HomeMy WebLinkAbout95-0263al gs~va(~3
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.
Auc 1 s r~l
Date
~F~ H105.1~3 HSr. Y/97
TrrERnwT
w
PENMANENT
euaL wK
~ ova
V
-l
Z
w
U
W
O
Z
? •
Fran eropoli, ' ect
Division of Vital Records
P.O. Box 1528
New Castle, PA 16103
COMMONWEALTH OF PENNSYLWINIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
025Q~.1
NAME OF CECEOENTffia. Miede.Lrp 8EJ( SOdK SECI1pTY NUMBER ORE OF OEIPNiMdMh.Oea'~1
+• Florence Fox Female a 113 - 03 - 1627 ~ MA~CLI aid /g
ABE1La BYe.dry) uNOeru, vEM uroEn, ar oiaEacamH BYl7/MLACE IGyaw vucEasoEraHlau µ«+,~a•.-•..M+,~.•nd~..on
Mdrn . Dqe 11oue I MYear IM•M.Celt Ney 9aM nFpren Cgety)
"° aO~ ~~`^ 0°~^ '~ ^ ~...er^ cs~m^
77 Nov 6 17 Brookl n NY
caLwrvocBEaH arr,BOrw.7wravoE~o/, FACLT'NMIE~I~ol.mewm.o~•••e.lrwn.no.q w~g~ECEBErrtaaNreFr~ncanoBn w~cE-~«r~n~ne.n.arar.++l...t
~ Ne ..^.,,..v«r,aur,. 150.caf1
H QlsBct ~PiT~
D
hi
H
i
b
"~'F""°"""'r`
au
n ...
arr
s
ur >
,e.
uwALOCaw~B,oN wwoFSUawESanNOLlsrnn rwoECEBENrEVENw BECEOENraeouciBla+ MAaa~aBBUa-MrMe auNVNwasrousE
w ~ u.1 ANMED FORCFSt Nwr~ R
MII~' 4 R.N.O~'•nrion~rnul
1Y
BM «m
d
~
w
M
~r
nd
n
"^ New
'
~"
Correspo
a
t Pa Hlue Shiel ,_
,,, 1F
a "
,., Widowed ,
o~EBOmsM~a~a~Ba,EUtBt.wa~wro.e.aravcm.~ s ,7
Pa o
,7e
SC1 wae.•.e.~B,w
sr
9 Stailey Circle .
.
~
M
er.aae
Camp Hill, Pa 17011 d ~"
`e.rM„
~~
~
a ~~
~
~
d
~~
FBIIENSNAME (Feel. MieelR Lap M07MER'a1NME F•r. MieOe. M.M.nsarrlw
Charles Hershman ,., Beatrice Koval
MORW W7'aMIIMi[RWM~iO a YALwBABBIFAaIlwlCall4ar49nle. ZpCatlel
Cheryl Glunz 986 Galion Street Harris Pa 17111
METNODOF o~vEOrorerosr710N wrc[oFperarrtbN.N.rac«~r.rlp.n+ur LocvaN.cBWw.e.sw.mue.
cwral^ wnlrrae.ear.^ o.Kw.a >olerrre.
^
o.lw.e^ w.,
_, r a SI'Lli>°fT1aT1StOWn Pa
onrrnewACrBpASaucN
~ NAM[ANOAOONEabas
903 et
t
t
i54-L
as. ~
~~
il
~
~ eraer~ 1.e.raB.,a.rlooe.~.ers»~..ewanev~uasMa. L~sENUMaEn aaEwrEn
r.a
erra.rerne
w
wr,errrMee~
..r B..2BeeraeeepYwe ey
~aon.~epa~W~c«a..11~ w+acwsenEFEmEBroMEQ °'"MwEn'canoNEn'+
°f
~i
~ ~
~'
wJ°
/D; ~
`'1
M, ~; M
N 3D
S
l7.1e1117 F. Erree/A•awa. WialraravrgraMOrrwNCaaweerewl~0e na arwtlr mordNiq.rGraWC nryYrwyanM.NW aMMIW. iAPiWm~Y Mrt-! dlr aonidr
w
~
M~
~
litoiyralr CreMr rdln• lwenieleeleeen nn ra~inlMWryYqu
y
i•n
PNq+
e
n
.r
Br®uTeww«+ ~aer<.ea
d~ v ~
-
_
~«.n>
~
OUE W ICB ASACCNBEOIIENCE CFt
D
BaAt ~q
p1E W1~Nil4A Cp6E0UENCE OF7:
1
GINl
Oi
n
l
reror
ea, ~ e
wr.e acct ouE ro(dl AsACONBEOUENCE OFk ~
n.wlp ~ a.re1 LAST
a
w,aANAU7ovsr v,ENEAUmvarRNOwt4a Mua+EgoFOEaN ORE OFwAJRY 7wEOFwAwv wwmawo,un oESCwBENOwwwwrocdxwEB.
