HomeMy WebLinkAbout01-0041
/6 -0.20/- I
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
REV-1500 EX + (6-00)
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Bream S 1vester D.
DATE OF DEATH (MM-DD-YEAR)
COUNTY CODE
SOCIAL SECURITY NUMBER
YEAR
NUMBER
./
OFFICIAL USE ONLY
21-01-041
DATEOF BIRTH (MM-OO-YEAR)
717-12-7697
THIS RETURN MUST BE FILED IN OUPLlCATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
12/17/2000 01/20/1910
(IF APPLICABLE SURVIVING SPOUSE'S NAME LAST, FIRST,AND MIDDLE INITIAL
X 1. Original Return
4. limited Estate
X 6. Decedent Died Testate
2. Supplemental Return
4a. Future Interest Compromise (date of death after 12-12-82)
7. Decedent Maintained a Living Trust 0
(Attach copy of Trust)
(Attach copy of Will)
o 9. litigation Proceeds Received
3. date of death
. Remamder Return prior to 12.13.82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 10. Spousal Poverty Credit D 11. Election to tax under Sec. 9113(A)
(date of death between 12-31.91 and 1.1.95) (Attach Sch 0)
THIS SECTlOlt MUST BE COMPLETED."ALLCOARESPONDENCE'&,CONFIDENTIAL TAX INFORMATION sHouLD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
60 West Pomfret Street
West Pomfret Professional Bldg.
Carlisle, PA 17013
IRWIN McKNIGHT & HUGHES
TE[,.EPHONE NUMBER
R
E
C
A
P
I
T
U
L
A
T
I
o
N
1 249-2353
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or
Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(1)
(2)
(3)
Nor...'
None
None
(4)
(5)
None
116,009.88
(6)
None
None
13 ,351. 21
4,778.04
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116(a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of line 14 taxable at collateral rate
19. Tax Due
20.
97,880.63
x
X
X
X
.0 0
.0 45
.12
.15
Copyright (cl 2000 form software only The Lackner Group, Inc.
OfFICIAL USE ONLY
C'
(8) 116,009.88
(11) 18.129.25
(12) 97,880.63
(13)
(14) 97,880.63
(15)
(16)
(17)
(18)
(19)
0.00
4,404.63
0.00
0.00
4,404.63
Form REV-1500 EX (Rev. 6.00)
Decedent's Complete Address:
STREET ADDRESS
One Longsdorf Wav
CITY I STATE I ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
4,404.63
220.23
Total Credits ( A + B + C) (2)
220.23
3. Interest/Penalty if applicable
O. Interest
E. Penalty
Totalln'eresVPenalty ( D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (SA)
B. Enter the to'al of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WillS, AGENT
0.00
0.00
4,184.40
0.00
4,184.40
;;",'x.i;i
IN THE ipP~OPRIA~EB~OCi<S .
Did decedent make a transfer and:
a. retain the use or income of the property transferred;
b. retain the right to designate who shall use the property transferred or its income; .
c. retain a reversionary interest; or. . .
d. receive the promise for life of either payments, benefits or care?
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .
3. Did decedent own an ~in trust fo( 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.
Yes No
~~
o
o
o
IT]
IT]
IT]
Under penalties of perjury, I declare 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 complete. Declaration of pre parer other than the personal representative is based on all information of which pre parer has any knowledge.
Leroy Bream
_ _ J_Q _ P_'O"~Y"_f1~!_'O _I?!_~ ,,~_ _ _ _ - _ _ - - - - - - - - - - - - - -. - - - --
Carlisle, PA 17013
IRWIN McKNIGHT & HUGHES
60 West Pomfret Street
~ ~ - - - - - - - - - - ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --
Carlisle PA 17013
DATE
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
~ I.u lC"t
DATEl
eath on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
ouse is 3% [72 P.S. 9116 (a) (1.1) (i)].
es 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%
.5. 9116 (a) (1.1) (iO]. 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 jf 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 twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 9116( 1.2)
[72 P.S. 9116(aXn].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% (72 P.S. 9116(aX1.3)]. 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.
