HomeMy WebLinkAbout04-14-15 (2) IN THE ORPHANS' COURT DIVISION OF
CUMBLERLAND COUNTY, PENNSYLVANIA
PETITION FOR SMALL ESTATE UNDER 20 Pa. C.S. § 3102
IN RE: RUTH A. BOWERS, DECEASED ORPHAN'S COURT DIVISION
NO:
DECREE OF DISTRIBUTION
And now,this day of , 2015, in consideration of the facts presented in the
Petition for Small Estate administration for the Estate of Ruth A. Bowers, said petition is
granted under 20 Pa. C.S.A. §3102.
Pursuant to 20 Pa. C.S.A. §3102, William J. Bowers and Donald Ray Bowers, as
Executors of the Estate of Ruth A. Bowers, are authorized to transfer decedent's property
without probate of Ruth A. Bower's Last Will and Testament.
This Decree of Distribution shall be recognized by Computershare, as the transfer agent
for Met Life stock with the same authority as a short certificate issued by the Register of
Wills of Cumberland County, Pennsylvania. William J. Bowers and Donald Ray
Bowers, as Executors, are authorized to effect the transfer of the Met Life stock shares
owned by their mother, Ruth A. Bowers, at the time of her death,to William J. Bowers
and Donald Ray Bowers, as Beneficiaries of her estate.
J.
L
i
`R'E,.' R'VE'D Q F'F 1 C 5Q:F'
R'EtG'i S TE R OF W 1-"L:L S'
Anna Borro Hays, Esquire � 5 P - RM 2 9,
Attorney I.D. No. 70375
Saidis Sullivan &Rogers C L,E R,K Of
635 North 12th Street, Suite 400 ff ff',it AN""
Lemoyne, PA 17043C C C '
Phone: (717) 612-5804
Fax: (717) 612-5805
Entail: aborroha�s ,ssi attorne �s) Cofi2 Attorneys for Petitioners
IN RE: IN,THE COURT OF COMMON PLEAS
ESTATE OF RUTH A. BOWERS CUMBERLAND COUNTY,
PENNSYLVANIA
WILLIAM J. BOWERS and DONALD ORPHANS' COURT DIVISION
i RAY BOWERS,
Petitioners NO.:
PETITION FOR SETTLEMENT OF SMALL ESTATE
FILED UNDER 20 Pa. C.S.A. § 3102
AND NOW, come Petitioners, William J. Bowers and Donald Ray Bowers, by and
through their counsel, Saidis, Sullivan & Rogers, and file the within Petition for Settlement of
Small Estate Filed Under 20 Pa. C.S.A. § 3102, and in support thereof, aver the following:
1. Decedent, Ruth A. Bowers, died on January 15, 2015. (See, Exhibit A—Death
Certificate.)
2. At the time of her death, Decedent resided in a personal care facility, The Bridges
at Bent Creek, Mechanicsburg, Cumberland County, Pennsylvania 17050.
I
3. Decedent died testate. (See, Exhibit B—Last Will and Testament (the "Will').)
Decedent executed her Will on September 23, 1992.
4. Under Item III of her Will, Decedent bequeathed the rest, residue and remainder
of her estate to her sons, William J. Bowers and Donald Ray Bowers.
5. In Item IV of her Will, Decedent named her sons, William J. Bowers and Donald
i
i
I
18. Petitioners request this Orphans' Court to issue a Decree of Distribution so that
they, as Executors can have Computershare to distribute the 60 demutualized shares of Met Life
stock to them as beneficiaries of their mother's estate under her Last Will and Testament.
WHEREFORE, Petitioners respectfully request this Honorable Court sign the attached
Order of Court.
Respectfully submitted,
SAIDIS SULLIVAN &ROGERS
Dated: April 14, 2015 By: 9LV� A",
ANNA BORRO HA"J'S,
Attorney I.D. #70375
IN THE ORPHANS' COURT DIVISION OF
CUMBLERLAND COUNTY,PENNSYLVANIA
PETITION FOR SMALL ESTATE UNDER 20 Pa. C.S. § 3102
IN RE: RUTH A. BOWERS,DECEASED ORPHAN'S COURT DIVISION
NO:
CONSENT
I, William J. Bowers, consent to the Petition for Small Estate under 20 Pa. C.S.A. §3102.
William . Bowers
SWORN TO and subscribed 15-
This j�-day of &rl*l 20,14
Notary Public
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
KELLY R.HOWELL,Notary Public
Leymoyne Boro.,Cumberland County
Commission Expires September 2,2018
��^^IIN�/TDHE ORPH��77AN�^S('�COURT DIVISION OF
8.�t.., ,lR�r,�ER� AND COr>3�#.V,_ PPi,AsJ.3a�y.?f VANJ* F.
