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Form 2213
PRELIMINARY FORM FOR DECLARATION OF INTENTION TO BECOME A CITIZEN
4958
U. S. DEPARTMENT OF LABOR
NOT TO BE FILLED IN BY ALIEN
FOR USE OF OFFICIALS SEARCHING IMMI-
NATURALIZATION SERVICE
GRATION RECORDS
CLERK OF COURT:
RECORDS EXAMINED
Place number
In
CARD INDEX
upper left-hand corner of all copies of
declaration, immediately under your
INDEX BOOKS
declaration number.
DISTRICT DIRECTOR OF NATURALIZATION.
MANIFESTS
(NOTE TO CLERK OF COURT.- To guide you in preparing the Declaration: The black face lines on this form contain statements
in the regular order as they are to appear on the Declaration of Intention.)
I desire to file my Declaration of Intention (first paper) to become a citizen.
Mr.
My name is
Mrs.
Harry (Alien should rint typewrite Berg here
35
; age,
years.
Miss
or truesoriginal, and correct name)
(Give age last birthday)
Also known as
(If alien has used any other name in this cauntry, that name should be shown
I used that name because the letter H is pronounced "B
gaving Berg.
here)
The full namo of the person shown on my steamship ticket
in was Russian Banglage
My mother's maiden name was
My maiden name was (if wollan)
My present occcupation is radio electrician
My personal description is: Color, white ; complexion, dark
; height, 5 feet 5th inches;
weight, 152 pounds; color of hair, black
; color of eyes, brown
;
other visible distinctive marks: Liban Scaron back side
I was born in
Russia
(City or town)
(Country)
on the 6th day of march
My present residence is Miller
83 years st., nep 1892 London, Com.
Radio To C.G
My Padiostation post office address is new Num ber an London beer, street (City Conn. town) (County) sayd
or
(State)
A
Liken Bassie
The place where I took the ship or train which landed me in the United States was Headach
, on sept (Month)
11
1908
(Day)
(Year)
The ticket on which I camo to this country was bought at
(City)
(Country)
The I Coronia
name of the ship or railroad on which came was
(OVER)
614-8
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Document data
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"ocrText": "Form 2213\nPRELIMINARY FORM FOR DECLARATION OF INTENTION TO BECOME A CITIZEN\n4958\nU. S. DEPARTMENT OF LABOR\nNOT TO BE FILLED IN BY ALIEN\nFOR USE OF OFFICIALS SEARCHING IMMI-\nNATURALIZATION SERVICE\nGRATION RECORDS\nCLERK OF COURT:\nRECORDS EXAMINED\nPlace number\nIn\nCARD INDEX\nupper left-hand corner of all copies of\ndeclaration, immediately under your\nINDEX BOOKS\ndeclaration number.\nDISTRICT DIRECTOR OF NATURALIZATION.\nMANIFESTS\n(NOTE TO CLERK OF COURT.- To guide you in preparing the Declaration: The black face lines on this form contain statements\nin the regular order as they are to appear on the Declaration of Intention.)\nI desire to file my Declaration of Intention (first paper) to become a citizen.\nMr.\nMy name is\nMrs.\nHarry (Alien should rint typewrite Berg here\n35\n; age,\nyears.\nMiss\nor truesoriginal, and correct name)\n(Give age last birthday)\nAlso known as\n(If alien has used any other name in this cauntry, that name should be shown\nI used that name because the letter H is pronounced \"B\ngaving Berg.\nhere)\nThe full namo of the person shown on my steamship ticket\nin was Russian Banglage\nMy mother's maiden name was\nMy maiden name was (if wollan)\nMy present occcupation is radio electrician\nMy personal description is: Color, white ; complexion, dark\n; height, 5 feet 5th inches;\nweight, 152 pounds; color of hair, black\n; color of eyes, brown\n;\nother visible distinctive marks: Liban Scaron back side\nI was born in\nRussia\n(City or town)\n(Country)\non the 6th day of march\nMy present residence is Miller\n83 years st., nep 1892 London, Com.\nRadio To C.G\nMy Padiostation post office address is new Num ber an London beer, street (City Conn. town) (County) sayd\nor\n(State)\nA\nLiken Bassie\nThe place where I took the ship or train which landed me in the United States was Headach\n, on sept (Month)\n11\n1908\n(Day)\n(Year)\nThe ticket on which I camo to this country was bought at\n(City)\n(Country)\nThe I Coronia\nname of the ship or railroad on which came was\n(OVER)\n614-8"
}