HomeMy WebLinkAbout04-25-79 (2)
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COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
SUPPLEMENTAL
,.
RESIDENT DECEDENT
COUNTY OF
CUMBERIAND
IMPORTANT:
This return must be completed in detail and filed in duplicate, with all attached, with the Register of Wills of the
County where decedent resided; Return is due within nine months after date of death, unless an extension is granted
by the Secretary of Re~enue. (Section 703 of the Inheritance and Estate Tax Act of 1961.)
IN THE MATTER OF THE ESTATE OF
Late of
Cumberland
} AFFIDAVIT OF
EXECUTOR
County ADMINISTRATOR
MAY R. BAER
(STATE FULL NAME OF DECEDENT)
State of pennsy 1 vania
County of Cumber land
} ."
~
Doris J. Morrison and Bettv M. Hosfelt
of the estate of the above-named decedent being duly sworn, depose
Execut~ ices
and say
Decedent died
June 27
(MONTH)
Name and address of attorney or }
other authorized repres.entative to whom
all correspondence should be mailed.
(DAY)
. 19~{testote leaving a last will, copy of which i. hereto attached..}
(YEAR) ~
Sylvia H. Rambo
P. O. Box 261. Carlisle. Pa.
17013
That as such executrices deponent is familiar with the affairs of said estate and the property constituting
(EX ECU TO R-ADMINIST RA TO R)
the assets thereof and their fair market value.
That at the time of death there was no safe deposit box registered in decedent's individual name, or jointly with, or
as agent or deputy of another, or in decedent's individual name, with right of access by another as agent or deputy, with the
exception of the following: _
NAME AND ADDRESS OF BANK OR OTHER INSTITUTION
IN WHICH DECEDENT RENTED A SAFE DEPOSIT BOX
The Farmers National Bank of
Newville. Pa.
THIS SAFE DEPOSIT BOX RENTED
IN NAME OR NAMES OF
RELATIONSHIP OF JOINT
HOLDERS TO DECEDENT
Ma R. Baer
That the contents of said safe deposit box or boxes are itemized under SchedulesA&E of this return,
wi th the exception of the fOllowing, for the reasons hereinafter set forth:
That Schedule A attached hereto and made part hereof sets forth fully and in detai I all the real property
in the Commonwealth of Pennsylvania of which decedent died having an interest therein. It also sets forth the
mortgage encumbrances upon each parcel of real property at the date of death, giving the amount still due at
death, name of mortgagee, date, rate of interest, and book and page of record thereof. It also sets forth in the
columns provided therefore the assessed valuation of each of said parcels, the estimated market value thereof
as of date of death of decedent.
That Schedule B attached hereto and made part hereof sets forth fully and in detail all personal property
wheresover situated owned by the decedent at the time of death; all moneys left by the decedent at the time of
death, whether in decedent's immediate possession, standing to decedent's credit in banks of deposit, savings
banks, trust companies, or other institutions, whether individually, or in trust for any other person or persons
gi vTngalso separately the accrued~-interes tthereon, if any, down to the last interes t day prior to decedent's
death in the case of savings banks, and to the date of decedent's death in all other cases; all bonds, postal
savings, treasury certificates or notes and other evidence of indebtedness of the United States to the de-
cedent; all. obligations , whether by statute .01' agreement they are designated as tax free, of the United States,
or any state, or political subdivision thereof, or of any foreign country, which are owned at the time of death;
all wearing apparel, jewelry, silverware, pictures, books, works of art, household furniture, horses, carriages,
automobiles, boa ts, and any and all other personal chattels of whats oever. kind or nature, left by decedent,
together with the fairly estimated market value thereof; all bonds and mortgages held by decedent and of all
claims due and owing decedent at the time of death, and all promissory notes or other instruments in writing
for the payment of money of which decedent died possessed, of whatsoever nature, with interest thereon, if
any, giving the face value and estimated fair market value thereof, and if such estimated fair market value be
less than the face value, it sets forth briefly the reasons for such depreciation as to each item; all moneys
payable to the estate from life insurance policies carried by decedent; all annuity and endowment contracts
the proceeds of which were payable upon the death of the decedent; all and the corporate stocks and dividends
due thereon and unpaid as of the date of death, bonds and accrued interest thereon to the date of decedent's
death and other investment secur:rics owned by the decedent at the time of death, with the market value there-
of at such time.
