13)
,...,,
......... .
.,..
..14.
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
0. 0
0
15•
0.
0
0
16. (a)(1.2) X ~0 -
Amount of Line 14 taxable
9 5 1 0. 7
2
1s.
4 2 7.
9
8
at lineal rate X .045
17. Amount of Line 14 taxable 0 _ 0 0 17 0 • 0 0
at sibling rate X .12
0 .
0
0
18. Amount of Line 14 taxable 0 0 0 18
at collateral rate X .15
... ....
19
...
4 2 7.
9
8
19 . TAX DUE .............................. ..............
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505610240
1505610240
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 11 0329
DECEDENT'S NAME
LEO A. WAGNER
STREET ADDRESS
1883 GEORGE AVENUE
ciTY
CARLISLE
STATE
ziP
PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
(1)
2. Credits/Payments 427.98
A. Prior Payments 362.87
B. Discount 20.81
Total Credits (A + B) (2)
3. Interest
383.68
(3)
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. (4) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 44.30
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 : ............................
.........................................
^
a
b. retain the right to designate who shall use the property transferred or its income; ............................... ^
c. retain a reversionary interest; or ................................................................................................ ^ 0
d. receive the promise for life of either payments, benefits or care? ....................................................... ^ 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ^ a
3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her death? ......... ^ Q
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(0)(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(0)(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(0)(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-1503 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
LEO A. WAGNER 21 11 0329
All property jointlyowned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION
1. 38 SHARES OF PEPSICO, INC. STOCK
38 X $62.66 PE SHARE _ $2,381.08
TOTAL (Also enter on line 2, Recapitulation) ~ $
VALUE AT DATE
OF DEATH
2, 381.08
2.381
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
IN RES DENTEDECEDENT N PERSONAL PROPERTY
ESTATE OF FILE NUMBER
LEO A. WAGNER 21 11 0329
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointlyowned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER VALUE AT DATE
DESCRIPTION OF DEATH
1. JEWELRY/COINS -APPRAISAL ATTACHED 246.43
2. PERSONAL PROPERTY 10,819.50
(INCLUDES 2000 CHEVY ASTRO VAN)
3. 1996 CHEVROLET S10 EXTENDED CAB 3,120.00
4. F& M TRUST -CHECKING ACCOUNT #33-09487 2,530.79
5. MEMBERS 1ST FEDERAL CREDIT UNION -SAVINGS ACCOUNT #267867-00 45.27
6. (MEMBERS 1ST FEDERAL CREDIT UNION -CHECKING ACCOUNT #267867-11 I 4,244.85
TOTAL (Also enter on line 5, Recapitulation) I $ 21 006 84
(If more space is needed, insert additional sheets 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
LEO A. WAGNER 21 11 0329
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.
fTEM DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
1. F&M TRUST
IRA SAVINGS #000-0900451
BENEFICIARIES:
KIMBERLY HAYMIRE
TERRI REISINGER
DATE OF DEATH % OF DECD'S EXCLUSION
VALUE OF ASSET INTEREST (IF APPLICABLE)
2,092.69 100.00
TAXABLE
VALUE
2- 092 69
TOTAL (Also enter on Line 7 Recapitulation) ~ $ 2 092 69
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
LEO A. WAGNER 21 11 0329
Decedents debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION
A. FUNERAL EXPENSES:
1. HETRICK CREMATION SERVICES
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
SUeet Address
Clty State ZIP
Year(s) Commission Paid:
2, AttomeyFees: IRWIN & McKNIGHT, P.C.
3. Family Exemption: (If decedents address is not the same as claimants, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: REGISTER OF WILLS
5. I Accountant Fees:
6. Tax Return Preparer Fees: PATRICIA A. ROSENDALE, CPA
INCOME TAX RETURNS AND FIDUCIARY TAX RETURN
7. F&M TRUST -SAFE DEPOSIT BOX KEY
8. HARRY E. DONSON -APPRAISAL ON JEWELRY/COINS
9. REGISTER OF WILLS -SHORT CERTIFICATE
10. CUMBERLAND LAW JOURNAL -ESTATE NOTICE
11. THE SENTINEL -ESTATE NOTICE
12. BILL ROWE -COMMISSION -PUBLIC SALE
TOTAL (Also enter on Line 9, Recapitulation) ~ $
If more space is needed, use additional sheets of paper of the same size.
AMOUNT
554.19
1, 800.00
111.50
475.00
10.00
10.00
12.00
75.00
187.54
3,273.82
6.509.05
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, ~ LIENS
LEO A. WAGNER 21 11 0329
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. SARAH A. TODD MEMORIAL HOME -NURSING 215.09
2. MANOR CARE -NURSING 1,775.50
3. COMCAST -CABLE 117.50
4. ICENTURYLINK -TELEPHONE I 90.23
5. PP&L -ELECTRIC 149.54
6. NORTH MIDDLETON AUTHORITY -WATER/SEWER 86.42
7. WEST SHORE EMS -AMBULANCE 6,022.09
8. CUMBERLAND GOODWILL EMS -AMBULANCE 83.50
9. FOOD EMPLOYERS LABOR RELATIONS ASSOCIATION 920 97
REIMBURSEMENT OF MARCH PENSION PAYMENT
TOTAL (Also enter on Line 10, Recapitulation) I $
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+(0~-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
LEO A. WAGNER .,. ~., ,,,,.,,,
~ 1 1 1 VJL.7
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. JASON A. WAGNER Lineal
333 DREESE STREET 1/3 REMAINDER
BEAVERTOWN, PA 17813
2. TERRI A. REISINGER Lineal
2215 CIRCLE ROAD 1/3 REMAINDER
CARLISLE, PA 17015
3. KIMBERLY A. HAYMIRE Lineal
1909 GEORGE AVENUE 1/3 REMAINDER
CARLISLE, PA 17013
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN:
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
Ir more space Is needed, use addltlonal sheets or paper of the same size.
LAST WILL AND TESTAMENT
I, LEO A. WAGNER, of North Middleton Township, Cumberland County, Pennsylvania,
being of sound and disposing mind and memory, do hereby make, publish and declare this to be my
Last Will and Testament, hereby revoking any and all former Wills or Codicils by me made.
1.
I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and all
inheritance taxes (whether such taxes may be payable by my estate or by any recipient of any
property) shall be paid from my residuary estate as soon as practicable after my decease and as part
of the administration of my estate. My personal representative shall have no duty or obligation to
obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other
property not passing under this Will.
2.
I give, devise and bequeath all of my estate, both real and personal property, in equal shares,
unto my following three children: JASON A. WAGNER, TERRI A. REISINGER, and KIMBERLY
A. HAYMIRE, with substitution of issue per stirpes.
3.
I nominate, constitute and appoint my son, JASON A. WAGNER, as Executor of my estate.
In the event he shall be unable or unwilling to serve in such capacity, then I appoint my daughters,
TERRI A. REISINGER and KIMBERLY A. HAYMIRE, or the survivor of them, to act in such
capacity.
4.
I direct that my personal representative shall not be required to file a bond to secure the
faithful performance of his or her duties in any jurisdiction.
Page 1 of 3 Pages ~~
L.A.W.
5.
I authorize and empower my personal representative, in his or her sole and absolute
discretion, to purchase or otherwise acquire and retain any investments of which I die seized or any
real or personal property of any nature; to sell, lease, pledge, mortgage, transfer, exchange, dispose of
or grant options in regard to any or all property of any kind forming a part of my estate for such
terms and such prices as he or she may deem advisable; to borrow money for any purposes connected
with the protection and preservation of my estate; to mortgage or pledge any real or personal property
forming a part of my estate or to join in or secure the partition of same; to compromise any claims or
demands of my estate against others or of others against my estate; to make distribution in kind and
to cause any share to be composed of cash, property or undivided fractional shares in property
different in kind from any other share; to employ agents, attorneys and proxies and to delegate to
them such power as my personal representative considers desirable and to pay reasonable
compensation for such services as may be rendered by such agents, attorneys and proxies; and to
execute and deliver such instruments as may be necessary to carry out any of these powers. In
addition, I direct that my personal representative shall have the power to conduct an inventory of any
safe deposit box necessary to the administration of my estate.
IN WITNESS WHEREOF I have hereunto set my hand and seal this 22"d day of June, 2007.
5 ~ (SEAL)
eo A. Wagner
SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Testator, as and
for his Last Will and Testament, in the presence of us, who at his request, have hereunto subscribed
our names as witnesses thereto, in the presence of the said Testator and of each other.
,,,, /1- ~;,,,
Page 2 of 3 Pages
COMMONWEALTH OF PENNSYLVANIA )
SS.
COUNTY OF CUMBERLAND )
I, LEO A. WAGNER, Testator, whose name is signed to the attached or foregoing
instrument, having been duly qualified according to law, do hereby acknowledge that I signed and
executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and
voluntary act for the purposes therein expressed.
Leo A. Wagner J
Sworn or affirmed to and acknowledged before e by LEO A. WAGNER, the Testator, this
22nd day of June, 2007.
Notary PUb 1C COMMONW
COMMONWEALTH OF PENNSYLVANIA
EALTH OF PENNSYLVANIA
Notarial Seal
Sharon E. Bloom, Notary Public
North Middleton Twp., Cumberland County
S S . My Commission Expires Aug. 5, 2010
COUNTY OF CUMBERLAND ) Member, Pennsylvania Association of Notaries
We, '~-~-n ~~~0~~''~l and ~ Yr ~ ,~Q I~~ I~ Y
the witnesses wh se names are signed to the attached or foregoing instrument, being c~''uly qualified
according to law, do depose and say that we were present and saw LEO A. WAGNER, the Testator,
sign and execute the instrument as his Last Will; that the Testator signed willingly and that the
Testator executed it as his free and voluntary act for the purposes therein expressed; that each of us,
in the hearing and sight of the Testator, signed the Will as witnesses; and that to the best of our
knowledge the Testator was at that time 18 or more years of age, of sound mind and under no
constraint or undue influence.
Address - ~ _ _ ~
~~ 5(~ r~iq 1 F~ i ~
Address ~1 ~;
<'~c ~ ~ ~ 17 o i 5
Sworn or affirmed to and subscribed before me 's 22°d day of J e, 2007.
Nota ub11C COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
C \SLB\Estate Planning\10265-will.3.h.doc Sharon E. Bloom, NOtary PubIIC
North Middleton Twp., Cumberland County
My Commission Expires Aug. 5, 2010
Page 3 of 3 Pages Member, Pennsylvania Association of Notarles
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LEO A. WAGNER ESTATE
d/o/d -FEBRUARY 26, 2011
Appraisal by:
Harry E. Donson 243-8943
CARLISLE COIN SHOP
25 Circle Drive
Carlisle, PA 17013
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ROWE'S AUCTION SERVICE (RH 79L)
Bill Rowe (AU 1538L~ 2505 Ritner Highway Carlisle, PA 17015
249-1978 697-4794 249-2677 Dave Rowe (AU 2295L)
Auction Is A' ^ct~ion Call "Rowe" For Satisfaction
SELLERS NAME ~:~~ ~;(` rl V V ~ ~ ~. r' DATE ~_~ ~ _ _
ADDRESS Y' ~ ~ -.tZ ~ tea-- T~- a
~ ~ r .T- PHONE . _ ~/ L~~a U
Y~C~ CS~l;1~ ~ Cam- - ~ ~ 13 --T- ,- ~
OTHER ~-7~ AUCTIONEER % _
AUCTION DATE/LOCATION I ,~A~ C~~~~' c1Lt LU - % ~-'~
io
DESCRIPTION OF MERCHANDISE ~laj; ~,,~ ~., a ~
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v ~ ~ i
~4- Cie--4 _ c
~l4 C,tsZ' S ~ ce.~t`~ ~ -, ~~ ~, C.l~rGa~-era - es+4~ T~3 ~
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I Commssion the Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise
to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen-
tative of the merchandise, goods and or property and have good title and the right to sell and that they are free
from all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of
title to the purcha r. I agree to hold harmless the Auctioneers against any claims of the nature referred to in
this agreement.
