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HomeMy WebLinkAbout06-27-12a 1505610101 REV-1500 °`t°'_1O' ~' n _ lvarria OFFICIAL USE ONLY PA Department of Revenue f~ sY County Code Year Bureau of Individual Taxes 6 ~~.~, INHERITANCE TAX RETURN PO BOX 28o6oi Harrisburg, PA i~iz8-o6oi RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY I -'' Die-c~edent's Last Name Suffix Decedent's First Name (If Applicable) Enter Surviving Spouse's Information Below MI ( MI :~. File Number ~ ~ ~~ ~- Spouse's Last Name Suffix Spouses First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE .~.~~~ `~ ~~ =~ ~' -~~`' ~~ REGISTER (3F WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return p 4. Limited Estate ~ 6. Decedent Died Testate (Attach Copy of Will) ~ 9. Litigation Proceeds Received p 2. Supplemental Return p 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) p 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) r,_) ~. R=maunder Return (date of death ^Gr to 12-13-82j O 5. Federal Estate Tax Return Required 8. T~ta! Number of Safe Deposit Boxes O 1 .. Election. to tax under Sec. 9113(A) {Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO Name Daytime Telephone Number REG'STER r WI~i.S US~ONLY ~ f-~ ~ )_~ ~ ~ FJ ~ r-R First line of address ' ' ~" r- ~ ~ -~ t t t _ r-+ Second line of address --~ c ~ ~~' ~' C7~-. ~~ " r` f7 -': ~ ~ , c J r ~ _ City or Post Office State ZIP Code --------~- ° ;,- • . C_ 1 .. Correspondent's e-mail address: "`~~ EL`F' s ., "'. '~'~:'+~{~'.r r~~=- Under penalties of perjury, I declare that 1 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. SIGNAT E F PERSON ESPONS LE FOR FI iNG RETU N DATE ._. /, 7 / ADDRESS .___.. _~.._ __-..__ ,.__,.__.-_m-........_..__._.,_.s..., _ __ ._,.~. SIGNATURE fd~ P{2EPA~ER OTHER THAN REPRESENTATIVE ~~~~ ~~ ~ ~ -.,_„w.,k..~,_•~~ ~^~-~~ ~~~ j ~ DATE ~. -~ M -~- ..a_.~ _,._ _.~.__ _.~..-oe _.. ._____. H~ ....__ ... ._ n PLEASE USE ORIGINAL FORM ONLY 1505610101 Side 1 1505610101 ?. ~) J REV-1500 EX Decedent's Name: RECAPITULATION Decedent's Sociai Security Number Y 12 ( ~ S S ~v 1. Real Estate (Schedule A) ............................................ . 1. (~ ~ 2. Stocks and Bonds (Schedule B) ................................... . .. . 2. ~ (~~ I ~ ~ • ~ jp 3. Closely Held Corporation, Partnership or Sole-Proprietorship {Schedule C) .... . 3. ~•~ ~ 4. Mortgages and Notes Receivable (Schedule D) .......................... . 4. ~ • 4 (~ 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)...... . 5. ~ Z 3 • ~ Z 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ...... . 6. ~ . © ~ 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) c) Separate Billing Requested....... . 7. ~ • 0 :? 8. Total Gross Assets (total Lines 1 through 7) ............................ . 8. ~ ,~ ~ ~ '~ €p . ~ ~` 9. __. a~_ Funeral Expenses and Administrative Costs (Schedule H) .................. . 9. ~ C~ ~ ( (,7• ~ (p 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. . 10. ~. ~ 11. Total Deductions (total Lines 9 and 10) ................................ . 11. ~ ~ ~ } (, ,~, (P 12. Net Value of Estate (Line 8 minus Line 11) ............................. . 12. ~ 3 ~ ~ ~ . "7 z i3. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ....................... . 13. ;~ . ~ 14. Net Value Subject to Tax (Line 12 minus Line 13) ....................... . 14. ~ ~ i) /+~ • /'~ ~ TAX CALCULATION -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 .0~ ~ 3 .o ~ b ~ ~. 15. ~~. ~ .w) 16. Amount of Line 14 taxable at lineal rate X .0 _ • 16. 17. Amount of Line 14 taxable at sibling rate X .12 • 17. 18. Amount of Line 14 taxable at collateral rate X .15 • 18. • 19. TAX DUE .........................................................19. 20. FILL fN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610105 1505610105 1505610105 O REV-],502 EX+ (01.10) 4 ~ ~ pennsylvania SCHEDULE A DEPARTMENT OF REVENUE -- REA! ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NU BER: All real property owned solely or as a tenant in common must be reported at fair market value. Fair markzt value is defined s the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable kno ledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. ~(~1~~ r~~~L TOTAL (Also enter on Line 1, Recapitulation.) 'l~ e /~;- ~.., ... If more space is needed, use additional sheets of paper of the same size. REV-150:1 EX+ (6-98) _. SCHEp1~LEByy COMMONWEALTH OF PENNSYLVANIA ~V4KS & DVIrVS INHERITANCE TAX RETURN RESIDENT DECEDENT LJ rRIC Vr' ~ ~ ~~ ~ww.ua.~ All property jointly-owned with right of survivorship must be disdosed on Schedule F. ~M NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. M~~ P~~. ~~ X700 l~ ~~~3 i I !~ I i"OTAL (Also enter on line 2, Recapitulation) $ ~ ~(:~ ~'°~ ~, ~ ~ {If more space is needed, insert addRanal sheets of the same size) REV-1507 EX+ (1-97j . SCNEDt~LE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF ~'~ 5,,-, ~ _ FILE NUMBER Tom! ,~.~~ ! ~'.. ~; , ' s':: i;~ -.;~ _ i - , _~ s , All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH TOTAL (Also enter an line 4, Recapitulation) $ G iQv (If more space is needed, insert additional sheets of the same size) r+~vasae IX • 1+~ CAMtJONWEALTH t)F PENNSYLVANIA n~HEwrnNCE rnx RETURN SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER 4-- -_ / .. tr-dude the proceeds of litlgation and the dad the proceeds were received by the estate, Aq property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. ~ i, ~ ~1 /^y / TOTAL (Also enter on line 5, Recapitulation) I S ~ 2 ~ . I (If more space is needed, insert additional sheets of the same size) pennsylvania SCNEp1~LE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: fJ~ t- J! /" F LE NUMBER: , If an asset became jointly owned within one year of the decedents date of death, it must be report ~ on Schedule G. SURVIVING ]DINT TENANT(S) NAME(S) ADDRESS .LATIONSHIP TO DECEDENT A. ~ J~..~s~ ~~ ~r.S~..3E.~'"~ ~ r'" --' ~,~~ '~~~7-r''~/ JT- ~ f 5'J ~ ~c _~ ~ +'~ ~ i~.~G J ~~~;r'.- r°~- B. C IOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR IOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTIDN ANO BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE. GATE OF DEATH VALUE OF ASSET % OF DECEDENT'S INTEREST DATE OF DEATH VALUE DF DECEDENT'S INTEREST 1. A. G/~,Ff_~ • !Ul)• Cia ~l 7 al G ~ 1/) Ic"[~LD 1":.f~ r,tC °'D fit? L1t (,]L~ e tf'y /~ ~ ~ ~d~ J j~.~ Q^r1 J ^~~ ~] i j , + N f!• („S ~a~(° t~ 1 a'~."y / n,~~7,t ~, . FS `fi~ ~ ~ ~' t . '1~~'~°`•-?''' , ,J ~'"!(j .~i~J+(~ ~ ~ /7 ~ ~ ^ 3 r ~~ . ? 5;'~"V l ~~r~ t!~ r ~.4r~° ~ ~ JI .