DATE:  ________________________ 

 LIFE HISTORY
(Information especially relevant for genealogical assistance)   

NAME:___________________________________________________________                            
             last                                first                                         middle  

CURRENT ADDRESS:  ____________________________________________   

PHONE:     home _____________________        work _____________________ 

EMAIL:  ____________________________

SEX:    M  (    )    F  (    )      ETHNIC ORIGIN:  ________________

BIRTH DATE:  _________________  BIRTH PLACE:_______________________ 

SPOUSE’S NAME:________________________________________________ 

CHILDREN’S NAMES:

EDUCATION:   

OCCUPATIONAL HISTORY: