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HomeMy WebLinkAbout08-29-11 (2)"' ~ 1505610101 -~ REV-1500 °` t°'-1O' ~ OFFICULL USE ONLY PA Department of Revenue pennsylvaMa County Code Year File Number Bureau of Individual Taxes oerrs*unrt ar xcv[xue PO BOX28D6os INHERITANCE TAX RETURN ® rn ~-~j~~ Harrisburg, PA s~sz8-o6oi RESIDENT DECEDENT l 1 j " ~ N [-'1 ~(J ~) ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY O ©© ~ ! ~~ Decedent's Last Name Suffix s R~ Date of Birth MMDDYYYY v o ~ a Decedent's First Name ~'~''~''(~~ MI ~T ~m Spouse s Last Name Suffix Spouse's First Name MI ®~rrrrrrT-r~ o Spouse's social Secudry Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ^ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Retum O 2. Supplemental Retum O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) Q 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number (If Applicable) Enter Surviving Spouse's Information Below First line of address Second line of address City or Post Office State S ~ ~' ._ ~ __ _ m ~ r, c: ~- , / ~~~m s~ ~ f 4a 3 ~ ; • ~~ -1 r~,.7 -_ ~..f, t't y~ ZIP Code -SATE FILED ,_ G, ~j / D ,~-, -r~ . Correspondent's a-mall address: Under panalGes 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 SIGNATUgE OF PERSON RESPt~IBLE F,OR FILJ,NG RETURN narF i .~/ // /~VVRCJJ~ {j~ ^ (J J.( .4 xTD~ c ~~~R o ~,g-~P~P~s.6a,e~' ~o~ / ~a/~ use L 1505610101 Side 1 1505610101 J REV-1500 EX DecedenPs Name: 1. Real Estate (Schedule A) ........................................... .. 1. 2. Stocks and Bonds (Schedule 6) ..................................... .. 2. 3. Closety Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. 5. Cash, Bank peposiLsand MLscellaneous Personal Property (Schedule E)..... .. 5. 6. Jointly Owned Property (Schedule F) O Separate Biging Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly (Schedule G) O Separate Baling Requested...... .. 7. 8. Total Gross Aasata (total Lines 1 through 7) .......................... ... 8. 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. t0. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... ... 10. 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 13. Charitable and Gavemmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ..... }~it~.~ .. • ~ ~ .. 14. TAX CALCULATION -SEE INSTRUCTIONS FQR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. Decedent's Social Security Number 20. FILL IN THE OVAL IF YOU ARE REAUESTMIG A REFUND OF AN OVERPAYMENT 1505610105 O SPtie 2 1505610105 1505610105 REV-1500 EX Pag9 3 Decedent's Complete Address: File Number DECEDENTS NAME r~ ~ Tn r". ~~~~e ~ eK STREET ADDRESS ~~__ ~ ~iE' iNG ti°o ~~ - __ CITY t5 ~~ A7us vf~~LL srATE ~ ziP / 7a 9l1 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FiN In oval on Page 2, Line 20 to request a refund. (1) D' Total Credits (A+ B) (2} ~ (3} (4) ~ - 5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 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 :.......................................................................................... ^ b. retain the right to designate who shah use the property transferred or its income : ............................................ ^ [X~ c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ ~, 2. ff death ocxurred after Dec. 12, 1982, did decedent transfer properly within one year of death without receiving adequate consideratiorr? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payahlewpon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement accourd, annuity or other non-probate property, which ~,( contains a beneficiary designatfon? ........................................................................................................ ^ Q5- ................ IF THE ANSYYER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE GANQ FEE R AS PART OF THE RETURN. For dales of death on or after July 1,1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to ~ for the use of the ~rvivirg spouce is 3 percent [72 P.S. §9116 (a) (1.1) (i)J. For dates of death on ~ 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 [l2 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the stadttory requirements for disclosure of assets and filing a tax return are stiN applicable even if the surviving spouse is the only ber-efiaary. For dam of death on or after July 1,2000: • The tax rate imposed on ttre net vale 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 steppa-ent of the child is 0 percent [T2 P.S. §9116(aK1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedents beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) (/2 P.S. §9116(a)(1)]. • The tax rate imposed on the rtet value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a}(1.3)]. A sI'61ing is defined, under Section 9102, as an individual who has at least one parent in common with the decadent, whether by blood or adoption. REV-1511 EX+ (10-06) scN~~u~~ x COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER r c. N rb /Ty ~ SHE2ic oz / /iii Qo3t Debts of decedent must be reported on Schedule L A. FUNERAL EXPENSES: t. ~iurs ~~~" ~~in~-Tq-~ey d U / ~ ~i9-~ I~ .~, o ate. 5~ ~~~, o 0 /~/ , ~G B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representatve(s) /a /Q~jt,~ ( ~`G/[3 (~ Vty '/,r~ QQ Street Address ~/~ / ~ gSPQ iAG /C Q ~} /~ City ~~~~~ 47 R~lS o~ /} v State ~ Zip ~ ~7 D 9 0 Year(s) Commission Paid: 2• Attorney Fees 3. Family Exemptbn: (If decedent's address is not the same as Gaimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees ~ 7. ~~O 5• Accountant's Fees ~vs'O. ~ 6. Tax Return Preparer's Fees .SD . 6~ ~. TOTAL (Also enter on line 9, Recapitulation) I S (If more space is needed, insert additional sheets of the same size) / 7s REV-1572 EX+ (72-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scN~uu~E ~ DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & DENS ESTATE OF ~ FILE NUMBER ~~ ~ b i T~f- ` S~lE~ ,~.K o2 / / / / / 903 / Report debts incurred by the decedent prior to death which remained unpaid as of the date of death. including unrelmhun.A m.dlr..~ ...,...... REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT w ~n~ ~ yr ~ ~ ~ ~ ~~~~ /~ FILE NUMBER ~ e a ~ iiii o 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. ~ ~~,e~~ _ v, ~~~~ ~C 1. ~~~~-I ~o.~~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I S (If more space is needed, insert additional sheets of the same size) Jeffrey A. Funeral and Cremation Service ...where Memories are Shared www.janauglefcs.com Mrs. Karen Reigle 4614 Spring Road Shermans Dale, PA 17090 janauglefcs@verizon.net Statement of Funeral Expenses for: Edith F. 5herick December 27, 2010 Date of Death: November .t8, 2014 FACILITIES AND PROFESSIONAL SERVICES: Services of Director and Staff $ 2,110.00 Embalming $ 635.00 Dressing / Casketing /Cosmetology $ 215.00 Use of Facilities /Staff for Viewing $ 325.00 Equipment and Staff for Graveside Service $ 170.00 Sub Total; MERCHANDISE: Casket: Clair $ 995.00 Outer Container: Monarch $ 775.00 (30) Memorial Folders $ 35.00 Sub Total: AUTOMOTIVE EQUIPMENT: Transfer of Remains Hearse Service/Utility Vehicle Additional Mileage For Transfer OPTIONAL SERVICES: $ 3,455.00 $ 1,805.00 $ 315.00 $ 320.00 $ 125.00 $ 145.00 Sub Total: $ 905.00 Hairdressing $ 40.00 Sub Total: $ 40.00 TOTAL FUNERAL HOME CHARGES: $ 8,205.00. CASH ADVANCES: Hillside Cemetery $ 1,620.00 5 Certified Death Certificates at $ 6.00 each $ 30.00 Gift to Church/Clergy $ 150.00 Morning Call Obituary $ 200.50 Harrisburg Patriot News Obituary $ 120.02 Sub Total: $ 2,120.52 Total Funeral Expense: $ 8,325.52 Total Payments Made: $ 5,297.00 Balance: $ 3,028.52 135 W. PUMPING STATION ROAD ~ QUAKERTOWN, PA 18951 (215) 536-3343 1-800-304-4441 FAX 215-536-2250 Jeffrey A. Funeral and Crsrrletipn Service ...where Memories are Shared www.janauglefcs.com janauglefcs@verizon. net STATEMENT Mrs. Karen Reigle 4614 Spring Road Shermans Dale, PA 17090 RE: Edith F. Sherick December 27, 2010 Date of Death: November 18, 2010 Form of Amount of Received From Payment Check # Date Paid Payment American Memorial Life Check 453846 Dec 27, 2010 3,041.00 American Memorial Life Check 453845 Dec 27, 2010 2,256.00 Total of Payments: $5,297.00 Total Cost of Funeral: $8,325.52 Balance: $3,028.52 TERMS NET 30 DAYS. A service charge of 1 % per month or an ANNUAL PERCENT OF 12%, is applied to the unpaid balance beginning 30 days from the date appearing on the payment agreement. Balance Due on Receipt (Seal) (SI R F FU RAL DIR TO 135 W. PUMPING STATION ROAD ~ nUAKERTOWN, PA 18951 (215) 536-3343 1-800-304-4441 FAX 215-536-2250 Hillside Cemetery 10 x.8;55 SUMMARY OF CHARGES ATNEED PRENEED 1. Interment Rights f f 2.. Merchandise f + '> '$ f 3. Cemeeery Services f +-" f Subtotilf < ti ; ' f 4. Total Purchase Price y -~i Payment Method: a Cheek (Glen _~ rekrh aaiarra+tn(mrbera rarA Msde prysbk to Seller n Cub Credit Cud o Pepding Other Source AxoY66 e~rNaay; e'agwsartrewd -1~VTAL PURCHASE PRICE pma Saaaary 9rC~TcrJ DOWN PAYMENT Batch TRADE-IN/CREDIT TOTAL DOWN PAYMENT & TRADE IN/CREDIT: (5+6) Descriotion• -Account No• TOTAL AMOUNT FINANCED: Nepard9a/aw) (¢7)~ FEDERA L 'TRUTH IN LEND ING DISCLOSURES AND TERMS OF PAYMENT Mnual Perantaps pate The txat of your credit at a yeery nuts Chu9e le) ddlar amount the a dM will unt Financed (8) j Dial of Payrtttade (1% otN SaN Price ' rate e at Yal amount of aedh prov he arrant ~ you wIS have~peld alb tool wet la your purdltse o you an ywr tgltaf have made as b , Induding your dorm payment d - Inprat Foe Fades: (1 b -~ (7110) ,ti r 4 Your Pa went schedule wiR be: Numbs of Amount of Month and Year Firer Paymcn[ is due Pa mts Fa rats ezdudin darn a ent When Paymenb ate due /each Mn: Yr. Menthly Annual 5th 15th 25th Payment Options anal Senri.Annuil Prepayment, Security and Delinquency O Statement a n f ou a ofErul , ou will not have to a a and ou will be mtided to a artiil refund of the finance eh a c Bank Draft (m aJJarbtd aarbwitannaiJ an mt arc vin a seruri mtemt N the odr or elmqumry Charge. f my uumlknent a not pied in CuU within (15) days afte ib due date as origindly scheduled or u defected P h Credit Cud Draft , urc uer Will a a deV um ch uil to the to eF Eaur 4°/. ercent of the amount of the icupllmmt or f5.00. on Suffidmt Fund: n the event the Pueehuer tmdua a check f (ice aefarMdaarhamf7pufiatf or payment of any of the ennnnp due and aueh cheek is rcNmed due t uffitient Cunds m the account on which said checku down, Purchase ahaV be rapamible for a Fee u to Fiftee f75 00 Yar has rM ngbt ro sane as p n ( . oliap. 'err for sense aaaad s~t~c-ri Ott rvrxr•Ht NDc By Providing written notice to the Seller, you, the Ptuchaser, may cancel this Contract within three (3) days of the date of execution and receive a full refund of all funds paid to the Sella for any merchandise and/or services not used By providing written notice to the Seller, you, the Purchaser, may camel this Contract after three (3) days from the date of execution and receve a refund based on the foUowirtg•. For services, facilities and cash advance items; A full refund of all monies paid towards the purchase price allocable to such items shall be paud to the Purchaser within thirty (30) days after mailing such request . Fot Merchandise Items: If, at the time of need, the Seller, after being