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| caption = | | caption = | ||
| birth_name = | | birth_name = | ||
| birth_date = | | birth_date = {{Birth date|1946|05|05}} | ||
| birth_place = | | birth_place = | ||
| death_date = {{nowrap| {{death date and age|1996|02|11|1946|05|05}} }} | | death_date = {{nowrap| {{death date and age|1996|02|11|1946|05|05}} }} |