Form G-1041 - Genealogy Index Search Request Page 2
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35.
List additional information about residences and dates
Part 2. Immigrant's Information (continued)
below (if any).
Other Information About the Immigrant
3.a. Date of Birth (mm/dd/yyyy)
3.b.
Is this date actual or estimated?
Actual
Estimated
Place of Birth (Include Town or Village, Province, and
Country, if known)
4.a.
Town or Village
4.b.
Province
4.c.
Country
Part 3. Other Information
1.
Date of immigrant's exact arrival in the United States
(mm/dd/yyyy)
6.
Other information about the immigrant that may prove
useful in the index search (For example, name of spouse
NOTE: If you are unsure of the date range, or it is unknown
and/or children, date of immigrant's death, military
select an additional choice in Item Numbers 2.a. - 2.d.
service, date of naturalization, date of female immigrant's
marriage, occupation):
2.a.
Before 1906
2.b.
1906 to 1924
2.c.
1924 to 1940
2.d.
After 1940
Where did the immigrant live in the United States?
3.a.
Street Number
and Name
3.b.
Apt.
Ste.
Flr.
3.c.
City or Town
Important: If the immigrant's date of birth is less than 100
years prior to the date of this request, you must attach
3.d.
State
3.e.
ZIP Code
documentary proof of death to this request. Do not attach
original records because we will not return them. See the What
3.f.
Postal Code
Information Is Required to Begin an Index Search section of
the Instructions for examples of acceptable documentary proof
3.g. Country
of death.
4.a.
Date From (mm/dd/yyyy)
4.b.
Date To (mm/dd/yyyy)
Form G-1041 12/23/16 N
Page 2 of 3
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