HomeMy WebLinkAbout12-19-05
REV.~U.(5-00) REV-1500 OFFiCiAL U;,~E eN:.
COMMONWEALTH OF
PENNSYIlIANIA
DEPARTMENT OF REVENUE FILE NUMBER ,.._---_.._-,-~-
1lEPT. 28OIlO1 INHERITANCE TAX RETURN l.L--D.i .Q-LQ.iL
HARRISIlURG. PA 1712lHl601 RESIDENT DECEDENT
COOllIYOOllE IDR NLOIlER
IlECEOENJ'S NAME (LAST. FIRST. AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
~ RilJ DE DONNA C. /'13-;).L{ - ~ 3 ~-S
z
W DATE OF DEATH (MM-OD-YEAR) DATE OF BIRTH (MM-OD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
Q
W JIIARcN ~I ;;l.oo6- S Cf'TE",/3 tER. 3 /93/ REGISTER OF WILLS
U
W (IF APPLICABLE) SURVIVING SPOUSE"S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
Q AlolUE-
~ ~OriginarRet:um o 2. Supp/emental RoIum 03. RlMnainderRetum (dllIeoflilllhplb'w 12-13-82)
~~~. ~LmiledEstafe o 48. Future tntefest Compromise {d8IlI atdodl aft6' 12-12-82} o 5. Federal Estate Tax Return Required
"~8 o 7. Oecedsnt~aintained alivirrgTrust(AtlMtltcpydT"*1
GQ. i 06. DeosdentDiedTesl&t8(AtiKtlccpyd'WIl o 8. Total Number of Safe Doposn Boxes
.. o 9. Uigation _ RealNed o 10.SpousalPovertyCnldit_ofdelt.b8twelrlf2-31-t11M1_1~) D 11. Elecfurrtotex underSec. 9113(A) (A118Ct1 Sch 0)
..
NAME UIU L. f(EAI DE COMPLETE MAlUNG ADDRESS
531 /~TII ST.
FIRM NAME 1'_1 /I)~ IV eL''''' 8-(II./G~ ~A.
TELEPHONE NUMBER -77"1- 5138 17070
7/
1. Real Es1ato (Schedule A) (1) 0
2 SlocJ<s and Bonds (Schedule B) (2) 0 (") :-:.:::-J
: !,
3. Closely Held Corporation. Partner.lhip or SoIe-I'roprie1Drship (3) () '--;0 (;':'-2
-.:-A'] .j
; ~.~~~ ~ \1
(4) 0 .~
4. MorlgIges & NoIiI5 Ro_ (Schedule 0) .':'" r-~- - ~~
(5) b09. 7{' \.?
5.. Cash, Bank 0epCl6it& & Miscelliineous Personal Property '. ,-~}
(Schedule E) (....... ~ I
Z :::..";-\ _ - ~ 1
0 ~'J.5o.oo ...c,... '--:" ( )
6. Joilltly Owned Properly (Schedule F) (6) -
5 ' ~;---1 ..- lTl
o SeparelB _f/Requesled ~-:I .,
, " .18 L"
:J 7. 1rTt8r-Vivos T ransfenr & Miscellaneous Non'-ProbatB Property (7)
~ (Schedule G or l)
iL ;;2,370.9Lj
< 8. TllIal~_(toI8lLines1-7) (8)
U 9. Fun...1 Exponsos & Adm~_lAb (Sched\lle H) (9) ?-1'1/"2..00
W
Ir (10) ~)8.<8.5"0
10. Dobis otDooedent, Mortgage Liabilities. & Lie... (Schedule I)
11. Total DedodIons (Iotal Lines 9 & 10) (11) tlJ 7 L( c.S 0
12. Net Value of Estate (line 8 minus Une 11) (12) e ~
13. Charffable and Governmental 8equeslslSec 9113 Trusts for which an election to tax has not been (13) - Q
mode (Schedule J)
f-4. NetV.ILIe SubjecttD To: (Wne 12 minus Woe 13) (14) _ Cl -
SEE INSTRUCnONS ON REVERSI! SIDE FOR APPLICABLE RATES
Z 15_ Amounl of Ll1e 14_atllle spousallllx 0 0
0
~ rate, orlrBnslelll under See. 9116 (0)(1.2) X.D~ (15)
0 - 0 -
~ 16. Amount of line 14 taxable at lineal raID X.O~ (16)
:J (' 0 -
l1. 17. Amount of Li'le 14 taxable at sibling rate x .12 (17)
:::IE
0 18. Amount of Lil. 14 taxable at colliter81 rat. 0 x .15 (18) 0
U
~ 19. Taw: 0- (19) {J
20.0 CHECK HERE IF YOU ARE REQU~STING A REFUI'JO OF o..N OVERPA~ MENT
{l;
De~edent's Complete Address:
STREET ADORESS r:.31 I(!,rll S/.
