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~ TxIS fIWAlIChiG STATEMENT b powowtt M a liliw, elfis? for fNia/ Ow«io~M M Ilr 11wi1orw Cowrwdol lidos O b. ~M dew (M ~I)a -
) lbbtor(s) (loot Noase firM) cad addnra(es) L Scarred fiary(irr) aaad oddrw(es) , hr ~Aflicrr (Oatr, Tkoo. Ne~brr, FiiM OHw.
~ "..:.ET:' ~:-SEAT; ~E?IL~'.AL r I ;A;:~r C ''.F 4a;
i i',': ' Al' 37~ F ~ EO ; ':D RECORDED
~ N!~_:~.Cc ~ L .~G =T r'I,_:r~ ;-L 33~•~:~ c LUC'~ r'~UR:TY. FL.~.
TMis firrorniw, arr:t...w1 cover. w falbr:. yp.. itr.r) er fir= 432
J All of the answer pods ner bcatod in K dent the ?rorisos constitvtinS dera ddtaKi rosidonco ~J f :3' ~ t+ ~ ~ ~ O
their eNress deco rot fereh er of ay otkor eddresr is rhitb eho sae ~e~ be rarered sd any E+ooorep
listed bobr. S. Aai/wre(s) of Sreorod ?argr ar•d Aaldnss(er)
~ The folbwief Mawb~ C' e J_~ ~ ~ .
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- 6. tn. rowra w.Mr..r.• :Ar.W .rwr¦ ad.., rr. rr rr rr~r .rrw~ ti Ogre 7rt, itrri Sw.a H w. trw~ w. -
Y ObJ/ M w a~ w/.r•rM. ~y air/~kr. M~ tl~ a~~ M arr ~ri~MM yFYrr rr r/ tM rr •cMa~.
r This atotesserrt is fdrd wiNaul Mrr drbtara .iS.eler. is o.rfe+ a sratriy trdrrest b s#atrrol. (Chock ®8 ao)
''i Akrody arrb)act b o searritp ietrreat is anwMr jwia6diew wfrrw it wes broeolq iota this ststr.
s which is prorrods of the eri~iaal aiWtrrol dasoriYrd above iw whit! • aeawiy iNOreN was Mnc~trd:
Ci»ck ®if ceararedr ~ f'rocerds of Gdiotrral aro ciao scared. Q Irodreta of foMotrral an obe cewred. No. of addrtiorwl Shots preterNrdc
f~lad witA:
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r~r=~~.r-_.i ,I , -
/ Si~watore(s) of paMor(d Si~aa*rre s) forM(ker
Form T7I~
• ~ rl'_";'•'!; OFFICER COPY-ALPHACSETICAL Avfxaad bT Richard (~t~)
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