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
)
—
}