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HomeMy WebLinkAbout02-19-13COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX(11-96) NO. CD 017187 HALBRUNER MARK E GATES HALBRUNER & HATCH PC 1013 MUMMA RD STE 100 LEMOYNE, PA 17043 fold ESTATE INFORMATION: ssrv: FILE NUMBER: 2113-0199 DECEDENT NAME: KOST R NELSON II DATE OF PAYMENT: 02/ 19/2013 POSTMARK DATE: 02/ 15/2013 COUNTY: CUMBERLAND DATE OF DEATH : 1 1 / 21 / 2012 REMARKS: RECEIPT TO ATTY CHECK# 8016 SEAL ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ $ 8,100.00 TOTAL AMOUNT PAID: INITIALS: HMW $8,100.00 RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS LAW OFFICES OF GATES, HALBRUNER, HATCH & GUISES P.C. 1013 MUMMA ROAD • SUITE 100 • LEMOYNE, PENNSYLVANIA 17043 (717) 731-9600 • FAX: (717) 731-9627 LOWELL R. GATES, LL. M. CORRESPONDENCE ADDRESS: LL. M. in Taxation Lemoyne Office MARK E. HALBRUNER WEB SITE: CRAIG A. HATCH, CELA www GatesLawFirm com Certified as an Elder Law Attorney by . . the National Elder Law Foundation CLIFTON R. GUISE Also Admitted to practice before the U.S. Patent & Trademark Office ALICIA A. BLANKENSHIP February 15, 2013 Cumberland County Register of Wills One Courthouse Square Room 102 Carlisle PA 17013 RE: Estate of R. Nelson Kost II Date of Death: November 21, 2012 Dear Register of Wills: BRANCH OFFICE: 3 WEST MONUMENT SQUARE, SUITE 304 LEWISTOWN, PA 17044 (717) 248-6909 STACEY L. NACE Paralegal/Office Manager TRACT L. SEPKOVIC Paralegal TRACT L. HILFERDING Paralegal Enclosed is a check for $8,100.00 from my law firm's escrow account payable to "Register of Wills, Agent" for the estimated Pennsylvania Inheritance Tax on the above-referenced estate. This is anon-probate estate. An original Death Certificate is also enclosed. Please send the receipt to my attention in the envelope provided. Thank you. Sincerely, ~~: Mark E. Halbruner ~V ~' a Enclosures o ~ ~ ~ r n +~ c°~ ~? -v rn~~ r t~ ~ :~ ~~ y. ~ ~ CO ~ ~ 7°: ~ C~ ~ 'TT „~ "°"~ C'~ ~ "'t~1 ~ ~- ~ ~, © ~ ~ _ t`U . ~ ~ ~ ~,, CJl ~ .© ri H105.805 REV (9/ll) LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. RECORDED OFFICE 01~ • Fee for this certificate, ~6.0o REGISTER 0 ~' I E.IS .,,,,,,-T~%~ --.--__ This is to certify that the information here given is ~~13 FEB 19 F~112 P 1~9~7599 Certification Number v C S ~/ .e/ Type/Print In Permanent BI k 1 k GLERK OF ORPNAI~IS' COUR `=` C~MBERLjAND CO., P correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. 2 ~' Local egistrar Date Issued COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ac n 1 . Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Yr) (Spell Mo) R. Nelson Kost, II Male November 21, 2012 S e. 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 Country) Mechanicsbur Penns lvania Months Oays Hours Minutes 84 January 30, 1928 7b. Birthplace (County) Cumberland 8 a. Residence (State or Foreign Country) Sb. Residence (Street and Number -Include Apt No.) 8e. DId Decedent Llve In a Township? P nn v8 is 312 South Broad Street QYes, decedent Ilved In ~p• S d. Residence (County) Cumberland 8e. Residence (Zip Code) 17055 ®NO, decedent lived wlthln limits of Mechanic 8burg city/born. 9. Ever In US Armed Forces? 