HomeMy WebLinkAboutL 12681 P 984SUFFOLK COUNTY CLERK
RECORDS OFFICE
RECORDING PAGE
Type of Instrument: DEED
N~_~m~er of Pages: 17
Receipt Number : 12-0003771
TRANSFER TAX NUMBER: 11-11758
District:
1000
Deed Amount:
Recorded:
At:
LIBER:
PAGE:
Section: Block:
079.00 06.00
EXAMINED AND CHARGED AS FOLLOWS
$0.0o
Received the Following Fees For Above Instrument
Exempt
Page/Filing $85.00 NO Handling
COE $5.00 NO NYS SRCHG
EA-CTY $5.00 NO EA-STATE
TP-584 $5.00 NO Notation
Cert. Copies $0.00 NO RPT
Transfer tax $0.00 NO Comm. Pres
Fees Paid
TRANSFER TAX NUMBER: 11-11758
THIS PAGE IS A PART OF THE INSTRUMENT
THIS IS NOT A BILL
JUDITH A. PASCA~R
County Clerk, Suffolk County
01/11/2012
02:25:27 PM
D00012681
984
Lot:
OO4.OO8
$20.00
$15.00
$125.00
$0.00
$50.00
$0.00
$310.00
Exempt
NO
NO
NO
NO
NO
NO
' Numbe~' of pages
This document will be public
record. Please remove all
Social Security Numbers
prior to recording.
Deed / Mortgage Instrument
Deed / Mortgage Tax Stamp
20t2 Jan 11 02:25:2?
~UDITH ~. P~$CfiLE
CLERK OF
SUFFOLK COUNTY
L D00012681
P ~84
DT# lt-~758
Recording / Filing Stamps
Page / Filing Fee _~0
Handling 20. O0
TP-584 1/
Notation / ~
EA-52 17 (County) .' .,~_:
C~m~m .. o¥'Ed. 5. O0
Affidavit
Certified Copy
FEES
Sub Total
Mortgage Amt.
1, Basic Tax
2. Additional Tax
Sub Total
Spec~'Assit.
or
· Spec./Add.
, TOT. MTG. TAX
Dual Town __ Dual County __
Held for Appointment __
Transfer Tax ~
Mansion Tax
The property covered by this mortgage is
or will be improved by a one or two
NYSSurcharge 15. O0 ~ _ , familydwetlingonly.
-- -- 3ub/otal Z YES or NO
Other ;"~'~/'~ / ,_(/~' --
-- -- GrandTotal ~,/~4~ b/ I~r Iff NO, see appropriate tax close on
Tax Se~ice
Verification
-- ~ . . ...... ~J~ / Improved_
6 Satisfamions/Discharges~eleasesListPrope~ners Mailing Address J . / /
.ECO~ & RET~ TO: I '~/ / Vacant Land
/TD
JOHN G. SMITH , /
935 JACOBS LANE ~ / mD
SOUTHOLD, NY 11971 ~~ TD
Mail to: Judith A. Pascale, Suffolk County Clerk J 7 J Title Company Information
310 Center Drive, Riverhead, NY 11901J Co. Name STEWART TJ.~.le
www.suffolkcountyny.gov/clerk J Title # STll - 11911
JOHN G. SMITH
Suffolk County Recording & Endorsement Page
This page forms part of the attached (~r¥~'~"4~9~Ljo'¢~ DEED
by: (SPECIFY TYPE OF INSTRUMENT)
The premises herein is situated in
SUFFOLK COUNTY, NEW YORK.
