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R. No. 8283829 Name COSTA, Rosa residing at 57 Wall St., Torrington, Conn. Date of birth Jul 12 1938 Date of order of admission June 6 1961 Date certificate issued June 6th, 1961 by the Superior Court at Litchfield, Connecticut Petition No. 7336 Alien Registration No. A10 496 504 1 Rosa Costa (COMPLETE AND TRUE SIGNATURE OF HOLDER)

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