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'i d 'I"riE CLERK OF THE CIRCUIT COURT. ~~~y~r ~ ~V
5~. -LUG i E _.~COUNTY. FLORIDA:
_ _
`;'`I•his is my declaration of Doaucile and Citizenship in the State of Florida that I am fling this day is accordince. and in '
_ conformity sritb Section 222.17, Florida Statutes.
I ~cas lormerle a 1ega1 resident of ~~NCS~~ • ~ and I
. ((,tits) (Staid
rrs~ded at ~L/'~~/YC?01d ~oeC•Gt' Aowever, I~ave ebangrd my domiu7e tp
(Street and Nursb~er) -
z n d amand have beta a bona Sde resident of the State of Florida since ~GC•t / _ day at
_ 19~,..~ and I reside at 6a ~
Q ~ (3trrei and Number)
_.~~_•E?T ~1T• - _ - _ ST. LUG I E County, Florida,
(ctit~)
and this statement is to betaken rs my declaration of atizenship, actual IegaJ residence and domicile in the State of Florida.
IF fOR THE PURPOSE OF ENROLLING I~ FOR HOMESTEAD PURPOSES, ;
CHILDREN IN SCHOOL, PLEASE STATE PEEASE CHECK2
THEIR NAHESS
. ~~thPy ~A. Grv~nl . .
l Y/C O.C~ i9 - ~H i~J
T~ic~ i4 ~ f~ /mil
1919 AUG 21 A!1 59
' EO AND~RE D
• - s ~ POITRA
CIRC(lITCOURT
' VERtfIfQ
r _ _ - - i
d
I li ~'T:~?R C'r:P.TIr'Y that I mill register st n:y Io:~J sddress when the registration books reopen, snd co~sply ~:-~5 xD
~
' `~~•r requirements of a legal resident of this State.
I FURTIiER CERTIFY thtt I have no intrntioa to return to m~ former domicile, and I intend to remain in
T. U C 1 E _ County,
lCzt7) _
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(,tea
' ~ ~ ~ (Addreu)
r ~ ~ ~ : r d acb~ zr~,~d bsfore me this day of ~ -
G • r A_D.19_
,79
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-2 Pnl__.~..._,~_ CLERK OF C fRCUt T COLT
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