_ - --_r.;�i . - � -- - - - . . ,�. .
<br /> ' �cr(U , . . .. � , � . _. ��
<br />-.� � . _ . 't:_:.
<br />_-� ',i . • ` . . . . . - ', . ' � . . - .. ' . . - ' i , -. i � � � �`v .
<br /> �/¢T� . . . - f '� . � .- _ .. .. �<., . 4��
<br /> +�'r}� • -. c. C - � . :h` . ' �_ ! ` Y. "�Yl��`' 4 l,..-
<br /> . . .
<br /> ✓'
<br /> . . { � _�.�-w. . "i , '(,lk a _ " . .
<br /> f�� . . ' ` , - rv .....ti..l.. � i... � _ .. . . .. ' .. . [... . . � . ' � . ' � �- � . _ �'�... __ .
<br />-�3� .� � . ` Ft�`� +�an.-.�.�_-„ , t _
<br /> �t...
<br /> ���-�` `� . �' , .� , ' .. : �. - _ . . .
<br /> . • .�': -� . .
<br /> — " _ . ' '•3 ,' .
<br /> m .,. . �.__-,� - , � LS�1f8Vi16SOQPYGAR�'"��RAtS�.4F1lLOFlf1E11f�PASfUBf$df.7!lAil�/AJ6?LtlHSERU/CES -t_.�<'_ _t..:_``.:',
<br /> , . . S � SYBIEI'd 1TQ�4Td{FBELObf/lOBEA 7R!lE COiiYOF 1f�Q�Q1PlAL RECORD01+1 fREtNIlN < .' `
<br /> I1fE iV�RASHA lOEALTHAf�tIi/fdARt 8F�17CE.9 89�8'/ERZ VAQ1.B�QT�B�ECnOhb V/HiCNiS ' . �, .�
<br />�.�- � . ; •� 1XE f.EOAt OE�OSlT062NFOR6IilQL RE/�RA4 r_ �� � • ,-
<br /> —3��.. . . � � .
<br /> �:� � � .. . � DAfEQFB� ��� �
<br /> �• _ ' , . . � *�'C2 4199$ � ��►� � �` `
<br /> �, c 1jMSfATER�01�TftAR
<br /> �: '. ' :t • lWf:QlJKA�RA8dUA flEAL1NA8iDNt�iAAtB�lt�88Y8TE� , . .. .
<br /> -- � - . �` ��o� :�-r-
<br /> ��� - - .
<br /> ��� - - ' . -` (�� _
<br /> ���,,` ' PHS 7881YS/REV.�-ST STATZ OF NffiRHSSA . . F
<br /> �.r " � ' D�wm�rer�r op rosttc aeu.a�r. DSPl4ATA�lENT OF HEALTB
<br /> � : . . , E�ucnTtart�rm wEt.p� 8nseaa at Vital Slattsties . �• .`.. .
<br /> _ �' . Et - J _
<br /> � : �Ho.�s... �e�c��oa� nEw�ra ����Ko. _.6...4_..�.��8 d . � . _ .
<br /> � t uwA��tsM..f�.Aa.t �1«ro1m.►arW.am...r+yw) .�
<br /> ' , , 1.DLt6R OI Of4iM a ST�►TL 0.OO!!s!r , . .
<br /> _� 4:. � << - � 0.���. � G.�so � , - . �
<br /> �
<br /> ` e. ur+r.mew.aaaaaT� s.tcM�rx w star n�te e.emr.rowKOn wcarws
<br /> �� f.��� � �YA3611� Qi�TI$ �8� �
<br /> _.x.� � .. _ :'::.
<br /> . �. d.h�ri 0� tli aof tn�a*PUd.tbr mrd aCpa+) J.STR[[7�OPA[SS . . . _,. .
<br /> _ y ItOSVrT41 OR � �� J� ' � •`��.
<br /> . . � � � INSTI7UTION s$� ��� � '
<br /> ��' i.I$R['i�OE�C�IASICE GTY UY�Tp 1iS /. /ARM NE310[llCtt 1[S _ . .
<br />� 'i i . '..!t , t.�S Oi CMTH IIIStOt LWIT51 TES fl0 pp NO . ��1^-:.
<br /> . 4 r . , y , _ �_ . ,.-s,
<br />-� ' � . � j,�y • DAit Menfl G�1 Y'�� '< .�_,:,:-
<br /> , �.RAnC o/ ilnt AlLS� ,,
<br /> � �
<br /> 111� o►� � ou�rM �0 ��f ��' `�
<br /> E� �� . . . . MT(Of BIRTN 9 �a rJn Nmi V Y10[/1�[0 2� _ � � . ...-� ':
<br /> S.S[71 6 C6t0A OR W1R � MAAAQD O��aARAI[D❑ 9� !�p t �QOf) K�W O� qwn b4�
<br />..��"- ` . : . _ �iR9 � RIOOwiOU� GtYOAqD °�•� � . � :�_
<br /> �'. • �Qo.uswaacaw�mn araretaaofmo,taoar 10D.IIIbD0I8{lStlttSSGNilifOUSiRY 11.BiNTHG�ttLSafto�IOfQpq�00�!) . 12 O�N�1�M4TOOIWifli� , - ,'r _
<br /> � � � �.
<br /> � � ��pGftimro�l►�►►� � � 0 eg� �. •.� '.
<br /> n 7do �R�� • • ..�
<br />. ;'� *, .._ � ' ' . I�L.YOTMLN'SM4�a11EYIIL II. I�tY[O►M{I�aRDOflNt/� -.. e_(.�. ..;;•�.i.-:-
<br /> . } . - . � 17tl�TxtR 5 NAY[ �
<br /> � lfasgaa�et,Aa Bnrs4ea �]�t I��l.o1c Qa�ls� �.
