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Home My WebLink AboutOC1969-0056 - ESTATE OF HAZLETT: ... L--- -! '· \ ., "'-.._ ., 'I .,......__.__ .. r ~ • IN THE COURT OF COMMON PLEAS OF WASHINGTON COUNTY, PENNA. (ORPHANS I COURT DIV. ) No. 56 of 1969 A. A IN RE: ESTATE OF CHARLES ADDISON HAZLETT deceased PETITION .FOR SETTLEMENT OF SMALL.ESTATE (DECREE WITHI'N) {/. j ·1~' b~ ~~ ~~\ ~'I)' 1 r3 N ·vd ··o3 tcoleM_ tHSV.M J. S11tM 30 1B!Si53::J "" OUH:P/71 113SSfU! l\\~ ~ . ~ ~E!~1N U. J!~~~' ATTOR~f"J~LAW ~ _I WASHINGTO~.alwe}.lji~ WASHINGTON TRUST BUILDING S;1:ll\Y. :: _J ;):. _ ;;.; ~1~J~ (!.H;;.Jr.i::·:.;, 11';J.S_,.!;1:J:iJ tn l''I'JJ ((-..., .. , w· .-. .-(.·-\._.. ~tt -,.! ·'·' u:;~::.:.~r ·L ~: ~ ({] -n ~·, ;I ~~ -\': f. . -·-Jl : ... IN THE COURT OF COMMON PLEAS OF WASHINGTON COUNTY, IN RE: ORPHANS' COURT DIVISION ESTATE OF : NO. 56 CHARLES ADDISON HAZLETT,) Deceased . . PETITION FOR SETTLEMENT OF SMALL ESTATE TO THE HONORABLE JUDGES OF SAID COURT: of 1969 PENNA. A. A. The petition of Herbert D. Hazlett, respectfully represents: 1. That Charles Addison Hazlett died October 14, 1968, age 77, at Torrance State Hospital where he had been confin for approximately four years, said decedent having been a residen . of Morris Township, Washington County, Pennsylvania, prior to his adjudication as an incompetent by Your Honorable Court at No. 383 of 1964 o. c. 2. That Pittsburgh National Bank was appointed guardian of the incompetent's estate by Decree of Your Honorable Court dated November 19, 1964 and said guardian has filed its First and Final Account at No. 56 of 1969 A.A. which shows a balance of $1,614.62 for distribution, said balance constituting the entire estate of said decedent. 3. That the decedent died intestate and that the only person interested in his estate is your petitioner, Herbert D. Hazlett, who is an adopted son of the decedent, said adoption decreed in the Court of Common Pleas of this County on December 3, 1917 in proceedings at No. 181 February Term, 1918 A.D.; the decedent's wife, Elva c. Hazlett having died May21, 1964. ·4. That the decedent had arranged for payment of his funeral expenses during his lifetime and that there are no creditors of the decedent's estate except the Commonwealth of Pennsylvania for the decedent's maintenance at Torrance State Hospital, said claim being in amount of $2,017.70. WHEREFORE, petitioner prays Your Honorable Court to direct distribution of the balance shown by the account of the guardian to the Commonwealth of Pennsylvania after payment of the costs of the audit, filing of this petition and counsel fees and costs in amount of $76.00. COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF WASHINGTON Personally appeared before me, the under- signed authority, HERBERT D. HAZLETT, who being duly sworn according to law_deposes and says that the facts set forth in the annexed petition are true and correct to the best of his knowledge, information and belief. Sworn to and subscribed before me this 1st day of February, 1969. ~""'""r,t.~"r"'? r"''"' ~, lwU\h'"" ,, •. , • , ~ t .... ..,, P~:~,1~C WI.