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(Country or other po itica division ~ , ~
OONSULATE GENERAL OP '1~18 UNITED STATES OF AMERICA ~
(Name of Consular Office): ~
I ~ ,Consul
of the United States of America at ±
duly commissioned and qualified, do hereby certify that on this
day of 1966, before me personally
appeared _
to me personally known, and known to me to be the individuai described
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in, whose name is subscribed to, and who executed the foregoing instrument
and being informed by me of the contents of said instrument, said person
duly acknowledged to me that he (or she) executed the same freely and
voluntarily for the uses and purposes therein mentioned.
IN WITNESS WHEREUF I have hereunto set my hand and of ficial seal
the day and year last above written at
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( SFAL)
Consu 1 o~`-the United States
. of America
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