HomeMy WebLinkAbout10-02-14 (2) 1505611185
-J REV-1500 EX(02-11)(FI) ppFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN 21 14 0 411
PO BOX 280601
Harrisbur9,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MnnDDVYVY Date of Birth MMDDm�'
172- 04192014 03311938
DecedenYs Last Name Suffix DecedenYs First Name
MI
KENNEY
KATHLEEN R
(If Applicable) Enter Survivi�g Spouse's Information Below MI
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
_ _ REGISTER OF WILLS
FILI IN APPROPRIATE BOXES BELOW ❑
� 2. Supplemental Return 3. Remainder Return(Date of Death
� 1. Original Return Prior to 12-13-82)
� ❑ 4a. Future Interest Compromise(date of ❑ 5. Federal Estate Tax Return Required
4. Limited Estate death after 12-12-82)
� � 7. Decedent Maintained a Living Trust � 8. Total Number of Safe Deposit Boxes
6. Decedent Died Testate Attach Copy of Trust.)
(Attach Copy of Will) � ❑
� 10. S ousal Pover Credit(Date of Death 11. Election to Tax under Sec.9113(A)
9. Litigation Proceeds Received � getween 12-31y91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIADaytime Telephone NUmber BE DIRECTED TO:
Name
CRAIG A • HATCH, ESQ •
717-731-9600
REGISTER OF WILLS 1}�.F ONLY
c � �' rn
�. o rn �
� � c�'�' �? ca
First Line of Address � � � --i � .=�
�
2109 MARKET STREET �' � f:� rv F i ��'
.;� -
Second Line of Address � ` ` ::? �':�
� r� "�'t
'.�f
DA7H P�L�
City or Post Office State ZIP Code -- �
E.-� � m
PA 17�11 �
CAMP HILL � � �
CorrespondenYs e-ma11 address: C • H A T C H a H H G L L P • C 0 M
Under penalties of perjury,I declare that I have examinad this retum,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all' rmation of which preparer hDATE knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN �v�� /a o�
CRAIG A � HATCH, ESQ • � EXR •
ADDRESS A M p �, P A 17 011
2109 MARKET STREET DATE
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE O � %v/c�
CRAIG A • HATCH, ESQ •
ADDRESS CAMP HILL� PA 17�11
2109 MARKET STREET
PLEASE USE OR INAL FORM ONLY
Side 1 �
� 1505611185 1505611185
OM4647 3.000 \ ^
\;\
�
� 1505611285
REV-1500 EX(FI) DecedenYs Social Security Number
oecedentsNarrie KENNEY KATHLFFN R 172-3��4506
RECAPITULATION
„ � $0 • 00
1. Real Estate(Schedule A) . • • • • • • • • • • • • • • ' ' ' ' ' ' ' ' ' � '
2. Stocks and Bonds(Schedule B). . . . . . . . . . . . . . . . . . . . . . . . .
2 $40 •98
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C), , , . . 3.
$� • �0
4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . 4• $� • ��
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E) , , , , . 5.
$107,362 • 12
6. Jointly Owned Property(Schedule F) � Separate Billing Requested , , ,
6 $0 • ��
7. Inter-Vivos Transfers&Miscellaneous Non❑-Probate Property 7 $� . ��
(Schedule G) Separate Billing Requested .
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . .
8 $107,403 •10
g. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . .
. s. $11,060 - 47
10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) , , , , . . . . . 10.
$1,321 •39
11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . .
, ��. $12�381 • 86
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . �z. $9 5��21 • 2 4
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which $Q . Q 0
an election to tax has not been made(Schedule J). . . . . . . . . . . . . . . . 13•
14. Net Value Subject to Tax(Line 12 minus Line 13) , , , . . •
. �a. $95,021 • 24
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 $� •��
(a)(1.2)X.0� $0 • �� 15.
16. Amount of Line 14 taxable $� . �Q
atlinealrateX.O.� $� •00 16•
17. Amount of Line 14 taxable $2�2 8� • 51
at sibling rate X.12 $19,0 0 4 •2 5 ��.
18. Amount of Line 14 taxable $],],�4 0 2 • 5 5
at co�lateral rate x.15 $7 6,017 •0 0 �$�
19 $13�683 • 06
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
$id@ 2
1505611285 1505611285 �
� OM4648 3.000
File Number
REV-1500 EX(FI) Page 3
Decedent's Complete Address: 21 14 0 411
DECEDENTS NAME
KENN Y KATHLEEN R
STREET ADDRESS
M R N D STATE ziP
c�T�" 17 011
CAMP HILL PA
Tax Payments and Credits: ��� $13,6 8 3 •0 6
1. Tax Due(Page 2,Line 19)
2. Credits/Payments
A.Prior Payments $13�0 0 0 • �0
a.oiscount $6 8 4 • 21 $13�6 8 4 • 21
Total Credits(A+B) (2)
3. Interest �3� $� • 0�
4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. (4) $1 •15
Fill in box on Page 2,Line 20 to request a refund.
$� • ��
5. If Line 1 +Line 3 is greater than line 2,enter the difference.This is the TAX DUE. �5�
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS
Y� No
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred . . . . . . . . . . . . . . . . . . . . . . . : � a
b. retain the right to designate who shall use the property transferred or its income . . • • • • • •
c. retain a reversionary interest . . . . . . . . . . . . . . . . . • � � • ' ' ❑ �
d. receive the promise for life of either payments,benefits or care? . . . . . . . . . . . . . . . . . . �
2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death X
without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . : a �
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?
4. Did decedent own an individual retirement account,annuity,or other non-probate property,which ❑ �
contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1,1994, and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.�9116(a)(1.1)(i)1•
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 p.S,§9116 (a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.�9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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.
OM4671 2.000
R EV-1503 EX+(&12)
pennsylvania SCHEDULE B
DEPARTMENTOFREVENUE STOCKS & BONDS
INHERffANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
21 14 0411
Kathleen R. Kenne
All property jointly owned with right of survivorship must be disclosed on Schedule F.
VALUE AT DATE
ITEM OF DEATN
NUMBER DESCRIP110N
1. One (1) Series EE U.S. Savings Bond; Serial $40.98
No. L570595670EE
TOTAL (Also enter on Line 2,Recapitulation) S $40.98
zwasss z.000
If more space is needed,insert additional sheets of the same size
REV-1508 EX+(0&12) SCHEDULE E
pennsylvania
pEPPRlMENTOF REVENUE CASH, BANK DEPOSITS &MISC.
INHERITANCE TAX RETURN pERSONAL PROPERTY
RESIDENTDECEDENT FILE NUMBER:
ESTATE OF: 21 14 0411
Kathleen R. Kenne
Include the proceeds of litigation and the date the proceeds were received by the eslate.
All ro ert 'ointl owned with ri ht of survivorship must be disclosed on Schedule F. VALUE AT DATE
ITEM DESCRIPTION OF DFATH
NUMBER
�. PSECU $106,876.05
Regular Shares Account
2 Susquehanna View Apartments $448.00
refund
3 Genworth Financial $1.05
refund
4 Monumental Life Insurance Co. $13.00
refund
5 Stonebridge Life Insurance Company $24.02
refund
TOTAL(Also enter on line 5,Recapitulation) 3 $
107,362.12
If more space is needed,use additional sheets of paper of the same size.
2W46AD 2.000
REV-1511 EX+(0&13) SCHEDULE H
pennsylvania FUNERAL EXPENSES AND
DEPPRTMENTOF REVENUE
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENTDECEDENT FILE NUMBER
ESTATE OF
21 14 0411
Kathleen R. Kenne
DecedenYs debts must be reported on Schedule I.
ITEM AMOUNT
NUMBER DESCRIPTION
A. FUNERAL EXPENSES:
� Auer Cremation Services
funeral goods & services not covered by $46.00
pre-paid plan
g, ADMINISTRATIVE COSTS: $4,500.00
�, Personal Representative Commissions:
Name(s)of Personal Representative(s)CraiQ A Hatch
Street Address 2109 Market Street
City Cam Hill State PA ZIP 17011
Year(s)Commission Paid:2014-15
$5,500.00
2. Attorney Fees:
3, Family Exemption:(If decedent's address is not the same as claimanYs,attach e�lanation.)
Claimant
Street Address
�i� State Z�P
Relationship of Claimant to Decedent
$173.50
4. Probate Fees:
5, Accountant Fees:
g, Tax Return Preparer Fees:
7.
1 Patriot-News $196.82
publication fee
2 Cumberland Law Journal $75.00
publication fee
Total from continuation schedules . . . . . . . . .
$569.15
70TAL(Also enter on Line 9,Recapitulation) $ $11 060.47
If more space is needed,use additional sheets of paper of the same size.
3W46AG 2.000
21 14 0411
Estate of: Kathleen R. Kenney
Schedule H Part 7 (Page 2)
3 Comcast $13.36
cable bill
q Miscellaneous administrative expenses $500.00
paid to clear out and clean apartment.
5 U.S. Postal Service $55.79
postage
$569.15
Total (Carry forward to main schedule)
REV-1512EX+(12-12) SCHEDULE I
pennsylvania
DEPPRTMENTOF REVENUE DEBTS OF DECEDENT,
INHERITANCETAXRETURN MORTGAGE LIABILITIES &LIENS
RESIDENTDECEDENT FILE NUMBER
ESTATE OF
21 14 0411
Kathleen R. Kenne
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
VALUE AT DATE
��M OF DFATH
NUMBER DESCRIPTION
�• Cumberland County Office of Aging
$242.93
personal care services
2 Jitterbug $23.62
urgent response services
3 Comcast $72.78
cable bill
4 West Shore EMS - ALS $gg2,06
emergency medical transport
TOTAL(Also enter on Line 10,Recapitulation) E 1 321.39
If more space is needed,insert additional sheets of the same size.
ZW46AH 2.000
REV-1513EX+(01-10) SCHEDULE J
pennsylvania
pEpPJtTMENT OF REVENUE BENEFICIARI ES
INHERITANCETAX RETURN
RESIDENT DECEDENT
FILE NUMBER:
ESTATE OF: 21 14 0411
Kathleen R. Kenne RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECENING PROPERTY
Do Not List Trustee(s) OF ESTATE
� 7AXABLE DISTRIBUTIONS�InSeCe91t16h(2)P(1 2).�istributions and transfers under
�, Donald E. Kenney
6230 58th Court
Vero Beach, FL 32967
20� of Residue: $19,004.25
Brother $19,004.25
2 David C. Kenney
822 Harper Ave.
Drexel Hill, PA 19026
20� of Residue: $19,004.25
Nephew $19,004.25
ErlTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
�� NON-TAXABIE DISTRIBUTIONS
A.SPOUSAL DISTRIBUTIONS UNDER SEC110N 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISIRIBUTIONS:
1.
TOTAL OF PART II-ENTER�Oore spa e s�needed,luse add tlonassOheets oE papeFof he same s'��Ze.ER SHEET. S
�`�.��
9 W 46AI 2.000
21 14 0411
Estate of: Kathleen R. Kenney
Schedule J Part 1 (Page 2)
Item Amount
No. Description
Relation
3 Keith Kenney
1500 N. Congress Ave. , 3571
West Palm Beach, FL 33401
20� of Residue: $19,004.25
Nephew $19,004.25
4 Kyle Kenney
c/o Doug Kenney
21441 Wilderness Lake Blvd.
Land O Lakes, FL 34637
20� of Residue: $19,004.25
Nephew $19,004.25
5 Clay Kenney
c/o Doug Kenney
21441 Wilderness Lake Blvd.
Land O Lakes, FL 34637
20� of Residue: $19,004.25
Nephew $19,004.25
DEATH CERTIFICATE
��Ca�. RECISTR�4R'� CERTIFICp►TIC�� t�� ��ATH
W�4RNfNG: ft is illegai to dupEicate this copy by phatast�t ar ph�tograph.
Fee tor this certificate, 56.00 „��� Th�� is to certif}� that the information here �i�•en
� ' 1HOfp �
�,���'�� - F�j�;� co>>c�tly copied from an oii�inal Certific ue of Bea
,,�o��` ��`rr=__ ciul� f�led ��>ith me as Local Registrar. 7'he origin
,;'��; .�'� �� `�; ce�t�ticate �cill be 1'oi��arded t�� the State Vit
��° i�; Record� Office f�or permanent filing.
i'�c� -v b
� \\oF��\�. _����,,_ /'�, � c( dS ' Iti
� � a � �. � � � : _ .
-- `°--.rMENT OF _ t,.c.
�,,,�
Certification Nun�ber
���""'��� Local Registrar llate issued
Type/P�int In COMMONWEALTH OF PENNSYlVAN1A�DEVARTMENT OF HEALTH�VITAL RECORDS
P«m,,,�„: CERTIFICATE OF DEATH S�ate File Numben
Black Ink 2.Sex 9.Soclal Security Number 4.Date ot Oe�th(Mo/Day/Vr)(Spell Mo)
1.DeceGent's lesal Name(First,MltlAle,Las<.Sufflx) A ril 19, 2014
Kathleen Ruth Kenney Female 172-30-4506 P
Sa.AQe-Last Birthdry(�'rs) Sb.Undar 1 Ysar Sc.Und�r 1 Da fi.�ate of BIrtA(MO/Day/�'sa�)(Spell Month) ��'B�HO11(de a^bU•t!or F ee"^�uV8t1' e
Mon[hs Days Mours Mln�tes I.,]eTCh 31� 1938 7b.Birthplsce(COUnCy) B181T
76 8c.Did Decedent Live In a TownshipT �WP
Ba.Resltlence(Staie or ForelQn Country) 8b.Resitlence(Strce<and Number-Include Apt No.) �YQ:,aoceeen��ivea in
Penns lvania 208 Senate Avenue� Apt. 319
8d.Residence(COUnty) �No,aeceaenc uved wrcnin nmm ot Camv Hil l dav/boro.
Cwnberland 8e-Residence(21p Code) 17011 i i �o nrsi marriage)
9.Ever In US Armed Forces7 10.MariCal Sia<us at Time of DeaLh �Ma��ietl �
Widowetl 11.Survlvin`Spouse's NaTe(If wife,s ve name pr or
�Ves �No �Unknown 0 Divorcetl �Neve�Ma��ietl �Unkno`N13.Mothe�'s Name P�b�to Flrzt Msrria�e(fi�ii,MlGtlie,Last)
12.Fath�r'z N�me(First,MldEle,Last,Suffia)
Lewis Evan Kenney Martha Jane Dively
14b.RelaHOnship to Decedent 14c.Intorm�nYS MallinQ Adtlress(Sireec and Number,Qty,Stete,Zip Cotlt)
1aa.�n+o�manc•:t�ame 2109 Marlcet Street Cam Hill Penna lvania 17011
Mr. Craig Hatch Execui o a Cc o e __ _ _ __ __ _ __
G _ -_ _ _ _- _ _ -__ _- _? . _ceo eac _ nYon _
It Death Occurred In�HosplLl: ���+Padeni I�f Death Occurrctl Som6wh6re Other Than a Hosplial: d Hospice Facility t7 DecedenYS Home
°C �satl on Arrival O Nursin6 Noma/LOn�-TSrm G�e Facllity 0 aher(Sp�cNy)
0 EmerQancy Room/OUtpa<lent � 'SSC.Qty or Town,Sdte,�ntl Zip Cod� 15d.County of Ceath
'o�G 15b.Facllity Name(H.,os�..sen..no.,,s��e str..s a.,a n.,mb.�1 Cumberland
� Fioly S irit Hospital Camp Hill Pennsylvania 17011
16a.Method of Uispositlon � Burlal � Crematbn 16b.Oste Of DisposiHOn 16c.Pl�ce of Dispos{Hon(Name ot cemeSery,crematory,or oiher place)
m O Remowl from Scate O DonaUOn
�Oeher(Specify) April 24�2014 Cremation Society of Pennsylvania
� 17a.57`nature o/iunersl 5 ice Llce s r'ln Char{e of I�terment 17b.License Number
� 16d.LooHOn of DlsposlNOn(Cicy or Town,State,and ZIO) $'p-138948
� Harrisburg� Pennsylvania 17109
� 17c.Name and Complete Address of Funeral Facliity - V
V 20.Decedent's Race-Check ONE OR MORE rac<s to Indlute what
e�' 16.OecedenYs EducaNOn-Check the box that best tlescribes the 19.Decetlmt of HlspaNc OriQin-Check the
� highest desrce or ievN of schooi compleutl aa the tlme of deaah. box�hat bes2 dezcrtbes whether the decedeni the W^i[�dent considered himself or hersOe1fKOrean
� gth arade or less is SpaNSh/HlspanlUVtino. Check the"NO" m glack or African Ameri<an � Vletnamese
� No dlploma.9th-12th arade boz H decedent Is not Spanish/Nispanic/LaHno. �Amariun Indla�or Al�ska NeNVe � aher Asian
�$ HI`h school6rstluate or GED eompleteE �I No,not Spanish/Hispanic/LaHno �As,� �d+�� 0 NaHve Maw�����
� Some college cretll4 6ut no dearee O�'es,Mexican,Mezican Ame�ican,Chieano �Chin¢se O Guamanlan or Chamorro
� Associate tleQ�ee(e.t.�.�) . �Yes,Puerto Rlcan �Fllipino 0 Samoan
� Bichelor's desrce(e.a.BA.AB.05) �Ves,Cuban �opanese � Othe�PacNic IslanEer
0 Master'z de{ree(e.s.MA,M5.MEng,MEd,MSW,MBA) O`�es,other Spanish/Hispanic/LaHno p Other(SpeCify)
� Doctorsie(e.g.PhO,EdD)or ProfesSional Eegre� (Speclly)
a. .MD ODS DVM LLB l0
21.Deced<nYt SIn{�e Race Self-DesfgnaHOn-Check ONLY ONE to Ind�cate whac the decedent considered himzelf or herseM so be. 22a-oecedenc's Usual OccupaHOn-I�dlcau rype o/wor
�-��P���ye O Samwn done duMnL most of workin{Iife. DO NOT USE NETIREO.
