HomeMy WebLinkAbout01-0504
REV-1500EX(6-00)
w
...,
:.::~U)
,,"''''
w""
rOo
,,"'''''
..Ill
..
"
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
I
1
OFFICIAL USE ONLY
_~~= .;< '3 2=5{____
FILE NUMBER
~I -0 l --~rL'L
COUNTY CODE YEAR NUMBER
INHERITANCE TAX RETURN
RESIDENT DECEDENT
I-
Z
W
C
W
o
W
C
SOCIAL SECURITY NUMBER
J!)'J..
~:1b'L
DATE OF DEATH (MM-DD.YEAR)
.sfffT 17. D>>-o
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE I TIAL)
I'll,
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
~1.0riginaIRetum
D 4. Limited Estate
~ 6. Decedent Died Testate (Attach copy of Will)
D 9. Litigation Proceeds Received
o 2. Supplemental Return
D 4a. Future Interest Compromise (dale of death after 12-12-82)
D 7. Decedent Maintained a Living Trust (Attach copy 01 Trust)
D 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
D 3. Remainder Return (date 01 death prior to 12-13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach SchO)
...,
Z
W
o
Z
o
..
'"
w
'"
'"
o
"
FIRM NAME {If Applicable)
10 l) ,/0 *-K. Rt>I\f) 0 7 V
IIIe:W C...~"EAJ..MO/IA. _)10
TELEPHONE NUMBER
I . ))4- ~'b~
Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
OFFICIAL USE ONLY
(1)
(2)
(3)
(4)
(5)
-
4. Mortgages & Notes Receivable (Schedule D)
-
'6'6~.l)b
z
o
~
::l
l-
ii:
<C
o
w
0::
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or l)
8. Total Gross Assets (total Lines 1-7)
(B)
"J4Q .14,
(6)
\~"1().l.Ij
(7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
(9)
(10)
~~l6 \.9 S'"
11. Total Deductions (Iolallines 9 & 10)
(11) 5"1.1 \. ~ 5"
(12) -----O-!';.FICt'\
(13) -
12. Net Value of Estate (line 8 minus line 11 )
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (line 12 minus line 13)
(14)
p~ "'let\"
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
z
o
!ci:
I-'
::l
II.
::IE
o
o
~
15. Amount of line 141axable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
x.O_ (15)
x .0 (16)
x .12 (17)
x .15 (18) ~bS"' 5k
(19) I).b~.~b
16. Amount of line 14 taxable at lineal rate
17. Amount of line 141axable at sibling rate
18. Amount of line 14 taxable at collateral rate
"iD.Ll~
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Decedent's Complete Address:
I STREET ADDRESS
CIIT ~:'\L :Nb~~
~,,'O
I STATE
fp
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
Total Credits (A + B + C) (2)
(3)
(4)
(5) 'b5".;(.,
(SA)
(5B) 'ur;SI.
3. InteresUPenally if applicable
D. Interest
E. Penally
TotallnteresVPenally ( 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
I
I ZIP
rill? ~
':!os-: 5 (..
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + SA. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
No
~
[M-
o
g
[!'(
[d'
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;. ................................
c. retain a reversionary interest; or....... ......................'" .................................. ...................................
d. receive the promise for life of either payments, benefits or care? ............. .........................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ..... ............................... ................. .................................
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .... ............................ .....................
Yes
....0
o
o
..0
......0
o
.................0 ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
DATE
,-".'. \
Under penalties of pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct
and complete
Declaration of pre parer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
1'1", W\'fJ~
ADDRESS "1
---1n ~L."'E RIj'l,eMIJ Aui;
~RTHAN REPRESENVo.TIVE
ADDRESS C 0
J J()D lU((ft... ~OA.1iJ) fVf;/N .M(3F.RLANO \fA
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. 99116 (a) (1.1) (i)].
H A~~IS.~ ill.
, (A.
Ii) I J..._
17DI/)
DATE
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. 99116 (a) (1.1) (ii)].
The statute does not exemot 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 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. 99116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use ofthedecedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99118(1.2) [72 P.S. 99116(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. 99116(a)(1.3)J. 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.1508E.X+(1-97)
ESTATE OF
'*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
U\ k'f.:t:;V i
FilE NUMBER
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
f (< f\.tJCES
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
~
fl.\~N\~l\(.
