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HomeMy WebLinkAbout09-27-111505610140 REV-1500 EX ~°~-,°> PA Department of Revenue Bureau of Individual Taxes OFFICIAL USE ONLY PO BOX 280601 INHERITANCE TAX RETURN Coun Code Year File Number Harrisbur , PA 17128-0601 RESIDENT DECEDENT ~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYY`fY Date of Birth MMDDYYYY 1 8 5 2 2 3 5 9 7 0 7 0 1 2 0 1 1 0 2 1 9 1 9 2 7 Decedent's Last Name D E ~ A Suffix Decedent's First Name P U A MI M I L D R E D E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE FILL IN APPROPRIATE OVALS BELOW REGISTER OF WILLS 1. Original Return ^ 2. Supplemental Return ^ ^ 3. Remainder Return (date of death 4. Limited Estate ^X 6. Decedent Died Te t ^ 4a. Future Interest Compromise date of death after 12-12-82) ( Pnor to 12-13-82) ^ 5. Federal Estate Tax Return Required s ate (Attach Copy of Will) ^ 7. Decedent Maintained a Living Trust 0 ^ 9. Litigation Proceeds Receiv (Attach Copy of Trust) ed ^ 10 S 8• Total Number of Safe Deposit Boxes . pousal Poverty Credit (date of death between 12-31-91 and 1-1-95 C ^ 11. Election to tax under Sec 9113 A ORRESPONDENT -THIS SECTION ) MUST BE COMPLETED . ( ) t Name . ALL CORRESPONDENCE AND CONFIDENTIAL TAX INF ORMATION SHOULD S U S A N H BE DIRECTE Daytime Telephone Number D T0: C O N F A I R 7 1 7 ~~ 3 1 __ 3 8 3 _,_ ~ ~ REGISTER ~ USE ONLY ~ First line of address ~' (` 2 3 3 1 M A R K E T 7 + ~ ~~~_ `~ `' ~- Second line of address S T R E E T 1, :~ `,-; ..,-, _ ~ __ ~~- f ~~ City or Post Office ~.- ~, ~ ~ =; / C A M P H I L L State ZIP Code i_____ _ .DATE FILED __ _ P A 1 7 0 1 1 Correspondent'se-mail address: SCONFAIRaREAGERADLERP C•COM Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and it is true, correct and complete. Declaration of preparer oth t s atements, and to the best of my knowledge and bell er than the personal representative is based on all information of which SIGNATURE OF P RSON RESPON E FO ef, RETURN preparer has any knowled e. g 4DDRE r~ DATE 1049 COUNTRY CL B ROAD SIGNATURE OF PREPARER OT ER THA~REPI ADDRESS 2331 MARKET STREET L 1505610140 CAMP HILL PLEASE USE ORIGINAL FORM ONLY L L Side 1 O! PA_ 1~1 DATg PA 17011 1505610140 J ~~~ 1505610240 REV-1500 EX Decedent's Name: M I L D R E D E. D E C A P U A Decedent's Social Security Number RECAPITULATION 1 8 5 2 2 3 5 9 7 1. Real Estate (Schedule A) .. , , . .... ..... ............ 2. Stocks and Bonds (Schedule B) .. , , ...... 1. • 3. Closely Held Corporation, Partnership or Sole-Proprietorshi 2 • p (Schedule C 4. Mortgages and Notes Receivable (Schedule D) . , , , . ) ... 3 p 5. Cash, Bank De osits and Miscellaneous Personal Pro ert p y (Schedule E) 4 • .. 6. Jointly Owned Property (Schedule F) 7. Inter-Vivos Transfer Reque t & ^ . , , 5 s s ed ... Miscellaneous No (Schedule G) n-Probate Property ^ Separate Billing Re ... 1 8 ~ 6. 8 8 5, 0 5 quested ... $. Total Gross Assets (total Lines 1 through 7) . , . ..... .. . ... 9. Funeral Expenses and Administrative Costs (Schedule H) .. $ 1 8 8 8 $ • 0 5 , . 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) . 9 1 0 0 6 8 • 2 2 . ...... 11. Total Deductions (total Lines 9 and 10) .... . ..... ...10. 1 8 2 7 2. 2 3 .................. 