HomeMy WebLinkAbout09-27-05
REV.15QO EX (6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER. ,I
c2L - ~ --5. 11 ~k :t. _
CQLt;TY COllE YEAR NUM R
THIS RETURN MUST BE ALED IN DUPL CA TE WITH THE
REGISTER OF WI LS
SOCIAL SECURITY NUMBER
203-20-1504
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Yasalonis, John J.
SOCIAL SECURITY NUMBER
210-16-7186
DATE OF DEATH (MM-DD-YEAR)
01/14/2005
DATE OF BIRTH (MM-DD-YEAR)
06/12/1924
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Yasalonis, Sophia
[i] 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy ofWdl)
o 9. Litigation Proceeds Received
o 2. Supplemental Retum
o 4a. Future Interest Compromise (dale of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Mach copy ofTrust)
o 10. Spousal Poverty Credit (dale of death between 12-31-91 and ','.95)
o 3. Remainder Return (dale of death
o 5. Federal Estate Tax Return Req ired
o 8. Total Number of Safe Deposit xes
o 11. Election to tax under Sec. 911 (A) (Attach Sch 0)
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THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE III
NAME COMPLETE MAILING ADDRESS
Sophia Yasalonis Sophia Yasalonis
FIRM NAME (ff .Awlicable) 309 Evergreen St
New Cumberland, PA 17070
TELEPHONE NUMBER
(717) 774-6620
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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 Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
(1)
(2)
(3)
(4)
(5)
0.00
14,706.66
0.00
0.00
0.00
(6)
0.00
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
(7)
40,082.93
(8)
7,872.82
0.00
(9)
(10)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been
made (Schedule J)
(11)
(12)
(13)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
___~___________4~,~..:1~L!Z x .0 _Q...~ (15)
_~__.____________~ 0.00 x.O __ (16)
__~______._______O.OO x .12 (17)
0.00 x .15 (18)
(19)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
190 Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
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,789.59
7,872.82
6,916.77
0.00
6,916.77
0.00
0.00
Decedent's Complete Address:
STREET ADDRESS
309 EverQreen St
CITY New Cumberland I STATE I ZIP
PA 17070
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
0.00
0.00
0.00
0.00
Total Credits (A + B + C ) (2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
0.00
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)
(5B)
0.00
B. Enter the total of Line 5 + SA. This is the BALANCE DUE.
0.00
0.00
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: Yes
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.......................................................................................................................... 0
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of 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 Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ ~
No
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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 dedare that I have exlmined this retum, induding accompanying schedules and statements, and to the best of my knowledge and belief, ij 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 FILING RETURN
A~m~
36 f UUt(;-llh..J Sf ;vf...v (Un-I ~fl2fA.-j)
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
fA 17V7{)
DATE
. __2"'m~.~-:- m~
DATE
ADDRESS
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[72 PS 99116 (a) (1.1) (i)],
For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P,S. 99116 (a) (1.1) (ii)].
The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneficiary,
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [72 PS, 99116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P,S, 99116(1 ,2) [72 P.S, 99116(a)(1)J.
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 PS, 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption,
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REV-1503 EX+ (6-98.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
FILE NUMBER
ESTATE OF
Yasalonis, John J.
All property jointly-owned with right of survivorship must be disclosed on Schedule F
ITEM VALUE AT DA E
NUMBER DESCRIPTION OF DEATH
1. Prudential common stock; 276 shares; Avg market value per share on 14Jan05 =$53.285 14, 706.66
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TOTAL (Also enter on line 2, Recapitulation) $ 14 706.66
(If more space is needed, insert additional sheels of the same size)
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PRUDENTIAL COMMON
Issue 10: 230010
Enter a date (MM/DD/YYYY) ~
Press Submit to vi:W Historical Market p~c.:.;Ce'i#""~
Date as of. 1 ., ". n",
Trade Date Price Close High/Ask Lbw/Bid
01/14/2005 53.880 53.960 2.610
01/13/2005 53.050 53.580 2.750
01/12/2005 52.980 53.250 2.250
01/11/2005 53.020 53.280 2.070
01/10/2005 53.150 53.420 2.570
01/07/2005 52.620 53.430 2.600
01/06/2005 53.320 53.720 2.950
01/05/2005 52.940 53.900 2.890
01/04/2005 53.470 54.280 3.470
01/03/2005 53.860 54.970 ! 3.860
12/31/2004 54.960 55.270 154.830
~ Drevious I next ~
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REV-1510 EX+ (6-98*
COMMONV\lEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
Yasalonis, John J.
