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95-0217
~--Q5-a21~ 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 1 d 200T Date ? • Fran eropoli, ct Division of Vital Records P.O. Box 1528 New Castle, PA 16103 Ntas.,a~CTED tTEMS• #6 - COMMONWEALTH OF PENNSVLWINM • DEPARTMENT OF HEALTH • VITAL RECORDS TrPEmENT pplG FD DATE:, 4-12-95rc CERTIFICATE OF DEATH w PERYANF/IT NAME OF DECEDEM (FYa MWra, SLQE FaI te_ Euac W 3 0 025! ? 5 K ab 9E% SOCaLL SECUfMfYNUMEEp D OF DERMIMOML Oey. YVR +• Elizabeth Ann Butler >x Finale ]. 176 - 24 - 1385 .. r Q s AOE aar Eyelyy) tNDEn,rEAR LNDERtOA' DReocENrN SIRTNPLACEIQyaFd PuccvoERfl(c],.r, anryane-r•/a•ucudnsanodw aap M•,lal. IMMr tY•Nr) s DM No,r Mb . = ~ edr hrorFaeglCouryl " 63 vl. Teton, PA "'F'r"t l°L ERpIIs.eNa G Du^ ""r'q otlw ' 7-9-31 ,. Nrn. ^ Reedellce^ Isb.rd^ COIMIY OFDEArN an,eDRO,TwraFDERN NAMEpna~ril~on.t7+rmtawm.nbwl oecEDENroFNEmANICO+MON7 A,I,e,IM„~,efa,LehrLyMdr .+e E P b ~ . . . enns oro Rtap. Ctmberland Mrda4 gr,oRler,, „` white ROOF N18N1ESSMgUEIRy MME N SEDI1CRIp1 ,l ' I:Ida.awdordqMayy~rpmar d•+rM•SrlC da netwwiad.) us' ~M.~W,yMdow4 MnlrrraM '/ DECEDENrsMAa>MBADOItp tt E$UCatlOn , Mr Na® N+21 I,~ar5+1 td. W1C~ONlel~ {saerC+wwrm StraDpCadM S 11 4 tE . . 17a. Slate-Pennsvlvanla D,d th®Mw.a.Ma,d MUdw T/xiP1' 12 Merino Lane sEIENCE Allen ~~ I.a MFa ,~ Mechanicsburg, PA 17055 mrll~.dd~ ~~.,]~~~ ,71. ~'ut•'JC.L land ~•"•WP7 ~~I~I Nq dtaedrdMM /7'a Ft .LJ wdAwrdrrr E11EJyS NAME Fer MiOdle, Lar) Norbert R. Corrigan MDTIER's wNEffir Mrdr. M.dm srlrr, NrarwrraNAMEaMt.*+o ,~ FYanceS Heck John C. Butler "'FORM""`'s""WMO/00~s"'~«L~'"T.."sr..zecaeN ]IETNODasDMFOaROI, OaE ~ 12 Merino Lane Mechanicsbur PA 17055 srr® c,.,ll.dr^ Rea,or•Ieomaw^ ~ Oa11en^ ° ~~018P0&tIDN-NrraCrrw,tC,rnrNy LOCRgN-cllyrla..,.aw.aFCod. ""'~" ^ March 7, 1995 r.. St. Gabriel Cemet erY Hazleton PA SERtnCEUOR PERSO//ACTIIIp ASSUCN NIMNFA „a , NAME ANDADORESSOF RIGUrvparthemore Funeral Hare, Inc. m,FD 012 849 L ]><. •rF •+Itllarrr•E dr batt~myhrMedpe,drdt aocv,wrdrenl•.dW andtdr»arhd. LiCEIbE Y rtrr ddttrb T _ D owr4rL (licit, D•y. tbttl 71L Iltllla94'JSaelltM ralPlll•dby /ra•n rAl•POtruewdWR OF DEATH OREPRDNOIM/CEOOEAD portn.pp,,bep CASE REFERRED 70 MEDICAL DUMNERK)ORDNER7 ~~ i u M. ~. ~.^ Ne^ ~/.MNTk EnM tr a•ew•~InMN.arcpnVlkn'wr•bM arwdtM dtrt. OO nat naerFr nndaWWe9.rcb rcrdhcr rlrl.rakr Mad hi W. I W anyorreaar en eaUlYw. MWTIk OYrr Y/ y praabisraartlWMlytadWll br IhMer NMEO+ATE CAIUE(Frlel ~artrW drM ^0f~ginlMUAdn1/ilE tareElt'••WR1Rft d ~7 tlrrr~n n I ~ 2S t ' w dtrry--. , , llE /~ i~a o i ~ 3` S DuemroM ADDNSEOUENCEOF} v / vt ~P fi ~a., i n s.al,raryr ollalrr b .it.DS ~ . r.nMws„E,ab,,,,,.d•,. rrr.ErrtNONILYNO I DUEW~A~S,,A f S ~' W<J Pr:~.a+Mw j eaw 1 JC/"/~C f/~ ~ ~ 'l I .e erldYq in drllptAf7 Ol1E TDIORASACONSEOUENCE OF1. i 1M6ANAUIDPSY ~A EpFgy~Ftpygg MANNER OF OEQN DAE OF N.IURY 7IME OFINJUT' RAFOgMEp7 M4AMYRMORI(7 DESCREIE NOw INJl1Ry OFCAUSE ~~ . NWeI ^ Nomldr ^ ' Mle ^ N•~ MN ^ N• ^ SukMe ^ CauM nr lr dtNrmfned M' ^ PLACE OF aLURY-N Mme. htm rrW he,rX alb , , . LDDATIOt+lsa•el. Cay/Wwn. ShN) 3db. 2s. ~4. re. (SPx1y1 ~Iy*E1L ICMCIt aiy an•1 7ne. ]Of. 'COTTIPYNO FM VtIC1AN(p1,Y+~ ~N1*4 cwwWdrN rtron ar~aa.w cAYM~~+n nan ValwlmCed dsunaM CandNed 11am 23) i1TlE OF CERTIFIER 76 EIa Oeel q'•P la,elehdye, derb ea.„mr /ue M aw ,,~+ ee••Nel.nd manner r.ww ..................................................... ^ 7tb. ~~PA~D ~a110 ANO CEIITVYNOP11Y91ClAN(Plgy~iy.boa. pona.mcnq O•em ana c~alYn9 WCauaeof dae-q R ~I ~E NE/p, .ay, 1UYr1 ry•^•~bd9•,arbeaaamdrdt.Yre,Gh.rrWace rtesa.blM 5-~ ~~ O/~~5- ~~ ~ , .. e••eellendmrwrN•{a1W .......................... 7/e. 95 ]Id. / AND ADDRESS OF PERSON WNO COMPLETED CAUSE OF DERV 'MEDICAL EILAMINER/CORONER (Sam 271 Typer Pdr ~f, fJt.a.~ Ty•/~4L 1 rMnrbn rlNw bwarlpalFon in m o inion d m , . y p , ee mamlar r ~~ oeeurred N tAe Lim., dab, amf plaoa, rid dw b IM awes s eM ]u. .................................. f 1 ^ l 0 8 ~ gKh ...................... : ... ................... REDI 'SSNiNRWiE A/~NUMBER ]2 ur•y G /~.A. /7J y3 ORE FILED pAOMn. Osy,lrri L N N. ~. ~9s~- ~~t ~ .r"~ u~d~' C i 1 c?U~C~~ d rA.