Showing 2573 items
matching 1871-1894
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St Kilda Historical Society
Ephemera - Invitation - mayoral dinner, To mark the Festive Season and the end of the Year, 1918 or 1929
Although the name of the Mayor and Mayoress, and the year of the invitation are not stated, the fact that music was provided by 'Miss Gertrude Emily Johnson' provides a possible clue as to the date. Gertrude Emily Johnson (1894-1973), coloratura soprano and theatre administrator, was born on 13 September 1894 at Prahran, Melbourne. She was a student of (Dame) Nellie Melba at the women's singing school that Melba founded at the Albert Street Conservatorium, East Melbourne (later the Melba Memorial Conservatorium). The date specified in the invitation, Thursday 19th December, indicates that the event was either in 1918 or 1929. As Gertrude Johnson moved to London in February 1921 and returned to Australia in 1935, when she retired from her singing career, it appears likely that the invitation to the mayoral dinner was for 19 December 1918. Elsie Fraser would have accompanied her on the piano.Cream coloured card printed in gold and with Christmas bells and holly in green and red, being an invitation for dinner with the Mayor and Mayoress of St KildaTo mark the Festive Season, and the end of the Year, the Mayor and Mayoress of St Kilda would be very pleased if ... will take Dinner with them in the Mayoress' Room, on Thursday, 19th December, at 7pm. Music by Miss Gertrude Johnson and Miss Elsie Fraser. RSVP before 12th December.gertrude johnson, elsie fraser, st kilda council, st kilda mayoral function -
Uniting Church Archives - Synod of Victoria
Printed image, 1930
Reverend James Noble MacKenzie was born on 08/01/1865 on the Isle of Ewe and died on 02/07/2956. He arrived in Victoria in 1894. He served in Santo and Korea. He is notable for his work among lepers. Moderator of the Presbyterian Church of Victoria in 1939. He authored two books. B&W full length printed image of Reverend Mackenzie with Mrs. Mackenize and four children." Rev J N & Mrs Mackenzie and Family". Photo for "Young People's Mission Bands of Presbyterian Church of Victoria 27th Annual Report 1930.mackenzie, james noble, rev., presbyterian, minister, moderator, young people's mission bands -
Stawell Historical Society Inc
Photograph, Mr Edmund Craigie Grant
Edmund Craigie Grant died 1894 63 years. Married 1862. The firm Grant, Lamont & Coy were the first to erect Quartz Crushing machinery at Concongella Creek and later in Stawell at what became North Park. They built a house called "ALVIE" 39 Darlington Road (still standing 2005).Black & white photograph of Edmond Craigie Grant sitting in a chair holding a manuscript or magazine. Creelwaut Co (?) Burlington Galleries, corner of King & George Sts. Sydney Arcadestawell portrait -
Rutherglen Historical Society
Image, 1970s
Fairfield Vineyard was established by George Morris in 1859. In 1894 it was the largest vineyard in the southern hemisphere with 280 hectares under vines, storage a million gallons and 120 Chinese employees. it is also reported that Ned Kelly worked at Fairfield Vineyard Fairfield House is a historic Italianate mansion built in 1889 and restored in 1975.Black and white photograph of a Victorian era mansion, with a brick winery building with a three-arched roof to the right of the house.On back of photo: "Fairfield"wineries, north east victoria, wine industry, fairfield cellars, fairfield house -
Glen Eira Historical Society
Document - St. Mary’s Church, Caulfield
A list of subscribers to St. Mary’s Anglican Church Caulfield from 1871-1922. Includes miscellaneous information on parishioners and activities from 1887-1895. Also includes another list of contributors that includes additional information on St. Margaret’s Church 1923.slaney street, st. margaret’s hall, halls, foundation stones, slaney fanny, slaney henry, head mrs., hart mrs., glen eira road, st. mary’s, shelford girls school, kindergartens, helenslea, hood crescent, hood justice mr., langley h.t., moffit graham -
Bendigo Historical Society Inc.
Ceremonial object - Ceremonial collar
Ancient Order of Druids was formed in London in 1871. Their motto was "Justice, Philanthropy and Brotherly Love". The Order was established in Australia in 1851.The Sandhurst Lodge 247 met at Queens Head Hotel (Lockwood cross roads) and was first mentioned in the Bendigo Advertiser in 1863.Ceremonial collar in red velvet with gold metallic bullion fringe around outside edge and lower inside edge and gold metallic lace to edge. At one end (LHS) there is a large gold metallic star in sequins and gold metallic bullion. At the other end (RHS) the initials PA are worked in zardozi work in gold metallic thread 5cmx7cm.ceremonial collar, ancient order of druids -
City of Greater Bendigo - Civic Collection
Photograph - Three photographs : Bendigo Easter Fair, 27 April, 1938
The Bendigo Easter Fair was established in 1871 to fundraise for the Bendigo Hospital and the Bendigo Benevolent Asylum. Donated by the Sadner family who were associated with the Bendigo Hospital, these family snap shots capture the regalia and atmosphere that the Chinese community bring to this community event. Set of three black and white photographs. All photograph are taken on the streets of Bendigo during the 1938 Easter fair and parade. 0322.1; Exterior; Three people on horses in traditional chinese costume. Person in the foreground is holding the reins of one of the horses. 0322.2; Exterior; street view with children in foreground and a line of people in costume holding chinese banners. 0322.3 Exterior, street view from balcony of the two cars with people lined up on either side.Verso; 0322.1, 0322.2 27 April, 1938. 0322.3 Handwritten; Late 1930's C/r Mitchell, Garsed Streets from Terminus Hotel Balcony.eugene and mollie sandner collection, bendigo hospital, eugene sandner, mollie sandner, mollie sibson, bendigo easter fair, mayor sandner, mayoress sandner, bendigo chinese dragon -
Uniting Church Archives - Synod of Victoria
Bible, University Press, Oxford, MDCCCLXXXVIII [1888]
Black embossed leather covered bible with a metal fastening and gilt text. The end papers are brown marbled paper. The bible includes monochrome plates and coloured maps. There is a handwritten dedication label stuck inside the front cover signed by the Minister and Steward."Presented to Mr and Mrs A. G. Youngs by the members and friends of the Primitive Methodist Church Moonee Ponds Victoria as an expression of affectionate esteem and earnest good wishes on the occasion of their departure for England, August 1894. H. Bride Barker Minister William Halling Steward"primitive methodist church moonee ponds -
Port Melbourne Historical & Preservation Society
Photograph - Josephine Antoinette MacDONALD, 1912
Photo taken in 1912 at the Macdonald family farm at Alfredton, North Island, New ZealandPhotograph of Josephine Antoinette MacDONALD (nee LIARDET) in 1912 (holding baby). Other adults are Josephine's son Evelyn Poniatowski MacDONALD (1871-1962) and his wife Mignone Caroline - nee WILSON (1878-1940). Children from left to right ; Robert Ian (b1910); Ardis Mignone (b 1908); Alan Lowell (b1907); Ronald Evelyn (b1904); Frank Leon Gordon (b1912) - on Josephine'slap; John Sylva (b1905) families, liardet family, josephine antoinette macdonald nee liardet -
Bendigo Historical Society Inc.
Booklet - Rules and Regulations
The Society of Old Bendigonians (1853), Rules and Regulations booklet for the rules and regulations established on 27th September 1870. The booklet was printed by Maurice Moran, Mundy Street in 1871. the booklet includes the 27 rules and a list of members on 31 October 1870. The front and back covers of the booklet are blue, with the pages inside an aged creamy brown. The print throughout is black. A photocopy of the original documents has been made and is located with the original.old bendigonians, rules and by-laws, 1870s, rules and regulations -
Bendigo Historical Society Inc.
