HomeMy WebLinkAbout95-0190Zi-g5-dlqo
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 20pT
Date
TYOEMEIT
M
EEIIYMIE~If
LL/1CI(r11C
a
II
'1
V
W
0
? ~_
Fran eropoli, ' ect
Division of Vital Records
P.O. Box 1528
New Castle, PA 16103
COMMONWEALTH OF PENNSYLIMNIA • DEPARTMENT OF HEALTH • VRAL RECORDS
CERTIFICATE OF DEATH
Q14542
NAAE OF DEOEDFlIf IR,l MF1d4r, Lrl) l10CIAL 9ECURIfY NU-EQi~•
DAE OFDFRN (Marnl~.Oay. Ar)
'• Ethel Mae Seale : Finale ~. 172 - O1 - 7399 .. Ftib 21, 1995
ADE 0.arBrEklaN UIDEII, YEAR UNDER,IYY DyaEOFBIRT,1 BE1nwtACelctyrd t1ACEWOFAEH(clRCk aN-arirrucYOnanolM •dN
tAarr Dm Nan = MF•Ar M«RDaY,Aap sur«r•«.p~cameq
82 YR Neti
r 3 Steelton , PA Irya11Me ^ ERpuprNr ^ ow ^
~ ~
^
l
„
„~„~•
^
ODUNtY OF DEAN Crtl; 80110, 71UP OF DERV NAMEpnol Mtlaal•n. V"•r•r art rvnhsr) MRS DECEDIXfOF NIBPNNC ORIOINT RACE-Nnrlrn bdl«4 Bbr4 WNb, rc.
Ctmbesland ~ Hanpden Tap. Country Meadows m~,,w ~ii~:.~'"""'""'"~ white
,0.
DECEDENfau9lMl I~/DOFBIISEIESBANDI/SfRY Rah EVEAw DECEDDR'sEDI1CIPgN N.tw n.awia~ aurvrvwoarousE
a ~Er~de~ °u~wmo~ u.s.AnwEDFORCEST m.e..Dn.nwas,n.ee)
®
'"""",'~owi0'y („~) °'~'w°
Tax Examiner w.^ Naf~
State GOVBLYI[Ileilt
,a
,,. ,.. widowed ,a
DE(~DErrt~swu(a+DADDRESS(saw.wrRa~.sr.avc~n s
,A. slr. Penn~ylVania dd ,Ye.®n.
e.ca.^w.ab i-lanrrl~n
355 Sporting Hill Rd. ,,,p
.
rreua
,a Mechanicsburg, PA 17055 «+ ~ ~ ~m Cunbesland MST ,,,,^ er~br~rr~"d..r
FA11ER'S NICE (fir. MbOe, LAeO MOTi1ER'S NAME p9rr. Mldr.. Mrden surmr
FY+ed Bennett Orpha Coble
EiFOnAAFR's NA-E Rwr^M
Sandra S. Stauffer BwuuNB ADDREBBReaI. CAMb•e. SYIa, LpCoda)
114 Yellow Bs+eeches Drive, Cane Hill, PA 17011
MEIIIOD OF 016POBRgN G9EOF DNiPOSITION PLACEOF DIBPOBRpN. NrrrCamrry,GarblY LOCIBION •CMy/bwn, Stab, 2lp Cede
Bulal® GnWlon^ Ram•valimm 9bb^ OaYtNr) «Otlta ~bca
D«Iaer^ w.,~ p Flebruary 24, 1995 Blue Ridge Memorial Gardens L. Paxton Twp., Dauphin Co.,
]/R S70.
BIDNatRE t.ICENSEE OR.EReoN ~CTE+DASSUCH I.ICENBE NIMBER NAtAEANDADDREBB OF fACrm Parthemore Ftneral Hom
Inc.
e
FD 012 849 L
aar
aalMro wa.crmy rwwNap•.srnaca.narm.ua..ar..nao~r•.ara. ucEraE NUNeER
TAW DRE SgNED
rre.rarnb em
~
R/ tS K (N«r+.Dex~w)
~.
aaru.
