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Home My WebLink About09-01-06 .-J 15056051058 REV-1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Number Date of Death OFFICIAL IJSE ONLY CountyCode Year INHERITANCE TAX RETURN RESIDENT DECEDENT File Number 21 05 1034 Date of Birth 194-52-0452 10/28/2005 10/21/1957 Decedent's Last Name Suffix Decedent's First Name MI Regan Matthew A (If Applicable) Enter Surviving Spouse's Information Below Last Name Suffix First Name MI Spouse's Social THIS RETURN MUST BE FILED IN DUPLlCA.TE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW c=: 4. Limited Estate CJ 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required ce,) 1. .original Return CJ 2. Supplemental Return c.=: <=} CJ 4a. Future Interest Compromise (date of death after 12-12-82) CJ 7. Decedent Maintained a Living Trust (Attach Copy of Trust) CJ 10. Spousal Poverty Credit (date of death CJ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Artach Sch. G) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFOIRMATION SHOULD BE DIRECTED TO: Name D(jytilTleTelephoneNumber 6. Decedent Died Testate (Attach Copy of Will) .Q. 8. Total Number of Safe Deposit Boxes c=, 9. Litigation Proceeds Received First line of address (717) 1'24-0266 b.,) H"("::)'" ..... ...(:=.. I REGISTER ~S USE Ot!.t,;( [_ f-:L; ,;.:.J G:: i.' r"', _1] r'l t' ~~:; t?, -v ,:; .~~~. ::;} ; '. --' " ",' -,~ ::'\~j~ (..) c= . :::lJ -,'1 --/ Ql\..E FILED U 3: I' .) (~--) I ':.. I Elizabeth J. Goldstein Firm Name 355 N. 21 st St. #202 Second line of address C) . C') I ' ; 1 I,-,~ ZIP Code or Post Office Camp Hill 17011 Correspondent's e-mail address:egoldstein@elizabethgoldsteinlaw.com Under penal~es of pe~ury. I declare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is tnue, correct and complete. Declaration of preparer o~er than the personal representa~ve is based 011 all information 01' which preparer has any knowledge. S\GNATUR~OF/PERSON RESPON~IBLE FOR FILING RETURN DATE \ "i\ l..,..", ',,',,' '- \-" /' -,'. ? ,} ,'~!\ '1,', ,_. 'I \ t 'j f" '), _. ,\ ,"-I,. i>(.t '} 'L - ~. ADDRESS " ~l 35 Farm Lane; James Creek, PA 16657 SIGN/l.T'b/ O~rlREPARlfJ.oTHE.R THAN REPRESENTATIVE Cc_~(~ll ~~'t/~,,('L ADDRESS 355 North 21 st Street, Suite 202; Camp Hill, PA 17011 PLEASE USE ORIGINAL FORM ONLY DATE '1 2 b - l- ,,",- Side 1 L 15056051058 15056051058 .-J \. ~ ---I 15056052059 REV-1500 EX Decedent's Name: Matthew A Regan RECAPITULATION 1. Real estate (Schedule A). 2. Stocks and Bonds (Schedule B) . . . . . . . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) 4. Mortgages & Notes Receivable (Schedule D) . 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . 6. Jointly Owned Property (Schedule F) Separate Billing Requested . . . . . . 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . 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 Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) . 14. Net Value Subject to Tax (Line 12 minus Line 13) TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable at lineal rate X.O 45 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 19. TAX DUE. . . 10. 11. . 12. . . . 13. . . . 14. 15. 0.00 16. 17. 18. .. . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 L 194-52-0452 Decedent's Social Security Number 1. 2. 3. 4. 5. 8. 9. 15056052059 131,50000 0.00 0.00 0.00 19,920.28 0.00 0.00 151,420.28 18,810.55 141,489.21 160,299.76 -8,879.48 0.00 0.00 0.00 0.00 --.J REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 05 1034 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Matthew A Regan 194-52-0452 STREET ADDRESS 1901 Dartmouth Street ~- n I STATE ,--:;;;:;--~---- CITY . ZIP Camp Hill i PA I 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 0.00 0.00 Total Credits (A + B + C ) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty 0.00 Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, 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) (5A) (5B) A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. 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;.......................................................................................... D b. retain the right to designate who shall use the property transferred or its income; ............................................ D c. retain a reversionary interest; or.......................................................................................................................... D d. receive the promise for life of either payments, benefits or care? ...................................................................... D 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which t. b f" d' t'? r.;l con alns a ene IClary eSlgna Ion. ....................................................................................................................... ~ No ~ ~ [iJ [K] [K] ~ D IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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 three (3) percent [72 P.S. 39116 (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 zero (0) percent [72 P.S. 39116 (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 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 zero (0) percent [72 P.S. 39116(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 four and one-half (4.5) percent, except as noted in 72 P.S. 39116(1.2) [72 P.S. 39116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 PS. 39116(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. REV-1502 EX+ (6-98) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Matthew A. Regan FILE NUMBER 21-05-1034 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F ITEM NUMBER 1. DESCRIPTION 1901 Dartmouth Street ,Camp Hill, Pennsylvania 17011 VALUE AT DATE OF DEATH 131,500.00 TOTAL (Also enter on line 1, Recapitulation) $ 131,500.00 (If more space is needed, insert additional sheets of the same size) A. Settlement Statement U.S. Department of -Housinq and Urban Development ~ ,r OMS No. 2502-0265 B. Type of Loan 1. o FHA 4. OVA 2. 0 FmHA 3. !8:l Conv. Unins File Number 859484-LAW (GMS -C) Loan Number 0150422178 Mortgage Insurance Case Number N/A 5. 0 Conv. Ins. C. NOTE:This form is fumished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "p.o.c" were paid outside of closing; they are shown here for informational purposes and are not included in the totais. D. NAME AND ADDRESS OF BORROWER: '.~f'.1JJiIJT!i1J/i(..Y().l!.el(.. .1.1flj'ore1!k,R(j'a1fiG.l~n-mb(lre,i?A1!1a43 E. NAME AND ADDRESS OF SELLER: 73WD~~~~~7;;s:ee~eg:')"p Hill, PA 17011 G. PROPERTY LOCATION: 1901 Dartmouth Street Camp Hill, PA 1}'011 P..NAMEANDAIDElR1';SS'GlPbE;l\I.!'lJiiR:" . i-'''',2~'t';fr~,:':'~',:~'''':'~-' _~ - . $."31 ,500. 00 102. Personal Property 1 03~:-S~ettJemenhrchargeS;to"bOlTower: (from line 1400) 104. 