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV 1500 COVER SHEET's yes
FILE NUMB~R
- I
DESCRIPTION OF PROPERTY T .xABLE
ITEM INClUDE ~E NAME OF ~E TRANSFEREE. ~EIR RElA-nON~IP TO DECEDENT ANO DATE OF DEATH % OF DECD'S EXCLUSION
NUMBER ~E DATE OF TRANSFER ATTACH A COPY OF ~E DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST tlF APPlICAelEI I\LUE
1. IRA; Prudential Annuity 97630254;50% Fixed-50% Prudential Stock Index; 30,082.93 100 30,082.93
2. 1998 Buick Park Avenue 4dr Sedan 10,000.00 100 10,000.00
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100
100
100
TOTAL (Also enter on line 7 Recapitulation) $ 40,082.93
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Values
Statement
Prudential ~ Financial
The Prudential Insurance Company of America
A Prudential Fimmcial Company
Annuity Services
P.O. Box 7960
Philadelphia, PA 19176
August 22, 2005
SOPHIA S. Y ASALONIS
309 EVERGREEN ST
NEW CUMBERLND P A 17070-1325
Owner: SOPHIA S. Y ASALONIS
Annuitant: SOPHIA S. Y ASALONIS
Contract Number: 97630254
Contract Date: 01/21/1993
Type of Contract: Variable Investment PI n
Market: IRA
The values provided on this statement are calculated as of 01/1412005.
statement.
Any activity after this date is not reflected in thls
!
If you surrender this contract you wi1110se the right to future annuity benefits under the contract. In addition, all or part f the
distribution may be subject to federal and/or state income tax. You may also be subject to a 10 percent penalty tax for e rly
withdrawal. You may want to consult with your tax adviser if you have any questions concerning the applicable tax tre tment,
as Prudential cannot offer tax advice.
Account Summary as of 01114/2005
Although great care has been taken in preparing this statement, we reserve the right to amend the statement as needed.
additional information about the benefits available to you, please refer to your original contract.
Fixed Rate Option
Prudential Stock Index
3,258.49938
4.682100
$16,255.77
$15,256.62
Surrender Value as of 1/14/2005
Contract Value
$31,512.39
$0.00
$1,142.69
$286.77
Misc. Fees
Surrender Charge
Recaptured Bonus
890160, W SH
Variable Investment Plan is issued by The Prudential Insurance Company of America. Unit values of the variable investment options are determined at the
end of the business day on the trade date of the transaction. .
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The Prudential Insurance Company of America
a mutual life insurance company
Prudential Plaza, Newark, New Jersey 07101
Annuitant(s) JOHN J YASALONIS
Annuity Date JAN 21. 1994
Agency N-W SH-E-068
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We will make monthly annuity payments startin9Ql"'ltheAhnp,wp~te we show above. We make this proml~e
subject to all the provisions of this contr~ct..' I
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Please read this contract with care. A guide to iU;cQnten't;)is on the last pag~'&Elfore the back cover. A sum tr
is on page 5. If there is ever a question about it, or if therei~~91?irn, just see onegfour representatives or 9 in
touch with one of our offices. . .,.. .
Benefits and values under this contract may be on a variable basis. Amounts directed into one or mo e of
the variable subacco u nts will reflect theinves tme ntexpe..ri,e,nce, of those subac counts:T hey are subjep t to
change both up and down and are not guaranteed as todqUar amount ~xcept as prOVided under the qeath
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of Annuitant and Payout Provisions sections. , .. "",' jl
Right to Cancel Contract.-Not later than ten days after you.get this contract, you may return it to us. AI you
have to do is take it or mail it to one of our offices or to the~g~rit who $Old it to you, We will cancel the co tract
and promptly give you its contract fund, less ~ny portiQn of ..~heC()I"Itr~ct fund that r~ulted from additional
amounts we have added (see page 8) determined as of the a,ate ~Ol.lr request IS received ..
