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~~ <br />_ ~ Qi~ <br />i •i, <br />A: ~~ <br />J r-~~~~- MINE REPORT <br />Note-Please fill out this report carefully, write plainly and answer all questions folly. Be sure to <br />date the report and sign it. Fill out both stdes of the sheet. <br />~p%t=~_________. Colorado, _ ~---------------, 191y- <br />-'- ---- ---- C <br />,~.; <br />y BUREAU OF DSINES, STATE OF COLORADO. <br />T. R. Iiennhen, Commissioner of Dlines, <br />Denver, Colorado. <br />Sir: In accordance with Section 4299, Reviecd Statutes, Colorado, 1908, I submit report as follows: <br />Name of Company-The---------------------------------------------------------- <br />Incorporated in the State of______________---------------------------------------- <br />Prineipal once ---------------- --------------------- ------------- -----------.. <br />Cnpitnl stock ------------------------ --Shares, at :y____________ per share. <br />u .con .nr. P. 0. Addresses <br />ou not e~l. Nome <br />ryace: othu+laa <br />leare Il black ~ , <br />If a ern <br />or partncnhlp, <br />all out thla <br />.pace; otlwnrLt <br />Icn'• Il blank <br />iV ncllher <br />mnanr oor <br />ImrttmnhloplI <br />nn out tae <br />avarc <br />resident -------------------------------------- -- <br />>ecretary ------ ----------- --------- ----------------------------- <br />Creasurer ----------- ----------------------------- <br />--------------------------- <br />---- <br />lanager ------------------------- <br />--------------------------------------- <br />l 9f ,( ' <br />l'itle of Partnership-_--li-_~__-~~a-s~r~~j'-~-- - --'~,•~(~~~,_.-_.-----_..---- <br />Partners' ~anles ~• P. 0. Address <br />Sfanugcr---------- -----------------_ _ <br />~ Nltvles of Owners <br />P. 0..lddresscs <br />I <br />,Alunagur-- -~ --- - ------------~-- <br />tituUr nmacs of claims: <br />~ Patented Unpatented <br />- - --- <br />--- - ------------------------------------ <br />'1'otul acreage putented____~.~r/1CL---/-~------acres; unputented_...___._.___--. _ - - .acres. <br />llo you owa or lease these claimst______..lll~~~~~'- --- -- <br />if you lease them give uume of compuuy or person Yrom wham lensed__.-.._ - --- -------- <br />- -- _ (Over) <br /> <br />~I <br />I <br />I <br />II I <br />1 <br />II <br /> <br /> <br /> <br />