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HomeMy WebLinkAbout04-25-13 ESTATE OF : IN THE COURT OF COMMON PLEAS ELEANOR KETCHUM : CUMBERLAND COUNTY,PENNSYLVANIA rte_ ORPHANS'COURT DIVISQ w rn NO. pz M C'> J C n PETITION UNDER SECTION 3102 OF THE PROBATE, -� E ESTATES AND FIDUCIARIES CODE FOR SETTLEMENT OF SMALL ESTATE TO THE HONORABLE JUDGES OF SAID COURT: John Copley,your Petitioner,files this Petition for Settlement of a Small Estate under the provisions of Section 3102 of the Probate,Estates and Fiduciaries Code and in support thereof avers that: (1) Your Petitioner, John Copley is a competent adult residing at 5896 Townline Road 187,New London,OH 44851,and is the nephew of the above decedent. (2) Eleanor Ketchum, died on December 4, 2012 at the age of 96 years, but prior thereto was domiciled at 770 South Hanover Street, Cumberland County, Pennsylvania. A copy of decedent's Death Certificate is attached hereto as Exhibit"A." (3) Eleanor Ketchum died with a Will dated March 18, 1999, and a Codicil dated September 8, 2003. No Letters have been issued.A copy of Decedent's Last Will and Testament and Codicil are attached hereto as Exhibit`B." (4) Eleanor Ketchum had no probate estate when she died other than the following: .Checking account and investment account with PNC Bank,N.A., with a balance of$4,666.78, as of February 18, 2013. A statement from PNC Bank is attached hereto as Exhibit"C." A death benefit in the amount of $1,000.00 with State Teachers Retirement System of Ohio. Benefits with the State Teachers Retirement System is a non- taxable asset. (5) The heirs listed in Article V of the Codicil to the Last Will and Testament of Eleanor Ketchum are as follows: Joyce Heichel,Niece John Copley,Nephew Chapel Pointe at Carlisle (6) Your Petitioner avers that there are no creditors of the decedent. The expenses, costs of administration and attorneys fees to be paid for the estate exceed the _ assets of the Estate. Statements are attached hereto as Exhibit"D." WHEREFORE, your Petitioner respectfully requests that an Order be made authorizing John Copley to act as Fiduciary for the Estate of Eleanor Ketchum, and close the accounts with PNC Bank and the Sate Teachers Retirement System of Ohio,with the proceeds made payable to the Estate of Eleanor Ketchum, pursuant to Section 3102 of the Probate,Estates and Fiduciaries Code. f By u ! ugl .Miller,Esquire Supreme Court I.D.No. 83776 IRWIN&McKNIGHT,P.C. 60 West Pomfret Street Carlisle,PA 17013 (717)249-2353 STATE OF OHIO COUNTY OF John Copley being duly sworn according to �w,deposes and says that the facts contained in the foregoing Petition are true and co s of w ge,information and belief. (SEAL) John Copley Sworn and subscribed before me this day of April,2013. Notary SF'-- "? _ 9t' KAREN R DALE,NOTARY * •*_ STATE OF ONTO MY COMMISSION EXPIRES:814/2015 H105.805 REV(4/11) LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING:,it is illegal to duplicate this copy by photostat or photograph. Fee for this certificate,$6.00 i „r,,,,, This is to certify that the information here given is Ij11, �p11"OfiPF/j� correctly copied from an original Certificate of Death t,•�'�Q�` `rte duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital °> Records Office for permanent filing. . P 7 wit 1 o�� J 0 99TMfN�OF��`P�I, / Certification Number „rrrrtNll gi r r Da e Issued Type/Pent In COMMOFIWFALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS Permanent CERTIFICATE OF DEATH State File Number, BI k t 1.Decedent s Legal Name(First,Middle,Last,Su x) 2.Sex 3.Social Security Number 4.Da4 art Death(Mo/DaY )(Spell Mo) Elea2nar *�TMYi Yt* Ketclltmt r�nale 375-20-3019 Decresnber 4, 2012 So.Age-Last Birthday rs) 5b.Under 1 Year S..Under 1 Da 6.Dote of Birth(MO Day ar)(Spell month) 7;�I P ZR amend taOH FOnelin Gauntry) 96 Months osys Houn Minutes AXWJL2j3t 29, 1916, NGF7 7b.Birthplace(County) B Or�fstats nr.Fggsign Country eb.Resid..Ca Street antl Number-Include Apt No.) 8c.D1tl Dececedenrt Ws in a Township? !g 1Ve]1.I-L7. 770 S013t�'1 � St_ OY.,decsdant lived In twP• ed.Residents(COUnty} 3 ea )g NO,daaadr nt IIvW within umrio Of Cty/barn.LMXd:ar Resd.-(ZIP Cads) 1 701 3 4.Ever In US Armed ForcesT 10.Marlul Status et Time of Dea Mauled caeca 1..._v g Spouse's Name(if wife,give name prior to first marriage) .3 Yes )1 No O Unknown i3 Dlvoroad [�4iaver Married Unknown 22,Famor's Name{ rat,Middle,Last,Suffix) 13.MOthir"r Name Friar to First Marriage(First,Middle.Last) Carl .3'.ZCetchtun Mabel V. Newc crnb 1M.In rman�MN meet' Sob.Retetionship to ant 14c.mformam:'s Mafl»g Address(Street and Number,CRY,State,ZIP Code) r3',p]�n � Netphew 5896 Towrxlinel 1kd. 187, New X.XIC., C1H 44851 ............................ py .....'°'..............,..,........................a. aca o a ec on ant ,.....,.,...,...,...,..._........... ............................... if Oeath Occurred in a Hospttali •• L"/tnpaWnt If Oeath Uceurred Somewhere Other T�iin atiosplteL (�'liospiee Facility O Eme Room/OUtpotlant Wstl on Arrtvel Nund Home/ -Term Care Fad Other(S ) lSb.Facility Na ms(I not Institution,slue street and number, 1.C.City or Town,State,antl Zip Code SSd.County of Death G apel PCS11rt C.atr3.1E31e I A 1 701 3 CluTlb�sslataud Method of Disposition Burial Cremation SSb.Da�+s i Disposition 1ge.Place of Disposition(Name of cemetery,Crematory,or other p ace) )3 Removoi from State )3 Donation 1 2/7/2Ul 2 B1 .net' C..L-g[Ia.tOZ"y, =sLC• Ocher( ify} 1�nof.Dladas�iol�( RytT 3f4r'ICftate,and Zip) 17a.Si nr(tYfe of centres Service Licanse! r person in Charge of Interment 17b.License Numbs, ��-`J - 'F D-1 38866-I. 1 a t.Adds t Funeral F dl �e"�j,r�C`=��.}rsar`�laneaz-aj I'<cxcte„ 31 25 Walnut St. PA 17109 lg.Decad.nt's EducatlOn-Check the box that beat desaribas th. ...Daoed.nt of HlsPI nI;Origin-Check the 20.Decedent's Race-Chock ONE OR MORE races to indicate what high.st dog or level of school compl.xad at the elms of death. boa that best describes whether the decedent the decadent considered him NE or herself to b!. 0 8th grade or Is" Is Spanish/HispaniC/Lotino. Check the"No" R2 Whet. E3 Korean )3 No diploma,Bth-12th grede box If decedent Is not Spanish/"IsPanlc/Lotino. Q Black or African American C3 Vietnamese )3 High school graduate or GED Completed in No,not Spanish/Hispenic/Latino Q American Indian or Alaska Native )3 Other Asian C3 Some College Credit,but no degree i3 Yes,Mexican,Maxtcan American.Chl-O r3 Asian tndtan O Native H:wenen C3 Associate degree(e.g.AA,AS) C3 Yes,Puerto Rican �Chinese Q Guamanian or Chamois rX Bachelor's degree(..a.SA.AS,SS) d Yes,Cuban 0 Filipino O Samoan (3 Misters degree(e.g.MA.MS,MEn&.MEd.MSW,MBA) 0 Yes,other Spanish/HlspanlC/L.atinc i]Japanese )3 Other P..Ifl.Islander )D Doctorate(e.g.PhD,EdD)or Professional dog- (Specify) E3 Other(Specify) .MD D S AVM i.8 JD 21.Decedent's Singls Rate Se fASSlgnotlon-Check