HomeMy WebLinkAbout07-18-05
RE\I-l500EX (6.QO)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
G
DATE OF DEATH (MM-DD-YEAR) D
REV-1500
OFFICIAL USE ONLY
INHERITANCE TAX RETURN FilE NUMBER
;;<'L-DS
RESIDENT DECEDENT COUNTYCOOE YEAR
O~3L_
NUMBER
-r
OF BIRTH (MM-DD-YEAR)
12~11--ILJ
SOCIAL SECURITY NUMBER .,-'
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THIS RETURN MUST BE FilED IN DUPUCATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
- 7 - OS-
(IF APPUCABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
g 1. Original Return
04. Limited Estate
o 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death afler 12-12.fl2)
D 7. Decedent Maintained a living Trost (Allach copy of Trust)
o 10. Spousal Poverty Credit (date of death hetwee.tl \2..WiH <II1\! H-95}
o 3. Remainder Return (dale of death priortcl12-13.fl2)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach SchO)
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COMPLETE MAIUNG ADDRESS
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1, Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Rece.lvable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Properly (Schedule F)
o Separate Billing Requested
7. InterNivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8, Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage UabiliUes, & liens (Schedule I)
11. Total Deductions (to1al Lines 9 & 10)
12. Net Value of Estate (line 8 minus line 11)
(1) -0 - OFFICIAL USE ONLY
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_0 - () =
(2) = =
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(3) - 0 ---:0 1"00
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:r'=1::0 . "::0 :xJ
(4) -O~ i'"~m .:....--1 c=J
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/ 7 B 1- I I 48 :'~E (n ~ 0) :-:DC)
(5) } . t~}CJO 0
:> -n
(,<62 S7 -:"""")0" ::c -"
(6) 2-:2-0 . '-'Ie eS
1 :- .:0 'R ,~.._ rTl
-~}2 -i 0?C)
0 --n
- 0 - <D
(7)
(9)
(10)
(8) 39 €3 . BC;~. os-
-, 8.3 0 Cf7 .
2-104,15:'
(11)
(12)
(13)
~ q 3 s, I 2-
3g>q~,?3
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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 (Une 12 minus Une 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
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15. Amount of Une 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 {a}(1.2)
16. Amount of Une 14 taxable atllneal rate
17. Amount of Une 14 taxable at sibling rate
18. Amount of Une 14 taxable at collateral rate
19. Tax Due
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
3
,,0_ (15)
, _0 !J5' (16)
3<6g) 1~3~ 73
/ 7 5"03 I I
,
, ,12 (17)
, .15 (18)
(19)
17'503.11
Decedent's Complete Address:
STREET ADDRESS "
(orr
210
CITY
oa..d
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
ZIP I 7 2..:
11 S- 0 3, II
;7 ~50
I 7~
00
It:.
Total Credits ( A + B + C )
(2)
3. InleresYPenally ~ applicable
D. Interest
E. Penally
TotallntereslfPenally ( 0 + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT,
Check box on Page 1 Line 20 to request a refund
(3)
(4)
(5)
(SA)
/ ~) 'f~ s. ) (,
q O<.K. 05:'
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Ves
a. retain the use or income of the property transferred; ................ ................................................................ ........ 0
b. retain the right to designate who shall use the property transferred or its income; ..................................... ...... 0
c. retain a reversionary Interest; or........................................ ...........................................<<.."""".,.......u....... ....... 0
d. receive the promise for iife of either payments, benefits or care? ................................................................ ..... 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year 01 death
without receiving adequate consideration? .................................................... ......................................... 0
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 Relirement 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,
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IlING RETURN
Under penalties of pe~ury, I declare tt1all 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.
DATE
7 - I 'if - O~-
n:V/1
'rA
DATE
/'(0\ S.
For dates of death on or after July 1, 1994 and before January 1, 1995, Ihe tax rate imposed on the net value of transfers 10 or for the use of the surviving spouse is 3%
[72 P.S. ~91t6 (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% [?2 P.S. !l9116 (a) (1.1) (ii)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and fiUng a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after Juiy 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. !l9116(a)(I.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. !l9116(t.2) [72 P.S. !l9116(a)(I)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [?2 P.S. !l9116(a)(1.3)]. A sibling is defined, under Section 9102, as ar
individual who has at least one parent in common with the decedent, whether by blood or adoption.
''''~'''''EX'I''".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
R SIDENT DECE ENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF I A T r FILE NUMBER
!"\arc) . 19GA.I"V\L V" 2.. I - OS - b3-LJ-./
lndude the proceeds of litigation and the date the proceeds were received by the estate. All property jointty-owned with the right of sUNivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
2.
3.
4.
DESCRIPTION
NoM-hweS\- So."l~ fu\'\K ~IV\V~~T
Mo-.V\a~c;yq A ('N)<X\\ 0# s-r} - # - 3p'l:3- fkio
L-,\~ stYec+ 0.1- ;(V\Q .f\!0<\~
\.UD..I"~,?A I (" 3~
Un \ ~ Sb:t.ks,. ~V\V\.% <;;::, ~jv\'cL:s. Ub:;l)
-:L ~ 'SI-red. \ q --71,- ~ oJd\~eo\
Uf\I-\u)( ~~s. s'^V\~'S ~ (~4q)
~~ \<1,7 -- ~ ~~
i./7 S~ tJ\e-t- LIPt: I ~. c.. ~ck.
VALUE AT DATE
OF DEATH
/43/ ~1. ?~
17) OLf.3. S7f
1'5)&'-'7,63
'2)051,07
TOTAL(A1soenteronline5,Recapitulation} $ /7 g 12/1.415
(If more space is needed, insert additional sheets of the same size)
REV.'" EX. "." .
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DEC DENT'
ESTATEOFV\o. G (AV'y\CA""
~ T.
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SCHEDULE F
JOINTL Y.OWNED PROPERTY
FILE HUMBER ,,<" 0. J
.z., - l.L> - '.3. 4-
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A Dt\v'ld. GGtCt'"lCV-
\-C. Z- I .s:0Y1 I N'I
t~lo,
3 S \ t..J ~\.rt\CIV'" $11-) J\-p'T. 2- ')
\>Gtt I fA- I S)'2-.0\ - I ~'-fO
PO Box ,()~D CJ~\I~\O\.rd J
) 00 4-4- t \0 -
oq
s 0\('\
B 3~ GCVV\-eK
~ucf'- -\<Jr
c. b \tot Y\e \t-o '~o.Jccd
cl~
JOINTLY -OWNED PROPERTY:
LETTER OA.TE DESCRIPTION OF PROPERT'{ %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of ~nancial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT deedforjoin6y-held reatestate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. o.-+huJ(',S*- \l1~~$ I"\~ D lOG JSG: (,/ 5a~ 5"3) t~. 31
CD ~ 10;2. "'30 3(..g S{p ,
2.. B t-j~s-\ So-.."\~ ~f\'f- (j) IOS, 1<I~.1t SOO 5:l..~ ;;;'71, .;t3
CD ~ 102.. 30 "cr-'f8
.3. e. )JorthweSt- ~v'H'~S '&..t'\.~ i06)f.~J.<f. 53 :uL J.. if
CD ~ 102.. 3D 3 (,q I'" I
if, f) ~~l.U'€S-\- ~,,\~<; ~"'\:... tD 106, </&:/. 9 7 ~ol?A 5"3 Pl..3/,2.:;
e-o #- 10 2..3D3"~ I
5 &" G/;;..71 tJo~e.s.\ ~\~s;. ~t\.k- ;2.1 "30, I <.I- ~o~ J 0&<;:' 07
.loo3 e..D ~ I02.3D2S II ~ \c:-
t,. F 3"/a71 No~est S:.t:A1I\~S Y\ 2-1 30. l'f sz,~ /o,,~. 07
~3 C-D.~ 10"2...3025 I.fc;;.3
7, G 9/).7/ No....-+t\ we.st & Vi ~s &. f\ l::.. :2. I 3,0. 1'+ /OI",~07
3,,003 c.....D ~ I05l..3 0 2..(, l.3cr
8, \+ f\J o~..u-es.-\- 'So.. v' \ ~ c;;. ~"\Y\ k.... 2.... I 30, I if- /O/.,5::'tJ7
c..D 1:t 10;>..302& I r, 2
9, I.. 'b/;).7 No.rt1'\.~\ So-:./I~<; ~C 2- I 3D, ''+ So 0 /o~07
;)..0'03- c..o ~ I 023o;;U:i ~g 7
TOTAL (Also enter on line 6, Recapttulation) $~
(If more space is needed, insert additional sheets of the same size)
REV.""""".9".
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT .
SCHEDULE F
JOINTL Y.OWNED PROPERTY
ESTATE OF
~'i' \"
Got V"Y\.RJor
FILE NUMBER
:2... I - () s:' - O~L.{..I
tf an asset was made joint within one year of the decedenfs date of death,lt must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
K.}) $..f\Ct-
2-4- ~C"S S~k
~C\0"( Ie I pJ\ \ 7a."4 J
403 13\~1 AJ~v-e./ Od Cd-J. I fIT
l(.,301
c.!o.~ \t\ tqr
'tr~~
~ .E:. Frar'\K.. A Wttl kt.-r
~ F. ;+t\dtreu) S. ~ \ \<.er
7-'+ C\t\~s\-n.ui" ~c4
Nc.uJ "d\ e, f> A 17 .2-q-\
~~
JOINTLY -OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %DF DATE OF DEATH
ITEM FOR JOINT MADE Include name of financial institution and bank a::counl number or similar identifying number. Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deed for jointly.held real estate. VAlUE OF ASSET INTEREST DECEDENT'S lNTEREST
10 ;S "8/c1.7 N o~ecl ~v'j~~ ~\'\k.. 2..130. '1 SOCiA /o~ 07
.:;l.a)3 c...o 4-- I 0 2.. 3 0 '2..." I os-
\\ K.- g/ J.l! ~o.-thvJe~ ~"i~ ~,,~ :L I 30. 1'1 5o~ /D/'~. 07
'~c03 ~D " 10230 220
IL L tt3/a7)
blG02 N ~\,\Je.d-- ':'SO'- 'J l "'--() ~ ~t'\ ~ ;).....\ 3D. 'i- SO~ /O(..~ lJ
(LP ~ I 0 2.. ~ 0 25 <.{ 2..0
TOTAL (Also enter on line 6, Recapitulation) $ 2.2f)j ~~. 5
7
7_
(If more space is needed, insert additional sheets of the same size)
REV"""""OW
COMMONWEALTH OF PENNSYLVANIA
'NHERlTANCE TAX RETURN
RESIDENT DECEDENT'
SCHEDULE F
JOINTL Y.OWNED PROPERTY
ESTATE OF
M.{A~T Ga~
FILE NUMBER
.:2./ - 0 ~ - 0.3. 41
tf an asset was made joint within one year of the decedenfs date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS RELATIONSHIP TO DECEDENT
;. 1+. A-klCO!'\o.ev- CArll'
(> I-\~. LA 1'\00,. Le-13> t\. VlC-
/.fCf7 W. ~CR~ ~.Owk~ R.r.. c;fV'tl..r\Oc.hdd
02./; I.3U
cJ 6 K.'$. Lt II\da \...c. ~I'\(!.
4q7 W. 8ca.ckR.d., C'..0aMeS~ R -.r- r-"'-cl.dll \d-
O ,~
I' G. De \dxe.. A: Co-r"
r/.L Dc lIa eo.. r " (\0
,
clo Mrs. L\V\do.. )..e:~\tl.nc...
4-~[ v.), ~cJ, ~') ~nu.vt\ ~(Vl.Ac1c)l11d.
o;;.Zl3
JOINTLY.OWNED PROPERTY:
lETIER OI\TE DESCRIPTION OF PROPER1'l' %OF DATE OF DEATH
"EM FOR JOINT MADE Include name of financial institution and bank account number or similar Identifying number, Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VAlUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A.
TOTAL. (Also enter on line 6, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
REV.'''EX.''.'"*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT'
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
T.
FILE NUMBER 0
2.-1 - s" - 0 3, <f I
GUt f"1'l.U'"'
11\(;( rtt
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
It J. ~'':S'''i.:f U:>W \-e
., ~ Me \\SS2::I 1=.
. t'rzj\ Ie"'" oc.xl
4 L I' \ere QX. \.00.. \ ~
~,,\S
4ZS- w. ~ctA. ~
CV-a~s-h>wv\ I ~ 02.'25 /3
-:z..tos- E. I S-c~ S.fnocl-
0.e.ve.\o..Y\d. <.l C>T\- 4-LJ 110
G~d.c..\I\\ \cl
<0 Y'o. v-cl cl~ \ ,o;:l
36 :P I f\ c... 13cv-k. ~~ -# ~o
Cot'J.,-d "s;.v'l.\le I I"\t>
- ----:::J .z.. I 630
G~\ \<:1.
JOINTLY-OWNED PROPERTY:
lETTER DAlE DESCRIPTION OF PROPERlY %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of Rnancial institution and bank account number or simila' iderllifyirlg nt,lmber. Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deedforjointly.held realeslale. VAlUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A.
TOTAL (Also enter on line 6, Recapitulation) $
..
(If more space IS needed, Insert addlliOnal sheets of the same size)
RJ;:V-1511 EX+ (12-99) .
*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF l ^ T
f"\~~ .
~rV\c V-
FILE NUMBER
2-.' - O~ -073411
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FU~ERAL EXP~SE~ --/tow.e. IS ?->I~ ~r ~ ~
1. I;-~\JV\.
I WeuN \ Ie ( P i7.;{ <f J '-J. S3S.~
A +\o.r'\ d -HwS/Z. ) )
It- b be H-s: CUM \ PA - ck ~ I'\.et"" ce S.OS
U. S'o. Is;- F I or-llI s..h9<>Pe) Newv \Ile.J fA 17~<t I I 74. g-
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s) ~\"\c:\. W~ I kcv- N/A
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address 2. 'i Ch cs~ ~-ck
City NCWv~Hc:.. State P A- Zip 172-~1
Year(s) Commission Paid:
2. AtlorneyFees - ~+h~e+'\ K ~vll'~ I 'Cs:q .
4<-\ S V\~ 9-. l~,~)~A \7013
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) J L.i 5-~. Ol:>
Claimant
Street Address
City State _Zip
Relationship of Claimant to Decedent
4. Probate Fees - c:.u\M ~lNV\d Cl> 2G ~. Ctf)
5. Accountant's Fees
6. Tax Return Preparer's Fees - (JrV'jt;;, W. ~he l~ , fc.. uJo..~ I PA- 100 . 00
7. Pp~--+-n; ll'\~ - ~ e-Y\n \'\c...i ) eo.. rl ~ I fA Is 7.03
- C01AA~ltl#\.d la.vJ ~o~ 7S".0-0
8 rD~\-zA~ - 107. TO
q, fl\'~ :.W\I-\e."l~ T~ ~ IS. t:ro
10. t-JO~~ ,S:;t"I~~ ~~k. ~ C~- a;> :l.. .q4-
TOTAL (Also enter on line 9, Recapitulation) $ 7~30. 'f7
----
s
(If more space IS needed, Insert additional sheets of the same size)
REV-1512EX~(1-971 ~
~ SCHEDULE I
COMMON,:ro~LTHOFPENNSYLVANIA DEBTS OF DECEDENT,
INH~~~:~~~i6EAc"E~~~~RN MORTGAGE LIABILITIES, & LIENS
ESTATE OF LA T r FILE NUMBER
1,,(Ary . lOo..rV\tW 2/ - 05- - 63.11
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
;)
3
If.
DESCRIPTION
AMOUNT
<;wo.\ tv,
.;2.\0 'SU?,\ 'SpI\~ RcV\.d )tJu..;vdlc. \ fA I{ "2-4-1
(~\o"," Ca.f.L ~~.s.:)
M. 0 kn k:x (.)( - ra...<.t~)
'""fhL HIt \o.V'.uC ) "f 2.D ~ \ ~ 17 roC:.> k. ~~
S~r4:'-~ \ M b 2/1~:2-
t1V\U\~ Co-.re. Rx
G To.. \1\ C\ W'\ M ~ C!J. 11'\' Q..'
106 S. \-h~ st- \ ~ewv'1\ \c) ~A 17 2.<f J
Z ) 0 I 7. :?,
q. efO
fe,(, - 4 '1
IO.q~
TOTAL (Also enteron line 10, Recapilulalionj $ 210 <j.. IS
(If more space is needed, inserl additional sheets of the same size)
REV-1513 EX+ 19-00.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
fI\(Ar~ T GarV\Cr
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outright spousal distributions, and transfers under
Sec. 9116 (al (1.2)J
1. 1><1"V I d 0CA <(" l(\VC'
(, q (p 2.. Qv,,-kl... ~;l.) A(),6rtSCXl A,-l-JY
- d 14/JO/
.:r ~ Go...',V'CX
3 S (}j. Bvt-lcv- ~) A-pt.2. ) 1>6t-t I PA
IS 2bl-I'3f/o
NUMBER
I
.;1.
FILE NUMBER
2/ -Os--
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
~OY'l
dc\ u~ t\ \-c.,r-
"D\U\\I\C- ~\\o~
Po Box IOLj-qO) C-\cwe.\o..i'\d})r-f <io...UF
::5"Cl..V\ct Wo-.\ \(lj ~ '+Ilo-d'-!-q D
.;t<.f c..\.1cstruJ'T &-) Newvd Ie) ~A dau'(f'Vk-v
172..4\
.3.
tt.
034/
AMOUNT OR SHARE
OF ESTATE
1/ 'f-
{/q
1/4-
Ijc..j.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18. AS APPROPRIATE, ON REV-1S00 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
,.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1S00 COVER SHEET $
(if more space is needed, insert additional sheets of the same size)
Savings Bond Calculator
Page 1 of2
V.II",' ^, 'JI
107/2005 I
1_.
I_I
BlIntllnfo
Series
IE BondS.
Denomination
Serial Number
Issue Date
~J
R~')lIlts
# Bonds Total Price Total Interest Total Value YTD In.
49 52,325.00 513,342.03 515,667.03 5359.