CITY iJE kJ Gl:I~ 8t"(~/4"oI I STATE ~14 I ZIP /7070
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1) 0
2. CnldilS/l'aymen1S '0'
A. Sj)llUSai PooeIIy Credit JJ
B. Prior Paymenls
C, Disoount - 0
ToIaI Credits (A> B +C) (2) 0
3. In_enally ~ applioable 0
D.lntllrest
E. Penally ~ -
0
TotallnlerestlPenally(D+E) (3)
4. If L"" 2 ~ greale' than Line 1 + Line 3, enler the dilference. Th~ ~ the OVERPAYMENT. 0
Check box on Page 1 Una 20 III request . refund (4)
5. If Line 1 + Line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5) c)
A. Enler the interest on tho lax due. (SA) 0 -
B. Enter Ihe total of Line 5 + SA. This i,tho BALANCE DUE. (58) e
Make Check Payable to: REGISTER OF WILLS, AGENT
{*1~!i#"~'M- - ~"'r - II -- !illiim 1..!L~~~i\\';
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN .X" IN THE APPROPRIATE BLOCKS
,. ~.Mj =:t=:, ~=~ ::properly ~nsferl8d;..........,..,.....................,................................................----..f No
0
b. roJain the right to designate who shsll use the properly lnlIlSferred or its income; ..._........................................ ~
c. roJain a reversionary in_; 0'.......................................................................................................................... 0
o. _...tho promise lor life of either payments, benefits or ea",7 ...................................................................... 0 y
2. ~ death OCQJrreo afte, December 12, 1982, did decedent ~nsfer properly within one year of death ~
without receiving edequate consideraUon7 _....................................._..................................,.................................... 0
3. Did _ own an'n trust fo(' or payable upon death bank aa:ounl or security at hi, or he, death? .............. 0
4. Did _ own an Individual Retirement Account, annuity, or other ,",n-probate property which ~
conle!.. a _~ry de~gnalion? ."."."........,.......".".".".".".............................".".....,.".................................., 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.
lkJder~ ofpetpy.1 dlldlnt'lll tlI'I'8eX1lrined iii mm. indulIng.........,,.-.,;.'" sa.cu. andllllilmlnbl, RDl'lebelll: rlmyknowledgll n:I belief, itilM. correctn ccmpIetI.
0lIdlnI0n rI pNp8IW ohr ....... penonII ,....... II baled on aI irIarmaIion of Yotich prBparW hat .. krawl8dgt.
SIGNATURE OF ~R~PONS~L1NG RETURN DATE
/2./ /9 J .:) dO 6-
.
ADDRESS / t,/-II 5>;- /VEitI Cv/l?~Jq..d f//f- /7d7d
f3J
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
;jiiiliil',,-__Di . tjl I f[1IJl11!!i'1 -. _lU~1 ~ui " fti .__.~~'ft!1l~i
For dates of death on or aIler July 1, 1994 and belore January 1, 1995, the lax ,"Ie imposed on Ihe net value 01 ~nsfe'" 10 0' lor the use of the surviving spouse ~ 3%
[72 P.S. ~9116 (a) (t.1) (ill.
For dall!s of death on 0' afte, January 1, 1995, ihe lax ,"Ie imposed on the nel value oll,"nsle,.1o or for the use of the surviving spouse is 0% [72 P.S. ~9118 lal 11.1) Iii)].
The statulB does not BxemDt 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.