PETITION FOR SMALL ESTATE UNDER 20 Pa. C.S. §3102
IN RE: RUTH A. BOWERS,DECEASED ORPHAN'S COURT DIVISION
F
NO:
CONSENT
I, Donald Ray Bowers, consent to the Petition for Small Estate under 20 Pa. C.S.A.
§3102.
Donald Ray Bow
SWORN TO and subscribed o20�
This j 0 day of&rj I -2$44-
Notary Public
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Desiree Anne McFall, Notary Public
White Twp.,Indiana County
My Commission Expires April 15, 2017
MEMBER,PENNSYLVANIA ASSOCIATION Of NOTARIES
t
VERIFICATION
t
I,Donald Ray Bowers,state that I am the Petitioner and hereby verify that the statements f
made in the foregoing Petition for Settlement of Small Estate are true and correct to the
=did that fibe s:ezmenft,h-
are made subject to penalty under Title 18 of the Pennsylvania Consolidated Statutes
Annotated.
Dated: .5 2015
Donald Ray Bowers
VERIFICATION
I, William J. Bowers, state that I am the Petitioner and hereby verify that the statements
made in the foregoing Petition for Settlement of Small Estate are true and correct to the
best of my knowledge, information and belief. I understand that false statements herein
are made subject to penalty under Title 18 of the Pennsylvania Consolidated Statutes
Annotated.
Dated: r(J✓';�
Willis J. Bowers
EXHIBIT A
H105.805 REV(9/11)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00 This is to certify that the information here given is
tt0pll`p,,l it OF pEy- correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will be forwarded to the State Vital
a. a Re c rds Office for permanent filing.
P 21368198
Certification Number """ENj""",l) Local Registrar Date Issued
Type/Print In COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS
pal cklnkt CERTIFICATE OF DEATH
State FII¢Number:
1.Decedent's Legal Name(First,Middle,Last,Suffix) 2.Sex 3.Social Security Number 4.Data of Death(MO/Day/Yr)(Spell Mo)
RutA !1. 13owe2s F 796-22-9422 aanuaicry 7 5, 201 5
So.Age-Las[Birthday(Yrs) I.b.Under 1 Year Sc.Under 1 Oa 6.Dac..fol (Me/Dey/Year)(Spell Month) 7a.8jrthplaea(City anQS or Forel,"Country)
87 Months Days Hours Mlnu<es �p-ZZpJLbx ,J�te
-2 71 7 927 7b.Birthpbce(County) Ome24
Be.Rositlence(Scale Or Foreign Country) Bb.Residence(Street and Number-include Apt No.) Bc.Did Dacodent Live in•Town hip?
7�enn� 2van i a 7 9 NaLel/ze.6 CrLoz.6-i, �7 vas,tle.eaent 6yea In �2 v mit Sn.2 in 4 7wn two.
8d.Resident¢(County)
Cil m e 2-9a nd Be.Residence(Zip Code) 77025 Q No,decedent lived within limits of etty/bor..
9.Ever In US Armed Forces] 30.Marital Status at Time of Death Q Married Widowed 11.Surviving Spouse's Name(if wife,give name prior to flet marriage)
Q Yes ®NO Q Unknown Q Divorced Q Never MerciEd Q Unknow
12.Father's Name(First,Middle,Last,Suffix) 13.Mother's Name Prior to First Marriage(First,Middle,Last)
C.ea,zen Ge 7= a enn.ie HOOVp_,&
14a.Informant's Name 14b.R¢IatlOnship tO Decedent 141,Informant's Mailing Address(Street and Number,Clty,State,Zip Code)
Rowe..6 Sort 19 Na_i U,ir.e.6 C=a a in Erzo 2a 7�r1 17025
�. - - - - - - -- - --- -1 0.P ale O Rat -.h.on y one _ - -_ -- - - -
lf Death Occurred In a Hospital: ❑Inpagent I If Death Occurred Somewhere Other Than a Hospital: I]Mosplce Facility L]Decatlent's Home
25 Q Emergency Room/OULpatlent Q Dead on Arrival NursingHome/Long-Term Care Facility Q Other(Specify)
a� lsb.Facility Name(If not instit 97,give iVeet and number) I-c.City or Town,5[a2e, d Zip Code l:County of Death
The BZ-1-d e.s reit 13enf Cicee% /72chQnLee�ec2 /'tea 77050 rim a_-,LX rLd
160.Method of Disposition Q Burial j$ Cremation 16b.Date of Olsposltlon 16c.Place of Disposition(Name of cemetery,crematory,or Other place)
Q Remgyal rrom st.te Q Donation CLn 17, '10 5 Evan-6 Crcema4.ion Se/ty� _ce
Q otner,(SPeei"'
2 16d.Lec,ll*n of.Disp-Itlon(City or Town,State,and Zip) 17a.Signa o Funer 1 Serve icensee or erson n Char
ge Of Interment 17b.Uclnse Number
g Leola, 7'a 17540 ('0091897-L
17C.Name a Co plate Address o�.Fu arse Facility n O a 2.i Le
el 2 e Evan /CGneAa C.cema4.Gon Se1zVzCe.61 LLC
18.Decedent's Education-Check the box that best describes the 19.Decedent of Hispanic Origin-Check the 20.Decedent's Race-Check NE OR MORE races to Indicate whet
highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be.