105. ;: 106. Cltyltown tax8:s 107. County Taxes 1 08;:-As?_es_~rn~Dts 109. 110. 111. it<:j to $526. 65 11Z. $'132,026.65 201. Deposit or eamest money $9,588.00 203. Existing 10an(s) taken subject to 204. 205. 206. 207, 208. 209. ADJUSTMENTS FOR ITEMS UNP"ID BY SELLER: $115,716.31 "> ';;' 509. ADJUSTMENTS FOR iTEMS UNPAiD BY SELLER: 510. taxes to $35.37 212. Assessments 512. Assessments to 213. 214. 215. 216. 217. 218, 21!l; 514. 516. 518. 301. Gross amount due from borrower _(line 120) 302. Less amount paid'f>y!foibbrr"We~iir\E!j~?(1l' 303. CASH ( 0 FROM) (0 TO;) $111,935.37 520. TOTAL REDUCTIONS iN AMOUNT DUE TO SELLER: .. .. .,,~ l6,@Jl;;G'p.~IB,*T>:'$&lEm~aMSr)j!1'5'l'(!ro'j~W~~~E5l;e.E:f'{1. $137,687.45 601, Gross amount due to seller (line 420) $125,339.68 $132,026.65 $125;339.68 ( 0 FROM) (0 TO ) SELLER: $6,686.97 HUD-1 (3-86) - RESPA, HB 4305.2 PAGE 1 HUD-1 (Rev. 3/86) OMS No. 2502-0265 L. SETTLEMENT CHARGES 700. TOTAL SALES/BROKER'S COMMISSION BASED ON PRICE $131,500.00 @ 6 %= $7,890.00 PAID FROM BORROWER'S FUNDS AT SETTLEMENT PAID FROM SELLER'S FUNDS AT SETTLEMENT DIVISION OF COMMISSION (LINE 700) AS FOLLOWS: 701. $3970.00 to Re/Max Real Associates, Inc. 702. $3,920.00 \0 Re/Max A-1 Realt 703 $0.00 to 704. $0.00 to 705. Commission. paid at settlement 706. Transaction Fee to ReMa..x A-l Realt:y/Re.Max Realty Associates, IDC. $195.00 $7,890.00 $250.00 800 ITEMS PAYABL IN CONNECTION WITH LOAN' 801. Loan origination fee % to WeLls Fargo .. Bank , N.A. B02. Loan discount % to Wells Fargo Bank, N.A. '803. Appraisal fee 10: Michael Connor $275.00 804. Credit report to: We21s Fargo Bank, N.A. 805. Lender's inspection fee Wells FargdYBank, N.A. 806. Mortgage insurance application fee to Wells Fargo Bank, N.A. 807. Assumption fee Wells Fargo Ba.:nk L. N. A. B08. Mtg Broker Comp $1,852. 57.lPoc to Global by Wells Fargo B09. Broker Processing. Fee to Gl.bba2 Mortgage Services $495.00 810. Broker Fee to Global. Mortgage Services $495.00 811. Flood Cert Fee to WFFS $19.00 812 Doc Prep Fee to Wells Fargo Bank:, N.A. $125.00 813 Funding Fee to Wells Fargo Bank, N.A. $375.00 8>4 Tax Service Fee to WFRETS $100.00 815 ., 816 817 - 818 81. - 820 900 ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE' 901, Interest from 01/31/200.6 to 02/01/2006 @ $17. 651day $17.65 902. Mortgage insurance premium for f"i' mos. to 903. Hazard insurancs premium for .: yrs. to 904. Flood insurance premium for yrs.to 905. . 1000. RFSERVES DEPOSI ED WITHJLENDER: 1001. Hazard insurance 100;:'. Mortgage insurance 1003. City property taxes 1004. County property taxes 1005. Annual assessments 1006. Flood insurance 1007. Scboo~ TaJces 3.00 months@ months@ months @ ; 12.00 _months @ months @ months @ ,'>'. 8. 00 months @ $38.58 permonth per month per monlh $35.86 per month per month per month $106.09 per monll1 per month $115. 74 $430.32 $848,72 1008. months @ 1009. Aggregate Accounting :JEscrowAdjustmeI1t 1100. TITLE CHARGES: ]. ($413.51) 1101. Settlement or closing fee to LAW OFFIC2 OF DARRELL C. DETHLEFS 1102. Abstract or title search /0 1103. Tille examInation 10 1104. Title insurance binder to 1105. Document preparation to 1106. Notary fees to -'107. Attorney's fees 10 Re/Max Re~ty Associates, Inc. Darre~'l C:' Detb..lefs,.Esquire $10.00 $100.00 $10.00 (includes above items Numbers: 1108. Title insurance 10 Securi"ty ~.itleILaw Office of..DarrB.1~ C;DethJ.efs (includes above Items Numbers: Reissu~ - 3 End . 1109. lender's coverage $105,200.00 -1110. Owners coYersge $-131,500, :00 1111. C~osi.ng Service Letter Fe'e to Security Tit~e $105,200.00 $131,500.00 1112 1113. 1200 GOVERNMENT RECORDING AND TRANSFER CHARGES' 1201. Rscordingfees: Deed , $43.50 ; Mortgage $69.50 ; Releases $113.00 1202. City/county tax/stamps: Deed $1,315.00: Mortgage $1,315.00 1203. Stale tax/stamps: Deed $1,315.00 : Mortgage ; Other $1,315.00 1204. " 1205. 1300 ADDITIONAL SETTLEMENT CHARGES 1301. Survey to < 1302. Pest inspection to 1303, Overnight Fee to LawOxf4'ce -ofDarre~L-C... DethJ.efs (UPS) $18.00 $18.00 1304. Law Ofc Darrell C. Det:hl.~fs (e=dl Doc Fee) $25.00 1305. Law Ofc Darrell C. De tb..l~~fs (!'i!lX CertFeeReimb) $5.00 1306. 1307 1400. TOTAL SETTLEMENT CHARGES $5,660.80 $9,588.00 REV-1508 EX+ (6-98) '-* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISe. PERSONAL PROPERTY ESTATE OF Matthew A. Regan FILE NUMBER 21-05-1034 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. 2003 NISSAN EXTERRA 2.. NCFU SAVINGS ACCOUNT 3. NCFU CHECKING ACCOUNT 4. NCFU DIVIDEND 5. TAX REFUND 6. UNCLAIMED PROPERTY 7. ASPIRE REFUND 8. FINAL PAY CHECK VALUE AT DATE OF DEATH 15,425.00 85.00 8.11 1.42 2,693.00 240.94 179.00 1,287.81 TOTAL (Also enter on line 5, Recapitulation) $ 19,920.28 (If more space is needed, insert additional sheets of the same size) Elizabeth Goldstein, P.C. 355 North 2151 street Suite 202 Camp Hill, PA 17011 Attn: Amy D. Lacomba Dear Ms. Lacomba: Pursuant to your letter dated May 1,2006, in regards to Estate of Mathew A. Regan the information is as follows: Account Number: Owner(s) on Account: Date acct opened: Date of Death Balances: YTD Taxable Dividend: Loans: YTD Interest Paid: 66295 Mathew A. Regan 12/28/1989 S 1 (Savings) $85.00 S4 (Checking) $ 8.11 $1.42 $17,709.79 (Paid of by Life Insurance on the Loan) $ 1,873.04 I was not sure what you needed in regards to the credit card, so I enclosed copy of three months worth of statements. If you need anything additional in regards to this information, please feel free to contact me directly. Sincerely, .' I \ !.. 1)..___ '0.~. \... . .v \. 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I- %~ C ~ ~ ~ C'IIl:>9,._CIIl ~"""(l)1Il .9.~E.(l)~O>ro ~3:e."Q~C~ u.l(\)......~ro<J,o ..ou(:::>b~cO OZ~ _(\)o.(l) O(l)FIIl-C ~ N:>:;>-C,,-,(l)'Cii g~E'~'6~fu C:;:'3"Og~O~ _ ._ C ~ ~ (\) ~ ~"C,rol,)'.clll~ ..... ro III (\) (l) ~ . -0 o.c l7i:>ro~ (l) III 0 -... ~ ... .". .- .-c III .!2 "0 ro .... .p ._ C ~ .- 0. (l) 0.01,).~'" ~ '6 0'.0'.0"0 (l) .........(l):c'ro.S.p ~~'ro~0'(l)~ ~ro ~ I,) .,!!.p ro ._ :> 0 ,,-,.c ... 0 ... (\)._ ~ "-' 0 "-' ~.c~...o""""O <!.,,-,wro"-'''O(l) . (l)2 E. -C (l):=.-:::7 I,) C ro (l) "0 .- ,~ c._:>ccccl'- ....._ E. (l) 0 '.0 23 III g ....-;:;o....cco o 23'- ~ (l) .- ro . U (l)~"O o..'!! b 2:.- .:i"O:;;.(l)IIl"C,'" . 00 .~~oo~ S"-' "C,.D C 0."0 0 "0 0 ro (\) -0 'if> (l)(l)0.(::'\1,...1Il1ll 2.S ~ ro E..'!! (l)'~ cO crill:> ~.c.D 0 :;>- (l) .-:::: I,) I- "-' (l) ....p.~.~ .0'6 ~c I,)CC ~.9.~'fro.9.~~ ,,-,..0 o-ti ro 0 ..0 ro ro''p ~ ro.c ';:: oE....ro.':d.IIlIll(l) o...(l)~"C,c"O... N.8~roroeco @.S 0>:> 0."-' ro...... ? c<'. r- ? .0 o o c~ r" t;:c c-' '0 <:::. "'" ;;,\ "'" N Y. 7.