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Registrant ID: Country: Registration Date (Conflict): Registration Location: Serial Number: Registrant Name: Immigrant ID: Age: years Birth Date: Home Address: Birth Place: Occupation / Employer: / Citizenship Status (Country): Height / Build: / Eye Color / Hair Color: / Nearest Relative Name: Relationship: Nearest Relative Address: Nearest Relative Immigrant ID: Comments: residence: Rose Ave. between Monroe Ave. & Mendocino Ave. / mole on right side of cheek near eye / birth date: May-1883 or May-1884