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~ o~ my ~`,~~ '~ ~ B ; w <br />~ i3 <br />MINE REPORT <br />Note-Please fill out this report carefully, write plainly and answer all questions fully. Be ears to <br />date the report and sign it./Fill oat bot/h sides of~the sheet. Q <br />___-!/_(.t_G_Li~c!t3Lj___________, Colorado °`~-et/_`_u__~__, {~ <br />[3URF.AU OF *rrLTr.S, STAT); OF COLORADO <br />T. R. A ~ommiesioner ofllinca, <br />Denver, Colorado. <br />Sir: In accordance with Suction 4299, Revised Statutes, Colorado, 1908, I submit report ns follows: <br />If ~ Comp~nr. <br />en not t 1. <br />ryett; alherwlw <br />love It k6nk <br />II . Ilan <br />ar PrrlnrnAlp, <br />011 aut ihb <br />rpere; olhrrwlu <br />lurr It hunk <br />'Name of Com pnny-The---------------------------------------------------------- <br />Incorpornted in the State of_____________________.-_________________---------____-- <br />Principal ofHco -------------------------------------- --------------------------.. <br />Capital stock ________________________ __ Shnres, at ~________..___ Per share. <br />Name P. 0. Addresses <br />President --------------------------------------- - --------------------------- <br />SecretnrY -- ---- ---- ----------------------------- <br />Trensurer -------------------------------------- ----------------------------- <br />Afnnngcr --------------------------------------- ----------------------------- <br />Title of Pnrtnerehip______________ <br />Partners' Nlunl•s P O..lddress <br />----C~~-~~---------------------- ----~~_____~a.'__~~_ <br />linnnger___~_~ ~z~~:~ <br />--' Names of Owners P. O. Addresses <br />_.. _.. <br />--- <br />~~ P~nr nor <br />____ Iw rlnenhlp ________ -.________________________________ <br />nn aut tur. ----------------------------------- <br />.p¢e <br />Alnnnger------------~- --------------------------------- <br />- ~iatc names of claims: <br />Patented Unpntented <br />n the <br />----- --------------------------------- <br />-- --------=-------------------------------- ------------------------------- <br />----- -- ---------------------------- ------------------------_ _ncres. <br />----- <br />__ ~ ncrea; unpntent ----------------------- <br />7bL•II ucreage patented____2 -~'pr //~ --- ~ . <br />tpnny Do you own or ]ease theao claimsf___1(~..~---~~-~---~~/~z~V L__~___________ ___________ <br />_____ If you lease them give name of company or person Yrom whom lcased-------------------------------- <br />---------------------------------------------------- <br />_"____ (Over) <br />~r~ <br />I, <br />I,'ll~ ; <br />