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Form 7990 Department of the Treasury-Internal Revenue Service
(Rev. July 1978) United States Estate Tax Certificate of Discharge From Personal Liability
Decedent's First Name and Middle Initial Decedent's Last Name Date of Application
y 8tttlet ~tt~>< 14, 1977
Decedent's Soaal Security Number Residence fDomicilel at Time of Death
3f?1.07.339!
Date of Death
Dec..b~: 10. 197.6__ _ nosia• ~ ~ -
To-Name and address of applicant (number, street, aty or town, State, and 21P Code)
Mss. Q•caldlas Mscta' Ottt~ llsss. t•'.
>~u 2. IMac 1141
l~SCt H•rc•, ~LoTida 33450
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I certify that the estate tax for the above decedent's estate has been determined and paid. This certificate, issued in acoordanoe with
sectioh~2204 of the Internal Revenue Code, disdtarges the persons whose names and addresses are listed below from personal liability
for any defiaenty in estate tax that may be later found due from this estate.
Mss, G~aldiss lMeka~ Otbt - ,
• '~t• 2e leac 1141 '
Ifastt M•re•, iLssids 33450
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Signature Title Date
DISTRICT DIRECTOR
o~strict or office JACKSONVILLE, FLORIDA 32202
Form 7990 (Rev. 7-781 Department of the Treawry-Internal Revenw Service
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