HomeMy WebLinkAbout08-08-14 � 1505610140
REV-1500 �` �°,_,°>
OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes �NHERITANCE TAX RETURN
Po sox 2eoso� 2 1 1 4 0 6 1 6
Harrisbura PA 1712&0601 RESIDENT DECEDENT _
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of BiRh MMDDm^r
0 5 � 8 2 0 1 4 0 9 0 2 1 9 2 2
Decedent's Last Name Suffix DecedenYs First Name MI
B R E W E R R E G I N A 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
REGISTER OF WILLS
riLL iN f�e�PR�PRiATE BVi.LS 6EL�W
� 1.Original Retum � 2.Supplemental Return � 3.Remainder Retum(date of death
prior to 12-13-E2)
� 4.Limited Estate � 4a.Future Interest Compromise(date of � 5.Federal Estate Tax Return Required
death after 12-12-82)
Q 6.Decedent Died Testate � 7.Decedent Maintained a Living Trust _ 8.Total Number of Safe Deposit Boxes
� (Attach Copy of Will) (Attach Copy of Trust)
� y.L�iiyation�roceeds Rz�:eiv�d L`j i f;.Sp��sal Pove��+Credit(date af�Eath � �1.�le�ior to tax unu'-er Sec.5;i 3�A)
between 12-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
,..�r
M A T T H E W A • M c K N I G H T 7 1 7 2� 9 2 ��5 3�.,;x;
-.
�-,-, ,E,�. ,..�,r-M1
REGISTER �l`.g USE O �}"r-(i�'
�;�:4 � r.,.., ,-�_:`
� � .., � �- �•-__
r;;
First line of address ��-, ` `-;;
��:-: �' -i_;
I R W I N 8 M c K N I G H T , P • C • Co�-_, � f=r �
Second line of address p � _ �n�
6 � W E S T P OM F R E T S T R E E T �
City or Post Office State ZIP Code DATE FILED
C A R L I S L E P A 1 7 0 1 3
CorrespondenYs e-mail address:
Under penalties of peryury,I declare that I have examined this retum,induding accompanying schedules and statements,and to the best of my knowledge and belief,
it is frue,corre�t and complete.Dccla�ation of preparer other than the pesoral repre�entative is based or all information of which preparer has any knowledge.
SIG T RE OF PERSON�2ESPONSIBLE FOR FILING RETURN DATE
� —� �
A DRESS
12D FAIT CIRCL CARLISLE PA 17�13
SIGNATURE OF REPARER OTHER THAN REPRESENTATIVE TE
-- —l
ADDRESS
60 WE T POMFRET STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 15�5610140 1505610140 �
� 1505610240
REV-1500 EX DecedenYs Social Security Number
DecedenYs Name: R E G I N A E• B R E W E R
RECAPITULATION
1. Real Estate(Schedule A) . . .. .. . . .. . .. .. . .. . . . . ..... ..... ..... . ..... �• '
2. Stocks and Bonds(Schedule B) .. . . ........ .. . .. . .. . . . . ..... . . . . . . . .. 2•
3 5 5 6 . 5 3
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ... . . 3. •
4. MoRgages and Notes Receivable(Schedule D) .. .... .. . .... . . . ... . ...... 4. •
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).. .. .. . 5. 3 5 9 0 . � 8
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested .. .. .. . 6. •
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) � Separate Billing Requested .. . . .. . 7. •
8. Total Gross Assets(total Lines 1 through 7) .... .... . . ... . . . . . .. . . . . . . . 8. 7 1 4 6 , 6 1
9. Funeral Expenses and Administrative Costs(Schedule H) 9. 1 1 3 1 3 . 5 6
.. . ..... .. . . . .. ...
10. Debts of Decedent,Mort a e Liabilities,and Liens Schedule I 10. 2 3 1 7 . 9 �
9 9 ( ) .. .. .. .......
