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HomeMy WebLinkAbout10-15-12__ _ _ _ _ _ ,_ 15056041125 REV-1500 EX (06-05) OFFICIAL U5E ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po sox zaosoi 2 1 1 2 0 7 0 8 Hamsburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 4 0 5 3 4 5 3 1 8 0 5 0 2 2 0 1 2 1 2 3 1 1 9 2 3 Decedent's Last Name Suffix Decedent's First Name MI L E W I S D E L I A A (If Applicable) Enter Surviving Spouse's Information Last Name Suffix Spouse's First Name Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS MI ^X 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) 1 OX 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) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST 8E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number W I L L I A M D O U G L A S 7 1 7 2 4 3 1 7 9 0 Firm Name (If Applicable) D O U G L A S L A W O F F I C E First line of address 4 3 W S O U T H S T Second line of address City or Post Office C A R L I S L E State ZIP Code REGISTER WILLS USE 191iL' Y ~ N ~ ~ ~ ~ J _ ` -+ 4 ;~ _,~ CJl - C1~`. . _~ C7 ~-~„ _ c~c. _ -- , O rr ~= ~~ p EyFILED ----~ - _ /1 PA 1 7 0 1 3 Correspondent's a-mail address: hbar'bourna ealthlink.net Under penalties of perury, I declare that I have examined this return, including acx:ompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other tha presentative Is based on all information of which preparer has any knowledge. SIGp~ITf/RE OF PERSON RESPONSIBJ,.Tj FOIj FILING RETURN DATF~ ~~ ADDF~E y ~ r De . \2, mZ.F SIGNATURE OF RP EPARER OTHER T N REPRESENTATIVE DATE PLEASE USE ORIGINAL FORM ONLY Side 1 15056041125 15056041125 ;~i c~ f c ;-n 0 ~~~ 12 15056042126 REV-1500 EX Decedent's Social Security Number ~ecedenYsName: DELIA A. LEWIS 4 0 5 3 4 5 3 1 8 RECA estate{Schedule A) ........................................ 1• 2. Stocks and Bonds (Schedule B) ............................... ... 2• ~' v ~ v 0 0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 4. Mortgages & Notes Receivable (Schedule D) ..................... ... 4. 3'0 5 2 9 2 8 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .... ... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .... ... 6• 0 0 0 7. Inter-Vivos Transfers & Miscellaneous Nan-Probate Property (Schedule G) X Separate Billing Requested .... ... 7. ~ 8 6 9 8 3 0 4 7 9 8. Total Gross Assets (total Lines 1-7) . . ... . . . . . . . . . 9 ~ 6 5 8 3 8 7 9. Funeral Expenses & Administrative Costs (Schedule H) ............. ... • 10. Debts of Decedent, Mortgage Liabilities, 8~ Liens (Schedule I) ......... ... 10. 11. Total Deductions (total Lines 9 & 10) • • • • • • . • • • • • • 11. ~ 6 5 8 3 8 7 12. ..................... Net Value of Estate (Line 8 minus Line 11) ....12. 6 2 1 7 2 0 9 2 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .................. 13• 6 2 1 7 2 0 9 2 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 0 0 (a)(1.2) X .00 16. Amount of Line 14 taxable 0 0 0 at lineal rate X .00 17. Amount of Line 14 taxable 0 0 0 at sibling rate X .12 18. Amount of Line 14 taxable ~ ~ ~~ ~ 0 0 0 at collateral rate X .15 15 0 0 0 1s 0 0 0 17 0 0 0 18. ~t ~13,a-58 , r3 0 0 0 19. Tax Due . jc! ~~ t~5p ~3 0 0 0 ................................................19. `~ O 20. FILL IN THE OVAL IF YOU ARE REQUEST OVERPAYMENT ^ Side 2 15056042126 15056042126 e REV-1500 EX Page 3 Decedent's Complete Address: File Number 0708 DECEDENT'S NAME DELTA A. LEWIS STREET ADDRESS 43 W. SOUTH ST CITY STATE ZIP CARLISLE PA 17013 Tax Payments and Credits: ~• Tax Due (Page 2 Line 19) (1) $0.00 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) $0.00 3. InteresUPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E ) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference, This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) $0.00 (4) $0.00 (5) $0.00 (5A) (56) $0.00 Make Check Payab/e to: REG/STER Of W/LL S, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No 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 ................................................................................................ ^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ X^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ 0 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ......... ^ X^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. ~ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P,S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. LAST WILL AND TESTAMENT I, DELIA ANN LEWIS, of Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, declare the following to be my last will and testament, hereby revoking any and all wills heretofore made by me. Item I. I direct my executrix hereinafter named to pay all my just debts and funeral expenses. Item III. I give, devise and bequeath all my property, both real and personal, to be divided as follows: A. Fifteen (15%) percent to Bonalee Winkler B. All the rest, residue and remainder of my estate to my niece, Glenna Taylor Cox. However, if Glenna Taylor Cox should predecease me, the remainder of said property (after the above-mentioned portion given to Bonalee Winkler) is to go to the heirs and assigns of Glenna Taylor Cox. Item IV. I nominate, constitute and appoint my niece, Glenna Taylor Cox, as my executrix, and direct that she shall serve without bond. IN WITNESS WHEREOF, I have hereunto set my hand and seal this C~~`'` day of September, 2006, ~~ ,.,T~'~.~~ Gem r .L.