NAA: A12027, 355-358

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NAA: A12027, 355-358
Series number: A12027
Control symbol: 355-358
Barcode: 4723480
Number of pages: 46
KOWALSKI Stanislaw born 9 April 1911; [Maria born 22 July 1915]; Krystina born 15 January 1944; Henryk
born 26 September 1945
lrno‘;|us cenrrnz Munster AUSTRALIA yr i * “"-- - l’>‘_>“» r F“‘"'-Y G"°‘*"’5l Name (Blocks) ‘ Christian Names Sex Date of liirth DP Card No. Nationality claimedKOWAISKI l utanislaw 9.4.11 403051 PolishEducation Technical 'Prirriary - ‘/écondary — Trade — University - Degrees -\- (ll )E?\2fi:l?|g:.. ., German .. Russian ., . .. . . BQlr:.Bh1.£ll.1QDéy~Documents Marriage... ., . . Birth (Childr .Original Passport No. .. . Divorce - .. Gaul: . ., .. . .
.l.R.O. Eligibility Address of Relatives or Friends in Australia Religionestablished R.C.Dependants whom applicant wishes (a) to accompany him to Australia 'Names I Sex l Date of Birth | Nationality Address | Relationship l
Employability .,
nPA,c A 0.i...i........j.$.l|lYJ....S§.l!1& ..f .........15.1.41+J " " hdaugizter . 425,9-45. ' " ., ./. ,,,. 5 \uCivil Oflences / I Literacy Test passed /Dare of Arrival Germany J From / ‘ha; ‘£¢67-1'14 mg
/.,,,¢.‘..4- ,-Knowledge of Engllsh ,.é‘ Letter of Authority No. R Travel Document No.Security -»/¢..¢- 4: deg-ea...’ ..-.., %¢. ‘Zr(a) Reason for coming to Germany. etc. .5-‘Q AZ‘(5)(CU! //0‘Employment in own country ”./ +
Employment (a) On arrival in{G' ermlanywr 7,476? /’/‘?%4> “ '% : F(h) nu, @ we »/-'- - -=9» -/,9 “*--¢»ovSuggested employment Australia Q Q - :Undertaking : I hereby certify that the personal particulars suppliedby me to the
Australian Selection Officers are true In every respectand that I have made myself familiar with the conditions under whichdisplaced persons can emigrate to Australia. I fully understand thatI must remaln in the employment found
for me for a period of up totwo years and that I shall not be permitted to change that employmentduring that period without the consent of the Department ofImmigration. 'Full Name YY . >< .. (alédtl)Erltlirung: Ich erkliire hiermit.
daB die perséinlichen Angaben, die lchden austmlischen Selection-Olzieren gegeniiber gemacht habe. In jederHinsicht richtig slnd, daB ich mich mic den Bedingungen, unter denen ver-schleppte Personen nach Australian
auswandern k6nnen. vertraut gemuchthabe. und daB ich mir duriiber klar bin, dafi ich ir die Dauer van zweijcihren in de! flir mich gefundenen Beschdftigung verbleiben muB und esmi! nicht gesmttet sein wird, diese Beschiiftigung
whrend jenel Zeit nhneZustimmung des D rtment mmigmtion zu wechseln. 4{K"“""’ &~ZSignature ofSelectlon Officers V’) Date ./ ..Z6£ PPSSiI<lQ)R39B6D'/'l0M/5-49 ‘ Z , ’\ -\ -_, V
SURVEY CARDnI-0atUn.-.--i¢i—» — " " "'**DATE PIEVIQIJS M.R. emu (IF ANY) A1‘!_./EA ‘KDATEOP BIRTH DATSAPFHBX.)NATIONALITY887‘I‘ SURNAME(BLOCK LETIERS)CHRISTIAN m\mE(s)I/fa/v\,,LI‘lo»!OCCUPATIONNUMBER OF FAMILY CONTACTS IN enours :I. l. sPRESENT ADDRESSNORMAL9 4 READING OF MINIATURE FILMDIAGNOSIS FROM as MM FILM 1:251:23zone REGIONCLASSIFICATIONor DISEASE
No.=uI_1-mun-E uIIIenosI:FROM LARGE rI|..uI(IE5 OVER)DISPOSALcARI:ICAMP COMPLETEDDom,” DISFENSARYEmnonxuu no ACTION
TUBERCULIN TEST METHOD NEGATIVE+W "' ++ +++DAPATCH TEST. I ../,\ \M ANTOUX’(MANTOUXMANTOUXDATE D NEGATIVE U NONYSIGNIFICANTU SIGNIFICANTSMALL FILM READING 35 m.m. 70 m.m. LARGE
FILM READING DATEA.B.PCIUIIIUUUD.E.F.FILM UNSATISFACTORYESSENTIALLY NEGATIVESIGNIFICANT PATHOLOGY OTHER THAN T.BNON-SIGNIFICANT FINDINGSQUESTIONABLE FINDINGSPROBABLE T.B.3.IIIEIIIIIIIEJESSENTIALLY NEGATIVENON-SIGNIFICANT LESIONSMINIMALMODERATELY ADVANCEDFAR ADVANCEDSIGNATURE _ ....__.._.........__...._...___.,__._._. _
. ,A\_us't.ra1i;1n' S‘ch'-me Grop: :5. ‘ S=qfj.1\IO: -_-K6‘ .; Intake No; ',4}£2» ' Ce'rt‘i1"ic-.a~’t,“ic§n of Blood Test. ‘ (Descheinigung uulavr Blutprobe). I hereby certify ‘bhu'b_ ' »Hiormit wird bcsohoinig"b,dus.~;- . , / I_(Kb»_;q1'srv¢
§7‘/0*?/S/u_\‘ 9->4./;'Surname and Christ -.T1u;1u/V01‘ .-u. Z,unc.1:1“0 Date of Birth, . - - Guburtsdatwl“ . _1'1as .bc-zen subjected to a V\7i1S.CL)TL1L\.TH1"K.Qhn / Blood '1‘o.¢:t for Vuneral Disease‘ sich oinur
vlussorm:.nn,’Kukm Blutprobu fuur G0-'30h1uOh‘\ZS1£I'C\YCh0i‘bOnunt orzogon herband tho rusult has b-L-uh found PO5!!¥Fr/1\1"1‘JG1»'1‘I\/E ,j. §.*’ 5’);-~.'Ins E1-gubnis wurdc nls §&r / Ncggcrhiv ' _ ' ‘{X /I .I ‘ ..D1230: "
‘Wlhtwn: ( Dr .R {S v ISignatuzx, of Sorologi atUntk.-1‘3ChI‘if't d.;s S01'O1Og'un
, ,____,__,_la-1 - ‘émdriulcaitis11-2. "1.6- Gueimtheruh n1+5. Luoatus#6. "14-7. Plioh48. "PramsN ado zdnZygmuni:MartaJoanJ ohmE dwardMargarc teu-Luup; J10.9.219.3.194-7.2126.11.181.10.18U1Q\.Tl-_\k20.5.1459.51.»¢~..--.--1canon:o-.-¢|-1».1-av--|a---|-0|»,
Subject:- i~;OTi’1§LSl';I Stanislaw, b. 9. 4.11, ii 0*-:2 0'01"_ Q1_’_22£<l_E2;iIQ§Q§.l__j ______ ________{ 'To :- 501 esettlement Proc.Centre 4'-4"’ IEO L-ledical B03113 *' . $EN_RE$_QFF’ l"OI'tS111011t1'l Barracks -» M Li n s
t e r, BAOR 12. ADMIN. oFF..W_...__;.._-~._From :- 1.4.0. 60 D.PG r e e 21V. lieference your letter aawa 14,12.49.MED;<>FF-»~A-~-~--_-;~»;;~;-‘~- ‘ DATE>‘_ 1RES. OFF. ..._.;.,_.......~,_.__...*.< ~ "Attached please find doctor's
ré'oi-'=t "tnlqrespeci Bi“ the a/n-deferree who hasvbeenéoperated for Hospital Hamhprn.G ' " ma Vofr" 25‘?T?‘§6 L 47-L/2. (1 ( (D§¢1%?S’tra11ns) 1 " ._.- <, . _,;'}w_.<T. .~ _;.<- _.},_‘.‘
“T '- ;,, -____. - i0' "f/£~~=.‘--’ -‘ £.¢_. .:rn Q &r.me-'} T“ "'“~-“'\ !’""::~f'~an‘L 0xii’ ‘Kowalski, Stanislaw . Lager Qxevengab. 4.Diagnose:Die VaricDiscisionkomplikatU \Enthasungsberieht.en an beiden Unterschenkeln wurden dureh
multipleen nach Klapp bes~itigt. Die haohbehandlung verliefionaios, ~Dxusnurg~liaJ1burn9. 11. aufgen, 29. 12, 49 anti 11 1 H0Varioen an beiden unnersehenkeln.
?I.LatiO!1' Dischar e-Report' QIAL uni Iaw Cam are anK SKI S - 8 P vcorn 4»-7-1.4. auuut wu Z7-..L4¢l4-9 dischnrgeu. J..L¢J.d)QDzapwaug Various on Both Legs.Varicea on both legs ware removed by multiple diacisiona
l.GcOr—ding to Klapy. Further attendance without complication.' signed Druled. Th.schu1te-lurunpenDuisburg-[unbornBarbara. - Hospital.|w l
v‘ 1‘U nu.801 1'cc=sett1<1ment l’rocus:,J1;; Centre 11 DICAL CONFIDEN’I‘I./LI110 liedicwl Bo.".rd' -Ifuenster, BAOR 12'. D_‘tL___ 1*“ mi.’ Portsmouth Bzxrrwcks. ‘ ‘ --—-—-—--—----~-—To:- Iiedicnl Officer c/0. ‘°' ’ DPAC " 5""! _
_Sg'Qj(;ct:,. I 0 v I 1 L: 1 , as-mu, 9 .(:..a1.A mu. spa,' The n./n p::rsOn has been deferred for trozxtmcnt V 1% for“I 6 """_“OrnigI"1tiOn ’co»__ LBIIIISI ___undcr _ ‘ !!£“_ RaGcheme, byI>i~.;nosis=- Hhrhuiq nip. ' _7 , _I‘ / .\ [X (‘V
4)-~11 _ V/W65;L WA ,3A’ /gab ' _.__.._.- ..._i.Dru. A.kL€'-Y/I\/InlzxterreI20 Senior Medical Officer
* YI. /. I I‘ Li» .’ /r///_’ > .. ' ,/, //l\Z9'-*<-A0-.’lIQga'u|uIIlOO'I‘0:- ;3.II.O., 511 DPAC Du‘t\.::-- _Sick Bay }Munster‘\Name . /Applicant to .".%1.’:' 7‘ 1/ax; trc: 111011 ,Diagjn.:- ....?r¢.1.¢.¢.q:...¢.m¢. .zr.~.r...;,~- 6}” &6/J1:/4414//‘1' ,
7#1-“z4<<4@..-....1;I:[::...........---.HO 1.EiDICAT1 BTDARDIw“\_ 1.v->q- .-.\'.\. -Iv‘Is!'-\:_‘\
»-2= IV - Miss BILSENQ91Schmrn ..-...H'...;2/........ Group .......5:.-..-The a/n person is fit for being called in. ‘........»....-.. . -.lsluens tar‘+4?
"—- a _. ,,,,, V» 7‘ ‘ 5:2. 61, .‘ YI. R. O. Resettlement Medical Examination FormPart I. Identication form to be completed by Assembly Centre doctor.I. Teil. Identikations-Formular, (lurch den Arzt der Assembly Centre
auszufiillen.1-§:::.l§..Q..\tsl.2~§_“1:;;. .. . gijjimt we 5-sex ., , M 6-c»1<»»~~»~r f-41Alter Geschleclit i H H Haarfarbe H IIII H '7. Colourof Eyes M y _ y s. Height '1/P‘, _ 9. Weight 91)Farbc d. Augen Grésse i Gcwicht I I0.
Scars or other Means of Id ficationm H H H _ V H HNarbcn odcr andere Kcnnzcic/ran\') '-11. DP. Number __ £3 Vi Mg 12. Claimed nationalityDP. Nummer Angcblichc Staatsange/iii:I certify that I have seen - lc/1 crlrlreMr. Herrn llowaiui-2| $i1\.u».',|»(ou.J .... 1»Miss - Fréiulein \_7 ’ .examined his/her D.P.I. Card. his/her photograph and his/her appearance, and am 1 'satisfied the particulars given are correct and that he/she has signed in my
presence.gesehen, seine/ihre DP}. Karte, seine/ihre Photographie urid sein/ihr Ansschcrikontrolliert zu haben. Ich bestétige, dass die Angaben richtig ‘sind, und dass er/sicin mciner Gegenwart unlcrzeichnct hat.rW w - _ _ _DateDatum Qt) hi’/6 r A Signnlurr Mrditll (‘Nicer - Unlerlrlnri/I 1L Arzh-I §iguMlure nl Cuuiliilnle - Unluradnrill d, Kumlillnle-nPart ll. To be completed by Assembly Centre doctor and signed by the Candidate.Il. Teil. Durch den Assembly
Centre Arzt auszufiillen,u. (lurch (IenKandi(Ialenzu unlerzeichnen.l. Family medical history _V +1 \/y.\ O1, ‘Kranlv/icitsgescliiclite.der F milie _ _ ' V ' ' ' V im L/\/\/\/‘ti, L1 l/i/Xx?/\/8 /w~ >'.No. of Children: a) Alive L b) Dead -_ c)
Cause of death _Zahl d. Kinder: Am’ Lebcn H i H i l Q V i Gestorben Todcsursac/re i2. Have any of your Family suffered from a) Tuberculosis, b) Mental Illness, c) Epilepsy? If " Ycs"gi\'e details:Hat jemand ihrer Familie an
[olgcnden Krankheitcn gelittcn: a) Tuberlrulosc, b) Geistcskranlrhcit. c) Epilepsie (Fallsucht).Wenn "Ia bilte néiliere Angaben: .. ...... .. . . ....,. 3. Personal medical history: Have you suffered from any of the following illnesses? s)
Tuberculosis, b) Mental illness, c) Epilepsy.d) Venereal disease. e) Kidney disease. f) Nervous breakdown. If “ Yes" give details:Pcrsénliche Krankhcitsgcschichtc: Haberi Sic an folgenden Krankheiten gelitten: a) Tuberkulose, b)
Gcistcskranklwit. c) Epilcpsic(Fallsucht), d) Gcschlec/itslrrankheitcn, e) Nierenkrankheit, f) Nervenzusanunenbruclz. W'cnn "Ia", bitfe nxihcrc Angaben:e - ’\. wv a4. Previous illnesses, injuries and operations of candidate. indicating
whether he has or requires prosthesis for amputation:Friihere K.“*kIieiten, Verlctzungen u. Operatiunen dos Kandidaten. mit Angabc ob sine Prothesc nach Amputation verlangi wurzle. i. ........ ..1 mm, tltlt the -hm llulnnentl Ill!-It
1., Inc in lnlwer In the foregoing question! IYQ lruc nul complete to u..- best oi my |..n.r. 'mi 1>¢.¢an,= an Ridlligkcil 0lJi[l.'I A,.,..im., Illld lllihlililllrh Ilddl M».-n. tum. wnm. 014/ ulle Frugeu geanlzlvrlcl =.. /...r..-...I>=== ......................
>A S*w=m<>*¢w"=h-~.. ./.‘/awf,/K/(Z... ¢$,..?.1/4Datum Unterschrift d. Knndidaicri .A74. -J __..___ _ _ 7 I _ _ ,___7 __ _ I
" *4 ‘ ' *7“ ’ - it ~ ' — » -— ‘u \ _. I 'PHYSICAL EXAMINATION.AERZTLICHE UNTERSUCHUNG. 'Part III. T0 be c‘pleted lay Ass‘/ly Centre doctor.Durch den, Arzt der Assembly Centre auszufiillen.Part IV. To be completed by
Medical Board in ResettlementCollecting Centre.I. General build - Allgemeines Aussehen . . . . . . . .2. Visual acuity - Schschéirfe a) tvlthout glasses a) ohnc Glaserb) with glasses b) mit Glésern3.Hearing-Gehér. . . . . . . . . 4 . .4.
Trachotna - Trachoma . . . . . .5. Teeth and gum - Zétmc u. Zahnfleisch . .6. Abdomen - Bauch, Ilnterleib . . .7. Hernia - Bruch , . 4 . . . .8. Operation scars - Operationsnarbcn . . . . . . .9. (‘Fntral Nervous Sysim - ZentralNcrvensystem1 Mental status — Psychischcr Status . . . . . . . . .i Reexes (note resgmsel — Reflex (beachte die Antwort)Pupils: n) to light Augenstern a) bei Licht . . . .b) an accommodation h) Anpassungsvermégen .c) knee jerks
c) Knie-Reflex . . ,d) plantar d) Fussohle . .3) Remarks - Bemerkungen . . . . .10. Respiratory system - Atcmsystem .ll. Cardiovascular system - Cardiovascularsgstcm5) Pulse rate a) Pals . . . 4 . . . . . .b) Rhythm and regularity b)
Rhythmus u. Regelmiissigkeit . .c) B. P. c) BP. . . . . . . . . . .d) Ausculation d) Untersucliung . ._ 12. Genito-Urinary - GeschIechts- mid Harnsystem . 4l3.Llrine-U1-in... I4. Gynaecological (Where necessary) - Ggnaecologisches (wo
ntig) . . . . . .I5. Locomotor Function (Note disabilities) » Bewegnngsfunktioncn (Slérungen any.)16. Date of last immunisations - Datum der Ietztcn Impfungen >a) Smallpox a) Poclcen . . . . .b) Typhoid Es Paratyphoid b) Typhus u.
Paratyphus .c) Epidemic Typhus c) Flecktyphus . .d) Diphtheria d) Diphtheritis .e) Others e) Andere .l7. Further notes 1 Weitere Angaben . . . t.R L ‘ R A I,Yes - Ia -’ No - Nein H >.... §§£@Q@jW 1;- ,, >7 .nil. ____ A
.n0r1m]. .... .. .. .“weal., .. no1ma]........... A " """" " wshamans a§iinmg; QQT> '“"i.lIl'II""' H ””” "7fl/' l.17.‘/i . . ._
..... ..I hereby certify that I have examined“ _ (ygcnand that the above findings are true to t my belief and
knowledge. l considerhe/she is fit to proceed to a Resettlemen. *ntre for medical examination.If/I besfétiy tliermif» dais i¢71 Hm untersucht und obigcn Befund lllahfheififtfe nach meinem besten Wissen erstellthabe. Ich crkliire
ilm/sie féihig. sic/1 bei ein m Resettlement Centre zur Erztlichen [Inter-suchung :11 melden. I, , I,Dam - D-Ifwvl ... .-....;‘..l’.......v.5iQ ture - Unters¢hril......& Aslenhl Centre Mnlienl om", .(r. Assembly Centre Am“i.)- - -22ét
fnayefsggp tttt Z tmmmmtt yyyyyy .5'19" . Albumen ...na.gatiyQ ../¢/ 4/- 3/ fI’.'ffl?é'§I§§§i§§§" The above person has been examined by me and is considered fit/unt to appearbefore a Selection Mission. V VDate .. Siélnature
IE,-mm»; Physiern , ~“ 1 / ‘/» / Osiealfe . ._ dPmiam. D. P. "1 Z _‘__v,_‘_vvmm5ter‘ v_ Resettlement Centre.