notified, cannot deliver the item(s) of merchandise within a reasonable period of time, a full refund of all monies paid towed the purchase price allocable to the apedfic item or items of merchandise shall be paid to the purchaser. After payment in full of the contract price by the Purchaser, if the Purchaser moves out of state, then upon written notice to the Sgllet, the Ptuchaser may cancel this contract and receive the principal amount of deposit for merchandise and services. TRUST DFPO ITC For all services, merchandise and facilities rented, GFteen (IS%) percent of the ptuchase puce collected will be placed into trust, and for future delivery seventy (70%) percent collected will be placed into trust. For all interment spaces, fifteen (15%) pemmt of the purchase price will be deposited into the perpetual/endowment care fund. No deposit will be less than fifteen (f15.00) dollars per interment right. Each ' paymmt'teceived on this Agreement shay be allocated firer to interment dghu, thm [o merchendiaq then servieea. For questiom or complains regarding this Agreement, please fed free to contact the SeBee at the adtlrcu or telephone number listed above. If the matter does not get resolved to your eaWfattioµ you mny taB the Stevan Enterprise Corporate Office in Louiaiwu. NOTICE TO THE PURCHASER: Do not sign this Agreement before you read it. You ue entided N an enact copy of the Agreement you sign. Keep thin AgrcemMt to protect your legal rigltp. The additional temra and conditions pceented on the reverse aide coostiNte and are made a part of ibis Agreement. By signing brims, Pumhaa acknowledges having acefuVy read the additionil terms and canditiona printed on the eevase aide hereof, which ace a part of tltia Agrcemmt and also uknowledges readpt of two fz) copies of the form for NOTICE OF CANCELLATION (if applicable). The execution of thin Agreement by the Company ie subject ro the Fmil acceppnek by management and until said uceptmce is signed by mamgement, this Agreement shall not be binding upon the Company but upon being ao signed the Agrcemmt shall 6e binding upon both (alb pubes, Dated this ~~ day of d -' : , ~. i ~ - 20 /~'.' and executed in multiple and Purchua uknowledgea rcuipt of an. exut copy of agreement. Fucchaaer acknowledges the this Agreement wan comple[e as m all esxmtiil provisionx before it was signed by Pumhuet. .. ire; ~ / I„ _ ~ ./~ y.y, . COUNSELOR ik CID # (print) ~ PURCfdA9ER ~ ~ I R's~a); ~ PURCHASER (sign.n,a) Print Name and Title SignaNrc rand Da[c ~ -~. ~ `. ~ ~ l ` ~ / .Snail Semriry Number Social Security Number Seller Acceptance BUYER'S RIGHT TO CANCEL: If shin a home solicitation Bale, you, the buyer, may cancel thin transaction at any time prior w midnight of the third business day after the date of this transaction. See the Notice of Cancellation form for an explanation of this right. Page 3 of 7 i i .' ffiiside Cemetery 1 U~ 8 5 5 1. INTE M -NT Rit`FiTC SRj RCTFD QtY A. Setece .a aeaetil, t o Developed o PmDeveloped ATNEED PRENEHD _Gmund Interment Righn .. ......................_.................................... .... . ...................,....._ ................................................................................................. -Ground lnwmrnt Rlghn Esbte ......................................................................No. of Righn: ..........f f _Brnc6 Space O Euemrn{ o Mawokum am ........................ ..No. of Righu: f f _Lwn Crypt o Single a Corttpardott/Double Depth o Other ..............._...No. of Righn: f f _Aigbt otAdditbaal Intemtrnt/Inummrnt o Interment t7 [numrnent ........... .. f i . . ............... ... .. .. .. eacripdon: Locuion: o interment/entombment o bench o cremation ePam (~ ~j'1 Garden/Sect Lot/Ro f w Spvee(s) Additioml Remarlu; _Privan Ma°ao4um ...............................................................................................No. ofliighn: _Columbarlum/Niche Inuttuernt Righn ........................................................No. of Righn: f f _Mauwkum Enmmbmrnt Righn ..................................................................... No. of R f f ~o Buifding/Unit o Single o Tme C n^ Delwe C ompanion O Abb n Other Seetion/Column ty , , f f t.evd/Row/ r tl Corridor/Floor. Ceypt(s): Additiaul Rertudy: _Oaauary/Scanu Cardin Location/Description: Other Crcmatlon Optiooa Deseuptiosu f f . Numlxe of Inurr,meretr_~ Laudon: f f _Othu (Dacription) _Othn (Description) f f Explenation of Ducount(s) f f Peepetual/Endowment Care(ro be applied to Property net of discount) f-_ f_ " f(--) •~f(____,1 SUBTOTAL "A" ...................................................................................... ................ .......$ t~ $ Qn B. Seka buildings/benchp beba, which does not include property rcHected N (A) above: -Private o Mawokum O Colwnbarhem (Na of R4M+rbsn sbew) ................ H'~d'^& I'°eao°n' Geuiite Color Drpriprirs axdAd&'rirsalFimvrr oa artb'srd rir Drrgrr 1'Apsralasdrr(yir! ra PxrAarer appran[ f f _Cremaden Options/Hrnah (Na sfR jMrrM~x aiwa) Descripdon lnntion: f f -Other (Decripton) ~ -Other (Dne:iprion) f f Explanation oFDiscoun{({) - f f f(_._~ f( ,~~ SUBTOTAL "B" ...................................................~....................,....,. .................... ................................ ......5 ~ $ TOTAL INTERMENT RIGHTS SELECTED (A+B+DocruneanrySrunpa/71.r/BndarwneatwPC1 (I) ~~ ....................................... 2. MERG ANDIC _ C ..FCT D ...:...f f Q'n ATNEED PRENEED _ DOurcr Burlal Coatahter or DCraoadop Intwtrnt/Outer HurW Container Dncripdon: OConcrcte OMeW DOthtt Line Type: Dl~ned t7Urdined f f _ DOutu Burial Conmintt of OCrertution Ietttmrnt/Outer BurW Container Description: OConaete DMeW DOther inner Type: OLined DUnSned f f Memoriak; o OM r °t r ((yrp/tp drraippaa br/QO~ o Q~g px[~Aaorlob6 sire paid is fx![ Gnrp,4p Mmrmr<[OrdrrFamtJ -Flat Hronu for GrowW Brehl Type. o Companion D Single ^ Cemorial n Matching Gav, Memorial ................. . . f ... .. ................._............ # of Emblems Included: _ # of Words/Chantten Included: _ Vase Included: nYn Descriptors; o No Derign: ....... f Size _ x __ Bue: Color. Size.- x _Gruamarlrer (abase aibavdJ Color. Size: x x __ -Upright Monumrn[ (sbm alfwrrdJ ^ Single O Companion OOther. #of Vanes included: Fi u l f f - r s t: Design: Gnrtite Color. Vau Sixe _ x Dimensiom/Rutish: Dic Bae/PedeaW: f f # of Words/Imcripriom, if included; da«ibe: _Vue (frrldapamplyJ Dacriba Size._z_...... ,.,...i f -Crypt Plate/Nkbe Pkte/Scroll # of Embktm Included.; __ # of Wotds Induded.: ........................ .. f . ............................ Dw ~ f ...... Size: _ x _Mu orlal Beach Name/Ducribe: Poliek Colon Dimensions: '. f f -Bronze Aefmkhlog Fee ........................._. f f ,.l_Iaacrlptlon/Lettering: ~ . ' , i ........................................................ O h ~ ...... f'-~T[~~~ f f d~L f t er (Dacription) + _Ot)IR (Description) f f MERCHANDISE SUBTOTAL Explanation of Discount ...................................................................... f~-~-- f ...... f f TOTAL MERCHANDISE SELECTED (2) i - i ». ' L - - / 3. CEMETERY 9 RVt C cF~FCTFD ~ ~ l t <~ ` ~ ~ / '' ' - ~ L<. - ''. f~ t Qtr ATNEED PRENEED _Certktery Profusional Service Fee ............................... .............. ... . ............................................... (ibis charge b far rxaWu weekM hwn~ ......................................................................... ................. / Prior m 2k1 pm. .. a f Addition) chega art nude afttt hours, Seo,rdrye, $we.ya snd Ho4days if ser.~ica art rtgaesnd by pwchuer during those chases er dsys.) ~lddidonal Charge for $pebai In[emunt Tune Requoted ......................................... _ .......................................................................................................... _Duinteement/Duen[ombment ................................... . .. f f .. ............................................................................................................................................................ _Scsuezing of tzema[ed eemains .................................................... .. f f .................................................... ............................................ ~ _VaultImWlatitm Fee ....................................... ., f f , ........ ........ ...............................~.............................:...................................................................... _MemorW InsWladon Fa/IAR (imtallation/Adjuatmem/RaSgnmcnt) .................................. .. .. f f . .......... ............................................................................. _Ownerelup TnmEtt Fe< ......................................................... f .. f .........,........... ......... ..................................................................................................................... -Cemetery Adndrtistnrive Fee ....................................................... ... .. f f . ......................................................................................................................................... -Travel Protection ................................................... . .. f f . ......................................................................................................................................... -Other (Dactiprion) ....' ....................•. f .. f .... _Otha (Daaipdon) ... .. f f ........ . f f CEMETERY SERVICES S TOTAL ............................... ~ ..................................._............................................... .............................................................. ......... Ezpiamdtm of Ducwm . ....5 f TOTAL CEMETERY SERVICES 5$LECTED (3) .................................................................................................................................................. ....._.... ~ ~ ....5 f .. ./ I Hillside Cemetery ~ ~ ~ ~ 5 5 CEMETERY PURCHASE AGREEMENT/retail installment contract Cemetery interment rights, merchandise, & services The cemetery rorporation designated by mark behrv it beniaafter refemd M err `S'eller': ^ George Washington Memodal Pack,lac. 80 Stmron Avenue Plymouth Meeting, Pa ] 9462 Teephone: (610) 828.1417 ^" fiillaide Cemetery, a/d/b/a of S.E. Acquisition of Pmnsylvattia,Inc. 2556 Susquebawna Road Roslyq Pa. 19001 Telephone: (215) 884-0696 ^ Suaaet Manorial Puk Company 333 County Line Road Feastetville,Pa. 19053 Mailing Addreas: P.O. Box 11508 Philadelphia, Pa. 19116 Telephone: (215) 357-8440 PURCHASER: ^Mr. ostra. DMs. Dodtter:_(PR1Nf t.EGIBLY> Name: ~~ =s • ~ , Address: _'Y , / ~1 ~ ~ t ~ _~ City/State2ip: , , ..~ . ~. ~ ; -t , : ~ > , Phone: ; i d - a , AIt.Phone: Email: Date of Birth: PURCHASER: Dale. DMn. Dote. Dother:_(PAgJi L¢claLY) Name: Address: City/State/Zip: Phone: ~`~ AIt.Phone: EmaiL• Date of Birth: ^ AT-NEED; DECEDENT NAME(S): .: , ^ PRENEED; BENEFICIARY (If Different from Purchase shown above): CCN C t. Certificate of Interment Rights Issued to (f Different from Ptrehaser(a): Upon the dealt of the Person for whom the services ue requested the Sellet may consult with the Putthasa, if available, or the fogowing peaoa(e): ~~ concemhtg the purchua for the Denedmc The Sella reserves the right ro masult with the indivi uala baying a