ntist Signature: (1 L) ,_44.x.m..a,.."... tzT25- istf s --Cfn i Number: 76 3 I (C..- OSN Institution: / MCC NEW YORK Uate: —.7 - 2 6 1 -19. Signature Btoa/Stamp: C. Ancrum DDS. PCF Prescribed by PCA07 fer tJental icer MCC New York Replaces UP-A6618o1JUN ID EFTA00049640 Bureau of Prisons Health