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2187
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
SlA1E FIlE :"\IUM8ER
:AMEOFDECE:r;r~'as/Yt . -'G-;;;;~;---------------------- ~~em~le'=rA1~3R=NU~8~R - 2303
AGE (LaSt B<tMay) UNDER 1 YEAR UNDER 1 DAY BIRTHPLACE ,Cry.M PlACE OF DEATH iC~eck ""'V ope -- -;ee 'PSI/ucl",,'. on OII>e, s.del
Month. Days Hour.o Stale 01 Fcreoqn Counl/vl HO$PI1Al. -
P a I~henl l\O ERlQutpaltenl 0 OOA 0
...
fAC1UT'( NAME {It f\O\ jf'o~'tuhOJ"l_ gIve sUee\ and numbel'
DATE OF DEATH ,Mcnlh Day.....a"
4.
J
II-()(j
lIc:.
~:=,tyl 0
77
Y~
5,
COUNTY OF DEATH
~
Dauphin
Harrisburg
RACE, Amenean Indian, Black. WMo. ele
(Speedy) Wh i t e
10.
OECEOENl"S USUAL OCCUP"'I'ION KINO OF BUSINESS/INDUS1RY
(GIve ku"ld of.otk aone dunng most
of WOfkt~ 1,le; do not use retl(ed )
110. Printer l1b. printing 00.
DECEDENT'S MAILING ADDRESS (St,...... Cdyl10wn SlaM. ZopCooel DECEDENT'S
1061 Allenjale Roa1 ~~~~ELNCE
Mechanicsburg, Pa ~l~~~~
MARITAL STATUS. Maroed
Never Ma"'ed. Widowed.
D"",!e~ (Speedy)
\'ll.:J..OW
SURVIVING SPOUSE
(II NIle, gIve maiden namel
ITh. County
Cumberlan1
Old
decadenl
we In .
lownsllip?
lWp
1..
F"'I'HER'S NAME (F"S1. M<1dle LaSt)
t7d.O :h~~nlh= ot
eolylboro
11_
INfOflMANT'S NAME (T vpelP"nl)
Dale
wayne vogelsong
MOTHER'S NAME ,Filsl M,ddle. Malden Surname)
Burns
HI,
INFORMANT'S MAILING ADDRESS ,Streel, ClryllOwn, Stale. lip Codel
2Ob. 1125 Baish Roa1., Mechanicsburg, pa
PLACE OF DISPOSITION. Nome ot Com.'ory, C,.molory LOCATION. C.lyfTown, 5.0.., ZI{) Code
01 01_ Place
Jennie TJyons
2Goo.
Ml:THOOOF DISPOSITION
8ul1J(X Cr.maloon U Removal "om Sial. U
Oonatton 0 Olhef (Speedy'
210.
SIGNAT
n
oJ.
17055
21cyoungs U.M. Church Ce 21d.
NAME AND ADDRESS Of FACILITY
~. sullivan ~.H.,51
LICENSE NUM8ER
Perry Co. pa
N. ~nola nr.,Bnola,pa
DATE SIGNED
(Monltl. Oav. Veat)
Items 2.,26 mu.' be completed by
~ who pronounc::es death
na.
TIME OF DEATH
24.
27. PART I: E(lter me diseaseS, IOtuOeSQf cocnphcatlOOS wh~h cauSed \he death Do
llS1 only one cause on eacJl tine
730
M 25,
t enter the mode 01 dymg. such as cardiac or respiratory aU8St. shoCk or heart failure
DATE PRONOUNCED DEAD (Montn. Day, Vear)
3~/J'-oo
iequanl,,'1y '''' condrtlOO.
f any, '--ding 10 .mmedl4l.e
~ En'.. UNDERLYING
CAUSE (Otsease or .nllllV
hal ""'.ated evenls
es.Alln9 III <lea\l'l\ lAST
(<ell/At.. c) ELL. C>{NC'i:~
DUE 10 (~~ONSEOUENCE Of)
Cd. L/
DUE TO (OR AS A CONSE~UENCE Of):
W'T I-! /J1ET5
1$.
