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That the nature and value of the pr~verty of the deceased,
hho died on the day of _ _ , 19~, as near as can be ascertained at
the present time, are as follows: Check On~
Name of Institution Address Full
S '
1. Deposits •
2. Deposits
3. Deposits .
4. Deposits _ -
5. Stocks and bonds (including jointly held) 92 II+D~---
6. Cash and uncashed checks on hand
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7. Household furnishings - estimated market value
8. Interest owned in any business .
- _ . " _ . ,S
9. Insurance payable to estate i
10. Insurance payable to individual beneficiaries li ~30 D~~ _ i
1~_. Votes and other debts due deceased -
12. Farm products, livestock and equipment ~
' 13. `totor vehicles - estimated market value ? ~
i se_ee ;
; Miscellaneous personaltv - estimated market value
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f 15. Real estate owned by entirety (include one-half value) ~ r
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~ i6. Other real estate owned and located in North Carolina ~
~ 17. Real estate located outside North Carolina ~
TOTAL APPROXIMATE VALUE OF ALL PROPERT . ~.02 050,00
' "~u~tl~i~ x[lie~~~lcnh~tf~tc~.,~-~ _
Sworn to and subscribed before me this _ u~~~a ~a =rwt Cos~ps~, 1~.A•
~ . - 1 ( ~ ! ! ~ % /
' . day of s. ~ 1 S • , - ,
- ~ A~st. Yict ~~ture of;Applicant.
~ P. O. Eox b31. :ii~h Yoint, H.C. 27261
; ~ ~ - ~ _ '~h~iBB W. E8IRa8YO~ Address -
~ssistant Clerk of uperior Court y~. p, V~- ~ndia6ficvs
Attornev
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! ~ ~~'1 ~C ~ 27364
p?O~ ~oz b~T,`1'ho`~sov i . . .
~ ,*jailu~..~dress -
881~ , . ti~ l/L~V
Certified copy of this application mailed to the Department of Revenue, Inherita:lce Tax Division
~ :aleigh, North Carolina, as required by_G.S. 105-?2. (Submit two copies to Depa tment o' Rev-
er.ue)
~ This Jf,~i.. day of ti 1~~ • " ' ~
• - Assistant Cler of S~rior Court
G. s. 105-22 , G. S. 28-1, -6, c~$~r'-;Z9.' }
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.10C-L Form 2 .!~,;'t~, County
P.ev 10/69 • . 1~ -1 ,
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