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Furm 3HII
1360304
4
Age, 41.
years
Declaration ofinition. No.1943.
issued by Clerke product
Courtel Coalubury
onlthe
15 day of December
Pelition, You. VIII No 1814.
Ondersignedunt, the 15
dayal
march
Name age, of residence, of wife:
blara, 37 yro.
30 Hatchicis,M. Waterley
Names ages and places of residence, of minor
children ameth 18yrs. hunderal
Anny
Charles. 174rg munder Can
morquinta pyrcloaturitis
Coun.
amand anthur Breehbubler
/Signature of notter.)
New Old Certificate contifiante. Na No 1360304 Received
Date April 19
1970
ed
H
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