HomeMy WebLinkAbout12-12-13 c
� 150561D14D
REV-1500 °` �°,�,°'
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Ind'nridual Taxes Cou�y Code Year File Number
Po eox zsoso� INHERITANCE TAX RETURN � 1 1 3 1 1 9 6
Harrisbur�,PA 17728-0B07 RE3IDENT DECEDENT
ENTER DECEDEN7 INFORMATION BELOW
Social Securily Number Date of Death NnADDYYYY Date of Blrth MM�DYYYY
2 0 7 2 2 2 1 9 1 1 0 0 6 2 0 1 3 1 2 3 � 1 9 3 D
Deoedent's Last Name Suffix DecedenYs First Name MI
G R 0 S S A N N A M
(If Applicable)EMer 3urvivfng Spouae's IMormatlon Below
Spouse's Last Name Suffix Spouse's First Name Mi
Spouse'a Social Security Number
THiS RETURN MUST BE FiLED IN DUPLICATE WITH THE
REGISTER 4F WILLS
FlLL IN APPRpPRIATE OVAL8 BELOW
Q 1.Original Retu�n � 2.Supplemental Returrt � 3.Remainder Retum(date of death
prior to 12-13-82)
� 4.Limited Estate � 4a.Future Interest Compromise{date of � 5.Federal Estate Tax Retum Required
death after 12-12-82)
� 6.Decedent Died Testate � 7.Decedent Malrrta[ned a Living Trust � S.Totai Number af Safe Deposft Boxes
(Attach Copy of Wil� (Attach Copy of Trust)
� 9.Litigation Proceeds Received � 10.Spousal Poverty Credit(date of death � 11.Eledian to tax under Sec.9113(A)
beMreen 12-31-91 and 1-1-95) {Attach Sch.O)
CQRRESPONDENT-THIS SECTION AAUST BE COINPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFOdtMAT1pN SHOULD BE DIRECTED T0:
Name Daytime Telephone'Number
M A T T H E W A • M c K N I G H T 7 1c 2 4 '9 2�J� 3
0
R�13, R OF MVII�IfSE�1L�
ITi � c"� ..� C7
� -�. f`� F—` ��� t'o�
First line of address r-- , rn � ;�.� c�
..
"'�• � �A i
G� ' C�
I R W I N & P1 c K N I G H T , P . C • . �
� � --� _�� ._:�t
` _�i � w_ 7
Second line of address ;'� � � ` = �,y
_ �:, c� E__ r,�
6 0 W E S T P 0 M F R E T S T R E E T -��, �� r.�,, v7 a
City ot Post Office StaGe ZIP Code ` �ATE F1f]SD
C A R L I S L E P A 1 7 0 1 3
CorrespondenCs e-ma11 address:
Under pena ' of pery'ury,1 declare that I have examined this retum,indudir►g acoompanylna schedu6es end statementa,a�to ihe best of my knanrledge antf bellef,
it fs true, and c:omplete.Ded tion of preparer other than the peroonal repreaentaUve ia based on all infarmation of which preparer has any knowledge.
SIGNATU OF PER50N SP IBL OR FILING RETURN DATE
c2 • ZDr3
��
934 W• TRINDLE ROAD MECHANICSBUR6 PA 17055
SIG RE F PAijER OTHER THAN REPRESEPITATNE pq'pE
� � '� -
ADDRESS
60 WEST POMFRET STRE�T CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 150561�140 1505610140 � � �
�,,
� 15�5610240
REV-1500 IX
DecsdeM's Social Security Number
oacaeenea Name; A Pt fd A M• G R 0 S S 2 0 7 2 2 2 1 9 1
�ECaarruu►noN
1. Real Eatate(Sc�edule A) ........ ......... .......................... t. �
2. Stocks and Bonds(Schedule B) ........ . ................ .... .... ..... 2. •
3. Closely Held CoTporaa�on,Parh�ership o�Sote-Proprktorah�(SchedUle C) ..... 3. •
4. MortOeges and Notes Ret�ivable(Schedule D} .. ........... ... .......... 4. •
5. Cash,Bank Deposits end AAiscellaneous Personal Property(Schedule E)...... . 5. •
6. JolnUy Owned PrcPerty(Schedule F) ❑ Separate Billfng Requested ...... . 6. •
7. {Mer-Vivoa Transfers 8�M€scellaneoua robate Property
tsd�a��e�� �Separate Billing Requested ....:. . 7. � . D 0
8. Total(ir+oss Assets(total lines 1 through 7) ................... ........ 8. � . 0 0
S. Funerel E�ensea and Admfnietrativs Cosb(Schedule H) .................. 9. 6 4 3 . 5 0
10. Oebts of Deadent,MorEqage Lfabllities,and Liens(Schedule I) ............. 10. •
11. Total Deductions(totai Lines 9 and 10) ............................... 11. 6 4 3 . 5 0
12. MsL Valus of Estate(Line 8 minus Line 11) ........ ............... ..... 12. - 6 4 3 . 5 0
13. Charitable and Govemmental Bequests/Sec 8113 Trusts for whidi
an ebction to tax has not bean macb(Schedule J) ...................... 13. .
14. �t Valus Subjsct ta Tax(Line 12 minus Line 9 3) ............ .......... �a. - 6 4 3 . 5 0
TAX C.ALCULATION-SEE IMSTRUCTIONS FOR APPLICABLE RATES
i5. Amourn of Line 74 taxaDle
at the spousal tax rate,or
Mansfers under Sec.911B
(�)(1.2)X•� _ �} . � � 15. �. {] �
1fi. Amount of Line 14 taxeble
ec i�neai rat� x.oa3 0 . 0 � �s. 0 . � 0
17. AmourK of Line 14 taxable
at sw�ng rate x.�z � . 0 0 ��. 0 . 0 0
18. Amount of Line 14 taxable
ac ooi�arorai�te x.�s 0 . 0 0 1g. 0 . � 0
19. TAX DUE ....................... ............................... 19. � • � 0
20. FlLL IM THE OVAL IF YOU ARE REUUESTING A REFUND OF AN OVERPAYAAENT �
Side 2
L Z5a561024� 15D5610240 �
REV-1500 EX Paqe 3 Flle Mumbe►
[5►ecedent's Complebe Address: 2� 13 1196
DECEDENTS NAME
ANNA M, GROSS
STREETADDRESS
1000 CLAREMONT DRIVE
CtTY STATE ZIP
CARLISLE PA 17013
Tax Payments and Credits:
�• 1"ax Due(Page 2,line 79) (1) 0.00
2. CrediislPayments
A.Prior Payments
B.Disoount
Total C redits(A+B) (2) 0.00
3. Interest
t3)
4, if Line 2 is grealer than Line 1+Line 3,enter d�e difFerence.This is the OHERPAYMENT.
Fill in oval on Page 2,Line 20 to r�eques#a refund. (4) 0.00
5. if Line 1+Line 3 is greater than Line 2,er�er the difference.This is the TAX DUE. {5} 0.00
Make check payable#o: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did dac:edent make a transfer and: Yes No
a. retain the use ar income o�the property bansferred: ...................................................................... ❑ 0
b. retain the right to designate who shaN use the property transferred or its income; ............................... ❑ �
c. retain a reversionary Interest;or ................................................................................................ ❑ 0
d. r�eive the promise br life of either payRrents,beneflts or care7 ....................................................... ❑ �
2. If death occurred after December 12,1982,�d decedent trarisFer property v�ithin one year ofi deaih
without reoeiving adequate consideration? ....................................................................................... ❑ 0
3. Did decedeni own an'in hust for or payable-upon-death aank acoouni or security at his or her death? ......... ❑ �
4. Did decedent awn an individual r�irement aocount,annuiry or othe�'non-probate property,which
contains a beneflaary designatlon?.................................................................................................. 0 ❑
IF THE ANSWER TO ANY OF i'HE ABONE QUEST[ONS IS YES,YOU MUSI'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 sunriving spouse is
3 percenf[72 P.S.§9116(a}(1.1)(i)].
