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N BLIC RECORD RELEASE REQUPT <br /> 1 . REQUEST RELEASE DATE_ 7- 20_ � <br /> : REQUESTING AGENCY PHONE NO. <br /> 3. AGENCY ADDRESS <br /> 4. INDIVIDUAL REQUESTING a N - &&HONE NO. Z7S x937 <br /> 5. INDIVIDUAL ADDRESS 4/ S0 X . 4A MDS 16L <br /> Fak 9N o efA <br /> FILE ADDRESS ITEM REQUESTED DATE PURPOSE OF REQUEST <br /> =TRISLT+"QUESTED POR PHOTOCOPYING <br /> SIGNATURE OF REQUESTING PARTY DATE <br /> LOCAL HEALTH DISTRICT USE 0 ZWPIC-IS <br /> PROJECTED RELEASE DATE -Z — <br /> SIGN TORE OF RELEASING OFFICIAL DATE Z� <br /> NAMES FST F MfMERS INVOLVE I HE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />