HomeMy WebLinkAbout06-12-121505610143
REV-1500 Ex(°'-'°'
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO 80X280601 INHERITANCE TAX RETURN r;' ~'n
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 12 GT-~LY "~~
ENTER DECEDENT INFORMATION BELOW U
Social Security Number Date of Death Date of Birth
11 05 2011 02 02 1917
Decedent's Last Name Suffix Decedent's First Name MI
HUEY LYDA
M
(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
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 4. Limited Estate ^ qa, Future Interest Compromise 5. Federal Estate Tax Return Re uired
(date of death after 12-12-82) ^ q
8 Decedent Died Testate
(Attach Copy of Will) ^ Y Decedent Maintained a Living Trust 0 8. Total Number of Safe De OSit Boxes
(Attach Copy of Trust) - p
^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (date of deatn 11. Election to tax under Sec. 9113 A
between 12-31-J1 and 1-1-95) ^ ( )
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JOHN S DAVIDSON 717 533 5101
REGISTER OF WILLS USE ONLY
First line of address
320 WEST CHOCOLATE AVE
Second line of address
PO BOX 437
City or Post Office
HERSHEY
State ZIP Code
PA 17033
Correspondent's a-mail address: jdavldSOn@yoStdavidSOn.COm
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Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
^~` >^ , ~ ;~ y' " ~r~- ~ ~ -{ ~ Mary Ann Carpenter
ADDRESS
175 Hollywood Drive, Middletown PA 17057
SIGNATURE OF PREP RER OTHER THAN REPRESENTATIVE DATE
,;~~~;~£~!l~t~>--- John S. Davidson .y~L~,.-4i
~~i
320 West Chocolate Ave., Hershey, PA 17033
Side 1
1505610143 1505610143 J
~~'
1505610243
REV-1500 EX
Decedent's Social Security Number
°e°ede"es Name Huey, Lyda Mae
RE CAPITULATION -_- "-
1. Real Estate (Schedule A) ..................................................................................... .. 1.
2. Stocks and Bonds (Schedule B) ........................................................................... .. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)....... .. 3.
4. Mortgages & Notes Receivable (Schedule D) ...................................................... .. 4.
5~ Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............. .. 5. 2 , 166.07
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested........... . 6. 1 , 74 6.80
7. Inter-Vivos Transfers & Miscellaneous ion,-Probate Property
(Schedule G) a Separate Billing Requested........... . 7.
8. Total Gross Assets (total Lines 1-7) ................................................................... .. 8. 3 , 912.87
9.
Funeral Expenses i~ Administrative Costs (Schedule H) ......................................
. 9. -- ------- -
1 , 401.75
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................. . 10. 8 6.13
11. Total Deductions (total Lines 9 & 10) .................................................................. . 11. 1 , 4 8 7 . 8 8
12. Net Value of Estate (Line 8 minus Line 11) ......................................................... . 12. 2 , 424.99
13. Charitable and Governmental BequestslSec 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) .............................................. . 14. 2 , 424.99
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .00 15. 0.00
16. Amount of Line 14 taxable
at lineal rate x .045 2 , 424.99 16. 10 9.12
17. Amount of Line 14 taxable
at sibling rate X .12 0. 0 0 17. 0. 0 0
18. Amount of Line 14 taxable
at collateral rate X 15 0. 0 0 18. 0. 0 0
19. Tax Due ................................................................................................................ . 19. 10 9.12
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243 J
REV-1500 EX Page 3
Decedent's Complete Address
File Number 21-12
DECEDENT'S NAME
Huey, Lyda Mae
STREET ADDRESS - --------
Church of God Home
801 North Hanover Street
CITY
Carlisle STATE ZIP
PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount 0.00
3. Interest
(1) 109.12
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box 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 the TAX DUE.
Total Credits (A + g) (2) 0.00
(3)
(4)
(5> 109.12
Make Check Payable to: REGISTER OF WILLS, AGENT.
