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I I — Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 16 of 16 <br />Name: <br />Name: <br />Address: <br />Address: <br />City, State, Zip <br />City, State, Zip <br />Day Phone <br />Day Phone Number: <br />Evening Phone Number: <br />Evening. Phone Number: <br />L\ <br />Comments: <br />-o <br />I a Lf- 5-1 <br />R L> ('V- <br />4 <br />V <br />Y, "W. <br />L 'U) <br />A <br />V)orx <br />, -) Y <br />17SO, <br />e - <br />N <br />J <br />'\V <br />REFUSAL OF TREATMENT <br />have been advised to seek <br />emergency medical treatment and transportation to a hospital or emergency <br />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 />