Book - Atlas of Physical Geography
The student's atlas of physical geography consisting of twenty maps, constructed and engraved by Edward Weller F.R.G.S. with descriptive letterpress by James Bryce L.L.D F.R.G.S. Published by William Collins, Sons & Company, London, Glasgow and Edinburgh 1871. Brown cover with the title of the book in gold letters. to the left of the title, also in gold, three circles with different pictures inside. the first of two boats on the sea, a volcanic eruption and a mountain peak.On first page in pencil the name Carrie Van Damme.geography, atlas, 1871 -
Ringwood and District Historical Society
Work on paper, Biography of Edward Thomas Miles 1849-1944 and descendants, c.2005
Copy of group presentation notes for a talk to Ringwood and District Historical Society by Elva Brooke on early local identity Edward Thomas Miles 1849-1944 and descendants, with photocopied newspaper pages 17 and 18 of The Leader Supplement, October 6, 1894, and extract taken from the book "I Exell - The Life and Times of Sir Henry Jones" by Bruce Brown (1991) - Chapter 4, including the story of Captain E.T. Miles. -
Greensborough Historical Society
Postage Stamps, Von Mueller collection 1, 1885o
Envelope fronts with stamps, addressed to Baron Ferdinand von Mueller. Upper image, 2 x 1penny yellow/brown Victoria Stamp Duty, postmarked at Melbourne on Sept 29, 1894. Lower image, 1 x 2 pence orange, South Australia, postmarked at Adelaide GPO on March 25 1900. Baron Ferdinand von Mueller (1825-1896) was born in Germany and migrated to Australia in 1847.He was the Victorian Government Botanist (from 1853) and Director of the Botanical Gardens (1857-1873). These envelopes and stamps are from correspondence addressed to him.Front of envelopes with address and postage stamps, enclosed in black stamp folder.ferdinand von mueller, postage stamps -
Federation University Historical Collection
Correspondence, Richard T. Vale, Correspondence between R.T. Vale and Mr Martell of the Ballarat School of Mines, 1898, 1898
R.T. Vale had a stationary and bookshop in Ballarat. He had studied at the Ballarat School of Mines, and served on its Council. In 1886 he was elected to the Victorian Legislative Assembly as the member for Ballarat West, serving until 1889 and again from 1892 to 1902. From 1894 to 1896 he was a minister without portfolio.Two handwritten letters from Richard T. Vale. .1) Letter on Government of Victoria Education Office letterhead dated 09 May 1898. .2) Letter of Legislative Assembly Victoria letterhead dated 28 October 1898..1) Dear Martell, I want you to send to dept details as to Room required size of classes how often they meet [illegible] of present accommodation and [illegible] how they clash ad how the proposed rooms are to be erected send at once. Yours truly R.T. Vale .2) 28.10.1898 D.M. I called at [illegible] today plans not quite colored yet I have to be traced from sheets full of detail drawings [illegible] to service and would made had it been safe when they tried [illegible]. I [illegible] would have to wait another fortnight. Yours R.T. Vale.richard t. vale, r.t. vale, legislative assembly victoria, goverment of victoria -
Flagstaff Hill Maritime Museum and Village
Leisure object - Tobacco Pipe Cleaner, W.D. & H.O. Wills, After 1897
Tobacco smoking became a popular leisure activity in the 19th century. The corkscrew and the tapper accessories are used to clean the pipe and remove the debris after the tobacco is smoked in the pipe. The tamper is marked Capstan, which is a brand of pipe tobacco. The brand was first used in 1894 when W.D. & H.O. Wills launched their new product. The pipe tobacco accessories are associated with tobacco pipes and with Capstan tobacco, which became available in the 1890s. Smoking has been a popular leisure activity since the 19th century and continues now. The manufacturer of Capstan, W.D. & H.O. Wills, was the first company to mass-produce cigarettes.Pipe cleaners; a pair of metal accessories tools for cleaning tobacco pipes. One is a corkscrew, and the other is a tapper, shaped like a tapered nail. The tapper has an inscription. The brand is Capstan."Smoke" "Capstan"warrnambool, shipwreck coast, flagstaff hill, flagstaff hill maritime museum, flagstaff hill maritime village, capstan, tobacco pipe tools, tobacco accessories, pipe corkscrew, pipe tamper, tobacco tapper, tobacco smoking -
Bendigo Historical Society Inc.
