HomeMy WebLinkAbout07-12-78
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'Wh,;'" 'i ' !' C'J( ; iY CCL'.ECTIONS
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TO "R/,W:,[ ::r; ~l[ClF<n P::S
REGISTERED n,l THE ~! \i~E
OF A RESlijFHT DfC::DEI'l1
f\Pt~=iCFriC~~ (MUST BE FILED IN TRIPLICATE)
TO THE P[=Hi~SYLV ANIA DEPARTMEwr OF REVH1UE:
/\op~icot:o'n is hereby made for ,~G'lSCl1t to :h,~ transfer (,f .he follc,wing S0curili,:e, of '1 P"~H1;,l,,:.lill
.P' ',r'l,')[1 0r () Noticiiol Banking Associ~iion located i"1 Pprn,,;lva:1i(1:
(b) Pa. National Turf Club I Jne.
(c)
'I' 'i:<~C'lii;[lg sccuritic5 enter In (0), ab 01(', '.'jt'lcr the, number ()f ~,fifHC:; of stock or ihe fLlce O'nnu,j r/
';" \'ereU L1i',ds, in (b), the name of the issuing compo;" r.nd in (c) the class ot stocl< or the stated intNc ; ;'1.('
d,l ',rdurilY date of registered bonds.)
IS~I"::C' Ci _J=.2Lc70..___.___, and hovinr a TOTAl. M,t,RKET VA-LUE OF $,_lOtGO_,p_er shar.e (50)
(i)'Jte)
'lS I): Ti~e dOlt;- of deoth of the decedent, _ ._qa~1_~:r:9..wn_ ..__
(Nom" ;.i DerecJent)
(<"':
3-::-14-78
(Dot(' f.\f c'<'(lir'l;
\~hC V~'QS IOf,? ~f
_.l2}_~2.?~~ _~tre~1:-..,_,_gil.E1.E..!l~!~ _ _,__,______
Cumberland
Fa.
1702.1
(SIre.,! and 'Nuinber)
(Po-;! Officc) .
(Cv',,,I!)
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The <,N'ur.ities ore ,(>y;stered as follows:____Q~!:.L~:rg1rJn,_~_Q9,:rj:.nne_A!._J3:r9.1fVIl~_ .. _._
(t.~Ofi'lf.' Or nOn1B'S in '., III ;:,:h -certif;ca1C.s (jre reg; ';..t(-"r(~ d)
.f: D ,I., ; N 1ST R p, TO R)C ()~.~~~_~~ Bro~___.___ 15 I~~_22nd _~t!~~~.L 9_~.E...I~~11.-!__ ~~."-_ .1 '(Oll
FXECUTOR) (Nome) (Addr"5')
NAME OF APPL!CA.NT_G.orinne__A..Brm-rn'__H
CfW'!lY f-t! F tl!J.',\R[:R..A.}"-2M2G_ ADD HESS Of- pPPLlCM1L__;!.57_~_"-3.~~~__~t~eeh gamp E'..11176~~
BUREAU Fl!,E ~JUMBEr~____,___SIGNAnji~E OF M)PUrAN~~ a..~
tW:i,,~F: IF YOU FAIL TO PROPERLY FIl:"L IN ANY PORTION OF lHIS APPLlCAnON, IT \.'JILL t~Cn BE
COI'lSIDERED COMPLETE AND WILL BE RETURNED TO YOU fOR COMPLETio:-l,
. COMMONWEALTH OF PH1NSYLVANlA - DEPARTMENT 01= RF.Vf>WE ~
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! !',C're',y consent to the transfel of the above securities now rf'gisteredin the na~r(; cd the okIPc,j.
D deli Oil,.: waive lilt: Llin~~ of a certificGte cenifyinc: :0 the pnyment of the trl;nsfer li,Leilcnc,:: iux t,) ',( ic
th::- "j;0perty I'Jf ;t;aidDccedent is rnnde subject pursuarit -0 the provisions of thE: AC.f of June 20; 1~119, F'.L. 521
as (ll1,er.ded end the l\ct of June 15, 1961, P.L. 373, os amended. This is also in accord(Ii'CF~ I'{i~h the p,"; sions
of the Act of April 9, 1929, P.L. 343.
"
Th;,'~ Cansent to Transfer the herci1 described p')perty ope:des only if) reference, to t;le estate Jf the
obo'lc''':(Jmcc' Deced~~nt.
*
Si,gned for the Secretary of Revenue
~ l- ?B. - 3 'lb
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(Signoturel_;
RICHARD It AI'ID~
REGISTER OF WIllS
--(TitI~)l,UIVIBERLA
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