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No. 5203478
Name THEODOR, Fannie
Dectxxx/x pg723
VOLLIX pg36
residing at 26 Walnut Street, Waterbury, Conn.
Age 32 years. Date of order of admission May 5, 1942
Date certificate issued
May 5, 1942
by the
Superior
Court at Waterbury, Connecticut
Petition No. 536
Fammer Theoder
(Complete and true signature of holder)
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