~. II'·~ 1'""'1~'-' My Commiss:on LJ.p:.;:s l;;br.:arJ ~7,'~·971 (~ ' l IN THE COURT OF COMMON PLEAS OF WASHINGTON COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: I ESTATE OF NO. 56 CHARLES ADDISON HAZLETT, of 19 6 9 .:A • :iPr.r i deceased DECREE AND NOW THIS :L(d.. day of March, 1969, , upon consideration of the within petition and upon motion of Sherman H. Siegel, Attorney for petitioner, the Court directs Pittsburgh National Bank to make distribution of the balance set forth in its First and Final Account as follows: Balance for distribution per audit petition Orphans' Court Clerk Audit costs $· 12.00 · Orphans' Court Clerk Filing petition for settlement of small estate Sherman H. Siegel, Esq. -counsel fees and costs Commonwealth of Penna. -balance . 7•50. 76". 00 1519el2 $1,614.62 pursuant to Section 202 of the Fiduciaries Act of 1949 as amended and supplemented, said Decree shall in all respects have the same effect as a decree of distribution after an accounting by a personal representative. ' TR·2 REV. 9-62 IN THE COURT OF COMI\1QN PLEAS OF itJASHINGrl'ON COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION EST NEE OF CHARLES ADDISON HAZLETT, AN INCOIVIPETENT, NO\'J DECEASED FIRST AND FINAL ft.CCOill~T "OF PITI~SBURGH NRTIONRl BRNK GUARDIAN NO. 80626-4 PITTSBURGH, PA. JANUARY T' 1969 SUI1'iMAR y SCHEDULE A PRINCIPAL -PERS Receipts Page 3 Amount transferred from Income-Personalty Principal~Realty Ol~ALTY $ 5, 898.97 376.52 .2,1J7 .53' nee ?ages l-t and 5 I Disbursements Bala 'I I I ·' SCHEDULE B INCOME -PERSON ALTY Receipts Page 6 Disbursements Page 6 Amount tra~sferred to Principal-Personalty for investment & distributio Bala SCHEDULE C P~UNCIPAL -REA ' He;;ej_pts Page '7 Jisbursements Page 7 Amount tr~nsferred to Principal-Personalty for investment & distributio Bala NET $ 24.03 n ~76 r-2 --' I o :J nee LTY $ 232 )17 n 2,117.53 ------- nee BALANCE ; $ 8,393 02 6,778 40 I $ $ 400 55 400 55 I I 'I I oo 1 f$ 2,350 2,350 00 >-I I I ~$ I --.· I . I j ; I I, - -- 4 62 1,61 I -< OjOO I I I o oq_l l 61 L . , ... f 62 -t CHARLES ADDISON HAZLETT ----- TR·2A REV. 9·62 - THE BALANCE CONSISTS OF THE FOLLOVJING: PRINCIPAL -PERSONALTY i ; I Cash $ 1,614 62 I I • I l ! I I I ~ I ' . I -2- .. .. I I ! ) '· I •· ,, ·~ !' ; CHARLES ADDISON HAZLETT 'rR·2A REV. 9·62 •. .. SCHEDULE A PRINCIPAL -PERSONALTY RECEIPTS 1965 I \ Feb. 8 Inventory filed · $ 3,961 97 ; I ' l Treasurer of the United States Social Security Benefits ~Jl111.1X91. -__ ,.,.,... --l+/21/65 to 10/8/68 1,937 00 Assets Acquil"ed Deposits to savings account at Dollar Savings Bank - $ 2/17/65 2,000 00 10/21/65 1,800 00 $ 3,800 00 Cash disbur.sed to acquire above assets 3,800 00 0100 Conversion of Assets Without Gain or Loss Withdrawals in full savings account at · Dollar Savings Bank - 6/1/66 $ 800.00 7/26/67 1,500.00 1/30/68 250.00 ; 2,550.00 Carrying value 2,550.00 0 00 . $ 5,898 97 Transfer frcm Income-Personalty for i investment and distribution $ 3'T6 52 ' Transfer from Principal-Realty for investment and distribution 2,117 53 2,494 05 ' I $ 8,393 02 I I - -3- .•: I ! I : I I ' •' :! j . I ; I I i TR-2A REV. 9·62 1965 Feb. 23 Mar. 11 1968 Dec. 19 1969 Jan. 7 ., . 