hundred and thirty-five of the General Code, and covers the
period ending ..............................................

.............................
Engineer.

Acknowledged before me a ...................... this
.............. day of ......................................

.............................


I, the undersigned, hereby certify that I am a mine-foreman
at the mine represented by this map, and to the best of my
knowledge and belief the same correctly represents the
excavations of the mine for the period ending
............................................................

.............................
Mine-Foreman.

Acknowledged before me a ....................... this
................ day of ....................................

.............................

(Sec. 904, 917, 937; Penalty, Sec. 976.)


Sec. 937. [=Owner, lessee or agent shall file map of abandoned mine