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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.
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PFAMANENT NMIE OF DECEDEIfT IFint. Mfddla, ~aq
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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 Q 3 6 8 5 4
SYREIRFNIReeBe .
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hurvwtnuH pF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
IARRISBURG, PA 17128-0601
ECEDENT'S NAME (LAST, FIRST, AND MI
=NT~~ ~Z.
X13-O~-C
f AP/LICMLEI SURVIVING SPOUSE
^ 1. Original.. Return
^ 4. limited Estate
^ b. Decedent Died '
(Attach copy of
1 ------
2. Supplemental Return
^ 4a. Future Interest Compromise
(for dates of death after 12-12-82)
^ 7. Decedent Maintained a Living Trust
(Attach copy of Trust)
NAME . ..
Q ~ ` COMPLETE MAILING ADDRESS
1. Real Estate (Schedule A) (1 )
2. Stocks and Bonds (Schedule B) (2 )
3. Closely Held Stock/Partnenhip Interest (Schedule Cj (3 )
4. Mortgagee and Notes Rsceivabts (Schedule D) (4 )
5. Cash, Bank Deposits 8 Miscellaneous Personal Property
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b. Jointly Owned Property (Schedule F) (b )
7. Transiers (Schedule G) (Schedule L) { 7 )
8. Total Gross Assets (total Linea 1-7)
9. Funeral Expenses, Administrative Costs, Miscellaneous
Expanses (Schedule H) (9) __ { U 5 Q . ~ (~
10. Debts, Mortgage Liabilities, Liens (Schedule I) (10)
11. Tatal Deductions (total Lines 9 $ 10)
12. Nat 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 131
g ~ N tt ~ ~ ~ ~ 1~ i,4 s t v 3 ~ 1 ~~. ~ ~ ~ r..l i..~o~sJ ~
TELEPHONE NUMBER
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15. Spousal Transfer (for dates of d ath ft
^ 3. Remainder Return
(for dates of death prior to 12-13-8:
^ 5. Federal Estote Tax Return Required
_ 8. Total Number of Safe Deposit Boxes
(11) 1 ('~ ~ n : Q(~
(13)
(14) ~ ~s 1 e - ~l
e a er b-30-94)
Sse Instructions for Applicable Percentage on Reverse (15)
Side
(Incl
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x
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.
u
e va
ues
rom Schedule K or Schedule M.) `-
-
16. Amount of Line 14 taxable at 696 rate (16)
(Include values from Schedule K nor Schedule M.) x .Ob =
-
17. Amount of Line 14 taxable of 1596 rate (17) __ ~ Q~ ((~ C.fc(
(Include values from Schedule K or Schedule M.)
x .15 = _1 c~-~ .
18. Principal tax due (Add tax from lines 15, 16 and 17.) -~ ~o~ ~ ~ j
(18)
19. Credits Spousal Poverty Credit Prior Payments Discount Interest -.
>0. If Line 19 is greater than Line 18, enter the difference on Line 20. Thia is the OVERPAYMENT. (20) r
! 1. If Line 18 is greater than Line 19, enter the difference on Line 21. This is the TAX DUE. (21) = 4 ~ ~ ~
A. Enter the interest on the balance due on Line 21A
.
B. Enter the total of Line 21 and 21A on Line 216. This is the BALANCE DUE. (21A) ._ „-
(21 B) ~ 3- ~- ~ ~
Make Check Payable to: Register of Wills, Agent
~ BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE .ANO YO 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 any knowledge.
SI ATURE OF PE7RIS~ON RESPONSIBLE fOR FILING RETURN ADDRESS / ~ _
-'~`1 ~'L ~-~(~ - ~ ~ Z~ ( i~G' C' C.~, 1 i~-1.-~.--~ (•~1rJ ~ ~~~ ~ t. DATE J
$IGNAFIIRF nF DR~peRFR nr V.4~
FOR DATES OF DEATH AFTER 12!31!91 CHECK HEF
INHERITANCE TAX RETURN 1F A SPOUSAL
RESIDENT DECEDENT POVERTY CREDIT IS CLAIMED ^
(TO BE FILED IN DUPLICATE FILE NUMBER
WITH REGISTER OF WILLS ~ ~ ~~' ~-~~~ 3~7 ~
COUNTY CODE YEAR NUMBE
ITIALI DECEDENT'S COMPLETE ADDRESS
DATE OF DEATH DATE Of BIRTH ~l Qw~ P l-~y '~, ~J~ 1 ~ ~ 1~
Cc ~--~ ~-~- - 36 -G ~ - ~ . Q (o co~nf ~~1..~tJ~~ ,
NAME (UST, FIRST AND MIDDLE INITIAII SOCIAL SECURITY NUMBER earl cur eere...~.. ,........
`1P~~;,-
~ ~~. ~
Act #48 of 1994 provides for the reduction of the tax rates imposed on the net value of transfers to or for
the use of the spouse. The rotes as prescribed by the statute will be:
• 3% (.03) will be applicable for estates of decedents dying on or after 7/1/94 and before ~1/1/96
• 2% (.02) will be applicable for estates of decedents dying on or after 1/1/96 and before 1/1/97
• 1 % (.O1) will be applicable for estates of decedents dying on or. after 1 /1 /97 and before 1 /1 /98
• Spousal transfers occurring on or after 1 /1 /98 will be exempt from inheritance tax.
PLEASE ANSWER THE FOLLOWING QUESTIONS
BY PLACING A CHECK MARK ~ /) IN THE~~APPROPRIATE BLOCKS: - ._-- ---
YES- NO
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred; ....................................................... i''
b. retain the right to designate who shall use the property transferred or its income, ............... v
c. retain a reversionary interest; or ................................................................................... ~i
d. receive the promise for life of either payments, benefits or care$ .......................................
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$...... .............................................................................................. ='~
v-'
3. Did decedent own an 'in trust for' bank account at his 'or her death$ ......................................
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE. SCHEDULE G AND FILE IT AS PART OF THE RETURN.
f ~
rEK1508 EX+,(2.87)
COMMONWEALTH Of PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS AND
MISCELLANEOUS
PERSONAL PROPERTY
Please Print or ,ypn
wlAlt yr _ FILE NUMBER
(All property Iolntly-owned with tl~e Riphf of Survivorship must be diseloud on Schedule F) t ~ ~ S O O
ITEM
NUMBER DESCRIPTION VALUE AT
DATE pF DEATH
~~C~C~ , ~
Q
TOTAL (Also enter on line 5, Recapitulation) I $
(A»ach additional 8'/1" x 11" sheets if more space is needed.)
REV-1511 EX+ (7.88)
l F
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES please print or Type
FILE NUMBER
AMOUNT
ra^.+^c yr
ITEM
NUMBER DESCRIPTION
A• Funeral Expenses:
1.
B.
2.
3.
Administrative Costs:
Personal Representative Commissions
Social Security Number of Personal Representative:
Year Commissions paid
Attorney Fees
q . H Ata ~ ~-r o~ , ~~
Family Exemption C~SU`"~'~.~IU`1~
Claimant Relationship
Address of Claimant at decedent's death
Street Address
C.
4.
1.
2.
3.
4.
5.
6.
7.
8.
(If more space is needed, insert additional sheets of same size.)
City State Zip Code
Probate Fees
Miscellaneous Expenses: i, ~ ~,?.~ ~'~~'
~.~ ____-
~f L~ ~1N...~ ~~ 1 t`~- u.'l~ ~..~ l ~1 ""' ...~ t~ art ~''l ~ ~ ~ ,'' IJ~ (, ~ C'. .
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~~~~~t~~
~~~ ~ L~ ~~
TOTAL (Also enter on line 9, Recapitulation) $ ~ '~ ~~
~ ~Z~" ~ ~,
REV-1513 E%+ (2.g7)
t ,~ I'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
- t
't v ~ I
ITEM
NUMBER NAME AND ADDRESS OF BENEFICIARY
A. Taxable Bequests:
~~ t~~ Krh tt j" I~o.c c.
C~ V Y'~ ~~ i--i , i t wq ~ -i c~ i I
d"•~~ ~. r,r C c~ ~ Y
~-r~e~C•- ~t/\ I-to5~
=3 ~~ ~ Y i`.,~ss
65`x+1 k~CC ~C ~ ~~..~..;
~til
N e :~ C ~J~. ~.,--. ~~ e_-- t o--.~~
~ ~-i-.R ~~ : s
ITEM
NUMBER NAME AND ADDRESS OF BENEFICIARY
B. Charitable and Governmental Bequests:
FILE NUMBER
~`L~~
`_i ~'i'`~ { ~~
-----.
RELATIONSHIP AMOUNT OR
SHARE OF ESTATE
~~ 1 3 ~..t..{...
Fir c' ~~ t-.r
r-G .F.1,~ ~_~--
t!n . t, ``'l..
AMOUNT OR
SHARE OF ESTATE
TOTAL CHARITABLE AND GOVERNMENTAL BEQUESTS (Also enter on line 13 Recapitulation) I$
(If more space is needed, insert additional sheets of same size)
,,. ~l
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