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MEMORIAL: <br />MEMORIAL HOSPITAL OF SOUTH BEND, <br />INC. <br />By: <br />Name: <br />Title: <br />STATE OF INDIANA ) <br />) ss: <br />COUNTY OF ST. JOSEPH ) <br />On this day of , 2011, before me, the undersigned, personally <br />appeared , personally known to me to be the of <br />Memorial Hospital of South Bend, Inc., and acknowledged to me that s /he executed the foregoing <br />instrument in her/his capacity, and that by her/his signature on the instrument, the individual executed the <br />instrument; as her /his free act and deed, and the free act and deed of Memorial Hospital of South Bend, <br />Inc. <br />In Witness Whereof, I have hereunto set my hand and affixed my official seal the day and year in <br />this Certificate first above written. <br />[SEAL] <br />My commission expires <br />STATE OF INDIANA ) <br />) ss: <br />COUNTY OF ST. JOSEPH ) <br />Notary Public in and for said County and State <br />CITY OF SOUTH BEND: <br />Mayor <br />Attest: <br />Clerk <br />On this day of 2011, before me, the undersigned, personally <br />appeared and , personally known to me to be the <br />Mayor and Clerk of the City of South Bend, Indiana and acknowledged to me that s /he executed the <br />foregoing instrument in her /his capacity, and that by her/his signature on the instrument, the individual <br />executed the instrument; as her/his free act and deed, and the free act and deed of said City. <br />