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REY"H~ (11"78)
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMEtlT OF REVENUE
BUREAU OF FIELD OPERATIONS
TRANSFER INHERITANCE TAX DIVISION
INHERITANCE TAX RETURN
FOR INSOLVENT ESTATES ONLY
OF RESlDENT DECEDENTS
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COUNTY OF f.!.iJ. J/1he.e.llllJL.
This return must be completed In dotall and filed in duplicato, with tho Rogistor of Wills in tho County whoro tho docedont rtlsiuou within nino
months aftor doto of doath, unloss an oxtension Is grantod by tho Secrotary of RovonlJo,
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Admll, Nil, 19..2Q I, ,/1J!cO / ,/ .
(N liME)
1,-.11 N..E_ "r
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Misc.
heing duly sworn aCl;ording to luw, deposes and says that he is Lhc
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.;;:,xEC" ADM" LEGATEE, ETC,l
or Ihe estale or /?7nf:!....iJ LLJ_,C..~l.A 11) F late ur----Ld<< I:"~!SL~_.._.____..
, (CIT;r,-'UOllOUGH, or~ TOWNSHIP) ~--,~_._-
deceased, ulld that the wholc of the estate of said decedcnt, who died oll_t!2.-cL.~-J:-.n___+(-"?LL._f[2~_~.. .~-..
(DATE)
consistcd of the assets listed bt:low and llmL nllo\\'i.lhlc dehlS and deductions cxcceJcJ the fair markcl \'aIm: of tht: asst:ts and
no Pennsylvania Transfer InhcriLance Tax is due.
Sworn ond subscribed before me
tho ISStCl:dla~~/0
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Typo of Anel: (.:!~r ,k ('.111,1" ':-II~d Co.. Pa.
Real eslote. Pars. 'I'~ l :;mrnis~icn E)',nifl!~ Nov. 1.1, 10n1
Properly, Jointly
Held Prop. or
Transfers
ASSETS
(Attach additional sheets If neceSlary)
Doscription of Anet
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TOTALS
Eslimalcd
Market
Value
Department
Valuation
CAUTION
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in this spoce)
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REPORT OF INIIERITANCE TAX ,\PI'RAISER
I, the undersigned duly nppointed Inheritance Tax Appraiser in and fur lhc abovc Coullty dn resJlectfully report thal I have
appraised the real and personal property as reported in lhe foregoing schcdule al thc values set fnrlh opposilc cach itt:l1\ tJl
the lasl columllla the right. j!h.A..~/.J JthwdL__-....---
Dated: July 24. 1980 (INHERITANCE TAX APPRAISER)
Name of Payee
OEBTS ANO OEOUCTlONS
Nature of Claim
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Amount
Claimtld
Amount ApPlovcd
hy Registor
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REPORT OF TilE REGISTER OF WILLS
It the undersigned duly elected Register of Wills in and for the above County. do respcctfully reporl lhatl hn\'c allowed
deductions in the amounls sel forth in the abuvc schedule as cl<limed, exccpt where I havc sct forth a glcaler r lesser ~IJlHHlIlt
in the last column (0 the/ri ht, which greater or lesser amount represents the sur~l....a\OW.J us a dCdjtinn.
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Date of Approval: '\". (., .
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