PRIVACY ACT MATERIAL REMOVED
.
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
ee
|
Sex fy)
SS
Age {3
Residence:
1954-1960_. L/K/EP
1960-1966
ul
nr sg MAVUEo
1966-1972
1972Wy AfUeZzo
Short description of symptoms:
hye. Te
Surgery
Sate
WS
lecTHZ@.
REE SrET No. 607
LZ -
ee
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
veyou
Surgery?
P
g
are now experiencing?
7
(Ate77ree)
Wo.
signature
7
soli guy
a
Cate Lz
PRIVACY ACT MATERIAL REMOVED