HomeMy WebLinkAbout0205 PLACE OF REPORT (Fentyn S~nic~ Po+t) ~
DEPARTMENT OF STATE riC~p ~!ilt~t
' REPORT OF BIRTH ABROAD pA7E OF REPORT (Month, DaY, r.~ ~
OF A CITIZEN OF THE UNITED STATES OF AMERICA 26 19 2 #
,
NAME OF CHILO IN FULI (Firr~ newe) (M~ddl~ nawe) (Lost no~we) SEX
~~.'~~1 P4at~cick ~]?~AALE QFEMALE ~
OATE OF BIRTH (Monrly dsr. Ywd HOUR PIACE OF BIRTH IN FULI MosPirol, Ciry, Sro+•. Coun„Y) '
October 9, 1972 T; 32~ ican Univwc~ft~ H~spit~l, seiut,
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THE FOLLOWING ITEMS MUST BE COMPLETEO FOR 90TH FATNER AND MOTHER: ?
FATHER ITEM AIOTHER ~
FULL NAME . ~~1~ I~O~ ~ ~
~n~i (Alse ~ir~ Alot6~r't nonN_ ~ ~
b~fot~ wanioy~) i~b1i~
t
Octob~r 9 1946 DATE OF BIRTH 2 195Z • ~
s (M~. ~r. rp?1 s ~
~ PLACE OF BIRTH ~s~~.~a~tC~ Q•S.A•
I?1eW Yo~'lc, O.S.A. tc~ti, s~o~., co,.,~.r~ s
~~~~8~y PRESENT ADORESS C~4 ~r~~s~
(StnN No., City, S~oN) ~~1'nt ~
6~05 ~r~ ~e ~i,~ ADDRESS IN UNITED STATES 6~OS ~YL'' Dt'f ~~Y~ .~t i
, (StrNt No., City, Stot~) r e Z•i~ 3J'~i ~
I j~ j EVIDENCE OF U. CIT ZENS IP ~ Qfi~~l ~t• ~nO718 ~
! ~ ~f
~io1 ~t• T~071~0 (~f eohpoliz~J, yiw ~et~, P~c~ ~ e~rf. >
! i8s~ 1~ 1972 at rfo. If natwdii~d eh~ou~ Potinf(s) iv~ ~S~~d ~ io~ 1972 j~ "
f dot~ rwr lowful ada~ission to U.S. tor '
~ ~soeNr~ r~sid~nc~ ond dof~, olac~, ond ~u ~,OR~ D~ C• '
WaSt1~~Q~ D~ C• ' c~r~. _.o. Por~nt(s) nmwoli:otion(s)) ~ Y
j IF AUEN, SHOMI NATIONAUTY ~
~ QCt• 19 ~~C. 1966 PREtISE PERIODS OF PHYSICAL ~n• i95 9 s
~ PRESENCE IN UNITEO STATES
(Do nd lisf individuel S~o~~s)
~ PRECISE PERIOOS ABROAO IN U.S.
~ ARMED FORCES, IN OTHER U.S.
GOVERNM{E!!T EIiAPLOYMENT, MITM
UALIFYING INTERNATIONAL ORGANI-
, ZATION, OR AS DEPENDENT OF
M P R 5 ci(
PREVIOUS MARRIAGES r
SHOM DATE AND MANNER
OF TERMINATION OF ALL _ ~
DATE AND PLACE OF PRESENT MARRIAGE UMon~. doY. ~ev•CHy, ston, country) E
Jul 25 1970 ~lorida O.S.A. ;
SIGNATURE OF PARENT, P YSICIAN, NURSE, OR OTHE R PERSON A~DRE55 (Stee~e oddnss, c1ey, staee, count?y)
FURNI G ABOVE 1 FO T~Ot~1 rican ~8~~~ ~iZ~l t~ ~~~OQ
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THIS SECTION TO BE CaAPLETED BY ULAR OFFICER, NOTARY PUBLIC OR OTFER PERSdd QUAUFIED TO ADAAINISTER OATH:
Y` Subscribsd ond swan to b~t«+ nr this do~r d r 19 n
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c~ Coaaul of ~he United State~ of Aser -
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FoRw F~.2d~' CONSI~AROFFICERSA~t15T RECUIRE APO IIST DOQJMENTSI~CESS Y TO SUPPORT FACTS RFPnpTED
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