7 7 CHARLES ADDISON HAZLETT DISBURSEMENTS Administrative Expenses J. M. Douglass, Clerk of Orphans' Court - 2 certified copies of guardian appoint- ment, 2 petitions and orders for allowance and cost of filing guardian inventory - Paid 12/30/64 to 7/6/67 $ Commonwealth of Pennsylvania - 2 death certificates of Elva C. Hazlett - Paid l/21/65 and 10/14/65 Pittsburgh National Bank - Appraisal charge property situate Old Route 18 s. Franklin Township, Washing- ton County, Pennsylvania Observer Publishing Co. - Advertising house, trailer.and lot for sale -Paid 6/ll/65 and 7/6/65 Sherman H. Siegel - Professional services rendered re guardian appointment $150.00 Costs advanced re guardian appointment 13.25 Sherman H. Siegel - Professional services rendered re sale of real estate 50.00 Cost advanced 13.25 Maintenance and preservation of property situate Old Route No. 18 s. Franklin Township, Washington County, Pennsylvania Taxes - 1965 Real estate tax - Paid 6/14/65 6.98 1965 South Franklin Township road tax -Paid 6/14/65 . 3.34 Repairs -Paid 5/12/65 to 6/l/65 79.31 Insurance - Fire -Paid 1/28/65 13.00 General liability - Paid 10/6/65 1.95 West Penn Power Co. - Electrical services - Paid 2/1/65 to 10/21/65 11.53 Russell Marino, Clerk of Orphans' Court Div. Filing this Account Sherman H. Siegel - Attorney's fee Pittsburgh National Bank - Guardian's compensation -4- ,, i : ---,-- ! .. 11 50 2 00 15 00 32 50 163 2511 I •I 63 25 116 11 16 00 130 00 300 00 $ .... !. ' 849 61 CHARLES ADDISON HAZLETT TR-2A REV. 9·62 i Is Amount forwarded 849 61 Distribution ' Payments behalf of Charles Addison ! on Hazlett: I Commonwealth of Pennsylvania - Maintenance payments - $ Paid 3/12/65 to 1/18/68 5,903 79 Dr. William Colan toni - Medical testimony at incompetency hearing Paid 4/:5/65 r.r 00 5,928 79 c::. :J· $ 6,778 40 .., ' ! .. ' ' l l .. ; -5-I I ' ' .. ';-~ i ' ' ' ' ; CHARLES ADDISON HAZLETT TR·2A REV. 9-G2 SCHEDULE B INCOME PERSONALTY I ' - RECEIPTS Interest -Saving_~ Account Dollar Savings Bank to 12/1/68 :$ 400 55 ! DISBURSEMENTS Guardian's compensation '-, ;;$ 24 03 i! Amount transferred to Principal-Personalty for investment and distribution 376 52 .. $ 400 55. I .. i .. -6- .. .. ·· ' I I ' !I ' ; ' :t-I I .I CHARLES ADDISON HAZLETT . TR·2A REV. 9·62 - SCHEDULE c PRINCIPAL -REALTY I RECEI P'l'S 1965 Nov. 1 Proceeds sale property situate Old Route No. 18 South Franklin ~ownship, Washing--, ton County, Pennsylvania 2,350 00 Less Observer Publishing-co: $ 35 75 \vashington Publishing Co. 38 80 Revenue Stamps on Deed 2 75 Pennsylvania Transfer tax 23 50 George E. Smith -Affidavit of value 10 00 James P. Weaver -Affidavit of value 10 00 Mabel E. Rutan -Notary fee ·l 25 Ruth E. Simpson -Pro-rata share of s. Franklin Township School tax 1965 10 42 Pittsburgh National Bank - Compensation 100 00 232 L~ 7 . I $ 2,11'7 53 ·-. DISBURSEIVIENTS ; Amount transferred to Principal-Personalty I for investment and distribution $ 2)117 53 .. I I I I I RAP: lmp I I I I I -7--I I ,•: .. I .. : II I '. .. ' . ; , . ·l ; I ! i 3Jn tqr (@rpqnnn· arnurt nf ltnnqingtnn ainunty In the matter of the Audit of Account in Estate of_~C~h~a.=r..=l;.;e:..!:s:!.......:A~d~d~i:..!:s~o~n~.!.:H:=a~z~l:..:e=t...::t:..J,._J No. 56 an incompetent TO THE AUDITING JUDGE: Gua:rd1' an Enter· _____ m:::..y.__ ___ appearance for·----~==-::==.:_ ________________ _ 21st day of. ___ ...=M~a~r~c~h~----· 19~ N. B.-Counsel shall, by separate paper, ·present a concise statement of each claim, with supporting calculation of any interest claimed. Objections to an account as filed, shall be concisely stated in a separate paper. Council suggesting proper· distribution shall file a separate concise state- ment in that regard. I en • U'>ct Ln O,..J·O. z·...J 4 c::n ~ ~ .. 