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HomeMy WebLinkAbout12-12-11 (3)J 1505610140 REV-1500 ~` ~°'-'°) PA Department of Revenue OFFICIAL USE ONLY PO BOX 21$060dual Taxes INHERITANCE TAX RETURN County Code Year File Number Harrisbu PA 17128-0601 RESIDENT DECEDENT 2 1 1 1 1 0 2 9 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Deatli MMDDYYYY Date of Birth MMDDYYYY 1 7 4 0 5 1 7 6 5 0 9 2 2 2 0 1 1 0 8 2 3 1 '9 1 8 Decedent's Last Name Suffix Decedent's First Nanne MI B L O S E R R U T H (If Applicable) Enter Surviving Spouse's Information Below E Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE FILL INAPPROPRIATE OVALS BELOW REGISTER OF WII_L$ 1. Original Return 2. Supplemental Return ~ 3. Remainder Retum (date of death [~ 4. Limited Estate ~ prior to 12-13-82) 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required © death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Livin Trust (Attach Copy of Will) g -. 8. Total Number of Safe Deposit Boxes 9. Lftigation Proceeds Received ~ 10. Spousal Poverty Cred t (date of death ~ 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 M A R C U S A M c K N`I G H T I I I 7 ], 7 2 4 9 2 3 5 3 REGISTE~F WILLS USL'ANLY First line of address I R W I N 8 Second line of address 6 0 W E S T City or Post Office C A R L I S L E TIVE .t:; :- ~~~ -=~ Corr'espondent's e-mail address: Under penalties of pery'ury, I declare Utat I have examined this return, inGuding acx:ompanying schedules and statements, and to the best of my knowledge and belief, ft is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAnURE OF PERSON RESPON5I~LE FQR FILING RETURN 109 SUSA LANE SIGNATURE ~~ ADDRESS 60 WEST POMF RE L 1505610140 M c K N I G P O M F R E ` r ~ --- ~_~ 7 r~ , H T : -= ~r_ ~ - ~,.. _ :r: ~ ftii C -; C.'> ~ _.. .. ~' y rSil~ FILED S T R E E T State ZIP Code P A 1 7 0 1 3 ~`' LISLE CARLISL PLEASE USE ORIGINAL FORM ONLY Side 1 P C . PA 17013 DATE PA 1701 1505610140 J t~~ V r Ofi20'[9SOS'C Ofi20'L9SOS'[ Z aP!S 1N3WAtld213A0 Ntl d0 ONfld32! tl JNIlS3flb3Z! 321tl (1011 dl 'ItlAO 3Hl NI l"Ild •OZ .................~.............................. 3f1a Xtll '6l Q E •L Q fi 2 '[ ..... sl . 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Dh20'[9SOS'C REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 11 1029 RUT__ H E_Bl_OSE STREET ADDRESS 77o souTl-1 HAn cITY CARLISLE STATE: PA ZIP 17013 Tax Payments and Credits: 1 ~ Tax Due (Page 2, Line 19) 2. CreditslPayments ` A. Prior Payments B. Discount 624.37 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. (3) Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is tfJe TAX DUE. (4) (5) Make check payable to: REGISTER OF WILLS, AGENT ~1) 12 487.38 624.37 0.00 11 863.01 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" fN THE APPROPRIAT 1. Did decedent make a transfer and: E BLOCKS a. retain the use or income of the property transferred; Yes No ................................. b. retain the right to designate who shall use the property transferred or its income; c. retain a reversions interest, or """"""••••°•••••••••••~• ^ ry ' d. receive the promise for life of either payments, benefits or care? .. ~ • ~ ~ • ~ ~ ~ ~ ~ ~ ~ ~' ................. X 2. If death occurred after December 12,1982, did decedent transfer ro ^ without receiving adequate consideration? P PertY within one year of death 3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her de.ath~ X 4, Did decedent own an individual retirement account, annuit or other non- rotate ro .•.~~~•~~ ^ a y P P Percy, which contains a beneficiary designation? ................... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE C AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use 3 percent [72 P.S. §9116 (a) (1.1) (i)]. of the surviving spouse For dates of death on or after Jan.1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adopfive 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 lineal beneficiaries is 4.5 percent, 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 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, undE Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-15DB EX + (f>-98) COMMONWEALTH OF PENNSYLVANIA • INHERITANCE TAX RETURN RESIDENT DECEDENT .a i a rE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY tUTH E. BLOSER FILE NUN InGude the proceeds of litigation and the date the proceeds were received by the estate.l All property jointly-owned with fight of survivorship must be disclosed on Schedule F. ITEM NUMBER ~~ CITIZENS BANK -CHECKING ACCOUNT #6225745398 2• JEWELRY VALUE AT DATE OF DEATH 98, 361.71 158.80 3. (PERSONAL PROPERTY -SETTLEMENT STATEMENT ATTACHED TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 809.50 1 REV-1509 EX+ (Ot-10) ' pennsylvania DEPARTMENT OF REVENUE • INHERITANCE TAX RETURN SCHEDULE F JOINTLY-OWNED PROPERTY ~~~ ~wo~u~n. RUTH E. BLOSER 21 11 1029 If an asset was made jointly owned within one year of the decedents date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. JUDY D. KRONHEIM 109 SUSAN LANE DAUGHTER CARLISLE, PA 17013 i3. C. JOINTLY-0WNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FQRJOINTLY-HELD REAL ESTATE. ~• A. CITIZENS BANK CHECKING ACCOUNT #6100735850 ~o OF DATE OF DEATH DATE OF DEATH DECEDENTS VALUE OF VALUE OF ASSET INTEREST DECEDENT'S INTEREST 4,422.18 50. 2,211-09 TOTAL (Also enter on Line 6, Recapitulation) I $ 2 211 09 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) . Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT 0 SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER RUTH E. BLOSER 21 11 1029 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMANwROTH FUNERAL HOME 8,620.28 2. CUMBERLAND VALLEY MEMORIAL GARDENS 1,819.00 3. WENGER MEATS & ICE -FUNERAL LIJNCHEON 453.56 B. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: State ZIP 2, Attorney Fees: IRWIN & McKNIGHT, P.C. 3. Fatuity Exemption: (If decedents address is not the same as claimants, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4• Probate Fees: REGISTER OF WILLS 5 Accountant Fees: 6. Tax Return PreparerFees: PATRICIA A. ROSENDALE, CPA 7. REGISTER OF WILLS -FILING FEE 8. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 9. THE SENTINEL -ESTATE NOTICE 10. POSTAGE 11. APPRAISAL ON JEWELRY 12. BANK CHARGES -CHECKS/SERVICE CHARGES 13. ROWE'S AUCTION -COMMISSION 5,750.00 257.50 375.00 30.00 75.00 189.54 8.80 25.00 34.22 323.80 TOTAL (Also enter on line 9, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. 1.70 - - ~ REV-1512 EX+ (12-OS) . Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS CJ I A l t Ut ~ FILE NUMBER RUTH E. BLOSER 21 11 1029 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. CITIZENS BANK -CREDIT CARD 18 79 2. CUMBERLAND GOODWILL FIRE RESCUE EMS -AMBULANCE 82.80 3. MILLENNIUM PHAR SYS. -MEDICAL ~ 228 58 TOTAL (Also enter on Line 10, Recapitulation) I $ 330 17 If more space is needed, insert additional sheets of the same size. REV-1513 F,(+ (01-1 D) Pennsylvania SCHEDULE J DENARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: RUTH E. BLOSER .,. ., ,, ,,,,.,,, ~~ ~~ ~~~y 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 outs' ht spousal distributions and transfers under Sec. 911"6 (a) (1.2).] 