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R No. 8283900 Name CAMPBELL, Thea residing at 40 White Street, Watertown, Connecticut Date of birthSept. 6, 1936 Date of order of admission June 5, 1962 Date certificate issued June 5, 1962 by the Superior Court at Litchfield, Connecticut Petition No. 7405 Alien Registration No. All 483 468 Ther Campbell (COMPLETE AND TRUE SIGNATURE OF HOLDER)

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