HomeMy WebLinkAbout01-1154
Estate of Richard E. Ellenberger
also known as N I A
PETITION FOR PROBATE and GRANT OF LETTERS
;l..J-D1.. ff 5 Y
Register of Wills for the
207 _ 0 7 _ 4 7'5 rPeceased. County of Cumberland in the
Social Security No. Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the execut or
in the last will of the above decedent, dated 30 December
and codicil(s) dated fl (On e
No.
To:
named
, 19B.lL-
(state relevant cirCllmstances, e.g. renunciation, death of exec1Jtor, etc.)
Decendent was domiciled at death in Cumber land County, Pennsylvania, with
h i~ last family or p(lncipal residence at 336 North Second Street
WormleYabur~, PA
(list street, number and muncipality)
82 12 November 2001
Decendent, then ___ years of age, died , 19
~ Cl~iremont Nurcing & Rehab Center .
Ex~ept 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: non p
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$ 30,000
$
$
$
none
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
pre~ented herewith and the grant of letters t e 5 t Hillen t ('1 "t'Y
(testamentary; administration c.I.a.; administration d. b.n.c, La.)
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA ~ ss
COUNTY OF Cumberland J
The petitioner(s) above- named swear(.~) or affirm(s) that the statements in the foregoing petition are
true and correct to the best uf the knowledge and belief of petitioner(s) an that as personal represen-
tative(s) of the above decedent petitioner(s) will an trulyadmin' t e ate according to law.
Sw orn to or affirmed and' SUb.scr..ibed.~...
before me this 18th day oil
" Decemberj ~' , _ l)j~
)?2t!f.~'1ff (. . ,~u,~.y/-"~ 41ic..uv!) 1
Mary C. Lewls Register" , ry
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Estate of Richard E. Ellenberger
, Deceased
DECREE OF PROBATE A~D GRA~T OF LETTERS
AND NOW December 20th, ~ 2001 in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated 30 December 1980
described therein be admitted to probate and filed of record as the last will of
Richard E. Ellenberger
and Letters testamentary
are hereby granted to Terry E. Ellenberger of 336 North Second Street
in Wormleysburg, Pennsylvanla 1704J
FEES
Samuel L. Andes
Supreme Court ID # 17225
Probate, Letters, Etc. .........
Short Certificates( 5) . . . . . . . . . .
Renunciation ................
x-Pages (2)
JCP
$ 60.00
$ 15.00
$
6.UU
$ J . 00
TOTAL _ $86.00
Decemb.er. 20th, 20.Q1. . . . . . . . . . . . .
ATTORNEY (Sup. Cl. J.D. No.)
525 North 12th Street
Lcmoync, p^ 17013
ADDRESS
(717) 761-5361
Filed
PHONE
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MAIL LE'ITEFS 'ill ATIURNEY SA.1I1UEL ANDES
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This is to certify that the infotmation here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to tilt' State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
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Fee for chis cenificarc. 52.00
P 7883923
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Date
~11'-2001"'"1154
i 4J Aev. 2187
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
NAME OF oeCEDENT (ftrSl. Middle. laszl
Rich3rd E .
..
Ellenberger
STATE FilE NUMBER
SOCIAL SECURITY NUMBER
..207 -417 -4750
DAlE Of DEATH IMcnlh. Oa~. "1'eaI,
.Nov.1 2,2001
AGE (Lase Blflhday)
UNDER 1 '(EAR
MonthI Days
UNDER 1 DAY
Hours Minut..
BIRTHPLACE (CoIy ..rod
Stale 0. fCfe.gn Counuyl
82
Yto.
Harrisburg,PA
::..,10
5.
COUNTY OF OERH
... Cumberland Co. ..~Iddlesex Twp. Id~laremont Nusing & Rehab. Ctr.
DECEDENT'S USUAl OCCUMfON KtNO OF 8USlNESSlINDUS1RY WJr,S OECEDENl EVEA W
(Gi....klnddworkdonedUflOgmosl U.S. ~FORCES?
cust~.;~rvi~el aas utility "'Y"'NoO
. n.. 1m. 12.
DECEDENT'S "AILING AOORESS (S".... C"'/TOwn. SIaM. Z", C_I DECEDENT'S
336 N. Second St. ~~~NCE
Wormleysburg,PA17043 ~~~~
.a.
fIilHEt\'S W,lrr.ME IFirst, Ml()dle, last)
11. Chester Ellenberger
1NF000000SNAME (T_P,in'l T E Ellenbe
_. erry . rger
METHOD OF OISPOSlT
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00_
17a. Stale
MARITAl STATUS - Married
Never Married. Widowed.
"'-codlSPoc>ly)
..,widowed '5.
Middlesex
RACE, Amencan IncQR. saack. While. etc.
1Spec4y)
'G,whi te
SURVIVING SPOUSE
(II .. grve malCIeO namel
Iwp
17b. Coo
Cumberland
174-0 ~~~oI
MOTHER'S NAMe iF.sl. MICkie, Malden Surname)
11. Jane parthemore
INFOR..ANT'S....IUNG AllOAESS (SIr.... C'!>'':i>-. SIoto. Zip Code)
aJ.36 N. Second st. ,wo:rmleysburg,PA 17043
PLAce OF DISPOSITION. NM\e 01 c........lfy. Cremalofy lOCAllON . CityITown. Stat.. rip Code
"'Toning Green Cemetery
21c.
...,-
Lower Allen Twp.,PA1701
21<<1.
N....E D ADDRESS OF FACllITY
24. ... as. 1\- 1)- - 0
27, Pa\AT I: Enter ,he dise..... inJUrMts or comc:*:ahonli which caused lhe death. 00 not enter (he mode of dyi~. such as cardiac 01 respira.tory arrest, shock or heart failure
List onty one cause on each Itne.
.3241brrrelA\e. ,lan::7yn:!,H\17
DATE SIGNED
(Month. DaV. '!UtI
12.€hJA\.. 1='b.'\...U\VlE:
DUE TO (OR AS A CONSEOUENCE 0Fl.
H-
I Apptoximate
I inl4MvaI bMwMI\
: onMI and death
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PAAT H: Ot.her stgniftcant condi&iona conIrQ.d:ing to death. tM.d
nd rnuttiog in the ~ cauH given in PART I.
AL.,-~':;\""'e:Y\ 5 ()S,
b.
DUE TO lOR AS A CONSEQUENCE 0Fl.
C-,to.p
1-lI oJ .
c.
DUE 10 (OR AS A CONSEQUENCE 0Fl.
d.
WERE AUTOPSY FINDINGS
_LABlE PRIOR TO
COMPLETION OF CAUSE
OF OERH?
MANNER Of DEATH
DATE OF iNJURY
tMonlh. Day, Year)
TIME OF INJURY
INJURV AT WORK?
DESCRIBE Ho.Y INJURY OCCURReD.
No@
Y.. 0
Not]
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Homicido
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o PLACE OF INJURY. AI hOmo. t.'m~;.... lad.,..,. ._
building. ."C;. \SpecIW}
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Hot.....
.Aecidenl
Pending Investigalion
... .....
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DATE SIGNED (Mone1. Day, 'l'earl
Coufd not be delannmed
2". 21b.
CERTifiER lCheck only onel
.CERTIFYING PHYSICIAN (Ph'1'$IC\ioOCeI\ltyW) cause d de~ wherr anOlhet' tlhVSlCoarl has pt'onounced dealh ana compleled l1em 231
To the bft,t of my know'-dge. death occurred due 10.... cauH(sJ and manner a. s..tltd. . . . . . . . . . . . . . . . . . . . . . . . , . . .
29.
.PRONOUNCING AND CERTIFYING PHV$tcIAN (PhVSICIafl bOlh pronouncing !Jealh and Cer1rfylllg 10 cause 01 deathl
To the Ne,1 o'.."y knowledgft, dealh occurred at the time. dale, oind place. and due 10 lhe cause(a) and ..".nner.. sa..led..
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'UEDIC..L EX....'NERlCORONER
On the ba.i. ot examination and/or invesligation. in my opinion, dulh occurred at Ihe lime, dale. and place, and due to Ihe cause(s) and
manner a. stated.. .. . .. . , . . , .. ... . . . . . ... . .. , . .... ... .. . ... .. ..... .' ... . . , .. . ............ . .' . , ... , . . .' .... ,
31..
REGISTRAR'S SIGNATURE AND NUMBEA
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12r/I~I/ I
WILL
OF
21-200J.-1l54
RICHARD E. ELLENBERGER
I, RICHARD E. ELLENBERGER, of the Borough of Lemoyne, County
of Cumberland, and State of Pennsylvania, declare this to be my
last will and revoke any will previously made by me.
ITEM I.
I direct that all my just debts and funeral expenses,
including my gravemarker and all expenses of my last illness, and
any and all taxes and assessments imposed by any governmental body
as a result of my death, whether on property passing under this
will or otherwise, shall be paid from my residuary estate as soon
as practicable after my decease as a part of the expense of the
administration of my estate.
ITEM II.
I give, devise, and bequeath all my possessions and
estate of every nature and wherever situate to such of my issue,
per stirpes, as survive my death by sixty (60) days.
ITEM III.
I appoint my son, TERRY E. ELLENBERGER, executor
of this my last will. Should my son, Terry E. Ellenberger, pre-
decease me or otherwise fail to qualify or cease to serve as
executor of this my last will, I appoint my son, BRADLEY J.
ELLENBERGER, executor of this my last will.
ITEM IV.
I direct that my personal representatives shall not
be required to give bond for the faithful performance of their
duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
thiscf 0 day of ;J~ , 19..ft;J
rr &~ 6! ft)_!
