HomeMy WebLinkAbout07-06-05
. REV-I500 ~ + (6-00)
*
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
OFFICIAL USE ONLY
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
DECEDENrs NAME (LAST. FIRST. AND MIDDLE INITIAL)
Sommer, Mary A
DATE OF DEATH (MM-DD-YEAR)
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04-13-2005
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
12-05-1907
DATE OF BIRTH (MM-DD-YEAR)
FILE NUMBER
II 06
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
6\0~
NUMBER
491-28-2197
THIS RETURN MUST BE FILED IN DUPUCATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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D 2. Supplemental Return
D 4a. Future Interest Compromise (date of death after
12-12-82)
D 7. Decedent Maintained a Living Trust (Attach
copy of Trust)
D 10 Spousal PovertY Credit (date of death between
. 12-31-91 and 1-1-95)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAIUNG ADDRESS
James D. Bogar
FIRM NAME (If applicable)
Bogar & Hipp Law Offices
D 1. Original Return
D 4. Limited Estate
[!] 6. Decedent Died Testate (Attach
copy of Will)
D 9. Litigation Proceeds Received
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III
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3. Remainder Retum (date of death prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 11. Ejection to tax under Sec. 9113(A) (Attach Sch 0)
TELEPHONE NUMBER
717-737-8761
One West Main Street
Shiremanstown, PA 17011
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
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)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non.Probate Property
(Schedule G or L) D Separate Billing Requested
8. Total Gross Assets (total Lines 1.7)
9. Funeral Expenses & Administrative Costs (Schedule H)
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(.)
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(1 )
(2)
(3)
(4)
(5)
(6)
(7)
OFFICIAL USE ONLY
None
None
None
None
4,252.59
264,824.09
None
12. Net Value of Estate (Line 8 minus Line 11)
(8)
269,076.68
(9)
1,962.50
11. Total Deductions (total Lines 9 & 10)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
(11 )
1,962.50
267,114.18
0.00
(12)
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)
20.0
(13)
(14)
267,114.18
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
0.00
12,020.14
0.00
0.00
12,020.14
CHECK HERE IFYOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
15. Amount of Line 14 taxable at the spousal tax rate, 0.00 x .00 (15)
z or transfers under Sec. 9116(a)(1.2)
0 (16)
i= 16.Amount of Line 14 taxable at lineal rate 267,114.18 x .045
<I:
I-
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a.. 17. Amount of Line 14 taxable at sibling rate 0.00 x .12 (17)
::!E
0
(.) 18. Amount of Line 14 taxable at collateral rate 0.00 .15 (18)
>< x
~ 19. Tax Due
(19)
>>BE SURE TO ANSWER ALL QUESTIONS ON REVERSE sloe AND'RECHECK MATH<<
Copyright 2002 form software only The Lackner Group, Inc.
Form REV.1500 EX (Rev. 6-00:
,j Decedent's Complete Address:
STREET ADDRESS
32 Center Street
CITY Camp Hill
STATE P A
ZIP 17011
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
12,020.14
601.01
Total Credits (A + B + C)
(2)
601.01
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (0 + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 1 Line 20 to request a refund
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. (SA)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
11,419.13
11,419.13
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;................................................................................ ~ ~:x
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? ............. .......................................... ..... .._................... ...... .................... ........
o [!]
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ......... 0 [!]
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ..............................................................-.................................................... 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.
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 of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FlUNG RETURN ADDRESS
BettY~. Butl~r e.
SIGNATURE OF P SON RESPONSIBLE FOR FlUNG RETURN
DATE
34 Center Street
Camp Hill, PA 17011
(p /30);[:)-
ADDRESS
DATE
ADDRESS
One West Main Street
Shiremanstown, PA 17011
DATE
(p /30Ja5"
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% [ .S. 99116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the ne t" i l\ ~
[72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a survi I ~ '" r D
of assets and filing a tax retum are still applicable even if the surviving SpOUSE
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child lwer
natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S.
The tax rate imposed on the net value of transfers to or for the use of the dec
99116 1.2) [72 P.S. 99116 (a) (1 )].
3 surviving spouse is 0%
equirements for disclosure
J. t\~
to or for the use of a
pt as noted in 72 P.S.
The tax rate imposed on the net value of transfers to or for the use of the dec
defined under Section 9102, as an individual who has at least one parent in (._.......
i) (1.3)]. A sibling is
lood or adoption.
, Rev-1508n+(6-98)
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMOfI!WEALTH OF PENNSv\"VANIA
INHERITANCE TAX RETURN
RESIOENT OECEDENT
Sommer, Mary A
IFILE NUMBER
21--
ESTATE OF
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property lolntly-owned with the right of survivorship must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION
1 Musselman Funeral Home - Refund for overpayment of prepaid funeral expenses
VALUE AT DATE
OF DEATH
4,252.59
TOTAL (Also enter on Line 5, Recapitulation)
4,252.59
(If more space is needed, additional pages of the ,same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule E (Rev. 6-98)
, Rev-1509111c+ (6-98) ..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTL V-OWNED PROPERTY
Sommer, Mary A
IFI;;_NUMBER
ESTATE OF
If an asset was made joint within one year of the decedent's date of death, It must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. Betty E Butler
34 Center Street
Camp Hill, PA 17011
Daughter
B.
C.
JOINTLY OWNED PROPERTY:
DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
LETTER
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSEi INTEREST DECEDENT'S INTEREST
JOINTLY-HELD REAL ESTATE.
1 A 2/18/1986 600 shares of Bell South Corp - Stock 15.756.00 50.000% 7.878.00
2 A 2/18/1986 BP PLC - Stock 73.512.00 50.000% 36.756.00
3 A 2/18/1986 Burlington Northern Santa Fe - Stock 16.342.02 50.000% 8.171.01
4 A 2/18/1986 Cinergy Corp - Stock 6.018.00 50.000% 3.009.00
5 A 2/18/1986 Conagra Foods - Stock 13.470.00 50.000% 6.735.00
6 A 2/18/1986 FPL Group Inc - Stock 16.404.00 50.000% 8.202.00
7 A 2/18/1986 General Electric - Stock 10.692.00 50.000% 5.346.00
8 A 2/18/1986 Hershey Foods Corp - Stock 12.310.00 50.000% 6.155.00
9 A 2/18/1986 Medco.Health Solutions - Stock 1.281.60 50.000% 640.80
10 A 2/18/1986 Mellon Financial Corp - Stock 16.458.00 50.000% 8.229.00
11 A 2/18/1986 Merck & Co Inc - Stock 6.904.00 50.000% 3.452.00
Total of Continuation Schedule(s) See attached
pagels)
TOTAL (Also enter on Line 6, Recapitulation) 264.824.09
(If more space is needed, additional pages of the .same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule F (Rev. 6.98)
I Rev-1509 a+ (6-98) .
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
continued
Sommer, Mary A
IFILE NUMBER
21--
ESTATE OF
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
JOINTLY OWNED PROPERTY
DESCRIPTION OF PROPERTY %OF
ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DATE OF DEATH
NUMBER FOR JOINT MADE NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSEl DECO'S VALUE OF
TENANT JOINT INTEREST DECEDENrSINTEREST
JOINTLY-HELD REAL ESTATE.
12 A 2/18/1986 Merrill Lynch Certificate of Deposit - ON 30.000.00 50.000% 15.000.00
Merrill Lynch Bk
Callable CD FDIC Insd
5.50% 10/22/2018
13 A 2/18/1986 Merrill Lynch Corporate Bonds - Merrill 20.186.66 50.000o/c 10.093.33
Lynch & Co Sr Unsub $20,000
Notes Global
6.00% 2/17/2009
Accrued Interest $186.66
14 A 2/18/1986 Merrill Lynch Money Markets/Cash - ML 34.128.21 50.000% 17.064.11
Bank Deposit Prog Mny Mkt
15 A 2/18/1986 Merrill Lynch Mortgage/Asset Backed- 42.36 50.000% 21.18
GNM P006571 08% 2005
Amortized FCR .00083
Estimated Market Value $42
Accrued Interest Paid $.36
See Page 5, CMA Account Statement
16 A 2/18/1986 Merrill Lynch Mortgage/Asset Backed- 35.29 50.000% 17.65
GNM P007523 08% 2005
Amortized FCR .00057
Estimated Market Value $35
Accrued Interest Paid $.29
See Page 5, CMA Account Statement
.
17 A 2/18/1986 Merrill Lynch Mortgage/Asset Backed- 215.48 50.000% 107.74
GNM P013449 08% 2006
Amortized FCR .00421
Estimated Market Value $214
Accrued Interest Paid $1.48
See PAge 5, CMA Account Statement
18 A 2/18/1986 Merrill Lynch Mutual Funds - ML Global 23.358.35 50.000% 11.679.18
Allocation B
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule F (Rev. 6-98)
,
I Rev-1509 EX+ (6-98) ..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTL V-OWNED PROPERTY
continued
Sommer, Mary A
IFILE NUMBER
21-
ESTATE OF
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
JOINTLY OWNED PROPERTY
DESCRIPTION OF PROPERTY %OF
ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DATE OF DEATH
FOR JOINT MADE DECO'S VALUE OF
NUMBER NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSEl
TENANT JOINT INTEREST DECEDENTS INTEREST
JOINTL V-HELD REAL ESTATE.
19 A 2/18/1986 Merrill Lynch Preferred Stock - Virginia 10.536.00 50.000% 5.268.00
Power Cap Tr II Pfd 7.375% 7/30/2042
20 A 2/18/1986 Merrill Lynch Preferred Stock - Wells 9.417.00 50.000% 4.708.50
Fargo Cap Tr IV Pfd 7.00% 9/01/2031
21 A 2/18/1986 Merrill Lynch Preferred Stock - Progress 12.600.00 50.000% 6.300.00
Energy Contingent Value Oblig
22 A 2/18/1986 Microsoft Corp - Stock 5.008.00 50.000% 2.504.00
23 A 2/18/1986 Nstar - Stock 11.100.00 50.000% 5.550.00
24 A 2/18/1986 Progress Engery Inc - Stock 16.044.00 50.000% 8.022.00
25 A 2/18/1986 Owest Communications Intllnc - Stock 663.52 50.000% 331.76
26 A 4/3/1986 Real Estate - All that certain piece or 115.910.00 50.000% 57.955.00
parcel of real estate having thereon
erected a dwelling house being known
and numbered as 32 Center Drive, Camp
Hill, Pennsylvania, being Tax Parcel No.
13-24-0807-021. The property was
acquired by Mary A. Sommer, the
Decedent herein, and Betty E. Butler, by
deed dated April 3, 1986, a copy of which
is attached hereto and incorporated
herein: The property was acquired as
joint tenants with right of survivorship. It
is respectfully suggested that the fair
market value of the real estate is as
follows: $115,910 (county assessed
value) x 1.0 (common level ratio factor) =
$115,910.
