]ty+ph l( rdS)Sb )tlZ[tb]
]#S QpSq[________________]
2] Q tSnZ)S[__________________]
3]NSgzZ
{nZ}[___________] 4KlZ(S) KtSbStSkSbw K[sk]mw Kl hn[n)z]w y)d[w]hyw h#m N[ydk
{hS}wZ]tn)l 5yd hm h)m Nyr[w]c Nwn) hmS hS)Sm (br) Nyzwz Psk yl(S Kl
>(< Myqw 6K#rSpSw Ktwskw Kmxl Nyd M( hyZdSyZ Nm h Q [__]smlw b#ml )bct
7Psk M Q Q#
{yZdS}wZ)S Nyrwx trb htn) Nwzm 8Ny(ls NwmyZhS yd h)m (SbSrS[) ]Ny[z]wz
K#rpSwZ KS[mxl ]Nyd M( N
{yZ}wZ[ Nm h Q Qs]mSlw b#ml N[y]bct yd h)m h)m 9yskn Nm ytyb Nm KnqrSpS)S yZ
{yZ})StSb#t M)w Nyrwx trb htnk Ktskw 10] Qlmk whS Q[ ] W W[ ]#S)Sk yl( )myq K[t]btk[w ]hStn)l yl Knb[yt)w]
11]bS Q[________________]
12NZ[nb___________]NZ[______]
{NZ}KS[___________________] W[_______] 13M)w Nyl(bSlZ NZ[bsn]tSyZ yd Nmz[ d( yskn ]Nmw ytyb Nm Nnztmw )bty )wh[t ]N[b]qn
14yskn Nm ytyb Nm Nnztmw )SbStS[y ]N[yw]ht Kmdq yml([ ty]bSlZ KhS)S hn)
>M)w< 15yl rm[t y]d Nmz lkbSwZ Ktbtk PSsSk Kl NZtSnml yZ[tr]yZ Nwbcy yd Nm[z d(]
16[______] W W W[____ ] W[____ ] W[___ )zx ydk hnd )r+# K]l[ Plx)]
17btk[ l( yd lwk hn]) yl( M[yq __________________________]
18rz(l) rbS hSdSwShSyZ l( Nw(mS# trS[b] htbblZ[_______] W W[________]
19Verso
hbtk h[#pn l( rz(l) rb hdwhy]
12
hS#Spn l([ Nw(]m#[ trb] )St[bb]
3dShS#S MS[_______]rSb wl)S[______]l) Q[_______]
4d[h]# Nw(m# rb )SmSwZtS
5[dh]# N Q Q[_____________]
6] rS [__________]
7