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Home My WebLink About95-0331a~~QS p33 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. AUG 1 ~ 2001 Date \~ H105.1~3 AOY.?157 7YPEIPIYIT w varuNOrr nnac rtlc yl ~ 2 _ ! ~ Fran eropoli, ct Division of Vital Records P.O. Box 1528 New Castle, PA 16103 COMMONWEALTH OF PENNSYLWNIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH ~;25~3% NAMEDP DECEOEI(r MWAa,trl) Female saocjt~ Inlrv rKllwl2EEA _6347 a°~larc~i '; l.w.n Rutll K C~rlt AtiE(WIBWdOy) uwEa,rEAn unom,aa aaEOPeINrn elrtnstACEtce,w xnceoFDEaHlcr.a~«+rw-s..r,ruaa,.rnalr.wn M«Olr D•Y• N«00 I MtrM F_.,AIaDO.D~tMrI 9a1.«F«~pnCw1Y) PA In001In0 ^ EWdOptlwO ^ DM ^ ,~ ^ ~ ~M ^ 86 Harrkbuy . rn, 1909 COIMI'/OF DEAR CRY, t101q,7WPOF OEia'N FACR(i'I NAMEpna1t01eNm. pY•tYrland raanta~ ~~Y01, tP00W Clem. RACE-A•Ixlrl M010•. Btaac Ylh10, 01c. St t ~'~ ree „~,,,P,,,,,a„,~,~„~ iite Cumberland Mt. Holy Springs 24 Chestnut I N, to DCCUPIQIDN KIND DF Bl~NE85ANDUSYMY wAS DECEDEIIi EVEAW DE(~OO/i'SEIXICRIDN MAIIPl8WU5•MOnNtl BUIriNI/Ki tiP0U8E DEL~B/T'7! _ y~~yy~~0 U.A Al101ED Nn~MOnl0d, wlaa••4 O+awgM mYdn~ , 11 1t. it t to DECEDOrt'B AIAl11O ADDIESSl3trsa1. C0y/6wt 51W,$Ca7y OECEDENf'8 Ih aw. dd 170.^N0. MOadMt1r01n Irp 24 L•IIEi~'11J<S~ RE&DEItCE OOrllrt Mt HDNy SPA, PA ay Cumberland "•'+ ~ N•.arMlntOrd Mt HDHy Sprkgs to ,,r, , .Mrflrbrrnw nry~°nnard e ~e `~'e g Y~~un~ia~"ret9`pef.M:a.,E«~a t i~ ~ WORIMNT'B MAItMD AD0RE~1~rlCM~19w.7+D~~N 11 C. {,ItlfR 1322 Gsorpeb~Mn Ckis CrlMis PA 17013 psvoertaN P ~OFD6PDSrt1DN.NrraCmMar,tCrmaYay LOC/JKNI•COy/fOwn. &MO, apCOa uE7laoaP DAE ~ ^ n.rw0amsr^ ^ Mt. Holly Sprk~s Cenlelxy AIL HDNy Sgrkgs, PA 17086 Maroh 10, 1995 oar0an^ onwAr»''~M 0. ~a oFaK~EgA~ ~DnvEr+eoN~cn~aASaua+ ~~n NAMEANOADOnEesocw~cam nc. o! X11589-L SOt N. Beltl~7are Aw., ML HDIy~Sprk)gE, PA 17085 Kwr49a•eAywMn tlrbattamy Maowro•.e.rnoo~wnarn»u«..er..nep.c..Ir.a. ucENSENUMeEn DAEEKrrED NI,~IIlrrrl•..relarrraarh raT~Op Ma+1,,D•Kltrt) aawalearK. - 10UIICED DEADM«N.Dy. 16ar) MNB CASE REFERREDIO MEDICAL / P0 t/-150MM0«•OIaI•dbY OF DERH P r«ia0rrdaltl4 aAO ^ N C$ ~ 1 ~ p a t- •AicS's ~ .qv5 x w. $:a5 M ~. . . n. MllOt En1a11M4A0aK W«Ir «aalgkaUOiN wNah un0Ah E0MK.Dona«rrlMnneaaeyYp, rchrura0e«rrptOb,anaM,aMOt«MrI NF00. lAppmiYnM PAIIT O! OUOraIVY0or0 anAbr Meeu«gb A0001 ba WI«OYan ryra an ra,Or. ItYrv0llrwOm MnMdYg NIM UnOwIYYq qOr OMnIn POJIT I. anMand00Mh N~IRT[CMMEIFaai i ti+.~.t t~e~F l,s~~>N. (-~~p~l'--7~. ,aa„r,ohd.Ih,~ •. DIIE 7D IOR AS A COHSE W ENCE OFx EpumllMrMmdWar e ~ m7, 1003gbY0nrAM0 DUE ID (OA ASACONSEOUENCE aF): i OOMM.ENOrIEO6aYMD Di i ~ t A[ ,vy c .M ( a~aa w taYMaA arr DUElO(OR ASACONSEOUENCE OFk I ~JipF 6A,)LAlT Q W119AN AUTOPSY WEI0E AU70PSY FINDNGS MANNEgOF D&RN DAE OF ULKIRI' TIME OFINJUNV N'UURYAWORK7 DESCPoSE )10Mf INJUIIY OCCUWIED. IN9VONMED7 gMI15tE P1110Mro M«th.Dry.W«) ~~'~ Nm.01 (~ NomkWa ^ oP NO ^ N• ^ AcadMK ^ PanNnptn•a00~1b• ^ M. `M ^ NO \Ya ^ No ^ S•tMa ^ Cab na MOp«mFwE ^ PUCE OF INJUYh'•Athan0. Mm.tbaM, ha«%olea I.OCAlON 151ae.CN«.MM) tddnQ atc. ISP•~M >d 10. 10a. 101. f81TIflE11a0/aay SIONAIXiE AND~ffIE OFCE_R~F.It~ • •CU-i7010 P/IYltICIAN(Physian ar0lyiprJUesda.r,rAien en00iar phyYCOn nrpanurcetl aael, OnOampetee Kam 23) / [/ / ~~ y'J ,. ~ - / ~-~~ 'Q'.