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HomeMy WebLinkAboutMisc Letters, disability letter i ...__i..a::......._�_ ._ ._....v.w��.�.a.•�o:���: - �:��• ..�..._. �3 — -.�iv-:rya uc�iL2? -St. Lucie Gaunty Phr/sician's Certificat'on of I Total acid'Permanent Disability = Parcel ID Number (for Cate Compliance use c mly) Physician's Name (Please Pri A physiciart licensed pursuant to Chapter 458 or Chapter 459, Florida Statues, hereby certify LQ t i larn Patient's Name (Please Arint) residing at: W=rul Patients Addrew is totally and permanently disabled as of Z) due to the following mental or physical condition(s): Date Quadriplegia Paraplegia Hemiplegia egal"Blindness Other total- and permanent disability requiring use of a wheelchair for mobility Please check-here if patient is totally and permaneritly disabled but does not require a wheelchair for mobility It is my professionaf belief that-the above named condition(s) render this individual totally and ermanently di bled and that the foregoing statements are true, correct,and trom to to be of my knowledge and professional belief. Signature: Date: 5 r f Address: 1 t f, Mice. 456 W .jb 33g01 I Florida Board of Medical Examiners License No.: Date License Issued: "