HomeMy WebLinkAbout95-0151`~~ -q' ~ - o~s~
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 16.20p1
Date
N,oB.,a atl. ,re,
rrrE~vwar
N
.erLANENr
Buac rrL
~~
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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
(Coroner)
oz4~7s
sWERLE NUMBEA
NAMEOC DECEDENT~ea. AOaea. Laeq socuLSECUflrtr NUMBER DaEDP DEATiI(Maen
Dry; Ye.,)
,
+. Nancy L Goodhart zFemale a. 208-24-1238 .. Feb. 10, 1995
A~+EM1+r~+~a•r, uaEn,vEAR uNDER,aa aaEOFB111TN SB~NnyiucE(GI,.nO nACEOFDE.BNrc~.d<«+Y«»-.tlin.uCom.mdD.r:id.)
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June 3
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6 Links M.H. Park Lot 24 REB,oEHCE ~
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fAT11ER'S NAMELFbp:MdOIS. L.bq MOTNER'S NAMEIRra Mioas,
Earl S
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. Miriam Harm
aM~OiBAANT'S NAME (TYpaP.iiry ADDRESS (SYSSI, Cq/6.n. SYes, zo COOS)
Yolon3a A. Rothenberger 8~7~Du31ey Roa3
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Feb 14, 1995 East Harrisburg Cem
Harrisburg, pa
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M••r Nil wwrk D•,••oleraM TIME OF DFAN D/JE PRONOUNCED DEAD~M«en, DAN'Yw) rMSCASE REiERREDro MEDICAL E%AMNERICCRp1ERa
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I0:54 P. M. February 10, 1995 w•6Q Ib^
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AN AUIOP$Y MEREAURJPSYFMIgNOS MANNEfl OF DEATN GATE aF lAN1Rr TN.EOF MLpIRy kUURY ATINMKT DESfHOW l41URY OCCURRED.
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^ URE AND
............. a, ~ Coroner
'~tlWBAND CERTIPYlp PIIYalCIANIPnMMOen DOM pariaaairi Oaaa~aritl aaaynp breusadae.e,)
•~rw•.raw.a..In••w.~waa.wa..ea...nawcw.aaeu.r.+n.e.~..Iq.aaaw«,..tlaaw .......................... ^ LICENSE R DATE SKi (M«en, O•Y•~1
a,•. a,a. Feb. 11 a 1995
•MEDICAL E%11aB11Ep/CORONER NAME AND ADDRESS OF PERSON YYIq COMPLETED CAUSE OF 0&VH
ro•n+z>l TYP.a Print
„,.ORDbn.a.ala.Drw~,Iwo,Lnrtl,q.a,D'LD•"ap~D'a.an°°a`~.a.L"b"n,•'a"•''"aPr•'''"°a"'w'"'
1R.nll.Ttl a.ae........... aAbap) as
.......................................................................
~~~•-~-~~~•~-'~' Michael L. Norris Coroner
405 Fairway Drive ~
REO 'S 9IGNATVRE AND NVMBEfl a: Mechanicsbur Pa. 17055
I
~ ,~ / ~ ~ ~ DATE FlLED (MyNn. DaY.lb«J
lu v isuu tx+ li vn
FOR DATES OF DEATH AFTER 13131191 CHECK HER
' + ^~ I.M~I~E1tITANCE TAX RETURN IF A SPOUSAL
"~ ~ ~ ~ ~ ~ ~ ~ RESIDENT DECEDENT POVERTY CREDIT IS CLAIMED ^
COMMONWEALTH OF PENNSYLVAN (TO BE FILED IN DUPLICATE FILE NUMBER
DEPARTMENT OF REVENUE ~~~
DEPT. 280601 WITH REGISTER OF WILLS)
_ HARRISBURG, PA 17128.0601 COUNTY CODE ~~ YEAR S NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) DECEDENT'S COMILETE ADDRESS
GOODHART, NANCY L. Six Links MHP Lot 24
Z SOCIAL SECURITY NUMBER Salem Church Road
W GATE OF DEATH ! PATE OF BIRTH
r
2~8-24-1238 ,~2/ /95 Mechanicsburg, PA 7,~
O Ilr MrIICAaIEI SURVIVING 3/OVSf'S NAMf (LAST, iINSi AND MI INITIAu SOCIAL SECURITY NUMBER CCYM AMOl1NT YFfFIVFn Ifee .ue•e.........- C1.lItilJE:i, 1
~ ~ 1. Original Return
Y ~ y
Y
w d ~
^ 4. Limited Estate
=oo
w
d oa ^ 6. Decedent Died Testate
~ (Attach copy of Wilt)
ALL CORRESPCiNDENCE s
^ 2. Supplemental Return
^ 4a. future Interest Compromise
(for dates of death aher 12.12.82)
^ 7. Decedent Maintained a living Trust
(Attach copy of Trust)
-- ---------._.r.,.., . ~,,..
