HomeMy WebLinkAbout95-012621-q 5 -(~ 12~
H105.1A3 Rsv. ?/B7
TYPEmaMr
.~
PERL7ANESTr
BuaL EaL
~~
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.
Date
AUG 16 2001
Fran eropoli, ' ect
.Division of Vital Records
P.O. Box 1528
New Castle, PA 16103
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
U~23~2
NAME DF DECEDQJT(FM. Midda, LrS aocuL sECUmr NUMBER D.vE oR DE/QN(M«M, D.y, War)
AGErtaa a~lYNay) UNDER, uNDER1oAd D,aEOFasTTH BwrHPLACE ICayarW PLACEaF DEATN(G•ckody eA.-...:aawtrn.manar:d»
M«Idra D•r• Hdaa i MlrAaes (M«Mn, Dax W.r) sNOa«P«Npn C«ntVl ~:
Vn.
•I L ,19 3 1 llsrn~Sb V ry ~ PA an.lwA ^ ERAdAwrrM ^ DGA ^ II ® RrMxa;a ^ rs ~+TI ^
~
coLNTrraFDEATN CRY,BOtq,TMhoPDEATN NAMELMndi4Nu7on.Dvaeaeelendnnibar) NM40ECEDEMOFHISAWICORKTINT RACE.
Amadnn bran, BIarJ(. wnA., nc.
p1
• Le.da• WGrc~nq aaLC~ Qe~s.~o.~.'k~~'.eA! •!anfer• ~6arr.w~'.w^"RrM", eao.aNCm.n'
DECmo+rawuAL000LnwION oveuss,EaBlwousTRr ~' wAS DECEDENT EVEN BI DECEDE/TSEDLICRgN s MARIrALSwua-Marhd 10. aLIRVIVINCi BPOUSE
'
MnOdr«kAyramum«I U.S. ARMED fORCE97
tlw~4 (Xww.oN•mraen nrrM
dagrbNrB7la; mrceur ro6raa.)
9
a
~
~
v
K. ^ No ®
'm•M'M
•m"°•ry Cw•s•
Dhvr
ls
ci
DECEDENraMAErq (sa«.cAY~R.s.N.rocoM) DECmENrs /~yy
17a. a1m t'~rLnS
IV6N.4 Dla /h
^ Wa
OaaMra 7vadr
~
~
.
.
_
9ss s, zs st. MoaMnL
,~ a^ . b~aerrlailPT N0. d.e.eNaswa
~ „b. C.7.,,6e~1G,.,~1 na®.Br,r.duYanb Cct
~~'8 !~ .~ MOTHER'SNAME(Fnt,Midda.MldanSrrrr~ns)
,..
BIFORMMITa NAME(fyprPriq
ADDNEaa(9YaaI, CY,1kwn.9rr, 21PCatla) .
t
N,'Il
J
~
W Q
METHOD DFDLaPOe,rIDN DATE GFDIBPOSrrlon PLACE O
F DISP
I%7N.l
prrr•Mr,,
-CAwibwr.aw,aPCeM
fM•nn.DSAlbar) «DBwPru
^ RamwallranSlW^
^
11
DarraS•n^ ~
•~ !1 tta. ~L 71d I SS 1 ~a~ "~ ~~ f
81G,U7,NiEaPCLINEnAL SERVICE oa PERSON ACTING AS SUCH R NAME ADORESSaP IAI.OfJi/lQ .m/Ny F.+AMII'~IRMaC
Snc.
~
m. S-O 3S9Z-L rn.2o ,
pA~t~rrrr~i•L ar77atdrMananraa MaMb T°IMMndmyluwrMEp..°wM'°«'"'•°nar wrr~ar,na p.n ar•a LICENSE NUMBEN DATE SGNED
• entl Tar)
ILIGrM, OM.'At«)
nrwddaaN.
banr 7428 aMR W 77a. .
7araan a,roPr••er•Nr diallr b/ OF OE(QN PRONOUNCED DEAO LM«ilb, Day, `kAr) CASE REPEIWEDro MEDICAL E%AMINERACOIiONER1
~. ^ N•®
7.. 9: O M
T4Tnvo.s• 2
7s
.
.
7s.
77. PART F. EnbrlMaaa...,byr.w«mrnpaalMra rAtA auwadra datlR Oan«aardr neMddYr7. NrdrneaNae ra.Pb.mry ee+•I. Mr•cb«MrtrFaa. iAPp«Jmn• MRT p: ONrrslyVlker¢c«IAIIar rnMrruurgro M.M. GA
LIraNY«raNm•WrFe.
