HomeMy WebLinkAbout05-08-79
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
APPLICATION FOR AND CONSENT
TO TRANSFER SECUR!TIES
REGISTERED IN THE NAME
OF A RESIDENT DECEDENT
'*
APPLlCA liON (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 Pennsy Ivania
Corporation or a National Banking Association located in Pennsylvania:
DATE ;VI Co.--/ :-~, : l( 7 Lj
r) e,)~ ,
I~
(aLl00---shaFes-_(b) Pem Central ~y ----------__ (c) ~
(NOTE --Tn-describing securities enter in a), ab Ole, either the number of shares of stOCK or t e face amount of
registered bonds, in (b), the name of the issuing compa~y and in (c) the class of stock or the stated interest rate
and maturity date of registered bonds.)
ISSUED ON ----- Ma~ 5 1975
( oter
as of the date of death of the decedent,
__, and having a TOTAL MARKET VAtUE OF $
191.00
Florence M. Rafael
(Nome of Decedent)
, on October I, 197.
(Date of death)
who was lote of_-304-South Pilbert St., Mechani-csh.trg,
(Street and Number) (Post Office)
CAaherland, Pemsylvania
(County) (State)
The securities ore registered as follows: _____-.-F1or~e M. Rafael
(Name or names in which certificates ore registered)
~)
EXECUTOR )
~02 East Keller St. , Mechanicslurg, Pennsylvania
(Address)
NAME OF APPLICANT _._---Ioseph P. Alexa
COUNTY FILE NUMBER~lM~____ ADDRESS OF APPLlCANTAQL~ Keller ~., f.fechanicsl:urg, Pa.
, 'f) I I
BUREAU FILE NUMBER_______SIGNA TURE OF APPLICANT -~~J (--:J-.~. I -. ;cl~ .~. /
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THIS APPLlCATIO~:' WILL NOT BE
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR COMPLElI0N.
.,
Joseph P. Alexa,
(Name)
COMMONWEAL TH OF PENNSYL VANIA - DEPARTMENT OF REVENUE
CONSENT TO TRANSFER SECURITIES
DATE
I hereby consent to the transfer of the above securities now registered in the name of the aforesaid
Decedent and waive the filing of a certificate c.:>rtifying 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, os 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.
-----
Signed for the
By_
Ble~[,",(J, t. .'i.;,,' "')'1
REGISTER or. ,.
Sl!;iii3~Wl::) c. i ~
(County)