ris = NAME
~o Diane M. Rupich, Esquire
oZ
v ~ TELEPHONE NUMBER
z
0
5
0
d
a
W
a:
z
0
f-
a
0
x
^ 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
iNgU~p B)E pIRErI:TED TQ;
MA L NG AD RESS
101 S. Second Street
Executive House, Ste. L1
• „ ~ - , Harrisburg, PA -;~ 71 01
(8)
17,017.12
33,450.82
(t2) -16.433.70
(13j
(14) -1 6, 433.70
(Include values from Schedule K or S h d l M (16) X .06 x
1. Real Estate (Schedule A) (1) 0
2. Stocks and Bonds (Schedule B) (2) 0
3. Closely Hsld Stock/Partnership Intere:t (Schedule C) (3) 0
4. Mortgages and Notes Receivable (Schedule D)
5. Cash, Bank Deposits 6 Miusllaneous P
l P (4) ~~
01 7
1 2
ersono
ropert
(Schedule E) .
y i
b. Jointly Owned Property (Schedule F) (6) ~
7. Transfers {Schedule G) (Schedule L) (7) 0
8. Total Gross Assets (total Lines 1.7)
9. Funeral Exppenses, Administrative Costs, Miscellaneous
Expenses(Sehedule H) ""
(9 ~ 8 4 . 4 2
10. Debts, Mortgage liabilities, Liens (Schedule 1) (l p) A 3 6 6 • 4 0
1 1. Total Deductions (total Lines 9 8 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Govsrnmsntol Bequests (Schedule J) ~'~
14. Net Value Subject to Tax (Lino 12 minus Line 13)
15. Spousal Transfers (for dates of death aher 6-30-94)
See Instructions for Applicobls Percentage on Reverse
Side. (Include values From Schedule K
S
h
d
l (15) ~
or
c
e
u
e M.)
16. Amount of line 14 taxable at 6% rate
0
® ^
t 1. If Lins 18 is greater thon line 19, enter the diffhrsnce on line 21. This is the TAX DUE.
A. Enter the interest on the balance due on Line 21A.
B. Enter the total of Lins 21 and 21A on Lins 218. This is the BALANCE DUE.
Make Cheek Payable to: Register of Wills, Agent
c • u e .)
17. Amount of line 14 taxable at 15% rats (17)
(Include values from Schedule K or Schedule M.) x
18. Principal tax due (Add tax from lines 15, 16 and 17.)
19. Credits Spousal Poverty Credit Prior Payments Discount Intereat
20. If line 19 is greater then Line 16, enter the difference on line 20. This is the OVERPAYMENT.
~ BE SURE TO ANSWER ALL QUESTIONS AN QEVEQCt: esne AND TO RECHECK MAl
Under penalties of perjury I declare that 1 have examined this return, ~ncludmg 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 value. Declo-ation of prepare. other
based on all information of whic6~reparer has any knowledge.
SIGNATl1~tE flf PEJ~ON RESPONS 6 O FluNr' QFniou
.15
(18) 0
0
(19)
(20)
(21) 0
(21 A)
(21 B)
~t my knowledge and belief,
to personal representative is
C
DATE
/~-9-9s
DATE
-i~~
Aet #~48 of 1994 provides for the reduction of the tax rates imposed on the net value of transfers to or for
the u ~ ..~ of the spouse. The rates as prescribed by the statute will be:
• 3'~ (.d3) will be applicable for estates of decedents dying on or after 7/1/94 and before 1/1/96
• 49su (.OZ) grill be applicable for estates of decedents dying on or after 1/1/96 and before 1/1/97
• 19~s (.01) will be applicable for estates of decedents dying on or after 1/1/97 sad before 1/1/98
• Spou:al transer: occurring on or after 1/1/98 wlll be exempt from intseritarce tax.
