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~::~o died cn ti;.. ~7-Y~_ day `.w.:.~ , as near as can be ascertained at
~aa prosei:t tic;.e, are .:.s :o~:;o:.s: -
Check One -
:.c.I:iC O: r.'~SLiV4LaV~. iiC.(~re`uS ~ Full
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~:~posiLs ~ $
uaposits - ~
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3. deposits
Deposits
$tOCeCS F+:.Ci bonds (including jointly held)
Cas;: aa4 encashed creeks on ha;.d
;oLSehoia f~rnisc.irgs - estimated .:.ar:cet value ~ - -
~rterest owned in any business
. ~a~rarcc payable :.o estate
~ns~:ra:.ce payable to individual beneficiaries $
:rotes. and o~i.2r debts due deceased
Fern products, livestock and equip.,ent
rotor vehicles -estimated r.ar'.cet value
~ 4iscellaaeois personalty -estimated market-value
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Real estu`e owned by entirety (include one-half value)
O;.ior real estate owned and located in north Carolina E , S l.l. W 20 1,5GO.Cd
~ Real estate located outside forth Carolina
iO:AL APPROfiI;'.AT;: VALUE OF ALL PROPE~: rS : ~;i,,.,~Cp. CC?
Scorn to and subscribed before me this
- day of r~riZ 19~q. L/~~ /
~ ~ Signature of~ Applicant
- '~'•=-t-- / - 8 A ~-~e ~.l~e I•:C 280:.
~~i.~-~:~ri.~ierk o Superior Court Mailing Address
~n •
J 1 ^~~e Berland
Attorne1~
~.0. Boa 721.8; Ashevli? e, i•;.C. 2:;oG7
a - ?failing Address
~;~rti:led copy of this applicatior. nailed to. the Department of Revenue, Inheritance Tax Divis-
~~n, Raleigh, \ortz Carolina, as, required by G.S. 105-22. (Submit two copies to Department of
E :venue)
F ~ is ~ day o~ ~ ' 9 ~i
/}-ice.-~ ~~nt C1er/c of Superior Court
l~ S. 1G5-22
1F s. 28-I, -6, -a, -29 county ,
..::C-L Fora 1
,.w l0/69 .
~o not use this space Do not use this s ace. -
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