PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
-
SEX of
age 37
Residence:
1954~1960-c hutgp
essen Sof 7
1966-19721972- o. jf we
Short description of symptoms:
Surgery Peptes tose
(“BELG
:
_
WEAK AL
THe
Time , weds
Year|
Have you been receiving treatment for any illness for a period
over one year?
a
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing?
Wp
Surgery?
Signature
_
nna
=
5011829
—e
.
Date
2/74
f
/
PRIVACY ACT MATERIAL REMOVED