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No. 4623635 Name DAGOSTINO, Modestino rolxivii pq239 Dicl XXTX rg 252 residing at 318 South Main Street, Waterbury, Connecti- cut Age 68 years. Date of order of admission September 13, 1939 Date certificate issued September 13, 1939 by the Common Pleas Court at Waterbury, Connecticut Petition No. 9589 Hastins (Complete and true Differtino signature of holder)

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