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Signature of holder of license.
Date of birth______
Place of birth_____ _SI/^lyy .. Qtr/&ct Lt s
___/V#l7ve \
A<
Native or Naturalized Date of Naturalization Place of Naturalization By what Court
Naturalization Certificate No..
Present address. b2Q__________/3/vc/
/3ay J/
Ot>/s
/f.
Passed visual examination...j Visual examination on file in the office o??_
* S S' ?
if. S. I.ucal Inspectors issuinit this lii'L-nse. I