legal right to control the final disposition of the Decedmc Tht Seger shag not be liable ro anyone for its decisions taken is good faith puauaat m conaul~don with any person. AGREEMENT FOR SALE AND PURCHASE. WITNESSETH THAT: The Seller agrees to sell and the Purchaser agrees to pttrchase the following designated Interment Rights, Services and/or Mechan- dise, to be provided by the Cemetery indicated on this Agreement. CONTRACT Si I~LMARv O Interment alah .; o Entombment ^ Intertnrnt ^ Inurnmrnt ^ Cremation Interment o Other. a- Merchandise Does this contort include the axles of merchandise Eor use in a cemetery? @ Yea ^ No IlYo, the Seller has determined as of the date of thin Contra that the merchandise indicted below will be accepted at the Eogowing cemetery, which is of the Purchaaels choice: tot Ptofesai 1 tvi F Dora the contact include theolea oECemetery Professionil Servitt Feu (Intmnmt/mrombment aetvice durga)? ^ Ya ^ No If Nn, the cuamt pdee For Cemetery Pmfeasianal Service fees eluting regulu weekday honer is f ~ This price is subject to change at any thne without notice unleaa purchased with this contract. If Cemetery Professional Sersticea fees are not putthased on a prmeed bans thin chugs will be made at the time of need ¢t the ate effative at that time. Additional chugea are made Eor aRa hours, gaturdays, Sundays, and hal;dayp iF services uc requested by Purchase doting those times oc days. t~"~ ~ INTEaatgil7a AE[EAaNDQ ADDCnONAL CONTRAC7a Initial>Putehsau:~ Purchasa:_ (1FAPPLIUBLE) (1FAPPL1U81F Pye1 oC 3• SOUACEM s.i. ;. a eastemDlYlsion Memorial-Form ' A~•• ~:~ ~`' ~Y _ ^ At Neod Pre-RapbtsradM Q Pre-Need StorodM i Seller LJ ! ~ '; ; ~I '~ Location N ` ~ ` ) /~ ,'~ 344: Deceased _"'" ~' ~ C tl ~ ' ~ t BUrlel LOCedOn: r ~y~ ~:~ i../ rl _ ~ .4 .` - f `. Type of Budal: ^ CryptNault ^ Ground/Lot D TomtNCopiny D NlchdCremorial11 # of Burials: Purchaser. ~"- _ ~~ , ~ .. / t.. Phone W.. "t I 'r • "- - ^ ~ `' `I Property Owner. __ I~ o i.~; r t r. ~ , , ~ l r, City' ~..{ ~ i ~ u .., i . ' l State: 1 .' ~ ~p , r 4 TAe Purchaser and Sa0er do y agree Mat SELLER vrq/ nrnrfnh a0labor and Mafeda/ roqulred for Me perlormanea of Ma kgowinp propose!. INSCRIPTION INFORMATION (Print Clesrly) Bronze Memorial ^ Vaea ^ No uses ^ Ridpslawn ~ e O Other p Sander Style: O Roekadaa ^ RspW O 54rMard ^ Hammered O Crownrxat ^ BsvN ^ Polhhsd Swat ^ Impad Border pin _ ^ CrypUNkha Plate/Scrodl: O Gowmment Match Bronze Sits: _x CakX:O Lpl ^ Mad O Dark Othsr. - Lagsr Styls: O Oval ^ Fist ^ Church Other. SEPARATE VASE ASSEMSLN ^ Yaw ^ No Vasa: man ^ Hammered Doric O Veteran's ^ Othsr 4. V Bewe $@a: X X Ma4dal: ^ Granite ^ Concre4 O Synthedc Color. • Emblem 1 ik - Emblem 2 a Emblem 3 ~ GROUND MARKERS `~ 'a ~ ' kYllal Monument Inafriptlon IrXiudsd: ^ Yp. ^ No Ma4del: ^ GroM4 Othsr. Dle Slza:_z _x Cobr: StodtManumanta 8uppllar. TyPa: Bess Stu: x x - CeMnas: ^ PFT, qRP ^ Odrer Style: ^ Flat ^ Sarp D Oval Db FlniM: D Pd6 D Pb3 O Poll ^ SOS D Sd2 D BRP Other. Wing Man: DFbI D 1/2 Berg ^,t/2 Oval Psdee4l (Wlna Monument Onty): ^ PoOShed top, Bal S4ele0 Ineeripdan indudad: O Yss ^ No Ma4dd: ^ Groni4 ^ Otltsr (WHERE AUTHORIZEL)) Styli: ^ Slant ^ Flat ^ BsvsNdMkday O Otlar ~ _ Sizs: z ~ X Vass Hob: O Ya ^ ~NO VASE Matedel: ^ Bronze ^ Grenita ^ Other ^ Grenits Squars Taper ^ CrypUNiche Color. ~ Size: StylslCatabpM PHOTO CERAMIC Size: O Cobr O BdW Supplier. _ Cdor Info: Cover, O Yes O No Enprovlnp rd Cover D lklpkfel Pho4 Endowed Number M Pereoru Rlna: O Yew ^ No _ LETTERING SgAs: ^ 3andblast ^ Bronze Other TyDS: O Crypt O Upright O Ground UthoehrorfFe: ^ Yss O No ^ Cobr Place Bskrvr. - t. •.i ~~ r: , -S~: I Cutlinee: O Yes ^ No Oudine Sty4: ^ Singh O Double Froetsd Panels: O Yae ^ No Number of Psnak SnadM hrwiruclbm: ^ wNmorlal b W InsWkM