10. Mar ital Status a[ Tlme of Death Q Married (~ WI owed 11. Surviving Spouse's Name (If wife, glue name prior to first marriage) Q Yes ®No QUnknown Q Di vorced Q Never Married Q Unknown 12. Father's Name (First, Middle, Last, Suffix) - 13. Mother's Name Prior to First Marriage (Pint, Middle, Last) Rae Nelson Kost Dorothy Heiges Informant's Name 14b. Relationship to Decedent 14a 14c. Informant's Malling Address (Street and Number, City, State, Zip Code) . Kath Debriclt Daughter 3560 Scotland Road, CtLambersburg, PA 17202 I ............................ . 1 a. ace o eat ee on y one .................................... ... t Death Occurred In a Hospital: ~( Inpatient :It Death Occurred Somewhere Other Than s Hospital: ~(~HOSplce Facility ~~ Decedent's Home a Q Emergenry Room/Outpatient Q Dead on Arrivals Q Nuning Home/long-Term Care Facility Other (Specfy) - • a~ lSc. City or Town, State, and 21p Code 15d. County of Death lSb. Facility Name (If not institution, glue street and number; LL 312 South Broad Street Mechanicsbur Penns lvania 17055 Cumberland ~, 16a. Method of Dlsposltlon Q Burial ® Cremation 16b. Date of Dlsposltlon 16c. Place of Disposltton (Name of cemetery, crematory, or other place) Q Removal from State Q Donation ~ ,_ ~ ~J ,_~ i, Other (Specify) O w Cremation Society of..Pennsylvania 16d. Location of Disposltton (City or Town, State, and 21p) 17a. Signature of Fu Service Licensee or Pe n in Charge of Interment 17b. License Number Harrisburg, Pennsylvania 17109 FD-013376-L 17c. Name and Complete Address of Funeral Facility Auer Cremation Services of Penns lvania, Inc., 4100 Jonestown Road, Harrisburg, Pennsylvania 17109 ~' Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic Orlgln -Check the 20. Decedent's Race -Check ONE OR MORE races to indicate what 18 .°- . highest degree or level of school completed at the lime 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 Q Korean Q No diploma, 9th - 12th grade box if decedent Is not Spanish/Hispanic/Latino. Q Black or African American ~ Vietnamese ~ American Indian or Alaska Native Q Other Asian i i L no c/ at Q Hlgh school graduate or GED completed ®No, not Spanish/Hispan Chicano Q Asian Indian Q Native Hawallan Mexican American i n Y M , , es, ex ca Q Some college credit, but no degree ~ Puerto Rican Q Chinese Q Guamanian or Chamorro QYes , Q Associate degree (e.g. AA, AS) Cuban Q Filipino Q Samoan BS) Q Yea BA AB ' d , , , egree (e.g. ® Bachelor s Q Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) QYes, other Spanish/Hispanic/Latino Q Japanese Q Other Paclflc Islander Q Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) Q Other (Specify) e. . MO DDS OVM LLB JD Decedent's Single Race Self-Designation -Check ONLY ONE to Indicate what the decedent considered himself or herself to be. 22a. Decedent's Vsusl Occupation -Indicate type of work 21 . ® White Q Japanese Q Samoan done during most of working Ilfe. DO NOT USE RETIRED. Q Black or African American Q Korean Q Other Pacific Islander Music Teacher Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure Kind of Business/Industry 22b . Q Asian Indian Q Other Asian Q Refused Q Chinese Q NatFve Hawallan Q Other (Specify) Q Filipino Q Guamanian or Chamorro Education ITEMS 23a - MUST BE COMPLETED 23a. Date Pronounce Dea Mo Day r 23 . Slgnat e o Per n ronouncing D (Onlyw en app ice c. License um er BY PERSON WHO PRONOUNCES OR ' ~ ~ Z •~ ,Z~y \ •1_ ~ v `-„~,~ CERTIFIES DEATH ~~/ ~ Z5~ Z 23d. Date Slg ed (M /Oay/Yr) 24. Time of Dea[h ?J 1 ~ ~-~~ .L- ~ Z.