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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-2a~7 ? .
Date Fran eropoli, ' ect
Division of Vital Records
fT6Yl8. ~ cay~ronwe~urn oR na+raru~u- • oar of ~~ • vrr~t. necoiros ~ I ~ ` _' ~ -"'` ~'
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To:
Register of Wills for the
__.__,___. _ L`ece~.;ed. County of CUMSERLAf~D ` in the
:ir~c,xt c,.,~,,-c ~;r~. _e%'7~.'^~~=~p'~lr,~__ Commonwealth of Per_nsylvarnia
:::~ p~.'itnY~: of the undersigned respectfully represents that:
".z'c~i~r ;~°:i~.ior~,cr(s), who is/are 18 years of age or older, appl_j_~ 5 for letters of administration
on the estate of
;c..b.n.; ;?cndenta lire; durante absentia; dorantc minoritate)
iaecender:" was ciamiciled at death in ~-~~'~~-~~~~ County, en Sylvania, with
?~ '?~'~ ,,'~t fa-nily or princi al residence at.L~c~~ ~ ~~~.___.~~-~R /~S ~
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(list street, numL+er and municipality}
D' cenc'.eY?t, tizen +7 ear/!g o/~~a e, died ~'~~~''~ ~ , 19 ,
a[ _~'`t'_C `` Y- ~;'_a0 / ~~i 1"„~ S / / T/t ~ ..' ~ 9N, aa" 1T~ f /Y l Fy' __.
1?eceszder.t ~k cicath owned property with estimatad values as folllows:
tizf lomicil::~ :rz a.) x.11 personal property ~
{.f net domiciled in Pa.) Personal property in Penrsylvania $
f r,nt do;rici3~°d is Pa.) Personal property in County $
~'ai~<c of rex~l es?€~ie in Pennsylvania ~
i e~,Ytiorze.___ after a praper search ha S ascertained that decedent left no will and was survived by
tape Fo°,h~wi~~ spouse iif any) and heirs:
+ __ ~`°,innze KclationshYZ~ Residence
~;dER£a~~~ ~'~, petitioner(s) respectfully requesk(s) the grant of letters of administration in the
appa~:~r:-;,2,~° is>rm :c the u~zdersigned.
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REV-1500 EX+ (7-94) ~,
INHERIT CE TAX RETURN FOR DATES OF DE~4TM AFTER 1 Z131/Y1 CHECK HERE
IF A SPOUSAL
T
S CLAIMED ^
RE ENT DECEDENT ~
FILE NUMBER
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COMMONWEALTH OF PENNSYLVANIA (TO BE FILED IN DUPLICA oof(
DEPARTMENT OF REVENUE
DEPT. 280601 WITH REGISTER OF WILLS)
HARRISBURG, PA 17128-0601 COUNTY CODE YEAR NUMBER
,,,.
DECEDENT'S NAME (LAST, FIRST, AND MIDDIk'INITIAL) DECEDENT'S COMPLETEgp DRESS
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W SOCIAL SECURITY NUMBER ~ DATE OF DEATH DATE OF BIRTH ~
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p (IF APPLICABIEI SURVIVING SPOUSE'S NAME IAAST, FIRST AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER AMOUNT RECEIVED ISEE INSTRUCTIONS)
~ .Original Return ^ 2. Supplemental Return ^ 3. Remainder Return
Y a ti (for dates of death prior to 12-13-82)
=co ^ 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required
U (for dates of death after 12-12-82)
Q°' ^ b. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust _8. Total Number of Safe Deposit Boxes
(Attach copy of Will) (Attach copy of Trust)
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y Z NA;,tE _ f, C MPLETE M GADDRESS s
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V ~ TELEPH NUMBER "``
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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 8 Miscellaneous Personal Property (5 )
(Schedule E)
b. Jointly Owned Property (Schedule F) (b )
7. Transfers (Schedule G) (Schedule L) (7 )
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses, Administrative Costs, Miscellaneous (9 )
Expenses (Schedule H)
10. Debts, Mortgage Liabilities, Liens (Schedule 1) (10)
1 1. Total Deductions (total Lines 9 ~ 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
15. Spousal Transfers (for dates of death after b-30-94)
See Instructions for Applicable Percentage on Reverse
Side. (Include values from Schedule K or Schedule M.) (15)
16. Amount of Line 14 taxable at b% rate (16)
(Include values from Schedule K or Schedule M.)
17. Amount of Line 14 taxable at 15% rate (17)
(Include values from Schedule K or Schedule M.)
18. Principal tax due (Add tax from Lines 15, 16 and 17.)
19. Credits Spousal Poverty Credit Prior Payments
Discount Interest
+ + - (19)
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. (21 A)
B. Enter the total of Line 21 and 21A on Line 218. This is the BALANCE DUE. (21B)
Make Check Payable to: Register of Wilts, Agent
(11)
(12)
(13)
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Under penalties of perjury, 1 declare that I have examined this return, including accompanying schedules and statements, and to the
it is true, correct and complete. I declare that all real estate has been reported at true market volue. Declaration of preparer other
based on all information of which oreaarer has anv knowledge.
s ~st:t~,
if my knowledge and belief,
le personal representative is
DATE
~" = l.~ ' rf,~
DATE
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% (.02) 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
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$ ...................................................................................................
3. Did decedent own an 'in trust for'. bank account at his or her death$ ......................................
IF TAE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOB MUS~~COI'~~L.ETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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REV-1508 EXt (2-8))
COMMONWEALTH OF PEI
INHERITANCE TAX i
RESIDENT DECEO
SCHEDULE E
CASH, BANK DEPOSITS AND
,A MISCELLANEOUS
PERSONAL PROPERTY
Please Print or Type
ER
~/I~adI3
(All prop~rfy jointly-owned with !h~ Right of Survivo~shio must b. di:elos.d en Se6.d~1. F1
REV-1511 E}G+ IqB) SCHEDULE H
FUNERAL EXPENSES,
CChMONWEALTH OF PENNSYLVANIA ADMINISTRATIVE COSTS AND
IN RESIDENTEDKEDENTRN MISCELLANEOUS EXPENSES Please Print or Type
ESTATE OE FILE NUMBER
~ d s ~. ~. L_ ,~ r ~~ od y3
ITEM
NUM BBt DESCRIPTION AMOUNT
A.
~_ Funeral Expense/s'~:'
~ y~S f ~//E~ie~~- l~~Gr.J, y0 p/ _
Q~~,~` Q. 90
~~ ~E~~.r ~~o t ~~. o0
~a ~ u~ ~,~~` i ago. o~
B. Administrative Costs:
1 _ Personal Representative Commissions _ _
Social Security Number of Personal Representative:
Year Commissions paid
2_ Attorney Fees
3. Family Exemption
Claimant Relationship
Address of Claimant at decedent's death
Street Address
City State Zip Code
4. Probate Fees
C. Miscellaneous Expenses:
1.
3. Li`d S ~ r f'~i- ~- 1F !./~ C ~~ P2 S
//
4. '
5.
6.
7.
8.
TOTAL (Also enter on line 9, Recapitulation) ~rJ'~~~
(If more space is needed, insert additional sheets of some size.)
i
RE~'i1513 EX+ (2-87) ,.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF FILE NUMBER
ITEM
NUMBER NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR
SHARE OF ESTATE
A. Taxable Bequests:
~~ s ~ ~ y
~ ~ a3 ~`I ~ f~ ~ ~'/~ ~~
~~2 ~~ ~, ~ s a ~,~ y~ ,~,9-
17 v.s6~
ITEM I NAME AND ADDRESS OF BENEFICIARY
NUMBER
B. Charitable and Governmental Bequests:
AMOUNT OR
SHARE OF ESTATE
TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation) I $
(If more apace is needed, insert additional sheets of same size)