HomeMy WebLinkAbout09-11-78
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COMMONWEALTH OF PENNSYLVANIA SEP 11 _.. ".
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
RESIDENT DECEDENT
COUNTY OF
Cumberland
IMPORT ANT,
This return must be completed in detail and filed in duplicate, with' all attached, ~ith the Register o( Wills of the
County where decedent resided; Return is due within nine mont~s arter date of death. .unless an extension is granted'
by the Secretary of Re-..tenue. (Section 703 of the Inheritance and Estate Tax Act of 1961.)
Late of
r.umhprlilnrl
} AFFIDAVIT OF
EXECUTOR.
ADMINISTRATOR
IN THE MATTER OF THE ESTATE OF
Olive B. Myers
(STATE FULL NAME OF DECEDENT)
County
State of
Pennsyl vani a
Cumberland
J ss,
County of
XDlIlOOUUI
Naomi D. Walker
of the estate of the above..nomed decedent being duly sworn, depose S
Executor
and 50.Y S
Decedent died
31,
(DAY]
. 19~{testote leaving a lost will, copy of whi.ch is her.et~. ~ttache,d"}
( YEA R) )(l~l)U(l)@( .
March
(MONTH)
Nome and address of attorney or }
other authorized repres.entotiye to whom
011 correspondence should be moiled.
Jon F. LaFaver, Esquire
317 Third St., New. Cumberland, Pa.
That as such Executrix deponent is familiar with the affairs of said estate and the property constituting
(EXECUTO R-ADMINISTRA TO R)
the assets thereof and their fair market vahle.
That at the time of death there was no safe _deposit box registered in de~~dent' s individual name, or jointly with, or
as ,,:gent or deputy of. anuther, or in decedent's individual name~.with right-of access by-another as agent.orJdeputy, with the
exception of the following: -
NAME AND ADDRESS OF BAN.K. OR OTHER INSTITUTION
IN WHICH DECEDENT RENTE.D A S.....FE DEPOSIT BOX
--Da~nin Depsoit Bank and Trust Com an
--Lemoyne, Pennsylvania
THIS SAFE DEPOSIT. BOX RENTED ..
IN NAME OR NAMES OF
- Naoml
RELATIONSHIP OF JOINT
HOLDERS TO DECEDENT
That the contents of said safe deposit box or boxes are itemized under Schedules B
with the exception. of the following, for the reasons hereinafter set forth:
of this return,
That Scheclule A attached he";to and made part hereof sets forth fully and in detail all the real property
.in the Commonwealth of P~nnsylvania of which decedent died having,an-interest-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 parceis, the,estimate."- market value thereof
as of date of death of decedent.
pI'
That Scheclule 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 possession, standing to decedent's credit in banks of deposit, savings
banks, trust companies, or other institutions, whether individually, or in trust for any other person or persons
giving also separately- the accrued interest thereon, if any, down to the last. int~rest day pri<< to de~edent's
death in the case of savings banks, and to the date of decedent's death in all other cases;.all bonds, postal
savings, treasury certificates or notes and other evidence of indebtedness\ of the United States -to the ~di-
. - ~ > .;A
cedent; all obligations, whether by statute or agreement they are des.ignated as tax free, of the United States,~
or any state, or political subdivisio.n thereof, or of any foreign country, which are owned at th~ time of d;ath; ...
all wearing apparel, jewelry, silverware, pictures, books, works of art, household furniture, ho~'es7carriages, .
automobiles, boats, and any and all other personal chattels of whatsoever, kind or nature, left b.y decedent, ;...
together with the fairly; estimated market value thereof; all bonds and m9rtg~ges held by deced~nt and-of all
claims due and owiI?-g decedent at the time of death, and all promissory notes ot -othe.r'instn~me~ts in w~iting
for the payment of money of which decedent .died posse.ssed, of whatsoever riatu~e, with interest thereon, if
any, giving the face value and estimated fair market value thereof, aili-if -such estim~ted. r~ir'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; al.l annuity ~nd 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 interest thereon to the date of decedent's
death and other investment securities owned by the decedent at the time of death,. with the-market value there-
of at such time.
'"
,.
In the case of securities of close or family corporations, the values reported are as far as
possible substantiated by financial statements of the corporations, showing the assets and liabilities
thereof as of the date of death. The schedule also sets forth the interest of decedent at the time of
death In any co-partnership or business, and in support or the value of such interest there Is annexed to
said schedule, f'inanclal statements showing the assets and liabilities of said co-partnership or 'b,uslness.
