& s._-Qj n , "3"--e5V- -it E. Dentist Sinalere: C 4_44.4.44,4...A.Aial>17.5 r Number. ' 76 3 Æ 059 Insttrution: MCC NEW YORK Date: 7-U.--19. Signature Mock/Stamp: C. Ancrum Dot PØ Prescribed by P6400 enter en MCC New York • Replaces: 6P-A061801JUN 10 EFTA00049330 BP-S353.050 SEP 05 U.S. DEPARTMENT