_ PRIVACY ACT MATERIAL REMOVED
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GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
,
Sex — fe
Age /3
Residence:
1954-1960 — grRICP
1960-1966 _LAsyr
1966-1972 —
197 2-
_
Lt KieP
LYAPERD
Short description of symptoms: (Surlle, trae) hiadhaeber, Sarang “tot,
effets
Surgery
— cate ,
pa CLs
pro
a &
Vat -
Gut baey beer rLinwerZy
Mor js* (Bet fe,t del)vear -
Have you been receiving treatment for any illness for a period
over one year?
ye
7
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing? Ko
surgery?
Maw
—
Signature_
5011854
|
“pate rf /9
/
fo?
PRIVACY ACT MATERIAL REMOVED