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Get PA Physician Certification for an Adoption 2010-2021

3. PATIENT’S NAME: 4. PATIENT’S BIRTH DATE: 5. patient’s address: please complete either part I or part II part I: life threat I certify, on the basis of my professional judgement that, due to a condition, illness, or injury, an abortion is necessary to avert the death of the patient. 6. __________________________________________________ 7. __________________________________________________ physician’s signature street address 8. _________________ date 9. _____________________.

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