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No. 4469276
Volxiv ng225
Name DUMSA, Mikolas Decl XXVIII Py323
residing at 1168 Bank Street, Waterbury, Conn.
Age 52
years. Date of order of admission January 16, 1939
Date certificate issued January 16, 1939
by the
Common Pleas
Court at Waterbury, Connecticut
Petition No. 8994
mikolas Dumsa
(Complete and true signature of holder)
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Document identity
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