The URL can be used to link to this page

Home My WebLink About98-00289 '" ...;,. .... ft ~ it ~ (~ ri,: ,1":- S .. ;),-r (1 f~ {.Jr-.:!J ~ "r.' ():/e -"c 0... "\~j . '~ ":,... } ~ \,,0 ::~~~~ f'\ I Ij t'::; rhei] 1- '~ ...-) ~Dr.l., , ~ It_ a '':;i V !'-) Q 0 "" --< , iTJ\F;Y p~.~ :]1 25 OO,lUlI"'/ ", f ()vl,jT\' CUI'/!~\::~ri~~,~t~(!iJ!ji;\ /t >- C1l 'E ::J - C1l en >- C1l " 'C: ~ >- C1l ~ ~ >- C1l 1l Ql C ~ >- co " Ul .= ~ f! ~ f ::J (/) ---. ul ,- ...-......-- - -. -~--_....--_.._._- ...... " '-r"u' L{) N 0') CO "t""'" N N -_.._~---- -~-_....__._.. ----"'-. ",---- -.-- "l:t ~ CO ,..... "t""'" N N -- -----.-"-- ---...-------- _._.-~--- . "'---- -..--.." ("i') 0 ,..... (0 "t""'" N N - u ...---- ,-----.--------- -.-- ---.- N 0') (0 LO ~ ~ N -- .u ~ CO LO ~ ~ ~ N . 0 ,..... "l:t ('f') ~ ~ N ..- '__K.~ (0 ('f') N 0') ~ N _..<--. ---......--------_..- --- .----- ------ ,~._~-._......_-- --l . .....---....-.- I ~ o o o N ~ :::J J ~ ('f') o ('f') 4, At all times materials hereto, Defendants owned, possessed, controlled and/or leased the premises located at College and Louther Streets, and in particular, the Drayer dormitory, 5, On or about June 26, 1996, Chantal LeBoulch was a business invitee at Dickinson College and was in the process of leaving Drayer Hall when the hallway swinging doors rapidly closed on Chantal and her arms were caused to go through the panes of glass in those doors, 6, As a result of the rapidly swinging doors closing, Chantal suffered severe and disabling injuries as described below, 7, The injury was due to the negligence, carelessness and ,'ecklessncss of the Defendants, including but not limited to: A, Allowing a dangerous condition to exist with respect to the unrcinforced glass panes in hallway swinging doors, where they knew or should have known students would be walking: B, Failing to warn persons such as Plaintiff of an unreasonable risk of harm presented by the dangerous condition of the unrein forced panes of glass in the hallway swinging doors and: C, Failing to reinforce, maintain, inspect and control the glass panes in the hallway swinging doors, '. "' fA W OFFICES OF HARRINGTON, KAUFFMAN & SHILLING A nORNEY: Howard D. Kaull'man SUPREME COURT I.D. NO.: 38963 100 PINE STREET, SUITE 300 HARRISBURG, PA 17101 (717) 720-0700 ATTORNEY FOR: Defendant DEBORAH B. LeBOULCH, Individually and as parent and natural guardian of CHANTAL LeBOULCH, Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL V ANlA \'S. lURv TRIAL DEMANDED TRUSTEES OF DICKINSON COLLEGE, Defendant DOCKET NO. 98-289 Civil TO: PROTHONOT AR Y .fRAECIeI; Kindly enter the appearance of Howard D. Kauffman, Esquire, on beha/fofDicldnson College incorrectly desianated as "Trustees of Dickinson College." Respectfully submitted, HARRINGTON, KAUFFMAN & SHILLING ~wm... fuq"re ."... (1' (: i'.s " ~ i :~, .. . ~) , n I , u.l: (',. . L. (,', (:.\ '-' 0.. I,:",', I!_j ( ) ( .;-"n (1 r:") ,. ('1 , iTil' tL":\.' (::. l!!'_l \".1 1)._ i-- ~" f\.;: t,\. r') ..' () (J' r..) " j S. Denied. After reasonable investigation, Answering Defendant is without sufficient information or knowledge with which to form a bellefas to the truth of the avennents of this paragraph. 6. Denied. After reasonable investigation, Answering Defendant is without sufficient information or knowledge with which to form a belief as to the truth of the averments of this paragraph. 7. Denied. It is denied that Answering Defendant was negligent, careless or negligent in any manner whatsoever. On the contrary, Answering Defendant acted reasonably and prudently under the circumstances. a. Denied. On the contrary, Answering Defendant acted reasonably and prudently under the circumstances. b. Denied. On the contrary, Answering Defendant acted reasonably and prudently under the circumstances. c. Denied. On the contrary, Answering Defendant acted reasonably and prudently under the circumstances. 8. Denied. It is denied that Answering Defendant was negligent, careless or reckless in any manner whatsoever. On the contrary, Answering Defendant acted reasonably and prudently under the circumstances. After reasonable investigation, Answering Defendant is without sufficient information or knowledge with which to form a belief as to the truth of the remaining avennents of this paragraph and they are accordingly denied. 2 9. Denied. After reasonable investigation, Answering Defendant is without suffioient Information or knowledge with which to form a belief as to the truth oftheavenncnts of this paragraph. WHEREFORE, Defendant denies that PlaintifT.q are entitled to judgment against the Defendant in the amount specified, or to any sum of money whatsoever, or to interest or costs and prays that Judgment be entered in Defendant's favor and against the PlaintitT and for its costs and fees and for such other relief as the Court deems appropriate. DEFENDANT DEMANDS TRIAL BY JURY. NEW MATIER 10. Plaintiff has failed to stale a cause of action for which relief can be granted. 11. Defendant reserves the right to challenge any award of delay damages in this case. 12. Defendant demands that appropriate hearings be conducted in this case prior to any award of delay damages. 13. Rule 238 of the Pennsylvania Rules of Civil Procedure, 011 its face, and as applied is violative of the Due I'rocess and Equal Protection clauses of the Fourteenth Amendment to the Constitution of the United States, ~1983 ofTitle 42 of the United States Code and Article I, ~I, 6, 11 and 26 and Article V, ~IO(c) of the Pennsylvania Constitution and imposes a chilling effect on the exercise by Defendant of its constitutional rights. WHEREFORE, Defendant denies that PlaintitTis entitled to judgm;Jnt against the Defendant in the amount specified, or to any sum of money whatsoever, or to interest or costs J ..... 0 \ ., (~(~' [ " ~"; ~~! , tUr:; , C) I'_~ ,..1 [':< i:,{" ,-'j I:' . '. 1-' F" ~'.J "< , U\ W. , I ... i l', 1_lr ("0 ",-) () (". . I ) .' '><. c::) ""',.. 11; l' I r:.: .." LU() ~-j () er_ Cl,., I , C\ I , 17\ [ I' , TI' , (I,.j , ,- ( [ , (,;) t ,., (,) ,. ':,~ ,.,J (.:- 'i/~' .,,:," j.:" ('...,.,' III ~. . ~2 , " II. ( " " , () , , , C-,-) (.'1' lu " ';c-), I fl,} U, !~" f.') I LL. "-'.. '..-; Lt~ Cn I (~) [} , (.) c. .' ~- 'j ~ L." \J'- ,~ ~ ~"'. '. . >-.. Lf~ ~ Cr'. ..:.J r<; .. :~.J ~}:, 11.1. - , ).." tV :.C ') .,~ , (~. Ii :.: ;:~~ 't:'1 'li:!; j-~l r,~ '-,):' II"> ':~)~1.~ c.\:". tj)';\ ~,.::I, \ : r.' iJijJ LL.., L'. ':lOot. i ~ . .... ..'Ii: It 0" :,:) U 0' U ~ C7\ ~i C':l I.... 00 ~Q ,..{ ('-~ ~ 1"-' ~~ i-f' <'r\> .:ry Fiji: N ='\1 ;:0- ~H~ LL.l Cl :z: a l:r.: CTI 0 '" . , By 4. All photographs. films, drawings, sketches or other reproductions of any thing, place or person or other subjects releYantto the litigation. 5. All documents prepared by you, your insurer, representative, agent or anyone on your behalf during the investigation of the subject malleI' of this action. 6. Copies of any and all documents Identified in answers to interrogatories. 7. All documents which you intend to rely upon or introduce at tria\. 8, All medical bills, records or documents of any nature relevant to this action. 9. All x-rays or other diagnostic: studies relevant to this action. MORGAN & MORGAN, P.C. DATED: April 1, 1998 ,,:,sal:l aLII JO pestltf" '. , .(. -;'-.:: r.: ''i' - VI ~ ,~ ~, .y , (f, - f:, Vi ~!'J .- u', . .-, ~ Co, ~ , ,^ ,.. t', .-' \'/ Ii: - .^ (>0- :'" \ . 1;'; ,.. ." '" l~ Cr- :>- 0- ,.. r."'l "- . 0 ....0) ;-., u', c. '.' Ii: C. " '. i .0 (; ~ ,>- u,... :; <tt\t:! U'I ....0:0 ~ ,c.~~ ",., c=:~o( ... <all., N ...'f~ ill ;..CIl % IIlB~ ~ ...._u a.. ~'A ~ ';:7.. ~ I ~ ! a 2 ~ ~ , I '. .. I ~i lIS t" i .,..; o j...... "0 ~ i- 'f""'l \lJ '."lo'w ,-1 .~ lrj u.l ~ rl '');J...' " .r-! ':,.,"" \= - ~ ~a r.n , - 'f', ::: ~:'~ ~ ,Q ..' ('" -8 wJ"",:. "" ;j :J -! U '-: .'7 ::;, 1.:;l (.~ ~\ :: ~W\.-l.-l~:J .'r,,'- H 1.0 .. .: ..,0 u.: u.. \lI CI'" ,;. t" 0 r.;' ~: orl <l- ,r, 'CO tJ '0'\ 1'"'; ~ .-l .,-l .c. ~,.. t-H \Ii a ~ ~ JI" ,.; g Vi .... o ...,. f.... O~ tn \!l ....,...J: ,j,. ...J 0 ~J.. ,.!, 4':::'::': .u '-. L.J W :: H ~.. II. A - ~1 I ~:(;; - -':., ..J ...!,,g; !,I I....',~. --.. .\. ~ - ':..J ...J'-' .-I:;': (J) "I ;: :JJ H ;:-2 -' .- .,.1 :- .~ )~ ~ ;:\ .J ~ U (..J I', " ~I" tJJ 1"". I' c o .r! _ ~ il,\ ~ . III u III t:. .r-' r-1 ~ "0 ~ .... "" "0 .-.: ~ ,1, .~ -E-tJ .... u -I u\ III .'G ,IiI C ~ ,;;: c ,"C! Ul U ,~ ~ - ... ,~ ,iG tJ., i- \II " ~ \j .. o ~ :l .. S .:. ~ '" 8 \ :l ~ :. ((J ~~\~ c. 7; '5 ";JI CY :l a: ~. ~oi cD ~ ," a , - a:. t ~ C % i ..la- g ~ 8 lUl_ I :\1\ :UI_ I 0 ~ ~ ~ i la- :l ... g J: \IS- ", '. 0 I' G 1\ - .. c. I'.. e '''' ~i t 0'" \, \!lH +: JI 'J .::J o ~ ..Arl 1::" I'ti).. '. a ~ c. ~~ U'l C j 0 -1""l 0" c.. ~ J:: C::J 11..-\ !.ll ~;~...J ,~. -~ '':'. ~, ", III 1.,1 .... ui !~ c. 7 \l1i..1ll~ ....;J ~ ~ . , ,.. '. .;: C h 1J2 ,~~ = .,., ..... 0 '.... U'\ 0. +' r: :!. 'C ;.. C. \l.i 0 ~ c! ~ \.. ).. ,::; \ u.. OJ', g ~ o .... i en c( ~ 'j.' I: you h~le :JI1Y ~ue.tlcrl' cont~c~ liD CCHNEC11Cvr ~EN LIP E ISS CO UHlTEO AIaLIHES '.0. lO~ SO~O II(I~RDOHH.lIS, IL 6Q~1. l.o<Jl: (815) D:)9..\$S In II.: 1=1 m.!I82' CUI 011L.; (lICO) S.1S09B:l. CONNEcnCUT OE~E" 'JF"i! INSURA.~CE COMP,UN AJ A~~r,1 P~r 8elcw UNlHD AlnLIIIE3, I~ ....oLO.,.E BENEm' PLA~ Date orcces,ed: Jul 24, 1900 Page DEBORAH LEBOULCH 2014 MERLIH CT NAPLES FL 33~42 ** Employe. Nam. .......... DEBoaAH LEBOULC:i Employe.,OISae Sec. 00000S620 Group Numcer",,,......... 04:21305 BranCNDI',I,len ........... 030 o.ylng DNle.: 370 NIJH ~w I. In bpl.n.tlon 01 aenem. 01 your Group Medl"'" eenellt. with UNITED AIRLINES INC. p.lI,nCCtIANTAl. L!BOULCH Rei: CHI~D (CH) Claim Cnt" II: 07SS02J1Ja1-0s0s9B 'ROVIDEIlI TOTAL NOT CoVeaED DEDUCT TV'E OF SERVICE SERVICE DATE IS) CHARGES COVERED AHGUNT ,lHOUlfT BALANCE Inventcry #: 1921160 PAIll TOTAL AT PAYIlENT RE -- AEST~eTtC t ftSCOt!STRVCT tUp.c SVa~EaY D\mATlENT SUROP.RV OIlT1'ATIENT TOTALS 06126/~6 06126/Q, 1750.00 4,50.00 1300.00 60.as 123~.15 ao~ 771.32 1 265.00 140,00 125.00 125 ,00 ao? 100.00 2 2015.00 s~o.oo 1425.00 60.15 1364,15 -1lli~ TOTAL PAID' 1071.32 PAYMENT SUMMARY SEC'nON Payment. made to: AESTHETIC & RECONSTRUCT SuaG Amount Paid: 1,091.3Z ACCUMULATlON SECTION 199alNDlvIDUAL DEDUCTIBLE SATISFIFW: 199a FAMILY DEDUCTIBLE SATISFIED: zoo.OO sOZ.SO 1996 INDIVIDUAL OEDUCTIBLE REMAINING: REMARKS SECll0N 1. $450.00 A ~ORTION OF THIS CHAaGe IS CONSIOERED OVEa REASOtlABLE ANG CUSTOHAay AS DETERHINED BV CO. IF YOU WISH TO A~~EAL DETEaHlNATION OF voua CLAIH, 'LEASE SEND VOUR WRITTEN REQUEST WITH ANY ADDITIONAL INFOR~TION YOU OR YOUR paOVIDF.R HAY HAVE WHICH WOULD SUBSTANTIATE THE HIDHER CHARDE. Z. .140.00 PAYHEHT HAS BEEN REDUCED DUE TO HULTIPLE SURGERIES PERFORHED. pLEASI! DIRECT ANY QU~STIDIIS TO THE IfIllWEST CLAI" SERVIce CEllTER AT TELEPHONE NUlIllF.R (aou) 535-'B25. lie SURE TO REfERENCe YOUR EH'LOYU fILE NUHlleR, 0000056Z0, oN ALL CORRESPONDEIICE AND INQUIRIES. THANK YDU. - Pt.IASE REFER TO RMFlSE SIDE FOR YOUR "IOHTS OFf ~EViEW ,AND APPc:Al. AND AN FtXP'..,A~.T1CN OF TE.q~,~IHO!..'XiY,- ,..RETAlN, THIS.STATEMEN't fORJAX AN 0, OTHER PURPOSES. HO,OTtIERRECORD WILL BE PROVlDED... ....... ... .. .. . .. COHTIIlUED ON NEXT "benefits are due (as Indicated In the Payment Summary Section), this payment(s) will be sent to the provider of .ervlce within 5 bu.lne.. days of the "Dale Processed". THIS IS NOT A BilL N131CC' 'IMI'I.O'l'U'S COPY "'m ~ .' ':' .1 , ., '4 .\ . :: ~ .1 ~\ I I". J '.I. "';1 \ i r' .. ... J i ' .' .. , .~ .:. ~ ,: '" ~, ~" A , , "... J : ~ .' tJ u h{ "'~?Q 1597 )~ 1 1\' ""'.... U(..,JI 8ft'QW1C1C JAl.4ES, INC, CUlIoI$ €I '/:~"'1 '3'J 7 1 J: '~l --- -- 717-2J4~14,:8 Si:l\~j"'"l(J', ~,;,,,,'h,,;'.:U"J r~.L tJ( , C3,l9 'fIl 111.r/ '1 " r " r . If ya<I~ ,.,., quMll<<" oontJd: ltO :'i!i,~~ LJ11 'Jll$ I:ll ,.,.~f1IlCIl\."" \J:l~.-IS. J. .tU~ 1.1'~ lJlCIII' 1111'....-. qt~iiiIW' lI"C'I-- o.CoIlU ,)~ IlUOll~' U!)OUlCll ~ ZO\~ HElll~ cT ....;' MA,LE' FL :13'U ~ "I... . ~ j ., ' 10 1010. . ~j c:.:.uEG.C: FAX:717-2.15-: F~~ e flC4!~~Ul't."~~ ~.MT~~~pmll"~ lXC1C fIlII"'- I'lIIl'I ,01 7 00o\OI"""......... loll t&".. )G;II ~ """, __._.....J.II llJOl,l.t1t l!n~ I~ 11M. . ......... (i''''''' ~\.'\I""_. IZzl,SIJ B'Jni:IVQ"'""" _ tu r,'f'\G QlHII "" M,11QlCIlUI I' _;~,~l ""_" lII1....pl...uOA.. a-"iU "your aro\lli !'.,.&a! I14t\01l1'1 whh Ulft'I'tEl-'lRUMU Ute. ...-&- ~...... ~~"".- ,-,.-- "llll'" .... .... ....., ,J,'C:i. ,.jll'm 'r.;ll'l ~..... 'II' .r'.AI. -..... -- 1I5TMT\1l\;~ 1lC~ laID ...,otill!'. OUT7,'I'lJiI'I 16IW'" _~..,..... ...""..rmrr .>>()U4Il "'T~ \'! ':l::~ ,,,""'ItCT~""'A," I!c:1\O" ,~~Ull ~.~1l.Wl \CCUIllU~Ol4 nC11(lll . 1_ ,"ri,l:ngu~ l)EQl.ICTIBUl ""'IIFlED: ,.. ,~,LV llf.lllJCT11ILI! IlAll,,'lel):, 1m! 1,;",11 ..,.It Itl.l." ~," ,...'1 I..... UII." 1.'1.11._ l~U." ..... lJS'l.u W 1ft." ..l 1J6o'. U TlITAlo ,un' 1~.1& 1~~ lULU .nl.U 1 .....1-- ..... ~ p.Id: 1."1.$1 .C 2.1.01 IoIZ.1I 1100 IH~rV\OUAl oo;,UCT18Lf ~~IIII1lQ: "'1'- tEMARKI;.C"T10" J. I~;.e' , ,OJUlltI _ na$l:lld04l IS caI:IlKaIII QVI'JI ..~ MO C,1lII~ ".lIfIUIdlP 11 aI. I' '/011 ~i'" .mAL KnIlll1llATJIII Of' """ tUJll. ....WI _ ycSIlIlIJ'lntlllli1l\ll'--' VITll MIT AIID(T~-" ~1I1lII naI ~ ~ ~R MV IlAVllnfmlllOllLll ~AHl'JA", TllE II%lIIP (;llo\IIII. z. .I~.. ,~'l!IIIIT 14M IIIIIl ~ JlUIl 'IlJ "ll:nPU .uIIII11J1 "",lIII1ID. rll~~1tT JIll \ll.If.S'IWI' TO 'IllI ~ a.AJIl JDYICl CIKl'fI AT ml?llllR ..... 1,,'1 AI.... lit IUIlI 'Ill 'UI~ 'Y1lUll1ll'\ll'!U ,UI 1UlIO. 100"1421, III AU. ClIllllf.....1lICt II#Il ........ 11I/lIIC "". ...,~\.uolO~ &lOll l'<lII'IOII~~IOH1SOf'"Mi'o' _....1"'...... _/oIl_...~A\'IClI r$I~V1~.- '""l!1I" ..-... "",...- ,-~....... --.............. -..... ""''' ,1~ ,.t't\!. '111"; ,~. :r, ..~,\\ .1':\' All II b&flOIlI" alii ~ 1M lndlcllAoClln "'" ,JyI'MllII\lll'lMl'l hc;Ilon). . lhla "ymon1(l) wi. lie ~ to lhIo Pflllllder of Mmea ..1\llI~ ....".. Py'oI""'~~' .' . (., ~.\ f. \'~l i '~1 Ii'! l~ ~li.." ~!.t"l Il,fT THIS IS NOT A BILL ~/.\R ? () 1997 1Iii;.~ ll- SEDGWICK JAMES, INC, ClAlh\S 1'1"00')1 I. (Y~.l) .. IIi _ ::l:l=::l=====::.I==-====:::l==::l=::i~ USF&G ELECTRONIC M..\:tL S'{STE."i ===~=::I=::::===:l!:.I::3=::ll==:=l=~==~::l= =='" === === Printed For: Rhonda.Huzvat' Department: NE Harrisburg :::1;== =='" ===~=====================~==~=====~~====~========~==~~============~=n======= === TO: &RHONDA CC: SUBJECT: ACORD GL -DICKINSON COLLEGE" ..,....,.,..",.",..,,',.,',.,.... I..'..'".."..,.".,."."..,",......,.. DATE: 03/20/97 POLICY NO: 1MP30121256000 GENERAL LIABIl,ITY LOSS NOTICE CLAIM NO: 2600 305260 FOR/1 ENTERED BY: RHONDA HUZVAR ===================~=======================~===============~============~====== =====~========~=~=========~=~======="======================~===~============== PRODUCER SEDGWICK JAMES OF PA, INC P. o. BOX 1675 (717)234-3333 COMPANY - U S F & G POL EFF DT: POL EXP DT: I~SS DT: TIME: PRV RPT: 01/01/96 01/01/97 06/26/96 =====================================================~========================= HARRISBURG CODE: SUBCODE: 26 3857 PA 17105 CAT NO: ===~===================~===~======================================~====~~====== INSURED DICKINSON COLLEGE P . 0 . BOX 1773 CARLISLE RESIDENCE ( ) CONTACT: NICK STAMOS-ASSOC.TREAS. ======~====:============~~===~===============~=====================~===~======= PA 17013 BUSINESS (717)245 1943 WHERE: WHEN: RESIDENCE ( ) BUSINESS (717) 245-1943 =============================================================================== I..oSS SECTION LOCATION: DRAYER HALL, DICKINSON COLLEGE, CARLISLE, PA AUTHRY CON'!': REPORT NO: DESCRIPTION: C.PUT ARMS UP TO BLOCK CLOSING DOOR/CUT ARMS LOSS ST: PA ====~=========~~~========================~=====================~===========~=~= ========================================================---==================== LIABILITY SECTION PRODUCTS INSURED IS: TYPE CODE: MANUFACTURER DESCRIPTION: ( ) ~=================================~=============~============================== ==================================================~======~===~=u============~~~ WHERE CAN PRODUCT BE SEEN: OTHER I,IABILITY: INJURED CHANTAL LEBOULCH (717) 236-7959 ~ (5:16:) (J~) I ' ( If?';) (Cl1h) -' '1 ,'.' . '". .,., . -.. ;. '. ;~.' _ , ,\.'" ~..'. -,.i ~ .' - ....,,1. l! Cl For Plastic and Aesih r,uy Philip W.Mllrciano,l>..,.): ('NJ)SI3-1J17 AI~ ), '/l!fghtS~, ,'r/,D. _/ CLINICAL SHEET , j'tC( ~( jJ r; ,k..c"'-r- 'IllClUCE W:ll.W,Y NOR om S&~v;Cl I I .. ..' ,'It ..,,,,,,1" I LA "a. :;;1 ) 70 5 1?'l--lD I )..~r: )~~-~~\ ) -. J!,.v!.' 2ltf I ;(/1 L( T () , Cfr V~ ' f.() v].t.--1)ctA./",~ -~ l/ti) -H-f7i'rY/ f/] Illfo ~ ..- ~(/,In 1/ II /___/) _.r '1 D:.--", i.A'<~r:-./? 'L.. II Lt?:Z... ..- ?({.,.~ ~ ~tv~/1--71M/r.~"", - "';;/7>= (};;) j),~ ,r jJ'Y10(1".~f,(,--'" t {v(,; 3 'l ./Jyz/0,j)v.,;.....[, ~1(p.3 J cl , , :; I ?, I .- j~/,/v--, ~ - d/&,( "' V.kfI-7 "(.'J-.'{ b6. {'6-' I =? Ic?-I - m-1.)~~J - . .- IA ,~ 7- L ;:: tA-- (~ ~) I'L,~~2 .- v 10r' / J ~ ,I / i! P:J Jj .h' hi . /)t4,///..,/?;' z"r ' 1 . . , , I ~- - - ,- . - - -- - - - , - :,L. ~. -... c.-. ;mIQIlI """. I - - r_"'-__' C:\RLlSLE HOSPIT..\L (,.I'i p-\m ~H1:~::T CM\l.I!iLE, PA 17!)1.J.C'~10 C I q;ZJ'/r;L( LCu r'~~~hr-II'rJ 12~LJO 1??.JE; J~J'T~}~f) ! ',I ," ,,~I\.. ,I":JL _",I,I"'j: I I VIIEIIT CARE'E~IEF,GE.'IC'1 RE31STilAilC ......----~~~. , I I II,',!!;; r~ '---"~Ir( .---..-- ,------------- ~ L- ~~---...--....----...--. --..----:------ f----, "2. '1'" t..v' 'f=-"".:fh..~c,-L..,L-'-"--..s~'_'.Cg_"'f)--~J-::c':)(~,J~~ ~t-"'. '~-4:-~tLL-" rt..~_L1~: i._.L-_d.:.!~...:.L_.. ::....~ ( ~-'.. . ~,~",_.,,/~;:', I () " ,-'. '/ /)", . . -- 'L - . ;. Co I~' r-' I --~_~-;'--""----<"--""_ ~ . '.' . ----"..~~.d--":;---'-~..-/ , I"""'AI """. I 'CJ,__j . /"'=--,., ,~fJ.fl>\1, f!E.J,L~o.. <<..& ad....: q ~ E__. p X X".".Q ~CM^ ,,_cg.......~J~. O'~{ V -' t.c-..,-~ ~-.--.~~~~1J~~"'~ 4"~?~--\:-..' ~ --(!) O'~~"-'-~~c:l /lh-)qtO,,~. ~L e-.J ~.Q--s___~ ~(!1_~T""-' -ifJ ::7~.. ~~ ~ <+~Y' -.4 6tD - C>c L 4" _.Y:.......l:!.~tJ.Y- . ;.J 50 -,s~~~~- "lelAN AD A ' ( .... < ~ .( .,.. M'" __ .') r"A "v FOR NURSI~IG ASSESSMENT SEE NURSING DOCUMENTATION SHEET \/ c::;:r (l::;, -- ~~ C'~ S~_ '" ~/. >(",,;) Lty1P: ':! .., .... ~ ..J _t~'\ 'c(CA/CJ qf\O,~/!pi'~J /1'-;-. yce1, tud!Jl~~ ::J, <- ........ I......... ) - /:- 4:. Cf. 01'Le- L- I] G\-.... .-e&~ - ~""I\ "I..,;' <.> Z. '- ~ Q v: .)~r............. 1_ "< S .J 'P,:> """".....\' IN '''''''' '\to"'L.. (i.j}I:! 0 .__ .7:A:l&1,~~ W;'<Jl) ~lt-L~ GiYe C'N>. ,-j? C\.l:o<Jc..rN.n-hl'Y\KJ\ Cec,Ir:x-~, ~N1 l~ PD nON' -C;U>-"-"_ V,a, D('l'f-\'(\c~(X\ /LDS ~ .' 9~~ . . 'D'i\.\cl{\QlQ. DiCTA TEV -r-- 5>Glo-Il,;l! :m"",rUFl~\IO c- W G.C 1. M,(\ ~OU~"".~ PRa3CIlIPf;m4so,ve.'1 NONE [ "i 1.-.... 'i (/o-.!..- __~_L:..:!..L;~..-&~ , CjSPGStnO~ rA 0 0 0 0 tl6",i;\e i\DMIT OBS TRANS OTHER rCIICIT:ON 0'1 CI:iCl-lAIloe -. o SAME Q!l-lMPROVED DISPOSITION FROM r.\l"€D 0 g~~ltb'~~~'JR IAI,.," 1$ ,,~q"/I fI.-.; .,I~I .r,'-,'1;;' ~IOTIFIEO TIME INIT. ~l!SPONDE!O LAC TO LT ARM PUT THROUGH ODOR Gl.ASS 95041 ,\~::t'l P>II 9tl999 fl'I~. c.-~ , , "]I'lI'''-- 1/j'ZB995 ""'"'L"~BOULCH, CHANTAL J. ;,~, OH" ",'. 06/:?6/% 20:46 12V ER.0508 (REV. 7/0 ~ C~r\i:>le H,):>pital ~7 and Heal:h S.~r,il:f::> CJ~""(int 1<J~"': t;:l :rj~.) i'V:'5, NU' NO DOCUMENTATION -- EMERC ;Y I CON'iE~IIENT DE PAR ,..,em CARE CENTER ~I,I,I,IE _L~'0~~ \.~- s:~ "- t~3)~_l:\\~~,r-l~~,f:~~~:~~;E~~:h)d') 01~~~.~~:I~\:"~1~1~~-l-i, ~-- ROO~.1 ;I . AGE ___\:d.._y\"_:}NT __~____~~____~ U Plloril'/l [J AlS [] BL.S :.~1 Pollet) C] Friend VirAL SIG~IS: TIME __~__()\.l 0 J __~L...'... ~~:..._,___ (J Prlof,!ylI iC-Amoul.:\lO(" l. P~trEmt Cl ramil'/ P l~t--- R __<:2::0_._. 8p J,\,~"]~("._._. r;: PIIOIIIY III [J \'/oooICh,'" ~) SI,'I r,<::Olho' --.\.- ~ [;1 FilS! TI,lCk L.J C<1((ltJcl ,,\. '\... fILL.EAGIE::" __~~~ .- ":-...-..------ .~...._-.-..--.- Chlo' Cornpl,\lfll _J~~(~)_,",:...~- _,~---=,-___r.~~_~_~~:.._'\.,~_ '\ CURRENT ~fIEOICA 7:0NS --.----- .......--.----.-----. _ c)....\'-_L~::.~;..__~~C?__ICJ=_"'j;::~J....1~_"=~.~..) ~&::~Q \J ...._______..._l0...Q..':'='-c----'-----.--.. ..:-L~~\.'~_'_""'.=,..,~"."'_""'--'~ ""-L..~c.,,, ==--,.r~:;::J;:"'-......,... ,. ________._.-'~.___ ----Y:"~~~~~~.~_~~.~\"',...~~:!-::~~~i.-~. OnSA! of Sjmptom~: _.~.s::_~~~~"....H----.-. Nursing Acllon.CCJmmonts: ___~_._._... ChildnOGd !mmunIUltIQM.: Q UTO ,0 ~hJ'ler Cl_____ Treatmont Prior tl) ,o\(ri'/31, _":.~t.:~~..:._~Q.,... ~ TETANUS STATUS \.i) \"'l '0' o Within 5 Veals C 5,10 Years o I'-lore than 10 YtlJrs Ci r~e'/or o Dusky o Cyanotic o N.i1be(ls o Circumoral ." = GENERAL APPEARANCE PULSE, -e Rogulor b Full Resp: 't(Normal ~OLOR ~i~ Good CJ Pa:e !I.~IN: ~tWarm - ':3\ Dry .. TRIAGE ~IUASE SIG/IATURE \l ~ ~~\' DRUGS: o Irregl1lar o Weak o OIM' o FILlshed II Jaundiced [) Cool 0 Ecchymosis, ___ o CI.mmy 0 Rash, __.__ o Laceration OEdema o Shallow 0 R.p,d 0 AlIdiblo o De.p 0 Slow Wheeze o Lacored 0 Stridor 0 Retractions = TREATMENT IN PROGRESS ON ARRIVAL: o CPR Down Time _ ~-===:::::::::::7riIrl:" 0 Monitor - Rhythm -- Rate --- o Airway _ 0 Oral, 0 ~ ~ize _ 0 Oxyg9n - 0 MclSk, 0 NC - ljMi~:,:::::_.. o Airway, eal Size [I Spinallrnmobiliza~ o y, Nasotracheal Size __. 0 Ma~ --.- o IV _ Solullon__---------'-___Site____Size _ 0 f1fessure D1essing 0 Other Manlal AutJSsmant: MogsllAllect: crApproprialo o Blunted/Flat o Oelonsivo o Approhenslve o ResUess/Comb,ltive ~,?c Sounds: flighr o Ral"s o Wheeze ormal CJ RhOnchi o Absenl o N/A Loti: o Ral-as o Wheeze o Rhonchi o AMont Pupil': \- . ,. . RighI - Size Reac.:lion __ 2, . 5. . LeU- Sizo__. o N/A Reaclion __ 3 ' . 6, . ThOUlJhl: ErCI€l3I1Sponl.]neou'J, o Vaguo/Disconnected o Disoriented o Slow 10 Answl)( Visual Activity: 00 OS o Wllh Olasse~ Cl WithOut Glasses = INITIAL NURSING INTERVIEW: TIME: ..:.~~ REASON FOR VISIT. ~UMA 0 MEDICAL 0 PSYCHOSOCIAL'EMOTIONAL PAST MEDICAL HISTORY: ['t:;,~r'j . .-----.-... SUBJ5CTIVE: C,uso ollnlury/H>Story 01 P'osenlfllne" (Whal Il>e p."onllell;-~~;') .a.:l c;t;:/7/J-::f" OBJECTI E ~ PATIENT PROBLEM: Nursing Diagnosis ~ Noncomplianco __.. SIlU-C,lro DEtlicil -.,cA::Omtor1. Alterations In _... AirNJ'( Cloa/allen, lr>oUor:ti'/1l _ Commul1lcJlion Impairod __ Anxiety __ Coping, Inotloctlvo _.. Breathing Pailorns Inol!I)":li'/e ~ FilJid Volume, AllOIatiol\~ In __ Cardiac OUtPlJ1. D'l ;reaS>Jel _.. OilS E:(Crl,1ngO, Ifl1pairiHl _< Dlt'lar _.._.. ._._.._.________.....__ Tissuo PorflJSlon, All In _ 5\;m Integnty Impairment ______ Tt10llght PIQCtjSSes, All 111: ._ H". oimlil (Faverl nlnelion, POlenlial __Inlury, Potanll.11 _._ Kl10Wled(jfl D>1!iCil ~Ml)blhl'llmpa:rocJ Olll,lr ____.._.___~_.___ QUTCOME,'GOAL' E (~OClo)d by Discharge: _______._~_________.__~_._.__....~...___ ~H==---~ --------- -- .....-- --.--- cfu=-._--/~~l;~i~i}?7-=~-t- -~ ---~---.-~ =~=:~~~~- ---~-:~~...~~~-=~~ -.. -,,--. ---~Z . ". L~ V-,,,- ~' ---;:;:;--.c:::::.- . '" Spoech: IT Normal/Clear o Sllem o Talkalivll o AepOlillvl/ o Mumbling Memory: ~Inlael o Impaired o Recanl o OislanVPilsl " K! ~ ~ M W U '" ~NlA l.MP: _... .. C> PLAN OF CARE: I. Mainlain Palient Airway J Monilor Cardiovascular Sla:us o IV 0 BP Monilor o EKG 0. Cardiac Monitor o Salely MeasLlres " Roslfainls 0 Suicide PrecautIons [1 izura Precautions o 51 Rails Up [I CornIa Measures o P Conlml L1 silion lor Comlar! [I Pr pore to, E'am C1 ~plaln Procedures o 'mollonal SuppM [I P~lonl T caching [.l Discharge InWuClions o Iher.___..__ o lor ___....._._.._____ [1 Olli ____......_..._ [I 011'''',,- = IV fLUID: I = MEDICA flONS ') lfptt/Aml, .~~I~~~~~~~- --=,~ -~-'-'-~~;qnltl;'~ -- [" ----,,~~~ - -l-D~ -~~(j;; r TI'~'~ ~:l---""-- - 51~~"~'~-~-f:~_. -- -----:t:::=s:. ---- E--~---- ---'--Itu-J'-~' '-'~lr::t.n:ill:I'~l~U:~to::~ o RES~~ THERAPY tREATMEfIT ~~~=::::~===_______ _ C=:. -=-= ___.____===_-= o TIME_~__._ T1ME____TIME___ = INTAKE: "-." = OU1PUT: ~ ~~:;::,"" '''' ~-= UM"~::TI,,:____ -;,,; "re - "'8~ ",,,:r:'-::- """ o ABG~ TIME.____TIM .______ TIME____ _,_.. __ __ _____ ___ o PULSE OX lIME__..~.~ liME _~ ____ __ ~ _ __._ __. o AIRWAY, TYPE_______~. liME ____m___ ____ __ _ __ o NASOGASrRlC TUBE . SIZE_____~IME.. = NOTIFICATION OF: o GASTRIC LAVAGE . AMT _ ~____ 0 H01pltal Social Worker ___ a Family Doc CJ Family 0 Coronor --- ~--- 0 Pollco 0 Ccmsullanl____ o FOLEY CATHETER. SIZE TIME -- __ (] C"';' Inl."""'on n' 0 Olh., ___~_ ._____ AMT, OUl COLOR _ 0 "u19ing Ham. 0 aiM' = VITAL SIGNS. 0 ON Bp MONITOR 0 MANUAL lime BP P dlCO ~ oo.L/S d3=o R NOTES: 1::> C\, lCLt-o wcJi. _ ~-~_ D\~~~_~. ~ W-'!cG. "~.(\) (L)ffL_--:J12~ ~ fX::I.n h Q ^- 0 b u:--tLt.A...-i r:s ;Q.fI'~"v,. ~ 11 ) 'S ~ ('O::n..~_~d:rn..iip( .Yo ...tili..Lrcb. Ou::; pplu.d, hj cr\'~, 1=4 -tu~W~ weLL-{)')S Lal_+'9-1QCl.!\~\--i(:.:r -Rx-eo.A.rv"\ c::':\c.e. ()..)mf:'u"-~{ &x.:d C'C30" .1\0 ~C12IJ~nsLA~A('Llm~ '-h 0}1~ ~ Q.<S<:c 5~.f\) T(~ (O^" ~_pt k:X)J\.LOC:-..('1.Cx> -() d.1..t::'! rJ1c.n '+&l. __ .~ W~ ,~\.e:: ~ ~-' C 0 RA G =53= CCt ~ /-" = EVALUATION AND DISCHARGE N~TES: _____-/ - ~ATIE"T I FAMILY VERBALIZED UNDER~~~~J>ING OF DISC ARGE INSTRUCTIONS, DISPOSITION: DISCHARGE: ~1f~J.v.Pj> WRITTEN I"STRUCTIONS GIVEN o Admllted 10: ~bUri1l0ry 0 ~,- Cl Chest 0 UTI o For OhservaUon 10: o Tran5lemtd 10: o AmbUlatory c Asslslance o Wheelchair o Ambulanco Olhor o F3mlly o Frland o Pollea fJ Valuables o Crutches C1 Kidney Slone o J.bd. Problem 0 Pelylc Inl. .6' Wound Canf 0 Sprain/Bruise o Clear liquid 0 Asthma o Fever 0 OCUCast o u~;.. Head ury ~e'al o Othor o Other o Morgue ~ATIENrs NAME ~+CJ. Le l~WcJ-..-.- __ NURSE'S SIGNATURE; t'It\ Carlisle Hospital ~, and Health Selvices CONSENT TO 1l0SPIT,\L lUlMISSIOH ....\,'D MEDICAL TREATMENT Name of Attending Physician Inl: Date of Admission: __ (, '2(, '9(;, Time: (A/olI_IP:'II_ ~l. 1, lor /l ~I;/ /P d ,f~ N~l~)( ,\ulhorizcd, Repr~~nlath't ., . 12.tJ.(.U.'CtL ..~(~J, !,,'9uEEenng trom a condition requiring hospital care, hereby Name or P~tj~'nl consent to rendering of such care, which may include routine diagnostic procedures and such medical treatment as the named attending physician Isl or other of the hospital' 9 medical staff consider to be necessar,. acting on behalf. of.) 2, I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury, or even death. I acknowledge that no guarantees have been made to me an to the result of e:<amination or treatment dut"ing this hospitalization, J. I understand ~hat: (A) It is customary, absent emergency or extraordinary circumstancesj that no substantial procedures are performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician or other health professional to the patient's satisfaction; (B) Each patient has the right to consent, or to refuse consent, to any proposed procedure or therapeutic course; and Ie) No patient will be involved in any research or experimental procedure without his or her full knowledge and consent, 4. I understand that many of the physicians on the staff of this hospital, includin~ the attending physicianls) named above, are not employees or agents of the hospital but. rather, are independent contractors who have been granted the privilege of. using its facilities for the care and treatment of their patlents. Further. I realize that among those who attend patients at this hospital are medical, nursing, anu other health caro personnel in training who, unless requested otherwise, may be present during patient care as a part of their education. Still or motion pictures and closed circuit television mOllitoring of patient care also may be used f.or educational purposes or tor documentation of the clinical course unless a patient expressly requests otherwise. 5, I release CMLISLIl HOSPITAL from all responsibility for all articles which I am retaining or will have with me during my stay at the hospital, I understand this includes clothing, bridge.....ork, false teeth, eyeglasHes, jewelry, money, radio I razor or any other item kept in my possession, I understand I may deposit valuables in a safe provided by the hospital; only if this is done will the hospital assume any re.9ponsibility for the safekeepin~. 6, I hereby acknowledge that I have received written information on the topics of Patient Rig~lts and Advance Directives. Date of Signature: & '7-6 'tfb (SIGNATURE OF PATIENT} -lS!ONATURE OF WITNESS} (If patient is unable to patier-t (is a minor __ years iB a minor, con'plete the folloowing:) unable to cansen because): (SIGH,\TURE OF LEGAL GUARDIAN OR CLOSEST AVAIL,\SLE REL,\TIVE} (SIGNATURE OF WITNESS) hD 0315 (10/91) CENTRAL PENNSYLVANIA YOUTH BALLET AT DICKINSON COLLEGE 107 Meetinghouse Road, CarliSle, PA 17013 SUMNER 8M.LET PROGRAH -, MEDICAL FOR/i Tho completed Hod.ica.l Fo~'m must be returned to tho CPYB d.'J Soon as possible. All ieems should be filled in by the parenes, (Please eype or prine plainly.) Student's / '-~.\. ,{n I~ fA~1 -I ';'('0,"11 ~(b~1BJ.rth I^. 1-:.1. ,(/4 Nam"'~L20-Ull!..1L.-1;.., I-J BSI, C/D """ 100 Date'.11'.':...L..L...Od. Lase /lame First ~ Hi d " Mother's I _If) JtJ~ I\L'rL '-:<:::C^'~)l/ /'7C:'-Occ"p~f) .J ..J-. Namel~DUL~[fl{lrlXL_ SSI"JJ.) <:;Jt-() o. hiolW .' RtalLL Home Ldst.r/l.,dme, ,f.irst, fUddle J 0, 1M n AcIdre.91_,::~Jj Il( IT.ULl1!.Ltt,--_iJB.f1r..s fL23i'L2Telephon"'L~LdI2 - JdJ.} WOt'k Number St'~e"e_., /'I,Si.e,y L Sea~fip.\99f1,e 'c<.: IIddr".s, tYilflrnt :I}..11-~-f...a.:. - bl/JI.t;;LL}:'l1K.1.L"-.'1I..1..phone'_~ Numb., Street C.l.ey 1ttc1te ZJ.p Code ~:;I~~r's ! L '/~/i) BSI,.fii.L:-fJt~ ~~~~;t!J.~ipekf ~~~;es;~~iM;Yl~.Ji1.;{r ~ , f\J~{~1j~ 0,-5,30 <I- L TeleP:?Je,qtj/ ~;>{j._1~~)1/ rCI-17/ Work N'I/"fj'" S~f~e9 (V -cre;!.... ~L SliatPI rip Cgde 1,.16 ' l\Cldressl I:-C({.q fX''4;-,.++1HI'I' I"iu.iI1ttlll/I'H t.,;Tl Tele "9f'".1C}_' -.:>::1/0- /lumbe,' SCreet City Staee Zip Code 7L1'r'lu! _ C,.y/_ .;1.&/-,::):> () J!4' .- I ' ./ C. . - 7/ Emergency Contact, 'uJl.f.i .-lii (l~: lLP{0j_C:......_ TelephoneQOL..'l{. 73::::' I( t .-<~ aSl;...lultjle T Fi6;'se 1'J1.,Hidcfle \~ r'Vl .1' Home Mdres., (.' .y.(11 ,IO~' {ICU( V:jLl f'(f'rl/} , ,I ,?'.'I)!'JI~"ylCC Number /1 Stree t Ci ty t Sta te Z~p Code tfL. {~t:L.,f 73tL~_ - /!.UvL:..<J CLu!~.' ,--::;/:;1 '.'d.;;J 7 -111~. NOTE, Students mutt-. be Covered by their own famt{y's hospitalization {nsur'" ance policy. 01 . -i-U/Ill- r:: A Medical frtsuranceil' -I-' A." 1 r j G.ou!i'":: Id"ntifj,c~tion Company,[ 'rnn'?e:r/~I(~~'Y1l.-n-=-- No.. r'~']....i\ No.,Oh.(,7A) l\Cldress of company,LJjlI< Pi). /~, 3"J1!D_L)uJ/jq..)U.LI lil!.. i.[{iiLi. /lumber Stretf.'-* Ci tJi I Seaee hp i:ode Parent in Whose Name Plan Is Registered']lU-t;u"'~~'~lann'fi.(c. HEDIClIL HISTORY 114rx. all items; "yes" or "no" O,t. with dates. Give data.ils below where applica- ble. Congenital Defects Frequent Sore Throats Sinusitis Frequent Infected Ears -4# ~i ""';"_!",;:'.: Emotional Problems Urinary Tract Defects Serious Operations Serious Injuries ,n ..tTT'r'J , -.&..-U) +1-1-> OVER ---> Hearing DefectiJ I-L.!......- Tuberculo9is Bronchitis ,\ t. Olabeten Pneumonia ~ Drug Allli'!t'9Y Serious Eye DeEects ~4>'L~ Food Allergy Gla..e. Insect Bite IIllergy Oastl:'olntestinal Defacts ('.' Asthma Heart Defect.s (-'>~l Hay Fevet' Rheumatlc Fever ~ Hives Musculoskeletal Defects ..tJ....L.!.- Eczema Tendinitis ~ Hononucleo91s central Nervou9 System I) A Chicken Pox Defects ' V Heasles Convulsions .JJ.V- German Heasles Faint ing ~i.L Hl1mps Date of latest tetanus immunization.