_— PRIVACY ACT MATERIAL REMOVED GOVERNMENT Ox THE MARSHALL ISLANDS Majuro, Marshall Islands Special dealth Survey Name __ : : Sex f— Age )—-- Residence: 1954-1960 4966-1966 1966-1972 _L972—- — Pragio - Oh ¢& _ ons De - Coe keenest jae jie 7 Short Gescription of symptoms: AQ . eq aay 7 . mypa te See. fly le o Sh Ba 7 a pio , fete Chew ee a) ue a Year weve you been receiving treausent for any illness for a pericd Ovlt one year? >). SOD mis anyone in your family complained of similar symptoms to tne OnésS you are now experiencing? L p> Seryery?Le Signature i Pe, folk» = T 2? meme S801 _ ... ( ' Date rfle / of a / PRIVACY ACT MATERIAL REMOVED