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HomeMy WebLinkAbout03-07-12COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128.0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EXt11-96y N0. CD 015675 PLACEWAY JOELLEN PETERSON 127 FOXBURY DRIVE ELIZABETHTOWN, PA 17022 fold ESTATE INFORMATION: ssrv: 2ss-to-coos FILE NUMBER: 211 1-0846 DECEDENT NAME: PETERSON DOLORES FARRELL DATE OF PAYMENT: 03/07/2012 POSTMARK DATE: 03/06/201 2 COUNTY: CUMBERLAND DATE OF DEATH: 06/23/201 1 REMARKS: RECEIPT TO ATTY SEAL CHECK#506 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ $910.94 TOTAL AMOUNT PAID: 5910.94 INITIALS: HEA RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF~ WILLS REGISTER OF WILLS Randall ~ Miller Attorney at Law 1255 South Market Street, Suite 102 Elizabethtown, Pennsylvania 17022 (717)361-8524 -- Fax (717)361-9071 March 6, 2012 Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 RE: Estate of Dolores Farrell Peterson Dear Sir or Madam: c'~ ,.wy ~O r.a ~~ ~ . « ~ ~7 ~ --~ ~ .=~ r , r.~ ~ ~• ~ ~ Enclosed herewith are an original and two copies of the inheritance tax return(s) in the above estate(s), along with a check in the amount of $15.00 for the tax filing fee and a check in the amount of $910.94 for payment of taxes due. Please file these documents and forward atime-stamped copy of the tax return and a receipt for taxes paid to our office in the envelope I have provided. Thank you for your kind attention to this matter. Very truly yours, +, Joanne M. Miller Legal Assistant to Randal]. K. Miller, Esquire J 150561D1D1 REV-1500 ~ `01.1°' PA Department of Revenue pennsylvaMa Bureau of Individual Taxes ~"""TM`..o~ ~NHERITANCE TAX RETURN PO BOX 28o6oi Harrisburg. PA i7iz8-otioi RESIDENT DECEDENT OFFICUU. USE ONLY County Code Year File Number ~i ~~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth hIMDDYYYY 296-14-4009 06/23/2011 02/28/1924 Decedent's t_ast Name Suffix Decedent's First Name MI Peterson Dolores F (H 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 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW QlD t. Original Return O 2. Supplemental Return 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~ ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Totai Number of Safe Deposit Boxes (Attach Copy of WiU) (Attach Copy of Trust) O 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 -1-95~ (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFlDENTUIL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytirrie Telephone Number Randall K. Miller, Esqu (717) 361-8524 ~, ~_~ REGISTER OeF~S USE First line of address 1255 S Market Street Second line of address Suite 102 City or Post Office Elizabethtown State ZIP Code PA 17022 rZ~~ ,T ,`)? f.., t7 ~~~-~~ ~.,: f _..~7 .....~ `1 D~ FILED °:~~ ~..~ 4 .-.,t ..~, C. J r^ 7 n-~ ri7 C?-t ~. 4.J l.. n ` .may ... ~:~ fi.,_.i f. _.'"R .._...~ - , =-, ._ --~ C` ~`__ 3"T-t ~~~ chi 'Ti correspondent's a-mau address: rkmand mm mall.com Under penalties of pery'ury, I declare that I have examined this retain, including accompanying sc u es an s men , an o e o my now ge an e~ it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS SI ATURE F EP ER OTHE THAN REPRESENTATIVE TE ADDRESS 1255 S Market St., Suite 102, Elizabethtown, PA 17022 PLEASE USE OR161NAL FORM ONLY Side 1 1505610101 1505610101 J J ]r5056]rD1D5 REV 1500 EX Decedent's Social Security Number Decedent's Name: Dolores Farrell Peterson 296-14-4009 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 0.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. Mortgages and Notes Receivable (Schedule D) .......................... . 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property {Schedule E)....... 5. 24,209.90 , 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 0.00 7. Inter-Yrvos Transfers 8 M~laneous Non-Probate Property 0 00 (Schedule G) O Separate Billing Requested........ 7. . 8. Total Gross Assets (Dotal lines 1 through 7) ............................. 8. 24,209.90 9. Funeral Expenses and Administredve Costs (Schedule H) ................... 9. 2,355.69 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule i) .............. 