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RCC'72 19~68.'
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COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
APPLlCA TlON 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 far consent to the transfer of the fallowing securities of a Pennsylvania
Corporation or a National Banking Associalion located in Pennsylvania:
DATE ()(''"""",.. ?" J97E
.
(a) 4 .-.,h",..",,, (b) ~"'," P"nnr.y' ""n;" ):1,,; 1 ,.."'"" r",of'''n~' (c) ~"P; t-", "t-",+
(NOTE: In describing securities enter in (a), ab we, either the number of shares of stack or the face amount of
registered bands, 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 bands.)
ISSUED ON?\,u<j'ust; :2 (j, 194 (j, and having a TOTAL MARKET V AWE OF $
(Date)
as of the date of death of the decedent, Stella M. Grubb
(Name of Decedent)
3Q OC
who was late of R n I, C'''rli 'i' Ie. "urnh" rl and rO"" ty .
(Street and Number) (Post Office)
, an 1\1l<J;,,~t] 4. ] 976
(Date of death)
The securities are registered as follows: St-""" Mr.,..",;,
(Name or names in which certificates are registered)
TJe'1tlji;;~/ 1 uani a
(County)
(State)
~xR~jf~)
EXECUTOR )
Hao F.!..."92ta ::;:ling-gr. ?.ahA. pnny Rn~r1. H.:.rr;.;:hnrg. ppnn~ylV"~n;::l
(Name) (Address)
NAME OF APPLICANT ~lac .".lvcsta KliR"Icr
COUNTY FILE NUMBER ?1-7R-?1C; ADDRESS OF APPLICANT ?;!h;! R"riy ):1""0, """'''';'''h'''''g, PA
BUREAU FILE NUMBER SIGNATURE OF APPLICANT 77ltJ, [/Lu_edc-J A{};/'}~a/
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.
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE
CONSENT TO TRANSFER SECURITIES &. ~.. .
DATE .,' (d7.ICl?:r
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,
of the Act of April 9, 1929, P.L. 343.
as amended and the Act of June 15,1961, P.L. 373, as amended. This is also in accordance with the provisions
above-named Decedent.
This Consent to Transfer the herein described property operates only in reference to the estate of the
,~~
~
Signed for the Secretary of Revenue
(Signature) ,
m;!~"',i\,?~~. ',rm~~lt
r:t"JJt:~ OF VnLL;,
(Ti'tte')",.cJi;\.J Vu".l.ill (County)
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