English Translation

W (Only used for the district administration) Entrance stamp pg-a To the German Beamien-Krankenbersicherung Bezirksberiwaltung Brag in Prag G3 Payable Dv. Otho R. Lelifferdechn 1. First and surname, stand, apartment of the regular insured. Oferepiempaal Prag tit Bemeshe Rie1,t. 2 2. Security number 5007 980 3. berfcher eit 7. Depeunten 1952 4.Fatif E Sick persons v. Berson: 5. Name and surname: 6. Year of birth: 7. insured since: Ros mare Tehiffedeher 1916 1 May 7940 8. Urt der Sickheit: 9. Duration of illness: Zahmbeh auden 3.V1.1944 h 65 14 819 bom 10. In hospital treatment: Is hospital treatment finished? 11. Is the illness based on an accident? 2 Accident health insurance is attached. since f. Schein Nr. PC S 12. For weekly grant applications: Should the newborn child be covered? 8 (If yes, please submit an application immediately). O a a ee d de a Issuer 318 a Ba b a d du dba d p ub d d d D A on my Bostfcheffonto Re. bet dem Bosftectamt dunch dhi Port bar aus-my Spartanto Shedlonto-No -saq pag Teaj The 30th Cpaic 7945 Helperdeleer 2 Place a d d ge d c (Untersafe dee Antagelle) & 16. Statement by the paying agency (Vertrauensmann) on the application: Until when are the contributions paid? , the (Dr) (Won here from only for the district administration) (Signature of the Bertrauenemann) 17. Issue=Instruction and income=Invoicing instruction. 9890. 9f. 0R93 $f. The caf is given, the amount indicated on the side of 1 in words 1. (a) Pfennig to be paid in accordance with the application - to be transferred — to be withheld from 2a) b) Contribution up to c invoicing items shown. c) (date) 3rd copy: 18. Notes for the 19th L. B. for Borjabr Lfd. Year Jusammen Pfennige 20. Paid d. palo Seft No. C. Notification Man Postabero. Woman . paid at the C child d. Bank Sched = Sparkasfe Überw. Nr. e Kind Kind. am 1 a : Motion for a resolution. 8080/4 Signature bes Kaffeenfübeers