Status: Complete

What is your name?: [crossed out] Ben [Benton?] [Steel?]

What is your age? (years): 24

What is your occupation?: farming

Where is your residence?: Wolftown Va

Where were you born?: Wolftown Va

Are you married?: yes

What was your wife's name before marriage?: Pearl Lindsey

Are you married to more than one woman?:

Have you children?: 3

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?: no

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?: yes

Dated: May 2. 1936

Signed : [crossed out, E. Jerrett] Benton D

Witnessed: : Bl Terrell

Witnessed: Birdie Scott

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