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RCC~72 (9~6B)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF 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 far consent to the transfer of the following securities of a Pennsylvania
Corporation or a National Banking Associalian located in Pennsylvania:
DATE
17
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~ 7f
(a}122 shares (b) ConttinentA1 'Fl"nk (c) Common
(NOTE: In describing securities enter in (a), ab Ofe, either the number of shares of stack 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 V'>l'i"rl , and having a TOTAL MARKET V AWE OF $ .3,751.50
(Oa.e) MCClellan Wilson, Jr. ,a/k/a
as of the dote of deoth 01 the decedent, G. B. McClellan Wilson ,on ~"rt"'mh..l")O, 1978
(Name of Decedent) (Date of death)
who was late of Wi 1 !'lnn l."n~, 11
(Street and Number)
n. 7, Mechan1c~burg
(Post Office)
CumQerlAnd
(County)
pp.nTlRy1vATlA1
(Stote)
The securities are registered as follows:
McClellan Wilson, Jr.
(Nome or names in which certificates ore registered)
ADMINISTRATOR} Nina M. Wilson,
EXECUTOR} (Name)
Wi] son I.AnP.,11.n,7, Mechll.t11c~burg ,PeMsyl'Jan1a
(Address)
NAME OF APPLICANT _ Nina M. Wilson
Wilson Lane, R. D. 7
ADDRESS OF APPLICANT
COUNTY FILE NUMBER~/. i'i., 11-
BUREAU FILE NUMBER SIGNATURE OF APPLICANT
NOTICE: IF YOU FAIL TO PROPERLY FILL IN ANY PORTION OF THIS APPLI TION, IT WILL NOT BE
CONSIDERED COMPLETE AND WILL BE RETURNED TO YOU FOR C LETlON.
COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF REVENUE
CONSENT TO TRANSFER SECURITIES ~ II> I(HI~
DATE ~. (' - 7 (\
I hereby consent to the transler 01 the above securities now registered in the name of th loresaid
Decedent and waive the filing of a certificate certilying 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 omended. 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 01 the
above-named Decedent.
B
IGI~ifl'!?'Ml8msrn.
REGISTER OF WillS
f:"'i"":t.~jl) CQtJ~
(Title) County)
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