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R CC.42 (4-771
COMMONWEALT-H OF PE.NNSYLVANIA
DEPARTMENT OF REVENUE
BANK NO.
DATE FILED
Submit in truplicate within
the death.
NOTICE OF DECEDENT ACCOUNT STATUS
STATUS OF ACCOUNT NO' (JOINT, TRUST, OR INVESTMENT
RETURN COMPL ETED
FORMS TO LOCAL COUNTY
INH ERITANCE TAX OFFICE
NAME
SURVIVING DEPOSITOR (BeneficIary) INFORMATION
RELATIONSHIP
TO DEC ED EN T.
A
S9 ... Market street
Blizabethvi11e, Penna. 17023
BANKIINSTlTUTlON ADDRESS
state capital Saving8 '- LOan AsSOC.
108-114 N. 2nd str~
Harrisburg, pa. 17105
9-22-78
SOCIAL SECURITY NUMBER(SI
Mi1dreCI J. Rissingu
or
sthel M. Daniel
DECEDENTINFORMA
NAME
A
4103 Delbrook ad.
CITY
Mechanic8bw:'9, pa.
DATE OF DEATH
8-14-78
COUNTY
ZIP
BALANCE OF ACCOUNT AT DOD $
INTEREST ACCRUED AND COLLECTIBLE AT DOD $
TOTAL $
BANK AUTliORIZATION
I HEREey CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS A
CORRECT REPRESENTATION OF INFORMATION IN OUR FILES IN ACCORD
WITH SECTION "/42 P I Ii< E TAX ACT OF 1961.
SIGNA J.U REO F FINANel,j'.L INVESTIGATOR
cJ p)L7!.?,C;f.JZA")-u-{< ~<- C/
DATE
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