HomeMy WebLinkAbout88-0240 PETITION FOR PROBATE n v
a d GRANT OF LETTERS
Estate of Charles E. Clementson No. _ �� - ��-��d
also known as To:
Register of Wills for the
Deceased. County of Ct�mhPrl anr� in the
Socia!Security No. 5 7 7-6 0-6 0 4 8 Commonwealth of Pennsylvania
The petition.n£the undersigned respectfully represents that: a 1 t e rn a t e
Your petitioner(s), who is/� 18 years of age or older an the execut rix named
in the last will of the above decedent, dated November 7 , 19$�_.
���i���
ar es . emen s ,
as renounce in avor o e a erna e, i gi i .
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decedent w�as domiciled at death in Cumberland County, Pennsylvania, with
h is last family or principal residence at_ 6 C� Pmcnn nr;�,P
(list street, number,Twp. or Boro.)
Decedent, thcn 85 years of age, died January 20 , , 19 88
at_ Holv Spirit Hosnital �
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 ow�ned property with estimated values as follows:
(If domiciled in Pa.) All personal property g 1, 0 0 0 . 0 0
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled in Pa.) Personal property in County $
Value of real estate in Pennsylvania $ None
situated as follows:
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters Te s t amen t ary
theron.
(testamentary; administration c.t.a.; administration d.b.n.c.t.a.)
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..� Camp Hill PA 17011
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF Cumberland } ss
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 represen-
tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed � ^ � �p�'�►^—
before me this
28TH day of rglnla rown �
arch 19 88 N a
�
�
'� C. I,E � Register y
;r--A-�, �
1 � — �� — � � � — l(o`l� ��•:'i�,,.�
No. 21 - ss - 24o
Estate of CHARLES E. CLEMEIVTSON , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW March 2 9 , 19 $$ , in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before 19 8 3
IT IS DECREED that the instrument(s) date November 7 ,
described therein be admitted to probate and filed of record as the last will of
Charles E. Clementson �
and Letters Testamentar
are hereby granted to Virginia L. Brown
� ,l
WILL BOOK #106
PAGE 7 5 0 ETC. Register of ls
MARY C. LEWIS
FEES
Probate, Letters, Etc. . . . . . . . . . $ 10. 00 Horace A. Johnson ( 06340 )
Short Certificates(� ) . . . . . . . . . . $ 6 . 0 0 ATTORNEY(Sup. Ct. I.D. No.)
Renunciation . . . . . . . . . . . . . . . . $ 2 ' �� p O Box 10 9 Lemovne , PA 17 0 4 3
X-Pages $ 2 • �� ADDRESS
TOTAL $ 20 . 00 � �1� � �61-4540
Filed . . . M�RCH 2 9 , . 19 8.�. . . . . . . . . . .
YHONE
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r4ailed letters to attorney on 3-29-88 .
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, � �i iZ� �_�isn-�.:r. �l�l�c �,ii��i�i�,il �eiiiti:�.te_ 0.,1( i>�� i�,�r�� ��.' i�� � �ti�°;i ii ��t��� � ,`,�;_ ���. � � � i.�;;� t�i:��
WARN3lP�i�: it o� iilec��i to cia.��9ic���x� ",-��_� -��Y �;e}, ��*������ta� �o� ��a��tcrr�r���r�a-
i �'.r f;�r rl�i� «��-��+ic,�.te, ,���_i)il �,�`��°.'� ��y�-����, �/j �Aw _ �'�
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_ _ �..916 O 1. `:'��� � �'�``�' JAN 2_� �yr,�i
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COMMONWEALTH OF PENNSY�VANIA
DEPARTMENT OF FiEALTH
VITAL RECORDS
CERTIFICATE OF DEATH
(Physician)
STATE FILE NO.
Name of decedent �Fint) (Middle) (Lastl Sez Date of death(Mo.,Oay,Yr.)
i
�. • Charles Edward Clementson ZNlale 3. 1-20-
' Race—le.g.,White,Black, ` Age la:t birth� If under 1 yr. it under 1 day Dad of 6irth,Mo,Day,Yr State o�foreign counvy ot Counry of birth City,Boro,or 7wp.of birth
Ame�� In �an,etc.l day Mos. Dsys Hou�s Min, birt
a. �i�e 5A. 85 se. � sc. � sn. 6-17-02 68.�iashington �,C. 6p.
ICounty ol death City,Boro,or Twp.of de�th Hosoital or Institutiun(If not eithzr,g�ve addressl If hosp.or inst.indicate DOA,
Cumberland East Pennsboro HO1. $ lY�l't HOS 1't31 OP/ER,o� inpatient(specify)
�n. �e. �c. Y P P �o.
DecedenYs Maihng Addresi(Street or RFD o.l (City or Town) (State) IZip Codel Mantai Status Surviving Spouse(lf wite,qive msiden name)
e. 6 Clemson Drive Camp Iiill Pa. 17011 sWidowed ,o.
Citizen ot what country7 Was decedent ever in U.S.Armed Forces? Social Sacuriry Number Usual OccupaGon(Kind of work done durmg most Kind ol businest or indus[ry
ot workmg hfe)
�� USA 1z ❑�es No 13 577-60-6048 „A Clerk 148U.S. Government
Where did �(�.State Pa. Did decedent live 15c.� Ves,decedent Gved in Lower Allen township.
decedent
xwally tive? 75b.Cou�ty Cumberland m a township� 15tl.❑ No,decedent lived wlthin aaual hmits ot city or boro.