Copyllght (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00)
REV-t'i08 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Sylvester D. Bream
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
SSf! 717-12-7697
12/17/2000
FILE NUMBER
21-01-041
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION
1 Adams County National Bank checking
2 Adams County National Bank certificate
3 Adams County National Bank certificate
4 Adams County National Bank certificate
VALUE AT DATE
OF DEATH
5,382.30
89,474.57
15,107.26
6,045.75
TOTAL (Also enter on line 5. Recapitulation) $ 116,009.88
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1508 EX (Rev. 1-97)
REV-1il1 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCET/4X RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Sylvester D. Bream
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER
A.
B.
SSfI 717-12-7697
12/17/2000
FILE NUMBER
21-01-041
DESCRIPTION
AMOUNT
1
FUNERAL EXPENSES,
Gibson-Hollinger Funeral Home
6,407.20
1.
ADMINISTRATIVE COSTS,
Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number{s) I EIN Number of Personal Representative(s)
Street Address
City
State
Zip
Year(s) Commission Paid:
2.
3.
Attorney's Fees IRWIN McKNIGIIT & HUGHES
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
6,510.00
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees
Register of Wills
260.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
1
Other Administrative Costs
Cumberland Law Journal - estate notice publication
75.00
2
Register of Wills - filing fee
25.00
3
The Sentinel - Legal - estate notice publication
74.01
TOTAL (Also enter on line 9, Recapitulation) $ 13,351.21
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev. 1-97)
REV-1St2 EX +(1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCETIV< RETURN
RESIDENT DECEDENT
ESTATE OF
Sylvester D. Bream
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
SSf; 717 -12 - 7697
12/17/2000
FILE NUMBER
21-01-041
Include unreimbursed medical expenses.
ITEM
NUMBER
1
DESCRIPTION
Alert Pharmacy Inc. - final invoice
AMOUNT
46.68
2
Check written 12/11/00 to Alert Pharmacy Service Inc. - cleared
bank on 12/18/00
93.07
3
Check written 12/15/00 to Cumberland Crossings - cleared bank on
12/22/00
3,Oll.00
4
Check written 12/14/00 to Yellow Breeches EMS - cleared bank on
01/03/00
50.00
5
Cumberland Crossings, final bill
1,577.29
TOTAL (Also enter on line 10, Recapitulation) $ 4,778.04
(If more space is needed, insert additional sheets of the same size)
Copyright (cl 1996 form software only CPSystems, Inc. Form REV-1512 EX (Rev. 1-97)
REV-15H EX + (1-97)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Svlvester D. Bream
SSfj 717-12-7697
12/17/2000
NUMBER
I.
1
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions):
Arthur E. Bream
898 Myerstown Road
Gardners, PA 17324
2
Jouetta M. Bream
406 Chestnut Street
Mount Holly Springs, PA 17065
3
Leroy G. Bream
70 Derbyshire Drive
Carlisle, PA 17013
4
Areitta B. Orris
57 Ladnor Lane
Carlisle, PA 17013
5
Karol A. Ream
932 Myerstown
Gardners, PA
Road
17324
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Son
Daughter- in-Law
Son
Daughter
Daughter
FILE NUMBER
21-01-041
AMOUNT OR SHARE
OF ESTATE
1/5 remainder
1/5 remainder
1/5 remainder
1/5 remainder
1/5 remainder
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 17. AS APPROPRIATE. ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS,
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
0.00
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc.
Form REV-1513 EX (Rev. 1-97)
w__~
I, SYLVESTER D. BREAM, of Dickinson Township,
Cumberland County, Pennsylvania, declare this to be my last will
and revoke any will previously made by me.
I. I give, devise and bequeath all of my estate ~f
every nature and wherever situate in equal shares to my son,
ARTHUR BREAM, my daughter, ARRIETTA ORRS, my son, LEROY BREAM, my
daughter, CAROL ANN REAM, and the widow of my son, Sylvester
Bream, Jr., JOETTA BREAM, providing they shall survive me by
thirty days.