Irrabn.,..n mlrsmatlrgr7w «wrdybrpcMr SMnr PARTI.
I anrrl tlrd Matlr
~' E
r.rrNn,„MaMrI~ a w~b-
DUE (OR ACONSEOUENCE OFI:
aapwMYayaM O«rdW«r, b. -
^ary,rWnpbinrraala
DUEro(OR ASACONSEOUENCE OF): )
carats. Enbr 111oBILYNG
~
;
GIISEIOIaaan«i,Irry C
O
IMea,wr DuEro(oRASACONSEOUENCEOFl: I
~wrµ
WASAN AUR3PSY
PERPOfY1ED? WERE AUTOPSY FINOBIGS
M/JLABLE PRMTR ro MANNER OF DEATN DA,E OF MJURV TIME OF NUURY NUURY AT W'OHK7 DESCRIBE NOW INJURY OCCURRED.
COMPLETION OF CAUSE
OF DFAN?
rq ~~ ^
NabAd IO (L1MCr, Dey, lber)
AWCeM ^ PendLp lnveWpa,len ^ We ^ No~
Yas ^ No® W
^ N
^ SrYeWe ^
^ M 7 a
a
• C•uld nq be MlernArratl PLACE OFINJURY.A,bmme, hrm. Aran, laClory,oMCe
LOCRgN(SIreM,CMrt .SWe)
eu.erY. nc. (SPec~Nl
lab. 79. 7M. 7af
CaNTIRER(CnscA ony meI .
'CEILTN^1MIG PNY8ICIAM (Pbyvcien CerNy'vp Cerree d Aealb vANn eriaarer PbYakien hea parox¢ed tlmnr entl Campleled tlsn 23) SIGNATURE AND TfTLE OFCE
TadrabW narT rreMadye,swar oeerrrae drreb Bre earne(e)and ar.merwnnea ..................................................... ~ 31b. °
•PRDNOIMN:WG AND CEATIFYIIIG PNY8ICIAN IPlrysidur bulb prMOUnciny Mnb arro
`
°
a
e
~ LICEN~ DATE SIGNED (MOrM, Dry.1bM
`
~
Tes.b.nnr.Yw.I•ew,M.a,.~e(.r.en».am..Mb.,r(aPrw..rasubw
.
.rre
.r
...we(
rr«..ww .......................... ^ 7,e. M O)(,
1~0 -L- 7,a. ! L
I.S
NAME AND ADDRESS OF PERSON WNO COMPLETED CAUSE
'MEDICAL E%AWNERR;ORONER (7em 27)Type«Prln TN _ CI
J IV. ~'1
On tlHr baab W a7aalbra,bn arWr MrasNynbn, In my •pinbn, daaBr otcunad n 1M tlma, data, and gaca, and dua to tM eauaa(a) and
aralrrralMaM,ad ......................... .... ...................... ^'
r 1, '" (''..' 7 a
/~
V~ Fi
REGISTAM'3 SIGNATURE ANO NUMBER DATE FlLED (MOrgb, Gay, `Aaer)
77. 3.. / ' / ~ / ~- /
~~~`
~ ~~
MMON
. OEP~
~~.'~., ~ INHERITANCE TA3C RETURN
"~>~;.` RESBDENI DECEDENT
ALTH Of PENNSYLVANIA (TO 13E FILED IN DUPLICATE
MENTOfREVENUE WITH REGI5TER OF WILLS]
1EPT. 280G01
URSi, PA 17128-0001
FILE NUMDER
~f IQs' dry
COUNTY CODE YEAR NUMBEf
o Joan P. Kipp 208 Senate Ave., Apt. 818
W SOCIAL 5 RITY NUMBER DATE DEATH DATE OF BIRTH Camp H111, PA 17 011
0 0-26-8905 -27-95 ~4-6-31 Cu mberland
_ County
Q 1. Original Return ^ 2. Supplementer Return ^ 3. Remainder Return
~-~^
r~~n.CYJ
^ 4. Limited Estate
^ 4a. Future Interest Compromise (for dates of death prior to 12-13-82)
^ 5. Federal Estate Tax
uKOJ (for dates of death after 12-12-82) Return Required
°'°~
u. ^ b. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes
d (Attach copy of Will) (Attach copy of Trust)
t ~
~ ~
w w
~o
oz
~o
a
Z
O
Q
a
O
u
x
Q
Albert J. Najjar, Atto
717 1 730-0456
( 8) _27,587.69
11. Total Deductions (total lines 9 & 10) (11) _2 , 992 • 89
12. Net Value of Estate (line 8 minus line 11) (12) -rlf-~r-rn.4 ~ 8n
13. Charitable and Governmental Bequests (Schedule J) (13) None
14. Net Value Subject to Tax (line 12 minus line 131 1'I~ 14) 24 , 594.80
1300 Market Street, Suite 8
Lemoyne, PA 17043
1. Real Estate (Schedule A) ( 1) _ JOI1~
2. Stocks and Bonds (Schedule B) ( __ 1. ~ 8 7.5 . 0 ~ _
3. Closely Held Stock/Partnership Interest (Schedule C) (3) NOne
done
dCnvlortgoges and Notes Receivable (Schedule D) (4) -
-~~ash, Bank Deposits & Miscellaneous Personal Property(: -~T7 Q14 ~1~~.
