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FITTIII 3911
19
Name Charles Me duna
Age,
40
years
Declaration of inlention. No 6856
issued by Supreme
Court of W. queens County
new York on the
of June ,9915
You 9
No. 897
Cridera the
9 the dayof
may 19.1922 ,
Name age, and place of wife:
Bogena 33, Ashford Com
Names ages, and places, of residence, ofminor
children Frank 10, Charles q
Joseph 4, all reside in
ashford Come
Phaseles Medina
/Signature of holder.)
New Old cerlifiante. Na
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