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HomeMy WebLinkAbout95-0104~-~~~ ion ~ 0 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 ~ s- X007 Date H70a.1~3 Rnr. 7/87 TYrEnRwT w pERIIANENT BLACK ^1K I~~ ~I W W W 0 r~ • Fran eropoli, ' ect Division of Vital Records P.O. Box 1528 New Castle, PA 16103 COMMONWEALTH OF pENNSYLIMNIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH 002422 NAME aF DecEDENr,c:s.MWAw lr9 soclALSECURmr«meEn---- DREar DEI^NA/lnn. o.y.Ib•9 ,. Vernon H. Shaffer :Male ].186 - 05 - 82 ~ T A<LESr aPaAly) UIDERIYEM UIgEA,DAT DATEOF B^IM BI11y1PlACE IGMaW MACE Oi DF1Q111LMCMONYan•-,rNluoion•ana.wl atlN M111M Or,a Illlaa MMM lMaal.Oq:'l,al Srbor Faagrl Calayt H08N91L: ~~ O.r ~• ~ ~ ^ oa. ^ Nar ^ ~~ ^ ~ ^ ! 91 YR 6-28-1 0 , Columbia P . COUNTYOF DERV CRI:BOIIO.YW/DF OERN NAME Pnalallrn. p.a raa antl nuniblrl 11R~8yD~aECEOFMOF NIaR1NIC ORIBw7 RACE •Mrrlr•Ylir4 Bbdl,YRib. a1C rsR'OM NCCl w^.yrlp«WCI+r. t ,5la~o-~R~ MlakrtRaabRYaa.r1. white Cumberland E. Pennsboro ~(LGL :S iR{ ~ ~ IANpDFeI>slllESanNOl,srRY w1aDEDEDE/a EYERw oEDEDENraEwu^IDN MARIPL aDBUi-MrrMA sl^lyly^q 9PDUSE U.S. AIYEBfGRCE81 Nlrr rrW.9YMrN4 Pw•. p.anrOrrrrnrl 1cN.I:,Ar Aar ms yfSY ~~ D1Ar1•A lSpr1N d..wl^rlcrrlll:,.'~NAt MIl^ N•L'S' lo-,z, I,.ds.l widowed a ,w • Truck Driver , Dai ,: , BE ~ M ~ADOIEaB pw1L C9N~•9NIR 21pCOAlI a lh^N..rrAa^MAin a lh s... Pa ~ ~1V Th 51() O io/dlly ,1EaE1EMCE West Fairview ~'°"` Cumberland Mbabrliy9 ~ w.~w+MA West Fairview / .rrasrrarr x ,h t9^NEA'aNAME IFb1L MiAAa,1x19 S NAME ffrl. MiAAI. MdAalaurlrlW Harry Shaffer , Adeline Kane /~ ^PoIY/ANi's NAME (,Rla~Plii9 Leona Lincourt s.w,BDADDr~ssa..a.w~..,.sba.aocaaN _ 544 Third St West Fairview 1 02 MErNDDOSOMVOernoM uREOFOmroenlDl/ nAC;EOSOmroalrlow-wrac«lala.cn.al.r LDOR,DM-o9,ro...]a..av~•r erwC2 cr.ar^r^ Rwrw,laasrr^ D•Kw•'t «wlr^rr orlrra~ Gwrlwlem ^ „~ Jan 12 1995 ],a Enola Cemete :,~ E ^^3NalwEOC aERV,cELICENaEEOarERaoNACrrNtAasucN lAM^En waADONEasosrACam m. 012228E „~ Musselman Funeral Home Inc Lemo e Mrr O./aaQaMloa^ylrq uco/sE NULIBFJI DRE 9laE~ M dr•yYwrAp•. AaaM•uNnAYMar.0111 •IW.boarwA b•1l rairlr Brd4rbb r111iN r,..rA.r. ]y, Ylla CASE REiFAREDID MEDICAL ~ ]I-Y91IAlrlbrrll^I11rbY OF OF/PN ORE PRONOUIICED DEADIMdMS, Daft Hart ,M^ NeW aba pa,wNrdla^L r+ J Q M. O. PARfk ErrMAfwra. lAluYasrap9erar vAidlt•INr MAl1M. O1nr «wr Mnn4dgiq. reAr r lnaa4 aMM,raa. IApOwbllb PRRf ^: OArrN^li^kaM •alE^ISI/orMMApbdrM.W IYa1rvY011aMa nulrwlagbM araNiquraadrrbRYlfL l.la r1lyar C•I~raatA^na. ,rN11 anAAaNlI 1 BB^FDbOE IF NI ~ ~ ~ L _ rwi,pn AaAy-~ DUE ropR As NCE oct: _. 