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HomeMy WebLinkAbout01-15-13 (2)150561D1D5 ~~ ~ ~E'$~ EX (ii-iz){Fn ` OFFICIAL USE ONLY PA Department of Revenue pennsytvanaa G~~~R;~a=..-~~~1~~ Gounty Code Year File Num r Bureau of IndividuatTaxes INHERITANCE TAX RETURN ~ ~ ~"~~~~~~ ~~ ~ ~ ~~ PO BOX 280601 ~ Harrisbur ,PAi'7128-0601 RESIDENT DECEDENT ~~ l ENTER DECEDENT INFORMATION BELOW 10192012 01081923 Decedent's Last Name Suffix Decedent's First Name MI Laviska Genevieve M (ff Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number - THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW C~ 1. Original Return ~ 2. Supplemental Retum +~ 5. Future Interest Compromise (date of death after 12-12-82) Q 8. Decedent Maintained a Living Trust (Attach copy of trust.) C~ 11. No Taxable Asset Return ~ 3. Remainder Return (date of death Prior to 12-13-82) O 6. Federal Estate Tax Retum Required ~ 9. Total Number of Safe Deposit Boxes C~ 12. Election to Tax under Sec. 9113(A) (Attach Schedule O.) Q 4. Agriculture Exemption (date of death after 7-1-2012) ~ 7. Decedent Died Testate (Attach copy of will.) C~ 10. Litigation Proceeds Received CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number : Joanne L Slusser {717) 254-6272 ~ REGISTER OF L~IJSE ONL ~ . __ / First Line of Address `~'" r~' I-..", ~" v ~`~ ~^~! 236 S Pitt St ° - ~, ~ . Second Line of Address _ _ _ _ _ _ _ _ _ _ .. ,. .. ,.. -r-; .. , ~ ~- .................................................................................. ................................................................. _ x .. ~; ,. p_.~. _ _..-. _ DATE FILED City or Post Office ......... ..................... ............. ............................... . State ZIP Code .............. ............... _._____.___..__. ~, ..; f Carlisle Correspondent's email address: beach 2$403 ahOO.COm ~~ ~,.a' } ~~;F ~ ~. ~. ~.~~ ~ , r ,~, .x i w.. .~;~ Under penalties of perjury, I declare 1 have examined this return, inGuding accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on alt information of which preparer has any knowledge. SIGNATUR OF PERSON RESPONSIB FILING RETURN DATE . 236 3'Pitt St Carlisle PA 17103 --- -__ SIGNATURE OF PREPARER OTHER THAN REPRESENTAT-VE DATE ADDRESS PA 17013 ~1 PLEASE USE ORIGINAL FORM ONLY 1505610105 Side 1 1505610105 h~1 J 1505610205 REV-1500 EX (FI) Decedent's Social Security Number Decedents Name: Genevieve M Laviska RECAPITULATION __ 1. Real Estate (Schedule A) ............................................. 1. 0.00 2. Stocks and Bonds (Schedule Bj ....................................... 2. 4,606.50 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ! 0.00 4. Mortgages and Notes Receivable (Schedule D) ........................... 4.. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property {Schedule E)....... 5. ....... 41,282.71 ...........................................................................: 6. Jointly Owned Property (Schedule F) C~ Separate Billing Requested ....... 6. 0.00 7 ransfers 8~ Miscellaneous No n-P pl y a r I l 0 00: o ( ) p g q Bi in Re nested........ Se rate Sched ule t 7. . 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ; 45,889.21 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 15,054.88 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. 0.00 11. Total Deductions (total Lines 9 and 10) ................................. 11. ! 15,054.88 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. : 30,834.33 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ...... ...........................................................................: an election to tax has not been made (Schedule J) ............ 13 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 30,834.33 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 _ .. ... .. __._ .._... ..._ . _.. -.. (a)(1.2) X .0____ 15. 16. Amount of Line 14 taxable 1, 387.54 ~ at lineal rate X .0 ____ 1 ~. ~ 1, 387.54 17. Amount of Line 14 taxable at sibling rate X,12_ 17. 18. Amount of Line 14 taxable _. _ _ - _. at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 1,387.54 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT >~ Side 2 1505610205 15O56102D5 REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENTS NAME Genevieve M Laviska STREET ADDRESS Thornwald Nursing Home 442 Walnut Bottom Rd _ CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2, line 19) 2. CreditslPayments A. Prior Payments ~~_~ B. Discount 69.38 3. Interest 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. (1) 1,387.54 Total Credits (A + B } (2) 69.38 (3) (4) (5} 1,318.16 Make check payable to: I~EGIST~R ~F WILLS, 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 .......................................................................................... [] b. retain the right to designate who shall use the property transferred or its income ............................................ ~] c. retain a reversionary interest .............................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable-upon~ieath bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains abeneficiary designation? ........................................................................................................................ --- U IF THE ANSWER TO ANY o~ THE ABOVE CUESTIONS IS YES, Y4U Ii~UST COIVIPI.ETE SCHEDULE G AND FILE IT AS I=ART flF THE RETURN, For dates of death on or after July ~ , 1994, and before Jan. 