Q 8th grade or less Is Spa nlsh/Hlspa nlc/Latino. Check the"No" (a White Q Korean
Q No diploma,9th-12th grade box H decedent is not Spanish/Hispanic/Latino. Q Black or African American Q Vietnamese
High school grad t¢or GED completed [g No,not Spanish/Hispanic/Latino Q American Indian or Ales"Native Q Other Aslan
Q Some college credit,but no degree Q Yes,Mexican,Mexican American,Chicano Q Asian Indian Q Native Hawaiian
Q Associate degree(e.g.AA,AS) Q Yes,Puerto Rican Q Chinese
Q Guamanian or Chamorro
Q Bachelor's degree(e.g.BA,AS,BS) Q Yes,Cuban Q Filipino Q Samoan
Q Master's degree(e.g.MA,M5,MEng,MEd,MSW,MBA) Q Yes,other Spanish/Hispanic/Latino Q Japanese Q Other Pacific Islander
Q Doctorate(e.g.PhD,Etl D)or Professlonal degree (Specify) Q Other(Specify)
.MD ODS DVM Ll0 JD
21.Decedent's Single Race Self-Designation-Check ONLY ONE to indicate what the decedent considered himself or herself to be. 22a.Decedent's Usual Occupation-Indicate type of work
®White Q Japanese Q Samoan done during most of working life. 00 NOT USE RETIRED.
Q Black or African American Q Korean Q Other Pacific Islander XOOd . a L"-ice Manage&
p Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure
Q Asian Indian Q Other Asian Q Refused 22b.Kind of Business/Industry
Q Chinese Q Native Hawaiian Q Other(Specify) 0e ♦.f. S->`.O 2 e
Q Filipino Q Guamanian or Chamorro n
ITEMS 23a-23d MUST BE COMPLETED 23a.Date Pronounced Dead(Mo/Day/Yr) 23b.Signature Of Person Pronouncing Death(Only when applicable) 23c.License Number
6V PERSON WHO PRONOUNCES OR -
CERTIFIES DEATH ..
23d.Date Signed(MO/L,ay/yr) 24.Time of D¢ ttJ
(S>• 25.Was Medical Examiner or Coroner Contacted? - Q Yes -' Q NO
CAUSE OF DEATH 1 Approximate
26.Part 1. Enter the chain of events-diseases,Injuries,or complications--that directly caused the death. DO NOT anter terminal events such as cardlac arrest, 1 Interval:
respiratory arrest,or ventricular fibrillation without showing the etiology. OO NOT ABBREVIATE. Enter only one cause on aline. Add additional linea If necessary. Onset t0 Death
I
IMMEDIATE CAUSE -------------> a.
(Final dl sense or condition Due to(or as a consequence on: 1 1
resulting In death) I
b.
Sequentially list conditions, Due to(or as a consequence of)::
1
if any,leading to the cause
listed on line a. Enter the ,
UNDERLy1NG CAUSE Due to(or as•conf<gUance Of):
(disease or injury ch<t - 1
S initiated the events resulting d. I
yy in death)LAST. Due to(or as a consequence of):
tj
a7. 26.Part 11. Enter Other slanifiu nt conditions ton<ributina to death but not resulting In the underlying cause given in Part 1. 27.Was an autopsy performed?
Yes
28.We autopsy findingsNO Mable
�- PSYaave
to Complete the cause o1 death?
