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ZO et FF en atlantic Div public Health I Helen QUESTIONNAIRE 1 V 3 85 like 1. Mrs S. Name 2. Address - Tempotary a Conni M I Permanent stamford Our, ner Canaan 3. Red Cross Badge Number 22964 ari e play 4. Date of appointment to service some time in Sept 4918 5. Date of discharge from service Fib 1919 6. Service with Army " " Navy M. " " Red Cross x " " United States Public Health Service Sabitary Zone " " Emergency, Influenza Epidemic, Disaster, etc. 7. Condition of health on discharge. 10. K. I 8. Condition of health at present time. 4. K. 9. Approximate date of illness if any and where. 10. Have you notified the Veterans Bureau or the Red Cross Nursing Service? 11. Are you drawing comper sation from the Veterans Bureau? no Date granted. Number. Hospitalization if any. Name and address of doctor by whom examined. 12. Remarks: 13. Number Vocational Training. nurse Publis Health for 6 years Where mained also private and churshing What kind. Length of course. 14. Remarks: 15. Are you drawing Insurance from the American Red Cross? no Date granted. 16. Present Occupation Housewife 2 2

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