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Home My WebLink About95-02202~-QS~~Q22~J H,05.1A3 Rw. ?/B7 nrEnRBTr w PERMANENT BLACK B11( ~I z 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 PEPq~iSYL1MWIA • OEFARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH c1~~~~ NAME OF DECFDENT(Fia twaa ~\ )~.~ ,/ '~~°""`"`"'~' \\C~ ~~ SODYIL SECURRV NUMBER DATE OF DFANi1AarMI.DM. ~br) , ov use ~-/.'~ . o 0 ~ a.o - o -.s ~ •. ~ 6 i ADE i Aar B laWgi UN061, YEM UNDEq 101Y OREOF BNM B,RO,PIACi IClT ••e PLACE Oi DE,QN(drrJl onyan•-+wir•b~rsp•onayr r,q ' Harr ~I•Y• Ilor• I Mln•N• IMaxn, O•R, Ar) SaNar FOrpnCaWy, ,p~,B~ OTHER ("~ {'~ Q (~ p ` 1 Yn ~R 30~ ( `~R 1~0'C1 Prl MiaNl• ~o, E1MDIrylaMly ^ Od1 ^ /b w ^ R•i0ao ^ (Sp~ciq COUNTY DF DERN cTIY DERV RlCItm NAMERea.rAU•m.pa laaana lA.•erl BKB DECEDENT DP NNIMNICDRgPiT RACE-AnIMe•n tAArl,BYgt, MA W. ae. 1 Q \a~_ ~ No 1C~. N• Bfa p•en1L10•n. f ~ M.•+e+n.w«~oRk•n.ra \t1 '(1't15~~ p ~ C1~J~T. PJ • M SUMYILOCCURYN)N KING DF BUSINESSIWDIISTRY WAB SEDIIGEKIN MARIDILSWUB•MrriW d~ ~M~Oem» riamoj U. D Nr•rWnM4 Wbsw4 BSI~IR1M~KaBnrS~POUE'E „ , 12 ~ ,~. ,.. ow ,,. - 6~My.~+o ark.nocaeR DECEDENT'S iTtis„r ® ls ~nCp.~ ~ OM ,Ta w..a.vaN•M.s (M\ \ CS u, 1-zo55 ~, ~' '••~• ~ ~ ' ~ ctrL NC ` ls. O: to+nr~T 17L~ wwnw~.lll sa ROT,ER'SNA61E lint Mip7•, _ SHAME Mrtl•n Su ,.. ~ ,.. r h~~n _ r ~ l_a ~\~~ IMPORMAHT'SMAEdIp mDeo.I !, . ~ -> SS' . ~~ CS ~ T S I s METIIOOaPDaPOeRIDn oREDPaerosrr,oN B•IY® CwIIMEe•^ RrnwahpeS,W^ ^ ~~) ~ PLACE DP aaPOBITIDN-Nwrac.IwKa.wr•I, LOCRKIN. 9tra apCar aOIMrP4o• jJ >hw ~~ q~` a,a`~'E'~il C a, \ lei o~ , NUMBER p~ oos~oq~-~ ~.n dd ~ ~~\~e~c:.s u ~zo6 ~ A.••aa•ew,..,Neorw,Ino tlr!•r~Tbo•1•Ep•,a..roon.lwael.•maO.1••nCpbrwe. UCFNBENUMBER DRESIDIIEo ilel •Y•60b r rl»aare t• rl a•w, Trraarw - IL,onIll. D•F w•11 . .kilo p~dglww.e..laM as DERV avE PRDNOUNCeo DEAD nwnn. D•r.wrr wASCABE RECERREDro wEDK;AL eJUUwERKX7RDNERT 47. M11-F. ~ IMA•••M•.fry~/IMaw•pllutlar wNC11 rJ1Y01M EMM. DD not MtMBr nabaErYq, r W/NPlnlory artMl. slndlaMYI WI•a IApgmYll•~• PARE B: DUNraiplBpntawadl•mll•MYgbAMBA Wt oa,alr orr•an ••dlYna rriEDIATECAIIae 'a••'^`tr rlea'~..n nal..wKl inwu•Nn,4gerwyN~n PW,T I. 1 (F:la ~ ~- ar - ~ 'G •rooaruNm ~ ~ ~~f L ; ~, , ; 3.~-,j l.. f I..Ilrgno•rnl-~ a DUEmIDR ASA ENCE OFI: / 1 E•PMnMW 4t oorlBliolr a C. C ~/ •^^ tJ(t "~I f r~ ~c -~ i Y~ J/'I _ DuEtD(aR AS ACDNSEOUENCE OFT. / - I ~YIfr.a~ww°`~ L. ~.~.. c.-r-K G t!-fir[{ ;• L7-., q1E TO (OR ASA CDNSEOUENCE OFk N•14p n 0•rI,IIAET a I YIRB AM AUTOPSY AUIOPBYPNd11DS MANNER OF t)ERN pRE DF INJURY TIME OF INJURY MJIRIYRNORKT DESCRIBE /10WINJlK,YOCd1RRE0. PERFORIAEDT AMK.ABLE PRKKI l0 (MaNh wn D•Y . . casLETIDNOPDAIUE ya N,,,,~ aPDEAUHT NN•1 ICy AxieN• ^ PMIAYp ^ M• ^ N• ^ 'M ^ No® 1'•• ^ II• ^ SukM• ^ CouMna MAN•rmNl•E ^ M. PLACE OF NiIIMY.AI henr Nrm abMl t 1w a•e• IOCR . . . % bN15b•n. Coy/, .SIaIN ar. ,a •al6q ae. ISD•aYl C6TTMIEII(Chock •ar on•1 a••' 701. ~TIP~;DaPNYBICIANIPhY~lyryyk5 ernaaarlh rn•n anallr ph,vcl•nnr ponauric•n Dean kna camgM•o non 23) SKiNRtWE AND TRLE OF CERTIFIER w/ luke•MeB•. arl •eeur.e au.