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. X9116 (a) (1.1) (i}]. For dates of death on or after Jan, 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 9 percent [72 P.S. §9116 I;a} (1.1 } (ii)]. The statute does not exempt a transfer to a surviving spouse frorvl tax, and the statutory requirements for disciasure 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, 2~t~4: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent er a stepparent of the child is rJ percent 172 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 4.5 percent; except as noted in ~2 P.S. ~9116(a}~1)]. • The tax rate unposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent (72 P.S. §9116(a){1.3)). t1 sibling is defined, under Section 9192, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-i5o8 EX+ (o8-i2) :~~:: SCHEDULE E ~<~~ ~<f~ ~~~~~~lv~r-si~ .~ 7EPARTh'Ei~TOfREVE"!UE ~~,~~~ ~~~~ ~}~~®~~~~ & ~~~~„ I~HERITAN~E T!;X P.ETUP,P1 ~~~~~~~L ~~®R'E~~ 8 RESiE3fRT D{~fEQENT --- ----- ESTATE OF: FILE NU~'BBER: Genevieve M Laviska 21121276 TOTAL t~tsc~ enter on Lire ~, REeapit~:iatic~n~ ~ 41,282.71 If mire space is IIe2d2~i, use a~dEtianaE sheets a` Raper of the sa~ie size. C~EpAR-; MENT OF REVENUE INHERi~r!.NCE TN: RETURt'J RESIDE~JT DE EQENT FNN~p~1\~g9'~~Ltltll~i~ E~~~~p~g;rr~Eff~ ~3'~ V /e4~~~I1~~~~~~ Y ~ 4~~~~ ESTATE OF FILE NUt~iBEl~ Genevieve M Laviska 21121276 E?ecedent's debts must be reported on Schedule I. ITEy PJUhIBER QESCP.Ii:'TION Ai`~OUNT A. FUN~Rr~~ EXPEND[=5: _ _ _ _ _ ~ ~ Executrix flight and room, car (N. Carolina} 1,249.91 :Andrews Funeral home 2,153.34 Hanover Monument Works (Headstone) 775.05 St Stanislaus Church Fees 1,600.00 Flowers _ _ _ _ 271.77 __ ~. At~h~9l~<ISTRATIVE COSTS: 1. Persona: Representative Cammissic;ns: iVarne(s) of Persarai Repres~~ntative(si Street Address City state ZIP Year;s~ G~~:mission Faid: 2 3. ~. 5. 5. ;, Attorney Fees: Family Exernptian: ;If decedent's address is no` the same as claimant's; attach explanation.? Ciai~r~ant Street Address City State ZIP Relationship cif Claimant to Ger_edert Prabate Fees: Accountant Fees: Tax RetE:rn Pre:~ar~:r Fees: :.Expenses for newspaper notices -The Sentinal and Cumberland Law Journal Postage plus certified Itrs, copies for notices, copies of Death Cert., copies of Short Certificate .Filing fees for Inheritance Tax Return __ __ _ _ Medical (Millennim Pharmacy Systems} Federal and State 2012 Tax Returns(estimate) Thornwald Nursing Home (5308.43} plus dentist at Nursing home(15.00} T~JTAL {Also enter an Line 9, Reeapitulatian} ~ $~ 2, 850.00 261.50 0.00 0.00 168.96 42.69 15.00 223.23 120.00 5, 323.43 15, 054.88 If n~or2 space is needed, use additi:,rai sheets oI paper of the sarf~e size. ~~'`~ ~~nns~lvan~~ SCHEDULE ~7 L~=PARtMtENI UFREVE"JJ~ INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Genevieve M Laviska 2112127fi RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSONS} RECEIVING PROPERTY Do Not List Trustee{s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a} (1.2},] 1 • Joanne L Slusser 236 S Pitt St Carlisle PA 17013 :Daughter 113 2 Mary M Snoke 300 Walnut Bottom Rd Carlisle PA 17013 Daughter 1/3 3 James Laviska 510 Tupelo Dr Melbourne FL 32935 Son 1 /3 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: i. n!a B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. __ _ _ ____ __ _ _ _ n!a TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ , 0 If more space is needed, use additional sheets of paper of the same size. REV-1503 EX+ (8-12) ;:;tir:: DE~AF:TMENT O~ REVEWUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDVLE B STOCKS & BONDS ESTATE ®F Genevieve M Laviska FILir ~~~$~~ 21121276 All property .ll~intly ~uantned vs+ikh right eaf survivorship must be disci®s~cl on Schedule F, If mare s~a~e is nee~~, insert additiazat sheets of file samz size Date 11/13/12 Page 1 Primary Account @XXXXXXXXXXX@943 Enclosures Genevieve M Laviska 300 Walnut Bottom Rd Carlisle PA 17013 Account Title Reward Checking Account Number Previous Balance 3 Deposits/Credits 2 Checks/Debits Service Fee Interest Paid Current Balance C H E C K I N G A Genevieve M Lavi @XXXXXXXXXXX@943 2,324.16 40,358.04 1,401.20 .00 1.71 41,282.71 C C O U N T S aka Check Safekeeping Statement Dates 10/12/12 thru 11/13/12 Days In The Statement Period 33 Average Ledger 29,951.14 Average Collected 29,951.14 Interest Earned 1.71 Annual Percentage Yield Earned 0.060 2012 Interest Paid 20.74 Total Fox This Perioc Total Overdraft Fees Total Return Item Fees $.00 $.00 Total Year-to-Date $37.00 $.00 Deposits and Additions Date Description 10/22 DEPOSIT 0 B TRUST DEPT PPD 11/02 XXSOC SEC US TREASURY 303 PPD 11/06 DEPOSIT 0 B TRUST DEPT PPD 11/13 Interest Deposit Amount 39,170.99 1,156.00 31.05 1.71 Date 11/13/12 Page 2 Primary Account @XXXXXXXXXXX@943 Enclosures Genevieve M Laviska 300 Walnut Bottom Rd Carlisle PA 17013 Reward Checking @XXXXXXXXXXX@943 (Continued) Electronic Debits and Withdrawals Date Description Amount. 11/05 PREMIUM UnitedHealthcare 245.20- PPD 11/13 returned soc sec due to death 1,156.00- Daily Balance Information Date Balance Date Balance Date Balance 10/12 2,324.16 11/02 42,651.15 11/06 42,437.00 10/22 41,495.15 11/05 42,405.95 11/13 41,282.71 Interest Rate Summary 10/11 0.4500000 10/22 0.2500000 THANK YOU FOR BANKING WITH ORRSTOWN BANK ~, Corporation ~~881, 4 III~1'II~'~~II'II1~~1~11~1~111~~~~~1~1111~~11~~11~'~~11111'lllll~ GENEVIEVE M LAVISKA 215 STONEHEDGE DR CARLISLE PA 17015 ~,omputershare Computershare Trust Company, N.A. PO Box 43078 Providence, RI 02940-3078 Within USA, US territories ~ Canada 800 446 2617 Outside USA, US territories ~ Canada 781 575 2723 vvww.computershare.com/investor FedEx Corporation is incorporated under the laws of the State of DE. Holder Account Number 00000870862 Company ID SSN/TIN Certified FEDX Yes T' FedEx Corporation -Direct Registration (DRS} Advice Transaction(s) I Total Date I Transaction Description CUSIP I Class ShareslUnits Description 16 Dec 2011 Transfer 50.000000 31428X106 Common Stock Account Information: Date: 16 Dec 2011 (Excludes transactions pending settlement) Current Current Total ' I Dividend Reinvestment Direct Registration Price Sharesl , per Share i Value ($) Units CUSIP Class Description Balance Balance 0.000000 ~ 50.000000 50.000000 84.890000 4,244.50 31428X106 Common Stock IMPORTANT INFORMATION -RETAIN FOR YOUR RECORDS. This advice is your record of the share transaction in your account on the books of the Company as part of the Direct Registration System. This advice is neither a negotiable instrument nor a security, and delivery of it does not of itself confer any rights to the recipient It should be kept with your important documents as a record of your ownership of these shares. No action on your part is required. The IRS requires that we report the cost basis of certain shares acquired after January 1, 2011. If your shares were covered by the legislation and you have sold or transferred the shares and requested a specific cost basis calculation method, we have processed as requested. ff you did not specify a cost basis calculation method, we have defaulted to the first in, first out (FIFO) method. Please visit our website or consult your tax advisor if you need additional information about cost basis. Upon request, the Company will furnish to any shareholder, without charge, a full statement of the designations, rights (including rights under any Company's Rights Agreement, if any), preferences and limitations of the shares of each class and series authorized to be issued, and the authority of the Board of Directors to divide the shares into series and to determine and change rights, preferences and limitations of any class or series. Assets are not deposits of Computershare and are not insured by the Federal Deposit Insurance Corporation, the Securities Investor Protection Corporation, or any other federal or state agency. If you da not keep in contact with us or do not have any activity in your account for the time periods specified by state law, your property could become subject to state unclaimed property laws and transferred to the appropriate state. 40UDR FEDX OOHSAB (Rev. 1/11) Please see important PRIVACY NOTICE on reverse side of statement OOICS0003.D.MUi 3462/0088(4/010345 FedEx Corporation (FDX} _~u 94.60 ~~ .35 0.37°!° 4:OOPM ESTQAfter Hours : 94.fi0 0.00 (0.00%)05:27PM EST dd to Portfolio .::: :............... GO Historical Prices Get Historical Prices for: • - - .-... --:.,:..,..... Daily Weekly Monthly Dividends Only Gefi Prices -~~ Oct 19, 2012 93.24 93.45 91.8 92.'C 1 2,4 4,300 9'G._96 Close price adjusted for divide s and spfit First ~ Previous ~ Next ~ Last Erices DALEY ZUGKER MEILTON MINER & GINGRICH, LLC 63 5 N. 12th Street, Suite 101 Lemoyne, PA 17043 For any questions regarding this invoice contact Janet M. Fisher, Billing Manager @ 717-724-9821. Ms. Joanne L. Slusser 236 S. Pitt Street Carlisle, PA 17013 December 31, 2012 Inv #: 136741 RE: Estate Administration of Joanne L. Slusser Client No. 12-258 Matter No. 001 DATE LAWYER DESCRIPTION 12/13/12 PCZ Initial Consultation (flat fee) Totals RECEIPTS 12 12/12 RECEIPTS 12 21/12 HOURS RATE AMOUNT 2.00 $0.00 350.00 2.00 $350.00 $350.00 $2,500.00 Total Payments $0.00 _~---~' -~r~7tit {dill ~itt~ ~r~:t<tiitcnt STATE OF NORTH CAROLINA COUNTY OF NEW HANOVER LAST WILL AND TESTAMENT OF GENEVIEVE LAVISKA I, GENEVIEVE LAVISKA, also known as GENEVIEVE MARGARET LAVISKA, and GENEVIEVE DUNITSON LAVISKA of the County of New Hanover, and the State of North Carolina; being married to MIKE LAVISKA; having three children, being JOANNE L. SLUSSER, JAMES MICHAEL LAVISKA, and MARY MARGARET SNOKE; do make, publish and declare this to be my LAST WILL and TESTAMENT; and I hereby revoke all Wills and Codicils heretofore made by me. ARTICLE ONE PAYMENT OF DEBTS AND EXPENSES 1.1. I direct that my funeral expenses, including the costs of a suitable grave marker, and all legal debts allowable as claims against my estate to be paid out of the general funds of my estate. ARTICLE TWO ADMINISTRATION EXPENSES 2.1. I direct that all estate, inheritance, and other death taxes (including interest and penalties, if any) together with the expenses of my last illness and all administration expenses, payable in any jurisdiction by reason of my death (including those taxes and expenses payable with respect to assets which do not pass under this MY LAST WILL and TESTAMENT) shall be paid out of and charged generally against the principal of my residuary estate. 2.2. I waive any right of reimbursement for, or recovery of those death taxes and administration expenses, except reimbursement for, or recovery of any federal or state estate tax attributable to property in which I have a qualifying income interest for life, or over which I have a power of appointment. ARTICLE THREE DISTRIBUTION OF MY ESTATE 3.1. I give, devise and bequeath unto my husband, MIKE LAVISKA, if he shall survive me, absolutely and in fee simple forever, all of my property, both real and personal, tangible and intangible, wheresoever situated and howsoever held, including any property over which I hold the power of appointment, my Residuary Estate. ARTICLE FOUR PRESUMPTION OF SURVIVAL 4.1. If my husband MIKE LAVISKA and I shall die u der such circumstances that there is not sufficient evidence LAST WILL AND TESTAMENT OF GENEVIEVE LAVISKA 1 to determine the order of our deaths, then it shall be conclusively presumed that he predeceased me; and my estate shall be administered and distributed in all respects in accordance with such presumption. 