10. 1,611.15 11. Total Deducdons (total Lines 9 and 10} ................................. 11. 3,966.84 12. Net Vales of Estate (Une 8 minus Line 11) .............................. 12. 20,243.06 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 20,243.06 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(t2) x .0 0 0.00 16. Amount of Line 14 taxable at lineal rate X .0 45 20,243.06 17. Amount of Line 14 taxable at sibling rate X ,12 0.00 18. Amount of Line 14 taxable 0.00 at coNateral rate X .15 15. 0.00 16. 910.94 1 ~. 0.00 18. 0.00 19. TAX DUE ............... 910.94 .......................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 J RE~F1508 EX+ (6-98) SCNEDYLE E COMMONWEALTH OF PENNSYLVANIA ~- BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF ................,.,...,...,,...,,._....,....,,.,.,,.,.,...,....,.....,...._,..,...,,..,...FICE'5~U~'E~ ,..~.,.~...,, Dolores Farrell Peterson 21-11-0846 Indude the proceeds of Ntigation and the date a pro s were r e e. AB property joinUy~owned with right of survirorshlp must be disdosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. M&T Bank Money Market acct #15004201570890 20,797.19 2. Senior Health Insurance Company of PA premium refund 488.26 3. Saturday Evening Post refund of premium 2.16 4. Woman's Day refund of premium 13.19 5. Allstate refund of premium 22.00 6. Aetna Insurance refund of premium 123.22 7. CerttttryLink refund of premium 13.38 8. M&T Bank checking #3740876440 2,550.50 9. Travelers checks 200.00 TOTAL (Also enter on line 5, Recapitulation) s 24,209.90 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-09) ~kt.~~~ pennsytvania SCHfDOLE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF Decede~'s debts must be reported on Schedule i. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: I' Hoffman-Roth Funeral Home & Crematory, Inc. 712.44 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP _ Year(s) Commission Paid: 1,500.00 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State ZIP _ Relationship of Claimant to Decedent 4. Probate Fees: 127.50 5. Accountant Fees: 6. Tax Return Preparer Fees: ~. Estate check order 15.75 ' TOTAL (Also enter on line 9, Recapitulation) $ 2,355.69 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-OS) `~ ~~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES 81e LIENS ESTATE OF ~°`~`"~'~~`~ Dolores Farrel Peterson 21-11-0846 Repo rt debts Incurred by the decedent prior to death that remained unpaid at the date of death, induding unreimbuned medical expenses. nEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1• IGnetic Imaging 5.45 2. Carlisle Regional Medical Center 271.70 3. Cumberland Goodwill Fre Rescue EMS 217.98 4. CRNA-Carlisle #535311 85.80 5. IGnetiC Imaging 9801 6.40 6. Chapel Pointe at Carisle 3.28 7. Mount Rode Inpatient Services 26.45 8. NYLTC tbo Owens_Illinois Salary Retire. Plan reimbursement 994.09 TOTAL (Also enter on Line 10, Recapitulation) $ 1,611.15 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (11-08) yi pennsylvarria SCHEDULE ] DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Dolores Farrell Peterson 21-11-0846 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY Do Not List Trustee(s) OF ESTATE _ I TAXABLE DISTRIBUTIONS [Include ouMght spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Jcellen Peterson Placeway,127 Foxbury Dr., Elizabethtown, PA 17022 daughter 1/3 2. Douglas Alan Peterson,17 Lakes at Cheshire Dr., Delaware, OH 43015 son 1 /3 3. Brent Charles Arthur Peterson, 30 Morley Dr., Norwalk, OH 44857 son 1 /3 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 16 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTION$ ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, Insert additional sheets of the same size. `~i~ts# ~.C ~tx~r (`~es#ax~rtex~# OF DOLORES FARRELL PETERSON I, DOLORES FARRELL PETERSON, of the Borough of Cazlisle, County of Lancaster and Commonwealth of Pennsylvania, do make and publish this, my Last Will and Testax~ent, hereby.revoking and making void all former Wills by me at any time heretofore made. FIRST: I direct that my just debts and