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01-09-13 (2)
r J 1505610105 REV-1500 EX (oz u)(Fq J!1'! OFFICIAL USE ONLY ennsylvania PA Department of Revenue PE„q ~~.. ~, ~ County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX z8o6o1 S NT ECEDENT / ~ ~ ~~ ~ ~ ~.) `:. J Harrisburg, PA 1y1z8-0601 R E IDE D ! / ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Dale of Birth MMDDYYYY 206-30-9617 05/20/2012 11 /18/1940 Decedent's Last Name Suffix Decedent's Fir st Name MI WISE MAXINE L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Lasl Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILE D IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) OD 6. Decedent Died Testate O 7, Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number KRISTY L. KELLY (717) 856-8336 REGISTER OF WILLS USE ONLY i C _ ~ c.._i ~ m ~n n ~ - )~ r-- I ~ ~9 rn ca :` s r,-, +`•a .' ~1 CAMP HILL PA 17011 ~ =,i ~-, ~` .w~7 ""'1 ,j 0lf - ~ I -..~ {fy M Correspondent's a-mail address: KRISLYNNKELLY@GMAIL.COM `?~ °~'t Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. DgGaration of Preparer other than the personal representative is based on all information of which preparer has any knowledge. First Line of Address 7 QUEEN ANNE COURT Second Line of Address City or Post Office State ZIP Code 7 17011 DATE ADDRESS + / 3600 TRINDLE ROAD, CAMP HILL, PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 J ~~ s 4 15D561D2D5 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: MARINE L. WISE 206-30-9617 RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. 0.00 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 4,373.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 0.00 4. Mort a es and Notes Receivable Schedule D 9 9 ( ) ......................... 4. .. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 9,411.00 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 0.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property O S S h d l G t Billi R t d 7 15 313 00 ( c e u e ) epara e ng eques e ...... .. . , . 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 29,097.00 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. 10,412.00 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............. .. 10. 0.00 11. Total Deductions (total Lines 9 and 10) ............................... .. 11. 10,412.U0 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 18,685.00 13. Charitable and Governmental BequestslSec 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. 18,685.00 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 00 . (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 18,685.00 16, 841.00 17. Amount of Line 14 taxable at sibling rate X .12 0.00 17. 18. Amount of Line 14 taxable 0 00 . at collateral rate X .15 18 19. TAX DUE ....................................................... .. 19. 841.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 15D561D2D5 15D561D2D5 REV-15D0 EX (FI) Page 3 File Number Tax Payments and Credits: i. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments _ B. Discount 3. Interest (1) Total Credits (A+ B) (2) (3) 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. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 841.00 0.00 0.00 0.00 841.00 Make check payable to: REGISTER OF 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 consitleration? ....................................................................................................... ....... ^ 3. Did decedent own an "in trust for" or payable-upon-death 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 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 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. §9116 (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 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 f ling 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 21 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 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 benef curies is 4.5 percent, except as noted in [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 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. REVa5o3 EX+ (8-iz) ~~~~~ pennsytvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER MARINE L. WISE All property jointly owned with right of survivorship must be disclosed on Schedule F. If more space is needed, insert additional sheets of the same size REV-i5o8 EX+ (D8-ia) ;~~~~ ~ Pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: MARINE L. WISE Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE 1. METRO CHECKING ACCOUNT #0023149263 1,375.00 2. WAT CHECKING ACCOUNT#4373-01 1,437.00 3. SOUTHERN UNION CASH IN LIEU OF FRACTIONAL SHARES 3.00 4, HIGHMARK REFUND 83.00 5. INTEGRITY LIFE 5,492.00 g, SUSQUEHANNA VIEW REFUND 166.00 7. AMERICAN GENERAL LIFE INSURANCE 105.00 g. MOUNT CALVARY EPISCOPAL CHURCH PREPAID INTERMENT 750.00 TOTAL (Also enter on Line 5, Recapitulation) $ I 9,411.00 If more space is needed, use additional sheets of paper of the same size. :. pennsylvania ti? DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF MARINE L. WISE FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELAT[oNSHIP TO DECEDENT AND mE DATE of rRANSFER. ATrncn A coav of THE oEEO roR REAL EsrATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION pF APPUCneui TAXABLE VALUE 1 American Funds IRA-Beneficiary Kristy Kelly, daughter 11,229.00 100 0.00 11,229.0( 2 American Funds Roth IRA-Benefciary Kristy Kelly, daughter 4,084.00 100 0.00 4,084.0( TOTAL (Also enter on Line 7, Recapitulation) ; I 15,313.00 SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY If more space is needed, use additional sheets of paper of the same size. j i~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: ESTATE OF FILE NUMBER MARINE L. WISE Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' MYERS HARNER FUNERAL HOME, MECHANICSBURG, PA 2,529.00 MOUNT CALVARY EPISCOPAL CHURCH, CAMP HILL, PA 750.00 B, 1. 2. 3. 4. 5. 6. ~. State ZIP Attorney Fees: Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS City State ___ ZIP Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: MEDICAL EXPENSES-HOSPITAL, AMBULANCE, PRESCRIPTIONS, ETC TAMMY MESSNER, HEALTH AID UTILITIES TOTAL (Also enter on Line 9, Recapitulation) $ If more space is needed, use additional sheets of paper of the same size. 86.00 600.00 5,196.00 1,100.00 151.00 10,412.00 t~ i Southern UnionComp~ any ~jomputershare l 002395 nlllulnlllllrllLlurllllllr"II'Illnllrlllllll'Illll'Illllli MAXINE L WISE SUSQUEHANNA VIEW APTS 208 SENATE AVE APT 414 CAMP HILL PA 17011-2345 Please see important PRIVACY NOTICE on reverse side of statement. Computershare Trust Company, N.A. PO Box 43078 Providence,R102940-3078 Within USA, US territories 6 Canada 800 736 3001 Outside USA, US territories 8 Canada 781 575 3100 vvvvw.computershare.com/~~esfor 000001~i 0883 I~IIINImNINIVIN CompanylD SUGP SSNRIN Certified Yes OOICS0100_dst.Dom C.SUGP.221507_502/0023951002395/i Southern Union Company -Corporate Action Advice Retain For Your Records This Transaction Advice is your record of share and cash entitlement receNad as a result of Ne automatic corporete action processing or 120.0804fi7 shares or DSPP • COMMON STOCK. Shares Credited Shares Presented Exchange Rate ~ ShareslUnits Credited I CUSIP Number I form of Share Credlt I Froe tJortal share A5T TO ISSUE ETE UNITS 120.080467 1.000000 120.000000 DRS 0.080467 Payment Advice Payment Date Tax Year Corporate Action Disbursement Detail Sharesl Units PricelRate Per Share Gross Amount Tax Withheld Foreign Tax Withhe Fees Withheld Net Amount 29 Mar 2012 2012 Cash-in-lieu of fractional shares 0.080467 39.972500 3.22 3.22 Sc,e~ . t3 ~ Ste, . E, 3. METRO BANK >00724 7593085 001 092140 MAXINE L WISE 208 SENATE AVE APT 414 CAMP HILL PA 17011 Metro Bank 3801 Paxton Street Harrisburg PA 17111-1418 1-888-937-0004 mymetrobank.com .... We're here 7 days a week, 24 hours a day at 1-888-937-0004. 