Basic Vital Statistic Information Form

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First Name	Invalid Input
Middle Name	Invalid Input
Last Name	Invalid Input
Your Email	Invalid Input

Doctor	Invalid Input

Date of Birth	Invalid Input
Place of Birth	Invalid Input
Were you or your spouse members of the U.S. Armed Forces?	YesNo Invalid Input
Marital Status	Invalid Input
Most Recent Spouse Name	Invalid Input
Are they living?	YesNo Invalid Input
Highest level of education?	Invalid Input
Usual Occupation, even if you are retired?	Invalid Input
	Residence
State	Invalid Input
County	Invalid Input
City or Town	Invalid Input
Street and Number	Invalid Input
	Your Parents
	Your Father
First Name	Invalid Input
Father's Middle Name	Invalid Input
Father's Last Name	Invalid Input
	Your Mother
Mother's First Name	Invalid Input
Mother's Middle Name	Invalid Input
Mother's Last Name	Invalid Input

Contact Person	Invalid Input
Contact's Address	Invalid Input
Contact's Phone	Invalid Input
Please verify you are human(*)	Invalid Input