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02-11-14
J • 1505610101 REV-1500 Ex(01-10) ! PA Department of Revenue Pennsylvania - OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PD Box 28O6m INHERITANCE TAX RETURN ® J HeMsburg,PA 1712R-06gs. RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW a_,. ..,:at' -v. d'ts;..ai;•i Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY =/ ltol-5144A7M 1 , 6411111401 . Decedents Last Name six Decedent's First Name Mf F 014-14.11d (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Sacral Security Numbers � THIS RETURN MUST BE IN DUPLICATE ITH THE REGISTER R OF WILLS FILL'IN APPROPRIATE OVALS BELOW to 1.Original Return C:) 2.Supplemental Return O 3. Remainder Return(date of death 't t 1 ' ''1, prior to 12-13-82) O 4. Limited Estate O 4s.Future Interest Compromise(date of C= S. Federal Estate Tax Return Required t = C. death after 12-12-82) tl�{6.Decedent Died Testate Q 7.Decedent Maintained a Living Trust 8, Total Number of Safe Deposit Boxes . n (Attach Copy of Will) ,(Attach Copy of Trust) O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death O 11. Election to tax under Sec.9113(A) A i between 12-31.91 and 1-1-95) (Attach$ch.O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name ✓ y,' � Daytime Telephone Number EL "/�J 7ho � b Fo- z-�Dd 1 -� REGISTER OF WR45 USE ONLY t1 = M First line of address W 6 C0,0114 $ Fe kkYlb 0 r f rnm Second line of address 3a � A i�y 'T? -rt 'rt Tr City or Post Office State ZIP Code c "SATE FILED -- '" T C t Gl 2'G ff 1 T O S 5 � 'I � i Correspondent's e-mail address: r s II;e to S .7 t J j ['d st n Gt Under penalties of perjury,I dada,that I have examined this retum,inducing accompanying schedules and statements,and to the best of my knowledge and belleL It is W e,coned and complete.Declaration of preparer other than the personal representative is based on all Information of which preparer has any knowledge. SIGNATU OF PERSON RESPONSIBLE FOR FILING RETURN DATE 1,7 tt .dZE�+AM^ v me P-ty _ ` f I ADDRESS S°RufX(yln. M1LZf�' 7252 Aw"CleTZli/GLE X 2).1 ORlBL/SrLFl FA 17015 SIGNATURE OF PHEE.TNTATtVE DATE ADDRESS C//-40 GES E. SHI,&GdS Xr 6 dZ,0U5gFW .4W /�I�CH/F.tIIC,Sp�G.Q(s i0.0 J 7 US'4 PLEASE USE ORIGINAL,FORM ONLY Side 1 1505610101 1505610101 J 1505610105 REV-1500 EX Decedent's Social Security Number dry Decedent's Name hl, AlolroAd iiE—CAPFuLATioN 1. Real Estate(Schedule A). 1. 2. Stocks and Bonds(Schedule B) ... 2. to 0 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) 1 4, Mortgages and Notes Receivable(Schedule D)... ........ .......... 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)... .... 5. 6. Jointly Owned Property(Schedule F) C= Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested... .... 7. AIL 8, Total Gross Assets(total Lines I through 7).... .... . .... .... 8. 9, Funeral Expenses and Administrative Costs(Schedule H).... JJ 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) .... ... 10, 1 0 X--A-4A- - 11, Total Deductions(total Lines 9 and 10).. ........ ... .... ............... ll, 12, Net Value of Estate(Line 8 minus Line 11) .... ... .... ................... 12, 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made(Schedule J) . ........... ... .... 13. 14, Net Value Subject to Tax(Line 12 minus Line 13) ...... ....... ........ ... 14. LM lim 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—0 15. J 16. Amount of Line 14 taxable attinealrate X.Oqir —LL 16. 17. Amount of line 14 taxable W at sibling rate X.12 IT 18. Amount of Line 14 taxable at collateral rate X.15 0 D i8. 19, TAX DUE .... ..... ........ . ... .... ..... 20.,FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C=) Side 2 1505610105 1505610105 REV-1500 EX Page 3 File Number 2 Decedent's Complete Address: DECEDENT'S NAME lylargore>< �/, /7lorrcw STREETADDRESS rr /J /l cfn srATE zIP Corn N.II 134- Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) p 2. Credits/Payments O A.Prior Payments S.Discount 17 Total Credits(A+B) (2) D 3. Interest O 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.4 (3) Fill in oval on Page 2,Line 20 to request a refund. (4) m 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred:.......................................................................................... ❑ [� b. retain the right to designate who shall use the property transferred or its income;............................................ ❑ c. retain a reversionary interest;or.......................................................................................................................... ❑ d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 2. If death occurred after Dec.12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ 19 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ �] 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? ........................................................................................................................ ❑ IV 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 disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent 172 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(1.2)[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. SCHEDULE E COMMONWULTN OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE ESIDENT DECEDENT RN PERSONAL PROPERTY ESTATE OF lhorro ul FILE NUMBER fY(Ar9Qret /!l. Include the proceeds of Ihgalion and the data the proceeds were received by the estate.All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Pl hmark Prem;urrt 'Re and Check A/ SB. 1 .7. Ri�AInark Preser;joh'on Dm Plan .7Y,6a e;hi zevis 2344k Chetk;nd *at No, 610,9 S-95' //o -X 7, RZa. /3 /f 0,'flzrns ,1&9k 04e4k,'�( het NO- 62 32 W ebb Ar�5.9b SCE Y4�u4Y70/1 �GJ�^ aTl4che.1) }F '04, Nofi : i41/JFGrt<».It/ /idu�ittrms pt a aotn.rer�t ore diSf�ed of lkedts Aye ih F'ee��ra�TnrJ r Gnfrry hie /1�1��3'�a� TOTAL(Also enter on line 5,Recapitulation) $ (if more space is needed,insert additional sheets of the same size) ' ' 'tl$i LNECK$SINGETflR ATTFtX IET CURRENCY CC9N DEPOSIT-TICKET USE WHEF SIDE FOR CHECKS � USEO=NER$IDC COR :`:�.'a:::`r• G �./�•(�:r;xQ: DATE Jr�-�r'"Y di '� BE SURE EACH REM 15 - 1`J j PROPERLY CHOORSE0. r.,, ,{ 1, 3l RfibS 1 '�. OEtlRNOOnQPr�nq FMXIXMOfOiI%MYf SUMCr IOMMGx9rFe5 u aMlpnraw cabxn[AU.Gm[wA u'It.G.af wuC[mvacranufm. � r�;.;,•,Y"l i':'.:%•r..:. Citizens .y 1. CfIOLfB wv rvpi BL n'iN/aEtpI MRP.V[MnKYtaWK •.' .::r�Ya��np!},�;^% F,TWALIRROM W.Eft SIDE Pennsylvania ' j 5 8 : 1: S6001f1`I, LSSF: 6234333S68", dfrx"lv"•�'�i'. ,, Oj4�35519� �1� ztinc' ANx } .• a�# ��" 'y �.��`� �?8 =rSua K S c4�r •�?tf,'wX x a � �k,� . ..Yr ��f4 1 �4 fNi't, , w r y�T a"Fr'', .: '�';�+��s•>" C y,- +� {� � s!„SSCr�' CX � C � ,y �a:•T r ,may a}y<tTM r bj�° r �Y ezp*;�.' v � �� Y �"4�K ..� Pxernzum rydRefFund �',�{,,5 s .eW i 4Ya Il' N Y w �f' '�'_ t3•rM.JYr. . r46sj1%1'ja2413 J. �rl� ei � '�$ R 158 29, � a1 yc °y '<'tw .-,6 �'.'cc3"x .�`$Cp,+ 'fritihS `s. t u' t Sri. sg' t3 a . . �, "vo"'"innnm rastwo Rk �Y l Xr tt ��" *+,ONEY�,HUNDREDS.FTrpT'Y�'ETGHT�P.�� 9fj<S].',OO�,.DO `.t r�a.!rE,*y�+a•'..s:hYr� ��p k j r �I "t:JT>F S � ;`du'r� fi +`.r II � 3.""°'° Or .•!i, ,§ .I u'�H���ES�A "�OE� p'aM/ 1,� OI2ROW� "�, a3f,R a=,zr ^a = sr x+» �r r � ° 7 rt,;�a;.h�b�=:.';fir?25'2s?.WER2%Z �EaRD.*�y!�.rv�ra.�',c£•a ... $n:�f.�,� �...fi,::.;r,�.;�, �Rs„+.«cb,, , a atn ...,. . ., .. . CARLISLE PF 1?4158293 '043 S'S I9n, 1:0360 ?61501: 620S452S8III, - US7 CHECKS SANELY OR ATTACH MY a � - CURRENCY• <.. ;y q' COIN• f '/ U ! i;: �a DEPOSITTICKET USEOTHER SIOEPOn E SURE EACH REM IS CHECKS IYJ- naY � PROPEPLY ENDORSED. ... .I •.ih;y:.'.'.Y ef.{S: DATE nEMS/ OTLL S CKbU ND O1HE111nW• gry[•fp10LM16(14116CCIYOTE HCA406 � r 4 , ♦'... . 6YK SC.S.HOT an wiE oiovnmtvlm. +���YS '.$ S4 r ". �1 Y, 11� T� Citizens Bank OTHERSH)c Pennsylvania 1: S600... l iSSl: 623433156811' l e aamm�•rrn 4.. .I '. aTifE�"BANx�,��,><, �e 043001�8�., 4 . E ^6f•�t��� ��-��,'��a"� �'sxpr � �:�Ou4��z�.0�t?d0130 ; '"S* �i'1'�7a Y�'��n�CS`�" 2 5S.�R°6tOL�,•'7 L4vgp 1nai�3AM w'liNn l�eRi1*')T` *�TWENTY� F'•:V �>�tlOB, D03r- S* r , n, OWN,' Y M"M MORROW a <syT�ag ft � C ~ *d'S T •/ ._ ..'' .2.a. °Nma;�so+liE�cl'y11'.;.i}3`G3Yj�'.' F�J�..-':i 4 HANICSBURG 'P 170'55 ;ME '0430018 n• '1:0360 76 1 50 : 620545258111' A C lU z e n s B a nk- One Citizens Drive 7 ROP112 Riverside,RI 02915 January 3, 2014 Charles E. Shields,III Attorney At Law 6 Clouser Road Mechanicsburg PA 17055 Estate of: M MAE MORROW Date of Death: May 02, 2013 SSN: .180-26-5581 . Dear Sir/Madam: In accordance'with your request, the attached information sheet has been provided in.the above decedent's name as of his/her date of death. The decedent did not hold a safe deposit box with our institution at the time of death. For Installment Loans or Line of Credit accounts,contact our Loan Department at 1-800-708-6680. For all other inquiries, please call 1-877-579-2667 Sincerely, y Kristen L. Petrucci Decedent Account Processing REF#: 623044 Citizens Bank Account Number 6100595110 Account Title M MAE MORROW Date Opened 912311997 Account Type Checking Prinei al Balance as of DOD $7823.13 Interest from Last Posting to DOD $ .00 Account Balance as ofDOD $7823.13 YTD Interest to DOD $ .00 J Cit izens Bk . . A Number 6232867266 Title M MAE MORROW ned 5/3/2011 Type Checking Principal Balance as of DOD $85.76 rom Last Posting to DOD $ .00 Balance as of DOD $85.76 rest to DOD $ .00 008422 ODO1 0001 000 IIGHMMK. =822-001-0 P.O.Box 382102 Pittsburgh PA 15250.8102 Invoice P.O.Box 382102 Pittsburgh PA 15250-8102 Date Group 04/05/13 0_6605179 �. o i3 Company Code Billing ID C/� 8S5 /G3. 75 01 900060203 4 N M MAE MORROW C/O DOROTHY M MILLER o° 7252 WERTZVILLE RD CARLISLE PA 17015-8293 3 i Member Covera a Period Account Status ID Number Beginning Ending Previous Balance 163 . 75 102836713001B 05/01/13 05/31/13 Payments Received CR (163 .75) Product: Medigap Blue - Plan B Adjustments 0.00 Individual Prior Balance Due 0. 00 Coverage Period Premium 163. 75 Total Balance Due 163 .75 III I III 1is space on future bills. We will provide updates on your benefits, "'A ' F J .,}. •. US.POSiAq you have any questions about your coverage, please contact our No ? $000-30 0 address and telephone number appear on the reverse side of this wN f Z[P" 15222 a r'• 3 0,6,3 1n14c1 it account, always include your Billing ID on your payment. averse side for important information. IGHMARKO -Y Date: 04/10/2013 This Month Gross payment amount 25.60 `Net payment amount 25 . 60 i 043001.8 . W. r , UIN NN ff s yypp,r Q¢rs rp� �01�/;1}0/2013 X254w60 Fit w o- VoN�ror•"'ma�M'+'3 tnin�W'cr �F rF.era.L-k AYw ` 3L-�3♦ ` ,�,y4,' � ,.�"'�Elha�'Sa�a z}"�y„��7tQ,TM��'�M M- MO 'OW .v* � r .' r pF ,xy�� r�^.3��,��� �•'��"�Zi j° ,� �. 4..kr+"r.�,.X�.N.1.:..-c.,�� �'"I(Z3BURG PH �.+�' - � �'.:.�r` ��'iiw�`� . ^' F 'Eic`f3x "`�k`54`=+�`.�',1' .�F•�� 116.0430018,18 E:03'607.6i50o: 62ost.,s258iu• SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF !V ar grel h7. /14�rrDtj FILE NUMBER 5 ai-13- ssy Debts of decedent must be reported on Schedule 1. ITEM NUMBER DESCRIPTION ' AMOUNT A. FUNERAL EXPENSES: Maloc2zi runeml Nome W Mechan'fcs&tj 325.113 Tindle 4ri4j Zit&mn CA&trcA for k0ttfil mea,l,rt. ASS:16 i B. ADMINISTWjWECOSTS. 1. Personal Representative's Commissions .// 11 Name of Personal Representative(s) kiolr.,0//j M. /6r Y 000. aO Street Address 725,2 Wer/Zy,'l city. 1_4r16e State—o!!?3LZip /701S Years)Commission Paid: C 2. Attorney Fees Lr�gl-�GS F. 6AI'6/415 7 ' —Z'6 °O 3. Family Exemption:(If decedent's address is not the same as claimant's,ahach explanation) Claimant Street Address City Stale _Zip Relationship"of"Claimant to Decedent e 1 / J- 4. Probate Fees a*w o.', ,;u /SSGe Dr Vo,? cv-I i17la/es fMy, 50 5. Accountant's Fees (/ //�i , C, 1,4/ A'b,'f&efb, &CA, /1kdvve5brr p•e�araA,ok 6. Tax Return Preparer's Fees aI oO.1E Ohi, pw Il0! ezz• (eahm•) a S-O° 7. /1•Ar'triis1'49 in ea,%ke,1and 8• �Avarl-is�/r,. r'n C'arl,'s/e �entbe/ and F,;%71 lkifaunf,'g ¢/�7.oG !o. o�PJ-v,u �iltar�e >/v �'•�iierls ,$d,A/G � a !$; °o TOTAL(Also enter on line 9,Recapitulation) S (It more space is needed,insed additional sheets of the same size) Malpezzi Funeral Home Tri 8 Market Plaza Way _ 02-_ Mechanicsburg,PA 17055 (717)697-4696 www.Mal ezziFuneralHome.com Jeremy J.Shartzey FD - Michael J.Malpezzi,Owner,FD Kyle C,Knipe,FD May 7, 2013 Dorothy M.Miller 7252 Wertzville Road Carlisle, PA 17015 This is the final statement for the funeral services of Margaret Mae Morrow We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way. PROFESSIONAL SERVICES: Services of Funeral Director/Staff - $5,475.00 FUNERAL HOME SERVICE CHARGES $5,475.00 SELECTED MERCHANDISE: Poplar Veneer Casket $2,995.00' Sentinel Vault ct era nm' 0992 3-76151360 193 DATE )ti�a O c20 1 PAY � �- $ TO THE � CA NV-p �']/� - ORDER OF ,L C/ /.✓ �OO DOLLARS 8' s AK Citizens Bank Pennsylvania / �,, n/� y/������ � FOR Gal lL�P�7' Cr:C , Ci- _�I Q�t� /.Cf IT u•0009921" t:036076L50t: 623433L56811' TOTAL CASH ADVANCES AND SPECIAL CHARGES $2,34233 CONTRACT PRICE $12,50633' HISTORY: 05/03/2013 Discount Pre-Need Guarantee $149.85 05/07/2013 Payment Homesteaders Life Company $12031.055 ' TOTAL AMOUNT DUE BY June 2,2013 $3 25.43 Pd S�ao�a o 13 c.Pe,tJo49a If you have any questions or concerns regarding this bill,please call our office at(717)697-4696. malpezzi Funeral Home 8 Market Plaza Way Mechanicsburg,PA I7055 - 'r i! (717)697-4696 www.MalpezziFuneralHome.com Jeremy J.Shartzey PD Michael J.Malpezzi,Owner,FD Kyle C Knipe,FD May 7,2013 Dorothy M.Miller 7252 Wertzville Road Carlisle,PA 17015 This is the final statement for the funeral services of Margaret Mae Morrow We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way. PROFESSIONAL SERVICES: Services of Funeral Director/Staff $5,475.00' FUNERAL HOME SERVICE CHARGES $5,475.00 SELECTED MERCHANDISE: 1 Poplar Veneer Casket $2,995.00' Sentinel Vault $1,425.00'" R"' r3o-:- ? $245.00- Laminated Obituaries $24.00, THE COST OF OUR SERVICES,EQUIPMENT,AND MERCHANDISE THAT YOU HAVE SELECTED $10,164.00 CASH ADVANCES: At the time funeral arrangements were made,we advanced certain payments to others as an accomodation. The following is an accounting of those charges. Opening Grave $900.00 Cemetery Equipment $190.00 ✓ Certified Death Certificates $36.00 '- Newspaper Notices-Patriot $368.19 Newspaper Notices-Sentinel $272.54 Clergy/Mass Offering $100.00 Organist $75.00 Flowers $275.60 Monument Engraving $125.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES $2,342.33 CONTRACT PRICE $12,506.33 ' HISTORY: 05/03/2013 Discount Pre-Need Guarantee $149.85 05/07/2013 Payment Homesteaders Life Company $12,031.05 TOTAL AMOUNT DUE BY June 2,2013 pct 5fa6fa0 13 cue da4q � If you have any questions or concerns r4arding this bill,please call our office at(717)697-4696. 1G SP DT TEA COOLER 2.59 FD 1G SW LEMONADE 2.59 6D SUBTOTAL 86.80 - TOTAL TAX .16 TOTAL 66.96 ��� DEBIT TENDER TENDER 86.96 Acct:xxxxxxxxxxxx3673 APPRVL CODE 216071 CASH CHANGE .00 NUMBER OF ITEMS - 10 Max Savings 1.79 Karns (Dual itY Foods YOU SAVED A TOTAL OF 1.79 gg70 Carlisle Pike THAT IS A SAVINGS OF 2% Mechanicsburg,PA Rich Brown Store Manager 901-6967 Trx:9 Term:5 Store:3 08:52:53 Todd Keys Meat Manager 901-3667 Thank You For Shopping at Karnsi Cashier: Ken B 31000 PRODUCTS ON SALEI 0991 '- 3-76151360 392 DATE ��� - c v ,w13 PAY TO THE �� y3Q f.-Ala 7 e AA/J.C� 1 $ q5 /V ORDER OF ���• ,-2, o�"'`� � iG0 �'-� DOLLARS 8 .. f� T� Citizens Bank Pennsylvania jj FOR IV�,1,¢i� 'IQ/LOJ( U 11.0009910 1:036076L50i: 623433L56ai1' roc m�-20 ) oi3 O z .CJ Cd W a n [d a Y ° N i \ Q (7 3 L0 fe , x V F u"i � n m � m M 2 Q Z Q a _ LO LL ~ w zgLo ° U3 o � i r � � a I u- iL 11] U O {� O a ,� H GO Lf) w CL W U W wn W 1- .. Z J a Z a Z d (:� 1-Q 1 Q Z o Z W S z w ° `3 O z N > a > a w W ¢ U Z 00 w 1G SP DT TEA COOLER 2.59 FD 1G SW LEMONADE 2.59 6D SUBTOTAL 86.80 TOTAL TAX .16 TOTAL 86.96 DEBIT TENDER TENDER 86.96 Acct:xxxxxxxxxxxx3673 APPRVL CODE 216071 CASH CHANGE .00 NUMBER OF ITEMS "r 10 Max Savings 1.79 Karns QualirtY Foods YOU SAVED A TOTAL OF 1.79 4870 Carlisle Pike THAT IS A SAVINGS OF 2% Mechanicsburg,PA Rich Brown Store Manager 901-6967 Trx:9 Term:5 Store:3 08:52:53 Todd Keys Meat Storee3 9013667 Thank You For Shopping at Karnsl Cashier: Ken B 3,000 PRODUCTS ON SALEI 05/07/13 08:50:36 SAVE THE MOST WITH MAX SAVERI WWW.KARNSFOODS.COM Deli Meats 58.29 FD _ LETTUCE-ICEBURG 1.29 FD SUGGESTED RETAIL PRICE 1.79 Karns Foods 03 1 ® 2/ 6.00 3.00 FD Mechanicsburg. PA 10 MARTINS CHIPS 717-901-6967 SUGGESTED RETAIL PRICE 4.29 4 99 FD Purchase $ 86.96 MIDDLEWARTH CHIPS PO 2,59 FD PIN Used 1G DECAF OT TEA 2,59 FD Debit Card MSXXXXXXXXXXXX3673 iG SWEET TEA 6.83 FD Auth # 216071 Payment from primary COOPER SHARP CHZ 2.04 F Lane # 05 Checker # 348 1/2G HOMOGENIZE MILK 05/07/13 08-:52 Ref/Seq # 054281 - Mrch=822710 Term=001 IC=DC EPS Sequence # 054281 Thanksl Have A Nice Day - Trx:9 Term:5 Store:3 08:52:53 7'4 - C 6z.# 0 lo lo G r > C. 0 O 2 CO G ) LU Q r i Q \ D trl Z C, w -0 11 Q 3 \ Of 0 m CC IL Gal F 1Tl L ^ ¢ M bJ y a Q V ° J Q10 h J Q Q Q = rq u_ 0 i U) CJ I_ w hi ZCQU 0 N 0 v CI u- fl: i4 0 O p- o v ce 0) s H cc u? Luw � ° z W wn v' ;. '� JQL Q .. gp G1 to it 2 o Z (AT w ~ --� F aZ U: ° LLJ , ii F- 3 w O U O 0 �i a 0 a w - 03 ¢ U Z O O w REV-1511 Ex-(11-03) SCHEDULE I COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN RESIDENT DEC MORTGAGE LIABILITIES & LIENS ESTATE OF /Y1G a�e� � /yJ, f!/prraw FILE NUMBER 2,1- i a -ssz/ ITEM Report debts incurred by the decedent prior to death which remained unpaid as of the date of death,Including unreimbursed medical expenses. NUMBER DESCRIPTION VALUE AT DATE 1. 6-Nate LrYi/1q eent-r OF DEATH V�1 ,( f/93.vS )are fs(4e Aeewry Goim : /p. '/ass 3 Cla,ilr kr mo, pd. kc/nw- d,o.W. 20, 1177-29, ;(3. Intl unseeu�d C�v�m f3 a, 3so.o8 (see alv' m AlAr 9A'9drel) TOTAL(Also enter on line 10,Recapitulation) S (pc� TH. O l (If more space is needed,insert additional sheets of the same size) golden P.O. Box 180970 living Fort Smith, AR 72918-0970 MAE MORROW C/0 7252 WERTZVILLE ROAD CARLISLE PA 17015-8293 OCT 04 2013 RE : Name - - - MORROW, MAE Account Number - - - 120186-03959-92878 Current Balance- - - *193 . 65 Dear MAE MORROW C/O: We currently do not have a payment arrangement set-up with you on the above stated balance . Please send payment in full for the balance of this account or call me toll free at 877-367-1716 to discuss payment arrangements. Please use the bottom tear away portion of this letter for making your payment by mail . If you are paying by credit card , please call me so that I may process this for you over the phone . Otherwise, please complete the credit card information below and return to our office . Your prompt attention to this matter is greatly appreciated . Sincerely, KATE MCPHAIL , Recovery Specialist 877-367- 1716 - toll free - -DETACH - AND SEND ALONG WITH, YOUR PAYMENT- - Account: 120186-03959-92878 Name: MAE MORROW Balance: $193.65 AMOUNT PAID: $ Security code (3 digit) : Payment Method: Check _ M/0 _ Visa M/C Discover _ Credit Card Number: - Credit Card Authorization Signature Credit Card Expiration Date GOLDEN LIVING P.O. BOX 180970 Fort Smith, AR 72918 (1200) 099 ' 3-]6t6lM PAY I�� _-¢ , DATE oZ0/3 isi TO THE ORDER OF_"J.J g14 f III $ X93. 