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r' C 1 TY OF ST. ANTHONY <br /> 3301 Silver Lake Road <br /> Minneapolis, Minnesota • <br /> I <br /> Directions: Please complete in duplicate Kith typewriter or by printing -in ink. <br /> Date: F3 <br /> 1. True Name: - (Last, First, Middle) <br /> O �.. <br /> 2. Residence Address: (Number, Street, ClAy, State) 3. Phone Number: . <br /> 0o <br /> 4. Business. Address: (Number, Street, City, ate) S. Phone Number: <br /> 6. Place o girth: (County, City, State) 7. Date of Birth: (Mo. Day/Yr.) <br /> 8. U. S. Citizen? Yes teL Naturalized? Yes If Yes, give date.and place. <br /> No No <br /> 9. If you have ever used or been Known. by a name or names other than the true name <br /> given in 81 above, list such name(s) and information concerning dates and places <br /> where used. <br /> Names Dates , Places, and Circumstances <br /> 10. [Marital Status: Single Widowed Separatcd <br /> Married Divorced <br /> 11. If .Married, true name, place andJ date of birth, and residence address of spouse: <br /> True Name: p 2E n1 1 EE 1p..,�lrZ�s <br /> Place and Date of Girth: -a 9, y/ <br /> Residrnce.Address: / .'A.,..� /rjli� St7 • �!-�,c2�r,:•�v�u�✓, f�/1�� <br />