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RCC..S;.t'4-73)'
. .
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
*
RESIDENT DECEDENT
COUNTY OF CUMBERLAND
IMPORTANT,
This return must be completed in detail and filed in duplicate, with all attached. with the Register of Wills of the
County where decedent resided; Return is due within nine months after date of death, unless an extension is granted
by the Secretary of Re'ienue. (Section 703 of the Inheritance and Estate Tax Act of 1961,)
Late of
Cumberland
} AFFIDAVIT OF
EXECUTOR
~
County
IN THE MATTER OF THE ESTATE OF
A. Ethel Heberlig
(STATE FULL NAME OF DECEDENT)
State of
PennsYlvania
} ."'
County of
Cumberland
~~n:!t'RlC
Adam R. Heberlig:
of the estate of the above-named decedent being duly sworn, dep0511l
Executor
and soy
Decedent died
October
30
. 19~{te5tote leaving 0 last will, copy of which is hereto attached. }
( YEA R) NiJiXIiIiX
(MONTH)
Name and address of ottorney or }
other outhorized representative to whom
011 correspondence should be moiled.
(DAY)
Robert J. Yocum. Attorney
116 East King Street. Shippensbur~. Pennsylvania 17257
That as such Executor deponent is familiar with the affairs of said estate and the property constituting
( EXECUTOR-~!iXn~
the assets thereof and their fair market value.
That at the time of death there was no safe deposit box registered in decedent's individual name, or jointly with, or
as agent or deputy of another, or in decedent's individual name, with right of access by another as agent or deputy, with the
exception of the following: -
NAME AND ADDRESS OF BANK OR OTHER INSTITUTION THIS SAFE DEPOSIT BOX RENTED RELATIONSHIP OF JOINT
IN WHICH DECEDENT RENTED A S.~FE DEPOSIT BOX IN NAME OR NAMES OF HOLDERS TO DECEDENT
The First National Bank of Shinnensbura Mrs. A. Ethel Heberlil! .
One West King: Street ~r1~m D onn
Shippensburg. Pennsy'..~n'~ , 7')",7
That the contents of said safe deposit box or boxes are itemized under SchedulesB .E
with the exception-of the following, for the reasons hereinafter set forth:
of this return,
That Schedule A attached hereto and made part hereof sets forth fully and in detail all the real property
in the Commonwealth of Pennsylvania of which decedent died having an interest therein. It also sets forth the
mortgage encumbrances upon each parcel of real property at the date of death, giving the amount still due at
death, name of mortgagee, date, rate of interest, and book and page of record thereof. It also sets forth in the
colullUls provided therefore the assessed valuation of each of said parcels, the estimated market value thereof
as of date of death of decedent.
That Schedule B attached hereto and made part hereof sets forth fully and in detail all personal property
wheresover situated owned by the decedent at the time of death; all moneys left by the decedent at the time of
death, whether in decedent's immediate possession, standing to decedent's credit in banks of deposit, savings
banks, trust companies, or other institutions, whether individually, or in trust for any other person or persons
giving also separately the accrued interest thereon, if any, down to the last interest day priOT to decedent's
death in the case of savings banks, and to the date of decedent's death in all other cases; all bonds, postal
savings, treasury certificates or notes ''and other evidence of indebtedness of the United States to the de.
cedent; all obligations, whether by statute or agreement they are designated as tax free, of the United States,
or any state, or political subdivision thereof, or of any foreign country, which are owned at the time of death;
all wearing apparel, jewelry, silverware, pictures, books, works of art, household furniture, horses, carriages,
automobiles, boats, and any and all other personal chattels of whatsoever, kind or nature, left by decedent,
together with the fairly: estimated market value thereof; all bonds and mortgages held by decedent and of all
claims due and owing decedent at the time of death, and all promissory notes or other'instruments in writing
for the payment of money of which decedent died possessed, of whatsoever nature, with interest thereon, if
any, giving the face value and estimated fair market value thereof, and if such estimated fair,market value be
less than the face value, it sets forth briefly the reasons for such depreciation as to each item; all moneys
payable to the estate from life insurance policies carried by decedent; aU annuity and endowment contracts
the proceeds of which were payable upon the death of the decedent; all and the corporate stocks and dividends
due thereon and unpaid as of the .L:\IC (If death, bonds and accrued interest thereon to the date of decedent's
death and other investm(.q -"-' l; :i.',1 hy (he decedent at the time of death, with the-market value there-
of at such time.
In the case of' securities of' close or family corporations, the values reported are as f'ar as
possible .substantiated by f'inancial statements of' the corporations, showing the assets and liabilities
thereof as of the date of' death. The schedule also sets f'orth the interest of' decedent at the time of
death in any co-partnership or business, and in support of' the value of such interest there 1s annexed to
said scherlllle, f'inancial statements showing the assets and liabilities of' said co-partnership or 9usiness.
A copy of thf' co-partnership agreement, (if oral, a statement setting forth the nature of' the agreement)
togt~thl:'r with a statement setting f'orth the character of the business, its location, and such other f'acts
perth.lY)'!'"f. to the business as may be pertinent to a f'air and just appraisal of' the decedent's interest
therei:J mH...t be submitted. It should also set f'orth in itemized f'orm, together with the fair market value
therpof, any other property owned or bequeathed by the decedent at the time of' death.
The Schedule C attached hereto and made part hereof sets f'orth a true answer to each inquiry
contained therein and in the case of transf'ers of property, real or personal, within two years of' decedent's
death, in contemplation of decedent's death, or intended to tl3.ke ef'fect in possession or enjoyment at or
af'ter death, said schedule sets forth the nature and value of such property, to whom transf'erred, the
relationship of the transferees to the decedent, the proportionate share received by each transferee and
all other facts of' a pertinent nature regardin~ said transfers. In the case of' transf'ers intended to
take effect in possession or enjoyment at or af'ter death, there is also attached to the schedule a cony
of the deed, trust agreement or other instrument creating the trust. Therl~ is also set f'orth in said
schedule a list of all property, real and personal, with its value, which pa~ses at decedent's death by
virtue r)f' the exercise by decedent, either individually, or jointly with another, or any power of' appoint-
ment vested in decedent, either individually or jointly, by the will, deed, or other instrument of' another,
with a copy of the instrlnnent creating such power attached to the schedule.
