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PAT I E N T IN FO RM ATI OND ATE NAME LASTFIRSTMARRIEDSINGLEMINORMALEFEMALEMSS# EMAIL ADDRESS STREET APT#CITYSTATEZIPBIRTHDATE TELEPHONE MONTHDAYYEARHOME #WORK#PLACE OF EMPLOYMENT ADDRESS IF FULL
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Information such as the baby's name, date of birth, parents' names, and any other required details must be reported on baby names starting with.
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