12• Net Value of Estate (Line 8 minus Line 11) ...11. 2 8 3 4 0 • 4 $ 13• Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made S 12 _ 9 4 5 5 • 4 0 ( chedule J) , , . . ....... .... ..... 14. Net Value Subject to Tax (Line 12 minus Line 13) ..13. • .... . ............ TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE 15. Amount of Line 14 taxable RATES .. 14. 9 4 5 5 4 0 at the spousal tax rate, or transfers under Sec. 9118 (a)(1.2) X .0 _ 16. Amount of Line 14 taxable 0 0 0 15 at lineal rate X .0 . 0 . 0 0 17. Amount of Line 14 taxable 0 ' Q ~ 16 at sibling rate X .12 0 . Q ~ 18• Amount of Line 14 taxable 0 ' 0 0 17 at collateral rate X .15 . 0 . Q 0 0 . 0 0 19. TAX DUE .... ...... 18. Q . 0 0 . ................. ............. 19. 0. 0 D 20. FILL IN THE OVAL IF YOU ARE REQUESTING A RE FUND OF AN OVERPAYMENT Side 2 1505610240 1505610240 REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME 0 0 MILDRED E._DECAPUA --- STREETADDRESS --- ------------ - ------___ -------- ------- ~0 MT. ALLEN DRIVE CITY MECHANICSBURG _ --- _ ~ STATE Tax Payments and Credits: i PA ~• Tax Due (Page 2, Line 19) 2• Credits/Payments A. Prior Payments (1) B. Discount 3. Interest Total Credits (A + g) (2) 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. (3) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (4) (5) Make check payable to: REGISTER OF WILLS, AGENT ZIP 17055 0 0 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" I 1. Did decedent make a transfer and: N THE APPROPRIATE BLOCKS a. retain the use or income of the property transferred; .... • • •... • b. retain the right to designate who shall use the ro rt transferred or its income; Yes No c. retain a reversionary interest; or ...,•,•...•• p ~ y d. receive the promise for life of either payments, benefits or care? ••••••• ••••••••'•""•~~~~•••••~•• ^ X^ ...................................................... ^ a 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ...••••••• 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? 4. Did decedent own an individual retirement account, annuity or other non-probate roe ^ ^ ......... ^ 0 contains a beneficiary designation?..__ P P dy, which IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHE ^ a For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate ' DULE G AND FILE IT AS PART OF THE RETURN. 3 percent [72 P,S. §9116 (a) (1.1) (i)]. imposed on the net value of transfers to or for the use of the survivin For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to 9 spous [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax filing a tax return are still applicable even if the surviving spouse is the only beneficiary. or for the use of the surviving spouse is 0 percent and the statutory requirements for disclosure of assets any 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 oun e adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. ~ The tax rate imposed on the net value of transfers to or for the use of the decedent's li y g r at death to or for the use of a natural parent, an 72 P,S. §9116(1.2) [72 P.S. §9116(a)(1)]. Heal beneficiaries is 4.5 percent, except as noted in The tax rate imposed on the net value of transfers to or for the use of