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OPTtONAI, FORM 175
(FORMERLV FS-88) '
MARCH 197i
OEPT. OF STATE ~ ~
50175-101
. Certificate of Acknowledgment of Execution of an Instrument
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, CLERICCC RCUIT~~S .
- rr!tor, yf.A~F1E~ COUA1 ~
(Country)
- of~ s 56 aM
(County aad/or otAer political division)
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(County and/or ot6er pditical division) ~ 3~'~~
(Name of foreip~ serrice oflice)
MAR1C L. WIZNITZER - vice consu2
oj tl?e United States ojAn:erica ot CaracA ~~_yen~
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duly commissioned and quaJifed, do hereby certijv that o~r t/ris ;
day oj DeClmhet, 197 7_ befo~e me persoiinllY a eared ~
(DATEJ ~ pn - - ~
_.~iAl~i11F.~.-.& - "
to me personally kiiown, and l:nown to me to be the individual-sdescribed in, whose
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nanre~_~__sz~bscribed to, aird who e.rec~ited the mtnexed instrame~rt, atd being
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infonned by me .oj die co~ite~rts ojsaid instrunre~rt.__S~l~Y'daly acl~nowledged to me
t{:at_.,_I~SYYecuted t/ie sanie jreely a?rd ?~ohurtarily for the t~ses and purposes therein
mentioned.
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_ ~r~~> witness wlrereof / hai~e hereuit~o set nly hand and
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- } ojfrcial seal the day and year last above written.
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ViCe Cc::.:::~ ojthe United States ojAmeiica ,
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NOTE.- prse ' siguwres to a docvment should be incl~od in one certificate. ~ `
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