ONLY ONE to Indicate what the decedent eonsitlered himself or erseif co be. 22a.Oecadsnt a Usual OccupaHOn-Indioto type of work =White 0 Japanese Q Samoan don.during most of working life. DO NOT USE RETIRED. [3 Stack Or African American E3 Korean )3 Other Pacific Islander 'Peachaw 13 American Indian or Alaska Native )3 Vietnamese a Don't Know/Not Sure 13 Asian Indian )3 Other Asian )3 Refused 22b.Kind Of Business/industry vy Q Chinese ]_-3 Native Hawaiian O Other(Specify) C3 Filipino C3 Guamanian or Chamorro tIcon Ma 29a M aK P _ et Pro sun a Mo ay r nature Faison Pronouncing n when.pplica le 23e, Cerise Num er OV PERSON WHO PRONOUNCES OR h { ,r'' CERTIFIES EATH ti� r"t 7-Lj'Z' _ War�Q t� $ 4 2td.Det 3l d Mir Day 24.Tiros°�C.ath 23.W s edical Examiner or Coroner Contacted? (3 Yes NO GAUSS OF DEATH i Approxlm.t. 26.Part L.Enter the Chain of swots--diseawa,lnjurles,Or complications--that directly Caused the death. DO NOT sitter tsrminai wants such as cartltac arrest, mtervat: respiratory arrest,or ventricular fibrillationtt without showing the etiology, DO NOT ABBREVIATES_ Enter only cans Cau:e on s since.Add addittonai lines if necessary Onset to Death IMMEDIATE CAUSE > a. C.1.Cc...J \4 �"'o'a�� QC' 4,(V-.41- 1 V� (Final dies-or condition Due to((or as a Consequence of): } resulting In death) (t b. Sequentially Ilrt cOndittonr, Due to(or as a compu:rice an: If any,leading to the cause listed on line a. Enter the C. UNDERLYING CAUSE Due to(or as a consequente,of): g (of-.-or Injury that Initiated the events resulting Cl. j in death)LAST. Due to(or as a.....quento of): ) 2E.Pert f.Ente,other 1-Ifiur+t;,vjntlitions c^_,nML•utin,to death but not resulting In the underlying Cause given M Port 1 27.Was an autopsy Fq rmed? Y.. No 28_Were autopsy""loss avollable t0 Complete the coW of death? Yse No 29.If F.mab: O.Did Tobacco Us.Contribute to Death 91.Manner of Oeath i$Nos pregnant within post year fl you )3 Probably laNaturai )3 Homicide y� Q death!t time Of tleh ���NO (3 Unknown [�Accidant i3 Psndi'a investigation .b' 17 Not Pregnant,but Pregnant within 42 days of death E3 Sutcide i3 Could not be determined i 3 Not pregnant,but pregnant 43 days to 1 year before death 32.Date of injury MO Day/Yr (Spell Month )] Unknown If pregnant within the past year 33.Tim.of Injury 34.Place of Injury(s.g.home;construction site;farm;school) 35.Location Of injury(Street and Number,City,State,Zip Code) 36.Injury at Work 37,If Transportation Injury,Specify: 38.Describe How Injury Occurred: E3 Yes M Dr{v.r/Oparator C3 Pedestrian L O No E3 Passenger (3 Other(Specify) o;:N - 39a.Cardflor(Chef only one): "�cartifyint physician-TO the best of my knowledge,death occu w rred due to the causg(s)and manner stated )3 Pronouncing&Certifying physician-To the best of my knc I*dge,death Occurred at the time,date,and place,and due to the causes)and manner stated (3 Medical Examiner/Coronsiyr 0 the basis of oxamination,and/or invlsttestion,in my opinion,death Occurred at the t/-e,data,and place,and due to the cause(s)and manner stated Signature of certMen U c jj i�t'1)+w-• TRie of-rifler: License Number �i NG.Name,Address and Zip.Code of Person Completing Cause Of Death(Item 2E) 38 C.Date /gold(MO Day r G6 co-s- 4t_ �4'C.P%-,W-- r. s•• 1M Z.7 f�C�t' ,rte 7,�r�v C. C."tLk- -1 i as nIF► r2s, Z3 r*+�,� S t 7m 1 L 40.Rent straw um I.M. s Signature eel M sit' r 49.Amendments to .