II. Should my son, Arthur Bream, predecease me or die
on or before the thirtieth day following my death, I give, devise
and bequeath his share to his wife, BETTY BREAM, if she is living
on the thirty-first day following my death; and should both my
said son and his wife predecease me or die on or before the
thirtieth day following my death, I give, devise and bequeath his
share in equal shares to their children living on the thirty-
first day following my death.
III. Should my daughter, Arrietta Orrs, predecease me or
die on or before the thirtieth day following my death, I give,
devise and bequeath her share to her husband, PAUL ORRS, if he is
living on the thirty-first day following my death; and should
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both my said daughter and her husband predecease me or die on or
before the thirtieth day following my death, I give, devise and
bequeath her share in equal shares to their children living on
the thirty-first day following my death.
IV. Should my son, Leroy Bream, predecease me or die on
or before the thirtieth day following my death, I give, devise
and bequeath his share to his wife, JOAN BREAM, if she is living
on the thirty-first day following my death; and should both my
said son and his wife predecease me or die on or before the
thirtieth day following my death, I give, devise and bequeath his
share in equal shares to their children living on the thirty-
first day following my death.
V. Should my daughter, Carol Ann Ream, predecease me
or die on or before the thirtieth day following my death, I give,
devise and bequeath her share to her husband, KENNETH REAM, if he
is living on the thirty-first day following my death; and should
both my said daughter and her husband predecease me or die on or
before the thirtieth day following my death, I give, devise and
bequeath her share in equal shares to their children living on
the thirty-first day following my death.
VI. Should the widow of my son Sylvester D. Bream, Jr.,
Joetta Bream, predecease me or die on or before the thirtieth day
following my death, I give, devise and bequeath her share in
equal shares to their children living on the thirty-first day
following my death.
VII.
I direct that all taxes that may be assessed in
consequence of my death, of whatever nature and by whatever
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jurisdiction imposed, shall be paid from my residuary estate as a
part of the expense of the administration of my estate.
VIII. I appoint my son, ARTHUR BREAM, my daughter, ARIETTA
ORRS, my son, LEROY BREAM, and my daughter, CAROL ANN REAM, or
the survivors of them co-executors of this my last will.
-IX. I direct that my executors shall not be required to
give bond for the faithful performance of their duties in any
jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand this
23rd day of May, 1998.
"ittU-{A''&n.- ~ p ....~~ /)'>'L (S-G1~
SYL ESTER D. BREAM
The preceding instrument, consisting of this and one other
typewritten page identified by the signature of the testator,
SYLVESTER D. BREAM, was on the day and date thereof signed,
published and declared by SYLVESTER D. BREAM, the testator
therein named, as and for his last will, in the presence of us,
who, at his request, in his presence, and in the presence of each
ot~~r?~a~e sUbsc~ed ~u~ names as witnesses hereto.
4.,,-,Ce;6'~?--' , &"7?.......e.<-
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0/tr d Prer.s ,f/;1- /73..J Y
~ ADAMS COUNlY
NATIONAL BANK
.... ffi:.' (S. r;;;'. '. D\""." ? "I
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L1,-d! 10 .,(, 11
'- l.,
January 11,2001
Irwin, McKnight & Hughes
60 West Pomfret Street
Carlisle, PA 17013
I!mvn.l lI...!I\I!f:f'"(. ," ,r'IIES
I\v 11~llllt..rd~iUill ~ :,vvl'i
Re: Estate of Sylvester D. Bream
Dear Mr. Hughes:
The following information is being provided as per your request:
Acct. Type Acct. Acct. Balance Ace. Int. Ownership Date
Number On D.O.D. to D.O.D. Joint
Checking 196-117-9 $5,379.80 $2.50 Joint wi 12-5-77
**The account was opened on 12-5-77. Cedle Bream
C.D. 153982 $88,500.00 $974.57 Individual N/A
**The account was opened on 10-20-00.
C.D. 153981 $15,000.00 $107.26 Individual N/A
**The account was opened on 10-20-00.
C.D. 153999 $6,000.00 $45.75 Burial Fund N/A
**The account was opened on 11-1-00.
Inquiries concerning ACNB Corporation stock information should be directed to the
Registrar and Transfer Company at 1-800-368-5948. If you need any additional
information, please feel free to contact me.
