Application For Admission To The New York Armenian Home Page 5
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10Husband’s Occupation: _______________________________________________________
(Wife’s)
( ) Inappropriate
Birthplace _______________________________
( ) No Data
Death Date ______________________________
( ) Never Married
RELATIVES NOW LIVING
: (children, brothers, sisters, nieces and nephews; if there are none or few, list cousins)
NAME ____________________________________________ ______________ ___________________
RELATIONSHIP
TELEPHONE
ADDRESS _____________________________________________________________________________
NAME____________________________________________ ________________ _________________
RELATIONSHIP
TELEPHONE
ADDRESS _____________________________________________________________________________
NAME ____________________________________________ ______________ ___________________
RELATIONSHIP
TELEPHONE
ADDRESS _____________________________________________________________________________
NAME ____________________________________________ ______________ ___________________
RELATIONSHIP
TELEPHONE
ADDRESS _____________________________________________________________________________
NAME ____________________________________________ ______________ ___________________
RELATIONSHIP
TELEPHONE
Person to be notified in case of illness, emergency:
Physician responsible for Ongoing medical care:
Name ____________________________________
Name _________________________________
Phone No.______________________________
Phone No.____________________________
Address :__________________________________
Address:______________________________
________________________________________________________________
______________________________________________________
Education:
(U.S.) Highest Grade Completed:
( ) Grade-school
( ) College
( ) High –school
( ) Other (specify) _____________________
Readiness of Applicant to enter the Home:
( ) Is ready to enter now at time of application.
( ) Is applying in advance of expected readiness in the future.
Languages:
Reads ___________________________________________________________________
Writes___________________________________________________________________
Speaks___________________________________________________________________
Burial Plans:
Name & Address of Funeral Director (if chosen) ____________________________
Cemetery Plot Location & No. ___________________________________________
Who holds deed _______________________________________________________
Any Special Arrangement: ______________________________________________
Date ________________________________
Signed _______________________________
-4-
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