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Form 390
1143482
32
Age, Name Samuel 32 years Backs
Declaration No 1044
issued by tratest
Waterbary
on the
30 day of Dec ADD
Perition, You. 6 No 1475
Creder. signation; the the 15 thayal
March 099019
Name are and place ofresidente of wife
Clara 30 yrs, 236 abboth
Names ages and places of residence nfaminor
Ave. Waterbany Common
children sorotly 9 years, Ercin
Jaint 3 years, 239 6
Comm. abbold are Waterbay
Sannel Jacks
Signature of holder.)
Old Na
New Certificate No 1143482 Receive
Date April 5 -
1919
Sammel Jacks
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