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' . • SNOHUMISN HEAL�H DISiRICT <br /> Courf Houu , <br /> Evenft, Y'ashi�lon ��� <br /> / � <br /> COMPLAINT SHEET <br /> The following musf be complefed tn full . Date g— .�' f — �� . <br /> ' �, <br /> Nonr of P�rson causi � , <br /> allep�d complaint • • <br /> 7 � <br /> Address or direcfions --�� � ���� � <br /> r <br /> Nofur� ofall�gtd eomplaint �„ �_ � �. �.. __ e. c7J � .-/� _e P) <br /> --_�-��..J f m .���� �(1 ���r.��.iA, � 1 <br /> Name of P�non Reporti� �?lease si9n)_ � 4�� _ _ � <br /> �4�{— <br /> Addrea / <br /> Phone <br /> •se..• . • • • • a � fa�� . . . • r• . r• •r •• .�s <br /> DO NGi WRITE SELG�A' TMIS LINE <br /> f�����f��f�ttH���f R�f}R�f�������tft��fi�if��f1�f4fif��H�i���������f t�f�x x>t fttM• <br /> Invesligohd by_ � � �_ . �f11 Da1e _ <br /> Condifioro found�� � � <br /> P�rson (�)eentacted <br /> Actio� loken � /�a , c+ - - �- ' ) �'n �J �" <br /> ����. ��..4�_ � I/. .J �-a ��G .� % ^— �u .� G � <br /> - -� _ �_ � �_� <br /> 1� - �- r7R._ �.r[.. Y. . ., � j t - 1' � � ' <br /> � ' ?"' �' <br /> . � <br /> 5168 <br /> , ... ...�_.._.... . <br /> _JI <br />