I ApprOXimate
: int&rVat between
I onset and death
I
:
PART II:
Other signlrK:anl con<fRioI\S contributing to death. but
not 'e,u""'9 In the unde"Y1l19 cause g",.n In PAFIT I
IIIIIIIEDtAT E CAUSE (F ,nal
Jl56aS8 01 conCl11()11
esu/IIn<;I on oeattl)-
DUE 10(00 AS A CONSEOUENCE Of)
NAS AN AUTOPSY
>fRFORMED?
d
WERE AUTOPSY FINDINGS
AVAILABLE PRIOR 10
COMPLETION OF CAUse
OF DEATH?
MANNER OF DEATH
NalUlaJ
~
o
o
DATE OF INJURY
(MonrtJ. Day, ~arl
TIME OF INJURY
INJURY AT WORK?
DESCRIBE HOW INJURY OCCURRED
AccKienl
Pending Invesugallon
o
o
o ~CE OF lNJURY . AI home, tar~,O:;eel, fact""" office
bUlkJing, .Ie ISpocl.....)
30e,
Y.... 0
NoD
Hom~ide
.....0
No
Yes 0
NoD
SuICide
Couki not be del ermined
31b.
llCEN~E NUMBER. DATE SIGNED~on\l'l. !jav, Year)
o J1C.OS ()06!5:S~,<... 31d.3/13/'Zvv-0
NAME AND ADDRESS Of PERSON WHO COMPLETED CAUSE OF DEATH
(IIem27lTypeo'Pfln1r. 1;, C. i/Li., (/VJ t2 0
o 2..0:; ilou,y-E AI/i..
J2. C /?'..-t.1 rC1 1-1, t.. .... f?,<J
DATE FILED (Monlh Day. Year!
'Ia. 28b.
:ERlIFIER \C~ec' oruv onel
.CERTIFYING PHYSICIAN IPhySlC..an cerhfymg cause ~ death whe(l Jf101hef Dt1''''~lClan has ptGnOtJnced death ana compl~lt!-d lletTl 23)
Ta the be.t of my ~now'-doe, d..th occurred due \0 the cauae(s) and mann.,.. I'.ted. .
29.
.PRONOUNCING AND CERTIFYING PHYSICIAN (Ph'fS'Ct.i:ln t)()lt~ >J'J(lout!Clng tJe..Uh dnd t;erlllYlnglo Cdu58 01 uedltl)
To the be-si of my knowledgf!l, death occurred at the time, d.le, i1nd pl.c:e, And due to the c;;~use(.) and manner as stated
'MEDICAL EXAMINER/CORONER
On the buia ot examination and/or Invesligallon, in my opinion, death occurred at the time, date, and place, and due to Ihc couse(a) and
manne'.. S1a1ed., , . . . , . . . . .. ....,........., .......,... ."..,..,..,..,...,............,..'..,..................
110
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REGISTRARS SIGNATURE ANDN.::~BJR
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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
DALE BURNS
1125 BAISH RD
MECHANICSBURG
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
06-05-2001
BURNS
03-11-2000
21 01-0404
CUMBERLAND
101
)~ ~
v/"
C/
REV-1547 E~ AFP (12-00>
JEAN
M
Amount Remitted
PA 17055
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 ~
RE-Y = lS4-j-Ex--AF-P--fi"2=ooY-NoTicE--oF-.ftiHEifiTANCE-TAX-A-PPRAisEMENT~--Ai:.i-oWAiicE-OR----------- - -- - --
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF BURNS JEAN M FILE NO. 21 01-0404 ACN 101 DATE 06-05-2001
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
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
H)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
178.85
585.30
36,047.20
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
HO)
5,413.00
392.94
(11)
(2)
(13)
(14)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
36,811.35
5.805 94
31,005.41
.00
31,005.41
14, IS and/or 16, 17, 18 and 19 will
returns assessed to date.
