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343,65
NATURALIZATION SERVICS
Form 2213
RECEIVED
FACTS FOR DECLARATION OF INTENTION
5472
JUN 161927
FAM
U.S. DEPARTMENT OF LABOR
OFFICE OF EXAMINER
NATURALIZATION SERVICE
NEW HAVEN, CONN.
DEPAKIMANY us TABOK
NOTE.- copy of this form will be furnished by the clerk of the court, the Chief Naturalization Examiner, or the
public-school teacher to each applicant for a declaration of intention, so that he can at his leisure fill in the answers to
the questions. After being filled out the applicant should take the form to the office of the clerk of court to be used
by him in properly filling out the declaration. Care should be used to state as near as can be remembered the day,
month, and year of arrival, as well as the name of the vessel on which the allon emigrated to this country.
TO THE APPLICANT.-The fee of one dollar required by law for the declaration, must be paid to the clerk of the
court before he commences to fill out the declaration of intention. No fee is chargeable for this blank, and none
should be paid for assistance in filling it out, as the Naturalization Examiner or the public-school teacher will help you
free of charge.
My name is Syloma Azlezingies and correct name in full.)
Age:
5,
years.
(Alien should state here histrue, originali
(Give age at last birthday.)
Also known as
Solomon thesinger
(If alien has used any other name in this country that name should be shown on line immediately above.)
Occupation: Farmer
Color: white
Complexion: stack Light
Height:
5
feet
8
inches. Weight: 165 pounds.
Color of hair:
brown
Color
of grey
Other visible distinctive marks: small growth are cline
(If no visible distinctive marks, so state.)
Where born:
Bielsk grodno
Paland
(City or tawn.)
(Country.)
Date of birth:
September
25
1876
9
,
(Month.)
(Day.)
(Year.)
Present residence: (Number and street.)
Broadway
Colchester
Connecticut
,
,
(dity or town.)
(State, Territory, or District.)
Emigrated from:
(Piace where alien on or to como States.)
Name of vessel:
(If alien majestic otherwise than the white character of conveyance star or name of Line transportation company
Biala got ship train Pode/ United
Paland.
,
(Country.)
the arrived by vessel, should be given.)
Last place of foreign residence: Biala Pade Syna
Paland
,
(City or town.)
(Country.)
*I am
married; the name of my
Swife (husband) is Sophie shlesinger ; (she) that was
*born
at Bocking Grodns ; and now resides at Colchester Cann
I am now a subject of and intend to renounce allegiance to The Republic
of Write name and title of sovereign and
Poland -
country of which now a subject; or if citizen of a Republic, write name of Republiconly
I arrived at the port of
new (City town.)
york
,
n.y.
or
(State or Territory.)
on OT° about January (Month.) ,
4
1923
,
(Day.)
(Year.)
NOTE TO CLERK OF COURT.-The two lines indicated by the * contain information which is provided for by blanks on the latest
declaration of intention form; until such time as you may be supplied with forms containing these blank spaces the information called
for herein should be inserted immediately ABOVE the twelfth line, which begins It is my bona fide intention," etc., as requested
in
circular letter of January 5, 1916.
14-8
(18557404
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"ocrText": "343,65\nNATURALIZATION SERVICS\nForm 2213\nRECEIVED\nFACTS FOR DECLARATION OF INTENTION\n5472\nJUN 161927\nFAM\nU.S. DEPARTMENT OF LABOR\nOFFICE OF EXAMINER\nNATURALIZATION SERVICE\nNEW HAVEN, CONN.\nDEPAKIMANY us TABOK\nNOTE.- copy of this form will be furnished by the clerk of the court, the Chief Naturalization Examiner, or the\npublic-school teacher to each applicant for a declaration of intention, so that he can at his leisure fill in the answers to\nthe questions. After being filled out the applicant should take the form to the office of the clerk of court to be used\nby him in properly filling out the declaration. Care should be used to state as near as can be remembered the day,\nmonth, and year of arrival, as well as the name of the vessel on which the allon emigrated to this country.\nTO THE APPLICANT.-The fee of one dollar required by law for the declaration, must be paid to the clerk of the\ncourt before he commences to fill out the declaration of intention. No fee is chargeable for this blank, and none\nshould be paid for assistance in filling it out, as the Naturalization Examiner or the public-school teacher will help you\nfree of charge.\nMy name is Syloma Azlezingies and correct name in full.)\nAge:\n5,\nyears.\n(Alien should state here histrue, originali\n(Give age at last birthday.)\nAlso known as\nSolomon thesinger\n(If alien has used any other name in this country that name should be shown on line immediately above.)\nOccupation: Farmer\nColor: white\nComplexion: stack Light\nHeight:\n5\nfeet\n8\ninches. Weight: 165 pounds.\nColor of hair:\nbrown\nColor\nof grey\nOther visible distinctive marks: small growth are cline\n(If no visible distinctive marks, so state.)\nWhere born:\nBielsk grodno\nPaland\n(City or tawn.)\n(Country.)\nDate of birth:\nSeptember\n25\n1876\n9\n,\n(Month.)\n(Day.)\n(Year.)\nPresent residence: (Number and street.)\nBroadway\nColchester\nConnecticut\n,\n,\n(dity or town.)\n(State, Territory, or District.)\nEmigrated from:\n(Piace where alien on or to como States.)\nName of vessel:\n(If alien majestic otherwise than the white character of conveyance star or name of Line transportation company\nBiala got ship train Pode/ United\nPaland.\n,\n(Country.)\nthe arrived by vessel, should be given.)\nLast place of foreign residence: Biala Pade Syna\nPaland\n,\n(City or town.)\n(Country.)\n*I am\nmarried; the name of my\nSwife (husband) is Sophie shlesinger ; (she) that was\n*born\nat Bocking Grodns ; and now resides at Colchester Cann\nI am now a subject of and intend to renounce allegiance to The Republic\nof Write name and title of sovereign and\nPoland -\ncountry of which now a subject; or if citizen of a Republic, write name of Republiconly\nI arrived at the port of\nnew (City town.)\nyork\n,\nn.y.\nor\n(State or Territory.)\non OT° about January (Month.) ,\n4\n1923\n,\n(Day.)\n(Year.)\nNOTE TO CLERK OF COURT.-The two lines indicated by the * contain information which is provided for by blanks on the latest\ndeclaration of intention form; until such time as you may be supplied with forms containing these blank spaces the information called\nfor herein should be inserted immediately ABOVE the twelfth line, which begins It is my bona fide intention,\" etc., as requested\nin\ncircular letter of January 5, 1916.\n14-8\n(18557404"
}