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. Rcc-33 (4.73)
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
*'
RESIDENT DECEDENT
COUNTY OF CUMRERLAND
IMPORTANT,
This return must be completed in detail and filed in duplicate, with all attached. with the Register of Wills of the
County where decedent resided; Return is due within nine months after date of death, unless an extension is granted
by the Secretary of Re\tenue. (Section 703 of the Inheritance and Estate Tax Act of 1961.)
NELLIE E. BURGETT
(STATE FULL NAME OF DECEDENT)
} AFFIDAVIT OF
- EXECUTOR S
~~l\!ll!X~~x
IN THE MATTER OF THE ESTATE OF
Late of
Cumberland
County
State of
Pennsy1yania
]"
County of
Cumberland
Mary G. Smith and Pearl M. Rrymp.ssp.r
of the estate of the above-named decedent being duly sworn, depose
Executors
X~Xtl(QC
and soy
Decedent died
February
26
, 19~J testate leaving a
(YEAR) ~eX9(tX
lost will, copy of which- is hereto attached. }
(MONTH)
Nome and address of attorney or }
other authorized repres,entative to whom
all correspondence should be mailed.
(DAY)
1 W.
R. Humer, Atty.
High St., Carlisle,
.:- 1---\ ')__
3 t> (
James
PA 17013
That as slIch Executors deponent is familiar with the affairs of said estate and the property constituting
(EXECU TO R-AJl(M(OOXOOXNDeX
the assds thereof and their fair market value.
That at the time of death there was no safe deposit box registered in decedent's individual name, or jointly with, or
as agent or deputy of another, or in decedent's individual name, with right of access by another as agent or deputy, with the
exception of the fullowing: -
--
NAME AND ADDRESS OF BANK OR OTHER INSTITUTION THIS SAF'E DEPOSIT BOX RENTED RELATIONSHIP OF JOINT
IN WHICH DECEDENT RENTED A S."FE DEPOSIT BOX IN NAME OR NAMES OF HOLDERS TO DECEDEN T
None
That the contents of said safe deposit box or boxes are itemized under Schedules Nt A of this return,
with the exception. of the following, for the reasons hereinafter set forth:
That Schedule A attached hereto and made part hereof sets forth fully and in detail all the real property
in the Commonwealth of Pennsylvania of which decedent died having an interest therein. It also sets forth the
mortgage encumbrances upon each parcel of real property at the date of death, giving the amount still due at
death, name of mortgagee, date, rate of interest, and book and page of record thereof. It also sets forth in the
columns provided therefore the assessed valuation of each of said parcels, the estimated market value thereof
as of date of death of decedent.
That Schedule B attached hereto and made part hereof sets forth fully and in detail all personal property
wheresover situated owned by the decedent at the time of death; all moneys left by the decedent at the time of
death, whether in decedent's immediate possession, standing to decedent's credit in banks of deposit, savings
banks, trust companies, or other institutions, whether individually, or in trust for any other person or persons
giving also separately the accrued interest thereon, if any, down to the last interest day prieT to decedent's
death in the case of savings banks, and to the date of decedent's death in all other cases; all bonds, postal
savings, treasury certificates or notes and other evidence of indebtedness of the United States to the de-
cedent; all obligations, whether by statute or agreement they are dc~ignated as tax free, of the United States,
or any state, or political subdivision thereof, or of any foreign country, which are owned at the time of death;
all wearing apparel, jewelry, silverware, pictures, books, works of art, household furniture, horses, carriages,
automobiles, boats, and any and all other personal chattels of whatsoever. kind or nature, left by decedent,
together with the fairly estimated market value thereof; all bonds and mortgages held by decedent and of all
claims due and owing decedent at the time of death, and all promissory notes or other instruments in writing
for the payment of money of which decedent died possessed, of whatsoever nature, with interest thereon, if
any, giving the face value and estimated fair market value thereof, and if such estimated fair,market value be
less than the face value, it sets forth briefly the rea sons for such depreciation as to each item; all moneys
payable to the estate from life inSlIf<ll1Ce policies carried by decedent; all annuity and endowment contracts
the proceeds of which were payable upon the death of the decedent; all and the corporate stocks and dividends
due thereon and unpaid as or Ill, ,i;Ii\' or death. bonds and accrued interest thereon to the date of decedent's
death and other investlT1''' I .... ";. i~'J hy Ihe decedent at the time of death, with thcmarket value there-
of at such time.
. In the case of securities of' close or f'amily corporations, the values reportert areas far as
I'oss:tble substantiated b;y f'inancial statements of the corporations, showing the assets anrl liabilities
thereof' as of' the dnte of rleath. The schedule also sets f'orth the interest of rlecedent at the time of'
deat.h in tln~' co-partnership or business, and in support of the value of' such interest there is annexed to
said sehrdule, linancial statements showing the assets and "liabilities of' salrl co-partnership or !Hlsiness.
A copy oj' ~,h>f' co-partnership agreement, (if' oral, a statement sett1ng f'orth the nature of' the agreement)
tOf!;pf)'".]' 'i) tn a statement settin.e; f'orth the character of' the business, its location, and such other facts
jwrL,:i,'lil to the business as may be pertinent to a f'air and just appraisal of' the decedent's interest
thf'reill n:\lst hl'submittect. It should also set forth in itemized form, together with the fair market value
tht'r(-'(:f" nn:,' ot.her property owned or bequeathed by the decedent at the time of death.
The Scf>edule C attached hereto and made part hereof sets f'orth a true answer to each inquiry
contained thlorein anrt in the case of' transf'ers of property, real or personal, within two years of' decedent's
dl:':'nth, .in cOTJtemplation of decedent's death, or intended to take eff'ect in possession or enjoyment at or
aft.er de':'lth, sairl schednle sets f'orth the nature anrl value of such property, to whom transferred, the
relationsldp of' the transferees to the decertent, tlle proportionate share received by each transferee and
all other f'acts of a pertinent nature regarding sairl transf'ers. In the case of' transfers intended to
take ef'1'ect in possession or enjoyment at or after death, there is also attache(1 to the schedule a cony
of' t.ht' deed, t.rust agreement or other instrument creating the trust. Therl~ is also set forth in said
schedul(' It list of all property, real and personal, with its value, which pa~ses at decedent's deatit by
virt.ue or tlw exercise by decedent, either individually, or.1ointly with another, or any power of' appoint-
ment vested in decedent, either individually or Jointly, by the will, deed, or other instrument of another,
with a copy of the instrlUnent creating such power attached to the scherlule.
That Scf>edule D attached hereto and made part hereof' sets forth the names and addresses of' all
persons lwneficially interesterl in this estate at tlw time of decedent's death, the nature of their res-
pecUve interests, their relationship, if' any, to the decedent, tog;ether wtth the ages at the time of
decedent1s death of all minors, annuitants ami beneficiaries f'or life llnrler decedent's Will. It also
cont.ains a statement showing which of the beneficiaries named in the decedent's will, if any, died prior
to de:.'edent, the dates of their death, their issue, and the relationship of such issue to the beneficiary.
That Scf>edule E attached hereto and made a part hereof sets f'orth all property, real and per-
sonal, owned by the decedent jointly with another or others, including; intangible, standing in the name
of the decedent and others, plus the date and place of record of instruments effecting the vesti ture of'
real estate and the date of acquisi tion of personalty, plus the name, a(ldress and relationship, if any,
of co-owners to the decedent.
That Scf>edule F attached hereto and made a part hereof sets forth f'ully and in detail all rlebLs
and deductions claimed for anQ on behalf of this decedent's estate, including f'uneral expenses paid;
family exemption, where applicable; costs of administration of' thts estate; eounsel rees (lnrl fudtclary's
conunlssions paid or to be paid; cost expended for burial trusts, tombstones or gravemarker's, and reli-
gtous services, in consequence of the death of the decedent; debts and claims owing and. unpairl at time of'
death; taxes accrued chargeable for period prior to decedent's neath (except those allowed Undf!r Spction
651 of' the Inheritance and Estate Tax Act); together with a statement of collateral pledgerl f'or obliga-
tions, if' any. It is agreed that the fiduciary will present proof of' said clatmed obligations upon re-
quest, that if the amount actually paid in settlement of any fee, commission or rlebt is less than the
estimated amount c1 aiming lind allowed, that the same will he reported to the Hegister of Wills, and thllt.
the amount of' tax assesserl can be reassesserl in accorrlance therewi tho
That the totals of the appropriate columns in Scherlules "A", "B", "en, "E", and "F" as directed therein,
have been carried forward and properly registe'!'ed in the Surmnary.
-~!i~{gu_m
~~~~~
4 22W1L.:ln.1Jt...S.t............18.....Fr.ont......St..
(Street Number)
Boi1il1K$PEtI1R?, P A ...17 0.0 7 ....
(City or Town and State)
NOTE: Before signing affidavit make sure all blank spaces in the affidavit and schedules annexed are
filled in with details or the word "None", and in case the asset.s inclllrle rare ami unlisterl securities,
securi ties of close or f'amily corporfttions or an interest in any co-partnership or business, that the
data and stllU'ments required. und.er the pflra~raph above relating to Scherlule "B" are ftttacherl. ;\1so make
certain tllat colunm .#1 in the "Summary" has been properly completed as ahove-{Urected.
Subscribed and sworn to before me thiB,l~....
....... 19.7!:J
i",~
Er.pircs July 1~. 19'~
Cumberland County
RC C.J4 (4_73)'
CdMMONWEAL. TH OF PENNSYL.VANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COL.L.ECTIONS
TRANSFER INHERITANCE TAX
'RESIDENT DECEDENT
SCHEDULE "A"
REAL PROPERTY
*'
Real property in Pennsylvania, with statement of mortgage encumbrances upon each parcel at death of dece-
dent. Property held by the decedent as tenant in common with another or other, should be identified
as to quantum of interest and the estimated value should be that of the decedent's interest only. (Property
held as joint tenants with right of surviorship or tenancy by entireties should be reported on Schedule "E.")
The real property located In the Commonwealth of Pennsylvania should be
ducrlbed by lot and block number, street and street number, together with
a general description of the property, with a reference to the record of the
conveyance by which the decedent took title; If a farm state number of a.
cres; 01.0 statement of mortgage encumbrance. upon each parcel at death
of decedent. Taxe., as.e.sment., accrued Int.re.t on mortgage., .tc.,ar.
to be lI.ted on Schedule "F" and must not b. deducted from this schedule.
(1)
(2)
(3\
OEPARTMENT
VALUATION
CAUTION
(Do not write
In this space)
ASSESSED VALUE
FOR YEAR OF
DECEDENT'S
DEATH
ESTIMA TED
MARKET VALUE
2 .
Lot 80' X 146' in Boiling Springs,
S. Middleton Twp., improved with
dwelling Nos. 412 & 414 Walnut St. and
greenhouse, conveyed by Geo. A. RichwinE,
Adm. of Est. of Wm. Richwine, deceased
to Walter E. Burgett (died Nov. 25, 197 )
and Nellie E. Burgett, his wife, deed
dated 4/10/31 and recorded in Cumberlan(
County Deed Book 11 "E" 524.
Assessed as two parcels, Nos. 15 & 16.
Lot 50' x 146' in Boiling Springs,
S. Middleton Twp., on east side of Walm t
St., and improved with greenhouse
conveyed by George A. Richwine et ux to
Walter E. Burgett and Nellie E. Burgett
by deed dated 12/7/45 and recorded in
13 "C" 74 and description corrected in
subsequent deed between same parties,
dated 9/7/56 and recorded in 17 "J" 461.
3930.0OV
2560.001/
25,960.00/...-V
1.
2l50.00V
8,600.00V
Insert this total apposite "real property", Schedule "A" in the X X X X X
"As Reported" column on the lost poge of this return.
34,560. 00V'3 :-l,.5ioCl .00
RCC-35
RESIn,:,,'] DECEDENT
SCHEDULE liB"
PERSONAL PROPERTY
_.~
. .
. "!'
COMMONWEALTH OF PENNSYLVANIA
TRANSF~R INHERITANCE TAX
INSTRUCTIONS: This Schedule must disclose all tangible and intangible personal property owned individually
by the decedent, at the time of' his death. Property owned by the decedent jointly with another or others
must be 1 isted under Schedule "E". Intangible personal property, titled in the name of' the decedent, but
payable at death to another or others, including but not limited to P.Q.D. U. S. Savin~s Bonds and tenta-
tive trust accounts, must be listed, despite the fact that they are not of' the administered estate.
