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expt sheguepahin 3-432 (Rev 44-877 Y SECRET Pp } SED REVISION a-2b-8T) ei i 1. Name ' 2. Aliases ees 3. Date and Place of Birth 4. Citizenship | 6. Race 7. Height 8. Weight DO White . D Black 5. Sex D Oriental 9. Hair 10. Eyes QO) Other 11. Scars, marks and identifying characteristics ; 12.0) Single Married (0 Separated (1 Divorced 13. Residence 14 Residence Telephone Nun ber 1. Occupation/Employer (includes academic institutions} 1) Enpley net Tek phere Mun ber Date Taken 19. identifying information Passport No. Country of Issue ___ __ __ __ Date of Issue >. Social Security No. ee a a Alien Registration No. Sy : i U.S. Person 0 Yes (No Naturalized U.S. citizen 1 Yes OONO pars ar evry wrt ws. iat Gre. Bune: 16: Fomentet affiliation Sah Otficial position is] Five tom eaah Bar ke 7. Narrative of activities 19 Predical or her ‘Inve sligaton, other ‘afer ataan te be reg utated Speuse + Nant, Dos, Ped ; c rtother? Nane, 008,P08 DECLASSIFLED 1 Dp Fathers Sane 008, 63 ON Sf 2-9 nee ® Siblings: Nene, 004, For Office of Origin Bufile No. Date Prepared CASE STATUS! OPEN Classified by: 76 SECRET Declassifyon: OADR F81/DOJ DOCUMENT /¢%