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Home My WebLink About07-31-06 C8MMCi'J\NE:'iL -:H I:=F PEf-]f'JSYLVA,NIA CEPARTMENT ~EVENUE BUREAL; OF T p)ZES DC:PT REV-1162 EXi11-96i RECEIVED i=ROM: PENNSYLVANIA INI-Il;RITANCl; AND l;STATl; TAX OFFICIAL RECEIPT EDGETT JUDITH P 170 WHITE DOGWWOD DR ETTERS, F'A 17319 I ESTATE INFORMATION: SSN: 205-09-9186 I I I FILE NUMBEFi: 2106-0669 I I DECEDENT ~JA!:/lE: WAGGONER ALVA J DA TE OF PA YMENT: 07/31/2006 POSTMARK DATE: 07/28/2006 COUNTY: CUMBERLAND DA TE OF CEA TH: 04/29/2006 - NO. CD 007033 ACN ASSESSMENT CONTROL NUMBER AMOUNT 06133023 I $105.00 I I I I I I I I TOTAL AMOUNT PAID: $105.00 REMARI<S: CHECI<# 1204 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WillS July 28, 2006 Register of Wills Cumberland County Court House Carlisle,PA 17013 Re: Alva J. Waggoner S.S.N.205-09-9186 Date of Death: April 29, 2006 I.' - -~ To Whom It May Concern: Enclosed please find the Information Notice & Taxpayer Response that was sent to me by the Department of Revenue, Bureau ofIndividual Taxes. I have also enclosed copies of invoices that have been paid since my mother's death. If you have any questions and need to speak to me my phone numbers are: Home-7l7-932-2475 and Work-717-766-4300, X1464. (I work Tuesday thru Friday, 9:00 a.m. to 2:00). Thank you. Sincerely, .',...., c-~" // ",,\ ~JL"" /' ( c~""t.Ji.L/L. /~/[z.L. ~. ,Judith P. Edgett Executrix 170 White Dogwood Drive Etters, P A 17319 Enclosures COKMONWEALTH OF PENNSYLVANIA DEPARTMrNT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 INFORMATION NOTICE AND TAX~AVcER RESPONSE , , FILE ACN DATE NO. 21 elL c \,~ ~ 06133023 07-07-2006 REV-1543 EX AFP I09-00l " , EST~~OF ALVA J WAGGONER s.s-.LNO. 205-09-9186 DATE OF DEATH 04-29-2006 COUNTY CUMBERLAND TYPE OF ACCOUNT o SAVINGS [Xl CHECKING o TRUST o CERTIF. JUDITH P EDGETT 170 WHITE DOGWOOD DR ETTERS PA 17319 REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 M & T BANK has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions may be answered by calling (717) 787-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 60023775 Date 12-08-1998 Established x 6,683.81 50.000 3,341.91 .045 150.39 TAXPAYER RESPONSE To insure proper credit to your account~ two (2) copies of this notice must accompany your payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x NOTE: If tax payments are made within three (3) months of the decedent's date of death, you may deduct a 5% discount of the tax due. Any inheritance tax due will become delinquent nine (9) months after the date of death. Tax PART [!] A. [ CHECK ] ONE BLOCK B. ONLY c. [] The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or you may check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. [] The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the decedent.s representative. ~ The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due ~F TA~, ~ JOnT~TRUST ACCOUNTS .L I -.-?\ . -' <;;. ,.. . 2 {v,,&-S'3 ~-S I 3 X 1=.-~: {){.' {, 4 3.~3 V / 'lIf 5 - /: (){~/I, /~ 6 Z; -"'.1172:. 7 X j U 8 /OS.t DEBTS AND DEDUCTIONS CLAIMED PART ~ TAX RETURN - COMPUTATION If you indicate a different tax rate, please state your relationship to decedent: PART @] PAID PAYEE *t.. Under penalties of perjury, I declare that the facts I complete to the best of my knowledge and belief. T~~~~LS-~/-P ?=~4 v1/ have reported abovecfre true, correct and~ HOME (7 17 ) 13 2 - Z V '7 /; . WORK ( )7;?7;t/ V) TELEPHONE NUMBER DATE q. /" (\ I ) 0.. .L}" . (j" (. "r;'L( 'C../ L I \/ c""- -_J. '-'...- / ( ,I I " (--. C' 1/ ~ .~ --~'S -('q--9/'i?~ DEBTS & DEDUCTIONS PAID Amt. Paid '''It !.t. ,:;; :3 c.:'_.- c::-' L / /J7': :J y. (...(./ "6LI 7 2_ 6.?;)....S" -.5/7y' a; ';L /()/. &<j 7 .5: {)Z:l ,,..-7 7 z 7. (/r.~) ~ / ,7;-; C,(,: *- ,- /y../ a ??d (:- -I /l'c,c /. '. .> I( . ." ~/' '. /:,/.' /?.v/A'}I L<.--/J, '~"" '. "l:. J (./ ....-:.. (,. C' / It 'k'L. ~L i"',- ~ //J / c~ t..'U J1 r ;) Balance Forward From Previous Statement 0.00 I Patient: ALVA J. WAGGONER Case Descrip: INPT/MEDIIBS 1/6106 Amount Paid by Dates Procedure Procedure Description Charge Insurance Amount Paid By Guarantor Adjustments Remainder 01106/06 93010 EKG INTERPRETATION & 70.00 -8.80 0.00 -8.00 53.20 /8~O JJ~7L/ IO[P THE ABOVE CHARGES ARE FOR EKG'S READ AT THE HOLY SPIRIT HOSPITAL. THESE CHARGES ARE FOR PHYSICIAN SERVICES, NOT THE HOSPITAL. ** All charges are billed to the appropriate insurance carrier before you are billed. This balance is now the patient's responsibility. Payment is due within 15 days from the statement date. We Thank You for paying your account promptly! Amount Due 53.20 EKG ASSOCIATES / GJ Statement United Church of Christ Homes Sarah A. Todd Memorial Home 1000 West South Street Carlisle, PA 17013 Judy Edgett 170 White Dogwood Dr. Etters, PA 17319 Statement Date: 05/10/2006 Due Date: OS/25/2006 Re: Alva J Waggoner Account Nr: 101729 Date Description -------------------------------------------------------------------------------- Payments Days Quant Rate Charges Balance -------------------------------------------------------------------------------- BALANCE FORWARD 03/31/06 Cable Television 03/31/06 Oxygen 03/31/06 Incontinence Suppli 03/31/06 Medical Supplies 03/31/06 Personal Laundry Se 03/31/06 Cable Television 03/31/06 Room & Board - Semi 04/01/06 Room & Board - Semi 04/01/06 RESIDENT INCOME 04/02/06 Guest Meals -Supper 04/28/06 Cable Television 04/28/06 Guest Meals -Supper -1.00 -1.00 -1.00 -1.00 -1.00 1. 00 5 30 1. 00 1. 00 3.00 8.45 25.00 11.03 39.99 24.40 8.45 211.00 211.00 4.72 8.45 4.72 7,508.87 -8.45 -25.00 -11.03 -39.99 -24.40 8.45 -1,055.00 -6,330.00 300.75 5.00 8.45 15.01 7,508.87 7,500.42 7,475.42 7,464.39 7,424.40 7,400.00 7,408.45 6,353.45 23.45 324.20 329.20 337.65 ~52.60 -rcL5/J5/tJ4 (Z /I#-/13~ ~ NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BUT NO LATER THAN THE 25TH OF THE MONTH ***** please remit the LAST AMOUNT printed on your statement. Include the ACCT# from the statement on the MEMO LINE of your check. Payments after 5/8/06 do not reflect on statement. NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25% LATE CHARGE PER MONTH ** A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS ** ./ ~ COfilputer Credit, Inc. CLAIM DEPT 083307 . 640 West Fourth Street. Post Office Box 5238. Winston-Salem, NC . 27113-5238 . 336-761-1538 - ACA May 30, 2006 INTERNATIONAL The Associ;ltion of Credit and Collection Professionals Member 1...111...111....1.1..1.1'1.11..1.1..11....1.11...1.1.1..1..11 ACCOUNT 126()O ~.tltL-__-31.Q-17 0362730094 / Rehab Health South --,,- For: Waggoner, Alva ~ 175 Lancaster Blvd ') Mechanicsburg, PA 17055-3562/",' - CREDITOR Date of Service: 01-27-06 Dear Rehah Health ~ollth: You have received the benefit of earlier notification from this office relative to your debt to Pinnacle Health Hospitals. Computer Credit, Inc., a debt collector, understands you still have neither paid this debt nor made satisfactory arrangements to do so. Your payment is expected if there is no reason for a continued delay. Computer Credit, Inc. strongly advises you to make payment to the hospital in order to discharge your long overdue debt of $22.00. Once again, this notice is sent to you in an attempt to collect this debt and to advise you that any information obtained will be used for that purpose. E. S. Barksdale President r8J~ I--- II~ (j)~ f //~.~-4'~ RETURN THIS PORTION WITH YOUR PAYMENT ........,'.....................-......'..'.........'..................._..".""..-..,-.._".. ........... .............-..-....-..... .....',.........".......,...",.......-.....-.,....,. . . .........".-- --- --. -. ,..."..........."."",.,..... . ......Aqqt.#~MI:O:...R~t@b......~~hll.$liutf1..... />1 OVisa OMasterCard ODiscover OAmerican Express CARD NUMBER EXP DATE SECURITY CODE (3 OR 4 DIGIT # AMOUNT ON BACK OF CARD) $ PRINT CARDHOLDER'S NAME CARDHOLDER'S MAILING ADDRESS ZIP CODe SIGNA TURE You may make check payable to: Computer Credit, Inc. N2m CLAIM NUMBER: 083307-450234747 0 31017 Pinnacle Health Hospitals PO Box 2353 Harrisburg, PA 17105-2353 111.111...1'111111'11.1.11..1.11111'11,1'1111'11.1...11..1.1.1 J 2/09/06 Wheelchair Van One-Way 2/09/06 . .flAi l~lige/""h~~I~hliir 'Ian W Total A0130 '80209 1 6 41.20 1.35 41.20 8.10 49.30 0.00 ~o.oo b~ f rfl~ ! ~ Iq/6;O f~jj3~ **THIS IS AN UNRESOL VED BILL**Your accoantba$ now been transferred to our Collection & Credit Department. **IMMEDIATEACTIONIS NECESSARY** Metro Med Services, 877 214-6018 WAGGONER, ALVA J. 06-3957 PAY THIS AMOUNT 1111. AMBULANCE BilLING OFFICE: P.O. BOX 726, NEW CUMBERLAND, PA 17070-0726 ~:!J' Monthly statement: May 1,2006 5 of 7 Customer service 1-800-829-8009 Internet address sprint.com/local Customer number 717-245-8559-181 - . Important Information State and federal regulatory news concerning your communication services. Pennsylvania allocation of charges The state of Pennsylvania Public Utility Commission requires your phone charges be separated into basic and other services. Your total payment due breaks down as follows for this billing statement: Service categories Basic services Other services All services Past due .00 .00 $.00 Current month 53.90 8.42 $62.32 Total due 53.90 8.42 $62.32 Basic services consists of the following: local phone service, interstate access surcharge, telecommunications relav surcharge, emergencv 911 surcharge, installation and other fees. Other services include, but are not limited to, the following: optional calling features, equipment, LineGuard, local toll calling, long distance, directory and operator assistance. Please contact Sprint regarding any questions or problems with your bill before the due date. A rate schedule, an explanation of how to verify the accuracy of your telephone bill and an explanation of specific charges can be obtained free of charge by calling the customer service number listed on this page. You may also request this information in writing by sending notice to: Sprint Box 4000 Carlisle, PA 17013 Customer rights - pay-per-call services This notice is to inform customers of their rights regarding pay-per-call services (for example 900 calls), as specified by the Federal Telephone Disclosure and Dispute Resolution Act. Charges for pay-per-call services may be billed on your local Sprint telephone bill by companies that have a billing agreement with Sprint. Further information about a pay-per-call service charge can be obtained by calling the toll free number of the pay-per-call service provider or its agent. Access to pay-per-call services can be blocked by contacting Sprint's customer service department. To dispute a pay-per-call service charge appearing in the local telephone bill, please call the Sprint customer service number shown above. You must call Sprint within 60 days of the monthly statement date to dispute a service charge. Sprint will accept notification of the billing error over the phone. Any dispute not resolved over the phone will be investigated, and Sprint will advise you of the outcome within 90 days of your initial notification (written responses provided on request). You may withhold payment of pay- per-call service charges under investigation, and Sprint will not pursue collection activities for these charges. In the event the pay-per-call service provider subsequently determines that its charges are valid, the pay-per- call service provider may use its own collection process to obtain payment for the amount due. The Federal Communications Commission classifies pay-per-call services as non-communications services, so non-payment of such charges cannot result in discontinuation of your local or long distance services. Failure to pay for legitimate pay-per-call service charges, however, can result in terminating access to pay-per-call services. 'b;~ ~ -z& '7' Jii II ~ Sprint~ Monthly statement: May 1, 2006 7 of 7 Customer service 1-800-829-8009 Internet address sprint. com/local Customer number 717-245-8559-181 Customer News Contacting Sprint For your convenience, information about your local phone service is available any time through Sprint's internet address at sprint.com/local. To speak with a customer care associate, call-in hours are: Monday - Friday 8 a.m. - 7 p.m. Saturday 8 a.m. - 5 p.m. You can find the number of your Customer Care call center in the information pages of the telephone directory and on your bill. Service problems can be reported 24 hours a day, seven days a week by dialing 611. To contact our repair department from out of the area, call toll-free at 1-800-788-3600. COMING SOON: SIMPLE, SENSIBLE, CLEAR I No doubt you've seen several exciting messages from us about our upcoming name change to EMBARQTM. We've explained that you can count on the same reliable, quality services you currently enjoy today as well as the same friendly and knowledgeable representatives. We've also said there would be many great changes coming your way. Beginning in June, we are introducing an entirely new, user-friendly bill experience. We believe our bill should be as clear as your calls. You'll immediately notice: -A new paper size and our new EMBARQ logo. -Inside you'll find a summary page that lets you quickly see the details of your charges. -We've added icons to make it easier for you to find specific information. -There is even a section to show you how much you save when you combine your services with us. -Should your services change during the month, you'll be able to see them all detailed in the "Partial Month Charges" section of your statement. -Although we can't eliminate the taxes and surcharges associated with your services, we have provided an explanation of what they are. Look for more exciting information and announcements in your mailbox or visit EMBARQ.com. Earn a $25 Sprint Referral Credit Don't keep great service from Sprint a secret - alert everyone you know! Visit www.sprint.com/referral to find out how you can earn a $25 credit when you refer a friend who becomes a Sprint customer (terms and conditions apply). ~ru 03/19/06 03/19/06 04/11/06 DOCTOR CHRISTOPHER LADD MD CHRISTOPHER LADD MD CODE 74000 71010 0299 DESCRIPTION ABDOrvrnN ONE VIEW CHEST SINGLE VIEW DENIAL BY rvrnDlCARE HEALTH ID NBR AND NAME DO NOT MATCH AMOUNT $27.00 $27.00 $0.00 THE BALANCE SHOWING IS YOUR RESPONSI- BILITY. PLEASE CALL US WITH OR MAIL ADDITIONAL INSURANCE INFORMATION IF AVAILABLE. THANK YOu. lyfD~ ~j~?f? Location of Service: CARLISLE HSP ER BALANCE DUE: $54.00 Patient: AL VA J WAGGONER Account Number: ARA-9334687 Statement Date: 04/11/2006 TAX ID 233016413 Andorra Radiology Assoc., P.e. PO Box 892 DIAGNOSIS 569.3 Concordville PA 19331 _ BMSINC1-0113343-0001224-0047609-001-001184-#O01417 For billing questions, please call 888-434-6170 <.:v ) Pinnacle Health Hospitals ',,;t:.7ij.":(.,;;a;il~;;~-:-~1YiHw.uw""~~@lI,\1rclt'\!tji;H(~;\j;<W..w;W'<~;:~f:'i;~~t:~:1F"'~:f~'d"V,$~::~1(".:vi;'';;:1),)~ffr.l:<i~*flf...ff1t;;;';:'b'2.'$.>;a'~:'r.Jik~1:<'i{,(.;...."B1f?'_.;1J::i:!tY~:o.1'i:ll*,":{r~iii'r,X?\;;.-t,!$m(r,"t~'i~W:iO'J1~fcO"l1;';;T~,i~'~~,!i}:~"$'i<:''i!i.~.$~;;I:';W'~~'~.<:rk''f~:.1!;;f;-!Wk,',"~{!;\y,\;~.'\;i-;:!<~~~'i,f;J~~;" P.O. BOX 2353 HARRISBURG, PA 17105 11111111111111111'; (717) 230-3717 For Account Information, Please Call(717) 230-3717 Transaction Date 04/03/06 04/03/06 04/03/06 04/03/06 04/03/06 04/03/06 04/03/06 04/03/06 04/03/06 04/03/06 04/03/06 04/03/06 04/24/06 04/26/06 Description PREVIOUS BALANCE 1 CROSSMATCH 86920 1 CROSSMATCH 86920 1 HEMOGLOBIN & HEMATOCRI 1 HEMOGLOBIN & HEMATOCRI85014 1 HEMOGLOBIN & HEMATOCRI85018 1 ANTIBODY SCREEN 86850 1 ABO & RH TYPING* 1 ABO BLOOD TYPING-A 86900 1 RH BLOOD TYPING-B 86901 1 BASIC METABOLIC PANEL 80048 1 LEUKOCYTE REDUC RBC PRP9016 1 LEUKOCYTE REDUC RBC PRP9016 PMT MEDI B VERITUS 701 MEDICARE MEDICARE DISCOUNT 701 MEDICARE Amount .00 221.00 221. 00 .00 17.00 17.00 26.00 .00 5.00 5.00 44.00 491.00 491.00 328.37- 1,128.91- Estimated Insurance Due: .00 Total Patient Credits: ~ i1IDl.Y~;, .0 I \\ r:&Y "~lance: 80.72 ) CUSTOMER SERVICE HOURS MON-WED-FRI 7:00AM TO 4:00PM TUES-THUR 7:00AM TO 6:00PM CALL 717-230-3717 LOCAL OR 1-800-603-6064 OUT OF AREA your J)Svtnent PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Tanunv Shoemaker, Classified Advertising Manager, of The Sentinel, of the C;:ounty 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) May 30, Tune 06, 13, 2006 COPY OF NOTICE OF PUBLICATION Affiant further deposes th<;lt hel she is not interested in the subject matter of th~ aforesaid notice or advertisement, and that all allegations in the foregoing s~atement as to time, place and character of ~~~ Sworn to and subscribed before me this 14th. day of June 2006. e-'7 It l,', <::'07, /' /I, .~ / ./' /} 'h v J, lY' I 'J-; ,{., ,./ I \ cI3 fn1J'k d, fhat.ue Notary Public My commission expires: NOTARIAL lEAl. IOHIrAA CM11 Notary N* CAIl"IOIIOUGK.~COUN'IY II\' ecw.lI\ IIII~...... Jun '0 .. ~ RETAIN THIS PORTION FOR YOUR RECORDS REMITTANCE ADDRESS I BILL TO THE SENTINEL - LEGAL JUDITH EDGETT P . 0 . BOX 13 0 , CARLISLE, PA 17013 AD NUMBER I CLASS SALESPERSON BILLING DATE LINES 307780 10 PUBLIC NOTICES wolfe 06/14/06 28 * 2 AD DESCRIPTION START DATE STOP DATE EXECUTRIX NOTICE LETTERS TESTAMENT 05/30/06 06/13/06 PUBLICATION INSERTIONS RATE NET AMOUNT GROSS AMOUNT 3 THE SENTINEL - LEGAL 3 LGL 101.64 TOTAL AD CHARGE 101. 