HomeMy WebLinkAbout08-29-13 (3) � 1505610105
REV-1500 EX(oz-ii)(FI) �
PA Department of Revenue pennsylvania OFFICIAL USE ONLY
�FP^a*^E�*�FwE�E��E County Code Year File Number
Bureau of Individual Taxes INHERITANCE�Ti4X RETURN �"��"� �� � ����"-"��""""��`�
PO BOX z8o6o1 !
Harrisburg,PA i'7128-o6oi RESIDENT DECEDENT �' ' �� 3 v���
;
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
184-12-4901 ; 04/22/2013 i 04/26/1924
DecedenYs Last Name ����� ������ ��������������� �"���Suffix DecedenYs First Name��� MI
_..... _ ..._..... __ ,
FICKES THOMAS � ;
_ . . . . _ _._ _ _..__,
(If Appiicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
._ .. __ _ . ., _��-. � _.. __ __._..�_. : ;_�.. . _.._ _ .._ _._...... ..__.._..__. .._..__. � �
Spouses Social Secunty Number
� � ` ` �� � � � '� � � THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
_ __
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
O 4.Limited Estate p 4a.Future Interest Compromise(date of p 5. Federal Estate Tax Return Required
death after 12-12-82)
C� 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 0 8. 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)
Beriveen 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT— THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
__..
'SANDRA K. HINKEL ; (717) 376-9537
_ _ _._ __ _.... __
REGISTER OF WILLS USE ONLY
C'� '_; _, -'
First Line of Address � • • a'y
___ , ,
_._._._. .._.._...
;NORTH RT 72 �f`' �"'
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_._.... �
Second Line of Address � " --
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City or Post Office State ZIP Code
C,"3 �RATE FILEDI'; - °"
__.,._.. _ ._.__.__�.� _.__________. _�. _ _.� _ ___, . ___.__... _ ___..._�... �..___ .��_._......_ � ,_;. _.� --- 5
;LEBANON PA . �17042 � '�._ �;�
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CorrespondenYs e-maii address:
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.De reparer other than the personal representative is based on all information of which preparer has any knowledge.
��, i _
AD ESS
North Rt 72, Lebanon, PA 17042
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 15056],0105 J
,
� 150561,0205
REV-1500 EX(FI)
DecedenYs Social Security Number
oecedent's Name: THOMAS L. FICKES i 184-12-4901
RECAPITULATION
1. Real Estate(Schedule A). . . ..... ..... .. ........ .......... . .. . ..... ... 1. ; 0.00 :
2. Stocksand Bonds(Schedule B) . ... ............. ...... .. .. ............ 2. : 0.00 ;
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) .. ... 3. - 0.00 !
4. Mortgsges and Notes Receivable(Schedule D)......... . ..... .... ..... ... 4. i 0.00
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. ; 6,786.67 :
6. Jointiy Owned Property(Schedule F) O Separate Billing Requested ... . ... 6. ; 0.00
___.._ _._..��. _�� �� �.....,..__,��_�
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Properry
(Schedule G) O Separate Billing Requested... ..... 7. : 0.00
8. Total Gross Assets(total Lines 1 through 7). .......... .. .. ...... ..... ... 8. 6,786.67 i
9. Funeral Expenses and Administrative Costs(Schedule H). ......... . ... ..... 9. ; 433.50 :
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I). ......... . .... 10. ; 0.00 :
11. Total Deductions(total Lines 9 and 10). .......... .... . . .. .. ............ 11. : 433.50 :
12. Net Value of Estate(Line 8 minus Line 11) ..... .. .. ... .. .. .. ........ .. .. 12. ; 6,353.17 :
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which •-°--°--- --....--._ _,,,_.._.._ ._�....._...�...__.
an election to tax has not been made(Schedule J) .. .... . ... .. .... . ..... . . 13. 0.00 :
14. Net Value Subject to Tax(Line 12 minus Line 13) .. .... . ... .. .... ........ 14. ; 6,353.17 !
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
_..... ._ ......._... . _._..._. . . ........... _._.
