HomeMy WebLinkAbout04-02-79
COMwOt,WlAL TH Of' PENNSYLVANIA
CEPA,'TMENT OF REVENUE
BUIH"U u.: COUNTY COLLECTIONS
APPLICATION FOR AND CONSENT
TO TRANSFER SECURITIES
REGISTERED IN THE NAME
OF A RESIDENT DECEDENT
'*
APPLICATION (MUST BE FILED IN TRIPLICATE)
TO THE PENNSYLVANIA DEPARTMENT OF REVENUE:
Application is hereby made for consent to the transfer of the following securities of a Pennsylvania
Corporation or a National Banking Association located in Pennsylvania:
DATE
April 2. 1979
(a) 171 8bares(b) Fanaers Trust Caapany (c) C~n Capi~al
(NOTE: In describing securities enter in (a), ab Ole, either the number of shares of stock or the face amount of
registered bonds, in (b), the name of the issuing company and in (c) the class of stock or the stated interest rate
and maturity date of registered bonds.)
ISSUED ON March 12, 1974 , and having a TOTAL MARKET VAtUE OF $ 5.557.50
(Date)
as of the date of death of the decedent, Leroy H. Bric1r.n.r
(Name of Decedent)
,0nAuaust 1, 1978
(Date of death)
who was late of
215 York Iload
Carlisle
(Street and Number)
(Post Office)
Cu.berland
(County)
Pa.
(State)
\, t.. 4 .. . OJ ., , ~' .
The securities are registered as follows: Ler~ H. Brickner
Paul L. Brickner, 780(Ni.ona.amcUp W~d;tjfc~rYi.'i~s:erv~. 17013
) Donald L. Brickner, I.. D. I, BOll: 314, Carlh1., Pa. 17013
EXECUTOR S ) (Name) (Address)
NAME OF APPLICANT Wi1lia. F. MIIrtaon, P.C.
COUNTY FILE NUMBER 21-18-423 ADDRESS OF APPLICANT 10 Ila.. H1~
BUREAU FILE NUMBER SIGNATURE OF APPLlCAN~~ Wrfr:/;-u.....
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THIS APPLICATION, IT WILL NOT BE
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR COMPLETION.
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE
CONSENT TO TRANSFER SECURITIES ~
DATE 'I-
I hereby consent to the transfer of the above securities now registered in the name of the af esaid
(~t)r
Decedent and waive the filing of a certificate certifying to the payment of the transfer inheritance tax to which
the property of said 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 operotes only in reference to the estate of the
above.named Decedent.
Signed for the Secretary of Revenue
(County)