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HomeMy WebLinkAbout95-0059This 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. AUG 1 ~ 2001 Date M,OS.la3 RSV. 2/37 nPEnRwT w PEAYANEMT ~~ BLACK Z Fran eropoli, ' ect Division of Vital Records P.O. Box 1528 New Castle, PA 16103 COMMONWEALTH OF PENNSYLININIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH ~ Ci ~ ^ }~ " _- ___ SE% SOCIAL SECURRY NUMSEA ~.~- DATE OF 06QH UAmN.Oaµ'bfG ~' rh'o.MAS rM / rH AGE ~• ~*rpavl uNge„ rEgR UNDER, DIr DiaE aF eSTrH '' ~/9 [ E p• 176 -34 -8718 ~. ~ z - I ;r - q y avrt t I~.VIIfC,mrA ars ane- : a ~~N y x. uarceorr on oal«spa, Monpr . Dap tare ~ MIn,Aw (Mena, D•C. 11ar) Str echaIIicsburg Inpatynl ^ ERYRaprwa G DoA ^ w ~ ~ ~ y~ oplr Yn. r 26 1942 A H ^ on» ,~ NefrperWL (Spf~ry, ^ COUNTY OF OFATH CR'/,BDlq,TW OF DEATH Ii1CKfIY NAME(N nd in,llaron. gna ]aM ariO nunibml ~ ~ o ME I,ISVANIC oRIGINT ~Y,rl,mrr, I,dYL SbrL PI,el1, ra ( I'Ie XJ G1bn. ~ ~ ~ MaabLPwrb Ricr i, DECEDENrsIreTlALOCGUP,QIDN IcrloaPeusrE . ,~40 Sam le Brid a Rd. .. ,~hite SSAT,DUSTRY WAB DECEDENTEYERM DECEDENTS EDUC~QIDN MAielgI SGPUS-Mfnwp (Givelard asora paM nmm U.S.APodED PoRCEgt ~SURVNNID SFO a,orab, w: m rbt w.°'.e~rea> NM Murlea, Wlpffine, ~ ,+ k iver , ed and Grain Ind "~ "°^ „ ( " g y (~t ~p~P~" ,J~arried D€cEEDENrs MAStIK, ADDRESStse.r Cily,Twv,, pOnn8 F. Bretz St.a. zbc p DEC ' , . . o .l EOEM S ACTUAL na5tw Pennsylvania ,z[^ Wa.eecfplrR9repir~ Silver SOriae TND ~ R ~ a .LVa.re 440 Sample Bridge Rd. E rr.be ,mlr'nOla PA 17025 moe,.w.1 IowrrlipT No e.Y.arettYee ,m ^ na YAtNn rslr lblasa PATIIFA'S NAME (FYm, A,Ipsa. Lae, ,a ohn Isaac Smith MOTHER'S NAME IFrr MippM. MaipanSvnnN) Vie' tNPanAANrs NAME (rypv,:rq ,,,Lucille Swartz INPORatANr•s MAILMKi A170/E$S 151af1 CApfpsr, Shan. Lp Capy h METIIDp aF DISPOSITIO mh.440 Sam le Brid a Rd. Enola, PA 17025 N ~ I PLACE OF DISPOSITK)N-Nrry a Ilelel al c~uoe^ I+.n•Yr eorasw.^ DATE DaYp win+~ aaln.,Prw c•n"M'xc'•'"r"r LDCaaN-c.yrre„n,sw..aPCOea ° '" ^ „ ~ °" O1r1s°°~'VL ^ ~~aDecember 21, 1994 t. Paula Lutheran Church C Silver Spring Twp. SIUNATURE GP PTINEnAL SERVICE LICENSEE aR PERSCII gCTW6 As sucH :,a 214 "DE"~"""'~" ""ME""D"°°rX:ss°PFAaLylyers Flinera ome ata. 012662-L h37 PS. Main St. , lleohanicsbur PA 17055 ~011~' tti I a I rr my •~••~•p0•. paaN ocarrW r eN mm, eateard plyrmrrh na.wrw rtfinedbrnb nd T,tly Place ahlfp. LICENSE NUMBER DATE SIGNED e an ycw»amrL (Moan. Dax 1bm1 ~ treuza-2e can e.<eelPlabeM ' 1M. OF DERH DRE PRONOUNCED DEAD1MaM, DaY. lbarl ~•• ~••^'~• p°^r••'••~1 NKS CASE REFEAREDro MEDICAL E%AWNERICOgp,1 ER, Z>. PRRT1: En4rtlrpsaaa i b ae, r*P aaoo,rpeeripm Mi arCNefObeprM. Da na aaw pm moMapyaq,rClatldlac or Lh1aN,ana calve onfearir r••P•rW aver. Sl Jtpnwrt laiAee. rAppreaaeay PART X: gtllar•171lekara unaeorr ma14repbpMN i•A , ~~ ,mmM Mlepaaln npl n•IleirSwtlr ladsyal, crM0lYenb PART 1. pmaeaaaopbeon MTfs ^•v~h5rp.eq-~ E5 />>RA Ta YtY FhrC. r,•,L r_ t DUE roION AS gCOlSEOUENCE OFt: 9•vllr•IeN em oonaMOrN e. ~n tvina n e ~ ~DN YS Lyt teerrlp b e,e•amele ~.~~ DUErotaR ASACO,LSECAIENCE OFk GWEID'nesrary.y ~ e. /4MYC 7-,tc~Pfiit (.q 1E.f•GL SC /E".2e Si i \/ f i 7 Eta a i n.l+llaara •"•fes DtIEro(DR ASACONSEOUENCE DF): nsahq r aerp LAST I a NKSAN AUroPSV WERE AU,O-SY FlNDINGS MANNER OP DERH DATE DPINJURY TIME DPIN.RIRY NUWYAT UORKT DESCPoeE HOW IWURY OCCUFFED. PERFORMEp9 AMIKABLE PIKORro COMRETK7N aF CAUSE ~ (~~. DaY ~) aDEA7H7 Ntlvel 1laniope ^ Aeeipfa ^ Per16np NNeeNgplsn ^ Yw ^ No^ M w ^ NS vu ^ Np CSap na W pNmmeNp Sutcitle ^ ^ PLACE DP IWURV A - I Horns, ferrrL anar, lacbry, ellka LOCATpN 2x0. 2f teilmr,,, re. ISpecily) 15treel CitYiTUWr, Stile) CEITTIFIER (CMa eaY orwl ~' lOf. 'C6ITIPYIM B PIIY„CIAII(Pnye,cmn c•~Yeq ~w.aesm Wien ananer PPYSnan nu poncuncfpawn ana compWfp ltvn 231 SIGNATURE AND 71TlE OF CE FlER T e.tr.rarey b,ewMp,e, pern•coPr•m euab M ewngflanam+nners eMtea ..................................................... 'P1101N)IANCINO AND CIDITIFYRq PNY9ICIAN (Pnyec~m, qoN wonamurp peaM anp eerplyny b ewse a Oeapp LICENSE NUMIaPm~_ DATE SKiNED (Norm.. DeY. (bar) ie the bwlaery arrosNe,e,pu,n aeeumNr,n.tlma,Wte, ana pMee,aM pwbtlle c••fNqand mennw ae staNm .......................... ^ ile. !"t 1~-~QS ~/O/ L H - 3,a ~ ~ fl9~R NAME AND ADDRESS OFPERSON V/FIO COMPLETED CAUSE OF DEATH 'MEdCAL E7(AWNEA/CORONER (Item 2T) Type ar PNa m~in~ner~ lea elnMeHOn and/or Investigtlbn, M my opinion, peaty xcwrW r tM Ilme, pate, and Waee, and pw to the ew ~ 1 P1.! k ~ /I i F [ ...... •e(el ald /~ 71e. .......................................... ...................... ^ ~C LU~fY lT Sle[r!1>CI '" REG RMR'S SIGNATURE AND NU R 3]• Al /' !-I I i.1 /I f, GATE FILED (Moan. Day, Val - . , 3e_..1..L ~ e ,,, ~ K ~ o I .. ~ \.. i ~~?~'~'~'~~~ ~'®~ ~i~t~~1~i,T'E ~iIld G~1~1~' G~~ L~'~'T~ItS ~~ _ ~""' E'sicrte cr ____ ~~ o ~n ~, _ ~ .