HomeMy WebLinkAbout07-09-13 � 1505610101
REV-1500 °`�°'_'°, �
PA Depaftment of RevlMl¢ '��� OFFICIAL USE ONLY
Bureau of Indivldual Taxes �+MY� Year FNe Number
ao sox zao5o� INHERITANCE TAX RETURN m � p O 7 7
Harrtsburg PA iyiz8-o6oi RESIDENT DECEDENT I
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
� � � otz �D�3v819TS �.
� DecedenYs Last Name Suffix DecedenYs First Name MI
� L � u C� cK �� �
(If Appllcable)Entar Surviving Spouse's Informatlon Below
Spouse's Last Name Sufix Spouse's First Name MI
°f'�Tf 1T1-T"TT'T"I �
Spouse's Social Security Number
r-��� THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
� REGISTER OF WILLS
FILL IN ARPROPRIATE OVALS BELOW
� 1.Original Return O 2.Supplemental Return O 3. Remainder Retum(date of death
. priorto 12-13-82)
p 4. Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Retum Required
dealh after 12-12-82)
O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust � 6. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit(date of death O 11. Election to tax under Sec.9113(A)
between 7231-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT- THIS SECiION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
eHAkc s E sH � c � � � � i 74 �6 0 09
R P I6 OF WIL�,4 USE p�iL�
Tj C_ �
?J = � � � C
First line of address r' n r `'� �
*.,. � n? � ;,-i rsi
C D u 5 E D D o �� "`" `'
Second line of address �-' C� `'�� '� � ��'�
C:
� '` 'a !—.., -- -
''
�.y DAT ED -.,�.. :;*
City or Post Otfice State ZIP Code �
CNR� N � C � l7� � 5� �'
CorteapondenPse•mafladdress: CeS���lds3�, Comcnst� hG�
Under penaltles of perjury,I declare ihat I have enamineC this retum,induding accompanying schedules and sfatements,and to tha best o(my knowledge and belief,
it is true,corcect and complete.Declaretion of Dreparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATU F PERSON RESPONSI LE FOR FILING RETURN DATE ..
,��'' d�9a- �af1P�a „ - �/e �3
ADDRESS y�o�T A'�,�CE1.4t(M d3.'tl �+e oM �, Yer��PA /97�e2.
SIXNATU PREPARER(]HJER T EF E DATE
��� y t 7 /3
ADDRESS �,/./,�QtES , f[/EG,DS d'� �O CIoUStX' Otf�� �YIP.C�((/��CS �l1'�� � I�OSS
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1505610101 1505610101 J
��
� 1505610105
REV-1500 EX p�'s Soeial SearKy Number
�,��aN�: J"ack ?. C'ellum, Tr. 1
RECnartuunoN
�a, ..� �..
t. Real Estete(Schedule A). .... .... .. ... ... ... .. ... .:. ... ... :. . .. ... ... . 1. � � � � � �' �
�III� 11
2. Staics and Bonds Srl�edule B ° I
( ) .. .. ... ... ... .. ... . ........ ... .. . .. ... . 2. I �� �
3. Closely Held Corporation,PaMership or SWaProprietorship(Schaduie C) ... .. 3. �
4. Mortgages and Notes Re�ivable(SchedWe D). . ... .. ... ... ... .. . .. . .. ... 4.
5. Cash,Bank Deposils and Miscellaneous Personal Property(Schedule E).. . .. .. 5. ` : `� � ��� �
6. JoinGy Owned Property(Schedule F) O Separale.Bil4ng Requested ..... .. 6. I '/ 7 .' ���, q
7. IMer-Vivos Tra�sfers&Miscellaneous Non-Probete�Property
(Schedule G) O Separete BNling Requested... . . . . . z ' � � D O
_-�.
. 8. Total Grou Assrts(to�l Lines 1 through 7). . .. . .. . .. . . . . . . .. . .. .. . . . . . . 8. , � $ � q 4�
9. Funeral Expenses and AdminisVative Costs(Schedule H). ... . . . .. .. . .. . .. . . 9. � •. g � 3 � � �
10. Debts of Decedent,Morlgage LiabiliGes,and Liens(Schedule i) .. .. . .. . . . ... . 10. (i ! B� .+� � �
1�. Total DedueNona(total Lines 9 and 10). .. . .. . .. . .. . . . . . . .. . .. . .. ... .. . . 17. � -'
12. Net Value W EsUte(Line 8 minus Line 11) . . . . .. . . . .. . . . . . . . . .. . .. . . . . 12 . ' O ( `. �' � :Q
13. Charitable and Govemmental Beques4s/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . . .. . .. . . . . . . :. . .. . . . . 13. -� � `� � �
14. Net Value Subjsct to Tax(Line 12 minus Line 13) . . .. .. . .. . .. . .. . . . .. . . . . 14. - " .. � � � ` Q
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABiE RATES
15. Artwunt of Line 14 taxable
at the spousal tax rate,or
transfars undar Sec.9116 �����'• ^���` �'�u *��II�
�a)�'12)X.0� � � �,II W�� � i ,,,. Q 15. . Q
16. Amount of Line 14 taxable � q
at lineal rete X.0� � , (7 .. �. � p 16. 7 ,r� � ; � Pj
� 17. Amount of Line 14 taxaWe
at sibling rate X.12 17. �
18. Amount of Line 14 tauable � t �.
at coltateral rate X.15 � � 18.
19. TAX DUE . . .. . . . .. . . . .. . .. . .. . .. . .. ... ... ..�, ... .. . .. ... ... ..... . .. 19. 7 Q� :' �.' .
20:� FILL IN THE OVAL IF YOU ARE REGUESTING A REFUND OF AN OVERPAVMENT p
Side 2
� 1505610105 15056101U5 �
REV-1500 EX Page 3 Flle NumWr pZ�'�,z.� 777
Decedent's Complete Address:
oec�Nrs rinrae
,�a ek i C''e//u�, �Tr. — ---
STREETADDRESS p Church Read
_ 770 oplar _ —
cm — C� f/%/ sTn� P� ziP �7 0�/
Tax Paymerrts and Credits:
1. Tau Due(Page 2,���,9, ��� �, �07. 3a
2. CredilslPayments
A.Prior Payments _ O
8.Discaunt O
--- Tafal Credits(A+B) (2) �
3. Inteiest
ca> s/. kz
4. If Line 2 is greater tha�tine 1 +��3,enter the dfierer�ce. This is the OVERPAYMENT. O
FNI in ov�on Page 2,Lim 20 to request a rehaid. (4) d
5. If Line 1 +Line 3 is greater than Line 2,enter ihe diflerence.This is the TAX DUE. (5) r7 i1,�� 0�
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 properly hansferred�.......................................................................................... ❑ �
b. retain the right to designale who shall use the property transferred or its income:............................................ ❑ �
c. retain a reversionary interest;or.......................................................................................................................... ❑ �
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �
2. If death occurted after Dec.12, 1982,did decedent transfer property within one year of death
witlwut receiving adequate consideration?.............................................................................................................. ❑ �
3. Did decedent own an"in hust fo�'w payable-upon-death bank account or security at his or her death?.............. ❑ �
4. Did decedent awn an individual re6rement account,annuity or other non-probate property,which
contains a beneficiary designa6on? ........................................................................................................................ ❑ �
IF THE ANSYYER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Far dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of trensfers to or for lhe use of the surviving spouse is
3 percent[72 P.S.§9116(a)(1.1)(i)1.
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 ihe surviving spouse is 0 percent
[72 P.S. §9116(a) (1.1) (ii)j. The stalute dces not exempt a transfer to a surviving spouse from tax, and the stahrtory requirements for disGosure of assets and
filing a tax retum are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or atter July 1,2000:
• The tax rate imposed on the net value of hansfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adopfive parent or a stepparent of ihe child is 0 percent[/2 P.S.§9116(a)(12)].
• The tax rete imposed on the net value of transfers to or for the use of the decedenYs lineal ber�eficiaries is 4.5 percent, except as noted in
72 P.S.§9116(12)[72 P.S.§9116(a)(1)1.
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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.
--
atu,we�.oen
SCHEDULE E
COMMOMMEALTHOFPENNSYLVANIA CASH� BANK DEPOSITS� 8o MISC. �
'""�s;�„����' PERSONAL PROPERTY
esrare oF CG//G/17. �c,� T� �I". FILE NUMBER �/-/.2— 777
Indude Me proceeds of Ifligation aM the da�the poceeds weie received Dy Ihe eshate.AA property joiMy�ovmed wkh tMe rigM of wrvNonAip must M 6aebaed on Scheduk F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
, mw�,bus /s�' �'dc.�/ Crrd;t u.nion
(�.J Sn.�:.�9s �4ce#: No. Y53/'fG-oo Soo
�8•J Ch�eK;�.� � No. HS3/y6 - // �6,s�28�
(C� Sn�: /fcen ln d.o.r�! en L1`tn�(8� ./�
�see Ya/•rad'or /G//ti� a�4rc/cd)
TOTAL(Also enter on line 5,Recapitulatim) S ��rJ�//. 16
Qf more space is nceded,insert ad�tional sheets of tha same size)
.tDef �/JO/�c ar+..—..._ . ..._
�
•
MEMBERSI"
P6DSRALCRSDTTUMON
SAVINGS ACCOUNT:
Account Number/Suffix 453746-00
Date Account Established 03/07/2012
Principal Balance at Date of Death $5.00
Accrued Interest to Date of Death $.00
Total Principal and Accrued Interest $5.00
Name of Joint Owner None
CHECKING ACCOUNT:
Account NumberlSuffix 453146-11
Date Account Esqblished 03/07/2012
Principal Balance at Date of Death $6,562.64
Accrued Interest to Date of Death $.14
Total Principal and Accrued Interest $6,562.98
Name of Joint Owner None
SAFE DEPOSIT BOX: None
M M RS 1 S'FEDERAL CREDIT U
�.�-��,- ��
Danielle A. Kline
Lending Insurance Support Specialist
August 29, 2012
Estate of: JACK T.CELLUM JR.