~f) Detail.,Tv of or ad,diUonal information on redical history. ~~t>>LV1-~~:;~l.tLcUI ~- \ WQ~~ . f;F 1,!,[__ 1',(' -;,~ ~ ..l~ .J;;.L -1...:/' 1'(', ~ rr, . L.:rJ Dft J,..Ji.L... L-L- Indicat.e medical treatment to be given during CPYB'a Summer Ballet Progr~m. Give full details of any treatment prescribed by a physician. This informa- tion is necessary for care during the program. ^ Ji\L..t..-J .. DICKINSON COLLEGE. This is to authorize the trainer, the physicians and nursing staff of the Infirmary of Dickinson College, Carlisle, PII., and/or emergency room physi- cians (and any consulta!'_t.s., that they deem nece7sary) of either Carlisle Hospital or BelVede~,,-;'HediCal Ce'l\:J'f' carl~s).EJ' ?4., ~o ,render necessary medical care to my daughter/aon ill j ,1/ i. 1'f,,' LJL.'_i...Lr~. In the event of an / (Name of 'Student) emergency, and if I cannot be reached, I consent that the physicians on the active staff of either Carlisle Hospital or Belvedere Medical Center (or another physician or hospital as the case may be) perform any emergency treatment, including surgery requiring the use of a local or general anesthet- ic. This authorization ahall be in effect as long as the student is enrolled in the CP~B Summer Ballet Program, Furthermore, I, the undersigned, will assume full responsibility for ail medical costs incurred by the student and not normally provided by the Dicklnson Infirmary as part of the 'CP~B Summer Ballet Program. I also attest that this student i. physically and mentally capable of meeting the demands of rigorous ballet instruction. I understand that no eye glasses or leg or. foot braces o( any type may be worn in c "ss. d J.- I ~L I..... I / r . ndJ _ . (Signat l'e pi Pa ent .<j} Legal Guard.lan) (II.. J.' I\.. h.. c I ~l(,,\ '-:l{:\ ,I I (,'^ h.... , (Signature of Student) Datel.~) '((~II( ,;1/ '1/1 .' 0". . . ( 'le> I ~ Carlisle IIospltal ','I ~' and Healt~l ~e1~ces I ," i M-. tk' u C: ( Ii , (j-,-(!~Iz! (_( lL.~,jr d. t u.: [t. (j"./ ~J:/ 1 ( (..iyCL" o PATIENT'S NAME.: INSURANCE CO,: Statement to Permit the 1?.~lease o..LMe~ical InlQun;).ti9n and .ruxruent or Medicare andlor Other Health Insurance Denefits andLQrJ~I1Ysician. I authorize Carlisle Hospital as the holder of medical Information pertaining to me to release the necessary and appropriate medical information to the fiscal intermediary or the Social Security Administration and/or to my primary or supplemental health insurance company or it's designated review agency ror payment ror services rendered, I authorize the Carlisle Hospital's and/or the physician's billing agent to submit a claim to Medicare or other health insurance on my behalr, or to requcst, on a one time only basis, from the Social Security Administration, such inrormation necessary to complete the claim submission process, I am the individual to whom the information/record pertains. or am authorized to consent, on behalf of the individual, to the release of the information/record. I understand that any false statement or representation knowingly and willfully madc or caused to be made for use in determining rights to Medicare benerits or payments may be punishable by a fine of not male than $ 10,000,00 or one year in prison, or both, I request that payment or authorized benefits be made on my behalf. I assign the payment or inpatient or outpatient hospital benerits to Carlisle Hospital for those services provided by Carlisle Hospital and/or 1 assign the benerit payable for phy" sician services to the physician, I certify that the information given by me in applying for payment of services under Title XVIII or the Social Security Act or ror any/all other health insuram:e is correct. Patient's Signature SSN Date ResponSible Party If Pallent Unable 10 Sign Relallonshlp Dale Ins'Jred Person's Signature (lIdlllerenl from pallanl or If pallen I Is a minor.) I )' .. . I ' . ~.~t' -L)l({.E&__a..l A.;((J.~/''lt,",'n.1 Reason Palle"t oould nol sign. Wlfne,,; Dale , . ., , -y(, '7 ) (,' cft") 'Yk . I;; l/;;.( I'F/ J "wC. ,'(./ .'. I.. C. .: '7 - I" . " I ',.: If --'-~-_._.- ,,, .,~. 'Ihlle Copy - Heallhcare Billing Canary Copy - Medical Record. I Ancillary Departments AD 182511/96 .' MCS QUALI1Y GUARANTEE Thank you for using MCS. At MCS, we aim to ensure every job meets or exceeds your expectations. This signed document will serve to guarantee that this finished job has been checked to your specifications. This page has been placed here by a trained MCS quality specialist. If an error has reached you, this page will help us determine where we need to improve our quality control methods. If you have any concerns regarding these documents, please contact our Customer Service Department immediately. Thank you again for using MCS. Quality Checklist ~~ch page checked for quality )2:ri>ocuments placed in proper order ca Final spot r.heck for proper packaging ~Check invoice for accuracy Tills section was compl~ted by: Q.C. Specialist_ //j Job Number . ~ r"'- '7/'/1 _ -1 ./ .~:r '. _~ . CERTIFl 'ATION OF ellST DIAN 1>1'1101(,\11 LE 1101'/,('11 /l'/\(n:r'iTIOF S,/'E 1l0UI,('(1 . , \'S. DICKINSO:-; ('OI.I.l:(a:,n),'IIlEHf..\Nl> CITY, . . I c., 1(" I'. I I' " . I' I'" CONtILlC'i'[CU'I' UEtil'llAl, L [FE HIS, I alll till' ,lullllll!Ll 1I,o.;ll'l 10111 II 'llllll S ill, _ ____..__..__.____..._._._.;'..__~_ ,.._____~._____~" .... alld 1 havc 111,' alllllorllv 1<> l"'llirv tllc all",'lIcd "'.""IIlds <>r: SIIM/'l'M, Lf. UOULClI 20110 MERLIN COURT' tlMt.l,s Ft. 3 )91,2 I IIlSUllANGf. J [killg dllly SII'IIIIl "ccoldillg III 1,,11', I hnchy c,'rlily, dcI'OS" "1Il1 s"y 111,,1 IIlcsc Icclllds II'CIC Sl'i1ldlnl II III I rcproduccd in my IHL'Sl'llc'l' i1tmy dill'clillll, Thl'sl' Il'l'(lIds IVl'IC plCp:IICll ill Ihc Illdillmy CllllIM' Ill' 1I11silll'SS Ill' allth\'lized I'CISIIIIII<:llIlI <>1' i1hllllt thc til11l' III' 1111." "\'(:111 <>1 i1l't alld C:IITllIl,I::lll'Il rill' IlIc I'cclllds IHls IIl'l'll 1l1:llk hy IIle IIr 1I11dcr lilY dill"'lh,,1. TIIl'ldlll", 1 ill's,' Iccmds C(IIISlillltC all IlIl' Il";<>lds III silid illdivid\I:r1 dl'SI.'rih,'d i1hIlVl~ , I IIEHEUY CEHTIFY TIIAT TilE FOLLOWING IS T(WE ANJI (,OHHECT: "'* A: I HAVE ATI'ACIIED _________l'AGES I _.____0 # OF X.HAYS, /I: TillS INCLUJlES ALL I\IATEIUi\I, HEQUESTED, C: 1'1115 INCLl10ES ALL COHHESI'ONDENCE BETWEEN M,L FM'ILlTIJo:S, D: I IIA VE AITACIIED TilE PATIENT INFOHi\IATlON SIIEET OH 10 SIIEET WilEN AI'l'LICABLE, E: PHIOH AI'I'HO\'AL HEQUIHED ON 110Sf.!IAL~ FOH $100,00 AND OVEH, ALL OTIIEH J~WVIDEHS FOH $SO,OO ANJI VEH, ~/; o/fr----------- '---S~1': - 1-- -).04) ,4L~__-.-..-.m.- Dale 'II .jl __ Ign -1~I'l.': r~ '~',///',///;;%'t'//'i00///'u .... ,//-//......0.'// ."."" '....,/,......, ..U,. ,,' . 'l/'/ /(.' ;.-j/~ %:,;;;;;,~:#//;/~",::. ~"; >,--:.-X,<~''l:)/ /..;///> '.:';:< ":<~. . ~ _';,~,,~~~:;>>;;~'>/<%~,~,~)~~/ /. x/.; ;'::;,:, ',:, -,/, ,/, _ . ,."/,,//,, .,'c _. '//"/'/"'//'//.'" ,'.'",.','.'.'...' ."....,,,",,'/..,, ",~, ,< ,<~;{:~~~<?j:~~J3{;~~<~L" ".'/,i." //;;.;/, THE DOCUMENTS HEQUESTED AHE NOT IN OUH POSSESSION DUE TO TilE FOLLOWING: Nil Records ~) X-I\i1Ys _ IZl'<:ol\ls Dl'slr<iycd Aril'1' ._.. l'C:II'S __ X.Rays Dl'Slruyed Arkr Y\':lrs Olhcr ---_._--_.,-_.__._._------------<-_._--~, -.,-..-- It is lu hl' 1I11dcrstuuLl Ihal this ducs lIut m\':111 Ihill thc rl'L1lll'SIl'd illrlllllli1lillll dUl's lIut l'~ist 1I11lll'l' al1ulhn ~pcllil1g or i1l1olhcr l1alll", Hllwever, wilh lhl' il1rOrmilliol1 rlll'llishl'L1 10 <>lIr ollkc allll 10 11ll' l1l'sl or III)' kl1oll'kdgl', I cerli!'y till' nhul'l' 10 h(' n 11'111' nlld llCCllrnlr slnlelllClIl. t'r /;< J /7 f' , Dail' -~---0~A..aJ!J_ff~__. Slgllallll\' 7~ MlIST SIGN AND HETUHN THIS PAGE! CIWI-JB2901. 52.C3.1.~_L.n3 , ....~.'.l.' ,w, 7'~i:~~~~\'i a;"" 1........1<~,~. '"I ,..,'t,,...,J"'{,,'IIillo ~'''i' !ii~"':: ':;;'::':,:;" ',;"':;:~'\;':,'",,".' ~" ," " ,i/(' ~,";' 'J " .., t::'. l;.,' .<~;.,:;,:~:' r.., ',,:,un r!~ ','>: 'j ~',' f.~~, . ':,.:.: ,tf,\PlPV1iE ~ME . ~;:" , tHl1/~~~"h.IJ,.JJ ,,' ~';:;;~?"""'.d", '''':'-; ~:" ,'..' .11~t"~ ('L.e:r7.\ , '~;)IO~" ~~:.;,'I:~. r.i~~',,' .r:;,.n'13";Y". ~~(;.":", :". (~,F(..J:f:J.{)~"tJlrt.n"'~'I"~ " r}:" ~'~~~.:'}.' I I . ",""; '.",", " '"'' ",,'~':~';"'I"{'r'\'Il..t7j.,,~.')>.\\tl\;:1'~I.',.j'.l,'" 1 :;'.. . . ':,;. \', . , " , .' ,. . , ~,.. '~. ,~ ;' ,. ,. " ' . . ii::, .;i'~ATI~NTNAME4'~O~lm'~CMAI'OVII . , ". ....... .:;" ,,' ,',.' ~~<"'\:;.;\ ~",J)~,H'1M'J.H ''''''''/1 J/~I~''t:~~.. ".,.... '.'.. ....".. ',. rT ". ~,:/,.,,""".jt~.. ~",';'~~-c:xt~r:l"~';";J~(frll"t1.L:!.'. '~.:..\;ro(j;!', ,.','-'1'; l ,', '/)i,:y,gf~'tJ." ~lt::,"'::::::';~~U~~~~ I~F~~~11~N . ,,-- '.:"":: ~:~t....;, ~~!',...~", I ',' t.::>t':.~. lit;'::'; . ~ ~,. WAS AttlO~0l\Il,4NU~'N~A~~t>'OIM,""OY~1 }\~it~.~..\l'..';:,!.,:,.I..,'.,~.'::....,:..".'....'..:-,,;..'...:....,...;:..,.......~:',....:!,.:.'!....'...:,.'....:,';..!.:.....'.:.~....., g . :: :~:~52:~:it~\~\~~~:~~1~~,.", '," ;<,' ! T'. (' ':' .1~l"HOrf'-...~,:~/.fll'::,::~1~. ,T:A.~,-le,.:li~lfft\"ft:.,~.,iJ";.,',',,r:t. ",.', ,I . ..' "'~l)M~A~\t': . '.' !.': .'.,,'. . .... < .': . 'CIlley", '.::.:.J',: ii~~\;'(( .., ,....:. . ~-- '::':' ,.. :~ . ",' , I l'~ . . ,.< 11 ' .' , I" 1" :", , . ,I :dV::' . :, .;~;'PERTlFlC~TION O'f Ace: 'MCV,::t-IP:~U.~HOAIZATION 'r~,nELEASftN~OR'MA'l'ION." ,,,,,,1..' -.""" .. '1~t(~1'I'~ ....'1"""1'.;.:.'1:1',.,.., r i":'r"~",,,, ~H.,.,~,),~,.~.~.t1' ~ ~'tr ~)'.. , I, ,'i ~". ',': ,'r"." ,"0' ,:. ~'~~:~.':,IA.:::<\:~'.:.:L~~/,\';~";:;:j:~.(t,,:,,: "'.' " , M,EP.l}~~~qtAll.M, . '.' .Q22l~O&': ,. ON1TltiAI~Ut'itll;"NC. . lMl'l.O....flll:NmT P\.AN ,j, " , .~,7~~.' '.' ',.,,~,...., ",'t " : ' : mAS! ArrllCH ITEMIZED bILLS '1',;,.'/ ,., , \ ':, ,:, , , , ,1 II'!; ",'., ."..., " ,'. ". ..! " xu 'W2 I' '. " ,,~ \ ',"1 :,;:'; 'j' " , r...' ~~. .J. ,,' ~""""~....~,!,' r;~~, ,i ; .',:" .,;~.':';; i;;r:.;:<::': ' ' ,:"":,;,~~,, ':-. :: ..' ,!:~~ :, 1- ~\ ,~ " I '.," .'" ',' " , , t",;l.' l~;:;:\ ;'l~::~':~:i'~.i;:"::',,:~::\': J.', ':.::"; :;. ,', .....: ...".:; ~/> '.: :: ::~~' '!.\"l.{. \..~..,.~,,,'.,.~..,, ." 'I' ", ..' '.', ..,. .. (tl ~ 11.1: ''':' 4' ,'," I ~., '. ,,<' . '(', ,. '. ,'~', ," .,.,'-" . 'r)t1{,~';.:H,:ff~M!~6~,llAilclN~T~P,M,p,'AOVi~EII . .' .'. "."'-"- ..' ~:~,:,;i.', ','; ',:, I~~ It"'~,,; .....~..,."*4II.4I.~...."..f. ...,,.......,. '-'~."""'''I, 1;i:;J"" ""'~""_QO'~" . . '_r....- ~iA:.::; . lXi' JJ./1.<. ,.,. "". ' . ,pc;;,."", _, "", i.. r' ,r', "'., '\ '\';'I';~' ,::;';'\: r;;\1,;:;.;.plV II n,tri' ~~::'i,5H '~~I~}'rI' Ii :'(,"/r,,~,.,.1 ~ :\,1"..,.. ,.", "'. ..~. . ~t~: ~.,':;' ,,,;;, ::,;, : ::.....: " ., :', ",..- , ~,;::'~: '~l ,::',:, .,i I ',I ,,'. <. ,"':.., .-: .,: _;: ':>::" ':.. i:'.; '. ,:,". :i '..;':. ::.':': .... <' . .' ,.' :!.. .. ~l~;J:,~::<:;;:p~(~.~~~':'~Pt,~ t:~~~1~\7~~~,..':gj~~I~,~~~f;~W,~~H~~~~,ftl~.,~~;~T:1~~:" ':':~ ";:' ". '" ,'. ..., '. ...'....... ....'" '..>u);:i1.,.",,:j:J:~,ii "i<'l'l;,l.:JJ,;'(i:' .' "', "..,., ,J,l','",' ". ,".. 'il;'P :l[j.c;II'I'G\it','~"I., .... """'.; ,,:";>.,,; !'.:'. '':~,,'; '; l~K ......rlDJi. '... KN.O'''VUhU.lJI''.~\IT VOU~.I\.l.Pj."lW;IlIftY ..JrlllTllrATM~"T..A1 lJII""T!VZI', .. :, '''.' ,:., :~,j\'11 '/........ '. .::. ". "'," !. 'I~ "Ii, '.' '1. ."C".' "';I/~'; '.t'! '{.". (\ ~'.";:".. ~If.i' (." ./. ....,'" . ~....;.;:.~,.~,.. ',.. ," .' "'.: ,': ...".... . ',.) ,,'1., I:. ',' .".. ,\,' , 1 l.~,:~..,:',';)' ':;'N'v~rtlh.li('" .i-r,l,;,~:~~!....r~;~,;y;,:~ I:~:);'t:.,i.'.lii,,/t' " ,"I>,'",'" ," " '.' " . :;';':;',:1\?;1[i~^V'11t'!ili iA"APit~~ilML iNVdict,'TO ON! CIJoIM"OftM,, .. ': ",1", '~'!':(,I; ';'-.,r::,.:';}~;!d~',:..,\ ,:.,,'. ":""Ji '..~ ,,:;. l"'~;:','..':.,,, :..... ...~) :',' :"'itj'i'"t 'l.t, tJ t,Jl1"! /I " {'l -1.' ':,t,1> ,J. \." ,'I ' , ;:'" .L;"i.',I...;/,f::":,;.'~'...:.,.<...',,. ":"..:,'., "".'. ':.:'. ".' ...'" i','.." " ",',... '":~J:',, :j\ . .!} i. ;)wm~,O~E'~pNTHSOfJMWAR'I' FEBRUARVANDMARCH; ftlEAS.E s~nMiT ONLY WHEN EXPe.,N,~.E,~ : i','" ',< ",l,:i~ .. , .: Ell~UD _60,00, '. . '04',. ,",', ';:;,i!j.~ .:; , . , :.} ,.... .' , . . ... : '. "rJ' ',j .', . .. . , , , . ., ,: .'. '" 'j;' l~;:l'~'~t . : \ .: , . . , " , . , , _ . ", f I, .. l',l ',I' j,: ,'.~!o'~ -', I , ", , ~ I. 'l' .., t .' ", ",-,:~~l . I , ,~ -. . ". , , ,\', , ~ , < '. ., . , '" ~. ". '/'jr.. . ,..;', !1,/,. ..' \ " . ' . ' _,',,' ,;. .', ", ~', I' \ t " , " , ' ,',. .' ,4 ", " ." :f,..lj' ~\ (, ' i'.,"i",!,',".,',' '.:1"" ::;' " ,',,: .:.;:.,.,.:';".,' I, "..,.. .":I\',)!i:)r..."..:';i~1>l'i:kt~!.i(,I..~".iI.>lii!i:'!J.j,\(4',1 ~W.~.f;j(.i f"';I.iir~t,.iJ/~jj.'1;'~;~~:1;1~~: ;,i!uJt;.,~~~ir~;~~\~~~:hfl~j;[ji~t~t;ll~~~~itA~~t ?1~~.~ ~~~ .;:~';:::~~ ;,-.,..;-t':1 . :lj,:'I4.';'/~' '. \ ':\. ; "," ~'<:" ~~l~:,~...'f,~;'% 'I' ,,. t! i',.. :, d ,: '/' . ',I, fr.., "...r, ""'.'. ,.j:,' " ~PlEA:)a:.. ',',f'. (l(lllc'r' '. ".:, ,s,r,WLJ! ' , ,IN r,~II:t , . ,\ M\51\ <C,.....r":.-:::.11~;"i'll,"i,IJIt\~~1'" 3,:'p" '.'.::,". .:,.:'" .': " .' "A ~' , . ii:' PATIENT i. ,~ T.'~"mr, '~,!:7'~:;~: T'.i: I: 1":, \...~;~,?~ .'h'r~~ 1/1(',..\ HEALTH INSurWICE:: Cl.AIM FOflM ----- '1"',\ " ,I'. f'."I"A",lllill~M \1 . "(, ~'((IM:.""'\V '.', :f 'j,tJtI.-f.,...,fI: II/.."~,, ~, I II"! t 1 'it! i'1',ni"lr':,1A'';{I~'1 oj I"~, " ., ':1'; . ".""., "." ... ..bg,!'\.9.l!.~G~ ,.GJLo\NJ A~ .J. }J 1',\' 1.'.I~;I Allr,11Gi'l ',0 '.JI''''(1 ,. <<014'NEALIN COURT \' Ci':r--:------- ~ . ~ ~'.' , .: .l.LS_... '-1- ~'~ llPt,OOii II ; j" '1' I'"" iL 33942 t6\fi,r:rI;l::;m.\i,o;H'I~'d'I: HI:" , ~:'" (:.,. '"...,._.1!QN~ .r ,4. 1)1111'1'\ '~l51J"'llt, ti .";/,1;'( ,/1' ' '" I" ,'" ',11;, I, " I t,l, . .' '" 1 ,I .1" ,Ill", 1 ' .:. , , . 1f,,', : ',',;,~,':';.:;:, Ii ! ", . ' 'J'~l'." n:~, -;u~rifliN;',7iiFf;';lD,\ ~r'l)l :\;1 101"1' I' i\~d"'1 ~U';iljU''''' i,:>,' ',r.t/Il..~ q~ : YV 'I I I I,'(.JI f', ' '., ',:~, lq:'rM?~~l't"~~~I;,~J't':'~:' /I;, / , ""11'" . 1'. (,I'tl'l f'I("0rNI i , . I~:i 'x ,~Il, t:.~, r'INiJI)~A;'Tc;~ ji'i),~ i,.iAll q ~". '" ""'1 I , .J ;it :.:~ fo ~ '( ,;', Iii I II; ,\~. '.....' ' r",. . .. /1., PJ~ ,~""-~:;"7'"" "'lleAo'IIi,,/;xli, ~("~i4 !I~~o~,...tl)'I4"~l\ilha';,'dliJ'll;ii;iht'I<.;,4'oti~I.' ~:~;, I:!'. "Arl~rs Of! AJJrI~ 1Ill,;:\111 ~ ~I',A }l': .\i'.11."'I:,fll. I ~""'~A'N hi 1"(.,lj,, ';, --l"1 'I'oll.....f,l.' 'JII',~ 'l~ 'II." "" ". ,.' ~L: ' Ilt1l1~~,'Y1,CIMn, I ,tl.'. 1I~"nl 1,>'1;""'''\ 'J1 ~'lI~Ul"''''''1 1~'tlllt'l~ ,I"I',OI~) Plljo,l' .,. I" "'''I:WI1 .'''1 '~,'Jn',l , ',.) ',' " ' ,rn ,\b4~'~(",.', ,~.;, r",:j,';"":':'",;. oJi" 'K><lC';,...SIGNATURE ON..FILE !.~'I '~I, (.">1:: ;:? .. ,\!"::,,, ' ~;(. 't!u,llli;i;;iw(il.;o,i~{,:(:,\ " ~:,1;;,::~^,~,I~~i.rii;""""i(i:;;"?O;"i;iI0ii~iiW,;i ,,' jiE;iilT'~"'i" i') ,ii ;;; :<1'" ',:ii; 7" ~iX&ivJ~;:1~.MEO EXAM NEC-ADMIN, 1..._ ... )/,': ~i::. 2.' \ ' (.~\ ~t::'~':':~~~... y ,. ...::.':-'::'L-:'~:.:::. 'r},,;,:,.:':.:::C.-:T...:::: (3 "', ("'fli,;Jl;')I~"I~'1 q,. 1/1_1 t"'ltnllllll,:"'ll'I~:,.Jl, II'~'. ..",', (l1:;':.,rHE1.:l'OO,:1 t= r.'t. .'f'"A'l I \I, 1';'lj~I'4'III\"U'lII/l;I"',I".",. I 'I'i' ,;,'1'(", I', .;-1" 1.\)4.'~~UlJP,:.:,:';-.o,( ~,.:,: ~M~. '" 2. 2.,.-'!1"T .~t~1_... '~.!,\. :: t:-".J,H'\l~'-H'" ..:'~~!:'!.i~I _L. 'rl~.'~~;t~l I .~~i~:::f' ~~\;:~. " ......Il -~r----:-:- =- ,;" ":;.~j};II.' , ~ l I j J" aD. 1 ,,''''''''~ li~I:l,.y~":'la....1.Lll.3..j,.. _ll. . .9.QD.llL...... :,,:'~;':1 7 ~.,..~, i '''',", _'__...,.~ "- ,r.:.:;;, :.', "", ',' .1'1 ;. ! I ",1' ',.:,:...::,,~ .. , ' ',. :IAX ,(\:,. -...----..,1 : ,... 1 .".__......~ t.- i +~: !... '~:.._:,:2:1; 1',:" ,1 ..j " .' ;; ,'/:' , ;1: I I, ,." 0 ~;.._.._....."..."... " I .. C'~' '. '.Iil';' '."-,,..o\-".~ } ,iG (":;' I.. , . \'::' ~ (? .............i. f :1 l...n__..~~: l: ~'" ., )1 I 1 , "'f": . ~ " i\ rrILin~'rnACI';"ii\';'''i:',;", l""n".;l,; ",,if,, "'..' '.', ,;,;,~' :....~:; '/,;',f:"~i':\;-'-IM\lib~:~7; ! ~i, _!!j::OOll~ML.. . X ..ll.J94l~. :';,',:'''', ," J.~,!lqt!""'. ,)$,.oo,~!..~~b:,i1g$!;f' /""':" "ll,l\ICI~^ITI~Cf""'~~I.nl)Il\;I""" ,II,I! ,\',.r,.l.lll,.llV.I'J~' t,lt,',..\ " '",\'~',,",lj'lt~ t-J!"~""'7'~(U~,il~~, iP't..:.".: j' ,",.'. INr.U,IOIli(j .~')J",jl,ii'')II\:lh' ." .'" 1\1,;'I'U,'I;'\l,'l"I'I'''>J '"."u ~ "'1" . \ "V I !. l it, I":'" ,. '"1"'"""""._ ADVANCED: Mf:DICAl . CINT!'.; I: :,:.:.:. ~ r," ''''''' .y""""'", N\ 2171 PIN\! 'RIOGE ROAD':'!,:,,",,', ',:-':H 11,/ .G:,,;. '~I((~?LEACH" MO i NAPLES,." u~"i '; '~:j ;,;:,:.r I;, .',: l.!'(l.I~O,' r1~J.!1/~3, ~"\'I -J.;'I,. It~ "~:I,;l:"',, ,,' ....... :,,;:;' IA''1't\t1~i~~'':'AIJ^I~;~ .t\~'ll' 114(1 ~'~ ~1I1~-';'~'4tcll . . l~MS"JIRIH1. ~l"'P~ ~"ll""'''''-~:I'.~M'~~~ .. ,':.; I}T~i~, ~,~J" " ',,I .',' ;" .' "'; '. ,'. ,,'.... ":J:""~""I'>\fltFtD: ,'.'ll""I'1q'~"'~I,I'~'~j~:' ;.~.~ t~ih .L:i~ t~,~~'~'~l.~~~'~;: ~ if'J i~~:f'.ti:~~i \~,~::~,~,{ j t~ j;'1~~\~-1"~;li~:.~__!l~.\ l~~!..:~i~:i{L~;;. ~ v.:i L(,.J ,t" l~;~~C w ,~o.I.'"...-, , ,,'~t1"..'i 1:1",(.1' 11': ~I fl, "1 ~'( I 1.'\ ':/01 I' r" I 1~!..'1.~ ,1'1 ~ .. ....I ... 'I r H I I' ~, 'j(' 'tll'i' f' \', tJl" (I' ,J 1,..10. q ~.) " , 1.\! I ~ll I, r ' ~ I . I ' ,,~11 ,I, I~ , lilr ';-I.\i \ ,;"",' ,',.' , '1'''''''' ,!,,,.F.,L'l I ""..",." '; ,~,~,}, ~I}"~.'} 0 ~. ,;/ I,'. ",',"{ 'I~ , ;:j'-\I,Ii""~ "" 1.1OI'1:",;i ,'.,/j' x ',' '."';-'!.';'IN .,,:.~M'_~' ',",', x I '''-'.~''-''i " .',' ,I . " '.. ,'".. .~ .. "-1"7;1^"i~: .' "i' ( , -" ~,- ,,- - ._-, ..---~- f 'I ,"I" "~to ilf/t,l.o.JLt,A.H~"C(JI~i .. , (013) 261-3219" ~ . .. ...."."--...-...-,_ 'J . I'" 11J,1' II "'-: )ill'.I) '.. ,;1., "<1 '" ,1..";'.1 /,1""., ... x (e 13 I I ", (."~, 'i'\I,\.("1 I , ~: ,,~,' . "I'I'i((>II:,::jk':.,III': '.,/'1,;,' '."" "I,'" X /,\, "~~."''''''...~,. ..- '. J'lI ' ,:.r, 'I ''','II 'I l~ r,IM 0(, If ',to ,j ',,,,, ;,~.';~<..'..:: 1 '" 1,1 \."""1'. ,7j;hmm;" 'ur,11,',(iH' ;'.~,l.i ,....~. --.... ..~. ,~'";-~ r! i'.' i:.,::;:~: ~ I .. ,.-___,~~~. 'I ;;.i,;(( I' 1', ;;4':.~~li';;,~ .'::K'; lJ.4. ,"'I' ,. t i ' ',' '; , ,; "':' J:,~;I a , . ,~~.!n~L, ;"" ,;,,,.,, . ,I, "-"."-'. ~ ! >1',; !;t:~4.._"II)f~ """.. ,I',":.f'.r.~~~~~;~~~~::: I ' .',:L'iU1~I.:(IAtl'llf.ll\.nU"('I~~,~) \l'::t,.-HUI\('~.JlJf\tll\4f. ' ; , " I I" ., ",";1..-;01. l'lIl~,1 Ii ~ !I'I.. .(\... '11' .-u~' 'l~ c:rM ,r t;.oofllil lQf' , , , ,.'.' 'l', .1.'1o.:,,1>ud I.'''~''' I,. . ";,' r ,::! ,J' . '. ;(l','.~.fl , ., . '., .: ,;<1;, ::~;~ ;~~;..~~ r,.t:"';";~'~I"'III.f. '~I'M~ j'l''''' l"4r~c:,C. ','~ ":,,..J' .til'.~' . V~t 1./) " ,_ "1M. 101\1 ,"."IY'/I,::',.,,': ' 1/1"/,1_,.,.".,,... ......-..,- -_.,..,~.. _ .~_..~.4.....~..! I , ','I''', '1:.1,(",1/ Il"ri":!Ir' ,'ii:1 (,'; '~'''''''N~~bCl''llr.f'' ' ',::: .,. ol:,l~~:'~::._:.' _._.:,_._.._t.~.,,::I.,~~i"IlliJ~; " 1,:0 .;'\11':111'14' 1."1'1 'CIMjl~1",. ,'.-.'",'.", "r '!:';'J.~:,', . " ~11G." " ~.., , f :, ;!'. ;:'i;),::,,;p':';.~I'1 . ~ .f" ......' ~..:.i. ,---../,~ .~ ..,~__, _....~~:.~..li.; . , '1"J~';I:"il'I':.',I~"I"II~l:i!I~~1 "'::~,".:,..\"'l i ,\,. - ..,. ......! . ~':.:'" ""~~-.:;':'L:2't ;i\;;( I" ..~ .Ii','A ',I;tl I'.'l./,\~!\ , .. I.' " 1 .1, ,j J "(~, \, t".\'1 :X,H' '12/31/93._.. Idun Ct'~tlA'l!NT' ~ "...~{ W(l-'~'I W.'l""c,nl(JII r:~ 'f ,,\ 11(.'17 HN.~ ~'A~) C111~.1r. (.l(l.~II,I(I.,d' 1,'/' 'l~,.w CO I .,~' IH.'i.:IIYi,"',:.loI"'j' H I ,il,':0I-III:)rrl.\lI1 Vi,l ':.0 '/", ".' ' .: . fo)'F.(I}j'\~I';"llW'1 I ir'.~^~ir(;ifil;iiS;.ii"I~' 'ri:;:.<,i:-;';'" rp'~' i;,i.i ,j,:,i;li;:i ' .' '~I':;:;,i' -"I;;'~li.j""1tl;;' r."ii;;;I\i>,',-;:l': ',It, . , .! O....ll . .r ',. .. r.' ... . ".... I,....," '," '.",~.,~. :! ,~'~,';"'I"''''~~ ~,~.",,~ ;...'~f::"":'l ~, '. :" ',:". ';', .~., '~r- .' , ' 'WJ""""1......---:;.....~..''\'''l'''h'l.,'''.,~.h..."...- lUJ llNITED :\ 11\ I.l N E~ MEDICAL CLA1M #0221305 UNI1ED AIR LINES, INC, EMPLOVEE BENEFIT PLAN COBRA _, _,,____.. RETIREtl __ ..... "..- DISABLED ,~____ PLEASE ATTACH ITEMIZED BIL.LS EMPLOVEE NAMElSUaSCRIBER 1L'51) LE80l/tilrFm'Dtl}"IL~f'''''~~'::'-' i~~. .--.- ;;~IACU~C~!'~V'~~1~~.."2u j '00AESS;r'E1.CmSrAr6ZIPI A C Q o,,""'P>lO"" . I, 1J{f-K:.U M (Ii - __J-I)Qf((i..rLL-_.?,?t/'-::- 1JJ"":eH 1- 2_~l..!.--- \ "AT\.;NT NAME IIF OlfF11REHT FROM ABOV~) \,,,sn if!!! U~ c /-I_=~C-J;12~ Tf.I_~~:~~~~=-=~JO!~: i'3r~ g_ 3 INSURANCE INFORMATION IMUST BE COMPLETED, DATE OF EMPLOVMEIH FIRST DATE OF DIAGlIOSISiTREATMENT .....--'" ----- DESCRIPTiO" OF ILLNCSS,,"JUfIV ------------ ---- YES NO 'I ~ )t )0 -------- I. I' WAS ACCIDENT OR ILLtlES'lIIHMEO '10 EMPLUYMEN'I ~ DATE? tSubrM 10 WOfllmufI', Comp Ca"'fll) IS THIS PAllEN, ELIGIBlE FOR MEDICI,RE/Mf,OICAIO? IS nus CLAIM A RCSUL' OF 'VEHICLE. ACCIDHIP I~; SPOUSE ~Mf'lOYED? IF' SQ, NM.lf (,:- ;:i~;I~fJvEA COMPANY__._ ~__.~ __~_.,.. _.___. POLlC'j ," AODRESS .__.___.____.___________ CERTIFICATION OF ACCURACV AND Au'rHClRIZATION 10 RELEASE INFORMA'i10N t. I Cfll!i',/ t~aI '1\1'1 '~,I'l'jQI/'l4 .n"lIm^'oQ(1l" IIU';'f~i ;~:;n~,IIl\ e;".. pWl/ldel, In~\lI.3nc:e C.)mpanv 01 Oll'\-:;;-;;:;i.:i-; 1(\ Ie,,... aflY. mt'di."" .", .'~J I 'r,,.,~O(\'...'M'CJ'...I'>':t..'n.!Qlnl/f.lliu'A<Un"lliILIICl'0f1ItJ9.,II' ~ ,..----. . --"---lrWii r;;;:iiiiNr SIC'''''?i11E-~~- "1Tf'w"-:;:' -~; .. _ ~.l(2.-_.. ~l.fp_._~__._,,_ AUTHORIZATION TO PAY PROVIDER ~ ",",,,,, ,"/'M"IO 'no ",.."""1"" n",," ml<I,,,' ",,,,,,,,,,, 01 011 m..",1 "'0'"'' 10' .:'::-:.::;:;:;- In"" 'n",,,,,~,~~ "'''''''''II ] --ftt~-18.l ~I."b' U'iS~ I i I USE PPO PROVIDERS WHEI1EVER POSSIBLE, CALL THE PPO INfOLINE AT l'OOO,~44,1'22 FOR FROVIDERS IH YOUR ZIP CODE AREA, I I I I ALL DRUGS PURCHASED AFTER 1/1/94 SIIOULO BE SU lMITlED TO CAREMARK. ReMEMBER TO CALL HEALTHCARE COMPARE 100o.s44o\5221 FOR ALL INPATIENl rONFINEMENTS. SAVE TIMEI SAVE MONEV' SUBMIT MULTIPLE BILLS FOR THE SAME PERSOH OH A SINGI,E CLAIM FORM. ASK OUESTIOIlSI BF. KHOWLEOGEABLE ABOUT YOUR ILLNESSIIHJ' AV AHO "REATMEHT ALTERN.\TIVES. :/. 'i"" vt,' .' ",4IiI1\l".....t"MllrtnHlIs. " " . .,,' , .." , ' . '. . " . ''', ", :. ", ' ,.' ". ,,' .....,... :,: .,'.' . 1 . .' :'. ;'.! . 1',.. ,~ 1 ' , "... 4 . ,,' ,., " .' ~ . l ,.:,;. ;,:', ~t a;'l'I",~J I:'~',rj..j ~.,\, .i 'V1LMJ~~ kJ:r";;'PJJ"'.il ",.:,~,.'.1i~lcl.:u..f.il,..l.~'~L 1*.ojJ~~:'I.~.'l,,'''':l'j ,.. .j:.J.iLL.,Mi.O~""" }'", 'r'f"::~-FV1I-1~~m;o:"':r, """;";:' , :r"~'''''~ ."., '. ."',......,~I., '.:' .E~'~'~t\Q'J<l;Y!J1,101:~'Ht';J' i:",! '.i..:\'.>I:",;,::"~'>~';;,~,,,,,,,,~, ',. -.,r :", Pl''''i'; ;,,.,:,:,;,,:::.~,. ;"';':,,,,,iAS~"":' iI, :.~,fr I ' t'O' Nt' r . l~,(: ~: ..tTAr1.i! .;:~t ~. 'I~~ lHt:i .(, ~:' AAS/\ ,'~' e., ", i~",: ,\""11'> . ..,', ""..,',,,:, . HEAL lH INSURAfICf. CLAIM FOAM "",; , . I t" 17";'llc.',I,OIC '~'t'>C"ln " CI~wP\.I'J,!.. ," , r)IAA''''/1 Mll:,jI' - :t~..:" ~I \,I.(.'l%1lf-D1I,lJ IILi\"I~/oI - 1"~ll"I!O';II.-\I.f~I' 1 . L....., _. _ MM !' ...... ,'f:...."., f".~1I '~',.""'.',.>"l,j __ ..'" ""1 ' V'" t 11U,.\f~.II, l.....~....,. lj~lJlf\t,,-~sRI' 1"..'"" 1 ~~,~J"JII 11:\.'''''1 lllr., \ I I' ' t.;r,ii",..,,-....... ;;~i~"j;';:'. ....; I,i .~~\;~.; iNii..' .,~,.. . 1 i; \'r:, ';':'j'",ji":~;',r~;i:. ..:..._,,:~~ ::, ..:. f";;;J.i';I;.[l.l'I;''';'~ I'il~"'l,:;':~,' f.;'.j,'j,';:"1 '~r,,~,~"r;':"fl I " , ','~' \1..; ." l"" ," H >". , I"'''' I ( I "I"I~" ".)'.._.1". 2~;....",__"." ;( .:' _.. _ ,;.OU',', _, '.r,," ". . _'-" ~ ...u..u~__. :\' ~t ,."(t~. ..~.IJ.'.\ ,'d ,"...., .'~;.-';l "I. ", il-l;"'f' trJlIp,,,llojC' ,:;,1\:"1'(;1," ~~:Ih'i\.;'i';~'-~'(.~I"" './.( I \,., t ~, :'"i \ . ,. I ; '~ . '''-l('~l'''' , '",. r' . l I i\\"':'~ I;~';~C'.;.,: "u u' ",' :.'~,~~,r':<::>':"~'~:'~~:;' ;:,(, x ........ ....._-_._..._.ri^'..---~.if :~::' rTCuir- '~'~i''''''':''fit';'';''I~~' ,; i':~'" :'i~-(:;i'll~" '" ';' iii iii'-;-'~':Ir ,'I \;~':;illl':'i,I,i,' ~L:)';'I' ~ ~"'.-'i ~ :(~t: ~11'~:. .... '." '1f'lr', ~;'~'~~'-~~li~'l II' ! ( ., g1::. ~G.t..~~ J '--' .... ' , '-. . ~ r'..,_ .. .. , .".,'.......",."..",. ',,';',,' ,'-;1,.',';-,','"'"","'",.,,,,, ,"",.::,',".,,--'" ". ._, ~~..~. -"'--..-.1"" ~..:'Y -llOJlh'.,I...<,,{,I",.....'1J. ",s .u'_';",I'lJ~" \".1'" 'i. .I".;,~'..:...."I,;I'IH:H:,^lt'l.r. ~..' o. ....,,, >; - . . 'i,,> ~..._.. ,..... ~ -,..... ~_.. ..E~~LL,...... ....,.,.,.,,'.,o',.j....,. .',.,V',:--, I"'I-"""-~- ~"....- ...,--- "-,'~'.' ,,- ._,. ~--'. "--.1'c~. :;rl. 1,i\..~~!l-<fR '111.:..... ~ 1.:1 j' J'< ,,',,:. " ,\,'J'IIt', I ~""I ',(I~.I',' 11..\.!llllltl~ ...~i, H,t"I"t,,'I, "" ~ ll" .. " :'~::)I'L_...." '.. ,. , )fl~ i '11I) . I,'~' ; CD.: n ~.j" "'; " r r n_),',,\t ,;"";'" \)l~r\ .'. \~JO"~ ~'I\\~ ,;.. ,..,,'." ~.I , .. " A, ::;.1, I.'" ',. 11..,1 ~~'" ,J-fl,;;.;,1j,.l:.ii.~~;i:i.in~.it:r.iJoni~i;~'....,I.n.~...,..~..- .,.~-::~;.,.~.~ ~ I:;:, ~"".., ',.1' 0,1 Ij,!. "1, ~ l.. ,,,, ~.: I . i.J.i ;'1' t.",.,olf' 10 \I ''''" '1''1'("'---' -.. "-,,", ""l;1 '.:, ,II 1.1' ;.-li;:l::~~Ni:'i!j:'l)Jl.;,:.;:;/n)i,}ii{;i-;iii:.;iN~.~..t' -'-_.......,.~'--:...l. ~. ~;. ~ I , . .. . , ,] ~ ~" I'H .'". r"'Ai'l[{,l . :,,~ ~,I,. ~"I;;l)Jj"'V..rf-';' 'z;..A-lIl '/1 .n..~...i;;'''\I' ..~u~. -- . , : ;,i,; -"ll"'if"';,,ih';;'l ;.i;":"1i:" .i~l: I ,'i 11'.'IA oVl',.>tllll'l1 rl.~l.nf I'G'JJ~1I ,'~Mj1 l'" l'; ~.., r ' 'j~,i':: - -- --,~., IlUO OAe" 'C~'P-OA-M.i"'OAt~C)I.t" - "...,,- . I:. ....J,~I!~.....l,~J!.I~. ''-' J?'~~ ~~::~~~~~~I~~'.l_~~~~'.~ I .. """,",; '" ""',,""" .."~,,. """:0"' , ..,~~ ~~':~,::~~: T,::~:O:..., ~ ,,,,,,01,,,,,",,,,, :, ~::~,:,~:F~~~~~~~~.;;: :~;:;~~~~~~ ~"~~~~,~ :jOI :.1';':1 f\ot'l.f,Jdl'/ll, l.l';r"H"'~ ;.,.1' I ,'.W; '.\lINtl i!,ll"",".1 l' ~,,""~~:" ',.' .'i"l, ,"II~' I', (l'"u:I,'" 10 !h'll.fl/ "P.: .I.',~p'" sr"~U ~l\1r.(,t~,1 :Il/'Qtt I . ~ U~'Q""'~1Il r.l'~\'" " I ',;-;,', I , . I t.'l'.-: UlmO.._.. .._~...i.'-T.C;~JA.r.~l.[....~...i:/I~.~~;..:,: r !'MI~ ~ ~'.I.. .. ~l\:' (j\Q'lflO__" ----. __..~__H_4 -..---2 d.:~ 'It,~''':O:...;uII~~:~f ~ :~~;.;~l~~~~;'~..,~,~r"~.r, ',~ ,~,.;'a'~'S;J;, '~~(:l;' .'1 ~~'{ ;r'~gl'A;' "~~i(',"~1:1 .~ ,l.\J~.~~':~',~~!",~~\~~~r~.~r~. '~:i.I~:~,t~,~~~~I\.tI~~I'.~;..'" ,~:'J 1 ;.~':: l'f~~f;1t'~'l'~jiJi.J i,j..I;:~~;;:;.~7:,~~f\;c.j; c; . ... 1t,.;,i'Ui.i;..j~."lf~lfiii;~,;)I:,I,;'I.~~~'.;;.. '1~~~~~;~~~I;H~~,~~~i.fiftru\ iJ;~~..k{~i1Ji~:;II.:;~~:;.:-:-.~:,~-: . j~p I' .' .. , ',. I );,01 PI1/j~~\M ;' (Ill ; H to. ..1M ; UO ; Y'I, . ,:'.. I f;:" "'_'__'_'" ... _ "... ....u .. ~._., u_ .""'-'V...,...;,,,;.,-,.-,.,,u',--_..~j,. ,.- ..._.._...........'..J...14._.I.-,..-....-..9" ;~:.'~ ,I) f1t'SI''''/(OH''I,C'''1 I...." ... 'I'~", ... S~;l""~e") . .. ".: ,~;l." '.....MI.'."1-....)1.....! ' ~j~. t_,_~..,_, _ . ..<' :l,_..~_. ~..<f".~::: _ _. ~.,_.lu......._"----:";'.~.;., ,\~/ 'I,D;A(.fo!:lr~'i (,I. "~"I~r,-~ Co ,;~ .,~'.~ 1I~'.'" Jii', ...\;.,.'f',!I:~I'~-;'.I,10"': ,',I(.~' .'1f I, !,Ufl '::: ....."..', -.\ ~;: (,',r;l:~.,IlII,V.SUt\.l,'I'j.SI(,I~ Otlh}INM (I.' ~l,) " , ~~::~. 'f" " r .. D I (. . l : " .,'/11 1/', I;'U:: flL:SF ,,}IC_=.I' __~.__M_'_ . ~ j.i VA .;Ii.'~lji;iJ,:,~~fi?j;'i.ulli.iil~ri-. ~i, ;: :~.'.~j=. .M~,". '. . -, ~.. -..~- ~U'''(''M(_~ ..,-'. -"-. r' - ...~, "') r. ~-..._.._.-:r..~:-..-.--.l'.. ."..'1,_.:{.. '.1._"."..',~"; :~',-..-_-_-~'_-.I( :',' ~-: ~ ~i: ~ . b. -,~ ~"I,II V" If" ( .. .'-.I'P;,I~~-' rj:' !"',:'tiiit:'ioij(.C-\ ,,"A.ij-F .,j'ii'LiIPl\lf.. ~. ~_.. .1.. -.-.. -- - 1J>\(1 fl' 1" -;- " ", S; '1 IK~ '"M "I I 'I':'~'''' ....~",\lI,,,',.'...I"(:I!~1 I O"I(j'.o\~, I ~"AI./(\tit . r,l\ 11~" W . QIt I tU,"'l!fWt!O 'Of:'.,'. . t' t'l. ..."" ,;..~,. O( l. .., I . ,., ,':Ml. .. .'.".'.'.".....'."'........ I LX^l,lJ~1 ,,'.:' .': ;-..' .-.--_.-."'... .' - ,.'" . ."-) I", ' ' t\ l" 11 V(", l.I <I,:" " , . "',.,,.\-..-. . - '-T-.~.-~ ._~~. ....' ... M_._....!...,....._~,._..,. _,.....-0,.___" "-r'-- -.--.-----.. 1 I ' " ,,',,':'.I'C ", .. .1 L ,. J -. t' e. O' h a:.:.J. ' I. ...._.,-~.......r o'~io.G... 1. .~.L.._.,_..___. 5. ;f;~tr.~"-'~: I' ,,' -~~"i'~--'~,: '11 . ._0 ",'''-r',~ ; L( I,,,, i .: \ 'j;: ~"-/.' .'-.'~":"~' .\OJ,, .~,- .~~..;J'.J...:....o.I~. """~ I ,....." 'j' .....,-_.--,.~~..L.._.-~.I:....\*'-\o/...'rl........-I._..--'..,._._...';l~: ,:{1' .; . I: \ , I f '.:~:, I O. ;.~.~.;'. ;:---::_, _:_' ---\~;~ ~- (.o-~ 1r-t -s-~-I-- .. -.[--.'-.-. ,--.....:.. ;, ~ ''-i,:;:'" ";-.-..: ., - . .__..~,-~.~'i.-~ ..-- .....Lj_..t ......-.,-.'...:~~l,i :l~\ '\' "r ,X,i, ' I .; : ii' t ".' a: " ./ ~J: I '1' J....' 1.'~ r ~~,..t .....\.. , ., "-",r.:'" ....o:t... - ....,-,"o",.',..".J", ;~, ...l..._.f~':~.,-J,j,lt,'.r-,I,!,l-M- ~1-,""-,,',.....,1.':",'.- ",' ;il iH~-,:~.,iM"ll.t .'11 ~'I ~1l1l"Tlllllr'IC~tl,t'.'.:. "~c::l''I'r~\I''),'I/.Itlrl .'\ I'AI,.. "'(I..... ~,.. ..,..~" ,;,.\" :::' ' ,I \ _1(,N',lII" tlt"l......r '110) I f)~r:4'- -,.. --.. (~.. y.Q.ll:t~J..~,; '.. .,d.' _ ..1,._ ._. . _ _.t\ \. ll.j,~~.\_ .):':',. ___..: h. "-"'-~':'1-'. dl..'~'UL J,= Jil~JlQ...L~" t" I !IOOII"'\J(If 1,11. l~jCI"'H", i\lIhIV.1 r'Q N,l.Lli "'ItI.illlJllrIol\ ,1( '~l;,'d1 ~I"tll~ "IH\nJ I""~~ 'J l)"nl'J~I1t' ;I"'h'....~1t S-",Wi ~~I. ~~Wt ~!I'..COO.. . ~ ' \' )t,;.. .\ItI'4IJI"M.\Cl",.~~rllonC1I.{jL.N',IJrI.. I Jl~l(tJe/IIW1'I,~'.,"n~..'f"":..llIl'1:.~ 1.I'IJ"lf-;~~ " ,.,\,O',,:J.J, Il:.lOl.'l r\?,(.o'i\.: . r.1~;/l..~-;;;',;.~;~,I;J;:;;;.I~IIJ4b ~ . I\CrvAN~et~,:,Mr.OlCAl. dCITNTGR , ~::I~)-~~, . I ., :\ 111; P,~NE...,rUi:ic.E 'h'ri~o;~\ "'I: '''''''''TI,o'J''O' r.':' '" ,,",. 'i O' . . .. "'{'Ali.",,"';:' 'I'" ".,.,',;., ',\:,~,.':.(" " 1.~.~'.1'.-'~;..I'.1,'.l.f.oo.~~ 1\,.:....r~v~I.t;;I.~.i'..M .;~..". " ,,' ,.,'."...~.,'I.,'.'I<,." '1,1' r:''''!;.;.u:r.',;h~~~I1J...,'~.,'r;.I''':',.'..i . j.:.~\;'~~~.;.,:.:..~. ';...,.,..'::~,:' ::a:,~~;~'~r.~;~:,{w. .,~~.,;,~;~~.~/~ ~ill~..'~~;,~;..,~:',~~,:.,:~I:,,:~,~,\.',.,:\.'.:; '::i ~:~~L,.~p:~"."" '~r: ~~~:;~':;::~:r~ ~,.~.t,'\:~>,';.}.:,:'"..~',..~,~ :1 'i~~: ~7'; ~,:~.. " . ~;.;~~':;:~;'~ ::,:',;::!:::'. I :~' ,~; r.~...,..~. "'.......V\M'<I,"....,~':~_ .,.. .v' .... J \lf/t"...r,;'-/l1iPQ -;,Un; po , T' . J~'.,;1i,'''~~'~~~ fl" tIlloi_;l:.,..rtb*fi:\,,~:v~~\tf;r;l.,"'., , '~ \tJ -1.ltG.~:.~h!:l.t:W;ej~ ~!L ::: .~,~' ..,::~~~~~,~ f~~(~t~~(ti,!~'i4~~;:~tl~tj~:~t:1' tr.:',r(r~l.;l~ .:~!~ ~iIQ{';:.\4';'~':, .; :f?i.~~ql,t~l.) ;li~.:1~d.~J:~~t~}.:":~I~~,(q\;..f:i,:~f .'. :.': 'r" " I I , ~~~~~~~~a.~mr:t~n~:::';~r::' ':::J:',t:'~. "1 ~/..s:'~'~,y.;n~l~~'l'.'I!d~~,~L::""i': ". ,Ii.' ~ljiIJ"~~';"~iW,i\,.....:. "..' " i:'~:~:Y'~":\'1,,}\":',~ i.>. ,:,\"., . 1...." '''~~.. :'\ '" .". . '. . ~,'~II:"{(""'lJN'JTE rj : ,.,' . ~',:-:'>({i'.~ ,,',.. ~ .~. r,:;',/::Ji~ \lLI:~ E~ J:;::,:};i:P,';i,( .... . . r,;; /\,,' " , ~".:;' ,(':iMPLOYEE ~AME/SUBSOriI8eR j .'t" .\' \'.', ,," .. - -----,.--..-..-..--. ~'''. :.' :,'~~. '''tL'~S'''fi'''',,,'..'j "'0 " """0 j . J. ~" , "'''IO~~i'' . . . . (Crt' '.. ;,,'..;;. 0;)'. ",,' (I ., (jI1 .j5BlIl7.'~ t~ '2 ~ 0 ,) () I '. ",;.... ";,.. ,;'.' . . .. I '. ~~:_.~!I,~,;::.__' ',. . . 'c'.'; R;,:',. ..;,. :.pp.~ass'S1~~5'T:r.rr~m,:r' .. /) L.i ill I' . ....... '" 1:;, ,:?--LJ'(7' .,/.'.1 .. ,.'~: W:!,\ 'i::," .;,'." . (;?I,f ,I /1181"1/111'. (;;r..1 -!/4U! P. "~I,' "-\.:5'( 'I -.' . ',..';f,; J'\ ,i',;::i.l.;.,t,''';~'~;;'~ ", ,'" , 1 ,', ' , , ,\,' ..,.I~Jhl ,'.:.'I,'.>,L,~.P'Ai'IENT'NAMeIIFD1PFE~GNi'F110MABcv!n : ,,~,)!,' ~, .'. .... '': '. ;':'~~ ~;'::;.:":" 1r1:fR'H~ ',"" -.. :'1t8'''' '",~S1]~V~' ~~ ~-':. (i.<IOasDJ..'ll ,.~.,. '...r'o<atm'"?~ 'J,Fl)u..I:ME5\1JDEmn';:i:~;' ~..., '. . l.i ",~ I_"'P! ' . 1 ," 10/1 .. ",I,.,. , '. , 3' . 'rfj I 0 : .ho, ~ ' "' .. . . . . "lJ'lI " I YES NO' ,,' ',"'\.I'\l'~'''' "I~J.~.._--:.~ ' ""j~',!h .. . \ . _ ~,'. I ' , ' ., l' "t .. j'" r' \ I' ~~ t',- ",J "):, .'., ~.. I. " 1"" , ~,. \ ~';~:'~t~'~ ,\,j~,\'~\ '.it)' .:".,' , ",j.". '.' 4 't"'. . ,.' ,1 ,.'l"l~ .\.' "'\'ffiCl~ANC"Wf':oaMATIOfJ(MU!;T'BEI;~'MI'L.IITEil :.', .." ., "c" ,., ~ ',","'" ., '...,'.,' '":,,,'1';". ~"""':""I' \,.tl,~,'''.:}..Ii':/i'j';'l'r,1'11J.'