--. - ,Q Va. Q NO
29.If Female: 30.Did Tobacco Use Contribute to Death? 31.Manner of Oaath
Fa NOt pregnant within past year Q Yes Cl Probably 10 Natural Q Homicide
Q Pregnant at time Of death J2r No Q Unknown
Q Not pregnant,but pregnant within 42 days of death Q Accident O Ponding Investigation
Q Not Q Suicide Q Could not be determined
pregnant,but pregnant 43 days to 1 year before death 32.Date of Injury(MO/Day/Yr)(Spell Month)
Q Unknown if pregnant within the past year- 33.Time of Injury
34.Place of Injury(e.g.home;construction site;farm;school) S.Location of Injury(Street and Number,City,County,State,Zip Code)
Q 36.Injury at Work F7IfTr:n,-5,PortItIO1 Injury,Specify: 36.Des.rib,How Injury Occurred:
-IQQ Yes / perator Q Pedestrian
QNo enger Q Other(Specify)
391.Certifier-physician,certified nurse practitioner,medical examiner/co or(Check only one):
11a Certifying only-To the best of my knowledge,tleath Occurred due to the cause(s)and manner stated.
Q Pronouncing&Certifying-To the best of my knowledge,death Occurred at the time,data,and place,and due to the causes)and manner stated.
Q Medical Examiner/Coroner-On the basis Of examination and/or Investigation,In my Opinion,death occurred at the time,date,and place,and due to the cause(s)and manner stated.
Signature o/certitler: /L--G Title of certifier: I�1� License Number: tt-t -f 2-
39b.
39b.Name,Address and ZIp Code of Person Completing Cause of Death(Item 26) , 39c.Date Signed(Mo/Oay/Yr)
i}zttca, t /� 3�r/- 7'Z.c �tit la.y I+,'n /'sI /�otr
40.Registrar's District N I41.Registrar's Signature 42.Registrar File Date(Mo/Day/Yr)
43.Amendments - -
H10S-143
Disposition Permit No.I Z 0 8 e REV 07/2012
2 1
• 1 Y
WILL
I, RUTH A. BOWERS, currently of Mifflin County,
Pennsylvania, being of sound mind, memory and understanding do
make and publish this my Last Will and Testament hereby revoking
and making void all former Wills by me at any time heretofore
made.
ITEM ONE: I direct all my debts which may be legally
collectible, and funeral expenses, be paid by illy Executors
hereinafter named.
ITEM TWO: All federal, state and other death taxes payable
because of my death, with respect to the property forming my
gross estate for tax purposes, whether or not passing under this
Will, including any interest or penalty imposed in connection
with such tax, shall be considered a part of the expense of the
administration of my estate and shall be paid from my residuary
estate under ITEM THREE without apportionment or right of
reimbursement. All such taxes on present, or future interests
shall be paid at such time or times as my Executors may think
proper regardless of whether such taxes are then due.
ITEM THREE: All the rest, residue and remainder of my
estate. of which I shall die seized and possessed, or to which I
shall be entitled at my decease of every nature and wherever
LAW OFFICES situate I give, devise and bequeath equally to my sons, WILLIAM
HOUCK&GINGRICH
23 N.WAYNE STREET J. BOWERS and DONALD RAY BOWERS. In the event a said son of
P.O.BOX 430
LEWISTOWN,PA.17044 mine is not living on the thirty-first day following my death,
said deceased son's 'share shall go to his issue per stirpes
living on the thirty-first day following my death.
ITEM FOUR: I. nominate, constitute and appoint my sons,.,
WILLIAM J. BOWERS and DONALD RAY BOWERS, as. Executors of this my
Last Will and Testament.
ITEM FIVE: I direct that my Executors, or their successor,
shall not be required to give bond for the faithful performance
of,. their duties in any jurisdiction.
ITEM SIX: No interest (including, but not limited to all
shares of principal and income) of any beneficiary under this
Will or any Codicil hereto or any trust herein created shall be
subject to. anticipation or voluntary or involuntary alienation.
IN WITNESS WHEREOF, I, RUTH A. BOWERS, the Testatrix, have
to this my Last Will and Testament, set my hand and seal (to
this instrument only) this day of September, 1992 .
SEAL
Signed,- sealed, published and declared by the above-named
RUTH A. BOWERS, Testatrix, as and for ber Last Will and
Testament, in the presence of us who have hereunto subscribed
our names at her request thereto in the presence of the said
LAW OFFICES Testatrix and of each other.
HOUCK&GINGRICH
Ile-
23 N.WAYNE STREET
P.O.BOX 430
LEWISTOWN,PA.17044
s"
EXHIBIT C
IN 111111111111111111111111111111111111111111111111111111111
• &mputershare
MetLIfe Computershare
PO Box 30170
College Station,TX 77842-3170
Within USA,US territories&Canada 800 649 3593
Outside USA,US territories&Canada 201 680 6578
001139 Hearing Impaired(TDD) 201 680 6611
�Ir�rll'III'll"�'I'SII'I'III""��Il�tl�l���llrll��l�l��'lll'll www.computershare.com/metlife
RUTH A BOWERS
19 NATURES XING
ENOLA PA 17025
The IRS requires that we report the cost basis of certain shares
acquired after January 1, 2011 and then sold. Shares
transferred out of an account will be done using our default cost
basis calculation of first in,first out(FIFO)unless otherwise
Instructed. Please visit our website,review the enclosed FAQ,
or consult your tax advisor If you need additional information
about cost basis.