~•
AUCTION SIGNATURE SELLERS NATURE
s=
Total Sales (Clerking Tickets Attached) $ L ~ ~ C°j
Less Sale Expense:
3~~ % Commission Auctioneer $ ~ ~ ~ ~' Z
~~ % Commission Clerks ~ L ~- 4'c~
OTHER: ~ ~'L~"~--5 1~-- `~ c~ o
TOTAL SALE EXPENSE DEDUCTED $ ?~ 2-~'l~, ~
SELLERS NET $ `~I ~' ~~ ~O ~--
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;~~!!~;
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• O~Q~~..~~ AUTHORIZED_REPRESENPATIVE -
LEO A WAGNER
1883 GEORGE AV.E
CARLLSLE PA 170:13
• Pennsylvania
DEPARTMENT OF TRANSPORTATION
_ . _ _ _ _ - '
• 4 ceNry" as"ot the date dt issue, the oHIclelrecoMs of Ne Pennaylvanla,Department ~ A~L:LEN. `p vi~Efll~~l~. '
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March 21, 2011
Irwin & McKnight, P.C.
West Pomfret Professional Building
60 West Pomfret St.
Carlisle, PA 1701-3222
T
Ru~T
Ir~~(IV ~ Srr9cl~IViGI~
?~At~ OFFIC~c
RE: Leo A. Wagner
To Whom ft May Concern:
In reference to the above customer, our records show the enclosed information to be
accurate as of today's date. If I may be of any further assistance, please contact me.
Sincerely,
~~~
Brenda Hahn
Deposit Operations Clerk
717-261-3668
717-264-6116 888-264-6116 P.0. Box 6010 Chambersburg, PA 17201-6010
FINA.N.CIAL SOLUTIONS... FROM PEOPLE YOU KNOW
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MEMBERS 1St
FEDERAL CREDIT UNION
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
Interest Earned 01/01/2011 - 01/31/2011
Name of Joint Owner
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
Interest Earned 01/01/2001 - 01/31/2011
Name of Joint Owner
Estate of: LEO A. WAGNER
Date of Death: 02/26/2011
Social Security Number: 204-26-9581
267867-00
07/14/2005
$45.27
$.00
$45.27
$.00
None
267867-11
07/14/2005
$4,244.56
$.29
$4, 244.85
$.34
None
~~~~~~~J
I]B091'iitl ~ iYl~irt99iiF8lt
~~W 01'~ICE~
M BERS 1ST FEDERAL CREDIT UNION
Danielle A. Kline
Lending Insurance Support Specialist
March 17, 2011
5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslst.org
Hetrick Cremation Services of Central Pennsylvania, Inc.
~~"125 Walnut Street
Harrisburg, PA 17109
Bill To
Terri Reisinger
2215 Circle Rd.
Carlisle, PA (7015
Client
Invoice
Date Invoice #
3/2/201 I
615
Terms ~ Due Date
Leo Wagner COD 3/2/201 l
QtY Description Rate Amount
Memorial Folders 35.00 35
00
4 Laminated Bookmarks 3.00 .
12
00
Private Family Viewing 175.00 .
175
00
Coroner's Release Fee 25.00 .
25
00
Newspaper Notice in Patriot News 160.97 .
160
97
Newspaper Notice in Carlisle sentinel 86.22 .
86
22
10 Death Certificates 6.00 .
60.00
$554. t 9
1t's been a pleasure working with you!
Payments/Credits I $-539.06
~ Balance Due $15.13 I
SARAH A. TODD MEMORIAL H
OME
1000 West South Street, Cazlisle, PA 17013
(717) 245-2187 • (717) 245-9733 FAX
www.ucc-homes.org
March 15, 2011
Terri Reisinger
2215 Circle Road
Cazlisle, Pa. 17013
Re: Leo Wagner # 102226
Deaz Mrs. Reisinger,
The account for Leo Wagner is now past due. We recommend your immediate attention in this
matter. Please forward the total amount due of $108.15 by March 31, 2011.
If this payment is not received by the stated date, please contact me to establish a meeting time to
review your options. If payment is not received or arrangements made within the above
mentioned deadline, I will be referring this account to our legal counsel.
Thank you for your prompt attention in this important matter.