(j'''1,tl.lh.,Lj~, ,1\:.'lllf'I'\I, '01, '.' ,_..,r",..,., , ' , '.', ,'l'I.:,~\;.,r. ., ..,," l ".t" I'S..,'I.., ,.~' ~"J' ''''~r'' I' ~ " ' ~ '" '11(> ," <'!t""t'>..lJ r~ .'-l' ,of:-t' r/;'''''~:('''~ Ht!:~~~",r~ll.'ij, ~-ll ~~U...: k ,.... ~~/-...i ,I ",1 j\ (h'i' b' 'II T' ,,~.... '.~, q 'I' 1'\..t ",,'f'" " ," ~,.. ,.1, .~ ~ 'I'. ':'., , ! ") ,r"l I ~ ~.. .' 'i ,J( 1~1'\,~ l_~ ,', /"~..~~~ '''iE'O'=~~lPI;.O,(~{l:NT'_ 1 .' ,-, rUL:l.:....' ;.-,. ~ ." "~' ~. ,,~. ','d ".' "',' ,,:' '.~':" ,I,... ,', r ," I " . "G:' . ,"" " I "",,,,:,,, 't' '... ",f',!,""': .'. .,1',', ~'. ~'~ '1' }J;j''''1 'C} .. ' '. , , . J' \~ ," ," ~.'I~ '1,.;,'_ .., 1 ' . . , " ," ~ ).." ' . . "~I I' . I ',' ""'.' \ :'t.'F-IAsT DAT~ OFOIAGl,lOSISITREATMEtfI' J . ":".:l...' ,. . " :-'; '",',;;, ,j,' , ~, , .'-...,', 'l"~ '''1' I . '.1 ,.'. .... A 4 \ ,'" I ')1' '., ~ '. ... ,. '" "I ' ' " , " -,,' 1'1' ~." .... ......, )~~,.\ ("II':' '.:,II; ,.,'..f ..~I'''' ~_ t' 'I' 1'1 tIC I "I'..... """::'.'~Il ., "~ :.J-.... ' " ii" j'j;' ,) l:7i~~illi' SC~'IPTi6N'OF"I;:i.~E~~;tru~V' j~' l' '"i7u{h,:~ih0'~~ ;10:, ,,;.,', '\,:f~ '1"",..".,\)1\' \ '~. ..., "~"'" , ,'.II'; I".' "'" p.,..'~ ~':..:..;/$.,:;I~f'jrl;:..~ 'V/,:'." '.:',", ~ -f.'::"17'1':',~ --,,' ,'..,' ',' ~,H,'I~.'f)l . ,i '.~ "i\"~::' q.." , " , G :u>.iU ' . . .f .'_ ., "",,,';:< '.:,~''''~\ ;,\'!!t;':,~\"~:<""~,<~,,,: 'J'l:',:,',':,,!~ l~'" ;,,~~ ','; ,:1 '~i~:~:,~':'~\ ,I, " '" :"~~'I? !}f..:.l~'.'t~1b1'!:'\':,t}-'~I.I"'; ~ ' :., '/.:,1 ~t:" ,~ t, I' ....~"\'~l , ". ' .,', "'!Iil~'" *~" rJ.,i~;I'".,,:!,.VE$ ~~) I"HO .' ..... i' I' \ 1 ~ I, ,\"... ,~\.", ,'. ", ' 'ti ~).1P~1~~:~~?1'1~~[j :;;~~ ";~:C:,?J ",~}A'S ACC:I~i OR ILiNe:ss'n~~~~1'r:O'ro~},lPLOOH~NT1 o~ni'! " , , ":"~~il'~' . ,t'~" ']vr,~~l-1~'~Jj~J:i. ~,(~;,:~r,' ~.\;...:,. (SUbmil.le; ~oi'kin&"'s doml) cJH~I~rl, ./' ,'j'\~7 :.. :. '," ~ '. 'I .. , . , , '~~~I:{~ '~"l."'n}",,,','l'''~'~' ""'<;"""',,' ,./, ~. ,,~.,. , . " ...f,i't~ ~'" '~,4 ~1~;~";~.~~10":;! :;.;/ ','..,' i-':'\ I::~""I r.n-'..:n " (,If.h ::' l~\!\~~rll:T;~!!I"J'i;- 11,: Q.1,~:,t\.i ,:.):" i ;'J' ) I, ~ ;, \ II. d; ,'./, i 01.: .,1, ~ ~ ';;~,.; ;~,..,. ,.~~" I , '<<I' ~~l" '.<4''': ,',',,",' lBTnIS!'ATIe~ITE(fOllllerOI,~I.'I,,'CA'ItI.f"OCAlu( ;. . . " '1 t' ,t~lr~r'r'I'~Jo'(t~~"",,,"I~,, ,'.".'..:. I,' {,I,l",~l,\'" "I,' ,'-'Ill. lU1l~~~. rl~~;/;n.>f~G~~~,: ~' ' 'IS~IS 6~IMA nESUl;rOF~ VI!HIr.l't:;.:c'dloirNT7 ' '::l\,~',;;. ':':"';.ii r] ;\! 'I','" ,. '/ ':':';. . ..\.~ ;: :~~,~:~jJ '" ~ ,j .IJ,')',1.t'(C' 4/' ./ I',. " . . ' / " '" r';'. ~ ~ . , ,,/ r \ ;i'.;'./~\':ift'''~''It'~~'i.'', . ' / ,:,"'j j' """"" 'I"" .:, '.'(lii', ,'!:Iia:~~r:,,\l:,~),' ,'CJ :'9spaUSEE~;PlOfE!mIi'S(),t'~I"IE'OF.eMPLOVd1:" "'. ," '.' .;'1"';'" ,,';,lh)"( :,.:,..-,':':,1 ~~'\Wlsi 'f;N1'~(jJr!.'''i'', ': '.,' . ,'"{"(\(ll:.1;""r ".J,:,,,:,:, .'", .' '';'f)' 51' J ~......tI."", ",.,,'.. ::',:,,~,' )~:;:~.:~i-~}l"'~~'f';",' .. COMPANy:J..L."YLlL_.d'3.I:_"'.'" POLICY' ,,~ l' vr ~u, l<.:........_.~~. .' ',J.,~~i: ~'t>l' ,. ~~~',I1:!,"11"1" . \; '." JL'lM::!'~~ I. (f" '~' ,.~. .--:7:...1 ," \!' >: :-: ..vE' ):"'11'/', . ::;. :':,l?~~ ..,,' ":'~I.'l'@ ....r,.s~~:.Iv...'~ \ '\', , ss' Irr f}.'; , ", /. '114 '/ ~ ".' l'"fi) , . "t.: \7I1.\~l:~""'''\~;~''):':"" ACDRE :. !-;..l.l~-=-''''t'.J ,: _' ~.....:..-.:.~ " ';'''~\-'~ . ~1' ~.R-tn~\<ll'':i ,. ", ";'" '. '.1'''.' , , ' " " !...; :', ,I .' , 'l I' , " ' ." , ~:.. ~ .' ','(f" 11"f:'.~\;1~ ",t:..~j!,l:'to~,l'\jl~'.r',.. . '". ',,1"1" ,\,' , " ) ".1..:."".... 'l..!l, "j'-..("....I.I,,~\ , ....'.11'1':. "\I\I>---.'\l ,"'I.f~'" t'ltffi<:'~lt';,O.(~""""i ',' , ' ~ ,"J . /"1" . I,., ,~Jt"""":'" ,'" '\ '.",.....,1",1.. ,I..' ,..',' ,,'t., ,.1\... I ,',,\'" ~1~1' ~:*.it}*.l1.'i!'M,sA.~ 91' A~~!J:AA0'A:~l(j AIiiT.~~,~H:~i~(!~~,l?;,R~lEAs'E I~FdRMAt!ON.::..: '1'," I;';\:':}: [, ll~iF1:\ I ~ ;-,,::;;;;J . J I\I.~ ~~ W&l~ ltn'.to~ol~'If\'Orm"H.;'~ll' tnlt IOU C'orMr.t. 1 ~lrtM,rll ~ :m't ~(l~CI1"'tG pfU'I'lder, tnMiHtI~. Cl1rnp, drjJ~ .,.WY'\O(fIteJl4. 9rty~"'f Olfolij.tt If~.: . ,', t'~T~ ~~~'I~''''''~ 1i..~etn\M"tht~OI'alfllrblh()P13~.A4r'nlnlslr1ll'o'ror~.~j1QfIU"','i'~"'11~1:<,',;',"'~ , ..' , .t',: ", :'" ",":., ~. .'~,,~.\~1; j;.)1{o" .n '---fL-"" '." . f,")~';-JJ'~I:I~:h;1~;"l\I::''''(; ',! ',,' ',.' ' . , ~, PA""'jU"'II\" ~SIONAtURE ,.!.; . 'h" '~1...t"""\'r'r:"""I" .",' .",', ,,' '.', ! "\ . ' ~.",.... "'.~r: -:'\"~~~"I"I];~~'\':'''.'''' " .' "'.' . ~ l)i fO.t.'-'~~ 11,: '1'''' il ,\ , . 'I ' r "'\'.' ~'~~J."',),"';r\\,~,<,,"" ',',,' I: ", I,..... '" l' , .L-~" ,\ " ,....'~~, '1\~2.iTt((.,:'j11.l;\'t!,.~,.:~~,\ .1, '" ' \, ';;'"l!\I.t:~':l.;,,'I,J' .',1'..,'" \,.I~IJ":"'.1, ,. \ 1,,'1,1. .. ,';..,., ~;:,~J.,""'~'~~"'ll;""'!;"."""~I"::'" '.' ; .' ,,:. ..,,~~,u,' 'i'~;~, ~rl;~~itWoW.~ffg,~!~'r!qN:,TO rAY,PFlOV1~ER ,,(, . " :,,;!; ,,:,::, ,j" ,~" ; ,;.' '. .;; 'J ';ir'.. ~h . !' "..,,;' I.', '. ,,'': ,\:".\. &l~;fm..~~!i,lim'~(~i-kfj~I~(\d,~i~hifMlli,;..t>1r!),~~.;i~,"I;,~i~~i'~~~,; "" ~...;d.~~;~ ~ll.\ljlui~, ';. ; .:....::!;p ,''';i!'.''',' ",'".,' , ~-r-ij-'4~'I,.t(affi' .. -'-~ ' /p' . -- ,. ..,..,". lfl'll!.ll11.iI.,;'m'~" .'j-,;',J.I""IJ,~,',jI:t~~..I,.)'.:..I.",";.J,";~.il,:~1'e:~U1~i"8' rune, . r;' ,'I JOATa '." , ",.~. .;';:lil~~ f:!t."< I" I~,~\.~ ~~~."I'I'.'"",,;' I' . I (" ,,/"" ' . ' , ", II ,', . 'I~"'I ""'I",~'I "'I"""\' ...~ll,",.,"I,. .~'I' I~ "II,'l,' ",,' ~"I'JI ,/,lil" 'I"" ,,,(,,~~ 'l"~' ;t>J'r>t lJ!'" ~j", I I I ,'I " I, ,J t' I 'I''', . I' "I ..' r' ' ... ~'" 1 ", "i't, l>,,~~~I~.'t''lI'~;'Sf~~f};)~X /'':,'\' I';"~" ,.',~'. '.'. t', _-;1...I'~:,:::.'""1.,, ,. """:,,' .' . ....'.,...i,:?iijA ::. '. . ,f.i1, ,. ~ '-'1." 11 .. 'i I ' ' 1. . \ I'" , ~ 'j II, !'I'~ II, t .,.' .'" -', ,'. " ,. '.. '. ;,' 'r.:::, ..("'~~',~}~,"I\,f"t:l';:'(J~'" ," ~ ,'-IIi"',"...., ".'...'.":'."':";', ~~;i~~~,~;~}:\"~~~.~~ ~c'~A~E~AFrEI'I ,i~~94 $HOUl? ell li,u:~M~!I',te:~ t,D,~itE,jAP.K; .: "'" ,::',:, :,"~";:i~Wl l' ~ .',.j~~~; ," ~li,~~ i~) ~L~ ~i;,AlTH~,,!, COM~AAE 1~(<l'OIl4:'ii;~h ~o,ri ":l{I~PATIENt CONFINEMEim, " . ,: . .: '>\.'~i If' ~i 1f.."'i'r,i.~ '1I1I\t,~, 'I. I',.. ,II J ,,' , .' ,," l.r. , ' ' " ' , I". ,"". I.,iI._} ft;;',,~'ty~' ,,,to ~~Il.vI~EA!1 '(I~t~HeV~hP'o~~lOlE. C~ll nil. ~,'dINFOLI~E;"T '.400-544,'S2HOA PROVIDERS IN yol);1 ZIP CODE AREA, ' :::>S~l J!\U:~~l,~,~;~~l~\~;'~I(s:~vtMbN~V;~~~M~'MUlTIPlE BllL~ ~ol;;:"IIl:~A~~P!R'$Otl ON A SINGl, CLAII; FORM, ' .> .;';."'''~~'~l\:'lt h",.'ljl,':ll" ""',: ;,., "I' ',' ...'1, (', ",,\., :' , 1;'4~lili)J~E~iC)~~J ifS:~pOWlEtldEAilli~a'oui~i:tirt il"I\I.,~(/.\,'UAY AND TREAfMe'<r AlTERllATIVES. . . . ..' ~1(~~"'.1..R'i "I,""@"frj'"'' ;..,1' ~'~ ,"'\' '''''',''''1':'' ,:," 'r' ",;1, .:-,I"~ ' ,',' , ,.."J.: ~""I~i'~ ~ r.l'" cl'.'''I''''~/'J-\ . ',.t, ','" . I I'. 11'1'to-, ',,', 'I ' ...,' ,I ""Ir.';"~),' ~'f!. .!:.1':) ~j;-";,';.;~n~~.....,,,t.:'i:,..r!~ll,~'l'i'!"I':'I" j:l'~ll')""-tI(!,oI'~S.~ " ",: 'j.,., 1 .. J,; ,',I "I," .".: ':1",1", ''':''~I;\'''':'-~(('ll~''''''l'''1.~,I!1iil~~,~ 'l'~' r,:,',',1 ",\~'\j""ql.t " ". ''''''',,1::\/.' 'l, '. . \"':. Y1,t4I.:;~~... :J.I~'~' t.""~~,r~,,,rt';,~:~Io;:~'')iJ.''''''''''::-'''.''''lljSll''J~:i'lrl'l,j:;I.~''".I, "I'. A ,./' \1.).:.':'J...': 'r""'~' .'1 .., 11t"'~,^"...."ii'!:l~"t"'~ .. '1\ .:tf'I' 'i 4"'11 '.', '-"'.,','., \. . .h\. ... ,. .Idl ,.' '1\1' . '.. , ':'~ ..,~ ,'.~L.\;l' '~~{.l'{i-;VI'\I'~';~~\;tljtMz.::q.l~.,4tl1lf.";1':r,tJI.~i "~. '.~~:Ir:~l~~~'",., "..' ;"7tl)~f~\',~1.:,jl},il'.l"1~...\,l~I,;:, " '-:.~,;'c .,. ,r,'i I :llli::' 1'''''"''k:il..~ii.l;~~;.;j~.J.,I:.i.: ""'.~~:":;...1."::";;:~,~,,,,:~,,,::,,_,"~"](l",/~),W!.:l'"'t,' ;.._1.. .;; .'1,,';~_ \.;" 1~1!'1"'1"'~ I..' ,"- - ......1 r'l.;'";........-...r-~.'''.. .I '-..1: .' ,..... "".'.': : ,,""1'," " , ,> I I" k I" /1('11' '1 .:i ,I" I: j, i' \,1 ,I, ", 11:1 li:\:',\,\':~ :'/: '. ';, " ,,;;' "j" . i ' Mr::ljIC \C CLAIM. . , , :".. '" '.:: #0,:21305 . U'II'TEOIlIR LINES, INC, E',\11'I.OYEE;BENEFIT Pl,AN I I . . . I ~ ~:: 'r -~,.~~. '~;~ ~~':' ". ';~~.~"~~,~ 'TTI~~' t~~:: COBRA RETIRED I':;; ". :.).. " :"~1 ":':,"'1 '",:'t;::, ',.'.:" " , ." , .j:.....' '.-. .r'T'.... I" l .\,'''. ; "',"', '., " " F (E',iln:dr:'1'~cf1ITEI;jIZEDBll.l.S' ,; .' DISASLEO _.~ ,,', \~: . ", ~' .11 I 1'11....~f,..~.J,Vg!.~fJr:-, 1.1,"NF:A~;<,I,~"':~ ~~0~~:~f1,;,r~"~::fli~I"1-ml~T""'~'~~~ ":".....---rr"r"":r"~:r;'1""'1"'~~1 ~~,. .~. J"<I"'" "'i.,.\.\,....olI."/..... ""~~'" ,~.l..~. .~,\".;o\'(,:-i<!'i','I\I.1)II'I,~':"'.;'I,.!lI,','~';'.;":,,, '.' ,1,., ' .,".. ),. " 1"'i!.lH,.,1 ., . , ., ~. ....'."~ '.../.....:..,.1.,.' '.'.' ",;,': " ", .':'-;..',:',J':".'J';""'~"';""""',"'I;i "~~i'.II'~"\'i,!!I~'Kj'l~~,:t'~.::t~'!I:"';:' ~:',':",",;'i:::,~'..':'"~':..'.^.>.,,,:'" "',": ,:"::'I.:I'~::1 :'!:':~I:::n~lh !(.'I:'lr'(;~; . " ' ,~ , ~",r\' "'; :"'~I ',' ,.', i,' I,' . 1 ' , 'I',,', I '. ~~.,l,r;I,"~tj"~,.,, '". .. .., ~'~O~~'1;<3~2::' t:: t,~""UrrOln",,'_' , . w." ~)tlf,I",U"Io.\,~r, " l,tOU1":)lJ."li'H)[S' [I.. (~(Jej1,'1 ..~~, j;~...,~~j(__'~,I~~"'" ':'1 .f],~, ;'1/J'I.~'.~ ,:,1'1':\ " , . ", ...1 ~~l~~;'i''.{r~,'::\l,>~ ' , '(,1' '!~ffw::';':'~ ".'rii:;; i ' , ..,,, ''" ,,', """e, CL^'M; """ . ,,'.ri:jJ~j, \ I:. J:..;... .. __~__,._,.,"__.-.... ....-..- r IL- 'f j' ',\ICrr\;4(:( \" l, ,'v 1",\1," 1'1 ,..'" ',/I I" I,.... t '1 I, I WI IIII'" II.\!' ,F II'" ,,"'J'~''',y 1, r .;II ;~:: i;'~'I/~~~111'-I"J'~:" [--L~'I' Ii " I;" 1 " .. '7F~,~ '; I't"'jr~ll~'..;;"'l~,', I 3.H,)3.tl110~ .." :,>', l'~ ."J,j, ",1';., ""le.:- .,.. _, .,...--... ,.. ._-..-...J.~m-'''''''''' '...,-----..,....-h...-....r--....----... -- .......,--.--. . 1!~t11~p:\f:'.,...I',""'\',\"..," "'"1'.\,,,"1'1' 11",l" ."1",11, __~',w___ "111" 1'1""1'"",\,, "'~'~"j(' ,.' Ir'l1) '!d~'; '1i:'.Olh',~:'1 }~}.!F!'.I..~~;J.~.._.. -j'" 5- _l,~~:~:J";fi'\;:'.,"II, lli11 "'IL_:':..Jl,,-~::t7<(,!!.::::~,!.!~,~r:~;:flr:........:.....~.--..:..::J1,' , .j11d'. l.J,,.,~itl!ilt'j(,'.~f'" ~\, "~4'. . (;;' 'II"",I'~ .,_11 f ", . I ,ll.l,,( ,'f~'_" 'I ~l ' "/"; 'Ill') ~.~ l^' 1'1 ' ' ,., r"" 'r-'" " r-'J J . I, "'~ :;>.~ ;0l.:i':'11G:~~..~r:.....,._.......__.~._~:.:LL,..::'..-, L~:;::.. :.."L.i...,___......___..... ..-- ,__._..__..,_.,c:!.~j:~i~" .. ,,:;:':: ',,:I~~,,\,- ' .. ' I " " ,('" 1'1) , I I' At' ,~. <:. IJ~""'~ I.' ,! I, , '-] CHl 1'---)' ' ., ~ 'jl.l~,f.lF.Jj!f!L...--.......--------,-"-~.-'=.: ",,[ ",.,,' ~ """ , .J:".___.._m.--..-'r-'---"--"-" ..--4~' "~':~. ,'~'V;.IJIj. " I "~",,,, "",\'" ..._, ".. -~ I' I' ,h' 'I ,..'>1.,.\'....(, \... i.,Ll;:' ~rg:$,'~I;\:'".'.:;:CJ;ll,42 :( ,)<"t) ",,;1 Jc.!\O : ,.....-11-.:;:-1',' ,j.....' . ,1......-: I ( ) .' ,.,.'~.:\~ J....1'(., I, " I,,,, I',' , .- _, ' ~__~_...____'___.~_... __________.,.,_.__ .,..,____._ _.....-___..........._ ~_.--~~..,_.,,-~_..-...---------. '~1 ."\'~' tI, "jl:'"I1'J\II'b..;'~ 1,1, ((' '/0' 1 " <\ ',,,.. ',Inl" , I', ,Ill ." \ 0: II , ,l"f,l."~ '" "\,, '\' . - I .1, (~'tl1 ~ ,.......1 ",."" ,,' f,'-J," J",... ,. . ,\. ') , . I~'~" ~" I, '." .' " 1 [~ " " ' , , 1,1' ti1~/' ,ii' ',.....~: .. .'" I ('~620, ,", ," ',1~ J~~'~ ~. i~I'!:I\.'~'1'"l,{) 1 ,w;-;'l,J~~ ~ur(71"'----''''' --',11 ~',f~' I""!!" ,111' .'1.'p! ,:1' "II, '1,'1;'" ,~j7:iiiT.T~iifr:;i\I~-'-'~----;--"'-'--::;;-"";7~, ,'. . l';~r.'.\r t"'i"'l~'~' ' , ' .' , ["-] [0' '<'- ~l 'J f ,1 ~ t (1 "''--1 "ED' <:'~'!"" :~t ;.,.:-Ft" " , _~--'~' _____ "1(,. . J'IJ f " I "1,111 '.,~ I. ,~,;~,:"" . ~",,,,,,",\'\...~.:t~(.""'?jT.Ti'"l'"'~''' ~.- _oJ.. ~_-rT,L.-~_L'r.,...~...--_....-.J_~. ~~- ........~~ . 1'~" '..... .' .., .' .., ' '" 1-" ,'I" ~1i'1 ' II'" (' '. fOp' ..,,,..'( iI' , If' n " "". ..... "(l~~':H}:;,~o, I:" , 1"-' {'-l I, r"'-)"" [\:'l',;, , llHlTE:D AU,L1IIES ,'. ;';~ I .I.:"".,. ,t.; ,fl" .;.L f I ,-----,' ' I, I '~r~~ i~~~~,'i\~r~ll~';:-" ;,i..~.-4~.- --"-'- -11" "...,1. '[:~]C"'d' '[:;;J' 1'-;:~U-II~IN,~r~~~c6i"';i.~Lii~--"~:~7J!~ ',1 "'~V~f~lr:~~'1,.I.'~' " ,': ," '0') ~, " , ,'r~!': t~,y~' 1;,",;t.",~i;U..:~;-'!1."-' l-r::>::i.:'I-'-I"--'--'-~1-T-~-rr.r "",,,. - 1 _........__._._.__r:.,...._..O:- .-~'''''--- -71~,_._~~---_..._~l ' ,~~(:. ~\,fJ4~~.'rtfo~'~'~"'(~"'" .>,1/,,1..,'1 "l"(l',,~r,.", "dlh!'; .'-11 l'l,lp~, I~I 1'.'1,,\1"'1'1"'1' '\"1 ",.1. 'Jr.:.', ,,1:'.'0, '.:'/.}t':..'....,:.. " I r~ r-I," 1,.,,/:,1; :ll,(.a.l ~",\.~".,"~..\ "'.' '{'" 'I" > , . lit' "~'I.t' ~"'I,:ol',~I...1),"(<K\~.\l~1"'r,.,i...~\'I. " .,~;r,., .", ...." I. . ~ \ "', ~~ ~,;: ., .':.'::,.~".,'AE'AD ij,1Cl'i or; FOft~ArCO;'wLrn~;O:r~.~I~;iQ1rl;~.;11tw:-.--1'.t~f'<;~ '1:!l '<.I ,.:",_r.-:' cr.:-: ~n...n!fiiw/~""'~ ...,....t'..l"h\ . ~ ;: "If' '."\~ l~r~II1'.\ dn Au"'''/~nLl'.~........,.,..., JfJ'j~',frI' II" t,' 'If ~,. ,"I'''' ~ ~~ ,~~\V ~,., rll ." ." I' II'll'\', ~ ,/'11".1 I '''.~',,. ....'~.\ II .... ,..,.., ~...j ,I .....-..' ~ ..~<.i.... ,1/ ""..",;o1l1lof1,1!~1~! , ~~':'f.,I!U~.'JtIi"I""')flll,,(il(O-lJ,r.>fIl':'~'l'y...!t'lv.'^~""\(,'J""tNI1'~'~11~"'\"I'""""'1'''''I''11\1'''~'a'' :~.., :'/j'I."I1 "0'''1' ,'\'" " . ., II I '~5 " ' '," I'" '';I'r:.l:l1~ ,.;, ,,';:'~'~'f'~'_-:": ' \, .'.' : .',1 ,I ~ :., ' .' ''g\"rj,'' ~ ~;},;,.t~:'~"''''''::''::'~':i~...". '.' . .'.~ "" :' ',c,;'! ,',. ~',r~~:''!lb' I'K";;. ~: faG~'~~"" " , . ,," ., " " ~', ,I, o.I1C -l' ~ :<~'~IC.)-___________ ,,~..rt,. \ ~>... , :.....' _ _--""--::;--_ ..___~ ..:;.-.;,.;;;;;";':0. __ r ' ~li", ~.' I }!l' ;7,11~ .ICI~'ItT .,.,..~ 1".',(; ~'j iF. 'I, """",,,~''''\ C'Jl, '.' I fj, ,~ "1,,' r.l .., I 411 , o\"!i ~'11..\~ II.' .\ I}., 1.' 11) ..L'A1i: ~.' f'lI,I.t:r(! l/'ftlr'f,! 'd ,'f' ,,'Ii ,,~ , , n".I"II"'C"~,r~tjo;"~.. J',:.t;~ ' "4J~:': ..rM;'~rlU:D,:'..~v~t....,,~} 't.:l.iflV(Al':1o.iMIlWI,.".:'.~1 .-',; 'fl''''',\~''rv:rO.;j': ,.,." 1,111:. f VY'. ,.. 0" <f.,l'~'i.;I'.U~1 .',,' ,," ,..~tM~I'Otl'i.'y,.f."~..";,'m~ J i'~',' ,~.;' 1,11:14;';(,:..,':::;', r'~o''')'';''''''~:''; L..X L-~'-.:-_"'::', .~.l~'...;,...~ '1',.>;'.' '. ~L~8:"....;,~..:'~'.C":' ''"'1' ';i",~jt}'i!' , . :.,:~~.; ir..~ w~s r!j!.fVrtnUMJ rnW,,(:'MI,(j,'\ ':ll'~".11 ~JlqP,X ~ '< .' I,'li, I.~t ~~ ("'I.'Fq F' 1'(.I:/'.'1~.I~ j11\ ,'!ol',''''' .' [1';' tlr.,'H'nlll.l:,I(:(,\If Oo\lY, IIl;LJ;:,,; 11;.';,,1,".....1 a~r1\~!:~:"" ',," jl :'t.~ . ~ I"...." 'ii'''(I'\ili'r'\,::O;~'I'''''I:' . ". "'0'" ,'.',' ,: !. ,'.".... ..' ..' ".. '.',. '.1"'." 0"', .''''''. '.: ""';'1""'; I':\'~'."'f" , '.VV~"'lll'lt '1,:/.:"..D~'\Tr ::.'.,PI_',r~!'" ).e:,?2o\:JG', .......:... ,'. "'0.:.'.".",.,.,,";,.....,.:- :."..,.;,;':"'iJ.",O;lt' , ::!~~>lli;:~~~ffl~f<~U""-';:"7,",> ..,..:,;..' :..., '. '7"'--:~"'~'-;-' ,~, '.l,~<<jb. .:..;. . .:.. i~' (,,,,;t,t7~:;>;::~':i:X'\r,,, (:ih7t.5{1:0!1111nAMHilijl::lRLN."lap.:~H'A;',L:C:Sr-.L' 33Sli,e, ;,' . ,'." ! :lr-;}'i [;X}~l.::::" ...:;'L':!".I';',~.''''N!;' , , .l" "t:..,..,..,..... ,.4-...._..--.;...________ ______..... - ".~ ____....li ' . (....::>:'.., . '-:1. tJ:#.".a:;alOI\ rt,\~Jnt:; '.':H..',,,,..Ij:,l...n 'Jr..;.)"r,< \'!t):..-\fj:; 1:'r:M:I',I~n ;';f' .j j,'; \H '.1 ';,1'. 011' LJI!I::'~ ' I'::: "1(" teAfI ,,":11..1>1.,"-1',',"'- N ': .. ,. ";, :,.':,. ':"', i'.'::"';l"'~ '1 f '~~~?;:L{.:'~~!'~~~'.:::~~,;.;~;~:"-~:::' .;' , '. ':':,'.': 'i, L__. __ .' .'. .i;.'! ;"".' .:z.:J:;"':';:"~:~<~~\,c.;{2'::.\\P.:~; , ~~';r~ II'!('~~" ...:.:(....~.,.,...,'(;" " " ,; ~r'""'J~w,"~;I;,'~'r,\'~I;r--,,'... ,", . " '" '):''"':'~'-f~~ fi~...;,.' .:t.,.:'!~~,~'~~~;':':"'!~'~'.':';,\",', \'.'.'..' ~"I~",' '. ." .' ' >,'~::'::I"'.':i:\i~,:t~,\l; .."~,. !.. (.1 'Irl\:,R4i,~'J,r'"~"':"1...'" :-. . ,L':," I '.'- ,{ '..1.::~~..:."~~;;'~2::~ .;(. '." -, :,.:;~.:lf'".,...l..~L\,~ i~\:.~~~~'~~:y.~~; :/:: ',;.~ ;~/:: r'n",,~nt.~;19ir.rji~,"iri : ~ ,'.:' ,.' , :'~ .::.,::;:;.,i,. ~~:,:,:: ;~~I'Jtl. ~~~.,~,~. .~~~~~ /" \..'~.~ ~'.: ~~,~ 1~.-k<. ~~, ':,J ;L!e ~~ll U-\.~ ~iI" l/\~:t1'A'\ ..:i'\ 4 "~~&B~JC \.; ~~~~. ,,~,.~~e' ~tr~J~ 'I"''' '.'... '(':.\i" -, ,. .,",jj.o'-:,n:j'., Hdo~~_ cr.rp~P:S' I~'~~!;':=';""~r'';~,~~~:' ~j. ":'" 'f1j'''lj\\( 'ff.e:f"9"'IX' ~' ""'!'1YIil'il 1 "':: l' ,~:' ,.,.,r: '\ " ~iGii'" ,. ~i{; ::tl:: ',,'~,' f, :', "~I ". ~ . !l' ::'\ L2~:":;"::.;..!;';:'~ ,\ '.' ':,' ,'" .;f"'" .~:.,~,l~'(ib';-';l '~,;-.f"h;..'r"'.:.;:.'~" ','~';' .:',:,\,) .~..,.., , ""'1' ',t] '\ " 1,," ".;,': :.-tl~:r:....IJ:':iI~I\:tr~-:J..l.t..,\;"I,.,~.,I~''.'' ,':",;"":t1; '..D':".I.... "\,:;,~',{iS..I\ :,'.:: ....,' ',"~ ',h.i. . ., i ,r, I ... j ~l'" ) " "~ . I' . I .' " ' ,. :}-t:'I""":":'"'.-~~' "', ~.." : p . ...::;:~....:. ..~~~...~Ht ":"'~1.0 ' I.r,._,. ~,,:~,'j;I\.\'::""'~r' r.l-/', "'.':' "I.': ~ \ .. I, '1',~lj!~' ';, t " '1'1 ,':,1 '~.'~(,.\ ;'~&:;'"'Il'-l,'~':''''(jf!;t~~'''~'''''''I''li~; "I ~. i' ,i, ,~'.' ..,\ ' " '- ~. '~'l,:t ..1'~'1" ", ~".L~,"P\:;':':;'''\'''':,i,''~ ,-;:,.1' ',. , "." -! '''\Ji' ."''', "'~/~,..~'h~ " ~...-- ".' ,,,, ~ f'" -~ . '_.J.,.:.;'~'..._.:.:~- .. ....'"~o! 1.11 ',','.')~""(Jf,r" ~,',"" l' " .;,"" " ":~ I lIt:, ,'I' lilld'" ""r"i,\ :4.,,:1. ...'e)f.t:... IL;...'...~I.J':'.' . ~I'.'~'; ~ 1""1" ! :\r , I, .:' :,,),',,"ljl.',l.1?, ':{~'~." ,,:. ",Ii' ;.\.., :': ',' , 'i ' ,; I I:' ,~: ''',': ,,0 :.,( ,,'" 'j": :., ", ". ,." ,0', .,' "'1. "~',i:",,~". '. <.11. f \- " '" ' .~....-- - _.;;...l~_.:.....o-:-~L__....-..- I ,- ----.~ ~~"""': 'l- \ ',1.......1. ~~'" ~ )1.' _ '. ..' 'I~" '., ' I,.. I -'.' ,:.,~ ". ~.tl. :I~f "'~"I'.fl,I\'l/I"i'~:i'I'" . "l[t"'" '" ,.,\'VI . "I" ",'~'('"'''l'''~' "t'lc:o;.:t'I/'r,!"'" '.'J:', ,,,,~~,_, ,'; '; 'Ii" ,,', ',1' ',!,'~'\I:"'~;'III'- .".},',:"! '.., I"r' <l',' ;;':;~ \"~"'."i":)Y..~n:. \' .,,~. _, _-----"-l _____"'..........-"'l. _.... . ---r -...- ~ "":_'ll\,;\~;"'!,l>':;I,.",:,,,~:,'(,,,'ll" -.,' '"'~ "1' '.', ....1'1\,:1\:..-'." ..:" ""'1" L '. ''1''~''\'''}Ht; f";1, 'i1"'i'I"~:~I"I',?, "" l', 't~+'.~ " .'~,' j".I' :,' ,~ .' , ".,' ; ,.' . .' '~"~",jl!'~.:(" ' ,"\"~" ,... , ....., . ,I I, . \.. ,l, I. ,"', , ' ~ ' , " .' ,'\ . I ., , 'I' . ' ,1, .". . , " ", '" "", ~1 -I ..a"I}"-"'" W" J' "1::..:.': ,,,,"'," -\ '~' ,',".,. . .~~,..' t,; 1M... ~ 1 \, ~H11- -lj.,~j i%:-' ~. ~;jT1.:.;rr:!:t:i1-l r;;:;,-7"~1~1t~.:i" ('JU;:t;:;~- rr.iti~.'~"f,H~ 11.-:- 'U~I ~v",w"N:r 1 luilr,m; ,. 'i' \l<5rl'~';f;~'-}wi~'ltl"'''''' ~Q(" 1, . I _":'\I"'~l"'t...~!:a.,\;o'''''~'" I" l..ff.'lr.l~' '8'.lr.lIr.ll""'I.~t:\-i '. :~;i"\"1',"''''''\;!( !".,-~" ~~ ~.L' " 31;18,." ,:,',1,,11'1 . <0. .' ",I),)of!"!' " :JI~'~ ,,".,,:'~ :~,> ?~!,,4., '_ ll' .. 'mw,~:~""S', ::- 'i':':"" :n;;f\T,~p :"1iTr.~1'I r'\;~ I"" 1/11/, ,,; 7.:',,..- r.,.Ii:';:~'r.f7i1.!1'I1II", 1C1:"l10"/ilt'!",l"Pl/. , ,~i'i fflJ,', ~~'i'hl~,,:';;l "'~~l~'~";~'~~::'~~;;~"~' " ,(;:,lM:ff'i": r;f.;'<'j!,t~I:.'b';1" i'l. D. l':nll,If1TH I~k nE'LDSi '1'1: 0: ';I/;j::~ . i"f.~' :Mt)~Il:,":"~~:.:1,::"",'~lh'i;,,.,.>: '...::;10\1' TAI~il\J1I":1'tl:l..'I~" Ilteli! 'rw;\)' rAI1IAI11 H,I; Ii 11111t! " i;:\t ':'IY,I,,~1 ,rk~'";l\J,,';FHl.n9 :,1'1 lHAPI.E::iJ ,Fl;'. 339413, " HH.'LIi.S,FI. 3.~9/j(1, I' ':-~'~I'~f4,1;!)ffltt~f~11"~'/'b~III':I{"#,ti"I'.'\"'<" ".c(",.\lj","'I,III"""" '" ',/', ".,..". ' ,.,' ~ It.,,~:;;..~4;:~.t1\\~~:;..'!.1!,:l?t!.:'~'~.~l/,:. :~'~I:';~A,,~~..,I"(':I"" (""fi'~~'\'4t).III;lli"i':.'" "~'"'' 1 '(/\l..~'i!it\',I'."f' :'b;: ,.,.. ';', ~, ~~:'<ti_'JIfPlr,'it..PJl .~. ,..*."~,,, '1/.\.li~';'.~.,...;!'1'.' \;',,:,,1',.; '! ~'"III\I"1j"I' .:1.-; '''fl-l~,.,\',-l',f Fl~"."'",,"",,'I" ,'" .', 'I ~ ~, .. ., ......~....l'll__ < 'f, - I ,-....""" /'U.'i~f"lf.l1, f" ,;'~,. 1~(i,l.\1I' ll")!19i;'l:,'i.,1'~:~):;~Al;:I' 'j' iirl 110/1 r,v{p.l!,: '. .'::'.;.::f,i :,~j::!.',. :,t\,'t.:'1;'6:i:~'f:;':":N.t~i~r!~~.;:1'",,,' ",'~ . ~':' .l.re...... " . ,Co . .' '.1<01'1"11 n~f'len"I5.tl'l:I,r.l"ij \"111 ..: '~,,' ''':.~ ',i'..~..Cr.~(''''''''d:.:\,:~n~',2'\~Jt'~IY,'~~lY.('''''' ',l,..,'q 1~.,,~ .t~ ~ .. J11'l1 ~ (~ 'lit!,' .:L~;, V' 1.~1" \~"~{M ~.t~~"~!l~~' ~.~I"f'I,i;.~$~Ot!~tlL1~"I\'~;~'~;!2t~V: iJ:Jd~':,\;'i;. .~ :~' '";I" r, j&U.. , -AI.1...-~jijj .;J:JIIlf'..:.:.:.J...~,'-iW...';.m:.....Cl; ." ... '..~ ' "~y:,;,::-.~'.iJ' .' ...'.'.1 Jf:~' .1...~I)o....."\g.:,.."l.,...;f ',' '.'J,:"".-l".'~ -rr"~~1:~~"~~~':1~1~191"rf'f~'~~ -~,,~....~'......... 1P' ,'~J ",;,.,., .r,r.I..t\....~....:-1t.I....,:, '."l~ t\~""" .."i~,l:'l".I.\,.:.~,'!:.~ 'I "I'."''.!.',.. ". ..'.'I'~I'.I"1.J~~I...". ,..1,10,. ',~ ," "., ' ""',' 'I "1'" 1 . .~.....;>,:'....:.'.....'... ":.',:::/::~:,;?,;~.';t.j.:II".",~:.:,.";,',t,?.; C'~"~'\'j"~I,!.j-4r..I.{~.';"Vjl'f' ,',," ': . "":\"1.';1,;' ';(,!JI'ltl.~h'!rt..::.. ... ~o\,' . /'1.\....."" !' , '. ",1 ,I , 1 , "",~ ' '.,. :f~,.~.,r~l,~".tl.:..' '. . ';I~O.~('~J;<...('~L;~ i"::: , 1"-. \ fr,'=' a., . '.. ,'J", 1 ,', ." ~~.._i,' 'f,';"~'rlo~H",,'~, lltjUi,':;l,:"I>lnts tl.. ~ -:1 ..;. )IL",;,"'~1f''''I'''1''~', I"'! u:' ,'1.Jt~',.'T'" ';' ..,'.{,\ .., ' .,~ (11'i:4:"II~"'}" ~ :tl, i.'lr;{~l'~;.:;i; , I "l' '. "';""C! Co"'" """ ""C' nJ~1 ';'1'" .. ---- --.--,.....,.--- - .. ,oM ~~t;'.i.,.','",H,~ \"1 'I (",.-",', ,,1/,,' '. ,I". ',I~'( ,t'I"I,~u~,I,l,IlI"j. .>. 1" J."l [''''1 "'1 ,_..",. ",.....' " . , 1 :?:~' i., 'J;Y/olitll ",II l'~'"'' I: \.. ('(I'..'" ,t I.";;' ~', I J.10J"trllD5 ,.":,t ~ .~,l, ..P'".....~~.- ~..~ .,. ,~.__..~,..._~..~~l~ .....-~.._._I.__-1_,~~, ___.~.._____~---.___.___.___,_~__ " \ .J. \'.., U:.jI,",,'d' I ,,' ~I' ,. '",,, \'" ,. " I ", 'f/ " 01 ". . \ '. , \ '.' '" pOl' .,,', I" ." .... " Jt" ..' .J' 'It'. -I " I' -- ,~-,' ".. .!\ .),.~' "r.::fIO~'lCH t:Hn~I~Al. J~ lO~ l~J~ 6.~ 'II ,1':< 'I LEt=tC1U~r.H r.'r:.DO:~';, j ': i,t,\,' '''l., , ...j. ;=--.-- .. ...-._..-..... .-,.-"./".-,.---..... "'[:1'''' ,. 1"i'1'>'Y''''--'' _.._.-..._~---,---....;..."..-. ---... , , ), ~t'L1 Ll'M. rl I 1IJI.I'll , "','1 h.', ~ ,-,)"11"., ('~).~., t t" I,U. ~, ,,' I ,.." I'~' ,.-.,~ ...., ", ,,'1 ~ ~ "j:!i'~ ...'[ ;'1I:.R H ,'r . "0: 'i-j' ",<, ;--1 ,~ . '...'0' !~1~' .~1.":.~':.._L..:.... ~.....,,_. ..___.,_...__l_c~ 1 ,.;....., L~ :::~.'~~~_ _,___,_,___"_,_"_,,_,,[~,,,,:,, ,",:, 1=;' 'i'l,.~:' t I ,lo I . '" t." \ ll" ,"1(' , . <. ,~t~1 ~'IA~.~~t~1 . ,. L : ,..r-],lt ,..- ,.~; ',~~ '~1 ' :: I~! "l~, "_'~""_'____. -,.,,----..-..--.~. ...._. L."", ,...,-----.---..,..-.-'---- Ill? 'i.'::!" ~,.',"~;I,it".'.' 1 l',~'''..H..;..''''',.,.,., '., _"_I,,;' ','.'; ~.," ."......,.I"T~', \:';,,1\.,,; ~i3::;~~~:'.":.,.\.:J:I",j2 ,( 'Jo'ol) i~';l ,]'21(\ ,.....:-.:<1,. .r"'" ..,,'-; ,( 1 .' "'("~' 11;:1:1' tl.' _.~______.______.__ .____.... _.....;~.~.... __:..--t.:...~___~__..___._...-},...,..,..-__ _..-_":"'" i,~ ~ ,""")0 j/mt:'T'1i1~~"!ill '110;-'1""",1''1' ,.' '1,1.,$n,."I""""n"~" .'~~.'I~"....' .'_,,".'.......'~I:r:-- I , ,," . ,~~'!;ol ,I, 'i',,', - I ' Or.'I'~n. I" ' ""1'\' ~' ~ ": ~f,j . ," t, '. ,I i,' , . , ;.; 0 c;; 1:-1 '. " " ',I!~I) ,f ,I ./., 'fiT' ~.~.-..~----...... --_._-~.-----, I - .---~' J~i' ":. . ,l..e.I,I~.:JII(..:JI'>'J.c~'_., "',1 ..,':~I"t( ,', ',I;,..,t.,".l'I'.."l~(\1 .;tll''l:''~'IJ'" I, I'o~. I' I ,A".;' .".. "' " , . ". .,.ft.. '. ,,1',' ['''-J C"'- ".. ., ., . LL.2" ./,1.., tn.. t, ." "',.' "".,', ", I .,'(', f ~I" I . I "0' .."+fIl ~, ~ r;,"lt.. '__..___.._____ ,r. . j'" L' ~. I . ~4( I. ~ " '~'I:':-~ !. 1.~~"t"tllLJlfN~d~w:rrn,. 1;."" .. I ~-,:;'.;7;'., _.J. ~(,,' ':"1 ' .~T~;:;-~-;:_;___;_.;,-.. ~..... ': ~:G~:~ t!~.,i,~O.l I J'f---1 .f'-l : "--)':1 r~:'l: t' ~! 1.INiTE.D Alr~LlI-i€S . ::~f; ,1'~'r." ._.;.........:-:';1,..l--r~ __... .~ .~~ ,_,~_'''.'' _" ._.__ '" ~:"J _---' ~_____~___._.______~_~~ I ,..:f,..~', ,'''l.."I~,IJ'('\'' AI.". ,"" 'I' ".. . ...:("11', ._.. I" "'lr"'~~','l.H.;"""'" .. ""~", .... '.~JI\ ~'i;flI,~r;'<:$\; '. r 1..:r:X I,.., I CIONA 'I'lrl0CO .' "".":,'Jt". ~,~>i1. r" '':1''~~--'''-'. \----,..-t'.---~.- -~1~~..--I-rL-,.J.,.._---_..~.,.-.----1-r-:---.-~-....----JI.- :tli:H:1 ~.......' \,.\.....''''.1,1'''1..\/./..,', If,{".lf'J',"li._j'.!-4 (I'...'......., .i~..'I."', ,',', '.l\'\-' i~"\:' ".'.1(1,: " " I ,---- "-r ' , ' . /,~t fil1!,~,'~~'i,,\~'}~:,:,::,,~.' :',,'.,, ',>,:'~,; .':J ", ,,;' . r .1,1~,I,"'J'" 1....r,,"l'.f-.,...'l(<II1.:'.".11';\I.il,1};.,.,!.t ,.;.'\'l,..", .:.~,'.' _....:.._'-'--__~,~J....:...~_ ,_,'___.._..__.......,.._._~_______.!-J.__~__,.-~,._.__~~.~, I ~~:J";':il .: ':':.':~'t.,;Jnt:A[)B.'CI'i or: I="O~~fr.eF'O~E l:':'~'PLS11ND" fi1~:lNI\jCl Tfl:5. ;1:HI~t., "., :,",.J~; ",.~1 .... ..~'...;. .,.,', "1.1' '1:'1"'''~f':/fJtt'''''lP..:',\,. :l i .1./ '. \ ,:.i 1>11 ~.itl dn 1:J"'=(l~a'. .....~.. i~J'-t:;r, ,~. 11,', II~" 't....., ... \.. ,........'.. ... '" NI '''II ,1\" II"JT, .I . .-e~',i .......;."'. Ho",t ,'I '" ro.... ..~, i. ..:..,. I ...<.i~ ',~ L'n\,'), ~'':IIl<'\I,,~, , i~." I ~\ it..~.'!l-jq.J.f"I"'.....I,I...1V.ft'f"'l'y.."''''....~~,,..'J\ "'~ 'l't,~lt '4 <.'.....',... "'L{" "''-1 ...... t:--;t . ;....... ..,...:1'+1.: . ;,;'i"lI!.~",,':I',':/"'t"l..'r:' '.' l' " '( JJ.)~IU/"JS "'-'>lJf~l':'~ 'or, .~:l .;<e',". :',:,', '.' " .. I' , ," ... "i:"";," 1.~~~~:if"l6~'.",. ',.' .. . . ..>. :'1.0\( --l ""'--t.. ,':"'\':,r~:'J~'I' It,.> ~ .....-: ~_ _"- ---- . ...;:;-.:=;;;.:,;;:;~;. _' .....' J , '; ..: 101 .'A1 ~ 0' C'''.itflIItT'''''''~ I\.~',i 'i~ :P., I ~ -"'~" \ r,H .... . I IJ. t >.\.;~ '. r" II .' 1(' .\lIe ; I, I ,VI, 1" , I}.~. ,1', I '~I ~....';:; 3. "".t: 'Ir (,.',61,:'! : d N ~"": 'l. .. ',';;'; '1' "",'~I'''' ()\iI't :':J-'.''l.' . :i1~.:.;'. :.t;,\'!~\r:.~~,.',\:~.Hr~::.~. .......n'l'r,~:~."";I\Jil....: '.,r." ". .,q.,'~.rl-l1.::J~jl" '.II.~ I ~i:' J 1'~" " ',. ~:'1'i,,""'J:I" ,.' '..;,~tI,l.:I:tlOi..'fi'!':'t:~:,IIl;.t ;~:'ti' .:~,. .'-1,'., -:.'I'.,:....,.~",\' MllQII..tll'<~}~~I.:.:....~l""',...:.:...~__~::.....:.:'_...:.:..~~, L-:..;...~L.-.:.:.....-.:.........:......:~~L:~..::....:J.._~:,_~~;l' "n~"ll, I', 'l~," il..~WJil l'lJ,rtlftlWIlI Moll':\: ~tI.;Jn .,1", 1 ~:'IIl.X ~ [",\ I '( '","'~'f'.::- 111 J:". .::'..'; ,',\,:"'. M, I",. ~.!...'..~:..I:I::'j ;}.4'.:", rll.~!:l.1 I::' ..:....,11..... T ,WI\~.::~.!I,'".. J 'I"~ "....:.IiC.:'N~il.H'r:'rElDIO.. ~ID 'FI " . i E2"4~E.' I' "".,,, , ,',' ,~,.,,'!'J.I,'.,~,',,'1l ~:~;,;1'~,~'Pd': " "',, :.!..l---:_.-'_!......:.:~ '_':-:__.___~....____}lII",,,,, .' t '! :-':-'" '.;J:,~..\'''.~.:.',~? !. ...:t.::,....:'1j1,";'l11!~'{ifH~U.W".. ' ~" "" \, " 1J~..?'lo-;:r~t,l'r' ~;.."'"'f{:.f:1. ',' .~br..lt "~..l...".J"'J.' '" tr-' r-.... . "'''''/' ~f.l\~.fJ.."jT~~Il' TRl N "_:.I'lP."!,ME~..~~_~.:J.94a '.~: . 1 .....,;..ts >q.,." r .'\~':'H' , t"~,';i.l~:I.~,.lr~~Hnf\o("n;n~',:I,r"~"";.;...n'JI.I.;<I.\"ti:.Jor.'-\ i-,,l.f:'II'..',,l,:.:t.~ 1:;n:.I':,I'iJ".Jl!I'. 1. J~~..~'c.~......t)?l.rJ\{~t."'t,~"'I' .. 'I "'\'1"1' '~"\':.l' ",~.{"'~"",i"',,'..:, " ,', I :;,",'. i;'~',P;1...:P;';...',>':\'!',' ?-',~,~ j~~i'" l,,!"~3~2..~",:, .', .".", .. ' '''".' ). I . .". \ " " ,,"1':'U;t ;~~"!I'.t\~:.:~::I~:~>"':""r. '.' .: . ' ,----, . ~)1 "'_f1 \~ ","-': ::fct;i-;---:'--:":-"";. :~\~,:~' ";'( ~I. ,I-;';"l I.' .. :'" "" ',. l!\ I . '., . " ",' .I.1'!\ '" I. 1 ,~. ~j:}l" /' . ,., . _'. \' 1 " . . , l::' - .. I , '1.(0,' '" ...~'~:.._.'..". ., l~ .(,,~ r "'~ . , .' '. ..~ .'I;..\>1t l,r. ":'7:---'" , . -~'=:'=;o;.1.""'''''-'''-''l:''' -~-J -r-;-------_............... ,J)':'( 'n.c.';^.t:i'." ,... ,," .'1 C. ~~~__~.....__:."..;..""" _ ,'. ..;..... _~" . ~f(,"\.-;-;-' 'JI .;r ,):"(ll.;q~~WCJ.sli.t\VG~"'..., ";>....., i;; r'.lC-':':Il~;lrB, y'lfl-..';U f;~ ~\P1'l.J~] ,>I '., :"""'" rr-t,t, I ',., . 'II l1} '.z,:"A~~,1"., ~,M,',::;,~ ',' 2 ".' ,;.~,'.o( , . .'IlI."..\>-...... r~",,,,,~,, ,1~ ,t';'#,~,OC" "!."'Ci''',' ,L'II> .~" /"''' , ",.~ . ,"r,\'fo',t"~{f,',r :Jl~:~' ......I._I~l(..,.Jj1M. 'J,~'~~"1<.l cr.rJJl;.P:;:i},!u.;:E::!:~~::;':.._>"~,.!~"" ," .:-'j.'. .' )tI f~~'" .11 '()'." ",oj"';' 'N,\;, "'Hldl,,':9'\,' '1"; '".J,.' '1'1' '1' 'Ii!'C' 1'< 1" . ":':1,,, ~3'G""" '.."s'efi 1'1' .' '. ., ;,.".",1,,' , ~;~"'1' '&,:I~"": lJ,".rJ~I.;:) 1 r::'~':". .'u..:.: ..~. . ',~'':'; C::;',' ,. ';Q. . I t' . ".';'":-:t:" ,.~ f ~ "'~"~l' .', . ., . ," -J..~..._:-""~..... ~:-----____---o..I._"_' .. - ,,,. ....... 01.', "';';'11 ,,', J .~ . "..1 "1 . , .'., 1.) '.' . ' ~ t. . II l' " '.1. I ' I . ',' r ' rJ.~ \lIoI' -:,,,'j'I.:f"j;.,:~,~~.'!f,:lr,/j:'i:i ",~',:.", ll",'/'ti~ .~':';i':"I. -\:: ~,',ll' I.'.: . I" '''I~., J " :', ,/>"I,l,l\:\~';f. ~~;':,:,u..'177.f.~":;l --: );:'"~:'l': './ "'f.~' ~'-'-......:~._~_-:""',~''':-:I ::~,.;, 't .' ,:.~--~ -:-, ~ .~_...':':"::~ ' :';{f:l;r,:fg~li;:",;(t:'\:';"" ;"'~'tr,';<..I:: ,';-:'li': .:':' "':1. ;'; :'>1:' 1:.1 H l'; ',,::,',' .'i:'Ilf! " '!l;> fi"-\ t' .. -')1 ._-.".:::..:.:.::..J...-'------J-----::T'--- _.L..;.j" -- -""'-;;;1 .:'b;"~:':"I~:b'::::i"";';:I::";;' I:, .'j,~' .'~ lb""1 '.', :'i~'..:.: '1" ", I, I" ~'.'" .>.':';,',,,; ,.,...~.., ...-t1~-J,,'t.J'~'L"I: '::p3i: '. ;,' 'I~.I.J..I,.I'; '...~' ':;,,;-'L' : t'l'.:..I...~.{:'".~ '1\'" ..........._~_.- -.___ -L.._~_...__. ___ .-_.........--. __L-..__. ......~.It. .~~ .. ,).~~..: "'I': '. II. Ej...' ,'. " . I, '. I "-' ,. I I' l'~ ,',' '~~.'''''~' .'..~.'r,:'I~r,\.'~I":, "j".,,', "...'.'.. "'\JJ." .,' ,',...,..'.;'. ,:.,',' "1' :'" "')"\""'''i~ /~~ll~:'.-;,:~'I~:..,.;';.:..~~,.~~>. ,,:':~-'.~~:' ~_..~:~~~~; ,-- ;i.~ ..t-r'.I--r-l-+;\~";I.~~:~~t;~: ..' ;1, '1"', ~b.I".,:; '. It:,.' .' 'I, I" I ". j . ,t .' ! t .t . ':>,', i;!.""1/ ", "t:.il.;f~.'J";'U!'}!,' ,~1' }.,"'. . l' .;2I'.':' I:'j '. \1 ',!\ i',' J ' ,"l':"':"'(l~l ':':'1.,~,':?i:'j:!~1. t.: l , 1ml ~l- -<Ij ,Jrr....... rl '7"\T1'T1..'\~~:t:':~ '-.' ~-~711r~.:!',,:qr\W"I;-;;Ir- If"~~~:, 1 ',' n'-.'l\";tiTJ J;- , I "dij.;rr~iir.:'1 l' .1t\i~~ -I")' _' . ' ''''J''''~.'l':l'\(ll .' ,"-l'" :~;;.:r,1~,b!lIi\l~~I~?0 /..:;IXl · 31.18"" ;:~I''', f'l" . p' :. e.5[ (JtJJ' 8~; \l;P"".,.'IHIl,q, ' :"~J.? ,~\'~~vrl:lfli,'''',Vi~~'''-,'.I,~.,~ .'- t.1:1 'n;~lh-,r,jI:'t:ir..:t~i1 ,"1ji~rf(l;:1 'r.1i .~"7i~~ r,!";i;':";.rjf.1'.f;fuir,.tCl,..':I:;,,..~...;:tm, r,Jtk1~li~r.;" ":",:""",,;;~'.I:~Ii'.C,,,..J;~'.:J-t'.I~'t"J:(,L',,' . "',t'1o r.:'."~'jI,t/"J4;J:liI'" "i'l 'I I~"t:'. ",... ''''I'... "1' "fll:~l ::;I:\I,ji'.s,.,:tl'MI"'!t\<"~f'''''''',''''~'''l\.I~''J ~:t..r/lf."JH W. "JII...:'II~l 1'110. III Et.!1 S r ",,,' -'\"\-"~1 I'.U. ',.,.'1. ....,. 'i'~~ ,>'111' ~ n"."'''' ,~,"J, " "j ""I iAI"X ^I'lX 't",[.,,, 111 Co" ." ", f"'1X A , 1 1'''' ," ,'" ,,, 'I' ; \,,:t" -I "'i, .,.., 'I . <..J tfllOJ '1 Pi '" _ .1. VI. ., "..t. NI . r,.., IOf L -':/~. I :"~~"~'~ii~tlft~iVl!~,\J,. ':~1,~,~:,'~'1,'" ',~!f:1F'I,p ,F;.,N.?,~!'~'" ,"" , ,: t~~"'L~,S/l 3r";]. 1'1 :',;~l~'li~~;!'\;.~".'~1i~l1i\'.''''' ';of',',1 ":.,,o .1,.' "'<:h~'\~","'!"'" :.'" ."." 1 "....'.,':,'..." '. ."i .. . I.. .:,,\ri~!J.'.J, 01'.'8".1,'" 'r..'.,.:1o ,~', .~C ,,,:,,.>,~;',,:," :: .',,~~. .. ~"i;...~ ~ ~""ll'~' ,t ',':1 "lll'~, :~. of .1','. ',:.','\f" ", ,') . I' "', .,.. . -.., "'" Ij'''- -.- "",_'~"f ~. l~~~~fl\",~, ~ ~. ;~'~it' !~','~.11€~~r:~:"I~N9i:~I~;':": t ',f;'r~tFASi~ '~liN ), OJ, TVP!.:." ,'" ,:;.;. r,: ;.~~j.,/)',/I.' 'l~'~,~:~ ~J~,-:- ..It<}.~,r~\'!r:i.;Jllll:' ,',"\ ~.,. )H\7t~ / :\'1 ~..;;": .\.,tiiJ."':, ~i'.I.i.1.~,.I';!;,\':~r-'d'/k~ ~.,,. ~ 'PI.....:11 ',:, "" it .,:'..l"~';.i.J..:...., "-f ';'.: o'Ifj.n.....!I: _...~.t,'14 ~:t'l\.I" ~,' If ~, ~ " .' .J~I:t\v.~K) ~.~.:1..l..kl.,~~~1.t.~ I)' 11 ~:I 'I '; 7~.~~~.I~: ,~\:.~. ":'t~;t,I,~~~~;j 't\ 1'\:"; ~...t~., f.' ~t.l/., '.f.;~:t~,}:'1.A . !,' ,)' fll __.____......lOIIoIt.I.l~ - _.-loill..... .......:--L.:,J'........,.<4aZ - . _-', lUh -..s..........._~ ~""'..:..~J I """,\. ,r~~7.'mm,~,'l\"o"'t\. ':f,r. '[ "'~~''''''' I, .If" 1';,<' ~~{:'!'I r' nKm" . .....,~ ~"'I:~1 r .:,,;~,~~. . .,,~~~'''', . , ~~'" ,..:...,....-~j;~.A;i ;J.1', '-'w:J .'.,.,1: ,',' 'h. ' .' , . '",. "~.." "" ',I.J 'I!i ',"', i','li' '/,'.," .~,.,,;1".' I' ." '. '.' ; .",;,', ..,..;,...~ ',"~"" ') ","',t ", '," , , '\.. '>' ~1,1,',":,~~ -' 'i;.:.