1. JUDY ANNE KRONHEIM Collateral 83,249.23 109 SUSAN LANE 22% REMAINDER CARLISLE PA 17013-1066 2. CYNTHIA MAE VANCLEAVE Collateral N80 W14207 CAMPUS COURT 21% REMAINDER MENOMONEE FALLS, WI 53051-3901 3. KENNETH G. DILLER Collateral 109 SUSAN LANE 21% REMAINDER CARLISLE, PA 17013 4. MICHAEL C. BOYD Collateral 5311 VERA CRUZ ROAD 8% REMAINDER CENTER VALLEY, PA 18034 5. GARY L. BOYD Collateral 12 BERRY ROAD 8% REMAINDER MARLBORO, NY 12542 , 6. STEVE BLOSER Collateral 150 BARNSTABLE ROAD 1% REMAINDER CARLISLE, PA 17015 7. THOMAS BLOSER Collateral 210 BARNSTABLE ROAD 1% REMAINDER CARLISLE, PA 17015 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18 OF~ REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: Y 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space Is needed, use addlwonal sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent RUTH E. BLOSER Decedent's Name Paae 1 21 11 1029 C:1.. Al. ~rhL~c• Schedule J - Beneficiaries -1 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [Indude outn'ght s ousal distributions and transfers under Sec. 91 i6 (a~(1.2).] 8. SCOTT KRONHEIM Collateral 194 SKYLINE VIEW 3% REMAINDER CARLISLE, PA 17013 9. DEBORAH WOLFE Collateral 5508 BEARCREEK DRIVE 3% REMAINDER MECHANICSBURG, PA 17050 10. LINDA KRONHRIM GAUVRY Collateral 216 N. 25TH STREET 3% REMAINDER CAMP HILL, PA 17011 . 11. KAREN VANCLEAVE Collateral 3083 REBEL DRIVE 3% REMAINDER SUN PRAIRE, WI 53590-4262 12. EMILY VANCLEAVE HARDY Collateral 11232 N. JASON DRIVE 3% REMAINDER DUNLAP, IL 61525 13. LISA VANCLEAVE OLSEN Collateral 1445 CONE FLOWER LANE 3% REMAINDER SHAKOPEE, MN 55379 ` Last Will and Testament of Ruth E. Bloser I, Ruth E. Bloser, of the Carlisle, County of Cumberland and Commonwealth of Pennsylvania, being of sound mind, memory and understanding, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking any Will or Codicil heretofore made by me. FIRST: I direct my hereinafter named Executrix to pay all of my just debts and funeral expenses as soon as conveniently possible after my death. SECOND: I direct my hereinafter named Executrix to sell any automobile I own on the date of my death as well as my real estate consisting of house and lot situate at 135 Heron Way, Cazlisle, Pennsylvania, at the fair market value on the date of my death, and I then give and bequeath the net proceeds from the sale of my said automobile, real estate, and all the rest, residue and remainder of my property, whether real, personal or mixed, of whatsoever kind and wheresoever situate as follows: 1. Twenty-two (22%) percent to my niece, Judy Anne Kronheim, 2. Twenty-one (21 %) percent to my niece, Cynthia Mae vanCleave, 3. Twenty-one (21 %) percent to my nephew, Kenneth G. Diller, 4. Eight (8%) percent to my nephew, Michael C. Boyd, 5. Eight (8%) percent to my nephew, Gary L. Boyd, 6. One (1 %) percent to my nephew, Steve Bloser, Ruth E.. Bloser LIIJl1m111J ULI l1lJ~Nl1t1UULll1 ~:LIIIUUIllILi tJLI lJl1lIIJ 4 2 el1111111111111111111ll1U llUllUll~ll U1111U11Ulillli U•: i8 2 3 2 U 5 7011 645„ 3 i56 • 7 7. One (1 %) percent to my nephew, Thomas Bloser, 8. Three (3%) percent to my great-nephew, Scott %ronheim, 9. Three (3%) percent to my great-niece, Deborah Wolfe, 10. Three (3%) percent to my great-niece, Linda %ronheim, 11. Three (3%) percent to my great-niece, Karen i~anCleave, 12. Three (3%) percent to my great-niece, Emily YanCleave, 13. Three (~%) percent to my great-niece, Lisa [~anCleave. THIRD: I hereby nominate, constitute and appoint my niece, Judy Ann Kronheim, Executrix of this my Last Will and Testatment and, in the event that my niece, JudyAnn %ronheim, does not survive me, I hereby nominate, constitute and appoint my niece, Cynthia Mae YanCleave, and my nephew, Kenneth G Diller, or the survivor, Executors of this my Last Will and Testament. None of my hereinbefore-named Executors shall be required to post bond. IN WITNESS WHEREOF, I, the said Ruth E. Bloser, have hereunto set my hand and seal to this my Last Will and Testament, which consists of two (2) pages, to each of which :[ have affixed my signature this ~U~ day of , 2009. ~~~~ __ Ruth E. Bloser Ruth E. Bloser 2 l1UlJmtltl lllJ l1lI~LILIl1lIUU ~:I111tll1L1llU LILI UlllJll 4 2 el1UlJ ULIIIlIUtlllllll LILIULIU~tI IIIJIJUl1UUlll1 U•: L8 2 3 2 U 5 70~ 645.3156 ~, . Signed, sealed, published and declared by the above named testatrix as and for her Last Will and Testament, in the presence of us, who at her request and in her presence and in the presence of each other, have hereunto subscribed our names as witnesses. ~ ~ ~ 7 ~ ~~ ~~~.. ~. `~~~~`~ ~ of ,.,fin f'!~ /' ~'~ 3~- ~ ~ P ~'9(~ -2t~u~v /,f23~ of Ruth E. Bloser 3 UUUmUU UU LIUN^UUUUUU ^:000UUUU UU UUUU 4 2 2000 UUUUUUUUU UUUUVUU UUUUUUUUU U~: i8 2 3 2 U 5 70U 645^^3i56 Citizens Bank' October 19, 2011 Attorney Mazcils A McKnight, III West Pomfret Professional Building 60 West Pomfret St Cazlisle PA 17013-3222 Estate of RUT)=I E BLOSER Date of Death: Sep 22, 2011 SSN: 174-05-1765 Dear Sir/Madam: One Citizens Drive ROP112 Riverside, RI 02915 ~~CEIYE~ OCT 2 4 2011 IRWIIV & McKflIGHt UIW OFFICES In accordance with your request, the attached information sheet has been provided in the above decedent's name as of his/her date of death. Account ending in 5850 has been jointly owned since 4/2002 per our records, due to our seven yeaz retention period, we are unable to provide information prior to this date. For Installment Loans or Line of Credit accounts, contact our Loan Department at 1-800-708-6680. For all other inquiries, please call 1-877-579-2667, option 2. Sincerely, Pamela Breton Decedent Account Processing REF#: 516154 • Citizens Bank, Account Number 6225745398 Account Title RUTH E BLOSER Date ened 2/17/2010 Account T e Checkin Princi al Balance as of DOD $98348.78 Interest from Last Postin to DOD $12.93 Account Balanlce as of DOD $98361.71 YTD Interest to DOD $64.86 '~' Citizens Bank Account Number 6100735850 Account Title RUTH E BLOSER/JUDY D KRONHEIM Date ened 6/6/1966 Account T e Checkin Principal Balance as of DOD $4422.C-5 Interest from Last Postin to DOD $ .13 Account Balance as of DOD $4422.1 g YTD Interest tb DOD $3.41 r hnathcim, Jud> I U9 Susan Ln larlisle. I'A 17(113-1066 Ph~me:717-249-7G89 (ktIR.2PIE 2032R2 1.0 SERV-77 estate sort thru MC~~l~1TZ J E W E L E R S Krcxthcint..1udy IU9 Swan I.n Carlisle, 1'A 171J13-I(JGG Phonc:717-244-7GR9 Immuliatc AR MasterCard 058470 Signature: ($25.00) 1 .2~'~ J~ fl•) v, ,. ~t `~ ~~ b ~ ~ ~;,r ~ } i;; ~ ~. ~+ v~ ; ~~ ~ ~ti ~ Bub Total: Shipping: Tax: 3780 Trindle Road • Camp Hill, PA 17011 • 717-763-1199 Total: 1160 Walnut Bottom Road • Cazlisle, PA 17015 • 717-243-493Cpayment: 4520 Jonestown Road • Harrisburg, PA 17109 • 717-545-7508 13aluncc: ~i~ ~1' AR $25.00 $25.00 $25.00 50.00 50.00 525.00 ($2.00) 50.00 ~ ~i,~ ~~I' Date : 11 -'^c5--~~ 11 00:23:58 er^v i ce Rowe" s Auction S ti ~`~r-~ E7? 9r~ 1 ~ ~ , 6 717-2 ~4 1 '3 7 8 97-47534 www. r^owesauctionservire. com Settlement Judy Kronheim 717-F?49-7689 Seller: 3 1053 S+.isan Lane CZr-lis].e PA 17013 Item Description price Qty •- BL - big wine bottle 1 - BL - sewing box/crocheting 1 - BL - ~ totes 1 - BL '- jewelry (CH) i?5.0O 2 - DL •- household lot/birds i - BL - cedar boxes/Buddas 1 - BL - pillow/blankets 1 •- BL - fleece blankets 1 - BL -• lamps/magnifier ~'** Not sold **~• -- BL - vase *** Not sold ~••~•~ ~- BL purses i -• BL - totes (CH) 6.00 4 - Charm bracelets 1 - Sterling jewelry lot 1 - Steif dogs i - Cast Iron Building Bank i - Jewelry lot 1 - Decorated plank bottom 1 chair '- ratDOl 1 - Apt. refrigerator- 1 - Oak stand 1 - Hitchcock style stool 1 - Depression dresser 1 Commission at 40.0O0X Items: 23 Amount: 323. 80 Less adjustments: Net due t;o seller: page: 1 Total 30. 00 4.00 10. 00 50.00 1.00 6.00 7. 00 2. 00 3.00 24.00 240.00 120. 00 60.00 35.00 530. 00 5. Q~Q~ 5. 0$ JJ. 00 20. 00 20.00 ~2. 50 809,50 -323.80 485,70 Thank you for^ your^ business Rowes Auct;ion! • RO~WE'S AUCTION SERVICE (RH 79L) 2505 Rimer Highway • Carlisle, PA 17015 Bill Rowe (AU 15380 249-1978 215-1044 5?x1.1008 Dave Rowe (AU 2296L) Auction Is Action Call "Rowe" For Satisfaction f~, ~~ SELLERS NAIdE ~ ~ i-- (,~~ ~ ~ !-c3 'r' - •' ~ _ DA (TE _ ~.(~ ~~'~ ,"~ ~ ADDRESS ~~1 ~ ~~ ~~r ,L.._, l~. ~t1~ ~~ ~c~ ~,~ PHd~E T 1 ~ ~~~ ~/ ~ 7~ ~~ OTHER AUCTION DA't'ElLOCATION AUCTIONEER % ~.~._ . CLERK % DESCRIPTION OF MERCHANDISE --~ ~..+~-~ -- ; ~,- ~~~ „L ~/ ~~ Aar, ~'~, _< I Commission t)~e Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise to be sold as is ~$ grwped as necessary to obtain bids. I certify that I am the owner or authorized repnasen- tative of the me~cchandise, goods and or property and have good title and the right to sell and that they are free from all incumb#anc:es. I agree to acxept aA responsibility for providing merchantable title and for delivery of title to the purcf-aser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in this agree n i i ,-~ , AU ON SIGNATURE ~ LLERS SIGN TURE Total Sales (Clerking Tickets Attached) S _~9' S~ -" Less Sale Eape~se: ~m ~ ~ % Commission Auctioneer ~ ~ 1. 33 -- Commission Clerks S OTHER.: l~ 1a,~.~c.~...Rr-' L sue, ~..=~ ~-m TOTAL SALE ~XPENSE DEDUCTED S 8 ~ 8 l ~t :~„/ (/ ~`~' i. -/ f^ `d- SELLERS NETS 4Z o =-' FUNERAL HOME Sr CREMATORY, INC Judy Kromheim 109 Susan Lane Carlisle, PA 17013 Statement of Funeral Expenses for: Ruth E. Bloser 219 North Hanover Sheet Codi~e, Pennsylvania 17013 717.243.4511 toll free 1.866.451.4511 fax 717.243.3723 www.tx~ifrrarroih.oa~n info®hoffmcx'roih.oom October 13, 2011 Date of Death: September 22, 2011 Account Id: 16341-204 PACKA E: Traditidnal Funeral Service TRADi~'IONAL FUNERAL SERVICE PACKAGE $ 4,650.00 Sub Total: $ 4,850.00 MERCHIq~NDISE: Caskef: Montgomery $ ;3,365.00 Sub Total: $ 3,365.00 TOTAL F?UNERAL HOME CHARGES: $ 8,015.00 CASH ADVANCES: 10 Cert~ed Death Certificates at $ 6.00 each $ 60.00 Newspaper Notice -Sentinel $ 193.28 Clergy $ 100.00 Flowers $ 212.00 Hairdresser $ 40.00 Sub Total: $ 805.28 Total Funeral Expense: $ 8,820.28 Total Payments Made: $ 8,820.28 Payments Made: Estate O( Ruth Bioser Check 103 Oct 13, 2011 8,820.28 Please return this portion with your Remittance. $ Amount Enclosed Ruth E. Moser Service ~D#: 16341-204 Balance: ;& 0.00 SERVING OUR COMMUNITY SINCE 1 907 ORICa1NAL 2861 ACCT. NO. .lieOeGL• e6~b~Ik' Funeral Services ~ ~ ~ ~x1 Name of Deceased (] CREDIT l~nerel Home & C~e~oatory. Inc. CARD ^ OTHER LAST BALANCE $ $~/ Q~O~ IrrrERESr ^ IeTTE PAYMENT CtlABSiE SUB TOTAL CREDITS LESS PAYMENT ~~p~_ ~~-- NEW BALANCE $ / Q ..~~ 16585 e v M o a Q ~.~' s ~~ ~'~ ~~~ ~IV A ~z~ ^h ~h~ -t 7_~ V~ `i~~GG~4AA .. G_ -C ~ ',, "~ ~ ~ ~ ~ ~~~~ ~~' ~~.a o~~.~~ ~U C q ~ a~ ~~~~ ,~ ~ h O ~ ~ `'' ~g~ ~ ~~E~~ a~ r~ ~~~i~°.. ~~ ~~~~~ O ~ ~ ^ c~ ~~ ~. ~^ i u '~ /$Qi ~ ~. _ N 4 ~+ ^~G N ''W ~~~ ~~ ^ U° ,~ °~ o F~ ^ ^ `~ ~~~ ^^~ ^p + y ~, o s o \:'~ ~~ ~pp a~ .A s h b ~y .~ ~ :~ ^ h ^~ ~i~~ F-1 ^ ~ u ~~ ^^ ~~ III ;~~., '{7 v 41 a~z~ - ~ ! 1 ~ n i; 3 ~ ~ ~~ ~ `, ~ t ' l4 K d9 Vi 69 f9 i9 i9 69 6y 1 I I I ~ c~~ ~~ ~ ~ ~' ~~ a ~~ .~ as-~,- i 0 ~ ~ ~' ;ob ~ ~ .. ~ ~ ,,. ~ I a ~~~ ~, U'°is~~ ~ a',~ Hi ~a~~~ ~ ~.~ ~' O aav~z°°~ O ~ ~' ~~ .~ .~ . ~ o ~~ ~ ~' ~ ~' z 0 ~~ n .,i ~. G~ r., t ~;I '~r ~" ~~ L ~~ '~ ~~ ~~ ~ ,~~~~ ' ~ ~ N . N .-y v ~ ~~~~ ~ r+ M O ~ ~~~ ~~ ~f ~, ~b~b F O F+ ~~ F ~ OCt U ,~ R. F .~.J ~N.+ .-....-. vvv V ~~ ~~ a .~ s a 0 .~ a .~ 0 ~~ o~ '~ d ~ .