- ",;. "'" 'C ~ > , , REV-1510 EX+ (6-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISe. NON-PROBATE PROPERTY FILE NUMBER 21-05-1034 ESTATE OF Matthew A. Regan 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 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COpy OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. Federal Thrift Savings Plan 5,455.46 100 0.00 0.00 2. Federal Civil Service Retirement Fund 47,500.00 100 000 0.00 Items on this schedule are reported for information only. These are qualified retirement plan benefits, exempt from inheritance tax under 72 p.S. 2111 (r) TOT AL (Also enter on line 7 Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) United States Office of Personnel Management Retirement Operations Center PO Box 45 Boyers, Pennsylvania 16017 Elizabeth Goldstein, P. C. 355 North 21 st Street Camp Hill, PA 17011 July 11, 2006 RE: Matthew A. Regan SSN: 194-52-0452 Dear Ms. Goldstein: This is in response to your inquiry regarding the total amount of contributions made to the Civil Service Retirement Fund by Matthew A. Regan. According to our records, Mr. Regan contributed $47,500.07 to the Retirement Fund. A lump sum death benefit in this amount was paid to Arline M. Regan on May 12, 2006. There was no interest payable on these funds. The lump sum death benefit is not considered reportable income for tax purposes. These funds were taxed when the money was withheld from Mr. Regan's salary. A 1099R will not be issued. If we can be of further assistance, please contact our office. Sincerely, fl', .,.' , ,/ t~~ And e K. Young Lega :1\dministrative Specialist 1-888-767-6738 .. TO OPEN - INSERT FINGER AND CAREFULLY SLIDE UNDER THIS EDGE .. Office of Personnel Management 'ement Programs 'ement Operations Center "s, PA 16017 CIAL BUSINESS ....L TY FOR PR I V A TE USE, $300 :W ARDING SERVICE REQUESTED ARLINE M REGAN PO BOX 504 JAMES CREEK PA 16657 iSS5770S0~-04 B003 '1,:: 1J:l1,:: 1J:;; J.:!: j:: ;)!1::;: I:!; ii:;;:!;: i!!::;:! . i.. i .JI FINAL STATEMENT OF LUMP SUM DEATH BENEFIT PAYMENT You are entitled to a lump sum payment because of the death of a former employee. This payment, shown in Block 5, covers only benefits due from the Civil Service Retirement and Disability Fund and consists of any unused contributions the former employee made to the Fund or any accrued annuity payable at the time of his or her death, or the Basic Employee Death Benefit :Jayable to a surviving spouse under the Federal Employees Retirement System. . Name of Deceased Federal Employee 2, Claim Number 3. Date of Birth 4. Date EGAN MATTHEW A CSF 3000356 10/21/57 05/11/06 . You Will Receive a Lump Sum Payment For 6. To Be Sent By 7, Interest (Included in Item 5) 8. Tax Withheld 47500.07 OS/25/06 $ NONE $ NONE . Remarks *****~ * - * * THRIFT SAVINGS PLAN Thrift Savings Plan P.O. Box 61500 New Orleans, LA 70161-1500 5/26/2006 ELIZABETH GOLDSTEIN, P.c. 355 N 21sT ST, STE. 202 CAMP HILL, PA 17011 Dear Sir or Madam: This is in response to a letter, to the Thrift Savings Plan (TSP) Service Office requesting information regarding the TSP account of Matthew A. Regan. The TSP is one part of the retirement system created for Federal employees in the Federal Employee's Retirement System Act of 1986. (See 5 U.S.C. 98351,8401-79). The TSP is a tax-deferred retirement savings plan similar to those authorized under section 401 (k) of the Internal Revenue Code for private sector employees. The TSP began accepting contributions from Federal employees in April 1987 and from members of the Uniformed Services in January 2002. In your letter, you requested information regarding the TSP account ofMr. Regan. Our records indicate this is the only TSP account Mr. Regan owned, and the account was held solely in his name. Additionally, our records indicate Mr. Regan had one outstanding loan at the time of his death. Loan number 0322004G outst~ding loan balance as of October 28th, 2005 was $5,455.46. This loan was declared as a taxable distribution on November 18t\ 2005. We hope this information has been helpful. Sincerely, 11(vv~~(~ LJld~-J cl fY\ Mrs. Unda Dean Chief Correspondence Officer REV-1511 EX+ (12-99)* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21-05-1034 ESTATE OF Matthew A. Regan Debts 01 decedent must be reported on Schedule 1. ITEM NUMBER A. B. 1. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Funeral Bill Luncheon After Funeral Cemetery Marker 4,810.39 117.58 250.00 0.00 0.00 0.00 0.00 2. 3. ADMINISTRATIVE COSTS: Personal Representative's Commissions 0.00 Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees 3,873.07 3. Family Exemption: (If decedent's address is not the same as claimant's. attach explanation) 0.00 Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 215.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 0.00 7. Legal Advertising Death Certificate 197.51 9.00 9,338.00 8. 9. Cost of Selling House owned by Decedent ( See attachment) 18,810.55 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) Matthew A. Regan File Number 21-05-1034 Schedule H , Line 9 Cost of selling House: Commission: $7,890.00 Over night Fee: $18.00 Tax: $5,00 Transfer Tax: $1,315.00 Document Prep: $100.00 Document Prep: $10.00 Total: $9,338.00 A. Settlement Statement U.S. Department of .-Iousinq and Urban Developrr,ent ~ ,r OMB No. 2502.0265 B. Type of Loan 1.0 FHA 4. OVA 2. 0 FmHA 3. [8J Conv. Unins File Number 859484-LAW (GMS -CJ Loan Number 0150422178 Mortgage Insurance Case Number NIA 5. 0 Conv. ins. C. NOTE:This form is furnished to give you a statement of actuai settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "p.o.c" were paid outside of closing; they are shown here for informational purposes and are not included in the totals. D. NAME AND ADDRESS OF BORROWER:..?'!"Jji!/T1irl.H'~.'9.>U.".fl(l.- .1/1'1!O'(jjtlfllk'Roaai;.~/...nil100re;'8A .,19343 E. NAME AND ADDRESS OF SELLER: FftW'b~'~':,~~7;;st~:r,eg:':"p Hill, PA 17011 G. PROPERTY LOCATION: 1901 Dartmouth Street Camp Hill, PA 1}011 P,'NAME AND'AIDGRESS'(iJp!ilE;l\Ijjj~R: $B1,500.00 (from line 1400) 104. 105. 106. Cltyltown taxes 107. County Taxes 108;;'Asl?~$xnE!Xlts 109. 110. 111. ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE: 2!Q-, to $526. 65 11Z. $132,026.65 201. Deposit or earnest money 202~:F.'~nqpal.a:m9_Y.~t;_~i.:fi~~t~~Q(~): 203. Existing loan(s) taken subject to 204. 205. 206. 207. 20B. 209. ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: .-....-- ';'~ ;;<:--" ,,,-,,,,:<}~ $9,588.00 t~ 503. Existing loan(s) taken subject to ~Q~:':J8'~.y.~ft:bhrrt~6;mpr{1;i.~~~~:~I_o~H~':-::.'::Jf8~"~9,~~!:t~t;~l1~,C;. 505. Payoff of second mortgage loan :5b~ 507. $115,716.31 ,. .. 516. $35.37 ;;~1 509. ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: 210. City/town taxes 10 510. City/town taxes to 2.1\1;Jt.b~~iYJi!&!i.~7 'S"-,Q;t~~Zf~Q;w~';;:o.,~~u'q~i ..ti;~,4.1E1~I~~:!~ ~__Q:tt1~m?~~~.,,;C'f,"if.1~blifagg'0~!