Dear Holder.
Re: RUTH A BOWERS
Company Name:MetLife, Inc. Account Number:0005350841
DRS book-entry shares:0 Certificated Shares:0
Policyholder Trust book-entry shares:60
As requested,enclosed are the forms and instructions needed to transfer the decedent's stock to a new account or another holder.We have also enclosed
answers to Frequently Asked Questions(FAQs)to assist you with completing the form and to answer transfer related questions you may have.You can find
additional helpful information in the"Help"section of our website, www.computershare.com/mefife.
To request the transfer,you will need to complete the following steps:
Step 1: Transfer Request form—Complete the enclosed form.All surviving registered holders(if applicable)or a legally authorized representative must sign
the"Authorized Signatures"section(section 7),with a Medallion Signature Guarantee for each signature.An individual signing on behalf of the current
registered holder must indicate his or her capacity next to the signature on the form(e.g.John Smith,Executor or John Smith,Custodian).See the
enclosed FAQ document for additional information.
If the decedent held any certificated shares,you must include the original stock certificate(s)along with the Transfer Request form.If a certificate is
lost,please contact us at the customer service number listed on the top right corner of this letter to find out the cost and process for requesting a
certificate replacement.Lost certificates must be replaced prior to transferring the shares.
Step 2: Form W-9,tax certification—The new holder should sign and date section 9 of the enclosed Transfer Request form. If the new holder is unable to
provide tax certification at this time,we will send him or her a Form W-9(Request for Taxpayer Identification Number and Certification)once the
transfer request is processed.Computershare will be required to withhold taxes on any dividends or other cash distributions until tax certification is
received by us.
Step 3: Sales Instructions—If the new owner wishes to sell the shares as a result of this transfer and/or from an existing account,the New Account Owner's
Sale Instructions in Section 10 must be completed and signed.
Step 4: Additional tax documentation—Obtain either(a)or(b),as applicable:
(a) If the decedent resided in a state in which an inheritance tax waiver is required,an Inheritance Tax Waiver form.
(b) If the decedent did not reside in a state in which an inheritance tax waiver is required,either(i)a Notarized Affidavit of Domicile(blank form
enclosed),or(ii)an Inheritance Tax Waiver stamp affixed next to the signature on the Transfer Request form.
See the last page of the enclosed FAQ document for additional information on these items and how to obtain them.
Step 5: Send all required documents outlined above to:
Regular mail: Ovemight/certified/registered delivery:
Computershare Computershare
PO Box 30170 211 Quality Circle,Suite 210
College Station,TX 77842-3170 College Station,TX 77845 <
It is important that you follow the steps above to ensure that your transfer can be completed.Depending on the type of transfer being requested,your transfer should
be completed within 10 business days of receipt.A statement will be sent to the new holder upon completion of the transfer. Please note,the statement cannot be
sent to a third party.If your transfer cannot be processed due to missing or incomplete documentation,we will contact you for more information.
If the value of the shares you are transferring exceeds$14 million,or if you have any questions,please contact us at the customer service number listed on the top
right comer of this letter.You can also submit your questions online through the"Contact Us"section of the website listed above.
Sincerely,
Computershare
Enclosures
EXHIBIT I)
MET Historical Prices I MetLife, Inc. Cormnon Stock Stock- Yahoo! Finance Page 1 of 2
Home Mail Search News Sports Finance Weather Games Answers Screen
Seat
Finance Home My Portfolio My Quotes News Market Data Yahoo Originals Business & Finance F
.........................................................................................................
_..............._............. ............. _._................._..._.............. ......................... .............. ................................._..........._.................................................._....................................................._.................................................._........._.._._............................
....
Enter Symbol Look Up Tue, Mar 24,2015,4
Dow 0.58% Nasdaq 0.32%
MetLife, Inc. (MET) - NYSE Watchlist
50.89 0.52(1.01%) 4:06PM EDT
After Hours: 50.89 0.00(0.00%) 4:31 PM EDT
Historical Prices Get Historical Pi
Set Date Range
Daily
Start Date: Jan v 15 2015 Eg.Jan 1,2010 O Weekly
End Date: Q Monthly
Q Dividends Only
Get Prices
Prices
Date Open High Low Close
Jan 15,2015 49.18 49.43 47.68 47.98 10,:
* se price adjusted for Bends and splits.
i
Al Download to Spreadsheet ' 5
Currency in USD.
........................... .......................... .......... _ _ k
Ad Topics That Might Interest You...