�. p�g� H103-2 Disppsitjon Permit No. dd a REV D7/200 12 V A OF ELEANOR KETCHUM I, ELEANOR KETCHUM, presently residing at 7 Alliance Drive, Carlisle, Pennsylvania, being of a sound and disposing mind, over the age of eighteen(18) years, and under no legal disability, and mindful of the brevity of this life, having placed my faith and confidence in Jesus Christ, my Saviour and Lord, Who redeemed my soul through His shed blood and death upon Calvary's Cross for my sins and Who, by His resurrection, thus assures me of eternal life, and knowing that the life which I now live in this world is by faith in the Son of God Who gave Himself for me, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me at any other time. Article I: I direct that my Executor, hereinafter named, pay all my just debts and funeral expenses as soon after my death as practicable, including all property, state and federal death taxes assessed against me, my estate, or my beneficiaries, without proration among my beneficiaries. However, all property bequeathed or devised hereunder, either outright or in trust, is bequeathed or devised subject to existing mortgages, liens or encumbrances thereon. Menges,Gent&McLaughlin,LLP Douglas H. Gent,Esquire Eleanor Ketchum 1157 Eichelberger Street Hanover,PA 17331 1 . I Article II: I give and grant unto my Executor appointed herein and his successors all the powers given under the common and statutory law of Pennsylvania at the time of my death, to be exercised in his absolute discretion, unless otherwise restricted herein, in any capacity to which such powers may be applicable. In addition to such powers, he shall have the following powers: A. To accept in kind and retain any property which I may own at my death, without regard to any principal of diversification, and to invest and reinvest in any form of property without restriction to legal investments for fiduciaries. B. To purchase.investments at a premium and, at his discretion,to charge such premium and the premium on any investments owned by me at my death either to principal or income. C. To give proxies and to join in any merger, reorganization, voting trust plan, or other concerted action of security holders affecting investments, delegating powers with respect thereto. D. To sell at public or private sale, exchange or lease for any period of time any real or personal property, and to give options for sales or leases. E. To borrow money and to mortgage or pledge any real or personal property. F. To register property in the name of a nominee or to hold property unregistered. Eleanor Ketchum 2 I I G. To compromise claims. H. To allocate any property received or charge incurred to principal or income or partly to each, without being obliged to apply the usual rules of trust accounting. I. In investing, reinvesting, purchasing, acquiring, exchanging, and selling property for the benefit of my estate or any trust created hereunder,they shall exercise the judgment and care, under the circumstances then prevailing, that men of prudence, discretion, and intelligence exercise in the management of their own affairs, not in regard to speculation, but in regard to the permanent disposition of their funds, considering the probable income as well as the probable safety of their capital. Article III: I hereby nominate and appoint my nephew, JOHN COPLEY, as Executor of this my Last Will and Testament. In the event he predeceases me or is unable to serve as Executor,then I