Sincerely,
J
Q + ~~ ~ a / Il ~/C/ a l -~
Mazy Jane Walker, NHA
Executive Director
A program of service for the older person sponsored by United Church of Christ Homes
~~ WSEMS -Chambersburg ALS/BLS DISCOVER ~^~
~~, 205 GRANDVIEW AVE SUITE 211 »sa~
~`` CAMP HI ~ a 1--~--~
~~ LL, PA 17011 ON REVERSE SIDE
~~~~ ~~ Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
ENIEP,GErfCl" MEDICAL SERVICES
PATIENT NAME: LEO WAGNER INSURANCE: MEDICARE B
HIGHMARK ESTATE
CALL NUMBER: C.2O1 O10669 DATE OF CALL: 10/22/2010 NONE
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
LEO WAGNER ACCOUNT SUMMARY
TERRI REISINGER TOTAL CHARGES: 158.86
2215 CIRCLE RD PAYMENTS/ADJUSTMENTS: 0.00
CARLISLE, PA 17015 PLEASE PAY THIS AMOUNT: 158.86
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
INVALID COACH ONE-WAY MEMBEI T2005
MILEAGE INVALID COACH S0209
INVALID COACH ONE-WAY MEMBEI T2005
MILEAGE INVALID COACH S0209 1.0
3.0
1.0
3.0 62.60
5.61
62.60
5.61
62.60
16.83
62.60
16.83
Total Charges 158.86
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -->
RETURNED CHECK FEE - $31.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: C2O1 O1 OGEi9 AMOUNT PAID:
04/14/2011
$158.86
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WSEMS -Chambersburg ALS/BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
WEST SHORE EMS -CARLISLE ~~
~a 205 GRANDVIEW AVE SUITE 211 V/SA' DISCOVER ~
~~ CAMP HILL P
A 17011
~. ~, ~ ~~ Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
EMERGENCY MEDICAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 209867W
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
INSURANCE: MEDICARE B ESTATE
HIGHMARK
NONE
DATE OF CALL: 10/25/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 165.94
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 165.94
_ DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE
Stretcher 2 Way Tx -Member T2005 1.0 137.00
WAITING TIME - 1/2 HOUR A0999 1.0 28 94
AMOUNT
Total Charges
DESCRIPTION OF PAYMENT I RECEIPT I PAYMENT DATE AMOUNT
Total Credits
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT --~
RETURNED CHECK FEE - $31.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: ZO9867W
04/14/2011
AMOUNT PAID:
137.00
28.94
165.94
0.00
$165.94
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
WEST SHORE EMS -CARLISLE I~~
~~'~ 205 GRA-NDVIEW AVE SUITE 211 ~ DISCOVER I~!I
•~~~`"~ CAMP HILL, PA 17011 ~~~~--J~
,; '~~,~
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
E64ERGENCY wVIEDICAL SERVICES
PATIENT NAME: LEO WAGNER INSURANCE: MEDICARE B
HIGHMARK ESTATE
CALL NUMBER: NONE
209919W DATE OF CALL: 10/26/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
LEO WAGNER ACCOUNT SUMMARY
TERRI REISINGER TOTAL CHARGES: 93.03
2215 CIRCLE RD PAYMENTS/ADJUSTMENTS: 0.00
CARLISLE, PA 17015 PLEASE PAY THIS AMOUNT: 93.03
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
WHEELCHAIR MEMBER 2 WAY A0130 1.0 93.03
93.03
Total Charges 93.03
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT --~
RETURNED CHECK FEE - $31.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 209919W AMOUNT PAID:
04/14/2011
$93.03
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~~~
~~
`~
E1ViERG~NC~' AA~'J1CAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 209964W
WEST SHORE EMS -CARLISLE I~~
205 GRANDVIEW AVE SUITE 211 DISCOVER
CAMP HILL, PA 17011 '~~~IJ~
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 10/27/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 121.97
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 121.97
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
I~FTd!`4i dl Al1ir nc~nr~nw~•.... .
-- ---'
DESCRIPTION OF CHARGE -.._...~••^••~+..~•
QUANTITY vn•v .viva VVIIAYHrMt
UNIT PRICE
WHEELCHAIR MEMBER 2 WAY A0130
WAITING TIME - 1/2 HOUR A0999 1.0
93.03
1.0 28.94
NT
AMOUNT
Total Charges 121.97
DESCRIPTION OF PAYMENT I RECEIPT I PAYMENT DATE
AMOUNT
93.03
28.94
Total Credits
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -->
RETURNED CHECK FEE - $31.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 209964W AMOUNT PAID:
04/14/2011
0.00
$121.97
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~~
~_~
', '.,~~~
EMERGENCY MEDICAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 OOO4W
WEST SHORE EMS -CARLISLE ~~
205 GRANDVIEW AVE SUITE 211 ~~SCOVER M. ,~, .~.,
CAMP HILL, PA 17011 ~~'
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 10/28/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 137.00
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 137.00
- DETACH ALONG PERFORATION AND RETURN STUB W/TH PAYMENT
_._
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE
AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0
137.00 137.00
Total Charges 137.00
I DESCRIPTION OF PAYMENT I RECEIPT I PAYMENT DATE
AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~
RETURNED CHECK FEE - $31.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 2~ OOO4W
04/14/2011
AMOUNT PAID:
$137.00
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~~~e~ a ~~
EnitF.RGcI~ICY MED(CF~L SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 OO54W
WEST SHORE EMS -CARLISLE DISCOVER '~,
205 GRANDVIEW AVE SUITE 211 ~~-
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 10/29/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 22$•82
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 223.82
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACHdLONG PFRFnRdr/nN dlVn ecrunni cr~ic unru [fwvewr~.r
DESCRIPTION OF CHARGE
QUANTITY - -- ----
UNIT PRICE -
AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137
00
WAITING TIME - 1/2 HOUR A0999
3.0 .
28.94 137.00
86.82
Total Charges 223,82
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ->
$223 82
RETURNED CHECK FEE - $31.00
?ATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 OO54W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
°~
~'~a
a~P
` ' ~ '
EMERGENCY MEDICAL SERVICES
WEST SHORE EMS -CARLISLE DISCOVER
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
PATIENT NAME: LEO WAGNER INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
CALL NUMBER: 210 51 W DATE OF CALL: 11/01/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
LEO WAGNER
TERRI REISINGER TOTAL CHARGES: 281.70
2215 CIRCLE RD PAYMENTS/ADJUSTMENTS: 0.00
CARLISLE, PA 17015 PLEASE PAY THIS AMOUNT: 281.70
DETACH QLnN~ PFQFAQAT/AAl AMA OCTI/011I CTIIO IA~ITU n
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137
00
WAITING TIME - 1/2 HOUR A0999
5.0 .
