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i J Lso561o140
I REV-1500 °` "'-'°'
PA Dep�MieM of F�Venus OFFICI�L IME OILY
Bure�u of IndlviAual Tema �°nl�'Cod° Y°e Fk Numb°�
Po�� INHERITANCE TAX RETURN 2 1 1 3 0 Z 2 4
. HeMebirA.PA 17126-0601 RESIDFM DECEDENT
'I ENTER DECEDENT INFORMI1710N BELOYY .
i Sockl Sxwrity Numbar �Ee of De91h M�ODYYW DBIe of&M NMDDYVVv
0 2 1 7 2 0 1 3 0 3 0 6 1 9 2 3
DecedeM's Last Name SuMbc DscatlenCs Fhst Name MI
C 0 U L T E R 3 U Z A N N E J
(ff MW�WN)Enar sunWpq spouNS hdormrilon eNow
Spouse'a Last Name Sufl& Spouee's Firat Name MI .
Spouae's Socisl&ecurily NumDsr —
THIB RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALB BELOW
� � 1.Oripinal RMum � 2.SuppkmeMal Return � 3.RemaiMsr ReWm(drb of deaM
pia to 12-1382) .
� 4.LImIOed Estale � �a.Fuluie I�orset Compromiee(dste d � 6.Fede�al EsWe Taz Rel�rn Requbed �.
death afEer 12-72-82) '�.
Q 8.DloerMnt Died Teste� � 7.Dsosdent M�Intainsd a LIWng Trust _ 8.Tqal NwN�er of Safe DepOa�Y Boms �'
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ADD�
16 50 CENTER ROAD TRAVERSE CITY MI 49664
REOF EP REPRESENTA7NE
AD
60 YE POMFRET STREET CARLISLE PA 17013
PLEASE WE ORIOINAL FORM ONLY
Sitb 7 `
� J \
150561�14U 150561U14U v
��v .
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedenrstlame: SUZANNE J• COULTER
RECAPITULATION
1. Real Estate(Schedule A) ................. . . ... . .. . . .. . . . .. . ........ 1.
2. Stocks and Bonds(Schedule B) .. . . .. . . .. .. .. . . . . . . .................. 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3.
4. Mortgages and Notes Receivable(Schedule D) 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)... .. .. 5. 2 2 8 2 8. 1 6
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested .. ..... 6. 5 5 0 2 6 . 5 3
7. Inter-Vivos Transfers&Miscellaneous N n-Probate Property
(Schedule G) t Separate Billing Requested ....... 7.
8. Total Gross Assets(total Lines 1 through 7) ........... ...... .. . ... .. . . 8. 7 7 8 5 4 . 6 9
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . .. . . .. .. . . 9. 6 0 1 6 . 5 0
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) . .. ... . ...... 10. 7 6 4 5. 3 7
11. Total Deductions(total Lines 9 and 10) .... .. . . .. .. . . .. .. . . . . . .. ...... 11. 1 3 6 6 3 . 8 7
12, Net Value of Estate(Line 8 minus Line 11) . .. . . .. . .... . ............... 12. 6 4 1 9 0. 8 2
11 Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made(Schedule J) .. .......... ...... ... . 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) ............. ..... .. .. 14, 6 4 1 9 0 . 8 2
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 0 15, 0 . O 0
16. Amount of Line 14 taxable
at lineal rate x.045 6 4 1 9 0 . 8 2 16. 2 8 8 8 . 5 9
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X-15 0 . 0 0 18, 0 . 0 0
19. TAX DUE . .... . . . .. . . . .. .. . .. . . . .. .. .. .. . . . . ... ... ....... ..... . 19. 2 8 8 8 • 5 9
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 0
Side 2
1505610240 1505610240
REV-1503 EX+(8-12)
pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE
INHERITANCETN(RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
SUZANNE J. COULTER 21 13 0224
PJI properly jolndy owned with rigM of survivo�ship muat be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
TOTAL(Also enter on Line 2,Recapitulation) S
If more space is needed, insert additional shcets of the same size
REV-7508 EX+(OB-12)
pennsylvania SCFIEDULE E
. DEPAR'fMENTOFREVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENTDECE�ENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
SUZANNE J. COULTER 21 13 0224
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property JoinGy owned with rigM of survivorship must be diaclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. ACNB BANK-MONEY MARKET ACCOUNT#1645196 15,806.1 S
2. ACNB BANK-CHECKING ACCOUNT#2244756 7,021.98
TOTAL(Also enler on Line 5,Recapitulation) E 22 $2$ �6
If more space is needed, use additional sheets of paper of the same size.
