HomeMy WebLinkAbout95-0337This 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 16 200
Date
;•~
H105.T43 Rev.2/87
nPEmaNT
M
PEnEUUiEirr
auac ERc
a
L
L
L
d
~--
~I
z
w
D
O
2
! ~
Fran eropoli, ' ect
Division of Vital Records
P.O. Box 1528
New Castle, PA 16103
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
X36864
NAME OF DECEDENT(Frel, Miada.Lw)
,. Pearl Eva, Darr SEX $OCUIL SECURITY NUMBER DATE OF DEATH pAaM. Day,Yw)
yr'emale ,. 201 - 16 - 3197 .. April 2 1
AfiE Sad Be3Way) U/IDEAIYEAR UNDERTDA' DRE OF BMTTH BWTIIPl/1CE (C'M arH PLACE OF DEQNIGrckarey one-ervWUdion on oar aiae)
,~~ I D•Y• „or,r, ~~ (MOrlr, DaY.Wr) 9nlear FaelOn Crurry)
10a Adams County
D
c HDBPRAL OTHER:
,,p,„r„~q ER,D,,,,~„^ DM^ Homes. ^ Rniaera ^ ~In)^
1
00
94 Y" ~
COUNTY OF OE/2T1 CTIY, BOIq,TWPOF DEATH FACWTY NAME (tl nd hatlLean, pivs atrwaM reAnbrl - wwgpECEDEHr oP H18MNIC oRIOIN4 RACE-Am.ncen bd.n. a.ac wM[...oc.
~ .
YYa ^ E yaR •p DYOubr.
No Bul
it
-
l
.
e
Cumberland Carlisle Carlisle Hospital MwglLp„rtlaRk~n~eb. Wh
M. eo. as ~. 10.
DECEDENT'S UBUALOCCUPATX)N gNDOF EpISNJE3311NO1/STRY WAS DECEDENT EVER 81 DECEDENT'S EDUCRION MARIPLSWUS•MrrIM SURVMND 6POUSE
.aq AIw3e. piva maiden rome>
Nrw Mrr4d
WId
o
ARMED FDRDESa
us
~
H
~
.
bnaawr^Lam. mor
CCa0N3ep~~
dwrahew.OOnaurriretl.) Vr^ No~ ~ (Id IX$~)
D v
ed
-
,
orc
Housework ,,,, Own Home ,t , . g ,~
. ,~
DECEDENT'S MAILMXi ADOHESS(Seeet City/Town, 51W.ZIpCcae) ~UCED~ENT'9 TT. st.n ennsy vanla ~ ~ North IYliddleton
na. ~.., e.nera 3wd ~~ Mp.
801 North Hanover atreet ~,,, ~°;"
,~arlisle3Pennsylvania 170 .aN 10. Cumberland brwwlltp7 Na.aeoadrah+d
na.^ wlWn aenrilhar
I
iNTIFA'S NAME (Fir[, Ardde. John Jones
a1 dOT1ER'S NAME(Frd, ~•a'roT~ir1C) -
'
,..
WFORMANT'B NAME (TYIAVPdr'q ~
~'~~'~"~t
'
eet
'C
Donald E. Jones 1VOY
Ln
r
~
arlisle, Penns ivania
MErnoooFOlsPasDl~
^ ~ a
e ~~,.,~~DlsroBRaN-wr»ac.rnr.xa«nron
r L j°Cyptloe TwpD~•
cr.rn.n.n^ R.mwrsrnsme.
Dorutlan^ olw(sp.c+,~ ^ y
Rprll 26,1995
:, init. Zion Cemetery
ra. *umberland Count Pa.
OF 8ERVICf LICENSEE OR ACIMID AS SUCH tICElLSE NUMBER NAME AND ADDRESS OF FACE.TTY
~ ee
~~~~h
~~1~ g~
,
~g
a4
P
win mothers s
1
Q. ~.. 00821 -L
E3aeord,wMn prWylrq wrd my MOwieeE.,ewn r dw.nd PNC• L MBER DArE STONED
a..ew.rsnada.wrb ,F )~/1~/( ~
~
`
tee.