funeral expenses shalllbe paid out of my estate as soon as conveniently maybe done after my death. SECOND: I direct that my entire estate, both real and personal, be divided into three (3) equal shares, with one (1) shaze being distributed to, my son, Douglas Alan Peterson; one (1) - , shaze being distributed to my son, Brent Charles Arthur Peterson, and one (ll) shaze being distributed to,my daughter, Joellen Peterson Placeway. If any of the aboveazamec~ beneficiaries should predecease me, I direct that that beneficiary's shaze be distributed to his or her surviving issue in equal shares per stirpes. THIRD: I direct that all inheritance and estate taxes which may become payable by reason of my death, including taxes on any property not passing under this Will, shall be paid out of the principal residue of my estate, and no part thereof shall be collected from or charged against any beneficiary, provided, however, that the terms of this pazagraph shall not apply to any such death taxes imposed with respect to any retirement benefits, unless the beneficiary is either my trust or my estate. FOURTH: I constitute and appoint my daughter, Joellen Peterson Placeway, Executrix of this Will; and if she should die or be unwilling or unable to act,. then I constitute and appoint my son, Douglas Alan Peterson, Executor of this Will. Except as maybe specifically stated to the contrary in other provisions of this Will, I authorize my personal representative of my estate to exercise the following powers, in addition to those given bylaw, to'be exercised in the sole discretion of my personal representative: to retain any real and personal property which may at any time form part of my estate for as long as my personal representative may deem advisable; to repair, alter, improve or lease, for any period of time, any real or personal property I and to give options for leases; to sell any real or personal property at public or private sale, for cash or credit, with or without security; to exchange or to partition any real or personal property and to give options for sales or exchanges; to compromise claims without Court approval; to continue any business which I may own or in which I may have an interest for as long as appropriate under the circumstances; to retain and pay agents, employees, accountants and counsel for advice and other professional services; to make distribution in kind; and to invest and reinvest according to the standards of prudent investment without being confined to so-called legal investments. No Executor, Guardian or Trustee named herein shall be required to give bond or security in order to qualify as such or to perform any duties of such appointment, regardless of place of residence. 2 FIFTH: A list of gifts, which I wish to designate to specific individuals, can be found with my important papers at home. If no such list can be found within thirty (30) days of the reading of this Will, it will be deemed that it does not exist, and the other provisions of this Will are to be carried out in full. IN WITNESS WHEREOF, I have to this Will typewritten on five (5) sheets, set my hand s~ and seal this .J day of , A.D., Two Thousand Nine (2009). 0'' v' (SEAL) DOLORES FARRELL PETERSON Signed, sealed, published and declared by the above named Testator, 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 subscribed our names as witnesses thereto. R' °'~~+-Y ~~ ~ residing at C ~ r 1 1 ~ ~ ~ ., PA l,~-~vVt4 residing at ~ , pA 3 COMMONWEALTH OF PENNSYLVANIA ) SS: COUNTY OF a ) I, DOLORE5 FARRELL PETERSON, Testator, whose name is signed to the foregoing instrument, having duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ~/ EAL (S ) OLORES FARRELL PETERSON Sworn or affirmed to, subscribed to and acknowledged before me, by DOLORES FARRELL PETERSON, the Testator, this ~`" day of cc„~c,c.J- , 2009. ~~~--~ , No ary Public COMMONWEALTH OF PENNSYLVANIA Notarial Seal Karen M. Tumer, Notary PubUc Carlisle Boro, Cumberland County My Commleaion ros July 22, 2012 Member, Psnneyhnn bf Notlbies 4 COMMONWEALTH OF PENNSYLVANIA ) j SS: COUNTY OF We, ~,~r ~.