15.
Father's name (Pirst) (Middlel (Last) Mother's maiden name (First) (Middle) 1Last)
16 John E. Clementson ,, Daisey Bosworth
Info�mam's name IType or Printl loformant'r (Streat or Rf D No.l (City or Townl (Statel (Z�D�de�
Mailing address
,eAMrs. Virginia Brown ,ea. 6 Clemson Drive Camp Hill Pa. 17011
�Buria� �flemoval Date of burial,etc. Name ot cemetery or crematory Location (City,boro,twp.) (State)
19A. DGemation �pcher �ss. 1-23-$g iec. Mt. Olivet Cemetery ieo. Washington D.C.
5lgpaeut!'o luner�l Airec r and icense nu Nart,e and address of funeral establishment
Fo-r���-a Myers-Hall Funeral Home Inc.
20A.
1 Registr s S nature � Date recfe ved by re strar 190 3 Market Street
� z���� � �� � . � � 2�e�/�V��� Z e�p Hill, Pa. 17011
To the betl ot my knowledge,deat aured at the time,date and place and due lo
� m �he wuselsl stated,
� M.0.
��� Signature �� ��7 `'� or
�. E�c 22A.and�Ne Wn.+.. �.�QL,(!'l.'.L1�1 �-'� L D.O. .
c O �te S�gned(Mo..DaY.Yr.l of �
� ��� Death --7 A.M�
m" 4�8. I"2��(r`) 22C. I'�S P.M. �S T
°� Name and Add�ess ol Ceru6er(Phys�cian,Mediwl Examiner or Coroner)(Print or Typel n Name ot Attending Physician
~sa. W.�. Su�1�v z.� MO 3 0 2 F5 �-(Ov�\C e.� SI • C�••� �"�'�� i l/? . I�G'1 ( zs. S T2.,.�C c �1,�C'_T�.�P!�- •-
26. IMMEDIATE CAUSE: Enter only one cause r Ime lor(AI(B)and(C) Interval between onset�nd death
L 1
IA1 `�Yi��II�SCQ�IOnf �Maeo�rs��,la� ��(fs�°CLaY - � Z"3V�nOS.
Due to,or as a consequence ol-. �Interval between onset and death
PART �
I lel
Due to,or as a consequence of�. Interval between onset and death
1
I
Ic�
PART�� Other Signifiwn�Conditions—Conditions contribu�ing to death but not ielated to cause given m Part I(a) Autopsy Was ate referred to Medial Ex
�Yes �miner or Coronert
C.�ti?�PGI r/� ." 1"`��Z/� �--���"� 27. �No 28. ❑Yes �No
If Act.,$uicide,Nom..Uodet.a Uate ot Injury(Mo.,O�y,Yr.� Hour of Gescribe how injury occuned�.
Pend�ng Investigauon(Specity) Injury A.M.
29A. 498. Y9C. P.M. 29D. ' .
n�ury at work Place o( njury At home,tarm,street,etc. l.ocation Sireet or RFD No.) City,Boro,or Twp.l IStatel �
oN„ n Y.,
19E. 19f. 79G.
!
1
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;
���x �i11 �tn� ���t�m�nx
I, CHARLES E. CLEMENTSON, of Lower Allen Township, Cumberland County,
Pennsylvania, make, publish and declare this to be my Last Will and Testament, hereby
revoking and making void any and all former Wills by me at any time heretofore made.
ARTICLE I
I direct the payment of my just debts and funeral expenses as soon after my
death as may be convenient to my Executor hereinafter named.
ARTICLE II
I give, devise and bequeath all the rest, residue and remainder of my estate in
equal shares to my children, CHARLES L. CLEMENTSON, VIRGINIA L. BROWN,
HELEN F. HICKS, JOAN E. NICHOLS and LOIS M. STAf�NTON.
ARTICLE III
I direct that my executor and his successor shall not be required to give bond
for the faithful performance of their duties in any jurisdiction.
ARTICLE IY
I nominate and appoint my son, CHARLES L. CLEMENTSON, to be Executor of
this, my Last Will and Testament. In the event that CHARLES L. CLEMENTSON is
unable or unwilling to act in this capacity, I nominate and appoint my daughter,
VIRGINIA L. BROWN, to act in this capacity.
F���.;��
1 �
I�I IN WITNESS WHEREOF, I have hereunto set my hand and seal this ��day of
�; November, 1983.
i
� ��,�.�.� �
� (SEAL)
!, Charles E. Clementson
i
i
Signed, sealed, published and declared by the above named Testator as and for
� his Last Will and Testament in the presence of us, who, at his request, in his presence
I' and in the presence of each other have hereunto ibed o names as witnesses. ;
II �
, �
I �----_
il
-2-
,. �_�_;,..
21 - 88 - 240
REGISTER OF WILLS OF CUMBERLAND COUNTY
OATH OF SUBSCRIBING WITNESS
Jerry R. Duffie and Horace A. Johnson
,
g�x
(each) a subscribing witness to the will presented herewith, (each) being duly qualified according to
law, depose(s) and say(s) that they were present and saw
C'harl P� F C'1 PmPnt�nn �
the testat °r , sign the same and that they signed as a witness at the
request of testat �r in h?S presence and (in the presence of each other) (in the presence of the
other subscribing witness(es)). �
Sworn to or affirmed and subscribed before
Jer u ie
me this 2 8TH day of (Name)
March lq 8 P. O. Box 9 , Lemo ne, PA 17043
(Address
RY C. W I S Register
or ce . o nson
(Name)
P. . Box 109 Lemo ne PA 17043
(Address)
REGISTER OF WILLS OF COUNTY
OATH OF NON-SUBSCRIBING WITNESS
r�,
f
(each) a subscriber hereto, (each) being duly qualified according to_.l��v,f depose(s) and say(s) that
_, .