65 AR Citizens Bank oo' BARS .8 t Pennsylvania_J49- o 3 95 9 q.Z 8 790 O .. FOR .I .2613 W12 f Q 11000099311• 1;0 r nI 9)hDD S i (.lid riiCSUUrgn, YFi 1]LO't-44U/ i RE: Estate of M. Mae Morrow a.k.a. Margaret Mae Morrow Resident Account No.: 03959928780001 Statement Date: 6/1/2013 Date of Death: 5/2/2013 Dear Sir/Madam: Morrow. I amenclosing Ch ckrNo represent he amount�Of S 193.65 in payment Of the statement Mae Morrow a.k.a. Margaret Mae dated 6/1/2013 covering her date of residence of 5/1/2013. Thank you for your assistance in this matter. Very truly yours, Charles E. Shields, III Attorney-At-Law CES/mjj Enclosure Illillllll�llllllllQ1111111111111111IN11111IN STATEMENT 1787992878 _ golden . QUESTIONS ABOUT living ( p`inters YOUR BILL? (866)325-5606 CAMP HILL Y cy RAM—<ST TEMENT;DA PATIEN j�NAME'_krtL 3 . "' A C©l]Nin Uro16! R? ; erb , L.. 06/01/2013 MAE. MORROW 03959928780001 arPFSE�VIOlJS1BA'IA(VC } I a kNEVJ:�aARGESr v'y PAYMENTSyIts �ADJUST,NIENTSi 4;qu C ',1h9 519 .25 1 -325.60 6.60 0.00 193 .65 ,DATE/F' F�13D COVEREDl ria1CGOl1f1T±ACTIW)fiJ QtbA S d'CH7CFIG€Sex P Ytv1ENT AD'.JIJGTMEf9TS' 05/01/13 05/01/13 PRIVATE PORTION . ' 1 193 .65 05/01/13 05/31/13 REV LAST MO PP . -31 -519 .25 When returning home, patients often require ongoing care that family members cannot easily provide. In these cases,AseraCare Home Health is an ideal solution. Visit homehealth.aseracare.com for more information. Thank you for choosing Golden LivingCenters. c�ct?*^ yrr- t`dr'4".a-�rX' r`S''�ww�4�tR�.Fr�," 'C'N-ijyAY�N1EtJ-Fa" tc'j -`� J- 1MAll_{YOUR] AYMENT:USING THEa000POA E65 LOW r �a b, 06/15/2013 2?y'�ru~ � kr?.' �,k�t�L�A'�is �i ^rOrAA- r" , '..*^"su' .'�,^ '' f �,�' AMOUNT'DDIJ� s �t 'P„A+.Y OUI B L`L�ONu"I" ;A 19 tw w gold r�hSfng corm a?I $-rc ” ' 19 _. .- .._....-..-.._-..._.. ... DETACH HERE AND RETURN BOTTOM PORTION WITH YOUR PAYMENT FOR TIMELY PROCESSING -------------------------------------------------------------------------------------------------------------------------------------------------------- GOLDENLIVINGCENTER-CAMP HILL 1'03959928780001 MAE MORROW C/O PATIENT ACCOUNTING- ADM OFFICE GILUNGOATE -DUEDATE AMOUNT DUE AMOUNT ENCLOSED 1000FIANNA WAY 'FORT SMITH AR 72919-2263 '06/01/13 06/15/131 193.65 c* hors to pay by credit card and enter credit card intormation below. to C1 VISA ❑MASTERCARD ❑ DISCOVER CARD NUMBER CVV CODE' ZIPCOOE E] Check box if address below is incorrect or insurance information has changed. Indicate CARDHOLDER NAME EXP. DATE changes on reverse side. ZI SIGNATURE AMOUNT '.The CVV code is a three-d'pn numbor u:uolN twn,;an the back d y i week card. Please Make Check or Money Order Payable To: .MAE:MORROW C/O DOROTHY MI GOLDEN LIVINGCENTER-CAMP HILL 7252 WERTZVILLE ROAD P.O. BOX 644407 CARLISLE PA 17015.8293 PITTSBURGH PA 15264-4407 104997039599287.8500 010601201300019365D0000000000 4.t,!.c( 711yl�3 WIN M NT pennsyrna lVa OENAPTi or PU SL IL ,W EL FAA July 10, 2013 CHARLES E SHIELDS III ESQUIRE 6 CLOUSER RD MECHANICSBURG PA 17055 I Re: Mae Morrow CIS #: 700440728 SSN: ###-##-5581 Date of Death: 05/02/2013 ESTATE RECOVERY STATEMENT OF CLAIM Dear Mr. Shields: Under State and Federal law, the Department of Public Welfare (the Department) is required to recover medical assistance (MA) reimbursement from the probate estates of deceased individuals who were over age 55 when such assistance was received. 42 U.S.C. §1396p(b)(1). 62 F.S. § 1412. This letter sets forth the amount of the Department's claim against the estate of the above referenced individual and explains the obligations of executors, administrators, and persons receiving estate property. Although the amount in the estate may be considerably less than that which is owed to the Department, our claim is against the estate, no one else. Statement of Claim Amount The Department maintains a claim in the amount of$62,547.36 against the above-mentioned estate. This claim is for repayment of MA granted on behalf of the decedent. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $30,197.28, 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 $32,350.08, is to be entered as a priority Class 5.1 claim against the estate. You should refer to Section 3392 for a more complete explanation of the priority rules. If a lawsuit is filed for injuries sustained by the decedent prior to death, then the Department may also have a lien against the personal injury action. A statement of claim for that injury-related lien must be requested separately. Bureau of Program Integrity i Division of Third Party Liability I Recovery Section PO Box 8486 1 Harrisburg,Pennsylvania 17105-8486 p nnsyl;an�a DYP,x TA4 T i3F FL1$tSG tdSS£fiRE Your Responsibility to Provide Information to the Department Please acknowledge receipt of this letter and advise whether the Department's claim is admitted and when payment may be expected. When the estate accounting is complete, please provide a copy. The Department audits all estate recovery claims and therefore we require documentation to substantiate all deductions from the gross estate. The regulations governing how the Department computes its estate recovery claim are found in 55 Pa. Code Chapter 258. These regulations are readily available on the Internet, in addition to being carried in most local law libraries. In order to document computation of the amount due the Department, the following items should be submitted to the address below: 1. For real estate: a. Copy of the deed b. Copy of the latest tax assessment c. Copy of a current appraisal, if available 2. Copy of the funeral bill 3. Copy of the statement of the burial account if one existed 4. Copy of the statement of the personal care account balance at date of death, if the decedent was in a nursing home 5. Copies of original and updated life insurance policy forms naming beneficiaries 6. Copies of any and all stocks and bonds 7. Copies of bank statements showing balances on the date of death 8. Copies of signature cards or other proof of when accounts were made joint 9. A list of any gifts or other transfers for less than fair market value made by the decedent (personally or under a power of attorney) Your Responsibilities to the Department Under State law, executors or administrators may be personally liable to pay the Department's estate recovery claim if they transfer estate property without the Department's claim being paid. Persons who receive that property without paying valuable and adequate consideration to the estate may also be personally liable. The responsibilities of the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to ensure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. Accordingly, you must ensure the Department's claim is satisfied before making distribution of assets to heirs. Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Box 9486 1 Harrisburg,Pennsylvania 17105-8486 perms [ ania, V DEPNRTMENT OFiPQBLJC WE CPARE Insolvent Estates and the Fiduciary Responsibility to Creditors If there are not enough estate assets to pay the claims of all creditors in full, then the executor or administrator has a duty to act in the best interest of creditors when administering the estate. If you must spend the estate's money to administer it, you must act prudently and make purchases as if the money were coming out of your own pocket. The Department's approval is required if you expect the legal fees to exceed more than the oreater of 6% of the estate assets or $1,000. Contingent fees for estate administration will generally not be approved. If you do not obtain approval, the Department may consider the excessive fees to be a transfer for less than valuable and adequate consideration. Sincerely, Jessica L. Frederick TPL Program Investigator 717-772-6238 717-772-6553 FAX Enclosure Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 - COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY DIVISION OF TNIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG,PA 171054486 July 10,2013 STATEMENT OF CLAIM SUMMARY NANI rTO5 Estate of MORROW,MAE iwv IID :£�` 700 440 728 SS' J �+' ',l,lk�G'7LASS 51�iw�FL s170TA1�'�I'�i. INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 30,197.28 32,345.99 62,543.27 DRUG yy wAG= .00 4.09 4.09 `nREIMBI'1RSEMENT'TO'DPW 30,197.28 32,150.08 62,547.36 PeiYER EA.F 4 :Xy EIN2�6003113 ', ` Page 1 o f 4 _ i•11.{4 x p WE L o: O 'INS,LVAs61% MENir NUB81C4W @LF July 10,2013 STATEMENT OF CLAIM Cy7�;R E NAM MORROW,MAE 700440728 GOLDEN LIVINGCENTER-CAMP HILL 46 ERFORD RD CAMP HILL PA 1701111p� y,� ro T.4?! i,+�e�l"}"'V.` .*MV+V�:b -'ft•AT£'OF SERVI•E~ }F A MEU DATE ORIGtNAL CRN AQJtN TEDi RN % FtiSUAI CHAR ES UN AP.�,ROVED .,c+ _ nx 'F3 :ter:hxae 4.�_ v+x C ksl'' -A ,pcz atk,. ..