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1'Ol.:h4 G <br /> I PLEA�E FURNISH SERVI�E(S) INDICATED BY CHECKED BLOCK(5). ; <br /> REQUIREG FEE(S) PAID. <br /> ❑ Show to whom, date and address ❑ Deliver ONLY <br /> where deifveretl to addre ee I <br /> Rec¢tred tha aurri6erEe4E't�e dercrtbed Le(nw. —� � <br /> RECIST[AFDNO. 316C4TUAEURIUMEUFAU�RFSS[E�fwtah��ayibefi!(�:jR)— �' <br /> ? � � i <br /> � cunFlcono. �� ;'�- c�- "• ; , ' lh Lhc follo�ving ` <br /> S�09S _ �'L��, �,2__ ' <br /> fIGNATUALOFADDpEtiEi'SAc[fli,IfAHY �'�C `�j;�' `i���� ��iS— <br /> IRURmHO. , ,., � tl(� ON1]C'I'�5� USll31 � <br /> zpG/ �`<-,�1et-f��LC ercinl�clo�v: i <br /> D6TC DEUYWIA SNOM IYH�tE o¢IYO�m(ar/�i/xq.etrd) I <br /> � _d Date Served <br /> G/7 7 Y -- -- <br /> RECEIPT FOR CERTIFIED MAIL-30�� _ <br /> '— scnr ro ros*M.+K � <br /> in /� _ ON DATE <br /> O) zir,ut�r�ona. '�'_ <br /> � -) U,. �I '; I;, .. ,,._.. . 1 . <br /> 1.[� " — <br /> '--"' -- � P.O_SidE,�ND Z�V CODE <br /> � - / .' .. .- '.�! �_ <br /> . CtiN1 SERYIC(S f0A �DOIpOXII f[[S � .. <br /> N�Ivrn Rmip1 n�Cn �6� <br /> Shnn�.�o whn.n Shnx�.en u�,on�, I AA ' e •�( n/y . ' <br /> ndtlnt• ,Inn�. nd.. � <br /> Odrfineretl Jrl:�n�.dr `_.I SQ� lee . .. <br /> � ❑ lOt Ice Lf J5f 7ec ;tCPecl <br /> P00 fcrm 3E�0 NO INSURANCC COVEN�CE PNDVID[D- (S�c ofhcr side) �CC� ' <br /> Inni.1%4 MOT FOR INT[RN�t10M�L A1111� <br /> addrecsed �u�d on thc dntc ect forth hcreinbclotv: . <br /> C�vncr I.�unc Mail Address Dat:c; Mai]cd <br /> ' Ncil Danard 2801 liewitt Avenue, Everett. Wn,_,—_ �+�^�.�a,?Q?2- <br /> i <br /> - . _ � U,�,� �" L��°`� _�L .. <br /> Robert K. Rovice ' <br /> SUI3SCRI)'�L:D AND S\YORAT to Ucforc mc this _day of . 19� <br /> I <br /> NOTA7:5' }'UliL1.0 in and for Lhc Statc <br /> (S]'sAl�) o� �h�a:hinglon� residin� i�i __u <br />