|
EVELC P M ENT APPLICATION FTZE*NUMSER:
<br /> Owmar. m AMU tc-L McDr-I-(Zaj, I Pre-Acv Med: �n
<br /> Acpllcant: (vim�t=�-\u..2 L f A i=i*ZvS I Fuil-App FiTed:
<br /> !ntake By: t Date Declared Com tete: u V
<br /> J P I Sae'Son No:
<br /> EWIRCNME3ML.PEY1Eiit rnyr > a «•. i^"
<br /> :,.. 21 1993
<br /> Tr'Yvirtct+tr> trrtL>J �itut tt i r 31crri4r >?E � res I v1ENTAL HEALTH
<br /> I7/SERVICES,
<br /> AFS A1il,.NQTIEE.&FlME
<br /> TYPE�1F 1EL'TE't'/ STAFF REd1E'hL :� ��SFAff f1EYlN: : � PVBtIC i1EAR `1
<br /> S T AF^ I QATE"
<br /> �,alcrrais:Scnt: �
<br /> ?c!ermit cue
<br /> AC710 N
<br /> :':;':
<br /> .. .. .....::. -: ... .. ,.. .. .:...,,,::•:.:::w. 'AVS.ILR.......:::.{:{nay{,v,,4;'{;:,5•.'Y`'.�x{•::}ii.;i{ :' 'sxv}aY.;Y:,.�Mt,C�`':Y{yf:}�"w,'•^
<br /> 5tatt.Acilon
<br /> ta(1,orlon ApPeefed
<br /> planning Cbmm{aslonAc3lan.,; y �` `�::`• •?;�`
<br /> •t{Y'.ia� ,G:ihvx•. ?,�?;e`itkv.�`::..
<br /> ..::.Tz::';'s,'ro 'A,•,: ..;e:��4.a»...;..;;s4e:a{:«ro-iec;,h�'i?»bxee;}5::;fY`�''�c.'�'„>.y«�ci:s:Si.
<br /> :•il.?! '{x:..•�f-"%Y': �.pYyvl;i�ipfJi:L'•{:'•�...•'•`iv..R. +.,�•H:4ti%
<br /> ��55�� Si�.^ :•[' .h.:�..vv^' „L%i^^{t�•s' 6.Sfii>'ry S
<br /> •yif' `!+'-••'�:`o��'J.• .�'.x;%at:�.�•Si�•.�.,✓�.3�''!{CiiaTM.M�.:T':4�:JAT �f�{��`�;:
<br /> �.e'�.is�,h.r..,:»:•wTT;:yYo �{,4i>»i.Y�,•ar�,.•.',�•a,'+.�v.:ii �:8,•:.'�"Y,Y
<br /> ..:<£fir..•t '�{? i" S y;';.4.ram-�Y,y.•>.' .: d1
<br /> YYi•. f•• ,{:}, 4�•0�'rG<v}v'v�,'''•�::L�
<br /> �tf:> .�,•,. ���Y.} �,�'f!^':%ifjMry{••-h��'fi9�Je{C�^;...nx:K<::•: :Jx,
<br /> v:^y:PY.(A, \ ::W.fi�.'w'::.m,v:.vn::.:.v.•.h:n',iM"•.:i-�fvJY,!S'riw.-
<br /> �.,�,�.:g.. :�.y.�{/..wn�:::w!:{:}w iA!w'w]^A.:-v'',;i..vw.... ... .•T:;y� V,Y,
<br /> >Pianritnp�,Cammi'ssfe e�Ae3fon�Appealad:. �{«.<;
<br /> Boaid Of SUgeryfsorAtflbr>
<br /> r�f-R•�;yua��T�.. .:i>y:y:�•{' Y:y3niciu.' �%-•'•{.:•J
<br /> % fnw�:..:o-t�<'i���o y�.'.`':%••l.'.,�P',h'•{Yfic!q?u•i'r.eriw�`n`+�?noe�
<br /> d:,i+i;a:::�... fdui{}iafo:Y. ••�'•`%-•��.:.•=rk-�fT�q�e��po:. n:s.wr
<br /> •:�i»:%S:irArN+x!ti-Yrr.O.i.T.Y
<br /> t'2Y'wv.YA3 .'Gii"..LM4y
<br /> w•::M,«..x{a�uL{s.:i•:'.J.m{v✓r:/.•hr::Y�•y,i-'wi�r..•:'y',n+SeY-^ia�a+,e:,..a�.y.�w+:.y.�>::,y.:r_+,.':.wi:T.:<:i"z:«.�..h,,�ya,CYw/;�:'�.•:�":?wv•.'��'•.,.i'{l,�y°y�`°'�G'�.e•.�'�.iv:F"a.{'r'.%-4f,»' a:�W-.�W>''�gc.M'iv•4�`T�':�W"i•5!�'�l.prf�d�f.•3:.N%1 x.p•Ml:
<br /> _
<br /> '<",i�.wY',9f,,if•.H,Fw+::,t.i:::,:x.:.i,-»tj::>7�Y.;;.K.,.b..•f,�iix`xu?.�a•.�Y..,k.a�«.,%�9:�.M1s�. .:r^.,�,.V.aw.'.rF.'�:':'...•-•�•M°;�.xM�'xg7wEZy✓j^,�;fi".�`�.!.%J`a��n
<br /> :
<br /> rR°
<br /> ......i.... �..... aT^ EesTraYoR
<br /> 3.tl
<br /> :i�{::.0 wwx>Tb.•^' N"i#Y.rdH:•i.ATt•�JCM SJ{kw.Fn!M. .^^..•AC"fY,•, �•r�eaa�•M _
<br /> Y�%:st%X::: ..ct"{
<br /> ..
<br /> 'xw. y� ,Y'� � �.:.,:.:.. ��� h , •,.,;,%oY�w: YbLT x"M�ogy! .,v "a3�N+f��.. `'�'- '4^6i r4����T lY�••.r•.�•
<br /> ................
<br /> ox
<br /> Cbmaners
<br /> ;{:1171 PT CY9fTTern#-P}istf>R$27i,TRi�22t}a,,O1e� �" -�E�+
<br /> fmorovemerrtfanssAa ay. •," =�' ,
<br />
|