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This is to certify that the certificate hereunto attached is a true and accurate copy of the origin~il
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.
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CERTIFlCATE OF DEATH ~ , ~ '
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AEOIafRM'a &ONAURE ANO
DATE FLED 1 wmi, DAr. ~l
Auc i s 2oa7 ?
Date Fran eropoli, ' ect
Division of Vital Records
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REV•1500 EY•+ (7-94) ~ V
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ERITANCE TAX RETURN FOR DATES OF DEATH AFTER 12/31191 CHE H RE
IF A SPOUSAL
. O POVERTY CREDIT IS CLAIMED ^
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~ RESIDENT DECEDENT FILE NUMBER
wEAL OF PENNSYLVANIA
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EPARTME T OF REVENUE (TO BE FILED IN DUPLICATE 21-9561261
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DEPT. 280601 WITH REGISTER OF WILLS
HARRISB RG, PA t7t2e-0601 COUNTY CODE YEAR NUMBER
DECED T'S NAME (LAST, FIRST, ANO MIDDLE INITIAL) DECEDENT'S COMPLETE ADDRESS
e ter Marie M. Cumberland County Nursing Home
~z OCIAL SEC TY NUMBER DATE DEATH DATE OF BIRTH Carlisle, PA 17103
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p (lf A LICABLEI SURVIVING 570USE'S NAME MAST, FIRST D MIDDLE INITIAII SOCIAL SECURITY NUMBER AMOUNT RECEIVED (SEE INSTRUCTIONS)
~ 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return
Yarn (for dates of death prior to 12-13-82)
W ~ v ^ 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required
~ ~ ° (for dates of death after 12-12-82)
Q" ^ b. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes
(Attach copy of Will) (Attach copy of Trust)
:ALL C RESPONDENCE AND CONFIDENTIAL TAX INFORMATIQN SHQULD'8f°.DIRECTED~%
y = NAME COMPLETE MAILING ADDRESS
illiam A. Duncan 1 Irvine Row
va LEPHONE NUMBER Carlisle, PA 17013
1. Real Estate (Schedule A) (1 )
2. Stocks and Bonds (Schedule B) ( 1,406.00
3. Closely Held Stock/Partnership Interest (Schedule C) j 3 )
4. Mortgages and Notes Receivable (Schedule D) (4 )
5. Cash, Bank Deposits & Miscellaneous Personal Property (5 )
_ (Schedule E)
b. Jointly Owned Property (Schedule F) (b )
~ 7. Transfers (Schedule G) (Schedule L) (7 )
a 8. Total Gross Assets (total Lines 1-7) (8) 1, 406.00
9. Funeral Expenses, Administrative Costs, Miscellaneous (~( 4, 309.15
"
Expenses (Schedule H) j
10. Debts, Mortgage Liabilities, Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 $ 10) (11) 4, 309. 15
12. Net Value of Estate (Line 8 minus Line 11) (12) -~2, 903.15)
13. Charitable and Governmental Bequests {Schedule J) (13) _
14. Net Value Subject to Tax (Line 12 minus Line 13) (14) NONE
15. Spousal Transfers (for dates of death after b-30-94)
See Instructions for Applicable Percentage on Reverse (15)
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ues from Schedule K or Schedule M.) ~ -~ Sri
16. Amount of Line 14 taxable at b% rate (16) ~ .t)b =
(Include values from Schedule K or Schedule M.)
17. Amount of line 14 taxable at 15% rate (17) r_
X .15 - _t~
z (Include values from Schedule K or Schedule M.) -_,.,
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a 18. Principal tox due (Add tax from Lines 15, 16 and 17.) (1 $) l
19. Credits Spousal Poverty Credit Prior Payments Discount Interest _ -
cis + + - .~ .(19) _ _~ -- ..
20. If Line 19 is greater than Line 18, enter the difference on Line 20. This is the OVERPAYMENT. `` j2"0) .
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21. If Line 18 is greater than Line 19, enter the difference on Line 21. This is the TAX DUE. (21) _
A. Enter the interest on the balance due on Line 21 A. (21 A)
B. Enter the total of Line 21 and 21A on Line 21B. This is the BALANCE DUE. (21 B)
Make Check Poyable to: Register of Wills, Agent INSOLVENT RETURN
~ ~ BE SURE TO ANSWER ALL QUESTIONS ON REVERSE'SIDE`AND TO'RECHECK MATH ~`
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 elief,
it is true
correct and com
lete
I declare that all real estate has been re
orted
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based on all information of which preparer has any knowledge. preparer ot
er than the personal representative is
SIGN RE Of PERSON RESPO SI L FOR FILING ETURN ADDRESS //"~" // DATEn ~
SIGNATURE OF PRE R O ER T AN REPRESENTATIVE ADDRESS DATE
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~~ REV-1503 EX+ (4-86) ~.
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS AND BONDS
Koester, Marie M.
21-95-261
(All property jointly-owned with Right of Survivorship must be disclosed on Schedule F.)
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
38 shares of McKesson Corp. Common Stock
value at date of death @ $37.00 per share
TOTAL (Also enter on line 2, Recapitulation)
1,406.00
S 1, 4,P16.00
RE~,S„ Ex. 1.881 SCHEDULE H
FUNERAL EXPENSES,
COMMONWEALTH OF PENNSYLVANIA ADMINISTRATIVE COSTS AND
IN RESIDENTEDECEDENTRN MISCELLANEOUS EXPENSES Please Print or Type
ESTATE OF FILE NUMBER
Koester, Marie M. 21-95-261
ITEM
NUMBER DESCRIPTION AMOUNT
A. Funeral Expenses:
~ Hass Funeral Home $2,968.44
2. St. Marys Church 400.00
3. Flowers 185.50
4. Headstone engraving 50.00
5.
B ~'oo~i-Fu}~er~l
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t 246.21
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ms
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ive oa
s:
1. Personal Representative Commissions _ _
Social Security Number of Personal Representative:
Year Commissions paid
2
. Attorney Fees Duncan & Otto, P. C. 325.00
3. Family Exemption
Claimant Relationship
Address of Claimant at decedent's death
Street Address
City State Zip Code
4. Probate Fees Register of Wills 53.00
C. Miscellaneous Expenses:
1. Stock Replacement fee 81.00
(Lost Stock)
2.
3.
4.
5.
6.
7.
8.
i
TOTAL (Also enter on line 9, Recapitulation) ~ S 4, 39.15
(If more space is needed, insert additional sheets of same size.)