HomeMy WebLinkAbout07-20-15 In the Court of Common Pleas of Cumberland County, Pennsylvania
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IN RE: CAROLINE R. OSTRICHE,Deceased �- �`-' r � ,,-� �
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PETITION FOR SETTLEMENT OF A SMALL ESTATE
Pursuant to Section 3102 of the Probate, Estates and Fiduciaries Code, the undersigned
petitioner respectfully represents that:
1. The name and address of the petitioner are:
Michele Northrop
38 Country View Estates
Newville, PA 17241
2. The relationship of the petitioner to the decedent is: CHILD
3. The decedent died at home at on March 13, 2015 at 38 Country View Estates,
Newville, PA 17241.
4. The decedent was domiciled at the time of death in Cumberland County,
Pennsylvania with a last principal residence at: 38 Country View Estates,
Newville, Pennsylvania 17241
5. The death certificate is attached hereto as Exhibit A.
6. The decedent died intestate.
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7. The names and relationship of all parties entitled to any part of decedent's estate
under intestate laws are:
Name Relationship Sui Juris
Michele Northrop Child Yes
David Ostriche Child Yes
8. Decedent was not married at the time of her death.
9. The assets of decedent's estate total less than$50,000, which is itemized below:
a. IRS Federal Income Tax—2015 refund $695.00
b. Mountain View returned deposit $454.00
c. Highmark/Freedom Blue PPO premium refund $57.00
d. MetLife premium refund $38.64
e. CenturyTel, Inc. refund $7•g4
Total �1�:52•4g
10. The Decedent did not own any interest in real estate.
11. The Decedent did not possess tangible personal property of commercial value.
12. Your petitioner is entitled to the family exemption as a child of the decedent who
died as a resident of Pennsylvania and who was a member of the same household
of the decedent at the time of decedent's death.
13. The following creditors, who are all of the creditors of the estate of which your
Petitioner has knowledge, are unpaid:
a. Funeral expenses:
David Ostriche—reimbursement for full payment of funeral and cremation
expenses: 2 906.58
b. Other claims
i. MS Hershey Medical Center $4,609.91
(Waived; please see Paragraph 15 below)
ii. Friendship Hose Company#1 $250.00
iii. MS Hershey Medical Center Physician Services $190.00
iv. PPL $34.89
v. Comcast $26.85
vi. Carlisle Regional Medical Center $25.00
vii. Davis Pulmonary Associates $25.00
viii. Holy Spirit Hospital $20.00
ix. Horizon Healthcare Services $16.78
5 198.4
Total �.$��LQ
14. All parties known to Petitioner to be beneficially interested in the estate, other
than the Petitioner, including all holders of claims who will not be paid in full,
have either (a) signed the joinder in this Petition which is hereby attached or (b)
been given by first class mail at least ten (10) days' notice of the intent to file this
Petition. Proofs of service of notice are attached hereto as E�ibit B.
15. MS Hershey Medical Center has agreed in writing to a 100% adjustment of the
decedent's balances. Such letter is attached hereto as Exhibit C.
16. The Petitioner filed the Pennsylvania lnheritance tax form for the estate on May
27, 2015, showing that no inheritance tax is due. A copy of the filing receipt is
attached hereto as Exhibit D.
17. The assets of the estate totaling �1�;.,5�4$, as set forth in Paragraph 9, are
insufficient to pay all claims against the estate totaling �3105.01 as set forth in
Paragraph 13.
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18. Pursuant to 20 Pa. C.S.A. §3392, your petitioner respectfully prays that this Court
award decedent's estate as follows:
a. Costs of Administration
i. Your Petitioner—Postage for USPS First-Class Mail - Certified
Mail with Return Receipt for notice mailed to creditors of intent to
file this petition: 60.48
ii. Your Petitioner—Register of Wills' fees
i. Inheritance Tax Return $]5.00
ii. Petition $15.OU
.00
b. Family exemption 1 1 2.00
Total �
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Date: / `
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Michele Northrop, Petitioner
38 Country View Estates
Newville, PA 17241
Telephone number: (717) 776-9233
Verification
The undersigned petitioner hereby verifies, subject to the penalties of 18 Pa. C.S.A.
§4904 that the facts set forth in the foregoing petition which are within her knowledge are
true, and, as to the facts based on information received, after diligent inquiry, she believes
them to be true.
Date: / � �
Signature of Petitioner
Joinder
I, the undersigned, being the sole party other than the Petitioner that is beneficially
interested in the estate of the foregoing Decedent under the laws of intestacy of the
Commonwealth of Pennsylvania, do hereby certify that I have read the foregoing petition
and join in the prayer thereof.
Date: � ��
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David Os che, Child of Decedent(Sui Juris)
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EXHIBIT A
DEATH CERTIFICATE
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WARNING: It is illegal to duplicat� this cc��a�� kay ,�6�{'=:G:� 1�1 ��r�� phatograph.
�r f�<>r this ccrtil�icatc. $6.U0 � , ��" � �� � �i �, tu c�rtil�� that thc �ni��rmauon hctc givrn i�
� /���L�h OFp�-��� �i J�� � o���cd lrc�m ui�uritinal C�rtilicatc of Death
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C�riilicatiun Number ��-=-'�-'-' "� >��; iZ���istr�u� Date Issuecl
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Type/PNni In COMMONWEALTH OF PENNSVLVANIA•pEPARTMENT OF HEALTH•VITAL RECORDS
Pef"'a"@"` GERTIFICATE OF �EATH
Black Ink State File Number:
1.Decedent's Legal Name(Flrst,Middle,Lasi,SuHix) 2.Sex 3.Soclal Sec�rlty N�mber 4.Date of Dea[h(Mo/Day/Yr)(Spell Mo)
Caroline R- Ostriche amal 165-32-5157 March 13 2015
Sa.Age-Last Blrthday(Vrs) Sb.Unde�1 Vear Sc.Under 1 Da 6.�aSe of Blrth(Mo/Day/Year)(Spell Month) 7a.Hirthplace I tl State or I Co ry
' �2 Months oav� Ho��s Mi��ies Ju1y 31 1942 -���em �e� ���Jey
�b.Hirthplace(County) a em
Sa.ftesltlence(State or Foreign Country) Sb.Resldence(Street and Number-Incl�de Apt N ) Sc.Dltl Decetlent Llve In:3 To hlpT
Pennsylvania 38 Countryvi�w Estate ��e5,ae�eae��in,Pai� �Prer FranKford M,P
8d.Residence(County)
C umb a r 1 a n d 8e.Restdence(Zlp Code) 1 4 O No,deceden<lived wi�hln Ilmlts of clty/boro.
9.Ever in VS Armed Forces? 10.Marital Status at Tlme of Death � Marrled O W�dowed il.Surviving Spou�e's Name(If wlfe,give name prlor to first mar�iage)
�Yes �Q No �Unknown �.Dlvorced � Never Married �Unknow
12.Fafher's Name(First,Mlddle,Last,Suffix) 13.MotM1er's Name Prior to Flrst Marrla (F1rst,Mtddle,last)
John Barn2s Mary-Rui�h �Edwards
14a.Informan<'s Name 14b.Relatlonshlp io DecedenC 14c.Informant's Mailing AtldrE�ss(Street and Number,Clty,State,21p Co,tle
o Michele Northrup Dauc,.-hter 38 Countryview Estates Newvil�lc����i
G isa.a a�e o oeac c e� o�Yo�e Ti
If DeaCh Occ�rred in a Hospifal [] �npatient - �If Death Occurretl Somewhere OCherThan a Hospital [7 Haspice Facillty y De<edent's Home
0 Emergency Room/O�tpatlent � Dead on Arrival 0 Nursing Home/Long-Term Care Factllty � Other(Specify) �
15b.Facllity Name(If not Institution,glve street and number) '15c.City or Town,5[ate,and Zip Code 15d.County of Death�
38 Countryview Estat�s Nzwville PA ].7241 Cumberland
i6a.Me�hod of Dtsposltlon � B�rial � Cremation 16b.DaTe of Dispositlon 16c.Place of Disposl[ion(N:3me of cemetery,crematory,or other pla<e)
p ne..,o„air�o.,,szace o oo.,at�o„ 3/16/2015 Hollincer Cremator
- o otner�sPeary� � Y
� 16d.Locatlon of Olsposlxlon(City or Town,Stat tl 21p S7a.Signacure oT�ral 5 Ice Llcensee or Person In t.-harge of Inte�ment 17b.Llcens�Number
� Mt - Ho11y Springs PA 1?7065 �'- �_ FD 13895 L
E 1Jc.Name and Complefe Address of Funeral Facillty
Eg er Fun.eral Home 2nc 15 Bi S rin Ave Newvilla PA 1 241
m 18.�ecedent's Ed�caSion-Check the bou that best descrlbes the 19.�ecedeni of Hlspanic Orlgln-Check the 20.Decedent's Race-Check ONE OR MORE r s to intllcate wFiat
� hlghesC degree or level of scFiool completetl at the time of deach. box that best tlescribes whether the decedent tfie decedent considered himself or herself to be.
� 8th grade or Iess Is Spanlsh/Hispanlc/LaLno. Check[he"No" 'fQ'White � Korean
O No dlploma,9th-12th grade box If decedent Is not Spanlsh/Hispanlc/Latlno. O B�a�-.k or Afrlcan Ameri<an � Vletnamese
� Hlgh school graduate or GEO completed �No,not Spanish/Hlspanlc/latino �Am.�rlcan Indlan or Alaska Native O Other Aslan
� Some college credit,b�t no degree � Yes,Mexlcan,Mexfcan Amerlcan,Chlcano O Asfan Indlan � Native Hawallan
�'ASSOCIate degree(e.g.AA,AS) 0 Ves,Puerto Rlcan � Chlnese 0 Guamanldn or Chamorro .
� Bachelor's degree(e.g.BA,AB,BS) 0 Yes,Cuban pino
o Fin o sar„oa�
� Master's degree(e.g.MA,M5,MEng,MEtl,MSW,MBA) 0 Yes,other Spanish/Hlspanlc/Latlno O Japanese 0 Oiher Paclflc Islander
O Doctorate(e.g.PhD,EdD)or Professional degree � (Speclfy) � OthAr(Specffy)
.MO ODS DVM LL6 JD
21.Decedent's Single Race Self-DeslgnaSion-Check ONLV ONE to Indlcafe what the decedent consldered hlmself or herself to be. 22a.Decedant's Us�al Occupatlon-Intllcate[ype of work
�WhISe �Japanese 0 Samoan done d�ring most of working Ilfe. DO NOT USE RETIREO.
� Black or Afrlcan Amerlcan � Korean � Other Paclflc Islantler ZJY]1 t C 1 e r K
p � Amerlcan Indlan or Alaska Native O Vletnamese � Don't Know/Not Sure
7S � Aslan Intllan �OShe�Aslan � Refus¢d 22b.Klnd of Buslness/Industry
� o ctii�e�e O NaTlve Hawallan O ome��sPe�iry� Ho s p i t a 1/Ma d i c a 1 f i e 1 d
� � Flllptno � Guamanlan or Chamorro
ITEMS 23a-25 MUST BE COMPLETEO 23a.Date Prppp tl�ead(Mo/Day �) 236.Slgnature of Person Vronouncing CJeath(Only when applicable) 23c.Llcense Number
BY PERSON WHO PRONOUNCES OR ` \1 2�� ^. ,C���j�
CERTIFIES DEATH � J �`������Q - /<!�/ � o i
23d.OaSe ed(M /1 ay/Vr) 24.Time'f Death �
25.Was Metllcal Examiner or Coroner�.ontacted? 0 Yes No
CAUSE OF DEATH � Approxlmate
26.Part I. Enter tlie chain of events--dlseases,tnj�rles,or compllcaclons-that dlrectly caused the death. DO NOT enter terminal evenis such as cardlac arrest, � Interval:
resplratory arrest,or ventrlcula�flbrlllaClon wlthout showing the etlology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add add7tlonal Ilnes If necessary. 1 Onsei to Death
IMME�IATE CAUSE ----------> a. \� 7�U L�!V l���� ( . A�� �/V O/Y_k� �
(Flnal dlsease or condlilon Due to(or as a consequenc¢of):
res�IHng In deafh) �
b.
Seq�entlally Ilst condltlons, Due to(or as a consequence of):
If any,Ieading to the cause
Ilsted on Ilne a. Enter the
UNDERLYING GAUSE Due to(or as a consequence of): 1
(disease or InJury that
'niHatetl the events resulting d. �
s In deaCh)LAST. Due to(o as a conseq�ence of): 1
� 26.Pari II. En[er other si¢niflcant condltlons contributlna fo deaih buk not resuliing in the underlying cause glven In Part 1. 27.Was an autopsy pert� oy. ed?
�
/q ST��.f� O ves Ig r�o
28.Were auxopsy flntlings avallable
m T���Y7�! 1/ O C ' � to complete the ca�se f tleathd
/ /� lJ�/'+ J
o ve� r�o
� 29.If Fe e: 30.�Id Tobacco tlse Contribute to DeatM1? 31.May� of Death
oNot pregnant wlthln past year � Ves � Probably �FJatural O Homlclde
0 Pregnant at time of death � No �nknown O Accldent O Pending Inves[igation
0 Not pregnant,bu(pregnant wlthln 42 days of deaTh � Sulclde � Covld not be determined
f- � Not pregnant,b�t preg�ant 43 days to 1 year betore death 32.Date of InJury(Mo/�ay/Yr)(Spell Month)
� Unknown If pregnant wlthln the past year 33.Tlme of Injury
34.Place of Injury(e.g.home;constructlon slte;farm;schoolj 35.Locatlon of Injury(Street and N�mt�er,CI[y,Co�niy,Sfate,Zlp Code)
36.Inj�ry a!Wo�k 37.If Transportatlon Inj�ry,Speclty: 38.Descrlbe How Injury Occurred: �
� Ves � �rlver/Operator .� Pedesirlan
� No � Passenger 0 Other(Speclfy) � �
39a. Ifler-physlclan,certlfled n e prac[IHoner,medical ezaminer/coroner(Check only onej:
Certlfying only-To the best of my knowledge,death occurred due he cause(s)and manner stated.