NOTE: If an assessment was issued previously, lines
reflect figures that include the total of ALL
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
.00 X 00
31,005.41 X 06
.00 X 00
.00 X 15
(9)=
.00
1,860.32
.00
.00
1,860.32
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
04-23-2001 AA496504 60.07- 1,920.39
TOTAL TAX CREDIT 1,860.32
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .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 "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
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RE\l-1500 EX 16-00)
'* COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128.Q601
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REV-1500
INHERITANCE TAX RETURN FILE NUMBER
.::J.L - Ll L
RESIDENT DECEDENT CaUNlYCaDE YEA'
- NUU"!/' 4- i-
SOCIAL SECURITY NUMBER
- /2.
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DECEDENTS NAME (LAST, FIRST, ANO MIDDLE INITIAL)
V vvt .)e <t '" 1'1.
DATE OF DEATH (MM.lJD-YEAR) DATE OF BIRTH (MM.Do.YEAR)
") -,I-~OOO 11-.-17-/'1~2..
(IF APPLICABLE) SURVIVING SPOUSE'S N E (LAST, FIRST, AND MIDDLE INITIAL)
/VA
~ 1. Original Return
D 4. Limited Estate
D 6. Decedent Died Testate (Allad'l copy of WiI)
D 9. Litigation Proceeds Received
2-;'03
THIS RETURN MUST BE FILED IN DUPLICATE WITH TIlE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 2. Supplemental Return
D 4a. Future Interest Compromise (datil of d8llh after 12-1:Z-82)
D 7. Decedent Maintained a Living Trust (Allacll copyofTrusI)
D 10. Spousal Poverty Credit(dalaofdlllllhbatween 12-31-9' and 1.1-95)
D 3. Remainder Return (dale of death prior to 12.13-B2)
o 5. Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Altach Sch 0)
1. Real Estate (Schedule A) (1) 0 ,-
2. Stocks and Bonds (Schedule B) (2) 0
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 0
4. Mortgages & Notes Receivable (Schedule 0) (4) 6
5. Cash, Bank Deposits & Miscellaneous Personal Property (5) Ilr,~S'
z (Schedule E)
0 6. Jointly Owned Property (Schedule F) (6) ,~s-: ;, 0
3 o Separate Billing Requested
::l 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) ,,(,0,+7,2..0
~ (Schedule G or L) I
it
<( 8. Total Gross Assets (total lines 1.7) (8)
U 9. Funeral Expenses & Administrative Costs (Schedule H) (9) S-:'-fI),OO
W
0:: , "39' ).., '} 'f
10. Debts of Decedent, Mortgage Uabllilies, & Liens (Schedule I) (10)
11. Total Deductions (total Unes 9 & 10) (11)
12. Net Value of Estate (Una 8 minus line 11) (12)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been (13)
made (Schedule J)
14. Net Value Subject to Tax (Une 12 minus Une 13) (14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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FIRM NAME (If AppliCable)
TELEPHONE NUMBER
COMPLETE MAILING ADIfESS . I . ^ \
117-.') Dd 1511 red
HI?CJ.lt.,lc.sh V~ Pit (Tosj-
It; ~ II ,)5"'
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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 tineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Une 14 taxable at collateral rate
19. Tax Due
20.0
x.o_ (15)
x .12
(17)
x .15
(18)
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
(19)
Decedent's Complete Address:
STREET ADDRESS
I<t
E;
CITY
STATE
p
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
I b"bO,32...
,
InteresUPenalty if applicable
D.lnterest
E. Penalty
o
o
a
A..oJ<ii> 8""70 = l;',;)
/I 3d @ 'lez. -= ~n. '12...
Total Credits (A+ B + C)
(2)
o
3.