~ .^.. 7,, , X65 Q /C7:.~ • / ~'~fi' ~'!e~ ( ~/ y ~ ~ O/ o!/ s s .... '7 J.', L/ l! ~ ~, ~. , ~~ CJ g ++~~ i t f ~, '. K -- ~ ~ .. ~ ,. t ti ~~ r Y'~ ~ ~ ^µ ~ { l ~ ; . J TOTAL {Also enter on Line 6, Recapitulation) I $ l~ I ~~i~:~ If more space is needed, use additional sheets of paper of the same size. REI!-1510 EX+ (68-09) 4 ~ SCHEDULE G -h ~ -~ pennsyEvania ~ nEPARTMENT OF REVENUE ' INHERITANCE TAX nFruuN RESU~Nr oE~oExr INTER-VIVOS TRANSFERS ANQ MISC. NON-PROBATE PROPERTY ESTATE OF FILE NU BER This scfiedule must be rnmpleted and filed if the answer to any of questions 1 through 4 on page three of the REV- 5Q0 is yes. TEEM NUMBHi DESCRIPTION OF PROPERTY nrauoe 1~ Nnv~ aF IrE InaesR~, ~ xaAnoxs~ to oECEO~xr ara Ttff DAT[ of 7RAttSFHI ATp4Ql A CoM ~ TfE DEED R]R &51L gotta DATE OF DEATH VALUE OF ASSET % OF DECD`S INTEREST EXCWSION pr a~auG&E) TAXABLE VAWE 1 ~~~~- ~ ~- rtJ t t ~a t D~ ( ~7~s /H~"Qv ~,K, ~O off. ~~n ~~ ~. ~c x, c"~® ; ~ ~. ~ . . t 1 P ~e ~~ > ) s • U• ~~Ul~~ b{~ ~ 1 ' vi`~ t.~-J~ ~1~~ .nl M~f~ F~k-~ ~'D ~ v1. 5 1 f ~4.iv'.P>.r:.6..5/:u' j~~~~r~ r ~ ~.I~:A ~ TOTA! (Also enter on Line 7, Recapitulation) $ ~ ~, If more space is needed, use addltlonal sheets of paper of the same size. REV-1511 EX+ (lU-tl5) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAx RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUM BER SUS r; ~ '~ L~ l~vc~c .~, , _ ; , ~~i ~ ~ ~ %~: ~. ~ ~ _ Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT _ A. FUNERAL EXPENSES: 1. Pte; ~1~J~=..: a=G~~~<~~. _ ~ ~~~=,~ ~ r ~ a. -' ~ ..: ~ ~ ~ ~ ,~ ~r~~ ~ cry ~= y.. '.' It~l ~~ ., B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) ~` ~`~ Street Address __ City _____ State ____ ZIP ______ Year(s) Commission Paid: 2. Attorney Fees: ~'(' I Q L)l7. ~~~ 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: ~~-~, ~- S. Accountant Fees: ~ jt). 6. Tax Return Preparer Fees: . t' r_ _ ~~( 1 ~ ~~ ~1~;~ It ..~ '"Y•-._ .. -. ~-. ~i'~ ~ X11 ~ - a _ in {~~; I;, ~~~~_ !~ ~. r _ _ i ~'. VCS`' ~ ~~ s.~ :°"• ~- Co ` _.. ~- ~ . )s. ~ sT ~, ~-~~-J s~~~ ~,~y ~ ~~f.~~~ 9 v ~ . ~ TOTAL (Also enter on Line 9, Recapitulation) $ ~v tp , ~ ~J -~ If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) ~~ ~~~ Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT INHERITANCE TAX RERIRN MORTGAGE LIABILITIES & LIENS ~ RESIDENT DECEDENT ESTATE OF FILE NU BE _ ~~i ~ ;-- _ ~;) ~'~ ,a~,,,,, ~~ t ~~® `-~-~• <<~ D ~e.~ p .P -- r' .~:~ ,~~ Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbu d medics{ expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH i. I~ ~ ~.~~ I i _ (~.6L> i I TOTAL (Also enter on Line 10, Recapitulation) ~ $ b~ ^c, If more space is needed, insert additional sheets of the same size. REV•1513 EX+ (01-10) `~, Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF: FILE NUMBER: RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE i TAXABLE DISTRIBUTIONS [Include outright spousal distributlons and transfers under Sec. 9116 (a) (1.2).] •.~ jj ~-l ~ ~ f cam/ ~; j, ~~ff ~ '~ / "y~ .-c-.'`jvl (;t ~ ~~L,; _i' j .'~y - ,~~r~'-,. € ~ C ` _ 11. j ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A I 6 APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: i. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size. REV-1500 EX Page 3 Decedent's Comulete Address: Fiie Number ,. , ., ..r,...