S.S.

sailing from

19

,  19

Questions on Passenger Manifest:

1.   Number on List     
2.   Name     
3.   Age       
5.   Married/Single     
6.   Occupation     
7.   Able to Read/Write     
8.   Nationality     
9.   Race
10. Last Residence - Country / Town   
11. Name & address of nearest relative in country of origin
12. Final Destination     
13. Number on list     
14. Whether having a ticket to final destination
15. BY whom was passage paid
16. Whether in possession of $50.  If not how much less?

16. Whether in possession of $50.   If not how much less?
17. Whether ever in U.S. before?
18. Whether going to join a relative; if so list name/address
19. Ever in prison, almshouse, for care of the insane or supported by charity?
20. Whether a polygamist
21. Whether an anarchist
22. Whether coming in with an offer, promise, or agreement of labor
23. Condition of health
24. Deformed or crippled
25. Height
26. Complexion
27. Color of Hair/Eyes
28. Marks of Identification
29. Place of Birth - Country/City or town