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<br /> ~ <br />,~ C . ryA. <br /> <br />x y <br />i ~/ <br />I <br />MINE REPORT <br />543 <br />Note-Please Sll oast this report carefnlly, write plainly and answer all questions inlly. Be snre to <br />date the report and sign it. Fill oast both sides of the sheet. <br />---------~ Colorado, -------------------------. 19--- <br />BURF.AU OF 11iINES, STATE OF COLORADO. <br />T. R. );ennllen, Commissioner of Mines, <br />Denver, Colorado. <br />Sir: In nccordnncc with Section 4299, RevisedStntntes, Colorado, 1008, I submit report as follows: <br />Nnme oP Company-The------~-/ s-~'-!~~---!_C1~~S~s`c""--------------------- <br />Incorpornted in the Stnte of------------------------------------------°----"----- <br />Principal ofAcc --------------------------------------~--------------------------- <br />Cnpita] stock __------------------------- Shares, at $____--____-- Per share. <br />It . Com P. 0. Addresses <br />eu oat t Imo. r' Nnme <br />,D.te; otkerwW <br />le..e n blot <br />President --------------------- ----------------------------- <br />------------------ <br />Secretnry ----------------------------- <br />--------------------------------------- <br />Trcnaurer ----------------------------- <br />\Innnger ---- ----------------------------- <br />If . Erm <br />or D.nomkip, <br />IIII out Wle <br />eD.ro: o[hererW <br />lease It kl.nk <br />I! oeliker <br />rompeur oaf <br />ertnenhl <br />SII ant ~ <br />.D.a. <br />--- <br />Pitle of Partnerahi ---- ---------------- <br />p----------------------- - <br />Partncrs' \amcs P. 0. Address <br />---- -------------------------------------- ------------- <br />-------------------------------------------- ------------ <br />S[anngcr------------------------------------ <br />Nnmea oP Owners <br />\fann¢ar ------------------------------------ <br />P. O. Addresses <br />--------------------------------- <br />--------------------------------- <br />--------------------------------- <br />_________________________________ <br />--------------------------------- <br />State names of claims: <br />Patented Unpatented <br />---------------------------------------------- <br />---------------------------------------------- <br />----------------------- <br />Total acreage patented-------------------------acrea• unPatented_:'_-----------------------acres. <br />--------------------------------------------- <br />------- <br />Do yon own or lease these alaime ____------- <br />It you lease them give name of oompnny or Pereoa Prom whom leaeed-------------------------------- <br />--------------------------------------------(Ocez)- <br /> <br />