Date of Death:07/09l2012
Scefal Security Number: 2B3-71-7680
SOOO i,ouise Drive • P.O.Box 40 • Mechanicsburg,Pennsylvania 17055 • (800)283-2328 • wavwmembesslst.oxg
�pEy.aASIX.(n.9D .._._
SCHEDULE F
COMMONWEALTF6FPENNSYLVANU JOINTLY•OWNED PROPERTY � �
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RESIDEM DECEDEM
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l. �/!C
N an as�atwas made JoiM wlNln ons yar ottM deude�R'�dah ot desM,R musl be rcpoMetl on Selietlub G.
SURVIVING JOIN f"ENANT(5)NAME ADDRESS REUTIOHSHIP TO DECEDEM
n. Yiolat hl, Cellum p?3�/ ��n w�, Yer/�, P�l /7�iZ Mo�r
s.
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JOINTLY-0WNED PROPERN: . �
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NUMBER TENPN� J(NM �pfprjpnyy.MNA21Wak. VRlUE0FA5SEf INIEREST OECEDENI'SMTEREST
�. n. e�rca SwsSaehannQ wea►r� ma,,,Qyem�nt,
a��' �alley Fmrq� Asset /hy,r��emu�' �r�'-
�4c�A'o. .�6 8— 6 3 5 9�j
(s�� ✓n/uaf,:n ���' a�a���� �355 85198 ,�op„ %77 9.78.89
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GE US Equity I
Date #NAME?
PX HIGH 2D.OA 19.975
PX_LOW 19.91
GSK US Equily �
Date #NAME?
PX_HIGH 46.62 46.41
PX_L.OW 462
GG US Equiry
Date #NAME?
PX HIGH 38 37.545
PX LOW 37.09
INTC US Equily
Date #NAME7
PX_HIGH 2621 26.01
PX_LOW 25.81
JNJ US Equity
Date #NAME7
PX_HIGH 67.96 67.795
PX LOW 67.63
KMI US Equity /
Date #NAME7 . �
PX HIGH 33.01 32.7 V
PX_LOW 32.39
KFT US Equity
Date #NAME?
PX_HIGH 39.05 38.92125
PX LOW 35.7925
MRK US Equity
Date #NAME?
PX HIGH 4226 47.B95
PX LOW 47.53
MSFT US Equiry
Date #NAME?
PX_HIGH 3023 30.005
PX_LOW 29.76
NEM US Equity
Date itNAME?
PX HIGH 48.09 47.74
PX LOW 47.39
PAYX US Equity /
Date #NAME? /
PX NIGH 31.5 31.275 v
PX_LOW 31,05
PEP US Equiry
Date #NAME?
PX HIGH 90.43 70.06
PX_LOW 69.69
PFE US Equity
Date #NAME1
PX_HIGH 22.68 22.565
PX_LOW 22.45
PG US Equity
Date #NAME?
PX HIGH 61.8 61.46
PX_LOW 61.72
SW US Equity
Date #NAME?
PX HICsH 29.3 29.065
PX LOW 28.63
TRI US Equiry
Date 1FNAME?
PX HIC�H 28.73 28.315
PX_LOW 27.9
TRP US Equity
Date #NAME?
PX_HIGH 42.52 4227
PX LOW 42.D2
TRV US Equity
Date #NAME?
PX HIGH 63.5 63.245
PX_LOW B2.99
VZ US Equiry
Date #NAME?
PX HIGH 44.75 44.57
PX LOW 44.4
VOD US Equity
Date #NAME?
PX_HfGH 28.39 28.25
PX LOW 28.11
WAG US Equity
Date #NAME?
PX_HIOH 29.78 29.555 �
PX_LOW 29.35
WM US Equily
Date #NAME?
PX HIGH 33.76 33.005
PX_LOW 32.65
IAU US Equiry
Date #NAME?
PX_HIGH 15.52 15.46
PX_LOW 15.4
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. .__._.. ___.___.. . . . . _ _ ._ .._ . . .
_ . _
� REV t5t1 EX+(i0-O6) � � � � � �
SCNEDULE N �
COMMONWEALTH OF PENNSYLVANIA fUNERAL EXPENSES & �
INHERI7ANCETAXRETURN , ADM�NISTRATNE COSTS . � �
- � RESIDENT�ECEDENT � �
ESTATEOF CG�'U!)�� .7ac.k T,, T� FlLENUMBER
2�-/Z ^777
Debta of decedent must he reported on Schedule L
ITEM
NUMBEfl DESCFIPTION � AMOUNT
n. FUNERAL EJ(PENSES �
, G,lbert L. 2}x�'ltj. Fwnun/ Noinc , e� flair:s6K.�. PA �/, BC�S.°Q
e. ADMINISTRATIVE C0.STS:
i. Personal Represenfe6va's Commissbns �
Name of Persmal RepreSentative�s) V/O�G/ /}7 (.,el��(,/J �a�VC�
Street Address _
c�ry sca�e np
Year(s�Commission Paid:
2. Alromey Fces l///4�Li$ F• c���E��S � FS� '� bOffi�M .T�11fM FS'F. f6 D�.��
. � �4f 4 dIS�AI}' '6CI�ip� �
3. Famity Exemption:(If decedenYS address is not�he same as GaimanCs,et1aM eaplenaeon)
claimant A�I A►/� �L/G/aLE /YDA�E
Stree[Address
� City � Shate Zp
Rela6anship of Claimant ro Decedent
4. Probate Fees p,�t[� mryQ�Ilp� 1 SSNG O'� ��pl�/ C.t/`11 l��Co-�CS. f 7!f SD
J
5. AccountanYs Fees � t�0!/O ��qF.SJf/!�� � /1cGr/Cw/ � 4dV/l.�S /'6: p.
6. Taic Retum Preparer's Fees ����� ��i 7D1�'/1Cr 7M�CSj�- . ����
� i4dYC��sin' �n Cu.n,bur�1 � �ourna) t7S.�
fG f}dver��'s:n1 %� Carl;�k o�i'tb'nel Ntu,tsPa.p+,/' f/J�7.OG
9. �,%n� Fec {o vieg:JJ�C/' ef .w.%/s /S,oD
lo. f�dd:�i"ona� �vro6a�e��it► {o �t9"sk�- s fi!.�/i%/s ¢/S. o0
TOTAL(Also enter on line 9,Recapituletion) $ �, �3/, Sb
(H more space is needed,'xisert addilional sheets of Me same size)
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH Receipt Date: 7/17/2012
Cumberland County - Register Of Wills Receipt Time: 12 :13 : 56
One Courthouse Square Receipt No. : 1070651
Carlisle, PA 17613
CELLUM JACK T
Estate File No. : 2012-00777
Paid By Remarks: CHARLES E SHIELDS III
DMB
------------- ----------- Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS ADM 30. 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 16. 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5. 00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check# 2815 $74 .50
Total Received. . . . . . . . . $74 .50
_
�.u� ✓TrackYOUr 1�0 2 I
°�`� �����OAUtaTravel ExPenaes... ' ... i
- " � ❑&uinea ❑Ed�retion p�.1eSieaUDenlal
� � .❑CheMiea ❑Entertainment p SeN�pg . .
❑Cblhilg �F� �Teze3 � /�
.. ODeprntlenFCere Olnw�a�e OOCier - .. �jf��' �(, ( ,. I .
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� � \i.1� 1 } � , ���0 .
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� , {y"�..�"�,/���� p � 1 . �O \1__0 "
. l '_ " ��(� '�C ��-I�IAVIA„�A. ,f�' L.�I�NIANLf � � �
TAX DE oEnoett I
. � �❑ WCTIBIE REM � � .
`! raxo
V�e.�j ,
.lemo ` I .i..
s}
Fof enh3r�gp sec�nty yar accpunt numb¢r will nW ya . �
_ � � �M�°��� NOT NEGOTL4BLE � �
__ i
� (Deeaipuoni . ..
