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IN TI3E COURT C1F Ct�MMON PLEAS
OF CUMBERLAND Ct�UNTY,FENNSYLVANIA
ORPHANS' COURT DIVISION
In re; ESTATE OF Mary E. Wetzel, Deceased No. '� �"�� Q�--
, -�
PETITIUN FO►R SETTLEMENT UF A SMALL ESTATE
Tt� THE H(�N(JRABLE JUDGES OF SAID COURT:
Jalene Gregar and Kimberly Wetzel, Petitioners, by and through their legal counsel,
Salzmann Hughes, P.C.,jaintly file this Petition for Settlement of a Smail Estate under the
pravisians of Section 31�2 of the Probate, Estates and Fiduciaries Code and in support thereof
avers that:
1. �aur Petitioners,Jolene Gregar and Kimberly VV'etzel, live and reside at 13 Q6
Dickinson Drive, Carlisle,PA 17013, and 541VIedia Road, Carlisle, PA 1�a 13, respectively.
2. Said decedent,Mary E. V�etzei (the"Decedent"), who died June 2,20I2,resided
prior to her death at Farest Park Health Center, 7a0 Walnut Bottam Raad, Cumberland County,
Carlisle, PA. See death certificate attached hereta as Exhibit"A."
3. Decedent died testate, leaving a self-proving Last Will and Testament, dated
November 13, 201 Q (the "WiII"), a copy of which is attached hereto as Exhibit"B"and
incorporated herein. The Wili has not been probated.
: 4. Petitioners are Decedent's daughter, Jolene Gregor, and Decedent's step-
daughter, Kimberly Wetzei. Bath are appointed as Co-Executors under the Will, and not required
to give bond.
5. The beneficiaries under the Wi11 are the Petitioner Jolene�regor, and the
Decedent's minar grarzdchildren, Makenzie Gregor{dob: 011211I 993) az�P��ielle�e t�i�; �y�� �: �
�r � ...1 ��
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11/01 l 1996). �` = ��� �
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6. IJecedent's spouse, Lonas L. Wetzel, died on July 1 C},2012; appraximately one
m+�nth after Decedent.
'7. There is no claim for family exemption.
8. Neither the Petitioners nor anyone else has received or retained any property of
the Decedent by payment of wages under Section 3101 of the Probate, Estate and Fiduciaries
Code, ox otherwise. The Decedent at the time of her death was unemployed.
9. The entire inventory of decedent's estate cansists af faur(4)refund checks with a
total balance of$9,442.15,itemized as fallows:
a. Refund check fram Argus $ 573.10
b. Refund check from Centurylink $ 53.53
c. Refund check from Medca $ 414.5�
d. Refund check from Farest Park
Health Center $8,401.00
Totai...........$9,442.15
1C}. The debts of the decedent's estate (priaritized pursuant to 20 Pa.C.S.A. §3392}are
as fallaws:
Cate�orv#1:
(a} Filing fee to Cumberland County Orphan's Court $ 43.50
{b) Filing fee to Cumberland County Register of Wills $ 15.00
(c) Co-Executar commission—Jolene Gregor � soa.{�0
(d) Co-Executor comrnission—Kimberly Wetzel $ 540.(JQ
(e) Certif ed mail costs,advanced by Salzmann Hughes,P.C. $ 12.62
{� Salzmann Hughes, P,C., estate administration fee $ 750.00
Cate�or T�#2: Nane
Cate,�o�#3.- �`alance Pro Rata
Due Share
{g) Estate of Lanas�etzel �funeral expense advanced by
spouse's estate� $ 177.23 $ 33.b5
(h) Guardian LTC Pharmacy $ 1,514.23 $ 287.54
(j} Pennsylvania Department of Public Welfare
{See Exhibit"C") $38,447.14 $7,299.88
Cate�orY#4: None
�'ate�r�#5: None
Cate�ory#5.1: None
; Categor�#6: None
11. Petitioners respectfully request the Caurt's appraval ta distribute all assets of the
Decedent's estate to satisfy the debts in Category 1 {a}, (b), (c}, (d}, (e), and(f�in fu11, and
Category 3 (g), {h}and{i}by pro rata share; at which time a11 funds wi11 be exhausted.
WHEREFORE,petitioner prays that your Honorable Court direct that the assets af the
Estate of Mary E. Wetzel, deceased,be distributed as abave stated.
Respectfully submitted,
ALZM ES, P.C.
IJated: � � � e�` C�„ B
y•
es . Hughes, Esq.
Coun 1 for Petitioners
A rney I.D. #58884
4 Alexander Spring Rd., Suite 1
Carlisle, PA 17015
717-249-6333
VERIFICATION
I verify that the statements set forth in the faregoing Petition are true and correct ta the
best of my knowledge, informatian and belief. I understand that false statements made herein
are subject to the penalties of 18 Pa. C.S.A. § 4a4,relating to unsworn falsification to authorities.
��
.�"''y�
regor
COIVIMONWEALTH (�F PEI��ISYZ�ANIA .
COUNTY OF C.:��1��-�t1�r.� .
Sworn and subscribed before me
this�day of �' t , 2�13.
: �'��``�- coM�wEa�.-m oF�NS�n.v�wu►
. b � ��
Tarnera S.Siie�ri�,Noka�y Put�tc
Not��ry Public �01�`�������
���,�;�n.va�u a+�ocra�+c�oF rarra�.rt
�ERIFICATION
I verify that the statements set farth in the foregaing Petition are true and correct ta the
best of my knowledge,information and belief. I understand that false statements made herein
are subject tc�the penalties of 18 Pa. C.S.A. § 404,relating to unsworn falsification to authorities.
.�4-
Kimberiy etzel
CC}M1VI(�NWE LTH OF PENNSYLVANIA .
COUNTY ClF ' :
Sworn and subscribed befare me
this,�day of "�t,� , 2�13.
l�\
„/� COMMONVItF.Ai.TH 4F PENNSYLVANTf�
,..'�`�L �� �
�4t�PU�?�iC Ti�'�i S«St�;►NO�Y Pubtk
so�a,��on�r�.,aa�na ca�ty (
My conan�s�on ex�aec.�zo�a �
�r�eEa,���a�►�►ssocvrrnon oF Hc7raa�r
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�
� LCICAL REGISTRAR'S CERTIFICATICJN t�F DEATH �
� WARNlNG: it is iliegal #o duplicate this cop� by photostat or photograph.
� Fee for this certificate, $6.t}0 ,,���r��"'"�-�-. This is to certify that the information here given
+'''"PL����pf�� conectl co ied from an ori inal Certificate af Dea
� �a`''�,�,'�`��-_ ___ �y`r�=, � duly fiied w th me as Local Registrar. The orzgin
� `�_ � � ,° == Z� certificate will be forwarded ta the State Vit
�
� ;v .,�= a� Recards C}f�ce for permanent�ling.
:
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� P �. $A�$$ Q41 =°�.�9 = . tia��'�' �����`�. .�u �~ ot2
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� ����,,;i C(1 I fv���E���
; Certi�cation Number Local Registrar _ Date Issued
�� �� Typw/PrinL in CQMMQIVWEALTH dF PENNSYIVANlA�dEPARTMENT OF HEAl7Fi+V17AL REGORC35
8
� `'ar""'"°"` ` CERTIFICATE 1�JF DEATH
� Black!nk State Fite Number.
1.D�cedent's Legat Name{First,Mlddle,Last,Suffixj 2_Sex 3.Sociai Security Numbsr 4.Date of Desth(Ma/DayfYrj(Sp�tt Mo)
� r�sa E. wetz�i F��►i ia�--as--s7ai ,�un$ a 2oi2
�,� Sa.A�e-lssY Birthday(Yrs) 5b.tJnder 1 Year St.Under 1 Da 6.Dat�of Birth(Mo/dayjYear){Speel!Monthj 7a.Birthpiate{Gty and 5tatt or For�i�n Country)
� Months Days Haurs Minutes G'�.r'1.�.31.@ PA
a '�,1 ?? M8r'cYi 25� 1935 7b.airtthptace{County)
� 8s.Residente(SLatc or Forefgn Country) 6b.Rasidence(Street and Number-Include Apt Mo.) Sc.DId Dec�dent tive in a Township7
� PA 700 Walnut Bottcxn Rd. pvgs,decedent iived In cwP,
: 8d.ResfdienCe(GOUntyj
� L'LZ[t1�,7���.$,I'1C�i $e.Residence(Zip Code) No,deced�nt lived within Ilmits of �rl isle ��tyjbora.