-.
familiar with the signature of ' ,
' codicil
testat of (one of the,.subscribing witnesses to) the will presented herewith and
codicil
that believes the signature on the will is in the handwriting of
..:�
'�.
to the best of �-�Cnowledge and belief.
Sworn to or affirm�d`and subscribed before
me this day of m2)
19
(Address)
, Register
(Name)
(Address)
. ,:�--'.�
w . ;�
21 — 88 — 240
RENUNCIATION
In Re Estate of��lat���.5 � ��-°mP��� deceased.
To the Register of Wills of �v m 6�.r�Qcn� County, Pennsylvania.
The undersigned �.��� e'�G�Y �^-� SoN of
the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters
�
be issued to V � W/J •
WITNESS � hand this a 7�day of �n , 19 � .
<�� �
(Signature)
(Address)
(Signature)
(Address)
(Signature)
(Address)
Register _of Wills Office FROM
To JOHNSON, DUFFIE, STEWART & WEIDNER
Cumberland County Court House
Attorneys at Law
Carlisle, _PA 17013 . _ _ P.O. Box 109
_ _ LEMOYNE, PA 17043
SUBJECT: Estate of_ Cha�'�es E. Clementson
FOLD � Estate No. 21-88-240 _ DATE: 4/18/88
Date _of pea�kh:_ January 20, 1988
- Enclosed_. i_s a__check in__the_ amount of $2 , 300 . 00 as a payment
on _account of.. �r�heritance Tax for the above-captioned Estate
to allow for the 5% discount . _
.
PLEASE REPLY TO ��► SIGNED _
Horace A. Johnson csh
REPLY
_ ,, . _.,
__ _ :�_ �,
,_ -. T�
_ _ _ . �
_ _ _.
__ _�.
_ _.
__
_ _.
__ _ _
DATE: SIGNED _ _
Item�F270 Grayarc,P.O.Box 2944,Hartford,CT 06 104-2944
��Wheeler Group,Inc.,1982
t�'�`-�.�� G�F'�4E �"C.��'Ft t^�F13€.P�C4!�FiF.f�'k���.`e'.'F��'Ef
___�_.�_____�___�----�--�.
�;No. �,'�►����� ' C�11Il1Vi"t�[+I�IIk/�1�L"t`�'I t'�� P�1��f5YLVAN�A �:
t?�PAR�`M�lrkT C�E�EY�NtlE
Rev:,,tr3 ex��3,se� C�F�ICtAL REi��t�+'�'+r P��t[+t�YLY�RNIA liktH��lTANCE AND�STAT�TA�L t � �.
�� :
RECEIVED FROM: �7�„r�j�ya �+ �x,�� ACN �
� ASSESSMENT
CONTROL � AMOUNT
NUMBER
Haratc� A. Johnson, E�q.
p. O, Br�x 109 �Q� �230d.00
]Le,maYnt+., PA 17043
- FOLD HERE
ESTATE INFORMATION: Fo�o neae_
� FILE NUMBER
21--68-2�0
� NAME OF DECEDENT (LAST)
(FIRST) (MI)
C.lementson Chaxl�s F-
� DA7E OF PAYMENT
� POSTMARK DATE� ��1 `�"g �'��8
COUNTY A r�"�' '1'8 Zg�$
DATE OF DEATH G ��' d
7
REMARKS � TOTAL AMOUNT PAID _$��OQ,OO
SEAL
RECEIVED BY ° r �
—�SIGNATURE
_�� �— � � � � � r � � REGISTER OF WILLS -
._._.--�---..-_.,.,__._, ..,...�._.._�.:,_
�Mo. ������� �C�?1U11Vlt��tW�ALr�i o� PEt�1'�1�Y�,V�►I�IA �`
, �!�PARTMENT f��REV�I+MUE ' �.� �
REY.;,�2��{��.g�, o���c��►r;��c�t�r +� r��Ns�riv����t�t�H���ra�c�aNn'�sr�►r�rax
� ACN
RECEIVED FROM: v j�g�ri�� �y Bx„�� ASSESSMENT �
CONTROL ' AMOUNT
NUMBER
Haxace A. John�c�n, Esq. 1.0� S��$ '�`�
P> +�. Box l�?9
L�rnoyn�, PA 1_70�3
- FO(D HERE
FOLD HERE
ESTATE INFORMATION:
� FILE NUMBER
21-88-240
� NAME OF DECEDENT (LAST) (FIRST)
(MI)
CZemsn��on �hr�rZes E.
aDATE OF PAYMENT
Ma 6 1.98g
� POSTMARK DATE
Ma � �.s�a
COUNTY
CLxFtI Ax"�. X1C3
JATE OF DEATH
REMARKS
�$� j �� ��� ���8 � TOTAL AMOUNT PAID ���S.95
SEAL
f
RECEIVED BY �
f
�.. � �;:r,.,�,j
' SIG ATU i
REGISTER OF WILLS "
FROM
Register of Wills Office _
To JOHNSON, DUFFIE, STEWART & WEIDNER
Cumberland _County Court House _ Attorneys at Law
P.O. Box 109
Carlisle, PA 170_l3 LEMOYNE, PA 17043
SUBJECT: �st�te qf Charles, E. Clementson 21-88-240 DATE: 5/5/88
FOLD �
_
_ __ _ _ _.
