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Furm 3411
1360320
20
Age Name Thomas 30 years Figgatricle
Declaration ofintention. No 3580
by Clerkio of Disluit
Court of Watubury
on the
4 day of Jance
You. VIII Ni1834
Order. signed yn the 15 day of
march 0991020
Nameshage and place ofresidente of wife:
Highland an. Beach Falls
Coaa 27 yrs
Names agerand plane infrasidence of minor
Corger.
children Celus 3yrs,
Cathanic 4mos
Highland air,
Bracen Falls
Comm.
thomas
Ditzgatnet
/ sighature of holder.1
New Old Na
Certificate No 1360320 Received
Date april
19'20
Thomas. T55Patrick
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