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Rcc-n (9-68)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
APPLICATION FOR AND CONSENT
TO TRANSFER SECURITIES
REGISTERED IN THE NAME
OF A RESIDENT DECEDENT
APPLICATION (MUST BE FILED IN TRIPLICATE)
TO THE IPENNSYLVANIA DEPARTMENT OF REVENUE:
Application is hereby made for COlsent to the transfer of the following securities of a Pennsylvania
Corporatilln or a National Banking Association located in Pennsylvania:
DATE March /2, 1979
(a) (b) SEE ATTACHED SHEET (c)
(NOTE: In describing securities enter in (a), ab Ole, either the number of shares of stock or the face amount of
registeredl bonds, in (b), the name of the issuing company and in (c) the class of stock or the stated interest rate
and maturity date of registered bonds.)
ISSUED ON
, and having a TOTAL MARKET VA'LUE OF $ 120.00
(Dote)
as of the date of death of the decedent,
(Nome of Decedent)
, on May 18, 1978
(Dote of death)
SUSAN R. JONES
who was Ilate of R. D. ~8,
(Street and Number)
Carlisle,
(Post Office)
Cumberland County, Pennsylvania
(County)
(State)
tificate in
AU<<KKit~)
EXECUTO"R[X )
The securities are registered as follows: 1\11 in name of Susan R. Jones excebt one Cer-
(N . h' h 'f' . d) er 20, 1959)
orne or names In W 'c cert, 'fates ore {eg'stere .
name of Jacob Jones or Susan R. Jones \ JacoD Jones d1ed Decem-
Grace L. Brenizer, R. D. *8, Carlisle, Pennsylvania, 17013
(Nome) (Address)
NAME OF APPLICANT George ~~. Houck, Esquire
National Dank Building
ADDRESS OF APPLICANT ~1echani / rg, Pa., 17 '55
COUNTY FILE NUMBER 21-78-271
BUREAU FILE NUMBER SIGNATURE OF APPLICANT
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THIS APPLICATION, IT wl(i.
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR COMPLETION. \~
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE
CONSENT TO TRANSFER SECURITIES . 11- ' ,
DATE 70.J. (rr~ (? '17
I hereby consent to the transfer of the above securities now registered in the name of the aforesaid
Decedent and waive the filing of a certificate certifying to the payment of the transfer inheritance tax to which
the property of said Decedent is made subject pursuant to the provisions of the Act of June 20, 1919, P.L. 521,
as amendl~d and the Act of June 15, 1961, P.L. 373, as amended. This is also in accordance with the provisions
of the Act of April 9, 1929, P.L. 343.
This Consent to Transfer the herein described property operates only in reference to the estate of the
above-named Decedent.
Signed for the Secretary of Revenue
B/iX::~4a,vJ " f , C~",JJ/I" 1'>,' (j<~
; ~ ' (.i~ture)' .
, .
:~
. [ .iry
(Title)
(County)
SECURITIES
1. 4 Shares Cumberland Valley Cooperative
Association Preferred Stock is sued December 10, 1955
2. 1 Sh are cumberland Valley Cooperative
Association Pre fe rred Stock issued r-:tay 20, 1960
3. 1 Share Cumberland Valley Cooperative
Association Preferred Stock issued ,) 11 1 Y 8, 1963
4. 3 Shares Cumberland Valley Cooperative
Association Preferred Stock issued July 25, 1968
5. 1 Share Cumher1and Valley Cooperative
Association Preferred Stock issued October 1, 1972
6. 1 Share Cumberland Valley Cooperative
J'~ssociation Common Stock issued December 10, 1955
7. 1 Share Cumberland Valley Cooperative
l\ssociation Cornmon Stock issued July 25, 1968