| berm Hog le 2” , PERSONAL HISTORY STATEMENT 1. Answer all questions completely. Uf question daa not apply write “not applicable. an ce Instructions: Write “unknown” only if vou do not know the answer and cannot obtain the answer - ~ . from personal. records. Use a separnie sheet fer extra details on any question or questions for which you do not have sufficient roar. 2. Attach 2 recent passport Size pictures to this form, date taken written on the back ' of each. “ _ 3. Type, print or write carefully; Wegible or inecsanpiete forms will noé receive consid- | eration. | HAVE YOU READ AND UNDERSTOOD THE INSTRUCTIONS? . ges Vey On KO SS rs aes = << SEC. 1. PERSONAL BACKGROUND . A. PULL NAME Mie Neuston. Ss off Milep TELEPHONE { soe Ailddle Senate i PRESENT ADDRESS | W/ LeELANON St Myuover tii ff U.S.A. : : Bt. ae ho. Any Matix 4 Gounuy j LEGAL RES!DENcE CF FIAHER Ade, Noun Ue tHOHM , NV. WY y USA Le i Ae Np, at . eed eM hey 1 ay i B. NICKNAME Seo ? "Y voice ceed '.. ANY OTHER NAMZA THAT YOU HAVE USED.......... { ' : MT Appr sAble oo... UNDER WHAT CIRCUMSTASCES HAVE YOU EYER USED THESE. i ‘ : .. NAMES? ........ Mer. APPT CABIE vce ce cece et et tecceeee ees } : HOW LONG?. Tt. IP A LEGAL CHANGE, Olve PARTICULAES AL Appl; c 4ble i Bee Where i a b puthostiy! ; ; ee — ——s c—paTeor pintn 7 WAKA /926 piace or marit MA sce cs a 1, Lowa, USA. i Rag OU ERTY D. PRESENT CITIZENSIIIP Aner CARH ay marin yes BY maRWIAGE? Adt appl rca ble : BY NATURALIZATION CENTIFICATE 3.77 este ET py _™ } . ‘Tene “coun 7 | . AT wot tepli< rble i : . m uy Btale : : Pasimies P HAVE YOU HAD A PREVIOUS ciTrzensiin? 490 4ppl © OE. be : . a TZENSHDP? 1 L — . ~ ve ts) HELD HETW EEN WHAT DATEA? . red) ASy Othe Cr 3 an
14-00000 ae . "GIVE PARTICULARS: | ot Applica ble beeevece evens Le betes es boc ct eset tecvttneeats : . HAVE YOU TAKEN STEPS TO CHANGE PRESENT NATIONALITY? C oive vatericuLARs:..0..... ne, Hat APPL OI ttt) ne : { . : KE. LAST U.S. PASSPORT: — NUMBER, DATE AND PLACE OF IssuR.. AOf Appl c Able... —— HOW MANY OTHER U.S. PASSPORTS HAVE You HAD? MOT ppl) C 4b  grye APPLOXIMATE DATES: : bance een ene reee Ieee ee EET Te CUNT E ENN EV ee OER ODED TREE REED EEE OEE SEE EEE En EES PASSPORTS OF OTHER NATIONS? . hot, ApP. | CR. 4 -) ee | "IF BORN OUTSIDE US. WHEN DID YOU FIRST ARRIVE IN-tHIs couNTRY? Mot Apple CABIR... ee a PORT OF ENTRY?,, Wa Apol ICADIG. ov rasspoRT OF WHAT COUNTRY? TTT, , ee LABT UB. VISA...... hot Appl cable coca vce a ans cee “ate of tang" SEC. 2. PHYSICAL DESCRIPTION Aor LO. SEX. MATE _. WEIOWT. 6” WEIGHT . /E0 bose Byes 8/u@ air... Brown booveee. COMPLEXION FAIR scans HOt... . ; . num. A764 6 LA ornen pistinauisiine FEATURES IONE . ‘ SEC. 3. FATHER (Give the same information for step-father and/or guardian on a separate sheet) : i ruts. NAME .. | : . Livine orn vecsassp fe U¢ vq DATE OF DECRABR TO _ CAUBR TTT. ee ee ee i _. -pReseNt-ortasrappiinas OY Fle ther Ave, Mount Cerner ff. q: Us A. =— i Bt & Re Foon, fie ? t Barestey | DATE OF BIRT ‘LACK OF hurt Osceola , OLA, ut. 2 AL crrzexampAMerr Art owien acquinnn: Bret wrens: ot Applic ahie bere occupation HeAb packer nant papnavan GAL Schad tf sfanl-Mever Co, } FMPLOVERS OL OWN TET AnrAm 1552 -L/Q27 St, hea derte , ae cf 5, a ; Ps bee hey rece tas 3 MILITARY BRHVICE PROM wan esse nee | BHARCICOM arneeR AE OY eoenpaiy Oo) 3 e DETAILR on oyren oer "es a an prises ef HA ru