��, Totaf Deductions(total Lines 9 and 10) ..... . . . . .... . . . . . . . . . .. . . . . . .. 11. 1 3 6 3 1 . 4 6
12. Net Value of Estate(Line 8 minus Line 11) ...... .... ..... .. . . . . . . . . . .. 12• - 6 4 8 4 . 8 5
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. � 6 4 8 4 . 8 5
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 . � 0 15. 0 . � 0
16. Amount of Line 14 taxable
at lineal rate X.045 � • � � 16, � • � �
17. Amount of Line 14 taxable
at sibling rate X.12 0 . � 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 0 0 18. 0 . 0 0
19. TAX DUE �
. ... . . . . . . .. . . ... . . . . . .. .... . . . . ... . . .. .... . . . . . . . . . .. 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTiNG A REFU�ID OF AN OVERPAYMENT ❑
Side 2
� 1505610240 � �,505610240 �
REV-1500 EX Page 3 File Numbe�
Decedent's Complete Address: 2� 14 0616
DECEDENTS NAME
REGINA E. BREWER
STREET ADDRESS
210 BIG SPRING ROAD
CITY STATE ZIP
NEWVILLE PA 17241
Tax Payments and Credits: ��� o.00
1. Tax Due(Page 2,Line 19)
2. Credits/Payments
A.Prior Payments
B.Discount 0.00
Total Credits(A+B) (2) 0.00
3. Interest
(3)
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 i+Line 3 is greater than Line 2,enter the difference. �his is tne TEiX DUE. (5) O.1�0
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; ............................... ❑ 0
c. retain a reversionary interest;or ................................................................................................ ❑ X❑
d. receive the promise for lifie of either payments,benefits or care? ....................................................... ❑ �
2, If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ 0
3. Did decedent own an'in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ 0
4. Did�ecedent own an individua{retirement account,annuity or other non-prcbata prope�ty,which
contains a beneficiary designation?.................................................................................................. ❑ 0
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 i�
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 suroiving spouse ftom tax,and the statutory requirements for disclosure of assets and
filing a tax return are still appiicable 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
adopfive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in
72 P.S.§9116(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.
REV-1503 EX+(&12)
pennsylvania SCHEDULE B
DEPARTMENTOFREVENUE STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
REGINA E. BREWER 21 14 0616
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 43 SHARES OF PRUDENTIAL FINANCIAL, INC. STOCK 3,556.53
43 SHARES X$82.71 PER SHARE_$3,556.53
TOTAL(Also enter on Line 2,Recapitulation) $ 3 556.53
If more space is needed,insert additional sheets of the same size
REV-1508 EX+(08-12) ��
pennsylvania SCHEDULE E
DEPARTMENTOFREVENUE CASH, BANK DEPOSITS � MISC.
INHERITANCE TAX RETURN
RESIDENTDECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
REGINA E. BREWER 21 14 0616
InGude the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with�ight of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. PNC BANK-STANDARD CHECKING ACCOUNT 3,590.08
TOTAL(Also enter on Line 5,Recapitulation) $ 3 590.08
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
REGINA E. BREWER 21 13 0616
DecedenYs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION , AMOUNT
A. FUNERAL EXPENSES:
1. HOLLINGER FUNERAL HOME 10,445.06
B. ADMINISTRATIVE COSTS: I
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
�
City State ZIP
Year(s)Commission Paid:
2. AttomeyFees: IRWIN & McKNIGHT, P.C. 1,000.00
3. Family Exemption:(If decedenYs address is not the same as claimanYs,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. ProbateFees: REGISTER OF WILLS 118.50
5 Accountant Fees:
6. Tax Retum Preparer Fees:
7.
TOTAL(Also enter on Line 9,Recapitulation) $ 11 563.56
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 DEBTS OF DECEDENT,
INHERITANCETAXRETURN MORTGAGE LIABILITIES�LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
REGINA E. BREWER 21 14 0616
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medicai expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. GREEN RIDGE VILLAGE-TELEPHONE STATEMENT 7.25
2. GREEN RIDGE VILLAGE-NURSING 2,310.65
TOTAL(Also enter on Line 10,Recapitulation) S 2 317.90
If more space is needed,insert additional sheets of the same size.
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TA.X RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
REGINA E. BREWER 21 14 0616
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 hansfers under
Sec.9116(a)(1.2).]
1. STEVEN R. BREWER Lineal
23 SMITH ROAD 1/4TH REMAINDER
GARDNERS, PA 17324
2. JUDITH A. STEVENS Lineal
122 MEADOW DRIVE 1/4TH REMAINDER
SHIPPENSBURG, PA 17257
3. PENNY S. SPAHR Lineal
120 FAITH CIRCLE 1/4TH REMAINDER
CARLISLE, PA 17013
4. CINDY M. DARHOWER Lineal
312 OPAL AVENUE 1/4TH REMAINDER
LITTLE RI!/ER, SC 29566
EN?ER DOLLAR AMOt!NTS FQR�J!S?RlBUT!OPlS SHOVI►N ABO�IE ON LIP:ES 15 TliROUGH 18 OF REV-150a C�!�ER SNEET,AS A?PROPRIATE.
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.
LOCAL REGISTRAR'S CERTiFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
�ee for this certificate, $6.00 ,,,������"'ry This is to certify that the information here given is
��' �:SH OF p s-
�,,�''�,P Ey-- correctly copied from an original Certificate of Death
rgr�� _ .� y'��, duly filed with me as Local Registrar. The original
�o_� � -;. y� certificate will be forwarded to the State Vital
,� � a� Records Office for permanent filing.
P 2 0 5 513 0 3 -°�'�q9�=-��:�= P��,'''' ��.�'_►_� �.
"--I�yENT�OE�►�;,� �� °'. � yex` MA� ] 1 I2014
�
Certification Number """����u�"""��� Local Registrar Date Issued
iyPe/PHnt In COMMONWEAITH OF PENNSYWANIA�DEPARTMENT OF NEALTH�VITAL RECOROS
Psi eklnk= CERTIFICATE OF DEATH
SWte Flle Number.
1.OeCedenYS Legal Nsme(Flrst,Mldtllo,La54 Suffix) 2.Sex 3.Sotial SeCUrity Numbe� 4.Date of Death(Mo/Da /Yr)(Speli Mo)
Regina E_ Brewer F 'I77-24-555'1 May 8,2014Y
Sa.Age-Last BlrLhday(Yre) Sb.Under l Year Se.Under 1 Da 6.Date of Birth(MO/Oay/Vear)(Spell Menth) 7a.B{etl�elatnLCi�gn�tate��reign Country)
J.QaV 1
j1 9, MOnths Days Nours Minutes September Z�1 9.22 �
� �� . 7b.BIRhPlace(COUnLy)
.� 8a.Resldence(Stete or Forelgn�.COUntry) �Sb.Residence(Sercet and Number-Include�.Apt No.) � Bc:Did Decedent Uve In a Tawnship7 � . � . � - � �
o nns lv nia 2'I O Big Springs Rd_ Oves,ae�ea��eu��ai� �;,,,P_
v etl�����"��a e�.n�:me�ce tzio code> q�uo,decea��c u�ed w�eni�u,.,ic�of nTawtr i �
�iry�o�o.
� 9.Ever In US Armad Forces7 � 10.Marital Status at Tlme of�eath ' �O MarHed �Wldowetl 11.Survlving Spouse's Name(If wife,glve name prlor to flrst maMage)
� O Yes No O Unknown O Divorced O Never Marrled O Unknown
12.FatheYs Name(FIBt�Mlddle,Last,Sufflx) 13.Mo her's Name Prlor to Flrst MartlaBe(FIrs4 Mlddle,Laa�) '
Leroy Crum A�ice Myers
i4a.in-ior.TanYs wame 14b.Rel tlo shlp to Oecedent i o 1 g 5 i an b I , Cate,Zlp�� � �O 1 3
sp�e Penny Spahr Daugtiter ��� �'��-�� �1=�`�� ��_�'€��e,
Cj _ ��� �. - - .: . 1 a P ac�o Deac C ec on�one-� �.. '. � � �. - �.
_ If Death OCCU�fed fn a Hospltai. � ��I�npSHent ' �If Death Octurred 5o eWh'efe Othp�Ttian e Hosplfal: [�Nosplee FaelllSy �DeCederi:'S Y.ome
.�� O EmerQency Room/OUt�aClent - - -��O Oead.on�Arrlval � 0 NuYSing Mome/Lon-Term Cere Facillty O Other(Speclfy) �-
SSb.Faclllty Name(If not Inrtitutlon,give street and nu�mber) 15e.Clty or Town;State,'and 2Ip Gode�� 15d.County of DeaCh'
_ ° . _ : 17 '1 Cumberland
m16 Mathod of D pasitlon �Burlat p _rematian 16b.Date of DlsposlCb� 16c.Vlace of DlsposlHOn(Name of cemetery,cremaWry,or ocher pla<e)
� O Re�+ov+i frort,seece O oo�ax�o� ` May 1 3�2 O l 4 Mt. Ho1 ly Spr ings, PA Cem'1 7 O 6 5
�Oeher Specify) � �-
Z 16d.Loodan of Dlaposltion(City or 7ow�,S�a�e,and 21p) . 17a:Slgneture of�FUneral Servlce Icensee or Person In Gharge of Iritermmt 17b,Ucense Number
� Mt- Holly Springs� PA 1 706 �.,,,.,;.. �.;. � O'I � 589L
;7c.hamB p!2[n AGdre�s of F�neral Faci Ity
s Ho�'��3.ngerFH&Crema�ory 50'IN.Baltimore Ave. Mt. Ho11y Springs, PA'17065
m 18.Deeedent's EdueaHOn-Check the box that best deseri6es the 19.Decedent of Hispanie Orig�n-Chnck the 20.DecedenYS Race-Cheek ONE OR MORE raees to Indicsee what
r highest degrce or level of schooi<ompleted at the time of death. box that best deseribes whether the decedent the decedent cons�dered hlmsalf or herself to be.
� Hth grade or less Is Spanlsh/Hispanlc/Lafino. Check the^No" �Whlee O Korean
No dlploma,9th-12th grade box If deeedant Is nat Spanish/NlspaMC/Latino. O Black or African American 0 Vletnamese
Hlgh School greduats or GED eompleted No,not Spanish/HlSpanl4latlno 0 Amerlean Indla�or Alaska Native � Ofh�r Asian
0 Some college Credlf,but no degree �Yes,Mexiean�Mexlean Amerlean,Ghlcano 0 Aslan InEian � Native Hawailen
0 Azsoeiate desraf(e.g.AA,AS) 0 Ves,Puerte'Rlean O Chinese Q Guamanlan er Chamorro �
0 BaCheloYs degrae(e.g.BA,AB,BS) 0 Yes,Cuban � PlllPlno � Samoan �
� MaSteYs degrce(e.g.MA,M5,MEng,MEd,MSW,MBA) 0 Ves�othar5panish/HlspaMC/latlno 0 Japanese � Oiher Pacifle ISIenCe�
� Oottorate(e.g.PhD,EdD)or Professional degree (Specify) �Other(Specify)
e. .MD DDS CVM LLB JD
21.DecetlenYS Single Race Self-�esignatlon-Check ONLV ONE to Indlcate whaL the decedeni consldercd himself or herself to be. 22a.DecedenC's Usual Oceupatlon-InCI<ate type of work
�.Whlta �Japanese � 0 Samoan done during most of working Ilfe. DO NOT V$E RETiRED.
p BlackorAfrlcanAmerlcan O Korean O OtherPaclflclslander Laborer
� �Amerlean Indlan or Alaska Na[IVe �Vletnamese � Don't Know/NOt Surc
p Asian Indlen O Other Aslan O Refused 22b.Kintl of Businass industry
� p Chinese p NativeMaWallan '0 Other(Sp�elry) F'OOC� 221�11St=]7
� FIIlpino O Guamanlan or Chamorro
1'fEMS 23a-23d MUST�BE GOMPIETED 23a.DeCe Pronounced Dead(MO/Day r) 23b.Signa�ure of Person Pronouneing Death Only when.applicab a) '�23c.�Lleense Number � �
BV PERSON WHO PRONOUNCFS OR � . - - '
CHRTIFIES OEATN �
23d.DaM Slaned(MO/Day/Yr) 24.Time of Dea[h �'�� � .. ... �. ..
� � : S /�'7 25.Was Medlcal Examiner or Coroner ContaeteC7 O� Yes �� 8�'No
- CAUSE OF DEATH � pppfoxitnaTe
26.Part 1. Enter the chain ef�vents-dlseases,Injurles,or eomplleatlens-that dlreCtiy eaused the deseh. DO NO7�nter terminal evMss such as ordlae arresi, � Int�rval:
respiratory arrest,or vencrlcular flbrlllatlon withou[showlnQ the etlotogy. DO NOT ABBREVIATE. EMer only one ouse on a IIRe. Add addltlonal Ilnes If necessary. t Onset to Death
IMMEDIATE CAUSE ----> �9D��a2�'rd�y �}}'�p���� 1
(Final tliaease e�eontlitlon Due ta(e� sequs C�o�: �
rcaulHng In death) � '. �` n /�Q�� � .
b. r-ti� �
Sequentlally Ilst condittons, . � Due to(or s a c sequence of): � �
ir o�v,ie.ams co en����se ¢}G'-Y�`-T� 2''�1�' ad�7J-- ��1`� i
Iisud on Ilne a. Enter[he (�82�_ ,
UNOERLYIN6 GAUSE Uue tD(o{as a Consequente of): � � �
� (dlaease or InJury thaC �
F Initlated the events resulting d. � �
� In death)LAST. Due co(or as a consequence of): ;
y � 26.PaK 11. Enter other rib In to d a but no2 resulTing In the unAerlying cause given In Var[I. 27.Was an autopsy pe�rt��o�edT
_1 � .. 0 Yes .�No �
�� y . 28.Were a:utopry flndings avallable
� to camplete ehe<ause of death7
� ..O ves 8 No
29.If Female: 30.Did Tobacco Use Contrlbui�to Death7 31.Manner of Death
y S �Q'Noi pfegnanC within pasS year � Vas O Probably {r'Netu�al 0 Homlelde
O Prcgnant et tlme of death �-NO O Unknown O .4ccldent O Pe�ding Investlgatlon
°m� p Not pregnant,6ut preg�anS wlthln 42 days of dea�h � p Sul<Itle p Could not be deiermined
. f- 0 Not pregnan4 but pregnans 43 days ta 1 year before deach 32.Date of InJury(MO/Day/Vr)(Spell Monih)
O Unknown If pregnant wlthln the past year 33.Time ot Injury
34.Place of inJury(e.g.home;construction site;farm;school) 35.Locatlon of InJury(Sereet and Number,Clty,County,State,21p Code)
36.Injury at Work 37.1/TranspoRatlon InJury,Specify: 3B.Describe How InJury Oceurretl: -
� Yes 0 OrlvayOperator � Pedestrlan
� �NO 0 Passenger � Other(Speelfy)
39a.CertlFler-physlcian,eertlfled nurse practltioner,medleal examiner/eoroner(Check only one):
- O Cerelrying only-To the bes!of my knowledge,death occurced due So the cause(s)and manner stated.