trans ers under Sec.9116 ;
(a)(1.2)X.0_ 0 00 ; 15.; 0.00 :
16. Amount of Line 14 taxable �"�.'____.._..�._'.�..".....�.._.._.�._.____ "°�..._,'__""" """°`° """""`_`"„""
at lineal rate X.0_ 0.00 : �6.I 0.00 :
�,.�.�,.,�,�.,.o .W�n.��n,..,��.,�., .�. ' ;�.,.�,�.....�..=,.�m ���.�...�__� �,�.,m..�.�:
17. Amount of Line 14 taxable
at sibling rate X.12 i 0.00 �7,; 0.00 ;
;...._.�. _...a�. ,� �.,..n...._ .w_���.�, ;� ,.�,_„�,..w��.�.,...�..w.�,�..��..�....,.w..,.�..�
18. Amount of Line 14 taxable 6,353 17 :
at collateral rate X.15 ` �g.; 952.98 ;
19. TAX DUE .... .. ..... .. .............................. ...... ........ 19.: 952.98 ;
____........._........._.........................................�._....._....._...._._..........._................._._.........�.........:
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
� 15056102�5 150561�205 �
, REV-1500 EX(FI) Page 3 File Number � / �/ J � � �/,�
Decedent's Complete Address:
DECEDENT'S NAME
THOMAS L. FICKES
STREETADDRESS
MANORCARE
1700 MARKET ST.
CITY STATE ZIP
CAMP HILL PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 952.98
2. Credits/Payments
A.Prior Payments
B.Discount
Total Credits(A+B) (2)
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4)
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 952.98
Make check payable to: REGISTER OF WILLS,AGENT.
.. �9e���� � ���'��%s�--�s' � z_.� ��"��y.���,1 :. �'�":: �',�,r� . a\��� €_ fi'n '"�'��� : a�
.et.<.q>e .s.,,. -wn r2.s,:, i,,,,, .....0 k<��..,» 4w .e s.i/ �:z.6d� c,,,a.> �-✓wia�..m�v . ��iY-mw,���� ..���il�s �a f,..-r<.asv� x,��'...£.y«....+<[ii'�
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 property transferred.......................................................................................... ❑ �
b. retain the right to tlesignate who shall use the property transferred or its income ............................................ ❑ �
c. retain a reversionary interest.............................................................................................................................. ❑ �
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �
2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ �
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ �
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? ........................................................................................................................ ❑ �
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FiLE IT AS PART OF THE RETURN.
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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
is 3 percent(72 P.S.§9116(a)(1.1)(i)].
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 the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)j.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 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at tleath to or for the use of a natural parent, an
atloptive parent or a stepparent of the chiltl 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 decetlenPs lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
. The tax rate imposed on the net value of transfers to or for the use of the decedent's 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.
REV-15o8 EX+(o8-1z)
� pennsylvania SCFIEDULE E
DEPARTMENTOFREVENUE CASH, BANK DEPOSTTS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
THOMAS L. FICKES 21-13-0812
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
�, Northwest Savings Bank,PO Box 128,Warren,PA 16365-Checking A/C#1856019672 4,937.28
2, Northwest Savings Bank,PO Box 128,Warren,PA 16365-Checking AIC#1856032337 1,849.39 '
TOTAL(Also enter on Line 5, Recapitulation) $ 6,786.67 =-
If more space is needed,use additional sheets of paper of the same size.
REV-isii�x+tia-o�}
� � pennsylvanfa SCHEDULE H
DEPAR7MENT OF REVENUE FU N E RAL EXPE N 5 ES AN D
INHERITANCETAXREfURN ADMINISTRATIVE COSTS
RESIOENT DECEDENT
E57ATE OF FILE NUMBER
TNdMAS L. FICKES 21-13-4812
pecedent's debts must be reported on Schedule I.
iTEM
NUMBER DESCRIPTION AMOUNT
A. fUNERALEXPENSES:
1.
