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:tEV-517 EX+ (3"1)
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APPLICATION TO
TRANSFER SECURITIES
FILE NUMBER:
COUNTY 21-78-683
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
TRANSFER INHERITANCE TAX
STATE
Pennsylvania
RESIDENT DECEDENT
NOTE: THIS APPLICATION MUST BE FILED IN TRIPLICATE WITH THE REGISTER OF WILLS FOR THE
COUNTY IN WHICH THE DECEDENT RESIDED AT THE TIME OF DEATH.
Name of Decedent: Grace Elizabeth Hempt
DATE
4/R/RR
Date of Death: 12/8/78 County: Cumberl and
Address of
Decedent: 2130 Yale Aveml@
(';!~ Hi 11 .
(CITY, BROUGH)
PA
(STATE)
17011
(ZIP CODE)
DESCRIPTION OF SECURITIES:
1. Stocks a.
917 b. common
(NUMBER OF SHARES) (CLASS OF STOCK)
c. Dau~hi~~8~~~[t?8~~A~~n
d.
various
(DATE OF ISSUANCE)
e. $?q r 14.:1 ()()
(DATE OF DEATH
TOTAL MARKET VALUE)
2. Bonds a.
b.
(FACE AMOUNT) (INTEREST RATE)
c.
(MATURITY DATE)
d. ..
(NAME OF ISSUING COMPANY) (DATE OF ISSUANCE)
f.
(DATE OF DEATH
TOTAL MARKET VALUE]
The securities are registered as follows:
(Miss) Grace Elizabeth Hem~t
(NAME OR NAMES IN WHICH CER IFICATES ARE REGISTERED)
Name of Applicant:
Address of
Applicant:
Mary D. France, Esquire
31 North Second Street
Harrisburg,
(CITY, BOROUGH]
(STATE]
17101
(ZIP CODE)
PA
CONSENT TO TRANSFER SE URITIES
'/~
I hereby consent to the transfer of the above securities and waive the filing of a certificate certifying to the
payment of the transfer Inheritance Tax.
({llj!. ,it. /:; 7 .'1'
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