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Suite 1913,=154 Nassau St. New York, Do X.
Form 2213
NATURALIZATION SERVICE
2270
FACTS FOR DECLARTATION OF INTENTION
A
DEC 1 4924
1924
U.S. DERARTMENT
I
dipartment OF LABOR
0.8. SOUTHERN DISTRICT COURT. NFW
779
the
4927
NOTE.-A copy of this form will be furnished by the clerk of the court, ho-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 alien emigrated to this country.
TO THE APPLICANT.-The fee of one dollar required by law for the declaration, must bo paid to the clerk of the
court before he commences to fill out the declaration of intention. No feo 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.
landed Tonourness is freak tacob (Aben should state here Round histine, original, and correct in Rosen
26
My name
Age:
23
Also
(Ifalien has used any other name in this country, that name should be shownon immediately above.)
father
years.
name fuith)
glast birthday.)
Occupation:
Color:
White
Complezion: Fair
Height:
5 feet 49
inches. Weight: 1405 pounds.
Color of hair:
Black darkboron Calor of
eyes:
Brown
Other visible distinctive marks:
Accommunitione? chin and backofreed
Ragon
no ma
Where born:
(CiDy or town.) Russia, now (If visible distinctivo (Country.) so state.)
Date of birth;
november
20
Present residence: 56 (Number and street.) It Cap behisters (City et/town.)
Come 1900 (Year.)
Columbia
(Plage where alien got on ship or train to come to the United States
Cherbouras
Newyork
,
Emigrated from:
France
(State, Territory or District.)
Newyork
Name of vessel:
Gerengane
(Country.)
(If the alien arrived otherwise than by vesser the character of conveyance or name of transportationgo: Jany should be given.)
Last
place of foreign residerio adom (City town.)
Poland
,
or
(Country.)
*I am married; the name of my (wife thusband ;
is
; lake? The was
*bome at
and now resides at
I
am now Hand a subject of and intend aud-or to renounce Russia allegiance to Republic of
(Write name and title of sovereign and Country of which now a subject; or citizen of a Republic, write name of Republiconly
I arrived at the nort of
(City or town.)
(State
on OT about
(Day.)
1923AV
monthly
(Month.)
(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.
GOVERNMENT PRINTING OFFICE
14-8
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"ocrText": "Suite 1913,=154 Nassau St. New York, Do X.\nForm 2213\nNATURALIZATION SERVICE\n2270\nFACTS FOR DECLARTATION OF INTENTION\nA\nDEC 1 4924\n1924\nU.S. DERARTMENT\nI\ndipartment OF LABOR\n0.8. SOUTHERN DISTRICT COURT. NFW\n779\nthe\n4927\nNOTE.-A copy of this form will be furnished by the clerk of the court, ho-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 alien emigrated to this country.\nTO THE APPLICANT.-The fee of one dollar required by law for the declaration, must bo paid to the clerk of the\ncourt before he commences to fill out the declaration of intention. No feo 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.\nlanded Tonourness is freak tacob (Aben should state here Round histine, original, and correct in Rosen\n26\nMy name\nAge:\n23\nAlso\n(Ifalien has used any other name in this country, that name should be shownon immediately above.)\nfather\nyears.\nname fuith)\nglast birthday.)\nOccupation:\nColor:\nWhite\nComplezion: Fair\nHeight:\n5 feet 49\ninches. Weight: 1405 pounds.\nColor of hair:\nBlack darkboron Calor of\neyes:\nBrown\nOther visible distinctive marks:\nAccommunitione? chin and backofreed\nRagon\nno ma\nWhere born:\n(CiDy or town.) Russia, now (If visible distinctivo (Country.) so state.)\nDate of birth;\nnovember\n20\nPresent residence: 56 (Number and street.) It Cap behisters (City et/town.)\nCome 1900 (Year.)\nColumbia\n(Plage where alien got on ship or train to come to the United States\nCherbouras\nNewyork\n,\nEmigrated from:\nFrance\n(State, Territory or District.)\nNewyork\nName of vessel:\nGerengane\n(Country.)\n(If the alien arrived otherwise than by vesser the character of conveyance or name of transportationgo: Jany should be given.)\nLast\nplace of foreign residerio adom (City town.)\nPoland\n,\nor\n(Country.)\n*I am married; the name of my (wife thusband ;\nis\n; lake? The was\n*bome at\nand now resides at\nI\nam now Hand a subject of and intend aud-or to renounce Russia allegiance to Republic of\n(Write name and title of sovereign and Country of which now a subject; or citizen of a Republic, write name of Republiconly\nI arrived at the nort of\n(City or town.)\n(State\non OT about\n(Day.)\n1923AV\nmonthly\n(Month.)\n(Year.)\n* NOTE 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 in\ncircular letter of January 5, 1916.\nGOVERNMENT PRINTING OFFICE\n14-8"
}