64 3 PROOF OF PUBLICATION 01PRF 6.35 PREVIOUSLY PAID -107.99 DA YS RUN PURCHASE ORDER PAY THIS AMOUNT .00 .00* Est.A.J.Wa oner gg . AFTER 07/14/06 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 bill please call 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 THE SENTINEL - LEGAL POBOX 130 CARLISLE PA 17013 Est.A.J.Waggoner . . " AD NUMBER CLASSO START DATE STOP DATE 307780 PUBLIC NOTICES 05/30/06 06/13/06 AD DESCRIPTION BILLING DATE TELEPHONE NUMBER EXECUTRIX NOTICE LETTERS TESTAMENT 06/14/06 717-932-2475 GROSS AMOUNT OF ,00 DUE AFTER 07/14/06 TOTAL AMOUNT DUE .00 ENTER AMOUNT ENCLOSED JUDITH EDGETT 170 WHITE DOGWOOD DR. ETTERS, PA 1...111...1..11....111.1..1.1..1 17319 20200000003077800000000000000000000000000000003 CENTRAL PENNSYLVANIA IMAGING PO BOX 157 LANDISVILLE, PA 17538 PATIENT: ALVA WAGGONER LOCATION: MXI PTS RETURN SERVICE REQUESTED ACCOUNT: A237-0043974-01 PIN#: 023702009913 ALVA WAGGONER 170 WHITE DOGWOOD DR ETTERS, PA 17319-9572 1...111...1..11....111.1..1.1...1.1.1...1..1.11...111...1,1..1 FINAL NOTICE BILLING INQUIRIES: MONDAY THRU FRIDAY 8:00 AM TO 5:00 PM (EST) TOLL FREE PHONE: 1-800-347-4219 07-14-06 The balance on your account is PAST DUE. Our office has sent you communications regarding this balance and we must resolve the balance due. Please make PAYMENT IN FULL immediately or contact us to discuss payment arrangements. Otherwise, your account MAY BE TURNED OVER TO A COLLECTION AGENCY for further action. Please send this statement with your payment to the above address. Include the account number on your payment to insure proper credit to your account. l\ \...(J )l ~ 0 BALANCE ()Vt,\ (') /IV / , V \..j /\ \ U 0 ACCOUNT '/\ 1'1/ '} \ Jy DUE: $27.00 # A237-0043974-01 DATE OF SERVICE: 02-11-06 IRS#: 03-0495904 PIN#: 023702009913 CENTRAL PENNSYLVANIA PO BOX 157 LANDISVILLE, PA 17538 IMAGING ALVA WAGGONER ACCT NO: A237-0043974-01 1223 01/01 Rl07-304 L064127 INSCRIPTION ORDER FORM MEMORIALS Since 1921 5243 Simpson Ferry Road, Mechanicsburg, PA 17050 (717) 766-5622 . Fax (717) 766-8007 · www.gingrichmemorials.com ingric~ No. 12- 20079 CEMETERY \ 'f' \ \V, \(: S t,~ \ '" ~ NAME OF DECEASED A \'1) ,:). \ ~)~ 1 0. ~ \"It: {" J LETTERING REQUIRED: LOCATION \l~ (..\'\ D..':' .'~ '- L1'.. V ' f\rK. ~q J ~OOG I ..'" H . -{~\ "1 \ t' (\.1..'" .- c-. V\o."<) 1 t, ' I~ (l Cl:.{' , FAMILY NAME MEMORIAL fdv Q ~, ~) "~Jt't\ti:(" IND. NAMES ON MEMORIAL TYPE OF MONUMENT U fy.;k\:" COLOR OF GRANITE ?i \'I ~ LOCATION: DRAW A PRECISE MAP OF LOCATION OF MEMORIAL ON CEMETERY (Use back of work order if necessary) BILL TO: \ " ,\-i "p E l ..I....,\. , t" ,,!\ \", _ ,let '.? \ ! t'lD W t" \ 1 t 1): .~; LU :.;-,' i Etl'-f V ~ pA \'-7') 11 D.I1':! i.' ...' \ ',I:.j '- 4\'-'10\ "'- DATE OF ORDER j..', \ ,) b ORDERED BY '):).,v,~ PHONE # (_) <)1;::'. -:;'I--{I )"' UPON EXAMINING THE ABOVE INSCRIPTIONS, I/WE THE UNDERSIGNED, FIND THE SPELLING AND DATES TO BE CORRECT. THE WORK WILL BE COMPLETED AS IT IS ACCUMULATED. NO SPECIFIC COMPLETION DATE IS GUARANTEED. SIGNED SIGNED PRICE DEPOSIT BALANCE DUE $ 12 t;, - $ $ ,~ 12~., - WHITE-Office YELLOW-Production PINK-Customer GOLDENROD-Branch u.J a: t:) 0- ("l ~ cJ ~-; ~Clg;![1' .':::: Q...-.cotnOOOO("l .~~RN~C; (/) ___....Jor- ::i ~ :::l0~ ::c ,0 u u.J ::E: 01 r- L!"") Z .- 5 -- - ~~ - - ~a~~~ <=> J t;;~ g -= . ~~ 0 == ~.., - ~~ .1 j t<l ()- \Jl \9'\ ~\/U- r 1 -'-, \. . PEC08DED OffiCE Or \~ "'1 i\~, .~. .' "'\: 3\ ~ . 20P( "'J" " u.~u J L.: \ P r;\ \: 53 (',\ I=D\{ 0:: (. \ Ul - m r)^ - ') ~ . () ~. "~~.. ~ \" ..~ ~ ~---- . ~ C ~-0 ^ ~ t ~~ "J ~~ ~ ~~ " \~ ~ ~ ~~ \0 - --