the decedent' ' Section 9102, as an individual who has at least one parent in common with the decedent, whether b s siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, unde y blood or adoption. REV-1509 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT STATE OF: SCHEDULE F JOINTLY-OWNEp PROPERTY MILDRED E. DECAPUA FILE NUMBER: If an asset was made jointly owned within one year of the decedent's date of death, it must be re orted SURVIVING JOINT TENANT(S) NAME(S) P on Schedule G. A. LINDA 0 • ADDRESS RHEN 1049 COUNTRY CLUB ROAD ^^ CAMP HILL, PA 17011 B. C. DAUGHTER TO DEC JOINTLY-OWNED PROPERTY: ITEM LETTER DATE NUMBER TENANT JOINT FOR JOINT MADE INCLUDE NAME OF FINANCIAL NSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD RE/1L ESTATE. ~ • A• 9/2002 PSECU - SAVING S PO BOX 67013 2. HARRISBURG, PA 17106-7013 A• 9/2002 PSECU - VACATION PO BOX 67013 HARRIIBURG, pA 3' A• 9/2002 PSECU 17106-7013 - CHRISTMAS PO BOX 67013 HARRISBURG, pA 4' A• 9/2002 PSECU 17106-7013 - CHECKING PO BOX 67013 HARRISBURG, pA 5' A• 9/2002 PSECU 17106-7013 - MONEY MARKET PO BOX 67013 HARRISBURG, pA 6' A• 9/2002 PSECU 17106-7013 - CD ATE OF DEATH VALUEOFASSET 2,532.70 .19 .46 0,790.09 3,219.52 OF DECEDENT'S INTEREST 50• 0. 0' 0' 0• ATE OF DEAT VALUE OF DECEDENT'S INTEr 1,266•_ .~ .2 ,395.0' 1,609.76 PO BOX 67013 HARRISBURG, PA 1X106_7013 1,226.12 50. 613.06 TOTAL (Also enter on Line 6, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. 8,885. REV-1511 EX+ (1D_09) Pennsylvania DEPARTMENT DF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MILDRED E. DECAP(1A SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS FILE NUMBER Decedent's debts must be reported on Schedule I. u 0 ITEM NUMBER A' FUNERAL EXPENSES: DESCRIPTION ~• MYERS-HARNER FUNERAL HOME, INC. AMOUNT 2' FLOWERS AND TWO MASSES - GOOD SHEPHERD CHURCH 8,50: 6- B' ADMINISTRATIVE COSTS: ~ • Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ___ ZIP Year(s) Commission Paid: 2• Attorney Fees: R E A G E R 8 ADLER, pC 3 Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant 1 ~ 500.0 Street Address City Relationship of Claimant to Decedent State _~ ZIP 4' Probate Fees: 5. Accountant Fees: 6' Tax Return Preparer Fees: 7. If more space is needed, use additional sheets 0 paper olf the sameosi elne 9, Recapitulation) a 10,068.22 REV-1512 EX+ (12.00 Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MILDRED SCHEDULE I MOR GAGEE L ABILITIE3ENT, 8 LIENS ~• UtCAPUA Report debts incurred by the decedent prior to death that remained u FILE NUMBER ITEM 0 0 NUMBER npaid at the date of death, includi 1. 2. 3. 4. 5. 6. 7. ng unreimbursed medical expenses. MEDICAL CARE DESCRIPTION - CAPITAL AREA HEALLH VALUE AT DATE ASSOCIATES * OF DEATH NURSING HOME - MESSIAH VILLAGE * 15~ CAREGIVER - NANCY KEHLER MEDICATION - ALERT PHARMACY FUNERAL FLOWERS - LINDA RHEN KNEE BRACES - CARING HEALTH CARE STORAGE UNIT - CAPITAL AREA STORAGE ~* TRANSFEREE HAS PAID THE DEDUCTIBLE ITEMS FRO ACCOUNT, THEIR ARE NO OTHER ESTATE ASSETS F'RO THE DEDUCTABLE M THE JOINT ITEMS. * M WHICH TO PAY If more space is needed, insert additional sheets~OrAe samse sizeter on Line 10, Recapitulation) $ ,272. 16,476 200. 40. 