(:,0,07
TotallnteresUPenalty ( D + E )
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
(3)
(4)
(5)
(SA)
-
5.
If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
-
I <s-'.GO, 32.
(.,0.07
I "l )..0" ~ "1
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + SA. This is the BALANCE DUE, (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;.......................................................................................... D
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
c. retain a reversionary interest; or............................................... ................................................................. D
d. receive the promise for life of either payments, benefits or care? ....................... ..................... D
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .......... .......................................................................................... D
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? ............................................................................................. ................. ..........
Under penalties of pe~ury, I declare that I have examined !his return, including accompanying schedules and statements, and to !he best of my knowledge and belief, it ls true, correct
and complete.
Dedaration of preparer other t n the person repre ntative is based on all information of which preparer has any knowledge.
SIGNATURE OF PE
DATE
4-),,7-.-01
ADDRESS 6' ill \ H { . I
/I LS- "l.lsh r<c edt<lYllC5k1VV~
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
(J/\
OOS- S-
DATE
ADDRESS
For dates of death on or after July 1, 1994 and before Janua!)' 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. ~9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)].
The statute does not exemot a transfer to a suNiving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum are still applicable even if
the surviving spouse is the only beneficia!)'.
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(a)(1)].
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(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.
~"'~''''''''''';"'').
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
3' eet"l ()lIvl-1S
FILE NUMBER
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
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
l-t(HlseJto(J ~"oJ5: (J- clvct(~k)
('7 'is, g-S-
TOTA~ (Also enter on line 5, Recapitulation) $ 11~, 6'.s-
(II more space IS needed, Insert additional sheets 01 the same size)
''''''''''''''',;0'''.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTL Y.OWNED PROPERTY
ESTATE OF
y ea.'" 6vv>1~
FILE NUMBER
If an asset was made joint within one year of the decedent s date of death, It must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A.
B.
c.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE Indude name of financial institution and bank account number or sim~ar identif1lng number. DATE OF DEATH DECDS VALUE OF
NUMBER TENANT JOINT Attach deed forjointly-held real estate. VALUE OF ASSET INTEREST DECEDENT S INTEREST
1. A. 1t..u-1'Is, <; tl:VI~ S 6<t.1r k .
Ac..d* I ~OOO.tO <<""01. (c4pckl'j "1",'-/,.>6 .s-eJ 'f'17,2..8'
'"
H-U-V"'5 ~VII1<jS y)J..l{k
Acct- # W6000.6&--6)-(54.v;'t:j ) 11{,,()) :J-O 8' 8',02...
..J
TOTAL (AJso enter on line 6. Recapitulation) $ 5'" 8' '7. 30
(If more space is needed. insert additional sheets of the same size)
'EV""'''''I'"_"II.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
:J elt VI
6VVI15'
FILE NUMBER
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY % OF DECDS
,,,I~~oc INCLUDE THE NAME OFTHE1'lWlSFEREE. THElRfl8..ATlONSHPTOllECEWlTANDTHE OATEOFTRANSFER. DATE OF DEATH INTEREST EXCLUSION TAXABLE VALUE
A".ACH ACOPVOFTHEDEEC FOR REAL ESTATE. '"'' '0 no ...",. ..,
1-
<;e(.vV'dr, F'r":>t GytlV{ 'bOO, 2..0 0 0 ){,o'-/7.z...
Po l~Y No A 01/'-1'1 "fo
10; O-zle.. f3>VV'Y15 (so..)
Ottt~; 0,/!05/00
TOTAL (Also enter on line 7, Recapitulation) $ '~Glolf7 ,)...()
o
(If more space is needed, insert additional sheets of the same size)
· SECURITY
FIRSTGRoup.
