VERM Nat Cards 452T_2311

Last Name (Family Name):

First Name (Given Name):

Street Address:

City of Residence:

Certificate No. (or vol. and page):

Country of Birth or Allegiance:

Date of Birth (MM/DD/YYYY):

Age:

Port of Arrival In U.S.:

Date of Arrival in U.S. (MM/DD/YYYY):

Date of Naturalization (MM/DD/YYYY):

Date Certificate Issued (MM/DD/YYYY):

Additional Information in Court Record: Petition No 1006 Entered the USA under the name of Soja Brunislowa