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TOWN <br /> TOWN <br /> w <br /> TOWN OF NL4SHPEE <br /> � Statement of Discontinuance,Change of Residence, Change of Location of Business, <br /> Withdrawal,or Deceased from Business or Partnership,Change of Business Name or Owner Name <br /> T TDATE <br /> Discontinuance <br /> In conformity with the provisions of Chapter one hundred and ten, section five, of the General <br /> Laws, as amended, the undersigned hereby declare(s) that Me has (have) this day discontinued(retired <br /> from) (withdrawn from)the business of <br /> conducted at <br /> STREET <br /> SIGNATURE <br /> Change of Location of Business <br /> I hereby state that the location of the business/my residence as it appears on the Business Certificate filed <br /> on has been changed to <br /> • Name of Business <br /> SIGNATURE <br /> Change of Name of Business or Owner <br /> I hereby state that the name of the business or the owner as it appears on the Business Certificate has <br /> been changed from <br /> to (AV S C.o2A <br /> d <br /> SIGNATURE <br /> Notary <br /> Bamstable ss. L J I —) O� <br /> Date <br /> Personally appeared before me the above named and -made oath <br /> that the foregoing statements are true. <br /> • L 0 Puhlic <br /> Margaret C. Santos a4_ae) <br /> NOTARY PUBLIC Commission Expires <br /> Commonwealth of Massachusetts <br /> origfluUly4� mmission Expires Sept.24,2010 <br /> Origf - _ <br />