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Statement of
George Hamiz
Oct 8th 1867
O.L.A. CoBur.R.T.t.A.K
Cohuoubur Tex
Enclosure 19

From + subscribed To before me
This Now day of October AD 1867
J.A.[[??]].Bur R.T + A.S. 

George L [[??]].6th L.Bar