1 IN THE CIRCUIT COURT OF THE STATE OF OREGON
2 FOR THE COUNTY OF JACKSON
3
4 In the Matter of the Marriage of: )
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5 SUSAN SAMORA COUTSOUKIS, )
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6 Petitioner, )
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7 and ) Case No. 94-3846-D-3
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8 PHOTIUS COUTSOUKIS, )
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9 Respondent. )
__________________________________)
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13 PERPETUATION TESTIMONY OF
14 HELEN SKOUTELI, M.D.
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16 BE IT REMEMBERED That the perpetuation testimony
17 of HELEN SKOUTELI, M.D. was taken as a witness on behalf of
18 the Respondent before Debra J. Dugan, a Certified Shorthand
19 Reporter for Oregon, on December 4, 1996 beginning at the
20 hour of 9:35 a.m. at the office of Patricia Crain, 800 W.
21 8th Street, Medford, Oregon.
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1 A P P E A R A N C E S
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3 FOR THE PETITIONER: PATRICIA CRAIN
Attorney at Law
4 800 W. 8th Street
Medford, OR 97501
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7 FOR THE RESPONDENT: CRISTINA SANZ
Attorney at Law
8 900 W. 8th Street
Medford, OR 97501
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15 C O N T E N T S
16 Examination by: Page:
17 MS. CRAIN 4
18 MS. SANZ 20
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1 S T I P U L A T I O N
2 At said time and place the following stipulation was
3 entered into between the attorneys present in behalf of the
4 respective parties:
5 IT IS HEREBY STIPULATED that all irregularities as to
6 notice of time and place and manner of taking said
7 perpetuation testimony are hereby waived. Parties have
8 stipulated to perpetuate testimony pursuant to ORCP Rule
9 39(i), and waive notice and objections to notice.
10 IT IS HEREBY STIPULATED that pursuant to Rule
11 39(i)(6), the perpetuation examination shall proceed as set
12 forth in subsection D. All objections to any testimony or
13 evidence shall be made at the time of the deposition and
14 any objections not made at the deposition shall be deemed
15 waived.
16 IT IS HEREBY STIPULATED that the reading and signing
17 of said perpetuation testimony by the party and the filing
18 thereof are hereby expressly waived.
19 ---oOo---
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1 HELEN SKOUTELI, M.D.
2 was thereupon called as a witness on behalf of the
3 Respondent and, after having been first duly sworn, was
4 examined and testified as follows:
5
6 EXAMINATION
7 BY MS. CRAIN:
8 Q Could you please tell us your full name?
9 A My full name is Helen, with an H, Skouteli,
10 S-k-o-u-t-e-l-i.
11 Q And of what town are you a resident?
12 A Athens, Greece.
13 Q Could you tell me just briefly your medical
14 qualifications?
15 A I'm a medical doctor of the University of Athens.
16 I'm a fully licensed pediatrician in Greece.
17 Q You also practiced or studied in the United
18 States?
19 A I was a research fellow at Childrens Hospital in
20 Boston and a research fellow in epileptology also in
21 Boston; three years, not in a row, in various, you know,
22 different times.
23 COURT REPORTER: Could you say that research
24 name again, please?
25 THE WITNESS: Research fellow is a
5
1 fellowship, but, you know, people who are research
2 fellows, they do not practice clinical medicine;
3 they're involved in research studies.
4 BY MS. CRAIN: (Continuing)
5 Q The court reporter did not understand the word
6 that you said for the research that you were in, the nature
7 of the research?
8 A Well, I was a research fellow in pediatric
9 neurology, which is my field now; and a research fellow in
10 epileptology, EEG, electroencephalogram. I also spent two
11 and a half years as a registrar in London in pediatric
12 neurology at Hammersmith Hospital; that was prior to my
13 coming over to Boston.
14 Q What was the name of the hospital there again?
15 A Hammersmith; for post graduate medical school.
16 Q Thank you. The court reporter is attempting to
17 type down everything you say, so we want to make sure we
18 get the spelling correctly and the pronunciation, so that's
19 why we keep interrupting.