Tangible personal property should be listed first (e.g. jewelry, wearing apparel, household
goods, and fUrnishings, books, paintings, automobiles, boats, etc.)
Intangible personal property, such as bonds, treasury certif'icates, cash on hand and in bank,
stocks, mortgages, notes, together with accrued interest or dividends, salaries or wages, insurance pay-
able to the estate or f'irluciary in said capacity, partnership interests, interest in any undistributed
estate of' or income f'rom any property held in trust under the will or agreement of' another, even though
located outside of' the State, at the time of death, should be listed in this schedule.
Item
No.
ITEM
List and describe fUlly
UNIT
VALUE
ESTIMATED
MARKET VALUE
DEPARTMENT VALUATION
(Do not write in
this space)
1.
2.
3.
Coal
Household furniture, sale price
The Com. Nat1. Bk., C/D #181216
dated 6/19/74, 4 yrs. 7 1/2%
Int. to 2/26/78
***
---
366.00" //
4 , 333. 80'
0000.
./
6,000.00' /"
312.33'
***
SEE Summary Sheet attached.
Other sale papers in file of James R. Humer
Insert this total opposite "Personal Property", Schedule "8" in
the "As Reported" colwnn on the last page of' this return.
x X
11,012.13.'/\\, G \"l-\""3.
'Rcc-Y!
cnMM()\W~>\LTIl (H.' PE:i\~YJ,\-i\NT ^
T~{A\~Fl.'I\ I:\H!"iiITi\\Cl;: TAX
SCI-W1HiU': !Te"
TH \'\"I''EliS
~.~~.
/j ,,' "-
.iff!l'!,'". ~..
1",,-..,,,>,.-,-,,
",,,~#,\"(."'>J
"'\,,";T'~."'"-!1<:."""
ilES I \)]-:\1 Ol,:ClilW\T
(1) Did {~e:Pdent, within two years of death, mak"'l.dll,v tl'unsfer of ilTl;'rT material part Hi' }lis estLtte, ....'"it-hout
receH'lng <l valuable ar.d H"dequilte consideratum thl"l'cf'lr? (Answer yes 0'. no)--':'~~__
(.::!) Did decedent, wi 1 hin two :yellrs of' rh~ltth! t.rnnsfer property from llimsel f to himsel f' and another or
(,Uwrs (inclllrUng il spouse) in joint ownership? (Answer yes or nf))~_
(:~) If the answer to (1) or (2) auove is in Uw aff'irmntive ~tate:
(a) A!.;e of' decPclent at time of' transfer N/ A
(b) State of' decedent' s h\~al th fit time (If milking the transfer. (Note 1).
(e) Calise of decedent's death. (Note 1).
(4) Did decerknt, in hi:; lif'etime, make any transf'er of property without receiving a valuahle or adequate
consideration theref'or which was to take effect in possession or enjoymef't at or after his dpath?
(,\nswer yes or no) No
(a) \\115 there any iJOssibility that the property transferred might return to
estate or be subject to his pow'~r of disposition? (Answer yes or no)
(b) \'dlilt was the transferee's age at time uf' decedent I s death? ~~
(5) Did decedent in his lifetime make any transfer wi thout receiving a valuable and artcllua.te consideration
therefor unrh~r wldeh transferor expressly or impliedly reserves for his life or any period which does
not in fact ewl before his aeath:
(a) The possPssion or er~.ioYlllent of or the right to income f'rom thf' property tl'anst'erred?
(,\nswer yes or no) No
(I)) The right to designate the persons who shall possess cr enjoy the property transferred or
income thertd"rom? (Answer yes or no) No
(G) If' the answer to (5) (b) above is in the affirmative, state whether the rigllt was reserved in decedent
alone I)r others N / A "_~________._______"_____~._
(7) Did clecedent in Ids lifetime make a transf'er, the consideration for which Wf1S transferee's promise to
pay income to or for the benefit of Cill'C of transferor? (Answcl' yes or no) No
un Did decerlent, at any time, transfer property, the beneficial enjoyment of which WflS subject to change,
because 0 f a reserved power to alter, amend, or revoke, or which cOllld revert to decedent under terms
of transfer or by operation of' I aw? (Answer yes or no) No
(9) If the answer to (8) ;lboVt~ L~ in the affirmative, was the power t/l alter, amenrl, or revoke the inter-
c."t of the beT'pf'iciary reservp(] in the decerlent alone or the decedent anrl others?
