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) MOM 5 EFTA00804446 11111 01. •OI 0 Personal HIstery Irdurnadoe COMPLETE THIS sicnom FOR ALL CASES NOW Mow is 'Yes-la any fifths fonomisp Milan; nigain in &SRI Pis I. Nan yet a. smoked cigarettes during the last 12 moriltn9 bchi b. used tobacco or products containing naofine witlin the
cian Information: Name, Address, and Phone? (ii known) 1. Date last seen end mason & Family ilstary Insured 2 (Indicate "almewn" when applicatdel Reiman' 'maim rromenu — 'nen:swage al onsei lespo Daly for cardiovascular (sea sal Age it Living Age at Death Cause at Death Father Mother Orothet
terans &oaks 0 160 Siockholders' Suits 0 190 Other Contract 0 195 Comma Product Liability O 196 Emnehise PERSONAL INJURY PERSONAL INJURY 0 310 Milan 0 362 Personal Injury • 0 315 Aiffilane Product Ma Malpractice Liability O 365 Personal Injury- 0 320 Astault. Ltd @ Product Liability Sland
550 Civil Rights 0 555 Pate Condition V. ORIGIN vi 1 rul ing Waco a 'X" imOne Ha Only) Transferred from O 2 Removal from n 3 Ro-fded- O 4 Reiman:dm Cl 5 anotherdistaiet O 6 M916district St to Court ate VI below) Reopened Dina y) litigation Appeal to District CI idge from ' Magistrat
terans &oaks 0 160 Siockholders' Suits 0 190 Other Contract 0 195 Comma Product Liability O 196 Emnehise PERSONAL INJURY PERSONAL INJURY 0 310 Milan 0 362 Personal Injury • 0 315 Aiffilane Product Ma Malpractice Liability O 365 Personal Injury- 0 320 Astault. Ltd @ Product Liability Sland
550 Civil Rights 0 555 Pate Condition V. ORIGIN vi 1 rul ing Waco a 'X" imOne Ha Only) Transferred from O 2 Removal from n 3 Ro-fded- O 4 Reiman:dm Cl 5 anotherdistaiet O 6 M916district St to Court ate VI below) Reopened Dina y) litigation Appeal to District CI idge from ' Magistrat
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