4.2. If any of my children JOANNE L. SLUSSER, JAMES MICHAEL LAVISKA, or MARY MARGARET SNOKE and I should die in a common disaster or accident, or under such circumstances as to render it doubtful which of us died first, it shall be conclusively presumed that said child predeceased me; and my estate shall be administered and distributed in all respects in accordance with such presumption. 4.3. If any other Beneficiary and I should die in a common disaster or accident, or under such circumstances as to render it doubtful which of us died first, it shall be conclusively presumed that said Beneficiary predeceasedme; and my estate shall be administered and distributed in all respects in accordance with such presumption. ARTICLE FIVE FAILURE OF SURVIVAL 5.1. If my husband, MIKE LAVISKA, shall fail to survive me, I give, devise and bequeath my Residuary Estate unto my children JOANNE L. SLUSSER, JAMES MICHAEL LAVISKA, and MARY MARGARET SNOKE, if each shall survive me, such that there shall be given, bequeathed, and devised: S.l.l. One (1) equal share as is practical unto my daughter JOANNE L. SLUSSER, 5.1.2. One (1) equal share as is practical unto my son JAMES MICHAEL LAVISKA, and 5.1.3. One (1) equal share as is practical unto my daughter MARY MARGARET SNOKE. 5.2. If any of my children, JOANNE L. SLUSSER, JAMES MICHAEL LAVISKA, or MARY MARGARET SNOKE shall fail to survive me, I give, devise and bequeath that share of my Residuary Estate that said JOANNE L. SLUSSER, JAMES MICHAEL LAVISKA, or MARY MARGARET SNOKE should have taken, had she/he not failed to survive me, unto her/his then living natural issue, per stirpes', the share their ancestor would have taken if living. 5.3. If any of JOANNE L. SLUSSER, JAMES MICHAEL LAVISKA, or MARY MARGARET SNOKE fail to survive me, not leaving natural issue, I then direct that that share that said JOANNE L. SLUSSER, JAMES MICHAEL LAVISKA, or MARY MARGARET SNOKE should have taken, had she/he not failed to survive me, be given, bequeathed, and devised in as equal shares as is practical among the surviving of JOANNE L. SLUSSER, JAMES MICHAEL LAVISKA, and MARY MARGARET SNOKE such that there shall be one (1) equal share to each of the survivors thereof, or per stirpes•, unto the natural issue thereof, the share their ancestor would have taken if living. ARTICLE SIX APPOINTMENT OF MY EXECUTOR 6.1. I nominate, constitute and appoint my husband, MIKE LAVISKA, as Executor of this my LAST WILL and TESTAMENT. 6.1.1. If MIKE LAVISKA fails to survive me, or is otherwise unable or unwilling to serve as Executor, I then nominate and appoint my daughter JOANNE L. SLUSSER as First Successor Executor, my son JAMES MICHAEL LAVISKA as Second Successor Executor, and my daughter MARY MARGARET SNOKE as Third Successor Executor of this my LAST WILL and TESTAMENT. 6.1.2. If all of MIKE LAVISKA, JOANNE L. SLUSSER, JAMES MICHAEL LAVISKA, and MARY MARGARET SNOKE fail to survive me, or are unable or unwilling to serve as my Executor, I then give the last serving of MIKE LAVISKA, JOANNE L. SLUSSER, JAMES MICHAEL LAVISKA, and MARY MARGARET SNOKE the power to appoint a Successor Executor to serve in his or her place. 6.1.2.1. Any Successor Executor so appointed shall have the same powers, duties, and obligations of the original Executor named herein. LAST WILL AND TESTAMENT OF GENEVIEVE LAVISKA 6.2. Absent death, no resignation by my Executor shall be effective until written: 6.2.1. Notice of ability not to serve shall be given to the Successor Executor and the Court of competent jurisdiction by my Executor, and 6.2.2 Acceptance of the obligation to serve shall be given by the Successor Executor to the Court of competent jurisdiction. 6.2.3. Any inter vivos designation of a successor may be revoked by my Executrix or Trustee (Fiduciary) at any time before it becomes effective. 6.3. No Executor of this my LAST WILL and TESTAMENT shall be required to furnish bond, or other security, as Executor. 6.4. No Executor shall be liable for errors of judgement in good faith or for the acts or neglect of preceding Fiduciaries. 6.5. I specifically give any Executor that serves on my behalf authority to appoint an agent within the State of North Carolina to accept service, represent him/her before the courts, and to conduct that business which he/she may not be able to conduct since he/she is not a resident of the State of North Carolina. 6.6. As for compensation that may be received by my Executor for services pursuant to probate of this MY LAST WILL and TESTAMENT, if: 6.6.1. My husband MIKE LAVISKA shall serve as Executor of this MY LAST WILL and TESTAMENT, he shall receive no fee pursuant to the probate of this MY LAST WILL and TESTAMENT, but 6.3.2. Other than my husband MIKE LAVISKA shall serve as Executor of this MY LAST WILL and TESTAMENT, she/he may receive a fee of one percent (1 °io) of the value of the assets so held in my Estate. 6.7. My Executor may receive reasonable reimbursement for the expenses incurred pursuant to his/her duties as my Executor. 