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I FILED aru ~ECOROED ~
Si,IUCIECOUATYfIA,
~ ~ ~ ; ~ ~ ' ROCE^ P~:,~TflAS ~
~ CLER~ C! GUIT COl1AT y4~~'~"
~ AFCnR~ ~r,~I~~iED_.,,..._
~ ~ ~ J~, 30 I? io PN'1~
~ ~ ~ ~ ~8i~69
~
~ To the Clerk of the Cirwit Court of County, I, - ~
NA OP CW7NTY , , NAME ~
~t,~,c~ O~R,~~ t r ~ l
~f ~ ~a , born 'YI.~a,wc.1~ ~'~c- on th~ ~ i
a
ADDLESS 3 y/ ~ ~J ~l Q. o?J ~ y~y I
~~1 Of Qh /9~~dWLtd a ~ G~LN~i~', /LC.~~ G~tG'd d~v d1tl.._~---y--
. ~ ~ . w~ ~ ~r Y'••~ •r~ t I•~M~t~~ ~
1~ r
,~.fil~~
~ r ~ T . :,l ~ .i 4 ~ a . . . ~
_ ~ + ~who, being duly s~?orn, saya, I un t~e penon nuned in the foregoing license and the pecson named in the diploma
' ~Which I displayed befae the Florida St~te Bo~rd of Dentistry, and am the lawf ul posussor of same. I h~ve, before ~e~!
M~eceivin this liume, complied, with ~Il the requirements to the examination requircd by l~w: that no money hu ~
~ 8
Ixen paid for such licen~e, except tlu ngular fa paid by ~~~'PPf~~
n~ o deret at sucl~ 1 cense s~ ulyd
be g anted. g ~
rrutske in any maurial regard wu employed by any one, or xcu
. ~,o~i~
$i8n ~ ao
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~COUN7Y OF
STA1E OF ~~`~"~'"~~J ~
' ~0 ~ I ~ d of , 19~
t, ~ $igned and ~vorn to be~ore me th~~ - ,,p
~ Officer ° ? ~i~~cZ~ ~D~~'~
, . ' Signawct of ~
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