made
TO In the TOWN of SOUTHOLD
JOHN (3. SMITH In the VILLAGE
orHAMLETof SOUTHOLD
/
BOXES 6 THRU 8 MUST BE TYPED OR PRINTED IN BLACK INK ONLY PRIOR TO RECORDING OR FILING,
(over)
CONSULT YOUR LAWYER BEFORE SIGNING THiS 1NSTRUMENT-TH~S INSTRUMENT SHOULD BE USED BY LAWYERS ONLY
THIS INDENTURE, mede the 29th day of November 2011
BETWEEN
JOHN G. SMITH, residing at 935 jacobs Lane, Southold, New York 11971
party of the first part, and
JOHN G, SMITH, residing at 935 Jacobs Lane, Southold. New York 11971
party of the second part,
WITNESSETH, that Ihe party of the first part, in consideration of
ten dollars
paid by the party of the second part, does hereby grant and release unto the party of the second part, the heirs
or successors and assigns of the party of the second pert forever,
ALL that certain plot, piece or parcel of land, wilh the buildings and improvements thereon erected, situale,
lying and being in the
Town of Southold, County of Suffolk and State or New York. being and more particurady bounded and described as set
torlh on S~hedule A hereto,
This deed is intended to cladfy the metes and bounds description ~'~he subiect premises consequent to a subdivision of
said premises. The Southold Planning Board adopted a resolutior~n November 14. 2011, whic~ subdivided 9,626
square feet from the premises known as 935 Jacobs Lane, Southold, New York 11971 (Suffolk County Tax Map
Identification: Disaict - 1000; Section - 79; Block - 6: and Lot 4.6) - said subdivided parcel is particularly bourtded and
described on Schedule B attached hereto.
Being and intended to be pert of, or a portion of, the premises conveyed to Grantor herein by deed dated 2/01/1999 and
recorded 2./2411999 in Liber 11947 Page 616. made by HMM Realty, Ltd., a New York Corporation.
TOGETHER with all right, title and interest, if any, of the pa~y of the first part in and to any streets and roads
abutting U~e above desc~bed premises to the center lines thereof; TOGETHER with the appurtenances and all
the estate and rights of the party of the first part in and to said premises; TO HAVE AND TO HOLD the
)remises herein granted unto the ~rty of the second part, the heirs or successors and assigns of the party of
the second part forever.
AND the party of the first part covenants that the party of the first part has not done or suffered anything
whereby the said premises have been encumbered in any way whatever, except as aforesaid.
AND the party of the first part, in compliance with Section 13 of the Lien Law, covenants that the party of the
first part will receive the censideratJon for this conveyance and wilt hold the right to receive such consideralion
as a trust fund to be applied first for the pu~ose of paying the cost of the improvement and will apply the same
flint to the paymenl of the cost of the improvement before using any part of the total of the same for any other
purpose. The word 'party" shall be construed as if it read 'parties" when ever the sense of this indenture so
requires.
IN WITNESS WHEREOF, the pa~ty of the first part has duly executed this deed the day,..aDd year first above
written.
/
IN PRESENCE~.~,~.~ ~~OF: ~ Smith~' ~
S~andard N.Y,B~T.U. Fora18002 - Bargain and Sa~e Deed~ with Covenant against Grantor's Acls - Unri'orm ~nowiedgment
Form 3290
ACKNOWLEDGEMENT TAKEN IN NEW VORK STATE
State of New York, County of Suffulk
On the 2~h day of Nuvember in the year 2011
before me. the undersigned, personally appeared
John G, Smith
personalty known to me or proved to me on the basis of satisfactory
evidence to be the individual(s) whose name(s) is (are) subscribed to the
within instmlncnt and acknowledged lo me that hc/sheffthey executed the
same in h/s/her/their eapacity(ies), and that by his/her/their signatu~(s)
on the instrument, the indi,Adual(s), or the person upon behalf of which
Ihe individual(s) acted, executed the instmmenl,
No, 01ZE6049647 Suffolk Coupty
Term Expires October 23.20T4
ACKNOWLEDGEMENT fly SUBSCRIBING WITNESS TAKEN
IN NEW YORK STATE
Slate of New York, County of
On the day of in the year
before me, the undersigned, a Notary Public in and for said State,
personally ap~arcd
the subscribing witness Io the foregoing instrument, with whom Iarn
personally acquainted, who, being by me duly swum. did depose and say
Ihat he/sheffthey reside(s) in
{ifllx:ple,':e ofre~Jdenceis i~aci~, i~clu~ iht atrel:t md ~:cn. nmab~ ff~T, Ihcn:oD
thai he/sheJthey know(s)
to be ~e individual described in and who executed the foregoing
instrument; that said subscribing witness was present and saw said
execute the same; and th~t said witness at the .same time subscribed
his~ther/the/r name(s) as a witness thereto
ACKNOWLEDGEMENT TAKEN tN NEW YORK STATE
Slate of New York, Courtly of , ss:
On the day of in the year
before me, the undersigned, personally appeared
personally known lo me or proved to me on the basis of satisfactory
evidence to be the individual(s) whose name(s) is (are) subscribed to the
within instrument and acknowledged to me that heJshe/they executed the
same in his/bet/their capacily(ies), and that by his/her/their signature(s)
on the in.stmmmat, the individual(s), or the person upon behalf of which
the individual(s) acted, executed the instrument.
