_—
PRIVACY ACT MATERIAL REMOVED
GOVERNMENT Ox THE MARSHALL ISLANDS
Majuro,
Marshall
Islands
Special dealth Survey
Name __
:
:
Sex
f—
Age
)—--
Residence:
1954-1960
4966-1966
1966-1972
_L972—-
— Pragio
- Oh ¢&
_ ons
De
-
Coe keenest
jae
jie
7
Short Gescription of symptoms:
AQ
.
eq aay
7
.
mypa
te
See.
fly
le
o
Sh
Ba
7 a
pio
,
fete
Chew ee
a)
ue
a
Year
weve you been receiving treausent for any illness for a pericd
Ovlt one year?
>).
SOD
mis anyone in your family complained of similar symptoms to tne
OnésS you are now experiencing?
L
p>
Seryery?Le
Signature
i
Pe, folk»
=
T
2?
meme
S801
_
...
(
'
Date
rfle
/
of
a
/
PRIVACY ACT MATERIAL REMOVED