6.7.1. My Executor may waive this reimbursement. ARTICLE SEVEN POWERS AS TO MY EXECUTOR 7.1. I confer upon my Executor all the powers granted to fiduciaries under the laws of the state of North Carolina, and particularly under the statutory provisions contained in Code Section 28A-13-3, and Section 32-27, subject to the restrictions of North Carolina General Statute, Section 32-26, in effect at the signing of this MY LAST Will and TESTAMENT whether my estate is administered in the state of North Carolina or elsewhere. 7.1.1. I incorporate that statute into this agreement by this reference. 7.2. In addition to any powers granted by Law, I give my Executor power, exercisable in the discretion of my Executor and without Court Order, to retain, sell (at public or private sale), exchange, lease for any term (even though commencing in the future, or extending beyond the date of final distribution of my Estate), mortgage, pledge, or otherwise deal for any purpose with the property, real or personal, from time to time comprising my Estate, for such consideration and on such terms (with, or without security) as my Executor shall determine; to borrow money for any purpose, at interest rates then prevailing, from any individual, bank, or other source, irrespective of whether that lender is then acting as an Executor; to invest in any property whatsoever; to compromise or abandon any claims in favor of, or against my Estate; to hold any property in the name of a nominee, or in bearer form; to employ accountants, depositories, attorneys, and agents (with or without discretionary powers); to execute contracts, notes, conveyances, and other instruments, including instrument, containing covenants and warranties binding upon and creating a charge against my Estate, and containing provisions excluding personal liability; to make distributions wholly in cash or in kind, or partly in each; to allot different kinds, or disproportionate shares of property, or undivided interests in property among the Beneficiaries; and to determine the value of any property distributed in kinds LAST WILL AND TESTAMENT OF GENEVIEVE LAVISKA 3 7.3. I direct that in making distribution of Iny estate, the decisions of my Executor, or Trustee, in making allocations in fulfillment of the bequests and devises hereinbefore set forth, and described be absolute and final, and binding upon all persons. ARTICLE EIGHT MY EXECUTOR'S POWERS AS TO ANY BENEFICIARY WHO SHALL BE LESS THAN TWENTY-ONE (21) YEARS OF AGE 8.1. If any of my Estate principal or income shall be bequeathed in a Beneficiary be less than twenty-one (21) years of age, my Executor shall have the authority, in my Executor's discretion, and without court authorization, to make payment or distribution of any principal and/or income vesting in and payable to any Beneficiary in any one or more of the following ways: 8.1.1. Paying the same to the parent, guardian or other person having the care and control of such Beneficiary and the receipt of such payee shall be full acquiescence to my Executor, 8.1.2. Paying the same to any relative of the Beneficiary as custodian for the Beneficiary under any applicable Gifts to Minors Act, or 8.1.3. Select a custodian for the Beneficiary under the Uniform Gifts To Minors Act or under the Uniform Transfers To Minors Act of the jurisdiction where the Beneficiary resides without court order, or 8.1.4. Deferring payment or distribution of any part or all thereof until the Beneficiary reaches twenty-one (21) year of age, meanwhile applying to such Beneficiary's use so much principal and income therefrom, and at such time or times as my Executor may deem advisable, or 8.1.5. Distribute or pay part or all of the Beneficiary's property to the Trustee of any trust created for the sole benefit of the Beneficiary. 8.2. My Executor, in her/his discretion, may apply part or all of the Beneficiary's property for the Beneficiary's support, health, and/or education. 8.2.1. If my Executor decides that such distributions for said Beneficiary's health care and/or educational tuition are in the best interest of the Beneficiary, my Executor shall make all such distributions, (said distributions to be made as much as possible from the income so earned), for said Beneficiary's education and/or health care directly to the provider of the education for the payment of tuition, and to the health care provider for treatment; and NOT to the Guardian of'said Beneficiary, or to the Beneficiary. 8.3. Any income not expended by my Executor shall be added to principal and my Executor shall pay over and disburse the principal to the Beneficiary upon such Beneficiary attaining the age of twenty-one (21) years. 8.4. My Executor, in administering this property, shall have all of the authority granted to fiduciaries under North Carolina state law, and under the provisions of the previous ARTICLE SEVEN of this MY LAST WILL and TESTAMENT. 8.5. My Executor shall account in the same manner as a Trustee. 8.6. My Executor shall not be required to post bond, file inventory, appraisal, account, or report to any court, but shall be required to furnish, by certified United State Mail, return receipt requested, at least upon the first (lst) day of March of each year, to each Beneficiary, or to his/her Guardian, and to each Remainder Beneficiary, a statement giving a summary of receipts and disbursements during each account period and assets on hand at the each of the account period. 