~,~ l ,° ~~ } `~-~ ~ ~~ a REV-1500 E%+(7-94) ! FOR DATES OF DEATH AFTER 12131/91 INHERITANCE TAX RETURN CHECK HEREIFASPOUSAL RESIDENT DECEDENT POVERTY CREDIT IS CLAIMED COMDEPARTMENTOFREVENUEANIA (TO BE FILED IN DUPLICATE F~LENUMBER DEPT. 280601 WITH REGISTER OF WILLS 21 X95 0217 HARRISBURG, PA 17128-0801 ~ COUNTY CODE YEAR NUMBER DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) DECEDENTS COMPLETE ADDRESS Butler Elizabeth A. ~ ~~ Lane DECEDENT SOCIAL SECURITY NUMBER DATE OF DEATH DATE OF BIRTH M~']arilCSbuYCJ (176-24-1385 03 03 95 07 09 1931 Coun G`tuttbexlarld F RSTAND MID~LERNITIIAL SPOUSE'S NAME (LAST, SOCIAL SECURITY NUMBER AMOUNT RECEIVED (SEE INSTRUCTIONS) CHECK APPRO- PRIATE BLOCKS CORRES- PONDENT RECAPfT- ULATION TAX COMPUTA- TIOIV 1. Original Return a 4. Umited Estate 0 6. Decedent Died Testate (Attach copy of Will) 2. Supplemental Return 4s. Future Interest Comprorttise (for dates of death after 12-12-t32) a 7. Decedent Maintained a Uving Trust (Attach copy of Trust) NAME J• Feirtour 're TELEPHONE NUMBER 717-236-3010 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Cbsely Held Stock/Partnership Interest (Sch. C) 4. Mortgages and Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) (Schedule L) 8. Total Gross Assets (total tines 1-7) 9. Funeral Expenses, Administrative Costs, Miscellaneous Expenses (Schedule H) 10. Debts, Mortgage Uabilities, Liens (Schedule I) 11. Total Deductions (total tines 9 & 10) 12. Net Value of Estate (tine 8 minus Une 11) 13. Charitable and Governmental Bequests (Schedule J) (8) 85,828.00 (11) 33 , 818.00 (12) 52 010.00 (13) 14. Net Value Sub'ect to Tax Une 12 minus Une 13) (14) 52 010.00 15. Spousal Transfers (for dates of death after 8-30-94~ See (15) Instructions for Applicable Pereentape on Paye 2. (Include x _ -- values from Schedule K or Schedule M.) 16. Amount of Une 14 taxable at 6°~6 rate (1 s) _ 52 , 010.00 x .os = 3 121 00 (Include values from Schedule K or Schedule M.) , . 17. Amount of Une 14 taxable at 15% rate I (17) 0.00 x .15 = 0 00 ( nGude values from Schedule K or Schedule M ) . . 18. Principal tax due (Add tax from tines 15, 1 s and 17.) 19 Credits S l P (18) 3 ,121.00 . pousa overty Crsdit Prior Payments Discount Interest 0.00+ 2,468.00+ 130.00 - (is) 2 598 00 20. If U ne 19 is rea~ e r than Une 18, ente r the d iff e rence on Line 20. This is the OVERPAYMENT. (20) , . ~1 ~~ ~~ y ~ y 3 ' FF ~ __~~I ~I ':':!1!~~. ..'~~!?....il@~ : n:.: i : ~Il Si i[f1l7,rR~• . ~Silii/!it(lili' _.. xl Ilii fill # f Si 21. If Une 181s greater than Une 19, enter the difference on Une 21. This is the TAX DUE. (21) 523.00 A. Enter the Interest on the balance due on Une 21 A. (21 A) 0.00 B. Enter the total of Une 21 and 21A on Une 21 B. This is the BALANCE DUE. (21 B) 523.00 Make Check Pa la to: R Ister of Wllis, A nt .::.:.i :. •:.:.::.:.: : ...:... ::::..,.: i ~ [ i=€.ill l . I i l ll ill}i(I =ilil : . ; ,,}}~~,{ i . !E1l: :.' .. I ~ :.:.....1~, ~ ....~~~'• . ~ , . `.......` .i~~i..~ ..• lifly~~i~:..:: ~• l ..• . ! ~ l {lil ~ , lil~lil II.:: ill {il yen o Per ury, •. . ere t at ave ex .... ne ~ th s return, udl axommpp~~a '..~::.~ .. 3 • l= : ~:°_:. l''•'' lief, it is true, correct and complete. I declare that all real estate has been reported~at~true market va~lue.~Daeteclarantion of preparer other than tt~te personal nltative (s based on all information of which preparer has any knowledge. jR OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS ~~ ~ DAT ~- fir- See Schedule attached ~l~s- ~ P ROT 1 (N gEPRES NTATIVE ADDRESS DAT .~..