~;(".I'::""" .1" ,.", .. '" " " I,j iI v.\ ". ,'.' 'l . , 'I " .' ~:'~':;i:,i{,".+Y ::'. ';' ~JIl~::I)lCJ\UCL.AIM '" t:\:,::,::,\k::UN'rrE [5. '. . .:, #0,21305 . COBRA ,_-..l.~ r,::}:~' ,\il\L1:-J ES E'~ljW~~E~~~i~~~~fT ~~~Il .' ,.,'\ $';-::'::"':\:' RSTIREO _-.:__..---:., {. ..'<....'.'..,. , ., , . 'I'''' ..., f'r'" ", i ,.., ...,..... ".'.~:?] ~;' '. \, ',: '.".}.',' "; d., "i., F l.,,',i,I,"",('...;.iCcl ITE,"IZ"D'SIL" A'. ,:: DIS,'3LEO -- .'." t-;;:' '<'~M~LO'(EE. NAMa/SUBSCRIBER i ' ",.", n M ~ ""',> (~:'..""":/:'~""'I" '.' .. '. 1f";1Sn.~~'~~ 'l--:-"-"-~.~-_-:-. --.Q.5CC""i.F.c"r;;r;:.---""J-'Flll;"-~'0" .'. ..:-..: "';,: ,''''-'''r:' ...., ..' '~'1" "'/::""0 ') I :> 'J' (f.r 0' 2 ..' I'> ':i' .:','Lt.Q" (I -'- .' , 12.EZLt0...G I:'J ,,0. 7.3.,,1\.:..:J..iJ:.fL.~ ,...,). O:,:,i ~:;i:".,..,:lDp~aSSIS""~51'C7nTm,z'p,. ./)j.) '. r..... ....r-:; ,?'-/J -;:ro~?,,'..'.c"e' .... Q';',' " ',"~, ri;\ri:/;;'" ,,:'t:;. ?'~/!,:L-L2~_L..JUa!l~I-~:I.:~"'}:d~~ 3 "cJr,f ~::C;J(Jf':"'."::;j~ ~'c~;:r:,~P'ATIENT'N^ME(IF01PFIlREHiFl10M~BCV!!) . ' """.' ' 'I' : ..' .. . '.' i 'c', ,,): ~i;;;;':~;:;:I~;n" ~i:;::, '6' '.IPI~Sllf.il ~ .;---:;; ::'ii:ii~OJ.'= -:..... , ,::: I "^TQ' 9~ OICWO:2 ' . j')lJ"'MES\uoElmf ::".,,,/'; If,,.,',;.llO\1'''' ""1",:';':;'(,~'l1al1'11-li' ":"".~\:..,. , "~/(_il3' to :1" .' '-Y~S:C1NO! !;";, !f:';i'<>i';~~';~:;"1 ,'f ::.C' ,:,' ,;.' -:, ' 'f.io'"-'_-;----7--. ..' .-:-"-' .' .... .=:-...,:,:;V~: 1",,,'-10'"-:-,1 ,~fl:\" . . ~;J' <, '," , . .' .. ' " ," 'r~ ',~.' -~,:.j $il~Al"C~.l,"F.O,R,MIAITIOjJ(MuUs:r.BEI:Q, MI',tEt,E,~ :'., "r'''", ," ", ,: .'. ',"".',". ,'''','' . ' ". ' ',,:.~'l!'I'. ....""'~!~/"I~i..."...1~\;''::<., ....1.}.-11 ""L~'I'!J' ",~~ ,~./l<-J". I, '.' .' .1',"''''1~' t {t""i~'l'~~'J)~'i;'k\"~;~''':Jsl'4'~'1,l''rit~:L,'.p;~;~.:""7 t/,...'".t1r./...\.i (',1 I" (1,"11 tt.'j ,,,lr''''}., '~",' ','I' ,(1,;::- l!>:rt'}' 1- 1'1..' ,,. ~ ~ /.;. ~'" ':'.. ':f,l:!.:~:' \ ,,'1'.! \ r"7'I~ ,'_:.' <' .~:f ,:?~PATE'O~ c~tPl:UY~tc:NT S ~ ~ '~.Ur..:~'" ,.. ~",,,, "~'" .:'~ '': .!.: ,~~;, ,.t",. ,," ~h .', .., ,.'_ t , ;....::g" ',<4, " ,I ,:;"L 'I", .., '~"~"lI,:,;'.1 ..... .1'" ,'~, '. ',.,' ~'I,J::..;...j.. D:~' ' .t.; ,;': It:l t -::. :::t1~;FIAS1'OATE'Of:OIAONOSilSrrREAmENf L.c.L~~~~ " . ~..--:.____ ,I:, ./:,',' ~h\(~;. .:~":<?)i.i\'\~: ),\ i,~,';':'1 '".'i :;:'.:! ;:"!",,~," ,"J ,,' '" \"'" ,.,;: ";"."":"'::'~f.:;;;,.:;.:;.:,j^' ,'. '~t~' h'. " ,\:i:~' ;):': ;i., ;:,1(::-~:D.rscri'PTiOiiO;'ILi.;'lEs's'J~jiJRyd~' 'll!?1.Lt~., V-[1J.l1~f!.,C!J.:_JY cUd.2.:~' :',::\,d~ ,'I' '>'''''\1'tJ}'''' .', '~"~. , ".,.~"-~ .. ~ .','.,,, ~,., '~.~';"i"..,..' '.n ,'(",;:.:u:.A41;);' " U' '- ':~4' ~',.. ' . 1 -' jj j~/') "Il"t~.r. ~')".T':4Y(;i. :q,:';:I'~'IIr.yll.''(;, ,,' '; :DBd '.:.'.' 'r" lI);'\A"I) '. "J"";"') '. ,,' "'Ii"" ,.'~" .;ll~l,' '.. '., . I' '. I .... ~ ,-" , f' .."\ ','.. "..:' ~"', ,. . "'.' , '," , .~ ,'. 1'. ': t, , ' " ('''1 l' " t;' , ,'I' I' '. . '~,,:' ~""" It,' .. ",,~ _ t',..,., 'l, .,'. ',,> ,I, ,J. ....' 1, I I. , .') 11',,- ~l.",~.....,'f.l~r;-'j,~'/"~ 'j"""" 1 ~,".',"l.'" '."i~ ~'f.:..".u'~'J:,:/A";vEs;:' 1,IHb',;':; ;":'1;: J.~ \ ' ,:" ",', "'~;:' " . ",', ,,' , ' t~' iLS:~ ~:it~j';'l(,i',;,g:';Ri~~d' ;!. :j:~'::: . ~)A9 ACP'I6hj~'OR ILiNESS:"g'G~I'EC;To~~lPLcr{M~Nl? OArS? '. ' ";:';I(~ .'-l::r ,f-- "''3''. \,r'" 'f "'(Sb 'fl'W 1.0. ..' d I~' (III' ',"" , , I l'r lL.~~':t.;r...'>~I;)\~~,\.,/,ld~~""~~;"', ,~.~I,~O\,;or.~~9"S,lO~!'4HU't),:.:''''''::'''' ',' j ", "'. :-" t-"t,~t, ~~,~~I- .~(1';ft1\)}:,,,10" ,', ,~,{ ,;:.,' '1'" \ ';:,"""[l!" :~." (1 r (.r~,,, "..1 (,I'j lj1J! i:.l~!:t";j"'~-oI.ll": t-....J, '~\; .. r.,. j ;'" ') 1,1,' 1>\1. .~; ,"Ii ~ H : ,,\'; :-~;~ ;~' ;.~'~."~2 d,~:t '~){.".':~ql}(.~ \ ,'-:.;..w''" 91rfISf!^~reNi'etIGllnE:FCH1t':1 'CAftt;lMl:;UCAlu.{...... . " .', "' . \/" t~ .t,""~r' ;\t;..qM:,:,t(,S:.;" ':.~ ~ "~'Z ' ..,' .' ;:..> ;:1 :" I', .I.~ I,.. ~', ~ ':.! '.' '.' '....,.,.~ ' ..' r , .q'. . " "J ".~. t;' ',1 I,,:,~,';;l'if'i't .,,<.) '0,'" r.\J'. ISTHIS.C&AIM. RoSllIJ 01' 1\ vJ:H',dr~ACCIO!;lm ;,:.1'..' 1 :,:1"; oj -;: . .. , .' ,:", :;~, ~ t if;;,r.:j",""l:t.:"'~'J' ", .1 ,"' " . ~ ,', ' , ,t7:"'.~ " " "I ',,\ ik.~ Ji;;'~"'iljf'~~~' ;./", ,.,".:i j'" " I"~ " " " ""-,'I"t;l ~ ~!i.1'\",l:i~'.:.'" "'C'J ,19SPOUSEef,ipU)VECI? Ii' ilO,r'"II'IE'Ol'SMPLO'iEf\; . '.,'. ". ' ;"",'.' ,,'.1 ,iJi,"( ..... .':J(i; :f;~~..,;;\~q'Jil11-',,;".'::' .,' .:.,:I"(l/1,j.-1,.(..'j:..:.,','..,., . ,,"';"'^"'l"SI'J.~./'n(l,., "',,,:,:.' ,',',,'~'i" lif,ii~I~~~!..brt:' ' , COMFAN'f.:.LL~Y.Lw;..-~/!:-:.I:.~- POLICY N_::.t...J.J.L / ~v'r 'UII<.:.>'_~ '..~.". ,,:.\:~,! ~',{l!ir.-t~':i~(;(i\1':.:. .... : N\'/1 v""tl' ,~j.)I..: ':'1Vl A';h'J' ., "f'l:.J:~"!;~I~' '", ,..,., ;J:;.-! ,.'11,""',,', ' :::. ,;,,11.... " :::',,;1Ji ."j':H';'~""~'~"\'" AQDRE'~o:""lll~()f'.!r'l !........VJ IJ,'MI' '-/ -'7,1 ". . '.~, "~ '. \it \"......t-h.',l~,. \ ., . .1':1, "''--_....,1'1 . , ~'l.~ , . ,,' ,.... \ ...:,'r";I~""'in~l,~,!i,,:',', ' ",", , '" ,I'.: " .1,. '" "1" . .'''-' ",{.. 1,~1;;f-YLW..!'~'~~~';".J' ',,:.' '. ' , , .' ,.' oj' ".'," , 'J' i, ,'~. ..' ,,,'I' \'1'" ("')l"" " ..~,' II., ". ,.../,,1-'.(1' "",.#~,, .hl1~t.fjf'~U:"I'ir(.o""" I.' " I)" ,.', ""'IIJ~"",'!',,'.,'" ,,, .:-;........"', ." ;,,'.'.1.'" , ,H'...... '" . h, '~i~~!.r:it;C"' ,f@dATj~'N O~ A~~'~,RA?;'" ,VlDAI~T:~~W:t:~~~N,1;d:~ELEA~E l~~d~M~T!o'N '. ; ','; <, ;,;', Y: i . :.!.'J;l!:~. I' ,'~;);;#: ,~~l~~. ~mlfj,(/il\! 1m: /OffjJolrl?lfllorm;\hOflI,ln;e .ndCOrTs.-:t,' ~U'"jl(ll) ~'lnllNU\CAtllpfU...IdOl', 1!'I~uf']O(ld c~mp, d(~il'ltllY1O(.I...l>4 .:ft1'1~f~~4rfilftfrT'l1"1 "j ""~~~ I ~~~l'f3I' ; '~lf9~~I'e.fbhli;l'Ih1;:tl'aIM rb Ih!) fll.1r. Admr.,t~rlUQ'( 01 Ita Jj}lXlI~' .'; { [~ 1'j'" ' , " ,'. , ' , ~~' , , "". ~' , ... ,.' .l.:,,~ I: ~;r~~f'if}~n:1.'.~:':: ',' (f ' I", I . . f... '--:--:--fL' ~lAlirJ'tt:1 j\!"~ S'~NAl\)AE hE';'~' OATS . ", ,t.)'. ','1,""" \".,:-,... ".' . ". " ,.' , . , .." 'rM ' /. c..- - . I: :-y.., 1!1~" ~,t\..~ .'; , , ' .' t f:1' ~ t i~'" ,~ ......../:.Jl;I).:..\.~;\ ~~l.~. ,';': ' ,I' j.. I, ~,. .' - .. . ".1'-'--:--! .:)" li~\~,~k~,l(";'l'l~(I~.\ ',.' '."~ " ',. ' \.':, \1\ 11;..'1.;,,,'1.;" ;'." J"" .'1';', '!i..~I' ).1.: . II ",). .~. ,~;~~1.,t1j':.t"l\";'"'~;'.'\ ,~,,,, ,'"' , .' ) . ' ,',' ., .: ~; , ' .,~,~. "'j~j,;'r:;~;%m'"'!"J~q~f~T.~o.N,'TO rAY PROV1Q~R ,~. : " ,:" Ii: , i; '" '"'' '.' ,;,. .;.; ,,1,:;.,1'<,: u,. , "w..;""" I. > " :, ' I::; ;1 ~.-;i"''1(' 'I " " _J.___........;,.I~~~_Lo -.. '., - ~~~ "1; f!1~~i~,'i(: ,'i~'.; ~~M/i;:',(\td,~.~h;:r~'I~jl ~~~m"'l"ll~",I.,ili<il ;:"I"~ble4i tMoiM lot ~...,;itli,i;jti;~ /iii,."..(I/ 01 i*<Mcl"l\1 ''',' ::, J, :'" .''.,'.h; 1J~I(~V~"~ ." 'N ~. {~ , ;' :- \ -C.......:l.1.1'...,.' \ _:' , ... . ' '. " 'I '\', .t"; '(J{t;.t~~t,,~.'.u~t"I"i;,j .:'~. i.I,',',JI~r,,~f,}~1 ~'\';h~~ :, ,," .,:':' eI,4RU1"1,"81'f1.1J~nlRE, ' ",,, I ; OAre '," , .. ",',',' \.fl'fIl; ~"h""'" 'i.~?"'l"J.t.h,' Ji"';" , \ I ( l' \ 1'1"''\'': . , , ., '. 11' . I'~ 'j"'1 'YI' i::~\'\!~ J"'~1'1"?oIJ"~,i,, ,,'.', ' .' '\ " .~ " I ,';,' " , , ' '~i'.' ~~ . ,/il,',,","" '...;, ",', 1'1 ,:~''{.o ~,lill~"":,~" (,. 'i' ",,, , '. 1'\,,\1' " ". ',' " " <'-'" ..' rl~'ie\'JI~J/\.'f"\I,. I, " ','!,. 1'- -~...,-,...~_----....------ .",. -',' ,,':"/:','" iJ",::;.~" r.-', ' ., , ",,' , . , ! 1 ..' I"'" ", ", <oil 'l".:.",."~-:,~",~~",l,, ".,". .'1' ,,', ~ ',:'1' :/;, ~'T' ,'" . ' ." "''0.,, ".,",.,' 4;L.,~~~~,+~qti~~cl~ PURc'HA$E~AFTEn ,ill94 $~OULJ PI! fill'a;~li"iEl;'\'O'CAREMAf1K,' ' " : <'.;/:i) ~~.:.~t::~~~V;:"jf'4"~J:;',,'J.l , "., ," ")' " 1'1'1 I',',">.'. ~ , . '. ,....."I,...',l':~ ti,,';~!-~;i~{@~~;~' ~~~.L,L, Ha.~~~Hc:"~,CbM,PAAE IP;(<l,~rl~;:~:!I'~~~,~,~l,~'INPM!E.ljt CONFINEMENTS: , ' "." :,~' ;::,;i ih" ~~,&:.\(S~l~J;O P,~OVIO.Ens ~ff~HEV~n:POS310La. C~LL nil ~fli"IINFbLIIlUT 1.&CO-!l44d5~HOFl'PROVIOEf19 IN YOUR %IP r.ooe ~RE^, ',,'.;. :, : "'I.~ J.:J t~;,'l' ".it .~l"i~ I" " , .."." ", ~ . ' .<.10. ~\1\~~.;rl.:r"b,~~~:Y)if.(E(sr0i ",o~.y~~tibMIt'MULTJPLe BILLS Foid,I'" s~lhpEASOtl Ofl A SINGli CLAIM POAM, . . ~ ~~l,;. if' 111' ,",',. ,"1\,,' "" r ,'I'" ,,'" l 'I ' ' .. ' I" 'Ji(~)(~Sl~I'" UW!(q~~! ~i;;~JlciwLitQ,dli,ijjU~~aui:vcu1/i~I;lj,".~~ I,'UiW.~No'rAEAMNr ~LTERHATIVES, " ' ~\j#;'K1~' "'''~i'''lrf!\\'''J:(,r(;r,r'i'':\''.lj.I'I;'''''\: ,,:':~ \:I;~,'~' "I'" '" '. \J~ '.. " .t.:.!., l'~"'.:.. '~t1".4\ ~j:'l~i ',"l: ')~~(:",.~..,~III "\,,' I'~',l ,:'I\l"t.,';"" (' ",', ~\'t.,"..i ,.,' . ~l.~~~~' J'':'''I ~(;i, ,.\'-?\~ i1\1',.~:{~"'~'i.k:~lhlll~.~.:} ;..:: 1 I) : ," ,,'I! ')'~"l/~ ""1/'\ +', '.. I., "1' "li~1 ., 1 j . ' ~',(f.~j' "~',;~;~l'"/<.\'7.I&~t..~":,,,:,,,,~ ;~:'I :1'1'\'.'111 J1}t:' t<..... jl",'.'~ . ~'" \', 4 .:" ....t.:':l',I!'J....I' .'.1,""-"'" , .' ~ 'l~' ."I~ .l~,~ t~'1,,~;':~J:'tJYiJ.u'a;k' ""111';1 i,",11:-1'i I ,~- \ ,;'l'~I" '", . ,..-'. ,.'i~:~(\I.',."'.I'~l...,;/i,".:. :.. .7' il." .'; t~ ~~J ~"'..w~!i.'i...J~I..i~tl,' ",.,...,~~..-:!t.K.....;,.,,~..'("c ",:,~ .I.]".,.i........t'i .,t / / ",It/," -,' '/,1\ "\l"~ ~ ' .,-~.- ~"-'.'" .... ". -,. ..,,, ,."'....~ \'\1'1'7'" .':....~~ \ , . -.':~ ".0;':" ',;'1.'":'Hy....!: :"7}Q,t;., ,';.: u~.....: il",ll':,';,"II'~~~ 'I:,'~':\l ~.. (.rT\~77""'7 ';:!r'~'7i.r'r.F! ,~:r:,,'r~,"~~~~r~,""l;"':7~r.'l~~\, ': ._,"~':"'~":'":~~''''?~''":'::-:~'::}.,.7.':'',r.}.':~,t.:.:~;,11,',1':," f~,\~t,~~.)i ~"'l'fl"""'\"" ; . .~,:,., , '.' . . ': ." '.' ., . ~'I.'f.'",:~:-z (;>'\,,1~1r :'.' ,~ '. " ':, "', '.j:;(. ,', :C! 'Ht" 'ni'IIJCCl ... .'~ ".,:<:, ,~:i;,1.)\t~\ . \ 'I" i 'F'. C. FIO:< ~1~1,'~:J '. . '~'<R~ ';.. 'll.,llil "', 'f.. tlQIJI\'[IOi'I:'lltr::1 ll, :;'''1-J1'1 ,;, ':,~1"-f,.l ~' .I(~ ~l ,.) , . n',.- "~l:'\., ' t I ., .' , t',;:' ," " . . ' CJ~ p'~. <,r: ; . . ,ill "; r' n':"f'll":'.l. ~~,\LI111~I'j'JIl'l."Cr: CL.\I~1 Jmt.... . 'l"fT"C'lj' ~ J.J.:.J_ _..-....,~"- _."~"'''''''''' 1"'___ __.....__ .. .'" --..-, "'1 ,. (,'II.. '...\/ , ',t~",";l': 'I""" , , ",\ '\,1, ,/I' 1i~1 ." '~' \ '1,1 I'.', I'.' ,',"'11, -, ,I \1', ",'" 'l j ~~. n~:l ,'::",'r'l' ":',,(-;, . rw--; ''-XT~' !dlll/[.:II',,'IC...-i, J3aJi\~1aS ' '.',".''? ':n.\\::~~!L..~~~~__.: :"I.:'::'::~ ~:'~~__L~~_':.:,....,...! ~'I, '~~:'_.r.E'-J._ .!~_ ---r-:-._~...-_._,_.-----_.___.__._.~~_. " l~;:' !1~~~o:U\;~';t~t~~f~'~ITlr~'L': 'J::" Ii' '~I'~"~' 1 i '~.3' ~r- "r' .x -1 . Lfr;o'utlc'rl ~'IDE rIO'R',~H"" ',\. " .' ',~ , ~.;l . r;:;-'7':ortl.rr':::'i:T"';;'--~"-'" ---.--- --'f" --I! ;~:I i,j ':"'T'~ "':-'51u12Jj-".;;;ii~?i';C];;. ;i':7~ ::;;,"-'--- ---- '--..n :W~, 2\:l0.;'l'j~I ~1.C!.~.;..___",:':)__,.s _Jr::;::~,I.:t.'{Q.L::f;< !?',;f'.JillL....Q_...__.;...__.. _...______~_ ; \. ; 'Jl:3J?~1'~",';~~;:',i,~ .,:, :":' , I ',I"~'::, ~,'I""lI;'I'r.~~::S.>:"" ~',-':' . ")"':/'" ", , " l::".' .: ',:.: . : .l..:t'111r.'l...S'" ". . I FL, "">',;1 <'u"';"[.' J,...,O' . , :t'. ~".1'211~1m~~0::-:-""~J:l',:rT';;':\;::!:'~. ;;;;-r::--;--;---': '. ..". ~..-! '.. ',':" .-. . ~ r~'::5tr:.-~-----'.i'17;:-;;;ni2"~I~"~"'t:--."I'" c;',,',..., . :;i.{T,;'\i:~J'Ha .(941) 2(!'1~21l1 :''''''I;':(~' ::;:;'["'l:""lr-'-]'! ": . .' I (' .....)" '.';'"i~'?\',. I;;"~ , ";..,-~.:!:.':" _":'_,..,...-,., _'~~~.__":'-'-'~-.'~":"-'''-i "1 .,.,.,.....r .,......:,.:!'.~., .__ ,..:..- .' _...,..--t"~_~_w_.:...,~_~~':-~:~'1. .t; "" f:/;p:'''_\~r':m?,'',,: ';"~~I~. 1.I.l::,I:~",""" ,'I,~ ,""~~' ~,u,'.., ,",I :"1 ' i 'i'"II,J'.ll,I.,d i" .;(,'~1II'1l.."":ll ~'), '. 'I "'iJ'";1,"",". '.:,..,, ,.-,' '." :"'~"'!". ".~':.~,' ii:~.,':',;,,!.<;,; .",:1~~':~:,~~~~:~~"_~ ." . . .~:.', ,',',: "";'~":'">"'f ',".,' ,:.' ",~~~~,~tJ~~~~~__.~. .", ': . '~~~r,,':~i~',:;~ ~.' rl~ "Nt.",~",:t,.:I\J.~l' ,.., v".t,~.H'I,,!,,;,I' :"""f!~1 " ,,',.. '11 rl'f'l'Vl';'ll" "l pit"'lf~": r1.c;U I'~H'" . Itj:'UI'f':fl1 r,~:'1',;"r),"I!l ; '. ,,', '; ",'-.;l,'j !"t',I":'1i~~:,~,,:~~:l:~' ":'" :" c' .' 1 '...l~~~'~u..[:iJ.If,., :'.. 1":.'~'~IO,):"(' ;"l[~ .t'~~';'l"i{~~~' Ij~"... ~''''rt;t'~''f~f~;'''''-.--n_~~_'-''''''.-'I '1. I ' ", ' I I' .:.:.L' ,', ,.~\ I J' .t:'''f.":'" '1.~.. ut{j.',~" . ~~,' , ". '., ';'\~Jl,ili11 . ,y "',-1("1: '"f,Ktd~llm.1jlo)'F(r' fl';rr;:cr~'4;;;ic!-.I':i,,;:' ....' ,,\0' :1; ..I \;. '~q " ,. r--l'L- ., I,",] . E"] '.. LUNIlED AIRLHIES ,,' .,",!,' I''':.; ,r;:, , I,' ,'I I ' ..! ~I (' .' I -'. It' ,.. ',"'1 , ~!'J t...:..--:J. , , ' '.. .' f J ,~.: L.' '" ._,._.._~",L..= 'r.--~-'-' ......L-... ,..L.. _ . . __.~_~_____._.._~_.__~ ' '''''~~/c,,,,~'...jf:'''C''''''c'' '~fl..r;'l.I..U~ , [,71 '1"'^"Ill',rl, [lllt<vo-t--tl.\\I.'IV'....I"to '"I~'I~I~~I, , , . ..:~ Ir; . :" I,,' '::~1~"'I\" ,',. ,'. . '" '. ~:' ~-;';l(.~ j'fM~\ ' CONNECT1CUT GEN ,.,' " J'::~; }d;""l' '.r,:""~' I 1 " ~ " , . " , I I, .:~ 'I $.;:.,. ,\ " . "'" , ' ,,].,~ .~"" ):J~~,1'MI$F.'fi';" r;,...,;:0t1tTi.;~I-V>,!~~_.--~, 17',iI'Jt'1 ~; '-.:1'iT;{;.IWI, "';~--lJ ~':G;:,"'i<j;\"f";7"'1r~,,;mr'\ .',' -:--'., ' " tl"":'" 'f:'~ ,i' ':1:;'';':'1 ,~j ,",' :,. " '" '.,'. ~ ,;". . Q~' rx-' . ,~. '~';~~J; il'. '>,! :;",-I.~,.) "):1' " ., ,-, ' I,)ll',~)~.,., ~'I":;L~~!IIO "/l"''''..':~1.....1:.>o"'1:r'..1tr'\fI_1.1A~:-1 I.{~<t-~.:....:~~ ~'E,Zfo13,,~ OF f:'R:1 E1~FOAC: CO'~41;'lfi,,,jGfbToii~~ETH"ls fQ~~-~';" I~ I', ~ r..i11i,,~ml rr,;'i'1i:ur...~. ."....".-=nl~~-.i,~~ ',,- fi;'f ". "~~ . '~, - , , . ./ ..,.,. 1w-.J'I1"J 1'.-\".1.0.1 ..~....Ll'(lf ""H~~~'" :'i" ~ :r.!<I'l' 'I: l..'IIlt,.~~c:<lliC1;'~(:.i \....', 11! 'I \ 11'1'111'. ~t .... ,,,. I 'f'-, "....j,l..;' ~L'l~" '''''<<.I) ~\'.h\l~.... 'r-..<...., .' " I... .~, :, \l , . ~ ".~,n.(I' , ,.~~~t!::1.:"'.....lI<l...-"~~~I'I"""r)r;I.,.,~.."wir..,tjll'Il.,'I(,.J.,Jyt..~t~'11t.'.'IM.aI/o'If,..iJli'I~/"5 ,1. , .' ~"'~,:~.,J ~')I;'t...I.I<J;;~.,,' .;(" ,'-.j 'I', .' '-j:, I .~~~(".,'lA;J \ r ~," '., ; ..) I;"~~,::~~ ~~'l~"'I"'."~"'\" ",'1'll,~.:; I,'),., . " .' ,l'~"I'.""'.~ .'.: :., ,,;1(' \, ""l:'~."\~l\'!; ..;.....:;t;....I~,~_I.:._~ ....__.~._~--.:......._......!!.:~lll.,~. ,"IItjJI~ ~ ~".'" ~ , . '-,....~._'_......"ll."(.__ ..........w- ..., -u.:' , '-;lI/"n.,qna!111",.'r, . i 1.1 f./(t.)tl ,;1! ....1'f10"11 Qt:! ,\ t r'lr,~~, ,"II" W 1.lJ',tlt\~!1~Vt.vl il.lJokJ':;':' 1'0 !l\Il(81'~rJ;'fl l"..,,,,\'3 f,l "n,'1' l'I':ur.I'1 'it \...: ,~,j~1'01'I ~:<,. .~' '.~.:r. . ',...1.' I ;;t'. I" ,'.' .',l.;tlrr~ (l,~oJo 11)1I ' ::, ' ,:"~'l{;j1,tr:,,.1 ''''~M 1 ot1t;V'1 '..' '" IA'A I j:> f I" ' 'U'A I lie. 1 I, Y,'1.,'/, ':, :f' ~I' .,' , I \, , F':~" '::l r J, 1bf1,\.r~_""':..Ji:.ILL.__. P<!~"\j.-....f'r~;'I, ':~, ._, _ ----.-:,1,..;~_...:.::....L.:: ,'. '1...~:1' r "I '.: '" ;. '. r .:.....:U.:.i.'.:.::.:!~ l].t~\;J."I.I'.iII1(:t.fl.':l' 1,1r,,,.I'"'N\I~Wl Ull mt.t'n,J, llr:Ij~' jl'.j ,(I tto,f,''fl 'I'J n' (rrt~.w.1~I!I'JCI"1 4"j'!I- t!lJ."~ fti.u'.~N'....,t',l'~.\ O.,,,T(~l "1 (.l,'lhl~;l r;1 of\1C/'t.~, . ~II I .j/.,,,...I'H~:nI'F.tl::l:![)S:'ND"'fU". G:P'8",SS, :'.:. . -'..,,, ""'~"'IO",,(,"." i,"'tI"~'I',r,\"..,,,.: :J~f.~~~~~'''1O.1''';i",I:..''',rt: ~ ,;,;,;.. I .,":,1".,1::,,1""'. 'i,:,r.rll("I'\,\,.,~ " "l\'r:',;:"".,;,\,,~(,,~~,~ . ~F.l;.;-~",.-............"_......__.__... .._I..__w......"...--..;..;..l._____~.. .-"~._---,--....-~.~~--...-:.;Jo. , C{l I: ,!!l~lf:v.li'''~.)I".:?:..ll. ~~& ' " ", r ,I,,~' ,;.: 1 ~': ,.,',,1, . ~~\!IJ1~;r.n Vilt ':Jt.f-1.1.~.\t,. '. ,/~'I'r'I..:::;'~"':' ; .\~~1!i,.i,ilfjr,HlIojx..,TRl H 1H1I2'NAPLI;S ,r,-':i:,iJ)i4il",;. ....' "l'7J,:~'_r^i" r 'iLJi... ..'.",,1:,,;i....'~\.. ,'- ..~~~.,;'!~~--~-!...-_- ..:.......:..~....::.:.:............_...:..!.:..~~,~_..::..:..w..:..:.---:..:.___ .1.. ~:..:E:L..:J~....:-__ ~, .:.._~~" ,f)' . 1t~~ . ~ltI'J'!I)..C'!lt+\",Mti.Q"'I.~,f...'\ "I':II,;'(mlf~'\llmt-ol!J!J'J';'.Jlnlf!;ll~~!iY{.'iiID" "r.'1l<.o'tlri.'l"i1"'17.~(1'r \ d' " ;" 'r....tl.11 l' 1~4rJj'''.'e'1.A'if.'''''./'1.'' , ,I, j' ,': ,1 .,.'., '!.;.l;U" I r;1'h,'llll,/;,1 .. ",': ..-'\I.ir~'~~' fl'!' . '~Y'm .l,~:, ::' ~ ':,' ," \:"." : 'I .' \ 'I I' ;'}I.~ 'I' '. .. ' ',', . ~ il,~'\l: I ;I'" ~-I~.' .' " I' .,__.... ," , I .__~.,... __' ,,-,~_~.......-_____.... . f"-' l~'~', '~. l::'~'r.'.I'.;t_.. "" '.. , ',", ' "I .'\ 'I' ,', ~ 1i'llj('I'\l;i}/,'1,,\I',1,..I"."~b' '1 J '. ~.,;.~, :",~..:-'"jl.',j. ..J,',...... ,,' . . ". ":,,, ,", . " . , ',,1' ~'1'" , "~(."?Ji"I~":~'i'II";:":'" :'" \' "0', ',,'.III'l';"'! ' . \ , .. " _ .',' .'(~~'~'~ ' ..;~.'" ,." .~ .,'" : '. " ','. I J " .' I ," I , ". ,': ' , " '-. I" "\,.,,, I..'", ^~---...__.- ._....J.-._P. '.lt~:.tI'.I.,("'-..-...._ , -........":l-----.-....--..T-............,... ... ~~~ . ;,I') ~f~,',,, ..~.. .( , ,.,"-'..l .~-l .~~...___.__.". t..;~-t.......;.,:...,.,..:J:. '.:._i..__ .--..........1....-:.......:...' 'L ~ .-~...!..-L.I-_.--:...;!:__::~.';..Iw 1.~l::, ',1 \\', 'li.t.:.f':(lWt;Cif1- ',',' 1"l1 t',;'j Q' :~,-:"I.~,~Ir.'I'..:liIl\jn;.U'f'J!l~ I, "'2+ " ;',~ ~""''l. ,',.' ", "C 'I',," ~'Yi' :r!,!~',l\ h',~'~..,-J.,/I\'".~,.,,';" ,,,,,,,,,,.,0',1,.,,,,,,1'1" "C"l','O,tl, ,I"'"'k,~'.'. "" ,-', ,,', COlI "'[1\1\)'-,4,'"'- . ~,'!'~~:Jl,f"'f ~!:!..LD'd':.."('~' ::'~'':~ J~ ".'. .~~';.L~..~~lll1i i~L:;.l"':~~ ..;~:::.::::L .:......,1...;.'..,....... l';~l .~:- ' ....__:.~......;~~ , :: i~ll;r';",~;i~,o/i~i;ep..l'ae1" 1'1 e",,~"lu<e'l ::"~i''-;.'.'~:r;t ,aJe<!, ": '".',1\:;;,100 .1 . .. ' '. . ,'.:,,'i~, 111~"';W*-"~t._.,...,.....7'--'" -. -,-~--.._---..:.~'"--,..~ --. iJ' -_..~ -----,- , ._.........,,~ v:Yj.i/.l~;f)-~'S'.l)"1'1"" '.!' . ,,;', "I" ,"',I I'~'" i,' "", .. ....", . i ,"":":"."l.'l~ 'r~;"'~:"lli,l/'\"';'I.,.,I '~G'''''I' 1""I":I'''''l~'~'/,,,,~,,': ','I ,;:. , ',\'~'..;, :21"1"" ,"""."" '~u::J."'" ',. " '.: .':...." ," -,. ".: , I., .~: 1'/'"_'1. ~~ ,:'il':;"';" ~~l \ 1,' .', ,,--;-: 'I - .-.--. -.;-'i' ''':'-'~--:"7:--'I '~~-, , ., I' t-~~~ ....-6- ~ ....-:""i;t,~11 4"'Xil"~Ii~'~'11...,".II',{,.I'i'''.,_I,.,4'''''J'' " "~,',l',",t,. ') l "1\".\; ,.!, "',ll",'1!",." ..,. I" " "" '~':\' '::l' ,.1,' 1 'I" , , I' ' ,', lI" , . " !" . ~ . . I " ,'. W1~ I; ';"'~''ll~"", ~~ ,.'~~' ,1'/.: ":.1\ :",,' ','" "i',';; 4 r. ,'. ~'" 'I, ~..t ;;....:, r '11' j'l' \..\':>'~\, ~ .. ,!~ ..~J..:..._..,__ ---......,-.1.__...... ,-___.__ _.~ __ _ ---4,--P;' ;-,:.....'IIX:.iU'rlJ7.d:I~:i"..~' ' ;" .' ,,-~",' ,...',',. ~ J.;.' :,,' 1'-' '1:1 :i~~"1'~'~ '{11~l'~"1t'~~(;);'ltI1"'''''''''' I '" j: I rJ" ';,",.' '...'1;'" ,', . "', ,~..I"1il~.,;. ..' ,'i"<,.,~ .~:~:I~.'i'I':.,..I' ,f'~;\" ,\'1'" I.li,'c ~'I',' ''1,,' " (" '.' ''''l'11':~~,iJ), "".. ,"", . ,c=.....L::-.: . '__h__."-'._ ..._J, ___-"-_ ___~._ _,:.........~,_. _ ._ ~.. ~~, l\I;f.,r..,: I,.~jj:"';!~f (,1/',1):"1' ,'. I.'., Y It I ~' " I' I :'"~.I\.',, ".' ,'j.; '" :1.' .'1 I' "....,', "~'" ~" ,.,I~l:'1 \'.~..J..' ""(' 'J" J "'1'" JII,'" '. ',' ~~ ~'~ ~~'fif1~~ ''4~'''~ ,:i~:ii:") '.: ,,','j ,..' ~'. "'j"'~'.":'!i':} \;'I,':,.,'~. .'.11,. h"l I, ' 'I ,~,. ',." , ,'W '" ~ - .... ------ --........... ....J.., ~,....~~ ~""-----~'--""'----"'''T--: - _...... .___...._._,_.. . \1 ..,~.\",~11.. ',.,1 "i"...'t. :' I' ,.' J ",' \ \'j 1 , ,. .\,; ,," " , J ' . ,j ,11 -\1'",: t':"/'t1'"'' i; ':11',',,'- .' I " Il"'" ,\.1. ,,:' ""I "" "J . ',' : ,''' . . '.. ~~~'-";:~~\:\I}'I~....':\', 1 'I, '. l'.., " '. " ,,',' ,'.! .,.. ,1 ! ;,. ,."'.' I,.:"", , ,! . ,;'l~ '~,.,. ",'K"'''.' ,'~'. ....l~,,,,l.,_ ,_.,J .' ,._,.,....~."'''''-E''-'''' ~'i.'....~~ ~~""..,..., -- -~ r--r....-....--. ...... l': IT '0:('. f/'i'f~';1~' "t, iH 1j)~~1,;' . . ~."" <; 'I "I ""'-:..',1 :) ~" " ,1,1 It.. . loI. "~ , .'~\ 1~:II'\' \) '....,;I,".-II;\:"{,' 1\, ,~" ,.~!, 1,',1 Ii. ,'~ tl",.,~\,' U, 1'1 I, .... 4.}'E.~~ 1!3f"3~l'." ri-;(j. lllt ~ " ,'.', ",' ~",A>." ,.. ,'" I e~ ,00 1 8:: 'flfL . II ,~kl: 't' ~'!!r, '~{r",.~ ";""\'(~~."~.l' . ,l",'~'l~", " "1:,,1, " If\l~ '!~]'\1 I . " " , . , "".""~'l' ~{: ~~:~t;f;{'~~~~~~'~~~'tl~;,;\"~~l:~t i~, ~<;~i't'l.t?;:lrl~;~~1,fPl"I'lnl ~l.'\ )7~~'-T'r:.::/ ~~!..,~, ..... Tllv.-il:'NI";'II'~" ~)11\1f" -:F7rl;"E":':;L"'J')/~'~ ;~'''#lr;~/f4~~-\fzr. I " ~'lr'~7 '~ .~t:iJ1IITit"l"~:I"J'~:''':1l''r:''^''''~~'Il'''f'' ,jr\~ l'1r.' f.1',"f4,,::\~1.:' "~\" n.V, ,.., , ~,r '''..' a, (fj.V. ",''r'1''. , 1",\:;9"':jtt'~!':!!:~~i,:!,,,:'t'~"~~Ir. " ,:'511)1". 'lAI111~111'I'lRL'H.,M1Q,! Gl11fj.tAMXAMt.TF.I. N "11iJ? ,''', : 'i) fil'll'lt:"T:'tl::~":liF;"El...r"a;',.r! '. NAPLE1~ i"ll.~,',1:,irt)",lJ ,,:,.; . :, I' ' J':IA~'l.rs" PL 33'i)..Ifl . 'I' '," ,'J.~}~I.lil:l>t71"'~~~I''t'lt,~" ~:'''I.,~/'''':'J'lr.'''J'~''''''':'~I''I'III:l' "'.\/" ",:, ..- "~~"'F" ;;:," ~,l'I.,', f' . ~ /4.'!"":'!/,~.,"'. ~'~~'I.,"-:''':''i..,...-':1''1'''''I'T'I:.,I,., ,1,;I"!I"'-'l..;:[ I' f '.~'T';I'" (~i.,'.?.t,'" ' ;:: '~ .~.\ '..!;:~rf~ ,.,11 f1I.:':1'l".t;,~ .~,'l'''.~:'' .~;.'~ /\': .~I~"'. ,I~II~\ :;'III'II':I~~" :~!l.l::(}' t, ~',~! "fl I' ~~J 'U~~~ ,~, :/':~\i,1\ t' ~.fl. \}l..,,.. , " ' , , ' ,~ ~. !lrt'., '~, ...........~~ _..1''''1,....111I__ " ....___<f'~ 1!"1~~ ~4"~'f' ~.tft~d;t~ ~~;{~~4:'~ .,l~'''~~~?;;r.;ii~ltj;i)(''''~' ), 'il'.~ 1~1~111 i St.: : ,r~ll~.J'l \0#, r~'l', ':' "': ':/,"l\~..', :.('1 ,f:(t~,!~. 1(f1n~f~' .~,,~~;'~l\n:l'll :'t~~( ~,t' '1 \l<.~ ',,: ..~....1'\ ~'" . ., o.7I"i;. i., .;.~,' \!.',. . ,1 '~J'~ '. ,',Ji., , . \ ~ 'r' ""'I . ...c.,. ..' ,\ A:;- ., ;,'.. ' I' ' . ;\ I '"'" t.':.1 '~~,~i.i~,:~'1'.'~jC: 1,,( "j\. ~I'~ ~. 'J' :.!lj.rj'1~~:I^'11" /1...... 1.1 1~~IrJ1t/t,,\I' ~"I't.UI;..-:..l... (~,~, 1.\0.. ~~\~,' '.." ,., {~ . II , '~~~~2i liI"ui J~~~W~~I~ ~~~\f, ;a:~\'.u!'I~::>f'!..~:r.1 !,~l""," :' . :-:., '" t.t.o ...._._\0. .....'...1,....'./.... i ,~ i , ,~ , . 1 I ' ~'~...,.~ ~'" T"'''''''"I' l' n, ....1" "." . ~ ..~., ,...."'"'. .~~r"1'l1..~"'.,."'- \<<....~\Ij~ ' 'I"" '1" ~?~.11:'J"'H \\,:.,'~. . \ ,:,\,.' I I I~'lt. ,I. :,: ,,', " '!'.',,'1 ,'" "',,1",,' .l 'tM'"" tl\ \ ,l ~ . " ~ f~ J' , . " ,( j. j 'l' 'I~' ' I, I, .' ; I \ ' .' iii", " ' '. ' ~~ ,)6. .i ,'.,'(~1'~~1 \~:1:' i"\ ~'~,\ " 11'~'III,jl.1'\I~lfl('II'l'tl ;' .'j,!I'" ,'"..' \"':I",::l,~ll'\')~;;~li'''~' 1,""'.\ ~ ~. :'to " ;.,~ r,~ .. , " l' , I I "I I ' ,. ; . ,~ J " . ~~/I,'~I..t.., " l~l'''')''1 ,,\It,\ .. '~I' 'I r .1 ~ I .. "',' " I ;.11" ,,'1,1 "II,' I' I,' _, ,. ',,'" 'I""~/ '," . "'I,'" \ ' ' "."" ,:' , ';"." ," "'" " ": \,. ~ l , ,,~~!~: ~.'~~;,l::'jl:i..It';;:~1 \~:, 1.","'1 :11':)!' j '. ":"il'lliA' L"T" ,; N' \liU"'.:'JN' :;;.. 'd',h.'\;;F'OI R"';: :: :"::::" ',,': i"~ , ", ' ~ I ,'r.~ d'''1' "11\\' " ,'''' '" ',' I H ~ ".." \~c:. .....'" Nt d' " Pk...... ''''-''J I'" , "';-,' .Ct\ I ~ 1"'.1 II' 14-'.' :., J ~1~~~~1-:'1'1111"~ I'~I' ~~Mldr,~~ftl~Mt, '~' !~.;111,nlltlli~l,4:tl,1[JV7, ' "1 , ~~'~... l:i: '. ~l:i~"''''''~l~fl.iii~.i '~'." ':~j)lr~!Fc1\~ "" 'I !\I"~ :"">9,:' '''':~' '1'" ",\. I,,,/,,, '/,." 1'; ,". '.' " I', . ",,0" 'IF 1'" ',<,.,ri,,\! ' ~~l;.,:, ,'3.,,].~. J, """ "'M_ I .L.. ,,,,,,,, ~ 11'11,..,,~ ~.U. .... 'I.;,.'''.....~,l. ;)l.lQ U:L.,._",._".., _ ,."...__.,;" I, I I,:j'~'ti"'i' ~ rillltf'i~1..t. 11:'1;1(. (',lIV! ,1,1:.,( I "~~, ~rd"I'lI;/'ji " . Uli ' t Ifl,I\ltI'l'J 'I ~i:t"'h ;'_11 'l~"'''''lltM~'1\'f IoIj.,.... iI' I~II . .' ,~ ),. ~ .~....:.i...J,......\~,\~~j:.(~t~'it,~-~tl ":,h1r.lr., .1.' ');'I'J,,;'~l'ol\":~A'tll ,,_..., """'U'l;!;';'(1jl"i.l,:' "\1,1\ '. ','~'I,~:1.)'!<' g '~'!.I.\J.,~t :a\"tlfi"I~I'!oI.i,,,,,,, , I'., 'l...."."".,CI~t...,,,I. .,_,.lJ" l:;!H: li..w.:l,~_HA.'l:"LL.:.__''''_'_''''~I~.j~' ',' " ~tui~ ~.... ~ (on,' i:-tt .'Ct ,'I:,; '7':1 i ,. ~ ", .' l l'^"~IH JlI:I""rl~I~lu" IfJ.IMunro 1 IJjjlJ/":O .1ALlIJJIK'Ifl,'j,/ nllHl1 " .' ~ I. ,!i""'P\;:';;~"lil'~!'Jlj~~i'~,,17d h,!~,.1' ''''1~)!~"",'{'1,~'''1f'1 c,'",.:: ' "..,,(,' '. U'J, :~::I': \:~,JI~ ,':"'., ,,,"': ' ,,:' "', . '. ,'I ':,6'11 "^13,r'1~rruil't,-!i" 7-1)- TNr"~'~---"-' '" .----~l;;:;T:f . ~";"'I f,' " I';, I.' I"'i" "~ ,t~, ~ 'I, r'1 ' 0'1 ~ _,' " , l~~!. ' 't ,:. ""'\":":';;:~~I'~'::'~l"/):' I,:.' .,l.,.\ ,;~ ,,~;(.t;ll(l!..., -"lIIllld l" '.~lr I..) __._ ' , ' ." ..:.~":_.....,,_._ _:-"_,.,.-J~ . h t" . ,.,~'~' U';<<. .t',; '1.1 ll;tccCII ~'~I rl/~JflI-/Ojr(!~jf."~lj'fJAMA(;~lJr.I''', 1'\,. ,.1) ':.. l^"{/':: '^:I;:".;"1.,,:\,:,,, ~ 0"""''''') ""''''''~~'''''''"'I'J <.~.. IV(:"''\ .\/ (..:J ,t::l. i ~.L...h: f (jr.i.\,.J\'. .~' \fI' Vl,.~'~, 'I ~" " ," I 1l1l.11~1~ 911JtJiIfII . ...., \ 0 ")}I-...lL'L '~)"d..,~,,l : m(l$l~~to'..~ i1l\74Ftt.r;. ~UI\...,!W~fi'.~7~t-. .,mMm~~~' !flrl~ TIl!'fil (1 '!.G\1'rGd'T(1 - Ti";.~tm15 , ~~~':C" CIH ~~~~ijirrrl-.- - -" ~.: LS~~~~..lJ'l:~~'j::~: '~~~~4J:'r_ ' . ~____~,~__.___~__.~___~____ "I IU ~n'._'" I'T !I~Il;t .. . "" I" "" '". "" ""HiJ'1,.(;lIlIU\.4.'~ '.,;llt;lnlioVICllal. .. ". 1lW1$'1I1JoMJ.. IjaA '."~~HA.l~",,,,,,,~ '~. -' ...'. ""', "....., II t"" ~i'#t; ".-.t.U1.'\~'F,:T 'f'~ , ., ," . '. .;, !"', 1/,"(' ", ~'.' ,'.t.'~"'I"'JI',:,: [J"" ~Ji'o,,:... ... . ',,'.~;!,:;' f J' '/.".':, ..... ~~lCIt,'>~7y: ~:A~10f\~r.I-:!l'ff't Pl..-\(:(!'91"1"'cl'I!JUft\fjC&PL-lNfI~""~~M~.4Mt.' ,..':,~,i:.\ m~l"'~':" "'W' "~-',! ',," ~"'II";' . ". 1""" ~ 1rl , . .' ',~.'. '~ '. , .~ ~'_.1L_Jl..' _'-IL.._.__.." ,,' ..' , _ ,....,i(, ,:~~ ' "/.' i".'j../:, f ~t,l;::.. ~ ".,' ,I.?, II'd ~eSli1WIJJ PG~ ~(X:...~ Ultlf oj.IQ ~11'i!-V! AMTtlQA,HSN :,..i1Ii/4jW "'.AN? ' :,' V'l' .Dt;::f. " ., .,.... '" ''')',.',{'!' ,:, .)"1' c., "'"." Ily" i:Jm,:, '",",,,,,~---,;,,,,,~. "]':'1 ".........--.-:~ ",_...<JIOIr . illmm;r-- ':1.'N;~tv;;;l;;mf(j1E'Il<lNH:O"M""I"""""..,. :" .1.1~~~;,~.~q't;~.7,;~~.7-~i~. ~:' ~~::~~~~~~~ff~~;;::~':.~~~ :::~~t<f(.~~~'~JJ~~' 'r' '/ ptt"tlIG1IbW~:~,~,'.:' ;,~':: :;,0\':.;:, .:';:I.I'.is':rG:.~~l:'<lj~g:OON\F'll-~/:".: .:I:i' . "~!:'<J tl (f, ,: ,,'.:' ,(: i{ ;',. , ~'..'. "j ;-";".{f?1".'\\ J.:.Yh!:":'-, ~ ',::"" ~. I :..., , . ,~. '. M11 SICNS . 't /l.t 'I .,./1 /" v" . -; '. :~ ,', ." .....,.;..o.J~...... ...:u_,J..............._.~. .-l........:,;.:.: ..,__"~.._. .'. .__.__~ _.. _. , ~U'-. .."...f." ,. '" .......t ri. .~_-.-.:. '..0:.-1 ............41 , 1~'; '.~I ".1'.1 ~,', 'r :P "MIf!'H I'l....Jl "'....0 9.4'19 "llll"'It.A.A Illll1i..lS 16' 0ATl:& Mli1J~t\,.lNA"\"F,1QWOIII( ....lcURrn.hTOCCl'p...r~~fl ,."~ '.' . .,,.~. ,.'~I,~' 'f." lOOit', ~""i ~~ ,00'<F.f+AS1'OMi! '1M, Q[) I 'N . J.drI', '0011 ,,,' ,\6.1.4 1"00, 'N /.' ..~, 1-~. " ~.'''q; );, ,ItA ON); ~l.I~\': 'l..:.,::" ~;'~' l . .' " F"IY'''''''! ' .' ro ~. ,It ",~,tI,~r~!~:[!f~ln~~r;rr~.~~"~~;,:;~:,; f?~JCri~Wti~;;(i'~HY!lICI^N I~. H09~~~'~~~H OIA~' AC;U!no YO. C~~~t1I.~1~nwv~~ "'-':", . '.Q;S~..;~..t'O:~~".:'" t _'.2.J:..i~UL___ FRCf.1 . fa .'1t~~ ....~.~l4.~~~::~~;,ITj;. ,.,...'~.\I' N OUf!olOlHAU1, lCHMICU It;': ~l~~hl :~;i~~",i,i\\~J~""~L~\I")11';" .'i,:.' .:; . YES' ~~~~,'lA;~~;Olt~i'~INJ1JR,(,' - ~------,-'" n l,fEO(CAIOI1E9UBMIS.'iI:fl ~~,.I'"''l'.'''~XhU,;'_''';''' "'_,'t;lj",1 ":.1,,'\. '. CCtlii ", ','1 CflI(lIH.Al~P.NO ~.' ~:'i~;.,'..;tl:'lI~~t.'.III'ctm_'" ".:[69 , , : ...:.~,',.::trtt;i,A':;'.'''~i)''''''t''''::':'''' 'I eA'III"'Wf " ~" ,~,~.7!'iWI"f.,~"lf";1CII. 1000So\Ill'f'l.Jt.,...... :':,; "'. O~I(l,'IlI'rrNI ~,. ':t\,l~O":1 Off",wt,.,8IQCI:i ",<<t,l~~: 1m'" ~'Ill. ~:;'\~:~J\;~,~fr,(II1l" . !H1t '\.A~ "!l" '::-l'!i .,,',,:: '6'3' ~"";L"" ~..';.U..,;~..,.tC.",L P'-1' -.)-- L '.'.ll,'} -'-;-J. _, ,;::, ::"'Io"~'" ' .'~' ,;.~:; 'l.'" ~. \ \.1. h ~..(.... r. G Y i. {., ,I) - '- ---_._---..~~ ~,~. :i~-;!}'.~: :~;l~.n \',';.Xj ,::r, \:~ "~;;:' ;': :'..: ~" ~:,' .1 ,l""....,'1,"...",>f\i.,'.,..<.......,.",...,_.....I.,.,....'~:..,......,.......... '(.; i'J: J:~: i~~ crTi .:.,r~i?!:Ji,,":;::! :':' '; i . ..,. :_~._~~=-- ,~~,~ 1'.11;' '. ."J.. ;~l '. j ,.:::' ~,~~~ . ", :~~.. -- III I.',.,. "",11:, ., " , , :t~~,~',' ":1 ',( , " '.:~ ~', "';: "\I~' ";','ir- ,';;. .., ,"~ , ~ T. :':: .;\1 '" , '{!I ':'~1~1 -..----, q '",,' J " i:j ;1 " 3'.: a~ li ""UIIWr I'QII',) \Q(:.I1.~ l' .~.....:. ",!! .;:': ,1 :~r :,':~\ ',," "". i I .--...--.-----..---..-. _,.:L__.._...__.._."..~~_~ _ ., " ". i~ i t :( ': , : ," ',~ !~i ,'1 .j . .; ". .. ~ . I:! ,.\'",,,,,,,,: ',',,; .' ,,'i'I.Ioil,' , .~,~...:~ ........~l..I~~l.l',~'t,I:i__'..' ".....:,;',;,,1 ._w,.._...."".... ..~""'.w r_.~"",;;,. '11rrrnl\ "1'll~m'l \"(ll~m\'I'1 "I' '~llt""Cl'~1I ~tlJ '1I;:T.' 'li"I":l'i1II!~ f;ll~ ;r':"~"("~II, ',I ~" . I '-~ol\r',~1"1' ~. I ~ II I 'J' 'L ~h.~' 1 '[It 1.~ \l'~" >, ' -I' '. . It., , :1 \,' ~1J"i}~I'f;?~'~~\~9 1" '~lJ "~If. :/::;,;..;:,1'~;;'~1 ~';,~ 'l\',~~ ,: I" ':';.I~~:,1f{~lli l \ '\ '~ ';l\~:' :';,\:ll~i~f..'; ~:'i,lj':')' ~'l'\J~'JOI:'::~ I :1',:;:,.'~~;~I\i\/~ll\ '~;~!'\~:\lllo6rJAA ,~,: _":,~;/!I:il'l li1 "'!I"""U'1 \';', "i'I;.'\i':lJ II'Tlitl ,1I1LlflliS,INC, :.."'~!, ",' '. ,'''.:' . .', ,""i.', ; . ,/, ~1;f.1 ~\ t:"dIM:I:'\I~I'li:; :'i ..I ::"r:'~, ::.~ 1'1,0 'II' Il pl!Nllnr "'LMI ,).. ,'.,i' ':' '; i;:'AI!T)f1~O ......:~]j,.,\:' , ~,~~ 1,'lU ' :,~;~;;r~":r 'II l'~ \" :,(~ '~'4~1~1, '.,~; 'I' };I' I I ',' ";', ,"" ~"""h ~'I~ll" l\."~'l.':.II"I\,~."~II'i ~''\.:\ff:j:'''''I'1 ~"i '.','I.\l.!'1'4)!II-....I.,..t'l, .' ',.i;, ~lrrl'r~I:\J "~" ;:j '.';i ,~j:!.1 I.,1i,:" F:, ll.r(MIII:rA'I", f.lflITr.!lllli),!lIL~o 1'/ I >.:,,1.. PI~~ULCP ,.._.__ ~, ~t~~l,~ll'~~~j,'\j~la~\~~~'.':'! :";" . ..;" ,". . l:;': ',;, !1: \ it: 1':'Ilill"~i;;~0,...';r:ry;;i'fr'~',~ :';;f~~~'I~; ~;i:'r'~,nl~F -:- -";;-;-i 177:' ~UjiiUjjr~';.(:""''''''~'''''-j 'j:! '1~'!~:,~i',.:r'~~i "l-i:I.j;Cll::'r;;'-v)~"'/I'( .;, "", , ". ....);~(\--<(-r.'1" /,C:T-~r, ",," &I~:j ~,iiM'ifl}.f~ \~t' #t.~1;7D;;";'~'::M:;"-)~" ."....) \ it "0) ~-( ..: i~i;~iic~k:;;L(" ~":,:, ,~d "V,!l '~~4!~< ..,'~~j~Y;~f~:.;!1'-:p!{:ti:g::~. \.:~~-_..," :.z!!i 2; ~3..-~:I.~~3LL:..:t~Jt. r~ .lJ ~{\I,;!,lp^Tlllwt'~r,~M~~~ lliti~'~M~~1 ~ ~.'J\'Wifi:;'\ .' ~l Ii"" ", "", ,,' ': ;. l::i'.';;'E~Jl:f':~. "",~ ~:~~7"~i~f~t tty~i'j. J, ,::t~'-'I~:i1i(l,ir.~"-~ ~-..- -"~']13~(~q} ~;~-J"'~'ii~TI, I !I1.UOUNTI : j' Y I ".' \' "~~ r.A)! . ..t:or 'J\ {) ,I; '\.I:!f'\I'''~''t:ifj' \. .1_ "x,' Y .~ r" I." 1-1'10 : 'J' !. ~ . ,',f' ,.,\~ !;-fl-.1""':.t" I I II. '" . r~iJ . l' ~ 1'11l" "'I"~. "".., .:'\<....,......' '1""-'"'' "r -- -.---..--,---, .........,-'" . '-1-- ~ ,::\II'~V :IN'ilu~~N~~,,'i~<~d~}l.4~TI~H iMU'lT ~~ COMPlETlIOI I.- I' ~ It ,(".,0,\.1,1. il'.., 1"rl.'1t"',,~ '__~ ~:;i",.i ,.:.'.li,::....~'J.;';::;;li. ',."llJ)"" :;.;7 , .rj (:.'\,.,. \" 'I' uo\tE op..e~(~Lo,.t1,r(Je~j ~~ - ~F:"_' I, .~']\:'\I,I"J'~~i'1~'.,:\-~.I" ,', (I ") , ,I [~F~;' . ::"'.; ;~ii1~:);;&~,O~~QI~~cisl~/TIie~T~ENl -----!.~~~~ 1~~~.___ tc' ( ---- - i r~'l.,~ft~~~ ' ~;"11.'1:,,:~..J.t,.t'!lff~i :>'.J, l!,.t ;::'1\ dl (,' '~!I/' I "I' f ,11(' ( U "";', . ,.1 "~"I'" .,' "'" 1,,' \1"/,,,,/, -'J'l' Ali __ :1 :~;lj >".";"i:i6',p,a~C~I,~t9,t{'Ofl,,IL>,~ ~~lNJ.uRY ~.---1._..~ _J.(, .. ..j - [), _" t'''''I''I;.";,,,;,::.t\i.')m,nH! 1,":"":"" ....:-:-,___,_J h." l~"', ,j". J.', . , '. ....'" 'I.'''.'''.. I ~L4", I":' {'><' ,"';,~~..I.-\, "',.' I" '::"'1 ~ ',; ~ta"H6" . .. in ':,:' ~;;,;!:;'I.d. ~ :-.:.~ ;l'i~.s'Ab~i6e'mclR ILLNESS A/;u'irl!C> 10 eMPLOYMENT? OATE'I ~',l; t:' ,,".' :. ' , " ,'1;:1: ,,/p,.::,', (SubmllfO'Wa,kmon's CompCall'lot) I ~>I'\lii". ~ !.: ij, .'ti "; \,,~ 1'~;\f\:iI~-~Ji~fr;~IC1I'Bl!~ FOR MeOrC:\AEIME~ICAID? III ,~' ,I 'Y-;....., .::' ,',";'i ' I h.1 (. n . ,p; IS',tHIS dLMh ReSULT OF A "E~i1CLg ACCIDENT? (<:.. " ,Q/ 0 IS~P~:4~~~~oyeO?<F SO,,1r-MEOF E"!'?LOY~~ , ~';:,'~':'!~ "/, COMrAN.,\' (/Li\JJ~,__,_t_ PQI"cn 1\ ,.C:.. ~;j?',i::'\~1Y:;,t.:;,.. . 'AOD~Ek~~____L ., . ~;[;~::i,,::M~~i~'I~ti~N:6F:icdU~A~_AND AUTHORIZATION~) RELEASE INFORMA;:~~ ~'~i~;".'. ...';"..' ',ml.("~' ~~,III1'.fwlgQII1~ 1f1'Ofm~lfon II' tl.l.I- l'lnd cOfflet.1 "uIMrtt.~ ~ 1111\/11\ C;,1fl1 ,,'ovid", IntUI!!n CI)IrlP 'fO( 0111" '0111110 'tl,',u MV mlWtlllnl 01 O1h.,. Inlorm". ~.F.I<(~.::: .L~~r<~,lf1l1,t~fCl.lmll~~~~nM~fl1flll~~~~l1nl', ._ ___J--Lt- ,." ~ , .' ...,. ..... ',. . ':,' /,.., ,,'. ".: '. ", - .._il.. " f,,,,e "" ..mti1A"AE h f' ~;jOATe - a 1.