HomeMy WebLinkAbout11-13-13 IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA ; m
n v m c-)
IN RE: : Orphans Court Di ulon Y
Estate of Margaret Jean Keiter, Deceased : No. 2012-01098 s N w ;o o $
Z Q �I
PETITION FOR SETTLEMENT OF SMALL ESTA?rc�
ry r`
AND NOW, COMES, Debra Keiter and Dean C. Keiter, Jr., by and thrrgugh their-e orneys,
Peter J. Russo, Esquire, and the Law Offices of Peter J. Russo, P. C., and avers the following in
support of their petition for settlement of small estate:
1. The petitioners, Debra Keiter and Dean C. Keiter, Jr., are the daughter and son
respectively of Margaret Jean Keiter, the decedent.
2. Debra Keiter has a physical address of 259A Ridge View Drive, Boone,NC 28607.
3. Dean C. Keiter, Jr. has a physical address of 31 Peach Lane, Carlisle, PA 17015.
4. The petitioners have an interest in the estate of Margaret Jean Keiter.
5. The decedent died on August 11, 2012.
6. Decedent's place of domicile was ManorCare Health Services, 1700 Market Street, Camp
Hill, PA 17011.
7. The above named decedent died testate, the Last Will and Testament has been probated,
and the Grant of Letters has been issued to Debra Keiter and Dean C. Keiter, Jr. on April
19, 2013. A copy of the Certificate of Grant of Letters and Last Will and Testament are
attached hereto as Exhibit"A."
8. The names, addresses, and relationships of all persons having interest in the estate of the
decedent as heirs or next of kin are as follows:
_.;, ..
, . x. . � . ,
..
_ Name Amount
Department of Public Welfare i $24,070.95
Total �+ $24,070.95
12. A time-stamped copy of the Pennsylvania Revenue 1500 Inheritance Tax Return, which
was filed on October 1, 2013, shows the amount of tax due upon the decedent's estate and
paid as set forth therein. A true and correct copy of the Pennsylvania Revenue 1500
Inheritance Tax. Return is attached hereto as Exhibit`B."
13. Ten days written notice of intention to present this petition has been given to the
beneficiaries and creditors in accordance with Cumberland County Orphans' Court Local
Rule 5.3, Time for Notice.
14. It is proposed that the following distribution of the decedent estate be made to the
following creditors, heirs, or next of kin:
_ Name Distribution
Deb Keiter (Reimbursement of probate $133.50
expenses)_____
Law Offices of Peter J. Russo, P.C. (legal $285.44
fees and reimbursement for probate
expenses)
WHEREFORE, your petitioners respectfully requests your honorable court to decree the
distribution of the decedent's personal estate to the persons entitled thereto as set forth in
paragraph 14 above.
Respectfully Submitted,
LAW OFFICES OF PETER J. RUSSO, P.C.
Date:
Peter J. Russo, Esquire
PA Supreme Court I.D. No. 72897
Paul D. Edger, Esquire
PA Supreme Court I.D. No. 312713
5006 East Trindle Road, Suite 203
Mechanicsburg, PA 17050
Telephone: (717) 591-1755
Facsimile: (717) 591-1756
Attorneys for Petitioners
RECORllc13 OFFICE OF
Last Will And Testament REGISTER OF MILLS
Of '`3 9FR 19 FM 12 59
MARGARET J. SEITER
CLERK or
ORPHANS' COURT
I, MARGARET J.MrM, of Cumberland County,Pennsylvania,being c9ld6tflifllnMp Go., PA
disposing memory and full legal age,do hereby make,publish and declare this to be my Last Will
and Testament,hereby revoking all Wills and Codicils heretofore made by me.
PARAGRAPH 1. 1 direct my Executor or Executrix,as the case may be, to pay
all of my debts, funeral and administrative expenses as soon as convenient after my
decease. Furthermore,I direct that all state, inheritance, succession and other death taxes
imposed or payable by reason of my death and interest and penalties thereon with respect
to all property composing of my gross estate for death tax purposes, whether or not such
property passes under this will,shall be paid by the Executor or Executrix of my estate.
PARAGRAPH 2. With the EXCEPTION of the items set forth in this
paragraph, my Executor or Executrix may, at his or her discretion, compromise claims,
borrow money, retain property for such length of time as he or she may deem proper;
lease and sell property for such prices, on such terms, at public or private sales, as he or
she may deem proper; and invest estate property and income without restriction to legal
investments unless otherwise provided hereunder. I authorize and empower my Executor
or Executrix to sell any realty and/or personalty owned by me at my death and not
specifically devised or bequeathed herein, at public or private sale or sales and to give
good and sufficient deeds and/or bills of sale therefor, in fee simple, as 1 could do if
living.My Executor or Executrix is authorized and empowered to engage in any business
in which'I may be engaged at my death, for such period of time after my death as seems
expedient to said Executor of Executrix.
1 give, devise and bequeath to my son DEAN.KFXrER,JR., my residence
located at 122' Peach Lane, Carlisle, Pennsylvania along with all furniture contained
therein.
lnitials:
I give,devise and bequeath to my granddaughter,NICOL E. CROWN,my.
collection of Bells and Spoons located at 122 Peach Lane,Carlisle,Pennsylvania.
PARAGRAPH 3. I give, devise and bequeath the balance of my estate of
whatever nature and wherever situate to my spouse,DEAN C.KUM.
PARAGRAPH 4. If my spouse, DEAN C. KEITER, does not survive me by a
period of at least thirty (30) days, then my estate I give, devise and bequeath in equal
shares to my children,DEBRA K.RILEY and DEAN KEUER,•JR..
PARAGRAPH 5. In the event that one of my children predeceases me or fails to
survive me by 30 days, I then give said deceased child's interest in all of my estate to their
issue of said deceased child in equal shares.
PARAGRAPH 6. In the event that one of my children predeceases me or fails to
survive me by 30 days, and leaves no issue,I then give said deceased child's interest in all
of my estate,to be divided equally,to my surviving children.
PARAGRAPH 7. I nominate and appoint my children,DEBRA K. RILEY and
DEAN KEITER,JR., to be the Co-Executor of this my Last Will and Testament.If either
of my children predecease me, fail to qualify or are not able or do not serve for whatever
reason, then I appoint the remaining child to be the Executor of my estate.
PARAGRAPH 8. No person(s) shall benefit hereunder unless such beneficiary
shall survive me by thirty(30)days.
PARAGRAPH 9. No Executrix or Executor acting hereunder shall be required
to post bond or enter security in this or any other jurisdiction.
Initials: 'U
PARAGRAPH 10. No beneficiary may assign or anticipate his or her interest in
any income or principal held or distributable hereunder, and no beneficiary's creditors
may attach or otherwise reach any such interest.
PARAGRAPH 11. The validity and administration of any trust established
hereunder and any question or disputes relating to the construction or interpretation of any
said trusts shall be governed and construed in accordance with the laws of the
Commonwealth of Pennsylvania.
IN WITNESS WHEREOF,I have hereunto set my hand and seal this. day of May,2001.
MARGARET 7. {MITER
Initials:
The preceding instrument,consisting of this and 3 other typewritten pages,was on the
date thereof signed,by the above-named Testatrix as her Last Will,in the presence of us,who at
her request,in her presence and in presence of each other,have subscribed our names as witnesses
hereto.
Peter J. Russo Melissa M.Mehaffey
5010 East Trindle Road 5010 East Trindle Road
Mechanicsburg,PA Mechanicsburg,PA
Initials:
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
I,MARGARET J. KEITER,whose name is signed to the attached or foregoing
instrument,having been duly qualified according to law,do hereby acknowledge that I signed and
executed this instrument as my Last Will;that I signed it willingly,and that I signed it as my free
and voluntary act for the purposes therein expressed.
MARG�RE�J.REITER
Sworn to and subscribed
before me this 15" day of
M y,2001
Z
Notary Public
OR
�Hc,;i �uG ��=agarT-;,SAC
1.
Initials: 21 .7 .
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
We, Peter J. Russo and Melissa M. Mehaffey, the witnesses whose names are signed to
the attached or foregoing instrument, being duly qualified according to law, do depose and say
that we were present and saw MARGARET J. KEITER, Testatrix, sign and execute the
instrument as her Last Will; and that she executed it as her free and voluntary act for the purposes
therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as
witnesses; and that to the best of our knowledge the Testatrix was at the time 18 or more years of
age,of sound mind and under no constraint or undue influence.
�--�/
Peter J.Russo Melissa M. Mehaffey
5010 East Trindle Road 5010 East Trindle Road
Mechanicsburg,PA Mechanicsburg,PA
17050 17050
Sworn to and subscribed
before me this 15" day of ( M!��TttiE?%1G" taJP�lo'du
May,2001 i v;7, :, �su�,ra:'s5a�:lTrsanU
' - iy";�O:::Ti��s�i7ll�u`a�^u�y?•9,fi1C4
n
1
Notary Public
Initials: Q 9
REGISTER OF WILLS CERTIFICATE OF
CUMBERLAND COUNTY GRANT OF LETTERS
PENNSYLVANIA
No. 2012- 01098 PA No. 21- 12- 1098
Estate Of: MARGARET JEAN KEITER
IFVt Mide .(a:e
Late Of: CAMP HILL BOROUGH
CUMBERLAND COUNTY
0 Deceased
Social Security No: 236-48-2806
WHEREAS, on the 19th day of April 2013 an instrument dated
May 15th 2001 was admitted to probate as the last will of
MARGARET JEAN KEITER
IFI.I.M/tl c lose
late of CAMP HILL BOROUGH, CUMBERLAND County,
who died on the 11th day of August 2012 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARYto:
DEBRA KEITER and DEAN C KEITER JR
who have duly qualified as EXECUTOR(RIX)
and have agreed to administer the estate according to law, all of which
fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYLVANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 19th day of April 2013.
e stet o dls
lY
**NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
RECORCEO OFFICE OF
Last Will And Testament REGISTER OF 1"JILLS
Of -0A OPR 19 Fn 12 50
J
MARGARET KEITER `'
CLERK OF
ORPHANS' COURT
1, MARGARET 1. ICEITER,of Cumberland County, Pennsylvania,being c9tibiikAllh9p Co., PA
disposing memory and full legal age,do hereby make,publish and declare this to be my Last Will
and Testament,hereby revoking all Wills and Codicils heretofore made by me.
PARAGRAPH I. I direct my Executor or Executrix,as the case may be, to pay
all of my debts, funeral and administrative expenses as soon as convenient after my
decease. Furthermore, I direct that all state, inheritance, succession and other death taxes
imposed or payable by reason of my death and interest and penalties thereon with respect
to all property composing of my gross estate for death tax purposes, whether or not such
property passes under this will,shall be paid by the Executor or Executrix of my estate.
PARAGRAPH 2. With the EXCEPTION of the items set forth in this
paragraph, my Executor or Executrix may, at his or her discretion, compromise claims,
borrow money, retain property for such length of time as he or she may deem proper;
lease and sell property for such prices, on such terms, at public or private sales, as he or
she may deem proper; and invest estate property and income without restriction to legal
investments unless otherwise provided hereunder. I authorize and empower my Executor
or Executrix to sell any realty and/or personalty owned by me at my death and not
specifically devised or bequeathed herein, at public or private sale or sales and to give
good and sufficient deeds and/or bills of sale therefor, in fee simple, as I could do if
living. My Executor or Executrix is authorized and empowered to engage in any business
in which I may be engaged at my death, for such period of time after my death as seems
expedient to said Executor or Executrix.
I give, devise and bequeath to my son DEAN.KEITER,JR.,my residence
located at 122' Peach Lane, Carlisle, Pennsylvania along with all furniture contained
therein.
Initials:
I give,devise and bequeath to my granddaughter,NICOL E. CROWN,my.
collection of Bells and Spoons located at 122 Peach Lane,Carlisle,Pennsylvania.
PARAGRAPH 3. I give, devise and bequeath the balance of my estate of
whatever nature and wherever situate to my spouse,DEAN C.KEITER.
PARAGRAPH 4. If my spouse,DEAN C. KEITER, does not survive me by a
period of at least thirty (30) days, then my estate I give, devise and bequeath in equal
shares to my children,DEBRA K.RILEY and DEAN KEITER,7R..
PARAGRAPH 5. In the event that one of my children predeceases me or fails to
survive me by 30 days, I then give said deceased child's interest in all of my estate to their
issue of said deceased child in equal shares.
PARAGRAPH 6. In the event that one of my children predeceases me or fails to
survive me by 30 days, and leaves no issue, I then give said deceased child's interest in all
of my estate,to be divided equally,to my surviving children.
PARAGRAPH 7. I nominate and appoint my children,DEBRA K. RILEY and
DEAN KEITER,JR., to be the Co-Executor of this my Last Will and Testament. If either
of my children predecease me, fail to qualify or are not able or do not serve for whatever
reason, then I appoint the remaining child to be the Executor of my estate.
PARAGRAPH 8. No person(s) shall benefit hereunder unless such beneficiary
shall survive me by thirty(30)days.
PARAGRAPH 9. No Executrix or Executor acting hereunder shall be required
to post bond or enter security in this or any other jurisdiction.
Initials: " U
PARAGRAPH 10. No beneficiary may assign or anticipate his or her interest in
any income or principal held or distributable hereunder; and no beneficiary's creditors
may attach or otherwise reach any such interest.
PARAGRAPH 11. The validity and administration of any trust established
hereunder and any question or disputes relating to the construction or interpretation of any
said trusts shall be governed and construed in accordance with the laws of the
Commonwealth of Pennsylvania.
IN WITNESS WHEREOF,I have hereunto set my hand and seal this.day of May,2001.
mARGARET jlknfEk
Initials: "V�'—
The preceding instrument,consisting of this and 3 other typewritten pages,was on the
date thereof signed,by the above-named Testatrix as her Last Will,in the presence of us,who at
her request,in her presence and in presence of each other,have subscribed our names as witnesses
hereto.
mil.
Peter J. Russo Melissa M.Mehaffey
5010 East Trindle Road 5010 East Trindle Road
Mechanicsburg,PA Mechanicsburg,PA
Initials:
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
I,MARGARET J. KEITER,whose name is signed to the attached or foregoing
instrument,having been duly qualified according to law, do hereby acknowledge that I signed and
executed this instrument as my Last Will; that I signed it willingly,and that I signed it as my free
and voluntary act for the purposes therein expressed.
�1
MARG' T JN.KEITER
Sworn to and subscribed
before me this 15 t day of
M y,2001
Notary Public
1.4i'S{p`.lE'"'••��I^.(�y-F�i�"tirl fi0'iai�f .
�'��:'�� 'ate?•;,��e3
Initials: �Q.
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
We, Peter J. Russo and Melissa M. Mehaffey, the witnesses whose names are signed to
the attached or foregoing instrument, being duty qualified according to law, do depose and say
that we were present and saw MARGARET J. KEITER, Testatrix, sign and execute the
instrument as her Last Will; and that she executed it as her free and voluntary act for the purposes
therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as
witnesses; and that to the best of our knowledge the Testatrix was at the time 18 or more years of
age,of sound mind and under no constraint or undue influence.
Peter J. Russo Melissa M. Mehaffey
5010 East Trindle Road 5010 East Trindle Road
Mechanicsburg,PA Mechanicsburg,PA
17050 17050
Sworn to and subscribed
before me this 156 day of
P 490
May,2001
n
Notary Public
Initials: QV
J
1505610105
REV-1500° 1°""`F1' ;
OFFICIAL USE ONLY
Department d ual7axes N
Revenue Pennsylvania
Bureau County Code Year File Number
PO BOX
Bureau Individual INHERITANCE TAX RETURN
_ Harrisburg,PA 128-0601 RESIDENT DECEDENT i
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
236-48-2806 08/11/2012 10/30/1932
Decedent's Last Name
Suffix Decedent's First Name MI
Keller Margaret J
(if Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
COD 1.Original Return . O 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
O 4.Limited Estate O 42.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12.12-82)
O 6.Decedent Died Testale O 7.Decedent Maintained a Living Trust 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. Elmlion to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Peter J.Russo, Esquire (717)@1-1755 m
CD c>
RBGSli�R OF WILISI SE ONLY7J
M ;- c-) o
First Line of Address I" F''' %-I CJ
5006 East Trindle Road
_.... .. _ . ...... . . .. n ..,,
Second Line of Address
Suite 203
-D —{ �. cn o
City or Post Office Stale ZIP Code '> DATE FILLUT
Mechanicsburg PA 17050
Correspondent's a-mail address:prusso @pjrlaW.Com
Under penalties of pequry,I detlare that I have examined this retum,Including accompanying schedules and statements,and to the best ormy knowledge and belle(
it is Imo,cones and wmpiale.Declaration of preparer other than the personal representative Is based on all Information of which preparer has any knowledge.
—=F=�PONS ILI` R T
ADDRESS
S RE P E R THAN REPRESENTATIVE
ADDRESS Itl
5006 East Trindle Road, Suite 203, Mechanicsburg, PA 17050
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105
REV-1500 Ex(FI) Page 3 Fite Number
Dece&ent's Complete Address:
.;DECEDENTS NAME
Margaret J.Keller
STREETADDRESS
ManorCare Health Services, 1700 Market Street
CITY STATE 21P
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
1 CredltslPayments
A.Prior Payments 0.00
B.Discount 0.00
3, Interest Total Credits(A+8) (2) 0.00
d. If Lure 2 is greater than tine 1+tine 3,enter the difference. This is the OVERPAYMENT. (3) 0.00
Fill In oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If tine t+tine 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00
Make check payable to: REGISTER OF WILLS,AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN"X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred.......................................................................................... ❑ 0
b. retain the right to designate who shag use the properly transferred or its income............................................ ❑ a
c. retain a reversionary interest........__................_.._............._......_.............._..__....................._...............__.._ ❑ a
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 consideralion?........................---._............................... ❑
3. Did decedent on an 9n trust for`or payablempon-death bank account or security at his or her death?.,............ ❑
4. Did decedent own an individual retirement account,annuity or other nomprobale property,which
containsa beneficiary designation? ....................................................................................................................... ❑ 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1,1994,and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent(72 P.S.§9116(a)(1.1)(t)).
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)(ti)],The statute does not exempt a transfer to a surviving spouse from lax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even 9 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 death to or for the use of a natural parent,an
adoptive parent or a stepparent of the chill is 0 percent(72 P.S.§9116(a)(12)).
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in 172 P.S.
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 individuat who has at least one parent in common with the decadent,whether by blood or adoption.
REV-1502 EX+(12-12)
pennsylvania SCHEDULE A
OEPARTMOTT OF REVENUE REAL ESTATE
INNERTTANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OR FILE NUMBER:
Margaret Jean Keiler 2012-01098
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is dented as the price at which property
would be achanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet If the property has been sold.
ITEM Include a copy of the deed showing decedent's interest If owned as tenant in common. VALUE AT DATE
NUMBER OF DFATN
DESCRIPTION
1 1972 New Moon Mobile Home 3,000.00
TOTAL(Also enter on Line 1, Recapitulation.) $ 3,000.00
If more space is needed,use additional sheets of paper of the same size.
REV-i5o8 EX+(o8-u)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERTEANCE
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
Margaret Jean Keiter 2012-01098
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
1. Furniture 300.00
Kitchenware
50.00
Clothing 100.00
Bells and Spoons Collection 50.00
TOTAL(Also enter on Line 5, Recapitulation) $ 500.00
If more space is needed,use additional sheets of paper of the same size.
REV-1509 EX+(ot-Jo)
pennsylvania SCHEDULE F
�i DEPARTMENT D ETU RN PROPERTY
INHERRAN(F TAX REVENUE
RENNN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Margaret Jean Keifer 2012-01098
If an asset became jointly owned within one year of the decedent's date of death,it must he reported on schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A•Dean C. Keiter,Jr. 122 Peach Lane Son
Carlisle, PA 17013
B.
C.
30INTLY OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DAIS OF DEATH
ITEM FORIOUR MADE INCllOE NAME OF rrN Cuu INSTITUTION AND BANK ACCOUNT NUMBER OR SIMIM DATE OF DEATH DECEDENTS VALUE OF
NUMBER TENANT IOINT IDeMMTNG NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OFASSET INTEREST DECEDENT'S INTEREST
J. A. 107106 Metro Bank Checking Account 837.87 50 418.94
TOTAL(Also enter on Line 6,Recapitulation) $ 418.94
If more spare is needed,use additional sheets of paper of the same size.
D'
METRO
BANK 0rri Harrisburg, PA 17111 my metr b0
Ha ank.com
July 19, 2013
Law Offices of Peter J Russo
5006 E Trindle Rd Ste 203
Mechanicsburg PA 17050
RE: Estate of: Margaret Jean Keiter
Tax Identification Number: 236-48-2806
Date of Death: August 11, 2012
To Whom It May Concern:
This letter is in reference to decedent account information you requested for the
individual listed above.
We are able to provide the following:
Account Type:Checking
Account Number: 537581332
Date Opened: October 27, 2006
Primary Owner: Margaret J Keiter
Secondary Owner: Dean C Keiter Jr CQd&A ak CE's
Date of Death Balance: $837.87
Principal Balance: $837.87
Accrued Interest**: $.11
** Please note: The accrued interest will not be paid if the account is closed prior
to the date the interest is scheduled to post.
Please feel free to contact me at (888) 937-0004 if I may be of further assistance.
Sincerely, J
Cindy Stanbery
Support Associate/Deposit.Services
Metro Bank
REV-1511 EX+(10-09)
. :� pennsytvania SCHEDULE H
DEPPPTMENT OF REVENUE FUNERAL EXPENSES AND
INMERRANCE TM RMRN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Margaret Jean Keiter 2012-01098
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
1. Myers Buhrig Funeral Home and Crematory 10,957.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Names)of Personal Representative(s)
Street Address
,city State_ZIP
Year(s)Commission Paid:
1,005.49
2. Attorney Fees:
3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.) 0.00
Claimant
Street Address
GN State_ZIP
Relationship of Claimant to Decedent
4, Probate Fees: 411.76
S. Accountant Fees: 0.00
6. Tax Return Preparer Fees: 0.00
7.
1
TOTAL(Also enter on Line 9,Recapitulation) $ 12,374.25
If more space is needed,use additional sheets of paper of the same size.
1 t.:
yJ t+1 L` 4 f
.. J ctY,n •S7 .7 c
Funeral Home W Cremctoy ,
7 4>
b1Eu-toI .... ._.r ,.zvs+ .y r3�t
Debra Keller
19912 Fairmont Court
Hagerstown,MD 21742 Invoice Number: 10483
Invoice Date: Aug 12,2012
Page: 1
Na eWpe8ps "M 9�>~�D-at$`'o`fDeat�i°' tn,tiifpa_iSTerms''�'r � r�.? �r�ne'ralTDlcector'�1D, '•c$I
1 Margaret Keiter I August 11, 2012 I - Net 30 Days Robert L.Buhrig Jr.
.Rr er an��. mo n
µ A_<
PS Professional Services $3,840.00
FSE Facilities, Staff and Equipment $1;829;00
V Vehicles $1,013.00
M Merchandise .$1,933.00
M Additional Merchandise-Extra Images on Memorial Video $ 13.00
M Additional Merchandise-Video of Service with 8 DVDs -$ 200.00
M Additional Merchandise-Keepsake Um $ 35.00
M Adjustment to Merchandise-Jewelry _ ($ 750.00)
CA-Newspape Cash Advance-Newspapers
CA-Clergy Cash Advance-Clergy - '$ 775.00
$ 250.00
CA-Death Cea 10.00 Cash Advance-Death Certificates $ 6.00 $ 60.00
CA-Flowers Cash Advance-Flowers $ 300.00
CA-Flowers Adjustment to Cash Advance-Flowers ($ 50.00)
CA-Coroner F. Cash Advance-Coroners'Cremation Fee $ 25.00
CA-Reception Cash Advance-Reception $ 400.00
CA-Reception Adjustment to Cash Advance-Reception ($ 100.00)
Thank-you for allowing us to serve ou and our fwniliL
Subtotal $9,773.00
We gladly accept the following forms of payment: Shipping $ 0.00
Cash,Check, Visa,MasterCard,Discover,American Express Sales Tax $ 0.00
Kindly make your check payable to: Total Invoice Amount $9,773.00
Myers-Buhrig Funeral Horne and Crematory Payment/Credit Applied $9,773.00
Past due accounts are subject to interest charges of 1.5%per month. TOTAL DUES :0'0
Nlotking with Those in Grief
Robert"Bob-L.Buhrig,Jr.,PD.S°I`KMw•Willinn,NNW 1..Christopltc,ru
Phone: m7)766-3421 - Fax: (717)795.7 291 • 37 East Win Street • Mechanicsburg,PA 17055 • www.Myers-Buhrig.mm Direclorsr4lyen-Buhrieculn
g � �
Funeral Home �-Cre7na ory P� ah'
lust er• ,�'�fi..' '.�.
1
Debra Keller INVOICE
19912 Fairmont Court
Hagerstown,MD 21742 Invoice Number: 10504
Invoice Date: Sep 14,2012
Page: 1
Name o eea s d - Uate"1,`ti ea h .Pay ent' ms n 1 U�irertor
Margaret Keller August 11, 2012 Net 30 Days Robert L Buhrig Jr
e N,kM be ,Q ant , Deusc, Pt: :Q;'y.Nm...: rtn ..' ., . �7�°I'Paice� uj _
M I 1.00 Merchandise- 11x14 portrait and frame $ 52.00 $ 52.00
M 1.00 Merchandise- 16x20 portrait and tame_ $ 65:00 $ 65.00
M 5.00 Merchandise-Memorial Video $ 10.00 $ 50.00
M 1.00 Merchandise-Candle $ _35.OD . $ 35.00
j M 1.00 Merchandise-Keepsake Urn $ 75.00 $ 75.00
M 1.00 Merchandise-Keepsake Urn $ 75.00 $ 75.00
M 1.00 Merchandise-Pendant $ 832.00 $ 832.00
I
it
ank you for allowing us to serve you and your famil .
subtotal $1,184.00
We gladly accept the following forms of payment: I Shipping $ 0.00
Cash,Check, Visa,MasterCard,Discover,American Express Sales Tax $ 0.00
Kindly make your check payable to: Total Invoice Amount $1,184.00
Myers-Buhrig Funeral Home and Crematory Payment/Credit Applied .- $ 0.00
z>-i-u
Past due accounts are subject to interest charges of 1.6%per month. TO W50!REP
YYalkixg with Those in Grief
Robert-Bob"L.Buhrig,Jr.,vasuNmi,or•Williom"Bill"L.Christopher,rn
Phone (m1766.3421 • Fax: n171795.7291 • 37 Ensi Main Street • Mechanicsburg,PA 17055 • rewu•.Myon-Buhrig.com DircuorsCMyers-Buhrin.com
REV-1512 Ex+(12-12)
pennsytvania SCHEDULE I
DEPARTMENTOF REVENUE DEBTS OF DECEDENT,
INHERTTANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT -
ESTATE OF FILE NUMBER
Margaret Jean Keiter 2012-01098
Report debts Incurred by the decedent prior to death that remained unpaid at the date of death,Including unmimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION
OF DEATH
I Department of Public Welfare 24,070.95
TOTAL(Also enter on Line 10,Recapitulation) $ 24,070.95
If more space is needed,insert additional sheets of the same size.
pennsylvania
DEPARTMENT OF PUBLIC WELFARE
December 13, 2012
PETER J RUSSO ESQUIRE
PETER J RUSSO ESQUIRE
STE 100
5006 E TRINDLE RD
MECHANICSBURG PA 17050
Re: Margaret Keiter
CIS #: 850300291
SSN: ###-##-2806
Date of Death: 08/11/2012
Dear Attorney Russo:
Please be advised that the Department of Public Welfare maintains a claim In the
amount of$24.070.95 against the above-mentioned estate. This claim is for restitution of
medical assistance granted on behalf of the decedent for which the Probate Estate is now
responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective
August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the
Department's itemized statement of claim.
A portion of this medical expense, namely $24,070.95, was incurred during the last
six months of the decedent's life; therefore, it Is a Class 3 claim pursuant to Section 3392 of
the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the
claim, namely .00, is to be entered as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of this letter and advise whether the Commonwealth's
claim is admitted and when payment may be expected. If the estate accounting is
complete, please provide a copy. If the estate contains real estate, please provide
copies of the deed, the latest tax assessment, and a current appraisal, if available.
Sincerely,
A
Angela D. Carter
Claims Investigation Agent
717-772-6612
717-772-6553 FAX
Enclosure
Bureau of Program Integrity I Division of Third Party Liability I Recovery Section _�..�._.
PO Box 8486 1 Harrisburg,Pennsylvania 17105-8486
COMMONWEALTH OF PENNSYLVANIA
• BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
RECOVERYSECTION
v PO BOX 8186
HARRISBURG,PA 1710584W
December 11,2012
STATEMENT OF CLAIM SUMMARY
NAME Estate of KEITER,MARGARET
ID 850 300 291
MEDICAL 3 ` 'CLASS 5.1 :: ,TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 23,596.96 .00 23,596.96
DRUG 473.99 .00 473.99
REIMBURSEME NIT.TO DPW 24,070.95 ,OD 24,070.95
COMMONWEALTH OF PENNSYLVANIA
'DEPARTMENT OFIPUBLIC WELFARE
EIN 236003113 : -
Page 1 of 7
?.: ;:, -�iCOMMONWEALTH OF:PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE'
December 11,2012
STATEMENT OF CLAIM
NAME% KEITER,MARGARET
IID',.. 850 300 291
MANORCARE HEALTH SERVICES-CAMP HIL
1700 MARKET ST
CAMP HILL PA 17011
DAT E. OF DATE ;ORIGINAL CRN ADJUSTEuCRN USUAL'CHARGES AMOUNT'APPROVED
02/01/12 - 02/29/12 08/13/12 20121994020680001 20121994020680001 160.44 166.02
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
03/01/12 - 03/31/12 08113112 20121994020670001 20121994020670001 4,973.64 4,847.16
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
04/01112 - 04130/12 08/13/12 20121994020690001 20121994020690001 4,813.20 4,591.74
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000 -
05101/12 - 05/31/12 08/13/12 20121994020660001 20121994020660001 4,973.64 4,764.78
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
061D1112 - 06130112 08/13/12 20121994020650001 20121994020650001 4,813.20 4,591.74
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
07/01/12 - 07/31/12 08/27/12 20122144188680001 20122144188680001 5,064.24 4,034.68
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
08101112 - 08/11/12 09/24/12 20122474085330001 20122474085330001 1,630.40 610.84
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 6559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
PROVIDERSUB TOTAL MANORCARE HEALTH SERVICES-CAMP HILL 26,418.76 23,596.96
03 102062927 0001
Page 2 of 7
COMMONWEALTH
' P 'W
DEPARTMENT F,ENT LIC ELFARE
X
December 11,2012
STATEMENT OF CLAIM
'NAME:; KEITER.MARGARET
$50 300 291
HEARTLAND PHARMACY PA LLC
7010 SNOWDRIFT RD
ALLENTOYM PA 18106
DATE OF=$ERVICE p
:RN �USUA(CHARGESJ,
031011112 - 03101112 08113112 26122006361090001 25122006361090001 .33 .33
DIAGNOSIS 1: 0
NDC CODE: 00536464410 SODIUM BICARB 650 MG TABLET ANTI-ULCER PREPSIGASTROINTESTINAL PREPS
03/01112 . 03101112 08113112 26122005366210001 25122005366210001 14.24 .33
DIAGNOSIS i : 0
NDC CODE: 00378621005 AMLODIPINE RESYLATE 10 MG TAB - OTHER CARDIOVASCULAR PREPS
03101112 . 03101112 08113112 25122005366220001 26122006366220001 t30 20
DIAGNOSIS 1 : 0
NOC CODE: 00143124001 DIGOXIN 126 MCG TABLET - DIGITALIS PREPARATIONS
03101112 - 03101112 08/13112 25122005366230001 26122006365230001 121.87 14.78
DIAGNOSIS 1 : 0
NDC CODE: 54092019112 PFXTASA 500 MG CAPSULE - NON-NARCOTIC ANALGESICS
03/01112 - 03101112 08113112 26122005366240001 26122005365240001 6.53 2.33
