Chapter XX: Appendix: #11

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STATE OF ________________________}
} SS.
County of _______________________}

Before me, the subscriber, a notary public in and for said County,

personally appeared _______________________________________________________

___________________________________________________________________________

___________________________________________________________________________

to me personally known to be the same person_____described in and who

executed the within declaration of occupation, and acknowledged that ______

h_____ signed, sealed and published the same as ______h_____ free and

voluntary act and deed for the uses and purposes therein set forth.

WITNESS my hand and seal, this _____________ day of _____________________,

19____

My commission expires _____________________________________________, 19____

_____________________________________________________
Notary Public.

___________________________________________________________________________

STATE OF ________________________}
} SS.
County of _______________________}

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

of the Count ______ of ___________________________________________ State of

______________________, being first duly sworn according to law, depose and

say_______: That_____h_____ citizen___ of the United States over the age of

twenty-one years; that _____ h_____ owner_____ by pre-emption, location and

occupation of the foregoing tunnel site, the said tunnel being prosecuted

for the development of lodes belonging to said affiant_______, also for the

discovery of other lodes; affiant___ further say ______ that ____ h_______

ha___ expended in actual work and improvements on said tunnel not less than

__________________________________________________________________ Dollars,

and that said tunnel has already been run the distance of _________________

___________ feet, and that it is bona fide ___ h______ intention to

prosecute work on said tunnel, so located and described, with reasonable

diligence for the purposes therein set forth.

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

SUBSCRIBED and sworn to before me this ________________________________ day

of ____________________________, 19____

My commission expires ______________________________________________, 19___

____________________________________________
Notary Public.

_______________________________________

LOCATION CERTIFICATE

OF TUNNEL AND TUNNEL SITE

_______________________________________

Tunnel and Tunnel Site of _____________

_______________________________________

in _____________________________ Mining

District, _____________________ County,

State of ______________________________

_______________________________________

STATE OF ________________________}
} SS.
County of _______________________}

I hereby certify that this Location

Certificate was filed for record in my

office at _____________ o’clock ____M.,

_________________________________ 19___

and is duly recorded in book __________

at page _______________________________

_______________________________________
Recorder.

By ____________________________________
Deputy.

_______________________________________

Fees, $________________________________

_______________________________________

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