� Pronouncing ffi Certlfying-To the best of my knowledge,death oc tl at Yhe tlme,tlate,and place,antl due to the causr(s)and manner sfatetl.
O Medlcal Examiner/Coroner-On the basls of examinatlon and/or In e IgaLon,In my opinlon,death occurre t the time,daie,and place,and due to the ca�^se(s)and mann tafed.
Slgnature of cert(fler: Tltle of certifler:�___ Llcense N�mber:�t/l Uf�����
396.Name,Add�ess and ZI otle of Completing Cause of Death(Ifem 26 39c.Oace Si n tl(M /Oay/Yr)
Jrv . owNs=�N�{J ,�v s�(�1� �n Si �l�wvrLl�. �� ���-K� /6 �a/�5
40.Reglstrar s Olstrlct Number 41.Reglstrar's Slgnat r 42.Regls(r Flle ate(Mo/Day )
� e�\-a\� .�� `(��c� 1� a0 tS
� 43.Amentlments
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- �(rt'�! � -- H105-143
DlsposlNon Permlt No. l l �Q�� REV 07/2012
EXHIBIT B
PROOF OF SERVICE OF NOTICE TO CREDITORS
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Postal Product: Features:
First-Gass Maii�'� Certified Mai'�M Retum Receipt
DATE 6 TIME STATUS OF ITEM LOCA770N
May 12,2015,9:41 am _ HERSHEY,PA 170J3
Your item was deliveretl at 9:41 am on May 12,2Q15 in HERSHEY.PA 17033.
May 12,2015,9.32 am Arr�ved at Unit HERSHEY,PA 17033
May 12,2015.R�.25 am Available far Pickup NERSHEY,PA 17033
h9ay 12.2015.4�46 am peparted USPS Faciliry HARRISBURG,PR 17107
May 71.2015.8:42 am Arnved at USPS Origin HARRISBURG,PA 17107
F aciiity
May 10,2015,2 11 am Departed USPS Facility MIAMI,FL 33152
May 9,2015,1p22 pm Arnvetl at USPS Facility MIAMI,FL 33152
May 9,2015,7213 pm Acceptance FQRT
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PosWl Product: Features:
First-Class Maii�' GeRified Ma(I�" Return Receipt
DATE 6 TIME STATUS OF ITEM LOCATION
May 13,2015,3:2A pm MECHANICSBURG,PA 17055
Your item was tlelivared at 3�24 pm on May 13,2015 in h7ECNANiCSBURG.PA 17055.
May 12,2015,11:42 am Available far P4ckup MECHANICSBURG.PA 17055
May 12.20i5,9;4$am Out for Delivery MECHANICSBURG.PA 17055
May 12,2015,938 am 5orting Complete MECHANICSBURG.PA 17055
May 72,2015.&.34 am Arnved at Unit MECHANICSBURG.PA 17055
May 11,2015,7:53 pm Departed USPS Origin HARRlSBURG,PA 17107
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Maq 17,2015,8 42 am �nvetl at USPS Origin HARRtSBURG.PR 17107
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May 10,2015,2:11 am Departed USPS Facility MIAMI.FL 33752
May 9,2015.10�22 pm Arnved at USPS Faciliry MIAMI,FL 33152
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7014287000D114658842
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Postal Product: Features:
F�irst-Class Maii�� Certfied MadT` Retum Receipt
DATE 3 TIME S7AtUS OF ITEM LOCATION
May 12,2015,9:41 am HERSHEY,PA 17033
Your ttEm was dellveretl at 9:41 em on May 12,2015 in HERSHcY PA 17033.
