HomeMy WebLinkAbout07-17-79
COMMONWEAL TH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
APPLlCA TION FOR AND CONSENT
TO TRANSFER SECURITIES
REGISTERED IN THE NAME
OF A RESIDENT DECEDENT
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RCC~72 19~68)
APPLICATION (MUST BE FILED IN TRIPLICATE)
TO THE PENNSYLVANIA DEPARTMENT OF REVENUE:
Applicatian is hereby made far ccnsent to the tronsfer of the following securities of 0 Pennsylvonia
Corparation or a National Banking Associatian located in Pennsylvania:
(a) Ion (b) 7Jh'Tt'P ,4,c/nII1;fe (c) {)',Yfln'\lJI..... ,
(NOTE: In describing securities enter in (a), ab e, either the number of shares of stock or the face amount of
registered bonds, in (b), the name of the issuing compony and in (c) the class of stock or the stated interest rate
and maturity date of registered bonds.)
DATE\7lt tlh 17
I
19J7
ISSUED ON :;} - / f - ') 7
, and having a TOTAL MARKET V A'LUE OF $ 4' I .8' i' 7, sO
(Oote)
as af the date af death of the decedent,J<lJ'1\""- A 4",m<;, ecJ'<'..'] J("
(Ngme of Decedent)
,on .:Ju"-,, 10 10, 7 1?
(Date of death).
who was late of;:'7 P;>.c:.T(;.,,,,'" 'Dr
(Street and Number)
C~r k\,1I
(Post Office)
{ \.1'l>'\.k, l~d
(County)
Pc"
(State)
The securities are registered os follows:~,.."" A Arro<.. ""~~
. (Name or names in which certificates o~ registered)
("30,,, SV<hh.'PI\c:. ((es5''''''{ l'\i\e('Jl..Anl('~b"i"1
n \ (Address) - I
NAME OF APPLICANT ~w,( ,i" L ~S'Ti2oJ
02/-7 ~ -:3 It)
COUNTY FILE NUMBER n ry~ ( 'r-' ADDRESS OF APPLICANT 0?,?-'es- '<;+<>-r~''''S &cr~CC;1 rea,
BUREAU FILE NUMBER SIGNA TURE OF APPLlCAN.,(S::\ u" '" Lo, ~~
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THIS A~'P1ICATION, IT WILL NOT BE ' J
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR COMPLETION.
ADMINISTRATOR) ~T(\('l'" lee tw'''r-.",-m~
EXECUTORlK ), (Nome)
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE A
CONSENT TO TRANSFER SECURITIES ~ 19
DATE
I hereby consent to the transfer of the above securities now registered in the name of the oior~soid .
/'1?? ,
Decedent and waive the filing of a certificate certifying to the payment of the transfer inheritonce tax to which
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 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.
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R~jM,'!.tt,AIIDER!lla
REriiSTER O~ WIllS
CUMBERlAND COUNtt
(Title) (County)