REV-1509 EX+(01-10)
pennsylvania SCHEDULE F
• OEPARTMENT OF REVENUE �OINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
SUZANNE J. COULTER 21 13 0224
M an asset was made jolnHy owned wkhin one year of the decedeM's date of death,R mu�be reported on Schedule G.
SURViVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
q. MARCIA S. KULESZA 2335 VALLEY VIEW CT. DAUGHTER
CLARKSTON, WA 99403
e. KELLY A. FERGUSON 9115 STEINER ROAD DAUGHTER
BELLAIRE, MI 49615
c.ANNE C. CRAWFORD 9008 MORDEN CT. DAUGHTER
RALEIGH, NC 27615
JOINTLY•OWNED PROPERTY:
LETTER UATE DESCRIPTION OF PROPERN 9:OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANGAL INSTITUTION AND BANKACCOUNT NUMBER OR SIMILAR OATE OF OEATH DECEOENT'S VALUE OF
NUMBER TENANT JOINT IDEIl�IFYINGNUMBERATTACH�EEDFORJOINTLV-HELDREALESTATE. VALUEOFASSET INTEREST DECEOENTSIMEREST
1. A. 08I2008 ACNB BANK 25,012.05 50. 12,506.03
CERTIFICATE OF DEPOSIT#173830
2. B. 08I208 ACNB BANK 42,520.49 50. 21,260.25
CERTIFICATE OF DEPOSIT#173831
3. C. 08I2008 ACNB BANK 42,520.49 50. 21,260.25
CERTIFICATE OF DEPOSIT#173832
TOTAL(Also enter on Line 6,Recapitulalion) E 55 026.53
I(more space is needed,use additional sheeLS of paper of Me same size.
REV-1511.EX+(10-09)
pennsylvania SCHEDULE H
. DEPAftTMENTOF REVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
SUZANNE J. COULTER 21 13 0224
DeadeM's dabis must be reported on Schedule[.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNER4LEXPENSES:
1.
B. ADMINISTRATIVECOSTS:
1. Personal Rep2sentative Commissions:
Name(s)of Persona�RepreseMative(s)
Street Address
City State ZIP
Yeahs)Canmission Paid:
p, nttomey Fees: IRWIN &MCKNIGHT, P.C. 3,500.00
3, Family Exemption:(If decedeM's address is not the same as daimanYs,adech explanatlon.)
Claimant
StreetAddress
City Stffie ZIP
Relationship of Claimant to�ecedent
4. ProbateFees: REGISTER OF WILLS 138.50
5 AccounfantFees:
6. TaxReWmPreparerFees: PATRICIAA. ROSENDALE, CPA 375.00
7. REGISTER OF WILLS-SHORT CERTIFICATE 5.00
S. TRACEY L. COULTER- POA SERVICES 2,000.00
TOTAL(Also enter on Line 9,Recapitulffiion) S 6 018.50
If mo2 space is needed,use additbnal shee4s of paper of the seme size.
REV-1512 EX+(72-12)
pennsylvania SCHEDULE I
� DEPARTMENTOFREVENUE DEBTS OF DECEDENT�
INHERITANCETAXRETURN MORTGAGE LIABILITIES 8�LIENS
RESIDENT UECEDENT
ESTATE OF FILE NUMBER
SUZANNE J. COULTER 21 13 0224
Report debts incurred by fhe decedent prior to deaN lhat remained unpald ffi the date of death,including unreimbursed medical expenaes.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. DARRYL GUISTWITE, DO-MEDICAL 56.42
2. PRESBYTERIAN HOMES- NURSING 6,631.81
3. PINNACLE HEALTH -MEDICAL 40.00
4. MILLENNIUM PHARMACY SYSTEMS-MEDICAL 717.14
TOTAL(Also enter on Line 10,RecapitulaGon) E 7 gq5.37
If more space is needed,insert addkional sheets of the same size.