~~,~~,"'r'N;:r'r.:.1lJ,~:';'~"n~'.:~"i,l?:'T\':7';':;;~' <~!,\':~n:~ft. '<':.:;": ..' ", 'r-F- J ' /.,....." (~t I] t l' l' :1f'J,'D:,~".I'!ii'I!:':t'!/o.:l:f.:';';':,"'~"'; ",,,' I '. -.,I., I'_~::{.;,~.~/)... (' / c;.;...,..'. " /, \-" 1~~;'4);At1~o~'i~kr;6~ 1'6 PAY' ~~O~IDCR ..' I . ~;l,l fi"" . '_l _.._...._.......' _..__._______----.:._ .....-.:...-...._~ ' ';~~~~,i .,J,~~~~Pim'm~ ~~~Jll~~" ~~h\lr:~~~'Il'(~~~~~ ~~:~~~.r~~ '~~ICj" Mrldlll.d Mv ~d't ~~!tl,n(.) 0; 1St000W.~11I, _ 1 .,,\;:~.j\,:,11 \'11""" '"I',": . .".7'Ti'1"T, ". l'~~OYUlIC,""I"c JATU J. "\' ,,'", " . , \ I 1':t,r,rlt...~~'i}H\'!\' q ::\ :"'/ ~ ',' ) I",,' " , ',' \ ", "I ' , I ..l.I'~""'~'''Jt,,''- t:' 'I ,'- I ~ .._...__.."_________----._____~_ ____...__H__ I I.N"~J1.:.'~'q'./,~S:,)I:...:1o::." ,,: -',. .'~ \ l.'~1~~i;%~~W~~~~.'#6~a~i~i;~:~~W~.lil;ii '~O'JLO ~e GUBMITTI!U TO I~RBMMK, :1.. ,"J ;:. ,.~ ;,..I'..,I'.'-;~.,'l.\ :,':'",' " .; .::'.Y :': ' ",: ,.".,\ : :il. ~f~:'~:r,n~~~~~.,~;r?:r:~t,r~,~~w~~~.i~r'~p~A~ (I09,BH.\n:I2} POll AlllNPATlB,lT CI)NfINEMHNT9. ,[{'i:(.J,,}~.,~,~!~,~~~yl,~d~~I~~.~~~.~v,~~ ~qge:Ul!, CALI nIP 1'1'0 INI'o",m AT 1,000,",1, "2l ~Orl PrlOVIO~rlD III YOUR :IP COOU ArlRA, :i '.~ 'i "" :~Vllrll\l.l9),Vll M~NIlY.19U8Mlt MIILTlPL~ DILla Fon TH~ Bel MI1I'~n~ON Nl A !lIl1aL~ CLAIM FOAM. i!': i:!,!.::j~;:!~~,~,l1,~~it~~~ld~~~~~L~D,?~~~~U ^,OOUTYOUIlILI,lIt90,IN,'"II1Y AND TReATM!NT ALTUJlNATIV~9 .... 'I' :1~\~tf.~'::1~\JVJ;t{:;\i'!L~i jj\:,i,:.~\,i\~-:,{'.:/.>,::~:~\, ,oj, ,j" 1,1':, . ,. '. . "~"I";': ,'..~ I(.~, '~i '!~.{d,.~I~";t~:"'!n.;:~:I~~'~~f..~~~;\~,~(,~"I.""':","'.,~v,~",.,. '''.'' .....'<".~;j,I:,.t~ ~v,.,r:,;::,'..;;:'.', .,' :. , '."(')~' I I '~t ,,'.. ~,~y-, ~ ~'W~j..,ht:a~~\\":'I'::1..r,;f';:'J",~j';: ;..,', d.," , ".,~ ". :;~~~':';~:\'~r':" "";\ N~"~:{,':"\." ;'''~.I . "'.J ..~ >./' .i ,'J'.. ; '."1;";'1,, , :, '~',:. or ' ',,' !~!r'~'i\.:i'dt\':f l:'.\!;:;~iIU" ;1'1:1'11, ,,!:,}.;;. ,.~. ::1' '" ':"';i,'.~ II' >, 111'1.:, ':ii:i'jj;:,'a,"~:,.j:!; '_'i:;l,,',l"d;'.;'~;.,': :",,'.:i:~,' . ... " '," ~~ijl,",iWiiW':I,;r~~, oW 111.~~j.:I"iI~:W~"",,~;~',OKI/~ ii:.l,#.~.tiI.'-.,....'t,..~...._lcLIllf~'~0i'I4'~.&~~I~MlII, I i , , .1 , '~ f 1 I '" ;~;.' ~ . i ( ~A C I '\ I? J'':' ( .. Vl.... \ c.i./ I u./ ..... ,_, ._' !..:;/ :rr; .', " :J '.1 I ',! ," .'d. "~"4 ,;'i . , 'J .1 :!: 'j 1 I , ~ .1;,.,' ".,".... .1{~.::.:'.; I ....,~_~....""""""'~ ,_ ~".I,.y~~.,..,...il\ , -,I;', .\-'~.,'Ir-'I'.~. '.' '."1.1.....: I I, .,,"'\.' ,~;'.!';<,<~':~,:,.:" .." ',"1<" ," , "",' ::, ..'d't1. ' .n.. ~"".I ,;':'::. Ii:" ITtD \1'" "N/'S , "'I ' ,:. E>.!~Lil~n:NAMEiSU3SCRIB2R Ic)m ''if::'1:. ' .;, '~~ VJ.}~ -;---'iM'Cf.;:i',-'-'-"-;'" ISOGIA.$E';Uf\IT'TI <!'. r~l" t "j "L"illii1!rftl:/ fl!, 'i)':.' ':.',\'r.2"';""" 330~-(J/~'~_J../'52,7.ri' '\OOAaS~(5'rf ;u;a'Crr;:"3,\'eZi~'i/ I ' ~., IJ' . 'j'~ ~11?1/-i".:::':;-~'-- ~,iYiW~ _:1011,1 '1---- Y: . .:' I,' ,~~'; . ~:' ~t'yf'II)":4~~~~: : ~a,ftitr.:-q"!'~'ii,:,;'~(IJ 'I qr; ~ !.Jtb~ 71 'i"" PATlE~NA'Mel'F"';:FP.RENTFROMADOVa)'".,.'" "",' .' ~(!,:,,~:,\I~~:,,4~?~U~~/r'Asr):cHlWrl1l_IMiCIlU~~i~~~ .. ___JO/~ti'3,)?3 l~;~~~~~T1 . f'''' ',' '" "'Ii,"~",' I') ,. , 1 ,,' '.", ' . i IlI-tJ..t,j:ti \I' ", .~ "_'~I' 11' ..,. '.~ '.,' '" '. ". . . " , '..~.<:.,:I"~, "'INJ;.~MAT$"i:f'('i,IOSTac.COf,lPLlrr~l)) ;<;, "":"'1' ,',;",,': ". , . ,.':,., ;'. .'f:~1"1'~~'~"" ' . ;~~ ~..,;..~;. <t-.~~<tt .~};l-;-., ~:,.~.(~. ,rl'~" ,.I!t :.; (~' ~', ,;,' ,';',:11 t.. " "~ ,I' I .: ".: ., ;1::; , ';.;;"-:-".t I '.T, I, ,"" ~ \ "I ': ,: r ;,' i!' , ""',' :;~~J~'..,{,Y::~l'~'\ /~K 'j~:~-1..~~t/~'1 ~O_?'I'~/i".~o;.)~t,'I'jl\:,'I~c1':j, 'II:J~";:"\~/' "",,"~\: .;,t~"p." "::.<', "~ '.i::\~ J,'-:' :Ie ~~'1 1;,"",': ",1,,\ vr: M~"at~J;~Tio;~ . .J2i ',.,'.1'~~~'", ,"':~J..:,1,'I" .i',1 ,l." i',: ,;, :'. . . , .,:":,,'",'\,,',',",:,.:.,',, ',';", "( . I" " ,'.'1 ',' ;;. I,: 1, ...1' '::'r. ..' ""'!;U f\~ '...! .... " :,"v 1" ,'. 'II, 'r"','. (', l}l .' ,. '\ '..1'':'1'''' 1 . ," " ':' r ! . ,,:. . "'i ,'/,(,.".'", I, ~1':!,~ ;,; ,:. .' \~ ::I.~ " :':.~Ii:i:'::r..-r~~lb' ~q;l: ::~:~ (;;';:~J~t\;I\.~j ~:\ \'j~'~ ~;l~~:: ";1 \~,lll ~ I~.{J~" :,'.: \~" ':;;, : ; ',;~: ,: \/:~' I,," ~" ~.(:. :~/:. '" ' jt,;,"'/:', ' "~'I,.i2~STO^1""O~bl ~~~~G,-;tMJlNT.'*~'" i ,'" '""lj':';:';;1 ,':;[L:...c:~.": '. ," " ,~;j~JJ\ 1''')I~.,:~!iJ 1~~,~~1J~::-,\\.'';l,.;::~t}';~;~~:'~~,rJ:!.~t.\i.~;t~'.1:~~;;/\;~~'!l~,:I.,t;JI~ 11;'~,' ll;:":'~'\"'::":,~,t. \~:;;,,~{". ;~ '/ .::>"t ,(~ ':~"::" \ i'.,;,n.~.)],. ',,' ::'O.~ScR)P';'IONOFIV1iess;"NJ\.JRY...~k1\'; .':':",'.'h1.~ f~l';'''I:) ill' , j\;l:')~','(;"r!,':.\;.',. ..: ,<,{ ,>\' > ' o"-' ~'.', ~,;::,:,r.;"-;" ~', '~'J,:'I+"" {..:~.; n~t"'T(,.. "~,, ~ ';,," ',:~"'\,:.r";';"'\'::t:J~"-:"'ll~~:-:~"i'I' , ...., I "," ~~1.-,,1...1: I': ,./".~ "."'~'I"/': .... "I'.,~' ",I," , ,,~!.:,,~,;,,:"i~,,:.\,,'~\l-: j"lllr: III il""r.".;II ',\1r ".: 'I"., '.~l', 1', ...Jti' 'J~' "'\1'" f.,,"<'.,j\ "'" .r'~\.'. ",',~.",(., 'I' ",~",' " ",,';ll,I, ,".'.' 11'~1 . ,,,. ~ -; ':'( . ....1'.. .' '. ,.' . ,'l.' ~ .~ J', ,:t ,;.;:,,' \ '!., I q.ll' .. ( , , . >l \', ,I,'~ " ' , , I I "LJ .I ,,',. :,' ':, " ", '. , l:';-'U-'I"i'~i: ,V'., ~ ", " . ,. '.. ,. ,. .+-1";' -- 1'''--;--:'''' ,: ':..: ,,~''i\r.I:'' '\'1;' 1"~'''''-;'.~:,,1':'~''~;''',:~'.~\':''fl\,'-:JII,'',1.j',''\~i;I~'~;'''~il'jfd''''~'''l> r' ':./"';'", :~ ~;~~"~"I' ,:I'~'lJ .. ~,'.;"',:~";:;".,~.',r: '..,i~>;;'.~~~\il';,:I:;::~/~~,',,{'JHI I"Iii "'2':36' ',' ',. "I ~J;'I"I.t,\o :,f, r~3..'"'HO..",,' ,1.,'\" ,,", ,-: "r,,, ,"~, ~, ~ v,- .,. I' :., ,-,"'.' !;p l"io' ' '., '", ..j . , , . I .' "' .,', ' ! -1 ' ,'f' '. ,~. " . I, ,,! . "." It""i'.,...,,.i!" l:) ; ',"I'I.')t.: ',WAs"ACCIOErH OR I(UIE5SR:E~eO:liO "Mi?U:~II.H;Nt? tlJii'f.? . ". , ... ,:-." . , ' , ", !;.::\',~, ,'.' .:,. " I':',"~ ,r~'Irl,I~,',\,~ "(~'lldw.." '?j[!""I ""l'" I""""" ,,"''',r,,,,' ,J> "/,,,,1,. .' 1:"'.""I;t!;.\,. ,"<'~'.\"~~1""'Y'lIm~tnS P,~~'tH\i'.'t;';:~'11.'II"""'.s~"; ,,'.; ", "..~:,'.,,", '" 11',,1 r':' 'I~":'~l'" I,,' "~'" In',r'-.lt'l."~' '\ . I"'.' ,,' '\""'" 4"~'R~'1 '''I'' ",.,"", ..'. ."~l /, '" ,. ..'. "/'" '.' g'r.i/~~ ~dn~:gtl~~\~'i~~~~~;'j:~~~....J~~::i~"':,\::r'f~,..~t7!; '?~! 'l~ ~lti~ll,'jJ;3\'d~~4'~V~:(J.f.'r:r ::t'~~}t ~f~J:. i f1'1 'II ,:~,:;::1t~<~i:~";;\-'1"1 ;,,:.' , ~'ir1'f:.1;i ';.~ \!~,\\~:~)'i~J1S:,H71,Sl?,\ttr~nl.~L}QI&~r M~ ~ IV; :~...j11,,.r:(\'.1~,',,'\I~t'!l/"1 /:".'4.~)"'1\i\"~"J:l . '" .",,', '~"i'rj~'t..'~ \A'.t ~.~:-. ~~,;~.. \,!.l. ('~~ ~\ 'q\I,,; ."~J.;,!; :," ":;,".;H: ~'~~;'''' .' 'J,.,: .'I:~ .:,.:.~:.0"~!~p!.,1;"!~ I!~,;j ]'~.: :~{,;I':, /:,'1 t~:'i:~ ti ~ <L.'~' '~: 'J';' ~/,~ ;, ,~:\ '. ;-., . ',: :;( .:,',' (1 i ~ : ~ j': ~1~, 'J, ~,~\ &J>~;',~~?~ !:.V,"~"Jij;;',:! IS tfllS CLAIM A 'f1ES/,JLT:o.~ "-'\lE@OL;' ~'~)'EIJ'I:'I,:. ;\":;':;;"1;' ':'. J 1 Y:'::,~:;;,~ ..",,1 :,.':' ~ , :F, ;.1'.'" '. ::q i,,-iY, ~ ,):'3}"/,~';~~~~;:,,~~;;;"~~~;y~::}':~r'~ . 'l .,~"y: \. " .:, .,:~ :~~. ! 'r ~ ~,' \ \-~.)t . ,~' ~.;'.' )':1 t ~'r r.dll,l ;" ;. :.~ )',,:, 'I " i,,:' ,: :': ~~} \',: ",~ ' ,~ , 1 " '\' -t,. : , '.. ":i" ~..,tH: ~t~"'I~,~~~.~",,'O.;/>\.C1:,::,'IS.S'p:buSEE~/PLr.)'iE'ti1J~Sb;N~~(lltl~).IFIIO'ir'lr/:~~;~,\.:,l' ,'/',' ':,~"";:I,.;,' ~ "'1;' 1 ," ,.,,,\,~~t';!{ .l:'," "", ..i ' ' , ,t, ,.. .' " " ' ,( I, f, "', .,' I ~ \', ' ", "", I',' ,\ " I ,I .,,) . " . 4 .:' '"' "..."I'..I""'~'. '."'f /,.' ~ (..' .I. " ' 0,' I"~ "":Kdflif "," ~",,;,. ", '''}It(.C. "I' \" I' 01" " I ,I,.". ',' )'" '" '.. ,. " I ' , , '., , , '" . "/ ~ ~, :'\ i' ,nl'l-.q! ',' ,'I.... , ',," , . "'COMPANY' " ,~ ' 'I 'PI')l:rCY. . I'., '., ~ : :" I,'. ' ,~:", ,'./, 'M~"~i,,,~,I,.;,,, .', \, ; '. " '", ' ---"'......."'..:..~." .,,'.' , ",:,,;,',,"'i' ~J"''\#'j ,',I '~l 'I< ' " , ! .,. ~'1 I, "I ! ': ',h,I~, . ",['NO< 1'Ji;1..1?::.~." ~ . . '.,~ .', I I',,"'. ,"L'\.~ . ,.":,'\,~..:, ,'.' ',..... ~?!:.llr..l .' '1..1'.i ",~ ' .' f\DOAE'S9'" , ,. .1 I'" ~" :. . . I',"".,. ;li~~~i.~';,\~'~~ ,,~" '; ::.,;.~, ' ,.', ., .".,,: ~ 1 ' ,', 1": ,:~~~~.~\'i! " , I' , ,.'. ,~'. '; : .~; >(.,;~', ~: ,:, ::: ;::~;:.. ,1, ',~, :;' '.. ,,~': l/l:t~:t:~~ml~~ilON ~~ ACC~I~A~ AND AYTH6Rii~T1i~N :r~~.\ib~AS~,I~~pAM"rl~N'.:, ;i;:;'!. ,',' ':/,/~;,\"" :.:\,iJt' ,*,"'1" i II ,,,,,,/y",,",,..milO,"Q """'MI'O/1 i. II," ,,.J 'q/,.".I >;,,,,,,,, '"t~U\,\ ,... ~'o,,,,I,, 1"IJ...rli.C"",p"""O'Olh"'.nU"I~I1jI""". .nymfd,,,' 0' oI"<'lnlo"""." :;;..jr" l~l;,~f::,l.', t1on,c'-f1c4n\ln~1"I.,o;hllmIOlh,pr"t'Ad",dI1JS'f,1I(i(<<~9Bg0r1I"" "':."'1',': .,Ii, I: """'"\~,/'l',,... . "',",t);.p",;'. ,';'." ,.", '.'..".':: J~.,:;~\J: ~~;'J,'~." ,... ,. , ~~-... \' ,.." ..l~..i..l,~l.;,_, , J . ,r , '~\I:r}1 l:~l,'~', :.", '....!'." ,(,' , ; I ,,'''\ ' '.,' .: ,. P^TI8 'A 'L'~I~lllj'I',I~F.,..J.' ...., 2 " q^T~ :'~ (j,.6') .' :, '.,.,~7{ ~'~'" :'1 ,11 ,", 'I ,. i .~, "~':' """,~, ",\ :,'" ,:' ".-'lq,,~,): l <~~ IJi; ~ '"',, I,' ""1 /', ',:';;, ;'",yl.~"',1~' ,,',I',. );'~ U ;1\J;~"1" ~';'"I .'.( ! {" : "i"~.'lk".. ~'U.~~.II,jL. I',. (, ,;'. ,II :'I~.' :,.,' :.,1: ;",;, "."" ";1 1~,!,~,l: ~i::". \"!; ,I.; /.'. ;;'; ':": '. I ,.':,; . I ~ )', ":>-':.l":';~.' ::,. i';l~':;' /~~:,~, i'; ".1 '~, ;~\, t' '. ,'~ \': ~.; JJ:';~" k;4"\~0 I ,~\.. ,,','" "," t.';(,..'.,~..':. t/\ ~~ " ,('I '" ", ., I ' " , " ' " , , ,., 'I," , ' "'"." g ~:j;:t~ '~tiA~j~~Ai~n~Ni.O'PA~~VID~~ ::, ~; i~ ':~:':~~~...~~'..iJ~,I,~~~~~\;~:~.-' ~ ::1 ~:'i~,1k~~;~:~I:~~:, ~..l,,:,:. ' ;.:"" ;':'.:.;;';:',':" '~',',' '.\ l~;~~!i'~ j\li~~~'~triM~ lii~~i~r:\ """" ~I~". "~kl,~\~l~" ~'~~j:I" b:~ii!""i,I'~ ".~..I,~,(~t.d!(~.b~'0<~ ~~'y.F"\:'1 01 P'~:::J"I"'.. '.: :'.'t:i~\1 \;1: .i;.i:;: ..1ij;1" '.. , J, . , -- -- ~.__~I~ ., -.. ]-- . , .. .,.' . , .1.. .I,t,. "m:!' l~, 'J'; ',:~'.J' ~~,:,,<'~'1~~'1~' '1 ~,! 'r'~': ,; I /1,.I.~ },. ",'1 ~. "~ . " : y/ ~pl O9IU:.! ,~]tIoA'I~t1~f~', ,~~1\':: :('1.,',1 ,: '~!'~(~!" '11 ~'I';: O,\'tL ~,' '4' '1 ' I. .. \ 'j"" \,.1., ':'~(1 .~'i\,~!.";f,,lr.lr,,:. i,llll'!]""")," :t!'r-{,.I~l~lr"':I.l'l\.l'l"'d~11 ""~"'lllj'III,'~tjl.' )"'~~Ii \" II :',,:,.:"~:>>~,~,:"i).'~;~..;,~/ .1<'li;,:;!':?/;:;:i!:.Xi:::;,:\:;::\'}:;":y":1";;C::," ,>,:.\(.ii,,::;:':;':':,;::~'H~;L!L::+;":';', :.":," ,:" ,,' . , ., ....I;I',\'.jft1~~u...!.F~,,\;~,a,l.-\.,.,I.':;.~'~1', "I'I~I"G~:':1IJ~"d.""G1':' :11' "'1./' ,,' ';fi,';'\I., ':"-1""1'","" P.I/1lC""SJ!l) Al'talli1l!/ol "ioUlJ) lie SiJ8Mlftf.i' 1\> (j~111:'AAA,(" '. r,:;:..' ',,", . I'," ., ". ~"".~,,{ . I ".":)'~!'~''':'~':d( : 'l\". '" "',I.(~.:' , ~ 'I .' '; I' "."', I,. I") " '." " \ ." "1~~;,,{'~::w.~t'l1iiAL1tkA'llicoidAA'iti;'cioo;~"~:1\~~if'tili:~U; II. '1,'rlEHi ~"NfIHo~;Et;rs".' , /~,~'~;:;J~~~~~~~;~~~~;~h~'~~~~~~'~J:~~,~.'~~;M1~,~~~~'1'~,.~!Li;;~ ;il1 ;"~~'~4<i,!22 .~OR 'PRbV;~e~9' IN ~olJn ~IP CI)OE _ne.l, J~ /: I '$Av~i~e{l/ht;.1d4i'rI'$'U',j~rf~iA:T,~i:~'~IL~'9 '~OI1.'TH'E SAllie PI!II'lllN ON A SINGLil CLAIM' ';O~M," 1~1 " : ,":' '. .' : i"~' ';"', j .~, 'I.' d., r t <II:" '. , " " I I 'j., ,; " . , ' , , '" :W~;: 'ASK:~e~TI~N~tBF. iilb~(rDcii;~hLe~edJTYOlJk~ltiE9Glir~;:~I~';IINI) rq~,;f,mjT "LTS~N~~IVeS, lJ~)~\::: ".' L',T~i~;if;'.+ ~l>:,,:'<~ ',,:, ,"! "', ":.:. :~':}.;'~;.:,.'::\ :~,.:;":'i:,~;:'~ '>':. H,;: !;: ' ',I.:f "I ,.' " ',,'i!"" ""{'I~:'r;'1:"~~<::"iTr1~~'. '''',''t'' 1"1 ;" "ft".. "J',,~""'l , ',: ~ l ' , " .' I' ,f".'.! \~ \,,' 'J . ' .,' 'I' . I. . ., " , ',"; J: ,I :' ~',' i' , :' . ' .'. 'I M ED 1 CJ~\ Lei_PI 1 M . 1I1):!~I~)~I"'111!1"Cl" IJNITSD An Uli~!,,"I:i INC~ ;;1,10 EMPLOYEE IIHNEITr PL^I'1 ~""''\'':''Vl'''~,..~ "~,"'~'''':' I .,- ",I'll" ",:;,':1'..'\.1', , .. , '''''''","'.- "i,' . " ,. ~',~.. :':" COElR,\ ___._,_ 'I :1" RETIRED , PLeASE ATTACH ITEI:II.ZED BILLS OISA OLE 0 'j;.d .'i ',;\:i'j~.\l ",:,""'..1' ,t.:,...",' ..,. ~(r-: /'I, VIL.L(~II:'~';P(~. ' :~7.:;1,:;:1,:: '~09 QOv, "fT' ,ll), p" '1'e ,t:~~",:-;'r.'" ,J. 1,..11.,,:: r,rJ r.I,\)IIFJ['\P~qO'1 ,:.' IC~"\'," ", NAPL.ES, Fl. ~):J~'I.() 1..'1.,1,10 ',.,,; '~,\~""'" i, ,; I. . . ","'''''' .' 9'\1) 2b2'^12.!> OI)"OI~96 "..:.....:"'~,. ..~)l~~\F/., "'I ,. "0)'" . Ll e~ n~" II: Mi:OQ 5:,%1, " , I l;'~:"'; : "NO '''' '"'' ,.:, .,,)/ ':;'1'"' F "d,n .~ 1 T ')' t D,I\: I!' :',O;~'!0I33:. . , '\'\~ :~,H~: ",,,,, ~:".;,,",, ,,,,,,0,' '" ,,,,..,,,, '., ."i;,~,E0~~:~:.&'CA" J';i t:!~., ':" LEa""M. 'MANTA' .. ,. ,aLl rrN<A "RS ,,"OR , .r~l: i'ii:">'; :',2014'HERLIN CT ;11. >>.1.:,' . ,;",:"t,} ~r:(''',' ... "'iJ.'.l'l,APl:.E..5. FL, 33942 . . I.: , '." ,,,!\ , . " ,';'.;;i'l, ~{i:::;"i"';/>"i';/''':i"\' ~Vi;~~j~ii\l;>o,.,:, .?""i. ;i~,..; !."." ! ,,' Mm' "0" po" i 00 0' Y?", 0," ".1F;~ ~;;. ,,,;,.,: ",>W' .,', "::' ~..~..",:'lo \,. f M". ",.,,,,, ;t.",., bill.. .!, 0" ",d d. "d.. :,-I~ ,~ ~,,: ...J. .. ....... "n' ",11"~" ".m, p,,, ""\ "".'.1;~' olol,..If "'" h"'. "".'~'!i1Il 1'~,''''''': '" ',~dadu:c:tJ:bl,j;~oliCy....~old ~IcClj',dit:1,(\1:f,orms unt11',you,haV~ mt3t.'.:!~jj~\, ,!~:ij,j:.~.,\: r:-:., .,:. .' . ;X~~r.:: ded....l9,tap~~,v::!1':l.1l :dj'n~ct~IIY, .t.p: .y~ur , i psur aneEl carr1~";:, '''1i''i,;~ ~ dli~~;'~i/~,;,';\::,',:; ,:::i:>. ,~\.;~.~~ ';:~('i, j;:L:~:,~::;w,j;:y~~; i'i Ji'\ (':J.' ip. ',i '!li:)ffjl rl(iiiii',::j::,,' ': ," ,".' :; < :;"., :: '. '~.~, ::;;;.1!,;';i* ",_"_"__~""",---""~-",,,,,,,"~-"-l"~~"l"''''''''''w~.,~ ..,..r., "~"'=~~--- --------- -----.... ,.- ------- "<!~ '~f,x;;fi~~~!~:&;;~~~$:d~'~~Fl."~~i:~~J ';W;!~1't:I'~f~~~i~*i~i~~Ei~\;3~1~'~~II' "f~l~~t~~'tlft'y ;,,:,'I.:6'J<,'; ';.0n1 ts': "C ~a\'.'~~!t":~~~ i,~~~~~1l;~'';'iu.J~~l~... 1...1 , '~~~~~.:.:.~~ ~1.~1+~ ~'J.'~l;.J~4.~~J;l~~I" JiU'J.~~~:~";'.:..:J~:":' '~~~'_'::""':~__;'';'_'__~J.;..,j~~~f;,\f ;:~"1':':~'" '.~~'L~~l~,',,..;'\h\\ 11'~:~~1:l1f.t;!"'.~)~.'f:r'i''''~~~~~1~1'''''',j~}) ,.,~~ W I, "!~II.:\;\i"'1.4;! '" " !,:" : /'," .' ,,' ; '0 ,~~j 1"I;.Y.'~i ',":\",'9. ,:~:",,7:,'i~k:';:i!? m...".~",,~lfi~,~;~';l'~(:\~~\!l,,!r~iW":i!~lt'9~ IT~I 11 ~~~~J iYll.~,W'~i,k' ::,~"'.!:"\I1.:~,;:,::I'I'';I,'.l' , I ..',: I .6} ~ O~"'1~,,';~~i" ';ii ;l';~ ,~1,'J;1~~f~~t~~I';' ,~~,~~0'IWYf;l;fl~\~if~I\~i;~r!;~~ ;~I~~~;!III:(lOO& dfi\i;i'.'!;f.~~:f:;~\lj~l';': :':: ,:, ;,.rt.6&Q51t-:~i:~~\ ~;.'. 9 " ,::J'6~O''''I'' '......~ ''''''.Ilr~v~''''I'j'f,'"~~r'tr~'J'';.'~'~~l'''\'i:!:' ~ '" " ,.1/.... ""'i"\~<-"''<'" " ." ' "...., "I"I"iW ~:~c,~ !~~ ~~~i'~j.\~~~.~~ti~~~\~:~ifr;~!t.X~!lg,'lf~~:I~it~$~\W;I;~~' ~liH~[~~;j~}~;f1,!,:;.j?!g( ,~; 'i ::ii;i.;:':: ,:;':< A~;;:~glJ;t';I;1 \,(f;"", ~, ," "'m 1";'I,\l.!ll~ ';'\"''',4:1', ,'. ~iA~,r,'';;;1j':''i)''>'''''II.~li:il,,~,!..~;,,:';I ...' . ";, '''12'':>:''1' ,"'. "I, !':"'3"'0' .,,~:i";:r.l ~'~. ~..V ' ,~?:~ t:. '.~,/N" t1':l:'\l1 Q'"..,,~,J.''"I,'Q~!1'OU1, :'( ,\'.'"'l,",1~. o;,~ 1'1 ., . 'If : ~ I~ V. .\.1"" . r.,lt"1r','" .. .. '11;11'''''' ~ "J;jJi~,I'S.1;)~~~' ;;~"'~"'.;;';.I'"'"~,F.I"I.;',i ,'.,:',~i,; ~ '. "."'." ....'.1.'1.,'''' . '^""1::'''''';'''''''''''~'''{ '" .,," ::'>1:' ,,)I' ;,J, "..,,,e; HI' ."" c,,,,.., ," .,"" " I..",' '," ., . ." ...",..."'1'''' "'. It~,~,J. .,l.Kt~"'I';.!J~"" .u~ ,~.l "."\'~'\'J';'I,!'t":,,!,},,.,;s"f.'I"ll:'\""" I'~:""""~ \, ,,\,.,I(,(,)~,,""":',"'d'("I\!! ~~t \~~t" ,,141 iJr'>f,~(,)t,i'~'r.~~r.t:~~:'~~~I;~Wjt2(t:~: ):~;;~~1:~11!::,r\i:1~,1 i: j{:,'.;r,ilh'; t :'.>~,;j\:ii~C:J ;'{:;I'~ :.::: :':~\;~ J~aN,.~\jT;;~~~~~~~ r; ~ l~ 1'(;;.;4,.,.').pl"v.J,r,''''''".,.,.."..".,..!.....'..:..o,.:.",.,.,',",'..,,..,"" ",.",:.,., . '," , ".."...",,' ']"rf'lr . ~l --;t ,fl"lt,1,/ .~,(',~.11'1'.:;.'~,'\...,'I.'~.:.t'''''q._,.'.''~". ,- '. t.:I'1 'fl,~;,:,"" \\"i..~.,.',.,..;..r',"~!~!.,..l;"'rl'i.I,Mli: , .' f'" ,.tll'.".....,'"c"y'l'.. ,"t'I,,'" """ ",s": ",""1...',"..1""" oC "'c'" ,", ,., ",..,,'~"i~,,"'/'" .~{, l~';'" ;',. .\ "";' ", .' ",' ,':."; :;"'1' ',..::l",;.,,'{','li':l' -:. ,,:,.'..':;:' ;,."..,:, ,.....',~i'i.'VI'..."'!J'~ . ~ ..',' "t:"',' ,'.,,". ,','.' ' I'.', .,d","""" '.." , . ,., ...,;:.,'0'1:, ., 'i ,. ',." 1 '. ,,' ,'.,', ':".,' . , ,,:, ,. .;, .1, ,'. "." ;:.:"" .'.' 1. ',.': ," , '. ',' ,', " ., ' , 'i' ,l.': '; m' ,\,... ",I."', " ~:: ~: ," '" ~".~'I'J~..,~{..:~;,t'.J._':,rll".~jl!I~, 'ht':,1'~":. ", : I '11;'i;,~"~"'. ".,.' .,. '. .", .. J /,", " I ' . " ' ,.., .', ' .. ,." .. , 1- .. t)j"fl '..' "10'.:1." .,',: '",,, .::',':'L::"\";"<:'~"'''' ,,,:,,,,,'1: ...:."..,.,...".., ,;,; '!'''r~OC'' '1'< '.." :', '..' "'" ). I,:..':" ',' '. :'. "I l,..' ,Il" ',,;,,' . ,'. " ',' . " ':c':.',: .::' , .. ".\'1,,,,.< .,~)... .\I'~ .l'~ '.'lJ J I',' ''.: .' . \ I",' '1"" ,,'"~ ,,',,'. .,',., ..),.1 ': J ..,' '" \ ' "1" ';,. '. , ' . ",,,..,,,' 'J< , ,," ..,.... ..') , ' '.' ,. . " ",', ,,' ,',,' . " "'.-10- ~1!"~".''''I'.''i'~',,,..,.:I:''':' ,1,: . .... ,'.' .....,'/.,' .', . I..'.' I'",' , '1 " \""~;""i ~(;lJ,.!Jfl:').. ,,'", '!'~, ,.", '. ',"' ',',,, '..... . i,... ' ',.' ",' ",~t-l'lll. ~. ~:IL-~iU,.;I..." .,,'.,.,'.' ",", ,,',':').',' ".." ',: ' . ': ',' ..;,' ",.', ",'"r, >>'<,,, ,,', ~")' ..... " ,." I" :.' " ' ' . ':'.' , , ' ".," ,. ,: ',,:;"', \ 4 ':1=.I,i~',,~ ,I""'" ..,," ' .,.,' "" ,,' .., . ".", . ,'" ,,IV" .! ,,\:;~.:':f: '::.:: "... ,,". . . ,'" ',,' ',.',. '. '''I . "', ;. ;',' .' : ' " ., ::le:,'l",l1! .~II~r.I"".',,,, ;,:, "'" ',,"'" .' .", 1"."':,':' ",' \( ''';''','l:~i~\j ~ './.;"11'" I ,. ' ,1 "(' " " " /. '\<' ,~~t~I' . '" '."'\,', "" "I, . ,. '.'''''., ",,' "" . , . ' '" ' , /. p, . ~,,;.i'" '" ," '.'.. ' ,,;. . .', ," ' " ,;, ""'Ii':'''' . ~", ':",IM~;!,I;':' . ':'..' ,. . : '. " ,.;.~(1'olal'char!;1e's' l':ji:l"~S","i,\i" ~ 1I,x:,d'~:~' ~,~. ""') . .;. ' " " l: .', l' ,. "d' . . .' ~..; r':t~tJ' l~ rI.~~IY",""';;~'~/'-:"/ ". . ". ':.. :' . ,,'\'olal:,cre lts: -:lj9,..'iSi'~'if"r, , ~.. f':t-~~t"J{~.:},';I,;,;.'.,.':,:i",""':" I;,,,"':' '1,',,1:,.,;"." /"";':(.8)(.:.:,', '!"::()160~"I.'J'~ .,., '," '.-'" ,," .....' '." "'" ." ."",..,. ,.,.."., ,.,.""..", ~,,11 (~~',' 'IJ;.'~;:;;~:!~t,,;:t:::^I:~:' jlj':,':,,'..,,~::;\;:~,:';:;""':I"'" . ,,'''~l,r:.fl:;a.]> ,~ue",'Thi:~' Y1'~it::,. "~':""~')~O:"!'}f.:'II, .~ I'"~ ""'{I,~~r;~h'lf'~' {i. I , r.'>~ "11'/1'" "t'" "~I' ,.",Il 'J' '\')''If! :1'1~' :~"rtithJll:.,.:,.~;,tl'r;lj/,'",::. ".'!I\'~,,;'~'.:f)"\lll,',f';" \ ~"'III'ifJ '''''ii-.J..:';: "\'~~'~.'I\"'~' /: ',".; ".;-;,':f' F',:bi ( I' ",.~""l" "',''''''_/~' ;,,;,.,..,"" 'I",,~ ,',' '" j"'" .,..,' "1' 'jt,;.;. 1 . ".' ,'.' I'" ',' A,..~I .~. \ .' 1,Ji.I:l1~!:;~,If1;t1;:!:\~~\'1i';f1\'j.'~h,; \r;'::.f'~,'~~l~'i::k:\"~r.:~:),:"; ,i~ ,', ,: ::<"I:lrl:t?r;;~,~t('l'a1 , 1,:':'):'\ '~~,~;~ i;' ", :, . .' .:/.dOi..;;<;io."o,!,j . ,,'IlI~ . '.'v' "'.''''''''~I''' ,,'. '~-'~" ," , ,,, .. . "r' I' am. IT' e.~a ,..oe ',......6 . '.1' .,.... r: ~ ~ i'f,'~XJi.,'#~;"J~~I~~i ,li~~'Jl{cW~' ,rl;~I"~"":' ',,"" ;":\' "'\' ,'''' oil"' 'i>'" ~. ,..;':'''~~ ...',;;~;; :.',;;,JP .. . ~~1 ,.,,*,. ::,. ~1' ':~;'~ ,!;"l", ,"'''. ',:~'';~ill''~'~\.J''''\.:~'I"jjj~:f;~; Ir''''';1~TI~,'7)f' ':' :~''-,'l'''~i~'~;'; '-:'''f~t.''~ ...::.i,.,':p:,W77:....; :a Ii ~ "':,I'1!il~e/1lh,'l'i J, i;\\lI'f'GO~;"<< t;"oY' ,~:~I"FlllrmEll'l..':,O ;ml9c ca : u<llne , !!l",..v\'t."u".~,., lr!' ,1Ji!,'T: i"P,::' '1,:. ~:;:',', ,- hY'$lcriill'n -:t'ot,' thEt.' ti~tviMS" de9ct 1bad ,abov",.' J:' l\r~O' '::'~I' '."':. :"I'.I;')1",'{ .': ,....:1 :' '.:.,!!,'''~';' ,t\UlhQ~'he...~the::'r .... 1,'/; ll'<',ili ; of ;'arl1". i nformat1otl nebElssal"Y, to':"I:;;;"" . ,.:>~"" ~ "" ,'"" ,,;yl,~' " ..lo.'" h" 1 !"'"';1' r I '.,.' !I"t~l'. ~ ,,,,, '.,1' ,,,,, . "" '.. ';,. proce",s "t .5 C a .l,~," Ii, " " .' ''>,,, ""'!',',o;1!,,, 'i,";';"";" ',', ,.' i ,,' .. '.1"",' ',:, . ',\', "',,' ,',,: , ..,,: ,,' ": .", ,,~ """,,':,B!:' I ""I' ", ,. ,.," ... ..,,, ,I..' ,. ' ,,', " ' , "1: "'j;~ "b'l"'"'\''L'''~lAj,i''''' '~'I~~ .,.'t~.l';'h,.".,.t", ,;Or.'..:" /,,' 0' .' '; ,I.'::, '.'..(:. ~. . "...Cln"'" ",l'1""U,e,;.l" . !"" ",,"" ,'.- ...' 'JI"'11 . " ' ate, - ' , ,;,..',' 1,0)"", "."..,,:J,:1"'" "" , ~..-~ "',"~," , ,'" ,'., ".:., ~'f/t't~J-~~';::li.'I\~I.'\':i':\~li{.b!~i~i{~ :~.1:::;:~"i'~I;<';~;.W1&1;?:'!;ifll~; I,"; ;';:')tl:.~... ..;:, ,: ~ ,," , ,,' ~~;.. i*=....>i ~..~ 'i.......~.....I'..~JI!,tij....~~ "11'1 ll,...."'~..........~.."''''......~==''''''.."".."..''' """,,~ , ". . . .l;L',,),l\' ~.:~."'~'~~~' ;1: ~ ,~:.'Yil,~",\;': ~\!~~~)JI'~I!(: ::i:,i'~ i:'/,1111 '<';:I,,"';\\;I'I"J~,,;i\::;;' \,;.G," : .:: " '." '. .'. " 1 ::,: ,.~ 1; 'j,l 1'1 '-,11-. '/I'" ';i~\~ Q"""i.';'~"I'I'~.''t~ ''''' "I t/i'iJi' "~'-'I~"'1'4.;t;'\'tr'I' \ ,~I,," , '\ I. :1 ~ ' ,t';",' l.l.'fo~~ Jt' ~~'I"'\'~II"'IrI:.t.."I'1.f <;t.:'i'~j~"'~""" "~I ,," :"~' .' " . r. "",t~ ~,,)..'i!p."s.~,l ".1 ,jl,,,' ",I:;' ;'" .,'.;1' ~ '!iti; ,.".' ,';: .' . ""L.'" ......10... ~Il. '..-,....." -~.......~.......~..--"'---- '. ~ ..... ~ : --""',,",<...,.,,- .."..,... ""'""" '.I ,,~'" -~ . ". , ~. '. 'l'".~' . ,H,,~' .J,.' , . .:.....,'-'.._....~, . 'I'. ...._,...~... ,~.,... .............. ''"'I'."r'';', ,,~~ ~... i;n;.:;.:.:::;-:.;;~;::::J.~~~~~ ~~ "._"fl<';. '-"~b ""uv'r.-.~ .II.~~' ,~,:..._,'~'~'.';rl;..l."",,_, ~~.~ ""'~,,..m. ''-'' "~'.. ""'""':l-r.1I7'<O.;J,t' ';:O~ ,..\.':J.,,:-....~,",..~ ~~:.~ ~.";'.. ", ~;~.:lI".,..;;~;~,~~:t&l..;,~"" ~..~ . I .:~: .,.,. c '.:!~,n:.;f:.'r: CUT (I, r.1r.::("3 Ct";:ER.';!; . , '. 1'."C'J . ,..'4..,\, ,- . , ". ',,<,\ I ~ '. '\'" . .,.. "'I,iA-I ., OJ,I_,i..L1WN., .... ., 61)914 'j ,. 1",: , " :: x;( i: ,''':.\ '. :~:, ~( ~ .m..:,l,r;.(INSURMiC2 elM,1 FORM -.-,- ..--- .-.- ------...., .-,...-----..-- -.. . . ~,~ " I,(,J. IVr..~1I1'4tt~VI. ,lI,l'.!F,'1 ,\,>.,,',tHII'.I'\'~J\ t.l., . ~ '. .' I .j "_"1 _' I' <I .'11, .. ..... . \ ~ .,..... '<" I.J I' 1'".'.\1~'I':J.(J, .1".( j,'N~1 I ..:.r,,: ffllJ, ,13::s~,r:.1'9~7' . r! ' .: 'i,T'f,ti'f:;','''' '.; ;-1.., ~,I -:;.-;- ~:;,.'~~~;i.:;;- "'--:~l-J,.~~~~,~,j"\~iii",';".h'" --"._,~;~"--:- 'rr;;:i r;i :;i 1l",:f,;',~,~,;:'J:;i;;;:;':'l.-:;'~:;'(-~~II""" .- ''', : .;.l:EIlt:.LL,CH CHPNTf:~~l.._._. .._:.. ..~.~!.3..~.~..I,'L,.._~ :C_ ...l:E~~.U_l.:r:>.i,_',p.:;:~I:!f1~,H -_..~::..:..._.__. ..,..! I j~,",I".~".':.'\\; '. '''It l"''\iE'lItfll..-\'':',"'I''fl"rj'Jlillll 1 r"t"llj,II.I!IA:'r',)~...3"I' :1"'1' . ""1 . I ,'.' J .' : _a?~.:- M~'~lclH ~E':l3:r:._.. ,___ ~~:,:LJ. J,.".,: :":'..:".~1... ~~ '::2.' .~!:.1..4 _~j,,~'l~~.~,S()U~!.,_...,L -..... ..I,::.....', ;7:1""1 . :~',\I~ l,j,"4.:(,I/ltr":lJ"J '';'H'' '':' r.: (';1 ','i .~ I '. ' ~2 t:{;\r~}::i:--.., -- -:li:;;:'-':;;,;:';;;;;:.'; ;::;.J:'l;"".X: ,~""' ,",,' C J 'd{~,~;'-; "':!'-'---l"?;;,c;;:L:,i":;;:::r~U,.:;:~,~. '!~ , >~'3'~,~,'~ 4~~ ~,r.- .~~,_~;_l~~ll~_~_!.~.~_~ ~.~__~.~ '~~'~"~~I_ :~.; ~~~,~~;,;.'I:, ;(', "~~I~;:;:~:'(]~' ~~'!~~ ~:::,,". ....~'._~~~!.~:::j~.~.!J~,,~..11~~~i:}.~ ,~'.:i t.2.: ','/;,\".,1:: I";" '/H,l,Hr.O ~ I,M.j~ .~.... -" p,,, ,""1 Iq "", /,l.t;,'.. ,,: .11 !.(j ,~.", tNf., ,:,~,,,,'II,,t H, '''~.\~() ::; ,\ I Ilj,! .11 .. ":1" , J;'( '..II(,ljo;. I',;! i'~...:., l"i~ll(fl! ,~... , !::; ." I 4ALri:;~!~~a'Zl"": .' 1 ","",:~ ~ ,. "__..____.~..,.~__,_. ,~._._~; . .~...... ," ,.~......._.~...._..,_.__~___...._..........,...."u., I' ".,.:,',-.:f.r..."....".~..SJ.J.. .n. l:.i':.l ';--:...,:; I .: 'I ",I';U;' ,I.yarn ! I. t. '.';'\ ,j",i;:'i r I ,~U'lI'j:.jll ()>l !'!l~ '/I(llj~! l' "'hi"" ~,.., ',' '.1' ':~ '11,' r!, \ ",~.J... 'l O~ ;..;,.;: j ~J'i.,=, "";0110 '1"1 ".~ ,:n:,.C, M"'"'j.' ""..~:',:..'X'i:..'.rE?: ::' .; ~ on;R;~Si~-:~~ :;~;1'7,-.- '5~';-.-- "--".-1, :I. "I ~~ "':G.~(!, "/ '~'\l;I; ~(V'f" ~:. iTi.;::.~: ; . ,.1.,':~~.~,7;,~;,t~;M~ ~~:r:~(J:~:-- ~'_.!~',;""~~~:', i::,~ :':-:/r~:;. ~{\1' iff.':: ?;o: ,', O;,i _.~'_..._....._,' l:';'" IX],,0UNIlE:) AIRLINES' .' :...,::....' ""':.".<l, '~~; ~:: ='-IPCi5Y'iA'SiiAi:lt;';;j', '~:,~~i.\ '.j;;vr.-"'-' -. - .. n -, : ,lf~n ~('::.I.:(..,I' :i"i;;1ii;:.~::~, "';, ;;;~:wi.-lJr;'n((,ljx;i~~..wri.......7~'~'~,:...Mo'.1:-. ">1 ~', ,i,i.~!,.-:i... i [-I," I'i'J"o ct'~NNt:dTlCUT ,riii::NERAi..: l~fSf:),>'::j~J, ~~'~'. ~ ~;.)Vlw'iCrji~;.fii;.wf~ii ",,~~~;,i;\'-i ;;;-I~'-"~ '~.m'_j.;(:"I~~i:;(ii;;t37t;li"'CZi;;i;>'IS;:'~.~. ~",i;~~i~.," ';1,;;;: :.tli-;-;-iF,iii;iijll~j;:r.:T"L\llr:?~.-:'.,:.~:..~. ~~ "-: ~J :~. \ rl "'. ,,' '. , I ." ,. " '.~ f ~~~r ,:~____._,_ _. _ .~.......__ ~_ _._ "__"~'_'__' _.,"'_.~_,..__._.._.~:ru~(~,\ .~,x:~!~~'.'~~~~~~;')~:::;~~~~!~~r<i~~~:~l:'j..,;.1 f~':.-1\' I,. Rll:'D J,lC~ Of lUAU )UIJ/ll!! ":';'~P~.1'INO . SIGtmtQ fill; ;o~.l"l II III'SI, 'I- ,'11 \1,.I~"i'\!'.cV 1.1:~~:rl.,I,\)(I,."'il,'l!.~ r 'jlill.';lt~'J" ,:'\'-\J' :1" , )~f, 1~ P"tlEP~ 0" "IJr-(l.l:'::~:, j I '1',( I. I, ~ r,llJlI . lit I ,I. t, ._ i' . "fll,~W~'.lo11 'T'o""~,4.' 1U'" "J~f" ~I~~l '~i".lolll IJ'tJ' 'II, '" "J :." !<I!'I. t~ t....,.11l'/;<1'..oJ1,w. (11I./,..'"'141\'1,1."...,....1.-). 'o.r:....'. '."j' ,~'i . ~,,': .('\JPfQC;.lruru,,j,.m'I<WI,f/..,f.., "I ., ""'I'~"""'l'lj1.'I,)d'J\-.Il-'16'r'4~"I"""lldJ:I'I~I.;t'illll'l '''''ff!<'I' ""~'~,"'J"".' ,,' ',....,.."'..,:.".. ,,:,,~,,''':'ll.'.'.:ll 'f..,r/~5~\~f~IGNATUR!O ON FILE '"" ';""070mt:> ,," ,,-" ii !)f.g ;GNATI..illJ:: :ONFl~:(;'~': ~;~~, J.:t ~~'W;... ,.,.&IC','EO ::.:.......1". . OAJI: ....i,.............:..:......;...;.... N\,..,ti' '~::;~'.~...; '.." .', ,,:~;;:. i; 1-;.. :::':!J? ,h.;:.. tol;.OMlQ4CvlHif.",..r 4::'" ,.( .,'/1.-1.)0"1011 I'I;..;F ..,\! tl.f H....:i",I!I 'JJl~Il, ::.1 '):!.I~."II '~I.'II.::~, l~ t,Af\ "" ,I,,\"l! 1'.1 ," /<I( './1 :vi<.111.1 .~",j1'\f",,"1 ~: t>:~ ~~.~'.i:;:,'A.,<J.I.,~O' 'I',' . """.~".L'".';ICH 'JI"h)'l\:J\(H~~ \1.l,I .111)'1 'f"'.,1 ',',' .,'.. 1.'1 \jM, IJ." ',Yi .... -I., :11''':' ,'.... ", ,'''u',','''r..;' ~\l;J1 I I', .' ;- ~IiCM I TO ',',', 1 ' ': I I! ..,..'.:.'.1,1~.'\i.i~'r~;:~::: "-:"';":""I~~;Cw;l 'j10r;;f.~,;v,it;:-' .....I~.,::; 'j7;. :/l~..Jli.;-li.t{;:.:;.~;ii.,..;;:;~'~';~~;:;~:t.~.._- iTiZii::.;:." : '.;~~~.;:?r:\;;-li;\:~~iT~~lr!ir:'I~,M~ri ~ ".~'~,i' \:;~ ~~.;..~:"". ( '.' l,flJ IJ. TV ,I,!'J ~ '('f : '.,' t' I~ 1> ..:: 1\:BCOl'Le:l~Ei!.Cll;::N.CY_._........, -_.... ..".-......- .-' --.-......................-..-... "'0", 10' ..::.,~.._....:._.1 F'~ ~:.' Ir~'~~~::~J.:.;~~:~~:"::'_..-._, ,........... .....- .-............--..... ..,-.-.---- ~..,~.11t~~'.'~x:l"~..j~- ~.~:~':~.'~:L f:.....~ ~:2:1:,';~.~~~ ~~..' ~l,f'l,\'~'.c:-~:~ qt\ '<Aft..-II: (;~ c;.I,li.'~5 Oi '/11'.111 ,.lieL,' ~:~ 1'~f,H ! ~ .l,Jrl I ~lJ dr,tJ ..~~ 11"f I. h,{, '''--'1 .~. "'-l~CI<:.A.~ 1I':.:H,I,)I.II:Jlj~'1i ~, '. .' ,( '.:.!. ~:'-. ;'~"""I""'; ': '.': .' 'I.,C...P~ -, . un~II/L\I.,.,!~,.,NO r. .' I'"f i~~":'~e5F~1";':'" ,..... '" "" ...,,' ..',. ..:, . r :, "'i . 1-,. .'. .' " ....... ',~ti" '1', 1'" '"_..._ ) L____ .,...."---..___....L.._'-__....-'-...__........... .., ~'I,:t'-'.', ';,':', ~...' ;-J,I'il~I\,\ui.,':,l::"'~;ell:I~'..jU.u1-4 '\II j' {r,:~ ~i'i~~~~~.- t~.i..l'::'_~=_~'4~M~__~-'-'" ~ 'T"-~' ,.__~~.~....b."~~':;';-I~_~__" "1"" l}1J: ~. _;~._..'.~ :'<, '~"';';'~_Rt.~ .~~~ ~..Hi] w..,;. ~~~...:1;.:..;~;.-_..-:-_._~_~._!L.._~~.;: .'.._,..._._--~~....."~_..__.._....... ~....__l.._.-.. ~~ ..._........r; -~:orl,~~, _!- .!.-t-~...-",< ~-.~ ,~._I';: :: ':s"~'. I 'FIJ.l.t4lt:I~~jU\"i'_ll t....r.;~'~ 'r\.i..'.'').;!\:':...;,i:~,:iUI\ll(i.1,l:~;;..IIF.f.;l.f \'I\(lti<;;';i' ;i....'''l;. "Al"',r.I":II."; ~ ,t.,!l'I,r.CI ,':t'.. !~i:' ~:~.~" '.'~n:' ,'J! ,11 <.;1 i ,ti.~l,oJ<'lw...(~...t'l.:,t;~",.'.\i...., II "...t::Of~' .~ "~~v'II'.~t;~: ' c~' flr1'Y/I;"'C (:OQ ('c.. I""!! ,.i,....:; /~,~ !-..::~~.~!!O-1.!..r~':1__..~1_........!ri-.I!:1"~ ;..~:r-(!1,~~;.~~.--L.MI.!:!d~t:L.__" ',_,"':.':':"....:._. ~..:.--.--~_..~ ,'.::!it:'1 NII~_ - -.:.0 ~":'::",-,,",-,;I I'~ r' '06'2'~: ~6" I?~ ili . ';''''0 I . '.. . , Jl :';1.i1'~0. '00.r..... ..i':L.:.HI i'~ .j t/ ',- ~ - 'I-.~'-"-'- 'r''> .l--..[~.......'" -,---.-.-.... .~.,,-..-....."-.'7 tf' - - '. -t' . t' -"'''-'--- .:!', :' '.1' I ". I \ ~ ' . 1 .~, 'J,..," I ~l~ .. '.( ~. ','}. " ' t I ,! j' \' '!j. .:.. I;:' ,';,. :~"i~':""U~'_'U!I'''- -.-...-. ..~;)~II_...llJ~~3~'_L..----q_..._- l...__..._..{ ':.J ;~~._~"l"'I_;L ,,;IX-r-'-' ~ -_.-, "'~...';" fJ.nJ;' ''''~l '. ...",,,. '.' , ; 1. ~.,.. l;: ", I :' .... ',.-' :';;L.~;"i'~, ,,!,~,.,: I I. I I ': Ji ;1,;,. ' '.':1 I' 1 ~\~I '!:~,t;," ~"',: .' I I ' ,I J .,,',~:.- ,. I.: i' ~~' i':""~" ;-:--:---'1 ... ,.....- --.. ..c...--.-................-.-..--. \'...-.........., .I.-\f-...:'..'rr~.--:. -...:!;';-:-:-::-;..~III.... ~,~~: ,~ ,; 1 I Ij: ' . :.~ / \ " :,1 . r fl.. =,~:' 1~~ ,':::;;' ,." ,;' t---... ., ....-it~. --'~-:..__.._..._-' i'--'.".""! i~~'~~":~11.tr':' ~-:t-:'--'~l;,< 1tq~,."r"" \ ~ \ I. )~''''..... ,.', '.',ot. .'(i'" "-'1 ~lr'.' '. '_J....~........ _ ......, ._. ." _.w_._--I.__~,...... w_..___.. '~'''''''~''.M~'''''''''' f, '.";";';_ .",._.~.......,...-' u." ...._. .. ......' .__;._---.__....~.,Vt.I.." ~~',' !,,', ';', I L': ,Il " ,~{/.lt'.: Ji, i. '. .,~:~~, ':. I >:'t;,-' ." ;!C'~: ~I, " I"., I I ~ I \1 ';,.~:;..l"~L.I... I" .1"11,,"" l :" i~',t'~: ~~. '~-~ ",Iiiil: ,,:<:,;',}' ,..;" .;,":;;'''';''''-';: p~.';,-,if...;,';:c;;,;l ,,,--":, ....~. C::tI:I'1:n~~'iJ~~\'~ii';-:i' ';,..tcif.Atc;i,\~~'" ......'r....; it~,;AJO~,MT;;..t;~',=i~;!--" ;. ~~ j ttL I . . .f~.!l"'JI',..lllU':I,lllh'."":.1 ~!J. ;tlJ~' , II .' ,.', ~ j""I 1 .,:~"" ._.23 '1 7i?:Zl (,7 . ...,;..,.x,...~._')6'l!t,._.. _~...._;..,. _c..:'.::":!"...!:(J.!~:.]_..:_ .~'lli01:!:l'a'~. ~,:t.'b~~.0ijJ.~t.:)16' ..0.0..1 : '~:'l ~, '11 ,:,\; .~. J'.i . I' ", ~'~'~Il 'J'."I'(,l;. r... 'iI<l,!l; AI.O ,\l.':-nF':Olil;t' h....;\,r.. 11"f.;'," ti~:I'JI!;I:"."I~!lfi H45~tt:lj.Jtlt'~"Uftl;~""~Jta~bfi~t"E' \; I ~ ! ,.1:,::'1Ir.:.:.'.~_.I\.,I!~llj~""~:. Ilf',i,I1~~OI'lI....;..I/'.~Jrnw','''/..-:n, " "'-,:'-"" ,~"'" ""IlU fI,"~"'"-."-r.'~' V ":" ,Yo' I :.'~':' :~'., ":':;"~~,..:,;."".~,:':';." CARL-1Sl.E. HOS~'lTAL. el, ,l\~.AY.'OF.:,Ce:lfliflfl\.. flA. t.p;.e' ,:',,' i~i /..n~Ri'::NcP; K THOMPSON t.!4~ PARKER'STREr."! 4lJ6'i,'IlEt..\I~OEfU;::. STRE;:<:r t ,.. ::':1 j~ 0702% CARL. lEil.E PA ~ ;:~Il J S~,~,9 ~1.E; , ,PA1?",1 ~ ~ft9 i010~ :;. . r. .. 'H' 1.".:1'<. '. "'U" AU 4 72t>B15 .... . ,1' '. .-'l __ .... "'''_.''''I.f,~(''';~~__~__' l '. . _,...~lo; ,~:.;,,'. .v,~~~(O:!./II..',~,',I~',I...!..HII..,1; iJ:'II,,'':f~ll "/ ~""'1pmN"~I'~fr':rv'i,,rl;' ',' ,Nu:.:!~~t;", flo...,..k;~("!~".~.'..'~\)~.'..':.,. :'~j ~'\!""'.l ':"'l" ,... ", .1'''; 111", ".'r'~'i'" ~''''''~''{'I:'''I''~l SVI'.lldl~'r,' .~. ~~~~'~~~'};~~~~L:' ~'...-4..I~k.-..~.~~~..,~_..ol.LI~.~~1 ..J~,iL J .tilliil~1 :;.j .~.t~~~':,~.~ ~~~.!4l.. . ,:.'::~. ::,. "~i'~Ji{;.;:~j':~. . j~.~~~,:~~1 ~ 1 , " ?;~:r:,l~ ~. ., '~ " ", '~4!"":'lJ,~;\:,:IJ,::{.?,~r-; u...;.....~...~~~...... "'1: ... """"",":' H' ":''T['~,~', l'" c:~' , q~J, "/:r'. . ; ~ ;1. ,. ,,' , ;\, I.; ',i", '< :.1',,'},'7'1, .."j":-\.'.l~-;"~]~:'1."'J~'7'~ , '. '''. 4 I ~. : ", '!, '. J ! '~'''',..., , .." "'''lIi;I~''.! ':: '..:.rl;, ';':,',', .':', '" :.( :~', , ,~')'\",' '/,"',r." l, " ','. I ' , ",f.'jl ,"';, ..",.t,: j .'l.' "t" . 1 ,r,"'j" 'I " ',11.1., I .,1. , " ll'~' ~;;' " ~' . '\' ~ 'q . t ",',,: I ~/" ~, .. .'.1 :' '.., , .l, "J'.1 . '"'A'.''''' 'I, .' >,',','): ~"~':/:} ',r:,\' .r,.'.:,~ 1;'~':'f: :~~:: ~~",,:~ J'?;J.~:X~ .. .d' ~(, MRilt7B/4.<l'" ,. '''. Ii",., :' ":Y'! i',r1!~' ".' ,.', L;;8CULC:-J, CHA.'ITAL J, - .... ' a,\IRRG 1)5IPT, ,;"1 .;::'1:, ':1 r. .,.,.... , ::;'::;'!"; :;~.~.. ..' , ' COIISUL r A TlCN TO: Dr, Ul'lIr:lr.ca X. T"lIlmp3011111 :/i:," OATS: C€/2=:/1'jt;6 I:"; " 'i, , rIP:: OF CCH3ULTATlO/J: E~'2RGENC,(Dt:i'AfrrMI:NT C6'NSULT,I"ION .; " .':'/i:,!, :i:,;;.':i:," ',. '.' . . . ::1:,:1),:..; ',,'/~f:.,:',~,.,;:';,:',i:::-f;~:;;~g: ;t;i:<'.,)lISTCRY: The above captioned Is 3 12,yaar-.:1d ydl~glii~~:\ih,ols, a ;d.~noaJ\u~ap).h~!h';9.