That Schedule 0 attached hereto and made part hereof sets rorth the names and addresses of all
persons beneficially interested in this estate at the time or decedent's death, the nature of their res-
pective interests, their relationship, if any, to the decedent, together with the ages at the time of
decedent's death of' all minors, annuitants and beneficiaries f'or lire under decedenes Will. It also
contains a statement showing which of the beneficiaries named in the decedent's will, if any, died prior
to decedent, the dates of their death, their issue, and the relationship of' such issue to the beneficiary.
That SChedule E attached hereto and made a part hereof sets forth all property, real and per-
sonal, owned by the decedent jointly with another or others, includiIig "intangible, standing in the name
of the decedent and others, plus the date and place of record of instruments effecting the vestiture of
real estate and the date of' acquisition of personalty, plus the name, address and relationship, if any,
of' co-owners to the decedent.
That Schedule F attached hereto and made a part hereof sets forth fully and in detail all debts
and deductions claimed for and on behalf of this decedent1s estate, including funeral expenses paid;
family exemption, where applicable; costs of' administration of this estate; counsel fees and nldiciary's
commissions paid or to be paid; cost expended for burial trusts, tombstones or gravemarkers, and reli-
gious services, in consequence of the death of the decedent; debts and claims owing and nnpaid at time of
death; taxes accrued chargeable for period prior to decedent's death (except those allowed under Section
651 of the Inheritance and Estate Tax Act); together with a statement of collateral pledger! for obliga-
tions, if' any. It is agreed that the f'iduciary will present proof' of' said claimed obligations upon re-
quest, that if the amount actually paid in settlement of any fee, commission or' debt is less than the
estimated amount claiming and allowed, that the same will be reported to the Register of' Wills, and that
the amount of' tax assessed can be reassessed in accordance therewith.
That the totals o~ the appropriate columns in Schedules "A", "B", "e", "E", and "F" as directed therein,
have been carried forward and properly registered in the Summary.
Subscribed and sworn to before me this .................._.........
....~........ ~"fs\~:.:z~
........~;~.~rg~. ,~~~~:~'~~~~r;,~~'i~:u:ty.:
(~mmlS';on Expires Mar. 26, 1983
Member, Pennsylvania I\s~odation of Notaries
NOTE: Before signing af'fidavit make sure all blank spaces in t}le aff'idavit and schedules annexed are
filled in with details or the word "None", and in case the assets include rare and unlisted securities,
securities of close or family corporations or an interest in any co-partnership or business, that the
data and statements required under the paragraph above relating to Schedule "B" are attached. Also make
certain that column #1 in the "Summary" has been properly completed as above-directed.
d~~1ix~--..............._..
Il9!1j:.~._.L................._.................._.__...."._.".._.._...
(Street Number)
Newburg, ~~~~~y'ly~ia 17240
(City or Town and State)
lIt'"-=C",S4 ("'7~)
COMMOu:/ll~.fTtl. OF PIIIA_",... ...
DEPARTMliNT OF R.VENltE
BUREAU OF COUNTY COLLECTIONS
TRANSFER INHERITANCE TAX
RESIDENT DEClrDENT
SCHEDULE "An
REAL PROPERTY
*'
Real property in Pennsylvania, with statement of mortgage encllmbrances upon each parcel at death of dece-
dent. Property held by the decedent as tenant in common with 'ili101her or ather, should be identHied
as to quantum of interest and the estimated value should be thal.of the decedent's interest only. (Property
held as joint tenants with right of surviorship or tenancy by entireties should be reported on Schedule "E. "J
The real property lo'ceted In the Commonwealth of Pen".ylvanla .hould be
described by lot ond'\loclc numb.r_ .treet and .tre.t number. togeth.r with
a general descrl'ptf~n of the property, with a refer.nc. to the record of the
conveyance by which the decedent toolc title; If a farm .tat. number of a..
cres; al.o .tateme"t.f mortgage encun,bronc.. upon each parcel at death
of decedent. Tax.., a.....ments. accrued Int.r..t on mortgage., etc.,ar.
to be Ii.t.d on Sch.dul. uF" and must not b. d.duct.d from thr. .chedul..
(1)
(2)
13\
DePARTMENT
VALUA TION
CAUTION
(Do no. write
In this space)
ASSEsseD VALUE
FOR YEAR OF
DECEDENT'S
DEA TH
ES TIMA TE D
MARKET VALUE
1. ALL that certain house and lot of ground situated
at 36 North Earl Street in tUe Borough of
Shippensburg, County of Cumberland, Pennsylvania,
bounded and described as follows, to wit:
ON the Northeast by North Earl Street; on the
Northwest by lot of Frank J. Novotny; on the
Southwest by lot of Zora Bower:; ,formerly a part
of this lot, and on the Southeast by lot of
Arthur K. Greiner and said lot having a frontage
on North Earl Street of thirty-two (32) feet and
two (2) inches, more or less, and extending in
depth a distaice of one hundred forty (140) feet,
more or less, to lot of Zora Bowers in the rear.
BEING the same lot of ground which John Gutshall,
widower and single-man, by his deed dated April 9,
1954 and recorded in the Office of the Recorder
of Deeds of Cumberland County in Deed Book "S",
Volume 15, Page 500, conveyed to John S. Heberlig
and A. Ethel Heberlig, his wife, and the said
John S. Heberlig died November 7, 1961, survived
by his said wife, A. Ethel Heberlig ,now deceased
SALE PRICE
$20,500.00V
$20,500.00/.---"'
Insert this total opposite "real property", Schedule" A" in the X X X X X
"As Reported" column on the last page of this return.
~D 500.00
I
RCC -3ii
COMMONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE liB"
PERSONAL PROPERTY
*~
INSTRUCTIONS: This Schedule must disclose all tangible and intangible personal property owned individually
by the decedent, at the time or his death. Property owned by the decedent jointly with another or others
must be listed under Schedule "En. Intangible personal property, titled in the name or the decedent, but
payable at death to another or others, including but not limited to P.O.D. U. S. Savings Bonds and tenta-
tive trust accounts, must be listed, despite the ract that they are not or the administered estate.
Tangible personal property should be listed rirst (e.g. jewelry, wearing apparel, household
goods, and fUrnishings, books, paintings, automobiles, boats, etc.)
Intangible personal property, such as bonds, treasury certiricates, cash on hand and in bank,
stocks, mortgages, notes, together with accrued interest or dividends, salaries or wages, insurance pay-
able to the estate or fiduciary in said capacity, partnership interests, interest in anyundistributed
estate of or income from any property held in trust under the will or agreement or another, eVen though
located outside of the State, at the time of death, should be listed in this schedule.
Item
No.
5.
6.
7.
8.
9.
10.
11.
12.
ITEM
List and describe fully
1.
Checking Account #223-384-6 - The First
National Bank of Shippensburg, PA
Savings Account #2828 - Orrstown Bank, Orrstown
Pennsylvania
,A3 shares, The First National Bank of
Shippensburg, Pennsylvania - common stock
/33 shares, The First National Bank of
Shippensburg, Pennsylvania - common stock
/24 shares, Orrstown Bank, Orrstown, Pennsylvania
c}lllllllon stock
--2 shares, Orrstown Bank, Orrstown, Pennsylvania
common stock
/1 share, Cumberland Valley Co-Operative Assn.
cpmmon stock
4 shares, Cumberland Valley Co-Operative Assn.
preferred stock
American Express Company - Travelers Checks
#P5l-76l-5l4 - $50.00
#P5l-76l-5l5 - $50.00
#P5l-76l-5l6 - $50.00
Proceeds from Public Sale of Miscellaneous
Household Items
2.
3.
4.
Arthur Greiner - Account Receivable _ balance owi g
on purchase price of property at 32-34 North Earl
Street, Shippensburg, Pennsylvania
Arthur Greiner - Account Receivable - balance owi g
on purchase price of property on North Seneca Str et,
Shippensburg, Pennsylvania
Insert this total opposite "Personal Property", Schedule "B" in
the "As Reported" column on the last page or this return.
UNIT
VALUE
ESTIMATED
MARKEr VALUE
DEPARTMENT VALUATION
(Do not write in
this space)
22.00
y
4,176.94 ..
468.51 V
726.00'/
/-
726.00/
'/
1,824.00,
22.00
76.00
76.00
152.00'
10.00
10.00/
40.00
l50.00~
10.00
6,540.65__
3,000.00-
12,000.00 __
x X
d,q, il'i.IO
29,814.10
Ree - 30
COMMONWEALTH OF PE\NSYLVANIII.
TflANSFFI\ gHEI\ITAXCE TAX
SCHEDULE "c"
TRA\SFEflS
IlESIDEXT DFCEnEXT
(1) Did. decedent, within two years of death, make any transfer of any material part of his estate, without
receiving a valuable and adequate consideration therefor? (Answer yes or no) no
(2) Did d.cedent, within two years of death, transfer property from himself to himself and another or
others (including a spouse) in joint ownership? (Answer yes or no) ""'0
(3) If the answer to (1) or (2) above is in the affirmative state:
(a) Age of' decedent at time of' transfer
(b) State of decedent' 5 heal th at time of' making the transfer. (Note 1).
(c) Cause of decedent's death. (Note 1).
(4) Did decedent, in his lif'etime, make any transfer of property without receiving a valuable or adequate
consideration therefor which waS to take et't'ect in possession or enjoyment at or af'ter his death?
(Answer yes or no) no .
(a) Was there any possibility that the property transt'erred might return to transrerer or his
estate or be subject to his power ot' disposition? (Answer yes or no) no
(b) What was the transt'eree1s age at time or decedent1s death?
(5) Did decedent in his lifetime make any transf'er without receiving a valuable and adequate consideration
theref'or under which transt'eror expressly or impliedly reserves for his lit'e or any period which does
not in t'act end bef'ore his death:
(a) The possession or enjoyment of' or the right to income f'rom th~ property transt'erred?
(Answer yes or no) no
(b) The right to designate the persons who shall possess or enjoy the property transferred or
income theref'rom? (Answer yes or no) no
(6) If the answer to (5) (b) above 1s in the affirmative, state whether the right was reserved in decedent
alone or others
(7) Did decedent 1n his li:fetime make a transrer, the consideration :for which was transferee's promise to
pay income to or for the benef'it of care of transferor? (Answer yes or no) no
(8) Did decedent, at any time, transfer property, the beneficial enjoyment of' which was subject to change,
because of a reserved power to alter, amend, or revoke, or which conld revert to decedent under terms
of transfer or by operation of' law? (Answer yes or no) no
(9) If the answer to (8) above is in the affirmative, was the power to alter, amend, or revoke the inter-
est of the beneficiary reserved in the decedent alone or the decedent and others?
(Answer yes or no) no
NOTE 1: The answers to these questions should be supported by af'fidavit by the attend.:i.ng physician as
well as a copy o~ the death certificate.
NOTE 2: If' answer to any of' the above questions is yes, set forth below a description of' the property
transf'erred, it's fair market value at date of death, dates or transfers and to whom tr~nsf'erred, with
relationship of transrerees to decedent, if' any. Submit copy of any trust deed or instrument, if trans-
fers are claimed to be non-taxable, also submit detailed statement of' facts on which said claim is based.
NOTE 3: List applicable property below in manner in which provided in Schedules A, B, or E.
ITEM
DESCRIPT ION
MARKET VALUE
(Es tima ted)
DEPT. VALUATION
(Dept. Only)
NONE
Insert this total opposite "Transfers", Schedule "e" in the
"As Reported" column on the last page of' this return.
~tltJ.E
RCC-37 (12-63)
CmlMO~WEALTH OF PE~,:\SYYLA~IA
TRANSFER INHERITANCE TAX
RESIDENT DECEDENT
SCHEDULE "D"
BENEFICIARIES
,
h
BENEFICIARIES AND ADDRESSES RELATIONSHIP SURVIVED
(If step.children or DATE INTEREST OF
State full names and addresses of all who illegitimate cj,iJdrcn DECEDENT OF BENEFICIARY
ave an interest, vested. contingent or other are involved, set STAn: YES IN EST.HE
wise in estate) forth this fact.) OR NO BIRTH
GeOrl!e H. Davidson, 500 Sand Banl
Road. Mt. Holly Snrinl!s. PA Grandson yes Specific Lel!atee
Eugene D. Heberlig, Box 233
Danhoro PA 18916 Grandson yes Specific Lel!atee
Ge1n F. Heberlig, Box 233
. PA 1 <l01'; Grandson yes Snecific Le"atee
Linda M. Plasterer, R. D. 1
NewbUTl!. PA 17240 Grand-daul!hter yes Snecific Lel!atee
Dale E. Plasterer, R. D. 1
Newburg, PA 17240 Grandson yes Specific Legatee
John C. Davidson Grandson Specific Legatee
Adam R. Heberlil!, R. D. 1
Newburv. PA 17240 Son yes Remainder Beneficiarv
Manfred G. Heberlig, Box 233
Danboro, PA 18916 Son yes Remainder Beneficiary
Beatrice E. Davidson (Myers)
Box 72, Walnut Bottom, PA Daughter yes Remainder Beneficiary
Vivian G. Plasterer, R. D. 1
Newburg, PA 17240 Daughter yes Remainder Beneficiary
Deponent further says that all the above-named benef'iciaries are l::l.ving at this time except below:
NAME DATE OF DEATH RESIDENCE
-
s ~
~J;'
~:' s:::
.c ~ 5
"s ~..:
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SUMMARY
(Sch. "A")
(Sch. "B")
... .........(SCh. "C")
(~c;I1."E")
Real Property
Personal Property
Transfers
Gross Taxable Estate
(I)
(As Reported)
$ 20,500,00
$ .29,814.10
$. 00.00
$.
$
$
u'n,7S2.];,
78,066.8;'
-., ...
(2)
(As n,'!<-rmined)
$
$
$
$
$
$
"
00
....
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RC C~38
COMMONWEALTH OF PENNSYLVANIA
TRANSFER INHERITANCE TAX
*
RESIDENT DECEDENT
SCHEDULE "E"
JOINTLY OWNED PROPERTY
10.
11.
12.
INSTRUCTIONS: This schedule must disclose all property, real and personal, owned by the decedent jointly
wi th another or others, including intangibles, standing in the name of the decedent and others. List
real estate ~irst, as entireties, or joint tenants, giving brie~ description, as indicated under Schedule
"A", plus the date and place of record of instrument effecting vestiture, but do not include entireties
or out of state real estate value in estate valuation column. Personal property should be listed as in
Schedule "B", plus date o~ acquisition, and the name, address and relationship (if any) of co-owners to
the decedent.
Description of Property, Date of Acquisition, Name
Address and Relationship of Co-Owners, and Place
of Record of Instrument, where Real Estate.
1V\ '^
'Y>
unit
Value
percentage
Share
Estate
Valuation
DEPARTMENT VALUATION
CAUTION-Do not Write
In This Space.
Value of Value of
Entire Decedent's
Property Interest
~~
<X
~ ;x;> ;.x
<X~
<X Q<
<X Q<
;x;> 'Xl
:X>
;x;
~
1.
Savings Account #111-154-5 - The First
National Bank of Shippensburg, PA, in
the names of Mrs. John S. Heber1ig or
Adam R. Heber1ig, son of Decedent, Route
1, Newburg, PA - surviving co-owner's
name added December 1, 1958
Total: $7,921.80 - 1/2 taxable
Accrued interest on above Savings Accoun
#111-154-5 - The First National Bank of
Shippensburg, PA - Total: $66.02
1/2 taxable
$1,000.00 Certificate of Deposit #6661 -
The First National Bank of Shippensburg,
PA - registered in the names of Anne E.
Heber1ig or Eugene Heber1ig, grandson of
Decedent, Box 233, Danboro, PA - dated
March 22, 1976 - 1/2 taxable
Accrued interest on above Certificate of
Deposit No. 6661 - $45.42 - 1/2 taxable
$1,000.00 Certificate of Deposit #6662 -
The First National Bank of Shippensburg,
PA - registered in the names of Anne E.
Heber1ig or Manfred Heber1ig, son of
Decedent, Box 233, Danboro, PA - dated
March 22, 1976 - 1/2 taxable
Accrued interest on above certificate 0_
Deposit #6662 - $45.42 - 1/2 taxable
$1,000.00 Certificate of Deposit #6663 -
The First National Bank of Shippensburg,
PA - registered in the names of Anne E.
Heber1ig or Adam Heber1ig, sone of Deced nt
R. D. 1, Newburg, PA - dated March 22, 1 76
1/2 taxable
Accrued interest on above Certificate of
Deposit #6663 - $45.42 - 1/2 taxable
$1,000.00 Certificate of Deposit #6664 -
The First National Bank of Shippensburg,
PA - registered in the names of Anne E.
Heber1ig or Linda Plasterer, grand-daugh er
of Decedent, R. D. 1, Newburg, PA - date~
March 22, 1976 - 1/2 taxable
Accrued interest on above Certificate of
Deposit #6664 - $45.42 - 1/2 taxable
$1,000.00 Certificate of Deposit #6665 -
The First National Bank of Shippensburg,
PA - registered in the names of Anne E.
Heber1ig or Dale Plasterer, grandson of
Decedent, R. D. 1, Newburg, PA - dated
March 22, 1976 - 1/2 taxable
Accrued interest on above Certificate of
Deposit #6665 - $45.42 - 1/2 taxable
22.71/
./
3,960.90
2.
33.01l ,e
3.
500.00/-
4.
22.7
.------
5.
c.
500 . 01 V""
6.
7.
22.7 v'
8.
500.0C~
22.7 /
9.
v'
500.0C /
22.71 /'
~/
500.001/
Insert this total ovvosite "Jointly Owned Property", Schedule "E"
In the" As Reported" column on the last page of this return.
~7,lS;)..13
24.
25.
26.
27.
28.
29.
30.
SGlEDULE "E"
JOINTLY OWNED PROPERTY continued
ESTATE OF A. ETHEL HEBERLIG
13.
$1,000.00 Certificate of Deposit #6666 - The First
National Bank of Shippensburg, PA - registered in the
names of Anne E. Heberlig or Vivian Plasterer, daughter
of Decedent, R. D. 1, Newburg, PA - dated March 22, 1976
1/2 taxable
Accured interest on above Certificate of Deposit #6666
$45.42 - 1/2 taxable
14.
15.
$2,000.00 Certificate of Deposit #8754 - The First
National Bank of Shippensburg, PA - registered in the
names of A Ethel Heberlig or Adam R. Heberlig, son of
Decedent, R. D. 1, NeWburg, PA - dated August 10, 1978
Accrued interest on above Certificate of Deposit #8754
16.
17.
$2,000.00 Certificate of Deposit #8755 - The First
National Bank of Shippensburg, PA - registered in the
names of A.Ethel Heberlig or Beatrice Myers, daughter
of Decedent, Box 72, Walnut Bottom, PA - dated
August 10, 1978
Accrued interest on above Certificate of Deposit #8755
/
18.
19.
$2,000.00 Certificate of Deposit #8756 - The First
National Bank of Shippensburg, PA - registered in the
names of A. Ethel Heberligor Vivian Plasterer, daughter
of Decedent, R. D. 1, Newburg, PA - dated August 10, 1978
Accrued interest on above Certificate of Deposit #8756
20.
21.
$1,000.00 Certificate of Deposit #7725 - The First
National Bank of Shippensburg, PA - registered in the
names of A. Ethel Heberlig or Eugene D. Heberlig, grandson
of Decedent, Box 233, Danboro, PA - dated June 24, 1977
Accrued interest on above Certificate of Deposit #7725
22.
23.
$1,000.00 Certificate of Deposit #7726 - The First
National Bank of Shippensburg, PA - registered in the
names of A. Ethel Heberlig or George H. Davidson _
grandson of Decedent, 500 Sand Bank Road, Mt. Holly
Springs, PA - dated June 24, 1977
Accrued interest on above Certificate of Deposit #7726
$1,000.00 Certificate of Deposit #7727 - The First
National Bank of Shippensburg, PA - registered in the
names of A. Ethel Heberlig or Dale E. Plasterer, grandson
of Decedent, R. D. 1, Newburg, PA - dated June 24, 1977
Accrued interest on above Certificate of Deposit #7727
$1,000.00 Certificate of Deposit #7728 - The First
National Bank of Shippensburg, PA - registered in the
names of A. Ethel Heberlig or Linda M. Plasterer, grand-daughter
of Decedent, R. D. 1, Newburg, PA - dated June 24, 1977
Accrued interest on above Certificate of Deposit #7728
$1,000.00 Certificate of Deposit #4909 - The Peoples
National Bank of Shippensburg, PA - registered in the
names of Anne Ethel Heberlig and Adam R. Heberlig, son of
Decedent, R. D. 1, Newburg, PA - dated June 1, 1976 _
1/2 taxable
Accrued interest on above Certificate of Deposit #4909 _
$26.69 - 1/2taxable
Estate Valuation
500.00<-'
22. 71 ~'
./'
2,000.00
34.45/
,/
2,000.00
34.45./
2,000.00-'
34.45 .---'
1,000.00 .....--
26.25 ".-
1,000.00'
26.25'
1,000.00/
26.25/
1,000.00
26. 25 /
500.00~
13.35
-'
SCHEDULE "E"
JOINTLY OWNED PROPERTY continued
ESTATE OF A. ETHEL HEBERLIG
31. $1,000.00 Certificate of Deposit #4910 - The Peoples
National Bank of Shippensburg, PA - registered in the
,names of Anne Ethel Heber1ig and Manfred G. Heber1ig,
~ son of Decedent, Box 233, Danboro, PA - dated June 1,1976
1/2 taxab Ie
32. Accrued interest on above Certificate of Deposit #4910 _
1/2 taxable - $26.69
33. $1,000.00 Certificate of Deposit #4911 - The Peoples
National Bank of Shippensburg, PA - registered in the
~ names of Anne Ethel Heber1ig and Vivian C. Plasterer,
daughter of Decedent, R. D. 1, Newburg, PA - dated
June 1, 1976 - 1/2 taxable
34. Accrued interest on above Certificate of Deposit #4910 _
1/2 taxable - $26.69
35. $1,000.00 Certificate of Deposit #2655 - Orrstown Bank,
Orrstown, PA - registered in the names of A. Ethel
Heber1ig or Adam E. Heber1ig, son' of Decedent, R. D. 1,
Newburg, PA - dated June 22, 1977
36. Accrued interest on above Certificate of Deposit #2655
37. $1,000.00 Certificate of Deposit #2656 - Orrstown Bank,
Orrstown, PA - registered in the names of A. Ethel
Heber1ig or Manfred G. Heber1ig, son of Decedent,
Box 233, Danboro, PA - dated June 22, 1977
38. Accrued interest on above Certificate of Deposit #2656
39. $1,000.00 Certificate of Deposit #2657 - Orrstown Bank,
Orrstown, PA - registered in the names of A. Ethel
Heber1ig or Beatrice E. Myers, daughter of Decedent,
Box 72, Walnut Bottom, PA - dated June 22, 1977
40. Accrued interest on above Certificate of Deposit #2657
41. $1,000.00 Certificate of Deposit #2658 - Orrstown Bank _
Orrstown, PA - registered in the names of A. Ethel
Heber1ig or Vivian G. Plasterer, daughter of Decedent,
R. D. 1, Newburg, PA - dated June 22, 1977
42. Accrued interest on above Certificate of Deposit #2658
43. $1,000.00 U.S.Government Series E Bond dated July, 1972 _
registered in the names of Mrs. A. Ethel Heber1ig or
Adam Heber1ig, son of Decedent, R.D. 1, Newburg, PA _
co-owner had legal access to Decedent's Lock Box _
Total: $1,051.20/.: 1/2 taxable
44. $1,000.00 U.S.Government Series E Bond dated July, 1972 _
, registered in the names of Mrs. A. Ethel Heber1ig or Mrs.
Vivian Plasterer, daughter of Decedent,R.D. 1 Newburg, PA _
45. $1,000.00 U.S.Government Series B Bond dated July, 1972 _
registered in the names of Mrs. A. Ethel Heber1ig or Manfred
Heber1ig, son of Decedent, Box 233, Danboro, PA
46. $500.00 U.S. Government Series E Bond dated July, 1972 _
registered in the names of Mrs. A. Ethel Heber1ig or
Mrs. Beatrice Davidson, daughter of Decedent, Box 72,
Walnut Bottom, PA '
47. $100.00 U.S.Government Series E Bond dated July, 1972
registered in the names of Mrs. A. Ethel Heber1ig or
George Davidson, grandson of Decedent, 500 Sand Bank
Road, Mt. Holly Spring;, PA
Estate Valuation
500. Oif~/
13.35 -
500.00-
13.35
1,000.00/'
25.00/
1,000.00_
25. 00 _
1,000.00-
25.00 __
1,000.00-
25.00 _
525.60
/
1,051. 20
1,051.20/
525.60/
105.12 ,/
SCHEDULE "E"
JOINTLY OWNED PROPERTY continued
ESTATE OF A. ETHEL HEBERLIG
Estate Valuation
48.
$100.00 U.S.Government Series E Bond dated Jul~ 1972
registered in the names of Mrs. A. Ethel Heberlig or
Eugene Heberlig, grandson of Decedent, Box 233, Danboro,
PA
./
49. $100.00 U.S.Government Series E Bond dated July, 1972
registered in the names of Mrs. A. Ethel Heberlig or
Glenn Heberlig, grandson of Decedent, Box 233, Danboro,
PA
50. $100.00 U.S.Government Series E Bond dated July, 1972
-~registered in the names of Mrs. A. Ethel Heberlig or
Dale Plasterer, grandson of Decedent, R.D. 1, Newburg, PA
51. $100.00 U.S.Government Series E Bond dated July, 1972
registered in the names of Mrs. A. Ethel Heberlig or
Linda Plasterer, grand-daughter of Decedent, R.D. 1,
Newburg, PA
52. $100.00 U.S.Government Series E Bond dated May, 1976
~ registered in the names of Anne E. Heberlig or Glenn F.
