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COMMONWEAL TH OF PENNSYL VANIA
DEPARTMENT OF REVENUE
HARRISBURG
RC 1>43 (4-69)
NOTE: TO BE SUBMITTED IN TRIPLICATE
Pennsylvania Department of Revenue
Bureau of County Collections
26 S. 4th Street
Harrisburg, Pennsylvania
Dear Sir:
Pursuant to Section 742, Pennsylvania Inheritance and Estate Tax Act af 1961,
we herewith submit the fallowing report:
NAME OF REPORTING
FINANCIAL INSTITUTION CC1fB Buk. If.A.
ADDRESS 331 Bridge street, 1II'ew Claberlal!l4, PA 11010
ACCOUNT NO. OF JOINT,
TRUST OR INVESTMENT DEPOSIT CbeolWIg AceOllDt 1195-2611-1
NAMES ON ACCOUNT ..._ 0 Shaffer with -..- ". ...........1-
OR INVESTMENT ~I' ~.~U ~ ~&W ..
DECEASED JOINT DEPOSITOR,
TRUSTEE OR INVESTOR Mary O. 8ha1'tel'
ADDRESS
AND COUNTY
51111 WalDut street, ~,PA 11oJi3
County - Calberlal!l4
DATE OF DEATH MInh 26, 1918
SURVIVING DEPOSITOR,
BENEFICIARY OR INVESTOR
no.........
EYe~ G. '!'rea.1el'
ADDRESS
RELATIONSHIP TO DECEDENT t1Dkn0Vll
DATE DEPOSIT OR INVESTMENT t7alaIovn
WAS ESTABLISHED
BALANCE, INCLUDING INTEREST
DUE, AT DATE OF DEATH $ $3.308.08
R. S. step
Signature ,;/
Sept. 29, 1978
.Dep. Opel'. Coor4.
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