� . 9.Ever!�tJS Rrmed Forces7 lq.Marital 5tatvs at Time of Death Married Wtdowed 11.Survivin Spouse's Name 1f wi#e, ivc name
{ Q g ( g prior co flrst marrlage)
�Yes (�(No ['�Unknown �0lvorced �Never Marrled O Unknown =,OT12tS t,� �117@'t2el
� 2 at r's Nam Flrst }ddle,las,5uftixj 19.
� 2,.f$bq_@r. O_,(_ �Nt r��?I?�E�r _fylit�ri�N�am,�Prl�or�to First Ma�r}a;e(Flrs#,Middie,last)
W ZL S C:8 M 15�3
j 14a.informanx's Name 14b.Reiationship to Decede�t 14c.informant's Mailing Address(Sireet a�d Number,City,State,Zlp Code)
' Jolene Gregor c3aught�r 130f Dickinsor� Drive, Carlisle, PA 1?013
q � ......................................................... ....,.......'•-"'•"•'-•'-... 1 a. ace o tat tc an one .. ... .. ......... .. .,. ... .......... ..... ... .. ,...... ......
. ...... ..i........................................................ . ... ........ . .. ... ...
. ........ . .. .. .. ... .. ..
If Death Occurred in a Hospltal: Cu{�inpatient - :If Death Occurred Somewhera Other Than a Nospital: �Hospiae Faciiity �+pecedent'a Home
� Emergency RoomJdutpstfe�nt �j Dead on A�rtval i Nursing HomelLong-Terrtt Carc Factiity Othrr(Specifyj
`� � 15b.Facliity hama(lf not InaNtutfon,give atreet and number; �25c.City ar Town,State,and Zip Codc � i5d.County of Oeath
For��st Park Health Center Carlisl�, PA 17013 Cumb�arlanc3
16a.Method Of OispasitFon Buriat � Ge�matlon 16b.Date of Dlspositian 16c.Place of DisposRion{Namc of camatery,crematory,or ather place)
� � d Ftemovai frort�state Q Donatton �7'unE„s 6� 201.2 We�tminster M�rial Gaerd�ns
Other(Speci )
16d.Lacatio�of Dispositton(Gty or Town,State,and Zipj 17a.Slgnat re of Fun fVICG LiCCft50 in Charge of Intarment 29b.Lice�se Number
'� t^arlisle, PA 17013 138504
.� 17c.Name and C=mplet�Addreas of Fune�ral Fadlity �
,e`� 18.DecedenYs Educatiort-Cheek the box that beat describes the 19.Decedent of Hispanlc Origin-Check tht 20.Decedent's Race-Check ONE OR MORE racas ta lndicate what
� E°- higfiest desroe or Ievei of schaa!corttple2ed at the#Ime of deatF. box tlrat besi dtscribes whether the docadtnt the decedent consld�rred himsaif or herself to be.
