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triplicate
(To be given to declarant)
No_____________
UNITED STATES OF AMERICA
999-
DECLARATIOM OF INTENTION
(Invalid for ail purposes seven years after the date hereof)
Ua i t.nd-Stftto3?og-Aaoy-Jlc-a?-
In the
A
----------------?- Court
?f--Uivi t o(1---S1>fttes--------ai --Ex-itwi-yrlitrrri-csi'p'D
a which baa b?en used, must appear bere )
a <atyorto?i.-------	Jian-	{3-sin-----------------------
, aged QPj............ years, do declare on oath that my personal description is:
i,____(Tubrunioli.Jarka................
?	%	_	.	?	(Fuji	txue	nama,	mithoutabbrerlatioQ.	and	any	other	nam^whlc!
now residing at......X3i
A* _	(Number	and	straat)
occupation ____XlSllOlTtnit.................
Sex ....doLo........., color ...wlli.tG_____ ....., complexion oJLi-VQ_____________________________________> color of eyes	....
color of hair jdtU.Uc.-.llLTOLV/iV^.gX?-n-yheight-5. feet....3-____inches; weight	___pounds; visible distinctive marks
...lia:Lton..jci?icii-^or-cua.,xi-................-................-.............................-.........................-...?
race____ jllia.ilir.iall...................._.....; nationality....................-.............-....?-----------------------.
? on...........
....-........
ibirr
I was born in-------------I3.tiSCQIlU03ffi-............?...........................
,	(City	or	town)	(Country)
I am __.HO_u.__ married. The name of my wife or husband is__________________^?
we were married ou ............?	...........?	?.............., at ? ^	?...........................................?^siia.or he was
(Month)	(Day)	(Year)	(Cityortowo)	(State	or country)
born at............~n ?-- ?........................................., on________??................................................, entered the United States
(Cityortowo)	(State	or	country)	(Month)	(Day)	(Year)
at ...................................................., on................._r*_......................., for permanent residence therein, and now
(City or town)	(State)	(Month)	(Der)	(Year)
resides at.....................r.................................... I have________410........ children, and the name, date and place of birth,
(City or town)	(State or eocntry)
and place of residence of each of said children are as follows: ............................................................................................
:c:.
I have I1Q?L. heretofore made a declaration of intention: Number? at
____, on.
(City or town)
my last foreign residence was _______3CS-COJ4-U0-VO--
(City or tow
I emigrated to the United States of America from.........
_ _ _ ??.?-??.?	0---------------------------------  ~ ? ?---------------?
(Kama ot court)
.J?a.5?l*Q---------------------------------.....................................
(City or town)	s	(Oyancry)
my lawful entry for permanent residence in the United States was at___________________________HQXi- Y-OL-lC-.....................?f - -Vo->>V-?
_	-	.	(CiEy or wwo)	vStattf^
under the name of ___&Ubl^iUxCil-JOX'iCO -,Tr?...........................---------------------, on-------........................-----.....
on the vessel .....SiL.JL?Si.^Eu.ul1.*..............-....-...........-..........---------------------------------------------------------------- ?
(If ocher tliaa by Teatei. ataCe manner oi arrival)
I will, before being admitted to citizenship, renounce forever all allegiance and fidelity to any foreign prince, potentate, state, or sovereignty, aiid particularly,*by name, to the prince, potentate, state, or sovereignty of which I may be at the time of admission a citizen or subject; I am not an anarchist; I am not a polygamist nor a believer in the practice of polygamy; and it is my intention in good faith to become a citizen of the United States of America and to reside permanently therein; and I certify that the photograph affixed to the duplicate and triplicate hereof is a likeness of me: So help me God.
(SECUR?UYi)Mi|i> PERMANENTLY AFFIX ?'?StTOTOQRAPH HERE)
(The seal of the court will be impressed.sj> as to cover a portion of the photograph)" .
_____s^L-ik-.,.,-------------
(Oriental ai*nature of dMiawUyfe^oufc abbreviation. alao alias, if uaed)
Subscribed and sworn to before me inTSe" MB.ce of the Clerk of said Court,
atlill ClK-Lyl2XG lilnS-i upi? this 2&~~? day of __Upry...............?
anno Domini 19.33.
XK336e .W ? ? lie" p'fioto^a^^^^^ ness of the declarant. X3 X 957
.........yt...............E^LJTcKld^Jr-............
Clerjpcj the	J_\i_0_li........ .....Court.
[seal]
By
;gt.
Form 2-202?L-A U. S. DEPARTMENT OF LABOR
-?>#-* IMMIGRATION AND NATURALIZATION SERVICE
w-:
DePuty ?ierk-
f 14?2623 v. a. oomNMXN? rmrrtsi orncs