•e nr ew...IN.nr •~rww «awa ..................................... ............... ~'4 as ~ ~ ~~ ~ - ~` `~7, 'PIIOMOUNUIp AND C,BRIPYINO PHYSIf.IAM LICENSE NU¢IBER 9KiNED (klarnh. py, lyrl To BI•s.aalnF•ne.I•M.eaBleeeulne.t~m•~r. aria. rwPl•e•~°, •I~wa r ~r sl Me~n~,'...rwa .......................... p ,, ••" o`~(h'~7-L a,a MIME AND ADDI,ESS OF PERSON WHO COM W)SE p&{fN 'MEDICAL E)<11MMER/CORONER (Item 27) Typ• or PrIM ~,~ ,,, . ~ P __ , / ~, ~ Two ~W~.~InNrllen.•ntlloF bw•aNq•BOn, in mY opfnlon, d•aA oecunM M tM WII•. En•. an0 pMC•~ rM du• to tM cwr(•) end /v ~ ~~ `~S/ .- c~~ / i a' _ f,. a. ~ // ~ REGISTMR'S SKiNRVRE AND NUMBER •~ ~ GATE FaEDIMaxn. DAY. ~1 ~I'yr ~~ ~ ~ r ~ ~ ~ ~ I ]]. 'L 1 ~) REV•1500 EX+ (7.941 x COMMONWEALTH OF PENT Z W W W O W a N _ ¢ O ~m a V! ~ W W so sz 0 ~a° z 0 -- a a w z 0 o. 0 v a 28-0601 ii, F1R5T, ~ ~~~~~ INHERITANCE TAX RETURN RESIDENT DECEDENT 4 (TO BE FILED IN DUPLICATE WITH REGISTER OF WILLS) BAKER, Dorothy L. 207-07-5113 2-8-95 1-30-18 coD~r APPLIGBLE) SURVIVING SPOUSE's NAME (UST, FIRST AND MIDDIE INITIAy SOCIAL SECURITY NUMBER 1. Original Return ^ 2. Supplemental Return ^ 4. limited Estate ^ 4a. Future Interest Compromise (for dates of death after 12-12-82) [~ 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust (Attach copy of Will) (AHach copy of Trust) FOR DATES OF DEATH AFTER 12/31191 CHECK HERE IF A SPOUSAL POVERTY CREDIT IS CLAIMED ^ FILE NUMBER ~~ d ZZC NTY CODE j YEAR ~' NUMBER b344 Concord Road Mechanicsburg PA 17055 E ^ 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 - --. ,~- ,.._,..,...,...,......~,..~,~~~~~R,ont,NLl:~;~s~~€sntvlcmglr NAME Dennis J. Shatto, Esquire lQl~ >i LLD'»BE DIRECTED TO:.;, ~ x +~.- :,,~, .. sc , ... - _ COMPLETE MAILING ADDRESS 31 North Second Street TELEPHONE NUMBER P. O. BOX 11847 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, Bank Deposits 8~ Miscellaneous Personal Property 13.176.49 - (Schedule E) / b. Jointly Owned Property (Schedule F) ~) _-_ 488.91 7. Transfers (Schedule G) (Schedule L) (7) -0- 8. Total Gross Assets (total Lines 1-7) ~3', Y `~{r~ ~„~ (g) 13, 665.40 9. Funeral Expenses, Administrative Costs, Miscellaneous Ex enses (S h d l H (9) ~'ry"~`6~~ ' p c e u e ) 10. Debts, Mortgage Liabilities, Liens (Schedule I) ~ 1 , ~nn_ 7~ 11 Total D d i . e uct ons (total Lines 9 & 10) (11) 8,177.16 12. Net Value of Estate (Line 8 minus Line 11) ~~'7' ''~(p (12) 5,4$$,24 13. Charitable and Governmental Bequests (Schedule J) - - (13) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 15. Spousal Transfers (for dates of death after b-30-94) _ See Instructions for Applicable Percentage on Reverse (15) -0 Side. (Include values from Schedule K or Schedule M ) X __ -0- . 16. Amount of line 14 taxable at b% rate (16) 5,488.24 (Include values from Schedule K or Schedule M.) X .ob . 329.29 17. Amount of Line 14 taxable at 15% rate (17) -Q- (Include values from Schedule K or Schedule M.) X .15 -~- 18. Principal tax due (Add tax from Lines 15, 16 and 17.) (18) 329.29 19. Credits Spousal Poverty Credit Prior Payments Discount Interest 20. If Line 19 is greater than Line 18, enter the difference on Line 20. This is the OVERPAYMENT. a (20) -0- r:~ .. 21. if Line 18 is greater than Line 19, enter the difference on Line 21. This is the TAX DUE. (21) 329.29 A. Enter the interest on the balance due on Line 21A. (21A) -0-. B. Enter the total of line 21 and 21A on Line 21 B. This is the BALANCE DUE. (21 g 329 29 ) . ---- -- - ~r....