ACKNOWLEDGEMENT TAKEN OUTSIDE NEW YORK
STATE
*State of , County of
'lOt iase~ Diswicl ofCol~mbis, Terrimv:. Pos,ses.si~ m Fm'eign Cc~nt). )
· ss;
On the day of November in the year 2011
hel'ore me, the undersigned personally appeared
Personally known to me or proved Io me on the basis of satisfaclory
evidence to be the individual(s) whose name(s) is (are) subscribed lo the
within instmmenl and acknowledged to me that he/shedthey executed Ibe
same in his/her/their capacity(tea), that by his/her/their signature(s) on
the inslmment, Ihe individual{s) or the person upon behalf of which the
individual(s) acted, executed the instrument, and that such individual
make such appearance before the undersigned in the
(add the cily. or political subdivision and the slate or country o~ other
place the acknowledgement was taken}.
Bargain and Sale Deed
With Covenants
Title No. ~:>'T'i t - I~ q t i
TO
DISTRIBUTED BY
YOUR TITLE EXP£RT$
The Judicial TIUe Insurance Agency LLG
800-281-TITLE {8485) FAX: 800-FAX-g396
RETURN BY FLAIL TO:
ACKNOWLEDGEMENT TAKEN IN NEW YORK STATE
Stale of New Ymk. Counly of Suffolk
On the 29th day& November intheyear 2011
before me. lhe undersigned. ~r~onally appeared
Johr, G. Smith
personally known Io me or proved to me on the basis of ~tisfacto~
evid~ce to ~ the [ndividual(~) whose name(s) is (are} subscd~d to
the individnal(s)acted, ex~oted the insmtmcm.
NQ 01ZE604~647 Suffolk Coun~
Term Expires October 23, 2014
ACKNOWLEDGEMENT BY SUBSCRIBING WITNESS TAKEN
IN NEW YORK STATE
State of New York, County of , ss:
On Ibc day of in tbe year
before mc. Ibe undersigned, a Nolary Public in and for said Stale.
personally appeared
Ihe subscribiog wiloe~s Io the foregoing ins~mrnem, wilh whom I am
personally acquaimed, who. being by me daly sworn, did de,se and my
IbM II~ll~lh~ re~ide(s) Jn
Ihal hefsh e~lhey know(s)
Io be lbo indlvldnal described in and who execttted tile foregoing
bL~/hefftheir name(s) as a wilness Ihereto
ACKNOWLEDGEMENT TAKEN IN NEW YORK STATE
Slate of New York, County of , ss:
On Ihe day of in the year
before me. thc undersigned, personally appeared
personally known to me or proved to me on Ibc basis of satisfaclory
evidence to b¢ the individual(.,:} whose name(s) is (are) subscribed to the
within instrument and acknowledged to me thai heJsh~/tbey executed tile
~me in his/her/their capacily(ies), and that by hi~berllheir signature(s)
on the inslmmenl, the individual(s), or thc person upon behalf of which
tile individual(s) acted, execuled Ibc inslmment.
