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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 1 +6 200T
r? •
Fran eropoli, ' ect
Division of Vital Records
P.O. Box 1528
New Castle, PA 16103
COMMONWEALTH OF PENNSYLIMNIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
X25904
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NAME OF DEDEpp(, ~Fyd MiOSa, Laap SEx soaA~sECUlm NUdeEn DREDFDERNddad,. D.v.'Arn
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REV- 1500EX; n-94) '
INHERITANCE TAX RETURN FOR DATES OF DEATH AFTER 12131!91 CHECK HERE
P
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OVERTY CREDITISCLAIMED I
I
RESIDENT DECEDENT FILE NUMBER
coMlulpNyyEALTH OF P~jJNSY,41/ANIA
DEPART
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F R
tVENUuEt (TO BE FILED IN DUPLICATE 21
95 - 0262
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HARRISBURG, P A7128-0601
WITH REGISTER OF WILLS .
COUNTY CODE YEAR NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) DECEDENT'S COMPLETE ADDRESS
E EVELHOCH,''r'LOYD M. 338 G Street
C SOCIAL SECURITY NUMBER DATE OF DEATH DATE OF BIRTH Carlisle , PA 17013
p 174-05-0749 03/19/95 09/06/13
E
N County Cumberland
T (IF APPLICABLE) SURVIVING SPOUSE' AME (LAST,FIRST AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER AMOUNT RECEIVED (SEE INSTRUCTIONS)
A B X 1. Original Return 2. Supplemental Return 3. Remainder Return
E P OL 4. Limited Estate 4a. Future Interest Compromise (for dates of death prior to 12-13-82
R C
(
QX 6
D
d (for dates of death after 12-12-82) ~ 5. Federal Estate Tax Return Required
P S .
ece
ent Died Testate ~ 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach copy of Will) (Attach a copy of Trust)
ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
R N NAME COMPLETE MAILING ADDRESS
E E Edward E. Guido, Es Saidis, Guido
Shuff & Masland
S N TELEPHONE NUMBER ,
26 West High Stz~$t :x
T 717 243-6222 Carl e PA 17633
r. neap cs~aie tacneaule Af (1) / 65, 095.87
2. Stocks and Bonds (Schedule B) ~- -
3. Closely Held Stock/Partnership Interest (Schedule C) (3}
4. Mortgages and Notes Receivable (Schedule D) (4) -
E 5. Cash, Bank Deposits & Miscellaneous Personal Property {Sch. E) ~, 119 , 480.3 9
C
A 6. Jointly Owned Property (Schedule F) (8)
p 7. Transfers (Schedule G) (Schedule L) (7) '- ---
T 8. Total Gross Assets (total Lines 1-7) ~,~--- (8)
~ 184
576.26
U
L 9. Funeral Expenses, Administrative Costs, Miscellaneous (~}--''~ 13 ,193.56
" _
,
T e/
Expenses (Schedule H) ~,.--'
I 10. Debts, Mortgage Liabilities, Liens (Schedule I) (10 811.55
O
N 11. Total Deductions (total Lines 9 8, 10) (11) 14, 005.11
~
12. Net Value of Estate (Line 8 minus Line 11)
(12) 170, 571.15
13. Charitable and Governmental Bequests (Schedule J) ~\ (13)
14. Net Value Subject to Tax (Line 12 minus Line 13) {14) 170, 571.15
15. Spousal Transfers (for dates of death after 6-30-94)
See Instructions for Applicable Percentage on page 2. (15) 0. 00 X = 0
00
(Include values from Schedule K or Schedule M.) .
~
16. Amount of Line 14 taxable at 6% rate ~°'~~~
(16) 170,571.15 - 10,234.27
(Include values from Schedule K or Schedule M.)
T
A 17. Amount of Line 14 taxable at 15% rate
(17) 0.00 X
.15 = 0
00
X (Include values from Schedule K or Schedule M.) .
CO 18. Principal tax due (Add tax from Line 15, 16 and 17.) (18) 10 , 234.27
M 19. Credits/Sp Poverty Prior Payments Discount Interest
P
u + 7,500.00 + 394.74
- (19) 7
894.74
A Z0. If Line 19 is greater than Line 18, enter the difference on Line 20. This is the OVERPAYMENT. ,
(20) 0
00
T ~ ® Check here if yyou are requestin a refund o. your ove tnent: .