~ '_''~' ToKw Matel•M I01••OarY•.Aaa•+aalrrryl Ono tetM ruap)a•0 nnm,rrr MMW ..................................................... f r `~'~ `_ C~ 7i f ' ~ F ~ ~ ~ l 1ta (~ .D•/.~) ~ •Pnollaw,wtDAInCFNfi7rN0'IIYSICWI(PhyumbahV~«aura.gtlea0isnaaaOYyvipbaaraCaWh) Math o0a0rn0 atYrtMa Aal• aM an/ aw bKN uwfgrM «wwrarW Ta Wa Mat«• b~•nMA 0 M• 3 .g(` 10. l~'~1 ~9~~~L 1 ,• .......................... , . ry . 0 P . NNAE ANDADDRE980F PERSON WINO COMPIE'fED CAUSE OF OFAN •M EDI w ~ IlMmznr7w«PrIM ~ L(:'3i~'1'L l~•.....or... ~ orlI~.I•rr•a~,e..ul«ew,.a.tn»u•I..an...laa•o..mea»wKrnw•(Nme r~ w ~Mrl.,..1.c.a .............................................................................:.................... ^ 1,0. Lz~ v.ls.,... 1T 4.1.,1. ~4 nab m. REOISIAM'89KiNAURE DATE FllEDIM«M. DaY•Ya•rl ~. ~ C ~ >•. ~, ~~ / ~~ REV - 1.`90 EX t (7-94) ,~}.~~`~ 1~COMDEPAREALT ,,~` ~ HARfiISB~~ D E C E D E N T ~.~01251 ~ (~ ~ X~ N INHERITANCt= 7AX Ft~'I'URN RESIDENT DECEDENT (TO BE FILED IN DUPLICATE 'ENT's NAME (LAST, FIRST, AND MIDDLE INITIAL) r'.k Ruth K ECURITYNUMBER DATE DEATH DATE OF BIRTH -12-6347 /07/1995 02/03/1909 DEATH AFTER 12/31/91 CHECK HERE FILE NUMBER 21-95-0331 OF WILLS) ~ COUNTYCODE YEAR DECEDENT'S COMPLETE ADDRESS 24 Chestnut Street Mt. Holly Springs, PA 17065 F APPLICABLE) SURVIVING SPOUSE'S NAME (LA$T,FIRST AND MIDDLE INITIAL) ry Cumberland SOCIAL SECURITY NUMBER AMOUNT RECEIVED (SEE INSTRUCTIONS) ~ 1. Original Return 2. Supplemental Return 3. Remainder Return C P B far dates of death nor to 12-13-82) H 4. Limked Estate 4a. Future Interest Compromise P CRC (for dates of death after 12-12-82) Federal Estate Tax Return Required K P S 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes (Attach copy of Will) (Attach a copy of Trust) C p ALL C RESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: R N NA COMPLETE MAILING ADDRESS HUGHES R D o er B. Irwin & IRWIN, McKNIGH S N TELEPHONE NUMBER 60 West Pomfret~5tr eet ~° - - T 717-249-2353 rlisle PA 17013 1. Real Estate (Schedule A) 89 , 000.00 (Schedule B) 15 , 248.00 d d B k S s on toc s an 2. 3. Closely Held Stock/Partnership Interest (Schedule C) (3) None 4. Mortgages and Notes Receivable (Schedule D) (4) None R 5. Cash, Bank Deposits & Miscellaneous Personal Property (Sch. E) 149 , 385.56 E A 6. Jointly Owned Property (Schedule F) 312 , 693.66 p 7. Transfers (Schedule G) (Schedule L) (7) None _ I T 8. Total Gross Assets (total Lines 1-7) (8) 566 , 327.22 ~ 9. Funeral Expenses, Administrative Costs, Miscellaneous 38 , 956.28 A Expenses (Schedule H) T I 10. Debts, Mortgage Liabilities, Liens (Schedule I) (1 3 , 798.09 N 11. Total Deductions (total Lines 9 8 10) {11) 42 , 754.37 12. Net Value of Estate (Line 8 minus Line 11) (12) 523 , 572.85 13. Charitable and Governmental Bequests (Schedule J) 5 , 500.00 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 518 , 072.85 15. Spousal Transfers (far 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.) ~/~p~f,~~8~ ~ 30 90¢-_.37 I 16. Amount of Line 14 taxable at 6% rate (jf+~ 5]~$~D~-.