RADIO Loa -v. ASSOCIATES
(KEY)-026372663051-1RACtIOLOGY
1176 FIFTH AVE 1ST FLOOR
026546464530, NW 10017
RI -IONIC: 21 2-241 -6381
Name: JEFFREY EPSTEIN
Card Number: >00000000000001"
Card Ekn Data: >C></>CX Card Not Present
Transaction Type: AMEX SALE
Merchant 10: 9334822
Transaction Amount: $50.00
^tin, Code: 161404
Ticket tt: 87170621
Invoice tit: 720691'3
[Date: 11/15/13 11:14:41 AM
CAFt0IVIEMBEFt ACKNOWLEDGES rxeceurrr OF
GOODS "NJO/OFt SERVICES IN THE AMOUNT OF
THE TOTAL SHOWN HEREIN ANJO AGREES TO
PERFORM THE OBLIGATIONS SET FORTH BY
THE CAIROMEIVIESEFt's AGREEMENT WITH ISSUER
SIGNATURE
CUSTOMER COPY
Mount Sinai Radiology Associates Date: 15 1/41Dv OiLc) 01- 02225
1176 Fifth Avenue, Box 1235
New York, NY 10029-6475
212-241-6381
1.
Rr eived from: £PSin $ ars25 tb+DVY)
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datient: ,0
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DOS: DH ft .4. DO LS
Amt. of Accoun (2) CC
Amt. Paid Cash
Balance Due /o Check #
Operators Signatur
EFTA00313837