Fo�dates of death on or after Jan:1, 1995,the tax rate imposed on the net value of transfsrs to or for the use of the surviv�ng spouse is 0 percent
(72 P.S.§9116(a)(1.1)(li}],The statute does not exempt a transfer ta a surviving spouss from tax,and the statutory requirements for disclosure of assQts and
filing a tax retum are s�ll applicable even'rf the surviving sPouse is the only beneficiary.
F�dates of death on or after July 1,2000:
• The tax rabe imposed on the net value of transfers from a dec�ased child 21 years of age or yflunger at death to or for the use of a naturai parent,an
adopave parent ar a stepparent of the child is 0 percent(72 P.S.§9116{a}(1.2)].
+ The tax�ate impused on the net value of transf�rs to or for the use of the dec�denYs lineal benehaaries is 4.5 perc;ent,except as noted in
72 P.S.§9116{1.2j[l2 P,S,§9116(a)(1)j.
� The tax rate imposed on the net value of b�ansfers to or for the use of the decedenYs sibEings is 12 percent[72 P,S.§9116�a){1.3)�.A sibling is defined,under
Secfion 9102,as an individual who has at least one parent in common with tha dec�dent,whether by blood or adoption.
REV-1511•EX+{10-U9)
� pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERfTANCETAXRENRN ADMINISTRATIVE COSTS
RESIOENT�CEDENT
HSTATE OF FlLE NUMBER
ANNA M. GROSS 21 13 1196
OecedaM's debts mast be reported on Scksdnle[.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B, ADMINISTR,4TIVE COSTS:
1. Personal Repreaentative Commissions:
Mame(s)of Personal Represer�ve(s)
Sb�eet Address
��Y S�a ZIP
Y�r(s)Cammissbn Paid:
2, n�neyFees: fRWIN 8 McKNIGHT, P.C. 600.00
3. Famiy Exemplion:(If de�enYs addr�s is n�i d�e same as daima�s,at�h explana�oo.}
Claimaat
StreetAddress
��f+ SYate ZIP
RelaBonship of ClaimaM�O Decedent
4, Probate Fees:
� AccourdaM Fees:
6, Tax Retum P�eparer Fees:
7. REGISTER OF WILLS-FILING FEE 43.�0
TOTAL(Also enter on Line 9,RecapilulaRion) S 643.50
If more space�S needed,use additlonal sheets of paper of the same size.
REV-7513 EX?{01-10)
� pennsy�vania SCHEDULE J
°�°'�""'�NTOF`�"�� BENEFICIARIES
INHERffANCE TAX RETURiV
RESIDEPtf DECEDENT
ESTATE OF: FILE NUMBER
ANNA M. GROSS 21 13 1196
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON{S}RECEiViNG PROPERTY Do Not Liet Tn�atee(s) OF ESTATE
I 7AXABLE DISTRIBU710NS pr�dude�M spousal distribub�ons and transfers under
Sec.91 6(a�(1.2}.]
1. DORIS L. DUNHAM Lineal
934 W. TRINDLE ROAD 4/2 REMAINDER
MECHANICSBURG, PA 17055 LIFE INSURANCE
2. RANDY L. GROSS Lineal
173 VINE STREET,APT E 1/2 REMAINDER
SHIREMANSTOWN, PA 17011 LIFE iNSURANCE
ENTER DOW4R AMOUNTS FOR DISTRIBUTIONS SHOWN ABONE ON LINES 15 THRQUGFf 18 OF REV-1500 COVER SHEET,AS APPROPRiATE.
II, NON TAX,4BLE DISTRIBUTIdNS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
i.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER St#ET. �
If more space is needed,use addl�onal sheets of paper of the same size.
__- — ---E�-T-�-T-E-nF - • IlX THE-COURT-OF-CQMIYIQN PLEAS - ------
ANNA MAE GROSS : CUMBERLAND COUNTY,PENN�LVAD�A
. � w m �
: ORPHANS' COURT DI�S�ON ��,-- � �
. NO. m � c� c -�'aa
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r- � rn oo ;c� n
a� v'- � ° c'
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o � Q 3 � -,�
c� 4 `� c>
PETITION UNDER SECTION 3102 OF THE PROB�'I�, c� r= rn
ESTATES AND FIDUCIARIES CODE FOR :.� -i �,,y c�n �
SETTLEMENT OF SMALL ESTATE �' �
TO THE HONORABLE JUDGES OF SAID COURT:
Doris L. Dunham and Randy Lee Gross, your Petitioners, file this Petition for Settlement
of a Small Estate under the provisions of Section 3102 of the Probate, Estates and Fiduciaries
Code and in support thereof avers that:
(1) Your Petitioner, Doris L. Dunham is a competent adult residing at 934 W. Trindle
Road, Mechanicsburg, Pennsylvania 17055, and is the daughter of the above
decedent.
(2) Your Petitioner, Randy L. Gross is a competent adult residing at 173 Vine Street,
Apartment E, Shiremanstown, Pennsylvania 17011, and is the son of the above
decedent.
(3) Anna Mae Gross died on October 6, 2013 at the age of 82 years, but prior thereto
lived and was domiciled at 1000 Claremont Drive, Pennsylvania, Cumberland
County, Pennsylvania. A copy of decedent's Death Certificate is attached hereto
as Exhibit"A."
(4) Anna Mae Gross died without a Will. No Letters have been issued.
(5) Anna Mae Gross had no probate estate when she died other than the following:
Life Insurance Policy with Colonial Penn Life Insurance Company with a value of
$7,554.00. The Beneficiary of the life insurance policy is The Estate of Anna Mae
Gross. A copy of the death benefit is attached hereto as Exhibit"B."
(6) The sole heirs and relationship to the decedent are as follows:
Doris L. Dunham, Daughter Randy L. Gross, Son
_ . _ ___ _______�7) Attomey_Fees in the amount of$600.00 will be charged to the estate.
(8) Your Petitioner avers that there are no outstanding debts of the Decedent.
(9) Since the only asset is life insurance, no inheritance tax is due.
WHEREFORE, your Petitioner respectfully requests that an Order be made authorizing
Doris L. Dunham and Randy L. Gross to act as Fiduciaries for the Estate of Anna M. Gross and
file a claim with Colonial Penn Life Insurance Company, with the proceeds made payable to the
Estate of Anna Mae Gross pursuant to Section 3102 of the Probate, Estates and Fiduciaries Code.
By
Matt ' w A. McKnight, Esquire
Supr me Court I.D. No. 93010
IRWIN& McKNIGHT, P.C.
60 West Pomfret Street
Carlisle, PA 17013
(717)249-2353
COMMONWEALTH OF PENNSYLVANIA :
COUNTY OF CUMBERLAND :
Doris L. Dunham and Randy Lee Gross being duly sworn according to law, deposes and
says that the facts contained in the foregoing Petition are true and correct to the best of their
knowledge, information and belief.
,
� G� ' . /�c�n��-�- SEAL
� )
Doris_L. Dunham
...:.
�
. �
,_.� .�
V ,
`:4::.�.-�'- _��,.._l'�-��-� (SEAL)
\ �Rrandy L. Gross
Sworn d subscribed before me
this %�ay of November 13.
M ONWEqL7}�pF pENNSYLVANiq
/ A
��S���a�o�ry Pubtic
C3ttWe Bo%�umEQMand County
Not Public ��n►�SSir,n Exp{re,p� g�Zp15
MEMBER,PENNSYLVqNrq�S�A��N�F NOTARIE�
II IOS.ti�I;RHV�9;I I�
. _. . _.. ..._ ___.. .__.������__����11� B ���9���N H���������09 ������� 9 �._. .___._._-.. ..____.__._ _...______-
1iUAFiN1iVG: ft is il9egai to rluplicate this copy ksy photosiaf or photograph.
