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i . <br /> For the Year 19 <br /> OCCUPATION OF <br /> FULL NAME OF FATHER MAIDEN NAME OF MOTHER FATHER BIRTHPLACE OF BIRTHPLACE OF DATE OF <br /> OCCUPATION OF FATHER MOTHER RECORD <br /> MOTHER <br /> in <br /> fill <br /> F <br /> r <br /> i <br /> I r <br /> a u <br /> I <br /> X - iiia <br /> y <br />! ry - <br /> 1, <br />