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f <br /> I ' <br /> For the Year 19 Id <br /> ;FPA <br /> ATION OF <br /> FULL NAME OF FATHF—R MAIDEN NAME OF MOTHERTHER BIRTHPLACE OF BIRTHPLACE OF DATE OF <br /> ATION OF FATHER MOTHER RECORD <br /> THER <br /> t <br /> r <br /> f, <br /> t <br /> f <br /> - rc <br /> _ 1 <br /> '1 <br /> �1 . <br />