~ rat , ~1-, Alo. also known as To: Register of Wills r r t , Deceased. County of Cv-„ in the Soda! Sec::ri .v No. ~ $' ~/i?" Commonwealth of Fennsylvania 'I'hc p^.titi~,n of the undersigned respectfully represents that: / Y~ t:r petitioner(s), who is/are 18 years of age or older an the execut h h q~ ~~ ~'h_ n d in the last ~,viil of the above decedent, dated , 19, ar;;i ;.edicil(sj dated ~._ r~ a. ~ ~~t1 ~ h (state relevant circumstances, e.g. renunciation, death of executor, etc.) ,Decendent was domiciled at death in ~ ~ `~~ last family or principal residence at ~., ;.~,`. ..~ ,t...a..~, -~~ .n " (list street, number and muncipality) ' V ~1\ ~ ,/ Decendent, then s ~~- years of age, died _ ~~ _, 19___L ~, Except a~. follows, decedent did n t marry, was not divorced and did not have a child born or adopted after execution of,Xtae will offered for probate; was not the victim of a killing and was never adjudicated incompetent: 017 z° Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ q00, 0 6 (lf not 3omiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ situat::d as follows: - _ ___ ~, o ire, b'1-lEl2EFOltE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) _ presen~~ed herewith and the grant of letters ~i-Cc`t ~ ~„e, h't4~ ~i (testamentary; ad~inistration e.t.a.; administration d.b.n.c.t.a.) theroa. v ~~ a x b c •-. ^ci; s ~,, ~ , -i..~~~t,~ . Y.91'~ ~l ~d ®~ ~~dA~~l`~ ~ JC~%iS ~A~SYild A 19~H 4 Ali ''1/f~'P~~1~~a~~tt~v~~E!°;i.~,71'~ ~~" ~~' 1mi1~T$q'LVt~~i~t'~ ~ s3 ~~~J~d'~'~ ~f~ ' CUNS3ERLAND Tne petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- ,,. tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirm. nd subscribed ~~~ Kf~% I ~ , t„ before trine this ~R[~ da of ~o' Lim-~~G , ~~~~~!~ ~'/ ~~ Register _ ~, _ ~` i - , ~ ;, -. r I " i 'S'^T"'. ..^s ter:'! ••*;ms, .~.-~-a~.r+-~r~ -^. '- .Fr-c •...+~cr.: :^v~.m .;Y.a~c -~~'^s- .. ~, ~3 . 21 - 9 5 - 5 9 ~~,~'~~.LL3.'. ~)~ Ti-IOP~'a J, SMITIf 9 '~~°ey~,r~~,$ 2~':i 1~. ~a~.~i 7.,R~y ~A'~~~.C~ 5i. R:i 1~°~19 ~ t~.BK'~`~l F .& V.~09r ~51rSi~ R. ~i.`~i~ ,qs;D ^<n3jJ JAirUARY ?_4 fg 95 in consideration of the petition on use :ev,:r~~4 sScle hereof, satisfactory proof tta/ing been presented before me, i'T FS Ds L's~r,~D that the irstr•.tment(s) dated FEBRUARY 20, 1982 described ti7erein be admitted to probate and filed of record as i~:e last will of __ THOMAS J. SMITH azg' ..°'trs~'^.- TESTAf~EfJTARY ' arn:~t:,~~p.r...^.tedto OOPIPIA FAY SMiTN FEES i'rc~bate, Leiters, lrtc.......... $ 18.00 5ho-t L.ertificates(1) .......... $ 3.00 ~erut~ciation ................ $ X-ra,es 6,00 JC? $ TOTAL ~ $ ~i~c ......... , ;1Ai~UARY 24, 1 R K' r~ ,~ ~ ~ y , .. ~ ~ - ~ .v `=~ , Ll: i r z c €.:.... ~~1 C 1~ J mod' ~~;ai'e~~~ 12iter> aid order to rxecutr Register of Wills MARY f/. LEw'IS ~ ATTORNEY (Sup. Ct. I.D. No.) ADDRESS PxaN~ _ ,.. _f__ 21 - 9 5 - 5 5 ~GIS~TER OF d'~'ILLS ®F G~ r~ ~ ~ r ~ ~ h ~ COLTNT~I OATI~I OF SUBSCRIBING FITNESS G codicil (each) a subscribing witness to the~aill presented herewith, (each) law, :6epasc(s) and say(s) that ~~ , = ,~ the tester „sign the same and that request cif testat,~ in 1~_ prese and (in the other subscribing witnesses}} Swor;x to or affirmed ax"sd subscribed before _~ me this ____„-~ day of 19 _ \ ` I 1 _-~ (Address) \ Register (Name,$ tD '- ~ ts' ca o (Addresa~ ~ ~' ~' C. ~ N p ,~: c ~- ._,>. <. 0 ~, 0 < ~: w ~ CUMBERLAND REGISTER OF WILLS OF ~iJ N'~ OATI~I OF NON-SUBSCRIBING WTi'NESS .,u•,., y~ ~Gn~ ~ d fi I / _ (eaci~; a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that l THEY ARE familiar with the signature of ....THOMAS J. SMITH " xao,~ipilxx testat ~~ of ()9:i~(X,~1(Xt~X~~t~~i:aE(XJ(r~i(~~(sXXt)6) the will presented herewith and i' THEY ~H that _" believes the signature on the will is in the handwriting of ,, THOMIaS J. SMITH to the best of Ti~EIR knowledge and belieyf~. ~~/J Sworn to or affirmed and subscribed before 1/~rn-+"~ ~~Err~~t1'E- me this __ ? 3RD day of ,Name JP,~!{1ARY 9 9 ~o ~ /7v L~ C1 ~ ~ ~ (Address) RY C. LEkIIS Register 'i+ ~ + TPG/~'Ic (Name) b` k~Y.- ~gso lVoo~L,a~~~ON~'yP , ~hoLa~ /~ ~7a~ ~ .~ (Address) ~^~_._ ~~: ~ :~•~ tir. qualified according to present and saw signed as a witness at the of each other) (in the presence of the r ~f~nT '~?'I,I, APED TF..STt4I~~''!' OF T~OA~AS J. S~I`fi~i I, 1's'iC~S ~. SAtII'ii, of the ~'o~fnahip of Silver Spring, Count;; v.~ C~.tzisberl~.rfld aa~d Mate of Pennsylvar3ia, b®ing of sound Ord ~3isp~asing mind, mer~ox~y and anderstsnding, do maker, publish :~s~ ~.ec~.are this my Last dill and ~®stat~ent. ]. . I c~:Lrect the, payment of all my 3uat debts and funeral e,~pc~n~us ecs soon after my doces.se as the camas can be conveniently A7 n "7 2. I g:Lva, devise and bequ®ath all th® rest, residue seed .~9~nr~ixde}~ of my est&t®, r®al, personal and mixed, xhatso®ver ~z±c+. xb.or~ssoev®r the same may be situatm, to my xife, Donna Fag Sm~.ttz, c~i~solutely and unconditionally. 3~ I:~ the ®vent that my wife, Donna Fay Smith, should p.r !~dace~aki~ nae+, oi~ should she di® at about the saw titxie as I do, suer. as 3n ~.n accident comm~on to both of ua, then in such event, I giv~a, dovise s.nd bequeath my ®ntire estate, real, personal a~c~ -~..