Sincerely,
f1o-W>(l"h~
Lois A. Kime
Certificate of Deposit Coordinator
Social Security No.
PETITION FOR PROBATE & GRANT OF LETTERS
21-01- '-/ I
To: Register of Wills for the
County of Cumber/and
Commonwealth of Pennsylvania
No.
Estate of Sylvester D. Bream
also known as
, deceased.
717-12-7697
The Petition of the undersigned respectfully represents that:
Your Petitioners, who is/are 18 years of age or older and the Executor named in the Last Will of the
above decedent dated Mav 23 , 1998, and codicils dated none . 19 ----..l. The
Executor named none died . Renunciations for
Arietta Orris, Arthur Bream and Karol A. Ream attached hereto.
Decedent was domiciled at death in Cumberland County, Pennsylvania, with his last family or principal
residence at One LonQsdori Way, South Middleton Township, Carlisle
Decedent, then lill.- years of age, died December 17 . 2000, at Cumberland
CrossinQs Retirement Community. Carlisle. PA
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the Will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property
(If not domiciled in PA) Personal property in PA
(If not domiciled in PA) Personal property in County
Value of real estate in Pennsylvania, situated as follows:
$103.500.00
$
$
$
WHEREFORE, Petitioners respectfully requests the probate of the Last Will and Codicil(s) presented
herewith and the grant of letters testamentary thereon.
Signature(s) and Residence(s) of Petitioner(s):
~I' ~,13~
Ler~am
70 Derbvshire Drive
Carlisle, PA 17013
717 -243-3156
~
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
S5
COUNTY OF CUMBERLAND
The Petitioner(s) above named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of Petitioner(s) and that as personal representative of
the above decedent, petitioner(s) will well and truly administer the estate according to law.
~~
Sworn to or affirmed card subscribed
before me this q < day of
January ,2001.
'--rY}gALL (1, X.U_JL~ 'PI, U,CJ.... ~:t~/;;l~f\{.L&.-
U Register . 0
Leroy Bream
No. 21-01- 41
Estate of Sylvester D. Bream, deceased.
DECREE OF PROBATE & GRANT OF LETTERS
AND NOW, January 9th , 2001, in consideration of the Petition on the reverse
side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated
May 23. 1998 described therein be admitted to pro~ate and filed of record as the
Last Will of Sylvester D. Bream ; and Letters Testamentary are
hereby granted to Leroy Bream
,
Yl'lJjC(j (~. Aj~ ('(~;~is~f;f::l. () Jk:;;zlz~J:l./ ~;;J,fJ(<-b'l-
IRWIN McKNIGHT & HUGHES
FEES
Probate, Letters, Etc. . . . . . . . $ 235.00
Short Certificates(-3- ) . . . . $ 9.00
Renunciation(s) . . . . . . . . . . . $5.00
JCP .................... $ 5.00
Other Will PaQes (-2-) .... $ 6.00
TOTAL: .... $ 260.00
Filed. ~~.U:A,R,X .~~. ~PO.l. ., . . . . ....
James D. HUQhes, ESQ. (05774)
ATTORNEY (Sup. Ct. 1.0. No.)
60 West Pomfret St.. Carlisle, PA 17013
ADDRESS
717 -249-2353
PHONE
CALLED ATTORNEY JANUARY 9, 2001
'."C. ,
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1,"\
1 C"lJ
21-01-41
REGISTER OF WILLS OF COUNTY
OATH OF SUBSCRIBING WITNESS
/ .
codicil ,,/
(each) a subscribing witness to the will presented herewi~each) being duly qualified according to
law, depose(s) and say(s) that present and saw
signed as a witness at the
and (in the presence of each other) (in the presence of the
the testat , sign the same and that
request of testat_ in h
other subscribing witness(es)).
