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itcuit Cou o _ Counry, I SC, tf A~~er~ ~ADe~v
To the Clerk~ R~y 3S N~E
a5~ ~ ~e~ItCL NAME OF COUNTY ~
n/.Y__ ~q-'
of ND~I,~,/C004D f~QR/~}f1 3.~1b?/, born at _~J~~~,~ , on the
~'ADDRESS f~GIrOHI~1~701~.5 cc 1~i ~~'RS~ ry OF / 73
~ d~y of , gradwted et .~~nRIR TA~P.A, /~E~~li C c~ date
MEDICAL COLLEGE
~ who, being duly awom, ays, I un the penon rumed in the foregoing tianse and the peraon rumed in the diploma which 1 displayed before the
Extminin` Boerd, and am the tawful poeussor of ume. I h~ve, beforo receiving thu license, oomplied anth all the requirements to the
ex~min~tan required by Uw; that no money h~s been p~id for such licen~e, exapt the regul~r fee puid by all applicants,, nd that no fnud,
miuepreknt~tion, or miat~ke in any material rogerd was employed by any pne, or occurred_in.orde~ tl~at such lian~ ~ould ~nted.
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1~ , - ~ Signed ~
Z COUNTY OF ~
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W , . .
L' STATE OF , , i ~ ~ ~ ~ ~ ~
Signed ~nd sworsto before me this • ~ ~ dey of ~ , ,19 ~
Q ~ E~~TE', I E: ~A{'~'~ ~ ~ ~ ' • ~
? ;.ior~~~ . ro~k S~ature of Officer . . - ~
o . ; ,,y„fy ~
- ~ " ~ ~ , ~ ~ _ ~ ~ ~.,.u ,3-30- g • ,
~
~ 0 STATE OF F~LORIDA , Clerk of the Cucuit Court
a~. COUN71l OF in and fur ~id County, da artify that ~ ~
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s~ ~ of _ has this day repstered the forcgoing ,
I
~ o ~ W a~c Licen~e ~nd Affid~vit w~ my office, ~
m~ z! opD r"i ~W = ~ r
~ = w c°~ ~'1TNESS; my hand and the u~l of raid Circuit Court at
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