Status: Complete

What is your name?: Charlie Green

What is your age? (years): 48 Dec. 2

What is your occupation?: [Laborer?] [Railway?]

Where is your residence?: Criglersville Va.

Where were you born?: [Rappenick?] [Rappahannock]

Are you married?: no

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

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

Have you children?: yes ---

Do your wife and children enjoy good health?: yes.

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. 1930

Signed : Charlie Green

Witnessed: : Edmond Jackson

Witnessed: Robert Cambel

Notes and Questions

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