27 A 2/18/1986 SBC Communications - Stock 13.630.76 50.000% 6.815.38
Copyright (c) 2002 form software only The Lackner Group, Inc.
FOnT! PA-1500 Schedule F (Rev. 6-98)
, Rev-1509 a+{S-9S) .-
COMMONWEAl. Tli OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F .
JOINTL V-OWNED PROPERTY
continued
Sommer, Mary A
IFILE NUMBER
21--
ESTATE OF
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
JOINTLY OWNED PROPERTY
DESCRIPTION OF PROPERTY %OF
ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEAT~ DATE OF DEATH
FOR JOINT MADE DECD'S VALUE OF
NUMBER NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASS
TENANT JOINT INTEREST DECEDENT'S INTEREST
JOINTL V-HELD REAL ESTATE.
28 A 2/18/1986 United Dominion Realty Tr - Stock 6.333.00 50.000% 3.166.50
29 A 2/18/1986 Verizon Communications - Stock 24.639.40 50.000% 12.319.70
30 A 2/18/1986 Vodafone Group PLC - Stock 6.652.50 50.000% 3.326.25
.~
.
TOTAL (Also enter on Line 6, Recapitulation) 264.824.09
Copyright (c) 2002 form software only The Lackner Group, Inc.
Fonn PA-1500 Schedule F (Rev. 6-98)
Global Private Client Group
~ Merrill Erynch
214 Senate Avenue
Suite 501
P.O. Box 0810
Camp Hill, Pennsylvania 17001-0810
717 975 4600 Main
800 937 0735 Toll Free
FAX 717 975 4663
June 2, 2005
James D. Bogar
Attorney At Law
One West Main Street
Shiremanstown, P A
RE: Estate of Mary A. Sommer
Dear Mr. Bogar,
Per your request, following is a list of the assets held long in Mrs. Sommer's and Mrs.
Butler's joint account as of close of business 4/13/2005.
I have enclosed a Historical Pricing Detail, which lists the Cusip Number and High, Low,
and Closing Prices for each security. For your convenience, the detail follows in the same
order as the securities listed below. I have also summarized accrued interest and
dividends payable information below.
Account # & Title:
872-37947 Mary A. Sommer and Betty E. Butler JTWROS
Description:
Date Opened:
CMA Account - money market and investment account
2/18/1986
The information set forth herein was obtained from sources
which we believe reliable, but we do not guarantee its accuracy.
Neither the information, nor any opinion expressed, constitutes a
solicitation by us of the purchase or sale of any securities or
commodities. Printed in USA.
, ~ KerriU Lynch
Stocks & Related
Ouantitv (Shares)
BellSouth Corp
Burlington Northern Santa Fe
BP PLC
Conagra Foods Inc
Cinergy Corp
FPL Group Inc
General Electric
Hershey Foods Corp
Mellon Financial Corp
Medco Health Solutions
Merck & Co Inc
Microsoft Corp
Nstar
Progress Energy Inc
Qwest Communications IntI Inc
SBC Communications
United Dominion Realty Tr
V o<iafone Group PLC
Verizon Communications
600
318
1200
500 .
150
400'
300
200.
600
24
200
200
200
382
176
572
300
250'
706
Dividends payable:
General Electric
Nstar
Progress Energy
SBC Comm
Verizon
Record Date 2/28/05 Pay Date 4/25/05
Record Date 4/08/05 Pay Date 5/02/05
Record Date 4/11105 Pay Date 5/02/05
Record Date 4/08/05 Pay Date 5/02/05
Record Date 4/08/05 Pay Date 5/02/05
$66.00
$116.00
$225.38
$184.47
$285.93
The information set forth herein was obtained from sources
which we believe reliable, but we do not guarantee its accuracy.
Neither the infomiation. nor any opinion expressed. constitutes a
solicitation by us of the purchase or sale of any securities or
commodities. Printed in USA.
· ~ MerriII Er'jEtcn
Mutual Funds
:ML Global Allocation B
1439.208
Preferred Stock
Virginia Power Cap Tr IT Pfd 7.375% 7/30/2042
Wells Fargo Cap Tr IV Pfd 7.00% 9/01/2031
Progress Energy Contingent Value Oblig
400
365
300
Certificates of Denosit
DN Merrill Lynch Bk
Callable CD FDIC Insd
5.50% 10/22/2018
30,000
Dividend payable:
Record Date 4/07/05 Pay Date 4/22/05
Corporate Bonds
Merrill Lynch.& Co Sr Unsub
Notes Global
6.00% 2/17/2009
20,000
Accrued Interest: $186.66
Government Bonds
Federal Natl Mortage Assoc
Callable Notes
Multi% 3/17/2009
10,000
Accrued Interest: $21.66
$140.14
The infonnation set forth herein was obtained from sources
which we believe reliable, but we do not guarantee its accuracy.
Neither the infonnation, nor any opinion expressed, constitutes a
solicitation by us of the purchase or sale of any securities or
commodities. Printed in USA.
.~ MerriH Lynch
Mort2a2e I Asset Backed
GNM P006571 08% 2005
Amortized FCR .00083
GNM P007523 08% 2005
Amortized FCR .00057
GNM PO 13449 08% 2006
Amortized FCR .00421
Monev Markets I Cash
50,000
Accrued Interest Paid 4/15/05:
Principal Return Paid 4/15/05:
60,000
Accrued Interest Paid 4/15/05:
Principal Return ~aid 4/15/05:
50,000
Accrued Interest Paid 4/15/05:
Principal Return Paid 4/15/05:
11L Bank Deposit Prog Mny Mkt
$.36 .
$12.74
$.29
$8.06
$1.48
$10.81
$34,128.21 .
The information set forth herein was obtained from sources
which we believe reliable, but we do not guarantee its accuracy.
Neither the information, nor any opinion expressed, constitutes a
solicitation by us of the purchase or sale of any securities or
commodities. Printed in USA.
~ MerriH L:ynch
On May 12, 2005, all assets were transferred from account 872-37947 to Mrs.
Butler's account as the surviving joint tenant.
Please give me a call with any questions or if you require additional information.
Sincerely,
dfu ~tis-~
Lori S. Hoffeditz
Registered Client Associate
Enclosures
cc: Betty E. Butler
The infonnation set forth herein was obtained from sources
which we believe reliable, but we do not guarantee its accuracy.
Neither the information, nor any opinion expressed, constitutes a
solicitation by us of the purchase or sale of any securities or
commodities. Printed in USA.
Historical Pricing Inquiry
BLS - BELLSOUTH CORP Cusip: 079860102
Date High Price Low Price Close Price Volume
04/13/2005 26.740 26.250 26.260 6508000
BNI - BURLINGTON NORTHN SANTA FE Cusip: 12189T104
Date High Price Low Price Close Price Volume
04/13/2005 52.835 51.260 51.390 1899700
BP - BP PLC Cusip: 055622104
Date High Price Low Price Close Price Volume
04/13/2005 62.260 61.150 61.260 4396300
CAG - CONAGRA FOODS INC Cusip: 205887102
Date High Price Low Price Close Price Volume
04/13/2005 27.250 26.850 26.940 882100
C1N - C1NERGY CORP Cusip: 172474108
Date High Price Low Price Close Price Volume
04/13/2005 40.700 40.120 40.120 848700
FPL - FPL GROUP INC Cusip: 302571104
Date High Price Low Price Close Price Volume
04/13/2005 41.550 40.850 41.010 1390900
GE - GENERAL ELEC CO Cusip: 369604103
Date High Price Low Price Close Price Volume
04/13/2005 36.220 35.540 35.640 20336000
HSY - HERSHEY CO Cusip: 427866108
Date High Price Low Price Close Price Volume
04/13/2005 61.560 61.010 61.550 1046000
MEL - MELLON FINL CORP Cusip: 58551A108
Date High Price Low Price Close Price Volume
04/13/2005 28.030 27.350 27.430 1224900
MHS - MEDCO HEALTH SOLUTIONS INC Cusip: 58405U102
. Date High Price Low Price Close Price Volume
04/13/2005 53.780 52.890 53.400 2009700
The information has been obtained from sources we believe to be reliable but we do not guarantee its accuracy. Past performance is not
indicative of future performance.
Historical Pricing Inquiry
MRK - MERCK a: CO INC Cusip: 589331107
Date High Price Low Price Close Price Volume
04/13/2005 35.300 33.520 34.520 25704000
MSFT - MICROSOFT CORP Cusip: 594918104
Date High Price Low Price Close Price Volume
04/13/2005 25.450 24.990 25.040 60947000
NST - NST AR Cusip: 67019E107
Date High Price Low Price Close Price Volume
04/13/2005 55.630 55.230 55.500 214800
PGN - PROGRESS ENERGY INC Cusip: 743263105
Date High Price Low Price Close Price . Volume
04/13/2005 42.280 41.660 42.000 1452200
Q - QWEST COMMUNICATIONS INTL IN Cusip: 749121109
Date High Price Low Price Close Price Volume
04/13/2005 3.810 3.720 3.770 7620000
S8C - S8C COMMUNICATIONS INC Cusip: 78387G103
Date High Price Low Price Close Price Volume
04/13/2005 23.970 23.710 23.830 8990800
UDR - UNITED DOMINION REAL TV TR IN Cusip: 910197102
Date High Price Low Price Close Price Volume
04/13/2005 21.240 21.090 21.110 1324400
VOD - VODAFONE GROUP PLC NEW Cusip: 92857W100
Date High Price Low Price Close Price Volume
04/13/2005 26.770 26.560 26.610 1005500
VZ - VERIZON COMMUNICATIONS Cusip: 92343V104
Date High Price Low Price Close Price Volume
04/13/2005 35.410 34.790 34.900 5076100
The information has been obtained from sources we believe to be reliable but we do not guarantee its accuracy. Past performance is not
indicative of future performance.
Historical Pricing Inquiry
MBLOX . MERRILL LYNCH GLOBAL ALLC FD
Date Bid Price
04/13/2005 16.230
Cusip: 589939206
Offer Price
16.230
The information has been obtained from sources we believe to be reliable but we do not guarantee its accuracy. Past performance is not
indicative of future performance.
,.
Historical Pricing Inquiry
VELPRA - VIRGINIA PWR CAP TR II
Date High Price
04/13/2005 26.440
Low Price
26.340
Close Price
26.340
Cusip: 928083203
Volume
13300
WSF - WELLS FARGO CAP IV
Date High Price
04/13/2005 25.860
Low Price
25.740
Close Price
25.800
Cusip: 94976Y207
Volume
46000
The information has been obtained from sources we believe to be reliable but we do not guarantee its accuracy. Past performance is not
indicative of future performance.
DN \'4"\~r("'\\\ L~r-~" Bk.
t.u..!:.\? ~ 5q()~ Ow ~:3'"3
<HELP> for explanation.
P?OC Corp HP
~. '-!
