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HomeMy WebLinkAboutL 12755 P 924 11111111 IIII Iflll 11111 IIIII IIIII II111 IIIII IIIII IIII 1111 1111111 Illlf IIIII flll IIII SUFFOLK COUNTY CLERK RECORDS OFFICE RECORDING PAGE Type of Instrument: DEED Recorded: 12/11/2013 Number of Pages: 9 At: 10:08:52 AM Receipt Number : 13-0158595 TRANSFER TAX NUMBER: 13-13011 LIBER: D00012755 PAGE: 924 District: Section: Block: Lot: 1000 110.00 01.00 007.001 EXAMINED AND CHARGED AS FOLLOWS Deed Amount: $262,500.00 Received the Following Fees For Above Instrument Exempt Exempt Page/Filing $0.00 YES Handling $0.00 YES COE $0.00 YES NYS SRCHG $0.00 YES EA-CTY $0.00 YES EA-STATE $0.00 YES TP-584 $0.00 YES Notation $0.00 YES Cert.Copies $0.00 YES RPT $0.00 YES Transfer tax $0.00 YES Comm.Pres $0.00 YES Fees Paid $0.00 TRANSFER TAX NUMBER: 13-13011 THIS PAGE IS A PART OF THE INSTRUMENT THIS IS NOT A BILL JUDITH A. PASCALE County Clerk, Suffolk County e + ' 2 Number of pages , RECORDED 2013 Dec 11 10:08:52 AM TUDITH A. PASCALE This document will be public CLERK OF SUFFOLK COUNTY record. Please remove all L D00012755 Social Security Numbers P 924 DT# 13-13011 prior to recording. Deed / Mortgage Instrument Deed / Mortgage Tax Stamp Recording / Filing Stamps 3 FEES 1 Page /Filing Fee Mortgage Amt. 1. Basic Tax Handling 2C'6' Oo 2. Additional Tax TP-584 Sub Total Spec./Assit. Notation or EA-52 17 (County) Sub Total Spec. /Add. EA-5217 (State) TOT. MTG. TAX Dual Town Dual County R.P.T.S.A. Held for Appointment Comm. of Ed. 5. 00 Transfer Tax (Pat Mansion Tax Affidavit i ~ The property covered by this mortgage is Certified Copy or will be improved by a one or two 15. 00 family dwelling only. c arge Sub Total YES or NO Other Grand Total -e y e rn /e If NO, see appropriate tax clause on page # of this instrument. -7 2O t3 4 Di; 13033846 1000 11000 0100 007001 5 Community Preservation Fund R-nffl Real Pro RPM H +~I~Illl~ll~l~llll~l~lllilllllJlllllllil~llf IJII~ Consideration Amount $ Tax Sen 09_DEC-1 I I 1 II i I 1 I I Agenc• CPF ax Due $ Verification Improved 6 Satisfactions/Discharges/Releases List Property Owners Mailing Address RECORD & RETURN TO: Vacant Land SUFFOLK COUNTY P DIV. OF REAL PROPERTY ACOUIg,A? ncasa TD O AND MANAGEMENT TD H. LEE DENNISON BLDG. -2nd FLOOR 100 VETERANS MEMORIAL HIGHWAY TD P.O. BOX 6100 HAUPPAUGE, NY 11788-0099 Mail to: Judith A. Pascale, Suffolk County Clerk 7 'Lytle Com an Information 310 Center Drive, Riverhead, NY 11901 Co. Name ARrruerTC Tarenunnuemgp wvwv.suffoikcountyny.gov/clerk • 'rale# O - - c715c~-~-Q 3 8 Suffolk Count Recording & Endorsement Page_ This page forms part of the attached E c- made by: JOHN ELLIOT DAWSON, A/K/A ELLIOT DAWSONSPECIFY TYPE OF INSTRUMENT) AND MARY HOLLAND,A/K/A MARY D. HOLLAND, The premises herein is situated in AYK7A MARY A TH HOLLAND, INDIVIDUAUWFOLK COUNTY, NEW YORK. AND A.-S DR1.412999 UNDER THE D TESTAMENT OF BETTY B. DAWSON AND OF KATHRYN T TO In the TO~of SOUTHO n COUNTY OF SUFFOLK In the VILLAGE or HAMLET of BOXES 6 THRU 8 MUST BE TYPED OR PRINTED IN BLACK INK ONLY PRIOR TO RECORDING OR FILING. (over) n9 -3?