| OCR Text |
Show .\dmitted •To, ame and .. <ldress of Patient Birthplace Occupation • Tame and Ad 1ress f Relative or Friend /, ,. &; 71 ijGI 1 7 , _ ~~ /~ • -- { ~?/~ / ~~:I ~ -.. . . .~ A / . ,_ . 7:; ,, /, J'oJ , c_, ,:.> u (, ?1 /I ,;2.j' II tFo I )-4 I ,, / , II I - I/ "' II I///, ?!~ //,/- // ,. lt - 11 I/ ,, I(, - " I - // (' // ,. - I ,, I/ ~ ~ ' . I -~ d ' ~ - 5 / ' ~ ~ I aLv ~ ~ - ~ ~ - (JJ /r;;;v/ /~~~~ /~/ ~4 . / ~ 4v.~ A ~ ~ ~ d ·- y'LJ tF- // ,,. '1 - /I " . ,r h l1 I @,l~ 4.~ a 1Y ~ II r:1~ ~ - ., -,7#J, ~ -~ ? / ~, ¥,~- $ ~ _§/ ~ , ~ -~J I/ , I/ I/, /. . ?fr~~-~ . ~,-:fr- //6/G. 1 1 /r..rd J. . /'Al tf: ~- ~ O ? t f l ~C:~ ~ - ~3fo~ a(74Jf~?:~-~:::5~ ~ , . _ ,/f--C-7'~ . . ~J£,,,,/f;/;;J, # |