Page 1/1
( 5 . 55.......5.52) ~.lLt.,.jy
HI 97.27 ON 4/13/05
AVE 97.273
MLNY/CLOSE/MID/YTM
"1ERRILI LVN Lle-'A' "'lERC 1 10' f')'J "-10 . qo 50'Jr/on 8r2C
I "'" "', _ I ,:) I .....~ Z ,I LL..., 0 _.I-! . . L:J ..10. L:J ,:J
Sour"'ce ~
Range ~'jl=fiU~ to ~'jj~~~:~~ Period [j] Daily
t'1a.rket Ii Mi d/Last LOW 97.27 ON 4/13/05
DATE Price YIELD DATE Price YIELD DATE Price YIELD
F
T
W 4/13 L97.27 5.791
..
Australia 61 2 9777 8600 Brazil 5511 3048 4500 Europe 44 20 7330 7500 Germany 49 69 920410
Hong Kong 852 2977 6000 Japan 81 3 3201 8900 Singapore 65 6212 1000 U.S. 1 212 318 2000 Copyright 2005 Bloomberg L.P.
G999-307-0 02-Jun-05 13'50:00
Historical Pricing Inquiry
'.
C6BC3 - MERRILL LYNCH a: CO INC Cusip: 590188JP4 Maturity: 2/1712009
Date High Price Low Price Close Price
04/13/2005 105.250 105.250
Coupon: 6
Volume
The information has been obtained from sources we believe to be reliable but we do not guarantee its accuracy. Past performance is not
indicative of future performance.
Historical Pricing Inquiry
HAF40 - FEDERAL NATL MTG
Maturity: 3/17/2009
Date
04/13/2005
Cusip: 3136FSDW8
Coupon: 0
Bid Price
97.280
Offer Price
97.410
The information has been obtained from sources we believe to be reliable but we do not guarantee its accuracy. Past performance is not
indicative of future performance.
"
& (\H'" ~ CO uS, \
C.~.I f ~ ~(. '2. O~ 2..:r 0 ~
<HELP> for explanation.
P205 Mtge H P
BGN/NY/CLOSE/MID/YIELD
Pool: Gt',.j5571
Page 1 / 1
Period [!] Daily
HI 107-31
AVE 107.97
ON 4/13/05
Range ~F~~ to li'Au=n~
t'1arket !i Mid/Last LOW 107-31 ON 4/13/05
DATE PRICE YIELD DATE PRICE YIELD DATE PRICE YIELD
F
T
W 4/13 L107-31
.
Australia 61 2 9777 8600 BraZll 5511 3048 4500 Europe 44 20 7330 7500 Germany 49 69 920410
Hong Kong 652 2977 6000 Japan 81 3 3201 6900 Singapore 65 6212 1000 U.S. 1 212 318 2000 Copyright 2005 Bloomberg L.P.
G999-307-0 02-Jun-05 13:51:41
C:r ~~ poc>,S2.3>
c..ug.", f> ;to :; (. '2. C ~ 5 L. c:. 'i
<HELP> for explanation.
P205 Mtge H P
BGN/NY/CLOSE/MID/YIELD
Pool: Gt,.,j7523
Page 1 /' 1
Range ~'Illl~~ to .lair:JjIJ.,
Per'i od ill Dai ly
HI 107-31
AVE 107.97
ON 4/13/05
t1a.rke t II Mid/Last LOW 107-31 ON 4/13/05
DATE PRICE YIELD DATE PRICE YIELD DATE PRlCE YIELD
F
T
W 4/13 L107-31
Australla 61 2 9777 6600 BraZll 5511 3046 4500 Europe 44 20 7330 7500 Germany 49 69 920410
Hong Kong 652 2977 6000 Japan 81 3 3201 8900 Singapore 65 6212 1000 U.S. 1 212 318 2000 Copyright 2005 BloOMberg L.P.
G999-307-0 02-Jun-05 13:52:16
C::r N fV\ P ~ 13'-\ '-\ q
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<HELP> for explanation.
P205 Mtge HP
BGN/NY/CLOSE/MID/YIELD
Poo 1: GI'H3449
Page 1 / 1
Period [!) Daily
HI 107-31
AVE 107.97
ON 4/13/05
Range __'j=fin.~ to ~f.jt=F.lO.~
lia.rket [[ Mid/Last LOW 107-31 ON 4/13/05
DATE PRICE VIELD DATE PRICE YIELD DATE PRICE YIELD
F
T
W 4/13 L107-31
Australia 61 2 9777 8600 BraZll 5511 3048 4500 Europe 44 20 7330 7500 Germany 49 69 920410
Hong Kong 852 2977 6000 Japan 81 3 3201 8900 Singapore 65 6212 1000 U.S. 1 212 318 2000 Copyright 2005 Bloomberg l.P.
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County Parcel No.
ijIqt$ ~~2h,
MADE the 3 rd day of
. in the year nineteen hundred and eighty-six (1986)
BETYVEEN RICHARD ALAN MYERS and VIRGINIA
April
L . MYERS , his wife,
Grantors
AND
MARY A. SOMMER and BETTY E. BUTLER, as joint tenants with~~
rights of survivorship, _______ou
Grantees
WITNESSETH, That in consideration of Fifty-Five Thousand ($55,000.00)---------
-------------------------------------------------------------DoThm,
in hand paid, the receipt whereof is hereby acknowledged, the said grantor S do hereby grant
and convey to the said grantee s ,
ALL THAT CERTAIN tract of land situate in Lower Allen Township,
Cumberland County, Pennsylvania, more particularly bounded and
described as follows, to wit:
BEGINNING at a point on the western side of a fifty (50) feet wide
road known as Center Drive, which point measured along the western
side of Center Drive is eighty (80) feet South of the southwest
corner of Center Drive and Citadel Drive, said point also being at
the southeast corner of Lot No. 106 on the plan of lots hereinafter_
mentioned; thence southwardly along the western side of Ceni:er Drive:-
seventy (70) feet to a point at the northern line of Lot No". 104
on the said plan of lots; thence westwardly along the northern line
of Lot No. 104 aforesaid one hundred twenty-five (125) feet to a
point at the eastern line of Lot No. 91 on the said plan of lots;
thence northwardly along the eastern line of Lot No. 91 aforesaid
seventy (70) feet to a point at the southern line of Lot No. 106
aforesaid; thence eastwardly along the southern line of Lot No. 106
aforesaid one hundred twenty-five (125) feet to a point at the
western s~~~_~f Center Drive, being the place of BEGINNING.