-0/10 SUFFOLK COUNTY BARGAIN AND SALE DEED WITH COVENANTS THIS INDENTURE, made as of the a7 day of 4:~G141 2013. - c~ - BETWEEN John Elliot Dawson, a/k/a Elliot Dawso'-,,with-an address at 81 Crows Creek Road, Pittsboro, North Carolina 27312/ and Mary Holland, a/k/a Mary D. Holland, a/k/a Mary Elizabeth Holland,/ with an address at 400 Short Road, Cutchogue, New York 11935,/both individually and as Devisees under the Last Will and Testament of Betty B. Dawson, Surrogate File#182921991 and under the Last Will and Testament of Kathryn Fleet, Surrogate File#720P1994, party of the first part, AND the COUNTY OF SUFFOLK, a municipal corporation of the DISTRIC State of New York, having its principal office at the Suffolk 1000 County Center, Center Drive, Riverhead, New York 11901/party of the second part, SECTION 110.00 WITNESSETH, that the party of the first part, in consideration of TWO HUNDRED SIXTY TWO THOUSAND FIVE HUNDRED and BLOCK 00/100 DOLLARS ($262',500.00) and other valuable consideration 01:00 paid by the party of the second part, does hereby grant and release unto the party of the second part, the heirs or LOT successors and assigns of the party of the second part forever, 007.001 ALL, that certain piece or parcel of land, situated in the Town of Southold, County of Suffolk-, and State of New York, more particularly bounded and described as follows: (see description annexed hereto and made a part hereof): THIS DEED is given in accordance with Article XII of the Suffolk County Charter, as amended and effective December 1, 2007, Resolution, and Resolution No. 1046-2009, all on file with the Clerk of the Suffolk County Legislature. BEING AND INTENDED to be the same premises as Parcel II described in deed recorded in Liber 9179 Page 354. TOGETHER with all right, title and interest, if any, of the party of the first part in and to any streets and roads abutting the above described premises to the center lines thereof; TOGETHER with all right, title and interest, if any, that the party of the first part has in and to any strips and gores between.the above described parcel and adjoining owners. TOGETHER with all right, title and interest of the party of the first part in and to all streets and roads abutting the above described premises to the center lines thereof, and the ponds, marshes, rivers, lakes, creeks, waters, and lands under water located in, upon or adjoining the above described premises, and all littoral, riparian and shore rights in any way pertaining or belonging thereto. 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 premises herein granted unto the. party 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. osoixe.aca IaZ Sl G 5W c d Nio)sci W%,km ~w PUIToaPo gg ON 30 04e4S Tqn a oN •guawnags,ui aqq paqnoaxa 'PagoP TPnpTnTPuT aqq go?gM JO ;Tegaq uodn uosaad aqq ao 'TenpTATpuT aqq 'quawnagSUT aqq uo aangeubTS sTq Aq gPgq pup 'AgroPdPO sTg UT awes aqg pagnoaxa aq gPgg aw og pabpaTMOU-[Oe pup quawnzgsuT UTggTM aqq oq pagTaosgns sT aweu asogM TPnpTeTPUT aqq aq oq aouapTAa AaogoP;sTges go sTSeq aqq Uo auw oq Panoad To aw og UMOUN ATTPUOSaad 'uosMPQ goTTTZ U/N/e 'uosMPQ -40TTTE ugor paapadde ATTPUOSaad 'PaubTSaapUn aqq 'aw aao;aq '£TOZ apaA aqq UT go APP y}ll sTgq uO ( Gvd N~ ao XiNnoo (VN170HVo HSHOx 30 RIVss PueTToH ggaqezTTH AaeW e/N/P 'PueTTOH •Q AaeW e/N/P 'puPTT A eW . 111~- UosMea 40TITH e/x/e 'uosMPQ JOTTTH U ,40r •UaggTaM anoge gsaT; aeaA pup App aqq paap stgg pagnoaxa ATnp seq gaed gsaT; aqg go Aqaed aqq ',3oZHZHM sszNxim HI •saaTnbaa os aanguapuT.sTgq go asuas aqq aanauagM „saTgaPd„ Peas qT 9T sp panagsuoo eq TTPgs tiATAHVdii CUM ZHZ •AaoguanuT Agunoo NTo;gns aqq UT aouds uado se UTewaa gsnw puP paZTTTaags ATguauewaad pawaap ST Taoaed ao aoaTd sTgq PUP 'Sasodand buTsnoq aoao;3[aoM aog paaanas aaaM (s)HQHM gOTgM 'wPaboad sggbTg quawdoTanaa ;O aagsueas aqq aog '900Z-ZTb ON UOTgnTosag Aqunoo XToggnS pup '(aagaPgo Aqunoo XTO3;nS aqq ;o IIX