s (corn examination date) BM: P971011:1X Pa firm &kin , -3-cc- (e E Dentist S;gnature: ( 0-44 CA--Aith-- >DS' Number. f -7‘ 3 i T.• pct.\ InstttutIon: MCC NEW YORK Date: —7 - 2-61 -19. Signature Block/Stamp: C. Antrum DDS. PDF Proscrtbed by Peace Chlet en a cer MCC New YorIc Replaces ii1