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# STATEMENT OF PERSONAL HISTORYINSTRUCTIONS: Read the certification at the end of this questionnaire before entering the required data. Print or type all answers. All questions and statements must be completed. If the answer is "None," so state. Do not misstate or omit material fact since the statements made herein are subject to verification. If more space is needed, use the Remarks section, item 20, and attach additional sheets if necessary. The information entered hereon is for official use only and will be maintained in confidence.1.  (Print) FIRST NAME-MIDDLE NAME--MAIDEN NAME (If any)-LAST NAMEMR.MRS.MISS Edifanio ROMERO-Delgado2. X CIVILIAN MILITARY ON ACTIVE DUTY3. ALIAS(ES). NICKNAME(S). OR CHANGES IN NAME (Other than by marriage)Piche4. PERMANENT MAILING ADDRESS1140 SW 9th St. Miami, Fla.5. DATE OF BIRTH (Day, month, year)PLACE OF BIRTH (City, County, State, and Country)PLACE CERTIFICATE RECORDED21 Jan 1936Candelario, Pinardel Rio, CubaCandelario, Pinar del Rio, CubaRACEHEIGHTWEIGHTCOLOR OF EYESCOLOR OF HAIRSCARS, PHYSICAL DEFECTS, DISTINGUISHING MARKSCau66"165BrownBrownNONE6. DO YOU HAVE A HISTORY OF MENTAL OR NERVOUS DISORDERS? ☐ YES ☑ NO ARE YOU NOW OR HAVE YOU EVER BEEN ADDICTED TO THE USE OF HABIT FORMING DRUGS SUCH AS NARCOTICS OR BARBITURATES? ☐ YES ☑ NO ARE YOU NOW OR HAVE YOU EVER BEEN A CHRONIC USER TO EXCESS OF ALCOHOLIC BEVERAGES? ☐ YES ☑ NO IF THE ANSWER TO ANY OF THE ABOVE IS "YES." EXPLAIN IN ITEM 20.7. U. S. CITIZENNATIVEIF NATURALIZED, CERTIFICATE NO.IF DERIVED, PARENTS' CERTIFICATE NO(S).DATE, PLACE, AND COURTYESNOXALIENREGISTRATION NO.NATIVE COUNTRYDATE AND PORT OF ENTRYA13 108 636Cuba21 Sept 1962TexasDO YOU INTEND TO BECOME A U. S. CITIZEN?YESX NO8. MILITARY SERVICEARE YOU PRESENTLY ON ACTIVE DUTY IN THE U. S. ARMED FORCES DRAWING FULL PAY? ☐ YES ☑ NO IF "YES," COMPLETE THE FOLLOWING:GRADE AND SERVICE NO.SERVICE AND COMPONENTORGANIZATION AND STATIONDATE CURRENT ACTIVE SERVICE STARTEDARE YOU PRESENTLY A MEMBER OF A U. S. RESERVE OR NATIONAL GUARD ORGANIZATION? ☐ YES ☑ NO IF "YES," COMPLETE THE FOLLOWING:GRADE AND SERVICE NO.SERVICE AND COMPONENTORGANIZATION AND STATION OR UNIT AND LOCATIONHAVE YOU PREVIOUSLY SERVED TOURS OF EXTENDED ACTIVE DUTY, DRAWING FULL PAY, FROM WHICH YOU WERE DISCHARGED OR SEPARATED TO CIVILIAN STATUS? ☐ YES ☑ NO IF "YES." COMPLETE THE FOLLOWING:COUNTRYSERVICECOMPONENTFROM (Date)TO (Date)TYPE DISCHARGES OR SEPARATIONS-GRADE AND SERVICE NO.9. EDUCATION (Account for all civilian schools and military academies. Do not include service schools)MONTH AND YEARNAME AND LOCATION OF SCHOOLGRADUATEDEGREEFROM-TO-YESNOSep 46Jun 49Escuela Publica San Cristobal10. FAMILY (List in order given, parents, spouse, guardians, stepparents, foster parents, parents-in-law, former spouse(s) (if divorced give date and place), children, brothers and sisters, even though deceased. Include any others you resided with or with whom a close relationship existed or exists. If the person is not a U. S. citizen by birth, give date and port of entry, alien registration number, naturalization certificate number and place of issuance.)| RELATION AND NAME                         | DATE AND PLACE OF BIRTH                                   | PRESENT ADDRESS, IF LIVING                               | U. S. CITIZEN |     || ----------------------------------------- | --------------------------------------------------------- | -------------------------------------------------------- | ------------- | --- ||                                           |                                                           |                                                          | YES           | NO  || FATHER <br> Felipe Romero                 | date unknown <br> Conzolaciondel Sur, Cuba                | DECEASED                                                 |               | X   || MOTHER (Maiden name) <br> Sagunda Delgado | date unknown                                              | Finca Sabana La Mar <br> San CristobalPinardel Rio, Cuba |               | X   || SPOUSE (Maiden name) <br> Ilda Martinez   | 1 Feb 1936 Candelaria <br> Pinardel Rio, Cuba             | "                                                        |               | X   || OTHER (Specify) <br> Arturo Romero        | 9 May 1962 San Cristobal <br> Finar delRio, Cuba          | "                                                        |               | X   || B <br> Balerio Romero                     | Finca Sabana La MarSan <br> Cristobal Pinardel Rio Cuba " | "                                                        |               | X   || B <br> Jose Manuel Romero                 | "                                                         | " <br> 76                                                |               | X   || B <br> Aniceto Romero                     | "                                                         | "                                                        |               | X   || B <br> Santiago Romero                    | "                                                         | "                                                        |               | X   |