410.0 14 4 . y, 848.85 REV-1513 EX+ (p1.10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: SCHEDULE J BENEFICIARIES -" ~• llECAPUA -~ NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PRO PERTti' I. TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfer,; and 1. Sec. 9116 (a) (1.2).] er LINDA 0. RHEN 1049 COUNTRY CLUB ROAD CAMP HILL, PA 17011 FILE NUM R RELATIONSHIP TO DECEDENT _Do Not List Tres+oer~~ AMOUNT pR SH OF ESTATE Lineal ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ggpVE ON LINE I II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN S 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. ELECTION TO TAX IS NOT TAKEN: I B. CHARITABLEAND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LIN If more space is needed, use additional sheets of Or REV-1500 COVER SHEET. P per of the same size. $ INVENTORY REGISTER OF WILLS OF cuMeERLAND COUNTY, pENNSYLVANI•A COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS File Number ~ ~ ~ ~ -~ ~~ Personal Representative(s) of the Estate of MILDRED E. DECAPUA deceased, depose(s) and say(s) that the items appearing in the following invento i and all of the real estate in the Commonwealth of rennsylvania of said Decedent that inventory represents its fair value as of the date of the decedent's death, and that D nclude all of the persona] assets wherever situate Commonwealth of Penns Ivania exce t that which a the valuation placed opposite each item of sai~. y p ecedent owned no real estate outside of the ppears in a memorandum at the end of this inventory. I verify that the statements made in this Inven- tory are true and correct. I understand that false state- ments herein are made subject to the penalties of ~ ~ ,` ' 18 Pa. C.S. ~_!.-~f1D 0 • RHEN - ~ § 4904 relating to unsworn falsification to authorities. Attorney -- (Name) SUSAN H• CONFAIR (Address) 2331 MARKET STREET (S'upremeCourtl.D. No.) 7024_ (Telephone) 717-763_ CAMP HILL 1383 PA 1701], DATE OF DEATH LAST RESIDENCE 7/1/2011 100 MT. ALLEN DRIVE M E C H A N I C S B U R G DECEDENT'S SOC. SEC. N0. PA 17055 185223597 FIGURES MUST BE TOTALED Stocks & Bonds r7 ~ _ ~, ,~- Closel ? ~ ' y-Held Corporation, Partnershi ` =c ~ \ .. ~r , p or Sole-Proprietorship ~ -1 cs .. Mort a ~ ,' 9 ges & Notes Receivable ~(: ""~ {~ _.~~ f _~_ Cash, Bank Deposits, g ~•~c Misc. Personal Property `` Real Estate (Attach additional sheets as needed) NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the clection of the TOTAL: item, but such figures should no[ be extended into the total of the Invento personal representative include the value of each Form RW-09 rev. rY~ (See 20 Pa. (,. S ~' 3301(b)) 10.13.06 - :.. L(,C,AL REGISTRAR'S CE:RT'IEIC~~.T(`~~,~ ~:"~= ~~,~- VVAIRNING: It is illegal to duplicate i~tt , `'ebb' i,y Tahvt Est: i -, ;, T, tr,q~~~~g~)~~. Fri Ian thl, rrrtrj,,~,il~~•. SiT.lh) P__1.7557344 ---_ REV 11/20D6 RINT IN ANENT K INK 1. Name d Decedent (First, mklae, feel, Mildred E. DeCa S. Age (Leal Birthdavl Ian Monms I Days Hour Minutes e Vrs. Bo. Count' of Death t tk. City, Born, Twp. of Deam Cumberland Upper Allen ~, rtu~ tit ~-~_ >, FL,, ~. ~a rr ~- ~~ ,t ~ i., . ~' A rK ' __ 9 ; • . ;;. I3 1 - July 1, 2~~1 1 0 __~ ~'~ -~-, ~,_ , . _ ~ ,, , '? ~~ "~ r ~ J (T.T r.,, -t 'rry~ ^-..I ` C. i~~~ _ COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF H r r EALTH • VITAL RECORDS sERTl nsCe ~ d e DE ~ (See tn n xa mp on reverse) STATE FILE NUMBER 2. Sex 315Ac~ Secunry N=ry~c Female ~zSS [2 3597 4 Dale of Death (Month, da , earl i. Date of Bidh (Month. tlav vane . _... 19 1927 ~Wilkensburo, pA Bo. Fadliry Name (II trot mstrtullon, gh'e street and number) MESSi V~°cr~ I U ER /Outpatient ^ DOA 9. Was Decedent of Hispank Ongi III yes, specmy Cuban, ,. ,t_~ , _. ',!iLa ursine Home U Residence ^Other ~ Specify No Q yes 10. Race. American Intlian, Black, WML 1 SpecilN Kits of Work Homemaker sy Kind of Busiryss ! IMustry Own Home IB Decedent's Mailing Address (Street, city I town, state, zp coda-~ 100 Mt. Allen Dr. Mechanicsburg, PA 17055 19. Famer's Name (Fret, midWe, last, suHU) 'Thomas A. Strobel 20a. Infomv3nl's Name (Type / PnnB Linda DeCapua Rhen 21 a. Methotl of DisposHion ^ Cremation ^ I)onaH 12. Was Decedent ever in the 13. Decedent's E--- Mexican, Pueno Rican, ek.l U.S. Armed Fomes? I3PeCify only highest grade compleletl) Elementary /Secondary (0-12 ^ Yea o 12 ) Collage (,.4 or h+) Decedent's Actual Rasidentt ,Ta. slate Pennsylvania Did Decec Live in a tTb.ca,nty Cumberland mwnship? Mildred E.~Bag 20b. InfonnanYS Maiing Atltlress (Street. cnv f i~ ^ AA Burial ~ Removal from State j W~ Cremsgpn or DonsUOn Aul n 21 b. Date of Disposition (Month, day, Year) 21c. Place of ~'''""d ~'~""yC0'011°rT~~OYeaONo July 9, 2011 Rolli 22a. al Futerel nice 226. Cherie Number 22c. Name end 014819 ~rB55 d FedI11yM Compete Items 23at only when wdHying 23a. To me best of m p75kien o trot availaby at tky d Beam to Y knowledge. tleam occurred el gy lime, date and pace staled ceniry woes d deem. ~ (Sipnalure erb Hllel Witlowetl, Divorced (Specify( marryo' I15. Surviving Spouse (If wile, give maiden name) Widowed n~ Yes, Decedent Lived in UDDer A11en I?d. ^ No, Decedent Lved within T' Adual Limqs of __ :ry Clu'b~Rd.,r Camp Hill, PA 17011 cemetery, crertyyry or other place) 21 d. Location (CHy /town, Male, zip code) Memorial Park Hill, PA net Funeral Home Number gems 24~ 23C. Date Signed IMOnth, tlav, y@ar) 26 must be competed by person 24. Time of Death w°w pmigegeg daaM_ L/ Jnq 25. Dale Pmwunced d ( , tlay, Year) " yr~ O I"I ~ ~ ~' C5 / ~ ! 26 Was Case R°terretl b Medical Examiner 1 Coroner Tor a Reason Other man Cremation or Donation? Item 27. Pan L Enter me dam of ewe CAUSE OF DEATH (See Inatructlone end examples) Q VBS h'"[' No k -diseases, injures, or wmpkaHons -mat direct reagralory arrest, or ventricular libritlation wHftout gfklWln thee' N waged the deem' W NOT enter larmktal events such as cardiac arrest, ~ ApDroximate interval: Pen II: Enter dher SionAwnt crud 9 6okgY, list only one wage on each line. Ilmet to Deets 2H. Did iobecco the Conlnbute to Deam? tWIEdATE CAUSE Final disease or i Cut not iewlting m the untlerying cats contligon reeAing 1° ~ml LL r e giwsn in Pen I. Q Yas Q prcpgbA, . -- a. 212/l)OYI~ ,L-1,/No D b (or as a consequence otJ r /L(.(~ ~s Q Unkrown SaQuentieguyy list wn611br13, q any, b. 29. II F ek: Iaa~rp b Ily wage uMetl on line a. ~ " / /T/-7 l(pj ~Q/.s n Ci -~ ~ EnUr 8ie UNDERLYING CAUSE Du° to (or es a consequence oR r .