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; To the Clerk of the Circuit Court of ~n ~ ~ r~~.~_ ~ounty,l ~o~ ~ C. F R I F ~1,~_
i NAME OI' COUN'fY NAME
of ~7 ~ IUK~, A -A ~ born at C~ ~ c.A~ , S l ~ . , on the ~ $ K`
AUDRESS ,
d~y of ~?~t.,~~,n 14 , graduated at ~N ~ ~ ( Pit~ r~+?,dpw~~~•N I~(,~ .~t~ date s' f 7 Z.
MBUICAL COLLEGE
who, befng duly aworn, says, I am the person named in the forcgoing license and the person named in the diploma which I displayed before the
Eximining Board, and am the lawful posses~or of same, I have, before receiving this license, complied with all the requirements to the
extmination required by uw; that no money has been paid ior such license, except the regular fee peid by all applicants, and that no fraud,
miuepretentation, or mistake in any material rcgard was employed by any one, r occurred in arder that such license should be granted. 1
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e~ ' Signed ~ ~ .
~ COUNTY OF OU • J
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STATE OF
Signed and aworn to before me this 3 D~~ day of G~1 ,Ig~s
Signature of Officer
S'fATE UF FIARIDA n , Clerk of the Circuit Couft
• COUNTY OF _r-~rt ~C11~P~ ~ in and for said County, du artify that ~~/Lt2„
uf ~..PiLo ~~i C~ has this day registered the foregoing
. License and Affidavit in my offica ~
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. r'~ WITNESS. my hand and the seal of said Gircuit Court at ,
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