8.6.1. Such accounting are deemed correct and are accepted as correct if no notice to the contrary is received by my Executor within ninety (90) days upon registered receipt. 8.7. If any said Beneficiary shall fail to reach twenty-one (21) years, I direct that his%her share shall be distributed to my Remainder Beneficiaries as I direct in ARTICLE FIVE of this MY LAST WILL and TESTAMENT. LAST WILL AND TESTAMET~'T OF GENEVIEVE LAVISKA - 4 8.8. My Executor may be entitled to an annual fee of one-half of one percent (.005%) of the value of my estate so held for said Beneficiary pursuit of her/his duties hereunder. 8.8.1. My Executor may waive this compensation. 8.9. My Executor may receive reimbursement for expenses incurred pursuit of her/his duties hereunder. 8.9.1. My Executor may waive this reimbursement. 8.10. My Executor may select any fiduciary named in this MY LAST WILL and TESTAMENT as such custodian without conflict of interest. ARTICLE NINE RULE AGAINST PERPETUITIES 9.1. Notwithstanding anything in this MY LAST WILL and TESTAMENT to the contrary, I direct that no bequest created hereunder shall continue for a period longer than permissible under North Carolina's Rule Against Perpetuities, and upon the expiration of such period, each such bequest shall terminate and the assets thereof shall be distributed outright to those persons then in being who would be entitled to receive the bequest principal from that trust at the time of the ternlination said bequest. ARTICLE TEN NO CONTEST CLAUSE 10.1. I direct that in making distribution of my estate, the decisions of my Executrix in making allocations in fulfillment of the bequests and devises hereinbefore set forth, and described be absolute and final, and binding upon all persons. 10.2. In the event any Beneficiary under this MY LAST WILL and TESTAMENT shall, singly or in conjunction with any other persons, contests in any court the validity of this MY LAST WILL and TESTAMENT, or shall seek to obtain an adjudication in any proceeding in any court that this MY LAST WILL and TESTAMENT or any of its provisions, or any of its provisions is void; or seek otherwise to void nullify, or set aside this MY LAST WILL and TESTAMENT, or any of its provision; then the right of that person to take any interest given to him or her by this MY LAST WILL and TESTAMENT shall be determined as it would have been determined had the person predeceased the execution of this MY LAST WILL and TESTAMENT without surviving issue; and such benefits shall be deemed bequeathed, or devised to the remaining legatee(s), or devisee(s), named therein. ARTICLE ELEVEN SPENDTHRIFT CLAUSE 11.1. I hereby direct that no Beneficiary of this my LAST WILL and TESTAMENT may encumber his/her share of this my Estate for the benefit of creditors. 11.2. My Executor, or Successor Executor, is specifically forbidden to make any payments to creditors on behalf of any of my Beneficiaries. ARTICLE TWELVE MY FUNERAL 12.1. I direct that my funeral services be in the form of a Requiem Mass to be held at SAINT STANISLAUS ROMAN CATHOLIC CHURCH, CASTLE HAYNE, NORTH CAROLINA. LAST WILL AND TESTAMENT OF GENEVIEVE LAVISKA 12.2. I further direct that my remains be interred in the cemetery at SAINT STANILUS ROMAN CATHOLIC CHURCH, CASTLE HAYNE, NORTH CAROLINA, according to plans I have made with ANDREWS MORTUARY of WILMINGTON, NORTH CAROLINA. ARTICLE THIRTEEN FAMILY BOND CLAUSE 13.1 It is my desire and hope that my children, JOANNE L. SLUSSER, JAMES MICHAEL LAVISKA, and MARY MARGARET SNOKE, will continue to maintain a family bond and relationship, and cooperate in every way in the probate of this My LAST WILL and TESTAMENT. ARTICLE FOURTEEN SEVERABILITY CLAUSE 14.1. If any provision of this my LAST WILL and TESTAMENT is unenforceable, the remaining provisions shall remain in full effect. ARTICLE FIFTEEN GOVERNING LAW 15.1. This instrument and all dispositions hereunder shall be governed by and interpreted in accordance with the Laws of the State of North Carolina. IN WITNESS WHEREOF, I, GENEVIEVE LAVISKA, THE TESTATRIX, SIGN MY NAME TO THIS INSTRUMENT ON THIS, THE FIRST (1ST) DAY OF AUGUST, 2000, AND BEING FIRST DULY SWORN, DO HEREBY DECLARE TO THE UNDERSIGNED AUTHORITY THAT I SIGNED AND EXECUTED THIS INSTRUMENT AS MY LAST WILL AND TESTAMENT, THAT I SIGNED IT WILLINGLY, THAT I EXECUTE IT AS MY FREE AND VOLUNTARY ACT FOR THE PURPOSE THEREIN EXPRESSED, AND THAT I AM OVER THE AGE OF EIGHTEEN (18) YEARS OF AGE, OF SOUND MIND, AND UNDER NO CONSTRAINT OR UNDUE INFLUENCE. GENEVIEVE AVISKA, TESTATRIX LAST WILL AND TESTAMENT OF GENEVIEVE LAVISKA (SEAL) STATE OF NORTH CAROLINA COUNTY OF NEW HANOVER WITNESS SIGNATURE ~~~~ - ~r~~i,-.~,-~i u ~ ~~ ~e K , and ~ ~ Q n the witnesses sign our names to this instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signs and executes this instrument as her LAST WILL and TESTAMENT, in our presence, and that she signs it willingly, and that each of us, at the request of the Testatrix and in the presence and hearing of the Testatrix; hereby sign this LAST WILL and TESTAMENT as witnesses to the Testatrix's signature, and to the best of our knowledge, the Testatrix is over the age of eighteen (18) years, of sound mind, and under no constraint or undue influence. (SEAL) Y V ~j '~ ~(it~~~ ~ I I WIN PRINTED AME 151. ~ C9"1 ~ . (SEAL) LL.~O r~ ~ ~ t ~ ~'l. b G~.~~ WITNESS PRINTED NAME STATE OF NORTH CAROLINA COUNTY OF NEW HANOVER CERTIFICATION SUBSCRIBED, SWORN AND ACKNOWLEDGED before me by GENEVIEVE LAVISKA, the Testatrix, and subscribed and sworn to before me by: ~'.