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HomeMy WebLinkAbout95-007321 95-(X73 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. AUG 1 ~ 2001 ? • Date Fran eropoli, ' ect Division of Vital Records P.O. Box 1528 New Castle, PA 16103 H705.7~5 Rev.2/87 TYPEAMENT IN PERMANENT BLACKEIK ~, ,1 ~z z 0 u 0 O Z COMMONWEALTH OF PENNSYLIMNIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH ~88~~~3 NAME OF DECEOENTIFira Middfe, Lap SEX SOCIAL SECURITY NUMBER-~, DA DERNIMOnfl. Day.'Aap '' s Male ~ 162 - 22 -7018 ~ / 'i d c~ ~ AGEILaN , ,nr DREDFBrR'N amwLACElcxyaad FucEasDEaNla+ea~«w«»--,e.~~w.«,an«aca Moarb orw Moto I MYMM {MONn.naKVaeN srr.«FOrapnc«,wy) ,pyp,ry,~ oR,ER: 64 Y~ j+7ar. 7,1930 ~myne, PA '^~e ERA71pNier G °°` ^ No~°. ^ Reaidr,ce ^ Is~+vl ^ , ~ COUNTYOF DEAN CRY,SORD. ivyP OF ceRI, R1CE1Ty'NANEI•nat.wer<n. pne aeraaro «an<nj MMS EpEN EC , aF NISMNIC ORIOIN7 RACE-MnulonMlMrl SOCk WIYb. <IC. D~ ' I. , / ^ N<tlG X.IJ Sy<a,.pany0ypan- ~') ~ Cumberland ~ East Peiu~sboro ~ / MUIan,PUwbRban.a,G White ~ ,a DECEDE/TSl1SUAL OCCUPIE'ION IONDOF BUSMIESSANg18T1TY WAS N SEDIICRgN MARIUL STATUS-Myriad (ci..w:wr.«AOOrladrnumor U.S. DFOR CE 37 - coal NnaaM,afMgWlOO•a4 pmrdr,nrnr a.a,rlrrS Ma; ao n<tur rWea ) . r / Ma^ No1tl ~ C0M•i ISOacyN ' „ Machinist ,,. Manufactur ,:. i ,~.1 '°,~' n~«s.I ,..Married wTCan E. Benner ' OECEDEM S MAEYq ADDRESSISe.aL CilyfbnrL Stale. ZgCoW, DECEDENT•s Penns lyania ACTUAL ,'nS,re Y n Hamrrlan e. mAaao.dreeaal• dd Mp 17 Kevin Rd. ~~~ a.<.dre a Mechanicsburg, PA 17055 ~ ~ ,n. Ctuoberland Oo. ~++P~ na^ w °'°01.a,w~ as FR,IER'S NAME (Fiat. Mille, Lap MOTlER'S NAME IFaal MidAe, Maiden Swnr„M ,.. A Miller Sr. ,,. Hilda Davis efOW11WT4 NAME fTyprPnp Joan E. Miller MET110DOF DREGPasPDBRaN S/FORMANT'S MAEMIDADpE391Slrer. CiIWTaw} gala, zo c<d•1 17 Kevin Rd.,Mechanicsburg,PA17055 e«w D«m~^ ~~^ _ ~ PLACEOFOEiPOBITgN- Nr,bac«rr«y,aweal<ry « LOCRgN-GAefto•aLSt.b.npcoae ^ °onr°"^ °tl"r t 28 1994 ~P ~ Slate Hill Cemet cry hiremanstown PA 17011 „~ r~ ~ , LICENSEE OR ACTeq AS SI/CFI LICENSE NUMBER NAPE ANDADORESS OF FACILITY _„. FD-013163-L ~usselman Ftuleral Hartle, Inc. , L2ngyne, PA 17043 lNnr ory eanXyYq baram,wa~.laew. 4atltoawradrlM t<,Ie,dW Mr pbq sta,W. W9rtlN rnr aNMa<b Y<rrN «dareb (5pnaaaeand TM) LICENSE NUMBER DATE SgNEO <rw, <rraa.rn. IMa+n. D•It wd ~'' ~ - xx ~••x~••K <e Mmpl•I•d <y DEATN/~ P110f10UNCE0 DEAD (MOrdn, Day, lber) WAS CASE REFERRED TO MEDICAL EXAMINERA:ORDNER7 PanonaAb prerb«IC•a MM/c / / rr 1 /J [ } ^ ^ ' ^ - V ~ ' ` 1M No ~ M. ZS. i M 7T. RART 1: EMrlM teaaeaY,i,jurMa«mrrlpacaa<r~wNCll cauaadlM darlt. n«erar the nb4d v,rlprarec«mperory arraal. aAad«MaR IN«e. iApprmtimW MRT M: dllraglSkry ooaW«noaMiEMYpbA1a/I.W Ur •dy OM reuse <n NCJt 4n. I/iMnr lM•een r,oUerAlYp In Ma UWnyYq eauMpwlN PA1fT I. IItlEDMTE CAUSE (Fnr t onr an0 daaM deYae«c«rOOn reaulbgndeatn)-~ • -T ~ iYl Vl OUE 81011 AS A CONSEOVENCE OFy -+L G ~ s w e u .Rtw a y o«,aawlb < e.n„N.mrtpbemrlaOAN IXR 101CR AS