~~_ Nauman Smith Shissler & Ha 83//~~S- it ears Hazz'isbu~'4~ pA 17108-0840 U 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 COMPLETE MAILING ADDRESS Nauman: ShLith 5hissler & Hall P. O. Box 840 Harrisbut~f, PA 17108-0840 (1) (2) ~ 74,992.00 (3) (4) (5) 10,836.00 (6) (7) (s) 12,004.00 (io) 21, 814.00 Estate of: Elizabeth A. Butler 21-1995-0217 Zhe following persons are signing the return as representatives of the estate: John C. Butler 12 Mexino Iane MecY~anicsb~lrg, PA 17055 PA REV-1500 F,C (7-94) 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% (.02) will be applicable for estates of decedents dying on or after 1/1/96 and before 1/1/97 • 1% (.01) will be applicable for estates of decedents dying on or after 1/1/97 and before 111/98 • Spousal transfers occurring on or after 1/1/98 will be exempt from Inheritance tax. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING A CHECK MARK (v) IN 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 properly transferred or its income ... . ........................... . ..... . . . . . . }{ c. retain a reversionary interest; or .................. .............................................................. X 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 receivi ng adequate consideration? If death occurred aft D e b er ec m er 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ............. .... . 3. Did decedent own an 'in trust for' bank account at his or her death?. . YOU MUST COMPLE1TE SCHEDULE G AND FILOE T AS PARTNOF THESRETURN. PA15002 NTF 8880 Copyright Forms Software Only, 1994 Nelco, Inc. N94PA002 REV-1503 EX+(4-86) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE B STOCKS AND BONDS FILE NUMBER Elizabeth A. Butler 21-1995-0217 (AIl P~~'~Y IcintiY-owned with Right of Survlvorshlp must be dlaclosed on Schedule F.) ITEM NO. DESCRIPTION VALUE AT DATE OF DEATH 1 ~~ Barney ~' 73, 885.00 (See attactunent) 2 PP&L Stoc]c - 54 shares at $20.50 a share 1,107.00 TOTAL (Also enter on link 2, Rec itulatlon) (If more space is needed, Insert additional sheets of same size.) PA15031 NTF 1212 4,992.OC HEV-1508 Ex+(2-87) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS AND INHERITANCE TAX RETURN MISCELLANEOUS RESIDENT DECEDENT PERSONAL PROPERTY Please Print or T ESTATE OF FILE NUMBER Elizabeth A. Butler 21-1995-0217 All oln -owned with the RI ht of Survlvorshi must be disclosed on Schedule F) ITEM DESCRIPTION VALUE AT NO. DATE OF DEATH 1 PA Public Scrnool Employees - 339.00 Retirement System 2 Certificate of Deposit - 10,001.00 No. 8000401606 Dauphin Deposit Bank & Trust Caa~any 3 PP&L -dividend 485.00 4 PP&L -dividend 11.00 TOTAL (Also enter on line 5 Recapitulation)~$ (Attach addrtanal 8 1/2" x 11" sheets rf mare space is needed.) PA15081 NTF 1215 10,836.00 REV-1511 EX+(7-88) SCHEDULE H FUNERAL EXPENSES, COMMONWEALTH OF PENNSYLVANIA ADMINISTRATIVE COSTS AND IN RESIDENT D ~ DENT N MISCELLANEOUS EXPENSES Please Print or Typs ESTATE OF FILE NUMBER Elizabeth A. Butler 21-1995-0217 I OM DESCRIPTION AMOUNT A. Funeral Expenses: 1 Parthemore Fluzeral Rostra 5, 351.00 2 I Boyle Ftiineral Hoa<ne - (inter7m>I~nt) B. Adminlstratlve Costs: 1. Personal Representative Commissions Social Security Number of Personal Representative: Year Commissions paid 2. Attorney Fees 3. Family l=xemption Claimant Relationship Address of Claimant at decedents death Street Address ~ State Zip Code 4. Probate Fees C. Miscellaneous Expenses: 1 C~xland Iaw Journal Advertising 2 Patriot News Advertising 3 Natnttan S~itith Shissler & Hall costs Advarx~ed -short certificates, P~~ge, notary, etc. 4 Reserve TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, Insert additional sheets of same size.) PA15111 NTF 1218 _. _ _ _ _ 3,700.00 0.00 1,680.00 0.00 108.00 40.00 106.00 19.00 1,000.00 2,004.00 REV-1512 EX+(1/93) COMMONWEALTH OF PENNSYLVANIA INHERITANCETAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES AND LIENS pleasePrfntor ESTATE OF FILE NUMBER Elizabeth A. Butler 21-1995-0217 ITEM NO. DESCRIPTION AMOUNT 1 ~~ Barney ~• -Margin ~~ 20,279.00 (See attac~mtent) 2 Alan C. Huff, DDS 45.00 3 Zhcanas P. Kunkle, D.O. 136.00 4 Family Physician Assn 5.00 5 Ieadex Nursing Home 963.00 6 Nauman Smith Shissler & Hall 214.00 Dolts advar><oed relating to medical records, etc. 7 PA Dept of Rlevenue 172.00 Taxes TOTAL (Also enter on line 10 Recapitulation) $ 21, 814 (If