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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 16 2001'
? •
Fran eropoli, ct
Division of Vital Records
P.O. Box 1528
New Castle, PA 16103
COMMONWEALTH OF PENNSYLYAlgA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
o3~la~
NAME OF DECEDENTIFmA Mima,Lrq SE% SOCIAL SECURRV NUMBER~~• DATE OF OFXH1Maal. Daµ'!aq
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REGIST 'S SMaNATURE AND NVMBER .
DATE RLEOIMwen. Day'Aarl
REV-tsoo Ex+ 17.9a) x
INHERITANCE TA ETI~RN FOR DATES OF DEATH AFTER 12131/91 CHECK HERE
POVERTY CREDIT IS CLAIMED ^
RESIDENT D DENT
~. FILE NUMBER
GOMMONWEALTHOFPENNSYLVANIA (TO BE FILED IN DUPLICATE
DEPARTMENT OF REVENUE
DEPT. 280601
ARRISB
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WITH REGISTER OF WILLS) 21 95 0302
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, PA 17128-0601 COUNTY CODE YEAR NUMBER
DECEDENT'S NAME (LAST, fIRST, AND MIDDLE INITIAL)
Martin, Jean M. DECEDENT'S COMPLETE ADDRESS
89 Regency Woods - North
W SOCIAL SECURITY NUMBER DATE OF DEATH DATE OF BIRTH C arl i sl'e , PA 17 013
W 223-86-7583 4/8/95 /25/55 c°~~, Cumberland
O IIF APPLICABLEt SURVIVING SPOUSE'S NAM ST, FIRST AND MIDDLE INITIAII CIAL SECURITY NUMBER AMOUNT RECEIVED ISEE INSTRUCTIONS)
~ 1. Ori final Return
9
^ 2. Su lemental Return
pp ^ 3. Remainder Return
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^ 4. Limited Estate (for dates of death prior to 12-13-82)
^ 4a, Future Interest Com romise
p ^ 5. Federal Estate Tax Return Required
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Decedent Died Testate (for dates of death after 12-12-82)
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ALL',CO ~'ii~#p~#EE AND~CONFIDEt~7'#AL`TAX #NFORMq .#~~+t~S OCiLD_BE.Dt.R~GTED TOc _ .•,=~ ~ _
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~o NAME
Debra K. Wallet ,
Esquire COMPLETE MAIUNGADORESS
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~ ~ TELEPHONE NUMBER iZ4 N . 3 2nd
717 737-13Q0 _
Cam Hil t PA~17011;~=~'. ~ f~
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B) (2) ,_.
3. Closely Held Stock/Partnership Interest (Schedule C) (3)
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4. Mortgages and Notes Receivable (Schedule D) (4) /`
5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 2 , 12 8 • 0 0
(Schedule E) -
b. Jointly Owned Property (Schedule F) (b) -
7. Transfers (Schedule G) (Schedule L) (7) J
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 8 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)
(g) 2,128.00
(9) 8,893.00
(10) 3,270•.72
(l t) 12, 163.72
(t2S 10 , 035.72 )
(t3) 100.00
(tal __ 0.0
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.)
1 b. 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.)
19. Credits Spousal Poverty Credit Prior Payments
(15) x. __
(161 x.06= 0.00
(17) .15
(18)
Discount Interest
+ - (19)
20. If Line 19 is greater than line 18, enter the difference on Line 20. This is the OVERPAYMENT. (20)
21. 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.
B. Enter the total of Line 21 and 21A on Line 21B. This is the BALANCE DUE.
Make Check Payable to: Register of Wills, Agent
~ BE'SURE TO'AN5WER ACt f1UFSTIONS ON REYERSE;S#DE AND TO RECHECK MATH ~ ~~'
Under penalties of perjury, 1 deck
it is true, correct and complete. I I
based on all information of which
that 1 have examined
are that all real estat
Iparer has env know)
return, Including accompanying schedules and statements, and to the best of my knowledge and belief,
s been reported at true market value. Declaration of preparer other than the personal representative is
>.