.\<‘ya».nv‘Part V. Special examinations.X-Ray of chest | Date Slllulp-»l@,, >1-l~.<_;-.1)Hen,-1 ........ .. . . .‘\>;‘..:¢;1Lungs HDate Slump----~-;~_-~11-.~---I,7 ........... . . b) Blood leg!c) Others Inge Sump. H .. "; ¢1¢.~‘.-y1...1;.OPart VI.‘ For Selection Team ' ' r on]Ihnve examined ..... ,. .... ..- - ............... . '> .. ..and certify 1/ he/she is t for euugruhon to » -2 e is un, 350,1 of .. .. ,. .. .. . . . \ ANTMissionQ Dale <3(‘/I >77 Signature ‘
7_‘T' “'7 ' 'rulmzies; :19 watt;-A QQE: :10r.:;:,1L.v Ok‘. U H ~. L J A 1 QT,%1']1SL21W' A-liLx_',' l\O.U-'_'1\J‘3(‘§7 \.’ V/'_/I/y/g /pr v' enzzmsiMin L\w.1>»',:<. \ .in//{‘;:Lu;;1~;,t. K/,\~r“-7~ __ _
SURVEY CARDanI-PCIRO|JA‘§ilz.‘{i _&PREVIOUS M_R. EXAM (IF ANY) A1‘: ‘G. A one 0: BIRTH DEE (.u>|=_m>><.)ETIONALITY ‘. 6 1 .‘ -5 1sunmxmz(BLOCK LETTERS)' Q1,/A A J /€_ /'é'i;'}¥i'§¥[Kii"i~I;&'»J|E'<é.'> " '~"»
’*4'4z’;;",‘ _@.__-<51 I1‘ 44¢,OCCUPATION‘ sNUMBER OF FAMILY CONTACTS IN GROUPS :1. A. 5PRESENT ADDRESSNORMALREADING OF MINIATURE FILMmus: FILMDIAGBIOSIS FROM as MM FILM ‘
REQUWEDzone REGION > NO.fll -10 -L8Cor; Mai.fnoiogyCLASSIFICATIONor mszass uo.:m_nw».~r= nmanosysFROM LARGE FILM(ass ovzn). X 1 /I/ , Q _ ., D AZ —' ‘CARDCAMP I OMFLETED
TUBERCULIN TEST METHOD NEGATIVE++++ ++FATCH TESTMANTOUXIMANTOUXIMANTOUXDATE [:| NEGATIVE E] NON-SIGNIFICANTSIGNIFICANTEA.B.0EIEIUUUI]D.E.F.FILM UNSATISFACTORYESSENTIALLY
NEGATIVESIGNIFICANT PATHOLOGY OTHER THAN T.B.NON-SIGNIFICANT FINDINGSQUESTIONABLE FINDINGSPROBABLE T.B.READING 35 m.m. 70 m.m. I LARGE FILM READING DATE ‘EIUIIIICIESSENTIALLY
NEGATIVE INON-SIGNIFICANT LESIONSMINIMALMODERATELY ADVANCEDFAR ADVANCED 'SIGNATU RE .._._..___.......I...._ _.._....._._....,._...._
i
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‘ .<<\_ A4.3l. R. O. Resettlement Medical Examination FormPart I. Identication form to be completed by Assembly Centre doctor.I. Teil. Identilcations-Formular, durch. den Arzz der Assembly Cenilre auszufiillen.~N ' " 1- C mp i 3L‘?.°.?"°“..Ql..N:z:.l'<.Q.l!s1...fj;.IA.;2.\.xl%., L;-W ...... Omcm4- 59° J U ,- l ‘1 l"\ . .,,. 5- 5“ ....... ,. . ..6- c°‘°‘" °l M5 , ,MC ............ .. .. .. G H ht H nuker esc ec as aC01“-1' of Evte§........ . .. .. ....... . 8- W=*9h%...........¢/. Farbe
d. Augen Grsse GewichtScars or other Means of I ntification "'Narben odcr anicrc Kcnnzcichcnft,Gui;. 17- .10.-~ \11. D.P. Number _ 0 Q K __ l2. Claimed nationalitym (g ‘ _DP. Nummer Angeblic/ie StaatsangehdrigkcilI certify
that I have seen — lch erklérePlinm of CandidateIn be nndm!M“ ' Herr" G R H - here and llllnpttl 'M"5- ' Fm" __ W _ and PhuluglnphieMiss - Frulein J. Kandidamih‘ kl I Jexamined his/her D.P.l. Card. his/her photograph and
his/her appearance. and am ' w'_“;;;:';':"satisfied the particulars given are correct and that he/she has signed in my presence.ilgcse/ion. seine/ihrc DP]. Km-te, seine/ihre Photogrnpliie und sein/ihr Aussehen Sump of J,kontrollicrt
zu haben. Ich bcstéltigc, dass die Angabcn richtig sincl, und dnss er/sic Anemlily * v ._\in nxcirzcr Gegcnwart uriterzeichncf hat. c""" ~ ‘SIEIIIPBI. Am-mbly .Cenlre. . ,- » qW m1 1 I = " ‘We - D-Wm 49¢ .146) ’l-/l!(l’(k/~/\5‘-'£»w
%’o¢<r%’ié' 1 Y/A M»! " _. ‘‘Q sa,t=.i.."1\n.|.¢.| Uicer-Unlernhri/I 4.4,“. siguulure |)‘CI|\Ili|lllE- ‘!vl.KI:mli:Iaten VIéI;am\Part II. To be completed by Assembly Centre doctor and signed by the Candidate.ll. Teil. Durch
don/issemblyCentre Arzl auszufilllen, u. durchllen Kandidaten zu unterzeichnen.I. Family medical history l A/W k‘/vv lKranklicitsgeschiclite der milie V ‘No. of Children: a) Alive__ _"—*_ ______ __ V H b) Dead‘ H _ __ __c)
Cause of death __Za/il d. Kinder: Am Lebcn Gestorben Todesursac/1cZ. Have any of your Family suffered from 5) Tuberculosis. b) Mental illness. c) Epilepsy? If " Yes “give details:Hat iemand ihrer Familic an [olgenden
Kranlrhciten gclitten: a) Tubcrkulosc, b) Geistcskranklieil, c) Epilcpsie (Fallsucht).Wenn "Ia", bitte néhere Angabcri:3. Personal medical history: Have you suffered from any of the following illnesses? a) Tuberculosis. b) Mental
illness, c) Epilepsy.d) Venereal disease, c) Kidney disease. f) Nervous breakdown. If " Yes " give details:Persnliche Krankheitsgeschlchte: Haber: Sie an folgcnden Kranlrheiten gelittcn: a) Tubcrkulose, b) Gcislcskranlrheit, c)
Epilcpsic(Fallsucht), d) Geschlechtskrankheitcn. e) Nierenkranklieit, E) Nerverizusammcnbruch. Wcnri "]a“, bittc niilicre Angaben:4. Previous illnesses, injuries and operations of candidate. indicating whether he has or requires
prosthesis for amputation:Frhere Krankheiteri, Verletzungen u. Operationcn des Kandidaten, mit Angabc ob cine Prof/iese nacli Amputation verlangt wurdc. ' .. 77 ........ ,,,,, ..l unify lhu uh; ilwve unementu mud; by me in nnlvrer
to the {oi-qoing queniaiu are true Ind complete to the hen ml my lizliel.ldl be1liI'Ii|e an Ridlligkcil obigu Angaben, llild wullrheilngelreu Ildl meinem mm. Mimi. nu] all: Frngcn gtlllllwnrtel III nab!-.\~l IDi--= Sam
orcandidate.....Elsi;..<.~1..(?4it:4T....lf12:z.2#f4¢'Datum Unterschrift cl. Kandidaten H V
- 7 1 —"- PHYSICAL EXAMINATION.AERZTLICHE UNTERSUCHUIVG.V - - —i_v — - —- sPart Ill. To be co’eted by Ass‘1ly Centre doctor. ' Part IV. To be completed by Medical Board in ResettlementDureh den Arzt der
Assembly Centre auszufilllen.Collecting Centre.l-3 General build - Allg?1neines Aussehen . . . . . r . . .Z. Visual acuity - Sehschirfe a) Without glasses a) ohne Gliiser .' b) with glasses b) mi! Glésern . . . .3. Hearing-Gehér. . . . . . . .
. . . . . . . . . . .4.T1-achoma - Trachoma . . . . . . * . . 5. Teeth and gum - Zihne u. Zahnfleisch . . . .6. Abdomen » Bauch, Unterleib r . . .7. Hernia - Bruch . 4 . . . . .8. Opqation scars - Operafionsnarben . . . . . . .9. Central Nervous
System - Zentral-Nervensystem1) Mental status - Psychischer Status . . . 4 . .‘ . .‘ 2) l!{efleX2s (note response’ - Reflex (bcachte die Antwort)Pupils: a) to light Augenstern kytict,-l . .b) on accommodation .3‘)-Ql-udgsvcrmogen .c)
knee jerks c) Knic-Reflex . .d) plantar d) Fussolzle . 43) Remarks - Bernerkungen. . . . . . . . .10. Respiratory system - Aterrisgstem .ll. Cardiovascular system - Cardiovascularsystcma) Pulse rate a) Puls . . . . . . . . .b) Rhythm and
regularity b) Rhythmus u. Regelmfissigkcit 4c) B. P. c) B.P. . . . 4 . . . . ,d) Ausculation d) Untersuclmng .12. Genito-Urinary - Gesr:hlechts- und Hamsystcm .l3.Urine-Hrin.....4...4....4.....14. Gynaecological (where necessary) Gynaecologischcs (wo nétig) . . . . . .15. Locomotor Function (Note disabilities) - Bewegungsfunktionen (Stiirungen ang.)16. Date of last immunisations - Datum der letztcn Impfimgena) Smallpox a) Packer! . . . . .b) Typhoid 6
Paratyphoid b) Typhus u. Paratyphus .c) Epidemic Typhus c) Flecktgphus . 4 .d) Diphtheria d) Diphtlieritis .A) Others e) Andere .‘ l7. Further notes - Weitere Angaben . . .-;. WVVVW R .. . .. . .
Y ”mmAMA&lWW M .... .. .