20 A Sure, no problem. Hammersmith is
21 H-a-m-m-e-r-s-m-i-t-h.
22 Q How long have you now been practicing in Athens?
23 A Since 1989.
24 Q In the course of your practicing as a doctor, did
25 you come in contact with Theodora Coutsoukis?
6
1 A Oh, yes, yes, twice.
2 Q Can you tell us the nature of your first contact
3 with her?
4 A Our first contact was when the family was
5 visiting Greece in, what was the year, if you could help,
6 in 1990, I think, when she was six months old. When was
7 she born?
8 Q Hold on a second, I have to look.
9 MS. SANZ: I think it's 1994.
10 BY MS. CRAIN: (Continuing)
11 Q 1994 perhaps?
12 A Yes. Well, the first summer of her life, put it
13 this way.
14 Q That's fine.
15 A The first summer of her life, the family was
16 visiting relatives in Greece, because Mr. Coutsoukis is of
17 Greek dissent, has family here in Athens. So when they
18 came, they saw a lot of pediatricians who saw Teddy --
19 Theodora -- and she was, I believe, either six or nine
20 months old. And he was a little, you know, concerned about
21 her neurological development; not the pediatric
22 development, the physical characteristics, but the
23 abilities and the milestones.
24 So this pediatrician referred her to me and they
25 all came to my office: Mommy, daddy, Theodora, and
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1 Theodora's aunt, Mr. Coutsoukis sister, I believe. That
2 was my first contact with the child and her family.
3 Q And tell us what you observed?
4 A From the medical point of view, or from the
5 social point of view?
6 Q Both.
7 A Both?
8 Q Yes, please.
9 A Okay. Well, from the social point of view, nice,
10 kind people, you know, English speaking, they preferred to
11 speak in English so that mommy can understand as well. You
12 know, no social problem, I mean obvious to me or anything.
13 From the medical point of view, the child was, had
14 psychomotor delay. She was behind in all areas of
15 development: Motor, and interactions, social interaction,
16 mental areas.
17 Q What did you do?
18 A Well, I told them that I think that she's behind
19 a few months. I didn't, you know, aggravate things a lot
20 because apparently I was the first one to announce the
21 news. And, you know, it's difficult sometimes.
22 Q For parents?
23 A Yeah, very hard from the first appointment. And
24 I said, you know, I see a developmental, a mild
25 developmental delay and I think you need to do a basic
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1 workup to discover the etiology of this. So, you know, I
2 proposed a list of blood tests and workup in general. And
3 they decided to have this workup done in the United States;
4 and of course I agreed, I said, you know, if you're going
5 to go back, you better have it there, I mean it's much
6 better.
7 Q Was that the end of the first contact you had,
8 then?
9 A Yes. Yes, I don't remember saying anything more.
10 I mean, it was an hour's appointment, of course we said
11 more; but it was more towards the, you know, the outcome,
12 is she going to recover from that, what do you think this
13 and that. Of course I could not answer all these questions
14 because the outcome is related to etiology sometimes, and I
15 was not clear as to what the etiology was for this
16 disorder.
17 Q After the family returned, then, to the United
18 States, did you continue in contact with them and with
19 doctors here?
20 A Yes. In fact, they had the workup done in the
21 United States, and Mr. Coutsoukis sent me the letters of
22 the doctors. And they had some examinations done and they
23 were not conclusive to the etiology of the disease again.
24 Q Was there a general consensus on what the
25 etiology might have been?
9
1 A No. But the general consensus was that indeed
2 the child was a few months behind.
3 Q Okay.
4 A So everybody agreed; it was not my only, my
5 opinion only, you know, here in Greece. But even the
6 doctors in the States agreed that she was developmentally
7 behind. But we could not find etiology of the organic
8 causes, where most of the organic causes, I would say all
9 of them now, they were excluded by blood tests and CAT
10 scans and all this, you know.
11 Q Okay. Did she, to the best of your knowledge,
12 begin any physical therapy, or occupational therapy?