B, ADMINISTRATIVE COSTS:
1. Personal Representetive Commissions;
Name(s}of Persana[Representative(s}
Streek Address
City State ZIP
Year{s)Commission Paid:
2. Attarney Eees:
3. Family Exemption: (If decedent's address is not the same as daimant's,atkach explanation.)
Claimant
Street Address
City State_�ZIP
Relationship of Claimant to Detedent
4. Prabate�ees: 133.50
5. Accountant Fees: 3Q0.04 '
6. Tax Return Preparer Fees:
7. _ _
TOTAL(Also enter on l.ine 9, Recapitulation) $ 433.50
If mare space is needed,use additiona!sheets af paper of the same size.
REV-1513 EX+(OL-10) �
� pennsylvania SCHEDULE �
DEPARTMENT OFREVENUE
INHERITANCE TAX REfURN B E N E FICIARI ES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
THOMAS L. FICKES 21-13-0812
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec.9116(a)(1.2),]
1. Robert Snavely, 196 Lewis Rd,Annville,PA 17003 Nephew 1/3
2. Sandra Hinkel,North Rt 72,Lebanon,PA 17042 Niece 1/3
3. Shirley Warner 320 Coffee Town Rtl Dillsburg,PA 17069 Friend 1/3
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
L
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
L
TOTAL OP PART II— ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed, use additional sheets of paper of the same size.
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1
WILL OF THOMAS FTCKES
I, THOMAS FICKES, of Middletown, Dav.phin. County,
Pennsylvana,a, declare �.his to be my last will and revake any wi].l
previously made by me.
ITEM I. I give a1.3. my automabiZes, and a3.1 other articles af
per�onal. and hausehold use, together with all insurance relating
thereto, to m� nepheca, R�BERT Ch[ARLES SNAVELY and my niece, Sp�NDRA
Ft. HINKEL, �.o be divided among them as they may agree or, in �.he
absence of agreement, as my executor may think appropriate.
ITEM II . I give all the residu� o�' my es�.ate, real and
personal., in. equal shares, to my nephew ROBERT CHARLES SNAVELY
and my niece, SANDRA K. HINKEL, provided �hat the share of any
niece ar nephew who predeceases me ar dies on or befare the
thirtie�h day following my d.eath shalS be distributed ta his ar
her issue per s�irpes Iiving an the thirty-firs� day fallowing m�
death and in default of any such then-living issue such shares
sha1.1 be added �.o the share for my other niece ar nephew.
ITEM III . No interest in incame or principal shall be
assignabJ.e by, or available to anyane having a claim against, a
beneficiary befc,re. actual payment �o the benefi.ciary.
Page 1 of 4 Pages .
ITEM SV. All federal, state, and other death taxes payable
on �he praperty farming my gross estate for tax purposes, whether -
or not it passes under this will, shall be paid out of the
principal a� my residuary esta�e just as if they were my deb�s,
and none of tho�e taxes sha11 be charged against any beneficiary.
ITEM V. I authorize my execu�or:
A. �o retain and to invest in aIl forms af real and
personal praperty, regardless of {i} any lzmi�ations impo�ed by
Zaw on investments by exec�tors or tru�tees, (ii) an� principle
of law concerning delegatian �f investment responsibility by
executor� or trustees, or (iii) any principle of law concerning
inve�tment diversification;
B. to compramise claims and t� abandon any praperty
which, in my executor's apinian, is o� li�tle ar no value; �o
borraw �ram, and to se11 property to others, and to pledg�
property as security fQr repayment af any funds barrawed;
C. ta se11 at public or private sale, ta exchange or
to lease for any periad of time any real Qr personal property, and
t� give optians for sale� or leases;
Page 2 of 4 Pages,
D. to �oin in any merger, reorganization, voting-trust
plan or ather concerted action of security holders, and ta .
delegate discretianary duties with respect thereto;
E, t� use adrninistra�ive or other expenses of my
estate as income tax or e�tate tax deductions and to value my
estate for tax pur��ses by any optianal method permi�ted by the
law in farce when T die, withaut requiring adju�tments between
income and principal for any resul�ing effect on income ar estate
taxes; and
F. to distribu�e IN KIND and to allacate speci�ic
assets among the beneficiaries in such proportions as my execu�or
may think best, s� long as the tatal mar�et value of any
beneficiary's share is not affected by such allocation.
These authari�ies shall extend to al2 �eal and persona�
property at an� tim� held by my executar and shall continue in
fulZ force until the actual dis�ributian of all such property.
Al1 pawers, autharities, and discretion gran��d by this
will sha11 be in addition to those granted by law and shall be
exereisable without leave of court .
Page 3 0� 4 Pages.
ITEM VI. I appaint m� nephew, RaBERT ChCARLES SNAVELY,
executar under this will, �hould my nephew, ROBERT CHAI�LES -
SNAVELY, fail to quali�y or cease to act as executar, I appaint
my n.iece, SANDRA K. HINKEL, executor under �his will. No personal
representative appointed hereunder shall be required tra give band
or furnish sureties in any jura.sdiction.
ITEM VII. The terrn "executor". and "trustee" or any pronoun
used to indicate the executar, �.rustee, any other fiduciar�r or any
beneficiary� shal3 be deemed to apply to ane or mare than one
person or corporation and ta the mascaline, feminine or neu�er
gender as the case may be.
IN WITNESS WHEREOF, I have hereun�o set my hand and �eal. to
�his, my last will, this G—�-��ay of May, 1994 .
�
���Z�I`���!� t sE�)
HOMAS FICKES
SIGNED, SEALEL}, PUBZISHED, and DECLARED by the aboVe
�estator, a� an.d for his last wil.l, in the presence of u�, who
thereupon at hi� request, in hi� presence and in the presence af
each other, have hereun�.o subscribed our names as witnesse� .
� �� � L'���'1/l.rt�,1'`--�. ,
� � ,
Page 4 0� 4 Pages .
. ' .
STATE C7F FENNSY'LVANTA }
( ss :
CaUNTY OF DAUPHIN } .
� ����� ,
We, �H�3 S F I CKES, -����'���/� 7 , and
� �
�Q.�� �� �'� �he �estator and witnesses, respectively, whose
names are signed to the attached or foregoing instrument, being
first dtzly �worn do hereby declare to the undersigned au�hori.ty
that the testator signed and execu�.ed the instrument as his last
will and that he had signed. willingly and that he �xecuted it as
his free and voluntary act for the purposes therein expressed, and
that each of the witne�ses, in the presence and hearing of the
testator, sa.gned the wi11 as wi�ness and that �o the b�st af dur
kn.awl.edge, �he testator was at that time eighteen years af age or
older, of sound mind and under no constraint or undue influence.
. �����
CdJ �-���'
TH(JMAS FICKES
- � �,,��L�� "
Wi�.ness
'W�.tnes�
SUB�CRIBED, sworn �o ar af�irmed, and acknc�wledged befare me - _
by the above-named testator and by the witnesses whose names
appear above on �� , 1994 .
� (,��t-�C- � "`�d
No�ary ubl�.c
� NC�I�THW��T
SAVINGiS BANK Cl��C�it�G ACCt�UNT �TAT�ME�IT
Where people r�iake the difference.
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This Cycle YFD
Tata!returned item fees 0.00 0•00
o Totaloverdraft fees 0.00 0.00
� Total fees charged 0.04 d.QO
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� This Cycle YTD
Refund of returned item fees Q.00 0.00
Refund of overdraft item fees 0.00 0.00
Total fees refunded f���� �-Q4
GET CfJNNECTED WITH FREE ONLINE BANKING AND BILL PAY,
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NNORTHWEST c������� ����u�T STAT�IV[�NT
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Where people make the difference.
