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No. 9587671 R Name GOETZ, Ingelore Renate Irene residing at 270 High Street, Torrington, Connecticut, Date of birth Nov. 29, 1936 Date of order of admission Nov. 14, 1972 Date certificate issued November 14, 1972 by the Superior Court at Litchfield, Connecticut, Petition No. 7868 Alien Registration No. A12 309 466 Ingeloe Renate Trene foetz (COMPLETE AND TRUE SIGNATURE OF HOLDER)

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