50 PLUS CHECKING 0023149263 Transactions By Date Interest Summary Fees Summary Metro Bank is offering Home Equity Loans and Lines of Credit with AMAZING rates! Apply today for the cash you need at your nearest Metro Bank store, online at mymetrobank.com or call Loan-by-Phone at 800.296.1015. Ask a representative for details on rates and terms. Interest may be tax deductible (consult your tax advisor). Equal Opportunity Lender. Looking for a credit card with an AMAZINGLY low interest rate, no late fees and no annual fee? Look no further than the Metro Bank Personal Visa® Credit Card! It's easy to apply. Visit your nearest store, call 800.296.1015 or visit mymetrobank.com. See pricing and terms for details on fees. A foreign transaction fee of up to 1% of a foreign transaction amount will apply. This is a fee charged by Visa and is not directly assessed by Metro Bank. J~1 • ~ ~ ~ t~ /~ l ~r. "L ~. ~r 5 ~, to ~ S ~cyci° NOTE :SEE REVERSE SIDE FOR IMPORTANT INFORMATION Page 1 of 2 gp~gp ROLL 07/11 Member FDIC For your convenience, a summary of overdraft and returned item fees appears on your monthly statement. Please note that the overdraft fee summary includes non-sufficient funds fees, uncollected funds fees and unavailable funds fees. The summary does not reflect refunded or waived Items credited to your account. y wsli~i/yyti~NYAYN.jYlnr~t1°C~SY. ~Ydy1.L~1^.'1i~14{~J d`/i ~~~~5'tl~1~.'~ - ^"-..'+++,m' WAT Federal Credit Union ~~a~,"~=~"~:;w~..:~~,.. ~, 445 Elrcnra St • Williamsport, PA 17701-4906 ~~~~ (570) 326-7033 • oll Free: (800) 788-9378 • Fax: (570) 326-7922 Email, memberservices@watfedcu.coop ,,,,~,,,,,~,~,,,,,,,,,,,,,~ Uate: 8/01/12 Time: 11;00:29 Teller: 23 Receipt No: 597@2' Account Tran Description Tran E Rrin 3 Int ~ Fee b Balance 'S 4373-01 BASESH 12 CLOSE ACCOUNT 170,16 1436.85 437,:,-15 DRAFTS 13 CLOSE ACC(JUNT 170, 16 . 00 MAXINE L, WISE Cash In: X08 SENATE AVE RF'T 414 Checks In: SUSQUEHANNA VIEW AF'T Cash Qut: CRMp HILL, PR 17011-2345 Ask about our Credit Card with a fixed Signature: rate and rewards program! NAME NAX I NE t_. WISE DATE AUGUST fa 1 ~ '~~ 12 CHECK f~ ~( ~ ~ /~ ry NUMBER L 1 ~} y P~.ir• a 1 ~ 436. S~ .~, ~. «3~a. 85 ~ ~.:. '_'' t415"~~Y~k~.,`d1'M ' y~~:'„',rz',I ~n Hri baid4 i ~ g r r, ~ , # ,, g~'"~~~ t ~ ~ ~ ~ ,~'~r y r r~ t r +-;~y~ ~ € ~ ,fin 3fi'$ t;' ' ~' ~dEnaa.'w:,tslki "1xt`~ .~„F ~i.~'~"iN ~ ~'~~.v va _.. S/ . 1 ¢. ... ,, .:. ,.,,, .. ..:....... ..........~..... .v ~«_ GHI~ti~R.l~~, Date: 06f05f2012 -~.is PRonth Gross payment amo sr~t £3 3 . 3 7 Net payment amount f33.37 0392519 ~`' f f; ~> ;; ~ ; Y,>; jay ~ , N f ,; ~,, .;_ _ ~~__ _-: ...__ _ __ - / / i CK TYPE: POLICY DISB , ~, ( fi ~~ " ' "'~ ~r f ~ r;~ CHECK NUMBER: 0010848032 f CHECK DATE: 09!28/2012/; PAYEE: KE . REF ID #: ' 1 C 112`.i738C0038 CHECKAhi~:~ ~~I Gross Amor. r Ei,492.a8 ~ Voluntary'ii O.UO St Withhold 0.i 10 Fed Withho'rl O.i)0 Shipping 0,x)0 Loan Payol` 0. )0 I ; ' :~:.K h,MUUNT: $5,492.38 Taxable G~:ii 61.38 Notes : Payee copy: detach before depositing ,, 3f. 4i~ v>,+s+ti~AU..41 n.eSwheAnd+~srsu..:wn+.v.M.v..ivti.v.4n4'.aa+:.+.ws+:...ea.w~.w..w.,w......+.m...h...rw r'.:.....:..,..-u...,.,:..-..... , .....~.,, .. ..... :. .._ :...........:.. .~..... ,_. ... .. _.., ...... .... ... DATE:66/19/2012 CK#:36716 TOTAL:$166.00***** BANK.Susquehanna View Operating(svackg) PAYEE:EState of MARINE WISE(t0003045) Property Account Invoice -Date Description Amount sva 2205-0000 :Refund - 06/03/2012 Move out refund 166.00 166.00 GS7FL'c-Y~ ~ ~~WCr'ne ~.. LCJ~~S~ AMERICAN GENERAL LIFE INSURANCE COMPANY DATE CHECK No. 06/26/2012 0011665362 EXPLANATION AMOUNT 40211212 GROSS AMOUNT FEDERAL 106.64 STATE _ 3.49 0.00 FOR INFORMATION PLEASE CONTACT CUSTOMER SERVICE AT 1-888-438-6933 1460042000 INSURED POLICY NUMBER CHECK AMOUNT MARINE L WISE SPIA013026 $105.15.•-,.: _~. -:z; ~ ,~ _. _ I .~. .,, . ~~~~i~~.~/ ~ P ~ir • Y.e r~' ~~ ts';!Y>fSF r~p~;q b <;, r u $y M~. fJ r r- ' t , ~ ,,,,,,~~ryyy Ery l~s( (~ J1G f y! + rY J~w"S ~ < / ! •y l 'v r. {~ q }~{~ nJ ~~ ~ ~; P. ~ 4 ~ n) ?~< s ~ •• y n+ k . ~`` 14 :• ', iS rf ^ / j~4V ( _~ i s IF+ (.(~ S p~ , e /r/_+ r4 V ti , ~' 4 ` ` ~s, YY ~ 1 r'1~ ' `~~ } .• ~ 1. I{IRI{'S GARllEN The Columbarium for Mount Calvary Episcopal Church Camp Hill, Peimsylvania APPLICATION FOR INTiRMENT LICICNSE ;; NAME 1`~~X!l~JF ~-- ~,t~I~~ ADDRESS ~.OS ~ E I.1F1T~ 1'r~E . ~ ~ t1U( TELEPHONC NUMBER. C~11~~ ~.~, p -`~3~~ DATE OF BIRTH /Vd~, ~ ~r /Q ~() I REQUEST TO BE INTERRED DIRECTLY INTO THE MEMORIAL GARDEN I REQUEST TO BE INTERRED IN A NICHE ~{ ~5 APPLICATION FEE: $50.00 i g) a • . LICENSE FEE: $700.00 ~ (( 7 f ~ II~o-a ~ ~ A DATE OF APPLICATION -~ ~3/G ~ ~~ SIGNATURE OF APPLICANT ~ - r~-n~._~~'-, ~-~!~t-~ APPLICATION APPROVED `~~ -~ ~~-~~ (Signature and Date) ~'~3~ ~0~ WHEN THIS APPLICATION IS SIGNED, DATED AND SEALED WITH THE SEAL OF THE CHURCH IT WILL SERVE AS A LICENSE FOR INTERMENT IN KIRK'S GARDEN FOR A PERIOD OF FIFTY YEARS FROM DATE OF APPROVAL. This approved and sealed Application will be given to the Licensee for their records. A copy will be kept by the Church. -,. ;",, .. ,. _-... _ .i T .... ......... ........ .......... ...~.....~_.~... ~-_. W.._. _. American Funds PO Box 2560 Nortolk VA 23501-2560 AV Ot 084937 84190H318 A"SDGT Irllrlll~~~rll~~lrlrrrl~l~llrlll Ill~rlllllllrllrrlllrrlllllrl~lll CB&T CUST IRA/ROLLOVER MAXINE L WISE/DEC'D C/0 KRISTY KELLY 7 QUEEN ANNE CT CAMP HILL PA 17011-1733 Since initial investment on Year-to-date since 1 06/12/2003 01/01/2012 '~, Beginning value $16,581.94 $11,227.43 d 1 J0 + Wit hdrawals and fees $28,428.7 .. . $12 228 1 !, ~ +/-Investment gain/decline _ $8 730 43 $1,001.28 Ending value as of 09/30/2012 $0.00 $0.00 '' Annualized slots initial investment on 06/12/2003 5.90% Year-to-date since 01/01/2012 10.80% 53.255 I ~~...._ OWI2/03 12/31/03 12/31N5 1?131r07 12/31/09 12!31/11 516,582 120,93e 122,661 522,785 314,085 511,227 *Net investment is the total amount you invested minus the total amount you withdrew. 1-AF1-03Q 111368-J15792.:_! oac9s7 uz `L yy.~~ V{ f~ a.1t r nY L-. Lc1 ~' S c= tz rJC~ ,Cry. ~, ... ,,.. _. f;,:'. 09R8/12 so Quarterly Statement September 30, 2012 Page i of 4 Primary account number: 68808618 Important information Unless there is subsequent activity with your account, this will be your last statement. Please keep this statement for your records. If you need additional information for your American Funds account(s), please visit americanfunds.com. As required by the IRS, we will be reporting the December 31 value of your account(s) to the IRS. _~ Q Gr wto h-and-income E~9 Equrty mcome °i ~~ ~I ~~ sl ~; ~~ s t ~,1 5300 Robin Hood Rd Nortolk, VA 23513-2430 Questions about your statement americanfunds.coMstatement 0.00% 0.00% 0.00% How to contact us Through your financial adviser DENISE CLELAN, DOUGLAS CLELAN (717) 761-4633 WALNUT STREET SECURITIES, INC. 210 GRANDVIEW AVE STE 101 CAMP HILL PA 17011-1769 americanfunds.com FundsLine® 24•hour automated servke 800/325-3590 Shareholder Services Representative 800/421-4225 (M-F 8 a.m, to 8 p.m. Eastern time) Mail Capital Bank and Trust Company PO Box 2560 Norfolk VA 23501-2560 Overnight courier Capital Bank and Trust Company t a S t . ~~~:; American Funds Year-to-date transaction history Quarterly Statement September 30, 2012 Page 3 of 4"i Primary account number: 68808618 Trade date Description Dollar amount Share pace _ _ _ Shares transacted Share balance O1/O1/12 Beginning balance $2,566.83 $27 09 94.752 01/18/12 Normal Distribution -$50.00 $28.16 -1.776 92.976 02/17/12 Normal Distribution -$50.00 $29.36 -1.703 9].273 03/14/12 Income Dividend 0.13 $11.87 $29.79 0.398 91.671 03/;6{12 Normal Distributlon -$50,00 $30.01 -1.666 90.005 04/18/12 Normal Distribution -$50.00 $29.50 -1.695 88,310 05/18/12 Normal Distribution $50.00 $2/.75 -1.802 86.508 06/08/12 Income Dividend 0.13 $11.25 $28.33 0.397 86,905 08/30/12 Transfer To `*******587 -$2,616.71 $30.11 -86.905 0.000 09/30/12 Ending balance $0.00 $30.65 0.000 .cw ~... ,..:. ,. t °tF ,: C:S.; :. "a r,.:: ,..f~~.1,a:N "?: .:., .a. ~ ....... .. ............. . ..... ... ...... .a .....,. ....... ... .~.... ... .. ...... .. ... .... ...;~`i ::: ... . .. .. ... :. ...... . . ..... e .......-.... ,., ::. Initial investment date: 06/12/2003 a . . i, ,. Personal rate of return of'thrs fund. `' _; Rate of retumIs not praviied for funds with a , O.QO°~6 of the accotlnrs assets are h this fund,` taro balance. Year-to-date transaction history Trade date Description Dollar amount Share price _ __ __ _ Shares transacted Share balance 01/01/12 Beginning balance $2,305.63 $28.40 81.184 01/18/12 Normal Distribution -$50.00 $29.30 -1.706 79.478 02/17112 Normal Distribution -$50.00 $29.92 -1.671 77.807 03/16/12 Normal Distribution -$50.00 $30.65 -1.631 76.176 03/23/12 Income Dividend 0.165 $12.57 $30.17 0.417 76.593 04/18/12 Normal Distributlon $50.00 $30.11 -1.661 74.932 05/18/12 Normal Distribution $50.00 $28.64 -1.746 /3.186 06/15/12 Income Dividend 0.165 $12.08 $29.50 0.409 73.595 08/30/12 Transfer To ********587 $2,268.20 $30.82 -73.595 0.000 09/30/12 Ending balance $0.00 $31.31 0.000 Initial investment date: 06/12/2003 _ _ ° O.Od h of the accounYS assets are In this fund Year-to-date transaction history sonal rate of return of this fund: Per Rata of retorrr`is flat provided far funds with a zero balance. ' Trade date Description __ __..-- - Dollar amount Share price _ Shares transacted Share balance O1'O1/12 Beginning balance $6,354.97 $16.76 379.175 01/18/12 Normal Distribution -$100.00 $17.01 -5.879 373.296 02/11/12 Normal Distributlon -$100.00 $17.38 -5.754 367.542 03/16/12 Normal Distribution $100.00 $17.49 -5.718 351.824 03/16/12 Income Dividend 0.165 $60.64 $17.49 3.467 365.291 04/18/12 Normal Distribution $100.00 $17.36 -5.760 359.531 05(18/12 Normal Distributlon $100,00 $16.79 -5.956 353.575 0615/12 Income Dividend 0.165 $58.34 $17.06 3.420 356.995 08/30/12 Transfer To ********587 -$6,343.80 $17.77 -356.995 0.000 09/30/12 Ending balance $0.00 $17.98 0.000 084937 y2 a ` ~ ~ American Funds PO Box 2560 Norfolk VA 23501-2560 AV Ol 084939 84190H318 A"5DGT ~~I~II'II~I~III„I,I11~11~~1~'11,I„I~11,11111~~111„'~~~~~'~~I„ CB&T CUST ROTH IRA MAXINE L WISE/DEC'D C/0 KRISTY KELLY 7 QUEEN ANNE CT CAMP HILL PA 1 701 1-1 733 Since initial investment on Year-tPdate since ~''~ Olpl/2003* 01/01/2012 Beginning value $2,452.56 . $3 647.42 + Additions $0.00 $0.00 - Withdrawals and fees -$4,173.77 _.. -$4,083.77 __. +)-Investmentga+n(decline $1,721.21 $436.35 Ending value as of 09(30/2012 50.00 50.00 Qluarterly Statement September 30, 2012 Page 1 of 4 Primary account number: 67428244 Important information Unless there is subsequent activity with your account, this will be your last statement. Please keep this statement for your records. If you need additional information for your American Funds accounts}, please visit americanfunds.eom. As required by the IRS, we will be reporting the December 31 value of your account(s) to the IRS. 0.00% .... ....... 0.00% *For accounts opened prior to 2003, an initial investment date of January 1, 2003 is used. ', More information is available at americanfunds.corNstatement. i Annualized since initial investment on OliU1/2eo3* 5.75% Year-to-date sinceOl/01/2012 13.65% i I/~~_` I ~\ i~ Growth-and-income- How to contact us _ _ Through your financial adviser I DOUGLAS CLELAN -Value of account --- Net investment* ~ (717) 761-4633, ext.4 - - -- - -- ~ WALNUT STREET SECURITIES, INC. sa.zzo 210 GRANDVIEW AVE STE 101 E3,618 .____ _. _. _-.. __._.. __... - --- --- -- CAMP HILL PA 17011-1769 ~ americanfunds.com FundsLine® 24-hour automated service szplz -°'^_.....-.,.-------------- ----------____.._~_:-___=-----~ __ ___..._....._ 800/325-3590 ~~, _ __ ~ Shareholder Services Representative st.rxx~ _ .... __._.. _ _ . _.. `. 00/421-4225 (M-F 8 a.m. to 8 p.m. Eastern time) st,2°6 _ _......... _.._....... _..... Mail ~, Captal Bank and Trust Company sboa ,. e` .... PO Box 2560 ~ ~ Norfolk VA 23501-2560 so olrolroa lz~siroa rzr3tro5 12/31/07 1zr31NV lztaull nene~lz Ovemigttt courier szASa sa,o6t 53s1o sa.zzo Ea,aza 33,547 so Capital Bank and Trust Company *Net investment is the total amount you in vested minus the total amount you withdrew. i 5300 Robin Hood Rd Norfolk, VA 23513-2430 ` -' questions about your statement 1-A1=1-030111369-n579z americanfunds.coMstatement oeavae vz ,/ Ua`~ ~` ' ~• ~+ crirE+ L. L(,r,~5f' ~ tz ~( G~ . _ } 9"r .. .. ..~ ~,s(.wt myv~+..m-r^n.....n •. .•rui+.!rnM'.+pT'aR<e Arr~erican Funds Quarterly Statement September 30, 2012 Page 3 of 4 Primary account number: 67428244 Year-to-date transaction history Trade date Description Dollar amount Sharc price _ Shares transacted Shan; balance 01/01/12 Beginning balance $3,647.42 $26.90 135.592 03/12/12 Share Class Exchange $2,972.87 $29.26 -101.602 33.990 03/12/12 Share Class Div Exch -$994.55 $29.26 -33.990 0.000 09/30/12 Ending balance $0.00 $30.44 0.000 0.00°,b of the accounts assets are in this fund Year-to-date transaction h Trade data _ _ _ Description _ Dollar amount Share price Sharos transacted Share balance 01/01/12 Beginning balance $0.00 $27.04 0.000 03/12/1'2 Share Class Div Fxch $994.55 $29.46 33.759 33.759 03/12/12 Share Class Exchange $2,972.87 $29.46 100.912 134.671 03/14/12 Income Dividend 0.1281 $1.7.25 $29.74 0.580 135.251 06/08/12 Income Dividend 0.1261 $17.06 $28.29 0.603 135.854 08/30/12 Transfer To ********582 -$4,083.77 $30.06 -135.854 0.000 09/30/12 Ending balance $0.00 $30.60 0.000 Beneficiary information CB&T OUST ROTH IRA MAXINE L WISE/DEC'D Account # Primary Contingent 67428244 KRISTY K KELLY Not Provided To update and read important legal information about your beneficiary designations, please go to americanfunds.com/beneficiary. Information about your investments Your responsibilities. Please review this statement carefully to confirm that we have accurately acted on your instructions. If you identify any discrepancies, please immediately notify your financial adviser or call us at 800/421-4225. If you delay in reporting an error, we may be unable to adjust your account. Estate planning information. If you are an executor or administrator of a recently deceased IRA owner's estate, we can provide a statement showing the value of the account as of the IRA owner's date of death. Please contact Shareholder Services at 800/421-4225 for additional details on how to order this statement We will provide the information within 90 days of the request. Personal rate of return American Funds uses the Modified Dietz method to calculate the rates of return for your fund holdings, accounts and portfiolio. This time-weighted calculation does not treat withdrawals as losses or investment amounts as gains. The formula factors in the amounts and daily prices of your account activity; the returns, fees and expenses of your specific funds; and applicable sales charges. Calculations may include closed and previously owned fw~ds. Portfolio rate of return is the combined return for all of the accounts on this statement. Returns for investments made before 2003 are calculated with an initial investment date of January 1, 2003, and the investment value as of that date. Returns for periods less than a year are cumulative total returns and not annualized. Your personal returns may differ from fund results shown on this statement and online. You can view your fund and account personal rates of return, updated after each business day, by logging in to your account at americanfunds.com. For more information, please visit americanfunds.com/statement or call Shareholder Services at 800/421-4225. Ua4939'L'L ,.. ~ ~~....:.. ... .. ,..... .. 4 x ., „ ~,. ~! L(X':11,1.1' O~1'SI?D A\I) OPFRAI'ISD Mrs. Kristy L. Kelly 7 Queenanne Court Camp Hill PA 17011 Services for Maxine L. Wise May 24, 2012 Cremation Package #4 Cremation Container MvE~~,~ts-13nu~Nt~a FuN~~xnl.. HoMF::. INr. 1903 MARKET STREET CAMP HILL, PENNSYLVANIA 17011 717-737-9961 717-737-4618 PHONE FAX June 18, 2012 Cash Advanced Newspaper Notice/Local Newspaper Notice/Out-of-Town Certified Copies Coroner Fee Total: Received from Insurance Company: Total: Non-guaranteed Cash Advanced Items: Obituary/Local (Addition) Obituary/Out-of-Town (Addition) Certified Copies (Addion) $ 197.00 148.00 36.00 25.00 $ 197.00 148.00 36.00 Balance Due: ~~~~~ ROBERT B. BARKER SUPERVISOR DUSTIN R BAKER FUNERAL DlltECTOR $ 2,450.00 $ 140.00 $ 406.00 $ 2,~36~6 - 2 147.69 $ 381.00 .». , .. wx r, r ~S~CLyC C,T ~ 7~1(z..~c ~~n r ~ ~.L~ `S ~. ~ ~~~ F ~"~ /; . .~ , r ,~ rw EXHIBIT A AGREEMENT NIIMRFR THIS AGREEMENT IS FUNDED BY LIFE INSURANCE r~ .-~ -., For the benefit of `r~ ', ~ l , _ ,`, ~ ~ ("t Funeral Recipient/Insured Social Security Number STATEMENT OF GOODS AND SERVICES GUARANTEED FUNERAL GOODS AND SERVICES Transfer of deceased to Funeral Home (-_ -'_---Miles) .................. .. ...............$ __,:,,, ~. Family car(s) Number @ $ ___ each .. $ ---- .. Hearse ...................... .... _... ... ...._.......... $ ~.._. Service Vehicle ..............:...._...:........................ $ , ~ , Forwarding/Receiving remains ............................. $ „.,.- Other Services/Facilities/Equipment: FUNERAL HOME SERVICES: Basic Services of Funeral Director and Staff ........ $ _ , Embalming ._ . _ ...................................... $ _ Use of facilities/staff/equipment for: Visitation days @ $ _______ per day . $ . -- - -- Funeral/Memorial Service ................................. $ ..,.- Graveside Service ..... $ ,.- $ - $ $ _ TOTAL FUNERAL HOME SERVICES ...... .......::...._ ..:. $ ~:; ~ ~; ; FUNERAL MERCHANDISE: Casket .............................................................. $ Manufacturer Model Name/Number Exterior Material/Color -- Interior Material/Color Cremation Container ........................................... $ Manufacturer ~ ; ~ Model Name/Number Outer Burial Container.........._ ............................ $ Manufacturer Model Name/Number Material -~ Other Guaranteed Merchandise (Specify) TOTAL FUNERAL MERCHANDISE TOTAL FUNERAL HOME SERVICES TOTAL GUARANTEED FUNERAL PRICE $ $ $ ~'~ l.~ % ` t ~-~ NON-GUARANTEED CASH ADVANCE ITEMS Acknowledgement Cards .................................. $ We charge you for our services in obtaining the Obituary Notices.._. $ _ following cash advance items: Death Certificate(s) (# ) ... $ $ ~ ~;, ~,~. ---- -- Clergy Honorarium ... $ Sales Tax $ $ -- uric ............................................................... _ Vault Installation ............................................. $ _ TOTAL NON•GUARANTEED CASH ADVANCE ITEMS... $ ~ ,'~~-; C:~. Grave Opening and Closing ... _ ._......_ ............. $ - Hairdresser ............._ _ .........._........................ $ TOTAL GUARANTEED FUNERAL PRICE...................... $ +, ,1 ;' t(_~(:, Other (specify) - __ $ _ TOTAL GUARANTEED AND NON-GUARANTEED _ $ --- FUNERAL PRICE ............................................... $ 'f ~ i ' ~~ ~ ~, , Charges are only for items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain the reasons in writing below. If you select a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if you selected arrangements such as direct cremation or immediate burial. If we charge for embalming, we will explain why below. Acknowleagement: Bycompleting and signing this form, you acknowledge that you were given a copy of this agreement, that you were shown general price lists prior to discussing prices of funeral services or merchandise and that you have read and understand this agreement. Funeral Home Name Purchaser ~ ~ I ,; ~ Address i ~ ,~-::, , ") ~- , j \ ~ ' Address Ignature o ut onze unera ome epresentative ate Signature of Purchaser Date I PN-REI-SGS- 04/07 1st Co Ik py -Company 2nd Copy -Agent 3rd Co _jY py -Purchaser .~ ~~>.. ~. 1, _ __ $ $ $ $ RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 WISE MAXINE L Receipt Date: 8/01/2012 Receipt Time: 08:30:06 Receipt No.: 1070825 Estate File No.: 2012 -00830 Paid By Remarks: KRISTY L KELLY HMW ----------------------- - Receipt Distri bution ------ ------- -------- --- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 30.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 12.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN Check# 158 ---------------- $85.50 . Total Received......... $85.50 - ~~`.~~ ~c•~- ~ ~ 7 ES~~ of /lZ~-K.%~,e l-. Gc.7~s~ - ' ~17 CONTINUING CARE RX-NEWPORT 6990B SNOWDRIFT ROAR ALLENTOWN, PA 18106 S RETURN SERVICE REQUESTED 002086 0101 PHONE: 877-670-6323 You may also view/pay your bills at: https:!lmyom niview. omnicare. com u~i~l~lli~ll~n~lllli"I~'~~IIIJIIn~lll~~l~'~In'~III~I~~I~II~ MAXINE WISE KRISTY KELLY 7 QUEEN ANNE COURT CAMP HILL, PA 17011-1733 39758 B STATEMENT OF ACCOUNT PAGE: 1 of 1 ACCOUNT NO: 9009-15 INVOICE NO: STATEMENT DX NO: KOPDX INVOICE DATE: 08/31/12 FACILITY: 9009 CUMBERLAND CROSSING PATIENT NO: 15 PATIENT NAME: WISE, MAXINE AMOUNT DUE: 321.30 TAX: 0.00 KEEP TOP PORTION FOR YOUR RECORDS -RETURN BOTTOM STUB WITH PAYMENT DuE DATE: 0 912 5 / 2 012 AMOUNT DUE: 321.30 39758*TLC08VNE8001017 3 LC09XM7 K:1.1 in~~~~~~~mm~~n~u~r~~~u~ WISE, MAXINE 9009 CUMBERLAND CROSSING • 9009-15 08!31!12 V N PREVIOUS BALANCE 321.30 f F. ~' .~~. ~~' ~/. 1 ', CHARGE5 0.00 0.00 321.30 0.00 °~' w N °D (71 r: ?, ,, }i i ~';;, . i:;;' ;~~~,~ %~',.. ~~HaLY O PI AL The Spirit of Caring 42447268 MAXINE L WISE 208 SENATE AVE APT 414 CAMP HILL PA 17011-2345 ~ ~. Patient Name: Wise ,Maxine L Statement Date: 06/18/12 Service Date(s): 05/14/12-05/20/12 Account Number: 42447268 Medical Record Number: 472713 Insurance Information Ins. 1: HIGHMARK SECU Ins. 2: Ins. 3: Ins. 4: .. ~. We have received the explanation of benefds from your insurance company(s) and have applied whatever payments and/or adjustments are appropriate. Please make payment for the balance due $350.00 OR take advantage of a 15% prompt payment discount and remit $297.50 on or before 07/18!2012. Here are two convenient ways to make payment: 1. Call Customer Service at 717-763-2138 to make payment by credit card. 2. Mail tear-off coupon below with payment using the enclosed self-addressed envelope. ®~~ ~ Previous Balance: #350.00 Total New Charges: # . 00 Payments/Adjustments: # . 00 Account Balance: #350.00 Please Pay This Amount: 5360.00 OR Discounted Amount of 6297.60 if paid on or before 07/18!2012 _~ ~. Please call Customer Service at 717-763-2138 to add or make corrections to your insurance information, or to make arrangements for a payment plan. If you are unable to make payment, please contact the Financial Counselor's Office at (717) 783-2885 to discuss financial assistance options. Please Note: Your physicians will bill separately for professional services. Maxine L Wise Kristv Kellv Cumberland Crossings Retirement Community 07/30/2012 D to Description Units Net Balance rom rou Char es Credits 6!30!2012 Balance Forward ~~ t ~~ ~~ 3,395.11 TOTAL BALANCE DUE $3395.11 N ~ ;i !'u Rf: 'UF POf;710N WITH YOUR FAVMEM". RE-TAIN 60TTOM Nr~p l ~Of l FOP. v~ I ~ FECVHU~ ~~~ N.'7. _ .. , ,. .w ....~.~...,...~..::~.:,::::~~W, :.~:~.,.~:d ~., A':.. a, N.... ..u.,...,,~..rta. R'r:.>«-.a.: i.War ~.,..,..• . .ryti1!.AMN~F\.Ry'Jl~:4...4..-.~::.~...~.,-4+wi:+~d~t. DESCRIPTION OF CHARGE '~ QUANTITY UNIT PRICE AMOUNT Stretcher One Way TransMemLer T2C1)5 1.0 96.06 ~ ~ 96.06 Transport Van Mileage 50~0~ ' 20.8 3.74 7779 Toni Charges 173.85 ~` DESCRIPTION OF PAYMENT EIPT ' Y PAYMENT DATE AMOUNT Medicare Assignment Adjustm(:nt O',i/10/2012 ~ i 24.24 Insurance Payment - HIGHMAF:K -Fh.EED )M 14506295 ~~~ 05/10/2012 53.55 ~~ , Total Credits 77.79 PLEASE PAY THIS A~AOUNT -INVOICE DUE UPON RECEIPT -- <,$96 06 q: RETiURNE:D CWECK FEE - X31.00 '~~ 'PATIENT NAME: WISE, MAXINE L CALL NUMBER:' 2286 ~ W AMOUNT PAID; 05/14!2012 -,;;~ ----- ..~ IMPORTANT MESSAGES: This is the amount due after your Insurance Carrier's payment. WEST SHORE EMS • E3L'S ;?(15 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011-1708 r @~~r~ '. %~ ,,, .,361 Alexander Spring Ftd: ?"Carlisle, PA 17(115 M{ I ~ ' rv '~~ '' e ~ _ 6 x ~ ~ ~,.: ~° bent Financial Services; ,,,' ,~ ;, 17-960-1680 a"'~~? ~.,.<~,: ~~~.,:. I1~~ PLEASE PILL OUT BELOW... ;'~- ^ ^ D ^a MASTERCARD ~ DI: COVER ~'~~SSaaNBA ~ a ~ ,. /J;IE7C -. CARD NUMBER s~; d ,'m t" k~ ~ v'~~*°~IY t v ' ~ L 4 *s:. x t a " ~~~ '^'~;~ v . 31GNATURE .k'`+I r ~; ECU F. S4flT x vTIENT NAME Maxine L Wise ACCOUNT NUMBER 1228575 {; ~oityedtlreas below is Intoned or changed end it dicate change(s) on back -' yo-, REMIT THIS PAYMENTSTUB TOi I ~ :fi "si oaeeaoioi'~~{VIAXINE 1. WISE CARLISLE REGIONAL-MEDICAL,;( ,~ ~~ ~~"? QUEEN ANNE CT ,,,/~-~~ PO BOX 281442 " " ~ ?° CAMP HILL, PA 17011-17ci3 4/ ATLANTA, GA 30384-1442 ~;~ ;` '`~~ mlt~llnnr~~nnnlu~hlllilnplll,Ilpllhllhlllll~llllr~l t Illl~ll~ll~lrlllllll~~l~lllllllll~lllln~luh~~~~ '~ ~~ r~ J''L119-y m e L-„ LL.j l~ S ,. Sc,h• ~~_ ~7_,_ 00000122857500000002000MAXINELWISE ,° ~' -F fr ft y~: r ~riC~LY OS ITAL The Spirit of Caring 42015883 MAXINE L WISE 208 SENATE AVE APT 414 CAMP HILL PA 17011-2345 Patient Name: Wise ,Maxine L Statemerrt Date: 04/27/12 Service Date(s): 03/19/12-03/23/12 Account Number: 42015883 Medical Record Number: 472713 Ins. 1: HIGHMARK SECU Ins. 2: Ins. 3: Ins. 4: .. We have received the explanation of benefits from your insurance company(s) and have applied whatever payments and/or adjustments are appropriate. Please make payment for the balance due $350.00 OR take advantage of a 15°~ prompt payment discount and remit $297.50 on or before 05/27/2012. Here are two convenient ways to make payment: 1, Call Customer Service at 717-T63-2138 to make payment by credit card. 2. Mail tear-off coupon below with payment using the enclosed-self-addressee envelope. Previous Balance: 823,364.30 Total New Charges: 8.00 Payments/Adjustments: 823, 014.30- Account Balance: 8350.00 Please Pay This Amount: 5350.00 OR Discounted Amount of $297.50 if paid on or before 05/27/2012 Please call Customer Service at 717-763-2138 to add or make corrections to your insurance information, or to make arrangements for a payment plan. If you are unable to make payment, please contact the Financial Counselor's Office at (717) 763-2885 to discuss financial assistance options. Please Note: Your physicians will bill separately for professional services. IYiGJJHV L"J GAYrr.~+.LJ u U~~viY '•'•'• Your Account Balance is Overdue! Please make Payment Immediately!!! ~'r>t>'r "'•'• Thank you for your prompt payment. Please call 717-731-8315 with any >'r>'r''r """ questions. >'r>t,'r ,, ,, ,, ,, ,, ;,,,,,,,,,,,ir.ric 9rv,,,..,.,,,.,,.....ic>'c..;~o'ric:~:k:r:r>'ric>F>,>Firicic:rdr ~>c>'r>Yic$c>'cir,r9c...cx..:r:cxici::c>'c 4c >t dr r.:c:c is Insurance Charges pending to Prv; 480.00 Ins Pay/Adj against Ins pending 305.76 -174.24 0.00 05/10/12 1 9 ]_ PROGRAM EVAL PACER, DUAL 93280 427.81 135.00 05/16/12 BS-FREEDOM B Payment 36.64 05/16/12 Accept Assign Add. -78.36 20.00''° L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment. DATE LAST PAID AMOUNT • ~ • - . ~ • • ~ • - ~ - , , , , , , 00/00/00 0.00 0.00 0.00 20.00 0.00 0.00 0.00 0.00 20.00`?s`. PINNACLE:HEALTH CARDIOVASCULAR INST, INC 1000 N FRONT ST (MOFFITT HEf'.RT & VASC) WORMLEYSBURG, PA 17043-1034 PAT~~ 1-MAXII:fE WISE PRV~~ 9-SMITH, MICHAEL F, MD, FA ., ~ 20.00* Ph:(717)-731-0101 Acct~~: 157086 Date: 07/27/12 Page 1 of 1 r ; "CAR1.ISlJ 361 Alexander Spring Rd. >' RFGIONnI. Carlisle, PA 17015 FOR CREOIT CARD PAYMENT, PLEASE FI~L+LwOUT BELOW... ~~ M^ASTERCARD ~~~ p^jSCOVER "i/ISA VISA ~ A^MEX K Patient Financial Services: ~~/ 717-960-1680 t - _, ,...... ., , . ,... . Ee~r~gerJ nn<r inrln:ale clmrir~r~fSJ on pack oo3e66 oioi MAXINE L WISE ~. 7 QUEEN ANNE CT / CAMP HILL, PA 17011-1733 (/ liullullillll!~ill~lnl!li!II!lilnlillnli~„lulillnnllil~l rx r. SIGNATURE SECURITY CODE PATIENT NAME STATEMENT DATE DATE DUE Maxine L Wise 06/25/2012 UPON RECEIPT ACCOUNT NUMBER AMOUNT DUE AMOUNT PAYING 1228814 $11.02 $ _ . REMIT THIS PAYMENT STUB TO: CARLISLE REGIONAL MEDICAL CENTER PO BOX 281442 ATLANTA, GA 30384-1442 Llllllllllln,llilllll,L.I,•nliill,ll,inli~llilllllil~ililill 654049A (PC. 00000122881400000001102MAXINELWISE g Sc.~ . /~ . '7. Please Remit Payment To' Cumberland Goodwill Fire Rescue EMS Billing Office PO Box 726 New Cumberland, PA 17070-0726 --- -- QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 I:3;: 717-214-6020 f-mr-, 7~: info@ambulancebillingoffice.com Date of Service: 5/14/2012 03:04 !'ieasr sir u„r webs~te ~o provide insurance or make payment; an^ Patient Name: WISE, MAXINE L. for additional paymenr options and frequently asked questions. From: CUMBERLAND CROSSINGS www.ambulancebillingoffice.com To' Holy Spirit Hospital ~u11~I: a - u - We have not received your payrreent. Your insurance made a partial payment, and you are'responsiblefnr the remaining balance. Please remit payment. Thank you. 5/14/12 BLS Emergency Transport 5/14/12 Mileage 5/14/12 Adjustment -Insurance 6/18/12 Adjustment -Insurance 6/18/12 Payment Total ~,~ A0429 1.0 630.00 630.00 A0425 20.3 12.08 245.22 -399.21 58.26 875.22 -340.95 -434.27 -434.27 DETACH AND RETURN 130TTOM PORTION WIIH YUUR PAYMENT. n..-0n.~....wr«~rd~i+. s-:.:: .. .,Ay...1 ./1. . aa11w1a.1rw~.~ _. _ ~ Pleaae Remlt Payment To:' .tat~fi~ ~ ~ _ ~ , - . • „ , _ East PF+nnsboro Amlbulance Service !nc t~,~u ~ --_ ,, i f'O iE i r 12-126506 7/6/2012 $97.79 f.r?~~ ~ . r = ~ `, F"~ 17C 70-0726 QJ ES-° Ut~r, as,,-.IT TH751BILL? Vhonc 877-214-6018 Espafiol: 866-724-4114 Fax: 717-214-6020 Email; info@ambulancebillingoffice.com :afe: ~.1 ; 319'20' 2 10:06 Please visit our website to provide insurance or make payment, and P= V'd15=, h1AXINE L. for additional payment options and frequently asked questions: RESIDENCE www.ambulancebillingoffice.com Holy Spirit Hospital * * * +~' * + ' 1. , .a::count is Past Due * * * * * * * Your account remains unpaid despite our previous billing accofuu Is rz~ w under collection review and may be forwarded to our collection agencyif this bill xemau 3/19i"2 E;I_S E:mergencyTransport A0429 1.0 800.00 800.00 3f19~12 `,M1ileac3e A0425 0.8 9.00 7.20 3/19/1: .'>,djustment -Insurance -473.68 4/1'111 i=~avment -235.73 >•otdt 807.20 -473.68 -235.73 4 '. DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. „ - .. Comcast, Contact us: C~ www.comcast.com ~ 717-540-8900 Account Number Billing Date Unpaid Balance New Charges Total Amount Due 09547189323-02-9 05!28112 $29.92 -Due Now $64.67 -Due 06!25/12 $94.59 Page 1 of 2 MAXINE WISE For service at: 208 SENATE AVE APT 414 CAMP HILL PA 17011-2345 News from Comcast We regret bsing you as one of our subscribers. Our records indicate that the final balance shown above is now due. Your prompt payment is appreciated. Any outstanding equipment must be returned to our office within 7 days. Please call us at 1-800-COMCAST any time should you wish to reconnect your service. Hearing/Speech Impaired Ca11711 Detach and enclose this coupon with your payment. Please write your account number on your check or money order. Do not send cash. Comcast® Account Number 09547 189323-02-9 Payment Due by Due Now 1555 SUZY STREET LEBANON PA 17046-8317 AV 01 004579 962468 12 A"5DGT Illllllllh'1'11'111'Ilnllli111'IIIII'Ill'rl"II'Ilhrlll"II, MAXINE WISE 208 SENATE AVE APT 414 CAMP HILL PA 17011-2345 .its , Total Amount Due $94.59 Amount Enclosed $ Make checks payable to Comcast "'I'1~1I'll~~l"~II111IIIIII 1111111'III"11111111i1~1~~1111111t1 COMCAST CABLE P 0 BOX 3006 SOUTHEASTERN PA 19398-3006 (79547 189323 02 9 0 09459 Q 0 0 m .. .. . ..._. , y, ....~. _.v.t ~" ` ~Niar~k you f©r being a valued' Comcast customer? x~;; ~i .., _.~, ~~ti,~ .` \ / Account Number D ~; D atc lrnuunl Oue \\/~ 717 730-7308 `688 21Y 6, 1/ l;: 156.38 ver~Loin Account Information Statement Date: 8/5/12 MAXINE L WISE Phone: 717-730-7308 Don't Move Without Verizonl Call 1-888-416-9691 before you move. We'll help set up your Internet, N and Phone for your new address. You can be up and running in no time! DON'T WAIT! And be sure to ask it FiOS is available in your area. Service availability varies. We Want You to Stay With Us You are a valued customer & we want to deliver the very bell service & value to you. Call us at 1-877-875-8490 to find out about the new ways Vedzon can save you money. We appreciate being your provider, and we would like to keep you with us longer by improving your Verizan experience. Better Bundles That Save Call 1-888-363-3644 or visit verizon.com/supreme to make sure that you're getting the best Verizon services at the best value. From phone, Internet and N bundles, to international plans and fun add-ons, together we'll find ways to save you more on Verizon's superior services. Account Summary Previous Balance Payment Received May 29 Adjustments and Credits Balance Forward New Charges - - Current Activity Taxes, Fees and Other Charges Total New Charges Amount Due Final BIII Questions about your bill or :srvice? View your bills in detail et verizon.com o' call i - 80( -VE i'ON (I-80)-837-4966). Enter your ten digit number 717-7:30-7306. is: if!8 i1 s,: Lod frr you r Customer Identification Number. Reach us by TTYnl1- 0)-9~'4-iN~)6 Account Number: 7 I7 7ai i-7306 fi8f' 21Y Charges Due: Jun ~~,',t012 Amount Due: 556.38 0 r~ 0 512 Do not send Payment You are enrolled in Veriz m's ~ u om atic F e i menl option. The total due will bed :dur h;d iro n your bank account on 6/ 271 1 ~!. 00009700 01 AV 0.350 VPC15711 0043 XX MA)uNE L WISE 208 SENATE AV APT 414 CAMP HILL PA 17011-2345 Idl[Iqurlllllld'rlrlririllrl'lit'liililrrllillr'rli[liiiiilli 117717073073086887028021030XXXX60000003143!UI7:]0`:D5b3fS200000 $31.43 -$31.43 $31.43 x3,.43 __ - -_ -$1.85 $26.80 S2a.95 ~L~M. s5s.3a -. Jc~>, . ~ . ~7, - LOCAL REGISTRAR'S CERTIFICATION OF DEATH _,, WARNING: It is illegal to duplicate this copy by photostat or photograph. ~ ~~ ` ~t ~,~` V i/1 :~.~ e for this ceRific~.~i~ This is to certify that the information 11ere,given:fi ~[ ))VV correctly copied from an original Certificate of Deat duly filed with me as Local:Registrar. The origin) \\w~// certificate will be forwarded to the State Vit; Records Office for permanent filing, ~ 18889733 ~y~ MAy2 ~,zo~2 .Certification Number --. _ __ Local Reg stray Date Issued TYpa/Print In COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH . VITAL REC0R09 Permanent !'FQTI CI!`ATC AG AC~ATLI 1. De[edent'a Legal Nam. (f leer, Mldtlle, Lift, 6ufflx) 2. 3rx 3. ~eelal Recurlty NVmbar~t ry4. Date Of Oaet (MO/Day/Yr) (Spell Mo Maxine L. Wise F. 206-30-9617 Ma 20 2012 Sa. Age-Coat Birthday (Vrs) 6b. Under S Vaar 6c. Under 1 De fi. Data of Birth (MO/Uay Yaer) (Spell Month) >a. Blrj1'.+{.I (GIN an Stara or Foreign Country) ~ Months Oayf Heurf Minutes Wi j.~ams crt PA 71 November 18 , 1940 >b. Blrthpbu (Cquety) Ba. Raaldence (3[ate Or Foreign Ceuntry) gb, Raildenca 6tr¢at antl NVmber-Include AptNO.) Penns lvania gt. Dld D¢C¢dOnt Llve In a TOwnfhlpT 2 ~$YSa, d.daa.nt uy.d m E. Pennsbozo tW' a R.f1~ ([aunty) 08 Senate Ave. P~ CAIIIlber,LarlQ Ba. Paaltlanca (Zip GOda] C7 No, decadent IlVetl wlthln limits o/ city/bore. 9. Ever In U9 Armed Fercesi 30. Marital Status at Tlma of Death Marrlstl WI owed 11. 6u rvlVln{ Spquse's Name (If wife, glVa name prior to first marriage) (] Yaa ~ No Q Unknown ~.f Dlyorwtl ~ Never Marrlatl [~ Unknown 12. Father's Nema (First Mltltlle, last, SVHix) 13. Mother's Name Prior tP First Marriage (First, Mid le, LasU Edward J. R der Violet M. Seiwell ~ 14a. Informant's Nams 146. 0.a atlonshVp to Decetlant 14 c. Informant's MFlling Atldrafs (Street antl Number, CI Staq. ZIO Cetle Krist L• Kelly Dau hter 7 een-Anne Ct. Hi~l PA7011 If Death OccVTad In • Hos PI[al: ~.~ Inpatient: It Daa[h DGOVfrod Somew era Ocher Than • Hof pIC31: ~(-Hospice Facility [~ D¢cedanf'a Home ' Emar •nc Room/OUtpetlant O. Dakd on ArrlVal Nuriln Moina/Len -Term Caro Faclll Other (6 eclfyJ 15 b. Facility Nama (1/not Inatltutlon, glVa street an number; 13c. City or Town, 9tata, antl Zlp Obde 14 . County of Death o irit~ s ital 1 1 ffi, 16s. Meti.ud Of plspOiltlon Burial Cremation 16G. Date of DISpOFItIOn 16c. Place Of Ulspesl[lon (Nams of ca metery, crematory, Or ether place) 0 R¢meyal from State ~ OonatlOn '. pth.r (6 ally 05/22/2012 Rollin er Crematory 16d. Location of Disposition (City or Tewn, Siete, and Zlp) 1>a. nature 01 F eral.Sarvlea Llcanaee ter Perso <Narge ^/ Inlermanf 1>b- License NUmbar Mt. Roll yin s PA 014819 1> ame and plate Atltlr f Funer Fa I Ity e -da n '~ ~Ei ~ Z . 1 rner rs era l ome nc 903 Market St. Hill PA 17011 ffi 18. Decatlant'f EtlucatlOn -Chock the boa that bast tla3crlbea 4ha 19. Dacetlant O Hif panic Orl{In - Checlt t e 20. Oacetlent s Racer - Chock ON OR MORE races to Indicate what Flghest dagre• Or level of acheol complefetl a[ the time of death. box that bait tlascrlbef wM1SCMer the tlecetlent the tlacatlent c^nsidaratl hlmaelf er herself to ba. ~ BtF: {rode or laf3 le 3Oanlf h/Hlfpanic/Letlno. Chock the "NO" ~ WM1Ite Q Korean NO tllplema, 9th • 12th grotle box If decadent is not Spa nlsh/HlspBnlc/Latino. rj Black er African ATarlcin ~ Vletnameae High achOOl glad uata or GED cOmpl¢tad Np, no[ Spanlf h/Hlf penlc/Latlno ~ American Intllan Or glaaka Na<Iya 0 Other Asian ~ ~ Soma [olio{. cratll[, but no degree Vas. Maxlca n, Mexican American, Chicano (] Asian Indian Q Native Hawaiian Q AsaOClate tlegrae (e.g. AA, AS) Q Vas, Puerto Rican Chinese ~ ~ GVamanlan er Ghamtrrro Q BachelOr'a tlagrea (e.g. Bq, AB, {31 ~ Yes, Cuban (] Filipino ~ Samoan [] Maalar's tla{ere (e.g. MA, MS, MEng, MEd, M9W, MBA) ~ Yes, other Spa nlah/Hlapa nic/Letlno ~ Jspanese Q Other PaclRC lalandar 0 Dettorate (e.{. PhO, EdOj er PrafafllOnal tlegraa (9paclN) ~ Other (Specify) . MD D 5 DVM LLB JD 31. paeetlent's Sin{le Race Gel/-Daalgnatlon - Gheek ONLY ONg to Indicate whet the tlreadant confltlarod himael/ or ersalf t0 ba. 22e. Decedent f Usual Oeeupatlon - Indleata Npe of week yVhlte Q J¢Pa^efe Q Samoan tlOna during moat 01 wprklnS Ilfa. DO NOT USE RETIRED. ~ Black or African American ~ KOroan ~ Other Paclllc Islantlar G 1~4merlcan lntllan er Aleake Na[lye QVlefnamasv QDon't KnOW/Not SUrF ~fL]-ce Assistant 0 Aalan Intllan ja Ottter Allen ~ ftefuaed 12b. Kind O/ BValnaaf/In ustry Q <Mlnue )_j Natlya Hawaiian [] Other (SpecINJ ~ FIIpInO Q GVamanlan Or GhemOrrO ITEM 2Sa - 13 MUST BE OMPLETEP 23a. Defer Pronounce Oaad o Day Vr) 23b. Signaturk b Parson Pronouncing paafh (Only w en appllca le 294. Llcanae Number BY PERSON WHO PRONOUNCES OR GERTIFI[S DEATH S ~ ~i2 13tl. pate Ignad (M Oey/YrJ 24. Time of Death R ~ 3~ ~ (~ G> ~taZ /Q 25: Was Medical nominee or coroner GOntactadi _ j$~Yas NO CAUSE OF DEATH APProwmat. 26. Pan 1. Enter the [halo of events-tllfeazes, Injuries, or cgmpllcatloni--that dlraetly causetl the death. DO NOT enter terminal events such as cartlla[ arrest Interval: rsapireCOry arrest, er ventricular flbrlllatlOn without ah w log the atl Ola O gy. DO NOT ggBftEVIq TE. Enter Only One cause On a Il ne, gdtl atl d ltlOnal Ilnef If necessary Onfet t0 peach / o / + ~ / ~ ~ / ~ IMMEDIATE CAUSE ------•---.----r ¢. /"T~ ~^ ~C+ ~C C !t ~--(ii^(I • ~ ~-3~ ~a ~Q_ (Final dlfaafe or Gentlltlon r UVa t0 (o a3 a cOnfaq V¢nce ef): resulCing In death) b. I Sequentlal{y 11sf condltiona, Gua to (er of a cOnaequa nc! oT): If enY. leetllna t0 the ca a listed en Ilne a. Enter rhe [ UN DFRLVING GgUSE Due t0 (Or of ¢ censegVence OfJ: ' (tllaaase or Injury LM1ae Inltla tad tna ayentf r SV lung d. in tlOelM1) LAST. Dua to (or cpnS¢gUen[a o}): as a 26. Part II. Enter other but net ref ultln{'In the untlerlYing cause given In pert 1 1T: Waa an au[oPSV Part rmetl? Y No ffi. ~~11 Z{.-Ware 4utoPSY Rndings available to cgmp)aN the cause of tlaathl ^ Vra NO 29. If Fermate: ' 3D. Old Tobacco Usa Contrl ufs to DaachT 31. Manner of Death f~ NOt prognen[ wlthln poet y0ar 0 Pregnant at time of death 0 yea Prababl Y ~NaCUral (] MVmlclde ~ Not Pfa{nent, but pregnant wlthln 42 days o1 death ~ No unknown 0 Accident O pentling inyestl{itlOn ~ Sulcltle ~ Coultl not be determined ~ Not pragnanU but pregnant 43 tleys [O 1 year before death ~ U k 1/ 32. Data Of Injury (Mp/Day/Vr) (Spell Month n nown Pregnant wlthln the Paat Year 33. Tlms of Injury 34. Place o Injury (g.g. home; construction ilta; farm; fchool) 36. LecaHOn Of Injury (Stree<and Number, CIN. Stets, Zlp Code) 36. Injury a< Work 3T, i/Tren~portatlon Injury, Epeclfy: 38. Defcrlbe How Injury OOCUfratl: 0 Vea 0 Drlvar/Operator ~ Pedestrian ~ No ~ Pasfan{err ~ Other (SPeclfy) 39a. CartlRer Chec only One): ~'CSrtlfying pNyflOlan -TO [ha beat Ot my kn^wledge, daatn Oeeurratl tlue tV the causa(sJ fnd manner stated ~ Pronouncing B, Gartthing phYalclan -TO the bast of mY knowledge, tlaath Occurred at the time, tlete, end place, antl due Co the csuaa(3) antl manner stated O Matllcel Examiner/Coroner - On [h beala Of exeminatlOn. antl/er InvestlgatlOn, In my Oplnlon, daaCh OCCUrred ft [he time, date, end piece, and dVa to tMe cauae(a) antl m r stated ' 61{nature o1 cartlllar: Tltl¢ of eartlRer: ~I c- License Number: r~•9 Y ~ 7/fi ~ •~ 396. Name, Adtlreff antl ZIP God¢ of Perfpn COmplatln{ Cause Of Death (Item 26) ~p ~/ ~r' ~~ gyC at D Igned M DgY r) ~ r' 2 rte ere y) F!-G,/ n .C 'Zt-% ul' ~ f'fn ~ ^ /, ~ ~ N O ^ e~ 40. Regtstrai f District Number 41. flag error atura ~/i/1 ~ 41. erg f[r a Dete MO Osy / ~ ~ 4 ~~e~~~d rl.l Z 43- Amendmantf H 105-143 ,, >, .-, :~T~AXIiVE L~GT1J=. Wis` I, i4AXII3E LOUISE WISE, of Cumberland County, c~ - z r. -., T rr r~ ~ _. 