HomeMy WebLinkAbout06-16-78
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COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
APPLICATION FOR AND CONSENT
TO TRANSFER SECURITIES
REGISTERED IN THE NAME
OF A RESIDENT DECEDENT
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DATE May 16,1979
APPLICATION (MUST BE FILED IN TRIPLICATE)
TO THE PENNSYLVANIA DEPARTMENT OF REVENUE:
Application is hereby made far cCllsent to the transfer of the fallowing securities of a Pennsylvanio
Corporation or a National Banking Associalion located in Pennsylvania:
(a) Three (b) Madison Fund, Inc. (was Pennroad Corp.) (c) Common
(NOTE: In describing securities enter in (a), ab Ole, either the number of shares of stock or the face amount of
registered 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.) "
3/30/79 to replace stock cert. for Penn road Corp. for 3 shares
ISSUED ON /dated7/20/39 ,o~d having a TOTAL MARKET VAtUE OF S 37.87
(Dote)
as of the date of death of the decedent,
Harry O. Fiery
(Neme of Decedent)
,on 3/17/78
(Dote of death)
who was late of
Bethany Villaqe,
(Street and Number)
(State)
Mechanicsburq,
(Post Office)
Cumberland,
(County)
PA
The securities are registered as fallows:
Harry O. Fiery
(Nome or names in which certificates ore registered)
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EXECUTOR )
Richard W. Cleckner, 31 N. Second St.. Barr isburg, PA 1 'V1 01
(Address)
Richard W. Cleckner
31 N. Second Street
ADDRESS OF APPLICANT Harrisburg, PA 17101
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BUREAU FILE NUMBER SIGNATURE OF APPLICANT V";P'?.--r/ ,{ L.Ce&~
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THIS APPLICATION, IT WILL NOT BE
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR COMPLETION.
(Nome)
NAME OF APPLICANT
COUNTY FILE NUMBER 21-78-172
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE
. CONSENT TO TRANSFER SECURITIES
DATE May 16.1979
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 amended 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 fo
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By \i
, ectetary of cveL~
(Signature)
R""W,r.n t- .v:rH?tl'
(Title) ;'L~'-'I~n(Cou~t 'I
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