Heberlig, grandson of Decedent, Box 233, Danboro, PA
53. $100.00 U.S.Government Series E Bond dated May, 1976
~ registered in the names of Anne E. Heberlig or John W.
Davidson, great-grandson of Decedent
54. $100.00 U.S.Government Series E Bond dated March, 1976
~ registered Anne E. Heberlig payable on death John W. Davidson
great-grandson of Decedent
55. $500.00 U.S.Government Series E Bond dated March, 1976
~ registered Anne E. Heberlig payable on death George Davidson,
grandson of Decedent -500 Sand Bank Road, Mr. Holly Springs, PA
56. $500.00 U.S. Government Series E Bond dated March, 1976
registered Anne E. Heberlig payable on death Beatrice Davidson,
/ daughter of Decedent, Box 72, Walnut Bottom, PA
TOTAL
105.12/
105.12 ,/
105.l2./'
105.12~
82.40
82.40/
./
84.56
'"
422.80(
/
422.80//
27,752.73
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMeNT Of REVENUE
BUREAU Of COI,l...TY C;:OLLECT!O...s
I1ARRISBI,lIlG
171~7
JAN 04 1979
RCe-4] (!.-;l)
I'lOn;: '1'0 lit:: ::iUMlI'I'Tt::Q IN TRIPLICATE
"
REPOOTlN(; FiNANCIAL IN::il'l'J'IJTlON
ADDRESS
l1rl$'t lfat1~ Dank:
1 ,,_to xt.ng at.
IhJ.p~~~ h. '.
ZIP CODE f1t:,',
l'ennllylvunia DcPIU"tlli4;lllt of'lle"enue
.' BUl;eau of Cpunty coq..~tlollli .
Cable B\li I ding. :lrcl,' Floor'
'/jll S, Secong Snee~, ". . .
, ffarrisbllrs, Pennllylvanilll' PI:.!7
',":' ,,' ',:,"', '; ,
Pursuant to Section 742, PennBylv~ntlll J.n~eI;H.n<;e Ang
of 196)., we hel,"ewith submit.the fotlQWil1,lJr.e~rt:
~St,4~!l 'f.~. ~t
4CCOONT NO. OF JOllff, T~ ACcOU2i:t.....t1~
INVESTMENT DEpOSIT
. ,,",.-
,..,
: "
, '
."
;~,'
N.oo;S ON, ACCOUNl' aa'M,'" SBeb.-'l f":~:lo~lt. 'H.~i.. g . .'.
INVESTMENT l'I1'8.......-,. _ ..~. . '. . .. '
, . .;.' . . , ,::'~-.j'.
~Ob. 30, '97~
DATE OF DEA'Ilf
.' :,
'"
: ,,-;,~:...,.;
'.,"
DECEASED JOINT DF;POSITOWRlI_
OR INVESTOR . .
ADDRESS ~ I" :.!ilarl st. . '. .
, Ih1De11"'-a. JIa..
s~.a.~Us
_t'
/
, "
'",',. ,
COUNTY '~~!i,.,.
~ll' ,C;OOt:' thc~ ' ~,", ~'-. .. ',' ,
<:",':. ", ;,;:.;:~'.r"';:'
S!JRVIVlNG DEPOSITOR, .....&dall a~ J!O~ "" ".
BENEFICIARY OR INVESTOR'. ..,.... . , .
1l. ]).l.~g. P1J. .t7240 >, ' .
ADDRESS
RELATIONSHIP TO D~CF;DENT
. .
Son .
"
. ....
"-, '0 .. '.
DATE DEPOSIT OR INVEST~er '.,.. t91>t3
WAS ESTABLISHED .' '. . ...... . ',.
"...."..
"
"'j
",,-._1
,',.,' ;\,"
. B.\!.4NCE, INCLUDING IN'fERES., 921.80 '0' ,.,
. DUE, AT DATE OF DEATIf ~ $...'~ 'tlI)~. +'ft t'I~'Ji. ,~r. :"Mfl"
1'Jn,~L. ~-!.iP;.~
$18Jlll,~ure ~ _~
, ,
"
A~~\
'~~
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
6UREAU Of COUNTY CQLLECTIONS
HARRIS6URG
17127
JAN 04 1979
RCC-43 (it- n)
NOTE: TO liE SlIllNn'i'ED IN TRIPLICATE
REPORTING fiNANCIAL INSTlTUTION
ADDRESS
ft..-t .1:1........, ....1r
1 ~ rh', ft.
lIhtr.~ Pa..
Zip C E b
Pennsylvania Department of Revenue
Bureau of County Collections
Gable BUilding, 3rd, floor
411 S. Sccon~ Street
Harrisburg, Pennsylvania 17127
Pursuant to Section 742, Pennsylvania Inheritance and Estate Tax Act
of 1961, we herewith submit the folloWing report:
ACCOUNT NO. OF JOINT, TRUST OR
INVESTMENT DEPooIT Oer1;. of ~1'1125
Ie Oer1;. td Dep. 16661
NAMES ON ACCOUNT OR
INVESTMENT ,b..... lllfIhel H4tberUg _ ~ ]). Hebal1g
DATE OF DEATH Oriober JO. 1978
DECEASED JOINT DEPOSITOR, TRUSTEE
OR INVESTOR Mule Bihel He'beUg
ADDRESS ~... lIaltl S",..
_D....lJuJ:gil Pall'
SURVIVING DEPOSITOR,
BENEFICIARY OR INVESTOR
COUNTY 0Wabe:r1aDd
ZIP CODE 17~,t-
:BugeQe D. Heb9:rl1g
ADDRESS
UhlMuw,
~
#7725
16661
'1.000.
1.000.
800"84 IDtl,
. .
.t26.25 --- 6/24h7
-~/22176
RELATIONSHIP TO DECEDENT
DATE DEPOSIT OR INVESTMENT
WAS ESTABLISHED
BALANCE, INCLUDING INTEREST
DUE, AT DATE OF DEATH $ 2.0'11.67
41J, a..~ ..-
Signature I
~4.~?...../
-... '"
~~~
'~~
COMMONWEAL TH OF PENNSYLVANIA
OEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
HARRISBURG
17127
JAN 04 HI7g
RCC-4:l (!,- ,1)
NOTE: TO liE SLJllm TTED IN TRIPLICATE
REPOOTlNG FINANCIAL INSTITUTION
ADDRESS
P1ni Bat10aal Be.1:lk
1 w..t 11"4"1'8 It..