Q$Xh grade ar less is Spsnishlh�xpanic/latino. Cfi�ck the^MO" �WhTte [,'1 Ko�ean
Q� Na dlploma,9th-12th grsde box if detedent is not SpanishJHispanicjtatino. (_J Slack or African Amertcar� [�Yiatnam�se
� [� High sehoo!graduate ar GEP campieted No,not Spa�ish/Hlsparticf�atfna Gj Am+erican indlan or Ataska Native �Other Asisn
[�Some coiiege credlt,but na de$ree Q Yes,Mexicsn,Mexica�Amerlcan,CMcano �]Aslan I�dia� � Nstivt Hawailan
.� �Associate degreae ie.;.M,AS) �Yes,Puerco Rican Cj Ghtnese � Gu�manlan or Chamorra
[� Bachelor's degroe(e.g.BA,AB,BS) C(Y�s,Cuban Cj Fffipino n Samoan
� - Q Master's degnse(e.g..MA,M5,MEng,MEd,MSW,MBA) [�Yes,other 5pa�ishlHlspanic/Latino [�Japanese - [,}Other Pacific istander
-� � Doctorate{e.�.PhO,8dpj or Professlonal degrse {Spectfy) �Other(5pectPyy
� " 't. .M't? [1C?5'OYM tLB!D s
21.DecedenYa Singia Race 5elf-D�signation-Gheck ONLY ONE to t�dicata what the decedenc coristderod himseif or herself to be. 22a.DecedenYs Usual Occupailoh-Indicata type of work a
� Q�Wh1ie Q 3apanese Q Samoan done duririg mast of working ltfe. Dt?N+QT t�SE RfT1RED. `€
' Q Hlack or African Ameriean Lj Korean (�Other Paeiflc isiendar ���$��x�� �
c� � (�Amertcan fndtan ar Alaska Na#Ive 0 Vietnamese � Oon't Know/Nat S�re
� [�Aatsn!nd}an j_J Other Asian []Refusad 22b.Kind of Business/Industry ��
� Q Chinexe Q Native Hawaila� [�Other(Spec)fy)
Q Fiflpino �Guamanian or Chamorro Sewing 'I''$CtC►X'�7' ���
�
IT MS 23a- UST BE CC3M LETEQ 2da.Daie Pronounce Dead Ma Day r 23 .Signaturo'o Person Pronounctng Death(Oniy when appltca Itj 23C.license Num er 3
BY PBRSON WHO 1►RONt7UNGE5 OR ,r..�-^['�� �� �� ���•,�`� _ �
CERTIFIES DEATH "� �Z- " l - ;-�-
` {� 1 '1 G �
23d.Date 51 ne (MO/DOy r) 24.Tlme of Death . t "'�-�" `
-� �-� '2,,,� 25.Was Medical Examiner ar Coroner ContacCad? Q Yes � tYo
S
CAUSE OF CIEATN � qpprozima2e �
26.Psrt i. Enter the chain of events--diseasees,i�Jurtes,or compitcacia�s-that directiy caused the deaih. D4 NoT enter terrninal events such as cardtac arrcst, yyy lntervai: �
respiratory arrelt,or ventritular flbrftlaHon without shawing th�attolagy. DO NCST A66REVIATE. Enter qnly ane cause on a Itne.�tdd addthona)(ines if necessarv � Onset to DCiih i.
iMMEDlATE CAUSE --------> a. ,�.i3.n...-� ��---- �
(Finai disaase or cnnditia» Due to(ar as a conseque�ce ot):
rssutting in dcath) ,/� .
b. .//�'�'�..���..
Sequerttta!!y(Ist condittor.s, Due to{ar as a conszquenct af}:
Ff any,ieading to the causa
a
Itsted on IMb s. Enter tfie c.
IINOERIYlNCi CAUSE Oue to(or es a consec{iaence o�: #
� idisaase or in)ury that � _
f
� fnittated tfie evants resulting d. ; �
� !n death)lAST. - Due ta(or as a consequsnce of): � "
� 26.Prrt 11. Enter oth�er i i c o 1 u i fi but not resulYtng in the underiying cause given in Part 1 27.Was an auLOpsy performed7 (
Q-" �y-.�-�. Yes o €
28.We�re autopsy flndln�s avallabic �
� �� - to comptete the csuse af d ath? f�
� . ' - • Yes o ��
29.if Fa 30.Did Tobacco Us�Gontrtbute to Deaih? 31.Manner af Desth �
tVOt pregnant within pas#year �Yes Q Protrably �^1�1�atura! (= Horr�icide k
, � Pre�nant st time of death � Na �tltriknawn �AcGdent � Pendin�Investl�atlon �.
a$' � Nat preyYnant,but pr�gnan#within+12 days of death Q Suicide {,� Could r�ot ba deterr»ined r.
r° Cj Noi pregnane,but prognant 43 days to 1 Year before death 32.Oate of In]ury(Ma/Day/Yrj(Spetf Month) (
[� Linknown if pregnant within the past year � � 33_Tlme of InJury � f:
34�Placr�of lnjury(a.g.hama;constructlon site;farm;schootj 35.Lpcation of InJury(Straet and Number,City,Sta�e,Zlp Code) k.