Sworn to or affirmed and subsc~jl1ed before
me this / day of
,/
19_
(Name)
(Address)
Register
(Name)
(Address)
REGISTER OF WILLS OF CUMBERLAND COUNTY
OATH OF NON-SUBSCRIBING WITNESS
James D. Hughes and Leroy Bream
(each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that
they are familiar with the signature of Sylvester D. Bream
eeaieH-
will
testat~ of (one--of--the--sttbsert~--wttnesses--~ the
that
each
presented herewith and
eeaieH-
believes the signature on the will is in the handwriting of
Sylvester D. Bream
to the best of
their knowledge and belief.
--
Sworn to or affirme&and subscribed before
me this q day of
Janua:: :U~/
'nJ~e . ~ ,+ t1d. ,/XC'7LM, t
Registe~
"-
60 Wi Pomfret Street. Carlisle, FA 17013
:UA~I3~S)
Le~ "iJiream (Name)
70 Derbyshire Drive, Carlisle, PA 17013
(Address)
21-01-41
RENUNCIATION
In regard to the Estate of
SYLVESTER D. BREAM , deceased.
To the Register of Wills of
Cumberland County, Pennsylvania.
The undersigned
children
of the above decedent hereby
renounce(s) the right to administer the estate and respectfully ask(s) that Letters
T estamentarv
be issued to
Lerov Bream
WITNESS our
hand this
5th
day of
January
, 2001.
w.rlw f.~~
SIGNATURE
'691 rh(J4.....~i~ ~/7SVf'
ADDRESS
~.It#-- 8.c12M.-../a.M..um.. ~
SIGNATURE
.f"7 ~~-. .~t;--- e.~ f?-/741.3
J J
ADDRESS
~J. .;.,.... ~ / (!M,/. a..... j)
. SIGN TURE I ~
Cl3d rrJ~.A~ M 17-Sc;lC/-
J ADDRESS
SIGNATURE
.. "\,".
ADDRESS
21=01-41
Thi-, is to certify that the information here given is correctly copied from an original certificate of death du~): flIed with
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent hltng.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
me as
No.
L~:- ~. \?.... <Il.:t;~~
Local Registrar "
Fee for this certificate, $2.00
p
6960214
DEe 1 8 2000
Date
H105.i4JA8"I,21B7
COMMONWEALTH OF PENNSYLVANIA. OEPARTMENT OF HEALTH. VITAL RECOROS
CERTIFICATE OF DEATH
RINT
Y..
STAlE "'l! NUMBER
SOCIAL SECURITY NUM8ER
,. 717 - 12 -7697
..ENT
INK
NAME OF DECEOENT (F'fSl'. M~e. La_,
1.
AGE{laSlBortNJ.y)
DATE OF BIRTH
,.Monl~_ Cay. '''eall
BIRTHPLACE iC.tv ~
S~leOl'fCfeognCOUl"ltry,
90
=.,,0
..
COUNTY OF OERH
.-1\
Cumbekland
Middleton Twp.
RACE - Amencan Indian. 81act1.. Whit.. e4C.
'_l
White
Ill.
DECEDENT'S USUAL CX;CUPMIOH KINO Of BUSINESSfINOUSTRY
(~"::n~Il~~~:::zt~
".. OWnek ".. GkOCek
DECEDENT'S ""AILING AOORESS (SIt.1. C~. State, Zip Codel
1 Long.6dokn Way
Cakli.6le, Pa. 17013
MARITAL STATUS. ".med
N....... "arried, W~.
Oi\ttofced(SpPCltyJ
SURVMNG SPOUSE
(rt......~m.a.,.,name)
la.
F.crHER'S "'1""E IFir",""oO~ LaSl)
II. Aaam r. tjk eam
1NFOA"nh OyE 1fke:a'in
....
