v2413-1149

Sydney M. Williams vs.

340

fefendant's Exhibit AA)

ii im No. 6f. V ~S VA Co. J4P(n^ j/^JLr ^ Amt. of Loss f

Policy No. JT/j^ ^/^ 7 ,37/

Broker

/4m-pr-' -

A g cnt ,^,^.

Expires - r ? - f n

Total Ami. $ J^ j? j"g , ^

Form ^r^f%^ r y. g Proof Instructions

Assured

Res. Addrese

Bus. tklress

Occupation t^r

_ _ / ^ / -% ' ^ ti ^ /

Date Lost ._^ Location

ben o/ C^c^/^^ A^. W^^rt^fC^^

^c -^r.- pi,.

r3Ly, c-e

~u*r * .?jK^r^^

Reporting Instructions:

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