A copy of the co-partnership agreement, (if oral, a statement setting forth the nature of tne agreement)
together with a statement setting forth the charact~r of the business, its location, and such other facts
pertaining to the business as may be pertinent to a fair and just appraisal of the decedent's interest
therein must be submitted. It should also set forth in itemized form, together with the fair market value
thereof, any other property owned or bequeathed by the decedent at the time of death.
The Schedule C attached hereto and made part hereof sets forth a true answer to each inquiry
contained therein and in the case of transfers of property, real or personal, within two years of decedent's
death, in contemplation of decedent's death, .or intended to take effect in possession or enjoyment at or
after death, said schedule sets forth the nature and value of such property, to whom transferred, the
relationship of the transferees to the decedent, the proportionate share received by each transferee and
all other facts of a pertinent nature regarding said transfers. In the case of transfers intended to
take effect in possession or enjoyment at or after death, there is also attached to the schedule a co~y
of the deed, trust agreement or other instrument creating the trust. Ther~ is also set forth in said
schedule a list of all property, real and personal, with its value, which passes at decedent's death by
virtue of the exercise by decedent, either individually, or jointly with another, or any power of appoint-
ment vested in decedent, either individually or jointly, by the will, deed, or other instrrnnent of another,
with a copy of the instrument creating such power attached to the schedule.
That Schedule 0 attached hereto and made part hereof sets forth the names and addresses of all
persons beneficially interested in this estate at the time of decedent's death, the nature of their res-
pective interests, their relationship, if any, to the decedent, together with the ages at the time of
decedent's death of all minors, annuitants and beneficiaries for life under decedent's Will. It also
contains a statement showing which of the beneficiaries named in the decedent's will, if any, died prior
to decedent, the dates of their death, their issue, and the relationship of such issue to the beneficiary.
That Schedule E attached hereto and made a part hereof sets forth all property, real and per-
sonal, owned by the decedent jointly with another or others, including intangible, standing in the name
of the decedent and others, plus the date and place of record of instruments effecting the vestiture of
real estate and the date of acquisition of personalty, plus the name, address and relationship, if any,
of co-owners to the deceden t.
That Schedule F attached hereto and made a part hereof sets fbrth fully and in detail all debts
and deductions claimed for and on behalf of this decedent's estate, including funeral expenses paid;
family exemption, where applicable; costs of administration of this estate; counsel fees and fudiciary's
commissions paid or to be paid; cost expended for burial trusts, tombstones or gravemarkers, and reli-
gious services, in consequence of the death of the decedent; debts and claims owing and lmpaid at time of
death; taxes accrued chargeable for period prior to decedent's death (except those allowed under Section
651 of the Inheritance and Estate Tax Act); together with a statement of collateral pledged for obliga-
tions, if any. It is agreed that the fiduciary will present proof of said claimed obligations upon re-
quest, that if the amount actually paid in settlement of any fee, commission or debt is less than the
estimated amount claiming and allowed, that the same will be reported to the Register of Wills, and that
the amount of tax assessed can be reassessed in accordance therewith.
That the totals of the appropriate columns in Schedules "A", "B", "e", "E", and "F" as directed therein,
have been carried forward and properly registered in the Summary.
...Q..~.......~..:.....?J..~~v...__......__
(E:recutor-Adminiatnlto!' )
186.7.. ..~9J.].y.._Qr_ty.~..........m..............._......................_......_.
(StTeet Numb....)
~arnP.~~}l,P.~~l!9..~.1.m..
(City or Tow" and State)
NOTE: Before signing affidavit make sure all blank spaces in the affidavit and schedules annexed are
filled in with details or the word "None", and in case the assets include rare and unlisted securities,
securities of close or family corporations or an interest in any co-partnership or business, that the
data and statements required under the paragraph above relating to Schedule "B" are attached. Also make
certain that column #1 in the "Summary" has been properly completed as above-directed.
.
i',...,~_
.'--~-........~..-....-_..'._,--."-.......
RC C.34 (4-73)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
TRANSFER INHERITANCE TAX
RESIDENT DECEDENr
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 cammon 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 surviarship or tenancy by entireties should be reported an Schedule "E.")
The real property located In th~ Commonwealth of Pennsylvania should be
described by lot and block number, street and street 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 g.
eres; also statement of mortgage encumbrances upon each parcel at death
of decedent. Taxes, assessments, accrued Interest on mortgages, ete.,ore
to be listed on Schedule IlF" and must not' be d_educted from this schedule.
