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Completed by Juan Medina And: Imelda Medina Date: 10/13/2007 www.somethingtoremembermeby.org Name: Juan Medina Name: Imelda Medina Birth Date: 11/20/1994 Birth Date: 11/28/1963 birthplace: Laredo,

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Completed by Juan Medina refers to a task or form that has been filled out or finished by an individual named Juan Medina.

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