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					                                                           Victim's
Victim's Family Victim's Maiden                         Previous/Other
     Name            Name         Victim's First Name    Family Name
                                 Victim's
                      Victim's   Approx.
Victim's   Victim's   Date of     Age at
  Title    Gender      Birth      Death
                           Victim's     Victim's Picture
Victim's Place of Birth   Citizenship      File Name
                               Victim's Father's
Victim's Father's First Name     Family Name       Victim's Mother's First Name
                                                            Victim's
                                Victim's Spouse's First     Spouse's
Victim's Mother's Family Name            Name             Maiden Name
                  Victim's #
Victim's Family       of       Victim's Permanent Residence (Town, Region,
     Status        Children                     Country)
    Victim's                                                 Victim's Organization
Permanent Street                         Victim's Place of        or Movement
    Address        Victim's Profession         Work                Affiliations
Victim's Residence
Before Deportation   Victim's Street
  (Town, Region,     Address Before
     Country)         Deportation
Victim's Places & Activities During War
                                              Victim's    Submitter'
                          Victim's Date   Circumstances     s First
Victim's Place of Death     of Death         of Death       Name
Submitter'  Submitter's
 s Family Previous/Maide   Submitter's Street
  Name        n Name           Address          Submitter's Apt #
                                                  Submitt Submitt Submitt
                                        Submitt     er's    er's    er's
                   Submitter Submitter    er's    Telepho  eMail   JGFF
Submitter's City    's State 's Zipcode Country    ne #   Address Number
Submitter Submitter's During the
 Shoah    Relationshi    war                           Submitter'
Survivor?   p to the  Submitter Submissio   Submission s Signature
(yes/no)     Victim     was…     n Date       Place    Image File

				
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posted:2/27/2012
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