Loading...
HomeMy WebLinkAbout96-04776 .. o " ,I , ;1 " , it ,J" " " ", , 'JI " .,1 I " 'i ", " " " " " I,' ,; , " ,,' 'I I , I I, " " J' " " ,I " if .'1 , , " ,\ I " , t"; !/ I ii' , , ;iI' " , , I ", ;1/ II . , " " " If 'I " " I-! II, ,'I , I '. " " 'I "" \ I 'j .' ,./ , , " , , '" " , " / I ",J " 1 , , till ,I . , , ( ... ~ " ,',','" ;,....'-, ..... , , " ", , / , ." , 'I ') " " 'JI I.. " ,I 'I I.ti 'I: " 'I " , , ' " ,IJ , I'! '~,ill; , I',!~ - : '-I { , " II , \ , I ',' , " 'I I, ' " ,/ " /, 1"1 , , , t" . . OLIN, Nlm. & llAI:l'lmCIl'l' ny: lIurtoll Null, EHlluh'u Idulllln~IlLloll Nil. llil48 ~6 HoutJl Chul"1:h Htr~ut WUHt ChoHtor, I'A lOil80 ((IIO)OOO,ilOilO A'lvI'OItNIW ~'Olt: 1'IIIIIllltf -. III1H, INC, d/blll 'I'O'I'^" CMUS 004 Null HII/lII, I'hoolll~vlllo,I'A 10460 J>llIlllllrl' IN "'ilK COUlt'l' 01" COMMON I'LlMS va, I (lllMIlI~IU.ANn COUNTY, I'I'lNNBYI.vANIA t NO, 'II" '/ / /1,. ('-" , ( 0" ,f'k' Bl.IZAlI~;'1'II onno 8~1 Worllvlllo Ilond, ~;noln, I'A lJorolldnnl I CIVil. AC'I'ION . l.AW Q,OMPLAIN'i' l. 'rho Illnlnlllf la III1B, In~, d/b/n 'I'olnl Cnro wllh Illu~e ul'hu~lIl1'HM lo~nlllllnl n6,' Nultlloud, I'hoonl~vlllo, I'unluylvnlllll, ~, 'I'ho dorondllnllH Blllllhoth Oddo, nllndull IIl1l1vhlunl who rObhle~ nt 8~ I Wurt7.vlllo llolld, Bnlllu, Cumborlnnd Coullty, Pennaylvllllln, ii, ~'rll1ll on or nboul Oclubor 6, 1005 tJlrouuh Novornhor 101, IIl1ln, ntthe rO'luo~t or LoulH Grlllllorl, 0,0" pllllnllfT provldod tAl dorondnnl nll'dl~nl HUlllllloH, IInUbloll~a nnd nuralnu Horvle"a otlho Umos, or lho klnda, In tho '1unnllUoa,l'or tho prl~eH nnd llurKunntlo tho torlllH aol rorlh In tho coplOl or InvolcoH uuachod horolll, rnndo II pllrl horour IInrl 1llnrkod E~hlhlt "A", 4, 1'ho nroroallld medlcnl HUlllllloH IIlld nnllhlullcH were of nlloodnnd morchlllltnblo qunllly IIl1d woru thoau ordorod, 1'ho dorondnlll ro~olvod nlldn~~olltod snldlllOdlcnl HUl11lllos nlld unllbloU~H, 5, Tho Ilroroanld nurHlIlll Horvl~oH wore IIOrrOrrnod III n Ilood nnd workrnnnllko rnnnnor, 6, 1'hollrlcoa dofondllnl WnK ~hnrllod woro fnlr nnd ron~onnhlo nnd woru tho Ilrlcua dorondnllt hlld ugroed 10 puy, 7, f'rol11 limo to limo, plu.lntllf hnH Honllu dorondnnt HtnlornontH l'of1ecLlnll II hnlllnce duo plnlrlUIf In lho Hum 01'$18,306,56 which Hllld HtntornontH dofondnnt re~olvod Wllhoutllrotoalthorolo, 8, Althoullh demund hns beon I11l1do by IllnlnUlfullon dofolldnntto Ilny lhu sum of$18,306,lIll, tho dofondont hilS fullod nnd roruaod to pny 1111 or II"" rtthoroof. WIIBREFOHE, plnlnUIf domnlldH Judglllonlnllnlnat dllfondnntln tho Ilurn of $18,:lOIl,511tAlgolhor wllh tho coata or thla IIcllOIl, OLIN, Nlm. & IIAI:9mCII'I' , By: - ~~{'- C.. Burton Noll, ~;a'lulro Attornoy ror I'lnlnLlIf NotlCCI Thllol!'loo 0' Olin, Noll & Haltl'oeht Is utwmpllnlC to l~llIoct.1 dobtund .IIlY Inf'onllllllon obllllnod will be WJCd tor fhnt purpllllC, , '" ,\ , " , . .. , II ,\ ,', ,I to ,'1' I , 1'1, It" '1,1....1.'-',' I ~ I/. 1/'1 HI I" I ".', . HI.I j h ~,h' IJiI,' _/ "'1.1,), '0 ".i'I';,;,," ,,, , 'r.:.1~ - ,'i'"'''I''' ~. """"1';" , r~ ,;,..i,'I"-'''''' "iJ'''',\'I...,,;;;,-.-_._''tn:.,I/'h , '., I II ,WI toll,', , I~"'h'" "'I. '1"''', ,'... II~ , ", 'II tJ. 1 II,' ,; jlll/l"Il'" Uh, ~ -" ~,,,-....-:..,,:....., , - ~". .-~~::" pAtIA .M{"TNlIli"lfl~~li ql\l~)jftlTfjii9)1 ' ~il;C:------':'. ,," __. ___",,_ I ~,lihl n.1i.illlhf "~1I1 '*11 ..hi) W~lll:d Inl"JII I I.J~r'll FI~11 f, ..'f'l, , 'hi I,,, h~IIU) ulln.Wr ..m "JUJ JitLf. ,,,,lln, ,:1,;, ",'1.;" "III : I ',,' I', ,', J" 'II (" :'Hlt · .J}l,lhlnr,r,'m;.IlHnnnrnrn1ffi'W,,..'-...----.-.-- ,-,.tw....1' .-... ,,--- r-;'IWIlr.rrih.1l'"r.ll'141WiTTilj1Illflj.il[JOJ;(i,hniT"-- ,,:, :.',j{:I'I:,II." ""'I.J []II"'" ,','.' ':,t, I ~ 1 I ) I' V )--, ~fn.ll i'jIH,,;",il',i,j'j."'.,;(;,i,j 11"-".' u ,1/,/ .'. ,.. 1'1'1'1.',1, loll ';: ~ t.. ,. -. tv l ,ul" ".T1ii"jl;l;;Jil1;mm,...!-;,tll>hlm"fi,'lN\;;;-I'W"" ~tc'u~' ,,'j,li',,1'1l ,1;!.J.,.HJtll, ,j ,;,r. 'Ill ..,-1..1,.'.1 -'~lIl -.IJ I "II II"JII "'Ii, II"'" .f1_. .,1',1,".[,] .""D I~ v:t(1',"IJ Hi '~I,rlll .; '.'11,1 ',lkllp.I"'II,1 'hO 0",. -"'1,'101 ,," [] [] """" . . , 11~,,11.':;';" .---..--,-",---.,,---...-. Ii 10 II "'I"I'II^,."II'~'I-'1I "11'.',1',-1"1-.....11.1 II., 1 '''' (,I 'I' H~I'lh.,lhI'li Il r --"iT .fl,HITLN1;,~V',lfjrIJiij1ffiiifojUUT 'ITJTIn-li r.lnili.--.-'-- ':0"'" '11"ilt'II"..",IIJ1JII-.'IUIIHI"'UlHl...IHHIM '1,.,I,lhu, ji.-~,;t;';iii'~ .u'lfrr:m;rrtl:ii1TiiTJ.I'I.Ullli----'--- "r 'Jl 1.',)tILU f: il\fEl ,., 'I, ,I() \ I' p, ...II_'-'.~I~~~ ~~~_,._l}1._, t.. fJ~: It t: \) 1 '1. 11I....hl....~"~ll". .-.- ._,. ~.;.'.';J-D """11'I---.mVotoTiJlr.;rr-- \hl~. ' Ihill I ,.,II"Iu "'i/ii/"t,',, . ,.,"'d;;r;;I"'~" ,,' ff';;w'.';;;;--- hI ,~, I '''t.u'h'III'17"\"I''.I.'~ ~ ,1I11'1I1l~ ".' i Ii'Ho, " ( I lL',1I C'14 'I U. / "~" .,' .1.. .. tl411IU hlllljA'rl,II"'~, (jll ,: ll,{~ 1'" '1' '1Itl/r,~ ""jhllJ""~J"I~'."h'II""'''IJI'IIII.''" :.....:~=:==~-=-~-.=-ml-m--nm. 'r~::~~~::{o"PJ{i61[O'Atin Q.Rl:!!'lf"Plmitl!'4,FrOnMAT~N.~-"":::rl-'t.fl'''~-~ - t tlVI==---= '-' ,,_,.lH 111'["tI II" ~'''',I'''''''I''I II IJ/",'" IJ"~"IIII"J",J.II rl', .~ If,""'" .,1 I' I ~lJlt I "",nd .~ tor, It II ,. "." I u~ . :hl"IIO;I, ~'/f"HIJIl" L j "..II I ,.'11 v~'" II '~~ n--ll/lllill,1Jiffi1lm--- Irollrnr-nnru.nr.in--- ~---------..._-. - nl1F,n'~7JTIj;illtil;I'I- - _J...J.__ 1.1/11, 1I11lJl,)"~ iiI';-Hil>>j;r;T;l~ i..t~"71'~.:;~;iiiiTi~~ii'7i".j~r,;ri;j'i-i~-;;ih::'~I'~iJ"',':jI"':--\, 1~ .;--"'~ t,' .:...-- ;;~;HI"o/JT.1irmr11blill1lt:~;'ii;1- -.---, . ,- J h, l. ..' '. l'lU', II.' r.':'''ll.fl L(Jl.ll~~ (,f.,lU;,EFII [1(', (,h.~I:!':J H.u'lIllJ liJol.~II~'IlI'U 'ilhi"wr;.hTI'OOiii1rJJrH.tiii1i lftllj-;i-,l M;;i mffiTi;ru:T8ji11li;;--.iIToiJiTl.l"'Clr;~1 ;.----- ---~--. - n-~rrmnJin_ti'ln"'milWfTlirnluT60ljTL.jrr.i"&jJliJliili-~--- p.~--:,~~~------._-- ," 1r..bjro,0l;,TUJ1aTl!)irOl-iiij,lnl,1t-a.~nlnmj'Rr;iil~ilTlhJititiTiJi'i;u1iH~1-J;'fnlji:crmUlirifT --- lI,o'v"o", _..~ : U .,: I 1.11',1, roJ :.E,;.f I , r;-- .' hH' " """Ll , IV"'bl~~'iJm'lf;;To1l' t-"T,";ffi1'f~"""""lr-- "MlllIII t.,; I ,I ~ I "'11" lG ~1,vr"l (C"l, ,j'I-I-"I)H,."I...h ,,",'l"III-'_'''...I'''''I)I'Io, 1___- . IjJlI 0' LlII~I~1 '10'.... \. .' ~.' 'I I -: ~" " '1.-1,1.'..1' , , .; I', ~-: t..., "l 'I~ l,t '-:-:-r:;;"'~~-~7T---'-'--- --rT~".: ~ ,-c.-,-;:-:-:'""7 :o;S---..- t. ' . ., I d; ~'I II,.,...-rn:-" liE" ..~ U , ~J IT,' "~ Tn I ".f./:'2F 4 TG-~T,'j7tr---~- ------,,- nrr IT-Ii:;:! rr:-'-- 4 l: :~..' ~ l" ~f" ;",..... I"), ::: , .. ~ .. ~ r , '~ f I, 11f'!. 11..1 I'~ I -:'. I" ,III'.: C J',,, ,'I" I... . ,. 1.;:11 11 "rnrrrl"/h"jlil?;'IIIIlIo""'I.I- ~I. '", IA.~' ,lI lI.t" '. iI~'''Vhl ~I '''''r ,..n ""t,r;o;;~""I>h"""1lm"'L 111111"11 IIJ'! '/'" .h 110,1 II' li~"1 III ~ 0'11111- "hlllll HI'11 I", Ill" lll-.Io!)'" IHlJl'HII '11111." EXI-IIBIT U A II ,.,,,:n__n[J~~, ___ ,"I"'I"~"IlI'''', En i-F,ill': 11"11 }(:/ 'UJllli"iil;mi;l'l 1 Lt:Cl~< ~~-;;;j"lii-;;,.uj.:,-; I~";:i, ;'-lli'-I'i"-I"I';"'-~' 111""""10 ~"I-hll ,',- i',~ ~I 10'. ,. ':.1'./. r,: "'1"11'01 IJ III "IHi..,,1I',(1l r '1 ""Ill' "1 ~III'.I' 1 '" J '''80''" III _ 0"" IIt.tll "11'11 "I-.ItI"hl, . _ M . .. ~ ~ .. ~ .. "11'1111 ""t"I.Io,I-.h,,,I,U loll' u~~.. III hl'''''1 "",1"1" I II.!.; 1.-11'"'''' --rr-~ ----,-' I,: l ~ . .. j . ''-'':1'',,:' I -t-.- , ~.. t,lj','l t.- ---f- , :,',lJ(j 1 -'~'r~~-;-:: 1 ---~'- ~--- till.' ---...-.... --t-- '..11..,;, ,: I , :j,:".: (/ 1-, , II.. ' I) l .ii,liijf-+-- , It/'ll" I;/; """'r'i:i';I""""r.M~n . -"1;1'111-"1,111.1, .' _I~l I' ---...._- I ~ \1 [~. , I. p -,--._- , " f' r. '..".':' ,.. j I. I, ,. _hI"" bvl ~ '; (: .... r, t. ",.."iOW- III ~" _;"J o Ov hH" ...00 i Ii':. I:: L i (, ,:' , 1.11 r r~ ('f., 0 I":' f IIIr '.' I, l, E, r 1-. 'I,IILJ (1.'.,' ~;~'t'.'- :'~ D: 1 ur "',L 'II; , ':r',h'. 1 Ii 11 t'j'<l:;':JE I~"I/' Iicf.f.15iio 11.14/ 1,,"" CftAMPUij.501 . , t:" :1 , " , . Ill. ~' -, I \': \'1 TE 1,.'.1(' , (; I ~' '. , L I 1 :d~ , . ll, , ;'1 1'111 "llll~I,II~hq ~ I '-II/lUll' .I,'~ \,t. Ill', '. 'lid III "-HI 1,111,' ~ ~ 1111 U,~I -1-rE"I::;V:r:;,"~,-, . t~r:iNI,i.'i[~~~--_hnw,~iii~ ,..,' -, ~1:1~.r.lit;--.;--m-1JI~~-'i;'i.Ti\;i;"ij--.1't"liW.\~11l ,I, ~UII M_ .I_I.. J.....L-::uUmn -:nr-r .-]jnl1HY.:qBritf'------.~.- _h__ 'l-mijhn...r;,"II....I'"II.n;11l11i,'n;)'n;;j"~ 'l ,Aw1,QIl P",.. IJ.. . - ,'" 1~r.'".i1Ii,fijl1;m.Wnliij"'m""'.--.. Ct.: u [,P 1 (,Idjf, .' I I "l'.~' 1:11 /1I'\,~'f: 'III l'I'lI'il i,.lijhl)'ThIillITi;nmrTo\.lnln;nlll,n-'--'-'- rm.r;;rn ,-...-... ..-.-.--..-. 'l'~if(.[mr , J1ii1>IDijTo;tl~lm!inmuill...- -I ~.I UWH.I" ~ '/, ,H{ ..., [J CO "..,1 , :'" ~ ;.1; I f,j till 1,1~IT"lilrJ.1;~;'~ lh ~'hr,jiii~- _. ~-rh1;,lii1ilijliwTh1i"iOk1iJiWJlj}.ln u_ lit. tl /11/11 hO I 111. ,'() Y FA I nr ~ 111....""'101) I U" t.", '" v .fTT~' ~tt".... "P · ,,"lIi.1 lI'!.),II' \""11; 1.111111 ,.;Ig;'i"'t.:J O -, 0 Ih"lJlll"'~I"I'lI.lIIU'IlIIUl~'IIIOIIl....t'IIlII" "....1- 't'.llllt'l"1 i'1.111~~Il""(I"i'lIl~~ - 'i1";';;i,~,li'~111 n",P"11t t,I'i11~u1iT. - l:.L l~' ttA T !l~L.~~'L!~L'=-L___~_,_.__+, _.__----1I.t!L...... (J '/:.!...~!:.i.~L.... t.lt;"IIl"""I11lIUOll ~ull'lJ""'ll""~HII _____ .fliY5ICIAN OR 5UPPLI~R INFORMAtiON tr'1n1T1)r- -f:u:mt;m~rnr1rl~l~~i:'~V" '. m\!i!:.V,,,,",iTIi'.7,;m;,-,;;, "l1IT'j\,,,r.tIl't~ '\,'I~L~\",,~ n-rlllT'nlil~mnio-.- Tr1im\Ol1lJtl'rll'..tI'lllt -- .-- 1,.W\'iiTf"iiiWt"i)'''..11111 -- Jilfjj"hlh.,,)KlI ,,,..,, ~I''''''')I111 '110" 11I'''~1t '. ""w'O~""'Il'UhG"'U'lli;:"IJ"l)IIi'''WUIl[II';'fio~I.j"ii~,,,[;"j1Jr''1 t:" rT[~- r.~~I:NfJl~&~~t~I~T~riJniQItGlll llJU 16 Gr, IIIGE" 1, 00 G:; 161 :,'j I ""'"IU I.,,,,,,,,.. ,. "u"."hU"U1llliti~~m-)'IItI.'lolfl~KI'"IItlJ~i'lJ",.l\I,m~hI'C (.I'~, IH l" 0 1lI)'l~1lmOUI.lt'IOuIl(ll.'UI In ~ (1I~IlQ" , .. Hlolli'L'hlhl'''''''' '1"0 [[] hlJ h"ll". "',, l'J 01,11'1/1 II ,:m.'/' .1/l'rJ"I'~~f:u "'~~/:"\". 'I"" ,;:::;-;:".,'" ""..,~II~IU' U'I'i\.lIKohlolhlll'. 11'1 "lIh'" ,. .. t.~l)~~Tijtlfirr"jiihlh 0" Ht~IlMI "'1,,1' b"I,hl,;.,' 10 hot'!)",,,". ,I, i.~I"''''hllifj;f,llilh'llll.l'''b1/1 'OBB.HI IYM~ DI6EA5E I' .. f~I,~~~~. f I' '1l0(t!lvl-1 L wi I)" ., '11o.~T~Tli7~h, . H(" ~ 1I <I"l" II HI.'''' 1J1"1~~h II Io,'CI' UI ("'~u"ll~.,q t. ll"U IJf"tI~lq '''ON T1Ji\7 ~ I 't' t:, " hHI u. ..,,~,q , ., IV ,.. ~ c. \.: 4 "101: l U I ( 'of, ~f t , 10(..;.\., 4 ~ It'llJ 4 r'. c: 1 (I 4 ,.. ,.~ J 4 ""." , .' ~ ",I...lhl,Jl. T'0ilJor , ~;:, tiEl< liE I~ 1li7u~/"'5 : Xl Eel I ':lIiTFi" "1011 I (J I I} "'I I '7 ~. I ~ ,I,'" I i l\. ~. t','; j _ i:' l'~. f) T I 01'1 fdi r '~E H T.l, \.1"1 '1~' C. I .. ~ '.I . 1 ; tl~\ h- ""1'1 ~,t.I"""'I"1 'lflJ~I""'NI h U"'II"}I.I'I,ll b'~', 11,r;:-l 0 tlL. .__.+.,~-- - )l. 'l!',Ill.l,,-,'hU"""'I'Ii.. 5H~,r\or~ C."fdEI': 1~1I U"lI 1 0 / ::-1 1 / 9 ~, >> .ou" ...."lhITiCl.(j;ji.lhO-----------~ u-.~;~I-,.-TilhiJ-..-.- I fJ66~B.,t.~J ~'., .',.:f; I ~ ., ,:t'St; l.\lr.I::f,F: ETL[I~' liT, IllY PI, 1 7n~2 tllll"";'" hLl '} l 7 1,~':3 - It t. 0 I ---- ..-.---.--..------,---. H. "'"''~''''\JII''IJ''' -._.-tB--m;;~~'1J -.'HhU'O' U~ltlr lhhJ, I IJuh' W I 1'11"1111 "-,.V!.,;b,,,....'.I"I""..'''IIIU' .ov.....".... -- hi 1r.I~Io J"t.')~'l'" oIfU/l~IU '''lI_UIlI'! ,"U'fI,O,dZf.TIOtl 011 FILE ----- 1 Il'tolll '''88''u ''''''1) h~"Io''''G I" 1.0 ~ ~ . ~ .. .. .. .. .. .. .. .. .. .. .. .. ~ .. .. .. .. .. .. . HI,!;" "IlIIOL/lI,,,lIuhhO Olt' .. II'" _...h. . .' l'.ct\~~" {'d~lll" 1/1011\ to, It.;; I ~'-l , -- , ~':o ~ f' J ~.' i.. , I; .. , ~OO ~OO f' VCi.: II'; l , 141\0 r' (IE. ~ ,.:. l . , It CO " P \.1 t .: I :: ~ , I 7t1j (l 14 r" ,n.~ I~' , :6: 14 f' Q h CltU,(,1 ,. .....10.111 .'0 "'H"Mlllvl , II: 1 ::1 'i ':: "'0 1lO""h_~Plllll"IiI'C-OIJ' :.: t: II ~::r,';~~'I~'~Ll~~r.I:' Ii'~, 11/(. lliD//, llJT;',L ,:AIiE ',i;!. 111/'/7 r,n~,ll !ifJ:'IIJ)'.'J1 :,E. f'A 194t0-3:,:,:: 'Ii .,OJ () 1 0 I ii' :l ~j .::.' 5 cJ b ;I"J:U.O' "")1(1 ""0 II" 01 ~.ltI;,7.i--;tO;;;:-;ii-;j""~!H1 1"1 ~-;l;---'- ._-_....H,il.";-;Ii"l"U;-~Ij.;(7j;jj;"~::il-- i;miil tiCF-A~fI500 ("14) UI.. "'I 1lIU" blll~(\ l t'IlJ I. mill CUAMPUS./so, \ /:,0 \;1l::I,EL ~UI TE I ~()(, l: \ 111" II \' ~ I , 1-'/\ I t~ ::;" : tI lh:'. I" l. .)(1 4 1011:41 l'I,..I..lIll..IIU.llll~IIIILjlll Hl!I~~ ~~h.""d H~~I>)JJIi,lk." IUIU,'I -~t;i~ti;L~';'~'~,"'-' "'-m' --t,f~7f~~~--'---- 1~.Vi ~IH~ 11i:::=J!] RI,I~\~IIl".":-- ITrii--ri -Q]lJf!ID]r~'OB 9. ,-. . ___ f~M'lz.n,,", i . . . U, II Jhl1If"m\l ".101' Nlb"ijiJihifiJ,lj Ii I I (I,', 1 I ,/ ~ I. II" H: l II [J P I) 0 _4___ \,rn:J;nl j--'--- ---.-. lli\immn:u,I1:Jl'1~Ull"." "'0 .1lJ;r;".uol'" 'HlI 0 [~II~ml l~Jt'o....~'/b~ '1""-.---"--" .......r....,--.... ----.- --,-,,~ . '--L :U.I~MH;~tJI I,iJl L-L~J"L~-~~~ toIJ, ~.'HT1~hl' i.1\II"lilU)'1iir~I""1i~~~fiiill"I.',m~ - ELl Uf.!'1 Ii lJIJP(J r.lTIl1;lTJT,f,1illl'ill;)Tnl1\"llllnniil'1i' ;I,~',l' flJlH,l.h i"l'ol~1 N I, .JUY h\ I/~t;;: r1il'Thl.~rlflillh...',rru-.,il:~~I1i-'- r~llllinW\1fiiiflj1i1iilmlil'6liTrr~uJ.i'irtiil- Ill' 1'''I"n ~ '''' II 1.11'111 '''''''''"1'0 '! I;' b (; :/- ,I ~"1I r-.-, 1""1 r;:J r:J, 1U1'ioTJ.,.IJ\I" ..."U".hll'f7lfiTMj,liD-hl11rhIUT1il"Ji;iij;.i'i'i""\;\.lJnl---- 11~i7,i;t,)~i'iliil It ..-.- ~~e'l~h If..... "'liP "llbhl~\'U,l.ll-.i'~I'.:iI'-)ii'lJI~~I'''~'LIIiU, I '" ".1 ",I..luhllllotlhl 11110 mil" . "'u,'I'11 o hh. [J ",.... if r:~N'~U"~,.lr.V tl\~ll ".l.Iu..""....H'... ~~- BIG"^TURE ON FILE lJ'1~743 LOlJlS (,RINL;ERI, LID IjR/td3ii! 'iih.tiif1'hb "'OUIol.r,umc-:i!it-;;;'-..Tlih;ii'.-.j.ji;jJjj:,';);:I"OfIojll rii'i'iI~il:ilon<<:il'--- ~--;-- Il"''' 0' I.HI)1(1 'hUN IU t ~) I '.J '1,' ';.~ () .. 1'1 0' "'.,. 0' Ullu(1 "U'I"III U'llIlilU,1 UIl~'~I'IlIl,",,,.....IotIlI.II~1 ~I ..'~... I .~' Ut.. ~ ~ liE ~I llJ77i '1" i oJ -;-:;-r:n-." 4 liE" /3d' 1 -'IN t.. I tI ,.:.: ~I t1EH " j I P I .J (,~ 1 t~, .:.4 b II[ II TU7lJ'fT'i1:::- f:TITO'-- 4 7mv-- 4 ! ,I IIJ 1" .., tJ t~ ~ ~ -r;-- ,1\1 I'! I 4 1.1::\1 ~I ,t I . .1", t' ~ ,~~, l~, . ~l1iTli'1)f";jiTIill~() W;r" lI,..:i'iilJ'hIlOiG '" l:h-'-lhlj,idjil'IlIIlH III' l ""IIoII..I,IJ..I". IlIl III "'''IHIl IHel'" ,~" 1111110" I: r:.1 " ~~f,':,. t~~~~~b~l\..:.:~,t~ ~",~~ ...."', lu ___~~:rl_,_D~_ );I ")lJII")('.~I!I"'~"() O' 'i~,~ g '''"I11oIIl,.I.....IHlu''''lll.u,llIllIlllllothllllll II "lI."UH "'lji;\'Lj';fj) ,.llllllm!j\lIll1 t,h Wit tlhQlll1 -- ~t.~,lj LUIlIJEI; ElTr,UET /1T. ,JllY PA 1'/55.? ,~"~~~_Zl1 b!\3-4bOI II. I.II.UtIV.'''''h~''. --[8--;Li;;i~Il-.".Ii'llb..~ ~I.lll' I lJull L-J"'L'r.. I ",10"1<<.1 ;-;O;;;-t"'I".t..'... 0' .,'"" ""/,.' nv.b,,"~",O -. ,.111,[, t4 ,It "I,i"h, "'(;KUh~I~JII t.t:Il,UU.'IU'" A\ifllL1rd ZAT 1011 ll/'j F 11.1' 1H1.IY.C'" (..;.111 '''''1.l1 '''88"V ,,.Iot'I'I'I",h'ttlj I" ..03 .. .. ~ _ ~ .. _ N . .. .. ........................, ....IlIII "Uh'L".,...hUllhl) ,II. II ~ ...~ 1"'''11 n,.~u . .' Ulll" 101 , 134110 ~'~ P , 3100 P I- , ~'10 ., P -I- ~ I :'110 . P ~ , 14'10 " P , %00 lOP l).1 1I,.1Ir. t-- IIOUI I " , ~ l;i ,~O I Ilit.h~lhli "I'r..'lm l).l)tl Q'I~PI>IlI ...!.IIIIH'IlL" .ll .l"'h~' IJoJI :~l:~ :'0 '1 CAlVI SHM,nt, Wt.K i Et. 11 :11 D~I, 1 0 / J 1 ... l;' 5 "U'~ifio" ""CIN,,1 hO i1l6, 1110:. Pi[;/A lOTf,L (;~.r;[ 'H 1IIIn Hll>P )1-i.::;;iiiT.:.j.;.ltli17ii-,;-;,-----. --------.- I Hi t r ~ 1 X V II. LEt F f~. 194 60 - : J 3 I~ ~.~:(J:r'i::'i: ''''1'; t.l~ilr;:J:~'<:~~bh f;,.l~ 0 II () t. I if ~j l"-,"IUI",~lJ"II.I;" .1.I1"IJ.I"IU~IIlW"'1 PH'YBloiAN 0"- BUPPLIl!R INFORMATION II ,I>" 0' ' :ll~.ilI.I\:.Jnm~~~t:'~~~'1mM"if=~.liT'..~"":r.r.;.-- , ~J,t~lii~,m;'m:.~~,"~:;;;;~ 'II ~"m~I,~'--- il D~U '~h"iin:iTl-rr--- ..-rml.6nim~ 1.1,..11,"11 --, fiiiTIiil~o, ..1\1 t I'UUIIH\0 IIl11M" '''1.>101 'i'fhi.IotIl)'IiI'lll"~tl(l..,I()IIUI"'/l(,l)I)"-;-.,.-;;"~jji"";("i:..i7ij;";'"...,"(11 '''IJ'' 11'"0iN1I 1r1'~:}"~lr,l~l~IJ.I'lL'ijj;jffi II" 10 QI. ..ON,IIIU IIJ",;"-jl~1l1 - ~imiilUlil )'I1l11-" ,,"10'1110111.1 OI.ltlidJI tl.i\lll U1J,tll--" lIIi InhO ("HIIIIII ~~~~,,~, ~~~tll,lll' 0' .~I..nrfJ._ihjij~nifiJl~.,.-I,) ~'"Xll)u''' ,.. U'II,oUl,lJ ,t ton.fllMI hul.lPTliiTTf -1 r-" ~O~II.61 LYNE IllSEU.,E 1 ~i66~e7~'J~ ''''''C' of ..lIrlCI "hO llt'lll' HII\I'CI ,t'lbl(Ctllll.III"1 M~(~ follotU'". ,'-~i7iioyii)~~-;;;'-r.u;t101- j:-tJtm iiCFA.l&OO (1.141 I,'; IHlllI _I tjll."I( I l)'~] I (JIIll CUAMPU5.601 I'mlll OWCP,' 500 l:orrn ARB.' eoo ~H~h~-.L ..,.,,~ !iUI 11' 14\'~1 r 1,1 nl, , 111." 1:.1 ((': '" 1" 'f., I, ',4 : "II,hull,loUf' 11I~lIlo1-l1 ' ,,(-I II. ",,1 "'1,',."1,,'" I hll"')1 "1~1-~,j/::.~i;\-~'~~'" -.-C1'--~I,i{~I..jf';Ii;.' - . -"[~~rr,I~,~l~I~. H~' r..... '!I't.,~,7t:,.' -._--~-U,\t,-.I'H'.-I~hij-'''.-~~..'II)i~;~IK_I .1111 - .l._L_____.n._.. ---"--pAllilff.A1l1I,HfR.n' rrl'&'R 'n, )"'-1\ "N'-'-'-'-'--L;,J~.~_._- ,'''ilhlj...rm1l;I)jf'fi~lr.i1Ir.ill1i,r,;,Ii;f;, . l"m~.tf,R'II~t~,r.g lIJ~n ,mrR '" ,.l.rI,~,:f1;I"'M"ilTT,~m;1W'il;liT.Tii,",~.- r,l.l~f.Hl/llHiLh' ":1 '. I" 1'1111-/'1111 Of II' 1', r,ml,'l'n'6,'ll'illmrmqmfj.nr,w-- -...-...,,,... 1"H1llhlH j" " -, ...,,,-_....' 1-'IWm~;1l"";J ,.',T>il.11l1.,trll1lilmrmilif,JITr-- ./.~.l.' LlJi'l~~" :",.d~ I "" [J ['n".", it',hl,..i!n':\ I'iT, JOY I'^ I nrJ' r-~n1 ~IT~j nl~i i.1,j;~'rjj-",l,:~l'r ,-~-,._. r.':"-I:;:~TIiT tHi).1;1JTiiTii1ih~n;ntJ1jJ.;m.'I}.I'" hI) I 1I11t1"''''''u / ,:' t: r:J - 'I.; (" t. 'i"TollOj;ll;t;;;J:l.=rr/''f.m'r.Ti 1j)l1mllrl:n, '70""\\1. .-. ~t~.tI~, _.Nfi.\~D.ofl~.~ ~"b ~rK;~'Ulflrlllill~_1 _ '-111_" n,' I'~)o'll ''''d; '''''11' n [J I'] D iltw:diuT,I)I""~I;i1lT;~l .-- ',-I" ,. I...' .'\Io-J O "1....1t1j)..IIH'IlH'tJ~"j)Uil.hltJ..lllhI)IIII I' .1111'''" iT~iit.~h,,,i'l ,11"1' 1,nmrJ';rt:~-- "I,',;l LVrll'I'./, 511;1:1:1 hl. ,111\' PA 17t;~,:.' . _~~-~'!~~~:~'.'.~__o_~LU_.E. 5 3 :llQ!_~___ 'I _ '11.WhJ~ """.UJt.. .----.-,-.~' ...[T'ii--D-Il~;;;;'J----~"'hlifol'ni)i(1-- ,nlll. ' L11" ... I "111/1111 .'.llllii;'i'i.'f'iot16U[' 'I'"" """"'~ ....--I ;"-I"t"1 ".'lhI"; ~ll;I~11rn;r;;, i. V'"I.......... '- ,,,~'. 'u;~N..;hmrr.rr ~ii;I~,~~;~,;;f\~i,~:~i.\;,;.i:1 ti:,,~:,~; ,';;:,~:,-"'- j:':I'I'~~ 11 ti;'i. 'T', r;;j" '~ I~ '''I~ j'l.'j, ~_~J \itl/\ 1.1)1;[' Uti F I L Ii --SloiiiNcjjf~~pp[:I~~'(/~';;: ATI~'N"""'"''"'''''''''''''IIII'''IoO''' ffill';r,u-;ml;,.!J '. f""" ";M:i1i1i""ii;lm~" ;nn;r.;1j;ll-,;Jj" " r(tllflfll'"II1"." l'INI'; Ckt..llml .,,,,i."'h-..,lh-iJ Jill' llllJUn . , .'Ih' ~ I ""Pol"''''' 11.0 0"1) hl,II'" ",II. o [] ",,'.. Ii bU'!)'- n',l11TlT,l'.r",nr--' lir,1\;,mii,O! illuth. 1t)~OM" I"IJ'" 1"1"1)'11111 ,lilt" ~n;iffi;t;;ffil(;;.1I ell lJr;j;1o.-;~~j;iJij'ii#:ijl~-uPTITii-r;-rr~"'l1.~~ -. li-!Jf~ff~i LVII S liR l'jGL:R', fJlJ (,rq I: 12'" ...."'" " It."'. _"P "0""..' o;mi;ifil,;j,jliiTlii;-,il~"iiTi+i"ii'70jl;ij;fh,-;;rh'.')"'1 cliiilJ-;n-;---'- ---- -~_.- ;;-;..~rrnail' ';/1,-- ," n"r~lI~R'~n~1'tlillironli1iln-~!'iitiU~nrl11I~r~EL ,.) "'I'~IIN"I ,It t';"T,;'iii\~HltlhUh.jijJ;"~ : oee, 81 L YI'lf II I fjUdil' l , In.. '''.1'1/1. -------.. II"IJ' '''08''" .,.0 hI) ""',,' ....IU"""~ ~~.~" - ~~.-.""~.""".""".l ii~ ,. 1).'lI,)I lIM~.q ,"".. IQ 1 U /1) I, /i7"S'-- ._- '~:,' ,,' 1I11H(j ( r~~~~ ~111J:r;rJ n~~:-I.~'t~IJ,,~l,r.n-;-iiJ;mr:1H ~IJ~~1 '.. ", , \1'1:..(1 I'tlll" "-!JII'l)...,,.II!)" hll 'JI'I, II HI .'" l,IIILJ~U~1 U "."1 ~rll,-,"~ ',"'~I,.,q l>1 Tr. r I. h I i ~ '.' '.' I '", - . '~':'W' LI~lj -V ~d;;.l "},l' 'II. m;r-- I 'I' lI'....'/I,. 1,,,'1 ~ IV' , I; 4'.\0 14 r- 4 TU7l''iT'i.~._- ---- .,. ~~:- 4 '71ib I U 7rrhr-:-'7~~ 1,._ ','II.L , rt':TT'7.f, ~,~ tln' 1\)7\,' I 9t 'IEh -,-- 'J ~/~'" I bl)(J ~"-""r -1- \I u... . ~~ I 57bCi --. ---1- , , I f I... . ~ ~ tin; 4 P ---.~_._....- -.-._- ----~ 1,..r;-1 D'" --,.. -'-~"I"" -, ),j w.,It~~ '., ~Il\llo, 'hll 1- , , h (II"MI\ w-iiiiJllJ '~""lI '''' , I";' I,: I 1,1" /,(j 'li--i;jtILi~"7~i,Tl"j'jV1:l ,,~t . ,1)~ij",w" ";'~lOmnlri~ 11111I1'hll.h "L. ~' rn;;'''or''t"",;r,;-" -'j'l' ~,r;;;;\",..,;r,;;;''ilr,jjj;l r=- --. T;T'1on''''l~'I'' ,,,,",,r.. . Ilililih'-'I,ji"JlI '1"1'" I"", j' .Hiit.l."HIJ;'l'u "'~..~n lI'hl hi 11~,i,l("JlUIIl I "H~, 101. " ~"n. ... I" " ".111 1111111., SIlM:ItI~ CLf, 111.: 1,: I' !.oUJ 101 :011/'1:, ~,Q;jliHTilll\Y.i.i:i)V'h-l..ij-'H '~'... 15bb:!Bn~ .,;;u-o;.iia-;;.'ji,OI-'~' ~j'II".';JI' ;'U'I "II,n "" ,;,i'.OI"'~ 11.",,,11-. 1111', II" I,/'If, llJ'ff.,l. ':/.10'1' ',I:': "'.'1 I I',IJ?,n -,"--i:;,,~ Hi;'1 i'-II;' -;ij"i;;;-'" .--..---. rl Ii E I ~ : x ') II L E, F '" I 9 4 ~ 0 .~ 3 ~ :] ~~ S I (, . ; . , .. J oIi to', C. I (,/ 9 ~i !" >-~. t:/ c t ~1'l'i;;)v'ii,il~'~,....'i'lJl;t'j~:;l-"- TwmliC;A.,aoO(inr 'l" ""Iln", '" 1i~1l1 f;,n) 'oUIU CtiAMPU6,&Of II. U ~1iL:hE ~ fiVIH 1400 E l r('lll H.\II 1" ,; 1'1:1 ~ 1 , ' It , III./t. ;." J L 1)1;' 10 IIH I .,1 Hilt lh~l,jIl.IJ," U ,",hi ".