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OPTIONAI. FORM 175 '
(FORMERLY FS•88)
MARCN 1975
OEPT. OF STATE
50175-101
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C'er 'tif'icate of Acknowledgment of Execution of an Instrument
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(Country)
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(Name ot forci6n se~vice office)
MARK L. WTZN~TZER vi,ce consul
ojthe United States ojAnrerica at Caraca~,,_Yen,~,,,P~ ~
July commissioned and quaJified, do he~eby certijy that on this 13th
day of_ December, 1977__, before rne persoiwlly appea~ed ' '
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to me personally known, mld known to me to be tlte individual~described in, whose
name~_s--subscribed to, and who executed the annexed in3tru»:ent, a~rd being
injormed by me of the contents of said i~:strume~tt..._~.Xduly ack»owledged to me
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that_~jtxecuted tlre same j~eely a~td volu~:tarily jor the uses and purposes therei~t 3~~?78
mentioned. f COqr~Y~l.
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witness wl:e~eof 1 hav~ hereunto set ~ny hand Qnd
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offtcia! seal the day ard year last above wiitten.
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Mark L. Wizr.~tzer ~ $
Vice Cdnsu( of ti : ~ i; ~..,~~St~~&_~-_ oj the United States oj Ame~ica
of Amcrica ~ '
t pr aU signawres to a document should be inctuded in one ccrtifiate. ~
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