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I , <br /> 6 <br /> V , <br /> RESIDENCE OF OCCUPATION OF BIRTHPLACE OF BIRTHPLACE OF DATE OF <br /> MAIDEN NAME OF MOTHER <br /> o PARENTS FATHER FATHER MOTHER RECORD <br /> i k <br /> ! ! F I <br /> i <br /> rt <br /> I <br /> L <br /> �M <br /> r <br /> 1 <br /> F <br /> § <br /> j <br /> E <br /> • I <br />