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J pennsylvania 1505613110
DEPARTMENTOF REVENUE EX(06-13)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
11172013 11251918
Decedent's Last Name Suffix Decedent's First Name MI
COHICK JOHN E
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH
THE
FILL IN APPROPRIATE BOXES BELOW REGISTER OF WILLS
Q 1. Original Return Q 2. Supplemental Return Q 3. Remainder Return(date of death
Prior to 12-13-82)
Q 4. Agriculture Exemption Q 5. Future Interest Compromise(date of Q 6. Federal Estate Tax Return Required
date of death on or after 7-1-2012) death after 12-12-82)
0 7. Decedent Died Testate Q 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
Q 10. Litigation Proceeds.Received Q 11. No Taxable Asset Return Q 12. Election to Tax under Sec.9113(A)
(Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
RONALD COHICK
First Line of Address
1974 LINDEN LANE
Second Line of Address
City or Post Office State ZIP Code
HATFIELD PA 19440
pCl!ICTCD/1C IARI 1 C.IJCC 1111 V
REGISTER OF WILLS USE ONLY RECORDEDOFHCEOF
DATE FILED REGISTEROF WILZS
2014 FEB 11
CLERK OF ORPHANS'COURT
CUMBERLAND COUNTY
Correspondent's email address: T J A C P A S a@ V E R I Z O N.NET I DATE FILED STAMP
Under penalties of perjury,I declare I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,it
is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNAT �OF���RESPfelNS18}�E�F(JRF�SIG RETURN � DATE�r
ADDRESS ((//���, ll f�(( �'1IVV_{t 1YI l/�J�
1974 LINDEN LANE HATFIELD PA 19440
SI A E OF PREPARER OTHER THAN REPRESENTATIVE DATE
j. � OA 02/04/14
ADDRESS
168 W RIDGE PIKE, SUITE 125, LIMERICK, PA 19468 1
PLEASE USE ORIGINAL FORM ONLY
Side 1
L1505613110 1505613110
J 1505613210
REVA 500 EX
Decedent's Social Security Number
Decedent's Name: J 0 H N E C 0 H I C K
RECAPITULATION
1. Real Estate(Schedule A)...... ..................................... 1.
2. Stocks and Bonds(Schedule B)..... ................................ 2. 123079. 00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)... 3.
4. Mortgages and Notes Receivable(Schedule D)......................... 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)..... 5. 64562. 00
6. Jointly Owned Property(Schedule F) 0 Separate Billing Requested....... 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) =Separate Billing Requested...:... 7. 608524 .00
8. Total Gross Assets(total Lines 1 through 7). .............. ............ 8. ?96165.00
9. Funeral Expenses and Administrative Costs(Schedule H)................. 9. 15960 . 00
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1).............10. 30 . 00
11. Total Deductions(total Lines 9 and 10).............................. 11. 15990 . 00
12. Net Value of Estate(Line 8 minus Line 11)............................12. 7 8 017 5. 0 0
13. Charitable and Governmental Bequests/Sec 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. 780175. 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.
16. Amount of Line 14 taxable
at lineal rate X 45 780175 . 00 16. 35107.88
17. Amount of Line 14
taxable at sibling rate X .12 .17.
18. Amount of Line 14 taxable
at collateral rate X . 15 18.
19. TAX DUE........................................................ 19. 35107.88
20.- FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OFAN OVERPAYMENT Q
1
Side 2
L 1505613210 1505613210 J
REV-1500 EX Page 3 File Number 207-03-7351
Decedent's Complete Address: 21-13-1260
DECEDENTS NAME
JOHN E COHICK
STREETADDRESS
1974 LINDEN LANE
CITY STATE ZIP
HATFIELD PA 19440
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (.1) 35107.88
2. Credits/Payments
A.Prior Payments
B.Discount 1847.73
Total Credits(A+B) (2) 1847.73
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT.
Fill in box on Page 2,Line 20 to request a refund. (4)
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 33260.15
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS i
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred..................................................................................... ❑ X❑
b. retain the right to designate who shall use the property transferred or its income............................................ ❑ ❑
c. retain a reversionary interest............................................................................................................................. ❑ FRI
d. receive the promise for life of either payments,benefits or care?..................................................................... ❑ Q
2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration?............................................................................................................. ® ❑
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?............. ❑
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?..............:......................................................................................................... ® ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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[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 F2 P.S.§9116(a)(1)]:
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is
defined,under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1503 EX+(8-12)
pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE -
INHERITANCETAXRETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Estate of John E Cohick 21-13-1260
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 1,638 shares of PNC Stock @$75.14/share 123,079
r
I
TOTAL(Also enter on Line 2, Recapitulation) $ 123,079
i
If more space is needed,insert additional sheets of the same size
REV-1508 EX+(D8-12) SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF RETURN REVENUE PERSONAL PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Estate of John E Cohick' 21-13-1260
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. F&M TRUST CHECKING#0003308812 61,622
2. Refund due from Claremont Nursing and Rehab Center 2,940
TOTAL(Also enter on line 5, Recapitulation) $ 64,562
If more space is needed,use additional sheets of paper of the same size.
