HomeMy WebLinkAbout09-04-15 Pennsylvania 1505614105
DE AannErvrorrerHUE EX(03-14)(FI)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601
INHERITANCE TAX RETURN -'
- ff
Harrisburg, PA 17128-0601 RESIDENT DECEDENT ` j-'1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
210-58-4711 08072014 05061957
Decedent's Last Name Suffix Decedent's First Name MI
......_ ...... . ......,........... ........... . . ...... _... _._...._. .. . ........., .............. ........., _........
.
HORST 'FLORENCE Z
..........................................-.................................................................................................................... ...............
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
I f
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
CD 1.Original Return p 2.Supplemental Return p 3. Remainder Return(date of death
prior to 12-13-82)
C=:) 4.Agriculture Exemption(date of O 5. Future Interest Compromise(date of O 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
C=) 7.Decedent Died Testate p 8.Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
C=:) 10. Litigation Proceeds Received p 11.Non-Probate Transferee Return p 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
O 13.Business Assets O 14.Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT— THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
_.........._............................................................................................_........................_............_..........._.......................
...........
........... ..............._........_.__._....._.,......._...._._._....
t
;MARIAN NOLT (606) 787-4233
... . .. . ........ . . ..................._...........__........................_......................................_..._......._.........
First Line of Address
4401 KY 910
Second Line of Address
................._................._..............................................._....................................................................................................................................................._......._.._..................
...................,
........................................_...__.................._............_.........................................................................................................................................................,.........................._._.....................................
City or Post OfficeState ZIP Code
;LIBERTY I KY 42539
_......__ ......___..._ _..__. ...__... _.
Correspondent's email address:
REGISTER OF WILLS USE ONLY
REGISTER OF WILLS USE ONLY
DATE FILED IVIMDDYYYY,.
Z
CD M 7
DATE EI ED;ST P —V Cya O
PLEASE USE ORIGINAL FORM ONLY 7 c,
Side 1
1505614105 1505614105
1505614205
REV-1500 EX(FI)
Decedent's Social Security Number
.........................................................................................................._........._................_........
.
Decedent's Name: 210-58-4711
RECAPITULATION
1. Real Estate(Schedule A). .. . . . ..... ...... . . . ................. ........ 1. ' 73,000.00
2. Stocks and Bonds(Schedule B) . ... ....... ............................ 2. 0.00.;
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 1 0.00
i
4. Mortgages and Notes Receivable(Schedule D) ....... ... ................. 4. 0.00
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 1 30,302.00
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 0.00
_...............................................................................,............................
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7. 1 0.00
8. Total Gross Assets(total Lines 1 through 7).. ........ ................... 8. 103,302.00
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 15,074.00
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)................ 10. '::. 60,514.00
11. Total Deductions(total Lines 9 and 10). ...... .... ............... ...... 11. 75,588.00
i
12. Net Value of Estate(Line 8 minus Line 11) .. . ....... .......... .......... 12. 27,714.00
13. Charitable and Governmental Bequests/Sec.9113 Trusts for which
an election to tax has not been made(Schedule J) ..................... ... 13. 0.00
14. Net Value Subject to Tax(Line 12 minus Line 13) .... ..................... 14. 27,714.00
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfersunder Sec. 9116 - ~_____.... .,._._....___.__.._...._._ ... _..._._.._... ...., _.......__._..__..._....._._ _.__... _....___. .__...._.__.__.,
(a)(1.2)X.0- 15. 0.00
16. Amount of Line 14 taxable
at lineal rate X.0_ 16. 0.00
17. Amount of Line 14 taxable ,_ _at sibling rate X.12 27,714.00 17 3,325.68
18. Amount of Line 14 taxable
at collateral rate X.1518. ° 0.00
19. TAX DUE .... .... . .... ... ........ .... .... ......................... 19. 3,325.68 ;
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Under penalties of perjury,I declare 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 preparer other than the person responsible for filing the return is based on all information of which preparer has
any knowledge.
SIGNATURE OF PERSON RESPONSIBLE O ILING RETURN DATE
x X s
ADDRESS
4401 KY 910, LIBER , KY 42539
SIGNATUR F RER OTLER THAN P RSON RESPONSIBLE FOR FILING THE RETURN DATE
08/26/2015
RES
721 E LINCOLN AVE, MYERSTO N, PA 17067
11111111111111111111111111111111111111111111111111111111 IN Side 2
1505614205 1505614205
REV-1500 EX`(FI) Page 3 File Number
Decedent's Complete Address: 21-2014-839
DECEDENT'S NAME
FLORENCE Z. HORST
STREET ADDRESS
145 MOUNTAIN ROAD
CITY STATE ZIP
SHIPPENSBURG PA 17257
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 3,325.68
2. Credits/Payments
A.Prior Payments
B.Discount
(See instructions.) Total Credits(A+B) (2) 0.00
3. Interest
(3) 30.27
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 3,355.95
Make check payable to: REGISTER OF WILLS, AGENT'
_. _. e,�
wo 5 rvtw
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE Af Ve-w ato'
1. 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 ............................................ .J ---
c. retain a reversionary interest .............................................................................................................................. ❑
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ N
2. If death occurred after Dec.12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑
1111111
3. Did decedent own an"in trust for'or payable-upon-death bank account or security at his or her death?.............. ❑ 0
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? ........................................................................................................................ ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a step-parent 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-1502 EX+(12-12)
pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
FLORENCE Z HORST 21-2014-839
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold.
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1. REAL ESTATE-3 ACRES @ 145 MOUNTAIN VIEW ROAD, SHIPPENSBURG 73,000
TOTAL(Also enter on Line 1, Recapitulation.) $ 73,000
If more space is needed,use additional sheets of paper of the same size.
I
REV-1508 EX+(08-12)
SCHEDULE
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
FLORENCE Z HORST 21-2014-839
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. ACNB BANK CHECKING#161756 5,721
2. HOUSEHOLD GOODS 9,003
3. CASH AND MISCELLANEOUS ASSETS 513
4. ACNB CD 900043206640 10,047
5. ACNE CD 900043206641 5,018
TOTAL(Also enter on line 5, Recapitulation} $ 30,302
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RE
RESIDENT DEC D NTTURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
FLORENCE Z HORST 21-2014-839
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. FOGELSANGER-BRICKER FUNERAL HOME 3,764
2. AMOS REIFF-COFFIN AND ROUGH BOX 165
3. RICHARDS&KNAUER MEMORIALS-STONE 1,846
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 5,000
Name(s)of Personal Representative(s) MARIAN NOLT
Street Address 4401 KY 910
City LIBERTY State KY zip 42539
Years)Commission Paid: 2015
2. Attorney Fees: 565
3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 256
5. Accountant Fees: 2,750
6. Tax Return Preparer Fees:
7. VEHICLE COSTS FOR ESTATE ADMINISTRATION TRAVEL 643
8. AUTHENTICATION FEE-REGISTER OF WILLS(LEBANON) 35
9. BOND FEE-REGISTER OF WILLS(CUMBERLAND) 15
10. PETITION&RENUNCIATION FEE-REGISTER OF WILLS (CUMBERLAND) 35
TOTAL(Also enter on Line 9, Recapitulation) $ 15,074
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN
RESIDENT DECEDENT MORTGAGE LIABILITIES &LIENS
ESTATE OF FILE NUMBER
FLORENCE Z HORST 21-2014-839
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
ACNB CHECKING-OUTSTANDING CHECKS 681
2. PPL ELECTRIC 211
3. CENTURY LINK-PHONE BILL 281
4. MSHMC PHYSICIANS GROUP 3,325
5. MS HERSHEY MEDICAL CENTER 258
6. MS HERSHEY MEDICAL CENTER 53,314
7. COMMERICAL ACCEPTANCE COMPANY-MEDICAL BILL 815
8. REAL ESTATE TAX DUE AS OF DATE OF DEATH 1,618
9. PERSONAL TAXES DUE AS OF DATE OF DEATH 11
TOTAL(Also enter on Line 10,Recapitulation) $ 60,514
If more space is needed,insert additional sheets of the same size.
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
FLORENCE Z HORST 21-2014-839
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
( TAXABLE DISTRIBUTIONS[include outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
MARIAN Z. NOLT
1' 4401 KY 910, LIBERTY, KY 17257 SISTER 1/5TH
IVAN Z. HORST
2' 1597 PINOLA ROAD, SHIPPENSBURG, PA 17257 BROTHER 1/5TH
EDNA Z.TOSTEN
3' 1597 PINOLA ROAD, SHIPPENSBURG, PA 17257 SISTER 1/5TH
PHARES Z. HORST
4. 8300 GREENVILLE ROAD, ELKTON, KY 42220 BROTHER 1/5TH
MARY JUNE Z. HORST
5. 1 CHIMNEY LANE, EAST EARL, PA 17519 SISTER 1/5TH
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
[[ NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOTTAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART 11—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET.
0.00
If more space is needed,use additional sheets of paper of the same size.
T5
S 8-20-14
LR
. TISMVICE
Andrew 717.582.5382-Victor 717-658.99-4it
-901511 ally Pitcher hr". Shi penshurg, PA 17257
REAL ESTATE APPRAISAL
FOR: Florence Horst Estate
SUS -'T: Real Es fate*145 M. View_Rd. Shippensburg,_Pa. _.
LOT SIZE: approx. 3 acres
DWELLING STRUCTURE TYPE:
14'x70' house trailer, w/10'x20' addition, 3 bedrooms, 2 baths,
WATER SUPPLY: private well
SEWER: private seepage bed
OUT BUILDINGS: 32'x24' 2 car garage, 8'xl2'garden shed
PRESENT GENERAL CONDITION: good
GENERAL AREA RESALE: good
PROPERTY SETTING: good
APPRAISAL PRICE: $73,000.00
ACNB
BAND
July 22, 2015
Edna Z Tosten
128 Stoughstown Rd
Shippensburg PA 17257
RE Estate of Florence'Z fTorst
Dear Ms. Tosten:
The following information is being provided as per your request:
Acct.Type Account No. Balance at Accrued Ownership Date
D.O.D. Interest to Opened/Joint
D.O.D.
Checking 161756 $5,720.65 $.05 Individual 5/4/92
Account
Certificate of 900043206640 $10,000.00 $47.45 Individual 2/24/14
Deposit
Certificate of 900043206641 $5,000.00 $17.97 Individual 2/24/14
Deposit
Inquiries concerning ACNB Corporation stock information should be directed to the Registrar and Transfer
Company:at 1--800'36&-5948. If you need any additional•information,p ease contact me at(7-17)339-5122.
Sincerely,
r�
Lois A. Kime
ACNB Bank
Deposit Services Supervisor
acnb.com • P.O. Box 3129,Gettysburg,PA 17325 - 717334.3161 • Toll Free 1.888.334.ACNB(2262)
6-4-15
A: SMVICE
Andrew 717.532.5382-Victor 717.65&9930
9015 Malty Pitcher Hwy,Shi penshurg, F,4.27257
AUCTION SETTLEMENT
CONSIGNOR: Florence Horst Estate
Auction held May 30, 2015 of Household Goods.
