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Home My WebLink About04-08-13 (2) ♦ � �,5�561,D140 • �� EX (01-10) PA Departmen#of Revenue OfFIC1AE.USE ON�Y Bureau of Individual Taxes Couniy Code Year File Number Pp Bpx��p� INNERITANCE TAX RETURN 2 1 1 3 0 1 2 4 _ Hamsburg,PA 1712$-0601 RESIDENT DECEDENT ENTER DECEDENT INFt3R�ifAT18N BE�{�W Sacial Security Number Date of Death MMDDYYYY Date of Birth MMRDYYYY 0 L 2 1 2 D 1 � 0 6 2 1 1 9 3 1 Decedent's Last Name Suffix Deceden#'s First Name MI � A C E R E N Z A T H E R E S A F �If Appl�cable}Enter Surv�ving Spouse's Infarmatian Below Spouse's Last Name Su�x Spouse"s First Name MI Spouse's Soc'ta1 Secu�ty Number THIS RETURN MUST BE F1LEQ tN DUPLICATE WITN THE REGISTER OF WILLS FIL�IN APPRt�PRtATE QVALS BE�t}W Q 1.Original Re#um � 2.Supplemental Retum � 3.Remainder Return(date of death � prior ta 9 2-'t 3-82) � 4.Limited Eskate � 4a.Future Interest Campromise(date of � 5.Fede�at Estate Tax Return Required death after 9 2-12-82) Q 6,Decedent Died Testate � 7.Decedent Maintained a Living Tn1st 8.Total Number af Safe Depasit Boxes {Attach Copy a#Will} (Attach Copy of Trust} � 9.Litigation Proceeds Received � 10.Spousal Poverty Credit{date of death � 11.Election to tax under Sec.9i 13{A} : between 12-31-91 and 1-1-95} {Attach Sch.O} CORRESPONDENT-THlS SECTION MUST BE COMPLETED.ALL CQRRESPOMQENCE AND CONFlDENTIAL TAX INFQRMAT��!SHOULD Bf DIRECTED T4: , Name Daytime Telephane Number .•°�... R � � E R 8 • I R W I N , E S Q U I R E 7 1 ?,�2�4 9 � 3 � � �C rr� �'► REGI R1� WII.LS� ON ' � 2�» r � '�� First line of address � � � C� � � � � � � � � I R W I N & M c K N I G H T , P • C . -� -� Second line of address � � � � .� � "t,� "� C.,J � � , 6 � W E S T P � I� F R E T S T R E E T x, � � � City or Pos#{'�ffice State ZIP Gade DATE�Il�p : C A R L I S L E P A L ? 0 1 3 Corresponden#'s e-mail address: Urxler penafties of perjury,l declare that 1 haue e�mined this retum,including ac,companying schecfules and statements,and to the best af my knowi�dge and belief, it is true,correct and compiete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SlGNATURE QF PERS N RESRQNSiBLE FQR F NG RETURN � � J� pA� � . � ADDRESB 31? JUNIPER STREET CARLISLE PA b7�1,3 SIGNATURE 4F P R R C}THE�THAN R�TATIVE ,� /°.3 DATE J ADL�RESS 6[J WEST P4MF STREET CARLISLE PA 17013 PLEASE USE ORICINAI.FORM ONLY Side 1 � ],505610140 ],5056],014� J � � + . � � 1505610240 A REV-1500 EX RECAPITULATION 1. Real Estate(Schedule A) .... ..... ... ...... .. ....... ..... ... . ...... . 1. • 2. Stocks and Bonds(Schedule B) .. ........... ... ....... . ... . .... . ..... 2• • 3. Ctosely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. • 4. Mortgages and Notes Receivable(Schedule D) . . .. .. ......... . . ..... . .. . 4. • 5. Cash,Bank De osits and Miscellaneous Personal Pro e 5 9 2 1 . 4 5 p p rty(Schedule E). ... . . . 5. �6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . .... . . 6. • 7. Inter-Vivos Transfers 8�Miscellaneous Non-Probate Property (Schedule G) � Separate Billing Requested . ..... . 7. 1 0 3 � 0 0 . 0 0 8. Total Gross Assets(total Lines 1 through 7) .......... ............ . ... . 8. 1 O 8 9 2 1 . 4 5 9. Funeral Expenses and Administrative Costs(Schedule H) .......... ....... . 9• 1 0 5 1 1 . 3 8 10. Debts of Decedent,Mort a e Liabilities,and Liens Schedule I 10. 1 2 0 8 . ? 4 9 9 ( ) ..... . ..... . . 11. Total Deductions(total Lines 9 and 10) ..... ... .. ............ . ....... . 11. 1 1 7 2 0 . 1 2 12. Net Value of Estate(Line 8 minus Line 11) .............. ..... . ...... . . 12. 9 7 2 � 1 . 3 3 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . ... ....... ... . . ... ... 13. . 14. Net Value Subjec#to Tax(Line 12 minus Line 13) ...... . . ..... . . ...... . 14. 9 7 2 � 1 . 3 3 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0 0 . 0 D 15. � . 0 0 16. Amount of Line 14 taxable at�inea�rate X.045 9 7 2 0 1 . 3 3 16. 4 3 7 4 . 0 6 17. Amount of Line 14 taxable at sibling rate X.12 0 • 0 0 17. 0 . 0 � 18. Amount of Line 14 taxable at collateral rate X.15 0 • 0 0 18. 0 . 0 0 19. TAX DUE .... . ....... . .. . ...... . ..... . . ......... ...... . . . . .. ... 19. 4 3 � 4 • 0 6 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT � Side 2 � 15�5610240 150561024� � REV-1500 EX Page 3 File Number Decedent's Complete Address: 2� 13 0124 DECEDENT'S NAME THEF2ESA F. LACERENZA STREET ADDRESS 317 JUNIPER STREET CITY STATE ZIP CARLISLE PA 17013 Tax Payments and Credits: �• Tax Due(Page 2,Line 19) (1) 4,374.06 2. Credits/Payments A.Prior Payments B.Discount 218.70 Total Credits(A+B) (2) 218.70 3, Interest (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) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 4,155.36 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: ...................................................................... ❑ QX b. retain the right to designate who shall use the property transferred or its income; ............................... ❑ Q c. retain a reversionary interest;or ................................................................................................ ❑ � d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ X❑ 2. If death occurred after December 12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ...................:................................................................... ❑ X❑ 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ XD 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?.................................................................................................. ❑ 0 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 filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 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 beneficiaries is 4.5 percent,except as noted in 72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. � REV-1508 EX+(11-10) �ennsylvania SCHEDULE E DEPARTMENT OFFtEVENUE • CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN RESIDENT DECEdENT PERSC�NA� PRtJPERTY ESTATE t}F: FI�E NUMBER: THERESA F. LACERENZA 21 13 0124 Inciude the proceeds of litigatian and#he date the prot�ds were received by the estate. All property jaintly owned with right of survivorship must be disclased on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTI4N QF DEATH 1. METRO BANK-CHECKING ACCOUNT#538a146$9 780.77 2. METRa BANK-SAVINGS ACC(JUNT#1t}832210 5,'140.88 TOTAL{Afsa enter on Line 5,Recapitulation� � 5 921.45 If more space is needed,insert additional sheeis of paper of the same size REV-1510 EX+(08-09) pennsylvania SCHEDULE G + DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER THERESA F. LACERENZA 21 13 0124 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. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OF DECD�S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSfER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. JAN I N E M. FOOS E 106,000.00 100.00 3,000.00 103,000.00 GIFT TOTAL (Also enter on Line 7,Recapitulation) � 103 000.00 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(10-09) pennsylvania SCHEDULE H • DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER THERESA F. LACERENZA 21 13 0124 DecedenYs debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOLLINGER FUNERAL HOME&CREMATORY, INC. 3,664.34 2. FAIRFIELD MONUMENT CO., INC. 559.00 3. CATHOLIC CEMETERIES 525.00 B, ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2, AttomeyFees: IRWIN & M�KNIGHT, P.C. 1,400.00 3. Family Exemption:(If decedenYs address is not the same as claimanYs,attach explanation.) 