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Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 12 of 16 <br />n <br />Name <br />Name <br />11 GeiZA– 6�' �Ei'l� <br />— <br />A ddress: <br />� Address: <br />— <br />City. State, Zip <br />City, State, Zip <br />Day Phone Number: <br />Day Phone Number: <br />Evening Phone Number: <br />Evening Phone Number: <br />Comments; <br />iiLoav�-. s�r�i'tb �.+&e_ S7) 1 t/sC+0 1'.-qA-r, E -$c -o; <br />"�5�G3�-. c b � '��..i� .�� '�' •'� ft -2 ?.A i 6E�. +QS L. <br />t, sAs Sz�4-RTI t <br />17�v is tiz ta��� <br />s�o�4. •`-.,� `�'t2�bf=��1 �c�.n,r�G�.�--� �,�,iZS• �-�GT'a� La e� Ei?.c�l�, c� <br />A s"�`i P�- a� a � Dc ElrSt� I p�,Jz Z �- ii i� t �1✓S _ ►Z1,eTL9,e - WAS <br />ttua_ �/D L� �Atc��f�- , +.�a�W bk_4t, <br />A t.;�� � AIr s. �..�.--� •� � '? ci.....rl �t� � L� �? � ' ci G%� C-�.vt.� r�e.� . -� t �4=c..�` � l.� � G <br />4 _te-PvLu An <br />REFUSAL OF TREATMENT <br />I have been advised to seek <br />emergency medical treatment and transportation to a hospital or emergency <br />l clinic. I hereby refuse to accept emergency treatment and/or transportation <br />to a hospital or emergency clinic, and further hold harmless Kittitas County <br />"and its personnel from damage and/or claims that may arise from my refusal <br />of services. <br />Signature: <br />Witness: ......... Witness: <br />Date: <br />