~~ ws nv8~srsr of ~IIIiF A9eOt Hoer penalties of perjury, I declare that I have exar is true, correct and complete. I declare that all real used on all information of which preparer has any I iNATII OF PERSON RE SON BtEFOR FIL RETURN ~~ _ T`- 31VA R F RE ER AER HA R ESENTATIVE ~ ~~ ~ ~ R ALi<:_QU~T101~S,O1~I,ItEVERSE" IQE AhiD TO~tECHFCK MATH ~~` ~ ~ , ~~~~ <- `~~~ .~ 'hls return, Including accompanYing schedules and statements, and to the best of my knowledge and belief, has been reported at true market value. Declaration of preparer other than the personal representative is dge. 0.E55 DATE r ~L3~~Gc7/~/GO/?,.ri ~,_/~ti /'~'I£C'/~ iG'dP~~~'.~'^, i 705•x" // ~ ~ ~~ RES ~/` ~D ~~' ~~'1 {~J•'j ~~~ ~//-F DATE / ~~~~%~~ ~-,, , 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 eatatea 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 1/1/9E, and before 1/1/97 • 1 °ib (.O1) will be applicable for estates of decedents dying on or after 1 /1 /97 and before 1 /1 /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 ~ ~~ 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 propperty without receiving adequate consideration$ If death occurred after December 12;;1982:;did decedent transfer property within one year of death without receiving ade ubte consideration$ ................................................................................................... 9- . ,~_ 3. Did decedent bwn an 'in trust for'. bank account at his or her death$ ...................................... IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOIt~MUST COI~P.~.ETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ~~,~.. ~- AEV.1508 EX+ (2.87) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS AND MISCELLANEOUS PERSONAL PROPERTY ESTATE OF Please Print or Type Dorothy L. Baker FIE NUMBER (All property jointly owned with the Right of Survivorship must be disclosed on Schedule F) 1995-00220 ITEM NUMBER DE4CRIPTION ~ ~ VALUE AT DATE OF DEATH 1. Annuity -Allstate Life Insurance Company contract no. 90513399 (sin le $ 13,062.39 9 payment of $16,718.41, payable on 9/1/97) -reduced to present value at discount rate of 9.6$ (see Schedule K) 2• Blue Cross -refund of premium 114.10 TOTAL (Also enter on line 5, Recapitulation) $ (Attach odditional 8%z" x 11^ sheets if more space is needed.) REV-1509 EX+ (12-88( Q 1' 1~{-~5~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dorothy L. Baker JOINTLY-OWNED PROPERTY Joint tenant(sj: Lowell T. Baker NAME A• Lowell T. Baker B. C. Jointly-owned property: ITEM LFORR DATE NUMBE JOINT MADE TENANT JOINT ~' A ADDRESS 6344 Concord Road Mechanicsburg PA 17055 DESCRIPTION OF PROPERTY Checking account - Dauphin Deposit Bank, account no.,13-35001-3 RELATIONSHIP TO DECEDENT Son TOTAL VALUE DECD'S DOLLAR VALUE OF OF ASSET % INT. DECEDENT'S INTEREST 50~ $ 488.91 TOTAL (Also enter on line 6 Recapitulation) $ (If more space ~s needed insert additional sheets of same size) . 91 REV-1511 EX+ (7.ggl (,f~ `~s',. ` ~~. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dorothy L. Baker SCHEDULE H FUNERAL EXPENSES, ADMINISTRATIVE CCSS1'S AND MISCELLANEOUS EXPENSES ITEM NUMBER DESCRIPTION ~-• Funeral Expenses: ~, Reinhard Funeral Home 2- Gingrich Memorials (6/9/95) 3• Reverend Michael Martin 4• Stephenson's Flowers B. 1 2 3 4 C. 2. 3. 4. 5. 6. 7. 8. AMOUNT $ 3,993.00. 63.00 40.00 120.31 675.00 2r9®A -6(~" 33 ~~. ~z~ 67.00 18.12 TOTAL (Also enter on line 9, Recapitulation) $ -~6 i 9~~4'3"°""" Please Print or NUMBER 1995-00220 'Administrative Costs: Personal Representative Commissions Social Security Number of Personal Representative: f Year Commissions paid ~ Attorney Fees Cleckner and Fearen Family Exemption Claimant Lowell T. Baker Son Relationship Address of Claimant at decedent's death Street Address 6344 Concord Road City Mechanicsburg State PA 17055 Zip Code Probate Fees 3/20/95 Miscellaneous Expenses: Patriot News -advertising (2/23/95) ~>tt more space is needed, insert additional sheets of same size.) REV•1512 EX+ (1.93( COMMONWEAUN OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Dorothy L. Baker SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES AND LIENS ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Plecse Print or T~ E NUMBER 1995-00220 DESCRIPTION AMOUNT Bell of Pennsylvania (telephone) - payment Mont ome g r'Y Ward - payment 20.47 Hess's - payment 10.00 Sears - payment 10.00 Bon Ton - payment 25.00 Boscov's - payment 25.00 Pealer's - payment 29.00 Sears - credit card balance 37.05 Montgomery Ward - credit card balance 336.84 Bon Ton - credit card balance 23.40 Boscov's - credit card balance 198.57 G.E. Card Services - credit card balance 377.82 Ira Sackman, M.D. - medical expense 30.98 76.60. TOTAL (Also enter on line i0, Recapitulation) $ 1 ~ 2 .73 (If more space is needed, insert additional sheets of same size.) REV.15I'3 EX+ (b87) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES ITEM NUMBER Dorothy L. Baker NAME AND ADDRESS OF BENEFICIARY A. Taxable Bequests: Lowell T. Baker FILE NUMBER 1995-00220 RELATIONSHIP Son ITEM NUMBER NAME AND ADDRESS OF BENEFICIARY B. Charitable and Governmental Bequests: 1. TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation) (If more space is needed, insert additional sheets of same size) S AMOUNT OR SHARE OF ESTATE 100 AMOUNT OR SHARE OF ESTATE REV.ISIa EX+ (b921 r COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE/ANNUITY/ TERM CERTAIN ESTATE OF FILE NUMBER Dorothy L. Baker 1995-00220 This schedule is to be used for all single life, joint or successive life estates and term certain calculations. For dates of death after 12-31-61 and before 5-1-89, actuarial factors for single life calculations can be Found in Revenue Booklet (REV-1501 B). For dates of death on or after 5-1-89 actuarial factors can be found in IRS Publication # 1457 Actuarial Values, Alpha Volume. The instrument creating the life interest is a: (Please attach o copy of instrument) ^ Will ^ Intervivos peed of Trust ^ Other Name(s) of Life Tenants Date of Birth Present Age (Nearest Birthday) Term of Years Life Estate is Payable ^ Life or ^ Term of Years __•_____-__ / ~ ^ Life or ^ Term of Years ~_ / ~~ ^ Life or ^ Term of Years _,______ ^ Life or ^ Term of Years -_ 1. Value of Fund from which Life Estate(s) is payable :......................................................... 