~F'_~
Pennsylvania Department of Revenue
Bureau of County Colle~tions
Gable BUilding. 3rd, Floor
411 S. Second Street
Harrisburg. Pennsylvania 17127
Pursuant to Section 742. Pennsylvania Inheritan~e and Estate Tax 4ct
of 1961. we herewith submit the following report:
ACCOUNT NO. OF JOINT, TRUST OR
INVESTMENT DEPOSIT .Od. of 1lep. ~~~
NAMES ON ACCOUNT OR
INVESTMENT Am:!. '/t. ,"..~.'Jfg ".. w.-:f'-A H"~Hg
DATE OF DEATIl
Oot~....... ~.. '978
DECEASED JOINT DEPOSITOR, TRUSTEE
OR INVESTOR A_a tL H~'1! I
ADDRESS }6 III ~ iO'lar1. gi:~~
- .tPr".~. h"
COUNTY n"'IJIhA-te1!:lMA
ZIP CODE '1'1257
SURVIVING DEPOSITOR.
BENEFICIARY OR INVESTOR
......"'-1 Ha.......1i.
~
'\
\( S ~ )
----
BALANCE, INCLUDING INTEREST
DUE, AT DATE OF DEATH $ 1.04~.42.
- , )
. V,,1!l,~')r'~
C<?- ~~y
~
~4~
~t,~< .\
~,)I. .
.,. ".~
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
HARRISBURG
17127
JAN 04 1979
J{C<>43 (i.-,'ll
NOTE: TO BE SUBNITTED IN TRIPLICATE
REPffiTlNG HNANClAL INSTiTUTION
ADDRESS
llmrt KaUo.nal Brmk
k1fee1; = St.
neB If Pa.
ZIP CODE 172
Pennsylvania Department of Revenue
Bureau of County Collections
Gable Building, 3rd, Floor
411 S. Second Street
Harrisburg, Pennsylvania 17127
Pursuant to Section 742, Pennsylvania Inheritance and Estate Tax Act
of 1961, we herewith submit'the following rePort:
ACCOUNT NO. OF JOINT, TRUST OR
INVESTMENT DEPOSIT C. D. 8754 & O. D.I666'
NAMES ON ACCOUNT OR
INVESTMENT .bile fihel Heberl1g or Ahm R. Heberl1g
DATE OF DEATII Octobu 30. 1918
DECEASED JOINT DEPOSITOR, TRUSTEE
OR INVESTOR .time Ethel Heberl1g
ADDRESS "Borth Eu'l S1I:ree1l
I'm.1.P~U>I&IU n.
CQUNTyCUmber1.Qd
ZIP CODE 1l~;'1
SURVIVING DEPOSITOR, .
BENEFICIARY OR INVESTOR
.Adam R. Heberl1g
R. D. 1. Bew1ra1'g, Pat 17240
ADDRESS
RELATIONSHIP TO DECEDENT Son
DATE DEPOSIT OR INVES~~_
WAS ESTABLISHED _-.. 10, 197e~o'lt 18754 ... W. 22,. '976 :tor 16663
.
BALANCE, INCLUDING INTEREST 875.... $2.000. AcCnH Int. 'M.45
DUE, AT DATE OF DEATII $ 666,... ~. '... .~___
~ _ m;=!T.
,,:::Ie. {r"'" ~iiJ-<A;tr
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY C:OLLECTIONS
HARRISBURG
17127
RCl>4:l (1,- ;'1)
NOTE: TO liE SUIlHl 'JTED IN TRIPLICATE
REPlltTlNG FINANCIAL INSTITUTION
ADDRESS
P1mIt ~I_' -- ...
1 .... ~I~r &k~t
"1..- ~
ZIP CODE'. +
Pennsylvania Department of Revenue
Bureau of County Collections
Gable Building, 3rd, Floor
411 S. Second Street
Harrisburg, ~ennsylvania 17127
Pursuant to Section 742, Pennsylvania Inhl!ritllnce and Estllte Tl!x Act
'of 1961, we herewith submit the folloWing report:
ACCOUNT NO. OF JOINT. TRUST OR
INVESTMENT DEPOOIT __. fd DID.",~ A OWl. 06 11eJJ'tI~ ~
NAMES ON ACCOUNT OR
INVESTMENT ~. ~!IiI1M.lif~ .. 1'.f~.. R.. ~
DATE OF DEATH
0ft0'bIat 50. 1978
DECEASED JOINT DEPOSITOR, TRUSTEE ,
OR INVESTOR .-. Mbe1 ~
ADDRESS. 56 ..~ Su1 S~
__1Ir~_.g.
COUNTY
ZIP CODE
SURVIVING DEPOSITOR,
BENEFICIARY OR INVESTOR 1'~W fl.' ~
ADDRESS .. ~ 1, 1lnJ'l-. Pa" '1240
RELATIONSHIP TO DECEDENT .. ,QlJJ~tw
DATE DEPOSIT OR INV~T
WAS ESTABLISHED rnzs. 11.000.
BALANCE, INCLUDING INTEREST
DUE, AT DATE OF DEATH $
~ 11.07'.61
m_
16664
G/24/'r1
" ,000.
1.000.
au.li1Uil114 lid.,
. .
t2t ],g
'j"-'.-",, _ -..<I..L
Signature ,I
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
HARRISBURG
17127
J{t;t;-43 (..-71)
NOTE: TO liE SUIlHlTTED IN TRIPLlt;ATE
REPffiTlNG HNANt;lAL INSTLTUTlON
ADDRESS
~ 1a't1aul Buk
1 ~-~ a:.. .'.
A1,..-.AffW ..
ZIP CODE ' . . "' .
Pennsylvania Department of Reyenue
Bureau of County CoIIElctj<:)Os
Gable Bui lding, 3rd, F,loor
411 S. Second Street .
Harrisburg, Pennsylvania 17127
Pursuant to Section 742, Pennsylvania Inheritance and Estate 'fax Act
of 1961, we herewith submit the following report.:
ACCOONT NO. OF JOINT~ TRlJST OR __ C 16665
INVESTMENT DEPOSIT uen. or Dep. r,,"" It .. D..
NAMES ON ACCOUNTj.~. :lIthel Bebftollg 01' :D.1e
INVESTMENT .
