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4 • I <br /> I;, 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 /> ------------- <br /> Ll <br /> I <br /> _ r <br /> f <br /> I <br /> I <br /> I <br /> I <br /> I / <br />