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No. 7060393 Name REBULIO, Jerry residing at P.O. Box 879. Palm City, Calif. Date of birth 8/6/03 Date of order of admission 7-17-53 Date certificate issued July 23,-9953 by the Superi or Court at San Diego, Calif. Petition No. 17765 Alien Registration No. 3457872 dearn Rabulis (Complete and true signature of holder)