REV-1513 E%i(Ot40)
pennsylvania SCHEDULE J
. �EPARTMENTOFREVENUE
BENEFICIARIES
INHERITANCE TFU(RETURN
RESIDENTDECEDENT
ESTATE OF: FILE NUMBER:
SUZANNE J. COULTER 21 13 0224
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not ListTnistee(s) OF ESTATE
I TAXABLEDISTRIBUTIONSpnGudaou6y'�htspouseldistributionsandtrensfersunder
Sec.97 f6(a)(7.2).]
1. MARCIA S. KULESZA Lineal 12,838.17
2335 VALLEY VIEW CT. 1I5TH REMAINDER
CLARKSTON, WA 99403
2. ANNE C. CRAWFORD Lineal 12,838.17
9008 MORDEN CT. 1/5TH REMAINDER
RALEIGH, NC 27615
3. MICHAEL L. COULTER Lineal 12,838.16
16550 CENTER ROAD 1/5TH REMAINDER
TRAVERSE CITY, MI 49686
4. TRACEY L. COULTER Lineal 12,838.16
PO BOX 560 1/5TH REMAINDER
BOALSBURG, PA 16827
5. KELLY A. FERGUSON Lineal 12,838.16
915 STEINER ROAD 1/5TH REMAINDER
BELLAIRE, MI 49615
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
R, NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
t.
8.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S
If more space is needed,use addilional sheets of paper of the same size.
LAST WILL AND TESTAMENT
I, SUZANNE J. COULTER, of the Bomugh of Newville, Cumberland County,
Pennsylvania, being of sound mind, disposing memory and full legal age, do hereby make,
publish and declaze this to be my Last Will and Testament, hereby revoking all Wills and
Codicils heretofore made by me.
ONE. I direct my Executor or Executrix, as the case may be, to pay all of my
debts, funeral and administrative expenses as soon as convenient after my decease. I direct that
my body shall be cremated and the ashes interred, and that the expense thereof be reunbursed out
of my estate as a funeral expense. Furthermore,I direct that all state, 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 Executor or Executrix of my estate.
TWO. My Executor or Executrix may, at his or her discretion, compromise
claims, borrow money, retain property for such length of time as he or she may deem proper;
lease and sell property for such prices, on such terms, at public or private sales, as he or she may
deem pmper; and invest estate property and income without restriction to legal investments
unless otherwise provided hereunder. I authoriae and empower my Executor or Executrix to sell
any realty and/or personalty owned by me at my death and not specifically devised or bequeathed
herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale
therefor, in fee simple, as I could do if living. My Executor or Executcix is authorized and
empowered to engage in any business in which I may be engaged at my death, for such period of
time after my dea[h as seems expedient to said Executor or Executrix.
Initial ��' (
_U _
THREE. I give, devise and bequeath all of my estate of whatever nature and
wherever situate as follows:
A. I give and bequeath to the person or persons idendfied in any written
statement which is signed by me, whether prepared at the time of making this my Last
Will and Testament or at a subsequent time, certain items of tangible personal property
described therein. This provision authorizing reference to such a sepazate statement does - _
not necessarily mean that such a statement has been made by me in connection with the
making of this my Last Will and Testament. To the extent that such a sepazate statement
fails to dispose of all of my tangible personal pmperty, or if the statement is not in
existence at the dme of my decease, then I give and bequeath the same in accordance with
Paragraph Three B below;
B. I give, devise and bequeath all of the rest, residue and remunder of my
estate in equal shazes to my children, MARCTA S. KULESZA, ANNE C. CRAWFORD,
MICHAEL C. COULTER, TRACEY L. COULTER, and KELLY A. FERGUSON, per
capita.