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^' i THOMAS L. FICKES, BY ROBERT SNAVELY,
� � FEDERAL FIDUCIARY �� � ;��� ��'s7'���e����`'° �����f
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o ANNVILLE PA 17003-9132
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�IIOS805 REV(9/1 U .
.� LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: it is illegal to duplicate this copy by photostat or photograph.
Fee for this cert"ificate, $6.00 ,, �„������°' --- hf__ This is to certify that the information here iven is
- . ,��'�p�SH Of pFy g
�� corre�tly copied from an original Certificate of Death
`;o� ` - _-_ �` duly filed with me as Local Registrar. The original
� � ` • 2, certificate will be forwarded. to the State Vital
� � � ,� _
?� - ,�. a� _ ecords Office pe ner�t filrng.
;* *; �
P �. � 5 � 6 � 62 _, ,
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Certification Number �9jMENT�F�E
,„,,,,,,��f"''���11
Local Registrar Date Issued
Type/Print In GOMMONWEALTH Of PENNSYLVANIA�DEPANTMENT OF HEALTH�VITA�RECORDS
°efR1d"`"` CERTIFICATE OF DEATH
Black Ink State File Number:
1.Oecetlent's Legal Name(First,MldGle,Last,Suffix) 2.Sex 3.Social Sec�rity Number 4.Date of Death(MO/Day/Y�)(Spell Mo)
'IHOMAS L. FZCKES Male 184-12-4901 April 22, 2013
�\ Sa.AQe-Last Birthtlay(Y�s) Sb.Unticr 1 Yea� Sc.Untl�r 1 Da 6.Date of BIKh(MO/Day/Year)(Spell Manih) 7a.Btrthplace(City and Ststa or Forelgn Country)
88� M�.onths oav. H���s �+���t« .April 26�, 1924.�� '
� � 7b.Bfrthplace(COUnty
Sa.Rasidence(State or Forelgn Country) 8b.Razitlence(Street antl Numbsr-Indude Api No.) 8c.Old Decedent Llve In a Township7 � �
PA �: � � ManorCar'E �� . � � p�re:,deced��c�wea i., � . . - cwP.
8d.f� ide{+ (Cq nSyl � � � . - � � � -� .
C.LICTl�2rland ge.Resitlence(Zip Code) . �NO,decedenY Iived within Iimits of C+8R1� Hl ll eity/boro.
9.Ev�r in US Armed Forces7 30.Marital Status at Tlma of Death Q Married [�Witlawetl 11.Surviving Spouse's Name(If wif�,give name prlor to first marriage)
�Yes 0 No 0 Unknown �Divorced �Never Marrled �Unknow
12.Father'z Name(Fl�st,Middlc,Last,Suffix) 13.Mo2her's Name Prior to Fi�st Mar�lage(First,Midtlle,Last)
CI-iarles J. Fickes Ottilla Myers
14a.Informant'z Name 14b.Relationship to Decedeni 14e.Informant's MailinQ Address(Stre�c and Number,City,Stat�,Zip Cotle�
� Robert C. Snavely Nephew/Executor 196 Lewis Rd. , Annville, PA 17003
..:...a�e.�,,.,e ez...
G .-"".............. � .._..........._.._....._ .. ......................................a _e�._o.,yo u.,e....��..._.... """. ..... . - .... .....
a Hospital: � �Inp H t �. ;If Deaih Occurred 5 h p p ca �ty���� � � ���
c If Death Ocw . C I ro Othe�Than a Hos Ital: �Hos I F ili . � �D d nt'S H a
Sy 0 Emergency Room/OuTpatlenf - � 0 Deed On Arrival 3 Nuning Home/long-Term�Gre Pacilicy� Other(Specity) � � �� �
a2 15b.Facility Name(1�not instltu[lon,giva stroet and��mber; 15c.City orTOwn,SSaCe,antl Zip CoOq � _ 15d.County of Death � . . .