Issue Interest Next Final
Serial Number Issue Date Series Denom Price Interest Value Rate Accrual Maturity
08/1977 E $50 $37.50 $215.52 $253.02 4.00% 08/2005 08/2007
09/1977 E 50 37.50 215.52 253.02 4.00% 09/2005 09/2007
09/1977 E 50 37.50 215.52 253.02 4.00% 09/2005 09/2007
09/1977 E 50 37.50 215.52 253.02 4.00% 09/2005 09/2007
10/1977 E 50 37.50 215.52 253.Q2 4.00% 10/2005 10/2007
10/1977 E 50 37.50 215.52 253.02 4.00% 10/2005 10/2007
10/1977 E 50 37.50 215.52 253.02 4.00% 10/2005 10/2007
11 /1977 E 50 37.50 194.54 232.04 4.00% 11/2005 11/2007
1lI1977 E 50 37.50 194.54 232.04 4.00% 11/2005 11/2007
12/1977 E 50 37.50 195.18 232.68 4.00"10 12/2005 12/2007
12/1977 E 50 37.50 195.18 232.68 4.00% 12/2005 12/2007
12/1977 E 50 37.50 195.18 232.68 4.00% 12/2005 12/2007
05/1977 E 50 37.50 220.08 257.58 4.00% 11 /2005 OS/2007
05/1977 E 50 37.50 220.08 257.58 4.00% 11/2005 OS/2007
05/1977 E 50 37.50 220.08 257.58 4.00% 11/2005 OS/2007
06/1977 E 50 37.50 22Q.62 258.12 4.00% 12/2005 06/2007
06/1977 E 50 37.50 220.62 258.12 4.00% 12/2005 06/2007
06/1977 E 50 37.50 220.62 258.12 4.00% 12/2005 06/2007
06/1977 E 50 37.50 220.62 258.12 4.00% 12/2005 06/2007
07/1977 E 50 37.50 220.58 258.08 4.00% 01/2006 07/2007
07/1977 E 50 37.50 220.58 258.08 4.00% 01/2006 07/2007
08/1977 E 50 37.50 215.52 253.02 4.00% 08/2005 08/2007
08/1977 E 50 37.50 215.52 253.02 4.00"/0 08/2005 08/2007
04/1977 E 50 37.50 217.56 255.06 4.00% 10/2005 04/2007
04/1977 E 50 37.50 217.56 255.06 4.00% 10/2005 04/2007
04/1977 E 50 37.50 217.56 255.06 4.00% 10/2005 04/2007
03/1977 E 50 37.50 217.56 255.06 4.00% 09/2005 03/2007
03/1977 E 50 37.50 217.56 255.06 4.00% 09/2005 03/2007
http://wwws.publicdebLtreas.gov/BC/SBCPrice 7/11/05
Savings Bond Calculator
Page 2 of2
02/1977 E 50 37.50 217.56 255.06 4.00% 08/2005 0212007
02/1977 E 50 37.50 217.56 255.06 4.00% 0812005 0212007
02/1977 E 50 37.50 217.56 255.06 4.00% 0812005 0212007
01/1977 E 50 37.50 222.66 260.16 4.00% 0112006 0112007
0l/1977 E 50 37.50 222.66 260.16 4.00% 0112006 0112007
o l/1977 E 50 37.50 222.66 260.16 4.00% 0112006 0112007
1l/1977 E 75 56.25 291.81 348.06 4.00% 1112005 1l/2007
07/1977 E 75 56.25 330.87 387.12 4.00% 0112006 0712007
06/1977 E 75 56.25 330.93 387.18 4.00% 1212005 0612007
03/1977 E 75 56.25 326.34 382.59 4.00% 0912005 0312007
11/1977 E 100 75.00 389.08 464.08 4.00% 1112005 11/2007
10/1977 E 100 75.00 431.04 506.04 4.00% 1012005 1012007
09/1977 E 100 75.00 431.04 506.04 4.00% 0912005 0912007
08/1977 E 100 75.00 431.04 506.04 4.00% 0812005 0812007
07/1977 E 100 75.00 441.16 516.16 4.00% 0112006 0712007
06/1977 E 100 75.00 441.24 516.24 4.00% 1212005 0612007
05/1977 E 100 75.00 440.16 515.16 4.00010 1112005 05/2007
04/1977 E 100 75.00 435.12 510.12 4.00% 1012005 0412007
03/1977 E 100 75.00 435.12 510.12 4.00% 0912005 0312007
02/1977 E 100 75.00 435.12 510.12 4.00% 0812005 0212007
o l/1977 E 100 75.00 445.32 520.32 4.00% 0112006 0l/2007
1~'IIl11 Viewing Bonds 1-49
Lp(end
Note Description
NI Not Issued
NE Not Eligible for Payment
P5 Includes 3-month interest penalty
MA Matured and Not Earning Interest
Please rate this service.
(please print and/or save this page before submitting your surwJY)
Service Excellent Good Fair Poor
Savings Bond Calculator 0 0 0 0
-
http://wwws.publicdebt.treas.govIBC/SBCPrice
7/11ffi5
Savings Bond Calculator
Denomination
Serial Number
.
IE Bonds
~100 I
R.....,.ults
1# Bonds Total Price Total Interest Total Value
51 $2,493.75 $14,549.79 $17,043.54
Issue Interest
Serial Number Issue Date Series Denom Price Interest Value Rate
05/1976 E $100 $75.00 $437.76 $512.76 4.00%
06/1976 E 100 75.00 438.92 513.92 4.00%
07/1976 E 100 75.00 438.84 513.84 4.00%
08/1976 E 100 75.00 438.84 513.84 4.00%
0911976 E 100 75.00 438.84 513.84 4.00%
12/1976 E 200 150.00 870.24 1,020.24 4.00%
01/1976 E 100 75.00 443.12 518.12 4.00%
02/1976 E 100 75.00 443.12 518.12 4.00%
03/1976 E 100 75.00 443.12 518.12 4.00%
0411976 E 100 75.00 432.96 507.96 4.00%
10/1976 E 100 75.00 428.76 503.76 4.00%
11/1976 E 100 75.00 433.68 508.68 4.00%
05f1976 E 75 56.25 328.32 384.57 4.00%
07/1976 E 75 56.25 329.13 385.38 4.00%
11/1976 E 75 56.25 325.26 381.51 4.00%
1211976 E 75 56.25 326.34 382.59 4.00%
01/1976 E 50 37.50 221.56 259.06 4.00%
01/1976 E 50 37.50 221.56 259.06 4.00%
01/1976 E 50 37.50 221.56 259.06 4.00%
02/1976 E 50 37.50 221.56 259.06 4.00%
0211976 E 50 37.50 221.56 259.06 4.00%
0211976 E 50 37.50 221.56 259.06 4.00%
03/1976 E 50 37.50 221.56 259.06 4.00%
03/1976 E 50 37.50 221.56 259.06 4.00%
04/1976 E 50 37.50 216.48 253.98 4.00%
04/1976 E 50 37.50 216.48 253.98 4.00%
04/1976 E 50 37.50 216.48 253.98 4.00%
05/1976 E 50 37.50 218.88 256.38 4.00%
05/1976 E 50 37.50 218.88 256.38 4.00%
06/1976 E 50 37.50 219.46 256.96 4.00%
06/1976 E 50 37.50 219.46 256.96 4.00%
http://wwws.publicdebt.treas.govIBC/SBCPrice
Page 1 of2
Issue Date
L___---1
[
YTD In1
$161.
Next Final
Accrual Maturity
0512005 0512006
06f2005 0612006
0712005 0712006
0812005 0812006
0912005 0912006
0612005 12/2006
0712005 0112006
08/2005 02/2006
0912005 0312006
04/2005 04/2006
0412005 10/2006
0512005 1112006
OS/2005 OS/2006
0712005 0712006
0512005 11/2006
0612005 1212006
07/2005 0112006
0712005 0112006
0712005 0112006
0812005 0212006
0812005 0212006
0812005 0212006
0912005 0312006
0912005 0312006
0412005 0412006
0412005 04/2006
04f2005 0412006
0512005 0512006
0512005 0512006
0612005 0612006
0612005 0612006
7/11/05
Savings Bond Calculator
Page 2 of2
06/1976 E 50 37.50 219.46 256.96 4.00% 06/2005 06/2006
07/1976 E 50 37.50 219.42 256.92 4.00% 07/2005 07/2006
07/1976 E 50 37.50 219.42 256.92 4.00% 07/2005 07/2006
07/1976 E 50 37.50 219.42 256.92 4.00% 07/2005 07/2006
07/1976 E 50 37.50 219.42 256.92 4.00% 07/2005 07/2006
08/1976 E 50 37.50 219.42 256.92 4.00% 08/2005 08/2006
08/1976 E 50 37.50 219.42 256.92 4.00% 08/2005 08/2006
08/1976 E 50 37.50 219.42 256.92 4.00% 08/2005 08/2006
09/1976 E 50 37.50 219.42 256.92 4.00% 09/2005 09/2006
09/1976 E 50 37.50 219.42 256.92 4.00% 09/2005 09/2006
10/1976 E 50 37.50 214.38 251.88 4.00% 04/2005 10/2006
09/1976 E 50 37.50 219.42 256.92 4.00% 09/2005 09/2006
12/1976 E 50 37.50 217.56 255.06 4.00% 06/2005 12/2006
11/1976 E 50 37.50 216.84 254.34 4.00% OS/2005 11/2006
10/1976 E 50 37.50 214.38 251.88 4.00% 04/2005 10/2006
10/1976 E 50 37.50 214.38 251.88 4.00% 04/2005 10/2006
1111976 E 50 37.50 216.84 254.34 4.00% OS/2005 11/2006
12/1976 E 50 37.50 217.56 255.06 4.00% 06/2005 12/2006
12/1976 E 50 37.50 217.56 255.06 4.00% 06/2005 12/2006
03/1976 E 25 18.75 110.78 129.53 4.00% 09/2005 03/2006
I_IIJ I Viewing Bonds 1-51
LetPlld
Note Description
Nl Not Issued
NE Not Eligible for Payment
P5 Includes 3-month interest penalty
MA Matured and Not Earning Interest
http://wwws.publicdebt.treas.govIBC/SBCPrice
7/11/05
.