1_ .r ' _~ - i _ ; '. rr !V ~7 1 Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time previously made. I. I give and bequeath all of my household furniture and furnishings, automobiles, books, pictures, jewelry, china, crystal, appliances, silverware, wearing apparel, and all other like articles of household or personal use or adornment to my daughter, KRISTY L. KELLY of Cumberland County, Pennsylvania ("My Child"). If any such other articles are not easily distributahle in kind or if it is impractical that they be so distributed, then I authorize my Executrix to sell such articles and the proceeds thereof shall pass as a part of my residuary estate or such articles may be given to charity, all in the sole discretion of my Executrix. II. I give, devise and bequeath all of the rest, residue and remainder of my property, real, personal and mixed, not disposed of in the preceding portions of this Will to My Child_ Should My Child predecease me, I give, devise and Pag° of 1 pages - _ - _ .. - _ .. _ - _ _ _ _ _ ._ _ _ _ _ _ r _ _ _ . _ _ _ '. _ _ ..._ .. - _ _. _ _ _ ~. _ ,~ ~tta~red the age .,_ t~.;er-_ -__.~ 2~ .~-~_- __ =--c ~_..._ -=_ _~- tie distribution of my residual estate, then such sor'c s<-:are shall be paid over to my Trustee hereinafter named, IN TRUST NEVERTi-?ELESS, to be held, administered and disposed of as a separate trust estate in accordance with ITEM V hereof for the benefit of either or both of My Child's Sons who has not by then attained the age of twenty-five (25) years (the "Grandchild's ''rust") . IiI. i hereby exercise all powers of appointment which may have at the time of my death in favor of my Executrix, and a_i property subject to all such powers of appointment shall be included ir_ my estate and be governed by the provisions of this Wii_. IV. All inheritance, estate and similar taxes becoming due by reason of my death, except any taxes relating to ge-:eratior. skipping transfers imposed under Chapter 13 of Subtitle 3 of the Internal Revenue Code, as amended ("Death .axes"), whether such Death Taxes shall be payable by my estate or by any recipient of any property, shall be paid by my Executrix out of the property passing under ITEM II of this Will as ~.n expense and cost of administration of my estate. Except to dace 2 0. -- owes ,, -__~ ex~e~~ a~.;-:e _ro-:_de^ _ ~xec~~_ix sha=_ have no duty or ~, ob L gation to obtain reimbursement for any Death Taxes paid by my executrix, even though paid with respect to proceeds of insurance or other property not passing under this Will. v. My Trustee shall have, hold, manage, invest and reinvest the assets of each Grandchild's Trust, collect the income and (a) So long as either of My Child's Sons (the "Grandchild") have not yet attained the age of twenty- five (25) years, my Trustees shall from time to time pay to or for the benefit of the Grandchild such amounts of the net income and principal of the Grandchild's Trust as, in the sole discretion of my Trustees, shall be necessary for the Grandchild's maintenance in a proper station in life, support, medical and nursing care and education, including college and graduate education, taking into consideration any other means readily available for such purposes. At the end of each year any unexpended income shall be added to the principal of the Grand- child's Trust. (b) After the Grandchild shall have attained the age of twenty-five (25) years, my Trustees shall distribute the remaining principal and any undistributed income of the Grandchild's Trust outright to the Grandchild. If the Grandchild shall have died before attaining that age, my Trustees shall retain the assets for the benefit of any issue of the said deceased Grandchild in accordance with the terms hereof, or, if none, distribute the then remaining principal and any undistributed income to the issue then living of the parent of the Grandchild who was a child of mine, per stirpes, or, if such parent shall have no issue then living, then to my issue then living, per stirpes; provided, however, in either event, if any such beneficiary is then a beneficiary of a Grandchild's Trust hereunder, the share of such bene~iciary shall be added to the principal of such Grandchild's Trust as if an integral part thereof, to Page 3 of 11 pages be held, adrnini stered a :d ~i scosed of i. accordance with the terms t'<~ereof . _ Vl. tiotning herein ~s intended to, nor shall it be construed to, postpone the vesting of any part of the assets of any separate trust estate hereunder for more than twenty-one years after the death of the survivor of me and my issue living at the time of my death. At the expiration of such period, the assets cf all the seoarate trust estates hereunder shall immediately vest in fee simple absolute in and be distributed outright to the person or persons then entitled to receive the income therefrom, whether in my Trustees' discretion or otherwise. Vii. ?Qo interest ir_ income or principal of my estate or' any trust created hereunder shall be subject to attachment, levy or seizure by any creditor, spouse, assignee or trustee or receiver in bankruptcy of any beneficiary of my estate or of any trust created .ereunder prior to the beneficiary's actual receipt thereof. My Executrix or Trustee shall pay over the net income and the principal to the beneficiaries herein designated, as their interests may appear, without regard to any attempted anticipation (except as may be specifically provided herein), piedgir_g or assignment by any beneficiary of my estate or of any trust created Hereunder and ~rJithout regard to ar_y claim thereto ?age _ o= '.1 pale ~~,= ;.. .. ..e:'p.e'v _~'-iv a~~ac. :"e~ ~:~~.._'~ .,r .~..____ _ _..~.-..JJ agar ... .. , _ _ said beneficiary. VIII. Any person who shall have died at the same time as I or under such circumstances that it is difficult or impossible to determine who shall have died first, shall be deemed to have predeceased me. Any person other than me who shall have died at the same time as any then beneficiary of income of my estate or a trust created hereunder or under such circumstances that it is difficult or impossible to determine who shall have died first, shall be deemed to have predeceased such beneficiary. IX. In the settlement of my estate and during the contir_uance of any trust created hereunder, my Executrix and my Trustee shall possess, among others, the following powers, exercisable without prior court approval, but in all cases to be exercised for the best interests of the beneficiaries: (a) To retain any investments I may have at my death so long as my Executrix or Trustee may deem it advisable to my estate or my trusts created hereunder (hereinafter "trusts") so to do, including securities owned, issued or underwritten by any corporate Executor oY Trustee or any of their affiliates. (b) To vary investments, when deemed desirable by my Executrix or Trustee, and to invest in every kind of property and type of investment, including bonds, stocks, notes, real estate mortgages or other securities or in such other real or personal property, including securities owned, issued or underwritten by any corporate Executor or Trustee or any of their a~filiates, or as to which my corporate Executor or Page 5 of 11 pages __~stee cr a~_~ ~- _^e-r aff_ia~es are investment advisors, as m~yr^Executrix or Trustee shall deem wise. (c) ~n order to e=feet a division of the principal of my estate or trusts or for any other purpose, including any final distribution of my estate or trusts, my Executrix or Trustee is authorized to make said divisions or distributions of the personalty and realty partly or wholly in kind. If such division or distribution is made in kind, said assets shall be divided or distributed at their respective values on the date or dates of tr:eir division or distribution. In making any division or distribution in kind, my Executrix or Trustee shall divide or distribute said assets in a manner which will fairly allocate any unrealized appreciation among the beneficiaries. (d) Tc sell either at public or private sale and upon such terms and conditions as my Executrix or Trustee mav_ deem ad,aantageous to my estate or trusts, any or all real or personal estate or interest therein owned by r-~y estate or trusts severally or in con~unctior. with other persons or acquired after my deatr by my Executrix or Trustee, and to consummate said sale or sales by sufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title, free and clear of all trust and without obligation or ~_iability of the purchaser