~tl~,,/! ::;:i/':,.;t}Nt'j1:; L::~l',,' :C(cr thll 0">( flv! \\fllqw~oo<;C!CIlr.t!y pwahcd hllr It'll11~fl9M~!qi!,3r.m.,lt1r~,:'Sh .a'~I:l3?:!Jf?D.i~~0}'i't:_'\;:::Y:';~;}\'; :";1f.:;;!:>'~u3taiMct .11UIt:ple Ji)'..1I1I~"~!I,on~:tc Iha hand.aJ v,'n:li;,~/.;I~IJq3r ~f'l~t9Iry~,lrrtl.'W.~~rrJ;Wi~t,/t!'''\i:{i;I?~:) ?;'C,....;,: ',request~d by "mdrge~/rccmphY3Iolan to repair '!~!! I~;~. r."t!8?j :<f,l1M.lit'''n.!sti1I,~~,Ih~t'~.~~ ~~nW't<.'\I,.~;:(!;,L!":m.,'I:;;~!i t;;'"..,:. ~.:,-,., "'li!aith h~, t:~~ geed.. S,h3- has no allOr~!Cs.... >'..~:. .:,".' ;':." 'J:!,.L :' ";~..' ). '.: :'I.'~'~,: :.-:1., i,:,::-,~.",,:.',:\'~..n,.:.~,.r~l.""'::~(~'~::'~,:,:,,~.:';.::T.>;:,:.~,.!7~'~~.''i',\{..'~..' y,' ;~l:ti ":;\L/,: ~ '.:, :' '. "'. . " .'." '." '. ; '., "'; '; ':, '. " :',' , ',: I:'~i:; ."io,I,:: :,1,; :;>;: i,', ;;~: /::'.;:'. .',;',: f {;"':~:' \:~: ,;',:;~..\r~t,:~. Ji,'>:J.rt'j'',o\t~~iJ~.:',: .W~,',i: ':": PHY.9JCAL E:t.\,lAiMA TlO~j: Pertlncn I phy:iieaJe:dni, 'iijliloh~iilio~s e';c~~~ i' :;i~o;6irr.J;~n '~~d~~;'iX\: +'H;;;:I'~i\l~:~J !~,'!(,:'!/ij~en!al!cn 13 ir,txt threughcut.:rhDr~:ara I11U~Jple~:I::'l~lIJ(!hs;!~Ohe~'~ ~uhb olng:to/~Wi/!1b~i~~'.;,I'.::;?Hi;;@~(t~ \;:~ {;;,\:,:ontl'.e.lhumb w.Ja mere or 1e53 a .trap dccriU',vell:ll!I~1':'lll!~I,Il\lWlla(,.cnElll' T~~~!r1'~I!~e<!,.~FP!~~h.\i:/(::;.'r;~,%.:. :~\jii~\},'mal~iY 1 r.m 10 2 om,.T11a length 01. !he la~~ l~caOlil:i 'n.f~,\!t::~~~\~Yllf!tl~~llu lor,ea!'11..}~~~r~{:t!;~;'i;i;'i:~:t!:'.~ltf&i .f.,.~,....",,!.,. 'sppro)(}mat-Iy ~ em' " ~'.. .. i' :: '~'". ,'; II:' ',r,: ':' I: , ,.4'1 ;", I'~ '.... ,. '""~'~~' ..:." (~, :,':1 l}:r, lj..L,'1~'I':,v"""'r.' "., ~'".,.~,~ ,~I{i,~;\ g,:y:~,::,):", -".' ',. ;,':! ,,:', . !J'!;:i',!A::,;,:'/~:r(',I':;'.'J~~~\~:ri~f;!l:':ri')N'~'{;;fi3>:;:i~~i~Ii),1~~Ji' \::: .... ."F",p'ROCED~RE: The wcund,wa~ ,aneslh.eti:~ with 11'1 ,~:!lp~in~~W,e:.P!nePhrJn,):~f.d,~~!!~}~;;'t:~'01i'~~'~~;; :~j~~~~!" :,.; ,:.:j,:p~epj:ed w'th S"t3d,o" nnd sa!/re,lpapeetlonlor 91!1!i 1:,\~a~,i~d9~:' ;.f'cItcVlln9:t"e71~~14ls,',~.~ln~,:~I;:,\i:?0"iIW"~~~ ,>~f':.'i./:" t...r. ,08 h3r.d:. heid C2.ut~rj. Ih..8 lar9~. r. .wo.' 4nd on Ihe fore:~I!I!:\l!...'rl'~.I.lP.}JofflJ#1.e"I!Hh. .m..!~~.'Fi1';'I.W'.~.e~.8<:i.,.'r',,'.,:tr..,Ll[f~!.:'; ~'),:j::.,:'.Inverted ~ ylcryl. In adsitfon:,a 4;QVioiY' 5ubouliml'.f; IJI/I~(I ':\,!~,9,~~; :Onll~I'!;:~m()~!(i1l!jf~r;t~;;?!,~,::,:t~',\'~I;'!A~!iil'k ,:~.;t::;':: :; multJple 5-Q Proiolne .wa). Used"Flnally, ~e(,palred .\11:IJc:,~ralloQs "r.!If1,mu~IR'<);(nl;'lrf1lRi.~~,':~:!i:')"::":'t~,'1 'f~qiW~ ~;~:~:~:A/proleno,T118 wound was. .lt1epWc,ss~~ WI'h,:AdBPlJ4: !1~~Ilr;IC!:I'i;'~~,~'~J::~~R'~;~.n~:.~~~~l~~'i:;r.~~::!i Yd.\iV:'.'J.iW?;~! ':I~~"j::""":;: nus Shot, ,ar~ ,curnmL ' ," ..";', ,",." . ',:, ',"' <:, ' ..' " '.1 :'~, .':"j ':'\ : ),('j ," . ';"'.; ,-'~) :_~.':,"hl': ;'.i"!':t;j"\) I},', ',~~':-,~:;llJ":;f':':.";,~ !,~~'ll~.-:,:,t~'{.;"~)l~ :..:.W,;c.:i'L "', .' ", "', ',' '. ":,. ,:. .". ,;';ni. :,.:,'1, :')'111,,":<:,1:,,:;,'0""';(",'_1',. .:,: :',:,~~i',P',r..{ . .;;,,:,;')"';11"',,,,,, i%tT::,;:;':,r/5 sw;",~sted L~al sha k&>lp th~ armelevat;;c,f/5 m:ikt{:;~ill?;islb)e:L~~; W:lS pl3f.~,.cn. c~f2.s~~::,i;:~i;.~;:::~~~h!'~}:: 1;.W:/::' ~mg 1l1(~ times a daYandOarvocal N 100 :'#.12 on~tll!i fr:1t!I?n1,:\ ~he Is .10 call Ih~_.~~!ntl1(t3'!:l~~ror,'i;j'i:~f:;"... >~'iJ, ~,:f' :i;a prcgre:s.1i'le ItpQrt and I~ to be,se~n pm ~jlha de~I:ll,te:,~P\~I,rWnent fp~FndJY,)~~~ wfthjtle.<),!"';'I!':,,<:: i;::~' <:1 :tiL~'/A;fl\O.~~r In Flonda.~nd gav~ her,ou~ evaluallonand tf,t:/l;rn"!ltr .':',',: . . ":Y)L;1;:i ;';':;'?i;~:"'::.:);:'i/! :,Hti! \,;~~< ~.J'FINALOIAO~IO~JS: ~Iultiple lacerations 01 the I~ft'hlllicjllncj i'lr~arm;.; ":'?'~'" '. "':':;".)ii;'.,:' :,i'\,\ii~' ~i:.;O! . .... . ...... ...., . '.. U~~,i ";;:.'~5'D!.\~ "'.j.' , :. 'jf '-.' . ',.' :.i' '''':.7.~",:.. !:~;il~::3:;L~!t:(3 ,'.,.,.,:A;)~,;; :;;:L;':"~::?: ., ";"""i,i ,>,.O,C6I2flI19C-il..11,oOpm " . :...,..,,"\'<.<1",......,..'.' "'. ','/\'YC:-: T; ~127119'76 .... .... 'l.J1wrene~'J<;Th'Qri1il$Qnlll; ~i;o:<.'. .,.:,;~;,:,.: ';W'Or, L~'Nreno.:l K.T11om~on III' . . ",:"i;::;-i~l" ,. . '.' '.,.,.;., "., "''';'. ~f~:;;i.;J, i FinanCial Counselots Off1e~: . '.~;e:Ji. .,;. .',;.:,J' '::,-"~f!,>:~':;!;' ,"". " \!,,~:i:, ..',:,,:, ,.f..1.\.", ,. I..... ", l.;:.::...~.:t,'!.,:,'.:'..:,.:,;I/>. .,' ',.Li, "'I" ." ,',,"; i';f; ,~'J:: ....<0:.;':,:1' . ."", ',,' '1 :~;,'I','. ;, " ':j', ' . ':\ . , '. ' . ~~ .:,..\'.;'.'.'l:.I,r"....'....:, . ' <l" ' '.. , . ,J . i . ..'" ','t,:';, :;' '" ,,:,:'i,",'; :\:~((:':":i~a!t'} ell aAR4~LEH~il"I',TI\,t,..;,I. ~'. ..': . ,',' ..' . : : ':'."i,'" ..,,;;;"" ~:.i'.........~....:t"'I""l'.., , ".'..... ..l't/')."A1AI..':J,l/III....1 ~"....."''t..'J.,'.J,~...1 ...I,."..,.I!.I; _,...,.IS.......~'~.I...'"",.... 4l...............,~.:.L,.;... ~;.- ... / ,.~.,''t-< j ~ I ,~ ~ ,', (" . /, L, ~ \ . ~:\ A, (~~l.I3~ (C ~,\i l~f,~I~':Ri".. I I.',' '~\'T I,' I~ : . fl: ~'\i'1I! '0 BOI :)(:4/) .i!J ,'I nW1 ' ~ r " " '.~I 10;\ I ':i)n'a~Hl:\JfiLl':J M"I' "," ~Tl,'~, ' IloJ.I.'" 1:":S!l~ll\III;I: r.!.,"'.1 :",:,.,: .' i"V _.._. ......___"'I;'_.__~ ,'----....~....__._. _r'''' ~,,, ......~.,..__"_~,__,_...._.._'__.._. .... ...-..........-...,...-. .,.. I It'\I',II,,l f ''',1';1' ,,"".l,"..i, 4' "\',',, ,"1" ... 1'1 I.' "i'," F' '. '.'JI 't' ~ m t "1\\ 'f I, 'I l I' I I r::,::",:~:~~_:: c~c:.::':~r: :,:-,::J:J"::: '/. l.i ' .:~ ~ ~",!! 5~.2 0, . , . J. I !' ^lq11f':.t,~"'l"_II"II"f'f'"",,,,,~"<'-II~I"'" ,1~1~;"'I,J . ,I Jl"I"II" ,.. ,", I."", iJ.,f,.~oil.~!~li.L..~JiL\.tFAI._.L ______.[I.JQ"n ..~L~O..._.L'l_~Mr;,_.._.,,_.. -- .."...... : II (" ..,\'!W,'J,\:J'J~d~('I'),G1r"'iJ ~ 1,\' Nl f~ ','"( 1>1; '''''Il\flH' 1 Ul1\Jn"\ J'i't ,:11' '..,.Il' . , , [J ,'" ,- rJ ~ h~.iLl.1.:U1f:BJ.J1LG.Q.VS..L.__~_._ ;:'~.....~: ~~I.. '.:''')..':::,'::.... .2,Q..LUi~~~I..~~_':.Q~.~T_, -[":-' , "'-, :: l:,,;(n '/, I l'jn.'.! 1P,qn:~~'1.'.r, "I,' . (2 . n~}.e~r.s.._-r:~ _,LLJ1 "",>, el' ", ,,,'J',,,, [J, N.M:gs",.. -. . .. ___ ...- ......_,-_. ..f_~__ ~ ~,'1 ';..cc". l1lfil'H,')N6: I "C"tll~ A."," (00'-1.1 ll" (..,')CI [U' r"H "'~ ,1t.(;I,Vf.I~ A/ltA' r. ('\1J i C2 , ...' . . . '.'''''''r:' ''']''''''''[) . \ V: 0 ,; rf.~.'14IU61 :.nH....., "___"Il..!!:~, ':"_. ~~,~.._, ]'1~.~;;:...,---_._- J.'1.41.L..{~,I.:}2 ~~~. !6 .~:. U~':rH'" ~;""""B "'Uq 1"",;:1". """'- "':;"''''''/1 "1.10"'"" r',,' '''''Oil '" 'r! 0 ;0. :: II, """"""',, 'I' , "'H'" C.P J,,,..,,,~Ij<A f '" .' l !:1;l'H:' ~,v"u,,,"po,,,, o"~~i~"""'-+"'--' . G..'''''~.'' I':: """,' to I"'" ",,'" :'. ",-itit;-;r;r~. 'f,',.. ~)Tf,fnT;I--' - '"--. '-'ID -. - .--- ,~' i" f" r " , ' . ,', ['" 1"'( .:" "": ,'~ : t'I "[1 '[1 ,/ ~,~ " " .1 ~ ...no " 'I .~ .,J." \ \, t~ U~"" tiil!.U~~n s CATil.TiliRT~:7'"'--,~.)( b, N.1f''') "'-l,'ffilC'llH' ,.(..\C1 ,1)1.811\1,: D,. e..;wLo-TEriTN^:J,~:cr-~i.~-r- ~- -.- --- j'!=3 . .: ,r"'" I F~D "'! . I un '[1- '" 1"0" .:, :. . ::t ~,' .,', \, ',' '1._\.L~~_ _. _11 L....J :,' ._____ _...._,~__._..__-._.~___~___. I- ~:1 .. ,,,..., In NiH.U! CIA .!;CHO';'''... HAMI u 011-tf\R f.t"IO'J'i ' i u.INSUl1.AlfCa f\AN lAU~ '.;of! \11 X ,1M.I f"'''''C :t ~ ,1,1 } ..',.. " It i' . ,~ , \' , :t . ~i i ' I' " , . , " ,r I ~ I I" , III ,'~ I I . ." Joo: 'I' : , " '" f"~ I ... ~1 ~I C:( I' ,t, ct lfiSUIlWJ'.l\l ~'If N"Mt! 011 jIf100A^\7~nrt-- ."I;j "e.~OI:ir ~" ~ '.(:,.4:'~ ~'-~ It m T~0N(;Tlw.'"ii,7c1rrm~~L""iN' .---- - ~ 0. )~~, ~1;1~\ \ ",., ,;', ~. "I, Dyp.s []NO (fyw,/,rt'l'Tl~~.,.JCOtt'il"...,..,1\1~~'1 1 ;1 ;,.',c ,.'''''''''.-''l,," :..~,.. i..,.. ""' - .--:,.- r"''''''';'''~-''~J ~J:, f2.~S,,"~lth.~'9S1(lNlif\JN 1I\j,':.,t:.I)'~,/tl"..Ic.lu1f~D,., .ro!I,'I\-",'~.,o)M't ~ I ~UiTWl1'leilll.......~-ot...~~,p.''(tda1"wwt.,~ .,~~'!~I~'~~:tt,-~;!.~,~~A~lif~~~~1l(~II~~I.~I"k/',.,.~'Jfu1r..:' ()Nl\lOflU..,...-I'tflt 1, "W\'OPt~dlif.lr::w , , 1kl:';';S~'.'f.llll\IRe:~'O~';'?iL~~" ~ YOll !1I-~,f,';~TVFlE: ON FILE ,: :. 1'1 "~'ilt\ 1 "'1'-", '\ ~ if 1!n I UI,.. . f1)tf..., \ ~J~ :.,8tOPfm~~~~~..,~_',. ", _~ t~ e -~L~.9ja.I~..qJ~....:;.:;.' \ -:lC1"lQn"':"'~A~.~_ --$-.- _' ,~, ~ tflCMta~4.:A."'A~Tt' ~1LLNttA:f,fFiMU)~lo.lI' C~ . ".l~ A~"eJ-tT Hf ~~\O \\IE ,)fI ~l~ !l'Jln l 'j~~.' 101. OJ,T6$ P~T1RN'r lfNAU',fi 1l,)W)('lk "ll~IJ~;leATc()CUMnOOj ;~' ~~ ,,",~~ca..<lo:v.v,~, u<<J'~Il'l'~~~H~ 4 '.ll'~i. ,f1k'J:'1;> t1: IA t'O, 'fV , ",' 'I 1,l.lJ. 00 , ,..., ,. "1M.: r-.o ,V'I' If,: '( ~t!,!'fr.~'~. f:~ ~:,\'.I'~..,.~, I"f(JL,~.t,ij(lY\WP)' 'I I : i ], ~M ~ '0 I: t}' t}! .oI'~FJ~'I'I't1YSII;l,4ll 007iff~;;PJ"- "'''' (D~~iiJi.T!:IC:l (I' \iil it!:Ii'Qi :",:~tiNT- \' !I .l<.."0t3PFru:ii'.Ar'O/l N~13~ 0 CUIlJ11Tm UElFWICUS i:, ~.~~ ".,'11..1 ~:), p ilIl/,.~ :I~l;,::;' :..~, " l ~"J' ,utJ, 0" '(Y U,t,t 1 f)O V'l r( 1:~'i .. 'l'l.ll"!;,'nASPE~\ red I~'~, ' -.-!:-: ,':': ',t11ml ': TO l' .: !111' "-'>: ISI'ffl ~O<I^"us. ""'~' ~.. -- .--..' Y'-- !D,C';r..;,-c\;j----Tcw.... "--... 1~1. vqll'.ll~':lil,'l','~' ,1,.,' """11' I .'0 M f, ~m~ ~"I,~1 ?~~";jl/I<i' ::l!:';":!,~ :"",:'~'. .;; ,:." , " : , ' :' .:' '11:9 LJ'IO L -L ~, Jj~i ~tlW] i1~mffif!Ofla'l.N:lOODttl~tltWjn?IJ\~mIWl"'JUn IT ~~-\l-:"~'iif"i>>(h'" ---:1~ tt',IED~Il)ll1:ii.jGi;t".o;?\C;II - -~ ,., li1~ ',p'.'';: ~'t."f I.ll~ "''':'1;.' t. ';:, 'f ""'CO...>DG., OA,i()I'V.J,PU "'0, ;,.,) ~}i'itt.'illf':~"TOP,f:Wl\WOVNO' r~M I1U, L..... .. '; ',_ __.1_ _ "~,,1' ~\,,'\1'\\,',."( ,:', ~J""~:',.;:,,l\: I, . l>>.flRlOF\,f.Jili.onl.:ArIOMfRIfrlIJ13H r "\"Ji;IW~l.;.\T.'.....t~,. '1,\,,1...1' N ' I'" ",...., ""i'rll\~'f" -~ '1"1., ~~ ", ' ~ ! ~ ~" ,'. '1\,'1:,,,.' 0 . ,-1'.' D 0" FI ' " '.. , ~;. .~"! '.. -.'~' '," ',.1' 4,1.;.,:: C'I.._ _._ _~_----.: .' ~r} ;let,,'," t"H='i,l ,,~-.,..,~,.2#+ r ..!L_' ~Lj,.__ __.~ .___'L-..... i- r )_! tot I ,J-L...N-..-t<..--l.. ,> ;~/J 1"i~~\:V..tt.lIT~Cft'!Aik6'"lr ,t~.~ ~,'(~ ~lAl!.,.:lC~ru ('n' t'!-'uIB Dl,vjJ,OOli) ~~ 011 'j !l:t'J<)tH I \ H.ea~ItQr-1fl' ~ ....,.\ ,'.. "f'~ ~, ",'."/~l'I.',:rro",~ r I~" . "''JoIJIl&IMCte~/flll. COCil ,~\' '::1'1 ~tffl.), ..' ,., !j~J,!'\; ":~""',Vj(bi~~ftiLtr-rr."'.':" IU.'lJ ,h!rr9;;~A.2".' J 1 f. 12 ~: 'l'" 6JoO!f 2611'111 J., ~r{ ~E'W tte:p ;:;ff~HE F~ '1 -. J~~-' -'. ..-.--,- r, i~ -- '-"".-, _. -~, '11'.I:~,<,I,,""':':'::c'I',;,' "1: :i,:.'.J~.1"':;"'" 'Lr nE:~'1.:8' n~ 'PE .. l., . , .. ~" ~. ~"P,,~."'.".~ ".':~':!\,;:.~~ .~~' ,.,.':":1:;':' ':'., ...::... ' _~~, _~.!~__., ;,_.~ ,\:~, ' . ,:' r~l l:r~l: :"J(I':':':"."lh~"i:"I:~""'(''.'.' ,',..: " I :',.:' ':.~ 1 'J ,I:': ~ " 1l1.i"!. "..... .1" ,", ",.' ,. 'r"" '1;." '1 ".... " ~. ll!' . .~~.iS:) ;'~';;~""!.;-';:'>(!I;;i.: "t:\{'.::~;,I, ',' ;' :"'I':"~;~ 1'1-'-l'-~~'''----- i~~";:-' - - , Ii ':'gP'; , ,'y.~ J" t,::' '1': t ",' \'.' ;'. ,I.:' 1 I ' I': ' 1#,:,.,., "I. , '~I -ioJ1 .,'~' . "!h',~",',,:i:'li'" ..',1,,' 1',"'/" (I, j:'Tn' , "~L-I,r--' -',tl,IY" ,-r- l !' f. ,~ . " r ' " .' " , II 1 ~ l. \;of I 1"'- , I ' 'I ~ ~.'l' I'" " " . I Y.l', " I :1 :,l ,:; r I " ~ "..:.L.;.......:... ' . .~ __. ,_ ~-.2Ir, __---.J.~ ." ~ . ;;~:!./,;,y,::,":);' i.:t.l::;!,~~~,_'iJ.!.":~'I~~j3...J!___,_;~f\li_.-l_ _ _'-_' t ,I' :\ i' ': \ltl~ TA;~ 1.0 fNMBfm ~ :\Jt :!I/lf ~,'j, i"^Trv.Nra^~(I' "10, , .,c;c~1'i ....,~S\(IN\'..:llr~ ,', :]'l,)l,~L C'1"llQ~ ~,. "~Il::'.F'lr "",/1;'. ..:0. B,ALA.'l<' ~H '1:4I,L~'-:\'~""""~1.:! j'" ~, I "II.,'I'.t,.,I'..., '1"~'f"""',r..""I"'''1 '~',. 1\;' ;:S:' '" . I;" 'I, ',' I, nI: 0006, 7.L93"" " '11,' Cl:"O ",',";1 . 6600 . NONE; . I,~,} 0 .~ ~~ !l{._ "",,, S.e.~.'(f~ WI (m r.lh..t~)' ':I~U N"i4~AAa 1ft OI'l.'~CIL '( ",iiEi,r lJIR'.afiiinti' ,PI1Y9lClA'Wi;',jiF';Uln',i iIll' ,-:,.,") rr\,,~::\t'nmriIr'- ,"~\Y.A 1 >. , ' IIT',,-,U '~,n,r t.l\E'CoihiI.'lUf".' 'Rt:ij01!~tO.. tlor ::a I'lrn\" f alh'~1 , 'd' "''pHCiN! ~, I , .; ..~".,.,t'~rr~l':".'!!'''':'''.,''''''''M''',. .~ 'l>.!:!I'HlI',!:",lllnCIPTT I ',~"'G !;,M~Rr.~'II.V PHY!;!I':lA~g .~~.I /. 1/,:;' I_ {~(... ~ !......-,.......,,,-... .....~'""'ll'il'J. I "1m 1:111:1 ' 'HOlY .;::,1, ~ UlllrEL,,1.ll1l1i'IEI'..i'II(',,' "". . I,'. iF.MPI (lV.,!; lIPl!:fl / Pt ',/I, J Rf TlrlfO t L j I PLflAUF. AT '^CIII II:MIIIH! 1~1,~1i~ DI':^Ol,W EMPLOy~e NAME/l-IIElSCI1IHr.n l. !]\ '''', . ... ..,._..1 ii:<:1li'.--....:r--l.;-j;I;,;j;,........ 'J',"""",;;" "'((1'ni;I;I^;:,iC;Jli",. . ",)"'.I;:"l:Z ' J "~:_hJ.2<'-" ,!/.',., jXI',L!;;!L , , ". ..I ",lac u.1.'!,: ' U" '. '.J.':..u'_ "J0r1;.\3I,rA'ijr.'''''.',r~rci ;'11'1, ' ~. 'I . , ,j\.~:." lJ^""ll'""olln. :::? Z -idCL~/._._~,1.1UJJ;~~~l___.....~_U_'__.._J...Ji(::;..lr jt.::{~:~' V~(tL,,-),(L~_):,::!l, ____. ; ~ri(tt .. PATIENT NAME liP OIPF~RENr FROM ADC'VE) " ;; 1:1",.:: ! tlSr) l.e.fi6'U'~:~IFlnf!:[V~~/;j~'-e}lii~!I' . "...... ..-- .~.i~~ft'm,o:om~ :-i~']iUl',:~~~ 8~~ - - ---7----.'--.---:_#'.._._... -___. rf::JJ..LLL2...___-,:, ,,~_ , Ilis'URANCE r~H'of1~iATION IMJST Dn COMPLE~BOI' . .'~' ::~i~':.' I ;'; ", ., ./ I I . : -iil. . ., .. '..' "". ?-)'71 r ", , ., .:bAT. OF EMPLOIM,~NT..:-<:' /.'" ;. '1)'; . :;1 ,I i j'ri . . 'FIRSI [)All OP 11IAONOSISIlRB1\WEN I '_. "_'__ __....... , 'f.; . _______ ... ____._._ ' OJ, I I. ,".. .:;~ OE&.lI'ilPTIOIIl')I"/(tNESllIINJVf\Y ___ ' _...._...._... ,: .'.... .... . :) It" ' .: . . ~I & t ., , .,::; . I ---1~-..--.._._.--;-"1 ":'." "; ,;' li}~~. ,~/ :'$~AC(;IOe'~O"'lLNeSS~~LATE9 r')E\tr'a-t~I~t9;~t :;','..:,1,':.: ""'i.' ....:.. " '}~ob.'"I"Wo"'m.~..Comp(;,,!iJ"'I" . j. t 'i\/I"<.' ;:\:':0 .' . ~;,/,'f~H'S p~eN.. T E.~~leLe "OR MeOICAI'E",IECHC'Itr1 i:' ; +::+hio; ~ :~er; ;'/iYHIS CLAIM 'A RrlSVllOF AVEHICle IIC(lOI:m7 I L'\}J : ':!)\~ill" ~ ,.' j,;! ,..'\ \r~',"I,:., ,'.:: , ,".'>; ,. 1 t';;.t,:,/.!~(,'C1;;';; :;p. '.: i<<srQ\JSE EMPloveo71F so': NAME OF E~IPLOVllt,. ';, ~i,!:.r~(t';:~;!;J~,I~~!{.': :~''': 'I,~:;,,/, _:.. ",. \' ~ " ' if '. """.1,1. ,. .... ~M!~Ny,__._-_______.PI,I.Ic:n . (':"ii J.ii~:i~: (:,; '.' ;l~';'; ',~-: ,;." I. ( . ~. ji ' J".". ;,.'....f.,.--.:,~.::' ",:~ .','...,;. . 'J'\P,D'p',E'SS,_ .'. __.'__.__ ' \. ,', \ , ' ~ ""f ' .\ :. .... . .' ".~ ",' ", "". I'.' . +, 1 ~~;\<.':;, ;;;~:~'l~\:l ,\:~~I';;l':".'~'.l .i~i~'~';" .:.. I;". E,"" . ',;_. j, 1'1.".:."."J,:t,.I~\tr.,"IJ..:.t""""~1 /''-:':' '. ' ',' rc' n',.: '. . r",,}l . ;;;i:..~$.r.f.~~~~ti~)p'(' A. .(:IJ~~qY;:AN91ii"~HCll1IZAT o,~ TO REL~~,$.~~ i;.>.~"".~~ttl..M'.,"~II~f.,Id'.. Inq~(q~tI9~:111I1I~ ~~dC. ,.,~..,,~I':.IIt1.. 11'In1l1~';~~ 11I'1111 carll' n1oy'dt.",., 1~.~nc.W" ' 1:>),\ "~i~~t~ct"~,~~'\C!~'~IO:I~~'~'l~~II~~lot.~'II,~'~91lf';!': ~i: '.:' ." '1-', '.$". :1</.\.":';"""~}':'iJ ",,""".i.f~',:;.. . " ., ""I""',;:, P~l . I)1Me;;r:sio;i,'-jUiiif~f" ;l\;';;'}\;g{.[f;::{~i!j\.:fr: ~'M:!:. '. . . . :,":: f':":..:~ :,;'CI iJ1LL,- 1,4; . r~;):,A~tJfgl\MA~!dN';~~~~ P!IOI/;~l:~:;':: ." !,' r . ;. " ~~:~"'~:"'~'~:~"':":~'~"'~'lol;,q~,~::'..~ "'~"~:;'I~'. ,.\ :,: :;":.~'>;.,"" .:1j . I ____._.._ .~. , . H-!!j\'l:'~~tle"',l/i.i~HyI~~III~i'~"" 'ii.JkliH"'~'dI:'!I~PI''''..n''j'' '" ,..,,~..,; ~,~~~ ,~t ",'.~J,'::~:J~"l ::"';~,~,:: ';:/t::;:;.}, ',.T~,. ,,: y: t' eMPtbYfe:~'IQNAruA,i:--'.~;~ ';;'I'~ \{)"';"~';":"~"'-i"(i:',\~':.::'~:"'- ;"~ i,' ~",';"",l ""'~;\l:'~l. " "~J 'I ,~, a::', I.' I I'; JI. :1" . ,:,' \ 'l:' ~. ; . ',; '''I n' ',' 1~ 'l fi ,'.' ~'!" :..r" \; 't ";,, \ ___,__' ]'1"'\ ".,' ,.'j" .j' '!', \. " . ""', , i \ I: !' ~~,., ;oj "~" ~'I~S ,')'1~""..~ ',', ' , I"'" '" ' , I\'~, "I ~~J~ ~u.:~~~~~~~~~ll ~t.im '''!9f8''0Vt:~'e~94~irT 0 TO CA~EMMI>([ " i: '\~J;" 'Ii! "',\' ',;.I""ll'!.lI/lII',J""d .',.. ,,' . ,.' . ',,- ',-'1" " s, ,\ J.\ ;'1.. ~!i;:(~iW~f~~;~~rl~{fJ~:~~LrI!CAAU,:,CO~PA~t(t~Od:9i~,I~i~) ~O.~ ALL INI'A1'1.~~Pcl 'a~'~:': . :, ";:\i ~~,~t~'1;~~~~~;~~N,EVeR PO$SISL~';r~~~ lH~.Pp 1,~rpLIIle Ai 1"II~,,~4q~, tl!fii?VI~EA9IN YOUR ZIP COOE MEA; );/; ~~~.j~.'fn~,~~i!9,Ney~ $~D!iIT MULriPLe: ~"_L~ PO~\"tl~ I:,<IM8 PnR9 Oil ';1/1 :.. 91 , . ~i\ ;'ORM. : '~j"1"1"~[1~P"~,""j'l!1f:1If'~" I I" \ ", .:(;W,. r ~~;t' I, :IT,;, , I. : .,:~~Sl(~ 'Qi$11~"~kNOWlj;008A9LE'ABoiiT:vOUR i~b't~IINJlJR'( ^NCll'll~AT~I~ ',',' 'LT~~~^TIVE9. ' "~~I'I~1 ,)/',l~JIIVJ "\'1," "":""" , ,r,!,'l'.'" '".3.' t' , ~ ~; I ~L~I~" ~'.' '1 I "t:9."I'~{~t",'~'i' "1'" ,.II'!I';" ,,'~ l "~ "\~>. , \~ 'I 'I" II,'$.' prfi"iJ'.'V; ':;.1 'r' ' ',:.'" , ';1" j , i'i' ", ' " ,. .... 'ljl'l'I"':~~:"'~~'~:#\'I:" , ; ,((i;),: ~j(;'i '11 ,:i ~' t~~:,! ,:' ':, 1'1 ~'l' l~lliIIJ'h\31jl j ii,':;';, '; '''.' : ,~.:",:;. ,',,"r',1'.I'1 ,:'" '.'" '. . 'lifV.,. : ' \'. '.' '., f: I .1\"1;11"\1"11',:..", Jr1dl" I"".., '.1,"11 ""I" 1111, \. I I ,.""., ", '1,11!.~'''t~'''11Ir' '~"""''''f'''l'~'t'rll'<~''''' ""~J ,t.,., I " ,_ "'.', ,j.,' ,~' ,. ii~ N. "~~~,ij~jl'~:;~Hjl~1jj: 'l/~~M~:li!,~Ji~Lj , . "~J.&lLtfl:,J,Lr~jL'}:;;l:1;2::~~J~~ IIN IlFII ,\1\111:'-"'....; 1;1 fln^ .,{ :;, '" ~, .~ --'-,- , ~ r i I .' -I 1 :fJ' OAle~-' ';' - ; .~_. 1 ) . :1' .'1' . .j " i \ f I I I ,\;~':!~.'Irr" :'d ",...'l,'....' . '.!I;]\"", ,!ill",., f,'/l .1~ ,.I~. ,-~' ~1 \:~.~rr;'l.;:'ii.;";,.jr:aT.. \ j " ." ~'ir" .. "'1',>"",,, , ,.Ii,b ,P,.r!(r1r- ';~r""( \._,. , , I I,t ., "M'I,Ll:i,~,~, M ._,JL::~',~lri', 1','r\\il.,I i';. t,7\)t1,(li!~\1 I' ':, ,.' , Ii '~,'.I:t .'~It\ 'j";' ": 'I ' : ,,7 7.'~'1 :.. 'Iq 'I'; I.~..r~ i'; i 1'1' 'IAI '" ',i~' ~I\~: '>I':t' U': : I' I ..r."l""'/ ,,, . L.. ' ..,' ,. )I ".1..1 "tt ['\G'" , ,1.,tl,,,'I' '111'1,1'1" ' I I '1'1" , , ~, ,... " 1'1'1"1"1'1\, "',I'iil'L I i.'"L' ''''''1 [' ,". "l";ll"\j"'OJC< '1 "1j , ~ .....H. _\lJ,l1...;~ _ ,,_'..u.,,~ ..", .... _,. . 'I . , ,_"~M" ".r' q, ir' I, ".. ,....J . .. '''I..,J iU;" . i .J..w. ---......., ,t.... __,'M ....., .'II'ili'1{....( Iflllll'l'./ 'I I<J'I~"" .," f! ,1"'1 ,"III..,.,~', W', '1' ',t 't""~ lll,,' ~,H~ ""j I , ; i'''~' ,.,i;' : r ~";I; :i ,'~i:;~'J':: ,,' 'I' ;""i' ~L\~ 1 ")j"'\ f{'; '""",' - i '\7!"-' .. '" . ~'1'. . t' ,..I ,', '.",. ".1...[ '>.~.1 ""~-:'''~''t ,....".t:.'"..~. ," ',;-, I ';.~" '~'I". ,:.........,.~".\I:'-. -'-"""I'~"J!'".-.. ...... , ,.. I ' .' .::.. ,'_J ,\,..ifi:.l, l" ""I)'~"l~r~, ' " 1 ,1"';\ Ill'II.J,.", I, nJ,..~,)o(d 1 !. ';.'O~~'lot.fl~~";" .....l""j'~~Jla "'1.\'[ ,...."'..'11>1".. ,~"".."i"""'\'l..."~,,,~,~:.".:I~"""I~1 " 'b,,!"i:.,I'I'~,j'I"I,l ' '. II i'o' , '. ~," I I t~I),{'~ I',.," 1 I: , !l ',ll . . I ' ., ," I -, I ~ w-- ~ ,;. 'L7.~'-""'-OU' ::',1" ~-:;.' ;,,); ;:~;_._. ..... -.. ..., ..-. ...-, .......""........., 'r.' 7'. '1"i'f""", ...~_. ~'i\:'i(ijri':"" "W'1i"J'{;',-'-~ijl;i5Clir'- i.'" u.b . ~. C.' J vI';." ,,' 11 ,,~tjiCl_"'oh'1~Q .tj"-: ~,~..awUJj)I\."::l.:"':',J.. Ij !.r.1" ...~__:t't1.'.lt_,__ 2014':IICI(LHl (')IJ~T I, . ,11' ::i:'" I' ' , " . ,; "J f' Iii' ,\1 :' ". 'I ::" - : I t, 1;.11!' '+-=1\'( I . 'l'," IV;PLf.S,F'l21U4,1 ' ,101',,' I ' ': ' \, ' c {oj f'll.i, I. ,'" ','. '. \' " ."", I':.'" "'" ~.~ ~$/~ ;~~!r;~ci"--:---'-'-'--'~'- ..:~~:~!:_,... :~".2:~~l'i' 1Wf,~~ ~- ~:.~:.()"t;'1 0;; ~:~:~r;T~'" '~'lli~~~t;ihfOJ;Wi:l'~~1iUji1:ti(li&iC~t.~\,~\i,:'i,r.~,:i:.:!;};,',:!', 1\" t'1:1U' l~~~.t(' "i;:~;'!30~(i)',) '" ::,rW,\.-: .,i.!:: "'14'N;' U'H~ll(j:tNCY,f1~O:oi ":. 129'11:15 ' " -.l4 191'~f) .. ' in '''~i~H:'M\~~bn:'~;;fm'n~ll\~J''ti?i\!;'h~~l;m:iG\'~I)IR\\.., :~:! I" ,~lIP~l: (~I . ~'~ji ,:!".i'~i(;':~~!'OIi':' t'! '\!'I,;:Pl!; :{~:'r: ::i ,!,\:': ',"":,' ')!..,:I' '" j . , ; . \'. ']1 ''''",;.iI'';' r I . 1,1'. ~.''.I!l.i...,Jt:.1 :';a;)'jl'.~.J;..!.:~..'::'" ,,;~ '."1'11 "~./:IIo'~,n. '.~\I~.:'\'I' .'(.!',l/,,; 1:or~i ~\~' : ":'!lllr'~ '.\. i ' '~t,~l! !"I'~~'I ,I,>I.j':! 1 'j" ,(,;, ,i"" Ie' 1\'.'1 j,'. , r,J:,'Hr. 't,.~;.I"';:l"'~'I' ~~""".'Jl....tl.~' .'" ~\'4,~,~1".#.I.r'.1 ,t,o)' ,,',dt l",IIJr,,',-, , ,",'1 '1,;'1I~,.' ,lji'l. '\)1,,"--00 IJI I. ,.~,. ~1... "l',' 1i.1... '.", "'I""'(l/' "\" "'..,.,,'!'I:': '.." ..;)::. . .' : ;':' "', 1 "lJ" , D~' :~~W~~J..ii,:;,;;:;:~!'~lt~~:~;i~f' tJ~~,~ ilj:~[~r~h'{.;; {~1(;~h?irbli;;:< \'::1,\ \i,i;:.\~\~ i,' . ',:~~'\ ;;~y:;:i ~\\~;"1; ,,' IlL:' J 'h Il.il,~f~ ttl,~~ ~ ~~J~;;!,~ ::~;~.}Jj:~~jUii~\Dt\*f~\~~~&.nii;'~i~ii:j;~1~ih1ei if.U~~\1~~~',';}; \;'l'!i) h?'~~ ~ 1~\~ ~k;j,~\~~~m:',J1: it 1,i~~~~~\ ;:n~,~~: t:ffri~, ~i~:J.~ r , .. ...".. ".,,' ',,',:.~l.~, ".1":.'1.' ':,,'.:i,c".1!;' ~t\~~"ll~';;';l'" /'/' t,';:,' 1" _ _. _, ",.,.. to i'l ~ ,..... -J "I "" ~ 1 I '1"'" _._-~..._, -..-.-. ..~. ,~-",-,'-~-'-"~------"-" ~_~ {' l'hS " "1(;" "I , ;I'J '~~~' 3,1\:1 ~f~n.,~ (HVH~~~5 Cllllll.J,PA (,'J::I\)I" II' "-11\ ,PII'.lr,! Fln.lrCI ar fl-1r,II.,t1 r,.'IOllrlml nl ~'la"o,~ ":') ? I} 1,(' ,"1 ':, ' ?IN :r.:.21....11ll~ ~ \,'.~ , TI,~~fi.i7mE'(;'.~Jio:\m,..:q;-:-., ";-;' '-".,.., llii(St.'R'.TiiO',7...,.... - -, - '-i'iiiii.\t y:4 ~1<fi,1 ~ii"'P~; 'T 'UlII; :(He; iii-!!.i' (~,)~\:\Ii.C~~l.I,Jr t1::q"~;d. Old?;') 1 J\l..,....J)$J/!lj~' U:-;")(lU'_(~/, 1'1"1.. 1'(1 ~r;t lOtC ~I,.:.' I 1 . ,~;t'nal~~.j.~~~~..!...l_:,'~l.::."....______._._, ._,,__. 1..._.......i:)j.iL:.._ !_,_, '~_""_'_"_' _.._. _____ :au..\rt,\NrO,; I' \-, .,' 'PAm~t~I'~I\M:~ ,,-- ' ,''';:,~'';,-i'' ,....\ :.'::~:I , . )[:,iW Lr:8rjIJLCH, CHild H. J. : ~ " ", " _I' 1 . "\/:...'.':'.:;'i.. "il.\;;CCUHi. 'TiC-::;: ;PiO\iiT.'Cli:nr.!TI"'.J!AG1:. NO. ; ,.::- _ .' ',}i)"i,i;',:, '1 lm 99 - ~" j., o,~, 12 6/9tl . 2 '\ ( I l;lii~~ji:;::i:' ~;IE1."T;aOO"~fO-::N(:I.pTI:Gii;\gGrc.', ,: P'lr:~/C';-D. is , " ;' LU{.I);ILCI1I W,il(IRMl ';i::~\t:' i356.~orZ:~_~Oi;L~.2,\:.:.:~.9 70 "l ?n;t.4 l1~f~L 01 c,)upr h1.:!, .EllI~W!{fCOPDS7l/.,J~Il;t"ltlATr::"" ..:.;:),::,.. 'NAII,I.ESt. F.L ,"!l14,? '-H'!{:!"': "1H7456 J 0;'/11/9(> ,:,,,,~'lrl,,' 'I' '~rt/:"':.,'~" --3.~_..__~~ 'I ,... ,., ' ,1J"!;") ',' I 1\I';COU~;J';P , ."1:..\,1;,;',' ,~, ," I,' ~ ,,:~; l~r;.I, .j. :,i'\1 'I! "'~I\'~""i'll~ .~"" 1:/' 1'\ II !. i:&~ \i "l,k.,;:!!"' 1\" ,f',:'II' ',,' ',,,,.',,,~L 'I "'c ,; '''''l~l!iii.':I1",>..ji~~I~~~~Ul~m~~;II\t.l'"- "I':";,,w ,', "",. "'. '''~I~('Y'' !&7[: ~I\ ""'Jl1,~,"~r;"",..:I':l..,:J I!KI~ ';:t'1~~'\ 'r\"I:,Wtn\,l"';f{~.:,,)~~,h.dIrJrl~L"l. l'o,j"V ":.f~"i\"'li..ti'eij~1'/1..~r.'II"ji i ~ ,~ [';'::"1'1" "';" "'i". ".', 1',,1' "I'" " '. 11 1'1 ""1: I " , .1,jt \':1';' 'l' I" . ',.' . . . ,',.' .'.' :' ," , '. ,1 . ,j ,I" :. f/t~ . " . , ' :)\">j'l\' I,:.::':::,:, '.. ,.,':"': :"'. III " ~J,.,.I'~ "~,;:,:~,~:-..,, " ,< "I'.' '\2.' . ... " '\ . It'l . ....f11;Sj'~l::~~/.lj:,.~ ,',",:,' 'I i \'M'''1/~I\',''~' ""\,~",~",,"l,, ,!," \ 'r ,. . . a 1\'~~J'.'1<' [i:i:: ii' ""k~ ~i'~'~.~~i,,; Rh ~g,c,IH~ ~T:t.0 ~ I'::, f ii~i~~(~{;':;':: , I' :;~I,. ~Q::[.0..H^~I1f...CY,:,::' ;,:, '\:", I' I,~. (10 ?, ~'~qiit;'. ,:".: .~i'!l.' i?,Q~I:~\~\i+.~\I'tfll','SJflI'IUES;.! .' .),:, i ";"30.(10 :",~~<Jl&I),',!,:,~, 1.J4"i~14'$'~;~\:E}iS:B'1iEMV!'W':~I""" I...,."",' ". '.','r;1Q1.CIO .\ 'h.I'!I,,~;IP;" tj~t...,,:\.\:~,~~~t::~;,',~~.;,h\:.i':r i" '1' ",'J. '. ," ,'" \' \"j~ll~'~t::2'\':'1 I t ,.;1:\',..1"",....,'/.' ~."'i.",.,'1't\, ", "1' . ) ~~{ ~'~' ',\1,'. I ('~II~::r.;:'i'i';:'. :'i:<,'.. 'I':; '., . :'1' T,atAlS ~;2'u6. 00 ,?'"\,? if. ~. .ao\t: ' ~:..,jld;.'(,~:.' "'~j.,-,' I )'1",I'1~.' Q'r, l~'../:J'.','J~:'.~':' . p, \ I ,1,1 'I', l '1t!1l' '~i:" l,tlLl, "'';i'''''llt';I~"j' , ",'" '.', I i:.~~.,t~1""'1Il" T~\ \ ~"..., ~ ' " ' ., '. ';."; , '. 'JI"~ \~ !'~" I t.'ll }~'f' " ,", I .,t.. 11, o', ","" >il'",rl(.'11' , ol~LV',\:~~) , .: "I':, " -,"J" '[" ~ '-', . 11lt~, '1,\ ...' ',' l ~\\lJ:ii~"I\:'I"" 1\\1"'\'" I" 'l' ","..' ~t r,. '''~;':r,t'.,j"., \ ~~'''''I''''''' l', ',: "j ,,' ,.' '1' I, -.J I I "%}~~~j "Jr., j7J.j,SIl , J '~:N:. ~"': :.Z)'l', ':'~ .;:' I ; .~}~~~~!..'. n I,., . Il~,~<ltlll\":'(l' """;i,,'l"'j"":~' ,', 'I , , kt'f',('~,,~'it\\(~'I': , ,"'~'j:',," :::"'1". "1\":"\' '. j", - ,:' , , ; , "'1" ';~:~'l',\, I'. " ..,.,'.-I;'\,,~.I),I,.,~:,t... r., .'. \ ,'I ""~I~'r.l'~"l' , I ,( ,;.-. ',', ~.i. . -".1 ""l~ ~ 1',)\ I'.; '. ~ ,I \ ~ ,. ,{ / . A il 11~ it l('.,~ 2;, " \, lij""l'fh'l~j'J'll"'I"~ :!"'''''!/\('l'''~'~ l,' J'l ';.', , . ,'.,1.', : if"l" 1i~'i1l\1"ll:'~';~li4"ij 'I "'I"'J,;"r:1:~ -i'''.}rlJ')~';'''''''7 ,;"."..' ,'J" ~,,'\ "(' ,(11 ," (~.~'^.t\l~:J"~ "~I I ~,)'l~.;1 :'~',":',J,,\;!....l~'dil"':_'t>:;~ . "\'~'l:': r,'~\,t : ..'.'.... I.-'ll'" r1~'!.~':~ ~"~,""'1' :,; ," -':' ~"'P~:""\""~\'!"'i:';"1~/!I-:~'\.I.'" ,~\" .;::\.'.."'". ";\\'rl~n':.'.j'j..JV~'" i:\":'i.;:!~'\~"':" '.' ,,~k,,'.:.l'i ':!'l' ',ii))' ::l{ .'(.,;.; ,:,!','~.',t.~ '-:'.' t',l' . ':\'~;~:'!i~,"~ , ;':"'cl'\i.;~.r;l:.'ll"'l~'~\'~"'~I"'f,~~I"",;lf'l" ,1,/, '".,"'~'~ ',j'I..'"i:'t ~~"I"""'1 '\ . ',t..," ,",..,,:,~'\', '......,tl;' \' J "1,1, '~ .~.,,!.~ ',>,' .',..1. . ; ;:-l;i! lo.'.'. ' !'J II'~ II/I. ",,,;,.,.. ,11:;::);j'''''1Jl. ~I ~'I..tC'\~ \ r~,1' "~\'I(;:n~ t~1 " '.I,';1'1,r '" ,.\ijf,"in; :, 'l:'!~' ,~",(I;;;i.~ti'-1'~"'~;'f~jl;l-~~:, ".(,,".; I:~~;I(, ~:\.I'. ",' ~ 1:\I~.1.' . ~:..t::;;...~~,;' . '.' ~,...\" 'I :!~L~I, . ;:"~},1: ~:;:J,I;1 '~~J ,',' \,: .l, i JI, ',h.~;; ',j (I'~~:' I 't.. ,;: ' ~, : '~::1 ;~; 1~~ol?~~\~~\~I.\"" . " , '~.J' '''$i.'' p'J ", "I..." '01,1.,. ("" '1 " "',;f,', \~"'~-s. ' .. '. 'J' . ., . ,,~ (:;;;.; '. L' ",' \ " , ' I, I,. I . !' ) ," ", .,' ~. ",l" '1:" '.' ',' -: _ 1~';(."'~/.'iI,,. I:: .':,,(, ' ",,"'~,' ,,'''~I . :"",;'1';1 i.~\(~','1 " ,J....l(.,.,..'.'.')11'1~..\''-..'''.). , Ih:I''i''J''~ ""~ " 1 ~\.t:IJ"lt. :" 'l\,I.\}....t ;,:", .I:l"!~1l;'11. !~,\l, :J,\.;,'" '';''If:OM..,d~. I,,' I' :!-""'I~. ! 1.1'lll~rlj,. \'lo,,), ",,".., '"'''' . J.I,J~'J~" "j'.:I~ d"~)"~~"',.\I, ','.1.1' ll" 1','1' ,[fl>Jij.,.... , "" ',,, r~,. I". \t1ln'}"''''~'' ,);,I'.,,',:,J1.'-:'" ".'l,c\;:I\;'I"'I'~\ J')I. '. ?' l':'if. 'l:.Al~'~'r.'\..;:"': I 'I ";\ ""':;~'I~'::" "'''1:1~1~',;/~II,:'11,':lh..~ :.It::~\~I"\~I'.:,;" II .~! 1l@f!~~.~t.lrrll" 1 . I -';1 ',.'.Y.'J,~"~II;F",~", l:l.r':"'I"~'N>:'" .~L;.>,r~tl' il::\'.~ !"'~ !"',' ~f. ""\~'\'~'~:"I"r... :\01 , '," ,., ..".,~.,. "'~ 'f' "'\"" ~"";;';'~' #, ~ 'J" I. ',~ ..~.."II'\I;t",\.J.\,~,\III""-:.'.: /;/,1'1".):1,1"_,.',' ; J". l't. ~,"""'~' I'.' .' ")l,'.i!~.J. "'1l' ;'r,~/" "\1 ,;,,~,.; l' ";:,' I ""I' Ilt~~' ''-/,1 "'~."'II!-:j';J", 'l.:;t,; ')Jf'1';"I:ll1;' ~~J. .,,'~ ","1'1 r" '.... I '~:""IIP~}, ; , ,,1,,: !'i"<"('J~[("M~,1''1.::IJ,f'~1' "~~'~';'.t:':i :,} '.'1'(" 1(I'la~ ',' ;'j :h: ~f'+l'~:\'f:~:" I~.I, I "'.,",..'..O,.lll...'r..,I~~~"'....., '1'1 ,""" '__'v. "'~"i 'Jf:~.,") "',',,:1 ,',,' , ;If,,':.I''.''~f.~J~','f '!"1 l!:~ ,.11.,..t"'I~' J'\~,:' I ,) "II "t~.~.U~ .rt~)~""'l. 1,',' ':,""~"'~!'~'~';'. ~ 111'i "":':~':~l ~ ,;::..1,,1.;'1'..;11' ~'.. ',,~ "~f~,!~'~." '~fr:'" I" t:,}'I,..\r'jf."~+'i''.J\"i~/:l!(:ll:ilj , ,"",\;:. 'J;oI:~~'!'I"~'j,"~i"j1") \, ,.,~~ '..... ~ 1'f..1."i'~-':' ~ ;,; ; ',:' "II~,~I'''''l'i .;,-g ~~:";~I"'~ "11,' ,,:~'jl,' .)/~.;;.r'~'r"",' ;'11' itt~-.ffr..,," .:/, '1-,I......I,....;f,l.},Io'":,'.r.I.I~.'t'l 1\";-1'11'1' '~.'" ,&.J,,\ 1.1, 1,1 -;1 "~IH\"'1\~~1'~' " ,.~,~...:I..t'l/,~/'~~'l-1~,:) -j:,'"\I''f',./v:''I~,,"}'l~~''''' 1;'1'1> ~'I.:l''''1,.,41'''. , ',- \" ",/, I "rJ ~ I.. ~ , I . rr: 'I' t H J' .., r" 1 . .([: 1In,.::..~\:\:..::!tl".1; -,";i~ .:':,.,.'l'.r...."fr ~'~~I ,~~".~, I,~: " 1(., ,."',.,1,,,;'/ ,'ll,",,~' '. ".:, \",\"~" ",,~, "',',~l: II} \ l,,...~~, ',t \/'I>.j ': IJ," , " ~''1 I ,,1\ I '..\:. ,'/ .1)1 ,.. ., '11 ,II' I' ,I:,. ....',1) .1 u,'" " ;; 'l,t 11. ,..11. "j ,.' ,,", ','f" ~ :... -'" I I (' 'Ij. , 1 . J' .' ~ '" ',I'A' ' . ,1 '.' ", f ~ I'"~ 1 " if ,:'~: '.'. 'ti" <tl'~~'U~~:!~~:, ,~'~', "; .~~ ~ :r~::\I' "J ?11:.: ~:~:'f~;:';.', # J~~' l~~',/1~;}~~/i~~~:: I,.' I ,.; \:1' 'j ','., "I '..1 ~ : , '" " , . ~:'li"I'" ; , . \, '. ri1\ , 'I I ' " ~ '\,,' . .... I ~ ' l ',' ,~.", r . '. "1 ." '~,. .,.' ..'"... \ '." \ , ,'I~ I' \1 ,I, . ,1"", " ',,, II" ..1,..,,'" " .' ,,' r. " . \ III, " ') I.,' J~,,;,.'i'.<,')',:,,'.,::4/i :,1, ,'.'~;~lll :, ~ :~r'~~~:j(~' I,,: :~,,~,' " ;';",' 't ,,'-~l:: """[1"" '7.',t ...... I .I., ,~l' .1.'" \ '{.I~~~I , 1 \" "j\ ,. ',' :1.':1 I ).", '\1'" ~'" l lo;l,(\~ ~ ~,' I' ~I ,f\ '." ~~,'~';I:'(:' 1:i1.,fl\" " ~\I",' ,'~I.(, ,~," I ."".'1ft;' f~!":' ;"11'''\',1,' ".,i~f "'\"':i'f.1,~:!J.',.;.t~/11 \ i'~ ~.lt-.:,\ "f" ",~.I 1 I 'lit, U (,~~~, ' l ,'q .~, ,\ I ",' 'r!.~"l', ';,'.....;..1 :,I"'1f,';"l;:'J ' .' .~.~~'r'.:-'l""_'~~ (II: . " I '1, .1\;1 ',',1", ~:' ,,'~\", \ '..,;:'.~ :":. "I~.I,'~I';"~'~'l~,I. ' \jl~::,..,'" ("Il~>,' , " /,,' .', ..<J '", I, " I', I I' ""~" 'I ( , " ,l.~ (' ,...., , ' I I,: ,I",~a:\ .,-(.:,]1""",1 ," 'II'; ."1'.1'," .,'(II?~'i.l'\:' : ,', .' 'f',\" ",~ ,~. , :' 1,) :", 4 ,'. j,.~" "...t'll ,,'" I,.", \...~ \ \ '" \", (, r .,1",' 4".. '." : I."~. ,I " , , . I 'j I', .,J'('!l'(I"i';Jjl",~~:I,~I'.: "1' ,:'.1~1'I'\ '.....,'{\ ..~ t,~l\""" I I t I" '1'~d."l" l,":~"~" '....',' .. 'J ~I"",,'.~~.~~.l'"(" ,\;,,! ,'''.;~. :" ,"",. /,' ';J-"I'~<\'~'{i(,'~I..~h;~)I,;,:." , '1" ',\,lil.ac,:\,:'I.\~L~'';'" ." (. l' ',. "1:ir&:')-~~ ~ -....-' '..'.. ., . '''is ~..l.."1.O,' ~..Jo.oo...:o:~_,~, , If.r.11e:s.'R;N' '" ~i f\~'bo;'r..~t':,:t.;;.:t1:r~~;.l$,i,~~<J; ACitUU)N:1l,AJ '.t'1(~"~";~~. 1i"~lIlmiil;;..u-.o'UP:_"""u.-'''H .._...~~,,""1 l''!'r"'rr.__.................._..___ ____ , ,.,.J:~..;...._. '~'1,~i.t:;;tx DETAIL STt\.t2M~NT 'Iii ./ \ H . -~- '";'.._,.....~_.~-:7i~ 1\n ''1;'r 'l;ldl , .' " , , ".'. I". J .. . #1.." , , ""'iI' ,\ ','''.-' 'i ,. o .' ;,'( \ I'" '" , . :~ ,'j , . r~~ l ,.); , t,\',', \1"1' \"/' ,/\'I':'l .':1.... 'f, :-f,': ,.~ ,'~, '.t'IJ,,: , ",'..., ! ..1.,1' , I:ii'l/l\, 1:;;'1 :t, "'I' I 't',~. , .~ . I , ,"(i,.jo, , }:/: ~ ~ . ."',,1:" , 1,:'\ ~"" '/,'.:...1 .'Vl{ I' :<11,::: ' 1,,1. \, ,~ 1," ';'1 , .z,'.1 !)~~. I~I~ ,..."; , ': 1 , ., ".J, " .'oJ ." I " , 1 '. I'," , '.' " " " I I', '.' ;. fi f .< " , i1 " ,. , " :. ~' ,'. ,'. i' " ',' " ':, 1\ ..,.j ...~ , .,,! " " 'I :~9 ; , ,"J1, " ';1 ..' I., " .. I' , " ,.,;1 / "{'" \' 'I' ,. " .\ ~t, () 1 I" . ,'p -,: ? ~ 'I,': ~ I .... ).11 '; 1.:..'1'1 ; j.~ ~, , ';/" > t .~ " " " .f , '. ," .. ( , ,e ,. I)!\ '.:; ;~~j .., '" '-t',: :'.:i ,'l! " 1 'I I 111 ,............... ",...-.., -,.,. .....-, .........., '1" . ,....... "..-...",-. ... ...,.....:' "-'~'''f''- ,., ,.. , .. ~...., '.", ,,'" ""'1"'11'1"' ,. ":"'ao~~,~,-:l'";-:"'''~'':'''''''''''''.'~J''~;:.:-''' " .' ~ I,:;" " , " .- " ,",." i::!;~"6 " ilr.v>lo" :"() C:J:< :11)40 ',',,'. Ii. THi3 I A UaUR~~N~Ar!IL 607.,. ~ ')f!A I ;t.1 "; ',. "'," , 'I"" I "'f" I""U" \'Ie'" CI "'I "'0""1 ... .. .""L ~;..,~,~ ~ /'\1/-,...,...,.,/'4 -l::il" 11"1':1 n,li c.:. "MId r' M.' ~.....,.:!' ,.r 't ~ , ..~...,......,........~.tl17 __~_"'"""""'____'''','_____,_,_'''''''__'''__ . _'__' '..' !i't":::t:;'JA;\t'; ..r,:"I":,.i,J ",1I,.I.l,'lj." ,'~/" ~"J~J)'II/'1 , t,~ "'I"ll'" ,', I' , ~1.f (. ",',''\,1.!,.. I,ll,. I~ '. 1,'./I'tvl i.\.I'I,'" !\ ~~.au.lI(-,)r.lJ.l...'futJ"f""~S.lJ('H"'V'Is:.ihl O"'A/t;o ni~'I"'H('(}I ,!,,]'l:t r~lrrt'J O~b~G . ~I ,~."', ~~~r~~~~t~~'~';:;"'~;:'1l~" ----)j.l.~~m1~1Mii1j",:~, I 'I.... h.l.''-''''l ''''~~:'':I-' -1,~~il(:\~1:;;;;;;';"".I~il;';;-\i:.ii 7;.:;;;----....-'..., '.1':':' , U\..l 01" 'II . II~'{ .1',; ...~;- ~ 0\ IL.C l~!_ ..~; H ~~} ~I:~__...,_. ___._~ ...!~j~'.!~}4.. ...~.':::~ "~~.~,~::olJ..., ~....s..,:,~:.,..,.I~,:c',....,.. ~....,.,'."~....,,"~.,..,....:.,..'4:,.,',~:.,.,.,....~~...," ._~ ~~ '. ,._.~_ _ ~.:.."./ ,. !,/'-\i't'.'l:'] ~.'::;/~!;j',~iJ" l!II'I'! "". " /1 f'M'~/" {1,;t.l,t:''''''i"I:,'''I, ': ~. . ~ ... I ~ W,;:~'1I4MfiljR.~Q.liii1.--i_..:. _".".,,__~' D";":,,::,P'~':'.i',~!. ..'~::Q.. _~(jLLi!iBEtJ_-~.9.Y!}_.._..~"._._..~i'ot '''', ;-ci,: .,' 11'" 'i' 1',I"o..Ia~l"'\11 -.-; , .14,:. 10 '1.:, 1.~~PU:'5 ~: .. _;;'':'':';.:..__"__.!:.~' .',..".rJ '''c'''[J ,),~,'[j /0.PL.,Ei,,_____.lh_________. f'L __ ~ i~.: [..,~~.~~; " .,'..: f ~"" '~~O,t'.)'N,'^.:. ~','" :~....""CJ ;" I',,, /"1 ' ",/; 'j:" :1";,,,,\ '. '.' 