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Siletti,Pamela E. NEWYORK 4AlE DEPARTMENT OF H EALTH Barlal - Transit PC= Bureau oArm Xe[ONa Name Fast Middle Li man ParmuM eb E.sw Dommi Barn Ag nwe"DomSAmiee Fortet DMrNwm mre.. wa,nrome: F. Pluolnoln StarPHdLinstiluem Ol 2 Le .iownorVi G4na Feld $Irtel Atltlre35 Gla^s Feb Xmpiml w unaeXwmm vemird wManre,d cean ®xan,s care ❑Audem ❑mmkiee ❑waee ❑curcur as mW, w Mea'wlceni(e, Name T"h 0 Sean Am, Adul -: rW Far St.Gland Felb,New Yale I [er Dears Lenilxax Fdeal MisstatementRussell CilY. "noNil fAmaFW `+n]1 ]A F01dunar DM Lammers,usual OF falM/Ores M1Y✓LQl Al New Gen•Nry QEnlomdmenl Address x Commoner puavmdry Tam.New rak ❑Donation Z ❑ m nenal Won PIECEPIECEPenmetl 0 and/or anep,lark N Hold Admoss N ❑4amp,mmion wR thud Fj ey Common nlon Career pe3un Dominant Dee Ome"rYAmr Femaleness Dole <mwrery Aaarear Permillsumdm PLpP,d'wn XumEer Nameol funeeallbme Alewnde Sawr Funam Xmne ttNT Aeerea, ague Main St WamneWg.Nw Yen 12M Name or FwarY film Imen Dun)( itwn orm Writer r Ramaivar i nOlherNan A}me E Address Of Q. ParmlaYon Is hanbY grained W dieXaea of ma human mm ns deevibed above as indleebtl. Dale hard aermnDm "Armw VIAlmnics xecmanswnwdrrcD..marmar dbwa9 vro+wai Dowd NomM, Sea Peat aerc Fail Nw Gres eenaY inn Are remalntAm aaedem Warner ahoeewem Finessed of in amwee wire mmPemia on: WDale of Domino $IN IV PlxeaoisFosuon E yPresent martimMl gname of x.Nn o,Reform in Cars of Pmnr n L °"T Time n � W sronnure wz Ti e DOHIwiveriMPlaf2 i Public Halth law Sec.4145(26) 012738 Receipt Hum mmmn of de in on f LO M 1 no<r ame�wy K nnq uK tuow m�o.mm