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r <br /> CITY OF. ST. ANTHONY <br /> -3301 Silver Lake Road <br /> • Minneapolis, Minnesota <br /> Directions: Please complete in duplicate with typewriter or by printing in ink. <br /> Date: - <br /> 04oCK2./.J 14_E% 41 A e iD ILL Itt_ <br /> L. True Name: . (Last, First, Middle) <br /> K LA IC& Rc1 L r9 IA.) <br /> 2. <br /> Residence A dress: (Nucaber, Street, City, State) 3. Phone dumber: <br /> SaO S'TtOStA) 'yi'i/1),t) <br /> 4. Business Address: (Number, Street, City, State) S. Phone Number: <br /> EFs. <br /> 6. Place of Birth: (County, City, State) 7. Date of Birth: (Mo./Day/Yr.) <br /> . U. S. Citizen? Yes - Naturalize Yes = I Yes, give date and -place. <br /> No No <br /> • 9. If you have ever used or-'beer, known by a name or names other than the true name <br /> given in 01 above, list such nane(s) and information concerning dates and places <br /> where used. <br /> ha7cs - Dates . Places; and Circumstances <br /> 10. Marital Status: Single Widowed Separated <br /> Harried _ Divorced <br /> %V_ &Lz C k2."A. <br /> 11. .11 ;tarried, true name, place and Sate of birth, and residence address of spouse: <br /> True Name: <br /> PIacc and date of Girth: dl)oRT.�F 'Doter <br /> Residence Address: 33� ll� SILO ER I-A&£ Rd. <br /> �s <br />