�, lt�Pronouncing&Certlfying-To the best of my knowledge,death occurred at ihe tlme,date,and place,and due to the cause(s)and manner stated.
� � Medlcal Ezaminer/COraner-On the basis of examinatlon and/or investigation,In my opinlon,death occurred at the time,date,and place,and due to�he cause(s)and manpne�r stated.
SlgnaLUrG af Certlfler: Ttle at Certifler:_�_Z� Llcense Number, O �
39b.Name,Address antl Zip Code of Perso� ple�ing Gause of Death(Itam 26) ' 39e.Date Slgned�MO/Day/V�) �-
� Sl�ea.l, a. an /Y10 M.L7. So 3 n/.,2/Sr"S77-ee M ./ / O/ 'Mc¢ $ �c t.�/
40.Reglstrar's Dlstrltt Number 41.Reglstrar's Slgnature 42.Regis rar Flle Date(MO�a`y�Vr)
� o��- ��� ,. .:�'5,���-=i r-. . ear 0. �� °��l,T-
43.Amendments � �
0
�
C O�O O� H105d43
Dlspo5ltlOn Permlt No. � RFV n7Hl11�
a
� t � �
LAST WILL AND TESTAMENT
I, REGINA E. BREWER, of the Borough of Mount Holly Springs, Cumberland County,
Pennsylvania,being of sound and disposing mind and memory,do hereby make,publish and declare
this to be my Last Will and Testaxnent,hereby revokin.g any and all former Wii_ls or�'odicils by me
made.
1.
I direct that all my legally enforceable debts,funeral expenses,testamentary expenses and all
inheritance taxes (whether such taxes may be payable by my estate or by any recipient of any
property) shall be paid from my residuary estate as soon as practicable after my decease and as part
of the administration of my estate. My personal representative shall have no duty or obligation to
obtain reimbursement for any such tax so paid, even though on proceeds of insurance or other
property not passing under this Will.
2.
I give,devise and bequeath all of my estate,both real and personal property,in equal shares,
unto my children, RICHARD L. BREWER, STEVEN R. BREWER, JUDITH A. STEVENS,
PENNY S. SPAHR and CINDY M. DARHOWER, absolutely.
3.
I nominate, constitute and appoint the said PENNY S. SPAHR and the said CINDY M.
DARHOWER, or the survivor of them, as Executrices of my estate.
4.
I direct that my personal representatives shall not be required to file a bond to secure the
faithful performance of their duties in any jurisdiction.
Page 1 of 3 Pages ����
R.E.B.
`
. � , ,
5.
I authorize and empower my personal representatives,in their sole and absolute discretion,to
purchase or otherwise acquire and retain any investments of which I die seized or any real or
personal property of any nature; to sell, lease, pledge, mortgage, transfer, exchange, dispose of or
grant options in regard to any or all property of any kind forming a part of my estate for such terms
and such prices as they may deem advisable;to borrow money for any purposes connected with the
protection and preservation of my estate;to mortgage or pledge any real or personal property forming
a part of my estate or to join in or secure the partition of same; to compromise any claims or
demands of my estate against others or of others against my estate;to make distribution in kind and
to cause any shar� to be composPd o_f c�sh, property er L�ndivided fr�ctional shares in pr��e*�ty
different in kind from any other share; to employ agents, attorneys and proxies and to dele�ate to
them such power as my personal representatives consider desirable and to pay reasonable
compensation for such services as may be rendered by such agents, attorneys and proxies; and to
execute and deliver such instruments as may be necessary to carry out any of these powers. In
addition, I direct that my personal representatives shall have the power to conduct an inventory of
any safe deposit box necessary to the administration of my estate.
IN WITNESS WHEREOF I have hereunto set my hand and seal this 4`h day of September,
2002.
