PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
a
Sex
Residence:
-
:
age V/
\
1954-1960 Ay
1960-1966
1966-1972
_1972-
a
.
an
ae
Short description of symptoms:
Surgery
— ferbeufer,
Chapuck Operelen
Year
4
LLp
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 you are now experiencing? Ap
Surgery?
Signature
~
|
ae:
;
SO0118%2
cantil79
[l /
|
PRIVACY ACT MATERIAL REMOVED