-
A ~ Company
DATE: 00/05/05
DALE S BURNS
1125 BAISH ROAD
MECHANICSBURG, PA
1 7 0 5 5
REASON: DEATH CLAIM
COMPANY: SECURITY FIRST LIFE
POLICY NO: A2044940
TICKET NO: Z5470
ANNUITANT: BURNS,
ACCUMULATED VALUE
JEAN M
TERIIINATED,
$ 3 7 , 944 . 4 2
SURRENDER AMOUNT:
INVESTMENT ACCOUNT
SUBTOTAL
TOTAL FEES
TOTAL PENALTY
DUE FROM COMPANY
TAXABLE INCOME
WITHHOLD 'Ii
WITHHOLD AMT
WITHHOLD 'Ii
WITllllOLD AMT
FED
FED
STATE
STATE:
DUE TO PARTICIPANT
DATE INVESTED
CHECK AMOUNT:
* 3 7 , 944 .42
$.37,944.42
$0. 00 ~ If
$ 1 , a 9 7 . 2 2 tol1tdl.C;1 r en a.. . y
$36,047.20 $36,047.20
$2.576.30
o 'Ii
$ 0 . 0 0 $ 0 . 0 0
o 'Ii
$ 0 . 0 0 $ 0 . 0 0
$ 3 6 , 047 .20
o all 5 197
$ 3 6 , 047 .20
EVEN THOUGH YOU HAVE ELECTED NOT TO HAVE FEDERAL INCOME
TAX WITHHELD, YOU ARE REMINDED THAT YOU WILL STILL BE
LIABLE FOR PAYMENT OF FEDERAL INCOME TAX ON THE TAKABLE
PORTION OF ANY PAYMENT. YOU MAY ALSO BE SUBJECT TO TAX
PENALTIES UNDER THE ESTIMATED TAX PAYMENT RULES IF YOUR
WITHHOLDING AND ESTIMATED TAX PAYMENTS ARE NOT
SUFFICIENT.
"oJ
I~"
J1'\
;""''''''''''''''''.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF ____ ,t{
~eLtl1 I..)vVi't5
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. 1l.f13Fi~ -f-1..1I1 E'r<\.. I t 'i 7"3lr'~
1.. I
13 1S"'"'~ ')v-we Jl~~I"C::) ~ >~
~,. 32
4. $/OO,!.tJ p,<tS~v f IOO~
~I{,O~ !tVier-J J I WIer
i: t '-10 c.a.. t I.bO~
~ "'11e. C <lTc/I "t<J
4 cr6 f!.<L
B. ADMINISTRATIVE COSTS:
1. Personal Representative s Commissions
Name of ~rsooa\ R~ntative (s)
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees
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
5. Accountant s Fees
6. Tax Return Preparers Fees
7.
. TOTAL (Also enter on line 9, Recapitula~on) $ ,/U"},OO
(If more spaca is needed, insert additional sheets of the same size)
;EV_"''''''''~"'''.
COMMONWCAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF ...- .A..
..-\e4'" J..JvvVl5
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
FILE NUMBER
Include unreimbursed medical expense..
ITEM
NUMBER
1.
2-
")
'-f
check. /2YJ.
clv-t-..-Je..b;t
el-vi.o )e~;t
c:.-ke.ck /).,'{O
c.Jeck. 12.,+1
o..v1rde bIt
eke c.k I ~'f2..
tlvio -de-bit
DESCRIPTION
st. ~d~'1..s C4'vvc/( offe-C'l'j
~/f AtLt<1'hc
Pf9- L
SVLNh<t1< cJ:J/e
CPO)'" 6dl,~'1 eeJer
PP'l-L
6e I( Ai-Icud-( ~
PfJ't-L
AMOUNT
t 120 , 00
(6,7/
'12.00
/-..{,)
~ 7,.)-1
'12....00
'1 , oj,
7"3,01
,
f.
f
~
"If'
TOTAL (Also enter on line 10, Recapitulation) $ "3 ? ^'. Ii Y
(If more space is needed, insert additional sheets 01 the same size)