~'" Ill" do, -'H"ll '''~ llti)j""1 tI,l~" III \tJl~1 -CJ'iiii:;m;r"'-'-'-O"iii;i',,",-'---~- - ",;m-------~';;)ii~ .-n""""Vh4 =m ."l' IlJtIHU,..,'.,il' Ihllll"""IIIMII, 1,~,r'~~".IIPtl ..,.',iOto. lIi"hl If'''''''''.''.'''' - _______H'. ----e2'- Mi"1 -'roUIDlffiio --'._ ~---- r"H\ilhl ~'h~)"IIIHT "'iwJ,;~~n;l'l H.uIJd.l~iM~1 ~ RW. g. , 1 I Ii mT'ii1ilhlNT1'JJlI;}Hr~'~~llhlh"lj - I'II'I<l.f'[1I /IJ11)(' \)1 I (U. L..'. jiLl7/:I<I:.11I 1'11'<1'11 l-l_\1ifil~ ~T:Gkn~ linnrL'jl"r;.ln,~7iifTl---_. r,n, \if"n r-- ,~.. .UJ,;.__ "1iWN~,ri'Nb llt.,,'1, :.Uwn:rmttllUii'ihriUllI ,.11 :'6~J[' I.lJi'lL-Eli lilhE[( ".1 [] GJ"'''' IbIJb'I1Hir, nTiil):lrl11 ;Uhtii)iljr'l;l~;~ru--'- . .-',ffiJill11-r\1iT~~;;l.jiijJQi&inl1lr ()" f' t,. t I ,.;Wiibl- /1'1. JU\' for, Int,:: lll' U.."".. ""Ill ",11'111 ()~~"'~I ~'1 -'''J I)b, , ijJ' Q,n,!;1 D - 1"~""IUI'I"huIIU"hlllUII"lli"llolh"llfl 1I1'~'II'''mo , t, ... I t- , , , "'hili "I~" 'rnliiflll' 'ii1ii'it'imf,.'" Ihn1"l~ I,. pTlo U;-\ln:[ITI'-- it ~. i:m,lu. H ;rrflllJ -- ~;;;iji.,. il,I,1.YiMr.r,1 (,n ~1.lrT,hlJllll -- ~hCtj~ ",....',.1'1)"11) I Jhbl~,l!(l Ilhll..HHI,'p "",11'" " . ''',I'' "."V,"'" ;'bbl' I.UI1l>ER GTR~EI ",0 m .,,, HI. JOY 1"11 1'l5F.:: , - -.!.'..'~'c'~'.~.!:.~_.J.l1...lllill.:..1.CQL.__ II, lu""'~Ul'l.lh"lJ'" ------1" -;'(i;;r-'-"~I(IH't. U,.IIJ~ ' 1.hIII L-J , "II'~III ''l,':::/,i:iJil',I,i'IIlffi!iIi'f./"i\\'i'Ti1tW,';W;'fIioTiiUw/ tlll':r.'7~ii:'J ". II'::;:~'::::;; ~;;;;;-- or~l.m~:.lm~l.:', ~I ~J~I\.'M'IIIW ,"f,',',,'''':"''" III llOUl1hkt,,,j ,. 11111. 111I11,.~Uhhl- II 'Ln~'{j'l f.' .1 I t.;,..) .r, I ~r\ H~I/fII"lhl '1.1'1'1 ,~, U r I' Of;; 1 7 A liON ON F I L e !.!1.hJE_.. .EJ, ~!.'~i_L~f::.E+__D.!L.f..tllL__.n.__..___..._,.____.!:!~_g 2..Lf~E.1 r, ~ .'~"'II""~lJ"IUII" "l/llol""'III..IoI,I.;"1 -linrul------.-j. --'i\I=If..I..-.r-'....-.~H.jIOIA_~ 6U~~!~f~RMATIOtt-m..o.n _ " :~h.,'I"\:'I,.t:I'S~li'~~.~,"''' .. rli!t!i~~ [,,,,,", 'w, ", , ~,:'::!'ill~'I..lf.".~~.o~"'".II, \nilln~linirjfil nr'-~'- ll~ntn;l1iJlml..,jjl.,rJ-..--.. ...---- nnJi.ifJo~ii";. ' Ii '1'"'' .) "U"" --..-.~_._-.---~..-. ..,~~~~----- ._____b_~_..._..__l~,t1"M.1I t::""l;- ~~~lrnl~b-tr~~ I' ",....v, 1'1'1/1"'111) 'lll"Ii;I"" 0"1)1101'- 1.0"''''1 "f ,.. "t ""11" H,lhl.I, LIt' l tIll I; S 2 :'4 3 ~ i.li..~I;.:I;~r,oijlt,.f". t, i/ll II" 11)"",/1, l.OU 16 r,IH NliEIi' J, no liF, I b I J(J I """"11 1""[",00" ";.i~UiTjlji~i\iii;nt;jjf~I:iji-m'I.(j' Illhlll/llll "tl;iii~iii:mcmTl- . H 1Il.","lu:JIl).lthllill)"" ,'TJii'j;jfNrriuV1~'ll~ t/),J1l e"ar---- 1I 'I 0: '~I ", ,.~Ilo LJ 0,,11,111 J1-'1~iT:ii;11\lt""6l1h\liiJ'iCt'ilii;HL.t':t1-;;;Wiin.ii1) rmiffii)mniiOirli~;riii17;';;iiItDlrmTil ,,( lltllN Ie I)" uiC,o,)nl ____________ 'OBB.!1 l.YME DI~EAGE I ;;-------.--- ",.11 u, "HlllI -..,- -, tl/lP U"tll~n 'lIfH:fliIMlmjic}Tlllllltli llM ~u"j>iill HH~ I.lklt.~lllu If'" H'IU1t-!i'"jf,- ., ~r.m1:lli1'TUfT' 'I"~'~ _~-.~ 'llh.,,,,,It"l>ljhU"~'II'l,.H,,,,,......h"LI'. I\o\(,l(i Il,F',',';)I> lOll/1M "...., '" 1(1/ :Ol'it. - 4 TUT:;'3 I 'i~;---- tlE ~: -., ,r,TET'iiTi'I:'TIi- t Illi... --- fYRThGE-To('(w/rjlfffiL E tIE~: ;;"4't.To-- ; Rile;, F 5-----.- ---- """""'-'. J Ul ':..f 19.., 4 4 '101 ::3/9~- A II~W TIll :: 3'19-5--'- --T,Y" I (j-- :TT-r.n-17:lITitj' 4 tiE ~I IOi::3/95- ,--, ,o, blO fVT(i[1I.G t.~tl( HH',/ 4 T I Otl a 1 tlEv/ n~~:T~m~m:"~~h u )iii>fl~j."";l",~'iU~1"l1~ 'j't W,It'1 ,.tIA,lty\,,1 1..'hll..."Nji;r- fnt.lL~t'.lhO'~U WIII~II~.t:~I'I,t,,~,'M~lhl' hIli y,",1 m't' III flj.IIiLuhP"lI 1""1 ,.____~iITl.ln'~~___- ).. ~II"H LiJo..,j.~'m"".., I toll r,HAF(Ot~ (,Ef., T Eti' To'; Ii "'" I 0/::) 1I9~, 1rt~A.}ilTii~n(.tiM;i;;iJ---- -...-.- ---------- 'Ii-.7J;;,,-jJ;j,i7;'illl',"iihi..-'--- u__.____ 1 ~66:!e'75ti '!'tHIOf II "WI(' j.hD rIl'l 01 ""w,q II n, ,-;-;~,:m;,t;";i.,:~.--- III N""~L ~J 1 \1':1", I ".:'11 ---------._-- ",'!lllt 1~1 t) II I ,.t.JA (.l ,IJ,,(;ll U" t~l (,11..1 !II h~lrl bill TIolHOTlllilttl- .n ~" lU""U" 1 U'llll "'B 8" tU"'11 t'I,."",,,U I'. hlJ .. .. .. . .. .. .. .. .. .. ~ .. .. - I .. .. .. .. .. .. .. .. , Hlllf" "uh.u"'~"hlJ/1 101) -- ,,~M,- IJ'."~I,l." [...~".. "11' .' ,., 111111, '0' u(j6.fll I ~ 411-Q 4 P (18&.~, 1 , :J::60~~!2 10 P ('eL e I I ""10 -E. P O(s[~l --_.t;.f-':" , 61L2. 5 (lU6,SI , Ib~O " P {JE~ , ~ l 1"610 10 P o ~l t'1t,.iiGT It j. 00.1" , I '" '.I_hel ~I , :;435 '10 I 343~, ~(J -1'1-..T.i1iT,iI,~1 1.1J"Mh~ ~m~~ I wor-" ."1.11\..'101....1 hll III!', I tK, f)/[;/I.. TUTf,L CAr,E \6" tlUrT rWMJ :/.1f.!,UIl1VllLE, FA 1~4bO-3331> 6 I 0 I', J ~I .. ~ f,,,,, Ic'''' tlCFA.1500 (1.141 ",'OIl CtiAMPU5.501 ,IH~ltk"~~I>LVIi l, f,tllTI: 1400 f) Tori ,- II ,5341 , .. ,iI", I I.. . ',..1,','\" . \'llIlI/l LtJ'1 (0 I 1141 -1"-1' -~~{:rf.J;:1J ~,'-'"" '-. r'-r'~i,jil~.~-~~j':-' -. 0..- [~'J- ~i:,~~'~..,,; '.. '!-~' !~~,;~t,I'C'I'" .--.--. ..~. -'1.1:':' .;". ,";i--'-n'.fiiw.r.::;;-;~.:;- .~----_.,_w_ "-'All~m:A]' 'ft' '16 .'..I@..fimrOR' '---_'____H~IJ...L___.. 1',i!ij" i 1."\i;llr"~n"lmurwim;,nh.ri'~ ytffl~,.r ~>>'l n{~ ,Qfi ~ . 1'1 '" rwl;,mh\l/Jl"lrh,"I-li;fli'l.hil;n;----.-- ~1~1~1~{b~I\I~MmP~P-i~iIl.),mW----'- -- r-IlI~.1 I'll. .ti:-_I--i.L.____ r ':~itk ~ ~M;,li.lJ-.WrJrl>>A\lfuli.rn;mlml-- ~6llL' L UNL>E Ii rd hI; ~ r ..., 0 GJ ".." I ~ibb ~e 'It,~ 111I11'IM,.,'Jltllll".III(H, 1I1~ lto 111\1, 'It,II'',~.h',U~, ',~ ~ N I.Mj ~IT. JOY fA 17ti!:i:t H1"1l. ~TJlnw;hliil~ll.i~~r,j~1ii.'-~--' . --.l;~lJ"l U. ohWfi;n-;151liTiirhlWl5'klTl:niliiliU,--- ,,,,,,,,,, '''' ~imb.~" '~m l I" n1ffiiihL-~; . . 1 : IIll,iii Tli--- oec& "U"'P ml, , , ". ".. """,\ f;hl lIhlll ~ b-) l;J' D . '.. >....,- -.._- .t III 1'11I,r;I'h 11."11", '1",11 I!II'II' ~6~~ LUN&E~ 61REET liT. ,JOY r'A I n~2 '~~':':~~~~:'....._1. LLbLl::11 .l.:.O.L . .11..11111 n , r."""~"~"I>UIt. ..d. [-J """" '--"---"'-~-i,";j-'D-;,-;;;-"vk"","ijlll"K1' . - ,-J ".11/. I llult , ",b~1 h T-r~TiIh1. qll "~"I~II'lm-"' 'l~' It 11/1 f i" .I~c).in-Jil';k~-.-------'-- 1i-1.,';jj;tj~1I Nli,iihTjifWJIlIt:.."iIt1Ti'l fh UilOU.t.lIJhll.l _ Iii' I':;"'''''' '''' , , ,....., "'.M ""'1" ".."",,'. ''''''''",,,,,...,,,, '''''"''','''1''',1''0' 1I',,'aU/Of 'IIv"lO. U Q H'IUi""h .'IIIt,,, lIlt to b HlU l!of"~' \iiI'" ..., ~hll."lIl"l _11111'1 IIUTltUrdZldlON ON FILE ~!L_lilJiliM.!lfiE ON F II E _~_ ul'--!!.7.LJl1J..!iL t.li;ohllll'''''u/oI/JOll.U1Ullto" J!"'''.Ohl - P '1'6 CI N OR SUPPLI~R INfORMATION 1rlllT!1i. l"'''' .\",,/,",,"", 0' """, ,v-I'" "" "",,,i];;',;;.i'/ll,,,r-- .11I-.mm;Ir,;i1iUlif l.d.ID". loll ll'dh""U ...." t, ll.i,;ltulI .,.;;i~~ nlhlh"U'III~uht I~. U.lu n"/lnll1ilirn01U-- Tr.,mnt, 't'''II:'.~'''jl~.- ----.----- ji~Tilj"J'~~;.)iTlll'....III') Ii vII" c)lIlll"" "Iljlll L...IIU.NII , "Illll II.kl}l.NIl ~rn 111'111"11I111'11.'1('. ~Wuh(llI. l>u'll( h'.ll/t'7Q'It-;:;;--llP I II ;:-m~I'" ---- }\l-nITTii;il1T~i1l'TD~ II I "GI~. 1 n fJ' ~ II .J 1.1.i,.I~iiUf,c,,'~.f'-. 1.(llI18 GRIN' ~ DP Gr,I"I:<ol ,...".. p.""..,.. 'I "... .1J~fillll'll'ltl" .1~11(""I"OIl\llli,~i"ltol""I'IJ"'IOh~'h(j1 Ir-iH'I.)tttll,Un'IlI'lOk~.. " . UI,II,'" 1",,,,1;1"'1111 'U 0 n"j, U.J "iil1-.m-. lrTllj}:ll\-ur.lj)hlllm~l'i5riiT;;ilri5"-.i;Iii"Tl'fin"'W1ihCr:niri1i01:liMiT .1, (ll"iJWI;mJ:riTj;TM~w:mijITi 1Ic;11i1l tOOl _____ 'OBB.el LY~IE OISU,,,E , '11 ~_'~~~GI' I II1U' '''BBhV tl& "1,1 'U."lth.hh'hQ " . "~:L' c rvw ..:, "0' I('"IJ 1to'th"IiII(I.I)/I.,,~", U~I.IJ'U"llq u .I.u,) IJ ~(It " " . " '1I1J1oI 'v "''')1_. l:/!ml'I" C"" ,I'I'H," I'""I~'I Uh)'e.HUl('he."WUUHI". L'.I!:~) .'. i,;"'~"lf- I' It, --L- -- JO,':::J/9l'; ~,4L 10 'EEDl~ .',' ~ : III (Je~.u ...;~ I J --.liUi. qL0. 101 ;':i I<;~ ---- 74~. 1 C, 15 .:tlL ll,r,U uE:~,.,j 1 , 4 tiE ~I ':4~(1 1012:1195 f4610 16 lONL (le&. e'- , ----1- tiE i 3/& IOI;::i1 t\ A-I L 1 0 IEEOL E MiT.TOCAfH.: :- G ('D~, 2 1 I 4 tinl 510 I'::J/95 A,j t: 1 (J lE' Lf AU(,J G(I, 1 H :Ij(, Uli~, ~ I ,1 NUl TOn~1 ~ CIe NE ~I 1''''0'' .ulltl."'I"'o""0 ~.~.~H ~......... ~~.... .............., vb' 1.110,'. iinm-Ji:;.r.;-- Q' , 0' -- --- p :: p p " p . "" " . 15~ '/0 o "''''DI ,", SHAROtI GEUfll1 i (: II pOl' 10 1:11 I ~ e, N lo,IIIIP.". 1,0 1566;)8755 :."JtU.o. ".~lC' ""D n,." ""~IC' tt 0 II CODn ell '''I..", ~J I (}:, ". 1 :. .'1 .PP~OVllllI~ ."".. COUltClL 01. ""EOlCh '11l~ICl e'OJ illS. II~(, n/~/I; l'GTI-.L r:?RE ;/,4 NUn ROAD ',~lrlF.tl : x v II L E, F' A 19 H O' :1 J:i G 010/9:'5-25b[' FOIfn HC' ,1100 (I -'41 fo,m CtIAMPU8,IOl N Il<v"I"'.IOIIIIIO 100 ~ " , " ~ ~~, , I ;: (, L " I: j. :, ~ 1, ,.. L ~1I1 H I ~()(J H ll!ll , HllUH L (,et I (JlI! ~ I ,,~ I" c' ,II 1'.Htl.thh~.M' t~~,,,, 'C~1.t I(,'IV. .""~Itl-b,ll~I~lUlJD,.\XIIIH\O"'1 DJ.;;IT.;r..r----m-~;;,.' ---..~'"iW;;,I-.'.-.-..--.~,;i,.,.-----~' ~" ,.." ,-"' =m .'"!' IlifblOlllMI, ;Vlbl~J ...JI tU'\Oh~l,~ ""I hJ~. .hil IU,..,".....h, . -".--. IDiI :A]" "-rn: -.' jD!m1HF9 - -- 'rT'I;lm"~l;nlr,jlj)'l;'l'li}';rn"iTiI;;m~ I ~~K~'811 CI . I.. J9 n. - fi,," n~'m;;r.n'Jii1""1 W..h, , ,'.'.11, 1;IIUd\FJIl CHllln ") I I,. L,,', /'lllj.f.Ell1 Il!',r,r, r'Il\1I~I.."m.mjli~11f'i~''''''mn;rm1;------ T,m, n\,........... --,-.--- ri\Wf f.rr"t.tliln1Iit;l'mi'lm~'li1l1lOr'-- ;: H,(, I, IJrII,;~f\ !j'f I'd,'" .", [J GJ ".'" I fJII/J ~a nb NT, JOY I:' f, I;' I,~~,;; ,nTrr.nN"i1n]~i;i+;f1;ri';J;.:r.nt--. r~ffi~m IU4t)u~ t,Q loIl1lfiiimlij"'Ei'hu CHlW liD. ~"I". ~lL..h.',~I'L . f.~~~t~'JI~,'~\:'~!\\f,lRmt~lI'MI~"lim,,Pm.Wi~IIII" III' ll'""n lU,I. .)11'111 ",~m"l~d"ilji;D-D () r I ~,t~ ''''11''111 '. 1"~IUIII: .h1l &;..O~I"ID" ...1'11,111" 1"HIII'IJh II 'h ~11,j)"1l I. I P (,It 'hll NrblJl. ~b~~ LUM~E~ 5T~EET ~tT. ,lO)' r'A l'/5~:I ..-'!.~~";~~~'''......JlL..!l."' :l- !li1JLI ". ll'J"''V..''Il'..cJ'" "~----'---,'''8-;-(i"'')I0~1;1(I~Utl "liit.tiii5mJiln-t "I~hl~ I '. 1,,,11 _ I "1101'111 ';j--I"-l.;(-/;"lr....-Ih'i '" .'"1''' !/I'I'" tb ",,,,..;;;hir- ,.1 ,l, It 'hI ,,111 II.;j(1 "H'~ c '" I,ruttllllt (\\ill/Or" Z,;T!ON UN FILE ~'!!''''lL..E.J (i N "'lJ.m.E__ n tL.f.L1JL ..._____._._n_u ~__._b.~L.. _Q .:-:!. Q,LLt ~__~ _t~'.1 U "hL..I'lll';!1 a""....I,III1..."....I" -----X.!iWJ:ii'f}Tf,f1 .---..em16lQ!hU.nOJlT!UP1~~I~!! It'l1f.9.f1MAT~j n~'l'-lJn'~-~':J~ u lUll n~ 1111'1 I" ,I ,,,,/1.:11 'h/III+I .t ulll ,l,~ [.;hb<l. III I,'~' I,,~ ..,. '. ,/ '~" I. lit" Ii I J GII ., I I"L(.' 1,1/111 'I' 1 MI. 1.1+11'\ t ~lllliOIl "lot'la 11111 "" I 'HU t 4'~lllal" I. j" O-'imnrnl'" UllllJ . ij-1i}'llfiifll5lj,TIj;i">>i\,rr-'---' ---..._~---~.--_.__._-~---- '1IJlliiin,j1ifijl-fj,ffiiilH . -- tiH~llIi \i'J rllllik ~ii.1aiHilkihlilm~i , :,:I::~'1 ;i.},iillT~~"",,,It-,',~r.-llii~-li~ i:.~~F:~~I~u~f.;rrjill~t~-i-;i3'---- '~~X}.lmrIl~.~J V:IWJ1iuJ::',~:I~ 11M LOUIS lir,INi,EI;!, DfJ l>lilt;I:iOI ,,,.,"," I,."....". ;r-mTihjj7iliJJiH.'ln ;i.;lli'l -';.j~r m.';itlb"'Ii;i:T~lii'j:i~iJl r.rr.r..~"j;'''ifTOH-rrrllTI--~--- ---0-'-- ---. jJ'l'lni5Jmrlllr~iJ;;~11iJ1jtlll11lNt"IIJ ~ 0011 bl ~ Il.:" IH 0 hit t:1.HOI.U, , J HI PII10 Ihtt.LII;'hl "'0 0"" ~ ail,I;lt.' ~..I... o [J ,,',," 'i'r'Tliarhiir.rH5hlliiJliUYilil nl;"-;li;Uli)T"Ti~llrTi.~,,'~rm"~\JI.."I, L ;t iilTfiiTTI~~hTTTT .. . ~Tt-6"-lli r..o:.i..t ___'___ 'OS8,/J1 L\'t1E OI!i~Mj" I , 1 ll'tlllt '''88''" H~ hit 'alot'IIhahhlhll ~ .. .. . .. .. - ~ ~ ~ .. .. .. .. .. .. .. .. - .. .. .. .. . to ""I!;I' a'lllll./",Jhl)t11l1J f . ~---at'i' lJl\,t;t1iJiiil"lIllt:lllV"llo~lTitfi.mtuni I' IIJlt u "I+tlll .,..q u '~"ll'hhi Jt:".'f ~,tI'" "11)101 ~ UI~:I'.!... JGr~T.VV~1 '1'11.'h"h,,~"J'UII,'(IIoUi.'''.:..JIIIIH...I', I on:,1 'i:5 ,;q id '3 IU ad I' I '''.1/1 III t III I I .. l 1;61' Ij. (Il.)~ "h'l~ Ill' , _,.'!._ '-....--:--TJ' _ t1Hl C,6pO, _..li P ;""tt.~IO IEF,~~,lll I<J':IIJ.'~l.. 1';J'~l. I:j.~.&l I - __L ~ 4'1.;1"0- fP~.Ln t-" 7 3 j':J_!!lHI- 056. H .__.1:PQ L..f'_ . 4 tlEW ,1J"'0 J P - -- ----- i"vf,TffiTTCC:':C7f."(ffie- 0'& {, , (0 i r-- - -. --- .j E tiEl: i-4/-I(' :f\t/-<:7.!-S " ~:'~['b'1;~'" Cia/Lol 1()/~'~/~'5 ~~/tt5 i 01 n.: 1/:5 TUr.'B 1 'i ~ (I ~~ ~ t ~: 1 1 fil! _.J . p I 0 I '... ';h'~- ..loJ f "~ 4 -- '~.l t.1(, " /, I SET 1,:\1 7lli lif. I ~-Ji:TI1iT".h''''''''I''llf'['III!I'''I'' t1J,'II~ l,;Mt"J.1 "Ht, tlHI ~i~L H..t hi I ~o al 't'JIl~ "1;0 , 161ill p Cl6~I~l ~ "'l""imT1iT"-I'r~""" '9" f.N,1""'"'"""1 \.\ ""'I"'I~\ t.j ,i " t 1I1~1 I' '~I( tit hit. l.J, " ""II~"}UlJ nIl-Uti 1l1~I"''' ., p t'~(z]_D hI; ,lo; tv," I I",...,.. Ul"It,IIIH) " .111),'" Jill ,. hl""e'i"iiVr"' , 161l ':0 I 166 ::to ~, ""I!o'(I.".~II' II 10.11 j,ull ijlll)oJ~ "a~ITI.IO/lI" ,.,1 UlIlI- HIJ II II H.t.-h It<l 6H~Rlltl CEI~TUlll:h IIlf, IN(' rJ/b/A Tll1M C~,Rr: ,,'" 10/:;1/9f, '.04 tHin r~CJAP "irm.jfi))liJhT1m)J.-"jhl-,;ij-.-.--m------.----..~ ~,~i1;:'.I-..r.7"i;'";;v~'---- ;II;I,W:, 1-' I ~ \) I l.l. ElF' A 1 9 -1 to - :3 338 1 t:. 6 6 ~ E 7 ~ ~ 5 j (J ~. 1;, 1 ~.~ I 61 (J / I(:j ~j ,- ~ t-j c b . 'J,HI (,~ "'hlel Jhll "",;j~;;t;i~;l.i~;jji.('; -.HllI;ylllllr "tJ. 1-.(jljht~ll j: (JIJIl HCFA-1500 (1 -14) "I all,. (lIl'~t't;I(,.l1 to~II~;'II,'~l j'(,ltll CUAMPUB.50' " ': ~.v ~IlLhL:L !i'.1I H I ~ (I~' EllWI ['I. 'Ill ,., .,. , 'I,n 1.1 I, .. . " I, \' ~ r-^ L (J( I I () I ti ~ ) I r,J41 t'H.llIlt,"IMltlj lI"lIlu.ij "'IlU Ill\!- 111>1"1,.,11'"1''''''' Itlll-")I :\~,~;!~::~:.;'~~~.:;~,~:-:~,';::~~~~.~~J~i1%~i~:~~i,;,@~trt~j~~;~~i~~;,:~;:~~,~;:::,;~~~ , lJ;'~lt,~(JI~ll~lnl1.~~&n1;m'Ji------ r'.l1~'.lnl,.~L_l-L :..---- rillil'M".! M~h.Wf1l~M~9..nifl!;f\Vli)~- ~Ilb[, I.. (JNbU, ii1/'o~~ J .'" 1.J rJ ".", l!'ihu;'U'lbt) NT, .10'( H, Ilt'.t,J r~n;r_'T1ili11in~..;,r hr,~\~~lli--"--. r"'lT.\'uh]li ~"t"t'.i. tif~mrirfi, IU n"IN hUl--- tll' U~I"H ''''Ill .1/'1'1 i '~::" l:'~' "~I;;Jiih114.1-'1i;C:!tHL~,n;I'i",f1i--' "~~"';:';i ,jl;tWlii kJ u .._L.l t~~"1\I "loW, .1Iu )ul)~{~t~J~t\lA'm .r1J~~r,~ll:1 ttl.''-j~) hi f . HIj,.1L IUIIIII"'II,I ,,,0 UJ." ()~..'1"h g 'h'III'IIlI'I""~IJI'll"hll';lJl''''bUIUhQIIIl .'IUII""" 'll._:;'~7:'"Yi;'. Ill! Hl";ii~rjT7;ii.mnJ(6iiiI---- U"I.I"t .,,1110 [J ""'" ~bL8 LUMG~R 6TR~tT In. ,JOY PA 175~2 , - "".':'~'.'" :.~u _.ULllli.:.I.::.4 t:.!ll_ II" (U.""'I"kl'jIlUM' ...'-... _.t-~-iil;;rDWUHII)r;'it"fiii3TTIJi;KI- U.'il' I lliJh , tiP,"'" ";-1"1';;1;;", ,,," I' "l"fiOl I..., ,ffirt;l 'I'u,;;;j'...,,;o'.---- 111,11-'" II "lJ.II "f()"lI11~,,~~ Li;' '. ulIIO,,", '''JTIHJld1J..'rJnl~ (JII j:!LE , :. ,'J;I]:i\ IV,,!!' 1r.I,rwltlU':r.~I~WA~I~';;~:'I~::~;::~':::;-:'; ;;~~~~._,., '1' .". II II....NI. Ii Ii ,.. ~ k 'l"I'llJ :r~HI' lLt<>"'" hi ",1)1'1 ',o",u 61.Ii1UiI.L'ftE n1Lf.Jll_______..._._!'!~LJl'lj.{l~L9...5 ..:~~.."IULII!IJII,'.Il"'Il~__N PfiYSICIAN OR SUPPLIER INFORMATION " 01110' t'l1;l1r,r;m'lI;;Jiili,o""''';'-ror1'-t''Tj;J,\i-ro:;;r.;'T'''''";1f:Toll'''1 , ,,-ma;;n;rr;;;TI'1t'iim1h 1.L:1"I6(,j'I.Ij" itjlijhU.C"I"'~ .I,I.,II~'" ""'1." 1I11,lh iJlI,lii.:iJ,,- "'1'11.11' lJ-'Inn:~lijmT'1T')-- ruJ1JriilTaJniIHHii;\,-'-- --.----------.-., -.---....-. r;:jrrilHiillifii:l~~1IilT . i(J'lJ"" lJ"OIlIl 'fIIJW ._1''''''''''1'111 ,,,...11I ~ Ihl1o.Nll ~ o. ""''''''hlJ ."1[;['''/1 Olllllhlll ~Qllr,q I., ~1I111~l'" h.."Lll lIr.. I " II I)t; Z 74:1 ~ r.%~~I~:11m~'JHlllUi'itin:. mJtriilh 1)1)' LOUIS f,r11NIl.fkl, on (,I'd/lI301 ,"v,,,'" I..,,,,,.,,,, 'ii'htwt;ht"iiiii1iit:.. ot1"['IITt~IiI,ii+t<<ITij;nm7.j"'t\j;1'iiir.t,,~ii!Tr.CT;--" ~t 1'1.' ~j..tk~llJ"l we"" ",",lJili;rui5Ulii1l1 ~Qijll o'.l(:ll ," n'-nml.ol;tOl"1ilrlJlJOTiITii11ntli:7c.~T1i111llll,~..h(Jt.,'lijHUJ{I~'" I" ttlll.....1J ~t "1""'''(' Io..,lol""' I , .1C '~~ I)~ cob'. :OS8,el LYtlE PlfjEA5E l , "" Cll,llQU . H"llt '''88''0 tU Ill) '~""Il .., ~h"U,U ..._~ ~.~..~~.. ...._...-..~....~. IO!.2e./9~ ~~ ~~;'I (r~J Itg~l~~t~J;1I"t.tl' c'" L~~"~.I " ".;y~ ,IHI.'''uIIUt.ll.~ "jo"l'.l..Il(.IIl\"II"'tl~"~I'1 A4bl() IV TU~IN~ ~ASJ' EOLU rl Of! H r 1:f.JL A,.tJIJ IEHLe :~c 1111 ..",I,)II jlUIIlLI"U-IICHIIIO '1 .. llU11JI UII,ItI "'0101 10 ll""\:.'Ll' l.I)O 'Il" ullll. " ~ .. ~ I 'h II. " 101 "J-u' I '"/1:..., .. ~I ,~ -L Oa~,61 IOi.2~/ljo5 ~ ~,~LlC' ~ A,' L I 0 "- 1;4:';)(1 " ':1 f.~. . ~ 1 j I (II.', I Mi. {;n~,~, 1 ,., ~ (j~ ..2 P 21 (J :; p , I ;0 /(1 ::(1 p TO/::~/'i5 1\)/25/95 16 .2tlL HI r,o ()31l. 31 ~,J!-.. IEEPLr: Mlc"C:CAT II ~_II OS~, f, I II E ~I .1/ t;Tft!'l j:~- Oe3.~1 IlEl1 ~f , . 101'" , o. . " IIFtl . o jl~ Cto . .. , .; 83 J.j(J , ,~t ,H.. "e 1 ~ ",0 . 4:J3 t~c II I,~ Ciltll IO~ fiHAr,Otl CERTEtOI(1! " 10/31/95 15bb2R75fj :t~tilIO' ..,...ICI AhD n~, 0' IIII~IC' rt 0 II COlln CII, fl" IU;~ ~! I (, .", I :' ~, "P'"O't'ID h ......" CCUhCIL 01, MIOICh UII't'ICf. 'rl) IfIS, Itl(. Il/b/A TI1TM. I:~,hl: ':~'I t1'Jl r r-OAD JlflE!11 )' '.' I L l.E, r. A 1'1460 "<1:~ :J:\ , .. fJ 1 () I " : I ~ ,.. ~ ~J b t~ ",m HC,,I,'1I00 (1,14) Fo,m CHAMPUB,lOl tell ... 10' 1t!..0 , I :, ~"E h:,.; :iu 111 1"('(' [I: I OIl I" ,./\ I ~', ~ I .1. I. IH.;L.U t ...< ": Lll( I IOIIJolI "'N.lIlll,~VIo~Ml "~I""i)III' Iljll" "'~It UHL In",lu..II!ilI).). btlu-NI ~~~~~~:;,~~:,:~!~~,~~:r.-.~ll~~t~%~~~~~i~:~~~ ~,," -:~:,t.:'~::~.~~~:~:: '=- 1-lltol J ,~/~~ij 1l{&\J14,nQMll;)TolI",--_,_-_, .--- nll'~lhli-.:..~-L .l.2_,_ 1-lili1lfliU~t~JjfJ.M;rfffiAA'OiIolommr'i1- ':1;('11. llJ~\llh f;lr.~f, j .," [J 0 ".'" l\'il,b.illlf,t'i r"....r,riJTii11 ~11I.:"~'i;,rr.;.,,,-r.;;.li.i--- ri,,~j~Jm"W;;;1) ,1)11 Q~w~ ".~. ull",'c. tl).,lj hU I 111, J[,y p~ I n~J UI' I'-'''~I ll",U "II"" Oa: .....Il. " 'A ~"-.. Q- I;:J-D f "",~l,I"IJ.lI.lllIhlJlllI~llijl,lJl'''lij''lhltWltM 11'It'II"'"I"1.I 'h~~"~"~ ~ ,1'HtlH"~." iiTii;t'tiljjjiilijiIhFrU'~ .. II f,iIDlrr- .'~. ',;yj.j" I 1i11TU 0 1~1l U.I() I I. tilt (II..' '1 CAt j -- te'I~"',;J:~"~),U~'rlP~h~ UH III II~" I- ~, Hhil · ..".."'."....", :Il>fi~ LUI1i:<EI\ filr<EEl '''0 GJ.., IH. J(jY ~A 1755J . .._lhlh~~-1..LLI to' '1-'" tn t 11.1 (I'~NI'U..,'O"~fl. -_._--'~.~-;rr.~7lc"iHIU -~iJii1iIiiT>fnii"jir- .t~llI. 1 iNIl' l--' I tI'''"IU ,- ...'i"l'.kl,,'l ".,''\ ", .'f""'" ,," .",L"....'I. ..I l(l H h,"'" 1I,01t 1".~111 lot"III'lJUIlhll' .\Ullilllil UlTJO/I Otl fILE " ~'I 'LI '" 'utI,; o [J ",." ~ U I f.t/A TIlliE WI F II L____ ,", .J!.1.Loj,L:....'t.., ~'""".V"IOIh.V'..Ih,"..,""",' I I~l~, ~ i I 1< '"A" ,HY~,?I~I~1 ~~'~~I~,~,tl,~~l~~ORMATI~~ ' ~ "" '''.''1m'' ' '" 'n. J 0"""'"'' '''''' n,' INSURANCE FORM "1- " ~mm:m;;wm- 'ij''1m]TImITrIilTm..--- . I mmmli1 W8Ilublllllled '''',N JII'IIL),,,,.. ,,,,,""' O'l._/~ '/i'_: ~tlTNi01 ",.""",/10 ;'1I'.'(I~1I OM oli.i" lil)Vfltt." "~'t11C loIhlu ~ij";tl, IJP J till C' 'r ~ 7 4:J ' " t41 LL...:.!..:. LOU 16, (IF< J Nf.F-I;) .QP (,~ Ut',,, L ".'"" I v,",,,,..,, '1 II~'" ~"b ,01.1"1" I)' '.ellltl ,.;trIii11")IfI."I"CTWI.I-;TijT';:IJtTii"~It ~ "''' 0"1'0" 'Il "U 1~ItO"Ul)"II'.()"'" ~l"IO~liUIIJ\,JI"1l1 tOlJIl OUItII lr-r~lit 2""~ll.I"' uI-ii'i1trliljliiJ:;;tili, "11.III)..ijltGln~~ tlll~W" b III Illll"lt.(ltoulolllJ1i\1T tlcY6Jip (lll, , CoO 8, III L YI1E 11 J 5E I,Sf /I 0' 1'1-"1 "ft,(, c r~~~~.~'1 f l~tr~:fl~Y:'l'I~~I>'tH '1"~ln~ ~I'. t l". 1'''I~'''I"IItl/~'''~~Uh''ll'';''tl.ll'I,oWU~hC'', lJ~I" ufu.II)I(i '1tI,I1tl tu IO/Ji'I'15 F OLl Ol~ (1(- f T ~'~JLI.Oh l.i' 'i T IOLlOII UP f T TAfE ThNE~O~E "\'f'~ I N(, 'II WI II \1 '~, r. II. j \' I N: tW(;611~G VI li'lI IPI flEW \>.. I.E E ~~ II II 4 10/1'1'15 I O/~O/'i\:i- 4 4 f 3119t:i :O/~~~.'Ij'~ 4 4 ~,'trill. "J 1: I (, l~ ( F. P R I" (.1-. F E I UI" II " ~,Hlt, HE II " H( ;i'1L,m..w It ",<)~"''''''l"l (I" .C""I,U "C" .,,~ 0'" ---'~~,'-- .,.--- )(: IUu"'O{,U fll,llhl,\ 5HM~IlN (,Er-<TEln Tefl "''' I 0 I 311 'I':, )) )~Il ~mr"I' ~r.d)~j.lho- ----. s'i-~"-"'~I-;tUh'':'' - 1 ~16t:~e75~, . "10('0' IIIIH(I ~hU I.ii 0' ""'Klll O'I(Ll~.,;;;l;;l;;;:;--- fillltl~fil.1 :'.1 u;',:;,', --..,I;;<<:;Y;:IIIH' .1"-' COl!li(ll (J!i IIl(()l(.-" bllll'l( l t'lU IU 100 '""ion I ,,.UI '''88'u ~u tlQ '~W'.' "1~"h'ltQ .. .. .. ~ .. .. .. ~ ~ . .. .. .. .. .. .. .. .. .. .. .. .. .. . """lit 'lJll'Lh.IUkJ""O ij~~~qll. (elll (IE b lEI 'It' vltlt, "I"~ 11-". ("'~ijU 0' '0' u(~~c: oe.~lal oeA.al ",;. t, I ~! 1 OS~I~l I -'4 [, P ~ItlOUh 11 l-'''Fr''iiVr o hell ..., I 311 ,. [ II ""~.'j"UI~~ " I),e )v ItH' ~"l.i I 1'''''1.1111100 , ,no 'HI S, I He. III 0 I 1\ i/;4 NUn ROAD ~.t\.(,i ( III r V II II:, FA {; I O/9~l!:<~)61, fefl" HCFA'1500 (1.141 f"fI" CltAMPUS.501 TIlT?,L r.A~'E 1~460-J:JJIl , I :.. " .1 ' 1 : ~ " .:- E. ::: \11 I [ : f, i, (, [ , I nil ['L \ LJ /'I, 1'/34 I , l, I' l' ~ ... I, II, L III ,. ',.. '.. '. L I)C I (C Il41 'Il A~ 1'1 IMUI..ftCl t~ ..,III' tllht .Uol ~ ~ IJ I"~ ""..1 .....NhIJ~ U, u..." "hVl~1 ]:J~'tX~~~.\\.~~ "1-')JliU.l n..-unmrnYTli1illlI11ij ". I I j I :;1 I ',\101' III Ilnnr' lJll';Jhl'hliliJI1I0lIil11nnmn;;mj, 2t:';r, l.lI~lI,t" 511'1:::l::r In u. ftl\\~,,,U' ""I , , II I MW' """ ,,"Wl w'Ditj'IlI,"~ t:tmll~- T7i\wWW~k~U"iJNJ;Jl.." ,'mDt... ""lOG 11"'1. 1 ~L~)~a'lfit5 'irnlr.ffilfKj'i;l..'niS"".I;l.t~ r--" rjhtij}.m-rtitiijJhiJjTj1iU1i(~J1;JUri'i1il11ITi17wljii,--- ~6hb LlIMbER 61kEEl Ilr, JOY r-A 17t152 ,__~.I_'!.'