UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
SCHEDULE 13D
UNDER THE SECURITIES EXCHANGE ACT OF 1934
SURREY, INC.
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(Name of Issuer)
COMMON STOCK
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(Title of Class of Securities)
86888L 10 9
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(CUSIP Number)
JOHN VAN DER HAGEN
SURREY, INC.
13110 TRAILS END ROAD
LEANDER, TEXAS 78641
(512) 267-7172
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(Name, Address and Telephone Number of Person
Authorized to Receive Notices and Communications)
DECEMBER 31, 1998
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(Date of Event Which Requires Filing of This Statement)
If the filing person has previously filed a statement on Schedule
13G to report the acquisition which is the subject of this Schedule 13D, and is
filing this schedule because of Rule 13d-l(e), 13d-1(f) or 13d-1(g), check the
following box. [X]
The information required on the remainder of this cover page shall
not be deemed to be "filed" for the purpose of Section 18 of the Securities
Exchange Act of 1934 ("Act") or otherwise subject to the liabilities of that
section of the Act but shall be subject to all other provisions of the Act.
(Cover page continued on next page)
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SCHEDULE 13D
<TABLE>
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<S> <C> <C> <C>
CUSIP NO. 86888L 10 9 PAGE 2 OF 4 PAGES
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1 NAME OF REPORTING PERSON
I.R.S. IDENTIFICATION NOS. OF ABOVE PERSON (ENTITIES ONLY)
John B. van der Hagen and Mary A. van der Hagen, joint tenants
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2 CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP* (a) [ ]
(b) [ ]
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3 SEC USE ONLY
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4 SOURCE OF FUNDS*
N/A (See item 3)
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5 CHECK BOX IF DISCLOSURE OF LEGAL PROCEEDINGS IS REQUIRED PURSUANT TO ITEMS 2(d) OR 2(e) [ ]
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6 CITIZENSHIP OR PLACE OF ORGANIZATION
United States of America
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NUMBER OF SOLE VOTING POWER
SHARES 7 900,227
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BENEFICIALLY SHARED VOTING POWER
OWNED BY 8 -0-
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EACH SOLE DISPOSITIVE POWER
REPORTING 9 900,227
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PERSON SHARED DISPOSITIVE POWER
WITH 10 -0-
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11 AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON
900,227
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12 CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (11) EXCLUDES CERTAIN SHARES* [ ]
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13 PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW (11)
36.2%
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14 TYPE OF REPORTING PERSON*
IN
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</TABLE>
*SEE INSTRUCTIONS BEFORE FILLING OUT!
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ITEM 1. SECURITY AND ISSUER.
This statement relates to Common Stock, no par value, of
Surrey, Inc. ("Issuer"), a Texas corporation, having its principal executive
offices at 13110 Trails End Road, Leander, Texas 78641.
ITEM 2. IDENTITY AND BACKGROUND.
2(a) John B. van der Hagen and Mary A. van der Hagen,
joint tenants
2(b) 13110 Trails End Road, Leander, Texas 78641
2(c) Chief Executive Officer and Secretary,
respectively, of Surrey, Inc.
2(d) N/A
2(e) N/A
2(f) United States of America
ITEM 3. SOURCE AND AMOUNT OF FUNDS OR OTHER CONSIDERATION.
Mr. John van der Hagen acquired shares of the Issuer at its
inception using personal funds. Mrs. Mary van der Hagen became a joint tenant
for no additional contribution.
ITEM 4. PURPOSE OF TRANSACTION.
Mr. and Mrs. van der Hagen hold the shares in the Issuer for
investment purposes. Both Mr. and Mrs. van der Hagen intend to continue holding
such shares for investment purposes only as passive investors.
ITEM 5. INTEREST IN SECURITIES OF THE ISSUER.
Mr. and Mrs. van der Hagen own a total of 884,727 shares of
common stock of the Issuer, redeemable common stock purchase warrants to
purchase 1,000 shares of the Issuer and currently exercisable options to
purchase 14,500 shares of common stock of the Issuer or 36.2% of the total
outstanding shares.
ITEM 6. CONTRACTS, ARRANGEMENTS, UNDERSTANDINGS OR RELATIONSHIPS WITH
RESPECT TO SECURITIES OF THE ISSUER.
N/A
ITEM 7. MATERIAL TO BE FILED AS EXHIBITS.
N/A
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SIGNATURES
After reasonable inquiry and to the best of my knowledge and belief,
I hereby certify that the information set forth in this statement is true,
complete and correct.
Dated: February 8, 1999
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/s/ John B. van der Hagen
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Signature
John B. van der Hagen, Chief Executive Officer
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Name/Title
/s/ Mary van der Hagen
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Signature
Mary van der Hagen, Secretary
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Name/Title
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