FOUR. ff, under any of the provisions of this Will, any principal becomes vested
in a minor,my Executor or Executrix, as the case may be, including any administrator c.t.a., shall
have the discretion either to pay over such principal or any part thereof to any parent of such
minor, any guazdian of the person or estate oF such minor, or any person with whom such minor
resides,or to retain the same as trustee of a power in trust for the benefit of such minor during his
or her minority. Any of the principal thus retained, and any oF the income therefrom, including
the whole thereof, may be paid to or applied for the benefit of such minor from time to time in
the discretion of the trustee of such power. When such minor reaches majority, the funds so held
Initial� 2
_
shall be paid over to such person, or, if he or she shall sooner die, to his or her legal
representatives. In so holding any principal or income for any minor, the trustee of such power
shall have all the rights,powers, duties and discretions conferred or imposed upon my fiduciaries
acting under this Will. I further direct that no bond shall be required from any person receiving a
payment hereunder and receipt from such person shall be a full dischazge to the trustee of such
power who shall not be bound to see to the application or use of such payment. The trustee of
such power shall be entitled to commissions at the rates and in the manner payable to a
testamentary trustee.
FIVE. I nominate and appoint my son, MICHAEL L. COIJLT'ER, to be the
Executor of this my Last Will and Testament. In the event he has predeceased me, failed to
qualify or is not able or does not serve for whatever reason, I then appoint my daughter,
TRACEY L. COULTER, to be the Substitute Executrix of this my Last WiII and Testament. In
the event she has predeceased me, failed to qualify or is not able or does not serve for whatever
reason, I then appoint my daughter, MARCIA S. KLILESZA, to be the Subs6tue Executrix of
this my Last Will and Testament, whereby the said substitute personal representatives shall have
the same powers as are given to the original Executor hereunder.
SIX. No person(s) shall benefit hereunder unless such beneficiary shall survive
me by sixty(60) days.
SEVEN. No Executrix or Executor acting hereunder shall be required to post bond
or enter security in this or any other jurisdiction.
EIGHT.� No beneficiary may assign, anticipate or pledge his or her interest in any
income or principal held or distributable hereunder, and no beneficiary's creditors may levy,
attach or otherwise reach any such interest.
Initial �J�1 l. 3
Ll
riINE. If any person or institution entitled to share in any distribution under the
terms of this my I.ast WIll and Testament becomes an adverse pazty in any proceeding to contest
the probate of this Last Will and Testament, such person or institution shall forfeit his, her or its
entire interest inherited hereunder and all provisions in favor of such person or institution shall
be declared void and of no effect. The shaze of such person or institution so forfeited shall be
distributed as part of the residue pursuant to Pazagraph Three B. hereof, except that if such
person or institution is entitled to share in the said residue, that interest shall be distributed
proportionately to the other residuary distributees.
[THE REMAINDER OF THIS PAGE HAS BEEN INTENTIONALLY LEFI'BLANK]
Initial� 4
IN WTfNESS WHEREOF, I have hereunto set my hand and seal t6is ��day of
November,2006.
(SEAL)
SUZ NEJ.0 ULTER
Signed, sealed, published and declazed by the above-named person as and for a Last Will
and Testament, in our pFesence, who at said person's request, in said person's presence and in the
presence of each other have hereunto set our names as subscribing witnesses. .
. �1
L
. � / .
5
ACKNOWLEDGMENT AND AFFIDAVIT
WE, SUZANNE J. COULTER, TRACI D. SMITH and CI3ERYL L. CLELAND,
the testauix and witnesses respectively, whose names aze signed to the foregoing instrument,
being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and
executed the instrument as her last wIll and that she had signed willingly, and that she executed it
as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in
the presence and hearing of the testatrix, signed the will as a witness and that to the best of their
knowledge the testatrix was, at that time,eighteen years of age or older, of sound mind and under
no constraint or undue influence.
ZANNE 3/ OiT� R
. �J � '
� G�l�_j , �
�CI D.SMI ,
J
C RYL L. CLELAND
COMMONWEALTH OF PENNSYLVANIe1 :
. SS:
COUNTY OF CUMBERLAND .
Subscribed, sworn to and acknowledged before me by SUZANNE J. COULTER, the
testatrix herein, and subscribed and worn to before me by TRACI D. SMITH and CHERYL
L. CLELAND,witnesses,this��day of November,2006.
COMM���'� OF PENNS unrn�+ �
r
xo�ats�ai �
p"b�"nri� Notary Pu lic
�en S.Nat,N�d C 8 2007
MYeclC��s,��+n Ex�'u�Dea ,
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�ACNB
BANK
��G��vr�
�AR 14 2Q13
Mazch 12, 2013 y}�Y�hl�&P�c141(� G
qAW�OFEICES
Irwin&McKnight PC
Attn: Douglas G Miller
60 W Pomfret St
Carlisle PA 17013
RE: Estate of Suzanne J Coulter
Dear Mr. Miller:
The following information is being provided as per your request:
Acct.Type Account No. Balance at Accrued Ownership Date
D.O.D. Interest to OpenedfJoint
D.O.D.
Money 1645196 $15,805.99 $0.19 Individual 8/]0/06
Mazket
Account
Esteem 2244756 $7,021.89 $0.09 Individual 8/10/06
Checking
Account
Certificate of 173830 $25,000.00 $12.05 Jt w/Marcia S Kulesza 8/25/OS
Deposit
Certificate of 173831 $42,500.00 $20.49 Jt w/Kelly A Ferguson 8/25/08
Deposit
Certificate of 173832 $42,500.00 $20.49 Jt w/Anne C Crawford 8/25/08
Deposit
Inquiries conceming ACNB Corporation stock information should be directed to the Registrar and Transfer Company
at 1-800-368-5948. If you need any additional information,please contact me at(717)339-5122.
Sincerely,
��"" '"- —
Barbara J W
ACNB Bank
Deposit Services Representstive II
acnb.com•acnbbusiness.com•P.O.Box 3729,Gettysburg,PA 17325•Phone 777.334.3161 •Toll Free 1.888334.ACNB(2262)
' �YL GUIS1'WITE,DO (717)609-2639
56 ASHTON STREET
CARLISLE,PA 17015-6914
Accoutrt Number Billine Dek P� np'^^Use Onlv
Su�anne J.Coulter 10466 04/15/13 1 MED
C!O Tracey Coulter
320 N Baltimore Ave.Po Box 97
MT HOLLY SPRINGS,PA 17065
$ervice Date CPT4 Desctiotion Prov. ��g Mes¢. cn� Peid Adiusdnent Petient Peid Belence Due
02/]3/13 99308 Nursing Home Est.Patient Leve12 DG 1 80.00 13.15
Patient:Coulter,Suzanne J- 10466
Servicing Provider:Darryl K Guislwite DO
04/15R013 Medicaze 52.60 14.25
02/15/13 99308 Nursing Home Est.Patient Leve12 DG 1 80.00 13.15
Patient:Coulur,Suzanne J-10466
Servicing Provider:Darryl K Guistwite DO
04/IS/2013 Medicare 52.60 14.25
02/17/13 99316 Nursing Facility Discharge Lv12 DG 1 110.00 19.97
Patient:Coulter,Suzenne J- 10466
Servicing Provider:Darryl K Guistwite DO
04l15/2013 Medicare 79.87 10.16
C���LL '7c'C:e.�'T c,cLS � .� !\u:�p�L�. L�.s. �, L\c_._ r�S L��er `c�c.�� 'tt�
�Jo z� �cuc3:,hc,�u� r'�ec��u.:� c�o� ��r��� ��c.:. `x; �\�:SZ�,e�
,-.�uk` Lc . , r.s�,u.�c� c�� L `��\ '�c�T,�,�T, . t �Jv;; Hc;.�e c:r�
�Ul.�S1 ��:\1S � e.�� �r� �� Z.V C_c:.\Jr�� c.-C. �1b- 35�v_, 5.,��r
Pleese PaY—> 46.27
Comments:
please pay within 30 days...thank you Suzanne J.Coulter
10466 185.07 46.27
Account Number New Cherges New Payments N�w�ns.Pmt. CurteM Due Pmt Due Fitmnce Cherge Scheduled Amaunt
Since last Bill Since Lest Bill Since Lest Bill /Billing Fa
Darryl Guistwice DO•56 Ashton Street•CARLISLE,PA 17015-6914 �
' DARRYL GUISTWITE,DO (717)609-2639
�56 SHTON STREET
RLISLE,PA 17015-6914
AccouM Num6er Billin¢Dete Pa�e Offia Uu Onlv
Suzanne J.Coulter 10466 03/13/13 1 MED
GO Tracey Coulter
320 N Baltimore Ave.Po Box 97
MT HOLLY SPRINGS,PA 17065
ServiceDete CPT4 Desai°tlon PI4Y. SLni�_s MC38, rn..oe Paid 'OQyustment P 'ent 'd BelenceDue
02/06/13 G0180 Hospice Initial Certification DG 1 65.00 10.15
Patient:Coulter,Suzanne J- 10466
Servicing Provider:Darryl K Guistwite DO
03/06/2013 Medicare 40.58 14.27
Commentt: Pleese Pey a I 0.15
Please pay within 30 deys...thenk you Suzanne J.Coulter
]0466 495.00 582.72 10.15
Account Number New Charges New PaymcMS New Ins.Pml Curten[Due Pest Due Finence Cherge Scheduled Amount
Sina[ast Bill $ince Lest Bill Since Lsst Bill /Billin6 Fa
Darryl Guistwite DO•56 Ashton Street•CARLISLE,PA 17015-6914 ��
' f ou have an uestions re ardin our statement lease contact the Business Office at 717 776-8256.