(,~ ~S' Not pregnant within pass year (dsaa or kryury Hal hiHeletl me events rewlting m deem) LAST °~ ^ Pregnant al bins of tleath r Due b (or es a consequertca oil: ^ Not pregrynl, but pregrianl within 42 days d. r _ of death ~8' W85 °n ~° r ^ Not pregnant, but pregnant 43 days to 7 year Pe °P°Y 306. Were Autopsy Findings 3I. M er of Deam t before death d0nn~~ Available Prbr to Complelkn 32a. Date of Injury (Month, day, year) 32b. Describe How In ^ Unknown II / of Cause of Death? Natural NrY iJcarratl pregnant within the past year s Fes' ^ H~b~ 32o Plac° of In1uN. Home, Farm Street, Factory, Q VB CCtt""" I'1o Q vas ~ ^ Acddent Q Pendng Investigation 32tl. Time of Inju OHice Buiklirg, etc. (Speciy) ry 32e. Injury al Work? 321. II Transponatbn Iniury /Spadly) ^ Sukide ^ CouM Nd be Determined 32g. Location of Inryry (Street, city I Iowa state) 33a. Gndyr (check only one) M. ^ Ves Q No ^ Drwer / Operelor Q Passeyer Q PedesMan Other ~ Spay/y~ • Grtifying physklan (Pnysiden wrolying rouse of loam when another phyMpan has pronounced deem aM competed Item 23) To tM eat of my Wowhdge, death occurred due to the cause(s) and manner u e 33b. Slpnature a Title of Ceniller • Pronouncing end ceNtying Phrikian (Physician bom pronouncin deem and cerH ~~ - - ""- ~ - - _ _ "'' _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ ~ ~~ To the hest of my krowkd g lying to cause d death) / ge, dam occurred at me lima, date, and plan, end due to the ceuse{a) end manner as saled_ _ _ _ ' Medksl Examlar / Caayr - Q 33c. Liwnse Number On the hate M exsminetlon end! or Investigatbn, In m - - - -"- - ~ ~ """' O 'L ~ t ~ .~ / 33d. Dal° Signed (Month, da , y opinion, death acumed N tly goy date, and place, and due to the cau 'l ] ~! ~ /~ y year) 35. Registrar's Signature and Dlsmcl Number a(U and manner a sMed_ ^ (/ 7 0 3 a0 ~~ 3q. e a A tees of Pe Co /7~ ~~ ~' , I ~ ( ~ ( / 38. Date FII (Man ,day, year) ~~ ~~ use al Death (M \iyp8/~ mT Jl . , r. 1 ' 1 _ ~7 6 /f /Lt~c~~-1~~1/rCS~3vs~G, ~PT /~i r (f/! ?0 ~~ / . ITL.(~/V Diepogiann Permit No. Oo10411 ATTORNEYS AND COUNSELORS A T L A W ?heodore A. Adler* David W. Reager Linus E Fenicle Thomas O. Williams John P. Neblett Susan H. Confair Wayne S. Martin, P.E.' Neely E. Meals Jay C. Whittle*** *Certified Civil Trial Specialist "Licensed to Practice in N.J. "Special Counsel September 26, 2011 Writer's Email Address: JGrossCa~ReagerAdlerPC coin C7 -}© ~: ~~ ,__ , ; Cumberland County Re ist f W -~_' ~..~ z~ -- = g er o ills 1 Courthouse Square _ --. ..,z - ' `~' `~ ~ ~~ _ - Carlisle, PA 17013 , , J-XJ ... ~ - ~ ._.~ . '} ~) RE: Estate of Mildred E. DeCapua ~.. ~ Our File: 07-561.001 Dear Sir or Madam: Enclosed please find the Estate Information Sheet, Death Certificate, Inheritance Tax Return, and Inventory for Mildred E. DeCapua. We will not be probating the estate as all the assets are 'oint so we will be filing Joint Assets Only return. Please provide a receipt for the filing. ~ Please contact me if require additional information or have questions. Verv truly yours, t r Gross Par legal Enclosures P R O ~ E N - _ __ R E S O _ - -- -- ---- -- -- __ U R C E S - --------- 2331 Market Street, Camp Hill, Pennsylvania 17011-4642 T: 717 763-1383 F: 717 730-7366 www.reageradlerpc.coin