HomeMy WebLinkAbout05-31-13 { 1505610190
"�'�� REV-1500 °` �°,-,°>
PA Depaftrne�rt W Revenue OFFICIAL WE ONLY
Bureau of Individuai Taxes Carity CAde Yeer FUe Number
Po eox 28osoa INHERI7ANCE TAX RETURN 2 � � 2 O O 7 8
Hamabum,Pn nt2e-oso� RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW � .
Societ SecuMy Number Dete of Death nwDOrrvr Date of Birth nnronarrYr
0 1 1 4 2 0 1 2 0 6 0 3 1 9 2 0
Daeedent's Last Neme SuHa DecedenYs Firet Name MI �
HAMI LTON HOWARm J
(If Applic�Me)Enter SurvW(ng Spouaa'a Infomiettm 8atow
Spouse's Last Name Suffix Spouse's Fltst Name MI
Spouse's Sxial Secunty Num6er .
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGfSTER OF WiLLS
FILL IN APPROPRIATE OVAL$BELOW �
Q t.Original Retum � 2.Supp�emental Ratum � 3. Remainder Retum(date of deaN
pnorto 12-13-82) ���.
� 4. Limitea Estata � 4a.FuWrc Intereat Canpromiae(date of � 5. Federal EataM Tex ReWrn Requlred ..
dealh after 12-72-82) .
� 6,Decadent Died Testate �] 7.Dacedent Maintained e Living Trust fl 8.TMeI Number of Safe Depaait Boxas �
(Attach Copy of Wilq (ANach Cvpy o�Trusq '
� 9.L'Rigetion Procae0s Received � f 0.Spousal Poverty Credtt(date of tleath � 11.EleUion to tax untler Sea 91 i3(A) �
belween 1231-91 and t-7,95) (Akaeh Sch.O) �
CORRESPONDENT-THIS SECTION MUSf BE COMPLETED.ALL CORNESPONDENCE AND CONflDENTIAL TIU(INFORMATION 6HOULD BE DIRECTED T0:
Name � DeytimeTekphone Number
J I L L M WI NEKA ESQUI RE 7 1 7 23�4 41�7 8
� �:: �
tlDlER OF WIL�I S US NL7
� :77 � G
u - ...,
�
First line of address � n � �,; ^ `;; �
1J 1 9 NORTH F RONT ST REET � � � ~ c ,.,
Secontl�fne of addreas J c; �-� � R� _.':'i
. � �-� ' , � �t .
..r� c � -� ':'� �
. � G`� - n�i�
Cily or Poat Office Stete ZIP Code "'� �TE PILED i"
HARf21 SB URG PA 1 7 1 0 2 � �' ��
cor.espa� o-man aaaiess: jwineka(�Pkh.com
Ut1d�pe � PB7ulY,I tleolare tllet eve examined thb rewm.InawNrp xmnpe�rq uheaukc a�M s�ate�nen[s,aM b tt�e Oeslot my knwAedpe a�M belief,
tt la true antl complefe.Oeder n d D�er ulher Ihan Nce pereonel repreeentatrve le basetl on al IntortnaUon of which praperer hea any knavledpe.
IG E OF PER N RES glE FOR FILMI R . OATE
/,� �-, z--7�-Zv�.3
ADDRE55
Beverl HamiRon 11 S.Penn Street Shi ensbu �Ap 17257-1913
RE EP R HER7H REPRESENTATNE _S / �O (��
AD E55
J� M. Wineka 1719 N. Front Street Harrisbur PA 17102
PLEASE U3E ORIGINAL FORM ONLY
Side 1
� 1505610140 150`.i610140 J
. .
J , �o=,F� o2ao
REV-1500 EX
DecetlenPs Social Security Number
oe��r5r+at„e. HOWARD J. HAMILTON
RECAPITULATION �
i. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 4 1 0 0 0 , 0 0
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 PropeRy(Schedule E). . . . . _ 5. 4 9 3 3 , 8 �
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. •
7. Inter-Vivos Transfers&Miscellaneous N Probate Property �
(Schedule G) � Separete Billing Requested . .. . . . . 7. .
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 4 5 9 3 3 , 8 0
_'-^-_----
9. Funerel Ezpenses and Adrr.inistretive Costs(Schedule H) . . . . . . . . . . . . . . . . . 9. 4 0 5 5 5 . 6 6
1�. Debts of Decedent,Mortgage Liabilities,and Liens(Schetlule I) . . . . . . . . . . . . . 10. � 2 A $ 9 • � 3
11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. � 3 O � 4 . 6 9
12. Net Value of Estate(Line 8 minus Llne 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72. - 3 7 1 1 0 , a 9
13. Charitable and Governmental Bequests/Sec 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. - 3 � 1 1 0 , $ 9
TAX CALCULATION•SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
atthe spousaltax rate,or
transfers under Sec. 9116
(a)(1.2)X.0 _ � . � � 15. � . Q �
16. Amount ot Line 14 taxable
at lineal rate X.0__ � , � � ig. � . � �
17. Amount of Line 14 taxable . ,
at sibling rate X .12 � . � 0 17. � . d ti
18. Amount of Line 14 taxable'
at collateral rate X.15 � • � � �g, � . � �
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. O . O O
20. FILL IN THE OVAI IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Side 2
� 15056102.40 150`i'o10240 J
REV-1500 EX Page 3 File Number
DecedenYs Complete Address: 2� �z oo�s
DEGEDENT'S NAME
HOWARD J. HAMILTON
STREETADDRESS
Cumberland Crossin�s _
1 lonqsdort Way
CITY STATE ZIP
Carlisie PA 17015
Tax Payments and Credits:
� Tax Due(Page 2,Line 19� (1) 0.00
2. Credits/Payments
A.Prior Payments
B.Discount
Total Credits(A+g) (p) 0.00
3. Interest
(3)
4. If Line 2 is greater ihan Line 1 +Line 3,enter the difference.This is ihe OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If Line i +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00
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 iransfer and: Yes No
a. retain ihe use or income of ihe propeAy transferred. ...................................................................... ❑ �
b. retain the rigM to designate who shall use lhe propetly transferred or its income: ............................... ❑ �
c. retain a re�ersionary interest;or ................................................................................................ ❑ �
d. receive the promise for life of either paymenis,benefits or care? ..............................................._...... ❑ Q
2. �f death ocarred after December 12,1982,did decedent transfer propedy within one year of death
without receiving adequate consideration? ............................................................................ .......... ❑ �
3. Did decedent own an"in irust for"or payable-upon-death bank account or sewrity at his or her death? ......... ❑ 0
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 ABOYE 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
3 percent[72 P.S.§9116(a)(1.1)(iJ].