. '
In the o-as-e of securities of close or family corporations, the values reported are as far as
possible substantiated by financial statements of the corporations, showing the assets and liabilities
thereofi(isoof the date of death. The schedule also sets forth the interest of decedent at the time of
death in any co-partnership or business, and in support of the value of such interest there is annexed to
said''$~h~'lit'r~~ financial statements showing the assets and liabilities of said co-partnership or 9,usiness.
A cOpy~ot~he co-partnership agreement, (if oral, a statement setting forth the nature of tne agreement)
together, lith a statement setting forth the character of the business, its location, and such other facts
pertahjlng to the business as may be pertinent to a fair and just appraisal of the decedent's interest
therein must be submitted. It should also set forth in itemized form, together with theOfair ma'rket value
thereof, any other property owned or bequeathed by the decedent at the time of death.
The Schedule C attached hereto and made part hereof sets forth a true answer to each inquiry
ccmtained the~in and in the case of transfers of property, real or personal, within two years of decedent's
.... ." j;.'..f '" .,~ ,"~. "" -,...
death, in contemplation of decedent's death, or intended to take effect in possession or enjoyment at or
after death, said schedule sets forth the nature and value of such property, to whom transferred, the
relationship of the transferees to the decedent, the proportionate share received by each transferee and
all other facts of a pertinent nature regarding said transfers. In the case of transfers intended to
take effect in possession or enjoyment at or after death, there is also attached to the schedule a co~y
of the deed, trust agreement or other instrument creating the trust. Ther'~ is also set forth in said
schedule a list of all property, real and personal, with its value, which passes at decedent's death by
virtue of the exercise by decedent, either individually, orjQintly with another, or any power of appoint-
ment vested in decedent, either individually or jointly, by the will, deed, or other instrument of another,
with a copy of the instrument creating such power attached to the schedule.
That' Schedule D attached hereto and made part hereof sets forth the names and addresses of all
persons beneficially interested in this estate at the time of decedent's death, the nature of ,their res-
pective interests, their relationship, if any, to the decedent, together with the ages at the time of
decedent's death of all minors, annuitants and beneficiaries for life under decedent's Will. It also
contains a statement showing which of the beneficiaries named in the decedent's will, if any, died prior
to decedent, the dates of their death, their issue, and the relationship of such issue to the beneficiary.
That Schedule E attached hereto and made a part hereof sets forth all property, real and per-
sonal, owned by the decedent jointly with another or others, including intangible, standing in the name
of the decedent and. others, plus the date andRJ,ace oj' r~cQrd of instruments effeC\~Tlg,.th:.;,es~.i_t.ure of
real estate and the date of acquisition of personalty, plus the name, address and relationship, if any,
of co-owners to the decedent.
That Schedule F attached hereto and made a part hereof sets forth fully and in detail all debts
and deduction~ claimed for and on behalf of this decedent's estate, including funeral expenses paid;
family exemption, where applicable; costs of administration of this estate; counsel fees and fudiciary's
commissions paid or to be paid; cost expended for burial trusts, tombstones or gravemarkers, and reli-
gious services, in consequence of the death of the decedent; debts and claims owing and unpaid at time of
death; taxes accrued chargeable for period prior to decedent's death (except those allowed under Section
651 of the Inheritance and Estate Tax Act); together with a statement of collateral pledged for obliga-
tions, if any. It is agreed that the fiduciary will present proof of said claimed obligations upon re-
quest, that if the amount actually paid in settlement of any fee, commission or debt is less than the
estimated amount claiming and allOWed, that the same will be reported to the Register of Wills, and that
the amount of tax assessed can be reassessed in accordance therewith.
That the totals of the appropriate columns in Schedules "A", "B", "e", "E", and "F" as directed therein,
have been carried forward and properly registered in the Summary.
SUb~ibed and sworn to before me this .................................
\.~~.=.\.\ d~ ... April . .... .........197.9.
.......~~.t.~.....................
\...L\\'I\l'" L [i7:;,S<;<:. !:0TAnV P'.:OLIC
S'YJTH.\~,':: 'i\-~';'! -I (_ \'" ;'_',\-:, ,) FGANKLltJ co"
J/ly S;;CMM1Sc.:Cil LXFiRES AUG, 11>119a1
~i!i 2z; 7.!;1(l~
..../it~~.._.._.
