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No. 6264231
da Americo vol63-Pg213
Name COSTA, Decl xxx11 Pg272
residing at 162 Maple Street, Naugatuck, Connecticut
Age 42
years. Date of order of admission May 2, 1944
Date certificate issued
May 2, 1944
by the
Superior
Court at
Waterbury, Connecticut
Petition No. 1713
Americo da Costa
(Complete and true signature of holder)
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