For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of t�ansfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9176�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 t,2000:
• The tax rate imposed on the net value of transfers from a deceased chiid 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 decedenPs lineal beneficiaries is 4.5 percent,except as noted in
�2 P.s. gs�is(�.z�pz P.s. §s��s(a)(�)],
• The tax rate imposed on the net value of transfers to or for the use of the decedenPs siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defned,unde
Section 9102, as an Individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1502 EX+(01-10)
pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
INHEftITANCETAX RETURN
REAL ESTATE
RESIDENT�ECEPENT
ESTATE OF: FILE NUMBER:
HOWARD J. HAMILTON 21 12 0078
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as ihe price at which property
would be exchanged between a willi�g auyer and a willing seller,neither being compelled to buy or sell,both havin�reasooable knowledge ot the relevant fads.
Real propeRy that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the propedy has been sold.
ITEM Include a copy of the deed showing decedenPS interest if owned as tenanl in common. VALUE AT DATE
NUMBER OFDEATH
DESCRIPTION
1. 1048 West Nesquehoning Street, Easton, Northampton County, PA 18042 41,000.00
See attached Deed dated 3/12/98, recorded 3/12/98 in Vol. 1998-1, Pg. 028409 as
Instrument No. 1998009216 transferring title to Decedent.
Also see attached HUD-1 Settlement Statement regarding the sale of the real estate
to third parties, Matthew and Giordan Telesca for the gross sales price of$41,000.00.
TOTAL(Also enter on Line 1,Re�;apitulation.) 5 41 000.00
If more space is needed,use additional sheets of paper of Ne same size.
REV-1508 EX+(11-10)
pennsylvania SCNEDULE E
DEPARiMENTOFREVENUE
CASH, BANK DEPOSITS, & MISC.
�aESOErAiNOECeoENiTURN pERSONAL PROPERTY
ES7ATE OF: FILE NUMBER:
HOWARD J. HAMILTON 21 12 0078
Include Ne proceeds of IitigaGOn and the date the proceeds were received by the estate.
All propertyjointy owned vrith right ot survivorship must be disclused on Schedula F.
ITEM VALUE AT DATE
NUMBER �ESCRIPTION OF DEATH
1. Credit on HUD-1 Settlement Statement for School taxes 764.19
2. F&M Trust, Checking Acct. No. uxxx8417 3,156.37
See attached 4/26/12 F&M Trust letter documenting DecedenPs ownership and
date of death balance.
3. 1982 Pontiac Brougham, VIN# 1G2AR69AXCP636384 -soid for scrap metal 398.20
See attached invoice from Ray Craft& Sons, Inc.
4. Eastern Area School District- real estate tax rebate 500.00
5. Hospice of Central PA-repayment tor prescription meds 49.04
6. Wells Fargo- refund 15.00
7. State Farm -refund for hazard insurance 51.00
TOTAL(Also enter oo Line 5,Recapitulation) E 4 933.80
If more spece is needed,insetl additlonal sheeLs of paper of the same size
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
oernarmeNr oF aeveNUe FUNERAL EXPENSES AND
iNnEwraNCErnxReruRN ADMINISTRATIVE COSTS
RESIOENt DECEDENT
ESTATE OF FILE NUMBER
HOWARD J. HAMILTON 21 12 0078
DecedenPs debts must be repoAad on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
1. Miller-Bowersox Funeral Home-original bill plus interest charged 8,844.28
2. Pastor Joh� Good and Reverend Roger Wilmer, Jr. -stipends for Memorial Service 200.00
3. Pat Putr - harpist at Service 150.00
4. Bethel AME Church - rent of Church for Services 100.00
5. Kathy's Deli - post-funeral luncheon food 605.00
6. Pam Lute- rental of Bed and Breakfast for post-funeral luncheon 300.00
7. Fisher Florist and Staples -flowers and Programs for funeral 340.00
B. ADMWIS7RA71VE COSTS;
1. Personal Representative Commissions.
Name(s)of Personal Representative(s) BeVerly HafTlilton 2,200.OQ
StreetAddress 11 South Penn Street
ciry Shippensburq State PA ZiP 17257-1913
Year�s)Commission Paid: 2013
p, AdorneyFees: PUfC211, Krug & Haller 7,800.00
3. Family Exemptiore(If decedenCs address is not the same as claimanfs,atlach explana6on.)
Claimant
Street Address
City Sqte ZIP_,
Relationship oi Claimant to Decedent
4. ProbateFees: Register of Wills 210.00
5 AccountantFees:
6. Tax Return Preparer Fees:
7. Register of Wills -JCS, ACF,WiII & Short Certificates 59.50
8. Cumberland Law Journal -advertising 75.00
9. The Sentinel -advertising 221.40
10. Closing costs on sale of Decedent's home: realtors'commission; unpaidlfinal 14,813.44
utilities; Mortgage payoff; adjustments for taxes; transfer tax; delinquent taxes;
notary fees; wire fees, etc. (Not counting $1,900.00 escrowed to ensure filing
of Inheritance Tax Return).
11. Towing of Decedent's car 3520
12. Register of Wills-fee to file PA Inheritance Tax Return 15.00
13. Derrick Graham -yard maintenance for real estate 160.00
14. Ron Hoyson -snow removal/yard maintenance 445.00
15. City of Easton - second municipal inspection required to sell real estate 180.00
TOTAL(Also enter on Line 9,Recapitulation) S 40 555.66
B more space is needed,use additional sheeGS of paper o(the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
HOWARD J. HAMILTON 21 12 0078
Decedent's Name Page 1 File Number
Schedule H -Funeral Expenses &Administretive Costs -B7.
ITEM
NUMBER DESCRIPTION
AMOUNT
16. Beverly Hamilton - reimbursement for fax charges, postage, office supplies, food 87.62
purchases while making funeral arrangements
17. Jim Hamilton - reimbursement for mileage to travel to site of real estate to assist 124.30
Executrix with clean out of real estate (220 miles x 56.5 cents)
1B. Beverly Hamiiton - reimbursement for mileage to travel to site of real estate for 710.77
clean out of real estate and to Estate attorney's office (1,258 miles x 56.5 cents)
19. Barry Warner- reimbursement for mileage and assistance with clean out of real estate 330.75
2o. Eastern Suburban -water services for DecedenYs real estate 200.53
21. City of Easton -trash and sewer services for Decedent's real estate 317.75
22. UGI -gas services for DecedenYs real estate 483.03
23. Met-Ed -electric services for Decedent's real estate 95.90
24. J&J Heating & Plumbing, Inc. -winterization of DecedenYs real estate 240.00
25. F&M Trust-fee to issue Estate checks 26.50
26. City of Easton -first municipal inspection required to sell real estate 225.00
27. Edward Campbell - disposal of moldy furniture to market real estate 95.00
28. Berkheimer Tax Administration - real estate taxes 504.23
29. State Farm - hazard insurance on real estate 46.46
30. UGI -fee to turn on gas at real estate 314.00
SUBTOTAL SCHEDULE H•B7 3,801.84
REV-1512 EX+(12-OB)
pennsylvania SCHEDULE I
DEPARTMENiOFREVENUE DEBTS OF DECEDENT,
wNeairaNCernuReruRN MORTGAGE LIABILITIES, & LIENS
RESIDENT DECEOENT
ES7ATE OF FILE NUMBER
HOWARD J. HAMILTON 21 12 0078
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. Green Ridge Village - nursing home services 14,342.32
2. Carlisle Regional Medical Care-medical services 14.27
3. Millennium Pharmacy Systems, Inc. - prescription medications 731.20
4. Smith Radiology, Inc. - medical services �,75
5. Health Network Laboratories 38.04
6. Care First Pharmacy Services, LLC -prescription medications 550.68
7. West Shore-Chambersburg ALS/BLS 83.69
8. West Shore-Chambersburg ALS/BLS 193.85
9. Elmcroft at Shippensburg - nursing home services 2,071.68
10. Newvifle Community Ambulance 131.55
11. West Shore Emergency Medical 1,025.62
12. West Shore Emergency Medical 1,016.26
13. Fayetteville Volunteer Fire 203.00
14. Wells Fargo HELOC Acct. No. 68177536671998-monthly payments of principaU 155.00
interest paid from death to sale of real estate
15. Discover Acct. No. xxxxxxxx1732 -credit card 4,878.73
TOTAL(Also enter on Line 10,Recapitulation) E qz 489.03
ft more space is neaded,insert additional sheels ot the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
HOWARD J. HAMILTON 21 12 0078
DecedenPs Name Page 2 File Number
Schedule I - Debts of Decedent, Mortgage Liabilities, 8 Liens
ITEM
NUMBER DESCRIPTION AMOUNT
16. PA Department of Public Welfare -Medical Assistance Class 5.1 Claim 16,979.04
See attached 3/2/12 letter and enclosure from PA Department of Public Welfare
documenting its lien
17. Summit Physician Services - medical services 72.35
SUBTOTALSCHEDULEI 17,051.39
GRAND TOTAL SCHEDULE 1 5 42,489.03 .
REV-1513 F�(i(01-10)
pennsylvania SCHEDUI.E J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
HOWARD J. HAMIL70N z� �z p��g
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee�s) OF ESTATE
i TAXABLEDISTRIBUTIONS pncludeoutnghtspousaldisMbutlonsandtransfersunder
Sec.9116(a)(12).J
1. William M. Hamilton Lineal
P.O. Box 126 $1.00 - �tem 3.A.
Mercersburg, PA 17236
2. Barry Warner Collateral
1415 East 8th Street 1982 Pontiac- Item 3.B.
Bethlehem, PA 18015
3. Beverly Hamilton Collateral
11 South Penn Street 100% of residue -
Shippensburg, PA 17257-1913 Item 3.C.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPRQPRIATE.
II. NON-TAXABLE DISTRIBU710NS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 8113 FQR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OP PART II-EN7ER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S
If more space is needed,use additional sheets of paper of the same size.
IN RE: : IN THE COURT OF COMMON PLEAS
ESTATE OF HOWARD JONES HAMILTON, � ORPHANS' COURT DIV S ONLVANIA
DECEASED : NO. 21-12-0078
TABLE OFCONTENTS
1. Last Will and Testament of Howard J. Hamilton dated July 28, 2010.
2. Deed dated March 12, 1998, recorded March 12, 1998 transferring title to the Decedent.
3. HUD-1 Settlement Statement regarding sale of real estate.
4. Letter dated April 26, 2012 from F&M Trust providing date of death value and ownership
on DecedenYs account.
5. Invoice from Ray Craft & Sons, Inc. providing amount paid for 1982 Pontiac Brougham
which was sold for scrap metal.
6. Letter dated March 2, 2012 and attachments from PA Department of Public Welfare
documenting its lien.
.
.._ iT: i�i .. ..
WILL OF -�=: `= -
HOWARD J. HAMILTON - �"-' -
'� -. - -'
I, Howard J. Hamilton of Cumberland County, F'ennsylvania, -� ^ -'
declare this to be my last Will and hereby revoke all prior Wilis and
Codicils.
1. i direct that ali my just debts, funeral expenses,
gravemarker and administrative expenses shall be paid
from my residuary estate as soon as practicable after my
death.
2. I direct that all inheritance, estate, transfer, succession
and death taxes of any kind whatsoever which may be
payable by reason of my death shall be paid out of my
residuary estate.
3. I direct that my entire estate be distribute� as follows:
A. I leave $1.00 to William M. Hamilton.
B. I leave any vehicle that I own at the time of my
death to my nephew, Barry Warner.
C. I direct that the remainder of my estate go to
Beverly M. Fiamilton.
D. Should Beverly M. Hamilton predec:ease me, I
direct that my estate go to Tina Harnilton Easter
and Tiffany T. Rase, in equai shares.
4. I appoint Beverly M. Hamilton, as Executr�x of this my last
Wili.
5. The Executrix of this Will shall have the power to
distribute my estate in kind or in cash, or partly in either.
6. I direct that no Executrix acting under this Will shall be
required to enter bond in any jurisdiction: -
IN.ILV�IT�i ESS WH OF �ave hereunio set mV hand this
LnwoFF�cESOF �tL day of �/� , 2010.
TEPFIEN J. H(?GG -- �-
9 S.HANOVER SIREET � . �Y? ��
stnrE �oi Howard J. H�ton
CARLISLE,PA 17013
_�-� G ��
_ _
_.
-- __ _._ . .
, - ------- ---------
_ __.
The preceding instrument consisting of this and one other page
was on the day and date hereof signed, published and declared by
Howard J. Hamilton as and for his last Will in the presence of us, who
at his request, in his presence and in the presence of each other have
subscribed our names as witnesses hereto.
,�
I�ESS 1 � �V
WIT SS
_
_ _ _
LAW OFFiCES OF .
3TEPHEN J. IiOGG
19 S.F3ANOVER STREET
SUII'E 101
CARLISLE,Pq 17013 � �
- -- _ ^. _._.. -- .__.__._ . __ �.
-._ __.__ _.
_ _ __ . ------ - --
ACK[�[01NLEDGMENT
State of Pennsyivania
ss
County of Cumber�and
I, Howard J. Hamilton, the Testator, whose name is signed to
the attached or foregoing instrument, having been duiy qualified
according to iaw, do hereby acknowledge that I signed and executed
the instrument as my last Wili; that I signed it willingly and as my free
and voluntary act for the purposes therein expresseci.
�����o��
- Howard J, mi{ton "
Sworn to or affirmed and a nowied bef e me by Howard
.1. Hamilton the Testator, this�day of
2010. PIOTAR49l sF..�l.. ` /�
Stephen d Hogy.katary PubR� � // .
CadMie 9oro,Cu�erkohd Ca.P� E
t�aae�„� � - ���� NotaryPublic/Att e
- AFFIDAVIT
State of Pennsylvania
SS
County of Cumberland
We, e � and � , the
witnesses whose names are signed to ttie att ched or for going
' instrument, being duiy qualifted according to law, do depose and say
that we were present and saw the Testator sign and execute the
instrument as his last Wili; that the Testator signed.willingiy and
executed it as his free and voluntary act for the purposes therein
expressed; that each subscribing witness in the hearing and sight of
the Testator signed the�il as a witness; and that to the best of our
knowledge the Testator was at that time 18 or more years of age, of
sou d mind and under no constraint or undue influenr,e.
f� .� ����-�� `
----- - -- -
--- —�rn fo or , irm and subscr ed to before me by witnesses,
this � �day of ��� � .� , 2010.
