DOCUMENT REQUEST FORM.
Originator: CIA
From: TFW
To: OFFICE OF SECURITY
Document date: 01/01/1963
Document type: PAPER - TEXTUAL DOCUMENT

## Page 1

104-10121-10267

2022 RELEASE UNDER THE PRESIDENT JOHN F. KENNEDY ASSASSINATION RECORDS ACT OF 1992

JOCUMENT REQUEST FOR

Cise No.:

Requestor

True Nane.:

1ües (inciuding middie same):

to be sired:

Date Pie

07.

Fratus or clues with which Subject is Inmiliar:

Height: 5110%

Weist

-720

Enir Black Eyes: Tam

Blood Typer

Tears glassest.

Birth dete- (26 80 235 1525)

Married?

@coupationi

DATA FOR BIRTH CERTIFICATE, AS OF TIME 07 BIRTH

06.

rather's names (Pedre)

F08:

Mother's sasides rime:

POB:

10

Year of birth::

3200

Occupation:

Salesma

Orcapatiani

Brontre

ca1 first 09 p3rur Dista

Residenci

Bour's tacoes

Else of joser troll

Number of dandrea bon to pareate prior to this birit.

*773

Spacify state or comatry where documentation will be used:

)K.

Documenistinn regrested

125.440STED

15)

(omina see Sorde 7

(s02 Incurance) 31

(Persication Porticiese) $l

"rt

crearance:

Midlar? surpie in alias:

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