(Answer yes or no) No
~OTE1: The answers to these questions shoul d he supported by affidavi t hy the atten,iing physi cian as
well as a copy of the cteuth ccrU ficate.
l\OTE 2: If answer to any of the above tl1h~stions is yes, set forth below i1 description of the property
transferrect, it's fair market value at date of death, dates of transfers and to v'hom tra,nsf'errerl, with
relationship of transferees to rlecettent, if any. Submit eopy of any trust rieen or instrUlaent, if trans-
f'ers are claimed to be non-t.axable, also submit (Ietailerl st.atement of' f'ncts on which said claim is based.
NOTE 3: List apJllicable rn'ollerty below in manner tn wllleh provined in Sched,ules A, B, or E.
t.ransferer
No
or his
ITEM
UESCRIllTION
MAHKET VMME
(EstImated)
DEPT. VI\LCAT~ON
(Dept. Only)
None
N~.~
Insert this tflt;l] opposite "Transf'ers", Schedule "e" in the
"As Reported" colul11Il on the last pa~e of' tlds return.
.REV~453 (8~'8)
COMMONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "D"
BENEFICIARIES
.
BENEFICIARIES AND ADDRESSES RELATIONSHIP
(State full names and addresses of all who (If step.Qtildren or SURVIVED DATE INTEREST OF
have an interest. vested. contingent or other- illegitimate children DECEDENT OF BENEFICIARY
wise, in estate) are involved, set STATE YES BlRTH IN ESTATE
forth this fact.) OR NO
Mary G. Smith '+OT Vo~ N/A 1/2 Estate
422 Walnut St.
Boilinu Snrinus PA l7nn7
Pearl M. Brymesser Dauuhtpr VI''' " I ^ 1/7 p~+~~-
18 Front St.
Boilinu Snrinus PA l7nn7
Deponent further says that all the above~named beneficiaries are living at this time except below:
NAME
DATE OF DEATH
RESIDENCE
WALTER E. BURGETT husba
17007
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e 0::
G-oss Taxable Estate
SUMMARY
(Sch. UA") $
(Sch. "8") $
(Scht "C") $
$
$
$
(1)
(As Reported)
(2)
(As Determined)
Real Property
Personal Property
Transfers
$
$
$
$
$
$
"'" '0
~ Z ~
'" t.IJ ~
" ~
;.. ::;:; Q
t.IJ Q
'" Q ...J
- Q <
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c.: ~ .~ <
Q. 0 " '"
Q. ~ 0.
" <r: "t.IJ > 0.
-" t.IJ -""", ;;, <
0 "'" ""'<r: ~
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Z '" "'" ....."'" " Z
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e 0 '"
.8 c.: -= 0
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., W
~ "'" ~
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.5 0 .::- 0
::;:; E
- E Q "
::=~ :;; " E
0 0
==<r: ...J U U
RESIDENT DECEDENT
SCHEDULE "E"
JOINTL Y OWNED PROPERTY
..RCC-38
COMMONWEAL TH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
INSTRllCTIONS: This schedule must disclose all property, real and personal, owned by the decedent jointly
with another or others, including intangibles, standing in the name of' the decedent and others. List
real estate first. as entireties, or joint tenants, giving brief description, as indicated lmder Schedule
"An, ph:.s the date lind place of record of instnunent erfecting vestitllre, but do not include entireties
or out of state real estate value in estate valuation column. Personal property should be listed as in
Schedule "8", plus date of acquisi tion, and the name, address and relationship (ir any) of co-owners to
the rlecedent.
Description of Property, Date of' Acquisition, Name
Address and Helationship of' Co-Owners, and Place
of' Record of Instrument, where Real Estate.
unit
Value
percentage
Share
Estate
Val ua t ion
DEPARTMENT VALUATION
CAUTION-Do not Write
In This Space.
Value of' Value of
Entire Decedent's
Property Interest
Nellie E. Burgett or Mary G. Smith
CCNB Bank, N.A.
No. 711 9152 2
Checking Account
284.90
Insert this total opposite "Jointly Owned Property", Schedule "En
in the "As Reported" column on the last page of this return. 284.90
7_t.'-l.40