(1)
(2)
(3)
DEPARTMENT
VALUA TION
CAUTION
(Do not write
In this spaCt'l)
ASSESSED VALUE
FOR YEAR OF
DECEDENT'S
DEATN
ESTIMA TED
MARKET VALUE
1. ~l estate situate at 520 Walton Street,
Lemoyne, Pennsylvania SOLD FOR
33,750.00 1-----
!!, If A- 'r Mn ~,
SG 9CJ
~
-;;, l t d)
7
Insert this total opposite "real property", Schedule "A" in the X X X X X
"As Reported" column an the lost page of this return.
33,750.00
.' j' ~ ..
RCC -35
u_ '._...
COMMONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "B".
PERSONAL PROPERTY
'*
INSTRUCTIONS: This Schedule must disclose all tangible and intangible personal property owned individually
by the decedent; at the time of his death. Property owned by the decedent jointly wi th another or others
must be'li8ted under Schedule "E~. Intangible personal property, titled in the name of the decedent, but
payable. at death to another or others, including but not limited to P.D.D. U. S. Savings Bonds and tenta-
tive tr3Bt accounts, muSt be listed, despite the fact that they are not of the administered estate.
.'Tangible personal property should be listed first (e.g. jewelry, wearing apparel, househo~d
goods, and fUrnishings, books, paintings, automobiles, boats, etc.)
Intangible personal property, such as bonds, treasury certificates, cash on hahd and in. bank,
stocks, . mortgages, notes, together with accrued interest or dividends, salaries or wages, insurance pay-
able to the,estate or fiduciary in said capacity, partnership interests, interest in anyundistributed
estate of or income from any. property held in trust under the will or agreement of another, even though
located outside of the State, at the time of death, should be lis~ed in this schedule.
Item
No.
ITEM
List and describe fUlly
UNIT ESTIMATED
VALUE MARKET VALUE
DEPARTMENT VALUATION
(Do not write in
this space)
1. The following Series "E" Bonds in the name of
Olive B. Myers:
5.
6.
7.
8.
9.
10.
11.
1976 Pontiac Catalina two door
Ladies Diamond Ring (see attached appraisal)
.. .......-
Checking Account No. 62 69 849 4 at Dauphin
Deposit Bank and Trust Company
Miscellaneous household furniture and equipment
Cash
Commonwealth of Pennsylvania.- Retirement Check
Settlement of damage claim from U. S. F. & G.
25 Q 2 347 826 428 E July,
25 .Q 2 368886 637 E Oct.,
25 Q 2 395 293 309 E Feb.,
25 Q 2 414 899 049 E May
25 Q 2 438 993 978 E. Sept.
25 Q 2 459 267 578 E gec.
25' Q 2 481 113 143 EVA9r-il
25 Q 2 507 533 284 E ~ly
25 Q 2 527 733 119 E VOct.
25 Q 2 547965.591 E 1b.
25 Q 2 580 294 699 E ay
25 Q2588 020 216 E ,ept.
25 Q 2 618 163 870 E vDec.
1968
1968
1969
1969
1969
1969
1970
1970
1970
1971
1971
1971
1971
31 . 08 ~
30.17 ,.....
30.51~
29.62. /
29.87:/,
29..15 /
29.15
28.43/
28.43 ....
27.67"
27.67./
26.93 ~
.2'6;21"
374.89
3,650.00
865.00
~ \oS,o 0
2.
3.
4.
1977 Income Tax Refund
1,962.40
362.00
96.00
28.00
356.63
880.86
\., ct.lo2 .<..[0
'3<:02.00
q. 6 ,00
'7-- '0. 00
3S6.fo3
g\30 ,<2>G
Account .No. 121158 at Pa. State Employees
Credit Union
2,542.33
7-, 'Sl.P... .33
Uo '\ S3 to :2.,"(
Savings
Savings
/'
Account No .1958 at West Shore
and Loan Association
16,536.29
Insert this total opposite "Personal Property", Schedule "B" in
the "As Reported" colwnn on the last page of this return.
x X
27,654.40
~ I) b'S'-t.40
-
.' ,0.
RCC - 36
COMMONWEALTH OF PENNSYLVANIA
TRANS<~R INHERITANCE TAX
SCHEDULE "c"
TRANSFEIlS
~.
~'\
~[DENT DECEDENT
(1) Did decedent, within two years ofdeuth, make any transfer of any material part of his estate, without
receiving a valuable and adequate consideration therefor? (Answer yes or no)
(2) Did decedent, within two years of death, transfer property from himself to himself and another or
others (including a spouse) in joint ownership? (Answer yes or no)
(3) If the answer to (1) or (2) above Is in the af'flrmative state:
(a) Age of decedent at time of transfer
(b) State of decedent's health at time of making the transf'er. (Note I).
(0) Cause of decedent' 5 death. (Note 1).
(4) Did decedent, in his lif'etlme, make any transfer of property without recelvlng"a;valuable or adequate
consideration therefor which was to take effect in possession or enjoyment at or after his death?
(Answer yes or no)__
(a) Was there any possibility that the property transferred might return to transferer or his
estate or be subject to his power of disposition? (Answer yes or no)
(b) What was the transferee's age at time of decedent's death?
(5) Did decedent in his lifetime make any transfer without receiving a valuable and adequate consideration
therefor under which transferor expressly or impliedly reserves for his life or any period which does
not in fact end before his death:
(a) The possession or enjoyment of or the right to income from th~ property transferred?
(Answer yes or no)
(b) The right to designate the persons who shall possess or enjoy the property transferred or
income therefrom? (Answer yes or no)
(6) If the answer to (5) (b) above is in the affirmative, state whether the right was reserved in decedent
alone or others
(7) Did decedent in his lifetime make a transfer, the consideration for which was transferee's promise to
pay income to or for the benefit of care of transferor? (Answer yes or no)
(8) Did decedent, at any time, transfer property, the beneficial enjoyment of which was subject to change,
because of a reserved power to al ter, amend, or revoke, or which could revert to decedent under terms
of transfer or by operation of law? (Answer yes or no)
(9) If the anSwer to (8) above is in the affir~ative, was the power to alter, amend, or revoke the inter-
est of the beneficiary 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 affidavit by the attending physician as
well as a copy of the death certificate.
NOTE 2: If answer to any of the above questions is yes, set forth below a description of the property
transferred, itts fair market value at date of death, dates of transfers and to whom transferred, with
relationship of transferees to decedent, if any. Submit copy of any trust deed or instrument, if trans-
fers are claimed to be non-taxable, also submit detailed statement of facts 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)
None
00.00
N 15"'--"-
.
Insert this total opposite "TranSfers", Schedule "e" in the
"As Reported" colunm on the last page of' this return.
00.00
.' .
RCC-3? (12-63)
COMMONWEALTH OF PENNSYYLANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "0"
.
BENEFICIARIES
BENEFICIARIES AND ADDRESSES RELATIONSHIP SURVIVED
(If step-children or DATE INTEREST OF
(State full names and addresses of~all who illegitimate children DECEDENT OF BENEFICIARY
have an interest, vested. contingent or other are involved, set STATE YES IN ESTATE
wise, in estate) forth this fact.) OR NO BIRTH
Charlotte D. Darr predeceased
D1ive B. Mvers leaving to survive ~
her the fol10wina 2 children who ar e
her sole heirs at law:
Naomi D. Walker. 1867 Holly Dr.
Camp Hill Pa. 17011 ni ece . yes adul t 1/4 of Residue
o,,+h E Neidia. 1176 Shoreham Rd. .
C,mn ~H11 Pa. 17011 niece yes adult 1/4 of Resi due
l:"~""''''. n;,.~ '~~"d 01 ive B.
10',,;nn tn survive her the
fol10wina 3 children who are her
on10 h,,;...o ~t l~w:
Maraaret Ruth Pace. R. D. # 1 I
Marvs vi 11 e Pa. niece yes adult lID Or KeS10ue
Fr..nces T Humme 1 "nn Frnnt St
Marysvi11e. Pa. niece yes adult 1/6 of Resi due
Charles William Dick 411 Cassel S, .
Marvsvi11e Pa. neohew yes adult 1/6 of Residue
-
,
,
,
Deponent further says that all the above-named beneficiaries are living at this time except below:
NAME
DATE OF DEATH
RESIDENCE
...
o .
- ",-
".0;"
b. c
.:g... s
._... ::s
S"-
'O"S,o
S ...
~ 0:
......'0
,S_CI.I
"..1::
... " 0
~ e e
~ II:
SUMMARY
. ....(Sch. "A")
.. .... .......(SCh. "B")
.......(SCh...C..)
Real Property
Personal Property
Transfers
Gross Taxable Estate
(1 )
(As Reported)
$ . 33.750.00
$.2.7,654.4Q
$. 00.00
$ ...
$ ...
$ .61,404.40
(2)
(As Determined)
$
$
$
$
$.
$
l-
Z ~
to f:<l
- " ..l
" "
>0 .0< i: ~
f:<l '"
en Cl -
- ~
-<
l:G '" Ill:
"" t.- '" lIo
"" 0 "Cl '" lIo
~ -< ~ !oJ c ..2: ~
'" ltl :..
f:<l .... l- 0:: .. Q
~ S
0 =:; :: .. "'- ...... s... ~
0 l- >-' Gl Gl "
Z l- en %:. c ~ ""
t.. f:<l ~ ~ l-
~ 0 . 0
co U ..c Ill:
c l:G Gl .;; i:
0 ..... -l
:e f:<l ~ 0; ""
.. ~ ~ ;-
b 0 0 , Ill:
.. c
'" ::: ~ ,j::. 0
0 E
's ,." ~ :: E
'=="'0 j " 0
::~ u u
a.' ..
RCC-~i8
RESIDENT DECEDENT
SCHEDULE "E"
JOINTLY OWNED PROPERTY
COMMONWEAL TH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
INSTRUCTIONS: This schedule must disclose all property, real and personnl, owned by the decedent jointly
With another Of' others, including intangibles, standing in the name of the decedent a~d others. List
real es tate fi rs t, as en ti re ties, or j oint tenants, giving brief description, as indica ted lmeter Schedule
"A", plus the date and place of record of instrument ef'fecting 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 of acquisi tion, and the name, address and relationship (if any) of co-owners to
the decedent.
Deseription of Property, Date of Acquisi tlqn, N ame unit percentage Estate DEPARTMENT VALUATION
Address and Relationship of Co-O....ners, and PI ace Value Share Valuation CAUTION-Do not Write
of Record. of Instrwnent, where Real Estate. In This Space.
~:>o :>OJ< "^ ><5OS:&::X> yy ex y Value of Value of
"^ "^ ex Decedent' 5
"x ex ex )< :x> I!.."'ntire
> "x ex :x> 0< "x X> Property Interest
None
00.00
Nil"'---'--
.
Insert this total opposite "Jointly Owned Property", Schedule "E"
in the "As Reported" column on the last page of this return.
00.00
~, ~
'.
REv..~ta (8"78)
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
P.O. BOX 2970
HARRISBURG
17105
IN YOUR REPLY PLEASE
REFER TO
Inheritance Tax Division
NOTICE OF FILING OF APPRAISEMENT
Naomi D. Walker
1867 Holly Drive
Camp Hill, P~nn~.
(Executo,r or Administrator)
In Re: Estate of
Oll ve B. MYPT"
Cumberland
County - File No.
21:"78-0185
Dear
Y au are hereby notified that the Original
appraisement in the estate af Olive B. Myers
has been filed in th~ office of the ReJlJster of ~ills of, Cumberland , .
County on 11 29, , 19~, Said appraisement reflects the followIng
valuations:
Real Estate
Personal Property
Transfers
Jointly Owned
Total
33,750.00
27,654.40 '
None
None
61,404.40
As ta 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 aggri~ved by this notice may object 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. 373.
Date 11:"29-78 Signed ~ _ J<. ..J.IA-_
Title
01561' Appraiser
?l--
--
Note: This is not a bill.
Rcd2 tZ-64)'.
..
DATE \ \ - --z.. <1. -Z '3
COUNTY('~,",-" 0 . _0
FILE NO. "2 l-t '3 ~ 0 I '2l <;
DE.PARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
HARRISBURG, PENNA, 17127
COMMONWEALTH OF PENNSYLVANIA
RESIDENT INHERITANCE TAX
APPRAISEMENT
Whereas, O.~ p, ~.~ Jateof \ _~.
in the County of ~1 ~ ~ ~ Commonwealth of Pennsylvania, having died on
the ?., l day of _(\r\. (~.1l-.- 19:JJa, seized and possessed of an estate
,
subject to Inheritance Tax under the laws of the Commonwealth of Pennsylvania;
Therefore, I, \ '\....p~ ('") 0 Q. . - , 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 lix
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 de.cedent after
the expiration ot 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 0' Auot
Unit
Valuol
Appral$emenl
Made for Inheritance
Till Purpole$
Roo '\?/'\~.,-, _---h.
P.Q~ -pr:::.
\/\ A ~ ^
<\.~ - ft 1\'::: u... 0 ~ 'f n
'-J
-
'-'
.4-
'--.J
$3-" 1<;0 00
'"2....( ioS4 4.0
N~
N(l)-L
~
~
'-.J
~ \ (-r: r.J n.A ~ ^
l.l 40Ll lj ()
',""
. .
.
Having been duly sworn according to Jaw, I do hereby certify that the above appraisement is made in con-
formity with law on this '"2- q day of. N ~. ~~ 1ltl.'!L.
Appraiser
~~ and Strtet)
l......~
, Penna.
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