aagdpgo) LOOZ IT aaguiaoaG aATgoa;;a PUP papuawP se 'weaboad UOTgoagoad zagPM buT:[uTaa Agunoo xToTgns aqq ggTM aouppaoooe uT spun; papuoq buisn pasegoand seM TaOaPd ao aoaTd pagPgsaao;e sTgz :AgTngadaed UT pueT aqq ggTM una TTPgs goTgM UOTgoTagsaa PUP gUPUaeoo P agngTgsuoo TTPgs gdeabeaed bUTMOTTO; aqq QMK •puPT 3o Taoaed ao aoaTd pagegsaao;e aqq wozg (j s)2iQHM„) (s)ggbTH quawdoTana? buTsnoH 80aogN-TOM (0) 03GZ ggTMaaaq SzanaS 'SOOZ-ZT6 'ON UOTgnTosaH Aqunoo NTojjns pup ';oaaagq (o)(Z)(K)Z -ZTO § og pagTwTT qou qnq buTpnToUT 'LOOZ IT aagwao@o anTgOag;a pup papuawP se 'aagaego Aqunoo >[TO33nS aqg 30 IIX aagdego ggTM aouepaoooe UT 'gaed puooas aqg go Agaed aqg UMV •asodand aaggo AUe ao; awes aqg 3o TPgoq aqq go gaed Aue buTsn aao;aq guawanoadwT aqg ;O gsoo aqq go quawAed aqq oq gsaTg awes aqg ATdde TTTM PUP quawanoadwT aqq ;O gsoo aqg buTAPd go asodand aqq aog gsaTg PaTTdde aq oq pun; gsnaq P se uOTgPaaPTSUOO qons anTaoaa og ggbTa aqq PToq TTTM PUP aoueAanuoo sTgq ao; uOTgeaapTsuOD aqq aATaoaa TTTM gapd gSaT; aqq go Agzed aqq gegg sgupuanoo 'MPZ UaTZ aqg ;o £T UOTgoaS ggTM aOUPTTdwoo UT 'gaed gsaT; aqq go Agapd aqg atm STATE OF NEW YORK) SS: COUNTY OF SUFFOLK) p~ On this 97 day of /V in the year 2013, before me, the undersigned, personally appeared Mary Holland, a/k/a Mary D. Holland, a/k/a Mary Elizabeth Holland , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her capacity, and that by her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. MARY E MC DONALD NOTARY PUBLIC STATE OF NEW YORK Notar Public: State New York SUFFOLK COUNTY LiC. X01 MC4?34956 CG':19d. EXP ~a ' 3 f BARGAIN AND SALE DEED DISTRICT 1000 WITH COVENANT AGAINST SECTION 110.00 GRANTOR'S ACT BLOCK 01.00 TITLE NO. 09-38-0150-7943 LOTS 007.001 JOHN ELLIOT DAWSON, a/k/a ELLIOT DAWSON AND MARY HOLLAND, a/k/a MARY D. HOLLAND, a/k/a MARY ELIZABETH HOLLAND Individually and as Devisees under the Last Will and Testament of Betty B. Dawson and of Kathryn Fleet TO COUNTY OF SUFFOLK RECORD & RETURN TO: PHYLLIS J. BENINCASA Dept. of Economic Development and Planning Div. of Real Property Acquisition and Management H. Lee Dennison Bldg., 2°d Floor P.O. Box 6100 Hauppauge, New York 11788 OS-0124:6'94 CHICAGO TITLE INSURANCE COMPANY SCHEDULE A (Description) TITLE 09-38-0150-7943 AMENDED AS OF 10/1/13: ALL that certain plot, piece or parcel of land, situate, lying and being at Cutchogue, Town of Southold, County of Suffolk, State of New York, more particularly bounded and described as follows: BEGINNING at the intersection of the northerly side of West Road and the westerly side of Creek Avenue running in a northwesterly direction, 977 feet more or less.to the point of beginning. BEGINNING at a concrete monument; THENCE South 61 degrees 46 minutes 30 seconds West for a distance of 467.84 feet (490.00 feet deed) to the edge of Wickham Creek; RUNNING THENCE the following 74 courses and distances along Wickham Creek: THENCE North 52 degrees 54 minutes 26 seconds West for a distance of 38.55 feet to an E Creek; THENCE North 59 degrees 57 minutes 06 seconds West for a distance of 30.90 feet; THENCE North 48 degrees 58 minutes 44 seconds West, for a distance of 34.27 feet; THENCE North 41 degrees 02 minutes 56 seconds West, for a distance of 34.38 feet; THENCE North 41 degrees 50 minutes 49 seconds West, for a distance of 24.41 feet; THENCE North 38 degrees 12 minutes 37 seconds West, for a distance of 24.00 feet; THENCE North 22 degrees 12 minutes 12 seconds West, for a distance of 23.19 feet; THENCE North 28 degrees 51 minutes 15 seconds West, for a distance of 30.88 feet; THENCE North 16 degrees 43 minutes 46 seconds West, for a distance of 32.58 feet; THENCE North 42 degrees 22 minutes 28 seconds East, for a distance of 37.82 feet; THENCE North 88 degrees 19 minutes 02 seconds East, for a distance of 24.28 feet; continued CHICAGO TITLE INSURANCE COMPANY SCHEDULE A (Description) - Page 2 TITLE 09-38-0150-7943 THENCE South 84 degrees 16 minutes 08 seconds East, for a distance of 28.76 feet; THENCE South 44 degrees 13 minutes 50 seconds East, for a distance of 24.36 feet; THENCE South 26 degrees 57 minutes 07 seconds East, for a distance of 27.58 feet; THENCE South 61 degrees 37 minutes 08 seconds East, for a distance of 36.22 feet; THENCE South 29 degrees 02 minutes 56 seconds East, for a distance of 31.50 feet; THENCE South 34 degrees 38 minutes 15 seconds East, for a distance of 31.47 feet; THENCE South 07 degrees 48 minutes 18 seconds East, for a distance of 22.90 feet; THENCE South 60 degrees 44 minutes 05 seconds East, for a distance of 40.84 feet; THENCE South 81 degrees 29 minutes 09 seconds East, for a distance of 28.67 feet; THENCE North 42 degrees 12 minutes 06 seconds East, for a distance of 13.00 feet; THENCE North 35 degrees 08 minutes 13 seconds West, for a distance of 10.70 feet; THENCE North 55 degrees 42 minutes 13 seconds West, for a distance of 21.92 feet; THENCE North 79 degrees 49 minutes 38 seconds West, for a distance of 24.64 feet; THENCE North 57 degrees 16 minutes 30 seconds West, for a distance of 15.52 feet; THENCE North 19 degrees 57 minutes 32 seconds West, for a distance of 16.10 feet; THENCE North 28 degrees 43 minutes 18 second West, for a distance of 16.23 feet; THENCE North 31 degrees 26 minutes 33 seconds West, for a distance of 16.09 feet; THENCE North 24 degrees 43 minutes 16 seconds West, for a distance of 28.66 feet; THENCE North 17 degrees 52 minutes 03 seconds East, for a distance of 21.11 feet; continued CHICAGO TITLE INSURANCE COMPANY SCHEDULE A (Description)- Page 3 TITLE 09-38-0150-7943 THENCE North 27 degrees 50 minutes 06 seconds East, for a distance of 33.57 feet; THENCE South 88 degrees 52 minutes 23 seconds East, for a distance of 23.36 feet; THENCE South 49 degrees 39 minutes 51 seconds East, for a distance of 17.08 feet; THENCE South 57 degrees 15 minutes 37 seconds East, for a distance of 20.58 feet; THENCE South 40 degrees 25 minutes 26 seconds East, for a distance of 26.21 feet; THENCE North 63 degrees 51 minutes 53 seconds East, for a distance of 9.26 feet; THENCE North 28, degrees 39 minutes 12 seconds West, for a distance of 25.62 feet; THENCE North 38 degrees 41 minutes 38 seconds West, for a distance of 21.04 feet; THENCE North 12 degrees 31 minutes 26 seconds East, for a distance of 5.70 feet; THENCE South 80 degrees 51 minutes 51 seconds East, for a distance of 16.19 feet; THENCE South 40 degrees 43 minutes 11 seconds East, for a distance of 16.15 feet; THENCE South 50 degrees 57 minutes 24 seconds East, for a distance of 19.45 feet; THENCE South 71 degrees 33 minutes 48 seconds East, for a distance of 27.27 feet; THENCE South 65 degrees 15 minutes 39 seconds East, for a distance of 28.30 feet; THENCE South 78 degrees 49 minutes 37 seconds East, for a distance of 23.67 feet; THENCE South 74 degrees 59 minutes 00 seconds East, for a distance of 27.47 feet; THENCE North 74 dgrees 44 minutes 02 seconds East, for a distance of 16.81 feet; THENCE North 46 degrees 50 minutes 51 seconds East, for a distance of'26.84 feet; continued CHICAGO TITLE INSURANCE COMPANY SCHEDULE A (Description) - Page 4 TITLE 09-38-0150-7943 THENCE North 40 degrees 25 minutes 27 seconds East, for a distance of 36.59 feet; THENCE North 36 degrees 26 minutes 39 seconds East, for a distance of 50.05 feet; THENCE North 29 degrees 17 minutes 31 seconds East, for a distance of 48.04 feet; THENCE North 20 degrees 15 minutes 57 seconds East, for a distance of 34.11 feet; THENCE North 05 degrees 15 minutes 25 seconds West, for a distance of 28.77 feet; THENCE North 41 degrees 23 minutes 00 seconds West, for a distance of 27.46 feet; THENCE North 36 degrees 11 minutes 05 seconds West, for a distance of 32.05-feet; THENCE North 20 degrees 12 minutes 02 seconds West, for a distance of 29.39 feet; THENCE North 18 degrees 06 minutes 27 seconds West, for a distance of 23.25 feet; THENCE North 03 degrees 25 minutes 22 seconds East, for a distance of 28.83 feet; THENCE North 38 degrees 39 minutes 57 seconds West, for a distance of 32.10 feet; THENCE North 44 degrees 28 minutes 08 seconds West, for a distance of 23.23 feet; THENCE North 50 degrees 21 minutes 28 seconds West, for a distance of 23.22 feet; THENCE North 54 degrees 38 minutes 11 seconds West, for a distance of 25.20 feet; THENCE North 66 degrees 31 minutes 25 seconds West, for a distance of 24.00 feet; THENCE North 67 degrees 06 minutes 11 seconds West, for a distance of 26.45 feet; THENCE North 68 degrees 54 minutes 03 seconds West, a distance of 22.56 feet; THENCE South 89 degrees 48 minutes 53 seconds West, for a distance of 41.48 feet; THENCE North 63 degrees 52 minutes 01 seconds West, for a distance of 20.64 feet; continued CHICAGO TITLE INSURANCE COMPANY SCHEDULE A (Description) - Page 5 TITLE 09-38-0150-7943 THENCE North 42 degrees 09 minutes 13 seconds West, for a distance of 16.08 feet; THENCE North 19 degrees 46 minutes 42 seconds West, for a distance of 18.02 feet; THENCE North 21 degrees 38 minutes 00 seconds West, for a distance of 19.29 feet; THENCE North 45 degrees 04 minutes 13 seconds West, for a distance of 19.33 feet; THENCE North 42 degrees 27 minutes 26 seconds West, for a distance of 17.07 feet; THENCE North 32 degrees 27 minutes 45 seconds East, for a distance of 13.56 feet; THENCE North 01 degrees 30 minutes 29 seconds West, for a distance of 32.16 feet; THENCE North 75 degrees 43 minutes 10 seconds East, for a distance of 266.68 feet (305.00 feet deed) to the westerly side of West Creek Avenue; THENCE the following (2) courses and distances along the westerly side of West Creek Avenue: THENCE South 00 degrees 52 minutes 50 seconds West, for a distance of 192.00 feet to a MAP; THENCE South 19 degrees 05 minutes 10 seconds East, for a distance of 398.32 feet to the point or place of BEGINNING. Ake" .r ~r PLEASE TYPE OR PRESS FIRMLY WHEN WRITING ON FORM INSTRUCTIONS (RP-52174NS): www.orps.state.ny.us FOR COUNTY USE ONLY p Gz , I New York State Department of C1. SWIS Code 10;-3 I a Taxation and Finance C2. Date Deed Recorded ( OMice of Real Property Tax Services am~~^yow RP- 5217 C3. Book T5.0 C4. Page Real Property Transfer Report (91`10) PROPERTY INFORMATION ! ~a ~s r G (Le G(G I~y ~ n L1` ~ ~ ocat°tio ! am- 9ot~n I I I I GTY aR TOWN VILLAC,E 2P COD[ 2. BuyerysI n J O Na f r , e-~~ I , Nee Sara m I Dow- I m61 Niel. 3. Tax Indicate where future Tax Bills are to be sent I Billing If other than buyer address (at bottom of form) ~7aRNxtrg-r'G~teQrl~ 1 161 I Address I I 6IIIEEr NUMaER AND aTREcT MME Cirf qTOWN IrTt LPCODE 4. Indicate the number of Aseessmerd ? (Only If Part of a Parcel) Check as they apply: Roll parcels transferred on the deed { 0 of Parcels OR Pan of a Parcel ? 