R. D. 3 Newville, Pa. 17241
.......................................f...............................................................................................
(Street NumbeT)
...,........................................................................................................................
(City or Town and State)
NOTE: Berore signing affidavit make sure all blank spaces in the affidavit and schedules annexed are
filled in with details or the word "None", and in case the assets include rare and unlisted securities,
securities of close or ramily corporations or an interest in any co-partnership or business, that the
data and statements required under the paragraph above relating to Schedule "B" are attached. Also make
certain that column #1 in the "Summary" has been properly completed as above-directed.
. .73)'
'M,,;;.~\-\IEAl;-. 11 OF PENNSYLVANIA
t"r'ARTMENT OF REVENUE
aiJ!:;i:AU OF COUNTY COLLECTIONS
TRArlSFER INHERITANCE TAX
IU:SIOE..,T i')ECEDENT
SCHEDULE "Au
REAL PROPERTY
Re(Ji ;,roperty in Pennsylvania, with statement of mortgage encumbrances upan each par~el at dec~l":1' G&.ce.
,:cnf. Property held by the decedent os tenant in common with another or other, should oe'identif:..:,:'
\1$ to quantum of interest and the estimated value should be that of the decedent's interest only. (Prt,;c,e,'i:1
h~!d as loint tenants with right of surviorship or tenancy by' entireties should be reported on Sche~l.Iie ';::,'
d,e real property 10catIJd In the Commonwealth of Pennsylvania should be
'I.lscrlbed by let and block number, Itre.t and .tre.t "limber, together with
Q general des,crlptlon of the property. with 0 reference to the record of the
conveyance by which the decedent took title; If a farm .tate number of a.
cres. aho datement of mortgage encumbrance. upon each parcel at death
of decedent. Taxe., a.....ment.. accru.d Inter..t on mortgage.. etc..ar.
to be lI.ted on Schedule "F" and mu.t not b. d.ducted from thl. .chedul..
(1)
(2) I
ESTIMATED I
MARKET VALUE
I
I
Ct:",,'f<'" ,
VA,,';)
ASSESSED VALUE
FOR YEAR Oil
DECEDENT'S
DEATH
CAUl'(~,;
(Do not ~"r.. "
In th Is . .4<""
Uowe:' MJ. f f:a.1ft '.'ownen1.p, CWllber lan4
County. Pa. - Deed Book C. Vol. 2~.
PS98 441 - 801d 9/25/78
$20,400.00
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'20,400.0U
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- FL.~:~ -;~;-:
COMMONWEALTH OF PENNSYLV.\NIA
T~\NSB~R INHERITANCE TAX
j\j.;SInENT DECEDENT
SClmDIJLl'; H"
PEHSONAL PROPERTY
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INSTRUCTIONS: This Schedule must disclose all tangible and intangible personal property owned individuall,;(
by the decedent, at the time of his death. Property owned by the decedent jointly with another or others
must be listed under Schedule "E". Intangible personal property, titled in the name of the deceden~, but
payable at death to another or others, including but not limited to P.O.D. U. S. Savings Bonds and tenta-
tive trust accounts, must be listed, despite the fact that they are not of the administered esta~e.
Tangible personal property should be listed first (e.g. jewelry, wearing apparel, household
'.flS, and furnishings, books, paintings, automobiles, boats, etc.)
Intll.ngible personll.l property, such as bondS, treasury certU'illll.tes, ell-lSlt em hInd Ana trr IY";I(,
,L:Jeks, Il\()t'tgll.ges, hoh!, together with accrued interest or dividends, salaries or wages, insurance p..;:..
~ble to the estate or fiduciary in said capacity, partnership interests, interest in anyundistrlbut~:
estate of or income from any property held in trust under the will or agreement of another, even thoug~
located outside of the State, at the time of ~eath, should be listed in this schedule.
~~
Item
NO.
ITEM
List and describe fully
UNIT
VALUE
--
ESTIMATED
MAJU(gl' V AIAJE
DEPARTMENT '(l '\J
(Do no t 'A'1:' i tu
this I>pli'~ej
.
.A.
Checkinq Accoun~ - The Farmers Netlonal
Ban~ of N~il1e, Pa. - Account *209 28 9 76
-.
$ 1.942.10
1.701.35
4,081.30
4.47
185.60
53.60
2.20
67.85
834.00 I
I
2
I Cheekinq Aeeount - ~he First National
~.nk of ....111.. Pa.' - Aaeount Ro. 012 76 t
I
I Hou..hold fu~n1.hln9. .old at publla ..1e
"
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~
l\efund - Unit.ed Telephone COltplUly
l(efund - Medicare
"
Refund - Belv.dere Medical ~
I Retund - Ad_ Sle~rlQ coop
Refund - P.. l1'ax
I Refllftd - a-reabyterlan Home
s
6
7
8
9
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lic'.:'- V,
enMMO~W}~ALT" 01. I'ENNSYLVANIt\
rH.A~~FFH nHFlUTANCF 'fAX
SfIIJ,:nULI'; "e"
Tn \NSI'l':IlS
nESlm:~a lWfEllFNT'
(1) Did decedent, within two years of'denth, m/lke /lilY tr'lulst"n' of any material purt of hi9 estate, without
receiving a vltlllahle and adequlltc consiriernt.loll t.herpf'or? (Answer yes or, no) Jla
(2) Did decedent, wi thin two years of death, trunsfer property from himsel f to himself and another 01'
others (inclllding n spouse) in joint ownership? (Answer yes or no) Ito
(a). ,If the answer to (1) or (2) above is in the affirmntive state:
(a) Age of 'decedent at time of transfer
(b) StAte of decertent's henl th at time of making the transfer. (Note 1).
(c) ~ause of decedent's death. (Note 1).
(4) Did decedent, in his lifetime, make any transfer o~ property without receiving a val~able or adequate
consideration therefor which was to take effect in possession or enjoyment at or after his death?
(Answer yes 'or no) No
(a) Was there any possibtlity that the property transferred might return to transferer or his
estate or be subJect to his power of disposition? (Answer yes or no)
(b) What was the transferee's age at time of decedent"s death?
(5) Did decedent in his lifetime make any transfer without receiving a valuable and adequate consideration
therefor nnder which transferor expressly or impliedly reserves for ,his life or any period which does
not in fllct end before his death:
(a) The possession or enjoyment of or the right to inc;ome from the property transferred?
(Answer yes or no) )Ie)
(b) The right to designate the persons who shall possess or enjoy the property transferred or
income therefrom? (Answer yes or no) 110
(6) If the answer to (5) (b) above is in the affirmative, state whether the right was reserved 1n decedent
<tlone Qr others
(7) Did ~ecedent in his lifetime make a transfer, the consideration for which was transferee's promise to
pay income to or for the benefit of care of transferor? (Answer yes or no) Nt')
(8) Did decedent, at any time, transfer property, the beneficial enjoyment'of which was subject to change,
because of a reserved power to al ter, amend, or revoke, or which could revert to decedent nnder ter1ll.~
of transfer or by operation of law? (Answer yes or no) Jqe)
(9) If the answer to (8) above i3 in the affirmative, was the' power to al ter, amend, or revoke the inter-
est of the bereficiary reserved in the decedent alone or the decedent and others?
(Answer yes or no)
NOTE 1: The answers to these' questions should be supported by affidavit by the attemling physician a.s
well as a copy of the death certificate.
NOTE 2: If answer to any of the above questions is yes, set forth below a description of the properLY
transferred, it's fair market value at date of death, dates of transfers and to ..horn trftnsferred, w1th
relationship of transferees to decedent, if any. Submit copy of any trust deed or instrument, if trans-
fers are claimed to be non-taxable, also submit detailed statement of facts on which said claim is b~sed.
NOTE 3: List applicable property below in manner in which provided 1n Schedules A, H, or Eo
ITEM
DESCRIPTION
MARKET VALUE
(Es tima ted)
DEPT. VALl.'ATmN
(Dept. Only)
lion.