1. Top Stocks to Buy
_..... 5. Fixed Income Investments
................_..._............................_...._...__........... . ........ .............._..._.... ........................... ........
30
2. Accredited Online Colleges 6. Auto Insurance Plans
3. Best Roth IRA 7. Online Education Courses
....................................................................................................... ................................................................................................................
4. Best ETFs To Buy 8. High Yield Investments
Feedback ads
littn://finance.vahoo.coii/a/hD?s=MET&a=00&b=15&c=2015&d=00&e=15&f=2015&Q=d 3/24/2015
EXHIB -
. ...IT E
SULLIVANFUNERAL HOME
•E.' ,.TI SERVICES, LLG, Emda�PAI wo. a1P 1 o0
26
4 gY' (3f' 9-216
3'�' a��1T�msas�t�,,s�mr9ts�3' '�p..�3ffi
Saturday,January 24,2015
William Bowers
19 Nature's Crossing
Enola,PA 17025
Dear William,
Thank you for placing your trust in our services.We hope that we have met your expectations and made this difficult time a little
easier.Below are the charges that your family has incurred.Please make payment within 30 days of the above date.
RUTH A.BOWERS
Total Funeral Service Selected
FACILITIES,STAFF AND EQUIPMENT
Use of Facilities&Staff for Visitation $795
Use of Facilities&Staff for Memorial Service at Funeral Home $795
FACILITIES,STAFF AND EQUIPMENT $1,590.00
AUTOMOTIVE EQUIPMENT
Flower Vehicle $250
Flower/Lead Car $295
Service/Utility Vehicle $225
TOTAL AUTOMOTIVE EQUIPMENT $770.00
OTHER MERCHANDISE SELECTED
Acknowledgement Cards 25 $65
Register Book $85
Memorial Folders $85
Urn/Vase Mackenzie white $300.00
TOTAL OTHER MERCHANDISE SELECTED $535.00
SPECIAL SERVICES
Direct cremation $1945.00.
TOTAL SPECIAL CHARGES $1,945.00 .
CASH ADVANCES
Certified.Copies of Death Certificate $60.00
Clergy Honorarium $100.00
Organist $100.00
Local Newspaper Notice Patriot News.` $428.47
Newspaper Notice Somerset News $124.32'
Coroner's Authorization $30
CASH ADVANCE TOTAL $842.79
LESS: Credits granted $1,145.00
Cremation Package C Disc. . $1,145.00
TOTAL OF SERVICES $4,537.79
LESS: Payments Made 4,537.79
Check#4281 $4,537.79
PAID IN FULL $0.00
Sincerely,
John C. Sullivan
t,
SOMERSET COUNTY
Invoice
MEMORIAL PARK INC
104 New Centerville Road DATE INVOICE#
Somerset,PA 15501
2/4/2015 7624
BILL TO
Bowers,William
19 Natures Crossing
Enola,PA 17025
PROJECT REP
Ruth A.Bowers
DESCRIPTION QTY RATE AMOUNT
Cremation Interment-weekday 475.00 475.00
Sales Tax 6.00% 0.00
Total $475.00
Page: 1
The Sentinel Print Ad Proof
ADNo: 128818 Customer Number:
Customer Name: BILL BOWERS Company:
Address: 19 NATURES CROSSING
City/St/Zip: ENOLA ,PA 17025
Phone: (717) 877-4593 Solicitor: M
Category: 50 Class: 95 Rate: MS300-0 Start: 2-3-2015 Stop: 2-9-2015
Lines: 4 Inches: .50 Words: 18
----------------------------------------------------------------------------------------------------------------------
Credit Card: Expire:
Order Number:
Cost: 14.00 Adjustments: 11.00
Payments: .00 Discount: .00 L��'� G"tyJ�1$C;
Balance;;25.00`
JUMATA MEMORIAL PARK
Two lots.tot No.76 firs.
1-2.Section F.Size(9+10A.
$15001old..(1171877.593
PEACHTREE RESTAURANT
Harrisburg, PA 1-717-545-3773 Customers �-
0067 TBL # 1 #Party 1 order No. Date //
AM CASHIER SvrCk: 8 12:38p 01/24/15 f 20//1-5
NameCy
OPEN FOOD, amountf/
777.00,CATERItJG b0 PPL 777.00 A1111111�ddress
- SOLD BY.. CASH C.O.D. CHARGE ON ACCT MDSE HEfD .PAID Olfr
Sub Total: 777.00
Tai(: L1;� 6z QUAN. DESCRIPTION
Sub Total: 823.62 PRICE AMOUNT
01/24 12:39pTOTAL : 823 - 62
THANK YOU FOR DINING WITN
PLEASE COME AGAIN! / e
Look for our daily specials!
