PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro,
Marshall
Islands
Special Health Survey
Name |
:
-
7
”
'
,
Sex
SLY
Age LO
Residence:
1954-1960 — WT.
1960-1966
_— 4,
1966-1972 __
1972-
—
*
Short description of symptoms:
oe
We
Leckhe,
}
beadsLe Geta
Rerperorrees
oodfasts
- Jeep
MCLG
thttt )
Surger
gery
Tk
7 ROD
CURRFOV
7
L 25
XY ear A22
7
Have you been “Cfo, CHE
treatment for any illness for a period
over one year? a Cpe .
-)
Has anyone in your family complained of similar symptoms to tne
ones you are now experiencing?
O
Surgery?
Signature
:
_
7
JO1 1843
ny
“pate
|
Pe [29
7777
PRIVACY ACT MATERIAL REMOVED
Ll ——/