Mano re a A 1
�, 16a.Method of Dlsposition � Burial 0 Crematlon 16b.Date of Olsposftlon 16c.Place of Dlspositlon(Name of cemetery,crematory,or other place)
� p a�,,,o,,.i frort,seac. o oo„at�o., Apr 29, 2013 Hershey Cemetery
� Other(Spacify)
� 16d„i catiop f Dlspo�iqn(Cyi�g[��n,S�ete,antl Zip) � . � 17a.Signature of funeral Servlce Licensee or Penon In Charge of Interment 17b.llce�se.Number
LYerSl'lEY� t'A 1 V �..� - o��� � !'lOfa 4' -G--
.� 1��FAC��KLER PWLCEDFMANVFr��UNERAL HOME 23rd & Der Sts Har i
°a� 18.DeeedenYs Edueation-Check the boz that best describes the 19.Decedent of Hispanic Origin-Check th< 20.DecedmYS Race-Check ONE OR MORE racez to Indicate what
�.- hYghest degro r lavel of school complated at the time of death. box That best doscribes whether the decedcnt the decedent considerad hlmself or h�rself to be.
Q 8th grade or less �s Spsnish/Hlspanlc/laHno. Check the"NO" [g Whita � Korean
Q No diploma,9th-12th grade box if dec�dent is not Span(sh/Hlspani4utino. 0 Black or African American Q Vietnamese
Q High school graduatc or GED eompteted [}�NO,noC Spanish/Hlspanlc/Latino Q AmeNCan Indlan or Alaska Nativa Q Other Aslan
� Some college credit,but no Cegree 0 Ves,Mexican,Mexican Amerfcan,Chicano 0 Aslan InElan � Native Hawailan
� AssociaTe d�grea(e.g.AA,AS) �Ves,Puerto Rlcan �Chinese � Guamanlan or Chamorro
� Bachelor's degree(e.g.BA,AB,BS) �Yes,Cuban �FIIiPino � Samoan
0 Masiar's tlegrce(e.g.MA,M5,ME�g,MEtl,MSW,MBA) �Vwa,othe�Spanish/Hispanic/Latino �Japanese O Othe�Paclfle Islandar
� Doctorate(e.g.PhD,EdD)or Professional tlegree (Spacify) �Other(Specify)
.MD DDS,DVM LLB JD
21.Dac�denYs Single Race Self-DesignaHan-Check ON�Y ONE to intllcate what the Eecetlent consldered himself or herselP to be. 22a.Decedent's Usual Occupatlon-Indicate type of work
�WM1ite �Japanese 0 Samoan done during most of working ilfe. �O NOT USE RETIRED.
Black or African Amerlcan 0 Korean �Other Padflc Islander Bank Mana eY'
0 American Indlan or Alaska NaHVe �Vletnamese � Oon't Know/NOt Sure g
� 0 Asian Indlan Q OtherASian �Refused 22b.Kintl of Business/Industry
� p cni.,ezo p Necn.e H.w.ne., p ocner(sae��+v> Bank.ing
Q FIIlpino O Guamanian or Chamorro
ITEMS 23a-23d MUST BE COMPIETEU 23a.Oaie Pronounced Deatl Mo Day/Yr) 23b.Signafure o P son Pronouncing Doath nly whmn applicable) �23c.license Numbe�.�...
BY PERSON WHO PRONOUNCES OR �� ��/� �'1 2Z Lp��j . � . .
CERTIFIESUEATH � ��� ��� ' !�'� �.�i _. ✓1 ' � cc.
