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| align="center" width="52%" valign="middle" height="25" bgcolor="#99ccff" | '''Place of Birth''' | | align="center" width="52%" valign="middle" height="25" bgcolor="#99ccff" | '''Place of Birth''' | ||
| align="center" width="16%" valign="middle" | X<br> | | align="center" width="16%" valign="middle" | X<br> | ||
| align="center" width="16%" valign="middle" | | | align="center" width="16%" valign="middle" | X | ||
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| align="center" width="52%" valign="middle" height="25" bgcolor="#99ccff" | '''Place of Burial''' | | align="center" width="52%" valign="middle" height="25" bgcolor="#99ccff" | '''Place of Burial''' | ||