Wit= '*.'r'±_ ~ ~ ~?Sasl, r ~ F.#, ~~ 3~ eki 11 . ~~ _
.. >....~
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 :............................................................................... j_~ 0
b. retain the right to designate who shall use the property transferred or its income :..................................
c. retain a reversionary interest; or ............................................................................................................. C~
d. receive the promise for life of either payments, benefits or care? ............................................................ . ^x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without r~
receiving adequate consideration? ....................................................._..........................................................._ ~~ IJ
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.......
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .................................................................................................................. ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G 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 of the surviving
spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 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
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 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)]. A
sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
Rev-1508 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
H
da Mae
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
FILE NUMBER
21-12
o~ ~~~~~c space s neeoea, aaD¢lonal pages or the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
Rev-1509 EX+ (6-98)
SCHEDULE F
COMMONWEALTHOF PENNSYLVANIA JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Huey, Lyda Mae 21-12
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Mary Ann Carpenter
B.
C.
175 Hollywood Drive Daughter
Middletown, PA 17057
JOINTLY OWNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT
NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR
JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSE % OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1 A 1992 Citizens Bank -checking account 3,488.59 50.000% 1,744.30
2 A 1992 PSECU -credit union account 5.00 50.000% 2.50
TOTAL (Also enter on Line 6, Recapitulation)
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
1,746.80
Form PA-1500 Schedule F (Rev. 6-98)
REV-1151 EX+(10-06)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Huey, Lyda Mae 21-12
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
See continuation schedule(s) attached
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
866.80
Street Address
City State Zio
Year(sl Commission paid
2. Attorney's Fees Yost 8c Davidson 300.00
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
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 234.95
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 1,401.75
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-Oti)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Huey, Lyda Mae 21 12
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral ExnenseS
1 Edward Carpenter -reimburse expenses of restoration of grave site after burial 100.00
2 Gingrich Memorials -cemetery marker 135.00
3 Michele Hughes Lutz -flowers for funeral service 31.80
4 Pastor Billy G. Holmes 100.00
5 Pastor Bradley Moore 100.00
6 Pastor Samuel R. M. Cuningham 100.00
7 Patty Keller -funeral luncheon 200.00
8 Ruth Sweigart -organist for memorial service 100.00
H-A 866.80
Other Administrative Costs
9 Edward Carpenter - 2011 income tax preparation fee and electronic filing fee 219.95
10 Register of Wills -filing fee 15.00
H-B7 234.95
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rev-1512 EX+~72-08)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, 8~ LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hue , L da Mae 21-12
Report debts incurred by the decedent prior to death that remained unpaid at the date of death. inrludinn nn~ein,n~~~~o.~ moa~~~i o.,..e.,~e~
to mole space is needed, additional pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08)
REV-1513 EX+ (11-08)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
Hue , L da Mae
NUMBER NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
I~ TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116 a 1.2
Mary Ann Carpenter
175 Hollywood Drive
Middletown, PA 17057
FILE NUMBER
21-12
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
DECEDENT (Words) ($$$)
o N t List Tru tee s
Daughter I entire estate I 2,424.99
~ ~ Total ~ 2,424.99
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet, as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II. 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 DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08)
LOCAL REGISTRAR'S CERTIFICATION OF DEATt~I
WARNING: It is illegal to duplicate this copy by photostat or photograph(.
Fee for this certificate, w6-l)(i il,'"~~~ OFp~f~ ~ _I hip i; tt, crtn tl al tht Irrfornul[iun huc t,*i~'en is
tytdtl. ~A~6~~ ~zl~i ~~ ~ 111f'C'IIV' ~t1{lIL'LI Ilr I11 ;II1 t)I lr~l [l a~ ~~l'l UI1~aIe lll'[~l'~l)~]
I~,~~`~~ ~ ~°~~;, ~i 11v File ! ~~ Ilh rite -t~ 1 tx~al Rclalsu~ar. The ori~~itZal
~`~' ~, z~ c ftlt~it.al~ ~~f!I '~c !~,rev.u~cied to :he State Vital
1;~~ v~~i ~a:, Rrccrrd~ t>*'sLS: t ( .,.,):)anent I~illm~.