13 A Yes. She had physical and occupational therapy;
14 and I had, on a couple of occasions, the opportunity to
15 review tapes, video tapes of her progress. They sent me
16 video tapes in Greece, and I had the chance to review them
17 and make some observations or suggestions.
18 Q Did you continue to do --
19 A Not a real medical follow-up, as you know; we are
20 quite a distance from the United States. But I had some
21 correspondence with Mr. Coutsoukis, he wrote to me her
22 progress; and Mrs. Coutsoukis called me twice.
23 Q Did you also --
24 A I'm not sure twice, maybe more than twice; but I
25 heard her voice over the phone a few times.
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1 Q Did you also communicate with Diane Williams,
2 the --
3 A Yes, the pediatrician in charge, yes, I sure did.
4 Because, you know, in the process of her developmental
5 delay, Teddy came up with some seizures, convulsions, fits,
6 epileptic seizures.
7 Q And that was later?
8 A That was later, that emerged later. It was not
9 there before; this is something that came up later in the
10 course of her disease.
11 Q Did you assist Dr. Williams in regards to
12 prescriptions and treatment?
13 A Yes. Yes, I did. In fact, I read the EEG's, I
14 gave some suggestions on the EEG's, they were sent to me,
15 mailed to me in Greece. And I suggested the use of the
16 medication that everybody would agree, it's an
17 internationally approved medication for the seizure
18 disorder, that particular one, called Depakine Sodium
19 Valproate.
20 Q Can you spell those?
21 A Yes. Depakine is the commercial name, Depakine
22 and Depakote are almost synonymous in the United States.
23 D-e-p-a-k-i-n-e, that's the commercial name. The substance
24 name is Sodium, sodium like potassium sodium.
25 Q Yes.
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1 A Valproate. Valproate is spelled
2 V-a-l-p-r-o-a-t-e.
3 Q Is this a drug that's commonly available in the
4 United States?
5 A Yes, very commonly available and very common in
6 pediatric populations with this particular type of seizure
7 disorder.
8 Q How did the child do with the prescriptions?
9 A She did, she did well; I mean, she had some
10 follow-up blood tests because this drug, as any drug, has
11 some side effects, it's not without any side effects. Of
12 course all this was explained to the parents; not to bother
13 them, of course, because they were not present in front of
14 me at that stage. You realize that the child had seizures
15 in the States later on. So some of the side effects -- not
16 some, all the side effects were explained to them; and they
17 had blood tests to monitor for any of those side effects.
18 And, in fact, she did not have any harmful side effects.
19 But Depakine alone failed to improve her EEG.
20 The EEG is a brain wave test that we repeated a few times.
21 Q So what was done next?
22 A So we decided to prescribe as an add-on therapy,
23 a second medication which is called -- I don't need to give
24 you the Greek name, I'll give you the international
25 chemical name, it is called Clobazam, C-l-o-b-a-z-a-m,
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1 Clobazam. This medication is an antiepileptic medication
2 again, and it's not marketed in the United States, but it's
3 fully licensed in England, Europe, Greece, Italy.
4 Q How did she do with that medication?
5 A According to Photius, she did well. According to
6 Susan, because I talked to her over the phone a couple of
7 weeks ago, she feels that it didn't help.
8 Q Okay. Have you seen the child a second time?
9 A Yes, I saw the child a second time last year when
10 I was visiting Boston, just, you know, as a visiting fellow
11 or something. The chance to see Teddy and her father, they
12 came over to Boston to see me; and of course it was a big
13 time lapse, the baby that I had seen in Greece the first
14 summer of her life and now she was a grown up girl and she
15 was walking independently. Her balance was very poor. She
16 had much better social response, she was responsive to me
17 and interactive; she was not withdrawn or anything, but
18 still with developmental problems, but I guess bridging the
19 gap slowly.
20 Q Did you observe her --
21 A I -- sorry. I did not notice any side effects
22 from the antiepileptic medications. I could not judge
23 improvement because I was not there at the time that she
24 started having seizures, you see, to compare how she was
25 prior to the seizures and how she became afterwards, after
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1 the control. Because clinically, she has no seizures
2 anymore. You don't see any seizures; you see only a normal
3 brain activity on the electroencephalogram.