i
REV-1510 EX+(08-09) SCHEDULE G
pennsylvania INTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
RESIDENT MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Estate of John E Cohick 21-13-1260
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH IN,OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IFAPPLIC"LE) VALUE
1. MacKenzee Burkett .10,000 100.00% 3,000 7,000
2. Allison Burkett 10,000 100.00% 3,000 7,000
3. ING Annuity Contract#90096853 456,573 100.00% 456,573
4. Fidelity&Guaranty Life Annuity Account#03006806 137,951 100.00% 137,951
TOTAL Also enter on Line 7 Recapitulation) $ 608,524
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+(10-09) SCHEDULE H
pennsylvania
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
RESIDENT DECEDENT ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Estate of John E Cohick 21-13-1260
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Hoffman-Roth Funeral Home 10,748
2. Wesleyan Church-luncheon 1,000
3. Opening Grave and marker 2,945
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
2. Attorney Fees: 353
3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 364
5. Accountant Fees:
6. Tax Return Preparer Fees: 550
7,
r
TOTAL(Also enter on Line 9, Recapitulation) $ 15,960
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN DEBTS OF DECEDENT,
RESIDENT DECEDENT MORTGAGE LIABILITIES & LIENS
ESTATE OF FILE NUMBER
Estate of John E Cohick 21-13-1260
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
Alert Pharmacy Services, Inc 30
TOTAL(Also enter on Line 10, Recapitulation) $ 30
If more space is needed,insert additional sheets of the same size.
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Estate of John E Cohick 21-13-1260
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
Ronald Cohick
1' 1974 Linden Lane, Hatfield, PA 19440 Son 397,795.50
James E. Cohick
2' 6539 Brethren Church Road PO Box 325, Newburg, PA 17240-0325 Son 259,844.50
Christine M. Cohick
3' 1974 Linden Lane, Hatfield, PA 19440 Granddaughter 30,770.00
Cassie A. Cohick
4. 1974 Linden Lane, Hatfield, PA 19440 Granddaughter 30,770.00
James E. Cohick III
5' 60 Hanna Road, Newburg, PA 17240 Grandson 30,770.00
Jenny R. Shoap
6' 201 Whitmar Road, Shippensburg, PA 17257 Granddaughter 30,770.00
Nancy Cohick
7' 1974 Linden Lane, Hatfield, PA 19440 Daughter-in-law 1,000.00
Jane Cohick.
8. 6539 Brethren Church Road, PO Box 324, Newburg, PA 17240-0325 Daughter-in-law 1,000.00
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
JAN-02-2014 14:42 From:METLIFE-LANSDALE-PA 2156994506 To:6104293240 P.2/4
LAST WILL AND TESTAMENT
OF
JOHN E. COMCK
1,JOHN E.COHICK,of South Middleton Township, Cumberland'County,Pennsylvania,
being of sound an.dtisposing mitid,memory and-understa�tnding;"do10,reby malce,publish and declare
this as and for my Last Will and Testament,hereby revoking all other wills and codicils heretofore
made by me.
.N 116.i•:_— -1.cl�rec .h�'. 11.1ti J �{ ; icral:catpcnses,dnc,1udiiTjmy.grave __.....
marker, shall be paid from the assets of my estate as soon as practicable after my decease.
SECOND: A) 1 give and bequeath the sum of$1,000 to my daughter-in-law,
JANIL COHIC:&if she survives me.
D) I give and bequeath the sum, of$1,000 to my daughter-in-law,
NANCY COHICK, if she survives me.
C) I give and bequeath all of the shares of PNC stock, any or
successor, 'thereto which-I may owifat the time of my'dea'th'in equal shares to my grandchildren
living at the time of my death.
CC/ TIT=: I give, devise an'd bequeath the residue of my estate, of every nature
and wherever situate, equally to my children, namely, RONALD C. COHICK and JAMES E.
COHICK,provided that should any of my children predecease me their share shall be distributed to
eir issue per stiTpes living at the time of my death and, in default of such then living issue, such
sb.are shall be added to the share or sbaxes for my other child and/or grandchildren.
FOURTH: I direct that all taxes that may be assessed in consequence ofiWy death,
of whatever nature and by whatever j urisdiclion imposed, shall be paid from my residuary estate as a
part of the expense of the administration of my estate.
FIFTH: i nominate,constitute and appoint my sons,RONALD C.COHI(7K
and JAAIES E. COHICK, or the survivor of them,Executors of this my Last Will and Testament.
JAN-08-2014 14:42 From:METLIFE-LANSDALE-PA 2156994506 To:6104893240 P.3/4
SIXTTT: I direct my Executors and their successors shall not be required to give
bond,for the..faithfttl�erfomaance:c� �thcix�cluiti es:iaa»ihas.or any�.other.;juuz sdiatican.
TN WITNESS WHEREOF,I have hereunto set my hand and seal to this,my Last Will and
Testament,consistbigof two(2)typewrittenpagcs,eachidentified by my signature,this
day of October 2010.
r
�'. '_(SEAT)
J E. Cohick
Signed,sealed,published and declared bythe above-maned Testator,John E.Cohick,as acid
for his Last Will and Testament,in the presence of us,urho,at his request,in his sight and presence,
and in the sight and presence of each other, have hereunto subscribed our names as witnesses.
JAN-08-2014 14:42 From:METLIFE-LANSDALE-PA 2156994506 To:6104893240 P.4/4
COMMONW EAUTT OF PENNSYLVANIA )
SS.
COUNTY 0F,.CUM-BE1U.-„AN- D )
I,John E. Cohick,Testator,whose name is signed to the attached or foregoing i»strument,
having been duly qualifi csd a.ecording to law, do?hereby acknowledge that I signed and executed the
instrument as nay Last Will and Testament; that I signed it willingly; and that 1 signed it as my free
and voluntary act for the purposes therein expressed.
Swdrn or affirmed to and acknowledged before mdby'.Tcihn E. Cohick, the Testatori'this
27 day of October 2010.
COMMONWEALTH OF PENNSYLVANIA (SEA--)
—_....._-Jo . Cohick, Testato
w.....:� ,... .._NOTARIACSEAL. . .. _ .._....
SHELLY SF�C�NO 7ocary- u IIC-- - 7
Carlisle Boro, Cumberland County ` , /
ell,
My Commission Expires April 26,_201 1 -�JN _ w
' Not "Pia 'c -
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA )
SS.
COUNTY OF CUMBERLAND
We; RONALD E. JOHNSON and �a.r L. the witnesses
whose names arc signed to the attached or.foregoing instrument,being duly qualified according to
law,do depose and say that we were present mid saw Testator sign and execute the instrument as his
Last Will and Testament; that John E. Cobick, signed willingly and that he executed it as his free
and voluntary act for the purpose therein expressed; that each of us in the hearing and sight of the
Testator signed the WiJ1 as witnesses; and that to the best of our knowledge tlae Testator was at that
time 18 or more years of age, of sound mind and under no constraint or undue influence.
Swore or d to and subscribed to before me by RONALD E. JOHNSON
ands r� L�vr 15 �o(-f�,� witnesses this 0'7 d&y of. _ tober 2010.
6EAL)
enald . Johnson mess
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
SHELLY SEXTON, Notary Public (SEAT,,)
Carlisle Boro, Cumberland County , W i ss
My Commission Expires April 26, 2011
Notary Pub)..
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
tNARNMG: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00 a„r", ,., This is to certify that the information here given is
,1j11�,�IN(IFpF; g
correctly copied from an oribinal Certificate of Dead
duly filed with me as Local Registrar. The original
r' certificate will be forwarded to the State Vital
Records Office for permanent filing.
19987280 F_RT�%EhTt4���� Sore A ruc�ue 5e�c'ale�C` N�'tl Z 2013
II
Certification Number °""""''"') Local Registrar Date Issued
Type/Print to COMMONWEALTH OF PENNSYLVANIA-DEPARTMENT OF HEALTH•VITAL RECORDS
Permanent Ink CERTIFICATE OF DEATH `
State File Number.
1.Decedent's Legal Name(First,middle,Last,Suffix) 2.Sex 3.Social Security Number 4.Data of Death(MO1DayjYr}(Spell Mo)
John Edward Cohick male November 17, 2013
So.Aga-Last BJft (Yrs) Sb.Under 1 Year 5c.Under 1 0a 6.Data of Birth(Mo/Osy/Year)(Spell Month) 7..Birthplace(City and S[at.or FeratIIn Ceuntry}
t '94 Months Days He.- Minutes MW 25, 1918 i 17241
Birthplace(County)
B..Residence(State Of Foreign Country) Bb.Residence(Street and Number-Include Apt No_) Be Old Decedent Live In a Township?
PA 1000 Claremont Drive C9 Yes.d...dam c lived in_ Midr�lesex two.
8tl.Residence(County) � ,
Cumberland ` 8..R.sidenc.(Zip Code) C3 No,decedent lived within limits of city/born.
