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OPTtONAL FORM 17S
(FORMERLV FS-8e(
MARCH 1975
DEPT. OF STATE
50175-101
Certificate of Acknowledgment of Execution of an Instcument
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(Country)
P~VIl~C~ ~i~ ~.'I'IY CE ~:S'II~.
(Countr and/or other political division)
Od[~S(JLATE G~iERAI. ~' TFIE ~ SS:
~ (County aad/or other political division) ~
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(Name of forcip~ aenrice otfice)
~.. ~ L. HIl~S ~~•
oj the United Stutes oJAme~ica at ~' ~Y
duly comn:issioned and qualifteJ, Jo hereby certijy Nrat on this__ ~~ _~_______
Juy oj__ JAN. 1981 __, bejore n:e personally Qpneared ____________
(DATEJ
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to nre personally known, anJ known to me to be the i~rdivide~al-srle~crebed in, whose
nan:e_s.atesubscribed to, and x~ho executed N~e annexed instrun:ent, ond being
injonneJ by me oj the coirtents of said iirstru~~ent.~ve.--duly acknow/edged to nae
that_t1~t_executed ~he same jreely a~rJ roltartarily jor the uses u~rd purposes therein
mentio»ed. 19~I F,r,? -2 Q!~' ~ Z4
515618 SI~t Ctt* 0 tM~~ Tf a
RCGER~ ~ITRAl~
Ct~RY, CI`..C';i' C'~ ~
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. hi wit~~ess wltereoj/ have hereunto set my hand and
i ~S~AL J -
- ojjicial sea! the Jay and year t ~bnve written.
. . ~ R,e~c L. Himes/~~[.-G
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$a,~~x 34~- P~~~ -----0o~et~---- oj Ihe UniteJ States oj America :
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~ NOTE.-Wherever practicabk a0 signatures to a document rhould be includod in one certificate. `
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