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.j REV-1500 EX(02-11) t. 1505610143 1 OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number Bureau of Individual Taxes OSPARTMEW OF FRVEPM PO BOX.280601 INHERITANCE TAX RETURN 21 14 0252 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 02 05 2014 09 12 1922 Decedent's Last Name Suffix Decedent's First Name MI STONER SR GLEN H (if Applicable)Enter Surviving Spouse's Information Below Spouse's Lost Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW RX 1. Original Return 2. Supplemental Return 3. Remainder Return(Date of Death Prior to 12-13-82) 4. Limited Estate 4a,Future Interest Compromise orn 5. Federal Estate Tax Return Required (date of death after GomtlZ!) 6, Decedent Died Testato ❑ 7. o intlned a Living Trust (Attach Copy of Will) u 1) 8. Total Number of Safe Deposit Boxes 9. Litigation Proceeds Received E] 10.Sgousal Pover%�red�t4Dar of Death ❑ 11.Election to tax under Sec.9113(A) b tween 12-31. an -1- 5) (Attach Schedule 0) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number.,., JOHN J MOONEY 111 717 63'4656 -;0 M 3:: 2 -- C� REGISTER Of W1LIt6,USEZONLy Cr, First Line of Address 230 YORK STREET CD Second Line of Address P—A 7) C:) r— f 6-ATE FILED r--1 cf) CD City or Post Office State ZIP Code HANOVER PA 17331 Correspondent's e-mail address: Under penalties of perjuryot deaclare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and co Tete.Qp9laration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PE ON E 11 IE�FOR,1AIGJW14RN— DATE John J.Mooney 111 6 /ADDRESSf s,I230�York Vreetj' hover/ 331 GN REPRER� HAN REPRESEN DATE7 John James Coney III � 0.0 ss A 00 33V 2�31V ork$treet,11/anover, RA 17 Side I 1505610143 1505610143 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: Stoner, Glen H. Sr. RECAPITULATION 1. Real Estate(Schedule A)....................................................................................... 1. 2. Stocks and Bonds(Schedule B)............................................................................. 2. 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3. 4. Mortgages&Notes Receivable(Schedule D)........................................................ 4. 5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 90,080 . 06 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers&Miscellaneoust{nD Probate Property (Schedule G) LJ Separate Billing Requested............ 7, 8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 90 ,080 . 06_ 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 21,178 . 65 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 8, 900 . 09 11. Total Deductions(total Lines 9 and 10)................................................................ 11. 30, 078 . 74 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12, 60, 001.32 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J)............................................... 13. 14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 60, 001 . 32 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 15. 0. 00 (a)(1.2)X.00 16. Amount of Line 14 taxable 60 001 .32 16. 2 , 700 . 06 at lineal rate X .045 17. Amount of Line 14 taxable at sibling rate X.1 2 0 . 00 17. 0. 00 18. Amount of Line 14 taxable at collateral rate X.15 0 . 00 18. 0 . 00 19. TAX DUE................................................................................................................ 19. 2, 700 . 06 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑ Side 2 I,�, 1505610243 1505610243 REV-1500 EX Page 3 File Number 21-14-0252 Decedent's Complete Address: DECEDENT'S NAME Stoner, Glen H.Sr. STREET ADDRESS 11 Whitmer Road CITY STATE ZIP Shippensburg PA 17257 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 2,700.06 2. Credits/Payments A. Prior Payments B. Discount 0.00 Total Credits(A +B) (2) 0.00 3. Interest (3) 4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) Check 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) 2,700.06 Make Check Payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;............................................................................... ❑ ❑x b. retain the right to designate who shall use the property transferred or its income;.................................. ❑ x c. retain a reversionary interest;or............................................................................................................... ❑ x d. receive the promise for life of either payments,benefits or care?............................................................ ❑ x 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receivingadequate consideration?.................................................................................................................... ❑ ❑x 3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ ❑x 4. Did decedent own an individual retirement account,annuity,or other non-probate property which contains a beneficiary designation?.................................................................................................................. ❑ ❑x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE 1T 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 172 P.S.§9116(a)(1.1)(i)]. For dates of death on or after January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent (72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent,or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)). • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)]. A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. Rev-1508 EX+(11.10) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE p p INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Stoner, Glen H.Sr. 21-14-0252 Include the proceeds of litigation and the date the proceeds were receivedby 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 1 Orrstown Guardianship Account-No.:31-00-2043 0 05 90,063.19 2 Pennsylvania Treasury-Bureau of Unclaimed Property(see attached check copy) 16.87 TOTAL(Also enter on Line 5,Recapitulation) 90,080.06 (If more space is needed,additional pages of the same size) Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev.11-10) REV-1511 EX+(10-09) pennsyivania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RESIDENT DE E ENETTURN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Stoner,Glen H.Sr. 21-14-0252 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT - NUMBER A. FUNERAL EXPENSES: See continuation schedule(s)attached 13,378.99 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) John J. Mooney ill Street Address 230 York Street city Hanover State PA ZiD 17331 Year(s)Commission Paid 3,600.00 2. Attorney's Fees Mooney&Associates 3,600.00 3. Family Exemption: (If decedent's address Is not the same as claimant's,attach explanation) Claimant Street Address City State ZID RelationshiD of Claimant to Decedent 4. Probate Fees 173.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 426.16 See continuation schedule(s)attached TOTAL(Also enter on line 9,Recapitulation) 21,178.65 Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule'H(Rev.10-09) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Stoner, Glen H.Sr. 21-14-0252 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Dollar Rent A Car-Vehicle rental for funeral services 277.59 2 Gerardi Funeral Home,Ltd. 7,084.00 3 Joji BP-fuel expenses 34.00 4 Mount Olivet 4,547.94 5 Southwest Airlines-travel fees for family to attend funeral services 1,148.00 6 Super 8 Mokena-Hotel costs for funeral services 287.46 H-A 13,378.99 Other Administrative Costs 7 Cumberland Law Journal-Advertising Fee 75.00 8 Register of Wills-Underestimate of Letters 150.00 9 The Sentinel-Advertising Fee 201.16 H-B7 426.16 Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98) Rev-1512 EX+(12-08) SCHEDULE 1 pennsylvania DEBTS OF DECEDENT, DEPARTMENT OF REVENUE INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Stoner, Glen H.Sr. 21-14-0252 Report debts Incurred by the decedent prior to death that remained unpaid at the date of death,including unrelmbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Ardbrook Plaza-medical bill 150.00 2 Cumberland County Orphans'Court-Filing fee for objection 5.00 3 Martson Law Offices 7,387.09 4 NCO Financial Systems,Inc.