4A Planning Board with Subdlvlslon Authority Exists 91. 4B. Subdivision Approval was Required for Transfer B PPrrooperty I 1 CE~~ X I OR 1 ~ a IC. Pa(~}eI1/A/pip for Subdiviai~n vIntth~Ma~P Provided `~FPa - •-~;M ;bivisi r`+~Sp I tp Sim 1 $2 6. Naalme { I [jWT lA~. AVZ L~.- ~ ! t 7cXy tidlt a-d; L`. T. Check the box below which most accurately describes the use of the property el tfie ems of sale: Check the boxes below as they apply: ? a. Ownership Typo is Condominium A One Family Residential E 2 AgrialtuAll 1 Community Service 9. Now Construction on Vacant Lend B 2 or 3 Family Residamhal F Commercial J Industrial ,(IA. Property Located within an Agricultural District C Residential Vacant Lend G Apartment IC Public Service 10B. Buyer received a dleclosi m notice Indicating D Non-Residential Vacant Lend H Enlensinment I Amusement L Forest that the property is in an Agricultural District SALE INFORMATION f 5. Check one or more of these conditions as applicable to transfer. 11. Sale Contract Date 1 Q / /t7 / A Salo Between Relelives or Former Relalives oar B Sale Between Related Companies or Partners in Business I ' C One of the Buyers is also a Seller 12. Date of Sale I Transfer / b2 O~ U uyer or Seller is GQMMTerd /teeny or Lending Inshtutlon ear E Deed Type not Warranty or Bargain and Sale (Specily Below I' Sale of Fractional or Less [hen Fee Interest ( Specify Below ) G Significant Change In Property Between Taxable Status and Sale Dates 13. Full Sale Price 5, o. o • 0 • t I H Sale of Business is Included In Sale Price ( Fug Sale Price is the total amount paidfor the property including personal property. I I Ober Unusual Factors Affecting Sale Rice ( Specify Below) This payment may be in the form of cash, otter property or goods. or the assumption of J None mortgages or other obligations.) Please round fo ere nearest whole do8eramount. 14. Indicate the value of pomonal y b 0 J Property Included in the sale ASSESSMENT INFORMATION - Data should reflect the latest Final Assessment Roll and Tax Bill 16. Year of Assessment Roll from I 1 . l 17 Total Amassed Value (of all parcels In transfert which Information taken -01 18. PropertyClass i ,3 I, -L L J 19. School District Name i. 1107-ri'7- j(r En * / w 20. Tax Map tdenfif girls) f Roll Identlner(s) ( B more than four, attach sheet with additional Ident[flsr(s) ) 1/001) 0,00-01r(.) o-004'001 I _ 1 I I L- _ . - J CERTIFICATION 1 cerily Nat ell of era Items of Isher tlen entered an this form tin few and eerreet (tar Ms beet of my' ugrrledgo and bel" and I understand that On making of any wMfel falw at¦temant of material fact henln will sub)ect am to the prevlalens of Me panel low relative to the making and filling of false Instmmenlo. SELLER SIGNATURE BUYER CONTACT INFORMATION (Enter inkhimMkn for the buyv None: N buyer a I.I.C. Society. msociatm, corpastar. pm sea /t ramparry, ee:sa a erety to and an InGdaul sgoa or fxkhdary. char a romp and convect edamaton tAf`l r _ I ;4 J Men krdMduellmpaaeN pwly who an onswa qunsom repardkrg IM aenala rrusl tro arcaed. SEVER MTIxB DAT type or print Cloudy.) l _ YEW GNATURE _ D Q, r I I17'J LA47 NMC MIT NAME /VI^_ „/JT1t 4 - -.DYER 81aNAlURE - - - aAIE BUYER'S ATTORNEY r MEA y"r~wr~E.x7a-ER .A T NAME ner NAVIe I arMETMM3ER • 91REEr NAME AR ~s3-s,33 CODE TELErN10NE NU1wER V- 1 J 4-• '1.+..8. MG ? N~ I 7 NEW YORK STATE 07YOR TGaN erATE ap coos COPY J