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AUTHORITY TO RELEASE INFORMATION I hereby authorize the following physicians and/or institutions or their employees to release to any authorized Tepresentative of the Federal Bureau of Investigation within one year of date any information regarding medical treatment and/or hospitalization received by me: VA_H OSPITAL co ene ent YEAR DIVE _Prrrsnurcy, PB I hereby release any such physician and/or institu- tion, including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request toe release information, or any attempt to comply with it. b6 b7¢ Tuli Nome: LOLBualLUa Full Name: Parent or Guardian: (If required) Date: Ci S, ? Current Address: b6 b7c Witness pec Be (Federal Bureau of Investigation)