rerr:oneEO7 ~.~BABLErnanro ~Mene,,o,,,,~
~~moNaFCAUSe Nr.r ~y N~ ^
M.
NM ^ N•~ vb ^ N• ^ 9ukMe ^ CwMna OeaeurnWwe ^ RACE Of wJURV-N nonr,Mm~, au•w.4cmr%alllu LOCRION fSYK
.r
:ee. ze. ~ t.,o•u» ~a.
rarer ~t e.MaM - slcewuBE 7u+o 7RLEOF cErt71F~En
'
/
•COrt,e7Bq nmwcuNM~r+•~anu.Mrwmw.darn,wwunon« onyrc~an nraaw.ue e.rn am oon~pera ~ z31
~/{
~
ewen..le.B.....reenrneerrerre.M•1eMewerrreMMe ..................................................... ^ , I~ / i
LICENBE NUIIBEA ave aavrEO ~. oe,: M,..1
'MBMOIwCJMB ANO C[NTIFYBIO MYa1CW/1P~yatir. Eoll. Vawnc'mG a..n an0cw01W.Y b arsd dMeq
Terre.rdr,.ww.~.ee.,e..w«•..,wrw.Bea..a.r.,eevwea..•aae.e.w.~aewNaeamw..«an.e .......................... +w l °s E ra. /NaI¢k 3! /Yq -
INMEANDAOBREBSOFRCR" IriIgCONPIETEDChl13E OFCEQN
•IIEa1C/1L E)<I1IW/RNCOAOIIEA Item 271 Typea Prnl K[cyr.s~j (~ L.l. cf.•s.~ fr Jf
On tlr eeeY of eae,rnrlen anma h,veaayatbn, In my oplnlon, deeM oecwred r the+Mr, dre, ane pace. am dw to,Ae eauee(p ene
rennrre+rW ............................................................ ~.................. ^ iZB~ KJ.i J~ii.i
................
mi
,~ c~.o. /fr ~/ /~ ~ ~vy
REGIaTww'S sIGNATUNE ANDIHIMBER ~ BqE FYED pApiln. psy. `eyrl
v
d
ti
IFt ,
,~ ~~'~~~ 9 501339~~~"" , ~~,
a .'-1500'EX+ (7.94)
; ~ FOR DATES OF DEATN AFTER 12f~1 /'~I~,C~IECK HERE
IFASPOUSAL
' INHERITANCE TAX RETURN '" `
`~
RESIDENT D I
PovERTY cREDir Is cLAIMED
,_
.. ECEDENT FILE NUMBER
CBNMONWEALTH OF PENNSYLVANIA
DEPARTMENT Of REVENUE (TO BE FILED IN DUPLICATE ~ f _ ~~ ~a ~ 3
DEPT. 2806ot
HARRISBURG, PA 17128.0601 WITH REGISTER OF WILLS)
COUNTY CODE YEAR NUMBER
DECEOENT'S NA!^(LAST, FIRST, AND MIDDLE TIAL) DECEDENT'S COMPLETE ADDRESS
LLaq~iu~~ L-ox
W
° SOCIAL SECURITY NUMBER DATE OF DEATH DATE OF BIRTH ~ S~~/L~ G3/j~C,LC:-
y J
~
'
W
v
W 3 /~~ D ' .~ I ~
~rl7~ /~i/~ //
Count G°C /!/s3c~ilLl~N
p (lf APPLICABLEI.SURVIVING SPOUSE'S NAME ILAST, FIRST AND MIODIE INITIALI SOCIAL SECURITY NUMBER AMOUNT RECEIVED (SEE INSTRUCTIONS)
~++
~ ~ 1. Original Return ^ 2. Su lemental Return
pp ^ 3. Remainder Return
x<Y
Wdca
p
^ 4. Limited Estate (for dates of death prior to 12-13.82)
^ 4a. Future Interest Compromise ^ 5. Federal Estate Tox Return Required
=
O
U
m (for dates of death after 12-12-82)
a ®b. Decedent Died Testate ^ 7. Decedent Maintained o Living Trust 1,8. Total Number of Safe Deposit Boxes
(Attach copy of Will) (Attach copy of Trust)
ALL CORRESPONDENCE AND CONFIDENTIAL TAX: INFORMATION SHOtItD BE DfRECTED TO:
y= NAME COMPLETE MAILING ADDRESS
C°.t~ TELEPHONE NUMBER ~'~ G/~L/Ui/ JJJ
z
0
5
f-
a
a
v
s
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages and Notes Receivable (Schedule D)
5. Cash, Bank Deposits 8 Miscellaneous Personal Property
(Schedule E)
b. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G) (Schedule L)
8. Total Gross Assets (total Lines 1-7)
9. funeral Expenses, Administrative Costs, Miscellaneous
Expenses (Schedule H)
10. Debts, Mortgage Liabilities, Liens (Schedule I)
11. 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)
(3) N~/~
(4)
( !I /. G1~
(b) n//da
(7) ~,a1.3
~."
/(9T yi ~ :Y.~ .
~7
z
0
a
F-
a_
f
°
x
a
15. Spousal Transfers (for dates of death after b-30-94)
See Instructions for Applicable Percentage on Reverse
Side. (Include values from Schedule K or Schedule M.)
16. 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.)
_~ L
(1 1) - ~ ~~:7~
(14) ,~~ Iy~J , `~
~'
~% rte
(t 7) ;P 6G (~ . ~ 5" _ _ .' lid • f -
~,
i~ (1B) L~3~ ~JS ~~. -
19. Credits Spousal Poverty Credit Prior Payments Disycount _. Interest ~+~
20
If Line 19 is greater than Line 18, enter the difference on Line 20. This is the OVERPAYMENT
If Line 18 is greater Than Line 19, enter the difference on Line 21. This is the TAX DUE.
A. Enter the interest on the balance due on line 21 A.
6. Enter the total of Line 21 and 21A on Line 218. This is the BALANCE DUE.
Make Check Payable to: Register of Wills, Agent
(20)
/~O'
(21) _ r:1 ~~ 7~
(21 A)
{21 B)
BE SURE.TO. ANSWERALL CtUES~TIfaN~ 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 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 env knowledge.
~ -- _ - y
S F ~ A OTHER ENTATIVE ADDRESS _
DATE
~ ~/ ~ 5
DATE
_~ ~ ~ ~ ~~~
3REV•1302 EX~ 112-85)
SCHEDULE A
REAL ESTATE
(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 Mtween a willing buyer and a willing seller, neither being compelled
~REV•1503 EX+ (4-86)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS AND BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
~~x Fla renee
(All property ioinfly-owned with Right of Survivorship must be disclosed on Schedule F.)
ITEM ~ VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
:~ .
~ 7 5 C ~ ~
r~ ~l~ , 5. ~~ i! i ~~, C~s r3~~ 1~i ~~ a ~-f- a i ~ I ()~
/i ~ L ~ ~ ~~ ~ - $ a-
~
~-
I` _ _
~ ~ ~~~ ~ J ~~
~ ~
~~~~ ~
~~~~ ~~
'.~ ' l~
~ ~ ~~ i ~ (.~~ ~ ~ ~ ~Fj _
l l' ~ ~
~~ O~j
'~`
~~. ~~ ~I 15 ~~~ ~~~ £s~ ~ ia~ ~~ r3~:~~~
I
i 3. ~, ,, i~ I a t~ ~ ~ ~ `i 3~ ~~ ~ ~ ~ 3~ ~ ~ ~
~ ~ { ~ ~~ I~ I ~ (.~ "~. 3~t c~ lc ~
`~1~~ , ,
a ~3.~~
,, ~~ ~ 1
~
(~ I , K ~ (~ y- Q 1 ~ lq r ~ ~ %7 ~1 ~
~~~~ ~
a ~ • (' ( I
~
i, ~.~ C i~~ ~'~~~~u
~s .SGv;~.~s ~~~~ ~J~~' ~3~~73
.
