HomeMy WebLinkAbout07-16-13 (2) J lsasb�av��
REV-1500 Ex'o,.'o, `�'
OFfICIAL U$E ONLY
PA DepaRment af Aevenue Pennsylvania �ounty Cotle Year Pile Niunber
SureauofSnd�viduatTaxes `�"�'� jNHER1TANGETAXRETURN
�soXZeo6o� �{ 13 5 3�]
Harrisbura,PA i7iz8-o6oi RESIDENT DECEDENT
ENTER OELEDENT INFORMpTION BELOW '
Social Security Number Date of Death MMOOYYYY Date of 8irth t�MDDYYVY '
04N 8/20i 3 11/21/1916
DecedenPs Last Name Suffix Decedeni's First Name MI
Wilson Edna H
(If Applicable)Enter Surviving Spouse'a Information Below �
Spouse's Last Name Su%ix Spouse's First Name MI I
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spouse's Socia�Securiry Number THIS RETURN MU$T BE FILED IN DUPLICATE WITH THE , '�
REGISTER dF WI�.�S i
FlLL IN APPROPRIATE OVALS BELOW i
� 1. Original Rewrn p 2. SupplOmental Retum O 3. Remainder Return(date of de8th ��
priorto 72-13-$2) i
p 4.limftetl Estate p §a.Future intarest Compromise{date of p 6. FBtlerai�Estate Tax Return Requiretl
death aRer12-12-82) i
m B. Decedent pled Testate p 7.Deoedent Maintained a Living Trust d 8. Tntal Number of Safe Depqsit Boxes
{Attach CoRy af Will) {Attach Copy of Tnist) ;
O 9.liGgation Proteeds Received O t 0.Spausai Poverty Ge�t(dete qf death O 11. Eiection to i2�c under Sec.9113(A}
ec
behveen 1231•91 entl t-i-95) (Atiacfi Sch.O) j
CORRESPONDENT- 7HIS SECTION MU37 BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORI�?ION SHOU�p � ECTi�T� I
Narz�e Daydrt�Ta�phone Num�er I'et n
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Mark W. Aiishouse, Esq. (717�8'��4A06 ^ � � !
. ... . . _ _ . . . . .. . . . .. . �E' q�9RDF V�1}S US� p II
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�"' � � Ljp �
First line of addrese � � G' � � � I
. ... . .. C7 O -r. '
... . . . .. . .. . �,.. T
4833 Spring Road ; � � ` I�
N ^- C� i
� N � i�7 I
Second Iine of address � ��„ p U3 O i
OATE pILfO i
Cdy or Post Office . .. . . . . . .. .. . .State . ..ZIP Code -
Sherrnans Dale PA 17090 ;
comaspanaent�s e.mais adaress: mark�christianlawyersolutians.com �
Under penalties of pa�ury,I declare thal I have examinetl ihis return,induding accomDanying achedules antl stetemenls,entl to the bast of my knowledge and beliel, '�,,
it is tme,correct and cqmplele.Declgretion of preperer other Man tl:e perwnal representative is based on all informatlon oi which preparer has any knowledga '�,
�SiGNAtU Of PERSON ftESFONSi E PQR fiiiNG RETURN DATE i
�,.a �f? �ct.a.�t�� '�'li�- `�3 I
ADDRES (
3 Carkon Lace Circle, Carlisle, PA 17015 I
SIG TURE F EPA E THAN REPRESENTATNE �
(
DRESS
833 Spring Road, She ans Dale, PA 17p$0
� PLEAS�UEE ORIGfNAL FORM 6NLY
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Sid@ 7 !
� ]�5C156101�1 15Ct56101C11 J
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J 15056101�5
REV-'IS66 EX
6ecedenk's Saciai Security Num6er
oecedenrs rvsme: Edna W.WilsOn '
RECAPtTUTATiON �
1. Real EsWte(Schedule A). ..... .. . .. ... ... .. .. ... ... .... .. . .. . .... . .. . t. 0.00 ,:
2. Stocks and 6orHis�ScheduVe e} ....................................... 2. _ .. .. . . . 72$�544.28
3. Closely Held Corporetion,Partnership or Sole-Proprietorship(Schedule Cy ., ... 3, 0.40 �:.
A. Mortgages and Notes fteceivable(Schetlule D).. ......................... 4. 0.00 ..'�,.
5. Cash,Bank Deposits and Misceilaneous Personal Property(Sahedule E)....... 5. 4,722.16 ,,�
&. Jointly Owned Praperty(Schedule P) O Separate Silling ftequested ....... 6. Q.00 �
7. lnter-V'rvas Transfers 8 Miscelianeous NwrProbate Property �'
(Schedule G) O Seperate Billirg Requesied..... ._ 7, 0.00 �j
8. Total Grosa Assets{tqtel Lines 1 through 7}.................._....._... 8. 7$Z��66.44 ��'���..
9. Funerel Expenses and Administrative Costs(Schedule H). ... .... .. . ....... . 9. 38,�73.78 ;
70. De6ts of Decetlent,Mortgage liablikfes,antl Liens{Schedule I).............. 10. 13,G87.44 �'��I_
it. 7otal Oedudions Ifotai Lines 9arM'f0).... . ........... ............. .... 11. $Or461.22 ,�
12. Net Valus oT Estate(line 8 minus Line 17)..................._......... 12. fiS�C,305.22 �.'''..
�3. Charitable and Govammentat 8equeststSec S'113 Trusts for which . ... . .... . . .... ....... ,.
an election to tax has nof been made(Schedule Jj . . .. ... ......._. ....... t3. � Q.OQ ;
14. Net Yalue Subject to Tax(Line 12 minus Line 73) ........................ 14. 68Z,$05.22 '�
TAX CAtCULA7ION-SEE 1NSTRUGTfON3 F4R APPLIGABtE RATES �
15. Amount of I.ine 14 taxable !
atthe spousaltax rate,or '�.
transters a�tler Sec.9116 �
(a}(t2)x.0_ 4.OQ t5. 0.40
i6. Amount of Line 14 tazable �
at linea�rate x.0 4y`� 682,305,22 7�, 30,70373 ',
i l. Amount of line 14 taXable ... .. . .. .. . . . . . . . ... . . ... . ...... �.,.
at sibiirrg rate X.12 ,,. a.ao
18. Amount of Line 14 taxable ..... . .. .. . ..... .. . . .. . .. . . ...... . .. .0.00 ��;
at collaterel rete X.15 18. ��,
1$. TAX DUE.......................__..................._.......... 19. . .. _ . . . .3O�143.73 ':
2p. �ILL IN THE OVAt IF YOU ARE REQUESTINd R REPUND OF AN OYERPAYMENT O
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Side 2
� L5i]561Clyfl5 150563�[I105 �
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REV-15�0 EX Page 3 Flie NYmher
Decedent's Gamplete Address:
DEQEDENT'S NAME
Edna H. Wilson
STREETA06RESS �
3 Cariton Lace Circie
CtTY - ----- - STATE ZIP -.
