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QUINTUPLICATE
Form No. 200
Revised 5-15-18
develop od's are
AMERICAN RED CROSS
M
billow
10
SERVICE APPLICATION FORM
Applicants for Nursing and Medical Service mist accompany this form with special forms supplied by the Nursing Service and the Medical Service Bureaue
of the American Red Cross.
These questions must be answered fully or the application will not be acted upon.
Date
Asgunt a, 3018
1. Name in full
Mary Thounton Davia
Telephone No Marblahid 113M
2. Permanent Address 0/o Judgo c.E. Davio, Land Qourt Houso,
(Number and Street)
(City)
(State)
3. Temporary Address, if any, to what date
Thzough Septomber 1928
34 Caragory Bt. Marbl Lohond, Mass.
(Number and Street)
(City)
(State)
4. (a) If any changes of residence since August I, 1914, give these in full with dates
5
304 E. 20th as l'ow Tork for House, Tarrytom
(b) Rent: What is The your present 1017 business or profession 13 31 Allerton
Name of firm or corporation with which associated
Duration of Service. 1 year(as Etafi &
Business Address nono: on montion (562 Nans. Ave., Bonton, Minn.
(Number and Street)
(City)
(State)
5. Date of Birth 1890 August 15 (a) Place of birth Boaton,
(Year)
(Montb
(Day)
(b) If of foreign birth, when and where did you arrive in the United States?
6. If foreign born, give date and court of your naturalization
7. (a) Single, married or widower
(a) Number of Dependents Hone
(b) Full name of wife before marriage; or husband
c) Birthplace of wife or husband
Nationality of wife or husband
(d) Birthplace and nationality of father of wife or husband
(e) Birthplace and nationality of mother of wife or husband
(f) Full name of father Chnzlas Thornton Davio
(g) Birthplace and nationality of father Concord, Now Ihmphiro- Amerionn
blue
(h) If father foreign born, whether naturalized, when and where
ball
(i) Full maiden name of mother Franceo Puzley Anderson
(i) Birthplace and nationality of mother Portland, thing
Americio
(k) If mother foreign born, whether naturalized, when and where
NA
(1) Full name and nationality of paternal grandfather Dr. Churleg Augustine Druvia
Amorionn (U.S.A.)
(m) Full maiden name and nationality of paternal grandmother Hery Parker Thornten
Amoriona (U.B.A.)
(n) Full name and nationality of maternal grandfather John Farwoll Andernon
Amorionn (U.S.A.)
(o) Full maiden name and nationality of maternal grandmother
Bosman Winter
Ameriona (U.G.A.)
8. (a) What previous business or professional experience have you had, stating nature, places and principal dates
3
thereof; the names of the firms or corporations with which you were associated
mos. 1928 sa
Resiment as House, Tarrytom N.Y. Cart
8
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Document data
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Context sent to Scholar
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"ocrText": "D\na\nL\nis\nQUINTUPLICATE\nForm No. 200\nRevised 5-15-18\ndevelop od's are\nAMERICAN RED CROSS\nM\nbillow\n10\nSERVICE APPLICATION FORM\nApplicants for Nursing and Medical Service mist accompany this form with special forms supplied by the Nursing Service and the Medical Service Bureaue\nof the American Red Cross.\nThese questions must be answered fully or the application will not be acted upon.\nDate\nAsgunt a, 3018\n1. Name in full\nMary Thounton Davia\nTelephone No Marblahid 113M\n2. Permanent Address 0/o Judgo c.E. Davio, Land Qourt Houso,\n(Number and Street)\n(City)\n(State)\n3. Temporary Address, if any, to what date\nThzough Septomber 1928\n34 Caragory Bt. Marbl Lohond, Mass.\n(Number and Street)\n(City)\n(State)\n4. (a) If any changes of residence since August I, 1914, give these in full with dates\n5\n304 E. 20th as l'ow Tork for House, Tarrytom\n(b) Rent: What is The your present 1017 business or profession 13 31 Allerton\nName of firm or corporation with which associated\nDuration of Service. 1 year(as Etafi &\nBusiness Address nono: on montion (562 Nans. Ave., Bonton, Minn.\n(Number and Street)\n(City)\n(State)\n5. Date of Birth 1890 August 15 (a) Place of birth Boaton,\n(Year)\n(Montb\n(Day)\n(b) If of foreign birth, when and where did you arrive in the United States?\n6. If foreign born, give date and court of your naturalization\n7. (a) Single, married or widower\n(a) Number of Dependents Hone\n(b) Full name of wife before marriage; or husband\nc) Birthplace of wife or husband\nNationality of wife or husband\n(d) Birthplace and nationality of father of wife or husband\n(e) Birthplace and nationality of mother of wife or husband\n(f) Full name of father Chnzlas Thornton Davio\n(g) Birthplace and nationality of father Concord, Now Ihmphiro- Amerionn\nblue\n(h) If father foreign born, whether naturalized, when and where\nball\n(i) Full maiden name of mother Franceo Puzley Anderson\n(i) Birthplace and nationality of mother Portland, thing\nAmericio\n(k) If mother foreign born, whether naturalized, when and where\nNA\n(1) Full name and nationality of paternal grandfather Dr. Churleg Augustine Druvia\nAmorionn (U.S.A.)\n(m) Full maiden name and nationality of paternal grandmother Hery Parker Thornten\nAmoriona (U.B.A.)\n(n) Full name and nationality of maternal grandfather John Farwoll Andernon\nAmorionn (U.S.A.)\n(o) Full maiden name and nationality of maternal grandmother\nBosman Winter\nAmeriona (U.G.A.)\n8. (a) What previous business or professional experience have you had, stating nature, places and principal dates\n3\nthereof; the names of the firms or corporations with which you were associated\nmos. 1928 sa\nResiment as House, Tarrytom N.Y. Cart\n8"
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