./
BEING Lit No. 105 on the plan known as "Part of Plan No.2, Cedar
Cliff Manor" which plan was recorded 'in the Office of the Recorder
of Deeds in an for Cumberland County in Plan Book 7, Page 13.
:i~ . ~~7-~f::~"~
Having thereon erected a ranch style dwelling known as 32 Center
Drive, Camp Hill, Pennsylvania.
,.BEING the same premises which Lester L. Richards, Jr. and Mary
",Richards, his wife, by their Deed dated August 17, 1979, and re-
=Ccorded in the Office of the Recorder of Deeds in and for Cumberland
, ,'"-,,,,-County in Deed Book "pl1, Volume 28, Page 516, granted and conveyed
. '.'unto Richard Alan Myers and Virginia L. Myers, his wife, Grantors
.0 herein.
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lownsAtp 01 .. -.......... ..,'t.~.~..
Cumb. Co., Pa.
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IN WITNESS WHEREOF, said grantors ha ve hereunto set their hand; and seal s , the
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I hereby certify, that the precise residence of the gx:antee herein is as follow : II
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"tfA~om or Agent for Grantee ! I
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CERTIFICATE OF RESIDEN'CE
(Cammanmc:zltlr af Jcnns~lilztnt2I
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On this, the 3 rd
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19 8 6 , before me
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the undersigned officer, personally appeared RICHARD ALAN MYERS & VIRGINIA L. MYERS
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On this, the
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the undersigned officer, personally appeared
known to me (or satisfactorily proven) to be the person
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, before me
whose name
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executed the same for the purpose therein
IN WITNESS WHEREOF, I have hereunto set my hand and
My Commission Expires ................................................
ClIommonfuczr1tfr of J2nn5~hJztntzt }
(tount~ of ....C:.OmbCl.!fl/l.rt.......... 55.
RECORDED in the Office for Recording of Deeds, etc., in and for s~d County,
in Deed Book No. of-U ,Page &Gq .
WITNESS my hand and official seal this .3 day ou1prt I ,19 8"6
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REV-1151 EX+ (12-99)
*'
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Sommer, Mary A
Debts of decedent must be reported on Schedule I.
I FILE NUMBER
21--
ESTATE OF
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City State Zip
-
Year(s) Commission paid
2. Attorney's Fees Bogar & Hipp Law Offices 1,462.50
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 500.00
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 1,962.50
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule H (Rev. 6-98)
Rev-1502 EX+ (8-98)
SCHEDULE H-B7
OTHER
ADMINISTRATIVE COSTS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
lIESIDENT DECEDENT
Sommer, Mary A
IFILE NUMBER
21--
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
RESERVES: - Costs to conclude administration of Estate including filing fee for PA
Inheritance Tax Return; preparation of Personal and Fiduciary Income Tax Returns
500.00
Subtotal
500.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B7 (Rev. 6-98)
4
REV 1513 EX+ (9-00)
*'
-
SCHEDULE ..
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Sommer, Mary A 21--
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not Ust Trustee(s)
I. TAXABLE DISTRIBUTIONS [include outright spousal
aistributions, and transfers
under Sec. 9116(a)(1.2)]
1 Betty E Butler Daughter Rest, Residue
34 Center Street and Remainder
Camp Hill, PA 17011
Total
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT
BEING MADE
.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule J (Rev. 6-98)
.
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111Cl51 JIlt!! Clttb Q[tslClmtttl
OF
MARY A. SOMMER
I, MARY A. SOMMER, of Lower Allen Township, Cumberland
County, Pennsylvania, make, publish and declare this as and for my
Last Will and Testament, hereby revoking all other Wills and
Codicils heretofore made by me.
FIRST: I devise and bequeath all the rest, residue and
remainder of my estate of whatever nature and wherever situate,
together with any insurance policies thereon, unto my daughter,
BETTY E. BUTLER.
SECOND: Should my daughter, Betty E. Butler, predecease
me, I devise and bequeath all the rest, residue and remainder of
my estate of whatever nature and wherever situate, together with
any insurance policies thereon, in equal shares, to my
grandchildren, NATALIE B. MILLER, ROBYN B. KROHN, TERRI B. DAVIS,
and SHELLEY B. CRUZ, or their issue, per stirpes.
THIRD: In addition to all powers granted to them by law
and by other provisions of this Will, I give the fiduciaries
acting hereunder the following powers, applicable to all property,
exercisable without court approval and effective until actual
~. distribution of all property:
-~ -~ (A) To sell at public or private sale, or to lease, for
;i" any period of time, any real or personal property and to give
\. "-
.J options for sales, exchanges or leases, for such prices and upon
,
such terms (inclu~ing credit, with or without security) or
conditions as are deemed proper. This includes the power to give
legally sufficient instruments for transfer of the property and to
receive the proceeds of any disposition of it.