2 o;:.~o :c:: <(-~ xu..~ c:::::: 0(;:1 ... 0 -Jtt;t-.::r ...J uJ Hl w r-...1 wfwz ""{/) ..... == V) """"% __, ..:: :::;~tn :1:: c::UJ~ -en ~J; LL. t:..C) .. No. 56 of , 19_ 69 , ».:»-------- In re Audit of Account in Estate of CHARLES ADDISON HAZT.ETT, an incomPetent AUDIT Jrarripr fnr Appraraurr FOR ~-t..tsbur.gh.--N.a tiona 1 .B.an.k,_,_ __ Guardian SHERMAN H. SIEGEL, ESQUIRE Attorney ~2 lin t4r ~rpijaus' C!Inurt of llmasl1tngtnn C!Inunty In the matter of the Audit of Account in Estate of CHARLES ADDISON HAZLETT, l No. ·56 of · , 19_2_9_, ~ deceal;)ed TO THE AUDITING JUDGE: my . ~ . Enter appearance for Henbe·nt D . .z.::Ra.Z-1ett 1 son and on 1 y heir · _ _;__ __ day of March ' 19_6_9_ N. B.-Counsel shall, by separate paper, present a concise statement of each claim, with supporting calculation of any interest claimed. Objections· to an account as. filed, shall be concisely stated in a separate paper. Council suggesting .proper distribution shall file a separate concise state- ment in that regard. / t'.", ~fg· ' ~ : . . ; tti,;s .....J ~' l&b, Cf1l "" ~ -=:.~ ~0) ~' ~n, ~ru ~ ... ~ 53 $ ·,' 0 ;<./)<i :.J a.. ! ::z: ·-J -.• -' o::·::fl: 0 <' 0 ::E &. :z-c:i:l> :2 . 0 -=~ .~-_g::=tb ""' ~~Z: ~~~-~fa$~ o::l)m < en~ Si::; :::)c.:;J • o::w 0:: No. 56 of 1969 , lKXXXXX~X In re Audit or Account in Estate or CHARLES ADDISON HAZLETT~ deceased AUDIT Jrarripr for }qtpraranrr ~1 ., FOR'- "I ~ Herbert D. Hazlett, s..on and. only bej r SHERMAN H .. SIEGEL, ESQ. Attorney -~2 Form for Guardian or Trustee Jttitinn 8Jur Aubit Jn ID~r OOrp~atts · QTnurt nf llas~ittgtnn Olnunty Estate of ................. g?..~E.~.~.~ ... A~.~.!.~.9.~.J~~.!!:.!.~.~.~ .................. . Filed at No ........ 5.9. ........................ of 196 ... 9.. ................................................................................................................................ Fiduciary ............... !:.!.S.~.~P.~E~h ... ~.~.~.!.9.~~.! .... ~.~~~ ................. . fix ..................................................................................................................... . . .......... " ................ " ...... <1.uS!r.!iiii!.tL ............................................................... . Place of record ®Kor-incompetent-IK!KteR!HIK of appointment .. N.Q.r ..... J.~.J ... .QJ .... l.9..§.{t .... Q ...... Q ............................. . Date of trust or guardianship ........... ~g.Y.~~1?.~E .. J2.~ ... J.?..?..~ ................................. . If there have been former accounts filed in this estate, list: . None filed Reason for filing this account.. ... .!E.S.9P..P..~.~.~.~~ .... ~.i~.~ ... £~ .. .9.£~.9.~.~.!: ..... ~.~.~ ..... ~2§.:~ .................................................................................. .. All persons having any interest, vested or contingent (including claimants), in the fund now before the Court, with the nature of their interests are: Herbert Hazlett, son -only heir Commonwealth of Pennsylvania, Torrance State Hospital All of said parties· have received notice as required by the Court Rules except as follows: No Exceptions The fund now before the Court is subject to the following taxes: None Set forth any legal problems requiring adjudication by the Court or difficulties that must be met in distribution: None j Balance for distribution per account, Additional debits not shown in account: (Indicate whether income or principal) Additional credits not shown in account: (Indicate whether income or principal) Balance for distribution ...... 