~~~~~___L L2-b!i:l~4cLlL___ H, (,I,...IOV.,I'IJ',llo"'. --,-. ~ll'~ lllcl"Uu ~'iiii.iiOTnM;";r- IIU... I INII I "I ""UI ..-1."l'.o...t......II'I..n." "'1'" 'nUO''''''N''IO '111 ,[,;.it """."\1 I)" ~11l~k:l U t.l; "'''111010\> AUllfOrdZATlOtl ON FILE ,~"'u 6..l.J111f., T Ufo E -.Qt1-Elb.~ -...--*----_~_..!l1.L~.s. 1,..I1IIJ"hbll"II'I;II'VlllulI,tllJf,Khl". PHYSICIAN OR SUPPLIER INf'OHMATION ,,""'" --1ml1M:J:,\11,imr~Lf~.'~""' Ift~"~,'~~"""""w,, . ~,m'17,',I:tl,mf.m1",,,,,, \l---n1llliljllfr_ll1Taj--- 'ij-mri~~nro;r;:~-- -.-.-.-- inliti1 " l"~ III . 'II t "llulI", 16 ...tJll~ ------ ~~---__._L",,.,,Ijo'" ...".. JI:"~~'I l. h""lmlll'lIlMII)"tl~ICIU'''KQh''""Uv'HI'''''\IIII't:''IHI/I''~1'1'1, Uf'J"" 1)C;:---.14:1 '1.::1"'1"'1,, OliO' II hOI)' LOlllEi GliltlGFRI. (,(I l,RllolJO! "0"'" 1 """"'VlO _I ",.... ""U "1J4jmrCi,i{j~t.i;lI,TIj;-;{i..jji'hiij'jljij;;fij,j,rtit;~i ..;i.Cf'-i~TI---' u ~~.I"'.~""'IC:'1l ~o"ni~IIIOI,tI~lllIIO\Ja btmr-.-- In, Jl'Y I;'A Ilt.~~~~ ""...,"..'. .,~, t:::.;:;~, 0) . ul..I" "UIIII,It~oIli~2fii~1I1 ~U1~rr;r Ii ,1,it:ri~'\ij';j;;TIIi--' ~~~t,~""'W""l' 11.,h 11)\..11~..,mlf'I..'~"lIln,i'li;r lIlI ll'l<<H II..,., ',II'11i ~(~L.,D"l- '-:"l_D III "'1 I ';'III'I!'lh "IH ,lJhJ ,. HLlh110 11I~IOI"I,,1 ." 0 [j) "" 1 H,"L;I'" .~t... 0 0,;11'111 o tJli" ~ ~ I '1IoIulllll.1 '''''''nl u ,.hll lUll hili U '''~Il11I'' /""1 t.. "',,, 'i'l7iJlJ,j"ii" nl'''I~~I~I''Hlllh .I~ootl- p." ," r.:--.0i1ii1ii5iiri'iij;l1'OH.~"1iJ""iIThl)'1111\ 111~UIlI1i11i1iMiIffiitii1,j"Ht;XI'kI"l I" cu,ul.lll1iTi'mfliThfT'ii'WijiTlii1 Ik6...I"',,, __. ~ : Olii3,bl Utili D/EiEAfii: I , .. . " II." Of ~Illllq 1-1'" ,,.,,,.. '" '" Ull.". .' Ivi:)!1 " " . , 'Tt17:nfl1s- 1',lt:1',1 ,I 'TUi,Jl/lu t..',i:IO 4 T(J73J/95 ~,'. t J (I 4 I (j /31 19~ t, 't IJ I {'I '1 10/31 I 9~, ~,' ~ I (, " l' lUh ~." "to"I'I'l ""l'" ~ lIf1l'''i:.uNlh"i:.I', i:f1Af<(.5 ,,1j,J 1,,,\, 01 tI::~ 1~1\1 711: NE V UBlhC ~~51C EOLU 1IOtISE1 NE~ :llE1iLT::~\'. llTi-- IIEII tiS ~1':1. -n'[,E) IOML .___!1.EJo!.... Nc 4 '.. l,Qi;ijij;.rorj..iit/-,clr"i:)" bll't-C11l 1lI1!::1 Ur)ohl) ..hi' pl' f;. IIIO'hll'lii,I'/",WI..""I" "IINth"lI"II'lfl HIt\IHh' I... 11I1.'11 .hOUI ....U, . ,,~,.I lI'Il,lI" liE I. l'l '0 II'I HbHII!II"t t1.<JW,flhlllht- [I.''''LOI>I'I,LI IIHI'I IHr")! D'" _-_,__,_..L.I.J__~,__,_, )J "",11"'"", U(..II'rl",) f3ftAP.CJN CEr,Ht:l r':H o..u IO/~Jl/9~ ;:r-iiMiilr.r..11"CC..lt,ih"lhi,--------------, j)*ii;;ii.IoIt.7,ij-..i"ij";;;;---- ---,---- 15bb211'lo5 '","CI Of ""~KI"hD "P'lO, U,.w,(ll' o./(.)oi.-o;;-i-;:Ii;;:;-- lit".".. . I!) '" I ' /. .:..!. - :.=--!_-~...!....--_._. ""HlOYlr) 1I'r ,.",,. (.CllnlCII Oljl-,ltllll.h blllYICI I,dlJ L"U'Q" 11'11.11 '''B '" D.o DilL) HI,I!III'Uhl1lh4 ........................ ..................... ....!lllI "lJlniJfI<I.hOh hU , tl'.lo" "'1 em; OI!B,~1 utt. \Ifill , tt lIh l"lr~ (I,.~".. . . , ". (leI:, ~ 1 (JE~ ,:: I (IS~ I ~ I I ~/I, . - Ir1Ol_lllIn~t h ...uht, INI , ,---- ----..:.;.Erff~ r.;w.;-...lr- :t.1.L.:l,e II t~rjL:I::~~'~'J~,,'tl; .. j,O_IUMlv M.. ,.,lIliijii""f., Ulll' 11 II fi , INC, O//J/A '!OTAL UhF '[... tjI,JlT r,o,;o 1;',IlQUlJ ^ v Il Lf, F,; 1'/460 -3:131) I> I C'/9:!~,- ;'~'.f,1 j.",,,, HCFA.'IOO 11.14) '111m CHAMPU6.5n1 , I .:. ~", r. /', I I ~... L 1;\/111. I'" (, l ~IIJl; f /, 1 ~ :14 : I" ~ ' . 'I '. IlJL~ ~ LCJC I IU\ 64) IIlHIIIIII~Uh"ML U","'LIoU I~'IIO.1J1\1("'lll "III....U,"b,.",'~ b/Phll ~l~-Rtlt~/t"J;:~-~~riv"U'h<)1 --'" ":\'jlil~I~~~~~-'---~-k't.fi~tU' - .i-I-------L..J.--f ililil1Jii-ils ~fiIDT.m"-':- 'rJlr,j1;' j Iil.l..m "'Oin,,1l r,..I.,~.;rn;lih, h4iT'f\1'~,~t5 ,~ I rR !:I,ll ~I.'trl' !11l1l1l'~'1 '" I LL allA'<I'T~111"'''A -;-ni'in;\'&'-m#lUiuATln:trmrrr.ITiWTI---- rny,l1iI1.ll----.- - -- riffif~~"u hl;ll,lStlliiiJ If Itlt.." .lJ,ntiWlrnr-- ~6~_" l.\'tll:l:I> 61bll t "'" [J G.l ""'" 1f,t,6::f!l'f,\; III. ,JUV f'A I H1~';: " U~,~ll '.",0 1.'1'1" f"l II D ..;;r;1~1' . ~.IoIl.I' I WI..,1l "Iltl H' 0 [j], '.1) .. h.,l,p,l .,,11.0 0""" U DU,O' ~r ~t1~::l~-:.!!..\1I to 'ltlOW '''"0104" ~W.O..M."Il...hG"...IC,t"C"O".."~"ClI.~ "vlliCIlj.lllltQ'hCrl UP t 1/11 l.l?t. 711:t lOUIS GRJNc,FRI. nil tin 1/"",,,, II ".... ...o....oo.l~i u~ ~....tll~l' l'lI,rtTIflj;'j(n IIt"l;llllol" \l17:11ilji;'T;;un~~-. II ll~~Q~~'Jtt:.~ijJnnmaifijJii;iiiirliin'~IXII>III'1 ,11(t.;lli~" ".-' .I'I~. '088,81 LHIr: DISEASE " I .' u~,. i.'r~J I'/ll,}(t"vltll "'~O'(.I ", /I~,d" eM ',,~h:rr U....lLo, Ultll't htt. ult,"t'IU "(11 It' "I '1'011I I. II.~'... .1(", II 'h.'I'tllh",bIlH U/l~ICUC"""'l"''-'''ItLI'1 ICT:; J /95 ,t 'i ~ ~ " NEE'.... :. Mil; IC':~, f~! ~' ~~ .. N . ~I 10:: I '95 1-.' t j r,! tli:t tl~ l' f-.tllll j(1, U, .. . ,..'111 4 _illJL I 0 / 'J , / ~ ~, P4c I 0 IV E T AI\T Ii I T ~ tllJL IO/31/~5 A q , i (, HfF-Mdtl I \: '~l / ; ~I~ 4 '!EP I C I :; 1 '9~ /-,;, r ; :,l 11l,I'AI':I, I 0.(,1,1 , ~; I II. rli. 4 VIAl. liE 1.1 Hr." .t."u"".;r;r.i;;n.;;;r, 'I.''''' 1:1'11')111 It'(~l ,un ~Ov t.O(,.t":rt\l~O ." 6HARUN r,E R H /11 r :'11 "" 10/31/95 .. ~OlIJl ~A'll"t.. .lUl1lJh. flU 'iilQUitj"'''Il;IJIl 'u hL 156628755 . ".lei Of 1l"~IC' "'''D h,.. o. Uhlt;' 11-i;a;-uA:ilf.hi,~C;------ ~IIU_. ~. I 'J ~ ':. I : ,I 1 ---,- - .l111'IIO\,[O Ill' .l~.l UJUftCH Oli I~fOIL~l MII\lIC( "e3 '1:1.' .'''' ......----,...."p'.,..- ," I _ _~~".IIL'hl ~"1oI uH'h~W. flh"U\l. WlIJlJilw.,li;i/- r'";h,~iiTliTIliTM hI) lotlUNNII ...1.1. u"'IU Uh'''UI o I III;" 1,A.,v"'''',' I "'"IQII 0 ."0 L(H'~IQ". tunot'" I' ~.hII'lHI ''',uIIIIl .lU4l/i UlU"" (ll! U.lU N'(.O'Oil 171552 U~lv' : '''''OuQn ., ~ lllHI,OltO',. . I tll . 10" 11~ .ON!III'" J O'.O'..IUi.I I JoIloUDIl.l'tOMIt "..0 "'Ill ouUII,ll ~1)u~OUKII In hQ ("."41. l 1""-" '''80." ..to DhO '.UI~ ~ ",..,hlhij .. . .. - - .. .. .. .. .. - .. .. .. ...... .. .. - - .. .. . U'!I./II 'lIlJu';M'HllIllt"O G u'.(~"u~~" OUb. 3 ~ .t~. 1.1,,11, II ~ .) II t". (!I.~1i , G' ,". OG~ 121 (J~2. S 1 vI, f. .I~ I Ob~.Cl o t~ ".llr,1 .WOv".I "I..."U I I i'~ ': (, It 9 -,() I' .~b;i~.'~~u~t};' . DIU Q 0\1 "...,_ ~~ lillfi, I tiC. Olf~ I A rnHL CARE ~.'L" Iwn r,()~,l; ;:1 W E /'II Z V It L E, f',; I 9 41t(J - J ~ :; E 61 O/9'JF:j.. :'::1",6 form HCFA.1500 (1.14) I'orm CHAMPU5.501 I (;(J .1 It E/, LF ~" L . l; ~\JI'f I ~oo t: , IIHI I' A I', :1 ~ I , .. iI~\.I1I UJ(r 10104 ) "I~IIIl"I'ufUJltl (llol""loflt.l IV.'" ""'''''(~IJ 11',~11~1,t ft.....:" btlt),~1 l....,-';.'.,..i----.--'r"'i.iu,i,,-'--- ..-~....;,."'-~.--~.,.r..... J....J.I.H~"~I .J...J INIIlIt.IIiMlj M\lhlll"....hl. .~lll"UI ~;-Hl~.Hml;..:;;~~;.l."ln~;;:;,;)~.,"If.Arl " v,~-m~ ,'" UmBEl j'.!\b,I, (:G"k,h11~mq~;~H\n"3i1r-----'--"--- nJl.1~h\I~-.'.'L J _ILL_ Im~lik~tl~t\1l"gRRP..o,nr.'6riir'- .:/J~"! I.UNl>C," 61 hHl .", [J [jJ II.'" 1~lbb~Ii"b15 IiH.'~l"P'~ ~"I" I.,h, Itl UIIII:,.I~ ""1 . ~hliil"""fiiijl,.m."IIIOilliii1ij'ij--- 111. JOY f'A I 7BfJ~ JlifIi11.1Tr.Ii11;oii...;,fljjh\~~rn--- ~mQTtiN" hUll/I' Q,.w" hllmiirJ1rCI ~IN hI) I Ih' U'OJ..U 1t"lll 1,)1"1" ;":;;'\mrr,,",;l:jli)~r.~Z.~~11:,~~~,',;;r)F'. -..- "~i;,;;;"g,TI]'1; ~ ~~er,~f.'''JUnl;o,~iJ[t,~~ilet'~^h;. ,,"W '1;'" "~'I'l.hll" ,. HoIoII,I ~ IWI'I..IWIIII InO IT}."'" 0" ~,5 Ih'II'~IUI"""'IHIIIJhllllHII"UU ''''1'1 QII " '..HI"....... II '''~lI.'J1 H~')Io. .-;n~IU tilt 1'..1, "1' t.IJ1l11 l'q~UI;Ii' "0 . h"1-11i1 "lIlIj [J '" 0."", .....,,(1I0nl~- "",,. fi lJi.1:t~,um.t.-1llL.E.L1.f...____.__. '"' () 7 .' (I t> L~' "'",.,'...."....:('~"..,," PHVSICIAN OR SUPPlll!R INFORM TON I' p.,. 01 l~li~\;'t'H~rJ'~f:d~:~Ulr. '. rJ;:.aI~!t'ru~ lIJhlllmFlomnit. ~,,,.t,,'~~,"~tt,ktR IJ1u t I' Kr:~J:\~'::j..~lt 10 , , Ill' '"ow ~It 'f hto""9'""'Il"'''Q'''''''W''C'''lJltllll'INIt(I~~''..''tll..Olh''1 UPI',.. 0987,13 LOllIS GRlllr,F.RI. no fir~lbl:.c1l ~~w~~fi:j{nflllolll"TOj.Jf)lT.i:fi~~loIlIlUICII D .. I t"iil III I '''ON 'ldllJo..lII11 ~ I to 10" at.... 'I lit '"~ J ~'(.k..I\QIU moo.s 1lI1D OUII1D, HM11l1nCl~ ., ..~I"ullID n~~lot ~ctlijff7J 11110'., '" Ih~ "11)1' P.~Ololl'" 10 ""Ol:llJI!~"11 (GIllY" '08e.51 UHF- OIEEi,Sf:: .u "0 'I'''''OU , "' .l If'ttll "'88'. n. hO '.....'I'"..hlIIIoU " . ,rt:" e " 0 , " II ~ ... I""'" 1I..IlCl'Ulltl" '~l' '1\(1... 10 ,'HI"'hllhllt.IIHUtI,""OMC."c,uIlI'''lor'll P,"Q ... C""~QU ., U"~l(a ,. e" 11 III ". 1 eJI ~5/9ti :LIFlU". .:Ci'I (J[: e , a J 4 tlF.I/ 1()/3l/'i~ n."rr"t-I/ ~('11 (J[.~ ,::: l L TC:U.DERM 11f; II I0/31/9~J ~~bIO r'RE5E I t;G EN u~9 , ~ J 4 I-J.L /1'11 l'fl,tJ" ..ullIllt'll,',lto""o .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . ,.aV'I"~~IQhl~lhllr.o~ih.r- (I'" 101olt111.1 iI~ol o HC".. W".., .. H.."C Du .. , 4041 '59 , '" ,........' . '. ""l' I II~HoT.ri.b 4 0 ~ I ~9 ..... .. 1 Cf'lDI ~ lOll SHAROtI C,EIiTEtll Tell pol' II lOll I 1/5 II lOUI mllllr. totCOUII' 100 156b ~ B 7::;5 :a'JfiU' UIlVICI ."ll n'l 0' UIl~I'II' otl COOl. 01, "'1 ."CII II H)vtlIN'I(U'M,O IIQ ~~(J~rfl:"/~ "PPltQvED a., ".... COIII,CI~ 011 J.,lfOIC.~ 611WIC( e,u i!'iS, IilC. O/E;/A TOTf..L (MiE ~64 t,'JTT ROAn :J~J~Etll)'VILLE, F'A 19~60-3331l 610/'/35-2566 FOlm HC~A'1500 (1,14 Foom CHAMPUB.aOl 1 ~0 ~IH I. l. ',I' St'Ilr. 14(,,:, o 1(J/j I I \ , " , I ~:; 4 I tull.U I .lJ( , I (J I Ii ~ I , -Cl~,~'.',~:~W, ".;--'--Fi-':if,\'~.l..I~hlj:-'.'.'" 'rl"}~I:f.~I~)t.~ ;'.,,;..,. ..-- '@' :l~.,~titlj~~.-~~l~~.:. hHni#;ii~ ~\'~\~,...u. .~I.; - -.----_,_l...L'______. -,RrRr- s-;l1f" 6 sqlWIIN:m:r' ---___IOJOI ---- 1-.jinjl"rn;rr.r'liIlhlNrTi")lh"lwn"I)iijih'I;~~U5 r. }f1n;rjj~~jRJ~n, rii' .ft I I Il Jl~niWJ '.11" h~W' ~-~'hlll~lj - III hl/llt,LI,"./JI'lI.'WIU,W I(.t(l;. U,""Olk' 'UI~jw.l"'I":" t1lllM'/ FI17/:r'F"H "1'01'11 "1 ',; I,'" rl !7.:I.I'II\ (~'IJ1 j-nm'-r.ln~Tit.ttijll-Hil\rmli'('ii[Jj-"--'--'--'-~ r-~~HT;I'n .'---.--- .--.....--..- ).-11\vfl(."Tlrhlmn~lt 'HII' H \t)W"i'hITJ!ll.ll ~b ~l, LlJllt,r.'" :n,.. u; r "',' [] [] ",,'" 1 til,~;, Ii n,\1 NT, JllV P':'. I ',f ~i~J~' -j.~T.ihT-'-;.lirf;ii;ii~T"'.'~'':''I"i ii --- l.hrij~n;ruii)ijij"h1jjijJl~,rlii"t. (1.lloI hO, l'IU'IlL"'hU mmm .ft>r,..C4ll:l.'" . UlhIIlIIUIII'h~ljh".." , '" I I It:"/@- ~~~ll~" h.~' ."11 ~lIt I h I ,\j~. IItIIll '~"I ~I,l'l ~ l'l' ".~'tl U'hLJ .....1111 () 10 : .. J,. g 0 kJ-D. l'r~LIl'IIUI"t.t",..,t.U.hlltQ~I"IU.I'hI"IIJlI" . "'.Il"~.~ I It l,i"W,,;ltl,,'ij;Tfi'-lj ~'tlj'.hh'll' "fiiITft'IIU~II_'''C1JII.' ~b~G lUN~E~ 61~EET Ml, JOV PA 1/5~~ ,-_.."!!.'~':::~~~~,~lL1Jt~!l.1L_.__ " h~'ll'" II. 1I1.1lI""UI'Ol,~1I6 "r;;!Jh')";/, '''';;;;;;''111''1''''''-0/ 1'''1'''''1 "~tl' .""/'tUi.i.""'..H -.-= D___~=-- ;'~~t""t~'-II3l,..1fD"~I~' "",<~~I::~I"l:~:::::~'T= """","',,''''' ".,. ",,' '''I'' "''''/' ''''''.1'' '",..'\"'."',,",,.",,""",,., ,.,.. ,., ,"".""..""..", :rJ....".. lJ, 1I0.llIhlll'I,I'I"lIj' 11t'11I IH"t.11 1,)11 Q II" ~ II ,,,,..1) .hH · ntl.,hH hi .1101t ;'.'..1 T Ii n r~ 1 Z f.. T J CHI Of! FIt. E '111h10 5 II;' I f.,llJf. F j2!LfJ,lJi._.______-!'!.!L..J~2.~i;_tl.1 ~, l"'hlll,'hLut.'IJ~" ~lil..~~':!......-.....____ PHYSICIAN OR 5UPPLIEII INFORMATION ii1~L'Ijrimri"'J;IiIN!o,, Ih/lilt'- I' wii.-;:~ltffiiliOt;;;'U'-;;'~TD~~"~I' ,'n'--pIT"[1i.1.3Tli1:r-- "",,,W,'.",,,,,,,, ,,,." ,,,,,,,,.. .,.,...';....11." ,;;,;;" ,,,,.,,,, '''I(~D- \'lim]Jrf~.t,~"'o ,.",. 0".'" b,"',,,,, ' i:llTriiT1 ItII1URAHCE FOrM - /I,.. .-J ''''0....'' ,"0. was lublUlIIB '6 ""....o.'"m,,,,'''ijr.n.lw''cItOIt'l WlitlC.I"I'Lot~(j;j";:iill""llltll ~IF~[l<;~:"\=J--~rn; ((') "llll__ LOUIS I~RJti(iERI,'p() li~lbl~OI """." 011,-;.--- "II ........ "hu_IJO"'It.to. 'H,II'I. ~'.l"" 'IlIlltl' fllhUihiii"'iiIiJij,'jill".",.r.::,,1 ~"'Ijlr~l. \ ,...I,JhIllIUWI6Ibl WINllb"io!I,---- . Hl,lhl.....'.PJlHII.1 '''0 [iJ,hlJ liPl1TliI---- llLL 0" (j'H'ijlr. tI .. '~~Q~'r\t ~C:IV'" 0' li\hlh Q1I1hJu1l1 "I~." M~h/'j',. 10) "lIotllNfllllt cO'llwiili'ii1ii1Tiifi.(1 h,,"'l'" I f - . -- , O[jS,&1 L Yt1E uI5Ei-&E 1 '....1l1 '''88''0 , '~"'llhH,"lhQ I" hll I - .. ~ - . . .. ~ .. . .. .. .. .. .. .. .. .. I ~ .. .. .. , . .."..)It .f.UllllJlI"UIC".,u .. , .. e III~U ,tto~J ~kt)lb~"ll.,.tlllth u".,~" CIo 't,tfhH " 1'.wl'I'"'' -- I)"" CI ""~'" ...."" lJ h'''"IIH H(II.' '11 'lI' 'fll4N 10 0' !,'iljj,',r~ ''', ,.'h"II'IlIt""II'ILIII)I("OIt('IIr,II"'I''''It., Ij'h'~11oIL (...~Ii.. " UII.,''':I , " llh'H I"" 10/:;-.3/95 : L;.~u",M~ ::UI (lP'~ . ~ I , ~ tinl "I e.'~ , p - i-----"'-'-=t"-' , - , , --- .~._. --I , , __n -- ------ r-----.. '---1 , , - , , I , , ~1KLi:"(~~~mw.\. .mr'lr"''':l.~'~''lIw.R'l :" tn' ,'1 ~~~:ll~~l \' 1f\I)~rll~~ i- )-nn'i'r,,;n.~; ... ."'001"" I I" t.I"'C~ DUt III Lh' ~ .' I lh "tllr . "I J'"I~Q " Uti,. -""\110 li"hlUlhHII~ H'I !tI' Il. " W U,,, II "Ut. I :lll, ""i W ~116 ~ _..~~'q:) __., O':~_ il1!'~tl(,.t.]~niii:irIl-~.w . lUll'''' II,CSJIII .../1 Ill' "... h" ~ 111',1' '11l'~1 . r.ultllr hi) SHARON ('E~'lErJl r ,:H ~ I i ~ , JW, u/!;; A lClrAL (1."1:' 1 1 /1 :J / '1~. , h ' (j'J 11 ROAD Dill '.." " to\lIl '.'11.." ~1.b)\j"1 ..0-- >>It,~'~;~lii-.;;;-n- -- :,~(;,iUII r',' 1l. LE, F'f, 1 94bO<1:',:,1. 156b~B7t-;~J ~ ! I' .Ir I. ': !~ 1 ~II 'r :t ~'I - : ~~ t; (~ ------ ---------.~--~-._, -;----, 9 . ",.q 01' UIIVICI"ItU It'l O. 1111\11(1 ,I oalfOll"llIll.., "H~ Il,Wt"'flll' .....",l()y(l) Ill' ~I~'" U)lJh.;11 1;11 ...( f)IC"'l !.1I"~lrt I. t I ,,,"" UCF'\'l&OO (I.U) '"II" CU,\MPUB.&Ol fill'" OWCP'l500 FOIIII HRB-1500 1/1.,\ cl,U.... E l>L >I) LUlIE I~OO L ~ ltJ N h\ 1'1341 , ... ,'I 11~llj:;~ LU( ~ 101841 "1.111' II,L'll'~h~ I ~ I.,ij I d./f I' III'~ Ill\ I, II~II IWMU.U lIl')c ~ 111 l'/I~j D ~VIT~~~~;"'" _.0 ~j;~r~-~~-~:l~,~~ -... r~J ~ f~j.'iJ~~~ ~ ~~; . : _ r,r' ~~~r.!~ t~. h. __' ~ - r~rJ~?~~:.~~~:I.~~. :_-.m~1!J~-~ ~ .1' "'~l .. _ . ... ... .. ,ATllHrrMfpJfjsjJ l~ a~gIU!J~R) IHFO!lMFflfl ... _ . .. __ _.__ T Hl.rhl. ,,~\ll unl M1J1 h/lini.};'~ WM>>TU.'l.;.~ ; ~;1.1j'PI~lll ~)II I 'h"'JJ/J~ llw\ ,'Hl hr"r;I~\Th.Nl ~Hl!llIiiTlrij~ j-t.~M{/'~fu~'\~HP,~PI~Tn;,,;;~--'--- --. r'i1!Mnl,l!L J L 1. ~bbr.< lUNp(ih 6 ThHI .,..!] GJ ".'" i' ili-;i'lt h J. M h1.~,J..ldr,rti.MJi ~../j\ill;T iilr.rm--- 1 ti /, t';" e Ifj ~ 111, JOY PA I n~," t'l\:j..ITMmk:'~i,;;ji"iiJ -lht;:r,j ii" '.',-'.' '--7h~,i"ljiT,;ii"tN;~ti'j~iii'NTCiTlcnili.. hO, "'''''',h,"" ~lm:i'1'-p,"" r-mhHII,UII I~~\I~ . "t ~, h ~ il'lii-cn.--- ~~en~" h'U, ".. IJM 1, ,\",t;f.l\! "". .~\,~l, llll ~I~,-',II . "" I, I. "'111 r:l 0 I] [J l~lU;J)ll\h~l;-mi)li,- --- . ~.I'I,,1 ~ IhllllJlloIl..1 II~ 0 [l] hll .. h"II',1 "j'''O [J "",. ~~II'U 5..1J.'itlHllflJ.:..J1U_EJ. u: ()~' t L ~jlhllll"H1"ll4hijllu.hli'lnl~,u"'/I/o"'IIlI" 10'1.1111'1111 'i,.~, nlllln'I' "TiT"i:iiT.hll t,~tuull ~b~~ LUN~[R 51R[El In. JOY PA 1755;:' _~~~~~t~~~'~_'~__~_1.LZ__l:. tLl::.t!Ld~_ f" (1.,I4I'v."""'.llJll' ,..+- -~'-'B-~.i;'~i-D' . W:;;:kIU -.;a'ihfjicnTii~iiTt- ~1.11!. I .. u",IJ _ t 1'111'111 '...'I';;'I:'j.'ll...;;i,;-\ '" .'"''' ~'hIU'ii ',', .""hIO"'" .'HI1'1 htlllh. kll)"I.IIt~I\;II)"'J u_tlo" 1"JllllJhlnrj(JI~ fm FILE .___._~,___...!!.!!-1lL:"D..t:L~t:__ l~~~h'lJl,.,.t"'II~~__ PHYSICIAN OR SUPPLIER INFORMATION I l) IlliiiiiiTiiiilllW'Tiiiil'~Ji7kILJ;I".-]-lfl-;llf,.,\rG:;;r.;mili\;;;l',jiiij,'r--.... ifll"miflt' ",' "II' i'"F" , ,', "~ ,. "ti~'-';h'jj~ II L.lM" t IINI-'I l'lJhI"I<Llh ~'''''l ~'A ,,0-.1' ,,' , I' I " "J:'r.~I-~~"~~ ~~-,,~- --.---.-------- "-h'=': IIJSUIlAHCE FOIlM ) .,jIl I "' '.1, '... ~ ..c, ,Q"l U'h.'llll Il~'I'C'" " I.". "",.. was lulJlIllllud "llI..~I..'lJoNII '1t')N, ,t , "~H' ot IIUI" IhQ,.ltnICl~ftO""II'lk~;p h..I.~.j;t;~I~;;,ah(t, UP! '1" lJ96 7P4 J - N"f,~UJ: on-.1.~_IJl.) IO\I'~ r;IJ,It.illUd. IlCL ' (,RII,I~nl ".""" r"~h1 .h ~PP)lI"O'" J.CILlit~n.,I~ICli,;ri;j:r..fij";i)OTj;jj;Ti;ti;i;~i;rcjj(Jr.~r;___--- it \II~~ I~it)"s:r.il>>.~t'fl~ ,.rmt.mroimlt_ 101111 o",tll U It rl~o~i'Dt gtt~ti.hlU1;lili;ru~llll,~l)hQ~I. IQ "kQCllJ~llllh ulluwh b h HI I'" ht! hlJlI.r,rrrrT , ,DBB.BI LVME PJ5EAEE II c '~~~.ISjl ( , . pu, 01 ""~IH fI'tIhl IQ ..t/ll Of III1l)ICI II C lJ P , ", '1~..L~'ltvhu~u~~ U 1I11(H ell c,"n.II"I""(I., . IV lUpINe. r"~I': till ! V F'Cl.~ 10/:10/95 A~~lO EOlU t 11109/9f. ---1/:103/95 __lJflL ~". LI '" ~I')llc'.h () u I I'tIItl;lIlu;t;ijj1 jTifIiliitjinr ~ "lhl t' \,!"r/ ,'tlll"I'I' 'tHU''''U.l1 .irl.H",llil H"'H ", '111.11 ,.. ~" IHlll.I''' III lOll II~ l D~_. )(l lO.NII t.lX'H r.'1~I. ~,,) 6HAI~(jt~ e,Er, TENl Tell '''' 11/14/95 >> U),,""i.Til"'''H,r,OIJ'''hl) "' PhO (I'~fl..lt It1>I,1 '''88h'' .u 110 ~HII~lh~hh!h," ........ ....................................... f;"oOll "UI'IUIt""'tlJ" hI,) . 1l.~~1 "'I> (lj' .b' ultll" .. ~.~ l.h O~B.::l ~..~~~u , , Q' '" ,. " ,;,es. E l ~ ~I \1Jl , , , I nl,)~(~t 101011 , )1 ",.I,I(~rlj!-,ltIMp,t)u 'h,ljlH'I~I'''t lit) no .,~j,It( 011 IH:::. I N(, Ill!::/., TOTAL CARE ~6,1 tlun RO?1l ~;;;,-;;;;;;;o.."---'-- :/.1,~I,Etll ~\' Il.L!::, F'it, 19460.:i3~B f.t O~li l;"1: hi G/9J!i-:'!':'f':1.1 ~f'I'IIO~EO IlY ~J.lJ. (C,IJt~~ rCfln HCFA:115DO 0,14) <Jtj t.ll!lIOt bll'Y'{ l ("I!J ~()Hn CHAMPUB.ODf 156h~t3755 .., ~r. o. ""\II(,I """ t)Pt 0", Hlltotlll 0 II (.f;t,Jl <"1'1 Itll &~(.- 1I11H"." 1;:J tiltEr.I' , 1,1.,1,\ ... 'w~I:1E :40'~, r I Hill ,.,. I'i ,) " "llll>,1 LO( l lei e " I "1 t\IHIMljh~I,L III ",~ 11.1111 '(Jill ~ 1,I'1'1':'l;llI1IoNli~U IiI I;:" 1Il11.M'1 D~~~!.\le~=-=cr~;'z~!~;-, .~-~~lffl~::~~t ~ u;~ "'1'- ~J - ii~i,~f1i~~;~~ ~=-~~~'...~!~"" ~::.:r:iI:m\~ ...;:;;-..= IlI"llollhIWTmmIW""II hlfij-ol"liir"',I"'!^ rJlij~l,~M" ~,,,,~,~gl\l~~ft I f~R"jJ!R'"l ;mn;rmtilTl;Thl'mJjfffi""..,-- Alb!liti~~~j'l\tnl-Wg\~on,/Tij;Ii---'--'------' r'IlI,;Onllu,'-L .. L LJ..._,.._ r:ll\ffith-tMt~.~~HOOiO"Ih<IU"I.rr-' .:"'~'~' lUI',bl.l'\ i<l,j;L 1 "',' [J [iJ ""',' lhbl",~lt;'~ rl T, ,JOy "I, In,b~ l-'j,~'i,il;tTilllTT~l;"r,~Iii'IQ"lil\:iljii.'''- .,., f-I~~-;-;~IUT'ijTii);;Jlhi;jii'jr9liw~ it_hi. lJllllt.. tl}lI.1 hUI - ~b~b rUHLE~ GTREEl 111, JOI' PA 1755:! .--"~~~~".~LLL.b.~..1:rLM ';! II. (11.1I1-'\J."~lh"l)'" -----'-, T~T;;r~ .lil.'htIIO' "/l~lCl ".IIJI> I 1,),,11 l-J"'''''''''' , follolllll ;;-\ "-t"t;,, l ,.... 'I "I ""I'" "tI"; '. ",Il"'~' ,hi IU;" 'II ~ul'h, II ,elll "u.a lo( '.lll"llh' /"JlIHlI\lll,TION llN FILl:: "Qhlll ml~ATlIh:~ Ol'l F ILE .__~_.~___._.~.._{L.zl~'~19t'i l'~hljj,'hL'I"lUCIHlJ'lll;Ii'IIIJ"I"l.l."1 PfiYSICIAN OR SUPPLIER INFORMATION lllimUl 1'lrm;Tiii1T11i'm'oJ1-"-' ",,;;o,~=;;;;;\';iljii-,"rr<,'TT.;' """'"J;jt;n;lJiiTillr;;'-~1~ ".(;or,iliu,,,',,,,, ,,,"" __L'-::";"l, ',",i.A"",lh""l;,,,, '''.,,~~ rr-m~::\~~J~rm-- TDmn1l'i'illi"'lr.miiil..---- ---.---- 11iTa:mllli"Jilj;ffiilll. ,hO'" ~''''I''J''II nIL," 1II0010iJIIII I. "."'l D. "1'IIUll"qjij;;~" Q-II 1)11'111 "QUIt(' It ~ ~r;-.~,:r.II'. ~uth(t1U F- III N D tl8-ITf-- NI,~t~I:I~lfJM~IJ~farliimThJrmrnml~' LOUIS Gr, NGERI, !J(, t',Rltd~11 "V,,,'" ",,,"..,," ";'l"i;7H'''hl)~OON.~.C -'(IIIII~~nnl-;-i"rll:."'I.l;I"II.lI"IJII'111 1I11'.1.;1oll;"'iiCTti(f1--..----- ..i;ffiiliOJinoJii''I'Ic''.'''k'O... Ii )lJIJ1iOlTitrr-- till IIU,\I ''',,1. ",Ihl" '-S(14a_~._,,~_, f,l~I--I'ilIJ--' .,_D ". !l ~L'I'tt"'Il\"" '~IIII'IH~I. u~ Il '" 'l~t -. lI~HI,~ , \)tD'~"l\ ~ Ih~"'1t11J I. l"huIU~ ~hlJ l;lJ~lllll.lln ."''''IH.'' _.!1!jt'It'HIt II H'~l~" .ll!IIlTU11....'p tIlt ".,. 'IHoh'l hllhllllolhllllolll,1 IuD 0'''' . ~l~'I;1t11 o .....I<i 01111'111 )It n-rJ');l.Q~n'i1tllIDilCiTiiTr.lii'Ollir;jIJNi'M~t.IlI.0~'. TJ I'hCXlwllll" (~Tiil ~I JiTiiTrI~litT1T .. 'iTc 'O~-IJH.ll(lf :OBB.fll LYtlE [lISEI\EE l . hQ lI'~"~I. ""Ill '"88''' ". ItO '.lollttt'l.hhlhij " , IfJ~f ~ICll 0 1,/"111 0"'1 Q~ U"~I" 1J1.~Ytll~'~ '''IJU '" "' Ull~'ll I'.) _ IJ/G1/95 ; Gr: oe,~ , 3l 4 t~E II I II (I';/9f; r-./tt..IC' "H, r: : s I ~ l~ it p;.L :-,"n "tl o E,~ . ~, ~ 4 ALL liE II --- U"OIt ~1111II11I,'~lll.lh hO .. """... ".........."...................., t..~~.. . "II' ..ell' 11\-')' IlIJhJl " '" 2:10\)3-21 p , :tl~.-2 r~ I I ---.-- '.-..-- .-----. -----....'...--.-.,-,... --,-- __h ----, _____1._. I , ..- -------.----- .-..-- -----f-- .((I"I'hlr.h...it;i~r.~- (IJ''''I.I;tIlIII~li'\i'OI I I ---- ----1- --- I I -lrT~(II.l-1;j.-t----~Jl/" III "'JIJ""WI , :. ~Jfj :t ~1 I :~:::j5 \ C I'l "''';I.ii..,r,n.rliIWi~''T1IW>>tiii''iJ;;rii~N1-illl)flI~. 'II'O}{lt fI,hlllHI'l'hl ".) '''0 0'" --------1-- -.,-- ),; IIIL"I bll"h ~I!.'IJ"I I h'} SHARIHl '~EroTEI" TO! "''' I III r, I 't t, "'irTiiVomImmo;r"T7,o--------'-'----- I 56h::Lln5 , ",...r:1 o. ""v,rl '"U '''10' "'1~1(1 .i;;i~7;~i:~hl,7l;.O---. tlu...,"'" 'f/::, 111(, l'tIbU, ~'1 IH! r 1 HI"1l jll;';:.ji f~l.,...iil~-,~I.',j~<-+- ---, _._~_. 'I f) r: III tV Ill. E I I. A Ifl h. ::J 1 ,:1 ::' (i- I .: : : ,__ _.~__.!}j..:.:,{~~1 ,-:t.~ b t. --;j,j:j;mjOii~J:...ll.~iOil',I~ rill/II tiCFA.'600 (,..