nominate my niece, JOYCE HEICHEL, as Executrix of this my Last Will and Testament. My individual Executor or Executrix shall not be required to furnish bond or surety. Article IV: I give, devise and bequeath all the rest and residue of my estate of whatever kind and description, wherever situate, absolutely and in fee simple, as follows: A. Twenty percent (20%)to CHAPEL POINTE AT CARLISLE, located at 720 Hanover Street, Carlisle, Pennsylvania, to be used at the sole discretion of the governing board of the organization; and i Eleanor Ketchum 3 I ' i I B. All the rest,residue and remainder to be divided equally among my nieces and nephew, JANET WAKENIGHT,JOYCE HEICHEL,and JOHN COPLEY. In the event my niece,JANET WAKENIGHT, shall predecease me,then this share of my estate shall be divided equally between my niece,JOYCE HEINCHEL, and my nephew,JOHN COPLEY. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 1+1 day of 1499. -{SEAL) Eleanor Ketchum Signed, sealed, published and declared by the foregoing Testatrix as and for her Last Will and Testament, consisting of!._pages, in the presence of us,who at her request, and in her presence, and in the presence of each other,have hereunto sct pur,Lands Zashness I,=to. r 4 COMMONWEALTH OF PENNSYLVANIA COUNTY OF li i 1113 E J:L F-?ti) I, ELEANOR KETCHUM, Testatrix, whose name is signed to the attached or foregoing instrument, being duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by ELEANOR KETCHUM, the Testatrix,this�_day of 11 1 E:� ' H ' 1999. Notarial Seal Eleanor Ketchum Betty Lou Zary,Notary Public ML Holly Spr"Boro,Cumberland County My Commission Expires Sept.21,2002 Member,Pennsylvania Association of Notaries Notary Pu lic My Commission expires: COMMONWEALTH OF PENNSYLVANIA COUNTY OF l We, y j J a o rl G', P- c and L a z's OA z� /e ,-- ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn to or affirmed and subscribed before me by�- and o i s (a f -,, -,1/� , witnesses,this day of J /7)f7 1999. � 11 Notary Pu ' is My Commission Expires: EHolly otarial Seal Zary,Notary Public Bo%CumberlaWn Expires Sept.21,2002 C ty Member,Pennsylvania Association of Notaries CODICIL TO THE LAST WILL AND TESTAMENT OF ELEANOR KETCHUM I, ELEANOR KETCHUM, presently residing in Carlisle, Pennsylvania, being of a sound and disposing mind, over the age of eighteen years, having made my Last Will and Testament dated the 18`"day of March, 1999, do hereby make,publish and declare this to be a Codicil to my said Last Will and Testament. FIRST: I hereby delete Article IV as stated in my Last Will and Testament and substitute the following provision: Article IV: I give, devise and bequeath all of my jewelry, clothing, household furniture and furnishings, chinaware, silver, pictures, works of art, books, personal automobiles, and other tangible articles of a personal nature, not otherwise specifically disposed of by this Will, to my Personal Representative(s); and it is my wish that my Personal Representative(s) dispose of said property in accordance with a memorandum or list I shall leave with my Will at the time of my death as a guide in disposing of the tangible articles hereinabove bequeathed to my Personal Representative(.). Any item of personal property not set forth on said list shall be disposed of as a part of my residuary estate." SECOND: I hereby add a new Article V to my Last Will and Testament to read as follows: Article V: I give, devise and bequeath all the rest and residue of my estate of whatever kind and description, wherever situate, absolutely and in fee simple, as follows: Menges, Gent& McLaughlin, LLP - -(- ! 41">- Douglas H. Gent, Esquire Eleanor Ketchum 1157 Eichelberger Street Hanover, PA 17331 1 A. Three Thousand ($3,000.00) Dollars to my niece, JOYCE A. HEICHEL; B. Three Thousand ($3,000.00) Dollars to my nephew, JOHN COPLEY; and C. All the rest, residue and remainder to CHAPEL POINTE AT CARLISLE, located at 720 Hanover Street, Carlisle, Pennsylvania, to be used at the sole discretion of the governing board of the organization. THIRD: I hereby ratify and confirm my said Last Will and Testament except in so far as any part thereof is revoked or modified by this Codicil. IN WITNESS WHEREOF, 1, ELEANOR KETCHUM, Testatrix, have hereunto set my ' 4VA hand and seal to this Codicil to my Last Will and Testament dated the D day of 2003. (SEAL) Eleanor Ketchum Signed, sealed, published and declared by the foregoing Testatrix as and for a Codicil to her Last Will and Testament, in the presence of us, who at her request, in her presence and in the presence of each other, have hereunto set our hands as witness thereto. 2 COMMONWEALTH OF PENNSYLVANIA COUNTY OF �U m 1oe:r \o n d I, ELEANOR KETCHUM, Testatrix, whose name is signed to the attached or foregoing instrument, being duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Codicil to my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by ELEANOR KETCHUM, the Testatrix, this�day of of rm b-- Y , 2003. f"2lu Eleanor Ketchum -q&—t6'1 d u Notary Pubic My Commissi . B ft Lou Zary,Notary Pd* COMMONWEALTH OF PENNSYLVANIA h.H*% p eoro.Cmis and COUM M►Oa wrbdon Expires Sept.21,2006 Member,Pawykenla Asvxietk�'�:-a COUNTY OF OU m 6e r- g nd We, A I M A 6A.5 and A �17 the witnesses whose names are signed to the attached or foregoing instrument,being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn to or affirmed and subscribed before me by M j1 6 fl 55 and Loot_N)A L ir) -- , witnesses, this day of _14j,-,,.,may- , 2003. Notary PAC My Commission Expires: Notarial Seal Belly Lou Zary,Notary Pd* W Hoy sp*W eoro,cumtriaW corxty 3 P*Ommisslon Expires Sept 21.2006 Member,Per ewft4ania Anw1eibn Of Notaries . PNC Bank Online Banking Page lofl ' .Accounts Transfer Funds PavBiUs Alerts Customer Service .`ma,* Accpuncucti°ov My AccQunrs �oumO0aji � Account List �mar' p � Deposit Accounts .s, /mov Ac^uvv,wumw~, uolanoV Availablen� Regular Checking cheomoQ x}VVwuX3459 $1.655-1e $1.655,1; Deposit Account Totals: $1.6e5.19 $1.05a.'r -~ Investment&Wealth Management Accounts 'nves:noruAcu=unus Account Number 801ano* Alerts ..`mw Investment Xxx6553 $3.011.58 mouueBan m Online Investment&Wealth Management Account Totals: $3.011.59 Overdrf° . PH[ xe. ; --ve.nciucies assets held at different entities. Deoosit and loan oroducts are held at PNC Bank t 1'~9!,nems other Man annuities.are field maumke,aoo account with Pmo Investments uC member imeoa'enemm The insurance carrier o,record wvn-deoosm investment nmouca are not FDIC/msvreci are not nuaraomaau` interactive Demo | Online Banking&Bill povGuarantee ' uemiceAureemont 1. Prwacvpo//m / n+^^ Loupv,mmuu,x The pwo Financial Services owuo.Inc. All n/"mswesp~'^'' Need no/uv Call voat 1'888'pwc'uAwx/7e2 22u,, ~naon,+/ nuou ^' ----- --- ------------- c ` https://www.onlinebanking.pno.com/algerv]et/OnlineBankingServlet 2/lW/20l� y ? ry -i a -f -f