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DL-326, (9/9q)
, ,
DATE: January 29, 1998
CERTIFICA TION
.
I hereby certify that Rebecca L. Bickley, Director of the Bureau of Driver Licensing of the
Pennsylvania Department of Transportation, Is the legal custodian of the Driver License records of the
Pennsylvania Department of Transportation, As the Director of the aforesaid Bureau, she has legal
custody of the original or microfilm records which are reproduced in the attached certification,
';
IN TESTIMONY WHEREOF, I HAVE HEREUNTO SET MY HAND AND SEAL OF
THIS DEPARTMENT THE DAY AND YEAR AFORESAID. "
~h J-}~ ~
BRADLEY l. MALLORY, SECRETARY OF TRANSPORTATION
I HEREBY CERTIFY THAT THE FOREGOING AND ANNEXED IS A FULL, TRUE AND
CORRECT CERTIFIED PHOTOSTATIC COpy OF:
'I) Official Notice of Recall dated & mailed 12/'11/97, effective 01/22/98; 2) Initial Reporting Form;
3) Letter from Family Physician Associates Inc, of New Cumbe.Q.and regarding defendant's
medical condition, and 4) Driving Record, which appears in the file of the defendant Walter
Karbley, operator's no, 02447284, date of birth 12/20/12, in the Bureau of Driver licensing,
Harrisburg, Pennsylvania,
,
.
CERTIFIED TO as prescribed by Sections 6103 and 6109 of the Judicial Code, Act of July 9,
1976, P,L, 586, as amended, 42 Pa,C,S, 996103 and 6109,
IN TESTIMONY WHEREOF, I HAVE HEREUNTO SET MY HAND AND SEAL THE DAY AND YEAR
AFORESAID,
cR~~t ~.
REBECCA L, BICKLEY, DIRE 'T R
BUREAU OF DRIVER LlCENSI G
_SEAL
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1 1-tt1 t,d'er S
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3213
FAMILY PHYSICIANS
OL.Un'....J
DEAR PAOYIOEAI
D~PMlT4It/ri OF t~A1I6polltATIOII
'1I1111AU 0_ blllVMl.lc611tllld
INITIAL REJjb"tINCl FORM
PAl/a all rr~t Il*Qv/!!m.'lifoAlllnoH
Ialoo
FOR BUREAU USE ON
Dil. R,o.'dd
0/1,., ,
Rif,,.... _
SECTION A:
-
Although lh~ Department IlMks you; JlJdciMltihl aboul your pallent'8 1n9d/cal fitness to s
operalf! li motor vehicle. /he decIsIon about your patient's drlvar's license Is a re5ponslbllJ
Ihe Depllrtment'S B'ureau 01 Driver lIce;,lllng Which musl IIlso lake Into accounl
conslderal/olls. !>Iease completll Secllon~ A,B,&b or It SeiZure Disorder Pallent, complete Secl
A.C,&D. ~~~~'2'!:l
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DATe OF EXAMINATION: _
"';O(~.r'J~.~1
DIAGNOSIS OF DISORDER Ot: DISABILITY:
, ~1!Alte Chock I.-I APpmprJlltli~t
::;;;i[Loes or Imoalnnent 01 II 10 ~ngilr, thumb, or hand
o Unstable DIabetes ,
o Cerebral Vasoular or CS1dloVllSCUlat dIsease
,0 J.oss 01 Consoloueness _ CauM:
;8OIeulologloal D/5otder
o Mental DeficIency or Marked Miihlal Retardation
o MenIal or Emollonal Dlilotdel .
D Alcohol, Drug Or Controlled Subatanca AbuM
o Vlelon Delh::lency (SEi4i reverse lildil for ViSUAl Manda/dill ....
o Olhel MedIcal condltlohil which wOll,Id Inlllrflir;; WIIh Ih6 pllUllnl's llblllly 10 drive _ E~phl/n below,
o COmlnent5:
",
DO IhuS~.5fnclltlons al/ec! the patient', .bll',y, 'rom a medIcal standpolnl only, to sahlly operate a motor
vehICle?~ YES 0 NO . "
~
ConVUlSive DISorder. 0 Yes~o
Dele 01 lasl seizure: ,
Does tile pallllnl meet any of Iht! D~parlm"nt.~ W"ver r~qultcrt\!lnt$ 0 n~ 0 No (::See laYerse slac)
If yes, pl~ase explain:
SE no D:
ALL IIlFOItIU,T101lIS CONFlbi!IlTI.l.lAli ~ItQVltltd ,III 'HIt i>A I/tklclil onol!, ut<:ttoH \>1t1d)"
_n.,. n. LtH-I", t'I. , =(JW=-r,uJJ/'~~
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OFFice ( (7 )
liHoNR
CUSS"ICAYlOH OR $'Icu.~I'"
1=. P.
STATe PHYSICIAN
L.ICENse NV",OIiR
t\t 1;},0i) I
(7fJ 7 t)
774~764l
RETURN THIS FOAM to:
BUREAU OF OAlVER L1CEN",lla
DRIVER OUALlflCATIONS SECTION
P,O, BOX 8002 '
HARnISDURO, FA 17105
:~ ADDITIONAL INFOAM^TI~i,"EO' ~e mt!~~)oN~C~717:7/ 3/
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