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FORM 1045
AMERICAN RED CROSS
REV. DEC. 1939
a
NATIONAL HEADQUARTERS
WASHINGTON, D.C.
Name in full mansfeld (SURNAME)
Bermie
Deane
(FIRST)
(MIDDLE)
Husband's name
et
Permanent address 191 State
Bangor
Penofact
mann
5
(STREET)
(CITY)
(COUNTY)
(STATE)
Probable address
Same
ce
for the next year
(STREET)
(CITY)
(COUNTY)
(STATE)
Telephone number Bangor
5428
(EXCIANGE)
(NO.)
I
Nearest relative or friend in United States, through whom you may be communicated with in
an emergency:
Dr. B m. (NAME) mansfeld
Sister
(RELATIONSHIP)
191 State
Bangor
manp
(STREET)
CITY)
(STATE)
PRESENT WORK (check below)
Name of agency or institution with which employed
Institutional
Public Health
Private duty
Other (write in)
Retired
Government Service: Army
U.S.P.H.Service
Veterans Administration
Navy
U.S.Indian Service
Children's Bureau
IF NOT ACTIVE IN NURSING check field of nursing with which you are most familiar:
Institutional
Public Health
Private duty
Other (write in) havy
Would you respond to an emergency call in event of local or national emergency, such as
epidemic, flood, war, etc. no- as subject to secall by havy D
(Granted of course that you could be released from present employment')
Present
physical condition good
Would you be interested in teaching classes in Home Hygiene and Care of the Sick? no
Are you a member of the American Nurses' Association?
yes
If not, why have you allowed your membership to lapse?
Badge No. 99
Current date march 21, 1940
Name of Committee Wainl State and Local Commuttee
Note:
If a nurse does not complete and return this questionnaire, and cannot be located
within two years, her enroilment will be removed from our active files.
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- Source index
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- Type
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- Media ID
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Document data
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- Core
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"ocrText": "3\na\nS\nf\ne\nFORM 1045\nAMERICAN RED CROSS\nREV. DEC. 1939\na\nNATIONAL HEADQUARTERS\nWASHINGTON, D.C.\nName in full mansfeld (SURNAME)\nBermie\nDeane\n(FIRST)\n(MIDDLE)\nHusband's name\net\nPermanent address 191 State\nBangor\nPenofact\nmann\n5\n(STREET)\n(CITY)\n(COUNTY)\n(STATE)\nProbable address\nSame\nce\nfor the next year\n(STREET)\n(CITY)\n(COUNTY)\n(STATE)\nTelephone number Bangor\n5428\n(EXCIANGE)\n(NO.)\nI\nNearest relative or friend in United States, through whom you may be communicated with in\nan emergency:\nDr. B m. (NAME) mansfeld\nSister\n(RELATIONSHIP)\n191 State\nBangor\nmanp\n(STREET)\nCITY)\n(STATE)\nPRESENT WORK (check below)\nName of agency or institution with which employed\nInstitutional\nPublic Health\nPrivate duty\nOther (write in)\nRetired\nGovernment Service: Army\nU.S.P.H.Service\nVeterans Administration\nNavy\nU.S.Indian Service\nChildren's Bureau\nIF NOT ACTIVE IN NURSING check field of nursing with which you are most familiar:\nInstitutional\nPublic Health\nPrivate duty\nOther (write in) havy\nWould you respond to an emergency call in event of local or national emergency, such as\nepidemic, flood, war, etc. no- as subject to secall by havy D\n(Granted of course that you could be released from present employment')\nPresent\nphysical condition good\nWould you be interested in teaching classes in Home Hygiene and Care of the Sick? no\nAre you a member of the American Nurses' Association?\nyes\nIf not, why have you allowed your membership to lapse?\nBadge No. 99\nCurrent date march 21, 1940\nName of Committee Wainl State and Local Commuttee\nNote:\nIf a nurse does not complete and return this questionnaire, and cannot be located\nwithin two years, her enroilment will be removed from our active files."
}