DATE
:Gl// r~- .~ 318 Indian Creek Drive, Mechanicsburg 5i ;5-~9..5
GNATU OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS pA DATE
24 N. 32nd Street. Camp Hill, PA 17011 CI,SI~y
(21) 0.00
(21 A)
(21 B) 0 00
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 decede~s dying on or after 1 /1 /96 and before 1 /1 /97
• 1 % (.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.
YES NO
1. Did decedent make a transfer and:
.......................................................
a. retain the use or income of the property transferred, X
b. retain the right to designate who shall use the property transferred or its income, . .............. X
...................................................................................
c. retain a reversionary interest; or X
.......................................
d. receive the promise for life of either payments, benefits or care$ X
2. If death occurred on or before December 12, 1982, did decedent within two years preceding X
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 X
adequate consideration$ ...................................................................................................
3. Did decedent own an 'in trust for'. bank account at his or her death$ ...................................... X
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
__
_„_
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REV-1508 EX+12.8 SCHEDULE E ~ -
:
CASH, BANK DEPOSITS AND
MISCELLANEOUS
COMMONWEALTH Of PENNSYLVANIA
INHERITANCE TAX RETURN PERSONAL PROPERTY Please Print or Type
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
Jean M. Martin 2.1-95-00302
(All property jointly-ownod with the Right of Survivorship must b~ disclosed on Seh~dul~ Fj
VALUE AT
ITEM - DESCRIPTION DATE OF DEATH
NUMBER -
1. Pennsylvania National Bank
4231 Trindle Road
Camp Hill, PA 17011
Account No. 201-53058 378.00
2. Misc, household furnishings and personal
belongings; bed, chest of drawers, 2 phones,
night stand, black and white TV, plant stand,
bookcase, kitchen table and chairs, ironing board,
coffee table, end table, crockpot, mixer, toaster
and two lamps. 150.00
3. Washer and Dryer - based on actual sale 100.00
4. 1985 Thunderbird - based on actual sale 1,500.00
TOTAL (Also enter on line 5, Recapitulation) $ 2 , 128.00
(Attach additional 8'/z" x 11" sheets if more space is needed.)
REV-1511 EX+ (7-BBI
SCHEDULE H
FUNERAL EXPENSES,
COMMONWEALTH OF PENNSYLVANIA ADMINISTRATIVE COSTS AND
INHERITANCE TAX RETURN
RESIDENT DECEDENT MISCELLANEOUS EXPENSES ~ "
Please Prnt or Type
ESTATE OF FILE NUMBER
Jean M. Martin 27..-95-00302
ITEM
NUMBER DESCRIPTION - AMOUNT
A. Funeral Expenses: -
~ Neill Funeral Home, Inc.
3401 Market Street
Camp Hill, PA 17011 7,595.00
2. Gingrich Memorials
5243 Simpson Ferry Road
Mechanicsburg, PA 17055 915.00
B. Administrative Costs:
1. Personal Representative Commissions _ _
Social Security Number of Personal Representative:
Year Commissions paid
2. Attorney Fees - Debra K . Wallet , Esquire
24 N. 32nd Street
3. Camp Hill, PA 17011
Family Exemption 250.00
Claimant Relationship
Address of Claimant at decedent's death
Street Address
City State Zip Code
4. Probate Fees - Cumberland County Register of Wills
short certif icates, inventory, inheritance tax return
C. and ~amil~ agreement
Miscel aneous xpenses: 103.00
1. postage, notary, copies 25.00
2 Commonwealth of Pennsylvania - transfer•of title to
automobile 5.00
3.
4.
5.
6.
7.
8.
TOTAL (Also enter on line 9, Recapitulation) $
8 3.00
(If more space is needed, insert additional sheets of some size.) ~
R EV.1511 EX+ (7-88~ ~,
~`~ ~ SCHEDULE I
COMMON WEALTH OF PENNSYLVANIA DEBTS OF DECEDENT
INHERITANCE TAX RETURN MORTGAGE L[ABLITIES AND LIENS
RESIDENT DECEDENT Please Print or Type
ESTATE OF FILE NUMBER
Jean M, Martin :~.I 21-95-00302
ITEM
NUMBER DESCRIPTION
AMOUNT
1• Department of Health & Human Services
Social Security Administration
Southeastern Program Service Center
P.O. Box 12263
Birmingham, AL 35282-9687
Account No. 223-86-758300081193
Social Security overpayment 72.40
2. Fingerhut_Corporation
' 310.56
P,O, Box 90
0
St. Cloud, MN 56395-0900
Account NO, 160-0491-623
3. Terminix International
5040 Louise Drive, #108
Mechanicsburg, PA 1.7055
Account NO, 114106-9 63.60
4. TV Cable of Carlisle
P,O. Box 247
Carlislb, PA 17013-0247 .
Account No. 50-05-187274-6 28.95
~. Bell Atlantic
P,O, BOX 28000
Lehigh Valley, PA 18002-8000 90.70
6. Giant Food Store #59
6520 Carlisle Pike
Suite 130
Mechanicsburg, PA 17055
Account No. 23044034 45.00
7. PP&L
Customer Service
P,O. Box 3500
Allentown, PA 18106-0500 1,061.85
Account No. 524 3566864
8. Nancy R, Sheibley, Tax Collector
Middlesex Township
3235 Spring Road
Carlisle, PA 17013
Account No. 21-04-0371-046 I 79.01
TOTAL (Also enter on (ine 10, Recapitulation) I $ 3 2~ 7 2
(If more space is needed, insert additional sheets of same size.)
Schedule I
Jean M, Martin
9. Peerless Credit Services, Inc.
3400 Trindle Road
Camp Hill, PA 17011
Account NO. 8371558
10. University Physicians
P.O. Box 854
Hershey, PA 17033-0854
Account NO. BF6 665554
11. Uptown Cardiology Assoc.
5499 Wm. Flynn Highway #200
Gibsonia, PA 15044
12. Polyclinic Medical Center
2601 NortYi'Third Street
Harrisburg, PA 17110-2098
Account NO. 5007623
Account NO. 5014000
13. Homedco
717 Market Street
Lemoyne, PA 17043
Statement NO. 000-031344
21-95-00302
- 155.00
5.00
35.00
12.00
32.65
1,279,,Q'0
REV~1513 E%+ (287)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF -FILE NUMBER '
Jean M. Martin 21-95-00302
ITEM
NUMBER NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP
_ AMOUNT OR
SHARE OF ESTATE
A. Taxable Bequests:-
1. Mary Foster sister residuary
318 Indian Creek Drive
Mechanicsburg, PA 17055
2. Cathy Wood
40 Spring Valley sister pets
Charles Town, WV 25414
ITEM AMOUNT OR
NUMBER NAME AND ADDRESS OF BENEFICIARY SHARE OF ESTATE
B. Charitable and Governmental Bequests:
1. Humane Society of the Greater Harrisburg Area
Sinclair & Eppley Roads
Mechanicsburg, PA 17055 $100--QO
( No assets expected to pay bequest) /'f~~~~
TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation) I$ 100.00
(If more space is needed, insert odditional sheets of same size)
L A S T W I L L A N D
0 F
T E S T A M E N T
J$ A N M. M ART I N
I, JEAN M. MARTIN, of Carlisle, Cumberland County,
Pennsylvania, being of sound and disposing mind, memory, and
understanding, do hereby make, publish, and declare this to be my
Last Will and Testament and hereby revoke all other Wills and
Codicils that I have made, including the Will dated November 18,
1993.
FIRST: It is my wish, and I direct, that after my death, my
body be cremated and that my ashes be disposed of as my sister,
MARY FOSTER, of Camp Hill, Pennsylvania, may deem suitable.
SECOND: I direct that any automobile that I may own at the
time of my death be sold by my sister, MARY FOSTER, and that the
proceeds be used to pay for funeral expenses, any other expenses
incurred by the Estate, or the bequest listed in paragraph Fourth.
herein.
THIRD: I give and bequeath any pets I may-own at the time
of my death to my sister, CATHY WOOD, of Charlestown, West
Virginia.
FOURTH: I give and bequeath the sum of One Hundred
($100.00) dollars to the HUMANE SOCIETY OF THE BURG AREA,
INC . ~ F~~~
FIFTH: All the rest, residue, and remainder of my Estate,
of whatever nature and wherever situate, I give, devise, and
bequeath to my sister, MARY FOSTER, so long as she shall survive
me by thirty (30) days. Should she fail to survive me by thirty
(30) days, then I give the residue of my Estate to my sister,
LINDA A. ELSTAD, of Herndon, Virginia, so long as she shall
survive me by thirty (30) days. Should she fail to survive me by
thirty (30) days, then I give the residue of my Estate to my
sister, CATHY WOOD, of Charlestown, West Virginia.
I direct that my sister permit the members of my family
(including siblings, parents, nieces and nephews) to take
whatever personal items they would wish to have before the
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remainder of my personal property is sold or otherwise disposed
of .
SIXTH: All interests of any beneficiary in the income or
principal of this Estate, while undistributed and in the
possession of my Executrix, even though vested and distributable,
shall not be subject to attachment, execution or sequestration
for any debt, contract,. obligation or liability of any
beneficiary and, furthermore, shall not be .subject to pledge,
assignment, conveyance, or anticipation.
SEVENTH: All inheritance, estate, and succession taxes
(including interest and any penalties thereon) payable by reason
of my death shall be paid out of and be charged generally against
the principal of my residuary estate without reimbursement from
any person.
EIGHTH: I nominate, constitute, and appoint my sisters,
MARY FOSTER and LINDA A. ELSTAD, as Co-Executrices of this, my
Last Will and Testament. In the event of the renunciation,
death, resignation, or inability of either sister to .act for
whatever reason in this capacity, then I nominate, constitute,
and appoint my other sister as sole Executrix of this, my Last
Will and Testament.
I direct that no representative named above shall be
required to post security for the faithful performance of her
duties in any jurisdiction insofar as I am able by law to relieve
her of such obligation. Any of my representatives shall be
entitled to reasonable compensation for the performance of the
duties set forth here.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
this
~ day of 1t~,~.,~ , 1994, on this, the third of three
typewritten pages. I have also signed the left-hand margin of
the first two of these pages for purposes of identification only.
• ~~
JEAN M. MARTIN
SIGNED, PUBLISHED, and DECLARED by the Testatrix, JEAN M.
MARTIN, as her Last Will and Testament, in the presence of us,
who at her request, in her presence, and in the presence of each
other, have hereunto subscribed our names as witnesses.
~P.~.,e-~,tc. ~..~~. _r
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~~~~
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N~ Cv,.~~ A.Q ~~a7~
A C R N O W L E D G M E N T
Commonwealth of Pennsylvania
County of Cumberland
I, JEAN M. MARTIN, Testatrix, whose name is signed to the
attached instrument, having been duly qualified according to law,
do hereby acknowledge that I signed and executed the instrument
as my Last Will and Testament; that I signed it willingly; and
that I signed it as my free and voluntary act for the purposes
therein expressed.
JEAN M. MARTIN
Sworn or affirmed to and subscribed before me by JEAN M.
MARTIN, the Testatrix, this ~~~'1 day of ~ , 1994.
~~~~ /~J
Notary Publi
Notarial Seal
Kathleen D. Snyder, Notary~~p~
1=ain7ew T
My Commission June 9,1996
A F F I D A V I T
Commonwealth of Pennsylvania
County of Cumberland
We, Debra R. Wallet and ~,.S~l~~ F, Gr04a.1 ,
the witnesses whose names are signed to the attached instrument,
being duly qualified according to law, depose and say that we
were present and saw the Testatrix sign and execute the
instrument as her Last Will and Testament; that JEAN M. MARTIN
executed it as her free and voluntary act for the purposes
therein expressed; that each of us in the hearing and sight of
the Testatrix signed the Will as witnesses; and that, to the best
of our knowledge, the Testatrix was at that time. 18 years of age
or older, of sound mind, and under no constraint or undue
influence.
~:~~ ~
I Sworn or affirmed to and,ts1ubscribed to before me by
~ID~(G ~ Wa ~~P~ and 1 1~15~ti T O~YI
witnesses, this I '
~_ day of ~] t,t IV _,_, 1994 .
• ~ ~~
Notary Publ'
Notarial seal
Kathleen D. Snyder; Nogry Public
FairviewT~p YalcCoun
MY ~m~san F~i~es June 9 1996