CONE T RMAT I ON DATE/TIME 12,06 12:19 TIME 00'28" DISTANT STATION ID PAGES RESULT M*1 MAINTENANCE (Please Print) I First Plaque I w-u to WWI Piques 001/001 OK StminessName FOR MARITAL PROPERTY STATES ONLY O Marred O Not Married O Legally Separated Name and Address of Spouse ACCOUNT RECORD