4 Q Is there any consensus that this is epilepsy or
5 some other disease?
6 A I think, I think this is epilepsy. This is a
7 child with epilepsy, and this is related to her
8 developmental delay. They come all in the same diagnosis,
9 you know, the one that we don't have in hands right now.
10 Q This is something that you and Dr. Williams and
11 the other doctors would agree with?
12 A Well, Dr. Williams agrees, yes; and I guess the
13 other doctors would agree, too. Because Susan wants to
14 take her to New York to some big center; and I said yes, of
15 course, you know, it's nice to have the agreement of more
16 than two or three people, you know.
17 Q Okay. And when you were seeing her with her
18 father, that was approximately last Christmas of '95?
19 A Yes, exactly, exactly.
20 Q Okay. Did you observe the interaction between
21 father and daughter?
22 A Yeah, it was very good, very friendly. She felt
23 very secure with her dad. I mean, you know, they look
24 very, very friendly to each other. She would do things for
25 her father that would not do for the examiner.
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1 Q During the time that you have been involved with
2 this family, has the father expressed appropriate concern
3 about the daughter? Could you hear my question?
4 (Short interruption.)
5 BY MS. CRAIN: (Continuing)
6 Q Dr. Skouteli?
7 A Yes, yes, yes. We got disconnected. I'm here.
8 Q I believe the last question I asked you was over
9 the time that you have been involved with this family, has
10 the father expressed appropriate concern and care for the
11 child?
12 A Oh, yes, yes; correspondence and phone calls
13 and -- oh, yes, yes, very much so.
14 Q And would you describe the relationship between
15 him and his daughter as a close relationship?
16 A That's what it seems, you know, when I saw them
17 in Boston; sure, very close.
18 Q And so the only time you have seen the mother is
19 the once in Greece, and then you have spoken to her on the
20 phone?
21 A We talked over the phone a few times. She was
22 kind enough when I was in Boston on some other trip, to
23 send me a present in my hotel, and called me. And she
24 called me a couple weeks ago here in Greece one night. She
25 was concerned that the second medication that we added had
15
1 no effects. And she said, you know, I think it's not doing
2 any good, and the new EEG is the same and the people from
3 here cannot find any difference; we'll send you the reports
4 and the actual EEG's and you have to decide what you want
5 to do with the second medication.
6 Q Okay.
7 A I talked to her over the phone, I mean, you know,
8 a few times; not as frequent as I talked to Mr. Coutsoukis.
9 And we did not write to each other. You know, with
10 Mrs. Coutsoukis, we had the medical correspondence between
11 the two of us.
12 Q Okay.
13 A But, yes, I talked to her. But I met her in
14 person only once, Mrs. Coutsoukis, this is true.
15 Q Did Mr. Coutsoukis also ask you for literature
16 on --
17 A Yes. Yes.
18 Q -- his daughter's?
19 A Autistic features, seizures, you know, some
20 syndromes I had suggested because I had some suspicion that
21 she might have had a syndrome called happy puppet syndrome.
22 But this, I guess, was ruled out by the appropriate
23 genetics examination that we suggested.
24 Q Okay.
25 A So she does not have this syndrome. That was one
16
1 of my thoughts.
2 Q What would be your recommendation for how the
3 child should be cared for and treated?
4 A Treated with interventional therapy; I mean, from
5 the point of view of epilepsy, I'm sure that she needs some
6 medication. Now, I cannot really decide myself if the
7 second medication does good or no good because I'm not
8 close to her; I don't follow her up every couple of months
9 or three months or so, you know. But the first medication,
10 the Depakine, I think is necessary. So that's one point of
11 pharmaceutical intervention for the epilepsy is necessary.
12 The other intervention should be the physical,
13 occupational, you know, educational therapy for her
14 developmental delay.
15 Q Would she need that on a daily basis, in your
16 opinion?