N~V 0
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- -- - --- --_, MfNT 9F err _ _._ _- _ - _ - ----- -1--~---
Certifjcution Number ,,,,=,ryt~~ l tfc;tl Rr~tf,tlar I>atc ]sued
!3 REV t1f2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
I PRIM IN
.ACKN NKT CERTIFICATE OF DEATH
(See Instructions and excamoles nn raverswl
1. Name of Decedent (First, middle, last, sullix) 2. Sex
+ 3. Sodel Securtry Number rv
i - d. Oats of Death (MOmh, day, year)
6. Age (Last amdey) Untler 1 ar der 1 de fi. Date of BiM Momh, de , r 7. Bi lace C' aM state or lor e' cou Se. place d Deam Check on one
k1r•ima Days Houn Minutes Hospital: Omer:
Yrs. ~ - a ^ Inpatient ^ ER / Outpatient ^ DOA
N
ursing Home ^ Resitlence ^ Other ~ Speciry~.
r~
-
Bb. County of Death f1c. CAy, Boro, 7wp. of Death Fadl' time (II not nstlNtlon, g street number) 9. Was Decedent d Hlspenk Origin? ICIiNO ^ Yes 10. Race American Indian, Black, While, etc.
_ (N Yes, sa~Y seen, (sperm
~ ./? Mexican, Puerto Rican, etc.) ti
'
11. Decedent
s Usua10 Ibn Kintl of worN done tludn moll d workin INe. De rid state retiretl 12. Was Decedent ever In the 13. Deceeem's Eduatbn (S onry highest grade completed) 14. MarAal Status: Martietl, Never Marred, 75. Survhing Spouse (If wife, give maiden nemel
Kind of Work Kind d Business!
Industry U.S. Armed Forcas7 Elementary (Secondary (0-12) College (1d or Si) Widowed, DNOrced (SpeciryJ
//
e V e 'T'% ^Ves ~JO ~ /'
16. Decedents Mailing Address OStreet c
Ny /town, state, zip code) Deceden's / ( Did Decedent
/
g 0 1 N o r7"7i !fa f1 o Ve r $} r2c~ Actual Residence , 7a. State _I_?Q1] L] S U / / I'l ~
T~^s
a
, 7c. ^ Vea, Decadent Lived in T
l
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wp
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_ ~ 17h. Co ~[ / ir1 ~, 2 `!n H O\ p 17d. ~No, Decedent Lived within.
Q ~
'
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Acluel Limits of t
n r
i ~
Q City J Boro
16. Father's Name (First, middl ,last, suffix) 19. Mothers Name (Firs(, mkWe, maiden sumeme)
/ ~ /
20a. Inlortnam's Name (type I Print) 20b. Inlamant's frig Adtlress (Street, ary I town, state, zip coda(
• r ~, ~ ~ '7
' "
21 e. Memotl d D
on ~ ^ Cremation ^ Donation 21 b. Date of DreposMan (MOmh, day, year) 21 c. Place d Dlapos' ~ me of certletery, crematory or dhe place) 21d. Loralion (City Irown, stale. zip code)
Ip Buda( ^ Removal from State i
Wee Cremation a Daxtlon Aumorhed
^ er ~ l by MMlcel EeeminxlCoronerT ^Ves^ Flo ~ ` r µ 1
,
' 1
.Signature of Funeral Samce Licensee (or person acNrg as such) 22b. License Number 22c. ame end Address d Fedliry k. ~ r4 ~ G ,~ f. n p ~~ r !