+s:A4nmw.4 04125/12 - 04130/12 09110112 27122304022050001 27122304022050001 1,116.42 1,116.42 DIAGNOSIS 1: 71580 OSTEOARTHROSIS-MULT SITE DIAGNOSIS 2: 0 PROC CODE: 000000 05101112 - 05131112 09110/12 27122304022110001 27122304022110001 5,768.17 5,271.42 DIAGNOSIS 1 : 71580 OSTEOARTHROSIS-MULT SITE DIAGNOSIS 2: 0 PROC CODE: 000000 06101112 - 06130112 09110112 27122304022120001 27122304022120001 5,582.10 5,085.35 DIAGNOSIS 1 : 71580 OSTEOARTHROSIS-MULT SITE DIAGNOSIS 2: 0 PROC CODE: 000000 07101112 - 07131112 01/14/13 55130104076330001 55130104076330001 5,768.17 5,314-51 DIAGNOSIS 1 : 71580 OSTEOARTHROSIS-MULT SITE DIAGNOSIS 2: 0 PROC CODE: 000000 08101112 - 08131/12 01/14113 55130104076730001 55130104076730001 5,768.17 5,314.51 DIAGNOSIS 1 : 71580 OSTEOARTHROSIS-MULT SITE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 09101112 - '09130112 01/14113 55130104077280001 55130104077280001 5,582.10 5,127.05 DIAGNOSIS 1 : 71580 OSTEOARTHROSIS-MULT SITE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 10101/12 - 10/31112 01/28113 55130244790420001 55130244790420001 5,768.17 5,116.73 DIAGNOSIS 1: 71580 'OSTEOARTHROSIS-MULT SITE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 11101112 - 41130112 - 01128113 55130244791030001 55130244791030001 5,582.10 4,935.65 DIAGNOSIS 1 : 71680 OSTEOARTHROSIS-MULT SITE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 Page 2 Of 4 July 10,2013 , STATEMENT OF CLAIM AME' MORROW,MAE ,ID[ 700 440 728 GOLDEN LIVINGCENTER-CAMP HILL 46 ERFORD RD CAMP HILL PA 17011 A "SN,rz"zCr.. li�$I' i �L' Affil ,, ,rSJ sM:h?V.��B�ay DATE Ef2Vi aE PAYiME DAffil O�R)1 IN,A.w�GRN .. A-JUStiE ti1ze fier�G RG NOs' Aak:t�R�t 12/01/12 - 12/31/12 01/28/13 55130244791670001 $5130244791670001 5,768.17 5,116.73 . DIAGNOSIS 1 : 71580 OSTEOARTHROSIS-MOLT SITE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 01101113 - 01131113 04115113 69130844020480001 691308"020480001 5,613A8 5,133.91 DIAGNOSIS 1: 71580 OSTEOARTHROSIS-MOLT SITE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 02101/13 - 02128113 04116113 69130844020510001 69130844020510001 5,070.24 4,586.83 DIAGNOSIS 1 : 71580 OSTEOARTHROSIS-MULT SITE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC,CODE: 000000 03/01/13 - 03131113 04122!13 20130914160460001 20130914160460001 5,613.48 5,133.91 DIAGNOSIS 1: 71580 OSTEOARTHROSIS-MULT SITE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 04101113 - 04130113 05127113 20131234033330001 20131234033330001 5,432.40 5,290.25 DIAGNOSIS 1 : 71580 OSTEOARTHROSIS-MULT SITE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 ' D �''1�1 ' ''''�" GOLDEN LIVINGCENTER-CAMP NILL LPNO, IDER'SN O7<A6 68,433.17 62,543.27 03 101553090 0001 Page 3 of 4 tT siiia`Y' ''i«kr '�' x'`k>eft :z,` * t � �-"bCOMIONN/EALTHtOFriPLNNSYLVA`1dA f T+'# s` T g�; S 4"'r- �'y!,. yta+;,,; t Al, July 10,2013 STATEMENT OF CLAIM 'tJAM MORROW,MAE 700 440 728 PHARMERICA INC#22000 49 AA BLUE EAGLE AVE QQ9H9ARRISBURG PA 17112 rt�''�k' �$# 09/04/12 - 09/04/12 10101/12 25122485344070001 25122485344070001 45.75 4.09 DIAGNOSIS 1 : 0 NDC CODE: 00228205750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS PROVIDER$U�TOTAL PHARMERICA INC#22000 S ` 45.75 4.09 24 100751181 OO13 �sx Page 1 of 4 1787992878 STATEMENT' gIC�o en INAng Centers QUESTIONS BOUT YOUR B (866)325-5606 CAMP HILL 06/01/2013 - E MORROW 03959928780001 �N 3�1 -IU j 0 0 .00 193.65 -00- MAN Z 0 5 1 PO3 05101113 PRIVATE PORTION 1 193 .65�5 g 519 25 -325 60 0.00 III 05101 05 1 LAST pp 1 �13 1311 3 REV -3 -519.25 0993 DATE PAY is 193. 65 TO THE OROER or 1-7 02 5 S �,�e _LLDOLLARS citiiens Bank Pennsylvania 0 3 13 5 9 q F 7 go 0 o FOR 013 --`��v000993110 1:0360761503: 623433156811• l 06/15/2013 T � M ON MY I-AWIME0009 NBC 193 -65 ------------ DETACH HERE AND RETURN BOTTOM PORTION WITH YOUR PAYMENT FOR TIMELY.PROCESSING. . , � . —----------------------------7-7-77--------------—------------------------------------------—------------- ACCOUNT NUMBER :IPATIENTNAIAE GOLDEN LIVINGICENTER- CAMPHILL 1395992878 011111 MORROW C/O PATIENT ACCOUNTING- ADM OFFICE 1000 FIANNA WAY FORT SMITH ANN, AR 72919-2263 -66loi/131 96/15/131 193.651 C1168C here to pay by credit card and enter credit card intonnation below. AMEX 0 VISA ❑MASTERCARD ❑ DISCOVER o Check box if address below is incorrect or CARD NUMBER CVVCODE1 ZIPCODIZ insurance information has changed. Indicate CARDHOLDER NAME 1. . I EXP. DATE changes on reverse SIGNATURE AMOUNT Plea"Make Check or Money Order Payable To: ,MAE MORROW C/O DOROTHY MI GOLDEN LIVINGCENTER- CAMP HILL 7252 WERTZVILLE ROAD P.O.,BOX 644407 CARLISLE PA 17015-8293 PITTSBURGH PA 152644407 1049970395992878500010601201300019365D0000000000 Ci Enhancing lives through living innovative healthcare- BILL TO: Camp Hill Patient Name: Moe Morrow Mae Morrow C/O Dorothy Miller Itemized Patient Statement Account It: 7252 Werizville Road 03959-92878-0001 Carlisle, PA 17015 DATE: 5/8/13 -R, Z iWX "P- ..qR i� :Q a jy 05/01113 05/01/13 _ PRIVATEPORTION 1 193.65 Note: This is on estimate of current charges,other charges may follow Sion Total Charges $193. T NOW DUE: $193.65 Total Payments $0. AMOUNT PLEASE SEND YOUR PAYMENT TO: Golden Living Camp 1401 If you have any question regarding this bill, PO Box 644407 Please Contact: Whitney Haynes Pittsburgh,PA 15264-4407 1-866-325-5606 Name: Payment Details CC#: Cashc:) DO NOT MAII,CASH Exp Date: Check c> Ck. ti Amt Paid: Credit Card<D Fill out info to the left Signature: (Mastercard,Visa,Discover) Payments are due by the 15th REV-1513 EX+(11-08) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAN RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF h., �,- [/ #74,-Jllr X. IYIOYY`vNd oZ/FIL NUMBER 3- RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS Of PERSONS)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright Spousal distributions and transfers under Sec.2116(a)(1.2).] 1. Spc�:Ak /eegqac:is � '`aoo.vo fn earl, Shry;v/ .4. oS/aron M. l 7aY9AJv{Zi,%1e Ad., �randeZ'hl 6700.Do 8. Jar/n /oxi, Tip 33� C'Q�.fo/ /7 !/ i v' R-ra"deC "/w Pa�.OD D%//aburg, Af /70/9 'l 17. //11r� !s/efzc/ �/15- C'anr6N�y .17r. ra41a/e62/<1/ �00.oa /IJec/en%esbu.y,DA /7/i5S Yobn (o N;<�rf Lune dws�lrtu y2 Jesiclue 1� Mechan;csbuq,PiP /7,05-S- 5. / I� 'Doro)LA t/ m• to;Ile,- 7aZS2 /NE/&v'1 1e eel Node. Pa4le //, I&Ir/r/p/rd&9azl' deeedevt) ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113.FOR WHICH AN ELECTION TO TAX 1S NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS i. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. f If more space is needed,insert additional sheets of the same size. LAST WILL AND TESTAMENT`+ I, M. MAE MORROW, of Monroe Township, Cumberland County, Pennsylvania, being of sound mind,menory and understanding, do make, publish and declare this as and for my last will and testament, hereby revoking and making void all former wills by me at any time heretofore made. FIRST. I Direct all my ,just debts and funeral expenses, including all inheritance taxes that may be assessed against my estate, be fully paid and satisfied out of my estate by my personal representative(i) hereinafter named as soon as conveniently may be done after my decease. SECOND. I give and bequeath the sum of two hundred ($200,00) dollars to each of my grandchildren living at the time of my death. THIRD. I give, devise and bequeath all the rest, residue and remainder of my estate, whatsoever and wherever situate and In whatever form my personal representative(s) have placed the same, in equal shares to my three daughters, namely, Dorothy M. Miller, Lanette M. Yohn and Darlene V. Morrow, share and share alike, or to their issue if any of my said daughters should predecease me. FOURTH. I authorize and direct that my personal representative(s) hereinafter named may convert all or any part of my estate into cash at either public or private sale or sales at the best price or prices obtainable in their discretion. It is my suggestion that my daughter, Darlene V. Morrow, shall be given first option to purchasakhe real property provided she is willing to pay a price equivalent to the best price available in the discretion of my personal representative(s). It is suggested that my said three daughters named herein shall have their choice of the furniture and personal-belongings, in kind, to the extent they desire and provided they can amicably agree; such items to be taken as a part of their share. LASTLY I nomM maw., constitute and;appoint my three daughterly Dorothy M. Miller, Lanette M. Yohn and Darlene V. Morrow, Executrices of this my last will and testament. In the event any of my said three daughters should predecease me, resign, renounce, refuse or be unable to serve for any reason, or die before my estate is fully administered, then,in any of those events, I-nominate, constitute and appoint the daughters or -daughter remaining. as Executrices or EX ecutrix, of this my last will and .testament. - - - IN WITNESS,WHEREOF, I he ve -=hereunto set my hand and seal this day of . 1981: _ 7 CG (SEAL) Signed, sealed, publshed and declared by the above named Testatrix, M. Mae Morrow, as and for her last will and testament, in the presence of us, who, at her request and in her presence and in the presence of each other, have hereunto subscribed our names as witnesses thereto. V C_. r N g rn n •� ZOD mU) O cn m = = C c o Fn 1 0 0 M — nnCm ci 6 N M O K O n Cl) - r <n � = vi7com - o C. - SD iL � bV � = DCO ZV ° ��n d�r� oo _ � Nd V mn � 3 �~o -NI LLJ u � U) co~ U = w = wOOcn n mAm . ui 0 = N j r ° r z 00 O N m N C B. N � o V 3 D c ° m � � A N A N