Census Form

Stamp Information

Proprietary Rug Stamp
 RB8a RB8b RB9a RB9b RB10a RB10b

#200 USIR Stamp
 R102a R102c

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 Manuscript Handstamp N/A

Date If Legible

Certificate?
 Yes No

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Other Information (i.e. Provenance, Ex-____)

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Owner Information

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Location (City, State, Country)

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 Name Name & location Neither

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