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Show 7. PHYSICAL DESCRIPTION DESCRIBE THE ORIGINAL(If known) r AND PRESENT CONDITION /k.; ,6~7 ' ~ /r.>~ / U,/~ v./~ ~ £7~.a-e ~~ , / ~~ ,~ ~~ ~ ,J#-h/]k> ~ k ; ! i'f/~ 1 «~ ~ ~ ~ ;f k#L/ P t/~ j' ~ ~ 77./ Ju-4/ ~ /aJ ~ ~ ~ ~ ~ ~. / ' ps. C~c .. /? .L Cd4/-j; (/xnY' ~ /?h~) /?q/ ;~ //H ~ £ ~~~. I'/C/~J 8. STATEMENT OF SIGNIFICAfu INCLUDE HISTORY , PERSONAGES , EVENTS, MAJOR SOURCES OF INFORMATION. ETC . ~, . 9. CERTIFICATION FORM PREPARED BY : (Name, orl/anlzation) STATE LIAISON OFFICER CERTIFICATION As the designated State Liaison Officer for the National Historic Preservation Act of 1966 (Public Law 89-665), I hereby nominate this property for inclusion in the National Register and certify that it has been evaluated according I HEREBY CERTIFY THAT THIS PROPERTY IS INCLUDED IN THE NATIONAL REGISTER . to the criteria and procedures set forth by the National Park Service NAME _______________________________________________ (Keeper 01 the National Rel/lster) DATE ____________________________________________ TITLE: ______________________________________________ |
