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No. 8841700 R Name FUCS, Roberto RFD 4, Forest Drive, New Milford, Conn. residing at Date of birth Oct. 24, 1939 Date of order of admission Nov. 12, 1969 Date certificate issued November 12, 1969 by the Superior Litchfield, Connecticut Court at Petition No. 7786 Alien Registration No:A12 345 607 Roberto (COMPLETE AND TRUE They SIGNATURE OF HOLDER)

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