Oo'tO,*" JO. 1978
E. P1ut__
DATE OF DEATH
DECEASED JOINT DEPifAiiR:ftWfTBb.Ug
OR INVESTOR . .
ADDRESS " Borth Bul S1;reet
. . St4p~ pq~. :ra...
COUNTY
ZIP CODE
0uIIlbe1U4
112&1
.,.
SURVIVING DEPOSITOR,
BENEFICIARY OR INVESTOR
a.. :1.'. 1, JltMNzog,. h.
,
. Dale L P1aR~
"240 .
('),.
..,.'\ :ii"
ADDRESS
'.,;. \"
RELAnON~Il' TO DECEDENT
Gnltdtkm
BALANCE, INCLUDING INTEREST
DU.E , AT. DATE" OE.PEATH $.
!otal . $20\1.1.67
DATE DEfOSIl' OR INVlfft'fF. '/24/T? .
WAS EST4BLISHED .' . .'
T11!1- .,,000.
,666~ ..
. .
16665 . 3/2211'
. /fJ}, ~
Signature.' .
J.e....4 :tat. .1.26.25
..........
dc...~...'..,..............
...' .. ":":" "-,'
( . "'.
~!:;> ~,(fI'fLE
, ,
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COLLECTIONS
HARRISBURG
17127
/(CC-1d U,- 71)
NOTE: TO liE SlIllNIT'J'ED IN T/(IPLlCATE
I(EPoo.TlNG FINANCiAL INSTlTUTlON
ADDRESS
ftat "I~~ .8MIk
. ~~."'_.
ZIP CODE .
Pennsylvania Department of Revenue
Bureau of County Collections
Gable Building, 3rd. Floor .
411 S. Second Street .
Harrisburg, Pennsylvania 17127
. .
Pursuant to Section 742, Pennsylvania Inheritance and Elitate T.aX4ct
of 1961. we herewith su~it the folloWing report:
ACCOUNT NO. OF JOINT, TRUST OR. '. ... .
INVESTMENT DEPOSIT o.J. 01 ~ 18?56 "OWl. .'" -.. H'66
NAMES ON ACCOUNT OR .
INVESTMENT MDt Jftbe1 ~_ 11t'S.tm :na.... .
. one,w, 50, t9'18
DATE OF DEATII.
DECEASED JOINT DEPOSITPR. T&usTEE 'f~~_
OR INVESTOR lIMe ~ __.........
^:..,
COUNTY "'+ 1Ii~1_
ZIP CODE tft" .... . .
ADDRESS
" ...... Eal'1 ~.
1h1.n+ 1........,. Ja..
SURVIVING DEPOSITOR.
BENEFICIARY OR INVESTOR
ADDRESS I.. .1). 1..~S. Pat
'iYia ~
"a40
RELATIONSHIP TO DECEDENT
~
DATE DEPOSIT OR INVtiWiU,TI81S6 8/iOIiea.
WAS ESTABLISHED' .," f'i>
BALANCE. INCLUDING INTEREST = #f-ggg..
DUE. AT DATE OF DEATII $ .... , . .
~ .,,07'.81
o. ..0. Hli6~ '/22/16
,;1}n .j.
f},1 . ,?!
sigl1l;\t~fi
(,,-
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF COUNTY COllECTIONS
HARRISBURG
17127
JAN 04 1979
RCC-4J (!.-,1)
NOTE: TO BE SUIlNJ'l'TED IN TRIPLICATE
REPffiTlNG FINANCIAL INSTITUTION
ADDRESS
nz..t BaUoaal l!luk
~":t.~n)a.
ZIP CODE.
Pennsylvania Department of Revenue
Bureau of County Collections
Gable Building, Jrd, Floor
411 S. Second Street
Harrisburg, Pennsylvania 17127
Pursuant to Section 742, Pennsylvania Inheritance and Estate Tax Act
of 1961, we herewith submit the following report:
ACCOUNT NO. OF JOINT, TRUST OR
INVESTMENT DEPOSIT #7126 OeriUloa'. o~ Depout
NAMES ON ACCOUNT OR
INVESTMENT 4. Bti1el ~llg_ G90J:8e B. DIP.Y14aoa
DATE OF DEATIl Ootobe7:'~. 1m
DECEASED JOINT DEPOSllClR.SlUISTEE....
OR INVESTOR . A. JRa8L _Der~g
ADDRESS )6 Ironh lCul 811.
8b:tl'...--t.ta&'e" ~
COUNTY eua....1AuI4
ZIP CODE "1".
SURVIVING DEPOSITOR,
BENEFICIARY OR INVESTOR George B. Dav1da1on
ADDRESS 500 &m4 ll8IIk u.., M1I.Holly, It. 17065
GftIncUron
RELATIONSHIp TO DECEDENT
DATE DEPOSIT OR INVESTMENT
WAS ESTABLISHED
I~ 24. 1977
BALANCE, INCLUDING INTERE~0a6 25
DUE, AT DATE OF DEATH $ ·
~/~
Signatu ..
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COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT Of REVENUE
BUREAU OF COUNTY COLLECTIONS
HARRISBURG
17127
JAN 04 1979
RCC-4J (:.-/1>
NOTE: TO liE SUllMITTED IN TRIPLICATE
REPffiTlNG FINANCIAL INSTITUTION
ADDRESS
wt"' "f'-" --~
l~., Irtq n.
~~Ir- *tI ..
ZIP . E ..
Pennsyl vania Department of Revenue
Bureau of County Collections
Gable Building, 3rd, Floor
411 S.' Second Street
Harrisburg, Pennsylvania 17127
Pursuant to Section 742, Pennsylvania Inheritance and Estate Tax Ac,t
of 1961, we herewith submit' the fOllowing report:
DATE OF DEATII
Qeflplttar 50. 19'18 '
DECEASED JOINT DEPOSITOR, ,TRUSTEE
OR INVESTOR A.. ~ ~Ug
ADDRESS
~=.:;;=:
COUNTY ~
ZIP CODE -''7ID
SURVIVING DEPOSITOR,
BENEFICIARY OR INVEl/TOR ,1M......, )\',....
4DDRESS R. ' De . a. SbI.~ r/W'tJulog. Fa. , 11251
RELATIONSHIP TO DECEDENT 4~1leJ.o
DATE DEPOSIT OR INVESTMENT, '
WAS ESTAIlLISHED ~ 10.1918
BALANCE, INCLUDING INTEREST
DUE, AT DATE OF DEATII $ ~\ilJ
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