Carlisle PA i�d�5
Taac Payments and Credits:
7. Tax Due(Page Z,Line 19) (i) 3d,703.73I
2. Credits/Payments � �
R.Pnor Payments ---.._...�-----._.�__.�.--- �
e.Discount 1,616=32 1,618.3�
-----------_........---------- Total Credits(A+6} (2} ^...
3. Interest �
{3) � 0.0
& I{�ine 2 is greater than Line 1+li�3,enter�e diHerence. 'ihis is ine OVERPAYAiENT.
fiii in ovai on Page 2,Line 28 to request a refund. (4} 4.0
5. IP Line t+Llne 3 is greater khan Line 2,enter the diHerence.This is the TAl(DUE. (5) � 29,087.4
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Make check payabEe to; REGlSTER OF WI��S,AGENT. �
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PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS I
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t. Did decedent make a transfer and: Yes No �
a. retain the use or income of the prnperty tranaferred:......................._.....,..,..........................................,,.........._ [] � I
b. retain the right to designate who shall use the property transterted or its iocome:..........................._,,.,........... ❑ 0 '�,
c. refain a revers�nary interes�;w._......_............__.........................................................................._.................. � � !
d. receive the pmmise tar life of either payments,benefits ar care?.................._.................................................. ❑ l� I
2. If death pccurred after Dec.72,1892,did decedenl transfer property within one year of death �i
withoutreceivingadequeteconsidereGon?..................._....................._........._....................................................._. ❑ � ;
3. Did Gecedenf am an"in trust fa"ar payable-upon�deatt�bank account w security at his a her death?.............. 0 0 i
4. Did decedent own an individual retirement accaunt,annuiry or ather non-prbbate property,which ','
contains a benefclary designation? ........................................................................................................................ � �� I
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IF THE ANSWER TQ ANY OF THE ABOVE QUEStIONS IS YES,YOU MUST CdMPLETf SCHEDULE f AND FILE!T AS RART f�THE RfTURN i
For dates ot Qeath on ar afler Juiy 1,1994,and befae Jan. 1, 1995,khe tax rate imposed on the net velue of Gansters to or for the use of the surviving spouse is
3 petCer�t(72 P.S.§911fi(a)(1.1)(i)l. i
For dates of tleath on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of tha surviving spouse is 0 perc�nt
�72 P.S. §9118 4a) (1.1)(ii)],the statute tloes not exempt a transfer to a surviving spouse from tax,end the statutory requirements for disolosure of assets a d
filing a tax retum are still applica�e ev�r if the surviving spouse is the oniy benefiaary.
For dates of daath on or aRer July t,2000: �
. The tax rate imposed nn the net value of transiers from a deceased ohild 21 years oi age or younger at death to or for lhe use of a naturel parent, �n
adopEive parent a a stepparent o(the child is 0 percenl(72 P.S.§9N6(aj(1.2)].
• The tax rate imposed on the �at value of translers ta or far the use of the decedenfs lineal bene6ciaries is 4S peroent, ezcept es noted�in
72 P.S.§9118(1.2)[72 F.S.§9N6(a)I�)1
• The tax rake imposed on the net vatue of transfers to w fw the use of the decedenfs siblings is 12 percent�72 P.S.§9116(a)(1.3�].A sibling is defined,un�er
Section 91Q2,as an individuaV xfixt has at least one parent in commai witts the decedent,whether by bbod rn adoption.
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REV-1503 EX+(&98)
scNEOU�E s
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN .
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Edna H.Wilson 21-13-0537
All propeRy Jolnttyawned wkh right of survivonhip must be d{sclosed on ScMdule F.
ITEM VALUEATDATE ,
NUMBER DESCRIPTION OF DEATH ',
� Merrill Lynch portfolio account no.807-10955 716,792.29
2. Merrill Lynch deposit program account no 807-11028 11,751.99
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TOTAL(Also enter on line 2,Recapitulalion) S 728,54428 ��''�..
Qf more space is needed,insert additional sheets of ihe same size) I'
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REV4508 EX�(8-98)
scH�ou�.E �
COMMONWEAITH OF PENNSYLVANiA �+�H, BANK DfPO51T5� Gt MISC.
INHERITANCE 7AX RETU42N pERSONAL PROPERI'`f
REStDENT DECEDENT
ES7ATE OP FllE NUN�ER
Edna H. Wilson 21-13-0537
I�Gufle the proceeds of Ntig6tlnn and the date Me proceeds were received by the eatate. -
AII property jalnUy�amrd wiN�right aF sarvivorahip muat be dlsdoeM on 3chaduN F. �.
ITEM VALUE AT DATE ��
Nl1MBER CESCRIPTION � OF DEATH �.
1. Cash and misceliaz�eous personai belo�ings 700.00
2. Sara A.7odd Memonal Home-�eiund o!overpayment 3,5zz,1 g �
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TOTAL{Also errter on line 5,RecapiNlatian) S 4,222.16 I��
Qf more space fs needed,insed edditional aheets of Me Same size) ��;
REV�i511 Ex+ (i0-09)
���� °; pennsytvania �CHEDU�E H
pEPARTMENTbFREVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRA7IYE COSTS
RESIOENTISECEpENT
EStATE OF PILE NUMBER
Edna H.Wilson 21-13-0537
Decadent's debts must be reported oo Scheduis 2. �
ITEM
NUMBER DESCRIP'170N AMOUNT ��.
n. FUNERAL EXPENSES !
i Harkins Puneral Nome: a.Gash adv�ces-floxe�s,newspa�r notices,etc. 1,799.44
b. Professional eervices-tuneral director,embalming 3,175.q0
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a Pacilities,equipment,staff and transportetlon 7,740.00 I
d. Casket,burial container,addiHonai merchandise 3,295.04
z. Silbaugh Memorials-grave marker inscriptian 315.00
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3. Favm Unfted PAeihadist Waman-funer�faod 250.00 �
a. Chumh organist 10p.00 I
B. ADMINISTRATIVE COS75: �
i. Personai Representative Commissians: 20,O�d.00 i
Name(s)of Personal Representative(s) JameS R.WilSOn _ i
street Addreu 3 Carlton �ece Circle ;
�gy Ca�IISIG _ State �'A Z�p 17013 j
Year{s)CommissWn caid: 2013 I
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S,OOp,00 �,
Z. Attarney Fees: I
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3. FamilY Exempiion:(ff decedent`s address is nat ihe same as deimant's,attach explanatioa)
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Claimant �'�..
Skreet Address__ ___,___ _ _
City . _ ___State___�21P _ i
Reletionship of Claimant ka Decedent__ _ i
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a. vrobate Fees: 643.5d I
5. Accountent Fees; �
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6. Taz Return Preparer Fees: �
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7. Gentral Penn Busiaess Jaumal-advertising fee 221.00 �
a. Cumberland Law Joumal-adver�sing fee 75.00 i
s. PSERS-reimburs�nent of avarpayment�f tetirement benefit 1$0.28 '
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36,773.7$'
TOTAI.(Also eMer on�ine 9,Recapikulatian} � �
If more space is needed,use addltional sheets of paper of the same size. I�
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uEV-isiz ex+�iz-oa�
� ��j= pennsylvania SCHEDULE I
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��I� oEPAA*mE�*oF AE�E��E DEBTS OF DECEDENT,
�NHER�TpN�Er^xRETURN MORTGAGE LIABILITIES & LIENS
RESIDENT OE[EDENT
ESTATE OF FILE NUMBER .
Edna H. Wilson 21-13-0537
Report debts incurred by!he decedent prior to death lhaS remained unpaid at the date of death,including unreimburoed medic�l expenses. �
ITEM VALUE AT DATE �
NUMBER DESCRIPTION OF DEATH '
1 Philhaven-medical bill 10.00
2. Millennium Pharmacy Systems, Ina-medical bill a� 8$
3. Sara A.Todd Memonal Home-room and board and services 13,585.56
4. George Branscum MD-medical bill 10.00
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TOTAL(Also enter on Line 10, Recapitulation) # 13,687.44 ���
If more space is needed,insert additional sheets of the same size. ��.
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REVd513 EX+ (01-10)
(' �'"'3,
°, � pennsylvania SCHEDULE J
' �EPANTMENT OFREVENUE
INHERRANCE TA%RETURN BENE FICIARIES
RESIDENT DECEDENT �
ESTATE OF: FILE NUMBER: �.
Edna H. Wilson 21-13-0537 '
RELATIONSHIPTO DECEDENT AMOUNT OR SHARE ���
NUMBER NAME AND ADDRE55 OF PERSON(5)RECEIVING PROPERTY Do Bot List Trustee(a) OF ESTA7E '�.
I TAXABIE DISTRIBUTIONS[Include autright spousal distributions and transfers under '.
Sec.9116(a)(11).] ���
1. Jo Ann W.Cubbage child one-third residual '
1731 North Green Briar Street,Adington,VA 22205
2. Carole W.Stauffer child one-third residual I
5055 Sorrento Court,Cape Carl,FL 33904 ',
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3. James R.Wilson child one-third residual �I
3 Cadton Lace Circle,Carlisle,PA 17015 �I
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ENTER DOLUR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-I500 COVER SHEEf,AS APPROPRIATE. !
�I NON-TAXABLE DISTRIBUTWNS �''��
A. SPOUSAL DISTNBUIlONS UNDER SECTION 9113 FOR WHICH AN ELECfION TO TAX IS NOT TAKEN: ��i
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B. CHARITABLE AND GOVERNMENTAL DISTRIBl1TI0N5: �'��.
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TOTAL OF PART II- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. � �',
If more sDace is needed,use addltional sheets of paper of the same size. ��
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r ngm qQr=� A�3 TlSTA�N'�'
2, EDNA H. S�ILSQN, of the Sarough of Millersville, County of
Lancaster anci Cammonwealth of Bennsylvania, hereby declare thie
to be my Last F7i11 and revolce all Wille which I have previously
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made.
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F2&ST: I direct that the debts which I am legally I
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obligated to pay and the expenaee of my laat iilness and funeral i
be paid as soon as practicable after my death. �
SBCOND: I am married to JOSSPH Ft. SPiLSON, and all �
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references in this will made to my husband are ta him. 2 have �
three children. They are JO ANN �P. CZ788]►G8 of Arlingtan, I
Virginia, SAb�B R. S�SLSON of Newville, Pennaylvania, and CAROLE �
�P. SPLSR of Elverson, Pennsylvania. Sn construing the provisiona (
of this Will, the tertn "iseue" shall include persons legally
adopted and the children or issue of persons sa lagally adopted. ;
THIR37: Sf my husband, J488PH R. �PIL80N eurvivee me, I ��
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give the cash and securities in my c«sh management account at I
Merrill Lynch to my son, JAM88 R. 4PILSON, IN TRUST, upan the �
following usea and purposes : I
A. Trustee shall hald and invest the assets oP !
this Trust, and pay the net income therefrom ii
to JOS�PA R. WILSON, in at 3east qtsarterly �
installments.
B. Upon the death af 3088PH R. YQIL30N, this �
Trust shall termi.nata, and the assets of the !
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Truat shall be distributed ta and among my
issue who ara then living, per stirpes.
FpORTH: All of the residue af my property, real and
personal, tangible and intangible, wheresoever situated and
hawsoever held, I give, devise and bequeath to my husband, J038PH ,
R. �ILSON, provided he survives me by thirty (30) days .
F2FTH: My husband and I have had a tradition of giving !
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the sum of $1, 000 . 00 ta each grandchild upon their marriage_ in !
the event that my huaband, J68gPH R. WSLSdN, should predecease me �
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ar �hould my husband fail to survive me for a period of at least �
thirty (30) days, I then give to each grandohild af rnine who does i
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survive me by thirty (30) days, and who has not previou�ly '
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received a nuptial gift of $1, 000 .40 Erom myaelf or my husband, ;
the sum of $1, 404 .00 .