Fee for this ceRificate, �6.00 ,,,,������������---.,, This is ro certiFy that the information here aiven is
,,,��p,�SN OFpF�=_ «R�ectly copied from an ori��in�il Certificate of Death
����o��" - \l=; duly file� ���ith me as Loca( Re�_istrar. The oriRinai
(�s'�_ � �; ccrtifica�e will be forwarcied to the State Vital
I;*( -y3- �*; Records Of1'ice for permanenl l'ilin;�.
.
�0 4.i:��' �,,.. �,. ,._ i.. '1 �' o � � �,�' )/y� �, ��r �' ���
-'� ..� _3�j �+ � �.7 �I �''°���`°, fi�, /�u'`L�
: �q9TMENT�F���'�� ,
Certitication Number ""���"""'��� %Local Reaistrai Date Issued
3�c
Type/P�Int In COMMONWEAITH pF PENNSYLVANIA•pEPARTMENT OF MEALTH�VITAL RECORDS
'°`"""`"` CERTIFICATE OF UEATH
Black Ink State Fllc Numbor:
1.Decetlen['s legal Namc(Flr�c,Middle,last.S�ffixl 2.Sex 3.Soclal SecuAry Numher 4.Oafe oT Dcath(MO/Day/Yr)(Spcll Moj
Anna Mae Gross amale 207-22-2191 October 6, 2013
Sa.AEe-lasf Birthtlay(Y��) SU.Untle/1 Vear Sc.Undar 1 Oa 6.Dw[¢ef BIRh(MO/O�y/VGnf�(Sp¢II MontM1) �a.Blrthptace(Cliy ontl Stete ar For�ign Coun[ry)
� 82 ^^°^�"� o'Y� "°"�° "^'^"�e° Dec 30, 1930 Mt_ Ho11 S rin s PA
7b.s1rtNO�ace(co�ncy)
Sa.RMidence(S[ato or Fora(gn Cauntry) Bb.ReslACnce(St�ee[a��G Numbet-Includc Apt No.) Bc.Old DeceAen[Live In o To�rcnshipT
PA 1000 Claremont D�ive �Vc.,dceodcnt Ilvetl in Middlesex t,,,,,,.
aa.ac:mence lcouncyl
Cucnberland Se,Re.itlence(Z�P Cotl¢) O No,tlecedant Ilvad wlthln Ilmi[:of elty/baro.
9.Ever In US Mmetl Forccs7 SO.Marital Stat�s at Tlme of Deaih O Marrled O W�dowetl 11.Surviving Spouse's Name(ff wlfe,g�ve name prlo�co r�sc�„a�naeel
O r �I no 0 u.,k.,e.,.� W owo.cea O n �riea O unkno�...
