HomeMy WebLinkAbout02-28-79
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~CC-33 (t?3)
'2\ -'l~ -O~3l
COMMONWEALTH OF PENNSYLVANIA '"
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS c ....4
DEe 081978 \C -\ '0
COUNTY OF CUMBERLAND
RESIDENT DECEDENT
IMPORTANT:
This return must be completed in detail and filed in duplicate, with all attached, with the Register of Wills of the
County where decedent resided; Return is due within nine months after date of death, unless an extension is granted
by the Secretary of Revenue. (Section 703 of the Inheritance and Estate Tax Act of 1961.)
IN THE MATTER OF THE ESTATE OF
Late of
Cumberland
} AFFIDAVIT OF
EXECUTOR
County *~MW~
MABEL H. KIMMEL
(STATE FULL NAME OF DECEDENT)
State of
Pennsylvania
Cumberland
} ss,
County of
-AJU.;II; i3 Ll a tVl
Marsha Digilarmo Lynes
of the ..tat. of the above-named decedent being duly sworn, depose S and say S
August 1, . 19~ ...ta., I_vlng. 1... wHI, C.P1 of which I. h..,t. .ttach.... }
(MONTH) (DAY) (YEAR) ~e
Name and address bf attorney or} James K. Arnold, Esq., Arnold, Slike & Bayley
other authorized repreMntative to whom
all correspondence should be mailed. 2109 Market Street, Camp Hill, PA l7011
Executor
Decedent died
That as such Executrix deponent is familiar with the affairs of said estate and the property constituting -
( EXECUTOR-ADMINISTRATOR)
the assets thereof and their fair market value.
That at the time of death there was no safe deposit box registered in decedent's individual name, or jointly with, or
as agent or deputy of another, or in decedent's individual name, with right of accessbyanother as agent or deputy, with the
exception of the following: -
NAME AND ADDRESS OF BANK OR OTHER INSTITUTION THIS SAFE DEPOSIT BOX RENTED RELATIONSHIP OF JOINT
IN WHI CH DECEDENT RENTED A S....FE DEPOSI T BOX IN NAME OR NAMES OF HOLDERS TO DECEDEN T
Fl.rst Bank and Trust Company of Decedent --
MRC"!h;:Jn;C"!~hllrg
Mechanicsburq, Pa.
That the contents of said safe deposit box or boxes are itemized under Schedules
with the exception'of the following, for the reasons hereinafter set forth:
of this return,
That ScheJule A attached hereto and made part hereof sets forth fully and in detail all the real property
in the Commonwealth of Pennsylvania of which decedent died having an jnterest therein. It also sets forth the
mortgage encumbrances upon each parcel of real property at the date of death, giving the amount still due at
death, name of mortgagee, date, rate of interest, and book and page of record thereof. It also sets forth in the
columns provided therefore the assessed valuation of each of said parcels, the estimated market value. thereof
as of date of death of decedent.
That ScheJule B attached hereto and made part hereof sets forth fully and in detail all personal property
wheresover situated owned by the decedent at the time of death; all moneys left by the decedent at the time of
death, whether in decedent's immediate pos session, standing to decedent's credit in banks of deposi"t,~avings
banks, trust companies, or other institutions, whether individually, or in trust for any other I',ers)m Or persons
giving also separately the accrued interest thereon, if any, down to the last interest day ~im t~)d'ecedent's
death in the case of savings banks, and to the date of decedent's death in all other ca~esi a(l:"bonds, p6stal
savings, treasury certificates or notes and other evidence of indebtedness of the United.:Staie s ~o the de-
cedent; all obligations, whether by statute or agreement they are designated as tax frCfe, 9~~th'e'Unit-~d States,
or any state, or political subdivision thereof, or of any foreign country, which are owned atifi}~ tiine of death;
all wearing apparel, jewelry, silverware, pictures, books, works of art, household furniture:'hof.s&S" carriages,
automobiles, boats, and any and all other personal chattels of whatsoever. kind or nature, left by decedent,
together with the fairly;estimated market value thereof; all bonds and mortgages held by decedent and of all
claims due and owing decedent at the time of death, and all promis sory notes or other. instruments in writing
for the payment of money of which decedent died possessed, of whatsoever nature, ~ith interest thereon, if
any, giving the face value and estimated fair market value thereof, and if such estimated fair-market value be
less than the face value, it sets forth briefly the reasons for such depreciation as to each item; all moneys
payable to the estate from life insurance policies carried by decedent; all annuity and endowment contracts
the proceeds of which were payable upon the death of the decedent; all and the corporate stocks and dividends
due thereon and unpaid as of the date of death, bonds and accrued interes t thereon to the date of decedent's
death and other investment securilii:s owned by the decedent at the time of death, with the.market value there-
of at such time.