Richard E. Ellenber
The preceding instrument, consisting of this and one other
typewritten pages, each identified by the signature of the testator
was on the date thereof signed, published and declared by Richard
E. Ellenberger, the testator therein named, as and for his last
will, in the presence of us, who at his request, in his presence,
and in the presence of each other, have subscribed our names as
witnesses hereto.
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COMMONWEALTH OF PENNSYLVANIA)
( SS.:
COUNTY OF CUMBERLAND )
I, RICHARD E. ELLENBERGER, the testator whose name is signed
to the attached or foregoing instrument, having been duly qualified
according to law, do hereby acknowledge that I signed and executed
the instrument as my last will; that I signed it willingly;
and that I signed it as my free and voluntary act for the purposes
therein expressed.
~/;~ to ~
Sworn or affirmed to and
acknowledged before me by
Richard E. Ellenberger, the testator
this cjt;)n day of /lLC'~jfY',,::jJL' 19i)O.
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Notary pub 'ic
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COMMONWEALTH OF PENNSYLVANIA )
( SS.:
COUNTY OF CUMBERLAND )
WE, SAMUEL L. ANDES and GEORGE A. VAUGHN, III, the witnesses
whose names are signed to the attached or foregoing instrument,
being duly qualified according to law, do depose and say that
we were present and saw the testator sign and execute the instrument
as his last will; that he signed it willingly and that he executed
it as his free and voluntary act for the purposes therein expressed;
that each of us in the hearing and sight of the testator signed
the will as witnesses; and that to the best of our knowledge,
the testator was at that time 18 or more years of age, of sound
mind and under no constraint or undue influence.
RffJ~
sworn or affirmed to and
acknowledged pefore me this
,,~OJJday of i.Lt(ijjnkl3f'l,. 19 (LJ.
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CERTIFICATION OF NOTICE UNDER RULE 5.6(a}
Name of Decedent:
Richard E. Ellenberger
Date of Death:
12 November 2001
Will No.
Admin. No. 2001-01154
To the Register:
I certify that notice of beneficial interest required by Rule 5.6(a) of the
Orphans Court Rules was served on or mailed to the following beneficiaries of the
above-captioned estate on 27 December 2001 :
I
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TO:
Terry Ellenberger
336 North Second Street
Wormleysburg, PA 17043
Bradley Ellenberger
800 Silverlake Road
Lewisberry, PA 17339
Jack Ellenberger
114 N.E. Tulin Road
Kingston, WA 98346
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except:
None
Date: 27 December 2001
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Name: Samuel L. Andes
Address: 525 N. 12th Street
Lemoyne, PA 17043
Telephone #717 761-5361
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Capacity:
Personal Representative
~ Counsel for Personal
Representative
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REV-1500
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT 280601
HARRISBURG, PA 17128-0601
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
E11enber er
DATE OF DEATH (MM-DD-YEAR)
Richard E.
DATE OF BIRTH (MM-DD-YEAR)
11/12/2101 04/13/1919
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
none
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!ZI1 Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach oopy a/Will)
D g. Litigation Proceeds Received
D 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12-82)
07. Decedent Maintained a Living Trust (At!.'3ch copy ofTrust)
D 10. Spousal Poverty Credit (date of death between 12.31-91 and 1-1-95)
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FilE NUMBER
20
COUNTY CODE
01
01154
-----
YEAR
NUMBER
SOCIAL SECURITY NUMBER
207
07
4750
THIS RETURN MUST BE FilED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (daleofdeatll prior to 12-13-82)
D 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under See, 9113(A) {Attach Sch 0)
NAME
COMPLETE MAILING ADDRESS
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FIRM NAME (If Applicable)
525 N. 12th Street
Lemoyne, PA 17043
X.o_ (15)
x.o~ (16) 1.126.30
x .12 (17)
x .15 (1B)
(19)
TELEPHON7If~E~ 6 1- 536 1
1. Real Estate (Schedule A)
2 Stocks and Bonds (Schedule B)
(1)
(2) 2,580.12
(3)
(4)
(5) 30,691. 74
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3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
(6)
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
(7)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10 Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
(9) 3,396.56
(10) 4 ,846.39
11. Total Deductions (total Lines 9 & 10)
12 Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to lax has not been
made (ScheduleJ)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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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 lineal rate
25.028.91
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
.. ---OFFICIAL USE ONLy
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(8)
33,271.86
(11)
(12)
(13)
8,242.95
25,028.91
(14)
25,028.91
Decedent's Complete Address:
STREET ADDRESS
336 North 2nd Street
CITY Worm1evsbura I STATE I ZIP
PA 17043
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits (A + B + C ) (2)
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( D + E ) (3)
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 (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due.
(5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
II IIIf e,_ ,-- --
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
......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,
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
...0
....0
....0
....0
.....0
No
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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
Declaration reparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE
ADDRESS
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 PS. 99116 (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. 99116 (a) (1.1) (ii)].