~ { . ADDRESS d~ CITY :-~ L-• -. ~ 3 JTAt t ~,, ZIP ~ ~ ~,~ r Tax Payments and Credits: €1.I ~,;~:.~ 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, tine 20 to request a refund. ~, 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. ` t~ "~~ Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes a. retain the use or income of the property transferred :.......................................................................................... ! .~ -; b. retain the right to designate who shall use the properly transferred or its income : ............................................ ~` f c. retain a reversionary interest; or .......................................................................................................................... ',_; - d. receive the promise for life of either payments, benefds or care? ...................................................................... '! _ - 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death _ ~- without receiving adequate consideration? .............................................................................................................. ~_ - 3. Did decedent own an "in trust for" or payable-upon~teath 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 benefiaary designation? ........................................................................................................................ ~ t 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 ~3se of the survnring spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)). 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 adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)J. The tax rate imposed on the net value of transfers to or for the use of the decedents 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 decedents siblings is 12 percent (72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Total Credits (A. + B ; 2 i .. PRENEED COUNSELOR SALES RECEIPT -- - - - ~_:. o- _ ~ t^ - , ., , - .; 1. DATE ~'~ ~ RECEIVED FROM _~ 0 v~.Q_ C ~ ~ O t/L1J~~SY~.~ [~ ?~' ameof(PUrchaser ~~ ~~~ /~, THE AMOUNT OF~~~~X'~~--O~.n ~C~,~~, ~~~1 Ch ~~,v~t..4 d ~c~~~ DOLLARS ($ tC?~ ~ - y/ )) AS: DOWN PAYMENT ^ REGULAR PAYMENT ^ ~ CREDIT CARD CHARGE ^ CASH ^ CHECKL-il,// CARDTYPE ^ FOR THE PURCHASE OF INTERMENT RIGHTS AND/OR MERCHANDISE AND SERVICES FROM THE ABOVE NAMED CEMETERY. RECEIVED BY CEMETERY SALES COUNSELO NAME SATE ^Y GEN 8002 {6/02) Contract File Folder Name/Number CEMETERY INTERMENT RIGHTS, MERCHANDISE, AND SERVICES PURCHASE/SECURITY AGREEMENT THIS AGRF.F,MF.NT PRnVinF.C FC1R PF.RPF.TiIAi./F.T111nwMF.NT reuF The undersigned, referred to as `Purchaser', hereby agrees to purchase the Interment Rights, Merchandise and Services described herein, subject to acceptance and approval of the above named cemetery, hereafter referred to as `Seller'. Purchaser. Last Name: I I! r l I I( I I 1 1 1 1 1 1 1 1 First-. I:: I I_.. !. I' I- 1 1 1 1 1 1 I I Middle: I I I I I I Telephone: (_~ .- SSN: DOB: / / Email: Address:' l ~: 1 1 ( I I i I I h f I- I 1'T"'I City: v : , State: Zip: - 1 1 1 1 1 1 1 I`.~ f I` I ~1-~ I t l 1 a [ il~• L I ~ }. I Co-Purchaser. Last Name: I l i l l l l l l l l l l l l l l l Ftrst. 1 -1 l l l l l l l l l l l l Mtddle. 