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HomeMy WebLinkAbout01-02-14 � _ _ _ . ._ ._Y __ - _. __ - _ � 1505610105 REV-1500°`�°�-�'��'1� PA Department of Revenue P�n$Y��Ma OFFICU4L U8E ONLY Bureau of Individual Taxes DEPMTMEMOFIIEVENUf County Code Year File Number � INHERITANCE TAX RETURN �� ���� � PO BOX 280601 J , , i HarHsbu PA 1 u8-o6o1 RESIDENT DECEDENT i� ' �� i ,'3 / ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYYY , �____.�m._____�_.�.._..�n___�_.�. ��_�..; �208-01-8980 � � � 08/03/2012 �� � i 11 /14/1916 � - ---_v �._._ _.__.____.____._ k._______._____ � Name � � � Suffix DecedenYs First Name � MI �___u��m..�.�_�, :.�_.___.._.o_ -- --,__._..._ .._.. ______.___.�.__._ McGreehan ; .; Sr ; ; �Iliam � i—F � ! � , �,___..__,�.._'__�.._._.._: __._.__'�.'_,._�..�__._"____.�._�..___._.._...__._.�_.._._..___ � 3 (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI �__v____.__, �.___�.__.__._�.._., _�_______._�______�___._____._.______________� � � � I � �_._._-� r � I i _____________ � �_______.__� ;� __� �__J Spouse's Sxial Security Number ������������ ������������-��"- �' THIS RETURN MUST BE FILED IN DUPUCATE WITH THE ; ' REGISTER OF WILLS FILL IN APPROPRWTE OVALS BELOW � 1.Original Return Q 2.Supplemental Retum p 3. Remainder Retum(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) � 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust 8. Total Number of Safe DeposR Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9.Li�gaUon Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between�2-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT-THIS 3ECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION BHOU�Q BE DIRECTED T0: Name Daytime Telephone Number � �__.__ __� Jordan D. Cunningham HV M�~��m�_~r� v ' �(717)238 � 0 , � ; � _._ �._._._.___..__._...___________._._ ___._...__.--_._.__.____.._.� E ' .', F'-'�► .. REGIST LLS US�IY �, � � r � � First Lme of Address � — ._.�..__..___.___.___._.�...�..._.________�___ .ry � � � N � 2320 North Second St ;� , � . � ._ �_�_�� __� ___________ . _____ __.____._._____ ____ Second Line of Address � � � � .� _.._�_�_ _._ __.._________.._____ .--__ _ __., ,.,.,. !J � 1—, L'3 ' ` Q !"1,� City Or Post Office �.... _._.._.._ _._.._....�._____�...w ` "`�1AT�E FILED C3 � � _�__ �� State�M_��ZIP Code .,,� _-'°`-'-� � r--�.-.�._.--__.__�__._.__._._�_`_.�._..._-r Harrisburg '�PA I !17110 i � ; ! ; , � F � , _ ________ ______�_________� .�________x �_._�__ti_____________.__.�___�...._....._�.___._______..� Correspondent's e-mail address:jcunningham�cclawpc.com Under ury,I dedare that I have examir�d this retum,induding accompanying scheduies and statements,and to the best of my knowledge and beltef, it is ,oomect and ete.Dedaration of parer other than the personal representa�ve is based on all infortnation of which preparer has arry knowled�e. SIG RE OF RES IBLE F FILING RETURN p z ZZ ADDRE8S . 755 iil , Lewisberry, PA 1 39 31 O R OTHER THAN REPRESENTATIVE DATE s ` : L2 ?ia/ 20 o Second St., Harrisburg, PA 17110 PLEASE USE ORI�i1NAL FORM ONLY ' Side 1 L 1505610105 1505610105 J � , j1505610205 REV-1500 EX(FI) Decedent's Social Security Number �o�ae�t's Name: �Iliem F. McGreehan, Sr. RECAPITULATION _- -----_ ___ __�_.--._.___-----, 1. �Real Estate(Schedule A). ............................................ 1. � � 2. Stocks and Bonds(Schedule B) .............�.......................... 2. �� � 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. ' � m_M_anu,...�����...�.,..�.,�.�.m.�..�...�.�„�_..��.�..��.�.�.� � 4. Mortgages and Notes Receivable(Schedule D)........................... 4. ' 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 2,301.15 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. ' ' 7. Inter-V'rvos Transfers 8�Miscellaneous Non-Probate Property -__ �..,.�..._.T...._.... _.....0. _.__w...Y.�_��..�__.. (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets(total Lines 1 through 7)............................. 8. 2,301.15 9. Funeral Expenses and Administrative Cos#s(Schedule H)................... 9. . 3,000.00 i � .. .,__.. _..,.�=�v_..�.�,. �,_.�n..� .._��.�.....�.m._.__�.�-; 10. Debts of Decedent,Mortgage Liabilities and Liens(Sehedule i)............... 10. 132,945.98 i �.�..�_ �..._.m.. ��u.��. .�..._,r�.�..�..�.�,..�...,.,..�.; 11. Total Deductions(total Lines 9 and 10)................................. 11. � 135,945.98 ; 12. Net Value of Estate(Line 8 minus Line 11).............................. 12. � -133,644.83 ' 13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which '� °"��`�"�"��'"'��`�"��'�`���`��`°`��'"��"�""�"""°.,��`°�`°'°'�°�°°� �an election to tax has not been made(Schedule J) ........................ 13. ! , ..�..�,�. ._�,.�_,�.,�w�.�..�.���.�.._,�._.�..�.��_.___,...,_i , 14. Net Value SubJect to Tax(Line 12 minus Line 13) ........................ 14. 0.00 � TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 _ __ _ _ _ ____ ._. _____._ .__._ _--__ �a)�1.2)X.0- 15. � ,. _. w . ._ ... _ _ �.._..._�_ .,...�,�_...x,�.,�..�.H��..,.�,..........,....� 16. Amount of Line 14 taxable " at lineal rate X A_ 16. 17. Amount of Line 14 taxable --�� _.._ _ __. . _ � _ _._,_. _ , „.. �. . .,_..H.. ._ _�._ ._��.Y.�_ ..�,._.u�n�.n���.�._._.m._.�; at sibling rate X.12 17. ,.,,._. . ._ „ __.: �,� ..; .._ .. .. _,,._.___ .�,.__-___....H..�_..w�_�__.�.��...._.d...d._.. ! 18. Amount of Line 14 taxable at collateral rate X.15 �g, 19. TAX DUE ......................................................... 19.' 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 L, 1505610205 1505610205 J REV 1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME Wlliam F. McGreehan, Sr. STREET ADDRESS 770 South Hanover Street ��N STATE Z�p Carlisle PA 17013 Tau Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 0.00 3. Interest (3) 0.00 4. If Line 2 is greater than Line 1+Line 3,enter the difference. This is the OVEI�PAYMENT. Fill in oval on Page 2,Line 20 to requsst a refund. (4) 0.00 5. If Line 1+Line 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 Vansfer and: Yes No a. retain the use or income of the property transferred.......................................................................................... ❑ � b. retain the right to designate 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 reveiving adequate consideration?.............................................................................................................. ❑ � 3. Did decedent own an"in trust fo�'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. 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)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disdosure of assets and filing a tax retum are still applicable even if the suroiving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate impased 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 child 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 decedent's 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 decedenYs 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-sso8 DC+(is-so) pennsylvania SCf1EpVLE E DEPARTMENT OF REVENUE W�SH, BANK DEPOSITS &MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: William F. McGreehan, Sr. � Include the proceeds of litigation and the date the prooeeds were received by the estate. All property jointly owned with right of survivorship must be discloaed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ' 1. 1st Summ�Bank of Johnstown 2,301.15 (a) Checking account _ TOTAL(Also enter on Line 5, Recapitulation) # 2,301.15 If more space is needed,use additional sheets of paper of the same size. REV 1511 EX+(12-99) scNEOU�E N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATNE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Wiliiam F. McGreehan, Sr. Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. �,��..��.���5��: . _ , 1. �Diamond Funeral Home _ .... ._� ._ 1,200.00 �...,._a .w,w.r_���AM���: .,. . . :: _ _ 1 � � �South Fork . �_�,� n�. .