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Furm 3911 1683877 27 Name Steve Skimba Age, 27 years Declaration ofinlention No 3651 issued by of u. S. District Court of new Haven onthe Perition, You. XI No 2687 23 day of August A.D.1916 the 15 day of December A91921 Name age, and place of wife many 23 yrs. 98 Itill St Walibury Come Names, ages and places of residence of minor children none Steve Skimba /Signature of holder.) New Old Na

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