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Application for Long-Term Stay at Lasata Care Center

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    1. Personal Information

    2. Gender

    3. Religious Information

    4. Funeral Arrangements Information

    5. Do you have a funeral Trust?

    6. Residency Information

    7. Out of County Applicants: If you do not meet the residency requirement (currently living in Ozaukee County for at least 1 year), indicate the name and address of an immediate relative who does meet the residency requirement: