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Form 341
1360301
1
Name
Age 35 years
Declaration ofinlention. No 7680
issued by Disluct
Walebury
10 day of Feburary 9.1.1917
Perition, You. VIII No 1809.
the 15
march 19.1919
Name, age und place ofresidence afriie:
none
Names ages and places ofminor
children
home
E dward slattary
/ Signature of nother:
New Old Na
Certificate No. 1360301 Receiped
Date
april 15
10/20
Edward slattery
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Context sent to Scholar
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