Va Form 21-1775 - Statement Of Disappearance Page 2

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23. DID THE MISSING PERSON LIVE CONTINUOUSLY WITH SPOUSE FROM DATE OF MARRIAGE TO DATE OF DISAPPEARANCE?
NO
(If "NO", give dates of all separations and the reasons therefore)
YES
24. WAS THE MISSING PERSON OR HIS/HER SPOUSE ENAMORED WITH OR INTERESTED IN ANOTHER PERSON?
(If "YES", give details)
YES
NO
25. INFORMATION ABOUT FAMILY OF MISSING PERSON
(List all children, brothers, sisters, mother and father)
NAME
AGE
RELATIONSHIP
ADDRESS
DATE OF DEATH
26. RELATIVES AND FRIENDS WHOM THE MISSING PERSON VISITED FROM TIME TO TIME, OR WITH WHOM HE CORRESPONDED, ETC.
NAME
RELATIONSHIP
ADDRESS
27. WAS THE MISSING PERSON IN GOOD HEALTH AT THE TIME OF HIS/HER DISAPPEARANCE?
(If "NO", explain fully)
YES
NO
28. DID THE MISSING PERSON APPEAR NORMAL WHEN LAST SEEN BY YOU?
YES
NO
(If "NO", explain fully)
29. STATE NAMES AND ADDRESSES OF ANY DOCTORS WHO ATTENDED THE MISSING PERSON AND DATES OF TREATMENT
30. HAD THE MISSING PERSON EVER BEEN TREATED FOR MENTAL ILLNESS?
YES
NO
(If "YES", state where and by whom, or in what institution, and whether an inmate of the institution)
PAGE 2 OF 6 PAGES
VA FORM 21-1775, DEC 2010

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