1 ^rrK lr6pbi,llbi111 u drE 7D IOR ASACONSEOUENCE OF} I alr. Err UIOdIYMB i CAIINpYrwrlyuy bi1W lwib DUE7OpR ASACOILSEOVENCE Dfk I nw~YprAway WT Y111a AN AL17OPSV y1ELlE AUID/SY f,HDMyD9 MAN/ER OF DEAN ORE OF 9LA111Y LIME6^6R11yy MN^IY RYYDRII? DESCRIBE /10W ^NURY DCCUPflED. IEAFOPMEM AMINNLEFla01,10 D•%'h•rl OF CAUSE I~ ^ K DE,OIIT ~~~ Nlaall ~+ 1b1 ^ N•^ ACray ^ Ral,Wybvaagalar ^ M. yba ^ N1~ 'M ^ N1 ^ 9ukM1 ^ Cur na rdalmynr ^ PLACE OF wRN,Y~NSa•a,,ann, abaaL bCb1X •Illr k 9/r1 •~ ISP•oM LOCRION (SMarL 2M M 11 0. ]9a. bl. C6RNIFlI IC,r drwM anN 23 a u S SN3NRU,'IE AND TTIF OF CERTIFIER O~ an b 1 'CEIrtNY^IB PIIY^ICIABIPSyllal•uaINy19 aurdullWyn a~MadM~+lA nr GronanfaAMM riA Uamp AMMrrary MnwbA^1.A7•^l oea,rrV Arb Mel.aNNrtlarlrawrNlbA ..................................................... ^ ],R LICENSE NUMBER DRE SNIIEDBAw13, DIY. Yr/ •-waolNleawANOCertrvwonnalaANlvnv.c+mm~aa~.wA.r•~~«~•nbcaw.darmt A s, M~Jolo ~-S~= ],e. J'~cra s1 {Y ......................... TO M brlNr-kral•M•. AIaN 1tar,N M M IIIM, Alb. al1A Pula, 1110 as b M urNN aM waver abb NAME ANDAOpESSOF NnN)CONPLETEOCAUSE OF OEAiH (Balrl271 Typ•ar PrbM wrr vY-4 /,~. CixYlf ~'••> 'MEDICAL EXAl11NE/000RONEN OR waballsrnalr,b,atl•rlod/rNrv•rlWlbn.bry opbyun, daatll aeewrW rUra tlrl,a, data, and pbea. anAduar tlb er,r(N arW ^ .............. d ~ //,,; ,.. /? w "}-~~ ' ........................................................................... rwrr r rr/ ]ta r ~// ]_. G 1 /L: / a REGISTRAR'S 516NATURE ANO~ ~~ OREFIIED FA•rY3. Day. ,bat ~. >.. s 1 U .~ :V-1500 EX+ (7-94) 1` INHERITANCE TAX RETURN FDR DATES.OFDEATH AFTER 11131191 GFiEGK H ^ U ~~ ~ ' CREDIT IS CLAIMED POVER Y RESIDENT DECEDENT FILE NUMBER COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE (TO BE FILED IN DUPLICATE v~~ ~ DEPT. 280601 WITH REGISTER OF WILLS) _ ~ t ~/ HARRISBURG, PA 17128-0601 NUMBER COUNTY CODE YEAR DECEDENT'S NAME (LAST, fIRST, AND MIDDLE INITIALI DECEDENT'S COMPLETE ADDRESS SHAFFER VERNON H. 516 WEST 3rd STREET w SOCIAL SECURITY NUMBER DATE Of DEATH DATE OF BIRTH WEST FAIRVIEW, PA 1 7 0 2 5 186-OS-8233 1 /9/95 6/28/03 c°~°I p I lf A-PLKAlIEI SURVIVING SPOUSE'S NAME QASI, FIRST AND MIDDLE INITIALi SOCIAL SECURITY NUMBER AMOUNT RECEIVED ISEE INSTRUCTtONSI ~ ®1. Original Return ^ 2. Supplemental Return ^ 3. Remaindbr Return >t a y (for dates of death prior to 12.13-82) c o ^ 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required ~ (for dates of death aher 12-12-82) a m ~ 6. Decadent Died Testate ^ 7. Decedent Maintained a living Trust _ 8. Total Number of Safe Deposit Boxes (Attach copy of Will) (Attach copy of Trust) ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: -i t" NAME COMPLETE MAILING ADDRESS JAMES M. BACH ESQUIRE 352 SOUTH SPORTING HILL ROAD 0o TEIEPHONENUMBER MECHANICSBURG, PA 17055 3 z 0 a a W o~ 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages and Notes Receivable (Schedule D) 5. Cash, Bank Deposits 8 Miscellaneous Personal Properly (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) (Schedule L) 8. Total Gross Assets (total Lines 1.7) 9. Funeral Expenses, Administrative Costs, Miscellaneous Expenses (Schedule H) 10. Debts, Mortgage Liabilities, Liens (Schedule I) 11. Total Deductions (total Lines 9 8 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests (Schedule J) 14. Net Volue Subject to Tax (Line 12 minus Line 13) (e) $ 47,848.97 (11) ? 13,732.04 (13) 0 (141 ~ "T 4. 1 1 E_ 9 "~ z 0 a f- d 0 v a F- 15. Spousal Transfers (for dates of death aher 6-30-94) See Instructions for Applicable Percenloge on Reverse Side. (Include values from Schedule K or Schedule M.) 16. Amount of Line 14 taxable at 6% rate (Include values from Schedule K or Schedule M.) 17. Amount of Line 14 taxable of 15% rate (Include values From Schedule K or Schedule M.) 18. Principal tax due (Add lax from Lines 15, 16 and 17.) 19. Credits Spousal Poverty Credit Prior Payments (1) $ 45, 000.00 ~ see r:xhinit A J (2) 0 (3i 0 (4) 0 (5) .2,848..97 (b) 0 (7) 0 (9) $ 13,732.04 (10) (15) x._= (le) $34, 1 1 6.93 x .oe = $ 2, 047.02 (17) x .15 = (le) $ 2, 047.02 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) $ 2 F 0 4 7 _ 0 2 B. Enter the total of line 21 and 21 A on line 21 B. This is the BALANCE DUE. (21 B) ~_ 2y Q 4 7 - ~~ Make Cbetk Payable to: Rigister of WFlla, Agent ~ ~ BE SURE TO ANSWER ALL GtUESTIONS ON REVERSE SIDE AND TO RECHECK MATH ~ ~ l Jnder 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, I is true, correct and complete. I declare that all real estate has been reported at true market value. Declaration of prepare, other than the personal representative is lased on all inFormation of which prepare, has any knowledge. IGNATURE F PERSON RESPONSI E FOR FILING RETURN ADDRESS DATE ~~~' ~ti~~-- 540 Third Street, West Fairview, PA 17025. 10/3/95 .IG ATURE PREPARER OTHER THAN REPRESENTATIVE' DDRESS DATE '~-.-- -; 352 S. Sporting HI11 Rd., Mechanicsburg, PA 17055 AMES M. BACH, EiSQ. 10/3/95 ~.~' ERE 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% (.OZ) 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 111/98 will be exempt from inheritance tax. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING A CHECK MARK (r) IN THE APPROPRIATE BLOCKS. YES NO x 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 . ............... x c. retain a reversionary interest; or .................................................................................. x d. receive the promise for IiFe of either payments, benefits or care$ ....................................... x 2. If death occurred on or before December 12, 1982, did decedent within two years preceding death transfer pro~arty without receiving adequate consideration$ If death occurred after x December 12, 1982, did decedent transFer property within one year of death without receiving adequate consideration$ ................................................................................................... x 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:; _- ~a~ G l r- ,_ ~ ..~ _ e REV•1502 EX+ (12-85) I. /~~j~ J ~ "K ' .t~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAI( RETURN RESIDENT DECEDENT V ESTATE OF VERNON H. SHAFFER SCHEDULE A REAL ESTATE FILE NUMBER (Property (ointly-owned with Right of Survivorship must be disclosed.on Schedule F) All reol estate should be reported at fair,market volue • OMB No. 2502-0285 - ~D 1 (Rev 3/e0) ~ • , < <! >: SETTLEMENT' CHARGES ~ L.:; .. PAID FROM PAID FROM 700. TOTAL SALES/BROKER'S COMMISSION 0 0 0 . 