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REV-517 (8-78)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF FIELD OPERATIONS
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APPLlCA TION FOR AND CONSEN ~./
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 ~~.;(~.J;~I
(a) 60 sbare- (b) ATLANTIC RICHFIELD COMPANY (c) Commnn
(NOTE: In describing securities enter in (a), ab Ole, either the number of shares of stock or the face amount of
registered b'onds, 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 June 30,1980
(Date)
as of the date of death of the decedent,
, and having a TOTAL MARKET VAILUE OF $ 2.973.75
(Name of Decedent)
, on July 28, 1978
(Date of death)
MARY ELIZABETH HOLMES
who was late of
137 East Park Street,
(Street and Number)
Carlisle
Cumberland
PA
(Post Office)
(County)
(State)
The securities are registered as follows: Marion David Holmes and Mary Elizabeth Holmes,
(Name or names in which certificates are registered) JT TENWIlOS
Marion D. Holmes, 137 East Park Street, Carlisle, PA 17013
(Name) (Address)
NAME OF APPLICANT William F. Martson. Attorney for
Estate of Mary Elizabeth olmes
COUNTY FILE NUMBER 21-78-463 ADDRESS OF APPLICANT ar isl A
ADMINISTRA TOR)
EXECUTOR )
BUREAU FILE NUMBER SIGNA TURE OF APPLICANT
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THIS APPLICATION, IT WIL[ NOT B
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR COMPLETION.
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE
CONSENT TO TRANSFER SECURITIES DATE dd. ~~ /f'rl
I hereby consent to the transfer of the above securities now registered in the name of the aforesaid
Decedent and waive the fi ling 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 operates only in reference to the estate of the
above-named Decedent.
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