PLEASE ANSWER THE FOLLOWING QUESTIONS
BY PLACING A CHECK MARK (r) HIV 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 ens year of death without receiving
adsqucte considsration$ ...................................................................................................
3. Did decedent own an 'in trust for'. bank account at his or her death$ ......................................
~F THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
REV-1502 EX +,i12 05) i
~~
~~~- SCHEDULE A
COMMONWEALTH OP PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF - -- __----_ __--- --_---_ - _-__-_ __ _ _ _ ,
.._ _ _ -_
FILE NUMBER --- - --__: _ _ _._._ -
NANCY L. GOODHART 2195-0151
(Property jointly-owned with Right of Survivorship must b• disclosed on Schedule F) All real estate should be sported at fair marko} value
which is defined as the price at which orooertv u,....t.l t.~ ~.s.____~ ~_.._-___ _ -- ,,~.
fling seller, neither being compelled
VALUE AT DATE
OF DEATH
_ TOTAL (Also enter on line 1, Reca itulation
---- --P---_. ~.._._ S _
(If more space is needed, insert additional sheets of same size.) _Q
K[r Ir,u, i.x~ la.ee,)
• ~- ~~
COMMONWEALTH OF PENNSYL
INHERITANCE TAY YFTUO~
EsTAre a
NANCY L. GOODHART
SCHEDULE B
STOCKS AND BONDS
FILE NUMBER
2195-0151
(All prop..ty j.,intly-own.d with Rioht of Survivorsltia must b. dl~eles.d sn Sel~.doi. F_1
ILL
NUN
c
r
- -• ---- • ---..._.._....o~....~ aum. s~ze.~
~IKIlW !X• ~}q~
. ~ ~ ~~~
scN~ou~i c
COMMONWEALTH O/ ~ENNSYlWW1A CL+OSiLY HELD STOCK
uu~~~ *~ AARTN~RSNIP ANp PROPRI~TORSIi1P
~~ ~ Plsasa Print or T d
FILE NWNBER
NANCY L. GOODHART
21 95-01 51
ITEM
NUMBER OiiCRIFT1pN VAWE AT
QATE OF CIEATH
~, NONE
r
r
c
~.
TOTAL Also ~nhr on lim 3, Raw itulation S 0 " ~
~~ 1NO"s +P°n ~ ns~d, imnf oddifiorwl sMNs of sonN siu)
Nf v 150% F%~ I/ NIQ
~~~
COMMONWEALTH OF PEA
INHERITANCE TAX R
pESIDENT D_ECE_DI
ESTATE OF
SCHEDULE D
MORTGAGES AND NOTES
RECEIVABLE
_ __ NANCY L. GOODHART
(All. prop~rt'y jointly-owned with tho Ripht o/ Survivorship mint b~ dJselepd on Sehodul~ F.)
ITEM
NUMBER DESCRIPTION
NONE
Please Print or Type
FILE NUMBER
2195-01 51
--- - -- -
VALUE AT
DATE OF DEATH
------~-- TOTAL rAlso enter on line 4, Recapitulation). _i S-'.___.._O __
(ff more space is needod, insert addilionol sheep of same size.)
IA
c
~.~~ SCHEDULE E
"'~ CASH, BANK DEPOSITS AND
COMMONWEAIiM OF PENNSVIVANIA MISCELLANEOUS
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY _ Please Print or T e __ __ __
___ ___YP _.._.
ESTATE OF --- ~ ~ ~ -
NANCY': L. GOODHART FILE NUJvtBER
_ _ 2195-0151
i,~ll I,rolxrrry joinrly~owned with the Right of Survivorship must be disclosed on Schedule F)
ITEM _._.-_.... _._.
NUMBER DESCRIPTION VALUE AT
_ _ __ I DATE OF DEATH
Dauphin Deposit dank 589.32
Account No. 54162793
1980 Buick Automobile (sold) 75.00
PSECC7
.Account No. 208241238 21.93
AFSCME Settlement of lawsuit 180.87
1988 Skyline Mobile Home 14 x 70
~ 16,000.00
1980 Buick Automobile (Salvage) I 150.00
---.