\ii~:"i;'0$;;'jJ.:;{~q06. 212. Assessments 10 512. Assessments to 213_ 214. "' :.- ;:},{:f~t~ ~~?t~i~~'?i:~~!~J~%~~:# 514. -:(:;". }t_fx,~i~Fr. ~~~i~~)~7~i.~~ 218. 51B. 2,19,; 220. TOTAL PAID BY/FOR BORROWER: 300;.'.eA'swr'',I1;c'"S~lil:lr:1l:Em~17lR~~!'I3.(DiB'(iJ51<<!)WE!!.<f:''' ., - '~:'~~~~:t:L~~Zf: f,/aJ:~'tt:f,;~ ~~\:ii~5tt?;: ~t~'i~tE~MjS::2i~::;~~l~ 301. Gross amount due from borrower .(Iine 120) 302. Less amount paidpy(fbtbOrrQWe~li~~j~~qF 303. CASH ( ~ FROM) (D TO;) BORROWER: $U1, 935.37 520. TOTAL REDUCTIONS IN AMOUNT DUE TO SELLER: "'g !8.@JJ,iG'A'?W~W:'$6.:1"1'~I:lr;Jer\J;P'l'il1(F,B-"@t'1~$EI;I!,E~- $137,687.45 501. Gross amount due to selier (line 420) $125,339.68 $132,026.65 $125;339.68 $25,752.08503.CASH (DFROM) (~TO) SELLER: $6,686.97 HUD-1 (3-86) - RESPA, HB 4305.2 PAGE1 OMB No. 2502-0265 HUD-l (Rev. 3/S6) L SETTLEMENT CHARGES 700, TOTAL SALES/BROKER'S COMMISSION PAID FROM PAID FROM BASED ON PRICE $131,500.00 @ 6 %= $7,890.00 BORROWER'S SELLER'S FUNDS FUNDS DIVISION OF COMMISSION (LINE 700) AS FOLLOWS: AT AT 701. $3 970.00 to Re/Max Realtv Associates Inc. SETTLEMENT SE:TTLEMENT 702. $3,920.00 to Re/Max A-1 Rea1tv 703. $0.00 to 70. $0,00 to 705. Commission paid at settlement $7,890.00 706. Transaction Fee to RaMax A-1 Realty/ReMax Realty Associates, Inc. $195.00 $250.00 800 ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan origination fee % to Wells Fargo Bank, N.A. S02, loan discount % to Wells Fargo Bank, N.A. .S03. Appraisal fee to; Michael CODDOr $275.00 804. Credit report to: We~~ 3 Fargo Bank, N.A. S05. lender's inspection fee Wells Fargo' Ba:nJc, N.A. 806. Mortgage insurance application fee to Wells Fargo Bank, N.A. S07. Assumption fee Wells Fargo BankL N.A. B08. Mtg Broker Comp $1,852.57,wOC to Global by Wells Fargo 809. Broker Processing Fee to G.IObalMortgage Services $495.00 810. Broker Fee to Global Mortgage Services $495.00 811 Flood Cert:. Fee to WFFS $19.QO 812 Doc prep Fee to Wells Fargo Bank, N.A. $125.00 813 Funding Fee to Wells Fargo Bank, N.A. $375. 00 81. Tax service Fee to WFRETS $100.00 -815 816 8i7 - 818 819 820 .. 900 ITEMS REQUIRED BY LENDER .0 BE PAID IN ADVANCE' 901. Interest from 01/31/200.6 to 02/01/2006 @ $17. 65/day $l7.65 902. Mortgage insurance premium for f.I.i mos. to 903. Hazard insurance premium for , yrs. to 904. Flood insurance premium for '. yrs. to 905. 1000. RESERVES DEPOSITED WITHJLENDER: 1001. Hazard insurance 1002. Mortgage insurance 1003, City property taxes 1004. County property taxes 1005. Annual assessments 1006. Flood insurance 3.00 months@ months @ months @ ~' 12. aO._months @ months @ months @ $38~ 58 permonth per month per month $35.85 per month per month per month $106.09 per month per month $115.74 $430.32 1007. Schoo~ Taxes w. 8.00 months@ 1008. months @ 1009. Aggregate Accounting jEscrowAdjustment 1100, TITLE CHARGES: ), $848.72 ($413.51) 1101. Settlement or closing fee to LAW OFFICE. OF DARRELL C. DETHLEFS 1102. Abstract or title search to 1103. Tille examination 10 1104. Title insurance binder to 1105. Document preparation to 1106. Notary fees to 1107. Attorney's fees to Re/Max Realty Associates, Inc. Darrel~ C:. DethlefS, Esquire $10.00 $100.00 $10.00 (includes above items Numbers: 1108. Title insurance to Security Ti tie/Law - Office ozDarre~l C . De tb..lefs (includes above itams Numbers: Reissu~ - 3 End. 1109. Lenders coverage $105,200.00 -1110, Owner's coverage $131,,500. ~l)0 1111. Closing Service Letter Fee to Security Tit~e $1.05,200.00 $131,500.00 1112 1113. 1200, GOVERNMENT RECORDING AND TRANSFER CHARGES' 1201. Recording fees: Deed $43.50 ; M.ortgage $69.50 ; Releases $113.00 1202. City/county tax/stamps: Deed $1,315.00 ; Mortgage $1,315.00 1203. State tax/stamps: Deed $1,315.00 ; Mortgage ; Other $1,31.5.00 1204. .. " 1205 c 1300, ADDITIONAL SETTLEMENT CHARGES 1301. Survey to .. 1302. Pesllnspecllon to 1303. OVeIIlight Fee to LawOxxi:ce o:f'Darrell--C. Det:.bJ.e:fs (UPS) $18.00 $18.00 1304. Law Ofc Darrell. C. De t:.bJ. fifs (smail Doc Fee) $25.00 1305. Law Orc.Darrell C. Det:.bJ.'l"fs (Tax. Cert.-FeeRei:mb) $5.00 1306. " 1307. , 1400. TOTAL SETTLEMENT CHARGES $5,660.80 $9,588.00 REV-1512 EX+ (12-03) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF Matthew A. Regan FILE NUMBER 21-05-1034 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Jaskin Nationwide- Nissan 335.70 2. Holy Spirit Hospital 30.00 3. Cigular Wireless 66.53 4. MCI 70.18 5. Premiere Eye Care 112.00 6. quantum Imaging Therapeutic 19.10 7. Herd Chiropractic Clinic 173.75 8. Pennsylvania Water 101.70 9. NCFCU-Visa 495.11 10. Northwest Consumer Discount (Burglar alarm) 3,677.05 11. Loan from Thrift Savings Plan 5.45546 12. NCFCU Loan 17,709.79 13. Homecoming Financial Network, Inc. 113,05508 15. PP&L 187.76 TOTAL (Also enter on line 10, Recapitulation) $ 141.48921 (If more space is needed, insert additional sheets of the same size) New Cumberland Federal Credit Union Your Community Credit Union P.O. Box 658 New Cumberland, PA 17070-0658 PhDpe: Ol7) 774-7706 . 1-800-716-2328 . Fax: (717) 774-7996 . Web: www.ncfcuonJine.org May 1 IS, 2U06 Elizabeth Goldstein, P.e. 355 North 21 sl street Suite 202 Camp Hill, PA 17011 Attn: Amy D. Lacomba Dear Ms. Lacomba: Pursuant to your letter dated May 1,2006, in regards to Estate of Mathew A. Regan the information is as follows: Account Number: Owner( s) on Account: Date acct opened: Date of Death Balances: 66295 Mathew A. Regan 12/28/1989 S] (Savings) $85.00 S4 (Checking) $ 8.11 $1.42 $17,709.79 (Paid of by Life Insurance on the Loan) $ 1,873.04 YTD Taxable Dividend: Loans: YTD Interest Paid: I was not sure what you needed in regards to the credit card, so I enclosed copy of three months worth of statements. If you need anything additional in regards to this information, please feel free to contact me directly. Sincerely, -, , ) ,r)'~,!'i.r.! i. (.. 1 t~.,bl~~ '. IJ..