~) f,li ~IIJII."1 ',111\-11 1 I,'~l 11"11l CUAMPUS.601 lOTld. (f,Rf 1 'i4 ,,0 -3 ::Je f;lI111 OWCP,tlOO 1'",11I HRB,'&OO \1 1\0 l;iI~I',H' I"'" fillll E I A () (, U Tl'N I'" I 'f~4 I " ,,(,d,1 I.Ull ((11114 I "lhllt IML,"~hq UHHlliI; "-Ill"- ~11~I~Nl,1 ""~iIVt,j 1I,l.t....ltlllh\1 J:J "lb".~'-"""""'I-"'b"'''------' .. --!!1.~__1.....J_'IolIIJli:"(II"l)1 "r';llijJ;ll1t;.),j}7inltwn iJil l.hrlinliilir;jma..~ AlII "~\jl~~~~l~ '~';;.~- '. . -- r-:"--:;f.r.~-C-,- --_._.~' -r!~I~llilTi~k\l--~:ffj~~~::~:--- , 'il-'''' "iiltr1c'''li''liru'''oh ....__.,..,_...._f",..:.J.~_._.__ LJRHD,_ h __/!JJ!I1.!1 'J!f "n .r!9t(I'-nl"h'~"-"",,,,,,,,,-~---,- . nl~(tL;tj d"l'~!" I ,.,,,,;~ 1.- ~tll IIh, ,,11' ,.,." 1,"1, "'lIlh, lit".,., r.j\lijlo~.M\'~~X~~lq~~~rn-r;ilili--_..m_.. Pil i-2'\II",,~ .:....lc.L... :6~,t., L\I~IL'~I; SJ ,,~~ I .'il IJ [1.1".", j-;i1li1'I/f.~ ,l,t ~i,~ ~"L~t.~~.~\Uih;f;;;li;;/,r..'-,-"- I ~, U, ;. /J 'Ib t', NT, JOY PA I '/t)t'," --rrl,T jll'~ .,I,-.li~;\;'t II:" 'j'it,.;L",;j;, Tj- .n --. .--,.;l,i:,liW1 uli.),it'l;o' iIJ~ijJii),j~h~V1"iH1i.'l1i lfli 'hb",-- .!l!!.!:!'u"l"u ~Irm ~;'I~ ,(" " l-----pfiilJi1;J1m I II. '. . 1 I '" , I' 'i'~I~ITil-'-- l~erJ~.~.UMmr.r.,~ i('" u"' "" ..~\'"d ll" II~,,~I 'lUlL ,1"111 O''',~'''',b )M I''''] bJ D t:J 1t,~'*"Jl'I~I'p..Jllu'''OUIlIIIIO.'IHHllll" , /,,,11.11'1.1, l~ I'" tS.;i}:)I:""~.f,)nij./ .-- "ii~--;-hRl~Nii. 'llI)..iU7.TjjiTl"'"lJ'l\mn:r~~Jlj .:~t:L. IlJ/1lJEh 61R[I,1 liT, .JO'( r-/\ 1 n:~2 II.,".,..:"~,~~, ,. , .1JLh. ti. ~.:llil,1.1__ II. 1.1I...I'Il.t.I'IIlI>"'" '~~~~~~rB~~J~Ll'~~..'.l,_~::="'~= " 1'''1''''.'1 "'"I'I""'I'i\"l"I'" 'I'v","""'"'" III ,l'.'l ."l,,~ '.' ",,,11 'l'llll t.<. '. \I Ul'l~ ",1I11101',1 ZA TI 0/1 Dll F 11.1: !!illL.-2l~1!b.!!lEt_ .fJ.tl_f !,6.1:_._ ._.._._ ....,.. _ . ." ,__!:!!L.___~j_7...Lg.!:..!I~ ~__ ~~~l;:."lll ';11.,,111',11,,111 I"I.t.o:1,1 PHYSICIAN OR SUPP~'ER INFORMATION 'I.pm Of 1.iThTh~1 ,l+iYiiii....ii..l.l:i~;;iUiit-lll-1 "~-I 1"i.Ti ~'T ,7l:"I!"IJ 17,~1"j iilil L--"~' 'lrli"11i"Jitn;fI.,'iiiT;in"t .ll t'lifllii.uH "1ll.jl,U, 'nH~ 'hi ,111,1. ~ H'I ~'~ 'II" . lll+ II"''-,f,, 41~' ".11. II ~tle,r:l~~~~~- if""1i1h .:1 hHH lMIi.ial--~-- --_.-~"._--_. -- ..--- rrIl1~f.ItI;.liinj,~1I I n;Nfiiiiiim.,,,;;;;;;;:~..; ;~'Z~"~,,,-'-";'-"""'i,..;.L::'::~:~ lJ i- i" illi *ri'i,:;-"/j :J -'---~'l.11),ifm~SNil,'\'a"'I~;:': ,,., L nUl B (j H 1 II (j E R I, PO (, Iii b I ~ 01 ".,".. I .'",.."" .1 h~~. .hb .otlhl'~ IJIl1-t',lii"ll'I'j;i1oni'ii;ii:I.,.ThHNu';;i "iji"j M"iiT;.ilN".t! di.fiT,rr.-- ----------...- lI~t;:Iil:Th1ii M)l~ ~1"'I)Jumljl.jta 11)\.111 o.'KII ~ ~~Hhl ~ IIH,IdWII.1 II"D Glhll " .' ~ '11111 .,," C'] [,] ,',," P"U 1.I'~IIIj" ," 'JrT""ff~lJ\~Ellijl"r1.TliThln-cfiljj~lfif.1i-~lru';:;j~~I.I11'~,:, "i:ii~~i1~nilTfiiTiitTi;0;IimTIT .."- : 08B.1l1 LytlE DISEASE I I . ~ (. 1I1\'nifti1'i:ii1iii01.Li).;m;.ij'Tilnli11imrr....rl;~h' ,.l~r, ~ljhr"I':n, ~Il""if,' ~1~):'1.1 'i~m~"l tcr;. .I~I".'.I"'U!""'~I ~1"lh.l.I,"('''l'....~II''q.! -- HFE Tl-MI:::Hi/';E 1I1I 111:\1 S\'rdll..F~': .I'lln~,> ...~..._.__~.__..,,!!.E ~L t=-Rtl (M'f, __1._ 1I1\~1 1"1/0;195--' -;\41.i"(t'-'E)r sF"T;:',-Tfl"---- " . 1J.lt tl~ ~'I/H" 'HIIII .. 11/07/95 Il/n7/~1:i _...-1_" 11107/95 4 --- "'}.mo'- 4 '''88'' IH "I) I""'" '.";I'I',U,II''''1l ~ ~ ~ ~ .. .. ~ .. .. .. ~ .. . .. .. .. .. .. .. .. .. R .. . I'll"," .ljlltl;h,HIIll'" "'I , ~,'t.h',.'1I (.ail _ (J~~. I! l 'tl' '11,'110 It I ~ ~l jhl'- a' lIa U,~~I,jI~ ----r- , _---?O( <I~ ~ ~ ~ I I I'B( . --1,,- M1'.,O I , :!4( ~ p .--...".- --1-- -- Oh~, ~ J . lli'RG : ----t-- --.- P ~ p liE ~I AoiITo- iv"T\ilTiIC"'D1T:'sl;i::iJ' V i. ~ . ~ 1 TlON Etil IjE~1 ?, i,'IT0- liiITFirr:;;:;;;-.iTti---- 11,\" ,. ~1Li1arfr.or,ilHI"1 "i'hllo"WI~ l\j,W' t:,,~11 ,ll ..~o, SHAr~l1t~ CEF,T(tn rOI 1\1Ib. IlK. IJI~,/A "... 111I1>1't~' ~,I,.I t,UI'I J..l)f.,O 1r'ilij";l1iJitTHi:.,:"""j;j,,n;,;-'H -...---.--- - ---, --- '-.------ -~i-i~h:...rwi,,;i..II,-;ji-I;;I.. -". ':''/ t'J [. ,~ I ) .~l II. L E, F 1-. 1566~en;t; ~,l L', 1 ; .,' I b Illl 'i:i~..,'~,I,t, . ':1.~1 0' U'hKI ~"ntt;:aL"';lj",~~~'-oj;l(7l~lit.-(~h-II.i..',-;--~~ -"--;Mj;;:;\li'-li~ ;'1~~~:'\~I;';'~II'_.--- j~';;~~i-UC;:-A'7f500 (1.14) " III ~"I'-" "" In 01'''1 f.III.." I tin 11,1111 CttAMPU5.1501 II ill; 19~) Ti7lf7 1 9 ~) - 4 4 ""l"=iiliThH,t"'"'''''' T,;ft~l" ir."""'" 'f'IT"11 ;;;0,. 1l1'lit..Yillil., ,hl't Ill.: h, ".1 Ifl,"llh r..r "hfK~1 ~H'H In Ill" iil ~ ~"'Q. ""Iii'"'' III III III . ~_.'!!.m....._D'" .... ...."Ii tl;("ttft.JII'l J he L ____ .-1!.E;:t( {Jt~ ~ . Ell ~Il r~ ;' I I' "iiHi-i,I,n~-r---- It jj..,,'i;nr.a " ~I~,,(j Il'l , ...-- ,\_.._\ll 'Lri~~ '-;m;;.;; ];l;u, m.!J.1.-1.r~ II t::1. i\~~~"l,t"~th . IHH' Q 1M .W,,. n "~ UlIl, " P TOHL CARF 1946(l"'J:I:f~ f')1I1l OWCP.1600 "''''" RHII.' aDO 1:;0 bl1h L ~ (.,. d, ':jIJ 11 E 140(1 E) 1 nil " I' \. _ .. " ~ ... f" I.. '<,:.'\: IC'L ~ I I. LC I (0164 ) III "dhll,'lJH"'l '1~IWIC"t.l .1 'll (Ii """""'111 tni).jli.m ",\.......I~tl \"'1 U."i-;;.j;l..h.----m.;-lllIh",- -. -m-.L".W''li~' -----~-ll~~r..';;t.'---~-- -lli:"'I.("~I,t,,~~- llol,llll""lhlJl IlIljlk."IUIUI! I\I'-~~L"'"IJ, ,~" II,hIJ, .'hj_~hl . -----.----- - '-'--.-q,y- iHQ.l~,nJJl-'-r' ."!IDijwntm - - I1l);n.Hhl"r~'~llii.HI-Jih~)'h)'iJfij,TII"1 'h--;II"~ Ii ~ i ~jR;fhl~Rlt~ 1)-i!l@ , l"AH-R. Wlll'~lhh'J """h"Wl"ll.ll.ll~I"II..I. l~hJ,M~,t~IJlilq~qP.trn"iHI'._.----- nllR,L,.II-.U.;:.._L...:'L._- i"1mtlf.I,.,J,,~~&f.1Urlt.~'"'1 ....-- ~t,f.l' l.\JtIll:i. fj1hEE1 .", 0 Gl ".", 15iJl.<llnB In. JOY FA 11B~'~ t III u"..ll 11'" II .. .." Ii (J . l I~, I-" .-.,. .ij}. [~ P. II ~hlll,j"'P"'WhlJllll'hU[(n'ttll).'IWhl/Il" l'tj~"LhlhlJ '1 b '~~ --1....1 l'fHI"~Hh llil"Nir'H"'h hf .n'timiltfi ttl 11_\'~u 10~. ;-;:i;t.j":".I;;iTii lJ lI"':hil~lll."'IIIH ,Ll".. (11I.#oI",;.r..lHlll - t~en t' "#oW, tIlHI). , . 1;&1"-, ';;"LJII)j 11.."1 t.1 Uil)' , · ,,,,'",,,.,,,,,,.,,,, ::b5l< LUMtJEfi 6TREE1 '.. 0 GJ. Iou 11T. JOY PI, 1755:1 ._._'~~,"'IJ'" "~-1-1L~.3..::1!D..4.1-._ I'. LI.tWI'\l.."'llt~II' ---, "io;]-~Jl''''''''''.n;;;cr- Ut'~~ I livl. L.J..'..... I ~1I1~11I "llt~G~,~*~l~l~IM;I,t,r.tJII,~~,: ~L'~::!J'I~~nvll;,!;~j!mEll~';lt~ I u~,~, h'l ~I ~ tM" "I....' ~ ;;::;:;.- lfTi~~~;tbl~'~~~~'~ ~ ~J ~t~:~~1 nl U1/IJPu u.'~'J'~N"1 iI- AuHWfdZATJON ON FILE ~'!'~_._li LCttJA.TJ.!.EE-.,lllLEJ.LE -_._.__~!J.7...!.!lb.L2L ,." ,,,,,,,,., L"",v'''''''''''''''''''', PHYSICIAN OR SUPPLIER INFORMATION iT1imor-- ~~ II: ri~~~r...,,~~l:J~~IW'''. "f.111~,,~~:1o;r.;i'lii.,;N~"'jJ- -I. ~,~n'~7~\;:tUti~f,~Lf~I~11l"11' r..ltiili,,,ji1.1;J;ri,,Pljj;hwn,_....-- fliii,iiJ;JD. IJhl)o,ol'..iriL" ...~w" htN. b" 'IU t~#oIW hOl " h~'III.1 '~IIJ o o ~1t'1" 11-'Il1tTr'lllill1Tllrrlo - 1\-1irURfTJmCUiiiiili- -----.--~ iJ'iTiiiJ~I"'i)';'_II'lllt fillull" I) "~,,_ ~-~--'-~- ~!~~~-----"-~",__._J~ I, hthll Or ""1""1"0 '"1''''''''0" ell'l" "VUII(II., l'uPI'( "Iu lit tGIIt'., UP I t, II U.., S 7 It ;j _4.011 Hi r'I,UtlG.!' fiLLIJll.lm_..~I;Jj 1I.:.,I.2DI.L~---- II htNr.hU.OO; ~'(J"1"Cl;':h ""I)lt IJI~llI 1I,I;I"lll",1..;;Jklto..",.t.hI IHI....,.,'11 II'"O\JQII I"i ., "'IC" dl~ I ,,,( 1-. (...."0.. trl"li"1:Qi;U\in1i;aruJTOT~\lJI ;;;;U~I toPlfii:'r.ihiX~~II),."1 'II (lJl"W~ b II~ to,",li.r"7fhI,,WIII". I , ~ . 1(.1)110 "IlJ ..- I , OBIl.61 l.YME OltoU.bE IMIlI "'88'" , hWtl~I'I'h"'hG III "0 I .. .................................-........, . ..,~ltJ" ..- . " ( IvW (, "":tw" 1l"'''' ...",., ."um'.. ~~"".hO"',O It ilt~I.I.h_ 1l.!tIJ' UIf)I{I hhl 1.1 ,...lln~lItHII t I..', Ill.. -- 'JlIJW .. '" ,11~1.'It U""'Y'I U"~IC'" Q~ (.'"'...WU."LI ~ Il"l>~~'" ("t\(," '" . ' -- lllluq , ., _I- if.1 "hill Ila 11/07/95 AI. 61 J II Ii ~tjL TUN,X 06~, ~ I . 4 tIEl,' .., ~'rl'~(I 4/ p -- . -, 11/07/';5 ~'Ud() liS lM'\L ~ E~ I ~,l . - -L tJEW ~;6C' -1 P 11/07/'15 ;4610 I/Et:I1LE MI(;IOU,TfI "''',- 06~, P.I .." . _i tI.UL _t'40 , P ------- t-06~,[j1 1I/07/9b f,"!! I 0 liE E OL E WI~IO('A'rH ~'4 ~ , 4 tlEI~ :'7 (, I P 11/07/'1';, ,;4tlO I V firM:T It T (,~~ ,~) , 4 Nnl 7120 I P 11/07/9~ ~-- Ao\~lO IIEF'U, III 10\1,' I rll. (if,E I .: I . 4 tiEW I 3 [:o'()(; .i3 P 1rf:~",'v'l ~' ~"l~"\" ." r..\I;",'''''"'':'b1,'',~'ll''I~,1 " '((\r-.tt.'lO"Wl\II"C'IIIohhll"l " Ie _I C.l"~~' I" ,.hlWlt,,. III I" '''l''''t.:IOUI "I llt'l I II' t 'I' "&llto .. t!!r.1fI'Ult II' ~ II~ HI... I.. I,,., 'l..fIItIOH 10; , I 377 " Ill' Iii _"D," ~..u,.. ""I 111"1 I :'; 7 ) '7 U "'R;;J 0"" " ~wfi~"~'~I.Jt:f"Ib7i... ,...n.OI"l""",'''Uol. _00111" 'I"WIlI 'i'tl;iiit.l;(~'1 C,,"j;;llh'j -...'-- 611ARCW GERTfJlllnl Oi!~ I I NC, LJ/[;/A TOTAL CARE l}!1 11/1IJ/~j':., IfJ." 1l\J T T ROM) twiiHli'i"li.cj->>,,\'d i;,)- .. ,;","i "'. ":'"llI ~ II' too. - -.--.. .. "IIF.NI X 'J II.LE, P,\ 19460"3338 " 'II hI: 15bb~(\75~, ;:.ll;::"l :','i til 0 193~;-::~Jl:b -------.,..-- - .-- --. --~'--~._~-'.._~- _. .--.--- .~'-'_._-------,- ------ ,0",,11111 r; lit I -. 0 '~~II lI'.(IO'I411~O 0"'" 0... 'I 'OV Q U o ,. "'''I I ul ""~KI ,hlJ It II '1' "Ii~" I 11 0 . I r.ClI.1 . I.'" . ,,' Ill' ~ Ill....".. HI'lll,..,.I'} I" ""'-#01111'''',11 (,r, UIIJlr....' MII-..ull;'bj " )j, .. Ilu~ II . , Li)~ II I Ii I ~f, I llll" i,dh,r. \iVIIE 1400 UllIN , , "I, \, 'I :14 t "Ij..lllllt,~lJ"""'l [1,.1J''',lj_ I' Ill,,. II j~',IJ'III."""'W Uv." Hl\h~'1 D ~,i~i'.',I, :':,-.:-n ::J,~f'~L "., '.~irm;~~~~ ;;:~.:-=- ~n~ I,'.'~,'n" ,--mir"I1.,1ij'mnowI;.,I1;'.i ilt,.r;h'loj~~ !H ilij~~!rJ!,J?,'1\~~I~g8 I! i-li~..~h~,~IHlJ01qW/.lhnf.;;n.--."--.' n,rf:k.l,. ,.!l~Lt2__ i:mn~~J;,~ ~li~iM!.,~RRr~mromvl~~- 'I.'~[' LU~IIiU, iiI RH I .'" [] GJ ".", I t'i61:;.o/ln~, NT, JOY p,~ 17ti5~ 1101 !I....,l! "..,.. ~",,,. \.'g'"~'-"it~ ~,. 'fr1k' ij} Q D Ii 1It101l''llll'I~''''JIUl_''Il(lj)''''b.llwhml'' " .., I ' , ' -.J.-l UHlI,It'lUI rl ~ I 1I111IillilLW-- ir ~~ lr;;;r;-)'<ll, ,;.llJJ- I) - il;i.tl;i:fu" -.tl:hiii"iiiiilIlI'.1l L1",. t,,,tlillll ila.lln 1~,,~rJ'~H _hl,Hl;i.l ~ "t.jlll, '1111')1111"' '" 0 "'JI1~ntrl._I;(h"~_~YlJ-,.;-t"'lir- l-,hti.1iTuTIlit:ll'''''o ,t;I~/)jlOlJ"h.W, h"flt"[I~II~"1l1 -- 111'I'tH,,/tl'IU .1.iij.TiTot~;,. I,~en~,"hi""'h · ~bL& LUN~&R STREET Mr. ,}[JY fA 175'),,' 11~!!,~~!:~I.!...'~-__J_1Li.JW=lU!..1~___ · '11'1..'" II, l,jI.W~"N""'iI" .",,, 0 [-J .;1"111 '-_.'h'--r '"'iCiil,-r-ur;:j;j;;i7Jl-.liiT.liiOH'lilli'l- . "_I". I Ill/II L-J"'" I ",I'''ilJ 'if 1"'1 "'~-iF'i"\t)~il~ .~.~~' ~'If~I.~'~l tl1~hf'1iij""tt'''~ --------.....-..--.------ -'i,.\"..t'h'1 .uHI"\.rrWlllI':H '" "I'll 'II iihtr"l'iiiiJL-~ ,.," "n..., 0" ",'1[',,'1 '" I ""li~H'" '''','''\,.. "".,..'"""......" ,,, ,,,', ,""" , """.,,'I"~. '. U",,,,. UfliU~IIWI"I.'''.Il,'..flbhttUI' !oJ I .u)tIH "~"'''N"ljl'IL'" . '1 CIl'll liar IL ,.,U II ',~, j ON F E [j} .., ~!L.~,fi!ifl.\!BL.Q!L.ElbI_._.________.!'!!.!_Jl1.!...I!Ii1'!. '5 . ""'1.,,"....'1"'" """""!!!""'''''_. PttV5ICIA~OR 5UPPLII!R INFOIltM)'ION ''''" ;r;Iiim.m;;;,;or,;;;;:r.-I,n" 'r:;;;ffiffii11ii,,,;;r.;.'io;r- ';0";;1'1" "tt"'P'''1 co ._t I "it'c~~r4ti~'it(I'INI'\ . (.;h "II]" ._ht'l~ Illh '0 ''''ll 1 ~111"~II' n-mrnTi1hrlilIIQ 1iIi"'nOlll/l"T1ii1liiiir,-- --------.- iJ1ijTjiiml~lii(iijlih ' Jii 11..11" 16 WOII~ HtllN 1"'''1,)'''''' 11'11'" !llItU)UlJ!I I' Mull). ill.IIlIlIhO,,"..i(,~"I,)IlIlI"llIlOufl{l j'~ Mi~;;i:'i"ii'r;;-;u'~c~flm lI9S" ~ 3 ~ r,gtJ.lfflflJJIT'JIi~~;'lj';'h0I141~1 LOlliS r.rnIIGEr,!, no r,r<Ul:JO! ".'",, '0"'.".",. 'il'1;i."N1"hu-;;&ltnffi[,;"';i-r....,illliil-.H:.IHThllioTIi-;;rl)i'i:IM m~.. ~ll;"ijjnii.r;--.' -~------- Trii}.~'1iOlirnilirllW"~Tlfi5ll'l b w",/JI H)oi~ i.l" Illt iT1m11iJ '.. t \"l"'iffi!'- "J:L ," Jr1,1~1~V'Jn~t,nWiT~!ill~j;;il~li"llTr;r~ijj;t~o~"7101~,,N~E...~m~I'i;li~Nilm-n. ~ OIHl.1l1 LnlE OlGEA5E I ~~~. I""ct '''88"" I" IlIJ '~"'I' 1'1 ~hh'h", ~--,,----'- --I' lJU,l.f "loll'll I-I~q 'kiJw 1<) ~I~::,q , ........:rnJ;;ll">t:,mi,m....m:;;oI,mr..'H.in,;n;;ro- liJ~h"t."'.'IO Ilfll ih'., liUi ..s-',Tr.."- 1lil~IYrl"llj(; .1 ~I'I ~'tl lIhlllo"h" IIIk..'Io~" t'"u,WU"M.IIo. ,; 4 b I " II E p,..~, l tI I ,j ill' , ~: L I Ii /'I L .--.'!..... --.---- .-~L6.L 'I~ w "'",UM 'ul/'I.,.""...."hO ~~~.~....... ...~....~.~...._-.~, .--- --.-- (Jb~. ~ I ._~ , , --f- t , ---.--,- --~.._-~ ------ -.---,+- .-- I , ..------- .-.-- -f- --- ""~~"11o , "Il' \j"111o II I ~. .I~"" '"i"T707 I 9l) " I;'~a:~~l ~'. . . ''LL p--. -.---.. --- -I- I , W.,illl,01ii>>'l-t- ~JoI m .. H~"Fi'IkiT. , -. '1'-i'I,,111~9~ ".___1... 'll---1!,.Q.G II ~t:r.'I~:~'~IlLt'II'r.:; Io" 'lH'Ij''')U''''~W' ,.1)1)11 "1'0,11, ~lll~UI:'lll~W';::~1.1 E'/fi~~I!'til~'Irm:~~~Ii~'~ll.f.~ ,...... III -~7inH~.ih.;1hl tlll)~r~ti;jT.r- f~t,UL~tl~IlD"1 IotH)1 lot' M 1"111' r, '. -I ll"'''IohItlIl,~11 ~H~I ___._'''[',J,.,. [J":, lI.\l''''''"I"._'~r',Ii,llh'l SHARON ('Er'l 011 j' (II .". 1111 b I 'I~'. V~'I"II_CO:N'i;lhii----.- .. 1566~A75f, . ""'.:11)l1I"~'(' ~',D 111"1" UI'~IO.ll;';IL;-W;:j;;;!.-;j.,-;-~----'- "11ot~1Uo' . tl.~;.~ r~L~ 'l I ""I'j"I"'llIlh ,.,.....11)1)"1:11 I," '''11;11,''1 1I ",II 1 '.ltrJ ilII~, IW:. IUlUA rCJl'f..L eM," ',to; 1;'.J1I H1MJ ',J l.\i r " I x V II L E, r~ f., 1 '/4 I> (I" :n:j fJ i: Ill/I;:.: ~', - .::~Ill h i;;;;,i',jcFA7iaoo 1...4) ""III CItAMPU5,aOI '.'1"' il',~,'~ I wi 1;:1j il'.j:i,,-, \' i ~ \ L11" 1,1. ~ I'L,'. Ii\) 1 11: 14,10 F' r II" '. , "'I :. L I 1.1I~ I 10 11l~' r, A I" J 4 \ 1'1 Jl1/1 IIILl,/t1JI,rl 1I M~ IIJ"W It~. (~ ""'tll~h' IU)JI~~ U. (~" 1M 11M'! '1"'""1 ':f1i.:;~"~I:u~- ---, ''''''''w.j!f.'i~:~,----n-~;~l\i\;-;;:'-'''--''~i'' -i'l'~,7r;'--~--';li;P"'''.-''-=rnll'li'~"", ".. - .1...J-'--..--.--L..L---l'~-rrnHn ' ' "Iii c--IIDJ"nBlqj ----- --- '1-m.i.I'I..W;'-,'lhJIWr"lmlil.,J,~n;~;i" T r;u1ftV.,~1RII 11 ' ,.1 R R '" ~ mliiJI1hi'il11'lill'U.rW>Ji;TOr.;foffi'---- 'm.r~'~LL-" '.! - ,J.l. :L.".__ l"i\Wnth.l.HI~~~~w.lt,RR~..rmnml.rr-- G]"0'" I e.bb ~'~ 'ltHl rt~jnJltMilh11J1Ili~,qHll'"'70"n-.------ -,.. 2 b~, [. L UI'i [, E Ii d Trd: UI """ [J NT, JOY fA I n~2 lia....ll i'fii"'iii..r.i;r\irlhLJiljU"'-' - 1-~TbTlir.N'htnijTn-HW;lmnllrml"'lililf"hirl--- O"g".'r, I"LlJlllf,llal~"'I.u'U."UllHllilll'llhlhlll'" l'!~~,!I. 11_11 "i--;-i;i~,liiii HIll 11fJThTITt':ri.rriT1" ltjllll ..-- .. II lI'ltl~1 I 1"111 llltl" ""',,''"'' M" "l'.i.1mflA" r.l n n D .~n,. j"~'''''ztL .l/~ l1D';l, ,~!I"i; ~.t.m;)~f.1Ji-'- .ir~Chi):\~'I.l1jj tt-.- t.~Ctl~"'"~I" ~ "" I H ~b)lIl:.IlIl'" I"~I il'lll....hll ~ ".1,."" .1"'1'111I"'11'11 , "'0 [iJ"1 :6~~ LUN~ER STREET Nt. JUY PA 17Ue2 -_.'~"I":!~~_"".---1J.LUJ.::fO ~ 'J . ~ hl",lltl Iq LI'~"~_.rvll"').' ~r' 'I ""ii: ~~"''''f,lr~ ...,,~ ....,1M~rl "'-llr.>'i l"f";;-~---":~~'~=~'--~~~':~ - '~:I~~-l~JL,j :'~:~::\':~I ::::' :::-I'~r~:::;~:::',,~:m-- '" ,'.', " '\" '''' ,b'.., ",1'."""'1 II... r" "/'1'" \1"0 <I,,, "h..'" ",.,,,, ,,' .".""", , ..."... II ~"o. 1,;' QI))jtl "','" . If fl' 1110111 b W."I COli"" I ....1'0 q'~ . l~II'" II "Idll'l I I,VTIIUr, lArlDN 011 FILE ~l)_.-fililll~J.!!li.f.-..!.ltLE..llE____ 1..I'---D..'l...:.....~!J;.L5~_~ '1411 UI'IIa.<JII'lIlJII'lIltoI,IIo1IIJ111i1lOI'I1 _ _ fHVSICIANOR SUPPLIER,IWORMATION II bI"OI m ,=r.;;i!o%""'."-r""! I ;;..n:;;;&;;1jlJ;w 0 ,,,.- i)"'r,'ffi;IkI"tl""Uill'1lr~m.-. ,"', "''''''1.,,'' "'0. n;,;""", .,.;,.'A'I". """,..-.""".. I ""'l~ IrwJUm:r.wno-- , 1IQJTojIj, 1<,"1,,,.. '" mnrno.n INSURANCE FORM --- '"'o______.__..___~""Wl., ~~t'im wu lubm"',~ '. hlloI'lJfIlUI"'llI"J,.n.IiK.I."lJlIlJh,I..'....,II{II.'I'\.~Il("'.II"...I"OI urwl"IA nr.;::'143 "1'~";IIHljH I" ',I '/./ LOlll1i (lRIN!',Elll' O(L (,r-lld~(,'1 ""'''I. 0/1,' " ,. h~lot. '1IP"lXIll~l~l'I..i1iIl.tM:lCi~i~;;;~OJiiJTT'(11 U ~..~ I~..mm,..., 11_ ~.. "' l~~J1;J1UlfN"ii'i'hlli"UilitNlrlTmf lJI"OhO.,. II) ..r.1iCTbvll' '1'1 'tllw"''' b ~t 1I1,,"I1;lT1;ijlijfliriTT - '[I~~U~f , :088,81 L\'NEDISU.SE l , 110 OI.IIQ" ''''01 '''88''. ". hO , .U'~ t '.''''hUII~ II . .' e ~~~~.~'I c , ~.lll.V~b,th Ufh'ClHAM , .tl' II l ..~ ~J.h~ C.II &, ""u" Ht,t' lie" . ,""v I. ""~ (10'\" " &lllt'll .,,,.. I'H'I~'hlll'l'.luH.lh)lll.l-"i;'"I."..,t.l.hl.'.1 (~ ) 1.1"'1. '., 1110;;'95 :=OLLOh \/r' Ill'" S I /1(,. vI ()f.6.~1 A !i T tiE I P - ""'1;" 'VlhQ".UltchhO ................... .........................., , , --I , . 1-' ~'"U .",t h; UTI "'0 , ___t.~,~~rtl__I_.D hI) tel UIIJ""')('.~IIl,thl} . 1011 ':10 il ~r.r8i~.,~~t.l1"~I;lh lW ~oo . 00 00 ,'" SH"': Oil (,EI\' t 1111 \ II ,.." I I /:30 / 9 ~, ~,1Tr'" , J.(.f..lJvhl hI) l56b:!875'5 'I'\~r., 01 ""WICI ,"'.11 n"ll)' ..,,;~"j";I;l";;-;;Ji~-;j;;l;;I"I;--' "llUII" ~,: (<"'r I . _._----,-,_. .,.-------- 1-I'/'llli\iIO It~ ....,. (f,"1,1'11 1111 ',lflilJ.., 1,lh"'IlIIl,ln IIlL, 11/(, D/b/A I; ,1 1;1,) II foOPIi W,Utll X '.'lI.l,E, F f, 16,,,, ~ 1 () " I; :! ~'j - ~' IT, I; h f'jIlIlIiCfA.'DOO II,U) h.lIll CIIAMPUS,DOI HITPl. ':P.R~ )'-~t;;'-,~-liH..it'-I~-"I'i,;i'-" -.-' 194f.()"J33S FOlln owep, noo fOlm RRII-1S00 'Ul'l"'~ 'f11i'f/l'lMIiN'~ 'WUIIIIO !IIM U'WU IlUWIlIlO IU,nO' 1/ UlOllll'YH . 'IIIN 'HI'O "UI~IO MYl I) " .1 , ~ - ~. l.tl ... ~.. ,;J I""lI tj; /.... ~'" ',' ''I:,) \: i~ 'I b ".... )~ --0'0 ~Z ~! :.I:: ) ~ . II- ,,!~ ....... II. ,... 1~~ 1" ~\II iN ,J,,~ ' , l.'2 ;Jffi ~ rl, ,"i "''''''l . ~ .. d ~ ~ ~ '" '... , r{ ~ ~ ~~'.~ I, I I. . " ... ~ 'I I. r I , " . ,. ., ,~.. - , . tll,IN, NI.;Jf, & IIAI:I'ln:cIIT IlY: IlUrllln N~II, 1':"'IUlru 11J,!/1I1I1~lIl1l1n Nil, 11:t'IH ~lIlillulh Chlll'~h lilr.'ul W.sl eh."I.r, I'A III:tHU (OIO)IiI/1l,:tU:1ll AT'I'OIlNI';Y 1"011: 1'llIlnllll' --- 1IIIIi, INC, IIlhlll TOTAl. (~AII/': 11114 Nlllllhlllll, I'h'lOnlxylllu, PA 1".HIll 1'IIIIII1Irr IN 'I'm: (:OUII'I'Ofo'I'IlMMIlN PI,":M Ys. 1~l/Mlllmt.ANI) COUNTY, 1'I':NNHYI.vANIA Nil (WII. AC'I'llIN . I.AW 1,;r.IMlmTIIOI)I)O 8~1 W.rlr.ylllu lI'lIlIl, '-;111,111, I'A I)urondllnl COMELAJ1ft I, 'I'h. JlIIIIIllllrlR III1H, In~. Iltl,/lI '1'111111 ('IIt1' with ,,111~" 1I1'1I"oll1"KK 1'11'111",111111',.1 Nullllllilll, I'ho.lllxy\lI., l'onluylvl1l1ll1. ~, Tho II.I'.IlIll1l1tl" Io:llwllOlh ("hlll, I1n I1dultlll"lvlllul1l whll ""8"h'8 lit H:ll W,'rl1.YIIIIIIlIIIIII, 1~1I011l, CUlllhorlllll" Coullly, l'ulll18ylvIII1111, :t, Frolll 011 or nhoul Odllh.r ll, 1111111 thl'lluuh N"\'IItIIllI'r 1,1. 1111111, I1tll", r~'III."tllr I.ouls Orlllllorl, 1),0" pllllllWr Ilrovlllull 10 II,,'i'llIllInl 1111'111"111 8I,,,pll"8, I1nllhlllll~" IInll IlIlrHllIU ""ryle"H 1I11h. 1I1ll0S, uf'lh. kll1dR, Illlho 'llll1nllllu", ,ilr th. "rl"1'6 111111 ,I111'6UIIIIlIll Ih~ Ii'r1l16 6"t rllrth 1111110 ~opl." or Involc.H nllnch.d h.r.IAl, 1111111. II pllrt h..r.lI1' iIl11lllll1rk"II I':xhlhlt "A", 4, Thu nroro811ltl m,'.lIcnl 8up"II"R 1I11111111l1hl011c6 11'<'t. '11'11 <<,11111111111 n"'r~hllnlllhl" 'lulIlIly 1111.1 wore lhoRo ord.I'.d, 'I'h. II.r.Il11l1nl n'cl'lv"II 111111 lI"cl'pll'" 011111 "II'dk,,1 Kllpplll," 111111111111hlollc". II, Tho nr"r.811111 lIurslnl! ""rvkI!6 11"r~ p"rlilrtll,.II 111 II UII",llIn" wllrklllllllllk~ mllllll.r. 0. 'I'h. Ilrlc.H d.r.II1111111 WII" chllrlll.II 11'''rU rlllr 111101 r"110111111111" 1111" "'uti' II", prl~I'6 IIl!li'11I1111111lllll nllr.od In pny. 7. Fromllm. to limo, Jlll1ll1l1ffhll. 6"l1tlo ,I..r,,""""t 61111"11I"111. r,'I1""111l1/ 11 hllll1m'l' 01"" pllllllllfr 111 tho Rum or$18,aOO.Il0whlrh 811111 HllltollHllo II,'li'llIlllnt n'n'lv,'" wlthllllt prllll'Ktth,'r..to, 8, Allhoullh d.mnlld hll" b....1I 11I1111. hy pllllllllll' UpOIl II,'li',"lnntlrl JlIlY th" 811111111' $IA,:lIlll.I\Il, lh. c1er.ndn"l hnl rllll.d nnd r.ru..d 10 !lilY /III or I1ny pllrlll1l'n"Ir. WlIlm~;FOHE, plninlllf dOl11nn.le Judl!lII.nlllunln6t ",.r"II,lllnt In Ih,. "nnlll' $IA,:WO.lIll10u.lh.r wllh lho CURlA of'lhlR /lcllon. Ol.IN, NEil. & "^l.'I'IlI';Cll'I' By: f.. , /lllrllin N"II, J':''1"lr.. Atlortll'Y rur 1'IIIInlllf Notll'C!l 'n'l! Oml'l! or Olin, N.II & IInlh'('cht IN lI11l'1l1111lnlf hI ,~,II('l'ln r1l!htlUlIl/lny Inrlll'll1ulllln ohllllnl!ll will bl! IIIIOd ~r tJlllt Iml1)11llC, , ' , ' , "I II '.\,1" 'I,' " ,dt. . 1'1.,1'1 ,1.t"hPlq ll~ 11'1101' ,,"I' t, 'II'," '1111 I II, ~,"II'tI,I' ~ 1111'/,\, ]:riiJi/;!;i.'J,:,,;' .,.'[::r:~i.v:i.~i,~:;:-.-Ll'~\'Il~t,~.,,:' '''lil'\;M{L--'' "-r:rV,lt'iiim..---n:rU\'.I,:.;-;;;-;:;::-- ~ "n'ij~;; :;~;.;~;;~'~~; 1,"ir~;'~~~~"I:;ni~tA11P,[f1i 7~~K~~g;,l ~,~l Qlilp'g ftl TIlf9,"M!lWl&f~~l~;=~'k;~UJ-.~~'~"== ,I 1;"('1.1" "1.'1/, I I ,'" I' '" 1'1 I ,II-I" ;,"1,11 j'-m~"1l'lI'[~lln1~llnnl'lnfTl;nm>TI-- -- nIl P,I\, 1- ~- ,..- - -. --,." I 'i'lI'il'l.l~lln;ri-;Ir1"',",lPlJ'ffllmlfJmn;t;"'n.T--- ":,, ;~)Ii,~" t'~lft.i "~IIL~] []Il""1 ,1,_, '~"~I I ~ 1, J 1'1 \' U I "~'~'; i'I'~n'iill';'.l ~I;;',;i ;"j'jj-".hf,;i,j il'-'-' . ,- .. -ltit~ilifrjiL~l);,l,'"lriilrl-.rJiT;j}1aUrlillrtlTirii#iiilj till 11'."11 ,It,d, 1,1111" "",."" ,," ',' I; t,.:"." tIll ____ _J'" .. Ll . I]__[J ; ." .' 'I'" m;lhTIToi:iL' .nr,1i:lmmT7.lT",r.'\""j",I "iI'ltr"'J~"'I' :!r,Il,d:, ~~'Ulj ,~w. ~ III .M,J.I.