Massechueetts Mutual Life Insurance Co 255 State Siren Sp ape al d. Massa chosen* (1111-G201 1 Name Pc.; vv, (Los. s.s ESL. st.c, _S-521 1 2. Heigh, 5b' Weight 3 It. I/ your weight changed by over 101b in the last year. indicate amount and mason IA 3. Name and Addresa4Parsot Physiclin: —