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Four leaves of lined paper, handwritten in pencil on the front sides of leaves one through three and on the front and reverse sides of leaf four. The document is in fair physical condition. The document was laminated. The top left corner of both the third and fourth leaves was torn away. There are numerous stains of unknown origin throughout the document. The document was folded horizontally into fourths, possibly for mailing. The informant citation is handwritten at the top edge of the first leaf. There is a handwritten "8" underneath the informant citation.

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