HomeMy WebLinkAbout02-0633
REV-150r;X(6-001 REV-1500 OFFICIAL USE ONLY
r _ COMMONW EALTH OF
PENNSYLVANIA II~ 75'- I
DEPARTMENT OF REVENUE INHERITANCE TAX RETURN FILE NUMBER
DEPT. 260601 RESIDENT DECEDENT aLL - ..a..Q! k'::-i :3
HARRISBURG, PA 17126-0601 --- -
CQUNTYCQDE YEAR NUMBER
DECEDENT'S NAME (LAST, fiRST, AND MIDDLE INITIAL) SOCIAL SECURliY NUMBER
I-
Z DIENER, VIRGINIA M. 198-10-1212
W DATE Of DEATH (MM.DD-YEARI DATE Of BIRTH (MM-DD-YEARI THIS RETURN MUST BE fiLED IN DUPLICATE WITH THE
C
W 06/13/2002 12/08/1920 REGISTER OF WILLS
()
W (If APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, fiRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
C
w !Zl1. Original Return 0 2. Supplemental Return 0 3. Remainder Rerurn (dale of dealh prior to 12-13-82)
""
::::.:::~CJ) 04 limited Estate 0 4a. F\ltU!elr.teles\CompTOm\se\~ateoldeathatter12.12-82) 0 5. Federal Eslate Tax Return Required
olI:'"
wa.o 0 0
IOO 6. Decedent Died Testate (Attach copy 01 Wil~ 7 Decedent Maintained a Living Trusl(AUacncopyofTrust) B. Total Number of Sale Deposit Boxes
ulI:~ -
a.<Il
a. 0 9. Litigation Proceeds Received 010. Spousal Poverty Credit (date 01 deathbetwGe~ 12-31.91 and 1-1-95) 011. Election to tax under Sec. 9113(A) (A1tachScnO)
<(
"" THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
z NAME COMPLETE MALING ADDRESS
w
0 GEORGE R. HETRICK, CPA 1867 W. MARKET STREET C-3
z
li' FIRM NAME (II Applicable)
<n DONOVAN,KLIMCZAK AND COMPANY CPAS
w
II: TELEPHONE NUMBER . AKRON, OH 44313
II:
0
u 330-836-9331
1. Real Estate (Schedule A) (I) OFFICIAL USE ONLY
...'
2. SIOCKS and Bonds (Schedule S) (2) .-
3. Closely Held Corporation, Parmer&hip or Sole.Proprietorship (3}
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Properly (5) 210,764
(Sch.dul'E) -'
Z
0 6. Jointly Owned Property {Schedule F) (6) 11,106
l;;: o Separate Billing Requested
-I 7. Intel.Vivas Translers & Miscellaneous Non.Probate Property (7) -....-
;:)
I- (Sch'dul,GorL)
ii: 8. Total Gross Assets (Ialal Lines 1.7) (B) 221,870
<C
() 9. funeral E'xpenses & Administrative Costs (Schedule H) (9) 4,999
w
a: 10. Debts 01 Decedent, Mmtgage Uabilities, &. liens (Sthedule I) (IO} 7,508
11. Total Deductions (lotallines 9 & 10) (II} 12,507
12. Net Value of Estate (Line 8 minus Une 11) (121 209,363
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has 1'001 been (131 5,000
made (ScheduleJ)
14. Net Value Subject to Tax (Line 12 minus line 13) (141 204,363
SEE INSTRUCTIONS FOR APPLICABLE RATES
Z Amount of line 14 taxable at the spousal tax
0 15.
l;;: rale,ortransters under Sec. 9116(a){1.2) X.O_ (151
I- 16. Amount of Line 14laxable at lineal rate 204,363 X .0 45 (161 9,196
;:)
c.. 17. AmounlofLine 14laxable alsibling rate X .12 (17)
:!E
0 18. Amol.lnlofLine 141axablealcollateral rale X .15 (18)
()
X 19. Tax Due (191 9,196
i5 20. 0 I CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT I
----
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
STFPA42021F.1
Docedel1t's Complete Address:
STREET ADDRESS C/o THORNWOOD HOME
442 WALNUT BOTTOM ROAD
CITY CARLISLE I STATE PA I ZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 191
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
9,196
460
Total Credits (A + B + C) (2)
460
3. InteresVPenalty II applicable
D. Interest
E. Penalty
TolallnteresVPenalty (0 + E) (3)
4. If Line 2 is greater .than Line 1 + Line 3, enter the difference. This is the OVERPAYM ENT.
Check box on Page 1 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)
o
8,736
A. Enter the interest on the tax due.
(SA)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
8,736
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transferand: Yes No
a. retain the use or income of the property transferred; ........................................ D IZI
b. retain the right to designate who shall use Ihe property Iransterred or its Income; . . . . . . . . . . . . . .. D IZI
c. retain a reversionary interest; or ............................ . . . . . . . . D IZI
d. receive the promise for life of either paymenls, benefils or care? ... . . . . . . . . . . . . . . . . . .. D IZI
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
withoul receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ......... D IZI
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ...... D IX!
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designaliOn? ....................................................... D IX!
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties oj peliury.1 dadals thai I have examined this return, including accompanying schedules and statements, and 10 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.
SIGNATURE OF PERSON RESPONSIBLE FOR Fill G RETURN
/'
44718
:?)l
ADDRESS
M. AND COMPANY
GerJIIed P'ublk. Al:wu.dlu.
1867 WMldllt SInlIt
For dates of death on or alter Jul~ClIuI.181aJanuary 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. !9tf6 (a) (1.1) (ill.
For dates of death on or after January 1, 1995, the tax rate im posed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. !9116 (al (1.1) (ii)].
The statute does not exam ot a transfer to a surviving spouse fmm tax, and the statutory lequirements fer disclosure ot assets anrl1iling a tax return are still applicable even
if the surviving spouse is the only beneficiary.
F or dates ot death on or after July 1, 2000:
The tax rate im posed on the net value of transfers from a deceased child twenty-one 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% [72 P.S. !9116(a)(1.21].
The tax rate im posed on the net value 01 transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. !9116(1.2) [72 P.S. !91 t 6(a)(ll1.
The lax rale imposed on Ihe nel value ollransfers to or for the use of the decedent's siblings is 12% [72 P.S. !9118(a)(1.3)]. A sibling is defined, under Section 9102, as an
individuai who has at least one parent in common with the decedent, whether by blood or adoption.
STFPA42021F.2
AEV-15oa EX... (1-97) (I)
, ,
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIOENT OECEOENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
VIRGINIA M. DIENER
FilE NUMBER
2002-00633
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
I. THORNWOOD HOME - REBATE OF NURSING HOME COSTS 3,008.83
2. PRUDENTIAL LIFE - DIVIDENDS ON THE BELOW POLICIES 1,251.36
3. NATIONWIDE LIFE - ANNUITY # 07-2007848 66,972.51
4. NATIONWIDE LIFE - ANNUITY # 07-4018783 132,248.23
5. PRUDENTIAL LIFE - POLICY PROCEEDS M05952100 3,564.25
6. PRUDENTIAL LIFE - POLICY PROCEEDS M04906638 3,718.99
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
210,764
STFPA42021F.9
REV-1509 EX + (1-97) (I)
. .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
VIRGINIA M. DIENER
FILE NUMBER
2002-00633
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME
ADDRESS
AELATlONSHIPTO DECEDENT
A. SANDRA K. SHOPE
6651 AMBLEWOOD ST., NW
DAUGHTER
CANTON, OH 44718
B.
c.
JOINTLY.OWNED PROPERTY:
LEmR DATE DESCRIPTION OF PROPERTY %OF O./.,TEOFIJE.IITH
ITEM FOR JOINT MADE Includenameotlinancialinstilutionandbankaccounlm.mbetolsirnilaridenlifyingnumber. DATE OF DEATH DECD'S VALUE OF
NUt.lBEA TENANT JOINT Allachdeedforjoinlly-heldrealeslate. VALUE OF ASSET INTEAEST DECEDENT'S INTEREST
1. A. 2000 BANK ONE, NA #000000629961129 10,568.87 50 5,284
2 A 2000 BANK ONE, NA #000001584380727 11,643.85 50 5,822
TOTAL (Also enter on line 6, Recapitulation) $ 11,106
(If m ore space is needed, insert additional sheets of the sam e size)
STFPA42021F.10
REV-1511 EX + (1-97) (I)
, .
COMMONWEALTH OF PENNSYLVANIA
INHEAITANCE TAX AETURN
RESIDEHT OECEOEm
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
VIRGINIA M. DIENER
FILE NUMBER
2002-00633
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
t. MYERS FUNERAL HOME, INC. 4,178.60
B. ADMINISTRATIVE COSTS:
t. Personal Representative's Commissions
Name 01 Pe{sanal Representative{s)
Social Security Nllmber(s) I EIN Number of Personal Representative(s)
SlreelAddress
City Sial. Zip
Year(s} Commission Paid:
2. AtlorneyFees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Cla'lmanl
SlreetAddress
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 70.50
5. Accountant's Fees
6. Tax Retucn Preparsr's Fees 750.00
7.
TOTAL (Also enter Dn line 9, Recapitulation) $ 4 999
(If more space is needed, insert addillonal sheets of the same size)
STFPMl021F.12
REV.1512 EX + (1.97) (I)
, .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF
VIRGINIA M. DIENER
FILE NUMBER
2002-00633
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
65.60
30.00
79.80
109.28
27.00
1,500.00
4,867.57
828.80
I.
2 .
3 .
4 .
5.
6.
7.
8.
WEST SHORE EMS - EMS SERVICES
PAUL D. DALBEY, DPM - PODIATRIST
PHARMERICA - MEDICAL SUPPLIES
VERIZON WIRELESS - WIRELESS PHONE CHARGES
ST. PAULS UNITED CHURCH OF CHRIST - FOOD
ROBERT SHOPE - REIMBURSE FAMILY EXPENSES FOR FUNERAL
THORNWOOD HOME - CHECK # 1251 NURSING HOME COSTS
PHARMERICA - MEDICAL
STFPA42021F.13
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
7,508
REV-t513 EX + (9-00)
COMMON~lJ'r\ OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
VIRGINIA M. DIENER
FILE NUMBER
2002-00633
RELATIONSHIP TO DECEDENT
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s)
I. TAXABLE DISTRIBUTIONS [include outright spousal distribulions, and transfefs
under Sec. 9116 (a) (1.2)]
SANDRA K. SHOPE
1. 6651 AMBLEWOOD ST. NW
CANTON, OH 44718 DAUGHTER
2 KEVIN R. SHOPE
155 WILLOWBEND DRIVE
CANfIELD, OH 44406 GRANDSON
3 MATTHEW D. SHOPE
976 MILL CIRCLE APR. 113
ALLIANCE, OH 44601 GRANDSON
AMOUNT OR SHARE
OF ESTATE
1/3
1/3
1/3
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1. ST. PAUL'S UNITED CHURCH OF CHRIST
626 WILLIAMS GROVE ROAD
MECHANICSBURG, PA 17055
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
STFPA42021F.t4
5,000
5 000
--..-..-"'---- .-.."...--. ,~~-,-- ---"-~... ~~._-_.__.~ .."-.,- ,.
CONNON1,EALTlI 01' PENNSYLVANIA )
SS.
COUNTY OF CUNllERLAND
)
I, VIRGINIA II. DIENER , the testatriX
whuse name is signed tu the attached ur fureguing instrument, having
been duiy quaiified according to law, du hereby acknowledge that I
siglled and executed tile illstrumetlt as my Last Will alld Testament;
that I sJgned it willingly; and that I signed it as my free and volun-
tary gct and deed, for the purposes therein contained.
Sworn and af f inned to and acknowledged
VIRGINIA E. DIENER , the testat rix
day of ,Januarv ' A. D. , 1996.
before me b~
this.Jft,
;1 . ,)
/J. ([{tA..---K..
~~.
Ncm1al Seal
Maliyn Kay Eal<ln, NoImy f'Ib'lo
MecharOcsburg 8010. CurnbeMr<l COunty
My CommIssion EJqjres i'bJ. 6, 1007
CO~INON"E^LTIl OF PENNSYLVANIA )
SS.
COUNTY OF CUNllERLAND
)
We, the undersigned, ,J. nOBERT STAUFFER
and SUSAN A. I!cGOY , the. witnesses whose names are
signed to the attached or foregoing instrument, being duly qualified
acco~ding to law, depose and soy that we were present .nd saw the
testat rix, VIRGINIA II. DIENER , sign and exe-
cute the instrument as:"Jdalt/her Last Will and .Testament; that the
said testatriX 'fInG-IUIA H. DIENER , executed it as
::n.l~/her free and voluntary act [or the purpo'ses therein expressed;
that each of us, in the hearing and sigllt uf the testatrix , signed
the Will as witnesses; and that to the best of our knowledge, the
testatrix was, at the time, elghieen (18) or more years of age,
of sound mIllO, atHl under no constraint, duress or undue influence.
Sworn and su~s,c~bed to befor
me this ,;( (y ( \ day of
,January 1996.
/I .
/r', y
. ((.-:~v'/z.
,!-
to./ /ri
,l"f (c1L.
/
~Sea1
MatfJn Kay Eakin. Not?.l)' NJIlc
MechanicSburo Boro. Cum\JeI1ard County
My CommIsSion Expires Ncv. 6. 1997
, ~Assodanonot
COD I C I L
I, VIRGINIA M. DIENER, of the Borough of Mechanicsburg,
County of Cumberland and state of Pennsylvania, being of sound
and disposing mind, memory and understanding, do make, publish
and declare this the First Codicil to my Last will and Testament,
dated January 26, 1996.
l.
I do hereby amend the paragraph of my Last will and Testament
dealing with the appointment of my personal representative, to
read as follows:
"LASTLY, I nominate, constitute and appoint my husband,
CHARLES E. DIENER, Executor of this my Last will and Testament,
and in the event that my said husband should predecease me, or
should he for any reason be unwilling or unable to serve in such
capacity, then in such event, I nominate, constitute and appoint
my daughter, SANDRA K. SHOPE, Executrix of this my Last will and
Testament, in his place and stead and in all instances, direct
that my said personal representatives be excused from posting bond
or other security for the faithful performance of their duties in
any jurisdiction.
2.
I hereby ratify and confirm my Last will and Testament dated
January 26, 1996, in all other respects and to all intents
purposes, not inconsistent herewith.
- 1 -
.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
this /sr day of June, 1998.
"
I J:) ,
L~e-1;." ,'^': ~,-> (SEAL)
V~ g~n~a M. DIener
and declared by the above named,
Signed, sealed, published
VIRGINIA M. DIENER, as and for the First Codicil to her Last Will
and Testament, dated January 26, 1996, in the presence of us, who
have subscribed our names hereto as witnesses, at the request of
said testatrix, in her presence and in the presence of each
other.
L~ d. /'}
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
)
I, VIRGINIA M. DIENER, the 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 the First Codicil to my Last will
and Testament: that I signed it willingly, and that I signed it
as my free and voluntary act and deed, for the purposes therein
expressed.
J G"C..-~ ~.A) )'rJ, J:)r-e"'~-(SEAL)
V~inia M. Diener
Sworn and subscribed to
before me this day
of June, 1998.
/YlQ.<~flh nte{r~,,-.
Notat'y Publi
. I
Notarial 56111 P\Jbl1C
MlI.....n 1::. VI\~\ams. N~3 nd County
"-~':::!...'11l eo,o cum~.a. 001
~~i"l~n !'.iplros N",,:.fj. 2
.._..'_ It...r,,.-;~'i'111 01 N('lI\lIlr.S
- 2 -
-..,:~~;i:....,w,'i~l<<"f";-"'''''''''';'''
.,........._..,.._.~.... .
. . "'." ~~...,,,,....,.,,,.......,.........._...__~.n
'~~~~:-:J~i~tJ,:~*i~;_:..~~: -
)::OMMONwEALTH'OF PENNSYLVANIA
i\-:;\~t'j~~;~,:',-(: ~, ~
:;I,:".;;?"l,COUNTY OF CUMBERLAND
.~~:;",:., .
We, the undersigned, J. Robert Stauffer and Susan A. McCoy,
)
.
.
)
the witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, depose and say
that we were present and saw the within testatrix, VIRGINIA M.
::<'~['~;<__~DI~ER, sign and execute the instrument as the First Codicil to
"her Last Will and Testament; that the said testatrix, VIRGINIA M.
DIENER executed it as her 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 the time, eighteen (18) or
more years of age, of sound mind, and under no constraint, duress
or undue influence.
~-;., /-
Sworn and,subscribed
-before me this
day of 'June, 1998.
to
Nolanal Seal
Manlyn E. WiQlams. Notary Pub~c
Mecl1anieSbu'1l Sofo, Cumbenand County
IIrt Comll\ls!llon Explres Nov. 6, 2001
M.mber. Pennsylv3018 Assacl3tlon af Notanes
~~ l Cv!vt.!~
Notary Public
LAS'f ,-JILL AND 'l'ESTAIIENT OF VIRGINIA II. DIENER
I, VIRGINIA 11. DIENER, of' the BorouGh of' llechanicsburg,
County of' Cumberland and State of' Pennsylvania, beinG of' sound
and disposin(l; mind, memory and understanding, do make, publish
and -declare this my Last Hill and 'festmnent, hereby revoking and
malting void any and all prior 1;Iills by me at any time heretof'ore
made.
1.
I direct the pa~nent of' all my just debts and funeral
expenses as soon after my decease as the same can be conveniently
done.
2.
I give, devise and bequeath-all the rest, residue and
reniainder of my estate, real, personal B.nd mixed, uhatsoever
and wheresoevel' the sanle may be situate, to my husband, CHARLES
E. DIEllliR, absolutely and unconditionally.
3.
In the event that my husband, CHARLES E. DIENER, should
predecease me, or should he die Hithin thirty (30) days from the
date oJ: my death, then in either of such events, I direct the
settlement and distribution of my estate to be made in the
folloHing manner, to Hit:
-1-
A. I give and bequeath the sum of Five Thousand
($5,000.00) Dollars to ST. PAUL1S UNITED CHURCH OF crffiIST,
of Hechanicsburg, Pennsylvania.
B. I direct that all the rest, residue and remainder
01' lilY estate be divided into three (3) equal shares and that
the same be paid out and distributed as follows, to wit:
(a) I give and bequeath one (1) such equal share to
my daughter, SAIIDRA K. SHOPE and her husband, ROBERT
R. SHOPE, share and share alike, or to the survivor
of said two legatees, absolutely, should either of
them predecease me,
(b) I give and bequeath one (1) such equal share to
my grandson, J~IIN R. SHOPE, absolutely and un-
conditionally.
(c) I give and bequeath one (1) suoh equal share to
my grandson, HATTHEH D. SHOPE, absolutely and un-
condit ionally.
C. For the purpose of faoilitating the settlement and
distribution of my estate, I authorize and empower my personal
representative or representatives, hereinafter named, to sell
any and all real estate loIhich I may own at the time of my deoease,
at either public or private sale or sales.
-::>-
LAS'rLY, I nominate, consti tute and appoint my husband,
CIIl\.RIJES E. DIENEn, Executor 01' this my Last \lill and Testament,
and in the event that my said husband should predecease me, or
should he be unable 01' unlrilling to serve in such capacity for
any reason, then in such event, I nominate, constitute and appoint
my daughtel', SJ\lTDHA r:. SHOPE, and PHC I3ANK, N. A., Co-Executors
I
of this my IJas t Hill and Testament, in his place and stead, and
in all instances, I direct that my said personal representatives
be excused from posting bond or other security for the faithful
performance of their duties in any jurisdiction.
IN HI'fNESS 1:IHEnEOF, I have hereunto set my hand and seal
this de., day 01' January, 11.. D., 1996.
VA l I -e-. ~<-'
Diener
(SEAL)
_1_
Signed, scaled, published and declared by the above
named, VrTIGINIA ll. DIEHEn, as and for her Last \-lill and 'restament,
in the presence of us, "ho have subscribed our names hereto as
witnesses, at the request of said testatrix, in her presence and
in the presence of oach other.
JNITED CHURCH OF CHRIST HOMES
REMITTANCE ADVICE
096873
MEMO INVOICE DATE INVQlCE NUMBER AMOUNT DISCOUNT NET .
THORNWALD MANOR )7/31/2002 073102 3,008.83 3,008.83
.
-
-
-.-.--....--..............
-
-
BANK =ONE.
-
Please keep this receipt as record of your
transaction. Transactions are suOiect to the
Bank's count, verification and aceeotance.
Deposits may nol be available for immediate
withdrawal.
Customer Receipt
~
~
o
THANK YOU!
.
~
;;
00010078404 354808/12/200215:18
ACCT~ 62SS611ZS
CHECKiNG DEPOSIT $3,008.83
;
08/12/2002
Prudential $ Financial
Retain for Your Tax Records
Date Reference Number
01124/02
30C05-1524
SANDRA K SHOPE
6651 AKBLEWOOD ST W
CANTON OH 44718-1389
3333-24
Dear Policyholder,
We're pleased to inform you that Prudential has completed its conversion from a mutual company to a stock company;
As part of our conversion, we are issuing cash payments to eligible owners of the company. This includes anyone who
owned an eligible policy or annuity contract as of December 15, 2000. Your check is I)elow.
This'does not affect your insurance policy or annuity in any way.
_ Your payment is a.benefit of holding an eligible policy or contract. It does not replace your policy or contract, or change
your benefits, cash values, eligibility for policy dividends or guarantees. You do not have to give anything up to receive
your payment.
How your payment was determined.
Company actuaries and external advisors developed a plan for dividing the value of Prudential among its owners. Factors
such as the type oflife, annuity or health policy or contract you owned, the face value, and how long you owned it
determined your compensation. Your payment was first calculated as a number of stock shares. These shares were then
converted to an equivalent value in cash. Compensation for all policies eligible for cash payment is included in this
check.
SEE BACK FOR MORE DETAILS.
PRU..{f01 New 1102
01001695~
J
":f
I
f
1
Prudential ~ Financial
Retain for Your Tax Records
Date Reference Number
01/24/02
30005-152"
SANDRA K SHOPE
6651 AKBLEWOOO 5T W
CANTON OH 44718-1389
3331-13
U: .' . Pot . . .'
Dear Policyholder, r fVj .
We're pleased to inform you that Prudential has completed its conversion from a mutual company to a stock company.
As part of our conversion, we are issuing cash payments to eligible owners of the company. This includes anyone who
owned an eligible policy or annuity contract as of December 15,2000. Your check is below.
Tbis'does not affect your iusurance policy or annuity in any way.
Your payment is a benefit of holding an eligible policy or contract. It does not replace your policy or contract, or change.
your benefits, cash values, eligibility for policy dividends or guarantees. You do not have to give anything up to receive
your payment.
How your payment was determined.
Company actuaries and external advisors developed a plan for dividing the value of Prudential among its owners, Factors
such as the type of life, annuity or health policy or contract you owned, the face value, and how long you owned it
determined your compensation. Your payment was first calculated as a number of stock shares. These shares were then
converted to an equivalent value in cash. Compensation for all policies eligible for cash payment is included in this
check.
SEE BACK FOR MORE DETAILS.
'.
PRU-Q01 New 1102
010016914
,,~~?
The One. Plus Annuityw
Quarterly Statement
Apr 1, 2002 to Jun 30, 2002
Nationwide Life and Annuity
POBox 182008
Columbus OH 43218
24 Hr. Annuity Line:
Customer Service:
Hearing Impaired:
(800) 848-8258
(800) 860-3946
(800) 238-3035
0001&467
VIRGINIA M DIENER AND
SANDRA K SHOPE
6654 AMBLEWOOD ST NW
CANTON OH 44718-1389
.
I
"
g
g
r
YOUR CONTRACT IS SERVICED BY:
AMY J SHOPE
BANC ONE INSURANCE SERV CORP
380 BOARDMAN CANFIELD RD
BOARDMAN OH 44512
Representative Number:
Annuitant:
070A00454473
VIRGINIA M DIENER
Contract Issue Date: ...
10/09/2000
___ Contract Number: 07-2007848
=
1:::m::::;gQUi:i~9ifQp}l.lm~4~pjwtYGQP,ti'j~::M~ij~~:'~~':::$;~(j$l(j]~*$7.:m:m:f:i::l
;;;;;;;;;;;
_ Nationwide will assume all transactions are accurate unless notified within 30 days.
;;;;;;;;;;;
=
Quarter-To-Date
Year-To-Date
Inception- To- Date
Beginning Value
Purchase Payments
Withdrawals/Charges
Earnings
Ending Value
$65,996.08
$.00
$.00
$965.74
'$66,961.82
$65,054.65
$.00
$.00
$1,907.17
$66,961.82
$.00
$60,000.00
$.00
$6,961.82
$66,961.82
tm~~~~!$~iIlffi~i5iH'#:~~!:l!m'!!i::1i'M:r,m@!i:!:1:m:!!f:@!ij:):!:itHi::;:~i:~~!!:!~{~~H:mm:::!!::t~tit:::\!ih'!:::!;:::!J!mj:;\:<m~::::~:;:::::!%d;~:~~:1;M:M~~t~}~::1
$60,000.00
6.00%
Base Rate
Guaranteed
Through
10/08/2002
2000
Fuud Total
$.00
Ending
Value on
06{30{2002
$66,961.82
'ji::):))f)$li6~9.6iJli::
Credited
Interest Rate
Year of
Purchase
Payment
Purchase
Payment
Amount
Withdrawals
Since Purchase
Payment
. l
hv0 r"cu,v~ ""'I
1\ Ui<'o( C(.1;J.
FBIHN 00 FI 072007848
000000010000000200025411100050543
Page 1 of2
The One. Plus Annuity~
Transaction ConfIrmation
July I, 2002
Nationwide Life and Annuity
POBox 182008
Columbus OH 43218
24 Hr. Annuity Line:
Customer Service:
Hearing Impaired:
(800) 848-8258
(800) 860-3946
(800) 238-3035
00003862
VIRGINIA M DIENER AND
SANDRA K SHOPE
6654 AMBLEWOOD ST NW
CANTON OH 44718-1389
o
<;
o
~
i
~
YOUR CONTRACT IS SERVICED BY:
AMY J SHOPE
BANC ONE INSURANCE SERV CORP
380 BOARDMAN CANFIELD RD
BOARDMAN OH 44512
Representative Number:
Annuitant:
070AOO454473
VIRGINIA M DIENER
Contract Issue Date:
10/09/2000
---
~
---
---
Contract Number: 07-2007848
. ~';:::mm:ii~i;~1!'!iillMQWf:mN~~Qmw~J.::~~yt;;9~~rl~:~IMIf'll~'l:~~,:$~ltt~i~im:ml:imi;',!l
---
---
-
Nationwide will assume all transactions are accurate unless notified within 30 days.
---
---
-
---
~
Beginning Value on 01/01/2002:
Purchase Payments
Withdrawals/Charges
Earnings
Ending Value as of 07/01/2002:
$65,054.65
$.00
( $66,972.51)
.....J1!?I?8~....
:m:'~:~~i8l1[~,"S;OO~,~"
",'''.'''.',
""""','.'
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m~~1i~~i~~l~m!~i1mm~m;~~~mi
..................--...............
....................
.,."""""""""",,,,,""', '.
'-"","',',"""""'"''0''''''
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:':. ;':i; .;'i': ';-:-i.:;: .~, ..._.
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m::!jmmmtm~~~jlmmmm~j:~j!~~:
Transaction
Dale
Transaction
Type
Dollar Amoont
Credited
Interest Rate
Base Rate
Guaranteed
Through
07/01/02
SURRENDER
( $66,972.51)
FBIHN 00 FI 072007848
?0ooooo1000000010000971800013834
Page 1 of 1
The One@ fuvestor AnnuitY"
00039005
VIRGINIA M DIENER
6651 AMBLEWOOD 5T NW
CANTON OH 44718-1389
Quarterly Statement
Apr 1, 2002 to Jun 30, 2002
Nationwide Life and Annuity
POBox 182008
Columbus OH 43218-2008
24 Hr. Annuity Line: (800) 848-8258
Customer Service: (800) 860-3946
Hearing Impaired: (800) 238-3035
g
~
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a
8
~
YOUR CONTRACT IS SERVICED BY:
AMY J SHOPE
BANC ONE INSURANCE SERV CORP
380 BOARDMAN CANFIELD RD
BOARDMAN OH 44512
Representative Number:
Annuitant:
;;;;;;;;;;;;;
~
);'l4W:ti9A'iQMlift~~#.itY;QMWjitiY:!l1,,~j~;$1~~~~$.4~i@1
=-
~
;;;;;;;;;;;;;
;;;;;;;;;;;;;
-
070AOO454473
VIRGINIA M DIENER
Contract Issue Date:
08/21/2000
Contract Number: 07-4018783
Nationwide wiD assume aD transactions are accurate unless notified within 30 days.
~
;;;;;;;;;;;;;
-
;;;;;;;;;;;;;
~
Beginning Value
Purchase Payments
Withdrawals/Charges
Change in Value
Ending Value
Quarter- To-Date
Year-To-Date
Inception- To-Date
$122,939.49
$.00
$.00
( $9,784.53)
$113,154.96
$121,367.86
$.00
$.00
( $8,212.90)
$113,154.96
$.00
$132,248.23
$.00
( $19,093.27)
$113,154.96
IY@iilii~Ji:i@l:~i!~$jjlfirniitiii&iii'@ifm;l;;ii;;ii;f@@;iifi;:iiii@ii@nmmti:rIi:itii@@fI;ti,i/i;;;i;@tiI:i'II
Fund
Name
IGRPINVTRST BLNCD PORT
IGRPINVTRST BOND PORT
IGRPINVTRST DIVEQUITY PORT
IGRPINVTRST DIVMIDCAP PORT
IGRPINVTRST EQU INDX PORT
IGRPINVTRST GOV.,. BND PORT
IGRPINVTRST LGCP GRTH PORT
IGRPINVTRST MDCP GRTH PORT
IGRPINVTRST MIDCAPVAL PORT
BlOIN 00 FI 074018783
00000001000000030007741000152399
Beginning--of-Quarter
Dollar Value
Quarter- To-Date
Payments Withdrawals
End-<lf-Quarter
Dollar Value
$6,023.66
$17,086.04
$19,165.28
$11,644.06
$14,258.64
$16,958.77
$9,271.16
$14,237.04
$14,294.84
',fl.
Q.<c-v.- 3
~ \ 4-~'~
~ \~b) ,9
$5,538.44
$1 7,676.91
$16,329.12
$10,373.25
$12,293.79
$17,711.63
$7,569.30
$12,299.84
$13,362.68
Page 1 of 3
~ Prudential
\S! Financial
The Prudential
tr.surantt Company
of America
Statement of Benefit
WJAOD
J
Check no:
JUL-29-2002 0211797 1010~
I Ben;i~A TH
I ~::m M05952100
!lnSured
V DIENER
I letters Check amount
L- $3.564.25
Certificate no.
Certificate amount
\ Claim
Number
JMA087141
SANDRA K SHOPE
6651 AMBLEWOOD ST N W
CANTON, OH 44718-1389
Payee
SANDRA K SHOPE EXEC OF THE EST OF*
VIRGINIA M DIENER*
Addressee
INCLUDED AMOUNTS
$569.00
2 , 984. 1 7
11.08
$3,564.25
AMOUNT OF INSURANCE
PAID UP ADDITIONAL ~NSURANCE
POLICY OR CONTRACT INTEREST
AMOUNT OF PAYMENT
Instructions for Payee on reverse of this form.
Please see paragraphhi}
1.
I Comb 34771 A \
\ OBJH01 \
. fE::;. Pmdential
~ Financial
The Prudential
Insurance Company
of America
Statement of Benefit
Check no.
~
W JAOO
J
JUL-29-2002 0211796
I aen~f~A TH
I Policy
Numbe" M04906638
I Insured
V DIENER
!letters Check amount
L- $3,718.99
Certificate no.
Certificate amount
\ Claim
Number
JMA08714C
Addressee
SANDRA K SHOPE
6651 AMBLEWOOO ST N W
CANTON, OH 44718-1389
Payee
SANDRA K SHOPE EXEC OF THE EST*
OF VIRGINIA M DIENER*
INCLUDED AMOUNTS
$566.00
3,141.43
11.56
$3,718.99
AMOUNT OF INSURANCE
PAID UP ADDITIONAL INSURANCE
POLICY OR CONTRACT INTEREST
AMOUNT OF PAYMENT
Instructions for Payee on reverse of this form.
Please see paragraph!s}
1.
I Comb 34771 A \
I DBJHOl I
-
-
BANK =ONE
-
Bank One, NA
P.0.Bo~260164
Balon Rouge, LA 70826-9944
T 1 007 117582
fv;d. # 000000629961129
1.1..1.1..11...1...111..1....11..11.1..1.1.1...1.1....111.1..1
VIRGINIA M DIENER
OR SANDRA K SHOPE
6651 AMBLEWOOD ST NW
CANTON OH 44718-1389
Jun 12 through Jul10, 2002
Page 1 of 2
A REMINDER FOR SAVINGS AND BUSINESS SAVINGS ACCOUNTS. 4 MONTHLY
WITHDRAWALS ARE PROVIDED EACH STATEMENT PERIOD WITH NO FEE. AFTER
4 CUSTOMER INITIATED WITHDRAWALS (SUCH AS TELEPHONE TRANSFERS.
INTERNET TRANSFERS AND LOAN PAYMENTS TRANSFERS) A $3 PER WITH-
DRAWAL FEE WIll BE ASSESSED TO YOUR ACCOUNT. PER MONTHLY CYCLE.
FOR AUTOMATED ACCOUNT INFORMATION. PAYMENTS, TRANSFERSAND TO
CHANGE YOUR ACCOUNT MAlLlNGADDRESS, CALL 1-800-310-1111 AN.YT1ME
OR VISIT WWW.BANKONE.COM. TELEPHONE BANKERS ARE AVAILABLE DURING
EXTENDED BUSINESS HOURS. FOR TEXT TELEPHONES (I'DDIITY). CALL
1-888-663-4833. PARA ESPANOL, LLAME AL 1-888-116-5663.
CLASSIC ONE
Accounlnumber000000629961129
,;
Inferest eamed this statement ceriod
Annual Percentaae Yield Eamed Ihis stalement ceriod
Interest oaid this year
Amount
$2.52
0.40%
$42.03
Beainnina balance
Checks caid
Other wnhdrawals
Decosits
Balance as 01 Jul1 0
$10568.87
- 14 968.97
0.00
+ 11652.11
$7,252.01
Cheeks paid
Number Amount Date paid Number Amount Date Dahl
1251 4.867.57 06-14 1257 ~ 1 500.00 07-02
1253" 828.80 06-18 1258 7.450.00 07-09
1254 , 27.00 06-27 1259 200.00 07-09
1255 65.60 06-27 Total 14,968.97
1256 30.00 07-08
* Checks not listed were shown on a previous statement or had not yet cleared as
of 07-10-02.
continues
T 1 0 07 117583
VIRGINIA M DIENER
Aeet # 000000629961129
Jun 12 through Ju110, 2002
Page 2 012
Fees and charges Your Classic One monthly service fee was waived
because you maintained a combined minimum balance of $5,000.00 or more in
qualifying linked deposit accounts each day during the statement period.
This message confirms that you have overdraft protection on your checking account.
Deposits and other additions
Date Descripffon
07 -02 Deposit
07-10 Interest Payment
11.649.59
2.52
11,652.11
GET YOUR MONEY QUICKER.
HAVE YOUR PAYCHECK OR SOCIAL SECURlTY CHECK DEPOSITED DIRECTLY TO
YOUR CHECKING ACCOUNT. IT'S SAFE. SIMPLE AND CONVKNIENT.
CONTACT YOUR EMPLOYER OR BANK ONE FOR DETAILS.
NEED MONEY FOR COLLEGE?
EDUCATION ONE LOANS CAN HELP.
CALL ]-888-663-2413 OR
LOG ON WWW-EDUCATlONONE.COM
LOANS SUBJECT TO APPROVAL.
. B8/29/B2 B9: 22 : B7
ACSFaxl-)
33B4924B72
....
--
BANK =~DNE.
-
fde... FClC
Consumer Signature Card
Al/\<<lunt No.
62996\ ll~
A/:COunI TIUe
~IR~I~6~^MKD~~~~t
IlI2-rr~ln~h
2 61-1 -m2
Type crt OWnen;hi~
Account Typ_
Calo Opened
as-2S-2DBDt
Mew Accoun
IdentillcaUon
11 198101212
2 OM RF1231S8
JoInt
Classic OBe
ConIiLErner AddreJll
8851 AMBLEVQQO SI NW
CANTOM OR '4118
AoknowlMIIMI't. ~ .1.,.... f\II; $l;Mhne Card. 11m I.pplvq 110 the lint: to 0J:l'-" 01. dtlll~"lICcaLlnt h:fblll!!d aD1M'. I certify !lid h Inl'om.uo"
JlVVldad hereon I.. ll\ll to,.. be., Qf my l.:naW~I.I"1lI .UlMIIH UIa SInk, 1111. 411crllkln. II:! ClIIIDI. CI'ItdIII'I~ Md -.layrMnt verllaUClnG iOn
me. llOlclllJWlldp rICII~~ of the 'anlt.. Account ~.. .nel ReaultUDta, Incll.lCllng .~ 11lPGCI_ rr-ta.. Ind .. 10 :tll tllliLlna Dy IN Cl'llInIIl'ItI BIId'
terme oontllntd thII/'lI"n. I .1110 ~wledG' 0'11t the B,,* ,.,..,. 15M", inrwll'1fltiGn oIIbClUt 1M ar mr ~ IoIIUullt'l>> conlSilionl duGl'll:iec:l thlNlIn. It I
hEw<e pn...d I C.rtIfIoI.,. 01 Copallt.I IcI{nowlld:e' rttellMng nCltir;:u Ql tlty _dv wilhclmwlilllllilnlllliliai IhlltilJ:lplf.