1' Principal $ ...... L.§lft,.Qf ............................ .. Income $ ....... :::::.::.::.::.::.::::: ............................ .. Total additional debits $ ...... NQng ........................................ .. Total additional credits $ ...... ~9,g~ ......................................... . Principal $ ...... !.1.9..!~.~.9..?. .............................. . Income $ ...... ::.::.:.:.:.:.:.: .............................. . Total $ ..... l.:~..§l.4.:~.R.f ............................. .. If the balance for distribution is not in cash, list items held in kind with carrying value designated, and if this is a distribution account, file elections to take in kind for all items so listed: Balance for Distribution consists solely of cash. " ·- ,. •. ""'' -"" ~Set forth accountants suggestion as to manner and form of distribution to be made, awards to be stated in pro- portions unless specific amounts or items are designated by instrument under which estate is being distributed: Suggest distribution be made in accordance with Petition for Distribution under the $mall Estates Act filed herewith. COUNTY OF WASHINGTON, COMMONWEALTH OF PENNSYLVANIA, The above named Fiduciary or representative thereof, being duly .......... §F.!?.~.P.: ........... doth depose and say that the facts set forth in the foregoing petition are true to the best of ............ h.;.~ ............... knowledge and belief. .~~.~E,~ .................... to and subscribed before me This ........... /..l. ................... day of ............ !19:I£h ..................... l96 .. 9. .. Signature of Officer.~.£. ... ~-.. ...................... .. Title of Officer ........................ N9.t.~~Y. ... ;P.JJJ?..:t:f..~ ......................... .. Office expires .............................. F.~.P..r.1J.9.r.Y, .. .l., .... l9.l.3 ................ .. f!iABEl E. RUTAN N01 r.RY PUBLIC \"A''J'" rro·;, · 'dii!GTON COUNTY, PA. ',:Y ::..~· .ISS'"J;, ·,: , l '.4flV 1. 197.1 ~ ss And your petitioner will ever pray, etc. PITTSBURGH NATIONAL BANK By .. ............................................ .t ....................................................................... .. Trust Jfficer . ....................... ; ...................................................................................................... . • .~ J ..... ..., ·"' Jrtitinn ~ur 1\uilit IN Tl-tE ORPI-IANS' COURT OF WASI-tiNGTON COUNTY FORM USED FOR GUARDIAN-INCOMPETENTS -OR TRUSTEES No ............ .?. .. § ............. of 196 .... 2 .... . ESTATE OF ................... g.~~E.~.~-~ .... ~!:!.9:.~.~ . .9.~ ... !!::!.~.~-~.!: t mR,. ...................................................................................................................... .. ................................ riii~ii;"~~;:;;p~t~;;:i=i~~t{·········"····· .. ·······"" .................... RJ.t..t~.!?..g£gh .... N~.E:.J.9.P.:~.l.. .. ~.?.P.:~ ........... . ................................................. G.~.~.E4J.~!L ...................................... . Counsel for the accountant shall submit herewith the following, if pertinent: 1. Will or trust instrument-attested. 