~ry . \ Barbra Wright,j Branch Manager *****~ * ~ * * THRIFT SAVINGS PLAN Thrift Savings Plan P.O. Box 61500 New Orleans, LA 70161-1500 5/26/2006 ELIZABETH GOLDSTEIN, P.e. 355 N 21 ST ST, STE. 202 CAMP illLL, PA 17011 Dear Sir or Madam: This is in response to a letter, to the Thrift Savings Plan (TSP) Service Office requesting information regarding the TSP account of Matthew A. Regan. The TSP is one part of the re:tirement system created for Federal employees in the Federal Employee's Retirement System Act of 1986. (See 5 U.S.c. 9 8351, 8401-79). The TSP is a tax-deferred retirement savings plan similar to those authorized under section 401 (k) of the Internal Revenue Code for private sector employees. The TSP began accepting contributions from Federal employees in April 1987 and from members of the Unifoffiled Services in January 2002. In your letter, you requested information regarding the TSP account ofMr. Regan. Our records indicate this is the only TSP account Mr. Regan owned, and the account was held solely in his name. Additionally, our records indicate Mr. Regan had one outstanding loan at the time of his death. Loan number 0322004G outstanding loan balance as of October 28th, 20015 was $5,455.46. This loan was declared as a taxable distribution on November 18th, 2005. We hope this information has been helpful. Sincerely, I{~~ VlcJ~ Mrs. d~a Dean Chief Correspondence Officer ADJUSTABLE RATE NOTE (UBOR Index - Rate Caps) THIS NOTE CONTAINS PROVISIONS ALLOWING FOR CHANGES IN MY INTEREST RATE AND MY MONTHLY PAYMENT. THIS NOTE LIMITS THE AMOUNT MY INTEREST RATE CAN CHANGE AT ANY ONE TIME AND THE MAXIMUM RATE I MUST PAY. OCTOBER 28TH 2004 HANOVER PENNSYLVANIA IDateJ ICily! ISlalej 1901 DARTMOUTH STREET, CAMP HILL, PA 17011 rProperty Addressl 1. BORROWER'S PROMISE TO PAY In return for a loan that I have received, I promise to pay U. S. $114, 000 . 00 (this amount is called "Principal "), plus interest, to the nrder of the L~nder. The Lender h HOMECOt-lINGS f'INANCIAI. NETWORK, INC. I will make all payments under tllis Note in the fonll of cash, check or money order. I understand that the Lender may transfer this Note. The Lender or anyone who takes this Note by transfer and who is entitled to receive payments under this Note is called the "Note Holder." 2. INTEREST Interest will be charged on unpaid principal until the full amount of Principal has been paid. I will pay interest at a yearly rate of 7 . 1250 %. The interest rate I will pay will change in accordance with Section 4 of this Note. The interest rate required by this Section 2 and Section 4 of this Note is the rate I will pay both beJ()re and after any default described in Section 7(B) of this Note. 3. PAYMENTS (A) Time and Place of Payments I will pay principal and interest by making a payment every month. I will make my monthly payment on the first day of each month beginning on DECEMBER 1ST, 2004 I will make these payments every month until J have paid all of the principal and interest and any other charges described below that J may owe umier this Note. Each monthly payment will be applied as of its scheduled due date and will be applied to interest before Principal. I f, on NOVEMBER 1 ST, 2034, J still owe amounts under this note, I will pay those amounts in full on that date, which is called the "Maturity Date." Iwillmakemymonthlypaymentsat 9 SYLVAN WAY, SUITE 100, PARSIPPANY, NJ 07054 or at a different place if required by the Note Holder. (B) Amount of My Initial Monthly Payments Each of my initiallllolJthly payments will be in the amount of U.S. $ 7 6 8 . 04 . This alllount may change. (C) Monthly Payment Changes Changes in my monthly payment will reflect changes in tile unpaid principal of my loan and in the interest rate that I must pay The Note Holder will detennine my new interest rate and the changed amount of my monthly payment in accordance with Section 4 of this Note. 4. INTEREST RATE AND MONTHLY PAYMENT CHANGES (A) Change Dates The interest rate I will pay may change on tile tirst day of NOVEMBER, 2007, and on tilat day every sixth month thereafter. Each date on which my interest rate could change is called a "Change Date." MULTISTATE ADJUSTABLE RATE NOTE. L1BOR INDEX MFCD8762 - 19/011/042-234364-0 I'a/!" J oJ 4 Modified FNMA/FHLMC Uniform fll,1rumcnt Form 3~90 1/01 MODIFIED BY HOMECOMINGS FINANCIAL NETWORK. INC. 07/06/2006 3:20:11 PM Page 1 Liz Compound Period ......... Monthly Nominal Annual Rate.... 7.125 % CASH FLOW DATA Event Date Amount Number Period End Date 1 Loan 10/28/2004 114,000.00 1 2 Payment 12/01/2004 768.64 360 Monthly 11/01/2034 AMORTIZA TION SCHEDULE - Normal Amortization Date Payment Interest Principal Balance Loan 10/28/2004 114,000.00 1 12/01/2004 768.64 766.42 2.22 113,997.78 2004 Totals 768.64 766.42 2.22 2 01/01/2005 768.64 676.86 91.78 113,906.00 3 02/01/2005 768.64 676.32 92.32 113,813.68 4 03/01/2005 768.64 675.77 92.87 113,720.81 5 04/01/2005 768.64 675.22 93.42 113,627.39 6 05/01/2005 768.64 674.66 93.98 113,533.41 7 06/01/2005 768.64 674.10 94.54 113,438.87 8 07/01/2005 768.64 673.54 95.10 113,343.77 9 08/01/2005 768.64 672.98 95.613 113,248.11 10 09/01/2005 768.64 672.41 96.2:3 11 . 11 1 % 1/2005 768.64 671.84 96.80 13,055.08'->- ~ 12 11/01/2005 768.64 671.26 97.38 12,957.70 13 12/01/2005 768.64 670.69 97.95 112,859.75 2005 Totals 9,223.68 8,085.65 1, 138.0:~ 14 01/01/2006 768.64 670.10 98.54 112,761.21 15 02/01/2006 768.64 669.52 99.12 112,662.09 16 03/01/2006 768.64 668.93 99.7'1 112,562.38 17 04/01/2006 768.64 668.34 100.30 112,462.08 18 05/01/2006 768.64 667.74 100.90 112,361.18 19 06/01/2006 768.64 667.14 101.50 112,259.68 20 07/01/2006 768.64 666.54 102.1 () 112,157.58 21 08/01/2006 768.64 665.94 102.70 112,054.88 22 09/01/2006 768.64 665.33 103.3'1 111,951.57 23 10/01/2006 768.64 664.71 103.9:~ 111,847.64 24 11/01/2006 768.64 664.10 104.54 111,743.10 25 12/01/2006 768.64 663.47 105.17' 111,637.93 2006 Totals 9,223.68 8,001.86 1,221.82 26 01/01/2007 768.64 662.85 105.79 111,532.14 27 02/01/2007 768.64 662.22 106.42 111,425.72 28 03/01/2007 768.64 661.59 107.0!5 111,318.67 29 04/01/2007 768.64 660,95 107.69 111,210.98 Ol2lmpound Period ......... 8tJ8gJ~88g ~:~8: 11 ~~ ~~~~ ~ Liz Date Payment Interest Principal Balance 30 05/01/2007 768.64 660.32 108.32 111,102.66 31 06/01/2007 768.64 659.67 108.917 110,993.69 32 07/01/2007 768.64 659.03 109.61 110,884.08 33 08/01/2007 768.64 658.37 11 0.27 110,773.81 34 09/01/2007 768.64 657.72 11 0.92 110,662.89 35 10/01/2007 768.64 657.06 111.58 110,551.31 36 11/01/2007 768.64 656.40 112.24 110,439.07 37 12/01/2007 768.64 655.73 112.91 110,326.16 2007 Totals 9,223.68 7,911.91 1,311.77 38 01/01/2008 768.64 655.06 113.58 110,212.58 39 02/01/2008 768.64 654.39 114.25 110,098.33 40 03/01/2008 768.64 653.71 114.9.3 109,983.40 41 04/01/2008 768.64 653.03 115.61 109,867.79 42 05/01/2008 768.64 652.34 116.30 109,751.49 43 06/01/2008 768.64 651.65 116.9~~ 109,634.50 44 07/01/2008 768.64 650.95 117.69 109,516.81 45 08/01/2008 768.64 650.26 118.3/3 109,398.43 46 09/01/2008 768.64 649.55 119.0!~ 109,279.34 47 1 % 1/2008 768.64 648.85 119.7!