~ ~~ and ~/Y~'IQ I~~et.da~e.FJ the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw_Testator sign and execute the instrument as he;r Last Will; that DOLORES FARRELL PETERSON signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us, in the hearing and sight of the Testator, signed the Will as witnesses; and that, to the best of our knowledge, the Testator was at the time 18 or more years of age, of sound mind, and under no constraint or undue influence. Witness Q~Ka ~ Witness Sworn or affirmed to and subscribed to before me b ~ d a~i~/~itnesses, this~day of , 2009. 1~~ L • br C/G~ No Public COMMOMWEALTH OF PENNBYLVANW Notarial Seal Karen M, Turner, Notary publk . Carlisle Baro, Cumberland County 5 MY Commisaion Expirea July 22, 2012 Member, Pennsylvania Aasodatior! o(Nolaries ~~ M~~ P, c~ ' ~ FKINRl7M (i) ~=-r~ r~(-aozan rev 8roe W r! f% ~ O ~ _ ..; ~ - -t 0 0 0 ~ ~ S ~ ~ Z ~ ~ ~ ~ ~ ~ o oa it O ~, ' ~ T ~ a ru ~ # ~~~ N 2 ~ ~ LJ7 0~ ~ ~ ~ 3 ~ \ •i ~ ~ ~-~, Q ~~ fiJ _ ~, ~ ~ r m .. r ~ ,7 O O Vf N ~ O m r j •O ~ -, ~ qpp~ O y~. ; O ~ ~ ~ ,, ~~ ~ ~ .c~ ~ ~ -~.8 ~ ~ O . M A~~ ~..~ ..... _. O'`.. ~.. ` ~ .o e E ' ~ ~r .. ~ ~ 3 11CCQUNT:N4:~. AGCOUNT'TYPE 15004201570890 MST MARKET ADVANTAGE 00 0 04345M NM 017 13852 DOLORES F PETERSON 1 ALLIANCE DR APT BT 104 CARLISLE PA 17013 INTEREST EARNED FOR STATEMENT PERIOD 2.56 INTEREST PAID YEAR TO DATE 2.57 ACCOUNT SUMMARY STATEMENT PERIOt1 .PACE DEC.04-NAR.03,2011 1 OF 1 STONEHEDGE ED ~ ' BA < .E QE x75 fl'fHERak1SDrTYONS; NIT if L& < ER _'SUBT.RACfLONS :;;. `~4IRRE11 1~'#EkE~~`. PAIb LJINCE NO. AMOUNT N0. AMOUNT 20,790.26 0 0.00 0 0.00 2.57 20,792.83 ACCC1lINT ACTTVTTV DATE ` > :' '[RANSAC'1~Z0N DESCRIPTT " T ,~1+tT T i OTHER: Abbe ~~ONS 1!f/DR i-~1LS SiTH SUBI`RAC :IOfiS 8..I4,Y BALANCE 12-04-10 BEGINNING BALANCE 120,790.26 01-03-11 INTEREST PAYMENT ' 0.89 ' 20,791.15 02-03-11 INTEREST PAYMENT. 0.88 20,792.03 03-03-11 INTEREST PAYMENT 0.80 20,792.83 ENDING BALANCE 120,792.83 . _ ______. _ _. -ANNUAL PERCENTAGE YIELD EARNED = 0.04 EFFECTIVE JUME 22, 2011, THE FEE FOR EACH NITHDRANAL FROM YOUR SAVINGS OR MONEY MARKET ACCOUNT IN EXCESS OF 4 PER MONTHLY SERVICE CHARGE CYCLE MILL BE 15. THIS FEE MILL BE CHARGED REGARDLESS OF THE BALANCE TN YOUR ACCOUNT, AND IS IN ADDITION TO ANY FEE FOR ANY ELECTRONIC FUND TRANSFER SERVICE WE MAKE AVAILABLE. A MITHDRANAL INCLUDES, AMONG OTHER THINGS, A NITHDRANAL MADE BY A CHECK, AT A TELLER, BY USING AN ELECTRONIC BANKING CARD TO TRANSFER FUNDS TO ANOTHER DEPOSIT ACCOUNT NITH US, OBTAIN CASH OR PAY THE PURCHASE PRICE OF GOODS OR SERVICES, OR BY TRANSFER MADE BY TELEPHONE TO ANOTHER DEPOSIT ACCOUNT NITH US. ,. ~a;~,. Voucher Number Amount 0000377462 $488.26 Check Number: 50006346 Date: 08/02/2011 To: ESTATE OF DOLORES PETERSON 13501 13501 Invoice Number Date 08/02/2011 Discount Paid Amount $.00 $488.26 TOTALS: $488.:?6 $.00 $488.26 .. .: •. Senior He~Mh Insurance Company of PA Tne sank of New Yortc Menon 50006346 Mellon Client Service Center 50dRoss Street 60-160/433 PO Box 64913 Pittsburgh, PA 15262 St Paul, MN 55164 DATE AMOUNT PAY Four Hundred EightyEight Dollars And 26 Cents 08/02/2011 $488..26 TO THE ORDER OF VOID AFTER 180 DAYS ESTATE OF DOLORES PETERSON 1 ALLIANCE DR APT 104 - '~`~=- CARLISLE, PA 17013-4133 ~~^ ~nnn ~. ~ ~. i>;a^ ~:D4 3 30 L 60 L~: 900~~~ 5 ?0 511' The Saturday Evening Post and 0954243 EF. NO. INVOICE NO. INVOICE DATE DESCRIPTION AMT. PAID DISC. TAKEN NET CHECK~I AMOUNT 000071057 30020225984 7/18/2011 SE Saturday Evening Post 2.16 0.00 2.16 Refun ~,' - .. ~ '..~ ~"~ ~ N .~ ,.~ M d- O M Q W Q H a ~, w w A Fi U 3 w ~ U °> -~ «i V ~ ~ ~ U Q U ., ~ ~ .~ ~ O ~ ~ ~• d y ~ r, ~ N a.~ ~ ~ , ~ ~ ~ 'i7 . .~ ..+ ~ ~ ~ ~ ? .b ~ .t~ ~ .. ~ ~ 3~ .~~ ¢ o ~ , ~ N Fr. - .O ~ Q ~ ~ U ~ ~ ,,Vy ~ y r ~~ ~~ ~ ~ ~ ~ A d ~ ~ ~ ~ U ~ a., U i , ,,.. ~ r ~ . 1 ^ V / ' ~""~~ p Q O . ~ Z Q1 ~ H' ~ °z M ~ a rl ~ Z ~ Q ~ ~ ~ N ~.. G O O~ a W 4 -: ~ ~ Q ~F W r -I O ~ Q ~ M ~ ~ ~ ~ ~ ~ d o -~ ml m cw. Q ~ W Q Z x rU, ~ ~ cn U ~ ~ ~ O .