(vardas ir pavardė didžiosiomis raidėmis, asmens kodas)



| |MARIANA AUGUSTO | |

| |(name and surname in capital letters) | |

| |Paulista Avenue, number 11 – São Paulo/SP Brazil | |

| |Postal Code: 0000-000 | |

| |Cel number: +55 11 99999-9999 | |

| |(address, tel. #.) | |

To the Lithuanian Central State Archives

APPLICATION

|October, 19 - 2018 |

|(date) |

Please carry out an archival research and provide certifying documents that the person lived in Lithuania till June 15, 1940 and held Lithuanian citizenship.

|Name, surname (maiden name – for women), father’s name |MONIKA VALATKAITS |

|Specify family relation if you apply on behalf of other |GREAT GRANDMOTHER |

|person | |

|Date of birth |April, 9 - 1898 |

|Place of birth |Vilnius / Marijampoles / Kaunas / Alytus |

| |FATHER – ADAO VALATKA |

| |MOTHER – MARIJONA VALATKA |

|Names and surnames of the family members |HUSBAND/WIFE – JUOZAS KLEIZA |

| |DAUGHTER – MARIJONA KLEIZA |

| | |

|Realty owned before 1940 (indicate - land, forest, buildings)| |

|Address of realty (street, house #, town, village, district, | |

|county) | |

|Indicate institution of graduation if studied | |

|Worked at till 1940 | |

|Served in the Lithuanian Army |since till |

|Name of regiment, place of dislocation, military rank | |

|Date of departure from Lithuania and place of residence till |She landed at the port of Santos/Brazil on August, 8 – 1927. |

|departure | |

|Place of residence of a family during census of | |

|Lithuania1942-05-27 (street, house #, town,village, district, | |

|county) | |

|Certified documents required for |RESTITUTION OF CITIZENCHIP |

| |(please indicate objective) |

|ATTACHED. | |

| |(please indicate a copy of ID, a copy of a the power of attorney for representation of non relatives |

| |

| | | | |

| |(signature) | |(name and surname) |

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