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191 LAFAYETTE STREET - BUILDING INSPECTION r' 191 LAFAYETTE STREET ' NEW ENGLAND CLAIMS SERVICE, INC. 365 Broadway Lynnfield, MA 01990 Form of Notice of Casualty Loss to Building Under Mass . Gen. Laws , Ch. 139 , Sec. 3D TO: B r Board of Health or Inspector of Buildings addresses RE: INSURED: Dlt�7 t/Q/j/ �iGtI�7Ls� (� � PROPERTY ADDRESS: POLICY NO. : (p0 a7O¢ r LOSS OFt �i (L 2 l3 ' 19 _ . FILE OR CLAIM NO. : O '3 ( ) Claim has been made involving loss , damage or destruction of the above-captioned property which may either exceed $1, 000 . 00 or cause Mass . Gen. Laws Chapter 143 ; Section 6 to be applicable. If any notice under Mass. Gen. Laws ; Chapter 139 , Section 3D is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number , date of loss and claim or file number. TITLE On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail . W SIGNATURE AND DATE . C . A&W �' �• . -Speed. Letter© 44-902 Speed Lette Tor®� j From Subject � r .+o 9 e TOFOLD MESSAGE� Date Signed REPLY ,o9�a1� o.a.o Date Signed WilsonJones RECIPIENT—RETAIN WHITE COPY. RETURN PINK COP GRAYLINEFORM 6C-804 3-PART C 1980•PRINTED IN LLS.A 1194 AND _TG..I'JI YcLl OV. @JN AND . _ °_, C. 55,_'