DIAGNOSIS 1: 0
NDC CODE: 00378003210 METOPROLOL TARTRATE 60 MG TAB - OTHER CARDIOVASCULAR PREPS
03104112 - 03104112 00113M2 26122005365260001 25122005365260001 281.60 24.28
DIAGNOSIS 1 : 0
NDC CODE: 00186037020 SYMBICORT 160-4.6 MCG INHALER - BRONCHIAL DILATORS
03107112 - 03107112 08113112 26122006365280001 26122005366280001 27.82 4.91
DIAGNOSIS 1 : 0
NDC CODE: 00246005810 KLOR-CON M20 TABLET - ELECTROLYTES&MISCELLANEOUS NUTRIENTS
03108112 - 03108112 08113112 25122005365330001 25122005366330001 30.33 1.84
DIAGNOSIS I ; 0
NDC CODE: 00246005810 KLOR-CON M20 TABLET - ELECTROLYTES&MISCELLANEOUS NUTRIENTS
Page 3 of 7
" '-7 "
fEALTH.0 F41Eb
. DEPARTMENT OF'o USLIC WELFARE
December 11,2012
STATEMENT OF CLAIM
NAME KEITER,MARGARET
85030D 291
HEARTLAND PHARMACY PA LLC
7010 SNOWDRIFT RD
ALLENTOWN PA 18106
is DATE bF SERVICE CHAR.G...E
8, AMOUNT APPROVED
03108112 03108112 08113112 25122005365350001 25122005365360001 618.36 50.06
DIAGNOSIS 1 : 0
NDC CODE: 54092019112 PENTASA 500 MG CAPSULE NON-NARCOTIC ANALGESICS
03112112 - 03M2112 08113M2 26122015533480001 25122015633480001 19.42 4.40
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.26 MIS TABLET - ATARACTICS-TRANQUILIZERS
03118112 - 03118112 08113112 25122005361450001 25122005361450001 10.64 4.93
DIAGNOSIS 1 : 0
NDC CODE: 00636454410 SODIUM BICARB 650 MG TABLET . ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/20112 - 03/20/12 08M3/12 26122005366390001 26122005366390001 300.91 26.99
DIAGNOSIS 1 : 0
NDC CODE: 00173069600 ADVAIR250-BODISKUS - BRONCHIAL DILATORS
03120112 - 03120112 08/13/12 25122005365400001 25122005366400001 162.24 13.72
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
03123112 - 03/23112 08M3112 25122005365420001 25122005365420001 174.84 6.59
DIAGNOSIS 1 : 0
NDC CODE: 00245003660 PREVALITE PACKET - CHOLESTEROL REDUCERS
03123112 - 03123/12 08M3112 26122005366430001 25122005365430001 14.05 2.38
DIAGNOSIS 1 : 0
NDC CODE: 00143124010 DIGOXIN 125 MCG TABLET - DIGITALIS PREPARATIONS
03126/12 - 03/26/12 08113112 25122015533560001 25122015533550001 19.42 AO
DIAGNOSIS 1 : 0
NDC CODE, 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
Page 4 of 7
i:COMNIONN/EALTH OF:PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE':
December 11,2012
STATEMENT OF CLAIM
NAME. KEITER,MARGARET
ID 1 850 300 291
HEARTLAND PHARMACY PA LLC
7010 SNOWDRIFT RD
ALLENTOWN PA 18106
DATE OF§ERVICE =£PAYMENT.+DATE :"ORIGINAL-CRN 'ADJUSTEgCRN USUAL CHARGES AMOUNT APPROVED
03131/12 - 03/31112 08113112 26122005365460001 25122005365460001 27.82 4.53
DIAGNOSIS 1 : 0
NDC CODE: 00245006810 KLOR-CON M20 TABLET - ELECTROLYTES&MISCELLANEOUS NUTRIENTS
04/09112 - 04/09/12 08113112 25122015534340001 25122015534340001 19.42 4.40
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
04112/12 - 04112112 08/13/12 26122005583780001 25122005583780001 300.91 21.99
DIAGNOSIS 1 : 0
NDC CODE: 00173069600 ADVAIR 260-50 DISKUS - BRONCHIAL DILATORS
04116/12 - 04/15/12 08/13112 25122005362130001 25122005362130001 19.90 7.62
DIAGNOSIS 1 : 0
NDC CODE: 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS
04120/12 - 04/20/12 08/13/12 26122005365520001 26122005365520001 14.05 -2.38
DIAGNOSIS 1 : 0
NDC CODE: 00143124010 DIGOXIN 125 MCG TABLET - DIGITALIS PREPARATIONS
04121/12 - 04/21/12 08113/12 25122005362600001 25122005362600001 10.64 4.93
DIAGNOSIS 1 : 0
NDC CODE: 00536454410 SODIUM BICARB 650 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
04123112 - 04123112 08/13/12 25122005409970001 25122005409970001 310.09 26.79
DIAGNOSIS 1 : 0
NDC CODE: -00597007541 SPIRIVA 48 MCG CP-HANDIHALER - BRONCHIAL DILATORS -
04123112 - 04123112 08/13/12 25122005583820001 25122005563820001 618.36 64.06
DIAGNOSIS 1 : 0
NDC CODE: 54092019112 PENTASA 500 MG CAPSULE - NON-NARCOTIC ANALGESICS
Page 5 of 7
' ° ' ' COMMONWEALTH OF'P,.ENNSYLVANIA ;yt
e ':., 1)EPARTMENTOF PUBLIC WELFARE
December 11,2012
STATEMENT OF CLAIM
'NAME,," KEITER,MARGARET
850 300 291
HEARTLAND PHARMACY PA LLC
7010 SNOWDRIFT RD
ALLENTOWN PA 18106
,DATE QF�SE DATE ,:.ORIGINAL CRN 'i:ADJUSTED CRN USUAL'CHARGES AMOUNT APPROVED
04/25112 - 04/25/12 08/13112 25122015534480001 25122015534480001 19.42 .40
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
04/30/12 - 04130112 08113112 25122005410290001 25122005410290001 162.24 13.72
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
05/09112 - 05109/12 08/13112 25122015534530001 25122015534530001 19-42 4-40
DIAGNOSIS 1 : 0
NDC CODE: 00228202760 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