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'b ...`",�ak ° �-t }'.�5°x�.°, �.{ ��sev °� ._�&�'ivt. .. � ��= ..E. .. #. ,- t �k:''� i�j+'��+ �:f�..rZi� � �
' Balance Fonvard $9,998.04
02/27/13-0 /27/13 XFER 12/12 HUMANA TO PP CO PAY Check $(100.00)
� 07/31/13-01/31/13 Rented Medical Equipment 1 $396.00 I $396.00
' 02/01/13-02/01/13 AllevynDrsg.5X5 1 $18.60 $18.60
i I 02/01/13-02(01/13 Ultra Stretch Brief Med/Reg 1 $49.85 $49.85
, 02/03/13-02/03/13 SYR 3/CC w/Safety 100Bx 1 $0.76 $0.76
� 02/07/13-02/07/13 SYR 3/CC w/Safety 100/8x 1 $0.76 $0.76
02l10/13-02/10/13 Ultra Stretch Brief Med/Reg 1 $49.85 $49.85
� 02/11/13-02/11/13 AllevynDrsg.5X5 1 $18.60 $18.60
il02/12/13-02/12/13 Drsg Allevyn Brdr Lt 4x4 ` � 1 $15.12 $15.12
02/14/13-02/14/13 Tena WiPes p ?:'; 1 $7.22 $7.22
i O2J16/13-OZ/16/13 Alle n D `i '�
vy rsg.4 X 4 NADH ' t $55.95 $55.95
I 02/17/13-02/17/13 Telephone 1 �,,;$9.06 $9.D6
I e ta�r�� , . G�, ;.� .
02/17/13-02/28/13 Room/Board-Self Pay "' ' ;;(12) �"'"�324.00) $(3,888.00)
TOTAL BALANCE DUE � '; 56,831.81
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FACILITY NAME RESIDENT NAME ACCOUNT NUMBER
SWAIM HEALTH CENTER SUZANNE J COULTER 61698GRV
Friday,March 01,2(N3 Page 1
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*** Thank you for your prompt payment. Please call 717-731-8315 with any *��
�*'� uestions. **�
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O1/03/1� 6 L PROGRAM EVAL PACER, DUAL 93280 V45.01 135.00
O1/25/13 HUIiANA GOLD Payment 12.01
O1/25/13 Accept Assign Adj. -82.99 40.00*
L-The 'PLEASE PAY' ineludes unpaid co-pay or co-ina. Please make payment.
