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% <br /> �... �. <br /> 6 � Form No. ld. / �. �VO « .. <br /> � / — / � Pllrntl n Ko.........:..�.: <br /> ' � L' � �L/� I <br /> i \o.... .. ..... ............�i. ..... / Strcet. � <br /> � r ....BcePr(1........ � / ................ <br /> ..... <br /> z i�. <br /> �. ............ ............i�o.� <br /> TO THF 9DPJsRI1�TGnDENT OF THIR ECERIiTT R'ATF.R CO\IP,\X1': <br /> , I p r / npl�l� tor the uxe of u•nter �n n�cordnnce �rlth the nJes nml rogidntlr.ns n( iLo `•:ci�ri•It l\'nt��r Cmnpany. nnd requAel <br /> F/ <br /> z(hnt n .J.�... Inch tnp be Inserfed In thr n nt th� pL�ce i ce v ted, - <br /> tT.S!�Nh�brr H9in �rill �lo n�3' �vork Is..� .. .. .. . . ..� . ......... ..................... ............. <br /> : . <br /> . . :. <br /> The owncr of ihe Premixrs fa............ ... .:....�............. ....... ........ ........................... .. . <br /> ThenR�.nt Iv.................... .................. ..... ................. . ................................ ............. <br /> �.... <br /> Thctennnt ia...................... .................. �......... ............. w <br /> ............... ................................ <br /> LThe a�nr.er reut nhmild be rhnrFed to.................... ................ . ............ .... ............................ <br /> . ...... <br /> • SlFned....�. ... .. .......�..... . .. .. . . .. .... <br /> � :(�3er Othnr 91do1. �pllrnnt. <br />