N \'-"--
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Rcd-37 (12-63)
COMMONWEALTH OF PENNSYYLANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "D"
BENEFI CIARIES
(
h
BENEFICIARIES AND ADDRESSES RELATIONSHIP SURVIVED
(If step-children or DATE INTEREST OF
State full names and addresses of all who illegitimate children DECEDENT OF BENEFICIARY
aye an interest, vested, contingent or other- are involved, set STATE YES IN ESTATE
wise, in estate) forth this fact.) OR NO BIRT,H
Betty M. Hosfelt
R.D. 3, Newville, Pa. Daughter yes 12/18/28 one-half
Doris J. Morrison
R.D. 3, Newville, Pa. Dauqhter yes 7/31/31 one-half
Deponent fUrther says that all the above-named beneficiaries are living at this time except below:
NAME
DATE OF DEATH
RESIDENCE
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f:! IX:
SUMMARY
Real Property .............. ....... ......... ............................................ (Sch. "A")
Personal Property ............... ........... ........................................ (Sch. "B")
Transfers ................ ............ ................ ... ...... ... .... ........... ........... (Sch. "C")
.. ........... .Joint.ly~held. ..Pr.ope.rty............. (S.ch......E).
Gross Taxable Estate ..
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(1)
(As Reported)
$. ....~'O'.f.4QQ..()Q..
$...... .?f. ~ 7.~. .~47.
$..................... .~. Q.Q..
$.....3.0.,..547...93.
$.................... .................
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(As Determined)
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l~ I SlllFNT DECEDENT
SCHEIllII.I' E"
JOINTLY OWNED patkERTY
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l\I\l\ltl"WI~^l.TII or PENNSYLVANIA
TR:\Nsn'R INIIElUTANCE TAX
-
I:\Sl'lUlCTIONS: Thl!'! !'!chertulc must dl!'!closc all propcrty. renl anrt pcrsonal, ownl!rt ."-'~/:':!.". ~~,:.:~~.,.
"I III IlIltlthrr or others, lncl\lfUn~ intan~ibles, stnnC1h1r. In the namp. or the decf'd(mt I!fHI otn~r"l. I.l'.t
r":ll I'stntl' first.. ns ent1retlcs, or .toint tenants, p;ivln~ hricf rtel'lcrlptlon, IUI tn/Hcat"rt "rlf'(~r l'I~h""III"
!,jus the dllt.e nrHt plnce or r~cord of instrument efff'ct.lng vestltllre, bllt do not. Ind./,I,. "ndret1,,~
,f of' slate r..nl estat.e value in eRtate valUlltion cnlumn. PerRonll1 property Rhould '". . Ist,.O II'! h,
;.' "II", pIllS dllt." of I\C/luisi tion, Ilnd the name, I\d/lress I\nd rell\ttonshl)l (I r any) of CII-O""".... "
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"II'! \tllI lIr Prllpf'rty, Unt.o or AcquisitIon, Nnmo Unl t. port'(mt,ngfJ ~~fltllt."
1,11'I'SS' lUll! l\elnUonshlp of Co-Owners, nnd Place V.alue Share Valuation
..I' HI'l'llrrt of Inst.rllment. where ""1\1 Est.nte.
DI';l'AIl'Ul<:NT VAl.k, '
CAUTION-Do not, " .
In Th18 s ,') II'
Value IJt i Va) I,
Entire ~ Decefk
Property j Intef'
1. SavingR Account - Th. Farm.rs
National B~nk of Nawville, Pat i
1~1457 - j~. w/ B.t~y M. Ilosfelt: ,
'& Doris J. Morrison - dote of I
death balance - $23,429.52 1/3 7,80io14 I
2. CD - AR2754 - The Farmer a .ationa
I 1
Dnnk of N';!\\TVille, Pa. ~ jt. with i
T~ctty l~. H03{alt &. Doris J.
Morri~on - 4/4/74 - $15,000.00 1/3 5,000.
3. Aceru~d interest on CD AR2754 _ $ 3.75 "1/3 281.
4. CD - AR2755 - The P",r..r. National
,'~ank of N'.1wvill~ - jt. with BCltty
:,1. H"H.!al~ " Doris J. Morrison _
4/1 '7.; - $15,000.00
1/3
5.000.<0
,
5. ,Ac:crt..iti int.e&..~ on CD AR27.55 -, 3.75
1/3
281. 5
6. en 4173 - People. lIational Bank of
"'; . ::;.penehurg, Pat - jt. with setty
fol. .~o.f.lt " Dori. J. Morrison _
12/1/74 - $11,150.00
'.