$5 3 .37 .06 =/ (Include values from Schedule K or Schedule M.) ~ ~ A 17. Amount of Line 14 taxable at 15% rate ~ 3 , 000.00 .15 =,~ 450.00 X (Include values from Schedule K or Schedule M.) ~i/~ f;,3~ C 18. Principal tax due (Add tax from Line 15, 16 and 17.) {18) 31 7 ~ M 19. Credits/Sp Poverty Prior Payments Discount Interest P 0.00 + 25 , 000.00 + 1, 315.79 - 0.00 (19) 26 , 315.79 U T 20. If Line 19 is greater than Line 18, enter the difference on Line 20. This is the OVERPAYMENT. (20) 0 .00 A T ~ ~ Check here if ou are regtaestin :a refund of:youc overjaiayment. ~ 21. If Line 18 is greater than Line 19, enter the difference on Line 21. This is the TAX DUE. {21) 5 , 218.58 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 Z1 B. This is the BALANCE DUE. (218) 5 , 218.58 Make Check Pa able to: R inter of Wills, A ent - - BE SURE TO ANSWER ALL QUESTIONS ON PAGE 2 AND TO RECHECK MATH ~ ~ Under penalties of perjury, I declare that I have examined this return, Including aecamparrying schedules and statements, and to tha 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 knowledge. SIGN, E OF PERSON RESPONSIBLE FOR FI ING RETURN Russell E. Clark DATE 'A~~ 1322 Geor etown Circle ~ ~' ~%? Carlisle, PA 17013 T SI AT RE OF PREPARER OTHER THAN REPRESENTATIVE. IRWIN , McKNIGHT & HUGHES DATE :f` ~ ~~_ ~ 60 West Pomfret Street Carlisle, PA 17013 f' 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: •3X (.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,Qr after 1/1/96 and before 1/1197 •1% (.01) will be applicable for estates of decedents dying on or after 111/97 and before 1/1198 •Spousal transfers occurring on or after 1/1/98 will be exempt from inheritance tax. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING A MARK (X) 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 Iffe of either payments, benefits 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? .. X 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 RET URN. Copyright (c) 1994 form software only CPSVStems, Inc. ' ~ ~ REV - 1502 EX + 02.85) COMIN~~yyl~~xCjlf~~~LVANIA SCHEDULE A II~~~~SSf~~~ N REAL ESTATE ESTATE OF FILE NUMBER Ruth K. Clark SS~~ 167-12-6347 03/0.7/1995 21-95-0331 (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 aeller, neither being compelled to a REV - 1503 EX + (4-86) COMINQIF~F $.yjyAN1A I SCHEDULE B ~~"Ib'~~ r~T+~N STOCKS AND BO ESTATE OF FILE NUMBER 21-95-0331 Ruth K. Clark SS~~ 167-12-6347 03/07/1995 V i aev -lsoe a + (2-a7) COMINO~IESIDEN~ECE~ENT NANIA OF SCHEDUhE E CASH, BANK dEPd$175 AND MISCELLANEOUS Ruth K. Clark SS~~ 167-12-6347 03/07/1995 II property ointly-owned with Ri ht of Survivorship must be disclosed on Schedule ITEM DESCRIPTION Please Farmers Trust Company, Certificate of Deposit ~~79820 (confirmation attached) 2 AARP GNMA and U.S. Treasury 14.74 Fund, account ~~00505700849-0 (confirmation attached) 3 1986 Buick sold 07/28/95 to Samuel & Florence Armolt Coin collection appraised by arry E. Donson (appraisal attached) ~~ Dauphin Deposit Bank & Trust Company, Certificate of Deposit ~~8000081784 '~ (confirmation attached) 6 Beneficial interest received ~ '~~~~~ from the Estate of Esther ~ f` y ~ a ~'~ ~ " ' Fisher - LfJ ~ ',m,E `j '~j~ Farmers Trust Company, Certificate of Deposit ~~77604 (confirmation '~' attached) ~~ Farmers Trust Company, I L savings account ~~6010311 `~ (confirmation attached) Miscellaneous rings/bracelets/costume jewelry appraised by Harry Donson of Carlisle Coin Shop Miscellaneous personal property, household goods sold by Rowe Auction Services 08/02/95 (see continuation schedule attached) Total of Continuation Schedule(s) TOTAL (Also enter on line (Attacn aatlrtlonal 8 1/Z"' x 11 sneers rc more space Is needed.) Copyright (c) 1994 form software only CPSystems, inc. FILE NUMBER 21-95-0331 VALUE AT DATE OF DEATH 10,034.25 27,781.32 3,000.00 260.97 20,151.89 6,b85.27 15,098.63 2,994.36 350.00 4,901.50 58,127.37 `~ _~ 149 .56 Form 1500 Schedule E (Rev.2-87) Estate of: Ruth K. Clark SS~~ 167-12-6347 03/07/1995 CONTINUATION SCHEDULE Continuation of'Schedule E ITEM DESCRIPTION VALUE AT DATE ~~ OF DEATH 11 Cash on hand 86, 77 Phoenix High Yield Fund 7 422.58 ,~y ~~693906634 confirmation ~ attached) PNC Bank, N.A., Certificate 15,256.97 7 of Deposit ~~1713160014383 (confirmation attached) 1/~~ ~-'1 PNC Bank, N.A., Certificate 20,322..22 of Deposit ~~1713160072410 (confirmation attached) vY~ PNC Bank, N.A., Certificate 10,038.83 of Deposit ~~1713160101395 '~ (confirmation attached) 16 1992 Pontiac sold 10/11/95 5,000.00 to Russell E. Clark 58 .37 REV - 1509 EX + (12-86) COMINq~rc~r~.s,~t~ANIA SCHEDULE F ~Ibb~~l5~~ -7 JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER Ruth K. Clark SS~~ 167-12-6347 03/07/1995 21-95-0331 Joint tenant(s): NAME ADDRESS RELATIONSHIP TO DECEDENT A. Russell E. Clark 1322 Georgetown Circle son Carlisle, PA 17013 B. Nancy A. Lippert 86 Purple Martin Drive (daughter Murrells Inlet, SC 29576 C. Jointly-owned property: ITEM NUMBER LETTER FOR JOINT TENANT DATE JOINT DESCRIPTION OF PROPERTY TOTAL YALUE OF ASSET D 'S °k INT. DOLLAR VALUE OF ECEDENT INTEREST 1 A 06/1992 96 shares, Financial Trust 11,088.0 50.OOY° 5,544.00 orp., common stock at 28.00/share 2 B 06/1992 396 shares, Financial Trust 11,088.00 50.00% 5,544.00 Corp., common stock at $28.00/share „r~ B 09/1990 Farmers Trust Company, ~ 10,014.59 50.OOY 5,007.30 Cer ate of Deposit ' ~~~ X9193 confirmation ~~ /vs t h d ~ a tac e ) ,, ~~ B 07/1994 Farmers Trust Company, 3,514.57 100.00y 514.57 Certificate of Deposit 107201 confirmation j/ 9v~ ~ ($3000 annual exclusion taken) B 12/1994 Farmers Trust Company, 25,320.55 100.00Y< 25,320.55 Certificate of Deposit X107542' onfirmation a tached) 9/~/tea U® ,~&~ A 07/1994 Farmers Trust Company, '~°~~,514.57 100.00y 514.57 Certificate of Deposit 07202 onfirmation attac e ) 9.~-/moo °7 ~i ~r~ (see contn sched attached) `" Total of Contn Schedule(s) TOTAL (Also enter on line 6, Recapitulatior (If more space is needed, insert additional sheets of same Copyright (c)1994 form software only CPSystems. Inc. 270,248.67 31 3.66 Form 1500 Schedule F (Rev. 12-88) Estate of: Ruth K. Clark SS~~ 167-12-6347 03/07/1995 CONTINUATION SCHEDULE Continuation of Schedule F LETTER ITEM FOR DATE ~~ JOINT MADE DESCRIPTION OF PPTY TOTAL VAL DECD'S VALUE AT DATE TENANT JOINT OF ASSET % INT OF DEATH ~f7~ A 12/1994 8 A 11/199 A 04/1994 A 04/1963 A 07/1976 y( ~.2~ A 03/1989 ~~ B 09/1990 A 04/1994 ~~.~ B 05/1994] ($3000 annual exclusion taken) ~~~ ~`~~ \, Orrstown Bank, Certificate 25,382.19 100.00Yo li 25,382.19 of Deposit ~~006-050381-C '~ (confirmation attached) !~ PNC Financial Trust Corp., 175,081.50 ~ 50.00% 87,540.75 7128 shares common stock at 24.5625/share PNC Bank, N.A., Certificate 50,284.93 100.00% 0,284.93 of Deposit ~~1713200174297 (confirmation attached) PNC Bank, N.A., checking 43,535.10 50.00% 1,767.55 account ~~5140182435 (confirmation attached) PNC Bank, N.A., savin s 15,294.38 ~ 50.00% .7,647.19 account ~p5130318052 ~ ~ (confirmation attached) PNC Bank, N.A., Certificate 50,886.99 50.00% 5,443.50 of Deposit ~~1713160109167 ~' ~ (confirmation attached) / PNC Bank, N.A., Certificate 14,026.97 50.00% 7,013.49 ~/ of Deposit ~~1713160136698 E (confirmation attached) PNC Bank, N.A., Certificate 20,130.79 100.00% X20,130.79 ~ of Deposit ~p1713200174827 (confirmation attached) ~ PNC Bank, N.A., Certificate 25,038.28 100.00% 25,038.28 of Deposit ~~1713200178726 (confirmation attached) 270,_ .67 REV - 1511 EX « (7-88) COM IN~~[;yt,r~;f! PE,j9,y~~LVANIA SCHEDULE H FUNERAL EXPENSES, ADMINISTRATIVE COSTS AND MISCELLANEOUS EXPENSES ESTATE OF FILE NUMBER 21-95-0331 Ruth K. Clark SS~~ 167-12-6347 03 07 1995 ITEM NUMBER DESCRIPTION AMOUNT A. Funeral Expenses: 1 Gibson-Hollinger Funeral 7,222.00 Home B. Administrative Costs: 1. Personal Representative Commissions Social Security Number of Personal Representative: 165-26-6307 Year Commissions paid waived 2 Attorney Fees 3. Family Exemption Claimant none Relationship Address of Claimant at decedent's death Street Address City State 4. Probate Fees C. Miscellaneous Expenses: 1 Steven W. Barrett Real Estate, appraisal fee 2 Cumberland Law Journal, estate notice publication 3 Harry E. Donson, coin appraisal 4 Graham Motor Company, Inc., repairs to Buick 5 Legg Mason Wood Walker, Inc., valuation fee Zip Code (see continuation schedule attached) Total of Continuation Schedule(s) TOTAL (Also enter on line 9. Recaoitulationl (If more space is needed, insert additional sheets of same Copyright (c) 1994 form software only CPSystems, Inc. 0.00 28,000.00 7 0.00 485.00 250.00 `~ 40.00 5.00 7 246.30 60.00 2,647.98 S 38, .28 Form 1500 Schedule H (Rev. 7-88) Estate of: Ruth K. Clark SS~~ 167-12-6347 03/07/1995 CONTINUATION SCHEDULE Continuation of Schedule H-C ITEM DESCRIPTION AMOUNT ~~ 6 Notary Public fees 24.00 7 Patricia A. Rosendale, CPA, 100.00 fiduciary income tax preparation 8 Patricia A. Rosendale, CPA, 600.00 706 tax return preparation 9 Rochelle Clark, organization 500.00 of decedent's property for public sale 10 Register of Wills, filing 25.00 fee 11 Register of Wills, short. 9.00 certificates 12 Rowe Auction fee 1,049.50 13 The Sentinel - estate notice 65.48 publication 14 Spahr's Antiques, appraisal 175.00 fee 15 Patricia A. Rosendale CPA, 100.00 preparation of Federal and State 1994 tax returns 2, .98 REV - 1512 EX + (1-93) SCHEDULEI COMMONWEALTHOFPENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN RESIDENT DECEDENT MORTGAGE LIABILITIES ANO ESTATE OF Ruth K. Clark SS~~ 167-12-6347 03/07/1995 ITEM NUMBER DESCRIPTION 1 Carlisle Hospital, patient ~~8583916 balance due 2 Carlisle Hospital, patient ~~8238883 balance due 3 Herman & Shenk Inc., account ~p11920 4 Carlisle Hospital, patient ~~8722092 balance due 5 Carlisle Imaging Associates, balance due account ~~579738 - 00 6 State Farm Fire Insurance Company, renewal of decedent's homeowners policy ~~3849-0052-2 7 Internal Revenue Service, 1994 taxes due 8 Masland Associates, Inc., patient ~~167126347A balance due 9 Metropolitan Edison Co., customer ~~644312714111 10 Borough of Mt. Holly Springs, water/sewer/trash, acct. ~~00003085 11 PNC Bank, medical insurance coverage thu d/o/d 12 Mark E. Pinker, DPM, FACFS, patient balance due 13 RWC Emergency