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<br />84 -003605
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<br />Lirn claimed by: ,"'...'u.......:rli.!-Y..2....u,....'u...""u..,. ,.....J9.'~~.... '
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<br />Address 1706 s.~, Holl.a.!rl..~ive.., ,......"'.., ., ,...........u..,2.~,2.Q.,~.,...l'9E~,I..~L,H___.......,.....,........... !
<br />/9-u.uu.u, Grand Island, NE 68801 Grand Island,~, 68801 Cr, !.;
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<br />::::::::: :::::r::::jf:::: ::::::: ::::::: :::: :::: :::::: ::: :::::: :::::::: ::::::::::::::::::::::::::::::11::::::::::: :::l:::::: r:::::::::T::::::::: III
<br />:: ::: ::::::::: :t:::::t:::::: :::::::::::: :::::: ::::::::::::::: ::::::::: ::::::::::::::::::::::::::::::It:::::::::: :::t::,::::t::::::::::r--:::::::::111
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<br />dul): S'worn, em his oath says that the foregoing itemized (Ucount of work, laboy, skill...._..u..__.__m._._.___m..-.....__.h__..~_nu...4u. -f I~
<br />materials, and improvements ":s tnu and correct: that same 'Were done and performed and furnished by the undersigned-l H
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<br />That at the time said contract 'lcas ~twde (I-nd labor and materials fu,rnished and delivered thereunder.m~......._.~...m..._
<br />.. ....~a,.D...Jiyiden.. . ...was the owner of saidPretnises'
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<br />That the date of the first item furnIShed and de/iver.d 1t'aL.~Qxinatel:\l.,l\pl:il..1,...l.'l8!1..,........., and the j ;i
<br />dale of the last item was.,. ......~YJ,6.!.. 1984 .... m.........""" '''''''''''......,.......... i
<br />Affianl further states that said labor was performed on. and materials were furnished for, delivered at, and used in I
<br />said building Or' premises On and between the dates SPeci{if:d. i
<br />That the prices charged therefor are fair and reasonable, and that there is now due on said account the sum of f
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<br />said account, to~'Wit:
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<br />The sum
<br />..Joy oj...
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<br />....claims (l lien on the said premises for the full amount of
<br />of $..2.,,5.5,Q...00...... ....... . . .. ....together with interest thereon at the legal .-ate,
<br />May _ 19 84 and further affiant sa)" not,
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<br />Subseribed
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<br />day of .
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<br />in my presence and sworn to bc:forc me this.... 5:th..._
<br />. ... ...J.11J..X. ";:-::"""7 Ip.~4.......
<br />/'.'k~':1/,)HJ..J)}(L "'J.;,.~~~':tip~blic:"
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<br />( See reverse side {or in;;trucdons)
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<br />Entt'red on f1unwrwai wd..x "ad Hled [,'r IT'curd
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