F�OTA�4E.�''JE�L. �r.� �
;AWO�c�oF ��"'".�-��rrpu5�ic otaryPublic/Att nj. .
STEPHEN J. �IOG CaeRtsa B�o,C��te�tsem�co.?s�
19 S.HANOVER STRF..E -CO�'�'°f°'`�c�'�s`-��'�Stxa�ra�..24t? � .
'_____._..�. �.�.�.......w.__.....�.��..._�
SUITE 101 � � �
CARLLSLE,PA 17013 .
��l�'�ii f{t.�
DEED
THIS INDENTURE, 1�1ade the 12th day of Ivtarch in the year of our Lord one thousand
nine hundred and ninety eight (1998)
BETWEEN DEIDRE J. MARCHIONNI, Administratrix of the Estate of Louise Apgar
Hamilton, deceased, late of the City of Easton, County of Northampto�i and Commonwealth of
Pennsylvania, party of the first part
AND
HOWARD 7. HAMILTON, of the City o£Easton, Counn� of Northampton and
Commonwealth of Pennsylvania, party of the second part:
WHEREAS, EaLI H. White and Louise A. White, now lmown as Louise:Apgar Hamilton,
became in their lifetime seised as of fee of and in a certain lot and tract of land situate in fhe City
of Easton, County of Northampton and Commonwealth of Pennsylvania, known as 1048 West
Nesquehoning Street and more particularly described hereinafter; and being so thereof seised,
Eazl H. White departed this life on July 25, 1966, whereupon the said Louise A. White, now
iui^vJv71 a.i iCi11S^ .�F.'`b3i HflTrilItOII}'ei.3mZ VPStg� 1n fee Sl?11r�e 2Il 3YSCl tG �le bL�L?11SeS 11CTE1213'�.ET
described by reason of the laws relating to tenancy by the entireties.
AND WHEREAS, the said Louise A. White, now known as Loui.se Apgar Hamilton
being so thereof seised departed this life on December 18, 1947, intestate, Letters Administration
CTA on her Estate having been duly issued by the Register of Wills in and for Northampton
County on March 12, 1998, at No. 1998- 113a:c� to the said Deidre J. Marchionni, all as in and
by the records of said Register of Wills, Recourse thereunto being had, appears:
NOW THIS INllENTIJRE WITNESSETH, That the said party of the first part, for and in
consideration of the sum of One ($1.00) Dollars lawful money of the United States of America,
well and truly paid by the said party of the second part to the said party of the first part, at and
before the ensealing and delivery of these presents, the receipt whereof is hereby acknowledged,
has granted, bargained, sold, aliened, enfeoffed, released, conveyed and confirmed and by these
presents does grant, bargain, sell, alien, enfeoff, release, convey and confirm unto the said party
of the second part, their heirs and assigns.
ALL THAT CERTAIN brick house and lot of land situate on the South side of
Nesquehoning Stree.t, in t?:e �ity cf Eastor.; County of Northampton ar.d State of Pen�syIvania,
bounded and described as follows, to wit:
P��E,19�8-7,
02$ 409
BEGINNING at a point on the South side of the said Nesquehoriing Street, which point is
in a line one foot West of the West side of the brick house now or late ihe property of Sally
Shafer; +hence extending westwardly along the South side of said Nesquehoning Street, thirty-
six feet (36') to properiy of Thomas McNicholas; thence extending southwardly of that width
One hundred forty-six feet (146') in depth to Cooper Alley, bounded or.i the North by said
Nesquehoning Street, East by property now or late of Sally Shafer, South by Cooper Alley and
on the West by property of Thomas McNicholas.
ALSO KNOWN AS NORTHAMPTON COUNTY iJNIFORM PARCEL IDENTIFIER:
MAP: L9SE4D BLOCK: 9 LOT: 6
IT BEING THE SAME PREMISES Isaac L. Hosier and Ida M. Hosier, his wife, by their
Indenture dated June 30, 1961, and recorded in the Office for the Recording of Deeds in and for
Northampton County in Deed Book Volume 153, Page 160, et seq. granted and conveyed unto
Earl H. White and Louise A. White, his wife, their heirs and assigns, an.d the said Earl H. White
died on July 25, 1966, leaving to survive as his widow the said, Louise A. White, now lrnown as
Louise Apar Hamilton, as the sole owner of the fee by reason of the la��s of the Commonwealth
as to tenancies by the enrireties.
:OGETu�R wifh a:'_ a:ad singu?a*, thr: buildinas, imprnvemen?s. �voods, ways, rights, liberties,
privileges, hereditaments and appurtenances, to the same belonging, or in any wise appertaining,
and the reversion and reversions; reinainder and remainders, rents issues, and profits thereof, and
of every part and parcel thereo£
And also, all the estate, right, title, interest, property, possession, claim and demand whatsoever,
of her, the said Louise A. White, now lrnown as Louise Apgar Hamiltoxy at and immediately
before the time of her decease, both in law and equity, of the said parties of the first part, of, in,
and to the said premises, with the appurtenances, EXCEPT as aforesaid;
TO HAVE AND TO HOLD the said premises, with all and singular the appurtenances unto the
said party of the second part, his heirs and assigns, to the only proper use, benefit and behoof of
the said party of the second part, his heirs and assigns forever, EXCEPT' as aforesaid,
AND the said party of the first part, her heirs, executors and administrators, does by these
presents, covenant, grant and agree, to and with the said party of the second part, her heirs and
assigns forever, that she the said party of the first part, her heirs, have not done, committed, or
knowingly suffered to be done or committed, any act, matter or thing whatsoever, whereby the
premises hereby granted, or any part thereof, is, are, shall, or may be im:peached, charged or
incumbered, in title, charge, estate or otherwise, whatsoever.
�f p.L: 1998T1.
pAGE:
02 $4 ! 0
IN WITNESS WHEREOF, the said party of the first part to these presents has hereunto
set their hand(s) and seal(s). Dated the day and year first above written.
SIG�iET,�, S�ALED ,:NDDELIVER.ED )
IN THE PRESENJC��pF US ) '� �
�i „
� - �--,-,�ti.,A� ,
Deidre J. Marchio ',
Administratrix of the Estate of
Louise Apgar Hamilton
STATE OF PENNSYLVANIA )
) SS
COUNTY OF NORTHAMPTON )
On the �,i' day of �p�.r.G'� 1998 , before me,
the undersigned officer, personally appeared Deidre 7. Marchionni known to me (or
satisfactorily proven) to be the person whose name is subscribed to the within instrument, and
acknowledge that she executed the same for the purposes therein contained, and desired the
same might be iecorded as such.
IN WI`I'NESS WHEREOF, I hereunto set my hand and official seal.