3,500.00 Claimant JANINE FOOSE StreetAddress 317 JUNIPER DRIVE City CARLISLE State PA zIP 17013 Relationship of Claimant to Decedent DAUGHTER 4• Probate Fees: REGISTER OF WILLS 123.50 5 Accountant Fees: 6. Tax Retum Preparer Fees: PATRICIA A. ROSENDALE, CPA 475.00 INCOME TAX RETURN &FINAL FIDUCIARY TAX RETURN 7. CUMBERLAND LAW JOURNAL- ESTATE NOTICE 75.00 8. THE SENTINEL- ESTATE NOTICE 189.54 TOTAL(Also enter on Line 9,Recapitulation) $ 10 511.38 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-08) pennsylvania SCHEDULE I ' DEPARTMENT OF REVENUE DEBTS OF DECEDENT� INHERITANCE TAX RETURN MORTGAGE LIABILITIES, &LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER THERESA F. LACERENZA 21 13 0124 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. GRAHAM MEDICAL CLINIC, P.C. -MEDICAL 24.74 2. CARLISLE REGIONAL MEDICAL CENTER-MEDICAL 1,184.00 TOTAL(Also enter on Line 10,Recapitulation) � 1 208.74 If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE J , DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: THERESA F. LACERENZA 21 13 0124 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distnbutions and transfers under Sec.9116(a)(1.2).] 1. JANINE M. FOOSE Lineal 97,201.33 317 JUNIPER DRIVE REMAINDER CARLISLE, PA 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, a If more space is needed,use additional sheets of paper of the same size. �� , � . � Y � LAST WILL AND TESTA�IVIENT I, THERESA F. LACERENZA, of North Newton Township, Cumberland County, : Pennsylvania, being of sound mind, disposing memory and full legal age, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking a11 Wills and Codicils heretofore made by me. 1. I direct my Executrix or Substitute Executrix, as the case may be, to pay all of my � debts, funeral and administrative expenses as soon as convenient after my decease. Furthermore, I direct that all sta.te, inheritance, succession and other death taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property composing of my gross estate for death tax purposes, whether or not such property passes under this Will, shall be paid by the Executrix or Substitute Executrix from my estate, and that none of the aforesaid taxes shall be prorated among those persons named herein or otherwise beneficiaries hereunder. 2. My Executrix or Substitute Executrix may, at her discretion, compromise claims, borrow money, retain property for such length of time as she may deem proper; lease and sell property for such prices, on such terms, at public or private sales, as she may deem proper; and invest estate property and income without restriction to legal investments unless otherwise provided hereunder. ,�...�; �, . . , 3. I authorize and empower my Executrix ar Substitute Executrix to se�l any realty andlor person��ty owned by me at my deafih and not specifically devised�r bequeathed herein,at public or private sale or sales and to give good and sufficient deeds andlor bills of sale therefor, in fee simple, as I could do if living. My Executrix ar Substitute Executrix is authorized and empawered to engage in any business in which I may be engaged at my death, for such period of . _ time after my death as seems expedient to said Executrix or Substitute Executrix. 4. I give,�devise and bequeath a11 of my estate of whatever nature and wherever situate to �my daughter, JA►NINE M. F{)OSE, and if she is not Iiving at the time of my death, �a my granddaughter,MICHELE M. ST.FIEP:RE. 5. I nominate and appaint JANINE M. FO►OSE ta be the Execut�ix of this my Last WiII and Tes��tner�t. In the event she h.as predeceased me, failed ta qu�a�ify or is nat able or daes not serve for whatever reason, I then appaint MICHELE M. ST. PIEp►.RE to be the Substitute Executrix of this my Last Will and Testament with the same pawers as are given to the original Executrix hereunder. b. No perscan sha.11 benefit hereunder unless �uch beneficiary shall survive me by sixty (6U)days. 7. No Executrix or Substitute Executrix acting hereunder shall be required to post bond or enter security in�us or any other jurisdiction. 2 �a . : 8. No beneficiary may assign, anticipate or pledge his ar her interest in any income or principal held or distributable hereunder, and no beneficiary's creditors may levy, attach or other�wise reach any such interest. }. I hereby suggest that my person��l representative ret��in the services of I��win & McKnight,P.C. as attorneys in the settlernent of my estate. IN WITNES�VVHEREOF, I have hereunto set my hand and seal this 29�'day of tJctober 2U12. �: �.�•��- U�.�'Z-.� . �----•� THERESA F. LACERENZA Signed, sealed,pub�ished and declared by the above-named Testatrix, as and for her Last Will and Testament, in our presence, who, at her request, in her presence and in the presence of each other have hereunta set au�r na�:nes as subscribing witnesses. ,�'"" _ �;. �,. 1 ` .:,.J �. ��f -.rJ f✓ r�;'�� I �`"- ' � –°�—•''''`�. �� c✓� -ti� '�j''.. .. .',;'.' '-�. v � ^ � � �,�7`7�l�rl�'� l.� ��-�ii�l�� P J � [ � /�"' . . ACI�:NOWLED+G�IE�1'T AND AFFIDAVIT � �_ WE, THERESA F. LACERENZA, 14�ARTHA L. NOEL and S�I��RpN L, SCHWALM,the Testatrix and witnesses respectively, whose narnes are signed�o the faregoing : insb:�tmenfi, being fust du�y swarn, do hereby declare to the undersigned authority that the : Testatrix signed and executed the inst�u�ment as her Last Wil1 and that she had signed willingly, � - and that she executed it as her firee and voluntary act for the purpase herein expressed, and that " � each of the witnesses, in the presence and hearing of the Testa�rix, signed the vvill as a witness and that to the best of their knowledge the Testat�ri.x was, at t�tat time, eighteen years of age or alder,of svund mind and under no constraint or undue vlfluence. , l j � � �,..__ THERESA F. LA EREN `. .�, , .�`.,� '�J �,,,: ,�, ,,r �Tf�/ �- � r° •�• �/" , ''�..f t':�fJ 7 Ef'rl��:.F s'��4. '��i r tr�;�; � MART�, L. I�TUEL �. .�__.__- ., ��.��'t✓.L�r.+�" ��.�� , � . .� SH[ARON L. SCHWALM COMMONWEALTH OF PENNSYLV.ANIA : : SS: CC�UI'�TY UF CUMBERLAND � i Subscribed, swarn to and acknowledged before me by THERESA F. LACERENZA, the Testatrix herein, and subscribed and swo�m to befare me by MARTI3A L. Nt}EL and SHARON L.SCHWALM,witnesses,this 29 day of Octaber 2012. � �� otary Public C4MM TH QF PENNSYLVANIA �tadal Seaf ' Roger 8.Irwin,Natary Pubiic Ca�llsle 8oro,Cum�bertand Cou�tty My Gomml�r�xpires Oct.3,2016 MEMBER,PENNSYLVANIA ASSOCIA12pN OF NQ?ARIE$ . �� 3801 Paxton Street 888.937.0004 Harrisburg, PA 17111 mymetrobank.com �;'��. _ � 2/14/13 � � ;;, � ;�� ; �,+��;� . , Roger B. Irwin - - West Pomfret Professionai Buiiding 60 West Pomfret St. Cariisle. PA 17013 RE: Estate of: Theresa F. Lacerenza Tax Identification Number: 193-28-1436 Date of Death: January 21, 2013 To Whom It May Concern: This letter is in reference to decedent account information you requested for the individual listed above. We are able to provide the following: Account Type:CK Account Number: 538014689 Date Opened: 07/21/2008 Date Closed: 01/21/2013 Primary Owner: Theresa F. Lacerenza Date of Death Balance: $780.77 Account Type:S�V � Account Number: 10832210 Date Opened: 07/21/2008 Date Closed: 01/21/2013 Primary Owner: Theresa F. Lacerenza Date of Death Balance: $5,140.68 Please feel free to contact me at (717)412-6127 if I may be of further assistance. Sincerely, _ ��,,,,w,,.,,...�.:.__�......- __--'--��.,..-�-.T._�� __---�--�.� Nw+a�+ ✓ ..•� � �. Y�, . .� ~ Jennifer Jacobs Research Associate Metro Bank . � i/1 �� pi � /IR Hollinger Funeral Home & Crematorq, Inc. Eric L. Hollinger,Supervisor January 25, 2013 Janine Foose 317 Juniper Dr. Carlisle, PA 17013 The Funeral Service for Theresa lacerenza: We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES,AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. Professional Service Cremation Package C—Memorial/Graveside Services $3045.00 Merchandise . Bronze Snap Cube Urn 90.00 Prayer Cards 50.00 AT THE TIME FUNERAL ARRANGEMENTS WERE MADE,WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. Cash Advances Certified Copies of Death Certificate (8 @$6) 48.00 Cumberland County Coroner's Authorization 30.00 Sentinel 199.74 Stamford Advocate/Darien News 76.60 Clergy 175.00 Organist 150.00 Total Charges $3864.34 CK Cash Advances from Janine Foose -200.00 Balance Due $3664.34 501 NORTH BALTIMORE AnENllE • M011NT HOLLY SPRINGS, PENNSYL\7ANIA 17065 • (717)486-3433 • FAX(717)486-3215 www.hollingerfuneralhome.com y;� p� t.�..a: � ��b�'�lfr��'�a�� ;„� . i, t.,� :4�^ qS .a... ?��V a '��aF'`..��t.::l,..z�,-. Fairfield Monument Co, Inc. 1150236 Quality has no fear of time..... FEBRUARY 6, 2013 221 Hoyt St., Darien, CT 06820 Phone 203-322-7955 Fax 877-231-8b03 donC�ctmonumentgroup.com To Estate of Theresa F. Lacerenza C/0 Janine Foose 317 Juniper St. Carlisle, PA 17013 . . �_ . . . ... � � SALESPERSON j JOB ; PAYMENT TERMS ' DUE DATE � 3 '— � -- ! — - ---- — --.__._ �— ' � DRF i LACERENZA � Due on receipt � � t � QTY�' _ DESCRIPTION � UNIT PRICE � LINE TOTAL � ; -�--- -----� i1 � Inscription: i I , � � � i ; ' � I � ! i � i � I ( I � ; 1931 THERESA F. 2013 � i $525.00 ; I ; i ' � ? ' � i I i I � I , ; ; � j i ; i i i i � i � � � , ; ; ; � � ; I 1 , � i � � ( , I 1 I , � ; � � � ; : � , � � I ! ; � � � , , , ; � � + f � � I I - I I �- � --- - � ---� -! SUBTOTAL ; $525.00 � , TAX � $34.00 �---- � � TOTAL � $559.00 i � Make all checks payable to Fairfield Monurr�ent Co., Inc. Payment constitutes approval of work. THANK YOU FOR YOUR BUSINESSi ,aaMrN�s�a�o�c� csrbolia ceaur ' 236 J ev�+etc Avc�nuc �e° ��O�� Bridgep�n,CT 06�8" 203-372-43�1 �aX zo�-3�¢�5a8 �roc�s� o�$Rx��oR c�M�zr v�cc�s �e�rflc�oRr•s�ta rFOR�z s�.��t c��► 2205 ScrACfotd A�venue Scracford,CT 06615 Febnxary'24,2Q13 243-378-0404 Fax 203-378-0313 �AIV'BZ[RY St.Pecer Cemetery 71 I.�kc A�Cnue�,'xtensiun Danbury,GZ 068]0 2u3-743-9626 j��j�en S. Noel, �9uc 203-743-530b st,��, 'r"bis letter is in response for the famil.�r's request for p ent of the fitture J 25 C�p A�enu� inurnmexit of Theresa F.Lacerenza. Da=i�n,CT 468Z0 203-322-0455 k�x 203-595-9243 O�ur current charges are as follo�vs: GR�NWIC�I Opening and closing a gravc for crcmatcd (inclucung an sc.Ma�y-��c�e�ery outtr uemation vault)is $525.00 Monday-F ' y before 3:00 pm . 