~ o~--r?,~tr#-~AL) DELIA ANN LEWIS Signed, sealed, published and declared by the above named testatrix, as and for her last will and testament, who at her request, in her presence, in our presence, and in the presence of each other have hereunto subscribed our names as attesting witnesses: . ~', COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND We,~.~.~-„~-~ ~ 1 and L~~,c/_?C~:~ ~~~~.~' whose names are signed to the attached or for oing instx~ment, being duly qualified according to law, do depose and say that were present and saw testatrix sign and execute t11e instrument as her Iast will, and that she signed willingly and that she executed it as her free and voluntary act for the purposes therein contained, 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 or more years of age, of sound mind and der no c s into ndue influence. ,~ f Sworn to and subscribed before me this 1 ~,,~'", day of ~.eptember, 2006. ! ~" Nohriai Seals.a~ Anus M. Cox, Nohry Public Ca~lia BorouOh, Cumberland County My Coa~feeion Expires June 3, 200! _ _ _ COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND I, DELIA ANN LEWIS, whose name is signed to the attached or foregoing instrtiinent, having been duly qualified according to Iaw, do hereby acknowledge that I signed and executed the instrument as my last will, that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. fey:'=-~.~t ~-~, (~~~•~ZU <~ ~~:Y~,--% Delia Ann Lewis Sworn to and subscribed before me this the ~~day of September, 2006 ,3~ },. Nobrial Seaf Anne M, Cox, Notary Public Cariise h, Cumberland County My ComnNraion Expires June 3, 200! REV-1502 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER DELTA A. LEWIS 0708 All real property owned solety or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neiUier being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointlyowned with rieht of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NONE TOTAL (Also enter on line 1 Recapitulation) ~ S (If more space is needed, insert additional sheets of the same size) REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER DELIA A. LEWIS 0708 All property jointly-owned with right of survMorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH See Attachment Page(s) TOTAL (Also enter on line 2, Recapitulation) I $ 667 775 51 (If more space is needed, insert additional sheets of the same size) DELIA A. LEWIS Decedent's Name Continuation of REV-1500 Inheritance Tax Return Resident Decedent 21 12 0708 Page 1 File Number Schedule 6 -Stocks 8~ Bonds ITEM NUMBER DESCRIPTION 1. CAPITAL ONE NATIONAL ASSN VA ACCOUNT NO. 14042EPF1 2. CREDIT SUISSE NEW YORK BRANCH ACCOUNT NO. 22546QAF4 3. FEDERAL HOME LOAN BANKS ACCOUNT NO. 3133XRZ89 4. FEDERATED EQUITY FDS ACCOUNT NO. 314172560 5. FEDERATED TOTAL RETURN SERS ACCOUNT NO. 31428Q101 6. GOLDMAN SACHS BANK USA NY ACCOUNT NO. 381426D88 7. MIDDLEBURG NATIONAL BANK VA ACCOUNT NO. 596131 BC5 8. PRICE T ROWE GROWTH STOCK FD INC ACCOUNT NO. 741479109 9. ROWE T PRICE EQUITY INCOME FD ACCOUNT NO. 779547108 10. ROWE T. PRICE CAP APPRECIAT FD ACCOUNT NO. 77954M105 11. ROWE T PRICE SHORT TERM BD FD ACCOUNT NO. 77957P105 12. VANGUARD/WELLINGTON FD INC ACCOUNT NO. 921935201 13. VANGUARD / WELLESLEY INCOME FD ACCOUNT NO. 921938106 14. VANGUARD FIXED INCOME SECS FD ACCOUNT NO. 922031810 15. VANGUARD FIXED INCOME SECS PD ACCOUNT NO. 922031836 VALUE AT DATE OF DEATH $51, 976.65 $52,686.00 $53,000.00 $26, 565.87 $23,645.65 $76, 542.08 $51,729.65 $29,441.71 $18,356.31 $5,373.03 $50,166.14 $69, 985.36 $20, 949.04 $36,110.87 $54,520.51 SUBTOTAL SCHEDULE B $621,048.87 Continuation of REV-1500 Inheritance Tax Return Resident Decedent DELTA A. LEWIS 21 12 0708 Decedent's Name Page 2 File Number Schedule B -Stocks 8~ Bonds ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 16. VANGUARD FIXED INCOME SECS FD $46,726.64 ACCOUNT NO. 922031869 SUBTOTAL SCHEDULE B $46,726.64 GRAND TOTAL SCHEDULE B $ 667.775.51 __ ._ Charlene G. Peuchtenberger orrstown Financial Advisors Assistant Vice President / Fiduciary OEfieelr i7a to of Death; 05/02/2012 BeCate of: Delia JU'tn Lewis valua tion Pate; 05/03/2012 Account: 131 Proce ssing Date: USl04/2012 Report Tyne: Date of Death Number of Securitie a: 16 File ID: D. Lewis (!1312 shares 6ecurity fdean and/or Div and int Security or Par Description High/Ash how/Bid Adjustments Accruals Value 11 50000 CAPITAI, ONE NATL ASSN YA (14492EPF1} Financial Times Interactive Data DTD: OS/07/2Dtl9 Mat: OS/07F2D13 4,55 OS/o2/2D12 103.95330 Mkt 103.953300 51,9'76.65 Int: 11/07/2D11 to O5/OZ /2012 1,.103.22 Note: Put Option On DO^ 21 50000 CREDIT 5UISSE NEW YOR}C BRANCH (2254GQAF4) Financial Times Interactive Data DTD: OB/05/2010 Mat: DB/45/2020 4,3754 09/30/2012 1D6.90D00 109.03000 A/B 05/03/2012 105.45050 Mkt 105.3720 DO 52,6DG.On Int: 02/05/2012 to 05/02/2(112 528.65 31 50000 FEDERAL HOME LOAN 9AN!{S (31333f[:ZB91 GovestSmaOt/agency (Dealer QuoCationsl DTD: 08/27/2008 !•fat: 08/27/ZDSB S.ZY DS/OZ/2012 106,03125 105.96675 A/B 106.044040 53,n00.00 xnt: O7./z7/2012 to 45/02/2412 469.5, 9} 5399.568 FEDERATED EQUITY FDS (319172560} STRG VAL DV INST Mutual fund (a r. quoted by NA5DAQ1 05/42/2412 9. 