PRIVACY ACT MATERIAL REMOVED
GOVERNMENT
OF Ti MARSHALL ZSLANDS
Majuro
Marsnass tslandas
So0eci
nealts1
SOL VLY
ex /7
we
age 27
1954-1960 —- Gd
1960-1965
be
1966-1972 _
197 2-
4
tt
havc you been receiving treatment for
overs one year?
(
any illness for a pericssc
ry,
has anyone in your family complained of similar symptoms to the
Oncs you are now experiencing?
(ye
Surgery?
Signature
( Duh con [Ciexfetee)
?
bg
_
J011 38Gb
ate fz 1
PRIVACY ACT MATERIAL REMOVED