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Form No. 200
Revised 6-4-20
AMERICAN RED CROSS
Superseding Form 249 and com-
bining with previous issue of
Form 200.
SERVICE APPLICATION FORM
All these questions must be answered fully or the application will not be acted upon.
Date 1. Name in full Blanch Helen Kaceua
Telephone No
2. Permanent address (Number 519 and Street) 1st ave Wesh (City) Cedar Rapids Jawa (State)
3. Temporary address, if any, to what date
(Number and Street)
4. Name, address, and relationship of person to be notified case
Bratherin law
in 31-So of (City) emergency Clarence Jos st. U. Sterba Oak Pork les (State)
(Relationship)
(Name)
(Number and Street)
5. (a) Date of birth 1886 Zebr
3
(b) Place of birth
Walker (City) Dawa (State)
(Year)
(Month)
(Day)
-
(c) If foreign born, when and where did you arrive in U. S
-
6. If foreign born, give date and court of your naturalization
7. (a) Single,
married, widowed, divorced Single (b) Number of dependents
-
(c) Full name of wife before marriage; or husband
-
-
(d) Birthplace of wife or husband
Nationality of wife or husband
(e) Birthplace and nationality of father of wife or husband
-
-
(f) Birthplace and nationality of mother of wife or husband
(g)
(h)
Full Birthplace name and of father nationality of Jaseph father Rasejovitz Laceus Bolennia
(i) If father foreign born, whether naturalized, when and where
York
City
1878
(j) Full maiden name of mother
Helen Tikeys
(k) Birthplace and nationality of mother
Balnovel Bolenua
(m) Full name and nationality of paternal grandmother Ignac Racena Bolynuah
(1) If mother foreign born, whether naturalized, when and where not naturalized Requistroym
(n) Full maiden name and nationality of paternal grandmother
marie Schulh Botenian
(o) Full name
(p)
Full
maiden and nationality and nationality of maternal of maternal grandfather grandmothe
name
8. State schools and colleges attended, with year of graduation and degrees taken
Public Schools Walker ia
High School walker La mad 1905 Dip
Statrikes Husph maining School (Location) for Nerses Cedor Rapids Ju (Graduated) 1912 (Degree) Dip
Columbia University nyc 1914-19
(Name)
9. What is your present business or profession
warred Nurse
Name of firm or corporation with which associated Stuart Circle Harph Richmond da
Duration of service
8 mo
Business address
Stroot Circle Richmoun
Present capacity asch Sept
va
(Number and Street)
(City)
(State)
10. (a) What previous business or professional experience have you had?
sh Robb Likkes Long things fedor Rapids by aset asst sups Subs
Cook Co Hasph
Chicago Improvides
PINC
(Company)
(Location)
(from-to)
(Nature of work)
11. As reference, give names and addresses of three American citizens not related to you
Gyda Bates
1524-Have
Cedor Rapids Sa
wr S Lynn Crawford
Cedon Rapids
(Name) augusta naideu (Number and Street) (City) Cedor Rapid (State) to
Page data
- Page
- 90
- Source index
- 0
- Type
- photo
- Media ID
- a031b8a3786ce62a
- Size
- unknown
Document data
- ID
- 2661728
- Core
- doc
- Type
- document
DTO data
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Context sent to Scholar
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Document source extras
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"coverageEndDate": {
"day": 17,
"logicalDate": "1945-08-17",
"month": 8,
"year": 1945
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"day": 3,
"logicalDate": "1917-06-03",
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"ocrText": "Form No. 200\nRevised 6-4-20\nAMERICAN RED CROSS\nSuperseding Form 249 and com-\nbining with previous issue of\nForm 200.\nSERVICE APPLICATION FORM\nAll these questions must be answered fully or the application will not be acted upon.\nDate 1. Name in full Blanch Helen Kaceua\nTelephone No\n2. Permanent address (Number 519 and Street) 1st ave Wesh (City) Cedar Rapids Jawa (State)\n3. Temporary address, if any, to what date\n(Number and Street)\n4. Name, address, and relationship of person to be notified case\nBratherin law\nin 31-So of (City) emergency Clarence Jos st. U. Sterba Oak Pork les (State)\n(Relationship)\n(Name)\n(Number and Street)\n5. (a) Date of birth 1886 Zebr\n3\n(b) Place of birth\nWalker (City) Dawa (State)\n(Year)\n(Month)\n(Day)\n-\n(c) If foreign born, when and where did you arrive in U. S\n-\n6. If foreign born, give date and court of your naturalization\n7. (a) Single,\nmarried, widowed, divorced Single (b) Number of dependents\n-\n(c) Full name of wife before marriage; or husband\n-\n-\n(d) Birthplace of wife or husband\nNationality of wife or husband\n(e) Birthplace and nationality of father of wife or husband\n-\n-\n(f) Birthplace and nationality of mother of wife or husband\n(g)\n(h)\nFull Birthplace name and of father nationality of Jaseph father Rasejovitz Laceus Bolennia\n(i) If father foreign born, whether naturalized, when and where\nYork\nCity\n1878\n(j) Full maiden name of mother\nHelen Tikeys\n(k) Birthplace and nationality of mother\nBalnovel Bolenua\n(m) Full name and nationality of paternal grandmother Ignac Racena Bolynuah\n(1) If mother foreign born, whether naturalized, when and where not naturalized Requistroym\n(n) Full maiden name and nationality of paternal grandmother\nmarie Schulh Botenian\n(o) Full name\n(p)\nFull\nmaiden and nationality and nationality of maternal of maternal grandfather grandmothe\nname\n8. State schools and colleges attended, with year of graduation and degrees taken\nPublic Schools Walker ia\nHigh School walker La mad 1905 Dip\nStatrikes Husph maining School (Location) for Nerses Cedor Rapids Ju (Graduated) 1912 (Degree) Dip\nColumbia University nyc 1914-19\n(Name)\n9. What is your present business or profession\nwarred Nurse\nName of firm or corporation with which associated Stuart Circle Harph Richmond da\nDuration of service\n8 mo\nBusiness address\nStroot Circle Richmoun\nPresent capacity asch Sept\nva\n(Number and Street)\n(City)\n(State)\n10. (a) What previous business or professional experience have you had?\nsh Robb Likkes Long things fedor Rapids by aset asst sups Subs\nCook Co Hasph\nChicago Improvides\nPINC\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\nGyda Bates\n1524-Have\nCedor Rapids Sa\nwr S Lynn Crawford\nCedon Rapids\n(Name) augusta naideu (Number and Street) (City) Cedor Rapid (State) to"
}