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I 100ll>>t 8nd aatnowledp the 88'nt or 8ol101t.or 801101\ing and hking t.h1e' _"1108-
,tloll -. IV asent a8 well 88 the .gent of 8a1~0.pan,. and l UDd er8tan4 and asr.e that Bald
Isent or Bol1eltOJ' has no power or author1t, to bln4 said Ooapenr by eny r.~re8'ntatioD, arraD!..
Mn' or .sr....nt, .xoe~t Buoh e8 art herein ezpl'essl1 8d for1h; and in IIl8king thie 8ppl10a-
'lOll ~ .sr....Dt.. I a. relying solely UpOll IIl1 01Ul 1nforlD8Uon an4 innsUga\1on. and upon
th. pt~nttd lUer8ture of srd4 \iOllpany relating t.o said land. and not upon eny oral represent-
atloll or Qt8tement of 80y person .bomaoev6r.
Ae a ooD41t10n o~end a oons1deratlon for the aooeptanoe and a"roval of thls .pplioa-
tion by s8iel CO.Jl8ny I he~aby D18U the follOwing st8tem€nts and warrent the sama to be tnu
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1. ., 88' 18 47 yeers.
3. Oooupetlon Nurscr1*an.
6. MY wite's name Perley J. ~oott
I. I belong to Consregatlonal Ch~oh.
8. 1 belong to the tollowlng fraternel orders: Mesons
2. H8tlonellt, Sootoh. whltl,
4. Ka~:Ue4 (Yes or No) Je e.
6. I heve 4 oh1ldwen.
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9. 1 oerrl .6.000.00 lite Inenranoe; in followlng oOMpen1es Mutuel ot n. Y.
10. I 01lB resl estate es fol10w6: HOlM end 20 lote in K8nbett!Jn
11. Same ie enouabered for 1----. held b,--- -- -
12. I own 18000,00 wca'th Of persanal pro1)8rty.
nlte for $1,100
13. low. debts of 11600.00. oonsi8ting ot open 80Ct. 400.00
14. 1I1 net wor\b h ~16oo0.00
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>>aaege suit for $4000.00
16. ~bere rare no suits pending or Judgments eg8inst me exoept that Yoi11 never oome to trt.a1.
,. ,..;. ..16..>>0 you intenel to settle on the land you hen applied for' yes.
17. \jiY6 bank rellr....l l8t ~6t1oD.sl Manhat.t.n ~B.
18. My bank aooouot 1s In neme ot Chras. A. ~oott.- Kan88s Rvergreen liurserles .
Soott-!hrondeon Post 00.
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19. I am now in go04 h081th 8nd 1 heve not now. nor have ~ ever heel en, 418e8se of the
tollo.ing nailed orgBns or 8ny of the tollowlng nemed disl8ses: ApopleX7. Br1sht's
Dleease. >>r81D. Canoer, Oonsumption. Diebetes. B~11e~8y, Heert. ~ldney D1se8s8. ~ung8
or P8ra1ysis, Bone.
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IN WITB8SS w.HRRIO'. I heve her.unto Bubsoribed 111 neml thle 16th d8Y of July, 1922.
,Ohes. J.. Soott
.&PI110ent.
Witness: H. j. Che~erlin
501101 tor.
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This e~p1io8tion is eocepted end approved this
27th el8yof uo\ober. 1922.
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"Uet eD4 reoorded thie ~4th d81 of "en.
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(Ot.ct. ~88l)
1924}
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R. O. ildred. Olerk Cirouit Co~,
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1D41an !tiver Urange & Truok L8n4 "0.
By Joseph J. Heia.
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