�
The address of the within-named
Grantee is 1048 West Nesquehoning Street � Notariai Seary
Easton PA 18042- .v 3 ai� Autumn K.Hill,Nota Public
� Easton,Northampton County
My Commission Expire:s April 19,1999
RECORDED, in the for the Recording of Deeds in and for
in Deed Book No. Page �,,as° I hereDy CER7IFY maz this
- �'• �N�f�*i tl6Cilttl9tit i8 PBCGrdUd io
�:� • '�� the Rec6rder's Office oF
Witness my hand and seal of Office this day of °� `��°�Nortn�mpton Gaunty,
0
Recorder s� �.� ,-annsy��i5n�a.
,
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3.rypeotLOan '
LQFHn 2:�RN5 3.Qcom.uMns. 6, FNeN�mDer. - 7, �oenNamGe[ 8. MqiBapelreu2nceCaceNUmber.
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/lems muksd'(p,o.eJ'w�n paie eurriy�tM r.bsiny;fhey»aMan Mn brin/amre4vnelpwpoue entl a2�elAxJWeCin fM ptels,
D. Name antl Adtliecs ot B�yef. E. Name apd qddiass of Selief. . F. Nome end Mdreaa of l.entlar
Me1New T�leSCe Eclel<W HmnrC J.HamlXun Cmh ' .
GiortlanA.Televice ' vk/aHmardJone�HamYton � '
20B PhIIfP S4ret 11&Penn Strxt '
Eacton,PAt8W2 � Shlppe�66urg.PAl]2S� .
C.. ProPo�Q'LOCa�ion; . H. SelNemeq(Apent • 1.SettkmentDele:
tUGBWmiNeapueMnupSVeel Premi¢fLCnETanefarGOmpanyofPmnryNenp,LP . '
Eastoh PA 18042G335 310'I Emritic BNE.,SuN 101 � February 15,2013 �
NorthunPtonGOUnty,PannaylvyRiy 9ethlehem.PAt802P8o]'l Ph. �(BtD)993-2035
LBSE4D-4S ' wnofSetllement: -
3101EmriticBOUbvaM �
BetpkACm.pA iH020
J. Summe ofB� eYStran�aetion � K. Summ�ryoBNMYSfnewetlon '
I�O. GroaeMwuMDUehomBver: ��pp. Gfm�AmwMDUetaSelkr
i0t Con[mCSaka r'xz 41000.00 q01. �Mr de�lp niro ' ' ' di,000.00
IW. P1�conal �m ¢r p02. PYnonal �o en .
�.03. SeMemm2Char eafos�er unetapo� 2611�6 b09. ' �
16G. 4DG. ' ' '
105, - 406, �
�tl uetrnents br M�ms ald b lellar In adv�nce u�9n�MS fw H�ma Id S�IIw In aevan�e
108. C ?eWn TaXee , h �05.G oWn Tazes to
10�. GOUn io%ac to 40i.Coun TaXOS N
IOB. SGhodTe% 07/16/13 to 07A'I/'13 76C.79 4W.Sch �Taa ' 0 1 J to O]/J1I13 6�.18
109. �OG. '
110. a1 .
I11. 411.
nz. aix.
120. C.rwa Amount Oua(rom euyor aa,981.85 l20.�rosa Amaunt Dus to 9e1Nr d7,784.111
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?01_OeppaMoroamutmonr �000.00 507. FmuEe taeeinalru�tions �
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?o�. D(Ittln ben kkan aub eq to 503. Fx�tl ben s leken su ' r!Io' � '
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?�t. Coan Taw o��01n3 to 02/t6f13 SB,B9 511.Cwn Setw mN1/tJ to ov1&17 56.Bs
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?18. 516.
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The untlenipneE�ereEy b0 ipt of a mmpk�af copy ot Nh atalcnun[S eny atletlime�to he�an • ����
Buyu . . � Seller � �
c,t_eii,�i
, M q � ' '- Bcva ,yam poq xcwtN[of-�
1T+EeMS of Hv.wrd J.Hamlllnn
� ' - . eAr/s Howard Jones Hemlhon ' '
� � �Gloraen . elaso �
TO THE BEST OF MY KNOWt£DGE,THE H110.1 SETREMEHT STATEMFNT NMICH I HAVE PREPARED IS ATAUEANOAGCIIMTE ALt011NT OF TNE FIJN0.S
WHICM WERC RCCEIV[�AND tNVE EEEN OR WILL 8E OISBUrtSE�9Y TMC UNDCRSIGNE�AS PARi O�SCTREMENT QF 1HI5 TRPNSVCTION.
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01�92(2010 80:16 2026290737 PaGE 2�C�0'
MUD-1 Attachmen!
Buyer(s):MatthewTalesca , SelleKs): Estate of HoWerd J.Hamilton a/k/a
HowaM Jones Ham(Iton -
209 Phillip Street ' 11 S.Penn.Streef ' �
� �Easton,PA 186d2 Shippensburg,PA 17257 �
�GioMe�A.Telesca
209P.hI11ip,SVee1 , ' � -
Eeston�PA tB�42 �
� Lpnder,Cash -
. Setflementwgent:Prem�er Lantl Trans�erCompany of Pennaylvania,LP
(a84)895-4420 , .
P1ace of sattloment:310}Emrick Bouleverd � � ' �
. Bethlehem,PA 18D20 ' . .
Settfement[}afe:Feb(uary 45,2013 .
Property Looatlon:7048 Wast Nesquehoning Street
� 'Eas[on,PA 18042E336 ' -
. � Northampton County,Pennsylvenia � .
. L9SE4�-B-6 . � � �
AdditionalOishursementr ' .
Pay¢elDesetlption � NotelRefNo. Buyer ��Selier
Register of WiAs,Agent � � - .1;900.00
InhentBnce ta�c �
Northampton CoUnty Treasurer 26.00
movinA Pertnit � � �
Easton Suburban Wate� � 2U�.0o.
FinalWater �
Cib of EasMn ' � 38626
Current Sevmrrtrash #215960-0�
CiiyotEdsto� � � 300.00 �
ESCrow frnal Sev+er/ifa9h �
� ' 7otaf AtltlPoonal Disbursementa shown on Line 1305 ' $ � 25.00 S Z,786.26
Se{Ver Loan Payoff Detaits - ' �
, Payoff First Mortgage � to Wa11s Fargo Re:�oc671998 .
Loan PayoH 6,805.78 As ot OZ/1s/13 , �
Total Atldltional InLerest � -1 days Q k � Per Diem � �
Totai Loa�Payoff B,B20.78
� Totdl $ OAO E 0.00
� Ownera Tltle lns��ance � HORROWER SELLER
OwneYS Policy Premium � . 57�.50
to. First Amedcan Title Ins�rance Company � � .
� � � Total 5 571.5o S o.oa
WqRNING:k u�crime b Mwrin9b make f�We�hlemmb W Na Unkatl 36W on fhls ar ary Nmllar lerm. P�na16�c uqe�eonviatlon wn
induCe a fine anE NnprkorvnanL Far deblk cao:Tldo 18 U.S.Ceds 8�ction 1001 aM Srodon 1010.
� ' , - (13LV009i.PPW13LV00E1/40)
G^1/92/2010 BB:16 282629a737 FA�_ R_�q, �
ACKNOWLEDGMENT OF RECEIPT OF SETTLEMENT STATEMENT
Boyer: MatthewTelesca � . .
� Giordan A.Telesca
, Seller. Estate of Howartl J.HamiROn a1kla Howard Jones Namilton
Lentler: Cash .
. Settlement Agent: Premier Land T�ansfer Company of pennsylvania,LP
- - � (484)895-442� . . �
PlaceofSettlamant: 3totEmtickeoulevartl � �
� Bethlehem,PA 18020
SeHlement DaM: Febrvary 15,2013� . - .
Property Location= 1048 West Nesquehrning Street - .
' Easton,Pq�8042$335 .
Northampton CouMy,Pennsylvania � .
' L9SEqD-9-6
I have carefulry reviewetl the HUD-1 Settlement5tatement and to the best of my knowledge and belief,it la a Vue and
accurate statement of all receipts antl tliabureemenfs matle on my acco irt or by me in this tlansacNon. I fiirthe�certify
that f have racelved a m y of the HUD-1 SettlemPSt SWtement.
� ��hs,.'r�""�cs��^.J ,� .
. Matth Te Bevedy Hamil on,E+cecuMx of , -
. . The Estate of Howard J.Hamil�on
� a/k/a Howard Jones Hamilton
Glortlan A.. e e � �
To the best of my knowledge,the HUD-1 Settlemen[Statement which I have prepared Is a Vue and accu2te account of .
tbe funds which were received and have bers ar wifl ba tliSbU[aed the undefslgned e9 part of the 5M6ement of thls �
transaction. �
. Premier Land Tranafer Company of Pennsylvania,LP
. . � � SettiementABent . .
WARNING: It u a eMmo to knowingly meke false stabma�u to fhe unttea Sirin on thla or am/s���form.Pmettlea'upon comictton wn
include a fine apd Imprlsonmenl Far defeiK see: Tltla 1B LLS.CoGe Seetion 7001 and Saefkn 1010.
. .. . . � � USLVOOBt PFDH3LWOB7/45)
wx�w.fmh�usto��e.com
TRIJST
April 26, 2012
Purcefl, Krug & Haller
Attn: Jill M. Wineka
1719 North Front Street
Harrisburg PA 17102
RE: Howard J. Hamiiion
7o Jifl M. Wineka:
In reference to the above customer, our records show the enclosed information to be
accurate as of the date of decedents death. If I may be of any further assistance, please
contact me.
Sincerely,
�3�� �� _ ' . _
Brenda Hahn
Deposit Operations C;lerk
717-261-3668
717-264-6116 888-264-6116 P.O.Box 6010 Chambersburg,PA 17201-6010
FINAN.CfAL SOLUTIONS ... fROM PEOPLE YOU KNOW
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E1192I^<a'P aP:'.5 2926294737 PAGE 05/67
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PHII,LTFSBUItG,'NJ 08565 BETHL$I�EM, PA'. 18015 .: '
PI�: (998) f359-1990 _r' PH: (610) 86Z-1611
YAX: (908) Z13-109Q. p,A�C (610) 867-6195
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DBSCRIPTION OR�85 TARB NET PRZCB AMOUNT : '' .
#1 Cu
#2 Cn
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Insulated Cu wre
Ashy Cu Wire
Red Bzass
� Ye�l,ow Brass � �_ � �
Aluminum Cast �
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A.luminum LTBC .
A1Wniuutu Siding .
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CFC CERTTFICATE: . In.accotdauce with'Sectioit 60$ (bj(1.) anrl 608(c)of the 1990 C1eanAir A�ct;f�e
uztdersigued cert%fies that:all CFC refi-igecants have:been propezly..evacuated from.any zecyclables contained in .
thzs transaction.
I here.liy state thai I am,the law,fiil ovener of the tnateria(cleserihed hezOn,xhaR; have a rig�t to sell same;that .
all State redemQtiou mafect2l listed.is in£act valid S�fe r�demption mat tit,�nd that for payment received in
full,herebyacknQwlcdged,Isellandconvey.title'ofsamato: Ray'6,}rafl��ons;:tne. / " .
_ : ..' f�r . . --�: , -..---�
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;�� pennsylvania
DEPAFTMENT OF PUBLIC WELFARE
March 2, 2012
PURCELL KRUG & HALLER LAW OFFICES
JILL M WINEKA ESQUIRE
1719 N FRONT ST
HARRISBURG PA 17102
Re: Howard Hamilton
CIS #: 160194979
SSN: ###-.##-
Date of Death: O1/14/2012
DearAttorney Wineka:
Please be advised that the Department of Public Welfare maintains a claim in the
amount of$16.979.04 against the above-mentioned estate. This claim is for restitution of
medical assistance granted on behalf of the decedent for which the Probate Estate is now
responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective
August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the
Department's itemized statement of claim.
A portion of this medical expense, namely .00, was incurred during the last six
months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the
Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim,
namely $16.979,04, is to be entered as a priority Class 5.1 cfaim against the estate.
Please acknowledge receipt of this letter and advise whether the Commonwealth's
claim is admitted and when payment may be expected. If the estate accounting is
complete, please provide a copy. If the estate contains real estate, please provide
copies of the deed, the latest tax assessment, and a current appraisal, if available.
Sincerely,
r�,
' ,��`�l 1�-�-�..
