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all 15 No. TRIPLICATE Form 2903 Tobe to - 246 U. S. DEPARTMENT OF LABOR the Decloration) NATURALIZATION SERVICE No. 80.11 To the Honorable STATES OF The petitio First. My Second. M Third. I u Fourth. I DECLARATION OF INTENTION anno Domini 1.4 anno Domini 1.6 Invalid for all purposes seven years after the date hereof Idi at has United States of America, ss: In the District Court of the United States. Sixth. Southern District of California, County of Los Angeles at margartmand Wallaced 5t years, I have no u, occupation is: Hospital Color superinthant Dark declare height on oath that feet my s personal idches, description weight 153 pounds, color of hair Browncolor of eyes Brown other visible distinctive marks now 1 was born in Port Hope, Canada on the 13th day of anno Domini I 8661 now reside Seventh Potter (Give number, street, and city or town.) mourovia California. to organized go at intention to b I emigrated to the United States of Drove America from niagra Falls, given.) Cana ; my last particularly to on the vessel the character of congeyance or name of transportation company should be to reside perm (If the allen arrived touffille, Canaddam no gharried; the name foreign residence was Eighth. she was born at Winth. 1 of my wife is de and now resides at It is my bona fide intention to renaunce forever all allegiance and fidelity to any foreign this petition, prince, potentate, state, or sovereignty, and particularly to of this petition George V King of Great and Ireland of whom I am now a subject; Tenth. I arrived at the port of State of new years Falls the in the on or about day said .petition anno Domini 1 8821 am not an anarchist; I am not a of polygamist nor a believer in the practice of polygamy; and it is my intention in good therein: faith Attache together with to become a citizen of the United States of America and to permanently reside States of Ame So HELP ME GOD. (Original adgnature of declarant.)' Subscribed and sworn to before me in the office of the Clerk of said Court Declaration o) at Los Ángeles, Cal., this 3rd day of may [SEAL] anno Dömini 191 WILLIAM M. VAN DYKE, Clerk of the U, S. District Court, Southern District of California. By siggu FHimeon ; Deputy €lerk. 1+-1162 The afo contents ther and belief, an as and a each being se ma immediately entitled petit the said petit opinion, to b Depos york 1916 Subscribed of

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    "ocrText": "all\n15\nNo.\nTRIPLICATE\nForm 2903\nTobe to -\n246\nU. S. DEPARTMENT OF LABOR\nthe Decloration)\nNATURALIZATION SERVICE\nNo. 80.11\nTo the Honorable\nSTATES OF\nThe petitio\nFirst. My\nSecond. M\nThird. I u\nFourth. I\nDECLARATION OF INTENTION\nanno Domini 1.4\nanno Domini 1.6\nInvalid for all purposes seven years after the date hereof\nIdi\nat has\nUnited States of America,\nss:\nIn the District Court of the United States.\nSixth.\nSouthern District of California,\nCounty of Los Angeles\nat\nmargartmand Wallaced\n5t years,\nI have no\nu,\noccupation is: Hospital Color superinthant Dark declare height on oath that feet my s personal idches,\ndescription\nweight 153 pounds, color of hair Browncolor of eyes Brown\nother visible distinctive marks\nnow\n1 was born in\nPort Hope, Canada\non the\n13th\nday of anno Domini I 8661 now reside\nSeventh\nPotter (Give number, street, and city or town.) mourovia California.\nto organized go\nat\nintention to b\nI emigrated to the United States of\nDrove America from niagra Falls, given.) Cana ; my last\nparticularly to\non the vessel\nthe character of congeyance or name of transportation company should be\nto reside perm\n(If\nthe\nallen\narrived touffille, Canaddam no gharried;\nthe\nname\nforeign residence was\nEighth.\nshe was born at\nWinth. 1\nof my wife is\nde\nand now resides at\nIt is my bona fide intention to renaunce forever all allegiance and fidelity to any foreign\nthis petition,\nprince, potentate, state, or sovereignty, and particularly to\nof this petition\nGeorge V King of Great and Ireland\nof whom I am now a subject;\nTenth.\nI arrived at the port of\nState of\nnew\nyears\nFalls the\nin the\non or about\nday\nsaid .petition\nanno Domini 1 8821 am not an anarchist; I am not\na\nof polygamist nor a believer in the practice of polygamy; and it is my intention in good therein: faith\nAttache\ntogether with\nto become a citizen of the United States of America and to permanently reside\nStates of Ame\nSo HELP ME GOD.\n(Original adgnature of declarant.)'\nSubscribed and sworn to before me in the office of the Clerk of said Court\nDeclaration o)\nat Los Ángeles, Cal., this 3rd day of may\n[SEAL]\nanno Dömini 191\nWILLIAM M. VAN DYKE,\nClerk of the U, S. District Court, Southern District of California.\nBy siggu FHimeon\n;\nDeputy €lerk.\n1+-1162\nThe afo\ncontents ther\nand belief, an\nas\nand\na\neach being se\nma\nimmediately\nentitled petit\nthe said petit\nopinion, to b\nDepos\nyork\n1916\nSubscribed\nof"
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