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Er Male Female Mom discharged w/o baby Middle: Baby Diagnosis Code & Gestational Age Yr Discharge Date Mom discharged w/ baby Maternal death (1) Baby First Name: Day Weight (grams) Middle: Birth Order & Weight # of Weight (grams) / / Mo Day Yr Last: Care Level Normal Vag Del Level 1 Normal C-Sec Level 1 Complex Newborn Level 2 Neonatal ICU Level 3 Last: Care Level Normal Va.

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