Physicians, account ~~8583916 balance due (see continuation schedule attached) Total of Continuation Schedule(s) TOTAL (Also enter on line 10. Re iir more space Is needed, insert additional sheets of same size.) Copyright (c)1994 form software only CPSystems, Inc. Pleaae Print of Tv~e FILE NUMBER 21-95-0331 AMOUNT 27.70 13.20 414.95 9.40 1.98 28.40 1,875.00 20.11 304.39 294.85 80.65 8.65 16.70 702.11 7 s 3,7 .09 Form 1500 Schedule I (Rev. 1-93) Estate of: Ruth K. Clark SS~p 167-12-6347 03/07/1995 CONTINUATION SCHEDULE Continuation of Schedule I ITEM DESCRIPTION ,~0~ ~~ 14 Commonwealth of 609.00 Pennsylvania, 1994 taxes due 15 TV Cable of Carlisle, amount 8.50 due on subscriber ~~500200974113 16 United of PA, 717-486-3966 84.61 (282) 70 1 REV ~ 1513 EX + (2-87) COMINt~I,jtLQ~~~~~LV/WIA SCHEDULE J ~~"I~~b'~'S~~ n7 1J BENEFICIARIE ESTATE OF Ruth K. Clark SSdb 167-12-647 n3 /n7 /1A95 FILE NUMBER 21-95-0331 ITEM NUMBER NAME AND ADDRESS OF BENEFICIARY RELATIONSHIP AMOUNT OR SHARE OF ESTATE A. Taxable Bequests: y ` /~ Christopher M. Lippert ~ grandson 2,000.00 4020 S. Inca Street Englewood, CO 80110 Timothy R. Lippert ''l grandson ~ 2,000.00 4902 S. Garland Street Littleton, CO 80123 Lisa Ann Lippert ~ granddaught 2,000.00 4020 S. Inca Street Englewood, CO 80110 Carol Butler friend 1,500.00 5708 Linglestown Road Harrisburg, PA 17112 / f~! Betty Thompson neice / 1,500.00 430 Camp In Florida Daven ort, FL 33837 continuation attached . ITEM NUMBER NAME AND ADDRESS OF BENEFICIARY B. Charitable and Governmental Bequests: Evangelical Lutheran Church 602 McLand Dr., Mt. Holly Springs, PA 17065 Harrisburg Forest Tall Cedars of Lebanon ~~43 400 Roswood Lane, Harrisburg, PA 17111 Zembo Temple AAONMS 2801 North Third Street, Harrisburg, PA 17110 Cumberland Star Lodge ~~197 F&AM 25 Burnt House Road, Carlisle, PA 17013 Harrisburg Consistory Building AASR P.O. Box 2423, Harrisburg, PA 17105-2423 ,~ .. ~, ., i TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on ling fir more space Is needed, Insert additional sheets of same size.) Copyright (c)1994 form software only CPSystems, Irie. N `~ AMOUNT OR SHARE OF ESTATE 1,500.00 1,000.00 1,000.00 1,000.00 ~ 1,000.00 _ S 5,5 .00 Form 1500 Schad e ~ (Rev. 2-87) CONTINUATION -SCHEDULE J BENEFICIARIES Estate of Ruth K. Clark SS#167-12-6347 --- d/o/d - 03/07/95 File #21-95-0331 --- # ---------------------------------------------------- Name & Address ------------------------------ Relationslvp -------------------------- Share Nancy Ann Lippert daughter 40% remainder 86 Purple Martin Drive Munells Inlet, SC 29576 Russell E. Clark son 60% remainder 1322 Georgetown Circle Carlisle, PA 17013 ~! Gregory A. Clark grandson $2,000.00 P.O. Box 723 Woodbine, NJ 08270 / (~ ~` Russell E. Clark, Jr. grandson $2,000.00 `~ 203 Oakland Avenue Pleasantville, NJ 08232 Sherwood A. Clark grandson $2,000.00 `~ 51 Mountain Road, Lot 9 Mt. Holly Springs, PA 17065 *The bequest of stock to the grandchildren lapsed because the stock was held jointly with Russell E. Clark and Nancy Ann Lippert and therefore passed directly to them upon the death of Ruth K Clark. .. :, . ~r~x~~ x~~ ~~ ~ .e~~~x~t.