-Medical Center of Arlington bill 150.00 5 U.S.Treasury 1,208.00 TOTAL(Also enter on Line 10, Recapitulation) 8,900.09 (If more space is needed,additional pages of the same size) Copyright(c)2008 form software only The Lackner Group,Inc. Form PA-1500 Schedule I(Rev.12-08) REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Stoner, Glen H.Sr. 21-14-0252 RELATIONSHIP TO NUMBER NAME AND ADDRESS OF DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE PERSON(S)RECEIVING PROPERTY (Words) ($$$) Do of l s e s ITAXABLE DISTRIBUTIONS (include outright spousal distributions,and transfers under Sec.9116(a)(1.2)1 Janet L.Swope Daughter 100%residue 2116 Ruth Street Arlington,TX 76010 Total Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate. NON-TAXABLE DISTRIBUTIONS: II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10) LAST WILL AND TESTAMENT OF GLEN H. STONEI; , SR. I, Glen H. Stoner,Sr.,of 11 Whitman Road,Shippensburg,Ctmberland County, Pennsylvania,being of sound and disposing mind,memory,and understanding,do*hereby declare this as and.for my last will and testament hereby revoking all wills and codicils previously made by me. FIRST I direct payment of my debts and expenses of my last illness and funeral from my estate as soon after my death as conveniently may be done. SECOND I give,devise,and bequeath my entire estate to my daughter,Janet L. Swope of Arlington,Texas. THUM In the event my daughter,Janet L. Swope should fail to survive me,I-give,devise and bequeath my estate unto my son-in-law,Robert L.Swope. FOURTH I direct that any and all Inheritance,Estate and Transfer Taxes imposed upon my estate passing under my will shall be paid out of the principal of my residuary estate. FIFTH In additioft to the powers conferred by law,I authorize my personal representatives in their absolute discretion: A. To retain in the form received,and to sell either at public sale or private sale any real or personal property,and to distribute to heirs either in cash or in kind. B. To mainage'real estate, C. To invest and reinvest in all forms of property without being confined to legal investments,and without regard to the principle of diversification. D. To exercise any option or rights arising from ownership of investments. E. To compromise claims without court approval and without the consent of any beneficiary. SIXTH I nominate, constitute,and appoint my daughter,Janet L. Swope, as Executrix of this my last will and testament. In the event of the renunciation,death,resignation,or inability to act for any reason whatsoever of my said daughter, I nominate, constitute and appoint my son-in-law,Robert L. Swope,as surviving Executor of this my last will and testament. I hereby relieve my personal representative from the necessity of posting security in connection with their duties as such in any jurisdiction in which they may be called upon to act insofar as I am able by law to do so. IN WITNESS WHEREOF,I have hereunto set my hand and seal to this my last will and testament,this.,_,-d day of November,2011. wGIen H. Stoner,Sr. i Signed,sealed,published and declared by the above named testator,Glen H. Stoner, Sr.,as and for his last will and testament in the presence of us,who, at his request, in his sight and presence,and in the sight and presence of each other,have hereunto subscribed our names as witnesses. 