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32XTH: In the event that my husband, SOSSP� R. �ILBOH, i
ehould predecease me or should my husband fail to survive me for j
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a period of at least thirty (30) days, then I hereby give, devise '
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and bequsath the residue of my estate, real and parsonal, �
tangible and intangible, wheresaever situate3 and hcswsoever heZd,
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in equal shares to each child of mine who ie living at the time !
of my death and to the then livzng lawful isaue, colleetively, crf �
each child of mine who predeoeases me, such issue to take par i
stirpes the share which their anceetor, the deceased chilc3 of I
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mine, would have taken if alive. ;
SSVSl+ITSir I appoint my husband, JOSBPH R. wIL80N, as ;
Ea�acutar af tYris Will . Should he, for any reaeon, fail to
qualify or aease ta act as such during the administratian of my
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estate, i appoint my aon, JAM88 R. WIL80N, Executor of this Will,
to act with the same duties, powers and discretions as if
originally appointed. No fiduciary aating under this will ahall
be required to enter bond ar furnish sureties in any
jurisdiction.
BIQxTH: I suggest and request that my Executor employ the
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affice of JAMES R. LEONARD, JR. , ESQUIRE in settling my estate,
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as he is familiar with my affairs. ;
D12NTH; My Executor and his successors ahall have the ,
fallowing powera, in acidition to those given by law, ta be
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exerciaed in their sole diecretian: Ta invest in any real or ',
pereonal property without restriction to legal investments; to '
repair, alter, improve or lease, for any period of time, any real If
or personal property; to eell at puhlic or private sale any real '
or personal praperty; ta comgrom3se claims; and to make
distribution in kind. ',
IN TSSfiIM02�TY WHBRSOF, I, BDNA H. 4PILS0�7, have hereunto set '
my hand and seal to this my Laet Will and Testament, coneiating '
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of four (4) Pages, �� M_Ilersville, Pennsylvania, on the 9tr1' day
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of October, 1997 . i
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.� J �„ ) i' � tSEPiL)
L ai ,
Eana x. wilson
SItiNSD, 88ALSD. PIIBLZS� A2�D DECLARSD by the abave nameci
Testatrix, as and for her Last Will and Testament, in the '
presence of us who have hereunto signed our names as witnesses,
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at her request, in the presence of said Testatrix, and in the
pre �nce of each other.
�Z,,,,,,_ residing at �a�.,.��+., �
��_ �il��_ residing at J� �e/...._DA., /�a,.
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WTEOFHfATEMENT "�_'L_��91�Cj/_f:,,,,,. PeldNewaGmBrNOIkB '/1if t.5'�, 7,-_ � '
' ' Ld
ACFfAH6EF�iSE "�i.�e:;ti'f•n' -•st �--'-'� .s�: -
RVtCEB SELECTED �,❑�,N ,=...:.,
1.Pro/ialondServkes: •� _'�. .'. G./ � ,— _���4,-
�
6aam s.mcee d Wmerai oirecror a Stert..... "��TP,th� ,. , � ��
. , l
— A Olher YCY7t�°f r Y r-:,�+�-�.�r � '. �.A .,�'�, �
Emtrelmin ,.._ � '.
._......... _
. . �P�fion�bodt.................. f.SO.C!? TOTALGSHAdJANCES $t'���-_
�J�Qd Wd Me � �. ..::J �.
.................................... �� . . ,
' .+a.•� , . 9>Yabrwrearv�cminobielnm9:(app�Myc9eneWancelleme).
z.�.annsa.eaurpm.��a sr.n: 'L'`�f— - _._ ,
u..a�asmam.v�,prvw�... 1°13:a� sue�teaRf
iMSdF+p7pXek$mabrFVn6�aiCO�&miy.,. TotelFunerelNOmeCheryea.., � ��
�& �., J _
U99 oi FatlWa d Sbtl!br MamorWl Ssrvko.... .••...........S '. �� !/,fiV ��:
UBB d E l.cwel 3ebs Tan(tl applMaDle) ................$ '.
9�n&Stell br OreNYBIUe Service... SIN4Y Salea TeM(R appNeaWe).................S '..
U64otEW�PmbMdSbQbrChurchServke.... _2�,�_ . 'i
TotedCaehAb.znCes.......................S r � .L'; '
._..__ _........................ , - i
��y� tiRANDTOTAI$ O.t2c�3,Q{j
R Triniport�fMn: Leae creutts ena paYmems '.
rre�.i,r a raeme�ns m w�er�nome........ .3as.�_o,a $—. .�'�.
tieawe._....._...................... .354.a� L—, !
TdeiCra��ts..,,..,...._...........5 �
Umousim....................._..... �-- .
8stlen ................................ BALANCE DU8 �I s __ � ,
Servb/UtiBty Vehide.._................ ../'Jw'.OG� �,�__,�I ���
��,��a BIIIIngTp _,__ .
4.t1U»r Sqv&ms t F+c!/!WE l E _��. .
V�A�I' - ^a'HPS 'M ;
................................................... � DISCLASURES .. ��..
......._.......................................... �� ,�— eeasa,rore� � 'i
Tt7TALOFSERViCESSEIECTEQ......................S11!�2_.G!.� t�+��. - f'^ •va „�, ;.
B.CHARGE FOR MERCHANDISE SELECTED """ - - �
�e)....... . ....... ��L �'.L��j nanYlew,certretetyorcremefay�Ay�wnroheverpuNetlrhe
CesketlarMher ....... .� Av2heaeo�artY/1emaNafed,MelmwarequbameMbexMeU+eCMkw. '
NerrtetNa i..'�,�rx' .. _ f
Mebnd _�
' _ � Gr P��.t�`� ��,
Cala—.� .._... ���,..F4KG �—._._ .
OItl91&JrlalCq��g r.......�.............................. �Cr'�(i'J�S2 ` __ I..
Name�HO -;d�a�r;u.. �.c:;'� ACKNOWLEDREMENTANpqGREEMENT I
dfAAMet ' ���Y thet i MT itN is�ei�t�erta�ge iM flnai
_. SBrviCee�Me tltc888etl.eM I 8�thorlm th�fimetet peiapQWtm9�t( !.
G�d 8ntl Incur oubhb Chergee MauryeC i
nwieOpemeM Carcle ......... pe rm eervfees,Nmleh e.
