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E print legibly MUST be filed in accordance with NYS Penal Law Section265.26 MALE FEMALE VICTIM'S NAME (Last, First, M.I.): SEX: VICTIM S ADDRESS (Number, Street, Apt.): DATE OF BIRTH: CITY, TOWN, POST OFFICE: STATE: ZIP CODE: TELEPHONE NUMBER ZIP CODE: COUNTY ADDRESS WHERE BURN OCCURRED (Number, Street, Apt.): CITY, TOWN, POST OFFICE: DATE OF INJURY: STATE: PERCENT BURNED: % TIME OF INJURY: HRS. AREA OF BODY: Face/Head Neck/Shoulder Chest/Abdomen Back/ Buttocks Groin/Genita.

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