C ""$~ () ~ )\*'fVP
71Lt. D i>
31)'1,00
TOTAl(Alsoenteronline5,Recapitulation) $ 1013. ()v
(If more space is needed, insert additional sheets of the same size)
RfV-1509 fX+ (12-88)
'*'
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
I FILE NUMBER
Joint tenant(.):
NAME
A. N AlIlt') ~f:l'\.SI't\c.l'<..
ADDRESS
tp3~' BI.....e Rl88blU A rI~
/1 Io:fl. RI$8L\. N6 (?.. l"bn 1-
RELATIONSHIP TO DECEDENT
Vorv ~
B. fR.flo.N't< J. NBl'\S/tI<"K
l\
~Hf~
C.
Jointly-owned property:
LETTER
ITEM FOR
NUMBE JOINT
TENANT
DATE
MADE
JOINT
DESCRIPTION OF PROPERTY
TOTAL VALUE DECD'S DOLLAR VALUE OF
OF ASSET % INT. DECEDENT'S INTEREST
II tll."it
'bl,\,t;3
1.
A't$
I~ 3-'\,\
\\..,\~ _ CI-l tftllllb
~<Sb'fH~H1<i
n,-Yf3 Wll-..-,Pb\lVI BAN'K 'f1PH10'\lo
Pr.x.
~4Si\b\
'- .i\-
)j r. ~
5100.<\0
TOTAL IAlso enter on line 6, Recapitulation) S
(If more space ;s needed insert additional sheets of some size)
REV.151tEX.(1-971
'*
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
fR IWCfS
y
Kr=.f.N€:.
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS: 50.00
1. Personal Representative's Commissions Nf? l'I. b l.heA":"
Name of Personal Representative (s) fU (\. t00~
Social Security Numbe~s) I EIN Number of pe~nal Represetti~(S)
Street Address /..D~ ~ ~u-.E A Ib~~n) l/..~
City +t~(!-,,\c.(f,lJ.lRI. State . Zip nll:t- .?-3H
Year{s) Commission Paid: ~\
2. Attorney Fees 3!>o.j)i)
3. Family Exemption: (If decedenfs address is not the same as claimant's, attach explanation)
Claimant -1/. IV E
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
- ~'hV J 0.0"
7. fll..li I N~\ 1i1~\-(~~~e \ t;\y..
<to f1L.~ Pe';rn I)lV 1c> 6 $Mi.€. ~Ll.. F~TffTf, at>. ~'"
b- 1)0
1'- I'\~t./ V6>R. H Ab~~ f'JOT~"':1 lb, U l)
/0- Fu.s f~"f 6~ 1h1A1'-llUb
lL M.S. }\ t/2&l1t"l P'\IilO/ul,l.. ~R. 3<t4b.l1
11-... PM:. c~))rl Ct\~o J3f\'')Y
TOTAL (Also enfer on line 9, Recapitulation) $ bloS\~S'
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX < (1-W)
'*
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF.......
NUMBER
I.
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
FILE NUMBER
1.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
N~NC,'j Nf:M.S~\<.K. - 'I>) N. 8b~6'KI80J AVt
Jlf\it\S'8l1.~6'. ~-m ~~1
NoevG
AMOUNT OR SHARE
OF ESTATE
J &070
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1
TOTAL OF PART II. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
- "
t-l WaYRRi!lt
LOOK FOR US. WE'LL GET YOU THERE.
MARCH 15,2001
NANCY NEMSHICK
603 N BLUE RIBBON AVE
HARRISBURG PA 17112
The information which vou reQuested on the FRANCES KEENE DECEASED
(Social Security Numb;r 202-54-0302) is as follows.
Account Number(s) 920027096
Class of Account SA VlNGS
Date Opened 120393
Principal Balance 1100.00
Accrued Interest .90
Balance at Date of Death 1100.90
Account Ownership JTO
Name of Joint Owner, if any NANCY NEMSHI(!. K
Date Ownership Was Established 120393
Additional Information Requested PLEASE COMPLETE W-9
s~erelrf
Ka~. ;o~}
Senior Services Rep.
P.O. Box 1711. HARRISBURG. PeNNSYlVANIA 17105-1711
Toll Free I-B66-WAYPOINT (I-B66-929-7646} . www.waypointbank.com
'"
.
,
0PNCBAN<
235 EmLA ROAD
EmLA, PA 17025
Phone Number (717-732-4452)
REF. FRi\NCES V, KEENE
Nancy M. Nell&furl:cl<.
603 N, Ribbon Avenue
Harrisburg, pA 17112-2338
TO WHCM IT MAY CONCERN:
Frances V. Keene account number 5080053278 that was open on 01103/94. The type of
the account was interest checking account and titled Frances V. Keene , Nancy M.
Nemshick and Frank J. Nemshick. And the balance as of 09/17/00 $2,458.61 .
s~t~
v
MARILYN RHODES
FINANCIAL SERVICE CONSULTANT
,)
A member of The PNC Financial Services Group
E.",ola Pennsylvania 17025
.~
., .
.'
o PNCBAN<
235 ENOLA ROAD
ENOLA, PA 17025
Phone Number (717-732-4452)
REF. FRANCES V, KEENE
Nancy M. Nea&lnci:cl<
603 N, Ribbon Avenue
Harrisburg, ~A 17112-2338
TO WHCM IT MAY CONCERN:
Frances V. Keene account number 5080053278 that was open on 01103/94. The type of
the account was interest checking account and titled Frances V. Keene , Nancy M.
Nemshick and Frank J. Nemshick. And the balance as of 09/17/00 $2,458.61 .
S~~
v
MARILYN RHODES
FINANCIAL SERVICE CONSULTANT
,)
A membtr of The PNC Financial Services Group
L;ola Pennsylvania 1702S
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT.280601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
'*'
No.AA 496635REV.1162EX(11-9(
RECEIVED FROM:
I
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
ROBERT E MYERS ESQUIRE
101
.e03"Sb
1 00 YOR..:: ROAD
NEW CUMBERLAND, PA 17070
FOLD HERE FOLD HER
ESTATE INFORMATION:
FILE NUMBER
21--200 }-0504
......
.1'
SSN 202-54-0302
NAME OF DEC, EDENT (LAST)
KEENE FRANCES V
(FIRST)
(MI)
DATE OF PAYMENT
5/23/2001
. .
',',
I ;'J J
POSTMARK DATE
5/17/2001
'.
...
COUNTY
CUMBERLAND
TOTAL AMOUNT P.AID'~ .
DATE OF DEATH
9/17/2000
REMARKS .
RECEIVED BY
MARY :,L
REG I STER'o,
CHEC~~" 2541
SEAL
REGISTER OF WILLS
lJJ 0
~ ~
~ "0 l'-
~ 3 ~~
~ ja:Q..
.+-'~,j
~ tU 0 C
L..~>-~
~ C -0'- Q)
~ 00.0
~ ~ 0 E
I"'f"I ...... 0 :J
o ~O
~ ~
Z
l
~~
~~c:.
3~
cd;
:
,
\
\
~
\
i
1
I
\
\
\
~
('/<7'~- :~_- _;) ~
"- " <.~ ~
~- ;:.. C) q..
,': .<--- ~ (\J ~
" ~. ~ ~
.' .p
.~..' J'\ ~ L.
~ ~
2~~
\)...~
~~
cl.. cl
~ \u
~ 1
-
.....J) oS
~0
o
b
r.r3. t-
\ooA-'l -0 ......
~ ro4.
~ ~ & 0-_
~ ...J ~ -0
fC< ~o~
r-_'" >- >- ~
\ooA-'l Q)-OQ)
c..... C - J:)
c-: 00 E
~ ~g8
co. ...... ~
o ''Z
~
\})
..1
<J>
~
Cl
J.
'-..)
-
.-::
-
-
)
~
~
\
-:
=:
-
~
...-1
"',
100.
i')
('
'"
il)
. f'"
.M,
....
r-..
.,..t
JIJN I JYV\
3 ?001
IN RE:
ESTATE OF FRANCES V. KEENE
deceased
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS COURT DIVISION
NO. 01- .56~
DECREE
AND NOW, ~ ,
consideration of of Nancy Nemshick and
Robert E. Myers, Attorney, it is hereby ordered and
the Estate of Frances V. Keene, deceased, be awarded
2001, upon
on motion of
decreed that
as follows:
Cost of Administration as set forth in Petition
M.S. Hershey Medical Center
$442.68
640.32
IT IS FURTHER ORDERED AND DECREED that Nancy Nemshick, accountant
and petitioner, upon payment in accordance with this Order is
discharged from her responsibility.
J.
IN RE:
ESTATE OF FRANCES V. KEENE
deceased
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS COURT DIVISION
--
NO. 01-~lf
PETITION FOR SETTLEMENT OF SMALL ESTATE PURSUANT TO 20 PA.
CONS. STAT. S3102
TO THE HONORABLE, THE JUDGES OF THE SAID COURT:
The Petition of Nancy Nemshick respectfully states that:
1. Frances V. Keene (ffDecedent") died on September 17, 2000
and resided at 211 Enola Road, Enola, Cumberland County,
Pennsylvania.