METHOD OF OlSPOSlT~
O Burill ~ Cr.m.ion 0
Don.tiOn Ot...... (Spec/fy\
"o.
:NAT~F7i
c:omc... it.ms 2311-<: only WMl'l C4r1'fyi
~.nat ...,aitatMeall.m. OfdeAlh lO
certify c.auM of dIP.,tI
17b. Coun
();d
dec_..
Mlna
Cumbekland .....-, "0.0 :....-=~or
MOTHER'S NAME iF.st. Middle. MalOltn Surname)
II. NOka HaVek.6toCR.
INFORMANT'j. MAILl~ AD9R~SS (SIreet. CitylTown, Sla"'n Zjp Code)
.....70 vekOY.6/t.(ke Vk. CakH.6le, PA 17013
PLACE OF DISPOSITION. Name of C.,-netery, Cr.matory LOCATION. City/TOwn, Slat.. rIP coo.
or aU.... Place
C:;rHlth MirfrfP"trlV!
...
'''Y'''''"'
Removal from Sial. 0
"0. Ukiah ChUkCh Cemetek "0. Gakdne.k.6
NAUE AHD ADDRESS OF FACILITY
2kGib~on-Hollingek
LICENSE NUMBER
"b.R./IJ-JS 1113'- L
PART II: Ot~r $ignirlcantconcfi&ions concrbJl:ing to dlPath. but
nee ...strftinO in tM uncMrtying C&UH giYen in PART I
\~"'-"'" c.......\\ \..'-~ ~.,=\
DuE "'P'R AS ACONSEOUENCE CF):
c..."1.J,...~__~ (. t '- '-.W...
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DUE 10 (OR AS A CONSEOUENCE Of):
1...; ... 'tn.
DUE TO (00 AS A CONSEOUENCE OF):
WERE AUTOPSY FINDINGS ""ANNER OF DEATH
.lM'JLABlE PR~ TO
COIWPLETION OF CAUSE ~ 0
OF DEATH? N.ural HomiCide>
_nt 0 P.nding Inwsligalion 0
No [B" Yo> 0 No 0 ....... 0 Could not bre det.rmlned 0
CATE OF INJURY
(MDrllh. Day. ~all
TIME OF INJURY
INJURY AT WORk? DESCRIBE HOW' INJURY OCCURRED
Yoo 0 NoD
2Ia.. 2Ib.
CERTIFIER ICI'ecll or'Iiy 0f"Ie1
.CERTlFYING PHYSICIAN IF't1ysoeiOlnCP.fhly."9 cause rJ dealtl wtlen anOlt-er ptlYSI(::.an has pronounced dealtl ana compleled!1em 231
To th.- betlt ot my knowtedge, d.ath occurftd due to the caUM(sland manne, a. stated. .
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30.. :JOb_
PLACE OF INJURY. At horM.larm. Sire". lactory. offica
buidng, etc:, tSpec,lvl
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.UEDICAl EXAMINER/CORONER
On the b..is of e..millaflon and/or illveslIgo1tioll. in my opinion, death occurred lit the lime, date, and place. and du~ 10 the caule{l) and
",_nne, a. stat4'd... . . . .. . . .. .... . . .. .... . ....... _ . . . . .. . .... .... ..... ........ .' ...... .
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REGISTRAR'S SIGNATURE A
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'PRONOUNCING AND CERTIFYING PHYSICIAN IPhysoc<an txll~ ~:)nO\.Jnc"'l9 oea1f'1 and cert,ly,nQ rocaU5e 01 aeal"l
To th. ~t of my kno_Ied~l'!, de"I'" occurred at the time, date. and place. and due to th. cause('land manner.s slilled..
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CERTIFICATION OF NOTICE UJ'!DER RULE 5.6 a
Name of Decedent:
Date of Death:
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SYLVESTER D. BREAM
DECEMBER 17. 2000
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STATUS REPORT UNDER RULE 6.12
Name of Decedent: SYLVESTERD. BREAM
Date of Death: December 17. 2000
No. 21-01-0041
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following
with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete: --X- Yes _ No
2. Ifthe answer is No, state when the personal representative reasonably believes that the
administration will be complete:
3. Ifthe answer to No.1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes -X... No
b. The separate Orphans' Court No. (if any) for the personal representative's
account is:
c. Did the personal representative state an account informally to the parties
in interest? -X... Yes No
d. Copies of receipts, releases, joinders and approvals of formal or informal
accounts may be filed with e erk of Orphan's Court and may be
attached to this report.
James D. Hughes. Esquire
Name (please type or print)
60 West Pomfret Street
Address
Carlisle. PA 17013
City, State, Zip
(717) 249-2353
Telephone Number
Date: 5/9/01
x
Personal Representative
Counsel for Personal Representative
Capacity:
"y 16 - c2c / - /
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
04-09-2001
BREAM
12-17-2000
21 01-0041
CUMBERLAND
101
JAMES D HUGHES ESQ
IRWIN ETAL
60 W POMFRET ST
CARLISLE PA 11013
Allount Rellitted
51
(/
,/
REV-151't7 EX AFP <12-00)
SYLVESTER D
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
ifE"v=is4j-E3f-AFP-ci'2:o0Y-NO'TicE--OF-YNHEifiTANCE-'TAX-APPRAiSEMEtrT~--ALTowAifcE-oR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF BREAM SYLVESTER D FILE NO. 21 01-0041 ACN 101 DATE 04-09-2001
TAX RETURN WAS: (X) ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
CHANGED
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
116 , 009 .88
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
I~ an assessment was issued previously, lines
re~lect ~igures that include the total o~ ALL
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rate
16. Allount of Line 14 taxable at Lineal/Class A rate
17. Allount of Line 14 at Sibling rate
18. Allount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
PAYMENT
DATE
02-27-2001
NOTE:
RECEIPT
NUMBER
AA478081
DISCOUNT (+)
INTEREST/PEN PAID (-)
220.23
13,351.21
4 .778.04
(1Il
(12)
(13)
(14)
(9)
(10)
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
116, 009.88
18.1?Q ?5
97,880.63
.00
97,880.63
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
(15)
(16)
(17)
(18)
.00 X 00 =
97,880.63 X 045 =
.00 X 12 =
.00 X 15 =
(19)-
.00
4,404.63
.00
.00
4,404.63
4,404.63
.00
.00
.00
* IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDlYO' (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
AMOUNT PAID
4,184.40
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
Leroy Bream
according to law, deposes and says that he is the Executor
of the Estate of Sylvester D. Bream
late of _ Di~~i~s_~I!-_'!:9~l:)hJp _______ , Cumberland County, Pa., deceased and that the
within is an inventory made by Leroy Bream ., the said Executor
of the entire estate of said decedent, consisting of all the personal propt:!rty and real estate, except real estate outside
the Commonwealth of Pennsylvania, and that the figures opposite each item of the Inventory represent it's fair value
as of the date of decedent's death.
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
L
J
55:
being duly
sworn
Sworn
and subscribed before me,
2001
Date of Death
17
Day
~g~
Leroy Br , Executor
70 Derbyshire Drive
Carlisle, PA 17013
Address
12
2000
Month
Year
INSTRUCTIONS
I. An inventory must be filed within three months after appointment of personal representative.
2. A supplement inventory must be filed within thirty days of discovery of additional assets.
3. Additional sheets may be attached as to personalty or realty
4. See Article IV. Fiduciaries Act of 1949.
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Inventory of the real and personal estate of
SYLVESTER D. BREAM deceased
l. Adams County National Bank - Checking. 5,382 30
2. Adams County National Bank - Certificate 89,474 57
3. Adams County National Bank - Certificate 15,107 26
4. Adams County National Bank - Certificate 6,045 75
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TOTAL. . . . . . . . . . . . . . . . . .
116,009
!I
88
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