The statute does not exemDt 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 of the decedent's lineal beneficiaries is 4.5%, except as noted In 72 P,S. 99116(1.2) [72 P.S. 99116(a)(I)].
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)]. A sibling is defined, under Section 9102, as an
individual who has at ieast one parent in common with the decedent, whether by blood or adoption.
REV-1503 EX. (1-9T)
.
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Ect~tE" nf Ri,...h;::trrl 1= I=lIpnhArgAr
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
FILE NUMBER
2001-01154
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
72 shares of common stock in UGI Corporation
(see appraisal attached) $2,096.64
17 shares of stock in Prudential Financial Corporation
(valued at $28.44 per share) $483.48
TOTAL (Also enter on line 2, Recapitulation) $ 2,580.12
(If more space is needed, insert additional sheets of the same size)
Frank R. Baker
146 Springhouse Lane
Spring Grove, PAl 7362
Phone: 717/225-5450
Fax: 717/225-0494
e-mail: frankr.baker@suscom.net
June 21, 2002
Samuel LAndes
Attorney At Law
525 North Twelfth Street
P.O. Box 168
Lemoyne, PA 17043
Here is the information you requested concerning the stock value of UGI owned
by Richard Ellenberger as of November 12,2001.
Equities
Hil!:h
Low
A veral!:e
Shares
Value
UGI Corporation
UGI 29.22
29.01
29.12
72
2096.64
If you have any questions, please call me.
Sincerely,
~~
Frank R. Baker
Pr~dential ~ Financial
Retain for Your 2002 Tax Records
. DATE
01/25/02
REFERENCE NUMBER
24- 72041
6336525 24-72041
',ICHARD E ELLENBERGER
336 N 2ND ST
WORMLEYSBURG PA 17043
020002472041
,.
We're pleosed to inform you that Prudential hos completed its conversion from a mUll;al C\)jJljlaUY to a stock comrany~
As part of our conversion, we are issuing cash payments to eligible owners of the company. This includes anyone who
~~~l an eligible policy or ~nnuity contract as of December 15. 2000. Your check is below.
ThIs does not affect your In.~l1rance policy or annuity in any wuy.
Your payment is a benefit of holding an eligible polic-y' or contr",-(, It does not replace your policy or contract, or change
your benefits. cash values, eligibility foi' policy dividends 01' guarantees. You do not have to give anything up to receive
your payment.
How your paYlnent was detennilled.
Company actuaries and external advisors developed a plan for dividing the value of Prudential among its OIYners.
Factors such JS the type o@e, annuity or h~f!!!l Dolicy or c;ontract YOU o\~~led~ the f~ce__~alue, and h?w 10112 YOU o}Y!!.-e._~__.i.~
determined your compensation. Your payment was first calcuTiited as a number of stock shares. These shares were then
converted to an equivalent value in cash. Competlsation for all policies eligible for cash payment is included in this check.
SEE BACK FOR MORE DETAILS.
~
~
m
m
D
<(
:g
o
~
gj
17.0000
$28.44
$483.48
Questions? Call 1-800-243-1701 weekdays ham 8:00 a.m. to 7:00 p.m. (ET).
(Telecommunications Device for the Deaf, 1-800-619-2837.)
Prudential ~ Financial
-'.l'II'.'j'''I:''II''':I.II:l1:''''':Ut:I'III~lt.''~I..tf:::l~IIII~1=-":"'I~..r~I;"!I""I:::I:Il!Jf":I._
6336525
CHECK NUMBER
006336525
51-44
119
2301 10
24-72041
CHECK DATE
Please Cash Within 180 Days 01125/02
PAY TO TIlE ORDER OF
RICHARD E ELLENBERGER
336 N 2ND ST
WORMLEYSBURG PA 17043
CHECK AMOUNT
$483.48********
11'001;:1:11; 52511' ':0 ~ Flool,l, 51:
- ---'_._--".~._--_._'--_.-_._.__._.._-------_._,-.-__..--..- .....- '.----., -------..._.___.____...__n_.______.__ 0"_'__,__... ___"___"__'"'~'___'
ta Security Features Included (Details on Bac~)
'"
r(~
Authorized Official
EquiServe. Inc.
TO FLEET BANK, HARTFORD, CT
-----------.----------..---.--------.---------..----
I;Bo 2BII'
Prudential ~ Financial
--
Retain for Your 2002 Tax Records
DATE
01/25/02
REFERENCE NUMBER
24-72041
Ij336525 24-72041
RICHARD E ELLENBERGER
:l36 N 2ND ST
WORMLEYSBURG PA 17043
020002li72041
.,i-._
We're pleased to inform you that Prudential has completed its conversion ti'Om a mutval cQ[llPilliY to a stock comrany~
As pnrt of our conversion. we are issuing cash payments to eligible owners of the company. This includes anyone who
~11~~1 an eli~ble policy or ~pnuity contract as of December 15. 2000. Yom' check is helow.
This does not affect your inml'3nce policy or annuity in any way.
