HomeMy WebLinkAbout95-0056~ I -~5- o~,c~
This is to certify that the certificate hereunto attached is a true and accurate copy of the original
death record on file with the Division of Vital Records, and that Frank Yeropoli, whose name is
subscribed thereto, was at the time of subscribing the same and now is Director, Division of Vital
Records of the Department of Health, for the Commonwealth of Pennsylvania, duly appointed
and commissioned as directed by Act 66 of the General Assembly, approved 29 June 1953, P.L.
304.
Auc i s 2~7
Date
H105. t.3 Rev. 7137
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PERYANEN NAME
BLACR
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Fran eropoli, ' ect
Division of Vital Records
P.O. Box 1528
New Castle, PA 16103
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
19~fi8
T
'I K ~~c~n ~ Ire' "'O°°' ~~ SE% SOCUI SECURRY NUMBER DRE OF DEATH 1MOrN. Dar.'Rar
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+• Ellen B
Black
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~- Female x 193- 12- 9379 ~ /02~' a-~^ !
AGE (LaN Bimab, UNDERtYEAR
UIEIBiT DIY OREOF BIRTH BBT[IIPIACE IOny and PIACEOF OERH(CSea arry one-Yea/u1nrG.areanoFrM a0a)
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,~ William J. Black
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To:
__ Register of R'ilis for the
_ _ Y __ DecPCrsed, County of _[,~f~.Rt,~.rdsr~ the
"ar_;a? :~~^curit}~ .rv;A. ~ ~~~~~ ~ _~ Commanw'caith of Pennsylvania
Tile pet.it_~ t c,F t'~,c undersigned respectfully represents that:
'k'aur ?,etit~{~nr(s), w;to is/arc 1$ years of age or older, appl_.r~~'s for letters of administration
__ on the estate of
{d,b.n.; *.~,_,.^.dcr.t: live; durance absentia; durarte minoritate)
the above .decedent.
13ecerdent wac domiciled at death in ~,~_bGRt-A~d County, Pennsylvania, with
;~_~~,~ __ 1<7;t fa :wily or principal residence at ~'u.~s ~~R~~d Ca~u~rJ'~Y /~iy~fss%~~tt~o.~#"
(list street, number and mumc~pality)
r
I7ecendent, then . ~~- years of age, died ~ ~ ~ ~ .. , 19~-,
at ~'' ~- ~? fib ~:QN~ G ~s ~rv t- y yY/w /~S_ i ~f (~v rsr¢ G ~,4 t ~4G,c P.c.
rJecendent at death owned property with estimated values as folllows:
(lf domiciied in Pa.) All personal property
(if not domiciled in Pa.) Personal property ire Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real esU~te in Pennsylvania
situated as foliows~: ~a ~ 1=
$ Zd~a~da
$_
Pet.itioner._. after a proper search ha 5 ascertained that decedent left no will and was survived by
the followinb spouse fif any) and heirs:
name
~r,~j LG~7~ ~ ,~"4ti-~-G ~ ~Lg. Relationship i
,$Dh~ i xesaotence
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TI-ir,REFCRE, petitioner(s) respectfully request(s) the grant of letters of administration in the
appropriate fertn to tl-~e undersigned.
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The petitioner(s) above-named swear(s) or affirm(s) that the
statements in the foregoing petition are true and correct to the best
of tine knr~w~l~,i;;e: a;nd belief of petitioner(s) au'id that as personal
representaxtives) of the wbove decedent petitiener(s) will well and
truly administer the estate according to law.
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Sworn to or affirm~T~ctd subscribed .~(r.~G.fL.S2~3.~ `~ ~ ~~. ..
before n:c this - day of ~.. -.. ~t
N'ARl', 19
~.A.R C. LE4~lIS Register ~ 'v-,
NO. 71 -95-5,§
~ ~Q ~~ _ ELLEN B. BLACK ~ gg~
~~'~~~ ~k' ~.~'~E$tS ®'~ .AD16~I~I~ST'Y'1~1'+d
~;~ ~~iJ'h1 _ JANUARY 23, 19 95 , in consideration of the petition oa
tl~e reverse side iaereaf, satisfactory roof ha ' been resen ed before me.
?T IS I~IrC?Llr~,i3 that ~J I L L. I A ~. B LApC K , ~ R .
is/are entitled to Letters of Administration, and in accord with such fieding, Letters of Adrninistratlon
are hereby graated to WILLIAM J . BLACK, JR .
ELLEN B. BLACK '
In t}Sr estate Of ___
1 ~ ~
P"Lea„RStQ of Wi11s .
MARY C. LEWIS
FEIrS
Letters of Adanististration . , ... $ 25.00
Short Certifgc~t+Js(~ ,I .......... $ 3.00
~enuncis.tier_ ................ $
JCS' $ 5.00
T'®TAL _ 5~.~.Q~
Fi"cam, .....JA;....23.,....... A.IS. 14 q",
ADDr.~ss
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"~'i?iled ;et'vers and order to administrator on 1-23-95.
ATTORNEY (Sup. Ct. E.D. No.)
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REV-1500 EX ~ (7.97J
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( COMMONWEALTH F PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG PA 17128.0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
II-
z
W SOCIAL SECURITY NUMBER
~9'°- - 3
Q (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, Flf
REV-1500
INHERITANCE TAX RETUR
RESIDENT DECEDENT
use a blank bock ro separate wards
X111 .~
DATE OF DEATH
~a~~.
-a~
NUMBER
y
DATE OF BIRTH
` ~ 1 ~D ~~~
YNUMBER 7H1:
^ 2. Supplemental Retum
^ 4a. Future Interest Compromise (dace of death alter t2.12-ez)
^ 7. Decedent Maintained a Living Trust (Attacn copy orrrusp
^ 10. Spousal Poverty Credit (date ordeatn between f z-3t•st and t-t-ss)
9
REGISTER OF WILLS
m
Q y ~ 1.Original Retum
av
^ 4. Limited Estate
w
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^ 6. Decedent Died Testate (Attach copy orwm)
a
a
^ 9. Litigation Proceeds Received
i THIS SECTION MUST BE COMPLEI
w
O NAME
O R
V
W
K FIRM NAME (IfApplicaWe) ~ 3 //~}-
v
i
1
~ TELE~~QNENUMBER
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Q F'
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^ 3. RemainderRetum(dateordeathpriorbt2-t~.az~
^ 5. Federal Estate Tax Retum Required
_ 8. Total Number of Safe Deposit Boxes
^ 11. Election to tax under Sec. 9113(A) (Adam sch o)
J ~:~ ~
G ~ ~ ~,~c15 1.~_ /~/~- ~ ~7~~~3
1. Real Estate (Schedule A) ~ (1)
2. Stocks and Bonds (Schedule B) t ~
(2) ~
3. Closely Held Corporation,Partnership or Sole-Proprietorship (3) ~,,~t
4. Mortgages & Notes Receivable (Schedule D) (4) ~ ' f /.^~j cc. - .
~ t v
5. Cash, Bank Deposits 8 Miscellaneous Personal Property ' ' L
(Schedule E) (5) ~ t /~~ ~ ~ . ~ ~ ~_
y V
6. Jointly Owned Property (Schedule F) (6) ~ . _..,
> > C_.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L) (7)
e ~
8. Total Gross Assets (total Lines 1=7) (8) ; : ~- ~~ /_'~/
9. Funeral Expenses & Administrative Costs (Schedule H) (g) ~ I'~, t; j
lJ 1..~
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10) (11) '1r . d
_ s pE
12. Net Value of Estate (Line 8 minus Line 11 '~'°r"
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) ~ ~
made (Schedule J)
s ~
14. Net Value Subject to Tax (Line 12 minus Line 13) "'~ ~ , ~ ~ "`> (14)
15. Amount of line 14 taxable - ~ ' '
atthe spousaltax rate s r X 0 (15)
See instructions on reverse side for applicable percentage ' '
16. Amount of line 14 taxable
at 6% rate r : x .06 (16) r
17. Amount of line 14 taxable ~
at 15% rate t , X .15 (17) t
18. Ta(-x~Due (18) r
> BE SURE TQ;ANSWER ACL QUESTIONS ON REVERSE SIDE AND
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
than the rsonal re resentative is based on all information of which arer has an knowled e.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN AD RESS
l~/\v~ ,
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS
17CC:K MATtI < <
it is true, correct and complete. Declaration of preparer other
DATE
7- ~-Q
DATE
Decedent's Complete Address:
STREET ADDRESS CC.I a~ f1 P ~ ~ ~~~~ /~~ d / y
qTY ~ . ~ STATE ZIP%.~
Tax Payments and Credits:
1 Tax Due (Page 1 Line 18)
i. CreditslPayments
A. Spousal Poverty Credit _
B. Prior Payments
C. Discount
(1) C~
Total Credits (A + 8 + C) (2) LJ
InterestlPenalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E )
If line 2 is greater than line 1 + line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 19 to request a refund
5, If line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF
(3)
(4)
(5)
(5A)
(56)
,AGENT
~~ _ ~ ~ ~~~ ~ 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 : ............................................................. ^
b. retain the right to designate who shall use the property transferred or its income : ................ ^ [v~j'
c. retain a reversionary interest; or ............................................................................................. ^
d. receive the promise for life of either payments, benefits or care? ......................................... ^
2. If death occurred on or before December 12, 1982, did decedent within two years
preceding death transfer property without receiving adequate consideration? If death occurred
after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? .............................................................................................. ^ l~
3. Did decedent own an "in trust for" or payable upon death bank account or security ,~,/
at his or her death? ...................................................................................................................... ^ LJ
4. Did decedent own an individual retirement account, annuity, or other non-probate property?.... ^ [[~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN
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:~.u~_ ~ )~ S ~? x, s_.r ter.. - ~ , . ., t ,. .