�, . (SEAL)
� ��Q
Regi . E.Brewer
SIGNED, SEALED,PUBLISHED AND DECLARED by the above-named Testatrix,as and
for her Last Will and Testament,in the presence of us,who at her request,have hereunto subscribed
our names as witnesses thereto, in the presence of the said Te tatrix and of each other.
�
� ��
Page 2 of 3 Pages
s
COMMONWEALTH OF PENNSYLVANIA )
. SS.
COUNTY OF CUMBERLAND )
I, REGINA E. BREWER, Testatrix, 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.
����
��_•--_ —
Regi�Brewer�
Sworn or affirmed to and acknowledged before me by REGINA E.BREWER,the Testatrix,
th�s 4�'�1ay oi Septem�er, 2Q0?. �
b��` -
ot ' Public
Notadal Seal
C�MMONWEALTH OF PENr1SYLVANIA Lod A.suutvan,Notary PubAc
� Carll�le Boro�Cumberls�sd Coun(.y
: SS. MY�mm�es�on Expires Feb.16,2b04
COUNTY OF CUMBERLAND � Member,PennsylvaniaAssociationotNotaries
We, �-e h�en �- ��oo� and �j'1Cc�'bn � . �"�' �oo�
the witnesses whos 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 REGINA E. BREWER, the
Testatrix, sign and execute the instrument as her Last Will;that the Testatrix signed willingly and
that the Testatrix executed it as her free and voluntary act for the purposes therein expressed; that
each of us,in the hearing and sight of the Testatrix,signed the Will as witnesses;and that to the best
of our knowledge the Testatrix was at that time 18 or more years of age,of sound mind and under no
constraint or undue influence.
Address �/oD l .���s Ca.o �o��B
C�(.s f e �� /7e"1/3
A dress >D o l. �
�r� f 1701 '
�worn or a:f rmed to and subscribed befor e this 4th day of September, 2002.
t
�� Z�C�i��
Not Public
C:\SLB�Estate Planning\10342.2will.doc Lori A.SWli�an,�Notary Public
Ca�lisle Boro,Cumberland County
Page 3 of 3 Pages MY�mmission Expires Feb.16,2b04
Member,PennsVlvania A�ociationotNotaries
. �omputershare �'
� Prudential
Computershare Trust Company,N.A
PO Box 43033
� Providence,RI 02940-3033
� Within USA,US territories�Canada 800 305 9404
�
� Outside L1SA,US territories�Canada 732 512 3782
� 013 9 7 3 www.computershare.com/investor
�I�III"I���I�I��il���l�l�l����l�ll�l��l�l��l�������l��ll��il�l�� Pruden6alFnanaal.lnc.isorganaedunderthelaws
� of the State of NJ.
� REGINA E BREWER
� 120 FAITH CIR �
� CARLISLE PA 17013-8889 Holder Account Number .
= C0021345091 '
_
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Company ID PRU
--- — -- -- — -- _.__�_. . ... ----��---- __.SSI�IIiNl.e[tified:-----------�-_-
Transa�tion(s)
Daie �ransaction Description T°�� ����p C��ss
i I SharestUnits I Description
18 Dec 2001 Distribution of Value 43.000000 744320102 Common Stock
Account IMormation: Date: 13 May 2014(Excludes transacdons pending settlement)
Current Total
Qirect
Registration S Un ts ;Per Sha e Value($j CUSIP Descr ption
Balance
43.000000 43.000000 84.460000 3,631.78 744320102 Common Stock
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IMPORi'ANT INFORMAiION RETAIN FOR YOUR RECORDS.
This advioe is your recoN M Ihe shaia Ua�actlan a�feGing your ac�aunt on ihe 600ks of the Comparry as paK oi the Dhect Regishallon System.It is neAhere negodabie(r�strumeM nor a seciaity,and deHvery oF this advioe dces not of ifself
coMer arry rights on tl�e iecipieM. k slwuW be I�pt with your inporlant docunen�as a reooid�ya�ownership fitl�;e sl�.
No aclion on your part is requi�ed.unless you w'sh 10 deposit your e�assting ceAi6qtes,sell a request a cer6'fica�e,or transfer your book-eMry shares:
The IRS reqidres tl�at we report the cost basis of ceAain sha�es acquired aRer Janua�y t.2017.M your shares xrere cove�ed byihe le9isla�n ami you have soW or Uan�emed the sharas and requested a specdic rost basis calculation metliod,
we have proo�sed as teq�sled. If you�d rrot spedy a oosf basis wlalatlon metlrod,vra freve dekul�d m Ihe 5rst m.first ad(FIfO)rt�etlwd.Please wsit arcwebsite a oa�suft yar tax advirar iFyou need adddarel 6dannahon a6ou1 wst basis.