.~ 9
~
••reN Drawn. ~(~ (J
23a
DEAD Dex Tsar) vwsCASE 1~PErtl~Dro MEDICAL
r«n.nssmramnwlwni of
w'awR
"w
M
^ N
'
peram w
i"
o
'/
"
LL 7 w.
,~ :~S
Z7.MMT1: EnMrtlw draeaa, hirbe roonpACtlbmwNCnuwed the Do rolwrlnemoaerayYp, suMrcrdeeareeµrry ravel.eMCk ornwtleere. AppiwhnN Al/1T F. Otlwr aipYFCracrMabne cwmNNVpbderR cut
~hlrwlOrwMn nd MaullhB htlM UMMyYrp wra Biwrh PART I.
List raY arr nJlwtln secn lhe.
1 onw rr drtll
MI~IATE CAUSE (Final 1
r
DUEro( ASACO~SE ENCE OF}
/
•
s
•.~lie
8equraWyw oonaabna b (
DUEroIOR ASACONSEOUENCE Off:
Ery. Madrgmn•rWire
oeuw. EnMrUN061LYIND
1
~
CAUK IDi•e•e•ar"rymy c.
fnl irdEaleO cured DUE ro(aR AS A CONSEQUENCE OFj: I
raaAWp "n OeaYQ LAST
tl
.
WAS AN AUTOPSY WERE AUTOPSY FMIdrMaS MANNER OF DEATH DATE OFIrL1URY TNIE OFINJURy IILIURY ATWOiiKT DESCRIBE HOW BLIURY OCCURRED.
PERFORMEDT A11Ur •m a PRIOR ro PACna., Day, 1Yr)
COLWLETIDN OFCAUSE Nrvrr ~ 1lornicide ^
~
Yp ^ No ^
AcclasA ^ Penaag hwMiBYbn ^
M
.
yea ^ No[~ Yee ^ No ^ SubiM ^ Coub nd De arwmhea ^ PLACE OFIN,IURy-Al home, drrn, alrM.latlory, dBU LOCICION(Strw.CrtyR ,SWe)
EuESrq. re. (SpsrAy)
2b. 29. 30e. 301.
CdITlP1EA STeck aey one) -
•CMTIPYINB MIY81GAN pTyeidan uetllyinp eeueedaaelh wMnanaMr phydelan hr paau •eO aeelhaM CarnplMed Yem 23) _17~ BgNQURE AND TRLE O/~HTI R
!/J/(//
To Bre,ewt oTray knorMdOe.a••Tn occurred duabtlr eauayy rd w•nrrweWW ................................................. v~. 7/p
'PRONDYNCINB ANO CE1TTiYM1D PHYSN7AN(PhYeieian lwM pronwmiq aasln and CerNYegbeawsdasaY+)
rM dwmMeewe(sl arWmwrrr alaMd .......................... ^
awnaeewrW.trrBrrw
dwe
rM plae•
Te tlNbw of mykrowMdya LICENSE NUM/p/Eq~ ~ (~{ _ DATE STONED .Dny.16ar !~
L~(/w ~,?JJ'~~Z~ 37a J~„~Jr
.
.
.
, NAME AND ADORESSOF PERiQN,V/!70`CCAUSE DEATH
(Hein 27) Type a Print ~hi~y~ '
1 n
'MEDICAL EXAAtllIER/CORONER
On tM Uaals M sXarrnauon arM/ar ImaaNBatlon, In •9'opinion, deaN aoeumd r tlHr ThN, deM, and plan, and duo M IM waN•1+na
nuMnarwatMad ................................................................................................... ^
9/e. J-,
_
~,'7~'r• '7~3'~
~3
33. 1~ />~ ~ ~L ~~d6r
~(
''
~
~EGISTMR'S SMaNATURE BER ~~ ~ DATE F0.EDIManm. 03Y•~)
~
y
~
~(
~
1
~ `
'
9
r\\ ~ , l l~
„
. ~ N.
4
w
~ ;~r~.1'79605
RE "J• 1500 En ~ ~ -9a
~ ~
~Y
N
R FOR DATES OF DEATH AFTER 12!31191 CHECK HERE
f, ~ ~ ETUR
INHE ITANCE TAX P
^
''' ~ OVERTY CREDIT IS CLAIMED
J RESIDENT DECEDENT
~ FILE NUMBER
COMMONWEALTH OF PENNSYLVANIA
EVENUE (TO BE FILED IN DUPLICATE ~ f yJ` ~3~ ~
r DEPARTDEPT ZB~60 ~yITH REGISTER OF WILLS
~
HARRISB RG, PA 17128.0601 COUNTY CODE YEAR NUMBER
DECED T'S NAME (LAST, FIRST, AND MIDDLE INITIAL) DECEDENT'S COMPLETE ADDRESS
n
~ !~ ~~ Al ~'
•~~'
~ju ~L ~ ~`
f
Z IAL CURITY NUMBER DATE O EATH DATE OF BIRTH '
"
'
p APPLICABLEI SURVIVING SPOUSE'S NAME (LAST, FIRST A MIDDLE INITIALI SOCIAL SECURITY NUMBER AMOUNT RECEIVED (SEE INSTRUCTIONS)
u+ 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return
Ycy (for dates of death prior to 12-13-82)
=cc ~] 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required
~ (For dates of death aher 12-12-82)
a m 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes
(Attach copy of Will) (Attach copy of Trust)
,,~~-"r' 1r. %C'3Xc., kit. r t ~~~~ i n~..'~
a
vs 2 COMPL E MAILIN R
W W _
- ~ ~-,,
v ~ T EPHONE NUMBER ~ =~ ~ I
c7r -~ ~ ~ ~ 3 .- 3 Y~
z
0
r
d
a
W
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)
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)
6. 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)
(12) ~~ L°~'L~ J
(13) ~
z
0
s
>E
0
15. Spousal Transfers (for dates of death aher 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 695 rate
(Include values from Schedule K or Schedule M.)
17. Amount of Line 14 taxable at 15 ,rate
(Include values from Schedule r Schedule M.)
18. Principal tax due (Add tax from Lines 15, 16 and 17.)
19. Credits Spousal Poverty Credit Prior Payments
(-1
(2)
(3)
(b)
(7) R, , ~~
(9 - _ __ _
(10)
(15) x. __
(16)_ x.06=
(18) ,~ f fa ~ ~ ~ ,
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 L~ine^18 is greater than Line 19, enter the difference on Line 21. This is the TAX DUE. (21) s''s ! '° f ~`~-'
A. Enter the interest on the balance due on Line 21A. (21A)
B. Enter the total of Line 21 and 21 A on Line 21 B. This is the BALANCE DUE. (21 B) (~~~"}
Make Cbeck Payable to: Register of Wills, Agent
I the personal representative is
D9.F
( / `.
A E~
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the be
it is true, correct and complete. I-declare that all real estate has been reported at true market value. Declaration of preparer other thal
Act 848 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:
• 39/0 (.03) will be applicable for estates of decedents dying on or after 7/1/94 and before 1/1/96
• 290 (.02j will be applicable for estates of decedents dying on or after 1/1/96 and before 1/1/97
• 10No (.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 (rj IN THE APPROPRIATE BLOCKS.
YES NO
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred ~y
b. retain the right to designate who shall use the property transferred or its income, ............... i ~
c. retain a reversionary interest; or ...................................................................................
d. receive the promise for life 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$ ........:.......................................................................................... '~..
•,
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--id08 EX+ (2-87) SCHEDULE E
CASH, BANK DEPOSITS AND
'COMMONWEALTH OF PENNSYLVANIA MISCELLANEOUS
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DKEDENT
Please Print or
~R
(All property jointly-owned with the R1ght of Su vi hip must be disclosed on Seh~dul~ F)
ITEM
NUMBER DESCRIPTION
- VALUE AT
DATE OF DEATH
r~~~~ ~, r~ ~1 ~r~ u~~ i
~
~ i:- ,,
~.
%` -
~ .D : `~ G ~ 1 `~ F
i
TOTAL (Also enter on line 5, Recapitulation) $ ~ 7 ,
(Attach additional B'F." x 11" sheets if more space is needed.)
r
e
~''ft.i
REV-~?2,1 E7f+ (7-88) 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
~ ! - ;~
~~ .~ ~- r
~ - ~v 3~ r
ITEM
NUMBER DESCRIPTION AMOUNT
A. Funeral Expenses:
~7
~ ~ ~
~ ~;
5 .
~~
(~
.' .
u 'l. n~ ~ .~~ ~~ ~, .n,..,~ e.:: l: %'(/T r Z ^ +_ .. J, i a.,.ti-~" ~,'' 1 a+ L ~ , s ~:
r
x 4
. ,
- ._ .. .. - )~ - LC ~ _
7 J
.D
,~ ,
`-~ .• l
`E ~ ~.. Ct rI.A.. C_. f ,(l. G-ycit-.-~~rAt ~. I -) ~ 4.~, ~ri7n.h~ '
~
i-' ? h
'
1
~p _ f' ~ l~ P '../
t.T ClX f.[i~L.~7.1 ~~ '7.J ~
, ~ .
j { 4.-i.;
L ~
1 l 4
,
..
...
L.t
..~ r .. /`-...
ls ~-,~.°~`~~ " "~~.riv2~-~-c-'~--a.:.~-,-~C: .
~j ~..,-~.~
,~fTG~2~-~ `'-`k
~
~',.~
~
/.
~
~~ ~ v ~
B. ~
V
.
,
Adinimv
Cost ..
y 5~`~°0~
1. Personal Representative Commissions _ _
Social Security Number of Personal Representative:
~~~
Year Commissions paid
2. Attorney Fees
3. Family Exemption
~ r-
~' t i~~-~ Relationship -: Vic...,. %~z., f t).~.,;;;`
Claimant1.~~~~~~
,/
4'' ~ V L
Address of Claimant at decedent's death
Street Address ' t'~ v. ~ ~ ,L ` t ~ %~ . ~ ~ ~'` "
City ~, : i.~ ~ ` .~~ ~ State E> Zip Code i 'f~ ~
4. Probate Fees
C.
1. Miscellaneous Expenses:
2
3.
4.
5.
b.
7.
8.
/
f/~
TOTAL (Also enter on line 9, Recapitulation) $
~
t.
~~
/.
~1
(If more space is needed, insert additional sheets of same size.) I
~ REV-1513 EI(+ ~2-87~ ..,
.- . ...u.
COMMONWEALTH OF PENNSYLVANIA
INNERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
'~-
FILE NUMBER
ITEM
NUMBER i
NAME AND ADDRESS OF BENEFICIARY
RELATIONSHIP
AMOUNT OR
SHARE OF ESTATE
A. Taxable Bequests: ,
- ~ S ,(~ .~ /V ~' C,,j ~ ~~ ,
.yam,
-* !
e ~ "n, ~ -~
~^~ ~ ~, ~ ,K .~ ~ c k
~~t-aL.:.~
~C
~ ~
` ~ ~ 0 ~ ~
ITEM NAME AND ADDRESS OF BENEFICIARY
NUMBER
B. Charitable and Governmental Bequests:
AMOUNT OR
SHARE OF ESTATE
TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13, Recapitulation) $ ~ LO ~ C' `(T
/ , `~
(If more space is needed, insert additional sheets of same size)
-,w=,.
,.,~
G-
,. ~