more space Is needed, insert additional sheets of same size.) PA15121 NTF 2880 Copyright Forms Software Only, 1994 Nelco, Inc. N94PA721 REV-t5t3 EX+(2-B~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER REIVI A. ~~~ 21-1995-0217 ~~ NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR SHARE OF ESTATE A Taxable Bequests: 1 John C. Butler Son One-half 12 Merino Iane Residuary Mec33anicsbtlrg, PA 17055 2 James J. Butler Son One-'Yialf 8404 Sr>~ocaden Ioop Court Residua I~urel, 14ID 20708 tl'EM NAME AND ADDRESS OF BENEFICIARY AMOUNT OR NOw SHARE OF ESTATE B. Charitable and Governmental Bequests: None i TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on Ilne 13 Recapitulation) (If more space Is Headed, Insert addltlonal sheets of same size) PA15131 NTF 1220A _. _ 0.00 • RUG-31-95 THU ;.4.30 DAUPHIN DEPOSIT BANK FAX N0, 7172376156 DADPBIN DEPOSI? BANK AI~iD ?RIISr COtJPANY DBCEDEI~T CONFIR2lATION • ~~NBme . • . ..... ,_ • •- ~;~.. .. ,•Scc'i'a7..,sec•ur.i ty,•~•N .......,.;• . - -~ "`~:'°:T.-:•::::.,.; ...~•. •Date ;af•:~Desth .(aOD.~ • 'l~Iazcti 3~• 2995 .. . • ~: _ '- ..: _ "~• ..Y_. _:_:..:i~. .. •. .. i. . ..~ µ P, 02 Accouat Ko. 8000401606 =yPe Certificate of Deposit Date Opened or Issued 12/19/80 Date Closed or Matured Q4/11/95 (Closed) Date of Deatk Balance 510,000.00 PLIIS -~ Date of Death Accrued Int. 51.15 Joiat O~aera, if :ny John J. Butler (Decd) --~.,~ Date of Joint Ovaership 12/19/80 Special Comsaeacs: !-dditional informatioa available at $20.00 per hour. One hour miaim~~_ Date Prepared August 31, 1995 Prepared $y Cheryl A. Bowers Gastomer Management Information Dept. ielephooe Ho. (717) 255-2054 ...JUN - ~ 1895 ~,a A,1A~~34~$~~ COMM~NwEAC.~H-OF PEMNSYLVANJA .. - ~ ,, .;;' , :DEPAF~T,~pT~IT OF REYL'NUE . ' . ,, REV.I16$Exl,.wl ~-:OFFICIAL RECEI~.T~71:PENNS~(IfVANIA INHERITANCE AND ESTATE TA'X~ - ACN RECEIVED FROM: ~ ASSESSMENT CONTROL AMOUNT NUMBER FEINOUR J STEPHEN ESQ 101 X2,468.00 P O HOX 840 HARRISBURG PA 17108 . - FOLD HERE FC ESTATE INFORMATION: © FILE NUMBER 21-1995-0217 SSN 17b-24-1385 © NAME OF DECEDENT (LAST) (FIRST) (M1) DATE OF PAYMENT © POSTMAR E REMARKS JOHN C BUTLER C/O STEPHEN FEINOIR ESQ SEAL CHECK# 11 TAXPAI'ER TOTAL AMOUNT PAID ~~~ 466 00 O RECEIVED BY C~•- , GNATURE MARY C. LEW 5 REGISTER OF WILLS `,-1 ,'` ~. r ~~:~, ~, ~` j ~,r: I ~~°~ ors 'G Register of Wills of CUMBERLAND County, Pennsyly Certificate of Grant of Letters of Administratio No. 1995-00217 PA No. 2195-0217 ESTATE OF BUTLER ELIZABETH A. Late of LOWER ALLEN TOWNSHIP Deceased Social Security No. 176-24-1385 WHEREAS, BUTLER ELIZABETH A. , late of LOWER ALLEN TOWNSHIP CUMBERLAND COUNTY , died on the 3rd day of March and 1995; WHEREAS, the grant of letters of administration is required for the administration of. the estate. THEREFORE, I, MARY C. LEWIS in and for the County of CUMBERLAND Register of W: Commonwealth of Pennsylvania, have this da in y granted Letters of Administratioi to JOHN C. BUTLER ( , , who has duly qualified as administrator(rix) of the above named decedent and has agreed to administer the estatefaccordir to law, all of which fully appears of record in my Office at CUMBERLAND COUNT COURT HOUSE, CARLISLE, PENNSYLVANIA IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my Office on the 17th day of March 1995 ' 1 r i (LAST, FIRST, MIDDLE) _ rr~ ii t t~ i i ' ~~: _ ~ , x PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 STATE OF PENNSYLVANIA : ss. COUNTY OF CUMBERLAND : Roger M. Morgenthal, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, viz: _ MAR H 31. APRIL 7 14 1995 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested is the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Butte:, Elizabeth A., decd. Roger M. Morgenthal, Editor Late of the Horough of Camp Dill, M n11O ~~ Mechanic burg.