~ ~~ ~'~+ ~~ ~~ ~~ ~~ N v ~~ o ~ ~ I I I I `•~ ~ ~ w ~1 A ~~' ~ ~q ~ ^ ~ Zi ~ ~ ~ A VI ... ~ I I ~ ~ N H ~C ~ ~ ~ U ~ ~ ~~ ~ ~ A4 0 ~ '~ O U ~ ^ ~ ~ pC U :3 I e3 A ~ ~; ~, r ~ k i~ s i -~ ~~ ~ ~. ~ '~ i~' ~ ~~ ~~ ~~ ~, ~. ~s N ~~. ~ w ~~ I~~ .~ ,~ i i ~ '~ i~ i~ ~ ~ o ~ d~ ~ ~ .g c $~, ~~ n .~ ,~ o o ~ ~ w ~ ~ ~ ,g b ~~°a p t ~~,~ . 0 ~w~ b,~ ~ ` ~ s .~ ~ ~ ~~ ~~ ~~ ~~ ~b a ~ ~~~ a ~~~ ~ ~~~ ` s E ~ ~'~ z ~~ . ~~ ~~ W °°°~~ m ~ ~~ ~~ W3 ~ '~~ ~~ .. ~~ ~ W V ~ ppW~y~. ypC~ O O U ~~ ~~ O P4 ~ aO i~ QO F ~~ UO ~~ .~ ~~' ~i E ~ c .~ c ~°~~ ~~~~ C'~ ~~a ~~ ~~,~ w~~~ ~~ ~~Q ~ z ~. o o H~~ a ~.~~ ~ C ~ ~ ~ ~~~'o~ ~'~z~ ~~~ .~ ~_ o ~ ~ ~~~~0 ~~ o~~OZ° 0 0 '~ ~ ^, s s ~. ^~ C s .gam ~. .~ C~ ~ U .,.~. ~~ ~ ~_M b^ ~`,~~ ~ '.: ~`~ . ~ ... ~ ~. '': ~ ~ ~ ~.~~ s~ ~~~° ~~ ~~ ,~ . o o ~ ~ ~~~~ ~ ~~o.~ ~ ~~ ~~ g }~~ ~ ~ ~~ ~~~ a ~`~~~ 8~ ~ ~ s ~ •~ ~~ ~~~ ~ Q ~ p '~ ~~~ ~°' ~~ ~~ ~~~.~ ~~+ N M ~~ O .~ o ~ ~ ~~ ~~ ~ ~ ~, ~ w Q •~ ~3 a ~~ 0 A 0 `r ~ d fV .~ ~, .~ ~a e $ ~ ~~ .~ z a ~` g~~ W !s7 r+ fV z :a c~ 8 ~, el - . _ ~ `,~ 8 ~ . --- ~S"~ P'' ( 1i'f~3 ~`?•'>s~ _ KK ~ i; i -. On The YIFeI~ ~it~.. E. r Street y 4-"~s s ~ ~i7013 ;~3 :~ ~ ~4: 'ii CUSTOMER'S ORDER NO PHONE ;ICE 1A~ats.oom 316 811oornfiefd~-Avenue Newport, PA ~ 17074 Phone 567=632 1 ~' NAME ADDRESS (~'~. n ~ ._ _. n I ~ 1/ ~ - - SOLD BY CASH C.0.d. CHARGE ON ACCT. MDSE. RET'0. PAID OUT t - ~ .~ ~q ___~,~ ~ - rise, t 4 f 0 foa ~ ~~ rte, 1 _~ 'r ~ ~ ~ ` t 2 ~ ~ ~, ~~ ~'[.~ iL ~ { p.~s ~ ~ ^~ _ r ~-1 "r'D OO i 1 I TAX ~I~ RECEIVED BV TQITAL ~ ~, ill Ag cl8ims and reNrned goods N~WSiIJe 8txdp!t11p2afiBd~iY~is bill. ~_~ ~ ~,.,. THANK YOU PO BOX 18204 BRIDGEPORT, CT 06601-3204 1-800-684-2222 d111114111N1111M'ItI'IIIIIIItllidbd6ldllll1111'II'll'Illl CITIZENS BANNC CARD SERVICES PO BOX 42010 PROVIDENCE, RI 02940-2010 Illduhnllllpultl~PllhlP1i1'i'11111tgyytuplltitu111 RUTH E BLOSER serooopayc 109 SUSAN LN CARLISLE, PA 17013-1066 ~;;~ Citizen~si~ank~ Payment Informapon Account Number 5241) 38000858 4158 New B~~ $18.79 N6nimtrm Amount Due $18.79 payment Due pate October 16, 2011 Total ...... Encbsed ~ . ......... • ........... ............,....... .. ~ Check for change of addre~. Complete new addrosa on reverse. 0560008584158 000001879 000001879 Detach here. Qy~ Uils top portiari grid Yaw payraetit should to itrclided in gte emebpe. Mike your aback payable ro cidxero esak Card seMcas. Accound Number: 52403800085814158 Summary of Account Activity Presfats Belattce 12.18 payments b Credits _ 12.18 Trerwdionc + 18.79 8slsrtae 7rartsfers + 0.00 ~, Adva,~ + o.oo Pees ~rg~ o.oo Interest Charged + 0.00 New Balance 18.79 Total Creda Luna 8.400.00 AvaIWMe Credit B,~B7.00 Cash Credft Limit 1,800.00 Available Cash 1,800.00 Statement cbsing date 09019111 Number ~ deya in billing cycle 31 statement Date: August z0, 2011-September 19, 2011 Payment IMormation New Balance 18.78 Mlnlmttm Payment Due 1&~ Payment Due Date October 16, 2011 Late Payment Warning: If we do not receive your minimum payment by the date listed above, you may have to pay a late fee of up to >;,99.00 and your APRs maybe increased up to the PertaRjr APR of ?9.9996. '~ Minimum Payment Warning: It you melee only the minimum payment each period, you wiU pay more in interest and it will take you longer to pay elf trmtr balance- For example: If you make no additional charges You will pay off the And you will end up using this card and balance shown on this paying an est6rlated oath month statarrtertt in about... total ot... Y~ PaY••• Only the minuunum 0 ~~ ~ payment For credit counseling you may call 1-888-498-9815. Account Activity Tracts pate Post Date Reflrence Numtxr Transaction Description A~uM PAYMEMS AND CREDITS 0&29 08J29 76545141241000150423551 Payment Received Thankyou 12.16 (-) PURCHASES 