�..�.<<.�. . . � ��,� _� �� s�,....�.__��m. . � . � � _ , �..�..� .u.� �� .. ,. . . � �..��x �7a..�.�. , . n.� _ . � � , . � , . � ; .= ,r. .. , ± � 's �..�..�s �...,� � .. ,.�w..a.� u�,n..,..� - _ � � � � � . __. .— — # �. . � ,. .� � ; .. ?.�_�,a m..u,.. ��..z_.,���. �._.�., . .�.....,.�,� �....��.,,.,�.K_��.__. . ._ ..� � , . ,`. _. � ,.; . , ..- y � 6 � � � $ ! s , ....,,>_� L,.�.�. �. ,, _ � �_,,„�,� �.,.Ma_.. �:.m,_ .. .,., , _ _ _' ; ' .. - �..�., rv � � _ { � p �,»..�.� �w,�„,..,�....v,,w_, ...4... .. _ � B. ADMINISTRATIVE COSTS: 1. Personal Repr�sentadve's Commissions Name of Personal Representative(s} Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City:.w ,. .. . .State Zip Year(s)Commission Paid: 2. Attomey Fees Cunningham & Chernicof f, PC 1,450.50 ` � 4, �.�}�., ,�, . ��� 3. Famity Exemption:(If decedenYs address is not the same as daimanYs,attach explanation) Claimant, , Street Address : ���Y State _Zip Relationship of Claimant to Dec�dent a. Probate Fees Regi s ter of Wi l ls 104.50: 5. AcxountanYs Fees . 6. Tax Reh�m Preparer's Fees ,. . . ,, #.�_ �: ._ . .. �._. _ ,... . ., 7. `Cumberland Coun Law Joumal—Adv.Letters ��4.�..� .._.._u ,....,..�_ 75.00 . ._ _ . ��s. �._._ .T � � _ � � � � .' � _ � .�.. e ....,t.. . �Joumal Publica�ons—Adv.Letters 150.00 :.�� � ��� , �-� �. . _ - _ _ _ . + '` a'f'+,�.�:. .� � . �_..� .� �3. �- h�. , �Leventry,Haschuh,&Rodney,LLC 20.00 � �.. ��.�o-..�,.�..�,�... .�_.r �,_ ..�..,.�. .�3_.� .__. _ ,ti.�.,._.� ,_a�n�. ��_.���..��.. ._ . - ` .� .v. _ _ , .. .�. .. . , , ; , , ; �A..� �:xw..._U....�,_... . . , _ . _ __ ' _ �.�.�.! �.wu,�� _ _ � . � � . � ., . �. , �' � , � ,�_�� ��._.� _.�., ,1. � : .. . , �.��.� �.�...... , _.., _ . �. ,, . € � � . , . .. - �.�._�N,..�._�,__,� . � ._ . _. . ; . TOTAL(Also enter on line 9,Recapitulation) ;r 3,000.00 (If more space is needed,insert additional sheets of the same size) � . . _ -- -_- -- �,j��pww a c�r�co�,Pc. 0 5 0907 ,. Date: January 17,2013 CHE# 50907 � Amount: $150.00 Paid To: Journal Publications Matter# 414312 Client Name Armand&Ruth Apa Proof of Publication-Estate of William F.McGreehan Sr. _ . _. , T� , ,��.�_� ._...: .. ....t. _._.�... � - -- _ _ .� _..£._ . � _.�. �„�.,.�� � . _ . .��._v... _ �� ,� �.����_-,�.���;�,�;�.��..4�,.�..��:.�� _�.:____. z:,�._ `��=..�"� --- --y� _. . - .� 7 . ? t�� - - ---7t7fZDAN D.evlvlvrNCx�r CUrNNING.�[AM& CH ROBERT E.cxERtvrco�� ERNICOFF,P.C. HERSHEY'1'ELEPHONE �xc w.wrrzrc , ATTORNEYS AT LAW (�i�5�-2s� BRUCE J.wq�HqwsKy P.O.BOX 60457 TRACY L.UPDIICE IRS NO.23-2274135 Mcxor.,a►s A.FpIVELLI �'�A�RRISBURG,PENNSYLVANIA 17106-0457 Street Address: ' 2320 N.2nd Street TELEPHONE (72�238-6,57p Harrisburg,pA 17110 FAX(717y 238-4809 January 17, 2013 Journal Publications 1500 Paxton Street Harrisburg, PA 17104 RE: Estate of William F. McGreehan, Sr. File No: 414312 ;j � ���`.F ... ;.. �{\ ., � ; Dear Sir or Madam: Please publish an Executor's Notice,the form appears below, once a week for three (3) consecutive weeks in your newspaper. A check in the amount of$150.00 representing the required fee is ericlosed. Additional information for the Notice is as follows: Name of Decedent: William F. McGreehan, Sr. City and County of Residence: Carlisle, Cumberland County, Pennsylvania Date of Death: August 3, 2012 Name of Executrix: Ruth Apa Type of Letters Granted: Testamentary Name and Address of Attorney to whom Jordan D. Cunningham,Esquire payments are to be addressed or requests for CUNNINGHAM& CHERNICOFF, P.C. payment made: 2320 North Second Street Harrisburg, PA 17110 Please send Proof of Publication to this office together with your bill. Thank you. Very truly yours, C & CHERNICOFF, P.C. Jo an . unningham JDC/ja Enclosure cc Ruth Apa F:1Home\AHEWIT71DpC'S�q_C1APAIESTATE OF W[LLfAM F.McGREEHAN SRUournal Publications.wpd � � � NOTICE IS HEREBY GIVEN that Letters Testamentary have been granted in the following Estate. All persons indebted to the said Estate are required to make payment and those having claims or demands to present the same without delay to the Executrix or attorney named below. ESTATE OF WILLIAM F. McGREEHAN, SR., late of Carlisle, Cumberland County, Pennsylvania(died August 3, 2012). Executrix-Ruth Apa. Attorney -Jordan D. Cunningham, Esquire, Cunningham& Chernicoff, P.C., 2320 North Second Street, Harrisburg, PA 17110 �,,:r� . .�, _ _ t . _ _ _ _ 4 � w ' _w�� r" i � � � CUM6ERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)249-3166 Fax:(71�249-2663 February 15, 2013 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association antl is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Jordan D. Cunningham, Esquire RE: William F. McGreehan, Sr. Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. ------------------------------------------------------------------ - - -- - --- ---- - - ------- - ---- - - ---- - Advertisement inserted on following dates: February 1, February 8, and February 15, 2013 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director �. _ _ _ �- . _ _ __ _ _ __ ___ __ _ ___ _ ___ 1 - -- -�- � . -�--.-- *+ � ^` � t i `'" . � PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (tTnder Act No. 587, approved May 16, 1929),P. L.1784 COMMOr�WEALTH OF PENNSYLVANIA : : ss. COUNTY OF CUMBERLAND : Lisa Marie Coyne,Esquire,Editor of the Cumberland Law Journal, of the County and Sta.te aforesaid,being duly sworn, according to law,deposes and says that t11e Cumberland Law Journal,a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952,and designated by the local courts as the official legal periodical for the publication of a111ega1 notices,and has, since January 2, 1952,been regularly issued weekly in the said County,and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, viz: Februarv 1, Februarv 8, and Febru 15,2013 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in t11e subject matter of the aforesa.id notice or advertisement,and that a11 allegations in the foregoing statements as to time,place and character of publication are true. �... isa Marie Coyne, ditor SWORN TO AND SUBSCRIBED before me this 15 da,y of February, 2013 . . - Notary ______ �'M�.�s�'.,/r.,tiec'd. L�te o�Cm�iale. Executrix:Ruth ypa, ��ney�' J°rd�u D• Cunni�- NOTARIAL SEAL �' ����' �n��� � DEBORAH A COLLINS �'p'C''����' Notary Public °od 9�''eEt,Harrlabur�,FA 17110. CARUSLE BOROUGH,CUMBERLAND COUNTY My Commission Expires Apr 28,2014 RE1�1737-7 EX+(6-08) • scNEOU�E � pennsylvan�a �Se S�hed��e�, Pert 2,ONLY for DEPARTMENT OF REVENUE ����� O� ����pENT� proportionate method of tax computation. MORT�iA�iE LIABILITIES, & LIENS INHERITANCE TAX RETURN NONRESIDENT DECEDENT ESTATE OF FILE NUMBER William F. McGreehan, Sr. Part 1 must include mortgage liabilities, liens and taxes against the Pennsylvania realty that were due and owed as of the date of decedent's death. Complete Part 2 ONLY when the proportionate method of tax computation is elected. . , . ITEM NUMBER DESCRIPTION AMOUNT �.,�...�____..�..��u..�._.. ��.._�_, .._..._.,._�. ....,. _..,�_... M .... �_.�.. _ . _ «._ .,r. ��... ,. 1. ,,,. - � : �.m�,� �.a..x,�a_,__�._. . - .� ro..._,� �..� ..u�,...__, . . f i : e � , . . ' ....., ..,,._ ..__.. ... ... _., ... r ., , �.,:....,......w.«�,. �.«.✓-.<�d..�....,..»; .., . ' . ... .. _ . . .�._. .. �. �� � 4 . .. . . .. . . . .. .. . .. . � . . � . . . .. . ��. . t { r % A ; '. y fr b�,.�.e..wwa-wu7 L�..A�.«. . . �..-..—.-...:-.� �..�...�.......5,:..°..�..�r.. .....�..».�.. ..,... . .�_... ,. .. ' .. -. _ . . . .. .. ... .. . .. .. � . - . .. . . . , .. .. ._ _ �.... -.:-:. . . , , � '� '� ' ... � . j � Y . ... , � . . i t ��,».�,��,F C.�..«�-. :.. . � , � �.,«,....�.n.��.:.�.�..�....,.... �_�..._. ........ . ... . �- . . .. � . , # . . ... .:. .. . .. .. . .... .... � ... . . . p . 6 � � ��._.:_ ;.,�. .a _ . . . ,. , . w'r''�'i.r.w.u�rnni� �ma--u...�'._�.. .�._.r :' .�� . .. . �-: ... . . ... . .. . . ... .:. ...�.... , .��� ..., . ��.. . ... . ��:. ,.,.� �.i i � ; . .. . . .. ... . . .. . ... . . . ... . . .. .�:�: .... . E 2 ? � � � k �.«� " .....a��„;M.�,s«-. .. ,.. . , . . .� . , .._ . . �� . . . . ......:.:,-.«, .,,,, "., ,'. .. , , .. . . �_: ,;`. , �. � . .. �.: . . , , . , tl - '-, .... . ... . , .. . . . . . , . } .� . # . . ... .. .. .. � i � . , , ��.<.,.�,..,a+�.w..i rmw..�..rae»..�......,w, � . „ .���.. , �:= yova.ukuwwr�nf. �ewr�sww+wrr+�e.wx..« «....+�..��..:.-. , .. , . �.. . . . ��: . �.,:. .. �.:... . . . . .. .. . .. . . .. . - i � £ -� .. .. . i p � � � . .. . ..ti .... ..� ?r«.��..m . . .... .. ...... . . . . . . ... ... . . ... .. ..... ..... . ' . . . "... . . . .....q . � . .+... ... ..... . . . . ��� . . . O�� .. � �� �...�_�... � . . .. . ...,n.. ..,. • �. • ITEM NUMBER DESCRIPTION AMOUNT . _ _ _ ... x.. .,.. .... ..� ... , 1. ' �Commonwealth of Pennsylvania--Department of Welfare 432,945.98 � � �... ,,. ..�..a. �__ .,, � .. � �. � .,��a�_�n� ��..��.���,� ..._.�. M. , . _ , , .. . 5 ! • ��:w..w.�.,y.. �.w�w.�...� w.:.. .t- �.,..... ..,, , .,. _ .-.��.. .:, � ...,....»...�........:� ��..�.,�,...<.+«.._......,«..................<...., ......,....,. .:..... . .��.. . , '..... _ .:. �.�:�..' .... .. .... .. � . �� ... �..it . ld � .r... .. ,� ( i f �; �.� ...��s �.�....�,�._ . , �, ._.. . n �,.,,,...,.,.�,..� p�.,.�..�..N,�:..��...A.�..�.,..w::.� .� ...,._ ,..., . .. ... .... . ..� . . . � . . ... . ... . . ,. .., � j � .,_._ ._ �_. ._ - _ � .. ,.. . _. ..�. . + � , �..�,......... �...�,m..,.�,�-,�..:�� :_ .�... ., .. ., .... .,., ..�. , ... _ ,.. , �,� _., , h. 6, ..w.,,_,..._..a,� �..a.,.�.,...T._,.F.m�,r�..�..... . ... .... ._ _,. �:_ , ... .: . .:. ... . ... ... .. .�.,... � . . . ..�.. , „� , . , _, t F ' � ' ' ¥ f � ti � ��..:°:, w.._ a.�'°..w......,r�3.;._aM:.«�.. .` ..,... . . . _ ,v , ,_ ._,_ . . - . r . ...+�-+e �.._ -:. . .. ..:w. 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'_.,. ... .. . � , ,.�1, ..-.r, �;,.> .... .,n t . z... d..rt... e �� � F�...� �.,. -�..�.......... .....:.........�...,_..,,._....... ., .,. .. __._ . _..�v._... ,.___�.... .,<,..,.. . .. ......._,._ .. . _. _._....,.,,a .,.�� ,...�.�.,.: ,u�, x�ah" vav, v.-.re. :r.. . . � � .<.e d.�r.'ak.'^&?�^"",�5"�ti$s#�&.���r�.. ..... �, 13Z,946.98� TOTAL PART S r��,��r.��w.;_>������;��t�.���;�r�.. � � _, ... . _ ��...��: � TOTAL (Also enter on Line 10, Recapitulation.) � r 132,945.98,� �:3y�ct x"k 3,�vJ',i;(A&'k��+�f�Y,i�"�t�`S t S . (If more space is needed, use additional sheets of paper of the same size) , � s � ' a ��r���r������ ;pEPAFtTMEINT t}F F�UBE.IC 1NE�F�►RE � November 14, 2012 CUNNINGHAM &CHERNICOFF P.C. 70RDAN D CUNNINGHAM ESQ ATTORNEYS AT LAW PO BOX 60457 HARRISBURG PA 17106-0457 Re: William Mcgreehan sr CIS #: 150213126 SSN: ###-##-8980 Date of Death: 08/03/2012 Dear Attorney Cunningham: Please be advised that the Department of Public Welfare maintains a claim in the amount of�132.945.98 against the above-mentioned estate. This claim is for restitution of inedical 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 �16.756.58, 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 �116,189.40, is to be entered as a priority Class 5.1 claim against the estate. Ptease 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, �f' - � ' �' ��,, . Elizabeth M. Wilson TPL Program Investigator 717-214-1868 717-772-6553 FAX Enclosure cc: Ruth Apa 755 Heck Hill Rd Lewisberry PA 17339-9742 Bureau of Program Integrity � Divisfon of Third Party Uability( Recovery Section PO Box 8486{Harrisburg,Pennsylvania 17105-8486 � * COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY � " DNISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 84�6 HARRISBURG,PA 17105-8486 November 10,2012 STATEMENT OF CLAIM SUMMARY N�ME_ � Estate of MCGREEHAN SR,WILLIAM 1C� 150 213126 �'M�fl�€;�L`'' '+�LASS 3 G1.AS5 5.� i fi4Ti�L;:: . �'; INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 16,558.57 115,076.04 131,634.61 DRUG 198.01 1,113.36 1,311.37 R�lM�UR�EMEt�I'1'"T4�PW 16,756.58 116,189.40 132,945.98 _ ___ _ _ __ __ ___ __ ___ _ ___. _ _ __ __ _ _ _ __ ___ _ __ C�M�ht�t1►EALTH��F�Ehth��YLVAN�A .' �E#'Af�TMEI�T flF PU�LI�iNELFARE Elf�- �3wGUQ3'113 Page 1 of 24 � � ' �� �GINNIMM�N�1/EA1.TH C3►F PENNSYLVANIA ` ' dEPARTMENT�F PUBLIC WELFARE November 10,2012 STATEMENT OF CLAIM NAIVI� MCGREEHAN SR,WILLIAM ID 150 213126 CHAPEL POINTE AT CARLISLE � 770 S HANOVER ST CARUSLE PA 17013 � 'bATE;t��SERUI�E ARYMEhIT fi)ATE C�Ri+GII�IAL CRN AI�Jt��TED�R[U i�S��#L CH�R��� ' ��,ll�'"�IPRR�I�EC� 02/01/09 - 02/28/09 04/13/09 55090974053740001 55090974053740001 4,427.92 2,254.54 DIAGNOSIS 1 : 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2: 0 PROC CODE: 000000 03/01/09 - 03/31/09 04/20/09 55090974053900001 55090974053900001 4,788.26 2,717.92 DIAGNOSIS 1 : 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2: 311 DEPRESSIVE DISORDER NEC PROC CODE: 000000 04/01/09 - 04/30l09 05/25/09 20091244036880001 20091244036880001 4,633.80 2,563.46 DIAGNOSIS 1: 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2: 7197 DIFFICULTY IN WALKING PROC CODE: 000000 05/01/09 - 05/31/09 06/22J09 20091534032370001 200915340323700Q1 4,788.26 2,892.92 DIAGNOSIS 1 : 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2: 7197 DIFFlCULTY IN WALKING PROC CODE: 000000 06/01/09 - 06/30/09 07/20/09 20091834180280001 20091834180280001 4,633.80 2,563.46 DIAGNOSIS 1 : 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2: 7197 DIFFICULTY IN WALKING PROC CODE: 000000 07/01/09 - 07/31/09 11/08/10 55103064067170001 55103064067170001 4,788.26 2,966.54 DIAGNOSIS 1 : 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2: 7197 DIFFICULTY IN WALKING PROC CODE: 000000 08/01/09 - 08/31/09 11/08/10 55103064067420001 55103064067420001 4,788.26 3,103.54 DIAGNOSIS 1 : 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2: 7197 DIFFICULTY IN WALKING PROC CODE: 000000 09/01/09 - 09/30/09 11/08/10 551030640ST690001 55103064067690001 4,633.80 2,804.06 DIAGNOSFS 1 : 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2: 7197 DIFFICULTY IN WALKING PR�C CDDE: 000000 Page 2 of 24 �` � !CL7MM(3NVIfEALTH t�PENN�YLi�'AN�A ' :� ' �EPARTMENI`t��PU�L.1�WELFAFtE November 10,2012 STATEMENT OF CLAIM I�IAM� ! MCGREEHAN SR,WILLIAM � IQ 150 213126 CHAPEL POINTE AT CARLISLE 770 S HANOVER ST CARUSLE PA 17013 - !DAT'E������ll��. . ,,��1�Nl�NT'DATE : ('3�iGIi►1AL CRN ' ADJtJSTEE3 CRN USUAL�H�R���i �t1�'�U�'�RdttEt7!' 10/01/09 - 10/31/09 11/15/10 55103144064330001 55103144064330001 4,788.26 3,102.01 DIAGNOSIS 1 : 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2: 7197 DIFFICULTY IN WALKING PROC CODE: 000000 11/01/09 - 11/30/09 11/15/10 55103144064580001 55103144064580001 4,633.80 2,943.16 DIAGNOSIS 1 : 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2: 719T DIFFICULTY IN WALKING PROC CODE: 000000 12/01/09 - 12/31/09 11/15/10 55103144065030001 5510314406503Q001 2,780.30 1,053.96 DIAGNOSIS 1 : 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2� 7187 DIFFICULTY IN WALKING PROC CODE: 000000 01/01/10 - Q1/31/10 11/29/10 55103274066380001 55103274066380001 4,788.26 3,182.91 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 02/01/10 - 02/28/10 11/29/10 55103274066490001 55103274066490001 4,324.88 2,674.53 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 � 03/01/10 - 03/31/10 11/29/10 55103274066700001 55103274066700001 4,T88.26 3,187.06 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 04/01/10 - 04/30/10 12/13/10 55103414067220001 55103414067220001 4,633.80 3,148.40 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 05/01/10 - 05/31/10 1Z/13/10 55103414067420001 55103414067420001 4,788.26 3,273.46 DIAGNOSIS 1 : fi826 CELWLITIS OF LEG DJAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 � Page 3 of 24 • • � � �'S=; 3� .�i��iX1�N��1�..����G�N��Y�1i:7�1 `�° ' ; C��P��TM�NT O�pU�UC WE�.FARE November 10,2012 STATEMENT OF CLAIM C►IAME ' MCGREEHAN SR,WILLIAM IL3' _ _! 150 213126 CHAPEL POINTE AT CARLISLE T70 S HANOVER ST CARUSLE PA 17013 " ,��'C�-t��'���VIC� . 'f'A�ENT�3ATE : t�RIGtNAL��tN �DJUSTE�CRt� USUAt�C�CE� ���'T�PP�i��Q 06/01/10 - 06/30/10 12/13/10 55103414067650001 55103414067650001 4,633.80 3,099.64 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 O7/01/10 - 0T/31/10 10/17/11 55112844029810401 55112844029810001 4,7$8.26 3,659.65 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 08/01/10 - 08/31/10 10/17/11 55112844030050001 55112844030050001 4,788.26 3,536.65 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 09/01/10 - 09/30/10 10/17/11 55112844030270001 55112844030270001 4�633.80 3,354.34 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: Q00000 10/01/10 - 10/31/10 10/24N 1 55112924028580001 5511292402858Q001 4,788.26 3,864.31 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 19/01/10 - 11/30/10 10/24/11 55112924028850001 55112924028850001 5,214.60 3,470.14 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 12/01/10 - 1 Z/31/10 10/24/11 55112924029090001 55112924029090001 5,388.42 3,844.31 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DlAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 01/01/11 - 01/31/11 10/31/11 55112994028390001 55112994028398001 5�388.42 3,456.67 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 Page 4 of 24 *; : * ' �.c��raaw�����ENNS�r����a � , o���►R�nurENr���u���c w����aR� November 10,2012 STATEMENT OF CLAIM NANl� MCGREEHAN SR,WILLIAM 1t�' 150 213126 CHAPEL POINTE AT CARLISLE 770 S HANOVER ST CARUSLE PA 17013 , �'pA"t"�:�?����t�CE .`#�AYMENT DATE {}RIGtNA�.��N ADJUST�i�C#ZN USU�1L�h��E�' AMC���T�P��CC1�/�I� 02/01/11 - OZ/28/11 10/31/11 55112994028610001 55112994028610001 4,866.96 2,917.48 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 03/01/11 - 03/31/11 10131/11 55112994028920001 55112994028920001 5,388.42 3,456.67 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 04/01/11 - 04/30/17 11/07/11 55113054028340001 55113054028340001 5,214.60 3,438.94 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG _. DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 05/01/11 - 05/31/11 11/O7/11 55113054028630001 55113054028630001 5,388.42 3,715.73 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: Q00000 06/01/11 - 06/30/11 11/07/11 55113054028940001 55113054028940001 5,214.60 3,314.70 DIAGNOSIS 1 : 6826 CELWLITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 07/01/11 - O7/31/11 ' 05/07/12 55121254120310001 5512125412031Q001 5,388.42 3,700.33 �IAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 004000 08/01/11 - 08/31/11 05/07/12 55121254120550001 55121254120550001 5,388.42 3,700.33 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSlS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 09/01/11 - 09/30/11 05/07/12 55121254120820001 55121254120820001 5,214.60 3,512.70 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 Page 5 of 24 . � ��MMCiNWEAITH C}E�ENNSYL��4Nl�4� i DEPARTMENT�7F I�UBLI�1NELFARE November 10,2012 STATEMENT OF CLAIM NAME'': MCGREEHAN SR,WILLIAM � 1C�! :' ' 150 213126 CHAPEL POINTE AT CARLISLE 770$HANOVER ST CARLISLE PA 17013 : I��ITE�iC��'S�R�/1�� �#��Yl�A�1�1'�"D�TE aR1Gt�L C��+1 ACiJIlSTEE�CRN USU��;��G��� �t�;��'1�PpRt��[) 10/01/11 - 10/31/11 05/21/12 55121374554580001 55121374554580001 5,388.42 3,694.08 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG . DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 11/01/11 - 11/30/11 05121/12 55121374554790001 55121374554790001 5,430.90 3,404.20 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 1 ZI01/11 - 12/31/11 05/21/12 55121374555110001 55121374555110001 5,611.93 3,584.08 �IAGNOSIS y : 6826 CELLULITIS OF LEG �IAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 01/01/12 - 01/31/12 06/18/12 55121644398900001 55121644398900001 5,611.93 3,923.16 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 02/01/12 - 02/29/12 06/78/12 55121644399140001 55121644399140001 5,249.87 3,118.04 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 03/01/12 - 03/31/12 06/18/12 55121644399350001 55121644399350001 5,129.21 2,996.33 DIAGNOSIS 1 : 6826 CELLULITIS OF LEG DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 85/01/12 - 05/31/12 06/25/12 20121564050550001 20121564050550001 5,677.65 3,624.45 DIAGNOSIS 1 : 486 PNEUMONIA,ORGANISM hlOS DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 06/01/12 - 06/30/12 O7l30/12 20121854022450001 20121854022450001 5,494.50 3,318.30 DIAGNOSIS 1 : 486 PNEUMONIA,ORGANISM NOS DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: D00000 Page 6 of 24 � __ _ __ __ Ct7MMC}NWEALTH C3F PENNSY�.�IANI� ! �EPA�TM�NTflF P11BL1C WELFARE November 10,2012 STATEMENT OF CLAIM NAME ' MCGREEHAN SR,WILLIAM ID : 150 213126 CHAPEL POINTE AT CARLISLE 770 S HANOVER ST CARLISLE PA 17013 #��t�`�a'"`�F�111�� :�f�Y1��1�tI'DATE ! ORI�tNAI.�Rt+� !ADJIJST�Q Cf�N Ua�UA�;C�R�E� AI�C�J�"�1PpRC��Et3 O7/01/12 - 07/31/12 08/27/12 20122144288340001 20122144288340001 5,677.65 3,501.45 DIAGNOSIS 1 : 486 PNEUMONIA,ORGANISM NOS DIAGNOSIS 2: 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED PROC CODE: 000000 p���y�Q����g��}*;A�; CHAPEL POINTE AT CARLISLE 203,968.50 131,634.61 _. _ � 03 000745163 0001 Page 7 of 24 � �C}MMQt'�i'�i1tfALTH O�PEl�INS�(#�VANlA . DEPARTM�NT�?F PU��#+C WEI�FARE November 10,2012 STATEMENT OF CLAIM NAM� : MCGREEHAN SR,WILLIAM 1[� ' 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 1500 INDUSTRY RD STE A HATFIELD PA 19440 `��t't�filt�,�E#����, ;�'�Y1�A�N�'DATE ! �RIGINAL C�N ' At7�,lUSTEU�#?N'; USUAL C,���"'aES. Ai��1�"�►PPR��E� 02/2Z/09 - 02/22/09 04/27/Q9 25090885248820001 25090885248820001 3.48 3.48 DIAGNOSIS 1 : 0 NDC CODE: 00472033956 HYDROCORTISONE 1%CREAM - GLUCOCORTICOIDS 03/16/09 - 03/16/09 04/13/09 25090765541760001 25090765541760001 3.48 3.48 OIAGNOSIS 1 : 0 NDC CODE: 00472033956 HYDROCORTISONE 1%CREAM - GLUCOCORTICOiDS 04/01/09 - 04/01/09 04/27/09 25090915613820001 25090915613820001 3.48 3.48 DIAGNOSIS 1 : 0 NDC CODE: 00472034356 HYDROCORTISONE 1%CREAM - GLUCOCORTtCOIDS 05i11/09 - 05J11/09 06/08/09 25091315449190001 25091375449190001 3.48 3.48 DIAGNOSIS 1 : 0 NDC CODE: 00472034356 HYDROCORTISONE 1%CREAM - GLUCOCORTICOIDS 06/15l09 - 06/15/09 07/13/09 25091685606190001 250916856067 90001 3.48 3.48 DIAGNOSIS 1 : 0 NDC CODE: 00472034356 HYDROCORTISONE 1%CREAM - GLUCOCORTICOIDS 06/24/09 - 06/24/09 07/20/09 25091755315460001 25091755315460001 3.48 3.48 DIAGNOSIS 1 : 0 NDC CODE: 00472034356 HYDROCORTISONE 1%CREAM - GLUCOCORTICOIDS 06/29/09 - 06/29/09 07/27/09 25091825469670001 25091825469670001 3.48 3.48 DIAGNOSIS 1 : 0 NDC CODE: 00472034356 HYDROCORTISONE 1%CREAM - GLUCOCORTICOIDS OT/06109 - 07/08/09 08/03/09 25091875534100001 25091875534100001 3.48 3.48 DIAGNOSIS 1 : 0 NDC CODE: 00472033956 HYDROCORTISONE 1%CREAM - GLUCOCORTICOIDS Page 8 of 24 ,-�, ' ; , C�MMONrIItEAL�C3F PENMSYLVAN#A 'DEP`ARTMENT OF PU�LIG VWEL�ARE November T0,2012 STATEMENT OF CLAIM NAME MCGREEHAN SR,WILLIAM ID. 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 1500 INDUSTRY RD STE A HATFIELD PA 19440 ,; . ..; , , . ; ;, .; : #�A"f'�'��"S���C� i�'A�Y�►A�i+l'1"b;�AT� {3C�IGIf+1qL CRN AE?JtJST�Q;CRN USLIAL;Ct��ES ' �►!�!t,��'�R1�dVEC)' 07/11/09 - 07/11/09 08/10/09 25091935266160001 25091935266160001 3.48 3.48 DIAGNOSIS 1 : 0 NDC CODE: 00472034356 HYDROCORTISONE 1%CREAM - GLUCOCORTICOIDS O7/20/09 - 07/20/08 08/31/09 25092155361530001 25092155361530001 3.25 3.25 DIAGNOSIS 1 : 0 NDC CODE: 51672201802 HYDROCORTISONE 1%OINTMENT - GLUCOCORTICOIDS 08/08/09 - 08/08/09 08/07/09 25092225690160001 25092225690160001 3.25 3.25 DIAGNOSIS 1:: 0 NDC CODE: 51672201802 HYDROCORTISONE 1%OINTMENT - GLUCOCORTICOIDS 08/27/09 - 08/27/09 09/28/09 250924d544d710001 25092445444710001 3.25 3.25 DIAGNOSIS 1 : 0 NDC CODE: 51672201802 HYDROCORTISONE 1%OINTMENT - GLUCOCORTICOIDS 09/04/09 - 09/04/09 10/05/09 25092485413110001 25092485413110001 3.25 3.25 DIAGNOSIS 1 : 0 NDC CODE: 51672201802 HYDROCORTISONE 1%OINTMENT - GLUCOCORTICOIDS 09/16/09 - 09/16/09 10/1?J09 25092595640290001 25092595640290001 3.25 3.25 DIAGNOSIS 1 : 0 NDC CODE: 51672201802 HYDROCORTISONE 1%OINTMENT - GLUCOCORTICOIDS 10/26/09 - 10/26/09 11/30/09 -25093045310220001 25093045310220001 3.25 3.25 DIAGNOSIS 1 : 0 NDC CODE: 51672201802 HYDROCORTISONE 1%OINTMENT - GLUCOCORTICOIDS 11/09/09 - 11/09/09 12/07/09 25093135669850001 25093135669850001 3.25 3.25 DIAGNOSIS 1 : 0 NDC CODE: 51672201802 HYDROCORTISONE 1%OINTME�tT - GLUCOCORTICOIDS Page 9 of 24 +G�MMC7NWEALTH UF�ENNSYLVANIA '�DEPI�IR'tMENT t�F PUBLIC WEL��4RE ' November 10,2012 STATEMENT OF CLAIM NAME ' MCGREEHAM SR,WILLIAM 11� ' 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 1T055 " C3}tTE t��'S��'t1lt��: - �P�YM�IV`�`U1��'E ' QF�IG[NRL.CRN AQ,3USTE[��R�I USU�Ct-t�4R�E5 ': A111���!"