(�White . Koresn O OtherPacificlslsntler Clerlc
� Black or Afrlon American 0 � pa�'�K�ow/NOt Sure
� �Amerlun Indian or Alaska N�tive �v�etnemese 0 Refused 22b.K{ntl of Business/Industry
�Asian Indlan �Other Asian
�Chinese O NrtiveHawailan � Other(Specify) C1CT'iCal
� O F���P��o 0 Guamanbn or Chamorro � ����ble) 23c.Licens�Num er
s 23b.SiQnaturc of Person Pronouncin �eath On1Y�+hen app
1TEM5 33�-2.7d MVSf BE COMGIETED 23a.�ate Pronounced Deatl(MO Oay r)
BY PEPSON WHO PRONOUNCES OR
CERTFIES DEATM 24.Time ot Deal1� No
23d.Date SI`ned(MO/D�y/Vr) 25.W�s Metlical Eaaminer or Coroner ContactedT O Yes
' � Approximate
GAUSE OF DEATH ' i�cerva�:
26.Part 1. Ente�the�h In ot events--Olseases,inJuriez,or camplicailons--that directly caused the dea�h. DO NOT enter termin"^e�Aa�dditlonarldlinez if necesssrv. � Onset to Deach
rcsplratory arrest,or vMtritular flbrillaflon withoui zhawing the etfolosy. DO NOT ABBREVIATE. Entel only one csuse on a �
�
� o4�S
IMMEOIATE CAUSE ---^---'� • Due to(or�c a consequence of): � D ,�,�,S
(Flnal disease or eondiHen �
resWTins In tleash) ' �
b' oue xo(or as a cons•quence f): �
sequenc�+llv��at wnalnon:, �
�r am,ie.e�ni ao cna�ause
Ilstea on Ilne a. Enter che oue So(or as a consequence of): 1
UNDERlY1NG CAUSE �
¢ (disease or in}ury that �
W Initiated tha events resulting d� Du�to(or as a eonsequence of): �
c in death)�T�
�$ ly Q causs BWen in PaR 1. 27.WaSO/+VeaOPSY PC��NO d7
� 26.iaR��• Enter other fl t dlSi f Ib•[inv to death but not rcsulUnQ In the under In
28.Were sutoPSY nnCln<s awll�ble
S to eomplete che cwse�r tleath?
� . O Yes @'Ne
� 30.Did Tobacco Uze ConVib�te to Oeaih7 31r.Man�er of Oe�th Homlcide
� 29.If Female: � Yes � Vreb�bly y�rv��ural �
(a�pot pre6nant wkhin Past Year No p�known O A�citlent � Pentlin[Invesil[atbn
� � presnant at Sime of death � 0 Sulcitle O Could not be determ��eE
^m' � Not pregnant,but pregnant within 42 deys of death 32.Date of InJury(MO/Day/�'�)(Spell Month)
� Npt preQnant,but prcsnent 43 days to 1 year before death 33.Time ollnlury
� Unknown N PmBnant within Nie Past Year
34.Plate of Injury(e.g.home;construction zite;farm;school)
35.Locatlon of InJury(SCrcet and Number,City,County,StKe,Zip Code)
36.Inlury at Work 37.MTransPOrtatlon Inlury.SPecity:
38.Oescribe Mow InJury Occurretl:
� Yes O DrNer/Oper�tor O Pedestrisn
� No O PassMaer O aher(Spectfy)
39a.Ceri�l�er-physician,certHled nurse PrattiHoner,med(c�l examiner/coroner(Cheek only a;^�'er statetl.
O CeKNylni only-To the best of my knawledge,Ceaih ocwrred due to the cause(z)antl m � d due to che eause(z)and manner st a due to the ou e(s)��+d msnner st�ceG.
Qe,death ocwrred at the tim�,date,and plaee,an
�PronouncinL$CwrHfV��L-To the best of my knOwled ��my opinfon,death occu(�ed��the time,dKe,and plaee,an ��
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DlspoSiSion PermiT No. 1052629
LAST WILL AND TESTAMENT
RECO�D���� . � L� /-
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LAST WILL AND TESTAN��'�T�+?R 2$ A(� 10 38
OF C��;;;; 0�
KATHLEEN R KENNEY ����i'"��' �G U RT
U►�;Eci;'r�.',5� CO., PA
I, KATHLEEN R KENNEY,now of 208 Senate Avenue, Apt. 319, Camp Hill,
Cumberland County, Pennsylvania, 17011, do publish and declare this to be my Last Will and
Testament, hereby revoking all other prior wills and codicils made by me.
FIRST: Family Back�round and A�nointment of Eaecutor.
(A) Family and Background Information. I am not married. I have no children.
(B) Appointment of Eaecutor. I appoint as my Executor and Successor Executor(all
referred to as Executor) under this Will,the following named person to serve without bond and
without being required to account to any Court:
Ezecutor: CRAIG A.HATCH,ESQ.
Successor Eaecutor: MARK E.HALBRiJNER,ESQ.
SECOND: Funeral and Last Illness Eapenses; Tazes.
(A) Ezpenses of Funeral and Last Illness. I have prepaid my funeral expenses at
Auer Cremation Services of Pennsylvania, but I direct my Executor to pay any additional
incidental funeral expenses and the expenses of my last illness from my estate.
(B) Tazes. I direct my Executor to pay any and all estate, inheritance, succession,
legacy, transfer and other death taxes or duties, by whatever name called, including any and all
interest and penalties thereon, imposed under the laws of any jurisdiction by reason of my death,
upon or with respect to any and all property included in my gross estate for the purpose of such
taxes, whether such property passes under or outside of this Will, out of my residuary estate,
without being prorated or apportioned among or charged against the respective devises, legatees,
beneficiaries, transferees, or other recipients of any such property or charged against any property
passing or which may have passed to any of them. T'he Executor shall not be entitled to
reimbursement for any portion of any such ta�ces from any such person.
THIRD: Tan�ble Personal Propertv. Except for those items those items enumerated
in the Letter of Instruction, I bequeath all tangible personal property, including but not limited to
clothing,jewelry, heirlooms, furniture, personal effects, and all other similar articles, which I
own,to the Salvation Army or any charity willing to come to my apartment to secure them.
Tangible personal property shall not include: (1) any and all property used by me in any
business, (2) cash on hand or on deposit in banks, (3) stock or securities, (4) any type of evidence
of indebtedness, and (5) any life, health or accident insurance policies.
Any personal items not claimed by the Salvation Army or charitable organization shall be
placed on the "Free Table" in the Community Room at Susquehanna View Apartments.
� l.� �/,_----
�.�:
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LAST WII�L AND TESTAMENT
OF
KATHLEEN R KENNEY
PAGE 2
Notwithstanding any other provisions in this Article THIRD, I may lea�e a separate,
dated and unsigned Letter of Instruction, which I shall place with my Will, containing directions
as to the ultimate disposition of certain of the property bequeathed under this Article THIRD, and
such Letter of Instruction shall determine the distribution of such items.
FOURTH: Residuary Gifts.
(A) I give, devise and bequeath all the rest, residue and remainder of my estate, of
every kind and chazacter, real,personal and mixed, tangible and intangible, and wherever
situated, including any lapsed or renounced legacies or devises (and including any property over
which I may have a power of appointment), in equal shares, to my brother, DONALD EARL
KENNEY, currently residing at 6230 58t'' Court, Vero Beach, Florida, 32967, my nephews,
DAVID C. KENNEY, currently residing in Philadelphia, Pennsylvania, and KEITH KENNEY,
currently residing in West Palm Beach, Florida, and my great nephews, KYLE KENNEY and�
CLAY KENNEY, per capita. KYLE KENNEY and CLAY KENNEY are the minor sons of
Douglas and Heather Kenney, residing in Belcamp, Maryland, formerly of Johnstown,
Pennsylvania. If at the time of my death there is less than FIVE THOUSAND DOLLARS
($5,000.00) left in my estate, no monies shall be divided among my relatives. That amount
should be distributed to the Helen O. Krause Animal Foundation, Inc. (HOKAFI).
(B) Distributions Durii�Administration. Prior to final distribution of my estate, the
Executor, in his discretion, may make partial distributions to one or more beneficiaries or Trusts.
As a consequence, the Executorship and any Trusts created under this Will may exist
contemporaneously. A distribution may be made subject to any indebtedness or liability of my
estate.
FIFTH: Powers of Ezecutor. In addition to the powers and duties as may have been
granted elsewhere in this Will,but subject to any limitations stated elsewhere in this Will, the
Executor shall have and exercise exclusive management and control of the Estate and shall be
vested with the following specific powers and discretion, in addition to the powers as may be
generally confened from time to time upon the Executor by law:
(A) In the management, care and disposition of the Estate, the Executor shall have the
power to do all things and to execute such instruments, deeds, or other documents as may be
deemed necessary or proper, including the following powers, all of which may be exercised
without order of or report to any Court:
(1) To sell, exchange or otherwise dispose of any property at any time held or
acquired hereunder, at public or private sale, for cash or on terms, without advertisement,
including the right to lease for any term notwithstanding the period of the Estate, and to
grant options, including any option for a period beyond the duration of the Estate.
,
��; �� �� ;`�` _
LAST WILL AND TE5TAMENT
OF
KATHLEEN R KENNEY
PAGE 3
(2) To invest all monies in such stocks, bonds, securities, mortgages, notes,
choses in action, real estate or improvements thereon, and any other property as the
Executor may deem best, without regard to any law now or hereafter enforced limiting
investments of fiduciaries.
(3) To retain for investment any property deposited with the Executor hereunder.
(4) To vote in person or by proxy any corporate stock or other security and to
agree to or take any other action in regard to any reorganization, merger, consolidation,
liquidation, bankruptcy or other procedure or proceedings affecting any stock, bond, note
or other security.
(S� To use attorneys, real estate brokers, accountants and other agents, if such
employment is deemed necessary or desirable, and to pay reasonable compensation for
their services.
(6) To compromise, settle or adjust any claim or demand by or against the Estate
and to agree to any rescission or modification of any contract or agreement affecting the
Estate.
('n To renew any indebtedness, as well as to borrow money, and to secure the
same by mortgaging, pledging or conveying any property of the Estate.
(8) To retain and carry on any business in which the Estate may acquire an
interest, to acquire additional interest in any such business, to agree to the liquidation in
kind of any corporation in which the Estate may have an interest and to carry on the
business thereof, to join with other owners in adopting any form of management for any
business or property in which the Estate may have an interest, to become or remain a
partner, general or limited, in regard to any such business or property and to hold the
stock or other securities as an investment, and to employ agents and confer on them
authority to manage and operate the business, property or corporation, without liability
for the acts of such agent or for any loss, liability or indebtedness of such business if the
management is selected or retained with reasonable care.
(9) To register any stock, bond or other security in the name of a nominee,
without the addition of words indicating that such security is held in a fiduciary capacity,
but accurate records shall be maintained showing that such security is a Estate asset and
the Executor shall be responsible for the acts of such nominee.
(B) Whenever the Executor is directed to distribute any Estate assets in fee simple to a
person who is then under twenty-one (21) years of age, the Executor shall be authorized to hold
-%' ,,%�
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- - -
LAST WILL AND TESTAMENT
OF
KATHLEEN R KENNEY
PAGE 4
such property in Trust for such person until he/she becomes twenty-one (21)years of age, and in
the meantime shall use such part of the income and the principal of the Estate as the Executor
may deem necessary to provide for the proper support and education of such person. If such
person should die before becoming twenty-one (21)years of age, the property then remaining in
trust shall be distributed to the personal representative of such person's estate.
(C) In making distributions from the Estate to or for the benefit of any minor or other
person under a legal disability, the Executor need not require the appointment of a guardian, but
shall be authorized to pay or deliver the same to the custodian of such person, to pay or deliver
the same to such person without the intervention of a guardian, to pay or deliver the same to a
legal guardian of such person if one has already been appointed, or to use the same for the benefit
of such person.
(D) In the disbursement of the Estate and any division into separate trusts or shares,
the Executor shall be authorized to make the distribution and division in money or in kind, or
both, regardless of the basis for income tax purposes of any property distributed or divided in
kind, and the distribution and division made and the values established by the Executor shall be
binding and conclusive on all persons taking hereunder. The Executor may in making such
distribution or division allot undivided interests in the same property to several trusts or shares.
(E) The Executor shall be authorized to lend or borrow, including the right to lend to
or bonow from any trusts which I may have established during life or by will at an adequate rate
of interest and with adequate security, and upon such terms and conditions as the Executor shall
deem fair and equitable.
(� The Executor shall be authorized to sell or purchase at the fair market value as
detertnined by the Executor, any property to or from any trust created by me during life or by
Will, even though the same person or corporation may be acting as Executor of my estate or as
Trustee of any of my other trusts.
(G) The Executor shall have discretion to determine whether items should be charged
or credited to income or principal or allocated between income and principal as the Executor may
deem equitable and fair under all the circumstances, including the power to amortize or fail to
amortize any part or all of any premium or discount, to treat any part or all of the profit resulting
from the maturity or sale of any asset, whether purchased at a premium or at a discount, as
income or principal or apportion the same between income and principal, to apportion the sales
price of any asset between income and principal, to treat any dividend or other distribution of any
investment as income or principal, or apportion the same between income and principal, to
charge any expense against income or principal or apportion the same, and to provide or fail to
provide a reasonable reserve against depreciation or obsolescence on any assets subject to
depreciation or obsolescence, all as the Executor may reasonably deem equitable and just under
�/ ��
l�` :�. _
LAST WILL AND TESTAMENT
OF
KATHLEEN R KENNEY
PAGE 5
all the circumstances. If the Executor does not exercise the above discretionary power, the cash
or accrual allocation shall be in accordance with Chapter S 1 of Title 20 of the Pennsylvania
Consolidated Statutes, or the corresponding provisions of subsequent state law.
(I� If at any time the total fair market value of the assets of any trust established or to
be established hereunder is so small that the corporate Trustee's annual fee for administering the
trust would be the minimum annual fee set forth in the Trustee's regularly published fee schedule
then, in effect, the Trustee in its discretion shall be authorized to terminate such trust or to decide
not to establish such trust, and in such event the property then held in or to be distributed to such
trust shall be distributed to the persons who are then or would be entitled to the income of such
trust. If the amount of income�o be received by such persons is to be determined in the
discretion of the Trustee, then the Trustee shall distribute the property among such of the persons
to whom the Trustee is authorized to distribute income, and in such proportions, as the Trustee in
its discretion shall determine.
(n Except as otherwise provided in this Will, when the authority and power under
this Will is vested in two (2) or more Executors or Trustees, the authority and powers are to be
held jointly by the Executors or Trustees, respectively. A majority of the Executors or Trustees
may exercise any authority or power granted under this Will or granted by law, and may act
under this Will. Any attempt by one such Executor or Trustee to act under this Will on other
than ministerial acts shall be void. The action of one such Executor or Trustee under this Will
may be validated by a subsequent ratification of the act by a majority of the Executors or
Trustees.
SIXTH: Rights and Liabilities of Eaecutor.
(A) No bond or other security shall be required of any Executor.
(B) This instrument always shall be construed in favor of the validity of any act or
omission by any Executor, and any Executor shall not be liable for any act or omission except in
the case of gross negligence, bad faith or fraud. Specifically, in assessing the propriety of any
investment, the overall performance of the entire Estate shall be taken into account.
(C) Each Executor shall be entitled to receive reasonable compensation for services
actually rendered to my estate, in an amount the Executor normally and customarily charges for
performing similar services during the time which he/she performs the services.
SEVENTH: Spendthrift Provision. No beneficiary shall have the power to anticipate,
encumber or transfer his or her interest in the estate in any manner other than by the valid
exercise of a power of appointment. No part of the estate shall be liable for or charged with any
debts, contracts, liabilities or torts of a beneficiary or subject to seizure or other process by any
� .�J
��.� . �� ,�;_
--�--�.. .
�
LAST WII,L AND TESTAMENT
OF
KATHI.EEN R KENNEY
PAGE 6
creditor of a beneficiary.
EIGHTH: Taz Elections.
(A) In determining the estate, inheritance and income tax liability relating to my
Estate, the Executor's decision as to all available tax elections shall be conclusive on all
concerned. In accordance with IRC Section 2632(a) and without regard to whether a Federal
estate tax return is actually filed, my Executor shall allocate so much of the Federal Generation
Skipping Transfer(GST) exemption amount as will fully exempt any generation skipping
transfer which may occur under this Will.
(B) The Executor may, in its discretion, determine the date as of which my gross
estate shall be valued for the purpose of determining the applicable tax payable by reason of my
death.