<br /> '�` Th�a �� �itt� '
<br /> F.�'i' � � i���S 0[C[45f0 LKB p If 1 ARYLO�RC�A 16 SOCI�t SLCYR(TI 110. /T {Ad004KAMT AQ�►tN ��1 -.
<br /> �.��- ' aYiwr.�alNN IJJI�.Prrv�fm�$wnbt � {iYiD� �tf� �� i�V� ,. „ -
<br /> '+�� . .• �Q �� � :�J
<br /> IO C�Wi 0/OW?H�b1et/ioal/oa�taaMynt+ar�(nA(0 wa tr).� IIRLRYAL�t7MEEr _
<br /> c��i _ OMSLTIUm GTN '-�rr
<br /> '��1. � . . .� PUi7 t 0[ATNMASpUS[OHr• • . . :
<br /> �Ai.1'
<br /> �.-'y 1 . �YU�OUTt CAUS[(a) . . 'P'.
<br /> ��!,. � , � ' • �;�b:
<br /> :,{.!.' ` • ,� cboatrroa..��a��. ouc to te) ' ''"`
<br /> a
<br /> .l.5�,,', � ' :. . '1 vlH4 pan nN to i}`��.
<br /> „_'i:r`•• •. .J+ OOOCI fOail �07. _ .
<br /> _ , RalfnQ!tt on&�• 04f TO{t) �
<br /> l�inp ronr� faat. �aAS�VTO➢SV - - z.:;
<br /> • ��•.���� � O ►iNlflOtlmiSlGi�KAAfC01�1016�Mw6fOWM8Uf1�0►�QAROfOTM[1ptltY►015VLCM01i10hG/f[�IMVYiII(d -, . '�'�.:c:,.
<br /> ' . - ..' /tRfORN[4T ' .
<br /> -,. . - I � YLSE� ►� �
<br /> r.:.r " . . ,.
<br /> �'� � ' • , � 200.KttOini Su�CtO[ xOf+iG10t � D�SfA18[xON u�tUR�O[CUAN[0 fb'Nn vatnuOJmfa�I in Rvf!a P�!ll e/YI�s!/.I ,. .._. .. _
<br /> `�;';"� . .; ' ? � O D 0 •
<br />� -.o:. . j � 2pr twt 01 flour MoW�►.Daf.Y« � � -
<br /> - �,.. �' . I�IVHr O.a. - _ -
<br /> , F�;1.: _ , , o ¢�. -• . .. •
<br /> �`°"���. . - - � i EJ6 tlUlAl�OGCIiaN[O. 10t.G4Ct OI UWM N.0,•{1'A N rtAON�aaY. 20/t(ff.TOV�.O�WG�TqN COlfuir ST�?L . .. . _
<br /> '�;.�• . -.. � _ r/1111A7 � 110TWNM1L Q /90•lGRO10.ibld.alAqA�QO..lk.) , . - � . .
<br /> - �'�' � - � ' ' OOMI al tORK y . .. �
<br /> .�4'.�, • . .fo ��Z/i.�s(� �nd iu�N�lwi��llrs on � ~
<br /> .:;. �r y 2t. J�tt�nQxlM�dauaodlrem . r, .
<br /> � m on tMO�f►�t�tW �t�aT tA due ol m �no�t�dQ lto Nbuuu��f�t�d,
<br /> �. . D��tAate r�/d�� ?Zt.OATIS�GMO ,
<br /> • �#�%�" • � � , Qo.11 �q os t�q) � .
<br /> T{y6� ' " . /��� _ - - � .
<br /> � • . ,. . tRi4W.W[iutidL 2JD �T� 2k M� i OI CtYB?IIIY OA CR TON� L14 IOt�T70N IN/.tOSn.W tOYN/7 IbTott) - � .
<br /> tn a►u ,_,
<br /> •�•:',a:. . . ' aaroru lsytap� , _
<br /> ��,,r.: .. �� :r , � .. .
<br />_ .•.>,: ' . �:� SI.OwT[p[CO. �[G� •A� 25.It[G�S�L �� 76.NALEOIdOATbAAY ilO0t1[S4 . ..
<br /> ',;. . • �/ I.iO$tg8�Qt1�O�Tl1D� Gi'A1L� ZF�� �s .
<br /> .,
<br /> � :� � � � q3 � ... _ .
<br /> . .
<br /> �: .
<br /> . - . - - - .
<br /> . � . . - __._�.�._...._..�._.�. _... _. , . ..-...--- ; �. . .
<br /> � :. _ . .. ., . . ____ .
<br /> ,, .. . . ___._.._. . : .. ,. .. . . . . . .
<br /> ;,�,;,: . .. . � . . . . . . . . : . . . �. . .
<br /> ::.,. .. . .
<br /> .., . � . . . .
<br /> :� . . .� . :
<br /> :l�- . . . . . . . .
<br /> ���. . ..
<br /> �,,.-: � � . , : , � . �� �
<br /> �L�� ' . � . � � - . . -- • . . . ' � . .
<br /> �:'. . . . , . -
<br /> �.�, . . . ' • , . '. . ' �
<br /> �t� . _ . _ �" . ." .
<br /> .�,i1,,. _ . : - .
<br /> ,•�� �� � _ . � , ' , .
<br /> �. :' '
<br /> �L::.L, '
<br /> —� . . .
<br /> � •
<br /> C •
<br /> ���•,�� ,� , _-.
<br /> _".tt�r] .• .. .. .. .. . .. . _ .. . ' •. � _ . . _. . .... •. •� '- . ' . ... .. . . .. .. . .�~_ - ._... � - �... . �•• . .. ... .. .5t__ . - . . 1 . . •
<br /> 1'•_1
<br />
|