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~.iC~G4l~/ ~G <br />MINE REPORT <br />, -'.i <br />~ <br />I <br />, <br />Note-please flB oast this report carefully, waste plainly and answer all questions folly. Be sere to <br />dste the report and sign it F~11 oast both sides of the sheet. <br />OTC///%////Af,~~~~---------. Colorado, ----'~-~--~--~ o S- - --~ 19 ~~ <br />gt;ItI:4U OF TvfL`lES, STATE OF COLORADO. <br />T. R. FIenahen, Commissioner of dines, <br />Denvet, Colorado. <br />Sir: In accordance with Section 4299, Revised Statutes, Colorado, 1908, I submit report as follows: <br />~--- <br />The-------------------- ------------- <br />(lame of Compnny- <br />Incorpornted in the State of___________ __------ --------""--- <br />---. <br />Principal office -------------- ~ e <br />~ fo a- ~ eD ____ .-_ Shares, nt :1;__ ~=_--_- Per share. <br />Capital stock ------- <br />-----~ -- <br />P. 0. Ad resse~ <br />1! a ~ampanl. ~Pa ~ <br />ell oui tlil. <br />,pas: othanrW / ___~~~-______________ <br />lea.'e It blank ------- <br />President ---------- ---- -'---- -• <br />i. <br />--- <br />e--wz~'=--- -------------- ------ - <br />----- <br />Sccretary - ----------------------- <br />II~~ i ~~Lil <br />1 I ~ <br />~~1 ~• I. i <br />;,l,I~'~' (li <br />I <br />~ ~ '; i', <br />• , 1, <br />I' ; <br />~' i , <br />~~~~I~ <br />ill~~ <br />~~I1~~ <br />VIII <br />l" <br />'{ t~~, <br />j 1 ~I <br />~~~ <br />I1 <br />ft. .~ --- -------------~ n <br />ft. I Treasurer _ __ ~_ _ _ _- ~ ~_-~, ,(~__~ <br />------------ <br />~ ---- <br />191nnager __`~------- ----------------------- <br />ft. <br />ft. --"'- <br />(Title of Pnrtnerahi -"-"-"-- - -~~-- ----- - P. O. Address --_- - <br />ft. p------------ <br />Partnrrs' Humes <br />ift. - -------- <br />_----- - <br />ift. --------.._------- ~ ~ - ----- ----- <br />ift. ---- - ---------- -- -- <br />----------- <br />-- ------ <br />____________ <br />NI nut tld. <br />,Parr: PWend.e ______.._____-__ <br />___..__ <br />___ I.e.•It bl.nk ~____._.____________________.____________-. ___ <br />_ - _ <br />I_.-____.._________. _.._____ __________.____ <br />___ <br />_. ___ <br />- ~H anuger---------------- <br />--- --- P. 0. Addresses <br />-__ r Nnrues of Owners <br />--- <br />- - - - - <br />--- _ - <br />------- - <br />I!nelther ~__ ______________________. <br />.-- vmnP.nY nor _____-___..________ <br />__ <br />.___ Vurtnenhip. -..-______________________________________. <br />nll nut ti, I _-. _. ____ __. .___-_._ <br />^I'~n ___________.__ _.._ <br />_-_-__-_ <br />____ <br />~ .__-. _. <br />__ <br />I _ <br />~AlLLnagCl ____-__._ __._ __ <br />tiLttc Humes of claims: lluputented <br />Patented ______-.----- <br />~the --------- -- ---------- --- <br />G-r<s ~i-r~-------------- ----- <br />-- /- ](G~IC-_°_t~~-------------------~ - <br />---- <br />---- /~ ~~ Q / - - ------ <br />_._- <br />__. <br />_ _ <br />~ ___ - - aC7C9. <br />.._ ._!S_________________________________ _ <br />__-- lutented_. ---- <br />~,_S <br />_ . _acres; unl <br />9btal acreage patented_..Gl!`-`~--------" _ -' <br />----- -_ <br />~_~-~ <br />panY• I)o you own or lease these claims4_____.-_ -- <br />_. <br />_____ if you lease them give Hume of compunY o~J,t~rson front whom loused-_ --- -- <br />-----' <br />//ff A i ~% <br />~~_>~y_______ __.. __ _. _ -... - <br />_____ / (~Y¢r~ <br />