Elizabeth M. Wilson
TPL Program Investigator
717-214-1868
717-772-6553 FAX
Enclosure
cc: Beverly Hamilton
11 S Penn St
Shippensburg PA 17257
Bureau of Vrogram Integrity � Divislon of Third Party Liability � Rerovery SecUOn
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
, COMMONWEALTHOFPENNSVLVANIA
BUREAU OF PROGRAM INTEGRIiY
DNISION OF THIRO PARTY LIA6ILITY
RECOVERY SECTION
PO BDX 8486
HARRISBURG,PA 1]tO5b486
March 1,2012
STATEMENT OF CLAIM SUMMARY
NAME Estate of HAMILTON, HOWARD �
ID 16U 194 979
MEDICAL GLASS 3 CLASS 6 TOTAL
INPATIENT .00 ,00 .00
OU7PATIENT .00 ,00 .00
LONG TERM CARE ,OU 16,33'1.50 16,33'1.50
DRUG .00 647.54 gq7.$q
REIMBURSEMENT TO DPW .00 76,979.04 '16,979.04
�, COMMONWEALTH OF PENNSYWANIA �
DEPARTMENT OF PUBLIC WELFARE
EIN- 23-6003113
Page 1 of 7
---
j COMMONWEALTH OF PENNSYLVANIA �
L DEPARTMENT OF PUBLIC WELFARE
- March 1,2012
STATEMENT OF CLAIM
NAME HAMILTON,HOWARD �
ID 160194 979
SWAiM HEALTH CENTER
210 BIG SPRING RD
NEWVILLE PA 17241
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVE�
01/21/17 - 0'I/37/1'1 10l31/11 55112994456370U01 SSN2994456370001 2,034.56 1,949.31
DIAGNQSIS 1 : V1261 PERSONAL HISTORY,PNEUMONIA�RECURREN'n
DIAGNO5IS 2: 7872 ABt30RMALITY OF GAIT
PROC CODE: 000000
O7J01/11 - 02/28l17 '10/31l11 55112994456394001 55112994456390001 5,176.88 3,631.9'I
DIAGNO5IS 1 : V1251 PERSONAL HISTORY,PNEUMONIA(RECURREN'f�
D{AGiVOSIS 2: 7812 ABNORMALIN OF GAIT
PROC CODE : DUD00�
03/01I11 - �3/31/'11 1U13'I(11 55112944456380001 SSi72994A56380001 5,733.76 4,'163.54
DIAGIJOSIS 1 : V126'1 PERSONAL HISTORY,PNEUMONIA(RECURRENT)
DIAGNOSIS 2: 7812 ABNORMALIN OF GAIT
PROC COfJE: 000000 �
04I01l11 - 04l30I11 11/07N1 551'130544039600�1 55113054403960001 5,548.80 3,2�1.43
�IAGNO515 1 : V1261 PERSONAL HISTORY, PNEUMONIA(RECURRENT)
DIAGNOSIS 2 : 2859 ANEMIA NOS
PROC CODE: 000000
65l61l11 - 05�37�1� 7'1I0711'1 55'11305-04D3880001 55113054403880001 5,733.76 3,365.31
DIAGNOSIS 7 : W 261 PERSONAL HISTORY, PNEUMONIA(RECURRENT)
DIAGNOSIS 2:� 7812 ABNORMALIN OF GAIT
PROC CODE: 000000
PROVIDER SU8 TOTAL SWAIM HEALTH CENTER � p4,p29.76 16,33'1.50
03 '1007A9468 0012
Page 2 of 7
I� COMMONWEALTH OF PENNSYLVANIA
� DEPARTMENT OF PUBLIC WELFARE
March 1,2012
STATEMENTOF ClA1M
NAME HAMILTON, HOWARD �
ID 160 194 979
MILLENNIUM PHARMACY SYSTEMS(NG
5020 RITTER RD
STE 110
MECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
0'I@'I�'11 - Dt/21111 05102/91 25110975289800001 25170975289800001 71,2q 7.5�
DIAGNOSIS 1 : 0
NDC CODE: 00487020'101 IPRAT-ALBUT U.5-3(2.5)MGl3 ML - BRONCHIAL 61LATORS
01J21�11 - Ot)2111'I OS/OZ/11 25710975291580001 25110975291580001 52.10 9.34
DIAGNOSIS 1 : 0
NDC CODE: 24208075Q06 ATROPINE'I°1 EYE DROPS - OPHTHALMIC PREPARATIONS
01/21/'11 - 0'I/21l11 OSI02111 25170975297700007 25110975291700001 17.46 2.59
DIAGNOSIS 1 : 0
NDC CODE�. 00591�24105 LORAZEPAM� MG TABLET - ATARACTiCS-TRANQUILIZERS
07/21/11 - 01I21N'I OS/02/11 25110975291860001 25110975297860007 27,9'1 5,p7
DIAGNOSIS 1 : 0
NDC COOE: 06054035244 MORPHINE SULF 100 MG15 ML SOLN - NARCOTIC ANALGESICS
01/21/1'i - Oi127117 OS/09/�1 25111015674740001 25111015674740001 80.60 13.73
DIAGNOSIS 1 : U
NDC CODE: 6'IJ'14014405 BRIMONIDINE TARTRATE 0.15%DRP - OPHTHALMIC PREPARATIONS
0'i/21/17 - 01/21111 05/09/'11 25111015676950001 251'11075676950001 'I16.52 gg.q7
DIAGNOSIS 1 : 0
NDC CODE: ODD13830304 XALATAN 0.005%EYE DROPS - OPHTHALMIC PREPARATIONS
��/22/11 - 01/22N1 05/02/�1 25110975291930001 25110975291930001 5.64 2.89
DIAC,NOSfS 1 : 0
NDC CODE: 63304062510 FUROSEMIDE 40 MG TABLET - DIURE7ICS
Ot/22/'11 - 07/22/11 OS/02/'11 25110975292020001 251'I0975292020001 5.15 2.95
DIAGiJOSIS 1 : 0
NDC CODE: 00143147510 PREDNISONE 5 MG TABLET - GLUCOCORTICOIDS
Pege 3 of 7
-
�
� COMMONWEALTH OF PENNSYLVANIA —�
DEPARTMENTOF PUBLIC WELFARE
� � March'I,2012
STATEMENT OF CLAIM
NAME HAMILTON,HOWARD �
- ID 160 194 979
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
RAECHANICSBURG PA 17055
DATE OF SERVIGE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USl1AL CHARGES AMOUNT APPROVED
01/26111 - 01/26/1'1 O5/02/1'I 25'110975292370001 . 2511U975292370001 'f35.62 11.00
DIAGNd51S 1 t �
N�C CODE: 0022829961'I 7AMSULOSIN HCL D.4 MG CAPSULE - MISCELLANEOUS
Ot126/11 - 01I26/11 OS/02111 2511U975292850001 25110975292850001 21.0'1 9.50
DIAGNOSIS 1 : 0
NDC CODE: 62175D'12837 ISOSORBIDE MN ER 30 MG TABLET - VASODILATORS CORONARY
01/28lN - D1/28/N USlU2(11 25110995292940001 25110975292940001 71.24 3.61
DfAGNOSIS 1 : 0
NDC CO�E : 00487020'I07 IPRAT-ALBUT 0.53(2.5)MGl3 ML - BRONCHIAL DILATORS
U2f01(11 - 021�1l11 OS(OZl11 251'109752932'1000'f 251109752932'10001 9D.06 10.77
DIAGNOSIS i : 0
NDC CODE: 167'14008205 HYDROXYZINE HCL 25 MG 7ABLET - ANTIHISTAMINES
02f07/11 - 02107J1� 05�02111 25170975293A9D001 25110975293490001 71.24 3.61
DIAGNOSIS 1 : 0
