| OCR Text |
Show . Married or Single Age ;/4 t. 7Jv ;d /}J Jx./ •\ ' ?>t/ Location /~ _J~~ - 1 2~ .Ji3 ~1 I /(? /)1_/ /)( '/)(/ { i--- 1-I 'YI ~s 1 /)1_/ 2--Z-- /V 1uJ ?f / 1 I/ Ir r / a . ~ {( If It // It fl~ 1~1 (1_/ :2J I ~, I -t+ i p /) 11 I/ 2~ ti A)) ~A__ f. tf~ Ir It ,I ./ I( // , I'' f/ t, /( I(, (/ /~ II I t/- /hi' It 1d // {( / 5° ?-<1 /4 0 ;ti -i.,/ 7N ( /-.3--~ t,L It . /0 /16 3 rt I lf1: • /J;/ '2,,-"; [( 11t 1-3 1;J . ?71/ ,, ~ ( ' _ j ~ I o7 7 1s7 Discharged or Died ffe~ Q_ ?n/ ~r /7f I??/ Slf . Physicia11 If Tl ' ~I 1J I/ /t'e{, h I '/ 7 "J/ ( l I // /¥-t I( I/ l/ I 'r I 1 77 tr f/ A_ 8-~ rJi Diagnosis Remark |