1035 Wayfie Avenue 1015 Wayne Avenue Chambersburg,PA 17201 Chambersburg,PA 17201 i COMMONWEALTH OF PENNSYLVANIA : : SS COUNTY OF FRANKLIN I, Glen H. Stoner,Sr.,the testator whose name is signed to the attached or foregoing instrument,having been duly qualified according to law,do hereby acknowledge that I signed and executed the instrument as my Last Will;and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. We, the undersigned,the witnesses whose names are signed to the attached or foregoing instrument,being duly qualified according to law,do depose and say that we were present and saw the testator sign and execute the instrument as his last will;that the testator signed willingly and executed it as his free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the testator signed the will as a witness; and that to the best of our knowledge the testator was at that time eighteen (18)or more years of age, of sound mind,and under no constraint or undue influence. Sworn to or affirmed and acknowledged before me by Glen H. Sto4=,Sr.,the testator, and sworn to or affirmed and subscribed to before me by nL4 7/'foss and F,6z( �ec ,witnesses,this 3,,,? day ofdUe;n,fje, , 2011. �A9A4",1/2�; Glen H. Stoner, r. /MTNESS WITNESS NOTARY laCJ�dtiFdYi1!Vd+:ri!_[1',of PENNSYLVANIA Notnii9j Sed Csrc;d.Valmr,NoWly?ubtic chmillersturg smo,Fmrlklh,=Aunty err o:r;e:tap c;Y¢•`rEs Amit e,?01's I I *!,��,-'::�',:...., -_-:.,..l-."-*,-,,�11 . �� ... *.. �. �"Inm apply yQ:..:,�,-j.'.-'............ ;,-1,,�-,.......'....... ,-.,.,::l,"L.t'.'� ...'_ ; .�.'.',"�:.*:�-*.�,:-,.::";",�.�.,,-,�:..,.. ��`" ...:;.-,-.-�.�,,��.,.,,-.,t.,*:,:�,:...;...:�,.�,;.,;�'*�.'',!?- _ I . ..."..;� .. -""" , . ..-.1.�-'.�;-;"::..1,'..;. . - .1 �,�-i'�".,:.,�l,i!.,.'�,�,-.,.'�'I"..'i�-'.�,;",�,�*-,., . . - W,." ,4-.:,_,2:0;:.z-t-,1'.*.4*-.t . .... .� ... ,-E171. , 4 - ,, , f I. .�� :..'�'.'.'.'.'.'.'.'.'.'.'.......,. -..".-Z%--.';t-4,z�,�,,',.t.l..,I-AI Jk:h I:`,'�-'-,"''jt 1.".V-,,�::�l i,",'. � � � . � � � � � � � � � 1�....... ` � , .- --,,.- . 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Box 1837 HANOVER PA 17331-3270 Harrisburg, PA 17105-1837 FOLD ON PERFORATION,THEN DETACH CAREFULLY 0 O • O e - O • O � - - - "IME F s"-7ifflS.•ia?'vJti:G?:.,.;t'.e\'t•./,.' 1,: -.+•h ^-. ° - e _ . e e ,..t?,<`++,,r:;.....,:•::::•.:: F�.:.�!?.,....,.r >�r?' ..yir"f,`.i:+:f,!%:tn�v n�itb�:: ..�'.:?r,":�`• %,�;.s2+:.•:ir T•>:::J;,,r!\ti1;!�•9 w. �r r fi'.w' .iti v'i `v-a::'; ^:�i.: 4 /re�i .};,t. ;,:•;.;t::. :...� ltifi 1. 1. 1' :}:�r/' >:>;rS+ '•�t't 3 .t "t � „r k• c' r I� E Tr.•73�•'�� Z vim+ 0 r• 532 -� <t+ 'w;+l r r v ♦r 3- .s+ �tiy^c 1. av q *� J � t .r s S i. s•s•r tfY .,�.:5. 'i.�;.:k, :. .:SOS/E�R+, .1``•, AA(v�it.?.B.A,�K..'t.af.:^�ar%.-!.rrrt.;,:\ys •%�'Y,F.[{�.':-�iT5a!,;<fiS •,z,,l�;t£:."rr.";:F.1 sri�}t!'h,:'.::..1�f k�1:"f.,.,•r,�.v_,�x( 0_ '�:'•�..i1.�,•�•+:�Y,i.'.3�of.Itii•itr:..�'r',r,.ri,(sj.;;::J>;�r:"�l t^f•'ia•ir><b..�.,�5•...}.?;,¢,;at>+}z;'•.r.;1::•?'•Yi:t`t'<1I,5:�.v..::r�'.••c,F:,i}:f.7•ir,!'•✓•t.,.7 r1::a5�.M:, ::'f111 ADr�_r=ftit.ZH.Yril.-i,.E••✓>j t.e:7 a% :j i:�;�%iG.:<':o•s^kr..:'},,,•.r,/..: K::! (...<. :;c,,, .:•...:'rte.,''N;i�::^.u:•: :•..>s:,. t:..:i. y: ''=:VERIFI"'' N: VA ''� h- %•z,• ,•f;•::.. :.�.,,;.,'s3,;•#: •,'•a>';':; t_ NATIOCJSRIV +1?f11'!P.:OTEQ7ED`' }....,t.<.::c ;. ....;: :;...� .r}� :`•+t' •.:.'ii!' ���Rr:„";. �• �. f"•L'34<,c ,!��a;.�.:a..:_�•.. ,::�; ,t.r..>..r'rs= 0• r `"u t R.. A •j r. !� 11 (: }�1 Y -PAY, •SIP cr.Scfis•;:;:.. !..r-•-•-'-' `-VOID< ,s -.tw AFTER•18U b' Y, (r, i O.TME^O ,�DET R-OF l �O R h rv,N >r.f. n,fn;. - _ .ern �•. t � ':S:i• C itrf•:: 7 O, tits' :z ark•, :q:: a`:j";" 'r�� , 'Cy i;%; •i t - 7 :�;is ,.�„� :h...;;•;:`: jr •+:J i•. 'ice.` .r'•.i' 'a r5e.. acf+' Its S0000IS334a' „0313759791: 7680950598{1' 0T RE1.117MITM00 o e o e e o er rdiSTATEMENT OF FUNERAL GOODS AND SERVICES SELECTED ~ Charges are only for those items that you selected or that are required.If � . we are required by law or by a cemetery or crematory to use any items,we Fu ne ft tL will explain the reasons in writing below. Ifyort selected a fitneral that may require embalming,such as o funeral Lincoln Highway at 95th Avenue with viewdng,you may have io pay for embalming. You do not have to pay P.O.