��. �
,�"� 36.InJury a!Work 3'7.If TransportaUon injury,Spedfy: 38.Describe How fnjury Oceurred: �
� Q Yes , : Cj DNver/Operator � Pedastrian �'
� No j,:}Passenger Q Other{Speeify) �:..
39a�._C_�►�'�fiwr(Ch�ck only one):
('�'�Grrtifytn�phyriclan-To the best of my knowiedge,desth occurred due ta th�causre(s)and manner statcd
�[,'�P,rondunclr+t�Gr►tNylns physlc rt-To the best of my knowledge,death occurred ai the time,date,and place,a�d due to the cause{s)and mant�er stated
+yr Q M�dlpl Exssn/imrr/COroner- n e basis of axamina ,andjor investigatian,In my apknton,death accurred at the time,date,and piace,and due io the cause(sj and manner atattd
"� . Si�l�tatunt o1 prtlMfr. �'`Z"'�""� � Titl�e of certifi�cr. � Licanae Number: �'�'��"��f�El'.�
394.i`time,A nts and Zip Co e of Person Compieting Causa af Death(ltem 26j � 39c.Date 5i ed(Mo/Dsy/Yr)
:�`.�"i��J r o� 5'� �/.s�'✓ �t/ r-c,�r�c�- � z. 4� y'' ,•'�.
� . stra s - tnsmbe�r 41.Registrar s ture 42. e istrar i e at+e Ma qay r
��..��`"`.�' ,e.... b
,� 4�.Am�endma�ts .
� . .� � . � . , . ' , .
;
•' !�Cj (� '''2., u�nc.-.• �
Disposition P`ermit No. v `�O`e-�-✓
,
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4
t
I
� 1
WILL OF
MARY E. WETZEL
I, Mary E. Wetzel of Cumberland County, Cariisle, Pennsylvania,
declare this tQ be my last Wil! and hereby revake all prior Wilfs and
Codicils.
1. I direct#hat al! my just deb�s, funeral expenses, grav�marker
and administrative expenses shall be paid from my residuary
estate as saon as practicable after my death.
2. ! direct that all inheritance, estate, transf�r, succession and
death taxes of any kind whatsoever which may be ��yable
by reason �f my death shall be paid �ut of my residuary
estate.
3. I direc#that my entir� estate be distributed as foliows:
A. i direct that my entire estate go to my husband, Lonas
� �. Wetzel.
B. Shauld my husband predecease me, I direct#hat 5t}°/a
go to Jolene Groger, 25°la ga to Makenzie Groger,
and 25% go to Danieile Groger.
C. Should Jalene Grager predecease me, her share
shall lapse and be divided inta equal shares between
her children.
4. I appoint Lonas L. Wetze� Executor of this my last Will. If
Lar�as L. Wetzel sl���uld predecease me or cease to act in
such ca�acity, f appoint K�rnberl_y WeE��el and Jolene Groger,
jair�±ly.
5. The Executor af tnis Wil! shal! have the power ta distribute
my estate in kind or in cash, or partly in either.
' 6. 1 direct that na Executor acting under this Will shall be
required to enter bond in any jurisdiction.
IN WITNESS WHERE F i have h unta se# my hand this
_ ,,�/�
� day of , 2U1 a.
LAW OFFICES OF �
STEPHEN J. HOGG Mary E. e#zel
19 5.HAN4VER STREET
SUITE 101 � ��
CARLISLE,PA 17413
.
�
, .
The preceding instrument consisting of this and one other page
was an the day and date hereof signed, published and declared by
Mary E. Wetze! as and for her last Wil! in the presence of us, who at
her request, in her presence and in the presence of each other have
subscribed aur names as witnesses hereto.
�
,
. �
.
.
WITNESS NESS
LAW OFFICES OF
�TEPHEN J. HOGG
19 S.HANC}VER STREET
SUITE 101
CARLISLE,PA 17013 ��
� «
t ,
. '
, ,
ACKNC�WLEDGMENT
State of Pennsylvania
ss
County of Cumberland
!, Mary E. Wetze�, the Testatrix, whase name is signed to the
attached or foregoing instrument, having been duly qualified accard`rng
to law, do hereby acknowledge that I signed and executed the
instrument as my last Will, that I signed it willingly and as my free and
valuntary act far the purposes therein expresse�
�
Mary . Wetzel
Sworn to or affirmed and acknowled d efore me y Mary E,
Wetzel, the Testatrix, this_��day of ,
Zo�o. �
: � .x
� ����V'f� � _
��°"�.�,�wo�►p�,�c N ary Public/Attarney
���orm,Cumb��Ca„PA
u'�►+Gam��,�,,���,,���� VIT
���n..:��.0
5tate of Pennsylvania
ss
Gounty of Cumberland
^ r
� ���.. R� ��
We � � l�t and �7 � the
, ,
witnesses whose names are sign�d ta the attached ar foregoing
instrument, being duly qualified according to law, da depose and say
that we were present and saw "the Testatrix sign a�d execute the
instrument as her last Will; that the Testatrix signed wilfingly and
executed it as ner free and volunt�!�r act for the purposes therein
expres��d, that each subscribing witness in the hearing �nd sight of
the Testatrix signed the Will as a witness; and that to the best ofi our
kno ledge the Testatrix was at that time 18 or more years af age, of
so ,d mind and .�nder no constraint o undue influence.
,, .
�
S�rn ta or affir ed and sub cribed to before me by witnesses,
this da of ��'�i^�''�z�� , Q 4.
� Y
..,•`�'
LAW OFPICES QF ����.�t.,
�TEPHEN J. HOGG �°°�'�"�•�•��ry�+ui'�i8ta Public/Attarney
19 S.HANQVER STREET �����►,Cten�berlenel Cp.pA
SUITE 101 ��'°�������e�r g,Z013
CARLISLE,PA 17013 "�"`'"�"'-�"�"."
� f
�
��' pennsylvan�a � �
DEPAR7MENT OF PUBLIC WELFARE
October 12, 241 Z
SALZMANN HUGHES PC
�AMES D HUGHES ESQUIRE
354 ALEXANDER SPRING R4AD
SUITE 1
CARLISLE PA 17015
Re: Mary Wetzel
CIS #: 220309385
SSN: ###-##-5721
_ Date of Death: 06j02J2012
Dear Attorney Hughes:
Please be advised that the Department of Public Weifare maintains a ciaim in the
amount of$38.447.14 against the above-mentioned estate. This claim is for restitution of
medicai 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 �une 3�, I995. Enclosed is the
Department's itemized statement of claim.
A portion of this medical expense, namely �38.447.14, 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 Qecedents, Estates, and Fiduciaries Code, 2tJ Pa. C.S.A. 339�{3}, The balance of the
claim, namely .OtJ, is to be enfiered as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of this letter and advise whether the Commonwealth"s
daim is admitted and when payment may be expected. If the estate accounting is
compiete, piease provide a copy. If the estate contains real estate, piease pravide
copies of'tlte deed, the latest tax assessment, and a current appraisai, if available.
Sincerely,
��
Debra �. Kochel
Ciaims Investigation Agent
717-772-6616
717-772-6553 FAX
Enclosure
..:.�%�i'::?�c.; ,
F3�.are�i.s�`Progr n of Third Party LiabiHty � Recovery Section
PO Box 8486 j Harrisburg,Pennsylvania 17105-8486
� ` COMMONWEALTH QF PENNSYLVANIA
BUREAU OF PRQGRAM fNTEGRITY
, � DlVISlON OF THiRD PARTY LIABIIITY �
RECOVERY SEGTlON '
PO BOX 8486
HAFtR158URG,PR 17105-8486
October 12,2012
STATEMENT OF CLAtM SUMMARY
NAME' Estate of WETZEL,MARY
ID 220 309 385
MEDtCAL CLASS 3 CLASS 5.1 TC?TAL '
INPATtENT AQ .00 .00
OUTPATIENT .pQ .00 AQ
LONG TERM CARE 38,442.25 .QO 38,442.25
DRUG 4.89 AO 4.89
REIMBUR5EMENT T(}DPV1l 38,447.14 .00 38,447.14
CQMM{?NWEALTH OF PENNSYLVANIA
DEPARTMENT OF`PUBL[C WELFARE
EfN- 23-6t}03113
Page 1 of 3
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COMM4NWEALTN!JF PENNSYLVANIA
. ,, .
