HomeMy WebLinkAbout04-0792CERTIFCATION OF NOTICE UNDER RULE 5.6(A)
Name of Decedent: .~'/~ ,' rte q
/
DateofDeath: t~/,~s,,a~ 3, a~00
WillNo.: ~./50~- O0~°/o~. AdminNo.:
To the Register:
I certify that notice of(beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules
was served on or mailed to the following beneficiaries of the above-captioned estate on 15:~.~l, qa.l-~-q; ;LOOt4 :
Name Address
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date:
~iggnature
Name
Capa~iiy:
Iqll
Address
Telephone
~"~ersonal Representative
[] Counsel for personal representative
PETITION FOR PROBATE and GRANT OF LETTERS
Estate of' ~x',~'k*'.t
also known as
Social Securit~ No.
No.
To:
Register of Wills for the
County of
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 execut~,~
in the last will of the above decedent, dated 9..~ :Yx,*o~
and codicil(s) dated
in the
named
,19 q}~
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in Qb v~.~:~v\~.~ County, Pennsylvania, with
last family or principal residence at ~"/C~ l:%~X~k~ C~.,a~'c.~ ~/
(list street, number and muncipality)
Decendent, then "'/'~ years of age, died _'~ I'~o%x~ ~,¥ , ~ 9..~ ~,
Except as follows, decedent did not 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: .
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: 0
~o~>0
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters.
theron. (testamentary; administration c.t.a.; administration d.b.n.c.t.a.)
OATH OF' PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
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) and that as personal represen-
tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law.
Sworn to or af~f.~med and subscribed ~
before me..this ..Oq~ day of [ ~- ~- -' - ~ --
Estate Of
!
DECREE OF PROBATE AND GRANT OF LETTERS
, Deceased
AND NOW C'~ ~' ~__.x~ 0~ ~t~ o~"~.a"~00~, in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,..
IT IS DECREED that the instrument(s) dated '~ -- ~ ~ ~ ] ~/{~
described therein be admitted to probate and filed of record as the last will of
and Letters 0'~ '~~:¢~
are hereby granted to
FEES
Probate, Letters, Etc .......... $
Short Certificates( ) .......... $
Renunciation ................ $
$
TOTAL ~ $
Filed ...................................
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
~egi~ter ~f ~i~i~ ~f Cuml~edan~ (~auntp
OATH OF NON-SUBSCRIBING WITNESS
(each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that
We are~ familiar with the signature of ~ ~', r\ ('~ tiPS. [_-ec\(~oarT- _,testat of
(one of the subscribing wimesses to) the codicil/will presented herewith and that ~ ~ believes
the signature on the codicil/will is in the handwriting of ._~ '~', t' \ ~ ~ /¢~. L D c\<~ 0, r'V
to the best of 0 ~d '~ knowledge and belief.
Sworn to or affirmed and subscribed
~or the Reg
(Name)
(Address)
(Name)
(Address)
'hi, i~, ~o certify that the information here given is correctly copied from an original certificate of death duly filed with me as
I ,:~ ti I<egistrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00 ~ '/4~'~":- '~' ~ ~
Local Registrar
P 10529062
No. ~ Date
AUG 1 0 20O4
NAME OF DECEDENT (First, Middle, Last)
Shirl( M. Locld-tar t
AGE (Last Birth~ay)
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH ° VITAL RECORDS
CERTIFICATE OF DEATH
STATE FiLE NUMBER
SEX [ SOCIAL SECURITY NUMBER DATE OF DEATH (Month, Day, Year)
DATEO~B, BTH ~ ['. female I'. 172 - 24 - 8394
(M~. Day. Year) / BIRTH~ (~ ~ I~ ~ DEATH fC~ ~v one- ~ ~s~s ~ ot~r ~}
I
I NO~ Yes ~ If yes. s~ C~an, [ (Sp~y)
~. Cmberland East Pennsboro ,. ~ ~iv,4 ~,~t ]~.~R~n.,c. 11~. white
DECEDENUS USUAL ~CUPATION KIND OF BUSINESS I INDUSTRY ~AS ~C[~NT E~R IN I ~CE~'5 E~TI~ ~ MARITAL STATUS - M~, [ ~RVIVING SPOUSE
I
DECEDE~'S MAILING A~RESS (Stre~, Ci~n. Stale, Zip C~}l DECEDENT'S 17l State Pa
770 Poplar Church Road /~[~g ' -- ~' ~nt 11~ U Y..d~lliv. in ~p
~E
FATHER'S NAME (First, Middle. Last) MOTHER'S NAME (First, Middle, Maiden Surname)
~,. William C. Felker ,,. Mary Ellen Breach
(Type/Pdof) INFORMANT'S MAILINGADDRESS Strea< City/Town State. ZipCode)
2o,. Linda D. Stockslager 120~. 1911 Dartmouth St. Camp Hill, Pa. 17011
I PLACE OF DISPOSITION- Name of Cemeter/. Crematory [LOCATION - City/Town St• e Z~p Code
or Other' PlaCe '
DonationS] Burial [~l~Cremal~on [] t ....... ~.--) I / 2260 Herr St.
11,. 21b. 8-12-2004 ,Izl¢. Harrisburz.. East Cemeter
LICENSE NJJMBER [ NAME ~4qO ADDRESS OF FACILITY
~z.,. /w'~/o~/~L ~22c. Neumver Funeral Homo Inc.. Harrisburg,' 'Pa,
TO the best of my knowledge, death occurred at the time, date and p~ace stated.
, cause of death, (~gnat~e and lille)
231.
TIME OF DEATH DATE PRONOUNCED DEAD {M~nth, Day, Year)
person who pronounces death.