17 A Well, you see, the ideal situation, it lists here
18 in Europe is to go to a special kindergarten where she
19 could have it all in the session in the morning. Yes, like
20 a couple of hours every morning; that would be the ideal
21 situation for my country and for Europe.
22 Q And as far as the rest of the day, say, what
23 should be done with her by her parents, for example, what
24 would you recommend?
25 A Well, I mean, they, I guess they should try and
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1 be available to her. And I know that this is difficult,
2 since they are both working, I understand. But the more
3 available they are, I guess the better, because she needs
4 them.
5 Q You told me --
6 A But the specialized person can also take care of
7 her at home, I guess, right? I mean, it's not that only
8 her parents can do things for her.
9 Q Sure. Do you feel that maintaining the
10 relationship that she has with her father would be of
11 importance?
12 A I see her very attached to him, you know. I
13 think any child that you would try to disconnect her
14 completely or incompletely to somebody who is attached, it
15 hurts.
16 Q Okay. Would that affect her ability to develop?
17 A Not, not her organic ability, but her
18 psychological ability, yes, I think so.
19 Q Do you --
20 A It may -- maybe she's attached to her mother the
21 same way, but I didn't see it because I did not have a
22 chance to see it, you know.
23 Q Okay. When you saw her in Boston, how was her
24 ability to communicate developing?
25 A Who? Teddy?
18
1 Q Yes.
2 A The baby?
3 Q Yes.
4 A Her ability to communicate with people?
5 Q Yes.
6 A Well, she's not talkative, she doesn't say that
7 much; but she can understand commands and everything, and
8 she communicates with eyes, with her eyes.
9 Q Would you say she's still developmentally delayed
10 in that respect?
11 A Well, she's behind, yes, I would say that.
12 Q Okay. And in developing her ability to
13 communicate, would the environment be of importance that
14 she's living in?
15 A Oh, yes, she has to be stimulated.
16 Q Okay.
17 A She has to be in an environment that understands
18 her needs and her ability to communicate, they're specific
19 and she needs to be stimulated the right way, if possible
20 all day long. She needs to receive the correct impulses
21 all the time.
22 Q Okay. And if a parent were able to give her that
23 personal attention, do you believe that that would be of
24 assistance to her?
25 A The attention that her daddy gives?
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1 Q Or -- yes.
2 A Or her mom gives?
3 Q Yes.
4 A Or whoever gives her personal attention; is that
5 your question?
6 Q Yes.
7 A Yes, I think she's the kind of child who needs
8 interpersonal relationships. She's not just a child in a
9 group of other children, you know what I mean?
10 Q Yes.
11 A She needs and wants one basis intervention at the
12 moment.
13 Q Okay.
14 A Because she was much more withdrawn in the
15 beginning, and now she's developing into a sociable little
16 girl, you know.
17 Q Okay.
18 A So she still needs this interpersonal attention.
19 Q Is there anything else that you can add that you
20 would think would be of importance in understanding this
21 child and her development in the future?
22 A I don't think so. I think that they should
23 continue, what Susan said, they should continue the search
24 for the etiology. We excluded some of the entities, but
25 not all of them. Maybe if she goes to New York to a big
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1 center they would come up with fresher ideas.
2 Q Okay.
3 A I don't think that we miss anything from the
4 intervention point of view, meaning that I don't think we
5 missed the diagnosis, that we could do something
6 differently, drastically different to change the situation.
7 Q Okay.
8 A But from the etiological point of view, we're not
9 clear what exactly is her disease.
10 Q Okay. Thank you. The other attorney may have
11 some questions now.
12 A Yes. No problem. Thank you.
13
14 EXAMINATION
15 BY MS. SANZ:
16 Q Dr. Skouteli, this is Cristina Sanz. Can you
17 hear me well?
18 A Very well.
19 Q Okay. When the family was visiting in Greece --
20 A Uh-huh.
21 Q -- were you aware that the pediatrician here in
22 the United States, Dr. Williams, was also concerned about
23 some developmental delays?