92000 AUCt 4 .920040 26,665.87 6) 20f>1.521 FEDERATED TOTAL RETURN 9ERS (314281411 TOIL RET INSTL Mutual Fund (as quoted by }tASDAQI 45/02/2012 11..47000 t9kt 11,97DDOD - 23,645.65 61 %5000 GDLDMAN SAC}IS AR USA NY (381926 DB8) Financial Times Interactive Data DTD: 10/17/2467 hSAt: 10/17!2012 5.05 05/02/2012 107.. DSG10 Flkt 107..056100 '76,592.08 xnt: 04/17/2012 to 05/02/2012 155.65 t7o te: Put Option Oa DOD 7) 50000 MIDDLe,HURG tU1TL 8K V71 (5 9 6 13 7330 5 1 Financial Times Snteractive~pata DTD: 06/28/2010 Flat: 12/29/2014 2.1~ 05/02/2412 103.95930 Dikt 103.959300 51,729.65 Int: 09/28/2022 to 05/02/2012 11.67 iaote: PUt Option on DOD B} 771.129 PRICE T R041t GROl91'H STK FD INC (791479149) COM Mutual Fund fas quoted ;Jy NASDAQI 05/02/2012 39.18000 hlkt 38.180000 39,911,71 91 %25.259 ROWS T PRICE EQUITY INCOME FD (77954.71 D8} 9H BEN 1NT' MuCua2 Fund (as quoted by t7A5DAQl CSf02/2012 25.31440 MkC 25.310400 IB,35G.31 10) 279.12 ROWE T PRSCS CAP APPRECIAT PD (77954M105) s}; aEN zrrr Mutual Fund (as quoted by NASDAQ} 05/02/201.2 22,97044 tdkt 2z.974n4n ~,?%3.n3 gage 1 This report was produced with EstateVal, a product of Estate Valuations & Pricing Systems, Inc'. If you have ~iestions. please contact EVP Systems at (818} 313-6300 or o-rvnu.evpsys.rom. (Revision 7.2.4) DatO of Death: 05/02/2012 Estate of: Delia Ann Lewis 'Jaluatien Date : 05/62)2012 Report Type: Account: 1312 Date of Death Processing Dat e: n5/09/2912 rdumber of Securitiesi 1G File ID: D. Lewis .;1312 shares Security Mean and/or Div and Int Security or Par Oesr_ription High/Ask Law/raid Adjustments neerualF Value L1~ ,L 0393. 535 ROY/E T PRICE 5HORT TERM 8D PD 177957 P105) COM Mutual Fund las quoted by NASDAQ) 05/02/2012 4.85006 Mkt 9.BS000p 50,166.15 131 1208. 937 VAI4GDARD/67ELLINGTON FD INC (9219352D1} ADh1IRAL SfiAA.ES r9utual Fund (as quoted by NASDAQ} 65/02/2612 57.69000 Mkt 69 965 35 57.89000D . , 13) 878. 735 VANGUARD/WELLESLEY INC6rtE FD (921938106} COM Mutual Fund las quoted by NASDAQ) 05/02/2012 23.84000 htkt 23.890000 20,995.09 19) 3547. 237 VANGUARD FIXED INCOME SECS FD (922031010`, I?ITRM TNVGRDAD Mutual.~Und (as goofed by rtASDn01 05/02/2012 10.1860D _ hlkt 10.1©0060 36,110. A'! 154 5066 .962 VANGUARD PI}iBD INCOME S&CS PD (922031636} 9TR1H INVGRA All Mutual Eund fas quoted by NASDAQ) OSf 02/2012 1.0.76600 Mltt 10.760006 54,520.5'_ iG) 3229 .208 VANG6AAD~PIXED TNCObIE SECS GD (922031069) YNFL PAOT SECS Mutual Fund (as quoted by NASDAp? 05/02/2012 15.47800 h1kC 14,570060 46,726.69 Tata2 Value: 5667,"1']5.51 Total Accrual: ;2,268.63 't~ta1: SK70,044.14 Portfolio Endnoces Or stows ank Daily Depvs t -043990997 $ 2,798.27 Accrued inl, $ 0.00 X Date: Charlene v. FeuchtenhaY9er Acst. Vice re dent / r^iduciaxy Officer Page 2 'this report was groduced with EstateVal, a product of Estate valuations & Priczng Systems, Inc_ If you nave questions, ¢lease Contact EVP Systems at 18181 313-6300 or www.evpsye.com. (Revision 7.2.0) STATE ,,.~ O:iiC,CO'.J°JTY Oi: FJUTL~1?' MQ. (±~ t~ F _, ', t „ 1 ~•~~~~~~ ~°. CERTt~itA'tE OF Tat't~ V ,_ ~,'gy kart TC a MoTt7it L'Eit{CLE ;. i ~q! ~ ...,,± ~ - D~~.~.8 l~ttQ I~els-id ~ ~ 71 •._ ,'~• ;Ov.,+nr. f...r M;~ ~ - IU~e Nom,f iDeAr Ik+. *'..4. 5w+rdt .., rn a ~ r~ ~~~` ~; .,.. _... ~s-~Ihia~ttil~ H3.~-d H81n3.1~O+a v? ~ is thr ownee of th+c fotipwing described Mo+ar Yehirfe: ~ ~ YEAR 19'll Mfr's. Se.iai lVa. ~~?' ~'"r]~~~' ~ MAKE 0 MQt}EL ~ ldswab~ls G~tlas~ 33~ 7~ 8 G E7 'i T Y 3~ E ~ Dr ~.''!'s Q{'~. 7-d~. Fitret-Prrrrt!•.att t,; kr•: iwl; it c! ~1 t ~Y~f•;~~.~. - .. ,a.•au.-. .. :a nae -- _ :;. _ -~_ Y 214 NC>rfl-i HCir~r,,v.<~r SirE;E't ' r P CgriiSiiF PPnraV'~v~ini~~ 1 7C1 ; ~? i ~'. J/.i,,2 ` i i ,je~~i.~~ _ !.~' loll frEe l.~hb d51 451 1 ~ i ~ '/," - vsww.hoifrnnnroi~~ c~n_i I ~, ~/ ?=tINERAL. ~-30MF & CREMATORY, 1NC. itltcro hnftn'~rynrr~ih, r,^.rn Glenna T. Cox 124 West Middlesex Drive Carlisle, PA 17013 June 7, 2012 Statement of Funeral Expenses for. Delia Aran L.evvis Date of Death: May 2, 2012 Account Id: 16540-107 MERCHANDISE: Casket: Mansfield $ 3,945.00 Register Book $ 25.00 Memorial Folders $ 25.00 Gown R-9400 Peach/pink $ 125.00 Sub Total: $ 4,120.00 AUTOMOTIVE EQUIPMENT: Transfer of Remains $ 215.00 Sub Total: $ 215.00 OPTIONAL SERVICES: Forwarding of Remains $ 1,945.00 Other Preparation of Body $ 260.00 Sub Total: $ 2,205.00 TOTAL FUNERAL HOME CHARGES: $ 6,540.00 CASH ADVANCES: 10 Certified Death Certificates at $ 6.00 each $ 60.00 Newspaper Notice -Sentinel $ 312.02 Hamilton Journal $ 471.70 Airfare $ 628.38 iiairdresse~ $ 40.00 Sub Total: $ 1,512.10 Total Funeral Expense: $ 8,052.10 Total Payments Made: $ 6,990.00 Payments Made: PreNeed Disc Discount Cont vs PreN May 11, 2012 645.71 Monumental Check 3400075406 May 11, 2012 6,344.29 Balance: $ 1.062.10 ~, Please return this portion with your Remittance. Delia Ann Lewis Amount Enclosed SERVING GUR ~OMM,UNiTY SINCE 1 907 r. ~-~f; i!, %' ,' EUN~=RAL HOME & CREMATOR', lNC Service ID#t: 16540-107 CarfislF. f'r-r~n_ryvc7niC, 7 %U13 _` J 43.45 l iUH irec 1.~G6.45' .451 I ;pia i I ' ~n < 2i~~~ ~n~:n~w.hOtL ~ 1~n ;~uli ~.~.~..n, „~lff_?~a h[)iirrlanl C,ih.r.CUi $cFVING OUR COMMl1NITl' SINCE 1 9~% ' vVE~~[.ih No~inan F ttriF~ral l+~~m~': 2 t1 Rns; Ave ti,~miltnn, CH 4 `;~ i (~>1_~j ug4_go1t~ tvtanager :Ryan W. Kidd , 008547 The following is a detailed bill for the profession al services and/or merchandise arranged for Delia An n Lewis Date of Service : May 08, 2012 Glenna T. Cox Statement Date May 15, 2012 124 W Middlesex Dr Contract Number 693601000281 Carlisle, PA 17013-8495 Arranger Name Ryan W Kidd Initi al Selection Final Selection Difference Funeral Director and Staff Services Receiving Remains from Another Funeral Home $1,040.00 $1,040.00 -- Total Funeral Directcr and Staff Services $1,040.00 $i,t]40.00 -- Use of Facilities and Related Services Chapel Funeral Ceremony $350.00 $350.00 -- Total Use of Facilities and Related Services $350.00 $350.00 -- Transportation Service \~ehicle $45,00 $45.00 •--- Funeral VehicleJNearse $175.00 $175.00 -- Transfer to or From Airport $175,00 $175.00 --- Total Transportation $395.00 $395.00 -- Other Goods and Services Cemetery F_quipment & Tent Rental $100.00 $100.00 -- Total Other Goods and Services $100.00 $100.00 -- Merchandise Std Eagle Triple Deluxe Concrete $1,595.00 $1,595.00 -- Total Merchandise $1,595.00 $1,595.00 -- Cash Advance Hamilton Journal Obituary $471,70 $471.70 -- Hairdresser $40.00 $40.00 -- Total Cash Advance $511.70 $511.70 -- Initial election Total Services, Merchandise and Cash Advance $3,991.70 Allowances Preneed Insurance A{lowance ($341.65) Total Allowances ($341.65) Taxable hems $1,595.00 Toiaf Taxes $99.69 Total Charges (Total Services +1- Allowances + Taxes} $3,749.74 Less Payments Received: 518!12 Hoffman-Roth Funeral home $40.00 5/9/12 Forethought #7289184 $3,17.01 -- - ~` 5/14112 Naffman-Roth Funeral Home $471.70 Final Se{eclion $3,991.70 ($341.65) ($341.65) $1,595.00 $99.69 $3,749.74 ($3,638.71) [JiffQreare, Unpaid Balance Due $111.03 QRRSTO~'1TN~ BA~vx. ~ Trttdi,tion of Excelle~tce July 23, 2012 Douglas Law Office Attn: 1-ieather A. Barbour 43 W. South Street Carlisle, PA 17013 Fax: 243-89.55 Re: Estate of Delia Aivl Lewis Social Security Number 405-34-531 R Date of Death 5/2/2012 IT IS I-IEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD THE FOLLOWING ACCOUNT WITH ORRSTOWN BANK: C.HEC'KING A C'C'C) UNT ACCOL1nt No.- 108006'728 Account Type- 50+ Interest Checking Image Date Opened- 10/2/2006 Joint Account (name/date)- No Balance- $18,605.11 Accrued Interest- $0.06 Attached is also information regarding the deced.ent's OFA. account. Best Regards, Till R. Worthington Deposit Processing Clerk 2695 Philadelphia Avenue • C;hambersburg, PA 17201 Sovereign Bank ESTATE OF Delia A. Lewis SOCIAL SECURITY #: 405-34-5318 DATE OF DEATH: May 2, 2012 Account #: 1671077903 Type: Checking Open date: 10/27!2006 In the name of: Delia A Lewis (Glenna T Cox POA) Date of Death Balance: $340.81 Int.(YTD) from 1/1/2012 to 4!24/2012 $0.01 Accrued interest to date of death: $0.00 Other Info: Account #: 1675541476 Type: Call In the name of: Delia A Lewis ITF Glenna T Cox BENEF Date of Death Balance: $47,187.69 Int.(YTD) from 1/1/2012 to 4/30/2012 Accrued interest to date of death: $2.33 Other Info: Account #: 1675541484 Type: CD In the name of: Delia A Lewis ITF Glenna T Cox BENEF Date of Death Balance: $59,543.76 Int.(YTD) from 1/1/2012 to 4/30/2012 Accrued interest to date of death: $12.33 Other Info: Open date: 10/27/2006 $93.76 Open date: 10/27/2006 $495.34 Page 1 of 1 l ~~ U~T~ J E W E L E R S Trust Your Special Moments To Mountz. September 25, 2012 Glenna T. Cox '124 W. Middlesex.Drive Cariisie, PA 17013 Dear Glenna Cox;. At your request I examined the jewelry you submitted for valuation and have provided an opinion of the Approximate Fair Market Value for the estate of Delia-Ann Lewis; May 2, 2012 : - This report is valid only in its'entirety and the final figure excludes any applicable taxes. You may wish to take-this into consideration when-using the report. The value conclusions are subject to limiting conditions that are set forth in the body of the report. To the best of my knowledge and experience, I estimate the jewelry has a total Approximate Fair Market Value of $402.06. Photographs are included with the original report for your reference. I suggest that you keep your copy of this report in a safe place. This report was prepared in accordance with the Uniform Standards of Professional Appraisal Practice (USPAP). If I can be of any further assistance, please call ..~ Sincerely, r _.... .- y'`'~ ,. ~~..._ Chem Lynn Grove Certified Gemologist Appraiser, AGS Enclosures 3780 Trindle Road • Camp Hill, PA 17011 • 717.763.1199 • (F) 717.763.8953 • monntzjewelers.com Page.1 of 8 '®` A M E R I C A N G E 7.1 SOCIETY" - Table of Contents • Letter of Transmittal • .Table of Contents • Purpose • Intended Use • Definition of Fair Market Value • Approach to Value • Market • .Limiting Conditions • Subscriptions Retained for Value Consulting • `Metal Markets • Certification • List of Laboratory Instruments • Item-Descriptions • Photograph(s) • Biograpbicallnformation This report. is. valid only in its entirety and for its. stated purpose and intended use. and was :prepared in accordance with the Uniform: Standazds of Professional Appraisal Practice (tJSPAP). Statements: and .Limiting Conditions Purpose The purpose of this report is to describe and document the quality of the jewelry listed and to estimate it's- Fair Mazket Value. Intended Use Defintion.of Fair Market Value The fair market value. is the price at which the property would change. hands between a willing buyer and willing seller; zseither being under any compulsion to_buy or sell. and both having reasonable knowledge of relevant facts. Thee fair market value of a particulaz item of property... is not to be determined by a forced sale price. Nor is the fair mazket value. of an item of property to be determined by the sale-price of the item in a market other than_that in which such item is most commonly sold to the public, taking into account location of the item wherever appropriate. Taken from Treasury Regulation 20.2031-1 (b) Approach to Value There aze three traditional approaches xo value that are as follows: Income approach: Applies to income producing properties and is used only if an income situation or