NDC CODE: 00487020101 IPRAT-ALBUT 0.5-3(2.5)MGl3 ML - BRONCHIAL DILA7QRS
0217'IN'1 - 02/1'1117 D5102)11 251'10975296750001 2511097529675000'I 116.52 96.07 �
DIAGNOSIS 7 : 0
NDC CODE : �0013830304 XALATAN 0.005!EYE DROPS - QPNTHAIMIC PREPARATIONS
02/16111 - 02/16/1'1 OSI02/1'1 25'110975294180001 2571097529478000'1 71.24 7.6�
DIAGNOSIS 7 : 0 �
NDC CODE: 00487020109 IPRAT-ALBUT 0.5-3(2.5)MG/3 Ml - BR�NCHIAL DILATORS
02/21/71 - 02l27/17 OS/02117 251'10975288810001 25770975288810001 80,60 14.12
DIAGNOSIS 1 : 0
NDC CODE: 61314014405 BRIMONIOINE TARTRATE 0.15°fo DRP - OPHTHALMIC PREPARA7101JS
Page 4 of 7
I COMMONWEALTH OF PENNSYLVANIA
I DEPARTMENT OF PUBUC WELFARE
March'1,20�2
STATEMENT OF CLAIM
NAME HAMILTON,HOWARD
ID 160194979
M{LLENNIUM PHARMACY SYSTEM5�NC
5020 RITTER RD
STE NO
MECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT CIATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED
02/21/11 - 02/21I71 05/02/11 25110975295310001 25'11a9752953t�001 1'16.52 96.07
DfAGNOSIS 1 t U
NDC CO�E: 00013830304 XALATAN O.D05{EYE DROPS - OPHTHALMIC PREPARATIONS
02@Sl1'I - 02/25/11 OS/02/N 25NU975288340U01 25110975268340001 7'124 7.61
DIAGIJOSIS 1 : 0
NDC CODE: DU487020101 IPRAT-ALBUT O.S3(2.5)MG/3 ML - BRONCHIAL DILATORS
02/26/71 - 0226It1 a51U211'1 25110975287770001 25110975287770001 19.46 8.87
DIAGNOSIS 5 : 0
NDC CODE: 62175012837 ISOSORBIDE MN ER 30 MG TABLET - VASODILATORS CORONARY
Q2/26(11 - a2126lit 05102l11 25170975287910001 2511097528791D001 9.47 2.54
DIAGNOSIS 1 : 0
NDC CODE: 63304062510 FUROSEMIDE 40 MG TABLET - DIURETICS �
02126I11 - 02126111 05/021'i7 25'11097528812000'1 25'110975288'120001 100.27 11.71
DIAGNOSIS 7 : 0
NDC CODE: 16714008205 HYDROXYZINE HCL 25 MG TABLET - ANTIHISTAMINES
0212611'1 - 02i26N1 051021'I1 25710975288210001 2511097528821000'1 122-98 7012
DIAGNOSIS 1 : 0
NDC CODE: 0022829961'1 TAMSULOSIN HCL 0.4 MG CAPSULE - MISCELIANEOUS
02126/1'i - 02l26/11 OS/02/77 25110975288250001 2517097528825000'1 6.07 2.94
DIAGNOSIS 1 : 0
NDC CODE : 00143147510 PREDNISONE 5 MG TABLET - GLUCOCORTICOIOS
03/04l11 - 03/04/11 OS/02l11 25110975287450001 25'110975287450007 77.24 7.61
DIAGNOSIS 7 : 0
NDC CODE: 00487020101 IPRAT-ALBUT 0.5-3(2.5)MGf3 ML - BRONCHIAl01lATORS
Page 5 of 7
�� COMMONWFALTH OF pENNSYLVANIA �
DEPARTMENT OF PUBLIC WELFARE
March ti,2012
STA7EMENT OF CLAIM
NAME HAMILTON, HOWARD �
ID '160194 979
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 1IO
MECHAWCSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED
03M4/71 - 03/14/11 05/09/1'I 25111035506380001 251'11035506380001 7124 3.89
DIAGNOSIS t �. 0
NDC CODE: 0 0487 0 201 01 IPRAT-ALBUT 0.5-3(2.5)MGl3 ML - BRONCHIAL DILATORS
03/20/11 - 03l2011'I 05/16/11 2511109539697000'I 251'17095396970001 176.52 96.07
DIAGNOSIS i �. 0 �
NDC CODE: 00013830304 XALATAN 0.005%EYE DROPS - OPHTHALMIC PREPARATIONS
03/2'1111 - 03/21I1'1 OS123/11 2511116542417000'I 251'11165424170001 71.24 3.89
DIAGNOSIS 1 : 0
NDC CODE: 00487020'10'I IPR4T-ALBUT 0.5-3(2.5)MG/3 ML - BRONCHIAL DILATORS
03/24111 - 0312411'I OS/02I1'I 25110975285230001 25110975285230001 .02 .02
DIAGNOSIS 1 : 0
NDC COpE : 00677007070 FERROUS SULFATE 325 MG TABLET - HEMATINICS 8�BLOOD C:ELL STIMULATORS
03/25/11 - 03/25111 OS/0211'1 2511097528529000'I 25110975285290001 .02 .Ot
DIAGNOSIS 7 : 0
NDC CODE: 00677007010 FERROUSSULFATE 325 MG TABLET - NEMATINICS&BLOOD C��ELL STIMULATORS
03/25/11 - 03/25I1'I 05l02I11 25110975285810001 251'10975285810001 80.60 '19.85
DIAGNOSIS � : 0
NDC CODE: 6'1314014405 BRIMONIDINE TARTRATE 0.15%DRP - OPHTHALMIC PREPARATIONS
03/29/11 - 03/29/1'I 05/02/11 25'I10975285380001 2511097528538000'I 7'1.24 7.89
DIAGNOSIS 1 : 0
NDC CODE : 004870207U7 IPRAT-ALBUT 0.53(2.5)MG/3 ML - BRONCHIAL DILA70RS
04/04!'11 - 04/04/11 O6/O6/11 251'11295649160001 2511129564916000'I 7'1.24 7.4'1
DIAGNOSIS 1 : 0
NDC CODE: 0048702010� IPRAT-ALBUT 0.5-3(2.5)MG/3 ML - BRONCHIAL DILATORS
page 6 of 7
� COMMONWEALTH OF PENNSYLVANIA
DEPARTMENTOF PUBLIC WELFARE
March 1,2012
STATEMENT O(CLAIM
NAME HAMILTON,HOWARD
ID 760194979
MiLLEN131UM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
MECHANIC58URG PA '17055
DATE OF SERV{CE PAYMENT DASE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/O6/11 - 04/06/11 OSI02/1'1 25110965479200001 251'10965479200001 'I'16.52 51.96
�IAGNOSIS t '. 0
NDC COpE�. 00013830304 XALATAN 0.405%EYE DROPS - OPHTHALMIC PREPARATIONS
04/14/11 - 04/14N'I OS/09/11 25111045294040001 251'11045294040001 7'1.24 7.41
DIAGNOSIS 1 : 0
NDC CODE: 0048702D'IDt iPRAT-ALBU7 0.53�2.5)MGl3 ML - BRONCHIAL DILATORS
� 05/31N'I - 0513'IN1 O8/15/N 25112025278120001 25712025278120001 71.24 71.41
DIAGNOSIS 1 ; 0
NDC CODE: 00467020'101 IPRAT-ALBUT 0.5-3(2.5)MGl3 ML - BRONCHIAL DILATORS
PROVIDER SUB TOTAL MILLENNIUM PHARMACY SYSTEMS INC 2,286,52 647.54
24 OQ'f887261 OOU8
Page 7 of 7