DATELASTPAID AMOUNT
UO/00/00 0.00 40.00 0.00 0.00 0.00 0.00 0.00 0.00 40'.00
MAKE PINNACLEHEALTH�CARDIOYASCULAR INST, INC , ., , �
CHECK SOOO N FRONT ST
VAYABLETO: �]ORZILEYSBURG� PA 17043-1034 40.00*
Ph: (717)-731-0101
PAT� i-SUZANNE J COULTER PRV� 6-ZORNOSA, JOHN P, ?ID, FAC Acct�: 153195
Date: 02/O1/13
Page 1 of 1
nrv�me vaie.vuaei<v ia,nwunurtvrv 10I I,trVULI CK�a�u�rvne�,�reen niage wnage rv�-rn�,r.,�����..��_,���.�.��
.12/23@012 6635883 20.00 Temifiu Ore1 Cepsule 75 MG � - -� � - " - � $ 111.18 c $ 0.00� $ 111.18 RX
00004-0800-85 �
01/26I2013 881 9 24.00 AmioderoneHCIOreITablet2WMG $ 10.64 c $ 0.00 $ 70.84 �
00185-0744-05
01/28/20'13 6611001 24.00 Lewihy`oxine Sodium Oral Tablet 150 MCG $ 6.00 C $ 0.00 $ 6.00 RX
00378-1815-01 �
02/03/2013 8621877 100.00 Votteren External Gal 1% $ 42.57 c $ 0.00 $ 42.57 RX
83481-0884-47
02/07/2013 2036528 4.00 Fentanyl Tranetlermal Petch 72 Hour 25 MCGIHR $ 29,85 c $ 0.00 $ 29.85 RX
00587-3198-72
02/07/2013 2036597 1.00 Fentenvl Trensdarmel Petch 72 Hour 25 MCGIHR $ 6.46 C $ 0.00 $ 8.46 RX
00591-3788-72
02/07/2013 6611177 12.00 PromeTherine HCI Iniectlon Solution 25 MGIML $ 24.80 c $ 0.00 $ 24.80 RX
OOB41-7495J5
02/07/2013 4029948 24.00 CMP ABHR O.Smpl12.5ma10,5mal5mp Topicel Gel $ 8.08 c $ 0.00 $ 8.08 RX
00591-0240-05 ._
02/07/2013 2038527 30.00 Morahine SuHete $ 28.39 c $ 0.00 $ 28.39 RX
00054-0409-04 �
02I13/2013 H811027 30.00 Exalon Tranedermal Petch 24 Hour 9.5 MG24HR $ 95.00 C $ 0.00 $ 95.00 RX
00078-0502-15
02N 3I2013 6873951 12.00 Prometlrerine HCI Rectel Sunaoeitorv 25 MG $ 64.95 $ 0.00 $ 64.95 RX
45802•075930
$ 289.22$ 381.48 02/05/2013 a o.00 a 0.00 S 0.00 S 427.92 S 0.00 S 0.00 S 0.00 717.14 �
INVENTORY
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA
COMMONWEALTH OF PENNSYLVANIA 1
COCJNTY OF CUMBERLAND f SS FileNumber z�-13-0224
Personal Representative(s)of the Estate of SUZANNE J.COULTER
deceased,depose(s)and say(s)that the items appeazing in the following inventory include all of the personal assets wherever situate
and all of the real estate in the Commonwealth of Pennsylvania of said Decedent,that the valuation placed opposite each item ofsaid
imentory represenu its fair value as of the date of the decedenYs death, and that Decedent owned no real estate outside of the
Commonwealth of Pennsylvania except that which appeazs in a memorandum at the end of this inventory.
I verify that the statements made in this Inven-
tory are true and correct. ► understand that false state-
ments herein are made subject to the penalties of ��� � `����
18 Pa.C.S. § 4904 relating to unswom falsification to �� —
authorities.
Attorney-- (Name) DOUGLAS G.MILLER,ESQUIRE (Supreme Court I.D. No.) 83776
(AddressJ 60 WEST POMFRBT STREET,CARLISLE,PA 17013
(Telephone) (�17)_249-2353
DATE OF DEATH LAST RESIDENCE DECEDENT'S SOC.SEC.NO.
02/l7/2013 2I0 BIG SPRING ROAD,NEWVILLE,PA 17241
FIGURES MUST BE TOTALED
PNC BANK-MONEY MARKET ACCOUNT#1645196 15,806.18
ACNB BANK-CHECKING ACCOUNT#2244756 �az� 98
c� °': :;7
�.> ^ m
c o � r�
� � � � g
Q' ,� c ;,'7 :J
�'T� s � . ., c:y
� :a- N tqt ='
� � N �� =..s
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c� ,., - -;,
� � ��
r� c., �
:J f � t.7
� i.� l_4J � �
ro — �, vyo
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(A#ach additional sheeJs as needed)
TOTAL: 22,828.16
NOTE: The Memorandum of real estate ouGSide Ihe Commonweal[h of Pennsylvania may, a[ [he election of[he personal representa[ive include[he value of each
item,but such flgures should not be extended into the total of the Invenlory. (See 10 Pa.C.S§330](6))
Form RW-09 rev. IOJ3.06