DEPARTMENT t�F PUBLIG WELFARE
October 12,2412
STATEMENT OF CLAIM
NAME ' WETZEL,MARY
tD 220 309 385
, Ft?REST PARK HEALTH CENTER
700 WA�NUT BUTTt)M RD
CARLtSLE PA 17013
DATE OF SER1/iCE PAYMENT DATE ORIGfNAL CRN ADJUSTED CRN USUAL CHARGES AM4UNT APPROVED
12/01/'11 - 12/39/11 Q6l04t12 55121374'100890001 55121374100890001 6,537.28 6,403.36
DIAGNOSIS 1 : 08881 LYME DISEASE
DIAGNOSIS 2: 0
PROC CODE: OOQ000
01/01/12 - 01131/12 06/1811 Z 55121644184060001 55'121644184Q60001 6,537.28 6,485.51
DIAGNQSIS 1 : 08887 LYME DlSEASE
DIAGNtJSIS 2: 0
PRC?C CUDE: 000000
02/Q4112 - 02/29/92 06/18/12 55121644184040001 55121644'l84840001 6,115.52 6,067.09
DIAGN�SIS 1 : 08881 LYME DISEASE
DlAGNOSlS 2: 0
PROC CC}DE: 000000
03/01/12 - 03131112 t36/18112 55121644184050009 55121644'184050001 8,537.28 6,485.51
DIAGN4StS 1 : 08881 LYME DtSEASE
DIAGNt7SIS 2: 0
PR{JC CODE: 000000
04/01 M 2 - Q4t30112 05/28/12 Zo�����ao27s7aoo� 2012't 234427870001 6,290.70 6,290.70
DlAGN4SIS 1 : 088$1 LYME DISEASE
DIAGN4StS 2: 7288T MUSCLE WEAKNESS(GENERA�tZED}
PROC CC}DE: 000000
05101112 - 05i31J'IZ OS125i12 201215343Q3510001 20921534303510009 6,500.39 6,500.39
DlAGNOSIS 1 : 08881 LYME DISEASE
DlAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED)
PROG CODE: QOQ000
06/01J12 - 06/02t12 07130/12 2012'185402848000'1 20121854028480t�01 209.69 209.69
DIAGNOSIS 1 : 08881 �YME DISEASE
DIAGNOSIS 2: 72887 MUSCLE WEAKNESS(GENERALIZED}
PROC CQDE: OQ4000
PR(?VlDER SUB T4TAL FQREST PARK HEALTH CENTER 3g,72g,14 38,442•25
: 03 101867397 {1Q0'I
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CQMMQNWEALTH C7F PENNSYLVANIA
' DEPARTMENT 4F PUBCIC WELFARE �
October 12,2012
STATEMENT OF CLAIM
NAME WETZEL,MARY
tD ` 220 309 385
GUARDlAN LANG TERM CARE PHARMACY i
123 BRUBAKER RD
BROCKIGVAY PA 15824
DATE{3F SERVICE: PAYMENT DATE Oi�tGINAL CRN ADJUSTEC!GRN USUAL CHARGES AMQUNT APPRC?VED
04/16112 - Q4/16112 05i2$i1 Z 25121215485900001 259 21215485900081 6.66 4.03
DIAGNOSlS 1 : 0
NDC CODE: 002282Q5750 Lt?RAZEPAM 8.5 MG TAB�ET - ATARACTIC3-TRANQUILlZERS
04/17/12 - 04i17i12 05128I12 2512"l215487450001 2512921548745Q001 25.86 .86
DIAGNOSIS 1 : 0
NDC C{JDE: 00228205758 LQRAZEPAM Q.5 MG TABLET • ATARACTICS-TRANQUiLtZERS
PRUVIDER SUB TOTAL �UARDIAN LONG TERM CARE PHARMACY INC 32.52 4.89
24 102290878 0001
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