SEC FORM 3 SEC Form 3
FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
 
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1. Name and Address of Reporting Person*
Vartanian Nishan J.

(Last) (First) (Middle)
1000 CRANBERRY WOODS DRIVE

(Street)
CRANBERRY TOWNSHIP PA

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
12/11/2012
3. Issuer Name and Ticker or Trading Symbol
MINE SAFETY APPLIANCES CO [ MSA ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Vice President
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Common Stock, no par value 10,025 D
Common Stock, no par value 1,090 I By Wife
Common Stock, no par value 200 I UGMA account for daughter
Common Stock, no par value 250 I UGMA account for son
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Incentive Stock Option 02/23/2012 02/23/2019 Common Stock, no par value 5,608 17.83 D
Incentive Stock Option 02/23/2013 02/23/2020 Common Stock, no par value 4,060 24.63 D
Incentive Stock Option 02/23/2014 02/23/2021 Common Stock, no par value 2,980 33.55 D
Incentive Stock Option 02/16/2015 02/16/2022 Common Stock, no par value 2,725 36.69 D
Incentive Stock Option 02/27/2009 02/27/2016 Common Stock, no par value 2,397 40.08 D
Incentive Stock Option 02/21/2010 02/21/2017 Common Stock, no par value 2,408 40.095 D
Incentive Stock Option 02/26/2011 02/26/2018 Common Stock, no par value 2,210 45.24 D
Incentive Stock Option 12/14/2005 02/23/2015 Common Stock, no par value 2,189 45.68 D
Non-statutory Stock Option 02/23/2012 02/23/2019 Common Stock, no par value 3,825 17.83 D
Non-statutory Stock Option 02/23/2013 02/23/2020 Common Stock, no par value 3,131 24.63 D
Non-statutory Stock Option 02/23/2014 02/23/2021 Common Stock, no par value 536 33.55 D
Non-statutory Stock Option 02/16/2015 02/16/2022 Common Stock, no par value 1,310 36.69 D
Non-statutory Stock Option 02/26/2011 02/26/2018 Common Stock, no par value 894 45.24 D
Non-statutory Stock Option 12/14/2005 02/23/2015 Common Stock, no par value 358 45.68 D
Explanation of Responses:
Douglas K. McClaine, Attorney in Fact 12/17/2012
** Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 5 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number.