(Schedule E)
.Iointly Owned Property (Schedule F) (~~~._~v~~ CJ
~ ,`~ransfers (Schedule G) (Schedule L) j( 7) ~1cZn Et
~_~
l^ llotal Gross Assets (total lines 1-7)
iF3uneral Expenses, Administrative Costs, Miscellaneous (~2 s 9 9 2' a 9
~ ~Flxpenses (Schedule H) /
,-~_ ' [jebts, Mortgage Liabilities, Liens (Schedule I) (10) None
15. Amount of line 14 taxable at b% rate
(Include values from Schedule K or Schedule M.)
16. Amount of line 14 taxable at 15% rate
(Include values from Schedule K or Schedule lvl.)
17. Principal tax due (Add fax from line 15 and from line 1 b.)
18. Credits Prior Payments Discount
1,47
(17) .. 1 s 4
Interest 1,.4 7 5 .6 9
- - -- (18) -- -
19. If line 18 is greater than lino 17, enter the difference on line 19. This is the OVERPAYMENT. (19) _ 0
~^ - -
20. If line 17 is greater than line 10, enter the difference on line 20. This is the TAX DUE. (20) -~4 7 5 • 6 9
A. Enter the interest on the balance duo on line 20A. (20A) __ _
B. Enter the total of line 20 and 20A on line 206. This is the E3ALANCE DUE. (206) _
Make Check Poyable to: Register of Wills, Agent
_ , ~• tstp-l3E SIJR~ 1'O AtVSWCR /1LL QU.~STIONS ON RrVERSE'SIDE /-1ND TC1 RECWEGI('MATH~bu~_ _ _
Under penalties of perjury, I declare that I have examined This return, including accompanying schedules and statements, and to the best of my knowledge and belief
i1 is true, correct and complete. I declare that all real estate has been reported at true marker value. Declaration of preparor other than the personal representative i
bawd on all information of which preparor has any knowledge.
SI~tVAT RE Of PER~N RE ONSIBLE fOR 141NG R TURN ~, ADDRESS _ DATE
`i"' ~! 1`~~ ~-' ~~.\.c..,l~ji!'LGh.~.C i(((~(,(/' 7/( ~~1.~ ,l . /~C ~ J ~~.) 7._.~~i7J A Y~ ~ ~~~ '1 ~"I f J~iJ~~ ~ ! ~ -~ .~~~~J
SIG ~~ UR OFfP SPARER OTHER THAN REPRESENTATIVE ADDRESS DATE
l~,~ 1 ~ /r,l n ~ ~ ' _ _
t r i;'r•i.+~l'. Tti'~i'tt,~ fl '~%~i I ,5..~i "\f~, ~i,r.~ { iS, ~Y ~r /"-~,~,~, ~°~~ _!%_.,:~~
/ - ~. -
'N2Afl132~ 3H1 ~O 121~/d S~ li 3'i!J ~IN~ ~ 3'IQ1CI31.0~5 3.9.31~IL"~0~+ 1S~~1~~ ~`~~+,~~.
`S3A SI St~lOI1S3110 3/~O~Ibo 341 ~+® ,~R,f~~+' C31 ~~3~5~ 3~1~. ~1
......................Zy~aap aay ~o siy ~a }unoaap ~uraq ,ao~ ~sna~ ui, uo unno ~uapaaaia p{~,.~ '~.