rental property can be identified. Market Data approach: Compares the qualities of the subject item to an article with similar or identical qualities;-and researches and records current verifiable sales of such merchandise. Cost approach: Establishes thelotal value of an item by considering the value of its component- parts precious .metal content,. gemstone weights. and qualities, labor, and any other fees), together with the appropriate retail mazkup according to the norms of the jewelers in the locale, supplyand demand,' and the current state of the marketplace. Page 2 of 8 Fair Market Value is estimated using the market data approach. Neither the income approach nor the cost approach apply in establishing Fair Market Value. However, the cost approach to value was used to check on the reasonableness or market values found. Market To value an item a market (and market level) must be recognized. The most appropriate market for jewelry can vary depending upon the article's age, condition, quality, intrinsic content, aesthetic appeal, provenance, current fashion trends, artistic interpretation, period of manufacture among others. The type of retail outlet that most commonly carries the items being appraised is considered to be the most appropriate market: However, the auction market was also considered as another appropriate market in establishing Fair market Value for this type of jewelry. Limiting Conditions The jewelry described within has been analyzed and graded imaccordance with prescribed grading standards using "state of the art" methods and precision laboratory equipment. Jewelry constructed solely of, or in combination with, precious metals (i.e. platinum, palladium, yellow or white gold and/or silver) is.tested, analyzed and described for its type and content of such metal. Unless . otherwise stated, all gemstone weights, grades and measurements are approximafe and stones have not been- removed from their mountings. Diamonds are graded with the prescribed grading nomenclature of the Gemological Institute of America (GIA) and the use of pre-graded permanent master diamond-color comparison stones. Colored stones. are color graded according to :the GIA color grading system. Unless otherwise stated, all colored stones listed on this appraisal report have probably been subjected to various-treatments to improve their appearance. Treatments are considered usual and customarypractices when properly disclosed and when done without intent to defraud the consumer, The treatments are mostly stable and. do not require special care.- When a treatmentis detected and considered unusual it will be so noted by this appraiser: Some treatments are reversible and re-treatable. It may be beyond the -scope of an appraisal to determine exact treatment methods or the amount oftreatment present. Some treatments require sophisticated equipment not found in a standard gemological laboratory.. Prevailing market values are based on these universally practiced and accepted"processes by the gems arad jewelry trade: Sources are assumed to be reliable and the appraiser does not assume responsibility for their information. The appraiser assumes the ownership of the subject property is true as stated by the client. . The fees paid for this appraisal do not include the services of the appraiser forany other matter. In particular, fees paid to date do not include any of the appraiser's time or services in connection with any statement, testimony or other matters before an insurance: company, its agents, employees or any court or other body in connection,with the property herein described. If the appraiser is required to testify or to make any statements to a third party concerning the described property and/or appraisal, the applicantshaIl pay the appraiser for all of such time. and services so rendered. This document is limited to its stated intended use and is invalid if all items listed in the Table of Contents are not present. Unless expressly stated, the items appraised are in good condition. Any serious deficiencies and repairs are noted. Ordinary wear and tear is not noted. The information in this report is confidential Page 3 of 8 This appraisal process does not discover liens, encumbrances, or fractional interests but, if known, they are noted. The limited owner of this appraisal is the party for whom the work was performed. Possession of this report does not provide title to the items appraised. Possession of this report, any portion of this report, or any copy thereof, does not include the right of publication without the appraiser's written consent. Use of the information contained in the appraisal is invalid if all items listed in the Table of Contents are not present. Each item described in this report has been photographed and file copies of the photograph(s) as well as a copy of the report are maintained in the appraiser's files for at least five years after the report date. Third parties may rely on the information in this. report for the defined purpose and intended- use only. Third parties requiring further information than what is in the report must-obtain the written permission of the owner of the appraisal before the. appraiser will discus the report. No changes may be made to this report by. anyone other than the appraiser. The appraiser cannot be responsible for unauthorized alterations. The professional relationship between the appraiser and the client ends with the delivery of this report. Subscriptions