(C) The Executor may, in its discretion, decide whether all or any part of certain
deductions shall be taken as income tax deductions (even though they may equal or exceed the
taxable income of my estate and whether or not claimed or of benefit on my estate's income tax
return) or as estate tax deductions when a choice is available; and in the event that all or any part
of such deductions are taken as income ta�c deductions, no adjustment of income and principal
accounts in my estate shall be made as a result of such decisions.
rTINTH: Defmitions and General Provisions.
(A) 5urvival. Any beneficiary who dies within sixty (60) days after my death shall be
considered not to have survived me.
(B) Captions. The captions set forth in this Will at the beginning of the various
articles hereof are for convenience of reference only and shall not be deemed to define or limit
the provisions hereof or to affect in any way their construction and application.
(C) CLildren. As used in this Will, the words "child" and "children" shall include
persons who are legally adopted and the issue of said persons, whether born in or out of wedlock,
so long as any person born out of wedlock is acknowledged in a written instrument executed by
the one of their natural parents who is a descendant of mine to be the child of said descendant.
The word "issue" shall include descendants of all generations including adopted persons. A
posthumous child shall be considered as living at the death of his parent. The birth to me or the
adoption by me of a child or children subsequent to the execution of this Will shall not operate to
revoke this Will. Except for discretionary distributions which may be made unequally among a
group of persons and distributions pursuant to a valid exercise of a power of appointment, in
making a distribution to the children of any person, the property to be distributed shall be divided
./, ;
LAST WILL AND TESTAMENT
OF
KATHLEEN R KENNEY
PAGE 7
into as many shares as there are living children of the person and deceased children of the person
who left children who are then living. Each living child shall take one share and the share of
each deceased child shall be divided among his then-living descendants in the same manner.
(D) Code. Unless otherwise stated, all references in my Will to section and chapter
numbers are to those of the Internal Revenue Code of 1986, as amended, or the corresponding
provisions of any subsequent federal tax laws applicable to my estate.
(E) Other terms. The use of any gender includes the other genders, and the use of
either the singular or the plural includes the other.
(I+� Powers of Appointment are Eaercised. By this Will I exercise any and all
Powers of Appointment which I possess at the time of my death.
IN WITNES5 WHEREOF,I, KATHLEEN R KENNEY, the Testatrix, have to this
my Last Will and Testament, typewritten on eight (8)pages, including the Acknowledgment and
Affidavit, set my hand and seal this��,fday of August, 2011.
�
� /� � : ���
EEN R NNE „
Signed, sealed, published and declared by the above-named Testatrix, as and for her Last Will
and Testament, in the presence of us, who have hereunto subscribed our names at her request, as
witnesses hereto, in the presence of the said Testatrix, and in the presence of each other. Each of
us further declares that he or she believes the Testatrix to be of sound mind and memory. The
preceding instrument consists of this and seven (7) other consecutively numbered typewritten
pages including the Acknowledgment and Affidavit.
� "�� _ residing at��/ �r/) : '��
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(pri name)
ti residing at '-t e S� l 1'f�
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(print name)
ACKNOWLEDGMENT AND AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA :
: SS:
COUNTY OF CUMBERLAND :
The Testatrix and the witnesses whose names are signed and subscribed to the attached or
foregoing instrument, being first duly sworn and qualified according to law, do hereby
acknowledge, depose and say to the undersigned authority, that the Testatrix signed and executed
the instrument as her Last Will in the presence of the witnesses; that she signed it willingly or
willingly directed another to sign it for her; that she executed it as her free and voluntary act for
the purposes therein expressed; that each of the witnesses were present and saw the Testatrix sign
and execute the instrument as her Last Will; that each subscribing witness in the hearing and
sight of the Testatrix signed the will as witnesses; and that to the best of their knowledge the
Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint
or undue influence.
�� � �. �
Tes atrix �
. ��
itness
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� Wrtness
Sworn to or affirmed, subscribed to, and acknowledged, before me by the above-named
Testatrix and witnesses, this �� day of August, 2011.
� �_. 'l
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G����'�
�pMMpNyVEAITH pF pENNSriyANIA I�Tofary ublic
Noa�s� �My.�ommission Expires:
Teri L.WaNcer,Notary Public
Lemoyne Boro,Cumberland County
My Commission E�Ires Jan.20,2015
MEMBER,PENNSYl.VANlA ASSOClA7IpN OF NOTARIB
CERTIFICATE of
GRANT of LETTERS
REGISTER OF WILLS CERTIFICATE OF
CUMBERLAND COUNTY GRANT OF LETTERS
PENNSYLVANIA
� '�
No. 2014- 004� � PA No. 21- 14- 0411
Es ta te Of: KATHLEEN R KENNEY
lFi�st,Middle,Lastl
La te Of: CAMP HILL BOROUGH
CUMBERLAND COUNTV
Deceased
Soci al Securi ty No:
WHEREAS, on the 28th day of April 2014 an instrument dated
August lst 2011 was admitted to probate as the last will of
KATHLEEN R KENNEY
(FirsL Middle,Lasi1
late of CAMPH/LL BOROUGH, CUMBERLAND County,
who died on the 19th day of April 2014 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, L/SA M. GRA YSON, ESQ. , Regi s ter of Wi l I s in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARY to:
CRAIG A HA TCH
who has duly qualified as EXECUTOR(R/X)
and has agreed to administer the estate according to law, all of which
fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYLVANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 28th day of April 2014.
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**NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
PA REV-1500
SCHEDULE B
STOCKS and BONDS
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U . S . Savings Bond Redemption Receipt
Branch ID: 1 Transaction Number: 14-516174279161
Kathleen R Kennet Estate Craig Hatch Ex 467-51-1551�n Date: 05/16/2014
2109 Market St
Camp Hill, PA 17011 Teller ID: kessleea
Issue Interest Redemption
Serial Number Series Denom Date Issue Price Earned Value
L570595670-EE EE $50 10/1998 $25 . 00 $15. 98 $40 . 98
Total number of bonds redeemed: 1 Total Total Total
Price Interest Value
$25 . 00 $15 . 98 $40 . 98
Customer Signature
Metro Bank
3801 Paxton Street
Harrisburg, PA 17111
888-937-0004
Page 1 Of 1
PA REV-1500
SCHEDULE E
CASH, BANK DEPOSITS &
MISCELLANEOUS PERSONAL
PROPERTY
Document Number: 2832483
Account 0172xxxxxx KENNEY,KATHLEEN Effect: 04/28/14 Post: 04/28/14 Tlr: 0162
ID DUE DATE PRINCIPAL INTEREST FEES NEW BALANCE TRAN AMOUNT SEQ
----------------------------------------------------------
Withdrawal from REGULAR SHARES Prev Bal: 106,876.05
Ol 106,876.05- 0.00 0.00 0.00 106,876.05 #921572
-----------------------------------------------------------------------
Check Disbursed THE ESTATE OF KATHLEEN R KENNEY106,876.05-
KATHLEEN R RENNEY
APT 319
208 SENATE AVE
CAMP HILL PA 17011-2310
Document Number: 2832483
Account 0172XXXXXX KENNEY.KATHLEEN Effect: 04/28/7.4 Post: 04/28/14 Tlr: 0162
ID DUE DATE PRINCIPAL INTEREST F�ES NEW BALANCE TRAN AMOUNT SEQ
-----------------------
------------------------------ -- --- -- ---
Withdrawal from REGIILAR SHARES Prev Hal: 106,876.05
al _ _ �106_876_05______0_00_____0_00` +`_^ _ Q_00^ 106_876.05`#921572
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' , . ' �_ PA STATf�MPLOY�E$C�i�DIT I�NiON ; � ��
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Stonebridge Life Insurance Company .iallorgan cnasa Bank, N.A.
2700 W Plano Pkwy syracuse, Nv
Plano, Texas 75075 so-93�
No. 7070432401 z�3
May 31, 2014
P1y TWENTY-FOUR AND 02/100 --------------------------------------------------------- - - - - - - -
III�'I�II"I�'�IIII'I�'II�I�III�'I�'�I'III'��I"IIII'I���II��I��I NOT VALID AFTER SIX MONTHS
To the order of ESTATE OF KATHLEEN KENNEY
208 SENATE AVE APT 319 524.02
CQMP H I L L PA 1 7 O i l Stonebridge Life Insurance Company
By:
Authorizad Countarsignature Required if 550,000 Or Ovar
KATHLEEN R. KENNEY REFUND
82A05N2395 05/31/14 UT317031.7 CDSPF EU sy:
Authoriza Signature t
k
��' 7070ti3240 ��i' �:02L309379�: 60 ����8��� 575L9��'
Please Detach Before Depositing
Stonebridge Life Insurance Company
2700 W Plano Pkwy
Plano, Texas 75075 No. 70704324Q1
May 31, 2014
REFERENCE: 82A05N2395 DATE:2014-04-20
INSURED: KATHLEEN R. KENNEY
Our deepest condolences are extended for your loss.
This check represents a refund of unearned premiums
plus any applicable billing fees. The policy/certificate
has been canceled effective the date shown above.
;
07C CDSPF 707043240182A05N2395 052914 r
'��
4
' t
PA REV-1500
SCHEDULE H
FUNERAL EXPENSES and
ADMINISTRATIVE COSTS
Av�� ������ar�� ����r���s �� P�������.�j���, I�v�. �3�
�,�._.__,..�:
4100 Jonestown Road,Harrisburg,PA 17109 1-800-'20-8221 Fa� 1-717-Sa1-9943 Shawn E.Carper-Sopervisor
l916 Moore Avenue,Narth Apollo,PA 15673 1-8QQ-72p_8221 Fax 1-724-478-39Q0 Stephen V. Polinski-Supervisnr
Charges am onlr fbr itema that��ou selectad nr ih�t Aro mquirc�i. it we arc myuired b}'Iau�or by a cemetery or crcmalorp to usz any items vou ha��e not seleaed,we will erplain ths reasnns in
N9'IIi71�I7CION'. II�4'tlll I1dYY$£Iected serviocs ihat may n�quin cmbalmiog,you may have to pay fur a�nbalmiu�. You do not fia�ti io pay 1'or embalming[hat}rou did not app�nva [imhalming is nnt
required for direct cremation crr�mmediatz burinL Ii:mbaiming is not rcqnered by law,except io ce�ain s{�ecial casec If y��u are ei�arFed fw einbalminE,u^e aill explain why belo...
3TATEMENT OF GOODS AND SERVICES SE�ECTED 140411
lleceased:Ka t h 1 een Ruth Kenney Date of Death Apr 2 9, 2 01¢�ate of Arrangements Apr 21 , 2 014
Char eto: Mr. Crai Natch 2109 Market 5treet
� C'.am�� N9 1 1 AA �,7Q9 1 {717}877-5378
Vamc Address ; C:ny �m�c 7ip Cods Phnne\urnl:er
A. SPECIAL SERViCES: D. AUTOMOTIVE EQU(PRIENT:
Direct Cremation............................'.s������ Removal Venicle,....................................
Nationwide Guarantee Pro ram.,..,...... . �����ad
� ••��.��g_� Lead Car and/ariClergy Car.......................
--_.._......_._.—
orldw�ide 7'ravel Protection................... Fami(y Car(Sedan or Limo),..,..,...............
_....�u_
TOTAL SPECIAL CHARG�;S....................�s.� 7 a� __._._ _
.0t� Service Vehicle.....................................
___.....__._____�_
T07'AL QF AUTOMC)TIV[; EQCIIPMENT........ �p� p�p�
i3. PROFESSIONAL SERVICES: F. CASH ADVANCE ITRMS:
Services of l�uneral Director and Staff........��„���� Grave Openina................
.................... ..
_..._...___...___—
ressma and/or Cosmetizing...................___ Cemetery Equipment..............................
•_� _._�
Faciliucs�nd Stefl' for Memorial Service...... Ne�vspaper
_____ .......
_._......._...._..._.......... __..
rematory Charge...............................��u�d Newspaper
.......
ta an Equipment for Memorial Service.. -"°' ""� -�---
Newspaper__.__.__ .......
_._._......._. ---___ �..._
Private(D Viewing............................... Clergy....................
_ ...............................
—.................._�_
W imessin�;the Cremation....................... ChurchlSexton,�Organ i sdSo lo isl..,.,.............
__._..._....._.__.. ........
Packaging and Forwarding Cremated Flowers.............................. ..................
_�.....
RemainsbyRegisteredMail...................� _ CountyCoronerFee..,�.vr.�1�1?:.4!�!e�,,,.,, fiqm ��j
Persona! Delivery of Cremated Remains..... Certified Copies of the Ueath Certificate.5....���
Scattering of Remains over Land or Sea...... 195.0@
Me�_ca 1 pocument s Lcaur i.e.... .,...
__._�.
TOTAL OF PROFESSIONAL SERVICES....... �y q 5 p�p� -....-_.............---..._ ......
__._._ _.._..._
TOTAL OF CASH ADVANCES....................... $66.00
C. M.ERCHANDCSE: SUMMARY OF CHARGES:
Register Book.....................................__ ................$2� 14_5.0 0
Memorial Folders/Prayer Cards................. A. Special Charges...............
��"'"�"`"`._ B. �'rofessional Services.........................
T1ia�ik You Cards................................ ..�"19 5.00
Rememberance Package........................ C. :Merchandise...................................... $�.00
_..._.._.. —_._......_.._......._..
Urn(s)............................................. ..Tnc.Luded b. Automotive Equipment............................ S0.00
(Description �. ---
}P-3-�►.>-t-i-�-��g-�.ar— �r•�-�„'�-t�r . E. Cash Advanced Items........................... 556.0fb
Urn Burial Vault Container...................... T__.
. . _..................._ ,
(Descr�pt�on) SUBTOTAL..................................................�2 f a0�6 0!�
_.
Veteran Flag Case................................. CREDITS.............. -S •
-- ...................................._.$.�.�....�
Grava MarkerJMonu�nent..................... 546.00
...� TOTAL DUE...............................................
.�....__...._. �_.�.. ....... PA]D......................................... 50.00
....
.......... , BALANCE DUE........................
Cremation Container -- $46.00
v...�__.._._.._... _—...�___
_�___..__._ ......
_._.._ __.......
A MERCHANDISE..............................
.._......-5.0-._$@�
f3ecause our p�ckages�re sc>Id nt a reduced fee,no refimd�kiU be given far chxnges.
If nny leeal,ce�netery,or crematon requiremenl has required the purchese of any of fhe items listcd ahove,���c wiil explain the requirement below.
_-.�:ua3�a-1 m-i_nr�-._-i-s........no�-_.�r.e-c�eca.
I agn;e tbat I have exx�nineJ the items ol`good;and cervices sclected above ond tbund Uicm to be carrecf and acctxding to the attangtmcnts 1 have requesled. 1
act:nowted�e recei�t of'a copy of tl�is 5tetement of Cia�ds and Scrvices SelecKed. 1 rcpresent that T havc sul�icient funds available for payntent of the cash price liu the
goods und seroices seleated. I als�agree ta makc paymeat of$ within_____�IarS. 1 a�rcce to he jointly and severally liablc w-ith anyone clse who iigns
bclow. A Inte charge of_� _���: mpnth amounting to per year will be applied to the unpaid balance beginning�m¢. da}•s 1'rom the da�e��f lhis
a�reernent. I a�i11 ulsn pay to the u�'f n ra1 Director all re:�onabte costs paid by thc Funerzl Dirzetor tn collect a�nounts l aw�un�er this agr�ement. Those cosc.mm includc
attnrneys' fees,court ensts nnd other costs. Any additional serviccs or merctia�idise ordired or requested afler�he dace�if ihis a�rt�ement will b�considered part nf this
agrecment an�1 ihe cost thereot�+il(� 'eflecir.�i an ilre tina)bill t>r stazement.
�Seal)_.._. _. - .... /�_.�. Apr 2 Y , 2014
.. _........_.._-------
_._.
� ----- _......___�._
(Pirrchaser) (Date)
(503�) .,.m.
°"�
�t���. ����.�r�+��� �������s �� ��:��s�..��T�� I�c. �-�`
�
4100 Jonestowo Road,Harrisburg,PA t7109 1-800-720-8221 Fax t-71'7-541-9943 Shawn E.Carper-Sapervisr�r
t9l6 Moore Avenue,North Apollo,PA 15573 1-800-720-822I Fa.x 1-724-47$-3900 Stephen V.PoliRSki-Supervisor
I�VIPORTANT DISCLOSURES
The Federa] Trade C{ammissi�n Trade Regulation Ru1e fe�r "Flineral Industn� Prac�ices" reqnires cciKain disclosures and prohibits
misrepreseT�iatr�ans. This Disr,losure/Disclaimer f��rm is a check�lis1�we ask tlinse c4-e ser��e tc�read and sign,
llt��e��rho made the arrangements for the funcral and finat dispositron af the remains of Kathleen Ruth KenneY
do hereby 11lCSf�(� �E]C f0��t)Wltl�: (Name rd fl�ceasecn
{]� I/VGTC WCTC�,14ep/SIIOR'n a General Price List eifective on11�L 8�2 0��prior t�� discussing prices, ser�'10E'S,or merchandise.
f(��ue)
(2) 1/�'e were�;iven/shown a Casket Price t,ist effective on IVJA prior t�>drsciassing prices or caskets.