Fo, dates of deeth on 0' efter July 1, 2000,
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger al death to or for Ihe use of a natural parent, an adoptive parent,
or a stepparent 01 the child is 0% [72 P.S. ~116(e)(1.2)~
The lax ,"Ie imposed on the net value oflransfersto orforthe use of ihe decedenrs lineal beneficiarias is 4.5%. except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(aJll)).
The lex '"to imposed on the net value of ~nsfers to 0' for Ihe use of the decedenrs siblings ~ 12% [72 P.S. ~9116(a)I1.3)). A sibling ~ defined. unde, Section 9102, as an
Individual who has atleasl one parellt in common with the decedent, whether by blood or adoption.
REV-1508 EX'" (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DONNA C RENDe
Include the pI1lCOlIdI of Iltlgatlon and 1I1e _ the proceeds we,. ....Ived by 1I1e eslal8.
All property JalntlJ-owned with right of aurvtvorshlp must _ dlsdoeed on Schedule F.
ITEM VALUEAT DATE
NUMBER DESCRIPTION OF DEATH
}. SOlleR,e;'jN BANI< - CHEc/(/N9 -,4a,*771 033389 S-OCf.7"
TOTAL (Aiso enter on line 5, Recapijulation) $ ,r;O '"1 .76
(If more space is needed. insert additional sheell of the same size)
'REV-1509 EX+ (&98)
SCHIDUU ,
COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE HUMBER
[)., IIntJ '" c.. f(';A/ DI=
If.,. ","wn_.~~n em. y..,.ofth, ~~ dJI,"dHth." mu""~ l;tfJ $l;tItcI\II,G,
SURVIVING JOINT TENANT(S) _ ADDRESS RElATIONSHIP TO DECEDENT
"- 7ER/?y RENDE 55; Ic,TH $i SoN
L
ItIEIV C,-,...I5~I('<\""A. 1'14 17'''70
B.
C.
JOINTLY.OWNED PROPE1lTY:
illW< 0.,. -oESCfttPT1ON OF PROPERTY OIl" OAT! OF DEATH
"". Fl"'JOIlT .'1lE IfClUOf NAMf Of FIWfCIAl fiSTfTUTlON AHO !iNfl( ACCOUNT HlIMBER OR 81MLAR DATE OF OEATIi [)fCO'S VAlUE OF
NUUBER IDWlT JOIlT ICENTJFYJIG NUMBER. ATTACH DEED FOR JOIITlV.HEI..O REAlESTATE. \lALUE-OFASSET INTEREST OECEOeIrlrs INTEREST
1- "- fig 1'1<J3 01 E. (/1<0 a I SIV J, fioo, CO 50'10- / ~ So . 00
I A. ~()OO VEi/I"..'; ~ J(,8EG~SK S ?.F3:J.'l'l'1O )
U,NOi/,'ON F/t-II?
toTAL (Aloo enter online 8,lleGapituIalion) $ o ~5o. 00
(lI.....lI)l8C8 is _. _ __ _II of the..... Ii..)
~EV-1510 EX+ (6-98)
SCHEDULE G
COMMONWEALTH OF PENNSYLVANIA INTER-VIVOS TWolSF$S &
. ,- ", -, ""-',
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE 01' FILE NUIlBER
[)ONN A- C. RE.NDE
Thio ""'__bo~ond_ WthulIIWBftD any ci queotiono 1 throogh 4 on the-... oido oftlJo REV-l500 COVER SHEET is jOI.
DESCRlPTICW OF PROPERTY
IT:.J N1l.IlE"THE No\ME Of lHi: TRANIIFB&. 1HER REI.R1ClJIIF TO DECEtSfT N6J DATE OF DEATH % OF llECD"S EXCLUSION TAXABlE
NUll 1lE ME oF~:- AT'l"ACHAClJl"fOfM:DEED FOR RElLESTATE VALUE OF ASSET INTEREST '" VALUE
1. e".",,,,, t<<f. !3.4Nx' ~ CiYc-C,;(";'1l9 -- )celt 1.:l.2:t.3" 5"00.10 &11.18
OS'~~8:;l.1 )
TOTAL (Also onl8r on line 1 RecapitulaIion) $ (;11./6
(N more llplICll iI_. i__ _of the .... size)
REV-1511 EX... (12-99)
SCHIDUU H
COMMONWEALTH OF PENNSYLVANIA fUNliRAL liXPIiNSES &
INHERITANCE TAX RETURN ADMlNI5TRAllVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DtJAI.lVA C /( EN VI=-
De"- of dlCed.nt muat be reported on Schuule L
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
" PA~'HE/fIOa. Fi-WU4 I ')6~a..OO
/10... C- . 1 Ale.
Acc# ;), DO 6015.0.
PUASE SEE !4-7TAc.I-IED INllo IcE
B. ADMINISTRATIVE COSTS;
1. PollOooIR_INO'.eom_
Nome 01 POitonol ~.._lIllMt(.)
.
Social Sea!rity NUmber(I)lEiN-~ of Personal Re
.........
StrterMdrtM
City
'Ioor(.) Commission Po~,
2. Attorney Fees //)o1lJ!;.
3. Family Exemption: (If decedenfs addreu is net the llme-II claimant... attach explanation)
Claimant 1E~Ry L HEN DE
SttMt Add.... 5"3/ J,rll s/. J ;;l 50 .00
)
City J/EI/) c;.,,,,P,(R la..coI State~ZJp /7,;,70
_.ship ofCleimonllo_nt SO/V
4. _Fees
/1)0 JIJ G-
6. AcoounllnfA F66A NtJll.Jl:.
6. To: R8hJrn Prepil'8(', FHa jU"'I.!3.
7.
TOTAL (Also ente, on line 9, Recaplluiation) $ ~ q I.;l.. () CJ
(ff more opeoe 10 needed. iooori eddffi_ shoolll of tho Hme 01..)
A Family Tradition Of Caring
PARTHEMORE Funeral Ho~& Cremation Services, Inc.
.'.'~L_ :'l'~1 'm"oo,
531 Sixteenth Street
New Cumberland, P A I
1303 Bridge Streel We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way
P.O. Box 431 we can. Please feel free to contacl:us'ifyou have any questions in regard to this statement. The following
\;ew Cumberland. PA 17070 is an itemized statement of the seIVices. facilities, automotive equipment and merchandise that you selected
1"17) 774-7721 when making the funeral arrangements.
(Fax} 774-5546 fnm -~~--, . u_ ....___ __1
T enns I Due Date Account #
www.parthemore.com __~ ____ Net 30 __1- . -41iiI2005 --:~n -. ---- ~---
2005035.12 ,
.I
Description Amount
----,'~._----- --. -- ~-- -----,- -
-.---. Direct Cremation 1.070.00
Brass Seagulls Urn 229,00
Dove Register Book 4ROO
Dove Memorial Folders 4X.OO
Gilbcn W. Panhemore. Total Services and Merchandise 1.39500
F ollnder
Death Notice, Harrisburg Patriot 132.00
Cidben 1. Parthemore. Death Notice, Harrisburg Patriot, 2nd Day with Addition 100.1111
SlIpen.isor Death Notice, Harrisburg Patriot, Discount -50.00
Certified Copies of Death Certificates 60.00
Sl~phen K. Parthemore, Cumberland County Coroner Fee, Cremation Authorization 25.00
CFSP Total Cash Advances 267.00
f~rucc R. Parthemore,
Pre-.Veed Coordinator, CPC
-----.----
Professional Memberships:
\;FDA . PFDA
DCFDA . CCFDA
G~ [__n___......
rh,.Ru!c )"11< KWH,
Ti,e Pc()ph. rOil TnHI
_nm__n_~ ...... . .... .
Total $1,66200
pay~;~i~!<;-r~dit~J\'~1 $-1.66200
. Balance Due ,000
~ --- ----, -
ri7..ut .
..~, ...