Your payment is a benefit of holding an eligible policv or contmd It does not replace your policy or contract. or change
your benefits. cash values, eligibility for policy dividends or guanmtees. You do not have to give anything up (0 receive
your payment.
How your paYlnent was detennine_d.
Company actuaries and external advisors developed a plan for dividing the value of Prudential among its owners.
Factors such as the type oQg'e. annuity or heEl'h policy or contract you O\~ned. the face value. and how long you oW!l"'lit
determined your compensation. Your payment was first calculated as a numher of stock shares. These shares were then
converted to an equivalent value in cash. Compelisation for all policies eligible for cash payment is included in this check.
SEE BACK FOR MORE DETAILS.
"'
ill
o
'"
~
o
6
~
i!J
N
17.0000 $28.44
$483.48
Questions? Call 1-800-243-1701 weekdays from 8:00 a.m. to 7:00 p.m. (BT).
(Telecommunications Device for the Deaf. 1-800-619-2837.)
Prudential ~ Financial
-
....".II..!I'jll:[.II..:l.II::a:'.lH~Ui:I.I'I~I.."~I..ct::l~111I...I::aIol:r.,I.....I"'I~.!I".":::r:lM.':i;_
6336525
CHECK NUMBER
006336525
51.44
119
2301 10
24-72D41
CHECK DATE
Please Cash Within 180 Days 01/25/02
PAY TO TIlE ORDER OF
RICHARD E ELLENBERGER
336 N 2ND ST
WORMLEYSBURG PA 17043
CHECK AMOUnT
5483.48********
~--------,-----.-------_. ------------..-----------...--
~SeCUrityFeatu'eslnclUcled(DetailsonBaCk)
""
r(~
Authorized Official
EquiServe. Inc.
TO FLEET BANK, HARTFORD. CT
lI'oob:l:lbS2SII' ,:ol.l."IooI,I,S':
b802811'
Prudential ~ Financial
-
Retain for Your 2002 Tax Records
DATE
01/25/02
REFERENCE NUMBER
24-72041
6336525 24-72041
HICHARD E ELLENBERGER
336 N 2ND ST
WORMLEYSBURG PA 17043
020002"720'<1
.H.
We're pleased to inform you that Prudential has completed its conversion from a m.ut~aI cQl1jp"ny to a stock company~
As part of our conversion, we are issuing cash payments to eligible owners of the company. This includes anyone who
c:wl1eSI an e~gi~l,: policy or annuity contract as of December 15, 2000. YOlll' check is below.
This does not affect your insurance policy or annuity in any way.
Your payment is a benefit of holding .an eli~ible policv or contrnrt It does not replace your policy or contmct, or change
your benefits! cash values. eligibility l{;r policy dividends or gucmmtees. You do not have to give anything up to receive
yoW' payment.
How your paYlnent was detennined.
Company actuaries and external advisors developed a plan for dividing the value of Prudential among its owners.
Factors such as the type o~, annuity or health Dolicy or contract you owned, the facevalue, and how long you ow!!e(li~
determined your compensation. Your payment was first calcuTated as a number of stock shares. These shares were then
converted to an equivalent value in cash. Competisation for all policies eligible for cash payment is included in this check.
SEE BACK FOR MORE DETAILS.
en
ro
i'i
<<
~
a
6
~
~
i'1
17.0000
$28.44
$483.48
Questions? CaU 1-800-243-1701 weekdays from 8:00 a.m. to 7:00 p.m. (ET).
(Telecommunications Device for the Deaf, 1-800-619.2837.)
Prudential ~ Financial
-'l'II'.T"J":I'l".:llil1l:ll:"l"~Ut:I'llh~IJ""i'lII.ei::li'l.l.1.~I=-tl:r'lI"'..''''I:.!.'''lI.::I=IIIJF'l:l;
6336525
CHECK NUMBER
006336525
51-44
119
2301 10
24-72041
CHECK DATE
Please Cash Within 180 Davs 01/25/02
PAY TO TIlE ORDER OF
RICHARD E ELLENBERGER
336 N 2ND ST
WORMLEYSBURG PA 17043
CHECK AMourH
5483.48********
TO FLEET BANK, HARTFURD, CT
tDsecu,llyFeatureSlnCIUded(DelaiISOrlBaCk)
"'
r(~
Authorized Official
EquiServe. Inc.