~:~ I, RUTH K. CLARK, of the Borough of Mount Holly Springs, Cumberland County, Pennsylvania, do make and publish this as and for my last will and testament, hereby revoking any and all wills heretofore made by me. 1. I direct my executors to pay all of my debts, funeral and administrative expenses as soon as may be done conveniently after my decease. 2. I authorize and empower my executors to sell any realty owned by me at my death, and not specifically devised herein, at either public or private sale, and to give good and sufficient deeds therefor, in fee simple, as I could do if living. 3. I devise and bequeath all of my estate of every nature and wherever situate as follows: ~ ~ ~" The surn of $1,500.00 to Carol Butler, ~~ The sum of $1,500.00 to the "Memory Fund" of the Evangelical Lutheran~urch of Mount Holly Springs, for Ruth K. and Russell Clark, (c) 2,700 shares of CCNB Bank, N.A. stock to the three children of Nancy Ann Lippert, share and share alike, but Nancy Ann Lippert is to receive all dividends on said stock during her lifetime, (d) 2,700 shares of CCNB Bank, N.A. stock to the three children of Russell E. Clark, share and share alik e, but Russell E. Clark is to receive all dividends on said stock during his lifetime, (e) 270 shares of Farmers Trust Company stock to the three children of Nancy Ann Lippert, share and share alike, but Nancy Ann Lippert is to receive all dividends on said stock during her 1 ifetime, (f) 270 shares of Farmers Trust Company stock to the three children of Russell E. Clark, share and share alike, but Russell E. Clark is to receive all dividends on said stock during his 1 ifetime, ~ $2,000.00 to my grandson, Gregory A. C1~, ~' $2,000.O~to my grandson, Russell E. Clark, Jr., $2,000.00 to my grandson, Sherwood A. C~rk, ~(.j~' $2,000.00 to my grandson, Christopher M. ippert, ,(~k~ $2,000.O~o my grandson, Timothy R. ~ppert, ~~ $2,000.bO to my granddaughter, Lisa Ann Lippert, $1,500.00 of my niece, Betty Thompson, ~j' $1,000 0~0 to Harrisburg Forest all Cedars of Lebanon, in memory of my husband, Russell Clark, ~ ~ ~~ $1,000.00 to Zembo Temple AAONMS, in memory of my husband, Russell Clark, ,(.~-)' $1,000.00 to Cumberland Star Lodge No. 197, F. & A. M., in memory of my husband, Russell Clark, ~ ~ S,~ $1,000.00 to Harrisburg Consistory Building, in memory of my husband, Russell Clark, (r) 40% of aTl the rest, residue and remainder to my daughter, Nancy Ann Lippert and 50% of all the rest, residue and remainder to my son, Russell~Clark, share and share alike, the child or children of any deceased child taking the share their parent would have taken if living. 4. I nominate and appoint Nancy Ann Lippert and Russell E. Clark, to be the executors of this my last will and testament; they are to serve as such without bond. 5. I hereby suggest that my personal representatives retain the services of Irwin, Irwin & McKnight, as attorneys in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this Lt'=` day of June, 1992. Siyned, sealed, above named testatri the presence of us, the presence of each hereto. ~1 ~..~~~ C=~~x.