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| Front | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Name | Age | Address | Birth date | Nat. | Cit? | Occ. | Empl. | Loc. | Closest relative | Race | (Signed) |
| Stanley Chervin | 35 | 104 Luquer, Rome, Oneida NY | September 12, 1884 | Austria | Alien | Laborer | Rome Mfg Co. | Railroad, Rome, Oneida NY | Katie Chervin | White | Stanley Chervin |
| Height | Body | Eyes | Hair | Crippled | Official Signed, Dated, Location | ||||||
| Blue | L. Brown | No | J. R. Miller, Sept. 12, 1918, Oneida Cty, Rome NY | ||||||||
