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RABIES VACCINATION CERTIFICATE RABIES TAG NUMBER <br />NASPHV FORM 51(Re vised 2OO7) 1 10887 <br />I <br />MICROCHIP NUMBER <br />!Owner's Name & Address <br />Print Clearly <br />067 *858 *380 <br />LAST <br />FIRST <br />M.I. TELEPHONE <br />1 JORGENSON <br />MADELIN E /PETE <br />(541)998 -1487 <br />-- <br />- -� - -- <br />_ RI97448 <br />�NO STREET <br />NO <br />CITY <br />1 810 WALNUT ST. <br />JUNCTION CITY OR <br />SPECIES SEX <br />AGE SIZE <br />PREDOMINANT BREED PREDOMINANT <br />Dog X Male <br />_ <br />i Months [� Under20lbs <br />X <br />❑�LabradorRetriever <br />COLORS /MARKINGS <br />Cat ❑ Female <br />❑ 1 M 120 - 50 Ibs <br />' <br />Other EEJ (Neuter <br />_Years <br />X Over 50lbs <br />XINAME <br />[(Specify) <br />—_��- __ —J_- - -_ -- <br />- <br />Paco I <br />('Animal Control <br />License ❑ 1 Yr ❑ 3 Yr ❑ Other <br />DATE VACCINATED <br />PRODUCT NAME <br />Veterinarian: Breenna Buxton, VMD <br />07/08/2013 <br />License No: 6051 <br />MANUFACTURER ;- -� <br />-- - -- <br />(First 3 Letters) FM I E + R <br />NEXT VACCINATION <br />= — <br />Veterinarian's <br />DUE BY: <br />❑ 1 yr USDA Licensed Vaccine <br />Signature <br />X07/08/2016 <br />X 3 yr USDA Licensed Vaccine <br />Address Countryside Animal Clinic ~ i <br />I D 4 yr USDA Licensed Vaccine <br />225 W. 4th Avenue <br />j ❑ Initial dose ! Booster dose <br />Junction City, OR 97448 <br />18183B <br />__ Vacc. Serial (Lot) No, <br />