~p:~ck, whatsoever end xheresoever the sense ms,y be situat4, ~o ~y ~::~o stapchilcix~en, to grit, Robert Lee Di®hl end Debrah ?s. Dyc~i~? , ~.nd to any son, Thomas I. Smith, shar® and s;+,~re ~.ike. ^.;. 1 I ".f°;~~.ncte, constxtut4 an~1 ~ippaint my mother, Luciila~ S. 5:~zif~,a':A ~;~~a~'dian of the persot7s3 and ®ats~tes of z~y stc~pdsughter, ~cr'°a a '~. I3~.ah1, and mg son, ~i'horaas I. Smith, fcr s,aad d1,aring tYs~ ~.c~zr;, "a~`" their minority, hereby authorising ansi empax®ring said ~La~x~~"t_~ ~;o ~~,ot~na the pr~.r~ci_~a:. ~.s ~€cai~. ~s t~a,~ ~.nQC~ne off' os.aia ~~,~ _ __ _ ______._ ___ _ __ _ _ __ __a r '....;'-a:~~~ ?i`:`,7~:~~~~T~°~3 E3R'~?:~.~+~3 u~ +:s3~~L?~~ ~.~':~..°~" Q'd° ~.R'~~»° ~~"~I`~~b~.B3 a ~<`',::n;_,r;~~:^~ ~td.'t$~ ~%B.a.ffi'Ru~:~'2~L`af°~s Ea'+2C ~~~•~aa~~$aa~s i~Y.~~3C?',~ ~'~6 .~,~Sle,l~asit~ f „.. ; ~ ~3'+~ .''rT-r"~ ;:S"'~.k"~~° ~1'~.ci~ifa~~'i~~ S9% ~~.„~i'G~ CA~~idil~~i y. .:~:'at.°.~ 4ti',g v~SC~I ~"a'Q~.oS~~~° 9~A~ p~~~d.brri~~1 (,~'Q' ~~~~~ ~S~ ~u~~. ~~ V~ y r:w H~:~r,~:,;~ off` sri~ ~sln2lax°®tx ~i'~ho~u~ poting boua~ or o~~i~~ s®auri~g ~x~~,:~ ~,3~ •~':~~a~.j~ b~i~g oom~ml7.~ad ~c~ ~'ilo ~ ~.eoou.~~~3a6 0~' ~~r ~a~di~a ::,~:.~T.~,, T::h ~?~~ ~~r~~~ rs~ ~~.:4.c~ ~o4b.or ~~o~.eas~as~s m.~, o~ s;Y~oul~. rho ~,;~. ~;,~~.a:~`.~t~a ~ ~ ~o~~~ ~.zz r-su~*~2 oo.p~.ax~~ ~"~~° ~ r~€~son. ~~~a~a it ~tao~ ~~~s~~r ~ ~ ~aQ~:i.~e-~~, cors~~if~u"~:~ ~z~t~ ~.ppoin•x m~z u~ap~Qai, ~'tob~r~ ~~e~ !~s3~"a:~ .> gu~b dia~ off' too p~z°~ons s~~d c~a~~'G~~a off' ~~ a~~pc~~~ht~r, :r,•;F~z:^~°.fa ~;k9 ~~.~j~l, ~:as~ ~~~ scnD ~ao~as .I. ~s~fi.~~, ~®~^ ~~ ~t~ing ~~ao =, ~.~. r=,:~ ~~}~.~.~.;r-~ir~s~~~i~~g b~a9ca°b~ g~a~s~ing ~o ~~ ~~id ~ ar~psoaz, 'cl~® ~~~~.ws -K-.~,`~~~, ~S~°~.~~~.6g~~, pa!~~~~ d ~.°:~;~.o~ ~ae~°oim;~.b®~~c gr~n•~~~ w~ °~;~ ~.~o~~~r a~~ a~:~a~ g~ua.~di~e :C. y 7"~a?.~,~', I nox~simma•:~, ccxz~stitea~~ ~l appoi~a~ ~y ~i~~, ~~;~~°::.~-, x~aaa~ .`3~af,~~, ~~oou~rix off' ibis rsg Last ~E'il~. ~xd. '~o~ ~amen~, r~r3 ~.a,•~ ~~.aa ~~®~i~ •~ha•t m~ sari ~raL~® shculc3 pxod~oot~s~ ~~, th®n im ~.ae ,~~rea~a~, I r~o~in~,~e, coa~at~.~ut~ and appo3.a~t ~n.~ ~otb.®z~, Lucsille p "t~'~~~t., ®a~a~r~ o~ phis ~v Laa~t Mill quad Testait~~nt, im her - ~,~,a~faa s:~~ ~~~a~c~, a~~ in ~k~~ ~~®xa~ ~g~ ~ao~&~r~z° ~a~a~3a~ b~ ~1~1e to ~~; ~,~,o ~ ~~ such o~:p~ci'~~ ~a~ ~ ~oa~~o~, ~~an in s~.ai~ ~°~~rn~, I n;?c:,;x~i.:;ti:~.~•~~ s~ rox~s~i~az•~~ ~a~ c~ppo3±au :~ , ~~~ssox~, Rab~~~ ~.,~e~ ~3i~~t1, •~°~s~~:;~ ~aa~cr~~ o~ v~i~ zn~ Las V ~il~. ~.~aci ~as~:~.a~~ :;Aj~ '~:~:'P3~~°,~ ~n~i~:L~Qk~', .~ ~~.vc~ ~aeraaz;st~® s s~ ~~ k~s~ac~ d s~atl ,~ ~' ~a ~-~° c.~ ~,. ,per ~P,~.e~` ~^c~.%'r ~~ ..~fi....f~~~~"~'~~ ,..~..:e.....4,~.g .~l.a ~o p .s.~~U~.id+9 .~..... 0 j' J ~N~t ~~ca iD fA 9'?i~..S. ~.Si. ~~*xs °~ ~~a~~~, ~~.~l~dr ~~ta~.~ ~hs~d ~~~ ~®~? ~rcee~ ~~ tt3~ ~~ae9~e~ ~,~ ~ r;r ~~~A~ ~,. ~m:~t~~ ~~ eaa~ ~~r ~i~~ i1~~at ~i~.l ~c3 ~s~t~~xatg ~c~e.~ ~.~~.•~, :;.}? a::"' j.)~.'<'3.~.;C~~C~~ ~~' 1?,~g taArJ ~.3~? ;~~~~431"~'~EigC~ ~'s1P" ~~,~"#.:''S~ ~7.49P"."~~4y ~1~ ~f / U r P% 1 ~_. w.. s 3 x f :^~;~ R >" lJ " i~~ REV-1500 EX+ (~-9q ~. FOR DATES OF DEATH AFTER 12131191 CHECK HERE INHERITANCE TAX RETURN P ^ j OVERTY CREDIT IS CLAIMED ~. RESIDENT DECEDENT FILE NUMBER COMMatiWEALTH OF PENNSYLVANIA t DPARTMENTOFREVENUE (TO BE FILED IN DUPLICATE ~ ~ - ~ ,~-'-~oS-'~ UE PA 671 WITH REGISTER OF WILLS) _ HMRISB RG, 28-0601 COUNTY CODE .YEAR NUMBER DEQDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) ' ~~m~ DECEDENT'S COMPLETE ADDRESS /~ ~ /V ~lo v~l~p1E ~r~ ~Z SO S ECURITY NUMBER Q DATE OF DEATH DA~TE[OF in{iN ,/ ' ~ ~ {~ "~ O 2S ~~ ~ r~ r ~ W v // ~ 3 ~- J 7/~ p j'~ ~s ~ 2• 7 'T y4+ C ` 1O / uDn, T p IiF A4LICABLE( SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDD E INITIAL( SOCIAL SECUR IT Y NUMBER AMO UNT RECEIVED (SEE INS RUCT NSI I-- r / ' G- ~ s i 0 ' r T ~ 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return Y a Y (for dates of death prior to 12-13-82) 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Re wired q =pO U (for dates of death after 12-12-82) a m Q 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes (Attach copy of Will) (Attach copy of Trust) AlL CORRESPONDENirE!JkND CDNFfDEh-71AL TAX=lNF{3if;ilAAE'~'fiC3~:!SId3~r;~1;Ca~h,'6{;~ B,EC~1~:~'4).: - y' Z ~Z !{P.AE o n n - ern', COMPLETE htAlLlNG ADDRESS tf ~'fa' ~~, mp~6 ~~%~~f ~~ V O~ TELEPHONE NUMBER -- / ~ h G 1 Gj P Cl ~ -7 O ~ 1. Real Estate (Schedule A) (1 ) 2. Stocks and Bonds (Schedule B) (2 ) 3. Closely Held Stock/Partnership Interest (Schedule C) (3 ) 4. Mortgages and Notes Receivable (Schedule D) (4 ) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5 ) d O © 7 ~, Z (Schedule E) 6. Jointly Owned Property (Schedule F) (6) ~ 7. Transfers (Schedule G) (Schedule L) (7) J 8 Total Gros Assets (total Lin 1 7) ~ ~ ~~ , L J, a . s es - , ~ (g) / 9. Funeral Expenses, Administrative Costs, Miscellaneous (9) ~ Expenses (Schedule H) 10. Debts, Mortgage Liabilities, Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) (11) 12. Net Value of Estate (Line 8 minus Line 11) x(12) -° ' L. ~'7, ~ '~ 13. Charitable and Governmental Bequests (Schedule 1) (13) 14. Net Value Subject to Tax (Line 12 minus Line 13) ~ (14) r' ~ ~ 7 ~ „~.