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15153
Form 2213
PRELIMINARY FORM FOR DECLARATION OF INTENTION TO BECOME A CITIZEN
5040
U. S. DEPARTMENT OF LABOR
NOT TO BE FILLED IN BY ALIEN
FOR USE OF OFFICIALS SEARCHING IMMI-
NATURALIZATION SERVICE
GRATION RECORDS
CLERK OF COURT:
NAMET LIZATION SERVIOE
RECORDS EXAMINED
RECEIVED
31404
Place number
in
CARD INDEX
upper left-hand corner of all copies of
JAN 28 1927
declaration, immediately under your
INDEX BOOKS
declaration number.
OFFICE OF EXAMINER
NEW HAVEN, CONN.
DISTRICT DIRECTOR OF NATURALIZATION.
MANIFESTS
DEPARTMENT OF LABOR
(NOTE
TO
CLERK
OF
COURT.-To
guide
you
in
preparing
the
Declaration:
The
black
face
lines
on
this
form
contain
statements
in the regular order as they are to appear on the Declaration of Intention.)
I desire to file my Declaration of Intention (first paper) to become a citizen.
Mr.
30
My name is
Mrs.
Richard Dome
; age,
28
years.
Miss
(Alien should print or typewrite here true original, and correct name)
age last birthday)
Also known as
V
(If alien has used any other name in this country that name should be shown here)
I used that name because
The full name of the person shown on my steamship ticket was
3AM SERVICE
My mother's maiden name was
Emma Pede leef
My maiden name was (if woman)
My present occcupation is
Ceytile Operative
My personal description is: Color, while ; complexion, ofdin ; height,
color of eyes, yrey brown
fair
5 feet
1/4
4
inches;
weight, 130, hair, Brown
pounds; color of
;
other visible distinctive marks: none
I was born in
ashton (City under- town) Lyne, Lancastire, (Country) England
or
on the
5th day of Kebruay
My present residence is
216 High St, Baltic, bennecticut
897ague 1
(Number and street)
(City or town)
(County)
(State)
My post
office address is Box 332, Battie, Connecticut
The place where I took the ship or train which landed me in the United States was
Liverpool England
, on
July
26
1923
(Month)
(Day)
(Year)
The ticket which I this country bought ashton under Lyne, Lanegshire
on came to was at
The name of the ship or railroad on which I came was
S.S. (City) Samasia Country) Gonard
11/16
8/7/23
(OVER)
Boston
Page data
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- Source index
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- Type
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- Media ID
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- Size
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Document data
- ID
- 159596813
- Core
- doc
- Type
- document
DTO data
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"ocrText": "15153\nForm 2213\nPRELIMINARY FORM FOR DECLARATION OF INTENTION TO BECOME A CITIZEN\n5040\nU. S. DEPARTMENT OF LABOR\nNOT TO BE FILLED IN BY ALIEN\nFOR USE OF OFFICIALS SEARCHING IMMI-\nNATURALIZATION SERVICE\nGRATION RECORDS\nCLERK OF COURT:\nNAMET LIZATION SERVIOE\nRECORDS EXAMINED\nRECEIVED\n31404\nPlace number\nin\nCARD INDEX\nupper left-hand corner of all copies of\nJAN 28 1927\ndeclaration, immediately under your\nINDEX BOOKS\ndeclaration number.\nOFFICE OF EXAMINER\nNEW HAVEN, CONN.\nDISTRICT DIRECTOR OF NATURALIZATION.\nMANIFESTS\nDEPARTMENT OF LABOR\n(NOTE\nTO\nCLERK\nOF\nCOURT.-To\nguide\nyou\nin\npreparing\nthe\nDeclaration:\nThe\nblack\nface\nlines\non\nthis\nform\ncontain\nstatements\nin the regular order as they are to appear on the Declaration of Intention.)\nI desire to file my Declaration of Intention (first paper) to become a citizen.\nMr.\n30\nMy name is\nMrs.\nRichard Dome\n; age,\n28\nyears.\nMiss\n(Alien should print or typewrite here true original, and correct name)\nage last birthday)\nAlso known as\nV\n(If alien has used any other name in this country that name should be shown here)\nI used that name because\nThe full name of the person shown on my steamship ticket was\n3AM SERVICE\nMy mother's maiden name was\nEmma Pede leef\nMy maiden name was (if woman)\nMy present occcupation is\nCeytile Operative\nMy personal description is: Color, while ; complexion, ofdin ; height,\ncolor of eyes, yrey brown\nfair\n5 feet\n1/4\n4\ninches;\nweight, 130, hair, Brown\npounds; color of\n;\nother visible distinctive marks: none\nI was born in\nashton (City under- town) Lyne, Lancastire, (Country) England\nor\non the\n5th day of Kebruay\nMy present residence is\n216 High St, Baltic, bennecticut\n897ague 1\n(Number and street)\n(City or town)\n(County)\n(State)\nMy post\noffice address is Box 332, Battie, Connecticut\nThe place where I took the ship or train which landed me in the United States was\nLiverpool England\n, on\nJuly\n26\n1923\n(Month)\n(Day)\n(Year)\nThe ticket which I this country bought ashton under Lyne, Lanegshire\non came to was at\nThe name of the ship or railroad on which I came was\nS.S. (City) Samasia Country) Gonard\n11/16\n8/7/23\n(OVER)\nBoston"
}