COIlltl....." . I ..Mill' Onell' llIIlollV 01 PO~UIY IM1 (1)"'" ~ve' Ide_Ion Nu_, ~..n ~ "'_ .... (2) I .. no! &UbjOCl .. "''''''p
\'Yl1h"0I~119 tlec8U": (all .", _Iftl~ tram ~ldcup wllh~dlng, or (S.) In..... not teen notified tytne InlI!rn" ReYemlll 81!11'Vt:8 (tit!) lhat I.'" 'lUbjlllM:
IICII blakvp wiU'IIlCllClln(r Be 8 reeu~ of a fellu" to /WCln .1 rntnrt or dlvlden~, or (c) Ihl U~S N' N:lUD.d rN t'-t I -" rID bn;IIr .ubJ.eIl Ia ~eIWp
\lIhbho1cfng. (YDLI mulllnSt out It8m 2 .boVI If ~ nlY& been notllieCl by the tR$ l:het ~ aN c:urlrUllI' subjlct fl:I ~ wl'nhcldlng blClu" r;I
1J~~ lntIIM'JI .f dMUnds on your tIX return.) Tne Inl8mal' Re'Je"u& 88Nfce does Mt reql.lil'l )'aLlr IXIIII_ ID lI\y pror.1Rn Ollnll d=~l'I&
c:lther1tl.. the qeltlflCd1lonl ~wred to evok:l b...p wlthl\otdlns.
. . .. Data Ta.payer 1.0. No.
, ,,-i,.' ,'~ ~ ' <'~.QS ').-"......'" I
2) ~ ~ '-# - 2) 195-32-06~
3)~ 9~)
4) X \c~"" &\\P
Issued By Prepared By O~e. 5~~~
K SHOPE ~C ~\.S\~~O\.....
~H~p12-28*'\\O :?~t"~"'-;:
0~!a'200D ~ ~ '11\\\1:\
SU~ ""-\\.. 't
~\ O\~.
y~O
Buk llnq, NA
EI~ Roa~
00912
I Oslol"",; 10618 re;j
Page BB2
-
-
BANK=DNE
-
Bank One, NA
P.O. Box 260164
Baton Rouge, LA 70826-9944
- <\ll- to
~)~U~~l
/' JLt W'
pi ~t.
1,1..1,1"11",1".111.,1.",11,,11,1..1,1,1,,,1,1,...111.1..1
VIRGINIA M DIENER
OR SANDRA K SHOPE
6651 AMBLEWOOD ST NW
CANTON OH 44718-1389
FOR AUTOMATED ACCOUNT INFORMATION. PAYMENTS. TRANSFERS AND TO
CHANGE YOUR ACCOUNT MAlLING ADDRESS. CALL 1-800-310-1111 ANYTIME
OR VISIT WWW,BANK.ONE.COM. TELEPHONE BANKERSAREAVAlLABLE DURING
EXTENDED BUSINESS HOURS. FOR TEXT TELEPHONES (TDD/ITY). CALL
1-888-663-4833. PARA ESPANOL. LLAME AL 1-888-226-5663.
T R 0 07 650
Ace! # 000001584380727
Jun 12 through Ju12, 2002
Page 1 of 1
BANK ONE MARKET INDEX ACCOUNT
Account number 000001584380727
Interest earned
this statement periOd
Annual Percentage Yield Earned
this statement periOd
Interest paid this year
$5.74
0.90%
$195.67
Beginning balance
Deposits
Withdrawals
Balance as of Jul 2
$11,643.85
+ 5.74
- 11,649.59
$0.00
Transactions
Date Descripfion
07-02 Customer Withdrawal
07-02 Closing Interest Payment
NEED MONEY FOR COLLEGE?
EDUCATION ONE LOANS CAN HELP.
CALL 1-888-663-24/3 OR
LOG ON www.EDUCATIONONE.COM
LOANS SUBJECT TO APPROVAL.
Deposits
Withdrawals
- -11 ,649.59
5.74
5.74
11,649.59
'-86125/82 89:25:57
3384924812
A!:SBFdx24->
-
-
IJANK = ONE.
-
Member FDIC
Consumer Signature Card
Account No.
1584H0121
A=unl Tdla
VIRGINIA K DIENER
OR SAHORA K SHOPE
Cale of Birth
ll12-Qg-\S20
2 01-1S- H2
Type of OWl'lBnllllp
Joint
Date Opened
DHHm
Hew Account
AccountType
Can.umar Ad_
Market Index Account
Idenllflcallo..
~6SI AM8lEWOOO 5T NW
CANTON OH U1 U
Il1981U1211
2 DH RF 23198
ADknowledsment.. 8't Ilgnlllg 'lhll SlgI1ltUI'1 Clftf.l am epply~ 10 trte 8snk 10 cpetll'll dlI~.1t 4teI!Iul'lt rndlc2Dd .tmw..1 ~rtIfy e-.tlhllttfbrm""
JlroYIClld' t1ereOl'lII INI to 1ht bllGC Of my knOwIIdQI and aIlharlll d"II Bank. at Itl ClllCMtMnl'tO C1D1al'ft et!dt ,..~rt. ilU'If CIIplDytMnt. ..rft~.CIr\
me. I WikJ')(:JWlecoe teO*4f tI'I. Bal'lk't ACCOunt Flull.end ~Ida....~ JncfucIng IllPl'lIcel:l1e IrIlOrII, 8I\CI .. tie tlo ~ by U. '9""';'- ~
...... GOnlll".. 1IIo,aln.1 ~.. _owl"'a.,ilIt the IlMkllllY .,.,. hfonnU'CIl 0llCl1ll..... my ........II1lI. "" condlllo.. dariled ,_. III
hlMlllU_oda~n1n_o! llopooll.l_odg......Mng _oIonvWly_~_t'IOI~.
Conlll...... . I clll1lfy undOl peMl~ of pOljulY INll (1) Iho T~_Id_ Numb", glvao" co_ an. (2) I om nol ._ ID -p
wl1l1!lclllna b'_ (II'''' _I_ ~ wIlhhClll!lag... (all..... .......... moll'" tit.... ...m........_ s..... ~"8l "'011 ""'0_
to .. 'WImJd"g u a raull of a falu:re ID report 1l11nkl1'8ll at l:llvkllns. e~ (e) 1ft. .FilS I\ae. 1'I=m.d m. .. I &1ft 1'10 1orIg.. Uje~ b baGWp
wlln"""'.g. <"'" "",,' ._ "'" lI.m q oil_ W you ha... boon noIile<l1lv lho IRS HllIl '(W "" .."ronIly oubJoot lei ilIc~\IIl wlil1llo~lng _It ot
\ll1don"Il.'"'''II- oId_ on yoor..._.) Tho _ R......... ....1.. deal nllt rtqiAHI yoo.r......tlo w,~ pcoolOfCII Of1~ _....
""'.. ,.... "",..I'Ift_nc ..qUII"d '" avolll ~ WlIMollllna.
~~~
:~ ~-. . ~-f,1 aM
3) x
4) X
Issued By
Cam
~~:
Taxpayer 1.0. No.
I) t98-10-1212 I
2) 195-32-0&21
Pl'Ilp8/'IId By . '\,~f#~"
t SHOPE ~~.,p1:~
3301312-2666 _~.9-':':"';""
un 1,)"',,:.'"
06-28'2000 ,'t-"'~ ,.., . C\.~~
...... \ 't 'tv
~'J.~y: ~~
~~ .-,,\)..t
;,;:.\.~ ~~\;~
. ...;.v*-( 0
~~v
Buk ~ne, MA
Elm Road
DOW
I e.tolog # '0&'8 ~) I
Page 882
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, that I, VIRGINIA M. DIENER, of208
West Elmwood Avenue, Mechanicsburg, Pennsylvania 17055, have made, constituted and
appointed, and by these present do make, constitute and appoint my husband, CHARLES E.
DIENER, of208 West Elmwood Avenue, Mechanicsburg, Pennsylvania 17055, and/or my
daughter, SANDRA K. SHOPE, of6651 Amblewood Street, N. W., Canton, Ohio 44718, my
true and lawful Attomeys for me and on my behalf, generally, either jointly or severally, to do
and perfonll all matters or things, including the transaction of all my business affairs and to
manag~ all my property and/or affairs as completely as I myself might do if personally present. I
specifically authorize and grant unto my Attomey(s) the absolute right to make on my behalf all
contracts and orders, including the making, execution, acknowledgment and delivery of Deeds
for the proper, full and complete conveyancing of any and all of my real estate in fee simple,
wheresoever the sanle may be situate; to sell and transfer title to all motor vehicles registered in
my name; the specific right to open and enter into any and all safe deposit boxes rented by me at
any banking or financial institution, including the right to remove any and all the contents
thereof, as well as cancel the rental contract therefor; to collect and receive any and all proceeds
due me under policies of insurance covering me as an insured and/or beneficiary thereof, whether
the same be life, health, accident or other policies indemnifying me for any reason or matter
whatsoever; to collect and receive any and all pension or annuity payments or other benefits due
me whatsoever; the specific right to engage ill banking and financial transactions on my behalf
with any bank(s), credit union(s) or financial institution(s), such as, but not limited to collecting
and receiving any monies and assets to which I may be entitled; to deposit and cash checks in any
of my accounts, to sign checks, drafts and other instruments and otherwise make withdrawals
from any checking, savings or other deposit accounts in my name, including the right to endorse
checks payable to me and receive the proceeds thereof in cash or otherwise;.to open and close
checking and savings accounts, including the purchase and redemption of savings certificates,
certificates of deposit or similar instruments in my name and to do all acts regarding the
management of all of my said accounts as I could do if personally present; my said Attomey(s)
shall have the right to prepare and file Federal and State Income Tax Returns on my behalf; to
sell and transfer any and all stocks, bonds and securities which I may own, through any stock
brokerage finn or directly through the issuing corporation; complete authorization to procure for
my welfare and maintenance, domestic help, supplies, medical attendance and treatment of every
nature or kind whatsoever, sllch as, but not limited to, x-rays, surgery, rehabilitation and
specialist services, including also my admission and discharge to and from any hospital(s) and/or
retirement or nursing home(s) as my Attorney or Attorneys, at their sole discretion, shall deem
necessary for my proper care and treatment; to make and deliver any and all papers, instruments
and documents which may be requisite or proper to effectuate any matter or thing appertaining or
belonging to me whatsoever, with the same power, and to all intents and purposes, with the same
validity as I could if! were personally present, hereby ratifYing and confinning absolutely,
whatsoever my said Attorney or Attorneys shall and may do by virtue hereof, whether the same
- 1 -
be by their joint, several and/or separate act or acts, pursuant to the authority herein granted.
THIS POWER OF ATTORNEY IS INTENDED TO BE DURABLE IN ALL
RESPECTS, and shall not be invalidated or voided in any manner by reason of my subsequent
mental incompetency or physical disability or incapacity and shall continue in full force and
effect and may be accepted and relied upon by any to whom it is presented, despite its purported
revocation by me, my alleged incompetence or incapacity from whatever cause, until such time
of receipt of evidence of the appointment of a guardian of my estate, or similar fiduciary of my
estate, or written notice of my death.
IN WITNESS WHEREOF, 1 have hereunto set my hand and seal this C{./i day of
er, 1998.
1 . . ~
"~Y!J. . - f9"~
. , ,
ginia . iener
(SEAL)
COMMONWEALTH OF PENNSYLVANIA)
: SS.
COUNTY OF CUMBERLAND)
On this, the if Ida; of November, 1998, before me, a Notary Public.in and for said
Commonwealth and County, personally appeared VIRGINIA M. DIENER, known to me (or
satisfactorily proven) to be the person whose name is subscribed to the within Durable Power of
Attorney, and acknowledge that she executed the same for the purposes therein contained, and
desired the same to be recorded as such.
IN WITNESS WHEREOF, 1 have hereunto set my hand and Notarial Seal.
m4~~
Notary Public
Notarial Seal .
Marilyn E. Winiams. NOla~Ug:nty
M",*,anicsbu<g 60<0, Cumbo 2Q01
My Commission EXpires NO'I. 6.
Member, Penns'1llJiffila ASSOClation of NOtarieS
-2-
Myers Funeral Home, Inc.