,,'00b:l:lbS2S'" l:oU,'looI,I,SI:
._---_..,...~ ---.-....-..--.-- ---_.._~ .--------
b8028'''
REV-1508 EX + (1.97)
'*'
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Estate of Richard E. Ellenberger
FILE NUMBER
2001-01154
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
Checking account No. 0090081455 with Allfirst Bank
Balance at Date of Death: $6,170.30
Money Fund account No. 0950496556 with Allfirst Bank
Balance at Date of Death: $24,221.44
Miscellaneous items of clothing and personal effects $300.00
TOTAL (Also enter on line 5, Recapitulation) $ 30,691.74
(If more space IS needed, Insert additional sheets of the same size)
!l allflrst
Allfirst Financial Center N .iL
po. Box 900
Millsboro, DE ] 9966
January 16, 2002
Samuel L. Andes
Attorney At Law
525 North Twelfth Street
P.O. Box 168
Lemoyne, PA 17043
RE: Estate of Richard E. Ellenberger
Date of Death: November 12, 2001
Social Security Number: 207-07-4750
Dear Mr. Andes:
In response to your request, please be advised that at the time of death, the above-
named decedent had on deposit with this bank the following accounts.
1. Account Type........................... Checking Account
Account Number. ................ ... ... 0090081455
Ownership (Names of). .... ...... ... Richard E. Ellenberger
Opening Date..... ......................08/28/64
Balance on Date ofDeath.........$6,170.30
Accrued Interest
$
0.00
Total...................................... .$6, 170.30
2. Account Type........................... Money Fund Alternative
Account Number....................... 0950496556
Ownership (Names of).. ............ Richard E. Ellenberger
Opening Date.... .......... ...... .......07/19/00
Balance on Date ofDeath.........$24,185.22
Accrued Interest
$
36.22
Total........ ... ..... .......... ...... ..... ..$24,221.44
. Page 2
January 16, 2002
This letter does not include any accounts in which the deceased may have been listed as power of attorney,
custodian ofunllorm transfers, representative payee, or tnlstee under a written trust agreeIllent.
For any additional information on these accounts, please contact our branch at:
1200 Market Street, West Shore
Lemoyne, PA 17043-1417
Phone: (717) 255-2271
Sincerely,
Charlf~~,~r-/
(302) 934-2722
REV-15~1 EX+ (12-99) .
M
.i.~ . -'):
;~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
I
FILE NUMBER
EEtatil of Rich..rrl F FIIAnhArgAr
Debts of decedent must be reported on Schedule I.
2001-01154
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Rolling Green Cemetary Co. (purchase of casket) $1,625.00
Gerald Stephens Florist (flowers for funeral) $218.31
Giant Food Market (food for post-funeral reception) $208.14
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City State ~ Zip
Year(s) Commission Paid:
2. Attorney Fees Samuel L. Andes $1,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State ~Zjp
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills $86.00
5. Accountant's Fees
6. Tax Return Preparer's Fees $50.00
7. Estate Advertising:
The Sentinel $84.11
Cumberland Law Journal $75.00
Frank Baker (stock appraisal fee) $50.00
TOTAL (Also enler on line 9, Recapilulation) $ 3,396.56
(If more space is needed, insert additional sheets of the same size)
ROmNG GREEN CEMmRY COMPANY
18,. Cart,. Rood . c:on.. HlII."'170H . f71,..,7til..coeS
,
'/
1''\;
004248
CEMETERY INTERMENT RIGHTS, MERCHANDISE AND SERVICES PURCHASE/SECURIty AP~;'M~~
THIS AGREEMENT PROVIDES FOR ENDOWMENT CARE I _ I.
RETAIL INSTALLMENT CONTRACT, :5
-fA., ~_I r ..,;
This Agreement is made this / .3 'day of Pi h V ,20 0 I . by and be~ween the 1mdersi, ;eJS~r"
and -r:f>v/'U F FI/i""d'Jg</c~,r-1. ,her9naftercalledthe'; fcllaser;J-Q
Address ,,: -~ T - /1,j;J f / '3'< .J't.. ' , ~
ResidenceTe]ephoneNo.(~)- '€BayTelephoneNo.~) 'Slate(, '" ',i '.> ZIp _'['
WITNESSETH THAT: The Seller agrees to sell and Purchaser agrees to buy the following described IntenneDl Rights;MercHandise arid Services.
;E1Ueveloped 0 Predeveloped 1if'"' t 0 Lawn Crypt 0 Mausoleum 0 Niche 0 Other '!
Description of Inlennellt Rights: d e ~ C-" I-
'-
No.
I
IntermenIRighls(inc.S
MemoIialization_Type
Size
Memorial Base - Type
Size Color
MemoriallnstallationlInspectionFee.
Memorial Maintenance...............,......................................
Casket-Description f}/q; {J'ttfU/),M.ojIAfl..f'2
Material: Wood/Metal ' Gauge -
Outer Burial Container_Type
IntermentandRecordingFee..
Processing Fee.
Other
Travel Proteetion Plan (seebelow)...
Sales Tax.
(a) Total Cash Price (Including Sales Tax)..
INTERMENT RlGHTS, MERCHANDISE AND SERVICES
ECF) $ Less:
Down Payment Cash
Credit For ':if J ().::J
J !If
(l /C,;I>.oq)
( / V'/s-:<lO)
($30.;>"00)
19
7<)
-=3a7c:1.ou
't! {
$~ry~o.~dO
Design
(b) Total Down Payment..