28.94 137.00
144.70
Total Charges 281.70
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT --®
RETURNED CHECK FEE - $31.00 $281.70
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 2~ 0151 W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~.
~~
~~~'~' ~~
Eti?ERC;ENCY b4EDiCAL SERVICES
WEST SHORE EMS -CARLISLE DISCOVER t r
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
PATIENT NAME: LEO WAGNER INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
CALL NUMBER: 21 O184W DATE OF CALL: 11/02/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
LEO WAGNER
TERRI REISINGER TOTAL CHARGES: 223.82
2215 CIRCLE RD PAYMENTS/ADJUSTMENTS: 0.00
CARLISLE, PA 17015 PLEASE PAY THIS AMOUNT: 22$,$2
DETACH dLONC~ PFRFARdT/nAI eein oc~rr ~nei cry m w.ru .,
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005
WAITING TIME - 1/2 HOUR A0999 1.0
3.0 137.00
28.94 137.00
86.82
Total Charges 223.82
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT --->
RETURNED CHECK FEE - $31.00 $223 82
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 O184W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~~ WEST SHORE EMS -CARLISLE ~^
~~~ 205 GRANDVIEW AVE SUITE 211 DISCOVER rtl
~,g CAMP HILL, PA 17011
~~~~' ,~ Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
~1?ERGENCY MEDICAL SERVICIiS
PATIENT NAME: LEO WAGNER INSURANCE: MEDICARE B
HIGHMARK ESTATE
CALL NUMBER: 21023OW DATE OF CALL: 11/03/2010 NONE
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
LEO WAGNER ACCOUNT SUMMARY
TERRI REISINGER TOTAL CHARGES: 137.00
2215 CIRCLE RD PAYMENTS/ADJUSTMENTS: 0.00
CARLISLE, PA 17015 PLEASE PAY THIS AMOUNT: 137.00
DETACH ALONG.PERFORATIONRND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00
137.00
Total Charges 137.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~
RETURNED CHECK FEE - $31.00
$137.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 O23OW AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
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EMERGENCY DiIEDiC?,I SEP.ViCES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 O295W
WEST SHORE EMS -CARLISLE DISCOVER
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/04/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 137.00
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 137.00
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
__ _ __
DESCRIPTION OF CHARGE
QUANTITY
UNIT PRICE
AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
Total Charges 137.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ->
QGTI IRNIGrI f`NFC_K FFF _ ~'~i _nn $137.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 O295W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
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EM~2~ENCY N1EDiCAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 't1 O348W
WEST SHORE EMS -CARLISLE DISCOVER ~ M. ar
205 GRANDVIEW AVE SUITE 211 a
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/05/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 137.00
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 137.00
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
Total Charges 137.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~
QC'TI IQnlt`n r_I-IGr~K OFF _ ~~~ nn $137.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 O348W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
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EM~~2GENCY h~?EDICAL SCRVtCES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 O414W
WEST SHORE EMS -CARLISLE DISCOVER S
205 GRANDVIEW AVE SUITE 211 ~ ~~`~°"'
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/08/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 223.82
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 223.82
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
__
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
WAITING TIME - 1/2 HOUR A0999 3.0 28.94 86.82
Total Charges 223.82
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~
RGTI IRIUFr] (`HFf:K FFF - $.'~i _(1(1 $223 82
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 O414W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
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~~~~
EtiIERGENCY MEDICP~.L SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 210455W
WEST SHORE EMS -CARLISLE DISCOVER
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/09/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
194.88
TOTAL CHARGES:
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 194.88
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
nFrarN a~ nNC~ PERFORATION AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
WAITING TIME - 1/2 HOUR A0999 2.0 28.94 57.88
Total Charges 194.88
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~
n~r~ ~os~~n I+LJC/'4[ CCC - @4i nn $194.88
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 2~ O455W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~~.
~~~~ ~~~
~!~IER~ENCY iviEDICAL SEPViCES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 O483W
WEST SHORE EMS -CARLISLE DISCOVER
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/10/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 165.94
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 165.94
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
WAITING TIME - 1/2 HOUR A0999 1.0 28.94 2894
Total Charges 165.94
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT °>
Q~TI IRAI~r1 f_NFC`K FGF _ x.41 ntl $165.94
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 O493W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
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~~~~
EMERGENCY MHDiCAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 O544W
WEST SHORE EMS -CARLISLE DISCOVER tl.
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/11/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 137.00
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 137.00
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT _ .
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
Total Charges 137.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~-
QCTI IRAIGr1 (_I-1~[_K FFF _ ~.'~i rlrl $137.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 2~ O544W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
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~~~~
ENIERC;~NCY tvfEDtCAL SI/RV!CES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 O575W
WEST SHORE EMS -CARLISLE DISCOVER .•
205 GRANDVIEW AVE SUITE 211 ~ ~~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/12/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 165.94
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 165.94
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
WAITING TIME - 1/2 HOUR A0999 1.0 28.94 28.94
Total Charges 165.94
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~
ncr~ ~Qn~cn rucrE( Gcc _ ~Ri nn $165.94
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 O575W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
.~
EivIERGENCY NI DiCAL SER.Vh'ES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 O675W
WEST SHORE EMS -CARLISLE DISCOVER
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/15/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 194.88
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 194.88
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
ncrecu e~ nnrr. aFaFnRnTroN AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
WAITING TIME - 1/2 HOUR A0999 2.0 28.94 57.88
Total Charges 194.88
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT °-°>
w ~~ ~r~v rcc d`7~ nA $194.88
flG1 Vf117VV v~~w.a. r... .p~••~~
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 O675W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
;~~
~~
EMERGENCY P~?BDICAL SER~~ICSS
PATIENT NAME: LEO WAGNER
CALL NUMBER: 210719W
WEST SHORE EMS -CARLISLE DISCOVER ~ Ma ~
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/16/2010
SARA A TODD MEMORIAL HOME
FROM:
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
165.94
TOTAL CHARGES:
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 165'94
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
WAITING TIME - 1/2 HOUR A0999 1.0 28.94 28.94
Total Charges 165.94
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~
n~r~ ~owi~n nurr~[ rcc _ ~~~ nn $165.94
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 2~ O719W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
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~~~~
GMERGENCI' MEDICAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 2~ O757W
WEST SHORE EMS -CARLISLE DISCOVER '~
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/17/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 194.88
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 194.88
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
ncreru e- nNr_ aFRFnRdT-nN dND RETURN STUB WITH PAYMENT
__. __
DESCRIPTION OF CHARGE
QUANTITY
UNIT PRICE
AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
WAITING TIME - 1/2 HOUR A0999 2.0 28.94 57.88
Total Charges 194.88
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~
. r.~~~e~ i+u~nv cCC @4~ AA $194.88
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 O757W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~~
~~~
'~~t~/
~~ ~~
Eiv1EiZGENCY MEDICAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 210795W
WEST SHORE EMS -CARLISLE DISCOVER , ,.