_ En�losed for filing in the above-captioned Estate are the
following: _ __
_ ,1. Qriginal Inventory.
2 . Original and copy of Inheritance Tax Return.
-_ _ 3, Ck�e�k _in the amount_ of $15 . 00 , filin� costs .
4 . Check in the amount of $148. 95 , balance of Inheritance
__ _ Ta�, _ _ _ _
_
_ __ __
PLEASE REPLY TO --� SIGNED Horace A. Johnson csh
REPLY ._
_. _
_. _ _. __ __ .
__ _ _
_.
,_, .
_ _ _ _;- c� z,
_ _ . _ _ _ _ _ � :�.� =`j :,,�
_ �,
_ _. _._ _
DATE: SIGNED _
Item�F270 Grayarc,P.O.Box 2944,Hartford,CT 06 104-2944
�Wheeler Group,Inc.,1982
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REV-1500 EX+ (z-a�) �FILE NUMBER
`�' INHERITANCE TAX RETURN
��.�-� RESIDENT DECEDENT
COMMONWEALTH OF PENNSYLVANIA (TO BE FILED IN DUPLICATE
. DEPARTMENT OF REVENUE
POSTOFFICEBOX8327 WITH REGISTER OF WILLS) 21 88 240
_ HARRISBURG,PA 17105-8327 COUNTY CODE YEAR NUMBER
� DECEDENT'S NAME(LAST,FIRST,AND MIDDLE INITIAL) DECEDENT'S COMPLETE ADDRE55
o CLEMENTSON, CHARLES E.
6 Clemson Drive
V SOCIAL SECURITY NUMBER DATE OF DEATH DATE OF BIRTH Camp H111, PA 17 O 11
0 577-60-6048 1/20/88 6/17/02 ca��}y CUMBERLAND
� � l. Original Return ❑ 2. $u lemental Return
Q PP ❑ 3. Remainder Refurn
WaV� (for dates of death prior to 12-13-82)
❑ 4. Limited Estate ❑ 4a. Future Inferest Compromise ❑ 5. Federal Estate Tax
v�m (for dates of death after 12-12-82) Return Required
a � 6. Decedent Died Testate ❑ 7. Decedent Maintained a Living Trust _8. Total Number of Safe Deposit Boxes
a (Attach copy of Will) (Attach copy of Trust)
ALI,�CJ ES�P�3lI'�f?�1�C��N�CC�1l�1F1�3�NTIJ��.'fl��ti il�t�4lilR�k�!'!'LGI�l�.'Si�t�1�1�Bk��i�'�i.`T�I�iTCI�
NZ NAME COMPLETE MAILING ADDRESS
W W Horace A. Johnson �
� Z Johnson, Duffie, Stewart & Weidner Third & Market Sts .
O 0 TELEPHONE NUMBER
� a P. O. Box 109
717 761-4540 Lemoyne, PA 17043
1. Real Estate ($chedule A) ( �)
2. Stocks and Bonds (Schedule B) ( 2) _ _
3. Closely Held $tock/Partnership Interest (Schedule C) ( 3)
4. Morigages and Notes Receivable ($chedule D) ( 4)
5. Cash, Bank Deposits&Miscellaneous Personal Property( 5) $6 .2 5
� (Schedule E)
Q 6. Jointly Owned Property (Schedule F) ( b) 51, 6 8 6 . 6 3
F 7. Transfers (Schedule G) (Schedule L) ( 7)
a 8. Total Gross Assets (total lines 1-7) l' 5]t�7']2 , �$
a ( $�-t,�
W 9. Funeral Expenses, Administrative Costs, Miscellaneous ( 9) 7 , 9 6 7 . 17 � "�
� Expenses (Schedule H) -- � _-
10. Debts, Mortgage Liabilities, Liens (Schedule I) (10) 972 . 33
1 1. Total Deductions (fotal lines 9 & 10) (��� 8�""�9 3 9 . 5�
12. Net Value of Estate (line 8 minus line 11) (12) 42 ,_833 . 3$
13. Charitable and Governmental Bequests (Schedule J) (13) -�-
14. Net Value $ubject to Tax (line 12 minus line 13) (14) 42 , 833 . 38
15. Ar�ount of line 14 taxable at 6% rate (�$) 4 2 , 8 3 3 . 3 8 x .06 = 2 . 5 7� . 0 0
(Include values from Schedule K or Schedule M.)
16. Amount of line 14 taxable at 15% rate (16) x .15 = -�-
Z (Include values from $chedule K or Schedule M.)
� 17. Principal tax due(Add tax from line 15 and from line 16.) (��) 2 , 5 7� . ��
�
? 18. Credits Prior Payments Discount Interest
a 2 , 300 . 00 + 121.05 _ 2 421.05
� (�s� ,
O 19. If line 18 is greater ihan line 17, enter the difference on line 19. This is the OVERPAYMENT. (19)
X �o
� 20. If line 17 is greater than line 18, e�ter the difference on line 20•This•is the TAX DUE. (20) 48 5
A.Enter the interest on the balance due on line 20A. (20A) -�-
B. Enter the total of line 20 and 20A on line 20B. This is the BALANCE DUE. (20B) 148 . 95
Make Check Payable to: Register of Wills, Agent
'' �rt���StiR�'�Q,�NSW���LL c�U��'t'1€�t+t�t�t�i'i�i�l�t+t����bL`AN1�"�� ItE�F1�Ct�i�tl�'t`��t�iw '
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. I declare that all real estate has been reported at true market value. DeclaraTion of preparer other than the personal representative is
based on all information of which preparer has any knowledge.
SIGA¢4ytiRE OF.P�RSON f�ESPONSIeL�NOR FILIN�RETURN ADDRESS emson rive DATE
/ °� '"��� '��- - Camp Hill, PA 17011 �S''��
SIG RER T H N RE RESENTATIVE ADDRE55 DATE
i orac . o nson
c�S ��
REV•i5U8ES+ �2. " I SC1�EDldLE E I
X`,t.
��� CASH, BANK DEQOSITS APVD
COMMONWEALTH OF PENNSYIVANIA MISCELLANEOUS
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT i I Please Print Of Type
ESTATE OF FILE NUMBER
CLEMENTSOIV, CHARLES E. 21-88-240
(All property jointlyowned with the Right of Sur�ivorship must be disclosed on Schedule F)
ITEM DE9CRIPTION VALUE AT
NUMBER DATE OF DEATH
l. Pennsylvania Blue Shield - reimbursement 86 . 25
Probate Assets - Listed to Claim the
Family Exemption
Prudential Insurance Company
Policy No. 25 444 443
Insured: Charles E. Clementson
Beneficiary: Lucille M. Clementson
Deceased 3/13/81
Proceeds paid to Estate of Charles E.
Clementson - $ 524 . 84 -0-
Metropolitan Life Insurance Co.
Policy No. 523 609 579
Insured: Charles E. Clementson
Beneficiary: Lucille M. Clementson
Deceased 3/13/81
Proceeds paid to Estate of
Charles E. Clementson - $1, 359 . 36 -0-
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TOTAL (Also enter on line 5, Recapitulation) $ 86 . 25
(Attach additional 8%:" x 11" sheets if more space is needed.)
, REV-1509 EX+ (3-86)
COMMONWEALTHOFPENNSVLVANIA SCHEDULE F
INHERITANCETAXRETURN �OINTLY-OWNED PROPERTY
RESIDENT DECEDEN?
ESTATE OF FILE NUMBER
CLEMENTSON, CHARLES E. 21-88-240
Joint tenant(s):
--- — --- ----
-- ----------
-----------... ___----_- _ _
ME ADDRESS RELATIONSHIP TO DECEDENT
A. Virginia L. Brown 6 Clemson Drive
Camp Hill, PA 17011 Daughter
e. Helen F. Hicks 8904 Jandell Road
Lorton, Virginia 22079 Daughter
C.
Jointly-owned property: —
LETTER -
ITEM FOR DATE TOTAL VALUE DECD'S DOLLAR VALUE OF
NUMBE �OINT MADE DESCRlPTION OP PROPERTY
TENANT �OINT OF ASSET % INT. DECEDENT'S INTEREST
�, A 11/23/ Dauphin Deposit Bank - -
81 & Trust
Checking Acct . No.
23-07-8030 31, 593 .88 500 15 , 796 . 94
2 . A 9/27/ Dauphin Deposit Bank &
83 Trust
Money Market Account
No. 94-20-9758 55 , 449 . 99 500 27 , 724 . 99
3 . B 8/7/84 American Security Bank
Washington, D.C.
Account No.
23-980-74-610 16 , 329 . 39 500 8 , 164 . 70
TOTAL (Also enter on line b, Recapitulation) $ 51, 6 8 6 . 6 3
(If more space is needed insert addifional sheets of same size)
REV-751!E%+�8�86)
�,.;; � �C����L� �"�
"•���,� FUNERAL EXPENSES,
COMMONWEALTH Of PENNSYLVAIVIA ADMINISTRATIVE COSTS AND
INHERITANCE TAX RETURN MISCELLANEOUS EXPENSES Please Print or Type
RESIDENT DECEDENT
ESTAi'E OF FILE NUMBER
CLEMENTSON, CHARLES E. 21-88-240
ITEM D�SCRIPTION
NUMBER AMOUNT
A. Funeral Expenses:
1. De Vol Funeral Home — funeral expenses
(Washington, D.C. ) 3 , 701. 72
2 . Mount Olivet Cemetery - interment charges
(Washington, D.C. ) 460. 00
B. Administrative Costs:
1. Personal Representative Commissions ,
Social Security Number of Personal Representative:
Year Commissions paid
2. Attorney Fees — Johnson, Duffie, Stewart & Weidner 1, 800 . 00
3. Family Exemption
Claimant Virginia L. BrownRelationship _ Dau�hter 1 970 . 45
,
Address of Claimant at decedent's death
Street Address _ 6 Clemson Dr�v
City Cam� H i 1 1 State �_ Zip Code 1 7(l 1 1
4. Probote Fees - Register' of Wills - Cumberland County 20 . 00
C. Miscellaneaus Expenses:
1. Register of Wills - file Inventory & Inheritance
Tax Return 15 . 00
i
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i
TOTAL (Also enter on line 9, Recapitulation) I S 7 , 9 6 7 . 17
- i
(If more space is needed, insert additional sheets of same size)
REV-1i12 EX+�I0�86) �
�;� ;� SCHEDUIE I
DEBTS OF DECEDEiVT,
COMMONWEAITHOFGENNSVLVANIA MORTGAGE LIABLITIES /�ND LIENS
INHERITANCE TA%kETURN
RESIDENT DECEDEN7
ESTATE OF FILE NUMBER
CLEMENTSON, CHARLES E. 21-88-240
ITEM DESCRI PTION
NUMBER AMOUNT
�� Blue Ridge Haven West - balance -
decedent ' s account 150 . 54
2 . William A. Sullivan, M.D. - balance -
decedent ' s account 18 . 00
3 . Holy Spirit Hospital - balance - decedent ' s
account � 51. 59
4 . Kunkel Surgical Group - balance - decedent ' s
account 37 . 20
5 . Community Physicians , Inc. - balance -
decedent ' s account 37 .00
6 . Home Health Aide - balance - decedent ' s account 360 . 00
7 . H & R B�ock - preparation of decedent ' s 1987
income tax returns 51. 00
8 . Internal Revenue Service - tax due - decedent ' s
1987 federal income tax return 267 . 00
TOTAL (Also enter on line 10, Recapitulation) $ 9 7 2 . 3 3
, (If more space is needed insert addifional sheets of same size)
iEV.�517 E%a�2.E71 I I
���`�'�• 5�}�iEDULE J
'';�� �
COMMONWEAIiM OF VENNSYlVAN1A B E�l E Fi C lAR!ES
INMERITANCE TAX RETURN
RESIDENi OECFDENT
E57ATE OF FiLE NUMBER
CLEMENTSON, CHARLES E. 21-88-240
ITEM NAME AND ADORE55 OF BEtVEFiC1ARY RELATIONSHIP I AMOUNT OR
hUMBER SHARE OF E57ATE
A. Taxable Bequests:
�' Virginia L. Brown Daughter One-fifth
6 Clemson Drive
Camp Hill, PA 17011 i
�
2 . Helen F. Hicks Daughter i One-fifth
8904 Jandell Road
Lorton, Virginia 22079 i
3 . Lois M. Stanton Daughter One-Fifth
406 Skylark Boulevard .
Satellite Beach, Florida 32937
4 . Joan E. Nichols - 456 Joetta Drive Daughter One-fifth
Elkridge, Maryland 21227
5 . Charles L. Clementson Son One-fifth
4623 Butterworth Place NW
Washington, D.C. 20016
ITEM NAME AND ADDRE55 OF BENEFIClARY I AMOUNT OR
NUMBER I SHARE OF ESTATE
B. Charitable and Governmental Bequests: I
1.
�
TOTAL CHARITABLE AND GOVERNMENTAL BEC�UESTS (Also enter on line 13, Recapitulation) S
(If more space is needed, insert additionol sheets of same size)
inventory oT rhe reai ana oarsonai esiate oi
CHARLES E. CLEMENTSON deceased.
l. Prudential Insurance Company �
Policy No. 25 444 443
Insured: Charles E. Clementson
Beneficiary: Lucille M. Clementson, deceased 3/13/81
Proceeds paid to Estate of 524 84
Charles E. Clementson -
I� � �
2 . Metropolitan Life Insurance Co. �I
Policy No. 523 609 579 j! �
Insured: Charles E. Clementson I� {
Beneficiar�: Lucille M. Clementson, deceased - 3/13/81 � �
Proceeds paid to Estate of � �
Charles F. Clementson � 1, 359 j36
�� i
3 . :�ennsylvania Blue Shield - reimbursement �� 86 25
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TOTAL ij1, 970 � 45
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��MMONWEALTN CF PENNSYLYANIA ,
ss:
C^.l1NTY CF CUMSERLAND �
VIRGINIA L. BROWN
'�eing duly sworn according to law, deposes and says 4ha�s he is ExeCutz'ix ,
of the Estate or' Charles . E. Clementson
�ate oi Lower' Allen Township , Cumberland Counfy, Pa., deceased and that the
�«iThin is an inventory made by Vi r�j nia T,. grown _ , the said Executrix
ot the entire estare oT said decedent, consizting of al( the personal proparty and real eztafe, exceot real estate ouiside
�he Commonwealth or' Pennsylvania, and that the figures opposi�e each item af the Inventory represent i�'s fair va(ue
as of the date oi decedent's death.
Swoz'n to and subscrioed before me, -
�
_ � ,� _ �-c�,� �-�.�,
� J� 19 8 8 �e+e�x�����
Vi.rginia L. Brown, EYecutrix
� • 6 Clemson Drive
�,«�-Y�-'— — 'ti��`—° Camp Hill, PA 17011
DINNNE LENIG, Notar�t b1ic t
My Coamisslon Expires Dec. 21. 198
'Lemoyoe. PA Cumberland County ^ddr.s:
Date or Death 20th Januarv �988
Day Month Year
INSTRUCTlONS
f. An invenio�y must be fiied wiThin three monrhs arter appoinrment oT personal representative.
�. A suop(ement invenrory must be filed within thirty days or discovery ar additional assets.
3. Additional sheers may be aftacned a5 to persona(ty or realty
4. See Articfe IY, Fiduciaries Ac'r of 1949.
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REV-7��7 EX (12-87) �
COMMONWEALTH oF PeNNsv�va.nin � � +�� � NOTICE OF INHERITANCE TAX ACN 101
DEPARTMENT oF REVENUE APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
BUREAU oF INDIVIDUAL TAXES 1 � pF DEDUCTIONS, AND ASSESSMENT OF TAX
P.O. BOX 8327
HARRISBURG, PA 17105-6327 DATE 07-05-88
ESTATE OF CLEMENTSON CHARLES E FILE N0. 21 88-0240
DATE OF DEATH 01-20-88 COUNTY CUMBERLAND
NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS. MAKE CHECK PAYABLE TO "REGISTER OF WILLS, AGENT".
REMIT PAYMENT TO:
HORACE A JOANSON REGISTER OF WILLS
3RD & MARKET STS CUMBERLAND CO COURT HOUSE
PO BOX 109 CARLISLE, PA 17013
LEMOYNE PA 17043 Amount Remitted --j
CUT ALONG THIS LINE y RETAIN LOWER PORTION FOR YOUR RECORDS � _ _ _ _ _ _ _ _ _ _ _ _ _ _
- - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
R�\�-?547 EX. (12-87)
NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF CLEMENTSON CHARLES E FILE N0.21 88-0240 ACN 101 DATE 07-05-88
TAX RETURN WAS: ( ) ACCEPTED AS FILED (X ) CHANGED - SEE AT�ACHED �I�FOTICE':-�-i
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE -
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN � �- .
1. Real Estate (Schedule A) ( 1) .00 __
2. Stocks and Bonds (Schedule B) ( 2) .00
3. Closely Held Stock/Partnership Interest (Schedule C) ( 3) .0�
4. Mortgages/Notes Receivabie (Schedule D) ( 4) .00
5. CashlBank Deposits/Misc. Personal Property (Schedule E) ( 5? 86.25
6. Jointly Gwned Property (Schedu�e F) ( 6) 51,686.63
7. Transters (Schedule G) ( 7) .00
8. Total Assets ( 8f 51,772.88
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Administrative Costs/Miscellaneous � g) 6,082.97
Expenses (Schedule M
10. Debts/Mortgage Liabilities/Liens tSchedule I) (10� 972.33
1 1. Total Deductions (1 1) 7,055.30
12. Net Value of Tax Return (12? 44,717.58
13. Charitable/Governmental Bequests f5chedule J) ��3� ----- '�� -
14. Net Value of Estate Subject to Tax S t 4) 44,717.58
NOTE: If an assessment was issued previously, tines 14, 15 and/or 16 and 17 wi11
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of line 14 taxable at 6°10 rate (15) 44,717.58 X.06= 2,683.05
16. Amou�t of line 14 taxable at 15% rate (16) .00 X.15= .00
17. Principal Tax Due (17} 2,683.05
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST (-)
04-18-88 365465 121.05 2,300.00
05-05-88 365530 .00 148.95
PAYMENT MUST BE MADE BY 10-20-88z. TOTAL TAX CREDIT 2 570.0
BALANCE OF TAX DUE 113.05
INTEREST .00
* IF PAID AFTER THIS DATE SEE REVERSE FOR CALCULATION TOTAL DUE 113.05
OF ADDITIONAL INTEREST
(IF BALANCE DUE IS LESS THAN S 1 OR IS REFLECTED AS A "CREDIT" (CR), NO PAYMENT IS REQUIRED)
�.. .: . ..... . . , . -.. . . . � . .�...._�--•p.: v_.... . . .
. REV-1470 EX (2-86)
CQMMONWEALTH OF PENNSYLVANIA
DEPAR'T�,�IENT OF REVENUE INHERITANCE TAX
BUREAU OF INDIVIDUAL TAXES
P. O. BOX 8327 EXPLANATIOAI OF CHANGES
HARRISBURG, PA 17105-8327
DECEDENT'S NAME Charles �. Cleme�tson FILE NO. 21—$�—t�240
ACN 101
ITEM
SCHEDULE NO. EXPLANATION OF CHANGES
, �? B-3 Reduced ta 5�6.25, Family exeraption can only be clai�aed a�ains� taxable
probate assets.
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��* Paul Feeney PAGE
TAX EXAMINER:
- - '--'— ... `+--� :.�w-.�..a�.- ..•..�.*h+.-..-i*, � ..s w..-'--..'s_.�_-L-�.._->..�. ��._--..,..__,.
ONo. �,���'�►�� CClMMt'�1�(WEAL�'H OF PENhl�YL1/ANIA �.
t��PARTMENT CMF REVEI+IWE ''� � �
aev.�3a�ex��i.sn� Q���ICIA!RECEIP�' +1t PENN�Yl.VANlA IhIHEBlTANCI�I�.N��STAl'E 7AX` �
� ACN -- —
RECEIVED FROM: v��,g�n�� �o ���� ASSESSMENT �
CONTROL ' AMOUNT
NUMBER
H��ace A, �7a�nson, Es�, 0� �� 3 � �� --
T'. rJ. Bo� 1.�f9
z•�m�y'��, P� 17 t34 3
— FOID HERE
FOID HERt
ESTATE INFORMATION� I
� FILE NUMBER
� NAME OF DECEDENT (LAST) (FIRST) (M1)
� DATE OF PAYMENT —
� POSTMARK DATE
COUNTY
DATE OF DEATH
��rit1797"�s �Q�—�(���
REMARKS � TOTAL AMOUNT PAID __��.�.�.�T�
SEAL � �;,r j f
RECEIVED BY �,���/ '� t � . � . ,� � . -C.��
S NATURE �'
REGISI`ER OF WILLS �
s ,
REV-1547 EX (12-87) �\
COMMONWEALTH OF PENNSYLVANIA ��� d �
DEPARTMENT Of REVENUE �` I'il NOTICE OF INHERITANCE TAX ACN ZO1
BUREAU oF INDIVIDUAL rnxes �'� ..-�'-� APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
P.O. BOX esz� OF DEDUCTIONS, AND ASSESSMENT OF TAX
HARRISBURG, PA 17705-8327 G.;-�i-•r;�, � DATE O�—OrJ—BH
ESTATE OF CLEMENTSON CHARLES �� .: ' FILE N0. 21 88-0240
DATE OF DEATH O1-20-88 COUNTY CUMBERLAND
NOTE: TO INSURE PROPER CREDIT TO YOU�t�ACCO�1��'IT„ $UBMI,T THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX
' PAYMENT TO THE REGISTER OF WILL9'. M�lKE !G�HECK' PAYABLE TO "REGISTER OF WILLS, AGEidT".
