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Form 170
MEDICAL DEPARTMENT, U.S.A.
ARMY NURSE CORPS
(Authorized 15 February 1943)
Application for Appointment
Mc Namara
Marion
1. Name
Agnes
(Print or type all
(Last name)
(First name)
(Middle name)
(Maiden name)
on this line)
2. Permanent address
120 Carlton Ave. Jersey City
Hudson Co.
N.J.
(Street)
(City)
(County)
(State)
3. Probable address for one year 19 - State Normal - Place - Jersey City, Hudson Co., N. Y.
(Street)
(City)
(County
(State)
4. Name and permanent address of nearest relative or friend residing in the United States
Relationship Brother
Edward Mc Namara - 120 Carlton Ave., J. C., N. J.
(Name)
(Address)
5.
Bace
Nationality
Marital status
U. S. citizenship
What languages other than English do you speak?
(Specify)
White
Irish Amer.
Single
Widowed
Native born
none
Negro
Married
Separated
Naturalized
Other
Divorced
Noncitizen
6. If divorced, attach copy of documentary evidence.
7. If naturalized citizen, give date, number, and place of naturalization certificate
native born
8. If not a citizen of the United States, of what country are you a citizen?
-
Oct. 2,
1911
9. Date of birth
10. Place of birth
Union City, New Jersey
(Month)
(Day)
(Year)
11. Is father a citizen of the U. S. A.? Yes
No
12. Country of birth of father
13. If married, give husband's full name
not married
II
#
14. Permanent address of husband
15. Is your husband a member of the armed forces?
Yes
No
If so, what branch of the service and what grade does he hold in
that branch?
not married
List names of minor children, giving age of each
not married
16. Has adequate care been provided for minor children for the duration of the war plus 6 months thereafter?
-
17. What is your height in inches?
5-7
18. Your weight in pounds? 182
19. Have you had any of the following? If so, state when and degree of incapacity.
Disease of the nasal sinuses
Nervous breakdown
Tuberculosis
Menstrual disturbance
no
no
no
no
20. Major operations or serious injury (specify)
Appendectomy 1932
Rt. Oiphorectomy 1939
(A complete physical examination will be given before assignment)
21. Have you given up any pursuit on account of ill health? If so, state particulars
no
22. In what State or States are you registered?
New Jersey
Year
23. Number of Registration Certificate 6040
24. Are you registered for the current year?
Yes
No
25. Of what nursing organizations are you a member?
A.N.A. Red Cross - S. N. A.
26. Have you ever been arrested for other than minor traffic violations? If so, state particulars
no
27. Have you ever been served with a subpena? Yes
No
B-2-15-45-150M
new york
Page data
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- Type
- photo
- Media ID
- 41eb86a4d94f3d69
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Document data
- ID
- 2661949
- Core
- doc
- Type
- document
DTO data
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"ocrText": "Form 170\nMEDICAL DEPARTMENT, U.S.A.\nARMY NURSE CORPS\n(Authorized 15 February 1943)\nApplication for Appointment\nMc Namara\nMarion\n1. Name\nAgnes\n(Print or type all\n(Last name)\n(First name)\n(Middle name)\n(Maiden name)\non this line)\n2. Permanent address\n120 Carlton Ave. Jersey City\nHudson Co.\nN.J.\n(Street)\n(City)\n(County)\n(State)\n3. Probable address for one year 19 - State Normal - Place - Jersey City, Hudson Co., N. Y.\n(Street)\n(City)\n(County\n(State)\n4. Name and permanent address of nearest relative or friend residing in the United States\nRelationship Brother\nEdward Mc Namara - 120 Carlton Ave., J. C., N. J.\n(Name)\n(Address)\n5.\nBace\nNationality\nMarital status\nU. S. citizenship\nWhat languages other than English do you speak?\n(Specify)\nWhite\nIrish Amer.\nSingle\nWidowed\nNative born\nnone\nNegro\nMarried\nSeparated\nNaturalized\nOther\nDivorced\nNoncitizen\n6. If divorced, attach copy of documentary evidence.\n7. If naturalized citizen, give date, number, and place of naturalization certificate\nnative born\n8. If not a citizen of the United States, of what country are you a citizen?\n-\nOct. 2,\n1911\n9. Date of birth\n10. Place of birth\nUnion City, New Jersey\n(Month)\n(Day)\n(Year)\n11. Is father a citizen of the U. S. A.? Yes\nNo\n12. Country of birth of father\n13. If married, give husband's full name\nnot married\nII\n#\n14. Permanent address of husband\n15. Is your husband a member of the armed forces?\nYes\nNo\nIf so, what branch of the service and what grade does he hold in\nthat branch?\nnot married\nList names of minor children, giving age of each\nnot married\n16. Has adequate care been provided for minor children for the duration of the war plus 6 months thereafter?\n-\n17. What is your height in inches?\n5-7\n18. Your weight in pounds? 182\n19. Have you had any of the following? If so, state when and degree of incapacity.\nDisease of the nasal sinuses\nNervous breakdown\nTuberculosis\nMenstrual disturbance\nno\nno\nno\nno\n20. Major operations or serious injury (specify)\nAppendectomy 1932\nRt. Oiphorectomy 1939\n(A complete physical examination will be given before assignment)\n21. Have you given up any pursuit on account of ill health? If so, state particulars\nno\n22. In what State or States are you registered?\nNew Jersey\nYear\n23. Number of Registration Certificate 6040\n24. Are you registered for the current year?\nYes\nNo\n25. Of what nursing organizations are you a member?\nA.N.A. Red Cross - S. N. A.\n26. Have you ever been arrested for other than minor traffic violations? If so, state particulars\nno\n27. Have you ever been served with a subpena? Yes\nNo\nB-2-15-45-150M\nnew york"
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