-~~,( ca r r ,and ~~~02Ct ~-~l ~ • ~ ! IiC- i s 1~Q ~' the witnesses, this, the day of August, 2000. -_- _... -..~.-:.Notary Public My Commission Expires: ~- / , LAST WILL AND TESTAMENT OF GENEVIEVE LAVISKA % - DEFINITIONS A. "Executor." The term "Executor" includes any personal representative or representatives of my estate acting under this MY LAST WILL and TESTAMENT such as a successor Executor or Executors and any Administrator with the MY LAST WILL and TESTAMENT annexed. It also includes the term "Executrix" whenever the context requires it. B. "Death Taxes." The term "death taxes" means inheritance, estate, additional estate tax on excess retirement, accumulation, generation-skipping, transfer and succession taxes, and any interest and penalties on these taxes, imposed by reason of my death by any jurisdiction with respect to property passing under or outside the provision of this MY LAST WILL and TESTAMENT or any codicil to it which is includable in my estate for the purpose of determining such tax. C. "Child," "Children" and "Issue." The terms "Child" and "Children" mean lawful lineal blood descendants in the first degree of the parent designated, and the term "Issue" means lawful lineal blood descendants in any degree of the ancestor designated, but such terms shall include any person adopted prior to the time that person reaches the age of eighteen (18) and the lawful lineal descendants of any such person, whether of the blood or by adoption prior to such age. D. "Per Stirpes." Whenever a distribution is to be made to a designated ancestor's issue who are living at a designated time and such distribution is to be made "per stirpes, ", such distribution shall be made by first determining the generation nearest to such ancestor which has a person who represents that generation and who is living at the designated time. The property to be distributed shall be divided into as many equal shares as may be necessary to allocate one share to each then living person of the generation and one share to each deceasedpersons of the generation who left issue who are then living. Each living person of that generation shall receive one share, and the share of each deceased person of that generation shall be divided among his or her then living issue in the same manner. E. "Power of Appointment." A Power of Appointment is a power or authority conferred by one person by deed or MY LAST WILL and TESTAMENT upon another to appoint, that is, to select and nominate, the person or persons who are to receive and enjoy an estate or an income therefrom or from a fund, after the testator's death, or the donee's death, or after the termination of an existing right or interest. F. "Give." "Give" shall be deemed to include the term "bequeath" or "devise" when appropriate. G. "Survive Me." The tern? "survive me" is to be construed to mean that the person referred to must survive me by thirty (30) days. If the person referred to dies within thirty (30) days of my death, then reference to him/her shall be construed as if he/she had failed to survive me. H. "Inter 4 ivos." Between the living; from one living person to the other. I. "Natural." Proceeding from or determined by physical causes or conditions as distinguished from positive enactments of la~~. LAST WILL AND TESTAMENT OF GENEVIEVE LAVISKA "{ ~ p y ` ~ i ~- s ~5 ~~,f ~$~id~tF '§.,.~, a~ fi~"a .i vhf ~l ~ kK ~x P.,~. + .. ... .' ... ... 1.'~' if11' 31i?= ~:i"i?fii,~tt,.. ~;(? il.' _, .~c ~,~St.:~iii"-fitt S~`-~C± ~_'F~l'(i fft'. i.. _ ~fjl c,, 1. ty1Fi~ i11~ t;1 ( ~~~iit~A - ,.... ~. _. !~_i.':_Y i.,}., ail- s)It~ di. (i~j ~:.?~ ~'~:' S'- '/ , 1~~~ ~. 3 Type/Print In Permanent O 4 I w 0 0 O 2 _ _ ~ ~~ ~~~ ~~.-~. OC 1 9'2012 _ ~ _ „ ~~_((r, ~,s~a,°~i COMMONWEALTH OF PEN NSVLVANIA DEPARTMENT OF HEALTH • VITAL RECORDS !'CQT~C~!"ATC AC 1'1CATu State FIIe Number: 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (Mo/Day/Vr) (Spell Mo) Genevieve Margaret Lavi.s]ca Fem 237-30-6801 October 19, 2012 Sa. Age-last Birthday (Yrs) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (Mo/Day/Year) (Spell Month) 7a. Birthplace (City and State or Foreign Count ) ~ ~ ry gC~. Months Days Hours Minutes Jan 8, 1923 Castle Ha ne, NC 76. Birthplace (County) Sa. Residence (State or Foreign Country) 86. Residence (St reet and Number - Includ Apt No,) 8c. Did Decedent Live in a Township? P A 442 W 1n t B ~ q! tt a u O O m oa e Dyes, decedent lived in Sd. Residence (County) tN/P~ Cumber 1 a n d 8e. Residence (Zip Code) 1 7 01 3 Sao, decedent lived within limits of Car1l Q1P it /b c y orn. 9. Ever in US Armed Forces? 10. Marital Status at Time of Death ~ Married Widowed 11. Surviving Spouse's Name (If wife give name prior to first marri ) , age Q Yes [~No ~ Unknown Q Divorced Q Never Married Q Unknown 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior o F rst Marriage (First, Middle, Last) Andrew Dunitson Jean Kowa~s~ca. 14a. Informant's Name 146. Relationship to Decedent 14c. 1 formant's ailin Addres ( treet an N ber, C' St e, p Code Mar Mar aret Sn©}ce dau ht 3~0 W ~ ~ m `~ `~': ~ ~ ) 0 y g g er a nu B om 2c , ar e, PA 1701 ~i ............................................................................................ ....... ... ..:........ 