HomeMy WebLinkAbout04-30-79
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APPlICA TION FOR AND CONSENT
TO TRMISFER SECURITIES
REGISTERED IN THE NAME
OF A Rf SIDENT DECEDENT
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':OMMONwe...L THOF PUINlYLV."IA
DEPARTMENT OF REVENUE
',UREAU OF COUN'''' COLLECTIClt~~
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DATEd11cyu.,j 7)___.
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APPLlCA1IOl'! (MUST BE FILb) IN T~IPLlCATE'
TO THE PENNSYLVANIA DEPflRTMENT OF REVENUE:
Applie~t(on II herehy ,nod., for consent to the tronsfer of the following securities of a Pennsylyonir,
Corporatjo~ or 0 Natia.al B~nk;"g Auodation locoted in Pennsylyonia:
(a) /1 t (b).-Grngr~4.~/,c,,_Z{6,<<6_,<:s___._.._._,___(c)>(i;;l1/mo)u
(HOTE: In describing serourit;"s ent\!r in (0), ob ('Ie, eithcr the number of shores of stock or the face amount "I
registered '-'andl, In (1:), tl,e nar,'~ oltl,e issuing co npany and in (e) the closs of stock or the stated interest role
and maturity dot. of rtgilter!d l>>nds,)
(1,4. tS17D;;J,UOO)
,cA ::r;''l",-27(,s&} ',0.7" 0,
ISSUED Ot-I 6th no (0 ",..LJ.J-F-' and having 0 TOTAL MARKET VALUE OF $ '-' :"",,-/ F , J 0
,0 tJ C cd~l1.')"c.z. 0':')
as olth. dotR 0' 8'ecill;>o'1'\<<.fd'-~edenl, ,1u,y"'5 ,A _tkt:'2siZXj7') J , On, 10rlP /1J /9?I
L~__ ..--. ~___... __ _,_, ~_ ___ ________~ ~{H~-~~~oJ.D..:-edontL._ (Dote of death)...
who was I~te afd2_..&$..L(';d Tt" ~ C1mJ2-AL:.I/--- (UvrI. h-e/ /cJA/ Ii?.
(Str..t Qnd "'rJt...b.,) (Po.t OUlce) (County).; (State)
Th. ucurlllu or. r..glst.r.d ac; fallows:_:Jd/l,:J.":.{J",A,_4o:YJSUd.Z<"C/, J/
{Home ()-I 1"om". \n ,which (,.lIrH~ot(l. d'. '''oht.,.d)
ADMEIl-lISTRA TOR),i~7 Ie f~. Le.~_..tt13..l-!r'&:f______k.j6.SjftJ.&,s.-L}tJ<; >/ /1 J t1~('~~f$
EX CUTpRf X. ) (N....) ,;J (AJd,~!,) A /
HAME OF APPL ICANT ,/:;!D'tCJel-.J.eL.L-I:fLl1SI7."1!j,t? ,'_.
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COUNTY ~ILE NUMBERdb-?f::c,;WL ADDRfSS OF APPlICANT_.mC~~.1'I I rSbuv:; .----'
BUREAU filE NUMBER__.___ __.__,_. SIGNA 1 URE OF APPLlC^NT~.il'~ ";.,j cXjC.{:2L',?tLwfP<-r
NOTlC!!: IF YOU FAIL TO PRClPERLY FllllN ANY PORTION OF hilS APPLICATION, IT Wilt NOT BE )
COH1101:""D COMPl F.TE MID WILL BE H1URHEO TO YOU FOR COMPLETION.
COMMONWFAL TH OF PENNSYLVANIA - DEPARTMENT OF REVENUE
CONSEHT TO TRANSFER SECURITIES . ~nJ'
I here~y comnl to-,he t'aos~er.o~~-':~:'e~~::~ri"I~s.now' r~~~':~'~d in the nom~~ITt~~-!~~9??_
Oecedl>nl an,d waive II-. filing 01 a certilicote ccrii'ying 10 ,he payment "I Ihc 'ransfer inheritance tax to which
the praperty of soil! O..ceder:t i, ",ade subject pursHonl 10 the proyi,ions of the Act of June 20, 1919, PJ., 521,
as amended and Ih. Ad of Juo. 15, 1<;'61, P.L, 373. os amended. This is olsa in accardanee with the prayision~
af the Act ,f April 9, 1929, P.L, 343.
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Thil ~anlent to Transf". the hercin descrL,.d prcpcrly oporat.s only in relerenre to the estate althe
abave-named Dee.den"
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Signed for ,hc Secretary of Revenue
a ~ 1 .aJ..2. ~JH\1~J--'-'r
~;';!lo\!.on~'l
REGISTER OF WILLS '
GUMBERLANO GllUIl11t;, _____,_
(lill",) (County)
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