~ 109,159.55 48 11/01/2008 768.64 648.13 120.5'1 109,039.04 49 12/01/2008 768.64 647.42 121.22 108,917.82 2008 Totals 9,223.68 7,815.34 1,408.34 50 01/01/2009 768.64 646.70 121.94 108,795.88 51 02/01/2009 768.64 645.98 122.66 108,673.22 52 03/01/2009 768.64 645.25 123.3~1 108,549.83 53 04/01/2009 768.64 644.51 124.13 108,425.70 54 05/01/2009 768.64 643.78 124.86 108,300.84 55 06/01/2009 768.64 643.04 125.60 108,175.24 56 07/01/2009 768.64 642.29 126.35, 108,048.89 57 08/01/2009 768.64 641.54 127.10 107,921.79 58 09/01/2009 768.64 640.79 127.85 107,793.94 59 10/01/2009 768.64 640.03 128.61 107,665.33 60 11/01/2009 768.64 639.26 129.38 107,535.95 61 12/01/2009 768.64 638.49 130.15 107,405.80 2009 Totals 9,223.68 7,711.66 1,512.02 62 01/01/2010 768.64 637.72 130.92 107,274.88 63 02/01/2010 768.64 636.94 131.70 107,143.18 64 03/01/2010 768.64 636.16 132.48 107,010.70 65 04/01/2010 768.64 635.38 133.26 106,877.44 66 05/01/2010 768.64 634.58 134.06 106,743.38 67 06/01/2010 768.64 633.79 134.85 106,608.53 68 07/01/2010 768.64 632.99 135.65 106,472.88 69 08/01/2010 768.64 632.18 136.46 106,336.42 70 09/01/2010 768.64 631.37 137.27 106,199.15 71 10/01/2010 768.64 630.56 138.08 106,061.07 72 11/01/2010 768.64 629.74 138.90 105,922.17 00mpound Period ......... 87rsgf~88t! ~~~8~11 ~~ ~~~~ ~ Liz Date Payment Interest Principal Balance 73 12/01/2010 768.64 628.91 139.73 105,782.44 2010 Totals 9,223.68 7,600.32 1,623.36 74 01/01/2011 768.64 628.08 140.56 105,641.88 75 02/01/2011 768.64 627.25 141.39 105,500.49 76 03/01/2011 768.64 626.41 142.23 105,358.26 77 04/01/2011 768.64 625.56 143.08 105,215.18 78 05/01/2011 768.64 624.72 143.92 105,071.26 79 06/01/2011 768.64 623.86 144.78 104,926.48 80 07/01/2011 768.64 623.00 145.64 104,780.84 81 08/01/2011 768.64 622.14 146.50 104,634.34 82 09/01/2011 768.64 621.27 147.37 104,486.97 83 10/01/2011 768.64 620.39 148.25 104,338.72 84 11/01/2011 768.64 619.51 149.13 104,189.59 85 12/01/2011 768.64 618.63 150.01 104,039.58 2011 Totals 9,223.68 7,480.82 1,742.813 86 01/01/2012 768.64 617.74 150.90 103,888.68 87 02/01/2012 768.64 616.84 151 .80 103,736.88 88 03/01/2012 768.64 615.94 152.70 103,584.18 89 04/01/2012 768.64 615.03 153.61 103,430.57 90 05/01/2012 768.64 614.12 154.52 103,276.05 91 06/01/2012 768.64 613.20 155.44 103,120.61 92 07/01/2012 768.64 612.28 156.3(3 102,964.25 93 08/01/2012 768.64 611.35 157.2~~ 102,806.96 94 09/01/2012 768.64 610.42 158.22 102,648.74 95 10/01/2012 768.64 609.48 159.1(3 102,489.58 96 11/01/2012 768.64 608.53 160.1'1 102,329.47 97 12/01/2012 768.64 607.58 161.06 102,168.41 2012 Totals 9,223.68 7,352.51 1,871.17 98 01/01/2013 768.64 606.62 162.02 102,006.39 99 02/01/2013 768.64 605.66 162.98 101,843.41 100 03/01/2013 768.64 604.70 163.94 101,679.47 101 04/01/2013 768.64 603.72 164.92 101,514.55 102 05/01/2013 768.64 602.74 165.90 101,348.65 103 06/01/2013 768.64 601.76 166.88 101,181.77 104 07/01/2013 768.64 600.77 167.87 101,013.90 105 08/01/2013 768.64 599.77 168.87 100,845.03 106 09/01/2013 768.64 598.77 169.87 100,675.16 107 10/01/2013 768.64 597.76 170.8B 100,504.28 108 11/01/2013 768.64 596.74 171.90 100,332.38 109 12/01/2013 768.64 595.72 172.92 100,159.46 2013 Totals 9,223.68 7,214.73 2,008.95 110 01/01/2014 768.64 594.70 173.94 99,985.52 111 02/01/2014 768.64 593.66 174.9a 99,810.54 112 03/01/2014 768.64 592.63 176.01 99,634.53 113 04/01/2014 768.64 591.58 177.0Ei 99,457.47 Ol1'Jmpound Period ......... 8718gf~88~l ~~~8~11 ~~ ~~~~! Liz Date Payment Interest Principal Balance 114 05/01/2014 768.64 590.53 178.11 99,279.36 115 06/01/2014 768.64 589.47 179.17 99,100.19 116 07/01/2014 768.64 588.41 180.23 98,919.96 117 08/01/2014 768.64 587.34 181 .30 98,738.66 118 09/01/2014 768.64 586.26 182.38 98,556.28 119 10/01/2014 768.64 585.18 183.46 98,372.82 120 11/01/2014 768.64 584.09 184.55 98,188.27 121 12/01/2014 768.64 582.99 185.65 98,002.62 2014 Totals 9,223.68 7,066.84 2,156.84 122 01/01/2015 768.64 581.89 186.75 97,815.87 123 02/01/2015 768.64 580.78 187.86 97,628.01 124 03/01/2015 768.64 579.67 188.97 97,439.04 125 04/01/2015 768.64 578.54 190.10 97,248.94 126 05/01/2015 768.64 577.42 191.2.2 97,057.72 127 06/01/2015 768.64 576.28 192.316 96,865.36 128 07/01/2015 768.64 575.14 193.510 96,671.86 129 08/01/2015 768.64 573.99 194.6:5 96,477.21 130 09/01/2015 768.64 572.83 195.81 96,281.40 131 10/01/2015 768.64 571.67 196.9'7 96,084.43 132 11/01/2015 768.64 570.50 198.14 95,886.29 133 12/01/2015 768.64 569.32 199.32 95,686.97 2015 Totals 9,223.68 6,908.03 2,315.65 134 01/01/2016 768.64 568.14 200.50 95,486.47 135 02/01/2016 768.64 566.95 201.6!3 95,284.78 136 03101/2016 768.64 565.75 202.89 95,081.89 137 04/01/2016 768.64 564.55 204.0~3 94,877.80 138 05/01/2016 768.64 563.34 205.30 94,672.50 139 06/01/2016 768.64 562.12 206.52 94,465.98 140 07/01/2016 768.64 560.89 207.7!3 94,258.23 141 08/01/2016 768.64 559.66 208.913 94,049.25 142 09/01/2016 768.64 558.42 210.22 93,839.03 143 10/01/2016 768.64 557.17 211.47' 93,627.56 144 11/01/2016 768.64 555.91 212.7:3 93,414.83 145 12/01/2016 768.64 554.65 213.9B 93,200.84 2016 Totals 9,223.68 6,737.55 2,486.13 146 01/01/2017 768.64 553.38 215.2E3 92,985.58 147 02/01/2017 768.64 552.10 216.54 92,769.04 148 03/01/2017 768.64 550.82 217.82 92,551.22 149 04/01/2017 768.64 549.52 219.12 92,332.10 150 05/01/2017 768.64 548.22 220.42 92,111.68 151 06/01/2017 768.64 546.91 221. 7:~ 91,889.95 152 07/01/2017 768.64 545.60 223.04 91,666.91 153 08/01/2017 768.64 544.27 224.37 91,442.54 154 09/01/2017 768.64 542.94 225.70 91,216.84 155 10/01/2017 768.64 541.60 227.04 90,989.80 156 11/01/2017 768.64 540.25 228.39 90,761.41 Ol?lmpound Period ......... 8778g~88~ ~~~8~ 11 ~~ ~~8~ ~ Liz Date Payment Interest Principal Balance 157 12/01/2017 768.64 538.90 229.74 90,531.67 2017 Totals 9,223.68 6,554.51 2,669.17 158 01/01/2018 768.64 537.53 231.11 90,300.56 159 02/01/2018 768.64 536.16 232.48 90,068.08 160 03/01/2018 768.64 534.78 233.86 89,834.22 161 04/01/2018 768.64 533.39 235.25 89,598.97 162 05/01/2018 768.64 531.99 236.65 89,362.32 163 06/01/2018 768.64 530.59 238.05 89,124.27 164 07/01/2018 768.64 529.18 239.46 88,884.81 165 08/01/2018 768.64 527.75 240.89 88,643.92 166 09/01/2018 768.64 526.32 242.32 88,401.60 167 10/01/2018 768.64 524.88 243.76 88,157.84 168 11/01/2018 768.64 523.44 245.20 87,912.64 169 12/01/2018 768.64 521.98 246.66 87,665.98 2018 Totals 9,223.68 6,357.99 2,865.6B 170 01/01/2019 768.64 520.52 248.1.2 87,417.86 171 02/01/2019 768.64 519.04 249.60 87,168.26 172 03/01/2019 768.64 517.56 251.08 86,917.18 173 04/01/2019 768.64 516.07 252.57 86,664.61 174 05/01/2019 768.64 514.57 254.07 86,410.54 175 06/01/2019 768.64 513.06 255.58 86,154.96 176 07/01/2019 768.64 511.55 257.0~9 85,897.87 177 08/01/2019 768.64 510.02 258.6:2 85,639.25 178 09/01/2019 768.64 508.48 260.115 85,379.09 179 10/01/2019 768.64 506.94 261.70 85,117.39 180 11/01/2019 768.64 505.38 263.215 84,854.13 181 12/01/2019 768.64 503.82 264.8:2 84,589.31 2019 Totals 9,223.68 6,147.01 3,076.67 182 01/01/2020 768.64 502.25 266.3!9 84,322.92 183 02/01/2020 768.64 500.67 267.97 84,054.95 184 03/01/2020 768.64 499.08 269.5l3 83,785.39 185 04/01/2020 768.64 497.48 271.1l3 83,514.23 186 05/01/2020 768.64 495.87 272.77 83,241.46 187 06/01/2020 768.64 494.25 274.39 82,967.07 188 07/01/2020 768.64 492.62 276.02 82,691.05 189 08/01/2020 768.64 490.98 277.66 82,413.39 190 09/01/2020 768.64 489.33 279.3'1 82,134.08 191 10/01/2020 768.64 487.67 280.97 81,853.11 192 11/01/2020 768.64 486.00 282.64 81,570.47 193 12/01/2020 768.64 484.32 284.32 81,286.15 2020 Totals 9,223.68 5,920.52 3,303. H3 194 01/01/2021 768.64 482.64 286.00 81,000.15 195 02/01/2021 768.64 480.94 287.70 80,712.45 196 03/01/2021 768.64 479.23 289.4'\ 80,423.04 197 04/01/2021 768.64 477.51 291.13 80,131.91 Ol2lmpound Period ......... 