X
................................................. Zuoi}gaapisuoa a~onbapa 6u+n+a~aa ~no~{~~M ~~aap
~a araa~( auo uiti~inn ~(~aadoad aa~suaa} ~uapaaap pip 'Z86 ~ 'Z ~ aaquaaaad aa~~o pa.~ana~a
y~aap fi Zuoi~gaapisuoa a}ranbapa Guiniaaaa ~noci~in~ iC~aadoad aa~.suq.~~ zi~oap F~uiia:~a~;.~d
X sapa~C onn; uiy}inn ~uapaaap p{p 'Z861 ~Z L aaquaaaaa a~ofaq ~o uo paaa~~~aao y~oaia }{ .Z
....................... Zaaa~ ao s}i~auaq 's;uaw~Cpd aay~ia ~o afii ao; as~uao,ad a~~ aniaaaa •p
X
.................................................................... ao }saaa~ui ~a~auo+s.aana.z a ui-a~a~ •a
X
'auao~ui s}! ao paaaafsunaa ~{aadoad ay; asn ii°Ns oynn a~au6isap off. ~yf~u a~i~ uia~aa •q
....................................... •paa~a}suaa~ ~(~aado.~d aii~ ~o auaoau; ao asn a+.Sd ue~a~aa •sa
X :pua aa~suga~ ~a a:~ioul~ ~uapaaap p+~ ' ~
_ON SiA
'"a?i~A°1'8 ~l.d.~'~~a~~2~cid~'
3fas ~a f ~! ~ ~~avu ~~~~~a ~ ~Nia~~d ,~~ ~~~i~:~~~~ ~su~~a~~~s~.~ 3~s ~~~r~~i`a~~~ ~~~~~~~~
REV•1509 EX+ iI.86) ~.
COMMONWEALTH OF PENNSYIVANU
SCHEDULE B
STOCKS AND BONDS
Joan P. Kipp
21-1995-0126
(All property jointly-owned with Right of Survivorship must be disclosed on Schedule F.)
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
Liberty Circle Corp.
1. 100 SHS #NH6637
2, 100 SHS #NH6638.~
Reading Housing Authy. First Closed Mtg. Rev. Bond
(1954) .
3. #900 C 4~% per annum, matures 12/1/98
4. #901 ~'
Seal Fleet, Inc., Class A Voting Common Stk
5. #585722 ~ 210 SHS
TOTAL (Also enter on line 2, Recapitulation)
flf more space is needed, insert additional sheets of same size.)
0.00
0.00
900.00
900.00
75.00
s 1, 5.00
r.[v uo~ tx. p.eel
~~ SCHEDULE D
N40RTGAGES AND NOTES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN RECEIVABLE
RESIDINT bECEbENT Please Print or T e
ESTATE OF FILE NUMBER
Joan P. Kipp 21-1995-0126
(All properly lolntly-owned with the Right of Survivonhlp inure be disclosed on Schedule F.)
e
{If more space is needed, insert additional sheeh o/ same size.)
I
REV 1500 EX+12.07) SCHEDULE E
.'
CASH, BANK DEPOSITS AND
COMMONWEALTH OF PENNSYLVANIA MISCELLANEOUS
INHERITANCE TAX RETURN PERSONAL PROPERTY Please Print or Type
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Joan P. Kipp 21-1995-0126
(All property jointly-owned with the Right of Survivorship must be disclosed on Schedule F)
ITEM
NUMBER DESCRIPTION VALUE AT
DATE OF DEATH
1. Clothing and personal affects 25.00
2. JeweYry (3 rings: 1 carat; purple sapphire; and
3 amethyst stones) ..1;000.00
3. Apartment furnishings (6 yr. old port. TV and
VCR; microwave) 200.00
4. BS/BC deposit 620.62
5. Time, Inc. - magazine cancellation refund 108.77
6. TV Host 30.50
~ 7. Christian Churches United - BS/BC refund 583.50
8. State Farm, Ins. - renter's insurance refund 28.04
9. NHP Prop. Mgmt., Inc., - apartment deposit refund 108.01
TOTAL (Also enter on line 5, F
(Attach additional 8'h" x 11" sheets if more space is needed.)
ation) ~ $ 2, 70/1:44
REKI509 EXa (17.88(
r~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDIiLE F
JOINTLY-OWNED PROPERTY
ts~wrE yr FILE NUMBER
Joan P. Kipp ~ .21-1995-0126
Joint tenant(s):
NAME ADDRESS RELATIONSHIP TO DECEDENT
A• Joan P. Kipp 208 Senate Ave., Apt. 818 Self
Camp Hill, PA 17011
(B• Susan K. Rowland 455 S. 28th Street Daughter
Camp Hill, PA 17011
C.
Jointly-owned property:
ITEM
NUMBE LETTER
FOR
JOINT
TENANT
DATE
MADE
J
DESCRIPTION OF PROPERTY
TOTAL VALUE
OF ASSET
DECD'S
% INT.