.
In the case of. .secur;1t~esof clo.se o.r famll y co.rpo.ratio.ns, the values repo.rtedare as far as
. po.,ssible ~ubs ta,,~iated by fi,nanc.ial statements 0.1' the co.rpo.ratio.ns, sho.w.ing. the .assets and liabili ties
t.hereo.fas . of' the. date o.f'. death.' The schedule. also. sets f'o.rth the interest of' decedent at the time o.f'
death,..,!n any co..;,partnership 0.'1' business, and in support 0.1' the value o.fsuch interest there is annexed to.
said schedule, f'inancialstatements showingtheassets and iiabllities o.f' said co.-partnership or business.
'A.' ~6py 0.1' the co-partnership agreement, (if o.ral, 'a statement setting forth the nature af tne a~reement)
to.gether with a statement setting f'o.rth the character o.f the business, its lo.catio.n, and such ather facts
pertaining to. the business as may be pertinent to. a f'air and just appraisal 0.1' the decedent's interest
therein must be submitted. It sho.uld also. set fo.rth in itemized farm, to.gether with. the .fair market value
thereo.f, any ather pro.perty o.wned o.r bequeathed by the decedent at the time o.f death.
The Schedule C attached hereto. and made part hereo.f sets fo.rth a true answer to. each inquiry
co.ntained therein and in the case o.f transfers o.fpro.perty, real ar persanal, within two. years o.f' decedent's
death, in co.ntemplatio.n o.f decedent's death, o.r intended to. take eff'ect in po.ssessio.n o.r enjo.yment at o.r
af'ter death, said schedule sets fo.rth the nature and value o.f' such pro.perty, to. who.m transferred, the
relatianship o.f the transf'erees to. the ~ecedent, the pro.po.rtio.nate share received by each transf'eree and
all o.ther f'acts o.f a pertinent nature regarding said transfers. In the case 0.1' transfers intended to.
take ef'fect in po.ssessio.n o.r enjo.yment at o.r after death, there is also. attached to. the schedule a Co.ny
o.f' the deed, trust agreement o.r other instrumentcr~ating the trust. TheN~ is also set f'o.rth in said
schedule a list o.f' all pro.perty, real and perso.nal, with its value, which passes at decedent's death by
virtue of the exercise by decedent, either individually, o.rjo.intly with ano.ther, o.r anypo.wer 0.1' appaint-
ment vested in decedent, either individually o.r jo.intly, by the will, deed, o.r other instrument o.f' ano.ther,
with a co.py o.f' the instrument creating such po.wer attached to. the schedule.
That Schedule D attached hereto. and made part hereo.f' sets f'o.rth the names and addresses o.f' all
perso.ns benef'icially interested in this estate at the time o.f' decedent's death, the nature o.f their res-
pective interests, their relatio.nship, if' any, to. the decedent, to.gether with the ages at the time o.f'
decedent's death o.f all mino.rs, annuitants and benef'iciaries far life under decedent's Will. It also.
co.ntains a statement sho.wing which 0.1' the benef'iciaries named in the d~eedene s will, if any, died prio.r
to. de,~edent, the dates 0.1' their death, their issue, and the relatio.nship o.f such issue to. the benef'iciary.
That Sc;'edule E attached hereto. and made a part hereo.f sets fo.rth all pro.perty, real and'per-
so.nal, awned by the decedentjo.intly with ano.ther o.r o.thers, including intangible, standing in the name
o.f' the decedent and o.thers, plus the date and place o.f' reco.rd o.f' instruments effecting the -vesti ture o.f
real estate and the date o.f acquisitio.n 0.1' perso.nalty, plus the name, address and relatio.nship, if any,
o.f' Co.-o.wners to. the decedent.
That Sc;'eduleF attached hereto. and made a part hereo.fsets fo.rth fully and in detail all debts
and deductio.ns claimed far and o.n behalf o.f this decedent's estate, including funeral expenses paid;
familyexemptio.n, where applicable; casts o.f administratio.n o.f this estate; co.unsel f'ees and fudiciary's
co.mmissio.ns paid o.r to. be paid; cast expended far burial trusts, to.mbsto.nes o.r gravemarkers, and reli-
gio.us services, in co.nsequence o.f the death o.f' the decedent; debts and claims awing and llnpaid at time o.f
death; taxes accrued chargeable fo.r perio.d prio.r to. decedent's death (except tho.se allo.wed under Sectio.n
651 o.f the Inheritance and E~tate Tax Act); to.gether with a statement o.f co.llateral pledged fo.r o.bliga-
tio.ns, if any. It is agreed that the fiduciary will presentpro.of o.f said claimed o.bligatio.ns upo.n re-
quest, that if the amo.unt actually paid in settlement of any fee, co.m~issio.n o.rdebt is less than the
estimated amo.unt claiming and allowed, that the same will be repo.rted to. the Register o.f Wills, and that
the amo.unt o.f tax assessed can be reassessed in acco.rdance therewith.
That the totals of the appro.priate co.lumns in Schedules "A", "B", 1tc", "E", and"F" as directed therein,
have been carried forward and pro.perly registered in the Summary.
Subscribed arid sworn ; b~~ this ................................
......._..;}li?.~. cra:tti.............. 19.2.L
::::.~?1:..21!Z.. ......... ........' . ... ...........
thehu S. McCauslin, ~otary Pubbc
My Commission Expires July 1, 1~80
Ca~p Hm, PA Cumberland County
/l}=--tor.~~-
.......4.0.....Ashl.e~.....DJ:i.'V:e..~.....................................,......-..............
(Street Numb,")
......P.~.~.~.~.e~.!:.~.!.......~~........................................................................
(City or Town a:nd Stttte)
NOTE: Bef'ore signingaffl,davi t make sure all blank spaces in the affidavit and. schedules annexed are
filled in with details .o.~ the wo.rd "No.ne", and in case the assets include rare and unlisted securities,
securities o.f clo.se or' f'amily co.rpo.ratio.ns o.r an interest in any co.-partnership o.r business, that the
data a.~d stateme~ts req~ired under th~ paragraph abo.ve relating to. Schedule "B" are attached. Also. make
certain that co.lumn #1 in the "Summary" has been pro.perly co.mpleted as abo.ve-directed.
';...~;;")f{,:~~&~_.;;;,0~ji:cL;bt hi,.j-;JL: -j;L;j~>~~t:-:,;$(;~h~~,~ .j:_~~'1BJl~~~~~(~~~z,;;:t-i:d~;;,:,~::~~ilJi,~;:~"B-;s-;
.
· RG C-34 (4-73). . I
COMMONWEAL TI'I OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
TRANSFER INHERITANCE TAX
RESIDENT DECI!DENT
SCHEDULE "A"
REAL PROPERTY
*'
Real property in Pennsylvania, with statement of mortgage encumbrances upon each parcel at death of dece-
dent. Property held by the decedent as tenant In common with another or other, should be identified
as to quantum of interest and the estimated value should be that of the decedent's interest only. (Property
held as joint tenants with right of surviorship or tenancy by entireties should be reported on Schedule "E.")
The real property located In the Commonwealth of Penn.ylvanla .hould be
de.crlbed by lot and block number, street and .tre.t number, together with
a general description of the property, with a reference to the record of the
conveyance by which the decedent took tItle; If a farm state number of a.
cr..; al.o statement of mortgage encumbrance. upon each parcel at death
of d.cedent. Tax.., a.....menta, accru.d Inter.st on mortgage., etc.,ar.
to b. IIst.d on Sch.dul. uF" and mu.t not b. d.ducted from thl. schedule.