Retained for Value Consulting Drucker, Richard -The Guide. Northbrook, IL Rapaport, Martin -Rapaport Diamond Report, New York, NY Gold $1652.00 List of Laboratory Instruments Binocular microscope Leveridge gauge Electronic scale Thermal conductivity diamond tester Touchstone and-acids Ultraviolet light unit Spectrascope ProporEionscope Polariscope Dichroscope Refractometer Chelsea color filter Heavy liquids Diamond light and graded master comparison diamonds Page 4 of 8 Certification • I hereby certify that, to the best of my Irnowtedge and belief: • The statements of fact contained in this report are true and correct- • The reported analyses,.opinions, and conclusions are limited only by the reported assumptions and limiting conditions, and are my unbiased professional analysis; opinions, and conclusions. • I have no present or prospective interest in the property that is the subject ofthis report and 1 have no personal interest or bias with respect to the parties involved. . • My compensation is. not contingent upon the development or reporting of a predetermined value or direction in value that favors the cause of my client, the amount of the value estimate, the attainment of a stipulated result; or the. occurrence of a subsequent event. • I have made a personal inspection of the property that is the subject of this report: • No one provided significant professional assistance to the. person signing this report. • My analyses; opinions, and conclusions were developed, and this report has been prepared, in conformity with the Uniform- Standards of Professional Appraisal Practice. -~~ -_ ._,., _ ~ . !f Cher}e-f;Ynn Grove Certified Gemologist Appraiser, AGS 9/25/2012 Page 5 of 8 Prepared For: Glenna T. Cox Date: 9/25/2012 124 W. Middlesex Drive Carlisle, PA 17013 Item 1 Ring One lady's l OK yellow gold ruby and diamond ring. There is one approximately 5 x 3mm oval faceted ruby set with four prongs with a bypass style double open loop design with one approximately .0075ct round single cut diamond set with four prongs on either side of the center. The ring measures 9.53mm wide at the top, 1.54mm wide at the high polish shoulders, and 1.64mm wide at the base of the ring. The ring is stamped "lOK", weighs 1.Odwt, and measures finger size 4.25. Ruby Attributes Shape and .cut: Oval faceted Measurements: 5.00 x 3.00 x .1.82 mm (approximate) Weight: 0.22 Cts. (estimated) Clarity: Type II; severely included Color: Grayish, medium, Purplish/Red Proportions• Fair Finish: Fair Brilliancy: Poor - 10% to 20% Diamond-Melee Attributes'- -Shape and-cut; Round single cut Measurements: 1.3 mm Number of diamonds:.. 2 Total Weight: .02 cts: (estimated) Clarity: 1-1 'Color. I-J Proportions: Fair Finish: Fair - Total Approximate Value Excluding Tax $28.62 Item 2 Ring. One lady's l OK Balfour "Galaxy II" class ring. The class ring has a 9.5 x 8.Omm oval cabochon red glass. "Eastern Kentucky:State College" encircles the center, with two separate buildings on either ide with Caesar leaf engraving. The ring measures 16.80mm wide at, the top, 6.35mm wide at the shoulders,, and 4.Omm wide at the base of the ring. The ring is stamped "BALFORE IOK", hand engraved DAJ' ;weighs 5.9dwt, and measures fingei size 6.25. Total Approximate Value Excluding Tax $106.32 Page 6 of 8 Item 3 Pendant One lady's 14K yellow gold molte n abstract enlarged stamen with one approximately 7mm freshwater pearl. The pendant measures 23.9 9mm long, 16.53mm wide and 15.08mm deep. There are two approximately .0075ct single cut diamonds burnish set lower off to one side and an oval "O" ring at the top. The pendant weighs 6.3dwt. Pearl Attributes Number: 1 Size: 6.5 Color: Medium cream rose Shape: Mostly round Luster: Medium Diamond Melee Attributes Shape and cut` Round single cut. Measurements: 1.3 mm Number of diamonds: 2 Total Weight: .02 cts. (estimated) Clarity: 1-1 Color: K-L Proportions: Poor Finish: Poor- Total Approximate Value Excluding Tax $173.84 Item 4 Watch One lady's 14K yellow gold "Waltham" 17 jewel watch with one "Speidel" stainless steel and gold toned stretch bracelet. The watch measures approximately 15 x 15mm square with high polished raised angled panels on either side and raised high polish. triangular shapes on the lugs. There isone approximately .OOSct single cut diamond set with four prongs in a white leaf design on .either end of the bracelet where it connects to the watch. The watch is stamped "Waltham 14K 2697". Total-Approximate Value Excluding Tax $93.28 Total Approximate-Value for Ail Items -Excluding Tax: $402.06 Four hundred two dollars and siz cents ~,r ~~ /". _ _ _-~ Signature of Appraiser: f F! C- ~~" ~ -~ ~i_ .. ~-~ _.