Document 6bzGyG3ymoNaZR3Yp5yn0Jm71

-i SGCIAL ADDRESS,: SEX ?;*& 1..N ..,. ...L-IilSvuLli . . Hi : *t * 3rJ. i-SLc K: Da r. :>7`: ' . 'V ^-sp-sr '? o>_p?r : 9 v02Si <.-r.r r:i. : .I- H3S. IK Pvt tfW. SOS. ill P/t PPOt KGS. FftC pvt *AH. HOS. rREV PVC PRQC. CHFRiCAi-3 ujTSiDE .Xb 2/y ooi NO * iJC v p Li , ^ /f*: >rr'- j-v.-. .* .\r.ts^:.v; s *rui:-\ v.-;* rtfOKINo HISTORY CIGARETTES ONLY CIGARETTES PER DAY. \.tj AGE STARTED CIGARETTES AGE QUIT CIGARETTES CIGARS PER DAY; 00 PIPE TOBACCO PER BAY r/j ALCOHOL amiKPTlON EVER DRAW YES PAST DRINKER PAST MEEKLY IftlMCER YES CANS BEER RtR'UtEL' V J 01 CLASSES RIME PER OK 1 01 DRINKS LIQUOR PER W AGE iTARstD I? AGE QUIT 23 tfeg-5rAftTHt OHreftfc IEEE--b*# tv