Laserfiche WebLink
, , , � <br /> APPLICATION BY PEACE OR HEALTH OFFICER FOR EMERGENCY ADMISSION <br /> STATE OF MINNESOTA <br /> COUNTY OF � ��� <br /> CITY OF � c �,� �,l <br /> �_ n � � <br /> In the Matter of �'" 1.�.� i ��'��- � �-�� S �"3 ° E <br /> t, ] <br /> Address: � � � � '�w c+ <br /> C e���� �'l� � �3 �s � <br /> I, the undersigned, being a Peace or Health Officer (as those terms are defined in Minnesota <br /> Statute §253B ��e,c�.) have taken the above named person into custody and hereby direct <br /> that he/she be transported to a licensed physician or treatment facility. I believe that the <br /> above named is mentally ill, mentally retarded, or chemically dependent and is in imminent <br /> danger of injuring himself or herself or others if not immediately restrained. This person was <br /> taken into custody under the following circumstances and for the following reasons: <br /> � < < � <br /> � 1 �- � � v � t s �� v� � � t.� � � � � �,,-� �7 � �� � r c� <_r <br /> � c� l� , ��,1 L �� � ; � , � t /� /� <br /> � e� �N-.�7 � �a v �z � � 1-� t ��ccs�� <br /> i � � � <br /> �'ll�'� svs p� � '� s � ��F�� �� �v� i.� � l � c��� �r , j � <br /> i. �� ( �.cs S nes.-. S S � � <br /> � C e+t'L P� �e+ � C C�L U `T ��1 Nt S-C ( �' ` f'�C �t S ��,��t p c � ( � • <br /> i / � � �D�ir <br />— - - � e,�a�G,,c 5�.yL C7 Q ts 't�t�� �'tf� . .o l.c'C�:-F `�--lj��r9 Z9 .e�-c`�i a= � � <br /> I hereby apply for the emergency ad�is ion of the above nam�person to: ` <br /> �t9 � �-� <br /> � � � <br /> Date: � (� ' Name: � t t S �I s c � <br /> Signature Agency: (�.► e�,. t, �°� <br /> Address: <br /> Phone: �'t � �-- ���— �` 7 (J�� <br /> Transported by:�,���� �� <br /> � <br /> White Copy: Treatment Facility Yellow Copy: Ambulance Service Pink Copy: Police Dept. <br /> F-327 5/25/99 <br />