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Retain Mr Indicate: Promote (P) Retain (R) - Indicate: Promote (P) Retain (A) 01-93d0 EFTA01709793 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032, s. 64D-3.011, F.A.0 and s. 65C-22.006, F.A.C. LAST NAME J PARENT OR GUARDIAN D i r e t t i o n C • Enter all appropri
ve if additional space needed) C. LABORATORY (as indisated)., Hemoglobin /Hematocrit /cam • -6 NAM TITLE: ADORES (Please Print) Stool (0 & Tuberculin test: Sickle Cell ‘in Date 1ype -Fist date 7 / 34 1f results 9 OH 3040. 10196 (Riableces HRS44 Form 3040 which may ,(Stock Number. 5744-000-3
be between 1750 and 1856. NT-Not Tested NR-Not Reported Data Run Date: 11/22/2004 0115263 EFTA01710024 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032,8.64D-3.011, F.A.0 ands. 65C-22.00C F.A.C. FIRST Child'sSW (optional) MIAR IM DO MO/DA/YR STATEIMMUNIZATION ID#' Dire
s I •• •r aM) (attach narrative if additional space needed) .:• C. LABORATORY (as indicated) • type Hernaglobin/Hematocrit Stool (O & PI Tuberculin lest " results dte Lead Sickle Cell NAME TITLE: ADDR (Pleas. NRS-N (Stock EFTA01709998 .ms 1%3 (344) OFFICE of VITAL STATISTICS CER
I PHYSICIAN OR CONIC NAME (PLEASE PRINT) JATELY IMMUNIZED AGAINST 'DANCE. -//,1/2,73 DATE EFTA01710101 FLORIDA CERTIFICATION OF IMMUNIZATION Legal Authority: FLORIDA STATUTES 232.032, a 10D-3.088, F.A.C. and S. 10M-12, F.A.C. ATE PARENT OR GUARDIAN FIRS I MI DOB moinAnta Child's 5Stt (optional) ST
Injur•es explain) (attach narrative if additional snipe needed) C. LABORATORY (as indicated) It. He-nOglobtrilklematocrit Stool 1O 8 P) d Tuberculin test. Lead Sickle tell r NAME: TITLE: ADDRESS: • (Please Print) A MRS -N Form 5040, Mar 91 (0bsotetes previous editions LIM Oat am
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