ILICENSE NUMBER DATE SIGNED
I (Momh, Day, Year)
Approximate PART Ih Other significant coodibons/conthbuting to death, but
interval belwee¢ ~ol resulting in [he underlying cause given in PART I
coset and death
WAS AN AUTOPSY I WERE AUTOPSY FINDINGS I MANNER OF DEATH / DATE OF INJURY I TIME OF N JURY [ N JURY AT WORK? I DESCR BE HOW N JURY OCCURRED
PERFORMED? AVAILABLE PRIOR TO ~ I M~lh, Day Yea0
I COMPLETION OF CAUSE IN*,u~a, ~ .om,~, []1 I I I
[OFDEAT.? IAc=denl [] Pendtnglnvestigation mi I I '.,~ .o~1
[]~r~ [] No ~ I ' [] Could ~t he ..... ined ~~ offlce~' '
¢ .E..RflRER (Check o~y o~) -- S~GNATORE CEBI~FEB
~oE~h-ReFbYieatNOo~Y~%lnCl~At~N&?~Y stll~aa~h~ifyLn{~ ~ca~.se .of .~t h whefl, eothgr pt~ysicmn has p ..... d d~.ath and COml:~eled item 23)
'PTRiONOUNClNG AND CERTIFYING PHYSICIAN (Physician both proriou~clng death and ceetilying * ..... t death>
oth. bs~totmyknolMedge, death ..... .&tthetlme, dlle, andpl ...... ddultoth ....... IS)mhd ......... tared ...................... la 3,c. ~/""~/JO(,~lf~;6~' ~ la*d. K/.~ /~_~
NAME AND ADDRESS OF PERSON WHO COMPLETED CALrSE OF t)EATH
· MEDICAL EXAMINER/CORONER (Item 27) T_.~or Pnnl
311Onthlbea Sot examln&tlonandtorinvestlgatlon_ Inmyopnon, death occurred at the tlme, date andplace, snd due to the causea(s) and
........ ...d ........................................ : ............................................................. , ......................................................
REG.;,<,~.'S S.GN,~p,I~ A,~,~.E. '
DATE FILED (Month. Day. Year)
LAST WILL AND TESTAMENT OF
SHIRLEY M. LOCKHART
I, SHIRLEY M. LOCKHART, residing in Harrisburg, Dauphin County,
Pennsylvania, hereby declare this to be my Last Will and Testament and revoke
all wills which I have previously made.
IT~4 I. I order and direct that all of my just debts, funeral
and administration expenses be paid as soon as convenient after my death.
ITEM II. I give, devise and bequeath all of my estate, whether
real, personal or mixed, and wheresoever same may be situated to my husband,
WILLIAM R. LOCKHART.
ITEM III. I appoint my husband, WILLIAM R. LOCKHART, as Executor
of this my Last Will and Testament, and I direct that no bond or other security
for the faithful performance of his duties as Executor shall be demanded or
required of him. I direct that the services of HARRY G. BANZHOFF, Attorney at
Law, with offices in the City of Harrisburg, Dauphin County, Pennsylvania, shall
be used as counsel in the settling of the affairs of my estate.
ITEM IV. In the event that my husband, WILLIAM R. LOCKHART, should
predecease me, I then give, devise and bequeath all of my estate, whether real,
personal or mixed, and wheresoever same may be situated to my daughter, LINDA D.
RECKNER.
ITEM V. In the event that this portion of my will shall become
effective, I appoint LINDA D. RECKNER, Executrix of this will, and I direct that
no bond or other security for the faithful performance of her duties as Executrix
shall be demanded or required of her. I direct that the services of HARRY G.
BANZHOFF, ATTORNEY AT LAW, with offices in the City of Harrisburg, Dauphin County,
Pennsylvania, shall be used as counsel in the settling of the affairs of my estate.
IN WITNESS WHEREOF, I have hereunto set my hand to this my Last Will
and Testament, consisting of two (2) pages, this ~ day of July, A.D. 1968.
WITNESS
-1-
(SEA )
SIGNED, SEALED, PUBLISHED and DECLARED, by the said Testatrix,
SHIRLEY M. LOCKHART, to be her Last Will and Testament, in our presence
and in the presence of each other, who at her request and in her presence,
have hereunto subscribed our hands and seals as witnesses, we believing
her to be of sound and disposing mind, memory and understanding.
'~~~~/ residing at ~ ~a~S~ ~ ~~
-2-
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717)240-6345
Date: 12/06/2004
STOCKSLAGER LIN]DA D
1911 DARTMOUTH STREET
CAMP HILL, PA 17011
RE: Estate of LOCKHART SHIRLEY M
File Number: 2004-00792
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 12/04/2004
Your prompt attention to this matter will be appreciated.
Thank You.