2. Your Petitioner Nancy Nemshick, an adul t individual, whose
address is 603 N. Blue Ribbon Avenue, Harrisburg, Pennsylvania
17117, is not ~elated to decedent and was handling her business
affairs at and before the time of her death and is named Executrix
of her last will and testament.
3. Decedent was not married on date of her death.
4. Decedent left a will dated August 31, 1999, which has not
been probated, which is attached hereto and made part hereof by
reference.
5. Decedent was survived by your Petitioner, sole beneficiary
of her will.
6. A Statf~ Inheritance Tax return was filed on May 25, 2001,
as a deficit estate.
7. Funeral expenses were pre-paid prior to decedent's death.
8. A copy of letter from Public Welfare showing a Class 6
claim of $1137.73 is marked Exhibit B.
9. No family exemption has been claimed and it is averred
that no one is entitled to claim the family exemption.
10. The property owned by decedent at the time of her death
and the value +:hereof is as follows:
Furni.~hings - sold
Cash ::In hand
$774.00
309.00
Total
$1083.00
,.." ,
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF ~ SS
Nancy Nemshick, being duly sworn according to law, does depose
a~d say that she is the Accountant in the foregoing Petition for
Settlement of Small Estate, that the foregoing Petition is true and
complete as to all items of credit and debit; that no party has
given notice of any claim that has not been herein noted; that the
facts set forth in the foregoing Petition and in this Affidavit are
true and correct to her knowledge, information and belief.
Na~s~~
Sworn to and subscribed before me
this .:z <fu- day of ~ '7
Notar~ I-tu-U./~
, 2001.
NOTARIAL SEAL
MARY D. VER HAGE, Notary Publ~
Fairview Twp., York County
My Commission Expires May 7, 2002
LAST WILL AND TESTAMENT
OF
FRANCES V. KEENE
I, FRANCES V. KEENE of 211 Enola Road, Enola, Cumberland
County, Pennsylvania, being of sound and disposing mind, memory and
understanding, do hereby make, publish and declare this to be my
Last will and Testament, hereby revoking all other wills and
Codicils previously made by me.
ITEM I: I direct that payment of all my just debts,
expenses of my last illness, funeral expenses, and the costs of
administering my estate from my estate as soon after my death as
conveniently may be done.
ITEM II: I give, devise and bequeath all of the rest,
residue and remainder of my estate, of every nature and wherever
situate, together with all insurance policies thereon, unto NANCY
NEMSHICK, absolutely.
ITEM I I I : I direct that any and all taxes that may be
assessed in consequence of my death, including all inheritance,
estate and transfer taxes imposed upon my estate passing under my
will or otherwise, shall be paid out of the principal of my
residuary estate as a part of the expense of the administration of
my estate.
1
ITEM IV: I authorize and empower my personal
representative to compromise, adjust, release and discharge in such
manner as my personal representative may deem proper, all debts and
claims owed by or to me or my Estate; to sell, lease or exchange at
public or private sale or in such manner, at such prices, and upon
such terms of credit or otherwise, as my personal representative
may deem proper, all or any part of my property, real or personal;
to exec ute, acknowledge and deliver instruments of conveyance,
including deeds in fee simple; to borrow money for the purpose of
paying estate, inheritance or other taxes which are required to be
paid and to secure any such loans by pledge or mortgage of all or
any part of my property and to execute the necessary instruments to
carry out such powers; to distribute my estate in kind or partly in
money or partly in kind, and to determine the fair value at which
any property so distributed in kind shall be received by the
distributees; to conduct any business in which I have an interest
at the time of my death, for such period as my personal
representative may deem proper, power to borrow money and pledge
assets of the business and the power to do all other acts that I,
in my lifetime, could have done, to delegate such power to any
partner, manager or employee without liability for any loss
occurring therein and to organize a corporation to carryon said
business as capital to such corporation and accept stock in the
corporation in lieu thereof and hold such stock for the uses of
this my Will, and to vote said stock or sell the same as to my
2
personal representati ve may seem best; to retain all stocks,
assets, bonds and investments owned by me without being confined to
what is' known as legal investments; to execute any options to
purchase, to apply for stocks, bonds or other investments, to
purchase or otherwise acquire real estate and to execute the same
powers thereover as hereinbefore provided, to retain indefinitely
any part of my assets, real or personal, which is or may become
unproductive or to make sale thereof; to pay carrying charges and
expenses of the property out of other principal or income of my
estate; to invest and reinvest in all forms of property without
restriction to investments authorized for Pennsylvania fiduciaries,
as my personal representative deems proper, without regard to the
principle of diversification or risk; to exercise any law-given
option to treat administrative expenses either as income tax or as
estate deductions, without regard to whether the expenses were paid
from principal or income. The powers herein conferred shall be to
my named personal representative and all successors thereto and
shall be in addition and not in limitation of other powers
conferred on said fiduciary.