2. Inventory. S. Signed elections of items to be taken in kind-if distribution account. 4. Stipulation or certificate by minor approving account. 5. Praecipe for those represented. 6. Brief-for any question of law raised. .................................. ~.h.~I.ffi?.P.: .. J:!.t ...... !?.J.~g~J .................................. .. Counsel for accountant . FlLED BG9 APR 25 AH 9 : 12 RUSSELL MARINO REGISTER OF WILLS 'Vd ~·oo HOl!ltUHSVJA ST1H11 JO ?331S1~3l! O'MHfYl"'l 113SSO~ 6S 6 ·uv ~2 HV~ 6S, '(] 311 ;:1 • PJTT~~-·~:~JW~~A:;,J··:.'~L :>~ .-t.\ WAS:Ii::m;: ~fdSE PITTSBURGH NRTIONRL BRNK PITTSBURGH, PENNSYLVANIA 15230 Mr. H~rbert Hazlett R. D. 1 Dunns Station, Pennsylvania Dear Mr •. Hazlett: January 17, 1969 We enclose herewith copy of our First and Final Account as Guardian of the Estate of Charles Addison Hazlett, an incompetent, which we have filed in the Office of the Clerk of the Orphans' Court of lJashington County to No. 56 of 1969. This Account will be presented to the Court for Confirmation on March 3, 1969, and will again come before the Court for Audit during the week of March 17, 1969. We have received a bill from the Commonwealth of Pennsylvania, Torrance State Hospital, in the total amount of $2,037.70 as maintenance for your father for the period from January 1 to October 14, 1968, which bill we enclose heret-1ith. We would be pleased if you would discuss with Sherman H. Siegel, Esquire, the matter of dis.tribution of the estate of your father as a decedent under the Small Estates Act. CEB/s Enclosures Yours very truly, Chas. E. Enlow Trust Officer . . ~~f~~::;::stJ:i nr~:~E .'ihS~ii:G:·~;.,., -~A~~ , ·- PllTSBURGH NATIONAL BANK PITTSBURGH, PENNSYLVANIA 15230 Commonwealth of Pennsylvania Department of Revenue Torrance State Hospital Tortance, Pennsylvania 15779 January 17, 1969 Re: Charles Hazlett Patient No. 21>295 Gentlemen: We enclose herewith copy of our First and Final Account as Guardian of the Estate of Charles Addison Hazlett, an incompetent, now de- ceased~ which Account we have filed to No. 56 of 1969 in the Office of the Clerk of the Orphans' Court of Washington County. This Account will be presented to the Orphans • Court of Washington County for Confirmation on March 3, 1969, and will again come before the Court for Audit during the week beginning ~mrch 17, 1969. We are forwarding a copy of this Account to Herbert Hazlett, R. D. 1, Dunns Station, Pennsylvania, the son of Charles Addison Hazlett, with the request that he discuss with Sherman H. Siegel, Esquire. Washing· ton Trust Building, Washington. Pennsylvania, 15301, the possibility of closing the estate of Charles Addison Hazlett. deceased, on a petition under the Small Estates Act. ln this connection, we are advising Herbert Hazlett of the amount of your bill. CEE/s Enclosure Yours very truly, ~~ Chas. E. Enlow Trust Officer 3Ju t}fr ®rpqaus~ <tlnurt nf Basqiugtnn QTnunty ESTATE OF No ____ ~_§ _______ Of 69 19 ____________ , ~ Charles Addison Hazlett ------------------------------------------------------) _________________ _ In the matter of the .. .fi:r.~L?.-.tf_g_.:f._~Q§._L ___ _ -----~~--t.t:J:~~~P.~-~§_t:l:~) ____________________________________ _ now deceased. Account of ... J?..Ht.9.~~X".9:h .. N?J~QD.<?:L~.§.