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Form 390
38
Age, 36
years
issued by Bloghol Supman
Declaration of inlecting No.122674
Courin of nework County
newyric onlhe
8 day of
Perition, Vill VIIII No 1857
the 15 day of
march 19.19
Mayne age und plage in residence of wife:
Sella 33yrs.
125 no Eeuset
Names ayes and places
children David 9yrs.
Harry 3420.
155 no Elen St,
Cone
samuel (Signature of
Umograd
New Certificate Nol 360338 Received
Old certifiante. Na
Date
Aps. 17
1920
S.
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