~ot~ ~,~ ~~~~i~~~~~ °
~3.
`~
'~
~ I ~ a3~9 ~% I - (
~~7
3 ~ ~~
ICs=~
~.
I c~~, a~
~~ Ji ~~ L il~g 3RD ~3~ ~. i~~-~~- I'~ 8~ ~~
~~ , ~ ~ i ~ ~ I ~ ~ ~~ c~ ~ ~~~ s~ ~ ~ ~ [ ~~. a~
~~° r- it ,~., l ~~7 34-~-(~.~7 ~~7 ~ i~3, $8
ri ~, ~
,, ~ b a~~ ~~9~~ ~~ ~3 ~7 3. ~~
'~~~
a~.
~, .
-,
~ fa~a~a~r~s3~ I/73 1~3°'-F''~
3~- ,, '~ Liat~~ ~~37~4- ~1~3 i~3.~~~
'' ,, .
LB.~c~r5~~39 al
~~
~~9°~~
~~•
33~ ~' it 1., 1 aa~~~ ~~y9 ~~ , ~~ ) ~~1!~Ca f
TOTAL (Also enter on line 2, Recapitulation) I $ ~ ~ ~~ , ~ 9
JIF ......e ~....~e .....ee.~led .....es ...Lt:~:......1 ..L....a...t ......,........ 1
REV.1503 EX+ (4-86i
'~~~'~` SCHEDULE B
LTH OF PENNSYLVANIA STOCKS AND BONDS
ONCE TAX RETURN
Fax Flarel,e~
(All property jointly-owned with Righf of Survivorship must be disclosed on Schedule F.)
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
3~• hti• bid ~ i;~~av;ns ~anc~ L ~ ~it.>a~'~ ~ j ~~~.~ ~~~,~~
3t~, i ~ 1' ~fo~~~~rC F~l~:~ r~~~'~~
3'~ ' ~ ~ ~ ~--- I fro i ~ ~ ~ ~3 ~ ~7 ~ -~ ~ I~ ~~ I ~
.
~G. )I ~~ ~, 11~0I7a~ir~`? ~'~~a 11~,~t~
~~ '' 1--~3 ~ a ~ ~ t~ ~ i~.~ -~ i i ~ ~- t~ ~
~83~ i~ ~ ~i~ i i-~~,~8
~, ~ I t r , L ~ .~ ~' ~~ ~ ~ 7 ~ ~ ~~ i ~~ j • of U
I ~~ ~ , ~ L~
iy1L`
~y
1
t
-- _
it 1, ~.. ~aj1) ) 5 ~ ~~~ jl) 7i 1 ~1 ~ ~ C~
-.y
~
,
~ ,, ~~ ~ ~~ ~~at~ 7 ~~ ~ ~ ~, I e~~, q c~
'
"~~
~~
f i i l
1, ~ l~ ~~ 5FS ~~i~~ ~) ~~ 1~3,'~$
~~, i l '~ L iby-t~~13 913 l~~~i3 ~~1 ~`~~-
`~
~ ,, rl LfD~~aB-~'~~3~ i~~~ l~t~~~
~~ ` ,, ~ j v~ ~ ~a 3uc~g ~ (7 ~ I ~ 3i~~
• 1• ' ~ ~--- f U i`v'y ~ ~ r 9 ~
~ 3~
~ ~
14 ~
~
'
~
1~~ ti L f ~ l.o'~ ~ CJ ~tp'~71
7 ~'' p
~
~
' ~ ~ r TU
L i i L- t ~ ~ a. a el ~ t"J~ ~ 1
t i .J) i
rr _ 'y
ti 1 i u~14~ (~~, lC+ c~~ ~ ~~~~ ~~;, ,~ ~ ~
l ~ • ~ ~
~:.~~t it i' a ~~a~~~~~~ ~~~~~ 7~,t~5
TOTAL (Also enter on line 2, Recapitulation) $ ~,
(If more space is needed, insert additional sheep of same size.l A
EIEyLa03 EX+.IA-86)
` SCHEDULE B
COMMONWEAITH_OF_PENNSYWANIA STOCKS AND BONDS
ESTATE OF
Fix
F lor~e~ FILE NUMBER
(All property ) ointlyawned with Rtght of Survivorship must be disclosed on Schedule F.)
