ATI (ROAN! AT BIRTH U OTHER nal • • CERTIFIER-NA I a .nrl ST MING ADDRESS (5trtel or RIO Alp. f n Suer bol RICASTRUT 6. 'Spsm i 16 DAT CEIVED BY REGISTRAR IMo. NY Yr I GO %NI'S. 7 -' 7a 1100401-MAMEN lAiOOL LAST AGE TM Mme STATE OF Nilt RAM on/SA ova armor d al mip lb 2/ nn) \1