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Form No. 200 Revised 6-4-20 Superseding Form 249 and com- AMERICAN RED CROSS oining with previous issue of cath 888 Form 200. SERVICE APPLICATION FORM prevent 22 180 All these questions must be answered fully or the application will not be acted upon. Date Sept lond 1921 1. Permanent Name in full address Telephone No 2152 2. Number and Street) St (City) Gary Ind. (State) 3. Temporary address, if any, to what date (Number and Street) (City) 4. Name, address, and relationship of person be notified in of emergency mrs azastasia Urbanik (State) to case Sister 1640 Masoachusertts st - Gary Ind, (Relationship) (Name) (Number and Street) 5. (a) Date of birth 1885 nor. 24- (b) Place of birth Province (City) Oren Poland. (State) (Year) (Month) (Day) (c) If foreign born, when and where did you arrive in U. S may 2-1892- Baltimore 6. If foreign born, give date and court of your naturalization Fet-19-1915 Superiour Court - Cook CO. 7. (a) Single, married, widowed, divorced Wider (b) Number of dependents name (c) Full name of wife before marriage; or husband Josephine Survalska (d) Birthplace of wife or husband Nationality of wife or husband Lithuanign (e) Birthplace and nationality of father of wife OF husband Lithuania 11 (f) Birthplace and nationality of mother of wife or husband (g) Full name of father Joseph Suwalski (h) Birthplace and nationality of father Province Posen Poland (i) If father foreign born, whether naturalized, when and where (j) Full maiden name of mother Stanislai (deceased) (k) Birthplace and nationality of mother Province (1) If mother foreign born, whether naturalized, when and where (m) Full name and nationality of paternal grandmother magdalina Survalski Siwalsken Polish ). (n) Full maiden name and (o) Full and nationality nationality of maternal of paternal grandfather grandmother John Great Polish Polish name (p) Full maiden name and nationality of maternal grandmother maryanna Polerzyminoten Polish 8. State schools and colleges attended, with year of graduation and degrees taren grown St. Stamistaus Parochial School Chicago - (grammary School Chicago night 1yr School Joble school of Cirics Family 12 and Fengans academy laist register.) Summer Chicayo Chicago 915- also Burr special Public 1914 might High Philanthropy course ) (Name) (Location) (Graduated) (Degree) 9. What is your present business or profession nurse (a.n.) Name of firm or corporation with which associated Good Filling. Chick - Gary works Duration of service. Business address (Number 1800 and Street) Connect cut St. (City) Lary Present capacity In changing Indiana of morsing & Relief- (State) 10. (a) What previous business or professional experience have you had.? Supt Blue mound Sanatorium transatora his After asaduation, Private duty Forgune 1907 W.Act. 1907 -them Temporary Lisiting nurse Association Chicago man. 1-1908 to-Act1-1915 Oct. to July 1918 Good Filleds Club Ill's Steel Co Gary works overseas. Prish white Cress-(inching of unit to Oct-1920- (Inclustrant and Child relfare also Belief ) Then american (Company) (Location) (from-to) (Nature of work) 11. As reference, give names and addresses of three American citizens not related to you miss Employ Ai. hapierals. kis 1309 n. any Chicago It's mr. It.Q. Egibing Sings of Luber- Ill's Steel Co. Harry Ind - miss (Name) Edna L They Suites (Number r. .N.A. and Street) Chicago (City) (State)

Page data

Page
34
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0
Type
photo
Media ID
7eb3c97110c9067e
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ID
2661719
Core
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Type
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DTO data
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Document source extras
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    "naId": 2661719,
    "coverageEndDate": {
        "day": 25,
        "logicalDate": "1944-09-25",
        "month": 9,
        "year": 1944
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Page context
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    "ocrText": "Form No. 200\nRevised 6-4-20\nSuperseding Form 249 and com-\nAMERICAN RED CROSS\noining with previous issue of\ncath 888\nForm 200.\nSERVICE APPLICATION FORM\nprevent 22 180\nAll these questions must be answered fully or the application will not be acted upon.\nDate Sept lond 1921\n1.\nPermanent Name in full address\nTelephone No 2152\n2.\nNumber and Street) St (City) Gary Ind.\n(State)\n3. Temporary address, if any, to what date\n(Number and Street)\n(City)\n4. Name, address, and relationship of person be notified in of emergency mrs azastasia Urbanik (State)\nto case\nSister\n1640 Masoachusertts st - Gary\nInd,\n(Relationship)\n(Name)\n(Number and Street)\n5. (a) Date of birth 1885 nor.\n24- (b) Place of birth Province (City) Oren Poland. (State)\n(Year)\n(Month)\n(Day)\n(c) If foreign born, when and where did you arrive in U. S\nmay 2-1892- Baltimore\n6.\nIf foreign born, give date and court of your naturalization Fet-19-1915\nSuperiour Court - Cook CO.\n7. (a) Single, married, widowed, divorced\nWider\n(b) Number of dependents\nname\n(c) Full name of wife before marriage; or\nhusband Josephine Survalska\n(d)\nBirthplace of wife or husband\nNationality of wife or husband\nLithuanign\n(e) Birthplace and nationality of father of wife OF husband Lithuania\n11\n(f) Birthplace and nationality of mother of wife or husband\n(g)\nFull\nname of father Joseph Suwalski\n(h) Birthplace and\nnationality of father Province Posen Poland\n(i) If father foreign born, whether naturalized, when and where\n(j) Full maiden name of mother\nStanislai (deceased)\n(k) Birthplace and nationality of mother\nProvince\n(1) If mother foreign born, whether naturalized, when and where\n(m) Full name and nationality of paternal grandmother magdalina Survalski Siwalsken Polish ).\n(n) Full maiden name and\n(o) Full and nationality nationality of maternal of paternal grandfather grandmother John Great Polish Polish\nname\n(p) Full maiden name and nationality of maternal grandmother maryanna Polerzyminoten Polish\n8. State schools and colleges attended, with year of graduation and degrees taren\ngrown\nSt. Stamistaus Parochial School Chicago - (grammary School\nChicago night 1yr School Joble school of Cirics Family 12 and Fengans academy laist register.) Summer Chicayo Chicago 915- also Burr special Public 1914 might High\nPhilanthropy\ncourse )\n(Name)\n(Location)\n(Graduated)\n(Degree)\n9. What is your present business or profession nurse\n(a.n.)\nName of firm or corporation with which associated Good Filling. Chick - Gary works\nDuration of service.\nBusiness address (Number 1800 and Street) Connect cut St. (City) Lary\nPresent capacity In changing Indiana of morsing & Relief-\n(State)\n10. (a) What previous business or professional experience have you had.?\nSupt Blue mound Sanatorium transatora his\nAfter asaduation, Private duty Forgune 1907 W.Act. 1907 -them Temporary\nLisiting nurse Association Chicago man. 1-1908 to-Act1-1915\nOct. to July 1918 Good Filleds Club Ill's Steel Co Gary works\noverseas. Prish white Cress-(inching of unit to Oct-1920-\n(Inclustrant and Child relfare also Belief ) Then american\n(Company)\n(Location)\n(from-to)\n(Nature of work)\n11. As reference, give names and addresses of three American citizens not related to you\nmiss Employ Ai. hapierals. kis 1309 n. any Chicago It's\nmr. It.Q. Egibing Sings of Luber- Ill's Steel Co. Harry Ind -\nmiss (Name) Edna L They Suites (Number r. .N.A. and\nStreet)\nChicago\n(City)\n(State)"
}