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rate <br />~ ' ' - ~1~~~, ; <br />gym- .~ ~. <br />MINE REPORT 1- <br />Note-Please fill out this report carefully, wn and answer all questions fully, ga sni.e to <br />date the report and ~ it. Fill out both aides of the sheet. <br />r: ,~ <br />,.- ~- <br />w <br />~ ----_, Colorado, ~ ~ ______ <br />- ~I~RF.9T7 OF bIINES, STATE OF COLORADO. -' 10~ <br />-- ` T. ) 3enahen, Commi ~ner of Blines, ' <br />__ saver, Colorado. <br />--- ~ Sir: In acco'rdrinca"with Section 4299, Revised Statutes, Colorado, 1908, I submit report as follows: <br />Name of Company-The_________________________________ <br />--- <br />------------------------- <br />___ Incorporated in the State of______________ <br />---------- <br />rincipal ofTce __-.----------------------- - <br />4 ___________ <br />u . com .nn npital stock ______ _____ Shares, at b <br />---------------- <br />en not t L --------_-. - Per share. <br />ift. i°: ~`ii et:.`t" Nnme P. O..lddreases <br />if t. President __________-,_ <br />-------------------- <br />------ ---------------------------- <br />ift. Secretary _________.-______-_-_ <br />--------- --------- <br />-------- <br />ift. Treasurer ___________________ <br />-- ------------ <br />------------- -------------- <br />itt. 1lnnn er <br />~~ g --------------------------------------- <br />---------- <br />ift. Title of Purtn hip___________ <br />itt. ~ arG~i •n' :~anu's /, ~ I'. O. Address ~ ,/ <br />------------- <br />--- <br />t t. <br />-- J <br />If•erm - - -~------------------------- <br />/~----j ----~-~-- <br />ltt. ar D.rtnrnhlD. --~ -`-----"------ <br />1111 out thb <br />gate: orherwb. ~ __. ___~__ -__ _.__________ rJ' <br />Inrr It hunk -~-----__. __ <br />_________.__.__ __-.__________ I <br />__._ <br />'" Dfanagcr <br />-' Names of Owners P. O. Addrosses <br />-- <br />I! ndther _._____________________________..___ <br />_. mniprnl nor - _ _ .. <br />p _. _.___. _. .._ <br />- pvtm'nh1p~ __..__-_.___-_ _ <br />e 11 out tul. ___-_-'___________________________._ <br />- .p.ee ____..___ __________ <br />______ _. <br />Rtolic names of claims: <br />Patented Unpatented ~ ~ <br />e <br />-- --- <br />- __ ~ ~~ /~ IG6-C/ ~' / <br />1 ''`-- ~ --------------------------------------- ----~ i, <br />' Tot u! atreai-----//-(----~-------CC-------- ~ -------------------------------------------- <br />6 Patentedliaf~__~_~Y_~~___acre vap ented____________________ _n <br />Do you own or leneo these claimst____! f!~__. _ _ _ ___ ._ _ ____ ____ ~ ._ <br />If you ]ease them gire name of company or pen Yrom wLnm le =. _ <br />(Over) <br />cres. <br />--- t <br />