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Home My WebLink About03-03-14 (2) .J 1505610105 REV-1500IXt0'- 'tFI'Iff OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number Bureau ofIndividualTaxes INHERITANCE TAX RETURN 'J] I PO BOX 280601 bj'/�`— . I /r rl�n Harrisburg,PA 19128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW 06/20/2013 07/16/1938 ............. ....... Decedent's Last Name Suffix Decedent's First Name MI .._..--.._.. .........-....-. .....__..... ---_...... .... r------. .._..-.__ - .........--._ _-_.....-...... .. . _.....____--- Bossier Audrey L - ._ _ ------------------- - ; ------ _---------- _(if Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name - Suffix Spouse's First Name MI Bossier Glenn E I Spouses Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW OD 1.Original Return O 2. Supplemental Return O 3. Remainder Return(Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) , CIND 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 0 B. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Michael Cherewka, Esquire (717 232-4701 ......... ........................... _ REGISTERP WILLS USEj;LY = O First Llne of Address 624 North Front Street w r' Second Line of Address , -rt C. City or Post Office State ZIP Code DA FILED cn' ................ _.__.. ........_. ....-.... _ ...-.-.... _.._.__ ...._.._ .- Wormleysburg PA 170431 Correspondent's e-mail address: mcherewka @cherewkalaw.com Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,awract and complete.Declarat n of preparer other thanthe personal representative is based on all information of which preparer has any knowledge. SIG �—E OU5'`fp S P IBLE FOR FILI G RETURN D E 4,/ DRESS 160 West Big Spring Avenue, Newville, PA 17241 SIGN T OF PREPAf}EA TH R THAN� RESENTATIVE DATE ADDRESS T` / 624 North Front Street, Wormleysburg, PA 17043 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610105 1505610105 I 1505610205 REV-1500 EX(FI) RECAPITULATION 1. Real Estate(Schedule A). . . . . .. . . . .. . .. . .. . .. . . . :. . .. . .. . .. .. .. ... . . . 1. _ 0.00 2. Stocks and Bonds(Schedule B) . .. . .. .. . .. . .. . . . .. ... . .. . .. . . .. . . . .. .. 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) ... . . 3. 0.00 4. Mortgages and Notes Receivable(Schedule D) . .. ... .. . ... . . .. .. . .. ... . .. 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. . .. . . 5. 173,942.62 6. Jointly Owned Property(Schedule F) O Separate Billing Requested . . .. ... 6. -:. 85,727.35 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) Separate Billing Re q nested.... .. . . 7. 0.00 8.8. Total Gross Assets(total Lines 1 through 7).. . . .. . .. . .. . .. . . .. . .. .. . ... . 8. i 259,669.97 9. Funeral Expenses and Administrative Costs(Schedule H). ... . .. .. .. . .. .. . .. 9. 30,801.32 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1). . . . .. .. . .. .. . . 10. ! 9,256.84 11. Total Deductions(total Lines 9 and 10). .. . .. .. . .. . .. . .. . .. .. .. . .. . .. . . . 11. 40,058.16 12. Net Value of Estate(Line 8 minus Line 11) . . .. ... .. . ... ... .. .. .. . . . ... . . 12. 219,611.81 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . ... . . . . .. . . . . .. ... . .. . 13. 0.00 14. Net Value Subject to Tax(Line 12 minus Line 13) ... .. . ... ... . .. . .. ... . .. 14. 219,611.81 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 ,.....___.v�...., (a)(1.2)X.o_ 96,229.35 15. , 0.00 16. Amount of Line 14 taxable ;" .__ ...._. ....,e_.'......."_..�.._._._.._......�.,t )..._._..,,.....,.„,,._,,,..,,.,e.,_,_,.,...,.„.-.. ,,.,_.v..„.? at lineal rate X.0 45 123,382.46 16. 5,552.21 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable at collateral rate X.15 18. .__...__..._._.._..._._...-.------___..._�___,_....�..J n.,,._„....._.....:_._.._.._._.__......_,_s............_......... .�--; 19.1 TAX DUE . .. . ... . . ... .. . . . .. . .. . . .. . .. ... ... .. . .. . . . .. . . . .. .. . .. .. 19. 5,552.21 j 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 1505610205 1505610205 J REV-1500 EX(Fl) Page 3 File Number 21-13-0739 Decedent's Complete Address: DECEDENT'S NAME Audrey L. Bossier STREETADDRESS 98 Pepper Avenue CITY STATE ZIP Wormleysburg PA 17043 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19)' (1) 5,552.21 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 OVERPAYMENT. Fill in oval on Page 2,Line 20 to request 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) 5,552.21 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred .......................................................................................... ❑ 0 b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ ■. c. retain a reversionary interest .............................................................................................................................. ❑ 0 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?.............................................................................................................. ❑ 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ 0 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 V2 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-1502 EX+ (12-12) IRpennsylvania SCHEDULE A OEPARTMENiOFREVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Audrey L. Bossler 21-13-0739 All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's Interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1 None 0.00 TOTAL (Also enter on Line 1, Recapitulation.) $ 0.00 If more space is needed,use additional sheets of paper of the same size. REV-15o3 EX.(8-2) 12pennsyLvania SCHEDULE B OEPARTMENTOFREMUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER Audrey L. Bossler 21-13-0739 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH None 1 0.000 1 TOTAL(Also enter on line 2, Recapitulation) L 0.00 If more space Is needed, insert additional sheets of the same size REV-1507 EX+(04-13) pennsylvania SCHEDULE D DEPARTMENT OF REVENUE MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER Audrey L. Bossler 21-13-0739 All property jointly owned with right of survivorship must be disclosed on Schedule F. REM VALUE AT DATE NUMBER DESCRIPTION OF DEATH None -I .�_ e --•--- - -- — -- .,...�. _ ,.,,, ! _ 0.00 �.._ _a s . _ , r I I I (! f t i r � ---_� --�•-:._=--�.,--_--�--�.----.��-rte-=— __.._— --- =�=-; �' I�-.,_^-;,-.�....._,:._•._. a 6 TOTAL(Also enter on Line 4, Recapitulation) E 1 0.00 " (if more space is needed,Insert additional sheets of the same size.) • 11 REV-1508 EX+(o&1z) Ii J pennsylvania SCHEDULE E 1�' DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Audrey L. Bossier 21-13-0739 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. REM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Marysville Bank,Checking Account#424102 49,560.16 2. Marysville Bank,Cerfificate of Deposit,Account#3067042 43,098.29 3, Marysville Bank,Certificate of Deposit,Account#3068389 80,284.17 4. Personal Clothing,Furnishings 1,000.00 TOTAL(Also enter on Line 5, Recapitulation) $ 173,942.62 If more space is needed, use additional sheets of paper of the same size. RIVE RVI EdV BANK AND ITS OPERATING DIVISIONS 200 Front Street,PO Box B,Marysville,PA 17053 www.,iverv,,.b"kpa.com August 21,2013 Michael Cherewka RE: Audrey L Bossler 624 North Front Street DOD:6123/2013 WormleysburgPA 17043 Account Number(s) 424102 3067042 3068389 Type of Account Checking Time Deposit Time Deposit Date Opened July 28,2005 July 5,2012 May 7,2013 Principal Balance at date of death $49,560.16 $43,098.29 $80,284.17 Interest Rate N/A 2.0000% 2.0000% Accrued Interest not disbursed as of date of death $4.72 $7.92 Maturity Date July 5,2013 November 7,2013 Primary Owner of Account Audrey L Bossler Audrey L Bossler Audrey L Bossler Name of Joint Owner(s),if any N/A N/A Glenn E Bossler POA Beneficiary,if any Date Joint Ownership was Established May 7,2013 If within 1 year of death of Decedent could prior Account Be traced into a prior Joint Account in existence over 1 year prior to death of Decedent N/A Safe Depos' Box(s)and Location By: 2:--� Steven M s Halifax Bank Marysville Bank 300 Market Street 200 Front Street PO Box A - PO Box B 1&UfaxBank Halifax,PA 17032 arysyille : Marysville,PA 17053 www.halifaxbankpa.com www.marysvillebankpa.com REV-1509 EX+(oi-1o) pennsylvania SCHEDULE F �7 DEPARTMENT OF REVENUE INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Audrey L. Bossler 21-13-0739 If an asset became jointly owned within one year of the decedents date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A Glenn E. Bossler 9 Pepper Avenue Spouse Enola, PA 17025 B. C. JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % DATE OF DEATH REM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSnMION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. 01/01/95 93 Pepper Avenue,Enola,Cumberland County,#09-14-0834-001 140,400.00 50% 70,200.00 2. A. 09/04/97 Marysville Bank,Checking Account#402974 31,054.70 50% 15,527.35 TOTAL(Also enter on Line 6, Recapitulation) $ 85,727.35 If more space is needed,use additional sheets of paper of the same size. RWEW BANK ANV EAING DIVISIONS 200 Front Street,PO Box B,Marysville,PA 17053 - www.riverviewbankpaxom August 21,2013 Michael Cberewka RE: Audrey L Bossler 624 North Front Street DOD: 6/23/2013 WormleysburgPA 17043 Account Number(s) 402974 Type of Account Checking Date Opened September 4, 1997 Principal Balance at date of death $31,054.70 Interest Rate N/A - Accrued Interest not disbursed as of date of death Maturity Date Primary.Owner of Account Glenn E Bossler Name of Joint Owner(s),if any Audrey L Bossler Beneficiary,if any Date Joint Ownership was Established September 4, 1997 If within 1 year of death of Decedent could prior Account Be traced into a prior Joint Account in existence over 1 year prior to death of Decedent N/A S e Deposit B (s) nd Location By: Steven M Williams Halifax Bank Marysville Bank 300 Market Street 200 Front Street PO Box A - PO Box 8 Hal Bank Halifax,PA 17032' drlSV lle e. Marysville,PA 17053 !"-` www.hallfaxbankpa.com www.marysvillebankpa.com Property Mapper Cumberland County, PA PERRY COUNTY ra - k 4+4 YORK COUNTY 1NTY � ao �. wsc Copyrght 2011 Ear.All rights rese vad.FO Jan 3 201401:17:07 PM, 98 PEPPER AVENUE PIN:09-14-0834-011 Deedbook:0021C-00589 l `- Owner. BOSSLER,GLENN ELWOOD Land Use Code: 101 Property Type:R Acreage: 0.46 Square Feet:1861 Taxable Status:T Clean S Green Staters: Land Assessed Value$:34100 Bulding Assessed Value$: 106300 Taml Assessed Value$: 140400 Sala Prte$: Sale Data: %ear BU@: 1955 Munkc0alty:EAST PENNSBORO TAT Height In Stores: 1 Type of Dwelling:DETACH Primary Exterior:Vinyl Basement Percentage:100 Air Conditioning: NO . Total Rooms: 5 Bedrooms; 3 Full Bath: 1 Half Bath: REV-1510 EX+ (08-09) ?pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER—VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON—PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Audrey L. Bossier 21-13-0739 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. ITEM INCLUDE OF PROPERTY UDE THE NAME OF THE TRAIISRSUT,TNDR REUTI0N.4DP To DECIDER AND DATE OF DEATH % DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH A ODP;OF THE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST OF APPU VALUE 1. None 0.00 0.00 TOTAL(Also enter on Line 7, Recapitulation) $ 0.00 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+ (08-13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND _ INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Audrey L. Bossler 21-13-0739 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: _ _ I' Neill Funeral Home, Inc. 11!7977R L? Rolling Green Cemetery Company,burial plot , — 3,292.00 Funeral Luncheon 561.2721 ;Royer' Flowers_ � 62.991 5." ill _ Candy Kitchen,Funeral Luncheon [` 56.93 ❑ 4 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 10,411.68 Name(s)of Personal Representative(s) Ronald Houser Street Address 130 West Big Spring Avenue city Newville State PA ZIP 17241 Year(s)Commission Paid: 2014 .0 2. Attorney Fees: 000 0 3. Family Exemption: (If decedent's address is not the same as daimant's,attach explanation.) 0.00 Claimant Street Address - city State_ZIP - Relationship of Claimant to Decedent 4. Probate Fees.: 363501 5. Accountant Fees: q -+�-�--•� 1 6. Tax Return Preparer Fees: Z• Cumberland Law Journal-Legal Notice T5�00. F81 [Sentinel-Legal Notice L 150.00 � # — -1-2 0,801.321 TOTAL(Also enter on Line 9, Recapitulation) ;, If more space is needed,use additional sheets of paper of the same size. ° V �RSSOCIP�� CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)249-3166 Fax:(717)249-2663 September 13, 2013 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and 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: Michael Cherewka, Esquire RE: Audrey Bossier 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 the following dates: August 30, September 6 and