13.FaehCr'a NaTC(FIrSt,Mitldle,Laat,Sufilx) 13.Mothcr's Namo VrlOr to Flr�i Mar�lagC(FIrSi.Middle,Last)
George Richwine Rosie
14a.Inf lmant's Namc 34b. I��lo�sl ip to Decedenc S4c. s M�Iling Ad (5 e d be,City,State.ZI Cotla)
Dor�.s Dunham c�aug�a�er ����. Trinc`��e ��_; �ecFzanicsb�arg, PA 1705
� _ __ _ ___ _ ____ ____ _SSa_Place of Deat C eck on Yone _ __ __ ___ __ ___
If DcaH�Oecurred in a Hospical: ❑inpattent �If Oea[h Occu�retl So�newhere O[hcrTM1an a HosplWl: �Hospite Faclllty �Oecetlent'S Home
� 0 Emcrgency Roam/OVtpa[I¢n[ 0 Oead on Arrlval �N�f51n8 HOMe/LOng-TCrm Care FaCllity �OCilef(Spetify)
15b.Facillty Namc(If noe Inx[Ita�)lan,�IVC straa[and number 'SSC.CIN e Tpw S�a�e, tl Zlp C 1�d. y of D M1
� Claremont NuL-si.ng & Ret-iab_ Gltr_ Car`lis"le, �A 1�513 C�`'���nl�er`laand
S6a.Meihod of Df5pozlUOn Burlal 0 Cremation 3Gb.D�ta of Olsposltlon 16[.Plate o(�ISposltlon(Name of ceme[cry,t ematory,or otM1er place)
� o ao..�o��i r�o..,sc,�e o oo,,,n�� Oct 10, 2013 westminster Cemetery�
�Other(Specify)
� 16d.Lo<atlon of Dtsposition[City O�Town,5[atv`:�n�l 21p) 3Ja.Si6� af Fun 5 Ice Ucensee or Person In Cho�Cm of Inta�man< i�b.License Numb¢r
° Carlisle, PA 17013 � � 138504
� 0 3]c.Name and Complete Adtlr¢ss of Funaral Facillty
HoE£man-ROtiz Funeral Home & Crematory, 219 North Hanover Street, Carlisle, PA 17013
18.Doeedent's EducrHan-Check the boz thai be^.c describes the 19.Decedent of Mlspanlc Origln-C�eck tl�e 20.Decedent's Race-Check ON[OR MORE races to inCicate what
m M1tgheat degree or level oT schoM comple[ed at[he cl�ne of dea[h. boa that bezt tlescribes whether the dec¢dont the decetlenc co�is�tlereC himself or her.elf So Ue.
�8[�gratle or less Is Spanlsh/Flisponic/Latino. Check the"NO' �f WI�I[Q O Korean
O No tliploma,9th-lZth g�ade box If Cecetlen[Is no�Spanlsh/HlzpanlU�eaino. O B�ack or African iam¢rlcan � VIe2n�mesc
� HI¢M1 achool gradua�e or GED eompletetl No,not Sponlsh/Mispanlc/LrHno O American Intlian or Alaska rvative O ��her Azlan
� Soine colle8e �edi[,bu<no degrue Q Ye•.,Mezlc�n,Mexlean Amerlcan,Chiwno �A.lan Intllan � Naxlve Hawalian
� Assoclate deg ee(e.g.AA,A$) �YBS,Puerto Rlcan �Ch1�e5e � Guamanian or Chzmorro
� Buehele�'s deC�'ae(e.E�BA,A6,BS) �Ves,Cuban Q Fllipino 0 Samoan
' � M,stcr'^.tlegrce(c.E�MA,M5.MEng,MEd,MSW,MBA� O Ve.,other Spanizli/Hlspanlc/Latlnn �/ap�nesa � OtM1cr t+oclf�c�sianticr
� Ooctorate(e.g.PI�D,EtlD)or Profesalonal d¢6rea (Speclfy) O Other(Spe<Ify)
(e. .MD.ODS.DVM.LLB.JD
31.Decede�t'S SIne1C ROCC SCIf-OCSlgnatiOlt-Cheek ONLY ONE�o Indlca<e whnt<he decetln_n[considered htmzelf or her.elt to be. 22a.Decedee�t'S Vsual Occupatlon-Intlicaie type of work
$1 Whixc O lapanese O Samo�n donc d�ring mest ef wor4.ii.�li/�. 00 rvOT u5E nEr�REO.