(B) To partition, subdivide, or improve real estate and
to enter into agreements concerning the partition, subdivision,
improvement, zoning or management of real estate and to impose or
extinguish restrictions on real estate.
(C) To compromise any claim or controversy and to
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abandon any property which is of little or no va~ue.
(D) To invest in all forms of property, including
stocks, common trust funds and mortgage investment funds, without
restriction to investments authorized for Pennsylvania fiduci-
aries, as are deemed proper, without regard to any principle of
diversification, risk or productivity.
(E) To exercise any option, right or privilege granted
in insurance policies or in other investments.
(F) To exercise any election or privilege given by the
Federal and other tax laws, including, but not necessarily being
limited to, personal income, gift and estate or inheritance tax
laws.
(G) To make distributions to my he~ein named benefici-
aries in cash or in kind or partly in each.
(H) To borrow money from themselves or others in order
to pay debts, taxes, or estate or trust administration expenses,
to protect or improve any property held under my will, and for
investment purposes.
(I) To select a mode of payment under any qualified
retirement plan (pension plan, profit sharing plan, employee stock
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ownership plan, or any other type of qualified plan) to the extent
the plan or the law permits them to do so, and to exercise any
':\ other rights which they may have under the plan, in whatever
.\ "
,\L -manner they consider advisable.
~ FOURTH: I direct that all inheritance, estate,
J~
transfer, succession and death taxes, of any kind whatsoever,
which may be pay~ble by reason of my death, whether or not with
respect to property passing under this Will, shall be paid out of
the principal of my residuary estate.
FIFTH: All interests hereunder, whether principal or
income, which are undistributed and in the possession of the
fiduciaries acting hereunder, even though vested or distributable,
shall..not be subject to attachment, execution or sequestration for
any debt, contract, obligation or liability of any beneficiary,
2
. .
..
and furthermore, shall not be subject to pledge, assignment,
conveyance or anticipation.
SIXTH: I nominate and appoint my daughter, BETTY E.
BUTLER, Executrix of this, my Last Will and Testament. In the
event of the death, resignation or inability to serve for any
reason whatsoever of the said Betty E. Butler, I nominate and
appoint 'my son-in-law, ROBERT G. BUTLER, Executor of this, my Last
Will and Testament. I direct that my Executor or Executrix, as
the case may be, and their successors, shall not be required to
post security or a bond for the performance of their duties in any"
jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
to this, my Last Will and Testament, this ;;f-Fday of <;(4)c1.{~ULr/
1988.
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a:py A~,. ,Sommer
//'
Signed, sealed, published and declared by the above-
named Testatrix as and for her Last Will and Testament in our
presence, who, at her 'request, in her presence and in the presence
of each other, have hereunto subscribed our names as attesting
witnesses.
Address
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C I. 'lIUN ( /V(jd.f ~
Address
C'..zt.;l,/,>-"o?.L. O. &.r?4L'L-
(/
3
I COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CO 005528
BOGAR JAMES D, ESQ.
1 W MAIN STREET
SHIREMANSTOWN, PA 1 7011
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
__n____ fold ---------- --------
101 I $8,644.04
ESTATE INFORMATION: SSN: 491-28-2197 I
FILE NUMBER: 2105-0602 I
DECEDENT NAME: SOMMER MARY A I
DATE OF PAYMENT: 07/06/2005 I
POSTMARK DATE: 07/06/2005 I
COUNTY: CUMBERLAND I
DATE OF DEATH: 04/13/2005 I
I
TOTAL AMOUNT PAID: $8,644.04
REMARKS:
CHECK# 1282
INITIALS: JA
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CO 005529
BOGAR JAMES 0, ESQ.
1 W MAIN STREET
SHIREMANSTOWN, PA 17011
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
-------- fold ---------- --------
101 I $2,775.09
ESTATE INFORMATION: SSN: 491-28-2197 I
FILE NUMBER: 2105-0602 I
DECEDENT NAME: SOMMER MARY A I
DA TE OF PAYMENT: 07/06/2005 I
POSTMARK DATE: 07/06/2005 I
COUNTY: CUMBERLAND I
DATE OF DEATH: 04/13/2005 I
I
TOTAL AMOUNT PAID:
$2,775.09
REMARKS:
CHECK# 1865
SEAL
INITIALS: JA
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WillS
REGISTER OF WILLS
Thi~ is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
I ~()cal Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
.J' ,)
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Local R~
Fee for this certificate. $6.00
1-"
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No.
t"
APR 1 5 2005
Date
de.... 2187
COMMONWEALTH OF PENNSYLVANIA' OEPARTMENT OF HEALTH' VITAL RECOROS
CERTIFICATE OF DEATH
SEX
STAlE FllE NUMBER
SOCIAL SECURITY NUMBER
[)(lAD
:=......0
A. Sommer
UNDER t YEAR UNDER 1 OW
Monthe Days ttour. Minut_
.female
..491
-28
13, 200S
v...
BlRTHPL.ACi: 1Coty Olnd
Stale 01 fCle.gnCOUnlly)
Oreqon .
m1SS0Ur1
7. ...
FACJI.JTY NAME (II noIInSl'lutlon. g.\1'8 Slfeel and numbel'l
PlACE OF DEATH ICt>edI Oflly Ilf'e -- ... tOSlrucloOn9 on 0Ihet Sl(M)
HOSPItAL:
....._0
ERl()uq)atienl 0
I.
COUNTY OF OERH
Cumberland
....
RACE. Amencan Indirin. Black. While. Me.