0 0 ®6 . 0 0 0 as - E x 4 5 2, 7 0 0. 0 0 BORROWER'S SELLER'S , BASED ON PRIC FUNiaB FUNDS AT AT DIVISION OF COMMISSION LINE 700) AS FOLLOWS: SETTLEMENT SETTLEMENT ..n '. >2 .7 O O.O O'>:: ao OM $ EAO: GROUP>,;: 702. to i'i. ':. 2 '7 U U ~ Oti:.Oommleeton ald al :ieff~rilsht ' ;:.:. • .... ; :. ; ;, 704. 800. ITEM PAYABLE IN NNE TI N WITH LOAN: : < • <:< ANYLIt=Allun ~~ Q C RTC r~~ - nn FDSI ' ~.~: YIELD SPREA D ERO G TAX SERViC FEE<: G f ITEM R UIRED BY LEND R ' mersbi 1rom~ Morlasas Insurance orsmlu m for Ors ..A :~ f s 'ems .mlu m. t ~ Flood Insurance orsmlum ie - 0/ f ~. RE E DEP u»~•a.r+~eurance WI H ~ Mo t a a insurance ~div~oroperty taxes t t r axes • Annual assessments 3. Flood Insurance r. 1107. Attorney's Isss to (Includes above Bsme Numbsr~ itOtt. THIS Insuranc w 'Cedar' ;nncludea .above name'Numb4 ' 5 0. 3 5 P. O. C. NG BUREAU OR .SCHEDULE EE HART MORTGAGE ~: : . >•.; ..R _ _._ . 5.15 POC AL TO HART 1 459.06 AG`MORTGAGE'' PAID IN ADVANCE: to 52.02 mos. to TRIAD GUARANTY i S. I l0 ~; y: . ~: :. ~. 'mdnlh~ Q a : ... per month 0 2 5 2 months Q S 2 2 6. 0 1 sr month P . months p S _ '- 'per rtlonlh'' 0 0 118 8 months Q S 14.7 5 per month . >' 39 8. 4 `~?monihs~ i 3 .87:' v+ month:? months ®i per month ,: months Cap S __ par month : ++tt I.CURK l•LIPf noa~nn+. n...~..... •••~• - ............ 225, L 3rJVd s,n,ed6l8.,,.ryeg X25':. vogwnu uopao0puopl rs6edxe{ tosrroo Rw slyl uo wsoys regwnu ay{ {ey{ ~tquso l •Arnlred to aepleued rspun pue 'Mel 6q pssodwl aepleued leulwlro ro IIMo o{ {oslgns sq Rew nob '~sgwnu u. rsRedxet muroo mob ypM IL1 xoq sssl spleord {ou op noA p •~egwnu uopeo0puepl re6edxe{ touroa moA yqM IH xoq sssl splnord o{ Mel Aq psrlnbu '10601 wrodl0 slnPe4o8 ro/PUe LsLB wrof'LBLY luroj to sued pgeopdde oyl slsldwoo'suopOSSUert tey{o col :umpl xel swooul moR ypM wlee Lue rot 'sowppsd ledlsulyd to osueysx3 1o peg 'ettL wro~ pp 'souoppu ledlotyrd moR seM gelu rou pyt II ~8N011~AH18N1 H31T38 •ps{roder wsq {ou aey {I teyt eoulwrs{sP SHI eyt Pue pouoda sq o{ Porlnbu q wall pyt tl not uo pssodwl sq rylr uopouss rsyto ro Lyewd soueary0su a 'wn{ea a x01 0{ psgnber six noR p •solnreg snuseed lewe{ul syl o{ psypuml Eupq p pue uopewrolul xet lueuodwl el boo Pue EOf soup 'psrlgrgse p l04 Bull II ro) lo- sup uo pue 1 pue 'Ll 'p '3 srlool8 ul PeWetuoc uolttwrolul syl ~1N3W31V18 H3-1138 BtiOt Wklp~ 31(1L16Bf11i Z'S0£b eH `VdS3d - X98-E) l-OfIH 0 6 ' Z 5 T ' Z 6 ~d3iias (wod~ [~) (ol© ) Hsv~ •eos L 8 ' Z 9 L' £ -daAnotidoe (ol []) (woa~) Hsvo •eoe 0' L Z ~:' £ ' DZS aura .tBI tae anp '; }we u j su }~npe.~ sea}, • Z09 OZ~ ;au .Iento.Lao ..,.. ~,,., .._ „-.~ ...:.: ......... ... _ 00 <OSZ ~6''::; IL , ::.q .ID~~ q.:P-e.;;}uraowessal><',ZOE A. Settlement Statement U.S. Ospartmsnt of Hco.lny w and Urban DsvelopmsM OMB No. 2502-02ab B': Type of Loan 1. ^ FHA 2. ^ FmHA 3. ^ Conv. Unins.File Number Loan Number Mortgage Insurance Case Number 21122 4. ^ VA 5. ^ Conv. Ins. C. NOTE: This form is furnished to glue you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "p.o.c ' were paid outside of closing; they are shown here for informatbnal purposes end are not included bt the totals. ESTATE OF VERNON H. SNAPPER ... r..unnvr.n c: anno:.. _ ............. PHUF'EHIY 516 THIRD STREET LOCATION: WEST ~AIRVIEW, PA 17025 Agency; [nc. September 26, 1995 45,369.90 soy. pot: 203. 20A: 205. 3,217.00 a~~,.isoetk.,t.a~, SCHEDULE E ~~ CASH, BANK DEPOSITS AND COMMONWEALTH OF PENNSYLVANIA MISCELLANEOUS INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT Please Print or T pe ESTATE OF FILE NUMBER VERNON H. SHAFFER (All property loinllyowned with lha Righl of•Survivorshtp mull bs disclosed on Schedule FI ITEM DESCRIPTION VALUE AT NUMBER _ DATE OF DEATH 1. JOINT. CHECKING ACCOUNT WITH P.N.C. #5140111477 Vernon H. Shaffer ($ 6,000.92) B. Dolores Keyes Leona Lincourt ,1 /3 ownership: $ 2,000.30 2. JOINT C.D. WITH P.N.C. $2,000.00) 1/3 ownership: $ 666.67 3. JOINT SAVINGS A/C P.N.C. ($546.00) 1/3 ownership: $ 182.00 .- TOTAL (Also enter on line 5, Recapitulation) ~ $ 2 , $ 4 $ 9 7 (Alloch addlllonal 915" x 11" chsels If more ~pocs is needed.( AFV--1511 E%i (7.88) ~ SCHEDULE H !~; ~ FUNERAL EXPENSES, COMMONWEALTH OF FENNSYIVANIA ADMINISTRATIVE COSTS AND IN RESIDENTEDECE ENTRN MISCELLANEOUS EXPENSES Please Print or Type ESTATE OF FILE NUMBER VERNON H. SHAFFER ITEM NUMBER DESCRIPTION AMOUNT A. Funeral Expenaea: ~, MUSSELMAN FUNERAL HOME $ 3,255.80 GINGRICH MEMORIALS 60.00 B. Administrative Costs: 1. Personal Representative Commissions (Leona Lincourt, Executrix) Social Security Number of Personal Representative: _2 0 7 - 2 2 - 2 4 71 2 392.45 1 Year Commissions paid 1 9 9 5 2. Attorney Fees James M. Bach 2,870.94 3. Family Exemption Claimant Relationship Address of Claimant at decedent's death Street Address City State Zip Code 4. Probate Fees $ 1 2 0.0 0 C. Miscellaneous Expenses: ~, Bell Telephone 18.85 PP & L 77.44 Z, PA American Water Company 275.23 UGI 757.25 3, The Patriot News (Legal Advertisement) 69.97 Cumberland Law Journal (Legal Advertisement) 40.00 4, Borough of Fairview 69.00 Sarah Kluger 55.00 3, Patsy Maker (Real Estate) 418.50 Donegla Home Owners Insurance 70.00 6, Holy Spirit Hospital 15.19 Payment for Estate checks 16.42 7. Real Estate Commission 2,700.00 Recorder of Deeds 450.00 8. TOTAL (Also enter on line 9, Recapitulation) $1 3, 732.04 (If more space is needed, insert additional sheets of same size.) a , ~ REV~ISI~ E%t (T~E7) 1 '~ SCHEDULE J COMMONWEALTH Of PENNSYLVANIA BEN EFI CI AR 1 ES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF VERNON H. SHAFFER FILE NUMBER ITEM NUMBER NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR SHARE OF ESTATE A. Taxable Bequests: ~' B. DOLORES KEYES DAUGHTER 50 ~ LEONA R. LINCOURT DAUGHTER 50 ~ 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 space is needed, insert additional sheets of same size