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GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
.—_—ss_—e__iad.s,.,,,
ion
sex f-
Age V /
Residence:
1954-1960
hor
1960-1966 hg)
1966-1972
~ 7%
~
0
1972-
meas
Short description of symptoms:
Fiver,
tant G te cugitel hice)
surgen:
“aerf, ts pli Lin dering @ te year 7
Have you been receiving treatment for any illness for a period
over one ee 63
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing? U/,
oO.
Surgery?
Signature>
—
;
:
Date vy |79 |
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PRIVACY ACT MATERIAL REMOVED