Upon request,Ihe Company will fumbh to any sharehdder,wfthout chaige,a fuil slatement of the desigrtations,righis(indud'e�g�ights wider airy(bmpanys RgfdsAg�eamenC if any}.preferenoes and Itmilatlons W Ihe shares of�ch class and
senes auUiarized to be lssued,and the aulhorily of fhe BoaN of Diredors to divide tlie ahares info se�ies and to deie�mine am!d�ge rights,pieletences�d 6mffatlois of any dass w smies.
Pssels are irot deposils of Compulers��e and aie not insured by Ihe Federal Oepotit Inw�ance Ca�p�oiafion,B�e Seaaitles imestnr Pmtection Caporalion,ar airy alherfederal a state age�.y.
If you do not Ireep in conhd with is ordo not lave mryr adivny in your accamt F�Ihe time periods sperafied by s4te law,yu�rpmpeAy couid beeome wbjeQ�o ahEe wda6ircd propeAy iaws and transferted to tlie approp�iaEe afate.
� 40UDR P R U 'I'
;�. OOICS0003.dmix.05t744 4670N13973/015931
- ' a
OOH5AB-PRU(Rev.1N11 Please see imoortaM PRNACY NOTICE on reverse side'of`statement
PRU Historical Prices�Prudential Financial,Inc.Comm Stock-Yahoo... http://finance.yahoo.com/q/hp?s=PRU&a=04&b=8&c=2014&d=04&...
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Date Open High Low Close Wlume Pdj Close•
iulay d,�G14 81.41 84.50 HO.JO 83.25 4,298,100 82.�1
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1 of 2 8/4/2014 4:35 PM
._
Aug, l. 1U14 12. 04PM PNC Ba�k No. 9769 P. 1/2
���s ���
August 7,2014
Matthew A McKnight Bsq.
Irvvin�McT�night P.C.
West Pomfret Pro€Bldg
60 W Pomfret St
Carlisle,PA 17013-3222
RE: Regina E Brewer
551�: 177-24-5551
DOD: OS-OS-2014
Dear Mr. 1`.�cT�ight:
Yn response to your request for Date of Death(DOD)balances £or the custozxaer notied abo�'e, our
records show the following: �
Chec�ng Account
Account#5144181264 Established: 04-01-1963
REGTNA E BREWER
DOD balance: $ 3,590.08 non interest bearing
Savings Account
Account# 513032Z681 Established: 04-15-1986
REGINA E BRE'WER
bOb balance: $ 0.00+0.00 accrv.ed interest
Interest paid O1-OI-2014 thn�.OS-OS-2014� 0.00 YTD
**T}aas Account had a Zero Balance at the time of death.
Please note that this office pzovides date of death balances for deposit accounts(YRAs,CDs,Checking and
Savings)_ 'We do not process an�ffnancial transactfons or provlde statements. If you need.assistance witih
an�of these items,please call 1-888-PNC-BANK(1-888-762-2265)or sto�by your local PNC Bank branch
office.
Sincexe��,
Nationa.l Financial Ser�'ices Cez�ter
PN'C Bank,N'.A.
Member�`DYC
Paee 1 of 2
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.
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� ' . �. . ' .. ....' �.:.�-`.�___�_v �.�_-�._'.�__'-y�.• ' :. .. . .
�Io1�ng�r Funeral�Ianz.e&Crematorq, Inc.
` Enc L.Holl�nger Supei�sor';��
�. ' , May 13,,2014 :y., '
Reriny�pafir
' 12{3`�Fa�tfi Circle
_ Carl'rsle, PA 17013
ThesFunera[Service for R�gma..E:Brevver:
We sirtcerely apprecrate the confrdence uou t�,a�e�p}a�d in us ar�d w�tl�anfiinue to assrst�ou tn e�rerv
�� ; �� : :
way�we can Pt,�as""e£E�kfi`ree to contact us ifyou have�n�r questions►n r.egard ta;tl�ES�ta��rr►e�t
,
TFf�FOLLOWING 1S.�4N°lTER�1ZED STqTEMENT OF T#'E SERUiC�S, FA£lLtTt��,AUT�MO'TI�dE lEQt11P1VIElVT�
; Al�D MERCHANUISE THAT YOU SEtECTED W�1EN tVIAKfNGTHE�F1'JNERA!AR#iAf�IGEM.ENTS:
Professional��Service
Tra�itiariaf Package $5153:QU
NFe.rchandise
Caske�-G�u�net Popular. 2295:00:'
Vault—C(arkAirSeai steel 1325.00 -
Memorial Package-Angel
Register Book,Mem�ariai Folders,
Acknowledgement Cards;Sookmarks N/G
= ATTME TrM''E FUN�RpL ARRANGENtENTS WERE lV1ADE,WE AD1/ANCED CERTAIN PAYMENTS TO OTffERS,
AS AN ACCOMNtODRTION. THf'FOLLOWING IS.AN ACCQUNTING FbR THOSE CHARGES..