~.E:V"5'2.U."(U-()3) ...
leMlDUU I
COM;AONW~TH OF PENNSylVANiA DE8TS OF DECEDENT,
INHeRITANCE TAX RETURN MORTGAGE L1ABIUTIES, & LIENS
RESlOENT OECEnEHT
ESTATE OF FILE NUMBER
DolUl'\J A- G. I?E/IIO~
lepoil deIifj lncijftiil by tM diCidim prtOf to....ft. wme" remaln8d unpild fill, Of \\\8 d. Of deitti, IneWlng ufJfilmbuft(tll medical apen"'.
ITEM VALUEAl' DATE
NUMBER DESCRIPTION 01' DEATH
1- SEA~S Gobi .MASI-I!~ CAlld ~) 799. S0
At.:c.~ b/.< /-07'" 7 - 008/ - 3>30 3
1- Boo -~&q - Biffiro
)., J,e... PeA/Ney Acc.~f.)'1 T CARol
Ace 1'1'- '"S-C; 5"'-/ - 573 - 3 :(e,CfL{
1-860- 5'1,).. -0800
TOTAL (AlSO "ntilr on Iin" 10, RecapitulatiOn) $ ~,e;). e 50
(If more spa<;e IS needlld. Insert additional sheets of the Sllme SIZe)
REV-548 ex (12..(J3)
INHERITANCE TAX JOINT BANK ACCOUNT COUNTY FILE NUMBER
ADVANCE PAYMENT WORKSHEET INHERITANCE TAX RECEIPT NUMBER
DECEDENT'S NAME (UST) (FIRST) (MIDDLE INlTW.~
::'NDI:. D"'N/YA- c....
oeceoeNT DECEDENT'S SOCIAL SECURITY NUMBER D"TE OF DEATH.
INFORMATION /'13 -::l.L/-;)'3~-S- /l( II ~c J.I ;;{I ~oo6-
-.ooRESS OF OEC~oeNT CITY STATE ZIP
S 1 /~TH 57. A/EIU tful"1l3o?).:,.,d ;014- / Cl 0
NAM&: 01" !:'1NANcw. INSTlTUllON
FINANCIAL C ,.. "" e/lc. e BANK IIARRiS/)"1l N/A
ADDRESS CITY STATE "p
INSTITUTION /00 SeAJAT,; CQ". ///11 'A J 70 II
INFORMATION TELEPHONE NUMBER
(BSf, ) 7/7 - 937 -000
TYPE OF ACCOUNT
C SAVINGS Ja"CHECKING o TRUST C CERnFlCATE OF DEPOSIT CDTHER -
ACCOUNT ACCOUNT eAL,ANel; (INCI.UOe INTeReST TO OATe QF OI!ltT'H) ACCOUNT NUMUeft
INFORMATION I)o:l;l~. 3" o5"3~89;;{B~ J
ACCOUNT TITLE AS APPEARS ON SIGNATURE CARD OR CD ORIGINAL DATE ESTABLISHED
!>O + C/lEc.1{ IN /-:1..1 - o~
NAME ,La") ___ (Flm) (Mlddlelnnlal)
RE/V DE. E/?Ry L
SURVIVING AD"""" /~TN
03/ sf:,
JOINT OWNER CITY STATE bP CODE
INFORMATION 'ktu C",., Bel? /a,wl jJl1- /7070
RELAnONSHIP TO DECEDENT TELEPHONE NUMBER ,-~',"
SCAI ('717 ) 7/<-/- 6-/ ~ 8
NAME (Lut) (fIM) (MIdclIeIniti8I)
SURVIVING ADDRESS ""
JOINT OWNER CITY STATE ZIP CODE
INFORMATION
RELATIONSHIP TO DE:CEDENT }EI.EPHONE NLJMBER
( )
NAME (....t) (F""l tMIOd'le ~nltlal)
SURVIVING M>ORESS
JOINT OWNER CITY STATE ZlPcooe
INFORMATION
RiLATJONSlol1P TO DECiiDliNT TELIiPIolONi NUMBiR
( )
LIST DEBTS & DEDUCTIONS BELOW
Date Paid Pavee o.acrlotlon Amount Paid
Note: PlfIIlSe attach to receipt TolBI S
HI05.~05 REV l/O)
This is fO 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 certilicate, $6.00 t:kv fJl ~ .