ITEM
NUMBER DESCRIPTION VAIUE AT DATE
OF DEATH
do ~ ~ ~ • 1~.~ ~.% U ~ ° ~~ ~~~ ~!~'1Lt ~:~ ~ ~ ti ~~ 0 { ~ ~ ~ `7 (,y '~vi ~ ~' ~
I i i ~ ~~ ~ ~s'T l~'
~ t~ ~J ~ ~ ~ '7 "~ ~T ~ ~i
l.i~~ 11 '
(t ~~ ~~~~ 1~~~~ ~~~~~
!;~~~9 ~ C~.~
w
(~
1 rI _
~.~' 1, 1 I)
~ ~ U 1 V r ~ ~ ~"'~l
1 ~ .'7 ~
~~~'1
f
f
{ ~ ~.j i~ ~~ ~~~~~1 I~~~
I 1 J ~~~ .~~ ~~~i'a~~
L4 1
_~~ 1j 1i ~ ~ ~~~ y~ ~ ~ l (~ ~~ ~ ~ ~ r~ ~ ~ , ~.~
~,r
~.~ ~~ i~ ~~ i ~~ ~ 3 ~ ~~ 3~t ~ j ~ ~ ~ 33. ~~ ~
~13 1 ~ 1, ~, ~ ~ ~: ~ ~~ ~~~ ~ ~ ~ ~ ~ ~ 3t~~ r c~,
~~~
I~
'~ K ~a~~75 (~ ~
~I~~
~ 3~~~~ 3
11 1, K ~ ~~ ~~~ ~ ~-~ ~"~~
~~.
I; ~i ~`'3~io~,a~~,
I~
-~ ~j~~
o~3~s~°~
~ ~ ~ 3 ~ uLx~~,1 ~) ~ c- a~~: ~~
~~. .~ ~~ u ~u~ ~u~ ~ ~ ~~ ~~ ~~~~~~
~
(1 1~ a~3~u~~oa
° ~~~~ :~~~,
,,
~ ,, ; ~~ac~3~iu~(~~3
~ ~~
t ~~
aa~
~ ~
o
~~. ~
~
.{t K ~Q3~~~~~ i
r4 "1~-t ~ ~. ~~~~
l
~ 9 +. t a
~ ~L~c~~
~~~
~
;
~ 1, ~,
>
r
1~ ~ ~~~~h3~)~ -~
11
~r-~ ~ ~~3-W
a~~,~3
~~., ~ I ,~ ~ ~ c~~~~~ 3c~~ ~ -~~ a~t,~,
TOTAL (Also enter on line 2, Recapitulation) S ~ " ,
i~~ _-.,, .......e :..,<oa..rl. insor! addilionnl sheets of same size) ~ , ~
- •NEV--1508 EX+-i2-87)
SCHEDULE E
CASH, BANK DEPOSITS AND
4lTH OF PENNSYLVANIA MISCELLANEOUS
1NCE TAX RETURN PERSONAL PROPERTY
TENT DECEDENT
Please Print or
~~iHi~ car FILE NUMBER
~D~C ~' LUG NAG
(All properly jointly-owned with the Right of Survivorship mu:f b~ diselos~d on Seh~dul~ F)
REKISII E%+ Q•B81 SCHEDULE H
FUNERAL EXPENSES,
COMMONWEALTH OF PENNSYLVANIA ADMINISTRATIVE COSTS AND
INHERITANCE TAX RETURN
RESIDENT DECEDENT MISCELLANEOUS EXPENSES Please Print or Type
ESTATE OF FILE NUMBER
~ F~~ ~N~ -
ITEM
NUMBER DESCRIPTION
AMOUNT
A. Funeral Expenses: ~rD
,. y ~a3.