1 1 1 I I I I Telephone: (~ _ SSN: DOB: / / Email: Address: I I I I I I I I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 City: 1 1 1 1 1 1 1 1 1 1 1 1 1 State: I I I Zip: Deceased: La>t Name: I C- I I F I- [' I I 1 1 1 1 1 1 1 I First` I-: I M F I~ 'I •`.I•' I I I T i l l I Middle: I I I I I DOB: / / DOD: / / Burial Date: / / Veteran: Description of Interment Rights to be used: - - Memorialization Rights: Issue Certificate of Inerment Right to Address: City: State: Zip: INTERMENT MERCHANDISE & SERVICES • Interment Rights _ $ Urn -- _ (Includes Perpetual/Endowment Care of $ ) Supplier • Interment and Recording Fees Type/Color • Outer Burial Container - Design/Size ', Supplier _ Admin/Processing Fee Model/Design Other - MateriallColor _ Other • Outer Burial Container Installation -- Other '1fE'\IORIALIZATION Other • ~Ietnorial Other --~- - _ Other - TOTALS. ALLOWANCES & TAXES - Interment Rights ............................. °- ° _ ~:~-~ - Reason -_ - Merchandise/Service ........................................................ ( _ _ Reason - - - Apply to .-_ ;-: F'crpett~ai Etaodwa=~-^~° :=ire _ lierchandtse/Service ........................................................ ( -.. ~ • _ ~ ~ _ ; n tallat~~r± F~ ~ Reason t.c.__- _3z Inspection Ft-e ~_-.'. t^ ' ~a ".z,:23t2 Stroll Suh Total .. • ~tt..rn~ T~3taI Ta_aaGl: • Fi.a~.~ trace Sai~ Ta` if appli:al3,e .-..._ _ __ __ _. _ _......._... ---- _- TOTAL CASH PRICE ~ _ T.. 1:e Ci?ur Less: Down Payment DesignlSize Other • Vase Base --- Total-Down Payment ¢ - - = ~--) -- Size/Material ~ Unpaid Balance of Total Cash Price $ J . ~ 1~:_ _ • -:_ - _ lance not paid within _ _ - ~ - - -- '- - - ---- - --- --- -- -- -~ ---_ :. e _:..~ant recei~~ed and credit the ..- :~_r ,, ._...,: - _ _ _ - - - :-::- -_~- ~_.._ _ .- - --~ --- - -~ 11 _ - _ _ '-- _ _ - `- -'-. _ -- - -, _ _; ~_-_.._ _c ~~a~e. Seller wi retain title to _ _ - -, - - - - - _ • . _ - - _ - .= - -'~'c- -_ _ -a- -• : -- =~ . - _ tton and Purchaser I g g P - ~ -- -- -- - .~ - ---•-~ ~s ivin u ~+ , • _ - . ° _ _ Rziaton~ip: Accepted by: I mteu that I have reviewed this document ror accuracy and cumpletenrss. - ~'_'- - - ~ - Relationship: Date: / / - -~__ ~- `40TICE: See Other Side for Additional Terms and Conditions which are Part of This Agreement - -~ _. - - ~ \ ~ / /~A . ~ ~, °'-!' A Family Tradition C-f C~~~ng R' PARTH~C,)R~ Funeral Howie 8z Cremation Services, Inc. 1303 Bride Street 1?.O. Boy -', ; l iVeti~~ Cumberland. P_~ ~ ~0 ~U (-1?) ---#--~~ (Fay) ~-Y-~~-'r; ~~~~~ tiv.panhemore.com Gilbert Z~~. Partl~em~~re. Founder Mrs. Arlene B. Dougherty 218 Bailey Street New Cumberland, PA 17070 We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. The following is an itemized statement of the services, facilities, automotive equipment and merchandise that you selected when making the funeral arrangements. Terms ' Due Date Account # Net 30 ~ 5/9/2012 ~ 2012024.6 F Description Amount - r-- I SERVICES & MERCHANDISE Traditional Funeral Service 6,395.00 Honor & Glory Stationery Set 135.00 20 Gauge Steel Casket, Metallic Blue 1,395.00 12 Gauge Standard Steel Vault 1,345.00 I Total Services and Merchandise ! 9,270.00 4/9!2012 Sut7er~ i;or Stephen K. Parthemore. CFSP $ruce R. Parthemore. Pre-Need Coordinator. CPC CASH ADVANCE ITEMS Death Notice, Harrisburg Patriot 13 Certified Copies of Death Certificate Clergy Honorarium Flowers, Casket Spray Honor Guard 224.6? 