2. Actuarial Factor per appropriate Table ............................ Interest Table rate - ~ o o """"""""""••-••••••••••••• ' ^ 3/z /o ^ 6 /o ^ 10% ^ Variable Rate ~-~••~% 3. Value of Life Estate (Line 1 x Line 2) ........................... Name(s) of Annuitantlsl Ierm of Ysars Annuity is Payable U Life or ~J Term of Years ~_'Z/12 U Life or ~..J Term of Years U Life or U Term of Years U Life or IJ Term of Years 1. Value of Fund from which annuity is payable .................... 2. Fre uen of a """""""'•~~ q cY P Yout - ^ Weekly ^ Bi-weekly ^ Monthly ..................... ^ Quarterly ^Scmi-Annually ^ Annually ~ Other single nt 3. Amount of payout per period on 9 1 97 S 16,718.41 ....................................................................................... 16 ~ 718.41 4. .Annual payment ......................... ................................................................................ none 5. Annuity Factor (see instructions) Interest Table rate - ^ 3~/zoib ^ 6°r6 ^ 10% ^ Variable Rate % 9.6$ 6. Adjustment Factor (see instructions) .... 7. Value of Annui ...................................... ......... - If using ................... _ 3%z°r6, b%, 10°i6 or if variable rate and of period, calcu ation is: Line 4 x Line 5 x resent V rtOd P°Yout is at end If using variable rate and .Line 6...P ................a~ 13 062.39 period payout is at beginnin •... u@ ......................""' ~ (line 4 x Line 5 x Line 6)g+ Llnel3~~ calculation is: NOTE: The values of the funds which create the above future interests must be reported as part of the Estate Assets, Line 1 throw h Line 7. The Resulting Life/Annuity Interest(s) should be reported at the appropriate tax rote on Lines 13, 15 and 16 as required. { ~ ~K t ~~ ~u~N'a 7u y.g¢~°N:r~..~gt tt ~~y ."L~,~;~~d's ~I ~S ~L~.. ~~t ~P ~ -.. 1. f ~ qq ,~ c. 7 f rdl~~l L i',t~~~~ F s~ ~„J ~~. - :~ ~~ atwrri~~ }. .. ~. .,. ,, ., LAST WILL AND TESTAMENT OF DOROTHY LOUISE BAKER I, DOROTHY LOUISE BAKER, of West Hanover Township, County of Dauphin and Commonwealth of Pennsylvania, being of sound mind and memory, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking and making void any and all Wills and Codicils thereto hE~retofore made by me. 1. be paid as soon after my decease as may be found convenient. 2. All the rest, residue and remainder of my estate, real and personal, of whatsoever constituted and wheresoever situate, I give, devise and bequeath unto my son, LOWELL T. BAKER, PROVIDED, however, that if my son should fail to survive me for a period of sixty (60) days, then, and in such event, the fore oin 9 g gift, devise, and bequest in favor of my son shall be and become null and void and, in lieu thereof, I do provide as hereinafter set forth. 3. In the event that my son fails to survive my death for a period of sixty (60) days, then I give, devise and bequeath all the rest, residue and remainder of my estate, real and personal, of whatsoever constituted and wheresoever .situate unto DIXIE D. BAKER. I direct that all my just debts and funeral expenses Pa as 1 4. I hereby authorize, empower and direct my Executor to sell and to convert into cash, any or all personalty and real estate, without Order of Court, and without Bond, and for such price or prices as my Executor shall deem appropriate. 