"""""""""""" �, on qils StebmenS.I eckrwwlsE g(hgt I heva rpcphytl 1M GBnaral
Repil2efBOOk........................ ..............._„ �� Prlqe Liet and ths Ceeke� PYicq Llet and �hq Outer BUrial �'�
M�umu7FOltlen/1'YlryarCeNS......r.......................... CanitllnarPrkeliai . .: �
Gbthirip..............._............_........_._.. ietmt��enf: '��� n. - :. !'. t„Y-y:e�b%!:F' . �-:
.......................................................... i i
CrcmpibnUm...�.�.�.�.�.................................... __ _ �.7 AY/"!? /N ' n�/S �',.
......_.................. ....... ---- Full peyment is Gue no IaNr tlfen.._ O� /'�/ '�.zb/,� . - �'.
........__... �
.....-..._.........._.................... HanY bnarP�wMndie,8nwm�HCipgteCtATEGiAflCiE �.
TOTALOFMEHCMANDISESEt,ECTED.......... .S��u7 ot_�%Cer'rcnmANNWLPERCENTA[;ERATE j ��
.......,. t �%I ..
on th9 unpaitl bqldncp�WII ba due.I epree ro pey fhe Beluw9 pue �
C.SP6CIAL CHAR6ES raroe on cn�a suieman�,p�a e�y 4ere cn.,�,u,m�ere„�i�„n i� ���,
❑FonveNkp remeln¢to- p qa�rv���m����; Peymem m thia lu�eral establlehment,!ayree tp pay reasor,gy��
attomey's faes a�d ceurt cmtg in aCtlNion�p a�,y��Charge
-- ,. appiicabie.i ur�prqg�y ana aqree tivM i em gpgyminp pargpnat �:
hnmaHSte BurW..........._............................ ._�_ ��0�ry br the che9a eet bntr in ihis SlsbrtwM pntl Rut t�ia b In ..
Dbqo[C�emmbn ..,, additicn to the Ilabllity Impospd by law upon the eat�te o(th� ��..
�............•...._.••..............• EtlCNRNO.BY mY eitlneWre ONaµI he ..
WiB�.......... BnYj BdVIOwI �Y�Orw W�II d iM�Fw�� �
......................................... atlge receipt ol a copy W Mle SbtemeM. �.
TOTAL.OPSPECIALGHAfiGES_................_......$ � - -
_ i� !.���..�, .�. . , ,
. ;
sty"" — �y �;
p+ ��MMU�e.r . �.
TOTALFUNERALHbMECHARGEB ....................... $ Ocli�.lJV _..... — _ __ �,,.
(TMSlotdlUaen'roflnGUd4CeshAdvR�fCea) -- g%—y� _ .
AL'C �
��� �eM b P�+M�a@ aervlCa9. _ ,..
afthis54MrtNlff.
By ""„6�,�„"' - '.
Silbaugh IVlemarials
Main ofRce-248 5puth Main St. Shrewsbury,Pa. 17361-1599
Display Locations ^ Shrewsbury,Vark&Hanover,PA, ` Aberdeen&Pallstun,MD
.si .Cpn 717-TS5�6796 Fat 1-800-235-1922 Tc8 Frtc E-tnai{
Date of Death Inscript'ion Order Form
Thar�}rcw#ar g us ka�the da�of d�th insczlption. in an efEort to keep cosfs down we have instltuted a company poGcy ,
to heip our v�ued Customers.
Our company policy is to make one�ip to t�e cemetery at which dme the stone wtter chedcs Ne work and matches fhe lettering on the
memodal. Usuatly the lettering is sandblast cut-in letters;4ut,same6mes there is the old sryle hand cut letters;and ihey require more wak and are !
biiled ak out curren#bo�rates:and a�r bii4 is sent uppn twmpietian aP the wak. Smce you have not requ�3 a ve,�iflcaBon��estima�of i�e
cost,you wilf not ba biiled ihe$50.06 service charge for the eMra trip W Ihe cemetery. '
Fee 5chedul� and Inscriptian Optians
S�d�ast Year�Vy $25Q.00 �
ff paid with tfie order 5224.� ,
Sandbla��btevia0ed�u11 date -$3k� 1� � !
If�i wtih tlie a� �315.�
( Jan.Feb.Mar.Apr.May June July Aug.Sept Oct Nav..Dec.l j
�
S2ttd�st#uq da�spetfed out $395.Q0
if oaid with the order S3B5.00
Bronze year only death tab{3"x1"up to 4°x 1 Y.") CURRENT YEAR $290.00
tfsxssianerinsfa4lsthp�ives ••• 31�.04 ••>
Bronze Year only deaU�tab ' NO7 CURRENT YEAR $435.00
�If.customer inst�is ihemseives ••• $335.� •••
Bronze Icase scroll (sent badc&recast) 5655.00 '
Scxoli size 7�18'x 2" up to 15"x 4"; �
lfcustarner6rtrras ia�!&rer`nstaNsfhemseivas '•• 3460.00 `••
Bronze veteran saoli (9%:'X 1 118' or 18'x 1 118") $510.00 ',
li ass�met i�st�lls themselves **' S36Q.OQ `*' ;
�
*•* GRIINDING f)F NEW SCROLL MAY BE NEC SSARY TO FIT IXISTlNG HpLES OM FNAQUE '
"' NOTE "' Some cemeteriea have special entry ar inspecUons fees. My cemetery fees are�I�ifbnai charaes i
ra PEiocr�D 1MtiH 7ti1ffi;.�: Pleaeav�ycmair�Ors�atiasan.thahadc+��sl�ta.�:�nd6��?enyaniaeia+s.and ',
ahange er�ytl�tltet is wrong. VWe.�iN H�an '
protxDd v,dth tl1N nN�ic as w8 9�e in 1l�e�: (�letlot�aF WOrk U8ueA9 nxi6 9U-�?0 days dtehq�Mr�lm wEedhe�" dNpend4ig on !
xea8��.
�
Canawllation&Refund Rights: If thia order is cenceled prbr to completlon,there is a minimum cancellatbn tee of$45.Chargad�Cover mfnimur�
�min�tra6ve cosls. tf Siibaugh Memori�s is caitrac�d�engrave an sbsting memorisi and upors arrivai at cemetery we find that said�ttering h�s
kaears compie�d by another.S�gtr t�morials wUi etsarc,�the wsta�r a ca�rceii�f�for ihe drsl�tf9,ceme�ry v�it{s},admintstrative fees a�
other work assodated with fhis contract.
Thank you, R�mald S.Silk�gh
Updated Apd�15,2013 RSS
TAKENBY C}A7E BRIAMt FYMT WbRKORDER#
MARSFTA JLTNB 7.?A13 � '.�
MCCULLOUGH
—.
_ _ _
_ `�,AI���LU GUUKtU t? a.uw _ o.vµ r .
00020171100000
HATF:[E�D COOKED 1 C� 6.59 6.59 F
00020171100000
HATFIELD COOKED 1@ 6.79 6.79 F
0002C171100000
Ji= MARTIN DOM SW i � 7.76 7J6 F
0002G178100000
I�OTATO SALAD 1 � 15.31 15,31 f
00020135600000
SAUBELS AMISH MA 1 � 15.92 15.92 F '
00020135700000
58L CHNK CHICK S 1 � 32.51 32.51 F
00020096200000
DAIRY
H�ID MILK 1 � 1 .39 1 .39 F
00001540020174 '
iUBTOTAL 26 126.63 '
TAX 0,68
fOTAL 127.31
DUE==> 127.31 '
�—
+CHARGE* 127.31 4'-°�' '
ACCT 3243 +/�a, �fD•��L;
�
INV 10536140422 D ti�k '
FpWN UNITED METHODIST ��,.,ouw
�Hac+�.rs: �awn u��r..d,
f.HANGE DUE mwt►�•�i`7 0.00
c�"+434¢ ,Womih �,d 4/A3/ i3
YOU EARNED 4.65 IN DISCOUNTS ',
WITH THIS TRANSACTION '
C: heck� �l 3 93 .. 4l'�.9�/�
Ll�urch Qr�0.nr5t .�1 ob.ue
_
c-4��.aZ vnas�c Ev� Co brga.�cib't, '
- -._._ ___.
-�i"ovn eu�- b...r. 'L a..ct`C. . . ..',.
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. __ ._._ .. . .._. .._.. _. '.
.__ ._. ._. . .
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�
•
•
Y�li Pat{�It�txO11K�{II Kv.�^"` • �',,,.
2902 Whiteford Road
W1,it.3fa,=d MD 21160
_ ._ _ _ _ _ _ _ _ �
RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH Receipt Date : 5/09/2013
Cumberland County - Register Of Wills Receipt Time : 10 : 32 :26
One Courthouse S�uare Receipt No. : 1074141
Carlisle, PA 17 13
WZLSON EDNA H
Estate File No. : 2013-00537
Paid By Remarks : �K W ALLSHOUSE I
------------------------ Receipt Distribution ------------------------ ',
Fee/Tax Description Payment Amount Payee Name '
PETITION LTRS TEST 560 . 00 CUMBERLAND COUNTY GENERAL FUN ',
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN ,
SHORT CERTIFICATE 4 . 00 CUMBERLAND COUNTY GENERAL FUN
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUNI�
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUNII
SHORT CERTIFICATE 23 . 50 BUREAU O DRE�EIPTSG&NCNTR M D ',
JCS FEE
Cash ---- ---$614 . 00 ,
Check# 3046 g6 . 00 ,
Check# 3046 $23 . 50
Total Received. . . . . . . . . $643 . 50
- �
1 N V Q I C E
3500 PaxCon Street
Jt')URNA� Harrisburg,PA?7704 �12�i2fl13
L 717-236-4300
M U LT I M E D I A F.717435-6803 ORDER#: 90063
www.journalmWtimedia.com TERM3: Net30Days
INVOICE TO----------- __._�._.._ ADV8R7CSER---------
Christian Lawyer Solutions, LLC Christian Lawyer Solutions, LLC
Rccounts Payable
4833 Spring Road
Shermans Dale, PA 17090
INYOIGING Advartiser
pESCRIPTION OF CHARGE$ COS7 � CREDIT � 6ALANCE
PUBIICATiON; CLASSIFtEDtCEhiTRAL PENN BUS.JRNL -
COVER DATE: 8/7I2013 THEME: CLASSIFIEp AD/CENTRAL PENN BUSINESS JOUR '�..
RATE CARD: �
DESCRIPTION OF AD:
�egei iisting: Es�te of Ednn H.Wiison � (
REP(Sf: i
MARKSUNDAY . I
SIZE: LEGAL LISTING, PAGE: 221.00 '� i
Cdl4R: B&W 4.00 -
SPACE SUB-TPTAL: '221.00
• BALANCE DUE: 1221,00
CUMBERlAND �AW JQURNA�
32 SOUTH BEDFORD STREET
CARIISLE, PA 17013
7efe: (71Y�248-318$ Pax:(717j248-2883
June 7, 2413
Cumberland Law Joumai is pubiished every Friday by the Cumberland County
Bar Association and is designated by the Court of Common Pleas as the afficial legal
pubtication#or Cumberland County and the legal newspaper for publication af legal
notices.
TO: Mark W. A1lshause, Esquire
RE: Edna H. Wilsan 6state
�eflal advertiser�rents must be received by Friday Noan. Alf legal advertising
must be paid in advance. Make al� checks payable to: Cumberland Law JournaL '
Advertisement inserted on following dates: !
May 24, May 31, and June 7, 2013
Advertising Cast $ 75,00
Proof of Publication $ 0.00
Second Proof Request $ 0.00 '
Payment received $ 75.Q0 '
Total Amaunt Dus � 0.40
Becky H. Morgenthai, Exeautive Director
.
COMMONWEALTH OF PENNSYLVANIA
' PUBl.1C SCHOOL EMPLOYEES' RETIREMENT SYSTEM
PSERS 7ot!-free: 1.888.773.7748{1.888.PSERS4U)
`"' S N 5th Street Local: 717.787.8540
,��jp1"`j"" HaRisburg PA 1 71 01-1905 www.psers.state.pa.us
��,�y z, zo�s
JAMES WILSON -
3 CARLT6N LACE CTR
CARLISLE, PA 17015
RE: Edna Wilson
SSN: XXX-XX-2287
Dear Mr. Wilson:
The Public 5chool Emptayees' RetiremeM System is processing the benefit of Edna W ilson.
Piease accept our condolences on your Ioss.
PSERS �ssued the following monthiy retirement benefit{s}prior to processing Ehe dea#h benefit:
Check Date Check Amount
April, 2013 $769.69
Edna W ilson was entitled to a prorated amount of$809.41 far the month of ApriL '
�' Therefore, please reimhurse PSEFtS $166.28 which represents the tntal af the monthly benefit ;
payments and debts (if applicable) list�ec�"�aFi~ove, minus the prorated amount. Please make
yqur check or money order payable to Public School Employees Retirement System.