ACaNSEauENCE OFy I ~ <. r~b •M~+rV eel•MYI•d •~ • OIA: Tp (OR ASACONSEOUENCE OF7: rwMep n Wa11) LAST l a. WAS AN AU,OPSV PERFORMED? WERE AUTOPSY FINpNGS AdLIUIBLE PAXX110 YAMMER OF DEATH DATE OF WJURV TIME OF INJURY IN,IIINYRyvORK7 DESCRIBE NOW INAIRYOCCUWIED. COLNLETX7N OF CAUSE ,.,~/' I~b'~•~) OF DERNT NaMI I(~ Nanitid. ^ A«idre ^ ParMiq InvarlgNbn ^ 11e ^ No ^ YM ^ No Yea ^ N< ^ Suicide ^ Could nd IN dranniriad ^ oboe M JOC, LOCAf10N PLACE OF INAJRV -A, Mme h v rer factory S zr. 2e. , , , . ,raeL CiN/yiwt SW<) I OuMdMp rc. ISp•cnYl 70e. ]« f~ATIFIER ICMd «iy <nN . cEl,rlFYNOPNYSR:IANIPnysaancerNy.get,soaaeau,wl,«,aron,a,p,rso~naa««+wrtceaaeama~acor.nlal«n~za) reu,.ar«wylt•<~yeva.a.m«~urweu.,<n.<aw.b).w«.nn.ra•.w.a ..................................................... ^ SIGNRUfiE AND TITLE OF CERTffIER ~~ - a,a •PRON011NCX,0 AND CERTIFYIND PNYSM]AN IPnYSiian lean «onouncvg <ea,n ant cM w cause d eeaml T tl E ~ L NSE NUMBER DATE IMane.. yprl /~ ^ ,, r ~ ` D/~ Ih - ` < r my krwrbd9•, d.am occurred r d,e Ibu, dab, and pace, and wu b a c a< .r of se(q and mannata..n1W .......................... N VI / Yt , L ],d. 2 / q y i,<. NAME AND ADDRESSIX: PERSON W/fOCOMPLETED CAUSE aF DERV 'MEDICAL EXAMINERICORONER ptem 27) Type « Print On Me 0aie of eaamina,bn anNOr Inves,lgation, in my opinion, dead, occurred al tAa Nme, de,e, and place, and due,o Ma eause(e) arM ^ TMRH Y ata,rtd .................................................. ............................ . .. ]la. ................. 2. RE RAR'S SIGNATURE ANO NUMBER _ //I DRE FlLED(Mmm. pay lp«I ~// t !J 7 Tf ,l'n T.~f. n ~ z~ of T°~T"E OF ACCOUNT ESTATE C)P ROBERT A MILLET: '-' sAOrYK+~s S.S. PIO. 162-22-7010 CHECICYNO T~ATJi OF L+EATH 09-24-94 ~ TRUST COtS:IT!' CUMBERLAND J GERTYFYGATE fa~'a °riU7~iThEL t',"bE i. c'*+u ~t iii 5~ t"dY %7143 REMZT PAYMENT A?&0 FORN3 TOs REGISTER OF ~6ILLs CUMBERLAND CO COURT HOUSE Cr~RLISLE, rep 170.:. I+.A~dKYS NALaZ4~le~ ~'a.'~?ti. has provldad the GoPertaent with the information listed below which has been used in calrulatinp the aotantial t^x due. 7hoir records Indicate that et the death of the above decedent, you wars a joint owner/beneficiary of this account. If you feel this inforvat.4ar, is incorrect, please obtain written correction from the financial institution, attach a copy to this fen anc rsaturn it to th.~ Mbova aclr,'rma4. This acccwnt is taxogjm Sn.accordanco with thaIrrheritence Tax Laws of tM Comaonwmmlth of Panrssylvonla. I)uostior.s a:~v b.~ =nse!r.res! by eallinya (?177 787-8327. CC~t#~b.El°E P~~'='~°; 5 ~ s_O'~ ~ ~ ~ SEiE RE~ER3E SIDE FOR FILIP~G ANn PAY&4ENT I1~5TRUGTIONE ...etat:,yY ~~~9n. `?S °'l.'"ti ~:.d17~ t°rts 09-24-7 To insure Proper credit to yovar acco~4, two Edstn411sFaacB (2) copies of this notice oust atcoepany your a,~-<~:1r~S =1,.?1.r3,~,^ E,8~7.b6 payasnt to the RoBlstar o4 NSAls. Ilaka chock peyoialo to: ^Repiator o4 dills, Agent^. erca~nt Tc~xt.» ~.~a X 16 . bbl r?