;+
Mellon
Mellon Investor Servlces
05/17/2005
A Mellon Financial CompanY'"
FRANK R GARNER
CO NORTHWEST SAVINGS TRUST DEPT
LIBERTY ST AT 2ND AVE
WARREN PA 16365
PlY) ;t
liPq~a.)
.~
Dear Investor:
Thank you for contacting Mellon Investor Services ("MIS") to establish or change your Personal
Identification Number ("PIN") for your account(s) maintained by MIS. This PIN allows you to access
and manage your account online through Investor ServiceDirect'M at http://www.melloninvestor.com/isd
or through our autoinated telephone system.
As an added security measure, one or more of the securities you own may require you to enter an
authentication number the next time you use Investor ServiceDirect'M. If there is an authentication
number below, you will be prompted to enter that number when you visit Investor ServiceDirect'M for
the first time after the creation of your PIN. This authentication number will only be required for
your first visit - just your PIN will be required for all subsequent visits. If the phrase "Not Required"
appears below, you will not be required to enter an authentication number to access Investor
ServiceDirect'M at this time.
Authentication Number: 064A38526J
Mellon Investor Services is the premier transfer agent and shareholder services provider to small,
middle market and Fortune 500 corporations and their shareholders. Our automated systems are
available 24 hours a day. 7 days a week for convenient access to your account
This notice has been sent for your protection. If you have not recently established or changed your
PIN, or if you have any questions regarding your PIN, please contact us immediately at (877) 978-7778.
Mellon Investor Services
Visit us on the web at http://www.melloninvestor.com/isd
Mellon Investor ServiceDirect - Account Summary - 1.0
Page 1 of 1
@ Mellon
Account Summary
MetLife'"
-.....--.--"------..----1
Certificate Shares
Book-Entry Shares
47.0000
Total Shares
47.0000
Share Price*
$43.8100
Market Value
$2,059.07
o
'Share Pric'J for CUSIP: 59156R10 as C;' clese cf business: Monday, May 23, 2005
" S:i]rS Pr;,:E:: provided by Interactive Data Corp.)
i~" '.
!If~~b1W::f I
Book-Entry shares represent Trust Interests you currently hold in the MetLife Policyholder Trust.
https:/ /vault.melloninvestor.com/isd/myportfolio/accountstatus.asp?n0 _ cert= 1 &compname=METLIFE%2... 5/24/2005
F. CHARLES EGGER, Supervisor
EGGER FUNERAL HOME, INC.
15 Big Spring Avenue
NEWVILLE, PENNSYLVANIA 17241
717-776-3414
FRANK C. EGGER, Funerol Directc
March 16,2005
r'-~--.. ." .~7~r'
".J
Funeral Bill for Mary Garner
Date of Death Mafch 7, 2005
w') " s ?"ns
... ,~ --
~i'\ .
Cemetery Opening
$1,875.00
$325.0000
Professional Service
Clergy Offering
$170.00
A~
PAYEE#
ADMIN.
REC'O
PAY BY
TRAN COOE
15 Death Certificates
$90.00
PorI
Blue Sterling 18 gauge
$1,905.00
$170.00
Travel 263 miles one way $.65 a mile
Total
$4,535.00
'N1~&>>~ST~
~ ~)<U" _1Ih:Ud be
.rtlOfXM8ff....-TO~.LJGHU'O-VlEW~~ WATERMARK
~ 378777401
" NOLO DOCUMENT UP TaTtlE UGKI' :TO.
,......
DATE
AMOUNT
PAy$***********4,535.00 MAR 22,05
Fe'UI- Thc-usand Five Hundred Thirty Five Dc-lJars & NO Cents
*'H4,535.00
TO
THE
ORDER
OF
EGGER FUNERAL HOME, INC.
FBO ~1ARY T GARNER .
fne
DRAWER: NOAlHWEST SAVINGS BANK
'~
ISSUED BY INTEGRATED PAYMENT SYSTEMS INC., Englewood, CcIorado
TO C/llBANK NEW YORK STAT : BUFFAlO N.\'.
11...0 ~ :18"". ':0 i! W0081;8': 1;800:1 18 1 1 1..0 BII.
NORTHWEST SAVINGS BANK
DETACH AND RETAIN THIS STATEMENT
lHE ATTACHED CHECK IS IN PAYMENT OF JTEMS DESCRIBED 8El.OW.
If NOT CORRECT PLEASE NOTIFY us PROMPTlY. f<<) RECEIPT DESIRED.
:<1A!=~ 22 >t 05
CHEC\::. :j{. i OOOOC037377'7 i.;.();,
$************4,535:00
FUNERAL BILL/MARY T GARNER
'~~J/D 1023~)25941 CS/102
~
:) REPORT A LOST OR S'TOl...EN CARO. CALL OUR BUSINESS NUMBERS LISTED ATn-tE TOP OF EACH STATEMENT PAGE
10M 7 AM - 5 PM MONDAY TO FRIDAY AND 8 ~ 10 12 PM SATURDAY, OlHERlNlSE CAll 8OG-556-5678
;MEMBiaiNUM~R<':;'; ":~i.TtiArE :: :i?\:Wt~OOED..tTE '"
'_'c:';';:i.:;~:'\;{':::::_;:':'::;::;:::"'" .~::-::::::~~::_----" '-;-:;<:':;:;;.:::.:/:::_:::::::::,-:-::_:2~
8505153521 03/31/05 04/25/05
CREASE BEFORE l
DETACHING HERE T
10000.00
295.28
0.00
9704.72
ID 09 VISA LOAN
POST TRAN REFERENCE DESCRIPTION AHOUNT
0228 0226 24610431S09FEZPNO 5200 THE HOHE OEPOT #4149 CARLISLE PA 34.30
0302 0228 24455011WLM7MRSHR 5542 SAYLOR'S HARKET NEWVILLE PA 15.25
0307 0305 24323012179S99HPG 5251 5171 NEWVILLE DO IT BE NEWVILLE PA 10.14
0308 0307 24692162200KJ13AJ 5542 SUNOCO SV4 STATION HARRISBURG PA 16.64
0314 PAYHENT BY CHECK HAIl415 -332 102.20-
0315 0312 2445501281PW4T5FS 5542 RUTTER'S FARH STRE #58 ABBOLTSTOWN PA 19.84
0315 0312 244180029246KSS4H 5812 ATLAND HOUSE OF ABBOTT ABBOTTSTOWN PA 85 5 ~
0316 0314 24323012AEPA3W3QA 5541 UNI HARTS #4232 PLAINFIELD PA 7.04
0320 0317 24692162DOOF4QPX1 5542 SUNOCO SVC STATION HARRISBURG PA 14.64
0321 0319 24164052FB018WY4W 5542 EXXONHOBIL75 04210936 SAXTON PA 18.43
0324 0322 24323012J79SRJ47F 5542 UNI-HART #04232 PLAINFIELD PA 11. 06
0327 0325 24164052MB018XNIB 5542 EXXONHOBIL75 04210332 HARRISBU PA 14.55
0328 0326 24164052NB018YYKN 5542 EXXONHOBIL18 09996315 DUNCANNO PA 21.15
0329 0327 ~4164072PEGMLYEAR 5542 0263 SHEETZ 00002634 CARLISLE PA 17 .19
YTD FINANCE CHARGE, YEAR TO DATE 0.00
YTD FINANCE CHARGE, IN 2004 0.00
:::::::':~:~:~E)::n',~::::::, :~:.: .....
102.20
0.00
-:-::::::~~::::::,:,';
. ."". .,."
5.28
0.00
9.900%
12.900%
:-+~::):}'Y~~~:-::":)+-
295.2
0.00
:L~~~~~~:n)+ lDTALFlHANCEalAAGlE ~..