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 o~L~
C. Miscellaneous Expenses:
i . ~~mo,~i~L 9~ ~~
2. ~jL Gv~Q~N y Tr eS `r°
~~
3. ~~ ~ ~ s7-~'~~ ~~~L ~ q. ~ o
4' ~itsr~GG '~ ~?~Sy
s. ~~o~~ ~~~N~ y~~~ , `T~
~. C ~f c. L ,/~ ~wry1.,~ i ~y 'f~
s.
TOTAL (Also enter on line 9, Recapitulation) $ 5' ~-' ~ ~
ilt more space is needed, insert additional sheets of same size.)
a
SCHEDULE J
COMMONWEALTH Of PENNSYLVANIA BENEFICIARIES
INNERRAtICE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
..r-~
~bx ~La,~~~~
ITEM
NUMBER NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR
SHARE OF ESTATE
A. Taxable Bequests:
~ .
.o:y-a.~~~ ,cir~f~-X ~ a'/ FoR~ST Sr t~~=~,/ s,n~- N j/
c~v c..r ~ A! p`C>
z, ~-~,,.
R/pA1 TirA~Lb~ 37.7+ 1'GP/~ksitiu~.<H) GT ~it7Snia~c7tt (//1
G/~19N4sCtFJ ~»
~~Olr~"
~a~,rykc~r~i 1/A
ehe T~n~C~ ~'7o~'sl ~'+'/~~rcuu:,d c;T
CoQ~q-nJA S rr~ c ~
'~ ~~ ° try
L'~~KC~'S T 6Ccsu ~- 9 d'b ~µtlaa .ar f~gr.¢lJQct~ ~i4 ~.~jQ~A~4 o c~ ~/ ~"J~lJ'Oa• r~+
7.`~=i=~+An/n/CCunti~~6 GA>L~a~v ~?'/~.~~.~~rva~~ ~ 6,¢n,vatza¢u~~"~r <~,v~-o•
j'~~ C~[aoA1 sr /~flr~'ila~'`ty ~.~
/ j'GL.u,~1 c
licz.na ~PpnrgraN <~Uvo
~
g
p
,q ~'!?. ~~ urv2 / ~~ 6'A~e~r -~!" %~~~ ~ ,i2aM'~ .ca~f ~; D40 •
~L~ 3!>~/'sal.~~~cyo CT~Ga~v_er~r'~
uO~r~J E~7~
~tlG~s~7'~X- ~~~
e
~ .~
ITEM NAME AND ADDRESS OF BENEFICIARY AMOUNT OR
NUMBER SHARE OF ESTATE
B. Charitable and Governmental Bequests:
1.
~_.
:s~
TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation) $
(If more apace is needy, insert additional sheets of same size)
.>.,
Y
. C'U~g~7C~Y--NO
~_ .~ Register of Wills of ~ County, Pennsylvania
INVENTORY
Estate of _ /~LD.f? <'.,,[~-s' !'=07( No. ~ f ~.v~ G o {~G ~
also known as Date of Death 3 / ~U ~9S
Deceased Social Security No. l/3 D,3 j~o?~~
Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all
of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that
the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and
that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum
at the end of this inventory. I/We verify that the statements made in this Inventory are true and correct. I/We understand that
false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn felaification to
authorities.
Personal Representative:
Name of
Attorney: /1/~ _ rf'/~~7g1~G ~ (oL1.li~Z
I.D. No.: //,~p /~ /~
Address: 7 d ~ ~/~L./Q~tJ ~S'1~" Dated
f"~i~+ef l~clff ~ ~R / '/r~
Telephone: ~~'l' ~'(oC~ ~rf7T
/1t~i';7r! ~ Description Value 4~
S 17~Tc.~
~a~s ~y,~ ~~~
t~c~xS~~n L ~ ~ ~:
3''
Total: ~~ ~? Sif 3.
(Attach Additional Sheets if necessary]
NOTE: The Memorandum of reeal estate outside the Commonwealth of Pennsylvania inay, at the election of the personal representative, include
the value of each item, bu[ such figures should not be extended into the tote) of the Inventory.
RW-8