~'~Ii" l~.l'li(~ ',ill );hIlI'" ..1.1, lot. , ,. '.111,1"'11,,,,,.,.,,1 'II [J 0" '~d'" 111I""1111'" IWhl,I'" '''11 Hhl~UHIil '''''11)1.'' Itl-'IIII"IH, ',i-,I;1.7,j.jijl 'l.j.l,lrr.n~n17:'ii1T'11 ,,~ U)j,ll !.!."~1L-....._~.!.~~! '_~". '~_~I :~~~. _,~::' ~.o--':..!.!l___.____.__.____,_~!.!.!._~! ?:~~!.~~~_ l'~' Il"',l""~ I< ',"~I... ,ltl" II "I "I,~____ PH.Y6l~I~N OR 6LJPp.LleR INFOIlMAIION TlIil1rnr--~"\iO;rf"l"al'Tl1m;,."~,,,,;i", I ,rrmn;:;;;-",ji;',o'1i..';;" ---- iJI''T,mr.IIi;n-,~r,lror,m- Jtrnm~" co ., t II:flih'l,I~ #..1'..1".11{ .. ~fI: . hI "',II t.l""'~ .1 "I ~l; oli ,l;illl.i ij'H U,II. lit I" It IJ'lilll;1"lil"rili,llr- ;\Imfil!nlJTJ.n~,rr- -- '-"_-.0__- -....----.-. nl1i"n).lar;}l'jjiilli~fi hi h..,.~ l~ l'I'Jfl, 'Iu,," "'''u'''I'' 'hi hi 11'"'I,llltl ir,;r.;rnr~r'ij,ji,;;;qil.im-"'O~.)tlllll"O\llll"t' Pvlh'(I'I,rl;r~IMI, ~\} I I t' i\I--rcrnliii(t\li I J &,)110 ~ '11 ~IHJh"'~1 'H J h--r;:-~' 't.: 1,l;i:~~hliUfj')"I:"'~ LCli,/l ~j r"~,l N;,E f- I, r..f, I:~h ~.~ , 3< 1 H....,IIIU Ill'LU'~hIoIU lIhrwnj~OIJiijj;,linrl-,ii'I')--'I.rN1.1;.;.{n"'IIT"I:iJiTjll'i1""Ol';j1ijj;rl;T.'"I.;1JI-;:l.ijlT,lij'-~-'-------- l~1ti1ir.milij~~ii~TI1;m/hiTtI)-.j'ij';f:l )Olllll;",(l' .. t ',l l. V tllH: 1', Ii Iii f E 1 1'01, ,'0\ f'A ,'II,H:" --',I_I!~~~, ~~ _":!~_h_.l_l?_. to fJ ~t .. ,I i: 'I , II ."'111,1 Iq 1".W~"tollh'IlI" '''''' ["J C"] ',.,," .._..........~..,..,rD;;;:O';O;;1-i;.1T.[Om\l...... ~. __ .I"h.~ I lI~h I ~1""11I "r~p,,} ~!I.t"J~~I':t ":'~':'~-)-I~ ~~::j.;'~~~:I-;';:~~::-- ij---ir.Vt~t~ril.tttiim'~ ~ ~ ::,,~It l:.1 ,~rt.lJlI~ll'ar:IOh'O 1",rlt'l~lI'" 1,,'(lHL'll'" ,t..,I,~ ,r.'."'lll;I\' ~/,'I 'nil (:1. "ILF II~~ P'" l"~I.Io' . ~ru~lU"~"11i:"AIOTiill,ll"'I' 'hllJlI~ toll)Intrm1,jf1i57~'iil"lMirl" flll"IIh 11,lllmi1rr.rr'h.."Hirllnn --- .. - '''" "' - 1 . r G" " . ~ ~ : ' " ~ ,,' 1 t. II', F. II J . E '. : f IHUI '''88"" 'U~IlIlU''''hli II. hlJ ~ . . - .. ....~~...~..~.....~..~.., , ''''.It 'lJ~~I,~WfJ.f7'~r1J.-f~1iIT;1Ttl~~:rr.:rr--- ~"'Itl,,,,,.htl" hO ,..---;--_. " , ---._. 1'lIhl"."I< 1"llfJIl.ltt)lq h~ll l; 'LIiIU I hi' ,..'. .. +. 'hUIoi " If ~G"M.Y\'''''''''''''Jl ,llh.""'''..loi~, ,,".'q.,,/I('Ii....wll."'I. l"l.olol,tt __ l"'~',I\ h h' f I tl~'lJ f-."'~", I,h," 1111 --- .l../l:tl/,,:,t., - 1', .;ht :r:~' ----r-- ._" .1..'10......', \, IJt~.~~i I I h', I!E I: I (l(h~1 .:. I p , lIl...'''' "~ .- ..1,1 ,- ~ I J .~' " ,. . , '.. t,. ~'. .. ' I , . 1;1;... ..1:t.'{I'~J6 I ~ f. " ~ D I '\J9 I '/~ rrr II\ht:&f ~1 i., ~. I T1: (I (:: 11.1 --t-- I ~ I.EI, ,.,/(J I P I--~~ III I V~,I / 1 t . m: F.l"liC";rrr::-----.- f-.-r---n -I ,J t:.. ~'_ .. \~ , 4 II ~.: t"Jt,.1 :, f' I ~II II .. , ~ :-:-r~.(, t -- --- --t-- - t'\.,:, :.l , 11)1; :i I 'r F , li1' I, J,~I.:'G I ~ J I, , ~ .:' - -r J '. . ", . '" ,1.\" ", . I ~; ( , ~ .,.., , 'I [ 1.(: I, ll.: .'. :, r ~jiiffi~nn';;f~,.T,"I' TJ"f.!.l1}u.;rfWi\'I'W''''l .\ ~ "r"',~H:'h~I"""IO''''''h' I '"'' "'~hr.-~III-'" "'BI, I ~ :~"h." "",. 'tllllhlllt"U 'III"~I t' ..1 '"'lI1l I' ~I"~ HI,.III (, '''''11..\',,1, H'" 11I11 'H.". "'lJl. ", It I III 'I ''It)I',6 k 't,(:/ I, .1,1,C],__D,,_,,:.... ......--;;;;'iPm.-.~~i .,U'lJlltlIlOu~"U" 'OOfll~a. NUJlJl ,--'. ~"lo tlll""lJ"I hI' ,h I. I '. ,. 1 tI r" t" ~ , ,.., E. rt;'" f. It (~ EXHIBIT " A " I U( .. I) il i~, "It;- , lOT ',L ':r.,hf: pI-II 1(:, , " I 1,11 T rW?,D 1r-.ii,iiO;'io';lhll "'1....,,',...10,,,1.; . , .._--, 1".'[-11 J r, '.' /, L [ , r ;, I Ii 4 i.'j -:l :'::J E. l ~lJ ti~' t '.,1',1. " ",100 ~J I .... I 9 ~~ '~-, - ~' ~. f~ : ' , , __ ,_.___1-..,________.. FOlIO OWCP,1500 ~ ""...el o. IIh~IU ."u 1111 t,I LI t1~u-'-'.lli L I (1,l;U <1" t"l .",. ~"I'IIO\illllll .l...,. (',11I,(1\ FGIIIl HCFA,1500 11.141 l ItUtl.h~. till t,llllll,.l MIt\-'111 ftl . '.. ~ I r ~: II ~ ' I' I 1',1, I, I ,~Il <' d.. I. . " , ' II .. I . I, .'~ ' H..lh"fl"I,~.,ll \lj'lIllMI "".11" ' 'Jill'" ,11,1, '.- ',1' 1'1 f',l\' ~)-,,-,' ~lil;~~~"~;;I'" .-'. 14 'f.Nt:~\'iij:I:;"- .. .", 'L']' '~\7t,~~~~ ',"" ,+-. r~"\;';~ft:-'" '~'4+_~-1j:l~1~r;-i~i;i;---.' "'~'.f1;ii;~''''11 .~-:::-- '::7"'"1--'.:-:::-111 :l~': WI .~:'~::--.~A"ffUffAN 1JN~UI Rji~-rl~9ii1fm~lIDHI'Q1i' . rIQiT-T"::--':-n':I::-l1:~~r::-l"""r'::=~": 1 It. , It .""'111 ,,'" "j,~ h'HI.;,jJltIIIJljli~f;< ~f", {.(tfh... ~:r;ln . .It~.' ,.i;Jli II~J It,,,, ,I,. "~'" ""II.UI ,,,1,,,,/ 1:1.1:"lll \,1,1,', ,1\" I',' nl"\,~};:~II:rjl'(' ., '}i:lij"lrn6all.',1Hjnni1nmr1Inj)J4~"--'''~'--- )"Hl,lr,n) ," .-.....- ~ .,....uo...~ r-WWff.C,nthv 1'mrri;'Jmli1)lfir;h('j~ID11--" '.l~,1 l.l'l'~~t" ~11,"(j ,m'l] CD """'11 1~1,;t...t/L~j "', ,lilY ~" J nf: r i H,j~' -nnll~itlt~ij;"l'lir~j',;'IIIJ'--- rn;ltr.Im.-~"iNfhlfj:rnwn1:rWbTilf rnrfo'loI1;j)j-- 111'''111,,,, "I) ~ 1;/ t. t.:I"" 1.01 . "'",,,,!li';;oIT,:JilhF7r,;/mr.tmmur..rr.-:r.;\"""I""___ <, ~~~'I ~ hH.inhll '..11..... i,1I J~x.M~TL.-,i'wfli,~"1 ~~~l~ ~l;i r lI,' ""'''I' (""U I,IUI" ... L :l~ ~ Q r.;J 0 '''''u'''II'.I''~IIJIIII'hl.llli~I'''II'I'uhlHl'' "1~lhj'H" -' '-.- ..-_~ --- ~ U.l,T"I''''1) .NII" II l"hl-fij" 11.IH . . (, I ,1TiT"'f;l'lijTiL 'll;h'U EJ~tlt,T~L...9'1 f;ILE ..t~,r; l,I,lt:l'f.f G I I,!! 1'. 1 liT. JOY PI, ..___~..:.~I.'~~..__._.u.U.1~:tE.Q. ! .. ""1.1'" ". IIl'H""..I'tJItLLJII' "" r--J [J ,,'''I' - _,_"nB;'I;;rD;;':;;i;7~-'io1r.Ui"T1T~;;(j'-' L- __ "~I",,, I ._ 1.\11 I 1-11''''11 ""~'l llliir .'1"'11"'1 -,-.-.---.-.---.-- i"i--I,,,',;r""1 t""'lh .1' H"1\,IC.t"fii:-I',1 p Uhllr..~-- Ii," I ""1/>0>1/'''',,\''. < "".."",,,,.,,,,,, "., ,",'<'" """, ,," ,,,,,,,",, ,,,",,,,,, II., ,",," ."" ,,,,,",,,,,,,,,. h'J'ChOi\IZ/,T/OII nl~ FIl.E ~ 1'~.,,,,ll'IoII'1 '.111,,,1 IHO Q]"'J 17nt'i:i 'I r"'I"'Q';X'''o''tl~iil'i1~1".ml ~. .\1 I'W.'tlllt "hI II 'hi Lllt"H', I) I,I'QIltlllloll' "'h"" ""l" ..IIUI ~" " ~ "'""'l'm,,~.l''' I" ",,'''nm~~m. '. -~T'niil"rt "t~ I'"~ "t J:::.n' 11,'Il'il()1I11 "'/0 111101 '101"1,(;,, rr-llfTl"l;,l~lonln-lij-' irID1JT'UlQTlT'Jj;ffijj; ) . .....--- 'HIli 1111' 'lI,L1 ~ I.' llU" hi""" 11.11110 1'1011/1 n-f.11;fi~..1:~~ -- --------- 'Iou".. -j'-,--1~~.~T1Tl-.I.'"r..'.-..~- IIHilol 4111JolJU411 -"riJilI1r;"lf[orml~,mfiOn", -- I' ,.."', CI /11'1/0",'.1) '''Il''''h 011 011"" !ovuMIII' f ,."lrlll." II lit 'lolhCl, J.' , I' "t. J ~ :! '(ll'" '~'/ 1...10 el, , LOU I u 'jR 111l,E" I , DO (,:,161 :":11 U..W1IHu 1.,'.1I""",10 " /o~...l ''''II ~jjohimjl~.;i;-(~jll..w~jji:]1j;;jl;r.:rn~('1itii;-{;- n--.rrt'iTjiiJ;lTcMI MIl....'Io'fllW}bIN1Io,IIIIQl.JIlll'Jil...--- lrryjlo~"j)r'rn'j;1TijJir"U ,ii"hltiiIJ.I"/t,1l1 "ll.III)~...II':"tL to ~"Ut.lb.../ol '" lC.I..i1htmmjol"""~11 , I,.r"'~"'m , Ie,'..' - I : '~6.hl I:YME DlSEA~E '","Ill '''88''. 111,..,,,,'''1,,,,.. I" ioU . ........... -......................... ......, . ,"'..,. rU~I'Clll.r',.Jl"pfffi~~ ~th,,~rm.j,w~- ",It",,,,,,,IILJ""lJ II " '" - -- itilJ';,,,,.hjl - . It ~~ I d,. jJ".""',.""LI l,o 1o'~"IU', h,. '''''.1, , '''m.. '. .., lCl~I,I"I"''::', ,'Ih "11 Ithul'.U LI ",'~l. C~f ''''-',U~I~I'(II, lI'I(~~lliH J"'~LlI' 'j~~. . ' """(I ,.. ll'l \' ': I 'it :' -.------- , " - ,. I , . '~ . ",I, .!-,. .. 1.1.,:... 1:::1 , 4 /In: ~,~(I ~. FJ lll,' ~ "r, 'ft " "" . ,~ ,,~! '.~,~\J~r J~. \.. ~ .; . -I- , " , 4 m0\F1" t. E ~~ /J~ ;00 F 1 ,'I (jlr.. ~:'; - tJ-'t t I t' "'" J 1:.: , .:l , I 4 fI~ I~ 14';0 I f' TV/vir I 'I~ f. ~. c ~ \.1 ,),1 Hl r,~rll [I t:. ~ . .~ 1 - I 4 I; E ~I IU:O " f' - I (J' ,..." I .., ~. ;: I,,~. '.1 \) to (d ;: ~ . ,. '. ~ I .' " , ',I rill '. ~' I,; I , . T I 01'1 f~: r "Efl 1 7 /:',0 14 P , ItJ:\.'.,7"':fr ~,~ c , I,f ,. ~ .Ll ,:11 ..J~. i: . ;: j - .. J I , tiEl :~,." 14 F' n-r:~Uli[[f,"lkll.j.;;-IJ"-t.Jf.t "l'~(lUlJl'l~ ~1,ajlll'I.J (.11 K He. ~,I .~~~'~m~r.'~lJl' IU,IIIIlI " ,/;ffi"',,,,,,, -+--, n ,.,"'.. ..., .1" ......" 1 ""I /l'lL"tI, 0'1[11'''1'''' II, "~'! I"'JO ", ~ MH .~hllt,; H~'IoI' "'IJIIt,1 ~h' , "I" II~~" ,,. IIHil. ~~"I "'''1 I "l. {f", I "Ir. '1- ". ~ .. I '.. "toD ~ 1 """r~~'-"lt~I'fM. ~"~'OIlIiMl)u"h~""TWo1iiU'Tl'7.~ " :..._ ~hl.;II'''(,.I,,,t.; 'i"tiM'~'1 Ul\~~", SHi'hlJl, CUdE"; 1:'11 1H ~ I II':. I)/n/f~ Il,HL ,:AhE IJ'" IO,'~; 1 i 9~, '. t i. I ~ II 'f 7 r.: n tolJ iriUtj""'mh1T~(-w.i;;"h;l-------------- ll-Io',~;;ifj;j;;;:"'I';;j;'h'l:-'4"------- IIWIII)'.'!I :, E, ~' ~ 1 9 H (I - 3 :; :U; I ~b6~1l'/~::', ~. . :. .:1: I :. ' - ! '0"1, " 1 (J / ''::I~; <:5tJt:. -_._-_._---_.-.-,~,_._- ..-- ._,-" .---------- U,I. (}'/ 1'~lf.i lr~' 1o'''',II""l.,,'''IIt;'''l,IIH;IO' --PHV6ICiANOR 6upiiL'iEA l~flMATlON U~___ :I~:U.O' ""~K;I ""tI 1."10' t1llw,(I,1 il' f (t;l,Ilb 1:11 '''I II" ~ HH""Il1Utlo'lA-tl)IJ.,(l\ 1",IIll,fl,.' t.lh\,q t,tJ "'''111 HCF....1&OO (1014) '011" CU...MPU6.&Ol \to ~,,:,I,I,L l"'..~ ~;u"r~ 1~IHi I: ..11", P,\ I t, J4 : j " I ..' ,. ~' II oJ , I. I I. ii, I I (1 I C 4 I "1 hItIlM~/I~"" <1"-,1.1 IIMI ll,j'l (~ "11\1\....11 rUI),jIWJ Lll I).. " III I'J.II D-iii 'I" '"" ------,""4IiI";r.~;;_--- ..lltlI11UIiI h~1 ~'hll.:"'il hlJl "n.liiI'l ".l'iilil\',U'-I"llmlliiliiiil""r..f, 1::1.17 Ar,n" OlJrJU nUlliilTIf>llliJml,jH"1i11l1l10;n;jfjj :hb~ L~N~Lh bJ~E~1 ';.'w;;;;r---. ""r,>;'--MHmi;U;ii;i;O =m ul,,\, .~";'i;~,J., .....1 rHo IllhUl .""1 ' II,,, .,,,,.,. ""1 -- QJiIDllrflEQB - -~ , h ~Il HI' ~ .! \ ,...~ h~"'Timf'h1Vrl'AU "hi' tlililiiTill-;r'JlI ,il I (I" ~ 1::I.IIAI'UII lllHIO . - r,l1Tiirnt..-- - '---'iiIlifl'EiTlir.1i'1mi1'j,omlITo',rmli1i6\TThIiJiil.n-- 'HII l:J [!..J Illoth. 1 ~d'lCJ ..:.1: " t1t:J M I I ,HJY hIll C ti .: "Tj:'iTflilTJilil\io'mi:riit,t;}7Jijo'-- i-,miJb~ iJhlN~ I,U 1{l"IlI11~'''hH,j1 oIlHI;-.ll.ilol 100. I.H"'I"h~U '/l:' hf.<~"'4L'1J1 I" I" "" t~ '";J I i~ >>) I H-'- j t~e'rif. · ""r.tf,l,,,~l~m.miifm.. ;'l.,~\.\liiT' ll" "'''1''1I ~ld,H I,h'II' 'iiiqJtfii1i;)gll-~nil J;J~_LJ (p' ~~Ib ''''UI4U,l I~ IHhlJllO ~hl,lLlJ~IIIII,l"'HhIJIUI 101 '"~ III t'I~11 ,iO-;jhlll II , ~I)/j Il ,~It'Hlllh ~1~I'i 'j~ J.l,iilll ~6~8 LUnDER BT~EET 11T. JDY PA 1755:: ",,,,,",,,". 71" 653-4601 ["~II''\III....}..btJ,ll. - 1l~-' uvll "11"'10 " HIII,I. j1_~.UIIIIIII 11.0 [I] tou " h~,LI,,1 ",.. [] [J "",,. ""h":lIon~1 "<.1"111_ S J GU^ TlJl,1I O.~~.~J). t: _~,________---!:!!L~ I (I Ii I r/~ l,r,I,II11lllbllllllJl.lI"ultHIIIlIIIII',Ioi>t)fll PtlY5LOIA.N OR 5UPPLI~R INFORMATION 'I IU.ll 01 tI1l~~M~ l~r!,rml ~1~.~I--] ,r~tll~rr(M I' hl, I I (il-,U:/ h:i.-lj;r---- -il~,1.nrilll ~rt~'lU 1,...~~',lc)~tllllHI. rr-urnm3~J,ll\'ni)-. irb1.1Tf011<5lliii;\liil-;ri---' ---- ---- -~ - -...----. li__"IHi.llrllll~l-ll~~~i7L"ifi-" '''ulI 11111,0.)"'<.111 "It)W J'I.IIOtNII ~l)'''.''M'lhO,ltIlI'lm''C)IIQINiii7);ill~~lilij;-;'"''CII l1Ti1'-T7,.I. IJ""7,," " 1l.llltll4~Il'I.llhHI'iIOli\WI'IU'H,.,lItl"I)I~' vrll"t ,~. ~:., .t~jI'HII'n~"u, LDlJlS (,RIt~Cl:RI, UIJ (,FnoI301 ...,,,,, .'""'",,. ~, hHI."hb"oOlllb'U;I~(lllltl'll.I;..t.'jfi;"iITiiiTIii'ijjij~I~II'H,tUJlIlliliUitlLl1 U l'I)\,,,ItoIl.tc'ulllJiinniJjiliw oou , ,O~IlCH.lctl . l).~..t,,-~'l \ ~_ _~Ill_ '...', "1 'r oJ....,.... I 13~,"O -I- , 3~O I P 1--- , 5"10 :: p 1-- , lj(,l)O 10 rJ Il H (1I~..;r--t "~IIOUh ,1.11 " "I"hl: .)lll , - I ,: '.:0 l ;', I:' ~ IJ o'I"-;;,'iiii(,;;-.;,.,,-"~i-;lfil-'hiWiiQiiiJijjOj";.HDj)(iilTi';"i,,(;')iir- ~I.t. rl.' ~'H..h 101.1 II .1~~Q2~"Jt ~WTJi~~ Illhlt\--rrn;~II"1 ,,[i1lt 0l~11"t)~'1 111 Hu)(IIJVlIl'h .(:11,....'111) "nl"lh(1 ""NIiI1tl:TTT 'OUJ,61 LYME DISEASE '.. I II , 11"1. 01 U"~lq .Iluw , IJ I ',1'1,' ';::i ..r,,"q "'~ ~'IIIIt.. '. II"'. ~'I, l.I',,,,",h tl "~>l' ~ "",-,,,, ',hlLI""q t; ... -;:-r:1i-rr------- ~ tiE ~/ J U I ~I 'f" ';::' - ',J I.~' , U 4 /lEI, rr:rrcr-7\lrr:rTCTIrr:7G'- -oml tiEl, ~ " 'Il,r.:;-':iq 1-, .: ~ l. -\I[ E . r, f IIEII IO/O'lI'1~ 4 .. IJI,~I~ ,I." 4 l\.,l/U1/\Y\j- t.,,, t-.: I'J ,'V1i I 1-.1\, I,ll \.J t,;~ I L: 4 1:1::" I \J 1.,1, " If::' ,~~bblr,~ r,(,E I C. l.. to tJ ~ t. hit, L " 11[01 ~:-:IT ~~~i.' H"I' hI "' H~'H ""hUI".;"'I\' nlc~I''''IoII~ (I,l,..~ ()h. I, .,1 H ~I 11l,[:J 0'''' _.._...._. -0_- __..__ )Q ,null'-"",. "r",,,,, II') SflM\Otl ,'"f!' JELl 1:11 u"'. 1 0 ,':J I/'ib -u'-iWli~~lt."l J"~i.{j">iiltl'hi,-'--'O'- 0 1~bb..!87~i~ , "'"q Q' U"~fq "fill' In. (If HH~I{iM;c.orH-~;;-I-;:jI~';-;--" huh"", D,UJ C"~lUilb , 't1Ill1 '''a8''. 'l. hO I ~""I I', ~"II'~<.I ~ - . . .. .. ~ . . .. ~ .. .. .. .. .. .. - .. ""'UII ""lliUI,,~I'lJh hI) /,tlb '" ""lIb II I ,,~. ~I~"" ,,' ,.. :in P , I.~q .'J '1- , 14" 0 -1-- P ';! p 'Ii' . I")'!~I i.ii'l ij'ij'i. ;11' ,;;, iH6, ll~':, ()i~;II' TOTI-,L UJiE 1,4 1/II'fT "O/lD IIIJHnX\lII.l.E, Ft., l'i'.160-::I:ie ,I. ,,1, t, 1 \j/ fj :J~~" ~'~;oh :;0' ~ () : 'f 1 ~ ... i "1-!'I.Oyln IJ\ ,.,~. c.lilJt.r;ll l,fj ~lllll."l '~I "'.Ii I Ij,IlJ .. I I t~ II J I \ ~ i.. !',l"ol r I ~ \':' 1'1 'IW. I . j.,. 'I- Ill, I' I If., ~ 'I 'J ~ : ~ I; I, U, ~ , Hhlllll,t.,I'M.', q '''It ,HI , If, I /I, ,11',1'1','''.1111.,. I lIil' 'II ~~:~~~~I;:;;~.~I':~~;'~:~~m P:t~~~~RJ~,~]'~;~iWri)~)~~~~Jitlp~,:;~~~~~~~~~,"~~:~:"L ~~~ f'I.liIoH'.THOL'P(' "1'( ',I" i'11'Hllliiii',IIJ r.Im;ITlnllHm';il~llni1nmm,m;,~-""-_.~-- 1"',11;11, 11 ..- ~--",. .".....-.~". l-il\i1f.P'i1t~U"bj,',,"T""lll'lii1'fl1n\1'\1'1';litr.r.....-'-- .:Lbl' I.UI'I~~I. ;,II'~lr I ..., I:] C:J ".", Ibhl,:,i!'itl:1 111, ,JIlY 1'1\ I n~~ ,-"r;r:, 'Iii nmliGi;Tl;",j; ~'~'i~Jlijii-.-'-' n;r.j,JiJljTQtiUiijih~ 'j;jniliTliiJ'i;~w'rnlU'n1'iirtb I 1I1.,....."IhlJ II '/ c t',:J -'I 0: r: I ~"...rIJI''''h~'..~IL''"I1;nr\l1i! . I' l,l1Toil1m--- ~~nK;'.N~' IH ll~~~"ill~1I:1 HNI;~h'.llh"I" II" u~;o II 111,,11 I,IHIII ""1 LJ ' ''J-LI lrllt~rtri1;..71.I" >>1i111lihr ' II I, l~' ~' t I '.J O. IM',1o! III~ 1~'III'lll'hj)L, u,U'IU U ."'hulltI "1'1"11'1." l"Io"j'IIU;llli"ll,.W'jlll,lt U,ul1;j'(1)ljll ,I;t;~ Um~'f.l, !i'tl:cl:l hi I ,Ill \' PA I 715~,2 __,~.~~~~~_~Lj_.....J1I_.EJ!':I _:-~~~_ II. In',,,I'IlUI'--'ItPjIH, '-_.._..,-~- '..,f,~j"t'J' .-"I7iM!-'miliJJ,ilfii\m- 101, I u~ I I l,lt _ I 1'1111'111 1If!i:J,:,iJ,,~h,tVI'tll I I Sflt:lltl,~ii):~n[~W"IMJli1Vnit '" II:;'\'\-;-;,';t~;, ~~,,;;':;~:,;:;-.~- ii-'if.if::tr-4l 'L~'ii.fonirJ1;liii:NmEI ::r.:":,I:\~~'UhTil'- Lf"Ju""hNt"~ .'HIII "111' ,.i I "'1"111 bitft '''1 Ii " I to;"1) .~, 'I'f\ HI"ihH " 1.;1'i ,~~I III n f-: I ~' h 1'1 Clfl u" F I L I~ Ii I GtlArlJr;1' U!WLf. ---'~ys'ofAffo--~~lp-tiII7 "(/"~~9Rt Tlb1r~""'<""""""""'''.'' ____ \11iI11., ~ "'"1'/'1"'" "iilH., ," ,,,,.Y C!'''il'fI'' ~J;L;;,1~~r.,~ 'I 'TIIl""I"t "110\'.' ',----"f11TjQUTE[, - "",. I ,....,.",,,,,,.,, ,.,,",:~" ........", .c'""", .'" "". I ",n"l! 1rJil1mf:l':1~..rlii- 'i\Ii.mononmrm',fj--- . --------- t.,iTulrt,q IN8UIlMIC/: FO ' - H.uW ll"~l.l'".lll, 011..101 WOII b nM I~ ""11_ 0' 1I1I.IIM,!) "nl~ICI~" 1),.ull"II'''OIl;lIt I.~ '.'ltllll,n"iTil~111i.1''''--UPTTriTl-;-;;-;;:T:r-. iv'1"t'N,mt ~ IJ., mlllu" LC,'.JIS C,RI'jGl'RI, Gn (.rdcl~,"l "..",," QilJ-2J,.; '1 h~"'. ;ItD~oo".hu. .-'~'lll. rt"IPim;j(I~"I"lJl'llrl" I;h'llilnHijil~TlJi"iiiTfl.r;---_._-- Tfliii.fi1lj(iI. -_ to Hhp,l ~ I "'"... I WII,' IHD OJ hll II '!I,qht ,." L-] [J ""I' ~IUh~f) ,.ell '" n-n;;n",~];J;l'Efloi'T;jml~~~"""""""'O"""h'''li'l;;~ ~.~~.. "., "6'00' I . D!:~_~~I~._ , II'Ll/I '''88"" II., 1>0 "WII t '1..",,1,1) .. .. .. - ~ ... .. .. - . . . . . .. .. . .. .. .. . - ~ f II . 1l".0' "H)lLI '""'" I (j / 0'; I "ti to 'I1"'iiiim:rrlitfJ:rij\.JrtwTiiinnTloW~f"i[ I~,q l,Ih"I.lllb'..s,rj..~li,l;"i.4'II'jl..'" I. 0' )l; ., l"'."n'il,t. LlII.~ 11'1t1 --l- ~~I'I."'I\"'U~"H~I"~~~~~~, 1:1,: __. 7..:,,1, n.m.T'Tl'\7:J Inl. {J!.'-I~l 4 'j~~' I'h,I,1I 'LjIlILh,tlln""t'IU Tt;/v'i/'f!."""" I- ~ ~ i (; 1.1(. l".\...I. ,,1;'h -r----..' , (,41,\1\ 14 IIllHllh.lh" lit I'i. , , i ~.I I.,~. \,. .l tlEh --r---7- 'J~,~, It, F 1 vlO' I 'it: ~ 1It>l fJ " ~ I .. i u~::: , 6t:(; ----.1- \1 I ti'll::O 4 P ---.- ,-",-1- --.- F ., ~ liE I'; I , '-- ---+- - to 1""""1.' r" j[,'I't"i, "'I' t,n;;;~i.I~T;llI.n;;;;"" '''lh'''~lIihlli 11~.,'iil'l (' IoHI'!i 1"'~lJhTlil~hIHI.I ~"ht lu Hll 1\\ ~"P. I "~l/I' ..~, IIPII. I m-nrn;i;i;ihtTi;I'7,i7Jii:r.w " LI "jib O"'III,'i:.'II'~,~~, --I , I rm11lu;"ijiT;r'-'!-- li-iWi,Uh II ~'ili;fr'j);iJ '-fi;;j--_!';' :~" ~.~ T''';.--L.I~nJ,;-~~(j 'I :::rl~:t~WI~I,l.ll '101: ,,~.11oI/ 111I\ll' MW, -'UII "" r.IlIl III'D 0'" __..,,"'u .,._, ___ It:. II;"," .'1< '~I tI (vlo" t ilL SHM,OII U:r. 7[1;:~: f' .." I 0 I:! 11 ~:, ~m1ifhl. ",:wuhTi.o--.-...-----.--.-..--- 156b:!S7~~ . 'J.HIII' ""~IC' -'hD 'HI C, '" ,,~~(i;iOL7Uiiii"i7j;,l.',Jij;;.;--'-~'- ,.. ...~~ ~ I (, ~ 'j . ~ . I IIIE-, II;,' j.,'L /10 rnHI. ':/.hf, '.1' ,I "'.' T I I;()~.n I' t', E /I ~ r 'Ill I. f, I' I I? H 0 - 3 'T :E! 'I. 11'1 t.; I (, I '; :. ~ ," ~'~'j t. t. )'li,'i,;~rloll;;,ii;."j i:-,;,t->-- -------_.~_. .,..------ ..- ~H'IIlJY'IlIH #otJ-' '-Oljl,f.ll ljlt "'11/11#01 Ult~lll I'"! I~';;;'HCF,(.UOO 11.141 , , "" CIMMPU6.&OI '11.0 ~IiLf\EL h.'dl l\\JITF. 140C E I Hill ,. II ", \.'...;. I,., J I'.,~ 1'1 ~ 4 I HuL~1 LOCI (0 I li4) D rJ,'I!~"~I-';-',"-" J.....,~liUl.:it~-;'---._.-Ln'~~f;i..L;.~:-._.-L1.-11r.:f~" ~ r,'&I,,,,,r;;;r-~\,.\~,.... ..., ----. .....L_-"---IIDIfAHlr -U/ib s!)IffclfilIiIl1illr---- -W..J!. 1J}.1ijl,rnilWJi;~inlijn,"j,rhlijr)ii1)hij.,it;~j.~A P..jtijRTIII~'iI~~"'-O... '~lJJ Wt-~fiim~~. 1II11l"'llhltl.I;---- t'l,IlAI'EIIl npJ)f) (ll I (". 1 ,.", jil I J"r'(:IH noon r+.m~'I-ITJtiriti\.llhnlO;''''f;1nt~ll__,;'-(I)j;I,--'--.-- r-nl;JI, rtt'r-I--,- __lUJ.___.._. r1~WtlC.'''ItTlntl''lii.t3ll1immr~~IhIi"Jfil~ ~'b5[' LlJNl;Eli iiTRHr "'" [J [!]"",,, ltiIJbnn5 "IHlh.MIJf\IMl ClIIl,thllU IU'~\~ ..II\IUltlll'l.,)..jl,.....lhl,).,~ lit ll.h\1 HT, JOY ~A 17~~~ ~1l1 1I'V.... ll"llj ""'110 O~..l..I:,~i "7 ""j I (" Jirl 0- !;LD ''''II''IU1l.WhQIII.IJMH':UIINl.lhlWtPJII'' ;1'F'~:'''l) ~ t, ..., 6Jk' 1,,"~llIl'I.11 " l~Tf"'" , '\"lnrr;t~ijj'1;)n~liT'T "'\""~\ -" ..1IT.t7'''',,,:;1Tllo -;;-;;;-''''''''''''''''''''''''''''''1'''''", _ ~~nN"M, _""'HIII .'. ,i1li1'Ji'KI'SflHllfll:h,. ~I~ HI . .. '. , """,,,,.,,,,,,,,, ~blH' LlJI1IJER 6TnEET ", 0 m ,,,' NT. JOY PA 1755~' --'-'~~'~:.'~__LlUfiJL:liO I II,. 1.""I,lI'V~ 'POhMllll _....~-.-.r.- -"~(~D'.~ -..~~ lHllll I __ Il",lt I "111"",) 'I rl~'I,,'JM\t.V'I\j'ltIP tl',\:""',~~IW,~:lifii:m:I'-II~:J,';g'~n:o ;;:-'~\-I" , ,~;:-;,;:~;~';::;:-- "~f,~l:~'~r~bt~~~~r,I~: .\'Jtm<~ tH.l' ':~lIo:.~~,::,,"," u I)O~U'''h11 "', .)11,,1. '111'1 1l1b Ul'llllf biiT~'Il'f " /I I ~IUH(ll..r. .U,..I>I<I ,I fill L~ ,l, U Tit 0 I~ 1 ~ A T ION 0 NFL L E 5rGN/~TUr~E O~I FILE 1,"11 ()7/(16/<;~, b,\ihllll"lbv"II)~/I"u'm)III'lll'lllbCltl - '-PHYiiiciAtfOR -6UPPLI~RiNFO-RMATION II tlUI O. II I 1tIi1"'jiiiiTI11 III T).iliillolJ 1)11 InilJllt--~i';:Tti":i'lTi.:I;hi.~liio-I'o.;-;nil;;r- l,.ct,5f,i~fifli ,,,.tlh~hCt ,IWI"I __L_~I;hlolfO" irmlI7flilltmTnrr-- '"iiVl1trornn:r"fi"iP.i"'liir-- ----..--,-- " IihtJtI" IihouJ"1I "UJW ~"IO<jli" '"l-W 1llllo-IC)Il I~ h.WI O~ ftUlklllhl1 "lnhiC..', 0'11)11'1" t,OI,jItCl I. P ""~ll( 1"-.II;;-;r.lIll~lf I' t. It'll 'l.' ':- "14 'J ~ TO l 0 '10 1'1 .11 #< '1l1l)1~ \.: ,~ 1 -' T '- , l'O~ .11/.'10" U" I LOUIS GR1Ni.ERI, no I;I::161:iOI ,..'"" II;;,,,,"',, ,. hANI""li';DffiiITio;m~'i;rri;;(I"'I"OiI"II"~ ollllk t"AIt l'll",ta.-LfT;i.~-'-'------ '~O..ltl/lt "'Oil" "iiiTiiliIol i)Jij;'lllIOUII ol'tt:at tl~ 0,,0 (".hl,/I~ :,,' ;1~':~J~;n":~:~;,~m;;li~'~':~~f;m"oL"'O"'O<I"""""'."'.1'''''''''''1.".""., III II ',",ul In8D"' ~.hll~'''l.hh.hG In OhO .. .. .. . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. , . ~~r;~L'U'.hl,)h hO ". wTIn-#<III:h~ir.n7tlh'iUiijr-- .-;;a:iilolliiiiTlO:Jh1i lull QIlOlJ' h.l.I, lJll '11:"1:~.lij IjQI- ~ Jll 'l.I..1 _,II..; Ll [J 0,;'1'11' !'Gh'l.l "..,Hu' I'."I'h lloH.'lIlT , '"r.m'i"~ -~ " . llAlI 1,)' "'''H~I, ,"OW 10 l(IOO/9t. ~~.~'I " t I.~ I '~.hjo. , lit'" .)1 I;'...:~~t~ n,.L~, " . . .111'''1 II ~h .,1, u"',l",.~ U Ii~RI ~ l.'Il;lfll""'I>I'hlj 10 1;"1" 10' IEt'~1i " 1 OWi 1M 01;6,61 , 4 Nnl ---1i/2.Q 4 P :,0 C E F II J "rT';;(, M OB3, & l , 1 tlEI~ l.;'6QjlQ 10 p .YI'< Ni,t Ib<:<: lutlEEt'L MHI , B 1 , 4 e !!lii -''''0 P -7~I-o-- :RtJ CAPS -'GB8;"i!I ~f--" I 4 tlEII 6!LQ 5 P -",,1610- ~Xl SU I (l' 7~' O~8, B I 4 tl F. ~I 16~0 -, P A4610 I V HIGlt~(, t.~, r. i ( :;[H,U 08::,['1 , Tlml su m.l 1 ~6p.Q. 10 P ... ~t;(l~l .'.I\ICihhltl,l f...1hllll.hll'" (l.~":It~ki;r- ,. .loll).)h "lll ... '~I."tJ DiI' ."''1'11.,1 t\.o ~ OIllfl ,~I "'(~I , :;435~0 ~ 3435 9G "'I~ W'" )"-'holii(7;"'tT"'f:I;:""'i1'c.~ O~O"(j"IN k'~P1flll~' )1I"nllt '''('''11 "" nO i;---i7iiiii-lA:Xi.1 ICI,~'~i-hu -'---~-- lO/Z3/95 T7i7':23 1 9 t; l003/9r- 10123/95 lbl2~/9t5 SHARON GH. TENl TCII ".., IO/31/9~, w-lIii"Hli~"'-''ii:..l.lii;.n'lf ---'.-~ 1 ~66:u~ 7:'ib . "IIoCI 01 II /IrK' ~hD '11'1 (;;.I-Ii-;;CI;i"'()f;;r~~~~;;;---- "I~~II" ~ I ('.:', I ~ 71 .-.--.---------.-.,--.--. ~';PHO\l(lj III .....U (I;ljtj(;ll tJl. loll'rlltAI bUIVIl L t'ilJ 1115, It~C. I)/[:/A TOTAL CAr,e ;64 NUTT r(OM) :tfhlUJl~Vlll.E, PA 19460-3338 61 O/~3~,-~~,66 1'0101 HCFA'1500 (1,641 ,,,,,,, CHAMPIIS.60 1 jl--i-j~;III'...