__ Ch~rie~ynn Grove Certified Gemologist Appraiser, AGS Page 7 of 8 Biographical Background and Qualifications Appraiser's Name Cherie Lynn Grove, G.G., C.G.A. Education: Bachelor of Science, the Shippensburg University, 2000. Graduate Gemologist, Gemological Institute of America, 2006. Registered Jeweler, American Gem Society, 2007. Pear] Grading, Gemological Institute of America, 2006. Pear] Grading Laboratory, Gemological Institute of America, 2007. Identifying Synthetic Diamonds, Gemological Institute of America, 2007 Certified Gemologist, American Gem Society, 2008. Identifying Diamond Treatments, Gemological Institute of America, 2008. Identifying Ruby and Sapphire Laboratory, Gemological Institute of America, 2008. Identifying Emeralds, Gemological Institute of America, 2008. Certified Gemologist Appraiser, America Gem Society;.2008. Identifying Ruby and Sapphire Laboratory, .Gemological Institute of America, 2010. Colored Stone Treatments, Gemological Institute of America, 2012 Understanding Clarity Characteristics and Clarity Grading, Gemological Institute of America, 2012. Business: In the jewelry trade since 2000. Member American Gem Society American Gem Society Conclave 2007-Denver, CO. American Gem Society Conclave 2008-Seattle, WA. American Gem Society Conclave 2010-Boston, MA. American Gem Society Conclave 2012-Miami, FL. Page 8 of 8 x N {~ ~; , r J of ~ t~~` Orli~~ \,u~ f .cat i:- 1=sta(c° Se~~temher X131 Jflllill7 .Icc~ elm :_~ } ~~', ~'~ '~' "~lir REV-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN RES DENTEDECEDENT N PERSONAL PROPERTY ESTATE OF FILE NUMBER DELIA A. LEWIS 0708 Include the proceeds of litigation and the date the proceeds wen; received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1971 OLDSMOBILE CUTLASS $1,750.00 SERIAL NO. 332871M148434 CUTLASS MODEL NO. 33287 2. HOFFMAN-ROTH FUNERAL HOME /PRE-PAID FUNERAL EXPENSES $6,344.29 PAID BY MONUMENTAL LIFE 3. WEBB NOONAN FUNERAL HOME /PRE-PAID FUNERAL EXPENSES $3,127.01 PAID BY FORETHOUGHT #72891848 4. ORRSTOWN BANK CHECKING ACCOUNT $18,605.11 ACCOUNT NO. 108006728 5. SOVEREIGN BANK $300.81 CHECKING ACCOUNT NUMBER 6. MISC. JEWELREY $402.06 Class Ring, Pinky Ring and Watch TOTAL (Also enter on line 5, Recapitulation) I S 30 529 28 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+(12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER DELTA A. LEWIS 0708 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN-ROTH FUNERAL HOME & CREMATORY, INC. $8,052.10 2. WEBB NOONAN FUNERAL HOME $3,749.74 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) GLENNA T. COX Social Security Number(s)IEIN Number of Personal Representative(s) 224-68-8076 Street Address 124 W. MIDDLESEX DRIVE City CARLISLE State PA Zip 17013 Year(s) Commission Paid: 2012 2, Attorney Fees DOUGLAS LAW OFFICE 3, Family Exemption: (If decedents address is not the same as claimants, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees GRANT OF LETTERS & FIRST & FINAL ACCOUNTING $34,905.14 $27,924.11 $940.00 5 Accountant's Fees 6. Tax Return Preparer's Fees 7. VILLAGE CENTER AUTO SALES -Car Appraisal $60.00 8. THORNWALD NURSING HOME $446.38 9. CUMBERLAND LAW JOURNAL -ADVERTISING $75.00 10. THE SENTINEL -ADVERTISING $221.40 11. FILING FEES (INHERITANCE TAX RETURN & 1ST AND FINAL ACCOUNTING) $50.00 12. APPRAISAL FEE TO MOUNTZ JEWELREY $140.00 13. DATE OF DEATH VALUE FEE TO SOVEREIGN BANK $20.00 TOTAL (Also enter on line 9, Recapitulation) $ 76 583.87 (If more space is needed, insert additional sheets of the same size) o~ ~.. Village Center Auto Sales, 55 army Heritage Dr. Carlisle, ~a. I Scott Cox owner Village Center Au the 71 Oldsmobile Cutlass V1N# 3328711 estate of Delia Ann David. This car ha years and will reciuire a great deal of worthy in the future. This car is not s~ Chia time nor will it pass a Pa. state in. several prior rust repairs that are it car also had a prior re-paint in the pa. Sales have evaluated X1'48434 owned by the sat in storage for several it#ention to be made road fe to drive on Pa. roads at pection. it has had need of repair again. The t. The car does run and the engine appears and sounds okay.' However ,it has a fairly large oil leak on both sides of the eng~ne and most rubber components are in need of replacement due to dry rot. The I tires will also require replacement as well as brake ~~ lines/hoses/wheel cylinders etc.etc. The car is a restor~abie classic and will take significant restoration/repair to rnake it road worthy again. In my opinion this] car is worth approx. ,~ $175fl.00 in its current condition. ,~ Village Ceriter Auto Salea{I SS Amity Heritage Dr. Caolble, PA 77013 DI#1~ B63?~420 ____ ~• Thornwald Home 442 Walnut Bottom R.o~d Carlisle, PA 17013 Telephone: (717) 249-=1118 Glenna Cox 17.4 W. Middlesex Drive Carlisle, PA 1701.'> STAT ~ M ~ ~ ~T~ Statement Date: 05/O ij 2~;:1:% Due Date: 05/?_5/?!)1<~ Amount Enclosed $ Amount Due: $ 446.38 Account #: 1286 RE: Delia A Lewis -- Date ---------- -- Description Days want _ Rate Char es Pa r~ments __ Balances _ Balance B/F ~ 7,984.67 7,984.67 04/26/12 COX, GLENNA T 7,984.67 .00 04/07,12 Medical Supplies 5 12.16 38.42 38.42 04/24/12 Personal Supplies 4 1.01 4.04 42.46 04J28)12 Incontinence Supplies 1 10.92 10.92 53.38 04/18/12 - 04/30/12 Room & Board -Semi-Private 13 276.00 3,588.00 3,641.38 04/01/12 - 04/17/12 Room & Board -Semi-Private 17 267.00 4,539.00 8,180.38 04/01/12 - 04/30/12 Room & Board -Semi-Private 30 267.00 -8,010.00 170.38 05/01/12 I I Room & Board -Semi-Private 1 276.00 276.00 446.38 I I j Current 1 31-60 Days 61-90 Days Over 90 Days ~~ Amount Due `' _ .00 .00 .00 446.38 L----- 446.8 --~------ --- --_ EFFECTIVE: 06/01/?_012 Cable charges wi!I increase by $1.00 Payments MUST be rece~~red by the .5th of each month. Statement Date: 05%01/?i'1 ;' brie Date: 051251?(1-' Delia ALewis -Account #: 1286 Thornwald Name 442 Walnut Bottom Road Carlisle, PA 17013 Telephone: (717) 2.49-4118 ., T',nrnwalri F1nmE' ~~Rp - ~I~~1tlC~ ~8tai~ R@~OI"t 5t7i1f) i'L'35%. ilii Pl~ii D~-~1 ~1 Facility id: Facility Name: Resident Name: Resident id: Room: Item GL Code: Date: Item Description: .. Ifsrn Id: ~ Quanlil~ / JOM _~ P.+cE; 200 Thornwald Home Lewis, Delia 1286 Oa/07/2012 10.59PM Baza Antitungal 5oz tube TH-0066 1 /TUBE 12."6 04/28/2012 04 21AM Briefs Regular Prevail TH-0070 1 ~ PACK 10.',02 04l?