23tl.Daie Slaned(MO/Day/Y�) � 24.Tlm of Death . - . � � '�--�v��Z•�r-'�'T�
2Z� 10) � 3 Q riW� 25.Was MeGlea Examl�er or Coroner Con ccetl7 � Yes
� .� � � � � . CAUSE OF DEATH �� � �� -� � .� � f �,aaa�o.i,,,.ce
26.Part 1. Ent�r fhw chain of eventz--tliseases,Injurles,or complicatlons-that directly ca�sed the tleath.�00 NOT enter tarminal avants sueh as urdlac arrest. Intervat:
respiratory arresC,or ventMCUlar flbrlllaHOn wlthout showl g the eti logy. DO�ABBREVI@TE. EMer�n a Iine. Add addiilanal Ilnes if nettssary Onset to Death
�y ��u e,
IMME�IATECAUSE --------> li ��`
(Final tlisease or conditlon Due to(orOas a conaequ��ncaR���
res�ic�.,a��aeasn) �
b.
Saquentially list conditlons. � �uelo(o�as a mnsequence of):� � � � . .. - � .
If any,leading to the cause . � . � . � - . � � . . . . � �
Iisted on Ilne a. EnCer xhe� � �
UNDERLYING CAUSE ' � Due to(or as a cansequanee ofl: � - �� .� � � �
(dizease or Injury that . � � � . � � . � � .
•.. Initiated the events resuliing � d. � �� � �
� in death)LAST. Due to(or as a ronsaquence ofl: ��
� 26.Pavt 11. Entar otha� n 1 1 n Sr in but noi resultln�In tha unticrlying cause given In Part 1 . � . 27.Was an�autopsy psAormed?
O Y!5 No
� � �� � .. � . . � 28.Wara su[opsy flntlings available
� \_ � � . � � . - to complete ihe cause of daaih7
-4 'Y9 Yes O No
� 29.If Femaia: � . 30..Did Tobacc e ContrlbuSe to Death7 31.Manner of Daath �
E � Not pr�6�ant wlihln yaar 0 Yes SD Probably urai 0 Homicide
� 0 Preg�an!at cima of deaYh � No IZUnknown 0 Accidmc � Panding InvestigaSlon
� Noe prrgnant,but pregnani wlehin 42 days of dsach � � Suicide � Could not be d�terminetl
� � Not p�egnant,but pregnant 43 days fo 1 yea�befo�e deaCh 32.Date of InJury(MO/Day/Y�)(Spell Month)
0 Unknown If pregnant within the past year 33.Time of Injury
1._ 34.Place of InJury(e.g.home;constructlon slte;farm;school) 35.location of Injury(SYreet and Number,Ciiy,State,2ip Gode)
�
` 36-In)ury at Wo�k 37.If T�ansportailon Injury,Specify: 38.Describe How Injury Occurred:
4 �yas �Driver/Oparator � Pedesirian
� 0 Na 0 Passenger � Oiher(Spacify) '
39a.CertlFl .(Check only one):
t7 rtlfying physi[ian-To the best of my knowledge,dea[h oecurred dua to Che cause(s)and manner sfatetl '
� 0 Pronouncing 8.C�rtifying physlcian-To She besc ot my knowletlge,Geath occurroC af She tlme,date,and plac�,and due to the cause(s)and manner statetl
�. O MeElcal Examiner/Coroner-On the basis of exa and/or Investlgatlon,In my opinlon,death occurred at The Time,daie,and plaee,and due to the�c(a�use(s)and m�ajnner sta�c/ed
� Slgnaturc of cartifie. Title of certifler. Llcense Number:�'Y/ 0�Zb 6� C.�
39C.Name,Addross and Zip Code o evon mpl�ting Caus of Omth(ICem 26) '� � // 39c. te Sig (MO/Day/Yr),
� 4O.Registrar'S DlsSriCt Numb�r . . � 41. i tfar s Slgnaturc � � }� 42.Re ar Flle ce(MO Oay� .
� - r 3 ao l3
� 43.Amendments . . , . .. . . . ...
� �
08 5 7564 Hlos-143
Dispozitlo�P�rmli No. REV O7/2011
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