~i ;:'I'..,il-'''. ,lL:. ,iIILh~U ~I,ll n 140(1 I ~ 10'1 L>~ vii I q' '\' ,I. I ,IlIL 1J I ".1.", I, " ,\ IS J -II L()(.I (ill (..I I H'l'HIII!~,j",,~~ ll',NI~I'H "'~l. 1J",h 11',1 nL.".u/lh'~1 HI'},). '-"='-~~i;~::J;::'---'I~'-:'ri;'iii.\'~ .;.;:". "-'T:-l f.';f~li:t,;,;: -," (, :~'i;}.:'''t"' , --""-i"'1l.Ql;''';'';"'''--n-'l-:\II'~'~'' "'~;;;;--"- .J....L_______1...J,. "ifi""IiTIiN . 'n---- iiutilo" rAr;lf'oliT " ______..11..1_1-.....___. 'nHijh\ i hU.lOim;l'olJ 1 ,'.r,....w... "..,I..t Tll!. ';Dt~'T,,~~,qJi'i1'\~,r._/JI.~, J , 1 ,I, ~ ~];;m.h'.n;iln;j'.lll<Ii"".";jr,_,---- r~'~I!l~~;~J1.IJlb4l~P};ll1Ti,' '''II' ~b~L> LUNbEh Gl~fEl 'JJl~.1 nlr,~L.LL.L,.- l'Ttlil'li,\,!-tu4M~,J!k~~J\lhlli,nmr,rr..,- ""I 0 GJ ""'" I ~il,I1::e'li:J~ ~IT, JOY pt, 17!li!j:: 'rm;jhfntnliU;Tt,;].l";j.,~r.;,irt-..- '~TUTIliMhiJjijli1lIi1;iPiriiJnml'li";."iW"QI "" III' 1I",'''~1 C b-m,'-- _ (';:1 ~r'Llfl _D . ~ "11'~\I'I'lj'," Iij~ttlll"",,mll.r ll~ II I"", n~'1 HI I , '<Ill; 1'."1" O. r.'"'' 'LI" ",t,""1 u I~ I NIHlIl1J '1'111 U).ltlIU .IIW,", !JIlt! I' hl"'hUI '1t'ljtlIO' '1;IJhH~I..tll (.IJ III 'It'tl'j)1i ~65& LUN~E~ 6TREET NT, JOY PA 17i!ji!j2 -~~,-~~~':...-.llZ,.Il.t:.lL:.!lHl.L-_ u ~~~II "I II I [t'~WN. ~llLJItMl". .'110. [-"-1 1'-1 ,,1"111 --"'---'--':".'B-.E:~I'.-F'i.I~;U~.I-"t!ThltiiTH~.i,n- - ..,.- ~1'1<J~- L__..J 'I r'''''' OO"~""'k'l"r.;m''''~~ '~'''.'I!' [" '" ~1H;;m;;'-l.in .------'..-----.-....-." -1';'I"~I"'ll';~;~I;~;~i""lI'-lt" ";''':1:'.'''-- .1I,.6M'IlU. IohlHfo ""Ill IblUlllI')1 '''''k/!rUU1I'l;i lil 1"~I"'~\I'~"I~oJl'I""llIIUWI,,1 "'.111, "IIIoI,tlIUIU".'l'll tll,UU.U.... lJ' lllal""~'h "II HI II III. /I IJ N'"" IJ It., ~ II I ~IU'l Ie ,~ "UI,.hW II blllJlt T ,. I' ., 10' n f.' I L I', t,U 110 \ t I, Ii IIN HI '11.1 "''''IIl;IWlhl 11110 [jJ ',h 101'11010 ..fil ~U A1..J1M..JilLUU ._.____1...1' (17/(1,. /r,'~. "hihIU"'II.""lljljH"II"I,I"fIIJII"~IJ'tj PHYSICIAN OR aUPPLIER INFORMATION It bm 0' 'll'I .J"iiiiil.i1ififiihil" ";;;;;'] ,. ,'ilTit I '~l ~iilic;"qj'i;" t I r,T.Ti;T-';/"",","ll riot tJll l~ (IP ',ii'ii.I~"'''h~tt "111" t.ItLll'vl .'II'I;.~'i"lltlhl../i,I./Ull (,'.'1)111' H"/'nIliThTiliiTlo-- -rrw.ltH' ItI"llJ,.h~- . .iJmm>>ji'I';;,i-o.u,~, Ji hi.i" 16'~,j"1t ,tll.loI ____.__,~~~Il 11,,;101 111'li1.1JIij!l '. "'101' 0' I'H'''Illh4 'IlU,;(I.h "" 0 1111I14)lIl+q I', I'IJIIII( .', HIli "l;lhCl, 1I F' 1 t'l h P ~ S i 4 J ~ l,g:~lr"',flMJ\t:.'/LI'3T.ii~J.,~~II'UIIJ" (IJ~' ~~"~ ~~hV.J~*~#Lllli-JWami;f;mo:l,~~~t~ghnHj(j1 ;t~~~nnmrC1i~~l~':~~:~',DlOUIl t)mr~t ,,. p~~~ lrTff"ft~6'ihl.lij}arn""iii1atn.iJi"ihiii~nrl11, o.....I,J.'. to ,tlDt,o..", ,It (CllllIl, h ~mr 1."101111". , ~ ~ :";,,,-' LYME IllS",,' l , 'Plot "'88'. ... ItO l'hI'.tl'l....hlllli 'II' J tU..1t1 d.fR-l~h w~u,~~m-cn:;ij'riTr- ... 'hl~h' U .1;11 "":11 ,u, iJ"I -r.tf~~ ,.'H''''III",lv.I UII~f(Hl"""(,.w,,I.It~n, >,HIO IEU,~.~ __. :lrl '-'II/;" '111111.11.'1'10(;""0 .. . .. ~ .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. . , I;",':--~a~'. ~I"~" . ,iI' ...",1. 1'\"".1'''/1 . ' ,., (J6~~Cl o r' ut:~,~l oeb,81 , -- ,--2M -1 L ('f.~, 2l I ~jLQ. "P 0t~,~, tJ~~,61 Hi , h(l " H:.. oc'..~ Ic"iir.r, h(l " '~""C D\I I t~ ~ 'lO ..o.tI,'It'(.o\D, SHAROtl GEf.:rU!I'CII PI l0/31/9~, I II ... h liD 1566:!B75t; :.~:f:.O' ""~IC' ...hO tit'. O. U"vlel (t 0 "CI'IlU 011 1111 "0 ~j J (.1:..''1- l: II .lPjl"ovlO II\' "~A CQUt,CIL O~ 101((.110.\ 6fllVIr:f 6rU !ftS, It~C, (1/1>11, HIl!',\. (M:E ;/,4 tHin ROAD ,\1 [L" tJ : x v I \. L", Ft, I 9 ojt 0 . 2 J J C (J1(J/9~t~J-~56t.. Form HCFA,UOO (1,14 FO'III CHAMPUS,lOl u lev 1",,.~o"1t I "e L:.~, :... 1\ f_;~ :.:: I: I. , L :;\'1 IE I ~OIJ L (ll"j d 1~~i41 . ," tHll~1 LII(I (() 1 B ~ I D :tJ,'I;~'''',\"" ..~-= "l~~IIII".~..~It(l C~~I~ 'CflU ,('.. c.J H",I( HI,! MI;tJfV..I' ""o,:Il ~IIO'\1 ';;;;;~'---m~l11Tii;t".h'-~ .'i'i.."~lJo~~hl +-h~'il "UI, J"lIl~~~~_ nR~ '1. " h . I" !L"'llinl~.1 ",UI NIUUi]'ii;ir.iij-- , II' I. " -- n'n'l~tn ~s.._.L:. 1 .'" [J 1'1 I" ,',(\" III CIf'JHI rlltJ~tiU61ttr;i1Jnt1'il) IllTJ)~tI t 1)0lj ~b~G LUM~ER SlGEEJ ill t1IHI. 'TiTfi;Tllifillk~~n;r,"..';;'Tr-- TIiitUJi.O. u~~ hO IIH' QlkNffiWTi5i1tmiTl'lnOl- l bh6:~B "~,!~ N'I, ..'ny II' f, 1 '7 ~~j:! ltlf t.''''"H l!",,,, 1;11'1" - 14r1mrr,'~miih=L-D J ,.1 I'"io 1 "'1'''" 1 I,ll "I IHO m"" H~'~lhl '.",CJ 0...11'1" "ij rWI,:u.~'lr.vl/:,~ifIip r.1.,~l...I,\;~~t"~\Ij,'!III\,rm !llm\'..~n):J IL.::;-; ,,'. ,,,..:,~~,.,,,, tI' ~Oll"""'l"' "h."rllllli:\toilJ ~~"'li'I ItT6'hll'lll' )II,.. .?'ll~n. ."''''"'1111 1'111-" 1'1. I " '. rei' III "I' IIr, .. liffif f,mtuStrJ,1iMl1Il',o'llTl1ilillmJ;lTWli..- (H~'I;""!~ - 111....1t11.l 1.1..I',UII U .hl.llO~I~II.l.1 ,..hUIIII ..,.,hl "IJIf II ,,,......,IJ .111) "1.111111 r.ltt ".11 ',jltobll ~b5& LUN~E~ 5T~EET NT. JOY PA 175F,2 -'.!.'~,."",,, "3......-1., 7 b F, :J - 4 ,,() L__ II. ....~IIN.io~"blJ~io -r ';(1;-rD'lI'l'~"lI ----.mMh'iJiTlml-- '1.lwio I IIWIt I top.f/'U "-1~1",j,"l"'.'''I"' "IP<" ,,",'" :fp.,,,,...,,jil--- "' Il'hi -II .l./I"', "' ,ell ""~'I~lll t,( ,..u tlIQ" A\JTII11rdZATI0I1 lll~ FILE ~_G I CiN~,T~lr~E OtLLl1F. ______._ UHI }J.Y l'~6/Ii~ \'ijhIUII"iI.....IJCh.IJII...f/'ItU.IMilU:L___ _ P!iYSI~N OR SUPPLIER INFORMATION iTP'iTfOI 'Il" I I 'l'ijffilWo!CHH'Illilll II uHl',kj,)(,;htwll'bloo'c .., t I wl'i;l;;i1"ht ..~l\UWI~" ~N'- "" .'c........,.,,". ,,,,,,,,'.. .,.,,, "'"lh6"h'.'."'D"'~~ H ~tn:,:lt~~;rm--- II llUIiotlllclh Ill....'ll1T - TITrri'jf;"ijilii"lll,UilIllt- -....---- ,~~----_,_._._L~::~~ _ IMuN T1i1 I ~"~~II It ".W'VI IlI""",hQ "1l1'1('~"UlleJlI'IM lillJll(1 t" "lIlhl( "IHIIt .",1.(11 U~ I t.j II l'9 ~ I !;:3 h%"J.I~Nf1M~IJJI(..~.~.II''''II)'' lJltl LOUIS !iRINGElil, ~(j lil;:I/,'IJ<U ""'''I. .'1'"'''''' 'i'iIi'iWT>>.1i7iiIIl'I"l)I;;:C:iiif~-.wj1ifUhIK,,"Th~r;.rurroi;;iHTili;;j:I1,i1 UM"lJm;--------- 1fI'~"UUllllilO,.1i HJij'jj /II I iWTUlRrr--- tild II I Ill) !;;1l.llliH n A l)O.~hl;i.[ffillWiiI)rjiiT.llIl}1-11il",.n.rll'/fT,:r;;~iiil117..IWj;"m~l)""""'TnJ;fi;il~~TrrrIT I' -- "Ohe WI - l ~08e.el LYME DIEEASE U'tol>1 '"88''' 'J"llth.hh'hij 11' 100 .......... ....-...................... , ,,,,ell Jwll'tHl'/AllOhhO to . ,- e '~L~' OI'~'I'tUr,.el""I"J 1~b"..-m;;;(".. ""'" Illb'.iliJ.hlo- - O-.ltO' Uhlt' I'tHI \,I 1I.I'lll IHh, I I~ . "II' I-- '''l.I'' ,. " I-,~'~'U'- ~'~ lI'.~"I' . - II "~I~' .111'1.'" l/"II~lIH II ".11I. LII ~''',<j'''~I~''~ltl "" IIh'lt ... 1 0.' :' J / I.f 5 - ' ,;q id Ci IU,c.r..t11 1 (",1/1 t1L (lB~, Ii 1 , 4 tlnl ~I:no It p TO 1::3-/ 'n A4~ 1 (I lIT p~ u, 1 (J ,:,lI " ~ l- I (niL ':l6~. & 1 , ~ VIM tlE~1 --..-..tU 0 I P 10/::3/95 P4blO TPII KIT H 7:j~J 088. a I , 4 NE>I ,1 jliQ 3 P 10/::~,/',5 ,yri Itl~E 1 C.C': \iIloEEPL OSS.~l f-"" , ,\ E IIEI: 1110 4 P lul :5/115 - P,4f.IO 'fit! (A~S (1.3&. b l , ~ tiE ~I ::lU! , p . 10/::5/'15 - HI:10 SET I': l' ill-i OB2. ~ 1 -,AI , 4 tlEW 16~0 :: p 1rfIIlV1Ui'1 ~. I'~.tl~l.hij tu'tl,ta "..(lul}O'L'l.. ~W~I'~,~l' .. ~(I:t,., H,,(lh11hl ,r,u'IIIIII/IIII. " '0'" '''''''' , .. .."',., ", J~ ....." I.... "I &"1111// I .jr In:1 'I' '1o-11~lhlr.O .. ~ lit Hh' h.. (I.'"'' l;"l ~II' W.", 1.11 III Jh All WAul. 'I "'''Iv I 161> "0 .J... Ib6::0 !::J U "li-;;~Jt".,.~. 'iijI'~ij,f-~. ll:oi-Q"ti1~ ".101 AOOftlii1iiloom-'" _____~:' I ___ ~~_. ,..,1/1111 "l,Il I'll) ., u",lItA1l'h "(",,,ll h'J 5H~,Rotl (,F.RHlll1:H IItS, ItK, Otr; I A TOTAL CAF:E 11.1. 10/31/9~, ,64 tlUTT r~OAP W-iijUiI hii&hlT~I:i.u.illi-"li-- - .-- ..,.,. --,.. ---...--..--,. ~i" i;i;,ji'-"-';";l.i-"'; ,,-;;':' '--' .._--'--.---- JI,\:.~II J rlJ J l.l,E, fA 1941:0-3338 1566~E7~~ ._._~ :::. j (J ~r, 1: 'r J bl(J/9~J5"~566 --,-----. ., "'H 1 0' U"~t(' J"IlII~1 ell UII,'CIIIl,l 'If OIl', f;l, It.. ItH. "Iloilo-it., ...1'1'llrhln Ut ""H U)tlliC,ll (JII "'tfJlL"'\ lfll",,( I b'tl foolll tlCFA'fGDD (1.14) 'O'1ll CHAMPUB.GDl Fonn OWCP'IGDD fmlll RRB.1GDO : ~. 0 .., I ~ r,l. t. t,'.'I,11 1,"(' 1\1(111 l'IIO '" _., I Ilill.111 I, ~ . ,_ I, .' .. r. ,~ I 'i J 4 I L/J\', I I CJ 1 &4 ) l'I..III.tlll,,,,I,, t \ I'''' II HI ,'III ~ ~ 1.11\1, '1. I III l-,hlt'''', ~ ~ III1IMI . D~'i;~-';~',,,,:-' '-tJ-:i1~'il~\'~-~'" ---. 'ilil:r~'*~1::L .-;. .:" ,.t:n'i'~:if.:~'--"~:niJ.~ .. i""""=rr:r:if:,i,~.. '" ',", ~- ii"; ~'~'.~~~~~ ~;; ~"Wh~:~~;:~'~,fig .MlP.,JijRV:~M~II~~,,~'gJ!I~jmnID'~ff~~T-!{l1f.l';'-~-"lil\~ '''Tll'~:;';'~-- .J.I,11()11 t~FIHlnn 11))011......_..,-.--_____ ~"111' I cl,.. ~ LJ.t :.__ __"'''UlJ C,c.F.r '4111unnn ~~"._ I "'F.t 1;. lli,,1l Itl~ Nil m ,1,.(tlU,1 , ,.., n t. , . hlV,lf,TITi----';!II,uIt1"'liA,, l"ll'nPiliOJ.' In,"IOJUI 'II :"b(, l.UNL'li" ,il"~~r ",., [J LJ ""'" 15bbLIlnti N r. JUY U, I n,ti J r.niJ;;tTlillll-lj:i,li;.rl-;,.,It~~~"lD.-- i~n""iZ"'hb~oa1ir~Ji51iTflTtil.iN'''Q~- 1111 II";~I' ~~l~-iiJ.Zlimbt:~" - ~6'nO ,\,.,..--,~---- J;l ..,[,L .. '-1.._0 . 11lhPll".llll" lJ 'nl' (Ill If, ~I !' 'l>II~\"IIlIj" 1~~')ItlI'I";It"II"I"~ ~te'I~"tl~"'I'IU'U) I~~ 111111.:11/0 11"1 't.111I U,lI , .,,1111'111"'111.1101111' '1",1 .'1"1" CJ~Q"b ''''''''''III''I'''hl'I'IIU,IHl.llIlIUUI''hI,)IU' "1'111'1,." ii-;;;r;,i:jjl'.llIoTI1"'JTi.Ti"i7:tnmr;1111;Oli'l --, 2b~8 LUMDE~ 6TREET HT, JOY PA 17~52 -"~~':'~~'~.__.11 LMi:J..::.HJll____ .. ". +1101 III LI""''''', U"~IIl,;/I" 'ilmJr' .,,;n-.,t!r.;....'l-II.';'~';;-~r,;;l;;>1~. f"~l "I':;." '''\;;'h~. ._.:~_~._,_l?~:~.._, .;.~~I';~II~LI'~~\':,"1 :~,<:,':::',~L~:::::,:~;~j- .. 1"')"/1 "..., ,"" Ihol h' , ,,', 'I,m.." " ... '" I,.,. 'I"~" ','''' ""C'" "",.. ,,' .".. ''''h, , ,," """ II 'Ol. ..... 1.""lhl~h..JII.IIt'.I..',lhML......11 Ihl M'~lIuh.a"''''''''I~I.I.IIl)'' r' I I'IJ' HOld ~ ~,'r (jl~ lItl FILE ~,-,EJjjHATJ.l.f!LOt:L.E.J.lIL_____._"._,_.J~L.!llJi!~.L'l~ "'"'.""''''''''':~~!I''''''' PHVSICIAN OR SUPPLIER INFORMATION 1I1i)lTir-'--~' .,[orl.o;'Il1;"""'';I';'';;;;'''''''1'' ,;i.iT;.,n;-;;,,;,T,;;,';o"",,'-,- ";r-''''Ii;riTrF'' I '.'0 l't'lnlj~'I,lIl"II~"." 1,INI' t.I'I"II":" "....I;.~III' [':61'1'~1I"t I'rtiilITniihr~- .,runli11111J1~~ JA,aN.11 ;,l~l-;:i.I"IIJIII.It'lltt ' I'liu,i'I, \Q'...UIl. --. ~~____..~W'I' 'II.;" 111'.OI)Qll 't ft,..t o~ ""llllhft~ "1'11.11;.'" eM 011'111 LIMCI It. ..!.tn,' 1011111. "..IM-II U r'" r t, II r, ~ ~ 7 4 ~j il-rn-l.lr:jn!~lt11.\ Iu l.lllMmri\lI)h 4fH .....!..ll;rlJ 1ft,,!'>!l 1 NuEI, U+.. JHl,__]",..Jl rLL 612Ql -',=--' ~.'''.~:'t..."..r=", "",~. "71.~:'IN";:'~."'." "I'KI' 'I M'" ""Il.l.'I-;;'H\f:.lH.Ill)I'It'IIIIUII~I(I."lhl.IIIU."l1\I'I"Ti'UII'uhllt,;IIl.l1 II" 11)'1' ..... U",........~,.'"'\;/1- .... 'II 0 eLl '" IT'T'',llniL'i"i\01fhtl"U1oTCT"iithlihk Ih~1,o11l IIrm~Tll) "IHxllJ<.~l.tl (Oll.t"ii;li1" ~IHMI'.U hll"~11 I .'ic ~~-II~ti)6'i'.:':"-.__.. .____.. '099.91 LYME P15EAEE , '" ItO tl'"IQI. . ""Ill "'88'" till "I) ''''''II'hll.h'41,o II . U"I u, '11111(1 'M(oN ".I .' 11Hi I:' II 111'\ I , 11111' iiimmt!icl--c;;m-;;;, II h1iR;"I~r;.mTi"tr~""""1 ~ 1I""'L"Ilfltfliih'l , ,,J..11t ... oil.. .tt'; ~_~.!- .~~I Ult~'\UI.M('''(~''IoIIl,t,H, A4dO I'.' T'Jt,lri': [o,',S,,: ~f'1.1; TlOtlllil ,,~ IHr...: ::': IIII ..""." "lJII'I.."",lllj'Ihll ...... _ ..M............. ...._.._........ Nf. I 16 ;?/IL TVI;D rl~lL IEEPLE ~,IH.I(oUlli ~ ~, . ~..." liE>, .\1 S T flf. I'll " 1l,'I~:rL't~," Ltt'~"1 r. (I ~T:i.:.l- _._~._. ,,,- .. " ~.~ I 2/2Q , _13.2/!.Q -..i.Q L (IS~, f; 1 , o'~ Oil Q' uhll. Ill' nll't I.'" - lO/'::!i/9t,; .L J(J/~~/~'~, ;',,,t. J V 4 'Ol'~/'i~ /',46H . .....1 ..J __.L 10/:::;;9:5 A4~IO 4 1.0n~,/li::i 1. /1:': I ~I , 'j 101:~/ ~ I"~ bIG .. (I fl~' , ~ 1 0.%.&1 , ~ ~I 0 3 P 'J ~ ~,~ I , ~ I 'l() , I ~(1 I (! ~I ~ IEP~.f.. 'i 1':".1 1 M;. "Eli {)3~ I:!' I ." "'~"~I"l .\l0. CI" . C."~rl'U ht_l lll'il ," , 0',,", :(1 P 'M .. lU.ll SliM,Otl ~EPHtn 1':11 ." 10/3119:5 , '10m n" ~ tCiIlIl.tr;.~r-- , .; :~(:, I.~ J I .~t til',~~t; :1 IJbt ',0 II." . '0 433 ~G , '" 1566~8755 U~til."' UJlvu:t '"0 tl~1 ~I IIJII,'tI (f 0'1 COil II 0" ".ll.tk ~, I '..: t, I ; 'I .PPRO~(D 8y ........ CCU"CI~ Ct~ hlIOIC,l.IUqvICI e'l) III f:, I tI (. Iii l.i 1 A r III A l. ,; M: E ~'I t~'~lT r',OAD .JI.!jEIIl }"ill.l.l" 1'1, 19460<1~:,l\ tJ 1 () 19:1':1 - ::5b(:: Fo,m HC'A'1I00 (1,1 I Fc,m CHAMPUB.IOl IC~ .~ .e" I hCi I U' '","l',d L'. 1l'J \' \/11 r I.lull 1'.1,111J. 'I!:..I, I LI'J( I I<n1l41 pt. I 'i '1 ,I I "1.11I11I1.~1l"1,(. C~.'W 'l;"~ t.:.nl Clo "'oj" Ie 111\1 ""003'1,W .~CJCjo. .11l.HJ1 ,,,mhn"..limrmjJHll".., .,~p,f,1;1, '/.t~tI!r;-;'::--'~f.'~~:7r.;-, , ,-- - -lil c'IDn~rrnr.liK 1 ," II lfO ,~" . . . I. ~ nn;Il,~)l\\r-.LJ."J. --"::. ._n.' qi\itlir,H,l,~f.~J.thMMV-fkrm'.PI'" .mt 0 lLJ ,,,HI. '~~Lt)~e'Jb~1 n 'lIlL'FIIt IHtI',n "lYioauun\nrn "ltrr.lrlT~1T1~11 :bt',t:! \.lJrIL;f;h lill,H I .. 'li,n"Jlmi.n;~l7.nQ'k.:iifb-.- l-.T"'ijJ'l1m~r.Qjmf"~"'IU.l:l"'W hOI I'll. JllV 1'/1 17(WJ~ lid U"J~H ""'111 1)'1'1/1 ( .. ~ F, ~ ..@ [~ h;J D ",,:tlJ/lIIi'~I~hQHQ'''/.ltQI'tl.U.'.NhCHI'' , ,.".HllJ1U, I 1'1 ljjill1,o nililll .-- il- 'M"fllu' Hill ..~n~m;;rnt;r,-- 0"'''"'' ,," ~~"~ .'1- ., I' I ~ t 'UTai .. ') I t t~e~l~ mfil1'."" .~L .~ rn.", ."., ,,'" · " to HHIt" U'~I'HWPII ".0 0'fl0 ~b~~ LUMbn~ EIRtET rlT, Jill' 1'/1 17552 __!~~'-"'~~__.__LU._J&J.:..1,b.IU_-- II. 1;1"1,/'\1,'''')'''0''' ..----- ."-B'~-ir';i~Cr~=C"".t1U .'~'j.h'firlJnli}in- ~"hi. : ' IJl.II t .. "II,,",U -,----j.- --~_..,_.-~ -.---- " ""["""'l'".(''I''' ."'1\" l'I'll'"I"u,,'',''.''''' 1'1'1 ,IIHi 1ll>'j"I,'nuil hid: l~,hj.hOft r,U[lllJl'dlldlfJN l'iN FILl: hl't:p,1 .',. L.J [] ,"," ~~illNAI_~F<E orl .E.l~-L-_~,__._..._.-_E.'l__,QI!..s:.b..L,-~f_. bl""llJ"'lluJ<llil,II~ul..~~,________._ PHVSICIAN OR SUPPLIER INFORMATION " ""10' :LU,,, ,I i"Jll:r,miiiiT~,C'~.';-ITiI\.:'::};!'U;;""i1j'iJ';;;;-i",;"r -,q,nm~If~lJi]w:.~'-L' f"ma" " itlMm~JJI)Tlr-' ,llrcmu:,"trr.,;;w--'-' --------- --" iiiffilT;,,,,,,,,-,m;;;r;' - ___' "",. ____.l~~ II'," I """..... i\ "., 0,""'''''''. ,,,"K"" o. O",,",u,,",1 ," ,,,,,,e """" .n,,,e,, liP I !HI lJ 'if: 7 4 :l '.. l:i.':~I::,llI,t'~'l:I,n;m;orAm"~'o.'" LOUI6 GP,ltWEI,J, PD r,rd&I:/OI .".,11'" I:';''''"''" I' "., .,," ,""'liionT<",I;-;';;"fITl'",,''iiTi;m;j1;;,,;j;;r,r.;rr.;;-';;;j'7oOi'IT<O, -----. n-;;;li'lliffi11sIo.w,mj1iTl5i. "In,,n;;;;,o;mm- -,- III hlJ [I'Hlla. n-~')~hMin~-mmin1J1Iil.11.-r;tiiiii;;~rmm1'iifai;j;1T1li1'l:7KT1};jlif7Ij(~;- ",1111 ~ iIiiIHJ;fiiiJiw'",; liTTifll1' l c 6fi-u)t"'/l" . ' . oaB,Bl LVME ~ISE~&E 1,-,111 '''88''0 Il~ hlJ t , .""11 "I~II"'''~ . ~ ~ .. ~ . .. .. .. .. .. .. .. .. .. .. ~ .. .. .. .. .. .. I "'IOe.. ~vll'Ofl,,.IIt.iII 100 II t.tH.'I~h" ( 1~1.~I,~.ll~f;~11.~~l~~~I~'~It. .Ch ,Ie c; u II tIC~~I,'rt I '11~l~'I,\jt",b..h UIi~'~I'I;t1('I"..",~l~"L'" ~4pIF- 'tIU'~~,lr, 1\"~",In\I. :OMl. '1\ ~,L. tll:\1 .It, . ""\"1 ~ ,,~u. llfi) II r-' ,-,-- ~ , --- l;<' I'1i. ~jt.'1I o.'.f~!.L.. (J~~ ~~ emt lJtll"~Ia:.. J~'q flU)" II) 11~:I~1 101 ~~79g- ---' A F:. -!ill o o --l-- --' I , __- --1--- o I ---- -~ -_._~---- lot "I;L'''' hIAt;" h Il>l)~ IIhhl h u ,!itOIoI'I,l "HPI 1fl'i'iITl'" ,.. Ii, ~..I~J" II .~lJ.h'l ;;n- o 'T.\t-U'\i1~IJ.( ~--..Jl-- ",nn~#-f!() ~, ~::t, IH.I~"~I,.:lr:\;1 . "11.llli IflllNII ,,~.. . ~lMI JM ,II' I,mll ~ rI., II. ~ ;"-I-ll-;;ii-L-I,.i'.~"It.,.,;i..,rlT.l) .- IHI~" L tl\.. Il! bill TO' M_ C/',I~E t;/J II 11\11 r r(Of-.11 ,t>I,~Ij~NJX'lllI.E, r'~ 19AhO<13:lB I:.l(/rn~, "~,bb 1"'111 licm~oo (1,141 I """ cttAMPUS,~Ol 511^~lltl (,['I;,TEtO'ICIi Il~lt 1 0 I J 1/9 5 "ij'-rooIillUII'. ,,0:.0.1111 hoJ il--,i;I:Ii'jw;:-tiitliilllho- ----- ~J ~ fJ :. ci 1 : ., 1 ---------.----- ",'!'IIO__UJ PV "1,1" I:OIJhn\ lill l"ll (llr....l fit u.... ILl t,h) 1'<l1l11 oWCJi:ti'oo 1'"111I HHB.UOO '5b6~B7~~ 'l't.J<n 0' UII...-". ~hllnH 0' UII~llllllj.IC:O{JI'Il'III"II~--;;'---- .....~,,~. 'I, i 111:1". ~:; l' I II I II j'l ':1 G 1.1 (II, I, ,. 11 >,l .1' '. " ... : L 1)(' , (OIIJ.11 f ~ r II 1'1',,11 1'1-"1111',1 u~J"~. 1.1.,1.1 11./01.1 lit! H "'h. /.lIlL ".."IUJ' Ui'.k " hilt ,,.., ~i~'~,~:~...W-::''',','--''O-.'',it),'lf:';i;;,;''''-''''Ll\''i~~r,'t,;;,;,:- . '.~"'~r'f'~.f.~;t~'~-.'-~-i-t..,,,,~...a~,,~, ,,- :~\~"-UI"'III ~~-:-~'--,-:-""'~ ., -~-"'.-:--:-i'At]liR'fMi ]trURf}5_l'~fiRJI!lh)'ffiEQn g}r:_-~--.~. === ' .Il"hl 'hlijl ,,111,'.1 1,1,11.1,1 .'1.1"1"",", I 'Inf.,, 0" il ,.1, I '., I. ~twl 10m r;-.iiTiJi] h..1 .;iffiii ",I,,,, II I' Al":l'i qlln(J "'I " I . " /::,1 I' 'l'f'Tll f'/,JlIl ,-"m-"ll'llij,'II1L'-"I.lII '\I'Illl["J;n';)];r,--------- - -- 1""''"'';''11 i-- -- - -- -..------ . :llltl~ .Th....1ft.!J11!;<Ii\mn;rrr,w.."..'"fiulni,--... :1.1'''_ I.lHILlh Gl/..ji "'" [J [] """ I~il;t"i~n~, ~'~~fliil'~ri.r';;-"T,;:VJi;",~i,";7I1TIl---- l-:tlnJlinli~~liii7iTt~"wT~iilTlr~hlil__ /11. J[,y I'~ I nr.J 11I'~tollhl,..J '~OO'l ,...,'.l"mI (I~ ~;-~jT>>li~I'i'i1ili", I,. -r-~ . ",1 lti~II'-'" lr-- mtll,''''U, M,m,,~ t Jilt,",,,'... .,\\ffi\ III' tl-."q "">jj Lll'I" ,,J;;Jn'.>1b;tl1T1i/;l.-.D " o~' " . ""'V/I,U "lhlhIHU,I ,",1.1 LUll""',. 'H'll)lllI 1"'lll'''I''" 'h~tJ~11I .. mil ,17UI'1I1 C,1l ~I"II ""ltJl.l, _ .. Hq"'.'HI'PHhlPoI 11'0 ~L'5lJ IUI11i<fli fiTlll:~ I fH. .JP\' FA 17Gb.:? "_!~'!!~"'~'~--.,Z.J.1....L::;':.J=-Abn.L___ · hi 'I.".. II. LI'''HhJU.'V''~I'''' .."III 0 0 (.11'1" '--'---'lETci;;j'-"""il:iil;:j-..,i;liOOriH..r- 'I,,~~ I , Ilvh L-J I "'''''It) ';j ""I""""F"I' '1I1"1'~1h 1;';;;17.'ij'~I;r,lrm' ",-,-;;;1:;',;, --------.- ......,.;-I"t."I....".I'" "'"<1111"/['" '1'''''''''''''''- I.V"~Il,tlih ~II 'tJ '''' llJ'thlhl.1 ;,r';'tol/' UMlt05'~iI'IIILt.I""'I"'IoI"'Lt''''''~'~IhIHI''1 flll".'h"Ii~~"hl"'OIli'IIIW.ll 1."""0'110'" 1)'111.11'''.....,,, · 11I11 L 1'"'''' 1.1...'.111.... IJ 11'1' /I '''"1) Coli' 'Ht.,..,.HIII'IIIJI'I J ,\UrilOR U.l/Oll 011 FILl [jJ,IoI) 'IIJIo'D U /lillA Tll../i[...!ilL_lliL_______'"'' nl /'1~:..'i.L """"""V"V""'''''''/I''''''"", ..Jill'S ClAN OR SUPPLIER INFORMATION 'iiimICl" ITikliTiiij.lj)ijTiiJilh.IIJ"~ Ii uta _,IIU Cl.;h'",dl1i'i"'OJTJ' ,.. I' 1'~~"Ahl r.t' IHt;5f~lil.fltf~I'M."'t'It"''' t(:III;.tluft " H 'II' 'ir'lmT1il ---- INS~~ANCE ;~;-rnI'jCl WBS IUblfl/lleu J 'I,' on ~ j '." nnnrnlillil"lliTni- I ) lH1.'lTOlTi"l5:JTilii I ~liuM"ii)III':#I.. ,..~W __ -..--l.~1I ,,'UW '. "., ,,' .".""",,,,,,,.. C,,,,,, """I... ",,,,,,1,,,,, ""'" liF'ltll' I: 1:: i 4 :l r;l,IlJw:rI LOUIS GRIN ,E'~;I. nf! _,i,RI,\I:"11 '.1/,,,,, __,IV"''''',.,,, " ",""". ''''''1116, ''',,' I." l'i1i'io",inji;j;jj:w;;r;;,';j..-m;1; ".", " clr.r;-------- n~'"".E11l'Tf1iICi1i;J1iUi;11;r,' "'" .11", , , " ffinrll1iit n-TliinliBii1j51imlijJJC;JlTI1.Tini~iii;i;lti"Ji1.11~1U'MI.xI'~'" '11(1.)1\0.,,.... mm~I"'~1 "'I""" I . 'iTc:~ojib'lclll 'C.'BB,tll L'rME llr&EI1fi~ IH hO L.......(lH 1 ~/lIIJ" "lIl1l1AlIHIoU""l,l 1111.11 '"88''' II' 110 ''''''1 t "I"'.h,"~ ;; , .' , UAIIIJ' .., H~I~1 h"q '''''" IU '" .,'~ l(j/J~"/SI~ 4 10/17/<;>5 4 101 ?O/9:'J 4 1(Jt3Ii9:, I, .. -..~~... ..~~........-........-....~. " 'Jt' ",I..'. to IH~ I".,.... IJ' "_ 1U' U""~.lJ'" ll:t, C"'~"I' ,'OL I ':1" f' T '. 0l.1,0I', 'i T P(lLLGfl f'JT TME tlF- f. l.!.~ f. 'N(, 'I! 'I Ii tp r,~"~,~rl~: \'I t - ~ lIP Nl'T;E J rIG v I t I. H.,Ni:FO~E 1111 1I1:1~ .,1, ( 1\ "',F. E Lk IJ fl (IB b I!: J - "l't. '11 v\."" . H' OR~,:!J , l..M;!lD 7~ oeA.lll ; 0 " ~j: IL"I, , " ---f~."r\JI.\:l F. PRII (,/-,F ~ 'J"~I ....... I ~ :J ':, ~ , 'i 1 1\!! ~ I ~ oJ ~,1, 6 It, 4 "lffi""l\'UiIo1';;;Ti1m '.'G'l"'''''''''' . "'-!ill'''''''lt~,i''''I'' &J~ II t'flilt;H h.~,." . HI"""" bit "I ,.... 'II ""D." ".,.'1. "."1 "I~I I, I'"'' Hit'! ."~I' ,.... II~ \1 I't t~i,:.' Um,t1 ~.2.~.11I"".1. /oct , 5HM1lm r,ErdEtll TO, "". I 0 1 :J II ~ ~ ... mull htifi9t" "'CiJlJ"j h~- ---_. 11~r7l OliO It to;;J'-rcC:7,1'Tit,j~lii-~o u-~mt.iiiii;-;fj--h;'-'-" 'fit S, /II Co III D 1 A TilT 1-1. r. A F E il: 4 'IV'I ( I(lll-ll ';.II.'J[III~Vlllf:, FA 1'1460-:J3311 I; I 0;' 9:1~:-:. :566 I'm", tiCFA'I5DD (1,141 -. 1'0101 OWC;P.15DD hll'" CtiAMPU5.DDl FOIOI RRB-1500 1 ~166:::e75~1 . "HI 0' """tlq ""'D "'1 '" IIII1;;{, ft Q" wnl' I~h It'l .,,(, "IY""'., ~. I 0;<; : :' I ....,llllr;Vfc)U"t....I~~(;~- oti '-", r..ICAl Hllvl(f ~'IlJ , , j I. ,'\' ~ ' I, dLI III , '". , 1 ~~ \ li\J! It: E 1111', :: 'I:~ i\ ~ l : ~ \,( L< ~ \ II H, I'I:J 4 I Ill', I (C I HI "UdUlhh,IU.",(l (,1""" 'loll... l~'ot',~'" 1',l(lbil ~h~".ijU,u" IlIIlJil. nttJ'~~..~II\hUI .r:riiJ,~\';~ h" ~~1~"- ~ DBJ. . "I " W Li IIt.',.- 11111111:1'__ - rm'r.m 1-:....:-' ' --- llffiilr,.1Vh!mJmJllmrllfll'/Wlib'\T1h"mUIl' ",'LJ 0",,,' 1f,I.,~~il',1Ml ~H" to"" 1,,,,,I'Uhl 1'JlT;j10111;lilr,1'JITlmlT1;qrh'l1lnm;rn;;, . " h~WI W.DDI' lhltl.'~ F I '1,1', r '" 11 n n (, nl1ilwrmmr;ml11'tltl,mn:rn", :t !\t, 1.l1~II,t" 511'EET 111', ,J[, Y PI< I n~~' lTjill'~li1~"iIT;;~l~;~il---- r~mlliN;~LiiJl MWI 1l1l.lffij"l.'ijfho. 