- - -- ----- TOTAL (Also enter on line 5_Recapitulation) $1 7 _ _ '7__. 1 2
(Attach additional 8!h" x 11" sheets iF more space is needed.)
c
stvuuvex. paee
• ' ~,,~,J
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
:STATE OF
NANCY L. GOODHART
Joint teno~f(s):
DOLLAR VALUE OF
)ECEDENT'SINTEREST
r
JOINTLY-OWN D PROPERTY
FILE NUMBER
2195-01 51
_ _..
0
----- •••~o~~ ~wtnonm sheets o~ same size)
kEV~1510 EX+ h-g7)
Q ~.~ ~,)
' "~~ SCHEDULE G
COMtitONWEAITH OF PENNSYLVANIA TRANSFERS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF -- -` PLEASE PRINT OR TYPE
FILE NUMBER
NANCY L. GOODHART 2195-0151
HIS SCHEDULE MUST BE COMPLETED ANO FILED IF THE ANSWER TO A_N__Y__O__F THE pUEST10N5 ON THE REVERSE SIDE OF THE COVER SHEET IS YES.
ITEM ~ DESCRIPTION OF PROPERTY
NUMB[k IncL.de name o/the transferee, (heir reblionship to decedent, date of transfer. EXCLUSION TOTAL VALUE DECD. DOLLAR VAIUE
------------- OF ASSET °~0 OF DECEDENT'S
--- ~ ----- - - - INT. INTEREST
NONE
- -- - .. --- -- ----._.._ ---_-_ _ __ _----- I I I
---- ---__-______ ____ __ _ TOTAL (Also enter an line 7, Recopitularion) $
(If more spots is naed~d, insert additional sheets of some size.)
_. -_
0
c
. ~ ~;~~ ~~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
'E OF
NANCY L. GOODHART
ITEM
NUMBER DESCRIPTION
A• Funeral Expenses:
~• John Sullivan Funeral Home
Please Print or
NUMBER
2195-0151
AMOUNT
$730.00
u• Adroini-trativ~ Costs:
I • Personal Represenlotive Commissions
Social Security Numbor of Personal Roprosentative:
Year l:ommi::ions paid ___~._,_..••___
2. Attorney Fee: piane M. Rupich, Esquire
3. Fomily Exemption
Claimant Relationship __
Address of Claimant at decedent's death
Street Address
City State Zip Code
4. Probate Fee: Register of Wills
Register of Wills
Miscellaneous Expenses:
1. Patriot News
2• Cumberland County Law Journal
3• West Shore Emergency Medical Service
°• Holy Spirit Hospital
5' East Pennsboro Ambulance
0
300.00
29.00
15.00
114.88
40.00
495.42
1,156.30
203.82
I
SCHEDULE H
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
TOTAL (Also entor on line 9, Recaaitula
(If more space is needed, insert additional sheets of some size.)
S 3,084.42
MIVI51%IM• ()tlY~ 1
< , ~\ '~
COMMON W[Al1H Of PENNSYlVAN1A
INl/l RIIANCF IAl( Rk1URN
Rf SIUl N! OFCF D[NT
ESTATE OF
NANCY L. GOODHART
Pleose Print or Typo
FILE NUMBER --~-" '
2195-0151
F
r
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABLITIES AND LIENS
-----• ...--.. -••••••~...~..rlNFS or same size.)
KEV. isl:l Ex. ~sn~
COMMON WEAIIH Uf PfNNSYI VgNIA
INNERIiANCE TAX RETURN
_ ___ RESIDENT DEtEDEN_i_
ESTATE OF
SCHEDULE J
BENEFICIARIES
ITEM
NUMBER NAME ANO ADDRESS OF BENEFICIARY
B. Charitable and Governmentol Bequests:
FILE NUMBER
ONSHIP AMOUNT OR
SHARE OF ESTATE
AMOUNT OR
SHARE OF ESTATE
e
TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation)
_ $
(If more :pace is needed, insert additional sheets of same size) -- ~~ ------------