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[ ] HISTORY BOOK                                                                            [ ] FAMILY HISTORY BOOK

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(1)  BOOK TITLE: ______________________________________________________________________________________________________________                      

(2)  WRITTEN/COMPILED BY:_________________________________________________________________________________________________

Address:______________________________________________________________________________________________________________

Phone #, FAX # and/or E-mail Address:____________________________________________________________________________

(3)  DATE OF PUBLICATION: ________________________________________________________________________________________________

(4)  NAME OF PUBLISHER:__ ________________________________________________________________________

        Address:_______________________________________________________________________________________________________________

(5)  COPIES OF THE ENTRY MAY BE PURCHASE FROM: Name & Address: _____________________________________________________________________________________________________________________________________________

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Sherrills Ford, NC 28673-0093