(i)atc;
(3) IIWe nere giren/shotism an Outer I3urial Container Price Lisi effective on 1J/A prior to discussin� prices or outer
burial containers. rnxre�
{4) I/�L'e were not tc�ld that embalmin�is required by law and were tolt! that the 1an�daes nnI requi.re embalmina except in certain
special cases, if it was pm�=ided, this nas done s��ith my/our permission.
(5) I/We werc not told that any law requires embalming for direct cremations,immediate burial, a funeral using a sealed casket, or
if refrigeration is acailable and the funeral is without viewing or visitation and r}ith a closed caskes.
((�) I/We«�ere no� told that any taa- requires a casket f�r direct cremation or that a casket other than an unfinished«�c>od box is
required For direct cremation or for di.re.ct disposit.ion.
(7) IlWe were told that state la«�does not require the pwchase of an outer burial container or an}=�f the funeral goods or services
I/We selected except as set forth on the statement of funeral�oc�ds and services selected.
(8) 'Vo claims ivere mdde to me/us as to the merchandise or other offerings of this funeral firm (emhalming, casket, c�uter hurial
container) that embalming or the use of any merchandise available frnm this funeral firin w��uld delap the decompositinn of the
remains for a long term�r indefinite time,or would protect the bc�d}�from gr;►vesite substances.No representations or tivarraniies
were made tn us regarding caskets or outer burial containers. The only warranties,e?;presseci or imPlied;�ranted in connec�ion
R�itl�goads sold��ith the funeral service we arranged were the expressed written«�arrantics,if any,extended by the manufacturers
thereof. No othcr warr.tnties, including the implied �varranties nf inerchantabilit}> or fitness for a particular purpose were
c3ctended to us,
O) I/We were not t�ld that the amount of e7ch of the cash advance items n�as the cost to the fune.ral firm.We were told the cost mav
be clifferent based on volume or cash discounts or other proFessionaVtrade custoros. '
(10) I/We��ere given a Statemcnt of Goods and Services selected bv me/us and the price to be paid for each,ineiuding itemized cash
adwinces Ur a goad faith estimate if thc prir.es are nc�t yet known.A written statement of the actua!charge�s�ill be prcrF�ded before
the final bill is paid.
AUEft CRE�fATION SFHVIC]'S QF Pr.r•nvntiva.itiw, L�c, axyee„s tha� ur1 di.spules artst��g batwec��n tt and its�YCStomers s.hall he submff[e_d to �
nrbit�raltnn untte r the 13et1¢r/3usfnews Burxar�u;s ruXes arul u/i��llcuble state laue f�rcn�trled hnrac�.Kr,that no dlspur�sha!!be,sribmitted fi',r
arfiftrul�a:prtor ra t:rhn�rctto�i vTr�n tn/brma/grlevui:ce prnce�lure tru�rltcloriu!!7�u,rert hy the[3etier t3usfness liacreai�.
tVitttesseri
Person(s) �nakinR,ftnul arran�e.nrents
.��
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;.. .
.�,M- � - _,. . __ ��r 22 , 2024
...��r"�� � �rrchaser 1)�1tt
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AUIJMYfXlRJ RNrIT!SE'711RJ72'e' PtrrcAa�er "-
I)U(P.
Actii+Car��eno:a Seav�ca:e oF P�xm.v�;�u.T�c
��Pennsyh anie funeral Girectors Associatir,n
wwtriE�amw��
Form 0003 Revisgd 4J04
YELLCIN-Funeigl pirpctor
RECEIPT FOR PAYMENT
LISA M. GRAYSON, ESQ. Receipt Date : 4/28/2014
Cumberland County - Register Of Wills Receipt Time : 10 : 38 : 35
One Courthouse S quare Receipt No. : 1077802
Carlisle, PA 17Q13
KENNEY KATHLEEN R
Estate File No. : 2014-00411
Paid By Remarks : HALBRUNER HATCH & GUISE
DB1
------------------------ Receipt Distribution -------------------_____
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 60 . 00 CUMBERLAND COUNTY GENERAL FUN
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
SHORT CERTIFICATE 40 . 00 CUMBERLAND COUNTY GENERAL FUN
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check# 1131 $173 . 50
Total Received. . . . . . . . . $173 . 50
The Patriot-News Co. ♦
2020 Technology Pkwy � � ��O ,r ���
Suite 300
Mechanicsburg, PA 17050 N ow yo u k n ow
Inquiries - 717-255-8213
HALBRUNER, HATCH & GUISE, LLP
2109 MARKET STREET
CAMP HILL PA 17011
STATEM E N T ALL CHARGES ARE NET
ACCT# NAME AD ORDER# DATE EDITION ADDTL. INFO. TYPE OF CHARGE AMOUNT
245301 HALBRUNER,HATCH&GUISE,LLP 0002299919 05/20/14 XXX Kenney BASIC AD CHARGE $63.94
245301 HALBRUNER,HATCH&GUfSE,LLP 0002299919 05/27l14 XXX Kenney BASIC AD CHARGE $63.94
245301 HALBRUNER,HATCH&GUISE,LLP 0002299919 06/03/14 XXX Kenney BASIC AD CHARGE $63.94
AFFIDAVIT CHARGE $5.00
TOTAL: $196.82
This is not an invoice. Please do not remit payment from this Statement.
An invoice will be generated at the end of the month. --Thank you.
NOTE: This Statement replaces the Order Confirmation which we previously sent with Proofs of Publication
���'"°co
vJ�` ,� G��-
r r
��
�''QRrsoc+A�`°�
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tele: (717)249-3166 Fax:(717)249-2663
May 30, 2014
Cumberland Law Journal is published every Friday by the Cumberland County
Bar Association and is designated by the Court of Common Pleas as the official legal
publication for Cumberland County and the legal newspaper for publication of legal
notices.
TO: Craig A. Hatch, Esquire
RE: Kathleen R. Kenney. Estate
Legal advertisements must be received by Friday Noon. All legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on following dates:
May 16, May 23, and May 30, 2014
Advertising Cost $ 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Payment received $ 75.00
Total Amount Due $ 0.00
Becky H. Morgenthal, Executive Director
��� ` `��`��� Account Number _
08547 189303 03-9
Billing Date 04/28/14
Total Amount Due $13.36
Payment Due by 05/25/14
Page 1 of 2
Contact us:�www.comcast.com� 1-888-931-4379
Ki4THLEEN KEN[otEY � �������1��=1�� ��r���i�l �,��l,_� ���iil�,��..'��'�'.��.����`�,�, �..,.
Previous Balance �2 7$
For service at: Payments- received by 04/28/14
208 SENATE AVE APT 319 O.QO
CAMP HILL PA 17011-2353 New Charges -see be/ow -59.42
i'otal Amount Due $13.36
News from Comcas� Payment Due by 05/25/14
We regret losing you as one of our subscribers. Our � ;� �,� � — .���� r:� ��;$�� ; �
1��� ����n ' � ��l1! �.� i � � � h�� �.
records indicate that the final balance shown above is �� �.��-,� ���. ��_��a� �� �,� . �, ,: ���
��� .. �,. �� �u�u �� .
now due. Your prompt payment is appreciated. Any �i Partiai Month Charges &Credits -58.46
outstanding equipment must be returned to our office Changes were made to your account thls month.
within 7 days. Please cail us at 1-800-COMCAST any See the foUowfng pages for more detalls. �
time should you wish to reconnect your service. Taxes, Surcharges & Fees -0.96 W
0
Hearing/Speech Impaired Call 711 TOta) New ChBrges -$59.42
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����a��� Account Number 09547 188303-03-9
Rayment Due by 05/Z5114
PO BOX 985
TOLEDO OH 43697-0985 Tatal Amount Due $13.36
AV 01 002885 099068 12 A'*SDGT Amount Er�closed � /J�3 (�
��II'�Il�lll��l��tl����l��!'I�Il�l�l�l�l�ll�ll�����illllll��'�111 Make chscks payabls to Comcast
KATHLEEN KENNEY
208 SENATE AVE APT 319
CAMP HILL PA 1 701 1-2353 �������������������II�'�I��'�I�'��'�!'�'�'�'�I�"�f"�'�'I'��'�I'
COMCAST CABLE
P 0 BOX 3005
SOUTHEASTERN PA 19398-3005
PA REV-1500
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES
and LIENS
�,+`��c�`�,,� CUMBERLAND COUNTY
� � AGING & COMMUNITY SER
,
; VICES
\\ � 1100 C���ONT ROAD, C.�TU,ISLE,PA 17015
• `c�� (717)240-6110 ox 1-888-697-0371 ExT 6110
F�x: (717) 240-6118
Bazbaza B Cross
One Team ...One Mi.r.rion Chairman
Jim Hertzler
Vice Chairman
Gary Eichelberget
INVOICE FOR SERVICES Secretary
Teny L Bazley
Directar
Kathleen R Kenney
208 Senate Ave Apt 319
Camp Hill, PA 17011
invoice Number: April-14-30
Invoice Date: June 1,2014
SERVICE(S) PROVIDED: PERS- Monthly Fee& Personal Care
MONTH OF SERVICE: April 2014.