CC:
File
Counsel
Judge
Sincerely,
GLENDA FARNER STR3tSBAUGH
Clerk of the Orphans' Court
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUI~EAU OF INDIVIDUAL TAXES
DEPT. 280601
HAI~RISBURG, PA 17128-0601
REV~ 1162 EX!11 ~96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
STOCKSLAGER LINDA 0
1911 DARTMOUTH STREET
CAMP HILL, PA 17011
~~uuu fold
ESTATE INFORMATION: SSN: 172-24-8394
FILE NUMBER: 2104-0792
DECEDENT NAME: LOCKHART SHIRLEY M
DATE OF PAYMENT: 05/05/2005
POSTMARK DATE: 05/04/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 08/03/2004
NO. CD 005294
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $222.44
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$222.44
REMARKS:
CHECK# 96
SEAL
INITIALS: CCP
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF
THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY
UNTIL COMPLETION
STATUS REPORT UNDER RULE 6.12
Name of Decedent: ~ ~ M
Date of Death: A 1.1 ~ 11 T Jf
Estate No.: d- On LI - no., CJ :J. fA
lock h~ rl
No. J.'-OL\-07'1~
Pursuant to Rule 6.12 of the 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
2. If the answer is No, state when the personal representative reasonably believes
that the administration will be complete:
(date)
3. If the answer to No.1 is yes, state the following:
A. Did the personal representative file a final account with the court?
Yes ~ No
B. The separate Orphans' Court No. (if any) for the personal representative's
account is: fA No. ~I- 0'1- OH2.(Not Applicable in Dauphin County)
C. Did the personal representative state an account informally to the parties in
interest? Yes ~ No
D. Copies of receipts, releases, joinders and approvals of formal or informal
accounts may be filed with the Clerk of the Orphans' Court and may be attached
to this report.
-)
~>>,~A-,
Signature
Date: '5f!j?,1.A O~.S"
(\,.~
\..\"cAo-. 1). ~\o(ks\"-~'<.r-
Name (Please type or print)
<. )
\C\ \ \ \J ~'t"\'MOv..T~ ~T.
Address C", \'vi f \\ ~ \ \ I P A , '1 0 II
_(,I') 11,-3'11?>
Telephone No.
(".",)
(MAH:rmtlAM3)
Capacity:
V""
Personal Representative
Co"",,1 Co< P=,I Rel''''''e"']
Ii:.W.-58
C~Mb-'Lr\~nc{
Register of Wills of @a~r-"I.:.I County,Pennsylvania
INVENTORY
Estate of S ~ ~ r , ~ ~ M. LO-cJt' ~ DI. ri
also known as )h;r-le..y M. F-elkel"', Sp'""j'-d;
S; sT',
No.
;;tOOL! - DO J q~
. Deceased
Date of Death ~lAST "'1'~..Ob4-
Social Security No. \7 J.. -:;). L.f - '&- 3 q Lf
Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all
of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that
the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and
that Decedent owned no. real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum
at the end of this inventory. l!We verify that the statements made in this Inventory are true and correct. It We understand that
false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to
authorities.
Name of
A norney:
Personal Representative:
L\ 'l\.cko-- ~. ~i 0 c..~.s \ ctVI
1.0. No.:
Address: 10\ \ \ i)~ roT n-. 0 "'.,..~ ~.,..
Co.YY"'Ip \-\'1\\) PA \,1)\\
Telephone: b I ,) J ~ ., - 3>., 1-'
Daled
~/3/;).()Of)
, .
\.
Description
^",~r;LoI'f\ G-~"H...\ L;~c. - ~r~-f''''~ct .r"'\'\Ho>.\ '..#
p~;tI.'tO; n~~W\'1'tr Fl.\hH~1 HOVVlo{, 'L~c...
'~3 ~ N '2",~ ~T. N.T'r\s,Io" r~.f'A nUl
f",\roV\ ~O\~\( L\)~+u f"'\'\~h..\ e.).f>'t'~St'J
Value
5 000.00
,
c:t.
3 ~ ~~ . '?> 3
J
3. (he..:.I<;,,'l ACCOLl"" #05?>lt,.;lSI "1'8""
Co \"\"l W'V'\ lL r t.-e. ~"l'\"
'00 S~V'\""T< Av~.
C"''''''to ~; ,\ I fA liD\!
S'2LJ '1 E7, q I
'1".; _~ .
'\~~:.
Y.
O.
Fe.ol ot r", \ \' "-)t' ~ -e. -t ,^,,,,.A - d-.O 0 ~
({-et'lAhol F\A~H^,\ [)(p~.,seS
Y\.e.-v.~ 't 4.Y P.... n~rA. \ \"'-OV'l-<.,:\:nc..
\~~l.\ N. ~"'^ ~-r. \'"\~n'\"\()t-\rfl'I'PA "'10"2-
S ~\I \o(.\'h ~V\T - ~,t1\i-( R~, \ r--(.W\~\,,\ S"l~T.( ,
"3oW.3rol ST. PO Cbojt'\'"t;
'7. 0 ""o\TI"';slo...r'l,PA " lO\"- \\'-\'1
~ c":l'i<,v(1'5 Ac:..c.G"'ll'\r- WLcap <;)\'or~ \-\eI-\1"h....1h.
(Attach Additional Sheets if necessary) '"""c":...... "p'Hr\T"'......"~ ~
$O?,J 00
5' ~. 4 $""
(,)
".
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may. at the election of the personal representative, include
the value of each item. but such figures should not be extended into the total of the Inventory.
ud
RW-8
RE'?1500 EX (6.0(,)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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REV-1500
USE ONLY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
~L-()I{ o072J.
COUNTY CODE YEAR NUMBER
SOCIAL SECURITY NUMBER
17;;t-~q
&-3ct4
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
L Oc-\< ""rT"
DATE OF DEATH (MM-DD- YEAR)
15 1"3 I d.. 0 0'1
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
W Original Return
o 4, Limited Estate
~6. Decedent Died Testate (Attach copy of Will)
o 9, Litigation Proceeds Received
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 2, Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy oITrust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
o 3. Remainder Return (date of death prior to 12-13-82)
o 5, Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (All"hS,h a)
....
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TELEPHONE NUMBER
1'"1
,"1,-,3,\"3
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
J 3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank DepOSits & Miscellaneous Personal Property
Z (Schedule E)
0 6. Jointly Owned Property (Schedule F)
< o Separate Billing Requested
...J
::J 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
!:: (Schedule G or L)
11.
<( 8. Total Gross Assets (total Lines 1-7)
0 9. Funeral Expenses & Administrative Costs (Schedule H)
W
It:
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
COMPLETE MAILING ADDRESS C'
\<:l\\\ ba.rlVYlOl.\.T~ ~t:
CVi."-'F Hi \\J fA \'0\1
(1)
(2)
(3)
(4)
(5)
o
o
o
o
\4,50\.'J~
o
(6)
(7)
o
(8) \ '-\ , SO\. '/ :l.
(9) q 0 t..\. \. C\ ?>
(10) S \ b , 1 ::l.
(11)
(12)
(13)
q.Z;5%.~5-
4'Qtt?>.o'7
,
n
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)
Li "Ic..j~.DI
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
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11.
::E
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15. Amount of Line 14 taxable at the spousal tax 0
rate, or transfers under Sec. 9116 (a)(I.2) x .0 (15)
16. Amount of Line 14 taxable at lineal rate '-I., QLI3.o'1 x.o~ (16) 2~~.L\Y
17. Amount of Line 14 taxable at Sibling rate 0 x .12 (17)
18. Amount of Line 14 taxable at collateral rate a x .15 (IB)
19. Tax Due (19) .t" ;:l:l.:l. 4 LJ
200
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
CITY
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
ZIP \ -, 0 \ I
(1) .t ;t:l.:L. L14--
(3) 0
(4) 0
(5) ~d..)...44
(5A) 0
(58) do. d... :l.. Y Y
0-
o
o
Total Credits ( A + 8 + C ) (2)
3. InteresVPenalty if applicable
D. Interest
E. Penalty
o
o
TotallnteresVPenalty ( D + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
o
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
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
a. retain the use or income of the property transferred;.......................................................................................... D
b. retain the right to designate who shall use the property transferred or its income; ............................................ D
C. retain a reversionary interest; or.......................................................................................................................... D
d. receive the promise for life of either payments, benefits or care? ...................................................................... D
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ........................... ................................... ................... ... .......... D
3. Did decedent own an "in trust fo~' or payable upon death bank account or security at his or her death? .............. D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ D
No
\KJ
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~
[J
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
,
')
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.
DATE
ADDRESS
1"111 Da.rTmOwTh ST
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE )
CC\i')')O Hill PA 17011
, I
ADDRESS
DATE
. I
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%
[72 P.S. ~9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (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. ~9116(a)(1.2)J.
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116(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.
r8'-I508EX+('/-97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
S~I r-\ e ~ M. Loc..k~~tT ~OOL.I- 00,"1;1...
Include the proceeds of Iitiga 'on and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE A T DATE
NUMBER DESCRIPTION OF DEATH
1 Ch(,c.kin~ .Ac.cOIAI'\' .JJ-OS3";;>"'S'~~"
CornM~rCe (3",~J.<
\~O Se\'\O\'1'-e.. Ave.
COl""'~ l-lill,PA ,""'DII
R '€ FVI h '^-.- F'-\ h -e Y',,-1 C )(p-e hoSt'S
Y\e"''''''1~r FII\n-irA.1 HOrt\.e,Inc.
\~3L.\ ,oJ. "2-",,,," SoT.
l-{", 1"' r ~ S'to \..\ r-~J PA: q' 02-
S e.1T \e h"I e.nl" - SiO\'-!. A.eT\t'-em.tVl'T" S'ISTo'l
$'1'f\\.e" €rnplov-e~I.s 1'\1\re.....t:I'\T ~~s;n'1
30 N ~r~ ST. PD BOl"'\&.ji
\-\O\Tr~ S.bl.lr-~) fA I,IO~- \\4,
Lt. POI..T'ic.'1T5 Ac..c..OWhT
W.Q.S'" S\'or-e He.~\l"n ~ RehAb CeYlTe.r
lID PoplAr C.h\llr~h Rei..
CG\ ..... P tt \ 1\ I "A '1 D I I
~.
3.
5". .A"""-(.r~c..",~ (;..eY\.e.rp...\ LiP-e -Pre -p".,:J. f\A.,,-tr~'
Po...~oll"o: V1-e.y,""yt.r F"'hU''''' \1o.....~ "!:Y\c.
\ -"b "".> 4 N 1-.... ol S t". \-\~ 1'""~ sb '" y-~ . P.1t Ll\ 0,
(;. j-UlroVl (;~n\< CD .-.fur f....n-er".,l cXf'e.nses
~. r.e.-o\~rp..\ 'lp.-.,. (o(~~,^",c.{ -J.,.oo'i
.J5Y ~i'.'ll
I
5 8. '-I 5"
\\~..;t"
IOCL77
5 000.00
I
3/;2~cl.33
50b.OO
TOTAL (Also enter on line 5, Recapitulation) $ \ i...\ , So \ . J ~
(If more space is needed, insert addllional sheets of the same size)
HEV,'I511 EX+ (12'99)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
S~\r'\~)' M.
FILE NUMBER
Loc..khOl.\'" ~oOL\ - 007 q.;t
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
fg \~3.'&"~
"IO"Z- I
1.
FUNERAL EXPENSES:
n ~nA """' 'I ~ r t= io\ n e r~ \ H" 1""\ ('. I J: Y\ C -.. P A
I \ '!> 3'+ N 2...0( '3>1". t-lAY'r, 'lob....r~\
Me.WlO":"'-'~loY\~ I ,
eVlIlV\'!> Ce.r>e..T.(lt''/ M~mor\<\.)5
3 q f'o rl~ yo I\'~o..t
"i 0 w lZ... r C. i ry I P A , '1 ~ &" 0
(,1 ':),00
~.