, / l9
Bae.xaaEeAr M ~'
DEAD M«vR 0•y. Ner) W18CASERFFERRED IO NEdG1L E%AMMIERICORDNERT
~~ 3
tbteal Wlb p«oar••~
o µ
~
n.ENRi1: ~~ ~ ~ «'•w•ulla+•a•an~rdllbMalh.D•na wa•sdghq,••~ «naplrr•yanr,stpea«MrI1Waa `App1•Mnbb FRRtB: OebralpYlla.eaandltl•irmerMWpbtlaaa,tae
jiw l•„d6ala~ lint NrripblMUalrl,eprra ghinbFllRT I.
NrEDUIEUUa[(ca~r ~ -
rlYrb WIIdIEa.
l
baUeYl~ln deaed--
~~
DUE 10 (OR AC OFk
a
'
EanA b•dgbNaaadra
DUE 10 (OR ASACONSEOUENCE OFk
CaIw
EBbrIWD80.Y1NB
~
.
~ c
GWE(DIrW «at/Ay ~
~ DuEropRasACONSEaueNCEOFl:
'~
)
e
UN$AN AUR7oSY
PERFORMEM AUTOPSY Fe101NOS
A1RlABLE W,IORID MANNER OF DEAN DAE OF eAIIIRY TIME OF INIIIRY eL1URYA WORKT DESCRIBE HOW WJURY OCCURRED.
(„oiei. DqA.~,)
~IDNOFCAUSE N.n.r Na.A
Jd
^
.
r
ACCWNa ^ PaWiq MwrgEOn ^ w ^ No^
Yr ^ M
YM ^ No ^
SWtlda ^ Co«d natMdarrmMO ^ M• a]e.
RACE OF EIJl1RY-N Mnb, /rm.rnr.lm%aEa IOCAION ISVrt GY/f .Sm)
tab.
b. •~9, re.ISOsaY)
]••• ]ef
D6RIfllR,Cnwkonyar~ .
T
T
'
OQITIFYBq E11YS1D1AN Ip+ri~'+•n ~Wq crwd arm.ri.,.rwrw anvrl.,an Ms Ixmavwr darn and aaniPlelad IN.n 23j I
tP DF
A
a7'loi•rbM•.d••~MeunM•wbtM e•a•N•)r~earwrrr•bG .................................................... ],0. '
'PIIONDUNCIIq ANDC6RIFYElO PI,YSICWI(Pnyrcian COeip«.ourrinpdMnaM
b
d LICENSE a~p
.
Bf
y~
naq
~
AIMS..IraYNrrbdEa,rr•n oaa.twrrb ttau,dw,rr Ol•a•.rr`rbrwawa(
•)ane
aa«rrrrM .......................... ^ j
~
~
~
t OZ OJr ]t0.
/~`Y ',
NAME ADDRES9OFPERSON WHOCpAPIETED CAUSE OF DEAN
DA~~BeN
R (Item 2])Typea RM IO~'l~' ~~hGaE M.t~.
•~
/
S
a MIw•>pelbn. M my opinbn. dMh xaend rtM tFne. alert. ad Wr•. rld Ar to tM
rennrretrea .............................................................................. ......... au~N ~nd /
»
RE615TRM'S 81ONA111E AHD NUMBER DAE FRED (Iao.r.
t~ .
]]. >N.
U
A
e ~ ~ ~ ~ .~i
kEV-1500 I x+ p-gal -
j~
~°~ *~ `" ~ ~ o -_;~ -.~~~ "'~-~~-'-
INHERITANCE TAX RETURN
RESIDENT DECEDENT FOR DATES OF DEATH AFTER 12131191 CHECICHERE
IF A SPOUSAL
wOVERTY CREDIT IS CLAIMED ^
' FILE NUMBER
C(. nMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
E (TO BE FILCD IN DUPLICATE
~~ ~~ ~ ~~
H
R
R
a~ ~n/ITH REGISTER OF 11VILLS) O
T
A
RISBU
G, PA
128-0601 C
UN
Y CODE YEAR _ NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIALI DECEDENT'S COMPLETE ADDRESS / /J~
o SOCIAL SECURITY NUMBER DATE OF D ATH ,,: DATE OF BIRTH U 1/' ~ G~.~.~~G'~ ~ v~ (~/ ~/~ ~
U
w
p (IF APPIIUtlLEI SUflVIVING SPGUSE'S NAME (LAST, fIfl51 AN D MIDDL ~niAy SOCIAL SEC RITY NU BER AMOUIJT RECEIVED (SEE INSTRUCTIONSI
~ [~ 1. Original Return ' ^ 2. Supplemental Return ^ 3. Remainder Return
Yav, (for dates of death prior to 12-13-82)
wd~
=O° ^ 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Ra uirod
q
J
~ (for dates of death after 12-12-82)
a m ~ b. Decedent Died Testate ^ 7. Decedent Maintained a living Trust Q B. Total Number of Safe Deposit Boxes
(Attach copy of Will) / (Attach copy of Trust)
ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIF;ECTED TO:
yZ
Z NAME (~
I l C~ G L fl Sa
~/~ . Yf~' COMPLETE MAILING ADOBE'S
( ~ ~ ~-l f i- f Gc Gri ~ /j ~ «'Cr / ,~ ~ l./.r .
v ~ TELEPHONE NUMBER
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 )
z
0
J
K
v
5. Cash, Bank Deposits 8 Miscellaneous Personal Propert~("5~)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6 )
7. Transfers (Schedule G) (Schedule L) (7 )
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)
8. Total Gross Assets (total Lines 1-7) r...--
9. Funeral Expenses, Administrative Costs, Miscellaneous / / '- ___
Expenses (Schedule H) ~~~~~
10. Debts, Mortgage Liabilities, Liens (Schedule I) (10)
~''~~ 112) ~-Vii'--T~--r-l--
(13) --
~~
(14) ~ !--
z
0
ti
c
a
x
a
r-
15. Spousal Transfers (for dates of death after b-30-94)
Sea Instructions for A plicable Percentage on Reverse
Side. (Include values ~rom Schedule K or Schedule M.)
1 b. Amount of Line 14 taxable at b% rate
(Include values from Schedule K or Schedule M.)
17. Amount of Line 14 taxable at 15% rate
(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
(15)
~~
x. __
~ ~~~ /~
(17)
Discount Interest
+ t
,~ - -
20. If Line 19 is greater than Line 18, enter the difference on Line 20. This is the OVERPAYMEft7.
21. IF Lina 18 is greater than Line 19, enter the difference on Line 21. 7Fiis is the TAX DUE.
A. Enter the interest on the balance due on Line 21A.
B. Enter the total of Line 21 and 21A on Line 21B. This is the BALANCE DUE.
Make Chock Payable fo: Register of Wills, Agent
:<.15=
bf
-- (19)
(20) --
(21 A)
(21 B) -_
~-' BE SURE TO ANSWER ALL CIUESTIONS ON REVERSE SIDE AND TO RECHECK MATH i( +(
Under penalties of perjury, 1 declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, corroct and complete. I declare that all real estate has been reported at true market value. Declaration of preparer other fhnn the personal represontativa is
bo n all information of hick prep h ;any owledge.
SI tJATUR OF PERSON RESP iBLE OR IN ,ADDRESS UAT~ ~~-
l/ ~'Gc D«' ~ /! / !'.lip- r < ~-1-. ~-~-~==~ ! / ~ / G7! _."
SI ' OF PREPA OTIiEI~, AN R R NTATIV ADDRESS ,7 DATE jjj"`---
~ REV~1503 E%+ ~;d-861
1H..~~y;_~~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS AND BONDS
c.a~r~~c yr /~~ FILE NUMBER --
(All property jointly-owned with Right of Survivorship must be disclosed on Schedule F.)
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
/
~' ~~ G / ~iG I /~?(,r S/5 ~/G C~ v ~ ~ ZSI~ f}i~ r-, c, 2-G~. 2~ / D 6 . c=' G
`~. moo. (~(/~>T ~~~.G ~ O O S~~~z,, ~ ~o.~~- y,~o%~~
6.
N-/LA-~(f~Gr-/iN- rLrCTiz~c moo. ~~~~ ~~fln~'s~ ~~•~iG ~^ o O `'
`7~
~~ ~ ~ ~~ti~c- ~/o ~r-o ~ ~ ~ 2 S~~ ~ S ~d ~~ /8
4''? ~ l6
/~ / D
~, SU. C~~ Uli! /~~ jLL~4 cf As 2 ~O !t' ~ J oD,
0. Vvl v~r~~iPa~ l~rvvs~-,,,,v?.~T~~~T ~- ~f0 ~'~~'~ 2~~fc19,`/~
TOTAL (Also enter on line 2, Recapitulati
s3y~~2/.
r
4' o
?~ pO0, ~"
~~y OG
v/•
TOTAL (Also enter on line 5, Recopitulotion) $ '2~~~
(Anach additional 8%:" x 11" sheets if more space is needed.)
