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<br />Dace of Service_March 30-__- t9 82- <br />Gerson $?rvyr7---ldr_ live Gossett <br />(Pleas? Orint na~^? antl title) <br />Sitln3c~re------------------------- <br />(P?rsJn 5?rv?d) <br /> <br />!!I^iED ta~4D RECL~4~T10`~ 'JIV(SIUw <br />°Y--1-c~--~~~ ------- -- <br />(du'hOriZ?tl repr Sentd ti v?) <br />Michael S. Savage, Reclamation Specialist <br />------------- - -------------------- <br />(`: d.ra antl Lit10 - Glease print) <br />[M~pR ia:~T: PLEaSE READ THE REVERSE S[DE Ur TN[S PAGE. <br />l0/79 C.R.S. 1973. 34-33-1Z3 <br /> <br />