~ 25. Was Me ical Examiner or Coroner Con cted7 Q Yes No CAUSE OF DEATH ~ Approximate Interval: 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. = th Add additional Ilnes if necessary t Onset to Dea se on~a line l . y one cau T O N O lo g y D AB~BR~EVIATE. Ent r on ng the etio respiratory arrest, or venirlcular fibrlllatlon without show iw n 1 / ~, [ ~ ~ ~ - y ~ s IMMEDIATE CAUSE --------- (Final disease or condition oue to (or as a consequence of): ~ resulting in death) j b. 5 Sequentially list conditions, Due to (or as a consequence of): 1 if any, leading to the cause 1 listed on line a. Enter the c. Due to (or as a consequence of): UNDERLYING CAUSE ( W (disease or Injury that ~ initiated the events resulting d. Due to (or as a consequence of): ~ In death) LAST. 26. Part 11. En[t~er~orthe~r~f ( rt ~bu.,t/~n-opt resulting In the undlerlyi g causes given in Part 1 27. Was an autopsy p rformed? ' ~v a 4 (/ ~ ~ / ' 1' l.. ~ /c S (t ~ l~-L ~i- J Yes No 28. Were autopsy findings available ~ W fi ~:~s ~ % lw -nom ,y( ~(~ (~ ~ 1 S wL i ~ LJ ~]•r.w ~'~~. ~+_ l~r~ ~ ^~ .. to complete the ca a of death? t' ` (, G !~" i r -tK.,` _I -1. Ls Ivs G 7VQ'f/'rI _ Yes No 29. If Female: 30. Old Tobacco Use Contribute to Death? bl b 31 Manner of Death ~ Natural Q Homicide Q Not pregnant within past year y a QYes Q Pro No Q Unknown Q Accident Q Pending Invesilgatlon ~ Q Pregnant at time of death nant within 42 days of death re but r nant N t ~ Q Sulelde Q Could not be determined g p eg , Q o p Q Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (Mo/Day/Yr) (Spell Month) Q .Unknown if pregnant wlthln the past year 33. Time of Injury 34. Place of Injury (e.g. home; cons[ructlon site; farm; school) 35. Location of In]ury (Street and Number, Clty, State, Zip Code) 36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred: ' Q Yes Q Driver/Operator Q Pedestrian ' Q No Q Passenger Q Other (Specify) 39 Certifier (Check only one): death occurred due to the cause(s) and manner stated ie f , How Certifying physician - To the best o death occurred at the time, date, and place, and due to the cause(s) and manner stated knowled e f m h b ~ g , y o e Q Pronouncing & Certfying phys Ian - t Q Medical Examiner/coroner - the sI aminati vestlgation, In my opinion, death occurre- d at tt~e time, date, and place, and due to the capse(~ ~ n~ annLex stated ~- r _ J M N ~ y ~ '^V~V~rJ Lleense Number: Signature of certifier: Title of certifier: b 39b. Name, A dress and Zlp Cod of Person Comple~tiyng Caus~cof Death Item 26~ YA/A .. ' G r~ 11 ,irk rt (s ~?a~p ~ /+ ( / j L, g A ~ 39c. Date Slgn (MO/Da r) Ll z-~ z,-. _f ` ( / as I- ~i f~VC f 40. Registrar s Dlstrici Number 41. Registrar s Signature • .- 42. Registrar F= Date o ay r I 1 a ~ - ao ~- . s Y 43. Amendments - rte. ~ ~~ ~./~~ 1'11Y~-1Y~ Dlsposltlon Permit No.~, Ay REV 07/2011 0 v m~ o ~ p w z~ ~ r m ~ y ~ ~ Z D I.~.1 ~ ~ ~ o MM W ~ ~ G ~ ~ ~ D ~ z~ y ~ .: V m -~1 +•.~ C C ~ O ~~ w r , ~:, .:.. ~ ,.: ~ l ~~ .~., ~, q ~ ti ~ ..,~ n ~ ~, ~ t tf ~ +•s'~ rn ~y1 ~ ''~: m;~c7 ~~~ -.~ : , ~ • ~ ~L7 "`~'~ "~~ r i ,,,~ ~ ~., ~~ sue.? ~.,.. p ..... ...... f-%.? " ~ '--. U - . ~ ~ ~ ~ ,. ~ ~ - ~ »•.. ~... CC fD ~ ~_ ~ ~ -...... ...... ...... MAN: ~Mr '~+w~• ~nN'. ~ ^ ~ ` tiY~~ M~. w ~ . ' ~~: •~N ~ ~ ~ ' • •• ^ •~~ Z 'w~. ~~ ~ ~~~ ,~~. HASLER -w:... : ~ a ~. .. _ ~ O U1 ~ ~: v O~ ~ ~ ca ~~ ~ w US P4ST~~GE ,~ ;