~_J ___ _ ) _______________________________________ J)_\:l:§.r.9J§._D: _________________ _ ADJUDICATION AND DECREE And now _______________ M_c:u::r;lt_ ______________________ tZ/ ..... , 19.69 ... , this matter came on for hearing, audit and distribution at this session and testimony taken; and thereupon, upon due consideration thereof the balance for distribution in 'the hands of the Accountant is determined to be $1_,_.614_.__6_2 ________________________________________ and the accoun!t is accordingly confirmed; and it i3 orde·red, adjudged and decreed that the said balance be paid out by the Accountant in accordance with the schedule of distribution hereto O'ttoched and made a part hereof, unless exceptions hereto be filed sec. reg_ or an appeal be taken herefrom sec. leg. cu ·'·jzz(~~; SCHEDULE OF DISTRIBUTION Balance per account·--------------------------------------------------------------------------------· Balance------------------------------------------------------------------------------------------------------- Deduct Clerk's Costs & Receipts .... -------------------------------------------------------------- ' Attorney .. __________ §.~_\?_~-~-~~--:ff: .. f?.t~-g~~---------------------------------------------------· To the estate of Charles Addison Hazlett, deceased, balance, 1602.62 $.L.61~_._62. lJo balance JL , ( c:ra .. 0 Ln -0 fP7 o0cl ~ &r n ::l z n z-Ja.. -+ 0 ...f ~ en t:Y 0 :r --! " -+ c: <1) a:;-• v-+• <1) ::l . X:: <iJlO = 0 -+ 3 > c::t 0 ' .. ::£U..c t:Y -0 ' ' - . 0~ -· ~· ' .J. 0 ~ nr ,. .;:r-....J('Gfo- ra ""t """' w~ ...... 0 0 ~t>--Z -· -- c::: Q :f (I} :2 : = <1) !:)"-btl') ~ 0') ~I.U-t c.c C.:J: = t:Y ~ ' s ~ .. ~ ~ ~ ~ ~ ~ J COMMONWEALTH OF PENNSYLVANIA DEPAR'IMENT OF REVENUE BUREAU OF INSTITUTIONAL COLLECTIONS ~ ~~~~ :~-,~~'~ -~':~j~~~-.. ~~~ DETAILED AND CERTIFIED STATEMENT of Commonwealth of Pennsylvania Claim for Hospital Care and Maintenance Torrance State Hospital Institution 21,295 I Charles A. Hazlett I 3-3-69 t'attent NumDer Name ot t'atlent Date of Statement 6-17-64 I 10-14-68 I 6-17-64 I 10-14--68 Date Admitted Date of D Discharge o Furlough EJ Death From To A Period Total Charges for Period From 6-17-64 1-1-65 1-1-66 1-1-67 1-1-68 To 12-jl-64 12-31-65 12-31-66 12-31-67 10-14-68 . $ 871.20 1,6o6.oo 1,670.20 1,982.40 2,037.70 COMMONWEALTH OF PENNSYLVANIA COUNTY OF WEsrMORELAND $ B Total Payments for Period 120.00 2,240.80 1,374.20 2,194.70 220.10 $ c Balance for Period 751.20 634.80 -Credit 296.00 212.30 -Credit l;Blz.6o Total Amount Due ~ ._$ ___ 2'-, 0_1_7:...•...;7~0------1 It is hereby certified that the foregoing statement is a true and correct claim of the Commonwealth of Pennsylvania for the maintenance and support of this individual from 6-17-64 10-14-68 _______________ to ______________ _ inclusive, as shown by the records of the Department of Revenue of the Commonwealth of Pennsylvania at the above named institution. All absences have been credited. In witness hereof, the Department of Revenue of the Commonwealth of Pennsylvania has caused this certificate to be signed in its name by _______ E_._W __ ._R __ ag~er ______________ Agent, of the Department of Revenue, located at this institution this ______ -=3r_d~ __________ day f March 1 6o ( S E A L ) 0 --------~~~-----------------' 9~. ~ COMMONWEALTH OF PENNSYLVANIA, Department of Revenue By L. ""~ ~ RIc_ 200 ( 6 -6h) AgentoftheCi>D1110nweai th I