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| Front | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Name | Age | Address | Birth date | Citizen? | Place of Birth | Nat. | Occ. | Empl. | Loc. | Closest relative | Mar./Race | Mil. | Dep. | Exempt | (Signed) |
| Joseph Chervin | 24 | 745 9th St., New York NY | March 24, 1894 | Alien | Grajewo, Lomza, Russia | Russia | Bookkeeper | Goldenstein and Knutter(?) | 27 Remington St | No dependent | Single, ?? | No | No | Nerves | Joseph Chervin |
| Height | Body | Eyes | Hair | Crippled | Official Signed, Dated, Location | ||||||||||
| Brown | Blond | No | Moses Gans, June 5, 1917, New York | ||||||||||||