Photograph - Home of David and Augusta Lanyon
David Lanyon undertook many aspects of mining progressing to become the underground boss of the New Chum United Mine. In 1894 he became a member of the Bendigo Stock exchange and a successful speculator. He then moved into a new home, "Raelwa" in Beech St., GoldenSquare. This substantial home was designed by architect, Mr William Beebe10563.3a David & Augusta Lanyon outside their (Miner's Cottage) home in Ophir Street, Bendigo. Later after his success with investments he built a home in Beech Street which he named "Reawla" after his village in Cornwall. 10563.3b photocopy of Mr. David Lanyon, who made a fortune speculating ion the Bendigo Mines From undated photographsdavid lanyon, reawla, miner's cottage -
Kiewa Valley Historical Society
Book - Gundowring x2, Gundowring School 1872 - 1972 100 Years
A school was built in 1871, a shingle roofed wooden building built by the local residents. It was replaced in 1873 with the old school becoming the teacher's residence. The continues with a timeline, a pupil's insight into life at the school, a list of teachers and families. An interesting history of the area and education of the time. Gundowring is a farming town in the Kiewa Valley. The book gives an insight into the education and lifestyle of the time.Mustard cardboard cover with brownish print. Across the top "Centenary Celebration, Saturday, March 31st, 1973". It has 18 pages, some colored, printed on both sides and held together by 2 staples. It includes sketches.Glued inside the front cover "Mr & Mrs Roper & family" - Invitation. Also a newspaper cutting titled "Gundowring"gundowring, education, kiewa valley, school centenary -
HMAS Cerberus Museum
Sword- Captain WH Panter
Of Leut W.H Panter, First Captain of H.M.V.S Cerberus and brought the ship from England to Port Phillip Bay in 1871. The sword was donated to the Ran College in the year 1934 by Miss Orr's Grandaughter. One of the roads in H.M.A.S Cerberus is named after this Officer.Sword and Scabbard.The sword of Captain W.H Panter Captain commanding Naval Forces of Victoria, first Captain of H.M.S Cerberus presented by Miss.M.Orr. -
National Wool Museum
Architectural Plan, Wool Warehouse, Moorabool St, Geelong for Messrs C.J. Dennys & Co., Basement Plan No. 2
Original Jacob Pitman architectural plan of the Dennys Lascelles bluestone woolstore dated 1 March 1871 mounted in a wood frame under glass. Titled "Wool Warehouse, Moorabool St, Geelong for Messrs C.J. Dennys & Co., Basement Plan No. 2."Wool Warehouse, Moorabool St, Geelong for Messrs C.J. Dennys & Co., Basement Plan No. 2wool stores, pitman, mr jacob, dennys lascelles wool store -
National Wool Museum
Architectural Plan, Wool Warehouse, Moorabool St, Geelong for Messrs C.J. Dennys & Co., Ground Floor No. 3
Original Jacob Pitman architectural plan of the Dennys Lascelles bluestone woolstore dated 1 March 1871 mounted in a wood frame under glass. Titled "Wool Warehouse, Moorabool St, Geelong for Messrs C.J. Dennys & Co., Ground Floor No. 3".Wool Warehouse, Moorabool St, Geelong for Messrs C.J. Dennys & Co., Ground Floor No. 3wool stores, pitman, mr jacob, dennys lascelles wool store -
City of Kingston
Photograph - Black and white, Methodist Church Cheltenham, 1909
The first Methodist church built in Cheltenham was a wooden structure which burnt down in 1893. While the exact cause of the fire was never ascertained, it was believed that a spark from a passing train ignited dried leaves in the eaves. The original church was replaced by a brick building, with the foundation stone laid in 1894. This image shows the replacement building.Black and white photograph of the brick Methodist Church in Cheltenham with a white picket fence and gate at the front. -
Whitehorse Historical Society Inc.