37 East Main Street
Mechanicsburg, Pa. 17055
Boyd L. Myers Jr., Supervisor
(717) 766-3421
A STANDARD OF EXCELLENCE SINCE 1910
Thursday, July 11, 2002
Sandra K. Shope
6651 Amblewood Street North West
Canton, Ohio 44718
Dear Shope,
Thank you for selecting our funeral home to provide services for your family during your bereavement.
I hope that you found our services to be of the highest standards and that they met your needs and those
of your family and friends. The following is a summary of the service charges as previously explained and
provided in written form on the services for:
Viroinia M. Diener
SUMMARY OF EXPENSES
TOTAL OF SERVICE RENDERED
LESS: Credits granted
LESS: Total Payments
CURRENT BALANCE
Credits Granted: $1,520.0 Package Price Discount
Interest at the rate of 1 % per month ( 12 % per annum) will be added to balance after 30 days,
If there are any questions or concerns that remain unanswered, please call me.
Sincerely,
$5,698.60
1,520.00
0.00
$4,178.60
Boyd L. Myers Jr.
?&.
lH g.&t1 Ct-
"\ .....-0
/\A~ (;0
11 L.L r'"6'
RECEIPT FOR PAYMENT
-------------------
-------------------
Cumberland County - Register of wills
Hanover and High Street
Carlisle, PA 17013
Recetpt Date
Recelpt Time
Receipt No.
7/12/2002
10:30:03
1029912
DIENER VIRGINIA M
File Number 2002-00633
Remarks SANDRA K SHOPE
AC
________________________ Distribution Of Receipt ------------------------
Transaction Description Payment Amount Payee Name
PETITION FOR PROBA
CODICIL
EXTRA PAGES
SHORT CERTIFICATE
JCP FEE
25.00
10.50
18.00
12.00
5.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
Check# 1260
Total Received.........
$70.50
$70.50
PHONE
lIE:=:T 'SHORE EMS
503 N 21ST
CIII1P HILL, PA
(800) ~:67-0512
- BLS
ST
17011
TAX 1D
INVOICE
PATIENT NAME,!:, I EHER, V I RG nIl A 1'I
INSURANCE: MED I CARE B
1 :=:40::)57',3r5B
'::ANDRA ~;HOPE
6651 Al'IBLEWOOD ST NW
CANTON, OH 4.4718
DESCRIPTION OF CHARGE
QUANTITY'
WHEELCHAIR VAN BASE RATE
Transport Van Mileage
Transport Van Mileage
1.0
21.0
21.0
TOTAL CHARGES THIS CALL
c'~ESCRIPTlON OF PAYMENT
TOTAL PAYl'lENTS THIS CALL
23'-24E,::'::OCl2
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
REASON(S)
FOR
TRANSPORT
RECEIPT
2::lt)94
'.3:33::39W
OS/23/02
THORllllAL.D HOME
THORI~WALD HOl'IE
896 CENTURY DR
EYE EXAl'l
UNIT PRICE
:32.00
1.20
1.20
~~~\c?
~15wiJ .s
\)tWV
PAYMENT DATE of:;,
PLEASE PAY THIS AMOUNT _
A
~
--
~~
WEST SHORE
E:\IER( ;E~CY MEDIC,\L SER\"IC.:S
THOR A
. AMOUNT:'
32.00
25.20
2~1.20
$
82.40
c. 'AMOUNT;rtr~
+" ..a:;.1;;;';;'~~
0.00
$
82~'40
~;;..,~
HARRY A. DONOVAN, CPA
Donovan, Klimczak and Company
THEODORE C. KLIMCZAK, CPA
CERTIFIED PUBLIC ACCOUNTANTS
1867 WEST MARKET STREET AKRON, QH 44313
TELEPHONE 330-836-9331 FAX 330-869-9991
http://www.dl<c-cpa.com
SANDRA L. BENNETT, ADMINISTRATOR
August 31, 2002
Estate of Virginia M. Diener
Cl.o Sandra K. Shope
6651 Amblewood St. NW
Canton, OH 44718
F or Professional Services Rendered In Connection
With the Following:
. Preparation of Pennsylvania Form REV-1500
Inheritance Tax Return
. Preparation of Federal Estate Income Tax Return
Form 1041
Total
$
.,\;..
...;<,-
tot
""
~
,I
~
-.,
750.00
$
750.00
-----------------------------------------------
Date:
Code:
Account Number:
Description:
VIRGINIA M. DIENER
THORNW ALD HOME
442 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
1655 Closing Date: 6/12/2002
Charge: Credit:
. .
PAUL D. DALBEY, DPM
5 KACEY COURT, SUITE 202
MECHANlCSBURG, P A 17055
7-JUN-02
A9160
ROUTINE FOOT CARE $30.00
OS/20/02 CK#1248 PAYMENT-THANK YOU
ROUTINE FOOT CARE $30.00
DUE FROM PATIENT $30.00
$30.00
5-APR-02
A9160
~~13~
1Il~'(})
ev!-9 ~(7
DUE FROM PATIENT
$30.00
Your prompt payment is appreciated.
Current
Over 30 Days Over 60 Days Over 90 Days
Total Balance
$30.00
$30.00
PHARMERICA <ll~
For Comments and lor Concerns:
111 RUTHAR DRIVE
NEWARK, DE 19711-
For Payment:
PO Box 6413
Carol Stream, IL 60197-6413
IF YOU HAVE ANY QUESTIONS CONCERNING THIS STATEMENT OR WISH TO PAY WITH YOUR VISA, MASTERCARD
AMERICAN EXPRESS, OR DISCOVER PLEASE CALL A BILLING REPRESENTATIVE AT 800-352-9161 '
CUSTOMER NAME
DIENER. VIRGINIA
I FROM HRU DATE!
DATE RX NO.
0531 02
06 1 02
06/11/02
,0 102
06/17/02
PHYSICIAN NAME
BRANSCUM JR GEORGE P
STATEMENT
DATE ACCT. NO.
06/30102 5702-01-02053
DOLLAR
QTY. CODE AMOUNT
828.80
5 7556..
521748
0537 99
j-i~;1if,Z1,;'~'H~;i,y,n~~ji:'tr~~1t~1;~i~l
:'1.~t.;.;;.~,.L."\~~~~;'~7,e;<';>:fi;t;y\'.
lil1.3iC
RX 5
~t 9( 0'.""
:.Ji'hfu;;;:l~i"S~OO
50.00
~.',24:80
828.80 CR
~,~~;. '/.2:;<1::';':' 4~0';'.'~:sw~t;':':;;;~,";
~,
,~,,~~';~,,: ';:;S'i'i;:;?i~'iC!l';$';;;:Li"3.i~
~[!t','f,~;tj",
t~;~~~::J,~:::'.;.'; ::If('''~0_;;'':J~f;::1:v::+~
-~~:'~r," ~~~3$~~;;~B'><<;
:~~~~;;;>~~~0!;;
~\'!r~"'~~~
~,;:r_
i1-,"~~~
AMOUNT DUE UPON RECEIPT
CV=CONVERT TR=TRANSFER CR=CREDIT RX T=TAXABLE D=DISCOUNTED N=NON-COVERED
.,.
PLEASE RETURN BOTTOM PORTION WITH PAYMENT - Retain top portion for your records
477
'i..-
Simple. Affordable. National.
Verizon Wireless, an entirely new kind of wireless
communications company.
Check us OU~ at www.verizonwireless.com.
Previous Balance
payments - Thank You
Past Due Balance
69.06
69.06CR
Current Charges
Monthly Activity - 1 Service(s)
Total Current Charges
109.28
~liJ~ \..\J~~)
/1(~ ;f CQ '3
~\ <(
.g,)u't 'd
$0.00
$109.28
Tota 1 Amount Due ~
$109.28
Mobile Telecommunications Sourcing Act
TAX CHANGE FOR AUGUST - New federal rules require us to apply'state &
service charges based on your place of primary use (generally your
address on file with us) instead of where the service was provided.
affect the tax charged on your bill. For more info please visit
VZNLOOl1 (10-00)
~i,onWireless
Account Name:
Account Number:
Bill Close Date:
ROBERT SHOPE
99136419
07/14/02
Page
3
Account Charges Summary
Payments
07/07/02 - Invoice Payment - Thank You
69.06CR
Total Payments
$69.06CR
Monthly Activity
Summary for 330/730-9942
BUS/GOVT SR GL 100
Service Charges & Credits
Airtime Charges
Roaming Charges
Taxes and Surcharges
Federal
State
Fed Univ Svc/Reg Chg
13.67
2.80
87.61
5.20
Sub-total
3.35
1.33
0.52
for 330/730-9942
$109.28
$109.28
Total Monthly Activity Charges ~
New Balance Payment Due Date
$1,327.Q7 07t19i\l2
Amount Enclo.ed I $
Past Due Amount Minimum Payment
$0.00 $26.00
I Make your check payable to Rrst USA Bank, N.A.
New address or e~mail? Print on back.
JliANj( ;;;: (jN~
-
f1r J ~dO ;).07 OC(jIJ(CiJ{.'(/O "37/2;1..377
~ Y"'l!? 426681010624358000002600001327072
FIRST USA BANK, NA
P.O. BOX 94014
PALATINE IL 60094-4014
1,11"11."11",1,1",1,,1,1,,111..,,,,11.1,,1,,.11,1,,11",11
ROBERT R SHOPE
SANDRA K SHOPE
6651 AMBLEWOOD ST NW
CANTON OH 44718-1389
1,1.,1.1,.11",1."111"1,,,,11,,11,1,,1,1,1.,,1,1,,.,111,1,,1
3Q2.47"
I: 5000 lobO 2BI: to 100 1o0b 21. ~ sBo ?n"
~c
, ,
:':"
'"
-
-
BANK=ONE.
-
VISA ACCOUNT SUMMARY
Statement Date: OS/23/02- 06/24102 J:S::::<.r
Payment Due Date: 071'19102 ~
CUSTOMER SERVICE
In U.S. 1.800-945-2006
E.pailol 1 -888-446-3308
TOO 1 -800.955.8060
Outeide U.S. call collect
1-302-594-8200
Account Number: 4266 8101 0624 3580
ACCOUNT INQUIRIES
P.O. Box 8650
Wilmington, DE 19899-8650
Previous Balance
(.) Paymenta, Credit.
(+) Purchases, Cash, Debita
(+) Finance Charge.
(=) New Balance
$1,200.00
$1,392.46
$1,519.53
$0.00
$1,327.07
$26.00
$9,500
$8,172
$4,750
$4,750.00
PAYMENT ADDRESS
P.O. Box 94014
Palmine, It 60094-4014
Minimum Payment Due
Total Credit Une
Available Credit
Cash Acce88 Une
Available for Cash
VISIT US AT:
WWW.bankoM.com/creditcard
ECARD REWARDS SUMMARY
FINANCE CHARGES
Category' Daily Periodic Rate
33 daye in cycle
.02600%
.02600%
TRANSACTIONS
_' Trans
Date:-.::: Reference Number
c: 06101 c., 2461043H9232FRBFQ
.06/10-" .7426683J-jJ28NX:!XMD
06111 '." 2443565HK60MSVJSL
.." 06/12 -. 2402946HL WGS41 Y24
:. 06M2 -:. 2432301HL3F1DENKQ
06N3 2461043HM0350KJ8B
06114 _ 2443565HN8B60TSza
'leMS ,. 2402946HPWGS41 ZAS
OeM 6 .._ 2443565HR8B60TVOO
06117 " 2443565HR8BOPTl HO
06117 2443565HR8BOPTl H4
06N7' 2443565HT030VPA9V
06118 2440369HSSaQHSL3J
06/18 2461043HS2320RAVN
06/19 2461043HV2322ENM
06M 2461043HV2322E7VX
Purchases
Cash advances
ECARD REBATE:
$
.00
-_.~-->.
-...~:{@~.
Merchant Name or Transaction Description
. 5LEEP INN CARLISLE CARLISLE PA
. PAYMENT: THANK YOU
EAT N PARK RESTR 73 CARLISLE PA
MIDDLESEX DINER CARLISLE PA
CRACKER BARREL #431 CARLISLE PA
80B EVANS RESTAURANT #281 CARLISLE PA
EATNPARKRESTR73CARLlSLE PA
MIDDLESEX DINER CARLISLE PA
EAT N PARK RESTR 73.CARLlSLE PA
DIENERS RESTAURANT MECHANICS8URG PA
DIENERS RESTAURANT MECHANICS8URG PA
HOSSS STEAK & SEA #23 CARLISLE PA
VISAGGIQS ENOLA PA
QUALITY INNS CARLISLE PA
OUALlTY INNS CARLISLE PA
QUALITY INNS CARLISLE PA
":: . ._A/m_~~.~! .:::~:::.::~::
.. Crecht. ":"_"=-: - - Debl~-;::
..c.:~"~~5"i::.$192A(~
~;~~~~~fl1
. -'.""- ~.:$30.15
";$14.87
$26.32
'$43.81
$3.00
$25.39
$67.44
$224.97
$120.94
$602.64
$99.02
CorrespondlngAPR
PERIODIC RATE(S) AND APR(S) MAY VARY
Average Daily Balance FINANCE CHARGES
9.49%
9.49%
$0.00
$0.00
$0.00
$0.00
Total flnance charges $0.00
Effective Annual Percentage Rate (APA): N/A
Grace Period Type: B (Please see back of statement for the Grace P9riod explanation.)