0.00 0.00
0.00 0.00
FINANCE OHARG
PERIODIC TRANSACllON
:"eW~:):):
.......,.. ..",..
lOTAL
0.82500%
1.07500%
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0201 000 654 6
~\
.-- ..--.-..--...---- --~-~--~..-----.-- .------.- --- ~-l
$:fiSa . s gQOftaQ ghoppe 333 Gre.en Spring RoadJ
Newville, PA 17241
(717) 776-4778
www.lisas(loralshoppe.com
DeliveryDate '61 it 10<: M T W TH 0 S su
Vl/7c( r ,( /" \ 'l(.{., r >"\00,\
DELIVER TO: !L . L:::>Ct ".. j) e ("
'>1jh~ ~
-
Address
City
State_ Zip
I
I
Phone (
(~;~;~''1 SILK P~N~R DRIED BOXED LOOSE VASE
\ ,/
U'" i ; ; )' 1< 7' , ; J r, (II iI m 'D-mdh\ S (LtC. /,.) It.' 1~
@) // I,) A : I c: r ( \ c 1.", "'/,; C-~~-,:;;;;t;/I-) L. . .,
H. B. ANN. SYM. G. W. HOL CONG. T.O.Y. THANKS
Boy/Gi~
SOLD TO: 'hi" et /Je.. (/(N-Ar/,~~~~'d$135.00
')1/" -f I t -' : (, :) q, q 5
Address;' 7' /;, ,-rMc j7 f"';- . ..
City /~,jl-/ I,{ State _ Zip_ Delive'Y Charge
{" Service Charge
Phone (work) (hOme?? - {" 7 016> Sub Total ii' /-1:. / ;.-
Sales Tax !. ./ <
Total .I 7l.f,,g- f;;
Credit Card #
Credit Card Used
Expiration
Authorization #
/
FILLING FLORIST:
TELlFTD #
Contact:
Phone:
Time:
City/State:
Date:
THE LAw OFFICES OF
KATHLEEN K. SHAUUS, ESQ.
44 SOUTH HANOVER STREET
CARUSLE. PA 17013
PHONE (717) 243-6655
FAX (71 '7) 243-6618
Invoice submitted to:
Janet C. Wa~ker
24 Chestnut Street
Newvi~~e, PA 17241
Hours Rate
Amount
7/11/05 Notices of Beneficial
int to beneficiaries .5/$150/hr $ 75.00
7/18/05 Preparation of Inherit.
Tax Return 1.9/$150/hr 285.00
7/18/05 Prep. of family agreement
and informal accounting .9/$150/hr 135.00
7/18/05 Finalization of account 1.3/$150/hr 195.00
Total 7/18/05
4.6 hrs $150/hr $690.00
THE L..Aw OFFICES OF
KATHLEEN K. SHAULIS, ESQ.
44 SoUTH HANOVER STREET
CARUSLE, PA 17013
PHONE (717) 2436655
FAX (717) 243-6618
Invoice submitted to:
3/22/05
3/23/05
4/12/05
4/13105
5/18/05
5/18/05
5/23/05
6/3105
6/7105
Janet C. Wa~ker
24 Chestnut Street
Newvi~~e, PA 17241
Hours Rate
Office Conference .9
Prep. of sibling releases
& petition for appt. as
Administrator 1.2
Office - EIN number
appt at ROW; review tax
returns 1.0
Payment Cumbo Co. Law
Journal for advertising
Office - Release, TC to
NW Savings Bank, est.
Inheritance tax payment .8
Reimbursement for Cumbo
Law Journal ad
Revised release & mailed
to NW Savings Bank .5
TC from Mr. Jackson re
release revisions; TC
to client re release;
TC to Mr. Jackson; pre-
pare release for mailing .7
Payment (Check No. 11)
Amount
$150/hr $135.00
$150/hr 180.00
$150/hr 150.00
N/A 75.00
$150/hr 120.00
(75.00)
$150/hr
75.00
$150/hr 105.00
(765.00)
Total 6/7/05
5.1 hrs $150/hr 000.00
COpy
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of wills
One Courthouse Square
Carlisle, PA 17G13
Receipt Date:
Receipt Time:
Receipt No.:
4/12/2005
14:27:09
1040270
GARNER MARY T
Estate File No. :
Paid By Remarks:
2005-00341
JANET C WALKER
MW
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS ADM
RENUNCIATION
SHORT CERTIFICATE
JCP FEE
AUTOMATION FEE
Check# 1478
Total Received. .... ....
210.00
15.00
24.00
10.00
5.00
----------------
$264.00
$264.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
CUMBERLAND COUNTY GENERAL FUN
Invoice
p:t. Lf-/~-(js-
. U:...-=# ~
3/2/2005
FROM:
ORRIS W. SHELDON. P.C.
P.O. BOX 628
WARREN, PA 16365
BILL TO:
MARY T GARNER
C/O NORTHWEST TRUST DEPT, LIBERTY STREET AND 2ND AVENUE
WARREN, PA 16365
Statement of Charges
Tax return preparation fee 100.00
Sub-Total 100.00
TOTAL 100.00
Acc.t tJ 7]OLl3
'3/4/0 s
f .f";' '- Ccu l\. 0 3 t./.
p ~/'
S II ~i() 5
;)r:: ci-.{ T <k.X iC e +u. i' "\. '( ll"p (I ,.....fl.'-c
REMITTANCE ADD~ I BIll TO
THE SENTI L - LEGAL LAW OFFICES SHAULIS, KATHLEEN ~
P.O. BOX 130, CARLISLE. PA 17013
AD NUMBER I CLASS SALESPERSON BILLING DA IE LINES
284927 10 PUBLIC NOTICES c30 05/11/05 36 * 2
AD DESCRIPTION START DATE STOP OA TE
ADMINISTRATOR NOTICE LETTERS OF AD 04/22/05 05/06/05
PUBLICA lION INSERTIONS RATE NET AMOUNT GROSS AMOUNT
3 THE SENTINEL - LEGAL 3 LGL 130.68
TOTAL AD CHARGE 130.68
3 PROOF OF PUBLICATION 01PRF 6.35
DA VS RUN
PURCHASE ORDER PAY THIS AMOUNT 137.03 164.44*
est. mary t. garner
RETAIN THIS PORTION FOR YOUR RECORDS
. AFTER 06110105
MESSAGE:
Thank you for advertising with The Sentinel.
Deadlines for in-column legal advertisements: Monday is Friday at
11 a.m.; Tuesday is Friday at 4 p.m.; Wednesday is Monday at 12 Noon;
Thursday is Tuesday at 12 Noon; Friday is Wednesday at.12 Noon; Sunday
is Thursday at 12 Noon.
If you have any questions regarding your Legal b~ll please cali
Tammy Shoemaker 243-2611, ext 203.
Fax your legals to 243-3754, attention Tammy Shoemaker
You can also EMAIL yourlegaltoClassifiedads:classified@cumberlink.com
Please send a cover letter including your name and address as an attachment
DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT
E SENTINEL. LEGAL
BOX 130 CARLISLE PA 17013
D NUMBER CLASSO START DATE STOP DATE
284927 PUBLIC NOTICES 04/22/05 05/06/05
o DESCRIPTION BilLING DATE TELEPHONE NUMBER
~DMINISTRATOR NOTICE LETTERS OF AD 05/11/05 717-243-6655
est. mary t. garner
GROSS AMOUNT OF
164.44
DUE AFTER 06/1 0/05
TOTAL AMOUNT DUE
137.03
ENTER AMOUNT ENCLOSED
LAW OFFICES SHAULIS, KATHLEEN K.
44 SOUTH HANOVER STREET
CARLISLE, PA 17013
i 37, 08
*170138""
02000000028492700000000000000016444nnnnn"7A~~
PROOF OF PUBLICATION
State of Pennsylvania, County of Cumberland
T anuny Shoemaker, Classified Advertising Manager, of The Sentinel, of the County
and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a
newspaper of general circulation in the Borough of Carlisle, County and State
aforesaid, was established December 13th, 1881, since which date THE SENTINEL has
been regularly issued in said County, and that the printed notice or publication
attached hereto is exactly the same as was printed and published in the regular editions
and issues of THE SENTINEL on the following day(s):
Apri122, 29, and Mav 06, 2005.
COPY OF NOTICE OF PUBLICATION
ADMINISTRATOR NOTICE
Affiant further deposes that he/ she is not
interested in the subject matter of the
aforesaid notice or advertisement, and that
all allegations in the foregoing statement
as to time, place and character of
3:~~~
Letters of Administration 00 the Estate of MARY T.
GARNER, lats of the Township of West Pennsboro,
Cumberland County, pennsylvania, deceased, have
been granted to the undersigned.
All persons knowing themselves to be indebted to said
Estate will make payment immediately, and those
having claims will present them for settlement.
Janet C. Walker
24 Chestnut Street
Newville, PA 17241
Kathleen K. Shaulis, Attorney
44 South Hanover Street
Carlisle, PA 17013
Sworn to and subscribed before me this
11th day of May, 2005.
C-l({.~'-h.^"l) /2 IAY~Q
Notary . blic
My commission expires: q /;/tJl
COMMONWEALTH OF PENNSYLVANIA
Notu..1 Seal
Chnstina l. Wr:Jfe. Notary Public
Ca~isJe 8010, Cumberfand Coonly
My Commission Expires Sept 1. 2008
Member, PennsVlvania Association Of Notaries
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16,1929), P. L.1784
COMMONWEALTH OF PENNSYLVANIA
55.