~~~ ( SEAL ) '" RUTH K. CLARK published and declared by Ruth K. Clark, the x, as and for her last will and testament, in who, at her request, in her presence and in other have subscribed our names as witnesses ACKNOWLEDGEMENT AND AFFIDAVIT WE, RUTH K. CLARK, BETZI A. MORRISON and KATHLEEN M. KENNEY, the testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last 4Ji11 and that she had signed willingly, and that she executed it as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the Will as a witness and that to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. COMMON WEALTH OF PENNSYLVANIA . ss: COUNTY OF CUMBERLAND Subscribed, sworn to and acknowledged before me by RUTH K. CLARK, testatrix, and subscribed and sworn to before me by BETZI A. MORRISON and KATHLEEN M. KENNEY, witnesses, this LLB day of June, 1992. %' ~ ~~- ~N F 117Awa~ ~~Y rvRe+ V . .a. w~Y t~Mwneei0k DtP1A~s ocr. ~, tsoa .. r ~, _ _ ~ _ 1, ~.-r~ ,.E _ RUTH K. CLA K 1 REV-1547 EX AFP (12-95) COMMONWEALTH OF PENNSYLVANIA ACN 1 0 1 DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX BUREAU OF INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE DEPT. 2<,0601 OF DEDUCTIONS AND ASSESSMENT OF TAX DATE 03-25-96 ':ARRISBURG, PA 17128-0601 -r-rrr ESTATE OF C K U K FILE N0. ci y~-u~al DATE OF DEATH 03-07-95 COUNTY CUMBERLAND NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS FORM WITH YOUR TAX PAYMENT TO THE REGISTER OF WILLS. MAKE CHECK PAYABLE TO ''REGISTER OF WILLS, AGENT•• REMIT PAYMENT TO: ROGER B IRWIN REGISTER OF WILLS IRWIN ETAL CUMBERLAND CO COURT HOUSE 60 W POMFRET ST CARLISLE, PA 17013 CARLISLE PA 17013 Amount Remitted CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS t ---------------------------------------------------------------------------------------------------------------- REV-1547 EX AFP (12-95) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF CLARK RUTH K FILE N0. 21.95-0331 ACN 101 DATE 03-25-96 TAX RETURN WAS: ( ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Sonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property t5ehedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule Il 11. Total Deductions 12. Nat Value of Tax Return 13. Charitable/Governmental Bequests (Schedule J) 14. Net Value of Estate Subject to Tax (11 89. 000.00 (2) 15, 248.00 (3) .00 t4) .00 (5) 149, 385.56 (6) 312, 693.66 (7) .00 (8) 566,327.22 (9) 38,956.28 clo) 3.798.09 (11) 42.754.37 (12) 523,572.85 (13) 5,500.00 (14) 518,072.85 NOTE: If an assessment was issued previously, lines 14, 15 andior 16, 17 and 18 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: . 00 X .00= .00 15. Amount of Lins 14 at Spousal rata (15) 16. Amount of Line 14 taxable at Lineal/Class A rata (16) 515, 072.85 X . O6. 30, 904.37 17. Amount of Lina 14 taxabl• at Collateral/Class B rata t17) 3, 000.00 X . 15~ 450.00 18. Principal Tax Due (lg) 31 , 354.37 TAY f DCIITTC! PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST (-) 06-07-95 AA047848 1,315.79 25,000.00 12-06-95 AA082378 .00 5,218.58 TOTAL TAX CREDIT 31,534.37 BALANCE OF TAX DUE 180.000R INTEREST .00 TOTAL DUE 180.000R * IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN 51, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A ''CREDIT'' (CR), YOU MAY BE DUE r ems.,<~oEx,6-aa, INHERITANCE TAX '' r COMMONWEALTH OF PENNSYLVANIA EXPLANATION DEPARTMENT OF REVENUE OF CHANGES BUREAU OF INDIVIDUAL TAXES !1E ~T. 2i~i~ 1 HARRISBURG, PA 1 7 1 2 8-060 1 DECEDENT'S NAME FILE NUMBER ACN 1+t SCHEDULE INO. EXPLANATION OF CHANGES ,zF~ vzalue ~sx the estate 'r,as oee:Y <idjustc~3. as th.c, re~!zlt u.f. file correcr.rz7 cif an error .in _3ritll;aetic_. 1~ TAX EXAMINER: `?'~teila ~e~;:~rznPll _ PAGE