The pcov;.;on. on th;. and the follow,ng pag..:of 'b",_.,ot~prjse thee"lire op~tr.",. The oontract w~.
signed for Prudential on the contract date, which is the date of Issue.
Signed for Prudential.
j)~
President
Secretary
Variable Annuity Contract with Flexible Purchase Payments-Monthly annuity payments starting on Ann\Jity Date.
Payment as stated upon death before Annuity Date. Purchase payments payable during Iifetime(s) of an~uitant(s)
until Annuity Date. Cash value reflect investment results. I
VIP-86 - P
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Page 2 (VtP-86) .
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CONTRACT DATA
Annuitant (s) JOHN J Y ASALON I S
97 630 254
JAN 21, 1993
Contract ~umber
Contract pate
Annuity Date JAN 21, 1994
Agency N-W SH-E-068
Annuitant:
Name
Sex and Issue Age
Date of Birth
JOHN J YASALONIS
M-68
06-12-24
Beneficiary:
SOPHIA S YASALONIS, WIFE
ALLOCATION OF INITIAL PURCHASE PAYMENT
STOCK INDEX 50%
FIXED RATE OPTION 50%
***** END OF SCHEDULE *****
The maintenance charge is up to $30.00 annually. We explain this on page 12.
Service Office - Please direct any communications about this contract to:
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
P.O. Box 388, Fort Washington, PA 19034
Page 3 (VIP-86) (PA)
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BLUE BOOK- RETAIL REPORT
Pennsylvania · August 21, 2005
BLUE BOOI CLASSIFIEDS"
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1998 Buick Park Avenue Sedan 40
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Engine: V6 3.8 Liter
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Drive: FWD
Mileage: 70,000
Equipment
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Power Steering
Power Windows
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Retail Value Search Local ListinQs for This Car $9,105
The Kelley Blue Book Suggested Retail Value is representative of dealers' asking
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Vehicle valuations are opinions and may vary from vehicle to vehicle. Actual valuations will vary based upon market
conditions, specifications, vehicle condition or other particular circumstances pertinent to this particular vehicle or
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1998 Buick Park Avenue Sedan 40
BLUE BOOK CLASSifiED)
Seorm Used (IIr listings
Engine: V6 3.8 Liter
Trans: Automatic
Drive: FWD
Mileage: 70,000
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Equipment
Air Conditioning
Power Steering
Power Windows
Power Door Locks
Tilt Wheel
Cruise Control
AM/FM Stereo
Cassette
Dual Front Air Bags
ABS (4-Wheel)
Leather
Dual Power Seats
Alloy Wheels
Consumer Rated Condition: Good
"Good" condition means that the vehicle is free of any major defects. This vehicle has a
clean title history, the paint, body and interior have only minor (if any) blemishes, and
there are no major mechanical problems. There should be little or no rust on this
vehicle. The tires match and have substantial tread wear left. A "good" vehicle will
need some reconditioning to be sold at retail. Most consumer owned vehicles fall into
this category.
Private Party Value Search Local ListinQs I List This Car for Sale $6,825
Private Party Value is what a buyer can expect to pay when buying a used car from a
private party. The Private Party Value assumes the vehicle is sold "As Is" and carries
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1998 Buick Park Avenue Sedan 40
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Engine: V6 3.8 Liter
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Equipment
Air Conditioning
Power Steering
Power Windows
Power Door Locks
Tilt Wheel
Cruise Control
AM/FM Stereo
Cassette
Dual Front Air Bags
ABS (4-Wheel)
Leather
Dual Power Seats
Alloy Wheels
Consumer Rated Condition: Good
"Good" condition means that the vehicle is free of any major defects. This vehicle has a
clean title history, the paint, body and interior have only minor (if any) blemishes, and
there are no major mechanical problems. There should be little or no rust on this
vehicle. The tires match and have substantial tread wear left. A "good" vehicle will
need some reconditioning to be sold at retail. Most consumer owned vehicles fall into
this category.
Trade-In Value List Your Car For Sale Online $5,225
Trade-in Value is what consumers can expect to receive from a dealer for a trade-in
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.If FEEDBACK
11
REV-1511 EX+ (12-99>.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Yasalonis, John J.