� Please refain this iniormation for preparation of fhe member's fnal tax refum.
If yau have any qusstians, please cantact the PSEi28 Member Serv9ce Cen#er by ca0ing
to0-free 1-888-773-7748 (1-888-PSERS4U). Harrisburg Iocai cailers, piease use
717-787-8540. Ta contact PSERS b�� e-mall, use the following address: '
cantactPSEF2S�pa.gov. For your oonvenience, ttre Member 5ervice Center is staffed each
business day frpm $:00 a.m. to 5:00 p.m. For more genera! infarmation, you may visit PSERS
online at: www.psers.state.pa.us.
Sincerely,
�lt�i�fG .�CfuJ�d� ,rsNL�d��d� �Ctflt�ilt�it� ,��
�r������r�rin���N�n�i� i�M�Nr���u����r�n�H��n�
otaaoa�ae20000yoro
� _—
/. .
�
�'��e�:.
�����
Accannt Wilsbn,Edna H(447192) �� -� ��❑ ��
Program:Cm�sulaOider Adult
Admit Dste:031Q1/2013 Ilischarge Date: Cazd Numbea:
Statement Dste: May 7,2013 Please Pay This Amonnt: $10.00 Expiradon Date: Security Code:
IAxe Dste: May 22,2013 Amount Eadased: $ Sq��:
5334-16 �nted Name:
JAMFS 8c CARClT,YN WTLSON ❑
3 CARLTON LACE CIRCI.,E c��
Ct1RLLSLE�PA 1?025 Paymmt�anmc�iva7 xo
t I}etach Htst ax�ReNrn Pop Poculon with Ycw Yal�t �5�m YorN�p,{it i�Y,pyf Rsmrdaa �.
� P(eaadln�rowpa,ymeNandlC�ttp�oymentsddimindthr'rippli�pnrtAdnrr�Qenvsbp�. � ��
QfYou arr pay6�g jor mukipk xaoww with onaPa7���r Pkare include aApayment ambs.) '.
Sunomaiy Statement of Servicea(Detail on Reverse Side) '
Accawt:Wilson.Edna FI(447192) Due Date: May 22,2413 '.
Progrsm:t;ansult-41ci�Adult Statement Date: May�,2013 �
Admit Date: p3/Ol/2013 T'revia�s Stat!ement$slance: $0.00
D3ach8rgt Date:. PaylriCllts ReceiYCd Sinca I.Bat StAtemenE: $8.Q0
T�al iYew t9tatges: $14.00
`' Amount Xou Now Owe: $10.00 '
• The secount batance far the services rxeived is now due.At2 insurance activity,if aay,has bcen pmcessed and the
rrsnsiniug balance is due from you. If}roiu balance is zxo,Floaee retain dctsil foz y�r rawrda.
Services provided in the new calendaz year rnay be subject to additional patient liabiliry over and above the usual ;
co-gayment and�insurance amount,Co-payments,c�insurancc,dedudibles and noa-caverai�viees will be yaur
respons�'bility ac�ording to}�r hea2th insurance cavesage Piesse contact}rour insurance carrier with questions rcgarding
daluctible and co-insurance amaunt(s). ,
�ease remit the belance in futl within fiftan{IS}days using the tncl�ed reply envelt�x.Our offtce aace�pts chxks
and crodit cards.If yiru are unabie to pay your bslanct in full ar nxd assisCence in nnderstandiag your statement,please
cantact ouc of6ce at('I17)270-2A13 or toll free at 1(888)302-4710,Mcmday-Fridap 8:OOAM-430PM. Someono will be
gt"acicoassistyou. _ _... . .-.- –_._ _ . _ _ _ .. _ . __.._ _..._ _ .
Thank}+[�u far chaosing PhiThaven for yaur healthcare seavices.
6-59
�+ 2$3 South Butler Rd Mt 13rema,PA 17064-0554;Phone($8$)302-4710�t71'7)270.2413
�����s Business Offia Hours:N[onduy t}vough Friday$:00 am-4:30 pm
�K���
. _
Millennium Pharmacy Systems �,� � �
EKensingerDr . � Mitlennium
B1dg120 su�tesoo Pharmacy Systems Inc.
Cranberry 1tvp, PA 16066
7-866 — 466 — 7779 Opt. 4
INVOICE DATE: May WILSON, EDNI�1
14, 2013 WILSON,JIM
Account Number
3 CARLTON LANE CIRCLE $�'MH1694
Balance Due: 581.88 CARLISLE PA, 17015
Pharmaty location:
MECH 1
Please Detach here and Retum Top Portion with Payment
�'._'_".""._'_._'"'"'"._'_'_'"'""'_'_._'"'_'"."'"._'_'_'_._._._'_'_._.
- - - - - - - - - - -- - - - - - - - - - - - - --- - � -
Re: WILSON, EDNA Invoice Date: 5/74/2013 ',
-- �
Facility: Sarah Todd NC Balance Due: 581.88 '
`�_---...,. . i
Account#: STMH1694 Last Payment: 532.12 I
Pharmacy Loc: MECH Last Payment Date: 3/27/2013 ',
Dear Valued Millennium Customer,
Millennium Pharmacy Systems is committEd being the best pharmaceutical supplier in the industry. '
Our records indicate that Mr. /Ms.'s YVILSON, EDNA account is no longer active as of 4/18/2013 '
This is just a friendly reminder in regards to the aforementioned account. Please remit payment today,
to keep their account in good standing. If payment arrangements have been previously established ',
please remit your monthly agreed upon amount.
If you feei there is any discrepancy in regards to this balance please feel free to contact us and ask to I
speak with a collection specialist. ',
We look forwazd to working with you and thank you for your anticipated cooperation �
Sincerely, You can now pay your Bill Onlinett I'
Miilennium Pharmacy Systems www•MPSRx.com
Tel: (724) 940 —2490 � Contact
Fax: (866) 228 — 8267 � Pay your bill
. _ r .
STATEMENT
Senh A Todd Memorial Home Sfatement Date: OS/10/2013
5000 West South Street
Carlisle, PA 17013-2798 Due Dabe: OS/25/2013
Telephone: (71�245-2187 ,t--D� �O
Amount Endosed $ �,
Artrount Due: $ 5,031.70
Aaount#: 102111
RE: Edna H Wilson
]ames Wilson
3 Carlton Lace Grcle
Carlisle, PA 17015
M/OS�/OZ/13 �/1 d id-Semi-Private 30 280.00 -8;400. �153.