September 13, 2013 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 Total Amount Due $ 75.00 Pd Payment received by Neill Funeral Home,Inc. 3401 Market Street Camp Hill,PA 770114428 (717)737-8726 � / (R ✓ � �� Ov Supervisor:Kevin J.Shillabeer The following is a detailed bill for the professional services andlor metdtandise arranged for Audrey L Bowler Date of Service:June 29,2013 Glenn E Bossier Statement Date July 03,2013 210 Big Spring Rd,305 Contract Number 741101000423 Newville,PA 17241-9497 Arranger Name Kevin J Shillabeer Initial Selection Final Selection Difference Package Offerings Dignity Memorial Tribute Funeral Service $6,265.00 $8,265.00 — Std Sentinel Copper Concrete Ind Inc] — Dignity Tribute Burial Memorial Package Ind Incl — Transfer of Remains to Funeral Home Incl Incl — Funeral Vehicle/Hearse- Ind Inc] — Use of Facilities and Staff for Viewing Ind Ind - — Service Vehicle - Ind Incl — Chapel Funeral Ceremony Incl Incl — Embalming - Inc] Inc] — Dressing and Casketing of Deceased Ind Incl — Dignity Tribute Burial Flowers Ind Incl — Basic Services Funeral Director and Staff Ind Ind — Everlasting Moments Incl Inc[ — Total Package Offerings $8,265.00 $8,265.00 — Other Goods and Services US Aftercare Planner $225.00 $225.00 — Total Other Goods and Services $225.00 $225.00 — Merchandise 148032 Revere Silver Metal Steel 20 Gauge Crepe $1,795.00 $1,795.00 — Total Merchandise $1,795.00 - $1.,795.00 - Cash Advance Cemetery $1,720.00 $1,720.00 Clergy/Religious Facility $150.00 $150.00 -- Initial Selection Flnal Selection Difference Certified Copies of the Death Certificate $60.00 $60.00 — Newspaper Notice $261.00 $261.00 _ Total Cash Advance $2,191.00 $2,191.00 - — Total Services,Merchandise and Cash Advance $12,476.00 $12,476.00 — Allowances Dignity Discount ($585.00) ($585.00) — Total Allowences ($585.00) ($585.06) - Total Charges(Total Services+/-Allowances+Tabs) $;1,891.00 $11,891.00 _ Less Cash Received $0.00 Unpaid Balance Due $11,891.00 i Page 2 of 2 i ROLLING GREEN CEMETERY COMPANY 1841 CARDS)E ROAD ' CAMP FJLI.,FA 17011 ' rA7)7914 $ iN!? 8; 5 8 8 9 9'u.. Contract 624 11 D 5 Q R' File Folder Name/Number CEMETERY INTERMENT RIGHTS,MERCHANDISE,AND SERVICES PURCHASE/SECURITY AGREEMENT THIS AGREEMENT PROVIDES FOR PERPETUAL/ENDOWMENT CARE. The undersigned, referred to as'Purchaser',hereby agrees to purchase the Interment Rights,Merchandise and Services described herein,subject to acceptance and approval of the above named cemetery,hereafter referred to m'Seller'. Purchaser:Last Name: I I D I u IS 1 @ I r l I I I I I I I I I I Ff5L; I I P ^I al I l d l 1 1 1 1 I I I Middle: I�•I I I I Telephone: 3! , 2:- _yy4y SSN: _ DOB: /—� Email: Address: 11131DI IW(�S41 19111 ISIPIrl 141cil IQIUei I I city: 101eIWIVI111111°1 I I I I State: 1P1A1 Zip: Co-Purchaser:Last Name: I I I I I I I Fast: I I I I I I I Middle: I I I I I Telephone: SSN: DOB: / / Email: U= - Address: I I I I I I I I I I I City` I I I I State: 11 1 Zip: Deceased:Last Name: 131 D S I S 11 1 P—;r I I I I I I I I I I Fra1° 1 A 1 R Id I r l P-1 y l I I I I I I I Middle: I('1 I I I I I / / 3g , Z3 ,2o13 /- ❑ DOB: (d Q DOD: gpBuurrial Date: Veteran: - Description orlmerment Rights to be used: UI ock A _ Si'.01 on 26O OQce IDnd Z Memorializadon Rights: Issue Certificate of Interment Rights to: Address: - City: State: Zip: INTERMENT MERCHANDISE&SERVICES - • Interment Rights $ - Urn (Includes Perpetual/Endowment Care of$ ) Supplier • Interment and Recording Fees Type/Color • Outer Burial Container Design/Size / Supplier - Admin/ProcessingFee - - /2.o•�C) Model/Design Other Material/Color - Other • Outer Burial Container Installation Other MEMORIALIZATION - Other • Memorial Umw ni3Ofb L°IYOP p, 00 • Other Supplier Mc.A-4AewS • Other, ' Type/Color TOTALS, ALLOWANCES&TAXES Dcsign/Size 1 1 Y\P. 44 x I y Interment Rights............................................................... ( ) • Memorial Base AM�C.In IOn f[Ini fie. y36•0� Reason Supplier 'Si-a_r Merchandise/Service......................................................... ( . ) . Type/Color Y1 k p C.r 1 Reason Design/Size :4�k I yi Apply to • Memorial Perpetual7Endowment Can Merchandise/Service....................................................... ( ) • Memorial Installation Fee 0 O. Reason t Memorial Inspection Fee - Apply