FILE NUMBER
ITEM
NUMBER DESCRIPTION AMOUN
A. FUNERAL EXPENSES:
1. Traditional Funeral Service ,872.82
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s) -
Street Address
City State Zip
Yea~s) Commission Paid:
2. Attorney Fees
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.
!
TOTAL (Also enter on line 9, Recapitulation) $ t,872.82
..
Debts of decedent must be reported on Schedule I
(~ more space IS needed, Insert additional sheets of the same size)
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A Family Tradition Of Caring
PARTHEMORE Funeral HO~& Cremation Servjces, Inc.
~:=~:..~1 1"1712005
New Cumberland, PA I"
1303 Bridge Street
P.O. Box 431
New Cumberland, P A 17070
(717) 774"7721
(Fax) 774-5546
www.parthemore.com
We sincerely appreciate the confidence you have placed in us and will continue to assist you. n every way
we can. Please feel free to contact us if you have any questions in regard to this statement e following
is an itemized statement of the services, facilities, automotive equipment and merchandise th you selected
when making the funeral arrangements.
Terms
Net 30
Due Date
2/16/2005
Account #
2005009.0
4,959.00
2,450.00
7,409.00
Description
Traditional Funeral Service.
18 Gauge Steel "Kensington" Casket
Total Services and Merchandise
Gilbert W. Parthemore,
Founder
Stephen K. Parthemore,
CFSP
Death Notice, Shamokin
Certified Copies of Death Certificates
(2) Clergy Honoraria
Organist Honorarium
Soloist Honorarium
Altar Servers
No Altar Servers
87.00
60.00
250.00
125.00
75.00
15.00
-15.00
Gilbert 1. Parthemore,
Supervisor
Total Cash Advances
597.00
Bruce R. Parthemore,
Pre-Need Coordinator, CPC
Immediate Pay DiscouIlt - Thank you!
Overpayment Refund (check enclosed)
-148.18
15.00
Professional Memberships:
NFDA . PFDA
DC FDA .CCFDA
G~
The Rule You Know,
The People You Trust
~
Total
Payments/Credits
Balance Due
$7,872.82
$-7,872.82
$0;00
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REV-1513 EX+ (9-00)
'*
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Yasalonis, John J.
FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR\~ARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTA
I TAXABLE DISTRIBUTIONS ~nclude outright spousal distributions, and transfers under I
Sec. 9116 (a) (1.2)] 46'~16 77
1 Sophia Yasalonis; 309 Evergreen St New Cumberland, PA 17070 Surviving Spouse
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I
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ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEEt
II NON-TAXABLE DISTRIBUTIONS: I
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
I
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
,
TOTAL OF PART 11- ENTER TOTAl NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00
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(If more space is needed, insert additional sheets of the same size)
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1East Jlill anh ffitsl&Uttm
OF
JOHN J. YASALONIS
I, JOHN J. YASALONIS, of the Borough of New Cumberland, County of
Cumberland, and Commonwealth of Pennsylvania, do hereby declare this to be my
last Will and Testament, revoking all other wills and codicils heretofore made
by me.
ITEM 1: give, devise and bequeath all of my estate. real.
personal and mixed, of whatsoever nature and wheresoever situate. to my
beloved wife, SOPHIA S. YASALONIS.
ITEM 2: If my wife. SOPHIA S. YASAlONIS, should predecease me. I
give. devise and bequeath all of my estate. real, personal and mixed. of
whatsoever nature and wheresoever situate. to my issue per stirpes.