24 A I don't, I don't remember that very well, because
25 the Greek pediatrician was the one who called me and asked
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1 me to see this child.
2 Q So you're not aware Dr. Williams had seen her
3 prior to that?
4 A I don't remember this detail. You see, I
5 remember one day receiving a phone call from my Greek
6 colleague to see this child. Maybe the pediatrician was
7 concerned, too, but I'm not in a position to answer this
8 question correctly.
9 Q Okay. And when you diagnosed Teddy at that time,
10 you felt that she had psychomotor retardation?
11 A Yeah.
12 Q And one of the concerns you had was also for Rett
13 syndrome. You wanted to exclude that as a possibility?
14 A That was one of the possibilities. The other
15 one -- Rett syndrome; the other one was happy puppet
16 syndrome; some other chromosomal abnormalities were
17 excluded also. I suggested a CAT scan for cerebral
18 digenesis. Lots of things, you know, that crossed my mind.
19 Q Okay. And actually, eventually, in fact more
20 recently Teddy was seen by a Dr. McGinnis here in Portland,
21 Oregon?
22 A Yes.
23 Q And he, I'm sorry, she excluded, she determined
24 that Angleman's [phonetic] syndrome was not --
25 A That was a good thing that they did that.
22
1 Q Okay. And I believe Mrs. Coutsoukis forwarded
2 the medical records to you to review?
3 A Uh-huh.
4 Q From Dr. McGinnis; is that correct?
5 A Yes, it is correct. I have the records.
6 Q Okay.
7 A Not in front of me right now, but I have them in
8 her files.
9 Q Yes. You talked about the kind of activities you
10 feel that Teddy would benefit from.
11 A Uh-huh.
12 Q Would those kinds of activities, could you give
13 me examples, what you mean by that?
14 A Well, I think she would benefit from a school
15 setting, to start with, like go in a special kindergarten
16 with physical, occupational, speech therapy, special
17 education, like two to three hours per day, in a specific
18 interventional setting; that's the first thing.
19 Q Yes.
20 A Secondly, I think she would benefit from physical
21 activities in general, like walking, climbing, cycling with
22 easy bicycles, any kind of physical thing.
23 Q Swimming?
24 A Yes.
25 Q How about interaction, or at least some
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1 interaction with other children?
2 A Yes. Yes, of course. Not all day long, though,
3 because she needs interpersonal attention.
4 Q Yes, it has to be focused and part of a program?
5 A Yes. Yes. Of course she enjoys other children;
6 she's becoming sociable, I agree.
7 Q Okay. Thank you very much.
8 A Sure.
9 MS. CRAIN: I think we're finished, Dr.
10 Skouteli. And thank you for extending your day for us
11 so that we could take your deposition.
12 THE WITNESS: Okay. No problem.
13 MS. CRAIN: Thank you and good-bye.
14 THE WITNESS: Thank you. Bye-bye.
15
16 (The deposition was then concluded at
17 10:05 a.m.)
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1 CERTIFICATE
2
3 STATE OF OREGON )
) ss.
4 County of Jackson )
5
6 I, Debra J. Dugan, a Registered Professional Reporter
7 and Certified Shorthand Reporter for Oregon, do hereby
8 certify that, pursuant to the stipulation of counsel for
9 the respective parties hereinbefore set forth, HELEN
10 SKOUTELI, M.D. telephonically appeared before me at the
11 time and place mentioned in the caption herein; that at
12 said time and place I reported in Stenotype all testimony
13 adduced and other oral proceedings had in the foregoing
14 manner; that thereafter my notes were reduced to
15 typewriting under my direction, and that the foregoing
16 transcript, pages 1 to 23, both inclusive, constitutes a
17 full, true, and accurate record of all such testimony
18 adduced and oral proceedings had, and of the whole thereof.
19 WITNESS MY HAND AND CSR STAMP at Medford, Oregon, this
20 6th day of December, 1996.
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23
_____________________________
24 Debra J. Dugan, RPR, CSR
Certified Shorthand Reporter
25 CSR No. 90-0095