~ 15. Spousal Transfers (for dates of death after 6-30-94) See Instructions for Applicable Percentage on Reverse (15) x = Side. (Include values from Schedule K or Schedule M.) . _ 16. Amount of Line 14 taxable at 6% rate (16) x .06 = (Include values from Schedule K or Schedule M.) 17. Amount of Line 14 taxable at 15% rate (17) x .15 = c (Include values from Schedule K or Schedule M.) a 18. Principal tax due (Add tax from Lines 15, 16 and 17.) (1g) a 19. Credits Spousal Poverty Credit Prior Payments Discount Interest a 20. If Line 19 is greater than Line 18, enter the difference on Line 20. This is the OVERPAYMENT. (20) ~ ~ ^ 21. If Line 18 is greater than Line 19, enter the difference on Line 21. This is the TAX DUE. (21) A. Enter the interest on the balance due on line 21 A. (y l A) B. Enter the total of Line 21 and 21 A on Line 21 B. This is the BALANCE DUE. (21 B) Make Check Payable to: Register of Wills, Agent - ~. Under penalties of perjury, I deci~ it is true, correct and complete. I ~ based on all information of which BE SURE TO ANSWER ALL QUESTIONS ON R~VEl~1~ SlD(< AND TC- i~C~iECK MATH ~ ~ ire that 1 have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, eclare that all real estate has been reported at true market value. Declaration of preparer other than the personal representative is preparer has any knowledge. ~ ~ ~ {/J R FILINGRN ~ ~ E~ ~ ~~ Q ~ ~./yW'C.~ DATE EyPREK~SE(N)-TATIVE ADDRESS ~~ DAT~ Act #48 of 1994 provides for the reduction of the tax rates imposed on the net value of transfers to or for the use of the spouse. The rates as prescribed by the statute will be: • 3% (.03) will be applicable for estates of decedents dying on or after 7/1/94 and before 1/1/96 • 2% (.02j will be applicable for estates of decedents dying on or after 1 /1 /96 and before 1 /1 /97 • 1 % (.O1) will be applicable for estates of decedents dying on or after 1 /1 /97 and before 1 /1 /98 • Spousal transfers occurring on or after 1/1/98 will be exempt from inheritance tax. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING A CHECK MARK ~ ~) IN THE APPROPRIATE BLOCKS. YES NO 1. Did decedent make a transfer and: 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, ............... ~ 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 ~C death transfer property without receiving adequate consideration$ If death occurred aker December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration$ ................................................................................................... 