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HomeMy WebLinkAbout09-12-78 ~ RCC-42 t....77) COMMONWEALTH Of PENNSYLYANIA OEPARTMENT OF REYENUE r,~[ ...:' f"', "'1'\....'" .,",\ '=-- - ' _ :;.: i.:: BANK NO. ~r-~ 3-(l7 h-7 DATE FILED NOTICE OF DECEDENT ACCOUNT STATUS 7/12f(8 Submit in t.up the death. STATUS OF AI~:T NO: WOINT, TRUST, OR INVESTMENT Her01'''! 1)(".:, SOCIAL SECURITY NUMBE~S' 1!'1..1'l-7(13) RETURN COMPLETED FORMS TO LOCAL COUNTY INHERITANCE TAX OFFICE NAMES ON ACCOUNT ~'~nrrr,,;r.ct 3'1.ver NAME SURVIVING DEPOSITOR (Beneficiary) INFORMATION RELATIONSHIP TO DECEDENT. DECEDENT IN FORMA N DATE OF DEATH NAME ADDRESS !'.argaI'f!t SuVaI' ADDRESS ].~~ ? K p11 .(',y> fjt. 2/2Rf(8 ~ceh an1csbul'g ou.!'l TY 1 umoe ZIP CODE 17055 CITY BAN~INSTlTUTION ADDRESS "Ella :P':I.!'Bt Bank & Trtl!lt Co. "llin /I. MS1'ket <:ts. Meeh'lflteBl""'r:,"~ 17055 (C-fl/{.7 , r"1 I -; 'f. ... I'l/ ,,/. t! BA~ANCE OF ACCOUNT AT 000 $ INTEREST ACCRUED AND COLLECTIBLE AT 000 $ ToTAL $ "'. BANK AUTHORIZA TION I HEREBY CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS A CORRECT REPRESENTATION OF INFOR~ATtON IN OUR FILES IN ACCORD WITH SECTION 742 PIe. E TAX ACT OF ,a61. '~IIDnp!^!pu! ~u.pe:>ep .~ ~q PI.~ .~uno~>y (E OO'OOE$ '.pun UUDIDq D ~~!^' '~UnO>>D ~U!Dr ~ "~UnO>>D .H^' pUD puoq.nH (1 :UO p.A!nb... S! J,loda.. oN ".!j.lDd p'!~~ pUD .H^' pUD pUDq.n~ ~q PI.~ .~uno>>y (S '~~'''l O. pUD 's.JUnO:):>>D ...DIIS 'Hsodep fO '8,.0:)!11-I.18:>> SD 1t:>>"S 's.JUnO:):JD .JUaWI'8AU! JU!Or (Jr' .~uno>>y ~'"'.1 (E .~uno>>y 6u!~>.~:> ~U!Or (z Sluno:):).." S6U!ADS JU!Or Cl :uo p...!nba.l 5! ....od... y '(p.ppD '!'D~dW3) .,'(OOE$) S..I DHOP p."PUR'I "."Ii" pa8:Jxe IOU 'eap Llloap fO aW!4 8'14 "0 I!sodap elf'" U.lIMo .a.uno:):)o It:>>"S oJ pJD6liU U! paJ!nbcu aq IID'I' UO!",03!J!JOU ON ....unO:J:JD 8q1- 0'" SJDA!AlRS .10 JDA!AlRS 81f1- fO SS8JppO pUD awou 8'1'" pUD uOH."'I-!.Jsu! ID!:)UDU!j elf'" 'ill^" q.Joap fO G,Jop elf'" "'0 Hsodap UO.lO paIS.AU! lunOWD altl 'luawIS8AU! 10 Hsodep ISft..... .10 IU!ol 8'1'" fO uOHoa.l:J aap fa alop alf'" 'uos.aad pasDa::>>ap 81f1o fO .wau alf'" 6u!^!6 fGa"8'1'" .nU8^.~ JO ~U8Wj.lDdaa .~~ ~HOU ~ ~~D.p .~ JO .6p.l^'ou~ "8oijD s.(op (OL) v.... U!'1"'!'" UO,.JnIHSU! ID!:JUDU!j 8qJ fO -<Jnp 8'14 eq 110'11 I! 'a!p 110'15 IU8uq.S8AU! .10 Hsodap all'" 0", s&'....od .It... fO auo pUD SJalflo"o ..alt",OUD "Of ...sn..... U! Suos.lad.lo uos.lad DID .WDU ...... U! ..0 8f!M pUD puoqsn"t UD'fI .I81t...0 SUOS.l8CI a.lOW olD 0"'" fO saWDU a'fl U! D!UDAI,(suuad U! pa"'D~1 uOHn...!ISU! ID!:lIUDUH D U! pa...saAU! .10 pa.J!sodap S! ,(auow ualtM.. '1961:10 .1:>y X\f.L 3.1Y.1S3 aNY 3:>K\f.LllI"3HNI 3H.1 :10 Zlrl NOI.1:>3S