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''UBLIC RECORD "RELLASE RF0161 <br /> 1 . REQUEST RELEASE DATE <br /> REQUESTING AGENCY S, � PHONE NO. <br /> 3. AGENCY ADDRESS ,�22 ZZ-25&x <br /> 4. INDIVIDUAL REQUESTING !J/try �[ / cczo i PHONE NO. _��7 - ^qo0 <br /> 5. INDIVIDUAL ADDRESS 7-?/ lu . ya✓✓i sdN ST. sf/rel ( B7 <br /> FILE //ADDRESS / I//TEM REQUESTEDDATE �PURPOSE OF REQUEST r <br /> *ASTERIS ITEMS REQUESTED FOR P OTO PYING <br /> SIGNATURE OF REQUESTING PARTY r� ,� > � � DATE LS <br /> LOCAL HEALTH DISTRICT USE ONLY <br /> PROJECTED RELEASE DATE <br /> SIGNATURE OF RELEASING OFFICIAL DATE 7-,5o Ss <br /> NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND MONITORING OF THE RECORDS. <br /> EH 00 14 4/81 <br />