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(NomW Q� ­j )- <br />1117"­"d fs"m & ow, W61W, No 4"l <br />A <br />CLAIMANT CONTRACTED WITH: <br />( Name) ......................... .......................... <br />.......... .................. I ....... - ... <br />o.............. ........ .......................... ................... <br />..... <br />SERVICES OR MATERIALS FURNISHED BY CLAIMANT. <br />C1 .......... <br />1111cl <br />M. 7) <br />............ <br />............. . ...... . ..... ............ ... ...... <br />.............. ............................... ... <br />CONTRACT PRICE: s_1-3177 ---- AMOUNT UNPAID: <br />TIME LAST SERVICES OR MATEWAls FVRNL9HED: <br />... L91.7 ........ <br />... ........ <br />sil9mn" of Claiismant ........ <br />I, bdm* me A NOtWY Public in <br />said county. pmamay C&W and <br />to known to be the identical person or <br />PWW" Who executed the foregoing Mk".. and acknowledged the m., to be hm her, or thj, voluntary ad <br />Cleat and <br />Witness my hand and smal, in said <br />County, the day, and Year last above written.. <br />Ci <br />"Mau Imix" - two IN 44164ft <br />)EWL C U1 Si)w <br />C4",A El, <br />My Notary Public. <br />.... ...... <br />STATE Oi' <br />FrAwed On tmnmmW Indat and filed for <br />in the Regillar of Deads Offim ofmid <br />day of <br />Cftnty the j <br />at <br />O'clock and... <br />mad rswrdW in Book__ <br />........... <br />