5. I hereby nominate, constitute and appoint my son, LOWELL T. BAKER; to be the Executor of this, my Last Will and Testament, and do hereby empower him to service the administration of said estate, without Bond. In the event my said son should be unable or unwilling to qualify and act and continue to act as Executor, then I hereby nominate, constitute and appoint DIXIE D. BAKER, to act in his stead. IN WITNESS WHEREOF, I, DOROTHY LOUISE BAKER, have to this, my Last Will and Testament, hereunto set my hand and seal this ,,~~day of 1 985 . Dorothy outs Ba erg ~~ (SEAL) THIS INSTRUMENT, consisting /f two 2 t bearing the signature ;,f DOROTHY LOUISE BAKER( wasybywherton theedate hereof, SIGNED, SEALED, PUBLISHED and DECLARED by her to be her Last Will and Testament, in our presence, who, at her request and in her presence, and in the presence of each other, we believing her to be of sound and disposing mind and memory, have hereunto subscribed our name's as witnesses ty'~-.' ~ .'~, . it ess Address ~ - ' vl/ ~~~ Witness ddress 7//i - s This contract is issued to Allstate~lnsurance,Company.-(called;"you") as-Downer in consideration of the application, a copy of which is attached,.and your payment of the single premium. This contract and the application are the entire contracts Only our officers may change this contract or waive a right or require- ment. No agent may do this. [ ,~ ~.. Allstate Life Insurance Company (called "we" Qr__'_'us") will pay, the Annuitant or the Owner's designee the Payments shown on Page 3 if the Annuitant is tf~enaiv~ng If the Annuitant is not living, the Payments will be made to the Beneficiary. ~ C ~ 4 1 ~- ~ `' This contract terminates when all Payments have been m~acle. If you are not satisfied with this contract, you may void it by returning it to us or our agent within 10 days after you receive it. We will give you all of your money back. READ YOUR POLICY CAREFULLY. Signed forALLSTATE LIFE INSURANCE COMPANY at our Home Office in Northbrook, Illinois. Secretary LU977 ~ ~~. President Page 1 (1-87) r Allstate Life In surance Comp~~ny A Stock Company -Home Office: Northbrook, Illinois 60062 TABLE OF CONTENTS Page 2 Table of Contents for LU977 .. Entire Contract and Changes ................ 1 General Payment Description ................ 1 Contract Termination ....................... 1 Ten Day Right to Examine Policy ............. 1 Schedule of Payments ...................... 3 Annuitant Information ...................... 3 Date of First Payment ...................... 3 Date of Last Payment ....................... 3 Contract Number ......................... 3 Owner ................................... 3 Issue Date ................................ 3 Beneficiary .............................. 4 Change of Beneficiary ...................... 4 Incontestability ........................... 4 Minimum Payment Compliance .............. 4 Dividends ................................ 4 ~ , SCHEDULE OF PAYMENTS ~__ D A T E____ S?P 1, 1997 --------------A t9UU NT__-------__,_ $ 16718.41 _....