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

handle is hein.jfk/jfkarch38970 and id is 1 raw text is: 1401-10075 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. I. FULL NAME (last-first-middle) 2.DATE OF BIRTH 3.PLACE OF BIRTH (CityState.Country) . SOC SEC NO. Flores, Daniel o 1939 Texas 5. PRESENT STATUS (SinAle, widowed, divorced, or annulled) SPECIFY~ arriej:O 6. STATE DATE. PLACE. AND REASON FOR ALL DIVORCES OR ANNULMENTS 'NA SECTION I1. SPOUSE I. NAME OF SPOUSE tfirst-middle-maid n). DATE F BIRTH PLACE OF BIRTH (Spouse) Flores, t& 0 1935 Portland, Oregon 4. DATE AND PLACE OF MARRIAGE 5. C TIZEN5H1P OF SPOUSE fnaturalized, indicate date a place T r 96 0 natura j atiaon & cerififcatte no.) 18 November 1 1960 0 tet (0 USA 6. STATE DATE. PLACE. AND REASON FOR ALL SEPARATIONS! DIVORCES OR ANNULMENTS NA. 7. OCCUPATION B. PRESENT EMPLOYER Legal Secretary 0?6 9. EMPLOYER'S OR BUSINESS ADDRESS (No., Street City, State & Zip Code - Country if not U.S.) Street NW, Washington, D.C. SECTION III. RESIDENCE (Since date of last PHS, if overseas residence indicate only city and country) ADDRESS * LAST RESIDENCE FIRST (-numberstreet,city, stte.country) JULa4 INCLUSIVE DATES (month & year) FROM- TO- r0 May 1969 May 1971 ( 0Sept. 1971 Feb. 197 I jenna a Feb. 1974 SECTION IV. CHILDREN AND OTHER DEPENDENTS (Provide information for all children and dependents) NAME RELATIONSHIP DATE & PLACE OF BIRTH CITIZENSHI ADDRESS o~ ~ ~ a Mlr e cag h e 1 9 U S Aa V 06 Flores aughter 3 March 1971 USA Flores aughter 15 March 1974 USA _________ 17asington, D.. FORM OBSOLETE PREVIOUS (4) 12,70 44eE DIIeEDITIONS

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