wMn pale In fun ^ solo un8 tlma a need ^ Oroar now Derwr; M PYrcMm, I hanrby wrfay dNf 1 have ohaoka0 d,. oroar,aa eAOan, and Mrd rha atxrva to Ir. arracf. TrraroNre, I auerorrn you ro profsae wah aama. I also arXhoAta fha wm.faryronmov.m.mwwm,mm:ear:. aawhlAO»n.rapropMyarsappov..arh.potip am.monl on »aww.a «anpu.m, a»rnrwwla»nnom: ~. Purchawr Sianaturo t ~~ f r ,• :? Ali' ~ Counasbr. •,,~. f t . - '~' .Purehawsr Slarnturo: Rs4tlonMip, d notOwnu: ~ ~~..!:~ .:.. , =. ". F ^ Psrma Froms Commann: Wh14 - Msmorlel Dsperdnant Yslkwr - Rswrde Plnk - CusWmsr Copy ~' ~~LIVE c3AROEN 1'?_69 1200 Bethlehem Pike t•' ~th Wales, PA. 1945.1-1'22 ~ ~:a:2312s r~~~ i ,,. rl pia E~ :.4:=i5 `.il 11/26/2010 Gst 7 Guest No.l 1 Soft Drink 2.35 1 Bellini Peach Tea 2.60 1 Bellini I each Tea 2.60 1 Bellini Peach iea 2.60 1 Bellini Peach Tea 2.60 1 Coffee 2.25 1 Coffee 2.25 1 Coffee 2.25 1 AWM CYO Sampler 3 9.75 Stuffed Mushrooms Chicken Fingers Toasted Ravioli 1 L fh~cken Parmigiana 9.75 1 * .,: i ~ ;c,.r~ ~ Salad Minestrone 6.95 1 L Seutood Alfredo 11.25 1 * Chicken 8 Gnocchi Guest No.2 1 B Castello Poggio Moscato 25.00 i Water 1 Water ~ ~{ 1 Water i Water 1 L Chlcken Parmigiana 9.75 1 * Salad 1 L Braised Baef Tortelloni 10.75 1 * Salad 1 L Soup 8 Salad fkr~Gnocchi 6.95 1 Vint Bianco Poi Scaloppini 15.25 1 * Salad 1 Disc #07 FSI $2 off Lunoh for 2-2.00 Subtotal 122 90 Sales Tax 5.88 Oratuity :22.48 :.4:45;52 11/26/2010 Please pay this amount Total 11.26 ~I ~:4019)Visa 151.26 ~ Amount Dui 0.00 Changes O.oO f_li n~ Tn 1"H.ANKS FOP, VISITING US TOOAYi iIRACIAS POR VISITARNUS HOYI Joseph Bradley iiENERAI MANAGER • 1215) 646-4384 qn optional 18% gratuity will be :id~Jed to parties of 8 or more. " Ina pr•opina optional de 18X ser ~iyregada pare grupos de 8 o may. ~ '~ ` , Aoc nt Fte Ea Char ed - Letter of Adm or est circle one) ~+ , O D Value of Estate K "?_ ate ~tf Lion Sheet n/c , Photo ID Q n/c ,~' ~ n11 '~ ,..> r / - 1.00 . C of Will n/c ., ,r r ~" ', ~',ofidi~cil / / 1.00 Death Certificate vw.,rlno~ Yes No ~ n!c -' Renunciation '•"" g ~.: Bondwaiver/Adm- roved n/c ~w,.. ~. ,~ »~.~" e ,~~ `~ . ..~. ~:.__..._e n/c .r I~.J1J "" .~~ p y~, ~ ~~ ~ ~ a.'~~ - Automation Fea 5.00 5.00 x `~ ~.' TOTAL Attorne Email: Notes: Delive Waitin Mail to Personal R resentative Mail to Counsel Call for Picku 717- Prothv Box ~... ~` ~--~ penn~,rlvan~a DEPARTME. N.T OF PUBLIC WELFARE August 8, 2011 KAREN J REIGLE 4614 SPRING RD SHERMANS DALE PA 17090 Re: Edith Sherick CIS #: 960204578 SSN: ###-##-8686 Date of Death: 11/18/2010 Dear Ms. Reigle: Please be advised that the Department of Public Welfare is attempting to recover the monetary value of any and all eligible assets in the subject estate. Although the amount in the estate may be considerably less than that which is owed to the Department, our claim is against the estate, no one else. Your responsibilities, as the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to insure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. The Department of Public Welfare maintains a claim in the amount of 5140.903.24 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely 57.851.18, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, anal Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely 5133.052.06, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment and a current appraisal, if available. Sincerely, ~ x Nathan L. Snyder TPL Program Investigator 717-772-6266 717-772-6553 FAX Enclosure Bureau of Program Integrity I Division of Third Party Liability ~ Recovery Section PO Box 8486 I Harrisburg, Pennsylvania 17105-8486 a r~ .¢W.I .~ ~ ~~O N~ ~N , ~~ ~ ~o y n O O ;` 7 .xZ l'i- d C `J _... n ~U~ _~ N ~~ ~;....; ~,. ~ ... ca ~~ -~ ~ m Q ~ I'' ^3 \~ ~TrnQ~' V r Q a a ~, m~ m W c ~ ~ a~ ~ m c ~ ~~ m Yvai