000000 000673
ALL claims.and returned goods MUST be acco
Recd by mpanied by this bill.
/ �
Pamela's Flowers
439 X IEnola Rd pl : (S Statement
IEnola PA 170-7
Account No. : 7172372208
Date: 02/0312015
Inquiries about 0.s staP,ewent call:(717)732-1257
19 NeftgFe's (C'mn-ares P t ,qq eeyy
Errc-na PA 17025
S:01/21/2015}7 58 28—Farr.=in$esket! 1o_atirth Ban_rs _0�n+nn�r �_.__ $95.00 $7 95 _ $10295__
Altar Arrangement/ Ruth Bowers 01/24/2015 2 $10.00 $0.00 $20.00
Invc#268688 A: O.00H: O.00B:130.33R: 0.00X: $122.95 $7.38 $130.33
5:0121/2015 17:58:22 Fresh Flowers 20 $1.50 $0.00 $30.00
Fresh Flowers 1 $15.00 $0.00 $15.00
lnvc#268688 A: O.00H: O.00B: 47.70R: 0.00X: $45.00 $2.70 $47.70
RUTH A.BOWERS 603132112 4286
2100 BENT CREEK BLVD.
MECHANICSBURG,PA :17050
. - DATE f. ! {r; V•J .
PAY TO i 3'1 SIL a r� ? ��� I `A .. . f G, �?. .. .., ..
TiTE ORDER OF' - - ` �
! c
\/' n ,,zz<<_ .... �` �. -�--.�•-..-��. ����;'1
O&Tt so
Y.BAIK.CH016 .
MEr ao 7 i? WThis Period: $178.03
1:0 3 13 10 2 L 9.i s S ? 9 3 5 L O L 6 V 4 2 8 6 balance: $178.03
.e on/before : Feb 13,2015
------------------------------------------------------------ ------------------------------
Please return this portion with payment.
FRO R"D yen 1 ChgxAZ Y c nn f
19 Nature's Crossing
Enola. PA 17025 Data : 01 {:_}.:`1__ti^?O
Fernald°s Flowers
439 No lEmok Rd. Arnount Due : $178.63
Exio%,PA 17025-2128 Due On/before : Fe,�If 3,2016
Amounit Paid :
�� 112af t�J
ROWS TEAM �
Rosa Lucidon Team of Certified Nurses Pa�`�r
"' (act 15
717-422-6156
131�� �. � 1� �7� �- �-).83
Aw-va, NA/- &
fleAL OA-e_ �& /14� U`� Alt ataL
a4/� .
(10
<' A FINANCE CHARGE OF 1.50 t PER MONTH
ALE 219 North Baltimore Ave
Psetsi+racyStwncn%iNc. Mt Holly Springs, PA 17065 (AN ANNUAL PERCENTAGE RATE OF 18.0$) OR A
Responsive. Innovative. Reliable_ 800-266-9954 . (717)486-8606MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED
WWWAICrtPharmacycom ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE
STATEMENT OF ACCOUNT
,..;:.
IF YaT3 RECEIVE A NEW INSURANC)3 CARD FOR YOUR
k
::.:PRRSCRIPTIONS BE SURE tT0
UP A.A`:COPY
01/31/2015 '
Date
PMT DUE. . 02/23/15 BOWERU
BOWERS, RUTH A
BILL BOWERS GRP-58
F p ? Z ! <1
19 NATURES CROSSING PAGE 1
ENOLA PA 17025 Amount Paid I
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
. - -----------------------------------
0- - `APRT F�f�A127�1l�CY SREV. YNC:�19 NORTFI'UAT;2'IMOitV tKT SAGS, PA 17065
0-110
1 �.< - .fsr... ,.
I.
**
ACT-IV'iTY.;FOR BOWERS; RUTH- A BOWERU - -58
_.. -
::c::.- .
12/31/14' 4144164 ._. 60 . ACETAM/CODEINE #3.` 01 3?.OS- :: . ..: `` .^ _, 37_08-
- 01�- 5.49 00 5 49c
�O1/02/15 ...9280100-` 14 CIPROFLOXACIN 250. �
01/02/15 : 9280101 14 FLORASTOR 250 MG 01 *' 9.92 00-
i. 01/06/15-
0 1. 01/06/15: 9281455 142: THERA-GESIC ANALG •-. ' . 01 *, - ' 7.38'
01/11/15`,- 9276828 6399. BOOST--CHOCOLATE. 01 * .: 31.87 31 87
01/13/15 : .:. 9265107 ' ` 1 ' CETIRIZINE` 5MG. Ol * 2.65 U0 2 65
01/13/15 9220631 :'1 - MELATONIN 3MG .: 01 .* 2.33
.-01/13/15- 9220638 .;1 ROPINIROLE 2. MG ..` 01• .54 00 54c
01/20/15' Payment-Thank You 198.47- 00' 198 47-
CK# 23.72221679. -
60-1021
t
2
8
1
2
ILS =
WE' 73
RUTH
A.