'f!l('1~1"~';rA::'~~r~~~,~l:;~:~,.' '; ~" ,~; ,q.9~41,:----:::_L~ ~.iy, 2!!J.:i!_"J.~_ ,._.____,=il'j~~'_,..'._', ,,~,~l,;L .~?!l1.;;..:::~_.:..'.:_;_..:._~,__,.~'!....:~,__........:~:~ ~\' '~~,~ ' ,1 Ul,IIIi:I~1o'l1:vnf '1'11 ~t! (t.-"l '!t~'o.. ,-,,'11 rlMI"" ~l.'''~ 'i I' ,\) " \ ~ I~ ':^JI'i/1 !':' ~ lJIIC n CI' I II ..1' ''!!:. f(J: l!, (I~ llJj~~.:.' '. "01.:(;'-~~.i"(jll" ~).. <';'1:,\ !.',",\".i. ~ , , ttt" i'li:"'.:i:!&"')( ....,.:..,,,:.-., /'}")h,1 [I 1101)"'//"1',1, ,.. ",::.' .'., , $.' ~.~, " "!"'" , .~ ~ I /,' ...', " .' ,.,.. ~'\" '~"'---""._'---- _. ~ -< -' , , ~'1'~-'~'~'-'--------W~"""""'----"-'W"--~-4"""'._""'~ ..., '~'l, ~ a; omal\!m't.'ll.C. II ';\.IiC\' 01"1 (, l...'I",- NrJ\'!.I'~f\ .. [:\:f>1.o'<~llftll p,I'm~lr t,1 " 1l!.~lr'U~I. "I~:lJ:;\.t.. ,,~n~...,. I)'c,r,( t .F ~ ~""""'.~"":'''i''''''~',J:.--.", "."..,' :" '~"'. '.,' 'O'rnl '[',:J',( ., ", Y\I .r.\!. :'('1 '.' 0 ,...,' '4; 1:,~l\":'\~J'.;...t~/::'\~:,)II" . ",,'. ., II ,': , :' ':.<.', I-.t..- r~_J ::r ~""~ti ~_Ol}~~tJjW,"D.\Tilorr;i7j:--I::'< -.. ~ ~lf1b ~(;CIO!;~fI 'LH'Tj lj'",..r :.. ,.'i.'ii~~;t;/:ij:tii:..r"" ljG~~-ii;P::-.---;' .._-, .....~. ,9: ~~\ll.(~~)f:f;J~.df,y'(".,.:,fI'.' Ill-In ',,' ,lIIi""-l' "','::'j:'}Yu.l. 1;)',"( ',,'I" '. , I' _,...." .. , "'~' ~, ~.y'j;'~.:, r.~,;:-f~.. j,I..~:.':"":,-,: .....:.........,_..:.:.:..~...~_,_ ,','" \~', ,1 l.3 '--..:'J.. '.:.:~__,~-:.......:~_____._..~_.~_.;.:_;..,..... , "1\ "jM"'0t~'1 ~N'('!. CH SI.;~QOt. '.~....a. ' " Q'HUI,\}.(;CI(.l!:IU1 I J I, I, ~ t,'Hun,Vj'~.:! ~'lAn ItA),"_ C~l Nt~(Illfl,f '1M/.;: . _. " I' ;z:'f" r r'<"~ " l' ' J' I .. - I ' .! " . , ,. , ' . f , ' ,. . ,. .' "" , " , " 1.l" ~ ~":J\~'~' "'",' J.' .\' '," .' ( '. '!' 'OY!!')' 'r,)'I' ,..I.", . . ." ", ''', '.' . ..~. ~ .~ i'r':1~:-B'.I.,t.', .'11'$ I:, _..<~~_ _...-:.._ .;",' :._ 1_~:'S':!..: ~,.:.:::...;..:.:.;. ,..:...'..~_..:.""':-.:.'~_..~.~__~ .! \:::":':':'..,!i1~ ~J :..t4W~!il'\,"'~NAW6C-1~ ~r,':-,I~'II,Noal. j I'J-j, ~1;.:li:n\U(lI~I' '.;X:~. uc.~ " 1 1 JIlI'\(itl~ .',onlfll)ltl,"J. TH 1\1.'I(l~IT ,".,\/l? " .' r", n..~ if"I'~i,','~~'3'lh.,~:....',,, ". '''', .;, """,' ., ,,"',; '0" r'rl " . ',":, .,:,.:..~" I'~: ~"'1\~tl"1\,,:.;t,,'11$~...~.t~ ''"', ..0":.'. "I P~:,,\'i"I' I' " ,LI'" '. f(S UWj"t~ "~1I",I~I"'"h.'\It<;V"11~i\<<~"If~,., " '1"'1 ".,,~~~..:.:..:.-.--.:..~.~,--"-.......-.-~ ---.:(\, ----...~--'I~l''-LJ~..'..... -._-...........:..._~..._--_.. -......:. ." I ';:, \ . ~, '::U"'7l:'~'r" ','~t,~r.1( {ltI,JOttlltltlunmt. t,\I"',\v.'1':'~"" ~ "ltlMIHQ OI;f}f,5iW. ,f ~ ' '. 1,I,JJ.:;M.'I'ttIi ':Q.'lMmi(t1l,"4C ,1t:W..ch'~l !'JtGNMIi3iilMena ", .h 1 \~. ,t}.~;r ',ll~""ncNftll ~OPVf-.:.l,.""~ ~....nJRIi, ~,I' -'T'. ", loI......W.<<:lt'y r:WCo'w "f ("~ rh1"\I i ,i~~ " p.r.1",,,,,'1 .r....:,.-:IIe,.r<9't\t 1J 'I'WJ 1'/-ry,,'l\'n'JIt "JY'-<~t'" ....~ ~:.1. S', \ . '.1,1' ~"'~~'=Jf 't\j""I_~~l~"'l'lf~M"'~lfi"""'1""'tl3I1f~~'UNf1"lY"''{I,1Il'~'1I''h' "....lI'f ','. W..........fI>....(~'\:t\,~l:...... : . (.,), ,'r'll l:f" l~?'~iSLi#AidW{o~~~rLE'~;<' ',:,L:,:":"!"" ,';, ..>:.i); SfGN'ATURE 'ci'~i FIl.E.' ',,,,i,',: "';J<'Z f~:r ~.~?'I'~~\" ~~S;'ii'.'~i:~~~:_ ..~~.~.!~.:~;t'~ _' .. ",~.: ,"~~~/,QJ~~,,'~~L2!~; ,~1~~ -.:..m~ ,r~.;. '..~ ..~~~~~_ .' .~,~~:~,~: '~~:' -1 ~'\)" ',P~;~OF CMYlr...m'''~'lLN'' '1 Fot'lt H'n~(',l".Cf1 1/':3 II' PAf1!fH1' ~~!ltlIAOll"'Vf ()4! :.IN,l,J.I.''i/:.,w lit CMM tl,\-:,liNr lJHJlk1 T';- Vlelll". III ',L':I,I~)IT O":c:t;""~I'J~ l ,_j,!, ~t'~l t"tl.4if.t(O ll''f't' "1: l~n'h.i^-.v1uH(h'1 OI'f1F.tn~P^l"l!-,llil\4" lOI~,' '" .1 'i" '~M" jl() ,',...yf....' MIA I t::" ,'( , l~;'+~'" ;ij",q, '1',...., ~'IS},'~~,.',:~;:, MPl1hN"~.,(\,'jp,,," \ '/1) "t,'.,,.I,'tl "i ,I ,:'~"i.j Fn<m',' ;,.;,'.... 'r';l ,.: ;...~',. ',~'1 ,r/,..,;ij-k (E~M11if~ 1~~:JIC(..\'iOifOiijii\i:i;':il" ~ 1~\'I'.;:;;:;;-~q;mli1!li .i\i;;i"i1:;;'~ i, rti~,,~ 141 HI l!lri1::;'L:'~~\N-:H~iW' ,'i'f~rS""fOC'ViiRT:i'i'ii%,::c;~li 1 '1" I ":"""E'11.f1MI'I'f'",,,,~,"I.'\"" "~,...\, -", ' .',' ""1' 1.J/l "co. tv" , ;"... 0' I' ~,"., ,oj" RA'c;ili'.'CA5PERE'" .', " " I - I~' ~l "1 ".,.'" ,{Of _' ,''11'' !~f/~ _ , '..'l",i - !Ijl. , I. ".' j ~,\, . " ,f"" ":'101.( L' " , :1;'1 . " . '0 I : ". '.; it' -- - ----.. ...--..-,~ - -""'.-':-1- --.'-'"-. _--ri.. ---- . _... 11, t' lJ 1" A':~VU1(C;\~CC","V~ "'",( .~" """ I" r J' ,',', ~c ovp~<l:.A9r', ~~:' 1'C)1"1Ul!~"., I'r'''' '::": 'j'"' 1:'f.A;.!""..~;o,r:;,,;\';Iijlt,!J:;,:'~~"'," ~'i:.l.'.:,J "l,. <'. ' ,,'I' ,',,' """'ii' "',' ,'.", )"I....~.\,. ,Ii'~ ..~ f/'~!t.~:,~{=- 'i}.: r'\":"'I:"1'o "'. " . ~:' ,J .....' 1 ' "). ;1' ...., I "'If. \ ',' "I "'I':"! I, . 'O'tEiS r:litO" f " , , :" !,',... L':.:(~;'~',,!:.. ':I',"\I~~. .' ~ 1.~RV'.'j""""".""""''''~t ",", I" ,. r'I"" ,,,, ,I .~j " , W",. ,'I' ~~""" 'i" ,! '9 ;1,tlIADI~O.l\.t<<.1Vft2-~G:'J(...,lC,if~lL!(lY, (~:..\Ti"t-rt:'.l" I tJ ~n" '()'i1!Nli~lin:~~;[t":~:11J' . ?'J 1,':'o;~"rWWE'a!i,..:.,}1~ '~. ,. ll' "'.(\;\:1 t: '~~I j ,.~. ' (, J"lJ!!l~'; \,"/, ~~~i'l.;','^'" :........t;;~'(,,).. . '-',) ....h. , I:;'","':'" .C(.:(.1) - , ,:'l, "J:'~rl';~O~l.:lI!ol-'lN~jl.NO "\'1,o'p.-') f:1: '...._ ~~' '},',,: "0':','." ':,Or'EN 14DUNO ",ARM '''V. ":" ....',.,:'" , ,,', "'" J\. . ,,' ".:", .'; ",', :. "", I"~', "", 'Ii\ ' 1 <'--'l ;r._,t.'~' I~. ' .' ~ ,..' . I' '" l"....;_,...., " , ',_ ,~, I __"__,__I~_,______ . ., 1..e.:t.,.i.}....~'1H;).(I~;J.'" fl'i-\~'~l - ,\ '.....1\"'.\" ' ".':"" nPIlICR^'.J":"!'09'ZAT;(;;fMJloIiH:'1 ",' J""""",,'~'~ '_i~.} 1tJ;\:\'~~{''''~~\:,~'.;':''.t"l'' "/!;',i,h,:~; .. '-',",~ ';"":;"~"':":" '''!':'t'';~ ,'t"',.... l.~r'~':;~.j.".~~I, ." ';':'''''j:,/~I....,,~.,~~,... ;;j.7,:,"i ;~,.:"/Qf'EN ,;OUf'!,O' fl FIN.-'l~;!c::~'-'"'h' 'I.,'....',:,;,: ~:..._';_....J,"',.,~,'.,I, ',J,J.";;,.,I~-:<"rl~g,, :B~~ 1. 'h'fI,,\ ,~"!..,",,,. _~ ~-i '0. 1.......~~~:.-.:.~.-':,,_..!l-L'~' f ::.::.-~...-:...:... 1]' )L, I J ""'r' ~ ,; .1''/ ft.}, 1R~~ i...-.. r.'''AU~~Of'~'A'1X;! '.' :~ ~.t(" ,11'''1' rv.ocn,'\1,\C1h'Vl'_lCfAtJf\litif'rt.tH t~'>I,,~jI3"'~' '" ."'PA~!:W.cl. I .' i1rrtn~'Mo'~CoR" ~' ~,,; '." Ft-:m, "or, l,' .i.TO' ..'. 'frI~,~'11 I "il\"I.JI'~'C/C"",~fl""~lI/" '1/' '1-,.1, . ,:..~ ~ (n I'lm''1 ,," ~', "~ ~~;"."I1t"""C'':)'''''(l 'Ai:"',,!>> ''('r''!;.f''''''''''''j'.l :Frc'I;I'I'~ I ',IJOOr~lan, ,1\, 11.i00..~).} ..~CI'Ml,lr:~, '\ Ilf'ifTh l'lit' t!S"") COR ,,~iJ',lA~IJ(l'lh~',. ~ r, m--- ~ ..,........ . _._~ "-"~'~'~'''' -.,..... - - . _h ". __._(,0; :i' '~, ",' ",':i,.'jJ. '~-:-" ,."1: ,'!I"",~ I' .' # . :"", ;I~ . "1.''';.1 '( '. '.., I~' ,,<, 4 ,',' 'j' I'>, '()" "'6 fL.;L'. 'LI/;?, , ,M ;'0'"'' 1" 9 Q"P,'''j'' ". ,:,. -..,,'" . 'I' 1-" ",",''''. "66' '00.' '~'t ,',' , 4?6 0"., 1 ',., _'I I, - g Q ...0, '1 n ' ,....(, '1',., . ,~Il, "....~. './ I'" .... '4 ~,. ~.:<' ,QE"'t/f~I'S P"RFORMt' "S l"f;"- -~""-"r" ,:' :,~~.;: ;-::"i:,-:":r.;)' ~'-,---:' .' -:-:-';"- '-~. --:'._"""'- ii' 'r~:'. "I~' .'~" T:'",."N,., " ,~" : f: '1(.:'.'" 'I"I!, '", E~ " ,'.~ ,{ '" ", ;, /.: ~, ,. ,:,.: "I(~.\ '.".. .,.1.,.,.,"",.".,1,\.(, ...i"'j'" "EFlAlJh /GA~If>ER' ".,<"\'1':. ::'''.: ',"', ",,"1 "T""'~ ::...t:,;,- ,'~ 4 '~"'. ~,.~" : .- '-' ~ '.t ,:" ~':7'_."'la_........1~~"~7f-"" '" ..~+-- ' .' ~\. ~t ,': '--ii" ~ .,~/!I," '~~.:" '1,.. ,l'r"""':'l'J,,"I". :~I'i'L"" "J'"., ,~~.,..,.",T..{,lili' i;/' :..: ~ ~t,~ l"'~ t..:(tri~" : ,'.~~ :'.lr . 1 'J ,( ':1.;, /:: ,':' '; ~ ~:IJ; 11, " 'I', ;lJ'~" ;"1' ,,' . :" ~ /:' . , ':~>~. ,;; ", 'I;! rt~ o!:[":r -'~', .' _.lL1 '.,'. ", ..l...--_~__~r. '1" .;:.:;_r.._'.,_~.1 ~~.....!.,;..;.:, "',""'. .. ." "';; ..i'~'J ",'" ','1," ....., ",.... .','" :"lq "',,, ,n,.r;,' "" .' ..,'...., ,~,: . /"''''''1'' ."~r\ I "rl~"",,, ,...'....d'j.I".:..I,~' ."lA' "'1 ,..1 I" I, ' " :"'~'I"''''''o;.w.' ..... ". "," . ,~, f , ,I "" i' 'LEo" ,j '"'.''',',''' ',', ~ ;; ,', "'.,' 'I' -' "1; I, 4"""~ . I'~" ~.., ,;~~ I',,,,.. ~t.. . I "I . ',\. . "', ",I; .1,,' 1 ,>~.'" 1"'1:" '''. ,1. "1" , ,,/1 " . 1 ''',' ;1' ~'t' t IT.., .-....' ,-, '" .' :..-~ ....J......:.:...:......,.j.:.:.:-::..__,',_~ -'---:'-.:...1.. '" ".t,~ II ~~:".. , ':, ....i.'.";,':, .':"'1' I," "';(:'\";'I"~"""';j'l' ':;\'~"~." . ,.' i "':]"'":8-;''' I"";;" .""",,' .~ ' I '~'I '~i',~ I ,.,' "'" '~' ,,'11' 'tl....' "",',' "',,' . ," I'. '.", . ';." '~t"J~~~'~L...:!J '/L:', '.<~ ~."~'~,..... ~.,~,.t1.>.:;-:"::?:\"~I\'" I';',I;:,;',\,; .'.',; ,'"\,,,,::,~,:"l,;" h' '..,.!~ :,1 .. ~ - " __~ "'_~"'" ___.___... ~ ..._ ____..-.1 .Qj ~'~', ,. , ',~'" ','1' :'." J' '11'1'1," ,', -J(, .'1(",.t1.,:;I)i./I!:f~,.:. 'II ~~l-!ii~"'l' ~ -:.. "'1': t',/.,' ~ " t U' !;.,' ''': "I:'II:! :",-:'~'I'" ,~.,",l &I""\'~~'t.l J'~: ~'" If 1"11' ",,',) ',J.. '\ ' " '. _.{: \' ~"~~~. : , <' G"""'~ "'~':' " ,'I ..'~".,))'".' l',;,'/,:,"i .',:' '~~~~I'r. ','l. I. ,l, " I "",' ,1 ?I)I~ . ~~.:w. Y).;o: I:' ....;""~!It ~.:.t.o,j tiN t' ':!11 ::o';\f'iriii'S '1:~Ol.,n: ~jo.r7Lv~cH r;r,llt ti~MI f;'/ :i TQ~ 41. C.<4J..iOR' Err'" ;.!. i;;c');;l';: .... - !:;i;'nN.1,;;-tff.l.~, . '~l .~/', .'...... .. ~ .', ~!, . "'1'-!, ," ,'. ,.,'i',!: h\~','~'.' ~'1I~"'rr!lllt!.I"t;.~. ~ '.,:,,' . 1 " T1,.t '.':' U,,~:/~,3% J'" 5.1Jli-0002-.5Se3WH1,U!;'''!'C'II,e''.:11i1 .'" .,,';'66'&'01, c",; NONE' I. 6001) : ,')t ~ t > '''' ,~~~J1:'~,Cf~\lCWiOtl Jl :>~'tj,I'b~.. : "IfJ';-,-w.i'lJ ".4~r;pMjI!j>i eiTjMl'.);'~j~'liii'\1:'A(11~1' ~;r~'~il.'e' ..., ~-m:'-riC~i7i: 'tlP,"L..rif,:'91iri.iN~,'i\l,i!l Ao(r;;fiT~j~~71r. "r,;1 .1' 1'.;....1...."'" ~,(I"'"l1..O;tcnEot'J(t'~ ,~, w ..'~'.n!llff)l'lllltl"'\!:.fI\M'l\II~/I;:l'''fl I ,iJ ~,~'C.llf' ,I:." ~,,'I"", ' :1 . \' i ,'1 ,'~'''''I'''''.'_''''''''''''., ,~". '. C^'L l~lE 'LIOSF.'! T'I- ; "..~," -MER'"""N'"V "~'I~I"IA"S .",' I, ....r . "V/Id,"\tIl...:1I:4tm/'l""".9tl,,. ~N"i1~ .. I fl'" 0,./ ,r f"l...", fl... Co V...;o r'. ~ .. I~' II ,I !;"I~ ,~., '.'~' .:........,:. ' .'~',2'16 PARKE'R':;StREEj',':',' ; i I'! 8Rq'd.K~O'oD A'IE'I'):O SUliE"3~, ., t~ lp,~S~,ERE,Ce:RAG.l! .Hq;;)~;iFML 13L~::,PA'r::1idl<f,/. ',.f 'C'i~~.15t.:.E;f":~ t 70 t;: . 1.: ,~, ~:""! l;jji~50~07'124r96' o~ft..~,;',\r':~IQi;':;I)020"I~'::'~~J:l;',,"', '~GJ;~:~,:q'" :,:,,', 1111'Iii 426e.9.r{~:;'':;' ! '1Ijrt2.j22S:]j7Q :~.. :.,..,,' 'h " ,,~,.. ,,', ..,' '~"'.'''{V'.' , .".(,.,'.",..,..:,,', ,;""{"'!""""!':':"""'; '"d",'"r'~'~~'I~''',-~'''''''\rf~~~~'':''-;-..'''-;-:;''''' .~....,/il:" ~': "",...,l:-~':~rtl. ':'Jr;~~ft,.;~.;f "1i()1eJ,t1~1\':1i,,,,:,,.,...\;:'~~,~:t).'(;:.\.:IPJ:FA,rj#.,"pRN"ni'I' ;1'j'~Ei'~':'.' . ";'.\:"'" ::t'~.l",~~:.'j~.'~f~: P~"I'I ":',~I:~ ;\':;1 ",' '''nil 'IPI~'!P.'Io' 'I!"~; .(li~M,',u.i~~tt.l~'~..i;'., ~1",~,',~'~~',~'~.:h::',""~;".:~OJ~~04,f) ,;'.c". L)4,jjII't'':U1,o',w ~~,foi,,1'.I,','A~0l.1' .,,'.L,'~". "".",,j,,\ '," .' ....... ,. "... _ . _ .. .. ~,. ' -;,r.:t.... n":t:'f)'i':A"'1''''1l.,~-?',)n1' 1,"" ,;"~.,'~ ,~,_.. ,~,.,-" i-' .......'1-.....,' .' ,., ..'.......4 .J........tl, If 1\ '" ,;,.; ,,,,,"' ~,.I~ \11':,',<11" ,"I . ,I,' .' : ';' ',r,,~. ~,,"1,..~I' ,~"I'~"'U," . I~'. JI'.,I' :,'.\,) , ".' '. :.l,....'~":l....: ,1. ,: " I- , , 1'~i:..Jl,I. '~'...: ~ .,~.I':';; I 1''1; ,,', '1~.~~Ji.,.'5,' '~~~"" Ml!'.""~~"';'-'''. ," ."M M"'_'''']' '1"1"'" '1,1"'.:' ;1' ," ..... .....,...,,,,, .. .,....... ....,. 'j"'. ,,,,....,.. .,..,....;..:.~:,;;::;::::'.:-.: ::: ...........'.'1,;:;. ".1" "\ ""'k"j'I"l"; "", . /1"'" 1\""\""1""""" ,',...."1." ","", , 1/: \~,~~~'.j'~'~H!f,;'l'~' ,;l;ii",'",~.I~;J.L; ;t'~'.~',:":,:'~i ~ .", r :.;, l;~!;II'\:;,I! t I ~1:111:'ll : ~l:f, !,: :jl ;'{.'I,\':f':' >'~i ,(i',',,; .1;.; ",;'1"~ I '; I . ,I' ':\, ;, ~'::',(, ,:''-;, i , .'''.....1.,..; ~" ...,'.1 .. .^'" ....,:r. 1;"""1' " ,.'" I . ,"",'.11: I", I' 1 '/ " , , '. "",,1, 1'1' " "'j" , ., ,'.'. . , , -Nt:"':" ..,,^.C1 ,~,l;oO"...~.. .._~..~_ .." --,.--.".. 'M"""""'" .... ""- "'.. r,..iO.. ._~..... .. ...... .., ."........ .... .." ....".." ....-. !~;.\.~~.?~~~1:'~1::~i~'.r~r:;~;~'i';J,i~/l~~~~j ~\.'fu~~I'r';1']~i.~~ ~~~l;~I:IHI'~I'Jrl:li:U iJI;' :;1 "I~l:~ij)J.' ,;1 i~l;,i . ~~1' il\l';;i'!';.; ;',!;r:.T-: ::;'i::';"..:-.':' -~.-........; ,.' :'>, ...~.;.~~.,1 !if~ltLi:l ~ ',. t{~ r.~~tl~i'~I!,~~;i;"l~~' ~;i~~(,k:'t'.J I: ~t 'jl"l: I : If "l.(!:"11 ~!;'~ ;'1/.1; \"''ii~I']~~r, ')~:"'~'jt~'1 'I,T~',::; ':." /:; .i/.1~6.. "',.' I J ,. '~:;.'l"ll~. ,'li.l ~~'j~, . ~ '.' ."I},\ 'i\")'.IItI)o"':"I;,'j~i ...,"l~,;:J.. 'V,I'.'I! '! I' ." J1'. ,:" \'l'~.ll."".l ','l:III;1'1';~f;<',j,j'''.1 \"""'.'. '. ..;. 'ii' t"";'.'';;';~. '~"'..'~" 1 I i1;1;'~~f" ':~I' .>'.. \~l't,1 ~>l'i'~"'~liU~l'V' 71!11..:' l1i"djjl'. ,,' :' ". 1'''1 .", I :.,' :I:.:'~ ,,.'. .t'll'~l\'!\'I,,,':h,.i)'. )'1' '. I''')' 'c :.\ ,.;;.:.\.'..,. ". :'.:' " 'I:r,'~!,," "1\" a ' 1~ I\\':,;:ii~~'i~'!' ~i~'l~lil~~" .j, ,d'II~'1 "'11". i\ ,,t..(/ Y !lllW<';"i~:,:'<'h"~~'o(i:::\'"" :,';.' ",.[ . : 1,jjilj'.~__lllllililjl!'i'il:I~~~il,rl(IHitiil~~fr4 ~.;.;il!~;':; IY~l1n:J'{~hr~hi,t'~ )It':~H,,,''''i\l':~}.:~I~'''i(:~~i~: ':;;:', ',.fl'_"I~:'I:dl";,:, :(:'~!ill':;'I,,",{il' Q'I'O~'I',,;~'O' '\':':?"';~"I;"j~':"\~:'~J./:'! I:, :<:',."', ...,: ':; .,' : 1"'~:'''''I''''''''r'''''''''(''',i:''',''''''''''''''';'' .'." , ..........,,',I';"...{..l;'.~:.:..,....'~'f,.' l'{ ')'.1 I' 'I.) t','j' .1, ,,"','.."'" " :,1;,r."':'~';''::P{li111fl'\~''.K:Jr"j~~ ~~:: (,,~';'I,!,i:~'~"!";,':/".:;'rii,l":'i,;,'i.,\i :'I!"I i j '. "~~ ".I.'.~;'i ;:,,~,.'.'I';' "'\j'::,'"-:j j', ':;'! C':":~'" ,: "AI","','::I.I"ll.,l,'d~:"l::~\r(""';f" ;"",).,,;.1,(:;::, :-,;'.'" "l"t "I:!I '1""I"""l':;"I~::'1),:,:-"J":';';":~';I,:!.,~;.;. I ',i..,:~~f I";,':..'" :,,-"';',';,i':~!,I:':ll',~ :; . :~, :":"',:" : . .,:t~: I:, J : .,trt::lll'l)' :..' ,l I ": ':' : i ,~:, ..~,: ~, 1 ~ '" ;;',;,'y "i ~ ",:,.: ~' ::;" :'1 ,I ,I "I "1":';1'''' ;: !;':: f','" 1 ,~' ,; ,::.1 11.\ " : ~.} i, 1'.- " ;. i, ,\:' :'Ilj.' ':: . "'" ',,' ;.,.' .,' il.J.'~"'jI.lr'~;lill;IIIII'ji~li!l.f~.;'~~ii~lfiR{iji,j ~~;. :!;l "',,.. ,.-<!-t'" ", "',' ,-:-,,~""--:--~~""I ~ 'IIi j:1~'l'1'I' I :r~" . --OJ ." '~1'1'~: ...-..~' :.~ ',' -~"""-;'-"'''' ~:;l ';~ "~~ :~;JJ:',J IK:j~l~i ~i';l~:P:j I: I:'; ~;j~;' !;:: '(\ ) :,'!:', I:' ~:~ fJ t:'.i!\"'!1 {\, ;:ii.:: f>ii.' ;.: ),';.; \, ;i 1,'; ":, <:i! I; i"i ":,: 1.'1 ::'!h \~:l~i/ :', :,' r"'~~~A~i i\:~~~'il~~i~,.~!\:l: ',(:\\!;:rr,niM.11 :f1t.lll\i~ll: !,,':iJI~,4:1, 'I' "t,lr,Ji:::;;<iHt:o"';'" "i. .;, i' :;:,.1',," "" : >: ,:',;',.4; ~() , . (!~~~ft*~~$~; ;tt~~l:~~I;r~:t~~f'~l, ' rlllt~; 1~4,~\: ~J~).,~ )'~~!!~~l ~'I~I:~I;I"illl :Jll;\~ '''11,)~;~q1! ,:f'! 1, \' II.! ,,' ~r;, I; J~1.\'~(, 'i~':~; ; '('i \r~i 1:d-~.;,O, ("'~j~ot;i'~n'~"~ ~,~I.tfl~ra~tt~W~~ 'tl':il ~I'X .,.Ji.,\j\,"; \ :'i:JC '.ll!tl:l\t"III~~ f':I~ I ','I .I'I;'I(J~I~' ..:,)' , li< .,:,/ ' i ..l I' l: f.'! ,1 ~ ',~,' ;'" ..l, I ':,. ';~;3 ,:(;;-':1 ", to' a\l'I'1 'lll"r\!:.(.~~".a~-~'" 1 'j '~"''lJ(I''l)I'' I~"" ".... I~) 1 I" I 'H",II"I " .. ;'~I'I.t,l "I"' ~lI6'I~t~~' (f~f~.? I Wi~~l .,1, Ilil,J' ~t;.~I~\~Y-~~r.11~~I' 'I(~) i .'J111:'11 .\q;~,'~ I~"I ~i;>~:. ~,~,t i'\li I' \;", ,/ ,,-L' ',' : t'! ';' ':'::' ;(nGi -,+':/.:\ :' """'~'~~~,. ,}..' v:r~~\ ~ - r Jr"' "~'r-", "i" I I' ",1" , . 1'1 1,.1 "'1'1.1 j , , 'I I 1 ,,' ", '. ~ I' '.:.' ~~~t ~~/ '~If: '$l ti)1~"'1~,~,\trt.' . i'1~ ~ J': G'_ t. '~)"\" 7'1')/ !'J', , ~,) ,~',\~i (11) : I,' '1;,11 p t:'< :-;!' I I, d t '11" \ 1 1;' ,'j 1'/':" I .' "\-', ',",. '. 12 "i'):' ' '~J1V'II' '~' ~~if,:,'~*~,I'~.i',';:;'ih".1' ;Fli'J'iU!)~ll'I':;' (;H' ::!ij~l'" 1~li d'JI'iIJj':" 1<'~fIjJli,! ",/i.ll\':' i;J :1,', 'f' :."\', 'I' ;rii ;'J.": 'i ,'-'.:': ,Il'~' )fl): "1" ."'3' ,",' "i"~"'" "I ..""..' .', ";/J'';! ""I' < ,," 'I~ ,,' j.... "','" ." .', \!t:'~~':IJ. , , ill:.:. ~~' t~:..~104:11 ~}?, .\i, ~Ji"\. ')~~! 'I"~ ~'I'I"'1/111~j'~1 ",1\ 111,;~l; ;'J1.('~O,~H1l1' I '. J. I' I," ;., ,1::1 i.' , .;' ~ ,II ~ ',~ 4'.. !-,t) I " " ':lI. ,'..1 r;w ~"!. :4riJ' ""'~,\.. j \ , ' , 'T ,I I" ',1 { '1 ' 'I ~I '.1 '~" ," , "" .' .' , ' 'I' ~i " ~ l 'r,,'(1~~'~1I,~;' 1\ ;li~~t!l:~IL':t'l.t).1t.c,~)r~ '~{"\I'I~ w il'~::!,l:rr-k t;\)~l)~l''', ,~, II,' ,;' ;'1;,; , , . ',' ,".!4'..,~1~1 I ' 'jmh ~ :lh !" ~~" ;t~ ~~~~~,rt,~..]./ !!'I~ :.'1 .', ~j . I' ,:.\ I ,'i ~ '1"1' 1lt ~IIIJ III1 ~I ':~"I:I ' ')1 ,', 'I. " :1' ;'" ' 'l~ ,;,;",' :'~ ' ~ I, ':~ ,l'"j / ~ I ) : :' , . \, ,;, , ,I 'i'-" ~ i' ! ,,~'(:4'.~~~I~J"r"~' tt.r:"'Jtfr~",,"',.J.,,;I,~r,\,.":4,~11:f~,~:HJ 1,\'..\"'jt:,111" ',l,',l'-.l.i. ;,'1~/' I',~'''J;I "l\~,i, "};':I, ":,.-:',.1 :1, , l,fThi'''l,,~H ~~~ t~r~W\';,Jl-..'Z,~J~lf;'l!,:::4./;~u~uaf;t,tll-:'-' '1.,.,~llllll'ill.)l"'1 .11,..~~'il.l:~...1 ~Il' ,:';j~,:~;;,..I' II': '1,'~'~J;.d,'L5,. ~ : '+ .;', '~~<i2llf':' 110t.;'~~Wl:;~:,~{;:j!'B';~~~'" I' J; :;;,j ,.if,1".); I.:! ;1'11 i ,~I,:, 'i ;"~: 1 ':i',~:, :'. :':'" I" : /:H;:' ,1, "I' ':1 .;;:,';', '(" ., : ':,;. "'I. "'~ ~~:l!:""'" l'tj~",,!.j;l"~'\111"'ll'~ 1 ",'''~'''I'~lj 1'" I, 'J' ",'1' ,,,,/ ',;C,ll I "j" 'J ,-",' I,!,?, t.: ii).',.,I'l:JI"'~' cl" ,fit' 'l~ Jll'l!:.\Ot ,. ~[!'\"::J.' l!....JJI)II~~:- '.' ," :,\:1 'I" "I: ;'f'l~' 1'.j .';. ,", II: 'I" I "I,,';.r!, " 'I ...... ~ ,!\o, i,I; '~'~I,,'\l.t '" :.r-hl ..I./.r.:.... oJ: 1'1"1,' " 1< j "1)' "'. '\ J' J' I" ~t It' \ ,'..a"..,....., I'll" '-:11 [,:fill;:,'\! , "" ' ".. :.I ,,' ,'''.'' ,'Oo,"" ' ,,', ,. " ., .'"' i:~j~ 0; .~ ~!i.':~ ;.~~.t~,~X~I: ~:f~~I~ttJ:'!I')I~~;'rr~1'\~:rr,,:';:t~:(!'i,t:'1t ':/1111 :t~~,~';'~';'r~11r!(" :'.-~ ,'.', ~~ '; ;', I::.\\,~\::?!;..~,:,~I~'.'::'I;: ~, ~m" '$~' ~~r::~s :~'i!,jl~. i1 ::-;H~NL:~;~'.ilpl::~"I.',\;'" ,;, '"' ,1"1,' "F. "':;.: :1,' "I'Y";";;!<I<:"~~ . . ,.' '~~'~..., I,J:l:~:.f~ ';I~'li'~\":"1i\!::fl'l~cirJl\W!~jl.f~HI,! I ;1: Gil,'I\' ji '~":'I'l:' :':1' ~':;' ': "/1 :' ,\1; ,: i":1 ".!' .:' ~ ;':.": j, 1'" (~. 00.' . ~ '11.", "'~""n ;t" " """""'~I\,I"~I'll "., " ""..'" I 'I ' ," "1' ,',' "I " , '.. :'J .. I~~ /~1 f1., ;~~~., ~ i.1~!!tJ ~ +:,},:~h'ttl1IA,;~~(:..; 1 ~, Jilllll, ',~t,' D;II 1,~t1, I ,l;l:$ .;' 1.1 J;', ' ;. 'I' j : :', I; ~ L ': ' ; ,1 ~:! " 1 (,;, 4~ t f '...' l~ ~ .I':.....~ It.'ft'f,,, .., '?;...~ ,'" '~'Isr~ JQ" "I' j ':-.'/" '1 I"'" I" I~' . . ,,~~,~ i'''~~]~~~'I,{~+it'/j,':3(':':dIJ,cr-.:'~'~'JJ.91'.]: 1I'19jll:fl~!II~'l'/;Ij'lq/~'(li; ,;:,~~:-':, ,':', : 1.",11, ' d, ~ ,-',iJ7.'~,~j. , ,ij1f.'~..f""",v .~ID.l'~;"I~~~ (ft~'~:'f '~li~N' ;'~,iW""~i\'!Rlli I' j'll"""" "1)4' 1',(1';4.' ':,".. ,"I:' ",':, .' ,', < I',,' \ ; :,' /.'., eO;;:' ;.~ . t'i'~ cl""~11l\<,':, "., f" ~"'1 f "\ .'" '~i",W~(' ',1'1'" ~ I '", 'I ",,: :,,',', \, " 'J. , ',. , : ',' .,. . :~: ~,~ jt.Ji~]a~~~~ j ~:l .f;i;, I! \It r"i' ;:i,'\;t :',:Qjtl'lf; h r: ~~II ,/1 ~~ I:J J l~ I~ !""l \~';l ;'1 ,,:; -1; ~; ': ";Al ',~' .~'1' j' i , :, J' .-;, ~ '..i:1, ,~ ~~'-. < i~~PI~ll!i~ t\r~j~ IIr j' ~!(~.:tJ'l'J;&:~J '\!~! :f'~"!l:r'f' I, ~ r{,.\I~~I,:,;l<'j'VI ',i.)i) t.' ,:.. ;,i ',:.1 ::;~::~, ~: , : :: i :,:: ,~';,\~JI i ; !I:_ ,;",!;"\ l ~'''~~ I,: ~ "".!ii~~'," ld\;(:~~I<'I'f:HtJ;"ll{t ;1" i l:'il;, ;,11,( ll~: ' ~ i:,":,,:' :1'1,1:'1 I; ,~! ,: ;',1 ",',l::1 '- ,.'., '" '>>, ~":J",) ''<' ,;;':;0; I.' ~~"'\I'f~~",,;l,t.1b,~.~~,l~':'~;1'1'" ~,.JI4.i}\('II' ~l:~' '''i,,1I,: ~f,~~.,IJ.,\,\".:,~'..I!'.I}P": '\ ';,l I,j:.' -:.:.o~oI:,;t,df' ~r;. :~. ~,...~o1t l~t nil I ~tj ':(,~ ..~.'.:"~~; . 0 :i-~,~..~(~J1~'. ':h' ~!. i 1~ 1,,:jl)lll' U. ~..I; 'i,,!l ~;\,~~ 1~i~:i'~: "":1 !,'. ': I',' :,~!. ",;>.l ~<,11 ~l~ '.~'ll ,lii;:r: !.U--~'J)~l~.'J''''~'''T''''' ,t,~,,~f,~,,"'..'\."",.l< "It: '1"1 :I~I"'''/i"'' .,_...:t~;n,l' I"~ I ' , , .11','...,....., , . '" 'Lt,ii1<'~:" 'f~'.i".'r't'l.t.j.(!.\lI.~Ni!l'I~' "l~rl' 'l'f'Cl"I"''''''lc'''":",,,,,,~,,,,,,, ;.. r1''''<~'J:,,''' ~~l ,4.:~fl'ir~ ~;"~"~ 1/;~V "I..'j~~.';>.J'\~"U1~'I,~.,~\,r '11"lr~t':';~'''J.':d\lrt'?''I:I'!''j ,~ I .,..~'1 ~1:" <~l; . ~; !~~; <M: 1i~lli,' r~~~f~;' :;f1:! r~Gil !~~j~i~~t~m,<"'J nl~~~;,111': 1:,1:13(' (i, :'/' .',r:::}J'~;'.j ,;'} ,,: :,~.' ,J :',1 ~~ ':~i II ~ b{~';,~'~~ ; , I ,,,.., . ~ I..., ~. , ", " d', ,'. .', .. R, . ~ I _ I. " ." , " !l, , \ ~ ,...}'ljYl,.... "('1;"1,jll'~,4h'::'~"1" <~""""."l.\j, '1~IJII,.11~,dh'f' )F.,XU:N"I","'I\" 'i'il:""'~' ',' .' ,'; ,.1;.': " I;I',l \" """""'ZI' "'f~lH" ~..' . '''' "'"," .-;,~,' , , ',', ." . 1.\' v, " ." ." )" , '" "'<'" ' ':, t<:\'~''''''\~';.l''''lr:~';'d ;~'~,~fO!:Ci:) ~'!'111~:~.;1:;,;'.~~ft,~::t I 1,J.1ir-'li:I'~I'1 \f"o/. itl '~{II,~ A'J,.\llj: '\ ,! y, ~ ".1.", ',', - i '.1',:1 l-~.f-;~':: .'1 , U'~ ,!j,\f11~'~" f'. ,:'t''''~'!o'':, t.,' ~l. :-,,~( ,'1!.~ ~., 11.1, I'll" I" .""I"~1'J "",' ,. n 1 ' ,.~.'f~n'~!'J'~ ~....~ ::'f;;l~ ~~,.::'~;~~'j ~ ,'~r:).)l~ti./'~;J'r;~' ej (1:\)f11i" 1 I' '\', 'I "r'\ :""", \'j' ,"j' '!:'),' t " : '.,.': ' '? . :;tl '"1 l}$:l...ar '~'Jl~m;~ ~'. \""',\'s~ I '&~~l;~l;" ..'I~j)';;~'; .l'i" I i1 ~}d ~:r I II ~ll~, I i~ 11,11' J '.~ ~ ~;~~. , (f ;, i; ".',' I, 1 '''I i" . .1 ~:; , ' " ,..~,,,,;;..,, I' ~i1"'lW~'I" '. ,l j'!t I "'~''''!'~.' ifJ":"'" ('1:~\; 'i\.LI'I,~M~ to ~,Il)l~)"" I,," o,~' ,..',.~~ ''''\,.,',;', "., ,."~ : ,i -'11" ',' !"~~,~,,.r . 'I ,~!:,,~."II!~:~1f4~\..~1\~~Vtt~,~a~j;,lft~11:1:1::t':\. "";;:~;i:.]~:,'I~~~ll!l\j;t!~':1 r~ . ' ',"~I I" ,"'l:",'I"'! \::..' : ',," :'~' .\' I ....... ~ .'''~' ' ~' 't'., ( " ~,.~ 111' , ' , '" J . .~ _... .",~' f."''- ~I!oo"'~ r~""-' -j".-----........---.-. .....-,...- - -,-..------....-..- --- , I. i:.i~ '~~~"'i:~i--:. '.~~. I ~ ~r,::" :",~, "1 '.-, ":L F\~' f 'l.i ~-:i I V I'll 'I "~I <j, \ ,',' ( /' , " I . r..~~!jIli\l ...~>tllrl' ~~~.II':'O,.11~ ll;'ft,'" I 'ij'I'~l~...~I~,';l." \, I! ,','I,'.,.' '~""I: 'I ,'..',', " i;l~'IJl~:';',~~~~;; i~~; tJ!if.~Ir-~; I*NilJ~~~'il~jf.~~I:;.P;g~I~:,:l!~11:,'r 'i;:~c\;uril; ~m~~as~I{~:'Q~~I.. ~ 'I \~'i~: I F<:" ':11,' ". .;:,', ~.r, c /i;1~, ~'M't~~~r.' '.tIWJ!""'I-lt :W~ ,::P;l'~I;S'ii:.{';~~ ~~itlil:.il~;1~~llr" "I h"!",'r.!1I1' ~,,:'\ '11,V.Cll cr:I;P,'^'Y" ' ,,'m "~~i'1\,.<'<Ij~~I'('" ~.p.r<\' ,~,.,,~"1..'.,'.. 1'1',~AI1'd .'1" 'I'~' ",/ 11," ,.'"" " , " '. :\,~1 ,;,1'1"1'~" '1~;~;";'lr,1,,""~'j':'.he ',;;, lc,' ~r.r,,;:,.l1~j " ,. " ,'1.1.) ..t419j'H;~'lCl,l'I);!lT.i,~ !,ill",.g",' ,< . :''':" ;':"":~~'(i ,\ ';P.;~ i;n~' 1,' ~~ ~:, I," ~'t"\. . _'1!.,~fl!~ ,~,tpl -, .....~ ..;; 'j~/",.,,* ,}) , " . 1 ' ,.~ . {~",'1;.\ 1\ 1,",. ." 1/. ~ , ".,. ~::"~t, \'~ ~~.r.J .\\\ 'IJ,:1f;" fA,':''':" "Ill t lt~,llhl .....\..;.. \.r.j.,~I.." " , \' v''''I' 1 .. 11'..." 1\'''' ~ .. \' i \'~f'" "'1, "'\~I?' ',t, ,.. ;"~l" II' ,,. (. "', 'I ... 'I' ..., '. ~ . I -!" "J i' .',..'j'I.III....<l: j(' ~',. ".~" "II ,~"..'..'I'/"\.l............v',..'r' (~' ...,:.. ," "'" ~'.'r,.' ll' ,,' ,I '...".,," ,~....,..,J,j..;tk,.IoI....: l..l.l~...J',:",:,~'.t:,'.- , "1'., .''1',', ,~ ~ ,or'"~ ':' , '"I' "'1" II .'1 ' . +- ...'....1-..... ....; ", .,.... (.' ' .~:.....,. ,... _ .,1 .~ .. '.:4..1" ,,: ".. .,. ,.. ~--o".". ~ i," 1 ;~ : ':, I",,'~' r ..'.......,...,; , , '-.."'"'' , i \. :":";,<::;:;.:{~,,,,,\>;;,;.,,,,,,,,,,' --- . "',, i., .! ,,,..,,..l .. ,.,.,,' /'" ,"" j .: .... " ',' ," .".'" " " ,- .-'""'.".- .... '.' ., ' .nrt' ...,'''''''<N ...1-1.'..1......... ..:._._. ~,..._..-.'.''r.II''JI.I.. "'.'I'I'1':l"~I~'.""'''4 ."..."'j...,...~......,_.....:""",..!.."l.~.ll-;'f.. ...~.4'p~'1:,"...,;..1 ,"'..~',..~.S' ~.""""'_"""" ,., 1,,1'" ". ""'. . II'" 1"" "'''1 I "1 . PI" ' 1" J' 011 .' " , I,' ". '" . '1"'>l\l~J: ':';'::'1'..""""',..,<:"""""'" ,.,.c.,. ",;,'. "1'1, . ,.:,.,;,.,1'1"","'''' .,.,.,....,.,..,,";.. '. ,.t~~;;"''''.,;,o"lJ. ",..t,')1..,f'I'~'I:'!1\11'11",',\."~~1,',. ", ,,;,,:,,! . ,1,,\ I !1 11,,1,\ ,','" ,. I..;.... ;,,:,.,' ',; ~~I 1..1\11.. I "J:, I"" ".I,.""'~"."'" "" . \~"""""'"'' ,'",' ' " ." . . ., ,.' .," '" , ' ,~!::,':~~:l~.:t'''''':',~!I:,~......IW.J.~, ',t..., " _~I.:",:~:':"JIJiJl.J"l. . '" .., .,.... ,."J ,,, .~y'" .."..':':'.., ..IA......".., ,.,. ,.-' .... 1 ' <. .~\' j;;.,.'.,; I';W" F l"i,~"""l"~'lm' "1 ."."..i,.""..t'.'~"""~,' . .'\'1 "I'"' II'" '."'1 '1'''''~11'' ' 11.'..,111-'....1".'.'.....'...'.....,""".- ....,.I~......... .... "1. "tN~" ..tm"l';:..' ..~~. . ~ ., ~". ~ ,,: 1:,~j 1:I"~1. ,~,. . ;,': i ;, I' I:,. :~ I ~ 1 ,,:,' '\~' ". I ~ ;.:"(' :',. 1\"" "1.." .,'" :1 p, I ,i J. " . :.:*~}'.:,.~t'l:::~'..!: ~ f Il j' ... \ .1J,\.rj::..~1" !~\" ,,' I~I ;,:',1',4\ ,1',:' il .ll!' \ :~J'u:".',:i,~,\.~ ,.~:~\:"'''' "I:"l'j'I;~I"I',I/ .,., ,,!.' '~d ;' r." .'. ;11\.,,:,',' ,1<,,'. ,,, . II i"" 1!." ,"':"., ,'....'/'1.-,'.'.,: .,..' '1'i '; li~;\ll~\' f.I1t1}'.~"~. "~~ ti~~.,!~ . .J:!,:,~~ l~jtt'Wi' \J~" " , ,1 Il!~! 11:1\"1!~1 'r,~ I:, ',l'fi IL!~.1~~,~.h:,ll~..~~..,:~1..,:1l..~:~:~.,:~"':-. ~ ":' "11Nl';}f, ~l!J~,~~l' ~I:l'li" ~, t;\~ \ "'i);!l i'11 " .11,1 ;I;\;\!: l' 'll' 'I i i 11';i l~i~jf,(~:;\ ".. ',!~;'r '~"'(:1;,~::~i,');"" , ! lj.,,,,,,,~,~,~,, ~''!.ii.eil''':''.' ~f;l\~/,l.,:~~l~H! ~.:.~"." iJ;\<t,.;-,:; .,hil' !.\ illl: {Js' 1".,..1" ~l!' 'i"~\'Il-.~.'I"':Vlt,. .'! i:,(I' '.' ,r.'h"';'~."\'t11;':I':'~i" ,...JJ. l~'."'l~j" " Il.,.,.. ~ '~l' :t~~ll'1~ il~ ::iJ'.o1<\'f:; i :~:. ""'" ,:,' " ,.,,,:, I' ""'~' I' ,: 1;" 11 " , .' "I'l ,,' ,I;;~, ,; " I!.: ~'\"\": 1 ",,,,,,.,., .'. . ~'1~I~.!t."'~' ij"~' ~1t,~f~,1'~m'~~~.:I:d:I~.& :;rA~.i(~("~' '.i~tl',t3,];i ".,.;,1 :~I':J.d: tllll\ .'~.,~:j.\l""'l!-J'l';~'\~l' .:~i~~:~nl"l~.'j',:~l]'i!:i':' i.,tl """1!"...j~9':il'H~';I';i/{l"!' l''''~ f,~' I' t ;l.~~ ,rt 11" \1i;1j. '''''., 'J""""-'"'' ,.. ".U:,J"" ..1....' , ,.', \ ,.,~, "I' i~<~~. r't..~. ~'; J,..... ~~, it X. If""~" ,....,' :' ;.~,~t. ~~l ~! ,tf ".4.:~fl ,~, "fe/I. ~' lb' \1;."I;~lt;\~d.. .t'lfi:~;hl':,,~ .1 H l'I,'llh ,'I: ~I' ;t 1:~'.'l;.Vi:;':' " (! . .~';'I,' ., "I,h:;J: " :. il~.,1'l2,:,"'")~....,.~~~'\~f;:1,','-",'~.' .' . "'I...~.j;..:J:iil.i4 .. ~ I u.~ ~i ,~,J-"'l"_.~............~....H\l'.~..1'.1 ..~. ........Il"'\~' .~ ,..,,!IIi ...i'jI' _..H4.<.a!~~ ~..II..... ...........'~ " ~:'t,'\ .;'..~:l.;! l\;~~ )'~~'~;l'~; I,~~;, ;:{ "'" t ~ .~~1l ';~, l.~,' ' ,{." ',:,';o~;', ~ ,;., ~:-:\ '!'~1.,d, l~!\ j~, ,::,',-:1 I' I~ ',O~ ~~. ;I.I~ ;~i:1" ~.'.\\I;',,:.:t \.~; ~.;:), ',:,;' '1:\ . J <. . : .;;,;. I,',; " """"""".,:""".,.,, ,....,', I,"'. ",':.' "....:". ",,,"<'.;"',, , .' f' ..". .'i,.I'.'I}'.... ,,',". ,",,",,", ',. 1oP' i:;I",~'.\,ml".J.'iJl1{!:~I!~I:" I'J,' 11;11'1.,;) ,'),', id <\'I!"I,/l""'jl,", "1 ill \) 9hlll \l,~t!~i/'/I':' ,\;;,'\.U:U,:,::,':i:; .!, ".:",,: ",:''''.' . ',;,'. . +:.';r.t',:;!.tY [,'\1 :),;rJ~:;~\:: I'; ::i\i:i.(i",'}: ";",~..:,'\Ii' :t1 '1':;";: ~:.:'I' ':,'';';; ;:):.:.i'-:'I., ~>"i":.";" ~.~': ' \,::::::',::,'!'.".:' ':;:,1" ", ; <:,:' 1~i"'~\..::f~il'r'~'~II~,,#:J.; . ~:i:;;;~~:: ~:.~\~lli\:.(~111 tl\~~iji~f~'~.:...i}'r.:::"<; :~~mfi,~~i\t~.,'jf.f'.ji~ ~~~.. :rtw'1""'" , "",...~t~'''"",",J'''" 'It"".." ...... '''''''~''''l'''''''' ;o.i"'l'!':" ~_ .,.., ..~""'."""""'t.:'''''''~~~'....... ~""'''!'I'''h''''''\''''''"~''''~'u.f-''----:-~ "'--T"~~~:f-'''--I'''''-'' I" ,~--.'- . ~er~~.'J~'~~i .,:,:. W,,11!11')~i:," .J:.,:.~i:.::~'f,;~'.~;{:,,'.):?';. )),~ ;.1}I'J..",!I;i\'llH,;;'....1 ',",;\ ..j :~I'.I:,\. ,J;,i ;ii[[;'..>:'\: :'.!' :i!h\1'~ \':1'.;.: Ii.:":: ..',:: p;,;:?(lLlr'I'i.:':;jl. .'.i'.I/\ .JJ,.",'j,'4::1 .".......;....,~.l.."'~J\i\.~l:.....,,!..,~~.".:.,:'.''''l'.'.'1.',.Ii".',~" :I'lr. ",;,''':.'(I;,~,j,.~'J """,'~'~"'Li'~"'\.' 1,( .1,.....'...""l'H....'1 ,.:. ~ i . '(~;,;l(1;'! ,!",'''.ti' j!P:'l' 'r~' . ;.;r)!',.";";:!ii'.:'i",,:".c'i',yU' >~h"1 ,,! "":"".'.:,,,.':":/:' li,,:f, :, .:!,!.':~ 1;. i:;"';:'! ,",' I::", il!' ~'., i' I'" ,i."':'" i}~;;~.~'~~'~F.f:~1.1~:~11t.,~. .1.~.~4. ,t)!ell:'~i~I:':t)"~.;'i).~"J~.; i~i.:..j"1 \1:~"!!\I.)J i1";.p,.,,~. '. tlO.. ':.;.~,~(r;1.,o,..::i I't.i',:i I\' .1(4: ;r..ji);':!>iiiliJ~tr.#~. ~'.;':'1. I..,.,..,!:.\ ~~~".p~:(ttgft\"~~;Il)ilji$t:i',S~1 ;;:i..H~~:l~! "I~l~ \1'j~'B[lIHI'~'ii~,~,,:1 1'1' i'W .','::\"i;,['I,:i;.r'v.: :,,;\ ',:1 1 ii/,:t: ::'1 :'::. .~: :\.'.,' ", 2 rj';~;. " !it:' '~~': ~~~,~,:~~'tl\i!l1ji5i.;.';#*;..~~t"l'itI~l"I~1,'Kl'1~\,')j,-:\'l ~ii\II!!i 1'111 i ,.,:;,1 ,,:,I'/Ii ;,:1;:1': ',r.' ( 1:11 " ,; ; ,';j/.. :", ,~{:" P! ,:i: ::.~~!,I)'; ! IJil~~~],{jll~,;1i~gz~~~t:j)11 r:J:~~~;1#1~tfl~W~j~~I)i[t};i~:1 );\:\1: 1:'}221;;M\:~;J\hG+:t~, ~~.I:!\\ I', :i~! :';::'::0'1 :i.ill:l':u,:\\rt.,: 'i.:~i'I.\1 ... ,. ." Jt., . .1' " "';'. 'J"1i' _~ 'II I 'I~'~ '1. '11. .... "~~::' ;'1 'il":'}': .)~';" ,'. ~! .t' . I"'; "rl" It'" :' ,~,..: flol'~ jol' ,,:\ .' '.' 'il" . '....... ....' ~ :~' .I<.~...:, ,J;'f':U,:':":~.:,.'/,I, i'i"}:~+.' ;(::j:::h:'~:;::> ;,?:~;!.;i,~~:.,::,"/l:t~\~~~i:r;.":\'; 11 ,111,,1.11 I. 1 ""ll'~ tr] ""\1', :1:'1l""''''1T7'l''''''~'iill' .,: . ::'~ ,I" t' ,~,~ 'J{,~ ,:'~,jl'!l:\'F{' !lt~~tl'i'~ :,' '11 ,., .".,. ,....... ........ I' ,." . ". It,.1 "", .1"".,"J,_.",~\1"J.rJJt '.' ..' " nw.ii\fl. J', ({~~. ~~:;w.:1F~ L"ill':'1'/m~~"'.rJl~~'">'!Fll" m~?1fJ~. :rr~~ h.....~"~}J ;;~WJ.'HJ:l~ L;<.~~~t ~H~::~~ :~ij~\':1\'~" :t: ,,(I. i ~'::11."'l.-',I~,';~:~" ":';',)\1.-,1" l~;." . ' :\" l,\\'t,:c ' 'i I ", ~I,j :' ~ ., " f."~~'.'" \ ' :. ., \ ~ ,l I ( \ " , 1;\1":, ;. q" 'I, ".1 '.' ( " '" 'Ih..l '~'r: 1 't, )11, .',,' I,," l l\f.,l e' 'f'" I"'" '"",, II ',,;'d ',':" , '1,1'1' 11' . . "0'_'_''-'' ," _ ',' _ I ' 'I ~ !'" ,1""4 ["~J': ,I \ I! 1 \ \1 Ii. ,.,j " ' , I t: ~ 'j "II' i ,,; C'OlfL" I,'..\;~j d\ 'r. '~ir;,' 1:)""1 1....'1'1 " ;,,', , '. . ., ~.' . '" .~ . ! r, : ~ l'~"i' ;' ,j , 'I ,"." , '.',' , ~, ,',' ~ \ I, '\:' '." 'I I ~, I. .:\'," I' ,.~ ',"," 11 '" " I . ,.- /,,) , ~ I j .' . " I",. oj' '1 , ' ,~f:";:,~r~:::~,~' I'.,.~"".,,~ 1\'()1:1'.J;;\'11;,:,;r , 'I~I ;..1 '1 ~"ll' " . ...', jlll ' of '.'... '" I Il "~ I " :' ,It 'i . ' , '!. " ',' ~! II : , ' '.' I'~ \ . /1', t ' ' . ,.I, "\ . I ,. I ~.,,;.~,'fl1\'" '111 ~:)"'~f "I.'-I~~" .,.'~. , '-. 'dj"J~ ' , I '. I' ';< '1)1 \I:' ,;, ~ 1 ~111,11. 'N. "I, .,- i "I 1,;",' ',,',-I,,~.;J\i' I,ll _ t . '" ' , , 1'" j I~' >1" 't" ':n" "'ll,~ I ,', " II' \ ,~'~., I,!,,'l "\1 ~ I.~..':;-f.~r.t,';~,~" :.J,). 1, ,,(t:~~1 : ::.'\1:; \1 ~tll ';':',ii'J.',..~l.::::t.~" ,;\:1 ~ ,'~\:... ' '~J d ll'I'\;, .. ~ ~ ... I I'." . i, ',I : ~. ..' ;';\ '~ ! 'r : : ; ~ ~ ': "" :!,l.1, ",; \" ;,!' \' ,t~:\~1 'r.;IL'.l(;,:~,H}d ; 1,,\. ;, "(, ;} C '~''c. c: 'I' 'jl;: 'I rl',. :; ,~ " ".' \. ,. ' , I' ~ II \ I ',", :' ",' \ I I" .," ',1 :'. ,:' ',I,ll;', ~'\: 1 l, ''I' ,. I '"'' I 1'1"1'1" " ',: '. "",,'., "1 "'I"" ,'Ii' , " . '1 , I 'I , ' , . I 'I I" ~' ,. I .'."....I..,..j ,1,(11., 1.,11 'I 1" '..... ~ ~ , ;; , \' ," 'I, ,;! 'I ' ' 1: I I I I ".! \f' ." ."',' \ ' '"..", 1 .I. I "'" 'I: 'j '.:: !: 1 :~' ,:' ! '.! i'l '1,\' ". ,1 11 ., ," ':1 "ji , , I ':, '~\;:~ \,'1 .i~ ,. )',; 'I.'j ,. ~ ,,,' ' ," ,I .' , , ':'.,; 'I ;.. ~';) .-,: ~ .,,". "I '1".'1[';" ,,:',':i!'i:J:;':' ;-U!'J!;i ,_, .j 1 :','tl" .'.~I;! \; ,':, ,,~r "~,I, 'J' (h,. J]'1 i~~i'~;?I.'(':,~il ,,;':.', '.~:' l}fr':.'{::':.~ :.':CJ::t~fji " ,'; ; . ,: 'I: ,~: I, <<:oa , COBRA _____-"., l RL:T1HED _~_~ I" ~ DISABLED ___--..1 1 t ._-, $OCI^C-ru~~-~-_. Plce;-~,. ~. ;< 3Q;;,-ji/ - en \ C $-620"'c 1 DAYTlM6 PHONE I : . Ot//- C)('{,j-s,} I? '~I'" "~:'''''7''''~r;'-''f?'-n 'f :"rri:?~::~' "l'~l' , , ~'" , ..,','.-,....,..,... ... . "- ... ..... ~.. "<-vo...., . , '. ~'TED t';'l;;~-"-.L Alll. LINE~ .1\. '~A..;E;'VEIS-I ' , I .. '. I SE'P 1 7 '9'16 ' ',:; . ! By::, . ! J " . . EMPLOYEE ~IMn;~8Illo::;._, (lAST) 'f . J rtR31i x ":--'-'j'~ ~:;-LEI ") " ...1:::(30C( W~n (dFf;2!~!ill..~> AllORliS9(STREuT. CITY, !Tr~E, ZIP! .,. ~ . ' ,....\, '..... ":h. 'ii F/)f' t'I;"l._"n.i,. / )0 iY;,,_~.,:'f._ ""./ . 23'-7 if z... :;',i?-i . .:.....LL1.f..lI-4LI. .L...;.-L-V- ---.- _-L L-J..2 _ \!;W':. PA~'~NtNAMeilF:bl#;j~IlTFllOM^BOVE) I ! i I . (:'!~' ::"'fo'ST1"}.l6-~'d~k :~IAsrr"r:.-;~ .-(i.iilOLEI_ ]!:,f; j: :":"rf.'::I-;..;,'LJefUti.~h'i'.:::{'J ,/07rl/. i -<7, ",Jl . \ - .