78.00 200.00 2'_5.00 75.00 Professional ~4enlberships: NFDA • PFDA DCFDf~ • CCFDA r~r«~r,~,~,«~~r~.~ G ~`~~ DEN ULE , Tfre Kule }nu /Knotir. The People }i~u Trrtcr Total Cash Advances Immediate Pay Discount -Thank you! Total ~~1L ~~ ~ t• Payments/Credits 802.67 -130.60 $9,942.07 $-7,202.07 5,--~ ~ Balance Due $2,740.00 -- ~~ _..~. - ll9 PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Tackie Cox, Sales Director of The Sentinel, of the County and State aforesaid, being duly sworn, deb ses and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13~, 1881, since whic] date THE SENTINEL has been regularly issued in said County, and that the printed not 'ce or publication attached hereto is exactly the same as was printed and published the regular editions and issues of THE SENTINEL on the following day(s): May 2, 9 & 16, 2012 COPY OF NOTICE OF PUBLICATION Letters Testamentary have bee granted on the Estate of AUS71N C_ DOUGHERTY, deceased, la of New Cumberland, Cumberland Co~~~ Pennsylvania, to the undersi_ ed Executrix. , All persons having claims again t the Estata are requested to present they writing, and alt persons indeG ed to the Estate are requested to make immediate payment to: Ar ~ ne B. Dougherty ' 8 Bailey Street New C mbedand. PA 17070 or Albe t J. Hajjar, Attorney 1300 arket Street, Suite A L oyne. PA 17043 1 Affiant further deposes that he/she is not interested in the subject matter of th.e aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are e. ,!s ~/ v Sworn to and subscribed before me this I ~~'-/~n ~~ ~- ~V(1(ln~ ~ ~ ~ E ~ Public My commission expires: E.fii~i61 fltvfd H~uK.~t~DORid '? '' ('~lcfaiy Pubic CARLfsLE nOROl1GH. Cli'~S~ERLAND C\TY PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONV~ ALTH OF PENNSYLVANIA ss. COUNTY OF CUMBERLAND Lisa Iviarie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaic ,being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a leg periodical published in the Borough of Carlisle in the County and State aforesaid, was establish January 2, 1952, and designated by the local courts as the official legal periodical for he publication of all legal notices, and has, since January 2, 1952, been regulazly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the s e as was printed in the regulaz editions and issues of the said Cumberland Law Journal on the following dates, viz: Ma l 1 Ma 18 and Ma 25 2012 Affian further deposes that he is authorized to verify this statement by the Cumberland Law Journal, legal periodical of general circulation, and that he is not interested in the subject matter of the foresaid notice or advertisement, and that all allegations in the foregoing statements as o time, place and chazacter of publication are true. is Marie Coyne, Editor SWORN TO AND SUBSCRIBED before me this 25 of May, 2012 1 -- ~ i Dougherty, Austin ., deed. ~- / Late of New Cumperland. NOtary / Executrix: Arlen B. Dougherty, 218 Bailey Stree ,New Cumber- land, PA 17070. Attorney: Albe J. Haijaz, Es- quire, 1300 Mar et Street, Suite A, Lemoyne, PA 17043. NOTARIAL SEAL DEBORAH A COLLINS ,I Natery Public 6ARt#s34E eoROUaH, CUMBERLAND COUNTY ~ M~ O~r~mission Expires Apr 28, 2014