�OY 901 for ernbalming you did not approve Ifyou selected arrangement such as a direct cremation or immediate burial. If we charged for embabning,we F rani{fort,..H, 60423 will txplain why below. (815)469-2144 CASH ADVANCES Certified Copies of Death Certificate each No. Clergy $200.00 DECEASED Glen H.Stoner Musician DATE OF DEATH February 5,2014 PLACE OF DEATH Arlington,Texas Paid Newspaper Notice $244.00 DATE OF STATEMENT February 12,2U t4 INC=Included in acTca a rice Family Discount A Aied Cemetery A.CHARGE FOR SERVICES SELECTED Messenger Service L ProfessionalSenzces, Flowers $125.00 Basic Services of Funeral Director.............................. INC Embalming......................................................... TOTAL CASH ADVANCES $569.00 Other preparation of body.................................. INC 'A'c charge you for bur services in obtaining(specify cash advance items). ...................................................................... 2.fitcilWes,Equipinent& Staff. Use of Facilities&Staff for Viewing/Visitation........ INC. SUMMARY Use of Facilities&Staff for Funeral Ceremony.... ... INC Total Funeral Home Charges..................... $6515.00 Use of Facilities&Statl'for Memorial Service......... Local Sales Tax(if applicable)................... Use of Egrupment&Stiff for Graveside Service...... INC State Sales Tax(if applicable).................... Use of Equipment&Staff for Church.Serv.ice.......... � Total Cash Advances.............................. $569.00 GRAND TOTAL 57084,00 3. Transportation. Less Credits and Payments Transfer of Remains to Funeral Home................. Hearse...................................................... INC Limousine.................................................. Total Credits.............................. Sedan....................................................... ServicefUtility Vehicle................................... INC RAI,ANCE DUEO> $7084.00 4.Other Servires/Facilitler E,quipinent Billing To: Transfer from Midway Airport..................................... Janet Swope 2116 Ruth Street Arlington,TX 76))010 �1iTV TOTAL OF'SI;RVICFS SELECTTD...................................... $6415.00 DISCLOSURES Reason.for embalming S.CHARGE FOR MERCHANDISE SELECTED Casket(or other receptacle)................................ ................. Name/No. ilfaterial If arty law,cemetery or crematory requirements have required the. Color purchase of any items listed,the law or requitement is explained Outer Burial Container...................................................... below. Atame/No. Material Memorial Package-includes the following:....................... Acknowledgement Cards................................................... ACKNOWLEDGEMENT AND AGREEMENT Register Book................................................................. I hereby acknowledge that I have the legal right to arrartye the final Memory Folders/Prayer Cards............................................. $10Q,00 services.forthe deceased,and I authorize this funeral establigluuentto Clothing................................................. perform services,Aunish rgwods,and incur outside charges specified on this ......... Cremation Urn................ Statement. I acknowledge that I have received the General Price List and " " """"""""......' the Casket Price List and-the Outer Burial Container Price List. TOTAL OF MERCHANDISE SELECTED.............................. $100.00 Tema ofFayment DUE"UPON RECEIPT, Full Payment is due no later than . If any payment is not paid when C.SPECIAL CHARGES due,an unanticipated LATE CHARGE of per month(ANNUAL PARV_WrACiF.R ATP. a/al on.the unnaid halance will be due. 7 aures !,•:r.., '.,;!y�,;?^!.—Yt ;s?=cn:, ,..-s��'-.:. :r�' ' , �;a•.F ::i:t,, h ::.•-�:�"r-e L Accou�TB.el' GREENWOOD MOUNT OLIVET FORT.WORTH&ARLINGTON! ;:'•• :•..' FUNERAL HOMES CEMETERIES• MAUSOLEUMS! FLOWER SHOPS' ' PAID BY DATE: L•... � f t..i CASH i0 c. CHECK ' RECEIVED BY,�f -�Ulz r.- AMOUNT: 1 ---� THANK YOU FOR CUSTOMER SERVICE OR ACCOUNT INFORMATION PHONE 338-0584 • ••ACCOUNT R' ' G.REErIWOOD ` . - :•MOUN, :: LIVET FORT WORTH'.:&;ARLINGTON ... ',,:; :: .:. •::'':: - : ' FUNERAL HOMES'• CEMETERIES •MAUSOLEUMS'-.FLOWER SHOPS JV fWD BY: ; €� ;FOR:._ ;CC7�.., :•' '! k:F'`;>h.�,: .: DATE: `— CASH CHECK •' RECEIVED BY:`y�"✓�`— u"-{� /AMOUNT: 'r.. THANK YOU ��•`••:; FOR CUSTOMER SERVICE OR ACCOUNT INFORMATION PHONE 33843584.