Machine - Sewing Machine, c1860s
Willcox and Gibbs: Serial No. 158679.|The Willcox& Gibbs Sewing Machine Company was founded in 1857 by James E. A. Gibbs and James Willcox and opened its London Office in 1859 at 135 Regent Street . By 1871 the Company's Chief Office for Europe was at 150 Cheapside, London, this office was later moved (post 1885) to 94 - 96 Wigmore Street, then 37 & 39 Moorgate Street (by 1891 to post 1907) and later 20 Fore Street, London .Right from the initial production the manufacturing of the Company's single thread, chain stitch machine was undertaken by Brown & Sharpe, Rhode Island and this continued up until 1948.|A special hand crank mechanism was produced in England for the European market, but the general design of the Willcox& Gibbs remained essentially the same throughout its production. The only major improvement was in 1875 when the glass tension discs were replaced with an automatic tension device which ensured the machine could not get out of adjustment.|In addition to the domestic hand and treadle machines the company produced a wide range of industrial models.|The Company finally closed in 1973.|This Willcox& Gibbs came complete with its wooden carry case. The machine was made in America in the late 1860's but it has the ornate hand crank produced at Coalbrookdale near Telford, England which was, in Victorian times, renown for producing high quality ornate iron castings. This machine has the glass tension discs which were used on domestic models until 1875. The Willcox& Gibbs badge is located on the rear of the base casting and it also has a deep wooden base.|The cloth plate has various American patent dates, four dating between 1857 & 1860 relating to J. E. A. Gibbs, three dating between 1860 & 1864 relating to Chas H. Willcox (son of James Willcox), the machine was also licensed under five other patents including the infamous Elias Howe patent of 1846.|There are only two English patents one for J. E. A Gibbs and the other for James Willcox.Upright sewing machine. Machine is quite small and set on wooden table. Ornate metal sides and treadle feet. One drawer. Brass name medallion on back.Willcox & Gibb Sewing Machine co, New York.|Other inscriptions are :-|London, Paris|Measures|Thread type|Needle 12 stitches to inch|Brevettees G.D.G.|En France|Eten Delgique|Under Royal Letters|Patent|James Willcox|July 4 - 71 [1871]handcrafts, equipment -
Ballarat Heritage Services
Digital photograph, Graveyard Reserve, Ballarat East
Ballarat East, Section 103, Allotment 21 & 22, Peake and Tress Streets, Mount Pleasant. Surveyed by W. S. Reeves Contract Surveyor April 14th, 1871. Also shows allotments of T. Williams and F. Macalpin, as well as the Powder Magazine Reserve.Plan of the Graveyard Reserve and Mount Pleasant Powder Magazine.mount pleasant, w.s. reeves, plan, powder magazine, t. williams, f. macalpin -
Charlton Golden Grains Museum Inc
Photograph, St Andrews Charlton Presbyterian Church demolition c.1989 side view, c.1989
The St Andrew Charlton Presbyterian Church was built in 1871 by James Patterson, a contractor and grazier of Nardoo Park, Woosang. Dismantled in 1989, The view is of the side of the church and the roofing has already been remove. The roof timber have been exposed. Bricks litter the ground.Colour Photo of St Andrews Presbyterian Church. Being demolished in c.1989. View is from the back.charlton presbyterian church, james patterson, church, presbyterian, pastoral care, manse, demolition -
Charlton Golden Grains Museum Inc
Photograph, St Andrews Charlton Presbyterian Church demolition c.1989, c.1989
The St Andrew Charlton Presbyterian Church was built in 1871 by James Patterson, a contractor and grazier of Nardoo Park, Woosang. Dismantled in 1989, The view is of the back of the church and the roofing has already been remove. The contractor and their yellow dump truck are in the foreground. Bricks litter the ground.Colour Photo of St Andrews Presbyterian Church. Being demolished in c.1989. View is from the back.charlton presbyterian church, james patterson, church, presbyterian, pastoral care, manse -
Federation University Historical Collection
Book - Register, Ballarat School of Mines Library Register of Books, 1870-1896, 1870-1896