May 12,2075,g.32 am Arrived at Uni� HERSHEY.PA 17033
May 12,2015.8:25 am Available for pickup fiER5HEY,PA t 7033
Mey i2,2015,4A8 am Deparled USPS Faciliry HARRISBURG.PA 17107
Ma 11.2015.8�42 am Arrived at USPS Origin
y � Facility HARRISBURG.PA 17107
May 10,2015,2 17 am Departed USPS Faciliry MIAMI.FL 33152
May 9.2015,10�22 pm Anived at USPS Facility MIAMI,FL.33152
May 9.2015.77.14 pm Acceptance FORT
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Thursday,May 14,2015
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May 14.2015,10:28 am . � ALLENTOWN,PA 18109
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May 12.2015,8-A3 am Arnvetl at USPS Origin LEHIGN VALLEY,PA 18062
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May 10.2015.2�ti am Departed USPS Facility MIAMI,FL 33152
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- 70142870004114658804
Tuesday,May 12,2015
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May 12,2015,9:40 am - CARUSIE,PA 17015
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May 12,2075.8.32 am Availabie for plckup CARUSIE.PA 57013
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May 11.2015,8�A2 am Arrived at USPS Origin HARRISBURG.PA 17101
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70142870000114658590
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May 31,2015.2�.04 am peparted USPS Facility HARRISBURG,PA 17107
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May 13,2015,6:47 am .- -- CAMP HILL,PA 1T011
Your item was delivered at 6�.47 am on May 13.2015 m CAMP HILL,PA 17011.
f�Aey 12,2015.7�5F3 am Available for PickuV CAMP HIL�,PA 17011
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70142870400114658606
Monday,July 6,2015
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EXHIBIT C
MS HERSHEY MEDICAL CENTER-LETTER WAIVING BALANCE DUE
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P�(��;ST�7� ���tS�—I�Y c��f�Ji'��T��� ���S�EY
� � ��-;�Iiltc�n S. ��rsh�y �� Ct��le`� of�Vledi�ine
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June '!5, 2Q15
Ma#r
3$ Gauntry View Estates
hlewviile, PA 17241
Patient Name: Carc�line CJstriche
Patient Account: 2q7�25�
Dear Ms. Ostriche,
Thank y�u for your recent contact tc� our �ffice regarding c�ta�financial assistance pragram.
Based an our fiinan�ial assistance criteria, ycau quali�y for 10fl°l� �djustment of current
bafances an your account. Oniy balances that are deemed meciica(ly necessary wiH k�e
ad}ust�:d. Gertain Elective Services and Programs 'rncluding the Pharmacy Department are
excluded ur�der this program. Please contact atrr Prescriptic�r� rr�„ssistance Pra�ram as sc�on
as feasible tc� discuss opportunities that may be avaifable t� �ssis#yau in affording your
medications at 7�7-531�2�82 or 7'17-5�1-�023.
Future balances wilt nvt autorr�atically be adjusted. P{e�se cantact aur office to
determine if the balances qualifij far financial assista�ce. A4: thryt tirrte we will acce�s your
account and may ask fcr updated financial �nfr�rmation.
Thank you,
Financia! Caunseling Depar#mer�t
Miltor� �. Hershey Medical Center
Patient Financial Services
1-8�0-254-2619 ar 531-5(��9
Pean State Yiilton S.Hershev tteclic:��('cntcr•i'enn titatc C"r.�flcge��1'ltedicine
PatiezttTina�tcial Ser�•ices;9U Hope�i7rive,P.{?.�ox 35�r1�4}�.?�it:rsh��}�,(',�� 17933
TeI:"I?-j31-�t36R�•F�,�:7t7-5E1-O��95��tivtit�ti�'-Penn,taz�f�erslae��.t�r�l
An Fqiial(?nporttniity'C��a�i�er�+t�:
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EXHIBIT D
CUMBERLAND COUIVTY-REGISTER OF WILLS
RECEIPT FOR INHERITANCE TAX RETURN
,�„���,_.,�.,,,,�. ,
' ' REC�IPT FOR PAYMENT
LIS� M. �RAYSO�, ESQ. �_P� =ipt Date . 5/27f2015
Cumberland Coun�y - Registe� O� Wills �_f= �zpt Time : 09 : 01 : 33
Qne Courthouse S quare ��e�•=4ipt Nc� . • 1081465
Carlisle, PA 17613 ~ �
C7STRICHE CARC7LINE R
Estat� File No. : 2015-00583
Paicl By Remarks : M�CHELE NQRTHRO�
CJ
---- -- ----- ------------- Receipt Distributic�n -- - - --------- ------------
Fee/Tax Descript�an Payment Amc�unt Paye;> T�Tame
INH TAX RETTJRN 15 . QO CUMFsL�:R7=,.�,ND COUNTY GENERAL FUN
- -- --- -- -- - -- ---
Cash $15 . 00
Total Received. . . . . . . . . $15 . t7C}
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