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
State _ Zip
2. Attorney Fees
Year(s) Commission Paid:
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
4.
5.
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
Probate Fees C, '" WI 'b < to \ IA >\ J. t 0 \A h. -r '1 - R. -e ~ i S T e t" c.f \AI i \ \ .s
\-\CII.'f\o"~r"t' I-\,~h ~TS. GU"\i&I.e,fA- \10 '3
Accountant's Fees
46.00
6. Tax Return Preparer's Fees
7.
8'.
E.~e.cIATr-i)('s NOT;c..e "",'Io\~s~-ecA
i'n~ ~ll,T rO"l YH..w,$
?;'\';).. 'fY\^.....).(~'t" ST.
H P~. (' A.
V\T~' "ecoy-J..$- ~ c.."iP'es ()t ~(.A," C.HT~ti("A.Te
\"\.e..t.lie.c( -{&'\ es.T"'-Te.
\ ~.l> 0
\~O.05
ct 0'-\\ .OI~
TOTAL (Also enter on line 9. Recapitulation) $ 9. oY: ~_ q. 3
(If more space IS needed, Insert additional sheets of the same size)
REV-151i EX.. (1-97)
SCHEDULEJ
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEOENT
ESTATE OF S \ '
"" , y. \~ Y M. ~c...k~". r'''-
Include unreimbursed medical expenses.
ITEM
NUMBER
1
FILE NUMBER
~OOL; - 00 Iq~
DESCRIPTION
p~ yo "'" "'" e~ic... ~"'I~yoc..((pT C-,/lO/z..oOy)
Wfl:>T S \'or-e. EM So -ALS
~ 0 S G- r" Y\ cl V '~lN A v-fl,
S~\,e ~\l
LOtW\'f' \-\i '\,~A \"10 \\
AMOUNT
.# 5" \"./.2..
TOTAL (Also enter on line 10, Recapitulation) $
(If more space IS needed, Insert additional sheets of the same size)
.REV-1513 EX+ (9-00)
. ..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
S
FILE NUMBER
:;tOOL.l - D07'1:1...
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
(00 'Ie
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
I. \...inol~ 1>. S-roc.\-<.~\c..~-e.r
I C\ ,\ 1> Ik r T Yv" 0 IA. .,. h ST.
CQ.~f> \4d\, FA ,,0'\
u"'I4')h"t"~r
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
I.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
I.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
REGISTER OF WILLS
CUMBERLAND County, Pennsylvania
CERTIFICATE OF GRANT OF LETTERS
. I
\11. '1111",.,
()~ ~'-, / ",
\' (II/I" 'f,
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No. 2004-00792 PA No. 21-04-0792
Estate Of: LOCKHART SHIRLEY M
{Last, First, Middle}
Late Of:
EAST PENNSBORO TOWNSHIP
CUMBERLAND COUNTY
.
.
I.,
Deceased
Social Securi ty No: 172-24-8394
WHEREAS, on the 24th day of August 2004 an instrument dated
July 24th 1968 was admitted to probate as the last will of
LOCKHART SHIRLEY M
(Last. First, Middle)
la te of EAST PENNSBORO TOWNSHIP, CUMBERLAND County,
who died on the 3rd day of August 2004 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARY to:
STOCKSLAGER LINDA D
who has duly qualified as EXECUTOR(RIX)
and has agreed to administer the estate according to law, all of which
fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYL VANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 24th day of August 2004.
**NOTE** ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE)
I
1
",:-1
-'I
j
,.,.
--~.'
LAST WILL AND TESTAMENT OF
SHIRLEY M. LOCKHART
I, SHIRLEY M. LOCKHART, residing in Harrisburg, Dauphin County,
Pennsylvania, hereby declare this to be my Last Will and Testament and revoke
all wills which I have previously made.
ITEM I.
I order and direct that all of my just debts, f'uneral
and administration expenses be paid as soon as convenient after my death.
ITEM II.
I give, devise and bequeath all of my estate, whether
real, personal or mixed, and wheresoever same may be situated to my husband,
WILLIAM R. LOCKHART.
ITEM III.
I appoint my husband, WILLIAM R. LOCKHART, as Executor
of this my Last Will and Testament, and I direct that no bond or other security
for the faithful performance of his duties as Executor shall be demanded or
required of him. I direct that the services of HARRY G. BANZHOFF, Attorney at
Law, with offices in the City of Harrisburg, Dauphin County, Pennsylvania, shall
be used as counsel in the settling of the affairs of my estate.
ITEM IV.
In the event that my husband, WILLIAM R. LOCKHART, should
predecease me, I then give, devise and bequeath all of my estate, whether real,
personal or mixed, and wheresoever same may be situated to my daughter, LINDA D.
RECKNER.
ITEM V.
In the event that this portion of my will shall become
effective, I appoint LINDA D. RECKNER, Executrix of this will, and I direct that
no bond or other security for the faithful performance of her duties as Executrix
shall be demanded or required of her. I direct that the services of HARRY G.
BANZHOFF, ATTORNEY AT LAW, with offices in the City of Harrisburg, Dauphin County,
Pennsylvania, shall be used as counsel in the settling of the affairs of my estate.
IN WITNESS WHEREOF, I have hereunto set my hand to this my Last Will
and Testament, consisting of two (2) pales, this :L~
day of July, A.D. 1968.
WITft,ESS: ) .'
{. ,1. '" . / II?
':&'l~ il./a!Avl 1~ /
,k-r-,-,,~Ll D. r r
t/
~~l~Lu \\\.~
\
(SEAL)
-1-
J
SIGNED, SEALED, PUBLISHED and DECLARED, by the said Testatrix,
SHIRLEY M. LOCKHART, to be her Last Will and Testament, in our presence
and in the presence of each other, who at her request and in her presence,
have hereunto subscribed our hands and seals as witnesses, we believing
r
her to be of sound and disposing mind, memory and understanding.
,
j
1
I
j' ) /) i
vi . "~I _. ,/ _ I ~ f _ L-' -- ,/ ~/ ..,/ /
f')d.e:U1 ~. yLtM~'iding at '" 7,;;'j ..c- .~4v L&~ k.4<te4' ,4.'
1Jt~I9. r 7-
residing at
/t1 (l? .2h~(......, 57'
~~e1t.
tl/
Beverly Enterprises, Inc.
V~';:;: ... FAeJ(IT'f IN~f~~E INVOICE NUMBER INVOICE AMOUNT DISCOUNT NET AMOUNT
NUMBER
1-000 $~ BEVERLY ENTERPRISES 24430498
0028 ) WEST S ~ORE HEALTH & REHAB CAMP HI LL PA
F72931 00285 10-30-04 99803 109.77 .00 109.77
T ~TALS 109.77 .00 109.77
.
COMMONWEALTH OF PENNSYLVANIA
STATE EMPLOYEES' RETIREMENT SYSTEM
30 NORTH THIRD STREET - P.O. BOX 1147
HARRISBURG, PENNSYLVANIA 17108-1147
TOLLFREE: 1-80D-633-S461
www.sers.state.pa.us
September 16, 2004
LINDA D STOCKSLAGER EXECUTRIX
SHIRLEY LOCKHART ESTATE
1911 DARTMOUTH STREET
CAMP HILL PA 17011
Member SSN: 172-24-8394
Beneficiary SSN: 172-24-8394
Dear Beneficiary:
A check in amount of $112.26 will be mailed to you within two (2) weeks from the date of this letter.
The amount of $0.00 was withheld for Federal Withholding Taxes. If you have elected to rollover
then the taxable portion of $0.00 has been transferred to your qualified plans.
This payment represents your designated share of 100.00% in the Final settlement of the Account
of SHIRLEY M LOCKHART with this retirement system.
If the individual listed above was a member of the Retirement system before January 1, 1982, their
contributions prior to that date were taxed as part of their gross income at that time. Therefore, no
taxes are being withheld on that portion of their contributions. The difference between the amount of
your payment and your share of the deceased member's non-taxable contributions, if any, is
taxable for federal income tax purposes.
This payment has been reported to the Internal Revenue Service. If a 1 099R form is not enclosed
with this letter, you will receive one prior to January 31 of next year, with the necessary tax
information regarding this payment. Under current law there are no Pennsylvania state or local
taxes on any benefits paid from this system.
This letter and the 1 099R form that you receive should be kept in a safe place, as you will need the
information when filing your Federal Income Tax Return. This is the only notice you will receive.
There is a $5.00 charge for each request of duplicate information.
Sincerely,
~4i~ m. h1~
Linda M. Miller, Director
Benefit Determination Division
BEN31 FSL
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Date 9.1-3 / () ~
Inagreementwith ~hVD;l} ,--5/oc.K::'5 //Jr;EL?
o "-
Street /9// 3/JRt-mu/!h .... C;; .
City (ld/>7() /-11/ State ;:::>4 /7cJ/(
, ,
Phone 717 - 7...3? - -37/.3
Please enter my order for a memorial, with lettering as specified herein, for which I agree to pay you the sum of ~ '75. 0 0
&" ~. Dollars in the manner specified hereinafter, to be erected on Lot No. .. ,
i _::>1 A ~R/ s bf/ ..efhetery subject to the rules
( City and State)
and Regulations of said Cemetery. Materials, design, dimensions, finish and lettering of the memorial are to be substantantially as follows:
/ /'
0J?1l,/ 0::/e;q/J~-/ f" 0,e1'U~/l74R)/~1
B~,,;Pc~ . /!ppl2dV':~/ "'j)~SIj.,J
II. --,5. E~R!LlE.
I " TI"'H 111
l 1:';'0~.. ~0n'A.
. ~-'~""=,, ="v~''''-li
Y5tJaffl/J ?fJ(jJJ'lde;;f !J1CAn(W/di
39 Porter Road - Tower City, PA 17980
Phone: 717-647-2014
Artz Memorials - 570-682-9707
Minersvillel Pottsville Memorials - 570-544-0460
Millersburg Memorials - 717-692-0214
cl~ X I;?
.,..
~ ... If!" ", -....."I!ftJ,....':#""..,.,
No.
Ul
,
------.
f'~;"'~
$ t75. 00
ck# q3
q/;l.4/04
The said memorial is guaranteed by you against any defect in workmanship. The said memorial, with title thereto and right of possesion thereof, shall remain your personal
property until I have paid for it in full. In default of any payment hereunder I license you yo repasses and remove the said memorial without guilt of trespass or other wrong
and authorized and empower you, in my name and on my. behalf, to apply to the management of said Cemetery or other premises for a permit for its removal and to take
any other steps you may deem necessary or e~pedient and furthe( agree to save you harmless from and under any entry, repossession. and removal, you may then retain
said memorial or dispose Of it at your ~n discretion withqut being. fl'nsw~r,\pl\'l fp ~ for it qr any ~s therefro~'! Sale {joes\n~ include any future service (death
dates). Only the letterif19.berein specified is included iQ !heagreed price. This order is subject to any delay cused by any strike, lockout, fire or other conditions beyond
our control. I will inform you forthwith of any change in m~dress prior to final payment hereunder. There is no other agreement regarding this order other than contained
herein. Any part of this agreement contrary to the laws o1\any State shall not invalidate any other part thereof.
,
I
A reement of Pa " nts:
$ #
cash herewith:
r.
I
Die
Base
1\
$ In or within ten
days. after. erection of saidmemQ/iaI,.-*ExckJding niemori~1s
':' placed in any cemetery that does.'nQtNy~thE\tpuitdatioif;
, ; in ptacewhen the. memorial is inoUr.pl)ssesion, require
tkYmenun fuUupon. notification itit!\ecustomer of ,
'"'~Ieted memorial, not necessarily erection of memorial;'
This~er is not subject to cancellation after acceptance.
)(e\~ __X ~~'i/t'i
r- ({jff/, V)UJj/~
Tille
If not paid within 30 Days, 1.5% interest will be charged or 18% pery.ar will be charged. Any other collection fees will be added to your account balance.
~
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Signed
By
Cost
THE PATRIOT NEWS
THE SUNDAY PATRIOT NEWS
Proof of Publication
Under Act No. 587, Approved May 16, 1929
Commonwealth of Pennsylvania, County of Dauphin} ss
Joseph A. Dennison, being duly sworn according to law, deposes and says:
That he is the Assistant Controller of The Patriot News Co., a corporation organized and existing under the
laws of the Commonwealth of Pennsylvania, with its principal office and place of business at 812 to 818 Market
Street, in the City of Harrisburg, County of Dauphin, State of Pennsylvania, owner and publisher of The Patriot-
News and The Sunday Patriot-News newspapers of general circulation, printed and published at 812 to 818 Market
Street, in the City, County and State aforesaid; that The Patriot-News and The Sunday Patriot-News were established
March 4th, 1854, and September 18th, 1949, respectively, and all have been continuously published ever since;
That the printed notice or publication which is securely attached hereto is exactly as printed and published
in their regular daily and/or Sunday/ Metro editions which appeared on the 21st and 28th day(s) of December 2004
and the 4th day(s) of January 2005. That neither he nor said Company is interested in the subject matter of said
printed notice or advertising, and that all of the allegations of this statement as to the time, place and character of
publication are true; and
That he has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this
statement on behalf of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed
and adopted severally by the stockholders and board of directors of the said Company and subsequently duly
recorded in the office for the Recording of Deeds in and for said County of Dauphin in Miscellaneous Book "M",
Volume 14, Page 317.
COpy
Sworn 0 and subscribed before me
NOTARIAl. SEAL
Terry L. Russell, Notary I.
aty of Harrisburg, Dau
My Commission expires June 6. 2ClOJ!i T A PUBLIC
M.mb.r,P.nnayIY.nl.Allotl.llU:l'f~sion expires June 6, 2006
PUBLICATION
.XICUT~U~ NOTIce
~ of T_. on tho ..- of
Shirl.. M. Lockhart. "* of Ca.... HlII.
cumbor_ county. ~.M1nl...
I do--.' .-.... - tIrGI\IOCl to tho
, ............... elIl ...._ Illdobhcl to. oald
H_ art _*l to mllko l!1lrnodlato
payment and _ _ clalma will
...-t thom for oettlomont 10: ~I_ D.
Stacko'-, __Ix (1911 Dartmouth
Stroot. Ca..... Hili. PA 11'11).
LINDA D. STOCKSLAGER
1911 DARTMOUTH STREET
CAMP HILL, PA. 17011
Statement of Advertising Costs
To THE PATRIOT-NEWS CO.
For publishing the notice or publication attached
hereto on the above stated dates
140.05
Publisher's Receipt for Advertising Cost
The Patriot News Co., publisher of The Patriot-News and The Sunday Patriot-News, newspapers of general
circulation, hereby acknowledge receipt of the aforesaid notice and publication costs and certifies that the same have
been duly paid.
By....................................................................
rP~ 'I,'I/)"
~* ~Jf
RECEIPT FOR PAYMENT
-------------------
-------------------
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Receipt Date:
Receipt Time:
Receipt No.:
8/24/2004
13:!56:28
1037620
LOCKHART SHIRLEY M
Estate File No. :
Paid By Remarks:
2004-00792
STOCKSLAGER LINDA
CP
Fee/Tax Description
PETITION FOR PROBA
JCP FEE
SHORT CERTIFICATE
COPIES
EXTRA PAGES
Check# 1069
Total Received.........
Receipt Distribution ------------------------
Payment Amount Payee Name
25.00
10.00
6.00
1. 00
3.00
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
~4'5 ~ n J
~;;~ :;:;:: tJ;L
lr/:;tbj 0'1
RECEIPT FOR PAYMENT
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Rece~pt Date:
Rece=!-pt Time:
Recelpt No. :
8/24/2004
13:56:28
1037620
LOCKHART SHIRLEY M
Estate File No. :
Paid By Remarks:
2004-00792
STOCKSLAGER LINDA
CP
------------------------- Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION FOR PROBA
JCP FEE
SHORT CERTIFICATE
COPIES
EXTRA PAGES
Check# 1069
Total Received..... ....
