STRICTLY CONFIDENTIAL
Please read the Examples and Instructions shown on the back, and then fill up the Schedule carefully and in Ink.

To be filled up by the Enumerator.

1

No. ofschedule

NAME AND SURNAME:-

RELATIONSHIP to Head of Household.

AGE.

SEX.

MARRIAGE orORPHANHOOD.

BIRTHPLACE and NATIONALITY.

OCCUPATION and EMPLOYMENT.

Information only required in respect of MarriedMen, Widowers and Widows.

of every person who is alive at midnight on the night of Sunday, 24th April, 1921 and who, as member of the family or as visitor, boarder or servant in the house– hold or establishment:–

  1. Passed that night in the dwelling of thehousehold or establishent, or
  2. arrives and is received into the house–or establishment on the morningof Monday, 25th April, not having alreadybeen enumerated elsewhere.

No one else must be included.

(For order of entering names see Exampleson back hereof.)

State whether“Head” or“Wife,” “Son,”“Daughter,” “Stepson,” orother Relative.“Visitor,”“Boarder,” or“Servant,”

(See InstructionNo 1.)

Inyearsandmonths.For Infantsunder onemonthold write“Under Onemonth.”SeeExamples.

Ifmalewrite“M,”iffemalewrite“F”

For persons aged 15and over write“Single”,“Married,”“Widowed,” or ifmarriage disolved bydivorce write“D.”———— For childrenaged under 15 write“Both Alive”if both parents be alive“Father Dead”if father be dead“Mother Dead” if mother be dead, or“Both Dead” if bothparents be dead

  • If born in the UnitedKingdom write thename of the Countyand of the Town or Parish.
  • If born outside theUnited Kingdom write the name ofthe Country and ofthe State, Provinceor District, or
  • If born at sea, write“At Sea.”

If not born in theUnited Kingdom statewhether Visitor orResident in this Countryandstate also nationalityif born in a foreigncountry e.g.–“British Born”Naturalised BritishSubject,”“French,”“German,”“Russian,”etc.

Personal Occupation.

Employment.

Place of Work.

Number and ages of all living children and step childrenunder 16 years of age, whether enumerated on thisSchedule or not, i.e. whether residing as members ofthis household or elsewhere.

If attending a School of anykind ofEducationalInstitution forthe purpose ofreceivingInstruction write“Whole Time” or“Part Time” asthe case may be.

(See InstructionNo. 2.)

State here the precise branch of Profession, Trade, Manufacture, Service &c. Where the occupation is connected with Trade or Manufacture, the reply should be sufficient to show the particular kind ofWork done stating where applicablethe Material worked on and the Articlemade or dealt in if any.

If retired see Instruction 6; see also instruc–tions 3 to 11 and Examples.

  • If working for an Employer state the name andbusiness of the present employer (person, firmcompany or public body) or, if at present outof work, of last employer, adding “out of work.”
  • If employing persons for the purposes of businesswrite “Employer.”
  • If working on own account and not employingpersons for the purposes of business write “OwnAccount.”

Note—For Domestic Servants and others in privatepersonal service write“Private.”See Instructions 3 to 8, 11 and examples.

Give the address of each person's place ofwork.

For a person with no regular place ofwork write “No fixed place.”

(No entry is required for any person whois retired or out of work.)

Totalnumberundersixteenyears ofage.if nonewrite“None”.

For each child place a X in the columncorresponding to its age.

The number of crosses should be the same asthe number shown in Column (n).

(a) (b) (c) (d) (e) (f) (g) (h) (k) (l) (m) (n) (o)
Years Months

Age last Birthday

1 { UnderOne 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
2 {

Age last Birthday

UnderOne 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
3 {

Age last Birthday

UnderOne 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
4 {

Age last Birthday

UnderOne 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
5 {

Age last Birthday

UnderOne 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
6 {

Age last Birthday

UnderOne 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
7 {

Age last Birthday

UnderOne 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
8 {

Age last Birthday

UnderOne 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
9 {

Age last Birthday

UnderOne 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
10 {

Age last Birthday

UnderOne 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
I declare that this Schedule is correctly filled up to the best of my knowledge and belief.

Signature................................................................

(Head of Household, Manager of Establishment or other person responsible for making this return.)

To be filled up by the Enumerator. Enumerator’s Initials.
Males. Females. Persons. Rooms.

©Antony Lambert