Any and all payment or payments of any sum or sums, whether in
cash or in kind and whether for principal or income payable to any
beneficiary shall be made upon the sole receipt of the respective
beneficiary to whom the payment is made and free from anticipation,
alienation, assignment, attachment, and pledge and free from
control by the creditors of any such beneficiary.
3
ITEM V:
All shares of principal and income hereby given
shall be free from anticipation, assignment, pledge or obligation
of the beneficiaries and any of them and shall not be subject to
any execution or attachment, levy or sequestration or other claims
of the creditors of said beneficiaries or any of them.
ITEM VI:
I nominate, constitute and appoint NANCY
NEMSHICK, as the sole Executrix of this my Last will and Testament,
to serve without bond.
In the event of the renunciation, death,
resignation, refusal or inability to act for any reason whatsoever
of the said NANCY NEMSHICK, I nominate, constitute and appoint
FRANK J. NEMSHICK, JR., as the Executor of this my Last Will and
Testament, to serve without bond. In the event FRANK J. NEMSHICK,
JR. is unable to act for any reason whatsoever, I nominate,
constitute and appoint FRANK J. NEMSHICK, III, as the Executor, to
serve without bond.
IN WITNESS WHEREOF, I, FRANCES V. KEENE, have to this my Last
2/'7T
nd this d ~ day of
will and
/Ju b 119,.t
Testament,
(SEAL)
set
my
ances V. Keene
the
Signed, sealed, published and declared by Fra~es V. Keene,
above named Testatrix on the 3/ =!.- day of
If ~/ d tt )/ , 19 CJ'7 , as for her Last will and Testament,
4
in the presence of us, who, in her presence, and in the presence
of each other, have, at her request, subscribed our names as
witnesses hereto.
~2JcJ1PIUr}()
Name
~41Jfdfu
Name .
residing at 3(o~ UJa-'~ St~
'46-rr-i$ h~ I P.ot.. i 7/ {j 9
residing at /%.C;:; ~;a ~
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF ~ t{ H1~ete(..~ 0
SS
WE, the undersigned, the Testatrix and the witnesses,
respectively, whose names are signed to the foregoing instrument,
being first duly sworn and qualified according to law, do hereby
declare to the undersigned authority that we were present and saw
the Testatrix sign and execute the instrument as her Will, and that
she had signed willingly and that she executed it as her free and
voluntary act for the purposes therein expressed, and that each of
the witnesses, in the presence and hearing of the Testatrix, signed
the will as witnesses and that to the best of their knowledge, the
Testatrix was at that time eighteen years of age or older, of
sound mind and under no constraint or undue influence, and I, the
said Testatrix, do hereby acknowledge that I signed and executed
the instrument as my Last Will a~d estament, that I signed it
willingly, and that I signed it a . free and voluntary act for
the purposes therein expressed. ~
Testat ix Frances V. Keene
. ~ ..Jd~~
Wltness
~0~'
Witnes
Sworn to and subscribed before
me this 3/ ~ day of fJ'tt ~ v"? r
19
Kenneth l. ~~~~~!~::.~~~ ~
I~ HamPde.n f,"\lP~':, ~.;. '~,t.:. ..,p PUblic
my Com . 1..".'.' '1\;;.r'"'"ld '"'
m'SSiO'7 E :rnir~":' 0,:'" vOUI'lt\,
Mem" ,.8 r.,.,a"Ch IS:~
ber. PennSYlvania A --:-~..~--1-~,.. ~
SSOCtat,on of Nn'
.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
May 18, 2001
ROBERT E MYERS ESQUIRE
100 YORK ROAD
NEW CUMBERLAND PA 17070
Re: FRANCES KEENE
CIS #: 700142391
Co/Rec: 22/0219944
Date of Birth: 02/16/1917
SSN: 202-54-0302
Dear Attorney Myers:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of Sl.137.73 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense, namely ~, was incurred during the
last six months of the decedent's life; therefore, it is a Class 3 claim
pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20
Pa. C.S.A. 3392(3). The balance of the claim, namely Sl.137.73, is to be
entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. If the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sincerely,
/d~ --uL ~
Karen H. Peterson
Claims Investigation Agent
717-772-6615
717-705-8150 FAX
Enclosure
] 1 0'1.801, REV 9/86 . .