The CorreaDondlna APR is the rate of Interest YOU Dav when you earrv a balance on ourcio;aaes. or cash advances.
Eat' n Park # 73
Comments or suggestions?
Please speak to Alan. the
General Manager or the Manager
on duty before leaving or call
<717> 240-0569
Jun14'02 01:49PM
Visa
XXXXXXXXXXXX3580
06/05
014085
9961
652/1
51 MARIE C.
ROBERT R SHOPE
Date:
Card Type:
Acct #:
Exp Date:
Auth Code:
Check:
Table:
Sarver:
Subtotal:
Tip:_
Total:
'13.37
tJ'1
1'!.~7
Signature
I agree to pay above total
according to my card issuer
agreement.
~ ~ ~ ~ Customer Copy ~ ~ ~ *
Eat'n Park # 73
Comments or suggestions?
Please speak to Alan, the
General Manager or the Manager
on duty before leaving or call
(717) 240-0569
Jun16'02 09:48PM
Visa
XXXXXXXXXXXX3580
06/05
016039
1036
22/1
2746 TAMMY
ROBERT R SHOPE
38.81
JOB EVANS #02B 1
] rde t- # 0095
)6/13/2002 R050l 12 :55
3ALE $ 28.15
rIP $ 2.00
Date:
Card Type:
Acct #:
Exp Date:
Auth Code:
Check:
Table:
Server:
rDTAL $
30.15
ISA XXXXXXXXXXXX3580
SSUEO TO: SHOPE ROBERT R
XP. DATE: 06/05
UTH. #: 013691
Subtota I :
Tip:
Total:
.************.~**~****;***~.**
* *
; THANK YOU FOR VI~ITING ~
* BOB EVANS *
* Carlisle, PA *
***.*********~*******<.**.*~**
5'_
.
'{'2, J?-I
Signature
r agree to pay above total
according to my card issuer
agreement.
* _ . . Customer Copy ~ . . .
(717Y241-2e21
,'.~ ;J;~~~
.:. ~ 'V;
o
t1IDDLESE~{ DINER "
12~:.lI'A~!sa..<S PlfE
C>FLISLE, P1\ 17m,
lEPJ\IHi!.I.D,:
fE\rnitf[ ,:
.. 34,4 '
. ,
urSA
4266Si%Hj62435.3~
SiilPE
SALE
11811: '~]l
[;}',:@E
.:;~...
:~.!j]CE.~~,
'Tn~: ,19:t5'j;'~~~f
(LITH!lJ: BlS1Sl}\':
. ", ,..~-' "
tWE~ .!l..~ 1)1200"2
..
'-',
'I EASI::
I TIP'
'TOTAL
$23.3:;2
. $3.. ee ','.
. $26 ~,~:?-: .
:,.'
,
"
; .?>
Rff81T R
I ~m Topm~JOTiL "'JiIF;;,:
~):;YJ)riJ TOCRRD 1m ~.',.;
'~'iIT ffifE8fIjT IEm:Dn.trJJQERV'
.. ..~.. .. , -,'",;" ","~...n~~~~t;i~
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.'.,;.: ;':.: ~:~~~~~.
';..;.,,:;,:,;~':.,.~,,;..~~~~t::~~ ~' -: . ~c,<:",.
.:~~
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'~~
CHCCKOUT
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QUALlTY INH
CARLI3LEi PA 17013
6'r - ~t;:,69 -~:~~~ ~2
UEG J3\ '[;] 20;12 l@~U ;ill
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: ufJ26
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--:
Eat'n Park # 73
Commants or suggastions?
Plaasa spaak to Alan, tha
,naral Managar or the Manager
I dUty bafore leaving or call
(717) 240-0569
.a: Jun11'02 08:23PM
'd Typa: Vi sa
:t #: XXXXXXXXXXXX3580
) Data: 06/05
ch Coda: 011624
'Cl<: 9123
II a: 16/1
'var: 2746 TAMMv
ROBERT R SHOPE
20.94
:?o1J
:2.. 1:-1'1
Jtota I :
p:
tal:
gnatura
agraa to pay abova total
,cording to my card Issuar
Iraamant '
. * * Customer Copy * * ~ *
. _v.................._............~........~_......._^"_~~....,..____
SALES DRAFT
~c:::'s ,~.~~A~; ~ SEA ~23'-'
1::1 hHRR:SBlPB PIKE
:;~~::~E, r~ lt~lj
1ERnIr~AL 20E250
~ -':'~=:: i229'~':;
{::~:i-0: ~8:l6P\i
~)S i:~6S:{,f~6243520 EXP. ~605
A:~~. \~t~:. lB. ~12169i16166B7~
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i :EVER # 9426 ':~, .
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$68.44
~L__..:.2_ =-_
. -,:L:=f~!!LiJ
: ?::REE 1D PAY FtBDVE TDTP,C"AMOUNT' '. ',-Il
;.--.~,t'Rl1Ti,jr; in l"'ekrl '''It'~!jj:'R ^Gnr;:N~"rl ~:'lf
~~;~;,c :" ~~~~..."~;. r.o~n~"T.::.O~;CU--' 'n
.~ 1.,tr:+HM?1 .' 'tt,:t~.".l it .."Wi ,'ur~."J
r6EE~\Z~lyfZ7:~=-----~-
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TQ~\LD~y-rt~CHM~i SDT1DM CD?Y-CUSTDMEK
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,- ".'"'-. ...,...._-,....;.......'n
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4
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---...----...-.-.,.-.--.--.
(711) 241"':2\121
t'1IDDLE3E::~: DINER.
12~}3 HA,F;,,~!~EJj~iJ PiKE
Ch~j..ISL:; PH 170i3
1BMIliA LD.:
iffi~'l'l11 I:
J.::::j
l.JISA
426.tal~1%14-.~-SB
EEH #:a.~~3
S'JI?E
:','!'" l\.~TI:'
...:.r. L1'!lt
[fJr}6 .
SALE.
I~,mGE~ B9576S"
i:lITE: .JtlNl2: 7tif12. TI~E: 1?:i}2
~JTH ifu: 01~~5:3
.'---~~-'----- i?l.-.-__"'i.
i ";:'M~~ ..... ~_
TIP... . ..,_:.._~L~
TOTAL . ~_A_'-i.}j~
.~. .
. . .,.
!'1 ,,1 . ' '..
Re5E. R . .... ..,
X - rL--
" Il1J1TUrP/ i3JlDELlHE I '
. 1~=n,15 Z\JW4.2~
" c.,'.._.. .
.. IW ro PAvl4lO.lJOTAL l1iIfi.If[
m.oI~TO ~IW:f1aF8ei1:",,' :
(lOOWITiffmm.IFCP.EDlT \OOOERf I
- ' .1
. .--. -........ .....--- _.-.._---.--...~,.;
UISAGGIO'S
699C ','~ :ITZUILLE RO
Ell!: 17025
S-H-E-, ul:-H-l
7188,459
OOOO,~~lS566
stRUE,: :
REf: 0005
CD mE: ~ISA
lRlVPE:PURCHASE
DAlE: JU1I13,D1
Al-lOU1H
TIP
19:19:19
$199.97
_ ?S..:::-
TOTAL
~i."J7
ACCT:416681DI0614158D
AP:018674
IIAI{: R08ERl R SHUll
(:~p: o~/c~
.~R~~E'~t: '1 .:,.:~ ~ ,,,'~ji:'} :(~L.. '.IF ~oo~s
AIID;;R ':"'_":[', jlllHE ~MDUlIl or THE
TOTAL Sh0;.;:: l~l);:f~lI Al:r, HBREES 10 PERrOR~
THED8LlGAllDlISSElFDRlHBV!HE
CAROME~[R'S ~r,REEM[1l1 UI1H IHE ISSUER
IHAIIKS FOR USIIIG ~ISA
K_....m_m____ _________m_____n_
\1\1111111111111111
005192
Cracker Barrel Store ~431
Carlisle, PA
B97473 PAULA 0
1 2 2 /1 5 1 9 2 GST 2
JUN12'02 12:49PM
1 ICED TEA 1.39
1 ICED TEA 1.39
1 GRILL CKN SALAD 6.99
1 HOME CKN SALAD 6,99
Subtotal 16.76
Tip 2,50
Tax 1.01
Total 2 0 . 2 7
Charged Tip $ 2,50
VISA 20.27
--306074 CLOSED JUN12. 1:26rM---
Thank You
Please Come Back
www.CrackerBarrel.com
,
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Statement
United Church of Christ Homes
Thornwald Home
442 Walnut Bottom Road
Carlisle, PA 17013
Statement Date: 06/01/2002
Sandra Shope
6651 Amblewood Street NW
Ca~ton, OH 44718
Due Date: 06/25/2002
Re: Virginia M Diener
Account Nr: 496
--------------------------------------------------------------------------------
Date
Description
Days
Quant
Rate
Charges
Payments
Balance
--------------------------------------------------------------------------------
BALANCE FORWARD 4,977.94 4,977.94
05/10/02 PAYMENT 4,977.94 .00
05/15/02 Beauty & Barber 1. 00 10.25 10.25 10.25
05/31/02 Cable Television 1. 00 12.50 12.50 22.75
05/31/02 Personal Laundry Se 1. 00 15.00 15.00 37.75
05/31/02 Incontinence Suppli 1. 00 68.48 68.48 106.23
05/31/02 Medical Supplies 1. 00 81. 34 81.34 187.57
06/01/02 Room & Board - Semi 30 156.00 4,680.00 4,867.57
~ltl"S( ""'1
~"5Ce 1. :>
G,....1I-0~
C~ cl~Md.
~_/<-{-o ()
June 23,2002 County Fair 12:00 - 3:00
Return your R.S.V.P.
Bring a sald or dessert and join us for the fun
-...".........
?HARMERICA ~1t~
.
For Comments and lor Concerns:
111 RUTHAR DRIVE
NEWARK. DE 19711-
For Payment:
PO Box 6413
Carol Stream. IL 60197-6413
IF YOU HAVE ANY QUESTIONS CONCERNING THIS STATEMENT OR WISH TO PAY WITH YOUR VISA. MASTERCARD.
AMERICAN EXPRESS. OR DISCOVER PLEASE CALL A BILLING REPRESENTATIVE AT 800-352-9161
CUSTOMER NAME
)IENER VIRGINIA
FROM HRU DA TEl
DATE RX NO. DESCRIPTION
04 30/02 R A
05 01 02 .' 46 3 5
05/01/02 467401 CELEXA 40MG TABLET
05 0 02 ?il!14 7 0 20 ~0~",,"5J;;r~'W;;uLf;;S.:j;:$Th~z~~~;P~!~i"
05/01/02 481579 DAIL V-VITES W/IRON TABLET
o 01 02\!lf48163 M40 A L
05/01/02 481636 CELEBREX 200MG CAPSULE
05/03/02'1Ili521,];,,~ E'~ ,iE E. R
05/08/02 523506 CELEXA 20MG TABLET
05 6102 ""49915~,F '~0:25?'\' Y.n
05/18/02 527701 SULFAMETHOXAZOLElTMP OS TAB
05 0/02 ""'~'!!!['I!'l!ililI.l!i!!!PAYMENT?~THANK""'0Uj!1!'@ij_~~~!'~~ClI'}'i""\i11"''''fi''
05/22/02 529027 CIPRO 500MG TABLET
05/28/02 Jil'530973~.>iiI!XAI,;ATAN .Q;005WlStE-'BROP
05/29/02 481579 DAILY-VITES W/IRON TABLET aTe
05129/02; ...:>481635"FUROSEMIDE'40MG;rABLE~~."'J;illllIll>"""'!i;!l),.""i"""'#"")
OS/29/02 523506 CELEXA 20MG TABLET RX 30
05/29/02 i~,s29708.:i.'i, PREVACIDr15MG''CAPSULE'DR~~_#''''',;.~"".,;.I>ii.'' X",,:ll;i;i30*
OS/29/02 529709 VITAMIN E 200lU CAPSULE aTe 30
05/30/02- ;114801 03 .,,~ MURO,;;j 20/o'EYEDROPS "'.:~'l!\!!:,,~~I:' '.<1~""':';'''' T
PHYSICIAN NAME
BRANSCUM JR GEORGE P
STATEMENT
DATE ACCT. NO.
