PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro,
Marshall Islands
Special Health Survey
Name
;
¥
.
_ Sex_ Ff
oo
Age
3/
Residence:
1954-1960 — Lueree 1956
1960-1966 — (WRTuURD
1966-1972
v
197 2-
Short description of. symptoms:
Newoawes, eSpebes
7A n). OPERATIon) a
surgery Yeo
Year| 1996 So
Have you been receiving treatment for any rllness for a period
over one year?
%ES
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing?
surgery?
Signature _
5011938
eed
TE,
Date
May
zs 979
PRIVACY ACT MATERIAL REMOVED