`�1P'P1�C}VEQ' 01l11/10 - 01/11/10 03/15/10 25100485519720001 25100485519720001 9.20 9.20 DIAGNOSIS 1 : 0 NDC CODE: 45802043471 CLOTRIMAZOLE 1%CREAM - ANTIFUNGALS 01/23/10 - 01/23/10 03/15/10 25100485520280001 2510048552028Q001 9.20 9.20 DIAGNOSIS 1 : 0 NDC CODE: 45802043411 CLOTRIMAZOLE 1%CREAM - ANTIFUNGALS 01/28/10 - 01/28/10 03/15/10 25100485520370001 25100485520370001 9.20 9.20 DIAGNOSIS 1: 0 NDC CODE: 45802043411 CLOTRIMAZOLE 1%CREAM - ANTIFUNGALS 02/12/10 - 02/12/10 03/29/10 25100615685050001 25100615685050001 1.99 1.99 DIAGNOSIS 1: 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES�MISCELLANEOUS NUTRIENTS 02/15/10 - 02/15/10 03/15/10 25100485520470001 25100485520470001 8.59 8.59 DIAGNOSIS 1 : 0 NDC CODE: 45802043411 CLOTRIMAZOLE 1%CREAM - ANTIFUNGALS 03/01/10 - 03/01/10 04/26/10 25100915682930001 25100915682930001 1.99 .59 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES 8 MISCELLANEOUS NUTRIENTS 04/01/10 - 04/01t10 05/31/10 25101235591580001 25101235591580001 1.99 1.99 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-�fIT D TAB - ELECTROLYTES�MISCELLANEOUS NUTRIENTS 04/26/10 - 04/26/10 05/24/10 251011855335600Q1 251011855335600Q1 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS Page 10 of 24 Ct)MM4NWEALTt-�OF P'ENNSYi.'�tANt1� ' DEPARTMENT 4F PUBLIG 1�YELFAI�E November 10,2012 �� " STATEMENT OF CLAIM NAME ' MCGREEHAN SR,WILLIAM ID' 'I 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 " IWIECHANICSBURG PA 17055 y:� ., �C��`�"���`S�E��� 1�AYI�AENT UATE ' QRIGII�AL CRN AF?Jt1StE[3 CRN USUAL��tAR�ES �!��"AI�PI�Q�CS' 04/27/10 - 04/27/10 05/2M10 25101185533690001 25101185533690001 13.14 13.14 � DIAGNOSIS 1 : 0 � NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 05/01/10 - 05/01/10 06/28/10 25101525864590001 25101525864590001 1.99 1.99 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES&MISCELLANEOUS NUTRIENTS 05/04/10 - 05J04J10 05/31/10 25101255458890001 25101255458890001 13.14 13.14 DIAGNOSIS 1: 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 05/10/10 - 05/10/10 06/07/10 25101315559130001 25101315559130001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 05/17/10 - 05/17/10 06/14/10 25101385473230001 25101385473230001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 0�20/10 - 05/20/10 06/14/10 25101405647350001 2510140564T350001 13.14 13.14 DIAGNOSIS 1 : 0 � NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 05/26/10 - 05/26/10 06/21/10 25101485401470001 25101485401470001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2°�CREAM - ANTI�UNGALS 05r31/10 - 05/31/10 06/28/10 251015256376TQ001 25101525637670001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2°/a CREAM - ANTIFUNGALS � Page 11 of 24 ' � , ! CC�MMt?NWE�#�T�-t�7F PENNSY�.i�AN1A �EPARTM�NT��PUSL1�W�tFRRE November 10,2012 STATEMENT OF CLAIM C�AME MCGREEHAN SR,WILLIAM ID ' i 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 �14,'�;t��a�`��.1�l�E �AYM�NT Dl�'� C?RtC{NAL C�'tN ADJUS7'Et3'CRN USU�k�,G���SF� ����PF'�FtQV�t� 06/01/10 - 06/01/10 07/26/10 25101825327140001 25107825327140001 1.99 1.99 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES�MISCELLANEOUS NUTRIENTS 06/03/10 - 06/03/10 07/05/10 25101575299680007 25101575299680001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 06/07/10 - 06/OT110 07/05/10 25101605311360001 25101605317 360001 13.14 13.14 DIAGNOSIS 1 : 0 IVDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 06/18/10 - 06/18/10 07/12/10 25101695630330001 25101695630330001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 06/22I10 - 06/21J10 O7/19/10 25101755314920001 25101755314920001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTiFUNGALS 06/29/10 - 06/29/10 07/26/10 25101815437980001 25101815437980001 13.14 13.14 DIAGNOSiS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 07/01/10 - 07/01/10 08/30/10 25102135346980001 25102135346980001 1.99 1.99 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES 8�MISCELLANEOUS NUTRIENTS 07/05/10 - 07/05/10 08/02/10 25101875846820001 25101875846820001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS Page 12 of 24 �.�AMMOM�iEAL�F�O�PENN�I��YA�IU# �. DEPAf2TM�NT+�F'PUBUC WEI�ARE �. ' November 10,2012 STATEMENT OF CLAIM NAME MCGREEHAN SR,WILLIAM 1D? ! 150 213 126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 '�A7�t��S�#�1�'I+C� �. ,�AYIUIEIVT�13ATE QRiGINAL CRN !AE3JUST'EI�CR1�1'� LlSUAL�f�1R�'`aE5�:', �111��,x1NT�iP�1�f,�1IE[)' 07/13/10 - 07/13/10 08/09/10 25101945456950001 25101945456950001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS O7/22/10 - 07/22/10 08/23/10 25102105619210001 25102105619210001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 08/01/10 - 08/01/10 09/27/10 25102445423670001 25102445423670001 1.99 1.99 � DIAGNOSIS 9 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES�MISCELLANEOUS NUTRIENTS 08/04/10 - 08/04/10 08/30/10 25102185558140001 25102185558140001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 08/09/10 - 08/09/10 09/06/10 25102225552760001 25102225552760001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 08H 6/10 - 08/16/10 09/13/10 25102305627710001 25102305627710001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 08/25/10 - 08/25/10 09/27/10 25102425453970001 25102425453970001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTlFUNGAL 2%CREAM - ANTIFUNGALS 09/01/10 - 09/01/10 10/25/10 25102745347540001 25102745347540001 1.99 1.99 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES�MISCELLANEOUS NUTRIENTS Page 13 of 24 , , , ; , � � :.��n�ar�w�►��r��a���i%nvsY�.v��► �- ° QEPARTMENT OF PU�LlC�I1/EC���RE ` November 10,2012 STATEMENT OF CLAIM 1�IAME I�I MCGREEHAN SR,WILLIAM IC} ' 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 , � �331�'['�€��'$E�1�� �/���I�T DA�'E af�1GtNA�C�N ADJt1STEa CR�+�1 �1�U�t�HA��ES` l4l��E���'P'�tC?�/ED 09/06/10 - 09/06/10 10/04/10 25102535344610001 25102535344610001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11T01004514 B/AZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 09/17/10 - 09/1 T/10 10/18/10 25102645715010001 25102645715010001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11T01004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 09/25/10 - 09/25/10 10/25/10 25102T35421960001 25102735421960001 13.14 13.14 DIAGNOSIS 1.: 0 NDC CODE: 11701004514 BATJ►ANTIFUNGAL 2%CREAM - ANTIFUNGALS 09/29H 0 - 09/29/10 10/25/10 25102735422520001 25102735422520001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 10/01/10 - 10/01/10 11/29/10 25103055748220001 25103055748220001 1.99 1.99 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES�MISCELLANEOUS NUTRIENTS 10/04/10 - 10/04/10 11/01/10 25102785582740001 25102785582740001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 10/14/10 - 10/14/10 11/08/10 25102875365730001 25102875365730001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 10/19/10 - 10/19/10 11/15/10 25102935329010001 25102935329010001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS Page 14 of 24 ;` C�MMC�NWEALTH C7F PENNSYLVANtA ' UEPARTAAAEM'�J�F'UBUC 1NELFARE � November 10,2012 STATEMENT OF CLAIM �IAME MCGREEHAN SR,WILLIAM 11� : :.:' 150 213 126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 AAECHANICSBURG PA 17055 ; , ; , �'3A���SE�'U'[+�E Pii1'�MEN'�"i�A�TE ! QRI�If�IAL GRi�i 'AQJt1STEt�!GRN ; USUAL�H�R�E� ' �M{�Uhi1�A��t}�[� 10/21/10 - 10/21/10 11/29/10 25103055747390001 25103055747390001 13.74 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 11/08/10 - 11/08/10 12/06/10 25103145609420001 25103145609420001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 11/19/10 - 11/19/10 12/13/10 25103235307240001 25103235307240001 13.14 13.14 DIAGNOSIS 1: 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 11/2M10 - 11/24/10 12/20/10 25103285288330001 25103285288330001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 12/01/10 - 12/01/10 12/27/10 251033652847T0001 25103365284770001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 12/06/10 - 12/06/10 01/31/11 25110035455160001 25110035455160001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 12/13/10 - 12/13/10 01/31/11 25110035455600001 25110035455600001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 12/20/10 - 12/20/10 01/31/11 25110035456040001 25110035456040001 13.14 13.14 DIAGNOSI$1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS Page 15 of 24 £t�MIVl�,1M11�'EALTH�?F,PENNSY#.