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(YY THE KETTERING LABORATORY COLLEGE OP MEDICINE, UNIVERSITY CP CINCINNATI EDEN AND BETHESDA AVENUES CINCINNATI 1 9 , OHIO INSTRUCTIONS : BEFORE PROCEEDING PLEASE READ THE REVERSE SIDE OF THIS FORM The i n f o r m a t i o n r e q u i r e d b e lo w i s o f m a j o r i m p o r t a n c e .f o r t h e p e r f o r m a n c e c f t h e s e r v i c e t h a t y o u h ave r e q u e s t e d .

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September 2, 1969 George Roush, Jr., M.D.

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