11lHI'Lhl"O .,---ari.11iiil1i1i'H'\' ttetl~~ "filii ~.o,. ~III "'/'j~' lIl', Ii 011'1" -~I,r'~'\-~tl(jl .'::\1--- r.r:-'''_'lD_'I_r'___D ,,-:t~'n .. !1i1WI"III' " ,~tl"'IIJ"CI'''''''IU~ II '11 'II~IIIH 'l.lh "HI~ .,1 . Oi5f; } '11"li/o11J ........tJllll u,/) c 01'''' U" 1101... 1l111! "IUlu,..,,,,,, lhhll,jlJt. Hll;Io,,,. ,t.I",1I (Ih .1111 ~,"(Qllfl ~bh~ LUMbER 61REET I'IT, JOY "'A I Hill:! ,-;,'_'!":'''' ~.~_..__1 L:L_l1li:J.=..4Ml.l.-__ lll'IoI.-v.'t>VII.O.. ~i'I;;r-o~ --mr.('iiOTU~,(I- llotll "ll'''llI bt:j:ut~1Jf lP;"r U ltt~~'i~I.~~I"~l~:I~LtlH,al~t~\.~~I~';-- Ii" :t.~t:~~ ,'ltt~fl~~~U~~J~~M,. t I ,J'~lJ~il~Jtl"lhlll AurHO~llAT10N ON FILE S I "llA!J!fE Ofl F I Li: ______ ,'" il'/IIII;I.'lli._ ",,,,.,,,,,,,,,'"",,,,,,,,,,,,,,,,,,, ~BICIAN OR BUPP~I~R INFORMATION ;;--0.1. 01 :~l~i~Nfi1ffWrt~~lf~i.".4" r 2t~U'~~ "...-.TolI,;;;m,;;" 1i'l',',f.:fi1,',:tli'tU ,,,.,~,:'~"",,.. 1,-m1l.~~1;!hr~ilno- 1 , trQrTQnru.r~-- ----. trITicTJ.iiiIJlliilJiii"irt .._"..,11, no,"" ~"I 'I hi ~ III'''''''' "'I 1,' ,,,[J GJ, h. .. 1-",,1.1'" 1-,", o [J ,,,.,. ~IO ________.__ 'IILN -_,__._.___.L'.'II....'''II. ~ I. "''''11lt II.,.....I"Q t"OIlIWI, IJII Qtlllll LIII,mq I" "I"IHI~ "1'1111 '''1/0(1, UP I 'I n lJ C; f,14 :J ,. :~~~10~IlO~!~b ~~~I~t ~~~Iij-li~gi rilj;~jNO III ~,~!~!~gI lOH ojf,~r~-'--- 1111,,", It..IIO\J11,lII li-.;;mr.;;m-r.r.rn1[1...ro~I!mili'!1>I i,iYttiili-iiHh6tj 'u~.(, nWllllLl IIIIHIl~lll/lLl ;; ft~' \~.t"uolit MIll" "11\"i.i~lbh\lI',nl '0\1111;"'(11 ~~W~l ~~.:tUII' ll' 'HhniljlIThjI"lH-lIiWlfU.1m~,. 10 ","IKlllll"l '" (011,,1"''' lili~11~;'" '08,1,61 /.INE DI5EA5f 'H 110 U'UlQ" I ""'li' '''88'. II' toO I ""'11 "1",llIh~ ~ - - . .. .. ~ .. . .. .. .. ~ .. .. - .. .. . - .. .. .. , '0 II~tl tltUfl~1l1 1l1Ot.! IlJ I u " 3 II -n:;-- " Hhl III ~I ".'(1 , '1jInO~H"'~J I'/oOCIINIIIJ ~lLlIOI 11,,( ,lu I' Vlo"'." Ill. IH,IU'II " f.l1." ,Ifill L '1Ih""U'IU~"'ltl/l'I'I~LJI''''I'~V~~ _LJ'~I!:trl~.'~__ _("I-\'~~__ ,;.;,11,' chAkFil ,jGI (Jl!a,l-,' I JJ;~ ."11,11 I-1ol1l'I,h'HltlHI/olJ ,h. l.lllt' III t . "" " I.' 4 'T073'T117t,--- --- 01 (.,,~ L 1 (I ~).1;-"F,,' ::. I I-'l..' 'I'" , , 'I t II -!!Ill 010 ~ ,(; I 4 , It i: I () V 'i u [j I tl G t< ~. ~ J ': 1 1011 SE 1 '-"T.\ ~ ll'- ~Il EDt E ::::,', II,., t.'hdfl-'iS '21'11. lul,E) NUL. fi)~u NE~' 088,('1 ! O/~J 1/'iP;-- IO/3Ji95 4 (J&i:,f:1 IO/31/~- IIE\I 4 0[6,&1 10/3119:, ,- ~, 4 Id 0 NS IOM1, lIE I~ ~ ~((ITI ,U'C,hlf\"t ,t;'"IJ,I.wtt'r"- ("'W~ I.Jh,J, ,., ..~o, !jEll liar), r',,~ . .----...... _ -~_.__, k..L.:____ liO '''''"lllllh U",Il,lthl) (IS::, ~ I I "I 1f,i5nTi,~t j , ',\4'f Ill. "'-hl.,'~i(:;:h'D'-I"I,j'1 ~ I-",I,.'lhlIJ), 101 ft ~~I'I( )U 4 ,. tl(l~'IIJ~rn;;ttf.'~"I)ItI>~TI' 1I1I1I(\vl>>o R. ~~- lm,)&~:1 "I....~ .~~IIoI;II~1 ',."tl/ll' '~Il~I'Ar.' 1'1110 11'1 HItlI ~I h t 10 :1,8 SHM~tJN (,Er'HIII r'.l\ Il~!! '",,:1.htl.~2,~:~!.I\~(~- .'... __.. U-IUlJ-lllt'~ "I,,"UlllJlt IoU 1 :5bb28'155 .. ~"~I OII1I111Kt"'''D 11t'l ()J- "",'(1,1 I).. CullU "" '-;-'11';;--'- "'''1-11.. IIllt" I NC, llll.</A lOTAI. CPhE 'I," 11\111 r,r)f,ll '"Il.QtrlJ~VIlI.E, fA 194611-3:l31l .. __~_:~ ~:~~~L-..~_.~_.__.__ ___~l~; I 93uJ ,- :'~;,6t ...,,'" ttCFA'\500 11,14) r, . "\ r:HA MPIIPP\n I i~--ii,u" III~, ~'lj ii;ii-';,;'''''' , 1 .:, :, I., I'. I', ;, ( ~ ,. , l 5\" 11 I 'II (, I ~I (J I, , f I' 1'1,14 I ',., t', , 'I,.' "tIL~1 LO(,l I U IlIo\ I '1IIIIIIIh~UklJJ~ll'UIIol'("',1 11'111." 111\11. IIn' "h'''IIIWlIl.. ~ IJI II "", - . fJ~e,itJIIt~'.-_. 'i~"t~W;~"~IL;:I---o--'-- '~ii~~Ui~~~~:-- ---~'-~i~fifv~~ ~~fiiiim~~-~:i~IIII~."'''I~::I- - . -~:--~- LJ._--:-ti1"]J -'rniiTIJi1i--[~.1il~!nf'@"!IUJR~Q'. ~:---:--~- ~___ 1,~1 Pil U}14, u,.~1 Mwll,"~t MiHH'ilOilllt'liJ~ ri~,r~llfl~II" ,I.. . ' VI Pt w1I1mltror,IitlTUurliiiiTirii;.wIl .".Ii.~ ," /t.lk;~.~ ~~Il ,~Wit!WH'j;;IiI"'----- nlf,W}..tll--L;...I. t..:J..,._... .1\1itd~imr.HJlli'iH~gf/,RMRr.,nliUdn"-- :6t.[. I.lItll:l." SII,tr I ..., [J [lJ "..., 1~,b6:iQ'/F,() tlr, ,J() Y r'f, I n~,:: T.m-;mT,.l\ilii;h170:t'iiT,,,17,iilr---' r-;h\umTiilj1kiJhUi~l"wf1iJiilUI'i"r.iih1ii-- 2~~b LUN~~fi 51kEET Nl, .JilY FA 17~Hl2 .~',~'~.~'!..__H :LJ.~.'J=-A4CJ.l.____ II . (II'~I'\I' ~...,II~l.lIl' --, B ji'il'''r.-ll;,~ml~;l-llij''ItUiiini~..tr- ""Ill' 1 Ilvh ._ I toll'''IU "'I'i r,lt:l~',/U \',m\ fl.\'J IIVM' GI ftI ,~I'".;,\'J'J.h1' l,ll1'!lGEI!I\,( luN OIl fILE <<:"'1 0'1 L!.JJ l c: If '1141, 0""1...." UC".Ulj'l,;tU!!!.!:.~ Sl,~'~,~, g~~I~,~~I,~~,!N~ORMATIO~, .', . t,1i'iiIt1IT'1I 1;1jI11;II,O" "IIIH 11110 .U;liiuh.o,~. tu.. "., tl\NlJ ""Ill ..h'I" , ~=~~;L_D .. U.."II.'W...O....I'" '" [,1 (JJI hU "l'-'llhl hll;.D ['1""'111 .IO"'U 61 r.IIA ll!Rli rill FIt E \r'1mnl11m'1m~ '1\-~"llt. '.u",llF.OI\ ' ..thJA" ,Hiai,iiP '"'hi J 11''''1)\.4'' I. h~wl Q~ tlaHhlhhO '"1'1(1'" ell 011. "bol,lliCl I' 5 "l,I~UC ,.1 h It. "GI"tll U F' ~ I j II I: 'i t'. 7 ,I J LOO 5 l~'~IN(, rq, 1111 l~nlhL2'11 ~'hD .bOll (I' '.(UI '1'I..~ril~n 111110'IIID 1,.-0 (;j1a-j";"h I'Lm:'ii1i"'rr~;n.-. U A rl~O~~I~fUJ1 III" Ill.V' I. '''14'''' 0 OSR,81 LYME DISEASE 0..'" 'II ~OU''''h ),. 1,( hlj " . " U~I.O'U"v.q M..Ht '''ON '" no ,'Ih"'h "tol,ltllh U"~,'" ell [,lilL"'~I."q 'I LIllI'" 1(;/:; II '15 ~ It 'i t ! , f1EEI"~ :, !.lIe I c'U r H .:.: ;.!( 0\ t-Inl l 0/:: I '95 ..; ~ I (, II wIT hliid ')(A':H ., . ....'t\1 4 IH:i-1 i 0/11 /'i~i ,041: I 0 J V ETART fi J T . f.I 10/311'15 A 4 J i (, l~rPA F: J tl 1 C 1.1.' : tH.. 4 ,: II I C I:; 1'9~ ~., 1.1 ;1 IH,P/,r,; I, I I,' (I l.f..' ";L 1'- MI. 4 V I ~,I, tlEI./ ~.om;mn 0i1iJ;rn;r;;Q '...tTI'~lh',."..br"ToI.I'.J..~ 'iOll"'"'II'JllrliiHj"I'I~''' II, . Jot 1oI11tI'-ij'dt'l HH~ HhllU hi. II "hO~" "'~lll" ....HI "11110'1 " ~~f,IJ'. ~~~~~~\~ \,I~~;~I"lI~lh 'f' ~ ;Jc: to~ll~ot'H l (~II,tt 110 SHAROtl c.rhTHII r :1, ",., 1 0 I ::J II 9 5 -U-,Ui:iOniI'itTD'UtNII' hI) )l IO,,1i I-';~'I;'-,ij-~~"--- --- 156628755 ~'. I ,'j ~. r. I : ... 1 ----..--- A"I'II(J\irilla ""..... C<;lJIj(ll (Jlj t.lfOIC"', MIl~ltI, t,~) :a"J:f:.Of 1I""Ie. "ltO tHI C, ...,IU (Ill' I (oe,. (;" I,., uc, 0"" II';' "~"'''IU 11i1""ILllfU ..ltIllll~I"IQ.t'hI"tHI" j'L-IIIl"'''I' Ih'II~IU' "Imll . Iffi;'fJ'T7iJl",inl1." rilul. 1J..lhc.,."tll'hb.\'ii'iiTi ,t\<;U I ,,,,,"ow.. !itJJrNfUlJW/,\ 1u Ir~~hlIUIO" n'.l Ht,tllll~ U"U''''QIU t 1'1' I 11'1 ,. II)O\lIIICI_OIJtlOHICII '.. "0 '''''''lin I l .I'UJI '"88''' '" "I) 1~1oI'I'h"I",n.Q ~ .. . ~ . .. - .. .. . .. .. .. . .. .. .. .. . .. .. .. .. . '10"111 IIUII<I_"'OI'Il"",1l IJ'"''~I''' ":1,1: o ,~J t; . 3: "ll' "hlh II I.~ 1",:---- 'I' I". '" O~~,~l lJES. S 1 0l,F; I ~ 1 ub~ I ~ I , ,,~ , , ni1rr,-..ltntl;i~-f- ""0>/ II) ".;r,hlq 1M'" , I [.~ .. (, I 11~:r.;nYfr"ln U'" " ... ,.\;n] , ""/l Ih-'-~hl.i,1 lib ,lilli, 1//0:, Ii 11'1/\ IOTAL I;Ahf. ~,t'l IW I r r,lJ~,I; ',:I W f. N I Z 'JI l Ll: I ,,; I 'i 4 1.(, - :J :: ~ E (; I 0.' C;:! t,'" :'~:,' i. h,;mHCFA'1Ioo(1:l4) 1'""" CHAMPUB,BOl I ,~'J ,Jill: I.. t. I ~ .l. , L "\I I 'l ," 00 t I Ill/I I' A : ',:.14 ! , , 't" h~Lll I.IJ(' II) I U 4 I I'lhll. IIILIJ~#..I,(lll~'"' LlII' ll'Ii~" IJ ,''' 'd'lll In ~111l.l ~",.,. 11Ill~~1 -'.4-'~:if:Jl~iJ'~---'r4-~;~;t~f.':~~----'- ~':~Thl~::~:_- -k~t;--~rS[~1H'''l\~''~ U~lt'I~1 ;;;:::--- ,1_1...__- __.._..I....L_, --n-' Ii -IDID!ID.1H -- - ..-. Y-JHilhl. hlWJji)~T)iJ.wniit11h}hirlr'Lliifililr,~~A RVtt~ u 1:n, ~ II U ~I~~III~W' I'i'Jijll;Ml.t'ililitliiiilffij------ 1'1 J" ~H Ijl Ullun 0 I I "" ILl fJ. lLt'. r." 111 nORn j''i\f~Hrilil~llil~ ~ill..ff"i'\m.i,ffli:lj.------..-- '.')U,n;tn i-~.-t_.- - ~_._,- l-i1Wf1~'I~ ttQ .ttlM\\V1tin J1"nir)~m--" ~b~," LUH/',l:Ii 1i1 h~t 1 .,., CJ eLl "..., I r,61,.2I: 'Ib\\ 1'1'1, .)() V f-A I nl'i~ r-~n:Jhn.~lal~iiiLI;',f;"lii',~r;;~rii-'."'-'- r,iit.nlli\~1ji}"'iiiJ1~~"MTTmn:iii~- lIll U"I"I' 1",,11 lollll" (J~ "',~ ~h& ~. ~( .Y ~ hi ,. Ihliu"I"'.'''''''1In1''U,bc.n.jt'bhlt.l~IIJII'' l'II~/OLh "" ~ ,.'" }~ ' ~...! --1.-J ,.,.11".1"" 1 I' I' \ III 0 I .., ~I 'il:~l' - I __ f1T,iI,.' It"d;ljii u - n ltt u III "IlUH'~.1 (lit "lr;:ruwT', t~,,~"IW'-U-- .... 1'1:1..."", '","I""lIhll'" · ''''1",,,..,,,,,.,.,1 ~b51J LUt11>El'j 6TIIEET ,.. 0 [J] ,," HI. ,JOY I"A I '15~~ , __!'~".~".~!~c~. ,,__ZLLb.~2:AJ.cU.L.__ .. ~ [II.""" 't'v".IJII. ,--~-..,- ~i.DI.I(IH'1l6'MTlj[;;l;il1ii)j(C-- ,"h.. I ll~h I "11'''"1 '1 I"l"t;.'l ..... "~,,,~..'iiiJI;; I. "'"'....IU II. Il',,,, .IJJ'hl" 1..11 'I"VI~"'~'/.i; 'JJII.'IIJl\- 1\'JTIHi1\17Al1011 ON :'ILE " h.'ll,,1 .~ 10. [J [J ".." ~__il1i.1jAl.llftli.-ill1....E.LlF --_---E!~--!l1.1J!f&.L5 It t.1'Jh'II,'''''~.~,.ul,'l;''''IIlI1''''1J1t1 ~HYSIOIAN OR SUPPLIER INFORMATIO u ~JmF.m-flli::f.i' '~l,'I}"t",1 "",;iT,o,~, ,.. , \,.".17,',:rttm,',~I~L, "'", \rm1nmn;rna-ro- If''"''6i11nn'\117l''Vlhll.1l . bl1T\DffiiliiIli;p.iii.rr ' "ilU""'lho,Qlill __ '''UN J 1""01.10" '. M". 9' "" ""Iltl) """1('"'' "","Ii'1 .oOj/l{I.~, "'-Ihll: 1I1..11t "1I1,"Ctj UP 1'1" I.OllIS GRltlr,r:fiLl no iir;tr.t:,OI It "".... ,,"u .djiifii"tTtt,:-at ~I,fioi'itl;;cn. III"C11iiiJ7ll;t;;j1i'1':;t~"t.ri;llJtt cl',UI '1ILl'" ~OVIJII . I', f:fllff.fLJ~I/,\ IfJ 1.0.... Ii )llOh Gl..-a ~Ut.l'II'O b,.CII"".UU ,... nHlnO.UI,)M"~O"".JIUtJ ll:ll'Dullb'hell IJ.~I."""G'. :,1 ; ~:~:l~\!~Clm~~ ~:;Il ~.;.~'~ ;I~'~ ..,r.cm, '""'IMI ," '".v,,, , ~hl" .,....\, ...." '''a B'" ,....I",."'.".IoG... hO .. .. .. .. .. ~ .. .. .. .. .. .. .. .. .. .. " .. .. .. .. .. .. , , /'IlIIJII ~U"tlH~'Uhlt'l 100 rJ~e7,13 j, , 'WI " V " "tl' "~ h Uhll e"'lle'Ulh.ct " "1(..", " li'~I.:n; L'. (""\(,01. Q' ~ , .' vhlll '0' l(J/25/95 : L' r- L F. ,~.I' ~~I'I 'J(~:: , [i I ,-" , 0\ tll'it 179':') lU~il/~~ (Ur(1r'?11 .:(,1'1 {Jf..::,,::l 4 tlE .1 ....il 1 eJl 3Tj9~. ~ 46 J 0 t'RE 6f; I t;C TEG~,PEfi~ EN (,S5.Ed I 4 ~..L tHiH 3~,"':, " Il 1r.14.'ttI~lIl~f\i: Irr,'I~~~'~:, r.. .. lI'I'~!7,W~'b~ ~\~~tl~il~ ""1'1' 10 .,. II ""0_" ;.HI.II,.."I 1'._Ir, 1$ H.tt~IoI,l"II"O~IIo"'h (~_'II. Chl~' .~, Ill';', ...cw. hI,) 1CW.Jf~,,~ U 1;11",11 110 SHAROtJ GErdEtnHf! ."1 I II C'IlIn, .. Yo.J"',jlll'lrr. "cCO\/Itl IrO ~ H)l)"""hl,),.h~- ltJb6~27~~ :.'J:~:.o, U"~ICl__IrO 1m 0' '111)'1(1110.1 (,"oat 01.11'1."0 '.: t (/ _ I, t .. I : "PI'hO\llfl By".... C:Ollt,Cll ON ~(OIl...1 blll~lll elU G I me; " ..ltIWIr "I , _I,'d, I ~9 ,:l ;1:',~U,~!fb'l m.m;,. " .~u'"c ~ 4041 :->0; . "'" IHf:, !tIC. P/f;/A TOTAl, ':Af,E ',b'l tWIT r~OAll .gl~Etn )"J1 l Ll, f'A 194IJO.3~f:!1l III () 1'1 ~ ~ .. : t, b b Fe,,,, HC~A,UOO 1',14 ""Ill CtlAMPUS.lO I ..: 'J ~" I " L\'I 'i: l,i. 1,11(11, .' " I. I', :',4 I "../I.. tll tJ ~ I IOln.11 , -1~""--.~\,i;:;\~;:;;'P' -,ntJ'~J,\:i\'U,;':,,' t:] ';~'::'~~,i' ,-..,..:"'" ...~'fl~i~:I;C:..._--_.~~- '" "T~II~".~li.-"'1thij--"I~-:~III~~~IIl.:.I. ..t"1 .1-1______ "--'---lfl' AN "Ir:(r-'~ cifirr]jJl' mr-----JoJ.J.J!J- '1-'''lij.'r.'1.r'i,..n..n;'il'';li;'''li'iijiil-..,...~A I~ r . II'fR\,.~P,~\,W ~,~- I nil , ,,"h...r,.,m.Twrnn..w.;mJ;Ju;;r;;;;-- ~, 11' t, . 'II "r,,. I , 'I . I ,. 1:.1 I I . ,. I' r" ,., r, '111 r;Tlilltrt.{rtJ.;\\'rHfllinn1,MT1;)tf,\Til--.-~"'-'-- ...- -- 1,j,I"r\,"n f -..j.';'~.- ",,~.:.. '-'-..' I-flWltt 'il"'htdr.~lT,m.n/)'l1iTT.m\ij>>iiillvsr ~~i"-- :'cE~' tUft!',!:'" :J'rr.~tl "~l' [~J []""',l If'',u;,(:,'t.!:i "1""""1_ Milt. l ~lh"ll,"" I' .,,\~ "',",,; III_l"".IIu>>It.',.," HllHll WT, JOY fie l'l~it:,: "I' 1I~",q ..,'~ l.I,'II' (J,... ~ "- ',., """ Q J;J' .hJ D ;,g"i'ltuHII'.INhlJ~'".hPllnlhIUlttIN"IlHI'" 111''''''''''''11 ~J:..~ '-I'll" ..,,,.III I'l'" . Ulllll1lll_ITiii"U"KTttT1I, I11'lJit"l1 ~ Jiijfl\mr,~n- i1' ~ I'~";'l~ 'I. rrm'U II -- ii-.~i:ijj"II. ~III' nr;pr.jjT (,I. ~1.ll 'I~ llllll, t"~'J~1! h'WI."U-"I)bJ,f~ " '-lid llllU' ""I .W11,,, J , · .",,,,, '"'''''''''' :HoI, L U~I['lil" ~1 f'EE T "'0 Q."" Ml, JOY f'A 175fi:! . .-.'!~'~."~._.Z LLH1:: tliL1.2. II. LI'H4~'''I~I,''''''II' '-~"',,;j -CI ~;:;';;;;;kil;m;;"nw.-oil- ~1.I"t I 1._,1t . 1 NI"'IU It n~1IW,,~",1J~W71Ill' tl"NI'frl"W'~" t~ttl~":~~l'rfrfrl'r~~~':t U~ 1'''~l~~~~:~~I;;:;-'--- i'i'~i'I~i~1 U'~L~i ~t11~~j1~f~':~' Sf IT' ,;rulJ.~~IJ';~hi'j)-M lJ' 11011"""'1'" .Iltlf' '1"1i Ii' 111~"U un/) Ihl ~ /Iii ~"I .It.Hn .UI,."ho 10' 1111111'1 p, '~I T' IlH.; I Z fl. T I u tf 0" F J t. E ~!:!L-51 (.1 !L!.!!tLli!i.LlLL----;;HVsriiiANOR.i1lfji'di~ftWfi~~A-TI~N~=",., ""',,' """'I~~___. rromOl ~-"n;iif;;;;I',in,"r;r.I;;;;E! . "",,,'.l"lpm111" I' r.h1"'lil"7;;r.:n;r-j,rnml;1".rr ,... ..., "'--, 'II "~\.,'" " ..Uinr~\j.uii;lihhil" IdN~ -1_ ,,,\;,1..,,, ''''1. 'II" _Llllh,.,", G..'....l (I' t""," " ~tl~.r:I~~Jfllb- In;lI!11imrm,,,,,".--- .---.-- TIll..Tll IH5URAHCE FOrM tlliJN 111tl>"",,1I 'I>uN WBllubm'''. ii"'h"ij;fojt;jjTii;.t,I~I~;'t;~.IoI:"Ii"';jI~,TM~~.,:,j11 01--; h";;( ,'1;11;-1 .~II;;~I;' 4i,;T j-', ii-iJ~~: ~5--'[k'~flU").r: ,f 'J "lId LOll J S r';If!,!~.tlr~.l"~' VCl.__....._, ~tH.I 'd,'ijjJ l,_j_hr'_____.,_____ ~~:.:~~.~ 011_ =m~ " ".",,,,,,,,,,,.... ''''''''~'''"''''''''''''''','''U,,'''''''.'',.t,,' "'''''''''' " ."'" , "'Oh"'U"",,,", ,,,,,...If.,, , II' D"Q 1.1''''1>'' lnrtl1\~~~nmliil117JnliiJl",)Ii~Ti1Tn~"imY;\1'31>Il').ll.lOJhl 'h '~'\I~lini~nT;r'I~~~'lJ -.- . . ;, (I~il.cl LV'11i ~ISE';"E ....", '''8 B" IlN'11 III"h''''~ '., hO .. .. .. - ~ . .. . .. M .. .. .. .. .. .. .. .. M ~ .. ... .. . ' I'~"I" lUltll..h,Hlh,"hU '~;,nijT.nr;)r~'~r,i;ff~'h(;iilji-- - lli;l.7,klunli~iilrt;j'r';Ullt~~...1~fGtmITi1iirhiJj"- II ht.,l.I'" l,.h [] [J ",.." ---_.,-- - " , OU'I.lIHIIIIU I~N II.) 10/::~;95 ,- It." '" II "~l~. TliiiiiIDn;:rrn.1JT1'i't1i"mi1\, III ~Ii'h l.ltI"(11i t:h l7,"ili1 lI""u~"II.lI":"'lll,d,.~H'If'I1f1 'l,m\jiiiTtl.t1 I') "'IoT, -L- ,IU'I"h\l"\I"u"UII,I,."I.II~II+~"l>Ilhh\I', : L,:~t,r.n~ ;.\~, " 'VI 4 t:r:,/ -- "",Yt, I 1I~1 ._~~ (1[; ~ I r~ I I ;1 f.,J 1~ 'tL' I'''''' - I' I'~ I .h~ ,... -----, --'-- ----t-- , , 1-- __,.:~fI1_ __D.~':._ .. I',L," t.,... o~~"",,",I' ",J ~-- , , c ICI~t--~}V It .",,(1 tM , '. ,/. ", ~ L - I "'1 ..-......_..;.:,-,-'-fu --on'" r-' ~!:.r...o.. II ,~t,l-:f;"~~I..~i '~t;1 I" ~ ,t:Clt I} OIJ h.... .lm"'H ", lAO n-f'ia'i;iriii~tiT;jI\I."'O"~rl' 'lh(lull,"" 'q'1ilT.'r.i;M ".'"llhi; li h/'ilift h,/frioi ',\;;,'jllllh" Uh IIrM~l"~1 H~,t loj lilt. 'lL .he d. ".UI' ~"I "1111,,1, 5H~,ROtl (.E"lErJJ r:o- lliH 11/J:'~/9~1 lru;i;Jn;naiir..u:lAAin;i)-.-----.--.----' ii-.tl..,:~.iii~;;ii.lj;.'.l, -,;i:-' -" :11 ~, !tl(, Ii.' 1''' f, ',/,.j ,I'JI/ RO~,D ;,,'\!,)!:tll r'.' 1 !.t.E, F'I, .t... l (I '1 :~, ~:' - '.. ~~ t. t: ill"" HCFWOO(i'7'i4j' ",'''' CtiAMPU5'~Ol IOTAl. CAr.t 15bb~:?'7~:~J ~:(.{':,': -",,,,,:, Of UI"", ""., IHI Ulllll;;(';;Olft~.;;i;t;:I_;lO----- ,.-'-".-~-17,~li;j.;j;jil;-,.-t;~~.7;I,t.I,'L "'N"'''.-, I)/j Nll;"..t t;IIl',r(l I,,~l 1'1400.. :::i:of. -fOil" oW~p;fiQjj "0'''' /I/lB.1600 I/t\ \,"' I", c ['L,' ~ L'.I I r ~ I 4 0 0 ,J~I(JN I'A"/341 Ill" Ii I L lJ~ I (0184 I tll"IIIII"~l,tl~hlt C1'JNt,I.lf'" Illil~ U"o\k H,ll '~"hIW,lbll).). W 1'M'. :CJ~~~li~~~ ;~'~'.]:J~fi)J~Ji"f~::--__.4 T-'Hlij~I"-h)~I.ln' )t~Hl",h(1)j~"ijr1iirlbin;;;1il . 11tffi\~:-.- ~Kit~mtlll--.-' 1J&....a:~'lJt;&~1~D,~I,,).;;~,:-- .. -.- iIDirmnIt!Q ____-Y..J.. ~-- I " ~~ j ,.'" >> J . 1".1.1;' W" liJ.mliirJiAr,;".r.flMjl;-.-ihililij---- 1"~'~1 !M!~fi.~.~~n flt.l.P.~rnm1il;--- - 'no,~Jnll-,Q.f,..-.J.J.:L__- \-l1mmhl-,M 1i'.~..IJhiM,1H1tJ;..., 'ht,,,i11T<- j6l',[< LUNLL:h HhEL:T ..., [J Q 11.'" I tjhb::IU55 111, JOY PA I n~,,, mitrOrrniO~ti;:JTV'hi~TU- r~m folti)ol" hQ It)" QItW" hfNT"tlllr:f. (1;'1" hOl ~b~~ LUN8LR STREET /1T. JOY PA 1 'lGfJ2 ._~~~~~~-2.lLJ:...~ ~ -llil!~_ . H;.'I:l'" II. lU'./'lJ'lI'O"'~O"' ,,,,,tv 0 [-] ",1"111 -.----,-8J-;tTiii- Ll~IHlll ,Ttfhfl;"'iiJ1Jji;rr--- , ..~, )'11".' l}lJl, I HI,IoIQ "'--=r'" 'j;j'I-~"~"J'O . ~ '.., .1 "~'yt. O"'llt~'1 o.~..;,,~-----------.- 'i-I '-ll',;t,;;"L ,,,., "I OJ .'''K'' ""11';;[, '0.'.'''.'". .. I.iil,;"o"" III II.., ~'Ibll,.,l!, '1Ir"hl _I'~I ,,'II IU.I,"L~I"1,l 'h"u"'''~I''.Ulllhl .. KAt! "~vt'''', ",.:JtI"'h'KIl) Lr"",O..IO" u' QIHlIl WI" '1""1" .111" b ""U , hI". '''0 q., UUC."hI,hl'lllJl'I AUTHOR1Z~T1UN ON FILE " . .' I~~~~~~ , ""f ," .. 0 . " llUIl,)'UH)'1l1 "..q . " 'Mil. '" 0' ,'U'I_'" UI,"'Luh UIlHtt,t;Il{'''tt,"U'''{'''1 ""1111 ,,1:. U".-IC' , ,. e.-; 10/30/95 ~..; ~ I 0 I V ["l.::I( SOLV O~Il.i>1 - -"- t 11/09/95 I \' .jCS. e I ----1/:/oa 1'15 ...L.. tiE ~ 'W"''''1.l ""l'hC~ , __..._...~.~~_"Q~_~I /:l i bjJ 11olH;}.. 0100 I. ht/"'j"U' t ......."\ilfil, "U',UII Ii~" h"~PlI"'" 'I" CllOl ," ." J 111'''1'''1 'II, ~---"-i;;iI~;'1 V~!il';l; --- Ill' U"IIII ~1I1,jj Iohllll , rI '-i-D ~ 'fOj;f)I~rmlif:-l- , "'''''''' "",C"IIIII '0 0 GJ "" .IQII,1l B 1..UUAl.!lIl[: nIl F II t: '''' ()., (. I r,~, - ,,;;n;r.rn.iI'iilnt;1'"IU"";.~' YBI,CI~'~1 ~~~,~,~,~I,~R,1~~ORM 1J.:titifH\,"''-liJlifo"j,"., 'll*"f'l cChl,"'Ol! n rU,Hm 1Tn111"Jlm!;nm'n--- 'IIOlll\CTThTm;aim111 -- l'iiulthlhll>tIilo ,11\,;.. --1IItIIlJl";'1I I' "'H.'1iliIiT~iih"ii-"ll"It'. "" ullll" WvltCllt. ""'It~~,n-llll ","';;01 UP J II" -1JllJ I R-1jr, l/HiEfiJ. no (," I 1,1 "of) I _I t1"",1-t.;tt,lXltli'i 0 , 'C'i'li ~M~[inn;nI1ifii7oiOj"j';j\~~iiiTTilil. 1195'14 :.i n-l~iiJ\~"lfl"'l ~, llilhlniJ1i1iilulIr ~Il"'l MQllo'I' Ie toflotlPo"follll lOIUloIh llll~ ..mil I "u, , ,0813.1l1 U'iE OlEiEAfil: ~1~:I~I~!,~r,fE,'I~;t~~11 ~/~l"~'M~II"u,~t~, la" ~f~~t "'h~ 10 tm~'l:l~ ""P'~ NUll ~ .. III.lill)h " :~f,'J': lhL ~ 'l~ \.("~~ f1"'" ~ 5HAlwr~ (,Er,TEN 1 TOI "." II / i 01/95 -Il""tu;'i'il;-it,\ hll~CIMI'-"iJ-- _.,~ -- ~,-_._. ,"- .""-liJ.~II-iu~\.;tl''j;-;ii-,;;-;- 1566~B755 t "'HI 01 U"~IC' 'l1b 1_,iOfi.I-;;;;("'~lu'l LOll" 0,. lIoI IHIo ",..~lU. 9__0 __9~l.Q::lf 1~2..1.__ ~1'1'IiO\lUlllr 'hi" (l)lJIKll W,f.llOIOl blllYltL 15.ll CJ~ I 5 ::',~,~III:~.I.,"hOllli '''!J I.:IHI"IO" 1"',\uII" II I" vlllU UJ 11t.\1 II. I::I'''~ t ,,,.. --- 'lC.hllll,I,t.llIo'l/I;,...tJII'UU"II"'llt.l.l", TION ~,.,:\'I~!,mN~!'"tP' I'll '1,,1~\~,r ' " c; INSURANCE FORM -1....l- wBllubmllted , "',"~ I '; '~I" IV I,%:~l: 011 - HlhulllD U .....'liOIl).lo'u llrOIi. "IIilO~"'IP ovl.;bl 'UlJII bUIUr--- '" tit) (II.MO'I:. 1 ....Ul '..OOhU ."OD'"u ""'I,t','''''I''1i ~ ~ .. .. - .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . HIIO" "VI"OH,'''IIl)""u a;ll~~'lU -r- ob" Uhr.. '.ll)iI""1o. " 'uo ~ , 0'\ (It,",UII IH?:, IN(, IJll3/A TOTAL CARt ./J" rnJT r rdJ~,1l ;1.1~lErll X\'ll.Lf., r'A 19460-333B 61 O/93~,<5bb fOl/JlIiCFA'1I00 (1,141 fOfm CHAMPUS.IOl I::: ~,i1H,1.1 Ll.oI,\ '" ".1',1 ~ J I: ! ~ (ll: 1.,IlJI, H, 1'1.1, I ~ ,lId I, I l_ U( I I ( I ~ I, I l'I_IIIIIIIt.V"~'lll (l M~ "hij "it!~" Uti, I, ",",'It ''II, ~.IIIIJ IH'" t- 1.lllh~'j '-~;;t.~~~-;:t'~;----' T~-r~.;i.,~:?~y, --i' ~lJ.~'~if'I;~~-.-~-'~..:Pll~\~I" .'1 .~;::-_.. :nrnJID-, JMil1i'i;'m....1i..U'1\:rnJ- ...\...___..--.U.J.... ----- ..!lohmuJIJf. Ii !;IlL.. _ ___ ___..,_____ J n", t;~. I, ';\11 1 lh~lJ l. h.11T II}l11;rNn~l1t..~. tfl/il.i1 ,"dlh, "l~Unl i"~: L_LL L__ r-iIWlh:!.+k~~f1.~IJ..l.,kRIUW'iio;l'1J.To"ilil'\'-" tHIl [J [l] HNUI I b6 tl ;:~ J til.~ '0' '. ---,-._--- '-0-' -.-.. -. ....-.-...,-, ~Jl'i:;:/:'Jl hili !:M,....~~ hUI ~-'r.'~~-. h~i.T~:~~~~~~:l.in~~:~ij,;;;;;;j~Mfj FI ! ., "l' I, -I I 111'1\[1 -,"'l.t,) )'r/n mHhnrt'ih .'\Ilnrnoli--.-------- ,:"t;i:' l UI'lbl.f, tli ,I; II r1T. ,}[J Y I~/I 1 ~t~b~ Ti.I,J t~mnitiI:1;r,iiIi rij',tir~hlii""----- r~hfijl.ni'olitl;;n.liilJli"iffiUi1i.lm;mllTniliifhij"j-- IIiJII.~hl"U "., l.'b't-fj<?'(I~ ", . ,,,,,1 II ,,", 11",;I.U1m;rl' "'''1/,lm101 H,.. TonJ;;ri';iIL'''''--- ~~~'J~" ,,~...~ -.i'D#.ill.l~h" IhlU',j;. LJ'."- .lh ~'~i~'I~" . '"l Ul\".l' <1",11 \JII,." . Cl ,---, 0 all. l7:ijT;l,..III~imlj~-- .. HIoh"nn'Il,"loIlhl 11.0 [1]hU , _, ('~I '11 ,,,Iv 0 [J e'",' "-r"~'" o"X "0' l~' "~I.''-'"' ,II I' ~''''11c'' '.'.'1 -----.---- ''''''llll'lJtI. "\1' lJ .It' 1,)IU~f"',~ h'''"1 u.tl'Or"',II,'n'(".\I....'.llv"..,..I...,',....,.. ", IJ""""~" , ItOI' ,,"u, Q IoIHHI 0" I) ,.., ~ II t ,..." (....'. H.lI f,., ",.,,1,1'1 !!illL_!U GN~L\!hlLJl!' ) ~'.J J.; ,I l]j'" ''''IIIIIUI'''''HI'U 'hllUIIIIIlllltllhlhul'" "'HIIl~H" .;I~J.Ull..'II..,.11l111 [Ill il.l~ t.~r~)1J11 .--.- ;6~b LUn~ER STREET 111, JO'l' PA I iti5:? .~~';.!~'~~~~..!_~_IILl..~1.:.EJl1 ;, ", 1'.'..'.....'.'-\,\.."0,.. ----.f-~i(ii;I-D.;~ 1'Jijl;1j';lirmi~il- ''''!oJ' I l;\Jh I hll'''IU ~I~;~""LI'''''' n' ""'I'" 01;'"" ".,,,,,,~,,. 11,1 'll~N '",'hilll 'ell' MUlTIJ be '.'1.1 ~UO'" rV1HORIZATIO~ ON FIL~ F- I LIL--__~_._____~ 01' ('iL?L.. 1l!l,.hllll'hl"I'lu...Il~I/I"I".,/III~I"Io<.o"1 PHYBICIAN OR BUPPLIER INFORMATION !f/S, PIC, I1lbU. ~ 4 IlU f I HI~.1l '11i1'111 )'Vlll E, U, l~ lIt- , . ~Jl.:J:'I;I.:,': t.;l:J/~~~~1'-2"~bi' --",NiiiVii; ii,,~-'--;,,"";i.".' ~m.HCFA.1&00 0,141 ljt, h1llJll.*1 U IiVH l e,'bl , l)t!l\ CHAMPU5.&OI i1ImJ n, .... :~l~!tM;'~\l t~fm\~i1'f~~""--r m\1I:~~ "",~,-'io,;;;TWi1;;1 ilDllnllin;mmQ-.