�`AI�11�4 ; <. . ..; �EF"AF�TMENT�7F RUB�.IG WELFA�� November 10,2012 STATEMENT OF CLAIM NAME MCGREEHAN SR,WILLIAM IQ 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSSURG PA 17055 ; J.: , ;.. , . Ul�"�.�3����:��� �A�i1�MT�ATE CflE�i�INAt,CRN: ACy,IiJSTEC�CRN USE��t��F��E�, l�Mt��IiIT�`F'�tC�V��►. . . ;: :;, . , , ; � < . _ : ; 01/01/11 - 01/01/11 01i31/11 25110035456220001 25110035456220001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 01/01/11 - 01/01/11 02/28/11 25110325310300001 25110325310300001 1.99 1.99 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES�MISCELLANEOUS NUTRIENTS 01/05/11 - 01/05/11 01/31/11 25110055254080001 25110055254080001 13.14 13.14 �IAGNOSIS 1: 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 01/11/11 - 01/11/11 02/14/11 25110185695540001 25110185695540001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 01/19/11 - 01/19/11 02114/11 25110215634710001 25110215634710001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701Q04514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 01/28/11 - 01/28/91 02/28/11 25110325310070001 25110325310070001 13.14 13.14 DIAGNOSIS 1 : 0 , NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS ��02/01/11 - 02/01/11 04/11/11 25110765381300001 25110765381300001 1.99 1.99 DIAGNOSIS 1 : 0 - NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES 8�MISCELLANEOUS NUTRIENTS 02/O7/11 - 02/07/11 03/07/11 25110425673900001 25110425673900001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS Page 16 of 24 .�:, , _, , ; . - .. ' CQi�It�NWE��TH�F'PEhIN�YLYP►Nt,� [?�Pftif�Tl�lEhIT QF P'UBLI�W�L�ARE � ' November 10,2012 STATEMENT OF CLA1M NAME_ MCGREEHAN SR,WILLIAM ID " 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 11fl " MECHANICSBURG PA 17055 DA'�'��'���EI�IC� , P�'Y`I�IENT�I�T� '�: � f?I�I�t�At,CRN � ADJU�7ED CRN� USL1A[.��1��5�'; AI��+CT����Q' 03/01/11 - 03/01/11 04l25/11 25110915614870001 25110915614870001 1.99 1.99 DIAGNOSIS 1 : 0 � NDC CODE: 00904546080 OYSTER SHELL CALCIUM VIT D TAB - ELECTROLYTES 8 MISCELLANEOUS NUTRIENTS 03/11/11 - 03/11/11 04/04/11 25110705395940001 25110705395940001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2°�CREAM - ANTIFUNGALS 03/1 Z/11 - 03/12/11 04J11H 1 25110765382190001 25110T65382190001 13.14 13.14 DlAGNOSIS 1 . 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 03/17/11 - 03/17/11 04/11/11 25110765385920001 25110765385920001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 03/21/11 - 03/21/11 04/18/11 25110805630350001 25110805630350001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 03/29/11 - 03/29/11 04/25/11 25110885381190001 25110885381190001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 04JOU11 - 04J01/11 05/30/11 25111225540490001 25111225540490001 1.99 1.99 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES�MISCELLANEOUS NUTRIENTS 05/11/11 - 05/11/11 06/06/11 25111315460920001 25111315460920001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS Page 17 of 24 . .�f�MMONI�t'F..�tCTH C1F P'ENNSYLI/ANIA : ' C3E�ART�1lEhIT t�F PU�LIC WEL�ARE � November 10,2012 .. STATEMENT OF CLAIM N�4ME MCGREEHAN SR,WILLIAM (D i 150 213 726 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 '�;�'�t������lt� ;P�4YMEN'�'D�TE ' C?F�IGINA�:CRN ADJl1STED CRN USUAL�FU��+���: Ai�,IIC��V`�"I!kE��I�Q�CM 05/17/11 - 05J17/11 06I13/11 25111375383T40001 25111375383740001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 1170/004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 05/26/11 - 05/26/11 06/20/11 25111465694420001 25111465694420001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 06/01/11 - 06/01/11 08/08/11 25111935337380001 25111935337380001 1.99 1.99 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM VIT D TAB - ELECTROLYTES 8�MISCELLANEOUS NUTRIENTS 06/02/11 - 06/02/11 07/04/11 25111575768100001 25111575768900001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 06/07/11 - 06/0T/11 07/04H 1 25111585657580007 25111585657580001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 19701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 06/13l11 - 06/13/11 07/11/11 25111645746640001 251116457466400a1 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 06/23/11 - 06/23/11 07/25/11 25111795707500001 25111795707500001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS O7/01/11 - 0T/01h1 08/29/11 25112155366560001 25712155366560001 1.99 1.99 DIAGNOSIS 1 : 0 NDC CODE: OQ904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES�MISCELLANEOUS NUTRIENTS Page 18 of 24 ��M1VIt)NWE,�LTti�F P�NNS'Y#..U�41111� .. I�EPARTMENT OF PUBLIG`lNELFARE November 10,2012 STATEMENT OF CLAIM tVAIVIE ' MCGREEHAN SR,WILLIAM IQ 'i ' 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 ;�R'�����a��'111�� • PA'�""MEIyT�AT� �}RIGtNAL CRN ACiJl�ST�C�CRN USUI�►�:�NARGES� �NI��[�'I�11�M�RC?1�C�!' 07/11/11 - O7/11/11 08/08/11 25111925719140001 25111925719140001 i3.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2°!o CREAM - ANTIFUNGALS 07/18/11 - O7/18/11 08/15/11 25111995704070001 25111995704070001 13.14 13.14 DlAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 07/26/11 - 07/26/11 08/22/11 25112075452320001 25112075452320001 13.14 13.14 DIAGNOSIS 1: 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS � 08/11/11 - 08/11/11 09/05/11 25112235334780001 25112235334780001 13.14 � 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 08/16/11 - 08/16/11 09/12/11 25112295327910001 25112295327910001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 08/23/11 - 08/23/11 09/19/11 25112365450570001 25112365450570001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 08/28/11 - 08/28/11 09/26/11 25112455701210001 25112455701210001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 08/31/11 - 48/31/11 10/03/11 25112505637620001 25112505637620001 1.99 1.99 DIAGNOSIS 1 : 0 _ NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES�MISCELLANEOUS NUTRIENTS Page 19 of 24 ; �: ,.-_ .'; � , ' .. ' COMMONWEALT�-!�F PENN�YL�/ANt�4 �. ..� . DEPARTMEM7'Q�PC,lBLIC 1AfElFARE November 10,2012 _ STATEMENT OF CLAIM t+IAME ' MCGREEHAN SR,WILLIAM - 1D ' 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 `�_, 1�AfiE;�F 5���/I�E �1l�'NfENT��AY� ' €:IE�tGINA[�CRN ADJl1ST�f�CE�N USt��F�t+���', ��i�'�RF��Rt�VEQ! 09/01/11 - Q9/01/11 10/31/11 25112775797460001 25112775797460001 1.99 .58 DIAGNOSIS 1 : 0 r NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES�MISCELLANEOUS NUTRIENTS 09/02111 - 09/02/11 09/26/11 25112455702320001 25112455702320001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 09/07/11 - Og/OT/11 10/03/11 25112505638620001 25112505638620001 13.14 13.14 DIAGNOSIS 1 : 0 � NDC CODE: 11T01004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 09/20/11 - 09/20/11 10/17/11 25112645290920001 25112645290920001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 09/26/11 - 09/26/11 10/24/11 25112715567280001 25112715567280001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTlFUNGALS 10/03/11 - 10/03/11 10/31/11 25112775797590001 25112775797590001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 10H 1/11 - 10/11/11 11/07/11 25112855582600001 25112855582600001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS � 10/19/11 - 10/19/11 11/14/11 25112925489210001 25112925489210001 13.14 13.14 DIAGNOSIS 1 : 4 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS Page 20 of 24 . � �aMM�l�WEAITN�F PENN�Yt»VANIA DEF'ARTMENT UF PUB[.IC V!