8t~8g~88~i ~:~8: II ~~ ~~~~ ~ Liz Date Payment Interest Principal Balance 198 05/01/2021 768.64 475.78 292.86 79,839.05 199 06/01/2021 768.64 474.04 294.60 79,544.45 200 07/01/2021 768.64 472.30 296.34 79,248.11 201 08/01/2021 768.64 470.54 298.10 78,950.01 202 09/01/2021 768.64 468.77 299.87 78,650.14 203 10/01/2021 768.64 466.99 301.65 78,348.49 204 11/01/2021 768.64 465.19 303.45 78,045.04 205 12/01/2021 768.64 463.39 305.25 77,739.79 2021 Totals 9,223.68 5,677.32 3,546.36 206 01/01/2022 768.64 461.58 307.06 77 ,432.73 207 02/01/2022 768.64 459.76 308.88 77,123.85 208 03/01/2022 768.64 457.92 310.7:2 76,813.13 209 04/01/2022 768.64 456.08 312.513 76,500.57 210 05/01/2022 768.64 454.22 314.4:2 76,186.15 211 06/01/2022 768.64 452.36 316.28 75,869.87 212 07/01/2022 768.64 450.48 318.113 75,551.71 213 08/01/2022 768.64 448.59 320.0!5 75,231.66 214 09/01/2022 768.64 446.69 321.95 74,909.71 215 10/01/2022 768.64 444.78 323.86 74,585.85 216 11/01/2022 768.64 442.85 325.79 74,260.06 217 12/01/2022 768.64 440.92 327.72 73,932.34 2022 Totals 9,223.68 5,416.23 3,807.4!; 218 01/01/2023 768.64 438.97 329.67' 73,602.67 219 02/01/2023 768.64 437.02 331.62 73,271.05 220 03/01/2023 768.64 435.05 333.5H 72,937.46 221 04/01/2023 768.64 433.07 335.57 72,601.89 222 05/01/2023 768.64 431.07 337.5i7 72,264.32 223 06/01/2023 768.64 429.07 339.57 71,924.75 224 07/01/2023 768.64 427.05 341.59 71,583.16 225 08/01/2023 768.64 425.03 343.6'1 71,239.55 226 09/01/2023 768.64 422.98 345.6El 70,893.89 227 1 % 1/2023 768.64 420.93 347.71 70,546.18 228 11/01/2023 768.64 418.87 349.77 70,196.41 229 12/01/2023 768.64 416.79 351.8ti 69,844.56 2023 Totals 9,223.68 5,135.90 4,087.78 230 01/01/2024 768.64 414.70 353.94 69,490.62 231 02/01/2024 768.64 412.60 356.04 69,134.58 232 03/01/2024 768.64 410.49 358.1 ~; 68,776.43 233 04/01/2024 768.64 408.36 360.28 68,416.15 234 05/01/2024 768.64 406.22 362.42 68,053.73 235 06/01/2024 768.64 404.07 364.57 67,689.16 236 07/01/2024 768.64 401.90 366.74 67,322.42 237 08/01/2024 768.64 399.73 368.91 66,953.51 238 09/01/2024 768.64 397.54 371.10 66,582.41 239 10/01/2024 768.64 395.33 373.31 66,209.10 240 11/01/2024 768.64 393.12 375.52 65,833.58 Liz 87J8g~888 ~~~8~11 ~~ ~~a~' Liz Date Payment Interest Principal Balance 241 12/01/2024 768.64 390.89 377.75 65,455.83 2024 Totals 9,223.68 4,834.95 4,388.73 242 01/01/2025 768.64 388.64 380.00 65,075.83 243 02/01/2025 768.64 386.39 382.25 64,693.58 244 03/01/2025 768.64 384.12 384.52 64,309.06 245 04/01/2025 768.64 381.84 386.80 63,922.26 246 05/01/2025 768.64 379.54 389.10 63,533.16 247 06/01/2025 768.64 377.23 391.41 63,141.75 248 07/01/2025 768.64 374.90 393.74 62,748.01 249 08/01/2025 768.64 372.57 396.07 62,351.94 250 09/01/2025 768.64 370.21 398.43 61,953.51 251 10/01/2025 768.64 367.85 400.79 61,552.72 252 11/01/2025 768.64 365.47 403.17 61,149.55 253 12/01/2025 768.64 363.08 405.56 60,743.99 2025 Totals 9,223.68 4,511.84 4,711.84 254 01/01/2026 768.64 360.67 407.97 60,336.02 255 02/01/2026 768.64 358.25 410.39 59,925.63 256 03/01/2026 768.64 355.81 412.83 59,512.80 257 04/01/2026 768.64 353.36 415.28 59,097.52 258 05/01/2026 768.64 350.89 417.75 58,679.77 259 06/01/2026 768.64 348.41 420.23 58,259.54 260 07/01/2026 768.64 345.92 422.7:2 57,836.82 261 08/01/2026 768.64 343.41 425.23 57,411.59 262 09/01/2026 768.64 340.88 427.715 56,983.83 263 10/01/2026 768.64 338.34 430.30 56,553.53 264 11/01/2026 768.64 335.79 432.8:5 56,120.68 265 12/01/2026 768.64 333.22 435.4:2 55,685.26 2026 Totals 9,223.68 4,164.95 5,058.7:3 266 01/01/2027 768.64 330.63 438.01 55,247.25 267 02/01/2027 768.64 328.03 440.61 54,806.64 268 03/01/2027 768.64 325.41 443.23 54,363.41 269 04/01/2027 768.64 322.78 445.813 53,917.55 270 05/01/2027 768.64 320.14 448.50 53,469.05 271 06/01/2027 768.64 317.47 451 .17 53,017.88 272 07/01/2027 768.64 314.79 453.85 52,564.03 273 08/01/2027 768.64 312.10 456.54 52,107.49 274 09/01/2027 768.64 309.39 459.2!5 51,648.24 275 10/01/2027 768.64 306.66 461.98 51,186.26 276 11/01/2027 768.64 303.92 464.72 50,721.54 277 12/01/2027 768.64 301.16 467.48 50,254.06 2027 Totals 9,223.68 3,792.48 5,431.20 278 01/01/2028 768.64 298.38 470.213 49,783.80 279 02/01/2028 768.64 295.59 473.05 49,310.75 280 03/01/2028 768.64 292.78 475.8(3 48,834.89 281 04/01/2028 768.64 289.96 478.68 48,356.21 Liz 87J8gJ~88~1 ~~~8: ~ ~ ~~ ~~8~ ~ Liz Date Payment Interest Principal Balance 282 05/01/2028 768.64 287.11 481.5,3 47,874.68 283 06/01/2028 768.64 284.26 484.3,8 47,390.30 284 07/01/2028 768.64 281.38 487.26 46,903.04 285 08/01/2028 768.64 278.49 490.15 46,412.89 286 09/01/2028 768.64 275.58 493.06 45,919.83 287 1 % 1 /2028 768.64 272.65 495.99 45,423.84 288 11/01/2028 768.64 269.70 498.94 44,924.90 289 12/01/2028 768.64 266.74 501.90 44,423.00 2028 Totals 9,223.68 3,392.62 5,831.06 290 01/01/2029 768.64 263.76 504.88 43,918.12 291 02/01/2029 768.64 260.76 507.88 43,410.24 292 03/01/2029 768.64 257.75 510.89 42,899.35 293 04/01/2029 768.64 254.71 513.93 42,385.42 294 05/01/2029 768.64 251.66 516.98 41,868.44 295 06/01/2029 768.64 248.59 520.05 41,348.39 296 07/01/2029 768.64 245.51 523.13 40,825.26 297 08/01/2029 768.64 242.40 526.24 40,299.02 298 09/01/2029 768.64 239.28 529.36 39,769.66 299 10/01/2029 768.64 236.13 532.51 39,237.15 300 11/01/2029 768.64 232.97 535.67 38,701.48 301 12/01/2029 768.64 229.79 538.85 38,162.63 2029 Totals 9,223.68 2,963.31 6,260.37 302 01/01/2030 768.64 226.59 542.05 37,620.58 303 02/01/2030 768.64 223.37 545.27 37,075.31 304 03/01/2030 768.64 220.13 548.51 36,526.80 305 04/01/2030 768.64 216.88 551.7'6 35,975.04 306 05/01/2030 768.64 213.60 555.04 35,420.00 307 06/01/2030 768.64 210.31 558.33 34,861.67 308 07/01/2030 768.64 206.99 561.65 34,300.02 309 08/01/2030 768.64 203.66 564.98 33,735.04 310 09/01/2030 768.64 200.30 568.34 33,166.70 311 10/01/2030 768.64 196.93 571.71 32,594.99 312 11/01/2030 768.64 193.53 575.11 32,019.88 313 12/01/2030 768.64 190.12 578.52 31,441.36 2030 Totals 9,223.68 2,502.41 6,721.27 314 01/01/2031 768.64 186.68 581.96 30,859.40 315 02/01/2031 768.64 183.23 585.41 30,273.99 316 03/01/2031 768.64 179.75 588.89 29,685.10 317 04/01/2031 768.64 176.26 592.313 29,092.72 318 05/01/2031 768.64 172.74 595.913 28,496.82 319 06/01/2031 768.64 169.20 599.44 27,897.38 320 07/01/2031 768.64 165.64 603.013 27,294.38 321 08/01/2031 768.64 162.06 606.513 26,687.80 322 09/01/2031 768.64 158.46 610.113 26,077.62 323 10/01/2031 768.64 154.84 613.813 25,463.82 324 11/01/2031 768.64 151.19 617.45 24,846.37 Liz 8~m~7~88~ ~:~8: 11 ~~ ~~~~ ~ Liz Date Payment Interest Principal Balance 325 12/01/2031 768.64 147.53 621 . 11 24,225.26 2031 Totals 9,223.68 2,007.58 7,216.10 326 01/01/2032 768.64 143.84 624.80 23,600.46 327 02/01/2032 768.64 140. 13 628.51 22,971.95 328 03/01/2032 768.64 136.40 632.24 22,339.71 329 04/01/2032 768.64 132.64 636.00 21,703.71 330 05/01/2032 768.64 128.87 639.77 21,063.94 331 06/01/2032 768.64 125.07 64357 20,420.37 332 07/01/2032 768.64 121.25 647.39 19,772.98 333 08/01/2032 768.64 117.40 651.24 19,121.74 334 09/01/2032 768.64 113.54 655.10 18,466.64 335 10/01/2032 768.64 109.65 658.99 17,807.65 336 11/01/2032 768.64 105.73 662.9'1 17,144.74 337 12/01/2032 768.64 1 01 .80 666.84 16,477.90 2032 Totals 9,223.68 1,476.32 7,747.3E5 338 01/01/2033 768.64 97.84 670.80 15,807.10 339 02/01/2033 768.64 93.85 674.7H 15,132.31 340 03/01/2033 768.64 89.85 678.7H 14,453.52 341 04/01/2033 768.64 85.82 682.82 13,770.70 342 05/01/2033 768.64 81.76 686.88 13,083.82 343 06/01/2033 768.64 77.69 690.95 12,392.87 344 07/01/2033 768.64 73.58 695.0E> 11,697.81 345 08/01/2033 768.64 69.46 699.1 a 10,998.63 346 09/01/2033 768.64 65.30 703.34 10,295.29 347 10/01/2033 768.64 61.13 707.51! 9,587.78 348 11/01/2033 768.64 56.93 711.71 8,876.07 349 12/01/2033 768.64 52.70 715.94 8,160.13 2033 Totals 9,223.68 905.91 8,317.77' 350 01/01/2034 768.64 48.45 720.19 7,439.94 351 02/01/2034 768.64 44.17 724.47' 6,715.47 352 03/01/2034 768.64 39.87 728.77' 5,986.70 353 04/01/2034 768.64 35.55 733.0SI 5,253.61 354 05/01/2034 768.64 31.19 737.45i 4,516.16 355 06/01/2034 768.64 26.81 741.83, 3,774.33 356 07/01/2034 768.64 22.41 746.23, 3,028.10 357 08/01/2034 768.64 17.98 750.66 2,277.44 358 09/01/2034 768.64 13.52 755.12 1,522.32 359 10/01/2034 768.64 9.04 759.60 762.72 360 11/01/2034 768.64 5.92 762.72 0.00 2034 Totals 8,455.04 294.91 8,160.13 Grand Totals 276,710.40 162,710.40 114,000.00 Liz o97d~Pl38~E> 3?23P1~ 1p~p~~~e1~ Liz Last interest amount increased by 1.39 due to rounding. REV-1513 EX+ (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Matthew A. Regan FILE NUMBER 21-05-1034 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (al (1.2)] 1. Arline Regan Mother 100% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTiON TO TAX is NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVEI~ SHEET $ (If more space is needed, insert additional sheets of the same size) IllO'),90c; R[V.I.Olr'(l4 This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records m accordance with Act 66, P.L. 304, approved by the General Assembly. June 29, 19').). WARNING: It is illegal to duplicate this copy by photostat or photograph. /}.~ ~ d C4Q ~ (4 /y~ No. Charles Hardester State Registrar Calvin B. Johnson, M.D., M.P.H. Secretary of Health JUN 0 1 2006 Date HI05.144Hev lIY1 \..VMMUNVVc:.~LI n ur r"CI'\II'I~' LV,",I'\lIM." uCr"M.n I WICI" I ur nCM.LI n .. YIII-\L nc\."unu;:. TYPE/PAINT IN PERMANENT BLACK INK CERTIFICATE OF DEATH (Coroner) 104380 ~ Iii o ~ o w ~ < z A Regan SEX 2.Male STATE FilE NUMBER SOCIAL SECURITY NUMBER 3.194-52-0452 DArE OF DEATH {MIJnth. O<l~, Yea'] 4. October 28, 2005 Days UNDER 1 DAY Hours PLACE OF DEATH (Chec~ 001':1 O<'\e see \r'\S\fUC\\Or'\S ()f' olher sioe) HOSPITAL Inpatient 0 [l CIT So. 'vlARITAL STATUS - MaHied Never Married, Widowed, Divorced (SpeofVI Tiever: Mar:r:ied SURVIVING SPOUSE (l!wile.:;)lverna,rlcnname) DECEDENT'S USUAL OCCUPflJ10N (Give ~lnd of work done dUIPng most of working lile: do not use retired.) "Facker: ,li',tder:al DECEDENT'S MAILING ADDRESS (Sfreet. Clt'yrOWrl, Stale, ZiP Code) 1901 Dar:tmouth st. Camp Hill, PA 17011 16. FATi?i~~~~tirs1F~tJleR~gan 18 INFKc11T~eA~~VPt{egan 20a. METHOD OF DISPOSITION Burial 0 Cremation 0 Removal from State [J Other {Specifyl DECEDENT'S ACTUAL RESIDENCE (See instructions on other side) 17a. State CUMBERLAND Did decedent li~ina township? l1d.5a ':h~~;::;\i');:: of MOTHER'S NAME (FilS\. MirWile, Malden Surname) l.Ar: 1 ine M. Moor:e INFORMANTS MAILING ADDRESS (Streel, CityTTown. State. Zip Code) 2Ob.35 Far:m Lane, James Cr:eek, PA 16657 PLACE OF DISPOSITION - Name of Cemetery, Crematory LOCATION - Cityffown. State, ZiP Code or Other Place 17c.O Yes, deo~dent lived in "'p Camp Hill citylboro 11b. County Danahon [J . 21a. SIGNATUR~ O;f~NEAALSEF.I~ICE 22.. /'i:5t 11-11.0 ~ Complete items 23a'c only when certifying physioan is not available at lime of death to certify cause of death 3, 2005 UCENSE Nt~/ t' L.. ~j I 22b. To the best 01 my knowledge, death occurred at the lime, date and place stated (SIQr);ltlJre<lnrlTitle) 21,!;:ast L Har:r:isbur:g Cr:emator:y NAME AND ADDRESS OF FACILITY JibCKLER WIEDEM.AN LICENSE NUMBER Har:r:isbur:g, PA 17109 21d. 230. TIME OF DEATH P rx ~ DATE PRONOUNCED DEAD \MOf'\p., Day, Yea,) 24. 6:00 A. M 25. October 31, 2005 21. PART I: Enle' the diseases, injuries or complications which caused the death, Do oot enter the mode of dying, such as cardiac or respiratory arrest, shock or heart failure List only one cause on each line Hypertensive Cardiovascular Disease DUE TO IOR;'S A CONSEQUENCE OF) :Approllimate I Interval between l onset and death PART II Other signiticant conditions contributing to death, but not resulting in the underlying calise given in PART I Seizure Disorder DUE TO (OR AS A CONSEOUENCE OF) DUE TO (OR A2, ,\ CONSEQUENCE OF) Ye, [J ACcident M, JOe. St;lle) d WERE AUTOPSY FINDINGS AVAILABLE PRIOR 10 COMPLETION OF CAUSE OF DEATH? MANNER OF DEATH DATE OF INJURY (Montt'.Day, Year) TIME OF INJURY NatIJ'al }l':l. n o Homicide 'fes LJ NO~ No [1 PendinglnvesligatiOn o o 308. JOb. o ~~:d::9~~~~~~I~tt home, farm. street, factory, office 30e. Ye, 28a. 28b CERTIFIER ICheeJ._ Dnly one) .CERTIFYING PHYSICIAN (pr,,!,sician cer"fy'ng cav:..e of death when another physiCian has ::>ronouncml dealt. 3nd cm')>~ete(j Item 23\ To the best of my knowledge, death occurred due to the cause(s) and manner as stated. . SuiCide 29. Could not be determined SIGNATURE AND I 0310. LICENSE NUMBER DATE SIGNED {Monlt' Day. Yparj o 31<. 3". November 2, 2005 NAME AND ADDRESS OF PERSON WHO COMPLE TED CAUSE OF DEATH ,. --~-- (I!em 271 Type or Print Michael L~ Norris, CorOiler 6375 Basehore Road, Suite #1 Aechanicsburg, Pa. 17050 Coroner . PRONOUNCING AND CERTIFYING PHYSICIAN iPn'islciarl both prone-unClOg death and certlfy'nglD cau~>€ of death) To the best 01 my knowledge, death occurred at the time, date, and place, and due to lhe causers) and manner as stated.. . "MEDiCAL EXAY\NER/CQRONEA On the basis of examination and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner as stated.. 31a. REGISTRAR'S SIGNATURE AND NUMBER " 32. ]J.. j),ta-- ;}I DATE FilED (Month, Day. Yp<lr) 34. /. -) ,,}c'O s -