~ngle family dwelling known as
303 Brandy Lane, Mechanicsburg, Pa.,
acquired by decedent and her predeceasing
husband (September 1961) by deed dated
November 19, 1957, recorded in l8"D"324;
per attached appraisal
eHJ11.. d,
L'+AI~
6 I 'J., ()
1,0
,tjfD
1/
",f ' ,
")
-
(1)
ASSESSED VALUE
FOR YEAR OF
DECEDENT'S
DEA TH
Insert this total opposite "real property", Schedule "A" in the X X X X X
"As Reported" column on the last page of this return.
(2)
C3l
DEPARTMENT
VALUA TION
CAUTION
(Do not write
In this space)
ESTIMATED
MARKET VALUE
/'
$43,000 V L\:3 bOO. 00
,
~3tooo.oo
II
.RCC -35.
INSTRUCTIONS: This Schedule must disclose all tangible and intangible personal property owned individUally
by the deCedent, at the time or his deat~ Property owned by the decedent Jointly with another or others
must be listed under Schedule "E". Intangible personal property, titled in the name or the decedent, but
payable at death to another or others, including but not limited toP.O.D. U. S. Savings Bonds and tenta-
tive trust accounts, must be listed, despite the ~act that they are not o~ the administered estate.
Tangible personal property should be listed ~irst (e.g. jewelry, wearing apparel, household
goods, and fUrnishings, books, paintings, automobiles, boats, etc.)
Intangible personal property, such as bonds, treasury certiricates, cash on hand and in bank,
stocks, mortgages, notes, together with accrued interest or dividends, salaries or wages, insurance pay-
able to the estate or ~iduciary in said capacity, partnership interests, interest in any undistributed
estate or or income rrom any property held in trust under the will or agreement or another, even though
located outside o~ the State, at the time o~ death, should be listed in this schedule.
SCHEDULE "B"
PERSONAL PROPERTY
.
COMMONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
, RESIDENT DECEDENT
Item
No.
ITEM
List and describe fUlly
UNIT
VALUE
ESTIMATED
MARKET VALUE
DEPARTMENT VALUATION
(Do not write in
this space)
First Bank and Trus't Co'. :'
Checking account 130-773-5 ~
Savings account 800-555~5
Savings account 508-794-5 /'
(a)
(b)
(c)
V
2,562.40 V ~J 6~~. ~()
3,028. 61 ~t:--a. 0 a1. u I
1 , 5 3 3 · 9 4 "'" ~ 5 33. ct 'to
Share of intestate distribution from
the Estate of Marlin S. Wilt,
Cumberland County #21-77-766
348.15 ....V
a~(. \ 6
'l)~~ l\la:U.i'llDl~ ~'-,
p~~~a.\nla., ~L~
~
/00.00
'00.00
nsert this total opposite "Personal Property", Schedule "B" in
he "As Reported" column on the last page o~ this return.
x X ~73.Ib\
'>5'0. \0
~cc - 36-
COMMOXViEALTH OF PENNSYLVANIA
TRANSFER INHEIUTANCE TAX
SCHEDULE "c"
T RAN S FEns
rillS IDEXT DECEDENT
(1) Did decedent, within two years of'death, make any transf'er of' any material part of' his estate, without
receiving a valuable and adequate consideration therefor? (Answer yes or nMO
(2) Did decedent, within two years of' death, transf'er property f'rom himself' to himself' and another or
others (including a spouse) in joint ownership? (Answer yes or no) No
(3) If' the answer to (1) or (2) above is in the af'f'irmative state:
(a) Age of' decedent at time of' transf'er
(b) State of' decedent's heal th at time of' making the transf'er. (Note 1).
(c) Cause of' decedent's death. (Note 1).
(4) Did decedent, in his lif'etime, make any transf'er of' property without receiving a valuable or adequate
consideration theref'or which was to take ef'f'ect in possession or enjoyment at or af'ter his death?
(Answer yes or no) No
(a) Was there any possibility that the property transf'erred might return to transf'erer or his
estate or be subject to his power of' disposition? (Answer yes or no)
(b) What was the transf'eree's age at time of' decedent's death?
(5) Did decedent in his lif'etime make any transf'er without receiving a valuable and adequate consideration
theref'or under which transf'eror expressly or impliedly reserves f'or his lif'e or any period which does
not in f'act end bef'ore his death:
(a) The possession or enj~~ent of' or the right to income f'rom the property transf'erred?
