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Form 2213
PRELIMINARY FORM FOR DECLARATION OF INTENTION TO BECOME A CITIZEN
4875
U. S. DEPARTMENT OF LABOR
NOT TO BE FILLED IN BY ALIEN
I
FOR USE OF OFFICIALS SEARCHING IMMI-
NATURALIZATION SERVICE
GRATION RECORDS
CLERK OF COURT:
RECORDS EXAMINED
Place number
in
CARD INDEX
upper left-hand corner of all copies of
declaration, immediately under your
INDEX BOOKS
declaration number.
DISTRICT DIRECTOR OF NATURALIZATION.
MANIFESTS
(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.
My name is
Mrs.
Wladyslaw (Alien should print or typewrite here Lebisz true, original, and
32
; age,
years.
Miss
correct name)
(Give age last birthday)
Also known as
same
(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
My mother's maiden name was Eleonora Krukauska
person shown on my steamship ticket was Madyplan Telrizz
My maiden name was (if woman)
My Farmer
present occcupation is
73/4
My personal description is: Color, White ; complexion, Light
; height, 5 feet 8 inches;
weight, 156 pounds; color of hair, Dank Brown ; color of eyes, Blue
;
other visible distinctive marks:
I born Ontrolenka
was in
Russian, Poland now Toland
(City or town)
(Country)
on the 17
day
of
fugust
,9 1894
My present residence is R.F.D. Ne.
(Number and street)
Pertanting
(City or town) New (County) London (State) Come
My post office address is same
The place or
where I took the ship train which landed me in the United States was Patterdam
Holland
, on July (Month)
26
1913
(Day)
(Year)
The ticket
on which I came to this country was bought at New particity City) by Antoni (Country, Kinkauski
The name of the ship or railroad on which I came was
may tophother
(OVER) Rollerdam
c14-8
Page data
- Page
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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
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- Type
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DTO data
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Context sent to Scholar
Document identity
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"ocrText": "Form 2213\nPRELIMINARY FORM FOR DECLARATION OF INTENTION TO BECOME A CITIZEN\n4875\nU. S. DEPARTMENT OF LABOR\nNOT TO BE FILLED IN BY ALIEN\nI\nFOR USE OF OFFICIALS SEARCHING IMMI-\nNATURALIZATION SERVICE\nGRATION RECORDS\nCLERK OF COURT:\nRECORDS EXAMINED\nPlace number\nin\nCARD INDEX\nupper left-hand corner of all copies of\ndeclaration, immediately under your\nINDEX BOOKS\ndeclaration number.\nDISTRICT DIRECTOR OF NATURALIZATION.\nMANIFESTS\n(NOTE TO CLERK OF COURT.- - To guide you in preparing the Declaration: The black face lines on this form contain statements\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.\nMy name is\nMrs.\nWladyslaw (Alien should print or typewrite here Lebisz true, original, and\n32\n; age,\nyears.\nMiss\ncorrect name)\n(Give age last birthday)\nAlso known as\nsame\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\nMy mother's maiden name was Eleonora Krukauska\nperson shown on my steamship ticket was Madyplan Telrizz\nMy maiden name was (if woman)\nMy Farmer\npresent occcupation is\n73/4\nMy personal description is: Color, White ; complexion, Light\n; height, 5 feet 8 inches;\nweight, 156 pounds; color of hair, Dank Brown ; color of eyes, Blue\n;\nother visible distinctive marks:\nI born Ontrolenka\nwas in\nRussian, Poland now Toland\n(City or town)\n(Country)\non the 17\nday\nof\nfugust\n,9 1894\nMy present residence is R.F.D. Ne.\n(Number and street)\nPertanting\n(City or town) New (County) London (State) Come\nMy post office address is same\nThe place or\nwhere I took the ship train which landed me in the United States was Patterdam\nHolland\n, on July (Month)\n26\n1913\n(Day)\n(Year)\nThe ticket\non which I came to this country was bought at New particity City) by Antoni (Country, Kinkauski\nThe name of the ship or railroad on which I came was\nmay tophother\n(OVER) Rollerdam\nc14-8"
}