PRIVACY ACT MATERIAL REMOVED GOVERNSMINT OF Majuro, MARS WALL ISLANDS Marshall Tslands Special Heaitn Survey Name oo ; Sex fo _ age JJ. nesicence: 2954- 1939 _ (tte 1960-1966 — (.., 1965-1972 _ }y¢4 1972- Snort caescription of symptoms: Safer io Drenthe [PezDREMES /it-ees ae eed tPerryflepert J Oo Pe) aAeel c a ey } \ p77 4 " wed y Pir’tan tele vf Bc bhterss Thy. thrcxte Year -£¥2 you been receiving treatment for any illness for a perios . «2 ONG year? ( on.» anyone in your family complained. of similiar SYMP LORS to une ones you are now experiencing? (_. 7 Ay bosoe a7 Seagal qo surgery?fo. Signature- | ; EEE Date rhifr9 fF PRIVACY ACT MATERIAL REMOVED