PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name, Sex E Age 72 Residence: z aed 1954-1960 — feeb 1960-1966 — /% 1966-1972 _ "yn _ L972- ™m™ tr Short description of symptoms: Tite THILOMT5 (PALA EVER Com tw? an GAT OC tals (balk spot — (ha Cn Look - bitfeeulls — bat oe Dt y we. The beatles § CL,a> surgery ar Have you been receiving treatment for any illness for.a period over one year? . oc Has anyone in your family complained of similar symptoms to the ones you are now experiencing? | “PLO - surgery? Signature ns ee, 501183 _ Date _ >h/77 | [! / , PRIVACY ACT MATERIAL REMOVED ) — }