,e
,o
Ouoe�6urid mnraim .............. S_ � .�
GI�BERT I,.DAILEY FUNERAI,HOME,INC. :
"CJui�irtg Yaur 1Nay» _
� Marios BW�.F.D. Timo�)�ry.FD.
i�
650 S.28W Slree4 Harrisburp,PA 17103 • 717-233-1933
STATEMLNT OF FUNERAL GOOD6 AND SERVICES SELECTED
(]iv`s ee«iM(ar dns Imn Ju�ve ued.I(vs ve mWirtd M 6v m we m7�ain.�.e wN o�lYn In witln[hebw. �
B vw�elevad�fiviad vhirh�.Rmm mih�Min(.wrA r�fimml Wd�vkWni.1'a+m�Y Me m WP fa m�6Wq.Yau do noc hrve m
��far Ya dW nx�vP��'vai�elamd vr wrh r�dirxc amutlon u Imm�dm�bWd%we du'oed fa
�,..Mw�,.,�c/z 1'�fl' �, "�'- 9- �2
Fw tFc 9ecrke d iJ_.n ) D.a d De.d. -
n n /
cbns�«�ii,f�6-� //� ' �fx4 -; >'o.�� �i�. ,- �OPK�' /%'�.%�)J�J
Nurc � � Md'va Gry � . � $utt
A CHARGE POR SERVICE3 SELF%:IEDe Od�cluLi�p
1. Pm(aaeimd s«vics � f_
SmtimsoFPurerdDimctad5taff S — - 5—
F�o6alaing S _ Gw�timum..:...�................ E_
Olk'PRP�tlion of body ���� .
Come�dop'.drevsiv6 aod cslxting j —� . .
SwIQP cre vM1m embalming ia mt d«ted- j -_ mxER
Ueecivg md ptecioF in wsket w 5 �_� f—
dtemetive wotuner mly ' � f_
SUBTO'I'ALOFPROP696NALSFAVICES .. y _ S_
� TO'CAI.[�4.7tCFiAP1D19ESE1.P.G'IFD........... i—
2. F.dfian md eyuipme`K
Uee of(etllitlu fur WcW�g C SPECW.CHARC:E4�
Muwion/W�kc).................. S— Favyd�qpfree,unm �
Uadf.o6aa(ar(umel S_ . .HOKt. ts'e'r.al.�;v S%?�-.`�'"'
.. @��r..... �wd Hane) �
Ua d�dnriwe�uve meay rarytf?n
artumd+a*nF^�<<wnu......... S_ Necevi�YO(rmui�ufiwn ,
IhcdAtpv�tionroom.............. y�_ - ` S—
Ocha uee d 6o1itie � - ff�M+d Hamc)
� Mned'uaeBmW.:...........:...... $_
. � � DI.eaC�mutlon ................... f_ .
............ f— S—
...................... SUBTOTALOFSPECIALC71MGE4 ......... 3_
SUB'R71'ALOFFAmIi�3lEQU@A4+NI... y_ .
l. AVIOMOTNEES2UIP�ffi7C D.CASHADVANCED
Vdtide�o aPro�remain m Fv�vd Hmw. ��N Cnve..................... f_
lud.............................. 5_ �r�amen� ................ f_
Heuse(Cd�aCarN . LamdDad....................... $_
IucJ............_................ S_ �NoucaLool......�....... S—
linawiM NCnp�pvNmlmOutaf•Tow�....... S_
funl.............................. S_ Tekphane&T�m.............. f_
FsmilY nr - � A4fne............................ 5_
lanl.............................. f_ . �{�/Mu�ORer6f................ f_
� Ebwa cr ov flard dqwfuon �. •.`•.••..•••.•••...:•.••. p o
loul.............................. 9— � CatlBedCadnddnRad�CadMrz. 9� �
lod�/de�ar . ' . . . � PoliceExm[......................�... f_
[nc.l.............................. f�. � Fbwv.....................,....... i_
.....�...... f�,a
Gr fo�vdlbrnrn � - . ��C(9� ...,J .
IncY.............................. i_ � 5_
Ouodwvna�npantla+ ............5_ . f—
5—
s— i—
SUB'[O'IAI.OFAIJl'OM011VEYQl7@AtPX� f_ � t—
S_
10TALOFPROFESB[ONAL�tVIC&4. � SUBTO'[ALOPADVANCSS................. S_
PACW'llffi AND AiT1T3M(ri7VE -
p4i1�Nr................................ 5_ SUMMAAYOPCHARGES
� A PiotadaW Svwcs,FMlitle ud ' ,, ,, n
� &CHARGE POR MERCfiANDI�BFLECIER EpJqom4�nd AwaoalveEpWV�+K... f.�✓�"
Crka ............................ i_ � &Med�mdle�..........:............... S �8"
lDuciPtlmJ . G�Chw�+ .... � ... S�°o
o ��
� . �D.CW�AMrrrs � ...... � .r• S ��f o0
' � Oahd Rmyuc4 ...�.... t........ f_ • . +� . . t 1VIN.�'All.SBtECiLODA- r. .:........... S.L_iL�' o J '.
�W� PAID AT Tlbffi OP'OR PRIOR 7'O
Qrter6�Wmrcaim ......... . ARRATi(i@.ffidlS..n. .... . . .. 5���
...... S— BALANCEDUE ...�..1��_.... S J����a! �^
. �av�vdoN - ,
. . REA,90N PDR L'A �LMING . ,.
Adonvk�eme hr3.............. S_ Y Ir.cmemv,a vvo�av�equtr � e�e�d�ad d�e q
Red�mboo4(0..................... S_ � .qu6merb •�p /Z
MmuY fdde�..................... S— ������d the Irmn Wmd�bne Irv oc /
Pr•vv rrb........................ S— .
7emperv�a�vemckc....:......... S_
Bu6ldairin...._................ S_ .
I MeMq�thn I lrve auoirod tM�6ae a�d imn ad(w�d�Mn w be tmat ud�a6�dlni ro�Fe u'urmin�R�d md I
hveb��rlmowi��1P�d.�mpr d di meouWm md,iW++er.1 hehY n'P�d�u 1 Me a�cfer rea I�Y mW64(or
v�r�n v�ud nve07�md�+Ivrc1Y i�d s.mlh m m.ke wrmnr of S .�Wtiv � dq. �
n La dry�d va�mdi.owntlns m pc ya 4.ppGd m dx u�tld s.lucc bed�w�s �d�n fmm rhe
dMe d d�b y'm�+c AnY d3dad aMm ar mv�Avd�s udvad a�a�td�ha d�e dYe d dti�y'e�ent w�11 h mYidad pvt d
d�b �d�emttp diee�L*�6 h�rt�d m dm Bmi moeov�[.
(Sep�... f a.>�1_r r. y' : - o
�)
�)
e._...�......v._..w.w�..�) am r,�o���—a�f�lS,'
REV4512 EX�(12-03)
SCNEDULE 1
con�roiorvw�uni oF aEnursvtvnnw DEBTS OF DECEDENT,
INHERITANCETAXRENRN MORTGAGE LIABIUTIES & LIENS
RESIDEN(DECEDEM �
ESTATE OF /► G�l u/YI� �T'R[.� T. � FILE NUMBER
l• o�-!^ /2-777
Report daDts ineurtad by the daeeAeM prior to daath whieh nmafned unpaitl as M Me dab of death,fnelud{ng unnfmbursed m�dkal expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
�. �-lslY J'p;r;t f(c,sP.fo l �33..zS
a, k/est <Shore �� L'.e// � i2/i7�3A �97o. 8z
�. Wesf �ho�z �mS C'a!l ,# /�/l7 �5� ".S�S.oS
y L•�'i�inc �iYaray�s ' {.�eS �{� ivkrs,;�fl.nre �II�:'ca;d
P/.�n.�:�, /�.c/�ar.tirS'on af'�ua�;ans�i.p ��rSbn, irv:r..�
a� /rlalftrs oF :nhc.v�rtnee. //��`'u��ib/�,l�is,�a 6� /.a,:r9
S/�/G/�i �/R/$en G✓/�'I lll�i/19 S/S� //� /�4,��_
/
/�. �lta�lis E. Sl�ial� �t' !�, �7�. °O
4. sfz.zn fl�yy �z��.��
C. l7cw.i/ it/ssd.t , Kr�.srSx �/o�er L�..� '`97s,•o
� 1Yo y �irif �/o.�y:�a/ f2o.yS
�. Go/./cn �ir:nq �u►ttr � /,()est' Shore t� J�O, /D
7. p:nnacle �ltalf� �os p��'o/s ' �/•f,�z,
S'. �l�Rr/ylerica �/, /!�S9
p �QSt �G/lns6d'o /ff/h{1u.�a.wca �•iL� �]8, J7
!o. Quantp�„ �ma��n� t %�'4/Jewfi� �s�es. ¢a. �o
rl. /�l Op�'ons e� Ptn�s�/ra.ua `jns. BG
�a. Nea�fh A��v� f�:a�-t. �'65/oa
/3. �p /%%/ C�G�u y l%ys:C.a n s ¢�f D.o0
/
l`� C�JGCI�C 'fo J�li �/I1ark '�r' �ltal�i insuranca Pltmi
wr�ite�, beSorz �.v.d. e,�, l�C.a�t: at /neinbc+� kt ,EderR/
CPPsl� f C�n�on �n Seh�d E� N'h,�ch G�lt�Xs✓t�1� d.o-d. ��83.a0
TOTAL(Also enter on iine 10,RecapiNlation) S �� J O�. ��
Qf mme space is needed,inurt addNOnal sheels of ihe same size)
Haly Spirit Hosaital
503 H7ortb 21'�Street • Camp Hill,PA 17011 • (800)596-9947
June 25,2012
Your Accuaat WitL: Hoiy Sperit Hospitai
Account#: 42558189
For: Jack Caltum Jr �
Admission date: 45t24/t2
Total Due: 533.25
Uear]ack Cellum Jr:
This Ietter is to folEow up the above refere�ed uisit to Hoty Spirit Hospital. t7ur records indicate thst there is an
outstanding balance remaining on this aecount. Please remik payment in full upan receipt of this letter.
]t has always besn the coniinaing gaal af Holy Spirit Hospital to serve the community as a fuii service heatth cace
facility from the time of a patienPs initiat care thraugh the accounYs final resolution. tf you have any questions
re�;arding this account, please feel free to call this office at 1-800-546-9997 and speak with one of aur
representatives.
Thank you for choosing Holy Spirit Haspital and for resolving this outstanding balance promptly. To assure
proper application of your payment,ptease attach the bottom portian of this letter te it If you wish to pay by
credit card,please complete the required infarmatian on the reverse side ofthis Ietter. if yau have insurance tfiat
may pay all or a portion of this debt,please complete the information on the revcrse side of this Ietter and return
the entire letter. Psyment can also be made nnline at www.hsh.ore.
Sincerely,
Hoiy Spirit Hospitat
iormauoenr
.t�"Dda�7�E.uwar Pation AM Rdum WitA tMymwu•••
Accaunt8: 42558}84
Totai Due: 533.25
ONFIRIIO
PO Bwc 1022
Wixaq MI d8393-t022
)Eme 25,24i 2
Hdy Spirtt HospilN
PO Box 822181 � .
425561$9-19t 8f6t73862 P6ilsdelp6ia PA 19182-2I83 -
�t1��I���I�is�������I�1�f�e�h�1�h��f�FI����t��.i�,}ni.�lli11�� �������eEe�����1�.��r��{���������i���n��i�����s�{r������f�s�)
leokCellumlr � � . . ,
4$31 E Trindle Rd �
MxhaniuburgPA )7tl50-3618
OQ004255�189�0100DC{D06332500�OD73517000�fl013304
��'t 205 GRANQVlEW AYE ' ' '°`xo"fR
ti�; CAA4P NI�L, PA 17411-470$ � �_ �,�.. -----
`��T���T ��O r� Phone#: (800) 367-0512 Federal Tax ID: 23-2463002 oN R�ase sio�
i_;h-9�7 ' i'ar. ,� _.�., _.,
PATlEN'FNAME: JACKCELLUM iNSURANGE: HIGHMAF2K HIGHNUN
EHGM
cau.NuMSea: 'f 211783A onre oF cnu: o7ro212o�2
fFiOM: 770 POPLftFt Ctii1F2CH RD
To: HQLY SPIRIT HOSPITAL
JACIC CEitUM -` ±��I�'I'�If��i1ARY� �� � Y
%MELINDABIXLER TOTALCHqRGES: 970.82 �
4837 E TRINDLE Rp PAYMENTgJpp�USTM�NTS. ff.fl0
MECFtANiC56URG,PA i7055 PIEASE AAY THtS AMpUlIT: $70.82
vEracrracarucnFrrxaaaaaxavr�xervaxsrus werxa,anuErvr
. . ___.._ ---_ ___. _..
� � DESCRIPTION�.OF CHARGE �� . �QUANTf7V �WNR'�pR1�E�� � � AMOUM
ALS EMERGENCY LEVEL t 50207 i.Q 967.62 967.62
EK�ELECTR4DES(t} A0398 4.0 4.84 ��2�
Totat Cha�rges 970.82�
�. DESC�RIfR70N.OFPAYN{ENT� � RECEIPY �PAYMEA7.BATE . . . AUIOIlNT
ToFa!Ctedtts Q.00
PLEASE PAY TMIS AMOUNT-INVOICE DUE UPON RECEIPT —► S97p:82
RETURWED CHECK FEE-$31.00
�ar�rrrru�eae CELtUM,..t�ncK �;�; 12'!1'783A aMaurrrrnsr. .
� � � � . 0?1l1120Y� -
IMP4RTANT MESSAGES: A clafm for this involce has been sent!o your insurenca.
Payment may be made ta you.Piease remif paymant to as.
Thank you.