(c) Unpaid Balance of Cash Price (Amount Financed)...
(d) ServiceCharge(FinanceCharge)..
(e) Time Balance (Total of Payments) ..
(f) Time SlI]e Price............. ................................,
299C~o
ry '\": 114
Remarks:
1--0/1
$
The Travel Protection Plan being purchased hereunder is a product provided by a third party, not by the cemetery identified in Ihis Agreement. The third party provider is not
owned by or affiliated with the cemetery, and the cemetery is not responsible for the performance of the services associated with the Travel Protoclion Plan. The Purchaser
will be required to enter intoaseparatecontractwith the third party providerpertainihgtoTravel Protection Plan. That plan has been referenced in this Agreement and included
in the purchase price above solely for the convenience of the Purcha serinrriakingpayments.
ITEMIZATION OF AMOUNT FINANCED: $ ~ shall be credited to your account with the Seller for the Intennent Rights,
Merchandise and Services the Seller is providing to you ( . amount is equal to the Total Cash Price less your down {)itymcnt if any)
AN~UAL FINANCE Amount Financed Total of Payments Total Sale Price
PE CENTAGE CHARGE The amount of credit The amount you will have The total cost or YOUfJiur-
RATE The dollar amotmt the provided to you or paid after you have made all chase on creditjinc1u' Ing
The cost of your credit credit will cost you. on your behalf. payments as scheduled. your down payment of
aSayearlY4 --e-. r:9-.. $ ~o )a .(.n (b)
% (d) $ (e) $ (,)$ 3070.00 (a+d)$~, ? ~ n.
Your payment schedule wiJl be:
Number of Payments Amount of Payments nL When Pa ments Are Due \. ,
$ T .. ,,7 Beginning .
On, $ I , " ,
Prepayment: If you pay ofT early, you will be entitled to a rebate ofalJ or part of the Finance Charge. .1 'IIi' .::";:;
Security: You are giving a security interest in the goods and property being purchased. , ~J
L", Choc,,,, Iff"" ,'yment;, not m,de within 15 d,y, ,ft" i. i, d"" yoo will b"h"g,d $5.00" 5%of,ooh p'ym'n!, which"" i, Ie,". ,,~jf' ,;
Other Provisions: See this Agreement for any additional infonnation ab~:lUt nonpayment, default, any required ,repayment in full ((:xclusive of un ear . Hna~.se
charges) before the scheduled date, and prepayment rebates and penaltIes. .' , 'J'-i' ("
, .,'
rf accepted by Seller, the parties hereto agree to the following terms and conditions: !!
1. Agreement to Pay. Having first been quoted both a Total Cash Price and a Total Sale Price for the items described abpvc, and for value-~eceived, the.,'i
undersigned Purchaser, jointly and severally, ifmore than one, promises to pay to the order of Seller, at its address shown below, the al)lount identified above .....
as the Total of Payments in accordance with the payment schedule dates set out above. . <.
2. Title. Seller wiIJ retain title to said Interment Rights and Merchandise until the Total Sale Price has been paid by Purchaser to Seller.
3. Cemetery Rules and Regulations. Purchaser agrees that all rights conveyed under this Agreement are subject to, and Purchaser agreesto at all times
comply with, the present (and as may be hereafter adopted, amended or altered) Rules, Regulation~ and BylawsofSeller, which are available forexamina!ion
inSelJer'soffice. '
4. Prepayment. Upon prepayment in full, whether voluntarily or upon acceleration by reason of Purchaser's default and paiment in full or judgment being
entered against Purchaser for the unpaid balance, Purchaser sha1l receive a rebate of any unearned Finance Charge computed in accordance with the" Actuarial
Methud". H the Total Sale Price is paid within J2 months of the date of this Agreement, or on or before its maturity if it matures in less than 12
months, Purchaser will be entitled to a full rebate of any Finance Charge!
5. Interment and Recording Fee. Unless otherwise specifically provided herein, a charge for opening and closing the interment space and applicable
cemetery document recording (herein referred to as "Interment and Recording Fee"), is not included in the TOlal Cash Price set forth herein, and there will
be an added J:harg,e for this service at the lime of need. I,fthe)nterment and Recording Fee is purchased hereunder, the payment of such Interment
and Recording Fee"entitles the Purchaser to protection against ,overtime charges. Bowever,' overtime hours are limited to the following:
Weekdays Weekend . NOintermeiltswillbescheduledonholidays. IftheprevailingpriceforInterment
and Recording at the time of interment is less than the fees paid for such services under this Agreement, you will be refunded the difference.
6. Issnance of Certificate of Interment Rights. Upon payment of the Total Sale Price by the Purchaser, the Seller agrees to convey the above-described
Interment Rights by issuanceofa Certificate oflnterment Rights to the person(s) designated below:
NAME
ADDRESS
CITY
NEXT OF KIN
S/4t~
NAME
ADDRESS
CITY
,~,
Add=,
City.stoto.Zip
-,
Notice to the Buyer - (1) Do not sign this Agreement before you read it or if it contains anJ blank spaces. (2) You are entitled to a
completely filled-in copy of this Agreement. (3) Under the law, you have the right to pay offm advance the full amount due and under
certain conditions to obtain a partial refund of the Service Charge.