_4/2012 08:32PM Dentaswab Treated (10/pack) TH-0114 t /PACK 1.C)1 04/26/2012 12:45PM Dentasvdab Treated (10lpar.,k) TH-0114 1 ; F'ACI< 1.(11 04/26/2012 10~:~9PM Denfaswab Trealod (10/pack) TH-0114 1 /PACE( 1 01 04/29/2012 10~03PM Denlaswab Treated (101pack) TH-0114 1 PACK L;i1 rldl25/2012 0228PM Dyrem Slip grip TH-0222 2 / EACI~~1 15.0,11 (1412.dl2012 Oft 32PM Glove Medium Vin'Jf Powder-Free Th-I-0089 1 /BOX ,', C'~3 :)-,c ~aEi ~~ ~~u'_ia ~'iv° L"v I~iCS AdUll Pfe Cilil.llll (JOi~OUxf I r~-U(18~ > > tSGX I;.r~,i Totals for GL Code : 10 53.38 Totals for Delia Lewis 10 53.?8 CC_Activi,ybyResident,rpi Page 34 of 58 PAY TO THE Cumberland Law Journal ORDER OF _ _ _..._-- -------- -------..-- -- -.._ _. _ ___~ $ 7 5 .0 0 Seventy-five and 00/100 _.___ ___ DOLLARS ~ ... ORRSTOWNBANK /' ,-~4 Lewes ~,~~1 jrndilinn ofErcrll*nce ~~ J ~ '~ -C~ R __ _ ..-_..__.. ~ .__.._. -- --- - ~~ - _ _. _ - rm n'002646ii' ~:03L3~5036~: L08 LL2636u' ,. ..Tn..-~ .. ,..,,. _~.. - ... .. Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: William P. Douglas, Esquire RE: Delia Ann Lewis Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on the following dates: July 27, August 3, and August 10, 2012 Advertising Cost $ 75.00 Proof of Publication $ 0,00 Second Proof Request $ 0.00 Payment received $ 0 .00 Total Amount Due $ 75.00 Payment received by --- .. RECEIPT FOR PAYMENT --------------- ------------------ GLENDA EARNER STRASBAUGH Receipt Date: 6%26/2012 Cumberland County - Register Of Wills Receipt Time: 10:02:25 One Courthouse Scc{{uare Receipt No. 107041 Carlisle, PA 17Q13 T,EWIS DET_~IA ANN Estate File No. 2012-00708 Paid By Remarks: DOUGLAS- LAW OFFICE HEA -------------------- ----- Receipt Dist--rib ution ----- -- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 360.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 24.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN Check# .'596 ---------------- $427.50 Toi.al .Received..... .... $427.50 ,• 2668 ~~~ ~~ ~POlels trB~iA y 60-1503.313 °~ DATE ~ ~~ -~ ~ w ---"p u'00266811' ~:03L3i5U36i: iut;r +ice~e~~- 0 0 O V fA ~///~' V/ ' ~/ O E.i.~ O O W `~ r-~ = -_ ~~,~i ~_ /. h Y W _ J ;J ~ ~. ~' ~ `~'~ ~. ~ . ~ .. j V. J V ~ .- _ - ' .J w -~-~ ~o N ~^'~ f0 Y Q u ~i 2 N f6 ._ x 1~ ~ .~- cc ~ G ri ~ LL N ~ ~~ "r ~~ ~ ~ .^.. "7 f 1 ~~!^ ~ ri n y ~. ~ ~i N W = 5 _ _ J Y J O v - ~ .- 0 0 O 'V a~ 0 3 N (0 m O Y O U pp N ~p L U c~v 0 0 0 o g ~V 69 6A 69 0 ~ Y fsi Efl ~ W = ~ ~ C '" ~ 0 ~ c6 a ~ ~, m a r ~ H R ~ y m ~ ~ ~ ~ ~ m r N ~ N .--, N ,~ N1 ~ V~ ~o r~ ~ ~ ... ~ • r~ rl Vl • r-1 ~ O p .~ .r '~ r~ ~' ~ ~. o ~ ~ ^' ti P. ~ .. ~ " ~ .p x • ~~x ~ V • ~ O ~ ~ J yy W ~ V b ~ 0 ~ ~ G H~~, ~ ~ O ~--~ 1/~ M .~ `d' DOUGLAS LAW OFFICE IOLTA ACCOUNT (717) 243-1790 , 43 W SOUTH ST. GARLISLE, PA 17013 .~~. DOUGLAS LAW OFFICE 43 W. Sortdt St. CARLISLE, PENNSYLVANIA 17013-0262 WILLIAM P. DOUGLAS, ESQ. CERTIFIED AS A CIVIL TRIAL ADI~OCATE BY THE NATIONAL BOARD OF TRIAL ADVOCACY September 13, 2012 Sovereign Bank P.O. Box 12646 Reading, PA 19612 717-243-1790 FAX: 717-243-8955 EMAIL: douglasla~i earthlink.net Re: Estate of Delia Ann Lewis Social Security No: 405-34-5318 Account No: Unknown - 2 CDs and Checking Acct. Date of Death: May 2, 2012 Dear Sir or Madam: I represent the Estate of Delia Ann Lewis who has two Certificates of Deposit, $50,000 and $47,000 respectively, and a checking account with you. I apologize I do not have any account numbers. I have enclosed a check in the amount of $20.00 and request that you provide us with the following information: 1. The balance of the all accounts on her date of death, May 2, 2012; 2. The names on the accounts; 3. How the accounts are owned (joint tenants with right of survivorship, etc.); and 4. When the accounts were opened. And if they are joint accounts, the date they became joint accounts. A Short Certificate is enclosed for your file. If you need additional information, please let me know. Thank you for your assistance. Sincerely, D Heather A. Barbour Legal Assistant WAA:hb Enclosures ['he Senf~nel www.cumberlink.com ~itfo"~'v `GI P~ .AxusstE srt~xEriseuRCZ swan camrtv AOUGLAS LAW OFFICE 43 W. SOUTH ST. GARLISLE, PA 17018 717-243-1796 AD NUMBER PAGE NO. 414024 1 of 1 BILL DATE SALESPERSON 09123/12 wolfc START !)ATE STOP DATE 09/08112 09122/12 AD NUMBER AD WN CtA33 LINES 414024 EXECUTOR"5 NOT(CE LETT&RS TESTAMEN 10 PUBLIG NOTICES 40 ~ 2 cats Publication insertions Rate Net Amount Gross Amount 3 THE SHNTINEL -LEGAL 3 LGL 5212.40 TOTAL AD GHARC3E $212.40 3 PROOF OF PUBLICATION 04PRF $7.00 3 MOBILE SITE MOB2 52.00 purchase Order E'st. Della Ann Lewis PAY THI8 AMOUNT $221.40 $265.Bt3* *AFTER 10118/12 Thank you for advertising with The Sentinel! Deadline far in-column legal »ds Is 4:00 p.m. two business days prior to date of insertion. For ques#ions, call (717) 240-7130. THE SENTINEL c/o LEE NEWSPAPERS PO BOX 540 WATERLOO IA 507040540 ~~~~ taaxaa 11+# DOUGLAS LAW OFFICE 43 W. SOUTH ST. CARLISLE, PA 17013 nnwm ~n~ pwaon mrrr yawrP~Y++I~c Check # ^ Credit Card ~fi~®~®~ Acct #: ~P, b>3te: m m '~ N~tiN on Credit acrd ~ s19~~~e vteaee metre eneeks e~wt~le te: THE SENTINEL THE SENTINEL c/o LEE NEWSPAPERS PO BOX 540 WATERLOO (A 50704-0540 Legal Ad Number 41x024 Billing Dafe t?9tz3/12 Amount Due $ 221.40 ~~ Amount ~`Enclcsed $ THE SENTINEL c/o LEE NEWSPAPERS PO @OX 742848 C1NCtNNA7'IOH 462742648 i,i„~tittttti,pit,~tti~.~„i,ttitit~it,uttit,~ailt,~ti,~,il 2~,54D2DDDDDDD414D24DDDDDf7DD0^!7t]D17026568DDD002214D2 ~A}() P.001 1001 ~,~ ~~ ~;~d ~'~ ~