or purchasers to see to the application of the purchase money or to make irquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings which may be necessary or desirable in carrying out amy of the powers conferred upon my Executrix or Trustee it this paragraph or elsewhere in this F7i11. (e) To mortgage real estate and to make leases of real estate for ary term. (f) To borrow money frog any party, including my Executrix or Trustee, to pay indebtedness of mine or of my estate or trusts, expenses of administration, Death Taxes or other taxes. (g) To pay all costs, expenses, legally enforceable debts, funeral expenses ar_d charges in ?d~° 5 O~ -_ pdQ°S 5 ~ ~ ~. ~r~~1rr~~ 111~~ _r:1S~S . (h) To vote any shares of stock which form a part of my estate or trusts and to otherwise exercise all the powers incident to the ownership of such stock and to actively manage and operate any incorporated or unincorporated business, including any joint ventures and partnerships, and to incorporate any such unincorporated business, with all the rights and powers of any owner thereof. (i} In the discretion of my Executrix or Trustee, to unite with other owners of similar property in carrying out any plans for the reorganization of any corporation or company whose securities form a part of my estate or trusts. (j) To assign to and hold in my estate or trusts an undivided portion of any asset. (k) To hold investments in the name of a nominee. (1) To compromise controversies. (m} To disclaim, in whole or in part, any and all interests in property owned by me at the time of my death, including those passing to me by Will, intestacy, contract, joint ownership, operation of law or otherwise. (n) To divide any trust hereunder into two or more separate, but identical, trusts. My Executrix may divide any trust hereunder which would have a generation skipping transfer tax inclusion ratio other than one (1) or zero (o), into two (2) separate trusts which are fractional shares, known as the "exempt trust" and the "nonexempt trust." The exempt trust is that fractional share of the total trust fund that has a generation skipping transfer tax inclusion ratio of zero (0), and the nonexempt trust is the remaining factional share of she trust, with a generation s:{ipping transfer tax inclusion ratio of one (1). The terms and conditions of the nonexempt trust and the exempt trust will be identical. Any reference to a trust created under this Will, without a further specification or limitation, shall be deemed to refer Da,e '' of 1 pages -__~~-_~__ >.~__-- ._.__e _=_~.:~__~. T:"e assets of ~~_.. 4-_ rate exer~:pt a-:d r_onex_empt trust shall be held, ad~::inistered and invested as separate trusts, and my Trustees shall maintain adequate accounting and records or botr. such truss. My Executrix shall indicate on the federal estate tax return filed for my estate that separate trusts will be created ;or funded) and clearly set forth the manner in which the trust is to be severed and the separate trusts funded. to) To designate one or more persons or a corporation to act as ancillary fiduciary in any jurisdiction in which ancillary administration may be necessary, such ancillary fiduciary to serve without bond or security and to have all powers, authorities and discretions conferred hereunder. tpi To employ from time to time and compensate from income or principal, in the discretion of my Executrix or Trustees, investment and legal counsel, accountants, brokers and other specialists, and, whenever there shall be no corporate Executor or Trustee in office, a corporate custodian, and may delegate to investment counsel discretion with respect to the ir_vestments and reinvestment of any or all of the assets held hereunder. X. In the settlement of my estate: (aj My Executrix shall rot. be personally liable for any loss to my estate or to any beneficiary of my estate resulting from an election made i.n good faith to claim a deduction as an income tax deduction or as an estate tax deduction. !b? 'n valuing property in my gross estate for the purposes of any Death Tax, my Executrix shall not pe personally liable for ary loss to my estate or to any beneficiary of my estate resulting from my Executrix's decision made in good faith to use a particular valuation date. XI. T. any assets ::^.eid in any trust created hereunder are exemot from generation skipping tax as a result of an ?age ,. cf ~- ?ages 4 ~ . ~ ~ l ~ =~_er-al Revenue Code of 1986, as amended, my Trustee may, in the Trustee's absolute discretion, (i) create a separate trust with respect to the assets to which such exemption was applied with the balance of such assets, if any, being held and maintained as a separate trust under this Will or (ii) hold and maintain the assets to which the exemption was applied along with the non- exempt assets as one trust estate under this Will. XII. If, in the sole discretion of my Trustee, at any time any trust hereunder is or becomes too small to justify its maintenance as a separate trust, my Trustee, without any liability to any person or remainderman whose interest may be af`ected thereby and without the necessity of court approval, shall terminate such trust by distributing all the income and pr_ncipal of the trust to the then income beneficiary or beneficiaries of said trust. If any additions to any such trust are received after its termination under this ITEM, such trust s'_Zall be revived and this provision shall continue to apply to it. The Trustee's discretion herein granted shall in no event be construed as giving any potential distributee of a trust the right to compel a termination in whole or in part of such trust. XIII. I hereby appoint My Child as Executrix of this rr7ill. If for any reascn she should renounce, fail or cease to Page 3 0= 11 pages _.1-.y, Pennsy_v~___a, tc ser.~ as r,:y Executor. XIV. i here:~v aono_nt my son-in-law, KEVIN PRICE KELLY as Trustee of ar_v trust created hereunder. If for any -reason he should fail or cease to act, then I appoint his brother and sister-in-law, EDWARD R. KELLY and ALICE R. KELLY of Hershey, ?enasylvania, or the survivor o` them as my Co-Trustees to act or con=inue to act with all of the powers originally granted to my ^rustee herein. An individual Trustee shall be deemed to have failed to serve as Trustee hereunder if, among other reasons, the treating ohysician of said individual Trustee shall certify in writing tha= such Trustee possesses permanent mental or physical in~aoacities which oreclude such Trustee from discharging his or ^er duties as Trustee hereunder. Any Trustee serving hereunder shall have the right to resign frcrn suc'.~! office at any time, with or without cause and v;ithout Court approval. No successor Trustee shall be liable for tine actions of a resigning or removed Trustee occurring prior to such successor Trustee ta'.{ing o~~ice. All references in this r~r~__ t0 my °TruSteeS" Sf_a11 refer to my originally named Co- Tratees cr to ml; sole successor Trustee, as the case may be. XV. An•. Custodian, Executrix or Trustee shall qualify ana serve wit_nout the c~~t~f cr obligation of filing any bond or ~~~ e_.~itled to compensatior. far services in accordance with the standard schedule of fees in effect when the services are rendered. My individual fiduciaries shall serve without compensation. IN WITNESS WHEREOF, I have set my hand and seal to this, my Last Will and Testament, consisting of this and the preceding ten (10) pages, this Page 11 of 11 pages day of July, 2004. • ~ , ~, iil~ zu ~~ck.{ ~~,~ [ (SEAL) Maxine Louise Wise We, the undersigned, hereby certify that the foregoing Will was signed, sealed, published and declared by the above- named Testatrix as and for her Last Will and Testament, in the presence of us, who, at her request and in her presence a.nd in the presence of each other, have hereunto set our hands and seals the day and year above written, and we certify that at the time ~f the e cu io thereof, the said Testatrix was of sound and disgos/i'r.~ an arid( memory. r ,, .C~~~~~ u.~ (:t ~ b{. ~ L~~.~t~, ' SEAL ) Re i ng a t~ ~ ~w~ ~ l ,` ' LZ~ fl i ~~~j<<-~~ CL ~~ ~~ (SEAL) Residin at : jF:, l l<<~ g ~~ ~ t 4~ (Z-rric~. (%t ,,r---- °~~ `~' ~' itY ~ _ (SEAL) Residing at : ~sy~ ~u.~~;~~_ ~~~,,~._