:
COPY
HONG KONG Stamp Duty
$3.00 22.9.17.
I, CHARLES WILLIAM FALK of Victoria in the Colony of
Hong Kong a Master Mariner solemnly and sincerely declare
and say as follows
162
1. ON the 20th day of September 1917 I signed the Memorial and Humble Petition for a Certificate of Imperial
Naturalisation which is annexed hereto.
2. The statements cobtained therein are true and
correct in every particular.
AND
I make this solemn declaration conscientiously
beliefing the same to be true and by virtue of the provisions of the Statutory Declarations Act 1835.
DECLARED
at Victoria this } 20th day of September 1917 )
( sa )
C.W.FALK
Before me,
(Sd)
E.J.GRIST
Notary Public.
Hong Kong