O B�ack or Afrlcan Amcrlcan �Korean � OChC�POCI(IC ISlanticr Laborer
�Amcrlcan Indian ar AlaSka Na[IVC O Vletnamese O �on't Know/NOi Sure
�Asian InOian O Other Asian O ReTused 22b.Kind ot Business/Indu:try
� O cn�..e..e O Na[Iv�Hawalian O oan«�sPe�iry� Rubber Manu£actta�'ing
O Fllipino � GuamanianorCh�morro
ITEM$29a-29 MVST BE COMPLETED 23r.Date Pronouncetl Dead IMO/Day/Yr) 23b.Si�nature of Per.on Pronouncing Oeath(Only when applicablej 23c License Numbcr
BY V ERSON W NO PRONO V NCES OR
CERTIFIES DEATM L ?U/,3
s3a.oaea slsnad(nno/oav/rr) zn.rimc or oca�i� �N P�h1!9ffS0/-L
h E r Z U/ �7 f�� 25.Was Medical Examiner or Goroner Co tactedT O Yes � No
CAUSE OF DEATH Approxlm�te
2G.Part 1. Enter the ch�in of�vencc--diseaxes,inj�ries,or compllcatlons--tha[dlrectiy causetl the death. DO NOT eMe�2erminal evene.xuch as cardlac arrest, Interval:
respireeory arresc,ar ven[FlCUIe�librlllatlon witho�t sl�owin6���e¢tlology. DO NOT ABBREVIATE. Enter only ane cause on a Ilne.Atld atltli[lonal Ilne:If nece..ary. Onsei co Dca[h
1
�
IMMEDIATE CAUSE _______________> �,
N�Uw.oN�q. �
(Final tlisease or contllLlun Duc to(or a.a con.equence of):
res�lting In death)
b.
Sequentially Ilsi tondkions, D�e to(or as a consaqucnco on:
If any,Icading to[hc enus�
II.eAtl on IinC a. Entcr tlic e.
�6RlYING CAUSE D�e[o(er a�o concequence ot):
(dlceaee or InJury[haC
FInl[iatcd<M1e ovcntc r��ulHnR d.
in tle�th)LAST. Da�e co(O a��cOnsCqucnCC of):
S 26.PaK 1�.Ente�OthCr 1 1 bu[nOt�fSUlting Vn Lhc underlying ca�se given In Par[1. 2J.W�.a topsy perfo�metlT
�^Ye. 0'No
g 28.werc autopsy(Ind1n
„s avallablc
co ai�r�en���o�Pr aoo�nz
coO Ycs 0 No
29.if FCm�le: 30.Oltl Tobacco Usa Con«�bute GO O.:iCh? 31.Manner of�eaih
E �NOC pregnani wlih�n pa.st year � Ve. � Prebably B�NOiurul � Homicitl�
� Prc6�o����tima of tleath �No 0 Unknown 0 AccltlCnt O P��ame����-t�e�xio�
m Q Not preR�ant,b�t pregn�nt within 42 tlays of ticath � Suicitle � Co�ld nof be tleferminetl
� Not pregnant,but pregnont 63 days te 1 year hafore tle�tF 3J.D�t�e of�n�ury(vio/�ay/Vr�(Spcll Month�
� Vnknown 1(pregnon[withln chc past yca� 33.Time ef InJury
3M1.Place oT Injury(e.8-�+ome;eonscrucllon site;farm;school) 35.LocaClOn O�I'1fYry($t/CCC il�tl NuTbL•f,Clty,Ca�nty,Si�t¢.Zip COtlC)
,n 36.InJury aS Work 3�.1/Transportatlon InJury,SDeelfy: 3B.�escrlhe Maw I�J�ry Occurretl:
� O Ycs � Orivar/Operator � P�destrian
� No � PaS.^•enFC� � O[M1et(Sp�CItY)
`� 39a.� rtffler-physi[lan,certifled nurse praciieloner,m¢tlleal eKamincr/coroner(Gheck only one):
Ip CvrGfying only-To ehe b�st of my knowletlge,tlerth occunetl tlu�to tlie ca��e(s)wntl mann ced. �
� O PronounclnC&Certifying-Ta tha bc�t of my knowiadF•e,dea�h occurred�t tha[Ime,datc,antl place,antl aue to the c te(s)nnd m �sWtetl.
O MedlC�l Examiner/COroner-On the�asis of mina[i nd r Investlqa[lon,in mv apinlon.Aeath occUrred atChe time.tlate,ar+d place,and d�ie to the cau.e�.)antl m stwted.
� SiC�oture of certifier: TINe af certifler: ��YS���-4'�� Llcense N�mber:^�O-O�ILLa9�/r L
_� 39b.Namc.Adtlres.and Zlp Cod�o(Pcrsor�Con�pl ing f Ouath(It�m 2G) 39c.oa[c SlCnetl(Me/Oay/vi�7
�i2wE3r H. s.-/OSFsJ^' �f0 u� /83o G000 �E ,Co_ ��voe�t- �� �7bz.5 /o - 7- �3
� 40.PCgl.�i'p�'.-Dls[�ICt Number 91.R¢C�s �'S Signuturc G2.fta6�=T�r F�le O�te(MO/Day/V�)
��- /a / d' oZ(9 �
43.AmPntlments
�
/� q H105-193
Ol�po.iclon Pcrmlt No. ( /q [J I� REV O'!/2012
� Colonial Penn Life Insurance Company
Colonial Penn Plaza l9th c� N[arket Sts.iPhiladelphia, Pennsylvania 19131
Insw�ed: ANNA M GROSS Certificate Number: T'vI029187=�B
Issue Age: 61
Owner: ANN�. NI GROSS Certificate Date: NIARCH 0�, 1992
=�6 E PfiNN ST Pi�emium: �41.70 �'IONTHLY
CARLISLE PA 17013 Noilforfeiture Interest Rate: 7.00 io
PLAN This is ?roup modified benefit whole life insurance. The insurance is limited during the first two
. " certificate years for non-ac:ciclental de�th. We will pay the applicable death benefit if you die while
the certificate is in force,subject to the terms of this certificate. Premiums are payaUle to age ]00.
A. NON-ACCIDEI�ITAL DEATH BENEFIT
LIMITED BENEFIT AMOUNT 1ST CERTIFICATE YEAR �1133
LIMITED BENEFIT ANIOUNT 2ND CERTIFICATE YEAR $2266
FULL FACE ANIOUPfT 3RD CERTIFICATE YEAR AND AFTER $7���
DEATH
BENEFIT
AMOUNTS B. ACCIDENTAL DEATH B6►VEFIT
ATTAINED AGE 84 AND U[�IDER $15108
ATTAINED AGE 35 AND OVER �7�54
YEAfl ATTAINED CASH PA10-UP EXTENOEO TERM YEAA ATTAINED CASH PA10-I1P E%TENOEO TEflM
AGE VAIUE INSUflANCE INSURANCE AGE VaLUE INSURANCE INSUflANCE
1 62 $00 $00 0 YRS 0 DAYS I1 72 $1,725 $3660 6 YRS 209 DAYS
2 63 $114 $35=� 0 YRS 3�9 DAYS 12 73 $1,932 $3942 6 YRS 247 DAYS
3 64 $276 $S 16 2 YRS �6 DAYS 13 7=� $2,142 $4206 6 YRS 27� DAYS
4 65 $444 �1254 3 YRS 6� DAYS 14 7� $2,3�6 $4��16 6 YRS 275 DAYS
5 66 $606 $1633 � YRS 7 DAYS 1� 76 $2,5�0 $�663 6 YRS 26 i DAYS
6 67 $730 $2022 =4 YRS 290 DAYS 16 77 $2,754 $4573 6 YRS 238 DAYS
7 68 $954 $2376 5 YRS 139 DAYS l7 73 �2,9�2 $5053 6 YRS 19�4 DAYS
3 69 $1,134 $2712 5 YRS 299 DAYS 18 79 $3,156 $5244 6 YRS 147 DAYS
9 70 $1,332 $3060 6 YRS 67 DAYS 19 30 $3,360 $5413 6 YRS 90 DAYS
10 71 $1,530 $3372 6 YRS 155 DAYS 20 81 $3,552 $5�62 6 YRS 14 DAYS
Beneficiary: ESTATE, UNLESS SUBSEQUENTLY CHAIVGED.
579-SCH(HEUI