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momm No. , I <br /> -MAIDEN NAME OF MOTHER. RESIDENCE OCCUPATION BIRTHPLACE BIRTHPLACE <br /> DATE OF <br /> RECORD.OF PARENTS. OF FATHER. OF FATHER. OF MOTHER. <br /> 1 <br /> \ r 1 • + I , 1, mm • 1 • <br /> 1 � � <br /> 1 <br /> . r <br /> / <br />