HomeMy WebLinkAbout09-10-84
REV-517 EX+ (3-81)
.
APPLICATION TO
TRANSFER SECURITIES
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
FILE NUMBER:
COUNTY d I - 7'8' -1 /.s~
STATE ~-
NOTE: THIS APPLICATION MUST BE FILED IN TRIPLICATE WITH THE REGISTEfll OF WILLS FOR THE
COUNTY IN WHICH THE DECEDENT RESIDED AT THE TIME OF DEATH.
Name of Decedent: __I .. aadrbol4er DATE 1-10-&4
Date of Death: 1-3"". County: CWlberlaDCl
Address of a.D.M. ... ...,.,111..
Decedent: IIGII
..... .
(CITY, BOROUGH)
17241
(STATE)
(ZIP CODE)
DESCRIPTION OF SECURITIES:
1. Stocks a.
4. b.
(NUMBER OF SHARES)
t'!.l oa
(CLASS OF STOCK)
c.
~~A~~~:~~PANY)
.cw... 10.. ~ 1971
d. 6-416-0
(DATE OF ISSUANCE)
e.
1M. 00
(DATE OF DEATH
TOTAL MARKET VALUE)
2. Bonds a.
b.
c.
(MATURITY DATE)
(FACE AMOUNT)
(INTEREST RATE)
d.
(NAME OF ISSUING COMPANY)
a.
(DATE OF ISSUANCE)
f.
(DATE OF DEATH
TOTAL MARKET VALUE)
The securities are registered as follows:
__I .. lIWIIbo1der . ... L. 8U&'Icbo14le1'
(NAME OR NAMES IN WHICH CERTIFICATES ARE REGISTERED)
Name of Applicant: ..... L. lhIdIbo"r
Address of
Applicant: a.D.N. .. N. ....111e,... 17314
(CITY, BOROUGH)
(STATE)
(ZIP CODE)
~~ 'oI? aA,,(ll f. iJ. 1l1:.J
.(SIGN~
CONSENT TO TRANSFER SECURITIES
I hereby consent to the transfer of the above securities and waive the filing of a certificate certifying to the
payment of the transfer Inheritance Tax.
q -ID-3"'I
(DATE)
'n)~ C-. ~ f)LL-{)Kg,~
(REGISTER OF WILLS) I