9.Ever In US Armed FortasT 10.Marital Status at Tim.of Death .rrlCd WidOW d 11.Surviving Spouse's Name(if wife,give name prior t0 first marriage)
C Yes M NO C3 Unknown C Divorced � Never Marrl.d C3 Unknow
12,Father's Name(First,Middle,Last,Suffix) 13.Mother's Name Prior to First Marriage(First,Middle,Last)
Jahn Co r
hick Floence Pie r
lose Informant's Nam. Relationship to Decedent 14G. for nt's Mailing Address(Street and Number, Ity State,Zip Oda)
as Ron Cohick son �9' 4 Linden Lane, Hatf�.e�..r�, PA .�J.9440 '
_ _ _ _ act o e h(Check only one - _ _ _ _ _
I(peath Occurred In a Hospital: ej Inpatient !If Death Occurred Somewhere Other Than a Hospital: 0 HO,PIC.Faculty - `[�(Decedent's dome
C3 Emergency Room/Outpatient Dead on Arrival i CXNUrsing HOm!/LOng•T¢rm Care Facility C3 Other(Specify)
15b.Facility Name(If not Institution,give streat and number) 15c.City Or Town,State,and Zip Code 15d,County 110 Ith
z Claremont Nursin & Rehab Ctr Carlisle PA 17013 Cumberland
160.Method of Disposition L2L Burial L:l Cremation 16b.Date of Disposition 16c.Place Of Disposition(Name of cemetery,crematory,or Other place)
o
from State C3 Donation Nov 23," 2013 Of
Valley Memorial Gardens
E3
her(Specify)
16d.Lo Gallon of Disposition(City or Town,State,and ZIP) 170 ature of Funeral Se a tlClnsCa or Person In Charge of interment 17b.UGans.Number
21 Carlisle, PA 17013 013144L
E 17C,Name and Complete Address of Funeral Facility
8 Hoffman-Roth Funeral flame & Creme o 219 North Hanover Street, Carlisle, PA 17013
18.Decadent's Education-Check the box that best describes the 19.Decedent of Hispanic Origin-Check the 20.Decedent's Race-Check ONE OR MORE races to indicate what
>- highest degree or level of school completed at the time of death, box th.t b.zt describss whather the dac.dom the decedent considered himself or herself to be.
0 8th grade or less Is Spa nish/H$spa nlC/Latino. Check the"No^ 0 White O Korean
E3 No diplom.,9th-12th grade box if decedent is not Spanish/H(spenk:/Latfno. E3 Stack Or African American C3 Vietnamese
IM High school graduate or GEO completed C$No,not Spanish/Hlsps nic/Latino 0 American Indian Or Alaska Native C3 Other Asian
C3 Same College credit,but no dogma C Yes,Mexican,Mexican American,Chicane 0 Asian Indian 0 Native Hawaiian
0 Associate degr¢.(e.g.AA,AS) ID Va.,Puerto Rican C3 Chines.
C3 Guamanian or Ch.-.-C3 Bscfieto YS degree(¢.g.BA,AB,BS) C Y¢s,Cuban 0 Filipino Q Samoan
0 Master's degree(e.g.MA,MS.MEng,MEd,MSW.MBA) 0 Yes,Other Spanish/HIspaMC/L.tlno C3 Japanese 0 Other Pacific Islander `
0 Doctorate(a.g.PFD,EtlD)ar Professional degree (Specify) C3 Other(Specify)
.MO ODS OV M.LLB JD
21.Decedent's Single A...S¢if-Oesignatlan-Chock ONLY ONE to Indicate what the decade-Considered himself or herself to be 22a.Decedent's Usual Occupation-Indicate type of work
a White 0 J.P.nos. Q Samoan done during most of working life. DO NOT USE RETIRED.
C3 Black or African American C3 Korean O Other Pacific$,tantler Dairy Farmer
0 American Indian or At.ska Native C3 Vietnamese M Oan't Know/Not Sure
C3 Asian Indian (] Other Azlan O Refusal 22b.Kind of Business/Industry
N 0 Chinese 10 NOUve Hawaiian 0 Other(Specify) Self-employed
Q C3 Filipino C'] Guamanian or Chamorro
ITEMS 23.-23d MUST BE COMPLETED 23a,pate Pronounced Dead(MOfpay/Yr) 23b.Signature of parson PrOnOUncfnQ Death(Only whin appiiCnbia) 23c.Ucansa Number
BY PERSON WHO PRONOUNCES OR w,p v, f,�^ 2 r�, _ ..y U
CERTIFIES DEATH fir o sT yiy.�(r r� ^t p
23d.Data Signed I {Day/Y,) 24.Time of Death rti A{ +t (a�-
(J(r�/?'71 ( � �1^�/', 0g p /✓) 25.Was Medical Examiner Or Coroner Contacted? E3 Yes 6d No
CAUSE OF DEATH 1 APProximaR
1
26.Port i. Enter the chain of event,-disease$,Inlurtes,or compliCatlans--that directly ca used the death. DO NOT enter terminal events such as cardiac arrest, I Int rval:
respiratory arrest,or v.ntrlcular fibrillation without showing the etiology. 00 NOT ABBREVIATE, Enter only one cause on a line.Add additional lints if h.C.ssary_ 1 Onset to Death
IMMEDIATECAUSE -------> ( h/Jahs I'T+DAL 1
(Final disease or condition Dice to(or as a Consequence of): 1
resulting In death)
�L-t 'I�CG`Y't l'N`:14 /-�1�•2H�tM�tt, ya iYF1+ " 1
Sequ.ntialiyffst Conditions, Due to(.........equanee of};
t
If any,leading to the cause' - 1 '
listed an line a. Enter the i
UNDERLYING CAUSE ^ Due to(Of as f Consequence of):
(disease or Inlury that - 1
W initiated the events resulting d. 1
In death)LAST. - Due,to(or as a cansequ.nc.of): - 1
1
S 26,Part It. Enter other i If but not resulting in the underlying cause glv.n in Part L- 27.Was an autopsy pa rmad7
.. C3 Yes 0 No
1211,We-autopsy findings a,*liable
to comptete the cause of death?