to • Nameplate/Scroll - - - Sub Total '1qZ"0� • Lettering Total Taxable Flower Vase Sales Tax(if applicable)..................................... Supplier TOTAL CASH PRICE $ Type/Color Less: Down Payment 22.0(1 Dcsign/Size. Other rt • Vase Base Total Down Payment ( �Z�lI Z•O� ) .'Size/Material Unpaid Balance of Total Cash Price $ Notes&Payment Terms(where applicable): - y TERMS The Total Cash Price is due and payable as of the date of this Agreement. A delinquency charge of percent will be assessed monthly on any balance not paid within 30 days of the date of this Agreement. If less than full payment is received,Seller shall deduct the accrued delinquency charge from the amount received and credit the ..m,;.,n..,.f rh.,.a—.o,.,,h.T RAta„.r I West CheCK Date Table Guests Server 45 �0 APPT-SOUP/SAL-ENTREE-VEG/POT-DESSERT-BEV 902 Nov& °5w ad She Wowdeph s ,Ya 17 43 (717) 731-9100. � r T Thank You - Please a e in CHOK f 105GC60002 s o Ln \^ R X J N 9 u 9 0 3 U X ai -O O f'J CO 1 �f OC m XC •• CU GAO C ' R R -• R O O < YJ� y ti r Q O N fD C Q> O� Lf� L~fl O O N Ll C MO O xXXX p X w N o ash o o l� i o m u Jci i- � u z ti O Ma H m U m Q W E (!] RECEIPT FOR PAYMENT ------------------- - ------------------- GLENDA FARMER STRASBAUGH Receipt Date: 7/02/2013 Cumberland County - Register Of Wills Receipt Time : 11 :45 :34 One Courthouse Square Receipt No. : 1074713 Carlisle, PA 17613 BOSSLER AUDREY Estate File No. : 2013-00739 Paid By Remarks : RONALD C HOUSER DMB ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name " PETITION LTRS, TEST 260 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 25 . 00 CUMBERLAND COUNTY GENERAL FUN RENUNCIATION 5 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN Check# 3037 363 . 50 Total Received. . . . . . . . . ` bbl ' _ REV-1512 EX+(12-12) IVpennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Audrey L. Bossler 21-13-0739 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. Darryl Guistwite, DO 23.30 2. Millennium Pharmacy Systems, Inc. 86.19 3. Darryl Guistwite, DO 141.57 4. Swaim Health Center 9,005.78 TOTAL(Also enter on Line 10, Recapitulation) ; 9,256.84 If more space is needed, Insert additional sheets of the same size. DARRYL GUISTWITE,DO 56 ASHTON STREET (717)609-2639 CARLISLE,PA 17015-6914 - Account Number Billing to Lam office Use Only Audrey L.Bossier - C/O Ron Houser 10937 06/25/13 1 MED 130 W Big Spring Avenue Newville,PA 17241 Sen•ice Date CPT4 Description - 04/12/13 99308 Nursing Home Est.Patient Level 2 Prov' Units Mes_ Charge InsPaid Adiustment Patient Paid Balance Due Patient:Bossler,Audre L DG 1 80.00 Y - 10937 1 3.15 Servicing Provider:Darryl K Guistwite DO 06/18/2013 Geisinger Gold 04/27/13 G0180 Hospice Initial Certification 52.60 14.25 Patient:Bossier,Audrey L- 10937 DG 1 65.00 10.15 Servicing Provider:Darryl K Guistwite DO 06/05/2013 Medicare 39.77 15.08 � IY nments: ; Pl.:,.y=par within 70 Oa)'S...thank you - Please Pay—' 23.30 Audrey L.Bossier i )37 860.00 92.;7 23.30 ount Number New Charges rg es New Payments New Ins Pmt. Current Due Since Last Bill -Since Last Bill Since Last Bill Past Due Finance Charge Scheduled Amount /Billing Fee Darryl Guistwite DO•56 Ashton Street•CARLISLE,PA 17015-6914 O O O O O O O O O O O O O O' O 0 O O O q M M 0 p) 0t pi \ rn (P (T tT Cn V7 pf A A A A A N - ip A A A O t0 rn i> m rn m rn m m m m rn rn rn ❑ N N N N N N N N N N N N N N N N N N N m O O O O O O O O O O O O O O O O O O O O W W W W W W W W W W W W W W W W W W W O < O p fH + m rn m rn rn m m ar rn rn 0 0 0 rn rn rn rn m ar m m rn m v rn rn rn m rn � rn U U Vt A A W m• O O O [D t0 W tO t0 t0 f0 rn Z a O Irnl� W � � N W t0 O tD rn rn rn W tp tp l0 0] rn � � W rn W N V rn O V W N rn U N rn V W N rn U � N 0t 1n � N N N W N W W W W W m W W W W r O O O O O � W l.J O W 00 O O W O O O O O O O 0 0 O O O O o rn o o rn o 0 o O o 0 0 0 0 0 -0 0 o D 0 W Om fC p m 'mm+pO a o c d>x m Oowua(y[� Ooau+a O n y (Oo-T1, n dl a + � Or +dD Aaam U. am 09- Jy c�r uJoO 0 ro p °a .6F o^-M a. 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Nn �5 o a0 a@ No og a0 Z +N Aa Am a_ m- O m- Am Am N a- m@ O a @ -m +o b m b a- b- my °O a ° n O "0 p p M c o v 0 3 GA O 7 W O O 0 d c c L? m m O o n '� m O o Cn m O (n O -O m m o 0 N c y m 3 a a o y = 3 a r M °cm 3 41 c� .