John G. Nichols
                                     deceased
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  Then this obligation to be void, otherwise
to remain in full force and virtue.
                Clarence V. Burrage
Suffock, ss, January 22nd A.D. 1914
       Examined and approved
                   Harry R. Dow
                       Acting Judge of Probate Court

I Clarence V. Burrage the within named
executor declare that, to the best of my know-
ledge and belief, the estate, and effects of the
within named deceased do not exceed in
value the following mentioned sums, viz:
            Real Estate $25,000.00
        Personal    "   $200,00.00
             [Sign]  Clarence V. Burrage