Auction Total..........................$11,147.25
Less expenses......................... - 2,199.00
8,948.25
Income from other neighbor consignor..... + 55.00
ayment $9,003.25
EXPENSES:
The Guide..............................................$216.00
Valley Time Star........................................96.00
News Chronicle.........................................174.00
Shippensburg Sentinel..............................116.00
Franklin Shopper......................................181.90
Hand flyers..................................................42.00
2 port-a-pots..............................................160.00
Tents..........................................................100.00
10%commission................................. .1,114.00
2,199.00
FUNERAL PURCHASE CONTRACT
4110 (STATEMENT 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 FOGELSANGER-BRICKERFUNERALHOME,INC
or by a cemetery or crematory to use any items,we will explain the reasons in writing below.) NORMAN H.BRICKER,Supervisor
Section_13.204 of the Rules and Regulations of the Pennsylvania State Board of Funeral Directors requires this A"a P.O.Box 336.112 West King Street NO. -
contract to be signed by the person or persons arranging for the funeral service and by the funeral director. FEDERATED SHIPPENSBURG,PENNSYLVANIA17257 ;.i* 201
BASIC
BASIC SERVICESOFFUNERALDIRECTOR&STAFF ..:
(A) OURSERVICE: �. (717)532-2211 Date.
... $-- j�� / 7J
Full name of deceased 1 ) t f J f Age
EMBALMING ....................................... $ G r t / (PleasePST Nam
�e�
o if you selected a funeral that may require embalming, Date of Death ✓/Cd G /. ,,AQ1'�4 Deceased is bf person.arranging services.
x such as a funeral with viewing,you may have to pay for ° (Give Relationship) y
a a embalming. You do not have to pay for embalming you
o z w did not approve if you selected arrangements such as (B) CASH ADVANCE ITEMS: Total(A)Forward $ � °
d w z a direct cremation or immediate burial. If we charged
We charge you for our services in obtaining: yy
L
ti p LL for embalming, we will explain why below. - -6
w w REASON FOR EMBALMING: Opening Grave.................... ... $
z _ 1l d=I-MC �_/ � Newspaper Notices Out-of-Town. r
o- a- OTHER PREPARATION OF THE BODY .................. $
Airfare.........................I............... $
0 0 ¢ USE OF FACILITIES,STAFF&EQUIPMENT: L i1' j15'j
Clergy/Mass Offering.................... ......: $
Funeral Ceremony(Conducted at Funeral Home) . . . . . . . .. .. $ ''''p
Visitation/Viewing(conducted at Funeral Home)............ $ Certified Copies of Death Certificate f�.. ... :�•... $ cy !`�
Memorial Service(conducted at Funeral Home) $. ( Flowers ..................................'...:..',... $:.
f
Organist/Soloist ..:............................. $
USE OF STAFF AND EQUIPMENT: t+clc-X G1 $
Funeral Ceremony Conducted at another facility
Visitation/Viewing Conducted at another facili
Memorial Service (Conducted at another facility) ............ $ JJjj�� 0 _ $
Graveside Service................................. $—A� $ V " $ .
.
$ 13
........... Total(
(C) OTHER ITEMS:
........... $ $ t' Total(A)&(B)
TRANSFER OFREMAINSTOFUNERAL HOME............ $
$
( Miles Transported)
Total(C). .' $
AUTOMOTIVE EQUIPMENT: Total(A)(B)&(C)
Casket Coach(Hearse) $
Family Car ....................................... $ LESS: Preneed Adjustment / Allowance❑INS ❑TR.' $( )
Flower Car or Floral Disposition $
...................... Payment / Date ( ) ,.;": $( )
Lead Car/Clergy Car...........:.................. $ Other (Specify) r _ $( ,• _ ).
Car for Pallbearers ..........
BALANCE$
MISCELLANEOUS MERCHANDISE: +
Acknowledgment Cards.............
LEGAL,CEMETERY,CREMATORY OR®THER REQUIREMENTS COMPELLING THE PURCHASE OF ANY ITEMS LISTED
ABOVE:
Visitors Register ........................... $_�_ The undersigned purchasers)hereby aft,st to the following:(1)I/We did( )'did'not(. ")authorize embalming of the above
named deceased.(2)Ville were shown a Crsket Price List and an Outer Burial containerPrice:List before the showing of caskets;
Memory Folders................................... $ _ and outer burial containers.(3)I/We were given/offered for retention a General Price List upowthe beginning of a discussion of
PrayerCards..................................... $ funeral arrangements and/or selection of services and merchandise...
CASKET $ TERMS:Net due 30 days.A charge of %per.annum %
nnum( .per month)for unanticipated late payment
will be charged on any amount unpaid after due date. Purchasers)agrees to pay reasonable attorney's fees,court costs and
other costs of collection if incurred in the collection of this debt.
As Selected $ I,or we,having read the above,accept and approve same,and jointly and severally promise to`make full payment therefor..Each purchaser
OUTER BURIAL CONTAINER
( ) understands that this promise to jointly and severally make full payment means the Funeral Home.has the.right to collect the entire amount from
anyone or more of the purchasers without resort to any claim against any other purchasers.This right exists regardles§.of whether or not one or more
of the purchasers have agreed among themselves how much each will contribute to makeJull payment.Receipf.of a copy of this contract is
Receptacle(other than casket) $ Mfi now
e l fi'
Wearing Apparel $ fs 'f %;n-•- ! ~t d. /. lj(i f1 kf .e /
C j }J „� $ Signatbre of Purchasei(s)', � treet Address
ti_. Monument Engraving _ 2r vi iTjFr��s'f j' �!t[, { 11
.f r Yft� Ltt (4 i
$— S.S.No. City State Zip Co e
FORWARDING OF REMAINS TO ANOTHER FUNERAL HOME ............... $
CRMN RECEIVING OF REMAINS FROM ANOTHER FUNERAL HOME.............. $
- Signature of Purchaser(s) Street Address,:,.+;,;':; Cify.and State Zip Code
0.
DIRECT CREMATION(As Selected)..........................:........ $
Signature of Purchaser(s) Street Address:.; ,City and State Zip Code
IMMEDIATE BURIAL(As Selected) ................................... $ We agree to provide the service&merchandise indicated above.
S-7 PA Total(A) $ Fogelsangr-Bricker Funeral Home, Inc. 13y ��A:.t ,'
ICK-AUF,R W-Im ORIALS
worj-uweet Aiv--Ie: memerw-C,Pet stmes,foundatiW..teuerjwg,tkan-�ng,4L CVeMatia-M UrAr-,-
&R �d"-
et Tj,,arw:
,Oid Xr
A -23i
263'Warvdck Rfi,Eh'fz' -%nPA- 19'5' 921
15- phow&ETC
Date-APRAL-2,2_204
I do hereby Order'of RICnAAWS&KNAUM 2.63
Waryis &.Eh-Wlsc Pa,
as pc--size&roweriaLs givem bdow,to be e.-Wed in t&-
1AAB)d:
ZV=)1z—ADC)W i1JEW AND--
state,and for wWCh I ham`a9rCe to PaY I; RIFE&YCNAVER,26-1%famick Rd,EvvcxsonPA- 195-I&MI f-hi
EI(2fLELAZ
RICHAMS&KNAUER.agreeing to C=t Said MO,/Yu in 5r1AM41F)'z --mn-Aunim W—to.,m"
pruvent,&then as smi thamfter as pr,-
x X
Slant x
Bast
X x
Marker x x
Posts x
No claims io be maft if hof'an iu,-h more or less.
