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RCC~72 (9~6a)
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
APPLICATION FOR AND CONSENT
TO TRANSFER SECURITIES
REGISTERED IN THE NAME
OF A RESIDENT DECEDENT
APPLICATION (MUST BE FILED IN TRIPLICATE)
TO THE PENNSYLVANIA DEPARTMENT OF REVENUE:
Application is hereby made for consent to the tronsfer of the following securiti~,s of a Pennsylvania
Corporation or a National Banking Association located in Pennsylvania: I
I
(a) 340 shs. (b) CCNB Corporstion (c) common-
(NOTE: In describing securities enter in (a), ab <Ne, either the number of shores of stock br the face amount of
registered bonds, in (b), the name of the issuing company ond in (c) the class of stock or th~ stated interest rote
and moturity date of registered bonds.) :
Cert. No. 002549 - 330 shs. issued 3/26/70 and No. 004571 - 10 shs. issued 7/13/71
ISSUED ON / ,and having 0 TOTAL MARKET VA'LUE OF $ 4,420.00
,
DATE January 25, 1979
(Date)
os of the dote of deoth of the decedent,
Estliei' N. Westhafer
, on
March 23, 1978
'(Date of death)
,
(Name of Decedent)
(Post Office)
Cumberland,
,
(County) I
Penna.
who wos late of
709 Second Street,
New Cumberland,
(Street clnd Number)
(State)
The securities are registered os follows:
Esther N. Westhafer
(Nome or names in which certificdtes are registeted)
Jane L. Reese, 63 Springers Lane, New Cumberland, Penna. ' 17070
ll\li~~~)E.Lon:a1ne Gross, Box 264- R. D. 2, Dillsburg, Penna. 17019
EXECU~ES) (Name) (Add,e,s)
NAME OF APPLICANT Charles H. Stone
310 Bridge Street
COUNTY FilE NUMBER xl-P)J'-t9;;j ADDRESS OF APPLICANT New Cumbl!r1and, Penna. 17070
BUREAU FILE NUMBER SIGNA TURE OF APPLICANT y{'Ov-., ~ I)?z....':"f;::{ ~-
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THIS APkLfCATION, IT WILL NOT BE
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR COMPLETION. \
COMMONWEALTH OF PENNSYLVANIA - DEP ARTMENT OF REVENUE
CONSENT TO TRANSFER SECURITIES
DATE
I hereby consent to the transfer of the obove securities now registered in the name of th
Decedent and woive the filing of a certificate certifying to the payment of the tronsfer inheritance tox to which
~b , ?r
the property of soid 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 accordonce with the provisions
of the Act of April 9, 1929, P.L. 343.
This Consent to Transfer the herein described property operotes only in reference to the estate of the
above-named Decedent.
*~
Signed far the Secretary of Re~enue
,
B
1b~
(Signature)
BltHARO l!. ANOERSlll
r!:r::l::E:~ ~F IN!'!..3
(THI@!MBERlAND CDUNT1:<Co"nty)