/ELFARE ' November 10,2012 STATEMENT OF CLAIM MAME MCGREEHAN SR,WILLIAM tD: ; 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 ' UATE��,ra��11��� i PA'�`IVl�i�tT'DAtE ! {:►�tIGlNA�C#tN ADJUST�[)CRNi USll1�►L.CH�RG��� ,�At�Ui�"I�11�I�R4VEi�: 11/08/11 - 11/08/11 12/05/11 25113145527780001 25113145527780001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11T01004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS ' 11/2M11 - 11/24/11 12/79/11 25113295745360001 25113295745360001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 12/04/11 - 12/04/11 01/02/12 25113395372870001 25113395372870001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 117Q1004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 12/08/11 - 12/09/11 01/02/12 25113435737880001 25113435T37880001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 12/15/11 - 12/15/11 01/09/12 25113505605070001 25113505605070001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 12/31/11 - 1Z/31/11 02/06/12 25120135500710001 25120135500710001 13.74 9.86 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 01/06/12 - 01/06/12 02/06/12 25120135501030001 25120135501030001 13.14 9.86 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTlFUNGALS 01/16/12 - 01/16/12 02/13/12 25120175789510001 251201 T5789510001 13.14 13.14 DIAGNOSIS 1 : Q NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS _ Page 21 of 24 �� t � CC,IMMONWFALTH�F PENNSI(LVAN�4 DEPARTMENT t)F PUBLt�WELFARE November 10,2012 � � STATEMENT OF CLAIM _ _ NAME ' MCGREEHAN SR,WILLIAM � 1Q 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 1T055 � OAT�;t��SE�`t�� f�A'Y�I�NT 1�ATE C1Rt�tNAL CRN A13J11�T�D�RN �11SUAL GF�t�� ' A��If��'�F'�P1�UVEE� 01/23/12 - 01/23/12 02/20/12 25120235761150001 25120235761150001 13.44 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 02/04/12 - 02/04/12 03/05/12 25120375830280001 25120375830280001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004574 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 02/16/12 - 02/16/12 04/02/12 25120675691440001 25120675691440001 13.14 13.14 DIAGNOSIS 1: 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 02/22/12 - 02/22112 03/19/12 25120535679340001 25120535679340001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 03/O7/12 - 03/07/12 04/0Z/12 25120695401260001 25120695401260001 13.14 13.14 DIAGNOSIS 1 : 0 NDC CODE: 11T01004574 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 03/17/12 - 03/17/12 04/16/12 25120795788330001 25120795788330001 3.30 3.30 DIAGNOSIS 1: 0 NDC CODE: 00472073556 MICONAZOLE NITRATE 2%CREAM - ANTIFUNGALS 03/20/12 - 03/20/12 04/16N 2 25120815682470001 25120815682470001 13.14 12.41 DIAGNOSIS 1 : 0 NDC CODE: 11709004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS * 03/26l12 - 03/26/12 04/23/12 25120865890500001 2512086589�500001 13.14 8.41 " DIAGNOSIS 1 : 0 _ NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS Page 22 of 24 . , . - n . , .;; ' �C}MMC�I�11�11EAL.�QF PENNSYI��I}EMiA E � 'DEPAE�TMENT�1=Pt,IgEt�1NEL�ARE November 10,2012 STATEMENT OF.CLAIM NAtVIE ' MCGREEHAN SR,WIL�IAM !D : 150 213 126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 1T055 � DAT.E'�1�SE��It�� . . PAYM�NT bA'�E ORIGfNA�.+CRN ,Ai}JllSfiEt�CR1++1 tJ$UA��F�A��G��� AIUI��I'�':���Q�/E[� 04/01J12 - 04/02/12 04/30/12 251209357694T0001 25120935769470001 13.14 8.41 DIAGNOSIS 1 : 0 NDC CODE: 11T01004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 04/11 N 2 - 04/11/12 05/07/12 25121025585100001 25121025585100001 13.14 8.41 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 04J18/12 - OM18/12 05/14/12 25121105461200001 25121105461200001 13.14 12.41 DIAGNOSIS 1 : 0 , NDC CODE: 11701004514 BAZA ANTIFUNGAL 2°�CREAM - ANTIFUNGALS 04/25/12 - 04/25H2 O5/21/12 25121165597320001 25121165597320001 13.14. 8.41 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 05J04/12 - 05/04/12 06l04/12 25121285493650001 25121285493650001 13.14 8.41 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 05/28/12 - 05/29/12 06/25/12 25121505772750001 25121505772750001 13.14 12.41 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 06/03/12 - 06/03/12 07/02/12 25121565495960001 25121565495960001 13.14 8.41 DIAGNOSfS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 06/12/12 - 06i12112 O7/09N 2 25121655445600001 25121655445600001 13.14 8.41 DIAGNOStS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS Page 23 of 24 J ► �r � ; :. < :: . ,� , , :: '. . ' 'C(3MM�MWEAL"�N C3F i'ENNS�FLVANU� ; . ' E 3 �. i DEPARTMENT OF PU�LIC WEL�AR� November 10,2012 STATEMENT OF CLAIM �JAME MCGREEHAN SR,WILLIAM ID 150 213126 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 `DI�T�(�S��VI�� �a�tiii�lT[�1�"�E aR�ciru��e�rl �uu,�u���cR�1 u�uAr�G�±�ES' �,�It��'�pP�kq�C� 06/21/12 - 06/21/12 07/16l12 25121745386360001 Z5121745386360001 13.14 8.41 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 06/28/12 - 06/28/12 O7/23/12 25121815578250001 25121815578250001 13.14 10.41 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 07/09/12 - 07/09/12 08/06/12 25121915557600001 25121915557600001 13.14 8.41 UTAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 07/18/12 - 07/18/12 08/13/12 25122005525280001 25122005525280001 13.14 8.41 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS 07/25/12 - OT/25/12 08/20/12 25122075606980001 25122075606980001 13.14 10.41 DIAGNOSIS 1 : 0 NDC CODE: 11701004514 BAZA ANTIFUNGAL 2%CREAM - ANTIFUNGALS p�������u�-����q�; ; MILLENNIUM PHARMACYSYSTEMS INC 1,375.69 1,311.37 ' 24 001887261 0008 Page 24 of 24 REV 1737-7 EX+(g-p8) REVER3E � pennsylvan�a SCNEp�LE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RERIRN NONRESIDENT DECEDENT ESTATE OF FILE NUMBER William F. McGreehan, Sr. When flat rate method is elected, list the beneficiaries of the Pennsylvania property. When proportionate method is elected, list all beneficiaries. RELATIONSHIP TO ITEM DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not Liat Tniatee s OF ESTATE I. TAXABLE„DISTRIBUTIONS_�include outright spousal distributions and transfe�s under Sec.2116(a)(1.2)j 1 r _ �Ruth Apa Daughter 2 5� , ��..«�...4.,.��. . ,�, .. ;�._._�..�.� , , , . , ��..�_..�..wnv��. u. __ . .. _ _ ; 2 �William F McGreehan, Jr. Son ; 2 5� � , ;._...._:_.ti.�..�� ��..,w�_r._._. .. _ __ }. -, ... . �.-_..� .r, _ _ - ,,1. �� �: .,�,.e.�.....�,M e_ ��w����...._,.N.. .� � 3 iThomas M. McGreehan Son ; � �.��_ �:...�....w..... _..� __ 2�$ .. _ , �_---- e.�.��,.��.�..._.N�.r.r� a._. �..., . ; � _ ,: . � 4 �John A. McGreehan Son � 25� � � ��.__.. . __R.�...�.__u,__.,w,__ _ _ . . , . --- ° . � ,.�..,�.�w�u_.�.__._ .,.�:. . �.. w � � . . , .v r ;� ; _ : : � � � � � � , :� �_�.,.� _ .w,..�.�.� _ �.� _ ,.��.,..,�.� „�...�_�,.�.�����. � ,_ . . _ . , �� . , .. ? � P : ; � � < , :.M.,.,,�,...�. �c.,W.n:.M,.,,........�:,..,,., . .... ..._... ........ .. .. . . � . . .. . . . . . . . . . ��� . � .. .�.. „ ..,.. . . . . . . . . .. . . : . . .... - .. . ...,. �.. � ,�.«..,__.,... �..,,..,..v,.,«.....�..,.. , , .... , ..... ...,... .. . .. ...... ...... . . . . . . . . . .. . ... .. .. . . ...:. . }t i E � m.. �.x� _. � � _.,._.n , u a.v_.,�.... ..,_�. e�:... .._......�. _..,,_. . t '.�, ENTER DOLLARAMOUNTS FOR DISTRIBUTIQNS SHOWN ABOVE ON REV-1737 COVER SHEET OR THE PROPORTIONATE METHOD WORKSHEET ON THE REVERSE SIDE OF l�EV 1737 COVER SHEET,AS APPROPRIATE. II. NON-TiAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE �.......