~cvr~rt ve:3jrsw to TRx 1 4b7.97 kaTE: If tax payaonts arm aado within fhrcoo , (3) sontha of the decedent's date o4 death, Tex Rs9t~ K . 15 you aay deduct s S:C discount of tlw~ tax due. k'atant3ml Tex ?k;n 220.20 Any SnMritance tax due will bocasia delinquent nine (9) eonthr after the date of death. ~~~I A1FER ItE3POPISE -.- n -~- J , ;~,- f :. ~?'M`i.ti' 0~~~!~~>dL :'P`RA A3 _ ,.. ; ~~~;; ~ I; ~+.i.~-..L..•E~ ~.SY,_.-R.Y~~ i The aoovc inforaation a:,d fax dtwSa aorraet. `--' 1. You aay chooeo to rmSt peysu,nt to the Reaiater of dills with two copies of this notice to obtain ~~E(,,/ _ m disornxtt er avoid intmrwst, or you uay ehaolc box ^A^ and return thla notice to tFxa Register of `"'' ~ ;dills and an officSol assessasnt will ba issued by ttra PA Uapartnant of Revmm,e. I r~- { .,. arlE i3LUG"~ J _,. i ~ The sa'avs asset has ba::n nr will bs reported end 4ax paid with the Pannsylvanla Inharitsmom Tmx roturn `- oi~L~r to be filed by the doesdan4's rprasantatiw. t. ~ Ths above infareatlon is incorrect and/or debts and deductions were paid by you. ~J Yov must coaplatm PART 2^ and/or PART a below. F6erT :L4 yo~.d noicnt© ~ ePiffiorenf tax rate, Plmasr atatm your - ~~F'~~~~~„ ~',~~ . ~N~.T I ~~'^ I M , rcvlaafion ;yip to u~co~d~n#: ! 2 j ` I ~'"~ ~i~~a~~`~~t~~' ~~N~ Fl~~i''~~i race; ~:~ u~~~ - ~,~rn~i~r,~,TZaN ®~ 5'Sl?t ON .JOINT/TRUlST AoC~aNTg { I I I 'y ~ , 4 ~ ~ I ", ~Zfar 1. ~~~~ sts~-~.~.ish4^cl 1 _g ~ t~ >," I h I it {~ + I ~ ` ~ + " ' ~' '' mac. '~Cn.OI„71t 1'7.^.d+~,:S,-q 2 ca- ~ . r r ~ - ~ I , a ~rl t, ~ .,I,,f,: i~,,,., d,,{r,~ ,,. Cervcnt T+x~:~les Ste. r I ~ ! t,l r ~ ilt Ilp+ph~i!~I,~'!~ Itirl 'h,.,~~11 ,ISI !, y ~,. Amount ~ub~~~.i ;:c Ta;ax 4 ~ O / ~:, i ~~ ' I , III, , ~ I .i I~ ,III ii.l, ! a ~ ~. s~ro~ts .ara~ un^~raci:ionW a - ~ ' t it I ~ H f~' ~. r~71CL'n' TE3x ~,;:ar.~ 6 { ~ ~ 7 F~41 I~Il17 ti III I i 1~ ~I -~ r Trx R;:tm 7~ ~ ;,~; 'i J r ,, p' i~t4 I +I II , ~ r", ., t.~x C+uw $ ~ i , I. ~ I I ~ h I t>r.r•.T DEDTS AND DET~l4CTIONS GILAIP~ED ~_ '~r1TE ~~d'~i~ §'~fl'~EE DESCRIPTIOP~ ~IMOUNT PAID .:~,,+,:• ,,^~,n_,.).t:.:,,, ~r• :^:,vrv, Z 1c,rQ bhot tip? t`~cta 'E ~b~ rtc~x±rt~t9 ~ea~ era •krex~, r,p-rrs~t a,"td _ ~`~~ t~ _ ~.3 r~t c~F ~ne+,alti'ev~9 camp hwllestT. ,.r Ra~,ME C 3 +. ~ `~ ... ....... .-.-..__.~....-..~.._.~.-_ ~...~....~,....-..._._...~...,.tit,.,.F;.,.,..,4: E~ Y fr' 6J:'P ~is [L ~.,..~-.'....~.,,, ~-.....s, :~ a~i ' ~ - ~ ~ X ~ t fi''+t~.~'~IV ` ~v ~~ P~ ~^7.;~+'t ' 1 ~ ti, p+ ~s` ~ ~ tti~.C~ ih4, r ~r .. .. .,. -_ ~a, .- - ,. N+ti..- r .... •- . "' ~~ ~ ~NFOT£B+9AT']C®~' t~~'S'~GE ~~~ ~ I A ~ ~ ~~19 4 t r" 7i'~}'C631,~Y L°-. Tl ~~.`r9 ~^~Q~~a~ i ,p F%~.E ~dGn 21 - 4 CS° ~~ i :~G~B 941552b5 ~ ~31TE 12-22-44 r.;"- . t . y ~' ` (~ , , '; .-.r-,;.' '~ ,,„,,rr " t~ ti~+'.' ='I'+~e"$B~A°P'~~UV~? ~~~'~C~ ~ &'1'LF; Ed°.E'o 21 •- C~~ ~ ~ s ~,~ ~;. i 'r:f" `~ ,,; ~,~~' TA?t6~R,`l~R ~£~Sk~OP~9~E P~CPd 94155264 r. 1 .c;''"cf~;'"', DATE 32-22-94 ~, .>e- .:a'^.. ... cEO'l ~.,....~.,.~....~.~_._ .,, .r-,_~,,.-^an.r,...~.-.r_~.. TYPE OF ACCOUNT RT A P~ILLER I~ sA~ItdGS uSTATE OF ROB~ '' . S.S. N0. I~2-22-7018 ~ ~ CHECKING DATE OF' DEATH 09-24-94 _~ TRt1ST COL'N'TY CUM~ERLANI? !.J cERTIfICATE kEMIT FC,Yi7ENT ~1FS~ FORMS TQ: ''= iIL~~;~ ~3ILLER REGISTER OF WILLS A1Jn c_O t ehORCR t1 i O SF T . L ~ L R N U N1.7 ~11CR:YiC1:CIV ST CL r. ~`~ ~'L=ac~ CUNiBERLANFi PA 17070 CARLISLE; PA 17013 ; f }•r;tRR15 SA6'I~:=~ z~. f: ova`, ha: Frovidad the Daperteont wS th the information listed baba which hss hoer. used. in calculating the '~r'~~ pv'antial fa:< ^'.'n. Th~Sr ~ ,.;rds indicate that at tM death of the above docedan4, you were a joint owneNba-rofieiary of this account. '< ~ .~-,a +afe in ..{~. d. incorrect, please obtain written correction from the financial :.nstStution, attoch a copy to this farm - ^~ u ~ u. n : . to hr a ~.~e r..~r~~x:'. - This account is taxa#Ie-~ir,-ecerortlnrxa .wiNr the Znirorita+x+aa Tax Ceaa--af 't;,n LC1mdrP+mifi2it os isd-~asylvaais. ~aaxr~:ic~tc. a:a•t *.;s :5::-t+.4rmr. 'cy calling :717) 787-L321. ;~"3~'..F,`i%: ~%' ;:s :t ~El,®'~9 ~ 3~ ~ SEE F4~Y~RS~ SIDS F©Sd EKING AMD PAYM~~iT IMSTr~RUQ.`TIO~~iS µ~~,x.ca',::-,': ?~~. 03.-00016178 ~a}® 09-24-70 To Snwn proper credit to Ynvr account, two Esta-11SShsc! <2) copies of thin notice must accompany your payment to 4k» Register of Wills. Make check }fir, ¢; r; ~;e¢ 1`.,•~lanr. e~ 8,807.66 payable to: ^Register of Hills, Agent^. ~arLar.t T.s,xn'?l~ X 16.567 --- - NOTE: If tax payments are made within thrw ;`.t„1,.~~: :.u~::~r,•E 'r.~~ Trix 1,467.97 t3) months of the decedent's data of death, ;,~,, ): 1 5 you eay dedvcta SL discount of the tax due. i . ,. Any inheritance tax due wi21 become Wlinquant r "~-'t 220.20 ., %irs» :'ae'i s't'n nine '(9) months after the tlato of death. ,. ~ ~~*,~ _ - 7A3~PAYER RESPOPdSE u°° w ,a~.i3y~ . ~ ry ~ g ,li»»~~:r'Tr ~'Yl.~ t~l,.'d' Y~''~~i O~S~Y~YAL TAx ~SS144,;!~11~3 .~ '1'tEYS ~"f~CC~ ~ ~ ~' ~~ iv. ` I The above ;nformatim sad tax dw Se correct. '£5 ,J 1. Vou may choose to remit payment to ihs Ro9lstsr of Hills with two copies of this notice to obtain r- ~~iCS' ~ e discount or avoid interest, or you may check bax ^A^ and return this notice to the Register of i ~N~ 4111Sa a,id an officiol assessment will bs issued by tiro PA Department of Revenue. ' i-r~~?~ ~ The ebova asset Ftas bean or will bo reported ondtax paid w!th iM Pennsylvan Se Inheritance Tmx return ~. . ` L ~' to 5e filed by the decedent's represantativm. - ©YyLS" - ~1 The above information is incorrect and/or debts and deductions wore paid by you. LJ 'feu Duct coepleto PART ~ end/or PART O below. I ~ass eta#o Your PART Tf ycu indic;atc o differsnt $mx rs s ~~C~~~~`~~ ~t~F 'Q~~,~ ~y~~~•: ~ n . ~clstion~hi~ to decedent: ~~/ u - ~~T OF R~~~~i~~ ~A DEF"AR'TM _ '~ Tax ~ZsTURt~ - ~~rawu~ATZ~t~ ~~ Gx ar~~o~ TiTRUST Acc;Qc~Nirs 1 .. ~D _, - , - ~, LIFlE I. ~,atn £strtalisht,:l I I ~- y~ ~. ~rSeC"Si,r:'1 ~E3 ].~n.:ra ~ ~ ~ ~'' ~v,!}I G~ . ~. , ,,. _,~?^'i Tex.*;??SCE r '~ ~~ ~1 f,. 1ro~n': Ss.,..na;c Eo Tax sr ~ Y~~i ~' ~ 4 :J. ~i:.ia `l'.w t'.. ~'..u..:.tioni ~ - ~'. h P,. ~°;f,,Ln". ~K'.,..^'..~ e5 ~.~. ~~~ ~~. . ,derr..~w~e ; 5 : '. T x ,pia Yr9 7 ~a ~. tt ~L ~ ~° ~ye:e~or ~rn.e.•ei.ess cf her,aeary, I daclsrs $hat thg fitac$s I have roPOr:mdl abav® $~/ar~, :~tsr/ra~c/$ ..~~+aa.~:,o ,o ${+,a 'rant Qf sv knoaiedae and Cpeliaf. HOME C /~Z 3 ~? t ~ -1 ~J - 4lt~Rit } „`~:'=';a' ~.. _7Gial--o'i ±!; ~ tr'' i Pam N ., ,~ .. .. _ _ " ,"t' 'Y is r -04 (~ F. f"i~. Ft .i '~' as t-}-~ .~ ,i„ ~;r °Sram't ^~ T~'~fi i r ~` c-h ~k 3 i+~-k, ~ r > ~ 1. t3~ ~? 2hr r is..ar~ x ~ ~* `~'~ ~t ,~ = , ,~ ~. - ~°s . 1 r ~.'` .,,,;+ts ~*l"'``."~ -n ~ h,iM% ")d s'~,~^d` ~y- fa Y'd, a "'`a~r~.t t ~' a ri i t . ,tie R`.-~.?i3.~--5+'t,~-~+~<~,,;'A*e:4~ vt'~S~ ~~}~~w~`~~ ~'.~" #~i F ~, ~a~; u~~~~ ~~aa s~~ucTi~MS cLnarasn ~~ ~_; ~~:T _ P'=:;.n P~,`lEE DESCRIPTION AMOUNT PAID V ~~ ~ ~.. .~ 1 s .\ . ~ ~.~ ~ ~\ _...~`. „~.. -......:gyn......... +.~~. _.... ~... ~. ,~ . .... l~ ., ~~~ra~r:c+F tx~vi-~ atv-nas ~x ;s vil ~~'$':4:,~~ ~~~~ {P ~~~~~~~~~ ~~~1~~ ~d']~~~~~Tt~C ACN RECEIVEG FROM: ftSSESSMENT CONTROL AMOUNT NUMBER Fd~L.tftl MILLER -y~T'.',~b4 ~~ ~'~ w~°~RE~€?££id ~~'R~ET 94 S 5!~~63 9820.20 ~1~~ ~tai~'2~RLAA41~ F'R 17®70 - FOLD HERE f0(D MEFE TI ESTATE INFORMATION: IFllt NUMBER NAME OF DECEDENT (LAST) (FIRSTI (MIJ MT~_L£R ~~?~T A ~ DATE OF PAYMENT f) i ~~"P ,oQ.~__ ~POST~4ARK DATE i I CO U N T~ y'__Z'7`-,.a.-~rW`YtS7! ~1 i CA?E OF CEATN _ REMARKS SE,~,L .- ----.r.--•----------- ~~~. ~,~ , .... .~ R~ClSTtR OF DILLS r TOTAL AMOUNT PAID _~_ *JOAr~ RECEIVED BY _ GN URE ~ IST£R Q~' 1~T1_fl Rt / ~~.- REV-1607 EX AFP (12-95) CDMMONNEAITH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 INHERITANCE TAX STATEMENT OF ACCOUNT ACN 101 DATE 02-20-96 ESTATE OF MILLER ROBERT A FILE N0. 21 95-0073 DATE OF DEATH 09-24-94 COUNTY CUMBERLAND NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS FORM WITH YOUR TAX PAYMENT TO THE ADDRESS SHOWN. MAKE CHECK PAYABLE AND REMIT PAYMENT T0: , JOHN M EAKIN MARKET SpUARE BUILDING MECHANICSBURG PA 17055 REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 Amount Rswitt~d CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR FILES 1 ---------------------------------------------------------------------------------------------------------------- REV-1607 EX AFP (12-95) *~~ INHERITANCE TAX STATEMENT OF ACCOUNT *~* ESTATE OF MILLER ROBERT A FILE N0. 21 95-0073 ACN 101 DATE 02-20-96 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN 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: 01-08-96 PRINCIPAL TAX DUE: PAYMENTS (TAX CREDITS): 2,115.90 PAYMENT DATE RECEIPT NUMBER DISCOUNT C+) INTEREST C-) AMOUNT PAID 09-24-94 SPOUSAL .00 2,115.90 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST * IF PAID AFTER THIS DATE, SEE REVERSE I TOTAL DUE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE ZS LESS THAN 81, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A ••CREDIT^ (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ) 2,115.90 .00 .00 .00 PAYMENT: Detach the top portion of this Notice and subwit with Your paywent wade payable to the nawe and address printed on the reverse side. -- If RESIDENT DECEDENT wake chock or woney order payable to: REGISTER OF WILLS, AGENT. -- If NON-RESIDENT DECEDENT wakes chock or wonoy order payable to: COMMONWEALTH OF PENNSYLVANIA. All paywonts received shall be applied first to any interest which rosy be duo with any rewainrNr applied to ttw tax. REFUND CCR): A refund of a tax credit, which was not requested on the Tax Return, way bo requested by cowpleting an ^Applieation for Refund of Pennsylvania Inheritance and Estate Tax^ (REV-1313). Applications aro available at the Office of the Register of Wills, any of the 23 Rovonuo District Offices or frow the Departwent's 24-hour answering service nuwbers for forws ordering: In Pennsylvania 1-800-362-2050, outside Pennsylvania and within local Harrisburg area C717) 787-8094, TDDN C717) 772-2252 (Hearing Iwpairod only). REPLY T0: Questions regarding errors contained on this notice should be addressed to: PA Departwent of Rwemw, Bureau of Individual Texas, ATTN: Post Assesswnt Review Unit, Dopt. 280601, Harrisburg, PA 17128-0601, phone (717) 787-6505. DISCOUNT: If any tax duo is paid within three C3) calendar worths after the decedent's death, a five percent (5%) discount of the tax paid is allowed. INTEREST: Intorost is charged beginning with first day of delinquaneY, or nirw C9) worths and one (1) day frow the data of death, to the date of paywent. Taxes which baeaw delinquent before January 1, 1982 boar interest at the rate of six (6%) portent per annuw calculated at a dally rate of .000164. All taxes which becawe delinquent on and after January 1, 1982 will boar interest at a rate whiefi will vary frow calendar roar to calendar roar with that rate announced by the PA Departwont of Revenue. TFw applicable interest rates for 1982 through 19% aro: Year Intorost Rate Daily Interest Factor Year Intorost Rato Daily Intorost factor 1982 20% .000548 1987 97. .000247 1983 16% .000438 1968-1991 11% .000301 1984 11% .000301 1992 9% .000247 1985 13% .000356 1993-1994 7% .000192 1986 10% .000274 1995-19% 9% .000247 --Intorost is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUlIBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becows delinquent will reflect an interest calculation to fifteen C15) days beyond the date of the assesswent. If payeront is wade after the intorost computation date shown on the Notice, additional interest roust be calculated. REV•150b EX+ (7 94) ~ ~, c { , COMMt1NWEALTH OF PENNSYLVANIA GePARTMENTOFREVENUE DEPT. 280601 ~ HARRISBURG, PA 17128-0601 DECEDENT'S NAME (LAST, FIRST, AND MIDD MILLER ROBERT A ~0:~5~~~ INHERITANCE TAX RETURN RESIDENT DECEDENT (TO BE FILED IN DUPLICATE WITH REGISTER OF WILLS) o SOCIAL SECURITY NUMBER DATE OF DEATH DATE OF BIRTH 162-22-7018 09-24-94 03-07-30 D (IF APPLICABLEI SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER FOR DATES OF DEATH AFTER 12131191 CHECK HERE IF A SPOUSAL POVERTY CREDIT IS CLAIMED ^ FILE NUMBER CODE 21 UV` YEAR 9 5 NUMBER 17 KEVIN ROAD MECHANCICSBURG, PA 17055 CUMBERLAND MILLER JOAN E. 192-34-5828 L" x a ti ~ 1. Original Return ^ 2. Supplemental Return ]C =oo ^ 4. Limited Estate ^ 4a. Future Interest Compromise c' ~ m c pied Testate ~ 6 (for dates of death after 12-12-82) ^ 7 D d a h co Atta ( py of Will) . ece ent Maintained a Living Trust (Attach copy of Trust) ~q~ ~ NAME ~= JOHN M. EAKIN v ~ TELEPHONE NUMBER z 0 a J d a W s z 0 F- 0 x it is true, based on ~ a _ J F L S~~{T gE OF AREB OTHER THAN REPRFCFti~~~F ~ ~ ~ ~ ~~ ~ ~~ ~ ~~ ~ ~ ~ ~~~~~ .vim/l %• ~ t~ ^ 3. Remainder Return (for dates of death prior to 12-13-82) ^ 5. Federal Estate Tax Return Required _ 8. Total Number of Safe Deposit Boxes v~ , ~,_~~ - sue- .; . ,° MARKET SQUARE BUILDING MECHANICSBURG, PA 17055 1. Real Estate (Schedule A) (1) _ 9 8, 0 0 0 0 0 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 8 Miscellaneous Personal Property (5 ) (Schedule E) 6. Jointly Owned Property (Schedule F) (6 ) 7. Transfers (Schedule G) (Schedule L) (7 ) 8. Total Gross Assets (total Lines 1-7) ($) 9 $ , 0 0 0 . 0 0 9. Funeral Expenses, Administrative Costs, Miscellaneous Expenses (Schedule H) (9) 8 , 5 0 5 7 0 _ 10. Debts, Mortgage Liabilities, Liens (Schedule I) (10) _ 18 , 9 6 3 . 2 3 11. Total Deductions (total Lines 9 8 10) (11) 2 7, 4 6 9. 9 3 12. Net Value of Estate (Line 8 minus Line 11) (12) _7 0 , 5 3 0 . 0 7 13. Charitable and Governmental Bequests (Schedule J) (13) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 7 0 , 5 3 0 . 0 7 15. Spousal Transfers (for dates of death after 6-30-94) See Instructions for Applicable Percentage on Reverse Side. (Include values from Schedule K or Schedule M.) (15) 7 0, 5 3 0 0 7 x, ~ 3. 2 ,115 9 0 16. Amount of Line 14 taxable at 6°r6 rate (Include values from Schedule K or Schedule M.) (16) x .06 = 17. Amount of Line 14 taxable at 15% rate (17) (Include values from Schedule K or Schedule M.) x .15 = 8. Principal tax due (Add tax from Lines 15, 16 and 17.) (18) 9. Credits Spousal Poverty Credit Prior Payments 2,115.90 Discount Interest + + - (t91 2,115.90 20. If Line 19 is greater than line 18, enter the difference on Line 20. This is the OVERPAYMENT. (20) 0 ~^ 21. If Line 1 B is greater than Line 19, enter the difference on Line 21. This is the TAX DUE. (21) 0 A. Enter the interest on the balance due on Line 21A. (21A) B. Enter the total of Line 21 and 21 A on Line 21 B. This is the BALANCE DUE. (41 g) Make Check Payable to: Refit:ter of Wills, Agent ~n ~ ~~~,~, r~murmii I declare that I have examined this return, including accompanying schedules and statements, anc ste. I declare that all real estate has been reported at true market value. Declaration of preparer which preparer has any knowledge. ABLE GAF Fu Il.lr_ ocrneu ~r my Knowledge and belief, Te personal representative is DATE DATE ~~ ~~ 9s -~ . } P.EV-I50< E`/.