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V <br />MINE REPORT <br />Not~Please fill oat this report carefully, write plainly and anstrer all questions folly. Be sure to <br />date the report and sign it. Fill oat both sides of the sheet. <br />---------------------------------. Colorado, ------------------ ----,19--- <br />6L'RF.9U OF MINLS, STATE OF COLOfiADO. <br />T. P.. Iiennhen, Commissioner of dines, <br />Denver, Colorado. <br />Sir: In accordance kith Section 42!19, Revised Statutes, Colorado, 1008, I suhmit report ns follon•s: <br />Name of Company-The---------------------------------------------------------- <br />Incorpornted in the State of_____________________________________________-_______ <br />Principal office -------------------------- ----- - <br />~Capitnl stocl_ ______________________. - _ Sl:nres, at $________ ___ per shore. <br />11 a C°mpm), <br />nn °°t a11" j Nnme P. 0. Addresses <br />.~..,: °m~..w <br />I~„rltul.~ .President -- -- ----------- -------------------- -- ---------------------- <br />---- <br />~Seeretary - ------------------------------------- ----------------------------- <br />Treasurer ______-------------------- _- <br />-------------------------- <br />Afnnnger -------- ------ --------------- ----------------------- ----- <br />(Title of Partnership---------------------- --------..___-_ <br />i Partr.~•r<' Xunr,:, P. 0. Address <br />u.nm, <br />ar D:,nn.r"61p. <br />q~ur: avLervl"e <br />Ir,,,~ a ma,k ~ <br />I - -_... .. _._ -. - --------- - ~--~ ----~~-------------- <br />j-- - --- _ _.----- _ - - -- ---- -• <br />I! e,~itLer <br />~:,rW.nhl~ <br />01: wt W <br />.puv <br />~t:dc t: <br />'1'utal <br />Lo you <br />if yu^ <br />~/ /~~,~! <br />t <br />'~ <br />Y <br />~~J'~/Jf~/, n^ 'l <br />~~~Q~o <br />~~~ ~J~~ <br />acrr.5. <br />,I <br />