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DOC request three complete - Cannabis Defense Coalition

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OFFENDER I.D. DATA:<br />

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STATE OF WASHINGTON<br />

DEPARTMENT OF CORRECTIONS<br />

URE OF HEALTH INFORMATION<br />

I, hereby authorize the use or disclosure of my health information<br />

as described beiow. The following individual or organization is authorized to m~ke the disclosure:<br />

NAME: 'Ttl Gr \(Y\:-U\t co..l (\ J I '(\ \ Gs<br />

ADDRESS: \ 8' \ 't:, \O\..:)-t rl /We., Y'\G h+ ZA ~ .<br />

, b0~ k.,\/\A .... L w"f:: q 2:;1,) ~ 'S.- , ,<br />

(l.-\X') ~'1oq- ColbY:>' tux (LlJ'S")B£F\- Lp31~<br />

The type and date( s) of information to be used or disclosed is as follows:<br />

O--rvu\\~~'m~~m v..(.A

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