ACKNOWLEDGEMENT TAKEN OUTSIDE NEW YORK
STATE
*State of , County of , ss:
On the day of November in the year Z011
before ma. the tmders[gned personally appeared
evidence to be the individual{s) whose name(s) is (are) subscribed to the
wilhm instrument and acknowl~lged Io me Ihat heJsll~lhey execuled the
same in hi.~aTtheir capaaity(ies), that by his/her/their signature(s) on
the instrument, the individnal(s) or the person upon behalf of which Ibc
individual(s} acled, executed the instrument, and Ihal Such individual
make snch appearance before the nndemit.med in the
(add thc city or political subdivision and the state or eountp~ or other
place tbe acknowledgelnenl was taken).
Title No.
Bargain and Sale Deed
With Covenants
~>TI~ - Il qtl
TO
DISTRIBUTED BY
YOuR TtILE ~APERT$
The Judioial Title insurance Agency LLC
800-281-TITLE (8485) FAX: 800-FAX-93g$
RETURN BY MAIL TO:
11/14/2011 89:26 6317656893
MARTIN H. SIDOB
Chair
WILLIAM J.
KENNZTH L. EDWARDS
JAMES H~ RICH IE
DONALD J, WILC~NSKI
SOUTHOLD ELEM SCHOOL
PLANNING BOARD OFFICE
TOWN OF 80UTHOLD
P~GE 82
MA.II,lNG ADDRESS:
P.O. Box 1179
Scuthold, NY 11971
OFFICE LOOATI[ON'-
Town Hall Annex
543~$ State Route Z5
(cot. Maiu Ed. & Y0uns2 Ave.)
Sou~hol~, NY
Telephone: 631 765,1938
Fax~$91 765-3136
November 15, 2011
Alexander Crawford, Esq.
8 South Gate
Shoreham, NY 11786
Re:
Final Plat Approval. & Negative Declaration: Lot Line Change for Mellas
and Smith
Located at 340 Colonial Road and 935 Jacobs Lane, Southold
aCTIVIn1000-79-6-4.6 & 29 Zoning District: R-40 and A-C
Dear Mr. Crawford:
The $outhold Town Planning Board adopted the following resolutions at a meeting held
on Monday, November 14, 2011'
WHEREAS, this proposed Lot Line Change will transfer 9,626 sq. ff. from SCTM~1000-
79-6-4.6 to SCTM#1000-79-6-29. Lot 29 will increase from 15,000 sq. ff. to 24,626 sq.