1
O 21. If Line 18 is greater than Line 19, enter the difference on Line 21. This is the TAX DUE. (21) 2
339.53
N A. Enter the interest on the balance due on Line 21A. ,
(21A) 0
00
B. Enter the total of Line 21 and 21A on Line 216. This is the BALANCE DUE. .
(21B) 2 , 339.53
Make Check Pa able to: R ister of Wills, A ant
- - BE SURE TO ANSWER ALL QUESTIONS ON PAGE 2 AND TO RECHECK MATH ~ ~
Under penalties of perjury, I declare t at I have exam ned this return, Including accomparrying schedu es and statements, and to the best of my knowledge and belief, it is 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 based on all Information of
which preparer has any knowled
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.
SIGNAT URE OF PERSON RESPONSIBLE FOR FILING RETURN Emerson Evelhoch
-,r, ~ ^ ~ 1004 Pheasant__ Drive North
,~ r / ---
~. r: ~,~ ~1,;'~./1 ~`'/~~;.% Carlisle, PA 17013 ------------------
~ / /
-------- DATE
~ jo
aiunAluHEOF~FS~F ARER~THERTHANREPRESENTATIVE Saidis GUldO Shuff & M 1 d
Copyright (c) 1994 form software
, as an
26 West Hi~h_Street-
---------- ----------------------------
Carlisle, PA 17013
~.r ov~wms. inc.
DATE
rfa (of ~.)
Fnrm~ IRPV 7_q4~
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 111/97 and before 1/1/98
•Spousal transfers occurring on or after 1/1/98 will be exempt from inheritance tax.
PLEASE ANSWER THE FOLLOWING 4UESTIONS
BY PLACING A MARK (~ 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 property transferred or its income, X
c. retain a reversionary interest; or . .
d. receive the promise for life of either payments, benefks 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.
REV - 1502 EX + (12-85) '
COMINRES~DENTD7ECEDENT NANIA
SCHEDULE A
~~~ Ferm 1500 Schedule A fRev. 12-851
ESTATE OF FILE NUMBER
FLOYD M. EVELHOCH SS~~ 174-OS-0749 03/19/95 2195 0262
(Property jointly-owned with Right of Survivorship must be disclosed on Schedule F) All real estate should be reported at fair market value
which is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to
f
REV - 1508 EX + (2-a7) SCHEDULE E
CASH, BANK DEPOSITS AND
COM IKO~{N REA+LTFiIbTF PENNSy_LN ANIA MISCELLANEOUS
R~•sIb/Et+NtF ,1~fj„F.~Jll,li
Nr
c~.cu
PERSONAL PROPERTY Please Print or T e
ESTATE OF
FILE NUMBER
FLOYD M. EVELHOCH SS~~ 174-OS-0749 03/19/95 2195-0262
(All property 'ointly-owned with Ri ht of Survivorship must be disclosed on Schedule F}
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
1 AARP refund 149.50
2 Farmers Trust Money Market Account ~~ 3-97433 5,339.86
3 Farmers Trust Checking Account ~~ 4-11590 1,556.29
4 Farmers Trust Certificate of Deposit 103451 84 138.18
5 Farmers Trust Certificate of Deposit 107811 11 747.27
6 Farmers Trust Certificate of Deposit 109719 12,964.60
7 Newsweek - refund
8
Patriot-News Co. - refund 70.18
9
Agway Petroleum - refund 18.00
220
07
10 27" Zenith TV .
11
Roto-Tiller 250.00
12
Box Spring and Mattress 200.00
13
Harleysville Insurance - refund 10.00
30
00
14 Agway - refund .
15
Dishes 76.44
16
19085 Chevrolet Celebrity 10.00
17
Miscellaneous Personal Property 1,200.00
1,500.00
TOTAL (Also enter on line 5
~naacn aaamonal t3 U1 x 77~~ sheets if more space is needed.)
Copyright (c) 1994 form software only CPSystems, Inc.