05/31/02 5702-01-02053
DOLLAR
QTY. CODE AMOUNT
481.50
',135;20'."..
76.45
':30"
30
-'3
30
;,ill'~~~~;,';;Ltt
RX
aTe
.65
";:':30"'<~~;
RX
30
86.60
'lR"vill:f"50,OO'""",,
52.60
;-:r~25J4S:",:i:i~
AMOUNT DUE UPON RECEIPT
CV=CONVERT TR= TRANSFER CR=CREDIT RX T = TAXABLE D=DISCOUNTED N=NON-COVERED
~ cl.1:'Oxe.l. (q~f'?-V&
.lIl
PLEASE RETURN BOTTOM PORTION WITH PAYME::NT - Retain top portion for your records
j
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471
!
1
PETITION FOR PROBATE and GRANT OF LETTERS
Register of Wills for the
. Deceased. County of Cumberland in the
Social Security No. 1 qR-1 0-1?1? Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of a&e or older an the execut ri x
in the last will of the above decedent, dated J anllarY 26.
and codicil(s) dated June 1, 199tl '
No.
To:
21-02-633
Estate of VIRGINIA H. DITmER
also known as
named
,19~
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in Cumberland County, Pennsylvania, with
~ er last falllily or principal r!:.sidenceilt Thormlald Horne. IJ.LL2 Halnutbottom
oad, Carl1.s Ie, FA l7u13 tJar1is Ie Borough
(list street, number and muncipality)
Decendent, then ~L- years of age, died
at
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
June 13.
2002
,
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$ S.OOO.OO
$
$
$
WHEREFORE, petitioner(s) respectfully re'l\lest(s) the Rrobate of the last will and codiciI(s)
presented herewith and the grant of letters 1'estamentary
(testamentary; administration c.La.; administration d.b.n.c.La.)
theron.
.
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66<)1 Amblewood t., N. H.
CAnton, Ohio 11)17113
/~ -1,<,' ~
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA } ss
COUNTY OF CUHBERLAND
The petitioner(s) above-named swear(s) or affirrn(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law.
Sworn to or affi,rmed and subscribed {
before me this 12 tit daY8f
~l~ 2U 2
, / (!,;tOMj/OI. J/lf' /;}:;;;:;
/")- /6-:' /
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No. 21-02-633
Estate of
VIHGDUA 11. DIENER
, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW July 12 .~006 in consideration ( . ".: 1"':1[1(11: on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated January 26, ] 9g6
described therein be admitted to probate and filed of record as the last will of
Testament 01' Virginia 11. Diener and Codicil dated June 1. 1S/913
and Letters Testamentary
are hereby granted to Sandra K. Shope
~.I/~/(? ij!://R1:0//') n/.J ,O~.e.u-Z-/
l~,ter of WIlls j
FEES
Probate, Letters, Etc. .........
x-pages
ega'fc1.'Itificates( )..........
Renunciation ................
JCP
$
$
$
$ 5.00
TOTAL _ $ 70.50
....... .JULY. .12,.2.002......... ...
25.00
l11.UO
t~:98
J. Robert Stauffer (06,r,61
ATTORNEY (Sup. C,. LD. :'-10.)
Market Square Bldg.
Mechanicsburg. PA 170SS
ADDRESS
Filed
7l7-766~9673
PHONE
TO BE PICKED UP BY EXECUTRIX 7-12-02
P
1..'._
-~
,',.;
l,j
IlllhKP~ REV ~IS('
This is to certity that the information here given is correctly copied from an original certificate of death duly filed with me as
Local l~egistrar. The original certificate will be f()lwardcd to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
(Iii""jjH''''7;;~~~",
,,"'c,~\H OF Pb;----_
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>--!IMfNT ~,'t-\",
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LU~ 'I>-Al
Local R~ istrar n
Fee f(H this certificate, $2.00
P 8391717
r
I~
dOO2-
Date
21-02-633
Hl05 \4JRh 2167
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
TYPEJPRI"'T
'.
PffI.M"N(NT
III....CI(INI(
AGE (la..80<tt>0a1'l
UNOER'YEAf!.
- -
ST"UF'UNUMlIEIl
=~~~ siX SOC'''LSECUIlIT'\'NU'''llEIl
Vir inia M. Diener ,. Female 3. 198 10 1212
"~""~ 1 "'-'-",om. ,~~.",,_. ~."'~n."~"',_n__.,~'.'OO__'
_ : "'........- .~"mn.~'..., Sla'."'~CI.'9"COIJt..y, HOSPIt"I.. -
! Dee 8,1920 7. Mechanicsburg. Pa. lnpoo'......O EAIO"lp.""'" 0
Cfl'Y.6OFlO.TWPOfOf;NIi FACILIT"l'N"""EI" nol"''''''''''''.il'''''...etoIand.........,..,
O~IEOFOENH,,",,,,",,ua>._,
4. June 13, 2002
NNoIEOfDECEOENTlf""._,l"')
. 'II. Owner 0 erator 111l.
DECEDENT'S"'A'L'NGoWDf!ESS(SuHl_CofV/bwn,SIoot.zopCo<>>l
Retail Drug Store
IW.SDECEDEN1E~EIlIN
US.AAUEOFOACEli1
IUD Nl>KJ
'-
(14",~.)
:::....,0
.
COUNT'\' Of DERH
81
'"
Cumberland
OECEOENT'S USUAL OCCUPl\TION
'~:""k"':;;'~'::;zt::'i'
k
k.
I<IND00BUSlHESSIItfDI.ISTIlY
Carlisle
Thornwald Home
AAC(.......""an...,..".......\\IIUI..<<<:
,-,
DECEDENT.SEOIJCJlJION
..
White
"
...
lU.fl.I1.\I.$TlTUS._
N__...._.
--
Widowed
SUflrvTVlNGSPOlISf
,._,~"""''''-j
,.
FNHEIl'S NAME IF.... Mo<IdIe LIISII
442 Walnutbottom Road
Carlisle, Pa. 17013
DECEDENT.S
AC1Uol.l.
fl.ESIOENCf:
!See....."".......
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u..lito,.
Pa.
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-
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Cumberland ---.,1 ".._00 ::"'-===01
WJltlER.SNAME,f.... _,Ma.......SU'_1
I.. Esther Beatrice Swanger
lNFOfl.MAN1'SMo\IlJNOAOORESSlSo-_.~,SIalo_Z",C""-l
6651 Amblewood Street North West Canton, Ohio 44718
PlACEOFOIsPOSrTlOH'_IIIc.m...y,C,.......", LOCAtION-CoIyJluwn,St"',liI>Co<Io
._-
Carlisle
~-
..
1NF00000T"SNAME(lypod"""I
Herbert F. Wagner
"
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~
Jun 17,2002
Uc.
Conolite Crematory
...
SChaefferstown, Pa. 17088
LICENSE NUYIlER
NI4IlEJ.HDADDAESSOFFACIl'T'\'
FD-012662-L
M ers Funeral Home lnc 37 East Main Street Mechanicsburg. Pa 17055
LlCENSENUMllEIl DAESIGNEO
/M"""'_Ooly._,
.. .
W\,S CASE REFERREO TO MEOIC.lI. EXAMINEAlCOAONEA?
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OME PIlONOU"ICEO DEAO (M,""" Day, ......1
H. 10:10 A.M. U 25. June 13. 2002
27. PllRT I: E.........cIi.....5.i<Ij"'~or~_"......'MdoI.'~ DD""'_the...-otdyong,wc~uo:a,""'e"".OP"'l<lIya"M1._orhull""'.
L..onIy".....,....""UCllIifloo
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OUElOIOAASACON5EOO(NCEOfl
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Dl.ElOlOfl.ASACClNSEOUENCEOF):
OUElOIORAS"CONSl:OUENCEOfj
WEREAUlOPSYflNOlliGS
--....&I.EPAIOAlO
COMPI.ETlONOFc.wsE
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UANNEIlOf DEA1H
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(l.lorlInO"".....iII)
TIUEOI'INJUAY
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l........ot..''''wk............._acc__.....u''..(.l.nclm..........'_.
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-
SIGNIIlUIlE~LEOFC d
~ . . Gl. """~ L_h-______
tlCENSf,NUMIlER DIIl(SIGNED'Moo,.,_Oor......l
o I.., ""'0 Ql\.2. '1 I C. )!.L_.1~!;l~_.!..~ ~Q~ _
NAME ANo..OORE$$OF PERSON W)'fCOW'lElEOC..USE OF OEIIlH
(IIem27\TYPlIOlPnnt G> t.:Jf" u..~ Lt..J....... "I"r\\)
G',"''''''>- .
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'PRONOUNC'NG ANOC1iRllfYlNGI'tIYSICl.....'''''_ "",n;>O"""''''''''Y<l...,n ",....,...,oIy."Il ",0.""",0',,".,,,,\
T..__olmy........'-.lg......."occ"'Nd.I__.dal.,anclp'K...ncl_I".".c."..(...""m.noa,n".I-.l
'IUDICAI. EXAMlNERlCORONEIl
On Ih. b..i. 01 namin.tlon .nclJ.... in.o"lva1ion. in my opin'on. dUlh OC~"".d al t~e limo, Ital.. and plac.. ."d Itu. to the c.U"II'.ncl
....,.,......l.IR__........ ... ......_._.. ..... _._................. _... ._.... ..... d_... ........
".
REG'Sl
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.'
21-02-633
LAST lULL AND 'l'ESTAHENT OF VIRGINIA 11. DIENER
I, VIRGINIA H. DIENER, of the Borough of l1echanicsburg,
County of Cmnberland and State of Pennsylvania, being of sound
and disposing mind, memory and understanding, do make, publish
and declare this my Last Hill and Testament, hereby revoking and
making void any and all prior IHlls by me at any time heretofore
made.
1.
I direct the payment of all my just debts and funeral
expenses as soon after my decease as the same can be conveniently
done.
2.
I give, devise and bequeath-all the rest, residue and
remainder of my estate, real, personal and mixed, Hhatsoever
and Hheresoever the smne may be situate, to my husband, CHARLES
E. DIEllliR, absolutely and unconditionally.
3.
In the event that my husband, CHARLES E. DIENER, should
predecease me, or should he die Hithin thirty (30) days from the
date of my death, then in either of such events, I direct the
settlement and distribution of my estate to be made in the
folloHing manner, to Hit:
-1-
A. I give and bequeath the sum of Five Thousand
($5,000.00) Dollars to ST. PAULI S UNITED CHURCH OF ClffiIST,
of Hechanicsburg, Pennsylvania.
B. I direct that all the rest, residue and remainder
of lilY es tate be divided into three (3) equal shares and that
the same be paid out and distributed as follows, to wit:
(a) I give and bequeath one (1) such equal share to
my daughter, SAIIDRA K. SHOPE and her husband, ROBERT
R. SHOPE, share and share alike, or to the survivor
of said two legatees, absolutely, should either of
them predecease me,
(b) I give and bequeath one (1) such equal share to
my grandson, KEVIN R. SHOPE, absolutely and un-
conditionally.
(c) I give and bequeath one (1) such equal share to
my grandson, HATTHEH D. SHOPE, absolutely and un-
conditionally.
C. For the purpose of facilitating the settlement and
distribution of my estate, I authorize and empower DIY personal
representative or representatives, hereinafter named, to sell
any and all real estate which I may own at the time of my decease,
at either public or private sale or sales.
-2-
LASTLY, I nominate, constitute and appoint my husband,
CIURLES E. DIEIITm, Executor of this my Last >lill and Testament,
and in the event that my said husband should predecease me, or
should he be unable or unwilling to serve in such capacity for
any reason, then in such event, I nominate, constitute and appoint
my daughter, SANDl1A 1':. SHOPE, and PNC BANK, N. A., Co-Executors
I
of this my Last Hill and Testament, in his place and stead, and
in all instances, I direct that my said personal representatives
be excused from posting bond or other security for the faithful
performance of their duties in any jurisdiction.
IN HITNESS ,mEREOF, I have hereunto set my hand and seal
this de" day of January, A. D., 1996.
~,,;,'\M 'G,..;..._....
irginia l'l. Diener
(SEAL)
-3-
Signed, sealed, published and declared by the above
named, VIRGINIA H. DIENER, as and for her Last \1111 and Testament,
in the presence of us, lfho have subscribed our names hereto as
1-Ti tnesses, at the request of said tes tatrix, in her presence and
in the presence of each other.
-4-
COMMONWEALTH OF PENNSYLVANIA )
55.
