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104-10117-10075 JFK Assassination Records Archives 1 (01/01/1963)

handle is hein.jfk/jfkarch10684 and id is 1 raw text is: 104-10117-10075 I _______ I I I FORM OBSOLETE PREVIOUS 12.70 44eE DIIeEDITIONS _______________________________________ J ________________________ I IA) a (4) SUPPLEMENTAL PERSONAL HISTORY STATEMENT SECTION I. INSTRUCTIONS Submit in duplicate. Answer all questions completely. If question does not apply, write NA. Write UNKNOWN only if you do not know,-the answer and it cannot be obtained from personal records. If additional space is required use extra pages the same size as this page and sign each such page. Reference each continued item by section and item number to which it relates. 1. FULL NAME (last-first-middle) 2.DATE OF BIRTH 3.PLACE OF BIRTH (city.StateCountry)4._SOC Flores, Daniel oqg 1935 Texas 5. PRESENT STATUS (Single, widowed, divorced, or annulled) SPECIFY: Married a 6. STATE DATE. PLACE. AND REASON FOR ALL DIVORCES OR ANNULMENTS 'NA SECTION I1. SPOUSE I. NAME OF SPOUSE (last-first-middle-maiden) . DATE F BIRTH 3. PLACE OF BIRTH (spouse) Flores, 0( Oq 1935 Portland, Oregon 4. DATE AND PLACE OF MARRIAGE 5. C TIZENSH1P OF.SPOUSE (If naturalized, indicate date & place 4. DAT natura ization & certificate no.) 18 November 1960 fO USA 6. STATE DATE. PLACE. AND REASON FOR ALL SEPARATIONS. DIVORCES OR ANNULMENTS NA 7. OCCUPATION B. PRESENT EMPLOYER Legal Secretary o 9. EMPLOYER'S OR BUSINESS ADDRESS (No., Street, City, State & Zip Code - Country if not U.S.) Street NW, Washington, D.C. SECTION III. RSIDENCE (Since date of last PHS, if overseas residence indicate only city and country) ADDRESS LAST RESIDENCE FIRST (number,streetcity state.country) L INCLUSIVE DATES (month & year) FROM. TO- _ __ May 1969 May 1971 (0 Sept. 197 ' Feb. 197 Vienna, a Feb. 1974 SECTION IV. CHILDREN AND OTHER DEPENDENTS (Provide information for all children and dependents) NAME HRPELATIONSHIP DATE & PLACE OF BIRTH CITIZENSHIP ADDRESS 06 III) Flores Daughter 3 March 1971 USA Was-ington, .-.c. ---enna- -a---- Flores aughter 15 March 1974 USA 1Lashington, D.T

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