....IjIIQijIi1'iii“"""'""" ‘ w-4%. .I/1K:1u-r. .4,/I hereby certify that I have examined and that the above findings are true to the best of my belief and knowledge. I consi erhe/she is fit to proceed to a Resettlement Centre for medical
examination. -[Ch be-$7599 hi!’-‘l'Y""t» 595$ [Ch .. .. 3'" .. . untcrsucht und obigen Befund wahrheitsgetreu nach meinem besten Wissen erstellthabe. Ic/2 erkléire ihn/sie {ii/iig, sich bei einem Resettlement Centre zur iirztlichen
[Inter-suchung zu mclderi.Dare - Dawm... Signature - Umers¢hri;6?. Allernlaly Centre Medical Offiner < {I Juemllly Centre /lrlten..§7i*7#*~M.€€§;§4;a5Q;- M‘5;§i§??%%Y7 eye .1 .
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.=..r../".. .. Z -'.'/f L. .‘Z..)i?f.....li‘i..The above person has been examined by me and is considered fit/uniibto appearbefore a Sehaot-ion Mi i . fx—-J Examining Phylinilu A , “4; Z) si‘Jl1El"1'¢ ....... .. ? " 2-' Prepident. n. P. ml B»-. .
4. esilwlet Centre-5%.
» /7v _ ‘.,,. Y, .Q~ Part V. Special examinations,n) X-Ray of chest Ba“; 9Hem-¢ .... ., , .................................................... ., n°1'““"~1Lung; ........................................... ..??.‘.’....?’.?T*f.’A‘.°}.‘i%%‘./_ ................. ..I D513 ‘ I. , , . . . . . . . .
. , . , . . . . . . . . ...,; .. b) Blood testxPart VI. For Selection Team Medical Oicer only: ___ _ _,,,_,;_ y. K "'I have exammed ..
................................................ ..and certify 1/ he/she is t for emigration to ................. .. I
%%%%%%%%%%%% 567%? %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% ll.i ’M ;\/f 1/5ignn£Ilre........ .. Mission ...................................... ..
SURVEY CARDmI'-O0:Un.DATE PREV|0us M.» zxm (IF ANY) AT: ‘_: ,1q,,~/3‘ 3:-.. (:1 1; f_ on-zo|= mam _c:A;rE (/»~rvw><.)NATIONALITY‘ SURNAME. (BLOCK LETYERS)CHRISTIAN ~AME(s)OCCUPATION\ ,2 O [L /'
uumazn or rm»1n_v couucrs IN anours a, 4. 5'-‘»‘<-l ‘_'¢—,=.:< PRESENT ADDRESSNORMALREADING OF MINIATUEE FILMDIAGNOSIS FROM =5 MM FILM | ~,;*;g5,;g;*\ .zcms assuou i no.U01" mi.CLASSIFICATIONor
D!sEASE uo.=uL'r|MATz n|Aa~=s|sFaun LARGE mm(sse ovzR)1:11: 10 L-Z;‘lZllOJ.O§y121.; 4 ,- /DISPOSAL 4' 'CAMP N FLETEDARD“C7” wsvz smvsANA'roR|u>4| uo ACTION
TUBERCULIN TEST METHOD NEGATIVE+++ 7+-I-+PATCH TESTMANTOUXMANTOUXMANTQUXwere |:] NEGATIVE\:] NON-SIGNIFICANT D SIGNIFICANTREADING 35 m.m. 70 m.m.LARGE FILM READING DATEA. [3B.
[1c. Q0.E.F.DUBFILM U NSATISFACTORYESSENTIALLY N EGATIVESIGNIFICANT PATHOLOGY OTHER THAN T.B.NON-SIGNIFICANT FINDINGSQUESTIONABLE FINDINGSPROBABLE
T.B.I.2.UIII3.54.[15.[1ESSENTIALLY NEGATIVENON-SIGNIFICANT LESIONSMINIMALMODERATELY ADVANCEDFAR ADVANCEDSIGNATURE . _ ...__..._._
. ~3 LL‘/' ‘\_\, ,'/.1_ &: \_/ W1!‘ F./7VC]\/'\,‘\£'L1
V .LIiU, ‘ — —— 4. 54, <1~»»r~"I. R. O. Resettlement Medical Examination FormPart I. Identication form to be completed by Assembly Centre doctor.I. Teil. Identilcations-Formular, durdi den Arzt der Assembly Centre
auszufiillen. '1. N=m¢.l§O\§)h€>.i4\\... .. 2- cm. , 1 ‘3iLM.)r.\.4_l)O/1» / 41 6 'Name , Leg" omchah1-Av .. ..... .. ...@.i.Q...i4.o ........ . 5-5“ .. ...........~¢<11<>“= <>*11=1r..... Alter - Geschlec/it Haarfarbe71
¢°1°"§,9?...E.vs§......./@f),u_,|_ -. .8-1'1=1H11*. ¢"1 9- M11111‘ 6Fa:-be d. Auger! Grssc U Gewich-ti I l V Q Q V - - - - - ‘ 'H 10* scars °r Mb“ Means °f IdE“‘ati°“..._.....r:...... ........ .......... .. Narben odor andere Kennzeichen ' ' ' ' '
> - > I C V ' ' ' ' ' V ' ' ' ' ' I > ' ' I ‘ V ' 'H11- 111’-1‘1111=11==*, .... 11- ¢1=1m=d n=*1=>M11'Y.. .. .D.P. Nummer Angebliche Staafsangehiirigkeitl certify that I have seen - Ich er/rleireMr. - Herm 'Mrs. - Frau _ ‘HandMiss Frauleinexamined his/her D.P.l. Card. his/her photograph and his/her appearance. and am "mp,"satisfied the particulars given are correct and that he/she has signed in my presence. ' - _l if‘ “‘gesehen, scinc/ihre D.P.I. Karte,
seine/ihre Photographic und scin/ihr Aussehen Sm” at “>$\kontrollierl zu haben. Ich bestétige, dass die Angaben richtig sind, and class er/sicA--=m|.|y ;in meincr Gcgenwart unlerzeichnet hat. C'"'"' "Photo nl CandidateIo he nubedhere -nu lllmpePllaluglnplliuii. Kandidntertbier kleben um!Smmpel . '.1. Anlmbly \ ‘Cum-¢. .1 ;VWe-D1='""!. _. s nun Medical ems" . I/nnsrwliri/td.¢Ir:|s': sqmm olCu~uJidne- \n4.lg,;;.4sa¢miPart ll. To be completed by
Assembly Centre doctor and signed by the Candidate.Il. Teil. Durdt den Assembly Centre Arzt auszufiillen, u. durch den Kandidaten zu lmterzeichnen.i. Family medical history H _ M M l lKrankmgmm M M , /vv» ............ ..
............... ..N°- °f ch1ld"“’ B) Al.i.Y.?, '*.". . ,, 1’) mad , .. ~ . ...°) Cw" °f dam“ ........... ..Zahl d. Kinder: Am Lcben Gestorben TodesursacheZ. Have any uf your Family suffered from a) Tuberculosis. b) Mental Illness, c) Epilepsy? If
" Yes “give details:Hat iemand ihrcr Familie an folgcnden Krankheiten gelitten: a) Tuberkulose. b) Geisteskrankheil, c) Epllepsie (Fallsucht).Wenn "Ia", bitte nahere Angaben: .. .. ......................... ..3. Personal medical history:
Have you suffered from any of the following illnesses? a) Tuberculosis. b) Mental illness. c) Epilepsy.d) Venereal disease, e) Kidney disease. f) Nervous breakdown. If " Yes “ give details:Persnliche Krankheilsgcschichte: Haben
Sie an folgenden Krankheiten gelitten: a) Tuberkulose, bl Geisteskrankheit, C) Epilepsie(Fallsucht), d) Geschlechtsknankheitcrl. e) Nierenkranlcheit, f) Nervenzussmmenbruch. Wenn "Ia", bitte nihere Angnben:MW4. Previous
illnesses. injuries and operations of candidate. indicating whether he has or requires prosthesis for amputation:Friihere Krankheiten, Verletzungen u. Opcratiorlen des Kandidaten, mit Angabe ob eine Protllese nach Amputation
verlangt warde-.. . . . C . . . . . . C . . . . . . . . , . ..,I certify um Ih: um. -I-mm-1. “.4, by DE in -mm In th foregoing quullinnl ... Irma -mi cnmplele to the but ,1 my belief.IHI swan“ an Ridlliglreil .,u:,..- Angnben, und war-11-singm-»""’1r,¢ mlinlm sum. Winn: 814/ ~11, mm gcnnturnrtel Ill Imlaen..Date M A/Q _ W5 Signature of Candidate AW‘/L4/tlzf/{,4 db’Datum ,. .. .. . untenchrift d. Kandidag . . . . .. .. .... i
-1" ’ ‘W ”' ‘ ""r‘ Q-7:,-"J" _ __ — ~4 § PHYSICAL EXAMINATION. Part III. To lj: C0l¢l6d Ass~ly Centre doctor. Part IV. To be completed by Medical Board in Resettlement L ,AERZTLICHE UIVTERSUCHUNG. Durch den rzt der
Assembly Centre auszufiillen. Cgllggng Cent;-e_1. General build - Allgemcines Ausschen . . . . . . . .2. Visual acuity - Sehschrie a) without ‘glasses a) ohne GléserZ7) with glasses b) mit Glisern .3.Hearing-Geh6r.. Ye: - Ia YY .. ,.
No - New 5- Tseth nd gum - Z51” "~ Zhflcisrh - - '- . .. _ .,6. Abdomen - Bauch, Unferleib . . . . 7'. . ‘ H 4. Trachoma - Trachoma . . . . . . .7'H¢m1= - Bmh ~ - » - - - B. Operation scars - Operationsnarben . . . . . .9. éentral
Nervous System ‘- Zentral-Ncrvensysteml) Mental status - Psgchischcr Status . . . . . . . . . .3 RQHQXBS (11°!= 1'¢5P°B5¢) - Reflex (bvhw die AW‘/O") .. .Pupils: a) to light ~ Augenstcrn a) bei Licht . . . . - b) on accommodation b)
Anpassungsvermégen . __ _ ‘ V _¢)1<m1er1<s => Km-Rellcx - 4 4 .. Y! .. .. d) plantar d) Fussohle . . . H 3) R=~===1<= - B=m=rk=-»ge~- - V ~ - i - Y‘, 10. Respiratory system - Atemsystcm . .ll. Cardiovascular system Cardiovascularsystema) Pulse rate a) Puls . . . . . . . . .b} Rhythm and regularity b) Rhgt/zmus u. Regelméssigkeit . .c) BAP! c) B.P. . . . . . . , . .d) Ausculation d) Untersuc/lung . 412. Genito-Urinary - GeschIechts- und Harnsystem .