. , . : Cash Advances '
Grave Opening 700.U0
Cemeter�:Equ�pment '-375 00
Certified Copies�of Death Certifcate(10@$6;) 6Q.00 �
Clergy 125,Op
Flowers=Hinge spray,tireside basket,3.roses. 275:�
Newspaper Notices—Sentine! 140.OE
Engravi�g Date of Death; N/�
Total Charges _ ` ° $10445.06
'��C. -- _ �oao .ao _
��►►Ay t�
��l�aCd �`��-Q�
`501 NORTH BALTIMORE AVENllE • M�UNT HOLLY SPRINGS;PENN$YLVANIA 17a65 • (717)486-3433 • FAX(71?)486-3Q 15
www.hollingerFuneralfiome.com
RECEIPT FOR PAYMENT
-------------------
-------------------
LISA M. GRAYSON, ESQ. Receipt Date : 6/30/2014
Cumberland County - Register Of Wills Receipt Time : 12 :36 : 12
One Courthouse S uare Receipt No. : 1078431
Carlisle, PA 17�13
BREWER REGINA E
Estate File No. : 2014-00616
Paid By Remarks : IRWIN & MCKNIGHT
CJ
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 3C . 00 Ci.MBERI�ND CO'JNTY GEivEicAL rL'�J
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE lO . OQ CUMBERLAND COUNTY GENER.AL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . OG CUMBERLAND COUNTY GENERAL FUN
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN
RENUNCIATION 5 . 00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check## 8461 $118 . 50
Total Received. . . . . . . . . $118 . 50
Monthly Phone Statement ��=��SENIORLIVINC,
Statement Date Range 5/1/2014 to 5/31/2014
Facility: Green Ridge
Account Number 1254301053
Total Cost of Calls Made $0.00
Monthly Phone Charge $6.84
Sub-Total Amount $6.84
State Sales Tax-Basic $0.41
State Sales Tax-Usage $0.00
State Sales Tax Total $0.41
� Pay This Amount � $7.25
Phone Number (717) 776-8372 Regina Brewer
To*.�I Cost�#Calls Mac�e $0.00
Phone Number Surcharge $6.84 Phone
Total Cost for Number $6.84
Detail Listing of Calis Made
No Billable Calls were made
Monday,June 02,2014 Page 1
RESIDENT STATEMENT FROM
GREEN RIDGE VILLAGE Statement Date Due Date ACCOUNT NUMBER
SWAIM HEALTH CENTER
210 BIG SPRING ROAD 05/31/2014 Upon Receipt 177245GRVAL
NEWVILLE,PA 17241-9486 � . : . • � $2,310.65
717-776-8200
AMOUNT PAID $
Please make check payable to GREEN RIDGE VILLAGE
;��
REGINA E BREWER � �-- Remit To:
c/o PENNY S SPAHR Presbyterian Homes Inc/Green Ridge/Swaim
120 FAITH CIRCLE ' P O Box 416825
CARLISLE, PA 17013 Boston MA 02241-6825
Please detach and retum this portion with your remittance to the address above.
Comments
If you have any q��stions regard�n your statement pl�ase c�ntact thP Bus�ness Ofiice at(i1�776-�256
= Date` Description Days�� RatP Gharges/ Payments; B�lan�e�. .`
'' , � `; : � C�d'
> ,_ :,_ , .,. .`. __�.: . , . . . , :`, -
Untts . ;. � , , ,. ,; ,: .
. . .:.- (:..re rt) : :,,, .' �... ... . .
Balance Forward $2,285.40
05/14/14-05/14/14 ACH PMT FRM STMT 04/14-PD 05/14 Check $63.18
�5/14i14-05/14/14 ACFi PMT FRiVi STfviT 04/i4PD 05/14 Check $2,222.22
05/14/14-05/14/14 Reversal of ACH PMT FRM STMT 04/14PD 0 $(63.18)
05/14/14-05/14/14 Reversal of ACH PMT FRM STMT 04/14-PD 0 $(2,222.22)
05/01/14-05/01/14 Shampoo&Set 1 $18.00 $18.00
05/05/14-05/05/14 Telephone 1 $7.25 $7.25
TOTAL BALANCE DUE: $2,310.65
FACILITY NAME RESIDENT NAME ACCOUNT NUMBER
SWAIM HEALTH CENTER REGINA E BREWER 177245GRVAL