0825 08128 05410191237418181380844 LISPS 41118800131100134 CARLISLE PA 18.79 ~~~ 4 ~, ~QS ~%~'~ ~ ~~ ~~~ To Reach Us TOLL-FREE CUSTOMER SERVICE i N000.864.2222 LOST OR STOLEN CARD: 1 900-44~ 0164 l24 MOVRSI ONLINE U I ILEN56ANK GOMtCREUITCARD PAYMENTS: ~ CORRESPONDENCE: CRIZENS tSAtJK CARD SERVICES IITILENS BANK CARD SERVICES PO BOX 4:010 PO BOX 7082 PROVIDENCE, Rf 02040 20t0 BRIDGEPORT, CT' 06801 Billing Office ~ ~ ~ ' P.O. Box 726 New Cumberland, PA 17070 QUESTIONS ABOUT THIS BILLt Phone: 877-2146018 Espafial: 866-724-4114 Fax: 717-214-60,20 Email: InfoOambulsneebilltngofflce.com Date of Service: 9/5/2011 03:10 Please visit our website to provide insurance or make payment, and Patient Name: BLOSER, RUTH E. for additional payment options and frequently asked questions: From: Carlisle Regional Medical Center www.ambulancebillin To: CHAPEL POINTE AT CARLISLE g01'fiCe.COm This type of service is not covered by ambulance. memberships, Medicare, Medicaid a~tr~rr~os,~ se~Ofra(a~j+ ~nsurarteex Pcryment is your responsibility. _ ~ " . ,.. . ___..~.__.__ .HV___--__..._~ ...~_-~ ~>,~ 1_--c..:....~ _s,. ,. _.~__~ , ~ - ~ - - r~ar,'~ ~` ~~k ",gip ~'~~b".ya~~ ~~.";.~ ,.$~r ~...~ ~.u ~..._,,.-._ ..d 9/05/11 Stretcher Van One-Way Trans A0130 1.0 -80.00 80.00 9/05/11 Mileage S0209 1.6 1.75 2.80 Total 82.80 0.00 0.00 ~` r1 J 1}' ~r ~~ CrG` ~,~~ ~a~ ~~ ~ ~ ~ --------------- --DETACH AND RETURN BOTTOM PORTION WITH YOUR PA'fMENT. Invoice Date:043/30/2011, Acct#:CHAP1071, BLOSER, RUTH E, Chapel Pointe NC, A, BRANSCUM, GEORGE -X 09/01/2011 6356978 2.00 Polsesium Chloride CR Oral Tablet Extended Release 10 MEO $ 4.941 C $ 0.00 $ 4.99 RX ' 00781-1528-01 09/05/2011 6357939 t~0 2.00 } Nitrofwardoin Macrocryatal Oral Capsule 60 MG $ 6.68 c $ 0.00 $ 8.88 RX 00093-2130-10 09/09/2011 0~87~80 30.OO~M $ 8.00 c $ 0.00 $ 8.00 RX 09/09/2011 4015815 30.00 lorazepam Orel Tablet 1 MG $ 5.943 c $ 0.00 $ 5.96 RX ~~~ ,~..+ 00591-0241-OS 09/14/2011 20188Q4,. ' v ` -/ _ 30.00 Morp~hirre4 $ 8.00 c $ 0.00 $ 8.00 RX 09/1412011 36 12 6 35 4.00 CIoNIDine HCI Trenedarmel PeEch WeekH 0.1 MG24HR $ 8.00 C $ 0.00 $ 8.00 RX 00555-1009-18 09/14/2011 6361236 30.00 Nltrot7hrcerin Trenedormal Patch 24 Hour 0.4 MGMR $ 8.00 C $ 0.00 $ 8.00 RX 00378-9112-93 09!1412011 6361267 24.00 CMP t.oraaepam 0.5mrtlml Topical Gel $ 21.80 $ 0.00 $ 21.80 RX 00591-0240-05 09H4l2011 6349085 90.OON,,,, Albuoerd-Ipratropium Inhalation Solution 2.5.0.5 MGI3ML $ 20.93 c $ 0.00 $ 20.93 RX ----"`- ~ 00487-01201-01 09/18/2011 6381267 24.00 CMP Lorempam 0.5mplml Topical Gel $ 21.80 $ 0.00 $ 21.110 RX 00591-0240-05 09/20!2011 6363795 ! ' 15.00 Atropine Sulfate OphBrelmic Soution 1 % $ 5.00 c $ 0.00 $ 8.00 RX ^^24208-0750-08 ,~~t~ ld ~~, ~ arc ~~~ ~ ~ ~ .. $ 0. $ 243.25 09114/2011 $ 0.00 $ 0. $ 0.00 $ 122.1 $ 0.00 $ 0. $ 0.00 122.16 Invoice Date:10/31/2011, Acct#:CHAP1071, BLOSER, RUTH E, Chapel Pointe NC, A, BRANSCUM, GEORGE 09/01/2011 6038878 20.00 Gabapenlin Oral Capsule 100 MG -- - ~ $ 8.(10 c $ 0 00 $ 8 00 RX 18714.0881-01 . . 09/01/2011 6322799 40.00 Nifedical XL Oral Tablet Extended Release 24 Hour 30 MG $ 8.(10 C $ 0.00 $ 8 00 RX 00093-0819-01 . 09/01/2011 6322800 20.00 Priloeec OTC Oral Tablet Delayed Rebaee 20 MG $ 13.79 $ 00 0 $ 79 13 OTC 37000.0455.04 . . 09!01/2011 6341159 40.00 Clonidine HCI oral Tablet o.1 MG $ 8.C10 c $ 0 00 $ 00 8 RX 00228-2127-10 . . 09/01/2011 6350675 20.00 Isosorbide Moranitrate CR Orel Tablet Ex6~ded Reease 24 Hour E $ 8.C10 c $ 0 00 $ 8 00 RX 82175-0119-37 . . 09/01!2011 6350699 20.00 Mstdamne Oral Tablet 2.5 MG $ 8.00 C $ 00 0 $ 8 00 RX 001853050.01 . . 09/01/2011 6355593 45.00 Klor-Con M20 Oral Tablet Exlerxled Release 20 MEq $ B.GO c $ 0 00 $ 8 010 RX 00245-0058-16 . . 08/0112011 6373018 60.00 Ferrous Sulfate Oral Tablet 325185 Fel MG $ 1.89 $ 0 00 $ 1 99 OTC 00877-0070-10 . . 09/01/2011 6373020 20.00 Citabpram Hydrobromide oral Tablet 40 MG $ 8.00 c $ 0 00 $ 8 00 RX 55111-0344-01 . . 09/01/2011 8373021 40.00 ~I~ GumlD Oral Tablet 500.200 MG•UNIT $ 1.99 $ 0 00 $ 1 99 OTC . . 09/01!2011 6373022 20.00 P-edniSONE Oral Tablet 10 MG $ 5.82 c $ 0 00 $ 5 82 RX 00143.1473-10 . . 09/01/2011 8373023 20.00 Therems M Oral Tablet $ 1.99 $ 0 00 $ 1 99 OTC 005384881-10 . . 09/01/2011 6373024 23.00 Furoaemtda Oral Tablet 40 MG $ 7.63 c $ 0 00 $ 7 63 RX 83304.0825.10 . . 09/05/2011 6357055 13.00 ? Nitrofurantoin Mecroavstal Oral Capsule 100 MG L $ 8.00 c $ 0 00 $ 8 00 RX ~ 00378-1700-01 1 . . 09/09/2011 2018780 30.0,- 1` ~ ~,~ $ -8.00 c $ 0.00 $ -8 00 RX (~~ V' ~ ~ 09!09!2011 4015615 4 30.00 I-oraaepam Oral Tablet 1 MG ~. ty /'i 00591-0241-OS ~ $ -5.95 C $ 0.00 $ ~ RX 09/ - r „i, ` ~11~, ~ ~w 14/2011 2018804 30.00 Mom I~~u~l(ate ` $ .6.00 c $ 0.00 $ J RX 09!14!2011 6349085 90.00 Albuteroiawatropium Inhalation Soluton 2.5-0.5 MG/3ML `x^' $ .20.93 c $ 0 00 $ -2 RX 00487-0201-01 . ~ 09/20/2011 8380862 15.00 Atropine Sulfate Ophthalmic Solution 1 '~, $ 52 1 ~ 24208A750-OB . 0 $ 0.00 $ 52.10 RX -X 0/18/2011 $ 0.00 $ 0.00 $ 0. $ 86.88 $ 19.76 $ 0. $ 0.00 ~ 106.42 y~~ ~~~tiz~ens bank ~~ PO Booc 7000... ROP~450 Providence RI 02940 i-800-862-6200 Commercial Account Please oll us anytlme for answers to your Statement questions, aocountinfonnation, anentiates or to update your address & phone number. © OF 2 Beginning October oi, 2011 through October 31, 2011 Al' 01 075806 85$978233 A'•3DGT ~IIIIs+iu.l"~'I1~~6iN11'Ii111'~'~111111r~~llllurl~~~l~lllld ESTATE OF RUT~i E BLOSER JUDY ANNE KRO HEIM EXEC 109 SUSAN LN CARLISLE PA 17b13-1066 Commercial Checkitlg u s 10 2 m s u M N A R r ESTATE Or: RUTH E BLOSER 0 Balance Calctdation JUDY ANNE KRONHEIM EXEC Business Green Checking Previous Balance 102,752.18 XXXXXXX550-6 Checks 11,131.60 - Debits 34.22 - Deposits & Credits 193.90 + v ~ Conant Balante 91,780.26 = ~ ~ ~~ You can waive the mo ly maintenance fee of;9.99 by maintaining an average daily balance in \ ~ ~ ~\ _ your account of 52,000 r making 5 qualifying transactions. ~ ~ _ Your average daily b lance this statement period is 596,209 ~ Your number of qualifying transactions this statement period is 8 ~~- Pnevbus lalanoe TRANSAtTION DETAjILS 102,752.18 ~_ Checks' Thens is a imaok in d~eat saquw+ca ~_ Check t Neornt Date Check # AooYat x 'x Date ~ .80 10/12 105 .00 101 102 ti3.56 10/12 991' rX819.00 10/19 10/12 16 10%18 992 :v'82.80 1~ ~~ 22 10/05 . n total Checks 11,131.60 Debits Other Debits oounk Description Date Ar `~J J 10/13 v~ 2~ Harland Clarke Chk Order 111008 Ocpg94441256200 10/31 ~0 Service Charge f11 er Statement Fee ~G'-" Pa p n ToW Deb1Fa 34.22 Deposits & [resits Date Amounk Desalptlon 10/14 ~~661p Deposit 10/18 /158.8~ Deposit Thal D 8 CnMHts 193.90 (~ l Current salaon 91,780.26 m«aee<FOrc CLt r~r-w~rroLenar .`r' S'Iw4TE FARM FIRE AND CASUALTY COMPANY '"''' 100 State Farm Place ' Ballston Spa, NY 92020-8000 091 P-13-2627•F382 BLOSER, RUTH E, ESTATE OF C/0 JUDY KRONHEIM 109 SUSAN LN' CARLISLE PA 17013-1066 F H ACKNOWLEDGMENT OF CANCELLATION REQUEST Renters Policy POLICY NUMBER: 38-BR-S963-4 DATE CANCELED: SEP 23 201 1 RETURN PREMIUM: $35.10 TO: ^X INSURED ^ MORTGAGEE ^ OTHER Dear Policyholder, As requested, this policy has been canceled effective 12:01 a.m. (or the time which is required by state law) as of the Date Canceled shown above. We thank you for giving us the opportunity to provide this insurance. Location: 770 S HANOVER ST RM 15 CARLISLE PA Agent: JOMN ZAMPELLI JR Telephone: (717) 249-1582 - DATE PROCESSED szn ,2~ ar-o,-~ooa. (a,+,22sa) OCT 03 2011 .\ ~~ ~~~