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5207 Melville Road n~r w u 5207 MelVi.lle Rd 'te C~ )"a0
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,.r.~ Fredridc William Hansen ~TM Ma~h 18 1966
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ll~tk l~k Il FATMEII'S M~ME 1~. YOTNER'S w10EU IurE
s~~~~rse~r Q1Y`1StL~I1 I~dTLSeJI Amanda Nielson
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MIOIIK AT1W~K
21. 1~tt~nd~d tM d~a~wr/rom t• ~ 6 . to i"t dY'• f /ut Nw h,'~a~ di~~ on ~"~dl~. sl ~1966
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~11 lt~as 72~. NOIMri11t (DMa~rt6k) ?IA AoD11ESS ?7t. MTESKMEO
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a BernarZl D. Rass, M.D. Pt. St. Lucie Shaunin Ctr. 3-21-66
atta~at~. ~u. j~. ~yE pi CEyETE~Y OIl CREYATOIlY Z1/. IOCAT1011 (G~ff. ~s- M as~h) ~bT~~
tRlT'1d1 ~ 3-21-66 ~11$E ~ ~'.@iflBt@ Ple'T`~
v. s. ~eia zt. swciu? c ae s sr.~u?ruec901 1~:: "~t11 St • 2S. DATE REC0. ~V WCAL REC. . REGKTMR'S SIGMATURE
A...~oes Miltcn W. Baiid Ft. Pieroe ~
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" ~ERIFIgD ,
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.i~ittifj~ thb to be a me and cornct copy of the Loul F
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d~~rs' t'~°° r
d on file in the St. Lucie CouMlr Health Dsps~t- c
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Y~' R R B E D
- , ~':.-'rn~t--at:~t ?iaroe. Fbtida. , - -
wlid unleu rsised seal of the St. lucie 0 K
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t Heslth Department is sffixed.) , ~ .
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~ , N. 0. MIIIER, M. D. 1 y 7
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' R ST.fLUO? ~ ~as. CLERK
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~ ~ ~~n~ FLORfOA
C~•r ,
BOOK~~
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