3�9 N°�'s`�t (aftex 3:OOpm) an additional$275.00 per hour. 35 Parsoaa�e Road Gceennvich�C'x'06830 203-869-4828 2c�3`�6�-�p26 Saturday chacge's for opening is�525.00 with 'tional charge of Fax 2U3-869-9246 Ntwr�WN �i325.00 in&out by 12:30. Reaucrecdon Ceil�etecy' �/o Crace of Heaven Cemcccry After 12:30 an addirional char�c would be ad d of�125.00 pex bour. 1056 n�tucls�arm Road TrumbuU,crT 4bbi i �If we a� be of futther a3sistaace,please do not hesit te to coatact the 203-268-5574 y �ax 203-268-2203 office. NDRW�4LK Sc.John—St.Mary Cesnetery 223 Richard8 Avenue Norwsdk,CT OG85Q 2U3-838-4271 �ax 203-638-6843 Sji1C�p„ly 3r011xg, sraM�oRV • � � Queea of Pe�cr cerneeer�r . c/�$t]aha C,emetery 2S Camp Aven�xe Duien,CT 06820 Bsian MeDtimott 203•322-Q455 �� Fax 2Q3-�95-9243 rnu�reuct Cr�t�of Heaven Cd�netety' 1056 pac►iels Fa=a�Road Please note: All prices are subject to inere se without notice r�buu,cr o��>> 2U3-266-55�4 Fax 203-268-22U3 ��Z Aeeumption�GKCn Fsrms Aseumpaon,Bings Higfia�aY c/o Sz John Cemcccry 223 Richards Aver►ue Noi,valk,CT 06850 � aa3-s38-a2�a FAx 2q3-B38-6843 7f� 7nHJ a!4-!fT I.wnr �C 7 Qn•ra T c rra�!r�!�n _� � �_�" � ' � �n rn O � CrJ O!O00 OOdC �; � r� Q m � ..,� N h+#-+�-+� N�--.�-+N � lit: �. ► � '� H \`1\`,�, �,,.,'"�\""� � t/}? � N; �` � C -�t � 0�1t�0.� �C?C.C� �t-�t-� ' �; � ro '� � �r► �.�..��.�. �.'^.�.�. �E�t-� m� � F-+r+�+F-+ F-�►h-+�+ti � x- �E V�; o � � � v' ' WWWW WWWW � m 3 � �'" t�• �t: � r . m � O � � � � ~ � �� at- t-' r; o y ,��+ O O p ►� �''�� ,. Z E � � y . � 7x�d � O p � � �.... �'"'� �� p� = • �-�w ro ' � ' � t� t�ny � � p a " �+ � a � � �� • ,' - G � x ~ � y �� ro o�� '� �' � � � ~ , m; _ a �;, x � • �•• x�►�K t'��i �'i��C� � C � x O; � t'� N ttl t'S� .� t�n G�t�'i t�•H ~t'��.�d #► W � 7d � Sc? u � 1-�+ 7d H � ►.'�'L� t'f•C �� A!C," `��,.A !F C'� s tzJ 1 Cr1 '�' �C t-t H rt H '�►tQ aF � . k � C H � O * M C��G� �� '.7�' � H � M � � ' C�i!JI! -C'�i i� C'�i#�! C�i � � �' " u;ti b � - � C��•fyZ t'�F'•t'��d Oo M � � � � � � �]tM H ►-�Or1 H!�d W C!4 � 'zJ } � � � a�►w� w� a� ��' � � . • � �C�.�.�C �v �C�� Mc e�ra �E ba • • Q � B @ !� M ij � ' � � � p • y C? •� tD e�-t c��t rt �4 � a � M � � • C� 'ey G4 �F G� Ua � � • O � +�+ �O p.o � .o � o � „ ��`,, v o�o�«ros � � - Y � y o '" �p O [y L' �' H � .. st. �--� '"'� �D CCiw Ur � x � � ! � 00 !!D � t/� i. o ' � � �a�n � ro „ � r,, ; . �, � : � ° ' �� : � � c�s � � � r �. tD t7t Ut V i� • a� C C O � � • . • � r � b �, ' � � ; � . � � v ; ' � r ` O � � O O d O �d �F t� �!! s a • • : �. V � • ' O O O O Ct� �E O� W A .�' „ ?E E . ' �„�, � Q � +I I � � � .. I Oti �t- � • t� t-t' r'� • � Gi �J �E .� «� .. �� • . . . �. , �w •• V c� tp p �►v • .� h�t c�r� � �� i-+�.fi� V �E�4-�E O � .C�* � N " N � M� \�-+ I .C► N ' O � O , r-� t�s • ,�• .. . . . •. � 4t �-+ .� � . tn E,,,,, Cy . �"' O� 00 O . � � � � � . . --. _ _. ___._ _.___ ■ . PP.TIENT: Theresa F Lacerenza PATIENT #t 9544232 . BALANCEs $1,184.00 SERVICE DATE: January 20, 2013 Dear Theresa F Lacerenza Est, We wauld like ,ta take a moment ta say "Thank Yau" for selecting Carlisle Regianal Medical Center for your health care needs. We deeply appreciate your confidence in our ability to care for you and hope your visit with us was as pleasant as possible. We have received payment from Medicare in the amount of $4,350.36. We will bill your secondary insurance, Blue Shield 378 Medigap with a capy of Medicare's Explanation of Benefits. If you have questions or would like to speak with a pati�nt accaunt representative, please contact us afi the number below. Questians, pl.ease call: 717-960--1680 Qr visit www.carlislermc.com � � ' � f�� 3269-HMASTMT-1606730-1376553424-P;7096142-1-5;3305t1012-1;9 ( . . ;�"'�` 361 Alexander Spring Rd. R�IONA �arlisle, PA 17015 MEntCAL CENTtR � �• 001286 0101 THERESA F LACERE�IZA EST 317 JUNIPER ST CARLISL.E, PA 1?013-2525 11��I11n��iilli��I�Ill�l�lilr��illll��11�lii�lii��i�� 00�0095442�20�DOt1118400THERESAF�A�ERENZAEST �I1A001