PRIVACY ACT MATERIAL REMOVED Name ee — S ~~... , < ¢ CG Ci J Sex F TOF ht Q Majuro, Maxs "ee Special He tb GOVERNMENT OF THE MARSHALL ISLANDS Mf Agé we Residence: L IKIEP 1954-1960 1950-1966 1966-1972 L1972- Sr.oxt description of symptoms: Inrestulel, Casicer - Tanto Surgery YES Se Year) — S974 nave vou been receiving treatment for any illness for uw perice over one year? Abo. sGs anyone in your family complained of similar symptoms to toc OLES you are now experiencing? YES Aonature - _ 01184 Date | S109 PRIVACY ACTMATERIAL REMOVED