~________ N A M E_---------_-- _ SEX-- D A T E - ,~,_ OF BIRTH ~NNUZTANT; DOROTHX L _ FAKER FEMAyE JAN 3~J, 1918 'iRST PAYMENT: $ 16798.41 ON SF 1, 1997 .AST PAYMENT; $ 16718.41 ON SEP 1, 1997 'ONTR.~CT NUMBER: 9QS)3399 OiiNER: ALLSTATE INSURANCE CO SSUE DATE: AUG 24, 1ye7 PAGE 3 POL.T.CY DATA PAGE FC& LU.977 Unless you have changed it, the beneficiary is as named in the application. If no beneficiary is named or is living, the beneficiary is the Annuitant's estate. "Living" shall mean living on the earlier of: 1. The day we receive due proof of the Annuitant's death; or 2. The 15th day past the Annuitant's death. Unless you state otherwise, you may change the beneficiary while the Annuitant is alive. You make a change by writing to us. Once we record the change, it takes effect as of the date you signed the request. Each change is subject to any payment we make or action we take before we accept it. We may not contest this contract after it is issued. This contract is governed by the laws of the State of Illinois. The payments provided by this contract are not less than the minimum values required by the State of Illinois. This contract does not pay dividends. Page 4 -(~ • ~~ ss 9~q s~o 3 1. Annuitant a. Full Name Baker Doroth L. b. Social Security No. 207-07-5113 (PRINT) Last First Middle c. Address 7181 Catherine Drive Harrisbur Dau hip Pa No. and Street Cit 17112 Y County State Zip d. Phone (717 ) 545-066.4 e, girthdate M/D/Y O1 ( )---/~ 18 f. Age 6___9 ___ g• Sex F 2. Owner l~ Allstate Insurance Company a. Name ^ Allstate Indemnit Com an b. Relation to Annuitant Obligor c• Address Allstate Plaza Northbrook IL 60062 d• ( ) No. and Street City State Zip Phone 3. Singfe Premium $1 and other valuable consideration (must be submitted with application) 4. Type of Annuity C~ a. Certain Payments only (Annuitant's survival not required) ^ b. Single Life Annuity (submit proof of age, e.g. birth certificate) ^ c. Joint and Survivor Life Annuity (submit proof of ages, e.g, birth certificates; also submit LR512) 5. Number of Certain payments 1 (Enter "0" if none desired) 6. Payment Information a. rust payment date (M/D/Y) 0~ 01 / 9 7 b. Frequency: ^ Monthly ^ Annually ^ Irregular ®Other 1 luru~ sun payment c. Amount(s) of Payments L~9 i. Level payments of $ 16, 718.41 ^ li. Start payments at $ (percent or amount) • Increase payments iii. Irregular Payments (frequency and duratiorlS). Date Amount Date 1, I Amount Date Amount !. 7. Make payments to L~ Annuitant ^ Other designee (give name, address, relation, etc.) 8. Beneficiary (will be the Annuitant's estate if left blank) a. Primary: Name Estate Relation to Annuitant b. Contingent: Name Relation to Annuitant The Applicant represents that all statements and answers on this Application are true to the best of his or her knowledge and belief and completely recorded herein. / ~~~~rv,.,.,.., Applicant: Allstate Insurance Co by C M AGG 2~~~$7 Signature 1~ ~ LR511-1 ~ik~~~~W SEr~Fa~~r,,. Mo. tSay ~ "'v -. ... `-~vvc ,~ j..~_. 7'~• CJ -/.'I'CJ / ~~~ -. _ -- - _ __ ALLSTATE LIFE INSURANCE COMPANY J ~3 _ 3~ ~ ~ ~ ~~ ~ ~ ~ ~r ~ ~ Application for Single Premium Annuity q~_5~3 ~~R~d ''~~ ~~G 2 41987