Date of
ast Ap.
Surname
Na.
Fl. Front
or Rear
Date
Landlord
Dist.
Date
Address
Rms
Rent per mo.
Address
From
To
Binhplace Na
Date of Birth
Auy
Religlon
Marriage
Previous Marriages
Date
Place
Man's First Name
Woman's First Name
By whom
Maiden Name
Mental and Physical Defects
Occupation
Read and Write
Wages
Ins. Prem.
Civa at Ap n
Age c-Position
A
C
1. Man
2, Woman
Occ. at Ap. or
A School Grade
Children's
First Names
Date of Birth
Full Name of Husband or Maiden
Name of Wife, and Address
Wages
Ins. Prem.
Amt, per wk.
C
Mental and Physical Defects
per wk
4
10
Relatives and others in Family at
Ap-Fuil Names
Occupation
at Ap.
Wages
per wk
Kinshlp
Union,
Benefit Soclety
Pawns.
Installments
Other Sources of
Income
Amount
per wk
Relatives
Kinship
Friendly Visitor
Address
Address
Date
References
Connection
Address
No
Address
Date
Position
Dept.
Foreman
Employer
Wages
From
To
c, O. Dept, of R. S. F.-Case Record Form-No. 24
