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