NOTICE: BY SIGNlNG TIllS AGREEMENT, PURCHASER IS AGREEING THAT ANY CLAIM PURCHASER:MAY HAVE AGAINST
THE SELLER SHALL BE RESOLVED BY AMITRA TION AND PURCHASER IS GIVING UP HISlHER RIGHT TO A COURT OR JURY
TRIAL AS WELL AS HISIHER RIGHT OF APPEAL.
Buyer Hereby Acknowledges That This Agreement Was Completed As To All Essential Provisions Before It Was Signed By Buyer
And A Copy Thereof Was Delivered To Boyer At The Time This Agreement Was Signed.
I," ,/......
"
REV-1512EX.{1-97)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
~c:.t::::atl3 nf Rit"h::::arrl ~ ~"j::l.nhj::l.ral3r
Include un reimbursed medical expenses.
ITEM
NUMBER
1.
FILE NUMBER
?nnl-nll'i4
DESCRIPTION
AMOUNT
Terry Ellenberger (reimbursement of funeral expenses) $2,051.45
Claremont Nursing Home $2,275.51
Holy Spirit Hospital $90.21
Central Penn Medical Group $30.30
West Shore Medical Emergency $102.75
Yellow Breeches EMS $74.55
Metro Medical $29.00
PA GI Consultants $53.46
Claremont Nursing Home $119.30
James E. Blacksmith, D.O. (Medical bill) $19.86
TOTAL (Also enter on line 10, Recapitulation) $ 4,846.39
(If more space is needed, Insert additional sheets of the same size)
--
~EV-1513EX. (1-97)
'*
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Estate of Richard E. Ellenberger
FILE NUMBER
2001-01154
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1. Terry Ellenberger Son
One-third
336 North Second Street
Wormleysburg, PA 17043
Bradley Ellenberger Son One-third
800 Silverlake Road
Lewisberry, PA 17339
Jack Ellenberger Son One-third
11477 N.E. Tulin Road
Kingston, WA 98346
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. None
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART IT. 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)
\/?-02~- ?
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
SAMUEL LANDES
525 N 12TH ST
LEMOYNE
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
~COUNTY
ACN
09-10-2002
ELLENBERGER
11-12-2001
21 01-1154
CUMBERLAND
101
REV-1547 EX AFP 101-OZl
RICHARD
E
PA 170fi~
Amount Remitted
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 ~
REV =is"4,-e.X--AFP--foY=02Y-Ncffice.--oF-YNHe.ifiTANCE-YAjrjrPPRAise.iiENT-:--AiiowANcro"R----------- - -- - --
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF ELLENBERGER RICHARD E FILE NO. 21 01-1154 ACN 101 DATE 09-10-2002
TAX RETURN WAS: I X) ACCEPTED AS FILED
) CHANGED
NOTE: 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. 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
.00 X 00 = .00
25,028.91 X 045 = 1,126.30
.00 X 12 = .00
.00 X 15 = .00
(19)= 1,126.30
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate ISchedule A)
2. Stocks and Bonds ISchedule B)
3. Closely Held Stock/Partnership Interest ISchedule C)
4. Mortgages/Notes Receivable ISchedule D)
5. Cash/Bank Deposits/Misc. Personal Property ISchedule E)
6. Jointly Owned Property ISchedule F)
7. Transfers ISchedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses ISchedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequestsi Non-elected 9113 Trusts ISchedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
.00
2,580.12
.00
.00
30,691.74
.00
.00
(8)
3,396.56
4,846.39
Ill)
(12)
(13)
(14)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
33,271.86
8.242 95
25,028.91
.00
25,028.91
TAX CREDITS:
.......n. n"_"6' . (+J AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID 1-)
07-25-2002 CDOO1446 .00 1,126.30
TOTAL TAX CREDIT 1.126.30
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
* IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
I 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.)
fY/
STATUS REPORT UNDER RULE 6.12
Name of Decedent:
R \ c lc< r cQ E, E \ ~ (' ,v b p ,re) f' ,i(.
v
Date of Death:
II-j 2..-700 t
Will No.
Admin. No. Z/-OJ- itS1
Pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to completion of
the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes X No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes No ><
b. The separate Orphans' Court No. (if any) for
the personal representative's account is:
c. Did the personal representative state an
account informally to the parties in interest? Yes >< No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
Date:~
~~ -~-O.sl,
S.r ture
5,qfV\vI. E L C 4 iVOE5
Name (Please type or print)
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Address
(711 ) 7<'ot S:sC,1
Tel. No.
Capacity: Personal Representative
)( Counsel for personal
representative
(MAH:rmf/AM3)