ITEM 3: If, under the provisions of this Will, a share of my
estate shall become payable to any person under the age of twenty-one (21)
years. or if a share of my estate shall become payable to any person who by
reason of illness, or other incapacity. is incompetent to receive any or all
of the share to which he or she is entitled hereunder without the appointment
of a guardian or other fiduciary or the delivery of security. I hereby appoint
the DAUPHIN DEPOSIT BANK AND TRUST COMPANY. of Harrisburg, Pennsylvania,
Trustee and Guardian for such beneficiary. to hold in trust for the benefit of
such beneficiary, his or her share of my estate, and in this respect the said
Trustee shall have power to use principal as well as income in such amounts
and at such times that it. in its sole discretion, deems advisable for the
welfare, support and education. including college or trade school. of such
beneficiary. AND, further, the said Trustee shall have the full power and
authority to retain, sell, exchange, lease, invest, and reinvest any property,
real or personal of said trust without the necessity of petitioning any court
for permission to make such retention, sale, exchange, lease, investments, or
reinvestments in any manner it deems best, without being limited to such
investments prescribed by the laws of Pennsylvania then in force for the
investment of trust funds. AND, further, the said Trustee shall have the full
II
power and authority to borrow money from any person or institution. including
its own lending department. and to mortgage or pledge any or all real or
personal property comprising the trust. if such borrowing is necessary to
prevent the sale of any or all of the real or personal property comprising the
trust at a price less than the fair market value of such property. AND.
further. the said Trustee shall have the full power and authority to compro-
mise any claim or controversy, without the necessity of petitioning any court
for permission to make such compromise. The aforesaid Trustee shall pay to
any beneficiaries. when they individually reach the age of twenty-one (21)
years. and to any other beneficiaries subject to any other incapacity, when
such incapacity is removed, or to his or her estate if he or she should die
before reaching the age of twenty-one (21) years or before such incapacity is
removed, all the property or funds then in its hands which represent the said
beneficiaries' share of my estate.
ITEM 4: In the event that any beneficiary under this Will and I
shall die under such circumstances that there is no sufficient evidence that
we died otherwise than simultaneously. such beneficiary shall be deemed to
have predeceased me.
ITEM 5: I appoint my beloved wife. SOPHIA S. YASALONIS. Executrix
of this Will and direct that she be permitted to serve without bond and
without any intervention of any court except as required by law.
authorize
my Executrix to sell, encumber. mortgage, invest, distribute in kind, or retain
any item of property of my estate in such manner as she shall deem proper.
limited only by her own discretion. If for any reason my Executrix appointed
under this Will should fail to serve in that capacity, I appoint JOHN W.
YASALONIS and STEVEN YASALONIS, or the survivor of them, to be the Executors
or Executor. with the same powers and privileges set forth above.
r
IN WITNESS WHEREOF, I have. at Harrisburg. Pennsylvania. this
day of ~. 1985. set my hand and seal to this my Last
Testament. - /
Wi 11 and
~ (j, l1A A A L I - (SEAL)
rr r"'J~ J~r
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II
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Signed, Sealed, Published and Declared by the above-named
JOHN J. YASALONIS, as and for his Last Will and Testament, in the presence
of us, who, at his request, in his presence and in the presence of each other,
have hereunto subscribed our names as witnesses.
. ~~~~'U/I
~fl2. ~r"idence 57 r&/h..r J & I
. ~1> fJll /1J/ot/
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This is to certify that the information here given i... correctly coplvd from an original certific~te of death dulf filed with
Local Registrar. The original certificate will he forwarded to till' Statl' Vital Records Otl1ce tor permanent hlmg.
me as
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
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Local Registrar (J
Fee fur this certificate. 52.00
P 10~8999_~_
JAN 1
Date
I
7 200~
IS 143 Rev, 2/87
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
NAME OF DECEDENT (First, Middle, last)
SEX
51 A TE fiLE NUMBER
SOCIAL SECURITY NUMBER
DATE 0 DEATH (Month, Day, Year)
~Jan ary 14, 2005
5
COUNTY OF DEATH
80
Yrs
2. male 3. 210 - 16 - 7186
BIRTHPLACE (Cily and PLACE OF DEATH
Slate or Foreign Country) HOSPITAL
4Danville J PA Inpallent 0 ER/Outpatlent 0 DOA 0
7. Sa.
FACILITY NAME (U not institution, give street and number)
1.
AGE (Last Birthday)
8b
Cumberland
309 Evergreen Street
AS DECEDENT EVER IN
US ARMED FORCES?
Ye,D No IZI
12.
~~:~ty) 0
RAe - American Indian, Black, White, et
(Spe tly)
white
DECEDENT'S USUAL OCCUPATION
(~I'J:~:~'~;:i~~~o d~~le u~~rir~?ir~g)SI
MARITAL STATUS. Married,
Never Married, Widowed,
Divorced (Specify)
14. Married
SURVIVING SPOUSE
(lfwlfCil.QI'JtI Inilidenname)
hia Kanowicz
309 Evergreen Street
New Cumberland, PA 17070
17 a. State
Pennsvvlania
Did
decedent
live in a
township?
17c. 0 Yes, decedent lived in
twp
17b. County
Cumberland
17d. f8J ~~hi~e~~t~~7\j:~i~: of
New Cumber and
dty/ltOfU
MOTHER'S NAME (Fir5t, Middle, Maiden Surname)
1L Catherine Yascavage
INFORMANT'S MAILING ADDRESS (Street, CityfTown, State, lip Code)
20b.309 Evergreen Street, New Cumberland, PA 17070
PLACE OF D1SPOSITlON- Name of Cemetery, Crematory LOCATION - CHyffown, S ate, lip Code
or Other Place
2005
21.Rolling Green Memorial Park 21Joower AIle
NAME AND ADDRESS OF FACILITY Parthemore FH &
22cP.0. Box 431 New Cumberland
LICENSE NUMBER
24.
II; cf 2.-
UM
23b. 23<.
WAS CASE REFERRED TO A MEDICAL EXAMINER ORONER?
26, Ye, D No Ii'!
: Approximate PART II: Olher significant con itions contributing to death, but
: ~~~~a~:de::~~ not resulting in the u derlying cause given in PART I
LICENSE NUMBER
FD 013 340 L
To the best of my knowledge, death occurred at the lime, date and place slated
(Signature and Title)
23a.
TIME OF DEATH
27. PART I: Ent.r the di......, Injuri.. or complln,tion. which c"u..d Ih. d."th. Do nolent.r Ih. mode 01 dying, luch ". c"rdi"c or relpir"lory arrul, Ihock or he"rt '"ilur..
LI.' only on. tau.. on ..ch line
M.J .,<, '" \- (')F ~(I ~
h I;' ~'~uc.. h"",,-
o TO (OR AS A CONSEQUENCE OF)
SequtJnliCllJylist conditions
if any, leading to immediate
cause. Enter UNDERLYING
CAUSE (Disease or injury
that initiated events
resulting on death) LAST
! :
DUE TO (OR AS A CONSEQUENCE OF)
DUE TO (OR AS A CONSEQUENCE OF)
WERE AUTOPSY FINDINGS
AVAILABLE PRlOR TO
COMPLETION OF CAUSE
OF DEATH?
MANNER OF DEATH
Natural
ISJ
o
o
DATE OF INJURY
(Month. DdY. Year)
TIME OF INJURY
INJURY AT WORK? DESCRIBE HOW NJURY OCCURRED.
Homicide
D
o
D
Ye, 0 No 0
Accident
Pending IrwestigatLon
Ye, D No ~
Ye, 0
NoD
Suicide
Could nol be determined
30a. 30b. M
PLACE OF INJURY - At hurne, farm, strel:!l, factory, office
b..."ldlOg. tilc. (Spec.ly)
30e.
30d,
LOCATION (Street, CityfTown, ~tale)
301.
CERTIFIER
28a. 28b.
CERTIFIER (Check only one)
.~~~J:fJ~~tGor~~i'~~~~e~h.r.S~~:thC~~~~~~~~~u~: t~ ft~:~ha~~~~(:)I~~1JrJ:~l~~i~~d~~t~t~l:~~~~~~.~~.~ .~~~~~..~I.l~ .~~~~~I~~~::.~ .i.I~...I~ .::.l.. ............... lRl
29,
.PRONOUNCING AND CERTIFYING PHYSICIAN (Physician both pronoundng death and cel1ifylng lu cause of deClth)
To the be.t of my knowledgs, death occurred at Ihe time, date, and place, and due to the causes(s) and manner as atated..
'MEDICAL EXAMINER/CORONER
On the baai.. of examlnatlon and/or Investigation, In my opinion, death occurred .11 the time, date, and place, and due to t11l~ cau~8s(s) and
manner as stated ..................... ................ .............................. ... ...... .........................
31a.
33 REGISTRAR'S SIGZ(~~~,:~~Njjl ry:-; d,'Lt/....:~~.:L.... ~I / pt I /" I