04/07 13 ����� � 1.� �.12 242.9
�DP�� 1 1.22 1.22 244.
04/1 /13 Personat Laiaidry Servkes 1 27.50 27. 271.7
04/01/13-04/17/1 Room&Board-Semi-Private 17 280.00 4,760. 5,031J
WrnM 31-BO Dhrs 61A0 Dsys Ovar 90 Dws MauM Dw �'�,.
4,877•64 153.86 .00 .00 II
NOTE: s��ss PAYMENT LS WE UPON RECIIPf s•*+s BUT NO LATER '�
THE 25TH OF THE MONTH'M'k'a' Pleise reMt the AMOUNT DUE �.
your sf�rbnt Indude tha ACCT# trmi t1�e sp0ement un yx MEMU Statement Dabe: OS/10/2013 ��
of yaur fheck.Paymenec aIM 5/B/13 do rwt rMect on�, DUe DatE: OS �
NOTE:"'•UTE PAYMENfS ARE$UB7ECT TO p 1.25%WTE CHARGE PER �ZS�ZO13 '�
MONTH **A;30.00 PEE VJILL BE CFIARGED tor RETURNED piECKS
Edna H Wilson -Aaount#: 102111
Sanh A Todd Memorial Home
1000 West South Street
(3disle, PA 17013-2798
Telephone: (717) 245-2187
� � �
� STATEMENT
Satah ATodd Memoriel Hame Staterrrent F3a#�: 04I11J20f3
1000 West Squth Street
Carlisle,PA 17013-2798 Due Date; p4/25/2013
Telephone: (1in 245-21$7 (��j
AtnOttnt E�dosed $�� (�t0
Amount Due: $ 8,553.86
Actvunt#: 142111
RE: Edna H Wii5on .
James Wilsan
3 Cariton LaCe Circle
Cad�e,PA 17{}15
. 8
431u123 .7AI�1E5 $,$Q4.5 .
Q3R4/13 tltwnoe Suppiks 2 12.92 Z5.84 25.
03/30/13 ��'.� 6 2.12 11� 37.
(l3�3Q(13 128 .74 86.7 126.
Q3(3�/23 t3��dry 52CViC25 1 2J. 27. 353.
l01/1#-b4(3011 &9oard-Semi-Private 3Q 2�}. 8,440. 8,553.
Cutsa�t 32-86Wys 61-90Otys O+rw90Dns MaurttDue
8,553,86 .QO .00 .00
NqTE: t****R4YMEPti'IS DUE UPOM�CEfPT s+rss&TF tKJ LATER
11iE 25TH OF THE tAOt}T'H'""" PbN�e rerNt tlt@ AF1IXNtT Dl7E �.
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your ah�rt I�ude dte ACCT# fl'om the slabement on Me MEMO StaCement Ci�te: fl4jiiJ2013�
a your cnadr.raymena weer ve/a8 aa�oe rafM.cc«�saoane�t Due Dabe: 04/25/20131 �
NOTE:**tATE PAYMENTS ARE SUB7EGT TO A 1.2596 LA'fE CHARGE PER �.
MONiH '"'A f10.00 FEE NRl1 BE CHARGED for RETURNEO CHEIXS �
Edna H Wiison-A000unt#: 102111
Serah A Todd MamoA#1 Home
l000 west soucn streec
Carlisie, PA i7013-2J9$
Teiephone: (?17}245-2187 :
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• ; FED. IA.# 429842285 PHONE NO.: (304) 264-$5T0 ',
GEORGE BRANSCUM, MD '• E
— 77 NELSON DR. � �
— CARLISLE PA 17Q15-9337 C
_ �3 Stetement Dete: OSl14113 �
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• � • l„__w__......___.,_..__.. _ AMOUNT_ dUE � 10.00__,`�
f.•_-•-.ACCOUNTNl1MBER._..._..�y� �.. ....•-�..AMOUNTENC406�v� ED�-���
—_ +�003055J1--S 16--8 5 " 2�3 � ' $ '
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EdNA WILSON f ±
G!Q JAMES R WIt84N , � L
3 CARLTON LACE CIR ,
CARLIStE FA 17015-9114 � Y
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�����PtEASE DETACH AND RETURN'iQP SEGT{QN WITH YOUR PAYM ��M. J�
MAKE PAYMENT TO:
GEORGE SRANSCUM. Mp
3NOSIS '� DATE �PA�E���� NAME '��� CHARGES!PAYMENTS/ADJUSTMENTS . P�� ' �^surula nding
Q4E � � REFERENCE �� iCDDEi � �
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� ' BAL. FORWARD AS OF 03/14/13 00 ' S0 i00
' 03/21I13 ' � MEDFCARE ADJUSTMENT S.i33
04/04/13 ' , i ; PAYHENT INSURANGE ! 31 .�67
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'Your acoount is now 30 d�ysipast due. Please remit
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� THE AI�IIQUNT SMOWN
.04 10.OQ '. _ ,_ .__..�_Oa_ __ _r 00 -'---- .OO� IN THE PATIENT COLUMN .___ 10.Od � 00
__ _._ _ ___ _. __,_ � ,r _ . ___
CURRENT OVER 30 pAYS ��. pVER 60 DAYS �'�� OVER 90 DAYS ��. OVER 720 DAYS j'�, IS DUE NOW. � PATIENT � INS:pENDING
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05/1 d/M1 3 221 .Q7 . 283 m�s all ia dw�won raoNx The peuem is responside to pey any and eli cherges shaNn in--.
._..... _.__---.._ ..__.._.. . . .. _. .. . ..____,._. . __.. ... . _.._.._I tlre`Pa1lenCcdumn.Thechergesshoxn�tlie"t�urenCePendin9"column4avebe�+filedwiYh
STATEMENT OATE v7.D aATtENT PAYt�EN7S� nCC4UNT NUMBER � the petlenCa ireurance compeny on the petienYs beheM.The patient is e�ways reeponai6i�for the
. . .____._ .__, ._.__. _._ . _. . .. .._____._ ._ .__ ...._.
GEORGE BRANSCIMI, ND peyment of Mrry and aR servkes rentlered wfiict�are rwt paid by rc�rnar�.U�i hxtl�er rp�e,
osy oM+t tt�e amnunt shwvn in tMa•PatienP'column.