7. AC~1U~d interest on CD 4173 - $388 39
8. CD AR 813 - The Firat National Ball
. or Newvil1. - jt. with Bet.t.y M.
Moaf.lt II Doria J. M~rison _
4/15/74 · $11,950.00
1/3,
1/3
3,679.
128.
-.5'-' v' V<'''''
\5 /:' '(
A..<:,-,/1"
/....1 7
JY'-. 1-" ?
t~ .'
1/3 3,943.
9. Accrued 1fttu..t On CD813.. $143.4
'1/3
47.
\- ~ '~,.----------~ "---, '------.- -'-----,
Savings Account #143516, Cumberland
Valley Savings & Loan, Car1is1e,Pa.
jt. with Betty M. Hosfelt and Doris
J. Morrison.- 1/3/68 - $13,129.88
~.
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1/3
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4',376'r
total oppoe1te 'Joint1, Owned Propert,.,
i - , ,
REV-518 (8-78)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
P.O. BOX 2970
HARRISBURG
17105
IN YOUR REPLY PLEASE
REFER TO
.
Inheritance Tax Division
NOTICE OF FILING OF APPRAISEMENT
Doris J. Morrison Betty M. Bosfelt
R. D. 3 R. D. 3
Newville, PA 11241 Newville, P.A. 17241
(Executor or Adm ini strator)
In Re: Estate of
May R. Baer
Cumberland
County - Fi Ie No.
21-78-0369
Dear
You are hereby notified that the S1.Wplemental
appraisement in the estate of ~ R. Baer
has been filed in the office of the Register of Wills of Cumberland
County on May 9 , 19~, Said appraisement reflects the following
valuations:
Real Estate
Personal Property
Transfers
Jointly Owned
Total
None
None
None
4,376.62
14,376.62
As to such tax that is paid within three months from date of death, a five (5%)
percent discount is allowable. As to any tax that remains unpaid after nine (9) months
(fifteen months when death occurred from December 22,1965 to June 16,1971, inclusive;
and twelve months when death occurred prior to December 22, 1965) from date of death,
interest at the rate of six (6%) percent per annum is charged.
Any party in interest who is aggrieved by this notice may object thereto within
sixty days after receipt of said notice as provided by Section 1001 of the Inheritance and
Estate Tax Act of 1961, 72 P. S. 2485.1001, P. L..373. . ..
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D ~ 9 1979 S' d C'" .' -~ \. '-_k_,....../,~.A/y.._'-j" k.
ate' Igne-'/ (/
Title Administrative Officer
Note: This is not a bi II.
REV-457 (8-78)
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
P.O. BOX 2970
HARRISBURG, PENNA. 17105
COMMONWEALTH OFPENNSYLVANIA I
RESIDENT INHERITANCE TAX
APPRAISEM ENT
SUPPlEMENTAL
DATE
COUNTY
FILE NO.
May 9. 1979
Cumberland
21-78-0369
Whereas, MaY' R. Baer late of Lower Mifflin Township
in the County of l!nmh.,..l Ann Commonwealth of Pennsylvania, having died on
the ;:l7t:h day of June 19 ~, seized and possessed of an estate
subject to Inheritance Tax under the laws of the Commonwealth of Pennsylvania;
Therefore, I, Leo Fulginiti ,an appraiser duly appointed according to law,
having been designated to make a fair and conscionable appraisement of the said estate, and to assess and fix the cash
value of all annuities and life estates growing out of said estate, hereby file the following appraisement:
In the event that any future Interest In this estate Is transferred in possession or enjoyment to collateral heirs of the decedent after the expiration
of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer inheritance taxes at the lawful collateral
rate on any such future interest.
DESCRIPTION OF ASSET UNIT AppraIsement
VALUES Made for Inheritance
Tax Purposes
RAA 1 - $
None
Personal Property None
Transfers None
Joint-Held Property 4,376 62
TOTAL ASSETS $4.376 62
Have been duly sworn according to law, I do hereby c
with the law on this 9tli day of
raisemeI}t ~s made in conformity
--- 19 ..29...
Appraiser
Harrisburg
(Number and Street)
(Post Office)
- , Penna.