REMIT PAYMENT TO:
C i_
HORACE A JOHNSON �- � - REGISTER OF WILLS
3RD & MARKET STS CUMBERLAND CO COURT HOUSE
PO BOX 109 CARLISLE, PA 17013
LEMOYNE PA 17043 Amount Remitted
/ � �_
CUT ALONG THIS LINE "' RETAIN LOWER PORTION FOR YOUR RECORDS "�
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REV-1607 EX (12-87) �'^�
COMMONWEALTH OF PENNSVLVANIA _ �y���� ACN 101
DEPARTMENT OF REVENUE �! INHERITANCE TAX
BUREAU oF INDIVIDUAL Taxes L� STATEMENT OF ACCOUNT
P.O. BOX esz� ' DATE
HARRISBURG, PA 77105-6327 08-O8-HH
ESTATE OF CLEMENTSON CHARLES E FILE N0. 21 88-0240
COUNTY CUMBERLAND
DATE OF DEATH 01-20-88
NOTE� TO THEUADDRESSESHOWN FT MAKE�CHECKCPAYABLEUANDTREMITUPAYMEN�RTO N OF THIS FORM WITH YOUR TAX PAYMENT
r
HORACE A JOHNSON REGISTER OF WILLS
3RD & MARKET STS CUMSERLAND CO COURT HOUSE
PO BOX 109 CARLISLE, PA 17013
LEM�YNE PA 17043 Amount Remitted
CUT ALONG THIS LINE _ _ _ �"_ _ _ RETAIN LOWER PORTION FOR YOUR_FILES _ _ _ _ '� _ _ _ _ _ _ _ _ _ _ _
REV-1607 EX (12-87) ** INHERITANCE TAX STATEMENT OF ACCOUNT **
ES7ATE OF CLEMENTSON CHARLES E FILE N0. 21 88-0240
ACN 101 DATE08-08-88
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN
BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, THE APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND,
IF APPLICABLE, A PROJECTED INTEREST FIGURE.
CATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 06-27-88
PRINCIPAL TAX DUE:..................................................................................................................
.................................
2,683.05
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
I DATE NUMBER INTEREST (-) ,-, T
04-18-88 365465 121.05 2,300.00 � �=r?
.00 148.95 _
05-05-88 365530 113.05
07-16-88 4�1766 .00 ='=; :
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TOTAL 7AX CREDITS 2,6$3.05
BALANCE OF TAX DUE .00
INTEREST .00
TOTAL DUE .00
� IF PAID AFTER THIS DATE SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST
(IF BALANCE DUE IS LESS THAN $1 OR IS REFLECTED AS A "CREDIT" �CR), NO PAYMENT IS REQUIRED)
��.
REGISTEB OF WILL3 OF CUMBERLAND COUNTY
REPORT OF 8TATUS OF ADMII�II3TRATION
(For Resident Decedents Dying After July 1. 1984? . ,
�:-. ,.
ESTATE NO. 21�8 - 2 4 0
. -
' �'�'i � �
Name of Decedent: CHARLES E. CLEMENTSON
Social Security Account No.: 577-60-6048 '.'' ' -
Date of Death: January 20 , 1988
Name of Personal Representative(s):
Virginia L. Brown
Capacity Executor
X Administrator c.t.a.
(check one) Administrator
Administrator d.b.n.
Is the administration of the estate complete? Yes X No
If "yes", how was the administration ended? (check one)
By court accounting
By account stated to parties in interest
Did the parties release the
personal representative?
Other texplain) The Count Inventor showed assets in the
decedent ' s name alone of 51, 970 .45 , the Inheritance Tax Retur�olshowed
asset ' � � T�o� �, i nhPri tanrP t'ax ThPrP wac Il0
wn��n Sn ��=�a a� � • r—�-�X�—
amount remaining for distribution.
Tota] amount paid to date to creditors and for funeral and
$ 9 617 _ �0
administrative expense
Total value of distributions to date to beneficiaries
$ -0-
If administration is not complete, estimated value of assets $ --
still in administration
NOTE: This status report is due no later than the due date f�r fi c�,t�ne (9rolo ths
Inheritance Tag Retutn or, if no Inheritance Tag Return is requi
after the date of death; if the administration of the estate has not been concluded,
a summary report shall be filed annually thereafter until the administration is complete.
I certify under penalty of perjury that the for
'nformation is correct to the
best of my knowledge, inforrnation and belief.
10/27/ , 19 88
Date:_ --- , Personal Representative
Ho e . Johnson , Attorney for F.state
'IT�is report must be sgned by the personal representative, or one of them when more
��
than one. or by counsel for the estate.