• 3 A = m 3 A m m D a 0 o O m � W � m � � ❑ O m m m m m O ° _ r o ` m O G) m o f» to vi cn vi to to w to vi F» r» to cv cn �7y u+ cn u+ Z N O V to J N rn rn rn N rn � O rn rn rn N rn � O O rn A O N A A O t0 t0 lO f0 O rn V V V A V p D N fA f9 fA iA Efl fA fA 69 fA fA fA 69 W fA fA fA EA fA iH C O O o 0 0 0 0 0 0 0 0 0 0 0 0 0 o O o p1 d 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o y 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o o -I m o- o t» F» to to to e» r» e+ <n fn f» t» to t» En fn w to vi Dn to A rn rn rn N rn O rn rn rn N rn { WL O N A A O tO �D IO f0 O rn V V V A V O O O rn rn DARRYL GUISTWITE,DO (717)609-2639 56 ASHTON STREET CARLISLE,PA 17015-6914 l / 00 Audrey L.Bossier 10937 08/12/13 1 MED C/O Ron Houser 130 W Big Spring Avenue Newville,PA 17241 CPT4 05/13/13 99309 Nursing Home Est.Patient Level 3 DG 1 105.00 17.25 Patient:Bossier,Audrey L- 10937 Servicing Provider:Darryl K Guistwite DO 07/02/2013 Medicare 67.60 20.15 05/17/13 99308 Nursing Home Est.Patient Level 2 DG I 80.00 13.15 Patient:Bossier,Audrey L- 10937 Servicing Provider:Darryl K Guistwite DO 07/10/2013 Medicare 51.55 15.30 05/20113 99308 Nursing Home Est Patient Level 2 DG 1 80.00 13.15 Patient:Bossier,Audrey L- 10937 Servicing Provider:Darryl K Guistwite DO 07/10/2013 Medicare 51.55 15.30 06/03/13 99309 Nursing Home Est.Patient Level 3 DG 1 105.00 17.25 Patient:Bossier,Audrey L- 10937 Servicing Provider: Darryl K Guistwite DO 07/26/2013 Medicare 67.60 20.15 06/05/13 99308 Nursing Home Est.Patient Level 2 DG 1 80.00 13.15 Patient:Bossier,Audrey L- 10937 Servicing Provider: Daryl K Guistwite DO 07/26/2013 Medicare - 51.55 15.30 06/17/13 99309 Nursing Home Est.Patient Level 3 DG l 105.00 17.25 Patient:Bossier,Audrey L- 10937 Servicing Provider:Darryl K Guistwite DO 08/05/2013 Medicare 67.60 20.15 06/19/13 99308 Nursing Home Est.Patient Level 2 DG 1 80.00 13.15 ****** Continue On Next Page ****** Darryl Guistwite DO.56 Ashton Street•CARLISLE,PA 17015-6914 4 DARRYL GUISTWITE,DO (717)609-2639 56 ASHTON STREET CARLISLE,PA 170156914 Audrey L.Bossier 10937 08/12/13 2 MED C/O Ron Houser 130 W Big Spring Avenue Newville,PA 17241 CPT4 Patient:Bossier,Audrey L- 10937 Servicing Provider: Darryl K Guistwite DO 08/09/2013 Medicare 51.55 1530 06/21/13 99309 Nursing Home Est.Patient Level 3 DG 1 105.00 17.25 Patient:Bossier,Audrey L- 10937 Servicing Provider: Darryl K Guistwite DO 08/09/2013 Medicare 67.60 20.15 06/22/13 99316 Nursing Facility Discharge Lvl 2 DG 1 110.00 19.97 Patient:Bossier,Audrey L- 10937 Servicing Provider:Darryl K Guistwite DO 08/09/2013 Medicare 78.27 11.76 141.57 Audrey L.Bossier 10937 93.92 47.65 Darryl Guistwite DO.56 Ashton Street•CARLISLE,PA 17015-6914 5 o �zq CIE min m �+ U ° ml p: n ii=tm O n -1A r ry Of LLJ V`M mi of of ° W U tin,i Q W :y z m W W a J 2 ..Ctee d '7 7 Q �' m W ❑ O m m M - - of X X - F pzt v 0 CD - ° w O m m 1.G-F'w w V OI 0I = O C (hhun W m d y O W - O .may,,,:: m X ❑ ❑ ❑' d' W m W. !p m 1w`"r� cD tD O fD O M J V w ..1••" 0 0 0 0 0 LL UJ REV-1513 EX+ (01-10) pennsylvania SCHEDULE ] DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS(Include outright spousal distributions and transfers under Sec.9116(a)(1.2).) I. Glenn E.Bossler,98 Pepper Ave., Enola,PA Spouse $96,229.35 2. Ms Sherry L.Lessens, 836 Pinecrest Avenue,S.E.,Grand Rapids,MI Daughter 123,382.46 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 TAXIS NOT TAKEN: 1. 0.00 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. 0.00 TOTAL OF PART II— ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0.00 If more space is needed,use additional sheets of paper of the same size. LAST WILL AND TESTAMENT KNOW ALL MEN BY THESE PRESENTS, that I,AUDREYBOSSLER currently residing.in Enola, Cumberland County, Commonwealth of Pennsylvania, being in good health. and of sound and disposing memory do hereby make, declare and publish this as my Last Will and Testament, hereby revoking all former Wills and Codicils heretofore made by me. FIRST: I direct that all of my debts not barred by the statute of limitations, expenses of my last illness,funeral expenses, costs of administration and claims allowed in the administration of my estate shall be paid by my Executor hereinafter named, from my estate as soon after my decease as shall be found convenient. SECOND: I give, devise and bequeath my Certificates of Deposit at Riverview Bank representing remaining proceeds of my inheritance from my son to my daughter, SHERRY L. LESSENS. THIRD: I bequeath my automobiles,household and personal effects and other tangible personalty of like nature (not including cash or securities), together with any existing insurance thereon, to my husband, GLENN E. BOSSLER. In the event that GLENN E. BOSSLER should predecease me, I give, devise and bequeath my tangible personalty to my daughter, SHERRY L. LESSENS. FOURTH: I give, devise and bequeath the rest,residue and remainder of my estate, whether real, personal or mixed, and of any nature whatsoever and wherever situate,to my husband, GLENN E. BOSSLER. FIFTH: In the event that GLENN E. BOSSLER should predecease me, I give, devise and bequeath the rest,residue and remainder of my estate, whether real,personal or mixed and of any nature whatsoever and wherever situate, as follows: i A. FIFTY-FIVE (55%) PERCENT to my daughter, SHERRY L. LESSENS. In the event that SHERRY L. LESSENS should predecease me, I give, devise and bequeath her share to her children, ERIC G. LESSENS and ARIEL M. LESSENS in equal shares. B. TWENTY (20%) PERCENT to my grandson, ERIC G. LESSENS. In the event that ERIC G. LESSENS should predecease me, then I give, devise and bequeath his share to his mother, SHERRY L. LESSENS. C. TWENTY (20%)PERCENT to my granddaughter, ARIEL M. LESSENS. In the event that ARIEL M. LESSENS should predecease me,then I give, devise and bequeath her share to her mother, SHERRY L. LESSENS. D. FIVE (5%) PERCENT to my brother, RONALD C. HOUSER. In the event that RONALD C. HOUSER should predecease me, I give, devise and bequeath his share to my grandchildren, ERIC G. LESSENS and ARIEL M. LESSENS in equal shares. SIXTH: I hereby nominate, constitute, and appoint my husband, GLENN E. BOSSLER, as Executor of this, my Last Will and Testament. In the event that GLENN E. BOSSLER shall predecease me, or be unwilling or unable to act as my Executor, as aforesaid, then I nominate, constitute and appoint my brother, RONALD C. HOUSER without necessity for posting security regardless of state of residence, as Executor of this,my Last Will and Testament. In the event that RONALD C. HOUSER shall predecease me, or be unwilling or unable to act as my Executor,as aforesaid, then I nominate, constitute and appoint my daughter, SHERRY L. LESSENS without necessity for posting security regardless of state of residence. All references to the Executor herein shall be applicable to said substitute Executor. SEVENTH: My Executor shall have, in addition to the powers and authority conferred upon him by law,the following additional powers and authority: 1. To sell at public or private sale, exchange,transfer, partition, give options upon, lease, mortgage, pledge, or otherwise dispose of any property, real or personal, at any time constituting a portion of my estate, and upon such terms and conditions as the Executor shall deem wise. 2 2. To invest any money at any time in such bonds, stocks, notes, real estate, mortgages, life insurance, annuities or other securities, or such property, real or personal, as the Executor shall deem wise, without being limited by any statutes or rule of law regarding investments by the Executor. . 3. To retain,without incurring any liability, as investments, any property owned by me at the time of my death, as long as my Executor may deem it wise, and even though such property is not the kind of property an Executor would purchase as an investment; an d even though to retain such property might violate sound diversification principles. 4. To cause any security or other property which may constitute a portion of my estate to be issued,held or registered in the Executor's own name, or in the name of a nominee, or in such form that title will pass by delivery. 5. To consent to the reorganization, consolidation,readjustment of the financial structure, or sale of the assets of any corporation or other organization, the securities of which constitute a portion of my estate, and to take any action with reference to such securities which, in the opinion of the Executor is necessary to obtain the benefit of any such reorganization, consolidation, readjustment or sale; to exercise any conversion privilege or subscription right given to my Executor as owner of any securities constituting a portion of my estate resulting from any reorganization, consolidation, readjustment,sale, conversion or subscription. 