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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.
AUG 16 200T
Date
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ERMANENT
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Fran eropoli, ~ ect
Division of Vital Records
P.O. Box 1528
New Castle, PA 16103
COMMONWEALTH OF PENNSYLIMNIA • DEPARTMENT OF HEALTH • VITAL RECOfiD3
CERTIFICATE OF DEATH
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NAME DP DECEDENT IPia MNOe.Lrl socuLSEwwn NUMBER DREOF DERNIM«Nr. Dey,'ANr) _.
,. Dale A. riostetter :dale 208 - 24 - 1081 ecember 8,1994
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REVT1500 EX+ I~~I ~ FOR DATES OF DEATH AFTER 15131 f91 CHECK HERE
INHERITANCE TAX RETURN p
° OVERTT C EDIT IS CLAIMED
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COMroNWEALTH OF PENNSYLVANIA
E:PARTMENT OF REVENUE (TO BE FILED IN DUPLICATE
21 9 5 0123
DEPT. 280601
HIRRISBURG, PA 17128-0601 WITH REGISTER OF WILLS] COUNTY CODE YEAR NUMBER
DCEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) DECEDENT'S COMPLETE ADDRESS
Hostetter Dale A 8 Otto Avenue
o S~IAL SECURITY NUMBER DATE OF DEATH DATE OF BIRTH Car 1 i s 1 e
PA 17 013
208-24-1081 12/8/94 4/22/32 c~~~t ,
Cumberland
p (IFIPPUGaLE) SURVIVING SPOUSE'S NAME (UST, FIRST ANC MIDDLE INITIAL) SOCIAL SECURITY NUMBER AMOUNT RECEIVED (SEE INSTRUCTIONS)
Hostetter, Dolores J.
~ ~] 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return
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[] 4. Limited Estate ^ 4a. Future Interest Compromise (for dates of death prior to 12-13-82)
^ 5. federal Estate Tax Return Re ulred
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~a°e° (for dates of death aher 12-12-82)
Q~' 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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COMPLETE MAILING~ADORE55 ._
Andrea C. Jacobsen, Esq. JACOBSEN &MILKES
~d TBEPHONE NUMBER
717 249-642.7 G~dr~is~~ghP2~trg~~13
I. Real Estate (Schedule A) (1 )
1. Stocks and Bonds (Schedule B) (2 )
~. Closely Held Stock/Partnership Interest (Schedule C) (3 )
/. Mortgages and Notes Receivable (Schedule D) (4 )
!. Cash, Bank Deposits & Miscellaneous Personal Property (5) 4 ~ 5 5 3.6 0
Z (Schedule E)
F°-, 8. Jointly Owned Property (Schedule F) (6 )
~ J. Transfers (Schedule G) (Schedule L) (7)
a
8. Total Gross Assets (total Lines 1-7) 4 55 3.6 0
(g) t
4. Funeral Expenses, Administrative Costs, Miscellaneous (9) 4 , 547.84
Expenses (Schedule H)
10. Debts, Mortgage Liabilities, Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 8~ 10) (11) 4, 547.84
12. Net Value of Estate (Line 8 minus Line 11) (12) 5 • 76
1J. Charitable and Governmental Bequests (Schedule J) (13)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 5 • 7 6
15. Spousal Transfers (for dates of death aher b-30-94)
Sse Instructions for Applicable Percentage on Reverse (15) 5 • 7 6
Side
(Include values from Schedule K or Sched
l
M
)
x, ~ 3= . 17
.
u
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.
16. Amount of Line 14 taxable at 696 rate (16) x .Ob = • ~ ~
(Include values from Schedule K or Schedule M.)
17. Amount of Line 14 taxable at 1596 rate (17) • 0 0
x ,15 =
z (Include values from Schedule K or Schedule M.)
o
18. Principal tax due (Add tax from Lines 15, 16 and 17.) • 17
(lB)
19. Credits Spousal Poverty Credit Prior Payments Discount Interest
00
•
~ 20.~f Line 19 is greater than Lins 18
snNr the difference on Line 20
Thi
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th
OVERPAYMENT
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~^ . (20)
21. If Lins 18 is greater than Lins 19, enter the difference on line 21. This is the TAX DUE. (21) • 17
A. Enter the interest on the balance due on Line 21 A. (21A) . 00
B. Enter the total of Line 21 and 21A on Line 21B. This is the BALANCE DUE. (21B) . 17
Make Cheek Payable ro: Register of Wills, Aoent
Under penaltie
it is true, totte s of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
d and complete. I declare that all real estate has been reported at true market value. Declaration of prsparer other than the personal representative is
based on all in formation of which preparsr has any knowledge.
b10NATURE OF PE RSON RESPON BLE FOQ FILING RETi~eni snneeee 1
_rbe~-,-:$ Otto Ave. , Carlisle, PA 17013 (j ~5 R~
IAN REPRESENTATIVE ADDRESS
obsen, JACOBSEN &MILKES, 52 E. High St., Carlisle, PA 170~.~E $ ~(, S
~, REW1511 EX+p-8B~
COMMONWEALTH OF PE
SCHEDULE H
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
ifEM DESCRIPTION
NUMBER
A. Funeral. Expenses:
~• Ewing Brothers Funeral Home
2. Bethany Guild, St. Pauls Church
3. Wayne Noss Flowers
4. Tombstone
B. Administrative Costs:
1. Personal Representative Commissions _
Social Security Number of Personal Representative:
Year Commissions paid
2. Attorney Fees JACOBSEN & MILKES
3. Family Exemption
Claimant Dolores J. Hostet~{~tionship Wife
Address of Claimant at decedent's death
Street Address 8 Otto Avenue
C;y Carlisle State PA Zip Code 17013
4. Probate Fees
Filing Fee
C. Miscellaneous Expenses:
~• Cumberland Law Journal
2• The Sentinel
Please Print or
e:aEPUe car FILE NUMBER
Dale A. Hostetter 21-95-0123
3.
4.
5.
b.
7.
8.
AMOUNT
1,380.00
100.00
25.00
615.00
250.00
2,000,90'J~
54.00
15.00
40.00
68.84
TOTAL (Also enter on line 9, Recapitulation) I S 4,347.84
(If more space is needed, insert additional sheets of same size.)
REV.IS~B EX{ (2.871
SCHEDULE E
CASH, BANK DEPOSITS AND
4LTH OF PENNSYLVANIA MISCELLANEOUS
,ENT DEED NT RN PERSONAL PROPERTY
Please Print or
r.. FILE NUMBER
Dale A. HostetterL1-95-0123