05114112 - 05114112 08/13/12 25122005362970001 25122005362970001 10.64 .93
DIAGNOSIS 1 : 0
NDC CODE: 00536464410 SODIUM BICARB 650 MG TABLET - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS
05/21/12 - 06121112 08113112 25122005412180001 25122005412180001 618.36 51.32
DIAGNOSIS 1 : 0
NDC CODE: 54092019112 PENTASA 500 MG CAPSULE - NON-NARCOTIC ANALGESICS
05121/12 - 05/21/12 08113112 25122005412310001 25122005412310001 310.09 25.44
DIAGNOSIS 1 : 0
NDC CODE: 00597007541 SPIRIVA 18 MCG CP-HANDIHALER - BRONCHIAL DILATORS
05121112 - 05121112 08/13112 25122005583840001 25122005583840001 14.05 2.38
DIAGNOSIS 1 : 0
NDC CODE: 00143124010 DIGOXIN 125 MCG TABLET - DIGITALIS PREPARATIONS
05126112 - 05126112 08/13/12 25122015534740001 25122015534740001 19.42 .40
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
Page 6 of 7
COMMONWEALTH OF PENNSYLVANIA
- , DEPARTMENT OFPUBLIC WELFARE
e
December 11,2012
STATEMENT OF CLAIM
NAME- KEITER,MARGARET
IDS 860300291
HEARTLAND PHARMACY PA LLC
7010 SNOWDRIFT RD
ALLENTOWN PA 18106
DATE OF._SERVICE ;PAYMENT,DATE ::cORIGINAL.CRN - `:ADJUSTED�CRN USUAL CHARGES AMOUNT APPROVED
05/30/12 - 05/30/12 08M 3112 25122006412700001 25122005412700001 300.91 24.66
DIAGNOSIS 1 : 0
NDC CODE: 00173069600 ADVAIR 250-50 DISKUS - BRONCHIAL DILATORS
06/07/12 - 06/07/12 08/13/12 25122006363450001 25122005363450001 10.64 2.93
DIAGNOSIS 1 : 0
NDC CODE: 00536454410 SODIUM BICARB 650 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
06109/12 - 06/09112 08/13/12 26122005583870001 25122005583870001 27.82 .99
DIAGNOSIS 1 : 0
NDC CODE: 00245005810 KLOR-CON M20 TABLET . ELECTROLYTES&MISCELLANEOUS NUTRIENTS
06109/12 - 06/09112 08/13/12 25122015536010001 25122016635010001 19.42 2.40
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS -
06/13/12 - 06113112 08/13/12 25122005412730001 25122006412730001 162.24 9.53
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
06116112 - 06/16/12 08/13/12 25122006412750001 25122005412750001 618.36 47.81
DIAGNOSIS 1 : 0
NDC CODE: 54092019112 PENTASA 500 MG CAPSULE - NON-NARCOTIC ANALGESICS
06127/12 - 06/27/12 08/13/12 25122005366320001 25122005366320001 19.42 2-49
DIAGNOSIS 1: 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS -
PROVIDER SUB TOTAL: HEARTLAND PHARMACY PA LLC
5,457.64 473.99
24 101710595 0001
Page 7 of 7
REV-1513 EX+(01-10)
i v pennsylvania SCHEDULE J
• DEPARTMENT OF REVENUE
INNERUMCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Margaret Jean Keiter 2012-01098
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustees) OF ESTATE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
I. Dean C.Keiter,Jr. Son 50%
2. Debra K.Riley n/k/a Debra Keiter Daughter 50%
3. Nicol E.Crown Granddaughter Bells/Spoons
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON UNES 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:
3.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF 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.
VERIFICATION
I, Dean C. Keiter, Jr., verify that the statements made in the forgoing document are true
and correct to the best of my knowledge and belief. I understand that false statements herein are
made subject to the penalties of 18 Pa. C. S. § 4904 relating to unsworn falsification to
authorities.
Dated:
Dean C. Keiter, Jr.
VERIFICATION
I, Debra Keiter, verify that the statements made in the forgoing document are true and
correct to the best of my knowledge and belief I understand that false statements herein are
made subject to the penalties of 18 Pa. C. S. § 4904 relating to unsworn falsification to
authorities.
Dated: tPO 1.2
Debra Keiter
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: : Orphans Court Division
Estate of Margaret Jean Keiter, Deceased : No. 2012-01098
CERTIFICATE OF SERVICE
I, Derek M. Strouphauer, Paralegal, hereby certify that on the 12th day of November
2013, 1 have served a true and correct copy of the Petition for Small Estate upon the following
persons, in the manner indicated:
Via Certified Mail, Return Receipt Requested to:.
Department of Public Welfare
Bureau of Program Integrity
Division of Third Party Liability
Estate Recovery Program
ATTN: Angela D. Carter
PO Box 8486
Harrisburg, PA 17105-8486
Via Regular U.S. Mail to:
Mr. Dean C. Keiter, Jr.
31 Peach Lane
Carlisle, PA 17013
Ms. Debra Keiter
259A Ridge View Drive
Boone,NC 28607
Respectfully submitted,
L VAW OFFICES OF PETER J. RUSSO, P.C.
By:
Der ITOU u ale