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Complete Name 23aa onry when cedlrying 23a. To the best of my ledge, death occurted at the tlme, date aM place stated. (SlgnaNre entl NNa) 23b. umber 23c
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onth, day, year)
phyekian is not aveileda at Nme d deem to P
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12.ti15532~1 fl~11f,M.~,lt 071 0201(
Items 2426 must be can tetl
Wtp prppurx:es deem.
~ ~ ~~ 24. Time or Deam
~ykl
O~ D O A ( y )
~'~tre Pronounced d Monm, de , er
l 1 A, 1/" • /lrJ1 26. Wes Case Referted to Medical Examirer I Coroner for a Reason Omer Than Cremation or Donation?
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CAUSE OF OEATN (Sea
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l Appmximete interveh
Item 27. Pad I: Enter me rdlein of events -diseases, Inrydes, or complications -met tiredly ralxed th deem. W NOT enter romlirel events such es caNiec arrest
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D Ped IC Edar omer Hgni&ant mnditians hiblm.,w• tc death 28. Did 7obacce Use ConMbute to Death?
,
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eelh
res{dratory artest or ventrkular Abdlladon wNhout showing the eNdogy. List onry a cause on etch Ilna. ;
L
IMMEDIATE CAUSE IFnel dusaase or /Z bd trot tee
Wmg In me undedying cause groan in Pen I.
^pya~~t ^ p~yyly
LJ^I No ^ Unknown
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rondition resuPong in deem) ~, s. ( r ~ f
29. If Female.
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ue
o (or as a
uence oQ:
fialN list conditions, tl arty, b. ~I~~~
ro the cause Asletl on lire a. ot pregnant wNhin past year
^ Pregnant el lime of Beam
Emer a UNDERLYSiG CAUBE Due m (or as a ronsequerwe op: ^ Nc1 pregnant but pregnant wimin 42 tlays
(disease or injury mat idNatetl me c.
events resulting in deem) FAST. e~ deem
Due to for as a cortseguerwe o(1.
^ Not ore nant hm
g preonant 43 tlays l0 1 year
d ~ belare deem
^ Unknovm N pregnant wahm me past year
30e. Was an Autopsy 30b. Ware Autopsy Endings 37 Manrrer d Deem 32e. Date d In)ury (Month, tlay, year) 32b. Desedbe How Injury Occurred
Pedom~etl7 Available Prior ro Completion ~~55 32c. Place of Injury: Home, Fann, Street Factory
d Cause of Daem7 r~l Natural ^ Homaida .
ONice Builtling, etc. (Sperry)
^ Ves ~No ^Ves ^ No ^ Acdtlem ^ Pending Irrvestlgetion 32d. Time of Iryury 32e. In)ury et Wodr? 321 N Trensponetion Iryury (Ste~H1 32g. Location of inluy (Street c Ay ~ tcmm, state)
^ Suklde ^ Could Not he Detemaned ^Ves ^ No ^ Driver/Operator ^ Paseerger ^ Pedestden
M ^ Olher~ Spaciy:
33a. Cermar (dreck ody one)
• CMUylnq physkhn (Phyeiden certirykg cause d deem when another physlden has pronounced deem and carpeted Item 23
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ptMmylmowNege, seem acurretl euam me ausa(s)end manner tie etetae_______________
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ronouneing entl anllying phyekien (Physldan both pmnoundng deem and cediylrg ro reuse d deem)
T
h 33c. Ucense NMMer 33d. Date Signetl (Month
tlay
Year)
o t
e beat of my larosrktlge, deem oaurted M the [Ime, dale. tine pMce, entl due to the ceuae(e) and msnror tie ahtee_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ ~ (~ ~ r ,
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On the laeeb of exeminetbn entl / or InvesllgaUOn, In my oplnbn, tleam oxurred m the Ume, eels, tine plea, tine sue to the gees(e) entl manner es stsMe
^ 34
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erson WM Completetl Cause of Deam (Item 27) Type I Prirt
35. Registrars SigneNre entl Disbld NuMar
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