, at
dated ,19 , I have carefully executed the survey of
the claim of
known as the (lode, placer, or mill site)
situated in , Township ,
Range , Meridian, in the State of .
This survey, designated as number , has been executed by me and under
my direction and has been made in strict conformity with said order, the
Manual of Instructions for the Survey of Public Lands of the United States,
and in specific manner described in the foregoing field notes.