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COMMONWEAL TH OF PENNSYL VANIA
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIOtolS
REV-487 FO+ (8-7B)
ENTRY INTO SAFE DEPOSIT BOX
TO REMOVE A WILL OR CEMETERY DEED
April 2,.lQ86
(Date af Entry)
J. Nome of decedent:
Rob",.t M. Mllmma
2. j'ddress of decedent: Pennsboro Manor, WOl'm'" ,r"""Y'g _ p" '7043
3. Dote of death:
April 12,1986
4. Nome and address of person who requested the opening of the box:
Box #58, Bowmansda1e, Pa. 17008
Robert M. Mumma II
5. Nome and address of the financial institution where the safe deposit box is located:
Deposit Bank & Trust Co.
213 Market St.,Harrisburg, Pa. 17101
Dauj>hiIi
6. Number of Box:
3332
7. Title under which box is registered:
Robert M.Mumma or Robert M.Mumma II
8. Was there 0 will in the box? (Yes or No)
NO
9. If yes, state dote of will, nome and address of personal representative, if named in the will, and
nome and address of attorney, if any:
NONE
No Contents removed.
And now this 23 day of April ,19 R6 , I hereby
certify under penalty of perjury that the above record is correct and complete to the best of my knowledge
and belief.
( /;; ~~, ~ i1_d~~-HLH-<.i <!J(
SIGN -
Donald E.Cromwe11--Vice Pres.&Mgr.
PRINT NAME AND TITLE
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