Stone ordered: D*-mt 4'
tj�q
Lxnation in oewewry�___
TERMS: 50% DOWN WFM ORDER BAIANCE DUE UPOIN RECENT. Farckamr agrm to pay of "collect
f
WcWdW,!,*Wrsey's-feeL All Wduebafmxes(10 dam)will be"bjecttek ftr--q ftes of 4.51%,per month or 19%per
REMARKS
Tnp s 7-,P% - E/t)DS 8As7,r
-5MVOT
—5
/"2 4,ExTSA
With such emension&abbreviatiom as way be cwomwy Fwmw Nun an bwk
All
*7 (2
MO, I DA,
Ali future kqti_iqg,mov*.rmtdn&&fmu%d2tkw wrk etc.not figm-ed in 9611ing pnm at thm of instial sale vall be cbwp
no"-sswy to be doneaccmdirig to the prevall-ima,pex=at AL9t fmw..
it is also under4oad ms as pot of this water ffi*if the mono', is not wi in M tit the t�of this muftad Cm g,asst take tx
&appropriate it to their own use to sec=&e unpni4 palljon of the mmey,VvIgNmd rem froom atav Takw6w or appraisements laws of the
time of delivery Ve6fied in%e mifted is taken stkiod to Wber troubks,bmk doves at thequmimm,,ther Cw1memits beyond our cc
plime'. , C
Nrcbasees Signature. Ad&= t LLf V Q
,,F
? -ry
0
soldBy.
VO U C-C /OY
Escrow Account Fulton Bank 3283
719 E.Lincoln Ave.
Myerstown, PA 17067 60-142 12/2/2014
g 313
i
x
s
tPay to the $ 3,325 .25
Order of MSHMC Physicians Group I
r
A
Three Thousand Three Hundred Twenty-Five and 25/100*******************DOLLARS
i
MSHMC Physicians Group
P.O. Box 643313
Pittsburgh, PA 15264-3313 <-
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11' 328311' 1:0313014221: 0100 3661611'
STATEMENT DATE: GUARANTOR RESPONSIBILITYt MINIMUM PAYMEN
BF6 11/17/14 $ 50479,00 $ 50479.00
MSHMC PHYSICIANS GROUP
BILLING SERVICES
P 0 BOX 854
HERSHEY PA 17033-0854 00007515750 UP 0000000005047400111714
00001047 03
Mall MSHMC PHYSICIANS GROUP FLORENCE Z HORST
TO: MSHMC PHYSICIANS GROUP 719 E LINCOLN AVE
PO BOX 643313 ESTATE OF FLORENCE HORST
PITTSBURGH PA 15264-3313 MYERSTOWN PA 17067-2220
OFFICE USE ONLY FOR CREDIT CARD PAYMENT,PLEASE FILL IN INFORMATION BELOW =—'-=- 1 =
CHECK ONE l ,� I I I 7515750
M/C CARD NUMBER EXP DATE _-- _ - - - - �-�-�--- - ----
VISA $ 50479.00 12/08114
_DISC 1 =
Escrow Account Fulton Bank 3284
719 E. Lincoln Ave.
Myerstown, PA 17067 60-142 12/2/2014
313
Pay to the
Order of MS Hershey Medical Center
Two Hundred Fifty-Eight and 001100*** DOLLARS
MS Hershey Medical Center
P.O. Box 643291
Pittsburgh, PA 15264-3291
-Acct-21-355742�-Flarence-Z,.,-Horst--"*-,--""--"-".--'-'-----
1183213411ll iNO031301422i: 0100 aGG I Gil
......................... ........1,......... ..................................................... ...................... .... ...... ...... ... ...... ........
PENNSTATE HERSHEY Statement Date: 10108/14 .-Paffielnt arne-- _,Account- :mate A)ue-_
RX"I jMjlton S.Hershey HORST
ST FLORENCE Z _21355742 Upon,Receipt' ,
Medical Cve qtr
Ai&hb�n Paid"
Arrlourit'Due"��`,'
PO Box 643291
Pittsburgh,PA 15264-3291 $27,407.00
Check here if your address or insurance information has changed.
CHECKS SHOULD BE MADE PAYABLEAND Please indicate changes on the back of this page,
SENT TO': To pay by credit card.: For your convenience,you may pay by Visa,
MasterCard or Discover Card. Please indicate your credit card
preference,provide the account information,and sign below.
