English Translation

E A special application must be completed for each sick or ill person! (only for the district administration) Erledigu Application for the grant of bon entrance stamp p insurance benefits. 25 To the German civil servant health insurance Bezirksberwaltung Berlin in Berlin W 15, Liezenburgerstraße 46 Zablstelle Rezidk Dr. O.R. Scliffeedochee 31 1. Forename and surname, stand, apartment of the regular insured oferepieinagzat, Teay t15. Slau Benerile Rietest. 2 2. Insurance No. 5007 980 3. berschert feit 7. De 1932 4.Farif E Begw. gefächtte begew. befährte Person: 5. Pre- and surname: 6. Year of birth: 7. insured since: 6 Son Dorg Selifedkee 1943 3. Wa79Y3 8. Type of illness: 9. Duration of disease: bom 29.6.7944 to 19. In the case of hospital treatment: Is hospital treatment finished? 11. Is the disease based on an accident? __— Who is responsible for the accident? Are there any further costs for the repair of the consequences of the accident ? ..Accident-Berfs.-Schuß für Heilbehandlungs-Kosten bestand seit 12. In case of weekly assistance applications: Should the newborn child be covered? (If yes, please submit an application for admission immediately).Nüdseite, ge 13. Is there any other insurance cover against illness damage, if yes, with whom? Issuer 4. Interested: 3 invoices. together with 3 receipts, 1 prescriptions. — List overleaf. 15. I asked for the transfer of benefits under the insurance conditions and the tariff far duch di Porz to my Rostschedkfonto No. In my savings account Scheckfonto Rr. bet der- P a Phiffedaber den 30.10. 45 Det (Won bier ab nur für die Zahlstelle) (Subshrift des Angebungsellers) the opinion of the paying agency (Vertrauensmann) on the application: Until when are the contributions paid? a udh -, the (Det) (Woa here ab Nur für Begirksberwaltung) (Lnterschrift des Berirauenemannes) 17. (a) Pfennig request to be calibrated — to be over-edged — with retention of the accompanying item at 2a) b) Contribution to (c) Declared accounting items. (5 (date-of-fact) 3. Execution is pure: 18. Notes for the 19th L.B. for Borjahr Lfb. Year Together Bfennige 20. Paid d. Possed Notification Man Issue N.. Postaberiv. Exact Woman. at Child Payd d. Bank Sched Sparkasse Über. Nr. Kind Kind Kind. 3 am V 1 Eeslastungeanlage. (Signature of the Kaffeenführera)