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I
RED CROSS BADGE NUMBER
AMERICAN RED CROSS
22814
NURSING SERVICES
MILITARY SERIAL NUMBER
Mrs.
ANNUAL QUESTIONNAIRE - 1945
CHECK IF YOUR LAST NAME HAS CHAIGED
NAME (Last, first, middle)
TELEPHONE NO.
Riever Bertha maught Correhia NAME
2-5772
IF MARRIED, GIVE MAIDEN NAME
HUSBAND'
maught
PERMANENT ADDRESS (Street, city, zone, county, state)
Bierer James Daniel
Everett
Bedford state) Go. Pennsyhvania
PRESENT ADDRESS (Street, city, zone, county,
7 th St. mine miami Florida
NAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES
RELA TIONSHIP
mrs desley day, ear) Black Single
Sister
DATE OF BIRTH (Month,
Married
Separated
Widowed
Divorced
January 27-1882
LANGUAGES DO YOU PEAK?
YES
NO
Enghish
HIGH SCHOOL GRADUATE
NAME OF COLLEGE OR
DEGREE OR
UNIVERSITY ATTENDED
LOCATION
INCLUSIVE DATES
DIPLOMA
MAJOR
ARE YOU CURRENTLY
YES
NO
REGISTERED IN (State)
ARE YOU CURRENTLY A MEMBER OF THE AMERICAN
YES
NO
Puna
NURSES' ASSOCIATION?
REGISTERED?
PRESENT EMPLOYMENT If not employed, check
POSITION TITLE (H.N., P.D., inst., staff nurse, etc.)
SERVICE (Medicine, surgery, etc.)
NAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED
CITY
STATE
IF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY
HEALTH good
VOLUNTEER SERVICE
The purpose of the following statements is to identify the nurses who can be counted upon to respond to a call
to participate in a Red Cross chapter program. Please check the "Yes" box only if you are wi Lining and able to
serve if called on wi thin the next 12 months.
NAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS
YES
Attend an instructors' training program, if offered. (Funds are available for
YES
NO
1. Teach home
NO
nursing classes
training home nursing instructors. See local chapter.)
2. Servé in case
YES
NO
Attend disaster institutes, if
YES
NO
only in home community
of disaster
In other communities
offered, in preparation for service
3. Teach nurse's
4. Accept membership on chapter cóm-
YES
NO
5. Assist with other chapter
YES
NO
YES
NO
aide classes
mittee should services be needed
programs, as needed
If you have not answered "Yes" to any of the questions listed under VOLUNTEER SERVICE, do you anticipate that
YES
NO
you will be able to serve at some time in the future?
IF UNABLE TO SERVE, GIVE MAJOR REASONS-
DATE
House mip three perous
SIGNATURE
Sept 27th
Biener Bertha maugle
U
YOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FAITHPOLNESS IN
KEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONWAIRE AND RETURN IT PROMPTLY TO THE
N
COMMITTEE NAMED BELOW.
AMÉRICAN RED CROSS
8
ATTENTION
Fill in committee name and address before sending ques nurse.
NUNSL
SECRETARY
302 WABASH BUILDING
NURSE RECRUITMENT
PITTSBURGH (30), PA.
COMMITTEE
78504M
FORM 1045 ARev. July 1945
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Document data
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- Core
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- Type
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DTO data
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"ocrText": "Nee.\nI\nRED CROSS BADGE NUMBER\nAMERICAN RED CROSS\n22814\nNURSING SERVICES\nMILITARY SERIAL NUMBER\nMrs.\nANNUAL QUESTIONNAIRE - 1945\nCHECK IF YOUR LAST NAME HAS CHAIGED\nNAME (Last, first, middle)\nTELEPHONE NO.\nRiever Bertha maught Correhia NAME\n2-5772\nIF MARRIED, GIVE MAIDEN NAME\nHUSBAND'\nmaught\nPERMANENT ADDRESS (Street, city, zone, county, state)\nBierer James Daniel\nEverett\nBedford state) Go. Pennsyhvania\nPRESENT ADDRESS (Street, city, zone, county,\n7 th St. mine miami Florida\nNAME AND ADDRESS OF NEAREST RELATIVE OR FRIEND IN THE UNITED STATES\nRELA TIONSHIP\nmrs desley day, ear) Black Single\nSister\nDATE OF BIRTH (Month,\nMarried\nSeparated\nWidowed\nDivorced\nJanuary 27-1882\nLANGUAGES DO YOU PEAK?\nYES\nNO\nEnghish\nHIGH SCHOOL GRADUATE\nNAME OF COLLEGE OR\nDEGREE OR\nUNIVERSITY ATTENDED\nLOCATION\nINCLUSIVE DATES\nDIPLOMA\nMAJOR\nARE YOU CURRENTLY\nYES\nNO\nREGISTERED IN (State)\nARE YOU CURRENTLY A MEMBER OF THE AMERICAN\nYES\nNO\nPuna\nNURSES' ASSOCIATION?\nREGISTERED?\nPRESENT EMPLOYMENT If not employed, check\nPOSITION TITLE (H.N., P.D., inst., staff nurse, etc.)\nSERVICE (Medicine, surgery, etc.)\nNAME OF HOSPITAL OR ORGANIZATION BY WHOM EMPLOYED\nCITY\nSTATE\nIF OTHER THAN GOOD, SPECIFY NATURE AND ANTICIPATED DURATION OF DISABILITY\nHEALTH good\nVOLUNTEER SERVICE\nThe purpose of the following statements is to identify the nurses who can be counted upon to respond to a call\nto participate in a Red Cross chapter program. Please check the \"Yes\" box only if you are wi Lining and able to\nserve if called on wi thin the next 12 months.\nNAME AND ADDRESS OF THE CHAPTER IN WHOSE JURISDICTION YOU EXPECT TO LIVE FOR THE NEXT 12 MONTHS\nYES\nAttend an instructors' training program, if offered. (Funds are available for\nYES\nNO\n1. Teach home\nNO\nnursing classes\ntraining home nursing instructors. See local chapter.)\n2. Servé in case\nYES\nNO\nAttend disaster institutes, if\nYES\nNO\nonly in home community\nof disaster\nIn other communities\noffered, in preparation for service\n3. Teach nurse's\n4. Accept membership on chapter cóm-\nYES\nNO\n5. Assist with other chapter\nYES\nNO\nYES\nNO\naide classes\nmittee should services be needed\nprograms, as needed\nIf you have not answered \"Yes\" to any of the questions listed under VOLUNTEER SERVICE, do you anticipate that\nYES\nNO\nyou will be able to serve at some time in the future?\nIF UNABLE TO SERVE, GIVE MAJOR REASONS-\nDATE\nHouse mip three perous\nSIGNATURE\nSept 27th\nBiener Bertha maugle\nU\nYOUR VALUE AS A RED CROSS NURSE DEPENDS ON YOUR ABILITY AND WILLINGNESS TO SERVE AND YOUR FAITHPOLNESS IN\nKEEPING US INFORMED OF YOUR ADDRESS. PLEASE FILL IN THIS QUESTIONWAIRE AND RETURN IT PROMPTLY TO THE\nN\nCOMMITTEE NAMED BELOW.\nAMÉRICAN RED CROSS\n8\nATTENTION\nFill in committee name and address before sending ques nurse.\nNUNSL\nSECRETARY\n302 WABASH BUILDING\nNURSE RECRUITMENT\nPITTSBURGH (30), PA.\nCOMMITTEE\n78504M\nFORM 1045 ARev. July 1945"
}