x m 0 -f � A to C) z � Dm to m O D : __ r: CS O X 2> Z =' Z s o a m = 0 r- 9 b cm < 3 5 na _� > U m �, 3 z za C") 0 > m � , m D t jigs a � `r z" � -4 (D � � ri f�? n m � Z fi3 {`j �Z � r m X N � 4 R �' 0 � � m m � � 7 � 0 Z m ? � Z� w m �, rmns CO (D <ID w a < Z �-t 3� o u m z 3 m D m m sm h1 r'f mm m st tmn v r _ to ' a v Z m ; O < Z " (D coo C Qm 7 z m m ' C3 m m Om CA) w fnfo o00a CP 8 8 w wzi w i 1 4 w (A 0 a o a o o C 0pr 0 c 0r rt�nn b °w °w °w r+i g C1 w W z o f7 n CD 0 a n ° ? D Az r ` a t Z f tz_ - - V) iy 4 C rd t R caw oho . z III N Q STATE TEACHERS RETIREMENT SYSTEM � OF OHIO � zr5 East Broad Street ' Columbus,ox*az1sorr ,888-227-787 ,.vw.st'mhurg ^�~,"s^BOARD CHAIR ~ET'REM e�BOARD V,CE CHAI" uas�zz SECOND REQUEST m,c^,.E".",c,o" a/r.HAE-/.mcnF In reply,please refer to: THl72MZ January 28, 2U}3 John Copley 5096TownhocRd187 New London OB 44851 Re: The account of Eleanor Ketchum, deceased Please provide our office with the item(s) checked below so that this account may be paid. Estate's Employer Identification Number(]BIN)issued by the lRL8 A photocopy of the Letters o[Authority from the court—vve cannot pay by the Will If you have any questions,please call our Member Services Center toll-free at l-888'���'7D77 Member Benefits Enclosure o�ovv 04�0bb Chapel Pointe FormPB-01 at Carlisle 770 SOUTH HANOVER STREET,CARLISLE,PA 17013-4105 QUESTIONS?CALL: 717)249-1363 RESIDENT# UNIT I STMT. DATE 12468 M-21-A 12/03/2012 Miss Eleanor M.Ketchum RESIDENT(S) Bed M21A Miss Eleanor M.Ketchum TOTAL AMOUNT DUE $2,681-50 DATE DUE ' Upon Receipt • NOT PAY • • due will be •nically withdrawn from your bank account on 1 • NOT PAY OAT Urn s� CHARGES ; CREDITS, BALANCE; Balance Forward 796.50 11/04/2012 Payment-Thank-You!! 796.50 0.00 11/30/2012 Apt.Meals-Benevolent 10/01-10/31 1 215.00 215.00 11/30/2012 Contractual Allowance-IL 1 215.00 0.00 10/26/2012 Nurse Visit 1 25.00 25.00 heart palpitations 10/29/2012 Transportation 4 16.00 41.00 Clothes to CRMC 10/31/2012 Transportation 4 16.00 57.00 Walker to CRMC 11/01/2012 TV Cable 11/01-11/30 1 12.00 69.00 11/0712012 Hair Care-Wash/Set/Combout 1 10.50 79.50 11/14/2012 Hair Care Wash/Set/Combout 1 10.50 90.00 11/19/2012 Transportation 4 16.00 106.00 Dr.Carey 11/26/2012 Room and Board Private-HC 11120-11/26 7 1,855.00 1,961.00 11/28/2012 Hair Care-Wash/Set/Combout 1 10.50 1,971.50 12/01/2012 Monthly Fee 12/01-12/31 1 710.00 2,681.50 Reminder: Please remember to notify us of any new insurance cards by bringing the cards to the fmance office so that we may make a copy. Also,please be sure to review all enclosures. Remember to sign and return necessary forms to us (Ambulance,2013 Rate Sheet).Not all levels of care will receive all forms. RESIDENT# CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 12468 2,681.50 0.00 0.00 0.00 0.00 $2,681.50 RESIDENT NAME Miss.Eleanor M.Ketchum Form PB-01 CHAPEL POINTE AT CARLISLE,770 SOUTH HANOVER STREET,CARLISLE,PA 170134105 � EGIQR NAL MEDICAL CENTER tG+' • . INFORMATION • . PAYMENT OPTIONS Patient Name Eleanor M Ketchum Online at www.carlislermc.com Account Number 9539712 Date of Service November 20, 2012 {available 2417} Service Type Inpatient Services By phone-717-960-1680 Insurance Name Aetna Medicare Repic Name of Insured Eleanor Ketchum By credit card-complete section below and return Policy Number MEBF92BD Amount Due From You $258.54 ®By check-return section below with check YOU • YOUR OF Amount due from