~ a N ~ *" ~ z w~,M ~ A u~ x~' w~~ ~ w a ~a w , . ~~ ~ ~ ° aa. n¢¢U ~ L J a~~¢~ O ^ ru a cD ~~ C~ rf1 Q' r"f1 a .a Lfl 1 0 0 0 O ~-r sb Allstate Insurance Company Cheek number: 0070973230 s3i 10815 pavidSaylor Dri4e Charlotte NC 28262 Date.of issue: 8/23/2011 Policy Number: 001732405 _ /~~~'~~~~w~ Pay: Twenty-two and Ob/100. dollars \\I_ _ ~ ~+ You're in good hands, To the order oft ESTATE OF pOLORES F PETERSON Amount:. $22,00 127 FOXBURY DR ELIZABETHTOWN PA 17022.1763. ' Premium Refund Account Wachovia Bank, a division of Wells Fargo Bank, N.A. ~ ~. Pt,~ ,,pq Y~N~, Chapel Hill, NC 27514 "'^^^~~~`~~~ Lt-1 ~«~~~ Void if not presented within 180 days otthe date of issue AUthOrized 5lgnatUres 11'00 70 9 7 3 2 3011' ~:0 5 3 LO L 56 L~: 20 79 900 L L8 L 1511' u'OLOL2L399811' ~:03LL00209~: 3855749611' CBNTURYTBL, INC.. ATTN: Coatroller's Group ~~~~ P.O. SOX 4065 ~11` MONRO$, LA 71211 CenturyLink° 1-877-386-7151 Document / Date 2000844973 / 10/12/2011 Your vendor number 500000 Document Invoice Date Gross Amount Deductions Net Amount Text Payment is made on behalf of EQ United Tel-PA, T856: 1900042804 3141297020 10/07/2011 13.38 0.00 13.38 Refund Questions? Call 1 888 723 8010 Sum total 13.38 0.00 13.38 ~1°S - ^~ ~~~~~ ~ ~ Y+m1 S ~M'°, 219 Morlh Hanover Street Carlisle, Penruylvania 17013 717.243.4511 toll free 1.866.451.4511 /~ ~~ ..ZI~~`~2'.'^ /~, fax 717.243.3723 ww+vhoffrrxarnihcom .FUNERAL HOME ~ CREMATORY, INC. ~,~.,~~,,., July 18, 2011 Joellen Placeway 127 Foxbury Drive Elizabethtown, PA 17022 Statement of Funeral Expenses for: Dolores Peterson Date of Death: June 23, 20'(1 Account Id: 18271-139 PACKAGE: Embalming, Private Family Viewing, Memorial Service, Cremation OPTION 2 -Cremation $ 3,190.00 Sub Total: E 3.190.00 ._.._ TOTAL FUNERAL HOME CHARGES: S 3,190.00 CASH ADVANCES: 15 Certified Death Certificates at $ 6.00 each $ ?0.00 Newspaper Notice - Toledo,Blade $ 302.00 ~ Newspaper Notice -Columbus Paper $ 295.44. Coroner's .Fee $ :?5.00 Sub Total: $ 712.44 Total Funeral Expense: S 3,902.44 Total Payments Made: $ 3,190.00 Payments Made: PreNeed Disc Discount Cont vs PreN Jun 30, 2011 327.55 Homesteaders Check 469686 Jun 30, 2011 2,862.45 Balance: $ 712.E RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARMER STRASBAUGH Receipt Date: Cumberland County - Register Of Wills Receipt Time: One Courthouse Square Receipt No.: Carlisle, PA 17613 PETERSON DOLORES FARRELL 8/03/2011 10:42:04 1066538 Estate File No.: 2011-00846 Paid By Remarks: RANDALL MILLER wz ------------------- ----- Receipt Distrib ution ----- -------- ------- ---- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 60.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 24.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 CUMBERLANDD COUNTY GENERAL FUN Check# 10245 $127.50 Total Received..... .... $127.50 DO NUT SEND PAYMENTS/C.ORIiESPONDENCE TO: Kinetic Imaging Dept 13844 PO Box 1259 Oaks, PA 194NN56 IryIry'''''' INI, I~I~INIII~~III ~II,I~ - For billing questions call: 717-652-6105 Fax: 717-652-2165 Office Hours: Mon -Fri 7:OOam to S:OOpm DOLORES F PETERSON $ 1 ALLIANCE DR APT BT104 ~ CARLISLE PA 17013-4151 I~~~ill~~~lll~~~~~~ll~~li~~l~~l~~~ll~l~l~~~~lll~l~~l~l~~l~l~~l Kinetic Imaging 4520 Union Deposit Rd Harrisburg, PA 17111-2910 I~~~III~~~I~~~II~~~Ii~~~ll~~i~ll~l~~~~~llll~~~~~l~lll~~~~l~l~l ^ Please check box if above address is incorrect or insurance . PLEASE DETACH AND RETURN TOP PORTION WITH Information has changed, and indicate change(s) on reverse side. YOUR PAYMENT IN ENCLOSED EN4ELOPE Patient: DOLORES F PETERSON , Account: 9801 Services Rendered' At: Carlisle i2egional Medical Center Date Code Description ` Charge Ad usrtments Balance 7/19/2011 PMT AETNA MEDICARE 102.72 CR Adjustment'AETNA MEDICARE 356.00 Message: AETNA ME[31CAR>< C©NTRACT FEtw / , - ACCEPTED ASS)GNMENT 4.2 6/6/2011 77012 CT GUIDE NEEDLE PLACEMENT 250.00 7!19/2011 PMT AETNA MEDICARE '~ , ., 50.88 CR Adjustment'AETNA MFt01GARE 197.00 Message; AETNA MEDICARE C:ONTf~ACT FEE / - ACCEPTED ASSIG(yMENT ~.~.~_;._. 2.1 ~~ 99 DATE _ - a13 PAY TO THE ~ ~ .. ~_....... ,.. _ ..:,. ORDER OF I ~~ DOLLARS 8 COMMUNITY Union I BANK __ FOR QI ~,e~ ~P :;.~:0 3 13090681; tI~ i0 i 5~~~ 28 L~~14u• BALANCE DUE 55.45 PAY BY September 07, 2011 ` Please ca~li with; your insurance coverage or For billing questions call: 717-652-6105 remit the balance due'today_to: ~ Fax: 717-652-2165 452b Uafon [hpasif RQ; Office Hours: Mon -Fri 7:OOam to 5:OOpm Harrisburg, PA'`17i11-2910 Those charges showrrwth an "~" indicate pending insurance. STATEMENT ~~~~~~~ SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION ~~ 2 PAY 1'F#kS'Afdl7ltNT- '.' ACCOUNT NO.' 8/8/2011 $5.45 9801 CHARGES AND CREDfTS MADE AFTER STATEMENT SHOW AMOUNT ~ ~ , DATE WILL APPEAR ON NEXT $TA'fEMENT. PAID HERE ~~ MAKE CHECKS PAYABLE / REMIT TO: ~~ B; PArINO BY Y13A OA MASTERCJIRD, fU.I.OUT BELOW DVISA ^AYIBTERCARD NA~1 OV.OAT! T IIOIM7UR! MUST INCLUDE3Ox;1T SECURITY CCDE FROM SK'.K OF CARD -~_r~l~ d~K ~]IJ-O~.`I/_r1~1~1I~\~~ 00%852 858HMA 000086E l ~1.~ ONIIL, 45 Sprint Drive MEDICAL CENTER CadI81e,PA17013 ADDRESS SERVICE REQUESTED - Dolores F Peterson + 1 Alliance Dr Apt Bi 104 CARLISLE REGIONAL MEDIt:AL CENTER ChaQel Pointe p,0. BOX 281442 w Carlisle PA 17013 ATLANTA GA 30384-1442 ~n~~~~ur~~~euu~~~u~~n~n~ur~~i~l~nu~~~r~u~r~~r~~~n~ ~n~~r~~nnr~~r~n~u~u~m~~r~l~~~~n~u~~~i~~r~u~r~r~r~~~ • ~ ~ UPON REC:LIPT .MAKE CHECKS PAYA>SLE T0: T 0 F E^ - ", x <~ Da~or+~:a F Petersdri 949T045 05/29/2611 iN1~AT1•E'.~T ,„ 00000949704500D00027170DOl.ORES F PETERSON 4 ^ Pleese check if above address is incorrect and indicate change on reverse side. TO INSURE PROPER CREDIT, DETACH AND RETURN THIS PORTION IN THE ENCLOSED ENVELOPE. IF PAYING BY CREDR CARD, FILL OUT BELOW AND SEE REVERSE SIDE CHECK CARD USING FOR PAYMENT MASTERCARD DIS(:OVER YJ6~ PISA AMERICAN E%PRESS ^ -O ®^ ^ ACCOt)NT Np. STAT8IAENT OATS BA(,ANCS OUfi : g 949T045 08/15/2011 5271.70 C PAY TO TH ORDER OF ~ J -~ Union (COMMUN TY $ANK FOR .fX.~-t'%'~' `~~' GJ .~~. ~~ __ ._ ,~:0 3 i 309068: 1d 60'~ ss DAtE ~~ ~' ~ 313 `~~Oa ~ DOLLARS 8 ~ .:~ C •~ u• i0 i S..I 28 i... yn• Billing Office ~~ F.O. Box 726 New Cumberland, PA 17070 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info~ambulancebillingoffice.com Date of Service; 6/9/2011 17:30 Please visit our website to provide insurance or make payment, and Patient Name: PETERSON, DOLORES for additional payment options and frequently asked questions: From: Carlisle Regional Medical Center www,ambulanCebtlliingOffiCe.COm To: CHAPEL POINTE A7 CARLISLE z d *'~` ~~ ~~~~ ,' ~ ~_; ~ ,~ ~~• :~ - ~ ~ ~t~~`~i~a?C~k(Jlt~ COlJtl7CI OZlI'~ O~C2 ~ ~c~rry tf"-v4~'~r,'F 3 ~ a ,. - t K 4~ ~ J 6/09/11 Stretcher Van One-Way Trans A0130 1.0 80.00 80.00 6/09/11 Mileage S0209 2.6 1.75 4.55 aC.$ ~s: ,~` ~~Dia',~5 r Gt-r r~ ~ j ~~P~/"5dl't, PAY TO ORDER ., ~ ~_ . ~~~ 11-134370 • COMMUNITY ul'1l011 ~ BANK .- ........... ...___ ..~.~ .__..~._..~-~..~.-.._-..~-,-.~ __ - .m..., __ ~_... _ ,. _ . _. _. FOR ~~" ~ ~ I X70 ~..~• ~ -- ~:03 i309068~: 11' i0 i5~~~ i8 1~~ryn• ' _ ,~, - ~, _ .._..,.... ...:.i~r~ rvrc(1Vrv VY11H YOUR PAYMENT. ~ ~~ Credit Card; O MASTERCARD ^ VISA O AMERICAN EXPRESS ^ DISCOVER ~~ Card Number *~ ~~~ Name on Cant `_~~~-''--~ Expiration Electronic Check Deduction `= ~_ `-.r Please send a vo/ded check OR provide lnharmafion below: Rank Routing Numt;er ~~,~ ~-' Checking Account Number Siyn~iture n 6o-9os 99 DATE I~,i~' =-~ 313 .... .. ~ . $ ' ' _ ..: , DOLLARS 8 Amount Paid: D~--. $ $4.55 ~~7,9~ Pt: PETERSON, DOI.ORES Please make any corrections to address below. R a~i w 1 JOELLEN PLACEWAY CHAPEL POINTE AT CARLISLE 770 SOUTH HANOVER STREET CARLISLE, PA 17013 ~~- ASSET MANAGEMENT~Lc 1891 Santa Barbara Drive, li204 Lancaster, PA 17601 717.519-1770 or 888-592-2144 Dear DOLORES F PETERSON, We thank you far choosing CRNA -CARLISLE for your health care needs. You should have received a bill for services provided by CRNA -CARLISLE. The balance in full of $$5.80 is now due for payment in full. We realize this could bean oversight and not a deliberate attempt to disregard your obligation. ~gtafe. o•F~~o l o cre5 ~-rre. ~~ f e.~"E~So i'- PAY TO THE ~~ ~''} ) ~-9os 99 10~ /!!I 313 DATE - ~~L(,c.Q, ~ I G~~ DOLLARS 8 ~ `.:." (~1'I~Or1 I A~NK UNITY S?~S- - l I ~x~ec . FOR -~=-- ----- -~:0 3 L 309068: ~~' LO L 5~~r 28 i~n4~~' APEX ASSET MANAGEMENT LLC Please tear off and return lower portion with payment. PO Box 7044 Lancaster PA 17604.7044 I~~~~~~ 02442 ^ _ ^ ~Y/ -- Card # Securky Code Expiration Date Biging Address Signature Amount ~, ~ t„umonzea - ~i~ir'nyl~Ilr~Ilr~r~rrrll'~61I)II~II~I'r'nur~lrlrr~~urlll~ CARL78 16963867 105 LAN HSP DOLORES F PETERSON 31916-22 770 S HANOVER ST ~'0 CARLISLE PA 170134105 CRNA • CARLISLE PO BOX 468 EAST PETERSBURG PA 17520.0468 535311 SR5.80 September 23, 2011 DO NOT SEND YAl'MENTS/COKRESMINDENCE T0: Kinetic Imaging Dept 13844 PO Box 1259 Oaks, PA 19456 ~I ICI III III INI NIWII ~ IIII ~IH ~I ~~ For billing questions call: 717-652-6105 Fax: 717-652-2165 Office Hours: Mon -Fri 7:OOam to S:OOpm ~~~lIIII~~II'I~I~~~III~1~11~11~1~1„'~~'~"'ll~ll~'1I111~IIL o DOL.ORES F PETERSON. $ "~;~ 1 ALLIANCE DR APT BT104 s CARLISLE PA 17013-4151 IF PAYING 9Y VBSA OR MABTEpCApD, RLL OUT BELAW ~y~ ^ MASTERCARD 11I111lFA ew.MT6 JaauNr r~l@ MUST tNCLIJU[ 3 DIGIT sEUtetrv r,DUS F~ enclc T1F cnpD -_ ~ _..,, _ . a A U -,,&t ~ , .'~ .TE Y a 9/8/2011 $6.40 9801 CHARGES AND CREDITS MADE AFTER STATEMENT SHOW AMOUNT ~ ( r~ 1 DATE WILL APPEAR ON NEXT STATEMENT. PAID. HERE ~ • ~ ;,; ~~ MAKE CHECKS PAYABLE / REMITTO: B~ tseos~s Kinetic Imaging 4520 Union .Deposit Rd Harrisburg,l?A 17111-2910 I~~~Ill~rrlr~~ll~r~ll~~~llr~ltllrl~~~~~llll~„~~I~III~~~~I~I~I ^ Please check box if above address is incorrect or insurance . PLEASE DETACH AND RETURN TOP PORTION WITH information has changed, and indicate change(s) on reverse side. YOUR PAYMENT IN ENCLOSED. ENVELOPE Patient: DOLORES F PETERSON Account: 9801 SerJ[ces Rendered At: Carlisle R ipnal Medical Center Proc ayments Balance Description Charge Adjustments Date Code 3 00 ` 4 6/6/2011 47000 BX LIVER NEEDLE . . 6 7/19/2011 PMT.AETNA MEDICARE CR Adjustment AETNA MEDICARE. Message: AETNA MEDICARE CONTRACT FEE 1 ACCEPTED ASSIGNMENT '8/11/2011 Message: AETNA PPO NON-STANDARD ADJ; CODE ON PAPER EOB 6!6/2011 77012 CT GUIDE NEEDLE PLACEMENT 250.00 7/19/2011 PMT AETNA MEDICARE CR Adjustment AETNA MEDICARE Message: AETNA MEDICARE CONTRACT SEE / ~c~-«~-2, o~ ~o(orre5 I~arr2(~ ~ff2rsor~ PAY TO THE ORDER OF_ c ~~ 111017 102:72 356.00 4.28 50.88 - 197.00 ~~ 6G.906 99 ~a ~~ ~ ~ 313 DATE ~ ~~ ~~ ~ - ~, a, DOLLARS ~ ~ :u COMMUNITY I BANK FOR O~~ -;•i:03 L309068~: ~X ~C ~P II'LOLS~"28L~~~41I' BALANCE DUE_ ~ 56.40 PAY BY October 08, 2011 Please call :with your insurance coverage or For billing questions calf: 717-652-6105 ramif the balance due #oday to; Fax: 717-652-2165 4520 Union Depasfl Rd Office Hours: Mon -Fri 7:OOam to S:OOpm Harria6urg,1'A` 17111-2910 STATEMENT Iq1~~~ SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 16605-8 Cha el Pointe ar ca2t~re 770 S. HA,NOVER STREET, CARLISLE, PA 17013 Mrs. Dolores F. Peterson Joellen Placeway 127 Fozbury Dr. Elizabethtawn, PA 17022 ...., ~r. reru~Trn~~nC Forth PB-01 f~U~s~k~~s?Ca~.r~: _-: 71 249-1363 ESIt?E T # ' F'' ;UNIT 'T.`.F3AT 12647 BFT-104 09/01/2011 Ft~S1f~ENT S Mrs. Dolores F'. Peterson XQT'A~ ANlQUNT:©UE $3.28 D,4T~ ©UE~:= ~. ~'~ U on Recei t DETAGN ANU Kt I urcrv i nia rvr~i iviv ~~ ~ ~ ~ ~ ~ ~~~. ~.~~.,, , , ~.,...,~ RnTE - - - - - - - - - DESGRiPTIQfV , r xr t, ~ .~;~.r~-~~~s } ~.r~~ ' ~ ~~!l'~ - Balance Forward 0.00 08!11/2011 Miscellaneous. 1. 3.28 3.28 Postage to forward Mail ~yH'~f'. ~/. +kS - KL. a~'~ W ~ ~F CL'AP6~~ f~~iRESr1,. ~N .~ .,J s~ ~ ~,,, '~ .~' ~ ~ 1' yY ,- ~' RKET ST:-$WTE 102 ~~ ~ ~' ~ ~ ~i+~ ~ ~ jj '~ ri. ,,~x ` ~ ELI~~QVti4N, PA '17022-29~~, i ~ -, -~. ~, ~I ~~ kfll'~~1~~' ~ ~ ~ ! ~ ~ ~f//~ f. ~Y~ ~ . Due to an error with the billing system, charges for August TV Cable and Telephone may not appear on this statement. Any missing charges will be charged to your Oct.lst bill. Thankyou for-your understanding. RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE .12647 3.28 0.00 0.00 0.00 0.00.. $3.28 Form PB-01-. RESIDENT NAME Mrs. Dolores F. Peterson CHAPEL POINTE AT CARLISLE, 770 S. HANOVER STREET, CARhISLE, PA 17013 I~ MOUNT ROCK INPATIENT SERVICES PO BOX .37807. PHILADELPHIA, PA 19101-7807 I11'llrLll'I'll~'ll'I111~111III1111'IIIILrIII'I'llll'llllllrrlr 0312D5-000009497Q456-08 #BWNJFDB #OOOOOOOCLE240503# DQLORES F PETERSON 1 ALLIANCE DR APT BT CARLISLE`PA 17013-4151'. STATEMENT. OF ACCOUNT (1) Statement Dater. Novemberlk4, 2011 ACCOUNT NUMBER: CLE94970456 Patient Name: DOLORES F PETERSON Tax ID # 27-2992138 Account Balance; 326.45 Amount Pending. . Insurance' 30.00 Amount Due-From Patient (Current): 326.45 Amount Dus >=rom Patient (Past Due): ta0.00 : Pay This Amount: 326.46 .PLEASE REMIT RAYMENT BY "PAY.MENT DUE BY"DATE. THANK.YOU.. Please.refer to coupon below for payment...... instructions, f .