�,,,....w..,.��.� ,..�,�ttMw � .e_,� � P. � _. , 1 . � � � a,. . _ _ .�, . . �.��M..� ,,._.�.�.M_.,, _ . ,. _ ;, . ' ` � , � � • _ ..- � , �,..�.,,. w.,,.�. �. . .�.�_....� ,�.....,..�..n..�..m,..... .__.. . .. _ � , � i , � � � � , � �..a,w.v�� �,�.. ..�,.w._„r,.,. ., . _ _ _ _ _ ., , - .z..�..� _ ._ .. _ _ .,-; ... ,. �z.� �. ��__._,..���.___...._. :,.. ��. , ; � a , � � , 4 t + .,..w„�....� 5....�...�..���..,�..�.t.�..�r nE...,..�....... ,....,.. ..��... ..:.,.... ...... ....... .,.,.,- ... .. . . . . .. . . . . . . . . .. t B. CHARITABLE AND�OVERNMENTAL DISTRIBUTIONS 3�..�-�+.�.w,�...�..,w.c..m+.i...,...r. .., ... .. . . . . . . . . . .. ..... . . . . . . .. . . _ . ... �. , _ 1. � ; � , , x,.,._ :.,_.. .... . � { � a , .� �..,e..�.�.,:,..�...��,..., r. . �.�� � � �� . i � # , ,: .,...� fi ..�x ,,.<. .t .=, , ; . , ` , � � , , ��M ��. . a.. . .w�: .. _..�,.�. A_�.��.��. � s �.. � � . :w > . w � .. 3 �...a..�� � � � � , s ._._�__ . . _ , � x 1 � C : � i i ; . ��n...e.«...,....J. 'woae�,..w...,....—w..... . . �. , �� �,�-..aux<4_,.e..�..: . . . x x -.�73 , 3:... � . v....»...�,.m.,..y. �..m.e,.a.:....,,,.,..,..�..,.,.....'.,.',;' ..:. ':`�:.. '" ._. " ...:' ..... .. '... . .. , ...... . .. . . . . . . . .. .. .. � q � .. ., .. � ' :_: •.`.. r.<°, .,:.s ..n 1.,,-.m. .....+ } � � , � t � . , .._ "_ ._.. . .�.. �:-�-�. �_.�V4.. N .�.t��' }.�x�--r TOTAL OF PART II r��,y.:.. . ..;,:����`�,�.,...,.�. �:. (Enter total non-taxable distributions on Line 13 of REV 1737 caver sheet.) 4,.,.,,.r _„.,, „ ; _. ,..:.,,; --- �(If more space is needed, use additional sheets of paper of the same size) . �' , • . . • • . . � � � LAST WILL and TESTAMENT OF WILLIAM FR.AN IS McGREEHAN KNOW ALL NIEN BY THESE PRE5ENTS, that I, WILLIAM FRANCIS McGREEHAN, residing in the Township of Richlaad, County of Cambria, and Commonwealt6 of Pennsylvania, being in good healt6 and of sound and disposing tnind and memory,do make and publis6 this my Last Will and Testament, hereby revoking ait former Wills and Codicils by me at any time heretofore made. ITE I: I direct that my Executrix hereinafter named arrange for a simple but . �ignified funeral and burial at the Saint Michael Church Cemetery,loc$ted in Saint Michael, Pennsylvaaia, alongside my beloved wife,LETAH PERLE McGI�EEHAN. I also direct that � , the eapense9 of my last ilines9 and funeral shall be paid out of my Estate. ITE II: I give and bequeath unto my Executrix named in this Will any and all remaining tangible personal property owned by me at the time of my deat6 with the request that my said Eacecutrix distribute the same in accordance with any �nemorandum which I may leave. In the absence of such memorandum or to the eactent that such memorandum does C �� . , � : WILLIAM FRANCIS McGREEHAN 1 . � . not include atl such items, I bequeath the said tangible personai property in equat shares, to my surviving children. tf my surviving chitdren should fail to agree on the distribution of my tangible persona!property within siac(6)months�fter my death,that determination 9hai! be made by my Esecutrix. Any of said property which is unselected or undistributed in accordance with this Paragraph shall be sold and the proceeds distributed as pArt of the residue of my Estate. For the purposes of this Paragraph,tangible personal property shal! not include c�sh,securities,and other non-tangibles. ITEM III: I give,devise and beque$th ail the rest,residue and remainder of my Estate of every nature and wherever situate, in equa!shares, to my children as foilows: 1. TWENTY-FIVE (25%) PERCENT of my residuary Estate shall be distributed outright to my daughter,RUTH MARY APA,of Lewisberry,Pennsytvania,or to her issue,in equal shares, per stirpes, or in lieu of issue, in equa! shares, to my surviving children beneficiaries. 2. TWENTY-FIVE (25%) PERCENT of my residuary Estate shatl be disttibuted outright to my son, WILLIAM FRANCIS McGREEHAN,JR., of Fairfield, Ohio, or to his issue,ia equal shares,per stirpes,or in lieu of issue,in equal shares,to my surviving children. 3. TWENTY-FIVE (25%) PERCENT of my residuary Estate shalt be distributed outright to my son,JOHN ALBERT McGREEHAN,of Meclina,Ohio, or to his issue,in equat shares, per stirpes, or in lieu of issue,in equat shares, to my surviving children. � � � � � � Cw ��• WILLIAM FRANCIS McGREEHAN 2 ' � . - . �t. TWENTY-FIVE (25%} PERCENT of my residuary Estate shall be distributed outright to my son,THOMAS MICHAEL McGREEHAN,of Big Lake, Minnesota, or to his issue,in equa!shares,per stirpes,or in lieu of issue,in equal shares,to my surviving children. ITEM IV: I appoint iny daughter,RUTH MARY APA,of Lewisberry,Pennsylvaniu, Erecutria, of this my Last Will ancl TestAment. If my daughter, RUTH MARY APA i , s unable to serve as Erecutrix of my Will, then I appoint my son, WILLIAM FRANCIS � McGREEHAN,JR.,of Fai�eld,Ohio, to serve as Alternate Ezecutor of thi9 my Last Will and Testament. ITEM V: I direct my named Executrix, or her successor, to pay a!1 of my legally enforceabte debts,funeral expenses and costs of administering my Estate. [further direct my named Executrix to pay any taxes incurred by my Estate as a result of my death. Said items are to be paid from the residue of my Estate without reimbursement from any of the beneficiaries of this Wiil. ITEM VI: If any minor or incompetent should become entitled to any portion of my Estate,passing under this Will or otherwise as a result of my death,I appoint the natural or lega!guardi$n of that minor or incornpetent to be the Testamentary Trustee for the portion of my Estate so passing. ITEM VII: No Executrix,Trustee or Guardian named in this Will shall be required to post bond or other security for t6e faithful performance of his or her duties. I/"[_..�-1�' � �� ' C , � ., ��, � WILLIAM FRANCIS McGREEHAN 3 v' IN WITNESS WHEREOF, I have hereunto set my hand and seal this 6th day of Decem ber, 1999. • , ��c� 11�� � WILLIAM FRANCIS McGREEHAN The preceding instrument, consisting of this and three (3) other ty ewritten a es p Pg identified by the signature of the Testator,WILLIAM FRANCIS McGREEHAN,was on the day and date thereof signed,published and declared by WILLIAM F1tANCIS McGREEHAN, the Testatrix, therein named, as �nd for her Last Will, in the presence of us, who at her request, in her presence and in the presence of each other have subscribed our names as witncsses thereto. � � -- residing in Johnstown,Pennsylvania , . residing in Johnstown, Pennsylvania 4 • ' ' COMMONWEALTH OF PENNSYLVANI� * * SS: COUNTY OF CAMBRjA * We, WILLIAM FRANCIS McGREEHAN, TIMOTHY C. LEVENTRY and EVELYN R.BIBER,the T�stator and Witnesses,respectivety,whose names are signed to the attached or foregoing instrument,being first duly sworn,do hereby declare to the undersigned authority that the Testator signed and erecuted the instrument as his Last Will and t6at he had signed willingly, and that he executed it as hia free and voluntary act for the purposes therein expressed,and that each of the witnesses,in the presence and hearing of the Testator, signed the Will as witness and that to the best of their knowledge the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. �U�� `� � � WILLIA FRA McGREEHAN Witne �Vitness Subscribed, sworn to and acknowledged before me by WILLIAM FRANCIS McGREEHAN, the Testator, and subscribed and sworn to before me by TIMOTHY C. LEVENTRY and EVELYN R. BIBER, witnesses, on the 6th day of December, 1999. � � � C :..� Notary Public NOT^.rl��l._ .`_���AL f I !�rt.��t\4�, �'t_''�_!(^•'�� i'•�Ct3f`�P'.I���1C 1��.�;!.;�,.^,r;.? ;fif','?',"..,!(�O;�f���, �7� �.i.:1(.' J ���+y Cr;����r;;',:'.:�rt�'�c�'it�;s A.p�.2�,20Q0 5 - • . MEMORANDUM PURSUANT T4 ITEM II OF THE LAST WILL AND TESTAi1�IENT OF WILLIAM FRANCIS McGREEHAN SPECIFIC BEQUESTS DESIRED: Description To Whom Date Initial 1. 2. 3. 4. � 5. �6. 7. 8. 9. 10. 11. 12. 13. 14. ;� `, i ' �'� � c � -.�.J��t�rC� 1� WILLIAM FRANCIS McGREEHAN 6