_~S 19,480.39
Form 1500 Schedule E (Rev. 2-87)
REV - 7571 EX ± (7-88) ~ SCHEDULE H
FUNERAL EXPENSES,
COMMONWEALTH OF PENNSYLVANIA ADMINISTRATIVE COSTS AND
IN~~s~b'~"~r~bTi`:°~~~'iR" MISCELLANEOUS EXPENSES Please Print or T e
ESTATE OF FILE NUMBER
2195-0262
FLOYD M. EVELHOCH SS~~ 174-05-0749 03 19 95
ITEM
NUMBER DESCRIPTION AMOUNT
A. Funeral Expenses:
1 Hoffman-Roth Funeral Home 4,933.00
2 St. Paul's Lutheran Church - alter flowers 15.00
B: Administrative Costs:
1. Personal Representative Commissions
Social Security Number of Personal Representative:
Year Commissions paid
2. Attorney Fees Saidis, Guido, Shuff & Masland
3. ~ Family Exemption
Claimant
Address of Claimant at decedent's death
Street Address
City
4. Probate Fees Register of Wills
State Zip Code
255.00
C• Miscellaneous Expenses:
1 The Sentinel - legal ads
2 Patriot-News Co. - legal ads
3 Register of Wills - filing fees
4 Reserved for future debts and expenses
TOTAL (Also enter on line 9, Recapitulation)
(If more space is needed, insert additional sheets of same
Coovriahtld l9gd s,,..,,~s'..,~.e ,,..h, cpC..~fo,..e i,,,-
Relationship
7,500.00
75.56
40.00
25.00
350.00
IS ;-' 13,193.56
Cw•n+ ~snn C~I.di„la W /Rs., 7_AA1
REV - 7512 EX a (1-93)
SCHEDULEI
COM INHERITANCE T~ RETURN ANIA DEBTS OF DECEDENT,
RESIDENT DECEDENT MORTGAGE LIABILITIES AND LIENS Please Print of T e
ESTATE OF
FILE NUMBER
2195-0262
FLOYD M. EVELHOCH SS~~ 174-05-0749 03/19/95
ITEM
NUMBER
DESCRIPTION
AMOUNT
1 George's Flowers 163.24
2 Harleysville Insurance
3
United of PA 72.00
4
Borough of Carlisle 33.19
5
United of PA 18.94
6
Borough of Carlisle 56.84
7
PP&L 11.82
8
Borough of Carlisle 59.00
9
Agway 11.82
10
Agway 75.74
11
Borough of Carlisle 76.44
12
PP&L 11.82
13
United of PA 21.16
14
Shevlin's Maintenance Service 13.35
121
90
15 PP&L .
16
United of PA 27 84
17
United of PA 23 27
13.18
TOTAL (Also enter on line 10, Recapitulation) ; 811 .55
(If more space is needed, insert addkional sheets of same size.)
(:nnvrinht lrl tooe s....,, ..-c....___ --.. nec.....-~_ '"
_. _ _ _. _
REV - 1513 EX + (2-87)
COM IN RES~~ENT DTFECEDErNT N ANIA
SCHEDULE)
~ENEFICIAFIIE
~ 1ATE OF
FLOYD M. EVEI.HOCH SS~~ 174-05-0749 03 19 95
ITEM
NUMBER NAME AND ADDRESS OF BENEFICIARY
A. Taxable Bequests:
1 F. Emerson Evelhoch
1004 Pheasant Drive North
Carlisle, PA 17013
2195-0262
RELATIONSHIP AMOUNT OR
SHARE OF ESTATE
Son ~ 1009; of residue
- •-- ----•- -r~--~ ~~ ~~a~..cu, mxn aaaicrona~ sneeze OT SarY1e 52e.)
~ttst mill ttn~ ~rstttmpnt
I, FLOYD M. EVELHOCH, of the Borough of Cailisle,
Cumberland County, Pennsylvania, declare this to be my last will and
testament and revoke all wills which I have previously made.
I - I give, devise and bequeath my entire estate, real
and personal, unto my wife, Louise P. Evelhoch, absolutely and in
fee simple if she shall survive me.
II - If my wife, Louise P. Evelhoch, fails to survive
me, I give, devise and bequeath my entire estate, real and personal,
unto my issue per stirpes, absolutely and in fee simple.
III - If neither my wife nor any issue shall survive
me, I direct my executor to convert into cash and sell at either publ
or private sale all real and personal property which forms a part
of my estate, and to add the proceeds thereof to my residuary estate
which I give and bequeath one-half thereof to my next of kin and one-
half thereof to my wife's next of kin as determined ~by the Intestate
Laws of Pennsylvania in effect at the time of my decease.
IV - I appoint my wife, Louise P. Evel]och, as executri:
of this will. If for any reason she shall fail to qualify or cease
to act as such during the administration of my estate I appoint my
son, F. Emerson Evelhoch, as substituted executor; i.f for any reason
lie shall fail to qualify or cease to act as such during the adminis-
tration of my estate, I appoint Farmers Trust Company as aiternate
°xecutor.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
.his 2 9~ day of Q.~~-P,.~ 1976.
(SEAL
signed, sealed, published and declared
~y Floyd M. Evelhoch, testator above named,
is and for his last will and testament, '~
Britten on one sheet of paper, in our
presence, who, in his presence, at his
•equest, and in the presence of each
ether have hereunto subscribed our names
s attesting witnesses:
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