DOLLAR VALUE OF
DECEDENT'S INTEREST
1. A 2/70 Dauphin Deposit Bank ~~
q q-9'~9
Ck. Acct. #51437481
Pr. 1,987.57 0 993.79
2• Intl 0.44 50 0.22
3. A 9/92 Dauphin Deposit Bank
Svgs. Acct.#57-00340208
8 Pr.
~ 43,874.70 50 21,937.35
4• 9~~/
Int.
~ 153.78 50 7.6.89
~
P
_~
(If more space is needed insert additional sheets of same size)
TOTAL (Also enter on line b, Recapitulation) I $ 2 3 ,~$ . 25
REV•IS10 EXt (2•B~ • t'
OF
FILE N
Joan P. Kipp 21-1995-0126
THIS SCHEDULE MUST BE COMPLETED AND FILED IF THE ANSWER TO ANY OF THE CIUESTIONS ON THE REVEasc Stec ec ruc rnvco wccr is; vee
ITEM
NUMBER DESCRIPTION OF PROPERTY
Include name o! Ihs /ronslerss, fhsirrelalionship fo dend~nl, dote of tronsler.
EXCLUSION TOTAL VALUE
OF ASSET DECD.
96 DOLLAR VALUE
OF DECEDENT'S
INTEREST
NONE NONE NONE
SCHEDULE G
TRANSFERS
PEASE PRINT OR TYPE
TOTAL (Also enter on line 7 Rscapilulation) S NONE
(f/more space is needed, inseA additional sheeh o/ same size.)
REV-1511 EY.+ n.eol
~
~~
~ ~.SC6~ED~JLE I'~
n
='':i~
~-.;
~ FUNERAL EXPENSES,
•`'~`~
COMMONWEALTH OP PENNSYLVANIA ADMINISTRATIVE COSTS AND
INHERITANCE TA!( RETURN
RESIDENT DECEDENT MISCELLANEOUS EXPENSES
Pleaso Print or Type
ESTATE OF FIL[ NUMBE4t
Joan P. Kipp 21-1995-0126
ITEM
NUMBER DE~CREPTION AMOUNT
A. Funeral Expenses-.
~• Jas. R. Gingrich Memorials
5243 .Simpson Ferry Road
Mechanicsburg, PA 17055 Tombstone 1,543.46
Q. Administrative Costs:
1. Personal Representative Commissions _ _
Social Security Number of Personal Representative:
Year Commissions paid
2. Attorney Fees
1, 0 0 0. 0 0
3. Family Exemption
Claimant Relationship
Address of Claimant at decedent's death
Street Address
City State Zip Code
4. Probate Fees
120.50
C. Mince{laneous Expenses:
~' Patriot-mews-Estate i~tctice-5/3/95
97.36
2. Cumberland Law Journal- 4/7/95
40.00
3' Susquehanna Vieca, Ltd. Part- Apartment rent 2/25/95 70.00
~' Bell Atlantic- phone- final bill 2/25/95 16.79
5~ A.Z. Ritzman Associs. - Med. bill- 3/1/95
9.61
b.
Sammons Comanunication - final bill - 3/1/95
4.61
7.
Connor Rick Kearney Torchin Assocs.- Med. bill 79.41
8.
EKG Associates - final illness 11.15
TOTAL (Also enter on line 9, Recapitulationy $
2 9 . $ 9
(If more space is needed, insert additional sheets of same size.)
REV-1512 EX+ ~l•97)
CCIMMONWEARM OF PENNSVIVANiA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES AND LIENS
ESTATE pF
Joan P. Kipp
Please Prfnt or Type
NUMBER
21-1995-0126
~~~ more space 1s neeaea, lnser- additional sheep of some size.)
. .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TA% RETURN
~ RESIDENT DECEDENT
ESTATE OF
Joan P. Kipp
SCHEDULE J
BENEFICIARIES
FILE NUMBER
21-1995-0126
ITEM
NUMBER NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR
SHARE OF ESTATE
;4. Taxable Bequests:
1. Mrs. Susan P. Rowland Daughter 1/3 entire
955 5. 28th Street Estate
Camp Hiil, PA 17011
2. Mrs. Cynthia Kipp Williamson Daughter 1/3 entire
32-A W. Green Street Estate
Mechanicsburg, PA 17055
3. Mr..Donald W. Kipp Son 1/3 entire
1106 East Logan Street Estate
Republic, MO 65738
ITEM NAME AND ADDRESS OF BENEFICIARY ~ AMOUNT OR
NUMBER SHARE OF ESTATE
B. Charitable and Governmental Bequests:
1. None
TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation) I S None
(If more space is needed, insert additional sheets of same size)