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' Fere~ 66d U. S. TREASURY ~EPARTMENr - SnrEewi~ aEVeKUE sEavrtE • ~ Fa qrwwl Use 8~ R~cd' .ct
(REV. 8-67) ~ CERTIfICATE Of REIEASE 0~ iEOERAI TAX t~EN c_ o
DtSTRICT SERIAL NO. PQI t ~
~~~IL'Ir+i~ 18 714 B14~? P591.~ ~ OO~OK~~RCQ~T~
I her~br c~?tify thot os to th~ (ollowiny-na ~ ioxpoytr th~ r~quir~nNnts o~ S~cti~n ~~,f~~
6325(0), Int~rnal R~v~nw Cod~, hov M~n satl.~fi~d.w+th r~spect to fM tox~s eny-
m~rot~d b~low, to9~the? with oli stotutoryr addit~oes provid~d by S~ction 6321; o~d ~8
~ that the lie•+ (w such toxes and swtutay additions has thir~by b~~n r~l~os~d. TM
prop~r oNicer in th~ offic~ wher~ notic~ of intirnol nv~nw tox li~n was fil~d on ~
, ,~P~'#.etebez` 30~ , j9 69 - is henby outhori:~d to sak~ noMtion ~
oe his books to show the ~el~cse of soid li~n, insofor os tM litn i~kt~s to tM
followin9 tox~s.
NAME OF TAXPAYER ~ ~
~~~~~Z~~,~~~r~4 .
RESIDENCE -
~7 S. ti~Rl ~~j ~ ~!'N~ ~!'5~~~
CLASS OF TAX ? UNPAID BALANCE
(Tox Retur~ Form No.) PERIOD EN~ED ASSESSMENT DATE IDENTIfYfNG NUMBER ; OF ASSESSMENT
(o) (b) (c) (d) : (e)
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~ PLACE OF FILING
~ ~ ~ TOTAL S
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WITNESS my hand at '~^{~~nr~ 1? e~ ~'1 oz'+ca , on this,. 4
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rhs ~?~;-1 doy of =aF~erncc~r ,19.~~ ~U~~~ -
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SIGMATURE _ TITLE
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MOTE: Ce~~ificon d oN' ~r ~Mari:~ br lo.r ~e tek~ oc nowl~dy~~nts ~s net ~ss~ntio) le tM rol~dity of NNic~ ~ Fed~rel Tp Li~n G.C.M.
2b419, C.B. 195051. 1.) 5s
~ART 3-To b~ us~d for ncordins p~rpos~s
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