4 '_13.Urinc-Llrin....................H. Gynaecological (where necessary) - Gynaecologisches (we notig) . . . .16. Date of last immunisation: - Datum der letzten Impfungen~» smallpox => PM/==» - ~ - - r » .¢)EP1d=1==i¢ Tvrhus
¢)F1ec1=#wh~s ~ - - =1 Others *1 /“dew - ~ .4. 4/O is ff/ Anenbly Centre Marhonl omm Aulmbly cm" Arne:L ___ AL R L .. YY . /ll/J , llll at 17. Further notes - Weitere Angaben . . V.I herebl’ ¢E1'1ifY that I have Emied 011
The above erson has been ex mln d b d is ‘d d fit/UH! tand that the above findings are true to the best of my belief and knowledge. I consider before a SQSHEH mm a E y me an tons‘ are \ gmarhe/she is fit to proceed to a
Resettlement Centre for medical examination. r >Ich besrsr-‘ye hiermir. dw -‘ch am 1 Dare T ~‘ s" 7‘ -Q ‘ untersucht und obigen Befund wahrheitsgetreu nac/I meinem besten Wissen erstellt Elllnining m.,.'§Z}'; ‘ habc Ich
erklare ihn/sic féhia. Sic/I bei einem Resefllement Centre zur érztliahen Unter- S1 gnaw” / l O-‘ .1 ' x $“°’"‘"9 Z" '"eId¢"- ¥~~ i _ 9° Prelidenl. n.’ ads"-1 Yd ‘ l ~ ______ N Resettlement Centre.Dew - Datum , nature - Un‘l=rs<=hri
w"TI'f.I.£I::III.tT7;! ,. “Y .... _ ' Sugar _ A1b\-\m€l1 \/V‘) sugar V‘ Albumen .15. Locomotor Function (Note disabilities) - Bewegungsfunktionen (St5rungen any.) 0 U I‘ H b) Typhoid 8 Paratyphoid b) Typhus u. Paratyphus 4 .
WY, _ 0» d» r t t t "Yfi'"YKII1QTI?i2LII§I1'§Zfi§iifififfi..tii‘ Y
1:) X-Ray of chest|-1“,-; ........... .,Lung, .T1) Blood tealsC) Othersif-,_Part V. Special examinations. ‘ ‘Date Stnmp.,,.].e_l§.v‘Z+-1%................................. .;4.'_):;.,,;h.];......... . ., . . . ..Z10 £:(A ,1,‘ lvgypage sump ................... ‘f -3Part
VI. For Selection Team Medical Officer only.lheve examined -- K!’
. . . AP ‘Y . . IA and certify 1/ he/she is t for emigrating 10 . . . . . . . . . . . . . ‘ . . . . ‘ . . . . . . . . . . . . . . . . . . ‘ ... ..................... ._= ...... “ _ ,_‘ D“ ' a Slgllnre.
________________ ...................................................... .. '% 6 Mm»
§\MiI1 .T/M4/.s 4;: 7/ lsw 0 1* c~// #2/<w A/1’|.a.o. (s.z.) roam No 1CM/1 APPLICATION FOR |.R.Q. A$$|$TANCE/7"L/~/ /J//T‘/'74’/w ‘//41' K0“-IAL-Sn‘ <,¢¢‘41..~;(.m/ 4' ~?/- /4-4/9(c;,9_i;;,L<,,;Family ncrme26Dufe/Q94‘; /1Identity
No.60._ Other spelling or aliases3. Prot.Jew. Other 7Citizenship44S. (M: Sep.D.Erhn c GroupWid. Un CRe igionMorizl sfufus8. Names j0) M Xfa.w‘s(m,./ 1.20.4/.Reloiionship DggeTo head birth54%.Town, province and_ country
of birth » mpza.W /Em»: [Z9411 %r<»@ //§¢¢@_mJ(5) rFain.(6)(7)9. O\her members of fumy é?/9 ._w' JO» w,», .4?.-H namesbcdf9‘I0. Places of residence for lust 10 yearsFor whom dates Town or village, province and country
/O/‘Q;-712./€_ aw ”M@<d §@~»-Q->~?—r/4/vi-Mora azraw @41 572- /43;/4//1, rum.fm“
IIll Employment for last l0 years lnclud ng presentCM/IFor whomDatesType of work WagesTown, province Reason forEmployer and country changeQ//-r 7/437/3?dirrbwl/(4%/>/Ma/< /40 4?;/¢@1:44’-<q _37/VJ’M4.»? G341
%.We_ T séég-in‘ kg)/MI;.~@”<M/W0-I “”’q 4’~*"'é””“-12. EducahonFor ‘whom’Dates ‘ Type of School ‘ Town, province and countryQ0~ Baa uh.z._ ¥ 4&4; @az$’a_u/4 M \l13 LanguagesFor whomfluentlySpeak ' Read
Writes|;gh;|y fluently slightly fluentlyslightlyLanguagee £11-»~ l8K§7*‘l53%; & if/"4»~'-<¢¢; ;Z,J(//iiagizz
am -"cm/1 _‘I4. Financial resourcesFor whom Property Type Value LocationCash and Income\\Assistance fr om’/ relativesl5. Relatives‘ Full name ' Relationship Complete address‘l6. Assistance1. Have you or any member of your
family been receiving assistance from UNRRAi_i;~1GCl _ yes no yesl or from a Voluntary “c ? \i A yes no .‘ _ 2. If you have been receiving assistance, please give the number of months a3. If you have received cash, please
state the amount4. If you have been receiving assistance from a Voluntary Agency, please give the narne of the Agency L‘I7. Documents .§\s\A\'\tFor whom Date ' I Type Place of issue By whom9/. l 7-W1 1654’. g gbw - Pega_ ‘Z
_ 4, 44" Y- '5. Ya; V‘ . Iii
IV ‘18. OrganisationsCM/'|For whom Date Name Purpose19. Present AddressDateStreet address or name of camp Town or City Countryi 1rm /,4¢a.c.Je _€‘ .“KQ5t20. Remarks. Use for any additional information_21. Date and
reason for coming to Germany. i 0% 40"! AZ 2 wa-22. Valir! reasons for not returning. *0 Io! A‘ ~a'§Z‘¥"o( fa “"‘LM"‘~ ~°~"-*--~--vii-'1. />»\.-y 1 /4e-'/(:6 A“-j;fj*-J€f“'-*_l~ wee/4 re &::f<~.~z:-Q4, Qpumd ¢¢;¢@.,,. 44 'a"~»1\N9/>“4-v'u~ (,5-\~~l~ ‘V s23. I hereby declare that the above statements are correct to the best of my knowledge, and that I have made no- previous application far l.R.Q. assistance. '$c;,A"AL c-u 57¢. /we i5‘~i4".4='4'/v M/4% e .
sPS5 lHQtR a97| -"~‘/ 60M/5-491/-/1 </7 ifo .§_oéuuls éul iSignature of Interviewer DateX J5/Q0
,....I INTERNATIONAL REFUGEE ORGANIZATIONAPPLICATION FOR IRO ASSISTANCEI .. Kownes/<i (Nom de tamllle en majusculIesIdT'7lx_nprlmerie — Family Name inblock capitals - Familienname lm Druckschrttt -—
Nazwiako —drukowanymi literami)2.(Autres orthographes ou surnoms sous lesquels la lamllle estconnue — Other spellings or aliases by which lamily is known -Andere Schreibweise oder angenommene Namen unter welchendie
Familie bekannt isi. — Inna pisownia nazwlska lub pseudonimpod ktérym dana rodzina jest znana)3.Religion: (marquez un (Xe apres la vbtre)_L:a5nollgue roma1n.'..Grec orthodoxe . . . Protestant . . . Juit . . . Au re aque e . .
.Aucune . . . Non indiquée . . .Religion: (Check one with an ax») Roman Catholic . . . GreekOrthodox . . . Protestant . . . Jewish . . . Other (specify) . , . No-ne . . . Not reported . . .Religion: (einen uxn schreiben) Romisch Katolisch .
, . GrlchischKatulisch . . 4 Evangelisch . . . Judisch . . . Anclere (welche) . . .Keine . . . Nicht angegeben . . .I Religia: (postawié znak ax» w odpowiednim punkcie) Rzymsku -katolicka . . . Grecko - katoiicka . . . Ewangelicka . . .
Zydowska . . .Inna (jaka) . . . Zadna . 4 . Nie znaczona . . .I _-?uvI‘/z [c;<y~;1- 9~£/of _Date d'établissement du f rnulair CM/1 — Date oi! Co letlon(of I-‘prm CM/l -— Datum der Auatertigung des Form. CM/1 —Data sporzadzenia
tormularza CM/1)1.II 1.(CMJI Numéro —— /1 Number — CM/1 Nummer — cMI1 Numer)5. (a) Wm»(Pays de citoyenneté) ettez un (X8 apres 1e mot qui vous con-cerne -— Revencilqué . . . Prouvée . . . Ancienne . . .Présumée . .
