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Weight of Water Information Form
Email address *
Name of Person giving information *
Your answer
Name of person ill or deceased *
Your answer
Relationship to affected person *
Your answer
Years lived in contaminated area *
Your answer
Description of ailment *
Your answer
Year of diagnosis *
Your answer
Birthdate (and possible death date) *
Your answer
Address of affected person *
Your answer
Were you military or affiliated w military *
Your answer
Contact information (phone/email) *
Your answer
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