(Answer yes or no) NO
(b) The right to designate the persons who shall possess or enjoy the property transf'erred or
income theref'rom? (Answer yes or no) No
(6) If' the answer to (5) (b) above is in the af'f'irmative, state whether the right was reserved in decedent
alone or others
(7) Did decedent in his lif'etime make a transf'er, the consideration for which was transf'eree's prolnise to
pay income to or for the benef'it of' care of' transf'eror? (Answer yes or no) No
(8) Did decedent, at any time, transf'er property, the benef'icial enjoyment of' which was subject to change,
because of a reserved power to alter, amend, or revoke, or which conld revert to decedent under terms
of' trans f'er or by operation of' law? (Answer yes or no) No
(9) If' the answer to (8) above is in the af'f'irmative, was the power to alter, amend, or revoke the inter-
est of' the benef'iciary reserved in the decedent alone or the decedent and others?
(Answer yes or no)
NOTE 1: The answers to these questions should be supported by aff'idavi t by the attending physician as
well as a copy of' the death certif'icate.
NOTE 2: If' answer to any of' the above questions is yes, set f'orth below a description of' the property
transf'erred, it's f'air market value at date of' death, dates of' transf'ers and to ~hom transf'erred, with
relationship of' transf'erees to decedent, if' any. Submit copy of' any trust deed or instrument, if' trans-
f'ers are claimed to be non-taxable, also submit detailed statement of' f'acts on which said claim is based.
NOTE 3: List applicable property below in manner in which provided in Schedules A, B, or E.
ITEM
DESCRIPTION
MARKET VALUE
(Es tima ted)
DEPT. VALUATION
(Dept. Only)
l\.\ 0 no...
Insert this total opposite "Transf'ers", Schedule "e" in the
"As Reported" column on the last page of' this return.
~onL
. RCC- j7 ()2-63)
.. .
(,O!.Il\tO~WEALTIl OF rEN~SYYLANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "D"
BENEFICIARIES
RELATIONSHIP
BENEFICIARIES AND ADDRESSES (If step-children or
tState full names and addresses of all who illegitimate children
have an interest, vested, cont ingent or other are involved, set
wise in estate) forth this fact.)
Marsha Digilarmo Lynes
40 Ashle DrIve
Dillsburg, PA
Granddtr.
SURVIVED
DECEDENT
STATE YES
OR NO
Yes
DATE
OF
BIRTH
INTEREST OF
BENEFICIARY
IN ESTATE
50%
Saundra Gilbert
303 Brandy Lane
Mechanicsburg, Pa.
Granddtr.
Yes
50%
Deponent further says that all the above-named benericiaries are living at this time except below:
NAME DATE OF DEATH RESIDENCE
-
s.. ~
.s .~.....
E~""
Vi ~ s::
'2 ~ e
.- ~ ='
e~-
_0.0
...., e CJ
~ 0:
~CJ~
'5~"t
CJ =' 0
~eg.
~ ~
SUMMARY
Real Property . . . .. . . . . .. .. . . ...... ... . . .. . . .. . . .. . .. . . .. . . . . . . .. . . (Sch, "A")
Personal Property........ ..... .......... .......................... ................. (Sch. "B")
Transfers . . . . . . . . . . . . . . . .. . .. . . . . . .. ... . . . . . . .. . . . . . . . . . ... . . .. . . . . . . . . . .. . . . . . . . (Sch. "C")
Gross Taxable Estate ...
(1)
(As Reported)
$
$.........
$........................ ........
$..................... .
$................... . ................
$.................... .
(2)
(As Determined)
$
$...
$.
$..
$:... .
$
to-- :'0
Z .~
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~ :~
Q) ~ .~ ~
~ ~ :CJ
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en Q -
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~ 0 ~ A.
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Vl
(-< ~ t-< ~ c Q
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0 0 ~ OJ ~
Z t-< en ~
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------ 0
0 ..c ell:
c ~ .::: 0
0 ~ A.
:p W Cl.; ~
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0 ....
