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COMMOtH'iE.\L TH OF PENNSYLVANIA
DEPARTMENT OF REvENUE
8UREAU Ot= COUNTY COLLECTIONS
APPUCA TION FOR AND CONSENT
TO TRANSFER SECURITIES
REGISTERED IN THE NAME
OF A RESIDENT DECEDENT
'*
APPLlCA TIO"~ (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 Associalion located in Pennsylvania:
DATE l~arch 13, 1979
(aL-20- shares (b) Dl~qllF!snp. T.; ght Comp.a.ny.________ (c) common
(NOTE: in describing securities enter in (0), ab I'JIe, 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 dote of registered bonds.)
ISSUED ON ____,___
_" and having a TOTAL MARKET VA<LUE OF $ 355.00
(Date)
as of the d'JtE: of death of the decedent,
Virginia. Huffman
(Name of Decedent)
,on Aug. 12, 1978
(Date of death)
who was lo'k- of
311 . '" t '<'1;
.... ~. ,I. e A ~.
(Street and Numb.'r)
Carlisle ____CumberlanL
(Post Office) (County)
Pa.
(State)
The securities ore registered as foil lows:
Virginia {3, Huffmjin __
(Nome or names in which certificates ore registered)
ADMINISTRt.. TOR'I
~X~CUTO~ )
218 s. ~est st~ Carlisle, Fa.
(Address)
NAME OF APPLICANT. Dorthy L..___HllffTTlfin r.; F!R] i C'!k i
COUNTY FILE NUMBER 2-<-::"}~ --!L?-Cf- ADDRESS OF APPLICANT _~18 ~-'--~_ :;est
BUREAU FILE NUMBER________SIGNATURE OF APPLICANT )))--;;4
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THIS APPLI~~.filN~T WI
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR COMPLETION.
norothy L. Huffman Cieslicki
(Name)
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE
CONSENT TO TRANSI'.~II.SE(";URITIES DAT~')7
i heil:by consenl 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 properiy of SGid Decedent is made subject pursuant to the provisions of the Act of June 20, 1919, P.L. 521,
as amended 'Jr,d 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 10 Transfer the herein described property operates only in reference to the estate of the
above-named Decedent.
Signed for the Secretary of Revenue
By 0f;~~H:.l1nJ4~~ (j~
OF V'i'U.S
__. _________ ______-.J_~____~________
(Title) (County)