72 P.S. §9116 (a) (1.1) (i)~provided for the reduction of the tax rate Imposed on the net value of transfers to or for the use of the
surviving spouse from 6% to 3% for dates of death on or after July 1, 1994 and before January 1, 1995.
72 P.S. §9116 (a) (1.1) (ii) provided for the reduction of the rate imposed on the net value of transfers to or for the use of the surviving
spouse from 3% to 0% for dates of death on or after January 1, 1995. 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 JANUARY 1, 1995 - Please answer the following question by placing an "x" in the
appropriate space.
Did the decedent create a trust or similar arrangement which is solely for the surviving spouse's benefit for his or her entire
lifetime? Yes [~ No ^
If you answered yes to the above question, the tax on the trust or similar arrangement is postponed until the death of the second
spouse, at which time it will be fully taxable at the rate(s) applicable to the remainder beneficiary(ies). Enter the value of the trust on
Schedule J, Part II, in order to remove it from the calculation of the tax due in this estate. You may wish to file Schedule O in order to
make the election available under Section 9113. If the election is made, the trust or similar arrangement is taxed in -the estate of the
first decedent spouse, the portion of the trust or similar arrangement which benefits the surviving spouse is taxed at the zero tax rate,
and the remainder is taxed at the rate(s) applicable to the remainder beneficiary(ies). If you choose to make the election, you must
attach Schedule O to atimely-filed tax return, along with Schedule(s) Kand/or M in order to show the apportionment of the trust or
similar arrangement between the surviving spouse and the remainder beneficiary(ies).
REVa51 tEX . (1-97)
r
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
~ ~- ~n ,
SCHEDULE H
FUNERAL EXPENSES ~
ADMINISTRATIVE COSTS
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
DESCRIPTION
A. FUNERAL EXPENSES:
~t~~•~~ ~N,~ C3R(~U~:1 S~RU c ~'SI /`'1 ~R~.~C ~..~-/2J1
~., ~= j~(~i,U ~ a,~ ~ ~R~~
B• ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s}
Social Security Number(s) J EIN Number of Personal Representative(s)
Street Address
City State
Zip
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedents address is not the same as Gaimant's, attach explanation)
Claimant
Street Address
City
State Zip
Relationship of Claimant to Decedent
4, Probate Fees
5, Accountants Fees
6, Tax Return Preparers Fees
~. ~ E-T~ r~-~,~ ~,~~rR.~.
~S -
(It more space is needed, insert addltlonal sheets of the same size)
TOTAL (Also enter on line 9, Recapitulation) 15
AMOUNT
V ~ 4 ~ `,J
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~~ G ~
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J CJ
• REVd508 EX «~~-g7~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
a jai;
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.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
~ ._.- OF DEATH
~:a ~ oZd7~~ ~~~
um~~~,~~.N~ CG~~ ~ y ~uRS~Ii1C~
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TOTAL (Also enter on line 5, Recapitulation) 3 1 «
l~ ~,
(If more space is needed, insert additional sheets of the same size)
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Q6 7 DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-14)
PO
INHBOXERITANCE TAX DVISIOq
OFFICE OF STATEMENT OF ACCOUNT
HARRISBURG PA1,7128-0J01 I FI
R C7 WILL"
DATE 02-09-2015
7015 FEB 17 pM 1 13 ESTATE OF BLACK ELLEN B
DATE OF DEATH 12-28-1994
I-E r,:'\ OF FILE NUMBER 21 95-0056
FENSTINibliAAS' DEaORAH
COUNTY CUMBERLAND
—, rk, ACN 101
105CUMBE'Di ;k
Amount Remitted
2536 RITNER HWY
CARLISLE PA 17013
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
NOTE: To ensure proper credit to Your account, submit the upper portion of this form with your tax payment.
CUT ALONG THIS LINE RETAIN LOWER PORTION FOR YOUR RECORDS -- - ---- - -- - -- -- -
'E- -TAX-gfkfEA&if b� i6C70bAf
REV-1607EX AFP 01j:f4) Ni'NiiffA:N
ESTATE OF:BLACK ELLEN B FILE NO. : 21 95-0056 ACN: 101 DATE: 02-09-2015
THIS STATEMENT PROVIDES CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELOW IS A SUMMARY OF THE PRINCIPAL
TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 09-08-1998
PRINCIPAL TAX DUE: .00
PAYMENTS (TAX CREDITS) :
PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID C-)
TOTAL TAX PAYMENT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM
FOR INSTRUCTIONS.