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Vol XLV ng212
No. 4469282
Name RACICKI, John
Decl XXVIIL pg545
residing at 20 Lounsbury Avenue, Waterbury, Conn.
Age 51
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. 8981
Whn Pacicki
(Complete and true signature of holder)
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