6. To pay all costs,taxes, charges and expenses in connection with the administration of my estate, including such compensations to Executor which shall be in accordance with established fees throughout the period of administration of my estate. 7. To determine what is "income"and what is "principal"hereunder, and my Executor's decision thereon shall be final; and to purchase securities at a premium or discount, and to apply or charge said premium or discount against income or principal as the Executor may determine. L 0�� / �1it ter' ✓ 3 . 8. The Executor may make payments to or on behalf of any person who is the beneficiary hereunder but in no event, however, shall payments be made to any creditor or other such person because of anticipation of payment by the beneficiary, and any such claim made by way of anticipation by the beneficiary shall be of no validity or legal effect. 9. To borrow money from any person, fum or corporation, including any corporati on acting as an Executor hereunder, for the purpose of protecting and preserving or improving my estate hereunder; to execute promissory notes or other obligations for amounts so borrowed. 10. To employ legal counsel, accountants, brokers, investment advisors, custodians, managers and other agents and employees and to pay reasonable compensation out of my estate or any funds held hereunder to which said compensation is attributable. 11. To carry on any business owned or controlled by me at my death for whatever period of time my Executor shall think proper, and my Executor shall have the power to do any and all things my Executor deems.necessary or appropriate, including the power to close out,liquidate or sell the business at such time and upon such terms as my Executor shall deem best. 12. To do all other acts in my Executor's judgment necessary or desirable for the proper and advantageous management, investment and distribution of my estate. EIGHTH: I direct that all transfer and inheritance taxes, state or federal, assessed because of my death, whether the funds, property or insurance proceeds to which such taxes are attributable pass under this Will or not, shall be paid out of my residuary estate; that my Executor pay, or provide for payment of all such taxes at such time, or times, and in such manner as my Executor deems best. IN WITNESS WHEREOF, I,AUDREYBOSSLER, the Testator to this, my Last Will and Testament, typewritten on six sheets of paper which I have identified at the bottom of each page by my signature,hereunto set my hand and seal the day of �i 2012. AUDREYB` SSLER The preceding instrument consisting of this and five other typewritten pages, each identified by the signature of the Testator,AUDREYBOSSLER, this day and date thereof signed,published and declared by AUDREYBOSSLER, the Testator therein named, as and 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 witnesses. 5 COMMONWEALTH OF PENNSYLVANIA: : ss COUNTY OF CUMBERLAND I,AUDREYBOSSLER, Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. AU REYBOSSLER Sworn or affirmed to and acknowledged before me byAUDREYBOSSLER; Testator, the 13*" day of 12012. T (SEAL) Notary Public COMMONWEALTH OF PENNSYLVAN'•A I Notarial Seel Bfacha4 Chemwtca,NaBary pubis - Wormleyaburg Boro,Cumberland County My Commission F-pires April 2T^2,093 M-r.d+r,Pemm�iyiv'ania Assculation of Naiades COMMONWEALTH OF PENNSYLVANIA: : ss COUNTY OF CUMBERLAND We k L_c cj'— and at �°7 �} _ cl, ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testator sign and execute the instrument as her Last Will;that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed;that each of us in the hearing and sight of the Testator signed the Will as witnesses; and that to the best of our knowledge the Testator was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence. ' Sworn or affirmed to and subscribed to before me by Dtw,H 1-6A64,— and witnesses,this 13' day of , 2011 (SEAL) ALJ Notary Public COMMONWEALTH OF PENNSYLVANIA Notariat Beat 6 Michael Chere+*"'Ophuy Public Worm;eysburg Boro,Cumbariznd County My Commission Expires be!a 6,2093 . rr'.8nat`k2',Eznnsyte:xz�+ .aciaEcn of Notar{es