Local Registrar
p 1155681.1.- ~lAR 2 2 2005
No. Date
(") ""
-_.._~~~~-_.._---,-_.._,_.._--,._,-----~,-,-,---,..-.._- .~"O ~
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H105.1aRoW.W1 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS .. '"
-t='-
""' CERTIFICATE OF DEATH --.J
ST"lEFU~
'NT NAME OF DECEDENT" 1A'tt. MldoIIo. ~ SOCUIl SECURITY NUMBER OATE OF OfATH (MonltI. o.y. y~
'NK ,. Donna C. Rende .. 193 - 24 - 2355 ~ March 21 2005
AGe (lqI BItIl'ldIyJ
73 ,~ -0 -0 -0 ::..rl 0
..
COUNTY OF DEATH -Arn8deanlnllerl.B8d<.'MIl\e.
(So"',,
... Cumberland Select Specialty Hospital ". white
( 0ECECENrS USUAl OCCUPATION QECWENT" EVER IN OECEDENl'S El:lt.JCA.TIOM IrAARITM..ST#'-IUS_Mwl\td. SlJR\IMNl3SPOl.ISE
- U.S. -'RUED FORCES? N-=~)4od. (If-.~-_)
--. .....- Public Education 'NO Noll(l
11. Cros in Guard 11'. .. ... widowed
MAlU """ . Zip-OM) OECEOENT'S 17...s.... 17c.Dv..c:lec:edInllYedln
ACTUAL "'" ...
531 Sixteenth Street RESIDENCE --
,...- liw.ln.. 17d.~ ~-=-=of
.... New Cumber land PA 17070 onOltllr*ie) tnI.COLrtY Cumberland -- Np.w ClImhp.rll1nrl ""-
FATHER'S NAME (FlnI..........., M01l1ER'S NAME (Fnt, MIdlI.. .....,. Sun'\ll1IllJ)
,. William er Leidi ,. Frances M. Losh
'"' 1M'0RMANr5 MAlUNG AODRESS lS1rMt. Cil)lTown. S..... Zip CodI)
... Terr L. Rende .... 531 Sixteenth Street ~ew Cumberland PA 17070
MeTHOO T ~TE OF DISPOSITION PlACE OF DISPOSlTlOH- NoImI of CImMIry. CtIrnmry LOCATION.~own.StaIlI.ZipCodl
-0 ..... O~csa.-_,...O ~o.,.Y.-) <<--
21... Cbr~, o ,,. March 23. 2005 ~c.Con-O-Lite Cremato ftichaefferstown)
"""" , lJCEMSa OR PERSON ACTING AS SOCH LICENSE: NUUBER NAME ANOADDflESS OF FACIU'N ar emore
... .... FS 012 849 L ",P.O. Box 431 New Cumberland 1
Tolhlb-.tofmrknoWlldgt,dMlhOCCUl'lllIll..IiIIllJ. doIlIoII'Idpl<<.e....... l.lCENSE NUMBEflI
{S9'IIthnIRl'T")
.... ....
nME OF DEA1l1 W/lS CASE REfEAAEO TO'"
... 0 M .. ...
27. PART I: e.......--............................-.......... Do..._........ _ __...-"*"'..-._~or_,...., :~ PART II:
L/oIC....._____
~~ :OI'JIIIIoIIllldNlh
.
r lA.\ -...ho:>> \.\)0;
,.
,
MANNER OF DE#.1l1 DATE OF INJURY TIME OF INJURY INJURY AT VIoORK? DESCRIBE HOW INJURY OCCURRED.
~...o.1.Y_
..... IllI - 0
--- 0 PII!l(IngIIlYllI1lgllllon 0 V..O NoO
0 ... 3Gb. M. 3Oc.
'nO NoD ...... Col*Inotbll~ o F'l.ACCOFINJURY-Athome.l<<ifI......~.oIIte
..-.. "'.lSpiodtfl
.... .... ... ....
CERnFIER (Chd: only onIJ S1GNATUA
.~="~~~g3:!'IlI~~~~.~.~~.~.~~~.......
.~="-=~v:.:~~~~~.c::J:~~~~.:s:!....... .......
~.,,~....rl ..
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