-~.n.i ulvlUladr_alPavments.com /mpolrtanr Ilfles~ay~a: This s~temem is for the direct treatment and/or suppeervision of care you recently received as a resuk of your Inpatient rwspmi Y N.. a....-.- :. ""~... fees for this private physician aro billed aeparotsly from any hospital charges or other prafesabnal fees for whkh you may also be responsibb. Therefore, snouw you ~~..a,... a till from the hosprlal or other physkiiarrs for charges in eonnecdon with this visit, R will not include the items listed on this statement. "Payment Plans"Accepted Questions`about this statement?/Clams de Lunes a Viernes? Gall 1-800-522-3998 Monday through Friday 9:OOAM - 3;OOPM. Your automated system access code is 1072-94970456, or you can send email to statement_questions~emcare.com. ~,~e~a-o,;zzs ~~ Please detach and return,.bottom portion. with your.remittance. ~+y _ Dot:oRES 1= PETERSON STATEMENT OF ACCOUNT 1 ALLIANCE DR APT BTStatement Date: November 04, 2011 CARLISLE PA 17o1s-41.51 ACCOUNT NUMBER: CLE94970456 YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD PatleM Name: DOLORES F PETERSON PLEASE SEE REVERSE SIDE. Payment Due By: 11126/11 Make ahecklMoney Order payable to: Amount Due: 326.45 Amount Enclosed: (Q . [.~ "~ MOUNT ROCK INPATIENT SERVICES ISO BOX 37807 PHILADELPHIA, PA 19101-7807 iluiii,iuutiiiinaaiiiinnaiiiiatin.iiiatiatiniiri If your address has changed, check this box. and complete the reverse side of this form Go Green -pay online at www.MyMedicalPayrr~ertts.com The insurance information in our fib appearo below. Please make any corractbns and/or additions on the reverse side of this form and return it to us. Thank you. AETSR AETNA SENIOR CHOICE. MEBDSYWN AE4090161100 60054 ATTN: HEALTH CLAaAS EL PASO TX 79998- 1106 AETL1 AETNA US HEALTHCARE W064575301034702204900 80054 ATTN: HEALTH CLAIMS EL PASO TX 79998- 1106 031205000009497045600D026450000000000005 Owens-Illinois Salary Retirement Plan do New York Life Retirement Plan Services P.O. Box 796 Norwood, MA 02062-0796 September 23, 2011 Estate of Dolores Peterson BT 104 1 Alliance Drive Carlisle, PA 17013 Dear Sir or Madam: ~B-en-efits Complete' ~-OPLAN INFORMATION www.bcomplete.com or (800) 2943575 Information provided by *** *** We are sorry to hear of the death of Dolores Peterson. According to the Plan, the last payment due to the participant is the one falling due immediately before the date of a Participant''s death. We respectfully request the return of the 7/12011 payment in the amount of X994.09. This represents the payment made to the participant subsequent to their death. Please make a check or money order payable to "NYLTC fbo Owens-Illinois Salary Retirement Plan" and mail it to the address shown below: New York Life Retirement Plan Services P.O. Box 796 Norwood, MA OZ062-0796 Thank you for your assistance and please accept our condolences. Sincerely, New York, Life Retirement Plan Services _. ~ ~ - - ,~ _ .. - r ,, _~_ <. _ L ~ _ v ('f1 - ~ ^ ~ ~ ~ ~~ ~Z s ' `~ 1n ~~ ~' `~ a ^ ,~ g a ~ w ^ m~Z ~ m Y _ ~s~g d I O fit-' a ~ i 9 c - ~, ~' o ~ ;, z a off` to ~ 9 ~ rn ~°' ~ ~ ~ s ~~'&~ m d ~ EA J U 1i `'~ ga 9 LL °M y ~ ~ ~ ,y~ f °~° u"i ~» z a. LrnN ^ 9 o mg's ~ m- ~- ~ g 0.,1.~i {. azz, a~'igm -° ~g N x ~' ~ y~g s ~ ~ `~3 ~ , ~- C o -o ~, ,~ k ~ ~ v ~~ ~3 ~ LL~9 Cr z.~ ~5m E $g a~ m N ° ~ r O~ c`m~ ~ ~y~OO Qi 'mi.€q ". C * Qp G~m ~{a m£ t6 ~g~ ~ i"„ _,~ it tE .~'ga ~gS o~ ~q ~~aN `~"~ +r~> a5 z~~ ~.. ~a~ n ~ '~•- °' °d~= o~w~a tn~ -p~zs u4~~ ~ wu~7 u¢i `ns ^ ~L c~ E ~ ,~ ~ ~- _ ~" ^ N ~11rrr .,, ~ ~ 'may m '~°`° ~ A: m ~. ~~ ~ `c ~ ~~ ~.4 ". r~~ i ~„} 'fop .' L:: ,~ -r? ~/ A ~ ._ ~ ~ ~ t1j r~ Q "~. " c ." a LLL"' ~@ E o ~Oa 3 W LL~ a m .. ~ N SZ J (~ r m m ~ 4 Y Q [ ,a} Cm co U Q ~"'~ ~ ~~ ~p tpL p N z aa~++ x3Pa~ag"008'ti ~ ` ~ 6£~~~£9V'~OS~I _ ~ ~. • ~ = .... __.. - ~_..