~pA SWORN TO AND SUBSCRIBED before me this 17055. Attorneys: J. Stephen Feinour, 14 day of _ APRIL , 1995 Esquire, Nauman. Smith, Shis- sler & Hall, P.O. Box 840, Harris- burg, PA 17108. Notary ~ ~~~~ Nor~wuu, sE~ MERLENE MARHEYK~ Notary Public Carlkla, Cumberland County, Pa My Commlaaion Eapkee 6/8/98 Proof of Publication of Hoti~e in The Patriot and The Evenin Hews and Th 9 e Sunday Patriot-News IInder Act No. i68~, Approred May ia, iti-3Y, Commonwealth of Pennsylvania, County of Daztphin } 4x: .....................................Michael Morrow being duly sworn according to law, deposes and says: .................................................... Asst. Controller That he is the ...........................of THE PATRIOT -NEWS CO., a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, with its principal office and place of business at 812 to 818 Market Street, in the City of Harrisburg, County of Dauphin, State of Pennsylvania, owner and publisher of THE PATRIOT and THE EVENING NEWS and the SUNDAY PATRIOT -NEWS newspapers of general circulation, printed and published at 812 to 818 Market Street, in the City, County and State aforesaid; that THE PATRIOT and THE EVENING NEWS and the SUNDAY PATRIOT -NEWS were established March 4th, 1854, and February 15th, 191? and September 18th, 1949, respectively, and all have been continuously published ever since; That the printed notice or publication which is securely attached hereto is exactly as printed and published in their regular editions and issues which appeared on the 23rd and 30th days .......................................................... .o March and the 6th day of April 1995. ................................................................ .................................................................. That neither he nor said Company is interested in the subject matter of said printed notice or adver- tising, and that all of the allegations of this statement as to the time, place and character of publication are true; and That he has personal knowledge of the facts of resaid and is duly authorized and empowered to verify this statement on behalf of The Patriot-Ne a Co. aforesaid by virtue and pursuant to a resolu- tion unanimously passed and adopted severally b t e stoekhalders and board of directors of the said Company and subsequently duly recorded in the ofli e r the ording of Deeds in and for said County of Dauphin in H~sceilaneous Book "M". Volume 14, Pa 3 7. Copy of Notice or Publication ~~~ ' /~ / ~ /L Adminisir<atlon fn the Estate of EL~ZABEmTrHsAf BUTLER, late of Gump Hill, Cumberland County, John C Bu ler, Adminia~}ro p~vgil ~n~ns ITT ed to sold estate ore requlrW to moke payment and those having elalmi or demands to preaenifhe same without delay to John C. Butler, 12 Merino Lane, Mechanicsburo, PA T)O55 or to hla actor- SMITH, SH~SSLER ~ HALL, P OrBox 81UO~ HaN- rlsbure,'PA 17108-oB(p, ... ... .. Sworn to and subsc 'b fore me .day of ..... ......... AP 1 199 .... . fvOt^ri3! Terry L. Ru'ssell'. . a . . .. ...... .......... ... .. .. ....... Harrisburg. D`au t fi Countya Notary Public ~' - -- -- a ~Y.--- . _ 8'_~ ........................... Statement Advertising Costs .,.Nauman, Smith.{. Shissler~ &. Hall ... • ... Harrisburg, PA. 17108 .............................................................. ................ To THE PATRIOT-NEWS CO., Dr. For publishing the notice or publication attached hereto on the above stated dates - - $ 10 5.12 - ... .. ........... Probating same - 1.0 0 - - - - $.........l~.s'~Y~.... Total - - - - - - $ .................... Publisher's Receipt for Advertising Costs THE PATRIOT-NEWS CO., publisher of THE PATRIOT and THE EVENING NEWS and the SUNDAY PATRIOT-NEWS, newspapers of general circulation, hereby acknowledge receipt of the aforesaid notice and publication costs and certifies that the same have been duly paid. THE PATRIOT-NEWS CO. By ..................................................................................... SMITH BARNEY INC. ACCOUNT #: 724-09443 FC: DEAN COOK ACCOUNT POSITION SUMMARY AS OF 03~03~95 ELIZABETH A BUTLER C~O JOHN BUTLER 12 MERINO LANE MECHANICSBURG PA 17055-4882 MUTUAL FUNDS MARGIN BALANCE CDS ACCOUNT VALUE* 40,884.85 -20,278.77 33,000.00 53,606.08 * VALUE DOES NOT INCLUDE UNPRICED SECURITIES. THIS INFORMATION IS BEING PROVIDED AT YOUR REQUEST AND DOES NOT REPLACE OR SUPERSEDE YOUR SMITH BARNEY INC. CUSTOMER STATEMENT. THIS INFORMATION IS BASED UPON THE MARKET VALUE OF YOUR ACCOUNT AS OF THE CLOSE OF BUSINESS AND IS SUBJECT TO DAILY MARKET FLUCTUATION. • •~ . . b SMITH BARNEY INC. PAGE 1 ACCOUNT POSITIONS AS OF 03/03/95 ACCOUNT #: 724-09443 ELIZABETH A BUTLER FC: DEAN COOK C~O JOHN BUTLER 12 MERINO LANE MECHANICSBURG PA 17055-4882 QUAN'T'ITY SECURITY DESCRIPTION PRICE MARKET VALUE 411 COLONIAL TR III FED SECS FD 10.130 3,404 MFS HIGH INCOME FUND CL A 4.940 871 PUTNAM AMERICAN GOVT INCOME 8.210 FD SH BEN INT 559 SOGEN INTERNATIONAL FD INC 22.800 33,000 CONTINENTAL BANK - IL 100.000 *CERTIFICATE OF DEPOSIT DTD 07/2588 INT SEMI-ANN 9.10 07/25/1995 ACCRUED INTEREST 329.07 TOTAL MARKET VALUE* $4,163.43 $16,815.76 $7,150.91 $12,754.75 $33,000.00 ----sis;as4-s5 * VALUE DOES NOT INCLUDE UNPRICEO SECURITIES. THIS INFORMATION IS BEING PROVIDED AT YOUR REQUEST AND GOES NOT REPLACE OR SUPERSEDE YOUR SMITH BARNEY INC. CUSTOMER STATEMENT. THIS INFORMATION IS BASED UPON THE MARKET VALUE OF YOUR ACCOUNT AS OF THE CLOSE OF BUSINESS AND IS SUBJECT TO DAILY MARKET FLUCTUATION. r ~ s 'EV-1500 EX+ (2.871 1 '` ,~ COMMONWEALTH Of PENNSYLVANIA DEPARTMENT OF REVENUE POST OFFICE BOX 8327 __ HARRISBURG, PA 17105.8327 t- Z W 0 W v W 0 W Q WdV vam o. Q N 'z W ~y oe p OZ V a BUTLER, Elizabeth A. 176-24-1385 ^ 1. Original Return ^ 4. Limited Estate ^ b. Decedent Died Testate (Attach copy of Will) 1tG,CORRESPONDENCE AND CONFI ~c~o~~~ INHERITANCE TAX RETURN RESIDENT DECEDENT (TO BE FILED IN DUPLICATE WITH REGISTER OF WILLS) 03/03/95 07/09/1931 FILE NUMBER 21 COUNTY CODE 12 Merino Lane Mechanicsburg, PA Cumberland ~95 0217 YEAR .NUMBER ® 2. Supplemental Return ^ 4a. Future Interest Compromise (for dates of death after 12-12-82) ^ 7. Decedent Maintained a Living Trust {Attach copy of Trustl J. Stephen Feinour, Esquire 717 1 236-3010 ^ 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 Nauman, Smith, Shissler & Hall P. O. Box 840 Harrisburg, PA 17108-0840 Z O f- Q o. Q u W C Z O o. O u x 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) 5. Cash, Barik Deposits 8. Miscellaneous Personal Property{ 5) 25, 000.00 (Schedule E) b. Jointly Owned Property {Schedule F) (b) 7. Transfers (Schedule G) (Schedule L) (7) 8. Total Gross Assets (total lines 1-7) 9. funeral Expenses, Administrative Costs, Miscellaneous (9) 9, 144.02 Expenses (Schedule H) 10. Debts, Mortgage Liabilities, Liens (Schedule I) (10) 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 Value Subject Yo Tax (line 12 minus line 13) 15. Arylount of line 14 taxable at 69/o rate ~ . (15) 15, 855.98 (Include values from Schedule K or Schedule M.) 16. Amount of line 14 taxable:at 15°h rate (16) (Include values from Schedule K or Schedule M.) 17. Principal tax due (Add tax from line 15 and From line 16.) 18. Credits Prior Payments Discount Interest x:06= x .15 (17) 19. IF line 18 is greater than line 17, enter the difference on line 19. This is the OVERPAYMENT. ~^ 20. If line 17 is greater than line 18, enter the difference on line 20•This•is the•TAX DUE. A. Enter the interest on the balance due on line 20A. B. Enter the total of line 20 and 20A on line 20B. This is the BALANCE DUE. Make Check Payable to: Register of Wills, Agent (18) (19) (20) (20A) (206) JJ 1 •.7V 951.36 951.36 " w.ui-BE SURE TO ANSWER ALt;QUE$T.IONS ON~REVERSE SIDE='AND.TC!`RECHECKMATH~i~ .~ •~: ler 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, true, correct and complete. I declare that all real estate has been reported at true market value. Declaration of preparer other than the personal representative is ed on all information of which preparer has any knowledge. MATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE ( 8) ~.. 25,000.Ob" (11) 9, 144.02 (12) (13) (141 15, 855.98 ~A~OAREg OTHtAN REPRESENTATIVE ADDRESS ((~R// 200 N. Third St., P. O. Box 840 DATE '~ PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING A CHECK MARK (~) IN THE APPROPRIATE BLOCKS. 