(~. Whi te
DECEDENT'S USUAl OCCUP/mON
(~WO:::~~~:::zl,:T
.... home maker ....
DECEDENT'S MAlllNG "DllRESS (51..... c_. _. Z"'~I
1..
v..s DECEDENT EVER IN
u.s_ ARMED FORCES?
_ 0 NoXX
DECEDENT'S EOUCATtON MARITAL STATUS.......
S h com Never Man_. ~.
~nlary/Socandarj ~ ~~
1\lnk(()'12) ('-4Of~t-) ,..widowed
DkI "eXJ .....__.. Lower
--
Mine
Cumberland _, 170.0 ::...-=-..'.::..
MOTt!I'R'S N.\Iolli (Ff'" _~_ s..name)
1I~.1net:t:1e 1"\amsey
:r4C~"n~rD~""E!'armp~!n, PA 1 7011
PlACE Of' DlSPOSITlON. N......~. c.....-y lOCRlOH. c~ _. z;p~
'" ou... ......
SURVIVING SPOUSE
tn 1MIe. QI\III1'NlO8n l"IWT'l8l
".
32 Center Dr.
... Camp Hill, PA
fRHER'S NAMe (Filst Midde. Last)
11. James E. Taylor
1HF00000000.s NAME IT_;,,q
_. Ms. Bett E. Butler
IotETHOO 01' DISPOSITION
_0 "'.........IXJ -.......so...O
ou...(Spootv
17011
DECEDENT'S
ACTUAl
RESIDENCE
lSeeonsuu:......
on other SIde)
17.. s..,.p A
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17b. Coon
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UL ~AAlSER~E
Complete it... 23a-c only when cattJfyHlg
physiciM ill noli availablll .. time 01 ClNlh 10
ceRdy cauM of death.
Inc'L~~~ M~mmpl
llAJE SIGHED
_lloy,_t
Ave.
....
.... bell 01 my know'-dge, death occuned ~t lhe lame, dala and place Slaled
~.andTil&e)
Lite Crematory
N....E AND AOQRESS Of' FAQI.lt.Y
I;1.USSe.1man 1"t1&CS
LICENSE NUMBER
chaefferstown,
21...
PA
230.
E OF DEATH DATE PRONOUNCED DEAD (Month. DaV. Year)
24. ., '50 ~ M '". P<<.,\.. l ~ ~OO~
27. MIlT I: Enter lhe d....se.. intu,ies 01 complic.aliON which caused lhe death. 00 not .nI... lhe mode 01 dying, such as cardiic Of respwalory oJoffesl. shock Of hilart fatlufe
llSl onfy one cause on each...... ~
.......TE CAUSE (FIf\8I . ~
........ conoooon
'-.ling If'I dUIh)--..
DUE 10 (OR AS A CONSEOUENCE 0Fj'
DUE 10 (OR ASA CONSEOUENCE 0Fj,
..... Dc.
M$ CASE REfERRED TO MEOICAl EXAIA!.NERJCORONER?
.... IlJ we. t'
...
I Approximate
: iN........n
I QnMt and death
I
i
NeD
II.... 24-21 mUM be eompteted by
peqon who ~ OIa*".
PART M:
Odloroign6:onl__IO_. ...
notntSUling in" Uftderto/ing caa.. given in PART I.
~liIIIconditiona
iI......1Mding 10 immedi8te
'*-. Enter ........ytNQ
CAUSE (0iseaIe Of lOfUIy
. 1haI1I'IltiaIedev.u
'elIIllblg... deelh) LAST
DUE 10 (OR AS" CONSEOUENCE 0Fj.
'IAS AN AutoPSY
PERFORMED?
.
WERE AUlOPSY FINOtNGS
A\IlULABLE PRK)A TO
COMPLETION OF CAUSE
OF OERH1
MANNER Of DEATH
DATE OF INJURY
(Monlh. Day, Veal)
flUE Of INJURY
INJURY 1J WORK?
DESCRIBE HC1N INJURY OCCURRED.
....0
NoiIJ
_0
NoD
Suic:de
IiCI
o
o
Ham......
o
o
o ~E OF INJURY _ AI. harM. farm~~HI. tactofy, olfice M.
buikinG. Me. ISpecIfy)
300.
_ 0 NoD
........
-..
Pending Invea&igalion
33.
1,.,.(1/ ~I /("'1
Coukt not be delenmned
2... 21b.
aRTWlER ICheck oniy onel
"CERTIFYING PHYSICIAN !PhySIC.arl cerWytng cause cJ death when another DhVSlC.aI'l has pl'OOOUnced dealh ana completed Item 23)
To........ o' my knowledge, death occurred due to the UUae(s) and manner.. stated. . . . . . . . . . . . . . . . . . . . . . . , . . .
...
.PAONOUHCING AND CERTIFYING PHYSICIAN (f'hVSlC'iln bolt: j.llonOUOC1ng Oealh and cenllYIfl910 cause of cJealhl
To the -.. of my knowlltdge, death OCCUI'red at the lime. data, .nd placa..nd due \0 the cauM(.) and mann.r.. .'aled
'MEDICAl EXAMINER/CORONER
~~~:, ~:i:I::::.~~~~~I.I~~...n.~~ ~~~~~t~~~..~~: i.n. ~.Y.~~i.n.jO~: ~~~~~ ~:~~~~~ ~~ ~~~ ~i~~..~~t~: ~~~.~I~~~: ~~.~~~ ~~ ~~~ ~~~~~!~).~~ 0
11..
34.
~L If)
c? 0 0 . <;-