This is to certify that the information here given is correc~ly copied fro~ an original ce;tificate of death dul~ filed with me as
Local Registrar. The original certificate will be forwarded to the State VItal Records Office for permanent filmg.
WARNING: It is illegal to duplicate this copy by photostat 'or photograph.
Fee for this certificate, $2.00
p
6763052
No.
~ /JC r#~-p2-
Local Registrar (/
SEP 2 0 2000
Date
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
; R.v 2187
NAME OF DECEDENT (f"SI M_. L....'
SEX
I.F ran c e s V.
Keene
a.
83
AGE (La.. &thoay)
UNDeR I VEAR
~ Days
UHDlER I OM
Houoa MinuI..
BIRTHPLACE IC.1y iIIld PUlCE Of' DERH fCt>eck ""'y llf'e - - _ ,nSlructoOf~ on 0II'et _I
SlaI8 Of fCleoqn Counlfy) HOSPItAL.
E 1 P 1npaI.....:gr ER/OuqIa".nl 0 !lOA 0
7. n 0 a, a. ...
FACILITY NAME (II nollnSN\lltOn. goye Slr"1 and numllel.
g':=") 0
Did
dKedenl
live .. a
Cum be r 1 and lOwnIIlip? 17d.D ~'*.::'=of
MOTHER'S NAME ,Foil. MIlldla. M3Klen Sutnama)
II. J e s s i e Z i mm e r man
INFORMANT'S MAIUHG AOORESS (SIr.... Colyfbwn. Slate. Z'1Il Codel
603N. Blue Ribon Ave. Harrisburg, Pa.
PlACE OF DISPOSITION. Na.... 01 CemettlY. C'..".llIIY LOCRION . CilyI1Own, SI.... Zip coo.
01 0lIler PIKe
Rolling Green Mem. Par
:Uc.
NAME AND AOORESS OF FACIlITY
Uc. R i c h a r d son F . H . 2 9 S . E n 0 1 a Dr. E n 0 1 a P a. 1 7 0 2 5
lICENSE NUMBER ORE SIGHED
(MonIh. Oay. .....1
2311. 231:.
WAS CASE REFERRED TO MEDICAL ElCAMINERlCORONER? V
.... D No Iol!\
21,
I Approximal. MAT I: OIlIer ligniI\canl condIIions ~ 10 dNlII. buI
l ~ ~ nol ~ in lIMI unclaItying __ ~ in f'IIUrr I.
I
l
8 3 VIS.
I.
COUNT'( Of' DERH
..
Dauphin
Ie.
DECEDENT'S USUAl OCCUMIOH
(~-=:_:O~::~=r
l1..Houseduties 11...
DECEDENT'S MAILING ADORESS (SI,.. Colyfbwn. S1aeB. ZIIl Code)
211 Enola Rd.
Enola, Pa. 17025
,..
FRHER'S NAME (F.II. MKldIe. Last)
11. Chester R. Gates
INFORMANT'S NAME (TypelPrinl)
Nancy Nemshick
METHOD OF DISPOSITION
IluIwIIXI C.__ D RemowI.om SI... D
Olhet (Specllyl
DECeDENT'S
ACTUAl
RESIDENCE
(SeeIflSl~
on OI/ler _I
17.. Slate
Pa.
1711. Cou
-.=...... 24.:!e...... be completed by ORE PRONOUNCED DEAD (Monlh. Day. 'r\Iar)
~""-_pIOflOUflCMclealll 24. M. as. Sep-k-mber {t- 20:.:0
-~ 17. MAT I: E......... eli_.. injuries Of compIicationa wIlich causedlhe dealh Do not.lll.. Ilia mode 01 dying. Sueh as cardiac Of 'espi'alory alfllSl. Sllock 01 heart 'ailu.e
Lia! ontt _ c...- on HCII_.
..eDlATE CAUSE (FonaI
...... Of Condlbon
_ '-.ling on ......)_
~~ Iiat cancIilions
=1....1MdIng llI-..c1ia1.
'=_. ~UNDERLYIHG
-. CAUSe (DoseaM 01 ...y
-_oMiaIed_
=:i'-.IIng on deaIIl) LAST
E
I Nt:--P.(<..C TID t\.J
RE AUlOPSY FINDINGS
A\IIUI..A8l.E PRIOA 10
COMP\.ETION 0#' CAUSE
OF DERH?
MANNER OF DEATH
ORE 0#' INJURV
(Manlll. CaY. ~",)
""Ufal ~
Accldant 0
Suicoda 0
HomiCide
D
D
o
:;;;
..
Paneling Invesllgalion
... D NoD
v.. D
NoD
Could not be det.rmlned
ala. 21b.
CEJlTIfIUlICI>eck oniy onel
'CERTIfYING PHYSICIAN (PhySICoan cerlllyong ~se d dealh when anolhe' phYSIC"'" has pronounced dealh ana comPlele<lltem 23)
To'" ..... 01 my Ilnowlactge, ....tIt aceu"'" _10 .... c.....(.) .nd m.nn.. .. .,...... . . . . . . . . . . . . . . .
as.
~
::::;j . PRONOUNCING AND CERTIFYING PHYSICIAN (PtlV$lCoan bolh ".onouoc.ng death and c8f1olY>ll9'ocause 01 dealt')
;;t To 1M beet 01 ftly know'-dg.., de.lIIoc:c........,...lima. da'e, _plac., _due 10 _c.u..(.'.ndm.nn.....t.,ad ..................
:J
~ 'MEDICAL EXAMINER/CORONER
On 1tte balla 01 examinallon and/or investigation. in my opinion, d.ath occurr.d al Ih. 11m., d.le, and place, and due 10 'h. cause,a, and
manner a. Ita1ed.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
)1a.
I ~NATURe AND NUMBER
.33. ~~~'~7vz.----
~/I~~/I
STATE fiLE NUMIlER
SOCIAL SECURIT'( NUM8ER
3. 202
54 - 0302
00<"
MARllAl ST.Q'US . ........
N_ Married, W-.cl,
~(Speay)
14. Widow
17c.[J~.dKedenllivedin E a s t
RACE - Amencanlndian, Black, Whit.. etc.
(Spec:.Iy)
10. Wh i t e
SUfMVING SPOUSE
I" WIle. gove ..- namtIl
15.
Pennsboro
ctt>p~--
171 12
Lower
21d.
Allen Twp.
Pa.
TIME OF INJURY
INJURV R WORK?
DESCRI8E HOW INJURY OCCURRED.
~ 0 NoD
MO
17033
34.
t:J
",t('
Q....
IN RE:
ESTATE OF FRANCES V. KEENE
deceased
AFFIDAVIT
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS COURT DIVISION
NO. 01- boi
OF MAILING
STATE OF PENNSYLVANIA
COUNTY OF YORK
SS
Before me, the undersigned officer, personally appeared Robert
E. Myers, Attorney, who after being duly sworn according to law,
did aver that he mailed a copy of the Petition for Settlement of
Small Estate Pursuant to 20 Paw Cons. Stat. S3102 and attached
notice, on June 12, 200 I, by U. S. Mail, receipts for mailing
attached heretof to the following parties in interest:
M.S. Hershey Medical Center
P. o. Box 828632
Philadelphia, PA 19182-8632
MNBA Credit Card - PC Bank
325 Enola Road
Enola, PA 17025
Pa. Dept. of Welfare
Bureau of Financial Operations
Estate Recovery Program
P.O. Box 8486
Harrisburg, PA 17109-8486
.~~
(<I: ~
Rober E. Myers, Esquire
Sworn to and subscribed before
me this /~t;;L day of ~~
, 2001.
--/).. ./~ .d d 1. i ~.A/...{V ~ n
Notary Publ c 0
NOTARIAL SEAL
MARY D. VEA HAGE. Notary Publ~
Fajrv1~~ Twp., York County
M Commlssloll Ex ires Ma 7, 2002
June 12
, 2001
M.S. Hershey Medical Center
P_O. Box 828632
Philadelphia, PA 19182-8632
Pa. Dept. of Public Welfare
Bureau of Financial Operations
Estate Recovery Program
P.O. Box 8486
Harrisburg, PA 17105-8486
MBA Credit Card - PC Bank
325 Enola Road
Enola, PA 17025
RE: Frances V. Keene
211 Enola Rd.
Enola, PA 17025
Died - September 17, 2000
SS # 202-54-0302
Petition for Settlement of Small Estate of Nancy Nemshick will be
filed on or before June 18 , 2001, in the office of the
Clerk of the Orphans Court, Cumberland County Court House,
Carlisle, Pennsylvania. This petition is filed pursuant to the
Probate Estates and Fiduciary Code.
You are hereby notified that if you have any objections or
exceptions to the enclosed petition, the facts set forth therein or
the prayer thereof that you must file same with the said Clerk of
Orphans Court of Cumberland County, Pennsylvania within 20 days
from the date of filing as the said petition will after 20 days
have expired be presented to the Court for Confirmation and Decree
attached to the Petition.
Dated: June 12
f 2001.
~~
Nancy Nemshick
U.S. POSTAL SERVICE CERTIFICATE OF MAILING
MAY BE USED FOR DOMESTIC AND INTERNATIONAL MAil, DOES NOT
PROVIDE FOR INSURANCE - POSTMASTER
Received From: ROBERT E. MYERS
ATTORNEY AT LAW
10n York ROAd
New Cumberland, PA 17070
One piece of ordinary mail addressed to:
/11NIYl &JdlA- ~ pfl}(! ~
.J
'--~~ j f..J1?nl- JCf Rb
~. PA J70;;l)"
PS Form 3817, Mar. 1989
U.S. POSTAL SERVICE CERTIFICATE OF MAILING
MAY BE USED FOR DOMESTIC AND INTERNATIONAL MAil, DOES NOT
PROVIDE FOR INSURANCE - POSTMASTER
Received From: ROBERT E. MYERS
ATTORNEY AT LAW
100 York Road
New Cumberland, P A 17070
One piece of ordinary mail addressed to:
it ~. "3 W~A~
~~ ~/MAI/.A.J7 tPh.-,
~ ~1'~nL ~~
PC; ~. Wf -;:7
A tJ - j'~
PS Form 3817, Mar. 1989
U.S. POSTAL SERVICE CERTIFICATE OF MAILING
MAY BE USED FOR DOMESTIC AND INTERNATIONAL MAIL, DOES NOT
PROVIDE FOR INSURANCE - POSTMASTER
Received From: ROBERT E. MYERS
ATTORNEY AT ~AW
100 York Road
New Cumberland, PA 17010
One piece of ordinary mail addressed to: );,/d. &, .
~ -/ ~/T
fb~ K'~ y-- ~ ..=?;}.
//-tJ /-A d~~-Li.L P'~3 :l-
Ph /7/ R ~ -
PS Form 3817, Mar. 1989
Q
,.=>
Y:~I'\'.'"
col.':-' ..
l'.c ,:P ,
I ... J' . ''''''I
\ . : f "';
"'; \'\i;~~ z-.'.' .:'
".... ." L\,'l~..~. ...f:.....,
"'~jf)>;',e
d "r,Y"i" "~~:~tH~.
(;:) I~. _, ,f:!:. (/)
Ul -:ru.
en O-'Jmx
.,b.. C:N(:~m......""O
t-...J ~. .~f!~o~
~LT1 ::? ~ ~
Ul ~; ~
""0
J)
(/)
.".
---.JO;:P
c:: No rn......""o
z. --.J:J100
-oj 'or' (/)
o :r> -i
z :D
c: C1
. rn
""0
:r:-
:D 'c (/)
:r; '-3'"0'
O---.JCl?X
cNom......""o
z. -,J:J1CJO
-4 .or (/)
o X -4
- Z ::r>
CJ C1
. rn
-0
:r
\. /6-02052-';?
c;f-
v/
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
"'ACN
07-02-2001
KEENE
09-17-2000
21 01-0504
CUMBERLAND
101
ROBERT E MYERS
100 YORK RD
NEW CUMBERLAND
PA 17lJ],0
*'
REY-1547 EX AFP <12-00)
FRANCES
v
Allount Rellitted
CHANGED
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
1,083.00
1,370.43
.00
(8)
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 ~
REY=is4-j-ix-iFP--fli:oljr-NoTici-oF-'rNHEifiTANci-YAX-APPRAisEMENT-;-iiioWANCi-oR'-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF KEENE FRANCES V FILE NO. 21 01-0504 ACN 101 DATE 07-02-2001
TAX RETURN WAS: (X) ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E)
6. ~ointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule ~)
14. Net Value of Estate Subject to Tax
I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
re~lect ~igures that include the total o~ ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rate (15)
16. Allount of Line 14 taxable at Lineal/Class A rate (16)
17. Allount of Line 14 at Sibling rate (17)
18. Allount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS:
NOTE:
(9)
(10)
5,681.95
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
2,453.43
5.681 95
3,228.52-
.00
3,228.52-
(19)=
.00
.00
.00
205.56
205.56
.00
(11)
(12)
(13)
(14)
.00 X 00 =
.00 X 045 =
.00 X 12 =
1,370.43 X 15 =
PAYttENT RECEIPT DISCOUNT (+) I AMOUNT PAID
DATE NUHBER INTEREST/PEN PAID (-)
05-17-2001 AA496635 .00 205.56
TOTAL TAX CREDIT 205.56
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 PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)