COUNTY OF CUMBERLAND
)
I, VIRGINIA N. DIENER , the 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 and Testament;
that I signed it willingly; and that I signed it as my free and volun-
tary act and deed, for the purposes thereiu contained.
Sworn and affirmed to and acknowledged
VIRGINIA E. DIENER , the testat rix
day of January , A. D. , 1996.
before me b~
, this ,-/h
~ ~~.
_Seal
Mal1Iyn Kay EakIn. NotlIyf\JlJll::
Med1a,-,icsburg BolO. CUmberland COunty
My Comn1ssion ExjjI9S l'bJ. 6, 19'J7
COMMONWEALTH OF PENNSYLVANIA )
55.
COUNTY OF CUMBERLAND
We, the undersigned, J. ROBERT STAUFPER
and SUSAN A. HcCOY , the. witnesses whose names are
signed to the attached or foregoing instrument, being duly qualified
according to law, depose and say that we were present and saw the
testat rix VIRGINIA 11. DIENER , sign and exe-
cute the instrument aSldUalrlher Last Will and Testament; that the
said testatriX VIRGINIA J.1. DIENER , 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 the time, eighteen (18) or more years of age,
of sound mind, and under no constraint, duress or undue influence.
Sworn and S$~ctlbed to befor
me this ,(;J t'''- day of
January 1996.
'~0~
'/ (J
J; cdL.
NolaIfaJ Seal
~~': EakIn, NotlIyN:ilc
. .Boro. Cumbei1ard County
My CornmisOOn 8<pjres Nov. 6, 1997
-.~ ofNolaiiGS
21-02-633
COD I C I L
I, VIRGINIA M. DIENER, of the Borough of Mechanicsburg,
County of Cumberland and state of Pennsylvania, being of sound
and disposing mind, memory and understanding, do make, publish
and declare this the First Codicil to my Last will and Testament,
dated January 26, 1996.
1.
I do hereby amend the paragraph of my Last will and Testament
dealing with the appointment of my personal representative, to
read as follows:
"LASTLY, I nominate, constitute and appoint my husband,
CHARLES E. DIENER, Executor of this my Last Will and Testament,
and in the event that my said husband should predecease me, or
should he for any reason be unwilling or unable to serve in such
capacity, then in such event, I nominate, constitute and appoint
my daughter, SANDRA K. SHOPE, Executrix of this my Last will and
Testament, in his place and stead and in all instances, direct
that my said personal representatives be excused from posting bond
or other security for the faithful performance of their duties in
any jurisdiction.
2.
I hereby ratify and confirm my Last Will and Testament dated
January 26, 1996, in all other respects and to all intents
purposes, not inconsistent herewith.
- 1 -
,
IN WITNESS WHEREOF, I have hereunto set my hand and seal
this /.5; day of June, 1998.
L~~"'l;'''' ~~~?(SEAL)
V1 g1n1a M. D er
signed, sealed, published and declared by the above named,
VIRGINIA M. DIENER, as and for the First Codicil to her Last will
and Testament, dated January 26, 1996, in the presence of us, who
have subscribed our names hereto as witnesses, at the request of
said testatrix, in her presence and in the presence of each
other.
d.
COMMONWEALTH OF PENNSYLVANIA )
COUNTY OF CUMBERLAND )
I, VIRGINIA M. DIENER, the 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 the First Codicil to my Last Will
and Testament: that I signed it willingly, and that I signed it
as my free and voluntary act and deed, for the purposes therein
expressed.
.1 ~~) rn, J:)r€~(SEAL)
V~inia M. Diener
Sworn and subscribed to
before me this day
of June, 1998.
/!J~~ C~//~.
Nota y publ'
~ Se.Il I
h\lIIftyn E. Y/1Blams. ~~unty
~i!.~:S~:' Nov,.(;, 2001
My CgmmI.......... . '
k. T11a M.!;Q\.,~"lion of Noto.ries
Memll6', Peflfl\V.:D .._.' " f
- 2 -
,
COMMONWEALTH OF PENNSYLVANIA )
COUNTY OF CUMBERLAND )
We, the undersigned, J. Robert Stauffer and Susan A. McCoy,
the witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, depose and say
that we were present and saw the within testatrix, VIRGINIA M.
DIENER, sign and execute the instrument as the First Codicil to
her Last Will and Testament; that the said testatrix, VIRGINIA M.
DIENER executed it as her 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 the time, eighteen (18) or
more years of age, of sound mind, and under no constraint, duress
or undue influence.
d.
Sworn and subscribed to
before me this
day of June, 1998.
~~ lcJ,A,I~
Notar Public
Nolal1al Seal
Martlyn E. Williams. Notary Pubffc
Mec:tlanlCsburg Bofo. Cumbertand COtJflty
My Comrriission Expires Nov. 6. 2001
Member. PennsylvaRla AsSOCIatIOn of Notanes
- 3 -
~ ------
Name of Decedent:
CERTIFICATION OF NOTICE UNDER RULE 5.6(3)
frt. G t~f'
Date of Death:
U l'r-i/\,(,'o-.-
~U~ l3
,
d-oO~
Will No.
Admin. No. d-oOr{) - D(033
PIl F,'k)!u. 0:;1-002-0&33
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(~f the Orphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on w'Z) 1(P1 ~O>l. :
~
Address
(PJ(j, Wd((Q\'n~ G("ove.~
Med-.W\t~bUt A- t70SS
W ~ S { Ii t>t,b Le c.e.wd <:tt)JW
r~~. I CJ{f 44 7/~
/5 'S" ()J','[lI!W t3enJ (j i'.
Ccev~\'.efct { 0 tf Lf'f,'-{06
ql~ f'r\d{ Gi'e.Le /ipt- /{3
!+ ({t'aN. -e I 0 ff 'N00!
/lJ I A-
t
~1', Pcu.J's: (J~~ufa~,:rr
I flb--...t-t'- /. ~~
SanJ~ H. S'~
~BV'K ~. -Short
M~-ew b. 'Shepp
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date:
'1 / ICe / O~
, I
~Lk~
Signature
\)
Name S ctnc11'P-- k ~It~
Address &fRS( fJ-Mbt-ewocJ& -st /lJUJ
C ~l (') U 1.f,{7/ 'IS - {3 (jf
Telephone 1330) L/q4 - LfSO<r
~~ U: ' ) \ L t -:fr 70,
Capacity: ~ Personal Representative
_Counsel for personal representative
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INOIVIDUAL TAXES
DEPT. 280601
HARRIS8URG, PA 17128.0601
REV.1162 EXj11-96}
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
SHOPE SANDRA K
6651 AMBlEWOOD ST. N.W.
CANTON,OH 44718
nnnn lold
ESTATE INFORMATION: SSN: 198-10-1212
FILE NUMBER: 2102-0633
DECEDENT NAME: DIENER VIRGINIA M
DATE OF PAYMENT: 09/11/2002
POSTMARK DATE: 09/09/2002
COUNTY: CUMBERLAND
DATE OF DEATH: 06/13/2002
NO. CD 001606
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $8,736.00
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS: SANDRA K SHOPE
CHECK#1264
SEAL
INITIALS: CW
RECEIVED BY:
REGISTER OF WILLS
$8,736.00
MARY C. lEWIS
REGISTER OF WillS
I d-
Clv
STATUS REPORT UNDER RULE 6.12
Date of
Decedent: VI'I'~ "rU.o.-
Death: ~ I ,~o.:z
.
JI1. Dl'el'\.er-
Name of
Will No.
Admin. No. j I-O;J - O~ 33
Pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to completion of
the administration of the above-captioned estate:
1.
State whether administration of the estate is complete:
Yes X No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes ~ No .
b. The separate Orphans' Court No. (if any) for
the personal representative's account is:
c. Did the personal representative state an
account informally to the parties in interest? Yes )( No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
Date: /0/ j</ / dc)
I I
~*~
Signature
Sctn,/ra- k. 'S he ~e
Name (Please type or print)
(PCpSI A-tY\6IeLvood .s:t,IVLU.
AddressC~. 0 fJ 4q7tlr
(330) '1Cl'l-4sgo
Te l. No.
Capacity: ~ Personal Representative
Counsel for personal
representative
(MAH:rmf/AM3)
/7 - 7..5- /
"-
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG~ PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
GEORGE R HETRICK
DONOVAN ETAL
1867 W MARKET ST
AKRON
i'
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
11-11-2002
DIENER
06-13-2002
21 02-0633
CUMBERLAND
101
'*
REV-15~1 EX AFP IDI-D2:l
VIRGINIA
M
C-3
OH 44I>i:13
Amount Rellitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV:is'4-;-iiCAFP--fiiFiii!Y-NOYiCi--OF-i-NHiifiTANCE-YAX-A-PPRXisiiiENT:--ALrOWANCE-cfi-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF DIENER VIRGINIA M FILE NO. 21 02-0633 ACN 101 DATE 11-11-2002
TAX RETURN WAS: I X I ACCEPTED AS FILED
CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule AJ
2. stocks and Bonds (Schedule B)
3. Closely Held stock/Partnership Interest (Schedule C)
4. Hortgages/Notes Receivable (Schedule DJ
5. Cash/Bank Deposits/Misc. Personal Property (Schedule EJ
6. Jointly Owned Property (Schedule f)
7. Transfers (Schedule G)
8. Total Assets
III
121
131
141
151
161
171
.00
.00
.00
.00
210,764.00
11.106.00
.00
181
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Ad... Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Govern..ntal Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
191
1101
4,999.00
7.508.00
1111
1121
1131
1141
NOTE: If an assessment was issued previoUSly, lines
reflect figures that include the total of ALL
ASSESSMENT OF TAX:
IS. Amount of line 14 at Spousal rate (IS)
16. Amount of Line 14 taxable at lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
T CR TS:
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
221,870.00
1?~n7 nn
209,363.00
5,000.00
204,363.00
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
.00 X 00 =
204,363.00 X 045 =
.00X12=
.00 X 15 =
1191=
+
AMDUNT PAID
8,736.00
DATE
09-09-2002
NUHBER
CD001606
INTEREST/PEN PAID I-I
459.79
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
.00
9,196.00
.00
.00
9,196.00
9,195.79
.21
.00
.21
IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICRI, YDU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. I
RESERVATION: Estates of decedents dying on or before Dece~ber 12, 1982 -- if Bny future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estete for
life or for yesrs, the Com.onwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral) rate on any such future interest.
PURPOSE OF
NOTICE:
To fulfill the require.ents of Section 2140 of the Inheritance and Estate Tax Act, Act Z3 of 2000. (72 P.S.
Section 9140).
PAYMENT:
Detach the tap portion of this Notice and sub.it with your paYdent to the Register of Wills printed on the reverse side.
--Make check or .oney order payable to: REGISTER OF KILLS, AGENT
REfUND (CR):
A refund of a tax credit, which was not requested on the Tax Return, day be requested by completing an RApplication
far Refund of Pennsylvania Inheritance and Estate TaxR (REV-1313). Applications are available at the Office
of the Register of Wills, any of the 23 Revenue District Offices, or by calling the special 24-hour
answering service far for.s ordering: 1-800-362-2050; services for taxpayers with special hearing and I or
speaking needs: 1-800-447-3020 (TT only).
OBJECTIONS: Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or asses~ent
of tax (including discount or interest) as shown an this Notice must object within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
ADMIN-
ISTRATIVE
CORRECTIONS:
Factual errors discovered on this assessment should be addressed in writing to: PA Depart.ent of Revenue,
Bureau of Individual Taxes, ATTN: Past Assess.ent Review Unit, Dept. 280601, HarriSburg, PA 17128-0601
Phone (717) 787-6505. See page 5 of the booklet RInstructions for Inheritance Tax Return for a Resident
DecedentR (REV-1501) for an explanation of ad.inistratively correctable errors.
DISCOUNT:
If any tax due is paid within three (3) calendar months after the decedent.s death, a five percent (5%) discount of
the tax paid is allowed.
PENALTY:
The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax a.nesty period. This nan-participation
penalty is appealable in the same .anner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
INTEREST:
Interest is charged beginning with first day of delinquency, or nine (9) .onths and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of
six (6%) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after
January 1, 1982 will bear interest at a rate which will vary fro. calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2002 are:
Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor
1982 20;: .000548 1992 9% .000247
1983 16% .000438 1993-1994 n .000192
1984 11;: .000301 1995-1998 9X .000247
1985 13;: .000356 1999 n .000192
1986 10;: .000274 2000 8X .000219
1987 9X .000247 2001 9;: .000247
1988-1991 11;: .000301 2002 6X .000164
--Interest is calculated a. fallows:
INTEREST = BALANCE OF TAX UNPAID X NUnBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (IS) days
beyond the date of the assessment. If payment is made after the interest co~putation date shown on the
Notice, additional interest must be calculated.
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