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What is your name?: Robert Jackson

What is your age? (years): 25 July 6, 1906

What is your occupation?: Railway

Where is your residence?: Oakgrove

Where were you born?: Oakgrove

Are you married?: no.

What was your wife's name before marriage?: - - - - - -

Are you married to more than one woman?: - - - - - -

Have you children?: no.

Do your wife and children enjoy good health?: - - - - - - -

Are you sound in body?: Yes.

Are you subject to any periodic complaint which is liable to render you unable to follow your usual employment, or which is calculated to shorten life, and thereby render yourself, wife, and children a burden to this Lodge?: - - - - - - - -

Will you faithfully obey the laws and submit to all the penalties that may be imposed, should it ever be proved that you have made a false statement?:

Dated: Nov .7 .1931

Signed : Robert Jackson

Witnessed: : Edmond Jackson

Witnessed: Robert Camhel