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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 /> i <br /> A, - <br /> E <br /> /17 <br /> Ai Z4a <br /> 61/ <br /> r <br /> Vt <br /> 77 <br /> 44 AuOZ� <br /> y <br /> r ' <br /> = 1 <br />