3
R
BLVD. _
CREEK ..
2100 BENT. �--'
r�
70-
50-'
�1
PA`. -
G
:f
BUR
CS
CHANT -
.Iv1E
ATE f
.D -
E' -
'' PAY TO
THE ORDER OF !'
L -
fi s
1LS
t!A
(
ppam
G z
t q, � -
it
s
estO - -- - -_
' - xattBAtuafLHOttE - . . . ..
fAr
�1
d
9n
t
E <
i �
MEMO tC,
n -
91e 5 7
435
4 2B
-
/ 1
i
00
_ LEGEND ='NON LEGEND.`:j
FOR MONTH FOR:::MONTH',: TOTAL TAX
... ....- -:.
AMOUNT DUE
Fay
Preery®ms> :C&earges 86trs vnow4�a: .,�e08aPA�@��1�cPC TCS a 1�.�"{A rmEss Totat ment 8 Credits ..;
10
awm=onreverse
._ 00; �.;_.�:,= 255 :65 235 55 20.
PLEASE CACLAharmacy Serv(ces irtc at 9=800-266-9954ent Terminology on reverse
- Please return to:
HOLTGATE PODIATRY, PLLC
PO BOX 415 Bill To:
LEMOYNE, PA 17043
BILL BOWERS
19 NATURES WAY
ENOLA, PA 17025
Feb 03,2015 Amount Enclosed ¢
RUTH A BOWERS Check Numbers azy
2100 BENT CREEK BLVD. ROOM 206
MECHANICSBURG, PA 17050
Account#: PT00000886
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
STATEMENT
Account#: PT00000886
Sr-No. Serv. Date Description Provider Charges Pat.Bal.
1 12/10/2014 CHARGES:11721 Debride Nails more than 5 Holtz, Peter 55.00
MEDICARE PA-NOVITAS SOLUTIONS PAID:33.94
WRITEOFF: 12.40
CAPITAL BLUE CROSS PAID:0.00
PATIENT RESPONSIBLE:8.66 8.66
Patient Balance Note: Non-covered charge(s).
Total: 8.66
Amount Due: 8.66
Current Over 30 Over 60 Over 90 Open Credit
Patient: 8.66 0.00 0.00 0.00 0.00
Kindly remit payment by February 20,2015. Credit card payemtns by phone are welcome. C�_ Q S
8161 G�
Please make check payable to Holtgate Podiatry, PLLC and send with top part of this statement. THANK YOU!
Please call (717)731-1133 if you have any questions about this statement or amount due.
RUTH.A.BOWERS G0-102112 4285
2100 BENT CREEK BLVD. 313
MECHANICSBURG,PA 17050
DATE F&_L.
a PAY TO Pa-
THE
THE ORDER OF
CCt r �
/�•
dOl) DOLLARS
a� 0es8 50
YOUR SANK OF C�30I(�
MEMO'ifry-PI_D o11lonC)E,)-LL_
Page Iof1 :1:03131021.91: 57 935101 611' 8, 285
EXHIBIT G
{
RUTH A.BOWERS ,4 so-1o2i /1 r�O t�
a 313-12 42$9 r
c 2100 BENT CREEK BLVD'
MECHANICSBURG Pk"17050 I
DATE.
Ai
i {
- PAY Ti, e msaS .� 9�'
THE ORDER OFs
Ym BMK of Qia1cE
OUR
Ch
MEMO ''�_
COMMONWEALTH OF PENNSYLVANIA REV-1162 EX0 1-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT.280601
HARRISBURG,PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 020505
BOWERS RUTH A
2100 BENT CREEK BLVD
MECHANICSBURG, PA 17050
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
-------- fold ---------- --------
101 $5,600.00
ESTATE INFORMATION: SSN: 196-22-9422
FILE NUMBER: 2115-0412
DECEDENT NAME: BOWERS RUTH A
DATE OF PAYMENT: 04/14/2015
POSTMARK DATE: 04/14/2015
COUNTY: CUMBERLAND
DATE OF DEATH: 01/15/2015
TOTAL AMOUNT PAID: $5,600.00
REMARKS: RUTH A BOWERS
CHECK#4289
INITIALS: DBI
SEAL RECEIVED BY: LISA M. GRAYSON, ESQ.
REGISTER OF WILLS
TAXPAYER