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OPTIONAL FORM 17S C ~ _ - :
(FORMERLY FS-N1
MARCH 1l7s ~ U ~
OEPT.OFfTATE
5017&101
' Certificate of Acknowledgment of Execution of sn Lnstrument
Republic of the Philippines
(cowuy)
City of Manila
Embassy of the United States sS:
(co.wey ..e/ar alwr t ai.islo.)
of America
(r+a.~. of to.d~...nlo. affix)
t
I, Kathleen M. Caper Consul
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of the United States ojAmerica at Manila, Philippines
duly rnmmissioned aul qualiJled, do hereby certify that on this 7th
- of March, 1980 , before me personally oppcared
NA~1
~ L.- R~Wentholt 'k'~`_
to me personally known, aui known to me to be the lndlvldual~-described in, wlrosc ,
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name~subsci?~ititd-ta;
and~who executed theQnnexed instrument, and bcii~g j
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informed by me ojthe contents ojsaid instrument
h
-_.duly acknowledged to me T
that he executed the some jncly and voluntarily for the uses and purposes thtrein
mrntioned.
!n witness whereoJ'I have hereunto set my hand and
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ojjufal seal the day and yeor last above written.
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een M. Cayer
Consul
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ail tint w a dowmeat ~ouW ba icladed iu anis eertltiata.. I
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3. wt~°raw 800K~ PAGE
EnK~ Jule 1 /f7S
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