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 one year of death without receiving adequate consideration? ..................... ............................ 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. i REV.1508 EX+ (2.8~ SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASHM~SCELLAN OUS AND 1N RE51 ENTEDECeDENTRN PERSONAL PROPERTY ESTATE OF Please Print or Type Elizabeth A. Butler FILE NUMBER 21-1995-0217 (All property jointly-owned with the Right of~Survivorship must be disclosed on Schedule F) ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Cash from proceeds of settlement of survival action filed in the Court of Common Pleas of Cumberland County, $ 25,000.00 Pennsylvania, to Docket No. 96-5621 Civil Term (See Order of Court dated 12/17/98 attached hereto) ti ~~~ ~~ ~~ .~ TOTAL (Also enter on line 5, Recapitulation) $ 25,000.00 (Attach additional 81h" x 11" sheets if mare space is needed.) ~'~~.'~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF Elizabeth A. Butler ITEM NUMBER A• Funeral Expenses: 1. SCHEDULE H FUNERAL EXPENSES, ADMINISTRATIVE COSTS AND MISCELLANEOUS EXPENSES DESCRIPTION Please Print or T NUMBER 21-1995-0217 AMOUNT B• Administrative Costs: 1 • Personal Representative Commissions Social Security Number of Personal Representative: Year Commissions paid 2. Attorney Fees -Nauman, Smith, Shissler & Hall 8,333.34 3. Family Exemption Claimant Relationship Address of Claimant at decedent's death Street Address City State Zip Code 4. Probate Fees C• Miscellaneous Expenses: 1• Cumberland County Register of Wills (filing fee for supplementa 15.00 return) 2. Litigation Expenses reimbursed to counsel 796.68 TOTAL (Also enter on line 9, Recapitulation) I$ 9, 144 02 (If more space ~s needed, insert additional sheets of same size) • REV-1513 EX + (2-87) ~' ~ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA B E N E F I C IA R I E S INHERITANCE TAX RETURN RESIDENT DECEDENT tSTATE pF Elizabeth A. Butler ITEM NUMBER NAME AND ADDRESS OF BENEFICIARY A. Taxable Bequests: 1. John C. Butler 12 Merino Lane Mechanicsburg, PA 17055 2. James J. Butler 8404 Snowden Loop Court Laurel, MD 20708 ITEM NUMBER NAME AND ADDRESS OF BENEFICIARY B. Charitable and Governmental Bequests: 1. None FILE NUMBER 21-1995-0217 RELATIONSHIP ~ Son Son AMOUNT OR SHARE OF ESTATE $7,927.99 $7,927.99 AMOUNT OR SHARE OF ESTATE TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation) $ (If more space ~s needed, insert additional sheets of same size) DEC 17 ~ggg~ JOHN C. BUTLER, Administrator of the Estate of Elizabeth A. Butler Deceased IN THE COURT OF COMMON PLEAS , , Plaintiff CUMBERLAND COUNTY - NO.96-5621 CIVIL TERM vs. BEVERLY CALIFORNIA CORPORATION CIVIL ACTION -LAW n/k/a Beverly Health Caze t/d/b/a Blue Ridge Haven Convalescent Center -West, BEVERLY ENTERPRISES, INC., t/d/b/a Blue Ridge Haven Convalescent Center -West, BEVERLY ENTERPRISES - PENNSYLVANIA, INC., t/d/b/a Blue Ridge Haven Convalescent Center, Inc. and , BLUE RIDGE HAVEN WEST CONVALESCENT CENTER, INC., • Defendants AND NOW, this ~ day of !~ 199,x' upon consideration of the Petition of John C. Butler, Administrator of the Estate of Elizabeth A. Butler, deceased, for Approval of Wrongful Death/Survival Action Settlement, the Court finds that the proposed settlement is in the best interests of the Estate of Elizabeth A. Butler, Deceased. IT IS HEREBY ORDERED and DECREED that the settlement in the amount of $50,000 is APPROVED. IT IS FURTHER ORDERED that the settlement proceeds be distributed as follows: 1 . To: Law Offices of Nauman, Smith, Shissler & Hall: a. For reimbursement of costs: $1,591,35 b• For counsel fees: $16,666.67 2• The remaining balance of $31,741.98 is apportioned as follows: a• Survival Claim $15,870.99 b. Wrongful Death Claim: John C. Butler $ 7,935.50 James J. Butler $ 7,935.49 IT IS FURTHER ORDERED that the record in this matter shall be placed under seal. BY THE COURT: TRU~~: C~~'1~ ~~~~A~ R~CC~Ra in Testi~omg v~he~, t here uc~ta sit ttly hand and the ~uf saki ~at Caxiisle,-Pa. This. ~ ~..daY OCi~~1~.~ t ~1~~ i ~ tianotary ry O ti.. r cc~ w rn r r BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARR.T.SBURG, PA 17128-0601 J STEPHEN FEINOUR ESQ NAUMAN ETAL PO BOX 840 HBG PA 17108 DATE 04-26-1999 ESTATE OF BUTLER ELIZABETH A DATE OF DEATH 03-03-1995 FILE NUMBER 21 95-0217 COUNTY CUMBERLAND ACN 501 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR - YOUR RECORDS -~ -------------------------------------------------------------------------------- ----------- REV-1547 EX AFP (09-97) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE -------------------- OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BUTLER ELIZABETH A FILE N0. 21 95-0217 ACN 501 DATE 04-26-1999 TAX RETURN WAS: ( ) ACCEPTED AS FILED ( X] CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: LITIGATION RETURN 1. Real Estate (Schedule A) (1) .00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2) .00 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) (3) :00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule Dl (4) .00 of this form with your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 2 5,0 00.00 tax payment. 6. Jointly Owned Property (Schedule F) (6l .00 7. Transfers (Schedule G) (7) .00 8. Total Assets (g) 25, 000.00 APPROVED DEDUCTIONS AND EXEMPTIONS: 9,144 .02 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) ( 10) .00 11. Total Deductions (11) 9 .144 _ 02 12. Net Value of Tax Return (12) 15,855.98 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts [Schedule J) (13) .00 14. Net Value of Estate Subject to Tax (14) 15,855.98 NOTE: if an assessment was issued previously, lines 14, 15 andior 16, 17 and 18 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) . 00 X .00= .00 16. Amount of Line 14 taxable at Lineal/Class A rata (16) 15,855.98 X .06. 951 .36 17. Amount of Line 14 taxable at Collateral/Class B rate (17) •00 X .1 5. .00 18. Principal Tax Due (lg) 951.36 TAX CREDITS: PAYMENT DATE RECEIPT NUMBER DISCOUNT (+l INTEREST/PEN PAID (-) AMOUNT PAID 01-21-1999 AA324529 .00 951.36 BALANCE OF UNPAID INTEREST/PENALTY AS OF * IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 E% AFP (09-97) 01-22-1999 TOTAL TAX CREDIT 951.36 BALANCE OF TAX DUE .00 INTEREST AND PEN. 6.19 TOTAL DUE 6.19 ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. IF-TOTAL DUE IS REFLECTED AS A "CREDIT'' (CR). YOU MAY BE OUF f"REV-1470 EX (8-88) INHERITANCE TAX EXPLANATION COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE OF CHANGES BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 DECEDENT'S NAME FILE NUMBER Butler, EIIZabeth 2195-0217 REVIEWED BY ACN Larry Szollosy 101 SCHEDULE 'ND" EXPLANATION OF CHANGES E 1 Interest is effective December 22, 1998. FILE Page 1 pennsylvania DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX REV-1607 EX AFP (12-14) INHERITANCE TAX DjjII�VISION ``/� STATEMENT OF ACCOUNT HARRINU AD171�28 OFFICE 60�i G REGIS± C F WILLS DATE 02-09-2015 ?01S ��p 1 r7 FM 1 14 ESTATE OF BUTLER ELIZABETH A J 11 DATE OF DEATH 03-03-1995 kCr- FILE NUMBER 21 95-0217 COUNTY CUMBERLAND OffRN�)OUE.SQ'`>> J S ACN 101 G���A"ANA ETAL O BOX 840 Amount Remitted HBG PA 17108 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 NOTE: To ensure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE RETAIN LOWER PORTION FOR YOUR RECORDS - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - REV-1607 EX AFP C12-14) *** INHERITANCE TAX STATEMENT OF ACCOUNT X;; ESTATE OF:BUTLER ELIZABETH A FILE NO. : 21 95-0217 ACN: 101 DATE: 02-09-2015 THIS STATEMENT PROVIDES CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 11-27-1995 PRINCIPAL TAX DUE: 3,121.00 PAYMENTS (TAX CREDITS) : PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 06-02-1995 AA047834 129.89 2,468.00 09-05-1995 AA082103 .00 523.00 02-06-2015 SBADJUST .00 .24 TOTAL TAX PAYMENT 3,121.00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.