COUNTY OF CUMBERLAND
Lisa Marie Coyne, Esqnire, Editor ofthe Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law
J oumal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid,
was established January 2,1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
VIZ:
April 29, May 6, 13, 2005
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter ofthe aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication are true.
Garner. Mary T., dee'd.
Late of the Township of West
Pennsboro.
Administratrix: Janet C. Walker,
25 Chestnut Street. Newville. PA
17241.
Attomey: Kathleen K. Shaulis.
Esquire.
SWORN TO AND SUBSCRIBED before me this
13 day of May
NOTARI SEAl
LOIS E. SNYDER. Notary Public
C8/IiSIe Boro, Cumberland County
My Commission Expires Malth 5, 2009
~
~
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, P A 17013
May 13, 2005
Cumberland Law Journal is published every Friday by the Cumberland County Bar
Association and is designated by the Court of Common Pleas as the official legal publication for
Cumberland County and the legal newspaper for publication oflegal notices.
TO:
Kathleen K. Shaulis, ESQUIRE
RE:
Mary T. Gamer, ESTATE
Legal advertisements must be received by Friday Noon. All legal advertising must be
paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on following dates:
April 29, May 6, 13,2005
Advertising Cost
Proof of Publication
Second Proof Request
Payment Received
Total Amount Due
Payment received Aori125. 2005
by Beckv H. Morgenthal/Executive Director
$ 75.00
$ 0.00
$ 0.00
$ 75.00
-------------
$ 0.00
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PS Form 806, Receipt for Registered Mail Copy 1 _ Custom.,
May 2004 (753q.02-qOO-9951) . (See Information on Reverse)
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CP552254525US
United States Postal Service
Customs Declaration and-Dispatch Note - CP 72
The item'parr:;el may be opened officially. Please print and press hard. You are making fTlJitiple copes.
Sender's Name Sender's Customs I Insured Number
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Addressee's Name Importer's Reference - Optional (ff any)
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Detailed Description of Contents (1) Qty_(2) Net Weight (3) ","ee (US $)(5) For Commercial Senders Only
lb. oz. HS tariff number (7) Country of origin of goods (8)
Check One o Airmail/Priority [j SurfaceJNonpriority Total Gross WI. (4) Total Value (6) Postage and Fees (9)
Check One (10)0 Gift o Commercial sample " Other Sender's Instructions in Case of Nondelivery . . . e Date Stamp
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c Treat as Abandoned
Comments (11) (e.g.. goods subject to quarantine, sanitary/phytosanitary inspection, or othe~ restrictions) C Return to Sender - II} ~ '/ "
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License Number(s) (12j Certificate Number(s) (13) I Invoice NumbE: (14) charges at sender's expense. I.U ~~'~Jrn
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article prohibited by legislalion or by postal
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May 2004 (7530~02.000-g05~) (See InformatIOn on Reverse)
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Received by
04/22/2005
N"-W:'IL ~a.~_.._
~ n v LE Pi. ~ r r;rfI(-~-,-
NEWVILLE '''-
, . Penns.y I VCU~! Q
17;. ,!r-j::,.;8
4134870:'<. d09?
(300)~-"'-8 .177
12'49; 18 PM
Product
Description
--:: .-
Receipt
Uni t
P,'ice
Fina)
Pr'ice
Sale:)
Sale
Oty
WARREN PA 16365
First-Class
R~t~rn Recei pt (Gr~een Card)
Regl.tered
In.ur'ad Va I ue
Article Value
label Serial #;
$0.37
$1.7.0
$7.50
$0.00
$0.00
RB14275035lUS
IssllE; PVI ""$9~6;
Total;
Paid by;
Cash
Change Due;
=--~--,..
$9.62
$20.00
-$10.38
Bi I 1#;
Clerk;
1000301185038
03
All sales final .
RefUl1ds for g(ja~~n~~:~p~_an~ ~ostag€.
Thank you f ~ scrv! Cc~ onl y.
C 01 your bU510ess
lJ> tomer Copy
-
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NEWVILLE POS1 OFFICE
NEWVILLE, Peor~ylvania
112419998
4,>16",-,;41-0098
(OUU) 275-8777
-
11:28:39 ~M
1200~
--- -----
-
___ Sales Rece\pt
Sale Unit
Ilty Prlca
$0.83
Final
price
Juct
.;rlptiOic
- ..~._-----
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~RLESiOWN \\1 02813
rst-ClasS
Retucn Rece11-"t (Green Ca:~d)
cert if i ed
Label Serlal #:
$1,75
$2,30
70040750000205684749
--------
-----~--
$4,88
$0.60
I;;;;ue PVI:
CH~RLE'j(QWN RI 02813
First-Cla;;s
Return Rece\pt ,Green Cacd)
Cert if i ed
Laoel Se1-\ al #',
$1. 75
$2,30
10040150000205684756
----- .--
...-------
$4.65
$0.60
Issue pVl:
CLEVEL~O OH 44110
First-Clas;;
Peturn ReceIpt (Green Card)
certified
Label Serlal #:
$1,75
$2,30
70040750000205084703
--------
--------
$4,65
$0,60
Issue PVI:
OIL CliV P~ 16301
First-Class
Return Recei pt (Green Card)
certHi ed
label Serial #:
$1,75
$2,'30
70040750000205684770
--------
--------
$4,65
Issue PVI:
$18,83
Total:
paid bV',
Cash
Change Oue.
$20,03
-$1,20
I
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8illP: 10002011<0073
ClerK: 05
Al \ S3\~:5> flnal on stamPS ar\d postage.
Refundo for guaranteed ser,;i ceS onl y,
1horiK YOiJ fQf your bus' ness.
customer Copy
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NE'o!VII L~ POM
NEWVILLE" P : I OFFICE
, a.,r.~\/lvemi
17241999& ,d
03114/2005 4134870241-0098
(800)275-8777
S=1e:3
Sale
Qty
AD~IS~N NY 14801
Prl Or-l ty Mdi 1
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Ins~rad Value
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cabel Seriol #.
FTi'.x.luct
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RGC,~ijJt
Unit
f.'1 Il."e
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$6.80
$1.75
$'0- $8 8"
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B1427~0436eS
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~LEVELAND OH 44110 $\1.40
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$1 75
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$20,15
$3,95
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$1.75
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issue PVI: ----~
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cat.l Serial #:
$1,75
. $,;).00
~ll.'L. l;l)
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J"'I:i,'')u4U5US
Isslie PV1: --='-'-::=;;;:;
~rlA"LESI0WN RI 028'3 $1:3,7D
(lorityMcill. $'3.95
Return Kectli I,t
ReJl stererj {(1r~eei"l Card)
T .
_d1$1:lr-ej Val ue
Ar,tlcle '-Jall;e
LaDe) Sendl #:
Total:
Paid by'
Cash .
Change Due:
$1,75
$800
$50.00
Rti1 "-7' $5000
'.1 ~uj96US
1$5Ue PVI: --_::.::.~==
$1:J./U
$78 65
$8\1,00
-$1 35
011 J., 1
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Rl:lfu d\<;;"::> in-a-:, on o::.tdlll -
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Th al d' ,teed _ " ~ge.
2ink you tor' :::.er~Vlces unly
Clio:. tQme/C~~v bl:::' i fleSo:, " '
For the Account of:
Account Number:
Period:
Date Prepared:
MARY T GARNER INVESTMENT MANAGEMENT AGENCY
50 00 3043 OC 6
From Earliest Date
May 12, 2005
Statement of Transactions
NORTHWEST SA VINGS BANK
Date
Description
Income
Cash
Principal
Cash
Investment
Cost Basis
FOR MARY GARNER, NC#084097055AL
CHECK NUMBER 13529
12/15/2003 HANNA TRANSFER COMPANY-NORTH
PYMT FOR PERMANENT STORAGE OF HOUSEHOLD
CONTENTS - CUSTOMER #10186
CHECK NUMBER 14045
01/08/2004 HANNA TRANSFER COMPANY-NORTH
PYMT FOR PERMANENT STORAGE OF HOUSEHOLD
CONTENTS - CUSTOMER #10186
CHECK NUMBER 14500
03/04/2004 HANNA TRANSFER COMPANY-NORTH
PYMT FOR PERMANENT STORAGE OF HOUSEHOLD
CONTENTS - CUSTOMER #10186
CHECK NUMBER 15475
06108/2004 HANNA TRANSFER COMPANY-NORTH
PYMT FOR PERMANENT STORAGE OF HOUSEHOLD
CONTENTS - CUSTOMER #10186
CHECK NUMBER 2384
To\al DISBURSEMENTS TO OR FOR BENEFICIARIES
FIDUCIARY FEES
04/25/2003 MONTHLY FIDUCIARY FEE
05/19/2003 MONTHLY FIDUCIARY FEE
06/24/2003 MONTHLY FIDUCIARY FEE
07/22/2003 MONTHLY FIDUCIARY FEE
08/26/2003 MONTHLY FIDUCIARY FEE
09/23/2003 MONTHLY FIDUCIARY FEE
10/2212003 MONTHLY FIDUCIARY FEE
11/20/2003 MONTHLY FIDUCIARY FEE
12/22/2003 MONTHLY FIDUCIARY FEE
01/20/2004 MONTHLY FIDUCIARY FEE
02120/2004 MONTHLY FIDUCIARY FEE
0312412004 MONTHLY FIDUCIARY FEE
0412212004 MONTHLY FIDUCIARY FEE
OS/2012004 MONTHLY FIDUCIARY FEE
06/21/2004 MONTHLY FIDUCIARY FEE
07/20/2004 MONTHLY FIDUCIARY FEE
08/20/2004 MONTHLY FIDUCIARY FEE
09/20/2004 MONTHLY FIDUCIARY FEE
10/22/2004 MONTHLY FIDUCIARY FEE
11/2212004 MONTHLY FIDUCIARY FEE
12/20/2004 MONTHLY FIDUCIARY FEE
01/21/2005 MONTHLY FIDUCIARY FEE
02/1 8/2005 MONTHLY FIDUCIARY FEE
03/1 8/2005 MONTHLY FIDUCIARY FEE
04/20/2005 MONTHLY FIDUCIARY FEE
05/04/2005 FIDUCIARY FEE
05104/2005 ASSISTANCE PROVIDED BY THE ADMINISTRATOR IN THE
SETTLEMENT OF THE MARY T. GARNER ESTATE
Total FIDUCIARY FEES
OTHER EXPENSES
04/15/2003 HANNA TRANSFER COMPANY-NORTH
PYMT FOR PERMANENT STORAGE OF HOUSEHOLD
CONTENTS FROM 411/03 - 4/30/03
CUSTOMER NO. 10186
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
-33.25
-33.25
-33.25
-33.25
-427,381.44
-165.45
-164.69
-168.20
-167.33
-163.11
-162.20
-160.37
-160.20
-159.42
-162.86
-160.99
-161.45
-157.98
-157.64
-154.84
-152.97
-152.49
-146.84
-143.27
-140.33
-136.84
-133.36
-129.89
-4,699.47
-33.25
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00 /'
0.00
0.00
0.00
....--- ^
PAGE: 1 6144
1)10 b i 1 ex...
The Highlands
920 Ridgebrook Road
Sparks. Maryland 21152
r-"""."'''''.'''''''_''.''"I''.''''__''''''''I'''.''
t 04/15/05 I 9.40 I 1291497_
NURSING HOME: DR JASON LID
DATES OF SERVICE: 03/17/04 - 03/18/04
FORWARDING SERVICE REQUESTED
....................................
005501 1 AS 0 301
MARY GARNER
JANET WALKER
24 CHESTNUT ST
NEWVILLE PA 17241-1304
111111I1111111,1.1,,111I1111111'111111111,1,,1111,111111111111
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Mobilex USA
P.O. Box 17452
Baltimore. MD 21297-1452
AMOUNT OF PAYMENT: (
)
/,/('(1:1(' lfi'Well hell', wul"71dUJ;(',f1i$ J1f1rtifllllt'itll YOIW p""mp'l'''ym(,llf. J1wllk YfJl/!
DATE " PROCEDURE DESCRIPTION ,
t CODe ...
INSURANCE ADJUSTMENTS
MYMENTS PAY,-"ENTS
03/18/04 72100 SPINE LUMBOSACRAL 2-3 VWS 27.0
03/18/04 ALLOWANCE WRITE DOWN 14.64
02/10/05 S CALIFORNIA MEDICARE PA 9.86
02/10/05 ALLOWANCE WRITE DOWN .03
03/15/05 ALLOWANCE WRITE DOWN .06 2.4
03/17/04 73560 KNEE AP/LATERAL VIEWS 27.0
03/17/04 ALLOWANCE WRITE DOWN 17.02
02/10/05 CARE PENN PAYMENT 7.99
02/10/05 ALLOWANCE WRITE DOWN .01 2.0
03/15/05 COMMERCIAL PAYMENT .00 2.0
03/17/04 73560 KNEE API LATERAL VIEWS 27.0
03/17/04 ALLOWANCE WRITE DOWN 17.02
02/10/05 CARE PENN PAYMENT 7.99
02/10/05 ALLOWANCE WRITE DOWN .01 ,oj
03/15/05 COMMERCIAL PAYMENT .00 I 2.0
03/17/04 73520 HIP BILAT 2 VIEWS WITH 27.0 I
AP PELVIS
03/17/04 ALLOWANCE WRITE DOWN 12.36
02/10/05 CARE PENN PAYMENT 11.72
02/10/05 ALLOWANCE WRITE DOWN .01 "J
03/15/05 COMMERCIAL PAYMENT .00 2.9
P~TT~MT ~~~PON~TRTTTTV.
CURRENT 30- 29- 29- OVER 120 BALANCE DUE
9.40 .00 .00 .00 .00 9.40
CALL BETWEEN THE HOURS OF 9:00 A.M. AND 6:00 P.M. EST
TELEPHONE 1~800.786.8015
THIS BILL IS FOR PORTABLE XRAY SERVICES
Lf- ~ 7-0&-
tJ-.3
.m
SWAIM HEALTH CENTER
210 BIG SPRING ROAD
NEWVILLE PA 17241-9486
.
ACCOUNTS RECEIVABLE STATEMENT
Statement Date: 03/31/2005
RETIREMENT AND SENIOR
CARE SERVICES
-tis
6--9 -oS;
MARY GARNER
c/o JANET WALKER
24 CHESTNUT STREET
NEWVILLE PA 17241
i '. '1~1;1oafi!1"0:';I;i!f'~:::TIT801111'!l;::fC:8Plit1~iji>tl91'l
0310112005 - 0310112005 Oxygen Daily
03101/2005 - 03/0212005 ABD Pad 5 X 9
0310112005 - 0310212005 Sponge Gauze 4 X 4 8 Ply ST
0310212005 - 0310212005 Wipe T ena
03/02/2005 - 03/0212005 Prevacare Ointmenl2.3 oz
03105/2005 - 03/05/2005 Brief Promise Ultra Ig
03/05/2005 - 03/06/2005 ABD Pad 5 X 9
03/05/2005 - 03/0612005 Sponge Gauze 4 X 4 8 Ply ST
03/0612005 - 03/0612005 Telephone
03/06/2005 - 03/06/2005 Body shampoo royalmed 8 oz.
03/07/2005 - 03/31/2005 Room/Board-Self Pay
>1\>
. 'tbaY!lJl1liltsl'1f;,:.1
4.00
7.00
5.00
1.00
1.00
1.00
13.00
2.00
1.00
1.00
(25.00)
Balance Due: 2,017.36
Balance Due Cpon Receipt
RETURN one copy with your remittance;
RETAIN one copy for your records.
This is lhe only copy you will receive.
Account Number: 61199GRV
Balance Forward;
'!'Cffiirg8;;i!i[:tr::t>ilYI!l~ti':j:1
22.00
1.89
0.85
8.41
11.25
51.43
3.51
0.34
27.43
2.00
(6,000.00)
7,888.25
'i'S,X2"fa,atii'"t&;fnt,i,:;}jiil
7,910.25
7,912.14
7,912.99
7,921.40
7,932.65
7,984.08
7,987.59
7,987.93
8,015.36
8,017.36
2,017.36
TOTAL:
2,017.36
(5,870.89)
0.00
SWAIM HEALTH CENTER: MARY GARNER 61199GRV
~
\
.,
CONTINUING CARE RX
28 S 2ND ST IPO BOX 355
NEWPORT PA 17074
* * S TAT E MEN T * *
Statement Date:
4/30/05
Page:
1
Account #: 100021414
Name: MARY GARNER
JANET WALKER
24 CHESTNUT ST
NEWVILLE, PA 17241
If you have any questions regarding your bill please call
17171 567-2147 or 1-800-675-2279. Thank you!
Date
Description
Gty
Amount
-------- -------------------------------------------- ----------
P~evious Balance
66.44
Ending balance - Pay th i s amount ---------:> 66. 44
Past Due Past Due Past Due
Current 31-60 days 61-90 days 90+ days
----------- ----------- ----------- -----------
.00 41.44 25.00 .00
~
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Insurance Patient
Dale Code Description Provider Diagnosis Location Amount Balance Balance
Balance Forward: 0.00 0.00
)2/07/05 99312 SNF VISIT, MODERATE JAP 290.21 GRV 60.00 10.95
)4/06/05 MCCK Medicare Check -43.38
)4/06/05 MCDD Medicare Deductible 0.52'
)4/06/05 MCDS Medicare Disallowance -5.26
)4/26/05 AETCK AETNA CHECK -0.41
5-:2- -OS Gkt, ~ '-I
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100 S !J ~sl ,rJ::t-w.~
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Current: $10.95 Past Due: $0.00 Total amount: $0.00 $10.95
Please pay this amount: $10.95
Your insurance carrier has orocessed this claim and the
balance is now vour resoonsibilitv. Please remit oromptly
or contact our office to make payment arrangements.
".nformationonIy(Deductible&Denied)
(I)
Register of Wills of Cumberland County
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of Mary T. Gamer
a/so known as
No.
To:
. Deceased.
Register of Wills for the
County of Cumberland in the
Commonwealth of Pennsylvania
Social Security No. 084-09-7055
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl~ for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decedent was domiciled at death in Cumberland County, Pennsylvania, with h.!!L. last family or principal
residence at Green Ridge Village, 210 Big Spring Road, Newville, PA 17241
(Iist street, number and municipality)
Decedent, then 90 years of age, died March 7
Green Ridge Village, 210 Big Spring Road, Newville, PA 17241
.2005
.at
Decedent at death owned property with estimated values as follows:
(!fdomiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Po.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$ 100.000.00
$
$
$
Petitioner_ after a proper search ha~ ascertained that decedent left no will and was survived by the
following spouse (if any) and heirs:
N R I f hi R 'd
ame e a IOns uo est ence
David Gamer Son 6962 County Rle 2, Addison, NY 14801
Judy Gamer Dauahter 3514 Butler Street. Apt. 2, PGH, PA 15201-1340
Diane Hollowood Dauahter P.O. Box 10490, Cleveland, OH 4411()..()490
Janet Walker Daughter 24 Chestnut Street, Newville, PA 17241
THEREFORE, petitioner(s) respectfully request(s) the grant ofletters of administration in the appropriate form
to the undersigned.
Residence(s) ofPetitioner(s)
24 Chestnut Street, Newville, PA 17241
.
Register of Wills of Cumberland County
RENUNCIATION
Estate of Mary T. Ga.rn~r
Also known as
No.
. deceased
To the Register of Wills of Cumberland County, Pennsylvania
The undersigned Judy Gamer daughter and 1 of 4 heirs
(Name) (Relationship) (Capacity)
of the above decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that
Letters of Administration
be issued to my sister Janet Walker of 24 Chestnut Street, Newville, PA 17241.
Witness my/our hand(s) this .:3/ 5.t;;ay of ~..4 ~ <L 7"/ . 20 0;;--
,~~~~)
JudyGa r
3514 ButlerSt, Apt. 2, Pgh, PA 15201-1340
(Address)
. . NOTARIAL SEAL
ComrrussLOn Ex~tres:
JAN ~. COLeMAN. N~!;;l.~~ pubnc
f . + ur h Aile heny Co., PA
My CommIssIon Exp!res March ~2, 2CJ3
(Signature)
Or
(Address)
Affirmed and subscribed before me this
_ day of
(Signature)
Register of Wills
(Address)
Deputy
~
(Signature and seal of Notary or other official
qualified to administer oaths. Show date of
expiration ofNolary's commission)
.
Register of Wills of Cumberland County
RENUNCIATION
Estate of Mary T. G.Clr\'\e \"""
Also known as
No.
. deceased
To the Register ofWil1s of Cumberland COlmty, Pennsylvania
The undersigned David Gamer son and 1 of 4 heirs
(Name) (Relationship) (Capacity)
of tilt: above decedent, hereby renounce(s) the right to adrr.inister the estate and !'espectfully request(s) thlit
Letters of Administration
be issued to my sister Janet Walker of 24 Chestnut Street, Newville, PA 17241.
"'.=."00'''''''''''' q,t>,.,o' m9..Jl ~
Affirmed and subscribed before me this
,~f\ day of 1/1(')((1 k..-. OavidGamer (Signature)
~ /' / (iJ.r71 / 6962 County Rle 2, Addison, NY 14801
L~-d ;//cY,// /~ (Address)
Notary Public#' ASHLEY L MOSllER REG. 01 MOS09586:
Notary MMe, State" New York
My Commission Expires' Oual~ed In S.uben eo",ry 1 /,,,,::7
. MyeommIsslooExpIresJu~21, o(W/7
-
(Signature)
Or
(Address)
Affirmed and subscribed before me this
_day of
(Signature)
Register ofWil1s
(Address)
Deputy
(Signature and seal of Notary or other official
qualified to administer oaths. Show date of
expiration of Notary's commission)
.
Register of Wills of Cumberland County
RENUNCIATION
Estate of MaryT. Gl\l'ner
Also known as
No.
. deceased
To the Register ofWilIs of Cumberland County, Pennsylvania
l)iaVle
The undersigned. -Hollowood daughter and 1 of 4 heirs
(Name) (Relationship) (Capacity)
of the above decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that
Letters of Administration
be issued to my sister Janet Walker of 24 Chestnut Street. Newville. PA 17241.
Witnessmy/ourhand(s)this 9d.dayof ~~
.2001.
~ed and SUbS~ before me this
~day of /1..<' .k! .
c:r...o 0 ?
aA~()c;(~
Notary Public
Gll~.u. E-
u...~ l(" ~ ,-,(x J.
(Signature)
Diane Hollowood
P.O.Box 10490. Cleveland. OH 44110-0490
(Address)
My Commission Expires: ........
BARBARA A. COMSTOCK. Nolary ruuuC
STATE OF OHIO
My commission l:J<ll.res AprIl 20, 2008
(Signature)
Or
(Address)
Affirmed and subscribed before me this
_day of
(Signature)
Register of Wills
(Address)
Deputy
(Signature and seal of Notary or other official
qualified \0 administer oaths. Show date of
expiration ofNotary9S commission)
Jli05.S0S REV 1105
This is to certify that the information 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 the State Vital Records Office for permanent filing.
,
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate. $6.00
~~'~.H"~~~~~
Local Registrar
p
11330423
No.
"AR g?l1ll!i
Date
H105,14:lR"".2JfJ7
COMMONWEALTH OF PENNSYlVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
TYPElPRlNT
m
..........
""""'~.
aTATEFn.-E__
SOCIAl. SECORIT'( NUMBER
.084 -09 7055
~
~
"
~MEOf'DECEDEN'T(FIraI. _.L1111)
1. Mar
AGE (LllIIIlIrth<l1y)
90
'"
l.Fema1e
i'l1rPlffl""!~2'a(J!l'
.
T.
'"
-D =trfD
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MARtTALSTATUS_MRn18Il.
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SURVlVlNG SPOUSE
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..
11e.UY..,doloc:edw1llvedin West Pennshnrn lwp
11b.CoIrtY
Cumberland
11d.D~~aI'
"'-
MOTHER'S NAME (FWSl. Iollddl.. Sum_)
it. Mary McCleary
~~~~f~~!lf(~~ITWe;;r:tr~, PA 17241
PlACE OF OISPOSITlDN-Na'neorc-y, CnInlRIory '8rIONcfrlf<Mrl. ~ ZlPft'"J 0 1
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CAUSE(DiMaecrio1UlY
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PERFORMED? AVAlLABlEPRIORTO
COMPlETIO~ Of' CAUSE
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DATEOF1NJURV
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INJUR'I AT '.'\all<? OESCRI!l'E HOWINJURV OCCURRED
MANNER OF DEATI-l
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CERTIFIER (Chedconly......)
:=~~~~g8:f~~~~.~~.~.i.~?~)...
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SlGl'IATU
.............0 31b.
UaoN ~ (IolCO'llh,Osy.YMr)
............<031 1ft 31d. (Jt)
NAME AND AODR'ESS OF PeRSON W10 COMPLETE CAUSE OF DEATH
31~~~~.~:.1.~.~~_~..~.~.~.~.~:.~.~.~:.~.~~.~~~.~~~~..0 ~~;;I: (00 S ~};JJ~~-I
33.REGlmtAR'SSlGNAlURfiANDNUMBER ~. ~~ 1:J1~ laJ \,~ :TEFlLEOIM<>nIh.Day. v-J
''f:'':::::'G::~=~~~~=,==~klM':=l..,._eutad...
STATE OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SHORT CERTIFICATE
I,
GLENDA FARNER STRASBAUGH
es ta te of MARY T GARNER
Register for the Probate of wills and Granting
Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
the 12th day of April, Two Thousand and Five,
Letters of ADMINISTRA TION
in common form were granted by the Register of
said County, on the
, late of WEST PENNSBORO TOWNSHIP
(First, Middle. Last}
in said county, deceased, to JANET C WALKER
(First. Middle, Last)
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 12th day of April
Two Thousand and Five.
File No. 2005-00341
PA File No. 21- 05- 0341
Date of Death 3/07/2005
S.S. # 084-09-7055
d/ l\.ckL ~ L/CC 'urzd/lC&1- LUf (--,
- Register Of Wills / i/
L/l7cv-~v u.Uc) l~,-cv(~
( I '>I Deputy
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
c;OMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 005338
DUPLICATE
WALKER JANET C
24 CHESTNET STREET
NEWVillE, PA 17241
U_+n~_ fold
ESTATE INFORMATION: SSN: 084-09-7055
FILE NUMBER: 2105-0341
DECEDENT NAME: GARNER MARY T
DATE OF PAYMENT: 05/18/2005
POSTMARK DATE: 05/18/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 03/07/2005
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $17,550.00
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$17,550.00
REMARKS: J C WALKER
CHECK# 7
SEAL
INITIALS: VZ
RECEIVED BY:
TAXPAYER
GLENDA FARNER STRASBAUGH
REGISTER OF WillS