+ (12-85)r `~ ` SCHEDULE A COMMONWEALTH OF PENNSYLVANIA ( REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER MILLER, ROBERT A. 21-95-73 (Property jointly-owned with Right of Survivorship must be disclosed on Schedule F) All real estate should be reported of fair market value which is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled ,' RFV-1511 LX4 IS-86) ,. .~:`~ ..,, ~_t .~,. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MILLER, ROBERT A. ITEM NUMBER DESCRIPTION ~-• Funeral Expenses: ~• MUSSELMAN FUNERAL HOME LEMOYNE, PA . 2• GINGRICH MEMORIALS, LETTERING MARKER Please Print or DER 21-•95-7:~ AMOUNT $5,233.70 $ 78.00 B• Administrative Costs: 1 • Personal Representative Commissions Social Security Number of Personal Rep resentative: Year Commissions paid 2. Attorney Fees $ 750.00 3. Family Exemption Claimant JOAN E. MILLER Relationship WIFE Address of Claimant at decedent's death $ 2 , 0 0 0 . 0 0 Street Address 17 KEVIN ROAD City MECHANCISBURG State PA Zip Code 17055 4. Probate Fees $ 214.00 C• Miscellaneous Expenses: 1. FILING FEE 15 00 2• CENTRAL PENN APPRAISALS . 165.00 REAL ESTATE APPRAISAL 3• RESERVED TO CLOSE ESTATE 50.00 $ 230.00 (If more space is needed, insert additional sheets of same size) SCHEDULE H FUNERAL EXPENSES, ADMINISTRATIVE COSTS AND MISCELLANEOUS EXPENSES TOTAL (Also enter on line 9, Recapitulation) $ 8 , `5 0 5 . 7 0 I~ REV•1512 EX+ X10-86) F' ,~~~~~ I SCHEDULE I ~. DEBTS OF DECEDENT, COMMONWEAIiH OF PENNSYLVANIA MORTGAGE LIABLITIES AND LIENS INHERITANCE TA% RETURN RESIDENT pECEDF NT ESTATE OF FILE NUMBER ROBERT A. MILLER ~-_ ITEM NUMBER DESCRIPTION AMOUNT 1, 1ST FEDERAL SAVINGS 8 LOAN, MORTGAGE ON 17 KEVIN RI UNPAID BALANCE, SEE ATTACHED $ 693.44 2. SEARS ROEBUCK, ACCOUNT $1,071.00 S 3. MA ER CARD, MELLON BANK $2,863.42 4. NORWEST FINANCIAL, ACCOUNT $ 571.20 5.. HOLY SPIRIT HOSPITAL, MEDICAL BILL $1,077.40 6. TEUFLE ASSOCIATES, PROTHESIS BILL $ 150.00 7. SUSQUEHANNA SURGEONS, MEDICAL $ 140.62 8. WEST SHORE PHARMACY; 'PRESCRIPTION $ 200.00 9. E.K.G. ASSOCIATES, MEDICAL $ 4.32 10. WEATHER CHECK, UNPAID BILL FOR WINDOWS $7,796.00 11. BELL ATLANTIC, TELEPHONE, $ 97._36 12. PP~L, ELECTRIC $ 213.51 13. PA AMERICAN WATER COMPANY, WATER $ 3g.,~g 14. HAMPDEN TOWNSHIP, SEWER ~ TRASH $ 98.00 15. GOODS FURNITURE, UNPAID BILL FOR FURNITURE $1,389.28 16. J.C. PENNEY, BOOK ACCOUNT $2,558.69 ,' ~' ;" TOTAL (Also enter on line 10, Recapitulation) I $ ,1$ , 9 6 3 . 2 2 (If more spots is needed insert odditiona! sheets of same size) REL-1513 E%+ (2-87( r s _ I. SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT GCTATC n FILE NUMBER ROBERT A. MILLER 21-95-73 >TA B. Charitable and Governmental Bequests: TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13 Recapitulation) ~ $ (If more space ~s needed, insert additional sheets of same size) ITEM NUMBER NAME AND ADDRESS OF BENEFICIARY AMOUNT OR ' SHARE OF ESTATE