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/18/2010
SARA A TODD MEMORIAL HOME
FROM:
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
137.00
TOTAL CHARGES:
PAYMENTS/ADJUSTMENTS: 0.00
137.00
PLEASE PAY THIS AMOUNT:
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
ncrnru e~ nn-r DFRFnRdT-DN dND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
Total Charges 137.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT °°'
~.... err ~o~ nn $137.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: Z1 O795W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~~
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~9'~Y 1 ~~
E?e7c.RGENCY MEUiCAi, SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 O842W
WEST SHORE EMS -CARLISLE DISCOVER ~M. ro
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/19/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 223'82
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 223.82
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
nFre!`M dl AN[, PFRFARdTIDN AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
WAITING TIME - 1/2 HOUR A0999 3.0 28.94 86.82
Total Charges 223.82
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT --'
~rr~ ~~ure~ nu~nU CCC __ d'4~ nn $223 82
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 O842W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~..
~~
~~~
~~~~
ENIhRGENCY NIEDI: AL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 O927W
WEST SHORE EMS -CARLISLE y~q~ DISCOVER M s .ro
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11 /22/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
194.88
TOTAL CHARGES:
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 194.88
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
...,.. nrr~~rfonr~nll~ neon nG'r~u71V CTIIR WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
WAITING TIME - 1/2 HOUR A0999 2.0 28.94 57.88
Total Charges 194.88
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~
,~„ ,,.. $194.88
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 O927W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~:~~
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~~~~
G,~[ERGENCY M,iDT.CAL SSRVb~ES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 O9G5W
WEST SHORE EMS -CARLISLE y~! DISCOVER (
205 GRANDVIEW AVE SUITE 211 ~ ~ l
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/23/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
223.82
TOTAL CHARGES:
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 22$•82
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
n~~rnnu n~ ne-r_ vFRFARdTIAN AND RETURN STUB WITH PAYMENT
.,~ ,
_. _ .
..................
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
WAITING TIME - 1/2 HOUR A0999 3.0 28.94 86.82
Total Charges 223.82
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~
~~ $223.82
Fit I UKIVtu t,nc~.n r~~ - ~ ~.w
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 O965W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
ppyyd'
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EMERGENCY MED?CAL SEP.ViCE~
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 ~ O1 OW
WEST SHORE EMS -CARLISLE ~ olse~oveRJ ~ M 5
205 GRANDVIEW AVE SUITE 211 ~ L~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11 /24/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
137.00
TOTAL CHARGES:
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 137.00
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
...... nrr~rrfewr~nll~ nn~n ncr~wAl STIIR WITH PdYMENT
DESCRIPTION OF CHARGE __.
QUANTITY
UNIT PRICE
AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
Total Charges 137.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ---'
~.,.. $137.00
Fit 1 UKlvtu l,n~~.r~ r« - .w ~ ....,
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 211 O1 OW AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~,
~~
EMERGENCY MEDICAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 211129W
WEST SHORE EMS -CARLISLE ~ a
205 GRANDVIEW AVE SUITE 211 V/SA~ DISCOVER M ~a
CAMP HILL, PA 17011 -
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/28/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 194.88
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 194.88
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH AL~NC~ PFRFARdT/AAI dIVA GCTII011~ erg io a/ITV nw vAwr..r
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137
00
WAITING TIME - 1/2 HOUR A0999
2.0 .
28.94 137.00
57.88
Total Charges 194.88
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT °-
$194.88
RETURNED CHECK FEE - $31.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 211 ~ 29W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~~~
~~
~~~
~~~~ ~~
E1~ERGENCY MEDICAL SERVICES
WEST SHORE EMS -CARLISLE y~S,q• DISCOVER ~.
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
PATIENT NAME: LEO WAGNER INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
CALL NUMBER: 211 ~ 51 W DATE OF CALL: 11/29/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
LEO WAGNER
TERRI REISINGER TOTAL CHARGES: 137.00
2215 CIRCLE RD PAYMENTS/ADJUSTMENTS: 0.00
CARLISLE, PA 17015 PLEASE PAY THIS AMOUNT: 137.00
DETACH ALONG PERFORATION AND RETURN STUR w~rH aaynnFnrr
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
Total Charges 137.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT °~
RETURNED CHECK FEE - $31.00 $137.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 211151 W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
`~~~~
~~
EMERGEPICY MEDICAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 211193W
WEST SHORE EMS -CARLISLE DISCOVER I e .~ .
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 11/30/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 165.94
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 165.94
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFARdT/AN dNA RRTI ICA/ Cri ~Q unru nn vewr~~r
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137
00
WAITING TIME - 1/2 HOUR A0999
1.0 .