25.00
10.00
6.00
1. 00
3.00
CUMBERLAND COUNTY GENERAL
BUREAU OF RECEIPTS & CNTR
CUMBERLAND COUNTY GENERAL
CUMBERLAND COUNTY GENERAL
CUMBERLAND COUNTY GENERAL
FUN
M.D
FUN
FUN
FUN
~45 ~ n J
C 45. OO-? ~o)j ~
~ ~ ,/Yvr U via-- #F- 9;;L
It/ :;t b j 0 '1
WESTSHOREEMS-ALS r:"~:
205GRANOVIEWAVE ~
SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 INvoftftl Tax 10: 23-2463002 ~r'vIl~Q~
QUANTITY UNIT PRICE AMOUNT
1.0 512.49 512.49
1.0 4.23 4.23
. sM ~
PATIENT NAME:
SHIRLEY LOCKHART
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
INSURANCE:
MEDICARE B
PEBTF
DEPARTMENT OF PUBLIC
3028460A
172248394A
172248394
5101644440
SHIRLEY LOCKHART
770 POPLAR CHURCH RD
CAMP HILL, PA 17011
REASON(S)
FOR
TRANSPORT
DESCRIPTION OF CHARGE
PARAMEDIC INTERCEPT
EKG ELECTRODES
A0999
A0396
-rt_~flo
~
DESCRIPTION OF PAYMENT
RECEIPT
PAYMENT DATE
AMOUNT
fj~ ~c1
cvnj~
15471
3028460A
07/30/2004
MDEN
ECAR
WEST SHORE HEALTH AND REHAB
HOLY SPIRIT HOSPITAL
DYSPNEA
ASPIRATION
..~
ttCh1
516.72
O~L /)'-1
V ~tJ:.~ql
, ~ - ,. .
. ,iI',\~J~'" ~<~.t;"~"~:l>~llB~A. ,
,'''' \~..,w "", ,~~
PLEASE PAY THIS AMOUNT _
Total Credits
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Glenda Farner Strasbaugh
Register of Wills
and
Clerk of Orphans' Court
Marjorie A. Wevodau
First Deputy
Kirk S. Sohonage, Esq
Solicitor
Register of Wills and Clerk of the Orphans' Court
County of Cumberland
One Courthouse Square
Carlisle, PA 17013
(717) 240-6345
FAX (717)240-7797
INVOICE
Bill To:
InvoiceNo:
Invoice Date:
E8tate of:
E8tate No:
359
5/12/2005
Shirley Lockhart
21-04-792
LINDA D STOCKSLAGER
1911 DARTMOUTH STREET
cep
CAMP HILL, P A 17011
Qty
1
Fee Description
Additional Probate
Fee
Total
25.00
$25.00
Total:
'Pd v*OOCf9
$25.00
.....,;::.:
-.J
:-n
F3
1..0
Checks should be made payable to the Register oEWills. Terms: Net 30.
07-25-2005
LOCKHART
08-03-2004
21 04-0792
CUMBERLAND
101
APPEAL DATE: 09-23-2005
( See reverse side under Objections)
ABOunt Remitted I I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE _ RETAIN LOWER PORTION FOR YOUR RECORDS +-
REV:is47-EX-AFP-C03:0S'-NoricE-OF-iNHERiTANCE-rAX-APPRAiSEMENT:-ALLONANCE-OR---------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
SHIRLEY M FILE NO. 21 04-0792 ACN 101
::-,-r'i~,rr',,:~'
BUREAU OF INDIVIDUAL'TAxEs; ,
INHERITANCE TAX DIVISION
PO BOX Z80601
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
" - NOTICE OF INHERITANCE TAX
, "APPRAISEHENT, ALLOIlANCE DR DISALLOWANCE
OF DEDUCTIONS AND ASSESSHENT DF TAX
r' .,. ;. r,
((:,
C"
l j
07
c.
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
,
r~'i
''""'T
LINDA D iTOCKSLAGER
1911 DARTMOUTH ST
CAMP HILL PA
17011
ESTATE OF
LOCKHART
*'
AEY-lS47 EX AFP (06-05)
SHIRLEY
M
TAX RETURN liAS: I X) ACCEPTED AS FILED
) CHANGED
DATE 07-25-2005
I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
rll'f'lect ~igures tha1: include the total ~ ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rete llSJ
16. ~unt of Line 14 taxable .t lineal/Class A rat. (16)
17. A.uunt of Line 14 at Sibling rat. (17)
18. A80unt of Line 14 taxable at Collateral/Class Brat. (18)
19. Principal Tax Due
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Est.t. (Schedule A)
2. Stocks and Bonds ISchedule B)
3. Closely Held stock/Partnership Interest (Schedule C)
4. Hortgages/Notes Receiv.ble (Schedule D)
S. Cash/Bank Deposits/HJsc. Personal Property (Schedule E)
6. Jointly Owned Property ISchedule F)
7. Transfers (Schedule G)
8. Total Assets
11)
(2)
(3)
(4)
15)
(6)
(7)
.00
.00
.00
.00
14.501. 72
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Exp.,ses/AdII. Costs/Hisc. ExPenses (Schedule H)
10. Debts/Kortgege Liabilities/Liens (Schedule I)
II. Total Deductions
12. Net Value of Tax Return
13. Charitabl./GoYer~ntal BequestSj Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
110)
9,041.93
516.72
Ill!
112)
113)
114)
NOTE:
.00 X
4,943.07 X
.00 X
.00 X
.
INTEREST/PEN PAID 1-)
.00
AHDUNT PAID
222.44
DATE
o -04-2005
NUHBER
CD005294
~
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
NOTE: To insure proper
creel! t to your account,
SUD.it the upper portion
of this fo~ with your
tax paynent.
14,501. 72
Q.~IiR ;\;Ii
4,943.07
.00
4,943.07
00 =
045 =
12 =
15 =
.00
222.44
.00
.00
222.44
119)=
222.44
.00
.03
.03
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS RElllIIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF TlUS FOHN FOR INSTRUCTIONS.)