~r6mrGrT~t#...II'11 "..u,,~ 16~o.,)"" ______ .'"0" -~_~__,__t It'''lJLJ"., '. h.... lJ,ltU'''''lhf)l'U''ICIH. uIIO""" 'Ovll(l ,'~ "".l" 1'''lhl.~",ClI UI:'! Iltl Ot/87 4 J LOU I fi GI, JtKE 1\ I, DC, Ii ",II>1:J Ii I ~ihij';.iHiii"~T~ttl"l UHiKiIiI'lhL'liIO,,' I)I",~ In~III"~Wll;lll;~ JrTi>!)<moti""on;"u". 01 Illhim~"'"t 111il1~OIi,'IOfjU~lj;1I111 lit tOI....." 0 II. ~11TJiTj;rr""" 1C'~lib~ cObl , OB5. & I L.Y~IE 01 ~Eh5E " " ,tJII' PLIi'!"'" "'I~~ytuilTt"1IT'jij(mi1l)iCTan'iiffii.r-- Ilolil,'Io"IUhlll,....LlH If,;jE,--- -~m~lY~'" CCCII ,I th "h """',,1\ ,. ~.'(I ~ l,;lil'IIl"...~I.hll~, . nUlo, Ufl~lq '"1,''' " " "IHI e' 1I ""~ I I II \, 'i I 'i!:j :Lf.For.w :G~ IllO;ln 4 1-, t-. 'I ~'1 C' 4 i t ~'IJ r-:htl tlE11 5tl tiEl! ":LI: : := 11 ;(, ALl. ------ ~,;;Il~,..,.. n o:r:;Jfif"'~''''''.~''-' "'~"111I"'''' " .'''.r...'..,..lI.\I,..'''...'.. "'1r.'1 I II tHin h.tl h.I..I.llhl''''~ eh I"~ Htl~1. H"IIIO .. [,'.'11I' "M~l Ibl "~'I ' . Ill' I~'"' ".1)'. .111 ullllO', ___~,~~_L.D"r.-~G~I__._ )ljo h/"1o 1lUl.,h ~1""'''11 hlJ SHARl1tl ('fF\TEt~1 T(f/ .... I III f, 1'1 ~" u 'Ioult ~m..m .[(iM,t hll jJ'j,;"N j'Uj.iml ~-":!;"lj~'-' 15tJ6207~j5 :a'J:~.m UIt"!'It,' ""'Il IH'I UJ UIi~lfI,1 1.1', (Oil" ell "'1 ...r, " ':';"I~~m'lil:.~I,,'~:"."~ Ot-.I,lll .mr~;h.II,lt ''''JW 11""~1I . .~li'i'Iil~lIT1rri11T1lTifij~I.II'~'IO" hi ' I,Tilf;I;:.lUfi,)".li.h'\'--- H,w'''I'' J 1J"'"''''111 - " ~"I.lMjk.ll)~I~1iTO ijIDt)t)I~'CIIOlj"ot'~'1 tI ~ I I hI) LI"flv'r. 'l , ''''1.11 '''D ...0 8'" .. ""01) "I","'lolf ~ ~.~. ~...... ..~.._.. ........ ~ ......, .'I,lllt t-vhUJ""UIl.l" hO ll'."~l:,l" I 1.I!1~.." .:01) ~J:-_~~ ~~ 0t.~ 131 I ::::: 1"111 {I ~,~ , ~, 1 I 21~_;!_L , , --.- --I , , t Ilhh,,,I-'''''' ;'1 P , , t- I , " ll~ut(ii;.iij'-t'--~-'-- "-WWijfl'iTOJ" "I'hr.IW' " ",,., t. 'I' I '., '"," tc: \ 0 ........ oJ t;1;3h:-:-: .. _ .'.1 LJ 'IT r~lmffi.~I,t'I"t~i ,. 11)~~;rr.Iii..l.ICliffi N'UlIlt - IOrr,1. o.I',E l'i4cO-3~3e 1'0"" owcp,uoo !'allll RRII-UOO ;1 ~o ij"~hH t'. ,'. !HII.lE 14li(1 f> fC'N tf I, ,', F'A 19~41 ,,In, L I I.I/L I ( ('IIHI -rilfuU~h~IJm~~qJlw-"rn,1ijI----__ __ :6f.r., LWlll""; 61""1i r D' .,.,,,,, .---- .,."," ~----r::r~\;i;;;;;;i"-'-'--'--i"",;;;r--_'ffi'j;m:;;;~.r;-'''I'' ,.,."""" ,.,.""..,,, mfr'''''''''' -It\. """'.'" - ""'---. ,..J..U..~" ""I 'r>>1~~rn."To''i\n;M1;"r;,11H''.;"/i;]li;iI"', r;nfffWfM,~" 1I,,,illill1!lITlli 0 ," 'I l~1t'ii1l1h01iT1",'m1lr1liliiiiJO,""" (III ' J L" (I 11"'Fllf I1llfltl '-1-):1 r~)fn .--,.1.':1-_- ..- J__.... 'ry~\\tli.'"ib+t;t~rJi~fi1.1rti:rml1i1~/)I. IhtIUD' "" .." [] eLl ",.., ll:ib6~lInrj "l HIIIII'~UIi~'lq f.l"lt.I'C~" 'L' 'II 01 ~J I\~; "blll""NIIH'",\~" 1I11l,M, NT. JOY PA 1'/552 lll' U")IO~1 1I01,.. ..11'1" o 1>, o'"'ih ~ n( . ijh '-1 J.:J 0 ~ 1t"Utl'I"""'t'\IJIIU~hI)CU.I"llJh'''''''OII'' 1"'\:"0' , '~ "'_IIII"~11 ~I'~ - p 1Ii;\"iil'iil'H-- \T 1'1 l.:T.iD'~"III7ilill I) ---. "'i"iI';;iUhlll..llurul'.".11 'II. ~l~ll 'l~ttJO., ___ '1Ollli It I '.H" .I~ _h I ,. ~ ~ 1,1 hi. 'It", I, I 11I1101 1'~O T11H.,1",-,;rliliT;i;ij;:io"L),hi~~~rrl-.- ~li':\lj~ffiijliiijnlf.otLil>1j1l h~~lIJJaTJmi'iitJ1.01 [IJ':hlJ II ."'I;IM ",Ill [] [.=J ..11'111 '14"'0 , 0 l'r1m1'JITiJ1lTn'1 I. " IiHuHNlih':Ofl'k '"" ~.,"""" ,,,''" J '''''M. I' """"O'"UI",tl"O~tI~"O"OItII" t.oVh~~t~i:...r;:-I'iiT"lt"':~u-r~ 1/'1"-1')1:1,,:, l' 1':,)" --lU-TCii1T~~~I'~IIUiT('""""Q I l'I""HOItC'U~' r ~ ..., '1 j,i'iltiih'lhllllD"r,-..-'." LOU! S GH ltlG Ell!, Po ,'.Il I b 130 I ..'",,,,, I.,,,,,,,,,. " ...w, '". ..to'l".. ..""" ".1" "..',,, """',',, "I."".,,,.,, ""I ,nrrw -1fiIh ....,..... I\"''Jrmn/;;l'iiit;;rinr, """""'" I'" " r "1.1 "Il""l,ll~ n-rrill3R~]llijJJ"'Eri'imu OIlI"~I.IIlJ "ltj.1I j)..4Itu' ~ 10 tliutIU..... ," (ll,,,,,,,, II t, ~m~n;rn~r}T~.':" . -- " ... - I ".." '"88''' : 088.131 LYNE prSEA&E '.NIlI"I.h"'''O '.. "'I) .... ......................................., . t'/lIl..1l ""'''01'''''''0'' "I) .. . ., < rlJjlll~.,tClttJ t'hotLl1yfllJ t~IlI'.1 Ufl~ltl, IJlIl';;'~IH- t--'- . - 1l."O'Ulf)-lq hH' Uti".,., '''C,.,." IM"~1~'/l "!l' IIUhl'...ltll "10110 10 .. r.Cm,VI"' '""', ,IHI .II,lJ....~!J~. ..".." 1 LIi ('11(,,/1111."(1111 (I"~"" " t.11l~!C1 ....:IJ ',hlt. '" 1 1/07/95 1/..PE Ii' At~ E r. GI';E 11r;- o tL~: ~ :n , -L IIE\I I'OC ., P 11107/95 5\'fll t'~f 'J,: ,; ,lillt:n,_ (lei>. si f I 1-.4 E tiE ~, I'BC 4 P 11/07/95 P.4 61 0 PRtl (ME OIlS.131 --; t-L tlF.w :'40 . p 11/01/95- 1\4610 OT SET 1('.1 7 III ' os~':l1 -~-.. ~ 1 f---L /IEw I ~;fiC . p . II iOi/9~- A4610 I V ll!E1 tiC, lMi: SCII. U G fiE. ~ S 1 , 4 T I ON EEl tiE ~, II EI:?(: 7 P 11 I07/9~J A(I~lo- NEEnLE :: ~ GlTt7 USC).81 , 4 IIHI ~176 21 P 1rf:"'~'1::!~\if';lih . ."'r::I~!'''''u~h!l.'I\~'ll' 1l'.1 It .(V:11 ~'II'~~l~1 \1 lIiQtlltr;t.l, 10' '..., "..or-~ It ...... "'.,r ""'" 1>>1 II.):NII ~ /I~I lit ,,;r,.. 1.1~r.'II"O " ~ III H'I'I~'Q (\1,. "It'll _(,_I "1' Ill. . "'.lll. .,11 1I1111 I lIlt '9~ I 119 It ,..OJ .~-. lI-~"L'~Vij~~ .IIP701i41il~~'U3Ji." 'l"rA1O' III 'II IH.. hO " IOljli 'l..;/;,,_~ Ilc:...Mt"ll SHAfilltl C. ER T 011 rol fliHi I 11/1:. . III f; I A fOUl. CAfiF. II..,. 111lb/9~, ~. ~) .'1 t.u 1'1 h{j~,D 'ir'too"'niji,1-1~1::~U),hrh.).- ~. --.'-0--,.- Ii". iijl~;; i ;~;-;~, i '" iii'I;;; '. ,- -_._._~....- i,,/WI: II! X V II. Ll, f t-, I 9 4 6 (1- J ~j :I e -1.56628755 - ::, 1 C, ~.iL;:}L____ _~J!.l () 12.:1::"-25iJ/1 e ;1'J:~:.O' UIlWIC' ,.hO "PI QI "!Iltltl (f1)1' ClIlln ll'" 110' .H.~ -.rl'llil\'ll, lit -.'H 10Ultl.,\ (JII '~l DIU I ~lIt'l'lq e,jJ3 I d) tillf I' I.L (" '" :,IJ~ 11- 14(j(1 1'1,1111/ ~ r'l, II,:. ,\ : .. '\. - .." - - /luLul U,( I I () I B41 "I ~i1U II,.....J"~L (~~,y Ill<l~ I~".. (to 'H-\ IU~III '''''''I,W U.l~" 11Ill.M1 . ]~I ~W::..:.i,-,:,u ,.tJ','t.'.'I::'if,:'; - , '['-1' f;':lil~~: ;':"."T~ .~:'F,~,7t.1~'-- ~ t,I,IJ. .T~li"7Ui;iJ--- , U~I~\~"~II '~'" .1_.1..._...,_..,_..... .---.--.AI111lY::T m'll-. -80 .c-!fOO1Rr .1-1~1Ihnh;.wliiUlll.wJ f'''U;....Hf'NliJj''..-.-h;IIj.~ --.A nUfA,fh~F,~,t'rl,~_Bt II ~ lit II Tllh "'111"",'1. ,~r;;;.m~~j r hhh~ Mi~;t WI rftMI\~'mToIHi'--'." - ..-. -..- nn,Rhll,..J!;;...1....:. :1.._.__ r:j\m.E.I"J."B'8.~,~t~ll-Rfh~\Til;1~1ir-- "L'('.l, I.lItllEI' blli~EI ""'!:] [1.J""" 1t5"";:&nti T----rrI~fhr'1.l11T~i;i..,:;fllr,ht'Uiil1i--'- t'ih..'i;;;~;'iili""ilir"QliQU" ",We ull 'lc..tlJ.."" hOI (;I;t-.r '1 ,~, 5 11'"11''1111'11'1'01''' IhIHIHIIoIII'. 'NhUII" ..,"hi'''", ~~"'lJl) ''''',tllIllI flll U,lt '1'0>1111 - ~b~8 LUN~ER 5T~EEl NT, JOY PA 17~t52 - -'~~:.".':'-'~-ZJ.z....A~e.n..4.1. " "~'I,lhl II. "'.....h1.U.'JM.IJ". '.,to, [--"J I J U"," -'---~-~1~f.;nz=;~ - --- ,.u.... - 'L-J ;, r:~'/,~JM\r.V'I'\~:tIPr."~.~r,iJf:!~r',~~1i~1i1,~Wlt]I.'tJ,,,i~ilYtJ ,:.:,. ,". ,::::;;:::::;;-.-;-;;:;:-_. -;; 1:~i:i~jwtm;'l;::i'I~lmml.,S/ll' ,:PuW:~'~"''" lJllllh'''''hllh~ " "".1"''''1,,11) IoI'"llIll"TI) It," /II, VlI.1) Jt'.."T.. U....hul..1 11111;" ,l.U'fIHlrlllATION ON FILE :: -filJ.itlA.IUcLlJtLE.lll...---~HV6lciA-N 0 A ij~pp[;~~ fJFb~~A TI~.N' "!:,~~~"/lI"'","" I, ""11)/ ''''mI';;;iiiTIJiiffiM-1;;;o;'''.....--r. -,;tl\ir.H"~;;'"r...;;,;,,i'\;;"- " """r.;1,'tt "'''!'.' ,,' 11IT11"T1tl~~I'~" .... l~ttjOf")11J1i "1~Mh 'IlUt'l t "1.,lIlJ" . .,,,,,'U.A'I.'lh IIJIl11/uJi, Q'll'J.IU '. (lOlHM ilDllnlTillil"lliTlO-' .,VJ.l1i1it11mni;iliiTliTr- --------.......1>>llLi)."Ullii'tjj,bll,l.l~ IilluIIIlIt'lwu"" ,_,___,__ I Ill;"" __________1_1-',101.1'1'111 _')olj~ _ 11/I'U)t.IQl' 'Ii "HlIO' ""1 "''''IItQ,.,n'KI,,,"''iii''Cl.:j"'l t.oUfllll'f "~I"ll "IHII.,qhll, UP I t II I) ~ i' - ,/0 ,.. ~'T"'''lliu,mrrnnl'lll'c''''~TimlIt;''o'H , ,... ., ~ I 'I ..: 'L.~"l _IIUh,l".O,,(. -WlIllj c;r,lltlul'J:lL nn 'ilt II. I ~()1 ".""" 1",,,,,,,,,,, tl "'WnhlJ ..iiii1iUl 0' ;'CI~I-\tIII".,rr.--;':nrli(hnt:ju;;rnt.'1;-r.;-~ diiJliiii----- ~1j,..0I4~IO"1 ~clt" 'IIIIoll'im;uuU,tII0lJIIlJlhQ1-- IHC~lI"hlj" ~im~t~n"'i"ThI\m~l}in"l. ~m'il,l(~~"OinirnThl" h,"N~I/I" I . I _ ;,OS8.IlI LYME PISEASE I ''''''' "'88"" "''''1 I h'ItIt'''Q I" 110 ~ . - .. .. .. . .. .. ~ .. .. - .. .. .. ~ .. .. .. .. .. .. . I ....~ H,11"Ltl""IIQI"lO 1--'-- IH. JOY r. A Ilti ~I : 'III II'h.1I U'<llj loll'''' ,,,,,..,,,,,. 7~" l:f'1~1."'" r.1 r1 '.-' D ~ 1111'111 l,hllll ....'I.....fYil~ niillrljllt m,,~iT-\I"lrlli11l-- "L-~tTi.i;'i,J~..Tliilf't-L-- t:~~'J~I" hU41 .."u ~llM". ~~.U" 11;11,,, III lId' ~'~'.',\ 'h, r , ..I 1111 "WI'I'.;'''11t1 11'0 ClJ,II'l , ,.,..cn"=,'1l""'" .n;;rmr"",,,,,,,,,'I. _, hlh""I;lli'~If"i.cll ,It 0111'1.- r.rn-~',W". (IJIII. ,U~''''II''ItI,/'u~1 U"~'{"il"{ "'~WLI...{", A4bl0 NE ~"L rU~Ex tIEl" ; ,161\1 liS 1(,ML flEW ~,461 0 I/Er:~)~E ~1Ir.IOU,lH ""'1. .." III, ~I MillO IIEr:nL E W~IO(AlH :'4 G . !lUL 1,4tlO 1 V 5 r ~ ~;r II T _",iiU11n-;iCl- tJ,.,.~r;.,. U"~'ll' ~- (J6~ I ~ 1 : -/""f\'SO J!.::.~l , 'j'6(1 OBS. e I , ub6. ~ I -f4~ , :'7 (I {J;::~, I ~ I , lll~' " ."..l,n'",. . ' "",I, I.' H P t P ~ p - I f' -- NEW 1?C A,'t~ilEPM,I'i IO\lIlrlL (,[.E,1!1 ~ flEW I ~1[:'0C .i3 P ~':Cl" ,t,Io'G""I"II,.rill",,~_l_r,r"li:f~1 (1'~"l<1 ~ ''''')0,,1''''''0 """"tllM '1_'hlL';lH)I,lI "HI, I " :71 '7CJ J 377 70 ~ r-, .." 1'1~I1iil7j,ifrl>"i~M~1i:"llio" 4kov, h,Nl-tl ii, U '1. crull ------'rl~~ ~~_ .11111., 'tolJ" hI) ~ 11",1, ~l" '~I 1(.."'" h'. 4 ~,..t.'1 01 'i"l"'" ,\ '"f.::riWt"" "II'" ,,\1.'11,11 ~" " ""lhlll'lll 1""'"1"1' ',I~,l"'I""l.Ilt'I". ~,,,~, Hill I" I'" It\ 1-"'0" WUIf, ~ 'M "1"1 II fiHAROtI GErnUJI r(1i ""' II/lbl'?f, lrt3iiiiil1ilhl, "UJ)yltlh.J'--.--- - - ,. -._,- 1566~" 7~J5 p Olf-, INc. 1I/[<1I, "IJ'\ IIIJIT [,OM -ll- -il:,~i"wh'i;'il'~~ii-h---:-:--.-- "_'_"__h .' il,(.,1F. N t X V J l. L E, PI, 'II ,,, _.__ ._.;~.!i'.: ", I ::..~l~___...,~ ,__~~. 0 ,. 9 =' !) - ~~; 6 6 ""I""IVllJ ", "t~... I.f Hlllf,IL 1,1. I,Illlll,...1 I,l 11','11 l I.I~J ----,---- '_._----~'.- -, . ""q 0' ""VI(I "hlllltl mUll,,, I ,II" I I.l~I.1 ~ l.h 'ill U, ~ "I"'''~' TOTAL CARE 19460"3338 IlliG lil'IEH,( nunE 1400 ~Ol(JN l:I, ... , , lfiJlOI . ~, . I, lu~ I \ ~ 10 I 04) PI, 1'1:14 I D rJ,'i:.tW,:;;---_. 1X~r<~~ ,.,--r.:nii.~f;~:'--'-,~~-T.'I'~:f~"----ilr.It.'1;m,,;..-~ij,I!'..,,, ..:;-- . mHi miTis muHIilJ1JP.9- riili- --_lO.OI.L.!!.! . ....-nfijl.1TmliillT1il\lTI~imYl.1t{j&iT~il..HI nfJi:trn" ~r I II . .fl III U l~fwrii'in;;~unan~ilma Illjll~1l --.- n\l,RAIL-.!.!LL 1!:1.._. 1':\\\rll:,~,M~rit,UI1rR.RN1Jqlililf.mmrm-- N~II [] [l.l 'IN~II I t>i/jh~'U 7~t1 It I J.11111~UlhJ.h(. tl -"101 'lit-I'll ," ~ ~ 11",,1, ,,"I II !l'NtI."IJ 1t,1"" NII^~'j 'rh,~,lh~IHNl\1qWm" ,., "'hI, :t6~l< LUi'lbEh Ii'II~EE r NT, JOY PA 17~B2 III1 11"'>11 ''''Ill lillll" \~EL-,t.I'I', ~ I ~ ! ~.- ~- , ijJ' g'" p. [I "lj"~llllll)I.IN~llJlIlI-.ItIHl)II"II.lU'loIt'1l11lll "III"IILhlhU I' I" ,~l ' I. , ,..,.J 1".,111 "HI, tOil t', l'tlhu I (~\.I"iH\'1It!t;.),I) lllt;'"\:ii;iiTl1lla--W ~ "[m;r.;-\"1hl,jj,ilu,) ---- 1i....,M;"I;ijjt.~I)I:hl'~.tll'lll(II'LI.I.'!~t()1l11 ~"~nlttl'l "....1011 " p ~I) ..1 h ~ III S..'\iill H:~I H~lu.r,li , " · ,,,,,",,,",,,,,,,", ~'IJLb lUN~r:'~ 5TI\~ET '''0 [lJ,.,,, Nr. JOY fA 17552 ~1."':'::~.':~_LLLh5 ~t -_tlill.~.. " . (tt~IoI"""l'Uh'VIt' . ~1-B-~C';;j'-~~t'll -Ul1ifiiJJflffii(, U.lvl I =o:c Ilvll l--I""~I I ."I"'ILl It r~tl/,~JM1~ r.~111~mp l,tI_~t".ll t:~~t I,t,litmf t:l.r,:~,~,J ltW\'I~~'U~ ~;-) l-:~--:~~'~ ~:; ~"~.I~~~;"" ,.-- I.-j ~~t'l:~~rl!l: u~i~.Nt tRfl~~I~~' t Lt, ,tIt UIWJ'~I4,,1il- ."""'~"Ih\'Il"",r"''''lh10".." ,,"10 "",,,r,",,, r",n..",.," """". ';lnH[J"ll/l110I~ ON FILE ~L_M r;rJA T ~.i_Q!LL1!:.L__..~_____--2!!~.!_,,_!Jl./.{! t!_~ ~~__ }:~!!Il;"I'''''lollilJll.lIhHI/4'''Il~ PHYSIC'M~ OR SUPPLIER INFORMATION II D....U 01 ' ..... 111"'"I'lkU ..14J.loIolJ 0'" Ihtlllll ~1'"irI";11 "lill {L1,b:i1jj)ii)~TiW1j;,r;~ I~ It,.t~l'''I' !'~p.l uwllir----';"li"llolUj!Mtt .... ,,,"""'0.....,..",'...,"" I '''",'Ii," ',"",,,,,,,,.,, ''''"~'-'''I'''''.~ I, ~t:U:l~'::J..\mr- 1r1)ntrlJni)llT1i'~.I!III. . -. jt"'n'iifml'J.~bl'~h'lt fl*lJ~ -1,..t1UOlill '''uN _" 111'klNlJtt I. h_WI D' "'tllllllhQ I',:l.lCiihO;' Qljoj'" tOIl'I(j I'~ I'IIIHI( I"Hill ~IH."(11 UF' I t~ I; n9 S., 4 3 "l.!~lri~l'fJf.tJV~J.Tijl:"OltOI~' LOUI S GIn NGER J, no r.R l & 130 I ."."... I...",..... ~1_ltb -OOII'U v, '.(Illlt Vl-I'lilt ~I"~I(" "'''111'''11 I;t 011'111111." "';N(~iiOiliCll '"fnj. l.IKIII~lijht ~OiIiirITJI'IPI )01111 c"tt',,- ;-.m~hr.l;fi'HI~:1ir~,Hij.lhl;j~Ii~'--- r-;hLl;~nin;k1mu"lii" 1iliu.1I' Mt.l. Oil f,r~ lTliWi't6l- ~ h('llld ~v t" [J L~] ""'" IHI ~O~~t g~I~"t O'.ILlhlt'Oiaj~J7ffi b,_(ItyO~"lo f~otIIMI~.?IIlN" tl.) ~ hl;'iffii'ilI_,L!, ~ oao.81 LYI'I[ OJ6EA&r: I lito LIlJ.ttQH I '''01 "'8B"" ... 110 I ~H'11 "I."I.'~O to , I' e I.I~' r.\\,'r~J 1"""L'l"J "~."., "iii<m~ ,,,.,,,,. D_UVFUIt)1(1 f'tJ.q 01 Ill.. Heli ~,I "t " "..'" ,. o. ~Gl" I oHl'l ~lh "lllIb~'i U /4,I~I' ':"ll!lu,"~1 J.MI.j !)'.,~L1'" LI "~I~f .L lli07/9t5 ti46lC, HEP,\~; 1"1 I ,j Illl.' Ml IOl'Il 08f:. ill 4 VJAL IIEW t~W,1.Il".III." "I) ....~.......~ ~~.........._~~..-....... 1I1~\<iH "It' 1I~r1. l'IlH'h_"" . . t., I eO( p -- I , - ,. t t !-,-- I I . --t--- I .. '"'!.'I'''Oh.''' ",,,""];JhT="- jIlijll' ,""~I-'i-j~~~rNhl ,,\ti I" Ih_"ClO<.l, (j .,"'~ UI'LI1 ,~II "'C,, I hQ 0 ,-.-=---,..},:O'Lu I_==L~ 6 00 ~.,_~~~~ J' ~~~_. .~~,_ II ~~t.if:"~'~l.r'l"''tI;'/1 ."lllv II"fJII' hJ.hI" J.I)O_'" II' (.IlOl ,Iq IUII'w..,H I(LHIIIhl) ~ 1rJi\1'l.jll"IO' ''''If.'''' 'F"" t"" A""IH'~ QI'II'II ......" " [I 1"'111 [I 11'11'''/ ,. ,-Itl ..."" IJh III' ,.l~Ct"Ll ~""I t 10 HII II ~hD _" "'~VI.' tll 111/11 'I SHARON &ERTEtIlTCH HHS, ItlC, 0.'[1/1, IOT~.L ~(\~:E "'" 11/1 6 (n~ :, to ,1 ti U TT rdl~. p II ",."..".,,,,,,,,,,,t,. - r."""";;U>i;-;;;-;;;;------.-,;JWE Id x v 11..1..10, PI, 1'746('.3 3311 156628755 , 510:~1:'! hIO/~~5-2566 :,"':~~,o, UIlYICI ...hl) '"'' O. t1"~tCllll) 'I eflPI, 0" 11.IIIH.' .PPIiOyto U~ ......u COlJt1CU hi 011 holfflll.,IL flfllYIt:E b'IIJ I , :. II ... I. i. ~ ll~' . iiU I 'I: 14,10 F) '1111 ," '.. :, ~ I L LJ(, 1 10184 ) r- 1\ ~"': 4 "I '-I lit I".U""'"'U (~"'h1I":tlU lljltO *,,\J(I~I,114h>>1UJJU.{J("INIUM IU~I"''''IU''Q=m QIt,... _"1._ 1l111"UIIUIJI II'" "~IH '111" h""1 1.lluUII ihil....ll 2b~~ LUrllER 5Thl:Ef i'1'1 f.'.l ", ill7/,r, ,n;fI1 r~'~' ,~- rnm;.i""t';NIJ ."'0 [J...", lebb::e'/55 " 1'1 J ",.r.!' ljl Ill1llfl .,4t1n"lhtJ~\l~ .in'1:tI.nrrJ;J.-'~iiHI HT. JOY F f, ..... I1tTi"iilTilio';~ii:;TQ,hf,;iiiiJ--- '. IhlwliIO.OIlO.lt'"o ttlIlONJ\l'h"WJOll'.(..Cu.IIoIItO,-- ~65~ LUMBER STREET MT. JOY PA 17552 ~~~~~~LL.J&:1" e n 4 :-I (1'~Wtf'VI.I'o"~". -;:tTI;-'-~~ ." "(1,[ Ullwl(' .I~h,~ I lJl/h L-J "I- I ...."110 ';f-r"'I"ll~"X'''.",lt~.tl'''o'~ ,.""u"~'~I""'}"-'/'~"' '"f'''IIt---------- -"I~",'bl".1h .. "J""" ....,'" '.....,....,,, HI .,1) II II, ,.\.,.. t ~~t bb'h,'toIu II.)" Ii, -~'l ~It '1..1'01.1,._,.,. ~llu"I..'HI'I>IIoI'toI h'."I"'ri .V"t\1 iI,OI ""uClll ~ 'IIU Inow u, Qt)~'" w'h t "HI. lit"" WI".' (\ Q It,. "I 1'0 _n _Glto'ohWIl,lll\C"" AUTflordZATIOtl Uti FILE ~_....fi.l.al1A1J!E.E..~Lf_1l..f. ...!:~ 07 /(It&..Li'f.:-. ~~_l/I"C"Il'Uf1"Wl", l'HY61CIAN OR IlUPPLIER INfORMATION 111"lrifj"llin)iall)Wloil'h~IJII' ~NiiT~i71lil,w;u" h. I I~ iill II Il~ I"Cl' fl;i(lfti p",n"~h Ill..... It;hl.llll;I, .''''1'' III> 01) 0."0 II hl.t.,',. .,,1<; o [~l ~1t'1" 1,-n.."OI Irti'1rmjJ;rnrr,.,- , ii) u""l' ~tJ"" b l1ii1'iffiniUl.v') uT..@,r"~TI .,1 t (II[~ INSURANCE FORM WSS submllfed 011 Ii', , 'i / _____.___ ~~_ 1.II'''1JIJ(,1I ., "_101' Of ~t' "(1""1) ~I'U'('~" 0," 011'1" .Ul//I(fl.' ""111'( I" .\111 ~4' hl.tl UP ItJ n I, Oll IlLyI'd N(;I'I~l.!... D(L Gr- !-fI..t:1C' , il """'1 ~"Il_I)I)"fLt~)"""III~1 J.ti~IO~ "'MlIHb 1,.01,.1/1 10" IoUW, c" ell'UI Il~ ~ 1,1 3 'Io11W . .....nTlii';w - loull,Ij,llfil "IJWltIlU ,. ~"~I...~ii1L",." m- '" n to ri~4~il.o\ ~tt'UIlI 0' 'HhULlJ_ .hll/'" fllI,.l, b.,.l,\hO.,. 10 l..tl(IOv"I'ii;tIJ~\JW';D III ",HlllhU IoUllUIl. I , I : <lIlB.SI L\'Mr. OISU,SE l . 100 e....'.ul. ""Of '''8 B-o '.1 hO ''''''IIf'\..hhlhO " , " e ~~~~~.;'IU' f .Y, W<' ,,' " " 'El' _ , ~ I.A , """UU")KI HI.,{I ,,- " " "klW 10 ~'\'I'''''.''' 0,.....1 .l~ I . , .. /l~'~ I I' ". --L- 11'l'l_I" "Illl.IIH UII)lq"L:lIi;'''lI.W~I''hLI~ cou 'U.liijU 11"11. ,.. 1/0:;/95 ::OLl.(j1o. I/f' Ill';'" I //(. \' I (Jc6,~1 I ~ !i T tiE I ()(,I(}( P '/I'IJ" ~\lljIOIl.hllU" ..0 ............................................. ~~II.1 "'I'P 10 .. tU) .DhQ )) U}lJIl..-x'h e'j"'UhQ o L " 0 ~ I 100 ',.,0 J' t:b.11:j.~~lJt~"t~1 ~ 010 ",.WJ. .. "UII' . no (10 , en SHAFON GERTENIT(H "'" 1l/30/ni :t.a 10IJ1l .u..,., I _CUJulffho------.. 156628755 . "'.e1 0/' ........et "hD II" 0' II"~I{I rt Q.I (oen nh 1111 I". fI,,.Ual :',)(<'t)-l.. 'j --- . """110VltJ Ot .&t.l... COllt,ell O/i ',1~r;IL"'~ bEIlVIC( 1I,1ll ill(" Itl(, [)iHA TOTM ':~.h" 't4 Nun H1P,Jj ,J'.J;jEtlJ X','Ii.L.E, Pf, 194~0-:133e ld 0 I r,~; ~~ - ~'':,6() FOIl" HCFA,noO (1.1. FGlm CHAMPU6.501 )1 ,iMlwiViiiliil:-h;:---'--. I h ~"l h::l [I ,I lilli, TF 14vO l: t f {,III r' I' f, j '; ~ ,II r1I.1.l11 lU,1 " (111$ 4 ) tllhllllh~IJIi~"(. LI f.J1oI 'lIlII;. '~I'll~ N 1~""~lllllM.lhl-ll U,lt..',. lill ')"'1 -CI-:tJ~~'.~l;:;-=r:l~'tJJIUt~~:;I--- -r:r~lft~\f(~ ~I~j--~ - -~Qi1i~~~~lJ,,~ ii.trluii)-- 1 ~ ~1~tll'll ...."1 . ----, - ilIlRnH m- ..... Q.ftI!l!lfl ----.--,-- , 1-.}l.,"1 """1l1 jillf"linl"~l'hlll\lji'",'I";l;l1.A - Q1lft:r.~~RI,lt\" i "" nWIlJ-;;J\r,..lln",n;11lr.1l>1iiTOJ;itml'- T'~~A~,{Ir,fu1,jhrrtJf\Pfll1n;ra;r,~----- rn,i!.,h..I..~:...-L/....:'L_.,,- rPiWtff~i /;-'Mkf.~~Jrl/Mfuo" ,,,,U"I m-- ::b'~[' l.lllll.Uf, ~T"EET "" [J ,C] ".", IEllt~~'1~~; ll"ll< 11'1"1' tl'l~iiS;rr;:ffi)'ht;';;iijj)--" '''~lI~lb' ~"(N~Il1i~lr;IJtfi'iini'hlll,)ll,.t. ttllllllJO, - ~'''III "lrp"!5 \/ '~ltJ~Uhllll~IHhlJlll.l'''I)L(nl'''O.) .wI'ltHIN h~HIII POh IMlJ~ I"" HH~ I ~ I\IIIHI 1:111 UUl (.~ t.bblt ./Jl,I' L'J~lIr,ER EiThl!r: T N r, JOY r-A I 7!5r,~ --'~~""~~~_.2.L'1 '.fl~t..~O A "/ .. ft,,-,llltl II. lItH/I""~.""""o", .",10. 0 0 ..1"111 ----iE' '(1')1 lP.:IHIIl II W ~ I,Il'l ' l,l I rtu' I~ J"W,~ ~'\~I"l 1, "~lt~w,~nL'lltl:I~~I' '/iiI"j,'/'ijjlfu ~,:;;,~ \,,~~;;:,~~;;;;';;-"- 'I 1t.1t:l~f"Ut[~[t:~lll\I:,NofIT" Ilf~.A\IJ~."" b t.hf~It",~" Iil~" l'lt " IJ IJ'IU.'~ o~'T61"1" ~II \lito!) lq~fl'.llljhl/ ",I 'h~>> ~,ldHCJI~,IUTIOIi (Jtj FIL~ !1\Jhll) 6.LLJ1ATltRr! or' .El.LZ--____ ~!.L.Jl.2...::.!!.L.~2:.:. l""llllt'"''''''IIJl;'''ljIULA'''II.l~'''bll''' ..'___ IDSICII\N 011 SUPPll~IlINFOIlMI\TlOt1r.m 1TlilTID1- 'I'" ,', , ""/"""" TO; "'ilr;j;\j,,,,,;;;mroo,,,,,,r.;;\-,' '11. I' '".'TIl;m;r--~~-- II:LIDI,111l "'_hltlll" tl;I,I.o,j..1i , l.t''''I'h(;~,l;~.UIiI-'Q''Il)III~~ rr RnU:I~~J,.\'1 II) I lli o. tou.\. 1I,.1liiilT"--'-- .---..---~- j]lir;t;lliiJ.l;;:i1\,l'Ilo. ,H ~_______L"""""" _ ",.. INSURANCE FORM ., ".hll Of UI"""IItQ "tll'le"", ell Oli,llI LOlIIl'lln l'vIIl'C l'l;.du 'ijlhUl UP III If P ,; ~ "; '1 ~I p;j t.~t~lll: WBlliubrnlllod I {lIll El r. r~ LtJ r.:E.I~ I I fl,Q (, r, II, I ;:ull ".'"Ii' \' ') . 't ' ~I 1'1"101. ""0 "llbltii l.lr;"(I~1 -r;;;tiiT1TMIi2Tr,,"'ihiJ~~r.. hl)wrQTt~nitT;----~--'- n-mm.l 011__ M T, JO Y r.t, 17ti5;' ",,,,,"'. 7.' '~WfR'" f]'I" I I' I' . I U ~ I r ~I II' III ben~' Ui~ "~." "..':'M\,~lI lI'."H n _ T}'------D l"~I~'~~ II " " "~I.j"I., whl.-I~I"I I'~D ~I.IJ mm-- '.. ~1I3i.Jt ~ttrlJlJorriTia" OIl.It,lJlIl Hll"'lIl<Iouhll.'. to ""1)(11""1111" till!,"''' b"lif'1;TII"lh~l hulollilloll I) -- :OBll.~1 LHIE DISEASE l , liOlIRS 'Iur,s I tll, .....llDL 1I{,'JRf 1I'.I~,:i 11;(, !1..E.Ji HOURE "UREI~C O&~,~I WUL ___ ..JlJi~Q lJr- tIUfI{i1tl':' V I vIlB.;:1 , t IJUL ill\LQ. P.'I ~t..,,~.u '''ON< 10 , '~il "II~IU IHh"lh U"l,;~\Ih U"~ltl.I.l"N(\I"''' Iohtl'i IO/I./'Hi 10/ ;:3/95 lO:;~~/95 1,J'T F.r; J!li.1 T '()L LO'" __ _!if T 4 I I.' 08/9t\ .\ . . II.n n",; iI7/~II-t:ii,";'j~ !:iItAROtl {,Eli IEt'll1 (II ..." 1I/"0/9t'. ~T,.Triil-'rl7.tolji,fhjl--." "-., '.~..'.'.._.- ')',- '.j ;'h,~. j iii,;-;,-,-. ~ I';' ;,~ '.._-- 1 ~bb;!e"~I~'~ . ",,,q m """ltl "1,1) 1l;'~J' UII,MI., II' 1~.;llii'~J~-i;., ...;, .~---- "Hol,,"" __.L~ _/::._.:::J ,~_'_,!.._.. "IJPIHJvtn II~ "~,, (1lIJh'.11 OIl ""'lllII,"t M 1I~II'l 11'113 '''88.0 II' toO , ~llll ..''''II.'I'','"101,j .. ..~~..~ ~..~~........ ..~~....~....~, ""'~II ""1111111",,1,(;,, /of) "'''~~l'' cell (1[:3. f: 1 '!L' lJ"ll~ ., '0' . , , , t"~\ij (l~.:;' . ~ I , ",~ r, .. "nlO . ... " l"..t , " It i~1 ~q ,,' .... ... It ~~~ 0(, .~L :\l\~",tH~ . o ~... '1 coP. 1115, I tiC IJiL..~, rUT AI- CM:E ,0,1 tlU11 "lIAIi ,\.I~I,I'tll ~'IlILl, 1"1-. 19r,I,O'~:J:'F. t.. l ~.1 / I,' :! ~ - :: ~~ tl t: Fc.;m-tiCFA'1I00 (1'14) ,",", CHAMPUB.&OI !. " I, 'I', " , i 'I' " II ,t 'I " ti'!, !ill -" ! I." I;i' I:' .. I' I,' 11.11,1' .u i ~I "r " ", ~t~ ." 1\'>' U,I '\;:1 " l'l ,",.. I' " H, , " h\,' I I t ~ , I-' "II'~ ((, ~ ':'t1 .'1' \ ~;J t~ I', fs~ ~:' !; ,I " " ,I I' " " , "