ft., and Lot 4.6 will decrease from 96,747 sq. ff. to 87,121 sq. ff. Lot 29 is located in the
R-40 Zoning District and Lot 4.6 is located in the A-C Zoning District; and
WHEREAS, an application for a Lot Line Modification was submitted on July 8, 2011 by
Richard and Patdcia Mellas for the property located 991.72 feet northeast of North
Bayview Road, SCTM~1000-79-6-4.6 & 29, in the R-40 and A-C Zoning Districts; and
WHEREAS, on August 29, 2011, the Southold Town Planning Board at their Work
Session accepted the application for review; and
WHEREAS, on September 12, 2011, the Planning Board set a public hearing; and
WHEREAS, on October 17, 2011, the public headng was closed; and
WHEREAS, on October 31,2011, the Planning Board at their Work Session accepted
the submitted draft deeds; and
11/14/2011 89:26 6317656893 SOUTHOLD ELEN SCHOOL PAGE 03
Mella8 and Sm_l_th_
Paae Two
Noveml~, r 15. 20!__1
WHEREAS, the Southotd Town Planning Board, pursuant to Town Code §240-56
Waivers of Certain Pm. visions, may waive certain elements of the subdivision review if
in its judgment tl~ey are not requisite in the interest of the public health, safety and
general welfare. After reviewing the information submitted for this application, the
Planning Board has determined that it is eligible for a waiver of the ERSAP, the Primary
and Secondary Consen/ation Area Plan, the public hearing, and the Sketch Plan and
Preliminary Plat steps of the subdivision process for the following reasons:
1. No new lots are being created;
2. The tots involved are already developed;
3. No changes will occur as a result of this Lot Line Change that would affect the
character of the neighborhood; and
WHEREAS, the Planning Board performed an uncoordinated review of this Unlisted
Action pursuant to 6 NYCRR Part 617, Section 617.7 of the State Environmental Quality
Review Ad (SEQRA); and
WHEREAS, pursuant to the Lot Line Modification Policy set by the Ptanning Board in
February 2011, this application is eligible for decision from the Planning Board prior to
receiving approval by the Suffolk County Department of Health Sentices (SCDHS) as it
meets the following criterion set forth in that policy:
· The transfer of land from an over-sized parcel (larger than the minimum zoning
requires) where the over-sized parcel remains above the minimum lot size
required, and where no new development potential will be created in the parcel to
which the land is transferred; and
WHEREAS, the Planning Board has determined that the proposed action meets all the
necessary requirements of Town Code §240 for a Lot Line Modification; be it therefore,
RESOLVED, that the Southold Town Planning Board, pursuant to SEQRA, hereby
makes a determination of non-significance for the proposed Lot Line Modification and
grants a Negative Declaration; and be it further
RESOLVED, that the Southold Town Planning Board hereby waives the requirements of
§240 to submit the ERSAP, Primary and Secondary Conservation Plans, the public
hearing, Sketch Plan and Preliminary Plat steps; and be it further
RESOLVED, that the Southold Town Planning Board hereby waives the requirement for
SCDHS approval prior to Planning Board approval; and be it further
RESOLVED, that the Southold Town Planning Board grants Final Plat Approval on
the map entitled "Boundary Line Alteration situate: Bayview Town of Southold Suffolk
County, New York', dated June 1,2011, prepared by John C. Ehlers, Land Surveyor,
and authorizes the Chairman to endorse the map.
6317556893
SOUTHOLD ELEM SCHOOL
PaGE 84
Mellas aad_Sm it h.
P~aa.cle Three
November 15, 20._1_1_
Please Note: The Southold Town Planning Board, in waiving the requirement for
SCDHS approval prior to their own approval, is simply waiving a technical requirement
of Final Plat Approval under the Town Code and makes no representations as to
whether SCDHS approval is required. SCDHS approval of this Lot Line Change may be
necessary to be in compliance with the Suffolk County Sanita~j Code, and to be eligible
for futura construction or renovations.
Enclosed please find a copy of the map which has been endorsed by the Chairman.
Please submit a copy of the recorded deed to the Southold T~vn Planning Department.
if you have any questions regarding the above, please contact this office~
Very truly yours,
Martin H. Sidor
Chairman
I understand that Southold Town Planning Board approval of this Lot Line Modification
does not grant, guarantee or waive an approval, if required, from the Suffolk County
Department of Health Services (SCDH$). I understand that I will nccd to apply
separately to the SCDHS for any appli~ ~;.~ approvals.
Signature of Ap~ ~ or Applicant's Agent
Encl.
CC:
Assessors w/map
Building Department
Legal Description New Smith Parcel
Beginning at the Point and or Place of Beginning; said point being South
28~24'40'' West, a distance of 991.72 feet from the intersection formed by the
southerly line of N. Bayview Rd. and the Westerly line of Jacobs Lane.
Running thence from said Point and or Place of Beginning along the Westerly
side of Jacobs Lane South 28°24'40" West, a distance of 180.45 to the land of Richard
Johnson and Pamela Maino, and thence along said land and also land of Carol P.
Scott North 59°30'20" West, a distance of 481.52 feet to ~he land of Edward
Connaughton and Florence Connaughton, thence along said land the following two
courses and distances (1)North 31~22'20" East, a distance of 2.79 feet; thence
(2) North 61°18'30'' West, a distance of 28.65 feet to the land of Richard Meilas
and PattiMellas, thence along said land North 28°41'30" East, a distance of 160.02
feet to the land of James Hudson and Christina Hudson and running thence along
said land South 61~35'20" East, a distance of 508.92 feet to the Westerly line
of Jacobs Lane and the aforesaid Point and or Place of Beginning said property.
Containing 87,121 s.f. or
2.0000 Acres
,~_)(I 0'1-1N~
AR~A OF '.~.XI~"KINO TAX LOT 2~ FO~. I'-1~1 I.
,,-%~.EA 0= EXID¢INO TAX LOT 4.& FOP. 5H
A~ OD PROPOCED 1AX LO-' 4,& FOR 5M1TI~
ZON~ NO
T~ LOT 2q LIED IN ZONE ~ - 40
TAX LOT 4.~ i.lED IN Z¢~ A O
~'IH LOTS A~B ~N ~ P:5~GT D
~0~ I OT5 A~ IN PIMf OlD. ICl 2~
~OTH LOC5 A¢~ NOT IN A ~A 'FLOOD'
KO lES:
· DTAte.;F
LOT 6 REFERES TO FILED
'"":,AP OF: "C~Ok',bEY E. STAT-~E::,"
F1LE~D DEC. 2, Iq86
~O~N~A~¥ L. IN~- Ai-T~R, ATION
E~AYVIEId
TOI/qN OF: 50UTHOLD
DUI=FOLK C.,OUN~, NF:~ "(ORF--. '"""-,~.
EXtST. I',I¢
AF~E]A O~ EXI.C-,TIkI~ TAX. LOT 2~
A~A ~ EXIGTI~5 Z.~ LOT 4~ FO~ ~XIT~ = o~?~J ~.F. D~ 2.22~0 AGRE~
~05E~
' ,6
~,654 ,~ C.~-._=
)0 ACRE~
..,-
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I
0 4.0 ~ .~
/,
f
f
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S CHEDU~E ~
Beginning at a concrete monument found on the line that separates land of
Mel!as to the north with land of Connaugh~on on The south said monument being at
the Point and or Place of Beginning; Said monument situate the following two courses
and distances from the corner formed by the intersection of the northerly line
of Liberty Lane and the EasTerly line of Colonial Road. Running in a Southerly
direction along the easterly line of Colonial Road South 28041'30'' Wes~ 337.13'
to a point at the Northwest corner of land of Edward Connaughton and Florence
Connaughton and the Southwest corner of the Land of Richard Mellas and Patricia
Melias. Thence South 61018'30" East 160.21' along the property line separating
land of of Me!las to the north with the land of Connaugh~on to the South To the
concrete monument above referenced as the Point and or place of Beginning.
Running thence from the monument at the Point and or Place of Beginning North
28°41'30" East, a distance of 159.73 feet to the land of James Hudson and Christina
Hudson; thence along the land of Hudson South 61o35'20" East, a distance of 60.21
feet to the land of John Smith; ~hence along the land of Smith South 28041'30"
West, a distance of 160.02 feet to the land of Edward Connaughton and Florence
Connaughton; thence along the land of Connaughton North 61018,30" West, a
distance of 60.21 feet to the above mentioned concrete monument and the Point and
or Place of Beginning. Parcel contains 9,627 S.F. or 0.2210 Acres. ~
PLEA~'E TYPE OR PRESS FIRMLY WH'EN WRITING I~N FORM
INSTRUCTIONS: http:# w~vw.orps.state.ny.u$ or PHONE (518) 473-7222
FOR COUNTY USE ONLY
PROPER~ INFORMATION
""~ I ~
I
REAL PROPERTY TRANSFER REPORT
STATE OF NEW YORK
STA~E 8OARD OF REAL PROPERTY SERVICES
RP - 5217
I
3. Tax Indicatu whore future Tax Bdls ere lO be sent
Bitllnit ,f other than buyer addm~s Iai bottom of form)
I
4. Indicate the number of Assessment
Roll 1o~mds trenlfmTad on tho deed
s~ Bos~
P,o.,dv I }xl
i ~ (Only il Pm of
I p of Pamela OR Par~ of · Pemel 4~. Planmng Boa~l with SulxlNiaon Authority Exists []
rORI .~ ~).~, 4~. SubdNision Aplxova, wes Flequired tm' ,ret. afar []
' ' '~c~s 4C. Pemel Agl:Xosud ior Subdivislon vlnth Map Provided []
FIRST
7. Check the boa below which most aG'gilretidy dsaerlbsa the use of the praperty it the time of sale:
B I I 2 or 3 Family Resident'el ~ Commercial Indusl~'lsl
C U Residential Vacant Land A~aitment Public Service
D U Non. Residential Vacant Land Enterla;nmant I Amusement Forest
Che~k the bomm bdow sa they N2My:
~. Ov~Mmhip Type ia Condominium []
9. New Construction on VKaal L~nd []
I~A. Ptoper~ Located within an A~rioultuml District []
laB. Buyer recaivm:l a disclosum notice indicating []
that the pmpelly is in an A~Hcultural Districl
SALE INFORMATION
11. Sale Contract Date
i II/~(// lit
Month OW Yoar
,,.o..of,.,.,Treos.. t I/ / o~c/ / }t ~
.... ~.o.,,,
13. ~11 Sale ~ I , ~
14. ladl~ ~e ME~e ~ ~al I , , , , ~]
0
~My Incl~ In ~o ~ ~ ~ ·
ASSESSMENT INFORMAT~ON - Date should ~fle~t the latest Final ~sessmerzt ~oll Gad Tax Bill I
15, Check one m more of these comEflons is eMiliceble to
A ~ ~io ~n ~l~s or Former
B ~ ~le ~n Rela~ Com~ni~ or Panners in Busin~
C ~ One of the B~m is al~ a ~ller
D ~ Ba~r or ~ller is ~mme~ ~e~ or ~ing Institmion
E ~ ~ Ty~ ~ Wa~aoty or Baleen a~ Sale I~ BeI~)
F ~ Sale ~ Fm~nal or m ~an FeB Im~ (S~iN ~lw)
O ~ SignF~aM Cha~e in Pm~ B~n Te~ble Stat~ and Sale
II ~ Sale of Busin~ is Inclu~ in Sale ~e
I I Xl ~er Unusual F~m Aff~i~ ~ Pri~ (S~iN BeI~)
16. YonrdMmontRoflh'om I ) .J I l?.Tm.lA.~Valueiofellpar=dslntraosfofll
18. Prope~f Claes ' O~ ~ 1-1 I 19. Salton, Dl~ttlet Name I
20, Tm( Map IdattifimIM I Roll MentJfierie) (il more then bur, IttiCh Grit with additional idaittitio~a))
10oo o"/q. oo , , ,
, l.g,c oo¢,o 8 rrdO .007 ,
CERTIFICATION
I eerlify thai ~11 ~ I1~ ilee~ Ii in~t~malioa eolemd ua I~b fu~m ore lee amI eerwct ilo I1~ heel afm)' ~au~lea~e end bdlefl emi I
el #ny ~illful latw slal~nent e~ mmeriM lad I~min ~BI .~eel me le the prm~ a~ Ihe I~osl law relalh~ m b mald~l~ a~d ~
BUYER'S A'n'ORNEY
NAME FIRST h~P
I
INEW YORK STATE
COPY