15a. Place of Deat... Chec on Y one) ' z ° . If Death Occurred in a Hos ital: •• • .......... ........... ......... ...... p ~ Inpatient ~ :If Death Occurred Somewhere Other Than a Hospital: ~ Hospice Facility ~ Decedent's Home Q Emergency Room/Outpatient Q Dead on Arrival ursin Home Lon ~X`1 g / g-Term Care Facility 0 Other (Specify) • LL 15b. Facility Name (If not institution, give street and number; 15c. City or Town, State, and Zip Code 15d. County of De h Thornwald Home Car]i~sle, PA 17013 Cumberland -~ 16a. Method of Disposition ® Burial ~ Cremation 166. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) ~ Removal fr St t om a e p Donation Oct 22 , 2012 St _ Stani.slaus Catholle Church Cemete 0 Other (Specify) ry 16d. Location of Disposition (City or Town, State, and Zip) 17a. ign Lure of Funeral Servic icensep_or person in Charge of Interment 176. License Number Castle Hayne, NC ~ 013144E ~ 17c. Name and Com lete Address of Funeral acilit M F y ~, Hoffman- oth Funera l F3 ome & Cr story, 219 North Hanover Street, Carlisle, PA 17013 m = 18. Decedent's Education -Check the box that best describes the 19. Decedent of His snit Ori p gin -Check the 20. Decedent's Race -Check ONE OR MORE races to indicate wh t t a highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be . ~ 8th grade or less is Spanish/Hispanic/Latino. Check the "No" White 0 Korean ~ No diploma, 9th - 12th grade b if d d i ~ ox ece ent s not Spanish/Hispanic/Latino. Black or African American ~ Vietnamese [ ~ High school graduate or GED com l t d , p e e ~ No, not Spanish/Hispanic/Latino Q American Indian or Alaska Native ~ Other Asian Some coll di b d ege cre t, ut no egree 0 Yes, Mexican, Mexican American, Chicano Q Asian Indian Q Native Hawaiian Q A i t d ssoc a e egree (e.g. AA, AS) Q Ves, Puerto Rican ~ Chinese ~ Guamanian or Chamorro Bachelor's degree (e g BA AB BS) . . , , ~ Yes, Cuban ~ Filipino Q Samoan Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Yes, other Spanish/Hispanic/Latino ~ Japanese Q Oth P ifi I l er ac c s ander ~ Doctorate (e.g. PhD, EdD) or Professional degree (Specify) ~ O h t er (Specify) e. MD, DDS, DVM, LLB, JD 21. Decedent's Single Race Self-Designation - Gheck ONLY ONE to indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation -Indicate type of work Whit e 0 Japanese ~ Samoan done during most of working life. DO NOT USE RETIRED. 0 Black or African American ~ Korean Q Oth P ifi I l d er ac c s an er Homemaker American Indian or Alaska Native 0 Vietnamese Q Don't Know/Not Sure ~ Asian Indian 0 Other Asian ~ Refused 22b. Kind of Business/Industry Q Chinese Q Native Hawaiian ~ Other (Specify) O W n Home Q Filipino ~ Guamanian or Chamorro ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced Dead (MO/Day/V r) 23b. Signature of Person Pronouncing Death (Only when applicable) 23c. License Number BV PERSON WHO PRONOUNCES OR lei; ~~~ ,~ 1 ,~O ` ~ _ CERTIFIES DEATH "C- ~ ~ •G(~ti_ ~ G ~(~.1~Qe_ ~ ~ Z~. ELF ~ ~ ~ - 23d. ate Signed (MO/Day/Yr) 24. Time of Death w u ' ly ~~~ ` S 7"'~/~ 25. Was Medical miner or Coroner Contacted? Q Yes No CAUSE OF DEATH Approximate 26. Part 1. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest Interval: . respiratory arrest, or ventricular fibrillation without showing the etiolog y. DO NOT ABBRE VIATE. Enter only one cause on a line- Add additional lines if necessary Onset to Death - 1 Q IMMEDIATE CAUSE ---------------> a. \.~1 h(~C~3'~"l_f4~ \~L"Z rte'{' \(•l~ l ~~l . _- (Final disease or condition Due to (or as a consequence of): resulting in death) ~•y ` `~` b. F _ 5 N Sequentially list conditions, Due to (or as a consequence of): if any, leading to the cause listed on line a. Enter the c. UNDERLYING CAUSE Due to (or as a consequence of): u, (disease or injury that initiated the events resulting d. ~ V in death) LAST. Due to (or as a consequence of): a 26. Part 11. Enter other significant conditions contributive to death but not resulting in the underlying cause given in Part 1 27. Wa an autopsy performed? Yes ~ No m 28. Were autopsy findings available to complete the cause of death? ~ c ~ Yes ~ No Z9. If Female: 30 Did E: ° . Tobacco Use Contribute to Death? 31. Manner of Death ~ Not pregnant within past year ~ Yes ~ Probably ~ Natu rat ~ Homicide c m Q Pregnant at time of death ~ No 0 Unknown )] Accident j] Pending Investigation N ° p g pregnant within 42 days of death ot re Want, but ~ Suicide 0 Could not be determined 1 - ~ Not pregnant, but pregnant 43 days to 1 year before death 32. Date of In'u J ry (Mo/Day/Yr) (Spell Month) Q Unknown if pregnant within the past year 33. Time of Injury 34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, Gity, State, Zip Code) 36. Injury at Work 37. If Transportation Injury, Speci fY~ 38. Describe How Injury Occurred: Ves ~ Driver/Operator ~ Pedestrian No ~ Passenger Q Other (Specify) 39a. Certifier (Check only one): ~Ce rtifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated Q Pronouncing 8. Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated ~ Medical Examiner/Coron r - On the basis of examination, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to th e c a use(s) and ma n ner stated ~ ~ r ~ / Signature of certifier: Title of certifier: License Number- ~ ~J d ~ `Z. \ ~~ 396. Name, Address and Zip Code of Person Completing Cause of Death (Item 26) 39c. ate ~ Wed Mo/Day/Vr) ~ 60 ~, ~. ~~~s~m. ~-, ~~ -~~ ~ ..,,-. ~ ~w~ cz ryJ~., o'er t `~ A ~ o ~ 40. Registrar's District Number 41. Registrar's ture - ~ ~ 42. Regist ar Fil Date (Mo/Day/V r) ~1- a\b .~ ~~. ~ ~o ~a` 43. Amendments 6 Cl Q 'l ~ (~ H 105-143 Disposition Permit No. _ 1. ` a'S REV 07/2011