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,e~;ag C01~. MINE REPORT <br />e~ea . ~ Note-Please fill out this report carefully, write plainly and answer all questions fully. Be sure to <br />date the report and sign it. Fill out both sides of the sheet. <br />------=-=----- <br />J <br />------- _-- a~~----• Colorado, -------------- /~-- ---.., 19/n. <br />E3LREAU OF i1IINES, STATE OF COL RAD . <br />_ __________ T. R. IIennhen, Commissioner of Dlinea, <br />Denver, Colorado. <br />' • Sir: In accordance with Section 4209, Revised Statutes, Colorado, 1908, I submit report as follolva: <br />-~~y-~.~--- - Name oP Company-The---------------------------------------------------------- <br />~~=`=~`~- \ Incorporated in the State of------------------------------------ ----------------- <br />------------ Principal o(i'icc -------------------------- ----------- --------------------------.. <br />Capital stack ------------------------ -- Shares, nt :);__________-_ Per share. <br />'+ • c°'"p'°r• P. 0. Addressee <br />ml °ut tAl. NamC <br />.p¢e; othenrl.~ <br />___honrahift o-•rrlebl.nt President ___________ - <br />----- <br />--- ourahl@. Secretary ------- ----------------------~- <br />----- <br />___hour shift. Treasurer -----------------°'------` <br />---------------------------- <br />___hour allitt. <br />'.lfanager --------------------------------------- ----------------------------- <br />___hourshift. r <br />-- <br />___hourshi[t. f ~%-w __e'~l=cf-~ __ <br />Title of Pnrtnerahip______ ~_____ / P"i--------`-~-- - <br />___hourshiR• Partnr.rs' luaus P. O..Address / <br />r C <br />---hourahift ~ G` ~,-~--~c ~~"~>-cu ~-*0----~~~_ <br />5 --- --- <br />___hour shift. • r <br />-- <br />___hourshift, a .ern, <br />or D.rtnmhlD. -_'---__-...._ <br />fill out ehb ________-.__________.-________ __________________.._ <br />___honrahlft. rporr: othrrwbrt <br />luv. it bl.nt __________..________-...-___________ <br />y.. <br />Sfanngcr-------" -- ---- ------------------.. <br />r N:/mes of Owners P. O. A c resses <br />__-_________ If neither _________________________.._ <br />~.nnpmr nor ___... _____________ <br />._ _-_-__-_ __ Part nenhlpp. _.. _ _ _ __ __ _ _ _ _ _ _ <br />fill nut tiJ. ________________________________________..___ <br />_ •yrcr ~ __..______. ..________.._ <br />•------ titxtr. names of claims: <br />°------- ---UnpnbmtcA <br />Patented <br />~t ------------------ <br />---~ ~l_____ `"~----- -------------- <br />~rkmen la the ~ r <br />----- - <br />----------------------- <br />~G.---i --------------------------------------------- <br />._______-____ ______r __ _______________.____ _________.______-_________ <br />________________________--__DD-________-_ <br />/'.' ' - <br />•------------ 'Ibinl acreage patented_5~?"=?-~-/y acres; unpntented___-- -~~-!'e-_-r,- neres. <br />Do you own orlensa these claimat____-- - ----------------"--"-~-~---------- <br />-'CdffipaIIf-~ _ --------- <br />!f you lease them give name of company or person (Yroln wh//m'.;(,l/e~nsed______~-~~ - <br />(Over) <br />