C3 Yes No
3t 29.If Formal.: 30.Did Tobacco Use Cantrlbut.to Oaath7 31.Manner of Death
cC3 Not pregnant within past year 0 Yes 1-3 Probably 6lr( Natural C3 Homicide
C pregnant at time of death W No C3 Unknown (] Accident E3 Pending Investigation
C3 Not pregnant,but pregnant within 42 days of death C3 5u1c1d. 0 Could not be determined
r- E3 Not pregnant,but pregnant 43 days to 1 year before death 32.Data of injury(MO/Day/Y,)(Spell Month)
O Unknown If pregnant within the past year 33.Time of Injury
5L' 34.Place of injury(e.g.home;conatructlon site;farm;school) 35.LOCatlan of Injury(Street and Number,City,County.State,ZIP Code)
36.Injury at Work 37.If Tra nsportatlon Injury,Spee Hy: 38.Oascrlbe Hqw Injury Occurred:
4 C3 Yas L3 Ortvar/operator C3 P.d.,trtaI
L� C NO M Passenger Cj Other(Specify)
39-Certifier-physician,certified nurse Practitioner,medical examfnarfcoronar(Check only
C3 Certifying only-To the best of my knowledge,death occurred due to the causes)and manner stated.
M P,...uncing&Certifying-To the best of my knowledge,d ath ceu rred at the time,date,and place,and due to the cause(s)and manner stated.
E3 Medical Examiner/Caroner-On the basis of a 0mtna r invast{gatlan,in my opinion,death occurred at the time,date,and Place,and due to the causes)and manner stated.
r Signature of certifier: Tttta Of carYlftsr: t "S IC, Ucansa Numb.1 t'S y " 0`("2-(`1 uF'L^ i
�? 39b.Name,Address and 21p Code Of Person at n f Death(Item 26) 39C.Date Signed(MO/Oay/Y,)
1Y� GDOD "orb"" tL � 1 ,lo Ae 4 1?'e t?
40.R.gfsir0r's District Number - 41.Registrbr's Signature 42, gistrar File Date(MO/Day/Yr)
a 43.Amendments
u
c
0
Disposition Permit No. �'\`-'r�aJ tv-C REV 07/20
12
COMMONWEALTH OF PENNSYLVANIA SHORT CERTIFICATE
COUNTY OF CUMBERLAND
I, GLENDA FARNER STRASBAUGH
Register for the Probate of Wills and Granting
Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
the 26th day of November, Two Thousand and
Thirteen,
Letters TESTAMENTARY
in common form were granted by the Register of
said County, on the
estate of JOHNECOHICK late of MIDDLESEXTOWNSHIP
(First,Middle,Last)
a/k/a JOHN EDWARD COHICK
in said county, deceased, to RONALD C COHICK and
(First,Middle,Last)
JAMES E COHICK
(First,Middle,Last)
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 26th day of November
Two Thousand and Thirteen.
Fi 1 e No. 2013- 01260
PA File No. 21- 13- 1260
Date of Death 1111712013
S.S. #
Register Ut Wills
Deputy
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
L
rN
C
INVESTMENTS
Member FINRA-d SIPC
December 18, 2013
Ronald C Cohick
James E Cohick, Co-Executors
Estate of John E cohick
1974 Linden Lane
Hatfield,PA 19440
Dear Sirs:
Attached is the Date of Death Valuation you requested for the Estate of John E Cohick. This
Date of Death Valuation was done by our Estate Resolution Desk. If you have any questions,
please contact them at(800) 622-7086.
The Account Number is 001-556580, and was opened as an individual account on May 14,
1999. The balance as of date of death is on the attached.
Sincerely,
Donna J Pollock, Assistant.to
Charles E Little, CFA®, CFP®
Financial Advisor, Senior VP
Enclosure
PNC Investments LLC
Member of The PNC Financial Services Group
2 East Main Street•Mechanicsburg Pennsylvania 17055
wvwvv.pnc.com
W Important Investor Information:Securities and brokerage services are provided by PNC Investments LLC,member FINRA and SIPC.
'N0 Btl1'k ""'1°Ir`' Annuities and other insurance products are offered by PNC Insurance Services LLC,a licensed insurance agency.
�— P C
INVESTMENTS
Member FINRA and SIPC
December 18,2013
Donna Pollock
donna.Pollock(a)-pnc.com
RE: 001-556580/JOHN COHICK(INDIVIDUAL)
Dear Donna
The value of the above-referenced account on November 15th,2013 is as follows:
Symbol/ DOD r Accrued
Amount Description Cu'Stp I Price DOD Value; Interest
1638 PNC FINL SVCS GROUP PNC $ 75.14 $ 123,079.32
Grand Total (Market Value+Accrued Interest) $123,079.32
" Note: DOD price is based off the closing price on the day the client has passed away, if this is a non-business day the
price will be taken from the previous business day's closing price.
If you have any questions, please contact our Estate Resolution Desk at 800-622-7086.
Sincerely,
Ankit Patel
PNC Investments, LLC.
Estate Resolution Desk
The summaries,prices, quotes and/or statistics contained herein have been obtained from sources believed to
be reliable but are not necessarily complete and cannot be guaranteed.They are provided for informational
purposes only. Past performance does not guarantee future results.
PNC Investments LLC
Member of The PNC Financiat Services Group
2 East Main Street Mechanicsburg Pennsylvania 17055
wv,w.pnc.conn
n •\Iav Lose,V'dill r
.Nu P,:mk Guaramec Important Investorinformation:Securities and brokerage services are provided by PI C Investments LLC,member FIN RA and SIPC.
Annuities and other insurance products are offered by PIJC Insurance Services LLC.a licensed insurance agency.
JAN-16-2014 12:53 -From:METLIFE-LANSDALE-PA 2156994506 To:6104e93240 P.2/7
WWW.( F:91A
F&M 'Trust, Carlisle Crossing TR1,6BT
214A Westminster Drive
Carlisle, PA 17013
(717) 243-2978
Jarualy 10, 2014
Ronald C C ohick
RJ?: John T? Cohick R.state
1974 Ijnden 1'.n
Hatficid, l'A 19440
Dcar Mr. C'ohick:
Per your request,this letter details the balances and account activity of your late father's
checking account around the date of his passing. All information included in this letter is
in reference to Farmers & Merchants Trust Company of Chambersburg, PA (F&cM Trust)
checking;account 3308812, which was owned by the late.fohn 'R. C'ohick, from when it
wtls apcticd o11 Scptcrllbcr 27, 1996 to its closing oil December 6, 2013.
John E. Cohick's date of death is November 17, 2013,which fell on a.Sunday, and
therefore, not a banking business.day.As of the end of business day on 1'riday, November
15, 2013,John's balance in his checking; acccirult was $80,949.54.
On.Saturday, November 16, 2013, a $720.72 deposit was left ill the alight depository at
our Carlisle Crossing;office into John's checking account. Since the next business day is
Monday, November 18, 2013, the,deposit cleared his account the day alter his passing.
Also on Novcrrrbcr IS, 2013 a previously-writtcrr check 111097 c1c:rod the account irr Lhe
amount of$48.50. *11iis check was ' ttc;n un Nuvcrnbcr 11, 2013. 1'lresc twu tranSaCLLOTIs
clearing the account on Monday, November 18, 2013 rosultod Ill all account balance of
$81,621.76.
On Tuesday, November 19,2013, two other checks cleared Mr. C chick's account(check
numbers 1101 and 1102 respectively)for the amount of$10,000.00 cacti. '1'Ilcsc chocks
were written h-nd dated November 12, 2013, and therefore issued before the date of death.
'1'ho resulting balance;aftor thcsc two cheoks cleared tho account was $61,621.76.
Please feel free to contact me if I can be of any further assistance.
Sincerely,
Melissa J McGowan
Customer Service Rerresentative/11ead Teller
717-264-6116 888-264-6116 P.O.Box 6010 Chambersburg,PA 17201-6010
FINANCIAL SOLUTIONS ,.. FROM PEOPLE YOU KNOW
Page 1 of 2
V rizon Pnnt
Subject Fwd: Refund Amount- Cohick, John E.
From: RONALD <cohickl@comcast.net>
Sent: Jan 9,2014 12:42:23 PM
To: tjacpas@verizon.net
CC: cohickl@comcast.net
To Trout, James &Associates-
Re: Estate of John E Cohick
Attached is letter from Claremont Nursing and Rehab Center.
From: "Crystal Brallier" <cbrallier @ccpa.net>
To: "cohickl @comcast.net" <cohickl @comcast.net>
Sent: Thursday, January 9, 2014 11:31:36 AM
Subject: Refund Amount - Cohick, John E.
Mr. Cohick:
Per our phone discussion, the amount of the refund check on your father's account is
$2,939.78 and will be processed in our 1/24/14 check run.
If you have any further questions or concerns, please let me know.
https://netmail.verizon.com/netmail/driver?nimlet=deggetemail&fn=INBOX&page=l°... 01/09/14
Page 2 of 2
Thanks,
Crysta[D. BratTwr
Accounting Manager
Claremont Nursing & Rehab. Center
1000 Claremont Road
Carlisle, PA 17013
P: 717-240-1948
F: 717-240-1910
j` Please consider the environment before printing this message.
The information in this message may be privileged and confidential and protected from
disclosure. If the reader of this message is neither the intended recipient, nor an employee or
agent responsible for delivering this message to the intended recipient, then you are hereby
notified that any dissemination, distribution, unauthorized use, or copying of this
communication is strictly prohibited. If you have received this communication in error, please
notify us immediately by replying to this message and deleting it from your computer. Thank
you, Cumberland County, PA.
I
https://netmail.verizon.com/netma'il/driver?nimlet=deggetemail&fn=INBOX&page=l°... 01/09/14
a
JOHN a coHrCK 1101
12.4 LINDEN L1.,'P -/a-13
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11/19/2013 1102 $10,000.00
ING MSPO (C—time) GMT 1/22/2014 8 : 49: 31 PM PAGE 2/002 Fax Server
ING +
January 14,2014
RONALD C COHICK
1974 LINDEN LN
HATFIELD,PA 19440-2111
ING USA Annuity and Life Insurance Company
Decedent: John E Cohick
Contract Number: 90096853
Claim Code: 03010
Dear Mr. Cohick,
Thank you for your recent inquiry regarding the annuity contract listed above.Please find
the contract information below.
Death Benefit Value $456,572.87 as of 11/17/2013
If you have questions regarding this information,please contact our Customer Contact
Center,available Monday—Thursday, 8:30 am.to 6:30 p.m.,Eastern Time,and Friday,
8:30 a.m. to 5:30 p.m.,Eastern Time. Call 500-369-5303 and press 3 to identify yourself
as a beneficiary.When prompted, enter the five digit Claim Code above and press 4.
Your call will be addressed by a claims specialist.
Sincerely,
Customer Service
ING
Annuities issued by BOG USA Annuity and Lifelnsusanx Company.
1001 AB
i
I
October 11, 2013
Ronald Cohick
1974 Linden Ln
Hatfield, PA 19440-2111
RE: ING USA Annuity and Life Insurance Company 90096853
Dear Valued Client:
We have received a request to change the ownership designation of the above contract. Our records now
indicate the new contract owner(s) as Ronald Cohick.
If you have any questions, please contact our Customer Contact Center at (800)369-5303, and a
representative will be happy to assist you Monday through Thursday 8:30 a.m. to 6:30 p.m. Eastern Time and
Friday 8:30 am to 5:30 pm Eastern Time. You may also access your contract information online at
www.ingannuities.com.
Customer Service
P.O. Box 1337
Des Moines, IA 50305-1337
(800)369-5303
www.ingannuities.com
01 qr
08609 001001
< Fidelity & FIDELITY & GUARANTY LIFE
Guaranty Lifeam INSURANCE COMPANY
777 Research Drive, Lincoln,NE 68521
P O Box 82066, Lincoln, NE 68501
866-702.2194(Office) 402-479-0198 (Fax)
—— www.fglife.com
January 27, 2014
Ronald.Cohick
1974 Linden Lane
Hatfield, PA 19440
Policy: 03006806
Annuitant: John Cobick
Dear Mr. Coluck:
Per our telephone conversation today, you need a letter that indicates the value of this policy as of
11/17/2013. Please be advised that the policy value as of this date was $137,950.73.
If you should have any questions, feel free to contact our office and 866-702-2194 option 5.
Sincerely,
Claims Department/ps
Fidelity& Guaranty Life Insurance Company
Fldolity$Guaranty Llfe Is the marketing name of Fidelity&Guaranty Life Insurance company and,in Now York only,Fidelity&Guaranty Life Insurance
Company of New York,Only Fidelity$Guaranty Life Insurance Company or Now York is authorized to sell Insurance antl annulllos In Now York.
I
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Ronald Cohick
December 24, 2013
1974 Linden Lane
Hatfield, PA 19440
Statement of Funeral Expenses for: John Edward Cohick
Date of Death: November 17, 2013 Account Id: 17034-268
PACKAGE:
Traditional Funeral Service
TRADITIONAL FUNERAL SERVICE PACKAGE $ 5,050.00
MERCHANDISE: Sub Total: $ 5,050.00
Casket: Montgomery $ 3,745.00
Outer Container: Monticello $ 1,820.00
Sub.Total: $ 5,565.00
TOTAL FUNERAL HOME CHARGES: $ 10,615.00
CASH ADVANCES:
14 Certified Death Certificates at$6.00 each $ 84.00
Newspaper Notice-Sentinel $ 261.84
Clergy $ 100.00
Video Tribute $ 86.92
Sub Total: $ 532.76
Write Off On Casket Dec 17, 2013 200.00
Write Off On Vault Dec-17, 2013 200:00
Estate Of John
Cohick/Ronald Exec Check 108 Dec 17, 2013 10,747.76
Total Funeral Expense: $11,147.76
Total Payments Made: $ 11,147.76
Balance: $ 0.00
DO NOT DETACH THIS VOUCHER
PAYMENT OF THIS CHECX WILL BE gEFUSED.UNLESS -
RECEIPT IS SIGNED AND CHECK ENDORSED.
NOS 105
ECK NO. DATE–)—Q
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DATE .w R 1/� / 313
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RECEIPT IS SIGNED AND CHECK ENDORSED.
1111111III ,� No. 103
:HECK NO. DA - 60-430
RECEIVED OF: DATE / Q °s%o521- 313 1
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D, ()Q A)h I �J j 1X%I2 P/5RTlIY.l. I F -6='-D OLLARS IJ F.sro
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0000 10 30 40 3 1, 304 3061: L Lll1 L9060ii'
D Dew;e Esrn.e
Andrews &Johnson Invoice
78 West Pomfret Street
Carlisle, PA 17013 Date Invoice#
2-3_2478086 12/6/2013 1681
Bill To
John E Cohick Estate
c/o Ronald C.Cohick
1974 Linden Lane
Hatfield,PA 19440
T
Description Amount
11/21 Preparation of Probate Petition and Estate Information sheet 141.00
11/26 Office conference with Ronald and James re:estate 211.50
DO NOT DETACH THIS VOUCHER
PAYMENT OF THIS CHECK WILL BE REFUSED.UNLESS 104
RECEIPT IS SIGNED AND CHECK ENDORSED.
O.
64430 1
ECK NO.�" DATE�� / 1 11/Jf{ 313
CEIVED OF: �+ , y DATE C—'7) ✓ 1._
�• ;n ` � (�� PAY
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Total $352.50
-..DD NOT DETACH THIS VOUCHER
PAYMENT OF THIS CHECK WILL RE REFUSED.UNLESS -
RECEIPT IS SIGNED AND CNECK ENDORSED.
1 No. 101
CHECK NO; DATE
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RECEIVED OF: -'
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313
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SIGN HEREie'� ��. ����.,fd�.J1���/Lyyy1(I---I RESEInA{IVE E YIUIbiRnipR IpYlUlbinai111Y IgUS{FF GUAROIA�
:. ppEIGFE ESTAl.N . n■000 LOLn■,; i:03 1'30*4306�: .. L9060u' -
Trout, James & Associates, P.C.
Certified Public Accountants
168 W. Ridge Pike, Suite 125
Limerick,PA 19468
(610) 489-3200 Fax (610) 489-3240
February 4, 2013
Estate of John E Cohick
Ronald Cohick
1974 Linden Lane
Hatfield, PA 19440
PREPARATION OF 2013 INHERITANCE RETURN:
Form REV- 1500 and accompanying schedules $ 750.00
Less: Discount 200.00
TOTALDUE ........................................................... 5� 50.00
PAYMENT DUE UPON RECEIPT
(A finance charge equal to 1.5%per month is added to all past due amounts)
i
ALEXNf 219 North Baltimore Ave A FINANCE CHARGE OF 1.50 D PER MONTH
PHARMACYSEMcBs,]Nc. Mt Holly Springs, PA 17065 (AN ANNUAL PERCENTAGE RATE OF 18.0'1) OR A
Responsive. Innovative. Reliable. 800-266-9954 (717)486-8606 MINIMUM SERVICE CHARGE OF $ 1.0 0 WILL BE CHARGED
w1vw.A1ertPharmacy.com
�a
ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE
STATEMENT OF ACCOUNT
IF YOU RECEIVE A NEW I INSURANCE_.CARD FOR YOUR I
PRESCRIPTIONS.BE SURE TO .SUPPLY. US WITH A COPY.
Date- 11/30/2013
PMT DUE. . 12 24 13
COHICK„ JOHN E COHIJO
RON COHICK GRP-CNRC 7c
1974 LINDEN LANE PAGE 1
HATFIELD PA 19440 Amount Paid
— PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
DO NOT DETACH THIS VOUCHER
PAYMENT OF THIS CHECK WILL BE REFUSED.UNLESS
RECEIPT IS SIDNED AND CHECK ENDORSED.
NO. No. 102
IECK
iCEIVED OF: 60-43
DATE a(} ��� 313
NIA Ll'ti �` �r') PAY
ISPn.I RE,RFEERT.iNE QE .QELUtR.AR.,..An,.iRR.R„R:I„M,.IR,R�:iQL..RP,.R TO THE
OF THE ESTATE OF
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a
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/ D
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ON HERE RT 1 _ C
ALBD ENDORSE RACK OF CHECK
REP "n'f-QE L•T i FOJVY151Ri.�R aOLY:IISiFFiRY RL'FTFE GIIRIIOr1�AY
C DECOKE ESTN..
116000102119 1:0 3 1 3 0 4 3 0 61:
ALERT PHARMACY SERV. INC.219 NORTH BALTIMORE AVE. MT HOLLY SPGS PA 17065
D u o p 0
** ACTIVITY FOR COHICK, JOHN E -COHIJO - -5652
10/19/13 9050821 30 FUROSEMIDE 40MG 01 6.00- . 00 6.00-
10/19/13 9050821 16 . FUROSEMIDE 40MG 01 5.30 .00 5.300
11/15/13 Payment-Thank You 48.50- . 00 48.50-
CK# 1097
11/15/13 9136380 5 ATROPINE to EYE 5
01 30..42 .00 30.42
S
29 . 72 00
LEGEND TOM TAX
FOR MONTH
revious Balance Charges this month Finance Char e TOTAL CHARGES Total Payment&Credits P-0IV OUNT OUE
48 . 50 + 35 . 72 + . 00 = 84 . 22 - 54 . 50 29 . 72
:OR ALL PHARMACY RELATED INQUIRES PLEASE CALL Alert Pharmacy Services, Inc at 9-800-266-9954
Statement Terminology on reverse