28.94 137.00
28.94
Total Charges 165.94
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~ $165.94
RETURNED CHECK FEE - $31.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 211 ~ 93W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~~~'
~~ ~~rl'~
~~~~~~
EMERGENCY ivlEDi~AL SERVICES
WEST SHORE EMS -CARLISLE DISCOVER a ~
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
PATIENT NAME: LEO WAGNER INSURANCE: MEDICARE B ESTATE
HIGHMARK
CALL NUMBER: 211235W NONE
DATE OF CALL: 12/01/2010
FROM: SARA A TODD MEMORIAL HOME
TDB CARLISLE CANCER CENTER
ACCOUNT SUMMARY
LEO WAGNER
TERRI REISINGER TOTAL CHARGES: 137.00
2215 CIRCLE RD PAYMENTS/ADJUSTMENTS: 0.00
CARLISLE, PA 17015 PLEASE PAY THIS AMOUNT: 137.00
DETACHdLANr PFRFnve'r~nei neon n~~riie.. ~.r...~, .
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
Total Charges 137.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -->
RETURNED CHECK FEE - $31.00 $137.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 211235W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
_®
a,~
~~~~
~MSRGEN~Y MEDICAL SERV'!CES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 ~ 289W
WEST SHORE EMS -CARLISLE DISCOVER ~ M. ~_
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 12/02/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 137.00
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 137.00
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACHAL~NG PERFORdT/AN dNl] RFT/IRN cTiia innru nnvnece~r
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
Total Charges 137.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ---
$137.00
RETURNED CHECK FEE - $31.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 21 ~ 289W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
[ j~, ~~~
EAhER^vENCY MEDICAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 211335W
WEST SHORE EMS -CARLISLE
205 GRANDVIEW AVE SUITE 211 V/SA~ DISCOVER
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 12/03/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 137.00
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 137.00
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALnN[; PFRFAGdT/AA~ neon orr~ mw. c.r..., ....-........ __.._
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1
0
. 137.00
137.00
Total Charges 137.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -°~
RETURNED CHECK FEE - $31.00 $137.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 2~ 1335W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
WEST SHORE EMS -CARLISLE ~~
205 GRA-NDVIEW AVE SUITE 211 ~ DISCOVER jr c ~
CAMP HILL P ~ L---~'
~~`~ A 17011
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
`~` ! ~ ~~
EMERGENCY MEDICAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER:
211415W INSURANCE: MEDICARE B
HIGHMARK
DATE OF CALL: 12/06/2010
ESTATE
NONE
FROM: SARA A TODD MEMORIAL HOM E
TO: CARLISLE CANCER CENTER
LEO WAGNER ACCOUNT SUMMARY
TERRI REISINGER TOTAL CHARGES: 153.94
2215 CIRCLE RD
CARLISLE, PA 17015 PAYMENTS/ADJUSTMENTS:
PLEASE PAY THIS AMOUNT: 0.00
153.94
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher One Way Trans Member T2005
WAITING TIME - 1/2 HOUR A0999 1.0
2 0 96.06
28.94
96.06
57.88
Total Charges 153.94
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT --~
RETURNED CHECK FEE - $31.00
$153.94
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 211415W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~®
k~~~
;7 ~ ~'~r~
~~~Y ~ ~1
EMERGENCY ~4EDiCAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 2~ 1473W
WEST SHORE EMS -CARLISLE ,== ~ ~~
205 GRANDVIEW AVE SUITE 211 Y/SA~ DISCOVER M,
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
INSURANCE: MEDICARE B ESTATE
HIGHMARK
NONE
DATE OF CALL: 12/07/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 137.00
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 137.00
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFARdTIAN dNA ~a~T-/Oei cTi~n unru env.,.~..r
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
Total Charges 137.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~
$137
00
RETURNED CHECK FEE - $31.00 .
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 2~ 1473W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
.~~
a~~
~~~~ ~~
EMERGENCI' i~4ED[CAL SERVICES
WEST SHORE EMS -CARLISLE DISCOVER
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
PATIENT NAME: LEO WAGNER INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
CALL NUMBER: 2~ ~ 521 W DATE OF CALL: 12/08/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
LEO WAGNER
TERRI REISINGER TOTAL CHARGES: 165.94
2215 CIRCLE RD PAYMENTS/ADJUSTMENTS: 0.00
CARLISLE, PA 17015 PLEASE PAY THIS AMOUNT: 165.94
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
WAITING TIME - 1/2 HOUR A0999 1.0 28.94 28.94
Total Charges 165.94
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~ $165.94
RETURNED CHECK FEE - $31.00 __
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 2~ ~ S21 W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~" ~~ e
±®
EMERGENCY MEDICAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21 ~ 565W
WEST SHORE EMS -CARLISLE V7~~ DISCOVER
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 12/09/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 137.00
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 137.00
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFORATION AND RFTl/RN STIR w~TFI pavnnFnir
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Stretcher 2 Way Tx -Member T2005 1.0 137.00 137.00
Total Charges 137.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~ $137.00
RETURNED CHECK FEE - $31.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 2~ ~ 5B5W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~~
~~~ ~
+~~
EMERGENCY MEDICAL SERVICES
PATIENT NAME: LEO WAGNER
CALL NUMBER: 211817W
WEST SHORE EMS -CARLISLE DISCOVER ~ ~rd'
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
DATE OF CALL: 12/16/2010
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
TOTAL CHARGES: 93.03
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 93.03
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
WHEELCHAIR MEMBER 2 WAY A0130 1.0 93.03 93.03
Total Charges 93.03
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -°' $93.03
RETURNED CHECK FEE - $31.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 211817W AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~~~
~~~~
EMERGENCY AAEDICAi, SERVICES
WEST SHORE EMS -CARLISLE y~~ nlscovEe M. ,,.
