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�tF, v0 <br /> ..... rt, (U'3i/U ,v l� �qo( ^ .Ing3 s <br /> .y <br /> rs. <br /> �ry":7f <br /> ;y TOWN OF bLiSBPEE <br /> �auLE��' 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 /> D <br /> DATE <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 I/We 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 from)(withdrawn from)the business of 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 ess/my residence as it appears on the Business Certificate filed <br /> on as een t <br /> . e of Busines <br /> SIGNATURE <br /> Change of Name of Business or Owner <br /> I hereby state that the name of the business or the owner as <br /> it appears on the Business Certificate has I i0 <br /> been changed from�C� l ►V Q (G�I D V 161 A P Lt b1/fG�(.In ( O(IPGP 1 I� <br /> �Iji� <br /> too V,�r11-11-11d 017l l'P re- � i"<?P(C <br /> SIGNATURE <br /> Notary <br /> Barnstable ss. <br /> Date <br /> Personally appeared before me the above named and made oath <br /> that the foregoing statements are true. <br /> • Name-Notary Public <br /> Commission Expires <br /> OngfomdDiscontinuance <br />