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II
RoC C-38'
RESIDENT DECEDENT
SCHEDULE "E"
JOINTL Y OWNED PROPERTY
'*
COMMONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
INSTRUCTIONS: This schedule must disclose all property, real and personal, owned by the decedent jointly
wi th another or others, including intangibles, standing in the name o:f the decedent and others. List
real estate :first, as entireties, or joint tenants, giving brie:f description, as indicated under Schedule
"A", plus the date and place of record of instrument effecting vestiture, but do not include entireties
or out of state real estate value in estate valuation column. Personal property should be listed as in
Schedule "B", plus date o:f acquisition, and the name, address and relationship (i:f any) o:f co-owners to
the decedent.
Description o:f Property, Date o:f AcquiSition, Name
Address and Relationship o:f Co-Owners, and Place
o:f Record o:f Instrument, where Real Estate.
unit
Value
percentage
Sh are
Estate
Valuation
DEPARTMENT VALUATION
CAUTION-Do not Write
In This Space.
Value o:f Value o:f
Entire Decedent's
Property Interest
Nont...
NONE
Insert this total opposite "Jointly Owned Property", Schedule "E"
in the "As Reported" column on the last page o:f this return.
t\1onL
..
REV-Sle (e-78.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
P.O. BOX 2970
HARRISBURG
17105
IN YOUR REPL Y PLEASE
REFER TO
Inheritance Tax Division
NOTICE OF FILING OF APPRAISEMENT
Harsha Digilamo Lynes
40 Ashley Drive
Dillsbur~. fA 17019
(Executor or Administrator)
In Re: Estate of
Mabel B. n...l
Cumberland
County - File No. 21-78-0437
Dear Ms. Lynes:
You are hereby notified that the origiDa1
appraisement in the estate of Kabel B. n_l
has been fi led in the office of the Register of Wi lis of Cumberland
County on February 28 , 19 79, Said appraisement reflects the following
valuations:
Real Estate
Personal Property
Transfers
Jointly Owned
Total
43.000.00
7.573.10
.ne
IIOne
$50.573.10
As to such tax that is paid within three months from date of death, a five (5%)
percent discount is allowable. As to any tax that remains unpaid after nine (9) months
(fifteen months when death occurred from December 22, 1965 to June 16, 1971, inclusive;
and twelve months when death occurred prior to December 22, 1965) from date of death,
interest at the rate of six (6%) percent per annum is charged.
Any party in interest who is aggrieved by this notice may obiect thereto within
sixty days after receipt of said notice as provided by Section 1001 of the Inheritance and
Estate Tax Act of 1961, 72 P. S. 2485-1001, P. l. ~~. . .
Date February 28. 1979 Signed ~ t:\,JL()~
Title Adainistrative Officer
~
Note: This is not a bi II.
I
REV-457 (8-78) ~
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
P.O. BOX 2970 .
HARRISBURG, PENNA. 17105
COMMONWEALTH OF PENNSYLVANIA
RESIDENT INHERITANCE TAX
APPRAISEM ENT
DATE
February 28, 1979
Cumberland
21-78-0437
COUNTY
FILE NO.
Whereas, Mabel B. Ki_l late of Borough of Mechanicsburg
in the County of Cllllberland Commonwealth of Pennsylvania, having died on
the 1st day of ~U8t 19 ~, seized and possessed of an estate
subject to Inheritance Tax under the laws of the Commonwealth of Pennsylvania;
Therefore, I, Leo Fulginiti ,an appraiser duly appointed according to law,
having been designated to make a fair and conscionable appraisement of the said estate, and to assess and fix the cash
value of all annuities and life estates growing out of said estate, hereby file the following appraisement:
In the event that any future Interest In this estate is transferred In POSsession or enjoyment to collateral heirs of the decedent after the expiration
of any estate for life or for years, the Commonwealth hereby expresSly reserves the right to appraise and assess transfer inheritance taxes at the lawful collateral
rate on any such future interest.
DESCRIPTION OF ASSET UNIT APpraisement
VALUES Made for Inheritance
Tax Purposes
Real Property $ 43.000 00
Personal Property 7,573 10
Joint-Held Property Kone
Transfers lone
TOTAL ASSETS 50,573 10
"
Have been duly sworn accoIgi3P to law, I do hereby certi
with the law on this t . day of
Appraiser
(Number and Street)
Harrisburg
(Post Office)
. Penna.
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