| The State of Ohio, | ss} |
| , |
TEXT: Page torn; text supplied from context.

Signatures of JS and Emma Smith.

Each instance of “L S” enclosed in a hand–drawn representation of a seal. Handwriting of Frederick G. Williams.

Signatures of Joseph Pine and Frederick G. Williams.
TEXT: Printed form ends.
TEXT: “Seal” enclosed in a hand–drawn representation of a seal.