The listing of books in the Ballarat School of Mines library begins with No 1 and ends at No 1465. This book is identical to Library Catalogue No 00007, but isonly numbered to No. 921. Redmond Barry, Robert Broigh Smyth, Ferdinandy Von Mueller, the Victorian Geolofical Survey and many local illuminaries donated to the Ballarat School of Mines. Black cloth covered exercise book with handwritten lists of books in the Ballarat School of Mines Library dating from 1870 to 1896. The pages have been divided into columns with the following headings: Reg. No; Title; Author; Vol.; Issue; Donor, Receipt. Some of the books are as follows: 1. Memoirs of Geological Survey of Great Britain, Vol 1., 1846, Donated by Her Majesty's Government, 16/03/1870 19. Prospectus of the School of Mines, 1869, Donated by Her Majesty's Government, 16/03/1870 44. The Steam Engine, Rankine, purchased, 09/03/1871 72. Melbourne University Calendar, 1859-1860, donated by Sir Redmond Barry, 14/04/1871 85. Maps of County of Anglesey, donated by Minister of Mines, 23/05/1871 107. Electric Telegraph, R. Sabine, purchased, June 1874 356. Organic Constituents of Plants and Vegetable Substances, Dr. G.C. Willstein, donated by Ferdinand Von Mueller 375. The native Plants of Victoria Succinctly Defined, Baron Von Mueller, purchased, 1879 569. Platur's Manual of Qual and Quan Analysis with the blowpipe, donated by Henry Sutton, May 1884 738. German Bible, donated by R. J. Litton, 21.05.1886 802. Essays of Addison, J.R. Green, 18/06/1887, donated by Bella Guerin 803. Rec De Planches Dur Les sciences Les Arts Liberaux et les Arts Mechaniques, Vol VI, 1875, Donated by Theo William, 01/07/1887 Excel spreadsheet attached (incomplete)ballarat school of mines, library, books, ballarat school of mines library, william laplau, dr bunce, james oddie, bella guerin, j.f. usher, r.m. sergeant, redmond barry, robert brough smyth, cosmo newbery, john noble wilson, joseph flude, commissioner of patents, henry sutton, w.n. wooster, theophilus taylor, rivett henry bland, ferdinand von mueller, c.c. shoppee, william luplau, ferdinand krause, william wooster -
Bendigo Military Museum
Document - MECHANICAL TEST RESULTS WW2, Thompson's Engineering and Pipe Works, 1942
By referring to Cat No 7237.2 will bring up all items associated with Thompsons.This is a set of 3 sheets of steel tests on 6 PDR anti-tank gun tests. From Thompsons Engineering & Pipe Co. Lt Castlemaine to General Motors Holden, South Aust A/C Ministry of Munitions. 1. Barrel NRS 2483 - 2484 - 2498 - 2499 - Dated 1943. 2. Barrel NRS 1809 - 1812 - 1826 - 1827 - Dated 1942. 3. Barrel NRS 1876 - 1877 - 1859 - 1871 - Dated 1943.Signed off by (?) Martin.gun barrel tests, pdr anti- tank. -
Warrnambool and District Historical Society Inc.
Document, Thomas Bing Nurseryman, 1870s
These catalogues come from the firm of Thomas Lang and Company of 52 Elizabeth Street, Melbourne and Bridge Street, Ballarat. They list the seeds and plants for sale in the early 1870s. This company sold seeds and plants to all parts of Australia and to India, China, Hong Kong, Mauritius, Ceylon and Fiji. These catalogues have no known local provenance but have considerable antiquarian value and are of interest as they tell us what plants and seeds were sold in Australia in the 1870s.These are three booklets - catalogues of plants and seeds for Thomas Lang & Co, Nurserymen and Seedsmen, of Ballarat and Melbourne. The booklets are printed in black on a white background and are bound or stitched with fine string. They are a little foxed and dog-eared. Catalogue One is dated 1870 and is numbered No. 27. The cover has an ornamental border. Catalogue Two is dated October 1871 and is Number 36. Catalogue Three is Number 30 but undated and contains prices of seeds and current postal rates.thomas lang & co.,, nurserymen and seedsmen, plant and seed catalogues, 1870s, warranmbool, history -
Port Melbourne Historical & Preservation Society
Book - CD-ROM, Sands & McDougall, Sands & McDougall Pty Ltd, Melbourne Directory, 1860 - 1911
Melbourne Directory in CD case with white background cover .01 - 1860/1865; .02 - 1866/1870; .03 - 1871/1875; .04 - 1876/1880; .05 - 1881; .06 - 1882; .07 - 1884; .08 - 1892; .09 - 1893; .10 - 1901; .11 - 1903; .12 - 1904; .13 - 1905; .14 - 1906; .15 - 1907; .16 - 1911; .17 - 1896-1900 (2 discs). Commonly known as Sands & McDougall(Sands and McDougall)built environment - commercial, built environment - domestic, built environment - industrial, business and traders, statistics, sands & mcdougall pty ltd -
Tarnagulla History Archive
Death Certificate, 1872
A large lot of papers, including this and many other birth, death and burial records, were apparently found in the ceiling cavity of the Sandy Creek/Tarnagulla Post and Telegraph Office in the later 20th Century, during building works. Donald Clark Collection. Transcript of document (partly printed, partly handwritten): TO THE REGISTRAR OF THE DISTRICT IN WHICH THE UNDERMENTIONED DEATH TOOK PLACE I hereby certify that I attended Henry Alfred Emmett aged 11 months last Birthday; that I last saw him on December 18th 1871 that he died on December 18th at ________ and that the cause of his death was Diarrhoea, Duration 3 days. Signed E. Green Proff. Title: [indecipherable] Address: ___________ Date: ____________