PRIVACY ACT MATERIAL REMOVED . GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name ee | Sex fy) SS Age {3 Residence: 1954-1960_. L/K/EP 1960-1966 ul nr sg MAVUEo 1966-1972 1972Wy AfUeZzo Short description of symptoms: hye. Te Surgery Sate WS lecTHZ@. REE SrET No. 607 LZ - ee Have’ you been receiving treatment for any illness for a period Over one year? \ Has anyone in your family complained of similar symptoms to the ones veyou Surgery? P g are now experiencing? 7 (Ate77ree) Wo. signature 7 soli guy a Cate Lz PRIVACY ACT MATERIAL REMOVED