3. Did decedent own an 'in trust for'. bank account at his or her death$ ...................................... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ~~, ~. ~,., r, (~ i ~ ~ REV-1508 EX+ (2-87) COMMONWEALTH OP PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS AND MISCELLANEOUS PERSONAL PROPERTY ESTATE OF _ (All prop~Hy jointly-owned with the Right of Survivorship must b~ disclosed on Schedule F) ITEM DESCRIPTION NUMBER Please Print or 1 FILE NUMBER .~ - ~~~1~ /!~' 7~''j~~/j/P~' // ~~i-~J~'YL~~~:L ~ .~d'~'l.L.%~G\: ~~ `--~~~ ~~C ~~~~ ~s I //4 VALUE AT DATE OF DEATH I a ~ ~ S- ~~~~~5 ~5_~,~n K? TOTAL (Also enter on line 5, Recapitulation) I $ ~ C7 d {~ `~ (Attach additional 8'/s" x 11" sheets if more space is needed.) i REV-1511 EX+ (7-881 COMMONWEALTH OF PENNSYLVANIA INHERITANCE 7AX RETURN RESIDENT DECEDENT ITEM NUMBER A. B. 2 SCHEDULE H FUNERAL EXPENSES, ADMINISTRATIVE COSTS AND MISCELLANEOUS EXPENSES ~ ~ti~a ma,~ J ~s~n~, ~m ~~ DESCRIPTION Funeral Expenses: C~ :> ~.~ . rn.~~ Administrative Costs: ~ -~.-jL Q Personal Representative Commissions U `' ~~, ~ - ~~ - J ~~5 l Social Security Number of Personal Representative: `f- Year Commissions paid Attorney Fees 3. Family Exemption ~ Claimant ~ ~~i, t3?'naG`~ Relationship ~ Address of ClaimantlI'at decedent's death ((~~ Street Addre~~ss~~ ~~~' `~ ~ ~ o (~ ~iLi~~p I~t~ City _ ~~"~~.~tr State ~_ Zip Code ~ ~ ~ 2S 4. ~ Probate Fees C. Miscellaneous Expenses: 2. 3. ®" ` 4. 5. 6. 7. 8. TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of same size.) Please Print or Type JMBER ~ ~ -- ~ s -- S-G AMOUNT d~ `~ 1 ~ r G U 1I.7n o ~ iE,~ ° o c~ ~~ G p '7 0 v V ~] 3 1 ® r ~~ ~ ~ ~ 3 ~' ~ ~ rS~~~ c~ S` d d ~ ~5 16 ~ L ~~. ~ ~ r ~ REV-1513 EX+ (2-87) e` atr COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF ITEM NUMBER ~~oma.S ~ ~~8rQ~ NAME AND ADDRESS OF BENEFICIARY A. Taxable Bequests: N ~ ~~ ~~...~.~ ~ Coq t ~ FILE NUMBER -'h ; ~~1 ~ l 5 S RELATIONSHIP AMOUNT OR SHARE OF ESTATE L %~ ITEM NUMBER NAME AND ADDRESS OF BENEFICIARY AMOUNT OR SHARE OF ESTATE B. Charitable and Governmental Bequests: TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation) (If more space is needed, insert additional sleets of same size) S t ~`;. :- ) •.L J DB