SERVICE Unit Price Your reduced sliding fee Units Provided Total
scale rate
PERS-Monthl Fee 30.00 14.25 1.00 1425
Personal Care 17.20 8.17 3.00 24.51
TOTAL COST= 38.76
Payment Due Upon Receipt of Invoice. Payment Is Delinquent if not paid by June 26, 2014.
Contact CCOA if any issues.
Make Checks Payable To: Ct1MBERLAND COUNTY OFFICE OF AGING
,,
���c° CUMBERLAND COUNTY
��,�,.•� `.�,,�.�
,� � AGING & COMMUNITY SERVICES
�� / 1100 C��xE1�oNT Ro.�D, CA�u.�sLE,PA 17015
/ �
��� (717)240-6110 ox 1-888-697-0371 ExT 6110
r�: (717) 240-6118
Barbara B Cross
One Team ...One Mi.r.rion Chairman
Jim Hertzler
V�ce Charrman
Gary Eichelberger
INVOICE FOR SERVICES SQ°'e`°ry
Teiry L Barley
Drrector
Kathleen R Kenney
208 Senate Ave Apt 319
Camp Hill, PA 17011
Invoice Number: February-14-
Invoice Date: May 7, 2014
SERVICE(S) PROVIDED: Personal Care & PERS
MONTH OF SERVICE: February 2014.
SERVICE Unit Price Your reduced sliding fee Units Provided Total
scale rate
Personal Care $17.40 8.26 9.50 78.50
PERS 30 14.25 1 14.25
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TOTAL COST= 92.75
Payment Due Upon Receipt of Invoice. Payment Is Delinquent if not paid by June l, 2014.
Contact CCOA if any issues.
Make Checks Payable To: CUMBERLAND COUNTY OFFICE OF AGING
�
,�•�����,, CUMBERLAND COUNTY
� 1` AGING & COMMUNITY SERVICES
�\ � 1100 C��xE1�1o�vT Ro�D, C1��u.ISLE,PA 17015
����/ (717)240-6110 ox 1-888-697-0371 ExT 6110
FAx: (717)240-6118
Harbaza B Cross
One Team...One Mi.r.rion Chairman
Jim Hertzler
Yice Chairman
Gary Eichelberger
INVOICE FOR SERVICES Secretary
Teiry L Barley
Director
Kathleen R Kenney
208 Senate Ave Apt 319Apt 319
Camp Hill, PA 17011
Invoice Number: March-14-28
Invoice Date: May 1,2014
SERVICE(S) PROVIDED: Personal Care & PERS-monthly fee
MONTH OF SERVICE: March 2014.
SERVICE Unit Price Your reduced sliding fee Units Provided Total
scale rate
Personal Care 17,40 8.27 11.75 97.17
PERS-monthl fee 30.00 14.25 1,00 14.25
TOTAL COST= 111.42
Payment Due Upon Receipt of Invoice. Payment Is Delinquent if not paid by May 26, 2014.
Contact CCOA if any issues.
Make Checks Payable To: CUMBERWI�D COUNTY OFFICE OF AGING
� � �f greatcalla Remittance Section
'r`"� ���3���i��'!'�=?�ccun?�;, Account Number:
Date of Notice: 543149
Amount Due: �4�28�2074
Return Service Requested $23.62
Amount Enclosed: $ ��. �j �
Please put your account number on your check and make payable t
118800013B PRESORT 138 1 MB 0.435 P1C6�B>
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KATHLEEN KENNEY JITTERBUG
� 208 SENATE AVE APT 319 DEPT 8921 p2
�` CAMP HILL PA 17011-2353 PO BOX 122102
DALLAS,TX 75312-2102
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PLEASE DETACH ABOVE PORTION ANO RETURN WITH YOUR PAYMENT-THANK YOU.
PAYMENT REMINDER
Account Number Notice Date
Amount Due
543149 04/28/2014 $23.62 �
This is a reminder that your account is past due. Please remit the full amount
due; failure to remit the full amount due could result in a suspension of service. —
To make a payment free of charge using a debit or credit card call —
1-800-280-7708. °
Please disregard if payment has already been made.
=
=
Note that during any service suspension, all calls are redirected to —
GreatCall Care. 5Star Urgent Response will not be available, but
emergency services may still be contacted by dialing 911 from the
handset.
,--- _--_._. __ .___-----____ ___.__
�������� � Account Number 09547189303-03-9
, Billing Date 03/15/14
Total Amount Due $72.77
Auto Pay 04/07/14
Page 1 of 2
Contact us: �`�£k�'www.comcast.com�`�;� 1-888-931-1379
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KATHLEEN KENNEY ,k.,i �� ���. � �`` ' � ����� ��ff .�`, ���_;��_��,� �
Previous Balance � 72.77
For service at: Payment-03/07/14-ihank you -72.77
208 SENATE AVE APT 319
CAMP HILL PA 17011-2353 New Charges-see below 72.77
To#al Amount Due $72,7�
News from Comcast Auta Pay 04/07/14
Questions? Call 1-800-XFINiTY(1-800-9346489) - � �
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Thank you for your prompt payment. � �,f X�INITY TV � �8.20
You are enrolled in the Comcast Auto Pay Program.The E. �' XFINITY Intel"f1Gt 61.95 �
amount due which will be deducted from your bank accouM or ti
will be applied to your credit card may include charges OtheP Charges &CreditS 1.50 �
incurred or credits issued after the statement prepared date.
Details of any charges or credits posted after the statement Taxes, Surcharges & Fees 1.12
date will appear on your next bill.The amount due wilt be
debited from your account on the 7th. TQt81 NLw Chaf JES $7�,77
Hearing/Speech Impaired Ca11711 F " - �.� }. - ,' � , ,
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Detach and enclose this coupon with your payment.Please write your account number on your check or money order.Do not send cash.
Gomcast.a Account Number 09547 189303-03-9
Auto Pay 04/07J14
PO BOX 985
TOLEDO OH 43697-0985 Total Amount Due $72,77
AV 01 003711 74627B 18 A'�5DGT Amount Enclosed �
��1�'�1�1���1��'I'�'�11"�I�III"'�I�1�'�'�I�"�11'�'I�III����1'� Make checks payable to Comcast
KATHLEEN KENNEY
208 SENATE AVE APT 319
CAMP HILL PA 17011-2353 '�II'I���I���I��Ill�n�l�l�l���l�ll�'I'������11'�I'1�'���"I1���1
COMCAST CABLE
P 0 BOX 3005
SOUTHEASTERN PA 19398-3005
09547 189303 03 9 8 OD7277
WEST SHORE EMS - ALS � �
205 GRANDVIEW AVE STE 211 �`«a � D15�°��� MQSferCard�
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CAMP HILL, PA 17011-1708 ON REVERSE SIDE
�x�F,ST SHORE E?�1S Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
�:HOLY SPIRIT HEALTH 5Y�7EM
PATIENT NAME: K,qTHLEEN KENNEY INSURANCE:
MEDICAL TRANSPORTATIO HMODEN
NOVITAS SOLUTIONS, INC. MDIP
CALL t�UMBER: �4O6�Z7A DATE OF CALL: 04/07/2014
FROM: 208 SENATE AVE APT 319
�Q' HOLY SPIRIT HOSPITAL
ACCOUNT SUMMARY
KATHLEEN KENNEY
208 SENATE AVE APT 319 TOTAL CHARGES: 982.06
CAMP HILL, PA 17011 PAYMENTS/ADJUS7F�fENTS: 0.00
PLEASE PAY THIS AMOUIJT: 9$2.06
_ DET.4 CH ALONG PERFORAT/OlY AND RETURN STUB W/TH PAYMENT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
ALS EMERGENCY LEVEL 1 A0999 1.0 967.62
EKG ELECTRODES (1) A0398 967.62
4.0 1.84 7.36
GLUCOSE BLOOD A0394 1.0 7.08 7.08
Total Char es
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
�(���.�� 1��,�`�h{f� /�fi�C1(.1t�T s [F,t���[�� �E�� (J��h! F����[�� -�-
��1`�IRH�� �H�GE� ���m�31.�� $982.06
PATIENT NAME: KENNEY, KATHLEEN R C�LL NUNtBER: �4O6'I27A AMOUNT PAID����� �/4�
04/25/2014
«�������� �����`���` THIS ACCOUNT IS PAST DUE! Send your payment now or contact
our office to make payment arrangements.
WEST BHORE E(�IS -,4L5 205 GR�4tVDVIEW AVE STE 211 CAMP FiILL, FA 17011-1708
��* END OF ATTACHMENTS ***