REV-ISOBE%+12-871 `~
~;• ...~
!~
`"
' 5CHEDULE E
CASH
BANK DEPOSITS AND
~,
,
~. ,
COMMONWEALTH OF PENNSYLVANIA
iN RESID NTEDECEDENTRN MISCELLANEOUS
PERSONAL PROPERTY
Please Print or Type
ESTATE OF •r .~ FILE NUMBER
[~7-~~G ~ ~/~
~~frs~
~
-
.
- l ~
- c~ i c~ o
l ~
(All property jointly-owned with th• Right of Survivorship must be disclosed on Schedule F)
ITEM
NUMBER DESCRIPTION VALUE AT
DATE OF DEATH
I . /~
STR-T~ ~ /1'~OG Gy (!~L I ~ L' 'TI ,GG.~I ~ ir,T ~~ ~-e,s~ P!l- /~~Girr1"_ ~j ~}
-" ~ / ~ ~~
Z, ~ f~.GG Oi1~ ~ A N ~i ~ cc T-, ~ 2~ ~ OoO - 2y2/ C/t,t ~ 22~~ -~"
.
i-~-,~,~ti,s d ~~ 6, PA .
3,
~r~ Gc o.v g fi- sir ~ --- ~ . Q~p~, r ~ -2-~ ~ -z'~f~s~-~- G
~ ~~ ~~• 6
~~ ~
nf~ ~~u s y vr>'-nr /h / y i~--r-~o n~~y c ~ f3 ~~ - C. ~ ~o a< <r-~01~ ~f 3 ' ~n3 o
S, C. s+ .+-~ / ~-r ~ 0n
n
I' y ~/rt-.v~~r ~j~r~'1''~ ~.4~~r '^ C . QCp~ ,rte=3Gr~-ram
~ ITr.I! s
Z
~3 0Q?, ~;-_
~I
nn L~ ~H~ ,r/r c / /n
G p..~ri ~r<<
~ aev.isn ex, p-eal
~,,~~~; SCHEDULE H
!K:~~` FUNERAL EXPENSES,
COMMONWEALTH OF PENNSYLVANIA ADMINISTRATIVE COSTS AND
INHERITANCE TAX RETURN MISCELLANEOUS EXPENSES
RESIDENT DECEDENT Please Print or Type
ESTAgE OF FILE NUMBER
ITEM
NUMBER DESCRIPTION AMOUNT
A. Funeral Expenses:
Pfd 27` n`/` ~ o ,G ¢. /--' U nr ¢.Lsi e l'Y O,N ,re_ - /.~ v fie: ~ rt er ~..~ vim"
~vop v- /l?~S~ . ~ XPIe~ Su'S ~ bi,+r.,-/fI/9'/t-No.) tf f'1~!`e, 'Zo D• v v
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 - ~ CiM f i.tc.,-}~~~ Co.« r/ _ ~~-;;~ sTr,r ,,_ Zg,~b ~=
~^L L S
C. Miscellaneous Expenses:
1.
2.
3.
4.
5.
6.
7.
8.
,,
TOTAL (Also enter on line 9, Recapitulati~~°t,.. $ ~ y b- /, --
(ff more space is needed, insert additional sheets of same size.)
REV-1513 E%r (2~87~
~ti~t.~>ri
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAT( RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF /~' ~J/J FILE NUMBER
ITEM
NUMBER NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR
SHARE OF ESTATE
A. Taxable Bequests:
~)~t v6N7~,~ ~ ~ D
ITEM AMOUNT OR
NUMBER NAME AND ADDRESS OF BENEFICIARY SHARE OF ESTATE
B. Charitable and Governmental Bequests:
TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation) $
(If more space is needed, insert additional sheets of same size)
G
~J
~~~
`~~~ ~ ~~
.~ ~ ~~~
~~~~