you is$258.54 as of 0111312013 for The charges listed below do not reflect the discount that Inpatient Services performed on November 20, 2012. you and your insurance company received. Nursing 1,106.82 Total Charges $28,538.58 Pharmacy 3,005.39 Discounts/Adjustments Given $19,666.61 Radiology 760.31 Insurance Payments Received -$8,613.43 Lab 3,032.77 Amount You Paid $0,00 Cardiovascular Study 688.13 Respiratory 6,248.73 Nursing 4,836.00 Supplies 2,837.91 Occupational Therapy 690.68 Amount Due From You $258.54 Therapy 1,240.02 Emergency Room 2,332.52 Cat Scan 1,759.30 TOTAL-CHARGES $28,538.58 �� I111AIMl'dllll • • 3269.HMASTMT-1570691-1359982160-P;6983281-1-212;32952908-1;1 As of today,we have not received payment In full on your account.. Immediate payment is required, please contact our business office today. FOR CREDIT CARD PAYMENT,PLEASE FILL OUT BELOW... ❑ ❑ VISA❑ ❑ MASTERCARD DISCOVER VISA AMEX y � � 361 Alexander Spring Rd. CARD NUMBER EXP. REGIONAL Carlisle, PA 17015 MLDICT1. f[ iCP SIGNATURE SECURITY CODE PATIENT NAME STATEMENT DATE DATE DUE Eleanor M Ketchum 01/13/2013 UPON RECEIPT Patient Financial Services: ACCOUNT NUMBER AMOUNT DUE AMOUNT PAYING 717-960-1680 9539712 $258.54 Check box if address below is incorrect or changed and indicate change(s)on back. REMIT THIS PAYMENT STUB TO. 654049A(PC2) 006862 0101 ELEANOR M KETCHUM CARLISLE REGIONAL MEDICAL CENTER 770 S HANOVER ST PO BOX 281442 CARLISLE, PA 170134105 ATLANTA, GA 30384-1442 n�t�it'ti�di�il�t�till�iit�f tllLutl��lt��l�ititttl�l�i6li�lit 1�'�Itl�ti�t6ullnl�t�l�ll�luit'�ilt�l"IIIId�itIllN�tl�tltl 00000953971200000025854ELEANORMKETCHUM 6 CARLISLE Account Information RE610 AL Account# 9537905 MEDICAL CENTER Patient Name: ELEANOR M KETCHUM FINAL NOTICE Date of Service: 11/01/12 01/30/13 Balance: $354.91 We are writing to inform you that your balance is past due and a payment in full has not been received or a suitable payment arrangement established. This is a request for immediate payment in full on or before ten days from the date of this letter. Pay your account in full by check, money order or credit card payment using this form and enclosed envelope. If we receive no response from you this account will be referred to a national collection agency. If you have already sent your payment please disregard this letter. You may also pay your bill online at www.carlislermc.com. Thank you. Carlisle Regional Medical Center Questions? Telephone: 855-843-0549. Servicio en espanol, por favor Ilame: 1-866-301-0426. ass PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT OR MAKE PAYMENT BY CREDIT CARD. --------------------------------------------------------------------------------------------------- 11111111 IIII 11I11�11111 11 INIIIIII�II�I ❑ MCA Card Number Code ture Total Paid Carlisle Regional Medical Center © DISC Select card you wish 1 Signature Expiration Date 366 Alexander Spring Road ❑AMEX ' Carlisle, PA 17015 Statement Date SHOW AMOUNT PAID HERE Pay�!s Ar��runtr 01!30!13 r y <$ $ Account#: 9537905 JONBI9537905173 317041391762 52691000346010014 ® Mail all Correspondence to: — — 111111111111111111'111'I 111111111111111 111111111111 Carlisle Regional Medical Center —"" Eleanor M Ketchum PO Box 281442 5896 Townline Road 187 Atlanta, GA 30384-1442 New London, OH 44851-9409 00000953790500000035491ELEANOR M KETCHUM 8 V-V86VOODO0 OODO V 00 •°00000 >cn> > 0 mom 0 3 a'. 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