.(Country or citizenship) Check one with an -x- — Claimed . . ,Established . . . Former . . . Presumed . . .(Land der Staatsangehorlgkeit) Einen OD schreiben —- Forderte . . .Beweiste . . . Vorige . . . I-Ioilentllche . . .(Kraj
obywatelstwa) Postawlé ax» po odpowiednim slowie —Zqdany . . . Stwierdzo . Dawny . . , Przypuszczalny . . .§bI___ _, ____, i W, ,_ i , ,(Pays de derniere réslden hahituelie avant le déplacement) —(Country oi last habitual
residence prior to displacement) —(Land der letzten Auienthalt vor der Versiedelung) -(Kraj ostainiego p d wysiedleniem),n (0) 4&1(Gruupe etnnique ou national, tel que Ukrnlnien, Juli. Vellu-cieutsche, etc. — Ethnic or National
groups such as Ukrainian,Jewish. Volksdeutsche etc. -- Ethnische oder Volksgruppe, wluUkrainler, Jude, Volksdeutsche etc. -— Grupa etniczna lub narc-ciowosciowa, jak Ukrainlec. Zyd, Volksdeutsche etc.)s. (<1) g W IStatut
Nansen (rnarquez 1equel): Oui . . . Non . . .Nansen Status (Check one)1 Yes. . . No . ..Nansen Status (anmerken): Ja , . . Nein . ..Statut Nansenowski (zaznaczyé): Tak , . . Nle . . .I situation au point de vue mariage (Mettez un -xapres le motI qui vous concerns) — Marital Status (Check one with an -xx) -Personenstand (mil einen (X3 bezeichnen) — Stan cywilny (ozna-I czyé znakiem -Ix»)Marié -— Married — Verheirated — Zonaty . ..Ceiaiaire — Single
— Ledig — Kawaler . ..Séparé — Separated — Getrennt — W seperacji . ..Divorce - Divorced — Geschieden —- Rozwiedziony . ..Veut -— Widowed -— Witwer -— Wdawiec . . .Entant non-accompapzne — Unaccompanied child
— EinsamesI Kind — Dziecko osamotnione . . .Imiile vivant ensemble —- Names of allI I. Noms de tous les membres de la !a- Iparemé "Is'5'vI5jour, mois, année — ‘°ye““°‘é - Chk M1‘! ' I'rown, provinceI - ir nmembers 0! lamily
living together —I Namen van alien zusammenlebendenI Famillenmltgliedern — Nazwiska wszy-stkich razem zvlawcn czlonkvw rodzinyWeib —- PleéSexe — Maiéd" “"1 - 3°15‘ Date 01 an-tn Day, Country ot 5&1,-Elbe In - and
country olor Female -"°“§h‘P '0 head Mon. Year - Ge Citizenship - P at 21:, h 1 - sumMann oder ;mv§I;:n;I;:&I;g‘:';{5\g;\l:\:_m £53153’; Staatsange-"" 5‘°=“"ek ¢° urodzenia wen hmgke“ Tgtowy roclziny ’ Kraj obywa-I I I miesiac. rok
telstw.Ville, province atIDate de naissance Pays de “II Men" ‘m ' I pays natal-i_i.l=rovinz und GeDRI burtsstaat —E F !RMiasto, prowin-LA cja i lu-aj um-dzeniaNJ;Ind '0U< >%(a) Homme — Man — Mann -- ezczyznaKnur/eLs¢</;'
"mfremme (w¢I£mT;{n°I§IkZ1euné’ iii?) I I %I Woman (rst name and maiden name)Weib (vor — und Geburstname) 'Eniants prénom (et nom a'il est dil-iérent du nom de tamillel IChildren: 111-st name (and last nameit ditterent
from family name) IKinder: Vorname (und Familieunamewenn sie sich linclert mit der Fa-milienname des 1-lauptes)Dzieclz imie (i nazwlsko w wypadkurbznicy z nazwiskiem roclzlnnym).(I1)(E)3%(I) I O 7 T7 7 7 Il I II I [ll |\’ I v
\'1|\'u vmj IXFgobieta (imig i mUe) F I I_4w4~ I_ __I'-7i/M//1”/-jZ~;_./f/{I Wu _(C) :I(I) I I I IX__ ' IQ?1. $1. /7’// IIl.@'A».4@_wv</I I1; I »I</,/v F I I 4I I 90511 A nagate_e___en on __ — T, ‘ew/“rI, Autrea membres de la famille
vivantavec le requérant — Other members 0!family living with applicant — Anderezusammenlebende Familieumitglieder— Inni czionkowie rndziny zyjacy zea. _ 7I _ I_ _c. Vcl. I1.g "W T " "Wsktadalacym podanle. Ie. I')
Abreviatiom: R = revendiquée, P - prouvee. A — ancienne, DR - derniere residence babituelle avant le déplacement.') Abbreviations: C -1 claimed. E — established, 1" — iormer, LR - last habitual residence prior to
displacement.°) Verkllrzungen: F -= lorderte. B -= beweiste V — vorige, LA - Letztes Autenthaltsort vor der Veraiedelung.') Skrétlli Z - ildie. S -= atwierdzone. D = dawne, OP - ostami kraj pobytu przed wysiedlenlem. _’“ ' I —-._.._ _ .__i . _ .___g .__,_. .,__ ____= i
i / / 1/l\ I \ .7 7 W 7 "iiZ10. Lieux de réldence pendant les 12 dernleres années (répondre pour mute la période et pour mus les membres de is tamllle).Places 0! residence Xor last 12 years (account tor entire period and all
members at family).Autenhaltsdrter wlihrend der letzten 12 Jahre (Filr die ganze Zeit periode und tilr aile Fsmlllenmitglleder sntworten).Miejsca zarnieszkania podczas ostatnich 12 lat (uwzglednic caiy wymieniony okres czasu i
odpowiedzieé za wszystkich czlonkow rodziny).Rue. ville. village. province, pays (indiquer les noms des camps etle numéro cridentlté de la personne) — Street address, town, village.province. country (include names oi any
camps and identity numberat person) -— Sn-ssse. Stadt, Ort, Provinz, Land (Lagerbezeicbnungund Kennummer sngeben) — Ullca. mihstonwleé, prawincja, kraj(pod-ac nazwe obozu oraz otriymsny numer
rozpoznawczy).DatesMembre de la tamiile gmtenWhich member at family 3 y __Familienmitgileder Fdu aurCzlonek rodziny aim 3;od doI 1 ~ \ Mw /$’;7fL__/@2202 WWW___,, W, l _ Mqza ugh/.{‘l <1 /M y _ 744$ ¢M'7>7M=¢M
i/§_§¢0|,gT/@,lt,,_L¢,1lti'a,¢l@¢41l Qwaz/=Lll. Emplois, y compris l'emplol sctuei, occupés au cours des 12 ciernieres années, (répondre pour toute is période pour tous ies membres de lltamille qul son! ou qui ont eté empioyés)
— Employment for last l2 years, including present (account for entire period tor any member whois or has been employed). -- Besclusttigung, wihrend der letzten 1: Jul-ire einschiiessllch die jetzlge, (lr die gsnze Zeltperiode und lr
alleFamillenmitglleder die beschiiltig slnd oder waren — antwurten). — zsjegcie, z obecnym wiqcznle, wykonywsne w okresie oststnlch 12 lat(uwzglednlc caly podany okres oraz odpowiedzlec za wszystkich Izzlonk w rodzlny
ktorzy sq lub byll zatrudnleni).32:; Employegr (Nomi de la person- vm Ln t M M dne ou u serv ce gouverne- e. prov ce e o u change-Membre de la iamme Isis; Geixluje de "'5' mental) — Employer (Name pays - Town, pro- ment —
Reason torWhich member at Iamily i 5;‘ WZKTYP: 0! person or government dept.) vince and country — change -— Grund desFgmjuenmngueder du u Athenian _ — Arbeitsgeber (Name der Per- Stadt, Provinz und
Arbeitswechsels —czmnek mdzmy 1,-mm To Rodza] Macy son oder des Regierungsdientes) Land — Miasto, pro- Powéd zmianyah bu - Pracodawcs (Nazwisko lub wincja ikraj. zsjecised do nazwa siuzby rzqdowej)_ I " "1 I 1* | Y
\" Y" 172 /4793} Q/¢m‘¢M4 y W, 9 _‘ _ ya/c din _ _ y__ on , Qglw/ff? 7 MWM 4 A Mil ‘>‘0_1 ‘ <1/f‘m_oé;gp W e’ s§§,55__ ___1 i I y_ \1 iii a. Saiaires actueis. — Present wages. - Jeizlger Lohn. — Wynagrndzenie obecne.‘ M t‘
Azlmnt Par (jour, semaine, mols) Devise (par ex. shillings, marks, etc.)nunPer (day, week or month) Currency (e.g. shillings Marks etc.)Di I-Ih d L h 'e wisozgééo neg FL\r (Tag, Woche, Monst) Geld (z.B. Schiilings, Marks,
u.s.w.)wynagmdzema ‘ Za (dzien. tydzien. rniesisc) ‘ Walute (n.p. szyllngl, merkl it.d.)Membre de is tamilleWhich member or tsmilyFamillenmitglieder ‘Czlunek rodziny ‘iiI IH Ill l\‘were e1 i
12 Education (pour tous les membres de la Iaxnilie d'Age acolaire cu plus ages). - Education (tor all members oi\ ‘l.3tarnily 0! school age or‘olden-). -— Erziehung (ir alle Famiiienmitglleder im schulalter oder iiltere). —
Wyksztalcenie (dis wszystklch czionkéw rodziny w wiekuszkolnym lub starszych).DatesDates Dipimes ou grades et laMernbre de la tamilleWhich member oi tarnilyFnrnilienmitgliederCzionek rodzinyDuty iréquentée. -- Name 0!
last 5du luF;-gm Tc wa szkoly do ktorej ostatab 1 bisd010dDam“ Nom da la demlére éwle Cate orie Ville. province et paysschool attended. -— Name TYD9 T°Wn- Pl'°V1n¢¢51'\dc°\l1‘lh'Yder letzten Schule. — Naz- An Stadt,
Provinz und Landmo uczQmm_ ' Rodzej Miasto, prowincja 1 RIB]date. — Diploma or De-grees and dates. — Diplo-men oder Grade und DI-ten. — Dyplomy lub atopnienaukowe i daty.I ‘ ll lll‘ I\' i \' L \ IC~74-»1@4!4@ilQJ_'_4,¢.>_/01¢ 1;,/as 5_ , ,1 ‘ / \~ _ 1 (¢@W.r@f/%144 l_e_ $§i~@~_~¢__,_,_ f‘ »é6W.AW;.e _ _1_ _y _\I 1 =wm, i>}1Q/2X,a<,¢4/.~1ae13. Connaissances linguistiques (pour tous les membres de la lamilie qui ne sont plus en has
Ages). — Languag— Sprachen (iii: alle Familienmitglieder - kleine Kinder eusschliessllch). -—- Znajomosé jezykow (riotyczywyjatkiem malych dziecl).es (tor all members not intents).wszystkich czlonkbw rodziny, uPerle Lit
Ecritspeak Read WriteMembre de 11; Iamiile Sprichl Lies! Schreihl LsngueMbwi Czyta PiszeWhich member of tamily _ LanguageFammmmnguedel: couramment un peu couramment un peu courannnent | un peu SpracheClmnek
l‘0dZl!1Y uently slightly uently slightly uently 1 slightly Jezykgelliug ein wenig gelliuiig ein wenig gelaulig ein wenigbiegle sisbo ‘ biegle slabo biegle ' ‘ slabo/ I 1 1 1 1 1 1 1 \ \ \ 1 1 \ 11\'lH“ .1 >4 >< if ’7‘\y‘. r ._M_ h _ _ dfvtewa1\ 1 1
114. Ressources zinancieres (pour tous les membres qui ont actuellement ties ressources). - Financial Resources (tor ell members who have anypresent ressources). — Geldmittel (lr alle Famlelienmitglieder die jetzt Geldmittel
hekummen). — Stan majqtkowy (dotyczy wszystkichcztonkéw rodziny otrzyrnujacych dochod).NatureTypeArtRodzaj(terre, bhimeuts, etc.)(land, buildings, etc.)(Lend, Geblude u.s.w.)(ziemia. budynki it.d.)Membre de la
tamilleWhich member 01 tamilyFnrnillenmitglieder‘ Czlonek rodzinyBXEIISPropertyEigentumWlasnosévaleurValueWer:WartoséSituation des biensLocation oi PropertyLege der EigentumPoloienie wlasnoéci1 1 11
HiIVVEspecesCashBares GeldGotéwka(En quelie devise) ‘(What currency)(Devisenart)(W jakiej walucie) \Mon tentAmountBetregKwotaLieu de dépbtWhere keptW0 deponiertGclzie zdeponowana1 RevenuIncomeElrlkunttDoeh
on(En quelie devise)(What currency)(Devisenart)(Rodzaj waluty)Montant parAmount perdie Hiihe perWysokoéé zaRegu 01) at de quiWhere and trom whomreceivedW0 und von wem erbaltenGdzie i od kogo otrzymany > iAide
regue de parents Colis. mandets, especes, etc.Assistance ’Ol' relatives Prels. money Orders.Unterstlltzung von cash etc.Verwandten Pakete. Geld. Uberweisun-pomoc ocl rodziny ien u.s.w. — Paczki, prze-kazy. gotéwka
1t.d.Lieu 01‘; se trouvent canparents. - Location at re-latives. — Ort we sich die-se Verwandten benden. -Miejsce gdzie sie ta rodzinaznajduje.F _,l
W" 2' ~ I —- — e4ll. Parents (parents procbes ou avec qui la tamille desire etre réunie; indiquer tails ies parents des eniants non- accompagnés). -Relatives (any who are closely related or with whom family wishes to be reunited;
list all relatives oi unaccompanied child).Verwandte (nahe Verwandte oder die mit welche die Famiiie zusammenleben wilnscht; alle Verwandte der einsamem Kinder angeben).Rodzina (bliacy krewni lub cl z kiérymi rodzina
zyczylaby soble sie polqczyé; wskazac wszystkich krewnych dzieci osamotnionych).\Nam en entier Degré de parente Adresse complete (y compris le centre de rassemblement)Full name I Relationship . Complete address
(including assembly centre)Voile Farnilienname Grad der Verwandtachalt Voile adresse (Versammlungort einschliesslicn)Pelne brzmienie nazwiaka Stopien pokrewienatwa \ Peiny adres (wiacznie z centi-um zbornym)A »/Wizwé
/at I g_._ 49/F“,M /mm .3 + /71% 'u./<4 WM 1 /5/ww~/11/LL f__ {'iL- U\an __ _ J1_-¢4./l¢4.4¢- ./("L549/~i§$" " \ "\’ \ 1 fa / u M “ 4WM"P -5* 4/Z/*%4-'1-Ull a. Nom d'amis ou d‘emp1oyeurs éventuels qui pourraient etre utiles au
reqlléran‘ mums E‘ ad'e55°5)-Prospective employers or triends who might be or assistance $0 applicant (names and addmsiesi.Die Namen der Freunde ocler Arbeitsgeber, die den-i Betreenden Hiiie leisten kbnnten (Nalnen und
Adressen).Nazwiska przyjaciol i prmodawcow ktérzyhy ewentualnie mogli pomoc petentowi (Nazwiska l adresy).\ 1\ll. Assistance (y compria rassistance et Pentretlen dans un centre de rassemblement). — Assistance (including
care and maintenance in assem-bly centre). — Beistand (Plnschliesslich Beistand in Versammiungort). —- Pomoc (wiqcznie z pomocq l utrzymaniem otrzymywanym w ccn~ti-um zburnym).a. Un membre queiconque de la ramilie
a~t-ii été assisté par UNRRA: Oul . . . Non . . . par CIR: oui . . . Non . . . par une institution bénévoleioui . 4 . Non . . . — Has any member oi lamily been receiving assisiance irom UNRRA: Yes. . . No . .. IGCR: Yes . . . N0 . . . from
a Vo-limlary AS91193’? YES... N0--. —- Ha! Bin Mitglied der Familie Beistami von der UNRRA erhaiien: Ja Nein”. von IGCB: Ja Nein . . . Von Ii" reiwiiligen Agentur! Ja . . . Nein . . . - Czy ktorykolwiek z czlonkéw rodziny onzymywai pomoc od UNRRA: Tak . . .Nie . . . ed IGCR: Tak . .. Nie . . . od instytucjl prywetnej? Tak . .. Nie . ..b. S'll a éte assisté, pendant cornbien de mois? . .. — It assistance has been received, number oi months... — wenn er
Beistand erhaltenhat, die Anzahl Monaie angeben . .. — W wyparlku otrzymywania pomocy, podaé przez lie miesiecy . ..c. S11 recoit des espéces. régulierement . . . irrégulierement . . . — 1! cash received, regularly . . .
irregularly . ., — Wenn er Geld erhiilt.regelmiissig . . . um-egeln-iasslg . . . - W razie oirzymywania gotéwki, regularnie . . . nleregularnie . . .Montant . . . par — Amount . . . per - Betrag . . .per — wysokosé . . . zad. S‘i1 a eté assiste
par une institution bénévole, indlquez ie nom de rinsiitution — I! assistance received from i voluntary Agen-cy. the name at the Agency — Wenn er Beistand von einer treiwilligen Agentur erhaiten hat, geben sie den Namen der
Agen-tur an —~ O lie otrzymano pornoc ad instytucjl prywatnej, podaé nazwe instytucji11. Papiers (indiquez tous ceux en possession dc la 1-amille, y compris actes ou exti-alts de naissance et de rnariage. cartea d‘indentité,
cartelde travallleur, canes de rationnement. allidavits, declaration de témoins, etc.) — Documents (list all in tamilyapossession Including birthand marriage certicates. passporm, identity, cmployement, ration cards, aidavits.
statements or witnesses. etc). —- Belege (geben aie allediese an, die lm Besltz der Famine alnd, einschliesalichz Gehurts und Heiratsdokumente. Kennkarte, Arbeitakarte, aidavits. Blnmien derZeuge, u.a.w.) —- Dokumenty
(podaé wazystkie, ktére aa W poaiadaniu rodziny, wiacznle z aktarni luh wyciagarni urodzenla 1 maltestwa. do-Iodami osobistyml. kartami pracy, kartami aprowlmcyinymi. aidawitami, stwierdzenlami swiadltow etc.). ' __‘_Membre
cie la iamille 7 __ Date 1 Genre dc document Lieu d'@lf.!igment Délivré par (organisation ou individu)Which member 0! family ‘ " Date Type pucq 0; |§e By whom issued (organiution or indivi.. dual) — Von wem verabtoigt
(Organisa-1-‘amilienmitglieder ‘ Datum Art ‘ Verabtoligsort mm Oder perm") _ wydany pn (m._Czlonek rodzlny Data Rodzai ‘ Miejsce wydania ganiucja lub osoba)” (/W,(?i:)I"¢‘,£wJ!Iz5l_ e am’ m_M€.______A siuwcé 4_ A.33I;~‘§'u$3.as2
J’__ I miOrgamsatlons dent les membres de la tamllle out été rnembres (poll tiques, rellgleuses, soclales, d‘avant- guerre et d'aprés - guerre). — Orga-nlzatlons 0! which members at family have been members (polltlcal, rellglon,
social, pre-war and post -war) — Organlsatlonen von weltchen dle Famlllenmitglleder, Glleder waren (polltlsche. rellglose, so zlale, var und nach dem Krlege) — Organizacje, ktérych czlonkaml byuczlonkowle rodzlny (polltyczne,
rellgljne, spoleczne, przed 1 powojenne).Membre de la tamllle DateWhich member at family DateFamlllenmltglieder DatumCzlonek rodzlny DataNomNameNameNnzwaObjet (social, polltlque, rellgleux, etc.)Purpose (social,
political, religious etc.)Art (Sozlal, polltlsch, religios u.s.w.)Rodzaj (spoleczny, polltycmy. rellgljny lt.d.)IIIIV/ _,__,, ,____ \&Lc,@<dA/be //\/Hexi 1 ' ' 41,<,1>¢¢</611gDc’ MM ‘ ‘yaf19 Adresse actuelle de la iamllle — Present
address oi iamlly. — Jetzlge adresse der Femie.— Obecny adres rodzlny.Date Rue ou nom du campDate Street address or name oi campDatum Strasse cder Name des LagersData Ullca albo nazwa obozuVille PaysTown or city
Countryon . \ LandMle1scowos¢': ‘ Krai‘ 1 n 1 III 1 IVI9 a Pour un enlant non-accompagné vlvant chez des parents nourrl clers, lndlquer les uoms de ces dernlers. — For unaccompanied childllvlng ln tester family the name or
taster parents -- 0.1- eln etnsa mes Kind, welches be! Verwandten lebt, cue Femlllennamen dleser Ver-wandten angeben — W wypadku dzlecka osamotnlonego, zyjqcego u krewnych, podaé nezwlska tych ustatnlch.‘
_Q_@_/§Z0ac<Qee melee, 7 rialObservations Utlllser cet espace pour des renseignements complémemalres. — Remarks. Use tor any addltlonal lntormatlon. — Bemer-ktlngen Erganzende Auskunft lst hler zu ertellen -—Uwagl. Nalety tu umlesclé dodatkowe lntormacje..!(¢'vv\uv\A4¢»l/}|_Q“?L8/La//W» 746%’///D-/’”~ "WW12 1//4&1 can/1/» /7‘i”%~l’7”40'7/"£;ffC)W/{_ in/V0” 0/aw/1&4/1,1 /6,44/2/L"/1.» ' ;/ 1/1/u/1/I//‘-)0 J/, 0. 77/24”‘ A A//MM‘< \ 0'5/24/0/1/1/1» CL/l"/’./glfcu’ , / 1,0% /)/LI’! /1-/Z Z1///V0/}44/L.(>g/ _f¢.v_.\,=\_;,\/\/t A, C“ »./Vd /7304412/M, 61 f ,.4.¢¢/»/¢/1‘/ 7 L7K /;/L/- »-C1/1 "6X0 /I/M Signature du requérantK Slgnature at ApplicantUnterschriit des
Auskunigebers/)4-( _f¢Z'¢ Cid CL Poclpis skladajacego podanle y‘ I ‘L MM W ,a'1(A¢/+-:\:-q,.)-‘<\;. Prlfwg ~224-/\.~J' vm\~\7~u~\v\/V ‘K v<§\k-nu» QM hm‘/h @wwm¥;X;Qu£d:_‘ie3iewer¢ .I Slgnature at lntervlewer DateL»\h,\y—\,./3 \‘ \¢\~l‘qp~L‘ Untersclu-11! des Uutersuchers Datum\9 M Q V-‘<_,_,_ of K’, ' Podpls przyjmujqcego podanie DataW 1% G ‘ 9;?/£17 /744?//_.‘/4;/‘
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w Kk? —~ — —~ —~—W VCertificat de Civisme et d’ldentité, de Bonnes Conduite, Vie et Moeursdélivré en vue dc l'obtentiou d'un passeport7commune L‘ B°"'9=_""¥'= _ d I Co d 1 *1/§~ g‘ °"'"""‘""/1 DE/‘/Ta’/*1SIGNALEMAgé de
: ,. Taille : un mélreCheveux : Front :Sourcilsx .Yeux :Nu =Bouche :Memon xViaage : .Barbe : .Signes particulierSlqnnurclllprimuiz Wlllonnc dc: Conmunca. Lléqe e ' a mm'“" ‘ /Certie que M A 750%/7, "/@l"I//H‘ ,. é/“'1 ‘ '0'///1
@,5%z1+a/1/{,1 ' K//{Q1111 /,1 anEN-T (H dz nationallté 7 2 .... don: le signalcment eat ci-centreans né 5 .ga4Za/:1/-n \€{*/0-—~19hl‘le /g ‘T {Q75 , l 94' dc‘7 1/ . / ‘“M //a/7 :1 de r> »6~.':/uz-0" A4 , KP 5 ¢u44exerganl la
profession dc - ->Q(!€»¢¢rLI'est dc bonnes conduite. vie Q! mmurs. ct qu'£//I habile‘ cette communedepuia ../-//’ //5 .‘/.-I. _. rue /(1/I era1 n° /ZCondamnlnonl crimmellu encourucs dam In 20 nnntu . Condamnanuns
correcuonlellu dc plus dc 3 an: znrouruts - V ’dun: les l0ann¢n précédznles. W/Z///L (4 !\Condamnaxions corrzcuonnelles dc mom! dz 3 ans cncoururs ~ - . ».dans lea 5 aunées précédcnlzs.Condamnanons dc pohce cncouruea
dun: Ynnnt: pré- Itédtntr. \\ Pournutu en cour: - déchhnces '5 : Civisme I er condamunions en application ," (‘ /’ // 1 , dc Farrlté-loi du 19-9-I915dc rimerme. L /O _,f.,,. ..,,I‘, ~.\// 191 A Le Bourqmulre2% >dun ct dzrnicr cu menllonnzr
la non er pp-CONSBNTEMENTPOUR MINEURS D'AGBIt lonulgné (I)lutorllc ll pennnne lndlqutz :|-coltre I nolllcllcr III plucpon 1deltlnnlon cl:I1)Pal! II:(Slglnuu)Va pour léqullntion dc la nlgnmhue lppulée ci-dulln-41. .A ...... .. l¢Le
Bourgnenrc.(1) Nam at prmonn ainai que In qu-.lna (pen, mm. auteur. etc.) dc Inpernonne hnhllllle pour donnlr nonconaenuumm.(2) ludiqnu |= nu ‘lei ply! an an!-nltlom\photographic
Certificat de Civisme et d’ldentité, de Bonnes Conduite, Vie et Moaursdélivré en vue de Yobtention d'un passeportCOMMUN I C I plDE/C/4;/La ZSIGNALEMEAgé dc z .. Taille : un métreCheveux : . . , ,Front z ,Sourcilsi 7 ...... ,.Y!“
1 précédenrrs.Ne: :Bouche zMemo“ ‘ dans 1¢= 5 années précédentcs.Vinge ; _ cedum.Barbe :Signal particuliers 1Puurzuiles en cours - déchélnczsCivigmg ’ cl condamnnlions en applicationde i'arr!t¢-loi du I9-9-1915,Slgulturz dz
|'inItrea_\é. , _. ..//5/' / "Fm a "~11 1/Pu ordoltll] lndiquer si l'i§non: du conjointluprimeric Wniinnne dc: Colmuuu. LlégzE Le Bourgl.nuFre - dc la Commune d ‘/ ‘U 4lfc Certic que M ./7>Zi‘(’,"(/9’, z , ... ,. 'F/'74/~A,({4%¢ '
/'5/¢I/1/|_<¢/11.44,U 5 _ >_NT (ii de nationalité ..... don! le signalement es! ci-contra. 1/ _ , -4 ans né is /gad/€’0w¢~1, =d*4-9/n_1 ie §~:7.,~ 4”/J .61 -de»m ' / . ad: Q4/¢.z<*r/%@ , 4£'(§£.¢Ah,cent. 0 / 4exerqant la profession de
"1!_ est dz bonnes conduite. vie at incurs. ct qudepuis , ./1./J .rue ‘Q1/' ’¢y”‘””‘~("7 V n° Q’/ /Condamnllions crimmeiizs tncoumes danl In Z0 annézs - Condamnanons correwonnzlizs dz plus dc 3 Ins zncouruu ~ .. . . ,dun: its
ionunéu préctdenru, %' » / /4 ¢ 4 /“Condamnalions corrcciionneiies dc mains dc 3 Ins zucourues .. . , 7' 7' .. , ,Condamnanons dc police tncourues dam Hunt: pré- .»i (1, Y//' 4/bhabitg cettz commune\1' 5 (?("1{[* _ 194 [,4 Lt
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ligan-nue npponéz ei-dznuu.A le' Le Baurgmznn.ainli qua 1- qua-‘ em.) do 1-donnar nun;/Xédun cc dcrnicr cn m ntiolnzr lu non ct pré-
Certificat de Civisme et d'ldentité, de Bonnes Conduite, Vie et Mceursdélivré en vue dc l'obt t' d’/ -COMMUNB IL‘ Be°"‘9‘?"‘¥'° | P I, 2.1.13 Communed ¢ '1"/Ma/0 °""""‘°"'-7/K’ W/9 4 .5/1'/, (‘(/%2,1/1.4/3 /224.1/T ,J-%4€a ’
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Llégz//1'ENTanscent.Hnrérelst." 0/ "(U de nationalltévné é e(4»¢er\42/ /'D /id,“ £14»; 1 ,6:Lest dz bonncs codepuis prCCédtl'|I€S‘Condamnauons correcnConclamnuriom correctdam lea 5 annk: pctdenre.dc FarPm aPar11)
lndlquzrnon: du ccertie que M§' /' 0?Condamnnnons dz polexergant la profésion dc nduite, viz ct mczurs. cl u' h bi///"/(F. .rue/Condamnauons cmmnellu encouruu darn In Z0 annee: ~- onnellrl dc plus dc 3 am cncnurursdans lea
IO annécn précédenxu.lonnelles dz mains dz 3 ans eucourucsréctdemes.ac: cncouruel danl\ Pourauiles rn cour: - déchhnces/4Civisme I r: cundamnulions zn lpplltalibn /I (Krllt-loi du 19-9-I915en Ion un passeport_ 0,/n»c+.1.é.&P
.7 don: le signalemcnl est ci-centre' ¢¢@~4~@,*;1,1’le _/l¢rL/’ '{/'.”// ,l J, de/ at de P M /4; '14/"7»~*IQq a re ceu: commune4/3/ /¢7La¢/¢{¢l 2‘ n° j’: /"?’_% M /9\Fauna: pri-/’A1 z /L‘W X Le Bourgmzstre,ll I Z '
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Attached 5ertific~‘,te of Good Conduct certifies. . toBru.0have a clean police record.\ 'z"F*»\, //' ./:7 '__ 4,~+ " %4/ssels, § 19l+9. IRO Resettlement Officer.5:0-1":1’)35.)
>Attached F:!crt:1fi:~~.‘se of Good Conduct certifies. to have a clean pD1iU8 record./” 7 7 of/"Brussels, 25 Sep. 19h9. IRO Resettlement Officer.(J