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CIftuard <br />A <br />0 1 i SS isl (.,?Ice 01' Blind ,issistance • <br />Tyle ........................................................ . .....f11... <br />of Aid ..... <br />............. <br />•................. ............... ...... Age ..... NO. <br />---------- <br />county .......... !-�!P ................ <br />game .............. <br />iii <br />Address ... li." ..................................... <br />........................... Date ......... ... ... <br />Original Pa-Iment .......... .......................... <br />. <br />Old Age Assistance: Legal description Of real estate owned by recipient: <br />Lot 79 clock 1q9 '-?-LjvcrSI.t'7 Placaj flall C-mintys, <br />iska. <br />State Director <br />......... .............. ....... ................................... <br />................ 7' <br />........ <br />Signature of <br />Cti <br />- <br />------------ ------- <br />----------- <br />Cep <br />Fees $°-CG <br />