Questionnaire Text

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Identification and control numbers

1-2 State: _ _
3-4 County: _ _
5-6 City, village, city district: _ _
7-8 Local station: _ _
9-10 Enumeration district: _ _
11 Enumeration area: _
12-13 Number of building in building list: _ _
15-16 Number of dwelling in dwelling list: _ _ _

Address of dwelling: (street, house number, floor) ____