~-H .~_..._~____ ~~ril;: Li~~VMN6~IN~ti~tk~~ ~i~~~ COMP1.r.TED) I "'111f...~I~:/~!~\ '''\~l'I'''''' ,1,1 'r"~,.: I '''6f;,r:,' :'j t., ' ,.,~",.... ,I.,,' .." ,'"".'" '~'"7,'h' "1,\: '., I."(~ 1\'..... J.. ,.....l~#-., '~!. :. ~. '.( ~t .r;; .. "'I' ;',' '.,": tl,qeurcMP~ ENT' -:", '__'.._ .. ~1~!;'j::F:""" ':, '::~,,,,;,,;,,~,,'.'(;,".;:' ~'(.'I/JOz ',. 'i~~~~'q"!:'~RS'r;"At!;OFb'i\QNOSlsiT~eATMiji!f~::::~~.:_.I; Y 1 ." '(, _ ~Kt.' ,\,," ,'" ,. ~ ,', '" i",o"'";.''' i' ',I, ' '", ti:1':;,1 . ' ~"'::~",;J;.i(b~~J:~;O~'o~;~&i~~~~~S~/~j"i~~'I-~t.0v cA->;;~~ "'1":1,.".,'1",.,,,, .\1/ ~ ~. f., '1" 'i' ,;- I j',~" :,'\'. .' 1 .,':_, ~ ',', ., r " " " ~. ",(-f:r-::tt ',V"\~,:,'",, ' ....'..~IA i......-,: !"'. ',t.:,.,,, ~..:- ;.'- ' 'M:~;;i;':,,:: "'. " . .',:" .':' :_': 7'" /' ". ____ ':"":'. ~~f\;'1 ;"/,,,;" , ,':, ()' "', ,,' J ,I j ,~" f~~i~f!;~,U~'::' ,:~' . ,:~Jh.;!, ,\ . f, 96Z670QI~~a /t)\f.!'t);:,',;(i(:;f' ".! : ", ~i~f!CC1oe~IT otl'lu'fiESS RE,ATED l~J EMPlOYMENn D~,? h,~' ~~\f;.tll"l;\:.~,'r u"J(~,~1~~rkmun"sComPCm1Ih'J "J,,' '!HNt4i~hi;:; i;f;iid'~'i:~~I~~~i~~Tt1Ze" G1aLe FORlAfliiItJA'lI!JMe'or&Aith' : >'~:'~,'~~I.':::' . '\1,0 1\' ;-? ,. ~,4'~'1~.'1',\..", .1~,..",~u\t"!/II'.il.~.J'" ",..,1 '"., ri. ~ ~-',~,-;\'I{""'" ~J~ fl','\",,:,~',~i"i:jt'1I, ",.' ' ".: I' . ,"1' "'ill' ~ ';I~!'/'\~~it.qliS",l"i h:r!i$('!Il~iC~I!;l~, . ILTOF,HF.HtCt~^I)CIDENr1 '.' :\l,,; \.'1,%\ 'i,J,.; . ! ~jJf.~I"'.'" l~:ll:.o ...'-!... .' 1.; 'jl,.':'j:. BfA'i.rA"~1 :l'~, .'I , ,. , ..~ '. "'..1 ,'I '~'1 . . 1:i::~r,jn:;rj~:"",t;:&;j::':;S;~~!M'etiMPlQ: O?'IFS':l,/lAMe'OI'IlMP~9YEA: . li:\{~", i."";' ,.,'.1 .~!il".'1.'''', 'I ! "1 ']"1' ) "',il,'1 ~"'I:.;' '" " "")",, ~ I I~, . I ',,~ ',~"~\' " )1." ' '",'" 'l " "1"'"'1''",''''' ." ;.~ ~ '~' ~',." ~. . ~~>;5]~'I:1:ii,,,.;;,t:i,~, :":\.\:oo!;1P.~ii\l':~' ,. .\2,." .-: .. 'OLlcY,:i" ",'7:11t/1.f.I. ' :' I,!\:!"\ I"'''''''/' '.;I' I' IU 'l.,;, -;1:L _. ~ _'_. ~ ~ ( '~:J1'\,;~,:~~! h .1.:1l,; ..!., ~ll'tfi" ,~;i ......o,p'i~)"l ; .' 'j I, ' " " 1,... ~',ri~.t !,j.l~it;\ lfJ",li'llt. 1 '. ',' I ".1 ~1~1I " ".\~,' "'.~..,.., 'I ~ " I ", , tf ;'J.('''(;,',.>J 'i,.", , "~~~;'~':;"~~')r<.\;~!.\JII';':f .~.Ei!tS;:. 'jl' ".1 ___~..:. ,~, c. .,1'i"lii'il~;':" J."'''~i .' I;: l~",!,,11.1~'~':''',.l\..I(I,;~.......t (l)('~'~;:~9!'I~I.! )'. I . ~ l I '1,;.)~,,",,'l '~'tl'~. I, l'~':" .~J : :. , '1~,~1Itl' "1:'1" I ~,' .', 1\ "~JI" 'J'~l~, i,' I"", I, ) '~.itJ" ""I~'" j' . ',,21~ Y"1, ~~";P'li~\'8':"', '&~l'~rl1~"~~. .d. i ' ,'. 1 ' '., I,' , ': 'y';!] Il~ ; {.j "'f,\".; : /" ~',~ J li~Ii""1~1j191tf.\\;'CA,I~, ~tjr"c~~!~~P~~TOj:j,~l~~~l I~, .:r:~~~',1, ;l,.", J. ltlM"} ,t.. Pt<l"~'~l .'.~r;;;~~<. '11W"""'''''i1rll;;rn~,p'_i"I''''''",:, n . .bi....Ol"'. "'.' '1i>!IO"'I~;;;YinO<l"''''OI~''''",,,,,,,,, . ,:.,.... ..~. IO"""">:i ".U '.ilI.",...;.,O' """"~"""J "', . .. ,,: , ""1'''' ~!t"(I; "".',( i;: '(.;': " :.;;0;.... : 1;;'., ~"'. .' '.. ., .\ ',:"':01'''.'1,' ""I,ll1~"'J.;r.'..' 0t.~,. : : "w , J. t.:., "1. , '. ';"',,'...'.' ,.1, .' '! ' '~~\~"~~I~:llt.\;.~:'ij',ui~~":>'jJ..t~'lY~~.,Y'!;\l'i:'\!::i~:.,:\;.:.,;.,:.:".r'.~:I.':"" ,', p,,(~~ tfI"~~I~ ..,.1~::."io'1':", &. ';~';:'i,i!'I''<:;. ':-. l?An;; } l(l,f,.r~ ,~'.~';".,,".. II.' I ';""'u,,". ". "i"',!' ":1 J.." 'W;' Uh' ...,:,"~ '~~ .." ':'." ~.."' , "., ~"'\','''''.~",-':r.',...;,.-.~..,..,... "':'\'1'" j-" .,', ,.'11..(.." 1./ ,. "~~." . " 't;.;1i~:;!:N:"',,!,'~l:;:i.'n';!\V}'J':I.i.!.i<;,,',,'1'(!" ~1" '''''''. ,',.: ;:.;jl :~q~:~I'!.:,:c:("':l:iiJ,i}~:"b!.;\i,:;:i".\:-;:I"~I':,'t::, I,' '.": ~';~' :",.{r(~!i' ~I~">.t,((;) <',\ , ,'tj .:i':. .~tfi)~i'/lt-;'1;~r((~i\&('"'~'':~i1l~''\~''?f''1~'i~J;''~'''.i' ., '.' . ; :1. . '~:;(\~:lI't""'j"'~;r~. . '1.1'.'/1::,:"', ! . ""f..........'m'T ' ~' ij "O'F.-' 'a'''~L'!'' '" ,I,', """ """'~'l"" .' '. '.. .'.,' , u r~; l'tV I, " '... ., 'j' I',. j'" . ,'~ ,.... ...,\....._. \~. ... ","'. III '1.'1' ,,' '., ' ... ~,...~.~',;~."",l"."q..',f.l:~i..\'<;'''i.:......,..;,.~ 'l'..,~ 'ill:..iL,' ";'i"~"l"':";':''''~~.'{.' ~,;:j.. ',"1:.:,~Jj~""V..I,,','1'..1 I,~ Ii- ~'i~'''i \;j'~iihthl.~~'~~~~:;'';'~~;oi.' '. lWici"(;16~' "~jjk;;".....,;j~~;"AA~fdK~b~i';~i~~.~;'I!li"(tlo,~l<i;r~;II')' ' ~' ". .,.,c'::. i',: ',":', "~,:,:",',',' .",-, ';"'" '~.. " '.' ~"".', '.' '. :;', ". " , ",!-" ,,'J6.j.~il..;',!,1 :.:",',,,,,t., \\\1'11'1'":')'" ",,'. 'l':. !!M~ 'l\~.IP" All J'o,)I!"",.,lt, :,:" DI\Tli ,;.' '(" . ~1't 1,.. {>' t. . '. , 'I "....' I roO t ", , ~'....' '." ,,' " . j .:,>; '.'" I, ~~.' \, " ,.. ~I" ~;{~\i;~",;.t::;I'~~'1 If:,..,:.,{ ;'~I~;'-iJ':};,Jr,l,~:,,~,! i':~\,'I,\~!~ )' "'I. . ,~:. ;\\~'~/';~}: . ,~I:. . . I t~'j'M.t~;~ of. I,. '",. "1""1 ;i'1i ','l.~l _... . " . !Wj ,,,,::- '1,;,1",)" "-' '.' , " 'V'1l" ,!.< ,,-.\ f~'/,.' " ' Vii,:' ,I' \', . , ,',', "."''',':':''''1' " . '..., ,., ilf ,~jt;t~~~,g~ ~J~~~~~~~xrih~lfi~~,J~;;~l~,~~ s\J~~~W~b t~ ~i(~A~~r:;( ;r~;H}:~' :. . :; ';:: , ',' '1 f {tt~~~;:?{4#~€~~rH~~i~q~~.~"\~~.o:~~W{~~M;~:, ALL 1~;:f';"ENi' CO:N~;'I~~~,~TS, :,: , \i,i~;P,r!~.~ rlj'J;~o~:~e~~~m~~O^~lg~': ~lii,tij~:,;~o iN,:flLINe'~h800~~~.~I~~i~lYil:~~'o.vil1EIlS IN VOUA ZIP coor: /,ncA, gr,;l}j1,! ':~!1'; ,.::;, I:': "!.~l'" 1:i;*1';"~~J,,.f, I',,' I,}; ; ,', ,." " ..',;',. ',,"'J'''\r~ ",,,,", , f 11.ljWJ.j:,\,!~I~:n",.~i,~~~~ .~~I>lEfil ~,~~~~li~~lIP ..: ~Ii~ ~qR;*~ ilf.1~~ rel!~?!1 O~'A, SI~~~~~~~AI~ F61i~, " ' ~<j"1J~~,:\'A~~ ~~~"'O~~;'lltAAci~d~~~ A~:*,VOJ~'~~~~lltiQ!'~'~NO' f~~A;.~~;~j {&liFl~ATI:vt!l, i~.",.',.': ":';1',,'"'.', ,':l.'.',');t."",,.;),.l:'..",' ":,"I,.,"'.!;I, ". ,'. ~',.' ,.',',,!\il.','., ' "'j'I,,," ~":""'~o.l'. ~ l\';:',' . '~', ".' I '" /)),.. ..,.)~. '.~, , ':":1" ""''1." .. f;-, "., 'J .. ~lI'fIJ I. \ , ._'~"~,.~""I\""",,. .'. '., ,...J,. I""ll".~ ",'~I ,I,.,. ... . MEDICAL CLAIM /10221005 "~Z ')" 8 IJNI'rt:O AIR LIN I~ (.3 EMPL01'EE BE~IE~ pf I 00 I , i PLEASE Af'TACH ITEMIZED BILLS jJ'TJ 0; B'f'"H " ,:;. = FULL,n,YE .TUOENT'1 '~CJ NO I , ' .!' , -'- j I 'I,. f,',' i 1 , , f' " - ! ," I,,'c'., " i ".. .~ " , I . , I 1 ..... " i. ,'. , . , ,\ .~/ : l.~ .' " ",.1 'j >! 'Ii:) ~, 'j .' '1.1 . 'il~ '. ;:,~\7 : ,'.::';~~' . .,;",,1\ .' i.'''''' """', ~1-~ '::~\~ H-.,' .:;~;:~1 .,lid ,,:.:J 'I' ;i/:1 ::1'/ ,:.)) . '.iN '.'fi(r, ;:'. .~~ .:'....~l. ; r':~' I"', ';'/~i .'j , :'\ ; ";:MA ",1.1J 1 , , " I f ; I I .,!---VUn.---- '!!),:dNITIW ,..: ,t AIHl.1NES :'".: .~. 'tl .' " ;,~' : ' .,' 'l . PLEASe ATT..\Cli IT"!.'III:!EO OIL, '3 Q'SMlLED --......- ,:;,':;;;) 'E~PLOVEE N"MEJSUaSCAlaE~! ,,\:i',\,;, iV"ii'l MJJ' (PiAJ1) & "--6- IM~'CL:i"':t";.._.._._.- ~~""""")/'- '-Jiii.lI-i-;~~t. -1 ',",",;.1 ,."':. "i / fI1/'"1~ I ') .... -, . ~1. -rI1'-1. We!. Z . . -"I,' ' __, --,-- l'-L~_!.J.'..L_ ____ ,_, ,~__,.__,_ _ _,""I. _ '.) . _. .k'::f____ _...12.,... ",:\i;~ ,^9fn~~QEQl,~rn~F.TeCill1y,g'~ra'~/~~f1- ;;:1"71.~j ttl'? O""y,"M[:." d"IU'bL-32/L ,--;.,>):'1.' ;l "ll, ~ .v -' ')...~ ~ "" . ?~~~~~ ~ ; ,~ ".,,: ,',: . ~. ~ ) ,. I. .'_!I~~t._1'" .__________,; ,- . -" ';-_M~~ .-. ,;' I <.::~: l: PATI~F:Jl)lAl,1.E liP OIl'peRem FRO,M AaOVe) , l' "::, <~ ': ~ 11~''';:'(;;,';':n .'.j. IFiA~ IrAAAJAi IM,ociCi,-"- h.--jo,)'f 01 u'm~ (7 ~ l,u\~7il"'E "'UOE/lI1 :1 Ij~\i LiL...~.I.!.:t.t.r:U.:':'-_lL _' _.__.._,..,_ -+f..IL13:A~:.'I.E1l L1NO ':~, ,1'1:,:. ;; '1~~iJ'Rijj~~:iN~b~~A+i6Nrlu~T B~ COM~L~~eOJ; f":' (, . ':. ",~;~ :'1' ~,.;,'""~"",,r'''!''i,;:;I'i:''J'i'~'B' '7b' I,:,,', . I 'I~ ',,' ',! , ,.~, 1;~t",":~'....,~\.'I", ',(~ ,; - ~..' , , ",I ;~:. :. 1i:l ',\MdoF~MPl.C11'Me" , I . \ ,i; , ' I 1,: ~)~~' ':. ;21.....,.~:~Ah',:~((~...> '<'. .~, "".I' \l" Id :,":':':/l,' ''J't : ~ " ,.'0 '~' ., '"..:~)' I;:"".' '",:'!,fj:i!M'OATe'OF.OIAGNOSISITReA-rM5NT ,,/"Z :.::t.S::/L)<p "". ,_ " : ':' ',i", ":I:'.j'~ l;;~,' ":~I'\;':;fitih:JJ6~;~~'~~~';~~J~~I~J' '. i 6 ).~~" "": :i:~b.a' '; t1ffe' :,.; ~L 9iMu;~ -ftgJid ''1 y , " ',. ~lt ,<,} .,;t 1''' 'r''\.- " , . . , , I J... \,.--' .. , I, I I '(" . l" (,I" ...',..~;!:".~'t.:I~."...I'.,.,i."r"I:, '., .), ,"', II ,., .. ..', , "I,:I,~~~ I~; 1 ,I'i .j})f/'~' .~. ,;,;. 1', ;:.._ ~'..' ,'-' {'. ~ ,,: '''' " ,,~., 1 / .( , ' . I.'.,' ,."" t,'f ' , 1,< 't:: 'r.-~;I-' 1..',\;.1" '. ' _ ... " , I, ,"", \1,;,:;" :t,{~fl:l~,\:;,;-,"':i:' ."; c. ," '- . ".'." 1'I~"3~'"~'''' ' '. I'.' '. , ,;tr I~,...,\r.l~ ~i.~"":or; i\'~;t t li~ ' 'lP' I." " , .'. . "(, \ ~I I .11~ . . , ,II";~ i': .;.,.1\~(~/1'':';')-'I'W'ltft<''''NO'~' ~.;-' '. ' :' ," ,t,"'J ,:r " 'Ill.,.",: :%.'\"~~~'''''','~j~'r'1.- il" . \." . \ 'I I.'" I , " II' "/Ill ~.\:.{{;i~\l ~,'Zb. :;(,,/;;0 ".';WAs'ACClO' TOR ILLNess ~E!LA;.Eit1'D eMPl:6thile~T'1 DATE? r . ' ,,(;' ;. ':):': ~; ~"'J ""I:ll~ :'\\i4;:~';;~'1~::' ~,ri:;.:,'lof{SubmnloWoJ<rn8n'.compC.1ff!lJ~"" , ' '" 1 ,', ' " ..: ,;',:, ~:~( 1~~...~,.,.\.l,'t'Q,.":,.'~;t:'''i,,l'I'''''I.~!:.'.~ '.(, ,~' """," ".1',', , ,.' ., ,;., ~\'II~" ."f<~,I~II~IJ'~,..t..I~"V\~ i) .::..,1."" '~""""'~"1''r(\'I.f' I ,I' ' ,. ",I ""1'1' 1'~~:1'i;':fJt":~~I#~~:r~~:U]~<"r.'1i ',~,'lISTHiS'PATla Tswal!t[SF.oFtMEOICA1~e"AEi61Cft.II:n" "', ~ \. ;' ";:t'j ~I' 1 ';!" ,;,~.t,.lr~~r:f;:':"'1~~ ,:~"",':r.,~,;:),~.~" ",;:. ,1" ):: ".)"'11"". 'f" '! ' , 'I ,I, "\r..,,(~,l: : (:,;~,01~i~,t!~l:l:~~I,~lf!~~!9~1:~~;~~,S.;f.o~:,~:~:~~:~Le!~bplq"fij"l '.: : . ' ,'.' .. ,:. " ';,:':'\;'!!it;~;!:~)~ , I,':~d~)~~~, . ,{,. J~.Is.~p.ou$ea.;p oYeO?"'S9,NAME'OFEMPI,OYI!I1:'I' Iv 6'~" "~~ :',,~,di /1", 1; ,,~'~f1.~I.'~!I\,{1t:~. /"'1' ,,"":" '"I. ' , ~! t ~.. ,'( I. " , " . I ~ I '," 'Ij " v. ! 'I'lri~' if; ...:\,01," ' .(~:~:' PI<, f' f.. , ' ' ,'" I' \It :;:.p.., J' J',o;.'! 1~'w"):I~l",t .Fli..\iVlVIPANY:' ' .' ., 11lI'llCY.M' ' " ,.~,l<,;\}'l. ,,,- : .,.r..Jlt',.."\,.""I.,,, -..... . - - ."'1"1" i'1I~"~'~';~:.?"~~"?~I'j~~~~'~i\I:,>:"I!';..:';';':"'~'~:)':.,1 ~ ,.,';;':",;:(1:;":., ,(., ,~..' " ,'. ,', "'~.I.tJ';~:!'I'I\~11 '''''''''''.'~~ld.,.;:~tr'{1'R\~'I.~;."",;"..;.AOORESSt. '. ;', :',~'" ..I I . C' _"., , r \: ,[," ,\,"''''1, ~1,1\11111.!.".r:r""'I"'~~""""" '," , ,'" .", ~--'~"-, , --;-- ,,- ,,1"\:' ,'f'; ,~~1' ,~'J:'I~1~1~'I:~1~1\'f,f/;..,.~,,:11 ~ \.1,./,' ,!~, ,~( '1:'.I'i~ ,'1',., , ,.,', " )/1,. '~, . " , " '1 "''''(~~ :C""i:1'J~t,...",'tl..j/i'~I~I.t"';~"r"l'f, ~,,\.l,. ,,\" ;.:,)/,.(.:,' "i-'" r~" " . ~ '.1",', : l( ..... ~~t@~;q'j:i~cb'u:~i~AND ~\mj9ji,i~~tMJ~..:I~_~~r~~SE'I~F6R,MATIOfl, .: , __ 'i: 'l'~\:"'~'~i::: ~ ~ ~ I.j ~~.fcf~lng l11tr"IMtlon" trv,., it'd c<mrc1.ltt,llhOfIU rn'fhctitt, Clfo P"M~j,. qr\l\lt~ Comp.ny at attla, Qnhty 10 ,.1(1'''' ..."V 'I'fdlcIl6f eM",,", Inlofme-" ,\. 'I ~OWctill'nldtl1'PtI"AdmlnlStr..l(l(of IlioQl'I'nlJi':'-.:" ,1..r~:..::', . '" , I,,' ~., , ' , ','" ;,.' '/,",: " , '"I l~. '.', :',\ '," ,.,. "".'11'1 ,...." - t ..,' '\ , . I . . " ' . " . '\ ",lJ "~J\.~~rl""H,"."."'''",,:, '1 ,". 'PA T liiiT:BiilNA,:i)ii;i",'i ,~,.' ':,', ., : O~T1! 5' ~. "j,:"""~"~' " ',\1''>''''''1 "',' " '" ",,' "'M ~ : ". , ./ .., " ", '1:l'tlt ...,,:~~Il.#~i~h'~!':: l'~"~ ,.", -. .:,'" ~ ~'j ;J~ 'i I . : . leY - -- I~,; ,'t"~', tl ',t~t~'~: 1;'.....;.j~~";~'1(.~:.:. ",t ,',,' .'. ., --.,;;.,1... . -- ""~ :~~'dl, 'H~"'~N.t~I~'/,..l), ":', ."., ~,J ~t . ('.\~. .J: ~ I', ' ' 1 ~:l!: i 11' ,,'1 ... :: ' ': .' J,' ,,,': It,,:(";\~ "" "I~ ;~:;\t~ ~,,~~~l(4\l!':'.' '(',~;',' 'I'.', ), :,~ ',"" . t lI"JI' , ~,' '. " ,,' " I., I , 1\ '.ti ,I," ..1 . ATION,TO PAY.PRO :oEiFf' ,.;. :, ;;'. ','. i,' " ';_ '.:",t;:" ! """, i", ~'" ,I....'" ':, ;., \;".e 'II' 1 ~ ( .... I ~.,..,. "~" , " ' ~ - " I" ,I. '~ ',' ", 'I'. ".1' ,I, "f J' ~ ' ~.~ ~Ur:;.~'P;;';ij~~~l~'J.:O'"f;,"'d1"IP;""d.iil)bf~'II';;;;~7;,;;;I;;;~"";nd".,rMI~"Ph't' "'I.h(.i..""",ldoll.I'. ' ,'''\I,::l:1 ;. t' 1'lJ~~'."."(\"~' ,'.", -' -' "". ~'~"-:"'..l__I._ '. . 'E"' Y. ~~~, I h'Wt1~1It~M*~"/l?";"'~':'~"~~I\"'i"'r"'t,' '1'\ '''., .. SMPLOvee91l]~"TWlf!, ~, ,t .It,.' ,r',:, 'i Oil!!, " ;'ti 'j .' "II i,. .i., lft ~~I.l';,t.l'i~)',;.,Jl,).'P.i-' ."li. ".' '. '., ,~~i,',~,,~'. ." , '" I "'f,,,,' ,,' 1'11" ,1\ I ,,,~' 'f li_. l'~l':\"q,~j.~,~~.',J.~'~'~'''\ \'': :',,". . .",' ~:;/~ :,\'.," :' '10' :,'.' .'",',1-; ... '. ". :' .:.., '(~."\~, "#OJ fl.,\i".(.;'l'Jo~"\\~"" . " I". -----, . ---. I~ ~" ~ -I '1~~'~i'..,~1 "'.'\~I\.'~'.'.' j:t ..' ',i' i I I' " . '. *., ,~,: ", , 'l,' ' :,~~ .' ' ,;~ ,I, f,\'-'~ ~~I' l~ti~1~';~l~1:;li,!1,r"1.:::.ti~li'.. ':i~"""<';i .~l~~"~~~:":."~"" it I :.',1, ',1 ~f' ""~;'~"! "r:~.\~ L~" S'.II.':Ii't!fQ,'1-~P~r\YH.f.S~'AneFlll1(/sI10ULO Be.us"'l;teo Tel C;MSI'~AFli<, , ' ',;: .' ,!!, /ll~ 1;' ,rM~jl~",t ,,~,,~,~,ij~!~d;~E4iH,.(~.\~~ c);MP~~~\~oO:i~~';iM; ~ci;'; ALL 'HPiII1E~T'CONP'HE~E~19, ' 1 " ,',C' Ii ~IJ :It' ~~'.~I~ "., ',""" '.IL"'J,~"',"'" d" I", .,r:, ,I I',' ',ll'.'i.",', , "", ~." ,'" , ,(rt,;tJ ., r"~'.JJ',jlr"I"- 'lll'l..r-U,I', . 'lId\rl'>~I,;;rl'rliV i:UIJ_ UIIITt:O ,~ul L 'It! :j,,' IJC.\ ,I , SMP~Oygilll~NSi'H PL.l1l CO 8 (1,\ ..._,_..... _. _,.._, R!! flAW ..__....._h~~.. 22 23 24 25 11 1 was -- they were my contact point, And they are wonderful 2 at what they do, And theY're usually extremely attentive 3 co chings, and they facilitate our presence on the campus 4 quite well, 5 Q, Could you tell Us what it is that YOll told them 6 or what you said your concern was? 7 A, Over the years I've had a variety of concerns, 8 but I would say that my two major concerns'were probably 9 the security of the girls on the ground level for the 10 students who are living there, because on the back of the 11 building -- I guess it's the west side of the bUilding, on 12 the ground floor -- I guess it's the southwest part __ the 13 windows are almost at ground level, And the southwest 14 section of the bUilding has grating over the windows, And 15 the other windows on the northwest and then on the east 16 side, the ground comes right up to the windows, 17 And I know that I've been concerned about 18 people entering the dormi tory, It took me a number of 19 years, but I eventually got them to put I couldn't 20 think of any other way to do it, I wanted them to put 21 grating around all the windows so we didn't have problems with anybody coming into the dormitory, I eventually got chem to put wooden blocks in so YOll can only open the window about yeah-high (indicating), which is horrible on hot summer days, these ..---- Central Pennsylvania Court Reporting Services (717) 258-3657 or 800-863-3657 or fastfngers@aol,com --.. 12 1 I 'hildr'" "".ly di" Ro' r w" ,bl, '0 g" 'h" '0 po, 2 , blocks, So for the past several summers, either right 3 before the program or shortly thereafter, th~y put these 4 wooden blocks on as stops, 5 My recollection is that many of these have some 6 kind of a stop or block on it, but the college students 7 remove them, because ilpparently the college students 8 aren't as concerned about security as I am'with 13:, 9 14-year-old children in the dormitory, And besides that, 10 parents notice things immediately like that when they come 11 into the dormitory, and quefltion, And so my concerns and 12 the parents' concerns have brought about that, 13 And the other thing was, after the first 14 incident with -- I'm so conscious of these things, After 15 the first incident with the glass, there are six or 16 nine -- I can't remember exactly the design, but they're 17 li.ke a number of small panes of glass, And after the 18 first incident, I remember saying to a number of people, 19 these should be replaced with Plexiglas or something, 20 I mean, if you want to get into what else 21 concerns me, I have constantly been concerned about the 22 crosswalks there, because I am just about fearful of the ballerinas going to be hit and harmed, 23 24 There have been a number of things that I have brought to their attention, 25 Central Pennsylvania Court (717) 258-3657 or 800-863-3657 - Reporting Services or fastfngers@aol,com _..---.J Plaintiffs need to review the Dickinson College records, such us work orders, repair orders, muintenance requests regarding interior doors of dormortories on campus, Plaintiff's deposed Diana Jane Bail', (excerpts from her deposition transcript arc attached), Ms, Bair explains that she has been associated with the Pennsylvania Youth Ballet Summer Camp at Dickinson College for approximately fifteen (15) summers, Mrs, Bail' testified that upproximately two to three years before Chantal LeBoalch's injury, a similar incident occurred to another young lady attending the Summer Camp Youth Ballet at Dickinson College, She was unable to give a specific date, She recalls reporting the incident to Dickinson College and suggesting that the glass be replaced with plcxigluss or something. Next, we took the deposition testimony of Dorothy Warner. Ms, Warner is the coordinator of conferences and special events for Dickinson College, She testitied that she has no memory at all and no recollection of any incident similar to Chantal LeBouJch's incident prior to 1996, She stated that if there was such an incident and if it had been reported to her, it may appear in a note or incident report, Based on this information, Plaintiff needs to review Dickinson's records, as requested. In the Defendant's response to our Motion, Detimdant placed an objection to the Request for Production based on work products doctrine, attorney-client privilege and/or the disclosure of mental impressions of a party, attorney or its conclusions, opinions, memoranda, notes of summaries, etc, Defendant's objection fails on several grounds, First, Defendant is responding to the wrong document. Detendant has responded to Plaintiff's original Request for Production, not our second set Second, Defendant's objection is untimely, as Defendant had thirty days to place their objection and did not do so, Third, the objection fails on the merits. as 2 3, Any and nil records 01' documents maintained by the Public Safety division for any and all injuries sustained by any and all Central PAY outh Ballet students fl?r the period of January 1986 through December 1996, 4, Any and all records or documents maintained by the Physical Plant for any and all injuries sustained by any and all Central P A Youth Ballet students for the period of January t 986 through December 1996, 5, Any and all Central PA Youth Ballet files, records or documents maintained by Dorothy Wamer for the period of January t 986 through December 1996. MORGAN & MORGAN, p,c. DATED: August 24, ] 999 By ~,'\ Melis a Merritts Rivera, Esquire Atto evs tor Plaintiffs. LeBoulch , j , ' I I , \ I, I,.,: 10 .--- 1 similar incident, I couldn't give you a date, I really 2 couldn't, But I know it had happened before, 3 Q, Do you know if it was the same doors that we're 4 discussing today or if they were different doors? 5 A, Perhaps ironically enough, it was not only the 6 same set of doors, it was the same side. It was a double 7 door situation, and it was the same side of the double 8 door, Do you recall what happened in that situation? 9 Q, 10 A, Yes, A young lady put her a:cm through the 11 door, and did almost exactly the same thing as Chantal, 12 but it wasn't as extreme, And she appeared at my suite 13 door, I was not in the RA-on-duty room at the time, I was 14 in my suite, And she arrived at my suite door with her 15 arm bleeding, And I did just about the same thing that 16 happened with Chantal; had a towel, wrapped it up, made 17 sure she got medical attention, 18 Q, From your testimony it's obvious that you're 19 concerned about the safety of the girls that are entrusted 20 in your care, Did you ever have the opportunity to raise 21 any safety issues about the doors or the windows with 22 anyone from Dickinson College? 23 1'.. Many times, 24 Q, Could you tell us who you talked to or when? 25 Usually it was the conference center because I A, Central Pennsylvania Court Reporting Services (717) 258-3657 or 800-863-3657 or fastfngers@aol.com 12 1 children nearly die, But I was able to get them to put 2 ! blocks, So for t he past several summers, ei ther right I 3 before the program or shortly thereafter, they put these 4 wooden blocks on as stops, 5 My recollection is that many of these have some 6 kind of a stop or hlock on it, but the college students 7 remove them, because apparently the college students . 8 aren't as conc~rned about security as I am'with 13-., 9 14..year-old children in the dormitory, And besides that, 10 parents notice things immediately like that when they come 11 into t~e dormitory, and question, And so my concerns and 12 the parents' concerns have brought about that, 13 And the other thing was, after the first 14 incident with -- I'm so conscious of these things, After 15 the first incident with the glass, there are six or 16 nine -- I can't remember exactly the design, but they're 17 like a number of small panes of glass, And after the 18 first incident, I remember saying to a number of people, 19 these should be replaced with Plexiglas or something, 20 I mean, if you want to get into what else 21 concerns me, I have constantly been concerned about the 22 crosswa:ks there, because r am just about fearful of the 23/ ba:leri::as going to be hit and harmed, ! 24 I There have been a number of things that I have 2S I bm,gh, '0 ,"", ""ntion. :encn: ~sYlvania Court Rr,;porting Services (7:71 253-3657 or 800-863-3657 or fastfngers@aol,com I I . I I I i I I " . Plaintiff); need to review the Dickinson College records, such as work orders, repair orders, maintcnance requests regarding interior doors of dormortories on campus. Plaintit'rs deposed Diana Jane Bail', (excerpts from her deposition transcript are attached). Ms. Bail' explains that she has been associated with the Pennsylvania Youth Ballet Summer Camp at Dickinson College for approximately fifteen (15) summers. Mrs. Bail' testitied that npproximately two to three years before Chantal LeBoulch's injury, a similar incident occurred to anothel' young lady attending the Summer Camp Youth Ballet at Dickinson College. She was unable to give a . specific date. Shl~ recalls rcporting the incident to Dickinson ColIl:ge and 5uggesting that the glass be replaced with plexiglass or something. Next, we took the deposition testimony of Dorothy Warner. Ms. Warner is the coordinator of conferences and special events for Dickinson College. She testified that she has no memory at all and no recollection of any incident similar to Chantal LeBoulch's incident prior to 1996. She stated that if there was such an incident and if it had been reponed to her, it may appear in a note or incident report. Based on this information, Plaintiff needs to review Dickinson's records, as requested. In the Defendant's response to our Motion, Defendant placed an objection to the Request for Production based on work products doctrine, attorney-client privilege and/or the disclosure of mental impressions of a party, attorney or its conclusions, opinions, memoranda, notes of summaries, etc. Defendant's objection fails on several grounds. First, Defendant is responding to the wrong document. Defendant has responded to Plaintit'r s original Request for Production, not our second set. Second, Defendant's objection is untimely, as Defendant had thirty days to place their objection and did not do so. Third, the objection rails on the merits, as 2 >" cr:. l' r~- , :J , '. ""I' (T") t." " , I It. Cl ~_;l C-, (~-) U , . - j'.\ ('---.i ~~; .J~'f: <~;, ".1)1 J ,(~ . C';~-~ ),1\1.1 ,[\(:L. ,->~ :.J (-, " ('.;J F" ..~~ -~.. .", , , '1 "I 5, Minor Plaintiff Chantal LcBoulch has suhstllntially recovcred from the above injuries. 6, Defendant, through its liability insurancc company, USF&G Insurance, has agreed to pay $10,000,00 to Chantal l.eBoulch in exchange for a general release, 7, The settlement is beneficial to Plaintiff because (I) all medical bills have been paid for, so that no outstanding medical bills remain; and (2) Plaintiff appears to have made a very good recovery, 8, Plaintiffs retained the law firm of Morgan & Morgan, P,C, to represent them in this regard, and signed a contingent fee agreement providing for one-third fee to be deducted from the gross amount recovered, 9, Settlement proceeds payable to Chantal LeBoulch, the minol' Plaintiff, will he $6218.02, 10, The proceeds payable to minor Plaintiff will be deposited into an interest bearing account in the name of minor Plaintiff, Chantal LeBoulch, with the appropriate notation that no withdrawals may be made except upon Order of Court or until the minor attains her majority, 9, Plaintiff, Deborah LeBou1ch, parent of Chantal LeBoulch, believes this settlement to be reasonable and in her children's best interest. Her statement is attached as Exhibit "D," 10, Upon approval of this settlement, minor Plaintiff's natural parent and guardian, Deborah LeBou1ch, on behalf of minor Plaintiff, Chantal LeBoulch, will be required to sign a release discharging Defendants, and their liability insurance carrier, from further liability relative to this accident. A copy of said release is attached hereto as Exhibit" E, " 06/26 96 20.46 //s / 1112~5.r,r:~),~) CONVENIENT C~,RE/~~ERGJ!N9mY ~~TIQN I ffi&,",mti;,r -'- i:.::J'1~'1:f::"" I' '1 !;; 1~ M S "''''''' 'Ult"" ",,"'l""O' I t 10/13/93 i .~ 356-72 - 480 7 -----~. ~. UJ >- 9 a. ::;;' UJ GUMIANlOfl!) EMPLOYEIl . FLIGHT ATTENDENT UNITED AtRLINES MIAMt. FL . Carlisle Hospital and Health Services Ael . Carlltl~ I I '/AOS/SE In I n LEBOULCH; CHANTAL J. 2014 MERLtN COURT 29942 IAOOIl SS/PHONE/RE~I1ON/008/S(~.8I:C.NO {'I. LEBOULCH, DE80RAH 2014 MERLIN COURT 330-34-0185 29042 ,...--.---.-<"~~ NAME I ,I.DOI1EB..'l1 f.l10HE I flF.LATIO~11 ."JOC.5EC.~IO >- u. i= o z WEFlOGNCV t-IOfIfY LE80ULCH, VANNICK C941 '394-t!SI 1 . 1 B 70 UALFA 05620 --------------~~~------- DEBORAH 03 MIlUICAL 1t-1SUflMlCfi-------..m.-~- .n..____". ,--_... ---~---. CONNECTICUT GENERAL HFQRVlSH LAC TO LT ARM PUT THROUGH DOOR BLASS ~L f,O I^, II:HOltlf\ --_._-~~--------. OERACI, OA9PERE C MO NONE, REFUSED- _~__m'_ "P:-S',/- --~- f'I, E '\J D "I' tJ.ll...:.l-. tio...LL .II.~{. \ ALL ADDITIONAL CHARGES :;l<lI"\~ " .J). QJLLI .? 01'3. U BRIEF VISIT 26100 CAST ROLL, PLASTER CLASS I VISIT 26110 BIP MONITOR CLASS II VISIT PACER PADS CLASS III VISIT GASTROIHEMO SLIDE CLASS IV VISIT 26140 KIDDE TOURNIQUET Cl.ASS V VISIT 26750 OCl. PER FOOT CONVENIENT CARE I 27020 F,S,B,S, CONVENIENT CARE II 27025 TUBE GAUZE PER FOOT MINOR SUTURE EDS01 ED STAT MEDIUM SUTURE EDS 02 PULSE OX MAJOR SUTURE EDS 03 EXTENDED CHARGE I INTUBATION EDS 04 EXTENDED CHARGE II IV SET UP EDS 06 CARDIAC MONITOR EDS 11 PELVIC EXAM EDS 14 ' -- I NITRO SET.UP EDS 16 I I CAST, SCOTCH SHORT ARM 26031 \.._------ CAST, SCOTCH LONG ARM 28032 , I CAST, SCOTCH SHORT LE G 26033 I I CAST, SCOTCH LONG LEG 26034 \.. - .1'81, QV 26075 26037 , -- '\ ('" -=-::: , I II I 7_4 I II I I II I 26060 \.. __ __ M_ .J \.., - ~. .- -" ~ ) 26048 , ' (' "'" -- - ,- " I II I 79670 I I I I 80081 I I I ' \.. ) \.. - "_ - .._ - ._ .. .J .---~.,..-.-.-_..-.-.._------ 26014 , ") r"" - ... .. ,.. - -- "" " ESTAT I I I I I II I POXED I I I I "-________)\..________J 26760 ~""--..-..,- ,- --.. ", (- -..----.--', 26770 I I I I I II I I II I \..________)"---------.J ----... ~.----..,----"'~---- " -----~(- ------, I I II ' II II I I I II I )\..__ _)\..--------J '\ , ,_ ...""::-:::;- '(_=~b_,= ::::..:::-~-:;:-;;., , I I II I II II I I I II I J \.=-=-=-::: _"_' "" j "- - - .J ER,OW6 (REV, 7/114) RELEASE NO ALL MEN BY THESE PRESENTS: That the undersigned, Deborah B, LeBoulch, Individually and as parent and natural guardian of Chantal LeBoulch and Chantal LeBoulch, Individually, for the sole consideration of Ten Thousand Dollars ($10,000;00) to the undersigned In hand paid, receipt whereof is hereby acknowledged, do/does hereby and for my/our/Its heirs, executors, administrators, successors and assigns release, acquit and forever discharge Dickinson College, Trustees of Dickinson College, USF&G Insurance Company and St, Paul Insurance Companies and hls/herlthelr or Its agents, servants, successors, heirs, executors, administrators, and all persons, firms, corporations, associations or partnerships of and from any and all claims, actions, causes of actlon, demands, rights, damages, costs, loss of service, expenses and compensation whatsoever which the undersigned now has/have or which may hereafter accrue on account of or In any way growing out any and all known and unknown, foreseen and unforeseen bodily and personal Injuries and property damages and the consequences there resulting or to result from the accident, casualty or event that occurred on or about the 26th day of June, 1996 at or near College and Louther Streets, In particular, the Drayer Donnltory, It Is understood and agreed that this settlement Is the compromise of a doubtful and disputed claim, and that the payment made Is not to be construed as an admission of liability on the part of the party or parties hereby released, and that said releasees deny liability therefore and Intend merely to avoid litigation and buy their peace, The undersigned hereby declare(s) and represent(s) that the Injuries sustained are or may be permanent and progressive and that recovery therefrom Is uncertain and Indefinite and In making this Release It Is understood and agreed, that the under-signed rely(les) wholly upon the undersigned's judgment, belief and knowledge of the nature, extent, effect and duration of said Injuries and liability therefore and Is made without reliance upon any statement or representation of the party or parties hereby released or their representatives or by any physldan or surgeon by them employed, The underslgl1<."'Cl further declare(s) and represent(s) that no promise, Inducement or agreement not herein expressed has been made to the undersigned, and that this Release contains the entire agreement between the parties herp-to, and that the terms of this Release are contractual and not a mere recital, As further amslderatlon of payment of said sum, I, Deborah B, LeBoulch as parent and natural guardian of Chantal LeBoulch hereby to agree to protect Dickinson College, Tru,~tees of Dickinson College, USF&G Insurance Company and St. Paul Insurance Companies and hiS/her/their or Its agents, servants, successors, heirs, executors, administrators, and all persons, firms, corporations, aSSociations or partnerships, both known and unknown, against any claims for damages, compensation or otherwise on the part of my daughter, Chantal LeBoulch or any other party, Including myself, growing out of or resulting from Injury to Chantal LeBoulch in conne<.tlon with the above-mentioned acddent and to reimburse or make good to Dlckln~on College, Trustees of Dickinson College, USF&G Insurance Company and St. Paul Insurance Companies and his/her/their or Its agents, servants, successors, heirs, executors, administrators, and all persons, firms, corporations, associations or partnerships, both known and unknown, any loss or damages or cost said Dickinson College, Trustees of Dickinson College, USF&G Insurance Company and St, Paul Insurance Companies and hiS/her/their or Its agents, servants, successors, heirs, executors, administrators, and all persons, firms, corporations, associations or partnerships, both known and unknown may have to pay if any litigation arises from said Injuries. EXHIBIT "E" >- (<'I ~<. 'U: N 4~t. ~,. ,. /, I I (.:,~ ~a Oz ( \.'" ~ (j:;r I' "'" ,j . ~.\ C:\.... J ,:)1.: '~ 1(;; (,0 :...~, () 1...-'. I ;.li~ U..i" [;:-11, Cr", , :;:.) ,'f.i od. ~ ji. 0 r..,1 (.;) 0