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[[preprinted]] 
[Form 3, Ed.]
---
REPORT OF SCHOOLS,
(TEACHER'S.)
=============
State of ____________
[[/preprinted]]
March
[[preprinted]]_______ 1886/[[/preprinted]]
Retained
                        April 8th 1867
[[preprinted]]Forwarded,______________
              Received,_______________
[[/preprinted]]