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HomeMy WebLinkAbout2469 , - - - - - _ - - _ . . _ __~.R'~ . ~ _ • ' § _ ,.±~'F t•' ~ 01~4~L? DEPAIZTMENT. ~ ~~~~H. ~ : : . - r~..n ~s- D;e.. N... D~Y~i~N -_~:1fITA1. STA~1/TICi~ 14~.4e.~~~`r`~ y r«~- ~~C~RTIF.ICATE OF AFi?T~-~. , - ~ OECLI?sEO--i~IAMR ~ ' r_• ~11i~t : l~Mt : " A7Eo if.° • ~~'1.Y~ . ~ ~ - ~ • ,L ~ . . ' ' ` ' Kr, - ~ ~ ~ ~ce ?i... a[--~ ~ ..~uu a?: a +~e~ r < c~ i h+~! ~ _ j t:';~y~~..~ a. Al11~s aa, s... _ 1: atr, n~uoE: ot wcwt~a~ or o~?t~t• saeE an tyws OIMik_ . ~ : f ~~a.ntaR r ~ r~~ .~`.fl . _ ~ ~ . ~ ~`f ~ . k STArE o! ftdN ~1yau4t/~.+f..ar~: O~iAr a! p~dlt, _ i+w~t r ~~k . s~Mrf/ - . . . ' , ~ . ~~s. - _ . 1 " = ~ ` : ~ '•.,ti ~ i ~ ~ ~ - ~~f t. US~ M, sr • ~ SOCU4l Sl~tlTT 111Mr/ER wAi O~AlLb EVl~ Y. hA~ . ' c _ . z y ~ i ~ uswt lESwENt! ~2a ~ • - yYei, !`Q ~ 1 7e.i~lesr?w1~Nr at ,a~it : ,:{i~r'u~~u~u~?~~5+~ a}~ ~ . . _ . . w~Eet aEa.Fw~ ysu~c oca~~uwn t~w* ii.~ N•rw+ i... -W , y+4 4! !4Nrl~lt - uvrr. ~i oew~H _ d ; = «..It. : ' . N srN..~tJ - , ~N~jov~a.v. O 1"a3A1" - ~ - - - _ _ _ RES:DEMiEiOOff R A~ COINR~ QTr. YIiIARiE OR 40CA~ION . Cq7 t11H~i iTlElt l~.~ ADr/Si~OM. . I 7s ~?a~~ ~a.Ohio ti . ~tark ~4. C~asnto ,v~o ~ - ~A7NE*-t+.wE Finr Yf/Ilt LY . IWiYER-JiAt~Rl>NAAI[ FJru Ml~fM.. . I.ar Y Lc~uis To~zi u. Forence : : ° " . . Z INFORMANT--NAME rWtu~G AfI~Si ~SasN, ~r ~.D. M.,.w~i ~!N : ,;,?Izs.Ai~holaa '~o2zi ~n. ~FOG Cleve ` Mie 3 . r ~ n~u~ OEAT1+~ Wl1s C1WSE0 tY~ rEwres o~r o+~a uusE r~ wu we r.+.. ru, iwo w~ xuu F~~ v~Q~ ~ - z re. , < Y , f MIMfOIAfE GYlt , _ - - . a C•~ iyo~t. N ~s~. OUE TO. O! AS A~ Ci~s ' ~ r1i`A t_-s~ rir~ f~ IA) * _ ~ inasii~u sru i~). OYE t0. O! Af A OOMS60YMCE Cf. . Z ituir~ /~r t~Ln- ~~:~s 1nr tc 4 G_ F v ~ ~At7 f= Q: NE! S1GW N W1T WNOIf WlKaCes~itiass c~sb+i~eA[ h ItrtL irf ~M ~ M rsu ~i?w wr D~.I.I (il ~tttOKY lf r!f «w~ f wY~ss c~sri6~?~~t Z _ _ IYa A s lrqrs~ arr~ N.Iwr ~ _ T o 19~. 11f. 3. ~~o[?n. w~uve. No~uaOE o~rE a url1.R. MouR ~r+JUd xGwRW l6ra a~rf d iry~?1 i. ~w~rl.r ~rr N. Jre. t1tJ - o~ w~oETru~~Neo rS~rr;1~l r.Wrb. Uuf. Y..r? • ~ ~p„ il. t ~T' r ~t • t ~ ~H~un woec ?1wGE Of lnuri At h~r. t.... ,,...r. Jx,w~, iacwrw++ rSwe.r+r t,~.D.. rirs w•+Yy.. +rrti sy) qr lSPenO 7o u asI ~~t i!/j_, N~. fSHtif~1 a ~ _ . _ `i!3 ~a. i~ ~L . _ . 4 EtrF; ' 1r '~Att H OHIO ~ T . ' ~F~T:/.CA7iOK- M•ar~ i~.~ Y~a A1.+~i -D~q~ Yar ~u6 u~tt inw +aNU~e i D~ON~ HO! oE~rp OOG~~ M K• !.•r~ e~ - ~ sM:s~tw+. Auv! oN nfw tME ~00~ (MWKI rM ~.es. a1: M ! AT7END~ iNE TO Af~~i Dq YM AiTM 0[ATN. t~~. ~ r, ~ . jr~ 71.. OfcEASEO ttC~Y ~1~. 21c 7/d_ ttw M. iie r~(1J u~te1. fD cE~r~FUt~oN-cord+e~ o. ri~ Lui. N w ks:rr;u~ N.w IMri T1e ~ks~lnr ~Mo~rrr~I ~ Yu? HM. ~ ~ . • el ~Ii 6al~ a!/m rir i~erst/pti+s. iw ~1~s. ~~ti ~ r'~ o~rm~d tI~ t~r nJ J~r u dre tru(il tfr~/. ~ = n :r. JULY I 1973 8:n4 r' 'f •il O CEtifF~Eh~IAME IT~~r or Niaf) SIGNAtUlE Q?~?N N tirk ~ DJ1T[ f~GNED J ~1 » IILY ?4, in?~ y r"i' ~ ~ SNe ~4 tt~ 11. :te M ' • - ~ Y~ MAIIING ADOlESS-~CEfitflE! fitfET ~.1 . MO. pTr Ol YI\{AOE tfA/E Zif . I `C f-' ~ ~~~e 5'~.I'X ^Ul'~TY C~~'J:F:.:? ^i7 ~~YE~Afi'D AVE 2I p CRNfi()1'~ OFi10 ~.47f!Z Q? FiRI~t. C2E4A710N DATE N4/E p CE~IEINY O! ClfMAfOlY 10CAi~OM IC}q. ~~7~s~f. ~r t~anryl fSWr) ~ ~<«i'~l ~ 1i ~ ~ :~o. • 9r0. ~n 21c. 7Y. ~ O H~,wE O~ Et~iAUtF! iUG MO.) S lK. NO.) n~' ~s_ P.Jack F~efrock 5?2 A K~ r' iw+ftw: F~tM ~MD ADO~ESS ~sTUCr ?+o.r ~a tsrt , r-t n M.~ ?_bb 1( ~ . `C r OA1E ?t~1i ISSIIEO 51Gl1Ait1!! Cf ~ERipl 1t3~ DAIE RiC D~Y lEG~3 t'f SIGNATUlE . IOrJ6l tEG ~ ~ , r » ~~c ~ ~ ...z - . :