WEST SHQRE EMS-ALS 2p5 GRANpVIEW AVE CAMP Hiti„PA 17011-1708
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��-�`� 205 GRANDVlEW AVE SUtTE 219 � 3_� � �
��? CAMP HtLI, PA 17d11-170$ �
�� Phone#: (800) 367-0512 Federai Tax Id: 23-2463002 ON pEVERSES�DE
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PATIENTNAME JACKCBLLUM �NSUn�wce: HIGHMARK HIGHNpN
EHGM
GAF.1.NUMBEFt 1211?$9R BA�pp�p{y- 07/0312412
FROM: HOLY SPIRlT H6SP1T11L
� TO: �G4LDEN IIVING
JaCK CELLUM ���������
%MELINDA BIXLER TOTAL CHAR6E3: 505.05
463t E TRtNDlE RD - ppyM���g�E�� 0.00
MECFfAN1CSBURG�PA 17055 pLEASE PAY THIS AMOUNT: ��'��
._ ....DFTACX AtONCa PERFORATtON AND RETURN STUBWl7H PAYMENT
,. _.. . _ .. _ _ _... .. .. . . . _ . . _ . . . . .._. . . .
DESCRlPTION OF GMAA6E ��:�.: . . �QUAN'f ITY .UNR PRICE � . � AMOIJNT �
BLS NON EMERC,ENCY A0428 t.0 497.18 � 487.1$
BlS MILEAGE A042fi 0.5 13.73 fi-$7
INF CON'1`ROL GLOVES(PR) A0382 1.0 1.00 1.00
Total Charges 505A5
. 6ESGKtIP"llOtt#.f�AYNIENi � � � .�RECEIPT PAYMEMI`aAiE �XM()UC#T �
T�Cradits Q00
PLEASE PAY THtS AMOUNT-INVOICE DUE UPON RECEIPT —► 5505.05
RE7URElED GHEGK FEE-$31.00
PiaT1ENT N,UAE: GEl.LUM,JAGK���. . � cAi.t:»utNBER: 1�2117$$R A��� -. _ � .
07f1 tl2Ul2
IMPORTANT MESSAGES: A claim for this invoice has been sent to your insuranca.
Payment may be made ta you. Ptease remit paymerrt to as.
Thank you.
WEST 3HORE EMS-BLS 205 GRAtJDV1EW AVE SUITE 211 CAMP HILL,PA 17011-1706
� REV'd513EX+l,11-OB? � . � �� � � . .
�pennsy[vanea SCHEDULE J �
DEPRRTMENt pF REVENUE �
,NNeurnr�ran nt�uwv BENEFICIARIE$
RESIOENF i�CEDEtii
ESTATE OF FILE NUMBER
Ge lt u,rrt� �GGk 7� .�r. �af-l2�777
� aEUn��e ia oc�r� n�uwnr oR�
- NUMBER NAF1E AND ADDRESS OF�RS4N(5}RECEMNG PAOPEATY Do Not Ltst Tructee(sj DF EStATE
I TAXABLE DISITUBUTIONS([nelude outright spouul distributions and transFers under
Sec.2115(a)(1.2).] .
�. Yiole.t Jt1, G'ellu�rt rico{�..- lao�o
ai31�1 Fracdwn ttM►�',yerk, �o�r4 /'lY��.
!
ENTER D4ttAR MqUNT5 fqR DLSiRiBUTI6NS SM{7WN A80VE Ot{11NE5 k5 FNROUfiH IB Of REV-SSO4 COVER SHEE(,AS APAROPRTATE.
n �NON TAXpBtE DtS�RTBUitCINS:
A. SPOUSAL DIS7RIBUTIONS UNDFR 5EC710N 2113 FpR WHICH AN ELECTION Tp TAl(IS NO7 TqKEN
1.
� 9. CHARII`ABLE AND GOVERNMENTAL DISTRIBUTIDNS . -
l.
TDTAL OF PART II-ENTER TOTAL N4N TAXABLE DIS7RIRUTIDNS ON 13NE 13 OF REV-I506 COVER SHEEf. s
� If ma�e space is needed,insert additional sheets of the same size. �
I
CHARLES E. SHIELDS, III
ATTORNEY-AT-L1W
6 CLOUSER ROAD
Comer of Trindle and Clouser Roads
MECHANICSBURG,PA 17055
GEORGE M.HOUCK TELEPHONE (717) 766-0209
(19121991) PAX (717) 795-7473
July 5, 2013
Register of Wills
Cumberland County Court House
I Courthouse Square
Cazlisle, PA 17013
Re: Estate of Jack T.Cellum
No.21-12-0'777
Deaz Register of Wills:
; Please find enclosed for filing 2 copies of the Inheritance Taa� Return for the Raymond E.
Wall Estate as well as Check No. 208 in the amount of$15.00 for additional probate, Check No.
• 209 in the amount of$15.00 far the filing fee and Check No. 212 in the amount of$7,258.80 for
the Inheritance Ta3c due.
Thank you for yuur kind attention to this matter.
Very truly yours, �—
�����E�u�
Chazles E. Shields. III
Attorney-At-Law c �.; rn rn
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