MS HERSHEY MEDICAL,CENTER
PO Box 643291
Pittsburgh,PA 15264-3291 Account No.
Expiration Date CVV Code
Signature X
0000000213557420803141008140002740700
0
CJ
P"
00 1 Q
00
Escrow Account Fulton Bank 3285
719 E.Lincoln Ave.
Myerstown, PA 17067
60-142 12/2/2014
313
Pay to the
11$ 53,313 .67
Order of MS Hershey Medical Center L—
Fifty-Three Thousand Three Hundred Thirteen and 67/100****************DOLLARS
MS Hershey Medical Center
P.O. Box 643291
Pittsburgh, PA 15264-3291
emo: cc ornece ors
11' 328511' 1:03L30L4221: OLOO 3E.6L6110
PENNSTATE HERSHEY Statement Date: 10/07/14 ;-'Patient Name AC"COUnf N6rnb6e" — bate b6e:- -
--- ----- -- -
Milton Her,5hey HORST FLORENCE Z .10515750 Upon Receipt
'Medical Center
6 nf
nn 6 Due Al�noiAn a
PO Box 643291 A
Pittsburgh,PA 15264-3291 $ 153,392.42 1$ _6,3 73 13, 67
Statement ofHospit(d Services Check here if your address or insurance information has changed.
CHECKS SHOULD BE MADE PAYABLE AND Please indicate changes on the back of this page.
SENT TO: To pay by credit card: For your convenience,you,may pay by Visa,
MasterCard or Discover Card. Please indicate your credit card
preference,provide the account information,and sign below.
MS HERSHEY MEDICAL CENTER
PO Box 643291 j = J = J Fi-fi-51
Pittsburgh,PA 15264-3291 Account No.
Expiration Date CW Code
Signature X
000000010.5157500803141007140015339242
/ 0 Lab'5 tw)� peu/
00
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---------------
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FRIENDSHIP HOSE COMPANY #1
PO BOX 539
MECHANICSBURG, PA 17055
(717)776-4747
Federal Tax ID: 251395202
Patient Name: FLORENCE Z. HORST Patient Number: 30228
Call Number: 1400745
Insurance: Date Of Call: 08/03/2014
Call Time:
Caller:
From Location: 190 QUARRY HILL ROAD
To Location: FIELD
FLORENCE Z. HORST
719 E LINCOLN AVENUE Reason(s) 780.09
MYERSTOWN, PA 17067 For 959.01
Transport 459.0.
DESCRIPTION OF CHARGES HCPC QUANTITY UNIT PRICE AMOUNT
BLS EMERGENCY A0429 1.0 800.00 800.00
MILEAGE A0425 1.0 15.00 15.00
Total Charges 815.00
Total Credits 0.00
PLEASE PAY THIS AMOUNT=> $815.00
---------------------------------------------------------------------------------------------------------------------------------------------------
^DETACH ALONG ABOVE LINE AND RETURN STUB WITH YOUR PAYMENT"
Amount Due:$815.00
Patient Name: HORST,FLORENCE Z Call Number: 1400745 Amount
Patient Number: 30228 Current Date: 12/12/2014 Enclosed$
This account is SIXTY DAYS PAST DUE!Your payment must be sent IMMEDIATELY. If there are
problems or questions, please contact our office so we can help get this matter resolved.
Thank you.
FRIENDSHIP HOSE COMPANY#1 PO BOX 539 MECHANICSBURG, PA 17055
MARTIN AC
PUBLIC
PAID
Myerstown, PA 17067 R1 ^}j-E t t)r '„ILLS SCIENCE
SEP 01,'15
VNITEDSTATES AMOUNT
HIS SEP q P11 12 07 PO57°1000` $2.08
C L E.i 17013 00082475-03
0RPlri',
CU;t=iDEFP i
Cumberland County Register of Wills
1 Courthouse Square
Suite 102
Carlisle, PA 17013