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® / <br />' O <br />l ~_._. ~ <br />MINE REPORT <br />Note-Please fill out this report carefully, write plainly and answer all questions fully. Be sere to <br />data the report and sign it. Fill out both sides of the sheet. <br />~- -~--------~Co and ~~ ----------,19f!y` <br />,,yam or-~-"S!`-- <br />BU'"••,' nn +mrnn ^mATE OF ^OLUYa~nn <br />;fie aissioner of [in5s~ <br />Deuve•. .o. <br />Sir: In accordance with Section 4299, Re• // ..:ado, 1908, ,I(su°bmit report as ., <br />Name of Company-The_ ~~'e ~/~~!Q <br />Incorporated in the State of-! --~~------------------------- <br />Principnl otiice ----- - ~- ~~ -- ----•---------------------- <br />--- <br />Cn Itnl stock ~ ____.____~ U _ hares nt $_S--~____ <br />p ~ ----_----- per share. <br />s . roo.p..r. <br />au nu[ tbl. Nnme P. 0. A resses <br />ryu~e; oWenw <br />Ime It blink ~ /~,( / <br />President _ ~_________ _°_?'~~__.r____~'f~~r^_-_Q_`!__'~/7. <br />(Secretary --------- ----~.--- - -------------------------- <br />. ~~ ~ ~ Tree er ---/---/-----,/~ 7/- -p--- <br />/'E?~LCG`~`'~1faeager _.l_•!~_4/_!?~~Gl4Yc--------------- `r~~~--~'-a~°--------- <br />Title of Partnerehip------------------------------------------------------- <br />Partncrs' Vnnu~s P. 0. Address <br />------------------------------------------- -------------------------------- <br />u.em <br />ar V.rtnm6lp, <br />Gll onl thh ________________________________________..___ __________________..______________ <br />.V.re; other~W <br />lwr. Il Limk <br />;1lnnngcr_.__________ <br />Names of Owners <br />P. 0. Addreauee <br />If udth.r <br />umprnl ppr <br />p.rtuenhl~, <br />^I uvt tW <br />goer <br />~Ltle IIt1I[ll'e of claims: <br />PateateQ Unputenled <br />'1` ----- <br />/ , <br />----- --- <br />r q <br />~ , i~ <br />'I'ntel uc2"cu u- _- ___acres; un _. -ueres. ~ <br />6 Patented-------------------- patented---------------- --- <br />/~~-~i ivy <br />Do you own or lenso theen claimat__-~~`----- ------------------------------------- <br />If yuu lease them give name of company or person from whom Ieueed_______________..________---_.._-_ <br />(Over) i <br />,I <br />