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
PATIENT NAME: LEO WAGNER INSURANCE: MEDICARE B ESTATE
HIGHMARK NONE
CALL NUMBER: 212616W DATE OF CALL: 01/07/2011
FROM: SARA A TODD MEMORIAL HOME
TO: CARLISLE CANCER CENTER
ACCOUNT SUMMARY
LEO WAGNER
TERRI REISINGER TOTAL CHARGES: 93.03
2215 CIRCLE RD PAYMENTS/ADJUSTMENTS: 0.00
CARLISLE, PA 17015 PLEASE PAY THIS AMOUNT: 93.03
DETACH ALONG PERFORATION AND RETURN STUB WITH P4vMFNT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
WHEELCHAIR MEMBER 2 WAY A0130 1.0 93.03 93.03
Total Charges 93.03
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT °> $93.03
RETURNED CHECK FEE - $31.0
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 2~ 2G1 BW AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
_~
.~~~
a~~
~~~~ ~~~
EM°RGENCY MEDICAL SEBVICBS
PATIENT NAME: LEO WAGNER
CALL NUMBER: ~ ~ 03954A
WEST SHORE EMS -MALS DISCOVER M b
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: HIGHMARK ESTATE
MEDICARE B NONE
DATE OF CALL: 02/25/2011
FROM: ACUTE REHAB HOSPITAL
TO: HOLY SPIRIT HOSPITAL
ACCOUNT SUMMARY
TOTAL CHARGES: 1691.22
PAYMENTS/ADJUSTMENTS: 1603.79
PLEASE PAY THIS AMOUNT: 87.43
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
MICU EMERGENCY LEVEL 1 A0427 1.0 1545.32 1545.32
EKG ELECTRODES (1) A0396 4.0 0.80 3.20
GLUCOSE BLOOD A0394 1.0 7.08 7.08
NARCAN 2MG A0999 1.0 49.12 49.12
ALS MILEAGE A0425 6.3 13.73 86.50
Total Charges 1691.22
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Medicare Assignment Adjustment 03/28/2011 1254.04
Medicare Part B Payment 110162184 03/28/2011 349.75
Total Credits 1603.79
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT °-~ $87.43
RETURNED CHECK FEE - $31.00
PATIENT NAME: WAGNER, LEO A CALL NUMBER: ~ ~ 03954A AMOUNT PAID:
04/14/2011
IMPORTANT MESSAGES: WE ARE AWARE THAT THE PATIENT IS DECEASED AND YOUR OFFICE IS
HANDLING THE ESTATE. PLEASE FORWARD PAYMENT TO ABOVE
ADDRESS AS SOON AS POSSIBLE.
WEST SHORE EMS -MALS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
~®~
~~~
~~ ~ ;
E'•~?%RGFI~'CY MEDhAL SER`JICGS
PATIENT NAME: LEO WAGNER
CALL NUMBER: 21373OW
WEST SHORE EMS -BLS ® DISCOVER Ma f a,d•
205 GRANDVIEW AVE SUITE 211
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
INSURANCE: MEDICARE B WCS
HIGHMARK W1
DATE OF CALL: 02/05/2011
FROM: HOLY SPIRIT HOSPITAL
TO: ACUTE REHAB HOSPITAL
ACCOUNT SUMMARY
TOTAL CHARGES: 68.96
PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 68.96
LEO WAGNER
TERRI REISINGER
2215 CIRCLE RD
CARLISLE, PA 17015
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
__.
DESCRIPTION OF CHARGE
QUANTITY
UNIT PRICE
AMOUNT
Wheelchair One Way -Member A0130 1.0 46.52 46.52
Transport Van Mileage S0209 6.0 3.74 22.44
Total Charges 68.96
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT
Q~Ti iQniGn r_NGrtt FFF _ ~~1 nn $68.96
PATIENT NAME: WAGNER, LEO A CALL NUMBER: 2'I 373OW AMOUNT PAID:
03/14/2011
IMPORTANT MESSAGES: THIS ACCOUNT IS PAST DUE! Send your payment now or contact
our office to make payment arrangements.
WEST SHORE EMS -BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
.~~ Food Employers Labor Relations Association
and United Food & Commercial Workers
Pension Fund
911 RIDGEBROOK ROAD 4301 GARDEN CITY DRIVE
SPARKS, MARYLAND 21152-9451 SUITE 201
TELEPHONE: (410) 683-6500 LANDOVER, MARYLAND 20785-2210
(800) 638-2972 TELEPHONE: (301)459-3020
April 6, 2011
Dear Beneficiary:
In order to comply with the Pension Protection Act of 2006, the Board of Trustees of the FELRA &
UFCW Pension Fund previously changed the way in which the death benefit was paid. Effective April
28, 2008 the single lump sum death benefit was converted to a monthly annuity.
At their most recent Policy meeting the Board of Trustees made a change and the benefit will now be
paid as follows: The pensioner's single life annuity benefit will be paid monthly to the beneficiary until the
amount of the original death benefit has been met. For example, if the pensioner's single life annuity
was $800 per month and the amount of the lump sum death benefit was $2,500.00, then the beneficiary
will be paid $800 for three months and $100 for the final month. Please complete the enclosed forms and
return to the Fund office in envelope provided.
Your payment will be made as follows:
1St Payment $970.97
2"d Payment $970.97
Final Pavment $558.06
Total: $2,500.00
Since your last check may be different than the others, please advise how you wish to handle taxes from
that payment. You may wish to provide us with a percentage to deduct instead of a flat amount.
Also, please issue a certified check or money order for $920.97 to reimburse the Fund for Leo Wagner's
March 2011 pension payment.
If you have any questions, please contact the Fund office at 800-638-2972.
Sincerely,
Pension Department
aga