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What is your name?: [Robert Richard?]

What is your age? (years): 55 November 1887

What is your occupation?: farming

Where is your residence?: arroda [Aroda]

Where were you born?: arroda [Aroda]

Are you married?: married

What was your wife's name before marriage?: Mildred Baker

Are you married to more than one woman?: 0

Have you children?: 0

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?: yes

Dated: Aug. 7

Signed : W M. Weaver John [Jackt?]

Witnessed: : Birdie Scott

Witnessed: